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PebNiihe hentia Bia me oe Re Et bath a A marie once 4 eh hk Ss Baw ot aa bed PC er eae GarhediW Helen Weir Welbew MER Arvraen welt Ce oe te kcol Bett te Bes a Be) PA SUS + he ae bs aah ir Wospnon owe aha sede tidot gh aterm dom uy wade edewevee. Sew tha aie ieetr May Abe eae eae Ak Aa eae bots Cavey nee ie eeieers eerste wavs ey tide Le me Cat eM Eke I eeepc ort aoe ek eee sak eh baie seed eee Riasai iw aem sem 4 Grey TS AP are ee aoe en 5 Sow Ree Ale er Sigh iat eek weed aitiad 6 Vided wows makers hota ox Pree bene te by three ni bb ota? Lo ws Lew yal os dows ae ores aoe) ROA has br Goskem ae gs cn Sy AM iim witb be ae SRC ah rales bei Yanda ta Cbd ea PRN ately oem dead aby AAR ad he Oe PICU eere a aan AN ek eae Hie ae Be A eam dedi Rie eee Scien Wy ric tober ven vf 10 eho Us ete. Roma dig Haye Woke Be tS re te eae te Ot ARM ek sare de swe betes Eb week peat Fete aot ew 08 4 be Redd de 6.0 GM. CiMiaiAewen & pad Sh aeded, An ae beets tie PT Ser eet MO Lee re earns bree a ey rar ret Wren Heme int bir 4 Ode od Odd As. 6-60 AE a he be Ahedee wed. Ate ay Bie bed Pee ted GH se deter Oe Re ome PRN ea or ie) BRU CROC erat ici wony Rae earth hea taht Ae ee ee ened Friel rttha tad er thera + « tines C4 S ee Aad 0 eee Oe OR ee ee Oo. HORA A te Tel Hoek + Bede ehh Ue ete fh 45 414-18 Wot waded COE Reb e UDhee baie 4 eo eeu it i ar) Ce eee eee were YY ‘ ag a ‘ 8 dat PE Pale tars Cerra ee Tn Cd Raw SM are keR Mio Redr a Heat ae Cae d dae cca mre Wits seen hes) ‘ CSCS nm noe teen or Dey Me ta Wh Wario 6 thei hci ab stra CO ee Geb 8 & Qe ted-e ddr’ 4.4 Wh Soest dome aw atid iM ada ee deh eke “ fae LY . - THE PHILIPPINE JOURNAL OF SCIENCE EDITED BY PAUL C: PREER, M.D. Pa. Dd. AND RICHARD P. STRONG, Pu. B., M. D. WITH THE COLLABORATION OF OSCAR TEAGUE, M. S., M. D.; W. E. MUSGRAVE, M. D. VICTOR G. HEISER, M. D.; JOHN R. McDILL, M. D. FERNANDO CALDERON, M. D.; JOSE ALBERT, M. D. PHILIP K. GILMAN, A. B., M. D.; NELLIE LOUISE COOK, B. L., M. A. PUBLISHED BY THE BUREAU OF SCIENCE OF THE GOVERNMENT OF THE PHILIPPINE ISLANDS B. MEDICAL SCIENCES VOLUME VI 1911 WITH 21 PLATES, 5 FIGURES, 15 CHARTS, 3 DIAGRAMS, AND 2 Maps, MANILA BUREAU OF PRINTING 1911 / a 2421233 vale VIL. VIII. IX. XI. XII. XIII. XIV. XV. XVI. CONTENTS. No. 1, February, 1911. 2 Aronsuklans=) Nintiition amd) Growth':) 22222. sec ce cence nce sceeee cence Plates Ito 1V. Diagrams 1 to 3. Charts 1 to 6. . Sellards, Andrew Watson, and Shaklee, A. O. Indications of Acid Intoxication im Asiaitie’ Cholera... 22.2 eee coe eee ede . Willets, David G. A Statistical Study of Intestinal Parasites in Tobacco Haciendas of the Cagayan Valley, Philippine Islands... . Boynton, W. H. A Note upon Anthrax in the Philippine Islands.. Ty TRRGRVAGN ae rec ae a ce rE Se ee ee uae No. 2, April, 1911. Aron, Hans. Investigation on the Action of the Tropical Sun on INV riiercalty lies Atrasiiran Grapes ome ty oe wee eset nee Le ee Se Ee Ne Ne Plates I and II. Text Figures 1 to 3. Charts 1 to 4. Chamberlain, Weston P. The Eradication of Beriberi from the Philippine (Native) Scouts by Means of a Simple Change in elven reel) Te tama toes soe ora ree et ye RAAT 12 Beem eee Bowman, Fred B. A Case of Dysentery Caused by Balantidium coli with Coincident Filarial Infarction of the Spleen................ Plates I and II. |; Ruediger, EH. H. Some Observations on So-called Flagellates, Ci- liates, and Other Protozoa Encountered in Water and in Human SLOOlsm (Ere lumineamyaeenOnt ie ner ne eee Text figures 1 and 2. 1» LBXGRTAWEN Soe eseeess c= AU Rene Ns Re re a ee se Saeco IU No. 3, June, 1911. Garrison, Philip E. Davainea madagascariensis (Davaine) in tegen pimer MS and swe sen Ueteeee ec a Plate I. Chamberlain, Weston P., Bloombergh, Horace D., and Kilbourne, Edwin D. A Study of the Influence of Rice Diet and of Inani- tion on the Production of Multiple Neuritis of Fowls and the Bearing thereof on the Etiology of Beriberi...................---------------- fo} Plates I to IV. Charts 1 to 5. Stitt, H. R. . I eee 50 1,572 2, 532 “19.0 215 185 30 1.6 NUTRITION AND GROWTH: I. 39 Several authors (Oppenheimer, Rubner, Graham-Lusk** and Wilson™) have attempted to formulate mathematical laws concerning the relation of the caloric intake to the inerease in body weight. Rubner states that all young mammals, with the exception of man, in their first days of life need the same number of calories (4,808) to increase their body weight 1 kilo. This law would apply to a time when the food supply of the animal is controlled by nature, and we could understand a universal law under such conditions. However, it has already been shown that a number of Rubner’s data are quite arbitrarily selected and that others, equally reliable, lead to different results. Oppenheimer has observed that the growth in grams of normal, breast-fed children of the same age may be nearly proportional to the quantity of milk ingested. This question has also been studied by Graham-Lusk, who, from his own experi- ments on suckling pigs performed in connection with Wilson, and from older experiments on dogs done by Rost,* has shown that, “during the normal develop- ment of the young of the same age and species, a definite percentage of the food (expressed in the caloric value) is retained for growth irrespective of the size of the individual.” While it is difficult to give a satisfactory explanation for this law from the standpoint of energetics, it seems to hold true in practice. For instance, Bamberg,** in a recent investigation on young pigs fed with the same milk, has obtained results from which we might also find a con- firmation of Graham-Lusk’s law: First five weeks of experiment. | Number of pig. Weight at start. Quantity; J Increase onal Q Grams. | Grams. | Grams. Ce res 38 ek et ne Ee 1, 963 5, 004 4,621 | 1.08 Dee setae Jot. Soe eee 1, 743 3, 597 3,469 | 1.02 [Rene pes as oe ee 1, 850 2, 632 2,344 | 1.12 In spite of the entirely different quantities of milk taken, there is a very surprising agreement between the quotients “ which indicate the in- crease in weight per unit of food (milk). °° Ztschr. f. Biol. (1909), 42, 147. * Science of Nutrition, Philadelphia & London, 2. ed. (1909), 247ff. 2Am. Journ. Physiol. (1902), 8, 197, 212. ; *% Arb. a. d. kais. Gsndhtsmte. (1901), 18, 206. * Jahrb. f. Kinderhetlk. (1910), 71, 670. 4() ARON. I obtain figures confirming this rule from some of my experiments on amply fed dogs. If we compare the figures for a period of fifty days the following values are obtained: Increase. Calories recy (Neth fee WF A ee BN taken per Dog. Calories. Increase. gram in- From— To— crease, Grams. | Grams. | Grams. Geet le sae ae Mee event 19, 950 2250 3820| 1,570) 12-7 COMME se ON a reo nde e Scenes 13, 925 9220 3220 1,000 13.9 SVART dake ae steal Ue eat 9, 500 1265 2045 739 | 16.4 SNOT (at Pee a kei ve eee ee 10, 750 1785 2623 33. | 15-6 However, if we compare the well and poorly nourished dogs of the same litter, the law does not hold. It seems clear that an animal gaining 1,000 grams during fifty days needs fewer calories for this gain than one gaining 1,000 grams in one hundred or one hundred and fifty days. In the first instance the animal needs to be maintained for only one-half the time as in the latter. ‘Therefore, it seems nearly impossible to give any mathematical law, so long as the time factor can be varied freely. INCREASE IN WEIGHT AS AN INDEX TO GROWTH WITH SPECIAL REFERENCE TO CHILDREN, One of the most striking results of our experiments is the demonstration that lack of increase in weight in a growing animal does not indicate a lack of growth, but starvation, accompanied by loss of body substances. This is of importance in practical pediatrics. We learn from it that a child which does not increase in weight or increases slowly is so under- nourished that part of its own body substances are being consumed. We can go even further in our conclusions. If a child does not present the weight which we have a right to expect at its age, assuming that it was born with a more or less normal weight, this child’s body does not have the normal composition. It will contain a higher percentage of bones, a lower content of fat and muscle tissues, and a higher content of water and the caloric value of a unit of its body weight will be below that of a normal child. To feed such a child properly it is necessary first to attempt to replace water in its body by fat and protein. There- fore, it can use energy above the amount required for maintenance with- NUTRITION AND GROWTH: I. A] out increasing in weight, or, for a certain increase in weight it will need more food than a normal child of the same weight. This explanation, based on our observation of “Verwiésserung” as a consequence of con- tinuous undernourishment, may give us the key to the understanding of a very remarkable fact recently reported by students of pediatrics and already mentioned in this paper. As Rosenstern** and others have shown and as I can demonstrate from my own, observations, a child of a weight considerahly lower than that which corresponds to its age will need a higher intake in calories per kilo for a normal increase in weight than either an infant of the same weight but younger, or one of the same age but heavier (normal weight).?* This conclusion can best be shown by the following charts, which figure the food given and the weight observed in children of nearly the same weight but of different ages. These observations are taken from milk-feeding stations established by the Bureau of Public Instruction in connection with public schools and conducted by Miss J. Jackson, under the supervision of the writer. I am indebted for the use of the following data to Miss Jackson who made up the milk daily for the children and observed them during the week, while only weekly inspections were made by the writer when the weights were taken. Two characteristic examples are cited. MARIA INOCENCIO. -. Increase Calories Num- From To ber + week—/week—| of days. | From—]}| To— /|Per day.| Per day. | Per kilo. Grams. | Grams.| Grams. 21 26 35 3, 500 3, 600 3 350-375 100-105 26 31 31 3, 650 4, 225 17 450-120 115-120 31 35 28 4, 225 4,811 21 500 125 MIGUELA PRIEGA. 4,175 | 17 | 4 9 | 35 | 3,550 4,850 | 24 | | 9 13 98 | 4,175 350-400 100 | 450-475 105 | > Deutsche med. Wehnschr. (1909), 35, 295. * Finkelstein and other authors advise that a child be given the number of calories that correspond to its age, irrespective of its weight. 42 1909 N Y) YY CHART 6.—Showing weight and food of Miguela Priega. a NUTRITION AND GROWTH: I. 43 Maria Inocencio increased less than 5 grams per day, on a daily intake of from 100 to 105 calories per kilo, but 17 grams per day on a daily intake of from 115 to 120 calories per kilo, and she needed 125 calories per day to increase 27 grams per day. ‘This child at the time of observation was from twenty to thirty weeks of age. The other child of the same weight, but only nine to fourteen weeks of age, with an intake of 95 calories per kilo increased about 17 grams per day, and with one of about 105 calories per kilo it increased 24 grams per day. The question as to how far a continuous restriction in food, a constant undernourishment, may influence not only a single individual but entire nations and races, is doubtless very interesting and of unusual importance in the Philippine Islands. My experiments are not far enough advanced te justify conclusions concerning the possible influence of underfeeding upon offspring. The investigation of this question on mammals will - necessarily require a long time. However, my work so far seems to indicate that a constant undernourishment will inhibit to some extent the normal development of the individual. CONCLUSIONS. The most important results of my experiments may be Summarized as follows: A growing animal which receives only sufficient food to keep its body weight constant, or to allow a slight increase, is in a condition of severe starvation. If by a restriction of food the increase in weight is inhibited, the skeleton grows at the expense of other parts of the body, especially of the flesh. Most of the organs retain their weight and size, while the brain grows to reach its normal weight. The composition of the body—when at a constant weight—undergoes remarkable changes: Fat is consumed more or less entirely, the quantity of protein, especially of the muscles but not of the organs, is diminished and a great proportion of the body tissues is replaced by water ; thus, this water and the increase of the skeleton together, replace the body materials lost. The caloric value of 1 gram body weight of an animal which has undergone such a process to its extreme limit may amount to only one-third of the normal value. It is possible by supplying suitable amounts of food to maintain a dog in an emaciated condition, apparently in good health, and at the weight 44 ARON. of a puppy, for nearly one year, while its weight at the end of the year should be three times as great. If such an animal is thereupon fed amply, it fattens and rounds out, but does not reach the size of a control animal which from the beginning has been normally fed. It is unable to make good the growth suspended by the long restriction of food. The “growth” principally depends on the tendency to grow pos- sessed by the skeleton. The skeleton loses its capability of growing in more advanced age regardless of the size which the animal has reached. I wish to thank Mr. Pio Valencia, formerly demonstrator in phy- siology, for his kindness in watching the animals when I was absent from Manila. RECORDS OF EXPERIMENTS NOS. I-IV, SHOWING LIVE WEIGHT AND FOOD OF DOGS. TABLE 14, HXPERIMENT I.—Live weight and food of dogs I, II, III, and 1YV. Dog I. Dog IV. Dog II. Dog III. Day of Date. exper- é 3 ; ; iment. | weight. ee Weight. See Weight. eeEaae Weight. ee ; 1909. January 20_--_- il 1, 485 124 1, 480 124 1, 419 80 1, 390 80 January 25__--- 6 1, 465 236 1,570 236 1,410 125 1,310 110 January 30__-_- 11 1,710 285 1, 730 285 1, 480 130 1, 330 110 February 4_---- 16 1, 995 (270) 2, 090 (260) 1,575 95 1,510 (?) February 9_---- 21 Sick 290 2,100 305 Sick. (?) Sick. 110 February 14---- 26 2, 235 340 2,290 |. 330 1,705 85 1, 73d 110 Manchvigs=22=— 31 2,475 370 2, 560 350 1, 840 85 1,715 90 February 24___- 36 2, 660 340 2,670 330 1, 810 80 1, 720 85 Marchiiessss=s 41 2, 800 380 2,760 350 1, 865 80 1, 750 80 March 6_------- 46 3, 100 380 2, 950 359 1,910 80 1, 780 80 Marehiiieess=== 51 3, 220 380 3, 060 355 1, 8380 80 1,780 80 Marehul6==ss2= 56 3, 380 380 2,990 355 1, 950 80 1, 800 80 March 21__--__- 61 3, 560 C15) (eerie ote) ak See: a ie ire Aelia me oo eee ee March 26_------ 66 3, 850 A207 | iS ae Na ees | | a PS eee ee lke ee Aion Mase 71 | | 4,250 CU o Ween mPa eee ws CNN ey ee Crh, alee RE ee ne 3 FANG eee en 76 4,410 ADO | ucces See id ee eee ea dot bee ope cl pat aro! ee eS 2o a a ees Atprileie==eee 81 4, 420 AQHUIE Duce eae peer owe ae ea et 502, Eee ae eae NUTRITION AND GROWTH: I. - Taste 15, EXPERIMENT II.—Live weight and food of dogs V and VI. 45 Dog V. Dog VI. peri-| © g o| S| 8 < o 8 s 3 é < ment.| © |izol/ a i|a|s = )Z0 = | w Ss) 1909. Gms.|Gms. Grams. Gms.| Gms. February 19 1} 3,340 3, 260 February 24 6 | 3,345 3, 210 Mare hn les. 8 oe ee on 11} 3,805 3, 320 ETON Giseee see eee |) UG |) ke, 8, 340 Wine Wi Ses Reset P| 21 | 3,820 3, 380 is Ire ie Gee acd eet are 26| 4,000 |{ 59} 210} 21| 4201 9 4iq |] | | 7) 140 ILS ORD A Mesa SS oe ge 31} 4,040 3, 310 WaT Chi 262s |. 8. nS eee 36 | 4,280 3,310 March sles. <= a ales 41 | 4,400 3, 345 NON) by eee ee ee eee 46 | 4,620 3, 495 iA ohn dl 50) soa eee a UE 51} 4,610 3, 430 PACD i Te ase, 2 56| 4,720 3, 520 PAGOTHUNR DOV ko ASE 61 | 4,850 8,545 Nevill Ot) eee eee 66 | 4,850 3, 560 71 | 5,020 3, 540 76 | 5,090 }} 50/170} 17] 335] 3,560 50} 75} 75 | 150 81 | 5,310 3, 555 86 | 5,340 3,510 91] 5,300 3, 500 96 | 5,370 8, 500 MAAS OE eee =e ee ee eee OL | for380) 3, 530 RUN Cg Ae es SS eee 106 | 5,320 7 | 112} 45) 335] 3,500 7| 45) 18] 135 111 | 5,370 | 3, 590 116 | 5,275 13 | 120} 48) 360| 3,400 121 | 5,285 3, 430 126 | 5,260 \ Malton se’| ano)| 27220 ' 131 | 5,220 3, 310 136 | 5,290 3, 375 141 | 5,280 3, 330 146 | 5,320 3, 240 151 | 5,310 3, 150 156! 5,445 3, 030 92) 40} 16) 120 161 | 5,610 3, 000 166 | 5,690 2, 870 171 | 5,815 77 | 160! 641 480 2, 880 176 | 5,950 2, 835 181 | 5,805 2, 835 186 | 5,860 2, 830 191 | 5,780 2, 950 196 | 5,775 2, 830 SEDLEM DC lias aa ae eee 201 | 5,750 2, 850 September 12222255252 a 206 | 5,880 62, 850 3 DON 200150) September 14_________________ ZOSMIRMONS COR time cr ett ceat tite Ne SANE ap a 2 | ees 4 Two hundred and eighth day. b Two hundred and third day. 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Beas Gra IVs ieee Se cena ag oa 19 FFG 216 ‘T brO'T OO GI i So ieee see as ILC RATLCLV lease at ar 9g 086 OFS ‘T 180 'T CTS aerate ee ae ear aes SUSY sistas comme Sag omens s TS 1g £66 \| Sh8‘T 680 ‘I Che HIN cose serge | eae SANG Vee sore aie epee oe ate Soe oF oh6 | ogy 0F0'T COC Rae | rere reeaege ies ea SWINE Jello a gy oar cians 17 | 686 0c9 ‘ SOMOTSO 06 }!-8L6 areca ga PEM ESUIMOW a eteee ne ee tag See 98 SAMO[BO OL ST6 SOLLO[VO COZ GLG‘T SABD GG 086 ~ siup ee Cidlie Wates eat aa asia Ses any GMO UG IN: | isg Seas panei siren fee aha ie 1g “shep ce || 416 "skepzz — l zep‘r G16 SOUR ee peers oe Nina CES OUG NS |r terme ge rea ea ee ee 9% | 998 : 00F ‘T 0&6 OGG ieee eceeay wac aes aoe ee JAA EAG (OD 3) INES cies Poe tae ae a ie Paes IZ SOILLO[VO 00Z a ering Ee 0, Se ROU eer La iv ee, eee Sree A RJ oe ge foe Ss £08 DIT a ¢06 Sc oe \ 0F8 ZI Wore oI SOLLO[BO OLT ‘ S9MO[BO OLT O8Z SOTIO[BI CZ Ost‘T | SAB OS C18 SSO eNO } OCU se ae eee Se Ser see PEUOUGING 3 BSS Setar rare pee ge oes IL ~ skep 12" sAep 12 | See I aee eee eek ea lee ke SLL orb 008 SOTOTBO OST {| S29 te G Youre | eae “9 Ze 098 09L RRO Gl) gp PR CG AIBNI eg | Seeaetnen ee ena i *‘SULDLD SWUDLD | *SULDLY) SUDA) “6061 “poow ‘QUSTO MM “poowr “VU STO M “poo “VSO M “pooy “qUstoM 01Bq 4uoultledxe yo Auq “AIX S0q ‘UX sod ‘TX S0q ‘IIIA 80g | “AIX Pun ‘TIX ‘TX ‘TITA Shop fo poof pun 2yhram oavT— [J] LNAWIUTAX GY “QT WAV, 47 ie NUTRITION AND GROWTH ‘suleIs CLG ‘ peIp Aep 4SIy-AJOUIN p ‘suvi3 QOO'S : ABP Jsuy-AJI0J pue poIpUNy ou0 poly o ‘SUIvIS OOT'T ‘AUP WIXIS-AJ11q} puke perpanyg 9u0 pari q ‘sulevid G)Ee°g ‘Ap YIXIS-A}IOJ pue poipuny ouUO pal[Ty z SOTIO[BO- OCZ SABD 08 SOLLO[BO OOT skep C7 SOLIO[BO OFZ SABD ZE fa asban naan n anna anon nn OL oune ' 48 ARON. TABLE 17, EXPERIMENT IV.—Live weight and food of dogs A, B, C, and D. a Killed forty-ninth day. > Died one hundred and twenty-third day. Dog A. Dog B. Dog C. Dog D. Day of| Date. exper- Cal- Cal- Cal- Cal- iment.| Weight. Aer Weight. ee Weight. esac) Weight. pee day. day. day. day. 1909. Grams. Grams. Grams. Grams. CAN SUSE) =e sees ae il 1, 250 340 1, 380 225 1, 520 225 1,295 | 340 SAUIPUS ENG eee a nase 6 1, 340 340 1, 450 225 1, 580 225 1.360 | 340 August 11 ___- 11 1, 330 340 1, 480 225 1,580 225 1,425 | 340 ATL SUSty Ogee eee 16 1, 465 300 1,520 225 1, 640 225 1,485 | 340 AUR USt) 2100S sae 21 1, 490 225 1,590 225 1, 700 225 1,500 | 340 AU PUStI26iy sae eee ees 26 1,505 225 1, 605 170 1, 745 150 1,515 | 225 AIP UIS tro lye es 31 1,705 225 1,715 200 1, 935 110 1,700 | 225 September 5 ---------_-- 36 1,770 110 1, 780 225 1,890 |}, 110 1,840 | 225 September 10----__-__-_- 41 1, 860 110 1, 860 225 1, 920 110 1,900 | 225 September 15 -__------_- } 46 1, 950 110 2, 020 225 1,940 170 | #1,990| 170 September! 20 2-2-- 5 == - 51 | 1, 990 110 2,080 225 2,010 September 25______-__-- 56| 1,935| 110] 2,150] 250] 2,040 September 30 -___------- 61 1, 935 110 2, 250 340 2,130 October oe sass = 66 1, 960 110 2, 500 400 2,320 October 10222223 eesaae= 71! 1,935 110 2, 650 410 2,370 Octoberdo= === =a 76 1, 935 110 2, 830 410 2,490 October 20 =--=-s-----=_= 81 1, 920 110 3, 090 420 2, 680 Octoberi2b= sees === 86 1, 850 135 3, 180 440 2, 700 Octobens0 se === a == 91 1, 860 135 38, 325 440 2,795 November 4 ------------ 96 1, 900 135 8, 525 440 2, 935 November 9 _-----__-_-- 101 1, 850 170 8, 610 440 2,970 November 14 __--------- 106 | 1,915] 170| 3,720| 460] 3,095 November 19 ----------- 111 1, 940 170 38, 885 500 3, 130 November 24 -_----_---- 116 2, 045 170 4,010 500 3, 220 November 29 -_------.-. 121 2,020 170 4,110 500 | »3,340 December 4 —----------=- 126 2, 030 170 4,335 DOO gle State aa oe ee ic So ae | ees December\9)==2=-=—----=- 131 2,015 170 4, 460 O00 8 eee tee Oe ne Se eee | ee December 14 _------- ---- 136 1, 940 170 4,490 DOO S| eae Mates hi ee Leer eam | December 19 -_---------- 141 1, 960 170 4,595 DOOR ete eS a see lle eS ee | December 24 ______------ 146 1, 995 170 4, 820 OOK ete 22s tahoe) ee | ee 2 December 29 ___--------- 151 T, 990 170 5, 010 DOOM eae aoe Soe ae eee ee 1910. VADWanye ores see sea 156 2,000 170 5, 050 PSO} PMR se) FR ep a | Pie as VERE RAY 6) Se 161 2,010 170 5, 020 OOO Genes Da eal (Due ea a ee eee January 3) =e eee 166 2,015 170 5, 120 DOOY) sae we ee Eee ee a eee January, 18) ==2="22Sseaa= 171 1, 950 170 5, 100 EO i 2 ee ees Januanye2oi ee 176 2,010 170 5, 260 Ef) 0) || pss mem en | YC go a0 9 UEW OW ENAy Pte) 181 2, 050 170 5, 270 DOOR ee ee Ee ee ee A See Hebruaiyecises =e 186 2,110 170 5, 450 BVO S| Mee So Sa ee ee Hebruainyaipsen ee 191 2,040 170 5, 510 bo (Ue | |e erm EE so = ai Ea re Hebruanyel2 eee eee 196 2,090 170 5, 520 BPO see Lea ie i le eee | ees INSIDE AS NG ee 201 2,180 170 5, 605 DIG O in| Ses ee oe es | es ee nee Me brian ye 2 eee eee XT Ps OSO NS TAD GPRS Gye ee ee Hebruany cise 211 2, 230 170 6, 090 DO | Benen ea a, sea Peer Ns oi RE en ta March 40st ee ae es 216 2,050 170 6, 145 ESAs a oe a Ps er | eee NUTRITION AND GROWTH: I. 49 TABLE 17, EXPERIMENT IV.—Live weight and food of dogs A, etec.—Continued. Dog A. Dog B. Dog C. Dog pat Day of Date. exper- Cal- Cal- Cal- Cal- iment.) weight. ao Weight. pee Weight. ee Weight. Sper. day. day. day. day. 1910. Grams. Grams. Grams. Grams. MWfarre tif9) 525 ee ee 221 2,100 70 6, 140 no) i FC eee eae Se 226 2,305 170 6, 185 Marehyd 9s 423 4 ee 231 2,315 170 6, 335 Merch 24852200 5 ees 236 2,315 170 6, 315 WWereh 29h oo ee 241 2,310 170 6,370 PASE, Ae eee ee ae 246 2,270 170 6,300 PAN TE Qa as cede Set 251 2,220 170 6, 400 PAST V4 ee es 256 2,190 170 6, 330 PATIL) eobe ee ce ea 261 | 2,165} 170) 6,290 PANDY 2433829. es Aas 266 2,195 170 6, 335 PAD EI! 29) 222556 ea ae 271 2,150 170 6, 250 276 2,300 170 6, 270 281 2,300 170 6, 350 286 2, 290 170 6, 380 291 2, 220 170 6, 360 296 2,390 170 6, 450 301 2, 350 170 6, 420 306 2,400 170 6, 400 311 2,440 170 6, 460 316 2,360 170 6, 500 321 2,320 170 6, 500 326 2,340 170 6, 500 331 2, 350 170 6, 690 336 2,390 170 6, 760 G80t lense o a oa] K = oS ee eee 341 2,400 170 6, 800 346 2,520 170 6, 870 357 2, 450 170 6, 800 July 23 356 2, 450 230 6, 850 July 28 361 2,510 280 6, 850 PAID USE. 2) een 366 2,540 340 6, 800 AMISUSt Atet ose case e os 371 2,650 340 6, 700 A USt ace ee | 376 2,700 340 6, 680 PAIS US Go Te 381 2,790 340 6, 700. ANIRUSTE22 28 re, 386 2,910 340 6, 690 PUP Ustad 22 ee 391 3, 000 340 6, 550 September 1! -------_--__ 396 3, 040 340 6, 580 September 6 ___________- 401 3, 220 340 6, 700 September 11 ___________ 406 3, 250 340 6, 910 SeprembertGee= === 411 8, 225 346 6, 835 September 21 -__________ 416 3, 325 450 6, 865 September 26 ___________ LM QAO ADA FELON) I Gs) ee October Wa = ee 426 3, 630 450 7, 020 GSO) ek ee ee eS Sn ee oe See OctobenGmans 52-4 = 2 431 3,715 450 7, 005 680 October 11 _____ Ss 436 3, 740 450 6, 950 680 Oetober i=" 441 4,245 680 | 7,060 680 0 (0110) 1) 7) ES Ee ee 446 4, 390 680 7,060 680i |x sheets eee ae eS eI Se 101001——-4 2 Both dogs receive equal amounts. Eee 50 ARON. TABLE 17, HXPERIMENT 1V.—Lwe weight and food. of dogs A, etc—Continued. . Dog A. Dog B. Dog C. é Dog | Day of j Date. exper- Cal- Cal- : Cal- Cal- TEGO, Weight. mee Weight. ier Weight. on Weight. Riess day. day. day. day. - 1910., Grams. Grams. Grams Grams October26= ee 451 4,550 680 7,010 OBO) see See eS 2 See a | October Bl so 2222s 456 4, 690 680 | 7,080 GRO) | eee eal ca ee ea ee es November 5 461 4,810 680 7, 045 G80) Sie Se 3 [Ee a eos ee November 10 466 4,925 680 7,125 680) ese Ne eels eee RO aes November 15 -__--=-__=- 471 4,995 680 7, 250 GOS ee Sel eee 2 ee November 20 __________- 476 5, 130 680 7,340 680 |el Sheet eS eeks eee ees fecee (tut November 25 _---_------ 481 5, 290 680 7, 430 680))| ee Ba ae November 80 __-________ 486 5, 300 680 7,400 (5h) 8 iN fs eaeene etenetemreae= eels Pees AL Oe Decemberss) 222s 491 5, 435 680 7,365 GSO 5 ee es | ah pd ee December 10 496 5, 395 680 7, 320 G80 eee. ee ee ee ee ee December 15 501 5, 440 680 7,400 GRO jee S| ee rapes eae ILLUSTRATIONS. PLATE I, Fic. 1. Dog V of experiment IT at the 175th day. 2. Dog VI of experiment II at the 175th day. PLatTeE II. Fics. 1 and 3. Dog A of experiment IV. 2and 4. Dog B of experiment IV. Puate III. Fies. 1 and 3. Dog A of experiment IV. 2and 4. Dog B of experiment IV. PLATE LV. Fic. 1. Dogs used in experiment IV. o> Or Pm Co 2. Some of the bones of dogs A and B used in experiment IV. DIAGRAMS. . Composition of dogs II to VI of experiments I and II. . Percentage of water and solids in blood, brain, bones, and muscles of dogs V and VI of experiment IT. . Composition of bones in dogs V and VI of experiment IT. CHARTS. . Variation in weights of dogs I to IV of experiment I. . Variation in weights of dogs V and VI of experiment II. . Variation in weights of dogs VIII, XI, XII, and XIV of experiment III. . Variation in weights and calories of dogs A to D of experiment IV. . Showing weight and food of Maria Inocencio. . Showing weight and food of Miguela Priega. 51 “| S3atvid ‘3 ‘914 “| 914 TON ‘IA “TOA “10S ‘NUMOr “ITHg] [HEMONy GNV NOILIULAN : Nowy ll S1tVv1d “9 cold “} cold "T (ON ‘IA “TOA “IOS “NUNOL “TIE ] ['H&EMOUH NV NOMWIMGON : Noy ‘lhl S1Vv 71a TON ‘TA “I0A “IOS “NUAOL TIE] [HiMowy GNVY NOIMIUGAN : Nowy “Al S3LVAd "Z ‘Old ‘TE ON ‘IA “TOA “IOS ‘NUnOL “TING ] [HiIMOUD GNV NOMIMLAN : NoXy * 7 i ya 2 id: ’ pe y “ f * ‘ a i . ; % 4 oe ‘ J : } wal! y t es > a ‘ i i st ~ Bs f Aid INDICATIONS OF ACID INTOXICATION IN ASIATIC CHOLERA. By ANDREW WATSON SELLARDS and A. O. SHAKLEE. (From the Biological Laboratory, Bureaw of Science, and the Pharmacological Laboratory, College of Medicine and Sur- gery, University of the Philippines, Manila, P. I.) The position of the theory of acid intoxication in clinical medicine rests almost entirely upon the investigations in one disease, namely, diabetes. More or less prominent symptoms of acid intoxication may develop in some other conditions, such as starvation, the toxemia of pregnancy, and after general anesthesia, but the knowledge derived from these sources is of relatively minor importance when compared with that obtained from diabetes. However, there are certain features in Asiatic cholera which afford an interesting opportunity for the study of acid intoxication. An inerease in the daily excretion of sulphuric acid and of ammonia in the urine together with the presence of B-oxybutyric acid has been reported by Hoppe- Seyler.(1) In a concluding note of this same article, Quincke reports a case of cholera in which 30 grams of sodium citrate were given by mouth and by rectum in the course of three days, but during this period the urine remained acid. V. Terray, Vas and Gara(2) found a considerable increase in the excretion of sul- phuric and of phosphoric acids and also of ammonia and acetone. Acetoacetic acid was often present. Perhaps the most important feature in cholera which bears upon acid intoxication is the increased tolerance of patients for alkalies. The intravenous injection of sodium bicarbonate in relatively large quan- tities often fails to render the urine alkaline. In the interpretation of this tolerance, the anuria of cholera, following the excessive loss of fluid by rectum, offers a possible complication. The alkalies intro- duced into the body might be excreted by other channels, for example by rectum. However, if quantities of 30 to 60 grams were being ex- ereted into the intestine one would almost expect that the kidney also would excrete at least enough alkali to change the reaction of the urine. Moreover, if the alkali is retained in the body during the period of anuria, there is the possibility that it might be neutralized by sub- stances other than acids, such as serum albumins for example. There- fore, in Table I the intervals between the injection of alkali and the first secretion of urine have been included. Five control cases are also added. | 53 54 SELLARDS AND SHAKLEE. TasLe I.—Intravenous imjection of sodium bicarbonate in patients suffering from cholera. First injection. -*- Second injection. = ; Alkali. Urine. Alkali. Urine. o z . Inter- 5 Inter- | Cubic Inter- . A Per val |centi-| %eac- val be- Per Sal Cubic | Reac- = Amount. ~ | tion to} tween Amount, .centi- | tion to ‘a | cent. after.) me- |jitmus injec- cent. after meters.| litmus By alkali. | ters anions alkali ; 3 2 r : Grams. | Hours. Hours. Grams. | Hours al 0.5 10 No urine. 2 0.5 10 19 100 3 0.5 10 20 100 5 0.5 10 6 5 6 0.5 10 No urine. 7 0.5 10 No urine. 9 0.5 10 No urine. 10 0.5 10 No urine. 12 0.5 10 P 20 13 0.5 10 6 160 14 0.5 10 No urine 16 0.5 20 No urine 17 31505) 30 1 5 19 0.5 10 103 600 20 0.5 10 15 100 21 0.5 10 No urine. Third injection. Fourth injection. i Alkali. Urine Alkali. Urine. ® E I Inter- . nter- . 5 Inter- | Cubic Inter- | Cubie A |val be-| per val |centi-| Reac- | val be-| poy val |centi-| eac- — | tween Amount ~ | tion to| tween Amount tion to 3S ates cent. after | me Rav) || Shae cent. after | me- igrinis Fa) | Bed alkali.| ters UNH} LAN alkali.) ters. : 2 tions. tions. Hours Grams. | Hours. Hours. Grams. |Hours. ACID INTOXICATION IN ASIATIC CHOLERA. 55 TABLE I.—Jntravenous injection of sodium bicarbonate, etc—Continued. Fifth injection. Sixth injection. ¥ Alkali. Urine. Alkali. Urine. Total 2 erties z jal be poy Tater Ou Rene. Wal Be pop ma ae Reece | S dyeen cent, Amount after | me- ison te saeen cent, Amount after | me- ou ig I ae alkali.| ters. : Hone alkali.) ters, | “1™2US- mM Hours. Grams. | Hours. Hours. Grams. |Houwrs. Grams. A eee | meres | cee ee S| ree eS ey ||P ae (Ye Ye I ea ee a 20 Pn ee eel Se eee (gS ee cpa fee eo eae a nL ee Sy 50 | a | eee | eee | ee alee ee a Oe, |S eS Wh eee ee ee 25 £5) eee RH ns 2 el 2a See [eee Pe ree a Pome mavens sos etenee obese [cass eo 20 CC Mises peel | et a feral te PRS a a eee (SR a ae ea re, | ee 20 C7p tees ees Mme es A eet Wee ill vee SN Ss 22 “1 VISE [Te cet [eis Seen deeper ee 20 9 PY) || 15) 15 TWA SOR PAN aR tesa ee S| ee Lice ae ae nee eg |e 55 line. 10 9] 1.5 15 12 70 | Acid 12] 1.5 30 12} 120] Acid 90 TUR fh I ll ae (em a Ce eo eee | Sg ee eg | ee |e 30 WL Sig | eer || ek A ee |e Ne ee I flee 10 BLASS | meres |S ec ae eA ee ee | Pe ai Rx a es 30 AL Ge i | ee Se ee | I |S |e eee te 30 TIF] ses eee Nee (Ne | a | [eee | | sl | | (SS ae 30 PO | ees et ee oe i tere Bet Re See Re ee ie Ee to es a ee eo 10 PAO) a a | (ee ee Pee eee ene el eee a) Henn eee 20 ie eee. |e | Reet secs een Rens Wn ae eee Ae OS 2 ae ole Se he 20 sen Control cases for Table I. Alkali. Urine. | No. Per cone ps Reaction eet Reaction ne Reaction aaa of ae Panne pues litmus Pee Nunes ay ince ion alkali. * | alkali. ~ | alkali. 5 Grams. | Hours. Hours. Hours. a6 300 4.5 1 | Alkaline. QIPACICe ss eae ee 2) 1.5 200 3.0 2 | Acid. 5 | Acid. 12 Acid. 3) 0.5 400 2.0 1 | Alkaline. SiPAcids > jis 22=- 4| 0.5 500 2.5 2: | Acid. 3 | Alkaline. 5 Acid. 5 | 0.5 1,000 5.0 1 | Alkaline, 3 | Alkaline. 10 Acid. | | Recovery took place in all of the cases which are recorded in Table I. There were also four fatal cases; two died during the first day in the hospital without excreting any urine and in the remaining two, the first samples of urine following the injection of alkali were lost. Of the sixteen cases which are recorded, there was but one in which the urine had an alkaline reaction; the quantities of sodium bicarbonate which were administered varied from two to eighteen times the maxi- mum amount which was required to render the urine alkaline in the control cases. 56 SELLARDS AND SHAKLEE. As regards the increased excretion of ammonia in the urine, we have observed that occassionally the injection of rather large amounts of alkali does not reduce the ammonia out-put. A similar result may also occur in diabetes. (3) Suppression of urea.—lhe first specimens of urine voided after a period of anuria are often found to contain subnormal amounts of urea. If the test is made with sodium hypobromite, it also shows that the content of ammonium salts as well may be relatively low in the first specimens. ‘The explanations which suggest themselves may be con- sidered under the two general heads, 1. e. there may either be retention of urea by the organism or there may be a diminished production. In cases where there is suppression of urine, an acute nephritis is always present and one must consider the possibility of retention of urea on account of the kidney lesion. On the other hand, the nitrogen which is ordinarily transferred to the production of urea, might be diverted for the neutralization of acids. Lastly, a diminished production of urea might result from an impairment in the function of the urea- forming organs. A few data have been collected which have some bear- ing on these possible explanations. Hacretion of urea by the kidneys.—The possibility of retention of urea in the body was first considered. No determinations were made with the purpose of detecting an accumulation of urea in the blood or other tissues. Instead of this, urea was injected intravenously into patients who showed a well-marked suppression of urea, the object being to determine whether the lesions of the kidney were sufficient to prevent the excretion of urea, provided it were present in the blood. Previous determinations had shown that, in patients treated with so- dium chloride, the urea, after a period of partial suppression, returns very gradually to normal. Only a limited number of cases were tested. In order to avoid a sudden spontaneous increase in the urea excre- tion, very severe cases were selected in which recovery, if it occurred at all, would be relatively slow. The urea in solid form was added directly to two liters of Ringer’s solution and in every instance the injection was made intravenously. Relatively small amounts of urea were employed, the maximum being 10 grams. All of the cases showed a very acute nephritis in addition to the suppression of urea. The severity of the cases selected made it improbable that any spontaneous increase in the excretion of urea would take place. Four cases were obtained which were suitable for injection. The protocols are as fol- lows: The first patient (number 4) was admitted in partial collapse. During the first thirty hours in the hospital he received three intravenous injections of 2 ACID INTOXICATION IN ASIATIC CHOLERA. 57 liters each of Ringer’s solution of which the third contained 10 grams of urea. The records of the excretion of urea are given in Table II. TABLE II.—IJnjection of wrea, case No. 4. rere Cubic between| centi- | Percent] Grams speci- |metersof| of urea. | of urea. mens. urine. Hours Bowes 230 0.1 0. 03 Injection of 10 grams of urea.» 9 30 0.5 0.15 5k 50 0.6 0. 30 95 80 feed) 1.36 5 120 0.9 1.08 9 90 T2 1. 08 8 250 1.8 4,50 5 120 1.4 1,68 143 10 0.1 0. 01 Death after seventeen hours. » Preceded by anuria for twenty-seven hours. >This injection was made four and one-half hours after the first specimen of urine was obtained. Catheterization showed no urine at the time of injection. The volume of urine and the percentage and amount of urea are given, since the interpretation of the data is a little complicated because of the variation in the time intervals and the quantities of urine excreted. On the third day after admission, a fourth injection of two liters of Ringer’s solution was given. Death occurred on the fifth day of the disease with symptoms both of toxemia and uremia. In the two and one-half days after the injection of urea a total of 10.1 grams of urea was excreted. Assuming that the percentage of urea would not have increased spontaneously, we may calculate the natural percentage for this period as 0.1, i. e. the per cent found before any urea was injected; on this basis we may deduct 0.8 gram as the amount which naturally would have been excreted leaving 9.3 grams as the increase due to injection. In addition to this amount there were also two specimens of urine which were lost by involuntary micturition, i. e. only 8 of 10 specimens were obtained. We may estimate, then, that about 90 per cent of the injected urea was excreted within two and one-half days. A second case (number 11) required 8 liters of Ringer’s solution intravenously during the stage of collapse. Two grams of urea were added to the third and 8 - grams to the fourth injection. The period of reaction set in at the beginning of the fourth day and a fifth injection of two liters of Ringer’s solution was given for its possible effect on the urine. Death occurred on the fifth day with symp- toms of toxemia and uremia. During the first day, after the first injection of 2 grams a total of only 0.68 grams of urea was obtained and after the 8 gram quantity, only 2.6 grams were recovered although of the 4 voidings following the second injection one was involuntary and the specimen was lost. Hence in this case not more than one-third of the urea which we injected was recovered. The data are given in Table III. 58 SELLARDS AND SHAKLEE. TABLE II].—Injection of urea, case No. 11. Interval} Cubic ( between} centi- | Percent} Grams speci- meters | of urea. | of urea. mens. | of urine. Hours kee Seo 270 0.1 0. 07 133 110 0.1 0.11 Saal 40 0.1 0. 04 Injection of 2 grams of urea. 4 60 0.1 0. 06 133 230 0.15 0.35 9 180 [| 0.15 0. 27 Injection of 8 grams of urea. bys 160 0.3 0. 48 8 120 0.1 0.12 16 340 0.6 2.04 Death after six hours, | * Preceded by anuria for twenty-eight hours. In a third case (number 18) 5 grams of urea were added to the third injection of Ringer’s solution. The patient died in uremia, one and one-half days later. -During this period a total of 1.7 grams of urea were recovered. The number of samples lost by involuntary micturition was unavoidably large, only about half of the specimens being obtained. The data are to be found in Table IV. TABLE IV.—Injection of wrea, case No. 18. in| Interval | Cubic between | centi- | Percent] Grams speci- |metersof| of urea. | of urea. mens. urine. Hours. hs aE 2100 0. 25 0. 25 Injection of 5 grams of urea.» 3 60 0.5 0.30 6 50 0.2 0.10 93 100 0.7 0. 70 2a 15 0.11 0. 02 5 80 0. 25 0. 20 2 §5 0.3 0. 25 aoe after nine hours. . Preceded by anuria for nineteen hours. > This injection was made one and one-half hours after the first specimen of urine was obtained. Catheterization showed no urine at the time of injection. In a fourth case, number 15, death occurred thirty-six hours after injection without any definite changes in the excretion of urea. Two specimens of urine were obtained during the stage of collapse, the urea falling from 0.6 per cent in the first to 0.05 per cent in the second. Then after a period of twenty-one hours of anuria, 8 grams of urea were injected. Two specimens of urine were ACID INTOXICATION IN ASIATIC CHOLERA. 59 obtained before death. ‘The first one of 20 cubic centimeters contained 0.6 per cent of urea. This was obtained one and one-half hours after the injection. A second specimen measuring 10 cubic centimeters was obtained fifteen hours later. It contained 0.25 per cent of urea. As regards control patients, fatal cases have been frequently observed in which the variation in the urea content was very slight. A typical record of such a case is given in Table V. A patient dying in uremia has been selected since more or less pronounced symptoms of uremia were present in the four cases injected with urea. j TABLE V.—Control with sodiwm chloride. Interval} Cubic between| centi- | Percent} Grams speci- |metersof} of urea. | of urea. mens. urine. Hours. i seat eeae a75 0.2 0.15 13 100 oll .10 133 90 5 ll) oils 18 80 53 24 14 65 oe 13 10 70 A . 28 Death after twelve hours. 8 Preceded by anuria for forty-four hours. Of the four cases injected with urea, there is one (Table IL) in which a definite result was obtained. After the injection of urea, the percentage of urea increased eighteen-fold; then after a quantity equivalent to about 90 per cent of the amount injected had been excreted, the urea content fell to the same percentage that was found before the injection. This case would indicate that the suppression of urea is not always due to nephritis. The observations on this patient were carried out principally during the stages of collapse and reaction before symptoms of uremia were prominent. ‘The other three cases (numbers 11, 15 and 18) indicate that the behavior of this patient does not represent the usual result follow- ing the injection of urea, partly perhaps because of the difficulty of ob- taining suitable cases for carrying out a complete test, or perhaps the urea in these three cases was used in the neutralization of acids before excre- tion could take place. There is some evidence which indicates that the suppression of urea is not due to an impairment of function in the urea-forming organs. It was found in patients who were excreting only minimal amounts of urine that on the administration of bicarbonates the urea content sometimes rose almost to normal within a comparatively few hours. Thus, in one case, the percentage of urea rose from 0.05 per cent to 1.3 per cent in five hours. The data for this case are given in Table VI. 60 SELLARDS AND SHAKLEE. — TABLE VI.—Injection of sodium bicarbonate. Interval | Cubic between| centi- | Percent} Grams speci- |meters of/ of urea. | of urea. | mens. urine. Hours. eae ees 15 0. 05 0. 0075 63 6 0.05 0. 003 8 2 0.05 0. 001 Injection of 30 grams sodium bicar- bonate. 4 300 0. 05 0.15 23 110 0.5 0.55 il 150 0.8 eZ i 220 1683 2. 86 3 200 1.5 3. 00 4 240 WAY || BGI} | Recovery. This might be interpreted as indicating that until the alkali was injected, nitrogenous material was being utilized for the neutralization of acids. However, there is one step in this explanation which is not clear. If the nitrogen neutralizes acids, one would expect to find ammo- nium salts in the urine on testing with sodium hypobromite, unless the neutralization took place in such a way that the resulting product failed to be excreted in the urine, or perhaps failed to react with the evolution of gas in the presence of the hypobromite. For convenience, the results of the injections of urea and of sodium bicarbonate have been plotted in the accompanying charts. One of the urea cases (number 15) has been omitted as the data were incomplete. In two cases (numbers 11 and 18), the specimens of urine which were necessary for quantitative results could not be obtained; the qualitative changes, although somewhat suggestive, are not conclusive. The chart from Table II (case number 4) is especially interesting. Here the urea content following the injection of urea, rises from 0.1 to 1.8 per cent and then returns rapidly to its original point. The chart corresponding to Table VI gives the effect of the injection of sodium bicarbonate. Here the urea content rises from almost zero to normal and continues a normal course. In the control case, the amount and per cent of urea remain con- stantly low. 61 ACID INTOXICATION IN ASIATIC CHOLERA. S4Y By 924 96 94442 ‘SW/es§ UI) CDINJOIYEIOM DislIN'JO*SID \ (Th219e2 wo) +|“ON DSe ~ - \ EN A (2 - oe eae 9 9) > % SI 1) ° St Cc 5 8 2 ear Serie 002 to *# Ss (ay N 2 9 , LN 2 | 8 62 ime SELLARDS AND SHAKLEE. ‘22/0 JO le I) ascdNo.ll. | + rom tab 0 J c =2) eS le) c fo} = oO ~) 2S c ( [YO swel9 ead -e2un Swes9 O02 Ss ‘eauNn oo DUIINJO "S22 OFZ 002 O09! Ocl Dy ) ACID INTOXICATION IN ASIATIC CHOLERA. 0 i) c >) e ie) Cc CaseNo.l8. tabiely.) Inyectio (From ces.0FfU s7e- rae ‘eaun|swesn O'/ ‘eduN % O'/ 9°O ‘QUIN fO'SID 02/ 24 hrs. l2hrs. VY.) (Fromtable 9 ” We) oe) ie) c ~ Cc 9 Vv SELLARDS AND SHAKLEE. CCS.Of Urine e22un SWEID ¢-O @€0u0 of 4-0 ‘DUIIN JO'SID OD le-o 04 60hArs 48 hrs. 36 hrs. C4 hrs 12 Ars ACID INTOXICATION IN ASIATIC CHOLERA. 65 % rere : ae hg Injection of Sodium. = S / SS o Bicarbonate. Sas ene co © os >) Qo % + N + = 8 <9) ie) ape iat ~%b a age Beh Carbon dioxide content of the blood.—In view of the decreased alka- linity of the blood which has been reported in cholera, it would naturally be of interest to determine its carbon dioxide content. In selecting a method for carbon dioxide determinations of the blood it must be remem- bered that none of the various procedures are free from error. The gravimetric method was used in the following determinations, according to the technique of Kraus. (4) 101001——5 66 SELLARDS AND SHAiLEE. Blood was withdrawn with an ordinary syringe from a superficial vein of the arm below an Hsmarch bandage and defibrinated with glass beads in a closed flask. The pressure throughout tle apparatus was reduced to 16 centimeters. Approximately three to four times the theoretical amuunt of sulphuric acid was added using a 1 per cent solution instead of the more concentrated acid recom- mended by Kraus. After the addition of the acid, the apparatus was washed ' with air under the reduced pressure until the weight of the absorption bulbs was constant. Two absorption bulbs for carbon dioxide were used in order that the proccss might be carried out rapidly. The entire procedure was usually com- pleted within three hours. No determinations were made upon cases in collapse or in the stage of reaction, but only on those in which symptoms of uremia were present. ‘Two patients were available. Case number 15 was tested on the fourth day of the disease, two hours before death. A total of 50 cubic centimeters of urine were excreted during the course of the illness. ‘There were moderate symptoms of uremia, and a typhoidal condition was also present. Case number 18 was tested on the third day of the disease, twenty hours before death. A total of 500 cubic centimeters of urine ‘were excreted during the four days. There was only slight elevation of the blood pressure. The respirations were deep but the rate was not increased. Determinations with this method on normal human blood gave results which closely approximated those obtained by volumetric methods, namely 40 to 50 volumes per cent of carbon dioxide. The specific gravity ‘of normal blood (1.060) was used in calculating the volume of the sample of cholera blood from its weight. It is evident that this de- termination can represent only an approximation. However, the ten- deney of the error would lie in the direction of a high result rather than a low one. There was little opportunity for loss of carbon dioxide, but considerable care was required to prevent water from being carried over into the absorption bulbs. In these two patients there does not seem to be any reasonable doubt but that the carbon dicxide of the blood was definitely reduced below the normal. TABLE VIII.—Curbon dioxide content of the blood. Tuoreesenn welgm in COQs.—absorp- Volume sample, PG MM a) eign eee loxide. | dioxide. I, Il. \ Blank with water: Grams. Grams. Grams. | Grams. spore een, ace eae RRS E leas Seed OS 0009) |Gi= 5-255 a eee Pe rs pete ee aati Le Ps aa el hI nC QHOON Ts cose a ea eee eed Normal individuals | : INS aA Sop ae pea Sibu SS a 15. 10 0. 0144 0. 0003 0. 0147 51 Be cel ee ee aaa 17. 47 0. 0110 0. 0023 0. 0183 40 Cholera patients: | NON ste ee ee 17.125 0. 0062 0. 0023 0. 0085 26 | INO}1G 22s ae wel 27. 66 0. 0065 0. 0018 0. 0083 mee | } ACID INTOXICATION IN ASIATIC CHOLERA. 67 In connection with these carbon dioxide determinations of the blood. it is interesting to note that Wittstock(>5) has reported a decrease in the absorption of oxygen by the lungs and a decreased output of carbon dioxide in cholera. EFFECT OF ALKALINE SOLUTIONS. The results of alkaline therapy in diabetes have been of some value in the study of acid intoxication. Perhaps the simplest interpretation of these results is that, although an excessive amount of acid is usually present, yet it is probably not the sole ztiologic factor in the produc-, tion of coma. ‘The conditions in cholera in some respects are unusually favorable for observing the action of alkalies. For the most part, the patients are obtained after only a few hours of illness and before any symptoms of acid intoxication are present. It has already been found that alkalies in large quantities produce a prompt excretion of urine in the stage of reaction. The most desir- able period at which to commence the injection of alkalies and the most suitable concentrations were not definitely determined and there- fore these questions have been given especial consideration in the fol- lowing group of cases. In the main, two procedures suggest them- selves. An apparently satisfactory plan would consist in the use of salt solution during the stage of collapse, followed by alkali in case the anuria persists during the stage of reaction. This has the disad- vantage of requiring a considerable increase in the amount of fluid injected. For example, a patient receiving 5 to 10 liters of salt solu- tion during the first day of collapse may require perhaps an additional five liters of alkali to start the excretion of urine. There are also certain theoretical objections to delaying the injection of alkali until the toler- ance toward it has become well established. Such a delay would tend to favor the production of ammonium salts in the body. The toxicity of these salts in acid intoxication has been suggested by Mendel(6) and by Carlson and Jacobson.(7) Furthermore, if acids are allowed to accumulate, they may produce a permanent injury to the tissues which can not be remedied by the removal of the acids by neutraliza- tion. This suggestion has been offered in explanation of the merely temporary improvement after the use of alkalies in diabetic coma. A somewhat analogous condition may occur in cholera. It was noted in the uremic stage, that the late administration of alkalies would cause a prompt excretion of urime and apparently prolong life for several days, although death ultimately took place. The free diuresis, fol- lowing the bicarbonate injections when the stage of reaction appears, would afford better opportunities for elimination than could be effected by the intestinal tract alone. 68 SELLARDS AND SHAKLEBE. However, during the stage of collapse when many liters of fluid are being lost by rectum no measures whatever have been effectual in pro- ducing excretion of urine. It is also a fact that the use of alkali during collapse has given no definite indication that it possesses any advantage over a neutral solution. Indeed the higher concentrations of 1 and 2 per cent can only be used for the first injection in carefully selected cases. The following patients were treated with alkali with the object of determining the maximum concentration of sodium bicarbonate which -could be used during collapse as a routine for all cases. Although a previous series showed that a fatal uremia did not develop after large amounts of alkali, yet it is important to know definitely whether there is any increase in the number of deaths from other causes, that is, to know that patients who would have died in uremia were not merely dying in collapse under alkaline treatment before the uremic stage was reached. The possibility also has been suggested that uremia causes only an apparent increase in the mortality, namely, that those cases which die in uremia would terminate fatally from other causes if the course of the disease were not shortened by uremia. The patients available for this investigation were received at the hos- pital in the majority of instances rather early in the course of the disease only about one-half being in complete collapse. Several conditions indi- cate that the epidemic was at least moderately severe. During the period of investigation there were sixty-five deaths among untreated cases re- maining in their homes, although the number of recoveries under such conditions is not available. There were a few individuals who died imme- diately on arrival at the hospital, or at the commencement of the first intravenous injection ; two patients were received in an almost moribund condition and others repeatedly went into collapse, notwithstanding the frequent injection of salt solution. The disease in all instances was diag- nosed bacteriologically by the staff of the Bureau of Science, the cholera vibrio being isolated in pure culture from the feces and identified by ag- glutination reactions. Only uncomplicated cases showing typical clinical symptoms were selected; those presenting serious complications in addi- tion to the cholera infection were not included. Thus, one case, admitted in pregnancy at full term, is omitted from the series, as well as another in which there was extensive tuberculosis. On admission to the hospital, the patients were divided into two groups of which one received the ordi- nary saline treatment and the other a solution containing 0.5 per cent of sodium bicarbonate. In the stage of reaction, the concentration of the bicarbonate was increased to 1.5 per cent in those cases in which suppres- sion of urine persisted. As a routine the solutions were injected intra- venously in 2-liter quantities, during the course of fifteen to thirty ACID INTOXICATION IN ASIATIC CHOLERA. 69 minutes. In the stage of collapse, 4 liters of fluid were occasionally re- quired for the first injection while in the stage of reaction 1 liter of 1.5 per cent sodium bicarbonate was sometimes sufficient. PREPARATION OF RINGER-LOCKE AND OF THE ALKALINE SOLUTION. For the control series an isotonic Ringer-Locke solution was prepared ac- cording to the formula: sodium chloride 0.9 per cent, potassium chloride 0.042 per cent, calcium chloride, crystallized, 0.024 per cent and sodium bicarbonate 0.03 per cent. The sodium bicarbonate was added to determine whether these salts in the proportions in which they normally occur in the blood might not produce an effect similar to that obtained with larger amounts of the bicarbonate alone. A solution of the preceding formula can not be sterilized by heat without con- version of the bicarbonate to the normal carbonate followed by subsequent precipitation of the calcium. Consequently the first three salts were added and the solution heated in the autoclave. The required amount of sodium bicarbonate was added in solid form immediately before the injection of the solution. The formula was modified as follows for the alkaline injections during col- lapse: Sodium chloride 0.4 per cent, potassium chloride 0.042 per cent and sodium bicarbonate 0.5 per cent. The calcium was omitted on account of the insolubility of its carbonate. When the 0.024 per cent of calcium chloride was added in the presence of the 0.5 per cent of bicarbonate, a supersaturated solution oc- casionally would be obtained which would remain clear for a short period, but precipitation usually occurred after 20 to 30 minutes. An attempt was made to prepare the solution of sodium bicarbonate with a minimal conversion to the normal carbonate. The injection of sodium bicarbonate in aqueous solutions entirely free from normal carbonate would appear to be impossible since even at room temperature conversion to the normal carbonate takes place. Thus McCoy(8) found that in tenth molecular aqueous solutions at 25° C., 2.68 per cent of the bicarbonate immediately was converted to the normal carbonate and that equilibrium was not established until only 40 per cent of the bicarbonate remained unchanged. In stronger solutions the decomposition was much more rapid, e. g., in three-tenths molecular solutions, 77 per cent, and in molecular solutions, 86.2 per cent of the bicarbonate was decomposed at once. In view of these changes, the 0.5 per cent of bicarbonate was added in solid form to the sterilized solutions containing the sodium and potassium salts and the injection was made immediately without further heating of the solution. Samples of freshly prepared sodium bicarbonate were selected which were shown to be sterile when tested on ordinary culture media. The 1.5 per cent bicarbonate solutions for injection during the stage of reac- tion were prepared without the addition of any other salt and were heated in the autoclave at 3 kilograms pressure per square centimeter for forty-five minutes, about 25 per cent of the bicarbonate being converted to the normal carbonate, under these conditions. For the preparation of 0.5 per cent bicarbonate solu- tions on a larger scale, it was found that an average decomposition of less than 3 per cent occurred when the solutions were heated in the autoclave in tightly stoppered bottles at a pressure of 3 kilograms per square centimeter for forty-five minutes, allowing the autoclave to cool to room temperature before opening to the atmosphere. The amount of normal carbonate in the solutions after steriliza- tion was determined by titration at 0°C., against a hydrochloric acid in the 70 SELLARDS AND SHAKLEE. presence of phenolphthaleim. The solutions were titrated within four days after sterilization. In two separate lots of solutions, the variations from this mean of 3 per cent were only slight. This amount of change is not greatly in excess of the conversion which takes place in the corresponding unheated solutions. This solution was subsequently tested upon three typical cases in collapse and all recovered. The response from collapse was quite similar to that obtained with ordinary physiological saline solution. These three patients were sporadic cases occurring late in the cholera season, and for this reason they are not included in the group which is reported later. Another factor was introduced in that some of the severest cases also received an anticholera serum. The reports concerning antichol era sera indicate on the whole that there is a certain minimal benefit to be derived from its use.(9, 10, 11) Its effect on the death rate is not sufficiently great to constitute any conclusive evidence of its value. Furthermore, if the use of alkalies affects only those cases which die in uremia (15 per cent), then its influence on the death rate would not be very pronounced. By utilizing both methods of treatment it was thought that the combined effect might be great enough to show itself. Aside from its having antitoxic properties, the serum perhaps might be of some minor value in protecting the corpuscles and the proteins of the blood from the action of the alkali; also it might aid in the retention of the injected fluid within the blood vessels, especially if the exudation of fluid through the vessel walls is dependent upon vital as well as physical phenomena. The serum was prepared in a manner somewhat similar to that followed by Schurupoff.(10) Ten strains of cholera vibrios were tested and no marked dif- ferences were found in the minimal lethal dose of the killed cultures upon intraperitoneal injection into guinea pigs. The cultures were killed by adding sodium hydroxide to a thick emulsion of cholera vibrios in physiological saline solution. , Only freshly isolated strains of cholera were employed for the preparation of the serum, a new strain being obtained every month. The growth from 15 to 20 large agar slants was used for each injection, the slants each measuring about 3 by 8 centimeters. This growth was suspended in 20 to 30 cubic centimeters of salt solution and for the first injection the vibrios were killed by the addition of 2 cubic centimeters of - sodium hydroxide. Upon the addition of the alkali, the suspension changed from a limpid, opaque emulsion to a viscous, translucent solution. The viscosity was so great that dilution with an equal volume of salt solution was usually required in order to effect a thorough mixing. Further addition of the hydroxide diminished the viscosity of the fluid and apparently rendered it less toxic. The amount of sodium hydroxide was gradually decreased, until toward the end of the period of immunization, only one-fourth of original amount was used. This was not sufficient to kill the emulsion of vibrios, but their virulence for guinea pigs was diminished. ACID INTOXICATION IN ASIATIC CHOLERA. al The injections were made intramuscularly at intervals of about two weeks over a period of four and a half months. Determinations were made of the protective power of the serum for guinea pigs against intraperitoneal in- oculation of the vibrio emulsion killed with sodium hydroxide. The serum was tested before the injections were begun and at the end of the period of immuniza- tion, but no definite increase in this protective power could be detected. Three to 5 cubic centimeters of horse serum, either before or after treatment of the animal, when digested for thirty minutes with the minimal lethal dose of the cholera suspension (usually 1 to 2 cubic centimeters for intraperitoneal injec- tion) were sufficient to completely protect guinea pigs of 300 grams. Sera of much higher efficiency have been obtained, notably that of Salimbeni(12) 0.002 cubie centimeter of which neutralized twice the lethal dose of cholera toxin. The behavior of the horse itself showed little evidence of immunity. The sub- cutaneous injections produced a local swelling and some rise in temperature. As the injections were continued there was only a slight diminution in this reaction. Finally, the minimal lethal dose by intravenous injection of the killed cholera material was determined upon normal horses. Three months after the last sub- cutaneous injection and after the horse had been under treatment for nine months, the intravenous injection of the minimal lethal dose, akhout 4 cubic centimeters, produced a fatal result in twelve hours, = The serum was used intravenously in 200 cubic centimeter quantities in 1 to 10 dilution in 0.5 per cent sodium bicarbonate solution. No more than two injections were made in any given case; therefore the maximum amount of the anticholera serum for any patient was 400 cubic centi- meters. Favorable results have been reported with larger amounts, such as 1,040 to 1,390 cubic centimeters.(10) A very limited number of cases were treated with serum. Only those patients were selected in which the general symptoms were severe and the state of collapse was extreme. Six of these cases in the bicarbonate series were of this type. Two died in collapse without any definite response to the injec- tions. The four remaining recovered, but without any pronounced dif- ferences from extreme cases which recover under sodium chloride treatment. However, the recovery of four of these six patients was unexpected and a control series with normal serum seemed advisable, but practically no cases were available. Only one patient was tested. He was admitted in complete collapse, and the toxemia, though well marked, was not extreme. In all 600 cubic centimeters of normal horse serum were injected and a total of 12 liters of fluid. There was only a slight response to the injections. On the third day there were three moderately large hemorrhages from the bowel, and death oc- curred on the fourth day. Autopsy showed extensive edema of the left lung with adhesions of the pleura. Multiple hemorrhagic infiltrations extending to the serous coat were found in the small intestine. These areas measured about 1. centimeter in diameter; they were most numerous just above the ileo caecal valve and grad- ually disappeared in the upper fourth of the intestine. iz SELLARDS AND SHAKLEE. The results, with the two groups of cases, showed that with Ringer’s solution, only a small percentage of cases recovered after more than one day of anuria. In the bicarbonate group, a number recovered after one day of complete suppression of urine. The data are as follows: Duration of anuria. Treatment. iy Less than) 24 to 48 24 hours.| hours. Ringers S22 4e®. febdee 4 el ool od: ia ee een eee 10 3 iBicarbOnates i=) 2. oo AC eee Se hee a ene eas 10 8 In dividing the patients into two similar groups, both the severity of the cholera symptoms and the general physical condition of the pa- tients were considered. As nearly as could be determined there was no difference in either direction in the severity of the two series. The group treated with serum and bicarbonate represents those cases which went into complete collapse and in whom the symptoms of toxemia were more or less prominent. Of the fifteen individuals treated with bicar- bonate alone, five, and of the twenty-two control cases, twelve, were admitted in complete collapse. The following classification has been used for estimating the effect of the bicarbonate solutions on the cause of death. Under collapse and en- teritis are included those cases which die primarily from loss of fluid and also those whieh continue to live until the enteritis with its accompa- nying toxemia is well developed. The uremia of cholera, while differing from that of ordinary nephritis, is nevertheless characteristic. Two cases occurred in which symptoms both of uremia and of the toxemia of the cholera infection were present. Since each of these conditions may have been contributing factors in the cause of death, these are recorded as “in- termediate.” The final results are given in the accompanying outline. | Cause of death. Num- paotal., ae an ‘ Treatment. ber of Inter- f of eases. | Col- | Uree- | medi- | q eons recov- lapse. | mia ate "| eries, ® cases. Bicarbonate and serum #________ a i | eee ese |e see 3 4 Bicarbonateesesass see ae a eee 15 OE | Bee ete | ae 1 14 Total with bicarbonate____ 22 1 Fe ee eee ne 4 18 Control with Ringer’s ---________ 22 5 2 2 9 13 “Including one patient receiving normal serum. ACID INTOXICATION IN ASIATIC CHOLERA. WS) The patient who died under treatment with bicarbonate alone was a child eleven years old admitted in partial collapse. Although in the control series there were only four deaths in which symptoms of uremia were present, yet because of the constancy of ure- mia, its absence is suggestive in the group of cases treated with bicarbon- ate and serum. ‘Theoretically, the serum might prevent the development of uremia if it could abort the infection. There was no evidence to indicate that the serum was responsible for the absence of uremia. In large epidemics where serum has been used extensively, nothing has been reported to show that the incidence of ure- mia is lessened. he number of cases, treated without serum, namely fifteen, represent those which were less severe; but since even the mild cases are not always free from uremia, this group would suggest that it was not the serum which prevented the development of this complication. One patient (number 10), in the bicarbonate series, developed symptoms of uremia. This case was admitted in complete collapse and responded poorly both to the injections of iluid and also to the serum, 200 cubic centimeters of which were used. During the first eighteen hours, 6 liters of 0.5 per cent bicarbonate were injected. At the end of the first day, during which time only 15 cubic centimeters of urine were obtained, the concentration of the sodium bicarbonate was increased, | liter of a 1.5 per cent solution being injected. Eight hours later, 140 cubic centimeters of urine were obtained by catheter, but this rate of excre- tion soon diminished and after nine hours an additional 15 grams of bicarbonate in | liter of water were given intravenously. After a twelve-hour interval only 70 cubic centimeters of urine were secured. The patient was not clear mentally, the restlessness was increasing, and the general condition was not good. A sixth injection of bicarbonate was given consisting of 2 liters of a 1.5 per cent solution. As soon as the injection was well started, the patient complained severely of pain throughout the body and of cramps in the muscles. After the administra- tion of one liter, there was considerable contraction and twitching of the muscles, which was especially noticeable in the extremities. The rigidity of the muscles did not entirely pass away until after eight hours. This is the only case in the series which developed muscular twitchings. A specimen of blood taken at that time showed a trace of hemolysis, although none was observed after the use of 1.5 per cent sodium bicarbonate in a number of other cases. At this time, eight hours after the injection, no urine had been obtained and the symptoms of uremia persisted. In view of the pronounced reaction which had followed the last injection it did not seem advisable to continue the injections of alkali. This case had received a total of 90 grams of sodium bicarbonate in two days. The patient had certainly passed the stage of collapse and as the anuria had not yielded to the injections of alkali, it apparently constituted a definite exception to the other cases. However, after-an additional four hours 120 cubic centimeters of urine were obtained by catheter, and in the next twenty-four hours 1,200 cubic centimeters. The mental condition rapidly returned to normal after the excretion of urine commenced. 14 SELLARDS AND SHAKLEE. This group of patients showed definitely that the alkaline solutions were effective in starting the excretion of urine in the stage of reaction, whereas Ringer’s solution had practically no permanent effect in severe cases. The exact relation of acid intoxication and uremia to each other is rather difficult to determine; there is a little evidence which suggests that an excess of acid leads to renal disturbance. Experimentally it has been found that mineral acids such as hydrochloric, give rise to nephritis and the acid intoxication accompanying a long-standing diabetes is associated with renal lesions. Lastly, there are certain evidences of an acid intoxi- cation during the course of an ordinary uremia. If it could be shown that the suppression of urine during the stage of reaction in cholera is due to an excess of acid, then the diuretic action of the alkali could be con- sidered as specific and it would seem difficult to replace it by any of the ordinary diuretics. Early in the stage of collapse, when the anuria is due to loss of fluid by rectum, there is no evidence to show that in severe cases either the bicarbonate or the chloride solutions have any definite effect on the kidney. Apparently, no detailed examination has been made in regard to the action of diuretics in the stage of collapse, although free elimination by the kidneys in this stage might be of value. The use of 0.5 per cent solutions of sodium bicarbonate during the stage of collapse was satisfactory in this group of patients for the majority of the cases. In two severe ones the response to the solution was very poor. It seemed a little better to discontinue the 0.5 per cent bicarbonate solu- tion and change to Ringer’s solution in those patients where a suitable response was not obtained. However, such cases apparently belonged to that group which fail to respond to any solution or any method of treat- ment. There was no evidence of any harmful effect in the use of bicar- bonate in this series nor of any increase in the death rate from collapse or other causes. The early use of even relatively small amounts of bicar- bonate appeared to lower the total amount which was needed to obtain secretion of urine. The rather large quantities of 50, 80 and even 90 grams, which are occasionally necessary were thereby avoided in a con- siderable proportion of cases. Excessively long periods of anuria did not occur. ‘Thus, in Table I it will be seen that no patient who recovered showed complete suppression of urine for as long as forty-eight hours. The cases treated with bicarbonate often appeared to improve rapidly and to recover more promptly than corresponding patients treated with Ringer’s solution. However, this behavior was not constant. In one in- stance two patients were admitted in complete collapse and apparently were in almost duplicate conditions. The one receiving Ringer’s solution recovered promptly, while the other responded very poorly to injections ACID INTOXICATION IN ASIATIC CHOLERA. 15) of normal serum and 0.5 per cent bicarbonate, and died on the fourth day. The death rate was low for the twenty-two cases treated with bicarbon- ate and serum; under less favorable circumstances, with cases received in the late stages of the disease, it would certainly be higher. CONCLUSIONS. The stage of reaction and uremia in cholera and the acid intoxi- cation of diabetes have the following features in common: 1. There is a well-marked tolerance for alkalies; as much as 90 grams in cholera and even 200 grams of sodium bicarbonate in diabetes may fail to render the urine alkaline. In certain stages of both diseases, sodium bicarbonate possesses pronounced diuretic properties. (13) 2. The relative and absolute amounts of ammonia in the urine are considerably increased in both diseases. The administration of alkalies, even in large amounts, sometimes fails to reduce the excretion of am- monia. In cholera, the urine frequently shows a pronounced diminution in the amount and percentage of urea; some evidence was obtained which suggests that the nitrogen may fail to be excreted as urea or ammonia, even when the organs which form urea are capable of performing their function and the kidney is able to excrete urea. 3. Preliminary tests indicate that there may be a definite reduction in the carbon dioxide content of the blood in the uremia of cholera as well as in diabetic coma. 4. In both diseases, a diminished alkalinity of the blood has been reported. 5. The injection of alkalies in the late stages of either disease usually modifies the course without affecting the ultimate termination. The early administration of alkalies in cholera has been effective in pre- venting death from uremia without any apparent increase in the num- ber of deaths from other causes. The exact significance of these analogies can be determined only by a thorough investigation. Acetone and acetoacetic acid have been noted in the urine of cholera cases but no excess of acid has been found which corresponds to the quantities of B-oxybutyric occurring in dia- betes. Two forms of acid intoxication are distinguished by Naunyn, namely, a relative and absolute type. Loss of alkali from the body ‘apparently may result from a pronounced diarrheea, this loss giving rise to a relative acidosis. It also is conceivable that there may be an ex- _ cessive quantity of acid present, resulting in the production of an absolute acid intoxication in cholera. 16 SELLARDS AND SHAKLEE. REFERENCES. Horpe-SEYLeR. Berl. klin. Wehnsehr. (1892), 29, 1069. VY. TerrAy, VAS & Gara. Ibid. (1893), 30, 276, 309, 360. . HALLERVORDEN. Arch. f. exp. Path. wu. Pharm. (1880), 12, 237. . Kraus. Ztsehr. f. Heilk. (1890), 10, 106. , . Wirtstock. Amn. d. Phys. u. Chem. (Poggendorff) (1832), 24, 509. . Menver. Trans. Assoc. Am. Phys. (1907), 22, 265. . CARLSON AND JAcopson. Proc. Soc. Hap. Biol. & Med. (1910), 7, 50. . McCoy. Am. Chem. Journ. (1903), 29, 437. 9. Hesse. Berl. klin. Wehnschr. (1909), 46, 1611. 10. Kotte. Deutsche med. Wehnschr. (1909), 35, 2046. ll. Krause. Wien. klin. Wehnschr. (1909), 22, 43 & 1397. 12. SanimpBent. Ann. Inst. Pastew (1908), 22, 172. 13. Maenus Levy. Arch. f. ep. Path. u. Pharm. (1901), 45, 389. DAP ne wwe A STATISTICAL STUDY OF INTESTINAL PARASITES IN TOBACCO HACIENDAS OF THE CAGAYAN VALLEY, PHILIPPINE ISLANDS.* By Davin G. WILLETS. (From the Biological Laboratory, Bureau of Science, Manila, P. I.) TaBLe I—Summary of findings. Examinations and infections. | Number. | Per cent. IPETSONS,EX-aNM CC he es Bat ye ie ee a oh ee ee 4278) |e iPersonspinifec ted aaa aeek eae ere ad ss 3 eee ee 3, 656 85. 46 Persons infected with— ———— | ——_—————— SASCOLISS =e Sane ee eee m ise a Aerie ae PES LY 2, 653 62. 04 IE GOK O RUN ees = ees aie een eee Si ery A Soles 2, 326 54. 37 SUT CHUUT TS ene ee ee Se eee eee eee ae 342 7.99 ORY UT ISS eS ae eae eee Se eA eon ee eis sSaSiscae 64 1.50 RECN eae aa en ae Oe me ements Ae ES 59 1.38 FELUNTER OLED TS = etme ee nt ey gma Bee 8 IE 5 0.12 ISURONGYLOULES == = os SS ee ne 4 0. 09 MPTEM ALO C89 = 22= se E Se ee ee ee ee eet 1} 0. 02 [ Mo taleintectlons|= = = ss 6 ew ere ene se Ss Sta 5,454 | 127.49 8 Probably Fascioletta ilocana Garrison, 1908. Upon the completion of the medical survey of the town of Taytay,* Rizal Province, in 1909, which was an effort to determine the health conditions in a representative Filipino community and which included the examination of the feces of 1,000 persons, the Bureau of Health inaugurated a campaign to determine the frequency and medical im- portance of intestinal parasitism in other parts of the Island of Luzon with particular reference to the incidence and significance of hookworm infections. During the survey, 6,018 persons were examined at Las Pinas, Rizal Province; 2,594 at Tuguegarao, Cagayan Province; 802 at Santa Isabel, 3,310 at San Antonio, and 968 at Maluno, barrios of Ilagan, Isabela Province. ‘The results obtained at the first three places have already been reported.? The present paper contains the findings at the last two places named. * Read at a meeting of the Manila Medical Society, January 9, 1911. 1This Journal, Sec. B (1909), 4, 207. ? Rissler and Gomez, This Journal, Sec. B (1910), 5, 267. 17 78 WILLETS. San Antonio and Maluno are tobacco haciendas. At the former place, 74.25 per cent of the population was examined; at the latter, 93.44 per cent. There- fore, the percentages of the various parasites found may be accepted as repre- senting those present in the general population of the two haciendas. In order that the work of the haciendas might not be too greatly interrupted at a time when there was a great deal to do in the fields, it was necessary to allow the people to save the specimens overnight; hence, the great majority of these were unfavorable for examination for the presence of amcebex and flagel- lates, and no systematic search was made for the latter two classes of organisms. However, very few infections with these parasites were seen, so that it is believed they are infrequent at these two haciendas. The findings of Rissler and Gomez* in the Cagayan Valley are in accord with this impression and only. one ease of marked dysentery was seen; this probably was not amebie since it responded to bismuth. Nearly all of the persons examined were Ilocanos who migrated into the Cagayan Valley. There are included in the list the Spanish officials of the haciendas, 83 Ibanags composing cabeceria number 9, and 58 Visayans composing cabeceria number 33, of San Antonio. The find- ings among the Ibanags did not differ essentially from those among the Ilocanos, whereas the Visayans showed a high percentage of infection with the hookworm (77.59 per cent) and the whipworm (63.79 per cent). Hach hacienda is divided into districts which are subdivided into cabecerias. here are thirty-three such cabecerias at San Antonio and twelve at Maluno. Most of the houses are located on hills which are rocky, but which usually have a few trees. It appears that the selection of such sites for homes accomplishes a double purpose: It gives the tenants the advantage of available shade and places them above the water mark when the lowlands are flooded at various times during the rainy season. However, some of the houses are located in the low- lands. The variation in the location of the houses in the different cabe- cerias plays a role in the occurrence of the hookworm. Several factors are acting upon the persons examined, excepting the officials, to lower their general vitality and render complex the problem of determining the effect upon them of intestinal parasitism. Marriage occurs early ; child bearing is rapid ; smoking is commenced at a tender age and is indulged in excessively throughout life; drinking of native whisky is commenced early ; the diet is poor and consists of rice and maize, largely maize, with very little meat; and tuberculosis is common. Fortunately, malaria is rare. The results obtained are based upon the examination of two thin cover- — slip preparations of each specimen; it is understood that the findings of 3 Loe, cit. STUDY OF INTESTINAL PARASITES. 19 Rissler and Gomez were from the examination of one cover-slip prepara- tion of each case. However, my results may be compared with theirs according to the testimony of a Filipino boy who made many of the prep- arations at Las Pinas, a large number of the microscopic examinations at Tuguegarao and Santa Isabel, and practically all of my own prepara- tions, since no more fecal material was used in two of my prepara- tions than in one of Rissler and Gomez. RESULTS COMPARED WITH OTHER STATISTICAL STUDIES IN THE PHILIPPINES. The results obtained are compared in Tables II and III, respectively, with those in other parts of the Philippines as to the number of infections found and the various parasites present. TABLE II.—Percentages of persons infected and total infections in various parts of Luzon. aie Total Ee Place. gem, ER oem ere mec: | Pee Garrison,* 1908 _-| Manila ..____--______ Mostly males_} 4,106 | 23,447 | 84.00} 5,812 | 142.00 Garrison and |____- (6 (Cee eae e ee eee Women and 385 b 342 | 89.00 533 | 138.70 Llamas,*® 1909. children. Garrison, Ley- | Taytay, Rizal —--__-- Males and} 1,000 9959 | 95.90 | 1,726 | 172.60 nes and Lla- females. mas,® 1909. Rissler and Go- | Las Pifias, Rizal ____|_____ OO) eee 6,018 | 25,406 | 89.83 | 8,996 | 149. 48 mez, 1910. Noss Tuguegarao, Caga- |_____ domes. 2,594 | 21,932 | 74.13 | 2,887 | 111.30 yan. Dom sees. Santa Isabel, Ila- |_____ doses 802 2692 | 86. 28 927 | 114. 34 gan, Isabela. Chamberlain, | Baguio, Benguet____| Adult males __ 119 5110 | 92.50 209 | 174.00 Bloombergh f and Kil- bourne,’ 1911. Willets, 1911 _____ San Antonio and} Malesand] 4,278 | >3,656 | 85.46 | 5,454 | 127.49 Maluno, Tagan, females. Tsabela. ERG teal] eee | cp re ee te ee 19,302 | 16,535 | 85,66 | 26,544 |. 137.52 ee 8 Protozoan findings included. b Intestinal worms only. *This Journal, Sec. B (1908), 3, 191. 5 Tbid. (1909), 4, 207. ° Ibid. (1909), 4, 185. Sah (MUO). Oe bs) WILLETS. 80 | 8L'0 | SE 69°0 S&T. GPT | 082 8h°% | 8LP AS OS TOS AAO |) VA Ie 1 GBS) | SAI || CASSIE |] Se a a 1870.L | “BlOqBs] ‘UBZEI] ‘Ou aL‘0 | ¢ 86 'T 6¢ 60°0 | F OS*T | #9 48°bS | 978°S | 66°L (Gita ¥0°s9 | gc9'z 882 ‘F “NBN PUBOIMOJUW UBS | TI6L | SJOTIIM “dUINOG [IY pus Yysleqmoolg 00°0 |0 00°@r | ST 00°0 | 0 00°0 | 0 00°6@ | Gs 00°09 | a4 00°EL | 48 Go| Sencar jonsueg ‘omseg | TI6l | ‘UlB[ioqmBy yO “B[aq Bs] PL'0 | 9 LE ‘1 II 00°0 | 0 ZL | OL 8§ Ch | 9S &Z'9 0¢ 66°09 | 98P 208 ‘UBsBIT ‘ToqBs] BJUBS | OI6L | -~ 77> od $40 | 61 ogo =| SI 00°70 10 29°% =| 89 108 | 80 06°e% | ZL9 eg"sh | L06‘T F6E'°Z | UBARSUD ‘OvIvsONSNL | OIGE | ~~~ od *90UL *Z9UL05) 000 | 0 90°0 2 F2'G | GET C6'F | 862 PL IL | 119 OF SS | 1hZ'S | Ta"ZL | L9‘P 810 ‘9 AOI [BZ ‘SBUId SVT | OIGE | PUB JEI[SSTYy | ‘SBUIBIT pus 00'0 | 0 000 0 0L0 |Z 400 | f 09°IL | 9IT 00°42 | OLL 06°28 | 628 000T j-d0uTAOIg [Vzry ‘ABIABL | GO6I | SoUAOT‘UOSTIIBH *‘SBULB[T 000 | 0 08 0 I 09°0 | % 09°0 |Z cyst =| 9F 09°28 | 008 GZ'SS | Z8T css ~ 079 ‘s[eytdsoy ‘sprue | 6061 | Pus UOSTIIBH oro |¢ 01°0 0§ 00°S | Z&T 080 | 00°%¢ | SeL‘z | 00°6¢ | 9ch‘% | 00°92 | zG0‘T 901‘ |" WOSIId PIAI[Ig “BlLUBW | 806L | ~~~“ UosTAIIBH yue0 | “teq | ued | “10q | yu90 | ‘10q | 4ued } “10q | 4ued “18q “‘quo0 *I9q, ‘quad |.5, un Jog |-UNN| Jed |-WNN} Joqd |-mnN| Jog |-mny| Jeg | -uny Joq | -WnN od QUITS “pout : | -WBxX9 ‘208d ‘ay Vq *AUTIOYIN | TOquUINnN “sidajouawhAy DUBL ‘sapiojpibuo.ys | *sUinhxoO *M10M OOH *SUUNYOULT, “SU.UDIS - | ‘woenT fo spud yuosol{vp wi pazsodas sapspapd snor.wma ay, Jo uosi.mdwopg—T]{T aTav, STUDY OF INTESTINAL PARASITES. fol In some of the studies the number of persons infected with intestinal worms alone is not stated as indicated in the table. It is probable that the findings at San Antonio and Maluno do not differ essentially from those in other parts of Luzon, excepting Tuguegarao, where approxi- mately 10 per cent less of the population were infected than elsewhere. It is noteworthy that the number of infections with intestinal worms per 100 persons examined was decidedly lower in the Cagayan Valley than in other parts of the island; this probably is due to the relatively low per- centages of whipworm infections encountered in that locality. The striking features of the findings at San Antonio and Maluno are the high percentage of persons infected with the hookworm and the low percentage with the whipworm (T’richuris). “Rissler and Gomez found 45.38 per cent of the 802 individuals and 60.58 per cent of the adult males examined at Santa Isabel (which is also a tobacco hacienda) infected with the hookworm whereas 54.37 per cent of the 4,278 persons and 74.89 per cent of the adult males composing the present series harbored the parasite. That is, 8.99 per cent more of the general population and 14.31 per cent more of the adult male population was infected with the hook- worm than heretofore reported for any section of the Philippine Islands. _ Garrison’s series of 4,106 cases examined at Bilibid prison and which gave 52.00 per cent of hookworm infection, was composed almost entire- ly of adult males. In my opinion, three factors are acting to produce a high percentage of hookworm infection at the haciendas, namely, the nature of the soil, the tobacco plants, and the occupation of the people. The soil is composed of clay with which sand is generously admixed, the tobacco plants furnish shade-conditions which are favorable for the propagation of the hook- worm, and the cultivation of the tobacco keeps the people in the field daily during the greater part of the year. The belief that the infections are obtained in the fields is supported by the facts that the hookworm percent- age increases rapidly when the age is reached at which work in the fields is begun,® that males, who are in the fields more than females, give a higher percentage of infection than the females, and that a greater percentage of persons are infected in the lowlands than in the uplands. The findings in regard to the whipworm were quite as unexpected as those for the hookworm. Prior to the work in the Cagayan Valley, statistical studies had shown T'richuris to be very common in the Phil- ippine Islands, Garrison and Llamas finding as high as 87.60 per cent of 385 women and children of Manila infected with it. Rissler and Gomez found 25.90 per cent of the persons examined at Tuguegarao and 6.23 per cent of those examined at Santa Isabel to be infected with the same parasite. (See Table I1I.) At Maluno only 4.75 per cent ‘That is, about 7 years. 101001——6 82 1 Wii LES: and at San Antonio 8.94 per cent of those examined harbored the whipworm. At the latter place the percentage was raised because of the presence of some Visayans who had been in the valley about one year and many of whom were infected with the parasite in question and because the inhabitants of certain cabecerias made frequent visits in Ilagan Central. The low percentage of whipworm infection probably is due to a lack of introduction of this parasite in great numbers in the haciendas. Trichuris and Ascaris have thick-shelled ova and high percentages of these parasites are not infrequently found in a given community. The conditions favorable for the propagation of the one are, in a general way, favorable for the other. Now, the round worm is the parasite which occurs most frequently at the two haciendas. That the lack of intro- duction in sufficiently great numbers accounts for the relative infre- quency of the whipworm is supported further by the fact that the neigh- bors of the Visayans to whom reference has been made and persons living near Ilagan Central show a higher percentage of infection with this parasite than do those who live at a distance. Trematode ova in the stool of a boy 13 years of age appeared to be those of Fascioletta ilocana Garrison. Other than this, no unusual in- fection was seen. 4 COMPARISON OF FINDINGS AT SAN ANTONIO AND MALUNO. Practically all of the people at the haciendas are of the same origin, and since they are all engaged in the same sort of labor in the same kind of soil it was to be expected that there would be but slight variations in the findings at the two places. This proved to be true. Table IV shows the percentage of persons at the two haciendas who harbored single, double, triple, and quadruple infections and also the number per 100 persons examined. The great majority of the single infections was with the hookworm, or Ascaris; of the double, hookworm and Ascaris; and of the triple, hookworm, Ascaris and Trichwris. Taste 1V.—Percentage of persons harboring intestinal parasites at San Antonio and Maluno. Infections. an No Infected. anager ecto ex- | Single. Double. Triple. ile Place. am- Die: . ined. — Num-|} Per |Num-| Per |Num-| Per |Num-| Per |Num-| Per|Num-) Per ber. | cent.| ber. | cent.| ber. | cent.) ber. |cent.} ber. |cent.| ber. | cent. San Antonio___|3,310 |2,819 |85.16 |1,529 |46.19 |1, 183 34.23 | 151 |4.56 Maluno ____-__- 968 | 887 |86.47 | 509 {52.58 | 311 |32.13 17 |1. 76 0.18 |4, 272 | 129,06 (0.00 [1,182 | 122.111 oom | — I | |= "| | Totalesso. 4,278 |3,656 |85.46 |2,038 |47.64 |1, 444 |33.75 | 168 |3.93| 6 |0.14 |5,454 | 127.49 STUDY OF INTESTINAL PARASITES. 83 Table V shows the relative frequency of the various parasites found at the two haciendas. he variations practically are negligible, excepting in the case of Trichuris which was found nearly twice as frequently at San Antonio as at Maluno; this is accounted for by the presence at the former place of the Visayans and the proximity of certain cabecerias to Ilagan Central. No infections with Hymenolepis or Strongyloides were found at Maluno. TaBLE V.—Relative frequency of the various parasites found at San Antonio and Maluno. is Infected. Ascaris. Hookworm. Trichuris. Nae Place. ch t Sadi Num- | Per | Num-| Per | Num-| Per |Num-| Per . ber. cent. ber. cent. ber. cent. | ber. | cent. San Antonio_-___--. ---.-- 3,310 | 2,819} 85.17 | 2,082) 62.90] 1,788 | 54.02] 296] 8.94 Maluno sse0s 22s = 968 837 | 86.49 571 | 58.99 588 | 55. 58 46} 4.75 Oxyuris. Txnia. |Hymenolepis. pirongy: Total infections. Place. = Num-| Per |Num-| Per |Num-| Per |Num-| Per | Num- Pencent ber. | cent. | ber. | cent. | ber. | cent. | ber. | cent. | ber. ; San Antonio--—.---..--_- 51 | 1,54 45 | 1.36 5] 0.15 4] 0.12 | 94,272 | 129.06 Iisa Osos ss Sei ee 183) ) ageys 14} 1.45 0} 0.00 0} 0.00) 1,182) 122.11 | 4 One trematode infection included. Because the findings at the two places differ so slightly, they will be considered together in the following pages, excepting under the subject of geographic distribution, when conditions at San Antonio alone will be dealt with. SEVERITY OF INFECTIONS. The severity of the infections is measured by an impression of the number of ova seen in the specimens. Many of those with Ascaris, es- pecially the ones occurring in children, were heavy, and those with Trichuris, Oxyuris, Hymenolepis and Strongyloides were light except- ing a few cases of Trichuris. In one case the ova of the hookworm were very numerous, in a few instances not exceeding 15 ova per cover slip preparation were seen, while in the vast majority of cases, from 1 to 3 ova were present. It is surprising to find practically only mild infections with the hook- worm in a district where the parasite is found in over 50 per cent of the population. It has occurred to me that the flooding of the lowlands during the rainy seasons may be considered in this connection. Exper- iments have shown that fresh eggs of the hookworm die if they are placed in water, or if the culture medium (sand, or animal charcoal) is kept 84 WILLETS. too moist. The same results are secured with the rhabditiform embryo of the parasite. On the other hand, the filariform embryo will live for a considerable time in water. Now the lowlands of the haciendas are flooded nearly every year. Sometimes they are flooded three or four times in one year and they remain so for three or four days at a time. It is possible that during the floods many of the eggs and embryos are killed, and that many others are washed away. If this were true it would tend to lessen the percentage of persons infected, and the severity of the infections with this parasite. It is also probable that the heavy rains themselves tend to clean the infested soil yearly. These suggestions are offered only as possibilities, not facts. In my opinion, not less than 95 per cent of the hookworm infections seen were distinctly mild in degree. If this is correct, it seems necessary to believe that some factor or factors are at work to cleanse the infested soil from time to time. SEX. The infections with Hymenolepis and Strongyloides are too few to admit of comparison. Males were found to harbor the hookworm and Tenia more frequently than females, whereas more females than males were infected with Ascaris, Trichuris and Oxyuris, as shown in Table VI. TasBLe VI.—Sex distribution of infections. ; Infected. Ascaris. Hookworm. Trichuris. Num- Sex eae ned Num- Per Num- Per Num- Per |Num-} Per ber. cent. ber. cent. ber. cent. | ber. | cent. Males S25 ac Garis ve Ps ters 2,290} 1,999] 87.29] 1,349) 58.91 | 1,432 62.53 | 179| 7.82 Memailes\= 2222s eae 1,988 | 1,657 | 83.35 |) 1,304 | 65,59 894 | 44.97 | 163] 8.20 Oxyuris. Tenia. Hymenolepis. BE OU OY Total infections. Sex Num-} Per |Num-| Per |Num-} Per |Num-|} Per | Num- Per ber. | cent. | ber. | cent. | ber. | cent. | ber. | cent. | ‘ber. cent. Mialesi2. 2 eon ne enya, 23 | 1.00 35 | 1.58 @ |) O18} 3 | 0.13] 3,024) 182.05 Hemailes set eee eeres 41 | 2.06 24] 1.21 2! 0.10 1| 0.05] 2,429) 122.18 It will be noted that in the total infections present there were 132.05 per 100 males as against 122.18 per 100 females. AGE. The distribution of the parasites according to age is given in Tables VII, VIII, and IX. Ascaris was found to be more frequent in children than in adults, the highest percentage of infection (85.19) being in girls between 3 and 4 years old. Commencing with the group 7 to 9 STUDY OF INTESTINAL PARASITES. 85 years of age, there was a decided fall in the frequency of this parasite as age advanced, excepting a slight rise in females over 50 years old. Trichuris showed but shght variations as to sex and age. It was found more frequently in persons over, than in those under 15 years old. Infections with Tenia were met with more frequently in males over 50 years old, all of those with Hymenolepis occurred in persons under 16 years of age and Oxywris was found oftener in individuals under 15. The hookworm occurred more frequently in males than females in corre- sponding age groups, excepting the small group of infants less than one year old. Taste VII—Age distribution of infections. Nea Infected. Ascaris. Hookworm. Trichuris. Age (years). Pe ined, | Num- Per Num- Per | Num- Per |Num-| Per ber. cent. ber. cent. ber. cent. | ber. | cent. 20 3 | 15.00 3 | 15.00 1 5. 00 C0) a 74 87 | 50.00 36 | 48.65 7 9. 46 (0) eres 184 138 | 75.00 132 | 71.74 25 | 13.59 6 | 3.26 162 146 | 90.12 135 | 83.33 31 | 19.14 3.70 153 126 | 82.35 116'| 75.82 38 | 24,84 6; 3.92 172 , 155 90.12 141 81. 98 47 27.33 11 6.40 161 141 | 87.58 | 126 | 78.26 58 | 36.02 14] 8.70 375 337 | 89.87 270 | 72.00 202 | 53.87 33 | 8.80 495 443 | 89.49 346 | 69.90 308 | 62.22 38 | 7.68 1, 100 980 | 89.09 671 | 61.00 741 | 67.36 | 104] 9.45 955 789 | 82.62 472 | 49.42 591 | 61.89 78| 7.96 427 361 | 84.54 205 | 48.01 277 | 64.87 48 | 11.24 1,796 | 1,526) 84.97 | 1,305) 72.66 717 | 39.92} 114] 6.35 2,482 | 2,130] 85.82} 1,348 | 54.32] 1,609} 64.83 | 228) 9.19 = 7 Oxyuris. Tenia. Hymenolepis. She Total infections. Age (years). Num-|} Per |Num-| Per |Num-| Per |Num-| Per | Num- Per ber. | cent. | ber. | cent. | ber. | cent. | ber. | cent. | ber. cent. ON See On () ee (1) ieee 4 20.00 Wi} EBs (0) ae (0) eet On| ereene 44 59. 46 3) 1.163 (0) See CO) ee 1| 0.54 167 90. 76 1} 0.62 Opies oes Oi seekeee 0 174 | 107.41 4! 2.61 1! 0.65 1! 0.65 0 165! 107.84 6] 3.49 (5 eae Ol Sa Os (Eee 205 113.37 4] 2.48 1} 0.62 Oz ee tess Oy ees 203 | 126.09 aeals si Oe aes 2) 0.53 it ©, 27/ 515 | 137233 6 Uezal 2 0. 40 OR eet) OO} pees 700 141. 41 13} 1.18 18 | 1.64 2] 0.18 1] 0.09] 1,550} 140.91 13 1.36 P22) |) Del Op eee al 0.10 1,176 123.14 6} 1.41 14] 3.28 (0) eee (0) eee mee 550 | 128.81 32 Sai bern rd 0. 22 3 0.17 2 0.11 2, 177 121. 21 32 1.29 55 Daas 2 0.08 2 0.08 3, 276 132.40 86 WILLETS. Taste VIII.—Age distribution of infections (males). Infected. Ascaris. Hookworm. Trichuris. ae SSeS) eae Num-| Per | Num-| Per | Num-/| Per |Num-| Per ber. cent. ber. cent. ber. cent. | ber. | cent. 9 P| PRY Pp PN. OPA) DS ep leleettt: Op Re eke 48 21 | 43.75 20 | 41.67 4 8.33 (Tg eee 97 76 | 78.35 72 | 74.23 15 | 15.46 4] 4.12 81 71) 87.65 66 | 81.48 18; 22,22 2) 2.47 84 71 | 84.52 66 | 78.57 25 | 29.76 2) 2.38 86 81 | 94.19 73 | 84.88 27 | 31.40 7 | 8.14 86 70 | 87,21 65 | 75.58 33 | 38.37 5} 5.81 201 180 | 89.55 139 | 69.15 122 | 60.70 17 | 8.46 248 231 | 93.15 164 | 66.15 176 | 70.97 26 | 10.48 586 585 | 91.30 341 | 58.19 459 | 78.33 54 | 9,21 SIStOIS0 = Sasa ae a oes 515 446 | 86.60 239 | 46.41 374 72. 62 89 | 7.57 Over!50 zeae ete ee 249 210 | 84.34 102 | 40.96 178 | 71.49 23] 9.24 Wnderil bees nace 940 808 | 85.95 667 | 70.96 421 | 44.79 63 | 6.70 ban GOVE Re see eee 1,350 | 1,191 | 88,22 682 | 50.52] 1,011] 74.89) 116] 8.59 Oxyuris. Tenia. Hymenolepis. SH OngE Total infections. Age (years). Num-} Per |Num-|} Per |Num-| Per |Num-| Per | Num- Per ber. | cent. | ber. | cent. ; ber. | cent. | ber. | cent.| ber. cent. Ou Pees O/esa2eee 0) |e ee (Ve eereas 3 33. 33 Oj pees Oy ee {Ui Oise es 24 50. 00 3} 3.09 (Oni (1)t) See | 2Eeoe= 94 96.91. Oppesesees On/beaaeee Oj ee Ozer 86 | 106.17 3 | 3.57 Oi Seana Oy ee Aes 0 96} 114.29 1} 1.16 (gs SES Or eee 0 108 | 128.58 || P88 1} 1.16 Lh ee 0 106 | 123.26 2] 1.00 ON eee 1} 0.50 1 282 | 140.30 LOMON Aso heae ee 2) 0.81 2] 0.81 0) ees 0) eee 370 | 149.19 TS tO SO RSA Bees 8 Soe 3] 0.51 12} 2.05 2) 0.34 1} 0.17 872 | 148.81 B1:to/b0:2So see ae Bee, 5 | 0.97 WE] OL Os | eee 1} 0.19 672 | 130.49 OV eri50' eke eee 2{ 0.80 6| 2.41 (i)h) Beene Ou Saeko 311 | 124.90 UndersSae=aesaaee ee 13 | 1.38 3] 0.32 1/ 01 1} 0.11 | 1,169} 124.36 Ub} Cyavel OEP ee a 10 | 0.74 nyy || PRY 2) 0.15 0.15 | 1,855 | 187.41 STUDY OF INTESTINAL PARASITES. 87 Taste [X.—4Age distribution of infections (females). Infected. ° Ascaris. Hookworm. Trichuris. Ser pee ve: Sea Num Per Num- Per Num- Per Num-| Per ined. ber. cent. ber. cent. ber. cent. | ber. | cent. 11 1 9.09 1 9.09 Oye aw (0) See 26 16 | 61.54 16 | 61.54 3} 11.54 Ole eee 387 62 71.26 60 68. 97 10 11.49 2 2.30 81 75 92.59 69 85.19 13 16. 05 4 4.94 69} 55) 79.71 50 | 72.46 13 | 18.84 4} 5.80 Ges tse 86 74 | 86.05 68 | 79.07 20 | 23.26 4| 4.65 Gliese Men eel ee AD, 66 | 88.00 61 | 81.33 25 | 33.33 9 | 12.00 TNO Ose SP eee eee 174 157 | 90.23 131 | 75.29 80 | 45.98 16} 9.20 NONO 4 eeammas ee See So 247 212 | 85.83 182 | 73.68 132 | 53.44 12] 4.86 pS TOYO Mees ee aL 514 445 86. 58 330 | 64,19 282 54. 85. 50 9.73 BIC} een ee ewe ees: 440 343 | 77.95 233 | 52.95 217 | 49.32 37 | 8.41 ‘Overo0)==-ee 178 151 | 84.83 103 | 57.87 99 | 55.62 25 | 14. 04 Under 15 856 718 | 83.88 688 | 74.53 296 | 34.58 51 | 5.96 15 and over __-__-----_--- 1, 132 939 | 82.07 666 | 58.83 598 | 52.83} 112} 9.89 Oxyuris. Tenia. Hymenolepis. SI Total infections. Age (years). Num-| Per |Num-} Per |Num-| Per |Num-} Per | Num- Per ber. | cent. | ber. | cent. | ber. | cent. | ber. | cent. | ber. cent. 0) /E2ssaue! Ques Or aaa! CO) (ae er 1 9.09 1} 3.85 (0), | Seer Ope 0 20 76. 2 (Oy eee Qi eee C0) aos 1 73 83. 91 1 1,23 Ogee seas OS ase 0 87 107, 41 1 1. 45 il 1.45 1 1.45 0 70 101. 45 5 | 5.81 (4 ane ONES Ones. 97 | 112,79 PAI 22. (9 eae Or esece ae! Of eee ae 97 | 129.33 Dd | 2.87 (i) es il) Ley (0) eae 233 | 133.91 4] 1.62 ONE Sees OF Rees (0) Sees 330 | 133.60 10} 1.95 6] 1.17 O} eae Onecare Se 678 | 131.91 1.82 9} 2.05 Quizsxc 2 (\)y| eee 504 | 114,55 4} 2.25 8| 4.49 (0) ee On eee: 239 | 134,27 iy |) By 1} 0.12 2| 0.23 1| 0.12] 1,008} 117.76 15 and over __ 22 | 2.94 23 | 2.03 0) See = (3 nee 1,421 | 125.53 _ Two infants, one of 34 months, the other of 9 months, were infected with Ascaris ; another, of 9 months, with Ascaris and hookworm. The number of infections per 100 persons was greatest in the age group 10 to 14 in the general findings and among the males and among females over 50, namely, 141.41, 149.19 and 134.27, respectively. 88 WILLETS. The percentages of persons infected with the various parasites are given by years up to the seventh year for the purpose of calling attention to the very high percentage of children, even infants, who harbor intestinal parasites. The results obtained show that infants between 1 and 2 years give an infection of 50 per cent with 59.46 infections per 100 examined. A year later the percentages rise to 75 and 90.76, respectively. GEOGRAPHICAL DISTRIBUTION. An attempt was made to study the geographical distribution of the infections among the thirty-three cabecerias of San Antonio. The per-— centages varied as follows: TABLE X.—Variation in the percentages of the parasites found at San Antonio according to cabecerias. . Mini- Maxi- Parasite. anna. aa. | |, Per cent. | Fer cent. |; eAb@arissa as cole 2 ee A Ae eS eee 31. 43 82.44 | TEINS a a ee eee 22. 06 81. 00 | TPECHUTIS Sete ea Ee, a ere Oe oe Ls 0.00 63.79 ls Onyrirtisso Se Ne 2 a 3 a a eee eee 0. 00 5. 56 PENG snot ee Se ee SI eee Ce ae 0. 00 7.55 Since the cabecerias vary in population from 58 to about 200, it was to be expected that there would be considerable variation in the per- centages of the various parasites found. As a rule the lower percentages were obtained in the smaller cabecerias; the higher ones in the larger. This particularly was true in regard to the findings for Ascaris. The occurrence of the hookworm seemed to be influenced chiefly by the nature of the sites selected for houses. Where the homes were located upon a rocky soil the infection with hookworms was less than where they were upon the lowlands. For instance, in cabecerias 2, 18, and 26, which are built on rocky soil, 23.60, 22.06 and 35.37 per cent were infected against 81.00, 70.59 and 67.09 per cent in cabecerias 14, 4 and 13, built on the lowlands. Since women are not found in the fields as often as men, it would be expected that a greater percentage of men would be infected if the infection took place in the fields (lowlands). This was found to be the case in the whole series (74.89 per cent against 52.83 per cent) and in the representative cabecerias under discussion as shown below. STUDY OF INTESTINAL PARASITES. 89 TABLE XI.—Hookworm findings in men and women in selected cabecerias. Group A. Located on rocky soil. Number ON Gali Men. Women. ceria. Ee Positive. |Per cent. eee: Positive. | Per cent. 2 37 15 40. 54 42 12 28.57 18 9 9 47.37 19 4 21.05 26 26 13 50. 00 25 8 32.00 Group B. Located on lowlands. 4 25 24 96. 00 29 18 62.07 13 26 20 76. 92 25 14 56.00 14 40 37 92.50 28 23 82,14 The geographical distribution of infections with T’richuris was in- fluenced by the 58 Visayans, 63.79 per cent of whom were infected with this parasite, and association with people in Ilagan Central. The Visayans had been at the hacienda about one year and undoubtedly carried the, parasites into the valley with them. The whipworm was found more frequently among the persons living in cabecerias near them, than among those in other parts of the hacienda. The people who lived nearer Ilagan Central were more frequently infected with this parasite than those farther away, excepting the Visayans and their neighbors. The infections probably took place while the individuals were visiting in the town. These opinions are supported by the fact that Maluno, which has no Visayans and which is located at quite a distance from Ilagan Central, so that visiting is inconvenient, had fewer with Trichuris than had San Antonio. The majority of the infections with Tenia occurred in cabecerias which are located near the mountains where it is the custom to hunt occasionally. During these hunting trips raw pork or deer meat is some- - times eaten. MEDICAL SIGNIFICANCE. While the investigation had, as one of its objects, the determination of the medical significance of the infections found, particularly those with the hookworm, its chief aim was to obtain statistics relative to the incidence of the various parasites. The great majority of cases were seen only once so that it was impracticable to study them clinically. Nothing can be said definitely regarding the influence of intestinal parasites at the 90) WILLETS. haciendas, but nevertheless, general impressions as to the physical condi- tion of the inhabitants were received. As a class, the people are anemic and they have very little ambition. Many of the children present marked evidence of ascariasis. It was attempted repeatedly to select cases of infection with the hookworm before the microscopic examinations were made, but only unsatisfactory results were obtained. It was not difficult to secure a history of symptoms which are frequently present in intestinal helminthiasis, such as nausea, vomiting, pain in various parts of the abdomen, constipation, diarrhoea, headache, dizziness, and restlessness, but it can not be stated that these symptoms were caused by the parasitic infections. Many factors are acting upon these people to lower their vitality and give rise to the symptoms mentioned. Climate, early marriage, rapid child bearing, poor food, excessive smoking, habitual use of alcoholics, and tuberculosis, all have their influence as well as the parasites. To determine the proportion of the symptoms due to hel- minthiasis would be a difficult problem, the solution of which would require most careful study extended over a considerable period of time. The important question of the significance of hookworm infections among the Filipimos remains unanswered. A few years ago infections with this parasite were considered to be of importance, but during the past two years, there has been a growing tendency to attach less and less significance to them until now some believe them to be so mild that their influence is practically nil, or that the Filipinos enjoy a degree of immu- nity to the effects of the parasite. Such a change in opinion is neither a strange occurrence, nor one peculiar to the Philippine Islands. Beliefs regarding the significance of hookworm infections in the United: States have varied. Too much importance was attributed to mild infections a few years ago, whereas, in my opinion there is an inclination to attach too little to them at present. It is the consensus of opinion among those who have worked with intestinal parasitism in the Islands that marked cases of the disease are rare among Filipinos. On the other hand, it has not been proved that the infections are so mild as to be of no importance from an economic point of view, or that of health. That intes- tinal parasitism has an effect upon mortality and morbid conditions in the Philippines is evidenced by the results obtained at Bilibid prison upon the institution of a routine examination and a routine treatment against the parasites. The Director of Health reports that a few years ago, when the Bureau of Health began its work at the prison, the annual death rate was 238 per 1,000. In response to the institution of sundry hygienic measures, the mortality fell to 75 per 1,000, and it seemed impossible to decrease the death rate beyond this figure. At this time the routine examination of the faces for evidences of intestinal parasitism and the routine treatment of infected cases was begun, with the result that the STUDY OF INTESTINAL PARASITES. 91 death rate fell to 13.5 per 1,000 per annum. ‘The routine work has been continued and the death rate has remained low. In addition to this gen- eral finding, the Director of Health tells me that the fall in the death rate occurred in brigade after brigade of the prison as the examination and treatment progressed from one to another; this is more convincing than the general findings that the fall in the mortality was due to the expulsion of animal parasites from the intestinal tract. Prior to the inauguration of this work deaths had rarely been attributed to intestinal parasites excepting Ameba coli. This is in keeping with the generally accepted opinion among medical zodlogists that the chief influence of helminthia- sis is so to lower the vitality of the host that he is more susceptible to other diseases. The statistical results of the examinations at Bilibid Prison were reported by Garrison. (Table III.) It is noteworthy that the hook- worm ranked second in point of frequency. If the treatment for in- testinal parasitism was an important factor in the remarkable decrease ‘in the mortality at this prison, it is impossible to believe that the hook- worm did no injury, as compared to that done by Ascaris, Trichuris and the other parasites present. The fact should not be overlooked that Garrison found 142 infections with intestinal worms per 100 persons examined. Considerable work at Bilibid has convinced me that the hookworm is almost invariably as- sociated with one or two, and sometimes more parasites. The results obtained at the prison must not be attributed to the expulsion of hookworms, but to the cleaning of the intestinal tract of parasites in general. It is quite possible that the hookworm occurring alone is of little significance and the same may be true of Ascaris and Trichuris, ete., but that when several infections occur in one individual, they are of considerable importance. I am persuaded that were 10 (instead of one) cover-slip preparations of the feces of each case examined at Bilibid, fully 98 per cent of Filipinos entering the prison for the first time would be found to harbor one or more intestinal parasites; and that there would be very few single infections. It seems incredible that the remarkable fall in the death rate at Bilibid Prison was alone due to treatment for intestinal parasites. The general hygienic conditions at the prison have been improved year after year since the Bureau of Health was given control of the health problems of the jail. In my opinion, some of the sanitary measures introduced contributed to the low death rate during the year in which the routine treatment for intestinal parasitism was inaugurated. On the other hand, the immediate fall in the mortality upon the institution of the routine treatment is quite too remarkable to be considered as a mere coincidence. The writer believes that the results obtained prove that intestinal para- sitism 1s of no inconsiderable significance among the Filipinos. oe 92 WILLETS. Since parasites apparently contributed to the death rate at Bilibid Prison, it is permissible to believe that they are to be reckoned with in considering the morbidity; that is, the problem of intestinal parasitism is not only of medical but, also, of economic importance. Confronted with the results obtained at Bilibid Prison and with those of the statistical studies of over 19,000 people in the Islands, approxi- mately 85 per cent of whom, as the result of a meager examination were found to harbor one or more parasites, the problem of the proper disposal of human excreta is brought vividly to our attention. The fact that cholera, the various dysenteries, and other diseases would markedly be influenced by a proper disposal of the excreta does not subtract from the importance of the problem. ACKNOWLEDGMENTS. I was in the Cagayan Valley at a time when the people were very busy with their crops. The two haciendas are broken up into small cabecerias, and the tenants are provided with medical advice and treat- ment free of charge; thus my endeavors to make this study must have failed but for the cooperation of Sefiores Orros and Mesa, administradores of San Antonio and Maluno, respectively. I wish to acknowledge my indebtedness to them and their assistants for many courtesies. Mr. Manuel Ramirez and Mr. Rafael Santos, fourth-year students in the College of Medicine and Surgery, University of the Philippines, rendered me valuable assistance in the examinations, and J wish to express my thanks to them also for their thorough, painstaking work. A NOTE UPON ANTHRAX IN THE PHILIPPINE ISLANDS. By W. H. Boynton.t The existence of anthrax in the Philippines appears to have attracted very little attention. ‘The only reference to it in print is by McMullen,” who was sent to the pueblo of Tagudin, Province of Ilocos Sur, in January, 1904, to investigate reports of a disease among animals the outbreaks of which antedated the American occupation. The disease occurred each year at the end of the rainy season and was most virulent at the onset of the outbreaks, killimg animals in from two hours to three days after the first appearance of symptoms. Microscopic examinations of the blood from the viscera of animals dead of this infection revealed, anthrax bacteria. Cultures were made in the Government. laboratories in Manila. In April, 1904, Doctor Lusk, vetermarian of the Second Cavalry, United States Army, reported the death of two mules from anthrax at Camp Wallace, La Union. These animals were of a pack train which plied between Camp Wallace and Benguet. The infection was supposed to have been contracted along the trail. In addition to these observations, the correspondence files of the Bureau of Agriculture contain a few references to anthrax. The places mentioned are the townships of Bauco and Cayan, in the subprovince of Lepanto, Mountain Province; and Sual, Pangasinan. The existence of anthrax in Lepanto-Bontoe was questioned by a second veterinarian who investigated the matter. No evidence is at hand to show that any diagno- sis in these outbreaks was confirmed by cultures. ‘The records also show that three shipments of cattle from Hongkong were quarantined for anthrax. ANTHRAX IN TAYTAY, RIZAL. Dr. C. G. Thompson, in charge of the serum laboratory at Alabang, on the 14th of August, 1910, called the writer’s attention to a smear preparation of blood made by Mr. Cattell, a live-stock inspector for the Bureau of Agriculture. This preparation was taken from a carabao * Pathologist, Bureau of Agriculture, Manila, P. I. 2A Preliminary Report on the Presence of Anthrax in the Philippine Islands. Am. Vet. Rev. (1904-1905), 28, 935. 93 94 BOYNTON. which had died very suddenly in the vicinity of Taytay. Mr. Cattell stated that he made the smear immediately after the death of the animal. The staining material at hand was not of the best kind for distinguishing anthrax. However, upon microscopic examination, there was observed a large number of rather long, rod-shaped organisms with square-cut ends, some of them in chains, and others single, many being surrounded by what appeared to be capsules. It hardly seemed probable that these bacteria were putrefactive organisms, since the preparation was taken. from the animal soon after death, but to be sure of the fact several guinea pigs were sent to Taytay, and instructions were given to the effect that if any animals there died in a similar manner a guinea pig should be inoculated with some of the blood, smear preparations made, a piece of the ear of the dead animal cut off, and both ear and smear preparations sent to the writer’s laboratory at the Bureau of Science in Manila. CasE I, number 17.-—-Carabao owned by Juan Villanueva, Santa Ana, Taytay, Rizal; died August 30, 1910. One guinea pig inoculated at 2.40 p. m., August 30, with blood taken from this animal after death; two smear preparations and a piece of the ear of the dead carabao were received on the morning of August 31. The smear preparations were stained with an aqueous solution of methylene blue, recommended by M’fadyean.* A large number of rod-shaped organisms with square-cut ends, oceurring singly, in pairs and in chains, were present. Practically every organism was surrounded by an amorphous, violet or reddish- purple granular material. M’Fadyean states that he has never found this reaction in animals dead from diseases other than anthrax. ; Smear preparations were made from blood procured from the ear. These smears were stained in a similar manner, and similar results were obtained. Agar cultures were made from blood obtained from the ear. September 1: Guinea pig was found dead in the laboratory in the morning. Smear preparations made from the spleen, liver, and heart blood showed the presence of anthrax bacteria in stained preparations. Frozen sections made of the kidney, stained with carbol-fuchsin, showed the presence of anthrax bacteria in the capillaries between the tubules and in the glomeruli. Agar cultures were made from the spleen, liver, and heart blood. Agar culture made from the ear showed almost pure culture of anthrax bacteria characterized by the ground- glass appearance along the edge of the colonies, and showed, under the low power of microscope, long flexible filaments combining to form thread-like bundles. September 2: Agar culture made from spleen, liver, and heart blood showed pure cultures of anthrax. An emulsion of some of the cultures obtained from the spleen was made in sterile water, and 1 cubic centimeter of this was injected subcutaneously into a guinea pig. September 3: Guinea pig was found dead in the morning. Smear prepara- tions from the spleen, liver, and heart blood showed the presence of large numbers of anthrax bacteria. Agar cultures were made from these organs. September 4: Agar cultures made from spleen, liver, and heart blood showed pure cultures of anthrax bacteria. Juan Villanueva owns another carabao, which, up to September 14, appeared *A Peculiar Staining Reaction of the Blood of Animals Dead of Anthrax. Journ. Comp. Path. & Therap. (1903), 16, 35. ANTHRAX IN THE PHILIPPINE ISLANDS. 95 to be in perfect health. He has not had any animals die suddenly before this one, except in 1901, when, he says, a carabao died with rinderpest. The animal which died of anthrax was purchased by him from dealers from Binangonan Malayo, Tayabas Province, in December, 1909. It was kept every day in a pasture called Libis, with many other carabaos. This pasture is situated between Taytay and Laguna de Bay.. CasE II, nwmber 19—Carabao owned by Saturnino Morales, Santa Ana, Tay- tay, Province of Rizal, died September 1, 1910. Guinea pig was inoculated on September 1, at 10.55 a. m., with blood from dead carabao. One smear prepara- tion of blood and piece of animal’s ear were received at the laboratory on the afternoon of September 1. Smear preparation of the blood, stained with aqueous methylene blue showed the presence of a large number of anthrax organisms giving M’Fadyean’s reaction. Smear preparations from ear of carabao stained with aqueous methylene blue showed the presence of large numbers of anthrax bacteria giving the same reac- tion. Agar cultures were made from blood of carabao’s ear. September 2: Agar cultures showed characteristic anthrax colonies, and cover- glass preparations showed the presence of anthrax bacteria. Guinea pig died 11.30 a. m. Anthrax bacteria were found present in smears from spleen, liver, and heart blood, giving characteristic reaction to aqueous methylene blue. Frozen section of kidney stained with carbol-fuchsin showed anthrax bacteria present in capillaries of convoluting tubules, collecting tubules, and glomeruli. Agar cultures were made from blood of spleen, liver, and heart. September 3: Agar cultures made on September 2 showed pure culture of anthrax bacteria from spleen, liver, and heart blood. ‘This carabao was the only one owned by Saturnino Morales at the time of its death and when very young was brought from Antipolo. At the time of its death it was pastured every day along with a large number of other carabaos in a pasture place called Mahabang Sapa, which is separated from Libis by a shallow river. Case III, number 23.—Carabao owned by Victor Santos, barrio of San Juan, Taytay, Rizal, died September 8, 1910. Guinea pig was inoculated 8.35 a. m., and ear of carabao was received in laboratory about noon on the 8th. Smears of blood from ear stained with aqueous methylene blue showed presence of anthrax organisms and gave M’Fadyean’s reaction. Agar cultures were made from blood of ear. : September 9: Guinea pig was found dead and very much distended, showing that it probably had died on the evening of the 8th. Smear preparations made from the spleen, liver, and heart blood, stained with aqueous methylene blue, showed an enormous number of rod-shaped organisms. Some of them resembled anthrax, giving the characteristic reaction, while the others had the appearance of putrefactive organisms. Agar cultures were made from blood of spleen, liver, and heart. Agar culture from ear gave practically pure culture of anthrax. September 10: Agar cultures from spleen, liver, and heart blood showed mixed cultures; a few anthrax colonies were distinguished. Cover-glass preparations from. these showed anthrax bacteria. Victor Santos does not own any other carabao. The one which died was bought in Binangonan Malayo about two years ago. It was pastured every day along with many other carabaos in the pasture called Libis. Several years before a carabao owned by him died, but the nature of the death could not be ascertained. 96 BOYNTON. Case IV, number 25 —Carabao owned by Pedro Banals, San Gaibro, Taytay, Rizal, died September 18, 1910. The ear of the carabao was received in the laboratory early in the morning of the 14th. In smear preparations from the blood of the ear, stained with aqueous methylene blue, no rod-shaped organisms could be found. The only organisms seen were a very few micrococci. Agar cultures were made of blood from the ear. September 15: Agar cultures showed no anthrax colonies, there being a few scattered colonies which resembled Micrococcus pyogenes awreus. Cover-glass preparations from several colonies stained with aqueous methylene blue'showed the presence of a micrococcus. As far as can be decided from smear preparations and cultures, it would appear that this animal did not die of anthrax. This man owns three more carabaos. These and the dead one were pastured every day in a pasture called Mapandon, with many other carabaos. He bought the carabao which died in San Mateo, Rizal, about three months before. Case V, number 32.—Carabao owned by Rufino del Rosario, Mapondon, Tay- tay, Province of Rizal; died on the evening of September 28, 1910. The ear of the carabao received in the laboratory early in the morning of the 29th. Smear of blood from the ear stained with aqueous methylene blue showed presence of anthrax organisms giving M’Fadyean’s reaction. Agar cultures were made from blood of ear. September 30: Agar cultures from ear gave practically pure cultures of anthrax. This man owns five more carabaos, which, with the one that died, were pastured every day with many other carabaos, in Mapandan, a pasture ground situated on the opposite side of the town from Libis. Case VI, number 33.—Carabao owned by Mariano de los Reyes, San Isidro, Taytay, Rizal, died on the morning of September 29, 1910. The ear of the carabao was received in the laboratory on the morning of the 30th. Smears of blood from the ear, stained with aqueous methylene blue, showed presence of anthrax organisms giving M’Fadyean’s reaction. Agar cultures were made from blood of ear. October 1: Agar cultures from ear gave practically pure cultures of anthrax. This man owns two more carabaos. These and the dead one were pastured every day with many other carabaos in a pasture called Lambac, a subdivision of Libis. He had owned this carabao several years. CasE VII, number 39.—Carabao owned by Lazaro del Valle, barrio of San Isidro, Taytay, Rizal, died October 27, 1910. t The ear and two blood smears from the carabao were received in the laboratory on the afternoon of the 27th. Blood smear stained with aqueous methylene blue showed presence of anthrax organisms giving M’Fadyean’s reaction. Agar cul- tures were made from blood of ear. October 28:, Agar cultures showed practically pure culture of anthrax. This carabao was pastured on the 14th and 15th of October in Libis, but from the 15th of October to the time of its death the carabao was pastured in the fields of the barrio of San Isidro. CONCLUSION. 1. From the results derived from the cultures, staining reaction, and animal inoculations, it is evident that anthrax exists in the vicinity of Taytay. ANTHRAX IN THE PHILIPPINE ISLANDS. 97 2. Since the animals, which were proved to have died of anthrax, were pastured in Libis, Mahabang Sapa, Mapandan, Lambac, and San Isidro. the infection is shown to be widely disseminated around the town of Taytay. 3. As it is almost impossible to procure definite information as to the number of animals and the manner in which they died in these places, one can not state whether the infection is recent or of long standing in this vicinity. The general opinion of the veterinarians is that it is of long standing, but has not been recognized as anthrax prior to this time. 101001——7 ¢ REVIEW. Primer of Sanitation for the Tropics. By John Woodside Rithchie and Mar- garet Anna Purcell. Cloth. Pp. x +182. Illustrated by 94 figures. Price $0.60. Yonkers-on-Hudson: World Book Co., 1910. This little book undoubtedly is one of the best of its kind that has come to our notice, and could well be adopted by the public schools of the United States with certain changes to suit the different conditions there. By following its teachings children can soon learn the simple principles of cleanliness and how to avoid disease. The book treats of the causes of infectious diseases, what germs are, how they get into the body, how the body fights them, and how to avoid them. The principal diseases of the Tropics, such as cholera, dysentery, malaria, tetanus, tuberculosis, etc., are discussed in a language that any child can understand, and there is a sufficient repetition of the axioms governing a healthy life to impress the mind with their importance. In fact we can recommend the perusal of this valuable little work to adults as well as to children. CARROLL Fox. 99 Order No. 401, THE BONTOC IGOROT. | By A. E. Jznxs. 110 pages. 3 maps. 154 photographic plates. 9 figures. An interesting study; the result of almost a year’s residence among the Bontoe Igorots. Price $1 United States currency, postpaid. Order No, 402, NEGRITOS OF ZAMBALES. By WiLt1am ALLAN REED. 62 photographic illustrations. 91 pages. An interesting ethnological study of the pygmy blacks of Zambales. Price $0.25, Wnited States currency, postpaid. Order No, 403. THE NABALOI DIALECT, By Orro SCHEERER. ~ TOGETHER WITH THE BATAKS OF PALAWAN. By Epwarp Y. MILiEr. 199 pages. 1 map. 28 full-page photographic plates. 6 figures. _ The result of research work among this interesting tribe of primitive people. Price $0.25, United States currency, paper, postpaid. ‘ NOTE. Orders should be sent to the Business Manager, Philippine Journal of Science, Manila, or to any of the below-listed agents. Please give Order Number. FOREIGN AGENTS. The Macmillan Company, 64-66 Fifth Avenue, New York City, U. S. A. Messrs. Wm. Wesley & Son, 28 Essex Street, Strand, London, W. C., England. 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A Note upon Anthrax in the Phil-- ippine \Tslamd’s: (3 2272 Ss ae aa aan Ne ee esc he eee eee 93 REV LEV ee Ailing lao foe ee ene Meera AO The e “Philippine Journal of Science’’ is issued as follows: Section A, Chemical and Geological Sciences and the Industries, $2 United States currency per year. ) Section B, Medical Sciences, $3 United States currency per year. Section C, Botany, $2 United States currency per year.. Section D, General Biology, Ethnology and ee $2 United States cur- rency per year. The entire ‘Journal,’ $5 United States currency for Volume ae {II, IV, or V. There- after, $7 United States currency per year.” Authors receive 100 copies of their papers free. Subscriptions should be sent to the Business Manager, Philippine Journal of Science, Bureau of Science, Mails, P. I., or to any 6f the agents listed below. Please give order number. FOREIGN AGENTS. The Macmillan Company, 64-66 Fifth Avenue, New York City, U.S.A. Messrs. Wm. 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D,..., THE BUREAU OF SCIENCE Ae OF THE ta | GOVERNMENT OF THE PHILIPPINE ISLANDS Goran gp “ $s \ i * \ "MANILA _ BUREAU OF PRINTING ; 1911. oe Order No. 405. STUDIES IN MORO HISTORY, LAW, AND RELIGION. By Nasrres M. Saersy. 107 pages. 16 illustrations. 5 diagrams. \ A treatise on the history and customs of the Moro People. "Price $0.25, United States currency, postpaid. , Order No, 406. - THE HISTORY OF SULU. : ; By NaJsEeeB M. SALEEBY. 275 pages. ; A complete History of the Moro People in Sulu, with maps and many 3 translations from the original documents. . : ~ Price $0.75, United States currency, postpaid. Order No. 410. MINDANAO. THE SUBANUNS OF SINDANGAN BAY. _ By Emerson B. Cristie. : 122 pages. Profusely illustrated. This, together with the. History of Sulu and the Studies in Moro History, Law and Religion, is one of an authentic and valu- able set. of works on the origin, history and customs of these tribes, who are among the most interesting peoples of the world. Price $1.25, United States currency, postpaid. NOTE. Orders should be sent to the Business Manager, Philippine Journal of Science, Manila, or to any of the below-listed agents. Please giwe Order Number. FOREIGN AGENTS. The Macmillan Company, 64-66 Fifth Avenue, New York City, U. S. A. Messrs. Wm. Wesley & Son, 28’ Hssex Street, Strand, London, W. C., England. Mr. Martinus Nijhoff, Nobelstraat 18, The Hague, Holland. ; Messrs. Mayer & Miiller, Prinz Louis Ferdinandstrasse 2, Berlin, N. W., Germany. Messrs. Kelley & Walsh, Limited, 32 Raffles Place, Singapore, Straits Settlements. Messrs. A. M. & J. Ferguson, 19 Baillie Street, Colombo, Ceylon. CIRCULARS AND DESCRIPTIVE MATTER SENT ON APPLICATION, THEE Eee PINE JOURNAL OF SCIENCE B. MEDICAL SCIENCES Vou. VI APRIL, 1911 No. 2 INVESTIGATION ON THE ACTION OF THE TROPICAL SUN ON MEN AND ANIMALS. By Hans ARon. (From the Physiological Laboratory, College of Medicine and Surgery, University of the Philippines, Manila, P. 1.) The meteorologic conditions which surround us, such as temperature, humidity, barometric pressure and the movements in the atmosphere, all of which, to a great extent, are controlled by the radiation of the sun, are included under the designation of clmate. ach of these factors of environment has its characteristic influence upon the life functions of living organisms. We can, on the one hand, study the influence of differing temperatures, humidities, and movements and pressures of the air on men and animals in modern respiration calorimeters without the need of conducting the work in a particular climate. Rubner,’ especially, has carried on such work. But, on the other hand, the action of the sun of a given latitude can not be reproduced artificially. The radiant energy of the sun which reaches the atmosphere is in part absorbed while passing through the latter, and this ; absorption, other conditions being equal, should be smaller the less deep the absorb- ing layer. If conditions, such as layers of the atmosphere of unequal density which would tend to refract the rays, do not intervenc, and again, if all other conditions are equal, the absorption is smallest during the vertical incidence of the rays; that is, when the sun is in the zenith. *Arch. f. Hyg. (1894), 20, 309-312, 345-364, 365-371; (1895), 23, 87, 13-43; i (1900), 38, 120-159. Die Gesetze des Energieverbrauches bei der Ernihrung, Leipzig-Wien (1902). 101801 101 102 ARON. Because of the more nearly vertical incidence of the sun’s rays in the Tropics, a greater proportion reaches the earth and with a greater in- tensity on a given area than in the northern and southern latitudes. Of course, in granting this, such phenomena as cloud formation are excluded. The tropical sunlight, in so far as the violet and ultra-violet end of the spectrum is concerned, has been studied extensively in the past few years in the Bureau of Science in Manila by Freer,? Gibbs,* and Bacon,* and the effects produced by this portion of the sunlight have been and are being compared with those obtainable by observers using the same means of measurement in other latitudes. These investigations up to the present have shown that the spectrum of the sun’s rays does not extend much, if any, farther into the ultra-violet in Manila than in northern climates. Observations carried on daily during the year on the decomposition of a solution of oxalic acid under the influence of uranyl acetate as a catalyzer® have shown as great variations between individual days, even of the same apparent brightness, and some decomposition even on cloudy and rainy days; however, with a general tendency toward maximum decomposition when the sun is nearest the zenith and of minimum under opposite conditions. The com- parative measurements in other countries are not as yet available to any extent, with one exception. Bacon showed that the decomposition in Manila in July was from five to twenty times greater than in Chicago in June. The work with the ultra-violet spectrum was of interest not only because it is necessary thoroughly to consider these rays in a study of tropical sunlight, but also because of the number of authors,° especially in modern times, who are inclined to the belief that the action of the tropical sun on the human organism is to be attributed to the influence of the rays of shorter wave length. As a result of this belief a special underwear, which by its color should be impermeable to the ultra-violet rays, has recently been recommended for use in the Tropics. An extensive investigation of the relation of the color of underwear to the health of men in this climate was made by Phalen and Nichols’ *This Journal, Sec. B (1910), 5, 1. *Ibid., Sec. A (1909), 4, 183; (1910), 5, 9 and 419. *Tbid. (1910), 5, 267. *The solution of oxalic acid uranyl acetate is only acted upon by the ultra- violet end of the spectrum. The results of this work will be published later from the Bureau of Science. * Woodruff, C. E., The Effects of Tropical Light on White Men. Se York and London, (1905); Duncan, Journ. Roy. Army Med. Corps (1908), pe ills Simpson, Ibid., 441-449; Gihon, Twentieth CE Practice of ee New York (1895), 3, 253- 285. "This Journal, Sec. B (1911), 6, 525. ACTION OF THE TROPICAL SUN. 103 on 1,000 American soldiers in the Philippines. The results, as to the advantage of orange-red, were negative. This fact, when considered in connection with a number of observations which I have made during my stay in the Tropics, convinced me that the rays of the tropical sun having greater wave length, that is, those in the red and ultra-red end of the spectrum, play the most important réle in producing the untoward effects generally attributed to tropical sunlight. In making this statement it must be understood that it refers to organisms having the capability of regulating the body heat, and not to those low in the scale, such as bacteria or protozoa, for it has been shown repeatedly*® that in the case of the latter ultra-violet rays exert a most destructive action, heat coming into consideration only in so far as such organisms are not able to live when the tem- perature is above a certain point. Plants also, the normal life action of which depends on the chlorophyll, of course are markedly affected by the ultra-violet as well as by the other end of the spectrum. In order correctly to interpret the experiments given in subsequent portions of this paper, it will be necessary briefly to review the physi- ologic processes concerned in heat regulation in the bodies of mammalia. The body possesses the capability not only of regulating its heat pro- duction from the combustion of foodstuffs (chemical heat regulation), but also its loss of heat from convection, radiation and water evapora- tion (physical heat regulation). Normally, the thermal effects of the surroundings are compensated either by a suitable transference of heat to the surroundings, or by the conservation or production of heat within the body, so that the body temperature within narrow limits remains practically the same. However, there are limits to the power of regula- tion. If the body is heated too intensively or the loss of heat is inhibited, the latter will accumulate and the body temperature rise. The higher the temperature of the surroundings, the less will be the loss of heat by conduction or radiation, and if this temperature exceeds that of the body, no heat can be lost in this way, but on the contrary the balance is changed, and the energy lost to the body would now be accumulated in it were it not for the loss occasioned by the evaporation of water from the lungs and the surface of the body. High air temperatures alone do not change the body temperature as long as the latter can be regulated by the loss of sufficient heat through water evaporation.® Therefore, a man can withstand temperatures even of 129° for a considerable time if the air is comparatively free from water vapor. On the other hand, if the relative humidity is high and, * Loc. cit. ° Hill, Leonard, Recent Advances in Physiology and Biochemistry, London, (1908), 256-274. 104 ARON. therefore, the evaporation of water from the ‘body lessened, the loss of heat is inhibited.1° It will be recalled that in many localities in America or Africa the thermometer in summer often is much higher than it is in the Tropics, yet the heat by no means produces the same effect. The humidity in the Tropics is always comparatively high, because the air for considerable periods of time is nearly saturated with water vapor. It might be stated that it is not regions of high air temperatures, but those having a high relative humidity which pro- duce especially untoward effects by reason of their climate. However, if the air is in motion, even if it is very humid and hot, increased water evaporation and conduction bring about a great loss of heat. This fact is of great importance in the Tropics. The fresh winds prey- alent here render the climate of Manila in the months of May to August much more tolerable to human beings than is the case in certain parts of the Chinese coast or even on the Atlantic seaboard which lie considerably farther to the north. Generally speaking, the majority of people living in the Tropics are on the coastal-or intermontane plains, where the climatic conditions are nearly alike throughout the year. The high air temperatures and high relative humidity are maintained so that conditions retarding the loss of body heat are practically continuous, in distinction from those regions where, despite the fact that at certain times the heat and relative humidity are high, nevertheless the average for the year is low. How- ever, the body temperature of man and probably also of animals, in spite of this fact, normally does not exceed the physiologic limits. This has been shown by a large number of careful measurements of body temperatures of white and colored men in the Tropics, and of the same people in the Tropics and in temperate climates. Variations, when they have been observed, are doubtless not greater than the daily ones” encountered in other climates. Finally, the radiation from the sun is obviously an important factor. Any object exposed to the sun’s rays absorbs a portion of them. The majority of substances, and among them is included the animal body, have a much higher coefficient of absorption for heat than has the air, and therefore they become hotter in the sun than does the surrounding air. This effect of the heat radiated from the sun, while generally most intense in the Tropics, is present in all latitudes. Rubner, Cramer,’? and Wolpert** have studied the results of insolation in temperate climates. According to their experience we can calculate approximately * Haldane, Journ. Hyg., Cambridge (1905), 5, 494. *“ Of course it must be recalled that in the Tropics, where the relative humidity is high, the sun is often obscured by clouds. “Arch. f. Hyg. (1894), 20, 313-344; (1892), 33, 206-228; (1902), 44, 322- 338. ACTION OF THE TROPICAL SUN. 105 the temperature which corresponds to the thermic effect of the sun by adding half the number of degrees difference between the register of the black-bulb thermometer in the sun and the shade thermometer to the shade temperature. Applying this calculation to the conditions in the direct sunlight at Manila or other tropical place, for instance, Colombo, we find that this temperature is considerably above the one normal for the body. The pyrheliometer devised by Angstrom** alone seems capable of measuring exactly the caloric value of the radiation of the sun. This instrument has been adopted by an international meteorologic conference ia Innsbruck. Measurements with it have been made in other parts of the world, but as yet no work has been done with it in the Tropics. The Rev. José Algue, 8. J., Director of the Weather Bureau in Manila, has begun such investigations in connection with our experiments. How- ever, an important part of his apparatus was broken, so that after repairs on it had been completed here, we could obtain only relative values for the different days. A new apparatus has been ordered and the figures after its arrival will be recalculated into absolute values.** Therefore, we will shortly be in a position to furnish exact values for Manila and other places in the Philippines obtained by the pyrheliometer. It seems urgent that comparative studies in other parts of the world, especially tropical and subtropical regions, be made with the standard instrument of Angstrom. P. Schmidt estimates the heat effect of the tropical sun as being equal to 2 gram calories per square centimeter per minute. I have found in the literature only a few observations concerning the action of the tropical sun on animals. Scaghosi* exposed rabbits to the sun in Sicily. Their temperatures rose markedly, and upon continuing the experiment for a sufficient length of time, the animals died. Recovery took place if the direct insolation was stopped in sufficient time. Castellani and Chalmers” report some experiments which they performed in Colombo. They exposed rabbits with their heads shaved to the noon sun. The animals died in about sixty-seven minutes with all the symptoms and post-mortem appearances of sunstroke. Another rabbit, similarly treated, but protected by a red glass, lived. These authors concluded that sunlight can bring about “(1) sudden death, (2) congestion of the meninges of the brain. The ultra-violet rays seemed to have no effect and it would appear as if the active rays were in the visible violet.” Of eourse the red glass also absorbed a very large proportion of the heat rays. 13 Astrophys. Journ. (1899), 9, 332. “My thanks are due to the Rey. José Algue and to the Rev. Juan Comellas for the valuable assistance they have rendered, not only by the loan of apparatus and by conducting measurements, but also for advice on meteorologie subjects. *% Castellani and Chalmers, Manual of Tropical Medicine, London (1910), 86. ** Toad. 106 ARON. , Schilling ” mentions a few experiments on rabbits: A thermometer under the skin of a white rabbit in the shade showed 38°.4. The animal was transferred into the sun (air temperature about 26°, black-bulb thermometer 46°.7). After half an hour the thermometer under the skin showed 40°.4. The skin was shaved, whereupon after half an hour the thermometer rose to 41°.5. The shaved skin was covered with a piece of black cotton cloth and within twenty-five minutes the temperature rose to 42°.8, the black cloth was removed and the thermometer fell to 39°.6, finally the same place on the skin was blackened with carbon, and within ten minutes the temperature rose to 42°.4. P. Schmidt also exposed rabbits to the sun, but in a temperate climate, and observed in a white rabbit that the temperature in ano rose from 38°.5 to 39°.5 and from 38°.5 to 40°.2 in a black rabbit. The increase in temperature during one hour was only 0°.3 if the neck alone was exposed to the sun. EXPERIMENTAL. If the body of a dead dog or rabbit is placed in the sun of Manila, the temperature of the outer portion of the body, measured by introduc- ing a thermometer under the skin, rapidly rises to 45° and more, thus exceeding the temperature of the surroundings. The absorbed heat will finally also warm up the deeper parts of the body, and therefore a thermometer placed in the rectum will rise. The figures obtained by experiments on dead animals are shown in Table I. TABLE I.— Rise in temperature of the bodies of dead animals exposed to the sun in Manila. ae Temperature. Mercury ther- ‘ ‘ Black-bulb Date. Remarks. Time. ee Given TAD ID. RO In ano. the skin. in sun. 1910. Xf of XG Sept. 22 | Dead rabbit placed ona { HOMO Gy Ts Ee AS Oe DSSoeeyb ell yf. e eae | ae board in sun at 8 a. m. LE OO} aeons AG 32) eas ae ee oe ee ae eee Octie tpropmadee buns an/eun 2.30p.m.| 36.0] 40.0] 51°.4at2p.m.__| 32.0 on a vertical stick at 2 3.00 p. m. 36.1 AGB) |e ee ee 32.1 ae 8.80 /p.tml || auineseh| Mil m7 dOy eee se pee eee 32. 1 \ 4.00 p.m 37.7 ATED) NN ee Be 2 ae 30.7 Of course, the body of a living animal exposed to the sun absorbs heat just as does that of a dead one, and so its temperature would rise in a similar manner were it not able to lose heat more rapidly by reason of its capacity for physical heat regulation. A dog placed in the sun very soon exhibits the symptoms known as heat-hyperpneea. Its respiration becomes quicker and forced, the tongue hangs from the mouth and saliva increases and drops from it. As " Arch. f. Schiffs.-u. Trop.-Hyg. (1909), 18, 1. * Arch. f. Hyg. (1903), 47, 262-290; (1908), 65, 17-31; (1909), 65, 1-20; Arch. f. Schiffs.-u. Trop.-Hyg. (1901), 5, 207-233; 245-271. ACTION OF THE TROPICAL SUN. 107 dogs have no sweat glands, the evaporation of water, which in men is brought about by the secretion of sweat, is replaced in these animals by increased evaporation from the surfaces of the lungs, mouth, and especially the tongue. However, in spite of the increased water evaporation, the body tem- perature measured in ano of the dog in the direct rays of the sun for several hours may rise 0°.5 to 1°. If the temperature is measured by inserting a thermometer or a thermopile into the subcutaneous tissues through a small incision of the skin, the subcutaneous temperature is found to be above 40°. In a number of experiments, two comparable rabbits in each instance were kept side by side a few paces apart, one in the shade of a house or a wooden wall, the other exposed to the sun. The animals in the sun died in from one to three hours, the temperature in ano rising to febrile heights, the subcutaneous temperature in the sun increasing considerably above that simultaneously taken in recto. The animals in the shade behaved normally, their temperatures increasing but slightly. TABLE Il.—Temperature, subcutaneous and rectal, of rabbits in the sun and shade. =e Temperature of | Temperature of rabbit in sun. |rabbit in shade.| Tem- pera- | Black-bulb Date. Remarks. Time. ture | thermom- Subcuta- Subcuta- cae eter. wane, Rectal. nena Rectal.) shade, CXF °C. CXee oC: Gs, 7.55 a, m. 36.8 37.5 36.4 Cia ii Eee Be) 42° at 11 8.15 a.m. 37.8| 37.8 RG) eee) pagel! Ee te 1910. 8.30 a.m. 38.3 37.3 36.5 37.5 27.5 Oct. 12 | Two white rabbits. 8.45 a.m. 39.1 37.8 36.8 37.4 29.6 In animal house. 9.00 a.m. 39.2 38. 8 36.8 37.5 30.0 Exposed 8 a. m. 9.15 a.m. 39.8 39.0 36.8 37.6 29.4 9.30 a.m. 40.8 39.2 37.9 37.9 30,7 9.45 a.m. 41.9 40.6 38.0 38. 0 30.5 < Experiment discontinued, animals 9.50 a. m. { § taken in. Oct. 18 | Two brown rabbits 8.20 a.m. 36.5 38.0 36.4 SYAY/Al Sse 54° at 11 : Re z = a. m. In animal house. 8.50 a.m. 40.7 39.0 36.5 Bay | eee Exposed8.25a,m, |)%20 8m. | 44.5] 42.3) 37.6] 37.8 |_-_--__- 9.50 a.m. | Animal dead. 37.9 Seni ees Under the climatic conditions surrounding our experiments the num- ber of calories lost depends mainly on the amount of water evaporated in a given time. A dog, by its peculiar hyperpncea can evaporate rel- atively more water, and thus lose more heat than the rabbit. However, if we tracheotomize the animal this evaporation is inhibited. The expired air escapes through the tracheal cannula, so that the water vapor carried with the current can not reach the surface of the tongue, and therefore there is but a limited surface from which it can be evaporated. 108 ' ARON. In the shade, or inside of a room, a tracheotomized dog, while limited in its power of losing heat, shows a body temperature not above normal, but if such an animal is’ brought into the direct rays of the sun, the hyperpncea appears just as with a normal dog but without so great an evaporation of water. Under these conditions the rectal temperature rises to febrile heights. If the experiment is continued for a longer time, the animal finally falls and dies, the respiration having markedly increased, the pulse greatly quickened, cyanosis of the mucous membrane having set in, saliva dropping from the mouth and secretion even having set in from the mucous membrane of the nose. In fact, the animal shows all the symptoms of heat Le stroke. I have several times in- 46° terrupted the experiment before this last stage was reached. Then, if the temperature was not too ene high, it was possible to save the Rilo. aie animals. The animals died in two pe | Vv (ae 45° 44° 43° experiments; one, after a few minutes, the other after several hours in spite of careful treatment with cool water. During this time the animal exhibited signs of disturbed orientation ; it ran rest- lessly around, knocked its head against the wall, fell and jumped aa up again. These severe disturb- le ances of the nervous system cor- 36° See ty respond to certain observations jay made during heat stroke in man. a { Rabbit V The conditions described above ouccue Subcutaneous . _. Rectal are made clear by Table III. CHart I. ACTION OF THE TROPICAL SUN. 109 TABLE Il].—Temperature, subcutaneous and rectal of dogs m sun and shade, Temperature. Date. Remarks. Time. Te Pee em Rectal. | taneous. oC; °C, 9.00 a, m. 36,9) | eere eens 52°. latila.m. 1910. 9.30 a. m. Bath lies Oct. 5] Brown dog, tracheotomized Oct. 4, || 9.40 a.m. SON irl ie ia 1910. In animal house. Exposed |; 9.50 a. m. AQ le sae ae tee to sun 9.20 a. m. 9.55 a, m, 40.9 44,2 : O00 Bp se) ZI Ieee 10.05 a, m. 42.0 45.5 Falls down in lethal condition, taken into room, died 10.40 a.m. (Rec- tal temperature 41°. ) Oct. 19} Black dog, TEGAN e Oct. 17, Stoo ae one Bala li doadae aiken 1910. In animal house. Exposed oinstncy 40.7 42.9 mete sa a.m.; taken into a pees ad nec) room until 10.30 a. m.; exposed to TH:00 ai, ate age sun again. Taken into room at ee gene Soe) 12.30 p. m. 38.0 37.5 11.15 a. m.; recovers. Oct. 21 | Same dog from Oct. 18,1910. In ani- |; 8.30 a. m. 38.0 37.0 | 45°.6atlla.m. mal house. Exposed to sun 8.45 |) 9.15 a. m. 40.0 41.0 a.m. 44.5 ; 9.50 a. m. 44,2 { died. Tracheotomized rabbits, while inside of a room, act normally, but if they are exposed to the sun they die, the body temperature rising more rapidly than with normal rabbits. The post-mortem findings in the dogs and rabbits which died were: Hyperemia and a certain number of small hemorrhages in the sub- cutaneous tissues, hyperemia of all internal organs, especially of the brain and the meninges. Several punctiform and linear hemorrhages could be seen on the surface of the brain, as well as on the dura mater. I have attempted roughly to estimate from the loss in weight the relative quantities of water evaporated by rabbits in the sun and in the shade. I collected the feces, urine, and saliva excreted and deducted this amount from the loss in weight of the animal. Of course, the figures obtained in this way are not exact, the carbon dioxide excretion not being taken into consideration, but a comparison between two animals otherwise under the same conditions gives an approximate idea of the loss of water. The calculations are given in Table IV. 110 ARON. TABLE [V.—Loss of weight of rabbits in sun and shade. Reduced per hour and kilo body weight. In sun. In shade. Houall Weight Weight i EEA num- gat, Urine} Re gat. Urine Re: : ber of and | duced and | auced MOUrS | UAE VAG NT oe | ToS cs | LOSsior |. al vAttan | ae] Cel pesto: start. | end. aifectodl weight.| Start. | end. Miveatant weight. h. m. | Gms. | Gms. | Gms.; Gms. | Gms. | Gms. | Gms. | Gms.| Gms. | Gms. 8 to 9.50 a. m-_-__| 1 50] 1,640 |} 1,580 60 18 42 | 1,943 | 1,936 | Pee a 2%0 4p. mi —2=225 2 0| 1,795 | 1,744 ol 10 41 | 2,148 | 2,137 bh Be seen a 11 9.30 to 11.45 a.m,j 2 15 | 2,182 | 2,032 | 150 35 115 | 1,780 | 1,725 by ae 5 Loss in | segue loss in shade. Grams. Grams. 14 2 12 3 23 2 EE Cats behave more or less as do dogs or rabbits. Their body temperature rises, and if they are exposed to the tropical sun long enough, they will die. EXPERIMENTS ON MONKEYS. Experiments on monkeys promised the best result because these animals are at home in the Tropics. Monkeys, like rabbits and dogs, have no sweat glands, and their physical heat regulation is confined to the reduction brought about by water evaporated from the lungs and mouth by increased respiration. However, this capability to evaporate water is very limited. In my experiments the monkeys were fastened in sunny places in the garden, or on the roof to a small stick by means of a chain around their bodies. The body temperature of the animals exposed to the sun rose within one hour: from 38°.5 or 39° to 42° or more. ‘The subcutaneous temperature at the same time reached values of 45° and even 46°. Within seventy to eighty minutes the monkeys died, even if they were exposed to the sun in the early forenoon, between 9 and 10, in December and January. These months are among the coolest in Manila. Even an open umbrella gives sufficient shade to protect the animals from the injurious effects of the sun. I have especially studied the changes of the subcutaneous and rectal temperatures in monkeys and the relation between these two values deserves attention. The sub- cutaneous temperature in a normal monkey inside the house and for the greater part in the shade is somewhat below the rectal. As soon as the animals are placed in the sun, the subcutaneous temperature rises above the rectal, and, until the end of the experiment, exceeds the latter. The interior of the body is warmest in normal animals and becomes ACTION OF THE TROPICAL SUN. 111 cooler toward the periphery. In the sun, on the contrary, the body is hottest on the outside and cooler toward the inside, the latter now receiving heat from the periphery. As a result of this condition the temperature measured im ano in a normal animal is very nearly the same as that of the blood and surrounding tissues, but in monkeys exposed to the sun, it will lie, in all probability, below that point. The parts of the body nearest the periphery will show a temperature almost the same as the subcutaneous, the more central portions a temperature between the rectal and subcutaneous. Experiments may be mentioned in this connection in which two monkeys were exposed to the sun, the one with its normal coat of hair, the other, shaved all over. The tem- perature of the shaved animal rose much more rapidly than that of the other. On the other hand, in the shade or inside a house, the shaved animal has a slightly lower body, and a decidedly lower subcutaneous temperature. The explanation is clear when we consider the fact that the coat of hair protects both against loss of heat by conduction and an increase from radiation. The following characteristic examples of protocols illustrate these points and they are even more plainly brought out by the temperature charts. TABLE V.—Haperiments with normal and shaved monkeys. Temperature of— Monkey IT | Monkey x | Monkey XT Inponkey x1r,| Black F in normal exposed | in shade of shaved, ex- ‘nee Date. Remarks. Time. hair coat ex- to sun. umbrella, posed tosun. posed to sun.) 75 Gm- eter. Sub- Sub- Sub- Sub- cuta- Bee cuta- pee: cuta- Lees cuta- Hee: neous * jneous * Ineous * {neous : OGL || Cet | Leh | Oh | OC xO SCE Cxos 1910. sH0) elope | Biehl Wy Sth ee lee See pean) eee 52° INOWo UG Mio. eau My easy fay, swale | SIGE) eA), SS SR SE |e ee eee WS ORIG Snes) mos S Ore Ta en ie 415 Ol eae Oy emcees EE eee eee Be Uh BE Pose Gato Olay dm uy 4 Ona asia ee ees ee ee ee oe ee FSVBEae YEH, Hams HFM OL (OO) areas ZL eV ES he a a ee ecco eee MOlOStamiin, WASHOE aes | ees ee See | ay ee ee cea Slight cramps, forced and slow respiration, saliva dropping, 10.10 a. m. died. PO) 105 100s |p see 37.5 | 38.5 | 38.1] 38.4 | 36.6] 37.9 |_----_- 1911. 2 SOT a LOS eae eee [Smee CEPA Me het | CRE CO |) Siege COE) | ee disney, AMG} |) Wok erobbooysyl) Ip Myo sont |e ee ee | oe AOS eee OWES eC! wezeDo spelen | ees | eee 8 |e aE |e AaX6u 4850) lasaso— Tope oVoere lao) [I\) PAGO Ta) tools 43,2] 41.4 | 44.8 | 44.0 |-----__ SUT 2525! Oby pein.) eens eee ne Bea Say eee el eens 45.5 | 44.4 |_-_--_- Demeeeeeoe SalOMp em \esee esos o ne | Sse ee 43.8] 41.4 |__-___ Dieds 2 as= SEPA Dato eae ee Se ee ee Sil Or faa S| eS 3.35 p.m. |_----- Bete RAO NS) | eoeee ZMS LN) eee (eee Ree Fea 3:23 aI |e mele | ae | ee CUR fe amy erm baie, 3. OO) De tile | eee |e A0n2) E40; 0) |aeeeales cae slesn nat. ee Eeeeeen A200} pyle | eanea= eee eee eae Aan OV W430 4) |e oa 7 |e ee beeen. 4.15 p.m, |__----|------ 40.0 | 40.1 | 45.4 Wee \ Demet) ae 112 ARON. 35 45 Temp. 46° i<=) oO wo 55110 05] 10 (5) 10 25] 19 35] 10 45) 10 55 45° ie po SRS eles = l F i a) : Saeae 36° FEaaeed ee heel Monkey XI aes o------9 Subcutaneous Ce Rectal CuHartT II. ACTION OF THE TROPICAL SUN. 113 on 235] 245] 255] 305] 3 15] 325] 335] 3 45] 355] 40s] 4 is Time| 2 ‘>| 2 Temp 4° (a ss EE tec owseee-o Subcutaneous o——~ Rectal CuHartT ITT. 114 ARON. The following experiments were arranged in order to show beyond doubt that hyperthermia alone must be regarded as the true cause of the death and of the injurious effects brought about by the radiation of the sun. Monkeys were exposed to the sun, while at the same time a strong current of air from an electric fan was blown over their bodies. Under these conditions the temperature did not rise in the same degree as in a control animal exposed at the same time, but outside the influence of the fan. Monkeys in the sun but exposed to the wind behaved more or less as did the animals under an umbrella or in the shade, no injurious effects from the sun’s rays being noticed, because the motion of the air increased the loss of heat. When placed under the fan, the animals lost the exces-. sive heat which reached them by radiation from the sun. ‘The rays, including the ultra-violet, were nevertheless present and were absorbed by the body in the same manner and degree as by that of the control monkey. Table VI and Chart IV make the above experiments clear. TaBLeE VI.—Monkeys m the sun, with and without a blast of air from a fan. Temperature of— Monkey X | Monkey Monkey oe Monkey : in sun and | XIITinsun| XI1in sun ain avec XIV in sun Date. Remarks. Time. wind. and wind. alone. sind. alone. cuta-| Re | cuta-| B&e- | euta-| R&e-|cuta-| Ree-| Guta-| Ree neous eonus neous neous * [neous Y 1911, CE T0a || EXC I) SCR SGR SCR Oe es | Ses Seb) Seb) xe: Jan. 24/In animal houses222 2222 GEO) | aaraaee ener Bi. Ol oGu On| =see ae | aeeees | eee eee 38.7 | 38.9 Exposed to sun LOlargmeseeene, UO raly ee | STO 4 POOSAS | Goeaee| soca |Eee eee eS 41.5 | 40.3 Interrupted’ 222) sl0530))| aaasas Se eee BONO) aaeas pecans | nee eee 2 ene 40.9 Jan. 26/In animal nhousesesenaas Bei BO ec ea a BONO: sssees Boe ee eee ee 38.5 B45 7b bres eae 38516) | ete |S ale sea ere alee COG) (eeexeee Exposed to sun Oey aN ge: ee ee fe OSL Oy aos | eee 395311 39N8))| 2 eo s= EUS Se ake ee 40.6 | 39.7 9,30 pa eed 886) P4ONON sae aE eee ee ee 41.1 | 41.0 9745 | ees (eee 3912111174043) | weeese | sie | eee ee 42.2 | 41.8 O00); See rene BET MAO 6D! eRe ee aie | eee | ee 42.5 Tmierr ip e Gis Os Os eee Sees eee AQUI Ss Se ea Bite a Meee Se | 48.5 | 42.7 In animal |/10.30 OWRO i 45 tag Sie. 20 | seas |e Siebel CAE Bisa iy |p Si heb ee a Pe ee Exposed to sun NOHO) Eto Tabs 1) pee BONO M| =e 2 Semoun eee CADRE fos os Bie H oft Mere peels Leagan AGO RSD) | casas [eek a ADs Mis | eeee 39 1 Oe | aero eee ge XO) oes 39; 6a sess ae ee 42.4 | see (0a iy Pel ee TE TAO | POQ ND) eee | ee See eee 4458 et Be ADH eon | Sees |e eee i150) ome 4054 [eee nae 46.8 ae } Boel Oe he Viste aaa p.m. died. 1 (O10) eee BO Oe Bee oo Meh Foal ees 2 shee Sa eee 24056: |E ead aoe s Left in sun under fan. ACTION OF THE TROPICAL SUN. [Time|_9 45] 10 06] 10 15/10 26] a30] 8 45] 9 00] g 15] 9 20] g a5 oe = 46° 45° 4a° 43° 40° 35° aoe EEE ATT ri “as ee = nd OAH oul daf oh | plates sd i lo coal | H epee ie aia ie eS Ee ey = es is ie Hebe ears bese S._ Monkey _ ae | a poamomRectal CHART IY. 115 116 ARON. I have exposed the heads only of monkeys, by placing their bo- dies in a large wooden box 33 by 33 by 50 centimeters, the top of the box being fitted closely around the neck of the animal. Several holes were made in its walls to allow a free circulation of air, and, finally, the first box was placed inside a second, larger one, 50 by 50 by 48 centimeters. In this way the body was in the shade and well pro- tected against the rays of the sun, while the head was unprotected. Monkeys have been exposed in this way for several days, from morning to afternoon, without any effect. One monkey, number 6, was insolated in this way for a total of fifty-four hours in twelve days, and the animal is still well and healthy. Temperatures up to 47° were measured in the hair of the head during several exposures, but the rectal and subcutaneous temperatures of the animal never went above the normal. P. Schmidt *® assumes that the heat rays from the sun, although partly absorbed by the skin and bone of the skull, at least in part penetrate the brain, and the latter organ, being very sensitive to an increase of heat, will not withstand the effects of the rays. . In my experiments with the monkeys in the box the heat rays could penetrate freely to the brain. The fact that the radiation reaches the skull appears to have no effect, if the body temperature does not rise at the same time. ’ Deleterious effects are only observed when the body temperature rises to febrile heights, but if this rise is prevented by a strong current of air or by protecting the greater part of the body against the heat rays, the animal will not suffer from radiation from the sun. Post-mortem findings on monkeys dying after exposure to the sun, give the following characteristics : Hyperemia of the subcutaneous vessels and of all internal organs. In two monkeys small hemorrhages in the subcutaneous tissues and in some of the muscles are observed. I can not exclude injury from the chains with which the animals were fastened as a cause of the latter condition. The alterations in heart and brain are of greater interst: All monkeys ” which die after exposure to the sun show extensive hemorrhages in the muscular wall of the left ventricle. These hemorrhages are situated beneath the endocardium and for the greater part near the auriculo-ven- tricular border, sometimes they are also in the papillary muscles. Their extent and number varies somewhat, the smallest are rectangular, 3 by 2 millimeters. Considering the size of a small monkey’s heart, these are quite severe alterations. The vessels of the dura mater are far more distended than with normal monkeys, and at several places small hemor- rhages are found. The arachnoidea is slightly raised by an exudate lying “Loc. cit. * This protocol is based on seven animals. ACTION OF THE TROPICAL SUN. 117 between it and the brain. The blood vessels of the brain are very hyper- eemic ; fresh, small hemorrhages are found in several places on the basal side of the frontal lobe. There can be no doubt but that the changes in the brain and the lesions of the heart described above were fresh and characteristic of the effects of the sun. (See Plates I and II.) a The following seems to me to be the most probable interpretation of our observations on monkeys, dogs, rabbits, and cats. The heat radiated from the sun warms the body tissues more rapidly than can be compensated for by the regulatory organism of the body. The tissues and the blood in- crease in temperature to a point higher than is compatible with life. Ap- parently the organs most susceptible to this increased heat effect are the brain and heart. It is undecided whether the lesions in the brain or heart are the most essential in causing death. The most important fact shown by these experiments is that the outer parts of the body are heated by the sun to a greater extent than the inte- rior. Therefore, I next endeavored to ascertain the effect of the rays of the tropical sun upon the temperatures of the skin of man. I have not found any account of experimental work done in this line. Diiubler * discusses the skin temperature and shows the necessity of investigations in the Tropics. The only fact which need be mentioned here is a statement by Schilling. This investigator placed a thermometer between the teeth and cheek in the mouth of a man. In the room, the thermometer showed 36.6. The man exposed his face to the sun when the sunshine thermometer registered 55°, the thermometer in his mouth rose to 37°.05. THE TECHNIQUE OF THE EXPERIMENTS. Mercury thermometers, even if especially constructed for taking the skin temperature, are not suitable for this work because it is impossible to protect such instruments against the radiation of the sun. The only method suited to taking exact measurement of skin temperatures is thermoelectric, as it has been applied by Kunkel *? and Rubner, Kisskalt,?? Reichenbach, and Heymann ** in the study of the normal skin temperature in men. The greatest difficulty to be overcome in the construction of such an apparatus for our studies was to keep the secondary place of junction of two metals at a constant temperature, even in the sun, and to avoid disturbing currents produced by changes in temperature of any junction between two different metals in any part of the circuit outside the thermocouple proper used for the measure- ments. ™ Die Grundziige der Tropenhygiene, Berlin, 1900. 2 Ztschr. f. Biol. (1889), 25, 55-91. *S Arch. f. Hyg. (1909), 70, 17-39. *4Ztschr. f. Hyg. u. Infectionskrankh. (1907), 57, 1-22. 101801——2 118 ARON. This danger is avoided by introducing two thermocouples in opposite directions in such places, the one neutralizing the other. If care is now taken to keep two such junctions (x and y) at equal temperatures, absolute changes in temperature will not produce current from such junctions. This is shown by the following figures, in which Scheme I shows the usual arrangement and Scheme II that employed by me. Scheme I, Scheme O According to this principle I have con- structed an apparatus suitable for taking skin temperatures, and also others for taking temperatures inside of clothing or under the skin or even in the rectum of a monkey. Figure 2 is a diagram of the thermocouple used. Constantan in the form of wire (black in the figure) and iron wire (dotted in the figure) each of 1 millimeter diameter were soldered together. The junction at A was kept at a constant tem- perature which could be read to 0°.1 by means of a sensitive normal thermometer T, the mercury bulb of which M was at the same point as A. Both wires were hammered to a fine leaf of about 0.1 millimeter thickness at the “thermometric” junction B and soldered together so that two fine plates resulted, which were carefully cleaned from all superfluous solder by sandpaper. These were placed exactly in the same level. This system of wires, surrounded by silk and insulation tape, was inclosed in its upper two-thirds in a glass tube C fitted in its lower one-third into a wooden box H - of the shape of a tobacco pipe. The lower part of the glass tube and the wooden box were filled in with melted paraffine P. The lower end of the paraffine was formed into a block, the leaf-like junction B being carefully cleaned from all paraffine, so that there was left only a minute space between B and the paraffine block P. The glass tube C was now inserted into another, larger tube D by means of two rubber stoppers, EH and F, E having three holes, one for D and the other two for two glass tubes G, and G,, which served to circulate water. The iron wires coming from A were fixed in two pole screws S on the upper end of the glass tube C. The wires, I, led to the galvanometer. Finally, D was covered with a layer of felt and cotton K and inclosed in a cylinder of white carton paper L. Water entering at G, and leaving at G, kept the temperature of the secondary couple A constant even in the hottest sun. G, was connected by a rubber tube about 3 to 4 meters in length with a tank containing 50 liters of water. The copper wires, I, with a strong coat of yellow silk insulation were coiled in the usual manner. The measurements were taken on a flat roof, while the galvano- meter, connected by means of a copper key, and the wires, I, were inside the room, protected from the sun. The apparatus was freely movable and served the purpose well. I will not designate the form as ideal, but it must be re- Mmembered that it was entirely built in Manila. ACTION OF THE TROPICAL SUN. 119 The galvanometer was of the d’Arsonval principle, formerly used at the Weather Bureau and kindly loaned to me by the Rey. José Algué, S. J. Series of test experiments were made when the apparatus was complete. B was immersed in oil baths of different temperatures in one series, in another it was inclosed in a tube fitted with a thermometer and immersed in water, the temperature of which was varied. In a third series the temperature of A was changed and that of B kept constant. Of course, all the wire connections, the galvanometer, the scale, and the position of the telescope were kept unchanged. One division of my tangential scale was equal to 0°.19 of the thermometer, and half of this interval could be read exactly and quarter intervals approximated. Readings were therefore correct to 0°.1. The deflection of the galvanometer was directly proportional to the change in temperature if the temperature limits were not greater than 8° or 9°, equal to about 40 parts on my scale. The second type of apparatus is shown in figure 3. One constantan wire and one iron wire were soldered together. The place A was to be kept at constant temperature, and B to serve as the thermo- ¢ metric junction. Here the wires were ham- mered to fine leaf and soldered together in the form of a very flat V. They were insulated by tape and covered with a layer of silk and oilcloth. A was fixed on the mercury bulb M of a thermometer T and inclosed in a tin eylinder C so that the wires did not touch the tin box C. Two copper wires I led from the iron to the galvanometer, the places of junc- tion between iron and copper being kept at the same temperature. The tin box C was placed in a Dewar vacuum-jacketed vessel of about 300 cubic centimeters capacity, which was filled with oil O. The Dewar vessel, resting on a piece of bamboo H, was placed in a large glass jar F which was filled with carbon K. The Dewar vessel was closed by a cork stopper G, having holes for the thermometer and the four wires. The carbon was covered by a cylindric cardboard H, which latter was covered with cotton. Whe two wires of constantan and iron in this drawing are shown shorter than in the apparatus, the place B was freely movable and 1 meter distant from the jar F which was kept under a large wooden box. The temperature of A was constant for one hour or more at 0.01. Test experiments were performed for each apparatus at varying intervals by placing B in oil baths of different temperatures. One division of my galvanometer scale corresponded to 0°.423 on the thermometer in the apparatus I used most, so that the sensitiveness of this thermocouple was less than one-half of that used for measuring the skin temperatures. Thus, larger temperature variations, accurate to 0°.2, could be recorded with this second type of apparatus. A few words are necessary concerning the technique of taking the skin temperature. ‘Two persons must codperate in making the measure- ments, one reading the galvanometer, the other handling the thermo- metric apparatus. The latter work was performed by a clever native 120 ARON. of long training, who was also able to read the galvanometer. How- ever, I generally preferred to do this more responsible part of the work _ myself. After adjusting the apparatus, taking the zero point of the galvano- meter and being sure that the-place of junction was being kept for at least five minutes within 0°.1, the thermometric junction was warmed in the palm of the hand and then placed on the different parts of the skin, which were to be measured. The metal leaf must just slightly touch the skin, and must be kept at one place until the galvanometer just reaches its maximum deviation; with my apparatus twenty seconds was almost more than sufficient for this purpose. Especially in experiments con- ducted in the sun, the place to be measured must not be touched too long, because the thermometer itself casts some shade. According to Kunkel’s suggestion I have measured falling as well as rising tem- peratures, but I observed no difference between them. It is more tedious to take the temperature in the hair or under clothes. Here a thermocouple of the second type must be left for three or four minutes until the maximum of deflection is reached. Care must be taken to have the metal well covered by hair in taking the temperature of the air in the hair. The skin temperatures at different parts of the body,.especially that of the head and arms, were first measured on a number of people, both white and brown, inside of a room and also in a shady place outdoors. The values obtained vary within the extreme limits of 31° to 34°, the greater part of the skin showing temperatures between 32°.5 and 33°.5. The values given by Kunkel for a room temperature of 20° are nearly 1° higher on an average than those of Rubner for temperatures of 25°.6 and 26°.5, and then my figures are for room temperatures of 26° to 30°. My figures agree very well, on an average, with those of Reichen- bach and Heymann. Different places on the skin do not have exactly the same temperature ; that over thicker muscular parts or over abundant fat being always higher, often as much as 1°, than that found in places where the bones lie closely under the skin. This is very pronounced over the malar bones, and on the hand. The highest temperatures gen- erally occur on the forehead and neck; the palm of the hand is always warmer than the back, and similar variations occur in other parts of the body. Care should be taken always to measure the temperature on a dry skin; wet skin gives different values. Table VII shows normal values for the skin temperatures as obtained from a number of experiments on different people. The values given by Rubner and Kunkel are placed beside them for comparison. 121 ACTION OF THE TROPICAL SUN. € 8S 9°88 (OM Agee | Cee ree aes |e me | 8°38 lS } aera ae aaa! rf dinjeiedurie, uro0od ‘syoolqns ver 5) ae ees 8°38 32s CAR | Mesenteric all Ag IAS Seer i nae ue ee et Steno pag ene ae 0°S§ 9°S§ I ¥§ Bnet Sage en cya tae 8°&§ i : RT age le ae oe ainyeledure} uroor ‘syoolqns OAT, eee | See gree "ee o'Fe waenn-an----|---------|'eze [zeae 066 81n} 4 DEN youq uayoro y Resins cast st| een Lone 9S 0°S§ 8°cg Soa ae eine a pees OE IES 9°E8 Soros anaa|aomaoa=-—--=- 66 9injyBiodu1e} mOOL ‘yoolqns ouO oo . 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(1895), 140, 125-157. 126 ARON. must be for this reason that the brown skin, while absorbing more heat, is found to have lower temperatures than the white skin under similar conditions. The regulatory apparatus of the brown is more sensitive and works more promptly and successfully. This statement deserves at- tention, because the experiments on dead skin only served to convey a wrong impression of the behavior of colored and white skin when exposed. to the sun’s rays. TABLE I1X.—Comparative increase in temperature of white skin and brown skin when exposed to sun, as obtained in the three foregoing experiments. Time in minutes. Temperature of cheek. MIs II. III. In In su.) shade. White. | Brown.| White.| Brown.| White.| Brown. °C. °C. °C. °C. °C. °C. 0 0 32.4 32.6 33.1 32.9 33.3 | 34.0 AQu (Cees ores AaRe SC eee ae 35. 2 34.1 36.6 | 36.6 207 seo 36.5 BAG eee el A 37.4 | 36.4 0) SS eh eee 35.6 34.4 36.3 | 35.4 40 .||c2 ees a88)04] ' 838256 ))| 4 See ses Pee ees See ee Lee £5) 0 it (ae Fee ee (a peppers) rete ster ure eral) payee Toc ee | eas ey 60! |e aces eee Sea oDse SoS | Rees eee 0 0 33.4 33.8 33.3 33.5 33.9 | 34.4 DO), |[Se Se 2 |e eee Sen ee 36,2 30, 6 36.4 | 35.9 20 See 36.3 3651:)|-- eS sas Re ee 35.9 | 35.4 S108 ee a Eee sel ee 35. 4 34,8 35.6 | 35.2 (50) eee ee WB 2T4 BBS ON een ae ae ee are (ey eel eee 0 ee | eee 35, 4 O45 Oi See nena | aeons ® Muscular work. It is a matter of general observation that, at a time when the white man is perspiring over his entire body and the sweat is dropping from his face and forehead, the brown man shows only a fine, velvet like layer on his skin. It is not the sweat which we see, but that which we do not see which exerts the cooling effect; in other words, the water evaporated, not the water secreted is of value. Sweat which drops is water lost from the body without the corresponding cooling effect. There is economy in sweating, and the most economical way is to secrete no more water than can and will be evaporated. Hypersecretion is useless, and it deprives the body of water. It seems to me that the brown man is superior to the white in this economy of sweating, and we find an expression of that superiority in the lower skin temperature of the brown man in the sun. It is as yet undecided whether the result is due to the color, or if the nervous regulation of the sweat glands, or ACTION OF THE TROPICAL SUN. 127 even the anatomic build of the latter, is not different in the tropical races from that of white men. Daubler states that the negro has larger and better developed sweat glands than the white man. The fact that Rubner could not find greater water evaporation in negroes than in Kuropeans at high air temperatures does not contradict my supposition, for, if I am right, the dark skin is superior to the white only in the sun, where radiated heat is absorbed more intensively by the one than the other. Certain parts of the body, in brown as well as in white men, seem to sweat earlier and more intensively than others. For instance, the forehead always secretes sweat earlier than the arm. As a result, the - temperature on the forehead has begun to fall while that of the arms is still rising. In the sun the ultimate temperatures observed on the arm are generally higher than those on the forehead. The results obtained so far indicate that the temperature of the human skin increases in the sun, but does not reach the normal body temperature. In animals without sweat glands, the skin temperature rises above febrile heights and the tissues lying underneath are heated. On the other hand, penetration of heat through the human skin seems improbable, the effect of the rays absorbed being neutralized by water evaporation on the skin. The more perfect this water evaporation is, the better the normal body temperature may be maintained. The be- havior of normal dogs as compared with those which have undergone tracheotomy shows this fact plainly. Monkeys exposed to the sun in Manila die in little over one hour because of their limited capacity to evaporate water, while man, with his well-developed sweat glands resists the same climatic conditions for a much longer period without detriment. | My experiments demonstrate the enormous physiologic and hygienic importance of ample water evaporation in the Tropics. We are the better off, the better we can lose heat by water evaporation. Water evaporation from the skin is the most complete when a large part of the skin area is uncovered. The native laborer in the Tropics generally wears but little clothing, often only a breechclout. On the other hand, the white skin can not withstand the direct rays of the sun. Sunburn, erythema solare, or even more severe lesions, are produced by the sun’s rays, while such injuries rarely occur with the brown skin. The range of the rays which produces this effect is not entirely known, but it is to be presumed that they lie in the violet end of the spectrum and beyond. Now, because of this effect the colored man can expose his body to the tropical sun, but the white man must keep covered. Neces- sarily, under the same climatic conditions, water evaporation from the skin when uncovered is much more free than that from the same skin covered with clothes. If we further consider that the colored skin 128 ARON. seems to be so arranged as to provide for a greater economy in sweating and water evaporation when exposed to the sun, we must conclude that the colored man, as regards his physical heat regulation in the tropical sunlight, is in a better position than the white man. The temperature conditions surrounding the parts of the body covered by clothes depend principally on the class of clothing worn.?" It will be important to learn what proportion of the heat rays are absorbed by the clothes, how freely they permit of water evaporation from the skin and how far free circulation of air is possible within them. The ques- tion of the extent to which heat regulation in the Tropics is affected by different kinds of clothing is of great physiologic and hygienic im- portance, and this problem will be considered in future investigations. While men, by reason of their superior facilities for evaporating water, are able to counteract the radiated heat from the sun more efficiently than dogs, cats, rabbits, or monkeys, this heat is not without its influence on the human being. The water loss which equalizes the radiated heat is considerable. A man lying quietly in the sun, in one hour lost 280 grams in weight. The water actually lost from the body must have been considerably more, because the sweat absorbed by the clothing is not in- cluded in the above figure. The pulse rate of a man sitting quietly in the sun increases on an average about 10 to 12 beats over the number for the same man in the shade. I have proved this by several observations. The quantity of air respired is also increased. An average of a number of observations shows the following: Quantity of air respired in liters per minute. Mini- | Maxi-| Aver- | Number of observations, mum. | mum. | age. | 22am Shades shes 2 ee ee ae eee 4.70 5.98 | 5.28 | | MPU TU SULT Ss Oe Ne 0 So rE aa ee 5. 83 7.90 | 6.74 | Therefore, the volume of air respired increases 23 per cent, or from 316.8 liters per hour in the shade to 390.4 liters in the sun. If heat production within the body is very great, as it is during strenuous muscular work, then, even in a temperate climate, the heat- regulating apparatus is not able to diminish the heat by water evapora- tion as quickly as it is produced, and as a result rises in the body tem- perature are observed (Zuntz und Schumburg).** If at the same time the body is also heated by radiation, the heat accumulatéd must be greater with a corresponding rise in body temperature. * Zuntz, Lowy, Miiller und Caspari, Héhenklima und Bergwanderungen in ihrer Wirkung auf den Menschen, Berlin (1906). ** Studien zu einer Physiologie des Marsches, Berlin. ACTION OF THE TROPICAL SUN. 129 This increased body temperature probably accounts for many of the accidents which usually are described as sun stroke or heat stroke; how- ever, several strokes of this kind, some even fatal, have been reported with but slight rises in temperature. No reasonable explanation of these in relation to the heat rays have been given. I wish to offer one ex- planation which seems to me quite plausible: Under unfavorable climatic conditions during muscular work, P. Schmidt has observed water losses as great as 1 kilogram per hour. The body can withstand a loss of water in a maximum of 10 per cent of its weight. An acute loss of 3 to 4 kilograms within a few hours, according to our experience with animals (Czerny), necessarily must result in severe disturbances, collapse or even death. It seems quite reasonable to assume that an excessive, continued water evaporation, while avoiding a rise of the body temperature, may lead to collapse, similar to that observed in cholera if the water lost from the body is not replaced. SUMMARY. 1. Under climatic conditions, even during the cooler seasons of the year in Manila, animals, such as rabbits and monkeys which by nature have only a limited power of physical heat regulation, or animals the physical heat regulation of which is artificially inhibited (tracheotomized dogs) die if exposed to the sun, the body temperature rising to febrile heights. If the same animals are protected from the rays of the sun, or if the increase of heat due to radiation from the sun is com- pensated by an increased loss such as would be brought about by a strong - wind, then the animals suffer no discomfort. Insolation of the skull alone is without effect if the body temperature is kept within normal limits. 2. The post-mortem findings on the animals dying as a result of in- solation show decided hemorrhagic lesions of the meninges in the brain, and in monkeys, in the heart. 3. In animals without sweat glands the subcutaneous tissues are heated by the radiated heat from the sun to temperatures above those compatible with life. 4. The human skin if exposed to the sun is warmed to about 3° to 4° above the normal skin temperature (32°.5 to 33°.5). Amn increase, even to the normal body temperature, is prevented by evaporation of sweat. The cooling effect of the sweat secretion causes a fall of the skin tem- perature even if insolation is continued during longer periods. - 5. The brown skin of Malays, while theoretically absorbing more heat in the sun, shows a smaller rise in temperature in the tropical sun than the skin of white men under similar conditions. As an explanation, it is believed that an earlier and better water evaporation by sweat secretion takes place. 6. The air in the human hair, especially in black hair, under the 130 ARON. influence of the tropical sun acquires temperatures far above those com- patible with life. 7. It is demonstrated that in the tropical sun a man with a colored skin is in-a better position as regards heat regulation than is a man with a white skin. 8. Types of apparatus suitable for testing temperatures thermo- electrically are described. In concluding, I wish to invite attention to more general biologic questions as regards climate. The monkey, whose home is in the Tropics, withstands the sun less readily than any other animal I have observed, including even the white man. Of course, the monkey does not live in the fields; his home is in the forest, into which only a small proportion of the direct rays of the sun can enter. He instinctively avoids exposing himself to the sun for more than a few minutes. The same is true of the native of the Tropics, if he is left to his own cus- toms. Even if he is otherwise nearly naked, he often wears a large hat-like arrangement which shades not only his head but his body. Certain features of any climate must always be met. ‘The temperate climate is only suitable for man if he protects his body against it. Our chemical heat regulation would not be sufficient to allow us to with- stand the cold of temperate climates without the protection of clothes and houses. The question of the best way to live in a certain climate will always be to learn how to avoid its injurious effects, or to secure protection against them. No better example than the monkey, which is killed by the tropical sun in from one to two hours, can be found to confirm . the above statements. 1 a rts of souls exposed to the sun. — [ ‘Brain of mnasey exposed to the sun. 5 ees FIGURES. ams Naas connections noes geQucmenes and. ( Uhosenocouile 131 ARON: ACTION OF THE TROPICAL SUN. ] [PHIL. JouRN. ScI., Vou. VI, No. 2. ARON: ACTION OF THE TROPICAL SUN.J [PHIL. JouRN. Scr., Vou. VI, No. 2. THE ERADICATION OF BERIBERI FROM THE. PHILIPPINE (NATIVE) SCOUTS BY MEANS OF A SIMPLE CHANGE IN THEIR DIETARY.’ By Weston P. CHAMBERLAIN.’ I. CHANGES IN THE FILIPINO RATION FOR SCOUTS * IN THE YEAR 1910. Influenced by the work of Braddon, Stanton, Fraser and others on the effects of highly milled rice, this Board investigated in 18 Scout com- panies the incidence of beriberi as related to the diet actually consumed by the men.* As a result of the knowledge gained the Board (then con- sisting of Captains Phalen and Kilbourne) on September 30, 1909, recommended that the following changes be made in the Filipino Scout ration : 1. That the daily amount of rice used per man be limited to 16 ounces instead of the 20 ounces formerly allowed. * Read, with permission of the Chief Surgeon, Philippines Division, before the Philippine Islands Medical Association at Manila, P. I., February 22 to 24, 1911. * Major, Medical Corps, United States Army; President of the Board for the Study of Tropical Diseases as they exist in the Philippine Islands. “The organization known as the “Philippine Scouts” consists of approximately 5,000 Filipino enlisted men serving as infantry. The commissioned officers are Americans. This organization is under the control of and supported by the War Department of the United States and is scattered in small garrisons throughout the Archipelago. The Philippines Constabulary, referred to later, is under the control of the Insular Government and has an enlisted strength of about 4,000 Filipinos. It is much more widely scattered in smaller garrisons than is the Scout organization and it has an entirely different system of rationing its men. ‘Kilbourne, H. D., Food Salts in Relation to Beriberi. This Journal, Sec, B (1910), 5, 127. 101801——3 133 134 CHAMBERLAIN. 2. That Filipino number 2 rice (an undermilled article) be substituted for choice Saigon rice (highly milled.)* 3. That 1.6 ounces of beans be added to the ration in place of the 4 ounces of rice not used. » 4. That the issue be authorized of canned tomatoes in lieu of an equal quantity of potatoes, but not to exceed 20 per cent of the total issue. 5. That onions be issued on the same terms as tomatoes instead of allowing them to be substituted for the entire quantity of potatoes. | 6. That no savings be permitted upon the ration of fresh beef and potatoes or their substitutive articles. The components of the Philippine ration at the time of these recom- mendations are shown in the following table: TABLE I.—Filipino ration, Army Regulations 1908, paragraph 1220. Component articles. Quantities. supsiimiive Quantities. Bacon ae 8 ounces. Canned meat_| 8 ounces. BEE) IGS 8 cceans ccesseceoassecsacacsccy OE ce Fish, canned_| 12 ounces. Fish, fresh ___| 12 ounces. Blourse oe ee ae a Ee AD § ounces___-| Hard bread __| 8 ounces. Baking powder, when in field and Ovens are not available_ ---_-------__ O3230UN Cees 2a See RICG s2e Cle eo eee ee eee DAD) OOOO ae a Potatoes:s2 22 fo AE Se ee 8 ounces__-_| Onions ~--_--- 8 ounces. Coffee, roasted and ground ____________ ounce! 282k ee eee Sup ar 6 ty ie ee ea Sec ee QVOUNICES =| ee cee ae Vinegars 22 Jute, Re etch Sh a cient ae CU OFS be De sel hy ee Sea Salts. Sessa s ee ee eee 0:64 0UNnC E24 ESE ne epee, Pepper: blackies nes oe ee eee O}02F0unCe=s Faas aaa eee It should be explained for the benefit of those not in the military service that such a ration does not indicate exactly what a company eats. “Savings” can be and usually are made on some components of the ration °“Polished rice,” “highly milled rice,’ “scoured rice’ and “white rice” have been used by various writers as synonyms. They are contrasted with “under- milled rice,” “medium milled rice,’ “unpolished rice,’ and “red rice,” all four terms indicating that more or less pericarp has been left on the grain. Some rices have red pericarp and others have white. If the red pericarp is all milled off, the grain is then white. Therefore, the use of the term “white rice” to indicate a highly milled article is objectionable because it leads to confusion between milling processes and color of pericarp. As far as the presence of adherent pericarp is concerned undermilled rice corresponds with the “cured rice” of India (not used in the Philippines) and the “Filipino number 2” rice of the Scout ration prescribed by General Orders, No. 24. ERADICATION OF BERIBERI. 135 and the money value thereof used to purchase other articles of the ration, or articles not on the ration, for the purpose of adding variety to the company bill of fare; or the money value of the articles saved may be added to the company fund. The first and third recommendations and indirectly that portion of the sixth recommendation relating to the saving of fresh beef were made effective by the following instructions of the division commander and must have gone into operation at the individual posts between the middle of November, 1909, and the first part of January, 1910. HEADQUARTERS, PHILIPPINES DIVISION, Manila, November 3, 1909. The CoMMANDING GENERAL, Department of Luzon (Visayas, Mindanao, and Camp Avery), Manila. Sir: The division commander directs that the attention of all Scout battalion and company commanders be called to the directions of the Secretary of War, that, with the exception of the meat component of the ration, Scouts will be rationed as largely as possible on native food products; to the recommendation of the Board for the Study of Tropical Diseases, that the amount of rice be reduced from 20 ounces to 16 ounces per ration, and that beans to the extent of 1.6 ounce per ration be used in lieu of rice; to Army regulation 1262, under which native food products not procurable locally can be obtained from the subsistence department as exceptional articles. In view of the above, company commanders should not draw rice to exceed 16 ounces per ration. Savings should be made as largely as possible on potatoes, onions and coffee, and native products, such as camotes, mongos, squash, ginger root, etc., be purchased. Very respectfully, (Signed) J. T. Kerr, Adjutant-General. Furthermore, steps were taken by the subsistence department to obtain a Filipino number 2 rice (undermilled) to replace the highly riulled or “polished” Saigon rice which was used for the Scouts. None of this undermilled rice, however, went into use until about August (as will be shown below). We consider that the provision of under- milled rice combined with the above instructions of the division com- mander would have put into effect the most essential features of the Board’s original recommendations. The situation was complicated by the arrival, toward the end of March, 1910, of General Orders, No. 24, War Department, February, 1910. This order greatly altered the Scout dietary. The components of the ration thus prescribed are shown below: 136 CHAMBERLAIN. TABLE II.—Filipino ration, General Orders, No. 24, War Department, 1910.° ® Component articles. ' Quantities. pope utalye Quantities. Ba CONG ees 8 ounces. Canned meat_____ 8 ounces. SEE NG eceacesnesosessce secre: SESE Fish, canned _-___| 12 ounces. ISHSa, Tyas 12 ounces. Plour.. 22 -362o ee eee eee eee 8 ounces____| Hard bread __-_-- 8 ounces. Baking powder, when in field and | 0.32 ounce -_|____________________ ovens are not available. IRIiCe whip UO RN On =e ee 16 ounces___| Rice, Satgon e (when Filipino No. 2 can not be obtained). Camotess.Coe ae ees oe a BOUNCES oe ale eal Sie Mongos! 222 ee se a eee ie ea 4 OUNCES 5-8 |ee eee coe es Coffee, roasted and ground_________ OFD,OUM Ceres | CERe Seon ee pene Gingerino0ob jee eee ee ee Obrounceses | Hee ae eee Suga se ee Se 2 OUNCES2.23|3_ eee eee Vinegar ss 225}. foes Seta OVOSeTl= sess Sk ee ee eee Salitete sche ooo oe eae OGL Ounce ze | Ese Sees eee Peppersblacki.2 2) == eee eas 0}020un Ces |e en ee a The camote is a vegetable allied to the sweet potato. Linn.) is allied to the bean. means an undermilled rice. The mongo (Phaseolus radiatus “Filipino No. 2’’ rice as the term is used in this ration The Board had no knowledge of this new ration prior to the pro- mulgation of the order in the Philippine Islands. It will be seen, however, that the order carried out in spirit the three most important recommendations of the Board in that an undermilled rice (Filipino No. 2) is prescribed in the amount of 16 ounces daily and mongos (equivalent to beans) are added to the ration in lieu of the 4 ounces of rice taken away. DATES ON WHICH THE COMPONENTS OF THE NEW RATION WENT INTO USE. The subsistence department at once proceeded to obtain mongos and camotes, but in order to use up the large supply of Saigon rice on hand a delay occurred in the issue of the Filipino number 2 rice. In deter- mining the dates on which the Scouts would actually begin to subsist on these new articles one must consider the date the article was delivered to the quartermaster’s department in Manila for shipment to posts, the time of sailing of the transports, the time spent on the voyage, the time spent in unloading and the delays (due to rations being drawn ®Since July 1, 1910, Scout companies have been authorized to make money savings on the entire ration and purchase therewith such articles as they need, but the purchases must be made from the subsistence department, provided it has the desired articles in stock. This new system does not materially affect the feeding of the Scouts. The money value of the ration at the present time is about 14 cents United States currency. ERADICATION OF. BERIBERI. 137 only three times a month) which would occur after the articles actually reached the commissary officer at the Scout post and which could not average less than five days. All of these factors except the last have been embodied in Table III. From a careful study of all the conditions it is possible to set a date before which none of the articles could have become a part of the diet, and a period during which they must have been gradually going into use. None of the Filipino number 2 rice could by any possibility have been in use prior to July 15, 1910, and but little could have been issued at any time in July. In August the issue became more general, and probably all Scout companies were supplied by the last of August or first part of September. The first consignments of mongos and camotes were shipped simulta- neously and none left Manila until May 20, 1910. Under the most favorable conditions of unloading and prompt issue one Scout command (three companies) might have put mongos and camotes into use as early as May 21, but probably did not. No other Scouts could possibly have been using these camotes and mongos before May 25 even granting that they were issued at once on arrival at the station. About half of the Scouts could not have received any mongos and camotes until well into June. The issue to the last of the posts was not completed fill the first part of July. The first shipments of ginger root occurred at the same time as those of camotes and mongos. In some of the Mindanao posts ginger root was received about ten days sooner than camotes and mongos, but not, however, before the last two or three days of May. The importance of fixing these dates will be appreciated when the beriberi statistics for 1910 are considered. The details for the shipments are shown in the following table: TABLE III. mietcesived Dates ast invoices were turned over to the quartermaster’s de- PEHICTOROE in depot partment for shipment to Scout posts in the Department of— ration. commissary, Manila. Luzon. Visayas. Mindanao. INOs)2) TICese= = July 5, 1910__| July 14 to Aug. 23 __| July 14 to Aug. 3 ___| July 58 to Aug. 5. Camotes —----- May 20, 1910__| May 20 to May 23> __| May 20to June 2° ___| June 3 to June 8.° Mongos--_------ May 18, 1910__| May 19 to May 254 __| On May 18__________ June 8 to July 7. Ginger root ___| May 19, 1910__| May 20 to June 17 __! May 20 to June 2 ___! May 19 to July 8. Time consumed in transit to | 2 to 16 days; aver- | 4 to 11 days; aver- | 4 to 18 days; aver- individual posts. age, 43. age, 71. age, 10. a This July 5 shipment reached Cotabato on July 13 and Torrey Barracks and Davao Issues to the troops were not to be expected immediately after it arrived. on July 15. b One post rationed August 17. ¢ One post rationed July 2. dQne post rationed June 3. 138 CHAMBERLAIN. THE CHARACTER OF THE RICE SELECTED. The Filipino number 2 rice selected by the subsistence department was examined as regards its pericarp by this Board and approved. It was a mixed rice, having grains with red pericarp mingled with those having a white pericarp. A large amount of the pericarp had been left on the grain. By analysis made in the office of the Surgeon-General of the Army it was found to contain, nitrogen 1.32 per cent, potash (K,O) 0.223 per cent and phosphoric acid (P,0,) 0.489 per cent, whereas the polished rice it replaced had contained only 1.08 per cent nitrogen, 0.098 per cent potash and 0.260 per cent phosphoric acid. The mixed red and white rice was approved for two reasons. First, it was possible to determine at a glance, without staining, whether suf- ficient pericarp remained on the kernel. Second, it was thought that if this red rice proved unwelcome to the Scouts a change could be made in subsequent contracts to an undermilled white rice which, by contrast with the red rice, would then probably prove acceptable, whereas it would undoubtedly have aroused hostility if substituted immediately for the highly polished article the subsistence department has in the past been issuing to the Scouts and which they have come to like because of its snowy appearance when cooked. It is probable that few of the Scouts were used to such a highly polished article prior to their enlistment, and in many sections of the Islands a red, undermilled rice is commonly used. After several years in the military service where they received only the highest grade of polished rice these natives have become spoiled in this respect, and it was to be anticipated that the substitution of an under- milled rice, whether red or white, would be distasteful to them for a time. The truth of the above reasoning has been demonstrated by the ex- perience of the Philippine Civil Government. At the Culion leper colony the inmates objected to an undermilled red rice, but apparently are satisfied with an equally undermilled rice having white pericarp. The use of undermilled rice has eradicated beriberi from that and other civil institutions in the Philippines, and at this point it may be mentioned that on May 4, 1909, Governor-General Forbes issued Executive Order No. 3%, forbidding the use of polished rice in any public institution. DISSATISFACTION WITH THE NEW FILIPINO RATION. For many reasons the new Filipino ration, as ordered by General Orders, No. 24, caused dissatisfaction among the troops and in the sub- sistence department. The Filipino number 2 rice, in addition to being undermilled, contained many unhusked kernels and much broken grain and dirt and furthermore was thought to become infested with worms and insects more readily than did polished rice. The camotes did not ERADICATION OF BERIBERI. 139 keep well and neither they nor the mongos could always be obtained in sufficient quantities in the Island markets. Therefore, some had to be imported. The ginger root was not acceptable to the Scout as a partial substitute for coffee. Neither mongos nor camotes met with favor as constant articles of diet. RETURN TO THE OLD FILIPINO RATION, The dietary problem was still further changed on November 7, 1910, when General Orders, No. 24, prescribing the new Filipino ration, was revoked by a cablegram from Washington. The question of diet there- fore reverts to its former status, viz, the old Filipino ration (Table I) with 20 ounces of polished rice as a component. There is, however, so much Filipino number 2 rice on hand in the subsistence depots that its issue and use will continue for several months. Meantime the Board is making efforts, to have the ration modified to the extent of forbidding the use of more than 16 ounces of rice daily per man and prescribing a first grade undermilled rice with white pericarp, in place of the highly milled grain which the ration now calls for. LESSON LEARNED FROM USE OF FILIPINO NUMBER 2 RICE. A very desirable lesson has been learned from the issue of the Filipino number 2 rice. The Board now recognizes that the term Filipino number 2 rice was an unfortunate one for two reasons. First, some samples of commercial Filipino number 2 rice are highly milled or polished; second, this rice is second grade not only in respect to its milling (i. e., pericarp removal) but also as to its husking and screening and probably at times is produced from an inferior quality of palay (padi). The original selection by the Board of Filipino number 2 rice as the beriberi preventing type was due to the fact that when our recommendation was made no other kind of undermilled rice could be found in the Manila market and there was much less knowledge of and interest in the subject, on the part of the rice dealers, than is now the case. What the Board now recommends for the Scouts is a rice of the highest grade and in all respects like the “choice rice” of the subsistence depart- ment except that it is “undermilled” (1. e., has much of its pericarp left on). In this connection the use of the word “milling” refers only to the process of decortication carried on (in most mills) between a stone cone and the metal-gauze case within which the stone revolves, and does not have reference to the other processes carried out in the building, such as husking, winnowing, screening and polishing between sheep skin buffers. We also recommend that, for appearance sake only, this rice be prepared from palay having a white pericarp. 140 CHAMBERLAIN. Such a rice can now be produced in these Islands and the millers state that its keeping qualities should be equal to those of highly milled rice. The Board has recently examined samples of a rice from Siam styled “Asylum No. IV.” ‘This is an undermilled rice prepared under the super- vision of Doctor Highet, of Bangkok, who states that it has been used for six months in an asylum and found to prevent the development of beriberi. Except for an occassional red grain, the rice is white and has much the larger part of the pericarp remaining on the kernels. There are very few unhusked or badly broken grains. The dealers state that they can furnish in quantity rice conforming to this standard. This rice is found by the Bureau of Science to contain 0.52 per cent of phos- phorus pentoxide and this we consider an index of its safety. It appears that rices containing over 0.4 per cent of phosphorus pentoxide will prevent beriberi, and this can be used as an indicator, irrespective of whether or not one accepts the phosphorus theory of beriberi production. II. GREAT REDUCTION IN THE BERIBERI ADMISSION RATE IN THE YEAR 1910. The numerous changes which have occurred in the Scout ration during the year 1910 render necessary a somewhat elaborate analysis of the situation before one can decide to which factors should be ascribed any peculiarity which may be found in the beriberi rate for the period. From the standpoint of scientific dietetic study it is unfortunate that so many alterations were made in such close sequence. Let us now determine if any peculiarity is manifest in the beriberi admission rate for the year 1910. A glance at the following statistical tables will settle the question by showing an unprecedented decrease in the amount of that disease among the Scouts for the calendar year 1910. TABLE IV.—Beriberi statistics for Philippine Scouts, calendar years 1902 to 1910. itera Admissions. Deaths. B Peni eae strength Calendar year. |Surgeon- pencias Num- | Rate per} Num- | Rate per| Num- | Rate per i ber. 1,000. ber. 1,000. | ber. 1,000. 1902225522 een 4, 826 598 123. 92 29 6.01 2 0. 41 1903) 22 See ees 4,789 614 128, 21 22 4.59 5 1.04 | 904) 33a se ee 4,610 334 74. 62 ao 1, 52 6 1.30 1905.22.23 4,732 _170 35. 93 6 1,21 il 0. 02 1906 =o ee 4,759 176 36. 98 9 1.79 6 1.19 1907 Se eeee es 4, 679 115 24, 58 6 1, 28 3 0. 54 1908) Tse Boe 5,085 | 618] 121.54 7 1.35 13| 2,50 1909. Sees 5, 369 558 103. 93 12 2.17 33 5. 96 WMO -eeoaesscece 5, 422 | 50 10. 00 2 , 0.36 3. 0. 55 ERADICATION OF BERIBERI. 141 TABLE V.—Admissions for beriberi by months, calendar years 1908 to 1910." | Year. Jan. | Feb. | Mar. | Apr. | May.|June.| July.| Aug. |Sept.| Oct. | Nov. | Dec. | Total. | 90 Reese eel 14 34 | 102 23 ol 33 55 39 63 59 88 63) 624 | PODGM EEE eee 138 89 96 88 38 24 28 36 7 27 22 11 | 604 HOT OR 19 8 12 3 4 1 0 2 0 0 0 1 50 From a study of Table IV, it is plain that beriberi was very prevalent during 1902 and 1903 and that there was a slow and gradual yearly decrease in its incidence down to 1907, when the total number of admis- sions had fallen to 115. In 1908 there was a sudden increase to 618 admissions, the largest number recorded in any one year. In 1909 the number of admissions was but little less, 558, while for the year 1910 there were only 50 admissions, a most significant drop when it is con- sidered that all the sanitary conditions were unchanged except the diet. The drop in the death rate and in the discharge rate are equally remarkable. IlI. RELATIONSHIP BETWEEN DECREASE OF BERIBERI AND CHANGES IN DIETARY. It will be seen in Table V that 39 (or 80 per cent) of the admissions occurring in 1910 appeared in the first three months of the year, a time when the ration changes recommended by the Board had been in effect- but a short time, or were just being put into effect. It is important to note that some decrease in admissions began in the last quarter of 1909 and that just prior to that time members of the Board had visited many Scout posts, especially those where the disease was rife, and had in- vestigated the dietary actually in use and advised company commanders to limit the daily consumption of rice and to use liberally the other components of the ration instead of economizing for the purpose of making cash savings. We believe that the effect of the Board’s recom- mendations at the Scout posts visited, followed by the ration changes inaugurated by the division commander and by General Orders, No. 24, has been to diminish the quantity of rice consumed by Scout companies ™Table IV, except for the year 1910, is taken from the reports of the Surgeon- General of the Army. Table V is compiled from records in the office of the Chief Surgeon, Philippines Division. The discrepancy between the total admis- sions in the two tables is due to the fact that in the chief surgeon’s record a new admission is recorded if a patient is transferred from one hospital to another, whereas in the Surgeon-General’s report, one admission is recorded for such a ease. The admissions (50) for 1910 should really be compared with the chief surgeon’s figures for 1908 and 1909 (624 and 604, respectively). This would make the showing even more favorable than is given in the text. Fractionally it means that the admissions for 1910 were less than one-twelfth of the average for the two preceding years. 142 CHAMBERLAIN. and to increase the amount of meat, beans (mongos) and other com- ponents used. The harmful influences attributed to polished rice are believed by us to be due not to the presence of any injurious element in such rice, but simply to the absence from it of some substance neces- sary for proper nutrition. Hence, it becomes evident that a diminution of the quantity of rice consumed and a substitution therefor of suitable articles of food might produce the same results as would be obtained from the use of an undiminished quantity of rice in which the necessary nutritive substance was present in proper amounts. Therefore, favor- able results following the carrying out of our recommendations would by no means be in opposition to the polished-rice theory of beriberi even when the good results appeared before the undermilled rice went into use. UNDERMILLED RICE NOT THE CAUSE OF DECREASE IN BERIBERI ADMISSIONS. It is obvious on examining Tables III, V, and VI that wndermilled rice could have had nothing to do with the great decrease in beribert admissions which occurred prior to August 1, 1910, and it probably could have had nothing to do with the low rate in August. Undermilled rice ‘ may have contributed a share to the continuance of the good results in September, October, November and December. INFLUENCE OF MONGOS, CAMOTES, AND GINGER ROOT ON DECREASE OF BERIBERI. A study of Tables III, V, and VI (together with the remarks above Table III) will show that the marked decrease in the beriberi rate for April and May and probably for June could not have been due to the mongos, camotes, and ginger root added to the ration by General Orders, No. 24. At this writing there are no figures to show how extensively mongos and camotes were used as a result of the division commander’s letter of November 3, 1909; so that a beneficial influence from mongos and camotes prior to May, 1910, can not be excluded. For reasons which will not be entered into here the Board does not consider that there is any special virtue in mongos and camotes as compared with beans and Irish potatoes which would enable them to prevent beriberi. There is little doubt that the mongo is a good beriberi-preyenting vegetable, but it is not any better than the bean recommended by this Board on September 30, 1910. We do not consider either camotes or potatoes of much value in preventing the disease. The influence of ginger root can be eliminated because of its date of issue as well as for other reasons. THE REAL CAUSE OF THE ERADICATION OF BERIBERI FROM THE SCOUTS. From the above discussion the Board concludes that the important beriberi preventing factor in the new Filipino ration prescribed by Gen- eral Orders, No. 24, was neither mongo, nor camote, nor ginger root, nor undermilled rice, per se, but was the reduction in the quantity of rice consumed and the substitution, in leu of the rice taken away, of a ERADICATION OF BERIBERI. 143 legumen, which in this case was mongos but which might equally well have been beans as recommended by the Board on September 20, 1910. The following table will show graphically the periods over which there was active each one of the five new factors, (a) undermilled rice, (b) camotes, (¢) mongos, (d) ginger root, and (e) reduction of rice to 16 ounces and addition of a legumen. The solid part of the lines in- dicates the period during which the influence was general and the dotted part the period during which the influence was beginning and did not affect all the Scout organizations. TABLE VI.—Beriberi admissions by months, calendar year 1910, and influences acting thereon. Jan. | Feb. | Mar.| Apr. | May. |June.| July | Aug. |Sept.| Oct. | Noy. | Dec. Admissions______-_-_- 19 8 12 3 4 1 0 2 0 0 0; 10 No. 2 rice (a@)--------- aterieiatate Wa. OLES HO) ee a pe a Ne valley ereyeie 50 MOTT OSH (CG) eee alice ih satay lena execs haul ieenerenen syetere (Gubayeeye NOOO (@)) seer! I Io oSootcoo ULING! (A) Sel oo | Reduction and leg- | | | | It is obvious that factor (e), viz, reduction in the amount of rice and addition of a legumen, is the only one which has been operative during the whole period of marked decrease in beriberi admissions. It might be argued, by those favoring the nitrogen starvation theory, that the decrease in beriberi in 1910 was due to an increase in the amount of meat con- sumed by the Scouts as a result of the letter of the division commander which directed the making of savings as largely as possible on potatoes, onions and coffee. We do not think that an increased meat consumption has been an im- portant factor for the following reasons: (a) The Scout did not as a rule make large savings on his meat component and (6) the meat allowance is so great (12 ounces) that the Scouts could make considerable savings thereon and still have an amount larger than is furnished the soldier of many of the European armies, the French allowing 10.6 ounces of meat, the Russian 7.75 ounces and the Austrian 6.7 ounces. In considering these figures it should be borne in mind that the average weight of a Filipino is about four-fifths that of a European or American. IV. BEARING ON BERIBERI RATE OF FACTORS OTHER THAN DIETETIC. During the year 1910 we are aware of no changes in the sanitary conditions among the Scouts, other than dietetic, which could account for the lowered incidence of beriberi. There has been no marked de- crease during 1910 in the admission rate for other diseases. The 144 CHAMBERLAIN. average monthly admissions for all diseases was 420.5 in 1908, 393.9 in 1909 and 341.5 in 1910. Since beriberi was causing an average monthly admission of over 50 in 1908 and 1909, while the average was only 4 in 1910, it is evident that the average monthly admissions for all causes other than beriberi was not materially lower in 1910 than it was in 1909. That the reduction in beriberi among the Scouts in 1910 is not coincident with a corresponding lessening’ of beriberi cases in the gen- eral population in the Philippines may be inferred from the following table of death rates which was furnished us through the courtesy of the officials of the Bureau of Health: TABLE VII.—Deaths from beriberi. In 22 : ee : D popula- Fiscal year. Miserly, on Total. about 5,000,000). 1906 oe ee eee oa oon Soeur es Sena ee eee 406 2, 228 2, 634 OQ 7 eek eee eek eh ee ne a eee Noe tS ee 403 1,377 1,777 1908 eh ee sr es SRE ie 492 1,180 1, 672 WOO cee pe ce A TES Pe ea ae er 924 1,765 2, 689 LON0) 222 ee Se a ne 1, 002 1,395 2,397 1917), (firstihalf) e222 = See eee ee 911 (®)2 eeeeee see a a Not obtainable. It should be noted that the rates in Tables VII are for fiscal years while those in Tables IV and V are for calendar years. Also that the rates for Manila, 1911, are only for half a fiscal year and correspond to the calendar period of June to December, 1910, a period when the ad- mission rate for the Scouts was practically nil. We do not attach much absolute importance to the figures in Table VII because the death rates for the general population of the Philippines, even in Manila, are notori- ously unreliable for beriberi as well as for other diseases. We do feel, however, that the rates are, relatively, as reliable for 1910 as for the few years preceding and that therefore any extraordinary reduction in the incidence of beriberi in 1910 would have been mirrored in these figures which show a decided increase rather than a decrease in the death rate for the calendar year 1910 in Manila. The number of cases of beriberi among the Philippine (native) Con- stabulary, furnished through the courtesy of Major S. C. Guerney, are as follows: 1908, 52 cases; 1909, 193 cases; 1910 (11 months), 61 cases. The occurrence of cases by months for 1910 is shown in Table VIIT and compared with admissions for same months among the Scouts. ERADICATION OF BERIBERI. 145 TaBLE VIII.—Comparison of admissions for beribert among Scouts and Constabulary. Pa B o ae oe) ele isl 3 3 D 3 a ‘ g 5 2 a i FI Se no) Wy se |e eee nese Pe rerie ik “espn 0tBp) Ue sbMi EE Cih) Ap IAs S ® aS 5 Ss 5 ® 2 S 2 Ss fy = 4 = 5 5 <4 n fe) Z A SCOUUS 2 ose Se eee 19 8 12 3 4 0 2 0 0 0 1 Constabulary_-----_-- 7 14 i 1 7 9 4 3 2 6 (?) The Constabulary consists of approximately 4,000 enlisted men, widely scattered throughout the Archipelago. For some years their beriberi rate has been much less than that for the Scouts, this difference probably being due to the fact that they are differently rationed. The admission rate for 1910 is only one-third that for 1909, but is higher than for 1908. On looking at Table VIII it is obvious that there was no such falling off in the beriberi admission rate among the Constabulary for the last half of 1910 as was seen among the Scouts. It must be admitted that the very high Scout death rate (2.17 per 1,000) and discharge rate (5.96 per 1,000) for beriberi in the year 1909 — may have been to some extent responsible for a low admission rate in 1910 because these two processes, death and discharge for disability, doubtless eliminated many old chronic cases which had kept returning on sick report after apparently having been cured. We do not think, however, that this was the important feature in lowering the admission rate for 1910. Vv. SUMMARY AND CONCLUSIONS. THE BOARD STILL ADHERES TO THE POLISHED-RICE THEORY OF BERIBERI PRODUCTION. The real factors in the eradication of beriberi from the Scout organi- zations have been a reduction in the amount of rice consumed and the addition of a legumen. The result was accomplished without the use of undermilled rice. The Board still favors the polished-rice theory of beriberi production as being the one best supported at the present time _by experimental evidence and practical experience in many localities. It is considered that the good results with the Scouts help to support the theory. The Board feels that the adoption of an undermilled grain for the Philippine Scouts will allow rice to be used more freely by these soldiers with less risk of beriberi than would be the case if the polished article were supplied to them. ‘This is a very important point because, as a result of racial taste and custom, a certain number of natives will attempt to subsist mainly on rice no matter how extensive, varied or well balanced may be the diet supplied to them by the subsistence depart- ment. If polished rice is being issued to the troops, those men will be 146 CHAMBERLAIN. the first to develop beriberi whenever for any reason a period of un- favorable dietetic administration supervenes. Since rice is the natural and economical diet for the oriental native it follows that the free use of undermilled rice is likely to work in the direction of both efficiency and economy. CONCLUSIONS. (1) Beriberi has disappeared from the Philippine (native) Scout or- ganizations during the last half of the year 1910. (2) There have been no sanitary improvements to account for this except the changes in diet and there has been no corresponding decrease _ in the admission rate for diseases other than beriberi. (3) There was no corresponding decrease in the incidence of beriberi in the general Filipino population or in the Philippine (native) Con- stabulary. (4) The decrease in admissions for beriberi among the Scouts was clearly marked for four months before the use of undermilled rice began. (5) The decrease in admissions was well under way before the mongos, camotes and ginger root of the new ration began to be issued. (6) The decrease in the admissions for beriberi was due either to uh- known causes acting coincidently with a reduction in the amount of rice used and the addition of a legumen, or was due directly to these dietetic changes. As no other reduction in admissions even approaching that of 1910 has occurred since the organization of the Scouts in 1901 we do not believe that the present decrease is due to coincidence. (7) The facts do not oppose the polished-rice theory of beriberi pro- duction. On the contrary, we believe that they support it. A CASE OF DYSENTERY CAUSED BY BALANTIDIUM COLI WITH COINCIDENT FILARIAL INFARCTION OF THE SREEEN By Frep B. BowMAN. (From the Biological Laboratory, Bureau of Science, Manila, P. I.) The clinical history and protocol of the following case illustrate very well the very serious nature of infection with Balantidium coli. In a previous paper? I reported two cases and there is a great similarity between one of these and that about to be reported, both in the clinical history and the findings at autopsy. The case was found during the routine examination of feces at Bilibid Prison, Manila, and was immediately placed under observation in the hospital. The patient, when admitted to the hospital, complained only of mild diarrhoea. He rapidly recovered without any medicinal treat- ment, the parasites disappeared from the stool, and he was returned to duty. One month later (August 17) the patient was again admitted to the hospital, complaining of pain in the chest, cough, bloody diarrheea, and fever. Temperature on entrance, 40°. I was unable to follow the case closely for a few days, but the temperature gradually became lower and he seemed to be improving until August 26, when his temperature again began to rise, the pulse became weak and respiration more rapid. On August 30 I examined him and made the following notes: The patient is a male Filipino, age 40, with no history of previous illness except occasional attacks of diarrhea during the past year. He appears to be in almost a collapsed condition and is roused with difficulty and then can not answer questions. . He is hiccoughing regularly and coughs occasionally, bringing up large amounts of greenish-white material, greenish flakes, and some blood-stained mucus. The tongue is heavily coated and the breath foul. The eyes are protruded and the pupils dilated. The face is distorted as if from great pain. There is some pulsation of the vessels of the neck. The pulse is weak and *Read at the Highth Annual Meeting of the Philippine Islands Medical As- sociation, Manila, February 24, 1911. *This Journal, Sec. B. (1909), 4, 417. 147 148 BOWMAN. thready, although regular. The apical impulse is normally situated and the heart is not enlarged. Pulse rate, 95 per minute. Breathing is rapid; vocal fremitus somewhat intensified in the base of the left lung, and this area is also somewhat dull on percussion. In the bases of both lungs and up toward the axille, coarse rales may be heard and also an occa- sional friction rub. The spleen can not be palpated. The liver is normal in size. The abdomen is slightly prominent and this is particularly apparent in the left flank, where there is distinct bulging. The entire abdomen is tender on palpation, but this is particularly noticeable in the colon area on both sides and in the epigastrium. There is great general muscular weakness. The patient lies for the greater part of the time with the legs flexed. The bowels move frequently and the motion is accompanied by tenesmus. The stool is very thin and sanguineous. During the past week there has been much blood present, more than at any time during the course of the illness. Microscopic examination of the feces shows many balantidia present (30 or 40 in one cover-glass specimen) also much blood and mucus. Blood examination.—The blood is very pale and coagulates slowly. Hemog- lobin, 70 per cent; white blood cells, 4,000. Differential counts show no eosi- nophilia to be present and the blood picture is practically normal. Urine, some albumin and a few casts present. August 31: The patient is much weaker and can not be roused. Heart very feeble. He is still hiccoughing. The abdomen is very tender, but no other signs of peritonitis are observed. The patient died on September 1 at 4.45 a. m. Many methods of treatment were used without any definite effect being produced. Hnemata of quinine, silver nitrate and thymol were given, also ipecac by mouth in large doses. Protozoa other than Balantidiwm coli were never found during the course of the disease, although the feeces were examined daily. The RULADEY, was performed by me four hours after death. The protocol follows: Autopsy.—The body is that of a well-nourished Filipino. Rigor mortis is present. The pupils are equal and dilated. The superficial glands are not pal- pable. There is a fair amount of subcutaneous fat and the muscles of the abdomen and chest are fairly well developed and of good color. On opening the thoracic cavity the sternum is raised with great difficulty because of fibrous adhesions. The pericardial cavity contains a fair amount of straw-colored fluid. Some fibrous bands may be seen between the visceral and parietal pericardium toward the apex of the heart. A few “milky patches” occur on the anterior portion of the heart, some having tags of tissue attached to them. A layer of yellow fat surrounds the heart. The coronary arteries are somewhat hard and tortuous. On cut section, the heart muscle is of good color. The wall ’ of the right ventricle is thickened. The valves of the heart apparently are normal with the exception of the mitral leaves, which are thickened and apparently incompetent. The aorta is thickened near the ventricle and is only slightly elastic. The lungs, both right and left, are firmly attached throughout to the chest wall by fibrous adhesions and can only be removed by rupturing the lung tissue. Both lungs are crepitant in parts, less so in the apices than in the bases. On DYSENTERY CAUSED BY BALANTIDIUM COLI. 149 cut section the lung appears mottled with dark red areas surrounding the bron- chioles and from these areas bloody serum may be expressed and from the bronchioles a creamy fluid. No nodules or calcified areas can be found. The bronchial glands are not enlarged. The peritoneum is distinctly thickened and is not glistening. Scattered over the surface are grayish-white patches. The spleen is normal in size. The capsule is thickened and fibrous bands of connective tissue attach the spleen to the colon and posteriorly to the abdominal wall. On passing the hand over the spleen surface numerous nodules may be felt from 1 to 3 centimeters in diameter. These project somewhat from the surface. On section, the pulp is friable and congested. The Malpighian bodies are indistinct. The nodular areas extend into the pulp for a distance ap- proximately the same as their diameter on the surface. When a nodule is sectioned the tissue bulges out and is bright red in color. Fibrous bands extend in different directions through the spleen pulp. The mesentery is greatly thickened. The mesenteric glands are not enlarged but many of them show some injection. The liver is somewhat enlarged and firmly attached to the diaphragm above by fibrous bands, and is adherent below to the gut. Cross section shows a loss of normal structure with areas of congestion scattered here and there. The gall bladder is normal and the duct is patent. The pancreas appears somewhat smaller than normal and is firmly adherent to the adjacent viscera. The capsules of the kidneys strip with difficulty. The striations are irregular and the kidney substance pale. The stomach appears to be normal, also the duodenum and small intestine. The colon (see Pl. 1) in its entirety is one mass of ulcers from which hang tags of necrotic tissue. The description given in the previous report* exactly covers the condition here present. The ulceration in this case is rather more general than in the one reported before, but perforation: has not taken place. The ulceration is much more severe near the rectum, it gradually becomes less so toward the cecum and in general appears very much like an amebic infection. The urinary bladder apparently is normal. Scrapings from the intestinal ulcers show numerous Balantidiwm col but no other animal organisms; those from the nodules in the spleen, from the wall of the urinary bladder, and from areas of pleuritis were negative. Anatomic diagnosis.—Broncho-pneumonia; chronic adhesive pleuritis; chronic adhesive pericarditis; splenic infarction; chronic nephritis; chronic adhesive peritonitis; chronic ulcerative colitis (Balantidiwm coli); perihepatitis; mitral endocarditis; arteriosclerosis. Histologic examination.—The histologic examination of all the tissues will not be given, special reference being made only to those organs which were found interesting pathologically. Spleen:—Appears normal in parts, but other areas show severe hemorrhage, the sinuses being crowded with blood cells and the normal splenic structure indistinct. Filarial embryos may be seen here and there.lying close together in the sinuses in groups of two or three. (See Pl. II, fig. 3.) These are much more numerous near the center of the hemorrhagic areas, gradually decreasing in numbers until the normal spleen tissue is reached. Colon.—Examination of one of the ulcers of the colon shows some balantidia US BLO Gitte 101801——4 150 BOWMAN. lying in the necrotic tissue and a few in the mucosa, the largest number being in the submucosa. Here they are seen in nests in the blood vessels and in the surrounding tissue; and they again may be demonstrated in sections cut through apparently normal portions of the gut at some distance from any ulcer. SUMMARY. During the past three years I have seen ten cases of infection with Ba- lantidiwm coli, although during the past eight months balantidia have been found in the feces of 16 patients in Bilibid Prison hospital. Two of the ten cases terminated fatally, but the others have had no symptoms other than an occasional diarrhoea. Even in the severe infections, the diarrhea was more or less intermittent in character, the parasites being found in the feeces only during these attacks. This phenomenon might be ex- plained in the following manner: The organisms, moving along in the submucosa, become so numerous as sometimes to form “nests” from which low inflammations develop, and which, proceeding to ulceration, cause erosion of the mucosa and set free the balantidia. (See Pl. II, fig. 1.) At this time the organisms are found in the feces. In some areas the blood-vessels appear practically to be occluded by the number of balantidia present and this fact in itself is sufficient to initiate an inflammatory process by lowering the tissue resistance. The possibility that the parasite may carry bacteria and thus cause an inflammatory reaction has been suggested. I have invariably found that the cellular infiltration which is present around the organisms situated beneath the unbroken mucosa practically consists of lymphoid cells and a few eosinophiles (PI. II, figs. 1 and 2), very few polymorphonuclear leu- cocytes being present. This fact in itself seems to show conclusively that the primary inflammation is not caused by bacteria. However, the necrotic material covering the ulcers is composed largely of leucocytes and there is no doubt that the terminal, acute ulceration begun by Balan- tidium coli in the underlying tissue is due to a great extent to the entrance of intestinal bacteria. The manner of primary invasion is not determined. It has not been established whether the mucosa must be injured before the parasites can enter or whether they in themselves are capable of piercing the uninjured mucosa. A third possibility is that they liberate a cytolytic ferment which causes the injury. However, once an entrance is gained, multi- plication rapidly takes place and it is only a matter of time until the entire colon may be infected. I have examined many preparations, both fresh and stained and fixed in the tissue, but have never seen any distinct evidence of conjugation taking place between two organisms. The balantidia may be seen in groups and in pairs closely attached, but showing no nuclear cytoplastic DYSENTERY CAUSED BY BALANTIDIUM COLI. 151 changes. It often has been observed that flagellates and ciliates tend to group themselves together in fresh specimens. This grouping ap- parently has no relation to conjugation and probably is due to mechanical action alone. We know that the organisms multiply by division. In almost any field where they are numerous, either in stained sections from colonic ulcers or in stained feces, partial or complete division of the nucleus may be seen. Balantidia with central constriction may be found in fresh specimens as may also many very small, elongated young forms which seem to be the result of this division. As yet we have had no success as to cultivation. I have observed balantidia alive forty-eight hours after inoculation on Musgrave and Clegg’s amceba medium, and Walker in this laboratory has noted life for one week on the same medium, but the balan- tidia apparently had not reproduced and those which remained alive were left from the original individuals which had been inoculated. In view of the fact that Brooks has reported an epidemic of dysentery due to Balantidiwm coli among the apes of the New York Zoological Park* and Noc F.® a natural infection in a monkey (Macacus cyno- molgus Geoff.) we would expect to be able to produce the disease experi- mentally in monkeys. I have attempted to infect monkeys, but have been unsuccessful. Fresh feeces from a case of severe infection were many times injected into the rectum and the monkey suspended by his lower extremities in order that none of the material could be evacuated. Frequent examinations showed no balantidia present. A colotomy was also performed on another monkey and 20 cubic centimeters of infected faeces were injected into the colon on two occasions. The organism never appeared in the feces. Some tissue from an ulcer removed at the autopsy reported in this paper was inserted beneath the mucosa of the colon of a monkey and well sutured in. This operation was done in the hope that in the tissue of the ulcer, resting or encysted forms might occur which would be more resistent to manipulation and conditions incidental to the changing of the host, and which might develop and infect the animal. No balantidia were ever found in the feces, nor were any symptoms of dysentery noted. I have never seen anything which could possibly be construed as an encysted Balantidiwm coli in fresh feces, although many round, vacuo- lated, nonmotile organisms were found in old specimens. In a short time these organisms became flattened and irregular, and extruded granular degenerative material from the periostome. *N. Y. Anw. Bull. Med. Sci. (1902), January. 5 Compt. rend. Soc. biol. (1908), 64. 152 - BOWMAN. CONCLUSIONS. 1. Balantidium coli is a parasite and, although not so common an infecting agent as the amoeba, in individual cases it is more serious in its effects. The prognosis in early cases is bad and in late ones practically hopeless. 2. A search through the literature fails to show a report of splenic infarction due to filarial embryos in an uncomplicated infection. In- farets of the spleen with numerous filarial embryos present haye been reported in a case of Bubonic plague.® Infarctions occur frequently in plague and it is possible that the embryo filarie in the case cited above were only present coincidently and not the primary cause of the infarction. 6 tber die Beulenpest in Bombay im Jahre 1897. Albrecht und Ghon: II. Wis- senschaftlicher Theil des Berichtes. B. (1898), 237. ILLUSTRATIONS. Pate I. Photograph of colon, showing severe ulceration caused by Balantidium coli. Prats IT. Fie. 1. Section through apparently normal colon, which microscopically shows two balantidia lying in the submucosa causing cell infiltration which will probably proceed to ulceration of the mucosa. 2. Two balantidia lying in the submucosa. Practically no cell reaction present. 3. Filarial embryos in spleen pulp, causing infarction. 153 BOWMAN : DYSENTERY CAUSED BY BALANTIDIUM COLI. ] [ PHIL, JOURN. Scr., Vou. VI, No.2. BOWMAN : DYSENTERY CAUSED BY BALANTIDIUM COLI. ] [PHIL. JouRN. Sct., Vou. VI, No.2. SOME OBSERVATIONS ON SO-CALLED FLAGELLATES, CIL- IATES, AND OTHER PROTOZOA ENCOUNTERED IN WATER AND IN HUMAN STOOLS. (PRELIMINARY REPORT.) By E. H. RUEDIGER. (From the Serum Section, Biological Laboratory, Bureau of Science, Manila, P. I.) During routine examinations of diarrheeal stools made a short time ago among members of what may be considered a camping party, flagellates (species undetermined) were encountered frequently, ciliates (species not identified) occasionally, and on two occasions one other protozoon which will briefly be described later on in this paper. Whenever there is an outbreak of diarrhcea, especially in a camp, the drinking water naturally is one of the first things to receive attention. The drinking water at the place in question was distilled and obtained from a distilling plant about 2 or 3 kilometers from the camp. ‘T'he water was stored at the distilling plant in a closed, practically air-tight iron tank, and it was delivered in a closed iron tank every morning; it was stored at the camp in large galvanized-iron cans with loose covers, from which the coolers were filled for drinking purposes. In transferring the water from the receiving cans to the coolers a milk pitcher or similar vessel usually was employed and in so doing the hand frequently came in contact with the water, thus making an avenue for contamina- tion; and other chances for infection were numerous. Samples of water from the various places, the distilling plant, the water wagon, the receiving cans, and the water coolers at the camp, were examined as follows. 1. May 16—A sample of 1,000 cubic centimeters of distilled water from the storage tank at the distilling plant and one of the same amount from the water wagon were put into a sterile flask, about 20 cubic centimeters of sterile, melted nutrient agar was added and the whole incubated for three days. Result of microscopic examinations made May 19: No amebe, no ciliates, no flagellates. 2. May 16—A sample of 1,000 cubic centimeters of water from the receiving cans at the camp was put into a sterile flask, and the same procedure followed. 155 156 RUEDIGER. Result of microscopic examination made May 19: No amebe, no ciliates, but swarming with flagellates. 3. May 16—A sample of 1,000 cubic centimeters of water from the water coolers at the camp was put into a sterile flask, and the method outlined above was followed out. Result of microscopic examination May 19: Ne ameebe, no flagellates, but a large number of ciliates were present. The results obtained with samples 2 and 3 at once attracted my atten- tion. Water from the coolers which previously had been in the receiving cans yielded ciliates and no flagellates, while the water from the receiv- ing cans yielded flagellates, but no ciliates. The appearance of ciliates in water from the coolers is explained readily by assuming that the ciliates were in the coolers when the latter were filled, or that they entered that water in some other manner while the receiving cans had remained free from them. However, the disappearance of the flagellates which were present in the water from the receiving cans and absent from the water in the coolers was not so readily explained and became the subject of some study. EXPERIMENT 1. May 21.—About 10 cubie centimeters of sample 2, containing a large number of flagellates, was put into a sterile test tube and about 10 cubic centimeters of sample 4, containing a large number of ciliates, was added. On microscopic examination many flagellates and ciliates were found. On May 22 microscopic examination showed a large number of ciliates, but no flagellates. On May 23 microscopic examination showed many ciliates, but no flagellates. EXPERIMENT 2. May 23.—A clean bottle of 250 cubic centimeters capacity was nearly filled with water, and about 10 cubic centimeters of melted nutrient agar was added and sterilized. After cooling, a few cubic centimeters of sample 3, rich in flagellates, and a few cubic centimeters of sample 4, rich in ciliates, were added. Microscopic examination made immediately showed a small number of flagellates and a small number of ciliates. May 24.—On microscopic examination, a moderate number of flagellates and a moderate number of ciliates weré found. May 25.—Microscopic examination revealed ciliates but no Lge IIe. May 26.—Many ciliates, but no flagellates. May 27.—A large number of ciliates, but no flagellates. May 28.—Many ciliates but no flagellates. EXPERIMENT 3. May 30.—One large platinum loopful of water rich in flagellates was put into the cavity of a hollowed microscopic slide, three loopfuls of water rich in ciliates were added, and a cover glass placed over the cavity. Microscopic examination made immediately after mixing the two showed a large number of ciliates and a moderate number of flagellates. On examining the mixture two hours later, ciliates only were found, all flagellates having disappeared. May 81.—Microscopic examination made about twenty-four hours after mixing the two showed all ciliates encysted; flagellates were not seen. FLAGELLATES, CILIATES, AND OTHER PROTOZOA. Lot EXPERIMENT 4. May 31.—One large platinum loopful of a culture containing many flagellates was put into the cavity of a hollowed microscopic slide, three loopfuls of a culture containing many ciliates were added and a cover glass placed over the cavity. On examination immediately after mixing, both the ciliates and the flagellates seemed very lively and appeared to attack one another. The motions of the flagellates soon became sluggish, and after about ten minutes ceased entirely. One ciliate which appeared to be about forty times as large as a flagellate, guarded a group of 20 flagellates crowded close together and entirely motionless. The ciliate continually circled around the group of flagellates, and as soon as one of the latter started to move he was attacked by the former which appeared to whip him with its cilia, a few beats of which seemed to render the flagellate motionless. Unfortunately, the observation had to be interrupted and when I returned an hour later all flagellates had disappeared, but the ciliates were actively motile. JI was not able to determine in just what manner the flagellates were disposed of, whether devoured by the ciliates or destroyed by lysis. Ciliates, after having disposed of flagellates, contained many large granules which in size and shape corresponded to flagellates and which disappeared within twenty-four hours. Ciliates grown in the absence of flagellates showed no such large granules, on the contrary the organisms were finely granular. EXPERIMENT 5. June 3.—One large platinum loopful of a culture of ciliates was put into the cavity of a hollowed microscopic slide, three loopfuls of a culture of flagellates were added and the cavity covered with a cover glass. On examining the mixture immediately after preparation a large number of flagellates and a small number of ciliates were seen. Both were actively motile and appeared to attack one another. Microscopic examination made an hour later showed the flagellates actively motile and the ciliates sluggishly moving. Microscopic examination ten hours after the specimen was prepared showed the flagellates actively motile and the ciliates encysted. 2 June 4.—Microscopic examination showed the flagellates motile and the ciliates encysted. EXPERIMENT 6. June 4.—About 20 cubic centimeters of water were put into a test tube, a small quantity of nutrient agar was added and the mixture then sterilized. After cooling, 1 cubic centimeter of a culture of ciliates and about 10 cubic centimeters of water rich in flagellates were added. Immediately after having been mixed, a moderate number of actively motile flagellates and a small number of actively motile ciliates were noticed under the microscope. June 5.—Microscopic examination showed a large number of flagellates and a small number of sluggishly motile ciliates. June 6.—The flagellates were actively motile and all ciliates were encysted. June 7.—Microscopie examination showed a large number of motile flagellates and a small number of encysted ciliates. MULTIPLICATION OF THE CILIATES. What appears to be the adult ciliate is pear-shaped or egg-shaped, the cilia (their actual number was not determined) are situated at the narrower extremity, and the organism moves in that direction. One nucleus is usually present. The organism increases in size (means for 158 RUEDIGER. taking measurements were not at hand), the nucleus divides to form two daughter nuclei, one of which moves toward the narrower, the other toward the broad extremity, the cilia disappear, motility is lost, the organism assumes an oval shape and a transverse constriction appears al the middle. The constriction becomes more and more pronounced, a circle of cilia appears at the proximal end of each daughter cell, the neck continues to narrow, the cilia become motile; finally, division of the cells is complete and each daughter cell, nearly spherical in shape, moves slowly away. As the organism increases in size it assumes a pear-like shape. Nuclear changes are frequent throughout the process of cell division. The nucleus, large and distinct, suddenly disappears from view, to re- appear in a slightly different part of the cell after a few seconds. At times two distinct nuclei are present in a daughter cell, these move toward each other and fuse to form one. Multiplication of the cells was not observed in the flagellates. CULTIVATION OF THE CILIATES. The following cultural tests were made in conjunction with bacteria that were present in the water or in the stools. Attempts to grow the ciliates free from bacteria were not successful. Nutrient broth—When inoculated with material containing ciliates and bacteria, it became heavily clouded and microscopic examination revealed motile ciliates and bacteria. A gar-agar.—A heavy, translucent, whitish, moist streak appeared along the line of inoculation. Microscopic examination showed a large num- ber of motile ciliates and bacteria. . | Lactose-litmus-agar.—A heavy, translucent, whitish, moist growth ap- peared along the line of inoculation. Microscopic examination showed many motile ciliates and bacteria. Attempts to cultivate the flagellates on solid media were unsuccessful. THE OTHER PROTOZOON PRESENT IN THE WATER. The other organism mentioned in the beginning of this paper was twice cultivated from diarrheal stools and was always found in cultures made of sewage and from a spring which, during rain, received the surface drainage of several hundred meters of the wagon road. The organism, when seen in cultures made after the method employed in examining’ water for amcebe, is bell-shaped. (See fig. 1.) A hair-like line, about five times the length of the organism, arising from the part which corresponds to the top of the bell, extends to a clump of dirt, a cluster of alge, or any substantial anchorage, where it appears to be fastened. The part which corresponds to the open end of the bell is surrounded by a circle of cilia which are actively motile and set up a whirling motion of FLAGELLATES, CILIATES, AND OTHER PROTOZOA. 159 the water surrounding the cell. Apparently there is slight suction into the broad extremity of the cell, which appears to be closed by a membrane. As dirt and bacteria become entangled in the cilia and appear to be sucked against the membrane, the motility of the former ceases and with a quick jerk the organism assumes the position shown in figure 2. The jerk seems to have freed the cilia and the membrane from dirt, the organism slowly moves back to its former position and the cilia resume their motility. CONCLUSIONS. 1. Flagellates and ciliates seem to antagonize each other. The ciliates, when in sufficient numbers, destroy the flagellates. If the flagellates sufficiently outnumber the ciliates, conditions then are unfavorable for the ciliates and they encyst. 2. The ciliates can without difficulty be cultivated in symbiosis with bacteria on liquid and on solid culture media. Attempts to secure the ciliates in pure culture have failed thus far. 3. The ciliates multiply by transverse division of the cell. 4. Attempts to cultivate the flagellates on solid media were not suc- cessful. ~ f cultivated from diarrheal stools. me ep ee, REVIEW. The Treatment of Disease. A Manual of Practical Medicine. By Reynold Webb Wilcox, M. A., M. D., LL. D. Cloth. Pp. vit + 1023. Philadelphia: P. Blakiston’s Son & Co., 1911. This “manual” of over 1,000 pages lacks both the conciseness of a handbook and the fullness and completeness of a system of medicine. The author has attempted to cover too much ground and to discuss diseases beyond his personal knowledge and experience. The value to a general practitioner in the United States of the sections on “Nasha fever,” “Japanese river fever,” “verruga,”’ etc., seems questionable, while to a practitioner in the Tropics a more complete treatment of these subjects is necessary. ; In the nomenclature of diseases the author too often falls into the un- fortunate error of referring to the diseases according to the names of the early describers of the conditions, rather than according to their true nomenclature. ‘Thus he describes Brill’s Disease, Weil’s Disease, Duke’s Disease, Friedrich’s Disease, Gerlier’s Disease, Milroy’s Disease, etc. The use of “Anchylostomiasis” rather than “agchylostomiasis” is not in accordance with the latest revision of the nomenclature of tropical diseases. ‘The arrangement of the subject matter seems logical and clear for the most part. Of the modernity and accuracy of the subject matter little need be said after noting that typhoid fever, which is now recognized as primarily a septicemia to be detected by blood cultures and secondarily as an infec- tion of the intestinal lymph nodes, is to be treated, according to the author, with intestinal disinfectants, etc., and then “If the disease is not inhibited the first week of the exhibition of these salts, the problem is complicated by the fact that the infection has become systemic;” and again, in the section on “Beriberi,” by noting the statement that “It is, however, quite likely that rice is really the medium through which the germ of this disease operates, because if cured be substituted for uncured rice the disease disappears.” The advantages of this textbook as compared with the more reliable and readable “Practice of Medicine,” by Osler, are so few as to make its field of usefulness limited. IDE (i. 163 Order No. 401. THE BONTOC IGOROT. By A. E. 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MEDICAL SCIENCES Vou. VI JUNE, 1911 No. 3 DAVAINEA MADAGASCARIENSIS (DAVAINE) IN THE PHILIPPINE ISLANDS. By Puiie HE. GARRISON.* The worms studied in the present paper were received from Dr. Vernon L. Andrews, of the department of bacteriology and pathology of the College of Medicine and Surgery, University of the Philippines, who collected them at autopsy from the small intestine of an adult, male Filipino, at the morgue in Manila in March, 1909. Doctor Andrews’s specimens are of particular interest because the last finding of Davainea madagascariensis (Davaine) was fourteen years ago, and this is only the sixth which has been reported. Infection with this species has been observed only ten times, and the occurrence which forms the subject of this paper marks the Philippines as a new locality in the interesting geographical distribution of this parasite. This new material offers an opportunity for a further study of the anatomical characters of the species.” HISTORY OF THE SPECIES. In 1867, Dr. Grenet obtained the first specimen from a male child eighteen months old, at Mayotte, Comoro Islands. This child had landed five months before from the Antilles. Later, Dr. Grenet secured a second specimen from a girl two years old, native of Reunion Island, who had been in Mayotte * Passed assistant surgeon, United States Nayy, formerly detailed medical zoologist for the Bureau of Science, Manila. *I am indebted to Dr. Ch. Wardell Stiles for access to a part of the original papers consulted, and to Dr. Brayton H. Ranson for several suggestions regarding the interpretation of certain anatomical characters. CF 102362 165 166 GARRISON. two months. Only about fifteen isolated terminal segments of the worm were secured from the first case. The second specimen consisted apparently of a fairly complete strobila, but was without a head. These specimens were sent to the Directeur des Archives de Medicine and forwarded to Davaine, who, in 1869, described and figured the worms and proposed a new species which he called Tenia madagascariensis. These specimens were later deposited in the collection of Blanchard’s laboratory (Nos. 108 and 109, Collection Davaine) . In 1873, a second finding of the species was made at the small island of Nosse-Bé, just off the northwest coast of Madagascar. This was not published until 1899 when Blanchard found the specimen in the parasite collection of the Faculty of Medicine of Paris (No. 33, Collection Davaine) bearing the label “Nosse-Bé, November, 1873, passed by a little girl of three years.” This specimen was very incomplete, being only 32 millimeters long, but it possessed the head, and Blanchard’s paper in 1899 gave the first description and the only published drawing of the head of this species. In April, 1891, Dr. P. Chevreau announced the finding of four cases of infec- tion with D. madagascariensis in children at Port Louis, on Mauritius Island, off the west coast of Madagascar, where, at the instigation of Blanchard, he had made a special search for the parasite. Two of the children were little girls of five years. The sex and age of the other two were not given. The specimen from one of the children, which was sent to Blanchard (Collection R. Blanchard, No. 8) consisted originally of three fragments which in transit were broken into eight, and, according to Blanchard, represented parts of two worms, There was no head. Blanchard gave a brief description of the specimen in 1891. In the same year (1891) Leuckart reported that he had received from Krabbe a specimen of Davainea madagascariensis collected at Bangkok, Siam, from the three-year-old son of a Danish sea captain, living on his father’s ship which was plying in Asiatic waters. Later in 1891, Leuckart reported the results of his study of the specimen, which consisted of a single worm about 24 centimeters long, including the head. This material was further studied by Holzberg in 1897. The fifth and last finding of the species prior to the present one was reported from South America in 1895 by Daniels who obtained two specimens at autopsy from the jejunum of an adult, male aboriginal Indian at Georgetown, British Guiana. The heads were not found and, having only Davaine’s original, descrip- tion of D. madagascariensis available, Daniels considered his specimens to be specifically distinct and proposed a new species under the name “J'enia demera- riensis?” A part of Daniels’s material was sent to Sir Patrick Manson and through him reached Blanchard (Collection R. Blanchard, No. 236) who estab- lished its identity with D. madagascariensis. The history of the six findings of Davainea madagascariensis, accordingly, extends over a period of forty-two years, and may be summarized as follows: Grenet, 1867, Comoro Islands, two cases (male child eighteen months old and girl two years old, from the Antilles and from Reunion, respectively), two worms without heads; specimens studied and published with illustrations by Dayaine in 1869. ?, 1873, Nosse-Bé Island, one case (three-year-old girl), one immature worm with head; specimen found in Davaine collection, studied and published by Blanchard in 1899 with figure of head. Chevreau, 1891, Mauritius Island, four cases (two girls five years old, two with age and sex unknown); fragments of two worms without head from one case sent to Blanchard and briefly described the same year. Krabbe, 1891, Siam, one case (Danish boy three years old); one specimen DAVAINEHA MADAGASCARIENSIS. 167 complete with head; published by Leuckart in 1891. (Further studied by Holzberg, 1897.) Daniels, 1895, British Guiana, one case (adult, male native), parts of two worms, no head; published in 1895 as Tema demerariensis with illustrations; part restudied and published by Blanchard in 1899. Andrews, 1909, Manila, P. I., one case (adult, male Filipino), one complete worm and four nearly complete except the head; deposited, No. 305, in Helmin- thological Collection, Bureau of Science, Manila, and reported in the present paper.’ Three other papers are of special interest in the history of this species. In 1891 Blanchard and Railliet established the genus Davainea in which they placed about twenty-five species, including D. madagascariensis. In 1896 Stiles established D. proglottina (Davaine, 1860) of poultry as the type species of the genus Davainea. In 1898 Holzberg published a careful study vf the reproductive organs of the genus Davainea, Leuckart’s specimen of D. madagascariensis being among the material examined. © IDENTITY OF THE SPECIMEN. Certain not insignificant differences between the anatomical structure of the Philippine specimen and that described for earlier specimens of Davainea mada- gascariensis will be noted in the course of the following description. These differences were such that it seemed at first that we must be dealing with another species. Further study of the specimen and a careful comparison in detail with the figures and descriptions of other authors have convinced us that ‘while certain differences exist seemingly scarcely consistent with specific identity, an actual comparison of the different specimens will be necessary before the real value of such variations can be ascertained. Such a comparative study should prove most interesting and valuable as well in clearing up certain ana- tomical differences apparently existing between the several specimens heretofore described. Until the actual comparison of specimens can be made, there is no doubt that Dr. Andrews’s specimens found in the Philippines should be placed with those of Grenet, Chevreau, Krabbe, and Daniels in the species Davainea madagascariensis (Davaine, 1869) Blanchard and Railliet, 1891. DESCRIPTION OF SPECIMEN. The specimens received from Dr. Andrews consisted of five worms, one com- plete with head and gravid segments, the other four evidently nearly complete excepting the head. The five worms were entered in the Helminthological Collec- tion as number 305, A, B, C, D, E. The specimens were killed in an alcoholic solution of bichloride of mercury and preserved in 70 per cent alcohol containing 5 per cent of glycerine. The size and general characters are as follows: 305 A.—Thirty-nine centimeters long, head present and strobila complete in one piece from head to gravid segments. ; 305 B.—Twenty-eight + centimeters long, head and neck missing, remainder of worm in one piece from near the neck to gravid segments. ’Tt may be noted that while Davaine named the species after Madagascar, as indicative of the general locality where the first specimens were found, the parasite has never been reported from Madagascar itself. 168 GARRISON.., 305 C.—Twenty-nine + centimeters long, head and neck missing, remainder of worm in one piece from near the neck to gravid segments. 305 D.—Twenty-nine + centimeters long, head and neck missing, remainder of worm in one piece from near neck to gravid segments. 305 H.—Four fragments, apparently parts of the same worm; two pieces, 1.5 centimeters and 9 centimeters long, respectively, consisting of rectangular seg- ments; two pieces, 2.5 centimeters and 13 centimeters long, respectively, consist- ing of terminal, barrel-shaped segments. The complete specimen with head (305 A) was mounted in toto. Specimen 305 D and portions of 305 E were used for sections and digestion. In determin- ing the various anatomical characters, all of the material has been studied. EXTERNAL ANATOMY. Head.—The head and neck unfortunately became badly folded in mounting. The actual breadth of the head as it lies is 256 uw. Allowing for the folding, its full breadth appears to be about 320 mw but certainly can not exceed 400 uw. Blanchard described the head as about 930 u broad by 510 wu long. Leuckart does not give the general dimensions. The suckers in their greatest diameter measure from 105 to 125 wu, their lumena from 30 to 45 uw. They are devoid of hooks. In Blanchard’s specimen the suckers measured 465 mw in diameter with a lumen 100 w in diameter. They also were unarmed. Leuckart does not mention the presence of hooks on the suckers of his specimen. The rostellum is strongly retracted within the head and its contour can not be made out. Imbedded in the head there remain about twelve hooks of. the rostellum, of the peculiar “hammer-like” shape of Davainea. These hooks measure 23.5 to 25.2 w long over all. The long root is rather sharply bent somewhat | beyond its middle and measures about 21 mu in length and is about 5.6 w broad as it joins the blade. The blade and the short root are continuous in one line, each projecting about 2.8 mw, the blade being sharply curved and the short root straight and blunt. In Blanchard’s specimen the rostellum was invaginated, forming an apical sucker 250 w in its transverse diameter and 145 mw deep with a deep cup-like depression 83 mw in its greatest (transverse) diameter. The hooks were absent, having evidently fallen off. In Leuckart’s specimen the rostellum was plump, retracted, about 100 » broad and presented a circular depression at the apex of the head. Around the equator of the rostellum was a ring of about 90 peculiarly shaped hooks, each with a long, slightly curved root measuring 18 y, a short, blunt, posterior root, and a blade about one-eighth the length of the long root, with which it makes an angle of about 70°. Neck.—Because of the folding of the specimen the real breadth of the néck can not be made out with entire satisfaction, but it appears to be about the same as the head, and it is not possible to make out any tendency to the broaden- ing of the neck behind the suckers as described by Blanchard. From behind the suckers the neck gradually grows narrower and reaches a minimum breadth of about 160 » at a distance of about 2 millimeters from the tip of the head. At about this same point the first signs of segmentation are seen and the genital primordia appear shortly after. Leuckart states that the breadth was “only 500 m just behind the head.” Blanchard’s specimen measured 1,240 « a short distance behind the head and then decreased to a minimum of 500 m, at which point segments are already defined. Segments.—As stated, segmentation appears at about the minimum breadth of the worm (160 uw) at a distance from the tip of the head of about 2 milli- DAVAINEA MADAGASCARIENSIS. 169 meters. The youngest segments are only about 50 mw long, there being’ about 20 in 'the first millimeter after their appearance. Gradually increasing in length and breadth the segments attain a maximum breadth of 1.5 millimeters about 15 centimeters from the tip of the head and at this place the length of the segments has increased to something less than’ 1 millimeter, 1’ centimeter of the length of the strobila containing from twelve to fifteen segments. Thereafter, the segments increase in length,’ remaining about the same in breadth, for a distance of from 10 to 12 centimeters, when they aré about square. The lengthen- ing then ‘continues, while the breadth shows a tendeney to decrease, the segments at the same: time beginning to take on the “barrel” shape which becomes more pronounced as we approach the posterior extremity.’ The terminal gravid seg- ments, which comprise some 10 to 12 centimeters of the length of the strobila, measure about 2 to 2.5 millimeters long by 1 to 1.5 millimeters: broad. ' The total number of segments in specimen 305 A is ‘about 600. The younger segments tend to a trapezoidal form, the posterior border being somewhat broader than ‘the anterior and overlapping the anterior extremity of the succeeding segment. . -The genital pores are not prominent and in the younger segments are situated near the cephalic extremity of the lateral border, later holding a more posterior position, but always well forward of the mid-plane of the segments. They are unilateral with occasional transpositions. Usually the pore will be found on the opposite side in only a single segment, occasionally in two or three, and in one case (specimen 305 D) the pore was found transposed in about 70 consecutive segments. : INTERNAL ANATOMY. Excretory canals——The ventral excretory canals can be followed throughout the length of the strobila, connected at the posterior border of each segment by a transverse canal and attaining maximum diameters of 40 by 20 uw. The dorsal canal is about half the size of the ventral and can be followed in sections almost throughout the strobila. It is placed in a plane considerably mediad to that of the ventral canal, and both canals are situated a considerable distance to the median side of the lateral nerve. The vagina and vas deferens pass between the two canals and behind the lateral nerve in all the segments in which the relative position could be determined. Gemtal organs.—As indicated above, the segments develop Shown September 5, 1910, to the Manila Medical Society. RICE DIET. 183 in a cage and fed on palay (unhusked rice) and kitchen stuff composed of scraps of meat, bread, and vegetables. He was then fed on Saigon polished rice, being allowed 118 grams of rice daily, and, unlike most of the fowls we have used, he ate it all day after day. He did well until June 23, the 39th day, when he staggered slightly on turning. July 2, the 48th day, he was observed to go down on his knees® after exertion. From the 48th to the 90th days he remained about the same, showing his trouble after exercise, but doing very well when not hurried. On August 12, the 90th day, he showed pronounced and typical signs of neuritis, namely, drooping of the wings and inability to keep the legs extended at the knee. His weight, shown on Chart 1, ran as follows: Date. Day. |Grams. Remarks. May el Goon aa rs Se eee USHEt Sess | Se See st Saigon rice begun. RMlahy s 21s See eee eee ee Gth===== 878 Ji ol=)-3 apexes 2 IS Oe eS Se See eee W/o, 786 NUT Cie BL = Berk ee ls LU phe 722 DUM CNS eres see eee 34th ____ 736 RUN C823) ee eer San eee ae SObh ==== 680 | Staggers. UU Pn eee eee a ee 48th ____ 701 | Occasionally on knees. TLIO ee tee Se ae eae See 2 Oot hemes 687 Yl Ou ee tees eae ee AE 62d 694 GUN ye nae a eae eee eee 69th —___ 708 aiullty: SO; aoe ae sees oe Be ee 76th —__- 708 PAC US 6} 6 eee ee ee ee GBol = 637 PANU UISt il oe aes ae ee See 89th —__- 623 | Mixed feeding begun. PAS ENULS C72) See ae a ee Syjnay 666 PAUP UST 2) eee eee ee ee 104th ___ 715 September sess ae eee eee 112th ___ 722 SepLemiberiGsesea=2 a= ame eee 114th ___ 710 | Chloroformed On the 39th day,,when the earliest signs of neuritis appeared, he had lost 22.6 per cent of body weight. From this day to the 76th he remained almost stationary, but from that time on began to lose rapidly until on the 90th day, when the signs of multiple neuritis were marked, he had lost 29.1 per cent. On the 90th day this fowl (number 5) was given a mixed diet of palay and kitchen stuff, in an effort to save him so as to see whether or not spasticity would supervene, as it had in the case of another fowl (number 17) similarly saved from death by mixed diet after the development of neuritis. It had been our experience that fowls went on rapidly to death after acquiring multiple neuritis, rarely living more than five or six days, but in this case (number 5) we were able to save the fowl, and, while his general condition greatly improved from the first, the signs of neuritis grew more marked for several days and then remained stationary until the 114th day, when he was chloroformed. In addition to the usual leg and wing signs of neuritis there gradually de- veloped a spastic gait. The fowl would stand and walk with knees stiff, teetering forward on the toes, and with the ball of the foot scarcely touching the ground. In an effort to maintain his balance he would take short, quick steps, and seemed to carry the body so far forward that his feet had to hurry to keep up. Figures 2 and 3 are from photographs taken to show the spasticity, but unfortunately do not give a very good idea of it. °In this paper “knees” means the joint formed by the tibio-tarsus and tarso- metatarsus. 184 CHAMBERLAIN, BLOOMBERGH, KILBOURNE. We have not been able to find any mention of this spasticity in the literature on the subject. It did not appear in any of our fowls fed on the same rice as number 5 and allowed to go on to death. Evidently it occurs late in the disease. Holst(11) speaks of finding some slight degeneration in the white matter of the spinal cord in fowls dead of polyneuritis but does not mention a spasticity of gait observed before death. Microscopic examination of sections of the cord from fowl number 5 showed no degeneration in any of the tracts. The sciatic nerves were extensively degenerated. Fowl number 7 of this class was remarkable in that he remained well for 89 days on polished rice, showing no sign of neuritis before death, which resulted from exposure in a storm. In all our experiments with polished rice we have found that those fowls which ate well would remain free from neuritis for much longer periods than the average in whom anorexia with refusal of food appeared early. More will be said on this phase of the subject later in connection with our starvation work in classes 13, 14, and 15. Fowl number 7 ate well from the beginning and always consumed his daily allowance of 118 grams. His weight, shown on Chart 1, ran as follows: Date. Day. |Grams. Remarks. Ren tn Ae hectare TL et UB Eat ce sy A eeoeetet cect Saigon rice begun. SM Saif 11 Sie Eee 28 ai nae ene tie ere Se, el oo 1, 162 pl Jibb clin Meee aE ee ee ae alee ore shin eal ab ay) Afi baobab hese oo Oe el a eee ee ee PAI hoe 1,091 Jilin le Se oe ae ae ee ee PANO || Ital TIME 25 So ES Eas ee er eg raed td SHU Dy eee elon 62, Tiny AD eee MA in A en tie renal Es AQ || 51, 181) DULL ya es lee Dea ee ek ee 49th __--| 1,119 CAO a a a ee, 56th ____| 1,140 IiUa yD sa ales ee ON US Rae (GPel 1,091 Dy SO eee ee aoe ee 70th ____-]| 1,098 ARI USEIG ste nats Dee eee Sek ee 77th __..| 1,048 VAST BUS tid Dees ss a oe RE Sa Geol te 1,020 | Found dead. Microscopie examination of the sciatic nerves showed slight degenerative changes. The characteristic attitude in polyneuritis gallinarum is shown in _ figures 4, 5, 6, 7, and 8, which are reproduced from photographs of fowls numbers 6 and 8 of this class. Class 3. Fed on 118 grams of polished rice, given by force when necessary.— In view of the fact that most of the fowls soon tired of polished rice, ate only a small part of their daily allowance, and went rapidly to neuritis and death, we decided to study a series of four which were given polished rice, feeding the fowls 118 grams daily, by force when it was not eaten voluntarily. This amount, 118 grams, was selected because the birds that ate well and remained nearly stationary in weight consumed about that quantity. The polished rice used was the Saigon grain supplied by the Subsistence Department, and was fed raw and dry. When necessary to use force it was pushed into the crop with the end of the little finger. RICE DIET. | 185 Tt is doubtful if this maneuver was of any use. The bird’s appetite was probably a good indication of their ability to digest and assimilate polished rice, and an excess was probably not used. Of the four fowls thus fed, three (numbers 45, 48, and 49) ate but little yoluntarily, speedily lost in weight, and developed multiple neuritis in 27 to 31 days (average 29.6 days) and two of them died on the 42d and 63d day respec- tively. After showing well-marked signs of neuritis they were given palay and kitchen stuff without avail in two cases, which soon thereafter died. One (number 48) was saved by the mixed feeding and, one and one-half months later, had practically recovered the use of-his legs and wings. He showed no spasticity at any time. When he had nearly recovered from the neuritis he was turned . loose. The fourth (number 40) differed from the others in that he ate his full daily allowance and weighed more at the end than at the commencement of the eapert- ment. He did not show any signs of nerve involvement. He was released on the 8lst day of the experiment. The weight curves of the fowls forcibly fed are shown on Chart 2. It will be seen that the fowl remaining well (number 40) gradually re- gained the 11.1 per cent of his original weight, which he had lost during the first month. POLISHED RICE COMBINED WITH VARIOUS SALTS. In an attempt to explain the etiologic connection between polished rice and beriberi, the kinds and quantities of morganic and organic salts present have received a large share of attention. Schauman and others(8), (9) believe that beriberi results from phosphorus privation. Some (12) have suggested poisoning by, or a lack of, other salts, inorganic and organic, and others have thought that too little of certain proteids or enzymes may be etiologic factors. After investigating the dietaries of the native troop (Philippine Scouts), the United States Army Board for the Study of Tropical Diseases as they Exist in the Philippines found that the amounts of phosphorus and potassium consumed were deficient in the companies having beriberi, and varied inversely with the incidence of the disease. In our former report on this subject(10) the companies were divided into three classes, as follows: TABLE II.—Average number of grams consumed per man per day. | J Class. P205. | KCl. | EELS WIT) SAINT eM Iys CAS CSe— eee ame nem Scan Me SU ee 3.3474 | 1.0600 | 2 Haviney a few scattered scasesssu =. == tea ee 3.9399 | 1.1905 | See ean ayeen moi CIeS aee ee LN rs A ee oe hoes ae ees | 4.6279 | 1.6517 | The amounts of P.O; average 3.3474 grams in the bad companies, 3.9399 in those slightly affected, and 4.6279 in the companies for the prisoners having no beriberi; a difference of 1.2805 grams between the worst and best averages. The amounts of potassium chloride average 1.06 grams in the worst, 1.1905 in the medium, and 1.6517 grams in the best organization, a difference of 0.5917 gram between the worst and the best. 186 CHAMBERLAIN, BLOOMBERGH, KILBOURNE. These amounts of potassium chioride. do not run exactly parallel to the phosphorus content of the three groups, there being a greater relative difference in the amounts of the former. The increase of the best over the worst was 56.76 “per cent in the potassium chloride, but only 38.22 per cent in phosphorus pentoxide. In a set of experiments with fowls we added salts of potassium and phosphoric acid to the diets of polished rice, as follows: Class 4. Polished rice + 0.05 gram KCl daily. Class 5. Polished rice + 0.03 gram H,PO, daily. Class 6. Polished rice + 0.06 gram H,PO, daily. Class 7. Polished rice + 0.05 gram KCl and 0.03 grams H,PO, daily. Class 8. Polished rice + 0.03 gram HPO, substituted later by 0.05 grams KCl daily. In determining the amounts of the salts to be fed, the quantities found to be consumed by the Scouts from the organizations having no beriberi were reduced to correspond to the average weight of the fowls and a small amount added to provide a safe margin. Of course, we have nothing to show the require- ments of fowls and they may differ considerably from the human. The different salts were administered in solutions of such strength that one cubic centimeter of each contained the required dose. In these experiments with polished rice combined with various salts, we made no attempt to use organic phosphorus in the form of phytic acid or phytin (calcium-magnesium salt of phytic acid) because, first, it was not convenient to obtain these substances and, second, the experiments recently conducted by Aron(8) and Kajiura and Rosenheim(20) indicated to our minds that no beneficial results were likely to be obtained from their use. This opimion has just been confirmed by the experiments of Fraser and Stanton,(22) who found that phytin would not prevent neuritis. Class 4. Fed on polished rice + 0.05 gram potassium chloride daily.—Four fowls were used and all developed multiple neuritis in 22 to 38 days (average 30.5 days) and died on the 29th to 44th day (average 37.5 days). The weight curves of these fowls (numbers 21, 22, 23, and 24) are shown on Chart 3. The average loss of body weight to the time of the appearance of neuritis was 28.0 per cent and to death 43.8 per cent. It will be obvious, on glancing at the steep descent of these curves and on considering the time intervening between the commencement of the experiment and the occurrence of neuritis and death, that the administration of potassium chloride was of no avail, the “incubation period” and length of life being practically the same as for fowls fed on polished rice alone. Class 5. Fed on polished rice + 0.03 gram phosphoric acid daily—Three fowls were put on this diet, and all died after developing typical neuritis. The leg signs appeared after 22 to 27 days (average 23 days) and death occurred on the 27th to 34th (average 30.3 days). Their weight curves are shown on Chart 3 as numbers 25, 26, and 28. An average loss of 28.2 per cent occurred to the appearance of signs of neuritis and 40.3 per cent of death. RICE DIET. 187 ‘Nothing worthy of special mention was noted among these fowls except that they developed multiple neuritis and died in a shorter period than those on polished rice alone. Class 6. Fed on polished rice + 0.06 gram phosphoric acid daily.—After observ- ing the shortness of the “incubation period’ and the rapidity with which death supervened. in the fowls of the preceding class, fed on polished rice combined with 0.03 gram phosphoric acid and to throw some light, if possible, on the reason for this, a set of three fowls was fed the same kind of rice with a daily addition of double the amount of phosphoric acid or 0.06 gram. Of these three fowls two developed typical leg signs, one (number 60) on the 27th day and one (number 59) on the 31st day (average 29th day). Instead of allowing them to go on to death we fed them palay and kitchen stuff on the 30th and 34th days respectively and, as in the case of fowl number 5, greatly improved their general condition without in any way lessening the signs of multiple neuritis. Both of them also developed spasticity like that observed in number 5 and described in connection with that fowl. These two fowls were eventually chloroformed. The sciatic nerves showed marked degenerative changes. No evidences of degeneration were found in the tracts of the spinal cords. Their weight curves, Chart 4, resemble those of fowls fed on polished rice alone. An average loss of 25.2 per cent occurred to the appearance of signs of neuritis and of 30.2 per cent to the end of the experiment, that is to the begin- ning of mixed feeding. The fowls of this class kept well nearly a week longer than those on the same rice with one-half the amount of phosphoric acid, but probably this was a mere coincidence, for they fared no better than those of classes 1 and 2 fed only polished rice. The third fowls of this class (number 61) died of avian diphtheria, the lesions being in the nose. Nothing abnormal was found in the sciatic nerves. Class 7. Fed on polished rice + 0.03 gram phosphoric acid and 0.05 gram potas- sium chloride daily—tn this class the same rice was used as in classes 5 and 6 and the solutions of the two salts were given at different times during the day. Of the five fowls, three (numbers 29, 31, and 32) developed multiple neuritis in from 21 to 28 days (average 25.3 days) and died on the 25th to 34th day (average 30th day). The reduction in weight to the appearance of signs of neuritis averaged 32.4 . per cent and to death 40.9 per cent. Two of the birds (numbers 30 and 37) eontracted infectious conjunctivitis and died, without signs of neuritis, one on the 4th day and the other on the 24th day of the experiment. Class 8. Fed on polished rice + 0.03 gram phosphoric acid for 34 days and 0.05 gram potassium chloride for 91 days——One fowl (number 27) was fed in a manner like those of class 5 for 34 days and then, through accident, the acid was replaced by 0.05 gram potassium chloride: It was kept on polished rice and these salts for 125 days, and then weighed but little less than at the com- mencement of the experiment, and was apparently as vigorous and well as when first placed in his cage. We do not ascribe his continued good health to the salts but to the fact that he liked polished rice and greedily devoured all that was given him. Only a 188 CHAMBERLAIN, BLOOMBERGH, KILBOURNE. few of our fowls have voluntarily eaten freely of this rice and these have been able, by so doing, to maintain their body weight and defer or altogether prevent the development of multiple neuritis. Number 27 weighed 1,098 grams at the beginning of the experiment and after 125 days weighed 998 grams. A loss of about 15 per cent occurred in the 34 days during which he received phosphoric acid with his rice, and a steady gain took place after the substitution of the solution of povassim. chloride; whether or not merely coincidental we are unable to say. The average time to neuritis of the fowls of all the groups receiving phosphoric acid was 25.3 days as compared with 29.8 days, the corre- sponding time for those on polished rice alone, and similarly the fowls on phosphoric acid died in an average time of 30.2 days as against 34.7 days when fed polished rice alone. Average | Average Food. time to | time to neuritis. | death. Days. Days. Polishediriceyallome 226 = te A ee eS ae 29,8 34.7 Polished rice-—phosphoric acid) 228se sess se eee ee 25.3 30. 2 The difference in favor of polished rice alone is small and may have been due to idiosyncracies of the fowls, or to other factors. The table shows that the administration of this form of imorganic phosphorus is of no avail in preventing neuritis, for, if such were the case, the fowls receiving it should have remained well much longer than those fed on polished rice alone, whereas they became sick on an average of 43 days sooner. GROUP B. THIRTEEN FOWLS SUBSISTING ON UNDERMILLED RICE. Two kinds of undermilled rice were used, a Filipino “Macan” rice having a yellowish-white pericarp, and a native mixed rice with about one red grain to every four of the yellow grains. Both kinds were only partially milled, more than half the surface of the grains being covered with pericarp. ‘The second or mixed variety is that now supplied, on the recommendation of this Board, to the Philippine Scouts. Three classes of experiments were made, first (class 9), those on the first variety of undermilled rice; second (class 10), those on the second; and third (class 11), those on the first plus 0.36 gram sodium chloride daily. Class 9. Fed on undermilled rice having a yellowish-white pericarp.—tThe rice had 0.271 per cent of potassium oxide and 0.576 per cent of phosphorus pentoxide. Four fowls remained well on this diet for 79 days. None showed the slightest signs of neuritis or other sickness and were in good condition when taken out of the cages. (Numbers 9, 10, 11, and 12.) Three of the four gained in weight from 4.2 to 17.9 per cent (average 9.4 per cent) while the remaining one lost 17.2 per cent. 4 RICE DIET. 189 Class 10. Fed on undermilled rice having a red pericarp—The rice used in this experiment was that supplied by the Subsistence Department of the Army to the native troops (Philippine Scouts). Jt contained 0.223 per cent of potas- sium oxide and 0.489 per cent of phosphorus pentoxide. Three out of four fowls have remained in perfect health on this diet for an average time of 129.6 days. (Numbers 38, 39, and 47.) The fourth (number 46) acquired infectious conjunctivitis and died, without signs of neuritis, on the 26th day. The three healthy birds gained in weight from 22.8 per cent to 37.3 per cent (average 29.2 per cent) while subsisting solely on this unpolished rice. Class 11. Fed on wndermilled rice (yellowish-white) + 0.386 gram sodium chloride daily—Bunge in 1894(13) called attention to the relationship of the potassium and sodium salts of the food to each other, maintaining that an excess of potassium carbonate when ingested will react with sodium chloride forming sodium carbonate and potassium chloride which are soluble and are eliminated in the urine, thereby depriving the system of needed elements. Loeb(14) has shown the necessity for a balance between the sodium, calcium and potassium ions, and that the calcium and potassium ions counteract the effects of the sodium ions in the blood. When marine animals were placed in a pure solution of sodium chloride of the same concentration as sea water, their muscular contractility was lost. Small amounts of calcium and potassium ions antagonized the poisonous effects of the sodium ions. Le Dantec(15) in the course of experimental work with fowls noticed that the multiple neuritis produced when they were fed on polished rice was seldom (2 cases in 60) accompanied by the edema which is so frequently observed in the beriberi of man. Desiring to produce this edema he injected a solution of sodium chloride into the pectoral muscles and killed the birds in every case. He found that it also had the same effect when injected into starving fowls. He made no mention of haying administered the salt to fowls not in a cachectic state. As stated before when describing our experiments with polished rice and various salts, we previously found(10) that the dietaries of the Scout companies having beriberi were deficient in potassium and phosphorus. We also found that the Scouts were rather heavy salt eaters and suggested that this habit may have had an etiologic connection with penben. by abstracting needed potassium ions. In class 11 we fed five of our fowls a rice proved by previous experiments (class 9) to prevent neuritis, and in addition gave a daily dose of 0.36 gram of sodium chloride in solution, the amount being decided upon in a similar manner to the determination of the amounts of potassium and phosphorous used in classes 4, 5, 6, 7, and 8. On the 55th day the amount of sodium chloride was increased to 0.72 gram daily. Four of the five birds continued well, remained stationary or slightly gained in weight, and after an average time of 113.2 days, showed no signs of neuritis. (Numbers 33, 35, 36, and 58.) One fowl (number 34), after nearly two months of apparent health, acquired infectious conjunctivitis and died on the 6lst day with a loss of 26.5 per cent of body weight. The administration of sodium chloride in either dose, 0.36 or 0.72 gram, seemed to have no effect on these fowls, but it must be remem- bered that they were strong animals, receiving a neuritis-preventing rice, were in fine condition, and not cachectic like those of Le Dantec. 190 CHAMBERLAIN, BLOOMBERGH, KILBOURNE. GROUP C. FOUR FOWLS SUBSISTING ON UNHUSKED RICE. Class 12. Fed on palay or padi.—Although unhusked rice has been proved by numerous experiments outside of the Philippines to prevent polyneuritis gal- linarum, we undertook these tests with the native Macan unhusked rice to see whether or not it possessed the same qualities as the padi of other countries and to control the experiments of classes 1, 2, and 9 which were going on simul- taneously. Highty-one grams of unhusked rice, called palay in the native Tagalog dialect, were fed daily to each of four fowls and all remained well to the end of the experiment, 79 days, and showed no abnormal signs. (Numbers 13, 14, 15, and 16.) A loss of 17.9 per cent and 18.9 per cent of body weight occurred in two of the birds and a gain of 0.6 per cent and 5.6 per cent in the others. GROUP D. TEN FOWLS UNDERGOING STARVATION. As our experiments progressed we noticed that the development of neuritis was invariably accompanied by a considerable loss of weight. In no case did a fowl acquire the disease while gaining or while remain- ing stationary in weight, indeed, a reduction of 21 per cent or more, except in the cases of fowls numbers 2 and 20, seemed a necessary accompaniment of neuritis. In consequence we decided to feed some fowls reduced amounts of a neuritis-preventing rice and to give others water alone, with the purpose of producing, if possible, a neuritis as a result of partial or complete starvation. That this was accomplished is shown by the following experiments. Class 13. Fed on undermilled rice with yellowish-white pericarp. Fifty-two grams (one-half usual allowance) daily for 43 days; followed by 26 grams for 4? days and 13 grams for 25 days——One fowl (number 18) was fed 52 grams daily of the neuritis-preventing rice used in class 9, this amount being one-half the daily allowance given the fowls in that class, all of which remained healthy. With this amount he was able to almost maintain his original weight, losing only a small amount in 43 days. The quantity of rice given was then reduced to 26 grams and from that time a considerable loss of weight occurred, but to hasten the result this was further reduced to 13 grams on the 90th day. The fowl continued in good condition, except for general weakness which began to be evident about the 90th day, until the 107th day when weakness was particularly manifest in the legs. On the 115th day he was unable to rise, whether from neuritis or general weakness we were unable to say. To determine if possible the condition of his nerves he was then given palay and kitchen stuff and rapidly improved except in the legs. He became strong enough to stand, ate well and seemed bright and interested in his surroundings, but had the typical gait and leg signs of neuritis, which became more marked during the two or three days following resumption of mixed diet. He died suddenly on the 122d day. His characteristic attitude is well shown in the pictures, figures 9 and 10. On microscopic examination his sciatic nerves showed slight degenerative changes. When signs of neuritis were unmistakable he had lost 46.6 per cent of body weight; at death he had lost 49.4 per cent. His weight curve is shown on Chart 5 as number 18. RICE DIET. HO Class 14. Fed on undermilled rice with yellowish-white pericarp, 26 grams (one-fourth usual allowance) —Fowl number 19* was given a ration of 26 grams of the same undermilled rice as was used in classes 9, 11, and 13, and this amount, one-fourth that fed in class 9, was continued unchanged throughout the experiment. A steady and progressive reduction of weight followed accompanied by in- creasing weakness. His weight curve shown on Chart 5 as number 19, ran as follows: 5 Date. - Day. Grams. Remarks. ASU UULN 12 ee a shee 4 842 | One-fourth allowance begun. eyfliygal Greens eens aN Salyer 821 iby Ce eae Se ee ee Chior eee 765 UN ao Gia Se eet one eh LOthy =.= 751 | AOU PARE a oe a oe in} ogee 736 Atel Wi 8 (0) epee es SE Sree Ae ea ay ithe 694 PANIES (3 Bas Sree ee See 2iste==—— 659 WATE USt Gaerne ue eet oaths 595 ATUGTISD Aen ee 8 a SPIO l eee 538 | Died. On August 11, the 29th day, he seemed disinclined to move, two days later showed well marked early signs of neuritis, and on the following day died. In this case no attempt to save by mixed feeding was made. A loss of 34.7 per cent to the time of signs of neuritis and 39.5 per cent to death occurred. The sciatic nerves were extensively degenerated. Class 15. Water only—In a previous publication(16) we reported a case of typical multiple neuritis in a fowl that had been given water, but no food, and stated that the same experiments would be continued with a larger number of birds. In all we experimented with 8 fowls and unmistakably produced the disease in three. Two others very probably had the disease, but we were unable to save them by mixed feeding so could not obtain a clear clinical picture because the signs of neuritis were obscured by those of general weakness. However, the nerves of these two fowls showed degeneration. The histories of these 8 fowls follow and are given somewhat in detail. Fowl number 17 was purchased May 10, 1910, and kept in a cage on mixed diet, consisting of palay, undermilled rice and kitchen stuff, until July 14, when all food was stopped. After July 14, he was allowed only water. The first signs of trouble were noted on July 26, the 13th day of his fast. He had difficulty in jumping to his perch. On the 21st day he could not get up to it at all. When not disturbed he would stand with head close to the body and eyes closed, but was not observed sitting on his knees. On the 23d day he stood as above and with his knees very straight. When made to walk he showed a tendency to teeter forward. He was evidently very weak and we were unable to feel certain whether his condition was due to pure weakness or to something else. It was feared he would die within 24 hours if he were not “This fowl was reported in a paper read before the Manila Medical Society September 5, 1910, and published in the September Bull. Manila Med. Soc. (1910). 192 CHAMBERLAIN, BLOOMBERGH, KILBOURNE. fed, consequently we determined to resume feeding with a neuritis-preventing food in the hope that we could save him and make sure that the lee signs were not due solely to weakness. This we accomplished. August 6, the day following the resumption of food, the signs of newritis were greatly increased and left no doubt as to the nature of lis trouble. The characteristic attitude is well shown ’ in the figures 11 and 12. During the following days, in which palay, undermilled native rice, and kitchen stuff were fed, the leg and wing signs became worse, but his general condition improved rapidly. He became bright-eyed, interested in his surroundings, and gained in weight. His appetite needed no stimulation. The peculiar spasticity he had exhibited at the end of the starvation period increased until walking was performed on his toes, with knees almost straight. An effort to photograph and show the spastic gait was only partially successful. During the last week of his life this fowl partially regained the use of his right les. On the 55th day he was chloroformed and the sciatic nerves and spinal cord removed for microscopic examination. The sciatic nerves showed extensive de- generation. No areas of degeneration were found in cross sections of the cord. His weight, shown on Chart 5, ran as follows: Date. Day. |Grams. Remarks. ALi See eS ee AStees 991 | Starvation begun. AUT Gs ha es SUE ed oleae 921 DEO oe Ae Srey a CE ee ee Othye== 786 DULY 28) 2s Se Ee he eee Se oe Hise = 7712 UCL 7G ses a Se gt sn Pa Stee 722 UL yAS0 Ake cee a eae Des See see ited jigquole soe! 687 AN USti oreo Se oe Ose ORS Cen OS eee 596 AIO UIST: ta ee a eae ein ave roe. ie ea Doe | Seen Mixed feeding begun. HATA TS Up RSe SS eae Sie pL eg ales se S20 687 AUGUST 20 iss See ce a eae eee LOB Thy 715 PASS US G2 7a eee aed een eae eee 45th ___- 708 Septemberide sek so ee ates Gysfol =a 744 SE} OCION OYEDR he ee eee Seen) GENO oa 730 | Cloroformed. His loss of weight to the appearance of signs of. neuritis was 27.2 per cent and at the end of the starvation period had increased to 40.0 per cent. Fowl number 41 was put on water alone September 10, 1910. Nothing of importance was noted until September 13 when he became sick with avian diphtheria and died of this infection 5 days later, September 18. His loss of weight amounted to 39.4 per cent. Microscopic examination of his nerves showed slight degeneration. No clinical signs of multiple neuritis were observed before death. Fowl number 42. The water diet was instituted September 10 and was followed by a steady and rapid reduction of weight and muscular strength. On September 26, the 16th day, he was very weak, could not stand, and, when prodded, would not move his legs or wings. Although the general weakness was great we were of the opinion that there was probably, in addition, a peripheral nerve involvement. It was thought that he was not too far gone to revive with mixed feeding and a diet consisting of palay and kitchen stuff was then in- stituted, but without favorable result, for he was found dead in the cage the next morning, the 18th day. RICE DIET. 193 His weight ran as follows: Date. Day. |Grams. Remarks. September a0 = set 2e se eee Ishwaeess 963 | Starvation begun. SeplemiperiSea see tS se Sth 835 KS) OSH ail) oY Sy EY ANS ee ee eee Sym 22 602 SejouCranoysie PX) Se eee VAthyaee 524 | Mixed feeding begun. DOD UCM DOM Mesa ae ee eee eee te cS thie 524 | Found dead. A reduction of 45.6 per cent had occurred when the mixed diet was begun and it is probable that starvation in the case of this fowl was carried too far. Microscopic examination showed some degeneration of the sciatic nerves. Fowl number 43 died suddenly on the 14th day of the experiment without having shown any signs of neuritis. The day before his death he showed some general weakness and could not jump up onto his perch, but, on the whole, was in fair condition and we did not anticipate his early demise. A reduction of 37.6 per cent in weight was observed in his case. The sciatic nerves were not degenerated. Fowl number 44. Starvation was begun September 10, water only being allowed. On September 26, the 17th day, he lay on the floor of the cage most of the time; when prodded he would stand and walk a short distance. The gait was that of early neuritis and we had no doubt of its existence. Our belief was corroborated by the finding of extensive degeneration upon microscopic examina- tion of the nerves after death, which occurred September 27, the 19th day of the experiment and one day after mixed feeding was begun. His weight ran as follows: Date. Day. |Grams. Remarks. Seplemib en, Qj eae Oe SS) reer 970 | Starvation begun. Sejoneranl) oyereia is) Me ee Oth e238 807 September24 aes = si eee 15th 616 SCMLCTID CL 26s eee arse Se Iii eee 582 | Mixed feeding begun. SE DUCHM IO ymca a eer eee a BETTE 18th 531 | Died. A loss of 40.0 per cent to the appearance of signs of neuritis, and of 45.3 per cent to death was noted. No doubt we were unable to save this fowl because inanition was allowed to progress too far. Fowl number 54. Little need be said of this fowl, for his death occurred sud- denly, through an accident, while apparently doing well. On the Ilth day of his fast he seemed in good condition except for some weakness, but the following morning he was found dead with his head and one leg through a small hole in the bottom of the cage. During this time a loss in body weight of 29.8 per cent had occurred. No degeneration was seen in his sciatic nerves. Fowl number 55 was kept in one of the cages and fed a mixed diet of palay and kitchen stuff for three weeks and then, October 21, given water but no food. Like the other starved fowls he lost rapidly in weight and became progressively weaker until November 5, the 16th day, when feeding with palay and kitchen stuff was resumed. On that day he was very weak and lay on his side on the floor 194 CHAMBERLAIN, BLOOMBERGH, KILBOURNE. with his eyes closed the greater part of the time. When prodded with a stick he could be made to stand for a very short time. The comb and wattles were deeply cyanosed and his whole appearance was that of a fowl very near to death. When the grains of palay were put before him he would greedily devour them. From that time he improved in general condition, but like number 17 showed more marked signs of neuritis during the succeeding days; unlike that fowl, he did not show spasticity. At this stage pictures were taken which show the usual positions assumed by fowls with the disease. (Figures 13 and 14.) After 9 days of this mixed diet his gait had improved somewhat, but not more so than that of several fowls similarly saved from death after they had developed marked signs of neuritis when fed on polished rice. He was chloroformed on November 16, the 27th day, and the sciatic nerve removed for microscopic examination; it showed degeneration. His weight, shown on Chart 5, ran as follows: Date. Day. |Grams. Remarks. October:21y sire ee eee NG Passos 963 | Starvation begun. October:30 2222-2 oS eeae eee Othe 892 : INOVemib eri hears eee a en nae 16th ____ 700 | Mixed feeding begun. INoveniber!|2 2s ees Peyel = 729 INOVemib eral s==s= se eae eee PO, Se 800 | Chloroformed. On the 16th day, when signs of neuritis appeared and the mixed feeding was begun, he had lost 27.4 per cent of his body weight. Fowl number 56. The clinical history of this bird much resembles that of number 42. ; October 21 starvation, except for water, was begun and continued until No- vember 1, the 12th day, when a mixed diet of palay and kitchen stuff was given. This fowl declined in weight very rapidly and although starved only 12 days had then lost 44.6 per cent. He died on November 2, the 13th day, after one day of mixed diet. The appearance of this bird was similar to that of number 42; while the signs of nerve involvement seemed present, the general weakness was so great that we could not be positive on this point. However, on micro- scopic examination the sciatic nerves proved to be moderately degenerated. SUMMARY OF STARVATION EXPERIMENTS. Two fowls (numbers 18 and 19) were fed reduced quantities of a neuritis-preventing, undermilled rice and both developed multiple neu- ritis. Hight fowls allowed nothing but water gave three positive cases (numbers 17, 44, and 55), two doubtful (numbers 42 and 56), and three negative ones (numbers 41, 43, and 54). IV. GENERAL CONSIDERATION OF MULTIPLE NEURITIS IN STARVED FOWLS. Bykman(1) did not find polyneuritis in chickens fed on such small quantities of undermilled rice that they died from starvation. Sakaki(3) also stated that the weakness in starvation progressed to death without any staggering or other signs of neuritis. Holst(11) in speaking of Eykman’s nonobservance of poly- neuritis in chickens starved on small amounts of undermilled rice, says, “Nor have I found any polyneuritis myself, experimenting in a similar way with pigeons.” Likewise Fraser and Stanton(17) say in this connection, “Fowls RICE DIET. 195 receiving nothing but water do not develop polyneuritis, while fowls receiving only polished rice and water do.” The only statement to the contrary, we have found in the literature, is that made in the discussion of the beriberi papers(18) by Dr. Gorosaku Shibayama, delegate from His Imperial Japanese Majesty’s Government to the meeting of the Far Hastern Association of Tropical Medicine, held at Manila, March 5, 1910. He said, “Polyneuritis accompanies general cachexia and inanition in fowls, whereas beriberi, especially the acute, pernicious form, generally attacks well- nourished muscular men.” j This statement agrees exactly with the findings in our starvation experiments, and we believe the reason the evidences of neuritis were overlooked by other workers is that they appear very shortly before death and are obscured by the signs of general weakness. It is not an easy matter to resume feeding at exactly the proper moment to save the animal and leave the neuritis well developed. VY. RELATION OF LOSS OF WEIGHT TO DEVELOPMENT OF POLYNEURITIS GALLINARUM. The amount an animal can lose and still live varies somewhat with the individual. Withington,(19) in discussing starvation, refers to the following: Chossat stated that the total proportional weight loss of an animal dying of inanition was 40 per cent of the initial weight. But further experiments have shown that a fat animal may lose 50 per cent of its weight, while a lean one can lose only 35 per cent. Young animals in a growing stage have been observed to lose only 30 per cent before they succumbed. %* % * * * % * The ingestion of water, then, while postponing the fatal result of a fast, produces no important change in the mode of death from that which occurs in simple inanition. Le Dantee says that in polyneuritis of fowls, when fed on polished rice, the loss of weight is progressive and death occurs when the animals have lost about one-third of their body weight. Our two fowls, numbers 18 and 19, fed on reduced amounts of un- dermilled rice, lost an average of 40.6 per cent to the end of the experi- ment, which was death in the case of number 19, and rescue by resuming full diet in the case of the other, number 18. Those which developed easily recognized signs of multiple neuritis while being given only water, numbers 17, 44, and 55, lost on an average 31.5 per cent up to the time of the appearance of the disease and 37.5 per cent to the end of the starvation period when feeding was resumed. The losses in this class correspond very closely with those of classes 1, 2, and 3 in which the fowls developed the disease on polished rice alone and where the decrease in weight averaged 31.6 per cent to the appearance of signs of neuritis and 39.9 per cent to the end of the experiment, which was death in the case of eight and salvation by mixed feeding in two out of the ten fowls. 196 CHAMBERLAIN, BLOOMBERGH, KILBOURNE. One can not avoid wondering if the real cause of multiple neuritis | in fowls fed on polished rice is not general inanition rather than the lack of any one element in the rice. LeDantec(15) says “Fowls nouri- shed on white rice die of inanition and not of beriberi.” A similar view is expressed by Breaudat(23) who states that animals so nourished die of inanition with symptoms which are similar to those of beriberi. How- ever, he thinks, that intoxication .plays a part im the fatal result. In further support of the idea that the multiple neuritis of fowls subsisting on polished rice is due to inanition is the evidence supplied by those fowls that seemed to relish polished rice and ate their full daily allowance. As stated before, nearly all the birds fed on polished rice lost their appetite early in the experiment and would eat little or none of this grain, but a few were exceptions to the rule, notably numbers 5, 7, and 40, and they remained well for long periods of time. We are unable to reconcile our findings with the statement of Maurer(12) that those fowls which eat polished rice in the largest amounts are the first: to become paralytic and that by feeding small amounts of the rice the sickness may be postponed for a long time. As shown in Table IV, out of the entire 56 fowls experimented with 27 developed neuritis, the average loss of weight up to the appearance of symptoms being 30.9 per cent. Im every case but 2 (numbers 2 and 20) a loss greater than 21 per cent occurred before the symptoms developed. Of the 16 fowls which remained well throughout the ex- periments, only 5 lost weight at all and not one of these five decreased as much as 19 per cent. (Numbers 9, 14, 16, 27, and 33.) Only one fowl (number 40) gained when fed on polished rice and he was well at the end of 80 days when the experiment was concluded. VI. BEARING OF THESH EXPERIMENTS ON THE ETIOLOGY OF BERIBERJ. As stated before, our original object in conducting these experiments was not to prove or disprove the identity of multiple neuritis in fowls and beriberi in man, but to test the neuritis-producing qualities, when fed to fowls, of certain native and imported rices and to use the infor- mation thus acquired as an aid in selecting the variety of grain and the degree of milling best suited for the Filipino troops. Nevertheless, as the work progressed, certain points of dissimilarity between beriberi and polyneuritis gallinarum became apparent and it may not be inappropriate to mention them here. Fowls are especially susceptible to neuritis and get the disease under circumstances which have no effect on the nerves of some other animals. Monkeys, when fed on a diet of boiled, polished rice and water, remained well, although the experiments continued for more than three months. They had lost in weight and become weak, but did not show signs of RICE DIET. 197 neuritis at any time. We can find in the literature no mention of neuritis in man having developed as a result of inanition among the professional “fasters” or among groups of men who were starving. It would seem that the peripheral nerves of fowls are less resistant to degenerative influences than those of mammals and are among the first tissues to suffer when the animals are starved or given a deficient or ill-balanced diet. Our experience bears out the statement of Shiba- yama that polyneuritis of fowls occurs in cachectic animals, while beri- beri is prone to appear among men previously well nourished. Another point of difference is that cedema has been very rarely seen in fowls with neuritis(15) while it is common in beriberi in man. None of our fowls suffering from neuritis showed any cedema. Therefore, we are inclined to join forces with those writers who con- sider that polyneuritis gallinarum and beriberi are not identical but we are fully in accord with Fraser and Stanton in their statements, (a) that its capacity for producing polyneuritis in fowls is an accurate in- dicator of the beriberi-producing quality of a rice and (b) that a low phosphorous content is a reliable wndex of the dangerous character of the grain. However, we have found that in neuritis-producing rice and in beriberi-producing dietaries the potassium is even more reduced than the phosphorus. The comparison between the two elements in rices is shown above in Table I. The diminution in phosphorus as compared with potassium in beriberi-producing diets was treated of in a former communication from the Board(19) and is referred to above in the dis- cussion on polished rice combined with various salts (Table I1). The latest work of Fraser and Stanton(22) seems to indicate that much the greater part (85 per cent) of the phosphorus in rice polishings is of no value in preventing polyneuritis of fowls. It now remains to be shown whether the real neuritis-preventing factor in polishings is the small per cent of phosphorus not yet accounted for, or the potassium, or some other element. The inference from the foregoing is that neuritis in fowls and beri- beri im man is just as likely to be due to deficiency in salts of potassium as to deficiency in salts of phosphoric acid. The results of our starva- tion experiments suggested that, as far as fowls are concerned, it might be a defiicency of both phosphorus and potassium which led to nerve deterioration. The experiments in classes 4, 5, 6, 7, and 8 indicated that adding to polished rice either phosphorus or potassium, or both elements, in two of their common inorganic forms, did not render the grain any safer as an exclusive article of diet for fowls. We are about to undertake another series of experiments combining with polished rice other mineral salts, such as potassium carbonate, potassium citrate, potas- sium phosphate, and magnesium phosphate. 1023623 198 CHAMBERLAIN, BLOOMBERGH, KILBOURNE. VII. CONCLUSIONS DRAWN FROM THE OBSERVATIONS. 1. Fowls develop multiple neuritis when fed exclusively on polished rice, whether Filipino Number 1 or Saigon choice rice is used. 2. Forcibly feeding polished rice to such fowls as have no appetite for it will not prevent the occurrence of neuritis. 3. Those fowls that voluntarily eat heartily of polished rice are able thereby to maintain their body weight and to defer or to prevent the development of multiple neuritis. 4. The administration of certain inorganic salts of phosphorus and of potassium, either alone or combined, to fowls subsisting on polished rice neither prevented multiple neuritis nor deferred its onset. 5. Fowls fed unhusked rice, palay, do not acquire multiple neuritis. 6. Fowls fed undermilled (unpolished) rice do not acquire the disease. ?. Whether the undermilled rice has a red or a yellowish-white peri- carp is immaterial. 8. Fowls fed on undermilled rice combined with large amounts of sodium chloride do not develop multiple neuritis. 9. Fowls from which all food is withheld and only water allowed, develop multiple neuritis in some cases. 10. Fowls starved on reduced amounts of a neuritis-preventing under- milled rice acquire multiple neuritis in some cases. 11. Fowls kept entirely without food and those which are given all they will eat of polished rice lose weight with almost equal rapidity in the great majority of cases. 12. A loss of at least 21 per cent of the body weight almost invariably occurs before any signs of multiple neuritis become apparent. 13. The signs, symptoms, and nerve appearances are identical in neu- ritis produced by inanition and in that caused by feeding polished rice. 14. Spasticity is a late symptom in some fowls which develop neu- ritis and are then saved from death by the institution of mixed feeding. 15. In neuritis-producing rice and in beriberi-producing dietaries both the phosphorus and the potassium are markedly reduced in amount, the latter in greater degree than the former. 16. As an index of the beriberi-producing power of a given rice, reduction in the potassium content is probably quite as reliable as re- duction in the phosphorus content. RICE DIET. 199 REFERENCES. Eyxman, C. Polyneuritis bij Hoenders. Joarverslag van Lab. v. Path. Anat. en. Balat., Batavia (1896). Grigns. Med. Lab. Anal. etc. Weltevreden (1900). SAKAKI, J. Sei-i-Kwai, March 31, 1903. VoRDERMAN, A. G. Onderzoek naar het verband tusschen den aard der rijstroeding in de gevangenissen op Java en Moedoera en het yoorkomen van beri-beri onder de geinternerden. Batavia, 1897. Brappon, W. L. The Cause and Prevention.of Beri-Beri. London, 1907. Fraser, H., and Stanron, A. T. The Lancet (1909), 2, 406. Fraser, H., and Stanton, A. T. The Etiology of Beri-Beri. Studies from the Institute for Medical Research, Federated Malay States, Kuala Lumpur (1909). Aron, H. Phosphorus Starvation. This Journal, Sec. B (1910), 5, 73. ScHAUMANN, H. Beiheft. z. Arch. f. Schiffs-u. Trop. Hyg. Beiheft (1908) 5, 15-30. Kizsourne, EH. D. Food Salts in Relation to Beri-Beri. This Journal, Sec. B (1910), 5, 127. Houst, A. Experimental Studies Relating to Ship Beri-Beri and SALE : Journ. Hyg. (1907), 7. Maurer, G. Polyneuritis der Hiihner und Beri-Beri eine chronische Oxal satierevergiftung. Miinchen med. Wehnschr. (1907), 54, 731. Bunce. Physiologische Chemie, 3d ed., 1894, 108-116. ) Logs, JAQuES. Amer. Journ. Phys. (1900), 3, 327. ) Le Dantec, A. Contribution a Vetude du beri-beri experimental. Bull. Soc. path. exot. (1910), 3, 118. Karpourneg, E. D. Preliminary Report of Multiple Neuritis of Fowls Due to Inanition. Bull. Manila Med. Soc. (1910), 2, 238. FRASER, H., and Stanton, A. T. The Etiology of Beriberi. This Journal, Serb. (LOMO) ID) oo: Suipayama, G. This Journal, Sec. B (1910), 5, 123. WitHineton, C. F. Starvation. Reference Handbook of the Medical Sciences. Kagrura, §., and ROSENHEIM, O. A Contribution to the Hitolory of Beri- Beri. Journ. Hyg. (1910), 10, 49. GrRaHAmM-SmituH, G. S. Bacteriology of Diphtheria, Nutthal and Graham- Smith, page 300. FRASER, H., and Stanton, A. T. Etiology of Beriberi, Lancet (1910), 179, 1755. Breaupat, L. Sur les urines et sur le sang des beriberiques. Bull. Soc. Pathol. exot. (1910), 3, 620. CHAMBERLAIN, BLOOMBERGH, KILBOURNE. 200 ‘skBp 16 IO} apimo0[YO yATLBp [OM Wes 60'0 mnisssjod pus skvp $g§ 10} pros o1oydsoyds; C6) 5) PO oe eo Ope eee es ers 0 ik 8 Aq poeMoTpoy FOa®H werd ¢0'0 “ATrep tOd° A *BILOYIYAIP UBIAB JO Pots |-—————— 0 PL Ge 0§ §°co | € g Li WIRIS £00 PUB [OM wis ¢p'0 ‘s178s “BIIOUJYAIP UBIAB JO Pord x SaOETIA TEIN ‘SABP UIPE PUB 40 OY} WO pojnzysSUT 5 % BUIpsey PoXIU AG POABS OOM S[TMOF OMY VSO a [7-7 0 XG Iz (0) 66 |G g (0 cll a ea me Airep 'Od*H weis 90'°0 tear es QP @ € ‘0 &% | § g Gg | ~~ ~ATrep tOd®H Wei8 ¢0°0 are pl QO GLE G08 | i p | AIrep TOM weIs ¢o'0 “9011 *YVBOP OF OUT] OSVIOAB poystpod oY} UL PAPN[OUL 4OU SI PUB Y}BEP WIOIT PoAvS >y dnoiy SBM 0UQ ‘SkBp pg9 pu ‘pzEs “WI0gE 94} UO *ATBsso00U UNM 9010F SUIpod} POXIUL UPAIS OIOM S[MOFT 9o1Y} OSeL p 18 1 = ‘|e aint 0 G'z@pn 19°64 18 P eg Aq Aplep smeis gTT ‘uostes ‘MIIOIS B 19}JB PBVOp PUNOY o "YJvop 0} OUI, 9SBIDAB 9} UL popnjoUr OU sT *OuOTY pus Avp YIPIL oY} WO potuIOJOIO[ YO sem ABD W168 OU} WO pojN}WsUrl SUTpeey} poxrut Aq PoAus yueuL SBM YOIYM SijlunouATOd YALAA S[MOF OY} JO 9UO gq [~~ 0 68 To Sq Te | ¢ p Zz Jivdoaq so0uejsisqng uostes “BI1oJYdIp UBIAB JO Pole |----- ~~ @: | We || Tee 98 6Gal Pike Cee [eee | Semesar een = cae es T ON ould sing ‘shod ‘shog |shoq .) ta Z Ca Z on ae Z| 4 Q 4 eles i= oss 4 i=} is J 2} g - ° g Eh ° g Z g eh B A - BS |SB] oe /S8 | as Be |e jy 2 | ae |so] o8@ | Sa} of Beilsao| oe 2) GO Vo! SE troy Se | ee ire Sle Sek ea | Sacto as a=5 g i=5 mall ial B “(8 £B B ol = |S . “syaBuLery © os © = ® ? oO eh Z q “poo a | ‘SI}LIMNOU 5 5 ay -Ajod jo ‘sIqtaneudjod @ s* Hee sur0jdur As Jo suzo}durds a POULBUIeN | snowy podopeaoqg petd 3 ‘yqnap fo aaUuaLino00 10 sizvinau Jo yuawmdojaaap 01 sporsed sbp.2an pun Uo payuowrsodxa sjnof Jo soqunN— {I WIV, 201 RICE DIRT. ‘UOIJVIOUNSOpP SULUUTSAq PAOMOYS SOAIOU ILOY} Aypeordooso1 TL + “Wurnypoo sty} urgnd ore Aoy jolp pexttm Surpoey Aq Weg} dAVS 0} OTGvuNn a1OM OM SB nq ‘sytMeu pry A[quqoid ATA asoq] JO OMY “ABP YIOT 94 uUNsoeq suIpsoy pox 1o}78 ALPUAppNS poip PAY) oy :ABp IZ] ay} WO poulIOFOIO[YO SvM puB ABP WOT 94} uo SUIpeey poxrur Aq JoyjouR ‘Avp YEE oy MO poMIOJOIO[YO SUM PUB ‘ABP PEz OY} UO poyny fo ae ETS) -IJSUI SuLpacey poxtur Aq POABS SBA\ [MOF OO! | ~~ ae | Lit | $°pr Cl) | Samp ance Seen ena ean ee TILOMON)AN “oy [OSqy ‘q dnorp *SI}LINOU Oca ey] Ul osuByo yuoIBdde yNOYIM UWOTpuod teGua SET [Blouses oY} JO JUDUTAAOIdUIT poxyIVUR poesnBo ‘OOUBMOTL[V [BSN Ft ‘A[TVep oe tes ae ABP YIGTT OY} WO poINyYSUL SUIpedF POXTI: | "| O0 | 0 (a3 6 PL | sutvas 9% (MOT[eA) ourdrpnar Bs 5 ene “ATLBp SULBIS EL 0} (ABP 4106) VOOUBMO[T[B [Bnsn * fA[rep : Pei 5 IO}B] PUL SUIBIS 9z 0} pooNper SAvp Ep 10o}PVu |---| 0 | 0 Gol: | LOL €L | Sutvis gg (Moped) outditry e aces , “Oot ae vel yoke or (coma e sae ste ak ZL |7-7>>(Avyed) o011 uvoRy Ourd py “ou0lTy peysnquy 79 dnory “BLIOY}Ydrp UBIAB JO polds “ATLBD TORN ‘a7@S UIT, “pel[qnop sv yunoure styy Avp y4GG 94) UOs | Z'SIT 19 Or eo ee alae ee TL | suaeas 9g'0-+ (Moped) Ourdr aT ; i) 04 peT[rur ‘quoumjivdeq sue sisqng -lepul) “BIIOYJYAIP UBIAB JO pole | 9°6aT 9G. lle laa |e Sea eae or | ‘davored por wr ourdriy ‘OUOTY iq dnory GUampe esa (joer | Peers fe 6 |--divotred Mojjed WAT OUTLET LT 202 CHAMBERLAIN, BLOOMBERGH, KILBOURNE. TaBLe IV.—Individual numbers of fowls and percentages of weight gained or lost during experiments. ® Died of avian diphtheria. b Not known. ¢ Found dead after a storm. 5 ; sean ceraillnes Fa j Sr ile q z| ae (Bo yg | -|> | a le Se [ ou isa =| » wo |S Oo la crs S| 3 o a | : Seen ee me ees (ea) eee Food SM | ge |sadieaul = | &d | af |gel yg [se Come) ae Sot\saq as ee og |a5 g os a | Bon|aat) & aq So owiy s irs ro ty) mVt|2 a 6D (3) ze AIGA 3S reel ey Nea sl Sere a ‘a |e AIS q BSEIDHO o 5 Di} oO oO |ea fe = = oy = 4 |A a iA Gins. | Gms Gms. Bay" ems |e (By tee a eae 1 Class 1: 2] 1,190 | 1,077] 9.5) 885 | 25.7 |_----- | commen | ca Filipino By Ora || GRR ame BOG | ae Ty ae a Noe: Ala) 133) 700) 113873) 1628))| 45,1 eeeeee zh eters Be 20 | 1,218 | 1,034 | 15.2 | 828 | 39,1 |_-- Hg (ene ae 8 i) bikes 5 || 878 | 680] 22.6] 623) 29,4 |----__ nO Ree eee hope Alone. | saison Sub-| 6|1,006| 650} 35.4] 517 | 48.7 |---- 1] Nae BIstence ae GUp || ayy) |e se eee 1020) 19,3 ool 1 P ? 8 | 1,006 | 602] 40.2] 510 | 49.4 |______ ite | a laine Class 3: 40 O56] aaee eae eee if, 008 |e 5A eae us| or | eae pee eee (| Cm BE) Ban || BES | BBM |e ity |e hae Store seal 48 | 1,204 751 | 37.7 TRIB || S09) ese 1g | cet NSE SSEU Yo 49] 1,119} 700) 37.5) 623 | 44.4 |______ = (esr ee OH Mall ality | ft5) |) Ce) | 1 ey ais) ah 31 4| oem aes Class4: | 92] 1,218 | 914] 25.0] 744 | 39.0 ay ee ‘ .05 gram KCl : : Pipe lib te cet cll ec ee ae 3 | 1,268 | 864] 31.9] 687 | 49.8 |_---- viel eee ee Polished 241 970) 650/330; 474 | 51.2 |----- rT eae a fag rice. Clases D5, els 013.1 e779 \12302) in 700) kS079) eeeee rae ese i 0.03 gram 26 | 1,140} 800] 29.9} 708 | 37.9 |____ The vera et HsPO, daily. | 93/4 021 | 700 | 31.5 | 489 | 52.2 |------ ri ag Glnes 59 | 1,226} 970] 20.9] 871 | 29.0 |_____- esti ee With 0.06 gram 60 | 1,176 | 830] 29.5] 807) 31.4 |_-___ | aa aes : HPO, daily. | 61 | 1, 261 828 | 34.4 1 various I ad a O84 | Rese ae | easoeeecan salts. Sy OL | are || OLB Ge | BT a Pe ae Class a 2810) |) il, OBIE fee eene | (a eae | ee | 1 0.05 gram KC ‘ ey 9 = and 0.03gram| 8! | 1,091] 779 | 28.6 | 700 | 35.9 |______ of 3 Sate a eiaiaes H3PO,daily.| 32|1,070) 566] 47.2] 588 | 49.8 |______ ‘1 gf etal ee s 237 ene 0) meee | G51) 34g | ease | eae 1 Class 8: QTL OOS eet | eee 98% tend 2s eee eee Ay aeees 0.03 gram Hz PO, fol- lowed by 0.05 gram KCl daily. RICE DIET. during experiments—Continued. 203 TABLE 1V.—Individual numbers of fowls and percentages of weight gained or lost : q we [aS 2 ON es, |e | Bl FS Sa 5 2 < 2 wo |S mi lie As| 2 ale el |S) Sea We PEO | any | ed | = © o- 129 loe| a a Bs aH! SP leo a/weal #8 wo | as “ot = Hood: B3| £2 |Sesleae) = | se] ou las] § (os ‘sH | Boela os & A o& |oo]| A |B =O] ‘eo melt |o a p ® Alga] s mals mAO1S ou] oo S Beata iees g 13 SI © |P aA |GRO 2 5 De | o Os & = = ay Sl ee a (a aS) Gms. | Gms. Gms. 1/0 907 | Seen | eames 751 1 py jee Class 9: d Filipino with} 10 | 1,048 |_______|______ 1,112 it oscee Velloweperl“s Neel 1051/22 eee 1, 303 ike eee ae 12| 978 1,020 it eee Alone. Class 10: SB lean 76s ke ae ane rp |e PPG} suse ite eee Group B: eo are SOI EO Tes |e | ena i176] eee Dr Gul epee | ee Ua See | CLG nna) | eee se oe GD ge he ieee NCO a 1 milled rice. Department. | 47 | 1,042 |_______]____-_ AT AST es a 3153) eee iis : 33 | 1,028 SSO. [aller | eee |e Tei ice Class 11: re 5 With | Filipino (yel- Be | Lol BED [ASD Jiexeeee Saco RES u aie low) + 0.36 Booed 2OL pe eos pees Liisa 950) (tenes i iy eae pe eee lbe sells bce ae 22 1;282 |______ 178 [ee sfollecie i lets | a RYAN aes oe ee 75 nlelSeOy [eee |e er fia [eee 13 | 1,138 TES \7i | eee Ba(S)al eee our a aes Group C: Class 12: Re SHOTS Unhusked | Alone, | Filipino Ma- 14 | 1,077 885 | 17.9 |------|----- I ones d au 15 |{ Th ai@ys Le eS TIS eae HGh ees Ty |e alay). palay) GH eSEGO TE eaetot aaa FES | eG) eee it|lzasee Class 13: 18 | 1,006} 588 | 46.6] 510 | 49.4 |______ TU) | Sataie IE Sm Reduced| 2 allowance. under- = milled. Class 14: 19) 942)= 550))'84.7 || 510) 39,5 ))_---. i ome Le 2 allowance. Group D: 17 991 722 | 27,2 095 | 40.0 |------ BR (eee ees Starvation. a4] Cs li eae | (ee aR ASIN SO ag es cot eas pi ge veal COME) eee |e 2a cae OA ae Gib sess |e 1 Glasctiss BAB aah QZ. |e eal BGM Wes Oi [ee | ese il Absolute. omte-| Water only. | 44| 970| 582 | 40.0] 531 | 45.3 |______ rt le Wi ENA Uae ()' 7a | eee ees | ee G87 | Dosey |e eee 1 By) ROO az || rola) |) are |e Ay ence ee | aot 1S. | OSTA eel ae ESE OM ANG fh ence 1 ® Died of avian diphtheria. D Not known. ¢ Found dead after a storm. 4 Sick with avian diphtheria. e Recovered. f Died of starvation carried too far. & Cause of death unknown. h Died of starvation. CHAMBERLAIN, BLOOMBERGH, KILBOURNE. 204 SILIGNAN das AV Vd LYNN SUV G3Ws8040NO 1HO JLV 1 V1L SILISNSN GSN8VW 113M dO1SA3G LON GIG GNV LNSWId3dXxX3 LNOHINOYHL JOlY GSHSI10d JO 113M 3LV IMO4 SIHL CE INY SILYASN SILLIMAN SILIGNSAN LHSIIS oe SILIGN AN | WYOLS V NI G3id Z SIL uNAN dO 1SA30 LON GIG GNY LNOHSNOYHL 114 M ALY INOS SIHL | SILIGNAN RICE DIET. 205 CHART 2, POLISHED RICE, FORCIBLY Pel) (CLASS 3) ii} 2\ 31 4t i 6I 1 8i 40 | RELEASED 7 THIS FOWL ATE WELL OF THE POLISHED RICE THROUGHOUT THE EXPERIMENT AND DID NOT DEVELOP NEURITIS | g -RELEASED —_-—____——--— JNEURITIS hPALAY FED PALAY STOPPED AND FORCED FEED OF POLISHED RICE CONTINUE NEURITIS 3 Qi|NEURITIS PALAY FED \ ? PALAY FED 49 DIED 206 DAYS | | CHART 3 POLISHED RICE WITH SALTS.(CLASSES 45/7) 4 51 61 CHAMBERLAIN, BLOOMBERGH, KILBOURNE. GRAMS 23 aS THIS WEIGHT CONTINUED PRACTICALLY UNALTERED FOR 125 DAYS AND FOWL REMAINED ELL HE ATE WELL THROUGHOUT. RICE = InP, IMIDE PION asec RICE + H, PO, and K Cl, RICE DIET. 207 CHART 4, POLISHED RICE WITH O06 GMS. ,P Oe {CLASS | 6) DAYS 1 GRAMS 6| INFECTIOUS DISEASE NEURITIS CHLOROF ORMED PALAY FED PALAY FED OROFORMED CHAMBERLAIN, BLOOMBERGH, KILBOURNE. 208 Ip G34 AV Vd (44 Ggld 8! SILISNAN aaid 310 d SILIUMSN NE! t¥\\ eb SILIMMAN\ O3YYVW 173M SILIYNSN Nd O34 AV Ivd| 9¢ [| G3W40 5040 1HO GSNUVW 114M SILIENSN oS d34AV 1d SNOILYY G39NG3Y NO GSAYVLS IMO SIHL G3WYO 5040 1H /GG 06 08 OL (os) iv OS 0 (Gl? V1 €l SASSV 19) SIMO4 GSANVLS Of 'G LYVHO Fig. 1. 2s 3. Fie. 4. iG. 8. Hil, ILLUSTRATIONS. PLATE I. Cages used for fowls during experiments. Fowl number 5 in spastic stage. Shows extreme extension at knees and a tendency to teeter forward. Fowl number 5 in spastic stage. Shows extreme extension at knees and a tendency to teeter forward. Prate II. Front view of fowl number 6 showing well-developed neuritis resulting from a diet of polished rice. . Profile view of fowl number 6 showing well-developed neuritis resulting from a diet of polished rice. . Fowl number 6. Late stage of neuritis resulting from a diet of polished rice. . Front view of fowl number 8 showing neuritis resulting from polished rice diet. Puate III. Profile view of fowl number 8 showing neuritis resulting from polished rice diet. . Front view of fowl number 18 which developed neuritis from starving on reduced rations. Shows wing-drop. . Profile view of fowl number 18 which developed neuritis from starving on reduced rations. Shows wing-drop and leg signs. Front view of fowl number 17 showing late appearances in neuritis pro- duced by starvation. Compare with Plate II, figure 4. PLATE LY. Fie. 12. Profile view of fowl number 17 showing late appearances in neuritis produced by starvation. Compare with Plate II, figure 5. 13. Front view of fowl number 55 showing early appearances in neuritis produced by starvation. Compare with Plate II, figure 4. 14. Profile view of fowl number 55 showing earliest appearances in neuritis produced by starvation. 209 ae IE ‘os Sal AEN CHAMBERLAIN, BLOOMBERGH, KILBOURNE: RICE DIFT.] [PHIm. JOURN. Scr., Vou. VI, No. 3. Fic. 1.—Cages used for fowls during experiments. 1G. 2.—Fowl number 5 in spastic stage. Fic. 3—Fowl number 5 in spastic stage. Shows extreme extension at knees and Shows extreme extension at knees and a tendency to teeter forward. a tendency to teeter forward. PLATE I. - ~ 2 ert heer mer meLOe ot Reinstie wtam ie al Somes re teehee CHAMBERLAIN, BLOOMBERGH, KILBOURNE: RICE DIET. ] [PHIL. JOURN. ScI., Vou. VI, No. 3. Fic. 5.—Profile view of fowl number 6 showing well-developed neuritis resulting from a diet of polished rice. Fic. 6.—Fowl number 6. Late stage of neuritis resulting from a diet of polished rice. Fic. 7.—Front view of fowl number 8 Fig. +.—Front view of fowl number 6 showing neuritis resulting from showing well-developed neuritis result- polished rice diet. ing from a diet of polished rice. PLATE Il. CHAMBERLAIN, BLOOMBERGH, KILBOURNE : RICE DIET. ] [PHIL. JOURN. Sci., Vou. VI, No. ee) 8.—Profile view of fowl number 8 resulting from polished rice diet. FIG. Fic. 10.—Profile view of fowl number 18 which developed neuritis from starving on reduced rations. Shows wing-drop and leg signs. PLATE showing Fie. 9.—Front view of fowl number 18 which developed neuritis from starving on reduced rations. Shows wing-drop. neuritis Fic. 11.—Front view of fowl number 17 showing late appearances in neuritis produced by starvation. Compare with Plate II, figure 4. CHAMBERLAIN, BLOOMBERGH, KILEOURNE: RICE DIET. ] (PHIL. Journ. Scr., Vou. VI, No. 3. S| Fic. 12.—Profile view of fowl number 17 showing late appearances in neuritis produced by starvation. Compare with Plate II, figure 5. Fig. 13.—Front view of fowl Fic. 14.—Profile view of fowl number 55 number 55 showing early showing earliest appearances in neuritis appearances in neuritis pro- produced by starvation. duced by starvation. Com- pare with Plate II, figure 4. PLATE Iv. ah) OP? on A STUDY OF THE INTESTINAL PARASITES FOUND IN CAVITE PROVINCE.’ By HE. R. Stir.’ An out-patient department where medical aid has been given such Filipino patients as might present themselves, has been in operation during the year 1910 at the United States naval. hospital, Cafiacao, Cavite Province. The 932 stool examinations upon which the statistics to follow are based, were therefore made upon specimens from cases of sick people and of these only such patients as it was thought required such an examination for diagnostic reasons were made to bring such a specimen of faeces. The patients presenting themselves at our clinic come almost ex- clusively from the city of Cavite and the adjacent towns of Caridad and . San Roque. The conditions as regards rainfall and soil considerations are therefore the same for all of them. The rainfall in Cavite is slightly less than in Manila, where the yearly average approximates 75 inches. In this connection it should be stated that practically 80 per cent of the rain of the year falls in the months from June to October. Even after the most severe tropical rainfall the ground becomes dry in a very few hours. The average yearly temperature is about 27° C. and the difference between the average temperature of the coldest and hottest months is only about 4° C. The towns of Cavite, San Roque, and Caridad are situated on a low-lying sandy peninsula, the soil being chiefly coarse-grained sand. Many of the lower levels are covered at high tide with salt water from the adjacent waters of Cafacao and Manila Bay. These statements as to soil and climatic conditions are presented in view of a probable explanation of the small number of hookworm infec- tions noted in our stool examinations. Of the 932 examinations, 135 or 14.4 per cent failed to show the *Read at the Eighth Annual Meeting of the Philippine Islands Medical Association, February 24, 1911. * Surgeon, United States Navy, associate professor of medical zodlogy, Depart- ment of Tropical Medicine, College of Medicine and Surgery, University of the Philippines, Manila, P. I. 211 212 | STITT. presence of intestinal parasites or their ova. The remaining positive examinations gave findings as follows: Z Number Organism. of in- Per cent. fections. Ascanisi25 2 ee Be ee C8. ER ee ea a 627 67.2 ERUCHO CCD) UALS Set a Oana ee eee Sas ey ee 607 65.1 BENS HEU else = ea aE ee ee ee Ee ea 135 14.4 ANSTO OB 10 Be eA ee aT spe ee ee 111 10.9 IER OO KW. rinses Sw NEE ae eS Ss ee ae eS 23 2.4 PENG: SAG UIUC P= oem aes a OE SR OR er Nae ee 3 .3 Balantidiuima sss eee ee ae ee 1 wl Strongyloides: 228 - ee os Lee a es eee ee 1 it I personally, and very carefully, made the stool examinations in 100 of the above cases taken in sequence, using neutral red as well as with ordinary cover glass preparations, and obtained the following results: As- | Whip-| Hook-| Ame- | Flagel-|, Age. Cases. caris. | worm.|worm.| bx. lates. Under sryeats) aa een eee 42 By 28 0 2 2 5) M0) 0) SENS a eee 27 25 23 0 2 5 LOMO }25 wears] =2— == ee 16 9 14 i 2 1 ZOO; OOKV CRTs =e eee ee 10 8 4 0 2 il Overb0byieanss 2552 seem enese nee (5) 1 3 0 il 1 Motel Seas seen eee ene 100 80 72 if 9 10 Twelve of the cases tabulated above failed to show intestinal parasites or their ova. Of the entire total, positive for hookworm, 8 were between 5 and 15 years of age; 7 were between 25 and 35; 4 between 15 and 25; 3 over 35, and only 1 under 5 years. Among the specimens positive for amcebze there were organisms which as regards ectosare characteristics and distribution of nuclear chromatin corresponded to Hntameba coli and Hntameba histolytica. Both types would frequently be observed in the same stool. Very few of these amoebic infections presented dysenteric or other symptoms. However, in three cases with marked anzmia and loss of energy and with the presence of very great numbers of amcebe in the stools, ipecac treat- ment caused the disappearance of amcebe and complete restoration to health. We find, on comparing the percentage of cases positive for amcebe with the results of examinations of the members of the Hospital Corps of the United States Navy on duty at this hospital, that an examination of the stools of 26 of these native-born Americans, in August, 1910, showed 34 per cent to be infected. A similar examination of 33 cases in December, 1910, gave positive findings for amcebe in 37 per cent. There are certain: points to be kept in mind in judging of the greater INTESTINAL PARASITES. 213 frequency of amcebiasis in these members of the Naval Hospital Corps as compared with that in the Filipino patients examined.* First: The stools of the men in the hospital corps were examined within a short time after being passed. It is a matter of common observation that a stool showing many amebe may, after standing for a few hours, fail to show the presence of a single ameba. Many of the specimens brought to the labor- atory by Filipino patients were evidently many hours old. Second: The expedient of giving a dose of salts prior to examination for amcebe was not practicable with the Filipinos. Third: Our experience has been that amcebe are less frequent in young children and as about one-third of our Filipino patients were of such age, this should be taken into consideration. At Bilibid Prison, Garrison encountered amecebic infection in 23 per cent of the cases.* In the medical survey of Taytay, his findings were 2.7 per cent. Rissler and Gomez ° report only 0.39 per cent of amcebic infection in their examinations in Las Pinas and no cases showing such infections in Tuguegarao and Santa Isabel. Such numbers are in striking contrast with those of former investigators, some of whom have reported as high a percentage of infection as 70. Our findings as regards flagellates (14.4 per cent) correspond fairly closely with those of Garrison, namely, 21 per cent at Bilibid and 5.5 per cent at Taytay. Repeated examinations with Giemsa staining and the counting of flagella in preparations in wet Gram solution showed only one species of flagellate to be present, Trichomonas intestinalis. Lamblia was not found in a single instance. Garrison, for Trichocephalus infection, obtained 59 per cent at Bili- bid and 77 per cent at Taytay; Rissler and Gomez give 53 per cent at Las Pinas; 25.9 per cent at Tuguegarao, and 6.23 at Santa Isabel. Our findings were 65.1 per cent. As regards Ascaris we found a higher rate of infection than for any other parasite (67.2 per cent). Garrison encountered 26 per cent at Bilibid and 82.9 per cent at Taytay. The percentages of Rissler and Gomez are 77, 73, and 60 respectively for Las Pifias, Tuguegarao, and Santa Isabel. Garrison noted at Bilibid an incidence second only to Trichocephalus for hookworm infection, namely 52 per cent. His percentage of infec- tion at Taytay was 11.6. Rissler and Gomez found 11.14 of all cases examined, infected with hookworms at Las Pifias; 8.01 per cent in Tuguegarao, and 45.38 per cent in Santa Isabel. We noted only 2.4 per cent for Cavite, San Roque, and Caridad. * Thirty-five and six-tenths per cent as against 10.9 per cent for Filipinos. *This Journal, Sec. B (1908), 3, 191. *Tbid. (1909), 4, 257. *Tbid. (1910), 5, 267. 102362——4 214 STITT. The soil conditions mentioned above probably to a great extent ac- count for the low incidence of hookworm disease as brought out in our examinations. Instead of a fine-grained, sandy soil which holds mois- .ture tenaciously‘ we have here a coarse-grained sand which dries up completely almost as soon as the rain stops falling. Stiles attaches importance to the consideration that a wooded location is favorable to the development of hookworms because the shade of the trees counteracts the injurious effects of drying on the larve. ‘There are practically no shade trees in this section. The frequent flooding of low-lying sections with sea water at the time of high tides must also influence the possi-: bility of infection. Our findings as regards Strongyloides (0.1 per cent) were far below those reported by Garrison at Bilibid (3 per cent) and at Taytay (0.7 per cent). Rissler and Gomez found 2.24 per cent infected:in Las Pinas, but no cases were encountered in Tuguegarao and Santa Isabel. The same factors influencing hookworm infection in this locality may be operative for Strongyloides. Garrison found 0.2 per cent of the individuals examined at Taytay to be infected with ciliates, while Gomez and Rissler failed to find such infections at Tuguegarao or oun deals We found a single case in the 932 examinations. Our three cases of tapeworm infection were with Tenia saginata. *Views of Nicholson and Rankin as to favorable soil for hookworm develop- ment. THE DYSENTERY BACILLUS WITH A BACTERIOLOGIC STUDY OF AN EPIDEMIC OF BACILLARY DYSENTERY IN THE PEweIRPINES:: By EuGEeNne R. WHITMORE.* (From the Biological Laboratory, Bureau of Science, Manila, P. I.) Shiga,(1) in 1908, announced that he had cultivated a special bacillus from the stools of dysentery patients and considered this bacillus to be the specific cause of bacillary dysentery. Since that time much atten- tion has been given to the study of bacteria in the stools of patients suffering from dysentery. In 1900, Flexner(2) and Strong(3) described a similar or identical bacillus in the stools of dysentery patients in Manila and almost at the same time Kruse(4) gave an account of a similar one in the same class of material in Germany. He rightly described the bacillus as non-flagellated, while Shiga called it a motile bacillus with flagella. From this time on the number of observations on the bacteria found in the stools of patients suffering with diarrhea and dysen- tery increased very rapidly, and very soon workers began to note that there were differences between the bacteria isolated in various places, and between the bacteria isolated from different cases in the same place. Kruse .considered. his bacillus to be different from the Shiga-Flexner organism?” because it was non- motile and without flagella. Koch suggested that a commission should compare the various strains of the dysentery bacillus isolated by different men. This was done, and the Shiga, Flexner, Kruse, and two Déoberitz strains were found to be morphologically and culturally alike. None of them bore flagella, while all of them showed a marked oscillating molecular motion. However, the Flexner strain did not agglutinate as strongly with the serum of a convalescent patient in the Déberitz epidemic as did the others. Several observers, following this work, described dysentery-like bacilli which were found in various dysenteric conditions, especially in asylum dysentery. These organisms resembled the true bacilli of dysentery in cultures and in hanging drops, and they were agglutinated in as high dilutions of the serum of convalescent dysentery patients as were the true dysentery strains. However, staining showed them to have flagella, and further growth on different culture media proved them to be different from the true dysentery bacilli. From this it was evident that the serum of convalescent dysentery patients could not be used for the differentiation of dysentery and dysentery-like hacilli. Martini and lLentz(5) immunized animals to two different strains of the *Major, Medical Corps, United States Army; detailed to the Biological Labo- ratory, Bureau of Science, Manila, P. I. * Flexner described his organism as a motile bacillus with flagella, while Strong was not able to demonstrate flagella. 215 216 WHITMORE. . dysentery bacillus and tested the agglutinating power of the different specific sera on the various strains. They also made a careful study of the morphology and cultural properties of the latter. They began by attempting to immunize rabbits and guinea pigs to seven strains, but so many animals died that they abandoned this method. Rabbits resisted one strain of the Flexner organism, and a good serum was obtained. Martini and Lentz then immunized a goat to the strain “Shiga,” and prepared a very active serum. They were able to show from the agglutination reactions with these sera that the Shiga, Kruse, and eight other strains were identical (Group I), while the Flexner and Strong strains from the Philippines differed from the latter (Group II). It was further proved that one of Strong’s strains differed from the Flexner in its agglutinability, although Martini and Lentz do not seem to have made it into a separate group at that time, but left it with the Flexner, pseudo- dysentery (Kruse), and several others, all of which were different from the Shiga and Kruse types. Hiss and Russell(6) described a bacillus which they isolated from a fatal case of diarrhea in a child. They called this organism “Bacillus dysenterie Y” and it soon was shown that the bacillus of asylum dysentery was identical with this variety. It does not appear that Martini and Lentz tested the agelutinability of bacillus Y to their “Flexner” serum, although they seem to have had it in their series (Pseudodysentery Kruse) and found that it did not agglutinate with their Shiga serum. Since we know now that the serum from the Flexner organism often agglutinates Bacillus Y in as high dilution as it does the Flexner, it would have been interesting to have studied this question. Hiss and Russell differentiated their Bacillus Y from the Shiga bacillus by means of mannite- and maltose-litmus agar, and almost at the same time Lentz(7) used these same media for the differentiation of dysentery and dysentery-like bacilli. He worked with the strains which Martini and Lentz had used in their agglutination experiments. By means of the sugar media, he was able to show that one of Strong’s strains was different from that of Shiga and Flexner, while the two latter were also proved to be different from each other by their behavior in the sugar media. This corresponded to the finding of Martini and Lentz, as a result of their studies of the agglutination reactions of the same three strains. This brief review of the literature shows that the dysentery bacillus had been divided into four groups by the use of sugar media and that three of these groups ‘were also distinct in their agglutinability. The following table gives the cultural differences in sugar media that are relied upon for isolation of the dysentery bacillus and to separate it into types: Cultural differences in sugar media. Appearance in culture of bacillus. Litmus agar with addition of— cing iga- . reantise Wie Flexner.| Strong. aiCtOS@ 25 eas eee as el Se ee Blue. Blue. Blue. Blue. Dextrose bias ek ae Red. Red. Red. Red. Marimba esa te Se as ices ee be ee oe ol Blue. Red. Red. Red. Mailitose seis) ee ee eee ee Blue. Blue. Red, Blue. Saecharose). 2.2 ee eee Blue. Blue. Blue. Red. THE DYSENTERY BACILLUS. 217 Three of these types (Shiga, Flexner, and Strong) correspond exactly to the agglutination reactions, while the other one (Bacillus Y) is only irregularly differentiated from that of Flexner by that reaction. Fur- thermore, the action on mannite corresponds to a difference in tonic- ity; the Shiga-Kruse type which does not produce acid in mannite, is very toxic for animals, while the other types which produce acid in manmite are not nearly as toxic. ‘This difference in toxicity was clearly shown by Martini and Lentz at the time they differentiated their two groups on the basis of the agglutination reactions. A number of other types have been added at times, and the above have been separated into a number of others by various workers. Thus Shiga(8) made a fifth type which differed from the “Flexner” in that it produced acid in mannite in the first twenty-four hours, and then alkali. It was very close or similar to the Flexner type in all other properties, including agglutinability. . Ohno(9) grew a large number of strains of the dysentery bacillus in the sugars for fourteen days and in this way divided the dysentery bacillus into 15 varieties because of their action on the sugars; but when he tested the agglutinability of his various strains he did not observe these varieties. Hetsch(10) already had pointed out that the reaction differed somewhat ac- cording to the percentage of sugar in the medium. In addition to sugar, the media contain peptone and albumoses, and while the decomposition products of the sugars are mainly acid, those of the peptone and albumoses are mainly alkaline. The bacteria attack both classes of substances and upon the amount of one or the other present, as well as the avidity with which one or the other is attacked, depends the acidity or alkalinity of the sum total of the products of decomposition. Again, an organism may change in its relative avidity for the carbohydrate and the proteid content of the medium. Hiss and Russell(6) and a number of others have shown that an organism may,change in its action on sugars after it has been on artificial media for some time. Finally, the absorption experiment of Castellani has been used for the separa- tion of the dysentery bacillus into types, but it gives so many that it almost hopelessly complicates the placing of any particular strain. During an epidemic of bacillary dysentery in the Philippines occur- ring in the summer of 1909, I was able to isolate dysentery and dysen- tery-like bacilli from the stools of a number of cases, and I proceeded to study the organisms along the lines indicated in the foregoing review of the literature. In isolating the organisms, I tried the various lactose- agar media, but did not find any of them to be superior to the litmus- lactose-agar for practical work on the dysentery bacillus. I prepared my plates in the laboratory in Manila, took them with me into the provinces where the dysentery was most active, streaked the plates there and then brought them back to the laboratory with me, or else, when I remained in the provinces for a few days, I picked colonies and transplanted them into tubes before coming back. In this way I was able to isolate a bacillus of the Shiga-Kruse type from 12 out of 40 eases of severe, acute dysentery in natives of two towns of Batangas Province where there was an epidemic of acute dysentery with a high 218 WHITMORE. mortality.* No other strain of the dysentery bacillus was found by me in that locality. I was able four times to isolate a bacillus of the Flexner- Strong type and one of the Shiga-Kruse type once from sporadic cases of acute dysentery around Manila. Besides this, I obtained a large number of dysentery-lke bacilli. These organisms were determined by the cultural characteristics, in- cluding their reactions in sugar media, their pathogenicity for lower animals, and their agglutination reactions with sera of animals im- munized to known strains of the various types of the dysentery bacillus. As all but one of the strains of the Shiga-Kruse type came from one locality and all of them were identical, I chose the Manila strain (P. S. IL) and one of the Batangas strains (P. S. 1). Im the same way I selected two of the Flexner-Strong strains (P. A. I. and P. A. IT) and six of the dysentery-like organisms (L. I. to L. VI). As my further work in agglutination reactions was to Immunize animals to each strain and then to test the agglutinability of every.strain with every serum, it was manifestly necessary for me to keep the number within working limits, and there was no necessity of working with a large series that culturally and by agglutination reactions had been shown to be identical. Again, reasonable economy in animals required that I should not use too many strains, especially as I was working with rabbits, and my Shiga-Kruse strains were so virulent for them that I lost a number of animals before I prepared a serum that agglutinated in sufficiently high dilution to be of any value.* The following chart gives the morphology and cultural character of the strains chosen: by me for further work, as well as two of the Shiga- Kruse type (S. S. I and 8. S. II) and one of the Flexner (8. A. II), kindly sent to me by Professor Shiga, and one strain of the Flexner- Sane type (S. A. I) brought from Heidelberg by Doctor Coca. I also tried Jehle and Charleton’s(11) serum medium with the sugars. The result was entirely in accord with the findings on agar. From the following chart it can be seen that the first four strains fall in the Shiga-Kruse type, while the next four belong to that of Flexner- Strong. The last six easily are shown not to be dysentery bacilli at all. There is no example of the Bacillus Y. ST took blood from each patient for agglutination tests, at the time that I obtained the stool. The blood-sera of patients who had been sick less than three days did not agelutinate the dysentery organisms; the sera from those who had been ill three to five days agglutinated cients or not at all, while that from patients who had been ill over five days agglutinated from 1: 40 to 1: 100, but no special work was done in this line, as the patients’ sera were not depended upon at all for determining the organisms. ‘Martini and Lentz say that the serum should agglutinate in a 1: 300 dilution. 219 “SYOOM XIS I0]Je plow A[IYSI[S omvoog v THE DYSENTERY BACILLUS. AKC Wee NP ee eee ODEs eee O Dare | eee KO) Oe pee ODses= 3 Fer OD mesaai tae = (Q) ORS apa aa Sot OD eam See Uo Ci aca | ee | a OD Saas mae ONG EAL : “m10940q 4B *do} wo winds *poyBpnsvoo WOTJBIO “Oy *oA0GB : ‘juetIpes AABEH | JOU ‘pozt1o[O09q | esuBYO ON | pezIIo[O.eq |- aSuRYO ON | -[Ode8p ‘ploy |-——~ Op GIMOIS Wory | IOs |—— uy zesuo7y |-----A “T oS ad ae ree ete ES prey ‘sn[roRq SULA fete BPs eae Ope srr a cas OD sian sSeaes (== -4qStIS ploy |---=- (a) SSA eaeOs Lelia eee = eae eal dumyd y10yg |---"AI “1 “yuourrpas AARey : 2 “9A0qR “UP MOTS Yory po op ~OuUlBALY |-—— OUL[VALY |-~~ ouLpexLy | -——— OND pr aang ODsaana ~ YMors LOyOry | aa ed weg} tesuoTy | “TIT “1 “De Windle Ss | Seas = (0) Ne mae “OsUBYOON | - POV |-JUSIIS Ploy | NOLO vere Oye ir caln ore cL LOA LGL| Se eee a pee a ae OD ESea| ia eas YE 741 “m0}40q ye B pe} B[nSvo0o : WOTIBIO ‘sfep ¢ 2 ‘quomrpes AAveyT | OU ‘oulpeyTy | ~~~ OI 7 OUl[VYLV |-—~ sUI[BYTY | -[Odep ‘ploy | — OD aaa TOVZB YSIMOTIOR | 7 ir et ee ae ODE gees S- 535, ie 4 POG ier acs Oar aren Oates age ee ODT mass ODaie lisse Ope yal = Op ie se (ja SIP ements, ees te OD SAI ue Nie Ve OGe = ieee Opss=|=--= OD neal | Raa (gs P= oyse == fre Oy FERSS (ppp RaSE ERE Opus==s | ae aeaes eee Cieaeas Ves RO (ie aes ke oy eee Opens eas ODee= saa ODeea Opatag ese Qo OD== sea lassaaaee Oprecanleser cee salsa eae ane Og evar COC ESE = prem eer age OD arair eee ODE en Neb DONG ie eres DLO Von emai OD ines |sence OD reste cee ee Op SI SONY, Palepisas ODrnse. SMOG “Gl nO Glee: sae eo aera O Deana Fa, OD taller eos OD eieae eae OD gS a|hraie Opis ae sacar (OfOao aml bra eiege es ODE age Roa nas reac sa eer OD aaa Page at Fs) LOX CE wal Sone ae OD es rapes (0) ag alg Oana Goa Ope Sse = OD naan Sacea ODFsria| fae gees OD roa apes Sa Sage | alee ODeaeas ea Sens ROXG FB Oe rte em mse OD mean aqyge | Os sae | enue ODisgeenl ees (0) ase a ge ae OD ase tases OD aaeas ee See ODEs |S ae ee 2 |ocaes ODmeaas Fue 4st Sel do} 10 uInds ON ; 5 ‘ayyjes 03 AduS *po}B[NSvOd Jou “AYUSITS SUL “SNT[LOBq -pus) WIM ‘ApnoTO | ‘prov ATAU SITS |--“9uL[eyLy |--- ouL[eyLV |--~ ourlpexpy |----—— ~~ ploy |-osuvyoon | -peords ‘ayy | Cleat dummyd y104g |-~“I ‘§ ‘d “IBVSB a SIB8B *1B8B "IBSB “IBSB 2 s Z “UOTTINOg “YIU snwyry | -osore yoo -9S0] [BUL -ouT MUO dso} xep -9S80] 0B] . ‘IVSB ULV “1011 | & ; “SOUT -SOUILT -SNUYT “SUIT “SMUT -onpoid = S UIIOT “9g{nNO jopur |* | - PUB 92S —U0 YJA\018 JO soyazedorg ‘VY Lavo 220 WHITMORE. Using the four Shiga-Kruse strains, I attempted to determine their type according to Ohno’s method. Two of my strains (P. 8S. I and P. S. II) were isolated recently, while two (S. S. I and 8. S.-IL) had been on artificial media for some time. All of the four belonged in Ohno’s type A. Hight months later I tested these same strains again. One (P. S. II) had changed to Ohno’s type B, while the other three remained in his type A. I used rabbits for the preparation of specific sera and made all in- jections intravenously. The animals were weighed once a week and the injections were given as closely as possible within the same interval, consideration being given to the weight and general conditions of the animal. The first four or five injections were of organisms grown in agar for 18 hours and heated to 60° for one hour, while the later ones were of living organisms. Hach animal usually received fourteen injections. The first was always very small and later the dose gradually was in- creased. I had great difficulty with the rabbits which were given the Shiga-Kruse cultures, 1/50 of a loop of a killed culture of one of the recently isolated strains killing rabbits when injected intravenously. I lost animals from the use of these strains as late as the fourteenth injection. The two strains received from Japan were not so virulent, possibly because they had been on artificial media for some time. The animals withstood larger doses of the latter and this may account for the fact that I attained sera with stronger agglutination from them. These facts appear in the agglutination tables given below. No especial difficulty was encountered in giving the Flexner strains and non-dysentery organisms in much larger doses than is possible with the Shiga-Kruse strains.° The animals were bled about ten days after the last injection. In order to obtain the large amount of serum needed for this work and still not to kill the rabbit, the following method was used: A large test tube was provided with a rubber stopper having two perforations. A piece of glass tubing connected by a short piece of rubber tubing to a long, slender aspirating needle passed through one perforation; a piece of glass tubing through the other, the later connected with the vacuum apparatus by a long piece of rubber tubing. The rabbit was placed on its back on an animal board, °* At the same time I immunized a horse to both Shiga-Kruse and Flexner types, by giving weekly intravenous injections of living organisms alternating with the filtrate from an old culture in alkali bouillon. One horse died of an intercurrent condition after it had received ten injections, but another received seventeen injections and at the end of that time his blood agglutinated Shiga at 1:800 and Flexner above 1:1000. The animal was bled ten days after the last injection and the serum put up for use in the treatment of bacillary dysentery. So far we have had very little opportunity to try it, as the epidemic dysentery under discussion was over by the time the serum was ready for use. THE DYSENTERY BACILLUS. Daal chloroform given, and the lower part of the chest and upper part of the abdomen shaved. The aspirating needle was passed through the abdominal wall just to the left of the ensiform cartilage and about 0.25 centimeter above the tip, and upward until the impulse of the heart wall was felt against it, when a slight thrust pushed the tip into the cavity of the left ventricle (sometimes apparently the right). By now producing a very slight vacuum in the tube, the blood begins to flow freely into the tube. In this way 20 to 25 cubic centimeters of blood could be obtained from a rabbit without any apparent inconvenience to the animal. The operation was repeated the next day and the next, and the serum from the three bleedings was then mixed. I readily secured 20 to 30 cubic centimeters of clear serum from each rabbit and the animals are alive and well six months after the bleeding. The serum is always sterile, as it is never exposed to the air until it is to be poured off the clot. The macroscopic method as given by Martini and Lentz was followed very closely in carrying out the agglutination tests. The salient points are: (1) Use 24-hour agar cultures, suspended in salt solution; (2) the same loop is always employed for scraping off the culture; (3) 1 cubic centimeter of the serum dilution and one loop of the culture are always taken; (4) agglutination takes place at room temperature (about 27° to 30° in this climate); (5) a test is made as to whether the agglutination is true or false by giving the tube several (5) short jerks while holding it by the top. My readings were taken at the end of sixteen hours. The following tables give the results of the agglutination tests. For the sake of brevity, tables of only two of the non-dysenteric sera are given, although all were tested and the other four had as little action on the dysentery strains as did the two tabulated. j TABLE I, Is agglutinated by — Sa 2 a Gian Rabbit serum ‘‘P. S. II’”’ in a dilution of — Culture. iC) of — = & z z B 3 SOM OmSOM some Nice |loulicos 3 Aeon ise ba ls Se iS |= (Slee JEL IS) Mote soee| Sl eee ae See + : F | + pore) bs S| ee IPS Sra ene SS | |saeelieece|| 5) t + t -} +] + SS | ee ale Sg Saee nese == | = ececliceee| Se |) 5) t i stra a ato Meese feet |e eee oe) Sas oie a cee: SET ee se crea cre rae ee edi oal |e come DIVAS Ihe ame Bef | LS) ST ee SE feo (a a) ee a a (ee eevAC Al ees le el Se S| Se | Fi a Pe Ke | To | SecA ea cet | nme [ ree me | ee [ee | ee elo oo [Yee See Ar teas a |e eee ts (mE ems [ee eee |p PY Cee SP |e [Rae ey Yonge Ree ae Ses em | eer Cg Pera em fee elf Ce tt Ie Se 1p Ot sya cel |e oe (| ce | ees | Bm Paes AN Nd D0 Be te Se | | et) | ee ee eee (ees ee) a BSLV ee = Beal (> Sait te) Pa | S| a cae era MN a Wy Ws 2 Be NE TEV ae. BS emt i | ees ere Ga | vem eee | ere | ce | ee | OR P| eek) | fe | TDA ee Se ae caret ae set err] NP be (eR ee aN ied | ia a | dilution of— COOETE a ee eee tien ooo't:t | a+ 1 | cOe mal = gicgie eaiecie ies 006: | + + 4 +4 fougr srl atest teal oog:t | + aoacre|| Mt ie 004: T - ae FP =+ 009: T -+- + + 00G¢°T | + ‘O0F = T PSP ae ‘008: T t een 006'T | + als ‘00L: T Tipe sists v ssh TABLE II. WWE Se See aE Is agglutinated in rabbit serum P. S, I. in a WHITMORE. TaBLe III. 06:1 Pe eae al Is agglutinated in rabbit serum S, S. in a dilution of— i +/+] 4 ait [ed ee pe al Wee | sear se se 4= I I ae eo sah] Culture. Culture. Pails See eee ee SWS! Mic pee ie een Baal pips a 0 (ares et ie eee Sil Mi aets ao eS PSS Whe ae soos ater cae as DS relly eee ee Se oe SBN tS bl eae ti An Sea ppt ey ae a a Prev Ag Min = Sas Se hes Ty, UV ose ee Saeed 222 223 HoH oH “000 ‘T: a “006: dilution of— dilution of— i is agglutinated in rabbit serum S. S. Ilina TABLE IV. TABLE V. sone sessesse||psee)\eo= sae || sae ||sqee|/ sae )/ eee ||o sao |/os- = Is agglutinated in rabbit serum S. A. lina Be =5 Ss o THE DYSENTERY BACILLUS. Culture. Culture. iP, Sip dt See Je SU eee Je 0: i Ea eA Wa ee Shug Wau Sapa lies oe SE eS We (ae eee re 10s TOD Ge aie iran ease as See SS Noe Ween eons aera ese! 10h NW ee es ea Opie eee ees NBS ps TN i pe ons Se Yaz ee SAR ATT eo ce A ee AT Tee eee Ek JERS IL aes eS IS hss Les See ete eee eae (Shira) Ee eee ae Sree te JES Ny RSE a eee eg ee WHITMORE. 224 TABLE VI. Is agglutinated in rabbit serum P. A. Ilina dilution of— “000 ‘T: at + “O0F « Culture. Dia Vo] Kee eee ea pag 6 Tear ee Ty Wale oe ee TABLE VII. Is agglutinated in rabbit serum S. A. Tin a dilution of— ‘000 ‘T: ail ail “006 = “008 : “004 : “009: “00¢ : 00P: ‘008 : “00 : ‘OOT « ‘0G: 0G: ‘OL: +) +] 4 +] + Culture. PAS ee Se eee eee SUSI ecet es seee ec es ow Shs (Sk IE seen stenceeseetece|| = |as--|----)-s+4|eoe-|ecee||oseo|sens|sems|aeos||sese|—oe|/=s0= ES AN sleet 2 Se IP ARs bts fa eno ae SicAl Ri Seeee eens ss 3 Uipg) Nie eS eee 225 THE DYSENTERY BACILLUS. TasLe VIII. Is agglutinated in rabbit serum S. A. Ilina dilution of— 000 ‘T: “OOT + n T +/+|+]+ Culture. IPs Giclee ee ee Ty van eee Re aone, ata 12 ik, Thee eae Sh VNer 10S ee ee ee Wy, DUD Lent see See Se TABLE IX. Is agglutinated in rabbit serum L, VI ina dilution of — 000 ‘T: “006 « » “008: ‘004: “009: ‘00S: “OOF: “008 = 006: *OOL: 0G: +/+] +] +} +}+]/+}4+]4+]+ 0G: ‘OL: Culture. Pe Goes 2s a ee Se Sn LSet ee Pep AG a ee ee See Shige) (eee Se See Shy Uae Le Se aE Wg DIN a ay spe] ct pL | ec DE pe eee eae oe ee 226 WHITMORE. TABLE X. Is agglutinated in rabbit serum L. [ina dilution of — Culture. | ; ’ : : S alele/SlSisleigisleisisls PuiSi eee eee a eee ee) eee [aire et eee eS ae eee ene (seer ea ae (DES 5 ce ee Saeeenee Se eo eae [ms er | nr | eee ere ee [Re | Sat; dy Se eee ae PH ea aA AH ce 2 || ee el SiS UE cass Soe ey NS S| ee ee | a Se | ee IP SPAG Te Ws ap Pe aS ete cme ee Ue oe | eco || al ed eee ey Pe Oe Ae UT sear aes eas et ath Pee et) tee (em [Sy Te Pe ee SpA al ese eee ee S| eg ee ee ee eee Sa) Poa eee oe |eoce ee ae SNe df) Ue ae EV bd med |e (ere eee Pesan [my a] a | (ee dO ee Se ee es ae Se iPSr ar Sear se Seo se se |) ae oar es | = SM PU Se nw hes fps RI se Ps SS | roe ce [ececee |2e w Je Ub STAN eet SL Cee Pan ee Se [eee omer fern Pere aera a fe | oe TEEN Ai teh eon WES Sete ee | aN oe 1 2 | a (| ee |e 1 ee \ feet eee tere rae Tp | Syke a tee NU 2 ol oes EO ee | iat) | A \ Less os cerca alee ah re Eo Maal ees tee en Ponape oe | ed en al [eae a Poet [a From the foregoing tables it is evident that the first four strains are identical; also that the next four are identical among themselves, but are entirely different from the first four. Two of the first four strains (S. S. I and §. 8. IL) are known to be of the Shiga-Kruse variety, while two of the next four (S. A. I and S. A. II) are Flexner strains. I was interested in finding that non-dysentery strains L. V and L. VI were both agglutinated in a dilution above 1:1,000 of serum L. V and serum L. VI. On checking them, I found that L. V and L. VI both came from the same patient and that, owing to an error in the spelling of the name, two stools from the same patient had been examined as coming from different ones. SUMMARY. 1. In an epidemic of bacillary dysentery with a high death rate in Luzon, Province of Batangas, P. I., it has been shown that the Shiga- Kruse type of dysentery bacillus was the causative agent. 2. At the same time, the Flexner-Strong type of dysentery bacillus was found in some cases of dysentery around Manila. 3. The Bacillus Y and the Strong type with which Leutz worked were ~ not found. 4. Great care is necessary in describing types of the dysentery bacillus from their reactions in sugar media alone, as the amount of sugar present and the length of time the organism has been on artificial media often affect the reaction. THE DYSENTERY BACILLUS. DAT REFERENCES.°® (1) Suie¢a. Centralbl. f. Bakt. etc. I Abt., Orig. (1898), 23, 599. (2) Frexner. Bull. Johns Hopkins Hosp. (1900), 11, 231; Centralbl. f. Bakt. etc. I Abt., Orig. (1900), 28, 626. (3) Srrone and Musecrave. Report of Surg. Gen’l. U. S. Army (1900). (4) Kruse. Deutsche med. Wehnschr. (1900), 26, 637. (5) Hiss and Russett. Med. News (1903), 82, 289. (6) Martini and Lentz. Ztschr. f. Hyg. u. Infectionskrankh. (1902), 41, 540. (7) Lenaz. Tbid., 559. - (8) Suiea. This Journal (1906), 1, 485. (9) Onno. Tbid., 951. (10) Herscu. Centralbl. f. Bakt. etc., I Abt., Orig. (1903), 34, 580. (11) Jpu~e and CHarRLeToN. Ztschr. f. Heil. Abt. f. Int. Med. (1905), 26, 402. ®°The excellent article by Lentz in Kolle & Wassermann’s Handbuch d. Path. Mikroérg. (1909), Erg. Bd. II, p. 391, gives a full discussion and a full bibliog- raphy on the subject. PRACTICAL EXPERIENCES WITH BERIBERI AND WNEOEISHED RICE INT THE PHILIPPINES. By Victor G. HEISER.* The advances made during the past year in placing the etiology of beriberi upon a scientific basis have now proceeded sufficiently to war- rant the inference that prophylactic medicine has the knowledge at its command to place this scourge among the preventable diseases. While it has been possible to control outbreaks of beriberi in public institutions in the Philippines during the past ten years by reducing the rice in the diet and replacing it with meat, vegetables, mongos,* ete., yet it was not until the papers which were read at the last annual- meeting of the Far Hastern Association of Tropical Medicine, especially those of Fraser * and of Aron ® gaye the clue, that a rational method for the prevention and cure of the disease became available. Briefly, it will be remembered that these gentlemen showed by ex- perimental data that beriberi in man and polyneuritis in fowls could be caused by using as the staple article of diet, rice, from which the outer portion or pericarp had been removed, and that, unless advanced degeneration of the nerves had occurred an immediate amelioration of the symptoms took place when rice with the pericarp, or its equivalent, was substituted. Numerous analyses of rice sold in the Manila market have been made by Aron, and these soon proved that Saigon rice number 2, as well as *Read at the Highth Annual Meeting of the Philippine Islands Medical Asso- ciation, February 23, 1911. *Passed assistant surgeon, United States Public Health and Marine-Hospital Service; Director of Health for the Philippine Islands; and professor of hygiene, College of Physicians and Surgeons, University of the Philippines. *A small bean, Phaseolus radiatus Linn. (P. mungo Blanco), similar to katjang idjo of Dutch Hast India. It has been proved by the native physicians of the Philippines as valuable as katjang idjo as a popular remedy for beriberi. According to the analysis of Aron (This Journal, Sec. B (1910), 5, 88) this bean contains 23.75 per cent protein; 9.56 per cent water; 0.77 per cent P.O.; 4.5 per cent fat; 6.4 per cent crude fiber. *Tbid., 55. * [bid., 81. 102362——5 229 230 _ HEISER. locally polished rice, almost invariably contained less than 0.4 per cent of phosphorus pentoxide, unpolished or slightly polished rice was found to contain from 0.5 per cent to 0.75 per cent of phosphorus pentoxide.® Since the opening of the Culion leper colony in 1906, rice has been the staple article of diet in the place, and it was customary to use either Saigon rice number 2, or local polished rice. Beriberi was more or less continuously present in the colony until February, 1910. By substitut- ing meat and mongos for rice it was always possible to reduce the num- ber of cases of beriberi, but the disease was never completely eradicated. It was found later that this failure was probably due to the fact that many of the lepers preferred to deny themselves food rather than to eat mongos, so that we had starvation as well as improper diet to deal with. The total number of deaths at Culion by months from February, 1909, to February, 1910, among an average population of 1,537 was as follows: February, 39; March, 54; April, 52; May, 47; June, 48; July, 57; August, 61; September, 65; October, 43; November, 80; December, 188; January, 164; a total of 898. Of this number 309 were due to beriberi. In February, 1910, the use of unpolished rice was made compulsory for all inmates of the Culion leper colony. The total number of deaths for the months from February, 1910, to February, 1911, among an average population of 1,952, or a population greater by 27 per cent, was as follows: February, 66; March, 36; April, 29; May, 22; June, 27; July, 15; August, 24; September, 12; October, 13; November, 15; December, 58; January, 52; or a total of 369. The increased death rate in December and January was due to an acute outbreak of bacillary dysentery. Of the number cited, there were no deaths from beriberi after February, 1910. At the end of January, 1910, there were approximately 50 cases of beriberi undergoing treatment in the Culion hospital. Upon the sug- gestion of Doctor Aron, 30 grams of rice polishings mixed with milk and sugar were given to these patients twice daily. With the exception of two very advanced cases that died within a few days after this treat- ment was begun, all of them were able to leave the hospital, and within four weeks every case of beriberi was reported as cured by the attending physician of the hospital. So much for Culion. Prior to May, 1910, beriberi was very common throughout the Phil- ippines, in jails, light-house stations, charitable institutions, on Govern- ment vessels, and among the Philippine troops of the United States °T wish to make clear that the amount of phosphorus in rice is only given because it is a ready method for determining the degree of polishing that a given rice has undergone; in other words, the estimation of the amount of phosphorus is a laboratory method of ascertaining whether much or little of the pericarp has been removed and at this time it can not be said that the lack of phosphorus causes beriberi. BERIBERI AND UNPOLISHED RICE. 2a Army. An investigation of these has shown that it was the invariable practice to use polished rice as the staple article of diet in all of the places mentioned. In May, 1910, an Executive Order was issued by the Governor-General of the Philippine Islands prohibiting the use of polished rice in all public civil institutions. Since August, 1910, only two cases of beriberi in the above places have come to the attention of the writer. One of these was among the crew of the steamer Rizal. An inspection of the ship’s stores showed that the rice was of the white polished variety. Further inquiry elicited the fact that it was custom- ary for the crew of this vessel to use a varied diet which may account for the fact that there were not more cases. The other case occurred in a prisoner in the jail at Tacloban. The physician in charge reported that it had not been possible to purchase unpolished rice at Tacloban and for that reason polished rice was being used. He added that every effort was, however, being made to comply with the spirit of the Exec- utive Order by using more meat, mongos, potatoes, green vegetables, and fish. At the Hospicio de San José, which is an insane and orphan asylum of over 700 inmates, beriberi has almost constantly been present, at least during the past ten years. Since June, 1910, unpolished rice has been used, and a few weeks after its use was begun beriberi disappeared, and since that time no further cases have been reported. _ Extensive inquiry made throughout the Philippine Islands has almost invariably shown that in districts in which hand-pounded, or, in other words, unpolished rice, is commonly used, there is little if any beriberi, whereas in districts in which machined, or, in other words, polished rice, 1s served as the staple article of diet, beriberi is quite common. However, an apparent exception to this general rule is found among the residents of the Batanes Islands. It may perhaps be mentioned that these are isolated islands north of Luzon and south of Formosa, which have communication with the outer world only a few times each year, and, owing to their inaccessibility, they generally escape visitations of cholera and other dangerous communicable diseases. The Batanes are poorly adapted to rice culture, and for this reason a considerable amount of polished rice is imported each year, and it would seem reasonable to infer that if the present theories with regard to the etiology of beriberi are correct, cases of this disease should be encoun- tered in these islands. However, an investigation of the dietary of the inhabitants of the Batanes Islands shows that meat and potatoes are more commonly used than in other parts of the Philippines. In brief, food of various kinds, other than rice, is so plentiful that rice is not the staple article of diet to the same extent as elsewhere in the Archi- pelago. Considerable difficulty has been encountered and much opposition has Zon, HEISER. resulted from the attempt to introduce unpolished rice. When the Army and the Insular Government entered the market to purchase large quan- tities, it developed that rice dealers were unable to supply the demand because managers of rice mills refused to adjust their process of manu- facture to meet the new requirements. This resulted in the use of large quantities of rice that came from the mills immediately after it was husked. The machines that are employed locally for this purpose allow many of the smaller rice grains to pass through without the husks being removed from them. Previously such rice went directly to the pohshing machine which not only polished the grains but the husks were also removed from such as still retamed them, so that the finished product was clean. It was apparent then that much of unpolished rice which was issued in the beginning was not very clean and contained many husks. This gave rise to much complaint among those who were re- quired to use it. It was frequently alleged that the husks tickled their throats and often caused gastritis. Upon investigation no reliable eyi- dence as to the gastritis could be obtained. Commissary officers, prison wardens, and others who were directly charged with carrying out the orders to use unpolished rice were constantly besieged with complaints, and it was but natural that they should take the course of least resist- ance and recommend that its use be discontinued. To add to the diffi- culties of those who were insisting upon the use of unpolished rice, the rumor spread that the latter, when stored in bulk, soon spoiled, thus causing great financial loss. Investigation of this matter showed that there was no reason to believe that unpolished rice when stored under the same conditions as polished rice spoiled any more rapidly. A campaign of education was then begun. Doctor Aron frequently went to the rice mills in person and was invariably able to demonstrate that rice could be rendered clean and free from husks without polishing it to a degree that would be harmful. Similar work, with like results, was accomplished by Highet in Siam, so that it may now be said that clean unpolished rice, satisfactory in appearance, can be obtained in the Philippines and abroad, and that the original objections to its use no longer exist. By January, 1911, so much evidence had accumulated showing un- polished rice to be an important factor in the prevention of beriberi that it was deemed most desirable to bring about its general use in the Philippines for a few years at least, in order to test the theory thor- oughly. At the most no harm can result, and upon the other hand every promise was held out that many hundreds of lives could be saved and a still greater morbidity avoided. Experimental investigations made by Doctor Aron showed that a rice which has only been polished to a point where it still contains 0.4 per cent of phosphorus pentoxide may be regarded as incapable of producing beriberi. Almost at the same BERIBERI AND UNPOLISHED RICE. Zao time similar conclusions were announced by Highet. Therefore, for purposes of convenience a rice containing less than 0.4 per cent of phosphorus pentoxide is regarded as polished and that which contains a greater percentage of phosphorus pentoxide as unpolished rice. Accordingly, a bill was drafted which had for its purpose the bring- ing about of the general use of unpolished rice in those quarters where it furnished the staple article of diet. After considerable discussion with physicians, lawyers, legislators, and others, it was deemed advisable to attempt to secure the desired result by a law that would impose a tax of 5 centavos (2.5 cents United States currency) per kilogram upon all polished rice sold, whether it be foreign or domestic. However, owing to the fact that the Legislature adjourned during the early days of February, there was not sufficient time to present this matter to both Houses. Because of the successful experience with unpolished rice in the prophylaxis of beriberi m the Philippines during the year, and since these data confirm the work of Fraser and Stanton,’ Aron,® Kilbourne,® de Haan,*® and Highet,"* as reported at the last annual meeting of the Far Eastern Association: of Tropical Medicine, it is believed that the time has come for the medical profession to aid in completing the last step in the test which promises so well to place another weapon in the hands of prophylactic medicine for the eradication of another of the world’s serious and costly diseases. . 7 Loe. cit. 0 Tbid., 65. 5 Loe. cit. “[bid., 73. °This Journal, Sec. B (1910), 5, 127. PERINEAL LITHOLAPAXY (KEITH’S OPERATION). By A. Hooron.* (Rajkot, India.) The trend of general surgical opinion, with reference to the treat- ment of stone in the urinary bladder, is, I suppose, more and more in fayor of the employment of crushing operations in almost all cases in which they are practicable, and while admitting that very large stones usually are best dealt with by suprapubic lithotomy, and that certain cases associated with cystitis or suppuration about the neck of the bladder derive benefit from the drainage which is most easily afforded by a perineal lithotomy, I take it that everyone will agree that any safe procedure which enables litholapaxy to be applied to stones which would otherwise have to be removed by serious cutting operations is worthy of consideration. Keith’s operation has this application, and it is with the view of bringing it to the notice of surgeons who perhaps may not previously have heard of it that this short account has been written. It may first be noted that several procedures involving a combination of erushing with a larger or smaller incision in the perineum have from time to time been advocated by various authorities. Dolbeau was the first surgeon, so far as I am aware, to publish an account of such a combined operation, but his operation, which in essentials is that still described in the text-books under the name of perineal lithotrity or litholapaxy, differs from Keith’s in the important fact that a much larger opening is made in the urethra to allow of the passage of large instruments designed merely to break up the calculus roughly, and not to crush it completely; and, indeed, it may be said that this method has more in common with lithotomy than litholapaxy pure and simple. Dolbeau’s operation apparently was practiced intermittently by various surgeons for many years, but it was not until Dr. Keith of the Indian Medical Service introduced his modifica- tion that any large number of cases of crushing through a perineal incision were published, and that the operation—so changed in its details as to be practically new—acquired almost all the advantages of an uncomplicated litholapaxy. Dr. Keith, in his capacity of Civil Surgeon of Hyderabad, Scinde, with its five hundred cases of stone a year, had unrivaled opportunities of demonstrating the value of the procedure, and recorded a series of fifty-three cases in men, with three deaths, and one hundred and six cases in children, with no deaths. Surgeon- General Stevenson, Colonels W. H. Henderson and R. Baker, I. M. S., and other * Major, I. M. S. 236 HOOTON. surgeons, have also employed Keith’s method in the same hospital with most encouraging results, and Colonel Henderson has published a series of a hundred and ten cases with three deaths. Keith’s original operation in its turn has in recent years undergone further modification at the hands of various operators. Surgeon-General Stevenson, it would appear, makes a slightly larger opening so as to allow of one instrument being introduced alongside another, the principle being’ to retain a guide all the time; while Major 8. Evans prefers to make his incision somewhat further back, and thus strike the wider prostatic portion of the urethra. Both these modifica- tions would tend theoretically to minimize what I am convinced is the reason of the comparatively slow adoption of the operation by surgeons who have not had opportunities of seeing it actually performed, namely, the risk of missing the opening in the urethra in working without a guide. However, this risk is not a great one, for Keith’s original incision strikes the urethra at a point where it is easily accessible, and where the wall, surrounded by the constrictor fibers, is more likely to grasp the instrument and so prevent leakage. In my experience it is not easy to work through a small opening using say the lithotrite as a guide for the canula to follow it; and, finally, the figures quoted above speak for themselves. In the account given below, I have adhered closely to what 1 under- stand was Keith’s original procedure, for any knowledge of which I wish to express my indebtedness to Colonel Henderson. J may remark that my own experience is limited to thirteen cases, all of which re- covered. Those only which call for comment were three children with large stones, necessitating prolonged manipulation and the repeated passing of instruments, and in whom the small incision did not heal, as it ordinarily does, by first intention. ADVANTAGES OF KEITH’S OPERATION. A comparison may perhaps best be made with suprapublic lithot- omy in adults, and lateral lithotomy in children and in both, perineal litholapaxy is usually, I would urge, very much preferable. Supra- pubic hthotomy has, I think, a larger mortality, it necessitates prolonged confinement to bed, and the patient is a nuisance to himself and his attendants. Lateral lithotomy, although very successful in children, has all the disadvantages of involuntary micturition, and there is reason to believe that in some cases the sexual powers are interfered with. In Keith’s operation there is usually no shock, micturition is volun-* tary, the sexual apparatus is not injured, and the period of convales- cence is usually not much longer than that of ordinary litholapaxy. I personally make a practice of keeping cases in for five to seven days, but often, after twenty-four hours, healing is so far advanced as to prevent any further escape of urine from the wound, and instances have frequently been noticed in which all urine escaped via the meatus from the first. PERINEAL LITHOLAPAXY. Wah INDICATIONS. Various authorities recommend perineal litholapaxy under some or all of the following conditions: (1) A large or very hard stone necessitating the use of a lithotrite which will not pass easily by the natural route. (2) Stricture, in conjunction with a large or hard stone, or perhaps with any stone. (3) A diffieult or narrow urethra. (4) Imperfect equipment—the absence of the smaller sizes of lithotrite. (5) Cases in which litholapaxy has been commenced in the ordinary way, but can not be completed satisfactorily owing to swelling of the urethra and deposit of débris. THE OPERATION. Perineal litholapaxy may thus be performed: The patient is placed in the lithotomy position, and the thighs held so that the parts are as symmetrical as possible. A curved staff with a median groove is introduced into the bladder and held as in lithotomy, but neither drawn up beneath the pubes nor depressed. The scrotum is allowed to hang down in the natural position, and neither the operator nor the assistant steadies the skin. A very small incision, or stab, is now made with the point of a tenotomy knife or double-edge scalpel, in children about one inch, in adults one and a half inches in front of the anus, through the median raphe in the direction of the staff; the groove is entered and the urethra incised for one-eighth inch or more and the knife withdrawn, slightly enlarging the superficial part of the incision as it emerges. The point of an ordinary director, which should not be too blunt, is inserted through the wound into the groove of the staff, and passed into the bladder; the staff is withdrawn, and graduated female sounds or Hegar’s dilators introduced up to the required size. Some operators do not pass the dilators so far as the bladder, but there is at all events no harm in doing so. Dilation is proceeded with slowly, and each instrument is left in position some little time; when the required aperture has been attained the director is with- drawn, leaving a circular, gaping orifice into the urethra. The appropriate size of evacuating catheter is now passed, and the bladder injected, and the lithotrite should follow without difficulty. If preferred, the director can be guided into the groove of the staff along the knife, before the latter is withdrawn. Both cannula and lithotrite are entered point downwards, and carried into the bladder by the usual rotatory movement. The operation is completed in the same way as an ordinary litholapaxy, and as a rule there is no difficulty in retaining fluid in the bladder; if leakage should oceur at the margins of the wound it is easy to compress them against the instrument. In order to avoid a valvular aperture (which renders the introduction of instruments difficult) it is most important that the skin should not be displaced when making the incision. Also, it is better to enter the knife too far forward than too near the anus; in the latter case the instruments enter the urethra at an acute angle instead of vertically, and are much more likely to slip past the opening, and there is the added difficulty of working in a deeper wound. The chief danger of the operation lies in thé lithotrite or cannula missing the urethral 238 HOOTON. opening, and passing upwards between the bladder and the rectum; the possibility of a small median wound of the bulb, especially in children, need not give rise to anxiety, and so far as I am aware, no cases of troublesome hemorrhage have been recorded. It is worthy of note that, contrary to what the anatomical text-books would lead one to expect, the most difficult part of a child’s urethra, after the meatus, is often well in front of the membraneous portion, so that an incision in the situation recommended almost always enables instruments of reasonable size to be passed. REFERENCES. Keitu, J. Forses. Lancet, London (1892), 1, 1234, 1292. Baker, R. Jbid (1896), 2, 1007; (1897), 2, 648. Henperson, W. H. Ind. Med. Gaz. (1900). STEVENSON and Evans. Proc. Bombay Med. Cong. (1909). A CLINICAL STUDY OF HOOKWORM INFECTION IN THE PHILIPPINES.’ By Lisor1o GoMEz. (From the Biological Laboratory, Bureau of Science, Manila, P. I.) The greater part of the work which has been done in relation to infec- tions with hookworm has been statistical. Thus the publications of Garrison,(1) Rissler and Gomez,(2) Bowman,(3) and Willets(4) have established the varying percentages of infection in different parts of the Philippine Islands. The investigation which is the subject of this paper was undertaken mainly to determine the effect of the hookworm on Filipinos and to determine whether there is any immunity enjoyed by the race, com- parable to that of the Negros in Porto Rico, in the southern United States, and in Africa. / MATERIAL AND METHODS. A series of twenty-six cases was studied clinically, and subjected to a careful examination of the blood and urine. The clinical examination included questions of ‘the occurrence of previous diseases which would be likely to produce anzmia, such as tuberculosis, malaria, or dysentery, and queries as to present complaints. A close examination of the conjunctiva was also made because by this means the best evidence of pallor in dark-skinned people can be at- tained, and evidence was secured as to the presence of diseases of the lungs, heart, liver, spleen, stomach, and skin that are likely to produce eosinophilia. The blood was examined for hemoglobin by the Tallquist method and the erythrocytes and leucocytes estimated quantitatively. Wright’s stain was used in the differential count of the leucocytes, from 300 to 800 leucocytes being counted in each case and care taken to examine the edges as well as the center of the smear. The urine was tested for albumin by means of the heat acetic acid *Read at the Highth Annual Meeting of the Philippine Islands Medical As- sociation, February 24, 1911. : 239 240 — GOMEZ. and nitric acid methods, because the Anamia Commission of Porto Rico(®) found that in many cases of hookworm infection albumin is present in the urine. In a few cases the hookworms were collected and counted. It has been my procedure to collect the stools in every case. The patients were directed to pass all the stools in a vessel for twenty-four hours following the last purgative in the treatment, but considerable difficulty was experienced in making them comply with the instructions. Inas- much as some worms may still be passed later than twenty-four hours after treatment, the number which I obtained may not represent the total number of parasites in every case, but the error can not be very great, as the number of hookworms recovered bears a very close relation- ship to the number of eggs found in a cover-glass preparation ; it usually being about one to three. Ten cases without hookworms but with other intestinal parasites were selected for study as controls. DISCUSSION OF FINDINGS. As is shown in the table, five cases out of twenty-six complained of a certain amount of pain in the stomach. The other symptoms, such as emaciation, a feeling of dizziness, pain in the joints, difficulty in urina- tion, a sensation of oppression on the chest, tympanitis, neuralgic in- tercostal pains, or debility, can be attributed to other diseases such as malaria, tuberculosis, dengue fever, cystitis, and nephritis. The vague pains in the stomach suggest the presence of hookworms, either alone or associated with other intestinal parasites, as their removal is followed by immediate relief. Pain in the gastric region as a symptom accompanying hookworm infection has been frequently observed by Doctor Rissler and me in our work in Rizal and Cavite Provinces and the Cagayan Valley. One particular instance was that of our own assistant in Las Pinas, Rizal, who complained of poor appetite and vague abdominal pains, and who was promptly relieved on the expulsion of hookworms. The oceurrence of vague digestive and abdominal symptoms is also men- tioned by Bass(7) in connection with mild infections with hookworm in the southern United States. The reference of the pain to the stomach and abdominal region may be explained by the anatomic arrangement of the sympathetic inervation of the duodenum which is connected, through the solar plexus, with the remainder of the abdominal organs, and par- ticularly with the stomach. As compared with the control cases, eosinophilia is generally present in the patients harboring hookworms. Five out of 10, or 50 per cent, of the control cases gave an eosinophile count above 4 per cent. In patients infected with hookworm, 20 out of 26, or 76 per cent, had eosinophiles above 4 per cent. Only 3 of the controls had over 5 per HOOKWORM INFECTION. 241 cent, whereas in the hookworm series, this figure was reached by 20 out of 26 of the cases. No control shows 13 per cent or above, whereas 9 (or 34 per cent) of the cases harboring hookworms gave an eosinophile count of 13 per cent or above. The lowest count in the control cases was 0.3 per cent, and the highest 12.80, whereas in the others the lowest was 0.3 per cent and the highest 21.9. It is to be noted in the control series that individuals with T'richuris or Ascaris, or both together, hardly show any deviation from normal (0.5 to 4.00 per cent, Cabot), those hav- ing high eosinophile counts harbored amcebee or Tenia. Chamberlain (6) in his work on light infection with uncinaria among southern-bred white soldiers found eosinophilia to be present in the majority of cases, the lowest count being 1 per cent and the highest 26. The percentage of hemoglobin in the control series varied from 80 to 95. In the cases infected with hookworms, the percentage was from 75 to 95. The count of the red and white cells does not show any marked difference between the two series; the lowest for red cells in the hookworm cases is 4,000,000 per cubic centimeter whereas in the control cases it was 4,500,000. In two instances (3 and 12), albumin was found in the urine but this occurrence can be attributed to nephritis which was independent of the hookworm infection. ; The number of hookworms recovered varied from 1 to 20, this small number corresponding to the paucity of eggs found in the microscopic preparations. One case has been followed closely: Case 17.—N. S., age 23, from Gerona, Tarlac. Patient previously was a clerk. Examination of the feces, April 13, 1910, ova of Ascaris, Trichwris and hookworm were found. Previous diseases—No tuberculosis, no malaria. Present complaint.—The only complaint is fleeting pains in the gastrie region, about one and one-half inches to the left of the median line at the level of the costal border. This pain existed for more than three years and occurs especially in the morning when the patient’s feet are bare and cold. The pain is dull and when it occurs there is simultaneously the appearance of thin watery saliva. This condition lasts from one to three days and is repeated several times a month. It has no connection with the patient’s food. Physical examination —The conjunctiva are of good color, the tongue not coated, plantar surface not fissured. No murmur in heart, slight accentuation of the pulmonic second sound. Blood examination. Hemoglobin 85 per cent, erythrocytes 5,580,000, leucocytes 6,000, polymorphonuclears 26 per cent, small mononuclears 35 per cent, large mononuclears 9 per cent, eosinophiles 20 per cent. Two weeks after treatment the patient was interrogated concerning his pain and he said it had entirely disappeared. A month later leuco- cytes were examined with the following results: Polymorphonuclears 43.4 per cent, small mononuclears 36.2 per cent, large mononuclears 6.1 DAS GOMEZ. per cent, eosinophiles 14.1 per cent. The feeces were negative for ova of the hookworm. The eosinophilia is possibly due to a toxin secreted by the worm. According to Ashford and King(8) this was isolated by Lussano by evaporating at a temperature of 60° to 70° the urine of a patient in- fected with hookworms until it became sirupy, then extracting with absolute alcohol and dissolving the extract in distilled water. He made subcutaneous injections of this supposed toxin into rabbits continuously for eight days, causing a diminution in the number of red cells, poikilo- eytosis and rapid formation of fibrin, all of which symptoms disappeared upon the cessation of the injections. The parasites were then expelled from the patient and a similar preparation from the urine afterwards had no effect. Bohland(9) also believed a breaking down of the body albumin to occur, due to a poison. The persistence of eosinophilia after the removal of the worms is explained by Leichtenstern * as a result of the hypertrophy of that por- tion of the bone marrow concerned in the production of eosinophiles. The comparative absence of clinical symptoms in hookworm infections in the Philippines probably does not mean the presence of racial immu- nity among the Filipinos, as the infecting organisms are few. Accord- ing to Thornhill,* there must at least be 500 present for from six months to one year, in order to produce such symptoms, and other patients may develop anzemia and debility as a result of only from 100 to 300 para- sites. | In Porto Rico, where the disease is evident clinically, Ashford and King(12) counted the number of hookworms expelled from twenty-two patients with the following results: In 9 cases there were less than 300 worms, in 8 cases between 300 and 1,000, in 3 cases between 1,000 and 2,000, in 1 case 2,749 and in another 4,397 hookworms. Therefore, the disease in the Philippines corresponds to the light type of Stiles, (13) in which the patients show ova in the stools, but do not exhibit any, or sufficiently marked, symptoms to attract especial attention. CONCLUSIONS. 1. The most frequent and only subjective symptoms in these cases of uncinariasis occurring alone or in association with other intestinal parasites were vague abdominal pains and loss of appetite. 2. Kosinophilia was found in a majority of cases, the lowest eosino- phile count being 0,3 per cent, the highest 21.90 per cent. 3. Hookworm infection among the Filipinos corresponds to the light type of Stiles, that is, patients have the ova of hookworms in their stools, but no symptoms. 2 Cited by Boycott and Haldane. (10) * Cited by Scheube. (11) HOOKWORM INFECTION. 243 4. The absence of all clinical manifestations or their insignificant characters among Filipinos infected with hookworms can not be at- tributed to a racial immunity, as the number of the infecting hookworm organisms in each instance is small. REFERENCES. (1) Garrison, P. E., and Luamas, R. The Prevalence and Distribution of the Animal Parasites of Man in the Philippine Islands with a Consideration of their Influence upon the Public Health. This Journal, Sec. B (1908), 3 19) Garrison, P. E., Leynes, R., and LuamMas, R. The Intestinal Worms of 385 Filipino Women and Children in Manila. Ibid. (1909), 4, 185. Garrison, P. E. Medical Survey of the Town of Taytay. Ibid. (1909), 4, 257. (2) Risster, R. S., and Gomnz, L. The Prevalence of Intestinal Parasites in Rizal and Cavite Provinces and in Cagayan Valley. Jbid. (1910), 5, 267. (3) Bowman, Frep B. Some Observations on Parasitic Infections Among the Igorots. Bull. Manila Med. Soc. (1910), 2, 75. (4) Wittets, D. G. A Statistical Study of Intestinal Parasites in Tobacco Haciendas of the Cagayan Valley, Philippine Islands. Jbid. (1911), 6, 77. (5) I@aRavipEz, P. G., Martinez, I. G., and Sein, F. §. Report of the Anemia Commission of Porto Rico, 1906-1907. (6) CHAMBERLAIN, W. P. The Prevalence and Importance of Uncinariasis Among Apparently, Healthy Southern Bred White Men in the United States Army. Arch. Int. Med. (1909), 4, 8. (7) Bass, C. C. Mild Uncinaria Infections. Arch. Int. Med. (1909), 4, 446. (8) Asrorp, B. K., and Kine, W. W. A Study of Uncinariasis in Porto Rico. Am. Med. (1903), 3, 95. : (9) Bowx~anpD, K. Ueber die Eiweisszersetzung bei der Anchylostomiasis. Miin- chener med. Wehnschr. (1894), 41, 901. (10) Boycorr and Harpane. An Outbreak of Ankylostomiasis in England. Journ. Hyg. Cambridge (1903), 3, 95. (11) Scurusr, B. Die Krankheiten der warmen Liinder. Jena (1903), 560. (12) Asnrorp, B. K., and Kine, W. W. Observations on the Campaign Against Uncinariasis in Porto Rico. Boston Med. Surg. Journ. (1907), 156, 413. (18) Stires, C. W. Uncinariasis or Hookworm Disease. Osler’s Modern Med- icine, Philadelphia and New York, (1907), 1, 582. 244 GOMEZ. TasLe I.—Oases of Hi ; 2 Previous Previous Examination| Previous Present com- 2 Date. A residence. SUP ley ‘of faeces. diseases. plaint. cS) = : iS) B ; 3 a So G AY < 1910. Tee mes Ze dl eet ieal |e eee ee ee Scout sol- | Hookworm, | Negative ____| None -__________ dier. Trichuris. POW Wile. rf) USES) |) AUG} fa Messenger-_|_-__- oe eas REeee dose eeea |e Gowese.sees8 3 | Mar, 8 | 7979 | 40 | Naguilian, | Laborerin |----_ (lo) | Rheuma-| Frequent epi- Union. rice and tism. gastric pain. tobac- co fields. Ag anal 2a | ese 23) DMianila eee 2 Employee | Hookworm, | Cough --_____ Emaciation ____ in the Ascaris, prison. Trichuris. 5 | Mar.14 | 7994 | 24 |_____ Goreseaees Clerk eeee aes dosaa=s Negative ____| Vertigo for about a year. Cae Miers i837 6M liso eae eee ene Laborer in |_---- dopesses Malaria two | None —__-__. ____ rice pad- years ago. dies. ZO Witkrerallsy. | PSHO(0)NL |} ANS} se le 6l0)- = Hookworm _| Negative -___|----- (6loyeeneeene os Gh] Nitapealsy es) |) Ib eo ee Laborer -__|----- (Cl(G) eee eee dose eess| Raa (o\oyeeraertty se ES CY) |p iter ily WOR I BUG |e ee Laborer |}.---- (Voy ee (0 (oye ee does on aba- ca. 10 | Mar.29 18841 | 20 | Luzuriaga, |----- done Hookworm, | Indefinite | Pain in joints Occidental Ascaris. fever. but no fever. Negros. 11 | Mar.29 | 8410 | 23 | Malolos, Bu- | Laborerin | Hookworm_| Negative.__-_| None ~----__-___ lacan. rice pad- dies. 12 | Mar.29 | 8028 |} 56 | Indang, Ca- |----- domes Shae (0 Ko yee ee al ee ee OL Coughs; does marines. not urinate freely; pain in pubic re- gion; breath short when tired. 13) Mian 290 (840 7e 205 Canliemi pit ae Omens eee doe Reve WwW ma-) | None = sess ss eee Bulacan. tism. 14°) Miar!29)))\ 8408) | 18) |22222diojeaee esa aeee (lO 2 Hookworm, |----- Coe s=esee | Paine bbe Ascaris. epigastrium frequently. HOOKWORM INFECTION. 945 hookiwnorm infection. ° Examination of the blood. 45 , oa oe : g : ae Physical Ee 8 piel Naleseeeatie _ | Albumin | 68 examination. |'o9 S x AS 2 6 |inurine.| _# i) ° ical oo fay =) on 3) A 2 aS : © 4) og 5 - Seve re yee mal As ai ae oe ee sa 8p 8 zr a i) =) oY n 4 ica) 9 Z Negative ----_---- Sp) |Bes coe weee aes ese 47 28 6 18 0.4 |Neg a- , tive. Hezemasonmatiesyy | 075) | sees == sees e 67 16 6 9 eeeee too) eee 115 months’ dura- tion. Negative —-=-=---- 80 | 4,000,000 | 7,500 | 57.30 | 18.70 | 4.90 | 19.10 | 0.3 | Positive _|------_ pete do __-----------| 85 4,500,000 | 4,800 | 57 39 3 OFS esas Neto ra | hae e ‘ tive Sore do _------------| 85 4,920,000 | 5,600! 79 14 4 3 Eee es Pee (Oe eu eae aes do -------------| 90] 4,480,000 | 4,800 | 60 20 11 9 Pewee eee Om 2S. 15 oa oe 850 4s 5404 00016 9)240) | 54 = 1/26 7 ieee | ees ect een 720) Sluggish re-| 75] 4,880,000} 4,600 | 60 34. 3 OM = esses ped Ojzer a= aly flexes. Negative —-------- 75 | 4,600,000 | 7,000 | 62 16 8 IE ||. Be doOeeees ta ald Pale conjune-| 90] 5,200,000 | 6,960 | 63 21 5 TOR esa aod oees 2 6 tiva; coated tongue; tender- ness in epigas- trium. Negatives s=se—= 90 | 5,500,000 | 11,550 | 67 17 5 118 fel eee See (0 Coens aloe oe De, Slightly pale} 85] 4,420,000} 7,000 | 66 25 6 Oh iy eeaes Positive -| 17 conjunctiva; tongue coated; | bronchial breathing. Negative =---_____ 90 | 5,400,000 | 6,600 | 62 26 8 3 O33) |PNkevera)|Paease= a tive me, Slightly pale} 90] 5,700,000) 5,940 | 65 £28 6 Dies gh Sea Amen Exu@Onswalk ses ; conjunctiva. a 4 Cases 1 and 2 had hookworms collected together. 102362——6 246 GOMEZ. TABLE I.—Cases of : bed i z Previous teveons Examination| Previous Present com- Z DENS residence. employ of feeaes. diseases. amare 3S a \¢ Z a 4 15 | Apr.13 | 8452 95 | Victoria, Ge- | Laborerin | Hookworm_| Rheuma- Feeling op- rona, Tar- rice pad- tism. pression in lac. dies. chest at times. 16 | Apr.13 | 8457 | 27 |____- (o Ko pepeneaentates Merchant__| Hookworm, |____-do ----.-- Occasional Ascaris. tympanitis. 17 | Apr. 13 | 8456 | 23 |____. dome Clerk ——--_- Hookworm, |----- (ol oe Fleeting dull Ascaris, epigas Trichuris. tric pains. 18 | Apr. 20 | 6914 | 23 | Santo Tomas, | Merchant_-| Hookworm, |____- do Les. = Pain in abdo- Batangas. Ascaris, men about Amb x, umbilical Trichuris. region occa- sionally; no ‘ appetite. 19 | Apr. 26 | 8073 | 20 | Caloocan, Ri- |------------- Hookworm, |____-do_-_--_- Neuralgic in- zal. Ascaris, tercostal, Trichuris. and cepha- lic pains. 20 | Apr. 27 |19102 | 21 | Bautista, | Mechanic -|_____ doz==s Cough; pain | None --_-------- Pangasi- in chest. nan. 21 | Apr. 28 |12112 | 18 | Manila —______ Messenger_| Hookworm_| Negative ----| Vertigo--_--_--- 22 | Apr. 88 19110 | 22 | Luna, Union _| Laborerin |____- doe Malarial | None-----_----- rice pad- fever. dies. 23 | May 12 | 8109 | 26 | Sinay, Ilocos | Tailor -_-__|_____ doses Spat blood___|_-__- Go Meszeaks 3 Sur. 24 | May 16 |19278 | 24 | Pandan Can- | Laborer | Hookworm,| Spat blood; | Debility -------- tanduan, on aba- Ascaris, dysentery, Albay. ca. Trichuris. malaria. 25 | May 16 | 8550 | 65 | Albay, Albay_| Laborer —__|_____ dope Negative ----| Nome ---------__ 26 | May— /19300 | 18 | Manila _-_____ Clerkiasn ss: | Pas doeaaa=s Spat blood___| After meals he has pain on left side of abdomen. HOOKWORM INFECTION. hookworm infection—Continued. 247 b Stool not collected. o Examination of the blood. 4 eS ; ais 2 ue Physical Bes 3 a a Monon; g . | Albumin} °8 examination. i) 2 > g I 3 = S | inurine, B x e 2 Shier SNe) Iden as ag q S S| Se Bee es AS 8 B a poe eiarat tame Sn a a5 joe] | | Ay mn =) ic ies) A Conjunctiva| 80 5, 200,000) 8,000) 64 20 8 bce a acre mel N ec g a- 1 slightly pale; tive. tongue coated; fissuring plan- tar surface. Conjunctiva] 85] 5,640,000 | 10,200 | 55 26 6 oS ag eee ee Gee Ore se 5 pale; tongue coated. Slight accentua- | 85] 5,580,000] 6,000 | 36 35 9 20) Nieeee esd oes.) B tion of second pulmonie sound. Tongue coated ___| 90} 5,200,000} 6,600 | 58 21 7 Wa ee Po (oye ily Negative _________ (eae ee ete ee Hal 55.43 | 29.89 | 6.52] 8.42 |__-___ eed oues= 5 eee 6D senseeeceee|| BD Notes eee | CRC CGP) IP REBT PALS N) ONO) sao (oye le passes Cl Opetere = eeree | OO Rl es Bet Bh ee EL 7 27 8 a Os8. ea6lOs-) 1 Slightly palecon- || 85 |_-----______|_-______ 68 16 7 8 (052 eto (oye i Se junctiva. Negative =--+---__ (Sg a me nee (eee eee OSG |) Galak) ay aks) |) EBB) || eto Ko yenepeall Sete Slight dullness} 90 |----_-______ ..---.--| 47.38 | 19.92 | 9,47 | 23.01 | 0.19 |---do_____ 6 left apex; ten- derness over epigastrium. Mongues icoateds,|) 90)|/2ss=s sees |e ee 55.77 | 30,48 | 7.24] 6.59 | 0.18 |_--do--___ 10 eonjunctiva rather pale. ' NER Abie mexCept |) 95)| Seana eeeene mewn BBo7) || Pésetoly aG tent | SsbB Tet See efo Ko Pe some herpetic eruption. Taste II.—OControl Previous dis- eases. Present com- plaint. IAS GOMEZ. 4 o q ir . A Previous | Examina- a2| Date 5 Bs Sen aane employ- tion of 3 A I ment. feeces. 4H q fe) ° . 2 () o 4 its) A a |< 1910. 1 | Mar. 28 |18833 | 50 | Namakpa-| Laborer | TZrichuris, kan, La on to- Ascaris. Union. bacco. 2) Mar. 28 |18830 | 35 | Lawag,Ilocos | Tailor _____ Ascaris ___- Norte. 8 | Mar. 29 /18834 | 36 | Naguilian | Tobacco |-___-- doe Union. mer - chant, 4 | Mar. 30 |18850 |.27 | Manila _______| Clerk ______ Trichuris —- 5 | Mar. 30 |18851 | 79 |_____ Cl} eee Banquero _|-_--- d= 6 | May 18 | 8104 | 24| Bangued, | Carpenter_| Amebe ____ Abra, 7 | May 18 | 8108 | 27 | Narvacan, | Clerk -____- DET ONG, a Tlocos Sur. 8 | May 16 |19279 | 18 | Guinobatan, | Laborer | Zrichuris, Albay. on aba- Ascaris, ca. Amadbe. Oo May 16) (eSB o | 28s | tt ae eS eee Ascaris ——-- LOW Mar 8! |G004 a aees| asa ee eee | ees Amebe, Monads. Malaria a year ago. Opium smok- er; Spat blood. Spat blood in 1907; fever a few days ago. Negative Pain in chest and back; bloody stools. Has had headache frequently. Malaria; dy- sentery with mucus and blood. Mal ar ia; ehronie bronchitis. Pain in back. Pain in chest oceasion- ally. Bloody stools. Headache, pain in ab- dominal re- gion and baek; diffi- (oul gay a1 val urination. Pain in epigas- trium. — iS HOOKWORM INFECTION. 249 cases. a Examination of the blood. 2a : ’ oF ; ° / . : Examina- - a eas ° a Mononuclears. ED nee ae aS oe g 4 aap e i ual norionune ; 8 sg Sy 8S : cS) ‘3 for albumin. He) ee 2 ds I 2 el & B a) 5 be 3 ay o = A c oA g Ci o is2| fea) = av n 4 (<3) fQ Negative _-_-----_- 85 | 5,020, 000 8,600 | 70 18 7 Bs yal eeceteee Negative. ee GOs ee == 10790))|| 5, 4201000 5,600 | 63 32 5 0.3 0.7 Do. oats Ope nes ale 95) |p6,,0003000: 6,800 | 63 27 9 1 Pek coy Do. — do _------------| 90] 5,200,000} 10,000] 69.6 20.1 6 Gee eases Do. pepe oO eeee-====|| 90!) 48001000 5,400 | 70 20 6 4 esesets Do. oes LG se eee eee |) | eee ele I Sl 52) 50) e269 in Uae UPR) eee eo Do. Bees CO eee eee ti (Il Race eee eens ISS ele2onO4 | OsOLemml Ono 4d: |e a POSITLVES Momeawercoateld:) |" 190) (Pin 2 sae |e Ge LOM OSes OM ele gO) eee Negative. conjunctiva slightly pale; some fissuring of the feet, Paeeee se Sae Oy [Peete eee G9! 49) on 18164410 90383 De dig eee Do. INP albiVie jae eee 80 | 5,500, 000 8,500 | 67 DLAOO NP RSe tela e as ele eee Do. a oe CONE 3) RP ae oy A CONTRIBUTION TO THE ETIOLOGY OF BERIBERI.’ By WESTON P. CHAMBERLAIN and Epwarp B. VEDDER.” (From United States Army Board for Study of Tropical Diseases.) In the Lancet for December 17, 1910, Fraser and Stanton report a series of experiments in which they prove that 85 per cent of the phosphorus contained in rice polishings is negligible in the prevention of polyneuritis of fowls. Their method of experiment is briefly as follows: One hundred grams of rice polishings, containing 4.1 grams phosphorus pen- toxide were extracted with 0.3 per cent hydrochloric acid solution which dis- solved out 3.6 grams or 88 per cent of the phosphorus. They then added a sufficient quantity of alcohol to precipitate all the phytin contained in the solution which amounted to 3 grams or 73 per cent of the total phosphorus. . The phytin was filtered out and the filtrate contained only 0.6 gram, or 15 per cent of the total phosphorus originally present in polishings. They then fed one series of fowls on polished rice plus the phytin containing 73 per cent of the phosphorus and another series of fowls on polished rice plus the filtrate containing only 15 per cent of the phosphorus. The fowls receiving the phytin developed neuritis while those receiving the filtrate remained in good health. This proved that 85 per cent of the total phosphorus content (73 per cent contained in the phytin and 12 per cent which remained in the polishings) is unimportant in preventing polyneuritis gallinarum. We have repeated this work done by Fraser and Stanton and are able to confirm their results. We fed three fowls on polished rice alone and three others on polished rice plus the filtrate prepared according to their method, with the result that the three fowls receiving only polished rice developed neuritis in 18, 30, and 43 days, respectively, while of the fowls fed on polished rice plus the filtrate one died at the end ‘of 58 days of avian diphtheria without ever showing signs of neuritis, and the other two lived until the 73d day in good health, at the end of which time the experiment was concluded. : + Published with permission of the chief surgeon, Philippines Division. ?W. P. Chamberlain, major, Medical Corps, United States Army, and Edward B. Vedder, captain, Medical Corps, United States Army, members of the United States Army Board for the Study of Tropical Diseases as they Exist in the Philippine Islands. 251 252 CHAMBERLAIN AND VEDDER. This strikes a hard blow at the idea that the lack of phosphorus compounds is the cause of beriberi or polyneuritis gallinarum.* However, there is still a possibility that the remaining 15 per cent of phosphorus in some particular combination is the important element. We believe that our work disposes of even this possibilty, and that, as a result, the idea that multiple neuritis of fowls is due to a deficiency of phosphorus compounds must be abandoned. Our first step was to analyze this filtrate of Fraser and Stanton for inorganic constituents, and we found that it contained 0.18583 per cent magnesium phosphate and 0.01766 per cent of potassium phosphate. In a previous paper from this laboratory Kilbourne(1) had suggested the possibility that potassium salts might bear some relation to the production of beriberi and subsequently an attempt was made by this Board(5) to settle the point by feeding one group of fowls on polished rice plus potassium chloride, another groups on polished rice plus phos- phorie acid, and a third group on polished rice with the addition of both potassium chloride and phosphoric acid. ‘These experiments were completely negative and the fowls receiving these substances developed neuritis as promptly as fowls receiving polished rice alone. In spite of these discouraging results and the statement by Schau- -mann(2) that the inorganic salts can have nothing to do with the preven- tion of neuritis, we determined to give thesé salts a more thorough trial for the following reasons: First, we had demonstrated the presence of mag- nesium and potassium phosphate in an extract that was proved to prevent neuritis, and, therefore, even if these salts gave negative results, their elimination would further simplify the problem and would prove that a part at least of the 15 per cent of phosphorus found in the filtrate of Fraser and Stanton was not concerned in the prevention of neuritis of fowls. Second, we had observed in various analyses of rices and rice polishings that the potassium content varied in the same manner as the phosphorus content and appeared to be just as good an index of its neuritis-preventing or neuritis-producing power. The following experiment was performed for this purpose. Four groups of fowls, each group consisting of four birds, were fed on polished rice. In addition, Group A received daily 0.07 gram of potassium phosphate; Group B received 0.07 gram potassium citrate ; Group C received 0.07 gram potassium carbonate and Group D received 0.07 gram magnesium phosphate. These salts were administered in the dose of 0.07 gram because analyses showed that this amount was *The view that phosphorus was the essential neuritis-preventing element has been especially advocated by Schaumann(2) but not by Fraser and Stanton who were particular in stating that the amount of phosphorus pentoxide was only an indicator of the neuritis-producing power(3) of the grain. ETIOLOGY OF BERIBERI. 253 slightly greater than the quantity of potassium in five grams of polish- ings, which latter quantity is known to be sufficient to maintain fowls in health. In order to facilitate administration 7 grams of each of these salts except the magnesium phosphate were dissolved in 100. cubic centimeters of distilled water. The magnesium phosphate being in- soluble was simply suspended in water in the proportion 7 grams to 100 cubic centimeters. One cubic centimeter of these solutions and the suspension was administered daily to each fowl with a pipette. Therefore there can be no doubt as to what each fowl actually received. We might state at this point that this method of administration has been employed in all of our experiments. The result of this series of experiments is briefly as follows: Group A (receiving potassium phosphate) : One fowl developed neuritis in 22 days and one in 24 days. Growp B (receiving potassium citrate): One fowl developed neuritis in 22 days and one in 24 days. Group CO (receiving potassium carbonate) : One fowl developed neuritis in 21 days and one in 23 days. Group D (receiving magnesium phosphate): Two fowls developed neuritis on the 24th day. The experiment was discontinued on the 28th day since it was con- sidered amply demonstrated that none of these salts conferred any protection. We may draw several conclusions from this experiment. 1. Lack of potassium as a cause of polyneuritis can probably he excluded, because we have tried four salts of this element, one of them known to be present in rice polishings and one of them being the salt of an organic acid, and all of these salts of potassium signally failed to confer protection. 2. Magnesium phosphate, a salt present in considerable quantity in the filtrate of Fraser and Stanton, is also shown to be of no value. This probably excludes the element magnesium from further considera- tion. 3. By a rough calculation the phosphorus contained in the magnesium and potassium phosphate of the filtrate of Fraser and Stanton which we prepared is equivalent to about one-fifth of the 15 per cent of total phosphorus remaining according to their analyses. Since we have shown that these salts are unimportant we can state at this point that 88 per cent of the total phosphorus of rice polishings is negligible. We have not given all the figures for the sake of brevity and because our results by the method which follows are so conclusive as to the unimpor- tance of phosphorus compounds. _ Fraser and Stanton (?) have shown that the neuritis-preventing princi- ple of rice is soluble in hot alcohol and Hulshoff-Pol(4) proved that a decoction of katjang idjo (Phaseolus radiatus) has the same curative 954 CHAMBERLAIN AND VEDDER. and preventive power as the beans themselves, so that the neuritis- preventing principle of these legumes is evidently soluble in hot water. Our work, detailed below, has shown that the active neuritis-preventing principle of rice polishings is soluble in both cold alcohol and cold water. | Haperiment 1.—One kilogram of rice polishings was mixed with about 3,000 cubic centimeters of water and allowed to macerate. over night. The resultant mixture was filtered carefully after extraction had proceeded for 24 hours. Two thousand cubic centimeters of a deep yellow liquid was obtained. Four fowls were now fed on polished rice and given daily 20 cubic centimeters of this filtrate. In this way the fowls received the sub- stances extracted by cold water from 10 grams of polishings. After the experiment had proceeded for several weeks and the fowls appeared to remain in health the dose of the extract was reduced to 10 cubic centimeters. These four fowls all remained healthy for 70 days at the end of which period the experiment was discontinued. The neuritis-preventing principle of rice polishings is therefore soluble in cold distilled water. ; Experiment 2—One kilogram of rice polishings was mixed with 3,000 cubic centimeters 95 per cent alcohol. After macerating for 24 — hours, the resultant fluid was filtered, the filtrate being a perfectly clear, light green liquid. The polishings were expressed in a towel to obtain the whole of the fluid. This clear alcoholic extract was placed in a water bath on which an electric fan was’ turned. The alcohol was evaporated rapidly by this method without much rise in — temperature. When the alcohol had all disappeared the remaining liquid was placed in a separating funnel and after standing for about half an hour, there was a clear separation into two layers. The upper and larger layer was a deep green in color and contained all the fat extracted by this method. The lower and smaller layer was brown in color and was a thick, sirupy liquid. By carefully pourmg distilled water into the funnel the separation of these two layers was rendered easier, since the water lay in a third layer below the fats but above the brown liquid. The lower layer of brown sirupy liquid was then drawn off. The fat was discarded, since it has repeatedly been shown that the fat of rice polishing has nothing to do with the prevention of neuritis. The lower layer therefore contained all the substances that were dissolved out of the polishings by cold alcohol except the fats. About 25 cubic centimeters of this extracted material was obtained from 1 kilogram of polishings and was then mixed with 1,000 cubic centimeters of distilled water, when a precipitate was formed consisting of those substances, other than the fats, that are soluble in alcohol but not in water. ETIOLOGY OF BERIBERI. ZOO: Four fowls were then fed on polished rice giving them a daily dose of 10 cubic centimeters of this cloudy fluid representing the substances, other than fat, dissolved by alcohol from 10 grams of polishings. Of these four fowls, one died on the 69th day, probably of avian diphtheria, without ever showing any signs of neuritis, and the other three remained in good health until the 70th day, when the experiment was discontinued. Therefore, the neuritis-preventing principle is soluble in cold 95 per cent alcohol. Since the neuritis-preventing principle of rice polishings is soluble in both cold water and cold alcohol, it is apparent that by combining these two solvents the resultant extract can be much simplified, because certain substances derived from the polishings are soluble in alcohol but not in water, and vice versa. This is the principle that was adopted in the following experiment. Haperiment 3.—The cloudy extract used in experiment 2 was filtered until a perfectly clear yellowish fluid was obtained. This fluid con- tained only those substances extracted from rice polishings by alcohol and soluble both in alcohol and water. Four fowls were fed on polished rice, with a daily dose of 10 cubic centimeters of this clear extract. These four fowls lhved for 70 days in good health, thereby proving that this extract is,capable of prevent- ing neuritis, since in our experience fowls fed on polished rice alone developed neuritisein about 30 days on the average. Through the courtesy of the Bureau of Science* the extracts used in these experiments were analyzed with the following result: The precipitate which had not been removed from the extract used in experiment 2, but had been removed from the extract given to fowls in experiment 3, contained 0.000033 per cent phosphorus pentoxide and 0.00116 per cent nitrogen. The clear filtrate given to fowls in experiment 3, contained 0.00165 per cent phosphorus pentoxide and 0.0406 per cent nitrogen. It will readily be seen that the fowls in experiment 2 received the sum of the phosphorus and nitrogenous substances contained in the precipitate and filtrate. Im both experiments the amount of phosphorus received was so small as to be neghgible. One hundred cubic centimeters of the filtrate used in experiment 3 contained only 1.6 milligrams of phosphorus pentoxide and since the daily dose given the fowls was 10 eubie centimeters they received 0.16 milligram phosphorus pentoxide daily, whereas if they had been fed 10 grams of rice polishings they would have received from 200 to 500 milligrams of phosphorus pen- toxide. The total amount of phosphorus pentoxide in rice polishings *We hereby desire to express our obligation to Mr. Harry D. Gibbs, Dr. A. P. West, and Mr. R. R. Williams, chemists of the Bureau of Science, who independ- ently performed these analyses. 256 CHAMBERLAIN AND VEDDER. varies from 2 to 5 per cent so that a brief calculation will show that the extract prepared according to this method contains between 1/1,000 and 1/5,000 of the total amount of phosphorus contained in the original polishings. In other words, at least 999 parts out of each 1,000 parts of phosphorus are proven to be unimportant in the. prevention of polyneuritis of fowls. It is impossible to state positively that this minute trace of phosphorus. remaining in the extract is not the neuritis- preventing element, but we can at least say that it appears. utterly incredible that it can be of the slightest importance. Therefore, the theory, especially advocated by Schaumann, (2) that beriberi and poly- neuritis gallinarum are caused by a lack of phosphorus compounds, is strongly discredited to say the least. However, these findings do not necessarily conflict with the statement made by Fraser and Stanton(3) and by others, including this Board, to the effect that the proportion of phosphorus pentoxide present in a rice is an index of its beriberi-preventing powers. Such a statement has never, so far as we are aware, been intended to convey the impression that beriberi was due to a lack of phos- phorus compounds, but merely means that a rice containing phosphorus in amounts above 0.4 per cent phosphorus pentoxide necessarily has a sufficient quantity of pericarp adhering to the kernel; i. e., it is sufficiently undermilled. As shown by a former publication of the board(5) the presence of a certain per- centage of potassium appears to be an equally reliable index of safety, and so in fact would be presenc> in a rice of a definite percentage of any substance which is found exclusively or almost exclusively in the pericarp and the aleurone layer. The 0.0406 per cent of nitrogen contained in this extract would indicate a considerable quantity of proteid matter provided the nitrogen were present in combination with proteids. This would not seem to be the case, however, since the extract failed to give the xanthoproteic and biuret reactions and moreover we should not expect to find proteids in a fluid obtained by extracting with alcohol, but in order to prove this point we determined to test the extract by the method of dialysis. Hxperiment 4.—The brown residue obtained from 2 kilograms of rice polishings, macerated with cold alcohol according to the method described above in experiment 2, was mixed with 300 cubic centimeters of distilled water and filtered until clear. This small bulk of water was used in order that the aqueous extract resulting might be quite concentrated. This aqueous extract, which contained only those sub- stances soluble in cold water and cold alcohol, was then placed in a parchment bag and suspended in distilled water. his parchment was previously tested with solutions of egg albumen and sodium chloride, and it was found that the sodium chloride passed freely through the membrane while the egg albumen did not pass through at all. During the process of dialysis the apparatus was kept in the ice-box to prevent decomposition of the extract. At the end of two days, when the fluid on the outside of the bag had become a deep yellow, the diffusate was ETIOLOGY OF BERIBERI. 257 removed and the apparatus refilled with distilled water. This process was repeated three times, and the combined fluid removed from the outside of the bag, containing all the diffusate, was brought to 1,000 cubic centimeters, while the extract remaiming inside the bag, the dialysate, was diluted likewise to 1,000 cubic centimeters. Four fowls were now fed on polished rice plus 10 cubic centimeters daily of the dialysate and four other fowls were also fed on polished rice plus 10 cubic centimeters daily of the diffusate, with the following results. Group 1 (four fowls receiving polished rice plus dialysate): One fowl died of manition in 23 days. One fowl developed neuritis in 38 days, one in 42 days and one in 52 days.° Group 2 (four fowls receiving rice plus diffusate) : All four remained well at the end of 70 days. Therefore, it is apparent that the neuritis-preventing substance is capable of dialyzing through a parchment membrane. Analysis of this diffusate showed that it contained only 0.02 per cent nitrogen so that at least half of the nitrogen originally present must have been combined in some other form than proteid, because there could be no proteid present in the diffusate. The results of this last experiment are very far-reaching in their importance. Since the neuritis-preventing substance can dialyze through a parchment membrane it must belong to the class of crystalloids, and all colloidal substances, including proteids, gums, starches, dextrins, and many other substances, may be eliminated from further considera- tion. Probably enzymes also can be excluded. (6) CONCLUSIONS. 1. Polyneuritis gallinarum is not prevented by adding to a diet of polished rice any of the following substances; potassium phosphate, potassium citrate, potassium carbonate, potassium chloride, magnesium phosphate, phytin, phosphoric acid, or phosphoric acid combined with potassium chloride. 2. The neuritis-preventing substance in rice polishings is soluble in cold water and in cold alcohol. 3. Polyneuritis gallinarum may be prevented by means of an extract of rice polishings containing only those substances soluble in cold water *The rather long “incubation period” for the neuritis in this group we believe to be due to the fact that the first supply of dialysate fed to these fowls was prepared not in a bag (as described above), but in a bottle with the mouth covered with parchment. The small dialyzing surface probably rendered dialysis slow, allowing a part of the neuritis-preventing substance to remain behind and thereby delaying the onset of the disease. 258 CHAMBERLAIN AND VEDDER. and cold alcohol. This extract, so far as at present known, has the following composition : Per cent. Total solids 1.34 Ash 0.03 Phosphorus pentoxide 0.00165 Nitrogen 0.0406 Sucrose 0.88 4. Multiple neuritis in fowls fed on polished rice probably is not due to lack of phosphorus compounds in the grain, as claimed by Schaumann, since out of each 1,000 parts of phosphorus contained in the rice polish- ings at least 999 are not concerned in preventing neuritis. 5. The neuritis-preventing substance contained in rice polishings is capable of dialysis through a parchment membrane. ‘This excludes all colloids from consideration. We realize that the above conclusions are based on a small series of experiments, but the results appear so conclusive and are so far- reaching in their importance that it is deemed desirable to report them at once. Further experiments are now under way to confirm the above observations and also to determine the effect on fowls of the remaining untried substances contained in this extract, including the sucrose which it will be observed constitutes much the larger part of the total solids. REFERENCES. (1) Krzsournr, EH. D. Food Salts in relation to Beriberi. This Journal, Sec. B (1910), 5, 127. (2) Scuaumann, H. Die Aetiologie der Beriberi unter Berucksichtigung des | gesamten Phosphorstoffwechsels. Arch. f. Schiffs-w: Trop. (1910), 14, Beihefte 8. (3) Fraser, H. and Stanton A. T. The Etiology of Beriberi. This Journal, Sec. B (1910), 5, 55. . (4) Huxsuorr-Pot, J. Polyneuritis gallinarum en beriberi Geneesk. Tijdschr. V. Nederl. Indie (1909), 49, 116. (5) CHAMBERLAIN W. P., BLoomppren H. D. and Kizpournge HE. D. A Study of the Influence of Rice Diet and Inanition on the Production of Multiple Neuritis of Fowls and the Bearing thereof on the Htiology of Beriberi. This Journal, Sec. B (1911), 6, 177. (6) Wetis, H. G. Chemical Pathology. Hd. (1907), 41. Order No, 401, THE BONTOC IGOROT. By A. H. Jenxs. 110 pages. 3 maps. 154 photographic plates. 9 figures. - An interesting study; the result of almost a year’s residence among the Bontoe Igorots. 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The etiologic relation of amcebe to endemic dysentery, while not established upon all of the postulates of Koch, is supported by clinical, pathologic, and experimental evidence and has become generally ac- cepted; but, notwithstanding the attention these parasites have received in recent years, investigators are not agreed upon how many species are parasitic in the intestinal tract of man, whether they are obligatory parasites or whether amcebe from water or other external sources are capable of colonizing in the human intestine, their cultivability on artificial media, and the species concerned in the production of amcebic dysentery. The importance of these questions at issue is evident. They concern not only clinical and preventive medicine, but involve important financial considerations as well. The correct microscopic diagnosis of, and the application of early treatment to, amoebic dysentery depends upon our ability to identify the pathogenic amceba; and the requirement for radically different prophylactic measures as well as the necessity for large expenditures to distil, filter, or otherwise treat water from uncon- taminated supplies im the Tropics so as to kill or remove the amcebe which such water always contains depend upon whether or not the pathogenic ameeba is an obligatory parasite. 104912 259 260 WALKER. The problem is primarily one of species, of the identity of the amcebe that have been described by different authors in water, in cultures, in stools of healthy persons, and in ameebic dysentery. Anyone who has attempted to identify amcebee by the descriptions in the literature will probably admit that species determination of the Amcebide is in a chaotic state. New species have repeatedly been established upon inconstant variations. One stage in the life-cycle of an organism has’ sometimes been described as one species and another stage as a second species. Authors, failing to identify the amcebe in their possession with the in- complete descriptions in the literature, have established new species with diagnoses as indefinite as those of their predecessors. The determination of species of protozoa, it is true, is difficult, not only on account of the minuteness and the more or less complicated life-cycles of these unicellular organisms, but also because cultural and biologic tests, that enable the bacteriologist to determine species with a certainty second only to that of the chemist in identifying the chemical elements, have a limited application to the protozoa—how limited in their application to the parasitic amcebe will be apparent later. Protozodlogists, therefore, are forced to rely chiefly upon morphological characters to determine species. However, I believe such characters are adequate for the purpose, if a proper discrimination be made between variable and constant charac- ters and if all the stages in the life-cycle of an organism be taken into consideration. Many of the most obvious morphological characters of the vegetative, or trophozoite, stage of amcebze, such as shape, size, number and shape of the pseudopods, extent of the ectoplasm and contents of the entoplasm are classically variable; on the other hand the characters of the encysted stage are relatively constant and usually absolutely diagnostic: yet the descriptions in the literature of most free-lying and of many of the parasitic species are based exclusively upon the trophozoite, while the more constant and distinctive characters of the cyst have been wholly neglected. It has been my experience in studying amcebz that, if the characters of both the trophozoite and the cyst be taken into consideration, they can always be separated into species having well-defined morpho- logic characteristics. Therefore, it has seemed important to undertake a careful comparative study of the amceboid organisms found micros- copically and culturally in the Manila water supply, in the stools of healthy person, and in amcebic dysentery for the purpose of determining the genera and species represented, their parasitism, their cultivability on artificial media, and their relation to amcebic dysentery. REVIEW OF THE LITERATURE. Entameeba coli (Loesch) Schaudinn, 1903, is generally considered to be the amba first observed by Loesch in a case of dysentery at St. Petersburg in 1875. + was carefully described by Casagrandi and Barbagallo in 1897. Schaudinn distinguished it from a pathogenic species, Entamoeba histolytica, in 1903 and COMPARATIVE STUDY: OF AM@BA. 261 found it in 50 per cent of the stools of healthy persons examined in East Prussia, in 20 per cent of the stools examined in Berlin, and in 66 per cent of the stools examined in the East Province. Craig (1905) found :this species in 65 per cent of the stools examined from over 200 American soldiers stationed at San Francisco, California, and Vedder (1907) found it in 70 per cent of the stools of healthy natives in the Philippine Islands. Hntameba coli, as described by these authors, is round in the resting stage and opaque gray in color; the ectoplasm is scarcely differentiated from and is less refrangent than the non- vacuolated entoplasm; the nucleus is distinctly visible in the living ameba, is situated near the center of the organism, maintains its relative position in and is not deformed by the movements of the amceba, possesses a thick nuclear mem- brane, and contains a relatively large amount of chromatin; its movements are sluggish and it does not injest the red blood corpuscles of its host. This species reproduces by binary fission and by schizogony into 8 merozoites in the vegetative stage, and by sporogomy which is preceded by nuclear reduction and antogamy and which results in the formation of 8 sporozoite nuclei in the encysted stage. This 8-nuclear sporocyst is the resistant stage of this amoeba which serves for its transmission to a new host, in the intestine of which the 8 sporozoites are supposed to be developed. Schaudinn (1903) and Craig (1908) found Hntameba coli non-pathogenic for kittens. Schaudinn infected himself twice with the cysts of this species without developing dysentery. Entameeba histolytica Schaudinn, 1903, was first described by Jiirgens in 1902. It was distinguished from Hntameba coli by Schaudinn in 1903 and was found by this author in the dysenteries of Egypt, China, and Siam, and has subsequently been identified by a number of authors in the dysenteries of different countries. This species, in contrast to Hntameba coli, is oval in the resting ameba and trans- parent or, greenish in color; the ectoplasm is’hyaline, viscid, distinct from and more refrangent than the vacuolated entoplasm; the nucleus, scarcely, if at all, visible in the living ameba, is eccentric in position, frequently changes its relative position in and is readily deformed by the movements of the ameba, possesses no limiting membrane, and is very poor.in chromatin; its movements * are active and it frequently injests the red blood corpuscles of its host. Hn- tameba histolytica reproduces by binary fission, budding, and by the formation of spores which contain chromidia derived from the nucleus and which are budded off from the surface of the ameba. These spores become surrounded by a hard, impervious membrane and constitute the resistant stage that serves for the transmission of this species to a new host. Multinuclear cysts are not developed in the life-cycle of this ameba. Schaudinn (1903) and Craig (1908) found this species to be pathogenic for kittens. Craig obtained dysentery in 50 per cent of these animals by rectal injection and in 66 per cent by feeding dysenteric stools, and lesions characteristic of amcbic dysentery and containing motile Entamoeba histolytica were found at the necropsies. Entamoeba undulans was observed by Castellani (1905), together with en- tamebx having the characteristics of Entameba histolytica, in a case of chronic dysentery followed by abscess of the liver in a European at Colombo, Ceylon. This species is characterized by a single, long, narrow pseudopod, which is shot out from the body at short intervals and quickly withdrawn, and by an undulating mem- brane. No observations upon its life-cycle or pathogenicity are recorded. Parameba hominis was found by Craig (1906) in the stools of 6 natives in the Philippine Islands in which diarrhoea, associated in 3 cases with the passage of a small amount of blood, was the only symptom. This species possesses the distinct ectoplasm, the capacity for ingesting red blood corpuscles, and the active motility of Entameba histolytica, but the size, nuclear structure, and encysted 262 WALKER. stage of Hntameba coli; while it differs, according to Craig, from both species in its life-cycle. Besides simple division there is a development of spores within a cyst which are set free as small fiagellates. The cycle is completed by the development of these flagellates into amebe. This organism is believed by Craig to be responsible for the diarrhcea from which the patients suffered. Entamoeba tetragina was first observed by Viereck (1907) in 2 cases of dysentery from India and designated by him as Entamaba tetragina. At nearly the same time Hartmann (1907) found this ameba in 11 cases of dysentery from Southwest Africa, and South America. He considered it to be distinct from Entamcba histolytica and gave to it the name Hntameba africana ; but subsequently, becoming convinced of the identity of this ameeba with that of Viereck, he withdrew the spe- cific name africana in favor of the prior name, tetragina Viereck. Werne (1908) has also found this species in 9 cases of ameebic dysentery from Africa. More re- cently Whitmore (1911) has found it to be a common species in the dysenteries of the Philippine Islands and Indo-China. Hntameba tetragina, according to these authors, has the distinct, refrangent ectoplasm, the vacuolated entoplasm. the active motility, and the pathogenicity of Hntameba histolytica; but the distinct nucleus with a thick, nuclear membrane and rich in chromatin, characteristic of Hntamaba coli. However, the nucleus of this species shows an arrangement of chromatin which, according to Hartmann, is characteristic and which serves to distinguish the vegetative stage from that of both histolytica and coli. In addition to the peripheral chromatin there is constantly present a small caryosome which exhibits cyclical changes and which in its most characteristic stage is made up of a minute centriol and a concentric ring of chromatin granules separated by an achromatic halo. This species, moreover, resembles Hntameeba coli in its life- cycle. There is a sporogony in the encysted stage, but with the difference that 4 instead of 8 nuclei are developed in the sporo-cyst. Hntameba tetragina is considered to be a pathogenic species by all three authors. Hartmann found it pathogenic for kittens, but considers it less pathogenic than Entameba histolytica. Sections of the intestine of experimentally infected animals showed a typical ulcerative dysentery. Entameba minuta was found by Elmassian (1909) im a case of recurrent dysentery in a European who had resided in Paraguay, South America. It pos- sesses in the living ameeba the indistinct nucleus of Hntameba histolytica ; but the absence of a distinct ectoplasm, its sluggish movements, and its reproduction by sporogony in the eneysted stage are characteristic of Hntamoaba coli; and it is distinguished from both these species by its small size, averaging from 12 to 14 microns in diameter, and by the development of 4 instead of 8 nuclei in the sporocyst. In this latter particular it corresponds with Hntameba tetragina Viereck. Elmassian believes that both Hntameba minuta and Entameba coli may, under certain conditions, become pathogenic. Entameba nipponica was observed by Koidzumi (1909) in Japan, at first together with Hntameaba histolytica in advanced cases, later in early cases of ameebic dysentery, and also in dysentery of bacillary origin. This species cor- responds with Hntameba histolytica in possessing a well differentiated ectoplasm, a vacuolated entoplasm, a thin nuclear membrane, and the capacity for injesting red blood corpuscles, but with Hntameeba coli in the richness of its nucleus in chromatin and in reproduction by schizogony in the vegetative stage; but it differs from all other species hitherto described in the arrangement of the chromatin in the forms of 3 to 8 discrete clumps on the inner surface of the nuclear membrane. Sporogony in the encysted stage was not observed. This species is considered non-pathogenic by Koidzumi. COMPARATIVE STUDY OF AMG@BA. 263 Akashi (1911) has recently described 4 species of amcbe parasitic in the intestinal tract of man in Japan. Two of these are considered by this author as probably identical with Hntameba coh and Entameba histolytica respectively ; one he designates as Entameba tetragina, but states that he does not consider it identical with the tetragina species of Viereck; and the fourth is said to be a new species which the author does not designate by name. The descrip- tions of these species are in Japanese with a brief abstract in German. The chief point of interest in the inadequate descriptions (in German) is that re- production takes place by “schizogony” in the encysted stage in the two latter species, with the formation of 4 nuclei in “Hntameba tetragina” and the number of nuclei not stated in Hntameba sp. Musgrave and Clegg (1904) succeeded in producing a disease in monkeys and man having the symptoms and lesions characteristic of amebie dysentery by introducing into the intestinal tract of the experimental animals cultures of amebe grown in symbiosis with pure cultures of bacteria on an alkaline agar medium consisting of beef extract 0.3 to 0.5, sodium chloride 0.3 to 0.5, agar-agar 20.0, distilled water 1000.0, and made 1 per cent alkaline to phenolph- thalein, not only from cases of ameebie dysentery but also from lettuce and from the Manila water supply; and they were able, in certain cases at least, to recover in cultures amcebe from the experimentally infected animals. These authors, therefore, concluded that any amcba may become pathogenic when introduced into the intestinal tract of man. Lesage (1905) cultivated an ameba in 7 out of 30 cases of amebic dysentery on a culture medium consisting of agar which had been washed for a week in large quantities of distilled water and on which the growth of bacteria was largely inhibited. This amcba presented many of the characters of Schaudinn’s patho- genic Entameba histolytica and is believed by this: author to be the pathogenic species. Lesage in a subsequent paper (1907) states that leucocytic extract is a particularly suitable medium for the cultivation of the pathogenic amebe. This medium is prepared from the leucocytic exudate of the guinea pig. The exudate is kept on ice for 24 hours and then centrifugated. The clear, super- natant fluid is employed as the culture medium. In this medium Lesage cultivated amb from cases of amebic dysentery which were pathogenic. In 1908 Lesage cultivated a non-pathogenic ameeba from the intestinal tract of man in the Tropics, which is said to represent several varieties, and which this author considers to be the non-pathogenic species of tropical countries, distinct from the non-patho- genic Hntameba coli of temperate climates, and to which he gave the name, Entameba tropicalis. Walker (1908) cultivated amebe in symbiosis with bacteria on Musgrave and Clege’s medium, from the intestinal tracts of a large number of animals. These amcebe included one species designated as Amaba hominis from man. These cultures were made post-mortem from the intestines of the animals and were consequently believed to be true parasites. Gauducheau (1908) cultivated an ameba, Entameba phagocytoides, from 2 ease of amebic dysentery in Hanoi, Indo China, on ordinary agar, potato, and other media inoculated with Bacillus typhosus or other bacilli. This ameba ingests red blood corpuscles, multiplies by binary and multiple fission, and pro- duces spirilla-like bodies in its cytoplasm. Noe (1909) was able to cultivate an ameba three times from ameebic liver- abscesses and in five out of seven attempts from dysenteric stools in Indo China on an agar culture medium 0.5 per cent alkaline to phenolphthalein. The same species was also cultivated from the water. This ameeba differs in its morphology 264 vg gat 4 WALKER. ‘and life-cycle from Hntameba coli, Entameba histolytica, and Entameeba tetra- ‘gina. Noe believes this ameba to be the cause of the amebic dysentery and liver abscesses of that country. The cysts of this ameba, he says, are especially abundant in the surface waters of Indo China’ during the rainy season which corresponds with the exacerbation of endemic dysentery. However, he was unable to produce dysentery in kittens or monkeys with his cultures from water or dysen- teric stools. Werner (1908) was unable to obtain vegetative forms of either Hntamaba ‘istolytica or Entamoeba tetragina, but did secure growth and cyst formation of Ameba imax, a common water ameeba, in his cultures from dysenteric stools on Musgrave and Clegg’s medium. Therefore, he is of the opinion that the amebzx cultivated by Musgrave and Clege (1904), Walker (1908), and others from the ‘intestinal tract of man and other animals are cysts of similar free-living amebe which have been ingested with water or food, have passed unchanged through the intestine, and have found conditions favorable for development when the fxces have been placed on the culture medium. } Whitmore (1911) has also come to the conclusion that the amebe cultivated by him at Manila from dysenteric stools are free-living amebe of the lima type and not parasitic amcebee. AM@BA IN THE MANILA WATER SUPPLY. In consideration of the somewhat general belief in the Orient that the amcebee in the water are the source of infection in amcebic dysentery, and in consequence of the cultural and experimental work of Noc (1909) Williams and Gurley (1909), and especially of Musgrave and Clegg (1904), who state that they have produced dysentery in monkeys and man with amoebe cultivated from the Manila water supply, it has seemed desirable that a study be made of these for comparison with those found in the intestinal tract of man. The Manila water supply comes from an uninhabited watershed of the Mari- quina River and its tributaries. The water is stored in a reservoir on the water- shed by a dam constructed across a narrow gorge in the Mariquina Valley at Montalban about 24 kilometers from Manila. It is conducted from this reser- voir in closed water-mains to Manila, where it is distributed in branch mains and pipes to the various taps in the city. The water, therefore, is presumably free from fecal contamination and should contain only the normal ameebic fauna of that watershed. Samples of this water have been collected at different times from different taps in Manila for examination. In each case about 200 cubic centimeters of the water have been drawn directly from the tap into a sterile Hrlenmeyer flask and about 2 cubic centimeters of ordinary nutrient bouillon added to enrich it and favor the multiplication of organisms present in the sample. The flasks, plugged with sterile cotton, were kept at room temperature and the contents examined from day to day for amebe. In two or three days a scum forms on the surface of the water which, if examined microscopically, will be found to consist of bacterial and protozoan growth, among the latter ameebe are usually present. If a loop-full of this material containing amebe be transplanted to the surface of solidified Musgrave and Clege’s medium in a Petri dish an abundant growth of ameebe will be obtained in a few days. COMPARATIVE, STUDY, OF AM@B. 265 Twenty-five samples of tap water from the Manila supply have been examined microscopically, after enriching and incubating at room tem- perature, and by cultures made on Musgrave and Clegg’s medium. As the study of the parasitic amcebe progressed it became apparent that it was unnecessary to examine a larger number of samples, to con- centrate the amcebic fauna by filtration of large quantities of the water, or to study the amcebz from other surface waters, as had been originally intended. In 23 out of the 25 samples of water amcebe were found microscopically and culturally. In addition to these 23 cultures of amoebe, one culture isolated by Dr. A. W. Sellards in the Biological Laboratory of the Bureau of Science, and one isolated by Dr. EH. B. Vedder at the Division Hospital of the United States Army from the Manila water supply have been studied. Of these 25 cultures of amcebe, twenty-four have been found to be of one and the same species (Plate I, figs. 1 and 2); one culture was a distinct species (Plate I, fig. 3). Both species appear to belong to the so-called limax group of water amcebe, but because of the imperfect descriptions I have not attempted to identify them with the names in the literature, or to add to the confusion by giving them new names; nor is it necessary; it is sufficient for our purpose to determine the generic characters of these two species. This type of amceboid organism (figs. 1 to 3) is characterized by an amceboid trophozoite in which the nucleus is situated centrally in the resting organism and in which the chromatin of the nucleus is collected into a relatively large and dense karyosome that is surrounded by an achromatic halo, which possesses with rare exceptions, a contractile vacuole, and which reproduces by binary fission and by spore-formation (Walker, 1908); by an encysted stage that has a single nucleus of the same structure as that of the trophozoite, and in which no reproduction takes place; and by multiplying and encysting freely upon artificial culture media. These characters are those of the genus Amaba poe of which Amaba protens Leidy is the type species. AM@B4& CULTIVABLE FROM THE INTESTINAL TRACT OF MAN. The material from which these cultures have been made has consisted of fresh stools containing amcebe from 113 healthy persons or persons suffering from diseases other than amoebic dysentery, and from 21 cases of amcebic dysentery, and pus containing amcebe from 2 cases of amcebic liver-abscess, obtained from the drainage tube after operation and, also, in one of the cases, post-mortem from the infected liver. This material has been obtained chiefly from the hospital of Bilibid Prison, but in part from the different hospitals in Manila. I am indebted to the physicians in charge of these hospitals and to several of my colleagues 266 WALKER. in the Bureau of Science for the opportunity and for the assistance in obtaining it. The culture medium employed has been for the most part the standard medium of Musgrave and Clege (1904). Several modifications of this medium have been tried, including the substitution of nutrient bouillon, peptone, dextrose, or peptone and dextrose for the beef extract, and leaving out the salt and nutrient substances altogether. The cultivable amebe appear to grow equally well on any of these media. The methods employed in making these cultures and in isolating pure cultures of the amebz are those devised by Musgrave and Clegg (1904) and by me (Walker 1908) and are sufficiently well known not to need repetition here. It has not been considered necessary in this. morphologic study to isolate the pure cultures of amoebe with pure cultures of bacteria. Two hundred and seventy-nine cultures have been made from the stools of 113 cases of amebiasis without symptoms of dysentery, 158 cultures from the stools in 21 cases of amcebic dysentery, and 27 cultures from the pus of 2 cases of amcebic liver-abscess, in all 464 cultures from 136 cases of amcebiasis. These cultures have been made in every case from fresh material in which living amcebe had been demonstrated micros- copically, usually in the motile condition, sometimes encysted, and often in large numbers. Growth of amcebe in the cultures was obtained in 6, or 5.3 per cent, of non-dysenteric cases, and in 2, or 9.2 per cent, of the cases of amcebic dysentery. All of the 27 cultures from the 2 cases of amoebic liver-abscess were negative. Growth of mastigamcebe, flagellates, and ciliates was obtained in the cultures from several of the cases. In addition to these 8 cultures of amceba grown by myself from the intestinal tract of man, one culture isolated by Dr. E. B. Vedder from a non-dysenteric stool at the Division Hospital in Manila, one culture isolated by Dr. Marshall A. Barber from a case of diarrhcea in Kansas, one stock culture in the Biological Laboratory of the Bureau of Science from a case of ameebic dysentery, and one culture isolated by Musgrave and Clegg (1904) from a case of amoebic dysentery in Manila have been available for study. A study of these 12 cultures has disclosed 5 well defined species (Plates II and III). Among the 8 cultures from persons showing no symptoms of dysentery there are 4 different species. Among the 4 cultures from cases of amoebic dysentery as many different species are represented. Of the latter, amoeba 8 is the same species as amcebe 1 and 20,850 from non-dysenteric stools (Plate II, fig. 4) ; amceba 14,965 is the same species as ameebe 7, 7,658, and 20,998 from non-dysenteric stools (Plate II, fig. 5) ; and ameeba 7,671 is the same species as the amceba isolated by Barber from a case of diarrhcea in Kansas (Plate II, fig. 6 and Plate III, fig. 7). Ameeba 9 grown from a non-dysenteric stool and ameba “L” isolated by Musgrave and Clegg (1904) from a dysenteric stool (Plate III, fig. 8) are not duplicated among the cultures. However, amceba 9 is of the same species as the amceba cultivated from 22 out of 25 samples of water COMPARATIVE STUDY OF AMG&B2. 267 from the Manila water supply (Plate I, figs. 1 and 2). For reasons already stated no attempt has been made to identify these species with species named in the literature; it is sufficient for our present purpose, as in the case of the water amcebex, to determine the genus to which they belong. All 5 species cultivated from both non-dysenteric and dysenteric stools possess the characters of the genus Amaba Ehrenberg described in the previous section (Compare figs. 1 to 3 with figs. 4 to 10). AM@BA FOUND MICROSCOPICALLY IN THE INTESTINAL TRACT OF MAN. This part of the investigation has included a microscopic study of the living amcebe in the fresh stools from 142 cases of amebiasis without symptoms of dysentery, from 28 cases of ameebic dysentery, and in the pus of 2 cases of amcebic liver-abscess; of fixed and stained preparations from 21 cases of amoebiasis without symptoms of dysentery and from 16 cases of amcebic dsentery; and in sections of the intestine in 1 case of amcebic dysentery, and of the liver in 2 cases of ameebic liver-abscess. I am indebted to Dr. E. R. Stitt of the United States Naval Hospital, Cafiacao, Cavite, for a section of one of the cases of amcebic liver-abscess and to Dr. V. L. Andrews of the College of Medicine and Surgery, Uni- versity of the Philippines, for sections of the other case of ameebic liver- abscess and sections of the intestine from a case of amoebic dysentery. The stools have been studied fresh in ordinary cover-glass and slide prepara- tions. Stained preparations of the feces and of the pus from liver abscesses have been made by spreading thin smears on cover-glasses, floating them “wet” on the surface of Zenker’s fluid for 5 minutes, washing in water until the fixing fluid is removed, staining 5 minutes in aqueous alum hematoxylin, washing in distilled water, dehydrating in different grades of alcohol, clearing in oil origanum, and mounting in xylol balsam. I have found Zenker’s fluid preferable to Schaudinn’s alcohol-corrosive-sublimate mixture as a fixative for ameebe. Aqueous alum hematoxylin has proved a more precise stain for the chromatin of amebe than iron hematoxylin or any other stain that I have tried. The sections from one case of ameebic live-abscess were stained with iron hematoxylin, and from the other case of liver abscess and from the dysenteric intestine with hematoxylin and eosin. One type of amceboid organism has been found exclusively in all of this material (Plate IV, figs. 9 to 12 and Plate V, figs. 13 to 16). This differs from the Ameba type found in the Manila water supply and culti- vable from the intestinal tract of man in certain fundamental morpho- Iegical and biological characters. The trophozoite has the nucleus situated excentrically instead of centrally in the resting organism ; the chromatin is arranged peripherally instead of centrally in the nucleus; there is no contractile vacuole; reproduction by sporulation does not occur; and multiplication does not take place on ordinary artificial media. The eyst contains + or 8 nuclei instead of a single nucleus; a reproductive process takes place in the cyst; and encystment occurs only in the body 268 wins WALKER. of the, host (Compare figs. 1 to 8 with figs. 9 to 16). I believe, the characters of this type of amceboid organism are sufficiently distinct from the Ameba type to justify the establishment of the new genus, Hntamaba, by Casagrande and Barbagallo (1897) and its adoption by Schaudinn (1903). This genus should include the parasitic amcebe of man and also the parasitic amoebe that have been described in certain lower animals, namely: Hntameba ranarum (Grassi) Dobell, 1908, in the frog, Hnta- meba testudims Hartmann, 1910, in the turtle, Hntameba muris (Grassi, 1881) Wenyon, 1907, in the mouse, and Hntameba nutalli Castellani, 1908, in the monkey. What, then, is the significance of the species of the genus 4meba cul- tivable from the intestinal tract of man and other animals? These cultivable amcebze might be considered parasitic entamcebe that had undergone modification by their growth on artificial culture media. It seems possible that such a change in environment might modify some of the less constant morphologic characters of these organisms, such as size, shape, number of pseudopods, extent of the ectoplasm, and granula- tion or vacuolization of the entoplasm; but that it could cause a complete reorganization of the structure of the nucleus, develope de novo such a constant organelle as a contractile vacuole, or profoundly modify the life-cycle of the organism appears doubtful. Moreover, that the supposed modification resulting from cultivation on artificial media should in- variably take the form of a change from the characters of the genus Entameba to those of the genus Ameba is, to say the least, improbable. It might be claimed that, owing to some fault in my technique, I had failed to cultivate the parasitic entamcebe. Among my cultures are four isolated by as many different investigators, other than myself, two of which are from cases of amoebic dysentery and one of these isolated by Musgrave and Clegg (1904) ; all of these cultures, like my own, are of the Amaba type. Werner (1908) failed to cultivate entamcebe from cases of amoebic dysentery. Dobell (1908) and Weryon (1907) also were unable to cultivate on artificial media the entamcebe which they found in the intestines of lower animals. An examination of the de- scriptions and illustrations of amoeboid organisms cultivated by different authors shows in every case organisms not of the Hntamwba but of the Amaba type. There still remains the possibility that the cultivable amcebe, as well as the non-cultivable entamcebe, are parasitic in the intestinal tract of man. Since, however, organisms of the Ameba type are not found in the microscopic examination of fresh or stained preparations of faeces, liver-abscess pus, or in sections of liver or intestine, it seems probably that the amceboid organisms cultivated by Musgrave and Clegg (1904), Lesage (1905, 1908), Gauduchea (1908), and Noe (1909) from the intestine and liver abscesses of man, and by myself (Walker 1908) from COMPARATIVE: STUDY: OF AMCEBA. 269 the intestine of-man and other animals, are at most only temporary com- mensals in the intestinal tract, and more probably that they are, as Werner (1908) has suggested, only cysts of free-living amcebe which have been ingested with water or food and have passed unchanged through the intestinal canal. The entamcebz found in the stools of healthy persons or of persons suffering from disease other than dysentery present characters that correspond in part.with those of Hntameba coli Schaudinn and in part with those of Hntameba nipponica Koidzumi. In stools of such persons, in which there exists a natural diarrhoea or diarrhoea induced by a cathartic, the vegetative or trophozoite forms are commonly present. ‘The living trophozoite is rounded in the resting condition, 7.5 to 34.5 # in diameter, oval, ligulate or irregular when in motion, and porcela- neous and refrangent in appearance. The ectoplasm is ordinarily visible only in the pseudopods. There is no contractile vacuole and the ento- plasm is normally free from all vacuolization. The nucleus is distinctly visible in the living entamceba. It occupies an eccentric position, but in the rotation of the rounded entamceba the nucleus frequently appears central in optical section. It has the form of a rather heavy ring of refrangent material, that may be of uniform or of irregular thickness, which surrounds a non-refractive nucleoplasm and within which there may or may not be present a few refractive granules. The movements of these entamcebe are sluggish, even in fresh stools and they quickly loose all motility in cold stools. In preparations fixed wet and stained with aqueous alum hematoxylin the trophozoite shows a deeply-staining granular cytoplasm, usually without distinction from the ectoplasm. Occasionally a narrow rim of homogeneous, more feebly-staining ectoplasm is present. The ringform nucleus is seen in optical section to consist of a nuclear membrane en- closing an archromatic nucleoplasm and a relatively large amount of chro- matin. ‘Two varicties in the distribution of the chromatin in the nucleus ean be distinguished. In the first of these the chromatin appears in optical section as a continuous, segmented or granular ring of approxi- mately uniform thickness about the inner surface of the nuclear membrane, with or without some granular chromatin scattered in the nucleoplasmic network or collected in a small karyosome. This variety corresponds with the coli species of Schaudinn (fig. 9). Im the second variety the chromatin is collected in several discrete clumps on the inner surface of the nuclear membrane. This variety corresponds with the nipponica species of Koidzumi (fig. 10). Reproduction in the trophozoite appears to take place exclusively by simple division. I have seen no evidence of a schizogony, such a de- scribed by Schaudinn in Lntameba coli and by Koidzumi in Entamaba ‘nipponica, in either fresh or stained preparations. 270 | WALKER. In non-dysenteric stools that have become formed encysted entamcebe make their appearance. These cysts (fig. 11) are developed, as in the ease of the order Coccidiida, only in the intestinal tract of the host,:and not in the evacuated feces. If the process of encystment has already begun before the entamcebe are passed in the stool the development of the cysts may continue outside of the host; but motile and resting enta- moebee quickly degenerate and disintegrate in cold stools. The mature cysts usually contain 8 nuclei of the same structure, but smaller and poorer in chromatin than the nuclei of the trophozoite; cysts containing more than 8 nuclei are occasionally seen. Whether such cysts represent a dif- ferent species or variations in the same species, it is difficult to say. In the development of these cysts Schaudinn described a complicated series of nuclear changes, including an autogamous copulation of reduced nuclei, that preceded the formation of the 8 nuclei in the mature cyst. Such a reproductive process would constitute a sporogony comparable with that taking place in the order Coccidiida. ‘The mature cyst would correspond with the sporocyst and the nuclei to the nuclei of the 8 sporozoites that are supposed to be developed when the cyst reaches the intestine of a new host. However, I have been unable to observe any stages in the develop- ment of the 8 nuclei in the cysts which could be interpreted otherwise than straight-forward nuclear division. Dobell (1909) has come to the same conclusion from his study of the development of the multinuclear cysts of Entameba ranarum. If this interpretation of the process be correct then it must be considered either as a schizogony in which the cyst would be a schizocyst and the 8 nuclei the nuclei of the merozoites that are devel- oped in the intestine of the new host; or possibly as a gametogony, com- parable to that occurring in the order Gregarinida, in which the 8 nuclei would constitute the nuclei of gametes that are formed and which copulate in the intestine of the new host. Entameebe of the coli and nipponica varieties have been observed only in the stools of healthy persons or of persons suffering from diseases other than dysentery; but it is possible that they might occasionally be found associated with another type of entameeba, about to be described, in dysenteric stools. In such cases they would represent double infec- tions. Of the two varieties the coli is found much the more frequently. The nipponica variety may be encountered alone, alternating with the coli variety in different stools of the same patient, or associated with the colt variety in the same stool. Transitional forms between the two varieties are frequently seen, and the 8-nuclear cysts have been found associated with both the coli and the mipponica varieties of entamoeha. The entamcebe found in the stools of cases of amoebic dysentery, in the pus of amcebic liver-abscesses, and in sections of dysenteric intestines and of amcebic liber-abscesses, present certain morphological differences from the entamcebe found in non-dysenteric stools which appear to be COMPARATIVE STUDY OF AMGBAs. 271 fairly constant, and which in their sum serve to distinguish the enta- moebe from the two sources. The characters of the entamcebe from dysenteric material correspond in part with those of Hntameba histoly- tica Schaudinn, in part with those of Yntameba tetragina Viereck and, under certain conditions, with those of Hntameba minuta Elmassian. The trophozoites in fresh stools in acute dysentery are usually, but not invariably, larger, more often oval in the resting condition, and more hyaline and less refrangent in appearance than the trophozoites from normal stools. ‘The cytoplasm is uniformly hyaline in appearance with no distinction between ectoplasm and entoplasm. It contains a variable amount of granular material and often red blood corpuscles of the host as inclusions which, when collected near the center of the organism, leave a hyaline periphery that has the appearance of an extensive ectoplasm described by other authors. There is no contractile vacuole and the entoplasm is normally free from other vacuoles; it is only following changes in temperature or tonicity of the medium or in consequence of degenerative changes that vacuolization is present. The position of the nucleus is eccentric, and in the more actively motile entamoebee in dy cn- teric stools the nucleus more frequently changes its relative position and is more subject to pressure that tends to deform it than the nucleus of the more sluggish entamceba in normal stools. 'The nucleus, in con- trast to entamcebee of the col and nipponica varieties, is usually distin- guished with difficulty in the living trophozoite. Contrary to Schaudinn I distinguish a thin but distinct nuclear membrane. This membrane encloses a homogeneous nucleoplasm which is slightly less refrangent than the surrounding cytoplasm and which contains a small amount of gran- ular material arranged about the inner surface of the nuclear membrane and scattered in the nucleoplasm. In consequence of this thin peripheral layer and the low index of refraction of the nucleoplasm the nucleus has the appearance of an extremely pale vacuole and is distinguished with difficulty, especially in motile or vacuolated entamcebe These entameebe, in contrast to those of normal stools, exhibit an active motility in fresh stools which often persists in cold stools several hours old. In preparations that have been fixed wet in Zenker’s fluid and stained with aqueous alum hematoxylin the trophozoite in dysenteric stools usually stains feebly and shows a reticulated rather than a granular structure of the cytoplasm with no distinction between ectoplasm and entoplasmm. In the stained preparations the difference in the appearance of the nucleus from the nucleus of entamcebe in non-dysenteric stools is seen to be due to the much smaller amount of chromatin in the nucleus of the dysenteric entamcebe. Two varieties in the distribution of the chromatin can be distinguished. In the one the chromatin is extremely scanty and is arranged as a barely perceptable layer about the inner surface of the De WALKER. nuclear membrane, with or without a minute karyosome or a few scattered fragments in the nuclear-network. This variety corresponds with the histolytica species of Schaudinn (fig. 12). In the second variety the chromatin is rather more abundant and is arranged in part as a loose granular layer, that frequently shows radial projections, about the inner surface of the nuclear membrane, and in part as a loose central karyosome which, in its most typical form, consists of a minute centriol surrounded by an achromatic halo that is bounded by a circle of chromatin granules. This variety corresponds with the tetragina species of Viereck ut. Hart- mann (fig. 13). During the active phase of amcebic dysentery only the trophozoites of these entamoebze are present in the stools. With aqueous alum hema- toxylin, which is an extremely precise stain for the chromatin of enta- -moebex, only stages of binary fission have been observed. I: have been unable to find any of the chromidial stages that are said by Schaudinn, Craig and Hartmann to precede the formation of spores in Hntameba histolytica. It seems possible that the use of iron hematoxylin or other less precise chromatin stains may have resulted in mistaking bacteria or protoplasmie granules for chromatin. I have not observed any of the later stages of the formation of the spores or the free spores in either fresh or stained preparations. When the acute symptoms in untreated aiasape have passed and the stools of the patient are becoming normal the trophozoites become smaller, less actively motile and more rounded in the resting forms, and the chromatin becomes more abundant in the nucleus. These changes are preparatory to the development of the cysts. Such forms resemble the minuta species of Elmassian (fig. 14). Finally, encysted forms contain- ing 4 nuclei appear which may persist for an indefinite period or until the patient suffers an exacerbation of the acute symptoms. Thus in amoebic dysentery 6,442 there appeared in the stools on January 30, 1911, a considerable amount of mucus and pus streaked with blood. On Jan- uary 31 the stools were partly formed and partly fluid, consisting of mucus, pus, and blood and containing many ameeboids, resting and encysting entamcebe. The amceboid and resting entamcebe were small but with the histolytica type of nucleus, the encysted forms were the cysts of the tetragina type containing 4 nuclei. The symptoms abated without treatment, the stools became normal, and the patient has had no recurrence of the disease; but the cysts containing 4 nuclei have persisted in the stools up to the present time (August 23, 1911). Still more instructive is the following chronic case, amcebic dysentery 5,748, which came down with a typical attack of amoebic dysentery on April 29, 1911, with mucus, pus, and bloody stools containing many large entameebee of the histolytica type (fig. 12). The patient was. put under treatment to which he promptly responded, the symptoms abated and the stools became normal. COMPARATIVE STUDY OF AM@B. Bie Cysts of the tetragina type then appeared in the stools. On June 1 the patient suffered a relapse with some mucus, pus, and blood in the stools and typical Hntameba histolytica were present in the stools. This condi- tion has persisted intermittently in spite of treatment with ipecac until August 1 when the stools became free from mucus and blood. On August ” they had become formed and the 4-nuclear cysts again appeared in the feeces. The cysts containing 4 nuclei found in the stools of cases of amcebic dysentery, like the cysts containing 8 nuclei in non-dysenteric stools, are developed only in the intestinal tract of the host and not in the defecated stools. They differ from the 8-nuclear cysts in non-dysenteric stools, not alone in the different number of nuclei contained in the mature cysts, but, also, in a number of other particulars. The cysts are smaller; the nuclei are larger and contain more chromatin; the multiplication of the nuclei appears to take place earlier in the encystment of the entameba, often even in the amceboid stage; the cyst wall, although equally im- perveous to stains, appears not to be so thick or well defined; and the encysting entamceba more frequently contains elongated refrangent bodies which stain deeply with iron hematoxylin, but which do not stain with the more precise aqueous alum hematoxylin, and which, therefore, are probably protoplasmic or foreign bodies rather than chromatin. (Com- pare fig. 11 with fig. 16.) In the development of these cysts, as in the development of the cysts from non-dysenteric stools, no indication of nuclear reduction and autogamy such as is described by Hartmann in the development of the cysts of Hntameba tetragina, have been observed, but only uncomplicated nuclear division (figs. 14 to 16). If these observa- tions be correct then these cysts, like the cysts of Hntameba colt, would have to be considered either schizogenic or possibly gametogenic rather than sporogenic. Entamcebe of the histolytica and the tetragina varieties have been found only in the stools or tissues of persons suffering from or having a history of amcebic dysentery. The histolytica type I find, contrary to Whitmore (1911), to be the more common variety in the dysenteries of Manila. The ¢etragina variety when found, invariably has been. asso- ciated with the histolytica and transitional forms between the two varieties are common. Moreover the tetragina cysts, as the protocols of the above cited cases show, have been found associated with pure his- tolytica infections. In view of the observations that have been presented in detail in the preceding pages I am of the opinion that, although several of the varieties of entamceba hitherto described are represented, only two well defined species are found parasitic in the intestinal tract of man. One of these species includes the coli variety of Schaudinn and the mipponica variety of Koidzumi. This species is characterized by its porcelaneous and 274 WALKER. refrangent appearance, distinct nucleus and sluggish motility, in the living entameeba ; by the deeply staining, granular cytoplasm, and by the relatively large amount of chromatin, which is arranged either as a heavy continuous or broken ring (colv variety) or as several discrete masses (nipponica variety) on the inner surface of the nuclear membrane, with transitions between these two varieties, in the stained entameebe ; and especially by the development of cysts contaiming 8 nuclei. This species should, according to the law of priority, bear the name of Entameba coli Schaudinn. It is found in the stools of healthy persons and of persons suffering from diseases other than dysentery and is, there- fore, presumably non-pathogenic. The other species include the his- tolytica variety of Schaudinn, the tetragina variety of Viereck and Hartmann and probably the minuta variety of Elmassian. It is charac- terized by its hyaline and feebly refrangent appearance, indistinct nu- cleus, and active motility in the living entamceba; by the feebly-staining reticulated cytoplasm, and by the relative paucity of chromatin which is atranged either as a barely perceptible layer about the inner surface of the nuclear membrane with or without a few fragments scattered in the nuclear network (histolytica variety), or as a more extensive but loose, granular peripheral layer and a loose central karyosome (tetragina varie- tv’, with transitions between these two varieties in the stained enta- meeba; and especially by the development of cysts containing 4 nuclei. This species is found only in the stools, pus, or tissues of cases of amoebic dysentery, ameebic liver-abscesses, or of cases having a history of amoehic dysentery and is probably a pathogenic species. According to ‘the law of priority this species should bear the name, Hntameba histolytica Schaudinn. The differences in the arrangement of the chromatin in the nuclei of the coli and nipponica varieties and of the histolytica and tetragina varieties probably represent metabolic or reproductive changes in the nuclei of the two species. This view is supported by the presence of forms showing a chromatin arrangement intermediate between these varieties of the two species. It is probably that other imperfectly de- scribed species of Hntamaba that have been observed in the intestine of man -would be found, on a more complete knowledge of their morphol- ogy and life-cyeles, to belong to one or the other of these two species. The most important practical application of these differences in mor- phology between Hntameba coli and Entameba histolytica is the micro- scopic diagnosis of amcebic dysentery, especially in incipient or chronic cases, as a guide to treatment and prophylaxis.t The differentiation of *It is to be noted in this connection that the microscopic diagnosis of amcebic dysentery is not dependent upon Hntameba hystolytica being the primary etiologic factor in this disease, but only upon the apparently constant association of this entamceba with ameebic dysentery. COMPARATIVE STUDY OF AM@B4s. PATS) Entameba histolytica from Entameba coli must frequently be made without the help of the characteristic encysted stages. While the diag- nosis in the trophozoite stage is not easy, it can’ be made with certainty by a protozodlogist having sufficient experience and using proper care. The examinations for this purpose should be made of perfectly fresh stools, repeated if necessary on different days, and should be made, if any uncertainty exists, of stained as well as of fresh preparations. Prepara- tions fixed wet in Zenker’s fluid and stained with aqueous alum hema- toxylin should be employed for this purpose. Greater difficulty may be experienced in diagnosing chronic cases between the periods of exacerba- tion of the acute symptoms, in which Hntameba histolytica, in prepara- tion for encystment more closely resembles in some respects Hntameba colt; but under these conditions a careful search will usually disclose the presence of 4-nuclear cysts. The presence of such cysts in the stool is absolutely diagnostic of Hntameba histolytica; but a diagnosis from the presence of 8-nuclear cysts in the stool must be made with caution, since there might exist a double infection with Hntameba coli and Entameba histolytica. An experimental study of the parasitism and pathogenicity of the species of the genera Ameba and Hntameba, established by this mor- phologic study, has been undertaken and the results of it will be presented in another paper. SUMMARY AND CONCLUSIONS. 1. The ameeboid organisms found in the Manila water supply belong to the genus Ameba Ehrenberg. 2. The ameeboid organisms cultivable from the intestinal tract of man, both from healthy persons and from cases of amebic dysentery, also belong to the genus Ameba Ehrenberg. 3. The cultivable species of the genus Ameba are not parasitic in the intestinal tract of man; when obtained in cultures from the intestine they probably are derived from cysts of amcebe that have been ingested with water or food and have passed unchanged through the intestinal tract. 4. The amceboid organisms parasitic in the intestinal tract of man belong to a distinct genus, Yntameba Casagrandi and Barbagallo. 5. The entameebe are strict or obligatory parasites and are incapable of multiplication outside of the body of their host. They can not be cultivated on Musgrave and Clegg’s medium. 6. One non-pathogenic species of the genus Hntameba, Entamaba coli Schaudinn, parasitic in the intestinal tract of man, which includes Hn- tameba nipponica Koidzumi, and which develops cysts containing 8 nuclei, is recognized. 7. One presumably pathogenic species of the genus Hntamaba, En- 1049122 276 ' WALKER. tameba histolytica Schaudinn, which includes Hntameba ‘tetragina’ Vier- eck, and which develops cysts containing 4 nuclei, is recognized. ' -8. A differential diagnosis of an infection with Hntameba coli from an infection with Entameba histolytica can be made with the microscope. 9. An infection with either Hntameba coli or Entameba histolytica must always come directly or indirectly from another infected person. - 10. Water or uncooked food ean transmit amcebic dysentery only when contaminated with fecal matter from a case of amcebic dysentery. 11. The infection with Entameba histolytica may persist for an. in- definite period after the symptoms of amcebic dysentery have disappeared, during which time the resistant, encysted entamcebe may ‘be passed in large numbers in the stools and constitute an important source of infec- tion to others. Such persons are “carriers” of amcebic dysentery, com- parable to the “carriers” of typhoid fever or cholera. 12.’ The prophylactic measures for the prevention of amcebic uke are sufficiently indicated by the preceding conclusions; they are identical with those required for the prevention of other specific infectious diseases of the intestinal tract, like typhoid fever and cholera. LITERATURE CITED. bree Jel AKASHI. Ueber die Morphologie und die in tePcliin pepeennc tte"? der “Darmamoeben. Mitt. d. Med. Gesellschaft z. Tokyo (1911), 25, 6. CASACRANDI e BARBAGALLO. Entamoeba hominis s. Amoeba coli (seein, Studio biologico e clinico. Ann. d’Igiene sper. (1907), 5, 1. CASTELLANI, A. Observations on some protozoa found in human: faeces. Cen- tralbl. f. Bakt. etc., Orig. (1905), 38, 66-69.. : a Ipem. Note on a liver abscess of amoebic origin in a front, Parasitology (1908), 1, 101-102. Craid, C. F. Observations upon amebas infecting the human intestine, with a description of two species, Hntamoeba coli and Entamoeba LUST Am. Med. (1905), 9, 854, 897, 937. Le a Ipem. A new intestinal parasite of man..: Paramoeba hominis. eniien. Med. Sci. (1906), 132, 214-220. EeCsret nies chee IpemM. Studies upon the amoebae in the intestine of man. Journ. Infect. ‘Dis. (1908), 5, 324-377. eo Scere DoBett, C. C. Researches on the intestinal protozoa of frogs and toads. Quart. Journ. Microscop. Sci. (1909), 53, 2,201-277. - Sree : ELMASSIAN, M. Sur une nonvelle éspéce amibienne chez Pharr, Dataraeete minuta n. sp. Centralbl. f. Bakt. etc., Orig. (1909), 52, 3,325. GaupucHEAU, A. Formation de corps spirillaires dans une SRIEEL damibes. Compt. rend. Soc. biol., (1908), 64, 493-494. HarrMann, M. Hine neue Dysenterieamoebe, Entamoeba tetragina Viereck, ‘syn. Entamoeba africana Hartmann. Beih. 5, Arch. f. Schiffs- u. Trop-Hyg. (1908), 12, 117-127. pan IpEM. Untersuchungen ueber :parasitische Amoeben. I. Entamoeba histolytica Schaudinn. Arch. f. Protistenk. (1909), 18, 2, 207-220. IpeM. Ueber eine Darmamoeba, Entamoeba testudinis n. sp. Memorias do Instituto Oswaldo Cruz, (1909), 1, 1 pl. ek COMPARATIVE STUDY OF AMGBA. Dia HarTMAnn, M. und PRow4ZeEK, 8. v. Blepharoplast, Caryosom und Centrosom. Arch. f. Protistenk. (1907), 10, 306. Jurcens. Zur Kenntnis der Darmamoeben und der Amoeben-Enteritis. Ver- 6ffentl. a. d. Gebiete d. Militar-Sanitdtswesens (1902), 20, 110. Koizumi, M. On a new parasitic amoeba, Entamoeba nipponica, found in the intestine of Japanese. Centralbl. f. Bakt. etc., Orig. (1909), 51, 650. Lesace, A. Culture de l’amibe de la dysenterie des pays chauds. Ann. Inst. Pasteur (1905), 18, 9-16. Ipem. L’amibiase chez le chat (Dysenterie amibienne.) Compt. rend. Soc. biol., (1907), 62, 1191-1193. Ipem. Note sur les Entamibes dans la dysenterie amibienne des pays chauds. Bull. d. la Soc. d. Pathol. Exotique (1908), 1, 104-111. LorscH, F. Massenhafte Entwickelung von Amoeben im Dickdarm. Arch. f. path. Anat. u. f. klin. Med., (Virchow), Berlin (1875), 65, 196-211. Muserave, W. E. and Creac, M. T. Amebas; their cultivation and etiological significance. Bur. Gov. Labs. Manila (1904), No. 18. Noc, H. Recherches sur la dysenterie amibienne en Cochinchine. Ann. Inst. Pasteur (1909), 23, 177-204. ScHAuDINN, F. Untersuchungen ueber die Fortpflanzung einiger Rhizopoden. Arb. a. d. Kais. Gsndhtamte. (1903), 19, 547-576. VeppER, E. B. An examination of the stools of 100 healthy individuals, with especial reference the presence of Hntamoeba coli. Journ. Am. Med. Asso. _ (1906), 46, 870-872. VirRECK, H. Studien ueber die in den Tropen erworbene Dysenterie. Arch. f. Schiffs- u. Trop.-Hyg. (1907), 11, Beiheft I. Waker, H. L. The parasitic amoebae of the intestinal tract of man and other animals. Journ, Med. Research (1908), 12, 379-459. Wenyon, C. M. Observations on the Protozoa in the intestine of mice. Arch. f. Protistenk. (1907), Suppl. 1. WERNER, H. Studien ueber pathogene Amoeben. Arch. f. Schiffs- wu. Trop.-Hyg. (1908), 12, Beiheft IT. WuHitmorE, EH. R. Vorliufige Bemerkungen ueber Amoeben aus Manila und Saigon. Oentralbdl. f. Bakt. etc., Orig. (1911), 58, 234-235. Witiiams, A. W. and Gugiey, C. R. Studies on intestinal amebas and allied forms. Collected Studies from the Research Laboratory, Dept. of Health, City of New York (1908-9), 4, 237-246. Hie. 1. Fie. 4. Fie. bon t Fie. 9. 10. 11. 12. ILLUSTRATIONS. (From photomicrographs by Charles Martin.) PLaAtTeE I, Ameeba 1, trophozoite, culture from the Manila water supply. X 1000. . Ameba 1, cysts, culture from the Manila water supply. X 1000. . Ameba 19, trophozoite and cyst, culture from the Manila water supply. x 1000. Puate II. Ameba 8, trophozoite and cysts, culture from a stool of a case of amebic dysentery. x 1000. . Ameba 14,965, trophozoites, culture from a stool of a case of amebic dysentery. X 1000. . Amebe 7,671, trophozoite, culture from a stool of a case of amebic dysentery. X 1000. PuateE III. . Ameeba 7,671, cysts, culture from a stool of a case of amebie dysentery. < 1000. . Amebe “L” (Musgrave and Clegg), trophozoite, culture from a stool of a case of amebic dysentery. X 1000. This species differs from Ameba 7,671 (figs. 6 and 7) chiefly in not possessing a contractile vacuole. PLATE IV. Entameba coli, trophozoite, in the stool of a healthy person. X 1000. Entameeba coli var. niponica, trophozoite, in the stool of a healthy person. x 1000. Entameeba coli, cyst containing 8 nuclei only 5 of which are shown in the optical section of the entameba, in the stool of a healthy person. x 1000. Entameba histolytica, trophozoite containing red blood corpuscles, in the bloody and mucus stool of a case of amebic dysentery (No. 5,748). x 1000. PLATE V. Fie. 13. Hntameba histolytica var. tetragina, trophozoite containing red blood corpuscles, in the stool of a case of acute amebic dysentery. 1000. 14. Entameba histolytica, trophozoite in preparation for encystment, in the stool of a case of chronic amebic dysentery. 1000. 15. Entameeba histolytica, encysting entameba showing the first division of the nucleus, in the stool of a chronic case of amebic dysentery. 1000. 16. Hntameba histolytica, cyst containing 4 nuclei, in the stool of a chronic case of ameebic dysentery. 1000. 279 penne hriareaai : q 7 3 Raa Aer is nba . } ; < a \ Vines Sedgaees i : ; ~ i , rs 1 \ p y 44 ‘ ¥ WALKER: COMPARATIVE STUDY oF AmaaBz.] [PuIu. Journ. Scr., Vou. VI, No. 4. Fic. 1. Fic. 2. Fig. 3. : PLATE 1. OA eset Bi ai i ne, WALKER: COMPARATIVE STUDY OF AMG@B8. | [PHt. JourN. Ser., Vou. VI, No. 4. Fic. 4, e > bn) Fic. 5. Fic. 6. PLATE Il. WALKER: COMPARATIVE StuDY or AmasBa.] [Pur. Journ. Sct., Vou. VI, No. 4. Fie: 7. Fic. 8. FLATE ill. WALKER: COMPARATIVE STUDY OF AM@B4i. | [PuIn. JOURN. Scr., Vou. VI, No. 4, Fig 9) Fic. 10. FIG. Wile Fic. 12. PLATE Iv. “WALKER: COMPARATIVE STUDY OF AM@BA:. ] Fis. 13. Fic. 15. PLATE v. [PHIL. JOURN. Sct., Vou. VI, No. Fic. 16. IMMUNITY REACTIONS WITH AMOEBA. By AnpREw Watson SELLARDS. (From the Biological Laboratory, Bureau of Science, Manila, P. I.) The aetiology and also the diagnosis of amcebic dysentery involve the question of whether non-pathogenic as well as pathogenic amoebes may be encountered in the human intestine. In the development of the evid- ence bearing upon this question, two factors have arisen which are of especial interest. In the first place important morphological differences have been described for amcebe from various sources, and secondly cul- tures of amcebe have been obtained from dysenteric stools. It is main- tained that definite morphological distinctions occur in the amcebze found in the intestine with differences in clinical manifestations corresponding to the type of amceba which is present. ‘Thus, one of these types may persist over long periods of time without the. aaoimenne of definite symp- toms. This fact appears. to constitute the principal evidence in support of the existence of a non- -pathogenic-species of amoeba in the intestine. However, the.morphological differences between this type of amoeba and © that occurring in active dysentery have not been accepted by certain observers, and the existence of this type as a distinct species has been questioned. In regard to the cultivation of Hales there is some uncertainty concerning the exact significance of the cultures which have been obtained from dysenteric stools. Some investigators consider that the amcebe in these cultures are pathogenic. Others regard them as purely saprozoic forms, which are only accidentally present in the feces, maintaining that the morphological differences are sufficient to distinguish them absolutely from the ameebe ordinarily seen in a dysenteric stool. . In the present paper an attempt has been made to distinguish amcebe by their biologic properties without especial reference to morphology. Immunization of animals has been carried out with various strains of amcebee with the expectation of producing immune bodies for the com- parison of the various strains. It was intended, in the first place, to determine whether any differences could be detected in the immunity reactions of cultures of amcecbe obtained from parasitic as compared with those from saprophytic sources. In the second place, the sera of dysen- ‘ 281 282 SELLARDS. teric patients have been examined for changes analogous to those produced by artificial immunization with ameebe. The number of cultures under investigation was limited to four and these were selected, without regard to morphology, from sources which represented fairly distinct conditions. The first culture, Race A,* was obtained from the city water supply of Manila. This is an unfiltered river water which comes, however, from a practically un- inhabited watershed. Amebze are constantly present in this water. Race B. was cultivated from the stools of a case of amebic dysentery occurring in Manila. The two remaining cultures were secured from sources outside of the Tropics. Race C. was grown from hay obtained from central Illinois, a region practically free from ameebic dysentery. Race D. was cultivated in Kansas City, from the stools of a patient with slight diarrhea. In the preparation of these cultures for injection into animals, there are two factors which were considered to be of especial importance, namely, (1) the isolation of a single species of amoeba and (2) its cultivation with a single species of bacterium. Much of the morphologic work upon amcebe has been carried out upon material which might contain a variety of species but in attempting a differentiation by immunity reactions it seemed especially desirable to isolate single species of amcebe, i. e., to know that each culture consisted of the progeny of a single organism. The most feasible method for the isolation of single cells is that devised by Barber(1) and it is readily applicable to ameebe. In transferring single motile amcebe from cover glasses and pipettes to nutrient media they exhibit some tendency to stick to the glassware in a manner similar to certain cells, such as leucocytes and some of the capsulated bacteria. The cysts of amebex, do not possess this characteristic and they can be isolated and transferred readily. Ac- cordingly, the isolations were first attempted with the encysted stage. However, if was found that only a small proportion of the isolated cysts would multiply when transferred to agar, prepared for the cultivation of ameebe. The substitu- tion of a liquid, nutrient medium for the agar would reduce the manipulations to a minimum, thereby permitting the isolation of organisms in the ameboid stage without necessitating further transference in order to supply nutrient material. Normal rabbit serum was-found to constitute a suitable liquid culture medium. Emulsions of motile amcbe were prepared in serum in dilutions varying from 1 to 5 to 1 to 10 and the isolations were made immediately ‘in hanging drops on cover slips. The entire drop was not too large to come within the field of the one-sixth or one-twelfth objective. The fluid medium was quite clear and accordingly it could be determined definitely when a single ameba was obtained. In order to supply an abundance of nutrient material the size of the droplet was increased, after isolation was effected, to a diameter of 1 or 2 millimeters. Under these conditions, multiplication took place in about one- fourth of the isolations. In the remaining three-fourth the amebe disintegrated, eneystment rarely taking place. The hanging drop cultures were kept both at *These cultures have been designated simply by letters, in as much as the basis for the classification of amcebe into species is incompletely developec and the description of the various species which have been reported is often inadequate for their identification. IMMUNITY REACTIONS WITH AMGBA. 283 room temperature (about 25° to 30° C.) and incubator temperature (37° C.) ; either was found to be satisfactory. Within the first 48 hours as many as 10 to 20 organisms usually developed from the original parent cell. The drop was then transferred with a comparatively coarse pipette to agar media and the cultures were continued in the usual manner. One race (D) had already been isolated from a single cell before it was received at the laboratory. This culture was obtained by Professor M. A. Barber of the University of Kansas from the feces of a patient with a watery diarrhcea. Individual cysts were selected and isolated directly from the feces. Upon transferring to nutrient media, some of these cysts developed, thus not only giving a culture consisting of a single species of amceba but also demonstrating that the cyst-like bodies seen in the feces were true amcebe. The presence of bacteria in the cultures of amcebe * naturally necessi- tates a considerable number of controls in the study of the immune bodies resulting from the injection of these mixtures. To simplify these controls, somewhat, the four different races of amcebe were cultivated with the same species of bacterium. B. prodigiosus was chosen, since amcebe grow well in conjunction with it and its chromogenic properties simplify the detection of contaminations by other bacteria. As a further control, one of the races of amcebe was also cultivated with Vibrio cholere. The separation of amcebe from all of the accompanying bacteria except one species was found to be rather difficult. ven in the encysted stage, the amcebe are in general rather less resistant to physical and chemical agents than the sporeforming bacteria which occur with them. In the motile stage, they are intimately mixed with bacteria, the latter clinging to the surface and also being enveloped in the substance of the amebe, while the spores may resist any digestive action. The method devised by Mouton(3) was used for obtaining the amebe in culture with a single species of bacteria. The center of a Petri plate was inoculated with amcbe, the desired bacterium having been inoculated previously in lines radiating from the center. As the ameebie wandered over the plate they followed the lines of bacterial growth, gradually leaving the contaminating bacteria behind them. After several transplantations had been made in this manner, test tubes were substituted for Petri plates to avoid accidental contamina- tion from the air. The entire surface of an agar slant was inoculated with bacteria, the inoculation of the amebz being made at the base of the tube. After 24 hours in the incubator with the tubes placed in the erect position, the amcbe grew upward a distance of 3 to 5 centimeters, a sharp line of demarcation frequently appearing at the junction of the growths of the bacteria and the amebe. Many repetitions of this process were necessary before all of the con- *Many of the earlier observers have attempted to obtain pure cultures of ameebe, but no successful method was established whereby development continues indefinitely in the absence of both living and dead bacteria. However, very recently, Williams(2), in a preliminary communication, reports successful cultiva; tion in the absence of bacteria. 284 .» SELLARDS. taminating organisms were eliminated. It was a comparatively simple matter to obtain an apparently pure culture of bacteria, but more extended observations often revealed the presence of contamination. Thus minute quantities of a culture when plated out for development of single colonies frequently showed nothing but B. prodigiosus, while in the course of a few weeks, other bacteria might appear in the original culture, although it had been carefully protected from contamination. It is to be noted that the culture of prodigiosus lost its power of producing pigment on the amebe agar, but this property was at once regained on the first transplantation to ordinary agar. In the isolation of ameebe with Vibrio cholerw, a culture was readily obtained which showed only cholera colonies when small quantities were inoculated on ordinary agar. How- ever, the inoculation of a large quantity of growth into a highly active anti- cholera serum resulted in the destruction of practically all of ie cholexa organisms and a spore-forming bacillus developed in the serum. The stock cultures of amcebz were always kept in test- niece, Bactonia were added at practically every transfer and the inoculations were made in the same manner as for the purification of the cultures; that is, the entire surface was inoculated with B. prodigiosus, but only the base of the slant with amebe. Technique of cultivation—The majority of the various media for amebe depend upon the same principle, namely the reduction of the nutrient material to such a minimum that only a scanty development of bacteria can take place. Thus, there are the dilute liquid media such as the hay and straw infusions; the solid medium of Beyer inck(4) is prepared with agar which has been repeat- edly extracted with water; the alkaline agar of Musgrave and Clegg (5) contains 0.03 to 0.05 per cent of beef extract and no peptone. An agar based upon the last formula was used for maintaining the stock cultures of amebzx. The principal difference consisted in the reactions of the media, the final product when ready for inoculation being neutral to phenolphthalein. The following formula was used: Agar-agar 2.5 per cent, Liebig’s beef extract 0.05 per cent, normal sodium hydroxide 2 per cent. This medium, without clarification, was sterilized at 7 kilograms pressure per square centimeter for three-fourths of an hour. After sterilization it was found that the reaction of the medium was neutral to phenolphthalein, the alkali presumably having combined with the organic material in the agar. Furthermore, under these conditions of temperature and duration of heating, the quantity of alkali which was sufficient to render the medium permanently alkaline was slightly in excess of the amount which was sufficient to prevent the agar from solidifying at room temperature. Nevertheless, although the reaction of the medium was ultimately neutral, to phenolphthalein the addition of the excess of alkali gave a better medium for the cultivation of amebe than was afforded by the use of agar which was just neutral or slightly alkaline before sterilization. On agar media of the ordinary composition with an acid reaction such as are used for bacteria, no growth of amebe could be obtained, although some investi- gators have used such a medium successfully.(6) Under certain conditions, when it was desired to obtain amceba-free cultures of bacteria which were associated with amebe, ordinary agar was used, the first transplantations being free from ameebee. With the development of the methods for the cultivation of amebe, solid agar media have largely replaced the liquid media which were used by the earlier workers. Although straw infusions and similar fluids have been used in ob- taining amebe for study, their isolation and propagation has been carried out chiefly on solid media. It has even been stated that, with many amebz, direct IMMUNITY REACTIONS WITH AM@BA. 285 inoculation from solid to liquid media is difficult or impossible.(5) However it was found that some of the ordinary liquid media were very suitable for the cultivation of amcebe, provided that these media were first diluted to such an extent that the growth of bacteria was considerably restricted. Thus, amebe grew well in a solution of 1 part of peptone in 1000 parts of water and fair growth occurred in ordinary nutrient bouillon when diluted to 1. part in 100, although no growth of amebe took plac2 in a 0.5 per cent solution of peptone, or in bouillon of the ordinary strength. There was a fairly wide range. in the concentrations of peptone which were found suitable, abundant growth taking place in dilutions varying from | part in 1,000 to 1 in 5,000. The amebz could be transferred backward and forward from the solid to the liquid media, a good growth being obtained on the first inoculation, in the same manner 4s with bacteria. Occasionally, after cultivating a species of amceba for several months on the medium containing agar and beef extract, the composition was altered slightly for one or two generations by the substitutions of 0.1 per cent peptone and 0.05 per cent lactose for the beef extract. Sometimes, when the growth on agar became less abundant, a few transplantations were made in liquid media, using either diluted normal rabbit serum or a solution containing 1 gram of peptone and 0.5 gram of lactose in 1,000 cubic centimeters of water. As a general rule, the most aboundant growths of amebe were obtained at incubator temperature (35° C.). j : ‘One well marked exception was found to the apparent necessity of a highly diluted medium for the growth of amebe. All of the four cultures of amebx grew well in normal serum not only when it was highly diluted but also in the lower dilutions. Thus, excellent growth took place not only in dilutions of 1 to 500, but also in 1 to 2, and in 1 to 5. This ability to develop in normal serum was utilized later in testing for the production of immune sera. Technique for immunization.—The cultures of amcebe on agar slants were used for the inoculation of animals. Living organisms were in- jected in the ameeboid condition, emulsions being prepared in water from 24-hour cultures. The amcebe which were used for injection, were always grown with B. prodigiosus. No attempt was made to reduce the quantity of bacteria in the mixed emulsion of amcebx and bacteria, but when care was taken to insure favorable conditions for a vigorous growth of ameeb, the latter always predominated to a considerable extent over the bacteria. . Rabbits were used for immunization. The first two injections and sometimes the third were made intravenously and the remaining ones — intraperitoneally. The injections were made at intervals of ten days to one month according to the condition of the rabbits, and the maximum period of treatment for any one animal was thirteen months. For rabbits weighing about 1.5 kilograms, one-half to one agar slant of the ordinary size, (measuring about 1.5 by 8 centimeters) upon intravenous injection was usually fatal within 12 to 18 hours. Under the same conditions, 2 slants were usually fatal upon intra-peritoneal injection. Several rabbits were used for each of the 4 cultures and varying quantities. of material 286 SELLARDS. were injected. As a rule one-eight to one-fourth of an agar slant was used for the first injection and this was gradually increased to 6 or 8 slants. Perhaps the best result was obtained in a rabbit which at the first injection survived 1 agar slant given intravenously. Pronounced symptoms occurred ; within 6 hours the rabbit became semi-comatose, the temperature rose from 39°.5 C. to 40°.1 C. and the respiratory and heart rate were too rapid to count. This rabbit received subsequent in- jections of amcebe without loss of weight, or other symptoms and was eventually able to withstand 20 agar slants intraperitoneally at a single injection. Five other rabbits receiving a similar injection died within 15 hours. The preceding technique has been observed as a routine, but other ani- mals and other methods were also tested. ‘Thus one series of guinea pigs was injected with cultures killed by heating to 50° C. for fifteen minutes. Whereas guinea pigs, upon intra-peritoneal injection, were able to survive only a small oese of living amcebe as much as 1 agar slant of a killed culture could generally be used for the first injection and as many as 4 or 6 slants could be used in rabbits; however, the formation of immune bodies was not active and the subsequent injection of living amcebe was not borne very much better than when the first injections were made with smaller quantities of the unheated material. In one rabbit, the organisms were injected only in the encysted stage, viable cysts being given intravenously for the first two injections and the remaining injections being made intraperitoneally. This rabbit was used only in testing for agglutinins. In as much as antibodies form readily upon the injection of vegetable cells, of animal tissues, and of unorganized protein matter, and since they occur in natural infections with protozoa, it would be expected, a priori, that amcebee would also act as antigen. No attempt was made to investi- gate all of the immunity reactions which might be produced with amebe, but rather I have sought to obtain a reaction which would be suitable for distinguishing cultures from various sources. Accordingly, preliminary tests were carried out with only one of the cultures of amcebe (Race A). Of the commoner biological reactions those for agglutinins, precipitins, cytolysins, and anaphylaxis have been considered. Agglutination.—Agglutination tests were carried out on both the active and the encysted stages of amcebe with serum obtained, first, from guinea pigs and rabbits injected with the motile amcebe and second from a rabbit injected with encysted forms. In the amceboid stage, some difficulty was encountered in securing a uniform suspension of the organ- isms in the control preparations. The immune sera from rabbits and guinea pigs were tested in varying dilutions up to 1 in 1,000. In hanging drops, irregular clumping sometimes occurred in portions of the prep- IMMUNITY REACTIONS WITH AMG@BA. 287 aration, but differences from the control were neither constant nor well defined. In the encysted stage, uniform emulsions for agglutination were readily obtained. The serum from a rabbit which had been treated with cysts for 3 months proved to be entirely inactive. Also, the serum from rabbits treated with organisms in the amceboid stage showed no agglu- tinative action toward the encysted stage.* Precipitins.—Examination for precipitins was somewhat complicated, partly because of the difficulty of securing a suitable extract of amcebe and also on account of the controls rendered necessary by the possibility of the presence of bacterial precipitins. An extract of amcebe grown with B. prodigiosus was prepared by emul- sifying the growth from 24-hour agar slants in the water of condensation and grinding this emulsion with sand. The fluid was collected by centri- fugalization and clarified by filtration. A clear filtrate was obtained most readily by the use of a Berkefeld filter, but the precipitation re- actions were more satisfactory when the extract was filtered through mag- _ nesium oxide. Serum from a rabbit which had been under treatment for five months gave a well marked precipitation in 1 to 2 and 1 to 5 dilution with the undiluted extract from the mixture of amcebe and B. prodigiosus. However, this same extract also gave a precipitate with the serum from a rabbit treated with B. prodigiosus alone. In order to control the effect of bacterial precipitins, an extract of amcebe growing with V. cholere was tested against the serums of a rabbit immunized to amcebe growing with B. prodigiosus. Only a poorly defined precipitate was obtained in 1 to 2 dilution of serum from animals which had been under treatment for from two to five months. These preliminary results, therefore, did not indicate that precipitin tests would afford a very suit- able reaction for the study of amcebe, both on account of the technical difficulties and also because of the indefinite reactions which were obtained. Anaphylaxis—The usual test for anaphylaxis with death of the animal requires rather more material than conveniently can be obtained from cultures of amcebe. However, the intradermal reaction as devised by Knox Moss and Brown,(8) would be especially serviceable for work with ameebe. Rabbits and guinea pigs were tested within two to four weeks after the first injection and also at later periods after treatment had been continued for from 1 to 6 months. The injections were made intradermally with amcebe growing with B. prodigiosus. Two prepara- tions of amcebze were used. One consisted of an extract, filtered through magnesium oxide in the same manner as for the precipitin test. The other * However, successful agglutination of amebze by a non-specific serum, has been reported by Zaubitzer(7) who found that the serum of an animal when immun- ized to V. cholera, agglutinated ameebe growing with V. cholere. 288 SELLARDS. . was merely an emulsion of a 24-hour culture in physiologic salt solution. Nowell defined differences were obtained between the injections in normal animais and those injected with amcebe and B. prodigiosus.. The bleb produced by the injection was usually absorbed within the course of an hour. After 12 to 18 hours some cedema and reddening appeared at the site of injection. This was distinctly more marked in the cases where an unfiltered extract of amcebe was used, suppuration eventually resulting in some: instances. The differences between the normal animals and: the treated ones were slight and inconstant. However, the general tendency of such differences as were noted, was not in the direction of a greater reaction in the treated animals, but on the contrary these animals some- times showed signs of less inflammation at the site of injection: than the controls. The differences, however, were altogether inadequate for any satisfactory test and attention was next given to cytolysins. . e -Cytolysins—Tests for the cytolytic action of the sera were carried out microscopically. Ordinary hanging-drop preparations were made from equal parts of a suspension of amcebe and immune serum. The | suspension of amcebee was prepared in the water of condensation from the agar culture media, in preference to normal physiologic salt solution, sinee the latter is hypertonic for amcebe. A certain amount of. salt could. be used to advantage, perhaps, imitating the conditions which occur in surface waters, the natural habitat of some of these amcebe, but in attempting to determine the most desirable amount of salt it was found that the amcebe when transferred from agar to distilled water showed no defihite morphologic change and remained in the ameeboid stage for at least. several days. The serum dilutions also were prepared: with water, and not with salt solution. In’ testing for cytolysins, control SHeaeione > were made with normal serum, with physiologic salt solution, and-with distilled water. Slight changes were noticeable immediately after preparing the mixtures.. Some of the amcebe lost: their motility and assumed a spherical form, both in the:preparations with immune serum and also to a lesser extent in those with: normal serum and with physiologic salt solution, while in those with distilled water, no change was observed. With immune serum of a high grade cylotysis of the amcehz could be observed microscopically and in the course of one to two hours there was a well marked diminution in the number present in the hanging drop. Sera which were sufficiently active to cause immediate cytolysis were obtained only with some difficulty and after a comparatively long period of immunization. Furthermore, none of the preparations showed complete cytolysis of all of the ameebe, present, the differences between the normal and immune serum in this IMMUNITY REACTIONS WITH AMG@BA. 289 respect being only relative and not absolute. However, after 24 hours at 35° CO. a definite result was readily obtained, notwithstanding the fact that rabbit serum in 1 to 2 dilution furnishes a good culture medium in which a few surviving amcbe might develop. In the mixtures with distilled water and normal serum the amcebe remained actively motile without any encystment before the second or third day and without any significant change in numbers. No increase in number was to be expected since the concentrations of the amcebe in the suspension was usually greater than that which occurs in liquid culture media. In the test pre- parations with serum from treated animals the reaction was usually very definite. Hither there were many motile amcebe present just as with normal serum, or else there was almost a complete lysis of the amcbe with only a few cysts and an occasional motile organism present. Occasionally, in the preparations with immune serum, many of the amocebze took on a pink color. This was due apparently to the presence of granules of B. prodigiosus, although-no color was visible in the sus- pension of bacteria surrounding the ameebe. The reaction in this, form was then adopted for testing the behavior of the 4 races of amebe. The suspension of amcebe was always prepared in the water of condensation, from an actively growing 24-hour culture in the ameeboid stage. Equal parts of this suspension and the serum to be tested were mixed with a capillary pipitte according to Wright’s technique and a hanging drop preparation was made from a portion of the mixture. In order to obtain constant and well defined reactions, it is necessary that the amcebe in the culture should be abundant and should predominate over the bacteria present. The data which follow represent the conditions of the preparations after standing for eighteen to twenty-four hours at 35° C. The concentrations of serum are ex- pressed in the final concentration after dilution with the suspension of amcebe, for example, 1 part of undiluted serum and 1 part of the sus- pension is recorded as a 1 to 2 dilution of the serum. On account of the presence of bacteria throughout the entire procedure _ there are several interpretations which might be considered with regard to the cause of the destruction of the amcebe by the immune sera. Three general methods were used for detecting the effect of the bacteria. The serum of rabbits immunized to amcebe in mixed culture with B. prodigio- sus was tested against a culture of amcebe growing with B. prodigiosus and with V. cholere. Also, the serum of a rabbit immunized to B. pro- digiosus alone was tested against a culture of ameebe growing with B. prodigiosus. ‘These controls were carried out with the culture designated -A and the results of the first and second methods appear in Table TI. 290 SELLARDS. TaBLeE 1.—Production of cytolysins by injection of amebe in mixed culture with B. prodigiosus. Agglutination of B. prodigiosus— Lysis Of Sar cultivabon i ; im mised < n pure culture | culture wit B. prodigiosus V. cholerz at Sez eb ra at dilution of— | amebeat |atdilutionof—| dilution of— dilution of— Experi- |Experi-| Experi-|Experi-|Experi-|Experi-|Experi-| Experi- ment ment | ment | ment | ment | ment | ment | ment I. II. ite II. I. II. I. None. | None. | None. | None. BUpnOALGIOSUS aaa eee 1-50 - 1- =! prodigiosu. 1-100 50 1-50 { ic 1-2 12 12 Amebez and B. prodigiosus — 1-5 1-5 1-10 1-5 1-5 1-10 1-5 1-5 Control, normal rabbit Neen? None. | None. | None. | None. | None. | None. | None. seram (222 fe ee ee 1-2 1-2 1-2; 1-2 1-2 1-2 1-2; 1-2 From these data it appears that the lysis of the amcebe was due to the immune bodies formed in response to the injection of the amcebe, and not to the accompanying bacteria, since the amcebe growing with cholera were acted upon by the serum produced by the injection of amcebe and B. prodigiosus, whereas the serum produced by the injection of B. prodigvosus alone was inactive for amebe. In the comparison of the different races of amcebze it will be seen that there is some additional evidence in support of the preceding conclusions. The activity of the serum is of extremely low grade even for protozoan material. The highest serum which was obtained at any time was that from a rabbit which had survived on the first injection 1 agar slant of amcebe. The same dose was fatal for 5 other rabbits. Five months after the first injection, when the rabbit was able to withstand 4 agar plants intraperitoneally at one injection, the serum was found to be active in 1 to 50 dilution. This degree of activity persisted for only 2 days and then fell to 1 to 10; subsequent injections failed to increase it. Apparently, the repeated injections of amcebe instead of producing highly active sera only caused the low grade of activity to persist over longer periods. In considering the degree of activity which was obtained. it is to be noted that the amounts of material injected were rather lower than are ordinarily used in working with animal cells, such as red blood corpuscles. The quantities used were probably not as great as are usually employed for many of the ordinary bacteria such as V. cholere or B. typhosus. Two factors were concerned in producing this limitation, namely the relatively small quantity of amcebe which can be obtained from the growth on agar and the inability of animals to withstand the injections, emaciation and death resulting from an over dosage. IMMUNITY REACTIONS WITH AMGBA, 291 Character of the immune bodies——A few tests were made to determine whether the destruction of the amcebe was accomplished by the combined action of amboceptor and complement in a manner analogous to the action of hemolysins and bacteriolysins. The effect of heating is shown by the results in Table II]. The serum of a rabbit immunized to ameebe (race A) and B. prodigiosus was tested against the same mixture of amoebee and bacteria. One part of serum was diluted with 1.5 parts of water for the purpose of heating at 70° and 78°. TaBLE II.—Showing effect of heat on immune serum. —— 1 Temperature and duration of heating. Lysis produced D oem “i EPS onl Unheated by heated immune |. mune immune serum, Sauer 60°, one- 60°, 1 60°, 3 70°, one- | 78°, one- serum. z * | half hour. hour. hours. | half hour.| half hour. With complemeat added: Normal rabbit serum— 1-2 Active. ACHIVE Sl ee XC ULV Cee sant ee eee. eae Te 1 to 10 __--_- 1-5 Active. | Active. Active. Active. VACHiVie ase ee ee 1-10 | None. None. None. None. Sligh tis |e ee TF os ee aes 1-5 Active. Active. Active. Active. AICTLVCs | eee ee 1-10 | None. None. Slight. None. Slight, |-22-20 4 222 | 1-2 Active. Active. ACUIVG Geese esa eee Ree Active. 1-2 Active. Active. PNG OIDSOS Sat sea peiae |(E A N e ee Without comple- 5 ‘ 3 s ‘ - Sook 1-5 Active. Active. Active. Active. Active. Active. 1-10 | None. None. Slight. Slight. Slight. Slight. This activity of the serum after exposure to relatively high degrees of tem- perature seems at first a little unexpected. However, related phenomena have been observed with other protozoa and even with bacteria. Thus Réssle (9) found that an immune serum produced by the injection of paramecia was not inactivated after exposure for 30 minutes to a temperature of 70° C. However Réssle does not describe this serum as a true cytolysin and, furthermore, it was thermostable only when the injections were made with killed and not with living paramecia. Laveran and Mesnil (10) found that an immune serum for trypa- nosomata was only partially inactivated after exposure to a temperature of 64° C for one-half to three-fourths of an hour. Later, Hamilton(11) reported a thermostabile bacteriolysin for an organism designated as the “Ruediger bacillus.” However, these results with amcebe do not prove that the immune body is thermostable, unless normal heated serum also shows no activity. Accordingly, the effect of heat was tested both on normal serum and on the serum of a rabbit which had been immunized. This rabbit had formerly shown some immunity, its serum being active in 1 to 5 dilution. At the time of this test no injections of amcebe had been given for 2 months and as seen in Table III, the unheated serum was inactive, 1049123 292 i : _ SELLARDS. TABLE II1.—Lysis of amebe by heated sera. Serum Control, Dilution. oenera normal’ } rabpit. .- amecebe. |. 1-2| None. None. Control, unheated ‘1-5 | None. None. 1-10} None. None.’ Serum heated for one hour at— 1-2 | - Active.) Active. 60° Cle. 25 sas a eS ee eee 1-5 | None. None. ( 1-10 None. «‘)' None. 70°C { 1-5 Active. | None. | 1-10} None. None. | we ot ole ae This result shows definite activity of the normal serum when heated at 60° and of the immune serum at 60°, 70°, and 78° C.. An additional test was carried out to determine whether this: apparent | difference between the normal and immune sera at higher temperatures is a specific property of anti-amceba sera or whether it is.common to other immune sera: ' The sera of a rabbit immune to V. cholere was used and a second rabbit formerly immune to amcebe also tested in addition to the one used in the pees e[vesieie The results are een in Table EVs s ne ; aes IV .—Lysis a ameabe by: heated sera.! Serum formerly im- | .. Controls, normal mune to amcebe. jSerum im- “rabbit sera. Dilution.|. mune to; |i Swe Ts Ware : V. cholerz. ae e ; A. B. > : 7 Nea BL 1-2 | None. None. None. None. ‘None, Control, unheated_____:-__-__ ie 1-5| None. None. None. None. | None.: : eere : 1-10} -None. | | None. None. None: || None. Serum heated for one hour at— melee eae! j : ] 1-2 Active. | None. Active. | Active. | Active. G00 Os teens eae. ed 1-5 | None. | None. ‘| None. None. None,’ 1-10 None. None. None. None. None. 70° c { 1-5 Active. Active, None. | None, +}, None. Raman) Ghee ome 1-10 None. | None. None. None. None. ToC { 1-5 | Active. | Active.} None...|.’None.+| None. ee > | : 1-10 | None. None. None. None. None.. ‘*The word lysis has been retained in speaking of the action of the serum on the amcebe although the process, at least in the case of the heated normal serum, differs from that of the ordinary specific lysins. With an immune serum some solution takes place within the first few hours and although a period of eighteen "or twenty-four hours may be required to complete the process, yet it is accom- plished by a direct action on the amebe and it is not a secondary effect of the action of the antibacterial serum on the accompanying bacteria. Apparently the IMMUNITY REACTIONS WITH AM@BA. 293 ‘In: one instance in Table LV it will be noted that lysis of the amcebe failed to occur in.the 1 to 2 dilution of serum heated at 60° C. An emulsion was’ used which was unusually rich in amcebe and, although the differences were well marked after'the preparations had stood for 18 hours, yet the amcebe did notientirely: disappear: until after 24 hours. These results might be taken as indicating that exposure to a temperature of 60° C. for one hour represents about the minimum time which would be effective in producing this change in the serum. Perhaps a more mo- derate heating might have inactivated the immune serum without pro- ducing this change which renders normal serum active. Although it is definitely shown that the immune serum is active after heating yet the controls with normal serum show that it does not necessarily follow that the immune bodies are thermostable or that they do not consist. of amboceptor and complement, ‘No attempt was made to work out the mechanism of this action of the heated normal serum. It is possible, of course, that it does not act directly upon the amcebe, but affects them secondarily through a primary action on the bacteria; for example, the bacterial products formed in heated serum may be different from those in unheated serum. Apriort, however, the simplest explanation is that of a ‘direct action upon the amcebe. There is one instance in which heated normal serum can be shown to have a definite action on animal cells: This "phenomenon, which may be somewhat analogous to the reaction with amebe, can be demonstrated with red blood corpuscles® when heated normal serum develops the property of causing marked rouleaux formation of red corpus- cles suspended in salt solution.. The degree of heating which is required and the activity of the serum correspond rather closely to the conditions pertaining to amebe; thus, serum after exposure to 60° C. for 1 hour fs effective in producing rouleaux in a final dilution: of 1 ‘to 4, but not in 1 to 6; normal serum after the same treatment is active toward amcebe in 1 to 2 but not in 1 to 5 dilution. It may be noted that this action of heated sera in causing rouleaux formation is apparently only an increase of a normal characteristic of unheated sera. Simi- larly, it can be shown that although amebe grow well in a‘l to 2 dilution of normal rabbit serum, yet they are destroyed in undiluted norma] serum, or in a 1 to 2 dilution of heated normal serum. BIOLOGIC RELATIONSHIP BETWEEN THE DIFFERENT CULTURES OF AM@BZ. The serum reactions with the 2 cultures of amcebe obtained from saprophytic sources were compared with 2 cultures obtained from the intestinal tract to determine their indentity or non-indentity as tested by biologic methods. Rabbits were immunized in a similar manner to term 'lysin is seldom applied to immunity reactions with protozoa. | Réssle(8) observed that instead of lytic properties, cytotoxic sera often possess a paralyzing -action; the examples cited are the spermelonte sera, and the anti-sera against z epithelium and against paramecia. : > Bull. Johns Hopkins Hosp. (1908), 19, on1. 294 SELLARDS. the 4 races of amcebe, all of which were growing in conjunction with B. prodigiosus. Complete tests for the comparison of the 4 races of amcebe were carried out simultaneously, using sera of a low grade but sufficiently active to give well-defined results. The data for these tests are shown in Tables V and VI. TABLE V.—Biological relationship of the various cultures of amebe. [First determination.] Serum. Lysis of amoebae. i Immune to— Dilution.| Race A. | Race B. | Race C. | Race D. Race: 1-2| Active. | None. None. Slight. AM cocoa nenesecsese ctes 1-5 | Active. | None. None. None. 1-10} Active. None. None. None. 1-2} None. Active. None. None. 18} cen neces eae eoaes 1-5 | None. Active. | None. None. 1-10 None. Slight. None. None. | 1-2 None. None. Active. None. © seeccoscssesseccesece | 1-5] None. None. Active. | None. | 1-10} None. None. ‘Active. | None. 1-2] None. None. None. Active. WD) oan nema en ences | 1-5| None. None. None. None. | 1-10 | None. None. None. None. | -2 None. None. None. None. Normal rabbit serum _____ 1-5/ None. None. None. None. 1-10 None. None. None. None. Control] with water ______|-_________ None. None. None. None. eee SS TaBLe VI.—Buiological relationship of the various cultures of amebe. [Second determination.] Serum. Lysis of amcebee. Immune to— Dilution.| Race A. | Race B. | Race C. Race D. Race: “ 1-2| Active. None. None. None. Rac te ter ee Rae, { 1-5 | Active. | None. None. None. B if 1-2 None. Active. None None. Be Code Re aT i 1-5 | None. None. None. None. c { 1-2 None. None. Active. None. a aS eo 2 Te. 1-5 | None. None. Active. | None. D { 1-2 None. None. None. Active. PSS SORE MCR RR 1-5 | None. None. None. Slight. 1-2 Normal rabbit serum_____ { 1-5 } None. None. None. None. Control with water___----|---_----_- None. None, None. None. It is clear from these tables that the 4 races of amcebe are, biologically at least, distinct species, since the sera produced by them show a definite specificity. _ Here again it seems a little unusual that the first four races IMMUNITY REACTIONS WITH AM@B:. 295 selected should have reacted in absolutely different manners, not even group reactions being present. In Table V, the serum of race A ap- parently showed some activity against race D. Here it was thought that perhaps only a relative difference existed between the activity of serum A for amcebe A and D, but subsequent tests did not confirm this view. In Table VI the difference is absolute and this result was confirmed by two subsequent tests. This behavior of the sera corresponds with the results obtained by Réssle(9) who found that the sera produced by parameecia are also specific. The specificity of the sera for the corresponding cultures affords addi- tional evidence that the injections of the amcebe were responsible for the activity of the sera, since it was possible for the amcebee to vary in each culture, but the bacterial species, B. prodigiosus, was common to all. If any activity of ‘the antibacterial serum against the B. prodigiesus, in the symbiotic culture of amcebe and bacteria could have affected the growth of the amcebe, then this effect should have shown itself in all four cultures. A note on the morphology of these cultures is of interest in view of the biologic differences which were found. Dr. E. L. Walker of the biological laboratory, Bureau of Science, has very kindly examined these cultures and describes them as being readily distinguishable from each other on a morphologic basis, however all correspond to the limaz type. REACTIONS WITH SERA FROM DYSENTERIO PATIENTS. The interpretation of these biologic differences requires some caution. Many possibilities present themselves in view of the failure of these amcebz to fall into groups according to the source from which they were obtained. Thus any of these amcebe may be pathogenic or any may be harmless. In the case of the cultures obtained from dysenteric feces, it is ‘possible that the pathogenic species may fail to grow on artificial media and the organism which does develop may be merely an accompanying saprozoite. Accordingly, in an attempt to determine whether these amcebe bear any etiologic relationship to amcebic dysentery, these four races were tested against the sera of amcebic dysentery patients. In considering the possibility of the formation of immune bodies during the course of the disease it is of some interest to note whether there is any indication of the absorption of toxic products from the intestine which might serve as antigen. In the first place, it is note-worthy that there is some op- portunity for such absorption since the amcebx penetrate deeply, in large numbers, into the submocosa of the intestine. Second, changes in the formed elements of the blood are known to occur, a leucocytosis sometimes being present involving not only the polymorphonuclear neutrophiles but in some instances the mononuclear neutrophiles and the eosinophiles as well. Also, in severe infection some fever is often present. Perhaps the most favorable cases for the absorption of antigen and the production 296 _. SELLARDS. .° of immune bodies. would be those in which infection of the liver with abscess formation has occurred. However, one would not expect to find: very active sera in view of the low grade of immunity in protozoan infections generally and because of the comparatively shght response of animals to the injections of amcebe. Samples of sera were taken in the stage of active dysentery, during convalescence, and after recovery, the majority of cases having been treated with ipecac. The diagnosis of the cases was based upon the presence of a dysentery resembling the usual course of the amcebic type together with the finding of amcebz miscroseopically in the stools. No cases were avail- able in which spontaneous recovery took place, although some had ex- perienced repeated relapses alternating with periods of several months in which no symptoms were present. The sera from these cases were tested against the 4 races of amcebe. As a routine, the serum was used in dilutions of 1 to 2, 1 to 5, 1 to 10, 1 to 20, 1 to 50, and 1 to 100, the final readings being made after 18 to 24 hours. In the first case which was tested, the sample of serum was taken 4 days. after the subsidence of an acute attack of dysentery. A definite reaction took place at 1 to 2 dilution with Race A, the amebe obtained from the city water supply. The preparations in the other dilutions and with all of the other amcebe behaved like the controls prepared with normal serum. In a repetition of this test 4 days later, - no reaction was obtained in any dilution with any of the 4 races of amoebee. The second patient who was examined had exhibited symptoms of chronic dysentery for many months. The serum from this case re- acted only in 1 to 2 dilution with Race B, the amcebe cultivated from the stcols of a dysenteric patient. All of the other preparations showed no lysis. There was no opportunity for confirming this result. The remaining cases that were examined consisted of 5 acute cases, 8 chronic ones, and 3 with liver abscess. The acute cases were examined while the symptoms were active and also within two to four weeks after recovery. None of these reacted with any of the races of amcebe that were tested. The 8 chronic cases were examined during a period of relapse and 5 of these were also tested at a later period when they were free from symp- toms. - All, however, reacted like the normal control sera, the amcebe remaining numerous and active in the 1 to 2 preparations and in all of the higher dilutions. Of the 3 cases of amcebic abscess of the liver, one was tested 4 days before exitus and the other two were tested at operation and after recovery. The sera of these cases produced no lysis with any of the cultures of ameebz, and these cultures failed to agglutinate with the sera from the human cases. . From the behavior of these tests, it seems prabable that the enclose obtained in the first 2 cases were merely accidental. The reaction re- sulted in one case with amcebx secured from a well-protected river-water; IMMUNITY REACTIONS WITH AM@BA, 297 and in the other with amcebe cultivated from a dysenteric stool. In both instances, the tests were carried out at a time when the cultures were growing. only moderately well.. Both reactions were obtained in 1 to 2 dilution and it is not unlikely that the absence of amcebe is to be ac- counted for by the excessive growth of bacteria. In as much as these tests failed to show any evidence of immunity, it seemed desirable to carry out some of the reactions with amcebe known to be pathogenic, and to this end an attempt was made to utilize dysenteric stools in which the amcebe were very numerous. The serum reaction as used with cultures of amcebe, requires some modification in applying it to'a dysenteric stool, since the amcebe disintegrate within a few hours in the stool itself, or in any ordinary culture medium. Accordingly, mix- tures of stools containing numerous amcebe and the sera from dysenteric . patients were made in the same manner as for cultures. of. amcebe to determine. whether any changes would take place within a few hours, be- fore the control preparations deteriorated. Two patients were selected in which the stools consisted largely of blood and mucus, practically free from feecal matter and in which the amoeba: were numerous in every field. Equal parts of these stools were mixed, first with the undiluted sera from the corresponding patients; second, with the serum from a case with acute symptoms of dysentery ; and third, with serum from a patient who about three weeks previously had recovered from an acute attack of dysentery. Control preparations were made from normal serum. The amcebx remained alive and active for a period of 2 hours. At the end of 3 hours the motility was much diminished in all preparations and the amcebe were disintegrating in the preparations with the sera of dysenteric cases and in the control prep- arations as well. Further work upon the aetiology and diagnosis of amcebic dysentery by immunity reactions did not appear to be feasible on account of the lack of cultures known to be pathogenic. SUMMARY. The injection of cultures of amcebe into rabbits resulted in the pro- duction of serum which was cytolytic for amcebe. This serum possessed only a low grade of activity. No inactivation resulted after exposure to a temperature of 60° C. for periods varying from thirty minutes to three hours or 70° C. for thirty minutes. How- ever, the anti-bodies of the serum were not proved to be thermo-stable, since normal serum became active when heated for one hour at 60° C. Of the sera produced by 4 cultures of amcebe obtained from parasitic and from saprophytic sources each serum was cytolytic for the correspond- ing culture, but not for the other three. This specificity indicates that these amcebe are biologically distinct. Subsequent examination showed 298 SELLARDS. that these amcebe are also distinguishable from each other upon a mor- phologic basis. Examination of the sera of amoebic dysentery patients failed to de- monstrate any production of immune bodies for amcebze during the course of the disease. However, the method which was employed was not satis- factory when applied directly to amcebe occurring in bloody mucus stools. Consequently, the results do not represent any reaction upon ameebze which are known to be pathogenic. Tests upon cultures of amcebe did not give any definite evidence of the presence of either cytolisins or agglutinins in the patient’s serum. Unfortunately these results do not lead to any definite conclusion but merely indicate that either immune bodies were not produced or that the cultures under consideration do not bear any etiologic relationship to amcebic dysentery. Certainly there is no evidence of pathogenicity ; however, on the other hand, there is nothing but negative evidence in- dicating their harmlessness. REFERENCES. — (1) BARBER. Unw. Kansas Set. Bull. (1907), 4, 3 and Journ. Infect. Dis. (1908), 5, 379. (2) Wittt1ams. Proc. Soc. Hap. Biol. Med. (1911), 8, 56. (3) Mouton. Ann. Inst. Pasteur (1902), 16, 457. (4) Bryrerinck. Centralbl. f. Bakt. etc. Orig. (1896), 19, 257. (5) Muserave and Crece. Bur. Gov. Labs. Manila (1904), No. 18. (6) WritttamMs and Guriry. Collected Studies, Research Lab. Dept. Health, City of New York, (1908-9), 4, 237. 7) ZAusprrzER. Arch. f. Hyg. (1901), 40, 103. 8) Knox, Moss, and Brown. Journ. Hap. Med, (1910), 12, 562. 9) R6sstx. Arch. f. Hyg. (1905), 54, 1. 0) LAvERAN and Mrsniz. Ann. Inst. Pasteur (1901), 15, 673. 1) Hamirton. Journ. Inf. Dis. (1908), 5, 570. TYPHOID FEVER IN THE PHILIPPINE ISLANDS. By Weston P. CHAMBERLAIN." (From the United States Army Board for the Study of Tropical Disease as they Exist in the Philippine Islands.) Part J. PREVALENCE AND DISTRIBUTION OF TYPHOID FEVER IN THE PHILIPPINES. Part II. LABoratory INVESTIGATIONS OF TYPHOID FEVER IN THE PHILIPPINES. Part III. Crinican ASPECTS oF TypHOID FEVER IN THE PHILIPPINES. Part IV. A Stupy oF REcENtT TYPHOID EPIDEMICS IN THE PHILIPPINES. Part V. CONCLUSIONS. PART I. PREVALENCE AND DISTRIBUTION OF TYPHOID FEVER IN THE PHILIPPINES. INTRODUCTION. From December 1, 1908, to date of this writing (April 30, 1911) the Board for the Study of Tropical Diseases has been making for the Philippines Division the routine blood cultures and Widal examina- tions on the military patients suspected of having typhoid fever and, also, making for convalescents the cultural examinations of the stools and urine which are required before a soldier who has had typhoid is allowed to return to duty. For nearly all cases in which we obtained positive laboratory findings a clinical history has been furnished to the Board. From this laboratory and clinical material we have been able to learn much of interest as regards typhoid in the Philippine Islands. The greater part of our material for blood culture comes from a considerable distance, the time consumed en route varying from a day to several weeks. The same applies to the stool and urine specimens, and, furthermore, these excretions are not sent for diagnostic purposes but only to determine that the convalescent is not a bacillus carrier. Therefore, the cultural examinations in a large proportion of our cases are negative. It follows that for diagnostic purposes we must depend mainly on the serum reaction. Recently antityphoid *Major, Medical Corps, United States Army, president of the United States Army Board for the Study of Tropical Diseases as they Exist in the Philippine Islands. 299 300 CHAMBERLAIN. vaccination has been coming into quite general use among the American troops. As is well known, a typhoid vaccination will cause a positive Widal reaction, and of late it has been becoming obvious to us that the more general use of - antityphoid vaccination would largely vitiate any dedifctions in the future which could be drawn from positive Widal reactions in fevers of doubtful nature. For this reason we have decided to compile the results of our work to date, the possibility of typhoid vaccination having been excluded in all of the cases referred to below. riiseeh While several articles from the pens of different authors have appeared on certain typhoid epidemics in the Philippines, (11) (12) (15) nothing, so far as we are aware, has been written which gives a comprehensive view of the typhoid situation throughout the Archipelago. Therefore, we feel that such a report. can not fail to be of value to those interested in the sanitary problems of the Philippines. TYPHOID IN THE TROPICS. _ Typhoid fever, although not classed as a tropical disease, nevertheless is one which is of great interest and importance to those practicing in warm ‘countries where it should always be born in mind when the physician is confronted by a patient with any febrile disturbance. Manson says: “The existence of typhoid fever in the tropics was for long not only ignored but actually denied, even by physicians and pathologists of repute.”(1) Malaria has been the scapegoat for the diagnostic shortcomings of the tropical practitioner. At the present day it is quite gencrally conceded that typhoid is a common disease among white men resident in low latitudes and that it is alarmingly prevalent among young NWuropeans in many parts of the tropical Orient. Caste- llani(2) and Rogers(3) agree with Manson in this opinion. Rogers found that among Europeans born and bred in the Tropics the incidence of the disease was especially marked in children under 15 years of age. As regards the occurrence of enteric fever among natives of warm countries less: is known. Castellani (2) states that it is common. He says: “In most eases the temperature does not run the typical course described in text books on general medicine, having sometimes a high remittent type, and at others an intermittent type, while cases of mixed infection with malaria are not rare.” Rogers (3) found typhoid to be common among natives in India and believes it would be more frequently observed were it not that adult natives have acquired an immunity as a result of an attack in childhood. The sick native children are not often seen by competent attendants. . REPUTED OCCURRENCE OF TYPHOID FEVER IN THE PHILIPPINES. In the early days of the American occupation of the Philippines it was the commonly accepted view that the occurrence of typhoid in these Islands was unusual.(10) That this opinion still has adherents is shown by the statements published in 1910 by Dr. Victor G. Heiser, Director of Health of the Philippine Islands. He says: “While cases TYPHOID FEVER IN THE PHILIPPINES. 301 of typhoid fever are undoubtedly contracted in the Philippines the disease can hardly be‘said to be prevalent here. To prevent its acquiring a foothold regulations were prepared * * *.77(9) For a number of years, especially since more settled conditions have allowed general resort to laboratory methods, the belief has been growing among medical officers of the army that typhoid fever is by no means infrequent in the Archipelago. It is our opinion that the disease is wide spread and very common in the Philippine Islands among’ both white men and natives. Nichols in 1908 called attention to the frequent occurrence of typhoid fever among the Filipinos in the Visayas especially among the children.(11) Bruns, about the same time, stated that in his opinion typhoid was endemic in Iloilo. (12) Nichols also found typhoid fever among the natives at Taytay, a typical Tagalog town located about 32 kilometers from Manila.(13) La Garde(15) and Jack- son(10) have both expressed the opinion that the frequency of typhoid among the natives is not sufficiently appreciated. Brownlee, formerly stationed at Malabang in Mindanao, states that he has found typhoid quite prevalent in Mindanao.(4) Dulin, after a long tour of duty in the Cotabato Valley, reached the conclusion that typhoid is endemic at all times and in all places in that portion of Mindanao.(4) Shockley, who has seen much service in Mindanao, confirms the above opinions as to the prevalence of the disease in that island. (4) Arlington Pond in a personal letter gives it as his opinion that there is much more typhoid in the Island of Cebu than is recognized. W. A. Powell from Lucena mentions the occurrence of typhoid among both adults and children. Huber states that he finds typhoid almost constantly present in the town of Bayambang, Pangasinan Province, Luzon.(14) Phalen, for two years president of this Board, voiced the belief that typhoid is an ever present endemic disease throughout the Philippines.(4) Many other medical officers of the army have verbally expressed the same opinion. Spanish and Filipino practitioners refer to the frequent occurrence of a “calentura”, a fever of two or three weeks’ duration which does not yield to quinine. As will appear later, our laboratory findings confirm the above opinions as to the wide range of typhoid infection in the Philippines but can not, of course, throw much light on the frequency of its occurrence in the native population. TYPHOID STATISTICS FOR THE PHILIPPINES FURNISHED BY THE BUREAU OF HEALTH. Vital statistics in'the Philippines, particularly outside Manila, are notably unreliable because of the scarcity of competent physicians and because of the great number of natives who are never scen by any medical attendant even in an illness terminating fatally. In view of the almost universal tendency to ignore typhoid fever and to consider malaria the cause of the doubtful fevers it is probable that the following figures, obtained from the Bureau of Health, do not err in the direction of exaggerating the death rate from enteric fever. 302 CHAMBERLAIN. Taste I1.—Typhoid fever in the Philippines. Number of deaths. Calendar year. Manila. |Provinces.* 1906 25. 4h te ce ee ee ee oe a ee 47 2, 453 QO Fatale lL ee ee A ee ee a 77 2,183 190822 8s Boe EO a ee a eee eee 116 2,371 1909922... 28S kd ee eds Cee ae ee ees eee 90 2, 387 DOVOe Sete A ee ee a ee eee CP ety eeeeeeseer saa (ANCY ORC 3 feo ed ee ee eee eee 82.4 2, 336 a asusenes 8 The population of Manila in 1907 was 223,543, divided as rollows: Americans and Europeans 9,079; Chinese 18,028; Filipinos 195,292; others 1,143. The population of the provinces referred to is approximately 6,434,390. Granting a death rate of 20 per cent (which seems a liberal one and is much higher than the experience of the army among either white or native soldiers), the average of 82.4 deaths annually would indicate a yearly incidence of 412 cases of enteric fever in Manila or one per year for each 542 persons. This average yearly rate of 82.4 deaths in a city of 223,543 people represents a mortality of 36.8 per 100,000. The Census bulletins for the registration areas in the United States show the death rate from typhoid per 100,000 to have been 25.3 for 1908, 30.3 for 1907, and 32.2 for the period 1901 to 1905.(22) The rate per 100,000 from 1901 to 1905 averaged 11.4 for Scotland, 11.2 for England and Wales, 13.1 for Treland, 16.8 for Belgium, and 7.6 for Germany. The following list shows the position of Manila as compared with certain large cities in Hurope(2%) and America. (22) [The figures indicate deaths from typhoid per 100,000 of population.] City. Deaths. City. Deaths. City. Deaths. Ie ae Pittsburgh —___-___ 129.6 8. MANILA —-------__- 36.8 || 15, Omaha_____-_____- 20.3 2. Allegheny ___--__- 110.1 Oo LOled Osea saan 36.3 || 16. Milwaukee_______-! 18.1 3. Washington__-_--_- 56.6 || 10. Baltimore___-_____ 35.8 || 17. New York__--__-_- 18.1 4. Philadelphia _____. 52.3 || 11. Buffalo___-___-____ 28.9 || 18..London -.:+_-----: 12.3 5. New Orleans______ 40,9 || 12. Chicago_---------- 28.4 || 19. Hamburg -________ 5.6 | 6. Memphis_-__-______ 37.& || 13. San Francisco ___- 27.0 || 20. Vienna____________ 4.3 | 7. SteWouis se 2=-t es 37.2 || 14. Boston ________--_- 22.2 || 21. Berlin.__--..------ 3.8 As compared with American communities it will be seen that Manila corresponds with the middle group including such places as New Orleans, St. Louis, Toledo, and Baltimore. It is exceeded only by a few cities which are notorious for high typhoid rates. Its mortality record is far above that for the best American cities which themselves have an enor- TYPHOID FEVER IN THE PHILIPPINES. 303 mously greater typhoid rate than do many of the municipalities of Europe. hat As regards the accuracy of the typhoid death rate in Manila, Doctor Andrews, in charge of the city morgue, states that he encounters many cases of typhoid at the autopsy of native bodies and that he considers the average of 82 deaths per year to be well within the limits. Most of the cases he finds have been un- diagnosed or incorrectly diagnosed. THE INCIDENCE OF TYPHOID AMONG AMERICAN SOLDIERS IN THE PHILIPPINES. Considerable doubt may attach to the accuracy of the diagnoses in some of the deaths reported to the Bureau of Health as caused by typhoid, but in the case of the Army statistics for Americans during the past ten years this possibility of error is reduced to a minimum, since every soldier seriously ill is treated in hospital and the diagnosis in nearly all instances is made with the aid of laboratory facilities. During the year 1898 typhoid was everywhere epidemic among the untrained volunteer troops in the United States. Throughout 1899 it decreased at the home stations but was widely prevalent in the Philippines among the great numbers of newly recruited volunteers who were undergoing the hardships of a strenuous campaign. These two years would show nothing of value when com- paring the admission rates for troops serving in the Philippines and in the United States. Therefore, they have been omitted from the tables below which begin with the year 1900 and are compiled from the reports of the Surgeon General of the Army. TABLE II.—Typhoid fever in the United States Army, American troops. Philippine Islands. United States. Calendar year. Admissions: Deaths. Admissions. Deaths. Mean Mean strength.| Nyum-| Per |Num.| Per |Se™sth.| num-| Per |Num-| Per ber. | 1,000.| ber. | 1,000. ber. | 1,000.) ber. | 1,000. NO GOS So es 2 66, 882 716 | 10.71 141) 2,11 20, 690 115 | 5.56 9] 0.43 1901 (16) -------_- 59, 526 315 | 5.29 58 | ¢.97 26,115 250 | 9.43 17 | 0.64 1902(17) ---_----- 32, 942 201 | 6.10 32.| 0.97 39, 736 341 | 8.58 34 | 0.86 1903(18)----__-__ 18, 671 82 | 4.39 15 | 0.80 42, 264 246] 5.82 12) 0.28 | SAS (0 ie nee oe oe 11, 996 Pah |) al Gye 5} 0.42 43, 940 247 | 5.62 12} 0.27 Us ap eee ee 11, 057 31] 2.80 Sal One 42, 834 153 | 3.57 13 | 0.30 19062 = oh 12, 380 48 | 3.88 0! 0.00 40, 621 230 | 5.66 1D} 0328 || 9072 sees ee 11, 699 41 | 3.50 3 | 0.26 35, 132 124] 3.53 7} 0.19 | AOQB Sethe 11,971 33 | 2.76 5| 0.41 | 46,316 136 | 2.94 11] 0.23 | MOOS eS wee 12, 844 79} 6.15 Dye Os15: 57, 124 173 | 3.03 16} 0.28 Total _____ 249,968 | 1,569 ~>----- 264i) = see 394,772 | 2,015 |_-.---_ DAT ee Average for 10 VeaTrs o--5J-., 24,997 | 156.9 | 6.28 |] 26.4 | 91.06 89,477 | 201.5 | 25.10] 14.1 | 20.36 4 Average admissions and deaths per 1,000 are based on the average of admissions and deaths for ten years as compared with average mean strength for same period. For comparison with the above there is given below a table covering the same period and showing the number of admissions for malarial fevers and fevers of undetermined causation. 304 CHAMBERLAIN. TABLE III.—Malaria and undetermined fevers in the United States Army, _ American troops. — Philippine Islands. , United States. © | : ‘ Fevers |} Malarial fevers. |’. ~ Fevers |' Malarial fevers. Calendar year. undeter- . jundeter- : : | Mean | mined, Mean | mined, : strength} admis- | Admis- | Deaths jstrength) admis- | Admis- | Deaths sions per|sionsper| per \sions per|sionsper| per 1,000.. | 1,000. | 1,000. _ | 1,000..} 1,000, | 1,000. 1900 Mrer came wnt Ne 66,882 | 29,01:| $74.23|. 1.591 20,690) >~ 9.67 |' 158.47 |. 0.19 ROOD ed ud eee Be ek 59,526] 25.38.) 501.62, 0.65 |, | 26,515 , 8.22 | 109.07 0.00 1902 ein ee eee 32, 942 20..23 | 462. 94 0.64 |, 39,736 | 7.65 93. 09 0. 06 L9OSE Aes ae se 18, 671 (8) 451,33 1.26 | 42, 264 (8) 57. 46 0.00 LOOP cees ak See eer 11, 996 33.34 | 218.32 0.25 | 43; 940 6.25 | 47.48 0.00 1909____—- se eee ee ON O7 30, 27 | 258. 84 0.54 42, 834 6. 91. 43, 84 |. 0,02 1906 2222 oe SSeS aS 12,380 8.97 | 304.20 0.55 40, 621 7.73 50. 27 0. 02 1 W907 52 See eee ae ee DIAG 99, 15.73 | 167.79 0.17 | 35,132 4.67 i" 30. 20 0.00 1908____ aaron a nann nn na= 5 11, 971 | 25.31 |. 123.97 0.16 | 46,316 3. 80 26.69 | ~0.00 1009 2a eee eae 12, 844 25.46 | 112.35 0.15 | 57,124 2,15 | . 23,06 0. 00 “a No data. There was: no mortality for ‘the’ undetermined fevers shown in the Table III except in 1900 when it was 0.01 Ten 1 000 in the Philippines and ay OE Per 1,000 in the. United’ States. : On studying these tables it will be observed that for the eae period the typhoid admission rate per 1,000 has been higher in the Philippines than in the United States, 6.28 as compared with 5.10. The death rate from typhoid has been three times as high in the Philippines, 1.06 per 1,000 as compared with 0.36. During the years 1907 and 1908, when the sanitary conditions and the service conditions in the Philippines closely approximated those at home, the typhoid admission rate has not materially differed in the two countries while in 1909 it was twice as high in the Philippines as in the United States. The admissions for 1910 have been 38, making an admission rate of approximately 3.1 per 1,000 which exceeds the home rate for 1908 and 1909. In considering the comparative ‘admission rates for typhoid in the Tatras and at home, it is important to'bear in mind that in the United States the water supplies of many towns and posts are not above suspicion, yet little care is generally exercised by soldiers to avoid drinking these doubtful waters. In the Philippines distilled water, of unquestioned purity is everywhere furnished for soldiers and the fear of dysentery and cholera, together with the stringent orders on the subject, make the drinking of this water very general. If the same carelessness in drinking which we see everywhere at home were practiced here, we believe that the typhoid rate would be very much higher than it is at present. A consideration of the above remarks points very strongly to a wide spread and easily accessible source of typhoid infection in these Islands. TYPHOID FEVER IN THE PHILIPPINES. 305 That this source is also accessible to the native troops is shown by the following table: TABLE L[V.—Admissions among Philippine (Native) Scouts of the United States Army for typhoid, malaria, and-undetermined fevers. i ‘Admissions. Deaths.* | Calendar year. Bea cypher fever. Soe ees Eypherd fever pales Ping : fever ee : | | fever ‘Num- | Per per per | Num- | Per ‘|}_per ber. | 1,000. | 1,000. | 4°99: |. ber. || 1,000. | 1,000 4, 826 |. 9 1.86 | 704.11] | 35.02 1 0.21 | 1.66 “4, 888 |) ‘5 | 1.02 | 522109) . 0.00 Wil Whe 92.25 4,610 |’ 4/ 0.87 | 367.69.) 34.49 3 0.65} 0.43 | 4) 732 7 1.48 | 571.01 | 15.64 2 0.40} 0.81 » 4,759 4 0.84 | 393.15] : 21.43 ia 0.20 }° 1.19 i a ere Deere , 4,679 6 1.28 | $12.67} : 19.45 0 0.00}: 0.43 1G DS eees mE ste eo 5,085 .9| | 1.77] 236.97] 20.45 0 0.00} 0.19 TOD ae ee ee _ 5,369 7 1.30) 203.95] | 17.69 1 0.18} 0.00 a 38, 948 Bil aera arent Pe hs ee oe Average for 8 years ____| 4,619 | 6.35 1B 1 | eee el (ee 1.18 0. 24 qanonbe=- '" There were no deaths from undetermined fevers. Table IV shows that there has been a constant; though low, admission rate for typhoid among the Philippine Scouts since their organization. _ It is certain that the diagnoses for sick Scouts are less thoroughly worked up than are those of the white troops because’ of racial peculiarities and the difficulty of understanding their language, and also because of the fact that many of the Scout organizations are at small and isolated posts: with meager laboratory facilities. may lie hidden in the great mass of admissions for malaria and undeter- mined fevers, only the most characteristic cases being correctly diagnosed. Therefore, some eases of typhoid Since most of the Scouts are at posts where they come;in contact with very few white men, it is almost certain that, they pick up their infection at the post or in the country surrounding and that the disease is not imported from the United States as might be urged in’ the case of the white soldiers. The lesser incidence of typhoid among the Scouts'as compared with American troops corresponds with Rogers’ attributes this difference to the oe of typhoid in childhood. , DISTRIBUTION OF TYPHOID FEVER IN THE PHILIPPINES. experience with native troops in India. He The distribution of typhoid seupeout the Aestiblace, in so far as it has come under the notice of the Army medical officers, is shown in Table V. CHAMBERLAIN. 306 (1) (Z) (1) (1) (Z) (¢) (8) (g) vas ad (q) OT6T 606T 806T L061 9061 S06T eee ee OvUBpUIT FO6T “IOA0} PloydA, JOy SUOTSSIULPB JO IOqUINN ssoysypjs fuwpy ‘soumddywyd aCe ee MY ET Til ices te ee OLDOd USS, SS er ae ae ae at O[IO[] Fa pagal, ARTS ah a Tn al NRE PC a uBUISSOL fae da ae cat Ser eer ees oe Mae eee pass DOT MO[PNT SUBqRVIN -a---- ------ ---+----------------------- U0}19A0 ar SIBOLA. 0}8q,810D INYRIB AOTYIOM “pusy[stT ay, wi saaas proydhy Jo uorwngr.usiqg— A ATA], 307 TYPHOID FEVER IN THE PHILIPPINES. ‘90138 JOU OP S[e}0} puvIS [eo]JIeA pues [v}UOZTI0Y A[JUeNbesuoD ‘ATWO 9Svd BuO SB pojUNOdD ueeq sey (+) USIs sn[d B Y}IM PoyYIVM WeI] O44 S][e}0} [eJUOZIIOY 94} UL “1v9A OY} IOJ 180} OY} A[UO BAIS puv sysod oy} JO Aueul ye JoquInu oY} MOS JOU Op spi0d91 OY} JNq poYVOIpU AZI[VOO] OG} YB PetAND00 Sesvo o10M IO OU yey} B}¥O[pur (+) uUsIS sn[d @ QUAM peYIeM sooeds ‘OO6I-FOGT SOAIIVU 1OJ O[QVITEAG SoIysSI}eIS ON ‘sesvd DAI}VU ZUeSoIdeI () SeseqJUeIed UI peso[oUy S1equInN ‘[eUGSO_, WOISTAIG sepnyouy v (94) eae | (21) or | (4F) BF | (6) T8 | (8) ze | (F) Le | SP (LC baie Cohasset aoe eee | gc cect oe Ge See TROL Ts | sass =a | 2a = Ses | BEE eee | pee eoueasl| none aeieon [sess a a Meo See Se TYRe a) (() 0 ensen-==== ae eee a leer eco ea canaaaanananann= DOpr | sae eee ae ee [avd WES z | Ca) ee aps | aes ead | eee ny ieee tans eee est ‘Saba ee (6 | Root aaa EMER graeme ge a ODF ag (DS eer ke: a ae cr eh gg Doh 02 I j Ga>| p a 1T C5 Coe ime es og lane Beye s Me ee OD gach pace ae Se ae Ate a ee AOTULTOW ee ee ee ee ee eee bos Scose a |-------=--- PSS SERIE SoS SEER OEE @y9 SSSI | ROS ie eR SSR REISS SS SSS SSS SES SOTOATIBIL Qo ancora [pace] oon nanan] === =2--22]-=== -2--=- jsasssosess /sssecesasc ‘Tae oe Gligaaeee os eo aa ODetara|aamas Ease SEs pp RSE a ee IBild | (1) (G0 Gatieeneel saekhntssae beabeanaelaaaaaaaoee aoee Eee Eee ee oo perone ane eas OD) = aaaa lpi ae See Sake ae oe eae OBdBUBO | yee (CA ce |ann=-==--- |poeeee ste elses eer pom eeec es foo Sacer iis OD= "al aaer a ae Se ee suvqmBsug | @) iz (I) Tf T Th ag 286" See sale ser ee ee ae slr Se a | pea ODs2325|\ncaaaa Se ee a a WIBINOW QT ernnnnnone|-seee = QL [croc ac enn omen omen wee =| pee nnn | ence | a n nn e nnen enene Opts see ee ospNDIa ee eee knoe | oa a ee ee Seen eel eee ae [en (oe a SSS StER AER tees 5 - OPE. oa | ER El oan Se Re Se oe Ge: De Se using ee eee ee ea wonenn nanan 2 anna aa === 605-4 aS ae SSeS ee SOUvg SOT Te cee oes aaa cane wae eee ee oe paearrestee| ics a Tee ase OD Sse ene ee Sg Saag Hee ae SO SER TOON’ | 5 east ne | See ee | eee eee Se oe ian haar Sacer anes CO Disaaal baae cea: cea cna BOURLABPLOTT | @ | RRRPSstsee | pesceeee|| Sess ce eceal| Sees oaeees aE = hye | Peaeeeere Ce Pe clearer Ages Seon cat se OPTS a sain ace ate Ma pepe tae ae ae BavIBE | 1, Ses Wey eoometclles” oats B Peau lcamara ao prea sa ese Sieaiy iets cn a \ectge Sage pliers ace ence ae (0) eee secant rer Ses Sees See ERE AICTE: Snuty | (2) op | (2) @ (¢) aE | (1) @ (Date ale yh “Slee eee dlits ater tial ee ees OD ps a ape aes = See ee v8]SOq BLUR] 1) t4 (T) (1) z a a a ea il hae ae rail atte lee a Jooneee cond |annce anne enn anna ODrgesn bic ee Ge WTOUTEAA | Tipe: | Ses aes Mo eee a eee meee Salli ocam ieacgeweees | Sees The Laienfessae Soap nas mee op-----|- Se oh er a aah eee (tet Aust len) 0 ese=e= (61) [trwnawenne[-n2-2-= === |-===------ ee Sener |-=---=----|-- senna ant na anna nn= ae @ygpeeae = So apieees SR SE uolUp ‘opuBuiEy weg GRE | Bae se (1) Prot Get (ner aia a ae T § cs ae a oem — as ae 62) Ose ier| ean aes op ser yeeialy ARR g ee Ne iy 3 S0BT TBM | @ Sent enarer pee secons ecmaaecaioa[eescemi (Oro glasses aoaalspae tee oleae Been To ee ee ODS 5a mes Se aig) ae Pa Tease oe eae ByuByUy id (3) ON} Soe ict cate (ae ease ree asia as 400 ly 9 Ree Seeeeay em aa ----=-|-=------ wana nn-==- ol) ies lst En nec s8019 (@ pesssese== (3) a ea ee ee ee Ser ager ee ODE ssa ora ge Ra ep ae ee ee ee wuoonTy IL I (4 I g | g Ir] seen | Same sas | eee Sees ESR nae noe Se So MOAN | eo ae pe a oe oe 81nquds}o}s (z) ¢ (Tt) T Cox clu) he Ra es ae ass see jonsees*se5|"assS5-5 al eer aC Se aa JOPISeqI0g |---7 0 ape ass SSagp otha aera Sse STIN 104912——4 308 CHAMBERLAIN. The figures in Table V were obtained from the reports of the Surgeon General of the Army, the records of the chief surgeon, Philippines Division, the récords of this Board, and in a few instances from personal knowledge of members of the Board. The table does not pretend to be complete but it is sufficient to indicate how widely spread throughout the Archipelago is the infection with typhoid. The accompanying “spot map” graphically indicates the distribution. In considering Table V it must be borne in mind that the localities mentioned represent a majority of the places in the Islands where there are competent observers or laboratory facilities. The Bureau of Health mortality statistics for the provinces cover all parts of the Archipelago except Mindanao, Jolo, and adjacent small islands. These reports show typhoid to be an extremely common cause of death in all of the important islands, the mortality rate in some provinces for certain years ranging from 50 to more than 160 per 100,000 of population. We have not gone into these figures in more detail because of the uncertainty which attaches to the diagnosis of typhoid, or any other disease for that matter, in the provincial reports. WIDAL EXAMINATIONS ON THE BLOOD OF HEALTHY ADULT NATIVES. With a view to determining how large a proportion of healthy natives might show the influence of antecedent typhoid, as evidenced by a positive Widal reaction, the Board has obtained the blood of 307 adult male Fili- pinos and the results are shown in Table VI. These examinations were made in 1910 and 1911. TABLE VI.—Widal examinations on the blood of healthy Filipino adults. Widal, dilutions | Widal, dilutions ; Rae De Nui: about 1 to 20. about 1 to 50. Station or town. Island. ail ayes nee, me Positive. |Negative.| Positive. |Negative. Paranpy ose 5s Mindanao ___| Moro __-___- 12 1 11 il 0 Rarang ose PAIS Vays le eae Filipino ___ 52 4 48 4 0. Camp Wilhelm ____| Leyte ----___- Visayan __- 12 0 1235 ele Eee Camp James_______|_____ (yee é2do zee 12 |. 0 fe AD ie) PR A eo [See Gotabato —.-.-_-___ Mindanao -__| Ilocano __- 12 0 od |e he ea Setar sees Camp Wallace_.__- Tuzonyeeas ee Visayan ___ 12 0 PTW aoe) aL Wan aad Regan Barracks ___|_____ aKo) eee Tlocano ___ 12 2 10 0 2 Camp Connell_--_- Samar _______ Visayan ___ 12 2 10 0 2 Isabela —.---------- Basilan ___-_- Moro ___-_- 12 0 aD Laid ne De a gE | ere 2 Bojelebung-__-----|____- {0 Koye eee, oer does 6 0 Gh hee ee ee eel Bumpus —=---___-_- Leyte_____--. Visayan —__ 12 ll il 0 1 Hort Millse2-2eees Corregidor __| Macabebe _ 36 4 32 2 2 Camp Gregg_----- AE ZOMe eee Visayan ___ 40 0 c:(( Fe) eee tee Ure cy er CamprHaye en eee 60) aaa Igorot _____ 20 2 18 0 2 Camp Hayt_______- Samar ______- Cagayan___ 12 4 8 2 2 Kaligton __-.---~_- Luzon —__:_-_| Ilocano —__ 13 0 SS Sy ass ae UN eae ea Mont Mills) aaa Corregidor __| Visayan ___ 20 0 D0 ie Bae aeeen S Us, Motelly 22a es ee SE Oe 307 20 287 : 9 11 | Percentage - a): 2s abe NG as ae eee 6.5 93.5 Pi DIG) RUE eas Reactions in 1 to 50 dilution were done only on those cases which proved «postive in 1 to !20 dilution. } TYPHOID FEVER IN THE PHILIPPINES. 309 There are few data available to indicate what proportion of healthy men in any country might give a positive serum reaction from causes other than antecedent typhoid. The length of time that the Widal reaction persists after convalescence from enteric fever is variable, ranging from six weeks to twenty years, the long continuance in some cases perhaps being due to bacilli persisting in the gall bladder. The fact that 6.5 per cent of the adults we tested showed a positive reaction in 1 to 20 dilution and 2.9 per cent in 1 to 50 dilution probably points to an antecedent attack of typhoid in some of these individuals and, when taken with the statistical evidence already presented, is suggestive of a wide spread distribution of the disease in the native population. THE INFREQUENCY OF SEVERE AND FATAL EPIDEMICS AMONG NATIVES. The above quoted statistics and examinations indicate to our minds that typhoid is very generally present in the Philippines. The water sup- plies are almost universally bad, the proper disposal of excreta is almost entirely neglected, the crowding in the habitations and the native manner of eating favor contact infection. Yet, in spite of these unfavorable conditions, there is little evidence that severe and destructive epidemics of typhoid fever occur among the Filipinos. The relative scarcity of typhoid among the natives in India is thought by Rogers to be due to immunity acquired in childhood. Nichols(1!) expresses the opinion that typhoid is prevalent among children in the Philippines. To determine if evidences of previous typhoid in Filipino children could be detected, we performed Widal reactions on the blood of 284 healthy school children. The results are shown in Table VII and are entirely negative except for three cases at Ormoc, a town where we had good reason to believe that typhoid had recently prevailed. TABLE VII.—Widal examinations on the blood of healthy Filipino school children. Widal, dilutions Widal, dilutions Race about 1 to 20. about 1 to 50. Town. Island. or Number. tribe. j Positive. |Negative.| Positive. |Negative. IBA PUION 2224258555 Guzen Igorot __--- 45 0 CVS) pa Gee A Ce ea ee Paranaque --_._-__|---_- donee Tagalog —_- 30 0 S300 Sng | Ea ea pd ap LUCE ay =A Seed Se doses ere ees doje. 50 0 BO). | se teens atu eee Ormociee ee Ibeytey 2222-2! Visayan ___ 14 3 11 1 2 Malabang ----____- Mindanao ___| Filipino -__ 7 0 ieee eee 2 elle Semen IB aran pees ie eee eS (oO eet ES dora 30 0 SO a) Lae Sa ee wee LOSE Dy SR ees ee, doe ates =dos== 22 0 Pag eerie Soc ee We cake eee NOLO fase ween sees Volo ee sana MOrOre= 36 0 BO Doetee Same EL ue sees Floridablanea —__-| Luzon -_----- Filipino ___ 26 0 26 Tile IE ee Re ee San Nicolas____---_]_---- (oye el eed do 2. 24 0 py a eee A See eae STG Gra pee ah eh SAE 5 a bee SY 284 3 281 1 2 IRETCOMtA eS Gaal eets See oe een ote ee ees eee 1.0 99.0 OLB ase 310 CHAMBERLAIN. It will be seen that the percentage of positive results was much less than among adults. These children ranged from four to thirteen years of age and the majority were under eight years old. If typhoid were common among the Filipino school children, it is probable that the per- centage of positive reactions among them would be considerable. It is possible, of course, that the disease may occur widely among infants and that the agglutinating influence in nearly all cases had passed away before the time at which we saw these children. However, such an explanation does not appear to us probable. Our clinical records, to be discussed later, indicate that a considerable number of the cases which give positive laboratory finding present clinical appearances entirely different from the classic description of typhoid fever. Patients with a short course, little fever and few symptoms, were found commonly among both Americans and Filipinos. It is by no means unlikely that such cases throughout the native population are very common and that the true nature of the malady is overlooked. The disease in this form can be diagnosed by laboratory procedures alone, and it is only by working along this line that the true incidence of typhoid fever among the Filipinos can be determined. INFLUENCE OF SEASON ON PREVALENCE OF TYPHOID. In Europe and America typhoid fever may occur at any season, but its incidence is greatly increased in August, September, and October. In India, as a whole, Roberts has shown that the disease is very generally distributed throughout the year as follows: first quarter 18.1 per cent; ‘second quarter 31.3 per cent;.third quarter 28.1 per cent; fourth quarter 22.4 per cent. The experience for four years (the only ones for which monthly records are available to us) shows that in the Philippines the disease is distributed throughout the year in a quite regular manner. Taste VIII.—IJncidence of typhoid fever by months in the Philippines. [inte = SS EF Gn an eee TT : : Quarter. Month. 1904 | 1908 | 1909 | 1910 | Total. |\—————————_ i Number.} Per cent. JanNUany eee ee 2 3 1 ai 13 February --_-_________ 1 5 7 19 23 | 78 24.61 March {22-2 382 1 13 7 21 42 April {22 ee 1 8 1 2) 12 IM gy 2) teres) 0 9 2 0 11 44 13. 88 June =... Dae 5 14 2 0 21 Jly; ss 4 25 5 4 38 Aupust <2:2) Bese 2 23 8 0 33 90 28. 39 September____________ 1 14 3 1 19 |} October_22. 2 222 3 12 43 2 60 November____----_-__ il 17 3 0 21 105 33.12 December 2222 2222-25 2 13 5 4 24 otal se Rees 23 156 87 61 B17) Been | ae ee | TYPHOID FEVER IN THE PHILIPPINES. onl The considerable increase in the last quarter may be considered accidental since the 43 cases in October, 1909, all occurred at one post, the Ludlow Barracks epidemic. The season varies considerably in the Philippines in different localities and for different years, but in general it may be said that the period from December 1 to June | represents the dry season. Since our military patients mainly are drawn from a population consisting almost exclusively of young adult males, it has been impossible for the Board to draw any conclusions as to the influence of sex or age on the incidence of typhoid in the Philippines except in so far as we have mentioned the latter factor in the paragraph below Table VII. PART II. LABORATORY INVESTIGATIONS OF TYPHOID FEVER IN THE PHILIPPINES. During the two and one-half years that the Board has been working _ on the subject of typhoid fever the following examinations have been made in the case of persons having typhoid fever or suspected of having it. TABLE 1X.—Hazaminations by the Board on persons suspected of having typhoid, December 1, 1908 to April 30, 1910. Cultures from— | Widal Results. tests. Stools. | Urines.| Blood.| Bile. = — | (POSIUIV eit ne ee ey hee a 192 19 9 17 1 A INCE ALLV Chae Sues ees ace ee eee 261 498 320 139 0 NP ed Ue Al NEES 453)|bi7 |) 3001] 56 | 1 e The 453 serum reactions were performed on the blood of 369 persons. The 192 positive Widal reactions were made on the blood of 177 persons, of whom 118 were Americans and 59 were Filipinos. The 517 stool cultures were made on 199 individuals, the 329 urine cultures on 164 individuals, and the 156 blood cultures on 141 individuals. BLOOD CULTURES, 17 POSITIVE, 139 NEGATIVE. The organisms were sought in the blood by placing it in sterile bile, incubating for twenty-four hours and plating on Endo medium. Many of our specimens of blood were very old and the amount small, which accounts partially for the small number of positive findings. The fact that the disease in many instances was far advanced needs also to be considered. All of our positive blood cultures were obtained from patients in the Division Hospital or at posts we visited, and from these patients we obtained a large amount of blood and placed it at once in the bile medium. Since all of these cases came under our immediate observation, we feel sure that the days of the disease, as shown in the following table, are approximately correct. 312 CHAMBERLAIN. TABLE X.—Days on which positive blood culture was obtained. Number Number Day. positive. Day. positive. Second! .2282 eee TO wreliitlny 2s2 see ees ae 1 Do hfe Wee ee ee ee 1G (sib teenth saan 1 Siacth. oes se ee a 2 |) Hourteenth===--—--* 422523 === 1 Seventh: 2523 oe tee DN Op alsnON, it ee eee 1 IONS) 0 eee 3 Tot alicaelas se eae weal oa ey 17 INP DoH mene te ee Se SERA TE Re Beat 3 | Bleventh =: 2: ays ske re ee al 1 Among the cases which showed bacilli in the blood at the end of the first week or later the following are of interest: TABLE XI.—Relation of Widal reaction to positive blood culture. Day. Case. 2 Blood positive. Widal negative. Widal positive. 3 | Fourteenth.______-_-___ Twelfth 2.24 ee 225. Fourteenth. 4°) Seventh 2-2-2222 Seventh= ss. Ninth. | 2538) |ehiehth\ eee eee SPX Ghites ses eee Ninth. Welsevienth) 222s seenen anes Sixth and tenth__________ Twenty-first. BS) | Eighth =seseae ee Seventh)22232 sees oon Eighth. DW welfth = 222seeeeaseeee Twellth oes os (2) 402) 0 Sith) sea ene eee Sixth and seventh ______. Twenty-second. STOOL CULTURES, 19 POSITIVE, 498 NEGATIVE, AND URINE CULTURES, 9 POSITIVE, 329 NEGATIVE. 9 Stool and urine specimens were smeared over the surface of Petri dishes containing Endo medium. Cultures from the excreta were rarely employed for diagnosis. Nearly all of those shown in the table were made during convalescence to detect possible carriers, three negative cultures at six-day intervals being required before a soldier was returned to duty. These facts account in the main for the low proportion of positive findings. Another factor which must be considered is that the stools and urimes in many cases had come a long distance. Our experience, both practical and experimental, hag been that after a few days no typhoid bacilli can be obtained by cultural methods from a stool, whether naturally or artificially inoculated with Bacillus typhosus. CHARACTER OF TYPHOID ORGANISM ISOLATED IN THE PHILIPPINES. At the end of 1908 this Board had found the blue strain of typhoid in 5 patients in the Philippines and expressed the opinion that the prevailing type of organism in the Philippine Islands might be one which produced primary acidity in litmus milk followed after several days by alkalinity. Further ex- perience has not confirmed this view. During nearly two years we have isolated only one blue typhoid organism from either a native or a ‘white man, and TYPHOID FEVER IN THE PHILIPPINES. 313 recently, on re-testing a number of organisms isolated in the Philippines, all except that one failed to give the blue reaction. Therefore, it is, probable that the blue strain occurs with no greater degree of frequency in the Philippine Islands than in the United States. The distinction in type is probably of no importante and the variations reported may at times be due to the use of milks containing variable quantities of monosaccharid. In fact, acidity followed by alkalinity is given as the type for typhoid by Hiss and Zinsser. (20) It appears that there is no constant difference, either in their litmus- milk reaction or in their behavior in the presence of immune sera, between the strains of Bacillus typhosus found here and those met with in the United States. WIDAL EXAMINATIONS, 192 POSITIVE, 261 NEGATIVE. The 192 positive examinations were made on the blood of 177 indi- viduals of whom 5 had received antityphoid vaccination and two others gave a clear history of previous typhoid, leaving 170 cases in which the positive reaction was of diagnostic value. Only the microscopic method was employed by us in making the agglutina- tion test, both loss of motility and clumping being required before making a positive report. A dilution of 1 to 50 was used and one hour allowed to elapse before recording the result. Part of these tests were made with fluid blood and the remainder with dried blood, the dilution in the latter cases being, of course, only approximate. Nichols(1!1) and Bruns(12) in the Islands of Leyte and Panay inves- tigated two epidemics in which they found an absence of the Widal reaction until very late in the disease. In 11 cases Nichols found it absent on an average till the twenty-fifth day. In the 17% positive Widal reactions obtained by us we were often dependent on others for the statement of the day of the disease. As thus given, the figures are as follows : TABLE XII.—Days on which positive Widal reactions were obtained. | Day. Nem Day.’ Tums Day. ere Day. Non Second _______- 13 |} Eleventh _______ 7 || Twentieth_____. 1 || Forty-fifth______ 1 WUonrol 13 || Twelfth ________ 1 || Twenty-first____ 3 || Fifty-eighth____ 1 Fourth -..-____ 12 || Thirteenth _____ 5 || Twenty-third _| 1 || Seventy-third__| 1 Hips eee 14 || Fourteenth_____ 3 || Twenty-fifth ___ 1 |) Unknown®___-_| 35 Bites eae 8 || Fifteenth_______ 2|| Twenty-sixth _| 3 ota ie an Seventh -__-__- 14 || Sixteenth ______ 2 || Twenty-seventh|' 1 Pip hithy 22s 12 || Seventeenth ____ 1 || Thirtieth _______ 2 INphays Vee ey 6 || Eighteenth_____ 3 || Thirty-sixth____ it Menths 222-5. 5 || Nineteenth_____ 3 || Thirty-seventh _ 2 48 This “unknown” group contains 5 positive Widals obtained in persons who had been vaccinated against typhoid and who did not have the disease, 2 obtained in persons not suffering from typhoid but giving a clear history of a previous attack, a few from whom we never. received records, and a series of 20 natives found at San Fernando who undoubtedly had the disease but from whom no history was obtainable. 314 CHAMBERLAIN. From a study of the temperature charts of the patients we feel sure that many of the cases were somewhat further along in the disease at the time of the appearance of the Widal reaction than would be indicated by the above figures. On the other hand, most of the cases reported above as having a very late serum reaction undoubtedly would have shown one earlier, but none was done till the date indicated in the table. In a series of cases in which a negative followed by a positive reaction was obtained and in which the onset of the disease has been fixed with reasonable accuracy from the clinical records we found no notable pro- longation of the pre-agglutination stage. The figures appear in Table XIII. TABLE XIII.—Days on which Widal appeared in patients who had previously given a negative reaction. Chas Day. Case Day. num- num- ber. Widal negative. Widal positive. ber. Widal negative. Widal positive. 5 | Sixth and seventh ____| Eighth. 117 | Seventh and eighth___| Tenth. 214) Penthyeo2—2 ass 2 ee Eleventh. 108 | First and third____-___- Fourth. || Seven Eighth. 138i |, Six than eenennees Seventh. 45\(Seventh==ss= sa aaees Ninth. 131 | Second! —---__=---=----- Fourth. 3} || eR Thirteenth. 163 |) Gecorel Fifth. — 258)) |) Sixthiae seen eee Ninth. Seventh === ======aa= Eighth. LO 76a Sixth eae ee eae Seventh. 213) (Mii hi seis eee Tenth. 350 | Second 22-2 22--=-- === Fourth. 402 | Sixth and seventh ____| Twelfth. 852 | Seventh _-___._-___ -___ Fighth. wees Se 383 | Fifteenth__________-___ Twenty-fourth. Average __-__--___ Ninth. 137 | Fourth and seventh___| Tenth. From our 89 characteristic cases of typhoid fever, analyzed below and in which the date of onset could be quite definitely fixed, we obtained positive Widal reactions on or before the tenth day of the disease in 72 per cent and on or before the fifteenth day in 87 per cent. In all but one of the remaining 13 per cent no serum test had been performed prior to the fifteenth day, and it is probable that all or nearly all were positive before that time. From the above figures it is evident that the experience of the Board does not indicate any general tendency toward unusual delay in the development of agglutinins in the blood of patients suffering from typhoid fever in the Philippines. We have analyzed the clinical records of over 100 patients with elevations of temperature and for whom negative Widal reactions were obtained. In only one instance was there the slightest reason to believe that the febrile condition was enteric fever, and in this single case the temperature curve and symptoms were not entirely characteristic. Repeated typhoid serum reactions were negative up to the fourteenth day, after which time no specimens were submitted. Serum reaction with Bacillus paratyphosus was reported negative but fell in the class of reactions which some observers report as “partial.” The leucocyte count was 9,000 and there was 33.8 per cent of small lymphocytes and 9.2 per cent large TYPHOID FEVER IN THE PHILIPPINES. 315 mononuclears. No pigmented leucocytes were seen. A relapse occurred in this patient which promptly yielded to hypodermic use of quinine although previous examinations for parasites and previous use of quinine by mouth had resulted negatively. The true nature of this case remains in doubt. TYPHOID BACILLUS CARRIERS. Failure attended our efforts to detect carriers as a result of 517 stools cultures made on 199 individuals and 329 urine cultures made on 164 individuals. However, we discovered one typhoid bacillus carrier by accident while examining for dysentery the stool of a patient who had been having loose movements of variable frequency for nearly 4 months. The patient, aged 30, gave no history of typhoid fever. He had been in the Philippines one year and had ten years’ service in the Army. He had dysentery in 1907. The last part of June, 1910, while on a mapping detail in the field, he developed a very severe attack of diarrhea with some blood and mucus. Did not go on sick report and diarrhea persisted. Lost about 28 pounds in weight. On admission to Division Hospital September 5, 1910, he was having about 4 stools daily, usually liquid and yellowish or clay-colored. They contained neither blood nor mucus. During his stay in the hospital from September 5 to October 14, 1910, his temperature never went above 37°.4C. and was generally normal. Pulse averaged 90 at times reaching 110. Repeated examinations of the stools for ova and amcebe were negative. The first stool culture was made on October 13, the day before he sailed for the United States and about 110 days after his original attack of diarrhea. It was positive for Bacillus typhosus. Meantime the patient had sailed for the United States, but by telegraphic request we obtained a specimen of his blood while the transport was at Mariveles and this gave a positive Widal reaction. Under date of November 19, 1910, the commanding officer of the General Hospital at Presidio of San Francisco notified us that the soldier was still excreting typhoid bacilli. As far as we can learn this is the only carrier which has been found in the Philippines. PARATYPHOID FEVER AND GROUP AGGLUTINATION. Strong in 1902 reported the recovery at autopsy of a paracolon organism from a soldier who had died with the usual symptoms of typhoid.(21) Ruediger, at the Bureau of Science, recently isolated a para-typhoid strain from the blood of a dog which died of rabies and showed also a purulent pneumonia. Our experience with the paratyphoid organism is confined to one case. The patient, who also had tuberculosis, ran a febrile course of eighteen days’ duration, the curve suggesting mild typhoid fever. There were the usual premonitory symp- toms of typhoid fever, and the progress of the disease was characterized by constipation, tympanites, pain in head and neck, splenic tumor, and normal leucocyte count. From the blood was obtained a pure culture of Bacillus paratyphosus “A.” The blood serum at first agglutinated both Bacillus typhosus and Bacillus paratyphosus. At a later date it failed to react with the former organism.” *Since this writing we have isolated Bacillus paratyphosus “A” from the blood of a Japanese with a continued fever at Camp Stotsenburg. 316 CHAMBERLAIN. We have tried the agglutination reaction with Bacillus paratyphosus on a considerable number of patients, and aside from the above have obtained positive reactions only twice, one of these sera also reacting with Bacillus typhosus. A more detailed report of the above case and a discussion of the subject of group agglutinations is contained in our quarterly report for December 31, 1910. OBSERVATIONS ON THE BLOOD OF TYPHOID FEVER PATIENTS. The blood of all of the patients considered was examined’ for malarial organisms with negative results except as noted below under complications. No other blood work was done on the cases except leucocyte counts, most of which were made at the laboratory of the Division Hospital on patients who were being treated in that institution. Thirty-six white blood counts were made on the blood of 19 patients and 31 differential counts on 15 of the same individuals. The average results divided as to race, appear below: TABLE XIV.—Average white blood counts on typhoid fever patients. ew ies ; Leuco- |Polymor-| Small Large Taos | es Mast Average. ecytesper| pho- lympho- | lympho- | ,; OSI; S | ¢c.mm. |nuclears.| cytes. | cytes. | “nals. | philes. | cells. Americans) 2-22-2--- -—, 6, 540 66, 2 25.7 6.3 i 0.6 0.1 lip inos eee 10, 234 66.9 26.3 5.3 0.3 0.5 0.7 Both races-2-------=----=_ 7, 669 66.5 25.9 6 0.8 0.6 0.3 These counts were made in the first week or ten days of the disease and do not show a tendency to the usual leucopenia, the average being normal for the white men and rather above normal for the natives. The lowest count for a native was 6,300 and the highest 15,400. For the Americans ten counts were below 6,000, fourteen between 6,000 and 10,000,.and one was 11,500. Rogers in a study of typhoid in India found the small lymphocytes to be increased above the normal maximum of 30 per cent in over one-half his patients. In our series this was not the case, in fact we should consider the average of 25.9 per cent as low, since it has been our experience that in the Philippines the count of the small lymphycytes is uniformly high in healthy men, usually ranging above 30 per cent. This is true for natives, and for Americans with one or more years of tropical service. The low eosinophile count in this native series is very unusual and probably is due to the fact that most of the patients were Scouts who had been relieved of their intestinal parasites prior to acquiring typhoid fever. PART III. CLINICAL ASPECTS OF TYPHOID FEVER IN THE PHILIPPINES. After excluding vaccinated patients, persons with clear histories of previous typhoid and one case of paratyphoid there remain the clinical histories of 157 patients sick during the last two and one half years and. for whom the laboratory findings indicated the existence of typhoid infection. For clinical analysis we have divided these cases into four groups as follows: Group I; 7 cases terminating fatally; 4.5 per cent. TYPHOID FEVER IN THE PHILIPPINES. 317 Group II; 19 cases with short ill-defined fever of less than 10 days’ duration ; 12.1 per cent. : Group III; 41 cases of irregular fever of less than 10 days’ duration, probably representing last part of mild ambulant typhoid types; 26.6 per cent. Group IV; 89 cases of well marked continued fever, clinically typhoid, lasting more than 10 days; 56.6 per cent. GROUP I. CASES TERMINATING FATALLY. Seven patients out of the 157 died, a mortality of 4.5 per cent. The cause of death was peritonitis following perforation of the intestine in 3 instances, toxemia in 3, and shock following hemorrhage in one. Bacillus typhosus was obtained from the blood of 3 of these fatal cases and from the gall bladder of another. Rogers found a mortality of 16.3 per cent among 129 cases in Calcutta and reports that in the British army in India the returns show a death rate of 26 to 27 per cent at the present time (1909-1910). This in- dicates a more serious condition than is seen in these Islands. The range in the typhoid mortality experience of the Army in the Philippines for the last ten years as contrasted with that among the troops in the United States is shown in Table XV: TaBLE XV.—WMortality for typhoid fever in the Army tn the Philippines and United States. In the Philippine Islands, In the United States. American troops. Filipino troops. American troops. Calendar year. | Cases, |Deaths,| Mortal-) Cases, |Deaths,| Mortal-| Cases, |Deaths,| Mortal- num- | num- jity, per) num- | num- jity, per} num- | num- ity, per ber. ber. cent. ber. ber. cent. ber. ber. cent. | TAS] sf ao ee 716 T40 aL OF 69\ [se ee SS ee 115 9'| 7.83 LOO Pee ee ee eS 315 Sil, MSTA (PSS aes eee Ce ee 250 17 | 6.80 BLS (Sa a oa el 201 82 | 15.92 9 i |) this he 341 34] 9.97 OOS ee oe ae ad 82 15 | 18.29 5 1] 20.00 246 12] 4.88 IC 23 5} 21.7 4 3| 75.00 247 12} 4.86 90S 2e2S- See 31 3 9. 68 7 2) 28.57 153 13 | 8.50 90622 na os te as eae ee 48 0 0.00 4 1] 25.00 230 11| 4.78 OO (eeene ens ok oe 41 3 (582 6 0 0.00 124 7 | 5.65 90822252 ee 33 5 | 15.15 9 0 0.00 136 11} 8.09 GOO 2s eee lh ae ee 79 2 2.53 i 1} 14.29 173 16 | 9.25 Mote li tereew es 1, 569 PAY Uy fee 61 A)? | eee eer 2,015 149} eee setae Seeicers Ci Gay ees ee ee ee ZC) 4 The average mortality was obtained by dividing the total number of deaths for the period under consideration by the total number of cases for the same period. It will be observed that the average mortality is a trifle higher for the _ Filipino than for the American troops serving in the Philippines, 17.6 per cent as compared with 16.8 per cent. It is quite probable that 318 CHAMBERLAIN. the death rate would be lower if every case of mild enteric fever occurring among the Scouts received the appropriate diagnosis. Rogers found a death rate of 26 per cent among 50 native Indian cases. Among the 26 Filipino cases for which we received clinical histories only one died, a mortality of 3.8 per cent. The average mortality for ten years among the American soldiers in the Philippines is very much higher than at home, 16.83 per cent compared with 7.05. This can be attributed mainly to the large amount of typhoid with a high mortality in the first four years of the decade, a time when the facilities for nursing, feeding and sheltering the patients were less favorable than in the United States. During the last six years, when the conditions in the Philippine hospitals have approximated those of similar institutions in the United States, the mortality has been no higher than at home (255 cases, 18 deaths, mortality 7.1 per cent). Therefore, it seems safe to conclude that the type of typhoid infection now being encountered in the Philippines 1s, under present conditions, no more fatal to the American than that met with in the United States. GROUP II. CASES WITH ILL-DEFINED FEVER OF LESS THAN TEN DAYS DURATION. Nineteen out of the 157 clinical records (12.1 per cent) show a slight febrile movement lasting less than ten days with few symptoms and nothing characteristic on which to base a diagnosis. The true nature of these cases could be determined only by laboratory methods. In addi- tion to finding a clear-cut positive Widal reaction in all of the nineteen we were able to obtain by cultural methods the Bacillus typhosus from the stools of three and the urine of one other of this group. GROUP III. CASES WITH IRREGULAR FEVER OF LESS THAN TEN DAYS, DURATION, PROBABLY REPRESENTING THE LAST PART OF LATENT OR AMBULANT TYPHOID TYPES. Forty-two cases out of the 157 (26.6 per cent) presented an irregular temperature chart which resembled the last week or ten days of the classical typhoid curve. These patients were, in our opinion, suffering from a mild ambulant form of typhoid fever and came under observation only late in the disease. Such cases were particularly numerous in the Ludlow Barracks epidemic, constituting 33 per cent of the admissions, and many of them probably never would have come on sick report had it not been for the fact that the temperatures of all soldiers were being taken daily and every one with fever was placed in hospital for ob- servation. In addition to obtaining positive serum reactions in all of this group we isolated Bacillus typhosus from the stools of 5 patients and from the urine of another. TYPHOID FEVER IN THE PHILIPPINES. 319 GROUP IV. CASES WITH WELL MARKED CONTINUED FEVER LASTING MORE THAN TEN DAYS AND CLINICALLY TYPHOID. In this group there are 89 cases (56.6 per cent of the entire 157) which ran a febrile course of ten days or more and which in nearly every instance would be considered typhoid fever from clinical observations alone. The diagnosis was confirmed in each of these cases by the laboratory findings which for the great majority were positive Widal reactions and for the remainder cultures of Bacillus typhosus obtained from the blood or excreta. There were 4 positive urine cultures, 5 positive stool cultures and 15 positive blood cultures from this group. Based on clinical appearances we divided these cases as follows; typical, severe, 18 (20.2 per cent); typical, moderate, 46 (51.7 per cent); typical, mild, 10 (11.2 per cent); atypical, mild, (lacking a fastigium) 12 (13.5 per cent) ; atypical, severe, 3 (3.4 per cent). The clinical histories for many of these cases are deficient as regards the presence or absence of the less important symptoms and signs, therefore in the analysis which follows the percentage of occurrence for some of the minor features will be an underestimate. With all the clinical records there were well kept temperature charts which rendered easy a correct estimate of the febrile type of the disease. Onset of the disease.—The onset was sudden in 4 cases and gradual in the remaining 85. The premonitory symptoms included headache, backache, pains in bones and joints, lassitude, anorexia, diarrhcea, abdom- inal pain, nausea, vomiting, chills, fever, stiff neck, vertigo, and myalgia. They did not differ from those commonly encountered in the United States. Chills or chilliness were recorded in 10 cases. Febrile course—The onset of the disease could be fixed with reason- able accuracy in all of these 89 cases. The lengths of the febrile reaction, collected in groups each covering a 5-day period, are shown below. TABLE XVI.—Duration of febrile course for 89 characteristic typhoid cases. Days. Aum Per cent. Days. Nu Percent. Between 10 and 15 ---_---_____ 8 8.98 || Between 31 and 35 ____________- Si) alta Between 16 and 20 ____________ 24 26.97 || Between 36 and 40 __---________ 10 | 11.24 Between 21 and 25 ____________ 21 23560))||;Over40) 2-22 o. = ee ee 4 4.49 Between 26 and 30 ____--_____- 13 | 14, 61 Average, 25.1. The cessation of fever in all cases has been arbitrarily taken as the date after which the evening temperature did not rise above 37°.2 C. We believe that the above figures represent the minimum of febrile course and that possibly the real average was slightly longer as a result of the patients having been taken sick somewhat earlier than appeared upon the records. The average for our series was 25.1 days. For com- parison may be mentioned the 780 cases studied by the Spanish-American 320 CHAMBERLAIN. War Commission where the average duration was 10.5 days(19) and McCrae’s large series in America where the average was 31 days. The initial step-like increase of temperature characteristic of the early days in typhoid fever was rarely seen, the patients usually being well along the first week when they came under observation. A clearly marked fastigium was the rule, being present in 71 cases, 79.7 per cent of the series. For 18 persons a definite fastigium was lacking, the morning and evening excursions of temperature being pronounced even at the height of the disease. ‘The maximum range of fever is shown below. Never up to 39°.4 C., 9 cases. Never up to 40°.5 C., 45 cases. Never up to 40° C., 26 cases. Never up to 41°.1 C., 9 cases. The decline of the fever was characterized by gradually increasing remissions, such as are observed in typhoid in the United States, and no chart was found showing the unduly prolonged intermittent stage described by Rogers in India. Recrudescences and relapses.—Recrudescences occurred in 4 cases (4.5 per cent) the lengths of the febrile disturbances being respectively six, seven, ten, and eleven days. MRelapses occurred in 7 cases (7.9 per cent) lasting nine, twelve, fifteen, sixteen, seventeen, twenty-four, and twenty- five days, respectively. One patient was desperately ill during the relapse. Pulse rate-—That the pulse rate was slow as compared with the tem- perature elevation was the almost universal experience, the disease in this respect conforming to the classical type in Europe and America. The low pulse rate was especially commented on by Lieutenant Dulin in the Ludlow Barracks epidemic where it rarely rose above 100 and was often normal at the height of the disease. A dicrotic pulse was recorded in 13 out of the 89 cases, (14 per cent). Symptoms of intestinal origin.—Constipation was.a marked feature in this series. Diarrhoea has been credited to each patient who showed abnormal frequency for the evacuations at any time during the disease but there were only 21 such cases out of 89, an incidence of 23 per cent. Fifty-one patients (57 per cent), were constipated and, in 13 (14 per cent), the bowel movements were of normal frequency. In 4 eases there was no record. The percentage with diarrhea is slightly higher than that found by McCrae in his American series (17 per cent) but consider- ably lower than that met with by Rogers in India, where 63 per cent showed diarrhcea at some period of the disease. Curschmann in Berlin found 73 per cent to have diarrhoea at some stage of the disease. Since diarrhoea is considered of bad prognostic significance (3) (19) it may be that its low incidence among our patients is related to the low death rate of 4.5 per cent which was met with in this series. Abdominal pain was noted as present in 13 of the 89 characteristic non-fatal cases, (14 per cent), was absent in 2 and there was no record for the remainder. Tympanites was recorded for 21 patients, (23 per TYPHOID FEVER IN THE PHILIPPINES. 321 cent), was absent for 7, and for the remaining 61 there was no mention of this symptom. Vomiting at some time during the disease occurred in 13 cases, (14 per cent). Hemorrhage was noted in 5 instances, 5.6 per cent of the entire group. Also it was the cause of death in one of the fatal cases not included in the series of 89. This percentage corresponds closely with that found by Curschmann in Berlin and Osler in Baltimore but is much _ lower than the experience of Rogers who records hemorrhage in 17 per cent of his Indian series. Perforation was seen only in the fatal cases, occurring three times. Symptoms referable to the nervous system.—Headache is recorded in 40 cases, or 45 per cent. Delirium was noted for 10 patients, (11 per cent), stupor or coma for 7 (8 per cent), and subsultus tendinum in 2 (2 per cent). Under this heading may be mentioned the complications occurring in four cases, two having developed post-febrile psychosis, one a multiple neuritis of the lower extremities and the fourth a condition of eardiac and nervous irritability. Miscellaneous signs and symptoms.—Rose spots were noted as present in 26 cases (29 per cent), absent in 6 (7 per cent), and in the remain- ing histories there is no mention. The spleen was enlarged in 18 cases (20 per cent), not enlarged in 11 (12 per cent), and in the remaining eases the records are silent on this point. Cough was present in 10 cases and bronchitis is recorded in three. Urine—Albumen was present in the urine of 13 patients (15 per cent), was absent in 19 (21 per cent). Casts were present in 8 cases (9 per cent) and absent in 19 (21 per cent). In the remaining cases there were no records of the’urinary examinations. Complications and sequele.—Out of the 89 non-fatal cases the follow- ing complications and sequele were recorded; malarial fever, twice; eatarrhal otitis media, once; phlebitis of the internal saphenous, once ; bronchial spirochetosis, twice; multiple neuritis of the lower extremities, ‘once; post-typhoid psychosis, ee cardiac and nervous sei Dy once ; “afte hemorrhage, five times. Among the fatal cases, Group I. it will be recalled there were 3 cases of perforation and one of hemorrhage. TYPHOID FEV ER AMONG FILIPINOS. : We ave + erohmncdl laboratory tests on 105 Filipinos suspected of having typhoid fever and obtained positive serum reactions in sixty. Bacillus typhosus was recovered from the stools of three of these and from the blood of two. Twenty-one of the positive results were obtained from the San Fernando epidemic, and no case histories are available. From the remainder of the 60 we received clinical records for 26 patients cf whom 1 died with perforation, 1 ran an entirely atypical course, 12 Bye) CHAMBERLAIN. apparently were received in the last week of a classical typhoid attack while the remaining 12 passed through a period of continued fever rang- ing from ten to thirty-nine days in length and averaging 29.6. These last 12 cases, which on clinical grounds alone appeared to be typhoid, are included in our Group IV. considered above, but will be briefly touched on at this point in order to determine if the disease in natives differs from that seen in the white man. All but two of these natives ran a febrile course of over 19 days. The onset was gradual in all imstances. Chills were noted for two patients. The temperature chart showed a well defined fastigium in seven cases and the fever ranged at the height of the disease between 40° and 41.°10. Nose bleed occurred in three, rose spots in two, marked abdominal pain in four and tympanites in 7. Diarrhea was noted in 4, constipation in 5 and there was no record as to bowel movements in 3. As complications, hemorrhage oc- curred in two cases, post-typhoid psychosis in one and bronchial spirochetosis in two From a study of these cases it can be said that they did not differ from typical typhoid fever of moderate and severe type as seen among white men in the United States or in the Philippines. The atypical cases which constituted so large a proportion of the Filipino admissions in the Camp Gregg epidemic and occasionally else- where are of special interest because of their probable role in spreading and keeping up infection. We have not had enough of them under observation to make any analysis of their symptomatology profitable. Rogers found such types in 17.8 per cent of his patients in India, this percentage being much lower than was seen in our series. How com- monly these atypical cases occur in the general native population is one of the unsolved problems of tropical medicine. Summing wp the clinical aspects, we found that more than one-third of the admissions were atypical and that the well marked cases of typhoid in the Philippines, whether the patients were white or native, differed im no essential respect from the same disease as seen in the United States and Europe. The experience corresponds in general with the findings of Rogers in India. The atypical cases were about equally common in the two races. RELATION OF BACILLUS TYPHOSUS TO THE SO-CALLED UNDETERMINED FEVERS. It seems ‘to us that the most important point brought out by the clinical study of the cases is the frequency of occurrence in the Philip- pines of the short irregular and atypical forms of typhoid fever. Groups II. and III. constituted 38.7 per cent of the entire 157 cases of typhoid infection. These two classes of mild infections formed 45.6 per cent of the total admissions at Ludlow Barracks and 69.2 per cent of the ad- missions among the Scouts at Camp Gregg. Without laboratory exami- nations or the presence of a wide-spread epidemic, such as prevailed at Ludlow Barracks, few, if any, of these mild enteric fevers would have TYPHOID FEVER IN THE PHILIPPINES. 323 received a correct diagnosis. his clinical type of infection with Bacillus iyphosus may account for a considerable part of the so-called undeter- mined fevers met with in the Tropics, the prevalence of which in our army is shown in Tables III and IV. The sanitary importance of detecting such atypical typhoid cases is obvious. Throughout our analysis we have been on the look-out for cases cor- responding with the description of Brill’s disease but have seen none suggesting that condition or the recently described Manchurian typhoid. (24) DIAGNOSIS, PROGNOSIS, AND TREATMENT, In the well-marked cases of typhoid in the Philippines the diagnosis can be made by the usual symptoms and physical signs recognized in temperate climates. In the large group of short atypical fevers diagnosis is impossible without resort to laboratory procedures. The prognosis with favorable facilities for treatment is good, the mortality for the last few years, as shown aboye, being about 7 per cent and no higher than was seen in the United States. The study of our series suggested no- thing new in the direction of treatment. Hydrotheraphy was almost universally practiced and drugs were rarely used and only to relieve definite symptoms. The diet in general was liquid and consisted largely of tinned milk. PART IV. A STUDY OF RECENT TYPHOID EPIDEMICS IN THE PHILIPPINES. Many epidemics of typhoid fever have been recorded among troops in the Philippines before this Board began the study of the subject. The outbreaks chronicled below are ones in the investigation of which the Board took a share. The epidemic at San Fernando is of special interest in view of its occurrence in the native population of a town where there was no contact with an American garrison, the adjacent military post . of Camp Wallace being occupied by native Scouts. SAN FERNANDO (UNION) EPIDEMIC. In July 1910 we learned that an epidemic fever was prevailing in San Fernando and a member of the Board (Captain Bloombergh) was sent to investigate. San Fernando has a population of 16,000 and is located on the coast about 240 kilometers north of Manila. The municipal records show that cholera visited the ‘town in 1908 and is credited with 170 deaths. There are also recorded 34 deaths from intermittent fever, 26 from dysentery and diarrhea and 9 from menigitis for the same year. In 1909 there are recorded 45 deaths from dysentery and diarrhea, 12 from intermittent fever and one from meningitis. It is easy to see how typhoid may have been masked by. these diagnoses during 1908 and 1909. Statistics as to the amount of illness prevailing in 1910 were difficult to obtain. A native doctor said there were many cases and a mortality of 50 per cent. An intelligent priest reported much sickness but few deaths. An American teacher stated that out of an average enrollment of 392 children there have been 28 cases of fever with 1 death. 104912——5 394 CHAMBERLAIN. We obtained blood specimens from 25 persons who admitted having had the fever during the preceding 3 months. Two of these were evidently dysentery, and from the remaining 23 we obtained positive Widal reactions in 20. In addi- tion one of the 18 specimens also agglutinated Bacillus paratyphosus “B” while all gave negative reactions with Bacillus paratyphosus “A”. Thirteen other natives who furnished no history of fever gave negative serum reactions with typhoid and paratyphoid bacilli. Cultures were made from the stools of 4 of the school children AM with a febrile disease, and Bacillus typhosus was isolated from two. One of these two patients gave a positive Widal reaction and from the other no blood was obtained. The sister of this last case had died with a disease of similar clinical nature. In one house visited there had been originally 11 occupants of whom two, both children, had recently died with fever. Hight others were sick at the same time, the mother alone escaping. Of the 8 who had been ill 5 gave positive Widal reactions. ‘These two instances show how the disease may have spread by contact but it must not be forgotten that in San Fernando, as in other Filipino towns, there is excellent opportunity for the spread of the disease by any or all of the recognized methods of infection. Blood smears from 42 natives, inluding all of the cases recorded above as giving positive typhoid findings, were examined for latent malaria and no organ- isms were discovered. FORT MILLS (CORREGIDOR) EPIDEMIC. Three cases occurred on this island in December, 1910 and January, 1911. The first case was the wife of a white civilian employee. The next two cases were white soldiers. Two other soldiers suffering from continued fever also gave positive Widal reactions combined with negative cultural results from blood and stools. As these two men had received antityphoid vaccination, it is uncer- tain what the cause of their fever may have been. Several other soldiers with fever gave negative Widal reactions. A fourth case of undoubted typhoid in a native woman occurred in May, 1911. ; The source of the infection ‘in the above instances remains undetermined. The sanitary conditions on Corregidor were not favorable at that time because of the crowding and the great amount of construction going on. There was a large American garrison, a smaller force of Filipino troops and several thousand Bilibid convicts and native laborers engaged in work on the island. In addition many of the laborers had their families living in a village on Corregidor. The water supply was unsatisfactory in quantity and quality and the disposal of excreta .was for the most part by dry earth closets or even more primitive methods. CUARTEL DE ESPANA (MANILA) EPIDEMIC. Nine cases oecurred in company “M” of the 26th Infantry, all being taken sick within one week. No ‘cases occurred in any of the 7 other companies at the post. The sanitary conditions were very good at this station and were the same for all the companies. The cook for company “M” had a short fever and gave a positive Widal reaction. It was learned that two years before in the United States he had had a fever of a month’s duration followed by a relapse also lasting one month. It was thought that he might be a carrier and respon- sible for the outbreak in his company. However, efforts to demonstrate the bacilli in his stools and urine were unsuccessful. The men attacked were not élosely associated with each other in barracks so it seems probable that contact infection was not a factor in this epidemic. : TYPHOID FEVER. IN: THE PHILIPPINES. 325 LUDLOW BARRACKS (PARANG) EPIDEMIC. During the years 1909 and 1910 a very extensive epidemic occurred at this post, there having been 80° admissions to hospital in a period of six months beginning October 1, 1909. The official population of the post for the period averaged about 850 persons. Two cases diagnosed as typhoid occurred earlier in the year, July and August, but whether these had any bearing on the susequent epidemic can not be determined. The admissions by months, including civilians, are as follows: TABLE XVII.—Admissions for typhoid fever at Ludlow Barracks, Mindanao. 1909 1910 Au-| Octo- |N D J F pues = u- cto- ovem-|Decem-| Jan- eb- ' . AS July. gust.| ber. ber. ber. | ary. | ruary. March.| April. May. Admissions: Number ____- pe al 47 3 4 3 12 211 OQ} Oi vee Per 1,000___-_}______ e-a=4|,, 02.69 3.45 GH |) “Bais || seals) Oa h Ge eee ee Mean strength |______|__--- 892 868 726 837 988 870): ee Ee ae of command. all 4 See footnote 3. b These figures are based on an examination of the post records and the actual clinical histories. They differ from the figures in the office of the chief surgeon, Philippines Division, which showed 4 less cases for October, 1 less for December, 2 less for January, and 2 less for March. The differences are due to certain civilians not being included in the official records. At this point it may be of interest to note that the records of the post show that there was a small epidemic of enteric fever at Parang in 1902, the admis- sions having been as follows: Ra June, 1; August, 1; October, 4; November, 6; December, 1. At the time of the occurrence of the 1909-1910 epidemic the sanitary condi- tions at the station, except for the water supply, were good. The post of Ludlow Barracks is located on an elevated, easily drained site, the grounds were well policed and the barracks and quarters were of modern construction. Excellent water closet and bath fixtures had been installed shortly before the outbreak, the outfall being in the ocean about 600 meters from the post. Jus were not common, this ‘being the rule in the Philippines. At the time of the occurrence of the October cases ‘the garrison had been stationed at Ludlow Barracks for a period greater than the longest recognized incubation period for typhoid fever, even granting that the early cases had been sick a couple of weeks before the disease was discovered. Distilled water was supplied for drinking, cooking, cleansing of the teeth, and for dish washing and its use enjoined by orders. There was no reason to think *The Twenty-third Infantry, which formed the garrison at Ludlow Barracks during this epidemic, embarked March 20, 1910,’ on transport en route to San Francisco via Manila. At Manila ten suspects were transferred to the Division Hospital. Of these 4 proved to be suffering from typhoid. These should be included in the Parang epidemic, bringing the total number of cases up to 80 in six months. These 4 developing on the transport have been included in’ the i admissions we March in fable XVII. j 326 CHAMBERLAIN. this water was contaminated. For flushing of closets and for bathing the supply was obtained from the Nitwan river, a rapid mountain stream draining a country inhabited by Moros and but little known. The water was piped about the post and in the adjacent town of Parang which is largely frequented by the soldiers. That this water at times was used for drinking, dish washing, and cleansing of the teeth can not be gainsaid. (4) The Nitwan river is undoubtedly extensively contaminated with fecal matter. (7) It is a custom of the Moros to defecate in running water. That typhoid fever is by no means infrequent among the natives in Mindanao seems certain from the opinions referred to near the beginning of this report and from our own work. The Nitwan water was examined at the times of the two visits made to the post by members of the Board. No typhoid bacilli were isolated from it but its bacterial count was very high and it was extensively infected with the colon bacilus. (5) (6) Examination of the dock water (piped from a spring-fed stream) and of the Alphonso XIII spring, which supplied the swimming pool, showed high bacterial counts and the presence of a few colon bacilli. The town of Parang is a small village immediately adjacent to the post and depending for its support entirely upon the American garrison. A series of serum reactions with Bacillus typhosus made by this Board during the epidemic on 84 of the inhabitants of Parang gave the following results: TABLE XVIII.—Widal tests on the inhabitants of Parang, Mindanao. Number oe c Sick at Positive | Negative] ;; Race. exam- Fi 5 time of ined, |reaction.|reaction.) “pec, Chinese abs Seer deb lala ee 8 1 7 0 | NP DAN CSC erste Noses oe pe oe eae 10 6 4 4 MOO cen 0 52 ee Se Pee aan ree ae 12 1) 11 0 | RIN OOS ee et set me a eta 1 0 i 0 | Pilipinos.: 1s: sous ee 53 5 48 1 MG tally. MARINE ARES LIN COR nd 84 13 | 71+ 5 The five reported sick were all suffering from a disease clinically typhoid while two others who gave positive reactions had slight fever but no other symptoms. One of the latter was Japanese and the other a Filipino. A number of these sick persons were Japanese and Filipina prostitutes and their houses were still open to soldiers while the inmates were ill and not in any way isolated.(7) The opportunities to contract infections are obvious. Major Page, who was Surgeon at Ludlow Barracks during October, November, and December, in a report dated December 22, 1909, expressed the opinion that the epidemic was water-borne, the source of infection being the Nitwan River. He considered that the peculiar grouping of the cases in certain barracks was due to the Nitwan water supply having been first installed in those barracks, shortly before the outbreak. The evidence as to the coincidence of the dates of installing the pipes and the development of the cases in October seemed to us rather conflicting. During the later period of the epidemic, after Major Page’s departure, the same peculiar grouping of cases was evident although at that time the water was installed for all the barracks. The disease continued to occur after Major Page left Ludlow Barracks, flared up in March and April and then disappeared entirely following the departure of the 23d Infantry and a very complete and thorough disinfection of the TYPHOID FEVER IN THE PHILIPPINES. 327 barracks before the new garrison entered them. This was carried out under the supervision of Major Clayton who believed the epidemic was spread by contact and not by water. This Board made two investigations of the epidemic, one in the fall of 1909 and the other in the spring of 1910.(5)(6) From all the evidence at hand several months after the disease had entirely disappeared we concluded: (1) That the Nitwan river was badly contaminated with human excrement and that very probably some of the cases originated from drinking this impure water at a time when it contained Bacillus typhosus. There was no positive evidence to show how the first cases originated. (2) That the spread of the epidemic was due mainly to contact infection, ineluding in this the probability of cooks or attendants infecting food while handling it in the kitchens and dining rooms. We based this opinion mainly on the following facts: (a) The vast majority of the cases for the whole period of six months were peculiarly grouped in certain barracks, one group of adjacent organizations having few or no cases while another group of contiguous buildings had many cases. (6) The cases in Parang, where unboiled Nitwan water was prob- ably in very general use for drinking, were all among individuals coming in close personal contact with the troops. (c) No cases occurred among the officers and non-commissioned officers living in separate quarters. (d) Typhoid disappeared from among the troops at Ludlow Barracks following a change in the garrison and rigid disinfection of the buildings. The period of freedom has now’ been over a year.‘ (¢) There was complete failure to suppress the epidemic by means of stringent measures based on the water borne theory. The dates of admission of the cases to hospital largely supports the contact theory, but too much reliance should not be placed on this point since the clinical records indicate that many men had been sick between one and two weeks before going on sick report. j Efforts were made to locate typhoid bacillus carriers but without success. A more extended discussion of some features of this epidemic can be found in the references (4), (5), (6), and (7). A “spot map” of the post and the dates of admission are on file in the offices of the Surgeon General of the Army and the ehief surgeon, Philippines Division under the heading shown in reference.(6) The clinical aspects of the Parang epidemic are of considerable interest as possibly showing a rather unusually large percentage of extremely mild cases. The diagnosis in all cases, was made as a result of a positive Widal reaction (1 to 50 in one hour), nearly all of these serum tests having been performed by members of the Board. None of the patients considered had ever received anti- typhoid vaccination. In several instances the blood, stool or urine cultures were positive for Bacillus typhosus. On many soldiers suffering from slight indispositions the Widal reaction was tried with negative results. Including the July case and the 4 cases detected after the 23d Infantry left Parang we have clinical records of 81 patients in whom there was a positive Widal reaction. Of these three died, a mortality of 3.7 per cent. One showed at autopsy “congestion and slight ulceration” of Peyer’s patches. He apparently died of overwhelming toxemia about the 17th day of the disease. The second patient died of toxemia on the 22d day and at autopsy showed the character- istic intestinal lesions of typhoid. The Bacillus typhosus was isolated from the ‘Hight months after the epidemic ceased one case of typhoid was admitted to the hospital. The patient was a native. Three months later an American civilian was admitted with typhoid fever and two months after this another native, the latter coming from a neighboring barrio. 328 CHAMBERLAIN. heart blood. The third case died of general peritonitis following perforation” Of the ileum. Autopsy showed enlarged and ulcerated Peyer’s patches. ’ Forty-one cases, constituting 50.6 per cent of the whole, show on the chart: a continued fever ranging from sixteen to forty days and averaging 26.4 days. The temperature charts of 33 were eserd as typical of typhoid, showing a well marked fastigium which averaged 38~.8 C: in three cases 39°.4 C. in seventeen, 40° ©. in twelve, and 40°.5 C. in one. Diarrhoea was noted in 11, constipation in 21 and feulatity of the bowels in 9. Rose spots were recorded in 7 cases and dicrotie pulse in 6. Complications occurred in the shape of multiple peripheral neuritis in one and _post- typhoid psychosis, requiring transfer to the United States, in another. In this group of 41, Bacillus: typhosus was teens from the bload of two, the stools of two and the urine of one. The records of 27 of ‘the cases (constituting 33.3 per cent of the whole) showed temperature curves which résembled the last week or ten days of a typical typhoid chart. In one of these 27 cases Bacillus typhosus was .isolated from the stool, in another from-the urine. It is believed that these patients had been suffering from a mild attack of typhoid fever’ for pee ranging from. five to fifteen days before admission to hospital. ‘A third group consisting of 10 cases (12.3 per cent of the sails) raveieg trivial rises of temperature lasting for a few days and bearing no resemblance to the classical typhoid fever chart. All showed clear-cut serum reactions and from the stools of 3 the Bacillus typhosus was recovered. There is no reasonable doubt that all were suffering from extremély mild and atypical typhoid fever, or else were just at the end of.an attack which had never caused them to be excused from duty. Their actual appearance on sick report was not due to their own volition but was the result of the general taking of temperatures and admission to pop of all who showed any degree of fever. Of the 81 cases considered above 3 were natives and the remainder Danenta me. The total number considered (81) does not include the 5 cases in’ the adjacent town of Parang and referred to in Table XIX. : ‘Taken as a whole, the epidemic was characterized by constipation, absence af haemorrhage, very slow pulse, rarely over 100 and often normal, by a large ratio of very mild or ambulatory cases, and by a low mortality, 3.7 per cent: An analysis of the October epidemic was made by Lieutenant Charles T. Dulin and of the WEE period of the gpaceute by Lieutenant Cie K. Fronk. CAMP ELDRIDGE (LOS BANOS) EPIDEMIC. Eleven cases of typhoid fever occurred at this post during July and August, 1909, the garrison consisting of 4 companies of the 7th Infantry. The cases were quite evenly distributed. One _patient was a commissioned officer and of the 10 enlisted patients 4 came from “C” company, 3 from’ Cay company, 2 from By company and 1 from “D” company. i The post of Los Baiios is situated on’ an "elevated, well-drained site. The éarth closet system was in use at the time of the epidemic. The water for drinking purposes was boiled. That for bathing is derived from a stream, the intake being a considerable distance up on Mount Makiling. The possibility of its having been infected can not be excluded. An effort made at this laboratory to find carriers. among the company cooks or elsewhere in the command was unsuccessful. The garrison left Fort Wayne, near Detroit, (where typhoid is said to have been common) on April 30, 1909, and arrived at Camp Eldridge on June 6, 1909. The first case of typhoid fever entered hospital July 3, 1909. A study of his chart and of the charts of the next two cases, admitted July 9 and TYPHOID FEVER IN THE PHILIPPINES. 399 10 respectively, would indicate that the patients came into the hospital in. the first few days of their typhoid course. It appears, therefore, that the infection of these first cases was gained after the troops arrived at Camp Eldridge. As far as could be learned, there was no typhoid fever in the adjacent town-of-. Los Bafios except for the case of a soldier who while on furlough had been living at the hotels in Los Bafios and developed typhoid there. He subsequently died ‘of the disease in the Division Hospital.(8) The ice and bottled waters produced by a commercial company in Los Bafios fell under suspicion, since they were in use among the soldiers. Samples of the bottled products examined by the Bureau of Health in Manila were negative for the bacillus of Eberth. It was found impossible to locate the origin of the epidemic. Its manner of spread was not definitely determined but was very probably due to flies which were numerous at that time and may have carried the organism from the dry earth closets infected by the first case. Of the 11 cases reported as typhoid 10 presented iivenatin irene a febrile periods ranging from twelve to forty-one days and averaging 23.1: days. All but one of these showed a well-marked fastigium. From: the blood of 4 the Bacillus typhosus was isolated, four others gave positive Widal reactions: and in the two remaining cases no Widal reaction was performed but the diagnosis was elear on clinical grounds. The eleventh case diagnosed as typhoid is of a doubtful nature. The tem- perature curve is not characteristic and one Widal reaction and one blood culture, both done on the 11th day, were negative. A large number of mild cases of fever occurring in the command at the time were negative for Widal reaction and blood culture at the Laboratory ofthe Board for the Study of Tropical Diseases. As dengue was epidemic in the post at the same time as the typhoid outbreak, the number of cases requiring labora- tory observations was considerable. The progress of the disease in this epidemic was characterized by lassitude, headache, constipation, rose spots, enlarged spleen and dicrotic pulse. The charts indicate that constipation existed in 7 patients, regularity in 1, and abnormal frequency of bowel movement in two. Abdominal pain was marked in one case, delirium in another and intestinal hemorrhage in two. There were no deaths. CAMP GREGG (BAYAMBANG) EPIDEMIC. _ Fifteen cases of typhoid are recorded among the Philippine (native) Scouts at this -post between November 26, 1909, and April 5, 1910. Thirteen of these gave positive Widal reactions at the laboratory of the Board. As the other two had an irregular fever and as Widal and stool alounes were negative, ‘we have excluded them from consideration. This epidemic is of much interest because the entire command at this post is native with the exception of the commissioned officers and a half dozen _non- commissioned staff officers. The post is built on a slight elevation, located in a broad, poorly denied plain. The region is very malarious. The barracks are in rather poor condition. Feces are disposed of by the dry earth closet system. Flies are not common. ‘Drinking water is distilled. Water for bathing is piped over the post and drawn -from the Agno River, a muddy and badly contaminated stream: There: is no doubt that the Scouts frequently drink this water in the post and in the town of Bayambang, which adjoins the post. Lieutenant Huber in his report of the epi- demic expresses the opinion that typhoid is constantly present in Bayambang and states that he has seen several cases in the families of Scouts living in the town. 330 CHAMBERLAIN. The clinical histories of these cases are very meager, but the charts show some points of interest. Two of the cases are classed as typical typhoid, the febrile course being at least twenty days in one and nineteen in the other. There was a well-marked fastigium. One case had a relapse of twelve days’ duration and the other a post-typhoid psychosis. Two others might have been diagnosed clinic- ally as very mild typhoid, the febrile period after entry to hospital being between ten and twelve days and the temperature curve not typical. The nine remaining eases showed fever for a week or ten days and may well have been either entirely atypical or the last portion of a typical typhoid chart. The stools during convalescence were negative in these thirteen eases and cultures from small quantities of blood taken from several in the earlier part _ of the disease were negative. The specific diagnosis of typhoid rests solely on positive agglutination reactions with Bacillus typhosus. We might question the certainty of this method of diagnosis in the atypical cases were it not for the following points: (a) Two of the cases gave first a negative reaction followed a few days later by a positive one. (6) Many Scouts at the post during the same period who were suffering from mild fevers reacted negatively. (c) We have done Widals on several hundred healthy natives and only rarely have obtained a positive reaction. The writer as representative of the Board at the present time, wishes to acknowledge his obligations to the many medical officers at the Division Hospital and throughout the Philippine Islands who have furnished the materials for the laboratory studies and the clinical records for the analysis, and also to the former members of the Board who did a large part of the laboratory examinations on which this report is based. PART V. CONCLUSIONS. 1. Typhoid is a widely scattered and common disease in the Philip- pines; ‘its incidence in Manila is above the average rate for the United States and is exceeded by only a few of the worst American cities ; the average admission rate among American soldiers in the Philippines exceeds that for the troops serving in the United States; medical officers from many regions report its frequent occurrence among the Filipinos. 2. The statistics from the Filipino (native) Scouts show a much lower typhoid rate than for white troops, possibly due to failure to diagnose the atypical cases. 3. Widal reactions performed on the blood of 591 healthy Filipinos suggest a comparatively recent attack of typhoid in about 6 per cent of adults, but do not indicate that the disease is prevalent in childhood. 4. Many epidemics have occurred among soldiers in the Philippines and three outbreaks among natives have been studied. Epidemics of great severity among the Filipinos are either rare or unnoticed. 5. The occurrence of the disease in the Philippine Islands is quite evenly distributed throughout the year. The incidence is least in the second quarters. 6. The appearance of the Widal reaction in typhoid fever in the Philippines is not as a rule delayed. TYPHOID FEVER IN THE PHILIPPINES. Soll %. Paratyphoid organisms are occasionally isolated in the Philippines. 8. The leucocyte count in typhoid remains normal for whites and is slightly increased for natives. The differential count is normal for both races. 9. The mortality for white troops in the Philippine Islands during the last five years has been no higher than at home. It appears some- what higher for Filipinos but this may be due to failure to diagnose all the mild cases. 10. More than a third of the cases of enteric fever, whether among Americans or Filipinos, are entirely atypical and can not be diagnosed without laboratory methods. 11. Over one-half of the cases oceurring in the Philippine Islands can be diagnosed clinically and differ in no essential particular from typhoid fever as seen at home. This is true for both American and Filipino eases. 12. Much work still needs to be done among the natives to estimate the actual amount of mild and atypical typhoid which is occurring and to determine why extensive and destructive epidemics are not more often seen. REFERENCES. (1) Manson, P. Tropical Diseases. London (1907), 311. CASTELLANI, A. and CHALMERS, A. J. Tropical Diseases (1910), 800. (3) Rogers, L. Fevers in the Tropics (1910), 110 to 148. (4) Page, Henry. Report of Typhoid Epidemic at Post of Parang. Report made to Surgeon General, U. S. Army, December 22, 1909. (5) Puaren, J. M. and Kirsourne, E. D. Work of Board for the Study of Tropical Diseases. Mil. Surgeon (1910), 27, 56. (6) CHAMBERLAIN, W. P., BLoomBpercu, H. D. and Kirpourne, HE. D. Report of Board for the Study of Tropical Diseases. The Mil. Swrgeon (1910), 27, 529. ; (7) CLayron, JERE B. Report as to cause of Epidemic of Typhoid Fever at Ludlow Barracks. Made to Chief Surgeon, Department of Mindanao, April 13, 1910. (8) PHaten, J. M. and Kirgournr, E. D. Report*of Board for the Study of Tropical Diseases. Made to Surgeon General, U. S. Army, September 30, 1909. (9) HetserR, V. G. Unsolved Health Problems Peculiar to the Philippines. Phil. Journ. Sci. Sec. B (1910), 5, 171. (10) Jackson, T. W. The Clinical Side of Disease in the Philippine Islands. Med. Rec. (1910), 76, 511. (11) Nicnoxrs, H. J, The Simple and Double Continued Fevers in the Philip- pines. Mil. Surgeon (1908), 22, 365, (12) Bruns, E. H. Notes on Epidemic of Typhoid Fever at Iloilo. Jbid., 369. (13) Nicuots, H. J. Medical Survey of Taytay. Phil. Journ. Sci. Sec. B (1909), 4, 281. (14) Huser, BE. G. Report on Typhoid at Camp Gregg. Made to Chief Sur- geon, Philippines Division. CHAMBERLAIN. LAGARDE, L.. A. Comments on Epidemic Typhoid with Hspecial Reference to Contact Infection. Mil. Surgeon (1908), 22, 373. 16) Report Surgeon General, U. S. Army, Fiscal year 1902, page 56. ) Report Surgeon General, U. 8. Army, Fiscal year 1903, pages 46, 142 and 151. Report Surgeon General, U. S. Army, Fiscal Year 1904, page 70. Oster, W. Modern Medicine. Philadelphia (1907), 2, 70 to 230. Hiss, P. H. and Zinsser, H. Text book of Bacteriology (1910), 401. Strone, R. P. Johns Hopkins Bulletin. Baltimore (1902.) Mortality Statistics. Reports of Census Office. Washington (1908), 32. Havarp V. Military Hygiene (1909), 22. Editorial, “Manchurian Typhoid” and Brill’s Disease. Med. Rec. (1911), 79, 535. ~ ILLUSTRATION, ; the distribution of typhoid fever in the Philippine Islands in so as it has come under the observation of the military authoritics. Meeks ores Gite : 4 4 | i ; ee 1 t = : 1 : t * Px, , *', - - eS : Ss Shui 2 Re Sae e | ; ' ake er hui 4. oS ee ‘ } ae “ee “ a . ds Z : “ ae Lae i} & a ! - 2 Ap. ee : ad cs a E i Me ; e 4 vee - Loe e ; 4 nie i ul ; bn rf Hog 4 5 : | a . peoechelii | + f . Coc Ge Settee a i ie + 13 i > | 7 a: t j a ie ; @ : 6. a ; } SG + Sosa : f Bh ae HS sn e; ¢ a a ; ; 5 = es I 3 wa Q a Se ie ae oe qa ! = : fA. 4 eau > = : a 1 Seo . are 2 " fii 4 ‘ sass | Phe] Zoe . 2 } ae eng 0 8 Cea r= ' 4 f 4 I i i aa s + i ; : 2s Se ae | CHAMBERLAIN: TYPHOID FEVER IN THE PHILIPPINES.] [Put. Journ. Scr., Vor. VI, No. 4 (Y Baran ISLANDS aS Balintange Channel 2 ip DISTRIBUTION OF {fYPHOID FEVER (i Basuva ISLANDS in so far as it has come under the observatipn of the MILITARY AUTHORITIES. ( See Tabfle V.) (CO indicates. whelre cases have occurred amofng Americans. © indicates whejre cases have occurred. amomg Filipinos. indicates where cases have occurred among both races. 7 PRB ESI AN “as ", 4 io) \ VA. ECIUA S i t Bey; &/ TARLAC zi. GIFIC OCEA ‘duanes I. Cea/amianes Is, fe 26, Le py! A : Gena bY é eR Des Kagayanes Is. Kavill 12° «ub-Bataha 220 SWE wy) SEA Ces L 9 0° St Michael Is. voM I NDAN og 8 ee 4 oe ® # Qkagayan Sulu } i @ 7. o COTABATO ; v DIsTRIeCT! i DIs|\TRICT Davao. Gulf {| Saranga™ o Sarangoni fs. 1220 124° t26° MAP SHOWING THE DISTRIBUTION OF TYPHOID FEVER IN THE PHILIPPINE ISLANDS IN so par AS IT HAS COME UNDER THE OBSERVATION OF THE MILITARY AUTHORITIES. THE WASSERMAN REACTION IN SYPHILIS, LEPROSY, AND YAWS.’ By Horace D. BLoomMBERGH.* (From the United States Army Board for the Study of Tropical Diseases as they BHexist in the Philippine Islands.) — These observations were undertaken with a view of determining if the Wasserman reaction could be obtained in certain tropical diseases in which it has been reported by some authors to be positive. Owing to a scarcity of material at the time the work was being done we were able to examine only two cases of yaws. The methods we employed for making the tests followed in general the original procedure of Wasser- man except as regards the antigen, which was prepared from normal guinea-pig heart. Sheep are not slaughtered in Manila and fresh sheep’s blood from different animals can not therefore be obtained. The cells used in all our tests were obtained at different times as needed from the blood of the same sheep. Only during the last series of tests did the suspicion arise that the sheep had been bled too frequently, and therefore the cells were fragile and less resistant than usual to the combined influence of amboceptor and complement. The cells were thoroughly washed and used on the same day as prepared. The dose was 1 cubic centimeter of a 5 per cent suspension in 0.85 per cent salt solution. The complement was the serum of a guinea pig killed on the day of the test. In this factor we found great variation in concentration. At times the serum was found to be almost devoid of complement. On several occasions we attempted to preserve the complement by the addition of sodium chloride according to the method of Hecht(1) but without good results. The dose of the complement was 0.1 cubic centimeter, or, as employed in actual practice, 1 cubic centimeter of a 1: 9 dilution, in salt solution. The hemolytic amboceptor was the inactivated serum of a rabbit. which had been immunized by successive doses of well-washed sheep cells. As a rule, we have used the amboceptor in the dilution of 1: 600. Our practice has been to take at least twice the amount which, with 0.1 cubic centimeter of complement, _ completely hemolyzed 1 cubic centimeter of a 5 per cent suspension of blood cells in one hour, requiring, however, complete hemolysis with the quantity used in “+ Read, by permission of the Chief Surgeon, Philippines Division, before the Highth Annual Meeting of the Philippine Islands Medical Association at Manila, . P. 1, February 22 to 24, 1911. ? Major, Medical Corps, United States Army. 335 336 BLOOMBERGH. one-half hour. The invariable dose was one cubic centimeter of the diluted serum. The amboceptor has remained stable for over four months, preserved after in- activation in sealed ampoulles. The blood serum of the patients as a rule was removed from the veins at the bend of the elbow on the day preceding the test and the serum from the clot was inactivated on the same or following day. It was found later that 0.6 or 0.8 cubic centimeter of serum could be obtained from the blood removed by deep puncture from the finger and collected in small tubes. The serum resulting from the clot was centrifugalized and later placed in similar small tubes, floated on corks in water and inactivated. All inactivation was done at 55° to 56° C. for one-half hour. The serum at first was tried in the two doses of 0.1 and 0.2 cubie centimeter diluted with the necessary quantity of salt solution. Later the dose of 0.2 cubic centimeter was used exclusively. The antigen was made by grinding guinea-pig heart together with sand in a mortar and adding to this 50 cubic centimeters of 95 per cent alcohol. This was heated to 60° C. for two hours, shaken from time to time, and then filtered. The dose was found to be 0.1 cubie centimeter, twice this amount inhibiting hemolysis. The antigen has apparently remained a constant factor. The actual technique of the reaction as carried out by us does not differ from that usually employed. On all occasions on which the reac- tion was made, a positive syphilitic and a normal serum were used as the main controls of the effective specific action of our reagents. The sera were likewise tested to determine whether they, independently of - the antigen, bound the complement or whether they were actively hemo- lytic with cells alone, or in the presence of complement. While it was found in actwal practice that one hour was a sufficient length of time for the reaction, the final reading was always made at the end of two hours after the addition of the hemolytic pmbocepior a and red blood cells. At the time of our preliminary titration to establish the strength of our amboceptor, we made controls of cells plus complement, amboceptor and antigen, to show that the antigen did not inhibit hemolysis; and of cells plus complement and of cells plus amboceptor to show that hemolysis did not occur under these conditions. It is to be noted first of all that the results reached by us depend on the action of an antigen derived from normal heart and the question of the specificity of action of our antigen comes immediately into question. For our tests we have been unable to obtain syphilitic foetal organs in the city of Manila, and we may add that the work of others being conducted along lines similar to our work at the present time in Manila, is likewise undertaken with a similar antigen from normal organs. In July, 1910, Wasserman(2) still advocated the use of syphi- litic organs in the preparation of the antigen and the good results reached by Dean(3) on the reaction in idiots, referred to by Wasserman in his address, might indicate that in certain lines of research such an antigen is still a necessity. Bayly(4) used an alcoholic extract of rabbit’s heart and obtained as good results as with an alcoholie extract THE WASSERMAN REACTION. 337 of foetal syphilitic liver. The question is far from being decided but the weight of evidence would seem to indicate that extracts of syphilitic organs are not superior as specific antigens to the extracts of normal organs. . In all, 95 cases have been examined by us. Of these the following 76 gave negative results: Seventy-six cases showing negative Wasserman reactions. [Num- Num- ber . Clinical condition. ber Clinical condition. cases. cases. 18 | Leprosy. 1 | Exophthalmice goitre. 17 | Syphilis or suspected syphilis. 1 | Otitis media chronio. 9 | Syphilophobia. 1 | Pemphigus. 5 | Dysentery, amcebic, chronic. 1 | Rheumatism, muscular. 2 | Dysentery, amcebic, acute. 1 | Gastritis, alcoholic. 1 | Dysentery, bacillary, acute. 1 | Neurasthenia and syphilopho- 2 | Rheumatism, articular chronic. bia. 1 | Iritis. 2 | Dengue. 1 | Malaria, tertian, acute. 1 | Ulcer of the leg. 1 | Rodent ulcer. 1 | Fever, type undetermined. 1 | Liver abscess. 1 | Osteoma of the tibia. — \ lied Suspected leper. 6 | Healthy Filipinos. hel Tt will be observed that in the above list a certain number of cases are tropical diseases of a protozoal or presumably protozoal nature. It was our desire to work particularly on the reaction as applied to tropical diseases, but we have failed to obtain the material which we most desired. Apart from the syphilitics enumerated in the table our. negative results have not been disappointing, and are entirely in agreement with our ideas of the results of Wasserman reactions properly carried out. Many of the cases were taken from the ward for normal controls, but on account of the habits in general of many of our patients, we habit- ually used several normal controls at each examination. _ Certain cases were examined for purposes of diagnosis, notably the two following: A case of ulcer which gave a history of a sore of eighteen months’ duration on the dorsum of the nose. The first examination made of this patient’s serum showed a slight inhibition of hemolysis; subsequent examinations proved that the case was negative. Long continued: mercurial treatment had no effect on the condition, and the case was considered to be one of rodent ulcer. A case of osteoma of the right. leg, which gave a history of a chancroid or soft sore on the penis in 1901 and no history of secondaries or any other symptom or sign of syphilitic infection. The man noticed a swelling of the right shin in 1905 and states that occasionally it aches but as a rule he had no trouble in any way due to its presence. The soldier is married and his wife has two healthy children. Until the Wasserman test was used it was thought the tumor was very probably a syphilitic periostitis. 338 BLOOMBERGH. The seventeen cases in which clear luetic histories were obtained, but which gave a negative Wasserman reaction were, to a certain extent, disappointing, although the results were not out of accord with the findings of some other observers, as will be shown in the discussion a little further on. The three following are of interest among the syphi- litics who gave negative reactions. One case was a patient who had severe general rupial lesions and whose serum was examined one week after the administration of Salvarsan (‘606’). The case reacted negatively. However, it must be stated that the patient had been for a long time on very vigorous treatment with mercurials. He had not previously been examined with the Wasserman reaction because of our frequent negative results in cases under treatment. Another, which had been under mercurial treatment only three or four days reacted negatively. This soldier originally had a chancre in the inner canthus of the eye in which one of the Board had demonstrated Treponema pallidum. The reaction was made shortly after the appearance of a rash. Whether the absence of the reaction was due to an insufficient liberation of antibodies, or to the treatment received we are of course unable to say. A third case of more than passing interest was that of right-sided hemiplegia. This undoubtedly was a syphilitic condition occurring as it did in a young man who gave a history of a typical primary lesion, the usual secondaries, an iritis, and finally, almost two years after infection, a hemiplegia with aphasia. This patient had been thoroughly under treatment with mercurials and iodide, par- ticularly for the month or so preceding transfer to the Division Hospital. The Wasserman reaction was negative. That the condition was really syphilitic was demonstrated to our satisfaction by the marvellous improvement which the patient showed after treatment with Salvarsan. The remaining fourteen syphilitic cases which gave negative reactions had all been under treatment for several months. A symposium on the theory and workings of the Wasserman reaction was held at the Seventy-eighth Annual Meeting of the British Medical Association, and on this occasion Wasserman(2) made some statements which are pertinent at this point. He said exhaustive investigations have shown that in the majority of recent cases we can cause the disappearance of the reaction through quicksilver treatment. Ehrlich’s new arsenic preparation appears to cause in a higher per- centage the disappearance of the reaction; whether permanently or not can not yet be decided. Mulzer,(5) working both with the original. Wasserman procedure and with a modified method, has demonstrated that during a mercurial course the serum reaction may change frequently from positive to negative and again to positive at intervals and concludes that it can not be used to determine the sufficiency of a cure, and that for diagnostic purposes it should not be utilized during or immediately after a course of mercurial treatment. It is useless to repeat the various reports in the literature which show the poor results that are obtained in attempting to secure positive reactions with treated cases of syphilis. Harrison(6) quotes various authors who have proved that heated serum loses its deviating power to a certain extent. He found that after heating for ten minutes at 55° C. the complement for hemolytic amboceptor was lost and that in well-treated latent cases a considerably higher percentage of positive results were obtained by this method than with the same serum THE WASSERMAN REACTION. 339 heated ,for thirty or sixty minutes respectively. If this is confirmed, an improved technique in this direction may result for the investigation of the sera of treated cases. We note in his table of results(7) the statement that of 151 cases of secondary syphilis, 136 were positive; 15 were negative, and, in a footnote, he says that 13 of these negative ones had received at least one course of inunctions or injections. ‘The following is a list of our twenty cases which gave a positive Wasserman reaction. Twenty cases showing positive Wasserman reactions. | Num- Num- | ber of Clinical condition. ber of Clinical condition. ' cases. cases. — —| ——— ——— eed lj le 5'| Syphilis secondary. | 1 | Dementia precox. | 7 | Syphilis tertiary. 1 | Periostitis, chronic. | 3 | Leprosy. | 1| Rheumatism, acute articular 1 2 | Yaavs. i | (probably syphilitic). | } Ag } f ye a: | The small percentage of positive results obtained by us in cases of leprosy was referred to briefly in the last quarterly report of the Board. We stated then that 18 out of 21 cases were negative, and that of the three positive, one gave a clear history of syphilis of seven years’ duration. The two remaining positive cases passed from observation and we unfortu- nately were unable to make inquiry from them as to the existence of syphilitic infection or infection with yaws at some previous time. Wechselmann and Meier(8) have recorded one case of leprosy in which the reaction was positive, using extract of syphilitic liver. The case had originally been considered syphilitic, but later lepra bacilli were demonstrated in the lesions. Hitner,(9) after having obtained a positive reaction in a case of leprosy with a watery extract of leprous tissue, later secured in a second case a positive reaction using as an antigen an alcoholic extract of normal guinea-pig heart. Cases referred to frequently in the literature are those of Slatineanu and Danielopolu. (10), (11) Their first report referred to 26 cases of leprosy examined by means of leprous antigen and of these 20 were completely positive and 4 “more were reported positive, although the complement fixation was less com- plete. With alcoholic extract of syphilitic liver their results were different. Of 21 cases examined, 11 were “completely positive,” 5 apparently less so, and the remainder negative. At present the general tendency of workers on the Wasserman reaction is to deal with positive and negative reactions only, al- though occasionally the importance of partial reactions is emphasized. In this connection we might add that almost invariably our results have been distinctly positive or négative and only in rare instances has there been a partial arrest of hemolysis in negative cases. : Baermann and Wetter,(12) working in Sumatra, found that there was about 7 per cent of manifestly syphilitic individuals present among their laborers and that about 20-per cent of apparently healthy workmen gave a positive Wasserman reaction. Their percentage of positive reactions in leprosy varied between 50 and 65 per cent, the difference depending upon the type of leprous lesions present. Syphilitic antigen was used in their tests. 1049126 oe Sr le 340 BLOOMBERGH. From our own limited experience we consider it doubtful if a posi- tive Wasserman reaction is to be obtained as a result of infection with the Bacillus lepre. Before attributing a positive reaction in a leper to his leprosy alone it is necessary to consider the possibility not only of syphilitic taint but also of present or antecedent frambeesia. This latter is especially important when working with leprosy in those parts of the Tropics where yaws is prevalent. Recently, we have seen a Filipino leper who also showed typical lesions of yaws. In yaws we were able to make observations on only two individuals. The serum of one case was forwarded to us by Lieutenant J. R. Barber, Medical Corps, from Corregidor Island, and came from a young Fili- pino adult in the active stage of the disease. The diagnosis was based on the clinical appearances and on the presence of Treponema pertenue in the nodules. The second serum was obtained from a ten-year-old boy who had long been a frequenter of the skin clinic at St. Paul’s Hos- pital in Manila. Both of these sera gave the same strong inhibition of hemolysis that we obtained from our untreated syphilitic cases. The finding confirms the results of many others who have tried the serum reaction on yaws. It will be of interest to add that seven days after treatment with “606” in the Philippines General Hospital, to which we had transferred the boy and where we obtained the blood a second time through the courtesy of Dr. Donald Gregg, the serum reaction of the second case remained positive. Evidently the time was not suffi- ciently long for the substances in the blood arising from the activities of the Treponema pertenue to disappear. Incidentally, the recovery in this case was remarkably rapid, although the boy had done very poorly on the iodide of potash treatment given him at the clinic over a period of more than a year. : Of the syphilitic cases which gave positive serum reactions few had ever been on mercurial treatment and not one had been recently treated. Four cases gave negative histories of previous syphilitic mfection and in two the diagnosis could not have been made without the aid of the Wasserman reaction. One patient had been transferred to the Division Hospital with the diagnosis of chronic periostitis, cause unknown, and had been on sick report at intervals during the preceding eight months, the total period of disability being more than three months. The diagnosis of syphilis was made by us on the strength of a positive Wasserman reaction. The condition began to improve shortly after _ the inauguration of mercurial treatment and the soldier was subsequently re- turned to duty. A second man, “C. P.,” had been transferred to the Division Hospital with the diagnosis of malarial fever after a considerable time on sick report. There were no signs or symptoms in this case other than the presence of fever, and the serum was tested in the expectation of obtaining a negative result. The THE WASSERMAN REACTION. 341 reaction was positive. The therapeutic test confirmed the diagnosis of syphilis as the febrile condition disappeared promptly on the institution of mercurial treatment. The third case gave a history of previous syphilis. One thumb, showing - rupial ulceration, had been removed on account of the resemblance of the lesion to carcinoma, and the failure of the condition to improve on mercurial treatment. This case gave a good Wasserman reaction in spite of previous treatment with mereury and after an intravenous injection of Salvarsan, the rupial condition, which was then general, disappeared promptly. Altogether the Board has been pleased with the practical results of the Wasserman reaction and it is a matter of regret that we were unable to make a wider use of it in our study of tropical diseases because of difficulty 1m securing suitable material at this time. In conelusion, acknowledgment is made to the various officers of the Division Hospital, particularly Captain Snyder and Lieutenant Shields, from whose wards the majority of our patients were secured, for kindly cooperation and many courtesies extended. REFERENCES. (1) HecutT, Hueco. Zur Technik der Seroreaktion bei Syphilis. Ztschr. f[. Immunitatsforsch. Orig. (1910), 5, 575. (2) WASSERMANN, A. The diagnostic use of the complement fixation method. Brit. Med. Journ, (1910), 5, 1428. (3) Dean, H. R. An examination of the blood serum of idiots by the Was- sermann reaction. Lancet, London (1910), 179, 227. (4) Bayty, H. W. The practical value of the Wassermann reaction. Brit. Med. Journ. (1910), 5, 1430. (5) Muuzer, P. Zur Technik und praktischen Verwertung der Wassermannschen Reaktion. Ztschr. f. Immunitdtsforsch. Orig. (1910), 5, 247. (6) Harrison, L. W. The serum diagnosis of syphilis. Journ. Roy. Army Med. Corps. (1910), 15, 39. (7) Ipem. Ibid. p. 50. (8) WECHSELMANN und Merrer. Wassermannsche Reaktion in einem Falle von Lepra. Deutsche med. Wchnsch. (1908), 34, 1340. (9) Errner, Ernst. Zur Frage der Anwendung der Komplement-bindungsreak- tion auf Lepra. Wien. klin. Wehnsch. (1908), 21, 729. (10) SuatinraNU and DaNtELoporu. Sur la Présence d’Anticorps spécifiques dans le Sérum des Malades atteints de Lépra. Compt. rend. Soc. biol. (1908), 65, 309. (11) Inem. Réaction de Fixation avec le Sérum et le Liquide Céphalo-Rachidien des Malades atteints de Lépra, en présence de l’Antigéne syphilitique. Ibid., 347. (12) BarRMANN and WerrTer. Die Wassermann-Neisser-Brucksche Reaktion in den Tropen. Miinchener med. Wehnsch. (1910), 57, 2131. REVIEW. Practical Bacteriology, Blood Work and Animal Parasitology including Bac- teriological Keys, Zoological Tables and Explanatory Clinical Notes. By E. R. Stitt, A. B., Ph. G., M. D., Surgeon, U. S. Navy; Graduate London School of Tropical Medicine; Associate Professor of Medical Zodlogy, Phil- ippine Medical School. * * * Second edition revised and enlarged with 91 illustrations. Cloth. Pp. 345. Price, $1.50. Philadelphia: P. Blakis- ton’s Son & Co., 1910. The reviewer’s prejudice against all pocket manuals is strong. As a rule they contain nothing but what may be had in the larger works, and in the attempt to abridge it becomes a task to know what to omit and what to include. Asa result many important facts are omitted, others are only partially stated, if not actually given a wrong setting, and hence the student receives a wrong conception of the actual facts in the case. While the volume under consideration is no exception to the above criticisms, still it contains some things that the student will not readily find elsewhere. It is more than a compilation of facts from larger works. The author has drawn extensively from his wide experience as a clinical laboratory worker and teacher, both in the temperature zones and in the Tropics, which gives the book a different setting from the ordinary pocket manual, and forms the real worth of the volume. The reviewer would not recommend it as a text-book, but the busy interne in the hospital and the practising physician would find it helpful and suggestive. Wiss ae 343 7 Brien 4 401, THE BONTOC IGOROT. _ By A. E. JENKS. 110 pages. 3 maps. -154 t photographic plates. 9 figures. An interesting study; the result of almost-a year’s residence among the Bontoc Feorais: Proce $1 United States currency, postpaid. Order No. 402, NEGRITOS OF ZAMBALES. oe | By WitLiAm ALLAN REED. 62 photographic illustrations. 91 pages. 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M. & J. ‘Ferguson, 19 Baillie Street, Colombo, Ceylon. - CIRCULARS AND DESCRIPTIVE MATTER SENT on APPLICATION. 7 CONTENTS, j Messrs. Velarde and Feliciano. ®Max Riibner, Ztschr. f. Biol. (1879), 15, 115-202; Karl Thomas, Arch. f. Anat. u. Phys. (1909), 219-302; Muneo Kumagawa, Virchow’s Arch. (1889), 116, 370-431. ¥ 365 RICE AS FOOD. R=} eo} i | CO = ot I— Lo "§&— “SUD. G&S 8s 9°CE ¥ 02 | 80°% 99°T $9 T &1'% 6 66 6 68, 610 90°L 1 i) 400 69 ‘TL. 9L°8 9L°% LO°L 19. r0'S CPOr | SST ‘SULD.D | ‘SULD.Lp 00°9 OFF b0S 6°38 "SUD GP “| LP Tr 06¢ ‘3 080 ‘2 G19‘ 016 ‘3 §10]0ULIyU80 ayqno gée S19JOMIIJUID dIqNd Ggc nAOYS SUIBIZ OT aaah Sd[UInj} SUIBIS 00S sete eta aos OSIUI SUIBIS OOT Leen ddI SUIVIS 009 Si9jeuIIUeD dIGnNd 008 Fraps sae cane BO} SIO}TT 1 NAOYS SUIBIS OT aor eoe sdruiny suv ocz emma care OSIUI SUIBIS 08 90 SUIBIS OCF PRESS 48S pus SUOTIE] Z —---IBS3NS 9UBO SUIBIS (OF —-— IBSNS F[LUL survss OZE Tee NOP VOM SuUIBIZ OOG -MOIIVUT OUOG SMIBIS 78 +40BIVXO {BOUL SUIBIS Fz OdII SUIBIS 8E9 8P | | : 6°GL GL “SOU ---- sounder *plo siv9d 43 -toyjNy esas TOUINY “pro sivot ¢Z UB] *(9) BMBSBUIN Y ~-(g) seuIouL = (7) couqny “Q0UB[Bq ued -OTJIN 94/8) UL jo jue0 Iod *‘SUIBID) OBIUL jo jua0 Jed *SUIBID *‘s008,T ‘QuTIN “pooy zeyjo ul TRIOL 2011 ul > —jnd 4n0- —uds01}IN —o4 BUT 4u stom Apoq TWRISO] “PT ted “18101 ‘SOHOTBD *qUuOTIT -I9d x9 jo u0on -BInqd ‘ “poy Atrea . ‘yoatqus ts “rOyInY TH Flav. 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Ries aR Cat aa J JUepNys [BoIpeW -| 8 008 cL OG Sirce ae | ages caer 00F 008 RS Ae Saraiae spear aga eee ODNeaas L OOF cL OG SS oe oi eee eae 00F | 008 OWE Ore ee slo hecigar ors waaare bak Oo 9 002 GL COI. ee |e Se 00F 008 OND SO eet oS ere eat q Ieuosiid | ¢ | | 008 o¢ OG Cae ee liner Sle DEES | 00Fa ORS ha Sa eee ea ra re ne OQ) Tr P | 008 0¢ OGD aie "Sse t eoeas “Soren OOF: ONG home acme so co (D0) 09¢0¢ Jeuostig | § eLT | 09 TBO Beak” iene gta |e ae ere OOF OSES: tee lero es ama a JUSPNIS [BOTpoWW | Z | | 0c 09 SSS ie ae acoso eee OOF LCE ee | ges are A Juepnys [BOI pay | T “SUID. | “SWDID | “SWDLD | “sw | “swD.UD | “suD.u9 *SOUUM | | aus) [eer es 22 ee Beer IE | | | (fears | ‘00D | ‘uooVg | “1B3NnS “USla “pRolg dy | | ‘faq | | | nusrom eitig ae | | Apo tS) | E ewes | rays SS | pod | aed | “Xo | “pooy JO oBzUI ATE “AL GITEAVE 367 RICE AS FOOD. ‘A[UO OULIN IOJ SOINSIY ‘“oIN[leJ BV Sadwy JO UOT}EIIUIIT o “peysi[od ‘soll euIG MA q *A[UO poysny ‘voll poy x Mm 2S (0) (2) GPL TZ‘ CORON RGO abe) | eiennninee |e (0) (0) | 9°08 48°9 910 7G°8 | 06 G 29°60 | CB) OTIS AOUOSIIg | ST | 80°0— | 0'0F 8c 0 g"¢9 ¢6 0 2800 | Sh°L 08 0— | L"Gz 86 'T T¢8 a9 1410 06°4 8% °¢ CONC heal | ees eet (*)) 98L8T toWOSTId | FL | OL ‘O— | a'r £10 9°LG IL'T €80°0 | LL'T &L‘0— | 12% 12°% T¢8 &L°8 610 4Z"0L | 06°¢ LOD lagi Scapa ot seg a ee Qe fat 2 0— | 6 Gh 91°0 9°L¢ 82 $80'°0 | 2L°T tL'0— | 0°61 £0°% P18 968 610 1Z°0L | 06°S DA Te lena see (CU) 4169 dauositg | 2r 290+ | b°S9 OP'S $°c% 88 'T FOL'O | 9F'¢ WAR | PLS G‘29 SLL €2'0 6P IL | 46°8 CONG eee rere aan aS ak Or 1 | TOO | 4°E | 2¢°0 9°OL PLT t80°0 | Lo°T 880+ | 0°FS #9°% GUL L6°L 1Z'0 66 ‘OL | LP's CONG gas | pes ee ee eas eee V Jouosiid | OL 100— | 0°88 6F ‘0 G29 080 $800 | 82°C 900+ | 9°12 69'T GL 06°¢ 810 09° 9L‘F Poko SElcRe Same sae (‘@) 410p Jauosig | 6 seme oie sania eee ir te [eee (ents a ei gememeal ckae ta AO = | TCeen CCI ingen OCs 8h: 9 8 TO) /kC096 5g (998¢) a) KOCei os ene incre cane sie UODNISI(¥OtDO Wie og0— | F'sE | 19:0 |o'88 | 49°T | 620°:0 | S8r |861—| 908 | 88's 1828 19976 | 2T'O | 90°1E | TG | 96 Qf OG I+ | L°LE CST | 218 | 9¢°T 1L0°0 | 16°F 80°3— | 8 FE §2'° 1°18 92°8 ct0 1h'6 916 CCRO) Mal sates Cates ce ee ees am OD eee 9 16'0— | L°8P €4°0 OOTS| FL°T €20'0 | 0G'T 19°h— | $98 68° 0'00T) Bacongilye-ae- ee | 0,75 | 0.056 Fish (dalag)—_______ S200 |o S222 oo 25 Fish (salmon) -_---- | 3. 60 0. 40 | Salt codfish_________ 4.37 0. 346 RONION Seseee eee 0. 14 0. 06 Gram. Gram. | TiO 8 ee ee Se ee ene Coffee 150 ce____ -__- ONOZIe) Eaeeeeeenes SiragOl TOA SY aa 5) sos Soe eerie Coffee 500 ce________ | 0.02 0. 016 L reeer peru’ Se Rr ce ee ea ON wl ie ae « Fat 12.2 per cent. » Fat 86 per cent. EXPERIMENT No. 1.—September 22 to 24, 1910 (subject, medical student V ; weight, 53.7 kilograms). | ae lows Calories | , Daily food. (OME 8: (estimated). | Grams | 400:grams rice I 222.2 a seats sees: Seen ee Se ee ee ae ae 4, 44 | 1,300 | | LooOigznamsirice Cakenloe 20. = _ 20 se .ce nec Ue tek hse hs em ce eRe eee 0.81 | 340 | LOO! gramsibananas-e<2! 23-2. ce. co sce ee ee eee ee ee 0, 22 80 | 40 PTAINSISUBAT 2-3 Sones oe een ee jane ee | 160 | 60 grams bacon I___ aotsosa| 0.49 , 480 | WG) (ESOS CON a ee Ss SE ee SE SS SEE SEE | O02 seas es | | Total intake per day 2. Je eee eS) ee ae Soca Reco SS ee ~ Analyses of urine. Day. |= — | Analyses of feeces. | i) Quantity. |Nitrogen.| | | ce. Per cent. September 22__________ | 530 (1, 000) , 6.09 |)61.5 grams feces containing &. 80 per cent nitro- September 23__-___-__- 560 (1,000) 5. 75 gen and 94,9 percentsolids. Total nitrogen, September 24________-_| 880 (1, 000) 5. 76 5.31 grams. Total nitrogen___|-------_------ 17.60 RICE AS FOOD. 375 Balance sheet, per day. Grams of nitrogen. Outgo in urine 5.87, Outgo in feces 1.77 Total outgo 7.64 Intake, total 5.98 Balance 1.66 EXPERIMENT No. 2.—September 22 to 24, 1910 (subject, medical student F; weight, 54.0 kilograms). ci ewe Calories Daily food. Nitrogen. (estimated). Grams. AQOVE rams TiCe Ih 2-55 Soa ea eee ee de eee eae 4.44 | 1,300 deecOO 2 TamMsirice cake Ursa. 2: [ea oe ees ee noes eee oo eee eenee 0. 81 340 STOWE ea OAS DLT) BUD GS see eae pee eee ee a Le ee 0. 33 | 120 BOSOM AMS SUS AT) nee ga 58 See ee en Se BS sede esate lake | Seuss Ss t- 160 GOR ram Sips Complete es ae ae ee Pet he i ee ak 0. 49 480 PHOS TATMSICOM EC Cis ee ee ee ee ne Ne eae = a ee es Seeks OR O23 Ewe ees | motwMpintake peri ays 22 2= ase ees ee 6.09 2,400 | | Analyses of urine. | Day. mae oo | Analyses of feeces. Quantity. | Nitrogen. | | | | ce. Per cent. September 22_____________ 930 4.87 |)75.0 grams dried feces containing 8.28 per | September 23____ .________| 1,075 4.92 cent nitrogen and 94.6 pet cent solids. To- | September 24___.___-_____| 725 4.78 tal nitrogen, 6.19 grams. Total nitrogen______|_--____-_-- 14.57 | | Balance sheet, per day. Grams of nitrogen. Outgo in urine 4.86 Outgo in feces 2.06 Total outgo 6.92 Intake, total 6.09 Balance — 0.83 376 ARON AND HOCSON. EXPERIMENT No. 3.—November 16 to 21, 1910 (subject, prisoner C; weight, ; 49.0 kilograms). Calories ,Pe0s.- (estimated) | Daily food. — Nitrogen. j Grams. | Grams. 400:grams Ticeiy2 2. - oni teh os aes eee ee a 5.16 3.08 1,350 100\grams! onions 22-225 on Ne 2 2 ie ae 0.14 v. 06 50 50 grams bacon II_ 0.38 | 0. 03 350 300; grams coffees 224i See aa eee 8 ee ee ety 0.15 (0:05 as5 ee ee Q0ierams lard |= e seo Bele Be a ES a Sa a | 8 ies - 150 H0SraAMS SUPA TE oa een oe ee a So esee dete yeses se sssee span ees eee eh ee eee 200 Total:intake:perid ay2=22 "ee ee ee een ene 5. 83 3. 22 2,200 Analyses of urine. Analyses of feeces. | Day. | Quantity.|Nitrogen.| P.O;. [eicuaeasen lNapeatsiaade iea 2 as ee ca ; | (GG: Per cent. | Per cent. | i) 1 aN b ee 640 ee, a 400 204 grams dried feeces containing 6.11 per cent Novae on “a 400 17.05 4,129 nitrogen and3.97percentP,O;. Total, 12.46 NOTE Ie 480 grams nitrogen and 8.10 grams P30;. © Balance sheet, per day. Grams. of Grams of nitrogen. P20;. Excretion in urine 4.26 1.03 Outgo in feces 3.11 2.03 Total outgo 7.37 3.06 Intake, total 5.83 S22 2 Balance ‘ —1.54 520) 116 #e) Peace ' ExprRimEenT No. 4.—November 22 to 25, 1910 (subject, prisoner C; weight, 48.6 kilograms). Senter co . | Calories Daily food. Nitrogen.| P,0;. (estimated). Grams. Grams. A0Q0 STAM SiTICClWilees saeco eee ee oe ee ee oe ee ees : 4.24 1. 28 1, 350 OOS ramsomi ons ees a ee a ee eee eels 0.14 006i) ee HOisramis: Dae om ss a ee oa ae Roe ee Te hue coe " 0.38 0. 03 390 800'srams Cofiee asta se te a es pcan eee ee 20 grams lard ____ Ol) EWING UG ta oe See ee ee Pe Totallintakeiperidaya2s0s=25225: Sook ae ee eee 4.91 1,42 2, 200 Analyses of urine. | Day. Rite Analyses of faeces. | Quantity. |Nitrogen.| P2O;. ce. Grams. Grams. November aaa gree 132.4 grams dried feeces containing 7.05 per November 23 ____ 1,305 i 17.04 4.16 cent nitrogen and 2.50 per cent P,O;. Total, November 24 ____ 850 , ; = | 9.33 grams nitrogen and 3.31 grams P.O;. November 25 ___- 980 “ RICE AS FOOD. Balance sheet, per day. Grams of Grams of nitrogen. P2205. Outgo in urine 4.26 1.04 Outgo in feces 2.33 0.83 Total outgo 6.59 1.87 Intake, total 4.91 1.42 Balance —1.68 — 0.45 377 EXPERIMENT No. 8.—September 27 to October 1, 1910 (subject, medical student F; weight, 54.0 kilograms). Daily food. Nitrogen. | estimated). Grams. OOl PAIN SiN Ge! Ty eee a SE I Se Pe es 4. 46 1,300 P20} ere s\ fi STi (Cal) sae) ps na Se eee oe ee 4. 26 100 PHO}e ram sibanan as) sss Sea ee es i ee ee 0. 33 120 POO STAINS nl COT CA) KEI yee eee ert een eee a nan eae oe oe So ES 0. 85 340 AOSTA SSL Sar eee mt eee ene ee Re a ee a Oo I i sees ~ 160 HOUSE NA IUS COLE = nen mee er anes Senne eae ae oo Le = 2 Neen O02) | Bae ee nee as BRANES PTI SCT le ee ee ie een NS SE A NEE Fe Se < Seer e S| ) BO ee ee 80 PRG Calera RES C1xG iyi cee ee ee a 9. 92 2,100 | Analyses of urine. Day. | Analyses of feeces. Quantity. | Nitrogen. Gs Grams. September 27 ____| 690 7.37 September 28 ____ 915 7.60 ||/46 grams dried feces containing 6.85 per cent nitrogen September 29 ____ 1,475 9.09 and 98 grams dried feces containing 7.73 per cent September 30 ____ 1,315 8.71 nitrogen. Total, 10.73 grams nitrogen (5 days). October 1 -----=_— Ibostag| Sessa Motel) 2s Aeuibens Gc. Ts 232.77 a4 days. Balance sheet, per day. Grams of nitrogen. Outgo in urine 8.20 Outgo in feces 2.15 Total outgo 10.35 Intake, total 9.92 Balance ; — 0.43 106073——_3 378 ARON AND HOCSON. EXPERIMENT No. 9.—June 27 to July 3, 1910 (subject, prisoner D; weight, 43.5 kilograms). l Me ‘ Calories Daily food. Nitrogen.| P20O;. (estimated). j — — == one Grams. Grams, 200) erams rice Jl 27k 23. MS ae ee eae 2.57 0.56 650 150 grams bread eect a eote se eoeaes eee Sse se see Sse sssssent 1.93 0, 24 300 NO PTAs SA lMMOM a eo ee tee eA en ae ee aia 2/84! 0.32 100 THO ras! SUp are oa ey ee a Ne sata cea noe 2 | ee oe 600 500" prams coffees. teas aN EE oh SRC eee ee See ee 0. 26 OG? |b 22 ees Total intake: perjsiday’= sass See ee eee ee ae oe: 7. 60 1,28 1, 650 Ss - ~ - — -———— = | Analyses of urine. | Day. — - — Analyses of feeces. Nitrogen.| P.O;. | Grams. | Grams. 11. 01 1, 419 140 grams dried feces containing 7.02 per cent nitrogen and 2.08 per cent P,O;. To- tal, 9.83 grams nitrogen and 2.91 grams P.O;. | 12. 96 1. 848 11. 41 1.563 DRO belli oes ea ese 39. 38 4, 830 Balance sheet, per day. Grams of Grams of nitrogen. P2035. Outgo in urine 5.90 0.80 Outgo in feces 1.64 0.49 Total outgo 7.54 1.29 Intake, total 7.60 1.28 Balance -++0.06 —0.01 EXPERIMENT No, 12.—July 23 to 25, 1910 (subject, prisoner H; weight, 54.0 kilograms). Daily food. |[Nitrogen.| PaOs. | scaler . | Grams. Grams. | 250: sTams Tice asker 3.075 0. 925 800 I) 2200's bree cee eat een ee seers ete tenn et US ee ree “2.56 0.34 400 | LCOS TAMS Salt COGS ee ees es ea ee eet 4.37 0. 346 150 | 100 grams sugar 3 | 500 grams coffee | Do teal etmibed en CTC Ey eee eee ae 10.265 | 1.77 1, 750 RICE AS FOOD. 379 EXPERIMENT No. 12.—July 23 to 25, 1910 (subject, prisoner H; weight, 54.0 kilograms )—Continued. Analyses of urine. Day. Analyses of feeces. Quantity. |Nitrogen.| P.Os. | | GG. | Grams. | Grams. : liv 23) 222 see 2, 030 9.09 1.65 |)74 grams containing 8.26 per cent nitrogen Muiy 242 28 1, 250 } 8. 80 1.13 and 3.01 per cent P.0;. Total, 6,112 grams OU yr 2b eee SS 830 (1, 000), 9. O1 0.91 nitrogen and 2.29 grams P,O;. Motalec: (ae. ere ok | 96.90 | 3.69 Balance sheet, per day. b 7 q 4 , : Gramsof Grams of nitrogen. 205. Outgo in urine 8.96 1.23 Outgo in feces 2.03 0.76 Total outgo 10.99 1.99 Intake, total 10.27 1.77 Balance —0.72 — 0.22 EXPERIMENT No. 13.—July 26 to 30, 1910 (subject, prisoner E; weight, 54 kilograms). Daily food. Nitrogen. Calories P205. (estimated). Grams. Grams. OOM HIN Sail COME see mete ca eee el Eee eer OS Sie Boo te 8.075 0,925 800 ZOD Fr Sn Lea Ces ae eer ee ee enn Se Pe ee 2.56 0.34 400 LOWE TAMISISAiTCOGTISh eee 1 2 none SE eee 4.37 0. 346 150 BUC) OOF UY SHS UL Ge Baye ese fe ete et ee BE Pee oe eee eee Soe 400 BUDE TR TNS CONC Cae as 2 eee een oe Soe ee ene ee 0. 26 OFIGh |b--s-See a Motalsintake per(d avec seas eee eee ee eS 10, 265 1.77 1,750 | Analyses of urine. Day. = apt Sats Analyses of feeces. | | Quantity. |Nitrogen.| P,0;. ce. | Grams. |\Grams. July 26 --| 660 (1,000) | 8.66 | 1.08 |}95 grams dried feces containing 7.18 per cent ni- | July 27 --| 640 (1,000) 8.41 | 0.98 trogen and 2.30 per cent P.0;. Total, 6.82 grams | July 28 __| 670 (1,000) | 9.13 | 1.28 nitrogen and 2.19 grams P.O;. July 29 __| 600 (1,000) 8.45 | 1,29 July 30 __| 580 (1,000) | 8.76 | 1.25 | 380 ARON AND HOCSON. Balance sheet, per day. Grams of Grams of nitrogen. P20s. Outgo in urine 8.73 1.11 Outgo in feces 2.217 0.76 Total outgo 11.00 1.87 Total intake 10.27 Wee Balance —0.73 —0.10 EXPERIMENT No. 14.—August 10 to 14, 1910 (subject, prisoner G; weight, 45.9 kilograms). 7° | Daily food. Nitrogen.| 205. | aloes ). | i sus zt plc cig a an | Grams. | Grams. |: (200) ‘gramsirices Bp 208 Seay ad BOL Se ee aes ere en eau nea | 2. 46 0.74 650 | 200 ‘grams “bread joke ee ele a eee 2.56 0.34. 400 | 50 grams sugar ____- co eS a ae ets GR e Sel MAE RRS EA eee 200 60serams' salt: icodfish=22. 2 St a eee ee 2. 62 0. 21 100 500 ‘erams \cofiee:to2-0 22s 5 eases ee Le eae ee ee 0. 26 (O16 eae | Motalwinitalcenp etal ajyameewa es seem aeeea nen guna cele 7.90 1.45 1.350 <= = = — ——— = = Analyses of urine. Day Analyses of feces. Quantity. |Nitrogen.| P,05. ce. | Grams. | Grams. | Aveqigh iat —--- 8 830 114 grams dried feeces containing 6.93 per cent | August 12 -_-.--- 1,020 96. 88 3.796 nitrogen and 2.04 per cent phosphoric anhy- August 13 _______ 1,570 dride. Total, 2.33 grams phosphoric anhy- August 14 __-.___ 1,550 dride and 7.90 grams nitrogen. Balance sheet, duration 4 days. Grams of Gramsof phospho- nitrogen. ric anhy- dride. Outgo urine » 6.72 0.949 Outgo feces 1.985 0.583 Total outgo 8.705 1.532 Total intake 7.90 1.45 Balance — 0.80 —0.08 «toa RICE AS FOOD. 381 EXPERIMENT No. 15.—June 16 to 21, 1910 (subject, prisoner H; weight, 53.0 kilograms). : Daily food. i Nitrogen.| P.0O;. (esimarea) Grams. Grams. PAO FRATEAT TA SUNT CC iss ears te ee ae ee Ds se Ee ae cet RUS I 3. 08 0.93 800 DANG) CAD cath os Wap2(0 | ete ees ee Pees Ane See ee nie ee 2.56 0. 34 400 eQiaramsisallixcod fisht-es=o sa ee UR Se eS eee ee 2.62 | 0.21 | 100 ROPE TANTS: SUG sh Ny ee ser ie ae a ae EU ee Sek 300 PI GURE ANTI ENC OLLC Cesena a pace eh ee ET eee ee 0. 26 [Oa Ne (eee ee SS | Rotalhintakeypend yess ass ane seis eel ne 8.52 1. 64 1,600 Analyses of wrines. Day. Quantity. | Nitrogen. sateaaael| | ee. Grams. Grams. 1, 050 sO) | Seo see oe 840 |). 705 \ 13.75! 2.135 550 sae URN GPT a a aN ead OS Pah 5 Beg ER nee SEEM Sa) RAO | 1, 030 } odd ae Balance sheet, duration 4 days. Grams of Grams of phospho- nitrogen. ric anhy- dride. Outgo urine 6.87. 1.21 Outicopiecesti, Naditomemncr t . Taki. tiperean cen rc. piece eeuale ae Total outgo Total intake 8.52 1.63 Balance é PRG ee a AS See Kat, eri yn eee 4 ba Wie THE EFFECT OF ULTRA-VIOLET RAYS ON AMOEBA, AND THE USE OF THESE RADIATIONS IN TPHESTERIEIZATION OF WATERY By WeEstToN P, CHAMBERLAIN and EDWARD B. VEDDER.? (From the United States Army Board for the Study of Tropical Diseases as they Ezist in the Philippine Islands.*) Tt has already been shown by several investigators that the ultra-violet rays of the spectrum are capable of killing bacteria in a few seconds, and the .Westinghouse Cooper Hewitt Company of London and Paris have constructed several types of practical water sterilizers utilizing these rays. The ultra-violet radiation, upon which the action of these sterilizers de- pends, is produced by a quartz mercury-vapor lamp either suspended over or immersed in the water. One type has a capacity of 132,000 gallons (528,000 liters) of potable water in twenty-four hours, and only requires an electric current of three or three and one-half amperes at 220 volts for its operation. It has been demonstrated by experimentally pol- luting water with Bacillus coli that these organisms are killed during the passage through such a sterilizer, although the water remains in the ap- paratus for only five seconds. A more complete description, together with photographs and diagrams of this apparatus, may be obtained from the articles of Foulds(1) and Thresh and Beale. (2) There are many features about this method of sterilization that render it peculiarly suitable for use in tropical countries and by armies in the field, among which the following may be mentioned. It is automatic and can be intrusted to a comparatively unskilled man, this automatic action being secured by a valve in the inlet which is operated by the current of the same circuit that produces the rays, and which prevents * Published by permission of the Chief Surgeon, Philippines Division. 2W. P. Chamberlain, major, Medical Corps, United States Army, and EH. B. Vedder, captain, Medical Corps, United States Army, members of the United States Army Board for the Study of Tropical Diseases as they Exist in the Philippine Islands. *The apparatus for these experiments was supplied by the Bureau of Science, and the exposures were made in that Bureau. 383 384 CHAMBERLAIN AND VEDDER. any water from entering the sterilizer if the current is interrupted. The apparatus is small and one type is portable. The water is neither heated nor altered in taste by the process. It provides a rapid method by which a badly polluted water may be transformed into one of potable quality, and finally it is very economical in operation. The low cost should place it within the means even of poor native villages, a small gasoline engine being capable of producing sufficient power. For army use this apparatus with dynamo and gasoline engine could be readily carried in an escort wagon or automobile. In case the latter were used a special gasoline engine could be dispensed with, and the motor of the automobile utilized to drive’ the dynamo. ‘The small type of apparatus delivers 130 gallons (520 liters) of sterile water per hour, and it would be capable of supplying an entire regiment with a quart of water for each man after only three hours’ operation. The larger appa- ratus, although designed for permanent installation, could also be carried in an escort wagon, and would supply 132,000 gallons (528,000 liters) in twenty-four hours, thus providing in twelve hours a little over 3 gallons (12 liters) of sterile water for every soldier in a division of 20,000 men. The delivery of pure water would commence within a few minutes after arrival in camp, would be continuous, and the water would be unchanged in taste, a great desideratum when dealing with soldiers whose objection to the flat taste of boiled water is well known. Also there would be no time wasted in waiting for water to cool as is the case when sterilization by heat is resorted to. But in considering the use of such a sterilizer in the Tropics we are confronted by the fact that bacterial pollution is not the only nor, in some cases, the most important danger that lurks in the drinking supply. Ameoebe are found in practically all tropical surface waters, and while the free-living species are not pathogenic, it is to be expected that Hntameba histolytica will be encountered under the same conditions of pollution that would cause the presence of typhoid bacilli or cholera spirilla in the water. In similar circumstances, Balantidium coli, Lam- blia intestinalis, and other protozoa, as well as the ova or larve of various parasites are liable to occur. Therefore it is important, before adopting any method of water purification for tropical countries, to show that the procedure will protect the consumers against infections with animal parasites as well as against the bacterial causes of disease. Filter beds will eliminate 99 per cent of the bacteria in water, but will not remove — amoehe or other protozoa, so that this method of water purification is impracticable in the Philippines for this reason and also because of its great expense. It seems quite probable, from what we know of the action of the EFFECT OF ULTRA-VIOLET RAYS. 385 ultra-violet radiation, that protozoa and the ova-or larve of intestinal worms may all be killed by this powerful agent. It has been shown(?) that radium emanations on short exposures inhibit, and on longer expo- sures kill various forms of bacteria, protozoa, ova, embryos, and larve. The only reference we have found indicating that the effects of ultra- violet rays have been tested with protozoa is an article by Hertel (4) showing that parameecia are killed by these short length waves. We have failed to find in Manila any reference indicating that the influence of ultra-violet rays on amcebe has been investigated. These considerations seemed to indicate the desirability of studying the effect of ultra-violet rays on amcebe and the experiments about to be described were undertaken for this purpose. The source of the ultra- _ violet radiations used by us was a quartz mercury-vapor arc lamp owned by the Bureau of Science in Manila. This lamp, which was made by the firm of W. C. Heraeus, Hanau, Germany, was rather small for our purpose, but produced a brilliant light particularly rich in ultra-violet rays. A description of the lamp may be found in the Zeitschrift fiir Electro-chemie. (5) The strain of amcebe used was originally isolated from a normal human stool, has been kept constantly under cultivation for a year, and is the same that was employed previously to determine the efficacy of the ipecac treatment of dysentery.(6) These amcebe belong undoubtedly to a free-living species, but it is believed that any agent which is found to be detrimental to the growth of such free-living organisms will prove even more efficacious against the parasitic amcebe which are much more susceptible to unfavorable conditions as shown by the fact that it has hitherto been impossible to cultivate them on artificial media. The experiments were performed in a number of ways, using both solid and fluid media, and with exposures for different periods of time at various distances from the source of radiation. After the exposure, cultures were made at once from the exposed amcebe to determine whether they had been killed by the rays, and these observations were controlled by similar cultures made from amcebe grown under identical circum- stances, but which had not been subjected to the action of ultra-violet waves. The effect of the rays on the amcebe has also been compared with the effect produced on Bacillus typhosus and Bacillus dysenteric (Shiga) by similar exposures. Before proceeding to an account of the experiments themselves we will give a brief description of the stock culture of amcebe and the plates used, and the method of exposing the cultures to the rays. A. Stock culture of amebe.—The amebe referred to previously were cultivated for several weeks in a 250 cubic centimeter Erlenmeyer flask containing plain 386 CHAMBERLAIN AND VEDDER. bouillon mixed with double the quantity of distilled water. During this period the flask was handled with care so that the fluid was never shaken, and the amebz that developed were found in countless numbers lying in the surface film of the bouillon. This flask was then used as a stock culture from which all the inocula- tions of an experiment were made, and a single large loopful taken from this surface film was used for each inoculation. B. Plates.——The lamp already referred to is in the form of a small are and the rays, both visible and invisible, radiate from this are in every direction. The radiations diminish in intensity as the square of the distance from the source, and therefore it was desirable to make the exposures quite close to the lamp, approximately 10 centimeters from it. But it seemed probable, if ordinary-sized Petri dishes were used at this distance, that the outer margins of the plate might be beyond the sphere of effective intensity of the rays, and that for this reason some of the amcebe might not be killed. In order to avoid this difficulty we used special plates consisting of aluminum ointment boxes 2.5 centimeters in diameter and with tightly fitting covers. These boxes were sterilized in the autoclave, filled with plain sterile agar and covered with their lids. This kind of plate avoided the difficulty just mentioned, and was very convenient to handle, took up less space in the incubator, and required much less agar, points by no means beneath consideration when it is a question of making several hundred exposures. C. Method of making exposwres—tThe inoculated plate was uncovered and placed directly under the center of the lamp. ‘The cover was turned upside down and placed beside the plate in order that it should also be exposed to the rays with a view to killing any amebe that might have contaminated it accidentally. The switch controlling the current operating the lamp was then closed and the appearance of the light timed with a watch. After the desired number of seconds of exposure, the switch was opened. We were thus enabled to time our exposures accurately. As soon the exposure was completed the cover was replaced on the plate. This method was quite satisfactory except for one particular. We know that it is necessary for the lamp to become warmed up before it is capable of producing its maximum output of ultra-violet rays. This occurs a few seconds after the current is turned on, in which time the lamp becomes quite hot. It is probable that this temporary lack of efficiency in the apparatus when the current is first turned on explains why some of our cultures were not killed by exposure for a period of five seconds. This will be referred to again later. In order to prove that the amebez and bacteria were killed by the ultra-violet rays, and not by heat generated by the lamp, we exposed a thermometer 10 centimeters from the lamp, that being the nearest point at which the cultures were ever placed. After a forty-second exposure the thermometer had risen to 50° centigrade. Thus it is shown that although the lamp itself may become very hot, sufficient heat to injure bacteria or ameebe is not radiated to a distance of 10 centimeters in a period of forty seconds. Only a slight sensation of warmth is felt if the hand is exposed close to the lamp, although a severe burn might be caused if the lamp itself were actually touched. Experiment I.—In this experiment plates made as described above were exposed to the ultra-violet rays immediately after they were ino- EFFECT OF ULTRA-VIOLET RAYS. 387 culated. Part of these plates were inoculated with a loopful from the stock culture of amcebe, part from a stock culture of Bacillus typhosus, and part from a stock culture of Bacillus dysenterie. A few of the plates inoculated with each organism were at once placed in the incubator to serve as controls while the remainder were exposed to the rays as described above, for periods varying from five to eighty seconds, and after the exposure they also were placed in the incubator. In order to compare the effects of the rays at different distances from their source, exposures were made at point 10, 15, and 23 centimeters from the lamp. After incubation for twenty-four hours, the plates were examined for growth and the results of this experiment are contained in Table J. In this as in subsequent tables, the plus sign means that growth occurred, while the minus sign indicates a sterile plate or culture. TABLE [.—Haperiment 1: Agar plates exposed to ultra-violet rays immediately after inoculation, and then incubated 24 hours. | Time of exposure in seconds. Con- | aE iae No. Organism exposed. l | note | 5 | 10 | 20 | 30 | 40 | 50 | 60 | 70 | 80 |posed. fi mele: Atm ce ose rasa bee ee — — —|—|-—|]— + 2th Aum Ge b ees sae eee ee oS — —}—};—J}J—};—}|—}]—-]— ae el ocr Su EBenbyip DOSS) sass == sees = | — | — | =} =| 1 =] = | = | — ae . eile 4B sty phosus,) 2. snae eee ee (8) |= |=] )=)=])—)/—)= on 6) |) 153; GlyS@eks +(2) !|—);—!—};—! —}; —; —!1 — + GhimBardvsentenicow=s=—— see ss eae — | ee di Ha |oAum Ge bees =. Se BSS ee tele SS SSS SS ea aS SS = EE SislaeAtm Ge bee) ses wag a ae eis, = = 4 9) B. ay = : a rae : Beis cin! B. typhosus -_--.---____-_-__. + OR Baby phosusie ee ee = Se es al Bs een Nh a i ab i) |) BY Dyseniterise 2225-2 +(1);—}/—!—}—);-;,;-|-);- + | 12) || Bi Dysentenias === = 4(Q) | =| ===} =] == Ty | ie oh Atm cob gore ata e Seton Ae 2h + Pars} ae) aed ae) all t | 48) Ann ce cewek os ee Se } } fp te |) te |] ee ff fe “i SEVP HOSE Spe ae see toe ee \ Tre A POR StN Heese | Dees ll en Le face Gos an 5 | B. typhosus +(3) | + ] + 4 Se elon Baty pO OSUS eae ae ene AD) | seo Se | ef Se |] Se ak | Ald |) 1s Ghycerierues 4:(@) | +e | ef =] Sf S| SH | Se wit 18) | Bo diysenterice 2222525 ses) 4G) Je eH] Hla yayeH le 4+ The figures in parentheses in the 5-second column indicate the number of colonies found on the plate after incubation. As is shown clearly in Table I, a profuse growth was found on all of the controls which were not exposed to the rays. Of the plates exposed for five seconds at 10 and 15 centimeters, some of those in- oculated with bacteria showed growth and others were sterile, but none 388 CHAMBERLAIN AND VEDDER. of the plates inoculated with amcebe showed growth after this exposure. However, it will be seen that the effect of the rays on the bacteria was very pronounced even in five-second exposures, because instead of a profuse growth such as was observed on the control plates, only a few scattered colonies were found. If the lamp had been in preliminary operation for a few seconds, so that it was producing its maximum of rays at the time the exposure began, it is probable that all of the plates exposed for five seconds would have been sterile. It would have been very difficult however to make accurately timed exposures with the lamp continuously in operation, and in any case the results are sufficient for our present purpose. Others have already demonstrated that bacteria are killed in five seconds by such exposures. This experiment shows that in exposures close to the lamp amcebe are destroyed by the ultra- violet radiations quite as readily as Bacillus typhosus or Bacillus dy- senterie. At a distance of 23 centimeters from the lamp it required twice as long an exposure to kill amcebe as compared with Bacillus typhosus and Bacillus dysenterie. This is unimportant with regard to practical sterilization of water in the apparatus as manufactured, for the reason that in these sterilizers all the water is forced to flow close to the lamp, and furthermore the lamp used is probably much more powerful — than the are employed by us. The conclusions which can clearly be drawn from this experiment are -that amoebe are destroyed by exposure for a few seconds to ultra-violet rays, and that at 10 centimeters distances they are as readily killed by this agent as are dysentery and typhoid bacilli. However, it was desirable to determine whether encysted amcebe would be killed by this method, since it is quite probable that amcebe in a water supply would usually be present in the encysted form. The following experiment was performed for this purpose. Experiment 2.—Plates were inoculated exactly as in the first experi- ment, but were incubated for twenty-four hours before exposure. During this period of growth many of the amcebe became encysted. Since it is impossible to tell by microscopic examination whether an encysted amceba is dead or alive, this point was determined by cultures. After exposure to the ultra-violet rays the growth was scraped from the surface of the plate and inoculated into a tube containing a mixture of 1 part of plain bouillon and 2 parts water. This culture was incubated for twenty-four hours and then examined for motile ameebe. Cultures were also made from control plates that had not been exposed to the Hg, The results of this experiment are shown in Table IT. EFFECT OF ULTRA-VIOLET RAYS. 389 TABLE I1—Haperiment 2: Agar plates inoculated with amebe and cultwated for 24 hours before exposure to ultra-violet rays. Plates contained encysted forms. Time of exposure in seconds. | Gon- Distance from No trol, lamp. 5 not ex- 10 20 30 40 50 | posed. 1 = = = = = + 2 + = = = ar A. 10 em. : 3 = == + = = ar 4 = = = = = ar ah | |e 5 — — = = = F B. 15 em. Sea ste eee ae : 7 a8 — a. — — + 8 x te aE a7 == + 9 IF ar oF se at oF oe % C. 23 em. o 1 * z ag presley iS 11 Ar ate + Ts + + 12 oP 3F ar 25 ate 4 | By consulting this table it becomes apparent that exposures at a distance of 23 centimeters from the lamp were entirely ineffective, but that the amcebe exposed at distances of 10 and 15 centimeters were invariably killed in forty seconds, and usually killed in ten seconds, although an occasional positive result was obtained even after exposures of thirty seconds. However, these failures may readily be explained. _ The growth of amcebe and associated bacteria on plates at the end of twenty-four hours is dense, forming a very perceptible layer on the surface of the agar. It is well known that the ultra-violet rays of hght have no greater power of penetration. Therefore some of the amcebe in a few of the exposures have survived owing to the absorption of the rays by the superficial layers of the growth. This could not occur in water passing through a sterilizer operated by ultra-violet rays. Since all of these plates contained many encysted amcebe, and since positive cultures could never be obtained from those plates exposed forty seconds or more at 10 and 15 centimeters, and rarely after ten- second exposures, we are justified in concluding from this experiment that encysted amcebe are killed on solid media by ultra-violet radiation. The subject of encysted amcebz will be further discussed in Experiment 7, where a fluid medium was used. The effect of ultra-violet rays upon amcebe in a fluid medium was now tested. These experiments are considered to be of much more value than the preceding ones, because they approximated the conditions which 390) CHAMBERLAIN AND VEDDER. would obtain in the practical sterilization of water by the apparatus above described. 'The results are shown in the following 5 experiments. Hapervment 3.—A number of ordinary hollow-ground slides were ster- ilized and a large drop from the stock culture of amcebe was placed in the hollow chamber of the slide. A culture was then made from this drop by transferring a small loopful from the slide to a test tube con- taining weak sterile bouillon. Ags soon as the culture was made, the slide was placed under the center of the lamp and the current turned on for a few seconds. After the exposure to the ultra-violet rays a second culture was made in a similar manner from the drop on the slide. Table III shows the results of such an experiment. TABLE I1].—Haperiment 8: Result of cultures from bouillon inoculated with amebe. Cultures made before and after exposure to ultra-violet rays. 10 em. from lamp. 15 cm. from lamp. No. | Culture Exposure] Culture | Culture |Exposure Culture | before in after before in after | exposure.| seconds. /exposure.|exposure.| Seconds. |jexposure. 1 ae 5 = 4: 5 + 2 + 5 — + 5 _ 3 ah 5 -— af 5 ar 4 + 10 — + 10 — | Da + 10 — + 10 = 6 + 10 _ + 10 — 7 3F 20 - +- 20 — 8 + 20 = + 20 — | 9 a 20 i aL 20 ee 10 4 30 — + 30 _ 11 + 30 _— + 30 —_— 12 ae 30 — 4 30 — [ss It will be seen that in this experiment the amcebe were killed in every trial at 10 centimeters from the lamp and were also killed in all exposures of ten seconds or more at a distance of 15 centimeters. This experiment was particularly satisfactory although it must be admitted — that all circumstances were very favorable, since the amcebze were in a thin layer of clear fluid. Hapervment 4.—This was performed in a manner similar to experi- ment 3. Distilled water was placed in ordinary staining dishes in sufficient quantity to form a layer 2.5 centimeters deep. ‘This water was heavily inoculated with amcebe from the stock culture. A loopful of this water was cultivated in a test tube of dilute bouillon in order EFFECT OF ULTRA-VIOLET RAYS. : 391 to prove the presence of amcebe, the dish of water was then exposed to the ultra-violet rays, and a second culture at once made to show the effect of the exposure. The results of this experiment are shown in Table IV. TABLE 1V.—EHaperiment 4: Result of cultures from water inoculated with amebe. Cultures made before and after exposure to ultra-violet rays; distance from lamp, 10 centimeters. Culture |Exposure) Culture No. | before in after exposure.| seconds. |exposure. 1 ae 5 = 2 + D) = 3 | + 5 — ee a = 5 4 5 + 10 } — 6 + 10 - 7 + 10 ~ 8 - 10 | - 9 = 70 | 10 A eS 11 + 20 — 12 + 20 — 13 + 30 == 14 Eb 30 : 15 ne 30 = 16 ae 30 _ i] This experiment was equally satisfactory in demonstrating that motile amoeb can readily be killed by exposure to ultra-violet rays. In order to clinch the matter two more experiments were performed. Experiment 5.—Distilled water was inoculated with amcebe, and ex- posed in the same manner as in the previous experiment, but instead of merely taking a loopful for cultivation after the exposure, the entire amount of water exposed was poured into a small flask containing bouillon, and this flask was examined for amcebe after several days’ cultivation. Expervment 6.—This was the same as the previous experiment except that instead of distilled water, muddy water taken from the Pasig River was used. This was done in order to determine whether amcebe would be killed in cloudy water or whether the rays would be intercepted by the particles in suspension, thus permitting some amcebe to escape. For controls in both of these experiments a dish of the water used was inoculated and without exposure was at once poured into a flask of bouillon. These two experiments are shown in Table V. 392 CHAMBERLAIN AND VEDDER. TABLE V.—Haperiments 5 and 6: Results when clear and muddy waters were inoculated with amebe, exposed to ultra-violet rays and the entire amount of water poured into flasks containing bouillon; distance from lamp, 10 centi- meters, Experiment 5, Experiment 6, clear water. muddy water. No. 5 xpo- Expo- sure in caliure sure in Cultene seconds. * | seconds. ¢ 1 10 — 20 — 2 10 — 20 — 3 _ 20 _— 20 _— 4 20 — 30 — 5 30 — 30 = 6 30 — 30 _ Control Control 7 not ex- + not ex- + posed. posed. From Table V it is evident that amcebe were killed by the ultra-violet rays in both clear and muddy water after ten-seconds’ exposure in the former case and after twenty-seconds’ in the latter. Another very interesting and important point was noticed in experiment 6. The control flask that received the Pasig River water inoculated with amcebe not only developed many amcebe after a few days’ cultivation, but also a large number of balantidia of unknown species. No balantidia were found in any of the flasks containing water which had been exposed to the ultra-violet rays. This affords very good evidence that balantidia as well as amcebe are killed by ultra-violet rays. These balantidia are more or less constantly present in the Manila water supply and are probably harmless, but Balantidiwm coli is recognized as a dangerous parasite. Tt will be remembered that in experiment 2 the encysted amcebe on solid medium were not destroyed invariably by exposures of less than forty seconds. In order to demonstrate conclusively that encysted amcebe may be killed by short exposures to ultra-violet radiations the follow- ing experiment was undertaken with a fluid medium, thus avoiding the possibility that some organisms were protected from the rays by the thick overlying film of amcebe and bacteria. Experiment 7.—Amcebe from the stock culture were grown on an agar plate for forty-eight hours, at the end of which time microscopical exam- ination showed very many encysted forms. These forms were as nu- merous as the active organisms. A little distilled water was poured upon EFFECT OF ULTRA-VIOLET RAYS. 3938 the plate and the amcebe scraped from the agar; thus forming a suspension containing immense numbers of amcebe, both encysted and motile. A little distilled water was then placed in a shallow dish, inoculated with one large loopful of the suspension of amcebe, exposed to the rays and immediately thereafter poured into a flask containing weak sterile bouillon. After all inoculations and exposures had been completed the suspension of amcebz was again examined microscopically and the presence of large numbers of encysted amcebe demonstrated, thus proving that the encysted forms had not changed into motile forms during the course of the experiment. The flasks into which the exposed amcebe had been poured were incubated for forty-eight hours and then examined for the presence of the organisms. The results are shown in Table VI. TABLE VI.—Haperiment 7: Clear water inoculated with encysted amebe, exposed to ultra-violet rays, and the entire amount of water poured into flasks of bouillon ; distance from lamp 10 centimeters. Time of exposure in seconds. is Controls No. = not 5 10 20 30 | €Xposed. | = issteteescee anpwne | He ee | This experiment conclusively proves that encysted amcebe are killed by exposure to the ultra-violet rays for a period as short as five seconds. CONCLUSIONS. These experiments taken as a whole undoubtedly demonstrate that in a water supply the amcebe, whether motile or encysted, may be killed by a comparatively short exposure to ultra-violet rays. Balantidia, also, appear to be destroyed by the same agency. ‘These facts afford a very potent argument in favor of the use of these radiations in the practical sterilization of water in the Tropics. We have had no opportunity to test the apparatus manufactured for this purpose, but since the results of these preliminary experiments have proved so satisfactory we hope to perform this important work in the near future with a view to de- termining whether the rays are fatal to amcebe and other protozoal parasites under the conditions obtaining with the commercial sterilizer in practical use. 1060734 394 CHAMBERLAIN AND VEDDER. REFERENCES. (1) Founps, M. Sterilization of Water by means of Ultra-Violet Rays. Journ. Roy. Army Med. Corps (1911), 16, 167. (2) TuresyH, J. C., and Brats, J. F. The Practical Sterilization of Potable Waters by means of the Ultra-Violet Rays of Light. Lancet (1910), 1849. See also Lancet (1910), 1784, for article entitled Sterilization of Water on a large Scale by means of Ultra-Violet Rays. (3) Hussaxorr, L. On Recent Investigations of the Action of Radium on Plants and Animals. Med. Rec. (1907), 72, 89. ; (4) Herter. Ztsehr. f. allg. Physiol. (1904) 4; (1905) 5; (1906) 6; Reviewed in Biol. Centralbl. (1907) 27, 510. (5) BoprnsTEIN, M. Eine Quecksilber Bogenlampe aus Quarzglas. Zeitschr. fiir Electrochenvie (1904), 10, 123. (6) VeppER, E. B. A Preliminary Account of Some Experiments Undertaken to Test the Efficacy of the Ipecac Treatment of Dysentery. Bull. Manila Med. Soc. (1911), 3, 48. A SECOND CONTRIBUTION TO THE ETIOLOGY OF BERIBERI.! By Weston P. CHAMBERLAIN and Epwarp B. VEDDER.” (From United States Army Board for Study of Tropical Diseases.) Our previous paper on this subject(!) entitled A Contribution to the Etiology of Beriberi, as well as the present communication, deal exclusively with polyneuritis of fowls. Therefore it is fitting to state, as an explana- tion of our title, that we believe that polyneuritis gallinarum and beriberi are essentially the same disease. The identity of two diseases may be considered from several standpoints, including their etiology, patho- logy, and the symptom complex presented. The causes of beriberi and polyneuritis gallinarum are apparently identical, both diseases being produced by a deficiency of the same as yet unknown substance in the food, and the pathology and symptom complex of the two conditions are practically the same with the exception of the fact that cedema is commonly observed in beriberi and only rarely found in the multiple neuritis of fowls. The similarity is so striking that it is hard to avoid the conclusion that the two conditions are due to the same pathological - process causing slightly different manifestations in diverse species. We should expect that two species, varying as widely as man and the domestic fowl in their anatomy and physiology, would react very differently when subjected to the same unfavorable diet of polished rice. The surprising thing, therefore, is not that there are differences in the symptomatology of beriberi and polyneuritis gallinarum, but that the similarity is as great as it is. In a paper by Chamberlain, Bloombergh and Kilbourne(?) it was shown that in some cases polyneuritis gallinarum could be produced in fowls by prolonged starvation. This observation, however, does not con- flict with the statement that the etiology of beriberi and polyneuritis * Published with permission of the Chief Surgeon, Philippines Division. 4W. P. Chamberlain, major, Medical Corps, United States Army and Edward B. Vedder, captain, Medical Corps, United States Army, members. of the United States Army Board for the Study of Tropical Diseases as they Exist in the Philippine Islands. 395 396 CHAMBERLAIN AND VEDDER. gallinarum are apparently the same. If a fowl is starved completely it is certainly deprived of the neuritis-preventing substance present in food. In such an experiment, therefore, it simply depends upon indi- vidual idiosyncrasy whether the fowl will die of starvation before neuritis can develop or vice versa. In other words it is a question whether the bird will die of general starvation or develop neuritis as a result of the absence of certain food elements necessary to nerve nutrition, a pheno- menon which we will term partial starvation. In the great majority of cases the fowl will die without nerve degeneration as we should expect, but there will be a few exceptions to this rule for the following reason. Cocks fed on a diet of polished rice contract neuritis in an average of thirty days. In some instances a much longer time is required, while on the other hand many birds develop neuritis in less than thirty days. Several fowls in our experiments have contracted neuritis in nineteen days. Cocks that have been given nothing but water have lived from fourteen to twenty-three days. Therefore, it is apparent that in a few cases it may be possible for the nerve degeneration resulting from partial starvation to occur before the fowl succumbs to general starvation. So far as we know, nothing at all resembling beriberi has ever de- veloped in a professional faster or among men who have undergone starvation. But it has been shown by Frazer and Stanton(3) that it is necessary for men to subsist at least eighty-seven days on a diet of polished rice before cases of beriberi begin to appear, and it is extremely improbable that any man could live eighty-seven days without food. In the case of the fowl, therefore, the incubation period of polyneuritis is such that in a few instances it may fall within the time the bird can resist starvation, a condition that is impossible in the case of man. The observation that certain fowls when starved will develop neuritis is, therefore, no argument against the similarity of beriberi and polyneuritis gallinarum, since there is a perfectly satisfactory explanation for the presence of this phenomenon in fowls and its absence in man. In our previous communication referred to above we showed that the neuritis of fowls could be prevented by means of an extract of rice polish- ings containing the following: Per cent. Total solids 1.34 Ash 0.03 Phosphorous pentoxide 0.00165 Nitrogen 0.0406 Sucrose 0.88 We further showed -that the neuritis-preventing substance must be soluble in cold alcohol and in cold water, and must be dialyzable. How- ever, we stated that these results were based on a comparatively small ETIOLOGY OF BERIBERI. 397 series of experiments and that further work would be performed to confirm the observations. We are now able to state that these results have been fully confirmed. We have prepared this extract. on a large number of occasions, and from five different lots of rice polishings. The quantitative analyses of these several extracts have varied slightly from that given above, as might be expected, but there has been no essential difference. At different times we have fed seven groups, each of which consisted of four fowls, on polished rice combined with this extract in its pure form or after it had been modified by dialysis or by fermentation, with the following results: Group 1.—Four fowls remained well at the end of seventy days. Group 2.—¥our fowls remained well at the end of seventy days. Group 3.—Four fowls remained well at the end of one hundred days. Group 4.—-Three fowls remained well at the end of fifty days and one died, apparently of starvation, without evidence of neuritis. Group 5.—Four fowls remained well at the end of sixty days. Group 6.—Four fowls remained well at the end of fifty-four days. Group 7.—Four fowls remained well at the end of thirty-nine days. This makes a total of twenty-seven fowls that we have maintained in health on a diet of polished rice by the addition of this extract. This same rice repeatedly caused the development of neuritis within thirty days in fowls of our other experiments. Fraser and Stanton report a number of experiments in which the fowls were kept for only thirty-five days, a period within which neuritis ordinarily declares itself, but we have kept our birds from fifty to one hundred days. We have now been studying polyneuritis gallmarum for more than eighteen months and alter observing a large number of fowls we think it is quite certain that no group of twenty-seven fowls could be maintained on a diet of polished rice for thirty days without the development of a single case of neuritis, unless they received some neuritis-preventing substance in addition to the rice. When this period is prolonged to fifty, seventy, and one hun- dred days, the results become conclusive. Therefore, we regard it as proved that our extract of rice polishings prepared as described in our previous paper contains a neuritis-preventing principle. By the same reasoning we regard it as proved that this neuritis-prevent- ing substance. is dialyzable. The four fowls that were kept one hundred days were fed on polished rice combined with the diffusate obtained from this extract. In this connection it is interesting to note that after our first paper had gone to press we received the last communication published by Frazer and Stanton(3) in which they showed that the dialysate was in- eapable of protecting fowls from neuritis, thus independently confirming 398 CHAMBERLAIN AND VEDDER. our observation. ‘They also stated their inability to obtain the diffusate resulting from the process of dialysis owing to its putrefaction. 'There- fore, it will be interesting to give in detail the method by which we succeeded. The condensed extract was placed in a parchment bag and suspended in a glass jar containing distilled water in such a manner that the surfaces of the two liquids were on the same level. A few cubic centimeters of chloroform were then added to the bag and also to the water outside the bag, and the whole apparatus was placed in the ice box. The combined action of the cold and the chloroform prevented all decomposition and the dialysate and diffusate were perfectly sweet after ten days of dialysis. The diffusate was removed every two days, and replaced by fresh distilled water, in order that the dialyzable substances might be completely removed from the extract in the bag. These separate portions of the diffusate were subsequently mixed before feeding it to fowls. This method was effectual and enabled us to collect and test the diffusate, proving that it contains the neuritis-preventing principle. The next step was to consider the action of the sucrose contained in this extract. It was utterly inconceivable on physiologic grounds that sucrose could have the slightest power to prevent neuritis, but since 0.88 out of 1.34 per cent of the total solids consisted of this dialyzable sub- stance, we decided to give it a fair trial by experiment. ‘Two separate experiments were undertaken for this purpose as follows: Experiment 5.3—A quantity of extract was prepared from rice polish- ings as described previously, and was then inoculated with kitchen yeast and allowed to undergo fermentation in the incubator. Fermentation was very rapid for several days but finally ceased entirely. The extract was then filtered until it was absolutely clear and the microscope showed no yeast cells in the filtrate, in order to avoid adding yeast cells or their subsequent decomposition products to the extract. The alcohol formed by fermentation was then expelled by boiling the filtrate. This was subsequently diluted to its original bulk, reimoculated with yeast, and fermented again in order to make sure that the accumulation of alcohol had not stopped fermentation before all the sugar was exhausted. After assuring ourselves that the sugar was all removed from the extract by fermentation, the yeast cells were again carefully filtered out. This extract contained all the substances extracted from rice polish- ings by this method with the exception of the sucrose,* and it was made in such proportion that 10 cubic centimeters of the extract would contain the substances extracted from 10 grams of polishings. A solution was ’ Experiments one, two, three and four are detailed in our former article the title of which is given in reference one. “The sucrose was undoubtedly removed. It is possible that some other sub- stances also may have been broken up by the action of the yeasts or associated bacteria. We have some reason to think that the neuritis-preventing substance may be decomposed by action of bacteria. ETIOLOGY OF BERIBERI. 399 also made containing 2 per cent of chemically pure sucrose in distilled water. Eight fowls were now fed on'polished rice. The first four were given a daily dose of 10 cubic centimeters of the fermented extract, while the second four were given 10 cubic centimeters daily of the solution of sucrose. The result of this experiment was as follows: Group A: Four fowls fed on polished rice plus 10 cubic centimeters of fermented extract daily—One fowl died of imanition, after thirty days having refused to eat for several weeks. This fowl did not have neuritis. The three remaining fowls were alive and well at the end of fifty days when the experiment was discontinued. Group B: Four fowls fed on polished rice plus 10 cubic centimeters of a 2 per cent solution of sucrose——One died of inanition in twenty- four days without neuritis; one developed neuritis in twenty-six days; one developed neuritis in twenty-eight days; one was alive and well at the end of fifty days when the experiment was discontinued. Neuritis developed in 2 of the 4 fowls which received sucrose in twenty-six and twenty-eight days respectively, and did not develop dur- ing fifty days in any of 4 fowls that received the extract deprived of sucrose. This indicates that the sucrose is of no importance in the prevention of neuritis. I Experiment 6.—This experiment arrived at the same result as regards the inefficiency of sucrose, but in a different manner. An extract of rice polishings was prepared by the method detailed in our previous paper(1), and was slowly filtered through bone black (animal charcoal). As is well known this kind of charcoal adsorbs many substances, but allows practically the entire bulk of the sugar in a solution to pass through. The extract as poured on the bone black was yellow in color, but the filtrate through the bone black was perfectly clear and appeared like water. However, fermentation tests, showed that this filtrate con- tained practically all of the sucrose present in the original extract. The bone black remaining on the filter was then transferred to a flask and repeatedly shaken and washed with distilled water in order to remove, if possible, the ingredients separated from the extract by this substance. The attempt was only partially successful, since a clear fluid having a very faint bluish tint was obtained, as compared with the straw-colored fluid originally poured upon the bone black.® Hight fowls were then fed on polished rice. The first 4 were given a daily dose of 10 cubic centimeters of the filtrate through bone black while the second 4 received a daily dose of 10 cubic centimeters of the sub- stances subsequently removed from the bone black by distilled water. The result of this experiment is as follows: *The bluish tinge is believed to have been due to some impurity “in the charcoal. 400 CHAMBERLAIN AND VEDDER. Group A: Four fowls fed on polished rice plus 10 cubic centimeters daily of the filtrate through bone black.—Two fowls developed neuritis in twenty-two days; one fowl developed neuritis in twenty-four days; one fowl developed neuritis in twenty-six days. Group B: Four fowls fed on polished rice plus 10 cubic centimeters of the washings of bone black daily.—One fowl developed neuritis in forty- one days; one fowl developed neuritis in forty-nine days; two fowls were alive and well on the fifty-sixth day when the experiment was discontinued. In this experiment all 4 fowls that received the filtrate containing sucrose developed neuritis. This experiment and experiment 5 show conclusively that sucrose is incapable of preventing polyneuritis gal- linarum. We also have demonstrated in the last experiment that the neuritis- preventing principle is retained in a filter of bone black, and, therefore, bone black must have a strong power of adsorption for this substance. Washing the charcoal with water appears to remove some of the neuritis- preventing substance as shown by the fact that 2 out of 4 fowls were completely protected for at least fifty-six days, while in the case of the 2 birds which. developed neuritis the disease manifested itself only after an unusually prolonged incubation period. It is probable that the neuritis-preventing principle can be extracted completely from this bone black by using other solvents and that this will afford another new method for the separation and identification of this important substance. In addition to the experiments with extract of rice polishings just described, we have tested the neuritis-preventing properities of several other articles. Experiment 7.—It has been suggested several times that beriberi and scurvy are closely allied diseases. This seems quite improbable owing to the vast difference in the pathology and symptomatology of the two conditions. Lime juice is well known to be both a preventive and a cure for scurvy, and if there is anything in the supposition that the two diseases are allied we might reasonably expect that the administration of lime juice would prevent the development of polyneuritis gallinarum. To test this hypothesis 4 fowls were fed on polished rice and were given a daily dose of 0.8 of a cubic centimeter of lime juice diluted with water to 10 cubic centimeters. This quantity for a fowl is equivalent to about 40 cubic centimeters for a man, which is ample to prevent the develop- ment of scurvy. The result of this experiment is as follows: Group A: Four fowls fed on polished rice plus 0.8 cubic centimeter of lime juice daily—One fowl died of inanition on the twenty-fourth day; one fowl developed neuritis on the twenty-fifth day; one fowl de- veloped neuritis on the thirty-sixth day ; one fowl was alive without neuritis, although rather weak on the thirty-ninth day when the experi ment was discontinued. ; ETIOLOGY OF BERIBERI. 401 Two fowls out of 4 developed neuritis while receiving lime juice daily. Therefore, it is apparent, that there is nothing in lime juice which will prevent polyneuritis gallinarum and it seems quite probable that there can be no etiological similarity between scurvy and either polyneuritis gal- linarum or beriberi. It has been suggested by several authors that neuritis of fowls and beriberi are due to a lack of nucleins in the food. The nucleins are combinations of an albumin with nucleic acid, a very complex substance containing a considerable proportion of phosphorus. Our experiments have excluded such a substance from consideration since it would not be dialyzable, and since it has been shown in our former article(!) that phosphorus is immaterial and unnecessary in preventing neuritis. We desired, however, to experiment with nuclein in order that we might have a direct experiment with one of these highly phosphorized proteids. Experiment 8.—Therefore, four fowls were fed on polished rice and given a daily dose of 0.2 gram of dried nuclein. This is a very large quantity compared with the nuclein that would be naturally received in the food of a fowl. The nuclein was obtained from a leading phar- maceutical house in Manila. Group A: Four fowls fed on polished rice plus 0.2 gram of nuclein daily.—One fowl developed neuritis in thirty-three days; one fowl deve- loped neuritis in thirty-six days. Two fowls were well after fifty-six days when the experiment was concluded. As 2 fowls out of 4 developed neuritis, it is not believed that the nuclein used had any decided power to prevent polyneuritis gallinarum. Since the incubation period for the 2 fowls which did develop neuritis is pethaps slightly above the average, and since 2 fowls remained well at the end of fifty-six days, it can not be denied that there may have been a small amount of neuritis-preventing substance in the nuclein, a quantity sufficient to retard the outset of the disease. As will be stated later on, our work has led us to suspect that the neuritis-preventing principle may ultimately be found among the decomposition products of protein. It is possible that small quantities of such material may have been present in the nuclein. We have not made any further experi- ments with nuclein because the question as to whether or not nuclein was efficacious had no direct bearing on the main line of ieeesuipaions we were pursuing. Hulshoff-Pol(*) proved that a decoction of katjang idjo (Phaseolus radiatus) prevented and cured beriberi. It has been generally accepted in the Philippines that these beans, known here under the name of mongos, possess this property, and for a while mongos were supplied to the Philippine Scouts (native) as a part of their ration for the purpose of preventing beriberi. However, it was found difficult to obtain mongos 4()2 CHAMBERLAIN AND VEDDER. in sufficient quantity in the local market, they did not keep very well, and the Scouts did not like them as a steady article of diet. There are no such objections to the use of the ordinary white bean that con- stitutes a part of the army ration, but there was no information obtain- able as to whether it would prevent beriberi. It seemed to us quite probable that the white bean would be just as efficacious in this respect as any other legume. ‘Therefore, we tested these beans in the following experiment. Haperiment 9.—One kilogram of dried white beans was soaked over night in distilled water, and the following day boiled for two hours, allowing the decoction to evaporate down to such a point that 1 liter of fluid remained. The cloudy liquid obtained was filtered until per- fectly clear. This fluid was of a deep yellow color with a tendency to become opalescent on standing, and had a distinct odor of beans. It was preserved in the ice box with the addition of a slight quantity of chloro- form. Ten cubic centimeters of the fluid represented the substances extracted by boiling water from 10 grams of beans. We then treated 1 kilogram of mongos in a precisely similar manner, obtaining from them a corresponding extract. Nine fowls were now fed on polished rice. Five fowls received daily in addition 10 cubic centimeters of extract of beans, while the other 4 fowls received 10 cubic centimeters of extract of mongos. The result of this experiment is as follows: Group A: Five fowls fed on polished rice plus 10 cubic centimeters of extract of beans daily.—All five fowls remained healthy at the end of sixty days when the experiment was discontinued. Group B: Four fowls fed on polished rice plus 10 cubic centimeters of extract of mongos daily—One fowl developed neuritis on the thirty- fifth day; the other three fowls remained well at the end of sixty days when the experiment was discontinued. We do not believe this experiment to indicate that mongos will fail to prevent beriberi. On the contrary, we believe that they will prevent this disease. The extract of mongos as we prepared it was filtered until perfectly clear, and it is quite probable that we removed in this manner many of the substances which were present in Hulshoff-Pol’s decoction. This part of the experiment, therefore, only demonstrates that the extract as we prepared it failed to confer complete protection. The important fact in this experiment is that the fowls receiving extract of beans were completely protected. Therefore, the ordinary white bean, must contain a neuritis-preventing principle. . While we do not wish to claim too much on the basis of a single experi- ment, we ourselves are convinced that the ordinary white bean will prove equally as efficacious as the mongo in the prevention of beriberi. This is a very important observation since it indicates that we may use these ETIOLOGY OF BERIBERI. 403 beans as a preventive against beriberi in the rations of native troops, native prisoners, and others. Probably in actual practice the ordinary white bean may be even more efficacious than mongos, because beans are more savory and are more desired as an article of diet by all classes of men. This point must be borne in mind when prescribing for natives a diet consisting largely of rice. If the natives do not happen to care for mongos, or the other articles introduced into the ration for the purpose of preventing beriberi, they will not eat them, but will live on an almost exclusive diet of rice; but the man, native or white, who does not relish well cooked beans is hard to find, and it is believed that they would be generally eaten by persons who would'refuse to eat mongos. It is also quite possible that this observation will be of further as- sistance in identifying the beriberi-preventing principle. . Extracts of beans and of rice polishings doubtless contain many substances peculiar to themselves, but we may find some substance, or a few substances, -common to both of these extracts. If this should occur, it is probable that the neuritis-preventing principle will be found, or at least the search for it will be restricted to very narrow limits. We have also performed some experiments in the course of which we evaporated the extract of rice polishings to dryness in a water bath at 100°C. This necessitated prolonged heating at this temperature and we found that the extracts so prepared had lost their efficacy. It has long been known that even a brief exposure to a temperature of 120°C. destroyed the neuritis-preventing substance and it is now shown that prolonged exposure to a temperature of 100°C. will also produce the same effect. It is possible that this is the reason why our decoction of mongos lost some of its power, and we would recommend, therefore, that no extract supposed to contain the neuritis-preventing principle should be boiled for more than one hour. CONCLUSIONS. We have made some progress in the identification of the neuritis- ' preventing substance contained in the extract of rice polishings prepared by the method described in our first paper. Of 1.34 per cent total solids contained in this extract, 0.03 per cent was ash. This we believe to be negligible since it consists entirely of inorganic constituents, chiefly of lime, magnesia, and potassium carbonate. We have tried salts of calcium, magnesium, and potassium and found them wanting. Nitro- genous matter comprises 0.04 per cent of the total solids. Of this only 0.02 per cent was present in the diffusate, which has been shown to contain the neuritis-preventing principle, and the remaining 0.02 per cent can be eliminated because it remained in the dialysate which failed to prevent neuritis. The 0.88 per cent sucrose is of no importance. Com- bining these unimportant substances and subtracting them from the 1.34 404 CHAMBERLAIN AND VEDDER. per cent of total solids, we find that there is only 0.4 per cent remain- ing. The neuritis-preventing principle must, therefore, be sought for in this 0.4 per cent of solid matter and must be a substance that is dialyz- able, that is soluble in water, in 95 per cent alcohol, and in 0.3 per cent hydrochloric acid, which is easily decomposed by heat and which possesses a strong affinity for bone black. The same substance or a similar substance is also contained in a decoction of ordinary white beans. Bodies corresponding to this description are found among the decom- position products of the proteids. Therefore, it appears to us, that we have obtained sufficient information with regard to the nature of this body to attempt to identify it by the direct methods of chemical analysis. We have already begun experiments along these lines with the assistance of Mr. R. R. Williams, of the laboratory of organic chemistry, Bureau of Science, Manila, and expect to report them in the near future. REFERENCES. (1) CHAMBERLAIN, W. P. and VEppER, H. B. A Contribution to the Htiology of Beriberi. Phil. Journ. Sci. Sec. B (1911), 6, 251. (2) CHAMBERLAIN, W. P., BLoomBereH, H. B., and Ki~BourNE, H. D. A Study of the Influence of Rice Diet and of Inanition on the Production of Multiple Neuritis of Fowls and the Bearing thereof on the Etiology of Beriberi. Phil. Jowrn. Sct., Sec. B (1911), 6, 177. (3) Fraser, H., and Stanton, A. T. The Etiology of Beriberi. Studies from the Institute for Medical Research, Federated Malay States (1911), No. 12. (4) Hunsuorr-Por, J. Polyneuritis gallinarum en beriberi. Geneesk. Tijdschr. V. Nederl. Indie (1909), 49, 116. A STUDY OF ARNETH’S NUCLEAR CLASSIFICATION OF THE NEUTROPHILES IN HEALTHY ADULT MALES AND THE INFLUENCE THEREON OF RACE, COMPLEXION, AND TROPICAL RESIDENCE.! By Weston P. CHAMBERLAIN and EpwaArpD B. VEDDER.* (From the United States Army Board for the Study of Tropical Diseases as they Exist in the Philippine Islands.) INTRODUCTION. In the quarterly report of the Board for September 30, 1910 (pub- lished in the Military Surgeon for February, 1911) there was a pre- liminary report upon some observations by the Board regarding the Arneth classification of the neutrophiles for Filipinos and for white men living in the Philippines. Since the original work a much larger series of cases has been studied, counts having been completed on 72 Americans and 50 natives. The earlier and the later observations were made in- dependently by different members of the Board and the results of both series are practically identical. ‘Therefore, it is safe to say that the personal equation, which might be a considerable factor in this kind of work, has been discounted in making up the final result. These exam- inations were originally undertaken as a part of the investigation into the influence of tropical light on blonds and brunettes, and the research was subsequently extended to natives among whom most interesting results have been obtained. As far as we can learn no work along this line has previously been undertaken in the Tropics. BRIEF DESCRIPTION OF ARNETH’S CLASSIFICATION. A classification of polymorphonuclear neutrophiles based on the number of nuclei or nuclear fragments was proposed by Arneth in 1904.(1) He described * Published by permission of the Chief Surgeon, Philippines Division. ? Weston P. Chamberlain, major, Medical Corps, United States Army and Ed- ward B. Vedder, captain, Medical Corps, United States Army, members of the United States Army Board for the Study of Tropical Diseases as they Exist in the Philippine Islands. 405 406 CHAMBERLAIN AND VEDDER. 5 main classes.* Class I has a single nucleus which may be round or of irregular shape. If the nucleus is round, the cell is then identical with Ehrlich’s neutro- philic myelocyte(3) which is not found normally in the peripheral, circulation. Class II includes the neutrophiles with 2 nuclei or nuclear fragments. Class III has 3 nuclei or fragments and is the largest class in normal blood. Classes IV and V have respectively 4 and 5 nuclei or nuclear fragments. A fairly constant proportion between the different classes is found in normal blood. The “neutro- philic blood picture” as given by Arneth is for each one 100 polymorphonuclear leucocytes as follows: | | _| Index |. Class I. | Class II. | Class TIT. | Class IV. | Class V. | Nan, (Bushnell | | Treuholtz). | 5 35 | 41 | v7 2 40.0 60.5 | Simon(3) gives the following normal range for each 100 neutrophiles: 4-9 21-47 33-48 9-23 2-4 | | Class I. | Class II. | Class III. | Class IV. | Class V. | | The so-called nuclear fragments seldom if ever represent separate nuclei, but only lobes of a polymorphous nucleus, the connecting nuclear substance being drawn out into a fine thread. The “index” is a standard for comparison of different pictures. Arneth adopted as an “index” the sum of classes I and II while Bushnell and Treuholtz selected the sum of classes I and II and one-half of class III.(13) (14) : The polymorphonuclear leucocyte is the active phagocytic cell of the blood stream and the corpuscles with 3 or 4 nuclear fragments are considered the adults and are thought to be most active as phagocytes and best fitted to protect the body against invading organisms. The superannuated cells represented by class V and the immature cells represented by classes I and II are less able to take up the defence of the body. Pottenger in a series of experiments found a gradual rise in phagocytic power from class I to class IV inclusive, and a decrease in class Y. ‘ When the first and second classes are increased above normal and the third and fourth are correspondingly decreased the condition is spoken of as a “shift or a drift to the left’? while the reverse alteration is called a “shift to the right.” Pottenger,(4) Klebs,(15) Kagan,(2) Minor and Ringer(13) and others have found a decided shift to the left in patients with marked lesions of tuberculosis and Kagan also found a less marked shift to the left in cases ’ Arneth subdivided his 5 main classes into a number of smaller groups with distinctions depending upon the indentations and the character of the loops and lobes. These sub-groups seem to us to be an unnecessary and im- practical refinement and moreover the number in each sub-division is too small to be of value unless 500 or 1,000 neutrophiles are counted(6). Such a procedure is very time-consuming and does not appear to us to promise compensating advantages. ARNETH’S NUCLEAR CLASSIFICATION. 407 of sepsis. Solis-Cohen and Strickler were not able to find any shift to the left in tuberculous patients at any stage of the disease although the poly- morphonuclear cells were reduced in numbers.(6) Arneth considers a shift to the left an evidence of lowered resistance to the disease affecting the patient whose blood he is studying, as is indicated by the fact that when a tubercular patient improves the blood picture tends to return to the normal. (13) OUR METHOD OF STAINING AND COUNTING. Most of our counts were made with very thin smears stained with Wright’s stain. A few were stained with hematoxylin and eosin after the method of Bushnell and Treuholtz. This method gave excellent pictures but did not seem to offer sufficient advantages to compensate for the trouble of making a second stain for the differential count. Whatever staining method is used, it is important that smears be thin. We have tried the technique of Wiedenreich, but without success. (16) Even in a well-spread and well-stained slide there will always be an uncertainty as to the group in which some nuclei should be classified. Pottenger considers that these doubtful cells constitute 12 per cent of the total when Wright’s stain is used. To obtain uniform results, we adopted the following rules in counting: (1) Nuclear masses connected by a distinct isthmus were counted as 1 nucleus, while masses connected by only a thread were counted as 2 nuclei. (2) Nuclear masses clearly superimposed were considered as separate nuclei, but where the superposition was not distinct the body was considered a single nucleus. (3) In all instances when there was doubt as to whether a cell should be grouped in one or the other of two classes, it was always placed in the higher class. By a careful adherence to rule 3 we have avoided the possibility of producing an artificial shift to the left. If all doubtful cells had been recorded alternately, the first in a lower and the second in a higher class, the shift to the left which we found for bloods in the Tropics would have been even more pronounced than we now claim. In our work we enumerated for differential counts 200 cells for each individual. For the Arneth work we counted 200 cells each from a part of the men and 100 each from the remainder. While an enumeration of 100 cells for Arneth work and of 200 cells for differential counts may in a few instances lead to slight errors for the individual, it is believed that it is ample to give accurate average results such as we were seeking in our investigation. The following table indicates how close an agreement in the results for both differential and Arneth counts was obtained by our two in- dependent observers working at different times. 408 CHAMBERLAIN AND VEDDER. TABLE I.—Agreement of differential and Arneth counts as made by two independ- ent observers in the Philippines. Z - Le) f seen Arneth’s classification S| Men observed. Differential counts, per cent. per cent. H = Ix 2 2 ell MES . ieee . SS | | 2 | es 5 we | a Fac ti a ic [eae 2 |23 : fee eS Gsle Ee eb | | a |=5 5 Race. |e | 3 a, | eS eS oS | ae | Lt I. | I. | IV. | V.}] [= | —& Fe 2 I 5 ao oo! "3 | 2 i 2 ee Re ee am ea ee sis Q Ba S i) ee ase FE TS) ais Ibe Bre A | Americans____| 22 | 56.4 | 5.1 | 30.0 /4.1 |8.5 |0.9 | 18.4 | 34.8 | 39.0 | 11.3 |1.5 | 48.2 | 67.7 B | Americans___-| 50 | 57.0 | 3.2 | 32.4 |5.0 /1.7 |0.7 | 18.2 | 32.0 | 36.3 | 17.3 |2.1 | 45.2 | 63.3 A | Filipinos, ____- 21 | 48.1 | 13.6 | 28.1 |6.2 3.2 |0.8 | 28.1 | 41.2 | 24.7] 5.3 |0.7 | 69.3 | 81.6 B | Filipinos______ 29 | 55.1 | 8.6 | 31.2 )3.4 |1.1 /0.6 | 27.0 | 36.3 | 26.6] 9.1 |1.0 | 63.3 | 76.6 | It will be observed that the Arneth index of Observer A is slightly higher for Americans than that of Observer B and that the same is true for the observations on Filipinos, so there is complete agreement between the two observers as regards the finding of a marked shift to the left for natives. The same remarks are true when the Arneth counts are com- pared on the basis of the index of Bushnell and Treuholtz. THE INFLUENCE OF RACE AND TROPICAL RESIDENCE ON THE DIFFERENTIAL AND THE ARNETH COUNT. The appended tables (Nos. V and VI) give the individual data for our series of 122 counts. When divided according to race, American or Filipino, the white cell count per cubic millimeter was found within normal limits in both races, (7) averaging a little higher for the Filipinos, 9,248 as compared with 7,304 for Americans. The average differential leucocyte count showed for both races the characteristic changes found by this Board,(9) (10) and by others,(11) (12) in the blood of Filipinos and of white men resident in the Philippines, namely, a decreased poly- morphonuclear count associated with an increased percentage of small lymphocytes and, for the natives, an increase in the eosinophilic cells due in the vast majority of cases to infestation with intestinal parasites. 'The reduction in polymorphonuclear neutrophiles was slightly greater for natives, who had 52 per cent of these cells as compared with 56 per cent for Americans. When the Arneth count came to be considered very marked. differences were found between the averages for the two races. There was evident a slight shift to the left in the average count for white men as compared with the standard recognized by most authorities in Europe and America.* Since we have not counted for comparison any extensive series of blood ‘These normal “standards” vary considerably with the writer, and we believe this variation is in part due to the fact that most observers have counted too small a series of normal cases. : ARNETH’S NUCLEAR CLASSIFICATION. 409 smears from men residing in America, we are unable to state whether this slight drift to the left is due to climatic influence or to our own personal equations in enumerating. For the Filipinos we found a very decided shift to the left and are sure that this represented an actual and wide departure from the Caucasian average, because we have as a standard for comparison our series made simultaneously on white men in the same locality. ‘ Our average results for differential and Arneth counts for the two races, compared with several writers’ estimates of the normal are shown in Table IJ. For the 72 Americans the average length of the present tour of tropical duty was 14.6 months and the average total tropical service 28.7 months. TABLE II.—Arneth counts on healthy Americans in the Philippines and on healthy Filipinos, contrasted with normal counts in Europe and America. g Differential counts, per | Arneth’s classification, = I cent, per cent. oI = | : So © Pie Saaaainy | Raa ; = Os u ‘ ‘ i aq er ot) 3 4 |e ° | = aa = ws x) n =|) Si | | eS) ere sirs lene) )|ane yy. ves] | @ 18/8 |aslem| 2 ge Na gest ea a= | BS = |S wo] | o o | Se S| ee ia |S | E/E = Ay Bin 4 =| | | ) A = es -_— = ——e -| ——————s } 3,000 | 60 1/ 20; 1/0.2 4] 21} 33 Bi 2 25 | Normal (Simon) _____- to | to | to | to | to| to | to | to | to | to | to| to |} ____ | 10,000 | 70 4! 30) 6!1.0 9! 47| 48; 23] 4 56 Normal in Europe (Ar- | OLY © BUNS) fe os a ea Ee a heel Paes 5| 35; 41] 17] 2] 40.0) 60.5 | Normal in United | | | States; (Kagan) see sul iierst ilutean a2) Feealbeaee | 5| 19| 46] 25] 5/240) 47.0 | 5,000 | 70|0.5) 2 | Normal (Buchanan 0 a0 Be ; ta to to | to | to |to}»0.5 8 | 36) 42) 13) 22 | 44.0) 65.0 | and Williams )> _____ 10,000; 90 4} 30) 6 | Average for 72 healthy 53 iif Sgal mets oie Bina ee a ee | ea? Americans in Philip- | pine Islands_________- 7,304 |56.8 | 3.8 |31.7 |6.9 | 0.8 |13.3 32.9 [37,2 [14.6 12,0 | 46.2 | 64.5 Average for 50 healthy ; MU pINOS ese 9, 248 [52.2 |10.6 |29.9 6.6 | 0.7 |27.5 (38.3 |25.8 | 7.5 0.9 | 65.8 | 78.7 1 a With the large lymphocytes have been classed the transitional forms, following the grouping of Simon. bThe average white and differential counts given in this line are from R. J. M. Buchanan, Blood in Health and Disease (1909). The Arneth averages are from 100 counts on 55 individuals in the United States by W. W. Williams in Colorado Medicine (1911), 8, 175. From the tables it 1s evident that there is a very marked shift to the left in the Arneth count for Filipinos and apparently a slight movement in the same direction for Americans resident in the Philippine Islands. THE ARNETH INDEX IN THE TWO RACES. The index, referred to in an earlier part of this paper, is very useful to give at a glance a basis of comparison between different Arneth counts. 1060735 410 CHAMBERLAIN AND VEDDER. The more marked the shift to the left, the higher will be the index. For our American series the index adopted by Arneth (sum of classes I and IL) was 46.2 which is but a little higher than the index of 40 found by Arneth for normal individuals in Europe. For the Filipinos of our series the index is much elevated, averaging 65.8. Using the index adopted by Bushnell and Treuholtz (sum of classes I and II and one-half of class IIL) there also appears a decided eleva- tion for the Filipinos, average 78.7, as compared with 64.8 for Americans resident in the Philippines, but the differences are not as great as when the index adopted by Arneth is employed. THE INFLUENCE OF THE COMPLEXION OF WHITE MEN ON THEIR ARNETIH COUNT IN THE PHILIPPINES. We have for eighteen months been at work on the influence of the Philippine climate on soldiers of the blond and the brunette types of complexion who have served a year or more in the Islands. By blond we mean a man with light brown, sandy, red, or flaxen hair, blue or gray eyes, and a light or ruddy complexion; by brunette one with dark brown or black hair, brown or black eyes, and a dark complexion. Men in whom eyes, hair, and complexion do not all conform to the same type are classed as mixed types and excluded from consideration. The blood counts considered below are from men who were pronounced specimens of the type they represent. TABLE III.—Lewcocyte count, differential count and Arneth’s count on 28 blonds and 28 brunettes resident in the Philippines. 2 4 neal Arneth’s classification, zc 5 Differential counts, per cent. per cent. = 8 Saat ea = ae fi AP ‘ 1 9 he Bor eee ae g | es Complexion ES a vi = 2 ® ° type. eee) 2 ee lea| @ |, eg | 28 ome ra at CS ess) S| I, SUE 1) AUD Ey 1 AYA NY — SL | S roy = >| 2 EO) | - we 2 | S Silas wi) © a g q PI = o a pes K * a NS EO el cs | s | See eS ae Ss) ee | BS hoBee| Blond beara 7,077 \55.5 | 4.3 | 33.0 | 4.5 | 1,9 | 0.8 | 11.5 | 31.6 | 38.2 | 16.2 | 2.1 | 43.1] 62.2 Brunette ___| 7,888 60.2 | 3.5 | 29.0 | 4.5 | 2.1 | 0.7 | 14.5 | 34.5 | 35.7 | 13.6 | 1.8 | 49.0) 66.8 The length of the present tour of tropical service averaged 16.5 months for the blonds and 16.2 for the brunettes. If previous tours of tropical service are added then the average total tropical service was 29.1 months for the blonds and 36.0 months for the brunettes. It will be observed that the proportion of the polymorphonuclear leucocytes (phagocytic cells) is shghtly less for the blonds (55.5 per cent as compared with 60.2), while the brunettes show a somewhat higher index for the Arneth count, whether reckoned by the method of Arneth or that of Bushnell and Treuholtz. We believe that these differences are unimportant and due to the inherent error attaching to such a small ARNETH’S NUCLEAR CLASSIFICATION. 411 series of cases. Some authors have considered that blonds are less well able to stand the influence of a tropical climate. As far as our small series of observations is concerned, we do not think this view. is sup- ported; in fact the higher Arneth indexes for brunettes, if found to be constant in larger series, might indicate the reverse condition. THE POSSIBLE SIGNIFICANCE OF LOW POLYMORPHONUCLEAR COUNTS AND HIGH ARNETH INDEXES IN FILIPINOS. In estimating the significance of the blood counts which we have found in Filipinos it is necessary to consider the four factors discussed below. 1. Low polymorphonuclear count in Filipinos.—That the polymorpho- nuclear cells of Filipinos and of Americans long resident in the Philippines are reduced below the minimum point considered normal for Americans and Huropeans at home seems quite well settled. Some results found in healthy persons in the Philippines are shown in the following table. TABLE [V.—-Reduction in polymorphonuclear neutrophiles found in the Philippines. c : a ee ; = <= | | | o io) | ie ease is | | aa Residences | = = |9;]|8¢ of = jber ob-| in Philip- = fs E.G | FS s Observers. Race. ae pine S Sr ass = 3 | ed. | Islands. 2 sg (SP) Po] es | io on 3 a 2 | Cy | & a A S| = \Wivivoltelibaveys (1) eee eens Americans*_| 104 | Batangas__| 54.9) 5.1) 33.4| 6.1] 0.5 | Guerrero and Sevilla (11)____| Filipinos ____ 129 | Taytay -___| 51.6 | 11.2 | 34.5) 4.1] 0.2 This Board (10)-------------- Americans» _| 115 | Various____| 58.7 | 3.6] 32.6 | 4.6] 0.5 DOW IXoyen Rol ((G)) eee ee Igorots¢ _____ 40 | Baguio ____| 46.9 | 8.9 | 37.2| 5.7] 0.4 MODIS BB Oar dies jose ee Americans¢ _ 72 | Various____| 56.8 | 3.8 | 31.7] 6.9] 0.8 WD) QB ees ee eet Filipinos¢ ___ (0) Wee douse 52.2] 10.6 | 29.9} 6.6] 0.7 « These were all soldiers who had served continuously in the Philippines over 18 months at the time the counts were made. » All the members of this group were soldiers who had been in the Philippines over a year. ¢ All of this group were adult males. 4 All of these were soldiers with,an average of 14 months’ continuous Philippine service. e Includes transitional forms. In all of the counts made by ourselves care has been taken to count back and forth completely across the slide to avoid obtaining an undue number of small lymphocytes which are liable to be more numerous in the central portion of the smear than at the borders. That these low polymorphonuclear and high lymphocyte commits for Americans developed gradually after residence in the Philippines and were not present on their arrival in the Islands has been shown by Wickline. (12) 2. The cells of the body which are phagocytic—It is generally accepted that the small lymphocytes have no phagocytic power. Buchanan says that the 412 CHAMBERLAIN AND VEDDER. “coarse eosinophiles are actively amoeboid and to a certain extent phagocytie”(7), while Kanthack and Hardy consider that they never act in this way.(8) Wesbrook once observed phagocytosis by these cells, but considers it extremely rare.(8) It has also been stated that virulent living bacteria act in a negatively chemiotactic manner on eosinophiles.(5) Buchanan considers the large mono- nuclears to act as phagocytes,(7) but Kanthack and Hardy believe that only in case of feebly virulent bacteria are they capable of immediate action. That certain fixed cells, notably endothelial cells, have phagocytic power is generally accepted, but the extent and manner of their action is not very thoroughly understood. As far as the blood is concerned the chief phagocytic cell is the poly- morphonuclear neutrophile, the “microphage” of Metchnikoff. This is the only blood cell which is generally recognized as being able to ingulf and destroy bacteria. Its importance in the production of immunity was overshadowed for a time by the work of Ehrlich, but has again been brought into prominence by the researches of Wright. Cabot says, “Jt would appear that the degree of health in persons not organically diseased might perhaps prove to vary directly with the per- centage of polymorphonuclear cells in the blood.” 3. Influence on phagocytosis of a high Arneth index—As_ before stated, Arneth considers that classes I and II of his classification represent the immature leucocytes and that they are less able to protect the body than are the cells with three or four nuclear fragments. Pottenger (+) reports that the phagocytic power of the leucocytes for staphylococci gradually rises from class I to class IV inclusive and diminishes for class V. On the other hand, Buchanan, using cocci, could not detect any relation between the number of nuclear divisions and the number of bacteria engulfed by the cell. Turning from experimental researches to clinical observations, it will be found that nearly all of the work with the Arneth classification has been done on patients suffering from tuberculosis. It seems quite gen- erally accepted that a marked shift to the left indicates lowered resistance to that disease. In other words, a high Arneth index goes hand in hand with a low resistance or with a high degree of toxic and bacterial absorp- tion which is leading to the destruction of the actively phagocytic cells (classes III and IV). By a large number of examinations in various infectious diseases, Arneth has demonstrated a direct relationship between the blood picture and the course of the disease. The picture is there- fore considered an index of the protective efforts of the body against infections. (15) It seems to us reasonable to conclude from the foregoing that a bad Arneth blood picture, if found habitually in the apparently normal indi- viduals of a race, probably indicates a diminished resistance on the part of that race to various infections. This conclusion is merely offered as an hypothesis. 4. Leucocytometry in the Filipinos.—We have not been able to find ARNETH’S NUCLEAR CLASSIFICATION. 413 much evidence as to the number of white cells per cubic millimeter in the blood of healthy natives. Our own work on 29 adult male Filipinos gave an average count of 9,248. This may seem a trifle high, but it is at least well within the normal upper limit of 10,000 given by Simon, Buchanan and Cabot. It may be mentioned that our average of 9,248 agrees closely with the average of 9,000 given by Castellani and Chalmers for adult male Ben- galese in India. Summary.—After a consideration of the above four sections it will be evident that in our series of Filipino bloods there is: First, an absolute ‘number of white cells within normal limits; second, a markedly low rela- tive proportion of polymorphonuclear neutrophiles; and third, an abnor- mally high percentage of the neutrophilic elements which fall in classes I and II of Arneth and which are supposed to be deficient in phagocytic power. Therefore, in the Filipino blood there is both a relative and an absolute reduction in the phagocytes, the cells which, with the aid of opsonins, are concerned in destroying bacterial invaders. If this state of things is general in tropical races, it may be a visible indication of the lowered resistance of such peoples to certain newly introduced maladies and to some epidemic tropical diseases which gen- erally cause a higher mortality among natives than is experienced among Caucasians. In the first class of diseases may be mentioned measles, leprosy, syphilis, and tuberculosis, and in the second class plague and cholera. Apparently the natives of the Philippines have a good resistance to infections with staphylococci and streptococci, and this clinical fact may be related to the observations of Buchanan who could find no rela- tionship between the degree of nuclear subdivision and the number of cocct engulfed by the neutrophilic cells. POSSIBLE INFLUENCE OF TROPICAL CLIMATE. Whether the reduction we have found in the phagocytic elements of the blood may be the result of a tropical climate per se is an interesting subject for speculation and for future study. About a year ago we suggested (9) that the low polymorphonuclear count in natives and white men in the Philippines might indicate lowered resistance and be due to tropical conditions. The work of Wickline showing that the decrease of polymorphonuclear elements becomes progressively more marked as the length of residence in the Philippines increases, is suggestive that the change is due to the climate. Our recent work with the Arneth classification points in the same direction, since the index for white men who had lived over a year in the Islands is a little higher than has been found normal in temperate climates by most observers. On account of the many complicating factors, three of which are mentioned below, it will be extremely difficult to establish a direct relationship between climate and diminished phagocytic power. 414 CHAMBERLAIN AND VEDDER. In the case of the Filipmos in our series a possible influence of tuberculosis should be borne in mind. All of the counts were made on apparently healthy laborers, but no physical examinations were made to exclude latent or incipient tuberculosis as a cause of a high Arneth index. Although tuberculosis is widespread among the Filipinos, we do not believe that it is so prevalent as markedly to raise the average Arneth index of a series of 50 men ‘engaged in daily labor and to all outward appearances in perfect health. Intestinal parasites greatly modify the blood findings in Filipinos and are responsible for the eosinophilia almost invariably met with. It is impossible at present to state whether infestation with intestinal worms produces a modification in the Arneth index. Diet is a third factor which conceivably might influence a blood picture. The food of the Filipino consists largely of rice and is low in nitrogenous components. It would be of much interest to make a series of Arneth counts on Japanese and northern Chinese, people who dwell in a temperate climate yet have dietary habits similar to those of tropical races. CONCLUSIONS. 1. Both Filipinos and Americans residing more than a year in the Philippines had a normal average number of white cells per cubie milli- meter. j 2. In both races the percentage of polymorphonuclear neutrophiles was much decreased below the minimum considered normal for white men in temperate regions. 3. Probably the polymorphonuclear neutrophiles are the only actively phagocytic cells in the circulating blood. 4. The average Arneth picture showed a marked shift to the left in the case of Filipinos and a slight drift in the same direction for Amer- icans resident more than a year in the Philippines. 5. A shift to the left in the Arneth count probably indicates a dimi- nution in the phagocytic power of the blood in question. 6. From the first five conclusions it will be apparent that the Fili- pinos show an actual absolute reduction in the number of polymorpho- nuclear neutrophiles (phagocytes), and that of this reduced number an abnormally large proportion are deficient in phagocytic power. In other words, the Filipino has absolutely fewer efficient phagocytes than are found among white men either in the Philippines or at home. 7. This reduction in circulating phagocytic cells may be a visible indication of a lowered resistance to infections on the part of native races, 8. No material differences in the differential count or the Arneth picture were observed between two groups of American soldiers, one group consisting of 28 pronounced blonds and the other group of 28 pronounced brunettes. 415 ARNETH’S NUCLEAR CLASSIFICATION. Cl ‘mOrxe[du00 Jo adA} poxiul suvoUE “J ‘o}JoUNAG SUBOU “Ig “PUO[G SUBITU [Ff 1 OD |Or6e lors )Ocm [On| or O'el | O'S | 06s | 0'FG | 0'0 | 0 O'sT | 0'€8 | o's | O'8T be g0 OSL | Or | 0:08 | OFT | 90 | 0% OBL | 06% | 0c | O'9T [OT | OT Ores | ONGE | 01 | OI | GeO j/or¢ ost |cap jos |0%6 |0% |¢T OF |O0F |08% 04 JOT 108 08% | O'R O6f 0S | 00 | G0 O'PL | 0°68 OFF OE | 970 | OT OGL | O'Sh OZ | O's | OT | 0'9 002 | 0 | 0'e OTE | 0°0 | G9 OF |07E | 082 | 0% | O71 | G0 0°81 | 0-98 lores | ett | 0° | 9 O9L | OOF | 1g | GIT [et | 40 Gg | ecg | ¢-ze | ast | ovo | 0g 0% | 92% |0'Ge |0°6% | 0'T | 0°0 G6 |G"cs | o'ce |Get | G0 | 0'¢ G'6r | G98 | 0's | 00L | G0 | 0's OE | G68 | OTE | S'S | OT | OT O'8C | O's | 082 |0% | OT | 0% oct |o'ue | ose |G% joo |eT , i} “aMe |) Sino |) rat tl Te A == ISBN | og ‘UOTTBOYISSBIO YouLy C86 0&6 0 TS 08% ee 008 c'6L | 0°08 0&& gle G°as CrP GOP G°Sé 0a C8 0 FE 0 0& 0°8§ ¢ 66 08h C'8P [OT joe | oes | cor'9 | 06 | 000 foo8r | Tah | OF 91 0% |S | 0°04 | 002'2 | 26 000'006'F | “tet | 9L 91 Gr |0% | 0719 /000°0K9'F | 1d 91 91 0% | OF | 9°89 | 000 ‘008 “F | eek | 78 9 qr | Gig | @ay 000‘009'F | “ad | SF 9L oe |S | OvLG 000‘008‘F | ‘Id | 9 | 9F eT 01g) Gon o00‘0r9‘F | Id | 6r | 9T gr | esr | wxgg 000‘006‘F | “Im ST 81 ez | og Ie 000‘00e'F | ‘Id | 8T 81 eT |0°¢ | @'p9 [ooOsOOOGa | tee} ZT) at 60 |@1 | eee ooo‘oos'* | ‘If | eI | et — | Gp | OFF | 000‘09L'F | “Ia 9r | on Ge | 0'L | G'ap | caeagr ieee | 1a z z oz | 0's | 0786 Seeanaea es Lian ne i | | | | 0’% | 0% | 0°09 | 009'¢ | eg | aaa 1) dig} 8 T tA OI OM) | Onis) pres tq | &r cd Om 8%, ese HONE 105 Se Id i i GT | 0% ON SCH TOOGES Ss | CGhu: | snanenainnirns mcce IT II 0’ |¢°9 | O'6F | 0089 | 86 | WwW &I SI 0% |¢"9 | 0°09 | 0089 | 86 |~~>->=-== 1 98 9 0% | 0'F Osh | 009°¢ | G6 | W (69 6 O'* |0°9 |0'OP | 00L°9 | 06 | “W OL aL | 0d *1N0} | ‘s[BU ore 818219) er 199 | Pare Coye wee a “OS | ora | EE | ogres ‘AH | ‘SI[e0 poy xed “UBIL) 5 ary -4[0d | 100 j | ‘syquour ‘dor | -AIOS [BO1d 01, ‘souddyvyd 242 mw burpisa, sunriwauy Jo poo7q lencos |e UBSIYOUN | ~~ URSIOTIN | 6 6G) Waiae ee SIOULT[T | SIOULTIT | TZ 57a eee edoing |7-~---— odoing | 02 (0) | ica UISUODSTA\ | ~~~" UTSUODSIAA | 61 Gyealisgp acs sae (MOCO) J olgO | 8T (fog ea eae BAO] | BLUBA[ASUUOd | LT OS 7 | Reams BYSBIGIN eee UISUODSL\A | OT OG ie | nna eae SO sean SBXOL, | GT PGS See SIOUITI[ | SfOUTTIT | FL (AGE een BYSBVIQON | BUBIPUT | §L Gia AEBS eS BUBIUOW | BUBIUOW | ZT OG sais TINOSSI [>>> LINOSsiW | IT AG ee oe HMOsstq |” NMOsstwW | OL zg |" BluRBA[ASUUSg | BLUBATASUUed | 6 “BIquany } GG | CID) HO VOLEEIGL [ET SBSUBY | 8 (CPi BYSBIGON | -—~ YIOK MON | 1 Gig mal es BIOSOUUT | ~~ ~BIOSOUUTA | 9 Ge NE sesuByry |~~-~77"Wnosstyy | ¢ CC me a eee BIBIONY) |-—-——~ RUBQBLY | F zg |7 BruUBATASUUOg |7--—~ HIOX MON | eg |" BruBA[Asuuog | BIUBA[ASUUEY | % Chee AIOX MON [| FAIOX MON | T ‘asy| ‘eouopIsey ‘eou Td yyqaig ‘ON ay, UO SJUuN0D Yjyousp pun yoYuasofiriq— A AIAV I, CHAMBERLAIN AND VEDDER. 416 OT |O8L | 08S | OOF | 08 ¢"0 0% |} 0 O0L | 068 | OLE | OCI | OT 0% | O6L | 09F | 0°42 | 0°9 Ome 0 | O'6T | 066 | 0'0F | 06 0% 00 | 08 OGL | OP | OTP | 00 0°0 | OTL |00F 10 %E | OGL | OT 0S | O08L | 00OP | OE | 06 0°0 OT |00¢ | OTF | 066 | 06 OT 06 | 0% | 098 | 0°08 | OL ¢0 0% | OLT | 0S | 08% | O'S | 06 0¢ | 088 | 086 | O'L6 | 0% G0 OF | OFL | 098 | 0°98 | 0 0L | G0 OL | 086 | 088 | 016 | OTT | G0 0% | 016 | O'8F | 0'F2 | OF 0°0 0° |O8L | OGF | OTE | 09 OT 00 | 06 0c& | 0O'LF | 0'@T | 00 0G |O09L | 0h | 06 | OSE | G0 OT | OZT | 098 | 098 | 0'OL | 90 0% | 0°9T | 0°%E | 0°98 | OFT | 00 OT |} O°8T | 0°48 | OTS | OST | 00 0% | O09T | O88 | 0°CE | O'LT | OT OT | OST | 0°88 | 0°22 | O'9T | 0°0 0% |08 | 0c | 0°68 10°93 | GT | | DX ANE | U0 ‘II U “UOBOYISSBIO YOULY *mOIxe[du109 JO 9dA} PoxIUl sUvOM “JT ‘O8}JoUNIq sUveM “Ig ‘puo[q SUveM [qx OL ¢°0 Gy °% G0 0% G's GZ Gol 0°8 G'F Cl GC 0°0 Ge Cie 0°88 0°86 0 62 0°66 062 GOP ‘0g 0°94 Css 0 68 | 0°24 08s Ge CSP c OP GPs 4 06L | 0°08 1g G62 0 TS 0°82 GT |0°S |070¢ | 008% | 66 | 000‘00z‘¢ “Ig ix F% | L@ | BIOYVC YON GT |G | ¢°g9 | 00S‘ | 86 | 000‘069‘F Ig Oren NOS Gl ee a: Sexo], GT |0% | 0°09 | 006° | 06 | 000‘000‘¢ IG leohGa | PG |86 | = BITLOFITBO, G0 |G |e | 00c'8 | 28 | 000‘ecr F Td | OF Oh. || 6 |S TN OSs GT |G% |$°99 | OOL"0T | 68 | 000‘09L'r “Ig | (47 Ole dake) eee YIOX MON GZ | 0's o'r | 0022 | eg | 000 ‘000 ‘¢ | Ta | oF SEN Chie escenas BUOZIIY GT |OF |¢7¢s | 00c‘F | G8 | 000 0zeF ‘ta | op FZ | OF | S}esnqoussvyy OT | 0° |&%9 | 0088 | 26 | 000‘0F8‘F NG | gi) OL | GR. BJOSOUULN, OL |G | 00S | 0004 | 88 | 000‘008‘F BT |S Oe gil ae 9 Ts 2:2 eee odoing G0 |¢°¢ |0°Sh | 00¢'8 | 08 | 000‘0FF‘F Ta | ot | ot | ¢z@ |- BI0HBG YINOS GT | 09 ¢*09 | 00S‘9 | 06 000 ‘004 “¢ I | 91 91 Gio] pee qe G0 |09 | ¢'8¢ | 006° | ¢6 | 000‘096'F Ig Qe) GIL ee odoing GT |0% | 0°96 | 00F*2 | 08 | 000066‘ mist 19 9T_:'| 62 | -sosnqoRsseyy OT |G | O02 | 000°S | 06 | 000‘002'F Ta | & OTe | iScie|poumea es BAMOT 0% |¢% |¢'er | 0029 | 8 | 000‘o9F‘F mcs 91 91 | oo | UO}SsUTYSEM 0% | GF GLe | 00F‘L | ¢8 | 000 ‘0F9‘r Ig 14T | 2 | 0g |-syesnqoRsse Gt |}0¢ |0°249 | 0092 | 08 | 000‘008'F | “Aa Bees ae Ole 4 reel eaiaecahe BuBIpul 1@'% |G'¢ | 0°69 | 002 | G8 | O00‘09S'F | ‘Ta met Oe ee. | OpRIo[oD OT |G'¢ | G'zg | 006°2 | 28 | 000‘OFF‘F Ig OTe nO Ta RGG.alnee== YIOK MON 0 |0°2 | 0°8E | 008° | 06 | 000‘0F9 ‘F 7) SOTO OCs amen AYOn Uy GI |b | P'e9 | 00¢°L | G8 | 000‘00a‘F | 1a | wit | 9 | Lz GI |@¢ |G 6y | 00L'L | 08 | 000008 | Td | 9T | OF | 2 OT |Gr | ¢6¢ | 000 ‘Or 26 | 000"008'F | “Ia | 9 | or | 22 | (29 “d | } “Ino | | | [RIOT |; JUes | *S1B9]0} ‘s[joo i vUol | | -eld |, oa 2 pe any AA | 4H | ‘s[[oo poy =xeid eee eee | hoo? doUapPISoy ATOd | uecoy) | | ‘syjuour ‘sor | | |-ALes [BOLdor | e ~ BIOHBC YIION eas BIULOJILVO |e BIULONTBO Saieetar YIOX MON “BIquIN] -0 JO JORIS ~S}JOSNTOBSSBI, Seuce 35 adoing “si 9SNYOBSse JY ~S}JOSNYOBssB eae BUBIPUT UBSIYOIIV -----yIOK MON nee Ayonquey -o0B[dyyug cP se) ~~ ‘ON | “panuru0gj—samddyryd 247 mw Burprsa. sumrsowy Jo poo0)g 247 WO szunod YyjoULy pun poyuaialid— A WIA¥ I, 417 ARNETH’S NUCLEAR CLASSIFICATION. | | l ] ] O% |9FL |e | 6s | Ser |80 | 8s | Ate | eo | Ar | 89S | POEL | 68 | O00 LOLy | L'RZ | 9 FL a Gana asvIIAY 0% | 00 | 09 | 09% | O-9L oer | oo |OF | 0°69 | G06'¢ |¢8 | OOO‘9es’G | “Ma | 92 | 8ST | Gh | -~~yIOX MON [~~ adorngy 00 |04 | 0h | OTe | O-ZT 0h |0'§ |G | 0°92 | OOT'6 | 06 | 000 ‘oF ‘9 | Ie TS BION ee SUxoaT, | ~~ Ayonquey 070 |06 | OFF | 0°08 | O'LE oce |GT |0'¢ | 070 | 0084 | 06 | 00000. | ‘Id | f9 ef | 0g |~seqws peru -----------oryo 070 }06 | O88 | OE | O'9T Tr | 0 |G@T | 00S | 0022 | 68 | 000‘08*r | ‘Ta | TSrsh ete Oe Mlemesse es MNOS ae eta BMOT 00 |0' | 0°OF | O'SF | O'@ greg |-¢'T | 0°% | 0709 | 00% |08 | coo‘00's | ‘Ta | 91 | 9 | oa | Y1OK MON 10K MON 0% | 0°SE | 01S | 02% | O'¢ oes |0% | 0% | 09 | 009'¢ | 0OT | 000008 Id TE Cian |e ma BuBIpuy | vuBIpUl OL |0%G |0'%E |OTS |OFL |OT |O6 |O8E |YT |O% | 4°89 | 0024 | 48 | 000'000'9 | Ta | F GT | 86 (etme ALOR MON | ~-- ~~ STOUTTIT OT | OFT | 0's | OOF | OC | OT | Ss | Gz | OF | 0% | 0°84 | 000'8 | 08 | 000‘00FF Aq | 98 1a We 0 ae BIULSITA ones BIULSIT A 00 |0'8 | o'er lore | ost |G |¢9 Io6e |es |e | Gop 1000'9 | 66 | 000'00'¢ | wa | 98 gr | 2a | BpuBAyssuueg Pee AOS ULLoe 0% | 08 |0'0S | O68 | O91 |G: |e | G6 |S |Os | OOS | 008 | 08 | 000‘0D9's | NE 98 9T | $2 ~ Bruweatssuued ~ vluBAlAsuUeg 0's | OLE OTF |0% |oet jo jos |ete jou |e | 078 | 003'2 | GB | 000‘008"G 1 ite GE | Gg | OK MON | adoring 00 | OTE | 0% | OOF |Our | 0% | Ss | G0s |0% | 0E | 079 | 000'8 | 08 | 000000" | “14 PE ST | G3 | BruBayAsuued ~~~ adoing 0% |0% |o'cs |o'se jor {9 jos |o'98 | oe jot | o'ep [--—— (pom al feicee ca | WW rat aI | OF | ~SeIw)S pa}uy \~soieg poyuy Od (OO | OF Long Hirer Lom |r Par Os | Oe oda |= lenge Sit ga as ees - Wd 8 Be MG leone 4 SBSUBYLY [~~~ SUsSaBALY 0% |0% | 0%) joc | 019 jor joe |axe |o's jos | o%o jo | Sept Su Cs temas eel Ze Comte lgees YIOK MON 7 YIOK MON OF |O% OWS (OD, [OBE POT [OW sks | 0] POT |S ect Dee pee Iie cee UBSIYOUN | UBSTYOLN OT | OSL |0'S8 | O's | Or | eT |ee |06 [0% |0%G | 009 | ~~~ Se Sorea se | 1g 81 Qn hey tesco SBxeD | SBXOL Dat NWT 1 OR Oy |) We sg OF Ose ee GIS | GS a a ans 1g SI dia, We BIULBITA |= BIUTSIT A, 0% | O21 | O'S | 083 0S J0% |08 | 0°92 |0'8 |OC | ORG | We rap SIE mete St BIN Ve eae are cil pee STOUTTIE ~~~ ~~~ STOUTTLI 07S |0%% | 00S |O'9T }0G JO |G | Ges | GT | G9 | 0°99 | ~~ aoa beepers Saar ce ey Ne 9 Oi GINS ies gee HIMOsst ~~ MNOSSTIN 0% | OSE | 068 | OF | OO |00 |08 | OT | 0G | ORE | 0% | (eee agave hes sicst T¢ He Np Pea BPBUB) BpeuNy OD) | OHS TOT? | OE OB Oe POR |] WARE | ae OG hy | “ae gS 9 |og |~“MIox eM IOR MON 0% |0'2E | OOP joke |O'8 | 9:0 | Oe |e | 0'0 | Ge | G799 | OOL's | 06 | 000‘OR9'F | aq | OF OS We [Ee edoamgy ~~~ edoing 00 |0' |0°92 | 08h |012 |G0 |G% | 02% |} G0 |G | OT9 | 009'8 | 2 | 000'009'F | ‘Id Ie AOS eres BULOYVTYO MMOSSTN oe |O'9r |o2us | oes |06 |O€ |O' (0% | ST |O'e |G'c9 | 000 | c6 COO‘OS*r «a Ir OIE GS Pe adoing, ~~~ ~~~ adongy 0% | 0's |O'% |oe OF |G0 jo% |o%s [OT |G | 9'Fe | 002'9 | #8 | 000‘O8F'F =I Creare aes adomg ~~ ~~~ edoma or ot lowe lo / os (ot loo lowe jot lo, 'oror | oor'z |06 | 000'omZ'+ | aa #9 Otublscr alr caes BIMOYBRIYO ~—————- TaMOSSITY 418 CHAMBERLAIN AND VEDDER. TaBLE VI.—Differential and Arneth counts on the blood of Filipinos. EEN SNe Ss oO eoSecetorototonneoseate 2 oS : # Aes. aI A ira a x) Arneth classification. is 5 3 | Be |ae| oe) a | = SS ® — | eS} es | se = or | Sell @uibewe| hse Stel eee tee (eel mehe Peseta Paige tenets BS | 3 s eg 5 es | g a | | | shea ea) Ee Ihe taal Sos Soe aS [a 1a a ca) me | = == | ee = es | ee a es | | Pct | | 1 |) 17)” G0!) 8)900;|| <5155)))) 86059) 24.54) 2 teb |e 10) eon a 38 36. | 10 | 22) 90] 9,600) 57.0) 215) 5.5) 1.5) 14.0) 05 | 1 30 31 | 15 3) 19| 94] 9,700) 52.5) 33.5) 3.5] 05] 95] O15 | 99 32 iG 4] 29| 92] 9,800] 64.5] 25.5) 1.5] 2.0] 60] 0.5] 30 32 29 Q 5| 24) 985 | 10,800| 75.5] 12.5) 2.0] 2.5] 7.57 0.0] 24 35 30 | 10 6| 30] 87] 7,900] 72.0] 15.5] 1.5] 1.0] 10.0! 0.0! 20 33 28 «| 16 7| 38! 95 | 12,800] 585] 32.5] 3.5] 1.0] 3.0] 1.5] 38 22 26 6 g| 23) 93| 9,900! 48.5] 31.0] 4.0] 0.5] 15.5] 0.5 | 39 38 14 9| 24! 85) 7,500| 66.5] 24.0] 5.0] 25] 20] 0.0] a7 35 37 5 10| 37} 86] 10,600] 50.5| 345) 5.5] 2.0] 6.5] 1.0] 20 31 31 | 16 11] 23) 95/ 11,000] 68.0] 27.5] 1.0] 0.0] 7.0] 1.5] 30 31 25 | 14 12! 30! 988] 10,400] 46.0] 31.5] 3.0] 1.0] 17.5] 1.0] 35 44 15 6 13 | 17! 95] 11,500] 61.0] 26.5) 2.5] 1.0] 7.0] 2.0] 17 39 Soin | LON 14] 27 94] 8,600] 44.0] 43.5] 5.0] 1.5] 5.0] 1.0] 22 44 23 | 10 | 15/ 38| 96 | 11,200] 62.5] 23.5] 65] 0.5] 6.5] 0.5] 33 36 21 =| 10 16 | 32! 98) 8,000] 42.0] 42.0] 5.0] 0.5] 10.0] 0.5! 24 34 32 «| 10 17| 30; 99] 8,400] 55.0} 30.0) 4.0] 1.0] 9.0] 1.0] 35 40 22 3 1s | 36! 90] 7,300] 60.0) 27.5] 5.5] 1.5] 5.0] 0.5] 93 41 30 6 19| 36) 93]| 9,300] 67.5] 25.5| 2.0] 1.0] 25] 1.5] 33 33 28 5 20| 24/ 95] 8,400] 51.5] 30.5) 2.5] 0.0] 15.5] 0.0] 22 41 28 9 a1] 17) 92] 11,100} 41.5] 39.5] 6.5] 1.5] 10.0} 1.0] 22 25 32 | 19 22 | 25! 100} 8,700] 46.0] 43.0] 2.5] 0.0] 8.5] 0.0] 38 36 23 8 93] 22/ 90/ 8,300] 33.0] 52.0] 0.5] 1.0] 13.0] 0.5/ 21 | 33 | 35 | 9 24 | 24) 93! 5,500] 50.0] 38.0) 2.0] 1.0} 9.0] 0.0] 4 49 12 4 95/1 36) 99} 7,900] 42.5] 38.0] 5.0] 1.5] 12.5] 0.5] 49 38 15 5 26| 36| 97] 9,900] 60.5] 28.0] 2.0] 0.5} 9.0} 0.0} 29 43 20 8 97 | 22) 98 | 10,100] 41.0} 42.0] 0.5) 0.5] 16.0] 0.0] v4 37 29 9 | 64.5] 25.5] 35] 15} 5.0] 0.0] 14 35 36. | 1d 70.5| 23.5] 1.5] 05! 35] 05] 930 44 18 6 50.0! 33.0] 3.5] 6.0] 7.0] 0.5| 98 40 30 i 59.5| 17.0] 3.5| 3.5! 145] 2.0] 94 46 28 oes 59.0 26.5 5.0 2.0 6.5 1.0 28 45 21 | 3: 47,5] 38.5] 3.5] 35] 11.5] 0.5] 95 40 31 4 BM | [see oie 47.0} 32.5] 7.0) 6.0/ 7.0) 05} 35 38 15 | 10 | a8 | fA ee AA aoe ee 2 33.5] 47.0] 2.5] 1.0) 15.5] 0.5) 36 34 24 6 | 393 || Senge (OLS SE 37.5 | 49.0] 4.0] 3.0] 6.5] 0.0] 98 46 19 Gue 37 eee [B2>ict| aee 54.0] 17.0] 11.0] 9.0}; 9.0] 0.0] 31 47 99 0] o {fe copra ak ae 52.5 8.5 | 10.0] 2.0] 26.5] 0.5] 927 37 30 FO )t| ine. | 49.0] 29.5] 5.5] 1.5] 13.0] 1.5] 27 46 23 ae elt AQ) oot Ae la a 54.0] 15.5] 18.5} 4.0 6.5] 1.5] 16 37 35 12 fil ee A eee 50.0} 11.0} 8.5} 8.5] 21.0} 1.0} 14 39 25 16 Feet ae Halles sem 24.5 27.0) 5,5 | 2.0) 885] 2.5) 34 46 20 0 PO (eo | eee is So 43.5 | 45.5] 5.5) 2.5] 1.5] 1.5) 54 41 5 0 7 Veiga eee Se 50.0] 32.0] 5.0] 10} 11.5] 0.5] 40 47 13 4 ee | ee 42.0] 83.0} 6.U} 7.0} 11.5] 0.5} 30 43 22 4 AG Nace eal anes 48.5 | 34.0] 4.0] 1.0] 12.5] 0.0] 8 33. | 37 ‘| 19 AAs ete 2 we aay 69.5) 14.5) 2.5| 10) 19.5) 1.01) 33 44 16 7 ETA iene | eaten RS 63.5 | 22.5] 4.5] 20| 6.5] 1.0] 38 39 | 22 1 | AQ): |2 Seles oe 35.5 | 25.5/ 10.0! 0.0) 29.0] 0.0] 13 39 44 4 | 5a eats ea aa 39.5 | 37.0] 5.5| 0.0] 17.5] 0.5] 21 39 33 4 Average| 93 | 9,248| 52.2| 29.9| 4.6| 2.0] 10.6] 0.7| 27.5) 383) 258] 75 a | NOFPMSOSOOOFRFHFOCNNNWHEHON WN | | = o ARNETH’S NUCLEAR CLASSIFICATION. 419 REFERENCES. ARNETH. Die neutrophilen weissen Blutkérperchen bei Infections-krank- heiten, 1904. Kagan, 8. H. Nuclear Classification of the Neutrophile Leucocytes and its Relation to Disease. Boston Med. and Surg. Journ. (1910), 162, 709. Simon, C. E. Clinical Diagnosis, 6th Hd. 76 and 81. ) Porrencer, J. E. Phagocytosis in Relation to Arneth’s Classification of the Neutrophiles. Journ. Am. Med. Assoc. (1909), 52, 1981. Moscuowitz, EH. Eosinphilia and Anaphalaxis. N. Y. Med. Journ. (1911), 93, 17. Soris-Conen, M. and Srrickuer, A. A Study of the Leucocytes in Pul- monary Tuberculosis. N. Y. Med. Journ. (1910), 92, 248. BucHANAN, R. J. M. The Blood in Health and Disease. (1909), 135 and 148. Wessroox, F. F. Phagocytosis. Reference Handbook Medical Sciences (1903), 6, 578. CHAMBERLAIN, W. P., BLoomMBerGH, H. D. and KiLBRouRNE, E. D. Examina- tions of Stools and Blood among Igorots. Philip. Journ. Sct. Sec. B (1910), 5, 505. (10) Puaten, J. M. An Experiment with Orange Red Underwear. Philip. Journ. (11) Sci. Sec. B (1910), 5, 525. GUERRERO, L. and Sevirta, A. Medical Survey of the Town of Taytay. Philip, Journ. Sci. Sec. B (1909), 4, 277. WIickKLINE, W. A. Effects of Climate on the White Race. Mil. Surgeon (1908), 23, 282. Minor, C. L. and Rinerr, P. H. Arneth’s Method of Blood Counting. Am. Journ. Med. Sei. (1911), 141, 638. BUSHNELL, G. E. and TreuHoLtTz, C. A. Arneth’s Method in the Clinical Study of Pulmonary Tuberculosis. Med. Rec. (1908), 73, 471. Kuess, A. C. and Kiess, H. Hematological Studies in Tuberculosis. Am. Journ. Med. Sci. (1906), 132, 538. WIEDENREICH. Archiv f. microscop. Anat. und Entwickelungsgesch. (1908), lize THE SO-CALLED X-BODIES AS ARTEFACTS IN GLASS. SLIDES.1 By WESTON P. CHAMBERLAIN and EDWARD B. VEDDER.” (From the United States Army Board for the Study of Tropical Diseases as they Exist in the Philippine Islands.) Dr. Andrew Balfour(!) has announced the finding of the so-called X-bodies in the blood of a patient suffering from urticaria. These bodies were first reported by Horrocks and Howell(2) who found them in a case of tertian malaria, in several cases of undetermined fever, in the citrated blood from a rabbit and in the blood of oxen. They describe the X- bodies as follows: “The bodies, when stained, were characterized by a faint capsule with a circular centre staining deep blue; they varied in size, some being as large as a red corpuscle, others only about one-eighth the size of a red corpuscle. In addition to these forms, which were the most common, the following were also seen: (a) A small blue circular centre surrounded by four or more faint capsules, concentrically arranged ; (6) two circular bodies, each having a dark blue central point surrounded by a light blue ring, enveloped in one capsule which appeared indented as if two capsules were in the process of formation; (e) similar to (6) but the part surrounding the deep blue centre stained a deeper blue, and two indented capsules were seen; (d) a dark blue central part shaped like a erescent, containing a small circular body, with a deep blue central point within the arms of the crescent. None of the bodies on the slide showed any ‘signs of chromatin.” Neither Horrocks and Howell nor Balfour commit themselves as to the nature of these bodies. Indeed, the former authors say, “Having in view the diverse nature of the cases in which the X-bodies were found, we are not justified in considering that they were the cause of the pathological conditions observed.” It occurred to Balfour that such bodies might be contaminations from the skin, but this idea was subsequently dismissed, and none of these investigators appear to doubt that the bodies were really obtained from the blood. Fortunately they both furnish good and detailed drawings which permit of easy identification of the X-bodies. * Published by permission of the Chief Surgeon, Philippines Division. ? Weston P. Chamberlain, major, Medical Corps, United States Army and Edward B. Vedder, captain, Medical Corps, United States Army, members of the United States Army Board for the Study of Tropical Diseases as they Exist in the Philippine Islands. ; 421 422 CHAMBERLAIN AND VEDDER. We believe that we can point out the nature of these bodies, and that we should do so, not only because two papers have been published on the subject, but because it has come to our knowledge that other inves- tigators have been misled by them. Therefore, a statement of their true nature may simplify investigations in the future. These peculiar bodies were first observed by one of us in 1907 while studying the blood of dengue, and before the publication of the paper by Horrocks and Howell. They were at first thought to be parasites associated with that disease, but further study showed that they were frequently present in normal blood.. Subsequently they were found again in specimens from various pathologic conditions, and from different parts of the body, and the idea was finally suggested that they were artefacts in the glass slides. Search of a number of plain unstained glass slides having no specimens on them revealed the fact that these bodies could be found on many. On such unstained slides the bodies have the same morphology, but are without coloration. When the glass slide is pre- viously stained with a little Wright’s stain, as though staining a blood film, the bodies take on exactly the appearance described and accurately depicted by Horrocks and Howell and by Balfour. The X-bodies in these two papers are, therefore, artefacts of some sort, present in certain of the glass slides for microscopic use. We think that they are found more often in old slides which have been used several times, and have been kept for some time in the Tropics. We believe that anyone finding the X-bodies in a preparation can readily verify our statement by staining and examining some of his slides on which no smear has been made. The bodies are not in the stain, because they may be found in unstained preparations. Other facts that confirm these observations are: 1. The X-bodies have been found on slides made under a great diversity of conditions from both men and animals, including the blood from cases of malaria, un- determined fever, urticaria and dengue, and normal blood in the human, and also the blood of oxen and rabbits and the liver of oxen. We have observed them in slides containing scrapings of skin mounted in liquor potasse. 2. In the same case the bodies are not found constantly, but are only seen in a few out of many smears, although they are usually numerous in the particular slides in which they are observed. If present in the circulating blood, they should be found on all or nearly all the slides examined from the case at the same time, though not necessarily in large numbers. 3. So far as we are aware the bodies have never been detected anywhere except in smears or preparations made on glass slides. : As further evidence in favor of the X-bodies being in the surface of the slide we performed the following experiment : X-BODIES AS ARTEFACTS. 423 A blood smear was stained with Wright’s stain and showed many brightly colored X-bodies of various sizes. Several large ones were located with the vernier scale of the mechanical stage. The slide was then removed and scrubbed with water and gauze. On again bringing the located areas under the lens no blood corpuscles could be seen but the X-bodies were still there and unchanged in appearance except that the coloration was less intense. The slide was again removed, scrubbed with alcohol, and replaced beneath the lens. The identical X-bodies were present in the same locations as before, but all trace of the stain had been removed from them. If a clean new slide containing no specimen is stained in the usual manner with Wright’s stain, and the stain-film is then rubbed off with dry gauze or with xylol, X-bodies, still showing coloration, may be found. This fact suggests that the objects named X-bodies in most instances may be due to minute portions of the stain being retained mechanically im microscopic pits in the glass. Usually, the X-bodies are seen to be at a lower level than the blood corpuscles on a slide. We rarely have . found instances where they appeared to be above the corpuscles and the edge seemed to overlap a red cell. Such an appearance could hardly have been due to a pit, but might be caused by a minute scale of glass on the surface of the slide, which would entangle the stain and beneath which the edge of a corpuscle could slip. The shde on which this over- lapping was noted is the one described in the preceding paragraph and the X-bodies which appeared to have the edges slightly overlying red cells were the ones which remained unchanged in location after repeated scrubbing. Photomicrographs of these bodies are appended. The photographs were made by Mr. Charles Martin of the Bureau of Science, to whom we desire to express our obligation. The magnification in all cases is 1,000 diameters. The first three figures are photographs of X-bodies found on a slide containing a smear of normal human blood, while the last three are of bodies that were found on a glass slide containing no specimen of any kind, but which had been stained with Wright’s stain and the dry stain-film then rubbed off with a piece of gauze. The bodies were very numerous on these slides, a number being present in nearly every field, but it is almost impossible to procure good photographs of more than one or two on a single negative owing to the difficulty of obtaining an accurate focus on several of them at the same time. REFERENCES. (1) Baxrour, A. X-bodies in Human Blood. Lancet, London (1911), 1, 295. (2) Horrocks, W. H. anp Howett, H. A. L. X-bodies found in Human Beings and Animals. Jowrn. Roy. Army Med. Corps (1908), 10, 451. er it cance Wea | ‘ Tee ILLUSTRATIONS. Prats I. , and 3. X-bodies on slides smeared with normal blood. X 1,000. and 6. X-bodies on a clean slide which had been stained with Wright’s stain and the stain-film rubbed off with gauze. X 1,000. ; lotomicrographs by Charles Martin of the Bureau of Science, Manila. fo6072————G : 425 CHAMBERLAIN AND VEDDPR: X-BODIBS AS ARTEFACTS. ] PLATE 1. [ PHIL. JouRN. Sct., Vou. VI, No. i M6 se NT RD ioe eee Order No. 401, ee on ee e. 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Ng ge Orders should be sent to the Business Manager, Philippine Journal of “Bctence, Manila, © or to any of the below-listed agents. Please give Order Numb er. FOREIGN AGENTS. The Macmillan i ees Fifth Avenue, New York City, U. S. A. Messrs. Wm. Wesley & Son, 28 Essex Street, "Strand, London, W. C., England. Mr. Martinus Nijhoff, ‘Nobelstraat 18, The Hague, Holland. Messrs, Mayer & Miller, Prinz Louis Ferdinandstrasse 2, Berlin, . W., Germany. © Messrs. Kelley & Walsh, Limited, 32 Raffles Place, Singapore, *stvatte ” Settlements, Messrs. A. M. & J. Ferguson, 19 Baillie Street, Colombo, Ceylon, CIRCULARS AND DESCRIPTIVE MATTER SENT ON APPLICATION. : e Welle IoallelvMenve: JOURNAL OF SCIENCE B. MEDICAL SCIENCES Vou. VI DECEMBER, 1911. No. 6 OBSERVATIONS ON THE INFLUENCE OF THE PHILIPPINE CLIMATE ON WHITE MEN OF THE BLOND AND OF BepinWiNED LE pyre! By Weston P. CHAMBERLAIN.” (From United States Army Board for the Study of Tropical Diseases. ) CONTENTS. Parr I. INTRODUCTION: SOURCES OF EVIDENCE: GEOGRAPHY AND CLIMATE: SuN- LIGHT. Part. Il. PHysicAL EXAMINATIONS AND LABORATORY TESTS ON BLONDS AND BRUNETTES OF THE 1909-GRoUP AND THE 1910—GrRoupP. Part III. RELATIVE AMOUNTS OF SICKNESS AMONG BLONDS AND BRUNETTES OF THE 1909-Group, THE 1910-GrRouP, AND THE ScourT-CONSTABULARY— PoLicE—GROUP. Part LV. SymproMatToLocy AND Diprary HaApBits FoR THE 1910-GroUP AND FOR THE ScoutT—CoNSTABULARY—POLICE—GROUP. Part VY. RELATIVE PROPORTIONS OF BLONDS AND BRUNETTES AMONG SOLDIERS TNVALIDED HOME, AND IN THE Scour—CONSTABULARY—POLICE—GROUP, AS COMPARED WITH PROPORTIONS OF SAME TYPES AMONG TEN THOUSAND SOLDIERS. Part VI. CHARACTER, COURT-MARTIAL RECORDS AND SICK RATES FOR ALCOHOLISM AND VENEREAL DISEASE IN THE 1910—GROUP. Part VII. RELATIVE FREQUENCY OF OCCURRENCE OF SUNSTROKE AMONG BLONDS AND BRUNETTES IN THE UNITED STATES. Part VIII. Discussion or CLIMATIC INFLUENCES AND PIGMENTATION: GENERAL SUMMARY: CONCLUSIONS. * Published with permission of the Chief Surgeon, Philippines Division. 2 Weston P. Chamberlain, major, Medical Corps, United States Army, president of the United States Army Board for the Study of Tropical Diseases as they Exist in the Philippine Islands. 106711 427 498 CHAMBERLAIN. PART I. INTRODUCTION ; SOURCES OF EVIDENCE; GHOGRAPHY AND CLIMATE ; SUNLIGHT. INTRODUCTION. The influence of a tropical climate on men, especially the members of the Caucasian race, is an extremely complex subject. Among the general factors to which, with greater or less weight of authority, the deleterious effects of tropical residence are alleged to be due may ‘be mentioned heat, humidity, chemical action of the sunlight, lack of exercise, dis- turbed sleep, improper food, bad water, alcoholic and venereal excesses, and, perhaps most important of all, infections with those animal and vegetable pathogenic organisms which are confined more or less exclusively to hot regions. Individually age, sex, race, stature, previous residence, per- sonal immunity, and perhaps complexion have to be given consideration. The work herein reported has to do with only one of the above factors, namely the complexion type. The distribution of the black and brown races in the hotter portions of the globe and the difficulties which in the past attended the colonization of the Tropics by the Caucasian were matters of common observation long before the causes of tropical disease and deterioration received any adequate study. More recently several authors have claimed that the blonds tend to decrease in numbers or to deteriorate when they are transplanted from the relatively cloudy regions of northern Europe to sections in the Temperate Zone which have a much greater amount of sunshine. Woodruff, studying this phase of the subject in the Philippines, maintains that the blonds suffer more severely than do the brunettes from the deleterious influence of tropical residence and that the ill effects observed among white men dwelling in the Torrid Zone are due mainly to the large proportion of chemical or ultra-violet rays contained in the tropical sunlight.(2) (3) To determine what may be the influence of the actinic rays alone, as distinguished from the other factors enumerated in the first paragraph, is evidently well-nigh impossible. The question as to whether trans- planted fair-skinned races gradually change after many generations from a lighter to a darker average type, as a result of the survival of those best fitted to endure a high degree of sunlight, is purely speculative and of theoretical interest only. Whether men of dark complexion living ten, twenty, or thirty years in the Tropics can withstand the climatic influences more successfully than those having fair skin, light hair, and blue eyes is of much practical importance, but is extremely difficult to determine because of the almost insurmountable obstacles which stand in the way of making observations over such a period of time on any considerable group of men. When it comes to the relative resistance of the blonds and the brunettes during the comparatively short tour of duty (two years) which American soldiers commonly serve in the Phil- INFLUENCE OF PHILIPPINE CLIMATE ON WHITE MEN. 429 ippines, the task is beset with fewer difficulties and it is to the elucidation of this problem that our efforts have been directed during the last thirty months. The matter is of some practical importance in the selecting of recruits and civil service employees for tropical countries. SOURCES OF EVIDENCE. The ‘evidence on which this report is based is of several kinds and derived from various sources. It may be divided into classes as follows: Crass I. A series of observations carried out under the supervision of the Board, during the calendar year 1909, on enlisted men of the United States Army. This will be called the “1909-Group.” One hundred and_ fifty-seven blonds and 154 brunettes were observed. Besides the symptomatology and the sick record over a period of two years for these men, there were made 1,100 weight, 1,320 pulse rate, 1,320 respiration rate, 1,320 temperature, 880 blood- pressure and 880 dynamometer observations, spaced at equal intervals throughout one year.* There were performed by the Board 195 red blood cell counts, 195 hemoglobin estimations, 38 leucocyte counts, and 57 differential counts. Cuass IT. A series of observations carried out. under the supervision of the Board during the calendar years 1910 and 1911 on enlisted men of the United States Army. This will be called the “1910-Group.” Three hundred and forty- seven blonds and 346 brunettes were observed for one year. Besides recording the sick record,* symptoms, effects of tropical residence and sunlight, habits as to food and alcohol, characters, court-martial trials, fines and confineménts, there were made on the men, 3,694 weight, 3,986 pulse rate, 3,986 respiration rate, 3,986 temperature, 2,540 blood-pressure and 620 dynamometer observations, 1,134 hiemoglobin estimations, 1,134 red blood cell counts, 1,152 ‘urine and 601 stool examinations.’ These observations were spaced at regular intervals throughout: a year. There were performed by the Board 118 leucocyte esti- mations, 90 differential blood counts, and 56 Arneth counts on blond and brunette Americans, and, for comparison, 552 blood-pressure estimations on 386 Filipinos and 50 differential and Arneth counts on 50 Filipinos. Crass III. A collection of data from the commissioned officers of the Phil- ippine Scouts and the Philippines Constabulary and from the Americans in the Manila police force. These are men who have been a long time in the Philip- pines, the average period of continuous tropical service being 5.5 years. There were 186 blonds, 147 brunettes, and 235 of a mixed type in this group. As a class they are men who do a large amount of work out of doors and exposed ’The observations referred to in this sentence were made under the super- vision of the Board, by the following medical officers of the United States Army: Major C. C. Collins and Captains C. D. Cowles, jr., G. L. McKinney, and H. A. Phillips. [ *The sick record covered a period of over twenty-two months. 5 The observations referred to in this sentence were made under the super- vision of the Board, by the following medical officers of the United States Army: Majors A. E. Truby and Roger Brooke, jr.; Captains E. G. Bingham, John R. Barber, Mahlon Ashford, E. G. Huber, H. M. Snyder, and W. L. Hart; First Lieutenants J. B. H. Waring, W. R. Dear, C. E. Doerr, F. S. Wright, C. G. Snow, N. L. McDiarmid, Armin Mueller, T. J. Leary, M. C. Stayer, L. C. Garcia, and ©. E. Fronk, Medical Corps; and First Lieutenants W. F. de Niedman and C, A. Betts, Medical Reserve Corps. 430 CHAMBERLAIN. to the sun. These individuals are considered in what we will term the “Scout— Constabulary—Police—Group.” Cuiass IV. An examination of all patients invalided home from the Division Hospital in Manila during a period of one and one-half years and a deter- mination of the complexion type of each. There were 273 of these men. Crass V. An examination of 10,072 enlisted men of the United States Army to determine the relative proportions of the blond, brunette, and mixed types. The rate per 1,000 was. found to be, blonds 238, brunettes 206, mixed types 556. This information was used as a basis for comparison with the rates per 1,000 of the three types in Classes III and IV, the former consisting of men who had voluntarily endured the climate for an average of 5.5 years and the latter of men who had succumbed to its influences during their tour of military service. Cxass VI. A series of cases of sunstroke and heat exhaustion occurring in the United States and in which the type of complexion of the patient was recorded.° In Class II, the choice of the blonds and brunettes for observation was made by the medical officers referred to in footnote 5, and the selected men were subsequently all examined by the writer, and those who did not conform to the standard types were excluded. In Class I, selection was made by choosing from the cards of a group of 800 men, who had been under observation for two years, those on which the 3 recorded complexion factors indicated well marked blondness or a clearly defined brunette type. Throughout this report the blond group includes men with blue or gray eyes, light brown, red, flaxen, or sandy hair, and fair, ruddy, or light complexion, while the brunette group is made up of those with brown or black eyes, dark brown or black hair, and medium or dark complexions. Men in whom one of the complexion factors cor- responded to a certain type and the other two belonged to the opposite type were classed as “mixed,” and were excluded from the observations dealt with in Part II." Hach of the officers referred to in footnotes 3 and 5 had under ob- * These statistics were collected through the kindness of the authorities at the following hospitals, to whom we wish to express our appreciation of the courtesies extended to us: Philadelphia General Hospital; Roosevelt Hospital, New York, Bellevue Hospital, New York; Massachusetts General Hospital, Boston; Pres- byterian Hospital, New York; Boston City Hospital; Carney Hospital, Boston; St. Luke’s Hospital, Chicago; Mercy Hospital, Baltimore; Jefferson Hospital, Philadelphia; New Haven Hospital; Alexian Brothers’ Hospital, Chicago; Cook ' County Hospital, Chicago; St. Louis City Hospital; Rhode Island Hospital, Providence. We also received reports from a few other institutions, but as they came in our franked envelopes without address we are unable to credit them to the sender. * With such a classification there will be a very well marked average difference in complexion type between the blond group and the brunette group. However, it must not be thought that all of the blonds were conspicuous examples of blondness. A man with dark blue eyes, light brown hair, and a fair skin would fall in the blond class and, while not a conspicuous blond, would still be sharply contrasted with the man of dark brown eyes, black hair, and swarthy complexion. INFLUENCE OF PHILIPPINE CLIMATE ON WHITE MEN. 431 servation approximately equal numbers of the blonds and of the brunettes, and therefore in considering the final results the personal factors of the different observers need not be considered. ‘The conditions under which the men of the blond and of the brunette type lived during the observa- tion period were identical in all known respects. GEOGRAPHY AND CLIMATE OF THE PHILIPPINES. The observations were made at various localities in an Archipelago consisting of many hundreds of mountainous islands extending in latitude from 21° north to 5° north. No point even in the larger islands is in excess of 100 kilometers from the sea. With the exception of Camps Stotsenburg, John Hay, and Keithley, all of the military posts where the observations were conducted are located on or close to the coast-line and elevated but a few meters above the sea level.* Camp Stotsenburg is lo- cated about 50 kilometers from salt water on a plain at an altitude of about 200 meters. Its climate does not differ materially from that of the coast stations. Camp John Hay and Camp Keithley are in the mountains at altitudes of 1,500 and 800 meters respectively, and are characterized by a much lower temperature and a higher degree of cloudiness than are the lowland stations. The observations made at these two posts are not included in the general averages and were used merely for comparison with the lowland groups. Although everywhere tropical yet the climate of the Philippines varies considerably in different localities as a result of altitude, influence of mountain ranges, and proximity to the sea. In the regions where most of the observations were carried out the hot and dry season is in April, May, and June. The rains come with the cessation of the north- east monsoon in June or July and persist till October or November. The differences in temperature between the warm season and the cool season are quite noticeable. In the posts in Mindanao and Jolo the differences of season, as regards both temperature and rain, are less clearly marked, and, as a result of several factors, the heat is no greater than on the northern coast of Luzon, over 1,200 kilometers more distant from the Equator, and indeed is less intense than in many of the central parts of the Archipelago. Complete details as to the climate of the Archipelago can be obtained from Bulletin No. 2, Census of the Philippine Islands, entitled The Climate of the Philippines. A few figures are collected from this publication to show the more important climatological features at different points. ® Fort William McKinley and Camp Jossman are each about 7 kilometers in- land, but are little elevated above the sea. Fort Mills is on an island about 2 kilometers wide, but its highest ridge, where the barracks are located, is 200 meters above sea level. 432 CHAMBERLAIN. a- Taste [1.—Annual thermic oscillation in the Philippine Archipelago.* | Annual | Latitude |) Annual Latitude | oscillation. | (north). i oscillation. (north). Place. : — Place. a De- | Min- x De- | Min- | | Ae oe | grees, | utes. °C. oF. grees.| utes. li | [ al ic oe | Ao oe Ie 26.5) alatery 18) | 022741 Oil oan 3.8) 6.8 10} 42 | Darl acsesseseee slaps 2 | 9,4 15 | Bly || (OTM OC sees ae DO te oLO 11 00 | AT Ayah lee ese 4.6 | 8.3 | 15 | 85 || \Cebusa2e hen sexmans 27 | 4.9 10 18 | “Meira 2 eats 252 3.5) 6.3 | 14) 35 || Davao __-__________ | 22 | 4.0 7 1 2 This indicates the variation of the mean monthly temperature and not the extreme. For Manila, which is representative of most of the region under considera- tion in this report, the normal monthly means of temperature for the period 1883-1902 are shown in Table II. The maximum recorded temperature in Ma- nila (May, 1889) was 37°.8 C. (100° F.), and the minimum (Jan. 1907) was UHI Oh (GO 18) TABLE II.—Normal monthly means, Manila. —— eT 7 = 1 ~~ eek 77 = Tae == | Month. | Peet) acorns Month. 9g, op, | fe fe camel -| Npicisuaho Chey! eh | 25.0 PTS OW| eid liye ae tae eM 27.1 80.7 Hebruary eae Soe Sie 1 2554 } ie de OA UST ee eee Se See 27.1 80. 7 | JAMS: TG Rye ale evens Bs Een 26.8 | 80525 \Septemibers a. sasue ae nee 27.0 80.6 (p SAtp rile gees eee 28.3 S29) Octobers a. ses meee eaumtn paaaes 26.9} 80.4 Mayen ly secrete eee ee Bie ee 28.6 BEL Chl INOW Oee se 26.1] 79.0 | Jun es eoe eee eS |it'97.9\|).“89.9)|| December ul aS 25.2} 77.3 | | i {I | The rainfall for the sections where the blond-brunette observations were being carried out ranges from 205 to 256 centimeters per year.” The degree of cloudi- ness is of much importance in an observation having to do with the possible influence of tropical light. The average cloudiness for Manila is given below, the scale being from 0 for a clear sky to 10 with the sky entirely covered. The table also shows the average of clear and variable days and the average hours of sunshine. TABLE JII.—Average cloudiness, average clear and variable days, and average hours of sunshine monthly in Manila. | Average | | Average Month. | “clouds I2F894 ioursof | Month. clouds (287 84) hours of| iness. days. sunshine.| iness. | days. sunshine: ban PeMie [tb oe JS | a ee ee | a January _______- 4.6 23.9 | 193 || August____-_---_-| 7.5] 14.0] 148 February _-!_-_- 3.8 23.8 | 220 || September _______} 7.4 13.1 135 March) seeo-eeues 3.8 | 23.9 247 || October _-_--_- | 6.1 WEI! ate, Nyt 3.5 | 25.1 264 || November _______ 5.8 18.6) 160 | Mayo ves hi Sale| 19.9 220 || December__------ | 5.6 22G)|aql57, = | | TUNE se ee 6.8 | 17.8 | 160 | Meanie: Reaches [49.51 1848 | Afibil hip aeeys es Se 7s 14.9 147 : | | *This does not include Camp John Hay and Camp Keithley where the rainfall is much higher. INFLUENCE OF PHILIPPINE CLIMATE ON WHITE MEN. 433 Comparing the average number of hours of sunshine with the figures for certain places in the United States it will be found that Manila receives 51 per cent of the theoretical sunshine while New York receives 56 per cent, Chicago 57 per cent, Denver 69 per cent, and Santa Fe 76 per cent.(1) In other words numerous regions in the temperate United States are characterized by many more hours of sunshine than are the tropical Philippines. These figures of course do not take into consideration the question of intensity of the sunlight in the two zones. The quantity of watery vapor in the atmosphere has a direct influence on the climate, because it checks to some extent the radiation of heat, and the relative humidity is of still greater importance in studying the influence of climate on man because the greater the humidity the more marked is the interference with the thermolysis of the body resulting from the evaporation of perspiration. (21) The following table shows the monthly and annual averages in Manila for a period of twenty years. These figures may be compared with average relative humidity records for July of 70.6 per cent for Chicago, 70.4 per cent for New York, 71.0 per cent for Washington, and 72.3 per cent for New Orleans. TABLE IV.—Monthly and annual averages of relative humidity in Manila, per cent. | ecards ly | rec l li eT chen ae | | | | | | Jan. | Feb. | Mar. | Apr. | May. June. | July. | Aug. | Sept. | Oct. | Nov. | —— | | | ee 74.2) 71.8 | 70.7) 76.7 | Bld) 84.8) 84.8)” 85.5 eau 82.0 \ 1 | | Annual Dec. average. 80.7 | 79.4 | In most parts of the Archipelago the discomfort one would expect from the continued high temperature and humidity is greatly mitigated by the very general presence of refreshing breezes, particularly at midday and in the afternoon and early evening. The velocity and frequency of the wind in the vicinity of Manila is greatest during the season when the temperature elevation is the greatest (March to September). The average daily velocity of the wind for Manila is 217.8 kilometers, the monthly averages varying from 149.3 in December to 291.0 in September. ACTINIC POWER OF THE SUNLIGHT. Of late years the chemical activity of the sunlight has become a factor which, in the opinion of many, should be considered in discussing cli- mate and its influences. Freer,(1) Gibbs,(14) and Bacon,(15) at the Bureau of Science in Manila, have found that the tropical sunshine ‘produces chemical changes which take place either more slowly or not at all in temperate climates. It has also been shown by Freer that there are in the Philippines “actinic” and “nonactinic days,” the chemical action of the sunlight during the latter being much less powerful, even though the sky may seem as clear as on an actinic day. The causes of these differences have not been determined. The investigations at the - Bureau of Science have shown that the spectrum of the sun’s rays extends into the ultra-violet little if any farther in Manila than in temperate regions. (4) That concentrated ultra-violet rays have a harmful influence on bacteria, as well as on some higher forms of life such as protozoa, has been clearly proven by many observations made by ourselves(18) and by others.(19) Some writers, notably Woodruff,(2) (3) have considered that such rays were very injurious to white men, more especially to 434 CHAMBERLAIN. those of the blond type. The subject needs much more study before a definite conclusion can be reached regarding the influence of the chemical rays of the solar spectrum, but the recent work by Aron(#) seems to indicate that the deleterious influence of the tropical sunlight on men and animals is due to the long heat-rays rather than to the short length ultra-violet waves. Steinmetz(®) considers ultra-violet radiations of moderate intensity, such as occur in sunlight, to be harmless to the eyes. “When acting on the skin ultra-violet rays have little power of penetration, being absorbed by the blood, but whether they can produce such changes in that fluid as to lead to constitutional disturb- ances still remains an unsettled problem. PART Il. PHYSICAL EXAMINATIONS AND LABORATORY TESTS ON BLONDS AND BRUNETTES OF THE 1909-—GROUP AND TITE 1910-GROUP. The work on the 1909-—Group began in the first quarter of 1909 and ended in December of that year, there being records for each man of 4 observations evenly spaced over an interval of about eleven months. The examinations of the 1910—Group began in the second quarter of the year 1910 and ended at the same time in 1911, there being for each soldier 5 complete observations spaced at approximately three-month- intervals during the period of one year. ‘The observations were made under our supervision by the gentlemen named in footnotes 3 and 5. All of these officers are thoroughly familiar with the laboratory methods involved in the work, and the number of observers minimizes the in; fluence of the personal equation. . It should be understood that the men under observation were healthy soldiers, any who showed evidence of disease having been excluded before the beginning of the observation period. The length of time the men had served continuously in the Philippines at the commencement of the test varied from two months to several years.° The average length of the present tour of tropical service at the beginning of the year of observation was in the 1909-Group for the blonds 14.9 months and for the brunettes the same. In the 1910-Group it was for the blonds 6.4 and for the brunettes 6.7 months. Jn both groups it will be seen that the average period of tropical service prior to the commencement of the observa- tions was sufficient for the preliminary stimulating effect of the Tropics to have passed away. At the beginning of the observation period the total tropical service, including present and previous tours, in the 1910-Group was 32.9 months for the blonds and 34.4 months for the brunettes. In the 1909-Group the average height was the same for both blonds and brunettes, 67.4 inches (171.1 centimeters), and the average age was practically the same, 25.5 years for the blonds and - 25.1 for the brunettes. In the 1910-Group the average height was 67.8 inches (172.2 centimeters) for the blonds and 67.3 inches (170.9 centimeters) for the brunettes, and the average age was 27.4 years for the blonds and 28.1 years for the brunettes. * The men with several years’ service had voluntarily transferred from organ- ‘izations going home to others just arriving in the Islands. One man we have in mind was a most conspicious blond and had been twelve years COME in the Philippines, remaining in perfect health. INFLUENCE OF PHILIPPINE CLIMATE ON WHITE MEN. 435 These soldiers were dressed in a loose fitting uniform made of khaki-colored drilling and habitually wore white cotton undershirts and drawers. The headgear for nearly all consisted of a narrow-brimmed helmet covered with khaki cloth. In general the clothing was the same for the men of the Scout—Constabulary— Police-Group which is to be considered further on. The observations on both the 1909-Group and the 1910—Group will be taken up together and discussed under various subheads. Weight.—The maintenance of a weight proportionate to the height is generally considered one of the best guides to the health of the dividual and, therefore, the average of the individual weight observations was deemed of much importance in deciding whether a difference was mani- fest between the blond and the brunette groups. The results are shown in the following tables. TABLE V.—Comparative average weights of 111 blonds and 118 brunettes, 1909-Group. | Weight. | Type. Height. : ecia sees | : vate Ges First Second. Third Fourth | Lossfor | | | | quarter. quarter. quarter. quarter. | year. i} | 1 = } a ia TR Ins. Cm. | Lbs. | Kgms.| Lbs. | Kgs. Lbs. | woms.| Lbs. | Kms. | Lbs. | Kgms. | Blond ___| 67.4 | 171.1 142.8 | 64.9] 141.4 | 64,3 | 140.7] 64.0 | 140.2} 63.7 | 2.6] 1.18 | | | Brunette _| 67.4 | 171.1 | 144.5 | 65.6 | 142.7 | 64.9 | 142.7 64.9 | 141.8) 64.5 | az} 123 | | eG | ssl aape put matte it i. | yi TABLE VI.—Comparative average weights of 307 blonds and 801 brunettes, |: 1910-Group. iw Tah | 2 wes F | 4 Weight. { m Serres 3 | a Type. Height | Second | Third Fourth First | Second Woccitoree| quarter | quarter | quarter quarter | quarter Sani | 1910. | 1910. 1910. 1911. | 1911. > . sleet ei colt al ele ona Sees a Ins. | Cin. | Lbs. |Kgms| Lbs. lets Lbs. gare Lbs. Kgms| Lbs. \‘Kgms Lbs. | Kgms. | Blond ___| 67.8 | 172.2 | 148.1] 67.3 | 147.8} 67.2 | 147.8) 67.2| 147.2} 66.9 146.1 | 66.4 2.0 moll 67.1 | 147.3| 67.0 | 147.3] 67.0 : Brunette | 67.3 HL eS 67.4 | 147.7 146.5 | ee 18) .82 | On examining Tables V and VI it will be seen that both groups de- clined slightly and progressively in weight during the year of observation and that there was no significant difference in the degree of loss for the blond type and the brunette type. In the 1910-—Group the blonds lost 0.2 of a pound (0.09 kilogram) more than the brunettes, but in the 1909- Group the conditions were reversed and the brunettes lost 0.1 of a pound (0.05 kilogram) more than the blonds. In either instance the differences in the respective losses of the two types are so trivial as to be of no importance. Temperature—The temperature observations were taken by mouth and in nearly all instances in the 1910—Group the thermometers were kept in for five minutes to insure registry of slight degrees of fever if present. The results appear in Tables VII and VIII. 436 CHAMBERLAIN. TABLE VIL.—Comparative average temperatures of 111 blonds and 118 brunettes, 1909-Group. —s = ] — _ ae — —— — ie ——— _ | 7 | First Second | Third Fourth | ‘Average for | ype. | quarter. | quarter. | quarter. quarter. | year. | i | Op | og: | om | eg (1s oR og )) lop of, | °C. Blond _-.-241|) 98:8 |/ = ee oy) mdi estos =e ee 10 | Miannhoca ye alse eeeeae eee wen 11 | Palpitation of the heart? -___-___ 12 | SOTeIC VCS yee 13 | Taossiohmemony; sees een nee 14 | Do you lose weight in Tropics? —--__- 15 | Do you gain weight in Tropics? -_____ 16 | Does direct sunlight affect you un- | pleasantly? | In the sunlight do you suffer from— 17 | VeTUIR Oya sts Ae ee ieee seca | 18 | JSUT YOU) OV Syme eae se Bears a GS aes oes 19 | Nausea?) 22 e Fe ep aes PSs lees tae et eo 20 | Vomiting? Sosa JAMES eLEe: a | 21 | Photophobia? —--__-__----____--__ Wes es 25 22 | Excessive thirst ?_-_--_------_-_-_ NCGS tease 23 | Excessive redness of face? _----_- NICS Sees | 24 | Shortness of breath? -_-_--__---__ IP ViCSie =o 25 | Do you suffer from lassitude on aris- NiCstaeee =| | ing? | | 26 | Are you irritable in the Tropics? ----| Yes________ | 9 27 | Are you depressed in the Tropics?___ Yes________ 28 | Do you take a siesta regularly ? ______ ACen 29 Same -.2--— 30 |{How do your dietary habits compare Ie less___| 31 |{ with those at home? ie more _| 32 | Unknown _| Secout-Constabulary- Police-Group. 147 bru-| nettes. 323 teed blonds. 1910-Soldier- Group. 315 bru- nettes. ~I | Number. Rate per | 1, 000 | Rate per | 1, 000. | Rate per 1, 000. Rate per 1, 000 Number. | 38 32 108 306 150 259 823 88 34 54 60; 16! 50 115 | 123 | 381 885 | 200 | 619 174| 79) 245 715 | 230 | 712 111} 14} 43 85| 14} 43 72| 18) 56 191) 23) 71 68)/ES=3 (Stee 50) 12) 37 81| 15} 46 277| 29) 90 AVE) fame Hes SH) Peel ee 311 | 72) 223 85| 39) 121 174} 48} 149 9} 11} 34 ol allt 370| 70) 217 128] 43] 133 ----| 40] 124 Bb ect 200| 47] 146 891} 44) 1386 123) 41) 127 281 | 146 | 452 792 | 276 | 854 1140} 33 | 102 18| 10} 31 50) 4] 12 Sunstroke and heat exhaustion—This question covered the whole period of the man’s life, and many of the cases occurred in America. In the S-C—P-—Group the rate for sunstroke and heat exhaustion was higher for the blonds (38 per mille) as compared with the brunettes INFLUENCE OF PHILIPPINE CLIMATE ON WHITE MEN. 449 (27 per mille), but was a great deal higher still for the mixed types (60 per mille). In the 1910-Group the rate was also higher for the blonds, but the difference was less marked than in the S—-C—P—Group, 50 as compared with 44 per mille. In considering the figures for the S—C—P-—Group it must be borne in mind that the total number of cases was very small, only 7 for the blonds and 4 for the brunettes, so the element of chance may assume very large proportions. Enjoyment of tropical service.—In the 1910-Group there was no material difference, the rates of those who did not enjoy such service being 381 for the blonds and 375 for the brunettes. In the S-C—P-—Group the difference was more marked, 65 per mille of the blonds not enjoying the Tropics as compared with 54 per mille of the brunettes. However the number of men from the mixed type who did not like such service was far higher than among the blonds, 115 per 1,000. That a much greater proportion of the 1910-—Group, as compared with the S—C—P- Group, should dislike the service is natural when it is recalled that the former were enlisted men serving in the Philippines largely from necessity, while the latter were officers and policemen who had elected to reside in the Archipelago, in most cases after having had some preliminary experience with its climate. Feeling of well-being in the Tropics.—The proportion of soldiers in the 1910—Group who did not feel as well in the Philippines as at home: showed no material variation for the blonds and for the brunettes, 245 per mille for the fair and 241 for the dark complexioned. In the S—C—P-Group the difference was much more marked, 145 per 1,000 of the blonds not feeling as well as in America and only 109 per 1,000 of the brunettes. But here again the mixed types suffered more severely than the blonds, 174 per mille of them failing to feel as well as in the homeland. In the 1910—Group the number of blonds who felt better than in America was larger than the corresponding number of brunettes (43 as compared with 35 per mille), but in the S-C—P—Group the condi- tions were reversed, 109 per 1,000 of the brunettes feeling better as compared with only 65 per 1,000 of the blonds. However, the actual numbers of men in this class were small in both groups. The numbers who felt the same here as at home were practically equal for the blonds and for the brunettes in the S-C—P—Group and in the 1910—Group. With reference to the special symptoms complained of, the actual figures can best be seen in Table XXIII, and it will be sufficient to state here that in the S-C—P-—Group the incidence of insomnia, anorexia, sore eyes, and loss of memory was considerably more marked for the blonds while in the 1910—Group the reverse was the case for all except eye troubles. In both groups indigestion, palpitation of the heart, and diarrhcea were more common among the brunettes. It is interesting to 450 CHAMBERLAIN. note that for each of the above 7 symptoms, except anexoria, the inci- dence per mile in the S-C—P—Group was higher for the mixed types than for the blonds. Influence of direct sunlight—In both groups the number per mille of blonds who stated that direct sunlight affected them unpleasantly was slightly greater than that of the brunettes, but the differences were immaterial. Again it happened that the mixed types who made com- plaint were in excess of the blonds. The special symptoms asked about : namely, vertigo, headache, nausea, vomiting, photophobia, excessive thirst, and excessive redness of the face, were all somewhat more common among the blonds than among the brunettes of the 1910—Group, while in the S-—C-—P-Group the results were similar except for photophobia and ver- tigo, the former being slightly and the latter two and one-half times more common among the brunettes. Several of these symptoms were of more frequent occurrence among the mixed types than among the blonds. General symptoms.—tLassitude on arising in the morning was slightly more common among the brunettes of the 1910—Group and among the blonds of the S-C—P-—Group, but in this latter group the mixed types were much more affected than the blonds. Both irritability and depression were equally common or more common among the brunettes than among the blonds in each group. Both of these sensations were far more fre- quent among the mixed types than among the blonds of the S-C—P—Group. Detary and siesta habits, and maintenance of weight.—The numbers per thousand who ate the same amount and kind of food as at home was slightly less for the blonds than for the brunettes in both groups. In the 1910—Group increased consumption of food in the Tropics was more common among the brunettes, while in the S-C—P—Group there was no appreciable difference. The numbers of men per mille in the S—-C—P-— Group who lost weight were equal for the two complexion types, and there was no material difference in the numbers of those who gained weight. In other words complexion did not influence the weight in the S—C-—P-Group, and it has been shown in Tables V and VI that the same was true for the 1909-—Group and the 1910—Group. In both groups the siesta habit was very much more frequent among the brunettes. For the mixed types it was even more common than for the brunettes. SUMMARY OF PART IV. Summing up the subjective evidence contained in Table XXIII it may be said that for the 1910—Group, with its 18.5 months of tropical service, the differences are so slight and so variable for the two types that no clear distinction can be made out in the climatic effects produced on the blonds and on the brunettes. In the case of the S-C—P—Group, INFLUENCE OF PHILIPPINE CLIMATE ON WHITE MEN. ADI with its 5.5 years of Philippine service, the results are inconclusive. On most of the points the advantage seems to be with the brunettes, but on a few the reverse is the case. It is interesting to note that the men of mixed type, who stand intermediate between blonds and brunettes, appeared to suffer from the deleterious influence of the tropical climate more markedly, for nearly every point investigated, than did the indi- viduals of the blond type. This latter fact suggests that some factor other than complexion (possibly chance), may have had a hand in moulding the results in the S-C—P—Group. PART Y. RELATIVE PROPORTIONS OF BLONDS AND BRUNETTES AMONG SOL- DIERS INVALIDED HOME, AND IN THE SCOUT—CONSTABULARY—POLICE— GROUP, AS COMPARED WITH THE PROPORTIONS OF THE SAME TYPES AMONG -10,072 SOLDIERS. As a standard for comparison we carefully examined 10,072 enlisted men of the United States Army in the Philippines during the years 1909, 1910, 1911, and divided them into 3 complexion types, blond, brunette, and mixed, using the classification referred to just below Class VI under “Sources of Evidence.” The results are shown in Table XXIV. TABLE XXIV.—Comparative number of blonds, brunettes, and mixed types among 10,072 soldiers (1909 to 1911). Mixed Blond. |Brunette. type. | on or ! PNG HeomiM bp Cia sae eres aes enters ee Ee ee eo) | 2, 403 2,073 5,096 "| Riaiteypersl: OOOMMeN i setae. sane wet ee Soe ee Bee 238 206 556 RAC EDErSLOO DlON Gs) eeeee os eae we ee ee See Se eee 100 | 86 233 | In the last line of Table XXIV the actual numbers have been reduced to a percentage basis for subsequent comparison with other groups of men and it is seen that for each 100 blonds there were 86 brunettes and 233 of the mixed type. SOLDIERS INVALIDED HOME. The figures in Table XXIV may be taken as representing the average proportions of the 3 types among the enlisted personnel of the Army serving in the Philippines at the time of these observations. If the climate be more harmful to the blonds than to the brunettes we should expect that the proportions of incapacitated blonds to incapacitated brunettes would be greater than the ratio of 100 to 86. To determine if such were the case, we have carefully inspected during the last eighteen months all soldiers invalided home from the Philippines and the results, giving actual numbers and rates per 1,000 men, are shown in Table XXV. The mean strength of the command from which this invaliding occurred was approximately 11,678 men. } | CHAMBERLAIN. TABLE XXV.—Diagnoses of men invalided home, arranged by complexion types. Venereal diseases; all forms___- Blood and circulatory diseases: | Valvular lesions ----------- Anemia, pernicious Anemia, secondary Polycythemia —_------------ Phiebitiswea— eee Total blood and circula- Tuberculosis; all forms -------_- Malaria and its sequele -_______ Aleoholism, chronic-_---------- Gout and chronic rheumatism _ Kidney diseases; all forms_..___- Pulmonary diseases (except TILDELGUUOSIS) ae es Diseases special senses: Deafinesss 0 ee Otitis media and externa __ Retinitiss2s2sse=ns eee Total special senses —----- Sunstroke <0225 2 sue eee Wounds and injuries___-_______ Miscellaneous diseases -_------- Rate per 100 blonds___--_------- Blonds. Brunettes. Mixed types. | Total, all types. Diagnoses. fe Rate . Rate Rate um- per um-/| per Num-| per Num- | Num- ber. 1,000 ber. 1,000 ber. 1,000 ber. ber. men. men. men. Nervous diseases: NYE UUTE Sa S Do © 11 yer | | eee ee Dil ashe eee 7A Pea ene IB) eS yjee ae ee ee ees hE eee is) RI NMG OCU MGOUS eee] fiseeesces|) 4H ecco ence SB ere teneaas A hee Total nervous ------------ 14 368 18 474 i: 6 nies ea, 38 Mental diseases: _ pea ames Dementia precox __-------- 9 6 Melancholia2— = = ---=-- === 2 1 Depressional insanity —-_--- il 1 Insanity, type undeter- | TOUTE) ee ao Seew ee SS Ae thee ie 28 oe Ba) Oy ewe cea | ae Defective menibe lit yee |e ee Oy Bees te dy ese Wecaa | | a Motelemenitiales=ss= see 9} 225 17 425 14 Bi) eee 40 | Intestinal diseases: | oe mre SOO. Se ee ees eee We eecnaeee Nl ea 3. |Reeeesee Enteritis, chronic ---------- A oe ee fey 1 eae Dal pasa 7/4] as Seta | Dysentery, chronic_---- ----|-------- [pone Liew ni nee eae 9h lesen Diarrhea, chronic ‘ Ulcer of rectum —_------__-- Total intestinal_---_----_- 4 364 | 5 454 2 182 i ll Th ae py le ar By ae at Gy eer 6| 429 2| 149 Bde pee. 14 22 314 Frill SEG) ae CU EN S00) | Nn 70N OMe) 2! 500 1] 995 1 295 4 4 3| 600 1| 200 | 1! 200 5 5 bees Rare ESRD 3 500 | 3 500 6 Di SEB} 4 ley ee ee |e 6 | | i 2| 286 3] 428 | 2| 286 | 7 7 | 14 | ees es Pe Me RN 2 ia i Mie | OM hE as Bes | Bpoin pe iy fete ce ed Puen Fale see A aM te eee ese a i | eeu ae Se een Pits OAC Sasa | ae een (ee See ee ee eee Sa 3 ae 6 500 1 83 Bi Weer 7) | eee 2 au iy ae Of a) aan 1 1 al ten 77) 0333 10| 476 Dl ees 4 308 5 384 4 308 13 13 84| 308] 106]. 388 93 | 304] 273) 273 i) LL 156 | eee Foy eee ee aes INFLUENCE OF PHILIPPINE CLIMATE ON WHITE MEN. 453 On examining the total numbers of each type invalided home from all causes (which have been reduced to a percentage basis in the last line of Table XXV) one immediately notices that the proportion of mixed types is considerably lower than was the case among the 10,072 men taken as a standard. Turning to the blonds and brunettes it is seen that the ratio is 100 to 126, whereas the ratio of blonds to brunettes among 10,072 soldiers was 100 to 86. In other words while the blonds exceed the brunettes in the general military population the reverse is the case in the total of invalided merf. This is strong evidence that the blonds do not suffer unduly from the influence of the climate, but is at variance with the evidence adduced in Part III showing that there is more sickness among the blonds than among the brunettes. On considering the special causes of incapacity it is seen that tuber- culosis heads the list in importance, and shows a larger rate for brunettes than for blonds. In both nervous and mental diseases the rate is much higher for the brunettes. Neurasthenia, which especially has been at- tributed by some to the influence of the tropical sunlight, was nearly twice as frequent a cause of incapacity for the brunettes as for the blonds, and the same was true for intestinal and kidney diseases. Vene- real diseases, gout and rheumatism, pulmonary troubles, accidents, and miscellaneous affections were all higher for the brunettes. Only in cir- eulatory and blood diseases, alcoholism, malaria, and disturbances of the special senses were the blonds the greater sufferers. We would not argue from such a comparatively small series that the blonds.are better able to withstand a tropical climate than are the bru- nettes, but we do consider that Tables XXIV and XXV indicate that they are fully as resistant to the Philippine climate as are their darker skinned companions. RATIO BETWEEN THE THREE TYPES IN SCOUT—CONSTABULARY—POLICE-GROUP. — The members of this group have voluntarily elected to reside in the Philippines, usually after having had some preliminary experience with the climatic conditions. Many of them have been in the Archipelago for twelve or thirteen years and the average length of continuous tropical service is 5.5 years. Nearly all of the Scout officers and the policemen originally came to the Archipelago as enlisted men in the Army, and a good proportion of the Constabulary officers also were drawn from that class. If the climate of the Philippines affected blonds more seriously than brunettes we should expect that after several years’ residence the ranks of the blonds would be depleted by death, invaliding, and voluntary departure, and that the ratio of blonds to brunettes would be lower than the same ratio among the enlisted men (Table XXIV) from whom the S-C—P-Group sprang. Such is not found to be the case. Among the 568 men of the S-C—P-—Group there were 186 blonds, 147 brunettes, and 454 CHAMBERLAIN. 235 mixed types. Reducing these to the percentage basis we have, for each 100 blonds, 79 brunettes and 126 of the mixed type. It will be observed that the proportion of the latter type is lower than the Army average (Table XXIV), but that the proportion of blonds as compared with brunettes is higher than the average for enlisted men of the Army in the period from 1909 to 1911 (100 to 79 as contrasted with 100 to 86). . These facts tend to show that in an average tropical service of 5.5 years the relative resistance of the blonds is not so impaired as to lead to a depletion of their ranks disproportionate to that occurring among the brunettes. To refute these deductions it might be argued that the proportions of the three complexion types among the American troops may not have been the same 6, 8, 10 or 12 years ago, at which times many members of the S-C—P-—Group severed their connections with the regular Army, and that originally the blonds may have been much in excess of the brunettes in the S-C—P-—Group. We have no statistics as to the proportions of the different complexion types in the Army for the period 1898 to 1901 and it is possible that in the earlier part of this period blonds may have been relatively somewhat more numerous, es- pecially among the Western volunteers. However, we do have some statistics gathered in 1902 and 1903 by Woodruff,(2) and tabulated on page 215 of his book on Tropical Light.** Out of 1,294 soldiers there were 420 blonds, 356 brunettes, and 518 mixed types. Reduced to the percentage basis he found for each 100 blonds, 85 brunettes and 123 of the mixed type. On comparing these figures with those in the last line of Table XXIV it is seen that the blonds were not appreciably more numerous in the Army in 1902-3 than they were in 1909-11, and that they were considerably less numerous than they are at the present time (1911) in the S—C—P-Group. SUMMARY OF PART YV. The ratio of invaliding home is lower for the blonds than for the brunettes. The ranks of the blonds in the S-C—P—Group after 5.5 years’ tropical service, have not been depleted, the proportion of the fair com- plexion type being probably higher in the S-C—P-—Group now than it was among the class from which that group was originally drawn. These are strong arguments in favor of the assumption that the blonds are quite as well able as the brunettes to resist the tropical conditions met with in the Philippines at the present time. 7 Our system of classifying men into blonds and brunettes is the same as that described by Woodruff. His ratio of blonds to brunettes agrees closely with ours, but we find a considerably larger mixed class than he reports. INFLUENCE OF PHILIPPINE CLIMATE ON WHITE MEN. PART VI. CHARACTER, COURT-MARTIAL RECORDS AND SICK RATES ALCOHOLISM AND VENEREAL DISEASE IN THE 1910—GROUP. Woodruff (3) quotes some figures in support of a theory that the irrita- 455 FOR tion produced by an excessive amount of sunlight may effect the conduct unfavorably and increase the prevalence of crime. it is conceivable that misdemeanors would be more frequent among blonds than among brunettes in the Tropics. tigating this point the following tables have been compiled for the 1910-Group. The first shows the number of trials by courts-martial, the fines and days of confinement resulting therefrom, the military character given the men by the company commanders, and any changes of character occurring while in the Philippines. degree of alcoholic consumption and the days on sick report from al- coholism and venereal diseases. TaBLeE XXVI.—Comparative character and comparative averages of court-martial If such is the case With a view to inves- The other gives the trials. confinement and fines for 345 blonds and 343 brunettes, 1910-—Group. TABLE XXVII.—Comparative consumption of alcohol and comparative numbers of days lost from alcoholism and venereal disease for approximately equal numbers of blonds and brunettes.* Military character. Change of character. Disciplinary Type. | | | | C Ex- | | | No Trials | O° |... Very o-5-4 i | Bet- | No fine- | Fines, ch good, |4004.’ Fair. | Bad. ees ter. | VOTSC- change. Tene ment, |dollars.| : | | ‘ | * | days. | | | | | 1 = aes — San Blond! 22-2-- 207 72 29 | 97 | 27 4 12 | 329 0.4] 3.9] 3.49 Brunette _____ 202| 73| 26 | 8 | Seo 8| 328] 0.4) 3.6] 3.97 l a i Consumption of aleohol. Days on sick report from— =| «The figures for consumption of alcohol are for 323 blonds and 315 brunettes of the The days lost on sick report from alcoholism and venereal disease are for 1910-—Group. Type. aCes = apa : =e | ene | Moder- | Exces- SiGe. SIME, ate. Sive. lism. | padia Sed SGN TES) 0 TER ae epee ee ee ae ee Mr | 62 | 110 138 13 IBEMING Leia 2225 Al Mises te oe 61 | 163 - 9 Aleoho- | Venereal | } | i | disease. | al | 62 | 5, 327 31 |. 5,297 504 blonds and 500 brunettes, all the men in both the 1909—Group and the 1910—Group. In both these tables the numbers of blonds so nearly equal the num- bers of brunettes that the figures have not been reduced to rates per 1,000, since this calculation would not appreciably affect the comparison. As 456 CHAMBERLAIN. regards courts-martial and their results, the differences between the two types are immaterial. The numbers of trials are identical, the blonds had an average of 0.3 day more of confinement, but the brunettes received an average of 0.48 dollar more fines. The classifications of the two types according to military character agree as closely as could be expected in groups of this size. As regards change of character an equal proportion of each type underwent no alteration, but of the 16 blonds and 15 brunettes whose character did change, 12 of the blonds deteriorated as compared with 8 of the brunettes. However, the number who changed is so small that it would be unsafe to make deductions therefrom. In Table XX VII it will be seen that the number of abstainers was practically the same in both types and that the blonds had a larger number of slight drinkers and fewer moderate ones. The number of excessive drinkers was greater among the blonds than among the bru- nettes (13 as compared with 9). There were 18 admissions for alcoholism and 62 days lost among the blonds as compared with 6 admissions and 31 days lost among the brunettes. The days on sick report from venereal diseases were practically equal for the two complexion types. SUMMARY OF PART VI. In summing up it can be said that there was no appreciable difference in behavior between the blonds and the brunettes except in regard to stimulants, the excessive use of alcohol being somewhat more common among the blonds. However, too much weight should not be given to this last conclusion in view of the small numbers of persons who indulged to excess. PART VII. RELATIVE FREQUENCY OF OCCURRENCE OF SUNSTROKE AMONG BLONDS AND BRUNETTES IN THE UNITED STATES. The exact causation of sunstroke and heat exhaustion remains in doubt in spite of the many theories advanced by eminent observers. Among these theories may be mentioned that advocated by Maude of the British Army, who considered that sunstroke was due to the action, upon the head, of the actinic rays of the solar spectrum and believed that insolation could be prevented by inserting in the headdress a layer of material impervious to these rays. He employed a red hat lining. In connec- tion with our work on the influence of climate on blonds and brunettes it was desired to obtain statistics as to the complexion type of men suf- fermg from insolation. Such figures could not be obtained in the Philippines, because heat exhaustion is rare and true sunstroke prac- tically unknown in the Archipelago. Therefore, statistics were gathered from the large cities in the United States through the courtesy of the INFLUENCE OF PHILIPPINE CLIMATE ON WHITE MEN. 457 officials of the institutions enumerated in footnote 6. ‘The results are shown in Table XXVIII. _ Taste XXVIII—Numbers of each complexion type among 367 persons suffering from insolation in the United States. z = Bru- Mixed 7 Group. Year. | Blonds. | yettes. types. Total. I 1910 E) 48 9 66 Il 1911 4 65 i 80 Tit 1911 72 70 87 229 In Groups I and II the separation. into complexion types was made by the physicians at the various hospitals, our system of classification having been furnished them. It will be noticed that they placed ex- tremely few in the blond type, perhaps assigning to that class only the most conspicuous examples of blondness. In Group II] the physicians were requested to fill out for every case of insolation a printed form which contained among other things the following complexion-type table. Color of hair. Color of eyes. Complexion. Flaxen. Light blue. Light. Red. Medium blue. Ruddy. Sandy. Dark blue. Fair. Light brown. Gray. | Medium brown. Brown Medium. Dark brown. Black | Dark. Black. | The physicians prepared one of these blank forms for every patient suffering from insolation, and made a check-mark after the appropriate word in each of the three columns of the complexion-type table. The completed forms were then sent to us and, following the rule used in our work among the soldiers, we classed as blonds those who had the three check-marks above the dividing line, and as brunettes those where all the check-marks were below the line. If some marks were above and some below the man was placed in the class composed of mixed types. We received 229 of these cards and they are recorded in Table XXVIII as Group III. There were 72 blonds, 70 brunettes, and 87 mixed types. Reduced to a percentage basis, for each 100 blonds there were 97 bru- nettes. As shown in Table XXIV the proportions of blonds to brunettes among our 10,072 soldiers was as 100 to 86. ‘Therefore, it is clear that the ratio of brunettes suffering from the effects of the sun in the United States was materially higher than the ratio of the same type among 10,072 American soldiers. 458 CHAMBERLAIN. SUMMARY OF PART VII. Unfortunately we have no exact statistics to show what may have been the proportions of the two complexion types in the cities under consideration. Woodruff states that the blonds are less numerous in the cities than in the country. Our Army is recruited from both urban and rural sources and it is doubtful if the figures for complexion type in the cities differ very much from those found in the military service. If this be true, then it is obvious from a study of Group III that the blonds in the United States were not quite as subject to insolation as were the brunettes. If any deductions are to be drawn from Groups I and II, they would be that the harmful effects of the sun are very much less manifest among the fair skinned individuals. PART VIII. DISCUSSION OF CLIMATIC INFLUENCES AND PIGMENTATION: GENERAL SUMMARY: CONCLUSIONS. It seems to us by no means proved that the pigmentation of tropical races and the tanning of Caucasians is a protective effort on the part of nature against the chemical activity of sunlight. Several other ex- planations suggest themselves, but will not be discussed here. The integument of the negro is able to radiate heat more readily than that of a white man, but this advantage is least manifest when most needed, namely in direct sunlight, where the superior radiating power of the black skin is more than counterbalanced by the facility with which the dark colors absorb thermic rays. However, it does seem proven that on the living subject the brown or black skin, when exposed to the sun, is always slightly cooler than the skin of a white man.(4) This apparent anomaly is explained on the ground that the cooling effects produced hy evaporation are more marked in the case of the dark races, because of anatomical differences in the skin. Daubler states that the negro has sweat glands which are larger and better developed than those of the Caucasian. Some claim that the number of glands in a given area is greater. Aron considers that the brown skin is cooled more efficiently because the perspiration is secreted more evenly, the evaporation is com- plete, and the waste, due to the sweat dropping off, is avoided. The above conditions, taken together with the fact that the working native wears very little clothing, place the pigmented native in a better position than the Caucasian as regards the heat regulation of his body in the Tropics. The advocates of the theory that certain deleterious effects noted in the Tropics are due to the chemical rays of the sunlight, point to sun- burn as an evidence of injury produced by actinic rays and maintain INFLUENCE OF PHILIPPINE CLIMATE ON WHITE MEN. 459 that pigmented skin will absorb these harmful waves.(2) (7). .The pig- mentation following sunburn is considered a conservative effort on the part of the organism. ‘The supporters of the actinic theory advocate the use of protective clothing, a red, orange-red, or black layer being, recom- mended. Some advise a tinfoil lining for the headgear. Now it is a matter of general observation that the covered portions of the body do not become tanned or sunburned when ordinaty clothing is-worn.: If sunburn and tanning are due to actinic rays, and if the usual clothing is able to protect the skin from their effects, it seems to us reasonable to assume that the same clothing will protect the body as a whole from the effects.of these rays. This argument of course does not take into consideration that quantity of rays which may enter through the face and hands, but no one, as far as we are aware, has recommended covering these parts. Therefore, it seems probable on theoretical grounds that ordinary clothing gives sufficient protection, and the result of an ex- tensive practical experiment. by the Board(10) supported this view by showing that no benefit resulted from the use of orange-red hat linings and underwear. Recently Aron(4) has shown that monkeys, when exposed to the direct rays of the sun in Manila, quickly develop a high temperature and die in one or two hours. Monkeys exposed under similar conditions, while at the same time a strong current of air from an electric fan blew over their bodies, did not suffer any discomfort. Of course the amount of chemical rays falling on the animals was identical in the two cases. The inability of monkeys to stand sun exposure is considered by Aron to be due to the fact that these animals possess no sweat glands, and consequently have only a limited power of thermic regulation. There- fore, hyperpyrexia occurs as a result of the absorption of solar heat rays. No rise of temperature and no ill results occurred when monkeys’ heads were exposed for several days while their bodies were protected from the sun. Aron concludes that “hyperthermia alone must be re- garded as the true cause of the death and of the injurious effects brought about by the radiation of the sun.” While Aron was working at the Bureau of Science in Manila on the thermic factor in the tropical sunlight, Freer(1) and others have been engaged in the investigation of the chemical side of the problem without producing any results which would show that the actinic rays of the spectrum were distinctly detri- mental to man. et The researches of Freer and Aron, the results of the orange-red clothing jtest by Phalen(10) of this Board, the observations of Wickline(9)° on blonds and brunettes.and our own work on the same subject: render: it 106711——3 460 CHAMBERLAIN. very doubtful in our minds whether chemical rays of the sunlight and complexion types of Caucasians are factors of any importance in tropical pathology. The experiences of Gorgas in Panama, the reports of various other workers from many countries, and our own general observations in the Philippines, all lead us to the conclusion that the main cause of tropical deterioration, as seen in the past, was infection of the skin, blood, intestines, and other regions, with those parasites which are more common inthe Tropics than in the temperate zone. The vast improve- ment in the health conditions in Cuba, Panama, and the Philippines, which has followed action based on such a parasitic theory, is strong evidence in favor of our assumption. The enervating effects of con- tinued heat and humidity doubtless play some part, especially in the direction of discouraging out-door exercise. Nostalgia, isolation, and monotony, and the excessive use of alcohol resulting therefrom, are factors of considerable importance. ‘To account for what is observed in the Philippines it does not seem to us necessary to call in the hypothetical action of the actinic rays in the sunlight, nor do we think that there is any adequate evidence that such action is a factor in tropical morbidity and deterioration. It appears that the men who spend much time actively engaged out of doors in the Philippines are the ones who remain in the best health. Those who suffer most from nervous affections are the women, and they pass practically all their time in the shade. The situation is well described by Castellani and Chalmers who state that “the basis of the largest proportion of illness and death in the Tropics is bad sanitation and not climatic influences.” (7) The direful effects of the Philippine climate, which have been so vividly depicted by Woodruff, relate to the earlier days of the American occupa- tion and are not seen at the present time. It is our belief that these unfortunate occurrences were due chiefly to infections resulting from the poor hygienic conditions unavoidable in the early campaigns. It does not seem that any effort is now made to spare officers or men from ex- posure to the sunlight, yet the morbidity and the mortality continually decrease. Affections of the nervous system, including insanity, are among the diseases considered by Woodruff to be particularly likely to occur in the Tropics, as a result of excessive light stimulation, and he bases his argument on statistics from the reports of the Surgeon-General covering the calendar years 1901 and 1902. ‘To determine if the same argument holds good at the present time, the figures for the last seven years for which statistics are available have been compiled from the reports of the Surgeon-General of the Army and are shown in Table XXIX. INFLUENCE OF PHILIPPINE CLIMATE ON WHITE MEN. 461 TABLE XXIX.—Relative admission rates for insanity and for nervous diseases in the Army serving in the Philippines and in the United States, 1903 to 1909. | Admission rate per 1,000. Insanity. | Nervous diseases. | Calendar year. ore Pee | | ! ee United | ae United | | Talaniete. | States. | Islands. ; States. | = | pees =e THEY B Caf SoA A | AS Oa | 1.05 1.02 22.67 | 21.77 TGs ae ER SAAT ON Aa eee Nh etart 90.34! 22.10 | 0s Os EE SRDUR ELE SURE eo j 145] der) 20.58) 19.49 PpLOOG 25 eh D> Qkagayan Sulu 4 f 8 ABATO £ 4) KO |. fi a PMI ce Davao Gulf || Saranga"’ ; 4) Sarangontls. BRUNET TES WERE CARRIED OUT. 2 NE —s ee VAL He, Neve ee Beran, i f e nati Lis eee ae ne . : # RAUNT OB Hh ae a nee he ta} ey hi! eA rah mee pias A a e) am Tih 4 | hn | ae Pf tenn i re \ r \ t PR pie ns ‘4 4 i i : Ke ‘ a , y 1 i ae aera ' G { { a H a i i ree oo cr mys) e i aa treet «lho tes beta la mat me eerie eater Ns arid \ ‘ mn Hy : » 4 ¢ = bh “A . rh oan Ae * ash | ' ans Ls hs teins da ent i | 2 ’ i! VAS ; j mA & i f foo ; er % ? r 4 Se: $ WV ee Pe eT Seto «= ; { 4 aa : a. > | + J ‘ ey ik ' Apa Vo emcee le tals pe Aone ee rrer nam A LRA YG wht i ‘ fe * i i = ) y \ : $ i; a" i : le et =\ ; i ‘ i : ; a { 7 1 P= Ni y rr 4 a od } fo { | ; \ ewe, Bren oth € fa a hoeth cd! ; 5 : ‘ WAGE WE i n i amet hee i ee, i ve ae " 7" Sate eae y ‘ We aie, | aon De Dye 5 iy T P oe ble ai. om 3% : , © | ; ‘ wr yt IOC wi serrinihrecaehioihogeas NPS | eae ae wed APS UDY OF THE SYSTOLIC BEOOD-PRESSURE AND THE PULSE RATE OF HEALTHY ADULT MALES IN THE PHILIPPINES: BASED ON 6,847 BLOOD-PRESSURE READINGS ON 1,489 INDIVIDUALS, AND AN EQUAL NUMBER OF PULSE COUNTS ON THE SAME PERSONS.* By WeEston P. CHAMBERLAIN.? ' (From the United States Army Board for the Study of Tropical Diseases.) INTRODUCTION. During the period from January 1, 1909 to September 30, 1911 the Board for the Study of Tropical Diseases carried out in the Philip- pines two extensive series of observations, one to determine whether Americans of the blond type suffered more than the ae from the deleterious influences attributed to the tropical climate(1) and the other to discover whether the wearing of orange-red underclothing, which obstructs the passage of the actinic rays of the solar spectrum, was of any benefit to white soldiers serving in the Archipelago.(?) The com- piling and analyzing of the data was done by the Board. A part of the laboratory examinations were made by the Board, but the bulk of the observations were carried out by 24 medical officers of the Army who were specially detailed for the purpose and who worked under the super- vision of the Board. Asa result of these two series of observations an immense amount of data was collected, which was of value not only in settling the points for which the work was instituted, but also as affording a basis for the study of special features of the physiological activity of the Caucasian when living in the Philippines. The present report will deal with the subject of blood-pressure in the Tropics and with the associated pulse rate. During the above mentioned observations 6,128 blood-pressure readings and an equal number of syn- * Published with permission of the Chief Surgeon, Philippines Division. 2 Weston P. Chamberlain, major, Medical Corps, United States Army, president of the United States Army Board for the Study of Tropical Diseases as they Exist in the pee Islands. 467. 468 CHAMBERLAIN. chronous pulse counts were made on 1,042 white men.* Five hundred and fifty-two blood pressure readings and 200 pulse counts were made on 386 Filipinos, most of this work having been done by the Board, but a part by some of the officers mentioned in footnote 3. When the number of observers, all trained in laboratory methods, is considered, it will be obvious that the influence of the personal equation in this work has been reduced toa minimum. ‘The great number of observations enables us to avoid the errors inherent in a small series of cases. For convenience in reference the men examined in the orange-red underwear tests will be denominated the 1909-Group and those exam- ined during the blond-brunette observations will be referred to as the 1910—Group. CLASS OF PERSONS EXAMINED. All of the Caucasians examined were American soldiers, representing a good class of healthy young adults. Diseased men were barred by the stringent physical examination required at the time of enlistment. Fur- thermore, all the men in both groups were looked over just before the above mentioned observations began and any who appeared to be in ill health were excluded. Very few of the individuals were over 40 or under 20 years of age and none were below 18 years. The Filipimos examined were from various tribes. One hundred were soldiers of the Philippine Scouts and an equal number were from the Philippines Constabulary. The remainder of the group was made up of laborers, servants, and convicts. With the exception of a few of the convicts, all were under 42 and the majority were less than 30 years of age. A series of 20 Igorots living at Baguio (elevation 1,500 meters) was also examined, but these are not included in the general averages for Filipinos. Both the whites and the great bulk of Filipinos belong to a class of men of good physical development and constantly engaged in vigorous out-of-door work, with no special effort taken to protect them from the sunlight. CLIMATE AND GEOGRAPHY. Only brief reference will be made to the climate and geography of the Archi- pelago where these observations were made, because the subject is dealt with quite fully in another report of the Board.(1) The islands on which the blood- pressure readings were taken extended in latitude from 19° north to 6° north. Except on high mountains the climate is everywhere tropical with a maximum recorded temperature in Manila of 37°.8 C. (100° F.) and minimum of 15° C. (BYP 195). °The medical officers who participated in the making of these observations on pulse and blood-pressure were the following: Majors C. C. Collins and Roger Brooke, jr.; Captains C. D. Cowles, G. L. McKinney, H. A. Philips, J. R. Barber, Mahlon Ashford, E. G. Huber, H. M. Snyder, and W. L. Hart; and First Lieut- enants Armin Mueller, M. C. Stayer, L. C. Garcia, and C. EB. Fronk. SYSTOLIC BLOOD-PRESSURE AND THE PULSE RATE. 469 The blood-pressure work on white men was done at 7 points, Camp Stotsenburg, Fort William McKinley, Camp Jossman, Warwick Barracks, Torrey Barracks, Pettit Barracks, and Augur Barracks. Part of the natives were examined at these places, but the majority were tested at Camp Gregg, Corregidor Island, and in Manila. All of the 10 places above mentioned are located on or close to the coast-line and but little above sea level with the exceptions of Camp Stot- senburg and Camp Grege which are in the interior at altitudes not exceeding 200 meters. The climate at these two last posts does not differ materially from that at the other stations nearer the sea. BLOOD-PRESSURE APPARATUS AND METHOD OF USE. The instrument used for all of the tests was the portable form of Doctor Cook’s modification of the Riva-Rocci apparatus. The original instrument devised by Doctor Cook had a 4.5-centimeter armlet, which width, according to the experience of most observers, gives readings that are too high.(3) The results are more markedly exaggerated, above what they should be, when the pressure is considerably above normal or when the circumference of the arm is great. Erlanger, v. Recklinghausen, Gallavardin, and Janeway all advocate a 12-centimeter cuff. The in- struments with which our routine observations were made had an armlet 8 centimeters in width. In order to reduce the readings made with this 8-centimeter cuff to the basis of a broad armlet we made a series of 140 comparative observations on 60 white men and 288 observations on 120 Filipinos, using with Doctor Cook’s apparatus one cuff of a width of 8 centimeters and another of 12.5 centimeters (5 inches). We found that with the 12.5-centimeter cuff the recorded pressure on the average was lower by 8 millimeters for white men, and by 6 millimeters for Fili- pinos, than was the case when the 8-centimeter armlet was employed. The difference between the results in the two races probably was due to an average smaller circumference for the native arms. In the tables. which follow the average readings have all been reduced to the basis of a 12.5-centimeter armlet by deducting 8 millimeters for the whites, and 6 millimeters for the natives, from the averages of the original observa- tions made with the 8-centimeter armlet. It may be argued that a constant deduction of 8 millimeters would give inaccurate individual results for the very high and for the very low pressures. Even if this be so it would not affect the average figures given in our tables since they are in all cases the average of individual readings on great numbers of men and the 8- or 6-millimeter deduction is the mean difference in a large series of men of the same race, occupation, and physical type: : We applied the cuff to the upper arm and for determining the pressure used as a criterion the return of the pulse wave in the radial artery. Nearly all of our observations were taken with the soldier in the sitting posture. For some individuals the readings were made when the men were reclining, but the numbers so recorded are so small in comparison with the total number of men observed that it would not materially affect the averages even if it be granted that there is a constant slight difference between the readings in the two postures. Erlanger and Hooker found the pressures about the same sitting or lying and Janeway considers the postural variations to be insignificant.(3) Our observations 7 A470 . -CHAMBERLAIN. were made at various hours between 8 a. m. and 4 p. m. Those observations on white men which are included in the general averages were in many cases taken after the soldier had been performing his usual military duties, such as drill or fatigue. In a special group, not included in the general averages and which will be described later, the blood-pressure readings and pulse counts were made as soon as possible after vigorous exercise. In the case of the natives all pressures were taken when the men had no exercise immediately preceeding the observations. : The observations on the 1909-Group continued for ten months, blood- pressure readings being taken for each man on 4 occasions during that period, the time between readings being about three months. In the 1910-—Group, 5 blood-pressure observations were made on each individual, 1 at the commencement of a 12-month period, 1 at its end and the 3 others at quarterly intervals. In Tables II, III, IV, V, and XIII the average readings are made up from the combined 4 or 5 quarterly ob- servations taken on each man and so represent the mean annual blood- pressure. Therefore, it is obvious that the disturbing influence of such factors as excitement, alcoholism, temporary indisposition, the ingestion of food, or the taking of exercise, is reduced to a minumum and that the average for each individual must represent very accurately his normal blood-tension. STANDARD OF NORMAL BLOOD-PRESSURE IN TEMPERATE es The wide variations in normal blood-pressure which have been recor ded by different writers are probably due largely to the use of armlets varying in width. Janeway states that in young adult males the systolic pres- -sure ranges from 100 to 130 millimeters of mercury when a 12-centi- meter armlet is nsed. Gallawardin(4) considers the ordinary mean to lie between 110 and 120 millimeters. A very valuable series of statistics was published in 1910 by Woley.(5) He analyzed the blood-pressures of 1,000 supposedly healthy individuals, using a 12.5-centimeter (5-inch) cuff applied to the arm when the subject was in the sitting posture. He found the average systolic pressure for all males to be 127.5 millimeters and for all females 120 millimeters. Classifying his 1,000 cases accord- ing to age he obtained the following results: TABLE I.—Woley’s average systolic blood-pressures for 1,000 healthy persons in the United States. (12.5-centimeter armlet.) Range of | Average || Range of | Average | age. pressure. age. pressure. | 1 i: Years. iG, mm. Years. vil mm. | : 15 to 30 | 122 40 to 50 | 130 8 30 to 40 Gila 127 |: 50 to 60 ok 132 | Faught considers the average normal 1 syetolie pressure at the age of 20 to be 120 millimeters.(9). Bachmann(7) examining healthy students SYSTOLIC BLOOD-PRESSURE AND THE PULSE RATE. al: in Philadelphia’ with a 10-centimeter cuff found an average pressure of 114.3 millimeters for a series of 10 boys ranging from 15 to 20 years of age; 119 millimeters for 53 men ranging from 21 to 30 agi and 120 for 9-individuals ranging from 31 to 40 years. Most..of the older statistics for blood-pressure on healthy persons are based on readings made with narrow, constricting bands like the 5-centi- meter armlet used with the early Riva-Rocci apparatus. Such figures are always too high. The figures gwen above indicate that in the temperate zone and with a wide armlet the mean blood-pressure for healthy men from 15 to 30 years of age should be looked for between the limits of 115 and 120 millimeters, certainly not above 122 millimeters. INFLUENCE OF TROPICAL CLIMATE ON BLOOD-PRESSURE AND PULSE RATE. The average blood-pressure with the 12.5-centimeter armlet, based upon 5,368 readings on 992 American soldiers serving in the Philippines, was 115.6, and the pulse rate for a like number of observations on the same men was 81 per minute. These men ranged in age from 18 to 50 and the average was 26.6 years. The average length of their present tour of tropical service was about eleven months at the beginning of the year during which the men were under observation. Table IT shows the details of these observations. Taste Il.—Average systolic blood-pressures and pulse rates, based on 5,368 observations of each which were made on 992 American soldiers serving in the Philippines ; arranged according to age. (12.5-centimeter armlet.) eae — 7 7 i | Number of men sho wing pressures from— Ween Average | | | Hotel Average|Average Age period, years.| age, 91 101 | 111 | 121 | 181 | 141 | 151 | ber of | Pres- pulse years. to to to to to | to to | sure. Tate. 100 | 110 | 120 | 130 | 140 | 150 | 160 | ™en- mm. |mm.| mm. | mm. | mm. | mm. | mm. AS tole 19.4 1 |) 12 18 8 | ile OO tOl25e ae 22.8| 32| 156] 165| 87| 22 alee | 469 | 114-3 82 DEVS) ae ee 27.2) 16) 73) 103) 70|- 13; 3) 3) 286] 115.9 81 A (i Coe AL DEG CoD). DEEP ADO eR ed Ge eee 109 | 116,7 80 Baitoy40ee yin ees GW Oe ide! Seer | 3 ees 58 | 120.5 81 Over 40 ___._____- Oe EER Time 7 RE ee 1) 84) 496) 78 Totals or | | | | | el averages _ 26.6 | 53} 287) 369| 209; 53 15 | 6 992 115.6 81 | It will be seen from the above table that the blood-pressures for the ages from 18 to 30 average 115 millimeters, which is 7 millimeters lower than Woley found and 3 millimeters lower than Bachmann found for the same age period in the United States. However, it is exactly mid- way in the normal range set by Gallavardin and Janeway for temperate AT2 CHAMBERLAIN. climates. For the period from 30 to 40 years our average was 118 milli- meters, which is 9 millimeters lower than Woley’s but only 2 millimeters lower than Bachmann’s experience for the same ages. The pulse rate for all ages was 9 beats above the accepted normal for temperate climates.’ - INFLUENCE OF LENGTH OF TROPICAL RESIDENCE ON BLOOD-PRESSURE AND PULSE RATE. Since the number of men who had lhved over a year in the Philippines was considerably greater for the 1909-Group than it was for the 1910- Group these two groups have been tabulated separately according to length of tropical service in Tables III and IV, as well as combined in Table V. The average age of the men in the group for each quarterly period of tropical service has also been given because age has a distinct bearmg on blood-pressure. As stated above, our complete series of blood-pressure observations consisted of 4 or 5 readings for each individual, evenly spaced through a year, but in the next 3 tables only the first of these readings has been considered and the figures in the first column of each of the 3 tables indicate the number of months intervening between the date of arrival in the Philippines and date of the initial blood-pressure reading for each soldier in the sub-group. TABLE II.—Average systolic blood-pressures and pulse rates for 587 men of the 1909-Group, arranged by length of Philippine residence. (12.5-centimeter armlet. ) Length of tropical residence. Psat: opr sverase) AGeraee , mm SMON LN SOT CSS eee eee ee 76 110 75 23.8 STI CS) NBO ON OU NS aS 14 118 78 26.1 6. toyoimonthsa=s= 25. = ee eee 123 112 76 24.3 OM oul2;m On this 22s — eae ee ee eee 232 118 89 24.0 12:tonlbmonths= se ae ee eee 47 118 77 24.6 fp LUBY NOB} 2000) ON OS 26 122 7 30. 0 So iLO OuMON thsisases wee. eee eee es 22 119 83 30. 5 Over'86months 222-22 = = oe te ee 47 120 84 33.3 Taste I[V.—Average systolic blood-pressures and pulse rates for 404 men of: the 1910-Group, arranged by length of Philippine residence. (12.5-centimeter armlet.) Length of tropical residence. Auber press eeciaen cee lie OMe Glee etal | mm. | QameMGnS ORNS 158 116 7 | 27.0 SyLOLOVINI GI sa ee eel 74 120 80 27.0 x6ite: Oumontihs ese 5, Seen aaa area 88 117 75 | Dao Oto LQ months. 222 522 ee eee ee 59 118 | 73 30.3 Overd2:months 252362206 ee eee 25 124 77 33.3 SYSTOLIC BLOOD-PRESSURE AND THE PULSE RATE. 473 TABLE V.—Average systolic blood-pressures and pulse rates for 991 men, the combined 1909-Group and 1910-Group, arranged by length of Philippine residence. (12.5-centimeter armlet.) pe Length of tropical residence. Rapes Spree apace ee | ad 2 num, Stmontlisior Less \o2 se eee ee were WEEE 234 114 76| 23.2 feos CO OVMONtNSae se skate eee eae 88 120 80 26.9 GO OROUINOM TDS 9-7 seat SO eet pe a ee a 211 114 76 25.7 Spon Danton ths sae a ae) ee eee ai 291 rg 85 25.7 Over 12 months ____---2_- Petite oes 167 120 30} 29.9 It will be observed that in all 3 tables the blood-pressure is lower during the first three months of tropical residence than at any subsequent time, with two exceptions. ‘The variations between the average readings for the different quarterly periods are slight, rarely exceeding 6 milli- meters, and there seems to be no consistent rise or fall of pressure with increasing length of tropical service. The fact that the last readings in Tables [V and V and the last 3 in Table III are rather higher than the earlier ones can best be explained by consulting the column of ages, when it will be seen that the average age of the men for these periods was considerably higher than for those who had served shorter terms in the Philippines. The reason of this is that most of the individuals who stay longer than two years in the Archipelago are old soldiers, desirous of taking advantage of the fact that Philippine duty counts as double time in reckoning the thirty years of service necessary for retirement. Pulse rates in all the 3 tables are somewhat elevated above the average for the temperate zone, but there is no indication that increasing length of service aggravates the tendency to undue rapidity of heart action. Tables VII and VIII show that during a period of one year, through- out which observations were made quarterly, there was no progressive alteration in blood tension and that the pressure was not materially different at the beginning and at the end of this year of observation. Musgrave and Sison(6), working in Manila and using the Erlanger instrument with a 12.5-centimeter armlet, found among 97 foreigners, “mostly Americans from the Civil Service and the United States Army, that the blood-pressures were as shown in Table VI. TABLE VI.—Average systolic blood-pressures of 97 foreigners in Manila, according to Musgrave and Sison. (12.5-centimeter armlet.) Length of residence. | Pressure. Years. mm. | 1 or less. 124 | 1to5 115 5 to 10 116 Over 10 113 | 474 CHAMBERLAIN. It will be observed that Musgrave and Sison did not obtain readings during the first twelve months which were as low as ours. Their figures after one year of tropical residence coincide with what we found during the first year. In their article these observers conclude that blood-pressure in the Tropics is materially reduced. In view of the standards for temperate climates recognized by Janeway,(3) Gallavardin,(4) Woley,(5) and Bachmann(7) it seems to us that the average pressure of 124 millimeters found by Musgrave and Sison (with a 12.5- centimeter armlet) is not low and that even the average of 115 millimeters could not be considered so low as to be of much significance. SUMMARY OF INFLUENCE OF THE PHILIPPINE CLIMATE. Reduced to the basis of a 12.5-centimeter armlet we found the average blood-pressure for healthy white men in the Philippines to be 115 milli- meters for those between 15 and 30 years of age and 118 millimeters for those from 30 to 40 years old. These figures are little if any below those to be expected in a temperate climate when a 12.5-centimeter cuff is employed. The lowest readings were obtained in the first three months of Philippine service. There was no progressive tendency for the pressure to increase or to decrease with continued tropical residence up to a little over three years, beyond which point our observations do not extend. The pulse rate was constantly increased, averaging 9 beats above the usual standard of 72 per minute. INFLUENCE OF SEASON ON THE BLOOD-PRESSURE AND PULSE RATE. The hottest part of the year in the regions where our observations were made is in the second quarter, April, May, and June. The rains usually begin in June or July and last till October or November. December, January, and February are comparatively cool with a mean temperature of about 25° C. (77° F.). Tables VII and VIII have been prepared to show the influence of season on the blood-pressure and pulse rate. It should be noted that in the 1909—Group the observations began in the first quarter of the calendar year whereas in the 1910—Group they commenced in the second quarter. The individual observations could not of course all be made on the same date. In fact they are spread over a period of about six weeks, but the majority were made in the middle month of the designated quarter. TABLE VII.—Average systolic blood-pressures and pulse rates for 587 men of the 1909-Group, the 4 observations on each man being arranged by season. (12.5- centimeter armlet. ) | First |Second| Third | Fourth | Observation. quarter|quarter| quarter) quarter | | 1909. 1909. 1909. 1909. Blood-pressure == 222222 millimeters__ 116 111 114 116 Pulse rate 82 88 87 83 SYSTOLIC BLOOD-PRESSURE AND THE PULSE RATE. A475 TABLE VIII.—Average systolic blood-pressures and pulse rates for 404 men of the 1910-Group, the 5 observations on each man being arranged by season. (12.5-centimeter armlet.) r | cae | - | Second| Third | Fourth! First |Second | | Observation. quarter| quarter quarter, quarter, quarter| | 1910. 1910. 1910. | 1911. 1911. eee | | | Blood-pressure===——_--— = millimeters__ Bai | us TSH 18: 118 prise ate de. SSR ek eee eee Se eee GL | 77 78 77 | Pe ste. | | | nn “i In the 1909-Group it will be seen that there was a drop in pressure of 5 millimeters in the second quarter and of 2 millimeters in the third quarter of the calendar year. The months durimg which the marked reduction of 5 millimeters occurred are the hottest of the year. In the 1910—Group there was a decrease of 1 millimeter in the second quarter, 1910. -If the two groups were combined the mean drop in the second quarter would be about 3 millimeters. It appears, there- fore, that there is a slight but probably unimportant alteration in blood-pressure in the Philippines as a result of the seasonal changes. The pulse rate was unaltered throughout the year in the 1910-—Group, but showed an increased rapidity of 5 or 6 beats per minute during the hottest period in the 1909—Group. INFLUENCE OF AGE ON BLOOD-PRESSURE AND PULSE RATE. It will be seen on consulting Table II that there was a fairly well marked tendency for the blood-pressure to increase with age, the average for the period 18 to 20 years being 115.0 while that for the period 35 to 40 years was 120.5. The subgroup over 40 years of age contained no man over 50 and the average age for the group was only 43.3 years, which probably accounts for the fact that higher readings were not encountered in this subgroup. Increasing age produced no constant alteration in the pulse rate. These changes in pressure with advancing years correspond with the experience of observers in the temperate climates. The degree of increase found in our series for men below 40 years of age was rather less marked than that found by Woley in Chicago and Bachmann in Philadelphia. Our number of men over 40 years old is too small to be of value.in giving average results. INFLUENCE OF COMPLEXION ON BLOOD-PRESSURE AND PULSE RATE. As stated in the introduction we have been carrying out a series of observations to determine if blonds were more susceptible than bru- nettes to the influence of the Tropics. Pulse and blood-pressure observa- tions formed a part of this work and the results are shown in Tables IX and X. © . 106711——4 A76 CHAMBERLAIN. TABLE [X.—Comparative average systolic blood-pressures and pulse rates for 111 blonds and 118 brunettes, 1909-Group. (12.5-centimeter armlet.) | First Second | Third Fourth , | | quarter quarter quarter quarter Av OrBRE z0n | Aver-) 1909. 1909. | 1909. 1909. | Eat: Type. | age mim YE LS ae fSeaeel SE av ae | 88€. | pros | i‘ : | Tes: Pres Pres | Pres Pres- | sure, | Pulse. sure. | Pulse: sure, Pulse. eure Pulse Satie. | Pulse | Years.| mm. , | mm. | mm. mm. | | mm. | Blondi ss ==8-=== } 20.0 | 116 §2| 113) 93) 114) 89) 117) 85) 114.8} 87.2 IBTUNeiC a= ==e as 25.1| 119! 86 | 115} 92) 115 | 94) 118} 86] 116.8] 89.2 - | \ | | | TABLE X.—Comparative average systolic blood-pressures and pulse rates for 206 blonds and 198 brunettes, 1910-Group. (12.5-centimeter armlet.) | Second Third Fourth First | Second | . quarter quarter quarter qurater quarter ANY ee. for a Aver- 1910. 1910. 1910. 1911. 1911. . _ Type. age |_ re 22 iStn§ i = | 48. | pres Pres- Pres- Pres- Pres- Pres- ernie Pulse Sie, Pulse Si, Pulse Sie. Pulse aren Pulse Sie Pulse. meh. rs I. LARS [hs bid eae wt Te = Years. | mm mm. mm. | mm. mm. mm. Blond ______ 27.4 116 | 77 119 78 118 78 117 77 118 Ct Aaa leks) 77.3 | Brunette___| 28.1 DTS eal Seed: 77 118 | 78 118 77 117 77| 117.6 77.3 | | It will be observed that the average pressures throughout the year for the blonds and brunettes of the 1910—Group are identical while in the smaller 1909-Group the difference is only 2 millimeters of mercury. If the two groups are combined we obtain an average for 317 blonds of 116.7 millimeters and for 316 brunettes of 117.3 millimeters a dif- ference of only 0.6 millimeter. The pulse rate for the two complexion types is the same in the 1910—Group and varies only 2 beats in the 1909-— Group. Therefore it can be concluded that the complexion type does not appreciably affect the blood-pressure or the pulse rate in the Tropics when men are at rest. To determine if there was a difference after exercise we had special observations on the pulse and blood-pressure taken on two occasions, once near the beginning and once near the end of the year of observation. The results appear in Table XI. TasBLE XI.—Comparative average systolic blood-pressures and pulse rates on 136 blonds and 124 brunettes of the 1910-Group after exercise. (12.5-centimeter armlet. ) Second quarter | Second quarter | Average for two | observations. | Type. Wate MO J Bactgs Se {ie So oss 3 | Pressure.| Pulse. eae Pulse. | Pressure.| Pulse. | mm. mm. | mm. |. Blond 224 ee 125.4] 85.9] 123.8) 82.7 124.6 | 84.3 Brunette —-- eee 128.2 | 87.4 |« 125.7 83. 8 nel 85.6 These observations were made as soon as possible after the men had completed a march, a period of drill, or some other form. of: exercise SYSTOLIC BLOOD-PRESSURE AND THE PULSE RATE. ATT carried on out of doors. The exercise was as far as practicable the same for the two complexion types. On comparing the table with the pre- ceding one, which deals with the same men when at rest, it is clear that the result of exercise was to raise the blood-pressure by an average of from 7 to 9 millimeters, and the pulse rate by an average of 7 beats. This is what would be expected in the case of healthy well- trained men engaged in moderate out-door work. When we come to compare the two complexion types it will be seen that both pulse rate and blood-pressure are slightly higher for the brunettes. However, the average differences are so small that they are probably of no importance, and it is our opinion that variation in complexion does not produce any significant change in the blood-pressure and pulse rate either at rest or during exercise. INFLUENCE ON THE BLOOD-PRESSURE AND THE PULSE RATE OF THE USE OF ORANGE-RED UNDERWEAR AND HAT LININGS. Table XII was prepared as a part of the data which went to show that orange-red under-garments and hat linings for use in tropical countries were of no value. TABLE XII.—Comparatiwe average systolic blood-pressures and pulse rates for 294 men wearing orange-red garments and 294 men wearing white ones, 1909- Group.. (12.5-centimeter armlet.) | j | First Second | Third Fourth | quarter quarter quarter quarter everage for ; aver- 1909. 1909. 1909. 1909. MS Clothing. age tia | age. ia | Pres- Pres- Pres- Pres- Pres- ee, Pulse. ean Pulse. SiO. Pulse. Shi, Pulse. Src, Pulse. es | [eat 2 (vate =e ee Years.| mm. mm. | mm. mm. | mm. Orange-red __-____- 25.4 | 115 82} 111 88} 112 88 1) 83 | 118.6} 85.1 WnItee =. 222 Ais 25.4] 117 82) 2 89} 115 87 | 117 | 83 | 115.0} 85.2 | | | | | | Exposure to ultra-violet rays is said to lower blood-pressure and some have considered the sunlight in the Tropics to be richer in these rays than it is in temperate regions. If such be the case it is con- ceivable that the protection of the greater part of the body with a color which intercepts the actinic rays of the solar spectrum might have some effect on the blood-pressure. The experiment showed a lower blood- pressure for those wearing the orange-red garments, but the difference is so slight that, in our opinion, it should be attributed to chance rather than to the influence of the clothing. At the different quarterly periods the pressure of the orange-red group ranged from 1 to 3 millimeters lower, and for the entire year the average for the orange-red group was 1.4 millimeters lower than for the white. Such slight differences are of no significance. The averages for the pulse rate throughout the year varied by only 0.1 of a beat. 478 . CHAMBERLAIN. INFLUENCE OF INDIVIDUAL SIZE OF THE MEN ON THE BLOOD-PRESSURE AND PULSE RATE. Since the heights and weights of all of the soldiers in our series were on record it seemed an excellent opportunity to investigate the influ- ence of individual size on blood-pressure, a phase of the subject in regard to which few data are available. In addition to the 992 soldiers for each of whom we had an average pressure, deduced from 4 or 5 readings taken at intervals during a year, there were a number of other men for whom 1, 2, or 3 pressure readings had been taken and the observation then discontinued for one reason or another. The individual averages for these men have been combined with the averages for the 992 previously considered, making a total of 1,243 men on whom 5,775 blood-pressure readings had been made. These men were then divided into groups according to height in inches. The results are shown in Table XIII. Taste XIIL.—Average systolic blood-pressures and pulse rates, based on 5,775 observations of each made on 1,243 healthy soldiers in the Philippines, arranged according to height. (12.5-centimeter armlet.) ] + Average Average Range of height. | Average weight. ene ee ‘Average Ree’ bapa Cm. | Lbs. | Kkgms. | mm. Years. | Months. Under 64 inches ________- 162.5 132.9 | 60. 4 | 27 117.9 | 79.0 27.6 13.4 BMITVONGSO se 162,5| 184.7 61.2 1120 | Soet'1 4572 80S eG ei 7a mst Zeer 6apin Chiesa == eane 165.0 139.9 63.6 157 116.0 | 80.0 26.0 15.9 (KF MOV NAS oo. a 167.6 141.9 64.5 187 115.5 | 81.5 27.2 17.2 67a Chess 170.1 | 144.4 | 65. 6 225 116.2 | 80.4 26.7 16.8 6S inchest= see eee eee P25 '7/ 147.2 66.9 251 115.7 | 82.3 | 26.4 17.8 69m Cheste= ae eee 175.2 | 152.7 | 69.4 IPP ABS PA 82.6 26.2 16.1 (Onin ches eee eee eee Wien |) sobs 70.7 80 117.9 80. 2 27.1 16.0 TOL ODOS oe eee 180:3| 159.0) 72.3 40) 11983'| 81.5) 266 |) toe 72 inches and over ______ 182.8 | 164.5 | 74.8 35 | 120.6 | 83.0 25.8 17.6 Averages= 2 |e suse | 155 lee ioes sty ee ee 116.2 | ie Meme [ESA Bet aThis means that the men in the group were 64 inches or more, but less than 65. The next figure means that they were 65 or more, but less than 66. The same explana- tion applies to the subsequent figures. It is to be observed in Table XIII that the weight progressively increased with the height and that the average age and the average length of tropical service did not vary materially in any of the height groups. Therefore any difference in blood-pressure observed may safely be attributed to the influence of height and weight. It is plain that there is no progressive rise of blood-pressure with increasing size up to and including 70 inches (177.7 centimeters) in height. For the groups 71 inches (180.3 centimeters) and over 72 inches (182.8 centimeters) there does appear a tendency for the blood-pressure to rise 2 or 3 SYSTOLIC BLOOD-PRESSURE AND THE PULSE RATE. 479 millimeters, but these groups are relatively small so that the slight increase In pressure may have been due to chance. On the whole it can be said that there is no clearly marked tendency for either pulse or blood-pressure to rise with increasing height and weight of the individual. INFLUENCE OF RACE ON BLOOD-PRESSURE AND PULSE RATE IN THE TROPICS. In order to determine the blood-pressure of healthy adult Filipimo males 552 observations were made on 386 Filipinos. Several tribes were represented such as Tagalogs, Ilocanos, Macabebes, and Visayans, but they did not differ essentially in physique, habits, or character of residence. ‘T’wo hundred were soldiers and the remainder servants, laborers, and convicts. Most of the observations were made by the Board, but a part were by the officers referred to in footnote 3. The majority of these observations were taken with an 8-centimeter armlet.. For the observations on 120 Filipinos the pressures were taken with both a 12.5- centimeter and an 8-centimeter armlet, and it was found that the latter registered 6 millimeters higher than the former. ‘This amount has ac- cordingly been deducted from the average of the readings made with the 8-centimeter cuff. . The average blood-pressure, on a basis of a 12.5-centimeter armlet, for 100 soldiers of the Philippine Scouts was 115.0 millimeters and for 100 soldiers of the Philippines Constabulary was 115.9 millimeters. In. both groups the ages ranged from 15 to 40 and the average age was 24.7 years for the Scouts and 25.2 years for the Constabulary. For 145 Filipinos from various sources, ranging from 15 to 40 years of age and averaging 24.1 years, the average pressure was 115.7 millimeters. When using the actual 12.5-centimeter armlet the average of 166 readings on 120 Filipinos, ranging in age from 15 tc 40 years, was 116.7 millimeters. We may therefore conclude that the mean blood-pressure for Filipinos during the period of 15 te 40 years of age (average about 25 years) is 125 or 116 millimeters and that it does not differ from the pressure at. the same ages for Americans residing im the Philippines. For neither race is vt very materially below the figures to be expected for white men residing in temperate climates. “Musgrave and ‘Sison(6) obtained decidedly lower pressures in a series of 49 Filipinos, for whom the age limits are not stated. These observers found an average of 108 millimeters for 30 males and 113 for 19 females. We. do not think that any general deductions should be drawn from such a small,series. It is very likely that chance may have been an important factor in producing these low readings, especially in view of the fact that the usual relationship of pressures for the two sexes was reversed, the females having the higher tension, whereas the general experience elsewhere is that women show a systolic pressure lower by about 10 millimeters. (3) 480 CHAMBERLAIN. Two small groups among our Filipinos, which are not included in the above consideration, are of interest. One is a group of 26 Filipinos ranging in age from 40 to 75 years, the average being 50.6 years. The mean pressure was 144.8. This seems a high figure, considering the aver- age age, and possibly may signify that the elevation from increasing years comes on earlier for Filipinos than for white men. Casual obser- vation suggests that the other indications of senility occur early among tropical natives. The other group consists of 20 Igorots, all apparently young, but whose exact ages could not be determined. They gave an average of 122.0 millimeters. The Igorots were living at an altitude of 1,500 meters in a comparatively temperate climate, and though smaller in stature are better developed physically than the lowland natives. Their blood-pressures averaged 6 or 7 millimeters higher than the mean for the lowland Filipinos, the increase probably being due to the altitude.(8) The whole Filipino group, except the Igorots, is arranged by ages in Table XIV. TABLE XIV.—Average systolic blood-pressures for 366 lowland Filipinos; arranged by ages. (12.5-centimeter armlet.) | Number of men showing pressures from— | | ¢ Age period. | 80 ie | 101 | ms 121 | 131 | 141 | 151 | 161 peice SVerHEe | to | to | to | to | to | to | of men.|Pressures. | 90 | 100 0 2 130 | 140 | 150 | 160 | 200 | | mm. | mm. m. |} mm. | mm. | mm.| mm.|mm. ea ne enn nel ane cay ae | | | mm. | 15 to 20 years_________ [sous (oe | ee er ee 40| 112.8 | 20 to 25 years________- [Po ete) L0 FA 40) ao eaze 8 3 2 1 161] 115.4 Bbrtor spleens =e ecs INE! Ts) 7 ati a e223 lea) ly 95| 117.0 30 to 35 years_________ [eel hn PE eer Reams al tO ae ame tl tee ee 28| 116.9 | 35 to 40 years_-__-.---| 1 te bai 5) Rll it [tees ets | ae 16] 112.3 | Over 40 years ____--_- [eens - Oi paorb los od 4 eG 6 | 26] 144.8 | Motale.- aera 3|/ 24] 96 | WH ma ea a OG 366 |e ee | | It will be seen that the blood-pressure showed a tendency toward pro- gressive increase with age except in the period 35 to 40 years. The _ records for this period contained 5 exceptionally low blood-pressure readings and as there were in all only 16 men in this subgroup it is probable that such a low reading for the ages of 35 to 40 is merely the result of accident and would not be manifest in a larger series. Pulse rates were recorded only for the Scout and Constabulary groups and averaged for the former 75.7 (blood-pressure 115.0 millimeters) and for the latter 82.5 (blood-pressure 115.9 millimeters). These averages do not vary materially from the pulse rates found for our various groups of American soldiers in the Philippines. SYSTOLIC BLOOD-PRESSURE AND THE PULSE RATE. 481 CONCLUSIONS. 1. The mean blood-pressure in temperate climates for healthy males between 15 and 30 years of age lies between 115 and 122 millimeters of mercury when a 12.5-centimeter armlet is employed. 2. When the 12.5-centimeter armlet is used the blood-pressure of American soldiers serving in the Philippines averages 115 millimeters for the period 18 to 30 years of age, and 118 for the period 30 to 40 years. 3. This indicates that the blood-pressure of Americans residing in the Philippines differs but little if any from the average at home. 4. Usually the lowest readings for Americans living in the Philip- pines were obtained in the first three months of tropical residence, hut there was no progressive tendency for the pressure average to rise or to fall with increased length of residence up to a limit of three years, beyond which our work did not extend. 5. The blood-pressure of Americans was lower during the hottest part of the year, but the difference was very slight, only about 3 milli- meters. 6. There was a well marked tendency for the blood-pressure of Americans to rise with increasing age. 7. Neither complexion type nor the use of underwear and hat linings of orange-red color exerted any appreciable influence on the blood- pressure of American soldiers. 8. There was no well marked tendency for the blood-pressure or pulse rate to rise with increasing height and weight of the individual. 9. As was to be expected, exercise raised both the blood-pressure and the pulse rate. 10. Using a 12.5-centimeter armlet the average blood-pressure of Fili- pinos was found to be 116 millimeters for a large group of males ranging from 15 to 40 years of age and averaging 25 years. This pressure was practically identical with that for the group of white men of the same average age and living in the Philippines. 11. There is a well marked tendency for the blood-pressure of Filipinos to rise with increasing age. 12. The pulse rate of active Filipinos and Americans living in the Philippines averages a few beats above the usual standard of 72 per minute. . In closing we wish to express our obligations to the medical officers mentioned in footnote 3, who by their earnest and continued efforts made possible the collection of the statistics on which this report is based. 482 CHAMBERLAIN. (1) REFERENCES. CHAMBERLAIN, W. P. Observations on the Influence of the Philippine Climate on White Men of the Blond and of the Brunette Type. Phil. Journ. Sci., Sec. B (1911), 6, 427. PHALEN, J. M. An Experiment with Orange-Red Underwear. Phil. Journ. Sev., Sec. B (1910), 5, 525. JANEWAY T. C. Clinical Study of Blood-Pressure. New York (1907). GALLAVARDIN, L. La Tension artérielle en clinique. Paris (1910), 41. Wotrey H. P. The Normal Variation of Systolic Blood-Pressure. Journ. Am. Med. Assoc. (1910), 45, 121. Muserave, W. E., and Stson. A. G. Blood-Pressure in the Tropics. Phil. Journ. Sci., Sec. B (1910), 5, 325. BacHMANN, G. Measurement of Arterial Pressure in Man. WN. Y. Med. Journ. (1911), 93, 212. Faueut, F. A. Essentials of Laboratory Diagnosis. Philadelphia (1910). Faucut, F. A. Clinical Value of Blood-Pressure Studies. Med. Ree. (1911), 79, 207. . THE RED BLOOD CORPUSCLES AND THE HAEMOGLOBIN - OF HEALTHY ADULT AMERICAN MALES RESIDING INSDRE SPEIeIPPINES:. BASED ON 1,418 RED CELL COUNTS AND 1,433 HAMOGLOBIN ESTIMATIONS PERFORMED ON 702 SOLDIERS.* By Weston P. CHAMBERLAIN.* (From the United. States Army Board for the Study of Tropical Diseases.) The expression “tropical anzmia” in one that often occurred in the older treatises on diseases of hot countries, but more recent. investiga- tions have shown that most of the conditions formerly so designated are in reality instances of secondary anemia due to infections with various parasites, notably plasmodia and uncinaria. Scheube says “there is no anemia caused by the tropical ainiate alone.” (1) The investigations of Marestang, van der Scheer, Hijkman, Glongner and F. Plehn(1) on white men living in ate Tropics showed no material deviations from the normal condition as observed in Hurope. Castellani and Chalmers(2) state that a certain number of Europeans in the Tropics take on “a peculiar whitish color, even in cases in which the blood examination does not reveal any sensible decrease in the amount of hemoglobin.” Hijkman(1) also refers to this pheno- menon. Lehmann and van der Scheer(1) and Musgrave and Sison(3) consider this pallor of the skin to be a local vaso-motor condition. In 1908 Wickline(4) reported the result of examinations of the blood of American soldiers in the Philippines. The men arrived in the Archipelago in June, 1905, and the first observations were made in September of the same year. His results, which are given in Table I, showed that there was a progressive fall in the percentage of hemoglobin and a regular rise in the number of erythrocytes except at the last observation period. The color index progressively decreased. TABLE I. Wickline’s average estimations of the erythrocytes and hemoglobm of American officers and soldiers who arrived in the Philippines in June, 1905. | is | Average | | Number number 0 Average Average | ofmen | Vases Of ex erythrocytes | heemoglo- color examined, | | per cubic | bin. index. : | millimeter. ee | tl Per cent. | 70... Sept., 1905 4,980,555 | 94 QU92. | 104 | Dee., 1905 | 5,348,595 89 | 0.88 97 | Aug., 1906 | 5,429,960 | 86 | *° 0.79 81 | Apr., 1907 5, 330, 888 83 0:78 | 1 Published with permission of the Chief Surgeon, Philippines Division. 2 Weston P. Chamberlain, major, Medical Corps, United States Army, president of the United States Army Board for the Study of Tropical Diseases as they Exist in the Philippine Islands. 483 484 CHAMBERLAIN. During the last three years the United States Army Board for the Study of Tropical Diseases has been carrying out two series of observa- tions, one to determine if any benefit resulted from the use of orange- red underwear in the Philippines,(5) and the other to decide if complexion type was a factor in the resistance of white men to tropical influences.(6) During this work a large number of observations on the blood were made by the members of the Board and by certain medical officers of the Army who were detailed to make the examinations under the supervision of the Board.’ The large number of independent ob- servers minimizes as far as possible the influence of the personal equation in this work. The red cells were counted with the Thoma-Zeiss hemo- cytometer. The hemoglobin estimations were made in most cases with Dare’s hemoglobinometer and in the remainder with the von Fleischl instrument. ‘The number of men observed is so large that the element of chance is eliminated. With one exception the stations where the sol- diers resided were close to the coast line. Most of them were near sea- level and of the posts which were not so situated.none were at an altitude exceeding 600 feet (200 meters). It should be understood that all of the men were healthy soldiers performing their full military duty. The results are shown in Tables II and III. The average age of the men in Table II was 25.3 years and of those in Table III was 27.7 years. TABLE II.—Average erythrocyte counts and hemoglobin estimations on 65 Amer- ican soldiers who at the date of the first eramination had served on the average 14.9 months in the Philippines. Average number of Average Average Dates of examinations. erythrocytes| hemoglo- eolor per cubic bin. index. | millimeter. | mies Z EAE Ee Se eed sere Ser 2 we ee | Per cent. Fanuary, 90928 a4 hoe Meee a Bo Be ee 5, 276, 000 | 89.3 0. 85 Taally;, 5190935 3 S8 ee ee eee 5, 355, 000 88. 2 0. 82 Decembery1909 2-225 =e ee ee eee 5, 152, 000 90.0 0. 87 *The medical officers who were engaged in making the blood examinations referred to in this sentence were the following: Majors A. EH. Truby and Roger Brooke, jr.: Captains E. G. Bingham, J. R. Barber, Mahlon Ashford, E. G. Huber, H. M. Snyder, and W. L. Hart; Ist Lieutenants J. B. H. Waring, W. R. Dear, C. E. Doerr, F. S. Wright, C. G. Snow, N. Il. McDiarmid, Armin Mueller, T. J. Leary, M. C. Stayer, L. C. Garcia, and ©. E. Fronk, Medical Corps; and 1st Lieutenants W. F. de Niedman, and C. A. Betts, Medical Reserve Corps. RED BLOOD CORPUSCLES AND THE HAMOGLOBIN. 485 TABLE IIJ—Average erythrocyte counts and hemoglobin estimations on 601 American soldiers who at the date of the first examination had served on the average 6.6 months in the Philippwes. Average | | number of | Average | Average Dates of examinations. erythrocytes | hzemoglo- | eolor | per cubic bin. | index. | | millimeter. | | { e are Bie RSS dee EE PO} Percent. | OU ENGNG TINE TUT 5, 111, 000 90.3 | 0. 88 Marysanae sim e261 91ers ELE 5, 206, 000 | 89.6 | 0.86 | L a et ee, | It will be seen that in character our blood examinations agree with those of Wickline, although the alteration which he found with increasing length of tropical residence are not as pronounced in our series as in his. Our average erythrocyte counts at different periods range from 5,111,000 to 5,355,000, and the average hemoglobin readings from 88 to 90 per cent. The color index is consequently considerably below unity, varying from 0.82 to 0.88. In Tables IV and V is shown the range covered by the individual red counts and hemoglobin estimations for a body of healthy American sol- diers, who at the date of examination had served in the Philippines for an average of twenty months, the length of this service being for no man less than fourteen months. These tables include all the examina- tions that are shown in the last column of averages in Tables II and III, together with a few others which were not entered in Tables IT and III because there were no preliminary examinations for the individuals. concerned. Taste 1V.—Range of erythrocyte counts for 687 healthy American soldiers who at date of count had served on the average twenty months in the Philippines. if | Range of erythrocyte count | Number veneent Range of erythrocyte count | Number ey per cubic millimeter. of men. ibe per cubic millimeter. | of men. digas | | ab aes Eat ebeth bs -t 7 a ened os Meee | : zie Under 4, 000, 000 ______-____- 15 2.2 || 5,500,000 to 5, 749, 000_______ 76 11.1 4,000, 000 to 4,249, 000_______ | 26 3.8 || 5,750,000 to 5,999, 000_______ 39 5.6 4,250, 000 to 4, 499, 000_______ 37 5.4 || 6,000,000 to 6, 224, 000_______ | 35 peleg 4,500, 000 to 4,749, 000_______ 60 | 8.8 6, 225, 000 to 6, 499, 000_______ | 24 3.5 | 4, 750, 000 to 4,999, 000_______ 112 16.3 6,500, 000 to 6, 749, 000_______ | 12 NRG 5, 000, 000 to 5, 224, 000_______ 155 22.5 || 6,750,(00 to 6, 999, 000_______ | 14 tl 5, 225, 000 to 5, 499, 000_______ 77 | 1152) |) (Over 7,,000;'000----- = | 5 0.7 A486 ? CHAMBERLAIN. TABLE V.—Range of hemoglobin readings for 702 healthy American soldiers who at date of examination had served on che average twenty months in the Philippines. Range of hemoglobin. eed Recta Range of hemoglobin. Nomey een | “| number, || €M- | number. |———— SAN 9 eae =| eee a Seren ne siete eee | | Under 80 per cent ------____ 8 1.1 || 90 to 94 per cent___.________- 261 37.2 SO tOLs4penCenita==se= === | 64 SPH | Bi) CE) pXere Oe Oa ae 136 19.4 | 85 to 89 per Celt =e eee | 185 26.4 || 100 per cent or over________- 48 6.7 | It will be noted in the erythrocyte counts that there was a-consider- able excursion below and a still greater excursion above the 5,000,000 mark. The men with cell counts between 5,000,000 and 6,000,000 per cubic millimeter constituted 50.4 per cent of the total 687, while those with counts above 6,000,000 formed 13.1 per cent. The table of hemo- globin estimations shows that 89.7 per cent of the men gave readings of 85 per cent or upward. The normal erythrocyte count of young adult males at sea-level in temperate climates may vary considerably from the conventional 5,000,000 per cubic mil- limeter. Cabot states that 6,000,000 is by no means rare among healthy young men and that higher figures are seen occasionally. Among 50 young medical students in the United States Hewes(7) found an average of 5,809,000; the lowest being 5,120,000. Sorensen (11) found an average of 5,606,000 for male students ranging from 19.5 to 22 years of age and of 5,340,000 for young physicians from 25 to 30 years old. Ewing,(8) speaking of Welcker’s estimate of the ‘normal ted cell count as 5,000,000 for men and 4,500,000 for women, says: “Perhaps the chief contribution of later observers using Thoma’s instrument has been the proof that the numbers are more apt to exceed rather than, fall below these averages, especially in men, a fact that has become more certain from the more careful estimates of the last decade. Thus the average obtained by Helling was 5,910,000; by Frederickson, 5,072,000; Zaslein, 5,010,000; Neubert, 5,603,000; Graber, 5;081,000; Stierlin, 5,752,000; Reinicke, 5,209,667; Andriezen, 6,000,000; Hayem 5,500,000.” In view of the above averages it will be seen that the erythrocyte counts obtained by Wickline and by ourselves among healthy young soldiers in the Philippines could not be considered as differing from: the normal as seen in Europe and America. For 70 healthy American soldiers stationed in New Orleans, and in whom uncinariasis had been ruled out by repeated examinations of the stools, we found an average of 94.2 per cent of hemoglobin.(12) “The von Fleisch] instrument was used and, the average age of the men was about 28 years. Our own experience elsewhere in the United States has been that readings with this instrument rarely reach 100 per cent. Faught(10) considers 90 or 95 per cent with the von Fleischl apparatus to be normal. ‘The relative percentage of hemoglobin as estimated by clinical hemoglo- RED BLOOD CORPUSCLES AND THE HA‘MOGLOBIN. 487 binometers, is figured by Stierlin(2) to be 88.8 for the ages 18 to 25 years and 100.0 for the ages 25 to 45 years. Since the average age of the groups of men we examined was 25.3 years for that considered in Table II and 27.7 years for that in Table III, it will be seen that the hemoglobin percentages, which ranged from 88 to 90, were probably a little below the standard to be expected in the temperate zone. In the case of Wickline’s series the reduction of hemoglobin was more marked, but even among his men it was not low enough to indicate a definite state of chlorosis or anemia. z The color index, or hemoglobin quotient, indicating the richness. in hemoglobin of the individual red cells, is set by most authors at a normal of 1, this figure being based on an average erythrocyte count of 5,000,000 and an average hemoglobin estimation of 100 per cent. Bearing in mind the evidence adduced in the above paragraphs, namely that the red cell counts of young men range above 5,000,000 and that the hemoglobin reading commonly does not reach as high as 100 per cent, it becomes obvious that color indices as great as unity are not to be expected in most instances. However, we have not been able to find in Manila any statistics showing the mean index for healthy and vigorous young adults in the United States or Europe. It seems probable that average hemo- globin quotients between 0.82 and 0.88 such as were found in our exam- inations, may be a little low, but not sufficiently so to be considered as definite indications of anemia or chlorosis. We feel sure that such reduction in the hemoglobin quotient as did occur among the men considered in Table III is not due to a prevalence of mild uncinariasis, since the stools of these men were examined at the conclusion of the observation period and only 2.3 per cent were found to contain hookworm eggs. As regards the influence on the blood of the use of garments designed to absorb the actinic rays of the sun, it was shown in a former report of the Board(5) that the number of erythrocytes and the percentage of heemoglobin were constantly a little higher for the men wearing orange- red underclothing than for those wearing white. This difference was thought to be due to concentration of the blood in those persons wearing the orange-red underwear, which was warmer than the white and there- fore caused more profuse perspiration. As regards complexion type another report of the Board(6) showed that there was no constant or appreciable difference between the red cell counts and the hemoglobin estimations of blond and brunette American soldiers who had served continuously in the Philippines for periods ranging from eighteen to twenty-four months. In closing we wish to express our obligations to the medical officers referred to in footnote 3, who assisted the Board in making the hema- tologic examinations on which this report is based. 488 CHAMBERLAIN. CONCLUSIONS. From our own work it may be concluded that, after about twenty months of Philippime service, healthy American soldiers, living near sea- level and averaging 26 years of age, will show: 1. A red cell count averaging 5,200,000 per cubic millimeter, and rarely falling below 4,500,000. 2. A hemoglobin reading averaging 89.6 per cent, and rarely falling below 85 per cent. 3. A color index averaging 0.86 or 0.87. Such a red cell count does not differ from the normal at present recognized for healthy young men in the temperate zone. The hzemo- globin percentage and the color index are probably a little low, but not sufficiently so to indicate a definite anemia. The pallor not infrequently met with among apparently healthy persons in the Tropics we believe to be due as a rule to superficial ischemia and not to a deficiency in the total quantity, or in any particular constituent, of the blood. REFERENCES. (1) ScuHruse, B. Diseases of Warm Countries. Philadelphia. 2d revised ed., 150. ; (2) CASTELLANI, A., and Cuatmers, A. J. Manual Tropical Medicine. New York (1910), 69. (3) Muserave, W. H., and Srson, A. G. Blood-Pressure in the Tropics. Phil. Journ. Sci. Sec. B (1910), 5, 325. (4) WiIcKLINE, W. A. Effects of Tropical Climate on White Race. Mil. Surgeon (1908), 23, 283. (5) Puaten, J. M. An Experiment with Orange-Red Underwear. Phil. Journ. Sci. Sec. B (1910), 5, 525. (6) CHAMBERLAIN, W. P. Observations on the Influence of the Philippine Climate on White Men of the Blond and of the Brunette Types. Phil. Journ. Sci. Sec. B (1911), 6, 427. (7) Casor, R. C. Clinical Examination of the Blood. New York (1904), 54. (8) Ewine, J. Pathology of the Blood. Philadelphia. 2d revised ed., 104. (9) BucHanan, J. M. The Blood in Health and Disease. London (1909), 11. (10) Fauent, F. A. Laboratory Diagnosis. Philadelphia (1910), 36. (11) Santi, H. Diagnostic Methods. Philadelphia (1906), 627. (12) CHampernain, W. P. The Prevalence of Uncinariasis among Apparently Healthy Southern-Bred Recruits. Arch. Int. Med. (1909), 4, 8. THE OCCURRENCE IN THE PHILIPPINES OF ASSOCIATED SPIROCHAT4 AND FUSIFORM BACILLI IN ULCERS OF THE THROAT (VINCENT’S ANGINA), OF THE MOUTH, AND OF THE SKIN, AND IN LESIONS OF THE LUNGS (BRONCHIAL SPIROCHAETOSIS).! By WESTON P. CHAMBERLAIN.? (From the United States Army Board for the Study of Tropical Diseases.) In our quarterly report of March 31, 1910,(1) we referred briefly to the finding of several cases of the so-called Vincent’s angina in the Phil- ippines, and subsequently Bloombergh,(2) then a member of the Board, reported more fully on the subject. Since that time we have been on the lookout for the presence of Vincent’s symbiotic organisms in all throat lesions coming to the notice of the Board and a large number of cases have been detected. In 1894 Plaut(3) and in 1896 Vincent(4) called attention to a fusiform bacillus, commonly associated with a_spirillum, in ulcerative lesions of the throat, pharynx, and mouth. Since that time many writers have confirmed these observations and the two organisms have been found in various other kinds of lesions. Weaver and Tunnicliff(5) have demonstrated the organism in noma and others have found them in ulcerative stomatitis, diphtheria, carious teeth, hospital gangrene, appendicitis, brain abscess, fetid bronchitis, pyorrhea alveo- laris, and syphilitic lesions. Vincent,(10) Smith and Peil,(10) Bruce,(7) and ourselves(8) have met with similar forms in ulcerations of the skin. Recently Peters in Cincinnati has reported a case of fatal lobar pneumonia, a case of fetid bronchitis and a case of septic infection of the hand, in all 3 of which fusiform bacilli and spirochetse were present in large numbers in the exudate. In the case of hand infection the affected member had been injured by the teeth of another person. Hultgen(12) reports a similar case of hand infection where the patient had the nail-biting habit and the same organisms were found about the teeth. Bacillus fusiformis of Plaut and Vincent is about 10 u in length, the limits of size generally being set at 3 and 15 uw. Occasionally much larger ones have been seen by us. From the center the bacillus tapers toward the ends which are * Published with permission of the Chief Surgeon, Philippines Division. 2 Weston P. Chamberlain, major, Medical Corps, United States Army, president of the United States Army Board for the Study of Tropical Diseases as they Exist in the Philippine Islands. 489 490 CHAMBERLAIN. ee sometimes blunt and at other times sharp. The organisms may be straight or slightly curved and are frequently arranged in pairs, end to end. Occasionally wavy forms are seen. They stain readily with carbol-fuchsin, Loeffler’s methylene- blue, or Giemsa’s stain, and many show irregularity in the intensity of the staining which gives them a quite characteristic banded appearance. They are non-motile. The spirilla or spirochete are longer than the bacilli, ranging from 15 to 50 u in length, and are made up of a variable number of undulations, usually from 3 to 5. They are usually very slender and in fresh preparations are extremely active. With the ordinary aniline dyes they stain less intensely than do the fusiform bacilli and occasionally present a beaded appearance as is shown in one of the appended photomicrographs. Although several attempts have been made to cultivate these organisms from lesions containing them in great numbers we have been uniformly unsuccessful. They have been grown in pure culture by Weaver and Tunnicliff(5) (9) on slants of ascitic agar (1-3) and by Peters on Dorset’s egg medium, in both cases under anerobic conditions. Tunnicliff and some others consider that the fusiform bacillus and the spirochete are different forms of one organism. Some observers consider them to be protozoa. In smears from oral and faucial ulcers the symbiotic organisms of Vincent’s angina are usually associated with varying numbers of other bacteria, such as staphylococci, streptococci, and different species of bacilli, including the Klebs-Loeffler bacillus. Abel has found the organ- isms in normal mouths, and Gross in apparently healthy tonsils. (>) Some have suggested that to make a diagnosis of Vincent’s angina the organisms should be present in preponderating numbers, as compared with other bacteria.(5) Such a distinction is unsatisfactory, but may be of some clinical use and will be to a certain extent adhered to in the following report. PRESENCE OF THE ORGANISMS IN THROAT AND MOUTH LESIONS IN THE PHILIPPINES. During the last two years we have examined all patients with throat and mouth lesions who came to our notice in Manila. There were 106 of these, and in the smears from 34 (32 per cent) the fusiform bacilli and spiro- cheete of Vincent’s angina were present in preponderating numbers. In 22 others (21 per cent) a few of these symbiotic organisms were found, so that.in 53 per cent of the total 106 cases they were present to a greater or less extent. The pathologic conditions with which they were associated are shown in the following table. ASSOCIATED SPIROCHA:T4i AND FUSIFORM BACILLI. AQ] TABLE [.—Occurrence of spirochaete and fusiform bacilli in throat and mouth lesions in the Philippines. : i} | Present | i | in pre- | Present | | ponder- ;insmall} ,;., ating | num- | Absent. | num- bers. } Pathological condition. H Snore Bo FD Wicersiot tonsil; calise uncertain 2-8 es ee nae | Ulcers of tonsil, probably syphilitic _____________---__--_---------_---. | Ulcers of faucial pillars, probably syphilitic --------____--____-_______ | Ulcers of gums (ulcerative stomatitis) --_----.__-_-------__.-_..--=---- | Uilcersfotisums)probablysyphilitic =2=ss== =) -weer ena eee ee TORGERE Che (CGY Se ee Bs Sg ees Pe ee ee Uleer of soft palate, probably syphilitie___-_____________ --__-__-_-____, Ulcer of tongue, probably syphilitie __________________-_--____________ | Membranes on tonsil, cause uncertain ______________________.________. | Murcusspatelies::syphiliti@ see = = eee er eee | WISETO PEO MEU Cues EAE NG TES bo «ee ET gee Ey eek | | TERY EICHE VCONSI ease ee ee a oie eee eR ee | AP WOUS StOMabitiSs 225 2 eee ee ee ee sae cose Se ee \ MyTshiveriam LOSI] aren eee eens Naeem ere ae eee tae Alas | sNOnSWitis, acute LOlICUl ar les ee ee ee ee eee to ey Ss ey Sis (Se SS OS Sy) BS 09 SS) (ONS) 1: |e ce ee =) fe) (sar! oo =) \ i I | t 1 i 1 i t 1 1 1 i \ \ I 1 i i 1 i { | i 1 1 1 i) | i 1 I 1 1 i 1 1 1 1 I \ I ( 1 i 1 1 1 { i 1 i 1 1 I | ! Fa Wy) ic) te wo a The discrepancy between 38 in this column and the 34 positive cases found is due to the fact that 4 of the cases had positive lesions in two different localities in the throat * or mouth. It will be observed that the two organisms were present in preponderat- ing numbers in a considerable variety of conditions, the number of positive findings being highest in ulcers of the gums and of the tonsils. ‘Twenty- seven of the lesions tabulated by us were apparently syphilitic, 2 being primary, 2 tertiary and the remainder secondary, and in these luetic cases the organisms of Vincent were found in preponderating numbers in 10 and in small numbers in 1. In not all of these presumably specific eases was the diagnosis absolutely unassailable, but in some of those in which the fusiform bacilli and spirocheete were demonstrated in large numbers the diagnosis of syphilis was as certain as one could wish, being confirmed by the finding of Treponema pallidum, by the presence of a positive Wasserman reaction, or by the existence of unmistakable physical signs outside of the mouth. 106711 ——5 492 CHAMBERLAIN. - Fusiform bacilli and spirochete were not detected in any of the 4 cases where the Klebs-Loeffler bacilli were found by cultural methods. From 44 others of the 106 cases studied, cultures on blood serum were made with negative results as far as the diphtheria bacillus was con- cerned. Many of these lesions showed in smears the presence of large numbers of spirocheetee and fusiform bacilli. In some of them the local appearances were strongly suggestive of diphtheritic infection. Nearly all of our positive cases were young adult males, for the most part American soldiers. A few throat lesions among Filipinos were examined. Only one of these had any of the organisms and in this lesion they were not present in preponderating numbers. In the patients showing fusiform bacilli and spirochete in prepon- derating numbers the clinical appearances and symptoms were so variable that no diagnosis based on them could have been of value. As shown in the table the localities affected were diverse. The'ulcers were covered with white exudate in 2 and with soft grayish membranes in 8 cases. Fever was present in 6 of the cases of throat involvement, dysphagia in 16 and prostration in 1. Of the lesions on the gums 3 were very painful and 2 were painless. Most of the cases were acute, but 7 were chronic, some having had ulcers for several months. - On the assumption that carious teeth might be the cause of the fre- quent presence of spirochzete and fusiform bacilli in the mouth, an examination was made of the material from the interior of the carious teeth of 10 individuals. In the smears from 3 individuals an occasional — spirocheta was found, but no fusiform bacilli were seen in any instance. We also examined a number of smears from apparently normal tonsils. Most of these were negative, but in some there were a few spirochetz and very rarely a small fusiform bacillus. PRESENCE OF THE ORGANISMS IN LESIONS OF THE SKIN IN THE TROPICS. In speaking of tropical ulcer Castellani and Chalmers say:(10) “Vincent believes the affection (Ulcus tropicum) to be due to the association of spirochaetes and fusiform bacilli so frequently found in such ulcers. Vincent’s observations have been confirmed by Smith and Peil in Sierra Leone, Patton in Aden, and many other observers in various parts of the tropics.” In 1907 Shattuck(6) working in the Philippines reported that of 34 ulcers of the skin examined by him 5 contained spirochete in the exudate. He states that some resembled Spirocheta refringens and that others appeared intermediate between that organism and Treponema pallidum. We concluded that the spirochete were not of etiologic significance because of their absence in sections. He makes no mention of having found fusiform bacilli in the smears from the ulcers, but in his photomicrographs there are some large not very clearly defined, bacilli which somewhat resemble Bacillus fusiformis. Howard(13) reports spirochete, generally in company with Bacillus fusiformis, to be common in various types of ulceration in Nyasaland, and states that in sections the spirochetze can be seen spreading into the healthy tissue in advance of other micro-organisms. He also says they may be found in nearly all foul- smelling neglected ulcers. ASSOCIATED SPIROCHAT4 AND FUSIFORM BACILLI. 493 In January, 1911, W. J. Bruce(7) reported under the title of “Zambesi Ulcer” a condition which he had not previously seen described. The lesions, as seen by Bruce, were generally situated below the knee and consisted of punched-out ulcers which healed after one or two weeks without the production of any constitutional symptoms. In the smears from the ulcers he invariably found in great numbers a spirillum and a large fusiform bacillus. A little time before the receipt of this report of Bruce one of us found spirochetz and fusiform bacilli in large numbers in an ulcerated area ' on the foot of a Filipino. This ulcer was thought to be due to yaws, and smears from it were stained for Treponema pertenue. No trepone- mata were detected, and no other organisms except delicate spirochete, ranging in length from 15 to 50 m, and heavy fusiform bacilli the length of which varied from 5 to 10 wp. Photomicrographs of the organisms are appended. We were at once impressed by the resemblance of these parasites to those described as the cause of the so-called Vincent’s angina. The fusiform bacilli were of the same size and presented the same barred appearance on staining. Many were identical with Bacillus fusiformis of Plaut and Vincent, but on the average the ends did not seem quite as sharp as those of the organisms found in throat lesions. The spiro- cheetee were rather longer than those observed in the mouth and fauces and did not seem to stain as intensely with cold carbol-fuchsin. They were very slender and had from 6 to 12 shallow undulations, but differed considerably among themselves in size and shape. Unfortunately this patient passed from observation before these or- ganisms were demonstrated. Consequently no cultures were made and no history was obtainable. During the last two years we have examined smears from a large number of ulcers of the skin, but have not encountered these organisms on any other occasion. Doctor R. P. Strong and others in Manila in- form us that they have not met with them in lesions of the integument. Recently Lieutenant Armin Mueller, Medical Corps, United States Army, stated that he has found several such cases at Camp Jossman near Tloilo, P. I. BRONCHIAL SPIROCH HTOSIS WITH AN OCCASIONAL FUSIFORM BACILLUS. Bronchial spirochetosis was first described by Castellani in 1906 since which date numerous cases, both acute and chronic, have been reported by observers in various tropical countries. From the description given by Castellani and Chalmers in their Manual of Tropical Medicine it appears that most, it not all, of these diagnoses, have been made ‘from the sputum examinations alone. In 1909 Phalen and_ Kil- bourne(11) of this Board reported a‘case of pulmonary spirochetosis in a Filipino, but called attention to the fact that the causative rela- tion of the spirochzte to the disease was not proven. The report mentions — that a few large bacilli were present, but does not state whether they- 494 ! CHAMBERLAIN. resembled Bacillus fusiformis. Recently, on re-examining sinears from this case, we found a few perfectly typical fusiform bacilli; they had the’ characteristic barred appearance when stained. In searching fresh sputa for yeast the Board recently found specimens from 2 patients which showed large numbers of actively motile spiro- chete. Both of these patients were Filipinos suffering from typhoid fever. Specimens of sputum from 32 other patients having cough with expectoration were examined and none contained spirochete except one which had an extremely few, thick, spiral organisms such as might easily have entered the sputum from around the necks of the teeth where such organisms are common. Of the 32 patients, 27 were Americans and 5 natives. j The histories of the 2 cases, the sputa of which contained spiro- cheetee, are given through the courtesy of Captaims H. 8. Hansell and C. L. Foster, Medical Corps, who had charge of the patients. Case I.—Udasco, Private, 23rd Company Philippine Scouts, age 23. Service two years and eight months. Tribe, Ilocano. Admitted to hospital November 3, 1910. Family and previous history unknown. Bad cough for three weeks previous to admission, and slight expectoration. Noted no blood. Headache and fever but no chills. On admission to hospital patient appeared very ill. Pulse regular and normal. A few vesicles on back and chest. Rales heard over both lungs. Abdomen distended and typanitic. Liver and spleen not palpable. Sub- sequently spleen was found palpable. Patient ran an irregular febrile course for twenty days, followed by a period of ten days of continued high fever associated with abdominal distention and constipation (relapse?), since which time (twenty-six days) there have been several unaccountable elevations of temperature. The Widal reaction was negative November 4, 5, and 6, partial on November 7, and positive on November 8. Blood was negative for Bacillus typhosus on November 7. Stools and urine were only examined during con- valescence when they were negative for typhoid bacilli. The condition of the patient gradually improved after the relapse, and the cough disappeared. Eleven specimens of sputum obtained at intervals were negative for tubercle bacilli. Stools negative for amcebe and for ova except Tricocephalus dispar. No malarial parasites were found. There was a slight leucocytosis ranging from 8,000 to 15,000. Differential counts showed nothing of importance, averaging; polymorphonuclears 61 per cent, small lymphocytes 36 per cent, large mononuclears 2 per cent, and eosinophiles 1 per cent. Urine during febrile period showed a trace of albumin and a few granular casts. Diazo reaction negative. Subsequently urine became normal. On November 30 and on several succeeding days the sputum contained great numbers of spirochete. Prior to that no effort had been made to find them as will be explained below when referring to staining methods. The sputum was thin and watery containing a large number of small grayish flakes which consisted of masses of cocci, many kinds of bacilli, and a few epithelial cells and leucocytes. There was no blood and no bad odor. After a lapse of over four weeks (December 31, 1910) the sputum, obtained on forced cough, was of the same flakey character as described above and contained numerous spirochete. i ASSOCIATED SPIROCHATA AND FUSIFORM BACILLI. 495 Oase IJ.—Cassas, civilian employee, age 25. Tribe, Tagalog. Admitted to hospital October 31, 1910. Family history unknown. No previous illness. During last two months has had slight chills and fever at irregular intervals. Since shortly before entry had a cough with muco-purulent expectoration. Some headache, no diarrhea. Fairly well nourished, nothing abnormal found on physical examination except fever which pursued a typical typhoid course for a period of twenty-seven days when the temperature became normal for one week since which time (three weeks) it has been subject to irregular and unaccountable elevations. ‘The Widal reaction was partial November 1, and positive November 3. On November 1, Bacillus typhosus was obtained from a blood culture. On November 22 a stool culture for the same organism was positive. This patient became very ill as his disease progressed. On November 4 he vomited a great deal. The spleen became palpable. Subsequently pulse became dicrotic and weak and tympanites developed. On November 14 complained of sore throat and a patch of exudate appeared on the left tonsil. This was negative for diphtheria and did not show the spirochete and fusiform bacilh associated with Vincent's angina. On November 17 the throat symptoms had disappeared. On November 20 patient was very weak and began to cough up bloody sputum. This bloody expectoration lasted for several days and was quite profuse. After the temperature reached normal the patient gradually improved and the cough disappeared. In this case the blood was negative for malaria. The leucocytes ranged from 8,500 to 12,800. ‘The differential count showed nothing of interest; polymorpho- nuclears 68 per cent, small lymphocytes 30 per cent, and large mononuclears 2 per cent. The urine during the height of the fever showed a trace of albumin and a few hyaline casts. The stools showed ova of Tricocephalus dispar, and Cercomonas intestinalis, but no amecebe. After the appearance of bloody sputum an examination on nine occasions was negative for tubercle bacilli and on one occasion an acid-fast bacillus shorter and thicker than the tubercle bacillus was found. This specimen was inoculated into a guinea pig and at the end of eight weeks the animal was alive and well. At autopsy it showed no indications of tuberculosis. On one occasion motile amcebx and a flagellate resembling a cercomonas were found in the sputum. The character of the sputum was the same as in the preceding case except that it was blood-stained at times. It was found to contain large numbers of spirochete associated with many masses of bacilli and cocci. An occasional large fustform bacillus was seen. ‘The spirochete were found constantly present for a period of two weeks. After a lapse of nearly two weeks more (December 31, 1910), the patient meanwhile haying greatly improved in condition and the blood having disappeared from the sputum, spirochete were still present in considerable numbers though not as numerous as at the time of the hemorrhage. The sputum at this time, obtained only after forced coughing, was thin and watery with great numbers of the small, gray flakes described in Case I. There were no blood corpuscles. The spirocheetz in both cases were similar in motility, shape and size, averaging about 15 mw in length. They were thin and delicate and resembled the third class described by Castellani except that none having one blunt point were noticed.(10) In one of the patients (Number IT) there were found a few fusiform bacilli similar to those which are seen 496 CHAMBERLAIN. | in symbiosis with spirochetz in the so-called Vincent’s angina. It is interesting to note that in history, symptoms, and character of the sputum these two cases were almost identical except that one contained fusiform bacilli and the other did not. Whether the presence of a few fusiform bacilli in one of these sputa, and in the sputum formerly described by Phalen and Kilbourne, was due to a contamination of the phlegm while it was passing through the mouth can not be determined. It is certain that the bacilli were present in both sputa in much smaller relative numbers than is usually the case in ulcers of the mouth and fauces when the symbiotic bacilli and spirochetes are encountered. In many of the cases described in the literature spirochetosis appears to be an independent disease. In considering the two histories recorded above it must be remembered that both patients were very ill with typhoid fever and, therefore, the presence of the organisms in the bronchial secretion may have been due simply to a migration downward, in a debilitated individual, of the spirochzetee which normally have a limited habitat in the mouth. However, the persistence of the spirochete in the sputum far into convalescence seems to be opposed to this view of the matter. PREVALENCE OF SPIROCH TA AND FUSIFORM BACILLI IN LESIONS OCCURRING IN NON-TROPICAL COUNTRIES. These associated organisms are probably much more common in oral and faucial lesions than is generally thought to be the case and would doubtless be very frequently met with if the practice of examining smears from ulcers in those regions was more general. Rodella found the two organisms present in about one third of the 2,000 cases of pseudo-membraneous anginas which he examined.(5) Beitzke demonstrated the organisms in 5 out of 58 patients suspected of having diphtheria. Lublowitz reports the presence of fusiform bacilli in 6 out of 38 ulcers of the mouth. Arnold found the two organisms in 3 out of 5 cases of follicular tonsilitis. Rothwell(14) under the title of “Bronchial Vincent’s Angina” reports 4 cases, which have come to his notice in Missouri, where the sputum was swarming with fusiform bacilli and spirochetse, There was bloody expectoration and the symptoms somewhat resembled asthma. Cases of fetid bronchitis and pneumonia have been reported in which the sputum contained these 2 organisms, but as yet the reports of pulmonary cases in temperate regions are so few that no reliable estimate can be made as to the real frequency of the condition. It is not improbable that the organisms may go undetected more commonly than is generally supposed to be the case because of the fact that a majority of the sputa examined microscopically are stained by Gabbett’s method or some similar procedure. While the spiral or- ganisms in pulmonary spirochetosis stain well with ordinary aniline dyes, such as carbol-fuchsin or Loeffler’s methylene-blue, we found that ASSOCIATED SPIROCHATA: AND FUSIFORM BACILLI. 497 they were not acid fast and that they did not stain with the sulphuric- acid-methylene-blue as ordinarily used in Gabbett’s method for demon- strating tubercle bacilli. The same was found to be true for the spirochete in Vincent’s angina. ‘Therefore,.it is evident that spiro- cheetee in the sputum would be likely to be overlooked in making a routine examination of the sputum for tubercle bacilli. The occurrence of the organisms in infections of the skin in temperate regions up to the present time has been reported but rarely and no estimate can be formed as to the frequency of such lesions. The cases reported by Peters and Hultgen are referred to in the second paragraph of this article. CONCLUSIONS. From our limited series of observations it appears probable that more than one-half of the throat and mouth ulcers one is likely to encounter in the Philippines will show fusiform bacilli and spirochete in greater or less numbers, and that one-third of the cases will have them in prepon- derating numbers. This is a somewhat higher rate than we have ever seen reported in temperate climates. However, it must be remembered that in all of the cases examined we were on the lookout for these par- ticular parasites. The associated spirochete and fusiform bacilli have been found in an ulcer of the skin and in 2 cases of pulmonary disease. but as yet there is no evidence to show that in the Philippines they are common in these situations. a One caution needs to be given. In our opinion the finding of fusiform bacilli and spirocheete in a throat lesion does not justify one in resting content with a diagnosis of “Vincent’s Angina.” Experience shows that syphilis, diphtheria, carcinoma, (and very probably other etiologic factors) must be carefully ruled out. It is still an open question whether the associated fusiform bacilli and spirochete are ever causative of the mul- tiform lesions in which they are so often found to be present. REFERENCES. (1) CHAMBERLAIN, W. P., BLoompercH, H. D., and Kitpourne, BE. D. Report of the Board for the Study of Tropical Diseases. Mil. Surgeon (1911), 27, Ii. (2) BroompercH, H. D. Vincent’s Angina. Bull. Manila Med. Soc. (1910), 2, 180. (3) Prautr. Deut. Med. Woch. (1894), 49. (4) Vincent. Ann de l’Inst. Pasteur (1896). (5) Weaver, G. H., and Tunnictirr, R. Ulcero-membraneous Angina and Stomatitis. Journ. Am. Med. Assoc. (1906), 46, 481. (6) SHatruck, C. S. Notes on Chronic Ulcers Occurring in the Philippines. Phil. Journ. Sci., Sec. B (1907), 2, 551. ; 498 CHAMBERLAIN. (7) Bruce, W. J. Zambesi Ulcer. Jowrn. Trop. Med. & Hyg. (1911), 14, 1. (8) CHAMBERLAIN, W. P., VEppER, E. B., and Barser, J. R. Report of the United States Army Board for the Study of Tropical Diseases; made to the Surgeon-General, U. 8S. Army, Washington, D. C. March 31, 1911. (9) Tunniciirr, R. Further Studies on Fusiform Bacilli and Spirilla. Journ. Infect. Dis. (1911), 8, 316. (10) CasteLLtant, A., and Cnatmers, A. J. Tropical Medicine. New York (1910), 921 and 1118. (11) Puaten, J. M., and Kizsourne, EH. D. Report of the United States Army Board for the Study of Tropical Diseases; made to the Surgeon-General, U. 8. Army, Washington, D. C. June 30, 1909. (12) Huntern, J. F. Partial Gangrene of Left Index Finger. Journ. Am. Med. Assoc. (1910), 55, 857. (13) Howarp, R. Diseases Encountered on the Shores of Lake Nyasa. Journ. Trop. Med. & Hyg. (1910), 13, 70. (14) RortuweLr, J. H. Bronchial Vincent’s Angina. Journ. Am. Med. Assoc. (1910), 54, 1867. ILLUSTRATIONS. PuateE I. Fries. 1 and 2. Spirochete and fusiform bacilli in smears from an ulcer of the tonsil. Fic. 3. Spirochetz and fusiform bacilli in a smear from an ulcer of the tonsil, showing beaded staining. PuatE II. Fie. 4, Spirochete and fusiform bacilli In a smear from an ulcer of the gums. Fies. 5 and 6. Spirochetz and fusiform bacilli in smears from an ulcer of the foot. 3 Magnification in all figures 1,000 diameters. Photomicrographs by Mr. Charles Martin of the Bureau of Science, Manila. 499 CHAMBERLAIN: SPIROCHATA AND FUSIFORM BACILLI. ] [Putu. Journ. Sci., Vou. VI, No. 6. CHAMBERLAIN: SPIROCHHTA AND FUSIFORM BACILLI. ] PLATE I1- [PHIL. Journ. Scr., Vou. VI, No. 6. INDEX. A Acid intoxication in Asiatic cholera, in- dications of, 53. Action of tropical sun on men and animals, 101. Addison’s disease, 345. Adrenal tuberculosis, 345. Age, influence of, on blood-pressure, 475. influence of, on pulse rate, 475. Aleoholism, chronic, 452. Alkalies, increased tolerance for, in cholera, ba. Ammonia, increased excretion of, in Asiatic cholera, 56. ‘Ameba coli, 91. dysenteriz, 443. hominis, 263. protens Leidy, 265. Amebe, 212. effect of ultra-violet rays on, 383, 389. immunity reactions with, 281. in the Manila water supply, 259. in water, 384. review of literature pertaining to, 260. Ameebie dysentery, a comparative study of the amcebe in, 259. Anemia, 452. ANDREWS, V. L., review of Stitt’s Practical Bacteriology, Blood Work, and Animal Parasitology, 343. Anthrax in the Philippine Islands, 93. Anuria, 72. Aphthous stomatitis, 491. Appendicitis, 446. Arneth counts, 441. Arneth’s classification, a study of, 405. ARON, HANS, Nutrition and Growth: I, 1; Investigation on the Action of the Trop- ical Sun on Men and Animals, 101. ARON, HANS, and HOCSON, FELIX, Rice as Food: Investigation of the Nitrogen and Phosphorus Metabolism on a Diet Consisting Principally of Rice and Other Vegetable Foodstuffs, 361. Ascaris, 77, 212, 241, 443. Asiatic cholera, indications of acid intoxica- tion in, 53. B Bacilli, fusiform, and spirochete, 489. Bacillus dysenteriz, effects of ultra-violet rays on, 385. dysentery, 215. _ Bacillus fusiformis Plant and Vincent, 489, 492, 493, 494. lepre, 340. paratyphosus, 314. prodigiosus, 283. typhosus, 263, 494, 495. typhosus, effects of ultra-violet rays on, 385. 3 Bacteria in water, 384. Balantidium, 212, 443. ° coli in water, 384, 392. coli with coincident filarial in- farction of the spleen, 147. Batanes Islands, lack of beriberi in, 231. Beriberi, and unpolished rice in the Philip- Pines, 229, 395. eradication of, by change in diet, 133. etiology of, 177, 251, 395. Blond type, influence of Philippine climate on, 427. Blood diseases, 452. Blood pressure apparatus and method of use, 469. Blood pressure, influence of age on, 475. complexion on, 475. length of tropical residence on, 472. orange-red hat linings and underwear on, 477. race on, 479. season on, 474. size of men on, 478. tropical climate on, 471. BLOOMBERGH, HORACE D., The Wasser- mann Reaction in Syphilis, Leprosy, and Yaws, 335. See also CHAMBERLAIN, WES- TON P. Book reviews. See REVIEWS. BOWMAN, FRED B., A Case of Dysentery Caused by Balantidium coli with Coin- cident Filarial Infarction of the Spleen, 147, BOYNTON, W. H., A Note upon Anthrax in the Philippine Islands, 93. Brunette type, influence of Philippine cli- mate on, 427. Cc Cagayan Valley tobacco haciendas, intesti- nal parasites in, 77. Camotes, influence of, on beriberi, 142. Carbon dioxide in the blood, 65. Carcinoma of soft palate, 491. Cats, effect of tropical sunlight on, 110. 501 502 Cercomonas, 443. intestinalis, 495. CHAMBERLAIN, .WESTON P., The Erad- ication of Beriberi from Philippine (Native) Scouts by Means of a Simple Change in Their Dietary, 133; Typhoid Fever in the Philippine Islands, 299: Ob- servations on the Influence of the Phil- ippine Climate on White Men of the Blond and of the Brunette Type, 427; A Study of the Systolic Blood-pressure and the Pulse Rate of Healthy Adult Males in the Philippines, 467; The Red Blood Corpuscles and Hemoglobin of Healthy Adult American Males Residing in the Philippines, 483; The Occurrence in the Philippines of Associated Spirochete and Fusiform Bacilli in Ulcers of the Throat (Vincent’s Angina), of the Mouth, and of the Skin, and in Lesions of the Lungs (Bronchial Spirochetosis), 489. CHAMBERLAIN, WESTON P., BLOOM- BERGH, HORACE D., and KILBOURNE, EDWIN D., A Study of the Influence of Rice Diet and of Inanition on the Production of Multiple Neuritis of Fowls and the Bearing thereof on the Etiology of Beriberi, 177. CHAMBERLAIN, WESTON P., and VED- DER, EDWARD B., A Contribution to the Etiology of Beriberi, 251; The Effect of Ultra-violet Rays on Amebez, and the Use of these Radiations in the Steriliza- tion of Water, 383; A Second Contribu- tion to the Etiology of Beriberi, 395; A Study of Arneth’s Nuclear Classifica- tion of the Neutrophiles in Healthy Adult Males and the Influence thereon of Race, Complexion, and Tropical Residence, 405 ; The So-called X-bodies as Artefacts in Glass Slides, 421. Chancre, 491. Cheek, ulcers of, 491. Children, increase in weight as an index to growth with special reference to, 40. observations on, stations, 41. Cholera, 446; indication of acid intoxication in Asiatic, 53. Ciliates encountered in water and in human stools, 155. Circulatory diseases, 452. Climate and geography of the Philippines, 468. of the Philippines, 431. tropical, possible influence of, 413. Climatie influences on white men, 458. Complexion, influence of, on Arneth count, 410. influence of, on blood-pressure, 475. influence of, on pulse rate, 475. Corpuscles, red blood, of Americans in the Philippines, 483, at milk-feeding INDEX. CROWELL, B. C., Addison’s Disease and Adrenal Tuberculosis, 345. Culion Leper Colony, death rate in, 23. objection from inmates of, to undermilled red rice, 138. rice used in, 230. D Davainea madagascariensis (Davaine), 65. proglottina (Davaine), 167. Deafness, 452. Defective mentality, 452. Dementia precox, 452. Dengue, 446. Diarrhea, 446. caused by flagellates and ciliates, ily). chronic, 452. Diet, effect of restricted, 24. Dietary habits, 450. Differential count, 441 ; influence of race and tropical residence on, 408. Diphtheria, tonsillar, 491. Direct sunlight, influence of, 450. Dogs, experiments on, 6. temperature of, 109. tracheotomized, experiments on, 107. Dynamometer observations in the Philip- pines, 438. Dysentery, 446. amcebic, a comparative study of the amcebe in, 259. bacillus in the Philippines, 215. caused by Balantidium coli, 147. chronic, 452. E Entameba africana Hartmann, 262. coli (Loesch) Schaudinn, 212, 260. histolytica in water, 384. histolytica Schaudinn, 212, 261. minuta, 262. muris (Grassi), 268. nipponica Koidzumi, 262. nutalli Castellani, 268. phagocytoides, 263. ranarum (Grassi) Dobell, 268, 270. testudinis Hartmann, 268. tetragina Vierack, 262. tropicalis Lesage, 263. undulans, 261. Enteritis, chronic, 452. Epidemic of bacillary dysentery in the Phil- ippines, 215. Epilepsy, 452. Erythrocyte counts on American soldiers in the Philippines, 484. Etiology of beriberi, 251. Exercise, special observation after, 443. Eye diseases, 446. . INDEX. 503 FE Fascioletta ilocana, 82. Faucial pillars, ulcers of, 491. Fever, typhoid, 299, 301, 446. - undetermined type, in the Philippines, 446. Filipinos, leucocytometry in, 412. possible signification of low poly- morphonuclear counts and high Arneth indexes in, 411. Flagellates, 212. ciliates, and other protozoa en- | countered in water and in human stools, 155. Fowls, experiments on, 257; 396. feeding experiments with, 178. multiple neuritis of, 177. FOX, CARROLL, Review of Ritchie and Purcell’s Primer of Sanitation for the Tropics, 99. Furunculosis, +446. G GARRISON, PHILIP E., Davainea madagas- eariensis (Davaine) in the Philippine Is- lands, 165. Geography of the Philippines, 431. ' Ginger root, influence of, on beriberi, 142. Glass slides, x-bodies in, 421. GOMEZ, LIBORIO, A Clinical Study of Hookworm [Infection in the Philippines, 239. Gout, 452. GREGG, DONALD, Review of Wilcox’s The Treatment of Disease, 163. Growth, 1. Gums, ulcers of, 491. H Haciendas, tobacco, intestinal parasites in, TUG Hemoglobin estimations, 440. of American soldiers in the Philippines, 483. Heat effect of tropical sun, quantitative es- | timate of, 105. exhaustion, 448. hyperpnea, 106. stroke, 129. HEISER, VICTOR G., Practical Experiences with Beriberi and Unpolished Rice in the Philippines, 229. HOCSON, FELIX. See Aron, HANS. Hookworm, 80, 83-89, 212. in Cagayan Valley, 81, 89. infection in the Philippines, a clinical study of, 239. HOOTON, A., Perineal Litholapaxy (Keith’s Operation), 235. Hymenolepis, 77, 443. I Immunity reactions with amcebe, 281. Indigestion, 446. Influence of Philippine climate on white men, 427. Insanity and nervous diseases in the army, 461. depressional, 452. type undetermined, 452. Insolation in temperature climates, results of, 104. Intestinal diseases, 452. parasites, 443, parasites in Cavite Province, 211. parasites in tobacco haciendas, 77. K Katjang idjo, 253, 401. | Keith’s operation, 235. Kidney diseases, 452. KILBOURNE, EDWIN D. See CHAMBER- LAIN, WESTON P. L Lamblia intestinalis in water, 384. Leper Colony, Culion, objections from in- mates of, to undermilled red rice, 138. Leprosy, Wassermann reaction in, 335. Leucocyte estimations, 441. Leucocytometry in Filipinos, 412. Lime juice fed to fowls, 400. Litholapaxy, perineal, 235. Lungs, lesions of, associated spirochetz and bacilli in, 489. MM. Magnesium salts and neuritis, 253. Malaria, 446. and sequele, 452. Man, skin of, effect of tropical sunlight on, alain Melancolia, 452. Mental diseases, 452. Metabolism experiments, 374. Mongos, influence of, on beriberi, 142, 401. Monkeys, effect of tropical sunlight on, 110— alate unsuccessful attempts to infect, with balantidia, 151. Mouth, ulcers of, associated spirochete and bacilli in, 489. Multiple neuritis of fowls and its bearing on the etiology of beriberi, 177. N Nervous diseases, 452. Neurasthenia, 446, 452. | Neuritis, multiple, of fowls, 177, 395. Neuritis-preventing principle in rice, 253. Neutrophiles, Arneth’s classification of, 405. | Nitrogen excretion in urine, 373. metabolism on a diet of rice, 461. Normal blood-pressure in temperate climates, standard of, 470. Nourishment, effect of diminished, 3. Nuclear classification, Arneth’s, 405. Nutrition, 1. 504 O Observations on the influence of the Philip- pine climate on white men of the blond and of the brunette type, 427. Operation, Keith’s, 235. Orange-red underwear, influence of, on blood- pressure, 477. influence of, on num- ber of erythrocytes and percentage of hemoglobin, 487. influence of, on pulse rate, 477. Otitis media and externa, 452. Oxyuris, 77. P Padi, 178. Palay, 178. Paramceba hominis, 261. Parasites, intestinal, 443. intestinal, found in Cavite Proy- ince, 211. intestinal, in tobacco haciendas, alte Paratyphoid fever, 315. Periplaneta orientalis, 172. Phagocytosis, influence on, of a high Arneth index, 412. Phaseolus radiatus, 253, 401. Philippine climate, influence of, on white men, 427. Phlebitis, 452. Phosphoric anhydride excretion in urine, 373. Phosphorus metabolism on a diet of rice, 461. pentoxide in rice, 232. Pigmentation in relation to diseases in the | Tropics, 458. Pneumonia, 446. Polycythemia, 452. Polyneuritis gallinarum, 178, 257, 395. in fowls and beriberi in man, 229. Potassium salts and beriberi, 252. Protozoa encountered in water and in human stools, 155. Ptomaine poisoning, 446. Pulmonary diseases, 452. Pulse of men in the Philippines, 436. Pulse rate, increase of, in Man in sun, 128, influence of age on, 475. complexion on, 475. orange-red hat lining on, 477. race on, 479. i season on, 474. size of men on, 478. tropical climate on, 471. tropical residence on, 472. Pyrheliometer, 105. | | | | | | INDEX. 5 itt Rabbits, experiments on, 106. exposure of, to sun, 105. temperature of, 107, 108, 110. tracheotomized, 109. Race, influence of, on blood-pressure, 479. influence of, on differential and Arneth counts, 408. influence of, on pulse rate, 479. Red blood cell counts, 440. corpuscles and the hemoglobin of healthy adult American males residing in the Philippines, 483. Respiration of men in the Philippines, 436. Retinitis, 452. REVIEWS (BOOK) : Ritchie, John Woodside, and Purcell, Margaret Anna: Primer of Sanitation for the Tropics, 99. Stitt, E. R.: Practical Bacteriology, Blood Work and Animal Parasitology including Bacteriological Keys, Zodlog- ical Tables and Mxplanatory Clinical Notes, 343. Wilcox, Reymond Webb: The Treat- ment of Disease. A Manual of Prac- tical Medicine, 163. Rheumatism, 446. chronic, 452. Rice as food, 461. chemical composition of Philippine, 179. diet and inanition, influence of, on the production of multiple neuritis of fowls, 177. highly milled, 134. medium milled, 134. nitrogen and phosphorus metabolism on a diet of, 461. phosphorus and nitrogen content of, 362. polished, effects of, 134, 178, 395, 402. polishings, effect of, on beriberi, 23. polishings, effects of, 251, 398. polishings, extract of, 397. red, 134. scoured, 134. undermilled, 134. unpolished, 134. unpolished, and beriberi in the Philip- pines, 229. varieties of, 180. white, 134. Ritchie, John Woodside, and Purcell, Mar- garet Anna, Primer of Sanitation for the Tropics, reviewed, 99. RUEDIGER, E. H., Some Observations on So-called Flagellates, Ciliates, and Other Protozoa Encountered in Water and in Human Stools (Preliminary Report), 155. S Season, influence of, on blood-pressure, 474. influence of, on pulse rate, 474. SELLARDS, ANDREW WATSON, Immunity Reactions with Amcebe, 281. INDEX. SELLARDS, ANDREW WATSON, and SHAKLEE, A. O., Indications of Acid Intoxication in Asiatic Cholera, 53. Serum, anticholera, use of, 70. SHAKLEE, A. O. See SELLARDS, ANDREW WATSON. Siesta habit, 450. Size of men, influence of, on blood-pressure, 478, influence of, on pulse rate, 478. Skin diseases, 446. A temperature, 121, 122, 125. ulcers of, associated spirochete and bacilli in, 489. Sodium bicarbonate, eftect of, cholera, 54, chloride, injections of, cholera, 59. chloride in neuritis experiments, 189. Soft palate, carcinoma of, 491. ulcers of, 491. Special senses, diseases of, 452. Spirocheta refringens, 492. Spirochetze and fusiform bacilli, associated, 489. Sprue, 452, 491. Statistical study of intestinal parasites in tobacco haciendas, 77. Sterilization of water by ultra-violet rays, 383. STITT, E. R., A Study of the Intestinal Parasites Found in Cavite Province, 211; Practical Bacteriology, Blood Work, and Animal Parasitology, etc., reviewed, 343. Stool examinations, 442. Strongyloides, 77, 212, 443. Strongylus subtilis, 443. Sucrose fed to fowls, 399. Sun’s rays, injurious effects of, 127. Sunlight, influence of, on white men, 433. Sunstroke, 129, 448, 452. among blonds and brunettes in the United States, 456. Sweat, cooling effect of, 126. Syphilis, Wassermann reaction in, 335. Systolic blood-pressure and the pulse rate of | healthy adult males in the Philippines, | a study of, 467. of men in the Philip- pines, 437, T in Asiatic in Asiatic | Tenia, 77, 241, 443. demarariensis Daniels, 167. madagascariensis Davaine, 166. saginata, 212. Temperature, experiments on, 108. in the hair, 125. of body, effects of heat and humidity on, 104 of men in the Philippines, 435. of the skin, 121, 122, 125. rise in, of dead bodies exposed | to sun, 106. 505 Thermoelectric method of taking skin tem- perature, 117. Throat, ulcers of, associated spirochete and bacilli in, 489. Tiqui-tiqui, 180. Tobacco haciendas of the Cagayan Valley, intestinal parasites in, 77. Tongue, chancre of, 491. ulcers of, 491. Tonsil, chancre of, 491. ulcers of, 491. Tonsillitis, acute, follicular, 491. Trematodes, 77, 82. Treponema pallidum, 491, 492. pertenue, 340, 493. Trichocephalus, 212, 443. dispar, 494, 495. | Trichomonas intestinalis, 213. Trichuris, 77, 241. Tropical anemia, 483. climate, influence of, on blood-pres- sure, 471. influence of, on pulse rate, 471. possible influence of, 413. residence, influence of, on blood- pressure and pulse rate, 472. residence, influence of, on differen- tial and Arneth count, 408. sun, action of, on men and animals, 101. Tuberculosis, 452. adrenal, 345. Typhoid fever, 446. fever in the Philippine Islands, 299. statistics for the Philippines, 301. UU: Ulcer of rectum, 452. Ulcers of the throat, spirochete and fusi- form bacilli, associated in, 489. tonsils, faucial pillars, gums, cheek, soft palate, and tongue, 491. Uleus tropicum, 492. of | Ultra-violet rays, effect of, on amcebe, 383. Uneinaria, 443. | Underwear, relation of color of, to health, 103. Uremia, 73. Urea, suppression and excretion of, in | Asiatic cholera, 56. Urinary examinations, 442. | Urine, alkalinity or acidity of, in Asiatic cholera, 55. nitrogen and phosphoric anhydride excretion in, during rest and work, 373. Vv Valvular lesions, 452. VEDDER, EDWARD B. WESTON P. See CHAMBERLAIN, | Venereal diseases, 452. 506 INDEX. Vibrio cholere, 283. Vincent’s angina, associated spirochete and © bacilli in, 489. Violet and ultra-violet rays of tropical sun- light, effects of, 102. WwW WALKER, ERNEST LINWOOD, A Com- parative Study of the Amcebe in the | Manila Water Supply, in the Intestinal Tract of Healthy Persons, and in Amebic Dysentery, 259. Wassermann reaction in syphilis, leprosy, and yaws, 333. Water, sterilization of, by ultra-violet rays, 383. Weight, maintenance of, 450. of men in the Philippines, 435. Whipworm in Cagayan Valley, 81. | WHITMORE, HUGENE R., The Dysentery Bacillus with a Bacteriologic Study of an Epidemic of Bacillary Dysentery in the Philippines, 215. Widal examinations in typhoid fever, 313. Wilcox, Reymond Webb, The Treatment of Disease, reviewed, 163. WILLETS, DAVID G., A Statistical Study of Intestinal Parasites in Tobacco Haciendas of the Cagayan Valley, Philippine Islands, mitre Xx X-bodies as artefacts in glass slides, 421. Y Yaws, Wassermann reaction in, 335. TT. mi Zambesi ulcer, 493. O Order No. 411. INDO-MALAYAN WOODS. By Frep W. FoxwortHy. (Being Section C, No. 4, Vol. IV, of the Philippine Journal of Science.) 182 pages, 9 photographic plates. Price $0.50 United States currency, postpaid. TABLE OF CONTENTS. I. Introduction. a. Erroneous popular notions with regard to eastern timbers. b. Object of this work. ce. Definition of the Indo-Malayan region. d. Review of previous work and acknowledgments. II. Properties of Wood. a. 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M. & J. Ferguson, 19 Baillie | Street, Colombo, Ceylon. CIRCULARS AND DESCRIPTIVE MATTER SENT ON APPLICATION. CONTENTS. CHAMBERLAIN, WESTON P. Observations on the Influence of the Philippine Climate on White Men of the Blond and of the Brunette Type i RES PLA CHIN RGR Lees BLM ge | Ae 427 CHAMBERLAIN, WESTON P. A Study of the sect Blood-pres- Papal sure and the Pulse Rate of Healthy Adult Males in the Philippines. cae ie Based on 6,847 Blood- -pressure Readings on 1,489 eee and an Equal Number of Pulse Counts on the Same Persons. 467 CHAMBERLAIN, WESTON’P. The Red Blood Corpuscles and thes Uae Hemoglobin of Healthy Adult American Males Residing in the ‘Phil- iN app ES: Based on 1,418 Red Cell Counts and 1,433 Eizmoglobin Es-, ? Tt! timations Performed on 702 Soldiers _ ee a 483 Pea cic CHAMBERLAIN, WESTON P. The Occurrence in the Philippines of Lye Associated Spirocheta and Fusiform Bacilli in Ulcers of the Thr oa “incent’s Angina), of the Mouth and-of the Skin, and ‘in Lesions the Lungs’ ( Bronchial Ree ae MEGS Steal Aygo lt pore ---- 25-5 -- + =-=- \ Index, Title-page, and Contents PhS eC ees ated eens eenaans Pa gaiiet 7 Fa Se. The ‘‘Philippine Journal of Science” is issued as ; follows: SS Aa eee Section A, Chemical and Geological Sciences and the Industries, $2 United States ye : ourrency per year. cone tees ; Section B, Medical Sciences, $3 United States currency per year. . me eee Section C, Botany, $2 United States currency per year. ee Section D, General Biology, Ethnology and page te $2 United States ‘our- ere reney per year. : He The entire “Journal,” $5 United States currency for Volume II, iXI, IV, or. v. 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