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1 


Proceedings  of 

The  Second  Pah  American 

Scientific  Congress 


WASHINGTON,  U.  S.  A. 

Mouiaj,  December  27, 1915 
to  Satunlay,  Janaary  8, 1916 


CMi»a«d   Hid  «dltad    aadw  tlw  dhwtlM  1 
aitm  Lntm  Swiggatt,  AaAttat  Sacnterr  G«Mcal 


SECTION  vin 

(IN  TWO  PARTS) 

PART  2 

PUBUC  EIEALTH  AND  MEDICINE 

WIUJAM  C.  GOBGA8,  SURGBON  GENERAL  U.  8.  A,  CHAIRMAN 


VOL.  X 


WASBONGTON 

GOTBBNMENT  PRINTINO  OffVICB 

ltl7 


DEC  13  1917 


^  ^  CONTENTS. 

10 


SECOND  PABT. 

Letten  ol  traoflinittal *••  vn 

Register  of  writers  of  papen xm 

Foreword xv 

MamJDg  ae— ion  of  Jeaoarj  3, 1016 8 

A  r^sum^  of  some  of  the  recent  studies  of  the  United  States  Public  Health 
Service  relating  to  the  causation  and  to  a  method  of  preventing  pellagra,  by 

Joseph  Goldbeiger 3 

The  known  and  the  unknown  with  regard  to  the  etiology  and  prevention  of 

beriberi,  by  Edward  B.  Vedder 22 

Beriberi,  estudio  epidemiol6gico  y  experimental,  by  Mario  G.  Lebredo 29 

Concerning  the  chemical  nature  of  the  vitamines,  by  Rob^  R.  Williams 30 

Infantile  scurvy,  by  Alfred  P.  Hess 48 

La  nutrlci6n  en  la  altiplanicie  de  Bogotd,  by  Calixto  Torres  Umafia 62 

Influenda  de  la  chicha  sobre  el  metabolismo  azoado,  by  Oalixto  Torres  Umafia.  105 

Afternoon  session  (»f  Jaaoary  8, 1016 112 

Changes  in  the  food  supply  and  their  relation  to  nutrition,  by  Lafayette  B. 

Mendel 112 

A  safe  and  sane  milk  supply,  by  John  Weinzirl 127 

Proyecto  de  ordenanca  reglamentaria  del  comercio  de  leche  de  consume  de 

Buenos  Aires,  Argentina,  by  Ricardo  Sarmiento  Laspiur 130 

Vulgarizaci6n  cientffica — Higiene  bucal,  by  Julio  L.  Catoni 167 

Joint  session  of  Subsection  D  of  Section  VIU  and  Subsection  4  of 

Section  V 173 

Available  methods  for  the  sanitary  disposal  of  refuse,  by  Creorge  A.  Soper 173 

Disposal  of  refuse,  by  William  T.  Sedgwick 187 

Collection  and  disposal  of  municipal  refuse,  by  J.  T.  Fetherston 100 

Afternoon  session  of  January  4,  1016 205 

The  purification  of  water  supplies,  by  Edwin  O.  Jordan 205 

The  applicability  of  microscopic  methods  to  the  study  of  water-supply  prob- 
lems, by  E.  M.  Chamot 213 

The  significance  of  chemistry  in  water  purification,  by  Edward  Bartow 220 

The  control  of  Asiatic  cholera  on  international  trade  routes,  by  Allan  J.  Mc- 
Laughlin    228 

Fresh  air  and  ventilation  in  the  light  of  modem  research,  by  C-E.  A.  Winslow. .  232 

CUmatologia  dos  campos  do  JordAo-S.  Paulo,  by  Victor  Godinho 247 

Nouveau  proc6d^  pour  la  transfusion  du  sang,  by  Louis  Agote 248 

Morning  session  of  Subsection  B  of  Section  Vm,  January  6,  1016. . .  251 
Unifonnaci6n  de  las  estadfsticas  demogr^cas  y  de  la  fecha  de  levantamiento 
de  los  censes  de  poblaci6n  de  los  paises  panamericanos,  by  Alvaro  Covarru- 

bias  Arlegui 2G1 

Informs  sobre  el  deearrollo  de  la  estadfstica  demogrifica  en  la  Repdblica  de 

El  Salvador,  by  Pedro  S.  Fonseca 261 

Morning  session  of  Section  Vm  of  January  6,  1016 263 

AnaphyUxis,  by  Richard  WeU 263 

Teoria  bioldg^  de  la  inmunidad,  by  Julio  M^ndes 267 

m 


IV  CONTBNTB. 

Pag©. 
Specific  parenteral  digestion  and  its  relation  to  the  phenomena  of  immunity 

and  anaphylaxis,  by  J.  Bronfenbrenner 278 

The  mechanism  and  clinical  significance  of  anaphylactic  and  pseudo-anaphylac 

tic  skin  reactions,  by  John  A.  Kolmer 287 

The  relation  of  hay  fever  to  anaphylaxis,  together  with  a  theory  regarding  the 

nature  of  anaphylactic  phenomena,  by  G.  H.  A.  Clowes 904 

Anaphylatoxin  and  the  mechanism  of  anaphylaxis,  by  Richard  Weil 308 

Hay  fever  and  certain  other  local  ani^ylactic  phenomena  referable  to  the  respi- 
ratory mucous  membranes,  by  A.  Parker  Hitchens  and  Claude  P.  Brown 315 

Seroterapia  antipestosa  intensiva  (M^todo  de  Penna),  by  Jos^  Moreno 329 

£1  asma:  sus  causas,  defectos  e  inconvenientes  de  un  sdo  m^todo  exdusivo 
para  curarla,  como  el  m^todo  de  Efraim.    Necesidad  de  varios  tratamientos 

con  relad^n  a  las  varias  causas  asmatdgenas,  by  Jo86  A.  Rampini 836 

Night  session  of  January  6,  1016 839 

Los  alienados  delincuentee  y  los  delincuentes  alienados— Oeaci6n  de  mani- 

comios  cziminales,  by  Genaro  Giacobini 839 

Greacidn  de  tribunales  para  nifios,  by  Genaro  Giacobini 841 

Bducaci6n  fisica,  moral  e  intelectual  del  nifio,  seg^  la  ciencia  psiccddgica 

contempor^ea,  by  Grenaro  Giacobini 842 

La  heredo  am<n^dad  infttntil  y  su  influencia  social  pedagogics.    Higiene  all- 

menticia  del  nifio,  by  Genaro  Giacobini , 848 

La  delincuencia  y  d  crimen,  su  represidn  cientlfica,  by  Genaro  Giacobini 844 

Defensa  profilictica  del  nifio  contra  las  enfermedades  infecdosas.  Cread6n  de 
un  Institute  Inter-americano  de  profilaxia  infantil  de  las  enfermedades  infec- 
dosas, by  Grenaro  Giacobini 846 

General  i^oblems  and  tendendes  in  cancer  research,  by  Leo  Loeb 847 

Experimental  studies  in  heredity,  by  Maud  Slye 364 

Factors  in  immunity  to  cancer,  by  James  B.  Murphy  and  John  J.  Morton 3d0 

Immunity  to  transplantable  neoplasms,  by  William  H .  Woglom 382 

Tumor  immunity,  by  E.  E.  Tyzzer 365 

Ghemotherapeutic  experiments  on  rat  tumors,  by  Richard  Weil 382 

The  application  of  chemical  methods  to  the  study  of  cancer,  by  CWmir  Funk.  388 
Linf ocitosis  sangufnea  en  loe  sifiliticos  (signo  diagn68tico  y  pr(m<Setico)  by 

C&ndido  Patifio  Mayer  and  Augusto  Celestino  Gourdy 394 

Granuloma  ven^eo— Contribuci6n  provisoria  a  su  estudio  hi8tol<3gico,  by 

Federico  Susviela  Guarch 400 

Morning  session  of  January  6, 1916 407 

Morning  session  of  Subsection  C  of  Seotion  Vm,  Jsnoary  6,  1016 407 

Contribuci6n  al  estudio  de  la  etiologia  y  profilaxis  de  la  tuberculosis  deede  d 

punto  de  vista  socioldgico,  by  NicoUs  A.  Solano 407 

La  tuberculosis  en  Bolivia;  su  etiologia  y  profilaxia,  by  N^tor  Morales  Villaz6n .  437 

Profilaxia  de  la  tuberculods,  by  Constancio  Castells 447 

La  tuberculosis  en  d  Uruguay,  by  Joaquin  de  Sdterain 461 

A  tooth  is  more  valuable  than  a  diamond,  by  Felipe  Gallegos 466 

Joint  session  of  Subsection  E  of  Section  Vm  and  tlie  Amezioan  Associa- 
tion for  Oanoer  Beseardi 472 

Further  evidence  that  crown  gall  of  plants  is  cancer,  by  Erwin  F.  Smith 472 

Cancer  problems  in  special  biological  groups — ^fish  tumors— further  observations 

on  so-called  carcinoma  of  the  thyroid,  by  Harvey  R.  Gaylwrd 490 

Tissue  cultures  in  cancer,  by  Robert  A.  Lambert 493 

The  tissue  culture  in  cancer,  by  Montrose  T.  Burrows 494 

A  mechanistic  theory  of  cancer,  by  G.  H.  A.  Clowes 496 

Radium  in  experimental  cancer,  by  Francis  Carter  Wood 600 

Radium  in  the  treatment  of  cancer,  by  William  Duane 603 


CONTENTS.  V 

Page. 
Pathological  aapecta  of  some  problems  of  experimental  cancer  research,  by 

James  Ewing 512 

Serodiagnostic  methods  in  cancer  reactions  of  Freund  and  of  v.  Dnngem,  by 

A.  F.  (3oca 620 

Teratoma  de  la  r^6n  del  tuber  cinereum,  by  Guillermo  A.  Bosco 522 

IComing  session  of  January  7y  1016 529 

General  biology  of  the  protozoan  life  cycle,  by  Gary  N.  Calkins 529 

The  claasification  of  the  parasitic  amebie  of  man,  by  Charles  F.  Craig 536 

The  biological  and  medical  significance  of  the  intestinal  flagellates,  by  Charles 

A twood  Kof oid 546 

Discovery  and  identification  of  the  stages  in  the  asexual  cycle  of  the  causative 

organism  of  Peruvian  verruga,  by  Charles  IT.  T.  Townsend 565 

Un  nnevo  flagelado  de  las  plantas  (leptomonas  elmassianii)  by  Luis  £ .  Migone. .  572 

Paraaitologfa  de  ciertos  animales  del  Paraguay,  by  Luis  E.  Migone 578 

M^todo  de  Ascanio  para  la  coloraci6n  de  los  parisitos  del  paludismo,  by  Rafael 

Gonz^ez-Rincones 576 

Adrenalin  in  amebic  dysentery,  by  Theodore  Bayma 578 

Afternoon  session  of  January  7,  1016 586 

The  mortality  from  cancer  in  the  Western  Hemisphere,  by  Frederick  L.  Hoff- 
man   686 

The  relation  of  modes  of  infection  to  the  control  of  bacterial  diseases  In  Pkm 

America,  by  M.  J.  Rosenau 605 

On  the  inhibited  properties  of  magnesium  sulphate  and  their  therapeutic  appli- 
cation in  tetanus,  by  S.  J.  Meltzer 607 

Observacionee  sobre  par^tos  tropicales,  by  Rafael  Gonzdlez-Rincones 615 

A  method  of  approach  in  teaching  sex  ethics  to  girls  and  young  women,  by  Wil- 
liam R.  Manning 618 

Antirabic  vaccination  in  Habana  with  statistics  compared  with  those  of  other 

nations,  by  Juan  Santos  Feraindez 635 

Ensayo  sobre  profilaxia  de  la  sffilis  y  la  blenorragia,  by  Joaqufn  Travieso 637 

Horbosidad  y  mortalidad  infecto-contagiosa  en  el  Uruguay,  by  Alfredo  Vidal  y 

Fuentes 641 

A  historical  r6siun^  of  the  investigations  of  yellow  fever  leading  up  to  the  findings 

of  the  Reed  Board,  by  Geoige  M.  Sternberg 646 

Adjournment  sine  die  of  Section  VIII 652 


Letters  of  TransmittaL 


Washinoton,  D.  O.y  May  SI,  1917, 

Sib:  Punuant  to  the  recommendation  of  the  executive  committee  of  the  Second 
Fui  American  Scientific  GongresB,  which  was  held  in  Washington  December  27, 1915- 
January  8,  1916,  and  by  the  cooperation  of  the  United  States  Congress  (oigent  defi- 
ciency bill,  Sept.  8,  1916),  the  papers  and  discussions  of  that  great  international 
scientific  gathering  have  been  compiled  and  edited  for  publication  under  the  able 
direction  of  the  Assistant  Secretary  General,  Dr.  Glen  Levin  Swiggett.  In  this 
volume  is  contained  the  report  of  Section  YIII,  of  which  Gen.  W.  0.  Gorgas,  of 
the  executive  committee,  was  chairman. 

In  my  formal  report,  which  has  already  been  submitted,  I  enlarged  upon  the 
importance  of  tiie  Second  Pan  American  Scientific  Congress,  its  laige  attendance,  and 
the  high  quality  of  its  papers  and  discussions.  I  will,  therefore,  in  this  letter,  which, 
in  slightly  varied  f(»m,  introduces  each  volume,  make  only  a  few  general  references. 

All  of  the  21  Republics  of  the  Western  Hemisphere  were  represented  by  official 
delegates  at  tiie  Congress.  Unofficial  delegates,  moreover,  from  the  leading  scientific 
associations  and  educational  institutions  of  these  Republics  presented  papers  and 
took  part  in  its  deliberations.  The  papers  and  discussions  may  be  considered,  there- 
fore, as  an  expression  iA  comprehensive  Pan  American  scientific  effort  and  possow, 
in  consequence,  inestimable  value. 

The  Congress  was  divided  into  nine  main  sections,  which,  with  their  chainnen, 
were  as  follows: 

I.  Anthbopoloot.    W.  H.  Holmes. 

II.  AsTBONOMT,  Mbtboboloot,  AND  Sbumoloot.    Robert  S.  Woodward. 

III.  Consbbvation  of  Natubal  Rbsoubobs,  Agriculture,  Irrigation,  and  Forestry. 
George  M.  Rommel. 

lY.  Education.    P.  P.  Claxton. 
v.  Enoinbbbino.    W.  H.  Bixby. 

VI.  lNTBBNATIONALLAW,PnBU0LAW,ANDJUBISPBUDBN0B.     JameS  BrOWU  ScOtt. 

VII.  MiNiNo,  Mbtallubot,  Eoonomio  Gboloot,  and  Appubd  Chbmibtbt.    Hen- 

nen  Jennings. 
YIII.  PuBuo  Hbamth  and  Mbdigal  Scibnob.    William  C.  Gorgas. 

IX.  Tbanspobtation,  Commbbob,  Finanob,  and  Taxation.    L.  S.  Rowe. 

These  sections,  in  turn,  were  further  subdivided  into  45  subsections. 

Over  200  delegates  were  in  attendance  from  the  Latin  American  Republics,  while 
over  a  thousand  from  the  United  States  participated  in  its  meetiogs.  The  discussions 
and  proceedings  of  the  Congress  attracted  world-wide  attention,  and  it  was  undoubt* 
edly  the  greatest  international  scientific  meeting  that  has  assembled  anywhere  in  the 
history  of  the  Western  Hemisphere  and  possibly  of  the  world.  It  was,  therefore,  a 
fitting  successor  to  the  first  Pan  American  Scientific  Congress,  which  assembled  in 
Santiago,  the  capital  of  Chile,  in  1908,  and  to  its  predecessors,  confined  to  lAtin 
American  representation,  which  in  former  years  met,  respectively,  in  Rio  de  Janeiro, 
Montevideo,  and  Buenos  Aires.  Its  success  was  a  logical  result  of  these  preceding 
gatherings  in  Latin  America  and  of  the  hearty  cooperation  of  the  Latin  American 
Governments  and  scientists. 

To  thoee  who  may  have  their  attention  brought  only  to  the  individual  volumes 
covering  the  papers  and  discussions  and  who  wish  to  know  more  of  the  proceedings  of 
the  Congress  and  the  results  accomplished  by  it»  it  is  recommended  that  they  should 

▼n 


Vin  LETTEBS  OF   TBAK8MITTAL. 

also  read  *'The  Final  Act — ^An  Interpretative  Commentary  Thereon/*  prepared  under 
the  direction  of  Dr.  Jamee  Brown  Scott,  reporter  general  of  the  Congrefls,  and  the  report 
of  the  secretary  general,  prepared  by  the  latter  and  the  assistant  secretary  general, 
Dr.  Glen  Levin  Swiggett.  In  these  will  be  found  not  only  the  final  act  and  the 
illuminating  comment  thereon  but  lists  of  delegates,  participating  Governments, 
societies,  educational  institutions,  and  other  organizations,  together  with  a  careful 
story  and  history  of  the  Congress.  They  can  be  obtained  by  addressing  the  Director 
General  of  the  Pan  American  Union,  Washington,  D.  C. 

In  conclusion,  I  want  to  briefly  repeat,  as  secretary  general  of  the  Congress,  my 
appreciation,  already  expressed  in  my  formal  report,  of  the  hearty  cooperation  in 
making  the  Congress  a  success  given  by  everyone  concerned  from  the  President  of 
the  United  States,  yourself  as  Secretary  of  State,  and  the  delegates  of  Latin  America 
and  the  United  States,  down  to  the  office  employees.  The  great  interest  manifested 
by  the  permanent  executive  committee,  headed  by  Mr.  William  Phillips,  then  Third 
Assistant  Secretary  of  State,  the  Carnegie  Endowment  for  International  Peace  through 
its  secretary,  Dr.  James  Brown  Scott,  and  the  executive  aid  of  Dr.  Glen  Levin  Swig- 
gett, as  assistant  secretary  general,  were  vitally  instrumental  in  making  the  gathering 
memorable.  The  Pan  American  Union,  the  official  international  organization  of  all 
the  American  Republics,  and  whose  governing  board  is  made  up  of  the  Latin  American 
diplomats  in  Washington  and  the  Secretary  of  State  of  the  United  States,  lent  the 
favorable  influence  of  that  powerful  organization  to  the  success  of  the  Congress  and 
authorized  me  as  the  director  general  of  the  Union  to  also  take  up  the  duties  of  secretary 
general  of  the  Congress. 

Yours,  very  truly, 

(Signed)  John  Barrett, 


The  Honorable  The  Sbcrbtary  of  State, 

Washington,  D.  C. 


Secretary  General. 


Washinqton,  D,  C,  si  de  maio  de  1917, 

EzMO.  Snb.:  Em  cimiprimento  de  imia  recommenda^fto  emanada  da  Commissfto 
Executiva  do  Segundo  Congresso  Scientifico  Pan  Americano,  que  teve  lugar  em 
Washington,  de  27  de  dezembro  de  1916  a  8  de  Janeiro  de  1916,  e,  devido  ao  auxilio  do 
Congresso  dos  Estados  Unidos  (Lei  para  Or^amentos  extraordinarios  de  8  de  setembro, 
1916)  as  memorias  e  as  discussSes  dessa  assemble  scientifica  intemacional,  foram 
coUigidas  e  preparadas  para  publicay^  sob  a  proficiente  direct  do  Secretario  Geral 
Adjuncto,  Dr.  Glen  Levin  Swiggett.  Este  volimie  comprdiende  o  relatorio  da  sec^fto 
VIII  que  foi  presidida  x>elo  General  W.  C.  Gorgas,  da  Commiss&o  Executiva. 

No  men  relatorio  official,  que  j&  tive  a  honra  de  apresentar,  me  detive  sobre  a  impor- 
tancia  do  Segundo  Congresso  Scientifico  Pan  Americano,  da  sua  grande  concorrencia 
e  da  alta  importanda  das  theses  e  das  discussGes.  Na  presente  nota,  portanto,  de  uma 
maneira  muito  ligeira,  destinada  a  apresentar  cada  um  dos  volumes,  eu  farei  apenas 
algumas  referencias  muito  geraes. 

Todas  as  RepubUcas  do  Hemispherio  Occidental,  vinte  e  uma  em  numero,  se 
achavam  representadas  por  del^ados  officiaes  ao  Congresso.  Delegados  sem  nomea- 
^  dos  Gtovemoe,  mas  representando  as  mais  notaveis  sociedades  scientificas  e 
instituigOes  de  ensino  dessas  republicas  apresentaram  theses  e  tomaram  parte  nas 
delibera^des.  As  memorias  e  discus85es  devem  ser  consideradas  portanto,  como  a 
ezpressfto  de  um  justificavel  trabalho  scientifico  Pan  Americano  e  possue,  por  esse 
motive,  um  valor  sem  egual. 

O  Congresso  foi  dividido  em  novo  secgdes  principaes,  que  a  seguir  enum^,  com 
OS  nomes  doe  sens  presidentes: 

I.  Anthropolooia.    W.  H.  Holmes. 
II.  Astbonomia,  Mstbreologia  e  Sismolooia.    Robert  S.  Woodward. 


LBTTEB8  OF  TBAKSMITTAL..  IX 

III.  CON8BBYA9IO    DA    RlQUBZA.    NaCIONAL,    AoRICULTURA,    iBRIOAgXO    E    SlLVI- 

cuiTUBA.    George  M.  Rommel. 
IV.  IN8TRUG9I0.    P.  P.  Claxton. 
V.  Enoenhabia.    W.  H.  Bixby. 
VI.  DmEiTO    Internacional,    Dibbito    Pubuco    b    Jurispbudencia.    James 

Brown  Scott. 
VII.  M1NA8,  Mbtalluboia,  Gbolooia  Pbactica  e  Chimica  Industrial.     Hennen 
Jennings. 
VIII.  Saude  Pubuca  b  Sciencias  Medicas.    William  0.  €N>rga8. 

IX.  VIA8  DE  COMMTTNICAplO,   COMMERGIO,   FiNANpAS  B  ImPOSTOS.      L.   S.   RoWO. 

Estas  secedes,  por  sea  lado,  eram  subdivididas  em  45  subsec^des. 

Mais  de  200  delegados  das  Republicas  da  America  Latina  frequentaram  as  sessdes 
emquanto  oe  Estadoe  Unidos  se  achavam  representados  por  mais  de  mil  pessoas.  As 
discnasOee  e  00  relatorioe  do  Congresso  attrahiram  a  attengfto  de  todo  o  mundo  e  ioi 
Bern  duvida  a  maior  assemblea  scientifica  que  se  realizoa  no  Hemispherio  Occidental 
e  talvez  em  todo  o  mundo.  Foi  sem  duvida  um  idoneo  continuador  do  Primeiro  Con- 
gresso Scientifico  Pan-Americano,  que  se  celebrou  em  Santiago,  capital  da  Republica 
Chilena  em  1908  e  das  anteriores  assembleas  que  previamente  se  tinham  realizado, 
apenas  com  delegados  da  America  Latina  e  que  se  reuniram  em  annos  anteriores  no 
Rio  de  Janeiro,  Montevideu  e  Buenos  Aires.  O  seu  succeeso  foi  um  resultado  logico 
das  reunides  previas  na  America  Latina  e  do  cordial  concurao  doe  Govemos  da  America 
latina  e  dos  sens  homens  de  scienda. 

A  aqueUes  que  nfto  quiserem  limitar-se  a  consultar  os  volumes  que  cont^  as 
memcHias  e  as  discussOes  e  que  desejarem  conhecer  alguma  cousa  mais  dos  trabalhos 
do  Congresso  e  dos  resultados  por  elle  alcan9ado  se  Ihes  recommenda  a  leitura  da 
Acta  Final— a  exposi^fio  geral  concemente  i  mesma— publlcada  sob  a  direct  do 
Sr.  Dr.  James  Brown  Scott,  Relator  Geral  do  Congresso,  e  o  relatorio  do  Secretario 
Geral,  preparado  i>elo  abaixo  assignado  e  x>elo  Secretario  Geral  Adjuncto  Sr.  Dr. 
Glen  Levin  Swiggett.  Nestes  trabalhos  encontrar-ee-hfio  nfto  stoente  a  acta  final 
mas  tambem  um  magnlfico  commentario,  a  lista  dos  delegados  doe  Govemos  que 
adherinun,  sociedades,  instituigC^  de  ensino  e  outras  corpora^Ges,  seguidas  de  uma 
cuidadosa  historia  do  Congresso.  Estes  volumes  continuam  i  dispoei^io  dos  que  os 
pedirem  ao  Director  Geral  da  Unifto  Pan-Americana,  Washington,  D.  C. 

Em  conclusfto,  eu  desejo  repetir,  em  duas  palavras,  como  Secretario  Greral  do  Con« 
gresBo,  o  men  apre^o  e  reconhecimento,  que  }i  tive  occasiSo  de  ezprimir  no  men 
relatorio  official,  pela  cordial  coopera^fto  que  por  todos  me  foi  prestada  para  levar 
a  bom  exito  este  congresso,  desde  o  IVesidente  doe  Estados  Unidos,  V.  Exa.,  como 
Secretario  d'Estado,  os  Senhores  Delegados  da  America  Latina  e  doe  Estados  Unidos 
at^  OS  diversos  funccionarios  do  Congresso.  O  grande  interesse  manifestado  pela 
CommlssSo  Permanente  Executiva  presidida  pelo  Sr.  William  Phillips,  ao  tempo 
terceiro  Sub-secretario  d'Estado,  pelo  Instituta  de  Carnegie  para  a  Paz  Intemacional 
na  pessoa  do  Sr.  Dr.  James  Brown  Scott,  assim  como  a  collabora^fto  prestada  pela  Sr.  Dr, 
Glen  Levin  Swiggett,  como  Secretario  Geral  Adjuncto,  constituiram  obras  baailares 
para  o  successo  desta  reuni&o. 

A  Unifio  Pan-Americana,  institui^So  intemacional  sustentada  por  todas  as  Repu* 

blicas  Americanas  e  cujo  Conselho  de  Administra^fto  6  constitoido  pelos  represent 

tantes  diplomaticos  em  Washington  e  pelo  Secretario  d'Estado  dos  Estados  UnidoSi 

contribuiu  com  a  sua  poderosa  influenda  para  o  bom  exito  do  Congresso  e  me  aucto- 

rizou  a  servir  de  Secretario  Geral  do  Congresso. 

Com  a  maicnr  considera^fto,  subscrevo-me 

De  V.  Exa., 

Vor.  Mto.  Atto., 

John  Barrbtt, 

SeemarioChnh 
Exmo.  Snr.  Sbcrbtabio  db  EsTADOy 

WoikingUm,  D.  C. 


X  LBXTEB8  OF  XBA14I3MIIXAL. 

WASHiNOTONy  D.  G.y  SI  d€  mopo  de  1917. 
SbAob: 

En  cumplimiento  de  una  recomendaci6n  emanada  de  la  Ck>mi8i6n  Ejecutiva  del 
8^;undo  Gongreso  Cientffico  Panamericano  que  ae  reuni6  en  Washington  deede  el 
27  de  didembre  de  1915  hasta  el  8  de  enero  de  1916  y  gracias  a  la  cooperaci6n  al  efecto 
prestada  por  el  Gongreso  de  lofl  Estados  Unidos  mediante  bu  ley  sobre  lectificaci^n  del 
presupuesto  dictada  el  8  de  eetiembre  de  1916,  h^se  recopilado  y  preparado  para 
BU  publicaddn,  bajo  la  hdbil  dlrecci^n  del  Sr.  Dr.  Glen  Levin  Swiggett,  Subeecretario 
General,  las  memoriaB  presentadas  a  dicho  Gongreso  y  los  debates  a  que  dieron  lugar. 
El  presente  volumen  contiene  el  informe  relative  a  la  Secci<Sn  VlII,  de  la  cual  Iu6 
preddente  el  General  W.  G.  Goigas,  miembro  de  la  Gomisi6n  Ejecutiva. 

En  el  informe  general  que  ya  tuve  el  honor  de  preeentarle,  me  fu^  dable  considerar 
detenidamemte  la  importancia  del  Segundo  Gongreso  Gientffico  Panamericano,  la 
numerosa  concurrencia  que  al  mismo  asistid  y  el  elevado  m^to  de  las  memorias 
presentadas  y  de  los  debates  que  en  aqucl  se  suscitaron.  Por  consiguiente,  he  de 
limitarme  en  la  presente,  destinada  a  servirle  de  mera  introducci6n  a  cada  uno  de  los 
voldmenes,  a  algunas  consideraciones  de  caricter  general. 

En  el  Gongreso  estuvieron  representadas  por  medio  de  delegaciones  ofidales  las 
veinte  y  una  repdblicas  del  Hemisferio  Occidental.  Tambi^n  asistieron  al  mismo, 
tomando  participaci6n  en  sus  debates  y  presentando  trabajos  peisonales,  delegados 
particulares  de  los  principales  cuerpos  cientificos  y  de  los  institutos  docentes  de  esas 
mismas  repdblicas.  En  toX  virtud,  las  memorias  y  los  debates  mencionados  deben  ser 
considerados  como  la  expresi6n  de  un  amplio  eshierzo  cientifico  panamericano, 
encerrando,  por  lo  tanto,  un  valor  inestimable. 

El  Gongreso  estuvo  dividido  en  nueve  secciones  principales  que  en  seguida  paso  a 
enumerar  junto  con  el  nombre  de  bus  presidentes.    Fueron  las  siguientes: 

I.  ANTBoroLOGiA.    W.  H.  Holmes. 

II.  AsTRONOidA,  MbtbobolooIa  y  SiBMOORAFiA.    Robert  S.  Woodward. 

III.  GONBBBVAadN   DB   LAB   FUBNTEB    NaTURALBS    DB    RiQUBZA,    AoBICULTURA, 

iBBioAciiN  T  Sblvigultura.    Gooige  M.  Rommel. 

IV.  In8truogi6n.    p.  p.  Glaxton. 

V.  InobnibbIa.    W.  H.  Bixby. 

VI.  Dbbbcho  Intbbnacional,  Derbcho  Pi^blico  y  Jubispbudbncia.  James 
Brown  Scott. 

VII.  MiNBBiA,  Metalubqia,  GeologIa  Econ6mica  y  QufMiCA  Apucada.  Hen- 
nen  Jennings. 

VIII.  Salubbidad  Pi^buca  y  Giencia  MimoA.    William  G.  Goigas. 

IX.  Tbaspobtb,  GoMBBao,  FiNANZAB  B  Impuestos.    L.  S.  Rowe. 

Estas  secciones  estuvieron  dividas,  a  su  vez,  en  cuarenta  y  cinco  subsecciones. 

De  las  repdblicas  latino-americanas  asistieron  m^  de  doscientos  delegados;  en 
tanto  que  las  sesiones  del  Gongreso  concurrieron  m^  de  mil  personas  de  los  Estados 
Unidos.  Los  trabajos  y  debates  del  cuerpo  despertaron  universal  interns,  pues  indu- 
dablemente  fu6  aquel  la  asamblea  cientffica  mds  grande  que  registra  la  historia  del 
Hemisferio  Occidental  y  probablemente  la  del  mundo.  1^1  fu6,  en  consecuencia,  digno 
continuador  del  Primw  Gongreso  Gientifico  Panamericano  que  en  1910  se  reuni6  en 
la  capital  de  Ghile  y  de  los  que  previamente  y  con  una  asistencia  exclusivamente 
latino-americana  se  habfan  congr^ado  en  Rio  de  Janeiro,  Montevideo  y  Buenos 
Aires.  Su  6xito  fu6  consecuencia  l^ca  de  las  asambleas  que  anteriormente  se  habfan 
reunido  en  la  AmMca  latina  y  del  cordial  concurso  que  recibid  de  los  gobiemos  y 
de  los  hombres  de  ciencia  de  eea  misma  parte  de  America. 

A  cuantos  no  quisieren  limitarse  a  consultar  los  voldmenes  que  contienen  als 
memorias  y  los  debates  y  desearen  conocer  algo  mils  de  las  labores  del  Gongreso  y  de 
los  resultados  por  41  alcanzados,  se  les  recomienda  la  lectura  del  Acta  F^inal  y  de  la 
Exposici6n  General  concemiente  a  la  misma  que  escribid  el  Dr.  James  Brown  Scott, 
Informante  General  del  Gongreso,  asf  como  el  Informe  del  Secretarlo  General,  prepa- 


LBITEBS  OW  IBAHSMUIAU  XI 

rado  por  el  suscrito  y  per  el  Dr.  Glen  Levin  Swiggett,  Subsecretario  General  del 
mismo.  £n  esrtofl  documentoR  podr^  hallar  no  86I0  el  Acta  Final  y  luminoflas  consi- 
deraciones  acerca  de  la  muuna,  sino  tambi^n  la  n6mina  de  los  delegadofl  y  de  loe 
gobiernoe,  sociedades  e  insdtutoe  docentes  que  tuvieron  repre8entaci6n  en  la  Asamblea, 
j untainente  con  una  relaci6n  puntualizada  de  las  labores  de  la  miama.  LO0  que  deseen 
obtenw  estoe  voldmenes  pueden  aolicitarloe  del  Director  General  de  la  Uni6n  Pan- 
americana  en  W&ahington,  D.  0. 

Oomo  Secretarlo  General  del  Gongreso  deseo  hacer  conatar  una  ves  m^,  antes  de 
concluir,  el  agradeoimiento  que  en  mi  informe  general  expresd  por  el  cordial  concurso 
que  de  todoe  redbf  para  asegurar  el  6xito  del  Congreso,  desde  el  Presidente  de  los 
Efltados  Unidoe  y  usted  mismo  como  Secretario  de  Estado  y  desde  los  delegados  de 
la  America  Latina  y  de  los  Estados  Unidos  hasta  los  dlversos  funcionarios  del  Congreso. 
£1  gran  inter^  desplegado  por  la  Comiai6n  Permanente  Ejocutiva,  que  pre8idJ6  el 
Sr.  William  Phillips,  a  la  saziSn  Tercer  Subsecretario  de  Estado;  por  la  Fundaci6n 
Oamegie  para  la  Paz  Intemacional,  por  el  6rgano  de  su  Secretario,  Dr.  James  Brown 
Scott;  asf  como  la  colaboraci6n  del  Dr.  Glen  Levin  Swiggett,  Subsecretario  General, 
contribuyeron  poderosamente  a  hacer  memorable  la  aaamblea.  La  Uni6n  Pan- 
americana,  institucidn  intemacional  sostenida  por  todas  las  repliblicas  de  America  y 
cuyo  Consejo  Directive  estd  formado  por  los  representantes  diplom&ticos  latino- 
ameiicanos  residentes  en  Wdahington  y  por  el  Secretario  de  Estado  de  los  Estados 
Unidos,  tontribuy6  con  su  poderosa  influencia  al  ^xito  del  Congreso  y  me  autorixd 
para  que  desempefiara  las  funciones  de  Secretario  General  de  aqu61. 

Con  sentimientos  de  la  m^  alta  consideraci^n  me  subscribe 

De  usted  muy  atmito  sorvidor, 

John  Barbbtt, 

Secretario  General. 
Al  Honorable  Secretario  de  Estado, 

Wdshingtan,  D.  C. 


Washinoton,  D.  C,  jL<  51  mat  J 917, 

Monsieur:  Conform^ment  k  la  recommandation  du  Comity  Ex^utif  du  Second 
Ccmgrte  Sdentifique  Panam^ricain  qui  a  eu  lieu  k  Washington  du  27  d^embre  1915 
an  8  Janvier  1916,  et  par  la  cooperation  du  Congrte  des  Etats-Unis  Ooi  du  budget 
extraordinaire,  8  septembre  1916),  les  m^moires  et  discussions  de  cette  grande  reunion 
•oientifique  Internationale  ont  6t6  recueillis  et  6ditds  pour  6tre  public  sous  Thabile 
direction  du  docteur  Glen  Levin  S  wiggett  sous-secretaire  general .  Ce  volume  contient 
le  rapport  de  la  section  VIII,  dont  M.  le  General  W.  C.  Gorgas  du  Comity  Exdcutif 
etait  president. 

Dans  men  rapport  officlel  qui  a  6t6  d^j^i  soumis,  je  me  suis  etendu  sur  Timportance 
du  Second  Congr^  Scientifique  Panam^ricain,  sur  le  grand  nombre  de  personnes  qui 
y  etaient  pr^sentes  et  sur  Texcellence  de  ses  m^moires  et  de  ses  discussions.  C'est 
pourquoi,  dans  cette  lettre  qui,  aprte  avoir  subi  quelques  changements  sans  impor- 
tance, sert  d'introduction  k  chaque  volume,  je  n'en  parlerai  que  d'une  manito 
gen^rale. 

Toutes  les  r^publiques  de  rH^misph^re  Occidental  au  nombre  de  vingt-et-une 
etaient  representees  au  Congres.  De  plus,  des  deiegues  k  titre  offideux  envoyes 
par  les  associations  scientifiques  et  les  institutions  educatives  les  plus  en  vue  de  ces 
republiques  ont  soumis  des  memoires  et  ont  pris  part  aux  deliberations.  On  peut 
done  considerer  les  memoires  et  les  discussions  comme  I'expression  d'un  grand  effort 
scientifique  panamericain,  possedant  en  consequence  une  valeur  inestimable. 

Le  Congr^  etait  divise  en  neuf  sections  principales  que  nous  enumerons  ci-dessous, 
en  donnant  le  nom  de  leurs  presidents. 

I.  ANTROPOLoaTB.    W.  H.  Holmes. 

II.  AsTRONOMiE,  MirAoROLOOiB  ET  SisMOLOoiB.    Robert  S.  Woodward. 


XII  LETTEB8  OF  TBAKSMITTAL. 

III.  Conservation  des  Rebsources  Naturellss,  Aoricui/fure,  Irrioatioh 
BT  FoR^TS.    George  M.  Rommel. 

IV.  Instruction  Publiqub.    P.  P.  GUxtcm. 

V.  GAnib  Civil.    W.  H.  Bixby. 

VI.  Droit  iNTBRNATioNAii,  Droit  Public  bt  Jurisprudrnck.  James  Brown 
Scott. 

VII.  Minks,  M^alluroib,  Gioi/>oiB  pratique,  ct  Chimib  AppuquAb. 
Hennen  Jennings. 

VIII.  SantA  Publiqub  bt  ^ibncb  MAiuoalb.    William  C.  Gorgas. 

IX.  Transport,  Comufrcb,  Finance  it  iMpdr.    L.  S.  Rowe. 

A  leur  tour  ces  sections  ^taient  !*ubdivis^  en  quarante-cinq  sous-sections. 

On  y  cH>mptait  plus  de  deux  cent««  d^l^i6s  des  rdpubliqnes  latino-am^ricainee,  et 
plus  de  mille  d^I^u4s  des  Etutd-Unl**  ont  assist^  aux  reunions.  Jjq»  discussions  et 
les  proc^s-verbaux  du  Congr^  ont  attir^  Tattention  dii  monde  entier,  et  il  a  M  sans 
le  moindre  doute  la  plus  ^nrande  a»?emb16e  sciontifique  intemadimale  de  I'hl^toire 
de  rH^misph6re  Occidental,  et  peut-6tre  mfimedu  mor.de  pnder,  quise  soit  r^unie  jus- 
qu'ici.  Venant  apr^s  le  Premier  Congr^ Scientifiqie  Panam^ricaic  qui  p'cst  r^uoi  k 
Santiago,  capitaledu  Chili,  en  1908,  et  apr  .sceux  qui  ont  eu  lieu  pr^c6demment,  respec- 
tivement  ^  Rio  de  Janoiro,  k  Montevideo  et  k  Buenos- Ayree,  cos  demiers  n'ayant  que 
des  repr^Swntants  de  T Am^rique  Latine,  il  s'est  montr^  leur  digne  successeur.  8a  r^us- 
site  a  6t6  un  lo^que  r^iiultat  do  ce«  pr6c^ents  concours  dans  VAm^rique  Latine  et  de 
la  sincere  et  cordiale  ci  operation  des  gouvemements  et  des  hommes  de  science  de 
I'Am^riqne  Latine. 

Pour  ccux  qui  n'ont  port^  leur  attention  que  sur  lea  volumes  renfermant  les  m^moired 
et  les  dipcussious,  et  qui  d^reraient  connnttre  d'une  msni^re  plus  approfondio  les 
act?s  et  proc^-verbaux  du  Conp*^,  ainsi  que  les  result >ts  qui  e*on  Ront  sui\is,  je  leur 
conseillerai  de  lire  "L'actf-  Fiiul,  Oommontsire  explicatif,'*  r^dijr6  sous  la  direction 
dTi  docteur  James  Brown  Scott,  rapporteur  general  du  Congr^,  ot  le  rapport  du  Secre- 
taire G6n4ra]  r6dig6  par  ce  dernier  et  le  doc  teur  Glen  Levin  Rwiggett.  En  les  lisnnt 
en  n'y  trouver?  pad  soulemont  TActo  Final  et  le  commentaire  cxplicatil,  mais  encore 
les  listcs  dw3  a^l6&ru^,  des  gouvemements  qui  ont  particip^  au  Congr^s,  des  soci'^tA^, 
des  institutions  Mucatives  et  aiitres,  en  mdme  t  mps  qu'iic  compte  lendu  s<»gn4 
ainsi  que  Vhistoire  du  Ccngr^.  On  pent  se  les  procurer  en  lai^nt  une  demande  par 
toit  au  Direclenr  G^n^ral  de  TUniop  Pai.am^ric  ine  ^  Wapbin^ton,  D.  C. 

En  terminant,  je  vais  en  quality  de  Secretaire  G^n^ral  du  Congr^s  exprimer  de 
nouveau  en  peu  de  mots  mes  remerctments,  ce  que  j'ai  d^j^  fait  dans  mon  rapport 
officiel  pour  la  part  que  chacun  a  eue  dans  la  r^usaite  du  Congr^s  depuis  le  President 
des  £tats-Unis,  vous  comme  Secretaire  d'etat,  les  dei^gu^s  de  I'Am^rique  Latine  et 
ceux  des  £tats-Unis  jusqu'aux  employes  de  bureau.  Le  haut  int^r^t  manifeste  par 
ie  Comite  Ex^cutif  permanent  preside  par  M.  William  Phillips,  qui  etait  alors  troisidme 
Sous-Secretaire  d'£tat,  par  la  Fondation  Carnegie  pour  la  Paix  Internationale,  par 
I'entremise  de  son  secretaire  le  docteur  James  Brown  Scott,  et  Taide  prdte  dans  I'exe- 
cution  par  le  docteur  Glen  Levin  Swiggett,  comme  sous-secretaire  general,  ont  puisaam- 
ment  contribue  k  foire  de  ce  Congr^  un  evenement  memorable.  L'Union  Panameri- 
caine,  administration  officielle  intemationale  de  toutes  les  republiques  americaines, 
et  dont  le  Comite  d 'Administration  est  compose  des  diplomates  latino-americains  k 
Washington  et  du  Secretaire  d'etat  des  £tats-Unis,  ausede  sa  favorable  influence  pour 
assurer  le  succ^  du  Congr^  et  m'a  autorise,  en  qualite  de  Directeur  General  de 
I'Union,  k  prendre  en  mains  les  responsabiiites  de  Secretaire  General  du  Congr^. 

Veuillez  agreer,  M.  le  Secretaire  d'etat,  en  mdme  temps  que  mes  reepectueux 

hommages  I'assurance  de  mon  entier  devoOment, 

John  Barrbtt, 

Secretaire  GhUral. 

Monsieur  le  Sbcr^tairb  d'£tat, 

Washingtont  D,  C. 


REGISTER  OF  WRITERS  OF  PAPERS. 


SBCX>ND  PABT. 

Page. 

Agote,  Louis 248 

Bartow,  Edward 220 

Bayma,  Theodoro 678 

Boaco,  Guillenno  A 522 

Bronfenbrenner,  J 278 

Brown,  Claude  P 315 

BmrowB,  Montrose  T 494 

Calkins,  Gary  N 529 

Oastells,  Oonstancio 447 

Oatoni,  Julio  L 167 

Chamot,E.  M 213 

Clowes,  Q.H.  A .' 304,496 

Coca,  A.  P 520 

Covairubias  Arlegui,  Alvaro 251 

Oraig,  Charles  P 536 

Duane,  William 603 

Ewing,  James 512 

Pem&ndes,  Juan  Santos , 635 

Fethenton,  J.  T 190 

Ponseca,  Pedro  S 261 

Funk,  C^mir 388 

GaUegoe,  Felipe 465 

Gaylor,  Harvey  R 490 

Giacobini,  Genaro 339, 341, 342, 343, 344, 346 

Godinho,  Victor 247 

Ck>ldbeiger,  Joseph 3 

GonzAles-Rinconee,  Rafael 576»  615 

Gourdy,  Augusto  Celestino 394 

Heoi,  Alfred  F 48 

Hitchens,  A.  Parker 315 

Hoffman,  Frederick  L 586 

Jordan,  Edwin  O 205 

Kofoid,  Charles  Atwood 546 

Kolmer,  JohnA 287 

Lambert,  Robert  A 493 

Lebredo,  Mario  Q 29 

Loeb,  Leo 347 

Manning,  William  R 618 

McLau^ilin,  Allan  J 228 

Meltaer,  S.J 607 

Mendel,  Lafayette  B 112 

M^nde«.JuUo 267 

Migone.LuisE 572,673 


XIV  BBGISTBR   OP  WRITERS    OF   PAPERS. 

Page. 

Morales  Villazdn,  NMor 437 

Moreno,  Jo«6 329, 335 

Morton,  John  J 360 

Murphy,  James  B 360 

Patifio  Mayer,  Cdndido 394 

Rampini,  Jo86  A 325 

Rosenau,  M.J 605 

Salterain,  Joaqufn  de 451 

Sarmiento  Laspiur,  Ricardo 130 

Sedgwick,  William  T 187 

Slye,  Maud 354 

Smith,  Erwin  P 472 

Solano,  NicoUs  A 407 

Soper,  George  A 173 

Sternberg,  George  M 645 

Susviela  Guarch,  Federico 400 

Torres  Umafta,  Galixto 52, 105 

Townaend,  Charles  H.  T 565 

Tra vieso,  Joaquin 637 

Tyzzer,  E.  E 365 

Vedder,  Edward  B 22 

Vidal  y  Fuentos,  Alfredo 641 

Weil,  Richard 263,308,382 

Weinzirl,  John 127 

Williams,  Robert  R 39 

Winslow,  C.-E.  A 232 

Woglom,  William  H 362 

Wood,  Francis  Garter 500 


FOREWORD. 


The  work  of  the  hygienic  section  has  been  most  valuable.  It  has 
already  produced  excellent  results  in  causing  the  Rockefeller  Foun- 
dation to  undertake  the  work  of  exterminating  yellow  fever.  All 
the  South  American  countries  affected  by  this  disease  have  agreed 
to  cooperate,  and  if  it  had  not  been  for  the  European  war  the  work 
would  have  now  been  well  under  way. 

(Signed)  W.  C.  Gorgas, 

Chairman, 

XV 


GENERAL  SESSION  OF  SUBSECTION  Vm. 

New  Ebbitt  Hotel, 
Moviday  morning,  Jannunry  5, 1916. 

ChairmaQy  Surg.  Gen.  Rupebt  Blue. 

The  session  was  called  to  order  at  9.30  o'clock  by  the  chairman. 

The  Chairman.  The   session    will   please    come    to    order.    Dr. 
Qoldberger  is  to  present  the  first  paper. 

A  RfiSUMfi  OF  SOME  OF  THE  RECENT  STUDIES  OF  THE  UNITED  STATES 
PUBLIC  HEALTH  SERVICE  RELATING  TO  THE  CAUSATION  AND  TO  A 
METHOD  OF  PREVENTING  PELLAGRA. 

By  JOSEPH  QOLDBERGER, 
Swrgeon,  United  8tate$  PiMie  Health  Smnce. 

Introduction, — One  of  the  outstanding  featuiee  of  the  epidemiology  of  pellagra  is 
the  striking  relation  of  the  disease  to  poverty.  In  reflecting  on  this  and  in  consider- 
ing the  elements  that  differentiate  poverty  from  affluence,  diet,  in  view  of  the  con- 
spicuous place  it  has  always  had  in  discussions  of  the  disease,  naturally  arrested 
attention.  Approaching  the  problem  of  the  possible  relation  of  diet  to  pellagra  in 
this  way,  it  seemed  permissible  to  assume,  on  the  one  hand,  that  the  diet  of  the  poor^ 
that  is,  of  those  who  as  a  class  are  the  principle  sufferers  from  the  disease — ^is  few  some 
reason  pellagra-producing  and,  on  the  other,  that  the  diet  of  the  well-to-do,  who,  as 
a  class,  are  practically  exempt  is.  Ion  some  reason,  pellagra-preventing.  The  thou^t 
was  near,  therefore,  that  it  mig^t  be  possible  to  prevent  the  disease  by  providing 
those  subject  to  pellagra  with  a  diet  such  as  that  enjoyed  by  well-to-do  people.  Early 
in  1914  it  was  proposed  to  put  this  idea  to  a  practical  test.  Befoie  this  test  was 
actually  begun,  studies  of  the  prevalence  of  pellagra  at  institutions,  such  as  prisons, 
asylums,  and  orphanages  were  made,  the  results  of  which,  in  the  li|g}it  of  the  recent 
advances  in  our  knowledge  of  beriberi,  very  strongly  suggested  the  idea  that  the  dia> 
ease  was  dependent  upon  a  diet  that  was  for  some  reason  faulty,  and  that  this  fault  was 
in  some  way  either  prevented  (w  corrected  by  including  in  the  diet  suitable  propor- 
tions of  the  fresh  animal  protein  foods  and  legumes.* 


>  Prof.  VoagtUn  UUi  mt  thtt  si  ftbont  the  mom  or  tren  proviout  to  this  time,  ho  had  indopoodcntlj 
fonnod  aonioirlMt  fimnar  viowi  which  ho  protontod  in  o  pttpor  rood  Juno  26^  1914,  ol  tho  rnooUnc  of  tho 
Amoricon  Hodical  AModotion,  sod  imblithod  in  tho  Joarnol  of  tho  Amorlora 

S8, 1914.   Tho  bllowtnc  qoototiooo  from  thlo  popor  wOl  givo  tho  itiidont  of  thofobiloct  tho  OMiHob  of 
VoogtUn't  oonooptSon: 

"  From  o  forroy  of  tho  eUnlooI  and  potholofio  atpocU  of  poUofra,  I  hoTO  trrivod  ot  tho  oonehMloii  that 
wo  aro  doaliof  with  a  chronio  intoxioatlon.  Whilo  tho  aicanto  at  work  in  this  intoxication  aro  ao  yot  on 
known,  I  am  InoUnod  to  hoUo?o  that  toxlo  ■qbo>ancoi  ozlst  in  oortain  Ttcotablo  foodi,  not  nocoMorlly 
■poilod,  which  If  oonoomod  b7  man  ovir  a  long  poriod  of  timo  may  prodnoo  an  li^|iirloiit  offoct  on  otrtaln 
orgaiMofthohody.  This  hypothosb  dooo  not  nilo  out  tho  pooribtllty  that  a  diotary  doOcioncy,  •  •  • 
(Titamino)   *  *  *.  may  play  a  rMo  In  tho  production  and  troatuMot  of  pollacra.    BxtoulTO  fooding 

68486— 17— VOL  x ^2  B 


4  PBOCfiEDINGS  SECOND  PAN  AMEBICAN  SCIENTIFIG  C0NGBE88. 

Theee  findings  not  only  confirmed  the  original  conception,  but  helped  in  defining 
this  more  clearly,  and,  moreover,  made  it  possible  to  formulate  more  definite  plans, 
which  were  temporarily  broadened  to  include  a  test  of  diet  in  the  treatment  as  well  as 
in  the  prevention  of  the  disease. 

TRBATMBNT. 

At  the  suggestion  of  the  writer,  Dr.  W.  F.  Lorenz,  who  was  at  that  time  studying 
the  ps}'chiatric  manifestations  of  pellagra  at  the  Georgia  State  Sanitarium,  treated  a 
series  of  27  cases  in  the  insane  at  that  asylum  exclusively  by  diet.  Considering  the 
character  of  the  cases  with  which  he  was  dealing  his  results,  as  well  as  those  of  Dr.  D.  G. 
Willets,  who  for  a  time  continued  the  work  begun  by  Lorenz,  were  notably  favorable. 

When  the  various  recent  methods  of  treatment,  each  warmly  advocated  by  ita 
author,  are  critically  reviewed  in  the  light  of  the  test  made  by  Lorenz  and  by  Willets, 
one  can  hardly  foil  to  be  impressed  by  the  fact  that  the  one  thing  they  all  appear 
to  have  in  common  is  the  so-called  '^ nutritious  diet,''  and  it  is  difficult  to  escape  the 
conclusion  that  it  is  to  this  single  common  factor  that  the  marked  success  that  is 
usually  claimed  for  the  ''treatment"  should  properly  be  assigned. 

It  is  of  much  interest  to  note  that  fully  50  years  ago  Roussel  (Roussel,  1866,  pp. 
529-^530),  on  the  basis  of  long  experience  and  from  a  critical  review  of  the  literature  of 
his  day,  came  to  precisely  the  same  conclusion.  This  is  so  much  to  the  point  that 
it  is  quoted  herewith: 

Without  dietetic  measures  all  remedie$  fail.*  «  «  «  When  drugs  and  good  food 
are  simultaneously  employed,  it  is  to  the  latter  that  the  ciuative  action  belongs;  the 
former  exercises  simply  an  adjuvant  action  and  is  without  approved  efficacy  except 
against  secondary  changes  or  accidental  complications. 

Hereafter  the  clinician  who  would  attribute  therapeutic  value  to  any  drug  or  other 
remedy  in  the  treatment  of  pellagra  should  be  prepared  to  show,  what  has  not  hereto- 
fore been  done,  that  the  curative  effect  claimed  can  not  be  attributed  to  the  diet.  It 
is  true  that  the  claim  is  not  infrequently  made  that  the  beneficial  effects  of  the  remedy 
advocated  were  obtained  without  any  change  in  diet.  When  the  claim  is  critically 
considered,  however,  it  amounts  usually  simply  to  this,  that  the  observer  gave  no 
instructions  as  to  a  change  in  the  patient's  diet  or  assiunes  that  such  change  as  was 
made  was  too  slight  to  merit  consideration.  It  should  not  be  overlooked  that  the 
symptoms  of  the  disease  (sore  mouth,  diarrhea)  are  very  frequently  such  that  the 
patient,  entirely  on  his  own  initiative,  may  or  does  add  or  increase  the  proportion 

exp«rtmeDt8  vUdi  I  havt  carrtod  on  during  the  hut  year  with  anhnahi,  each  as  mice,  rata,  and  a  few  mon- 
keys, on  an  exclusive  vegetable  diet,  have  shown  that  these  lower  animals  develop  certain  gastro-intestlnal 
symptoms,  and  sometimes  die  if  pat  on  an  exdosive  diet  of  com,  carrots,  sweet  potatoes,  oats,  etc.  Symp- 
toms arise  often  within  three  or  four  days,  which  point  to  the  presence  of  an  intoxication  in  these  animals. 
Death  resulted  in  some  cases  in  a  remarkably  short  time  (three  or  four  days).  At  necropsy  constant  leslona 
were  found,  such  as  hyperemia  and  hemofriiage  in  the  gastro-intestinal  canal.  Sometfanes  the  kidneys, 
lanp,  and  other  organs  show  a  oongestion  and  sli^tly  hemorrhagie  condition.    *  *  * 

"  It  is  probably  more  than  a  mere  coincidence  that  the  population  of  that  part  of  the  world  in  which  pel- 
lagra is  endemic  Uves  on  a  mainly  vegetable  diet. 

"The  recent  advances  in  the  field  of  nutrition  suggest  new  avenues  of  approach  to  the  solution  of  this 
difficult  problem.    One  will  have  to  consider  very  seriously: 

"  1.  A  deficiency  or  absence  of  certain  vitamins  In  the  diet. 

"2.  The  toxic  effect  of  some  substances,  as  aluminum,  which  occur  in  certain  vegetable  food.  (The 
possible  relation  between  aluminum  and  pellagra  was  also  discussed  in  a  recent  monogn^  by  Alessan- 
drini  and  Scala,  Gontributo  nuova  alia  etiologia  e  pathogenesi  della  Pellagra,  Roma,  1914,  which  the  author 
received  at  the  time  of  proof  reading.  These  invietigators  claim  that  colloidal  silica  contained  in  drinking 
water  is  one  of  the  most  important  etiologio  Cactors.  inasmuch  as  they  succeeded  in  producing  lesions 
resembling  pellagra  in  animate  fed  on  water  containing  colloidal  silica.  Colloidal  almninam  hydroxid 
or  a  mixture  of  colloidal  silica  and  alumina  produced  the  same  results.  In  view  of  the  liMst,  first  discovered 
by  us,  that  aluminum  occurs  in  certain  vegetable  food  in  relatively  large  amounts,  the  work  of  the  Italian 
authors  ftimishes  additional  evidence  that  aluminum  occupies  a  prominent  position  in  the  etiology  of 
pellagra.) 

**3,  A  defidency  of  the  diet  in  certain  amino-adds." 

1  Italics  are  Roussel's. 


PUBLIO  HEALTH  AKD  MEDICnnB.  5 

of  the  liquids  (milk,  eggs,  broth)  in  his  diet.  And  this  may  be  done  even  before  the 
l^ymdan  is  consulted. 

Again,  in  order  to  substantiate  the  claims  made  for  some  particular  remedy  it  is 
sometimes  asserted  that  the  patient's  diet  had  all  along  included  an  abundance  of 
the  animal  proteins  and  legumes.  Careful  inquiry  in  a  number  of  such  instances 
has  almost  invariably  shown  that  what  is  meant  in  such  cases  is  that  either  the  family 
table  was  known  or  was  assumed  to  be  well  supplied  with  these  foods  of  which  the 
patient  was  perhaps  quite  naturally  assumed  to  have  partaken  abundantly.  The 
important  possibility  that  the  patient  by  reason  of  a  personal  idiosyncracy  or  otherwise 
did  not  actually  eat  these  foods  is  almost  invariably  overlooked.  That  these  foods 
may  in  some  degree  enter  into  the  pellagrogenous  dietary  calls,  however,  for  no  denial . 
Hie  question  always  to  be  borne  in  mind  is:  Was  it  enough?  The  possibiUty,  if  not 
the  probability,  of  a  "twilight"  sone  within  which  a  very  slight  chaoge  in  any  of  the 
dietary  components  may  cause  an  important  shift  of  balance  is  not  to  be  overiooked. 
In  the  present  state  of  our  knowledge,  therefore,  the  question  of  a  sufficient  proportion 
can  not  in  all  instances  be  answered  on  the  simple  statement  of  the  case.  That  as  a 
matter  of  hct  the  proportion  of  the  foods  in  question  in  these,  which  may  be  called 
borderland  cases,  was  not  enough  is  very  strongly  suggested  by  the  faivorable  result  of 
the  simple  expedient  of  having  the  patient  continue  the  diet  on  which  he  is  supposed 
to  have  subsisted,  seeing  to  it,  however,  that  there  is  actually  consumed  an  abundance 
of  the  animal  foods  and  legumes.  This  and  the  unsatis&ctory  progress  of  those  patients 
who  for  one  reason  or  another  fail  or  refuse  to  cooperate  in  taking  the  diet  is  decidedly 
illuminating. 

Such  observations  as  the  writer  has  been  able  to  make  strongly  suggest  that  real 
recovery  from  an  uncom]^cated  attack  may  not  take  place  untU  after  a  minimum 
of  about  three  or  four  months  of  full  feeding  of  fresh  animal  proteins  and  legumes. 
But  this  should  not  be  taken  to  mean  that  thereafter  recurrences  are  impossible. 
A  "recurrence, "  so-called,  may  conceivably  take  place  after  the  lapse  of  any  interval 
if  theie  is  a  return  for  a  sufficiently  long  period  to  a  pellagrogenous— that  is,  "ftmlty  " — 
diet.  In  pellagra,  as  in  other  conditions,  the  renewed  operation  of  the  essential 
causative  factor  may  be  expected  to  bring  about  a  renewed  manifestation  of  its  effects. 

PBBVBNTION. 

In  planning  the  test  ci  the  preventive  value  of  diet  it  was  decided  to  take  advan- 
tage id  the  universally  recognised  fact  that  "normally"  pellagra  tends  to  recur  in 
the  individual  from  year  to  year. 

In  order  to  obtain  as  significant  and  decisive  results  as  possible  it  was  necessary 
to  submit  a  large  number  ci  pellagrins  to  the  test  under  known  conditions.  Fortu- 
oatdy,  two  orphanages  were  found  in  liay,  1914,  each  having  a  high  incidence  <d 
pellagra  among  its  inmates.  Later  this  preventive  test  was  extended  to  include  two 
groups  of  insane  at  the  Georgia  State  Sanitarium. 

In  the  study  at  the  orphanages  there  was  associated  with  the  writer  Asst.  Surg. 
O.H.  Waring,  and  in  that  at  the  Qeofgia  State  Sanitarium,  Assistant  Epidemiologist 
D.  6.  Willeta. 

Orpkanage  ttudy, ^-Tbe  two  orphanages  at  which  the  value  of  diet  in  the  prevention 
d  pellagra  has  been  tested  are  located  in  Jackson,  Miss.  At  both,  cases  of  pellagra 
have  been  recognized  for  several  years.  During  ibe  spring  and  summer  of  1914,  up 
to  September  15,  a  total  of  209  cases  of  pellagra  was  observed  in  the  children  of 
those  <Hrphanages.  Althou^  a  number  of  these  at  both  institutions  were  known 
to  be  admission  cases,  others  appeared  to  have  developed  first  after  considerable 
periods  of  residence,  while  a  large  proportion  were  in  long-time  residents.  The 
factor  or  factors  causing  pellagra  and  favoring  its  recurrence  seemed,  therefore,  to 
be  operative  at  both  institutions. 


6  PBOCBEDINGS  SBOOKD  PAN  AMEBIOAK  80IBKIIFI0  C0K0BE8S. 

At  both,  places  hygienic  and  sanitary  conditions  left  much  to  be  desired.  Both 
were  overcrowded.  Each  drew  and  has  continued  to  draw  its  drinking  water  from 
the  public  supply.  One  has  a  water-carriage  sewerage  system  connected  with  that 
of  the  city;  the  other  is  provided  only  with  unscreened  privies.  At  the  latter  a 
great  deal  of  soil  pollution  was  noted. 

Before  beginning  the  test  it  was  requested  that  no  change  be  made  in  hygienic 
and  sanitary  conditions;  this  request,  it  is  believed,  has  been  fully  complied  with. 

Since  about  the  middle  of  September,  1914,  the  diet  at  both  orphanages  has  in 
certain  respects  been  supplemented  by  the  Public  Health  Service.  At  both  insti- 
tutions a  very  decided  increase  was  made  in  the  proportion  of  the  fresh  animal  and 
of  the  leguminous  protein  foods.  The  milk  supply  was  greatly  increased.  The 
children  between  6  and  12  years  of  age  were  provided  with  a  cup  of  about  7  ounces 
of  milk  at  least  twice  a  day.  Those  under  6  had  it  three  times  a  day.  Until  the 
spring  of  1915  the  milk  used  was  all  fresh  sweet  milk.  In  April  of  that  year  buttermilk 
was  added  to  the  diet;  this  was  served  at  first  only  on  alternate  days  to  those  over 
12  years  of  age;  later  it  was  served  to  all  at  the  midday  meal.  Eggs,  which  had  not 
previously  entered  into  the  regular  diet  of  these  children,  were  served  those  under 
12  years  of  age  at  the  morning  meal.  It  had  been  the  custom  to  serve  fresh  meat  but 
once  a  week;  this  was  increased  to  three  or  four  times  a  week. 

Beans  and  peas,  which  had  been  conspicuous  in  the  diet  only  during  the  summer 
and  fall,  were  made  an  important  part  of  nearly  every  midday  meal  at  all  seasons. 
No  canned  foods  other  than  tomatoes  were  allowed.  This  was  done  in  order  to  elimi- 
nate the  possibly  injurious  action  on  the  foods  of  the  high  temperatures  to  which 
they  are  necessarily  subjected  in  the  process. 

The  carbohydrate  component  of  the  institution  diets  was  modified  with  the  object 
of  reducing  the  proportion  of  this  element.  In  this  connection  it  may  be  noted  that 
though  the  com  component  was  much  reduced  it  was  not  wholly  excluded.  Com 
bread  was  allowed  all  children  once  a  week  and  to  those  over  12  years  of  age  grits 
once  or  twice  a  week  in  addition. 

Of  the  209  cases  of  pellagra  observed  at  the  two  orphanages  during  the  spring  and 
summer  of  1914,  up  to  September,  1915,  not  less  than  172  completed  at  least  the  anni- 
versary date  of  their  attacks  under  observation.  In  only  1  of  these  172  pellagrins, 
following  the  change  of  diet,  was  there  recognized  during  the  year  1915  evidence 
justifying  a  diagnosis  of  a  recurrence,  although,  on  the  basis  of  Rice's  *  experience 
at  an  orphanage  in  Columbia,  S.  C,  there  mi^t  reasonably  have  been  expected 
some  58  to  76  per  cent,  or  99  to  130  of  them,  to  recur.  Furthermore  there  was  observed 
no  new  case  in  any  of  the  nonpellagrin  residents,  168  of  whom  were  continuously 
under  observation  for  at  least  one  year.  Recent  admissions  aside,  there  has,  during 
1915,  been  no  pellagra  at  one  and  but  a  single  case  at  the  other  of  these  insitutions. 

Asylum  study, — ^Through  the  courtesy  and  with  the  very  helpful  cooperation  id 
the  officers  and  staff  of  the  Georgia  State  Sanitarium,  two  wards  of  pellagrins,  one  in 
the  colored  and  the  other  in  the  white  female  service,  were  made  available  for  the 
test. 

Large  numbers  of  cases  of  pellagra  are  observed  annually  at  this  institution,  the 
largest  in  the  South.  A  large  proportion  of  these  are  admission  cases,  but  cases  d 
intramural  origin  are  of  frequent  occurrence.  This  asylum  must,  therefore,  be  re- 
garded as  an  endemic  focus  of  the  disease. 

The  wards  were  organized  for  this  test  late  in  the  fall  of  1914.  In  selecting  the 
patients  only  one  condition  was  observed,  namely,  that  the  patient  should  be  d 
such  a  type  as  would  give  reasonable  degree  of  probability  of  remaining  under  obser- 
vation for  at  least  a  year.  In  consequence  a  considerable  proportion  were  of  a  much 
deteriorated,  untidy  class. 

lOoldberger,  Wiring,  and  WJlleU  1915  b^  P319e 


FUBUO  HEALTH  AKD  MEDICINB.  7 

The  diet  furniahed  the  inmatee  of  theee  two  wards  was,  as  at  the  orphanages,  sup- 
plemented by  the  Public  Health  Service  and  modified  so  as  to  increase  decidedly 
the  proportion  of  the  animal  and  leguminous  protein  elements.  A  cup  of  about 
7  ounces  of  sweet  milk  is  furnished  each  patient  for  breakfast  and  one  of  buttermilk 
at  both  dinner  and  supper.  Fully  half  a  pound  of  fresh  beef  and  2  to  2)  ounces  of 
dried  field  peas  or  dried  beans  enter  the  daily  ration.  In  order  to  favor  the  consump- 
tion of  milk,  oatmeal  has  almost  entirely  replaced  grits  as  the  breakfast  cereal.  With 
a  view  of  reducing  the  carbohydrate  component,  sirup  has  been  entirely  excluded. 
Com  products,  althou^  greatly  reduced,  have  not  been  entirely  eliminated.  The 
menu  that  follows  will  sorve  to  give  a  more  detailed  idea  of  the  character  of  the  diet 

M  *   %        %. 

WBBKLT  MBNU. 

Mcnday, — Breakfast:  Grits,  sweet  milk,  sugar,  broiled  steak,  hot  rolls,  biscuits, 
cofifee.  Dinner:  Boast  beef,  gravy,  peas,  potatoes,  rice,  biscuits,  buttermilk.  Sup- 
per: Stewed  apples,  light  bread,  coffee,  buttermilk,  sugar. 

Tuuday. — Break^urt:  Oatmeal,  sweet  milk,  sugar,  hamburg  steak,  biscuits,  hot 
rolls,  coffee.  Dinner:  Beef  stew,  potatoes,  rice,  bread,  buttennilk.  Supper:  Baked 
beans,  light  bread,  coffee,  sugar,  buttennilk. 

YFedneadlciy.— Breakfast:  Oatmeal,  sweet  milk,  sugar,  beef  hash,  hot  rolls,  biscuits, 
coffee.  Dinner:  Pea  soup,  com  bread,  gravy,  potatoes,  rice,  bread,  buttermilk. 
Supper:  Stewed  prunes,  light  bread,  coffee,  sugar,  buttermilk. 

Tkundojf, — ^Breakfast:  Oatmeal,  sweet  milk,  sugar,  fried  steak,  hot  rolls,  biscuits, 
coffee.  Dinner:  Beef  stew,  peas,  potatoes,  rice,  bread,  buttermilk.  Supper:  Baked 
beans,  bread,  coffee,  sugar,  buttermilk. 

Friday, — Breakfast:  Oatmeal,  sweet  milk,  sugar,  broiled  beefsteak,  hot  rolls,  bis- 
cuits, coffee.  Dinner:  Pea  soup  (pur^),  roast  beef,  potatoes,  rice,  bread,  butter- 
milk.   Supper:  Lig^t  bread,  coffee,  sugar,  buttermilk,  apples,  baked  beans. 

Saturday, — ^Breaktot:  Oatmeal,  sweet  milk,  sugar,  hamburg  steak,  hot  rolls,  bis- 
cuits, coffee.  Dinner:  Beef  stew,  potatoes,  rice,  bread,  buttermilk.  Supper:  Bread, 
baked  beans,  buttennilk,  coffee,  sugar. 

^ttfulrqf. —-Breakfast:  Oatmeal,  sweet  milk,  sugar,  mackerel,  bread,  coffee.  Dinner: 
Loaf  beef  and  gravy,  peas,  potatoes,  rice,  bread,  buttermilk,  pudding.  Supper:  Beef 
bash,  bread,  sugar,  coffee,  buttennilk. 

NoTS.— Qreen  vegetables  in  season  at  irregular  intervals.  Milk  and  eggs,  as  a 
■pedal  diet,  are  furnished  those  patients  who  may  require  them. 

Aside  from  the  modification  in  the  diet  and  the  increased  watchfulness  over  the 
individual  feeding,  enjoined  on  the  nurses  and  attendants,  no  change  in  the  habitual 
routine  of  the  corresponding  services  was  made. 

Of  the  pdlagrins  admitted  to  these  wards  at  the  time  of  their  organization,  or  shortly 
thereafter— ^hat  is,  up  to  Deoembor  31, 1914—72  (36  colored  and  36  white)  remained 
continuously  under  observation  up  to  October  1,  1915,  or,  at  least,  until  after  the 
annivefsary  date  of  their  attack  of  1914.  Of  the  colored  patients,  8  have  histories  of 
at  least  2  annual  attacks;  of  the  white  patients  10  have  histories  of  at  least  2  attacks. 
Nevertheless  not  a  single  one  of  this  group  of  72  patients  has  presented  recognizable 
evidence  of  a  recurrence  of  pellagra,  although  of  a  group  of  32  control  pellagrins  (17 
colored  and  15  idiite)  not  receiving  the  modified  diet,  15  (9  colored,  6  white),  or  47  per 
cent,  have  had  recurrences  during  the  corresponding  period. 

iSi^t/lcance.— Considering  the  foregoing  results  as  a  whole,  bearing  in  mind  that 
three  different  institutions  are  involved,  each  institution  an  endemic  focus  of  the 
disease,  and  bearing  in  mind  also  that  the  number  of  individuals  is  fairly  large  it 
would  seem  that  the  conclusion  is  justified  that  the  pellagra  recurrence  may  be  pre- 
Tented  and,  in  view  of  the  conditions  of  the  experiment,  that  it  may  be  prevented 
without  the  intervention  of  any  other  factor  than  diet.    In  this  connection  the  quea- 


8  PB0CEEDINQ8  BEOOKD  PAK  AMTCRTOAIT  SOIBiriinO  00KQBB8S. 

Hon  arises  whether  it  is  permissible  to  extend  this  condusion  to  the  primary  attack, 
apart  from  its  recurrence.  The  charactw  of  the  answer  to  this  question  will  depend  on 
the  view  held  as  to  the  nature  of  the  pellagra  recurrence. 

Among  the  epidemiological  features  of  pellagra  none  is  more  striking  than  the 
tendency  for  the  disease  not  only  to  develop  in  spring  or  early  summer,  but  to  recur 
year  after  year  at  about  the  same  season.  Various  explanations  of  this  singular  phe- 
nomenon have  been  advanced.  According  to  Sambon  (1910,  p.  49),  ''this  peculiar 
periodicity  of  symptoms  can  be  explained  only  by  the  agency  of  a  parasitic  organism 
presenting  definite  alternating  periods  of  latency  and  activity. ' '  A  somewhat  similar 
conception  appears  to  be  held  by  the  Thompson-MacFadden  Commission  (SUer, 
Garrison,  and  MacNeal,  1914c),  who  distinguish  between  conditions  favorable  for  the 
development  of  the  disease,  in  the  first  place,  and  those  that  permit  its  subsequent 
recurrence.  Why  these  and  many  other  observers  should  consider  this  periodicity  of 
symptoms  as  explicable  only  by  the  agency  of  a  parasitic  organism  or  of  a  virus  or  a 
toxin  presenting  definite  alternating  periods  of  latency  and  activity  is  rather  hard 
to  understand  when  it  is  recalled  that  in  endemic  scurvy  (Lind,  1772,  pp.  33, 34, 130, 
306),  and  particularly  in  endemic  beriberi  (Scheube,  1903),  diseases  of  well-known 
dietary  origin,  a  strikingly  similar  periodicity  is  present.  It  would  seem,  therefore, 
entirely  permissible  to  invoke  as  an  explanation  of  the  periodic  recurrence  in  pellagra 
what  undoubtedly  is  the  explanation  of  the  same  phenomenon  in  these  other  dis- 
eases, namely,  a  modification  or  change  in  diet  brought  about  by  or  incidental  to  the 
recurring  seasons.  Viewed  in  this  light,  the  recurrence  in  pellagra  may  be  consid' 
ered  as  in  beriberi,  etiologically  at  least,  as  essentially  identical  with  the  initial  attack, 
and,  therefore,  it  would  seem  permissible  to  conclude  that  the  means  found  effective 
in  the  prevention  of  recurrences  will  be  found  effective  in  the  prevention  of  the  initial 
attack. 

NATURE  OF  DI8B1BB. 

In  the  course  of  the  preliminary  studies  relating  to  the  prevalence  of  pellagra  at 
such  institutions  as  prisons,  asylums,  and  orphanages,  to  which  reference  was  made 
early  in  this  paper,  the  association  was  found  of  a  very  high  incidence  of  pellagra, 
restricted  to  certain  groups,  with  a  diet  which  differed  from  the  diet  of  the  exempt 
groups  so  far  as  could  be  determined  only  in  that  it  included  minimal  quantities  of 
the  animal  foods.  It  was  inferred  at  that  time  that  this  association  had  etiological 
significance.  Advantage  has  been  taken  of  an  opportunity  to  put  this  inference  to 
the  test  of  experiment. 

The  experiment  was  carried  out  in  association  with  Asst.  Surg.  G.  A.  Wheeler  at  the 
farm  of  the  Mississippi  State  Penitentiary,  about  8  miles  east  of  Jackson,  Miss. 

At  about  the  center  of  this  farm  of  some  3,200  acres,  well  isolated  from  the  sur- 
rounding community,  is  the  convict  camp.  There  is  no  history  of  the  previous 
occurrence  or  presence  of  pellagra  on  this  farm.  During  the  period  of  the  experiment 
there  were  quartered  at  the  camp  an  average  of  between  70  and  80  white  male  convicts, 
of  whom  some  30  were  present  throughout  this  time.  Throu^  the  kind  offices  of 
Dr.  E.  H.  Galloway,  secretary  of  the  Mississippi  State  Board  of  Health,  the  interest 
of  Gov.  Earl  Brewer  was  enlisted,  who,  on  the  offer  of  a  pardon,  obtained  12  vdunteen 
for  the  test. 

ExperimenL — White  adult  males  were  selected  because,  judged  by  the  inddence 
of  the  disease  in  the  population  at  large,  this  age,  sex,  and  race- group  would  seem  to 
be  the  least  susceptible  to  the  disease. 

The  "pellagra  squad, "  as  it  came  to  be  called,  was  organized  between  February  1 
and  February  4,  1915,  with  12  volunteers.  On  July  1,  1915,  one  of  the  squad  was 
released  because  of  the  development  of  a  physical  infirmity.  This  left  11  men  in 
the  squad,  24  to  60  years  of  age,  who  remaii^  in  the  test  to  its  termination,  October 
SI,  1915.    These  men  were  quartered  in  a  small,  practically  new,  screened  cottage, 


FUBLIO  HEALTH  AKD  MEDIdKB.  9 

about  500  feet  from  the  "cage "  in  which  the  other  convicts  were  domiciled.  Part  of 
thie  cottage  had  previoualy  heen  need,  and  continued  to  be  used,  throughout  the 
period  of  the  experiment  as  quarters  for  one  of  the  officers  of  the  camp.  From  the 
time  of  its  oiganisation  the  squad  was  segregated  and  under  special  guard. 

From  February  4  to  April  19,  1915,  a  period  of  2}  months,  these  men  were  kept 
under  observation  without  any  change  in  the  regular  prison  fare.  Having  detected 
no  evidence  of  pellagra  during  this  preliminary  observation  period,  the  diet  of  the 
squad  was  changed  at  noon  April  19,  1915.  The  ingredients  of  this  diet  were  wheat 
flour  (patent),  com  meal,  (com)  grits,  cornstarch,  white  polished  rice,  standard 
granulated  sugar,  cane  sirup,  sweet  potatoes,  pork  fat  (fried  out  of  salt  pork),  cabbage, 
collards,  turnip  greens,  and  coffee.  In  the  preparation  of  the  biscuits  and  of  the 
com  bread  Royal  baking  powder  was  used. 

The  quantities  of  the  different  articles  of  cooked  food  actiially  consumed  is  illus- 
trated by  the  following  for  the  week  ended  August  8,  1915: 

Biscuits,  41.81  pounds;  rice,  24.25  pounds;  com  bread,  24.56  pounds;  grits,  27.06 
pounds;  fried  mush,  33.87  pounds;  brown  gravy,  37.81  pounds;  sweet  potatoes,  23.62 
pounds;  cabbage,  4.25  pounds;  collards,  23.75  pounds;  cane  simp,  5.94  pounds;  sugar, 
8.75  pounds,  making  a  total  of  255.67  pounds  of  food  consumed  during  the  week,  or 
3.32  pounds  per  man  per  day,  having  a  value  of  2,952  calories. 

In  this  connection  it  may  be  i)ertinent  to  note  that  the  com  meal  and  grits  were  ol 
the  best  quality  obtainable  at  the  local  market  and  the  same  as  that  used  at  one  of  the 
orphanages  at  which  the  test,  already  discussed,  of  the  value  of  diet  in  prevention 
was  made  and  at  which  no  pellagra  occurred  this  year.  Except  for  one  meal  in 
which  4  ounces  of  meat  were  included  the  animal  proteins  and  legumes  were  almost 
entirely  excluded. 

The  character  of  the  labor  periormed  by  these  men  during  the  week  for  which  the 
statement  of  the  quantity  of  food  consumed  has  been  given  was  as  follows:  White- 
washing fences  and  buildings,  2^  days;  sawing  lumber  (ram  sawmill),  2  days;  rest, 
2i  days. 

The  volunteers  kept  about  the  same  hours  and  did  about  the  same  kind  of  work  as 
the  other  convicts.  The  amount  oi  labor  periormed  by  the  volunteers  was,  however, 
distinctly  less  than  that  by  the  other  convicts. 

The  general  sanitary  environment  was  the  same  tor  volunteers  and  controls.  With 
respect  to  personal  cleanliness,  cleanliness  of  quarters,  freedom  from  insects,  par- 
ticulariy  bedbugs,  flies,  amd  mosquitoes,  the  volunteers  were  decidedly  better  ofif. 

RemlU.'-Ot  the  11  volunteers  not  less  than  6  developed  symptoms,  including  a 
''typical "  dermatitis,  justifying  a  diagnosis  of  pellagra.  Loss  of  weight  and  strength 
and  mild  nervous  symptoms  appeared  early.  The  gastrointestinal  symptoms  were 
flli^t.  Definite  cutaneous  numifestations  were  not  noted  until  September^  12,  or 
about  five  months  after  the  beginning  of  the  restricted  diet.  In  all  6  cases  the  skin 
lesions  were  first  noted  on  the  scrotum.  Later  the  eruption  also  api)eared  on  the 
hands  in  2  of  the  cases,  and  on  the  back  of  the  neck  in  1.  The  scrotal  lesion  conformed 
to  the  type  described  and  figured  by  Merk  (1909,  p.  24,  fig.  6),  and  also  by  Stannus 
(1913). 

Although  the  entire  population  of  the  camp  was  kept  under  observation,  no  one, 
not  of  the  volunteer  squad,  presented  evidence  justifying  even  a  suspicion  of  pellagra. 

The  diagnosis  of  pellagra  was  concurred  in  by  Dr.  E.  H.  Galloway,  secretary  Missis- 
sippi State  Board  of  Health,  and  Dr.  Nolan  Stewart,  formerly  superintendent  Missis- 
sippi Asylum  for  Insane,  at  Jackson.  In  excluding  the  other  known  dermatoses  the 
expert  Imowledge  and  skill  of  Prof.  Marcus  Haase  of  the  Medical  College  of  the  Univer- 
sity of  Tennessee,  Memphis,  Tenn.,  and  of  Prof.  Martin  F.  Engman  of  the  Washington 
University  Medical  School,  St.  Louis,  Mo.,  was  utilized  in  consultation. 

Condu»ion8.— The  conclusion  drawn  from  this  experiment  is  that  pellagra  hfia  been 
brought  about  in  at  least  6  of  the  11  volunteers  as  the  result  of  the  one-sided  diet  on 


10  PBOGEEDINGS  SECOND  PAH  AMEBIOAK  SdBNTIFIO  CONGBESS. 

which  they  subsiflted.  Taken  in  conjunction  with  the  striking  results  of  the  test  of 
the  preventive  value  of  diet,  the  further  conclusion  seems  justified  that  pellagra  is 
essentially  of  dietary  origin. 

In  order  to  avoid  misunderstanding  it  may  be  weU  to  point  out  that  it  does  not  neces- 
sarily follow  that  all  one-sided,  unbalanced  or,  as  the  writer  prefers  for  the  present  to 
speak  of  them,  faulty  diets  are  capable  of  bringing  about  pellagra  any  more  than  they 
are  of  bringing  about  scurvy  or  beriberi. 

A  definite  conclusion  as  to  the  intimate  mechanism  involved  in  bringing  about  or  in 
preventing  the  disease  by  diet  can,  of  course,  not  be  drawn  from  the  available  data. 
It  would  be  premature  to  conclude  that  pellagra  is  necessarily  due  to  a  lack  or  defi- 
ciency of  fresh  animal  or  leguminous  protein  foods.  Clearly,  however,  the  dietary 
'*f9MlV*  upon  which  the  production  of  pellagra  essentially  depends  is  capable  of  being 
corrected  or  prevented  by  including  in  the  diet  a  suitable  proportion  of  these  foods. 
It  would  be  equally  premature,  moreover,  to  assume  that  the  pellagra-causing  dietary 
"&ult"  is  capable  of  correction  in  this  way  only.  The  possibility  that  there  may  be 
other  foods  capable  of  serving  the  same  purpose  is  by  no  means  to  be  overlooked.  It 
may  be,  too,  if  Funk's  suggestion  that  pellagra  is  a  vitamine  deficiency,  brought  about 
by  the  consumption  of  overmilled  com,  is  proven  to  be  correct,  that  the  use  of  under- 
milled  com  will  of  itself  correct  the  **fault"  in  a  diet  in  which  this  cereal  is  the  staple. 
There  is  to  be  considered  also  Voegtlin's  explanation  of  the  beneficial  effect  of  a  liberal 
diet  on  the  course  of  the  disease.  Voegtlin  suggests  that  by  substituting  for  part  of  the 
vegetable  food  animal  foodstuffs,  the  absolute  amoimt  of  vegetable  products  con- 
sumed will  be  reduced  considerably  and  thus  probably  also  reduce  the  possibility  of 
an  injurious  action  of  the  v^;etable  food  on  the  body,  particularly  the  irritant  action 
on  the  gastrointestinal  canal.  On  the  whole,  however,  the  trend  of  available  evi- 
dence strongly  suggests  that  pellagra  will  prove  to  be  a  ''deficiency"  disease  very 
closely  related  to  beriberi. 

For  the  practical  purposes  of  preventive  medicine,  the  point  of  chief  of  fundamental 
importance  would  seem  to  be  the  recognition  of  the  fact  that  the  pellagra-producing 
dietary  fault,  whatever  its  intimate  nature,  or  however  brought  about,  is  capable  of 
correction  or  prevention,  as  the  results  of  the  studies  above  summarized  clearly  indi- 
cate, by  including  in  the  diet  suitable  proportions  of  the  fresh  animal  and  leguminous 
protein  foods. 

SUMMARY. 

1.  Diet  is  the  common  factor  in  the  various  methods  of  treatment  recently  advocated . 
The  marked  success  claimed  for  each  of  these  methods  must  logically  be  attributed  to 
the  ^tor  (diet)  which  they  have  in  common. 

2.  The  value  of  diet  in  the  prevention  of  pellagra  has  been  tested  at  two  orphanages 
and  at  an  asylum  for  insane,  endemic  foci  of  the  disease.  Marked  increases  in  the 
fresh  animal  and  leguminous  protein  elements  of  the  institution  diets  were  made. 

Of  209  cases  of  pellagra  observed  at  the  two  orphanages  during  the  spring  and  sum- 
mer of  1914,  not  less  than  172  completed  at  least  the  anniversary  date  of  their  attack 
under  observation.  In  only  one  of  these  172  pellagrins,  following  the  change  in  diet, 
was  there  recognized  evidence  of  a  recurrence,  although  on  the  basis  of  experience  else- 
where some  99  to  130  might  reasonably  have  been  expected.  Nor  was  any  new  case 
observed  among  the  nonpellagrin  residents,  168  of  whom  completed  not  less  than  one 
year  imder  observation. 

Of  the  group  of  pellagrins  on  the  modified  diet  at  the  insane  asylum,  72  remained 
continuously  imder  observation  up  to  October  1, 1915,  or  at  least  until  after  the  anni- 
versary date  of  their  attack  of  1914.  Not  one  of  this  group  has  presented  recognizable 
evidence  of  a  recurrence,  although  of  a  group  of  S2  controls  15  have  had  recurrences. 
Pellagra  may,  therefore,  be  prevented  by  an  appropriate  diet  without  any  alteration 
in  the  environment,  hygienic  or  sanitary,  including  the  water  supply. 


PUBLIO  HEALTH  AND  MEDIdNB.  11 

3.  At  uk  iflolatod  convict  camp,  previously  free  from  pellagra,  with  an  average 
population  of  70  to  80  white  males,  11  volunteers  were  segregated  and,  after  a  prelimi- 
nary observation  period  of  2^  months,  placed  on  an  abimdant  but  one^ded,  chiefly 
carbohydrate  (wheat,  com,  rice)  diet,  from  which  fresh  animal  proteins  and  legumes 
were  excluded.  At  least  6  of  these  volunteers  developed  pellagra.  This  result  would 
appear  to  have  been  brought  about  by  the  diet  on  which  they  subsisted. 

4.  A  definite  conclusion  as  to  the  intimate  mechanism  involved  in  bringing  about 
or  in  preventing  the  disease  by  diet  can  not  be  drawn  from  the  available  data. 

5.  For  the  practical  purposes  of  preventive  medicine  it  would  seem  to  be  of  funda- 
mental importance  to  recognize  that  the  pellagra-producing  dietary  &ult,  whatever 
its  intimate  nature  or  however  brought  about,  is  capable  of  correction  or  prevention 
by  including  in  the  diet  suitable  proportions  of  the  fresh  animal  and  leguminous 
protein  foods. 

BBFBBBN0B8. 

1914a.  Funk.    (Casimir);  Die  Vitamine.    Wiesbaden,  1914. 

19146.  Idem.  Prophylaxie  und  Therapie  der  Pellagra  ins  Lichte  der  Vitaminl^ire. 
Munch.  Med.  Wchnschr.,  1914,  pp.  698-699. 

1914a.  Goldbeiger  (Joseph).  The  Etiology  of  Pellagra;  the  significance  of  certain 
epidemological  observations  with  respect  thereto.  Public  Heedth  Reports,  Wash- 
ington, June  26, 1914,  pp.  1683-1686. 

19146.  Idem.    The  Cause  and  Prevention  of  Pellagra. 
Idem .    September  1 1 ,  1914 . 

1914e.  Idem.  Beans  for  Prevention  of  Pellagra.  Joum.  Am.  Med.  Assn.,  vol.  63, 
October  10, 1914,  p.  1314. 

1914a.  Goldbeiger  (Joseph),  Waring  (C.  H.),  and  Willets  (David  G.).  The  Treat- 
ment and  Prevention  of  Pellagra.  Public  Health  Reports,  Washington,  October 
23, 1914. 

19146.  Idem.  Idem.  Reprint  No.  228  from  Public  Health  Reports,  Washington, 
October  23, 1914. 

1915a.  Idem.  Idem.  Reprint  No.  228  from  Public  Health  Reports,  Washington, 
October  23, 1914.    Revised  Edition,  January  15,  1915. 

19156.  Idem.  The  Prevention  of  Pellagra;  a  test  of  diet  among  institutional  inmates. 
Public  Health  Reports,  Washington,  October  22,  1915,  pp.  3117-3131. 

1915.  Goldberger  (Joseph)  and  Wheeler  (G.  A.).  Experimental  Pellagra  in  the  Hu- 
man Subject  brought  about  by  Restricted  Diet.  Public  Health  Reports,  Wash- 
ington, November  12, 1915,  pp.  3336-3339. 

1772.  Lind  (James).    A  Treatise  on  the  Scurvy.    3d  Ed.,  London,  1772. 

1916.  Littie  (Y.  A.).  The  Dietetic  Treatment  of  Pellagra.  With  report  of  eleven 
cases.    Southern  Med.  Joum.,  vol.  8,  August,  1915,  pp.  659-662. 

1914.  Lorenz  (W.  F.).  The  Treatment  of  Pellagra.  Public  Health  Reports,  Wash- 
ington, September  11,  1914. 

1909.  Merk  (Ludwig).    Die  Hauterscheinungen  der  Pellagra.    Innsbruck,  1909. 

1914.  Meyers  (C.  N.)  and  VoegtUn  (Carl).  Soluble  Aluminum  Compounds;  Their 
Occurrence  in  certain  Vegetable  Ftoducts.  Public  Health  Reports,  Washington, 
June  19, 1914,  vol.  29,  pp.  1625-1629. 

1866.  Roussel  (Theophile).  Traits  de  la  Pellagra  et  des  Pseudo-Pellagres.  Paris, 
1866. 

1910.  Sambon  (Louis  W.).  Projpress  Report  on  the  Investisation  of  Pellagra.  (Re- 
print from  the  Joum.  Trop.  Med.  and  Hyg.)  London,  1910. 

1903.  Scheube  (B).    The  Diseases  of  Warm  Countries.    London,  1903. 

1914a.  Siler,  J.  F.,  Garrison,  P.  E.,  and  MacNeal,  W.  J.    Further  studies  of  the 

Thompson-McFadden  Pellagra  Commission.    Joum.  Am.  Med.  Assn.,  Sept.  26, 

1914,  p.  1090. 
19146.  Siler.  J.  F.,  Garrison,  P.  E.,  and  MacNeal,  W.  J.^   A  statistical  study  of  the 

relation  of  pellagra  to  use  of  certain  foods  and  to  location  of  domicile,  etc.    Arch. 

Int.  Med.,  October,  1914. 
1914c.  Siler,  J.  F.,  Garrison,  P.  E.,  and  MacNeal,  W.  J.    The  relation  of  Methods  of 

disposal  of  sewage  to  the  spread  of  pellagra.    Arch.  Int.  Med.,  Sept.,  1914. 


12  PB00EEDINQ8  SECOND  PAN  AMEBICAN  801ENTIFIC  C0NQBB88. 

1913.  Stannus  (Hugh  S.).    Pellam  in  Nyasaland,  Trans.  Soc.  Trop.  Med.  and  Hyg., 
November,  1913,  vol.  7,  pp.  32-^. 

1913.  Vedder  (Edward  B.).    Beriberi.    New  York,  1913. 

1914.  Voefftlin  (Carl).    The  Treatment  of  Pellagra.    Joum.  Am.  Med.  Asm.  Sep- 
tember 26,  1914,  vol.  63,  pp.  1094-1096. 

1915.  WiUets  (David  6.).    The  Treatment  of  Pellagra  by  Diet.    Southern  Med. 
Joum.,  December,  1915,  vol.  8,  pp.  1044-1047. 

The  Chaibman.  Dr.  Goldberger's  paper  is  open  for  discussion. 

Dr.  AoBAMONTB.  The  question  of  pellagra  in  South  and  Central 
America  is  still,  I  believe,  to  be  investigated.  So  far  as  I  know, 
pellagra  has  not  been  observed  in  Cuba.  That  may  be  accounted 
for  to  a  certain  extent — discounting  the  possibility  of  unrecognized 
cases,  which,  of  course,  must  be  considered — by  the  fact  that  the 
diet  in  our  country  is  quite  abundant  in  leguminous  food,  particu- 
larly beans,  which  form  a  usual  part  of  tibe  menu  almost  every- 
where, and  as  for  the  orphanages  and  asylums  either  com  or  beans 
form  a  daily  part  of  the  diet.  The  fact  that  is  pointed  out  by  Dr. 
Ooldberger  and  well  known  to  those  who  have  studied  this  question, 
viz.,  that  the  disease  imtreated  tends  to  recur,  would  serve  to  do 
away  with  the  idea  of  the  disease  passing  unrecognized  amongst  us. 
If  we  did  not  think  of  it  the  first  time,  I  think  o\ir  attention  would 
have  been  called  to  it  the  next  time  or  at  a  subsequent  time,  so  I  feel 
safe  in  stating  that  we  have  no  cases  of  pellagra,  at  least  in  our  public 
institutions. 

About  three  years  ago  I  had  occasion  to  see  a  few  cases  of  pellagra 
in  London,  shown  to  me  by  Dr.  Sambon  at  the  time  when  he  claimed 
that  the  simulium  was  the  cause  of  the  disease,  and  he  explained 
the  reason  of  these  recurrences  by  calling  attention  to  the  fact  that 
the  recurrence  took  place  during  the  warmer  part  of  the  year,  when 
the  parasitic  nature  of  the  disease  seemed  more  in  condition  to 
develop.  Of  course  that  has  all  been  explained  by  Dr.  Ooldberger, 
and  the  argument  alone  would  not  be  sufficient  to  do  away  with  all 
other  arguments. 

The  Chairman.  Is  there  anybody  else?  I  see  that  Capt.  Siler,  of 
the  Robert  M.  Thompson  Pellagra  Commission,  is  here. 

Capt.  J.  F.  SiLEB,  M.  C,  United  States  Army.  I  think  we  should 
all  congratulate  Dr.  Ooldberger  on  the  very  thorough  way  in  which 
he  has  demonstrated  that  we  can  cure  and  prevent  pellagra  by 
dietary  changes.  I  think  those  of  us  who  have  treated  pellagra 
have  been  very  much  struck  by  the  fact  that  a  very  large  percentage 
of  the  victims  have  been  living  on  a  restricted  diet,  and  also  that 
recovery  would  occur  in  a  very  large  majority  of  cases  by  putting 
them  on  the  proper  diet.  I  suppose  that  in  the  three  years  I  was 
working  with  pellagra  I  have  probably  answered  two  to  three  himdred 
letters  from  patients  who  had  it,  and  my  advice  was  always  to  treat 
the  disease  as  if  it  were  tuberculosis ;  that  is  to  say,  to  build  up  the 


FUBUO  HBALIH  AVD  M^IGINB.  13 

nutrition  by  the  use  of  eggs  and  milk  particularly;  and  though  such 
a  diet  did  not  give  results  in  all  individual  cases,  in  a  large  majority 
of  cases  the  results  were  good. 

One  point  to  which  I  wish  to  refer  is  the  disappearance  of  pellagra  in 
institutions  and  in  communities.  We  made  epidemiological  studies 
in  Spartanbu]^  County,  S.  C,  as  well  as  other  places  in  this  country 
and  abroad,  and  we  found  it  to  be  not  unusual  to  have  a  large  amount 
of  pellagra  in  a  community  one  year  and  very  little  or  none  the  fol- 
lowing year.  We  had  a  number  of  instances  of  that  kind.  There 
is  a  mill  village  near  Spartanbui^,  S.  C,  in  which  in  1910  or  1911 
you  could  go  out  any  day  and  find  50  or  60  cases  of  active  pellagra. 
In  1914  there  were  only  two  or  three  cases  in  that  village.  So  far 
as  we  could  determine,  no  particular  dietary  changes  had  been  made 
in  that  time.  There  was  a  very  distinct  tendency  to  better  condi- 
tions in  the  way  of  improved  hygiene  and  sanitation,  but  we  could 
not  lay  our  finger  on  any  particular  change  or  changes  to  which  we 
could  attribute  the  marked  decrease  in  incidence. 

In  1913  I  made  a  trip  with  Dr.  Sambon,  of  London,  to  the  British 
West  Indies,  including  Jamaica  and  Barbados.  In  Jamaica,  curiously 
enough,  the  disease  appeared  to  be  confined  to  two  or  three  institu- 
tions. We  examined  several  thousand  people  in  villages  and  insti- 
tutions in  all  parts  of  Jamaica,  and  found  pellagra  prevailing  in  but 
two  institutions — the  asylum  and  a  home  for  children.  The  diet  in 
the  children's  home  was  very  poor,  but  even  so  it  was  better  and 
more  varied  than  the  inmates  were  getting  before  they  went  into  the 
home.  In  1913,  when  we  made  this  trip,  between  10  and  15  per 
cent  of  the  children  in  this  home  were  affected.  I  have  heard  recently 
from  authoritative  sources  that  during  the  past  two  years  they  have 
made  no  changes  in  the  dietary,  only  giving  tonics,  and  the  disease 
has  disappeared.  We  have  noted  repeatedly  in  our  epidemiological 
studies  that  the  incidence  rate  has  a  tendency  to  go  up  one  year  and 
down  the  next. 

I  also  noticed  in  investigating  conditions  in  the  West  Indies  that 
individuals  who  were  living  on  an  improper  and  poorly  balanced  diet, 
presented  all  the  evidences  of  undernourishment,  and  one  of  the 
strikmg  evidences  presented  by  them  was  interference  with  the  nutri- 
tion of  the  skin.  Dr.  Sambon  wished  to  class  these  as  pellagra, 
though  the  skin  symptoms  were  somewhat  atypical.  I  did  not  agree 
with  him  for  the  reason  that  I  could  in  no  instances  get  a  history  of, 
nor  did  I  personally  observe  any  individuals  with  the  gastro-intestinal 
symptoms  so  common  in  pellagra.  In  Barbados,  when  going  through 
the  poorer  sections  of  Bridgetown,  by  house-to-house  canvass,  and  in 
Jamaica,  we  saw  many  cases  which  seemed  to  me  to  fit  the  ones  that 
Dr.  Goldberger  has  described  to-day  as  occurring  in  the  convicts. 
I  particularly  wish  to  ask  him  just  what  the  gastro-intestinal  symp- 


14  PBOGEEDINOS  SECOND  PAN  AMEBICAN  80IENTIFI0  OONQRESS. 

toms  were  that  he  refers  to.  It  seems  to  me  that  in  a  crucial  test 
of  this  kind,  where  people  have  been  on  a  so-called  pellagra-producing 
diet  for  the  length  of  time  these  convicts  were,  he  ought  to  have  gotten 
two  or  three  cases  with  at  least  moderate  but  typical  intestinal  symp- 
toms so  frequently  observed  with  pellagra.  The  cases  that  I  saw 
in  Barbados  and  Jamaica  that  presented  somewhat  atypical  skin 
lesions  resembling  pellagra,  gave  no  definite  gastro-intestinal  symp- 
toms, and  in  not  a  single  case  did  I  see  the  picture  so  frequently  found 
in  pellagra  of  a  severe  stomatitis. 

There  are  many  observations  that  lead  me  to  feel  that  it  is  quite 
possible  that  some  etiological  factor  in  addition  to  dietary  faults 
enters  into  the  production  of  pellagra.  Dr..Goldberger  has  demon- 
strated very  clearly  that  the  way  to  cure  pellagra  and  to  prevent 
pellagra  in  practically  all  cases  is  to  give  the  proper  food.  In  con- 
sidering all  the  factors  entering  into  the  causation  of  pellagra,  there 
are  some  things  that  seem  to  me  to  be  difficult  of  explanation  on  a 
dietary  hypothesis  alone.  One  of  these  is  the  recent  appearance  of 
pellagra  in  this  country.  There  is  no  question  that  pellagra  has 
been  in  this  country  for  the  last  15,  20,  30,  or  even  40  years;  but  I 
think  there  is  also  no  question  that  about  1906  or  1907  it  began  to 
increase  very  rapidly  in  the  United  States.  We  are  told  that  the 
explanation  of  this  is  that  we  began  to  recognize  it  then.  I  do  not 
believe  that.  I  have  no  doubt  that  many  cases  were  missed  in  the 
early  days,  but  I  believe  that  there  is  no  doubt  that  the  disease  has 
increased  tremendously  in  very  recent  years. 

One  of  the  arguments  advanced  against  calling  pellagra  an  infection 
is  that  doctors  and  nurses  are  presumed  never  to  have  been  affected 
by  it,  though  thrown  with  it  constantly.  Personally,  I  know  of 
about  five  cases  among  nurses,  certainly  of  that  number  among 
nurses  employed  in  institutions.  I  know,  also  of  about  twelve  or 
fifteen  doctors  in  the  South  who  have,  or  have  had  pellagra.  Pellagra 
and  tuberculosis  are,  in  my  opinion,  comparable  in  many  respects; 
and  we  might  with  just  as  much  logic  argue  that  tuberculosis  is  not 
an  infection  because  doctors  and  nurses  working  with  tuberculosis  so 
seldom  acquire  it.  In  the  very  excellent  paper  presented  by  Dr. 
Ravenel,  before  this  congress  last  week,  he  laid  particular  stress  on 
the  fact  that  statistics  show  very  conclusively  that  tuberculosis  is 
but  seldom  acquired  by  nurses  and  doctors  working  in  sanitariums 
for  tuberculosis  or  by  nose  and  throat  specialists  who  are  constantly 
being  thrown  in  contact  with  cases  of  laryngeal  tuberculosis.  I  have 
had  occasion  to  observe  the  incidence  of  tuberculosis  in  doctors  and 
nurses  working  with  such  cases,  and  these  observations  are  con- 
firmatory of  those  cited  by  Dr.  Ravenel. 

One  thing  that  has  struck  me  is  this:  I  have  seen  a  number  of  cases 
of  the  very  severest  type  of  pellagra  that,  during  the  acute  attack, 


PTJBLIO  HEALTH  AKD  MEDICIKB.  15 

adhered  to  a  proper  diet — ^that  is  to  say,  an  increase  in  protein,  more 
particularly  milk  and  eggs — and  recovered  from  the  acute  attack 
with  no  recurrence  in  after  years,  notwithstanding  the  fact  that  they 
have  gone  back  on  the  same  diet  on  which  they  lived  before  they  had 
pellagra.  £  have  gone  into  the  diet  of  a  number  of  people  who  have 
given  such  a  history,  and  it  is  somewhat  hard  for  me  to  understand 
how  a  person  who  has  had  a  disease  of  a  dietary  nature  can  avoid  a 
recurrence  on  a  return  to  the  original  diet  causing  the  disease.  In 
beriberi,  we  know  that  if  one  returns  to  the  beriberi-producing  diet, 
he  is  very  likely  to  acquire  the  disease  again.  I  have  seen  a  number 
of  pellagrins  after  severe  attacks  return  to  what  is  theoretically  a 
pellagra-producing  diet  for  two  or  three  years  or  more  without  the 
slightest  evidence  of  recurrence  of  the  disease,  and  it  is  very  difficult 
for  me  to  explain  this  subsequent  immunity  on  ths  dietary  hypothesis. 

I  have  also  seen  this  happen:  Two  cases  would  go  into  a  hospital 
side  by  side — one  a  very  n^d  case  of  pellagra  in  which  we  wanted  to 
build  up  the  resistance  by  the  use  of  eggs  and  milk;  the  other  a  case 
of  such  great  severity  that  food  could  not  be  swallowed  for  several 
days.  We  would  put  them  on  the  same  diet  and  at  the  end  of  a 
month  or  six  weeks  the  mild  case  would  be  dead  and  the  other  prac^ 
tically  well.    You  see  a  thing  Uke  that  not  infrequently. 

I  have  also  seen  some  cases  where,  though  it  could  not  be  cUumed 
that  the  diet  was  perfect  from  the  viewpoint  of  the  dietary  enthusiast, 
it  seemed  to  me  to  be  very  well  balanced  indeed. 

In  our  epidemiological  studies  we  have  noticed  the  factor  of  dis- 
tribution according  to  race.  In  the  particular  section  in  which  we 
were  working  we  found  that  the  relation  existing  between  the  colored 
race  and  white  race  was  about  one  to  four,  certainly  one  to  three — 
that  is,  three  white  persons  had  pellagra  to  every  colored  person. 
The  diet,  in  my  opinion  (and  I  have  lived  in  the  South;  I  may  say  spent 
my  whole  life  there  until  manhood),  of  the  colored  tenant  farmers  in 
the  section  in  which  we  were  working  more  nearly  approximated  the 
diet  given  the  convicts  in  this  test  than  that  of  the  white  people  of 
the  same  section,  notwithstanding  that  the  proportion  of  pellagra  in 
that  region  was  about  one  to  three.  If  you  will  investigate  condi- 
tions in  Charleston,  S.  C,  you  will  find  the  racial  distribution  reversed; 
there  are  three  cases  of  pellagra  among  the  colored  population  to  every 
case  among  the  whites.  We  investigated  this  point  in  Alabama,  and 
found  that  in  Montgomery  the  disease  is  evenly  distributed  between 
the  negroes  and  the  whites.  In  formulating  any  hypothesis  as  to 
the  etiology  of  pellagra  these  factors  require  consideration. 

In  discussing  diet  as  a  factor  in  the  causation  of  pellagra,  and  par- 
ticularly the  matter  of  proteins,  I  recall  that  several  years  ago  in  the 
State  of  Illinois  a  commission  was  appointed  by  the  governor  to 
investigate  pellagra  in  the  institutions  of  the  State.    I  think  a  good 


16  PB0GEEDINQ8  8E00ND  PAK  AMEBICAN  SOAJtHTUfiO  COKQBBINI. 

many  people  have  overlooked  the  fact  that  this  commission  reported 
that  among  the  institutions  of  the  State  the  one  in  which  the  protein 
content  of  the  diet  was  lowest  never  had  had  a  case  of  pellagra. 

There  are  some  other  points  to  which  I  desire  to  refer.  In  my 
work  on  pellagra  I  have  had  in  mind  beriberi  and  scurvy — our  two 
well-known  deficiency  diseases — and  have  constantly  attempted  to 
connect  the  epidemiology  of  beriberi  and  scurvy  with  the  epidemi- 
ology of  pellagra.  For  instance,  it  is  said  and  we  know  that  nursing 
children  are  very  subject  to  beiiberi.  In  pellagra  I  have  never  seen 
a  case  in  a  child  nursing  its  mother,  although  the  mother  might  have 
a  very  severe  case  of  pellagra.  This  is  another  respect  in  which  pel- 
lagra differs  very  markedly  from  beriberi. 

The  age  and  sex  distribution  are  also  of  great  interest  to  me.  Dr. 
Goldberger  has  spoken  of  the  remarkable  fact  that  women  are  very 
much  more  subject  to  pellagra  than  men.  In  1913  we  had  collected 
a  series  of  740  cases,  of  which  in  a  group  of  414  between  the  ages  of 
20  and  44  there  were  357  women  as  against  57  men.  This  is  most 
remarkable,  in  my  opinion,  in  comparing  the  disease  with  beriberi. 
So  far  as  I  can  determine  from  mortality  statistics,  beriberi  is  more 
evenly  distributed.  It  might  be  argued  that  the  men  in  the  home 
are  getting  the  best  diet,  but  I  have  investigated  the  homes  of  the 
people  most  subject  to  pellagra  and  they  do  not  have  meat  every 
day,  so  the  men  could  not  get  it.  If  they  have  not  the  proper  food 
on  their  tables,  how  can  they  get  it,  and  how  do  the  tremendous 
number  of  men  escape  the  disease  ? 

This  is  a  very  haphazard  discussion,  but  I  should  like  to  ask  Dr. 
Goldberger  if  he  has  ever  gotten  any  negative  results  that  seemed  to 
him  to  indicate  the  possibility  of  its  not  being  a  food  deficiency  alone. 
For  example,  has  he  ever  made  any  observations  on  people  who  have 
had  pellagra  who  have  gone  through  two  or  three  attacks  and,  not- 
withstanding the  fact  that  they  have  been  kept  on  a  presumable 
pellagra-producing  diet  have  not  had  the  disease?  In  children  we 
have  foimd  that  it  does  not  recur  in  50  per  cent,  possibly  more,  of 
the  cases.     They  have  an  attack  one  year,  and  that  is  the  end  of  it. 

I  was  very  glad  to  hear  Dr.  Goldberger's  discussion  about  this 
disease,  and  I  should  like  very  much  to  hear  the  experiences  of 
doctors  from  the  Central  and  South  American  coimtries.  I  might 
say  that  as  far  as  Jamaica  and  Barbadoes  are  concerned,  and  also 
Bermuda,  I  have  some  knowledge.  In  Jamaica  the  disease  was 
confined  practically  to  a  few  institutions,  hardly  a  dozen  cases,  I 
believe,  outside  of  institutions.  In  Barbadoes  it  was  scattered 
generaUy  over  the  island.  There  had  been  200  deaths  from  pellagra 
in  the  two  years  prior  to  1913.  The  only  particular  difference  in 
the  diet  of  the  natives  of  Jamaica  and  Barbadoes  was  that  in  Jamaica 


PUBLIC  HBALTH  AND  MEDIOIKE.  17 

the  peasants  had  bananas  and  in  Barbados  they  did  not.  This 
dietary  difference  is  of  interest  in  connection  with  Maj.  Ashford's 
observations  on  sprue.  He  noted  that  sprue  occurred  in  the  cities 
and  towns  of  Porto  Rico,  where  the  carbohydrate  element  of  the  diet 
was  made  up  of  bread,  and  it  did  not  originate  in  the  country  dis- 
tricts where  the  peasant  secured  his  carbohydrates  by  eating  bananas. 
In  Barbados  sprue  is  very  common  and  wheat  bread  is  the  staple 
carbohydrate  food.  In  Jamaica  sprue  is  very  rare,  and  the  peasants 
subsist  very  largely  on  bananas. 

With  regard  to  the  use  of  legumes,  we  found  that  they  were  con- 
sumed with  great  frequency  by  the  people  of  the  Southern  States. 
In  Jamaica  and  in  Barbados,  as  Dr.  Agramonte  has  said,  they  use 
leguminous  foods  very  largely.  In  Barbados,  where  there  is  much 
pellagra,  the  people  have  15  to  20  varieties  of  beans  and  peas,  which 
are  eaten  throughout  the  year.  We  know  also,  if  we  can  beheve 
what  we  hear  about  the  diet  of  the  people,  that  in  Elgypt  the  fellaheen 
use  l^umes  as  one  of  the  staple  articles  of  diet.  We  also  know  that 
the  fellaheen  are  extremely  susceptible  to  pellagra. 

Capt.  Siler's  remarks  were  interpreted  in  Spanish  by  Dr. 
Agramonte. 

Dr.  Goldberger's  paper  was  discussed  fiulher  in  Spanish  by  Dr. 
Gonzalez-Rincones,  of  Venezuela;  Dr.  Teodoro  Muhm,  of  Chile; 
Dr.  CaUxto  Torres  Umafia,  of  Colombia;  and  Dr.  Luis  Migone,  of 
Paraguay.  The  remarks  of  these  gentlemen  were  interpreted  as 
follows  by  Dr.  Agramonte: 

Dr.  Rincones  has  practically  determined  the  absence  of  pellagra 
in  his  country.  He  refers  to  several  cases  which  he  has  had  occa- 
sion to  see,  but  which  turned  out  to  be  cases  of  uncinaria;  and  recog- 
nizing the  importance  of  Dr.  Qoldberger's  findings  with  regard  to  the 
treatment  of  the  disease  by  the  change  of  diet,  he  is  inclined  to  attri- 
bute the  absence  of  this  disease  to  the  fact  that  legumes  are  used 
largely.  He  says  the  observations  have  an  indirect  bearing  on  cases 
of  infectious  disease  in  relation  to  improving  the  general  condition 
of  the  individual  and  thereby  allowing  him  to  overcome  the  disease, 
and  that  he  has  decided  to  employ  the  treatment  as  soon  as  he  has 
an  opportunity  to  do  so. 

Dr.  Muhm,  of  Chile,  recalls  no  case  of  pellagra  in  his  country. 

Dr.  Torres  Umafta,  of  Colombia,  recalls  that  he  has  seen  no  classi- 
cal case  of  pellagra,  although  he  has  found  cases  similar  to  pellagra, 
produced  by  the  use  of  a  drink  which  is  called  '^  chicha,"  obtained  by 
the  fermentation  of  com  to  such  a  degree  that  it  contains  actual 
putrefactive  element.  The  individuals  who  use  this  drink  present 
disturbances  of  nerves,  skin,  and  gastro-intestinal  tract,  very  much 
like  pellagra.     He  considers  they  are  exactly  hke  the  classic  pellagra. 


18  PBOCEEDIKGS  SECOND  PAN  AMEBICAN  80IEKTIFI0  CONQBESS. 

Dr.  Migone^  of  Paraguay,  remarks  that  no  cases  of  pellagra  are,  to 
his  knowledge,  found  in  his  country.  Once  a  year  the  doctors  from 
the  interior  meet  in  the  form  of  a  congress  and  discuss  unusual  cases 
that  have  come  to  their  notice,  and  that  in  so  far  as  he  knows  pel- 
lagra has  never  been  reported.  He  states  that  maize,  com,  and  many 
vegetables  are  consumed  in  most  tropical  and  semitropical  countries 
in  great  quantity  by  every  one. 

Dr.  Eebleb.  I  was  rather  interested  in  what  Dr.  Goldberger  has 
said  relative  to  the  effect,  if  any,  of  drugs  in  the  treatment  of  pel 
lagra.  According  to  the  view  taken  by  Dr.  Goldberger,  drugs  have  no 
influence.  Dr.  Siler,  however,  seemed  to  give  the  impression,  whether 
he  means  it  or  not,  that  tonics  might  be  of  value  in  the  treatment 
of  this  disease,  when  he  stated  that  in  a  certain  institution  there  was 
virtually  no  change  in  diet,  but  that  tonics  had  been  added  and 
that  improvement  took  place.  We  have  made  an  investigation  of 
quite  a  niunber  of  these  so-called  cures  for  pellagra  on  the  market, 
and  as  in  the  case  of  nephritis,  tuberculosis,  and  other  diseases,  it  is 
quite  a  problem  in  these  cases.to  decide  just  what  to  do. 

Dr.  SiLEB.  May  I  explain  myself,  Mr.  Chairman  ?  I  did  not  say 
that  drugs  were  of  any  value.  I  did  say  that  they  were  using 
tonics  in  this  institution  in  Jamaica.  The  drug  they  were  using 
there  was  salvarsan.  I  would  like  to  have  it  distinctly  imderstood 
that  I  agree  with  Dr.  Goldberger  that  drugs  really  do  no  good  in 
pellagra.  Diet  is  the  most  important  thing  and  I  place  no  reliance 
at  all  on  drugs.  There  are  two  drugs  that  are  indicated  in  these 
cases.  There  is  no  doubt  that  most  cases  of  pellagra  have  a  distinct 
decrease  in  hydrochloric  acid  and  a  decrease  in  peptic  activity,  and 
I  think  as  a  kind  of  placebo  mdicated  in  those  cases  where  you  have 
such  factors  in  the  stomach  it  is  wise  to  give  those  drugs  to  increase 
the  digestive  action.  That  is  about  all  that  is  really  necessary — 
pepsin  and  hydrochloric  acid. 

The  Chaibman.  Dr.  Goldberger  will  close  the  discussion. 

Dr.  Goldbeboeb.  I  have  been  very  much  interested  in  what  the 
del^ates  from  the  other  coimtries  have  had  to  say  about  pellagra  in 
their  respective  Republics.  I  might  say,  as  the  result  of  some  cor- 
respondence with  colleagues  in  Mexico  City,  that  I  have  found  condi- 
tions there  as  regards  prevalence  about  the  same  as  in  these  other 
countries.  There  is  apparently  no  pellagra  in  Mexico.  I  learned  of 
one  case  in  Mexico  City,  that  occurred  a  few  years  ago  in  a  native  and 
resident  of  the  plateau  region  of  Mexico.  There  have  been  no  cases 
(up  to  1914)  in  the  ''Manicomio,''  the  National  Insane  Asylum  at 
Mexico  City,  although  com,  and  spoiled  com,  have  formed  at  times 
a  very  large  and  important  part  of  the  diet.  My  correspondent  who 
was  in  a  position  to  speak  authoritatively,  stated  that  if  pellagra 
was  the  result  of  spoiled  com  there  should  have  been  no  nonpella- 
grins  in  that  institution. 


PUBLIC  HEALTH  AND  IfBDICINB.  19 

While  I  believe  these  reports  to  be  substaQtiaUy  correct,  I  must 
nevertheless  confess  to  a  certain  degree  of  skepticism  as  to  the  abso- 
lute absence  of  the  disease,  an  idea  that  one  might  get  from  these 
reports.  I  say  that  because  I  have  very  keenly  in  mind  the  pellagra 
history  in  our  own  country.  Unquestionably  it  has  occurred  and 
has  prevailed  in  this  coimtry  for  many  years.  It  has,  however,  only 
been  definitely  recognized  in  the  last  eight  years,  and  even  now  after 
all  the  publicity  that  this  subject  has  had  in  the  medical  and  the  lay 
press  cases  are  constantly  occurrmg  and  are  being  seen  and  passed 
o^er  by  physicians  without  recognition.  I  know  of  instances  of  that 
sort  in  the  hands  of  very  competent  and  able  men  in  other  respects. 

That  brings  me  to  the  point  raised  by  Dr.  Siler  in  connection  with 
the  experimental  cases  at  Jackson,  at  the  State  farm.  Now,  in  the 
diagnosis  of  a  disease  like  pellagra,  concerning  which  we  have  no 
laboratory  methods  of  diagnosis,  there  is  left  a  great  deal  to  the  per- 
sonal point  of  view,  to  the  conception  or  mental  picture  that  the 
observer  has,  to  which  the  case  must  conform  to  be  classed  with 
this  disease.  We  have  the  same  sort  of  thing  in  other  diseases, 
notably  in  connection  with  yellow  fever.  You  will  recall  that  in 
cities  where  the  first  case  was  reported  or  was  about  to  be  reported, 
or  where  there  was  danger  of  its  being  reported,  unless  the  patient 
had  all  the  classical  symptoms  of  black  vomit,  profound  jaundice, 
suppression  of  urine,  etc.,  it  was  not  yellow  fever.  Now  the  same 
thing  undoubtedly  appUes  to  a  greater  or  less  degree  to  pellagra. 
Unless  the  individual  has  a  marked  eruption,  unless  he  has  a  severe 
stomatitis  with  nausea,  vomiting  and  continuous  diarrhea  with 
marked  mental  manifestations  in  the  opinion  of  some  men  it  is  not 
A  case  of  pellagra. 

Now  I  think  we  ought  to  know  a  Uttle  more  in  this  day  and  gener- 
ation about  any  disease.  As  with  other  diseases,  pellagra  varies  and 
does  not  in  most  instances  manifest  the  so-called  classical  picture  in 
cross  section. 

The  following  subjective  manifestations  were  presented  by  our 
cases  at  the  farm:  There  was  observed  marked  loss  of  weight  and 
strength,  slight  bumii^  of  the  mouth,  some  redness  of  the  tongue, 
eructations  and  dyspeptic  symptoms  and  irregular,  brief  periods  of 
looseness  of  the  bowels.  Not  any  of  the  cases,  as  I  stated  in  my 
paper,  showed  the  classical,  complete  gastro-intestinal  symptoms — 
that  is,  severe  saUvation  or  sore  mouth,  with  severe  diarrhea.  They 
were  cases  that  had  not  gone  that  far.  We  were  obliged  to  termi- 
nate the  test  by  a  certain  fixed  date.  Fortunately,  both  we  and  a 
nimiber  of  experienced  consultants  were  able  to  satisfy  ourselves 
that  it  was  pellagra  that  our  subjects  had.  The  skin  manifestations 
had  the  classical  anatomical  characters.  They  conformed,  as  I 
stated,  to  some  of  the  pictures  given  by  Merk  in  his  ''Handbuch''; 

68486— 17— VOL  x 8 


20  PBOOEEDINGS  8E00KD  PAN   AMEKTOAN  SODSKTIFIC  OONGBESfik 

thej  conformed  very  beautifully  to  some  of  the  observations  made 
by  Stannus  on  pellagra  in  Nyassaland. 

The  illustrations  of  the  eruption  on  the  male  genitalia  in  Merk 
and  in  Stannus  give  an  excellent  idea  of  what  we  observed  in  our 
experimental  cases  and  are  sufficient  to  indicate  that  what  we  saw 
in  our  experimental  cases  had  been  seen  by  others  in  other  places 
under  natural  conditions.  Nor  should  it  be  forgotten  that  we  had 
a  large  niunber  of  controls,  both  convicts  and  free  men  and  women, 
none  of  whom  showed  the  least  suspicion  of  the  disease. 

A  number  of  points  were  raised  by  Dr.  Siler  that  are  very  fre- 
quently raised  in  the  discussion  of  pellagra,  and  it  may  be  perhaps 
well  to  take  up  these  things  as  fully  as  my  time  will  allow.  One  of 
these  points  that  is  very  frequently  raised  is  the  question  of  the 
explanation  of  the  marked  increase  in  the  prevalence  of  the  disease 
in  this  coimtry  in  the  last  seven  or  eight  years.  As  I  mentioned, 
pellagra  undoubtedly  has  prevailed  in  this  coimtry  for  a  generation 
or  more.  Dr.  Babcock,  of  Columbia,  S.  C,  reports  that  he  has  been 
able  to  find  records  of  the  disease  as  far  back  as  1828,  quite  far 
enough  back  to  establish  that  it  has  existed  among  us  for  a  long 
time.  The  question  to  be  answered  then  is,  why  is  it  so  much  more 
prevalent  than  it  used  to  be  ?  This  probably  may  be  explained  in  two 
or  three  ways,  or  rather  two  or  three  factors  enter  into  the  explana- 
tion. One  of  these  is  that  when  we  know  a  disease  we  are  better  able 
to  diagnose  it.  Those  of  you  who  are  familiar  with  the  classical 
manifestations  of  the  disease,  know  it  has  many  relations,  side  chains, 
if  you  will;  the  dermal  manifestation  is  allied  closely  to  other  non- 
pellagrous  dermal  manifestations,  and  one  without  a  complete  picture 
of  pellagra  in  his  mind  will  be  inclined  to  consider  it  simply  a  skin 
disease,  to  call  it  dermatitis,  eczema,  or  erythema  solare,  and  let  it  go 
at  that,  without  paying  due  regard  to  the  other  symptoms,  just  as 
some  of  the  earUest  students  of  the  disease  did. 

Again,  the  intestinal  symptoms  are  sometimes  very  prominent 
and  dominate  the  picture,  and  to  the  inexperienced  observer,  who 
is  not  famiUar  with  the  complete  sjoidrome,  that  feature  will  con- 
centrate attention,  and  the  case  will  be  called  dysentery  or  "con- 
sumption of  the  bowels,''  a  very  favorite  diagnosis  in  this  country. 
It  is  the  same  way  with  the  mouth  symptoms.  It  is  reported  in  the 
early  American  Uterature  on  the  subject  that  a  very  distinguished 
clinician  of  this  coimtry  who  saw  a  case  in  consultation  after  a  very 
careful  investigation  decided  that  it  was  a  case  of  "glossitis."  It  is 
said  to  have  been  a  typical  case  of  pellagra.  I  mention  these  things 
to  show  how  important  a  clear  conception  of  a  disease  is  in  making  a 
diagnosis.  Improved  diagnosis  makes  for  an  increase  in  known  or 
reported  cases;  an  increase  that  may  be  more  apparent  than  real. 
Incidentally  this  also  brings  about  a  reduced  fatality  rate  and  then 
we  hear  that  the  disease  has  become  milder. 


PUBLIC  HEALTH  AND  MEDICINE.  21 

I  might  cite  evidence  also  to  show  the  importance  of  knowing  of 
the  existence  of  a  disease  to  help  one  recognize  it,  and  thereby 
further  increase  the  apparent  frequency  of  its  prevalence.  One  factor, 
ihen,  in  explanation  of  the  increase  in  prevalence  is  the  better 
diagnosis  of  cases,  an  increased  ability  to  recognize  the  disease  as 
the  result  of  increased  experience  and  because  of  a  knowledge  of  its 
existence.  This  same  factor  applies  also  to  the  laity.  The  laity  have 
learned  to  recognize  pellagra,  and  frequently  the  patient  comes  to 
his  physician  for  a  confirmation  of  the  diagnosis  which  the  patient 
or  friends  have  already  made.  This  was  not  the  case  seven  or  eight 
years  ago. 

Furthermore  there  are  good  reasons  for  believing  that  the  diet 
of  the  people  most  affected  has  changed  in  the  last  seven  or  eight 
years.  The  factors  involved  in  bringing  this  about  are  the  eco- 
nomic ones  which  in  the  last  15  or  20  years  have  caused  a  gradual 
and  progressive  increase  in  the  cost  of  food.  This  increase  has  been 
particularly  notable  in  the  last  seven  or  eight  years  as  compared 
to  the  previous  seven  or  eight  years.  Again  dietary  and  budgetary 
investigations  have  repeatedly  shown  that  there  is  a  very  decided 
difference  in  the  character  of  the  diet  ot  the  northern  as  compared 
with  the  southern  section  of  this  country.  The  diet  of  the  South 
is  more  largely  carbohydrate  than  that  of  the  North,  and  with  the 
change  in  economic  conditions,  as  regards  the  increased  cost  of 
certain  foods  without  a  corresponding  increase  in  income,  there  has 
naturally  and  inevitably  been  a  modification  ot  the  character  of  the 
prevailing  diet  tending  toward  a  further  increase  in  the  carbohydrate 
component  and  a  reduction  in  the  more  costly  animal  protein  ele- 
ments. The  effect  of  such  influences  will  naturally  be  most  appar- 
ent in  that  locality  where  the  prevailing  type  of  diet  already  has 
the  narrowest  margin  of  safety.  Such  are  some  of  the  more  impor- 
tant factors  which  must  be  considered  in  explaining  the  alleged 
increased  prevalence  of  recent  years. 

Another  point  mentioned  by  Dr.  Siler  was  that  he  had  observed 
that  in  spite  of  the  fact  that  a  good  diet  was  given  pellagra  patients, 
even  apparently  mild  cases,  some  nevertheless  died  in  a  month  or 
six  weeks.  I  quite  agree  that  this  may  happen,  although  rarely; 
but  I  can  not  quite  see  how  that  affects  the  question  before  us.  We 
have  the  same  thing  in  beriberi  and  scurvy. 

Then  the  point  was  raised  that  in  spite  of  the  fact  that  individu- 
als go  back  to  their  old  diet  they  do  not  always  develop  pellagra 
again.  The  fact  that  people  go  back  to  what  apparently  was  their 
diet  before  their  attack  does  not  constitute  conclusive  evidence  that 
the  diet  is  in  fact  exactly  as  it  was  before  their  attack.  Such  state- 
ments take  cognizance  of  superficial  appearances  only.  They  do 
not  and  can  not  recognize  apparently  slight  differences  which  may 


22  PBOGEEDINGS  SECOND  PAN  AMEBICAN  SCIENTIFIC  CONGRESS. 

in  reality  make  all  the  difference  between  an  inadequate  and  an 
adequate  diet.  It  is  a  type  of  ai^ument  that  I  am  sorry  to  say  is 
altogether  too  frequent.    It  deals  simply  with  surface  indications. 

With  regard  to  the  marked  difference  in  sex  incidence  in  individu- 
als with  the  same  diet  available,  it  is  well  to  recall  that  a  difference 
in  sex  incidence  under  like  circmnstances  is  recorded  tor  both  scurvy 
and  beriberi,  only  that  in  these  the  preponderance  oi  cases  is  in  the 
male,  not  in  the  female.  It  would  seem  therefore  that  we  are  dealing 
here  with  a  difference  in  physiological  requirement  in  the  two  sexes, 
an  interpretation  that  is  by  no  means  without  experimental  evi- 
dence for  its  support.  Other  factors  probably  also  contribute  to  the 
bringing  about  of  this  difference  in  sex  incidence. 

The  CHAiBifAN.  We  will  now  have  to  pass  to  the  next  paper,  en- 
titled "The  known  and  the  unknown  with  r^ard  to  the  etiology 
and  prevention  of  beriberi,"  by  Capt.  Vedder. 


THE  KNOWN  AND  THE  UNKNOWN  WITH  REGARD  TO  THE  ETIOLOGY 

AND  PREVENTION  OF  BERIBERL 

By  EDWARD  B.  VEDDER, 
Captain,  Medical  CorpSf  United  State$  Army. 

There  are  certainly  few  diseaseB  concerning  which  we  are  in  a  position  to  state  that 
everything  with  regard  to  them  is  known.  While  in  general,  sanitary  measures 
adopted  to  prevent  a  given  disease  must  be  based  upon  accurate  knowledge  of  the 
cause  and  methods  of  transmission  of  that  disease  if  they  are  to  be  effective,  yet  very 
effective  sanitary  work  in  the  past  has  been  based  upon  information  which  while 
accurate  is  still  incomplete.  The  sanitarian  has  controlled  smallpox  by  vacci- 
nation in  spite  of  the  fact  that  no  satisfactory  demonstration  has  yet  been  made  witib 
regard  to  the  exact  biological  relationship  between  vaccinia  and  smallpox.  Yellow 
fever  has  been  eradicated  in  several  localities  by  a  warfare  against  the  transmitting 
agent,  the  stegomyia  mosquito,  although  the  etiologic  agent  of  the  disease  is  still 
unknown. 

It  may  be  worth  while  to  take  stock  of  our  knowledge  concerning  beriberi.  Do 
we  know  sufficient  concerning  its  etiology  to  prevent  the  disease,  and  what  gai>8  in 
our  knowledge  remain  to  be  filled? 

Opinions  as  to  the  etiology  of  beriberi  have  varied  widely  in  the  past,  but  for  the 
most  part  fall  into  three  categories.  Some  have  believed  that  it  was  an  infectious 
disease,  some  that  it  was  an  intoxication,  and  some  that  it  was  caused  by  a  certain 
deficiency  in  the  dietary  of  those  affected.  The  result  of  this  confusion  has  been 
that  with  few  exceptions  the  sanitary  measures  taken  to  prevent  this  disease  have 
been  futile.  It  is  worthy  of  note  that  in  the  case  of  these  exceptions  the  measures 
that  succeeded  in  preventing  the  disease  consisted  in  certain  radical  changes  in 
the  dietary. 

At  the  present  day  there  is  a  very  general  consensus  of  opinion  to  the  effect  that 
beriberi  is  caused  by  a  dietary  deficiency.  It  would  far  exceed  the  limits  imposed 
upon  a  paper  of  this  character  to  go  into  all  the  details  of  the  work  that  has  led  to 
this  conclusion.    Moreover,  the  writer  has  elsewhere  ^  attempted  to  sift  all  this  evi- 

>B«rIberi.   Wm.  Wood  &  Co.   New  York,  1018. 


FUBLIO  HEALTH  AND  MEDIOIKE.  23 

dence.  As  a  result  of  this  study,  I  stated  in  1913  that  ''we  are  now  in  a  position 
to  prevent  beriberi  in  any  community  that  can  and  will  follow  our  advice,  just  as 
surely  as  we  can  prevent  smallpox  and  yellow  fever."  In  a  general  way  this  opinion 
was  based  on  the  following  facts: 

1.  The  c(Hnplete  failure  of  the  adherents  of  the  infection  and  intoxication  theories 
to  prove  their  case. 

2.  The  very  carefully  planned  and  controlled  human  feeding  experiment  of  Fraser 
and  Stanton/  in  which  they  demonstrated  beyond  all  cavil  that  beriberi  can  be 
experimentally  produced  in  men  by  too  exclusive  feeding  on  overmilled  or  highly 
polished  rice.  This  experiment  was  later  repeated  by  Strong  and  Growell  ^  in  the 
Philippines  with  a  similar  result. 

3 .  The  long  series  of  animal  experiments  which  have  been  repeated  with  substantially 
the  same  results  in  all  parts  of  the  world  and  by  which  it  has  been  equally  demon- 
strated that  various  animals,  but  particularly  birds,  when  fed  on  diets  that  will 
produce  beriberi  in  man,  suffer  with  a  disease  which  in  some  instances  is  identical  in 
symptomatology  and  pathology  with  human  beriberi  and  in  other  instances  is  so 
similar  that  we  must  believe  that  it  is  essentially  the  same  disease. 

4.  The  instances  referred  to  above  in  which  beriberi  has  been  eradicated  from  various 
institutions  or  groups  of  men  by  certain  simple  but  radical  changes  in  the  dietary. 
Every  sanitarian  should  be  familiar  with  the  practical  results  of  this  character  re- 
ported by  Van  Leent,*  Vorderman,^  Takaki,*  Fletcher,"  Highet,^  Heiser,^  Theee,' 
Chamberlain,'®  and  others. 

However,  beriberi  has  still  continued  to  prevail  in  many  localities,  chiefly  because 
sanitary  officers  have  not  been  convinced  of  the  truth  of  the  statement  that  beriberi 
is  a  deficiency  disease  and  have  been  unwilling  to  adopt  the  necessary  dietary  changes. 
Since  1913,  when  the  writer  published  the  results  of  his  investigation,"  there  has 
been  a  considerable  amount  of  experimental  work  that  has  confirmed  the  belief  that 
beriberi  is  caused  by  a  dietary  deficiency,  and  not  one  iota  of  evidence  to  the  con- 
trary that  will  stand  careful  analysis.  Many  statements  casting  doubt  on  the  dietary 
origin  of  beriberi  have  appeared  during  this  time  in  the  literature.  These  instances 
will  not  bear  careful  investigation.  Most  of  them  consist  of  occasions  in  which  beri- 
beri is  reported  to  have  occurred  in  spite  of  the  fact  that  the  dietary  is  stated  to  have 
been  "satisfactory  as  to  quantity  and  quality."  In  all  of  these  cases  either  no  details 
at  all  or  entirely  insufficient  data  as  to  the  diet  actually  eaten  are  given.  Often  these 
epidemics  are  reported  by  the  very  man  responsible  for  the  diet  used,  and  who  would 
naturally  believe  that  it  was  satisfactory,  although  he  might  actually  have  very  small 
reason  for  this  belief.  After  having  analyzed  a  munber  of  such  instances  the  writer 
stated,  in  1914,"  that  *4t  will  not  be  sufficient  in  the  future,  in  attempting  to  disprove 
the  dietary  origin  of  beriberi,  to  make  statements  that  the  diet  was  liberal  and  varied. 

1  StndJas  rrom  the  Institute  for  Medical  Resesrcb,  Federated  Malay  States,  1909,  No.  10. 

•  The  Etiology  of  Beriberi.    PhUippine  Joam.  Science,  1912,  VII,  271 . 

•  Aiefa  de  Ked.  Nav.  1867,  Oct.,  p.  241.  Communication  sur  le  Borlberf,  Cong.  Internet,  d.  8c.  Med. 
Amst.  1880,  VI,  170,  etc. 

« Ondersoek  naar  het  verband  tnsBchen  den  aard  der  rystroeding  in  de  gevangenissen  op  Java  en  Madoera 
en  het  voorkomen  van  beriberi  onder  de  geintemeeden.    Batavia,  1897. 

»  Three  Lectures  on  the  Preservation  of  Health  Amongst  the  Personnel  of  the  Japanese  Navy  and  Army. 
Lancet,  1906, 1, 1369, 1451, 1520,  etc. 

•Rice  and  BeriberL    Joom.  Trop.  Med.  and  Hyg.  1909,  Xn,  i27.    Lancet  1907, 1, 1776,  etc. 

'  Beriberi  in  Siam.    Philippine  Joum.  Science  1910,  V,  73. 

•  Practical  Experiences  with  Beriberi  and  Unpolished  Rice.  Philippine  Jour.  Science  1911,  Vi,  1237. 
Abo  Joum.  Am.  Med.  Ass.  1911,  LVI,  1238. 

•Note  sur  le  Beriberi  a  Poulo-Ccodore.  Ann.  d'Hygitee  de  Med.  Col.  1910,  xm,  16. 

>•  The  Eradication  of  Beriberi  from  the  Philippine  Scouts  by  means  of  a  Simple  Change  in  their  Dietary. 
Philippine  Joum.  Science,  1911,  VI,  133. 

M  Beriberi,  Wm.  Wood  &  Co.,  New  York,  1913. 

BSome  Further  Remarks  on  Beriberi  Am.  Joum.  Tropical  Diseases  and  Preventive  Med.  1914,  I, 
826. 


24  PROCEEDINGS  SECOND  PAN   AMERICAN   SCIBNTIFIO  CONGRESS. 

Any  such  communicatioii  to  be  worthy  of  attention  should  contain  a  detailed  state- 
ment of  the  food  actually  consumed  by  the  affected  persons,  for  the  90  days  prior  to 
the  development  of  the  disease,  showing  components,  quantities,  and  a  statement  as 
to  whether  the  articles  used  were  fresh,  cann^,  or  otherwise  preserved.*' 

Therefore,  while  we  do  not  even  suggest  that  our  knowledge  concerning  beriberi  is 
complete,  it  is  believed  that  the  points  that  remain  for  investigation  are  of  scientific 
rather  than  of  practical  interest.  They  concern  the  chemist,  the  physiologist,  and 
the  clinician  and  need  give  no  concern  to  the  practical  sanitarian,  who  can  eradicate 
beriberi  by  compelling  the  use  of  a  proper  diet,  even  though  the  exact  physiological 
vction  of  the  vitamines  has  not  yet  been  determined.  I  would  even  go  further  and 
say  that  the  sanitarian  who  is  faced  by  a  widespread  occurrence  of  beriberi  and  refuses 
to  recommend  the  changes  in  the  diet  that  experience  has  proved  will  prevent  beri- 
beri is  in  the  same  class  with  the  man  who  to-day  would  disinfect  the  mails  to  prevent 
yellow  fever. 

There  are  however  many  misconceptions  concerning  beriberi  and  deficiency  dis- 
eases in  general  which  should  be  dissipated.  Many  suppose  that  beriberi  only  occun 
on  a  diet  of  rice.  Beriberi  is  a  disease  resulting  from  foulty  metabolism  and  is  directly 
caused  by  the  deficiency  of  certain  chemical  substances  in  the  food.  These  chemical 
substances  have  been  called  vitamines.  Certain  foodstuffs  have  been  shown  to  be 
either  relatively  or  absolutely  deficient  in  these  beriberi-preventing  vitamines,  idiile 
other  foodstuffs  contain  a  rich  supply .  If  a  group  of  men  live  almost  exclusively  upon 
those  foods  that  are  deficient  in  beriberi-preventing  vitamines,  beriberi  will  almost 
surely  develop.  The  danger  of  contracting  beriberi  is  therefore  greatly  increased  by 
the  consumption  of  a  poorly-balanced  or  one-sided  dietary.  Beriberi  may  occiur, 
however,  on  a  mixed  diet  furnishing  a  suflicient  number  of  calories  and  containing 
the  proper  ratio  of  fats,  proteids,  carbohydrates,  and  salts,  if  all  of  the  articles  of  this 
ration  are  deficient  in  the  vitamines  that  prevent  beriberi.  Such  occasions  are 
infrequent,  but  they  occur  often  enough  to  cast  doubt  upon  the  fact  that  beriberi  is 
a  deficiency  disease  in  the  minds  of  those  who  are  not  fully  acquainted  with  the 
e\idence  that  incriminates  certain  foods. 

Obviously  the  sanitarian  should  know  which  foods  have  been  proved  to  be  beriberi 
producers  and  which  foods  will  correct  this  deficiency.  The  rdle  played  by  polished 
or  overmilled  rice,  or  rice  that  has  been  denuded  of  its  aleurone  layer,  in  the  pro- 
duction of  beriberi  is  too  well  known  to  deserve  more  than  a  passing  comment.  The 
fact  that  the  great  endemic  centers  of  beriberi  are  almost  always  confined  to  peoples 
that  use  rice  as  the  staple  article  of  diet  is  a  sufficient  commentary  on  the  part  played 
by  rice  in  the  production  of  beriberi. 

It  does  not  appear  to  be  so  generally  known  that  various  carbohydrate  foods,  such 
as  tapioca,  sago,  and  the  various  starches  and  sugars  are  quite  as  deficient  in  vitamines 
as  rice  and  will  produce  beriberi  in  man  or  animals  with  great  certainty  when  used 
too  exclusively  as  articles  of  diet.  It  is  even  more  important  to  note  that  ordinary 
white  wheat  flour  is  also  very  deficient  in  vitamines.  Little  ^  was  perhaps  the  first 
to  report  the  occurrence  of  beriberi  among  men  living  almost  exclusively  on  fine  wheat 
flour,  but  the  literature  is  fuU  of  outbreaks  of  what  was  evidently  beriberi  in  jails, 
as^'lums,  and  other  institutions  where  bread  has  been  used  as  the  main  staple  of  diet. 
One  of  the  latest  instances  of  this  kind  was  reported  from  a  jail  at  Elizabeth,  N.  J., 
by  Parker.'  It  has  also  been  shown  '  *  that  fowls  fed  upon  a  combination  of  rice  and 
bread,  or  upon  bread  alone,  develop  polyneuritis  quite  as  promptly  as  when  fed 
exclusively  upon  rice.    All  food  products  made  of  white-wheat  flour  must  be  regarded 

I  Beriberi  caused  by  Fine  White  I  lour.    Joum  Am.  Med.  Ass.  1912,  LVni,  2  2Q29. 

9  A  Report  on  Beriberi  in  the  County  Jail  at  Elizabeth,  N.  J.  Pub.  Health  Reports,  1914,  XXIX,  339. 
See  aim  V'edder,  Some  Further  Remarks  oo  Beriberi.    (Reference  12.) 

*  Vedder  and  Clark.  Polyneuritis  Gallinanim,  a  Fifth  Contributicn  to  the  Etiology  of  Beriberi.  Phil- 
ippine Joum.  Science,  1912,  vn. 


PXJBLIO  HBALTH  AND  MEDIOINB.  25 

as  deficient  in  beriberi  vitamines  and  as  beriberi  producers.  Macaroni  falls  into 
this  category.  It  produces  polyneuritis  in  fowls,^  and  on  at  least  one  occasion  >  a 
sanitary  officer  endeavored  to  prevent  the  occurrence  of  beriberi  by  substituting 
macaroni  for  the  rice  previously  used.  Quite  as  much  beriberi  occurred  after  this 
change  as  before,  and  in  this  particular  case,  instead  of  concluding  that  both  foods 
were  deficient,  the  erroneous  deduction  was  made  that  the  disease  was  not  of  dietary 
origin. 

It  should  also  be  noted  that  all  canned  foods  must  be  regarded  as  possible  beriberi 
producers.  It  has  been  shown  by  numerous  investigators,  including  the  writer,* 
that  heating  to  120^  0.  destroys  the  beriberi  preventing  vitamines  in  certain  foods. 
All  protein  foods  that  are  canned  must  be  subjected  to  about  this  amount  of  heat  in 
order  to  kill  all  the  putrefactive  organisms,  and  such  canned  foods  are  undoubtedly 
beriberi  producers  when  used  in  excess.  I  have  seen  at  least  one  case  of  undoubted 
beriberi  in  a  white  man,  a  ship's  officer,  who  had  eaten  a  most  varied  and  satisfactory 
diet  except  that  for  the  previous  four  months  everything  he  had  eaten  had  been 
canned. 

Com  meal  and  potatoes  are  intermediate  foods.  The  evidence  from  experimental 
animals  seems  to  indicate  that  beriberi  has  been  occasionally  produced  by  feeding 
these  foods.  No  extensive  occurrence  of  human  beriberi  to  be  attributed  to  these 
foods  is  known  to  exist.  It  is  certain  however  that  they  are  relatively  deficient  in 
protective  vitamines  because  their  curative  or  prophylactic  value  in  animals  or  men 
fed  <m  rice  is  practically  nil.  They  can  not  therefore  be  used  to  balance  an  otherwise 
deficient  ration. 

On  the  other  hand  a  number  of  foodstuffs  have  been  found  to  be  relatively  very  rich 
in  beriberi  preventing  vitamines.  This  is  particularly  true  of  rice  polisldngs  or  the 
powdered  aleurone  layer  removed  from  the  rice  in  the  process  of  milling.  Rice  which 
has  been  undermilled  and  which  theref(»e  retains  the  major  p(»tion  of  the  aleurone 
layer,  has  been  definitely  proven  to  prevent  the  occurrence  of  beriberi.  However, 
in  the  introduction  of  such  rice  as  a  prophylactic,  three  difficulties  have  been  encoun- 
tered. One  that  it  is  difficult  to  keep  ^e  rice  up  to  specifications.  This  can  be 
guarded  against  by  examining  a  sample  of  every  lot  of  rice  delivered.  If  a  few  grains 
are  stained  by  Gram's  iodine  solution,  the  percentage  of  the  aleurone  and  pericarp 
remaining  can  be  determined  in  an  instant.  Secondly,  this  rice  is  difficult  to  keep  as 
weevils  and  other  insects  are  very  apt  to  infest  it  if  it  is  kept  long.  The  authmities 
of  Java,^  have  investigated  sevend  preservatives,  and  have  found  that  the  preserva- 
tion of  undermilled  rice  may  be  secured  by  placing  here  and  there  among  the  rice, 
bottles  or  tins  containing  chloroform  or  carbon  tetrachloride  GGI4.  They  state  that 
the  use  of  these  chemicals  is  without  a  single  disadvantage,  and  that  they  do  not 
influence  the  taste  or  smell  of  the  rice  or  affect  its  prophylactic  value.  Tlie  third 
objection  to  the  use  of  undermilled  rice  is  that  natives  that  have  been  accustcmied  to 
the  use  of  pdished  rice  will  frequently  refuse  to  eat  undermilled  rice .  For  this  reason, 
although  the  use  of  undermilled  rice  has  been  made  compulscHry  among  the  native 
troops  of  the  Army  (Philippine  Scouts)  and  in  all  civil  institutions  in  the  Philippines, 
there  is  no  means  at  present  of  compelling  the  native  population  to  \ise  it.  For  this 
reason,  a  tax  on  overmiUed  or  polished  rice  has  been  advocated,^  of  such  an  amount 
as  to  practically  render  such  rice  prdiibitive  in  price  for  the  poor  people  who  are  the 

1  WeUman  and  Bass.  Polynearitis  Qallinarum  Caused  by  Different  Foodstuffs,  etc.  Am.  Joum.  Trop. 
Dia,  and  Preventire  Hed.  1913, 1, 1». 

sLoivelaoe.  Peripheral  Neuritis  in  the  Amasoii  Valley.  Am.  Joum.  Trpp.  Dis.  and  Prev.  Hed.  1918, 
1, 140.    See  also  Joum.  A.  M.  A.  1912,  LIX,  2134. 

t  A  Fourth  Contribution  to  the  Btiology  of  Beriberi    Phnipplne  Joum.  Science,  1912,  VU,  419. 

*  Ottow.  Testing,  Storage,  and  Preparation  of  Uiqwliahed  Rice.  Natunrkundig  Tyjdsdirift  voor  Ned. 
India.    1916,  LXXIV,  148. 

•  Haistf.  Beriberi:  GoTemmentia  aid  in  its  Eradication.  Medical  Record,  1912,  LXXXI,  616.  Ved- 
d«.  The  Prevention  of  Beriberi.  TransactlonB  16  Intemat.  Cong,  on  Hyg.  and  Demography.  See  also 
BecftMri,  Wm.  Wood  A  Co.,  1913. 


26  PBOOEEDINGS  SEGOKD  PAK  AMSBIOAN  8CIBNTIFI0  OONQBESS. 

main  sufferera  from  beriberi.  ThiB  would  compel  these  people  to  use  iindermilled 
lice  which  can  be  sold  at  a  cheaper  rate  than  polished  rice  and  which  in  addition 
would  prevent  beriberi. 

It  has  also  been  ascertained  that  various  species  of  legumes,  such  as  ordinary  white 
beans,  and  several  varieties  of  peas  when  added  to  a  ration  of  polished  rice,  will 
prevent  the  occurrence  of  beriberi.'  It  has  also  been  shown  experimentally,* 
that  peanuts  will  prevent  avian  polyneuritis.  It  is  probable  that  all  leguminous 
vegetables  are  rich  in  beriberi  preventing  vitamines. 

The  Japanese  have  found  that  barley  is  an  efficient  prophylactic  against  beriberi. ' 
Barley  also  prevents  the  development  of  polyneuritis  in  birds  fed  on  polished  rice. 

There  are  undoubtedly  other  foods  than  the  ones  mentioned  which  ^en  used  too 
exclusively  may  produce  beriberi.  There  are  also  undoubtedly  other  foods  that 
possess  a  prophylactic  value.  It  would  be  of  some  practical  value  if  all  foodstuffs 
were  tested  esperimentally  to  determine  their  content  in  beriberi  preventing  vita- 
mines,  and  the  writer  hopes  some  day  to  carry  on  this  work.  In  the  meantime,  how- 
ever, as  already  stated,  the  sanitarian  may  at  any  time  eradicate  beriberi  by  substi- 
tuting for  some  of  the  beriberi  producing  foods  enumerated  above,  either  undermilled 
rice,  beans,  or  bariey,  or  preferaUy  a  combination  of  these  foods.  The  combination 
is  preferable  when  possible,  because  through  accident  or  design  some  of  the  i>eople 
whom  we  aim  to  benefit  may  fail  to  eat  one  of  the  above  prophylactics,  and  this 
danger  is  reduced  to  a  minimum  if  several  such  prophylactics  are  used. 

Passing  to  the  unknown  with  regard  to  beriberi  there  are  three  problems  that  are 
of  the  utmost  scientific  interest.  These  may  be  stated  as  follows:  1.  The  relationdiip 
between  dry  and  wet  beriberi.  Are  these  two  types  of  the  disease  caused  by  the 
deficiency  of  the  same  vitamine  or  by  different  vitamines?  2.  What  is  the  physiolo- 
gical action  of  the  vitamines?  Do  they  act  as  indispensable  building  stones  for 
certain  tissues,  or  are  they  concerned  in  some  other  manner,  as,  for  instance,  in 
carbohydrate  metabolism?  3.  What  is  the  chemistry  of  the  vitamines?  The  sdu- 
tion  of  these  problems  is  not  only  of  great  importance  to  a  proper  understanding  of 
beriberi,  but  will  probably  throw  much  lig^t  upon  other  deficiency  diseases  and  upon 
our  conceptions  of  physidogical  problems. 

1.  The  niaiidnM'p  between  dry  and  wet  6m6ert.-— Althon^^  the  paralytic  symptoma 
in  beriberi  may  be  easily  explained  as  a  result  of  the  degeneratians  tlutt  occur  in  the 
nervous  system,  no  rational  explanation  of  the  occurrence  of  the  anasarca  and  effusioDs 
that  characterize  wet  beriberi  has  been  afforded .  If  the  pathological  condition  known 
as  dry  beriberi  and  that  known  as  wet  beriberi  are  both  produced  as  the  result  of  a 
deficiency  of  one  vitamine,  what  is  the  explanation  of  the  well-known  feet  that  in  one 
epidemic  most  of  the  cases  will  be  of  the  dry  type,  while  in  another  epidemic  most 
of  the  cases  will  be  of  the  wet  type? 

I  have  thought,^  *,  that  a  probable  explanation  of  this  strange  phenomenon  is  afforded 
by  the  theory  that  dry  beriberi  is  caused  by  the  deficiency  of  one  vitamine,  while  wet 
beriberi  is  caused  by  the  deficiency  of  another  vitamine.  There  is  a  certain  amount  of 
experimental  evidence  in  favor  of  this  theory,  since  it  has  been  foimd  that  a  simple 
alcoholic  extract  of  rice  polishings  contains  substances  that  will  produce  an  immediate 
cure  in  cases  of  wet  beriberi,  while  it  is  entirely  ineffective  in  the  treatment  of  dry 
beriberi.  However  if  the  rice  polishings  are  treated  in  a  different  manner,  the  vita> 
mine  that  cures  dry  beriberi  is  obtained,  and  its  administration  results  in  a  prompt 

1  Holahoff  Pol.  Ka^ang-idjo,  irn  noaveaa  medicament  oontre  le  Beriberi.  Janus  1902,  VTI,  534,  570 
See  also  BeibefteZmn  Arch.  f.  SchMb  u.  Tropenhyg.  1910,  XIV,  7. 

>  Roramel  and  Vedder.  Beriberi  and  Cottonseed  Poisoning  in  Pigs.  Jomn.  of  Agrieultnral  Reeeardi 
Dept.  of  A  ^culture,  Wash.,  D.  0.,  1915,  V,  Noii,  488. 

*  Saneyoshi.    On  Kakke.    Proceedings  of  the  Xni  Internat.  Congress,  Paris,  1900,  XVII,  78. 
« Vedder.    Beriberi,  Wm.  Wood  A  co.  New  York,  1913. 

•  Vedder  and  Clark.  Polyneoritis  and  QaUinamm,  a  fifth  oontnbcitlon  to  the  Etiology  of  Berfberi. 
Phittpptne  Joum.  Sdenoe,  1912,  VII. 


PUBUO  HEALTH  AKD  MBDIOIKE.  27 

cme  of  the  paralytic  Bymptoms  of  dry  beriberi.  These  facte  at  least  indicate  the 
possibility  that  rice  pc^isbings  contain  two  distinct  though  probably  chemically 
related  Titamines.  Unfortunately  concliudye  evidence  as  to  the  truth  or  falsity  of 
tills  theory  has  not  yet  been  obtained  because  a  suitable  experimental  animal  has  been 
lacking.  Fowls  and  pigeons  are  ideal  experimental  animals  for  the  production  of  dry 
beribm  but  appear  to  suffer  rarely,  if  at  all,  from  wet  beriberi,  and  t3rpical  wet  beri- 
beri can  not  be  produced  with  any  degree  of  regularity  in  any  of  the  common  laboratory 
animals.  Howerer,  within  the  past  year  Rommel  and  Vedder,'  have  found  that  pigs 
fed  on  polished  rice  suffer  from  wet  beriberi  in  a  considerable  percentage  of  cases. 
Further  woric  is  now  in  progress,  and  it  is  to  be  hoped  that,  having  found  a  suitable 
experimental  animal,  an  explanation  of  the  rdation  between  dry  and  wet  beriberi 
may  soon  be  afforded. 

2.  Whai  18  the  phytioloffieal  action  of  (he  vikxmines, — I  have  been  strongly  of  the  opinion 
that  the  vitamine  of  dry  beriberi  is  a  building  stone  which  is  essential  for  the  meta- 
bolism of  the  nervous  tissues.    This  oi^nion  is  based  upon  the  following  facts: 

1.  If  the  supply  of  this  vitamine  is  cut  down  by  feeding  exclusively  <m  polidied 
rice,  changes  in  the  structure  of  the  nerve  fibres  of  fowls  may  be  demonstrated  after- 
only  7  days  on  such  a  diet.  The  evidence  of  beginning  degeneration  at  such  an  eariy 
date  i^pears  to  indicate  that  a  certain  amount  of  this  vitamine  is  constantiy  necessary 
in  Older  to  maintain  the  nervous  system  in  a  healthy  condition. 

2.  The  nerve  cells  from  the  cord  of  fowls  suffering  from  polyneuritis  galHnarum 
I»esent  changes  very  similar  to  those  demonstrated  in  the  nerve  cdls  of  birds  that 
suffer  from  fatigue  as  the  result  of  long  flints. 

d.  Fowls  suffering  from  polyneuritis  may  be  completely  cised  within  a  few  homa^ 
by  the  administration  of  the  vitamine  obtidned  from  rice  poMshings. 

This  evidence  at  least  strongly  suggests  that  this  vitamine  is  a  constituent  tiiat  is 
essmtial  to  the  normal  metabolinn  of  nervous  tissue.  It  is  difficult  to  understand  how 
it  can  act  in  any  other  manner  than  as  a  building  stone  of  that  tissue. 

More  recently  Funk,*  and  Bradd<m  and  Cooper,'  found  that  when  fowls  were  allowed' 
a  fixed  amount  of  vitamine,  the  greater  the  proportion  of  carbohydrate  in  the  food, 
the  quicker  was  the  onset  of  polyneuritis.  From  thn  evidence  these  investigatoTB- 
coBcMe  that  the  vitamines  play  an  active  rdle  in  the  assimilation  and  metabolism  of 
carbohydrates,  and  that  it  is  in  this  way  rather  than  as  a  building  stone  for  nervous^ 
tissues  tiiat  vitamines  are  essential  to  the  Hfe  of  the  organism. 

It  appears  to  me  that  this  ccmclueion  is  premature  to  say  tiie  least.  It  has  always 
been  supposed  that  carlx^ydrate  foods  were  chiefly  of  value  in  the  animal  economy  a» 
fnd,  or  as  a  source  of  heat  and  energy,  ratiier  than  as  tissue  builders.  It  seems  highly^ 
im|»obable  that  carbohydrates  are  of  such  importance  in  tiie  metabdism  of  tiie  nervous 
tissue,  that  a  hult  in  cnbc^ydrate  metabolinn  would  result  in  tiie  profound  degenera- 
tion of  the  nervous  system  seen  in  beriberi.  But  aside  from  such  a  priori  reasoning,^ 
there  is  experimental  evidence  which  it  is  difficult  to  reconcile  with  such  a  theory. 
Schanmaon,^  produced  paralysis  with  evidence  of  degeneration  in  the  nerves,  in  both* 
rats  and  dogs  by  feeding  them  exclusively  on.  meat  that  had  been  sterilised  in  an  auto- 
clave at  120^  0.  If  beriberi  and  nerve  degenen^ons  may  be  produced  as  the  result 
of  the  destruction  of  the  vitamines  in  animals  that  eat  no  carbohydrate  food,  this 
would  appear  to  show  that  the  vitamines  are  essential  to  the  body  in  some  other  way 
than  as  factor  in  carbohydrate  metabolism. 

>  Bwlbcri  and  C«tteMeed  PoiaoDiiis  io  Pics.  Jour,  of  Agrteattiiral  Rwearah,  Waih.,  D.  C,  1916,  V, 
NoiL488. 

•  Fonk.  Die  RoDe  der  Vitamine  iMim  Kohtahydnt-StQffwwfaMl.  Boppa-Seylflfs  Zdtachrift  for 
PhjrsiolosiiolM  Chemto  1014,  LXXXIX  37& 

•  Braddoo  and  CoofMr.  The  Inituflnoe  of  MataboMc  Faotora  in  Baribcri.  Jonm.  of  Hygl»6  lOU,  ZIV, 
aSL    SeealM>Brtt.liad.Joitf]Liai4,I,1348. 

4  flohaomann.  Die  Aetiotogle  der  Beriberi  unter  Berooksiofatigtnig  dea  Oeaasten  Pho^hontoffweohaela. 
Befaefte.  ram  Ardi.  f.  Soliilb  a.  Tropcnhyg.  1910,  XIV,  825. 


28  PROCEEDINGS  8E00ND  PAN  AMEBIC  AN  SCIENTIFIC  C0NQBB88. 

Funk '  performed  one  experiment  in  an  endeavor  to  show  that  beriberi  is  not 
an  intoxication,  difficult  to  reconcile  with  the  theory  that  the  vitamine  is  concerned 
in  carbohydrate  metabolism.  Four  healthy  doves  and  four  doves  in  the  last  stages 
of  polyneuritis  were  killed,  plucked,  and  finely  minced  and  extracted  with  three 
times  their  volume  of  absolute  alcohol  in  a  shaking  machine.  The  extracts  were 
filtered  and  evaporated  in  vacuo.  The  residues  were  taken  up  with  water  and  fed 
by  mouth  to  birds  suffering  from  polyneuritis.  In  all  eight  cases  a  cure  was  effected, 
with  the  extract  from  birds  suffering  .from  polyneuritis,  as  well  as  with  the  extract 
from  normal  birds.  This  contradicts  the  intoxication  theory,  since  no  trace  of  intoxi- 
cation  resulted  from  the  administration  of  extracts  of  birds  suffering  from  polyneuritis, 
but  on  the  contrary  a  cure.  The  extract  from  healthy  birds  contained  more  vitamine. 
Funk  says:  "This  exi)eriment  shows  that  all  the  vitamines  of  an  organism  can  not  be 
mobilized  to  take  part  in  metabolism.  It  appears  also  that  the  organs  most  essential 
to  life  are  the  ones  first  robbed  and  the  animal  dies  before  the  whole  supply  of  vita- 
mine is  exhausted  from  the  body.''  It  appears  to  me  that  Funk  here  admits  what  he 
elsewhere  denies,  namely,  that  the  vitamines  exist  in  the  body  as  constituents  of  the 
tissues  and  particularly  of  nervous  tissue. 

Further  experiments  are  greatly  needed  to  determine  the  exact  r61e  of  the  vitamines 
in  the  metabolism  of  the  body.  But  at  present  I  see  no  reason  to  doubt  that  one  of 
them  is  concerned  in  some  way  with  the  metabolism  of  nervous  tissue,  probably  as  a 
building  stone,  and  that  this  is  the  most  plausible  explanation  of  the  degeneration 
of  the  nervous  system  in  beriberi,  which  occurs  when  this  vitamine  is  withdrawn. 

WTuU  x$  the  ehemUtry  of  (he  vitaminetf — ^The  study  of  the  chemistry  of  the  vitamines 
has  been  a  source  of  confusion.  Funk  '  claimed  to  have  obtained  the  viatmine  from 
rice  polishings  in  a  pure  state  and  gave  its  empirical  formula.  Edie  '  and  his  co- 
workers obtained  a  different  formula.  Suzuki  and  Shimamura  and  Odake  ^  by  a  differ- 
ent method  obtained  a  vitamine  of  still  different  chemical  composition.  Vedder  and 
Williams  *  obtained  substances  that  would  promptly  cure  fowls  suffering  from  poly- 
neuritis, but  were  not  able  to  obtain  sufficient  vitamine  in  a  pure  state  to  submit  it 
to  chemical  analysis.  Finally,  Drununond  and  Funk  ^  now  admit  that  they  can  not 
isolate  the  pure  vitamine  and  say  that  it  is  apparenly  decomposed  during  the  frac- 
tionation, and  all  trace  of  it  is  lost.  The  chemist  who  reads  these  various  papers  mig^t 
come  to  the  conclusion  that  the  very  existence  of  such  a  thing  as  vitamine  was  doubtful. 
However  the  fact  that  a  vitamine  exists  is  as  well  proven  as  any  natural  fact  can  be. 

All  of  the  above  investigators  have  succeeded  in  obtaining  from  rice  polishings 
a  chemical  substance,  which  in  doses  of  a  few  milligrams  was  capable  of  curing  birds 
suffering  with  polyneuritis  induced  by  a  diet  of  overmiUed  rice.  The  explanation 
of  the  uniform  failure  to  obtain  a  sufficient  amount  of  this  substance  in  the  pure  state 
for  a  B&dsiactoTy  chemical  analysis  is  very  simple.  In  various  foodstuffs  it  is  a  very 
minor  quantitative  constituent  and  it  is  very  difficult  to  extract.  It  is  rapidly  de- 
stroyed by  most  of  the  chemical  reagents  that  are  used  to  fractionate  these  complex 
foodstuffs  and  is  a  most  unstable  body  even  when  minute  quantities  are  obtained. 

Mr.  Williams  who  worked  on  the  chendstry  of  the  rice  polishings  in  Manila  has  been 
able  to  continue  this  work  and  is  now  able  to  make  some  definite  suggestions  with  regard 

1  E3q)erlmeiiteUe  Boweise  gegea  die  toxlsche  Tbeorto  der  Beriberi.  Hoppe-Seylers  Zeitachrift  (.  Phyai- 
ologische  Cbemie.    1914,  LXXXIX,  378. 

•  On  the  Chemical  nature  of  the  Sahstanoe  which  onreB  PoiyneoritiB  in  Birds.  Joom.  Ph  jalology,  1011, 
XLUI, »  also  1912,  XLV,  75. 

•  Edie,  Evans,  Moore,  Simpoon,  and  Webster.  The  Anti-Nearitie  bases  of  Vegetable  origin  with  a 
Method  of  Isolating  Tomlin.    Bio^:iienL  Joom.   Liverpool,  1911-1913,  Vn,  334. 

« Ueber  Oryxanin,  etc    Biochemische  Zeitscfarlft,  1918,  XLm,  89. 

» Concerning  the  Beriberi  Preventing  Substances  or  Vitamines  contained  in  Rice  PoUshlngs.  Phil- 
ippine Joom.    8c  1918,  Vm,  175. 

•  The  Chemical  Investigation  of  the  Phospho-Tongatate  Precipitate  from  Rice  PoUshings.  Bioobemioal 
Journal,  1914,  vm.  No.  S,  598. 


PUBLIC  HEALTH  AND  MEDICINE.  29 

to  the  chemical  constitution  of  the  beriberi  vitamine  and  the  reason  for  its  unstable 
nature. 

We  thus  find  that  while  there  are  still  important  problems  connected  with  beriberi 
they  are  all  being  studied  and  there  is  a  fair  prospect  that  they  will  be  solved. 

In  closing  I  can  not  refrain  horn  commenting  on  the  attitude  of  several  physiolo- 
gists toward  the  new  conception  of  the  vitaminee  and  toward  the  term  itself.  Thus 
one  physiologist  who  has  several  times  objected  to  the  use  of  the  term  vitamine  says 
inarecentpai)er: 

I  am  conscious,  in  the  midst  of  our  enthusiasm,  of  a  warning  given  by  Rubner  in  a 
protest  against  the  creation  of  a  new  scientific  vocabulary  and  the  danger  of  trans- 
forming ue  natural  sciences  into  a  play  of  words.  The  science  of  nutrition  must 
never  tolerate  the  substitution  of  unhealthy  speculation  for  what  is  admittedly  a 
laborious  undertaking,  namely,  experimentation. 

The  conception  of  the  vitamine  rests  securely  upon  experimental  evidence.  I 
suppose  there  was  a  time  when  Harvey's  discovery  of  the  circulation  of  the  blood 
was  termed  a  "play  of  words"  and  "unhealthy  speculation"  by  some  of  the  scientific 
"standpatters"  of  that  day.  The  chemical  constitution  of  the  vitamines  has  been 
very  uncertain  although  there  is  good  reason  to  believe  that  the  beriberi  vitamines  are 
members  of  the  pyrimidine  group.  But  if  the  chemistry  of  these  bodies  should  never 
be  thoroughly  understood,  it  is  equally  true  that  the  chemistry  of  our  common  foods, 
of  our  secretions,  and  even  of  the  blood  itself  is  still  very  obscure. 

With  regard  to  the  term  itself  it  may  be  possible  later  to  find  a  better  one.  But 
in  the  meantime  we  are  obliged  to  name  this  substance  before  we  can  discuss  it. 
"No  ideas  can  materialize  except  throu^  their  expression,"  and  for  the  present 
the  term  vitamine  is  quite  as  useful  and  plays  the  same  rdle  in  our  scientific  vocabulary 
as  the  terms  enz3ane,  hormone,  and  antibody.  The  existence  of  these  substances 
has  been  demonstrated  by  experimentation,  and  we  can  not  ignore  them  because  we 
are  as  yet  ignorant  concerning  their  chemistry. 

The  Chairman.  There  are  two  other  papers  on  this  subject.  If 
there  is  no  objection,  we  will  defer  the  discussion  until  after  the  com- 
pletion of  these  papers.  We  wiU  now  have  the  paper  of  Dr.  Lebredo, 
of  Cuba. 


BERIBERI,  ESTUDIO  EPIDEMIOLOGICO  Y  EXPERIMENTAL 

Por  MARIO  G.  LEBREDO, 

Je/e  de  la  Seccion  y  del  LaboraUmo  de  Investigacionei,  etc,,  Direccum  de  Sanidad,  Habana^ 

Cuba. 

De  ninguna  manera  negaremos  que  el  anez  pulimentado,  cuando  se  administra  en 
grandes  cantidades,  como  alimento  principal  o  exclusivo,  a  diversos  animlaes  en  los 
estudios  ezperimentales,  provoca  verdaderos  trastomoe  de  origen  polineurftico. 

Igualmente  estd  plenamente  demostrado,  que  esas  polineuritis  experimentales,  se 
deben,  en  d^nitiva,  a  la  pobreza  que  en  principios  fosforadoe  tiene  el  arroz  puli- 
mentado,  principios  nutritives  importantes  que  quedan  en  el  desecho  del  arroz  en 
las  operadones  de  pulimentaci6n. 

Por  lo  tanto,  es  evidente  que,  en  los  palises  donde  el  arroz  es  alimento  principal  o 
ezdusivo,  han  de  encontrane,  naturalmente  casos  de  esas  formas  polineurfticas, 
aniUogas  a  las  expmmentalmente  provocadas  en  animales  y  dasificadas  como  beriberi. 

Pero,  punto  concreto  que  hemos  de  abordar:  ^Debe  de  quedar  aceptada  de  manera 
definitiva,  como  tinica,  esa  explicaddn  etioldgica?    ^Deberi  quedar  convenido  que 


30  PBOGEEDINQS  SECOND  PAN  AMEBIOAK  80IENTIFI0  C0NQBES8. 

68  86I0  una  enfermedad  producida  por  falta  de  piindpioe  nutritivoe,  determinadoo, 
en  el  airoz  y  que,  por  lo  tanto,  sea  asunto  resuelto  que  ocupe  el  beriberi  en  loe  hituros 
congresoe  el  lugar  principal  que  ocupa  en  ^ste  entre  las  enfermedades  producidas  por 
una  alimentad^n  deficiente  (starvation). 

Nosotros  creemos  que  hay  algo  mds  que  hacer;  creemos  que,  tambi^n,  debe  de 
haber  algo  active  que  produzca  el  beriberi. 

Y  lo  creemos  porque,  no  siempre,  reviste  la  foima  cr6nica,  la  depaup^ante,  per— 
fectamente  explicable  por  prolongada  carencia  de  determinado  principio  nutritivo; 
porque  no  todoe  loe  que  utilizan  el  arroz  como  alimento  exclusivo  se  hacen  berib^ricos, 
como  debiera  suceder,  indefectiblemente,  de  ser  la  carencia  del  elemento  nutritivo 
indispensable,  el  causante  de  esa  enfermedad.  Por  el  contrario,  unas  vecee  formaa 
agudas  sorprenden  a  individuos  que  hasta  entonces  gozaion  de  perfecta  salud  y  que 
comian  el  arroz  agregado  a  una  variada  alimentaci6n;  y  otras  voces,  formas  verdadera- 
mente  fulminantee,  se  preeentan,  tambi^n,  en  individuos  que,  durante  afios,  ban 
estado  sometidos — sin  preeentar  la  menor  manifestaci6n  patol(3gica — a  la  ezclusiva 
alimentaci6n  del  arroz,  ataques  fulminantes  que  estallan  de  repente,  como  si  algtkn 
elemento  pat<5geno  hubiera  venido  a  provocarioe. 

Nos  parece  que  serfa  16gico  aceptar— y  conveniente  diferenciar  con  nombres  ade- 
cuados,  dos  mecanismos  etiol6gicos:  uno,  el  puramente  alimenticio,  provocando 
polineuritis  a  tipo  cnSnico  y  la  predispoeici6n;  otro,  el  t6zico,  tambi^n  orizeo,  provo- 
cador  de  fen6menos  de  intoxicacidn  aguda  y  subaguda  y,  quizes,  cr6nica  del  genuino 
beriberi. 

I.  En  el  trabajo  que  vamos  a  someter  a  la  con8ideraci6n  de  ustedes,  exponemos 
algunos  hechos  interesantes  de  epidemiologfa  del  beriberi  en  Cuba,  en  reladdn  con 
un  estudio  especial  de  virulencia  de  los  anocee  consumidoe  en  y  fuera  de  los  lugares 
donde  se  presentd  la  enfermedad. 

Nada  hay  m^  provechoso  para  el  investigador,  que  el  estudio  de  las  epidemias,  en 
regiones  indemnes,  de  aquellas  enfermedades  que  ezisten,  constituyendo  focos  end^ 
micos,  en  determinados  paises.  Y  mayor  provecho  hay  si  ha  side  necesario  llevarlo 
a  cabo  desde  el  importante  punto  de  vista  sanitario. 

En  loe  focos  end6micos,  por  lo  general,  el  inters  sanitario  es  de  d*tBminuci6n  y,  por 
lo  tanto,  no  llegan  a  discemirse  bien  los  matices  de  los  cases  benignoe  que  en  epide- 
miologfa son  tan  graves.  Experienda  de  ello,  y  grande,  tuvimos  con  la  fiebre  amarilla, 
enfermedad  que  vino  a  moetrar  bien  sus  formas  atenuadas,  benignas,  cuando  la  acci6n 
sanitaria,  en^igica,  hizo  descender  la  secular  endemia  amarilla,  a  reduddos  Ifmites 
epid^micos. 

Con  el  beriberi  pa86  lo  mismo. 

En  Cuba  se  tuvo  al  beriberi  como  enfermedad  corriente,  abundante,  casi  end^mica, 
en  las  plantadones  de  azticar,  en  la  ^poca  de  la  eedavitnd,  ^poca  en  que  la  inmigra- 
ci6n  de  esclavoa  africanos  y  hasta  de  semi-esdavos  chinos,  parecia  traer,  con  el  c<m- 
tingente  propenso  a  contraer  la  enfermedad  por  el  duro  trabajo  y  la  mala  alimentaci6n 
a  que  se  les  sometfa,  la  causa  desconocida  de  la  enfermedad,  naturalmente  considerada 
exdtica. 

En  un  trabajo  que  publicamoe '  en  1913  expusimos,  que,  en  esa  ^poca  ylassiguientes 
hasta  la  de  nueetra  independenda,  no  fueron  diagnosdcados  berib^ricos  todos  los  que 
debieron  serlo,  pues  se  pasaban  por  alto  loe  casos  f ugaces,  ni  fueron  poeitivos  todos  los 
diagnosticadoe,  engrosando  las  estadlsticas  como  berib^ricos,  an^micos  palddicos  o  a 
parasitologfa  intestinal,  hidroh^micos  por  miseria,  etc. 

Sin  embargo,  encontramoe  en  la  literatura  m^dica  de  ese  perfodo,  casos  aislados  y 
verdaderas  epidemias,  innegables,  de  genuino  berib^. 

De  marzo  de  1911  data  nuestra  primera  observad6n  de  un  interesante  brote  epi- 
d^mico  bien  caracterizado  de  beriberi. 

1  Beri-Beri.   M.  0.  Lebredo.   Boletfn  OflofaU  de  la  8«cretarla  de  Senidad  y  Beneflcencia  de  Caba,  mayo 
y  Jtinio  de  1013,  tomo  IX,  No.  5  y  6  (en  espafiol).    En  inglet  en  el  tomo  X. 


PUBUO  HEALTH  AND  MEDIOINB.  81 

Se  presentd  en  los  presos  de  la  c&tcel  de  Santa  Clara  (Provinda  de  Santa  Clara). 

Las  manlfeBtadones  patokSgicas  fueron  muy  evidentee  y  tuvimos  oportunidad  de 
hacer  la  autopsia  de  on  case,  muerto  per  lonna  agada,  cuya  agonia,  dolorosa  y  cruel, 
presendamos. 

Deseando  hacer  an  estudio  completo  del  arroz  que  consumlan  los  atacados,  recogimoe 
algona  cantidad,  estudio  ampUo  que  nos  llev6  a  condusiones  que  hideron  arraigar 
en  nosotros  la  idea,  de  que  el  beriberi  puede  ser  produddo  por  un  t6xico,  desarrollado 
en  el  arroz  a  expensas  de  la  substanda  amilicea  atacada  por  un  germen  amUoaimo, 
t6xico  que  actda  sobre  los  elementos  nerviosos,  est6n  o  no  predispuestos. 

Las  condusiones  provisicmales  del  estudio,  fueron  presentadas  al  Congreso  de  la 
American  Public  Health  Association,  reunido  en  la  Habana  el  2  de  didembre  de  1911. 

La  epidemia  fu6  grave:  de  siete  atacados  murieron  cuatro  con  len6menos  agudiisimos 
cardio-pulmonares. 

Cofrespondiendo  con  esa  gravedad  epidemiol6gica,  el  estudio  especial  del  arros 
que  se  consumia  allf ,  mostr6  una  notable  vinilenda  para  el  curiel. 

£1  arroE  contenia  un  germen  andlodmo,  a  esporos  resistentes  a  la  temperatura  de 
lOO^'C.  por  mis  de  20  minutes.  Este  germen  al  vivir  a  expensas  de  la  substanda 
amiUcea  dd  arroz  preparado  hervido,  fabricaba  substandas  t6xicas  (no  identificadas), 
mortales  para  d  curiel,  por  la  via  intra-peritoneal,  en  dosis  de  16  c.  c.  y  aun  menos; 
por  la  via  cerebral,  en  dosis  pequefias,  gotas;  y  en  un  case,  por  la  via  gistrica,  depu^ 
de  haberse  provocado  la  irritaci6n  del  aparato  digestive.  Las  substandas  t^caa 
paredan  tensr  una  exdusiva  acd6n,  directa,  sobre  los  elementos  nerviosos,  imtados 
o  no,  ya  que  fueron  inofensivas  por  las  vfas  subcutAnea  y  drculatoria. 

Los  fendmenos  presentados  por  el  curid  intoxicado  mostraron  una  interesante 
analogia  con  los  dd  beriberi  agudo,  cardio-pulmonar,  humane;  y  en  las  autopsias 
encontramos:  poca  cuagulabilidad  de  la  sangre,  dilataddn  dd  coraz6n  derecho,  exu- 
dado  end  pericardio,  en  las  pleuras,  aunend  peritoneoy  m&B  o  menos  limitadagastro- 
ileo-yeyunitis,  que  recnerda  la  duodenitis  que,  segtin  Hamilton  Wright,  acompafia 
a  todo  beribdrico  agudo,  o  existi6  en  aquellos  casos  que  encontramos  ya  en  6poca  de 
polineuritis  reddual  berlbdrica. 

II.  En  junio  de  1912,  y  en  febrero  y  abril  de  1913,  surge  de  nuevo  la  sospecha  de 
estar  atacados  de  beriberi  varios  penados,  en  la  misma  dlrcel  de  Santa  Clara  donde  se 
present6  la  grave  epidemia  anteriormente  dtada. 

Los  casos  de  junio  de  1912  y  los  de  febrero  de  1913,  no  pudieron  ser  retrospectiva- 
mente  confirmados.  Las  histcnias  clfnicas  de  los  presentados  en  abril,  sefialaron  algo 
m^  concrete.  Fufmos  a  verlos  y  no  pudimos  llegar  a  condudones  precisas:  ninguno 
(eran  6),  presentaba  aspecto  clinico  que  correspondlese  a  ninguno  de  los  cuadros 
tfpicos  de  las  formas  intensas  dd  beriberi,  ni  forma  htimeda  ni  athSfica  y  menos  la 
terrible  forma  aguda  cardio-pulmonar.  En  todo  case,  d  fueron  de  berib^  genuino, 
lo  fueron  de  la  forma  ligera,  fugaz. 

Creemos  que  existen  esas  formas  ligerisimas  en  d  verdadero  beriberi,  tan  diflciles 
de  difltingnir  de  algunas  manifestadones  polineuriticas  de  una  condderable  tenuidad, 
que  pueden  manifestarse  en  los  individuos  que  viven  recluldos  en  los  asilos,  donde 
causae  de  orden  moral  y,  prindpalmente,  d  hadnamiento,  la  vida  sedentaria,  la 
podci6n  habitual  de  pie,  la  monotonia  de  la  existencia  y  de  la  misma  alimentad6n, 
son  sufidentes  para  produdrlas. 

Ninguna  de  las  muestras  de  arroz,  recogidas  en  las  diversas  ^i>ocas  sefialadas^  se 
mostr6  virulenta  para  d  curiel. 

No  deja  de  ser  sugestivo  el  poisamiento  de  que  puedan  existlr  esas  formas  tenues, 
no  bien  acentuadas,  fugaces,  por  acci6n  trandtoria  dd  t6xico,  cuando  d  material 
infectado  (arroz)  no  es  muy  abundante,  coinddiendo  la  desparad6n  de  las  invaakmes, 
d  poeo  retieve  mostiado  por  la  epidemia  y  la  curaci6n  r&pida  de  los  iavadidos,  con  d 
agotamjento  dd  elemento  etiol6gice  por  censumo  del  arroz  tdxico,  resuhando  entonces 
taidfo  d  empefio  en  encontnur  muestras  infectadas. 


82  PROCEEDINGS  SECOND  PAN  AMEBIOAN  SCIENTIFIC  C0NQBE8S. 

III.  Airoces  de  div^safl  dases  y  procedencias  (caniUa  viejo  [old  hard],  Valencia 
corriente,  semilla  Siam,  Valencia  Bombay,  semiUa  corriente,  canilla  nuevo  Santiago 
de  Cuba,  semilla  americano,  semilla  S.  Q.*)»  estudiados  en  distintas  ^pocas  (14  muestras 
en  1914),  no  mostraron  ningdn  efecto  txSxico  sobre  los  curlelee,  ni  por  la  via  mds  activa, 
la  peritoneal,  ni  en  dosis  considerable  hasta  de  20  c.  c. 

Es  cierto  que  a  ocasiones  encontramos  en  estos  arroces  inofensivos,  g^rmenes  banales 
a  esporos  resistentes  a  lOO^'C.  amilozimos  en  corto  grade,  no  virulentoe;  pero  estos 
g^rmenes  no  llegan — o  si  Uegan  lo  hacen  mal — a  adoptar  la  especial  forma  de  tabaco, 
a  reaccion  amilodea  excepto  en  el  extreme  esporulado  que  en  el  perfodo  de  esporulaci6n 
toma  el  germen  virulento  estudiado  por  nosotros  en  nuestros  arroces  t6xicos  y  el 
encontrado  y  aislado  por  Le  Dantec  de  excrementos  de  berib^ricos. 

rV.  En  didembre  de  1914  se  desarroll6  en  Banes  (Provinda  de  Santiago  de  Cuba), 
una  epidemia  de  beriberi,  denundada  por  el  Dr.  Ruiz  Ariza,  m^ico  muy  competente, 
superintendente  de  la  Divisi6n  Banes  de  la  United  Fruit  Company,  quien,  solamente 
en  el  Hospital  de  la  compafila  a  su  cargo,  ob8erv6  siete  atacados. 

Ya  unos  dfas  antes  tuvimos  notidas  de  un  case  por  una  historia  cUnica  remitida  por 
el  jefe  de  sanidad  de  aquella  poblad6n. 

En  el  afio  1908,  es  dedr,  pr6ximamente  6  aflds  antes  de  la  ^poca  de  la  aparld6n  de 
este  brote,  hubieron  varies  individuos  atacados  de  beriberi,  no  s61o  en  Banes,  sine  en 
un  embarcadero  situado  a  pocos  kilometros  de  esta  poblad6n,  siendo  dos  de  los  cases 
fatales. 

Trasladados  a  Banes  pudimos  observar  varies  casos  de  genuino  beribm;  pero  todos, 
aunque  bi^n  pronunciados,  ya  en  periodo  de  desaparid6n  sintomitica,  fin  de  epidemia. 
Estudiando  retrospectivamente  las  historias  de  dos  individuos  f alleddos  al  prindpio 
de  este  brote,  resulta,  que  puede  considerarse  murieran  de  beriberi  agudo,  adem^s 
de  otro  case  tfpico  (Antonio  Gonz&lez)  falleddo  al  dia  siguiente  de  haber  salido  del 
hospital,  con  trastomos  del  coraz6n,  taquicardia,  etc.,  fen6menos  graviaimos  que, 
muy  amenudo  no  son  sospechados  por  el  mismo  enfermo  hasta  que  estallan  en  crisis 
mortal. 

Segdn  nuestras  observaciones,  el  proceso  pat6geno  desarrollado  en  Banes,  examinado 
en  conjunto  hi6  uno  polineuritico,  con  trastomos  m^  o  menos  marcados  de  la  motilidad 
por  tension  de  los  gemelos,  con  edema  tibial,  con  disminucidn  o  aboliddn  total  de  los 
reflejos  rotuUanos,  con  molestia  epig^trica,  con  pulse  frecuente,  con  angustia  precor- 
dial, con  taquicardia,  Uegando  los  trastomos  cardio-pulmonares  a  produdr  la  muerte 
en  los  casos  enumerados. 

Sin  entrar  en  profundas  consideradones  con  respecto  a  la  sintomatologfa  del  beriberi, 
no  podemos  menos  de  seflalar  que,  para  nosotros,  en  todo  genuino  berib^rico — ^ya  se 
estudie  en  su  primera  invasidn,  o  en  un  brote  siguiente — deben  de  mostrarse,  m^ 
o  menos  acentuados,  fendmenos  cardiacos  acompafiando  a  los  fendmenos  polineuriticos 
de  las  extremidades  inferiores.  A  este  respecto  dice  Lacerda  con  raz6n:  '4o  mds 
especial  del  beriberi  es  la  aparid6n  temprana  de  los  trastomos  cardiacos  y  de  los 
trastomos  respiratorios  ligados  a  alteradones  del  neumog&strico  y  del  fr^nico. '' 

En  Banes  recogimos  16  muestras  de  arroz,  en  6poca  en  que  aun  estaban  presentes 
manilestaciones  berib^ricas  en  algunos  de  los  casos;  de  ellas,  7  fueron  virulentas  para 
el  curiel. 

Correspondid  a  la  prueba  de  virulencia,  la  presenda  de  un  germen  amilozimo 
semejante  al  encontrado  en  el  arroz  pat6geno  de  Santa  Clara,  aunque  no  tan  activo 
en  su  desarrollo  ni  en  la  producd6n  de  substancias  t6xicas. 

V.  Ultimamente,  en  mayo  de  1916,  lleg6  a  Cienfuegos,  procedente  de  la  India,  el 
vapor  ingl^  Deioa  despu^  de  estar  en  cuarentena  por  venir  de  puerto  sucio  de  bub6nica 
(7)  atrac6  al  muelle. 

Al  dfa  siguiente  de  atracar,  ya  en  operadones  de  descaiga,  muri6,  repentinamente, 
el  indio  Latifall6e,  de  25  afios  de  edad.  Segdn  breve  historia  recogida,  resulta  que 
tavo  al  levantarse  ''un  pequefLo  dolor  en  la  regidn  precordial,  a  pesar  del  cual  con- 
tinue trabajando  durante  el  d(a;  por  la  tarde  se  acentu6  el  dolor  acompafiado  de  disnea, 


PUBUO  HEALTH  AKD  MSDICIKB.  33 

intensa,  colapeo  y  muerte."  Segdn  el  cwtificado  de  autopsia,  fu6  diagnoBticado  de 
pericarditiB. 

Tree  dfas  despu^s,  el  m6dico  de  puerto  visita  el  vapor,  y  encuentara  nueve  tripulantee 
con  el  siguiente  cuadro:  '*aspecto  deprimido,  flacoe,  eon  edema  de  las  extremidades 
inferiores,  cara  angustioea,  pupilas  contraidas,  trastomos  de  la  locomoci<5n  en  distintofl 
gradoe  hasta  notable  paraplegia,  el  reflejo  rotuliano  en  unoe  notablemente  disminufdo 
y  en  otros  abolido,  apir^ticoe,  pulso  frecuente,  ruidoe  del  corazdn  dismindidoe,  dolor, 
en  todoB,  m^  o  menoe  intense  en  la  regi6n  epig&Btrica  que  se  irradia  a  la  regi6n  pre- 
cordial." No  se  pudieron  tomar  mayores  antecedentes  epidemiol(5gicoe  por  dificul- 
tades  de  idioma. 

Sin  embargo,  ante  el  caso  de  muerte  y  el  cuadro  deecrito,  era  16gico  pensar  que  hubo 
un  verdadero  brote  epid^mico  de  genuine  beriberi  dentro  del  vapor  Dewa, 

La  alimentaci6n  casi  exclusiva  de  la  tripulacidn  era  el  arroz.  Interesadoe  por  el 
resultado  del  estudio  de  los  arroces  virulentos  y  no  virulentos,  antes  mencionadoe,  y 
por  la  correlaci6n  ballada  entre  esos  resultados  y  la  intensidad  de  los  brotes  berib^ricoe, 
tenia  x)ara  nosotros  un  gran  valor  el  estudio  del  arroz  Dewa^  que  habfa  servido  de  casi 
exclusive  alimento  a  esos  individuos  de  su  dotaci6n,  atacados  de  beriberi,  en  epidemia 
reciente,  con  muerte,  y  en  recinto  bien  limitado. 

El  arroz  recogido  result6  particularmente  virulento,  el  mds  virulento  de  los  estudi- 
ados  x>or  nosotros,  por  lo  que  vamos  a  dar  algunos  detalles  del  trabajo  experimental, 
aprovechando  la  ocasi6n  para  sefialar  particularee  interesantes. 

OERHBN. 

Contenia  un  germen  amilozimo,  a  esporo  resistente  a  la  temperatura  de  ebullici6n 
por  m&a  de  20  minutes,  que  despu^  del  tercer  dfa  de  germinaci6n  adoptaba  formas  de 
tabaco,  con  reacci6n  amiloidea  de  todo  el  elemento,  excepto  en  el  extreme  esporulado. 

Este  germen  result6,  como  veremos  comprobado  despu^,  productor  de  considerable 
cantidad  de  substancias  t6xicas  (beriberlgenas?)  para  el  curiel. 

En  el  arroz  preparado,  hervido,  y  dejado  con  bastante  cantidad  de  agua,  1  :  4,  el 
germen  evolucion6.  Como  es  natural,  esa  evoluci6n  influye  poderosamente  sobre  el 
medio,  en  el  cual  se  acumulan  los  productos  que  se  desarrollan  al  atacar  el  germen- 
fermento  al  almid6n  del  arroz,  U^ando  por  concentraci6n  de  esos  productos,  despu^ 
de  algunos  dfas,  a  bacerse  impropio  para  el  natural  desenvolvimiento  biol6gico  del 
germen.    Cuando  esto  sucede,  ocurre  polimorfismo  por  involuci6n. 

El  germen  no  se  desarrolld  bien  cuando  utilizamoe  como  medio  de  cultivo  otros 
medios  amil&ceos,  ni  cuando  esterilizamos  el  arroz  en  agua,  bajo  presi6n.  Su  mejor 
medio  de  cultivo  es  el  propio  arroz  que  debe  esterilizarse  seco,  en  el  autoclave  y  luego, 
seco  y  est^il  cocido  con  agua  est^il. 

Se  comprende  que  cuando  el  grano  de  arroz  contiene  el  germen,  porque  viene 
naturalmente  infectado,  y  estos  son  los  cases  habituales  de  nuestras  pruebas,  basta  con 
hervir  el  azroz,  tal  como  viene,  en  agua,  durante  20  minutes  y  pasarlo  a  frasco  est^ril. 

El  germen,  cultivado  en  agar,  pas6  a  la  forma  de  resistencia,  esporulando,  sin  dar 
la  evoluci6n  morfol6gica  que  en  el  propio  cultivo  orizeo. 

En  resumen,  el  germen  del  arroz  del  Dewa,  en  su  morfologfa,  biologfa  y  reacciones, 
fu6  semejante,  si  no  fu6  el  mismo,  a  los  encontrados  en  los  arroces  virulentos  de  las 
epidemias  de  Santa  Clara  y  de  Banes. 

Seguramente  que  el  germen  debe  de  existir,  de  manera  natural,  dentro  del  grano  de 
arroz,  infect&ndose,  quizis,  en  los  envasaderos  despu6s  de  pulimentado,  y  es  probable 
que  la  corteza  (c^ara)  y  principalmente  la  pellcula  peric^ica,  sean  contra  ello 
excelentes  protectores. 

VIRULENCIA. 

Este  arroz  se  ha  mostrado  sumamente  virulento. 

Via  intraperitoneal . — ^Por  Via  intraperitoneal  ha  side  muy  mortifero,  pues  no  s61o  la 
cantidad  clisica  de  16  c.  c.  del  agua  del  arroz  preparado  produjo  la  muerte  de  los  curi* 


M 


PBOOEEDINQS  8SC0ND  PAN  AMEBICAN  SOIBNTIFIO  OONQBESS. 


eles  inyectadog,  sino  que  canUdades  de  10  y  hasta  de  5  c.  c,  con  b61o  23  6  24  horas  de 
preparado  el  arroz,  mataron  a  los  curieles,  en  1^,  6,  6  y  9  horas. 
Dosis  de  1  c.  c.  nada  produjeron. 

InyecciSn  intraperitoneal. 


Caiiel. 


No.l 

Ho.  1,2  8.. 
No.  2, 2  8.. 
No.  8, 2  8.. 
No.  4,2  8.. 
No.  10,2  8. 
No.  11, 2  8. 


Feoha. 


Kayo  36 
JuziiolS 

...do 

...do 

...do 

Julio  20 
...do 


Cantldad. 


C.C. 


16 

16 

10 

10 

5 

1 

1 


Tiompo 

preparado 

elaiTos. 


23 
24 
24 
24 
24 
«6 
16 


Tiampo 

muerte 

desptite 

inyeoddo. 


HOTOt, 

1  all 
a  7 
a9 
5 

24 
No. 
No. 


6 

8 


Fendmenos 
yaotopcia* 


TIploos. 
Do. 
Do 
Do 
Do. 

No. 

No. 


■Dlaa. 

Lo6  fen6menoB  t6xicos  fueron  loe  mismoe  que  los  provocados  por  los  arroces  t6xico8 
de  Santa  Clara  y  Banes.  A  voces  hay,  inmediatamente  deepu^  de  hecha  la  inyecci6n, 
ligeros  fen6meno6  de  shock,  manifeetados  por  alguna  inquietud  y  sobresaltos,  p^o  son 
fen6menoe  que  duran  muy  poco  tiempo. 

Los  propios  sfntomas  t6zico6  no  aparecen,  nunca,  antes  de  la  media  hora  de  haber 
side  inyectados,  y  so  suceden  de  la  siguiente  manera:  ligero  malestar  que  se  acentda 
T&pidamente,  lenta  progresiva  angustia,  respiraci6n  con  contragolpe  diafragmdtico, 
que  poco  a  poco  se  hace  miuB  dificultosa,  erizamiento  del  pelo  del  cuello  y  cara,  posicidn 
recogida  en  bola,  y  a  voces  con  aspecto  leonino,  ojos  hundidos,  sufrimiento,  martilleo 
de  la  cabeza  con  movimientos  is6cronos  con  los  golpes  diafragm&ticos,  caida  de  lado, 
agonf a  lenta,  y  muerte,  conjunto  sintomdtico  que  corresponde  segtin  parece  deducirse 
de  la  autopsia,  a  trastomos  cardio-pulmonares.  No  ha  habido  reten8i6n  de  orina,  ni 
par&lisis  intestinal. 

En  la  autopsia  encontramos:  exudado  en  las  pleuras,  en  cantidades  de  0.1, 0.2, 0.25, 
•0.4  hasta  1.5  c.  c;  exudado  en  el  pericardio,  en  cantidades  de  0.1,  0.2,  0.3  c.  c. 

Exudado. 


CurleL 


No.  1, 1  a  8 
No.  1, 2  a  8 
No.2,2a8 
No.  3, 2  a  8 
No.  4, 2  a  8 


Cavidades  pleurales. 

Derecha. 

Isquierda. 

Ce. 

C.c. 

ai 

1.5 

1.5 

.25 

.0 

.0 

.4 

.1 

.2 

.1 

Pericardio. 


C.c. 


0.1 
.2 
.2 
.2 
.8 


No  transcribimos  el  resultado  de  la  medici6n  del  Ifquido  encontrado  en  el  peri- 
toneo,  porque  como  la  inyecci6n  ha  side  hecha  por  esta  via,  no  ha  habido  tiempo, 
por  muerte  r&plda,  a  la  total  absorci6n  del  Uquido  inyectado.  £sa  medici6n  es  impor- 
tante  en  los  exi)erimentados  por  la  via  subdural  y  gistrica. 

Los  demds  caracteres  de  autopsia  fueron  los  habituales  hallados  en  las  experiencias 
con  loe  arroces  de  Santa  Clara  y  Banes:  dilataci6n  del  coraz6n  derecho,  siempre  en 
m^  o  menos  amplitud,  y  algunas  voces  de  la  auricula  izquierda  muy  Inguigitada; 
venas  cavas  y  sus  gniesos  afluentes,  principalmente  los  de  la  superior,  sumamente 
inguigitadas,  encontr&ndoee  un  verdadero  molde  de  esos  vasos,  en  gran  parte  de  su 
trayecto,  hasta  el  corasdn,  formado  por  la  sangre  coagulada,  cuando  la  autopsia  es 


FUBLIO  HEALTH  AND  MEDIOIKE. 


85 


tardia;   cuando  es  muy  reciente  la  muerte  hay  que  ser  muy  cuidadosos  para  eea 

obaervaci6n  de  plenitud  vascular  veiioea,  pues  ee  considerable  la  disminuci^ii  de  la 

coagiilabilldad  eanguinea;  color  del  corazdn,  paido  obscuro,  con  gran  congesti6n  de 

8UB  paredes,  y  ocasional  equimosis  pequefio;  diafragma  la  mayor  parte  de  las  voces 

muy  abovedado,  reduciendo  considerablemente  el  espaclo  de  la  cavidad  tor&xica; 

pulmones,  a  voces  muy  blancos,  p&lidos,  con  focos  bien  determinados  de  infartos 

hemorr^icos,  y,  al  corte,  como   enfisematosos,  otras  voces,  mds  congestionados; 

intestino  delgado,  principalmente  yeyuno,  e  fleon,  color  rojo,  hasta  rojo  vinoso,  y  el 

estdmago  con  algimas  zonas  congestivas  que  ll^an  en  algunos  casos  el  grade  de 
equimosis. 

Via  intracranecma. — ^Ha  side  menos  mortffera  que  la  intraperitoneal.    Los  curieles 

murieron  en  4),  8  y  9  boras  despu^  de  la  inyecci6n,  desde  gotas  hasta  0.1  c.  c.  del 

agua  de  arroz  virulento,  de  43  horas  a  8  dias  de  preparado. 

Tnyecci&n  intracroTieana. 


No.  2,1 
No.  2, 1 
No.  4, 1 

No.  4, 1 
No.  6,1 
No.  6, 1 
No. «,  3 
No.  6,  2 
No.  7  2 


a  8. 
a  8. 
aS. 
a  8. 
a  8. 
aS. 
as. 
as. 
aS. 


Curiel. 


Cantidad. 


Vleotas.... 

...do 

0.1O.O 

.10.0 

.20.0 

.20.0 

.20.0 

.10.0 

.20.0 


Tiompo 

preparado  el 

arros. 


43  boras. 

...do 

Gdlas... 
Sdfas... 
Sdlas... 
Sdias... 
Sdlas... 
6d1as... 
fidtes... 


Tiempo 
suiertedea- 

pote 
inyeockSn. 


9hofM.. 
...do.... 

No 

...do 

..do 

nhOTM. 

..doV.V; 
U  boras. 


Feodmenos 
yautopsia. 


Tfpioos. 

Do. 
No. 

Do. 

Do. 
Tlpioos. 
No. 

Do. 

T4»iO08. 


En  total:  de  7  inyectados,  murieron  4  solamente. 

La  tunica  de  la  inyecci6n  es  simple:  punci6n  dsea,  punci6n  delicada  de  las  mem- 
branas  cerebrales  con  una  aguja  de  disecci6n  fina,  penetrando  muy  ligeramente  en  la 
Bubstancia  cerebral,  de  manera  que  se  provoque  ima  ligera  irritaci6n  de  la  viscera, 
sin  grave  traumatismo.  La  inyecci6n  del  agua  de  arroz  virulento  preparado,  se  hace 
muy  cuidadosamente,  sin  hacer  pre6i6n  sobre  la  delicada  estructura  cerebral.  Quizes 
algunos  de  los  fracases  experimentales  por  esta  via,  se  deban  a  un  exceso  de  precau« 
cidn  de  este  particular  de  la  t^cnica. 

Cuando,  a  pesur  de  todo  cuidado,  se  ha  producido  un  traumatifimo  grave,  se  pre- 
sentan,  inmediatamente  despu^  de  la  inyeccl6n,  contracturas  fuertes  hacia  uno  u 
otro  lado,  hasta  convulsionee,  en  cuyo  case  desechamos  al  animal  en  experimentaci6n. 
81  solamente  se  presentan  ligerisimos  movimientos  de  inquietud,  de  torsion  hacia 
uno  u  otro  lado,  rdpidamente  fugaces,  se  deben  al  ''shock." 

Los  fen6menos  t6xicos,  se  presentaron  a  la  media  hora  de  la  inyecci6n. 

Los  sfntomas  fueron:  inquietud,  marcha  algo  par^tica  con  ligeto  titubeo  de  las 
extremidades  posteriores;  luego,  inmovilizacl6n,  sin  par&lisb,  con  gran  malestar 
mientras  se  establecen  los  trastomos  reepiratorios  con  notables  movimientos  de  con« 
tragolpe  diafragm&tico;  despu^  se  echan  de  lado,  erizamiento,  etc.;  los  trastomos 
cardio-pulmonares  se  hacen  m^  graves,  y  agonizan  con  relativa  lentitud. 

Nunca,  en  nlnguno  de  los  casos,  (por  ningima  de  las  tres  vfas  efectivas  para  el 
t6xico),  ha  habido  retenci6n  de  orina,  ni  par&lisis  intestinal.  Al  contrario,  la  orina, 
abundante,  se  elimina  con  fuerza,  siendo  tambi^n  muy  notable  el  aumento  del 
peristaltismo  intestinal.  La  orina,  examinada  mucha  voces,  no  ha  mostrado  sine 
ocasional  traza  de  albtimina. 

En  la  autopsia  encontramos:  exudado  pericMico  0.1,  0.2  y  0.25  c.  c;  y,  hecho 
muy  notable,  exudado  peritoneal  en  cantidad  de  2,  3  y  5  c.  c.  Todos  estos  exudados 
perfectamente  If mpidos,  transparentes. 

6848e— 17— VOL  X— 4 


36 


PBOOEEDINQS  SECOND  PAN  AMEBICAN   SCIENTIFIC  C0NGBES8. 


Extulado. 


Curlel. 


No.  2, 1  a  S 
No.  2, 1  a  8 
No.  6, 1  a  S 
No.  7, 2  a  8 


Cayidades  pleurales. 

Pericardio. 

Dereoha. 

Itquierda. 

C.e. 

C.e. 

C.e. 

0.0 

0.0 

0.25 

.4 

.0 

.2 

.0 

.0 

.1 

.1 

.1 

.2 

PflritoiMO. 


C.e. 


5.0 
2.6 
S.0 
5.0 


For  lo  dem&8,  iguales  manifestaciones  viscerales  que  por  las  otras  viae,  aunqe 
mucho  m^  ligera  la  congestidn  del  intestino  delgado  y  de  los  meeenterioe  corre- 
Bpondientes. 

Nada  se  encuentra  en  la  cavidad  craneal;  si  acaso,  el  sitio  de  la  inoculaci6n  sefialado 
por  un  punto  casi  imperceptible;  pero,  por  lo  dem^,  no  hay  apreciable  congestidn 
ni  reblandecimiento  de  las  superficies  cerebrales. 

Via  gdstrioa. — Este  arroz  del  Dewa  ha  sido  particiilarmente  t6xico,  administrado  en 
muy  diverse  tiempo  de  su  coccidn,  por  la  via  g^istrica,  preparando  previamente,  por 
irritaci6n,  el  aparato  digestive — en  algunos  cases  hasta  sin  preparaci6n. 

Todos  los  curieles  en  los  que  experimentamos  este  arroz,  por  esta  via,  murieron. 

La  irritaci6n  g^istrica  e  intestinal  ha  side  provocada  de  diversas  maneras:  adminis- 
trando  pequefia  cantidad,  (una  sola  vez),  de  una  soluci<5n  clorhldrica  d6bil,  (3  a  5  por 
ciento,  en  agua,  o  en  alcohol  diluldo;  o  pimienta  molida  en  bastante  cantidad. 

Por  lo  general  no  se  di6  el  arroz  hasta  estar  seguro  de  que  el  curiel  estaba  bien; 
horas,  o  uno  o  dos  dlas,  despu6s  de  administrar  el  irritante. 

El  arroz  hay  que  ponerlo,  ya  preparado,  en  la  boca  del  curiel,  pues  raras  voces  lo 
comen  espont&neamente,  y  el  llquido,  rico  en  los  principios  t6xicos  solubles,  se  da 
por  medio  de  un  gotero. 

Administramoe  el  arroz,  una  sola  vez,  diariamente,  por  lo  general  por  la  maflana, 
en  dosis  variable,  lo  m&s  corriente,  15  6  20  c.  c.  o  m&s,  del  agua  de  arroz,  y  otro  volumen 
igual  del  grano,  en  muy  di versos  dias  de  preparaci6n,  2, 3, 4,  etc. ,  aunque  por  lo  general, 
usamos  el  preparado,  entre  los  3  y  los  8  dias,  en  que  es  mayor  su  virulencia. 

Lo  m^  importante  en  todas  estas  experiencias,  es  que  se  mantienen,  constante- 
mente,  a  los  curieles,  en  la  condiciones  de  vida  acostumbrada.  La  alimentacidn 
habitual  les  fu6  dejada  abundante.  Nunca  dejaron  los  curieles,  si  se  ponfan  en  sub 
cajas,  inmediatamente  despu^  de  administrado  el  arroz  virulento,  aun  en  dosis 
considerables,  de  comer  con  avidez  la  yerba  o  maloja  que  tanto  les  satisface.  Sin 
embargo,  por  lo  general,  dejamos  un  periodo  de  1,  2  6  3  horas  antes  de  volverlos  a  su 
dieta  acostumbrada. 

Los  fen6menos  presentados  fueron  los  mismos  que  los  ya  descritos  producidos  por 
otras  vlas  de  inyecci6n,  pero,  en  todos  los  casos  de  esta  via  g&strica,  durante  las  crisis, 
medianas,  graves,  o  gravlsimas,  se  ha  manifestado  un  sintoma  muy  importante,  la 
poresia  de  las  extremidades  posteriores,  pareeia  que  nunca  encontramos,  intensa,  entre 
los  slntomas  producidos  por  la  via  intraperitoneal  o  intracraneana.  La  paresia  se 
manifiesta  por  dificultad  en  sostenerse  sobre  las  patas  posteriores,  cuando  camina, 
tambaleindose  el  cuarto  trasero  durante  la  marcha;  a  voces  les  obliga  a  preferir  la 
inmovilidad,  pero,  enti6ndase  bien  nimca  Uega  a  haber  par&lisis. 

Esta  paresia,  asi  como  cierto  grade  de  inconciencia  y  los  trastomos  respiratorios, 
erizamiento,  etc.,  dura  horas,  hasta  10  y  12,  pero  al  fin  pasa,  para  reproducirse, 
siempre  con  gran  aspecto  de  gravedad,  despu^  de  unos  dias;  son  verdaderas  crisis 
que  se  repiten  muy  graves,  2, 3,  o  mds  veces,  sin  que,  ya  lo  dijimos,  haya  periodicidad 
fija  en  la  ^poca  en  que  viene  cada  crisis,  producida  tras  la  toma  del  arroz  virulento,  no 
Buspendido,  sine  ocasionalmente,  en  su  diaria  administraci6n;  al  fin,  en  una  de  eeas 
crisb,  la  gravedad  se  hace  extrema,  y  la  agonla  aparente  de  tantas  ocasiones  se  hace 
efectivamente  mortal. 


PUBLIC   HEALTH  AND  MEDICINE. 


37 


En  la  autopeia  encontramos;  exudado  peric^dico,  hasta  0.5  c.  c;  y,  peritoneal, 
hasta  4  y  5  c.  c. ;  en  cambio,  en  ningdn  cafio  bubo  exudado  pleural(?). 

?  Cu&l  ee  la  patogenf  a  de  eaos  f  en6meno6  de  intoxicaci6n  por  la  via  g^usrtrica,  presenta- 
doe  por  ese  grupo  experimental;  via  g^btrica,  tinica  por  donde  ha  de  infectarse  el 
hombre,  de  beriberi? 

Aunque  creemoe  que  eeguramente  esos  fen6meno8  ban  de  obedecer  a  algfin  mecan- 
iamo  en  el  que  juegue  principal  papel  la  preparaci6n  del  elemento  nervioeo,  no  noa  ha 
sido  poeible  comprobar  la  oportunidad  en  que  aparece  esa  condici6n. 

En  nueetras  experienciaa  por  via  gistrica,  ante  los  efectivoe  y  numeroeos  hechos  de 
muerte  (10  cases),  provocadoe  por  el  arroz,  no  hemos  podido  dilucidar,  si  para  que 
exista  la  predi8posici6n  al  t6xico — me  refiero  exclusivamente  en  la  producci6n  de 
forma  aguda — ^ha  de  haber,  solamente,  initacidn  especial  de  la  mucosa  gastro  intestinal 
para  que  el  t6xico  actde  sobre  los  filetes  nerviosos,  o  tambi^n,  alguna  especial  sensibili- 
zaci6n  de  estos  filetes  nervioeos. 

Unas  voces — ^pocas — las  administraciones  del  arroz  virulento  mataron  a  los  animales, 
al  poco  tiempo— uno  o  dos  dfas — de  hab^rseles  administrado  el  irritante  de  la  mucosa 
digeetiva,  tal  parece  que  por  acci6n  directa  del  t6xico  sobre  el  elemento  nervioso 
irritado.  Recordemos  que  este  mecanismo  ha  sido  comprobado  mtiltiples  voces  en  la 
producci6n  de  diversas  polineuritis.  Babinsld  >  al  tratar  sobre  las  neuritis  perif^cas, 
en  un  importantfsimo  capltulo,  dice,  que  a  veces  hay  acci6n  electiva  de  las  substancia, 
t^xicas  sobre  los  extremes  perif^cos  nervioeos,  lo  mismo  que  una  infecci6n,  o  una 
intoxicaci6n,  pueden  obrar,  localmente,  sobre  esos  nervios;  y,  tambi^n  Pitres  y  Vail- 
lard  dicen:  "contrariamente  a  la  opini6n  generalmente  aceptada,  los  nervios  sufrens 
muy  f^ilmente,  cuando  se  les  pone  en  contacto  con  ciertos  reactivos  (qulmicos, 
t6xicos),  las  alteraciones  nutritivas  y  degenerativas  que  se  tiene  costumbre  de  con- 
siderar  como  electee  de  la  inflamaci6n." 

Pero,  tambi6n  es  cierto,  que  otras  veces — en  la  mayorfa  de  nuestros  cases  experi- 
mentales  por  la  via  g^trica — al  empezar  la  administraci6n  del  arroz  t6xico,  los  animales 
no  revelaron  ningtin  sintoma,  aun  cuando  previamente  les  dimes  substancias  irritantes 
g&Btricas,  y  a  pesar  de  ingerir,  diariamente,  y  durante  muchos  dias — 12,  14  y  m&a — 
grandes  cantidades  del  arroz  virulento,  hasta  que,  un  dfa,  tras  la  administraci6n  del 
arroz,  estallaron  los  sfntomas  t6xicos,  poni^ndose  graves,  pareciendo  inminente  la 
muerte.  Desde  este  primer  ataque,  que  siempre  pas<5 — ^ya  lo  hemos  dicho — se  repi- 
tieron  otros,  mientras  administramos  el  arroz  t6xico,  sin  periodicidad  en  la  6poca  de 
las  apariciones  sucesivas,  hasta  morir  en  uno  de  ellos. 

^Se  ha  producido  en  estos  cases,  en  que  tr^  la  irritaci6n  preparatoria,  no  se  presen- 
taron  fen6meno8  mortales  con  las  primeras  administraciones  del  arroz  virulento,  una 
S6nsibilizaci6n  tardla,  especial,  del  elemento  nervioso,  producida  por  esas  primeras 
adminiBtraciones  del  arroz  virulento  ? 

Exitdaho. 


No.  4, 
No.6; 

No.  7, 
No.< 
No.  5^ 
No.  6 
No.8; 

No.  10, 
No.  Il,2a8 


laS.... 
laS.... 

IftS.... 
aaS.... 
2a8.... 
aaS.... 
2a8.... 
aaS... 


Curiel. 


CftTidades  pleurales. 


Derecha. 


C.e. 


ao 

.0 
.0 
.0 
.0 
.0 
.0 
.0 


.0 


Isquierds. 


C.e. 


0.0 
.0 
.0 
.0 
.0 
.0 
.0 
.0 


.0 


Peiicardio. 


C.e. 
0.5 
.25 
.1 
.5 
.2 
.0 
.1 
.1 


.1 


Peritoneo. 


C,e, 
1 
4 

5 

Qotas. 
.0 


Oo 


tas. 


Qotas. 


1  BtMtmki,  Oapttulo  en  el  Timit^  de  mMeofne  de  Charcot,  Bouchard  Brissand— Neuritis  perif^ricos. 


38  PBOCEEDINGS  SBOOND  PAN  AMEBICAN  80IBNTIFI0  OONQBESS. 

For  lo  dem&B,  conge6ti6n  pasiva  subcutinea,  y  muy  notable  de  loe  afluentes  de  la 
vena  cava  superior;  coraz6n  derecho  dilatado;  diafragma  alto;  pidmones,  per  lo 
general  pdlidos,  a  veces  m^  o  menos  intenBamente  congestionados,  con  zonae  hemorri- 
gicas.  El  corazdn  muy  rojo  y  vascularizado;  e8t6mago  y  parte  del  intestino  delgado 
contienen  exudado  gleroso  con  partfculas  de  arroz,  y  muchos  hematies,  que  pueden 
ser  tan  to  de  origen  congestivo  como  debido  a  lesiones  post-mortem;  alguna  congeetidn 
del  intestino  delgado  y  del  mesent^io  correspondiente.  A  veces  al  corte,  los  pulmones 
parecen  insuflados,  crepitan,  y  recuerdan  los  pulmones  de  la  anafilaxia  su^ca. 

El  proceso  total,  desde  la  primera  doeis  del  arroz  virulento,  por  la  via  g&strica,  hasta 
la  muerte  del  curiel,  en  estos  casos  prolongados,  a  crisis  repetidas,  ha  durado  prictica- 
mente  do8  meses;  hubo  un  case  de  1}  mes,  y  otro,  prolongado,  de  4  meses,  sin  que 
presentaran  nimca  atrofia  ni  parilisis,  ni-Hudvo  case  excepcional — emaciacidn. 

Y  terminamos,  sefiores,  sin  pretender  por  un  memento,  que  hayamos  dado  sobre  el 
importante  problema  de  la  etiologfa  del  beriberi,  valiosas  conclusiones. 

S61o  hemes  querido  exponer,  modestamente,  ante  ustedes  las  pruebas  y  contra- 
pruebas  que  anteceden,  y  que  son  sugeetivas,  porque  en  medio  del  complejo  aspecto 
del  asunto  tratado,  se  destaca,  sin  embaigo,  determinada  unilormidad. 

A  la  inconstancia  o  a  la  poca  intensidad  de  los  casos  humanos,  ha  correspondido  el 
fracaso  en  encontrar  muestras  de  arroz  virulento  en  el  sentido  en  que  lo  hemes  venido 
eetudiando;  y,  en  cambio,  a  la  intensidad  y  mantenimiento  del  brote  epiddmico  ha 
correspondido  la  virulencia  del  arroz  recogido.  ^Es  pura  coincidencia,  o  se  tratari 
de  una  verdadera  relaci6n  do  causa  a  efecto? 

A  la  investigacidn  respondieron  las  muestras  virulentas  del  arroz,  de  manera  igual, 
precisa:  presencia  de  un  germen-fermento  a  esporo  resistente  a  la  tempeiatura  de 
ebullicidn — ^por  lo  tanto,  arroz  no  esterilizable  por  la  cocci6n;  producci6n  en  ese  airoi 
cocido  de  substandas  que  matan  a  loe  animales  experimentales,  de  manera  brutal, 
con  paresia  de  las  extremidades  posteriores,  fendmenos  caidio-pulmonares,  lesiones 
agudas  del  corazdn,  derrames  serosos,  principalmente  pericirdico. 

^Escapar^  el  hombre  a  semejante  proceso? 

Indudablemente  habrd  causas  que  influyan  en  activar  la  produccidn  del  tdxico,  o 
en  poner  la  mucosa  gastro-intestinal  en  condidones  de  mayor  o  menor  sensibilidad 
del  demento  nervioso  sobre  el  que  parece  actuar  d  t6xico,  de  manera  que  la  acddn 
de  dste  se  manifieste  mils  o  menos  r&pidamente  grave,  mortal. 

No  debemoe  olvidar,  para  explicamos  posibles  mecanismos,  que  tambidn  en  d 
aparato  digestivo  de  los  giandes  consumidores  de  arroz  hay  gran  cantidad  de  este  grano 
sobre  cuyos  piindpios  amilAceos  deber^  actuar  los  fermentos  que  en  giandes  canti- 
dades  hemes  visto  contiene  cuando  est4  infectado,  resultando  de  este  mode  el  oiganismo 
preparado,  para  que  sobrevengan  formas  crdnicas  o  sub-agudas,  o  para  que — d  se 
producen  algunas  de  las  causas  predlsponentes,  aun  no  bien  determinadas,  a  que 
aludimos  en  d  pfoafo  anterior — estalle  la  forma  aguda. 

Le  Dantec  ^  encontrd  gran  cantidad  de  arroz,  sin  digerir,  en  excrementoe  beribdricoe, 
y  de  ellos  aid6  im  germen  amilozimo.  Por  otra  parte  Metchnikoff,  con  sus  importantes 
estudios  sobre  la  flora  titil  intestinal,  da  fundamentos  para  pensar  que  es  podble  la 
acUmataddn  de  un  germen  amilozimo,  en  un  intestino  caigado  de  material  amiUceo, 
de  la  misma  manera  que  se  provoca  la  aclimataddn  del  badlo  bulgirico  para  sus  titUes 
actuadones  sobre  la  leche. 

Reeulten  no  dertas  estas  condderadones  apuntadas,  no  del  todo  hipotdticas,  sine 
fundadas  en  razones  Idgicas  de  analogfa,  y  en  pruebas  experimentales,  la  intend6n 
deflnitiva  y  concluyente  de  este  trabajo,  es  exponer,  que  en  d  estudio  de  los  gdrmenes 
amilozimos  que  se  encuentran  en  d  arroz,  y  en  d  analftico  y  exprimental  de  las 
substancias  t6xicas  que  producen,  hay  que  buscar  m^,  antes  de  dar  por  cerrados  los 
capf tulos  importantfsimos  de  la  patogenia  y  etiologfa  del  beriberi. 

ff  1  Le  Dantec:  Pathologie  exotlque. 


PX7BU0  HEALTH  AND  MEDICINE.  39 

The  Chairman.  The  reading  of  the  next  paper,  by  Mr.  R.  R.  Wil- 
liams, of  the  Bureau  of  Chemistry,  on  ''Chemical  Nature  of  the 
Vitamines/'  will  conclude  the  symposium.  I  take  great  pleasure  in 
relinquishing  the  chair  to  that  distinguished  investigator  of  Cuba, 
Dr.  Lebredo.    Dr.  Lebredo  will  preside. 


CONCERNING  THE  CHEMICAL  NATURE  OF  THE  VFTAMINES. 

By  ROBERT  R.  WILLIAMS, 
Bureau  of  Chemittry,  Waskingtorif  D.  C. 

The  difficultieB  Involved  in  the  isolation  of  vitamines  from  yeast  or  rice  polishings 
have  proven  so  serious  that  success  seemed  doubtful  until  a  clearer  idea  should  be 
gained  of  the  chemical  nature  of  these  interesting  and  important  substances. 
Accordingly  attention  has  been  directed  to  the  preparation  and  testing  of  synthetic 
substances,  which  appeared  likely  to  display  some  curative  properties  similar  to 
the  vitamine  fraction  of  natural  foodstuffs.  ' 

Two  facts  were  considered  of  primary  importance  in  determining  the  direction 
of  the  work.  The  firist  of  these  was  that  the  curative  substance  is  probably  a  P3nidine 
derivative,  since  the  curative  fraction  of  rice  polishings  contains  nicotinic  acid,'  and 
has  been  found  to  develop  a  pyridine-like  odor. 

The  benzene  or  six-carbon  atom  ring  is  found  in  many  tissues  of  all  forms  of  plant 
and  animal  ^fe.  It  constitutes  an  integral  part  of  most  proteins,  and  in  plants  occurs 
widely  in  the  form  of  tannins,  or  the  extractives  which  give  distinctive  colors,  odors, 
and  flavors.  Het«x>cylic  nuclei  containing  nitrogen,  notably  pyrrol,  indol,  purine, 
and  pyrimidine,  are  encountered  very  generally  in  animal  tissue.  On  the  other 
band  the  pyridine  ring,  consisting  of  one  nitrogen  and  five  carbon  atoms,  has  a  very 
limited  distribution. 

Many  natural  vegetable  bases  are  pyridine  derivatives,  including  most  of  the 
powerinl  alkaloids,  such  as  nicotine,  strychnine,  and  atropine.  However,  such  sub- 
stances are  of  a  strictly  limited  occurrence,  and  no  one,  so  far  as  I  am  aware,  has  sug- 
gested that  any  pyridine  derivative  may  have  any  general  importance  in  normal 
physiological  processes. 

A  second  hint  was  foond  in  the  fact  that  the  blue  color  reaction  given  by 
antineuritic  foodstuffs  when  treated  with  phosphotungstic  add  and  alkali  seems  to 
be  rather  closely  associated  with  the  potent  constituents.'  Since  this  reaction  and 
the  similar  reaction  with  phosphomolybdic  add '  are  known  to  be  produced  by 
substances  containing  hydroxyl  groups  in  the  benzene  ring,  it  was  not  surprising  to 
find  that  hydroxyl  derivatives  of  pyridine  also  give  one  or  both  reactions  according 
to  the  number  and  position  of  the  substituted  hydroxyl  groups. 

Accordingly  a  series  of  pyridine  derivatives  was  prepared  and  the  therapeutic 
action  of  each  individual  roughly  tested  on  polyneuritic  pigeons  by  the  administra- 
tion of  doses  of  from  1  to  10  milligrams  by  intramuscular  injection.  In  some  cases 
doses  of  10  to  100  milligrams  were  administered  by  mouth  as  a  supplementary  test. 
The  series  included  nicotinic,  cinchomeric,  quinolinic,  6  hydroxy  nicotinic  and 
dtrazinic  adds,  a  hydroxy  pyridine,  glutazine,  2,  4,  6,  trihydroxy  pyridine  and  its 

>  Simild,  Shlmamiin,aDd  Odake.  Biochem.  Zeitsch.  (1912)43,  S9.  Drummond  and  Funk,  Blochem. 
Jour.  (1914),  8,  fi08  and  elsewhere. 

•  Funk,  loc.  dt.    FoUn  and  MoOallum,  jr.    Jour.  BloL  CheoL  (1912)  11,  206;  13, 363. 

t  FoUn  and  Denis.  Jour.  BioL  Chem.  (1912)  12,  239.  Funk  and  McCaUum.  Biochem.  Jour.  (1913) 
7,360. 


40  PBOGEEDINQS  SECOND  PAN  AMEBICAN  SOIENTIFIC  CONGRESS. 

anhydride  and  finally  2,  3,  4  trihydroxy  p3nidine  and  the  so-called  tetrahydroxy 
pyridine. 

Nicotinic,  dnchomeric,  and  quinolinic  acids  were  prepared  by  the  oxidation  of 
nicotine,  quinine,  and  qiiinoline,  respectively,^  and  citrazinic  acid  from  citric  add.^ 
The  methods  of  Pechmann  and  Stokes '  were  followed  for  the  preparation  of  ethyl 
amino  /3  hydroxy  glutamate,  glutasdne,  2,  4,  6  trihydroxypyridine  and  its  anhydride. 
Tetrahydroxy-pjrridine  and  2,  3,  4  trihydroxy  pyridine  were  produced  by  the 
method  of  Ost^  from  the  nitroso  derivative.  In  the  distillation  of  meconic  add 
for  this  purpose  the  modification  of  Peratoner  and  Leone  ^  was  used.  Better  methods 
than  those  of  Ost  are  offered  by  Peratoner  and  Castellana  *  for  the  production  of 
hydroxycomenic  add,  from  which  by  suitable  modification  of  Ost*8  second  method 
fair  yields  of  2,  3,  4  trihydroxypyridine  may  be  obtained.  These  methods  are  bdng 
studied,  as  are  those  of  Collie,^  Tickle  and  Collie,^  Lapworth  and  Collie,'  and  Baron, 
Remfry,  and  Tborpe.'*^  Coumalic  add  was  used  for  making  6  hydroxynicotinic 
add,"  by  the  distillation  of  which  a  hydroxy  pyridine  is  readily  obtained." 

The  test  animals  used  were  pigeons  in  which  polyneuritis  was  developed  by 
feeding  ad  libitum  on  white  rice.  Tn  all  cases  the  disease  was  allowed  to  run  its  course 
till  the  animals  were  unable  to  stand  or  make  controlled  movement  of  the  legs  or 
wings.  In  such  cases  death  usually  follows  within  24  hours  and  may  occur  at  any 
moment.  A  number  of  times  birds  died  in  the  experimenter's  hands  before  treat- 
ment could  be  administered.  During  and  after  treatment  the  birds  were  continued 
on  a  diet  of  white  rice,  and  under  such  conditions  a  redevelopment  of  the  symptoms , 
can  be  only  a  matter  of  a  few  days.  Since  forced  feeding  was  not  resorted  to  on 
account  of  the  time  necessary  to  care  for  a  lai^  number  of  birds  in  this  way,  it  was 
occasionally  the  case  that  the  pigeons  became  very  weak  and  emaciated  before  the 
symptoms  developed  to  the  deoLred  point.  Such  cases  are  not  of  course  strictly 
comparable  with  those  of  sudden  development  in  which  the  animals  retain  a  great 
deal  of  their  original  strength  and  vigor,  though  losing  muscular  control,  and  a  meas- 
ure of  uncertainty  is  thereby  introduced  in  occasional  cases.  On  treating  polyneuritic 
pigeons  with  the  substances  above  mentioned  definite  evidence  of  curative  power 
was  noted  in  the  case  of  a  hydroxy,  2,  4,  6  trihydroxy.  and  2,  3, 4  trihydroxy  P3rridine. 
The  remainder  of  the  series  showed  no  effect.  But  as  will  be  seen  later  such  negative 
evidence  in  the  case  of  any  hydroxy  pyridine  derivative  can  not  be  regarded  as 
conclusive.  The  first  of  the  curative  substances  tested  was  a  hydroxy  pyridine. 
Three  birds  were  treated  with  excellent  results.  Three  others,  however,  showed 
little  or  no  improvement.  On  proceeding  with  the  series  to  the  polyhydroxy  com- 
pounds a  rapid  striking  cure  was  obtained  with  a  preparation  of  2,  4,  6  trihydroxy 
pyridine,  followed  by  several  partial  or  complete  failures.  A  second  and  third  fresh 
preparation,  however,  produced  two  and  three  fairly  rapid  cures,  respectively.  A  sin- 
gle fresh  preparation  of  2,  3,  4  trihydroxy  pyridine  was  administered  to  three  pigeons 
simultaneously,  one  pigeon  receiving  2  milligrams,  the  second  1  milligram,  and  the 
third  one-half  milligram.  The  following  morning  the  first  bird  was  dead,  while  the 
second  and  third  had  completely  recovered  from  all  paralytic  symptoms. 

1  Weidel.  Annalen  (1873),  165,  330.    Weidel  and  Schmidt  Berichte  (1879),  12, 1140.    Uoogewerfl  and 
Dorp.  Rec.    Trav.  Chlm.    Pays  Bas.  (1882),  1, 107. 
s  Behrmann  and  Hofmann.    Berlchto  (1884),  17, 2687. 
«  Berichte  (1885).  18,  2291,  and  (1886)  10,  9094. 
«  Jour.  f.  Prakt.  Chem.  (1879)  (2)  19,  203,  and  (1883)  (2)  27,  257. 

*  Qazz.  Chim.  Ital.  (1894)  24,  U,  75. 
« Iden>  (1906)  36, 1, 21. 

7  Jour.  Chem.  See.  London  (1801)  50, 617. 
« Idem  (1902)  81, 1004. 

•  Idem  (1807)  71, 838. 
10  Idem  (1904)  85, 1726. 

i<  Pechmann  and  Welsh  Berichte  (1884)  17,  2384. 
"  Pechmann  and  Baltser  Berichte  (1801)  24, 8144. 


PUBLIC   HEALTH  AND  MEDICINE.  41 

In  each  case  all  the  cures  obtained  were  of  those  pigeons  which  were  first  treated 
with  a  given  preparation,  while  those  treated  with  the  same  preparation  a  few  days  or 
weeks  later  invariably  received  no  benefit.  It  was  obvious  that  the  substances  had 
changed  in  some  manner  so  as  to  lose  the  curative  power.  As  there  was  no  evidence 
of  decomposition,  it  seemed  probable  that  it  was  due  to  a  tautomeric  change;  that  is, 
a  rearrangement  of  the  grouping  of  the  atoms  without  any  actual  disruption  of  the 
molecule  into  simpler  substances.  Such  rearrangements  are  well  known  in  many 
chemical  substances,  and  have  greatly  interested  oiganic  chemists  for  the  past  dec- 
ade. No  emphasis  has  been  laid  on  the  possibility  of  a  biological  significance  of 
such  transformations,  though  they  appear  to  be  just  such  reactions  as  might  easily 
occur  within  the  animal  (organism.  M^ny  of  them  take  place  with  the  greatest  of  easo 
and  without  resort  to  the  violent  methods  ordinarily  employed  in  our  laboratories. 

The  existence  of  such  a  tautomerism  in  the  hydroxy  pyridines  has  long  been  recog- 
nized in  a  general  way.  It  has  been  observed  that  these  substances  under  certain  cir- 
cumstances react  as  hydroxy  or  enol  compounds,  under  others  as  ketones.  However, 
no  one  has  regarded  it  possible  that  the  two  forms  could  exist  in  a  free  isolated  state  as 
two  distinct  individuals.  Each  of  the  hydroxy  pyridines  is  described  in  the  literature 
as  one  substance  of  definite  though  dual  properties.  A  critical  examination  of  the 
literature,  however,  suggested  that  this  was  not  the  case.  It  was  therefore  decided  to 
study  the  tautomerism  of  some  one  of  the  curative  substances  more  thoroughly  than 
had  been  done  previously.  For  this  purpose  a  hydroxy  pyridine  was  chosen.  This 
substance  has  been  administered  to  about  80  pigeons  under  varying  conditions  and 
certain  important  facts  have  come  to  light. 

It  is  prepared  by  fusing  6  hydroxy  nicotinic  acid  and  distilling  the  residue  after  the 
evolution  of  carbon  dioxide  has  ceased.  The  oily  distillate  presently  solidifies  to  a 
mass  largely  made  up  of  prism  crystals  but  often  containing  a  few  needle  forms.  The 
residue  condensing  in  the  neck  of  the  distilling  flask  after  completion  of  the  process 
always  crystallizes  in  the  form  of  needles.  The  crystalline  mass  of  prisms  on  being 
melted  and  allowed  to  cool,  again  solidifies  to  a  mass,  now  consisting  largely  of  needles. 
If  this  remelted  mass  is  dissolved  in  benzene  and  recrystallized  therefrom  by  the  addi- 
tion of  ligroin,  needles  are  found  to  predominate  in  the  beautiful  crystalline  precipitate. 
With  care  the  needles  may  be  obtained  absolutely  free  from  prisms.  From  the  mother 
liquor  on  concentration  prisms  separate  and  may  be  obtained  in  a  pure  form  by 
filtering  from  the  hot  solvent,  as  the  small  residuum  of  needles  dissolves  freely  in  the 
hot  mixture  of  ligroin  and  benzene.  The  needles  after  washing  freely  with  petroleum 
ether  and  drying  rapidly  in  a  vacuum  desiccator,  melt  sharply  at  106°  to  107°.  The 
imsms  melt  at  the  same  temperature  but  less  sharply,  and  tiie  melting  point  varies 
slightly  with  the  speed  with  which  the  temperature  of  the  melting  point  bath  is  raised. 
Evidently  prisms  are  converted  into  needles  very  rapidly  by  dry  heat.  On  allowing 
the  solid  needle  form  to  stand  for  a  few  days  in  an  open  vessel  or  cork-stoppered  bottle, 
it  will  be  found  that  the  crystal  form  has  undergone  a  change.  The  needles  which 
were  originally  clear  and  sharply  defined  are  marked  by  transverse  lines  of  cleavage. 
In  the  courw  of  10  to  20  days  they  become  roughly  needle  shaped  aggregates  of  prisms. 
The  rate  of  this  change  seems  to  depend  greatly  on  the  amount  of  moisture  in  the 
atmosphere  surrounding  the  crystals.  By  exclusion  of  moisture  the  transition  takes 
place  much  more  slowly,  if  at  all.  A  water  solution  of  needles  on  slow  evaporation 
deposits  only  prisms. 

If  the  two  forms  of  crystals  are  titrated  in  the  cold  with  alcoholic  bromine  according 
to  the  method  of  Kurt  Meyer  ^  neither  absorbs  appreciable  amounts  of  bromine  in- 
stantaneously. The  prism  form  absorbs  bromine  gradually  and  the  needle  form  still 
more  slowly.  Neither  form  can  therefore  be  the  hydroxy  or  enol  form.  However,  on 
dissolving  either  form  in  an  excess  of  alcoholic  sodium  hydroxide  of  known  strength 

>Aiii»l«n  (1011),  880,  312. 


42  PB00EEDIKQ8  SEGOND  PAN  AMEBIOAN  8CIEKTIFI0  00K0BE83. 

and  titrating  in  the  cold  with  bromine,  instantaneotu  absorption  occutb  in  excess  of 
that  required  by  the  caustic  soda,  a  hydroxy  pyridine  in  alcoholic  sodium  hydroxide 
solution  is  unquestionably  laiigely  in  the  enol  form.  Presumably  all  the  metallic  salts 
are  likewise  enols,  a  prestmiption  which  is  in  accord  with  the  known  facts  in  regard  to 
other  enol-keto  tautomers .  If  the  cold  alcoholic  solution  of  the  sodium  salt  is  just  neu- 
tralized with  cold  alcoholic  hydrochl(»ic  acid,  detectable  amounts  of  the  free  enol  form 
are  momentarily  present  as  determined  by  bromine  titration.  The  existence  of  any 
considerable  prop<^(ms  of  the  enol  form  in  the  free  state  i^[>pears  to  be  brief  in  all 
neutral  solvents  and  no  method  has  been  found  for  its  isolation.  Since  a  hydroxy 
pjrridine  is  a  base  as  well  as  an  acid,  it  forms  well-defined  salts  with  strong  acids. 
Whether  these  salts  are  partly  salts  of  the  enol  form  can  not  be  determined  by  titri- 
metic  methods  since  the  presence  of  the  acid  makes  the  determination  of  an  end 
point  impossible.  If  these  salts  are  not  partly  enols  they  are  at  least  transformed 
into  enols  with  the  greatest  rapidity  during  titration. 

It  therefore  appears  that  there  exist  not  two  but  three  tautcHneric  forms  of  a  hydroxy 
pyridine  for  which  we  may  readily  imagine  structural  formulae  ^  expressing  intra- 
molecular rearrangement.  However,  in  the  present  state  of  our  knowledge  no  useful 
purpose  would  be  served  by  attempting  to  assign  a  definite  pictorial  representation  to 
each  of  the  three  forms. 

By  simple  means  we  may  cause  any  desired  form  to  predominate  and  may  pass 
through  the  cycle  repeatedly.  Each  exists  in  equilibrium  with  the  others  in  relative 
quantities  depending  on  conditions.  We  shall  understand  their  relationships  fully 
only  after  finding  a  method  for  determining  each  of  the  three  forms  quantitively  under 
varying  conditions.    At  present  we  can  measure  only  the  amount  of  enol. 

To  a  degree  it  has  been  possible  to  determine  the  curative  power  of  each  of  the  three 
forms.  Several  preparations  of  freshly  crystallized  needles  dissolved  in  water  imme- 
diately before  injection  have  been  administered  to  14  i)olyneuritic  pigeons  in  doses 
of  1  to  2  milligrams.  Improvement  or  cure  resulted  in  every  case,  as  evidenced 
by  change  in  weight,  paralytic  symptoms,  and  appetite.  In  general,  the  action 
appears  to  be  of  the  same  character  as  that  of  unhydrolysed  extract  of  rice  polishings, 
though  somewhat  more  rapid.  Most  of  the  birds  reached  an  optimum  from  1  to  B 
days  after  treatment,  and  alter  a  single  dose  of  1  to  2  milligrams  lived  from  6  to  1 0  days. 
Three  birds  were  partially  cured  a  second  and  third  time  alter  redevelopment  of  severe 
symptoms  and  lived  11,  13,  and  15  days,  respectively,  after  the  first  onset  of  the 
disease.  However,  six  cures  differed  markedly  from  the  others  obtained  with  a 
hydroxy  pyridine.  The  first  evidences  of  improvement  were  noticed  in  from  40 
minutes  to  2  hours  alter  injection,  when  the  animals  began  to  assume  nearly  normal 
attitudes.  At  intervals  spasms  of  spastic  movement  occurred,  which  gradually 
became  less  frequent  and  less  prolonged,  and  in  the  course  of  from  3  to  12  hoiirs  ceased 
altogether.  After  this  time  the  birds  did  not  differ  markedly  in  condition  from  those 
in  which  less  rapid  cures  were  obtained.  The  gain  in  weight  and  other  evidences  of 
improvement  were  of  the  same  character.  The  rapid  cures  obtained  with  2,  4,  6, 
trihydroxy  pyridine  above  reported  were  attended  by  the  same  symptoms.  Protec- 
tive experiments  on  healthy  birds  on  a  white-rice  diet  have  not  yet  been  made. 

The  physiological  effect  of  the  enol  form  can  only  be  guessed  so  long  as  it  remains 
impossible  to  obtain  it  free  from  the  other  forms  and  in  a  more  or  less  permanent  state. 
Injections  of  1  milligram  in  caustic-soda  solution  produced  fairly  rapid  cures  in  two 
birds  so  treated.  Administration  by  mouth  of  10  milligrams  in  caustic  soda  followed 
by  dilute  acetic  acid  also  effected  more  rapid  cures  than  the  needle  form  usually  gives. 
Ths.  silver  salt  was  also  administered  to  three  pigeons  in  doses  of  20  milligrams  each, 
follo>red  by  salt  solution  as  an  antidote  for  the  silver.  Two  had  recovered  from  the 
paralysis  the  following  day  and  lived  3  and  7  days,  respectively.    One  died  5  hours 

1  Kaofmazm  B«lchte  (1903)  30, 1083.    Deokar.  J.  Pr.  Ch.  (1900)  02,  266. 


PUBUO  HEALTH  AND  MEDIdKB.  43 

alter  treatment.  No  very  satialactory  conduaioii  can  be  drawn  from  theee  expert* 
ments  on  accoimt  of  the  disturbing  factor  of  the  toxicity  of  caustic  soda  and  silver. 
The  former  produced  severe  inflammation  of  the  tissues  with  which  it  came  in  contact, 
and  the  latter  evidenced  a  general  toxic  action  as  was  to  be  expected.  Nevertheless, 
there  was  indubitable  relief  of  the  typical  paralytic  symptoms,  and  this  action  on  the 
whole  appeared  as  rapid  as  that  obtained  by  treatment  with  the  needle  form.  I 
was  led  to  suspect  that  the  enol  form  is  the  rapidly  curative  one  and  that  the  needle 
form  is  beneficial  by  reason  of  its  gradual  transformation  into  the  enol  in  the  tissues. 
However,  this  is  very  uncertain. 

The  prism  form  has  been  tested  on  some  30  birds  under  varying  conditions.  Doses 
ol  from  0.5  to  100  milligrams  have  been  tried  by  injection  and  by  mouth.  Injections 
in  water  have  been  made  immediately  after  solution,  after  standing  several  days,  after 
boiling,  and  after  heating  under  steam  pressure.  Injections  in  mineral  oil  and  in 
fatty  acid  have  also  been  tried.  In  no  case  was  there  the  slightest  evidence  of  any 
benefit.  When  large  doses  were  administered,  the  action  seemed  distinctly  adverse 
in  several  cases,  as  the  birds  died  sooner  than  was  expected.  Doses  of  10  milligrams 
injected  into  healthy  birds,  however,  produced  no  gross  toxic  symptoms. 

This  absolute  lack  of  curative  properties  is  very  striking  and  suggestive.  It  is  ap- 
parent from  the  experimental  evidence  that  the  tautomeric  forms  exist  in  equilibrium 
and  that  there  is  fairly  rapid  transformation  in  any  direction.  One  would  therefore 
suppose  that  the  prism  form  would,  when  injected  into  the  body,  rapidly  convert 
itself  into  the  curative  form  as  the  latter  was  removed  from  solution  by  absorption  in 
the  tissues  or  fluids  requiring  it.  That  such  is  not  the  case  suggests  very  strongly  that 
the  pathological  conditions  of  polyneuritis  are  not  due  to  a  deficiency  of  a  substance 
per  se,  but  to  a  lack  of  a  certain  type  of  potential  energy  which  only  that  substance  can 
supply.  In  other  words,  one  is  led  to  surmise  that  it  is  the  potentiality  of  tautomeric 
change  that  produces  the  desired  result.  In  this  connection  it  is  interesting  to  note 
that  many  purine  and  pyrimidine  derivatives,  some  of  which  Funk  has  reported  to 
be  partially  curative  for  polyneuritis,'  are  also  theoretically  capable  of  a  similar  tau- 
tomeriam.  That  these  substances  are  to  a  greater  or  less  degree  enol-keto  tautomers 
18  very  strongly  indicated  by  well-known  reactions  of  uric  add,  for  example.  The 
existence  of  a  third  tautomer  is  not  excluded  by  theoretical  considerations,  but  lacks 
the  support  of  any  experimental  evidence. 

It  appeared  not  unlikely  that  other  hydroxy  pyridines  might  prove  more  easily 
controlled.  Accordingly  fi  and  y  hydroxy  pyridine  and  a  a  dimethyl  y  hydroxy 
pyridine  or  y  lutidone  have  been  prepared  and  are  being  tested.  They  show  curative 
properties  only  under  certain  conditions.  Each  crystallizes  in  two  different  forms 
and  forms  metallic  salts  which  absorb  bromine  rapidly  in  cold  alcohol.  In  every  way 
they  appear  to  be  strict  anologues  of  a  hydroxy  pyridine 

Dr.  Lebbedo.  The  discussion  is  now  open  on  these  papers.  I  will 
ask  Dr.  Guiteras  to  preside. 

Dr.  M.  X.  Sullivan.  For  about  six  months  I  have  been  working 
on  this  question  of  the  vitamines,  and  I  think  we  have  a  few  points 
that  might  be  rather  interesting  to  this  gathering.  One  that  stands 
out  particularly  in  my  memory  is  the  fact  that  the  mode  of  prepa- 
ration has  a  great  deal  to  do  with  its  being  effective  in  keeping  off 
these  polyneuritic  processes.  In  Boston  Dr.  Voegtlein  and  I  reported 
a  paper  showing  diat  if  you  kept  hens  on  com  bread  made  out  of 
com  not  highly  milled  and  baking  powder  that  the  hen  woxdd  run 
at  least  165  days;   but,  if  in  addition  to  the  com  meal  a  certain 


1  Jour.  Physiol.    (1913)16,480. 


44  PROCEEDINGS  SECOND  PAN  AMERICAN   8CIBNTIPIC   CONGRESS. 

amount  of  milk  was  added  by  doubling  the  amoxmt  of  baking  soda, 
in  14  days  it  would  bring  about  polyneuritis  in  the  hen.  That  is 
rather  striking,  because  we  have  added  to  the  diet  milk,  which  of 
itself  is  a  protective  agent;  but  we  have  doubled  the  bicarbonate 
of  soda  used,  and  this  in  the  process  of  baking  the  bread  destroys  the 
protective  kernel,  so  that  in  14  to  20  days  we  were  making  these 
hens  polyneuritic  with  com  bread,  showing  that  the  method  of 
preparation  of  the  food  makes  a  difference  in  its  effectiveness  in 
protecting  the  individual.  We  can  not  say  that  we  have  the  pure 
vitamine,  because  we  do  not  know  what  the  pure  vitamine  is,  but 
we  have  been  working  on  a  number  of  things  that  we  got  out  of 
liver,  peas,  and  beef  that  was  prepared  by  Dr.  Seidell,  and  one  of  the 
most  active  that  we  got  came  from  wheat  bran  by  hydrolysis  with 
acids,  not  very  strong  hydrolysis  and  not  very  strong  heating,  but 
it  was  by  hydrolysis. 

Dr.  Clark.  A  significant  point  was  raised  by  Dr.  Sullivan  in  his 
remarks  on  the  acid  solutions.  It  is  perfectly  possible  that  by 
making  the  solution  alkaline,  as  Dr.  Sullivan  did  in  his  com  bread, 
that  the  particular  element  was  more  easily  destroyed  than  it  would 
be  in  an  acid  solution.  I  am  reminded  of  an  observation  that  I 
made  a  year  or  two  ago,  which  may  have  some  significance  on  the 
treatment  of  infantile  scurvy.  It  has  commonly  been  recommended 
that  the  acidity  of  milk  should  be  neutralized  in  feeding  mUk  to 
infants,  and  there  has  been  a  good  deal  of  misconception  as  to  what 
we  meant  by  the  acidity  of  milk.  Determining  the  acidity  of  milk 
by  the  hydrogen  ion  concentration,  we  find  it  is  to  all  intents  and 
purposes  practically  a  vital  medium.  Now  Holt  and  some  other 
people  have  recommended  that  in  cases  where  limewater  is  not 
available  milk  of  magnesium  should  be  used;  but  I  found  that  in 
some  of  the  more  diluted  milks  fed  to  normal  infants  the  addition 
of  limewater  in  the  proportions  suggested  brought  the  hydrogen  ion 
concentration  far  below  the  point  needed  by  a  great  many  bacteria 
and  to  a  point  where  the  state  of  the  milk  was  changed  to  a  very 
large  extent  and  would  go  to  pieces  in  some  of  its  constituents  on 
pasteurization.  Such  milks  are  probably  more  alkaline  than  any 
food  which  is  taken  in  the  ordinary  course  of  events  by  any  adult. 

Dr.  Sullivan.  May  I  say  another  word?  It  is  said  that  there 
was  some  confusion  on  the  question  of  the  vitamines,  because  you 
could  heat  foods  like  orange  juice  and  not  destroy  the  vitamine 
and  you  could  heat  milk  and  destroy  the  vitamine.  It  is  perfectly 
right  that  this  should  be  so.  When  you  heat  milk,  you  lower  the 
hydrogen  ion  to  such  an  extent  that  it  comes  in  the  same  category 
as  com  bread. 

Dr.  Agramonte.  I  wish  to  say  that  I  am  in  perfect  accord 
with  the   opinion  that  this  disease,  beriberi,  as  well  as  pellagra, 


PUBLIC  HEALTH  AND  MEDICINE.  45 

scurvy,  and  others,  is  induced  directly  by  malnutrition  or 
faulty  nutrition.  The  interesting  experiments  reported  by  Dr. 
Lebredo  in  his  paper,  presenting  an  oi^anism,  an  extremely  resist- 
ant bacterial  oi^anism,  as  the  producer  of  the  beriberi  toxin  or  the 
producer  of  an  anaphylactic  substance,  is  new  to  me,  as,  of  course, 
to  all  of  you  who  hear  this  for  the  first  time,  and  I  think  should  be 
reserved  for  future  corroboration  or  confutation  as  the  case  may 
be.  The  germ  theory  of  beriberi,  I  think,  has  been  exploded  a  long 
time  ago,  and  we  need  not,  therefore,  go  over  the  old  matter  here. 

We  ought  always  to  take  into  consideration  the  personal  equation 
in  dealing  with  tiiese  diseases  of  systemic  disturbance  and  with 
all  infectious  diseases.  We  know  that  a  nmnber  of  individuals  in 
the  worst  epidemics  remain  unaffected,  resistant  to  disease,  and 
that  has  been  really  one  stxunbling  block  in  considering  beriberi. 
For  instance,  we  have  eight  or  ten  or  fifteen  individiials  coming  down 
with  the  same  disease,  but  other  individuals  who  are  subjected  to 
the  same  exposure  do  not  come  down  with  the  infection,  and  there, 
I  think,  the  personal  equation  should  be  considered.  In  this  case  I 
think  it  should  be  considered  as  much  as  when  we  consider  epidemics 
of  other  disease,  because  if  we  continue  to  say  it  is  due  simply  to 
the  lack  of  this  or  that  in  the  diet  the  question  immediately  arises. 
Why  have  the  other  men  subjected  to  the  same  diet  not  been  affected 
with  the  disease,  since  the  hiunan  race  must  be  considered  as  an 
entity?  So,  I  think,  we  must  consider  that  the  vitality  of  those 
individuals  who  are  susceptible  to  disease  is  below  par,  while  that  of 
the  others  is  a  little  above  par. 

Dr.  Tom  Williams.  It  has  been  stated  several  times  that  beriberi 
is  due  to  a  deficiency  in  the  diet  and  that  all  individuals  living  on  this 
diet  and  subject  to  the  deficiency  should  be  affected  with  the  disease. 
This  is  a  fallacy  which  I  do  not  think  can  be  exposed  too  often  or  too 
urgently.  There  is  no  reason  to  suppose  that  a  number  of  individuals 
will  all  be  affected  in  like  maimer  by  any  condition.  If  we  give 
strychnine  to  men,  there  are  no  two  who  will  be  affected  exactly  alike. 
They  aU  die,  but  there  will  be  great  difference  in  the  rapidity  of  the 
action,  etc.  The  same  thing  is  true  when  we  come  to  ii^ectious 
processes.  If  we  vaccinate  a  hundred  men,  95  per  cent  will  be  ^'takes" 
and  5  per  cent  will  have  to  be  revaccinated.  In  the  matter  of  food, 
we  all  know  that  what  is  one  man's  meat  is  another  man's  poison. 
Some  people  can  not  eat  eggs,  some  people  can  not  drinkmilk,  and  there 
is  no  reason  why  we  should  suppose  all  people  are  going  to  react  in 
the  same  way  to  food.  Some  one  man  may  consume  a  tremendous 
amount  of  one  substance  and  another  man  a  very  small  amount. 
Our  retention  of  uric  acid  in  the  system,  our  individual  metabolism, 
all  differs.  I  tlnnk  there  has  been  enough  said  on  that  point  to  show 
that  just  because  a  person  is  deprived  of  a  certain  chemical  element 


46  PBOOEEDIKOa  8E00KD  PAN  AMEBIOAN  8CIEKTIFI0  OOKQBESS. 

in  the  food,  all  persons  under  the  same  conditions  will  not  behave  in  the 
same  way,  any  more  than  they  will  do  anything  else.  Our  practical 
experience  indicates  the  same  thing. 

I  suppose  in  the  present  day  and  generation  everybody  will  admit 
that  scurvy  is  due  to  a  deficiency,  and  you  know  that  if  you  feed  a 
man  on  hardtack  and  bacon  long  enough  he  will  get  scurvy;  also  that 
if  we  feed  500  men,  as  frequently  occurs  in  sieges,  etc.,  all  on  the  same 
ration,  all  do  not  suffer  in  the  same  degree. 

With  regard  to  Dr.  Lebredo's  work,  I  want  to  say  that  I  think  his 
experiments  are  absolutely  accurate.  I  do  not  think  there  is  any 
question  about  his  facts,  but  I  differ  with  him  as  to  the  interpretation 
of  those  facts.  In  the  first  place,  if  you  extract  rice  or  any  other 
substance  which  has  proteid  materials  in  it — rice  contains  a  very  con- 
siderable amount  of  proteid — and  subsequently  inject  those  sub- 
stances iuto  the  body  through  the  skin  or  through  the  peritoneal 
cavity,  in  any  other  way  than  through  the  mouth,  you  will  iuvariably 
have  a  certain  amount  of  toxic  phenomena.  You  will  have  them 
particularly  if  you  inject  simple  peptones.  You  can  thus  kill  an 
animal  very  rapidly.  The  fact  that  the  mjection  was  at  first  harm- 
less and  that  only  after  three  or  four  repeated  injections  did  the  harm- 
f\il  results  obtain,  the  fact  that  the  harmful  effect  appears  with  pa- 
ralysis of  the  hind  legs,  respiratory  embarrassment,  all  suggest  very 
strongly  that  Dr.  Lebredo  was  dealing  with  anaphylaxis  produced 
by  foreign  proteid,  and  I  have  not  the  slightest  doubt  in  the  world 
that  he  can  kill  animals  in  that  way,  but  I  do  not  beUeve  that  it 
proves  that  the  rice  taken  by  mouth  is  toxic. 

Then  I  wish  to  point  out  very  briefly  the  focal  nature  of  Mr. 
Williams's  contribution.  I  think  Mr.  Williams  is  the  only  man  who 
has  had  the  conception  of  producing  these  vitamines  synthetically 
in  the  laboratory.  He  has  been  working  steadily  at  it  for  three  years, 
and  I  think  this  is  in  its  scientific  nature  as  important  as  Ehrlich's 
synthetic  preparation  that  will  kill  spirochetes.  It  is  an  absolutely 
new  idea  in  medicine.  We  have  been  talking  about  vitamines,  etc., 
but  now  we  are  going  to  get  them.  Of  course,  Mr.  Williams  does  not 
dahn  that  we  wiU  get  vitamines  as  we  find  them  in  food,  because  it 
is  not  known  what  they  are;  but  we  are  on  the  road,  and  I  think  the 
reproach  which  has  been  thrown  on  the  term  ''vitamine'*  should  be 
removed,  and  that  a  great  many  physiologists  who  have  beUeved 
that  we  were  discussing  things  that  we  knew  not  whereof  we  were 
talking  will  now  perhaps  revise  their  opinions  somewhat. 

Dr.  Lbbbedo.  I  will  answer  briefly  all  remarks  that  have  been 
made  to  me.  I  said  to  Dr.  Agramonte,  I  have  not  claimed  to  find 
anything  new;  the  only  point  has  been  that  the  experiment  has 
been  very  striking.  I  presented  it  to  the  AmericaiT  Public  Health 
Association  several  years  ago.     I  had  in  mind    anaphylaxis   in 


PUBLIO  HEALTH  AKD  MEDICINE.  47 

these  experiments  and  made  the  autopsy  in  one  case  of  beriberi, 
wishing  to  see  if  it  was  not  anaphylaxis,  because  I  think  in  beriberi 
more  than  the  etiological  point  is  that  of  pathogenesis.  That  could 
be  proven  by  taking  the  serum  of  the  particular  case  and  trying  it 
with  guinea  pigs,  also  by  using  different  kinds  of  rice  and  different 
ways  of  experiment.  I  could  not  find  anything  in  that  experiment, 
and  following  that  I  used  the  rice  when  I  foimd  that  the  rice  was 
toxic  and  truly  toxic,  acting  not  because  it  was  anaphylactic  in  the 
way  that  the  anaphylaxis  is  with  the  serum  anaphylaxis.  I  have 
studied  many,  many  kinds  of  rice  in  different  wajrs,  leaving  them  for 
several  days,  2,  3,  4,  5,  10,  and,  as  I  said  in  my  paper,  I  put  into  the 
peritoneum  20  cc.  and  never  killed  one  animal.  When  I  foimd  this 
special  germ  that  resists  the  temperature  for  100^,  I  began  killing  the 
animals  right  along  in  three  or  four  hours  by  injecting  into  the  peri- 
toneum. In  my  last  experiments  that  was  the  most  striking  thing. 
When  I  give  to  animals  rice  by  the  mouth  I  do  not  always  kill  them, 
but  when  I  cause  some  irritation  in  the  intestinal  tract,  then  I  can 
kill  the  animals,  occasionally  in  two  or  three  hours  after  giving  it, 
but  not  at  other  times.  But  it  is  not  anaphylaxis,  as  I  said  in  my 
paper. 

In  a  matter  more  important,  that  of  prophylaxis,  I  think  we  are 
all  in  the  same  boat. 

Ebcperiments  were  made  some  time  ago  with  chickens  and  guinea 
pigs,  using  rice,  but  I  never  have  seen  them  give  the  heart  troubles 
and  the  pulmonary  troubles  of  the  acute  beriberi  as  I  have  seen  in 
those  of  my  experiments. 

I  will  conclude  in  saying  that  we  should  take  great  care  with  the  diet 
itself.  I  am  in  accord  with  that  theory.  It  is  necessary  to  be  very 
careful  with  the  diet  and  to  have  it  mixed,  because  we  may  have 
the  more  chronic  form,  but  there  also  should  be  some  care  taken  as 
to  the  rice  used.  There  is  also  the  packing  of  the  rice,  which  is  one 
of  the  chief  things  to  be  considered  in  future  congresses,  because  I 
think  in  packing  lies  a  great  danger  for  many,  many  diseases,  as  in 
plague.  We  need  to  know  how  to  have  packing  done  to  prevent 
the  infection  of  the  rice,  which  to  me  is  one  of  the  things  that  must 
be  looked  for. 

Mr.  H.  R.  Williams.  There  is  very  little  further  comment  that  I 
woidd  care  to  make,  except  that  I  do  not  want  anyone  to  misunder- 
stand me  as  saying  that  I  consider  that  any  one  of  these  substances 
actually  exists  in  rice  or  yeast  or  any  other  food  substance,  or  that 
it  is  necessarily  a  substance  essentially  of  the  same  character.  But 
there  is  some  feature  of  these  molecules  which  is  common  to  them 
and  to  the  vitamines,  and  will  be  so  admitted  when  we  shall  event- 
ually find  out  what  the  vitamines  are. 


48  PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC   CONGRESS. 

The  Chairman.  Having  concluded  the  discussion  of  these  papers^ 
we  will  continue  with  the  reading  of  the  last  papers  of  the  session. 
I  will  now  call  upon  Dr.  Hess. 


INFANTILE  SCURVY. 

By  ALFRED  F.  HESS. 

In  a  consideration  of  the  'deficiency  diseases''  we  can  not  omit  infantile  scurvy. 
This  disorder  would  seem  to  have  made  its  appearance  in  the  course  of  modem 
civilization  since  artificial  feeding  has  replaced  mother's  milk  to  so  laige  an  extent- 
It  is  a  subject  of  increasing  importance,  which  concerns  the  health  and  welfare  of  the 
infant  population. 

As  is  well  known,  infantile  scurvy  practically  never  develops  among  breast-fed 
babies,  but  is  encountered  among  those  who  are  fed  on  cow's  milk,  and  more  especially 
among  those  who  receive,  in  addition,  some  of  the  proprietary  foods  which  are  so 
commonly  resorted  to  in  the  preparation  of  the  milk  formulae.  There  has  been  a  dif- 
ference of  opinion  as  to  whether  the  use  of  pasteurized  milk  alone  can  induce  the 
scorbutic  condition.  The  Commission  on  Milk  Standards,  composed  of  experts  on 
this  subject,  in  its  report  for  1912,  stated  that  pasteurization  does  not  destroy  the 
chemical  constituents  of  milk,  which  is  not  altered  by  exposure  to  heat  under  145°  F. 
As  a  favorable  opportunity  presented  itself,  and  as  the  subject  had  a  wide  practical 
bearing,  I  determined  to  test  the  validity  of  this  opinion.  Accordingly,  the  infants 
in  one  ward  of  an  infants'  home,  where  all  babies  are  fed  upon  grade  A  i>asteurlzed 
milk,  which  has  been  heated  to  145*^  F.  for  30  minutes,  were  separated  into  two  groups. 
As  regards  the  one  group,  no  change  was  made  in  the  diet;  they  received  pasteurized 
milk,  cereal,  and  orange  juice;  in  the  case  of  the  others,  the  only  change  made  was 
to  discontinue  giving  orange  juice. 

Without  going  into  detail,  the  results  may  be  summarized  by  the  statement  that 
almost  all  the  infants  who  did  not  receive  orange  juice  developed  a  more  or  less 
marked  form  of  scurvy,  whereas  those  who  continued  to  receive  the  juice  remained 
entirely  free  from  this  disorder.  The  opportunities  for  studying  this  question  were 
unique,  as  most  of  the  Infants  had  been  in  the  institution  almost  since  birth  and 
remained  there  for  a  period  of  years,  so  that  their  condition  both  before  and  subse- 
quent to  this  test  could  be  thoroughly  observed.  It  should  be  added  that  in  an 
investigation  of  a  disease  such  as  scurvy,  metabolism  studies  are  not  well  suited,  on 
account  of  the  slow  course  of  the  illness,  but  that  clinical  observations  of  the  effect 
of  diet  or  chemical  analyses  of  the  ultimate  constituents  of  the  body  are  far  more 
reliable.  These  results  were  published  in  detail.  However,  in  view  of  the  fact  that 
they  were  questioned  by  some,  another  test  of  the  same  character  was  carried  out  in 
the  subsequent  year.  The  results  were  the  same;  so  that  I  feel  safe  in  stating  that  a 
diet  of  pasteurized  milk  leads  to  the  production  of  scurvy  in  infants  unless  some 
antiscorbutic  food  is  also  given.  This  scurvy  is  not  as  a  rule  the  classical  florid  type 
such  as  is  frequently  met  with  in  infants  fed  upon  proprietary  foods  for  months,  but 
may  be  termed  latent  or  rudimentary — there  is  a  gradually  increasing  pallor,  a  failure 
to  gain  in  weight,  the  development  of  some  petechial  hemorrhages,  and,  in  the  more 
marked  instances,  the  classical  superiosteal  hemorrhages.  It  would  seem  probable 
that  this  insidious  type  of  scurvy  is  far  more  common  among  infants  than  is  generally 
recognized  by  physicians,  and  that  there  are  many  suffering  from  slight  nutritional 
disturbances  which  may  be  ascribed  to  this  cause.  When  the  pasteurized  milk  was 
replaced  by  raw  milk,  the  scorbutic  condition  improved,  although  it  may  be  added 
that  raw  cow's  milk  was  not  comparable  to  orange  juice  as  an  antiscorbutic. 


PUBLIC  HEALTH  AKD  MEDICINE.  49 

It  is  not  to  be  inferred  from  theee  conclusions  that  the  use  of  pasteurized  milk  is 
fraught  with  danger,  but  merely  that  it  is  an  incomplete  diet  for  babies  and  must  be 
given  with  antiscorbutic  food.  Its  use  is  highly  desirable  and  to  be  recommended 
for  pasteurization  does  not  seem  to  aSect  the  nutritional  value  of  the  milk  and  renders 
marked  service  in  preventing  the  occurrence  of  various  infectious  diseases.  There 
are  secondary  factors  in  the  causation  of  scurvy.  In  the  first  place  there  is  an  indi- 
vidual variation  which  must  be  taken  into  account.  This  would  seem  to  depend  ux>on 
hereditary  characteristics,  upon  the  amount  of  antiscorbutic  material  which  the  infant 
brings  with  it  when  it  comes  into  the  world.  Secondary  food  factors  would  also  seem 
to  play  a  part;  in  our  experience  those  infants  which  received  malt  preparations 
seemed  to  be  most  predisposed  to  the  development  of  scurvy,  and  it  is  quite  possible 
that  there  is  a  relationship  to  carbohydrate  diet,  similar  to  that  which  Funk  has  drawn 
attention  to  in  the  case  of  beriberi.  Whenever  the  connection  of  pasteurization  and 
scurvy  is  brought  forward,  the  statistics  of  various  French  writers  who  claim  to  have 
fed  some  thousands  of  babies  on  steralized  milk  without  encountering  scurvy,  are  cited 
in  refutation  of  the  harmful  effects  of  heat.  Without  analyzing  these  results,  it  may 
be  said  that  these  infants  were  cared  for  in  an  ambulatory  service  and  that  their  diet 
was  therefore  not  under  close  observation  and  probably  they  were  not  observed  for  a 
sufficiently  long  period  to  detect  the  rudimentary  form  of  scurvy  which  we  have  just 
outlined. 

Infantile  scurvy  differs  clinically  from  the  other  '* deficiency  diseases''  mainly  in 
the  fact  that  it  is  characterized  by  the  production  of  hemorrhage  in  various  parts  of 
the  body,  hemorrhage  into  the  gums,  into  the  skin,  beneath  the  periosteum,  into  the 
kidneys,  etc.  A  study  of  the  pathogenesis  of  these  hemorrhages  has  shown  that  they 
were  not  the  result  of  alterations  of  the  blood  itself,  a  delayed  coagulability,  or  a 
decrease  of  blood  platelets,  but  that  they  were  due  to  the  alteration  of  the  blood  vessels 
which  allow  the  blood  to  traverse  its  walls.  This  alteration  probably  should  be  regarded 
merely  as  a  part  of  the  general  tissue  changes  which  occur  in  this  disorder. 

Although  hemorrhage  is  not  encountered  on  beriberi,  another  typical  '*  deficiency 
disease/'  a  careful  consideration  will  show  some  clinical  relationships  between  these 
two  diseases.  As  is  well  known,  signs  of  involvement  of  the  nervous  system  are  the 
characteristic  manifestations  in  beriberi.  A  study  of  the  cases  which  came  under  our 
view  showed  that  infantile  scurvy  is  not  entirely  free  from  nervous  signs.  The  knee 
jerks  are  increased,  there  seem  to  be  slight  involvement  of  the  optic  disks  in  some  cases 
and  perhaps  sensitiveness  of  the  cutaneous  nerves.  Again,  dilation  of  the  right  heart, 
a  remarkable  pathological  condition  which  has  been  frequently  described  in  beriberi 
and  noted  by  Andrews  in  infants  who  had  suffered  from  this  disease,  was  found  to  occur 
likewise  in  infantile  scurvy,  as  demonstrated  in  numerous  Roentgen  ray  examinations. 
Oedema,  which  is  such  a  common  symptom  in  beriberi,  is  not  infrequently  present  in 
infantile  scurvy.  In  fact,  there  is  one  form  of  this  disorder,  an  exceptional  tyx>e, 
where  oedema  is  most  marked.  In  this  connection  it  should  be  remembered  that 
degeneration  of  the  nerves  has  been  found  by  Ingier  in  some  animals  suffering  from 
scurvy,  that  Hoist  and  Froelich  have  noted  that  guinea  pigs  fed  on  decorticated  or 
highly  milled  rice,  developed  scurvy  and  not  beriberi,  and  that  Darling  has  reported 
that  in  some  African  negroes  a  diet  that  caused  scurvy  in  one  set  of  men,  caused  neu- 
ritis in  others.  There  ia  evidently,  therefore  a  definite  interweaving  in  the  symptom- 
atology of  these  two  deficiency  diseases.  As  is  well  known,  beriberi  is  produced 
by  a  diet  of  decorticated  rice  and  may  be  cured  by  feeding  the  rice  polishingB.  In 
this  regard,  there  seems  also  to  be  some  connection  between  the  two  diseases,  for  we 
found  that  the  giving  of  wheat  middlings,  which  may  be  regarded  as  the  pericarp  of  the 
wheat,  in  some  instances  resulted  in  a  prompt  amelioration  of  the  symptoms,  although 
it  was  unable  to  bring  about  a  complete  cure  of  the  disorder. 

The  sovereign  cure  for  scurvy  is  orange  juice .  This  juice  is  efficient  even  when  it  has 
been  boiled  for  10  minutes.    In  order  to  test  a  juice  of  a  far  less  degree  of  acidity,  a 


50  PBOGEEDIKQS  SECOND  PAN  AMEBIOAN  80IENTIFI0  00N0BE8S. 

concoction  of  orange  peel  was  prepared.  This  was  found  also  to  poeaefls  antiscc^butic 
qualities  and  to  be  effective  even  after  it  was  boiled.  This  is  of  interest  in  view  of 
the  fact  that  Hoist  and  Froelich  showed  that  only  antiscorbutic  substances  which 
were  highly  acid,  were  able  to  maintain  their  potency  after  boiling.  Potato,  one  of 
the  best  known  antiscorbutics,  was  found  most  effective  in  combatting  the  sc(»butic 
symptoms  and  might  well  be  employed  for  this  purpose  in  infant  feeding  where  orange 
juice  can  not  be  obtained.  For  this  purpose  the  milk  should  be  diluted  with  potato 
water  instead  of  plain  water  or  the  usual  cereal  decoctions.  The  commercial  potato 
flour  was  found  to  possess  no  antiscorbutic  properties.  Ckni-liver  oil  was  also  found  to  be 
wanting  in  this  particular,  as  not  only  was  it  unable  to  cure  the  scorbutic  condition, 
but  infants  developed  symptoms  of  scurvy  in  spite  of  receiving  this  oil  from  the  very 
first  day  when  orange  juice  was  discontinued. 

In  connection  with  this  study,  observations  of  the  effect  of  infantile  scurvy  upon 
growth  was  recently  carried  out.  These  observations  were  continued  for  a  period  of  a 
year  or  more.  Three  periods  may  be  distinguished  in  this  investigation;  a  prescor- 
butic  or  preliminary  period  of  about  three  months,  during  which  the  infants  were 
weighed  daily  and  measured  every  two  weeks;  a  test  period  embracing  about  four 
months,  during  which  the  infants  received  the  diet  of  pasteurized  milk  and  cereal, 
which  differed  from  the  previous  diet  only  in  the  fact  that  orange  juice  was  no  longer 
given;  and  a  postscorbutic  period,  lasting  about  six  months,  whidi  dated  from  the  time 
when  orange  juice  or  other  antiscorbutic  food  was  once  more  added. 

During  this  entire  year  or  more  the  in&nts  were  weighed  daily  and  measured  every 
two  weeks.  As  far  as  I  am  aware,  no  similar  study  has  been  carried  out.  Such  an 
investigation  is  possible  only  under  the  conditions  which  obtain  in  an  institution  of 
this  kind  where  the  children  enter  at  an  early  age  and  remain  for  long  periods.  Its 
object  was  to  ascertain  the  connection  between  infantile  scurvy  and  growth— growth 
in  length  as  well  as  in  weight.  As  is  well  known  and  has  been  shown  by  Freund,  as 
well  as  by  Variot,  infiwts  are  particularly  tenacious  as  regards  growth  in  length  and 
not  readily  affected  by  nutritional  disorders,  even  such  as  reach  a  considerable  degree 
of  intensity.  However,  this  must  not  be  regarded  merely  as  a  study  of  growth.  It 
must  be  considered  rather  a  study  of  infantile  scurvy  and  of  the  effect  of  this  disorder 
on  growth,  as  numerous  other  conditions  may  affect  growth.  That  such  is  the  case, 
has  been  shown  admirably  in  animals  in  the  recent  investigations  of  Osborne  and 
Mendel,  of  McCoUum  and  others.  Where  growth  was  retarded  or  stimtdated  at  will  by 
means  of  diet,  but  which  nevertheless  can  not  be  considered  to  have  any  connection 
with  scurvy.  Scurvy  and  growth  stunting  are  by  no  means  the  same  either  in 
.animals  or  in  in&nts.  It  would  seem  that  these  remarks  are  timely  in  view  of  a  re- 
cently published  study  by  McCoUum,  in  which  he  shows  that  the  growth  factor  in 
milk  is  closely  linked  to  its  casein  content,  and  prefaces  his  report  by  drawing  an 
analogy  to  infantile  scurvy,  although  none  of  the  animals  showed  any  signs  of  a  scor- 
butic condition.  That  the  factors  which  stimulate  growth  are  not  neceesarily  anti- 
scorbutic, may  be  inferred  from  other  experiments.  For  example,  McCollum  and 
Davis  showed  that  butter  fot,  even  after  it  had  been  heated  to  a  high  degree,  was  able 
to  induce  growth  and  Osborne  and  Mendel  showed  that  this  fat  can  be  subjected  even 
to  steam  and  not  lose  its  growth  producing  power.  Notwithstanding  these  results  there 
is  no  doubt  that  butter  fot  in  pasteurized  milk  does  not  possess  sufficient  antiscorbutic 
properties  to  prevent  the  development  of  scurvy. 

Cod-liver  oil  has  been  foimd  to  possess  growth  promoting  qualities  of  a  hi^  degree 
of  efficiency,  but  there  is  also  no  question  that  this  substance,  as  I  have  stated  above, 
is  unable  to  prevent  the  development  of  or  to  cure  scurvy.  All  of  the  infants  under 
consideration  obtained  milk  which,  as  a  food,  has  been  shown  to  contain  all  the  con- 
stituents necessary  for  growth,  and  almost  all  of  them  obtained  cereal  in  addition. 
Particular  attention  was  given  to  the  foct  that  they  should  obtain  a  sufficient  quantity 
of  food,  so  that  the  question  of  starvation  might  not  enter  into  the  experiment.    To 


FUBUO  HEALTH  AKD  MEDICINE.  51 

this  end,  when  orange  juice  was  discontinued — that  is  to  say,  in  the  second  period  of 
this  test — more  cereal  was  given  or  the  strength  of  the  milk  mixture  was  increased  so 
as  to  obviate  this  complicating  factor.  When  the  scorbutic  symptoms  insiduously 
b^an  to  manifest  thenselves,  among  them,  loss  of  appetite,  particular  attention  was 
given  to  the  feeding,  so  as  to  induce  the  infanta  to  take  a  sufficient  quantity,  and, 
although  it  is  true  that  the  total  amount  which  they  consumed  was  not  in  most  cases 
as  great  as  when  they  were  entirely  well,  it  nevertheless  reached  a  total  quite  equal 
to  that  which  infents  frequently  consume  and  on  which  they  continue  to  grow.  In 
.  almost  no  case  did  it  fall  below  80  calories  per  kilo  for  any  considerable  period  of  time. 

First  as  to  growth  as  measured  by  weight.  It  was  found  that,  although  the  infants 
continued  to  gain  in  most  cases  for  a  few  weeks  following  the  discontinuance  of  the 
orange  juice,  they  soon  reached  a  stationary  plane  and  for  months  were  unable  to  rise 
above  this  level,  but  increased  in  weight  promptly  when  the  antiscorbutic  food  was 
again  added  to  their  diet.  In  only  one  instance  was  there  no  effect  upon  the  gain  in 
weight  during  this  test  period.  There  was,  however,  no  permanent  retardation  of 
weight,  the  growth  impulse  remaining  imaffected.  In  fact,  when  the  orange  juice  was 
rebegim  growth  as  manifested  by  gain  in  weight  generally  took  place  with  an  abnormal 
intensity.  These  infentp  have  been  found,  after  the  observation  of  about  half  a  year, 
to  have  r^;ained  the  normal  level  of  weight.  In  two  cases,  where  the  infants  were 
under  six  months  of  age  and  had  never  received  orange  juice  previously,  the  necessity 
for  adding  an  antiscorbutic  substance  to  the  diet  was  manifested  by  a  gradual  lack  of 
gain  of  weight  at  about  the  eighth  month  of  life.  It  is  very  probable  that  many  infants 
fail  to  continue  to  gain  at  this  period,  the  third  quarter  of  the  first  year  of  life,  for  the 
want  of  this  essential  addition  to  their  food,  and  that  for  this  reason  they  fail  to 
progress  until  mixed  feeding  is  b^un  some  months  later. 

As  has  been  stated  during  the  test  of  the  past  year  the  infants  were  not  only  weighed 
but  they  were  also  measured.  This  group  included  about  20  infants,  one-half  of  which 
continued  to  receive  orange  juice,  whereas  the  others  were  deprived  of  this  food.  Our 
results  in  this  connection  may  be  summarized  by  the  statement  that  scurvy  not  only 
has  a  direct  effect  on  the  weight,  but  also  upon  the  growth  in  length,  that  the  orange 
juice  contains  properties  corrective  in  both  regards.  This  fact  is  more  striking  than  the 
Mlure  to  gain  in  weight,  for,  as  has  been  mentioned,  growth  in  length  is  a  physiological 
impulse  to  which  the  body  clings  with  great  tenacity  and  which  is  rarely  affected, 
even  when  other  functions  are  held  in  abeyance.  This  is  true  likewise  in  animals, 
for  example,  Aron  showed  that  in  rats,  which  are  underfed,  there  is  a  marked  loss  in  fat 
and  in  muscle,  but  the  skeleton  continues  to  grow  and  the  total  ash  content  of  the  body 
to  increase.  The  same  holds  true,  as  in  the  case  of  the  growth  in  weight,  when  the 
essential  substance,  the  orange  juice,  is  once  more  given.  There  is  an  abnormally  rapid 
increase;  in  other  words,  the  stimulus  has  been  merely  temporarily  held  in  a  latent 
condition.  It  is  likewise  true  here  that  boiled  orange  juice  is  effective,  and  the  juice 
of  the  orange  peel,  although  it  seemed  that  the  latter  lost  some  of  its  potency  as  a 
result  of  being  heated. 

The  time  does  not  seem  ripe  for  a  discussion  as  to  the  nature  of  the  peculiar  dietary 
substance  or  substances,  which  are  clearly  so  essential  for  the  nutrition  of  the  body. 
It  is  evident  that  it  is  not  one  or  more  of  the  various  amino  acids  which  have  been 
shown  to  play  such  an  important  rdle  in  the  production  of  growth.  For  example, 
lysin  and  tryptophan,  substances  which  possess  most  marked  growth  producing  power, 
must  have  been  present  in  large  quantities  in  our  diet,  as  it  has  been  shown  to  exist 
in  considerable  amounts  in  the  proteids  of  the  milk.  Whatever  their  nature,  it  would 
seem  that  these  substances  are  intimately  associated  with  the  continuation  of  health 
and  life  and  until  we  are  able  to  define  them  more  definitely,  we  can  do  no  better  than 
accept  the  term  "vitamins''  suggested  by  Funk. 

The  Chairman.  The  next  papers  are  those  of  Dr.  Calixto 
Torres  UmafLa. 

68486— 17— VOL  x 5 


52  PBOOEEDINGS  SECOND  PAN  AMEBICAN  SCIENTIFIC  CONGRESS. 

LA  NUTRICION  en  LA  ALTIPLANICIE  DE  BOGOTA. 

For  CALIXTO  TORRES  UMANA. 
Introducci6n. 

Todo  el  que  haya  eetudiado  cienciaa  naturalee  sabe  que  hay  para  cada  organismo 
una  fisiologla  normal  o  i)atoI6gica  que  le  es  peculiar  y  que  esta  fisiologla  reviste  mo- 
dalidades  distintas  que  cambian  con  la  raza,  el  clima,  la  alimentaci6n,  etc.  Como 
consecuencia  de  estas  modalidades  fisioldgicae  vienen  tambi^n  variaciones  en  la^ 
higiene,  en  la  patologla,  en  la  terap^utica,  etc.,  cuyo  conjunto  constituye  toda  una 
medicina  nacional  o  regional. 

Hasta  hace  poco  tiempo  vivlamos  noeotros  de  las  investigaciones  hechas  en  Europa 
y  todavfa  hacemoe  muchoe  de  nueetros  estudioe  de  medicina  sobre  la  base  de  una 
fisiologla  que  no  noe  pertenece.  No  pocos  estudiantes  aventajadoe  ban  gastado  nada 
m^  que  en  corroborar  estudioe  hechoe  en  el  extranjero,  eneiglas  que  hubieran  podido 
ser  empleadas  en  resolver  o  tratar  de  resolver  imo  de  tantos  problemas  que  tenemos 
por  delante,  cuya  soluci6n  b<S1o  a  noeotros  pertenece. 

Porque  hay  que  pensar  que  lo  que  constituye  la  medicina  nacional  no  son  sola- 
mente  ciertas  enfcrmedades  propias  de  nuestra  zona,  sine  todo  el  cuadro  noeol6gico 
que  cambia  de  fisonomfa  desde  que  cambia  de  residencia. 

El  presente  estudio  que  representa  un  trabajo  mds  arduo  de  lo  imaginable,  es  una 
modesta  colaboraci6n  a  uno  de  nuestros  mds  trascendentales  problemas. 

Su  iniciaci6n  tuvo  origen  en  dos  hechos  de  observaci6n  diaria  en  Bogotd:  el  des- 
censo  de  la  cifra  de  la  urea  en  la  orina  y  el  descenso  de  la  temperatura  humana. 

Mis  primeros  experimentos  hechos  en  BogotA,  versaron  sobre  dos  puntos:  primero, 
temperatura  humana;  segundo,  numeraci6n  de  gl6bulos  rojoe  y  medida  de  hemo- 
globina,  o  sea  sobre  el  vehfculo  encaigado  de  llevar  el  oxfgeno  a  los  tejidos  para  las 
combustiones;  tercero,  sobre  el  anilisis  qufmico  de  los  alimentos,  es  decir,  el  examen 
del  combustible;  y  cuarto,  sobre  productos  de  de8a8imDaci6n  azoada  en  las  orinas. 

Durante  el  ejercicio  de  mi  profesi6n  en  Tunja,  poblaci6n  situada  a  mayor  altura 
que  Bogotd,  sobre  todo  como  medico  de  algunas  compafLlas  de  8^:uros,  tuve  oca8i6n 
de  observar  un  mayor  descenso  de  la  temperatura  en  casi  todos  los  individuos  exa- 
minados. 

Esto  me  Bugiri6  la  idea  de  emprender  en  aquella  localidad  observaciones  seme- 
jantes  a  las  de  Bogotd,  practicando  andlisis  de  orinas  tan  cuidadosos  y  completoe 
como  creo  que  no  se  hayan  hecho  antes  entre  nosotros. 

Estudiando  las  causas  del  retardo  de  la  nutrici6n  en  la  altiplanicie,  quise  darle 
especial  preferencia  al  asunto  de  la  chicha,  y  al  ef  ecto  aprovech6  la  buena  acogida  que 
di6  a  ima  solicitud  mfa  el  Sefior  Ministro  de  Guerra  General  Lujdn  y  emprendi  ex- 
perimentos a  este  respecto  en  scis  soldados:  experimentos  que  me  dieron  ensefianzas 
muy  interesantes,  como  se  verd  en  la  tiltima  parte  de  este  estudio. 

DEFINICI6N  DE  LA  NUTEICI6N. 

Toda  c^lula  viva  funciona  y  se  gasta.  Para  producir  eneigla,  para  repararse,  toma 
al  medio  ambiente  materiales  alimenticios,  y  despu^  de  haberlos  elaborado  en  su 
interior,  arroja  los  residues  de  esta  elaboraci6n.  Este  doble  proceeo  de  asimilaci6n 
y  desa8imilaci6n,  representa  las  funcionee  de  nutrici6n  celular  y  obedece  a  cambioe 
quimicoe  que  se  conocen  con  el  nombre  de  metabolismo,  el  cual  puede  ser  dividido 
en  dos  partes:  el  catabolismo,  o  reducci6n  de  los  compuestos  quimicoe  mds  compli- 
cados  a  los  mAs  sencillos,  y  el  anabolismo,  o  slntesis  de  cuerpos  simples  para  formar 
miks  complicadas  combinaciones. 

Los  actoe  nutritives  que  se  verifican  en  un  organismo  m&B  complejo,  como  el  del 
hombre,  son  id^nticos,  en  principio,  a  los  que  se  observan  en  los  oiganismos  unicelularee. 
Los  elementoe  que  se  utilizan  para  la  nutricidn  son  tomados  a  los  tres  reinos,  vegetal, 


PUBLIC   HEALTH  AND  MEDICINE.  53 

animal  y  mineral;  elloe  llevan  al  oiganismo  loe  elementoe  necesarioe  para  la  consti- 
tuci6n  o  para  la  reparaci6n  de  loe  tejidos;  las  transformacionee  que  sufren  eetos  aliment06 
en  la  economia  ponen  en  libertad  energia  que  se  manifiesta  en  forma  de  labor,  de  tra- 
bajo  mecinico  y  en  algunos  animales  en  la  de  luz  o  electricidad. 

La  miama  con8tituci6n  quimica  de  loe  alimentoe  noe  da  la  explicaci6n  de  su  papel 
energ^tico;  caei  todos  elloe  estdn  fonnadoe  de  albtiminas,  graeas,  hidratoe  de  car- 
bono,  que  eon  compuestoe  endot^rmicoe,  ee  decir,  fonnadoe  con  abeorcidn  de  calor; 
y  encierran  por  consiguiente  eneigla  latente;  la  desint^graci6n  de  eetoe  elementoe 
en  el  organiemo  deja  en  libertad  eeta  eneigla.  De  eeta  manera  Uenan  lae  fiincionee 
de  nutrici6n  un  triple  objeto  en  el  hombre  normal:  primero,  mantener  fija  la  compo- 
Bici6n  de  loe  tejidoe  vivoe;  segundo,  mantener  constante  la  temperatura  del  cuerpo, 
tercero,  reemplazar  la  energia  gaetada  por  el  trabajo  del  individuo. 

En  el  nifio,  durante  el  periodo  de  crecimiento,  y  en  la  mujer  durante  el  embarazo 
y  la  lactancia,  tiene  ademds  por  objeto  ayudar  al  crecimiento  de  loe  tejidoe.  En  loe 
convalecientee,  el  trabajo  de  reproducci6n  de  material  gaetado  ee  naturalmente 
mucho  m^  intense  que  en  el  eetado  normal. 

Loe  materialee  alimenticioe  siguen  en  el  mundo  un  ciclo  evolutivo,  tendiente  a 
una  complicaci6n  progresiva.  Loe  m&a  simples  no  son  otroe  que  el  oxfgeno  y  el 
carbono  del  aire,  que  son  fijadoe  por  la  materia  clorofiliana  de  las  plantas  verdes, 
bajo  la  influencia  de  la  luz,  y  entran  de  eeta  manera  en  la  compoeici6n  de  loe  tejidos 
v^;etalee.  Luego  loe  vegetalee  eon  ingeridoe  por  loe  animalee  herbfvoroe  y  eetoe  por 
loe  camf  voroe.  Ee,  puee,  en  definitiva,  la  eneigla  eolar  almacenada  por  lae  plantas,  la 
que  transmite  de  un  oiganismo  a  otro  y  representa  el  origen  de  la  eneigla  humana. 

£1  oiganismo  sirve  i)ara  la  transfonnaci6n  de  la  energia,  y  ^1  no  la  retiene,  como 
no  la  crea.  En  im  cuerpo  adulto,  en  equilibrio  de  peso,  la  eneigla  Uevada  por  los 
alimentoe  ee  equivalente  a  la  gaetada  por  el  individuo;  de  ahl  la  concepci6n  de  Ber- 
thelot:  "El  mantenimiento  de  la  vida  no  consume  ningima  eneigla  que  sea  propia  a 
la  vida.''  El  piincipio  de  la  conservacidn  de  la  energia  se  aplica,  pues,  al  animal 
tan  exactamente  como  a  la  mdquina  de  vapor. 

Lavoisier  habla  ya  demoetrado  que  el  principal  gasto  de  la  energia  humana  tiene 
por  origen  las  combustiones  veiificadas  en  el  organismo.  Berthelot,  por  el  descubri- 
miento  de  la  termoquimia,  resolvid  el  problema  demoetrando  que  la  nutricidn  se 
reduce  a  una  transformacidn  de  la  energia. 

Lavoisier  demoetr6  que  los  animales  viven  y  respiran  oxigeno  en  la  atmdefera  y 
producen  icido  carb6nico;  que  se  verifica  en  ellos  una  combusti6n  an^oga  a  la  com- 
busti6n  de  las  materias  oigdnicas  y  que,  como  ^ta,  produce  calor.  De  este  descu- 
brimiento,  hecho  por  uno  de  los  mayores  genios  que  haya  tenido  el  g^nero  humane, 
8ac6  Lavoisier  su  aforiamo,  que  el  ilustre  Richet  reputa  como  ''el  axioma  fundamental 
de  la  biologla."     "La  vida  es  una  funci6n  quimica." 

Pero  la  hipdtesis  primitiva  de  que  las  oxidacionea  86lo  ee  prodiician  en  el  pulm6n, 
fu4  destmida.  Suigi6  entonces  la  idea  de  que  el  dcido  carb6nico  y  el  agua  nacian 
a  favor  de  combustiones  verificadas  en  la  sangre  misma.  En  1837  Magnus  descubri6 
que  la  sangre  contiene  oxigeno  y  dcido  carb6nico,  lo  que  parecia  demostrar  la  nueva 
teoria.  Ludwig  lleg6  a  creer  que  las  oxidaciones  del  hidr6geno  y  el  carbono  se  efec- 
tuaban  en  la  sangre;  pero  despu^  de  la  publicaci6n  de  los  estudios  de  Liebig,  en  1842, 
qued6  establecido  que  no  es  hidrdgeno  y  carbono  lo  que  se  quema  en  los  tejidos,  sino 
albuminoideos,  hidratos  de  carbono  y  grasas. 

Fu6  Liebig  el  descubridor  de  loe  m^todoe  modemos  de  an&lisis;  vinieron  con  61 
gran  cantidad  de  conocimientos  respecto  a  compuestos  hidrocarbonados,  entre  los 
cuales  se  cuentan  muchos  prod uc toe  de  la  economia  animal.  E^stos  conocimientos 
suministraban  nociones  importantfsimas  sobre  la  constitucidn  de  los  alimentos,  de 
la  orina  y  de  las  materias  fecales  que  no  posey6  Lavoisier. 

Liebig  aplio6  estas  nuevas  nociones  de  quimica  a  la  resoluci6n  de  los  problemas 
debiologia.     I)e8cubri6  que  los  albuminoideos  contienen  dzoe,  y  en  1842  sugiri6  la 


54  PBOOEEDINGS  SECOND  PAN  AMEBIOAN  BCIENTIFIO  G0NQEE8S. 

idea  de  que  el  izoe  xxxlrla  ser  proporcional  a  la  deBtTucci6n  de  loe  albuminoideoe  en 
el  organismo.  Bilder  y  Shmidt  fueron  los  primeroB  que  hicieron  experimentos  sobre 
este  asunto.^ 

La  hlp6tesis  de  la  producci6n  del  calor  animal  por  las  oxidacionee  intraoig&nicas 
debia  dar  lugar  a  rectificaciones  importantes.  Berthelot  fu6  el  primero  que  observd 
que  el  oxfgeno  absorbido  por  el  animal  no  es  proporcional  al  calor  producido,  y,  por 
coneiguiente,  no  puede  servir  de  medida  aun  teniendo  en  cuenta,  por  una  parte,  el 
dcido  carb6nico  produddo  y  por  otra,  el  agua  avaluada  por  diferenda  pues  hay  en  el 
organismo  otras  reacciones  que  consisten  en  hidrataciones  y  desdoblamiento  que  son 
tambi6n  fuentes  de  calor;  de  modo  que  el  agua  y  el  dcido  carb6nico  no  son  loe  tinicos 
productos  de  transformacidn  de  los  materiales  nutritivos,  sino  que  hay  muchos,  como 
la  urea  y  otros  productos  azoados,  que  resultan  de  la  transformacidn  de  los  albumi- 
noideos. 

Aun  haciendo  abstracci6n  de  las  reacciones  de  hidrataci6n  o  de  desdoblamiento 
que  intervienen  en  todos  estos  cambios,  una  misma  cantidad  de  oxfgeno  como  lo 
dicen  Doyon  y  Morat,'  "reacciona  con  producci6n  de  distintas  cantidades  de  calor, 
segtin  que  obre  sobre  sustancias  diferentes  o  cuando,  dirigi^ndose  a  una  misma  sua- 
tancia,  da  por  resultado  grades  diferentes  de  oxidaci6n.*' 

El  dcido  carb6nico  producido  puede  corresponder  tambi^n  a  cantidades  diferentes 
de  calor,  por  razones  an^ogas. 

£n  fin,  el  estado  inicial  y  el  estado  final  de  la  reacci6n  que  absorbe  oxigeno  y  dee- 
prende  dcido  carb6nico,  puede  no  ser  determinado  por  el  conocimiento  de  los  ingeeta 
(que  son  los  alimentos,  haciendo  figurar  entre  ellos  el  oxfgeno  absorbido)  y  de  loe  ex- 
creta (o  sean  los  productos  de  desasimilaci6n  por  que  en  el  curso  del  experimento 
puede  cambiar  la  reacci6n  de  los  tejidos,  fijar  ciertas  substancias  que  provengan  de 
los  alimentos  y  eliminar  otras  que  provengan  de  los  mismos  tejidos. 

Ninguna  de  estas  transformaciones  se  hace,  de  manera  directa,  ee  decir,  que  no  son 
ni  el  carbono  ni  el  oxfgeno,  ni  mucho  menos  el  dzoe  los  que  van  a  producer  el  icido 
carb6nico,  el  agua  y  la  lurea;  son  principios  inmediatos  que  vienen,  sea  de  los  tejidos 
o  de  los  alimentos,  los  que  por  una  serie  de  transformaciones,  van  a  dar  nacimiento  a 
aquellos  cuerpos.  Ni  se  crea  que  estas  transformaciones  consisten  todas  en  reacciones 
exot^rmicas,  sino  que  pasan  tambi^n  por  reducdones  o  detddratadones,  que  dan  lugar 
a  absorci6n  del  calor.  En  virtud  de  estas  transformadones,  la  glucosa  pasa  al  estado 
de  glic6geno,  antes  de  convertirse  en  ^ido  carb6nico.  Pero  el  resultado  final  es  si- 
empre  la  producd6n  del  calor  puesto  que  siempre  ima  reacd6n  endot^rmica  est& 
compensada  por  varias  exot^rmicas. 

Los  testigos  de  la  reacci6n  son,  pues,  en  definitiva,  por  una  parte,  los  alimentos  y  el 
oxfgeno  (ingesta)  que  van  a  producirla  y  por  otra,  la  urea,  el  addo  tirico,  el  &ddo  car- 
b6nico  y  el  agua  (excreta)  que  constituyen  el  t^rmino  final  de  las  transformadones 
quf  micas. 

La  consideraci6n  de  la  destrucci6n  m^  o  menos  profunda  que  los  organismos 
hacen  sufrir  a  los  materiales  nutritives,  conduce  a  aproximar,  en  esta  relaci6n,  la 
nutrid6n  de  los  organismos  superiores  y  la  de  los  fermentos,  en  las  cuales  un  enorme 
poder  de  de8Composici6n  da  aspectos  tan  espedales.  La  descomposid6n  de  que 
acabo  de  hablar,  que  los  organismos  superiores  hacen  sufrir  a  la  albt!imina,  a  los  hi- 
dratos  de  carbono  y  a  las  grasas  y  que  terminan,  como  elementos  prindpales,  en  agua, 
&ddo  carb6nico,  dcido  drico  y  urea,  es  una  descomposici6n  muy  profunda  cuyo  rendi- 
miento  en  energfa  es  considerable.  Es,  por  ejemplo,  de  1,677  calorfas  para  una  mol^ula 
de  glucosa  (180  transformada  en  H3O  y  CO2).  Considerando  ahora  la  levadura  de  cerv- 
eza,  vemos  que  este  organismo  vive  a  expensas  del  azticar;  pero  en  lugar  de  conducir 
este  alimento  hasta  la  baja  escala  de  las  transformadones  mencionadas,  la  levadura 
lo  desdobla  simplemente  en  alcohol  y  en  &ddo  carb6nico.  Para  una  mol6cula  de 
glucosa  la  cantidad  de  calor,  es  decir,  de  energfa  disponible,  no  es  sino  de  setenta  y 

1  Graham  Lusk,  The  Elements  of  the  Sdenoe  of  Nntritloii. 
1  Doyon  7  Moral,  Traits  de  physiologie. 


PUBLIC  HEALTH  AND  MEDICnTB.  55 

una  calorias.    £1  reBdimiento  de  energia  es,  pues,  mucho  menos  coneiderable,  porque 
el  alcohol  ee  lleva  consigo  cerca  de  nueve  d^cimos  de  la  energia  de  la  glucosa. 

En  loe  oiganismos  superiores  hay  relaci6n  entre  el  peso  del  cuerpo  y  el  peso  de  la 
sustancia  transfonnada.  Estas  relaciones,  son,  por  ejemplo,  para  el  hombre,  de  500 
a  600  gramoe  de  materia  org&nica  para  60  a  70  kilogramos  de  peso  vivo.  Al  contrario, 
entre  el  peso  de  la  levadura  y  el  peso  de  la  sustancia  transfonnada  hay  una  despro- 
porci6n  enonne,  lo  cual  se  debe  a  que  el  fermento  no  hace  sufrir  a  su  alimento  sino  muy 
pocos  gradoe  en  la  eecala  de  destrucci6n  de  la  materia,  y  que,  como  dice  Lambing  ^ 
compensa  la  mediocridad  del  rendimiento  de  energia  de  esta  operaci6n,  con  la  masa 
del  alimento  transformado. 

Pero  eetafl  destrucciones  no  traen  nada  de  e6X)ecifico  que  haga  una  diferencia  de 
naturaleza  entre  estos  organismoe  y  los  organismos  superiores.  Y  aun  las  distinciones 
mencionadas  desaparecerian  si  se  considerara,  no  el  peso  del  alimento  transformado, 
eino  la  cantidad  de  energia  suministrada  al  fermento  por  eBta  transformacidn. 

"Lo  mismo  sucede,'*  dice  Lambling,"  *  en  lo  que  concieme  a  la  cantidad  de  mate- 
liales  alimenticios  consumidos  y  destruidos  por  el  organismo;  depende,  no  del  aporte 
alimenticio,  sino  de  la  magnitud  de  las  necesidades  del  orgauismo. 

Pero  se  nota,  en  verdad,  que  inmediatamente  despu^s  dela  ingestidn  delos  alimentoe 
hay  un  aumento  de  las  descomposiciones  qufmicas,  lo  que  parece  estar  en  contradicci6n 
con  la  ley  enundada  m^  arriba,  puesto  que  serf  a  la  entrada  del  combustible  la  que 
producirfa  la  combusti6n.  Este  evento  se  revela  por  la  elevacidn  sdbita  de  las  can- 
tidades  de  oxfgeno  consumidas,  como  tambi^n  por  un  balance  total  de  calorfas,  mayor 
cuando  se  pasa  del  estado  de  ayuno  al  de  alimentaci6n.  Asf,  en  un  experimento  de 
Levy,  un  perro  consumfa,  en  el  estado  de  reposo  y  en  a3ainas,  158  c.  c.  de  oxfgeno  por 
minuto.  Se  le  dl6  entonces  una  comlda  abundante  compuesta  de  500  gramos  de  arroz, 
200  gramoe  de  came  y  25  gramoe  de  grasa.  En  las  boras  que  siguieron,  las  cantidades 
de  oxfgeno  fueron,  respectivamente:  188,  204.8,  203.8,  212.1,  115,  210.7,  207.8,  209.3, 
211.3,  206,  188.5,  176.8,  "2.**  De  la  misma  manera  Voit  ha  notado  en  el  hombre  un 
gasto  de  calorfas  de  2,470  y  de  2,320  (t^rmino  medio  2,390)  en  24  boras  al  estado  de 
ayuno;  mientras  que  con  la  ingesti6n  de  alimentos  variados,  el  gasto  oscLlaba  entre 
2,350  y  2,940  (t^rmino  medio  2,556),  0  sea  un  aumento  de  7  porciento,  poco  mia  o  menos. 

Observadones  hechas  posteriormente  en  el  ayunador  Cetti,  en  Berlin,  confirman 
plenamente  los  resultadoe.  "Pero  este  aumento,*'  dice  Lambling'  ** depende  tinica- 
mente  del  trabajo  secretor  y  sobre  todo,  mecdnico,  impuesto  al  tube  digestive,  y  no 
del  aumento  de  las  combustiones  llevado  por  la  aUmentaddn.'*  Sin  embaigo,  eegtin 
la  autoridad  no  menos  respetable  de  Lable  ^  esto  no  parece  exacto,  pues  el  trabajo 
del  tube  digestive  no  exige  sino  un  gasto  muy  pequeno  de  calorfas,  y  por  otra  parte, 
la  concordanda  bien  notada  por  RQbner  y  Atwater,  entre  el  valor  calorfgeno  de  la 
rad6n  aUmentida  y  la  excrecidn  cal6rica  establece  el  hecho  con  precision: 

Mientras  m£a  coma  un  sujeto,  mds  calorfas  virtuales  ingiere,  y  m^  calorfas  realee 
gasta.  Se  necesitarfan  nuevoe  experimentos,  institufdos  en  este  Bentido,jpara  estable- 
cer  que  el  gasto  de  calorfas  varfa  a  voluntad  con  la  raci6n  alimenticia.  De  la  misma 
manera  que,  en  general,  se  ingiere  una  raci6n  alimenticia  excesiva,  se  excreta  probable- 
mente  una  suma  de  calorfas  demasiado  grande.  El  equilibrio  cal<5rico  podrfa  obtenerse 
con  una  rad6n  alimenticia  m^  d^bil,  aportando  nuevas  calorfas.  Lo  que  habrfa  que 
determinar  ee  precisamente  el  limite  de  la  inge8ti6n  alimenticia  susceptible  de 
mantener  la  temperatura  constante  sin  que  el  peso  del  sujeto  baje  y  sin  que  eet^ 
oblig&do  a  quemar  sue  propioe  tejidoe. 

Se  sabe  que  la  cantidad  de  oxfgeno  consumida  por  el  organismo  es,  en  muy  anchoe 
Ifmites,  independiente  de  la  cantidad  de  oxfgeno  ofredda  a  los  tejidos  por  la  reepira- 
d6n,  y  que  la  cantidad  de  oxfgeno  gastada  varfa  con  la  calidad  de  alimentos  que  se 
van  a  transformar;  100  gramoe  de  oxfgeno  transforman  38  gramos  de  grasa  en  HjO  y 

t  Lftmblns,  TraiU  d«  Pathologie  O^n^nle  de  Boaohard. 

*  LambUng,  obn  citada. 

*  M.  Labl6,  Les  regimes  alimentaires,  p.  30, 1010. 


56 


PBOOEEDINGS  SECOND  PAN  AMEBICAN  SCIBNTIFIO  CONGRESS. 


CO2,  con  produccidn  de  325  calorfas  u  84.4  de  hidratoe  de  carbono,  en  HjO  y  COj, 
con  producci6n  de  362  calorias.  La  cantldad  de  oxfgeno  pues,  ni  descubre  la 
cantidad  de  combustible  destnifdo  ni  la  energfa  puesta  en  libertad.  Cuando  hay 
cierto  minimum  de  aporte  de  materiales  azoados,  baeta  Buministrar  un  exceeo  de 
alimentoe  terciarios  para  que  la  neceeidad  de  energia  sea  cubierta;  eete  exceeo  puede 
ser  proporcionado  por  las  cantidades  mis  variables  de  grasa  o  de  hidratos  de  carbono. 

Este  es  el  cuadro  esquemdtico  de  nuestras  necesidades  alimenticias,  tal  como  se 
realiza  en  el  cuadro  eequemdtico  de  nuestroe  experimentoe  de  laboratorio.  Pero  en 
la  vida  ordinaria,  ^c6mo  pasan  las  cosas  y  c6mo  satisfacen  loe  hombres  sus  necesidades 
alimenticias,  tinicamente  guiados  por  su  instinto?  Es  aqul  donde  la  noci6n  de  los  ali- 
mentoe isodin&micos  de  Rdbner  esclarece  en  gran  manera  la  fisiologfade  la  nutricidn. 
Antes  de  la  adquisici^n  de  tal  noci6n  hubiera  side  imposible  abordar  este  problema. 

Sean,  por  ejemplo,  dos  individuos  de  los  cuales  el  uno  vive  con  120  gramos  de 
albdmina  y  269.7  de  grasa,  y  el  otro  con  la  misma  cantidad  de  albtimina,  mis  611.7 
gramos  de  hidrocarbonados.  Al  no  comparar  sine  los  pesos  se  veria  que  la  cantidad  de 
albdmina  representada  en  el  primer  case  es  de  30  por  ciento,  y  en  el  segundo  es  16  por 
ciento  de  la  raci6n.  ^C<5mo  podrla  pensarse,  en  presencia  de  estoe  cases,  que  la  albd- 
mina represente  en  ambos  el  mismo  papel  y  tenga  la  misma  importancia? 

Introdtizcase,  entonces,  la  consideracl6n  de  los  valores  calorim^tricos,  y  se  tendri: 

Primer  case:  Albdmina,  120  por  4.1—492  calorfas;  grasa,  269.7  por  9.3—2,508 
calorias;  total,  3,000  calorlas. 

Segundo  case:  Albdmina,  120  por  4.1 — 492  calorfas;  hidrocarbonado,  611.7  por 
4.1-— 2,508  calorfas;  total,  3,000  calorfas. 

La  albdmina  ha  aportado  en  61  un  case  y  en  el  otro  la  misma  cantidad,  0  sea  16.4  por 
ciento,  de  la  cantidad  total  de  energfa  gastada;  el  resto,  0  sea  83.6  por  ciento,  es  sumi- 
nistrada  por  cantidades  isodinimicas  de  grasa  0  de  hidrocarbonados. 

Rabner  ha  calculado  de  esta  manera  el  aporte  de  energfa  de  cada  especie  de  ali- 
mentos  observando  en  individuos  que  pertenecen  a  categorfas  sodales  menos  y  menos 
elevadas  y  que  suministran  un  trabajo  mis  y  mis  penoeo. 

El  cuadro  siguiente  resume  los  resultadoe  obtenidoe:  por  100  calorfas  suministradaa 
por  el  organismo  se  encuentran: 


Inanicidn 

Clases  ocomodadas 

Carpinteros,  sol(lados,etc 

Obreros  qii(<  suministran  un  trabajo  considerable 

Mineros,  obreros  de  f4briea 

Lefiadores 


En  albi)- 
mina. 

En  grasa. 

12.1 

87.9 

19.2 

29.8 

10.7 

16.3 

18.8 

17.9 

13.4 

21.3 

8.3 

38.7 

En  hidratos 
deoarbono. 


11.0 

.w.o 
r>6.9 

63.3 

fiS.S 
52.8 


En  lo  que  concieme  a  las  materias  albuminoideas,  se  ve  que  la  proporci6n  relativa 
de  calorfas  suministradas  por  ella  va  disminuyendo  a  medida  que  se  deeciende  en  el 
cuadro  y  esto  depende  de  que  en  lasclases  acomodadas  se  hace  uso  de  preferencia  de  la 
alimentaci6n  animal,  es  decir,  que  se  consumen  pesos  absolutes  de  albdmina  mucho 
mayor  que  en  las  menos  afortunadas.  Como  por  otra  parte  las  clases  ricas,  en  raz6n  del 
menor  trabajo  m^anico,  gastan  menos  calorias  que  las  necesarias  para  un  obrero,  la 
proporci6n  relativa  de  calorfas  tomadas  a  la  albdmina  se  encuentra  por  esta  raz<5n 
aumentada  en  los  ricos  y  disminufda  en  los  pobres  y  en  los  obreros. 

Para  las  grasas  se  pueden  hacer  consideraciones  anilogas.  Midiendo  el  ndmero  rela- 
tive suministrado  por  ellas  se  ve  que  va  disminuyendo  a  medida  que  se  desciende  en 
la  escala;  pero  de  la  clase  V  en  adelante  principia  a  aumentar  y  puede  de  nuevo 
Uegar  hasta  igualar  a  las  clases  acomodadas.  Esta  diminuci6n  se  explica  porque  el 
obrero  toma  a  los  hidrocarbonados  (almid6n  del  pan  f  ^ula  de  la  papa)  cantidades  ere- 
cientes  a  medida  que  el  trabajo  mec^co  lo  va  exigiendo;  pero  luego,  dice  RQbner, 
llega  un  memento  en  que  el  volumen  de  los  alimentos  impondrfa  un  trabajo  muy 


PUBLIC  HEALTH  AND  MEDICINE.  57 

coDfliderable  al  tabo  digestivo,  el  cual  queda  impotente  para  dominar  una  gran  masa, 
e  interviene  entonces  como  complemento  indispensable  el  alimento  grasa,  que  tiene  la 
misma  ventaja  y  asegura  un  valor  calorffico  considmable.  Agr^ueee  a  esto  que  las 
grasas  soli  ingeridas  caai  en  naturaleza  y  que  repreeentarlan,  per  lo  tanto,  en  una  masa 
igual  un  aporte  de  eneigfa  mis  considerable  que  los  otros  alimentoe.  De  esta  manera 
el  organismo  encuentra: 

En  100  gnunoe  de  came  flaca  a  21  por  ciento  de  albtunina,  86  calorfas;  en  100  gramos 
de  pan  a  8  por  ciento  de  albtimina,  86  caloilas,  y  en  5  por  ciento  de  almiddn,  258  calo- 
rfas; en  100  gramos  de  mantequilla  de  85  por  ciento  de  grasa  pura,  790  calorfas. 

Vienen,  en  fin,  los  Mdrocarbonados  adndrablemente  representados  por  los  vege- 
tales,  de  los  cuales,  por  ser  m^  baratos,  toma  el  obrero  el  total  de  su  racidn  alimenticia; 
pero  por  razones  ya  dichas  disminuye  el  tamafio  relativo  de  hidiocarbonados  hasta 
22.8  para  la  tiltima  categorfa. 

El  calor  de  combustidn  de  los  aKmentos,  o  sea  el  total  de  calcnlas  suministradas  por 
la  unidad  de  peso,  mostrado  por  el  calorfmetro  no  es  siempre  igual  al  que  se  produce  en 
el  organismo.  Si  se  trata  de  grasas  o  de  Mdrocarbonados,  tenemoe  para  un  gramo  de 
sustanda,  tanto  en  el  calorfmetro  como  en  la  combusti<ki  oig^ca:  Grasa  9.3  a  9.4  calo- 
rfas; hidrocarbonados,  4.1  a  4.2  calorfas,  pero  con  los  albuminoideos  no  sucede  lo 
mismo,  porque  el  izoe,  que  queda  en  libertad  en  el  calorfmetro  al  estado  elemental,  se 
transforma  en  el  organismo  y  se  elimina  bajo  la  forma  de  productos  complejos,  de 
los  cuales  las  nueve  d^cimas  partes,  poco  m^  o  menos,  son  urea  y  el  resto  deja  el 
organismo  bajo  forma  de  productoe  menos  simplificados.  Hay  pues  que  restar  el 
calor  de  combusti6n  de  eetos  productos  del  de  las  materias  albuminoldeas  para  lo 
cual  la  mayor  parte  de  los  autores,  tienen  en  cuenta  la  urea  y  hacen  abstracci6n  de  los 
otros  productos  azoados.  Como  100  gnunos  de  materia  albuminoidea,  a  16  por  ciento 
de  &zoe,  suministran  aproximadamente  34  gramos  de  urea,  o  sea  casi  la  tercera  parte 
de  su  peso,  hay  que  restar  del  resultado  medio  del  calor  de  combustidn  de  la  albtimina 
(5  a  6  calorfas)  la  tercera  parte,  poco  m^  o  menos  del  calor  de  combu8ti6n  de  la  urea, 
o  sea,  0.850,  correccidn  que  da  del  15  al  16  por  ciento  del  calor  de  combusti6n  total. 
Hay  que  anotar,  adem^,  que  el  izoe  se  eleva  en  algunos  albuminoideos  de  16  a  19 
por  ciento,  lo  que  aumentarfa  la  eifra  de  0.85  a  1  calorfa.  Hechas  estas  anotaciones  y 
despreciando  una  d^ima  parte  del  dzoe  que  no  se  txansforma  en  urea  sine  en  otros 
compueetos,  se  puede  tomar  como  cifra  media  del  calor  de  combustion  de  los  albumi- 
noideos, la  de  4.7  a  4.8  calorfas  por  gramo. 

Cuando  se  quiere  valorizar  el  podercalorimOtrico  de  un  alimento  pon  la  comparaci6n 
de  la  albdmina  ingerida  y  el  izoe  excrementicial  hay  que  hacer  dos  correcciones 
que  corresponden:  la  una  al  alimento  y  la  otra  a  la  excreci6n  azoada.  La  primera  es 
debida,  por  una  parte,  al  aumento,  de  algunas  albdminas  hasta  19  por  ciento  de  ^oe 
y  que  el  dosado  de  la  albtimina  se  hace  por  el  dosado  del  izoe,  y  en  los  vegetales  hay 
sustancias  azoadas  qu^  no  son  albuminoideas.  Por  este  motivo  se  baja  el  valor  caloil- 
m^trico  de  la  albtimina  a  4.1  en  vez  de  4.8  cuando  se  trata  de  alimentos  mixtos.  La 
segunda  causa  de  error  se  efectiia  cuando  no  se  hace  el  andlisis  del  &zoe  eliminado  por 
las  deposiciones.  RObner  estima  este  residue  en  8.11  por  ciento  del  valor  calorim^trico 
total  de  la  reaccidn;  algunos  Uegan  hasta  el  10  por  ciento  para  el  regimen  mixto.  Es 
natural  que  con  la  alimentaci6n  vegetal,  que  da  una  mayor  cantidad  de  residues  no 
absorbidos,  esta  dfra  debe  aumentar.  .^ 

Con  861o  dosar  el  dzoe  total  de  la  orina,  puede  medirse  la  cantidad  de  albtimina  de  la 
cual  ha  dispuesto  el  organismo,  es  neceeario  entonces  tomar  la  dfra  4.8  en  vez  de  4.1 
como  valor  calorim^trico. 

Sea,  por  ejemplo,  un  individuo  que  elimine  14  gramos  de  &zoe,  total  en  las  24  horas. 
Sabiendo  que  a  100  gramos  de  albtimina  corresponden  16  de  dzoe,  tendremos  la  si- 

guiente  relad6n: 

1400 
16:100::14:X,  de  donde  X»^    o  a  14  por  6.25X87.50  (6.25  es  el  coefidente  que 

resulta  de  dividir  a  100  por  16)  y  87.50  por  4.8=>420  calorfas. 


58  FBOOEEDIKGS  SEOOND  PAN  AMBBIOAN  80IEKTEPI0  CONGBESS. 

Ouando  b61o  se  desea  la  urea  se  hace  el  cdlculo  aproxLinado  de  esta  manera:  peso 
de  la  urea  multiplicado  por  1.30  o  1.14,  que  es  el  peso  del  dzoe  expresado  en  urea,  y  el 
producto  multiplicado  por  2.91  gramo  de  urea  ccHresponde  a  2.1  de  albdmina). 

Se  obtiene  de  eeta  manera  segtin  Lambling,  ^  con  aproximaci6n  muSdente,  la  cantidad 
de  albdmina  desaomilada.  Una  mayor  precifli6n  se  obtendr&  naturalmente  con  el 
primer  procedimiento.* 

Al  lado  de  esta  teorfa  isodindmica  o  teorfa  de  Rtlbner  viene  a  oponerse  la  teorfa  de 
Chauveau  mds  cientifica  en  mi  concepto;  y  si  he  desarroUado  m^  extensamente  la 
primera  es  porque  sobre  ella  est^  todavfa  reposando  muchos  prindpios  de  fisiologfa 
modema  y  porque  hasta  cierto  punto  ^a  viene  a  ser  necesaria  para  el  f undamento  y 
desarroUo  de  la  segunda. 

La  teorfa  de  Chauveau  que  llamar^  tambi6n  teorfa  glicog^nica,  dice  que  el  pod^ 
nutritive  de  los  alimentos  se  confunde  con  su  poder  term^eno  o  dinam6geno.  La 
grasa  no  puede  ser  utilizada  como  elemento  energ^tico,  sine  despu^  de  su  transforma- 
ci6n  en  glicdgeno;  hay  pues  en  este  alimento  tma  ]>^rdidade  eneigfa  sobre  la  que  sufre 
segtin  la  teorfa  de  Rtlbner.  El  glic<5geno  serfa  el  estado  a  que  tienen  que  U^^ar  las 
sustandas  alimenticias  para  produdr  energfa.  Es  dedr  que  un  alimento  es  tanto  m^ 
productor  de  eneig:fa  cuanto  mayor  sea  su  capaddad  para  transformaree  en  glic<3geno. 

^'El  cuerpo  que  en  el  organismo  llena  la  fund6n  eneig^tica,"  dice  Morat,  **  es  el 
carbono;  la  forma  qufmica  alrededor  de  la  cual  evoludona  en  esta  funci6n,  es  el  azticar 
y  el  cuerpo  que  en  su  conflicto  con  61  manifiesta  esta  fund6n  el  oxfgeno.  La  evolu- 
d6n  energ6tica  se  encuentra  como  condensada  en  estos  tres  t^rminos  correspon- 
dientes  a  funciones  que  son:  la  alimentacidn,  la  glicogenesis  y  la  termogenesis.'' 

Chauveau  ha  demostrado  y  confirmado  por  la  experimentaci6n  la  teorfa,  demostrando 
que  un  gramo  de  graaa  y  1 .52  gramos  de  azticar  de  cafla  son  capaces  de  suministrar, 
la  primera  por  oxidaci6n,  la  segunda  por  hidrataci6n,  la  misma  cantidad  de  glicosa  y 
por  consiguiente  de  glic6geno;  las  cifras  dadas  por  la  experimentaci6n,  son  exacta- 
mente  las  que  da  la  ecuaci6n  hipot^tica  de  la  transformaci6n  de  la  grasa. 

Lo  que  se  ha  dicho  de  la  grasa  se  aplica  a  todas  las  otras  sustancias  alimenticias, 
inclusive  los  albuminoideos;  de  aquf  que  haya  dado  a  esta  teorfa  el  nombre  de  teorfa 
glicog^nica. 

Pero  segtin  esta  tiltima  teorfa  la  grasa  y  el  azticM"  concurren  a  la  nutrici6n  en  el 
mismo  grado  no  en  cuanto  se  lee  administra  en  cantidadee  t^rmicamente  equivalentes 
(Rtibner),  sino  en  cantidad  es  propias  para  producir  la  misma  cantidad  de  glic6geno 
(Chauveau).  En  reeumen,  la  segunda  teorfa  le  quita  a  la  primera,  el  error  prove- 
niente  del  gasto  de  energfa,  de  la  p^rdida  de  valor  energ^tico  que  una  sustancia 
alimenticia  necesita  para  trasformarse  en  glic6geno. 

Es  una  conexidn  semejante  aunque  hecha  en  opuesto  extreme,  a  la  que  se  hace, 
segtin  Rtibner  a  los  albuminoideos  cuando  se  compara  su  valor  energ^tico  real  con  su 
vaJor  de  combusti6n  dado  en  el  calorfmetro.  Proviene  esta  cqnexidn,  de  que  en  el 
organismo  no  llegan  los  albuminoideos  al  mismo  extreme  de  de8Compo8ici6n  a  que 
llegan  en  el  calorfmetro,  sino  que  se  transforman  en  otros  productos  de  compostci6n 
tan  complicada  como  la  urea. 

Por  no  caber  en  el  plan  de  mi  estudio,  no  me  he  detenido  a  hablar  de  las  trans- 
formaciones  de  los  albuminoideos  en  el  tube  digestive.  En  un  capftulo  posterior 
hablar^  de  las  distintas  formas  de  eliminaci6n  azoadas  y  de  la  proporci6n  en  que  se 
verifican  en  Bogota  y  en  otras  poblaciones  de  la  altiplanicie. 

INPLUBNCIA    DEL   CLIMA    DE    LA    ALTIPLANICIE    SOBRE    LAS    COMBU8TIONE8    HUMANA8. 

Voy  a  hacer  algunas  consideraciones  sobre  los  climas  de  Bogotd  y  Timja,  poblacio- 
nes donde  he  practicado  mis  investigaciones. 

1  La  Taoi6n  media  de  mantenimlento  en  los  hombree  se  divide,  segt^  la  mayor  parte  de  los  fisUSlogos,  de  la 
maneiB  sigiiiente:  Albthnina,  185  par  4.1  equivale  a  563;  grasa,  140  por  9JS  eqoivale  a  1,302;  hidratos  de 
oarbono,  249  par  4.1  equiyale  a  1,021;  total,  2,876  oalorias.  Restando  de 68tas  tm  8  par  ciento  que  se  pierden 
en  las  deposloionee,  quedan  2,646  oalorias  netas,  o  sean  86  por  klldgramo. 


PUBLIO  HEALTH  AND  MEDICINE.  69 

Tomo  las  de  Bogotd  de  un  trabajo  presentado  por  el  Dr.  Julio  Garavito  a  las  sesiones 
cientificas  de  1910  y  las  de  Tunja,  de  mis  observaciones  personales  y  de  datos  tornados 
en  los  gabinetes  y  laboratorios  del  seminario  conciliar  de  esta  ciudad. 

Har6  luego  algunas  consideraciones  sobre  la  influencia  del  clima  en  las  combustio- 
nes  humanas  para  lo  cual  servird  de  mucho  la  comparaci6n  entre  dos  poblacionee  de 
altura  un  poco  diferente.  ^ 

Bogotd  estd  situada  cerca  del  ecuador  entre  las  Uneas  isotennas  25  y  28  grades,  pero 
8U  clima  puede  claslficarse  entre  los  medios  o  los  frfos. 

El  minimum  de  temperatura  se  observa  a  las  5  y  45  a.  m.  y  es  de  8.74  grados,  y  el 
maximum  a  las  2  p.  m.  es  de  16.95.  Las  mayores  variaciones  se  encuentran  durante 
el  mes  de  enero.  La  temperatura  media  es  de  12.97  grados,  la  amplitud  media  de  las 
oscilaciones  diumas  es  de  7.11. 

£1  estado  higrom^trico  es  de  79.5  por  ciento.  La  velocidad  maxima  del  viento  co- 
rresponde  al  mdximum  de  temperatura.  En  los  meses  de  junio,  julio  y  agosto  se 
observan  golpes  de  viento,  de  corta  duracidn,  que  alcanzan  hasta  15  metres  por  se- 
gundo. 

En  general,  se  considera  la  presi^n  atmosf^rica  en  Bogotd  como  de  560  mils,  de 
mecurio.  Segdn  los  dUculos  de  Garavito  hay  un  mjjximun  de  0.5609  y  im  minimum 
de  0.5579.  La  mayor  altura  del  bar6metro  se  observa  en  los  meses  de  junio,  julio  y 
agosto  y  la  menor  en  octubre,  noviembre  y  diciembre. 

Oxigeno. — Si  se  considera  la  proporci6n  de  oxlgeno  en  volumen,  es  casi  igual  en 
Bogota  y  a  nivel  del  mar  (21  por  ciento),  pero  si  se  tiene  en  cuenta,  no  el  volumen 
sine  el  peso,  es  natural  que  la  cantidad  disminuya  en  io versa  proporcidn  con  la 
presi6n.  Teniendo  en  cuenta  que  un  litro  de  aire,  a  la  preei6n  de  0.76,  contiene 
0.259  gramo  de  ox%eno,  se  ob tiene  poco  m^s  o  menos  0.192  gramo  de  oxlgeno  por 
litro  de  aire  en  Bogotd. 

Tunja  tiene  una  8ituaci6n  y  un  clima  muy  semejantes  a  los  de  Bogotd,  661o  que  el 
estado  higrom^trico  es  m^  bajo  en  aquella  y  la  velocidad  del  viento  mayor. 

La  temperatura  media  es  de  11.99  grades.  La  mayor  amplitud  de  las  oscilaciones 
diumas  es  de  6  grades.  El  m^imum  de  temperatura  se  observa  en  el  mes  de  enero 
y  el  minimum  en  julio. 

La  altura  sobre  el  nivel  del  mar  es  de  2,790  metres  y  la  presidn  media  del  banSmetro 
de  0.536  mils,  de  mercurio. 

Temperatura  humana  en  la  altiplanicie. — ^Todes  los  autores  europeos  que  he  consul- 
tado  estdn  de  acuerdo  en  fijar  para  el  hombre  una  temperatura  axilar  media  de  37 
grades  a  37.2  grades.  En  Begetd,  segdn  lo  habrdn  observado  todos  los  medicos  y 
eetudiantes,  la  temperatura  media  rara  vez  pasa  de  36.5  grades;  de  tal  manera  que 
muchos  consideran  come  febricitantes  a  los  individuos  cuya  temperatura  llega  a  36.8 
grades. 

El  Dr.  Pabon  en  135  observaciones  que  reunid  para  su  tesis  de  dbctorade,  obtuvo 
un  promedio  de  36.5  grades,  es  decir,  de  0.5  grade,  inferior  a  la  cifra  censiderada  como 
normal  en  Eurepa.  El  Dr.  Gerpas  en  su  tesis  agrega  100  observaciones  mds  que  dan 
un  resultado  de  36.3  grados,  lo  que  da  ima  diferencia  de  0.9  grade  con  la  cifra  de 
Beclard  37.2  grados. 

En  86  observaciones  tomadas  por  ml  en  Timja  en  adultoe  de  20  a  40  ailos,  pertene- 
cientes  a  distintas  clases  sociales,  obtuve  un  promedio  de  36.24  centlgrades  de  tempe- 
ratura, con  76  pulsaciones  y  20  reepiraciones  por  minute. 

Parece  pues  demostrado  que  hay  una  baja  considerable  de  la  temperatiura  del 
hombre  en  la  altiplanicie,  en  relacidn  con  la  temperatura  aceptada  como  media  en 
Eurepa. 

Todas  las  hip6tesis  que  pueden  hacerse  para  explicar  este  fendmeno  pueden  redu- 
cirse,  en  mi  concepto,  a  tree:  (1)  Influencia  de  la  temperatura  ambiente;  (2)  in- 
fluencia de  la  altura;  y  (3)  influencia  de  la  alimentaci6n.  Me  limitar^,  por  el  me- 
mento, a  las  dos  primeras,  para  ocuparme  lu^o  de  la  tercera,  en  capftuloe  poster iores. 


60  PROOEEDINGS  SEOOKD  PAN  AMEBICAN  SCIEKTIFIO  CONGRESS. 

Infiuencia  de  la  Umperatura  ambienU. — ^Ya  dije  que,  segtin  los  c41culo6  del  Dr.  Gara- 
vito,  la  temperatura  media  de  Bogotd  ee  de  12.97.  El  Dr.  Corpas  cree  que  esta  baja 
temperatura  exterior  es  una  de  las  causae  de  la  baja  de  temperatura  animal,  pues 
^^el  cuerpo  humano  en  busca  de  equilibrio  t^rmico  tiende  a  acercarse  a  ella.'' 

A  primera  vista  esta  causa  no  carece  de  importancia,  pues  aimque  todos  sabemos 
que  los  animales  omeotermos  tienen  i&edios  de  defensa  que  permiten  luchar  contra 
la  temperatura  ambiente,  tambi^n  es  verdad  que  un  descenso  o  un  aumento  considera- 
ble de  temperatura  pueden  hacer  variar  la  temperatura  animal  en  algunos  d^imos 
de  grado.  Esto  parece  confirmado  por  los  experimentos  de  David  y  los  postericn^e 
de  Mantcgazza,  Fousset,  etc. ;  pero  ninguno  de  estos  observadoree  ha  hallado  una  baja 
tan  considerable  como  la  que  se  encuentra  entre  nosotros,  ni  aun  en  atm66feras  de  pro- 
porci6n  higrom^trica  mds  considerable. 

Entre  247  observaciones  de  Mantegazza,  p>or  ejemplo,  no  ha  encontrado,  en  climaa 
mucho  mas  frlos  que  el  de  Bogotd,  sino  una  temperatura  minima  de  36®  4'',  que  alcanza, 
cuando  mds,'  a  ser  igual  a  nuestra  temperatura  media. 

Agr^gase  a  esto  que  las  razas  tropicales,  por  vivir  en  un  clima  siempre  igual, 
luchan  por  efecto  de  la  costumbre  mucho  mejor  contra  los  grandes  frfos  como  contra 
los  grandes  calores;  as(  las  pequefias  variacionee  de  temperatura  animal  que  se  observan 
en  Europa  del  verano  al  inviemo  no  se  encuentran  en  los  tr6picos,  al  comparar  a  este 
respecto,  los  habitantes  de  los  climas  mis  ardientes  con  los  de  los  mis  Mos;  de  modo 
que  la  temperatura  ambiente  (que  no  es  tan  baja  para  producir  un  descenso  de  tem- 
peratura animal),  no  nos  explica  la  baja  considerable  de  la  temperatura  animal  en  la 
altiplanicie. 

Presi&n  atmosfirica. — ^Para  mantener  bus  combustiones  oiginicas,  el  hombre  necedta 
introducir  en  cada  hora  segiin  los  cilculos  de  Briiner  y  Valentin  3130  gramos  de  oxlgeno, 
que  corresponden  a  2191  litros  al  nivel  del  mar,  o  sea  450  litros  de  aire,  que  se  intro- 
ducen  en  las  15  o  16  respiraciones  por  minuto,  que  se  consideran  en  Europa  como 
normales,  a  razon  de  500  c.  c.  en  cada  una,  quitando  los  50  c.  c.  que  son  expulsados  a 
cada  expiraci6n. 

Ahorabien.'como  en  Bogotilapresi6n  es  de  0.20  cms.  de  merciu*io  menos  que  a  nivel 
del  mar,  si  el  oiganismo  no  dispusiera  de  medios  de  defensa,  se  tendrfa  que  en  los 
21.91  litros  de  oxfgeno  no  introducirfa  los  31.30  gramos,  sino  mucho  menos;  de  donde 
resultarfa  una  gran  insuficiencia  de  las  combustiones,  que  podria  explicamos  la  baja 
de  la  temperatura  humana. 

Pero  hemos  visto  ya  que  la  actividad  del  metabolismo  celular  es  independiente  de 
la  cantidad  de  oxfgeno  ofrecido  a  los  tejidos.  Los  experimentos  de  Liebig  demuestran 
que  la  presidn  no  influye  sobre  la  absorci6n  de  oxigeno,'  y  aun  cuando  Truntz  ob8erv6 
un  aumento,  este  aumento  no  duraba  sino  cuando  mis  im  minuto,  y  era,  segdn  el 
mismo  autor,  debido  a  la  repleci6n  de  los  pulmones. ' 

De  la  misma  manera  que  el  oiganismo  no  toma  sino  el  oxfgeno  que  necesita,  cuando  la 
atm68fera  eeti  enrarecida  se  vale  de  ciertos  medios  de  defensa  para  tomar  todo  el  que 
le  sea  necesario.    Veamos  si  de  estos  medios  disponen  los  habitantes  de  la  altiplanicie. 

Bajo  la  infiuencia  del  clima  de  las  alturas,  ^'que  llevarfa  en  realidad  la  disminucidn 
del  oxfgeno  del  aire  en  relaci6n  con  la  presi6n  atmosf^rica,  el  ndmero  de  los  gl6bulo8 
rojos  aumentarfa,  en  una  gran  proporci6n,  hasta  el  punto  de  alcanzar  siete  y  ocho 
millones  por  milfmetro  cdbico  en  el  hombre.''  Seg(in  la  observaci6n  hecha  por 
T.  Viault,  en  sf  mismo  a  4,392  metros  de  altura  en  un  viaje  al  Perii,  la  hipeiglobulia 
se  producirfa  a  partir  de  los  700  metros.  Por  medio  de  esta  hiperglobulia  aumenta  la 
superficie  de  absorci6n  del  oxfgeno  y  puede  el  oiganismo  fijarlo  en  la  misma  cantidad 
que  a  la  presi6n  ordinaria.  Es  6ste,  pues,  un  mecanismo  regiilador  o  de  defensa  que 
se  pone  en  juego  a  medidaque  la  presi6n  disminuye.  Cuando  los  sujetos  sometidos  a 
los  experimentos  vuelven  a  la  llanura,  el  ndmero  de  los  gldbulos  rojos  vuelve  ripida- 

1  Ch.  RIohet,  La  ohaleur  anlmale.        *  Liuk,  Sdenoe  of  nutrition.         *  Journal  of  Physiology,  1907. 


PUBLIC   HEALTH  AND  MEDICINE. 


61 


mente  a  su  nivel  nonnal.  Algunoa  de  loa  hechoa  que  ban  servido  para  la  ediGcaci6n 
de  esta  teoiia  ban  side  vivamente  controvertidoe.  La  cueetii5n,  en  todo  caso,  eeti. 
todavia  oecura,  pero  lo  que  parece  demostrado  ee  que  la  hiperglobulia  de  que  se  tratai 
«a  aimplement«  perif^rica  y  que  el  nllmero  de  gMbulos  rojos  del  coraz6n  y  de  loa 
gnieflos  vaaofl  no  aumenta."  ' 

Loa  fligujentes  eidmeneB  de  Bangre,  practicados,  unoa  por  mf,  y  otros,  en  en  mayor 
parte,  por  el  Dr.  Jorge  Martinez  Santamarfa,  podiiji  damos  a^una  idea  de  lo  que  a 
eate  respecto  paaa  en  la  altiplanicie. 

Laa  nnmeracionea  de  ^Wbuloa  fueron  hechaa  eu  el  numerador  de  Bayem.  Algunaa 
hui  eido  recttficadaa  en  el  Thomas  Zeiss.  La  iiemoglobisa  fu^  medida  en  el  aparato  de 
Fleischl. 


1  Ohr.  Trall««l^tiMDtalnda  pbyilolDgle,  1910. 


FBOCEEDIKGS  SBOOND  PAIT  AHEBIOAIT  SOIEKTIFIC  CONOBBSS. 


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H4  aquf  mis  obaervacioDes  hechas  en  Tunja  en  individuoB  de  20  a  40  afioe. 


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Como  Be  ve,  estoa  21  aoiliais  dim  un  promedio  de  4,547,380  de  gUbuloe  lojoa  y  78 
por  ciento  de  hemoglobina,  la  que  corresponde  a  un  valor  globular  de  26  diezbillo- 
n^eimoe  de  milfgnuao.'    Pnra  los  de  Bogoti  y  17  para  lo°  de  Tunja. 


■  El  valor  glob 
tenleadD  en  cuei 
npresentael  vh 


itldBd  dehemoglobinaquBcontlenecsdii  globule  rojo,  ha  sldoobtenldo. 
In  sangM,  por  la  slguioole  Mnnula;  ^~  jfYi^^ipnTSo  sn  la  qua  X 
deosidad  de  la  tangre  prescEndltndo  de  la  coou  dtcliual  (looi);  II  la 
ea  100  gninios  de  saogre,  >■  NelnilnBrodagldbulosroJoa  pot  1  mm.  C, 


PUBLIC  HEALTH  AND  MEDICINE.  63 

Deede  que  el  Dr.  Joige  Vaigaa  Sudrez  practic6  sub  anAlisis  de  sangie,  todo  el  mundo 
creyd  (incluBive  el  autor  de  este  trabajo)  que  ee  trataba  de  algdn  defecto  de  t^cnica, 
puee  nadie  podia  figurarse  que  a  la  altuia  de  Bogota,  hubiera  una  dismiiiuci6n  de  las 
hematias  en  contra  de  lo  que  generalmente  se  admite. 

Fu6  pues,  el  Dr.  Vargas  Su^z  quien  primero  llamd  la  atenci6n  sobre  tan  impor- 
tante  asunto  y  a  ml  me  cabe  el  honor  de  venir  hoy  a  confirmar  su  observacidn.  Para 
mayor  abundamiento,  mis  promedios  de  Bogotd  y  los  del  Dr.  Vaigas  Su&rez,  dan  una 
cifra  casi  id6ntiea,  siendo  de  advertir  que  el  autor  de  este  trabajo,  no  tuvo  conoci- 
miento  de  la  teals  del  Dr.  Vargas,  sino  muoho  tiempo  despu^s  de  terminadas  sus  nu- 
meraciones  de  Bogota. 

Si  el  ndmero  de  mis  observadonee  tomadas  en  Timja  no  fuera  tan  inferior  al  de 
Bogot4,  aquelloe  contribuirfan  a  afirmar  una  tesis  absolutamente  opuesta  a  la  sob- 
tenida  por  Viault  y  otros  fisidlogos  europeos;  es  decir,  que  en  vez  de  aumentar  nuee- 
tras  hematias  a  medida  que  ascendemoe,  disminuyen. 

Ooncuerdan  estoe  resultados  con  la  baja  de  temperatura,  lo  que  quiere  dedr  que 
nuestra  raza  es  impotente  para  defenderse  contra  el  enrarecimiento  del  aire  en  las 
alturas. 

Pero  fuera  de  la  hii>erglobulia  y  de  la  hii>erhemoglobinuria  hay  otros  medios  para 
eeta  defensa  que  voy  a  anaUzar. 

Vimoe  atr^  que  el  oiganismo  no  toma  sino  el  exijgeno  que  necesita.  Vimos  tambi^ 
que  a  causa  del  enrarecimiento  del  aire,  el  habitante  de  la  altiplanicie  de  Bogota 
no  toma  en  los  21.91  litres,  los  31.30  gramoe  que  se  toman  a  nivel  del  mar,  en  el  mismo 
volumen. 

Lo  primero  que  se  ocurre  ee  que  los  habitantes  de  la  altiplanicie  suplen  con  una 
mayor  capaddad  tordcica  esta  insuficienda  de  oxigeno  atmosf6rico;  que  introdu- 
ciendo  en  cada  inspiraci6n  un  mayor  volumen  de  gas,  Uega  a  absorber  los  mismos 
31.80  gramos  de  exfgeno  por  hora.  Pero  en  54  capaddades  todUdcas  que  he  tomado 
en  hombres,  he  hallado  un  promedio  que  alcanza  a  1.8,  cifra  muy  semejante  a 
la  que  encontr6  el  Dr.  Corpas  (1.7).  £1  problema  se  reduce  entonces  a  averiguar 
cuinisa  respiradones  se  necesitan  en  Bogot4  para  tomar  la  cantidad  de  oxigeno  indi- 
cada  en  peso.    He  aquf  como  lo  reeuelve  el  Dr.  Corpas: 

Segdn  los  experimentos  de  Bruner  y  Valentin,  el  hombre  toma  la  cuarta  parte  del 
oxigeno  que  pasa  por  sus  pulmones;  de  mode  que  para  tomar  los  31.30  gramos  que 
necesita  en  cada  hora,  deben  pasar  por  los  pulmones,  126.20  gramos  que  est^  con* 
tenidos,  a  nivel  del  mar,  en  450  litros  de  aire.  Ahora  bien:  si  en  Bogota  contiene  un 
litro  de  aire,  0.192  gramo  de  ex|geno,  los  125.20  gramos  eetar^  contenidos  en  652 
litros  de  aire,  que  servir^,  a  raz6n  de  500  c.  c.  por  cada  reepiraddn,  para  1,304  rech 
piradonee  por  hora,  o  sea  21.7  por  minuto. 

Como  reeultado  de  100  observadones,  el  mismo  autor  encuentra,  como  tannine 
medio,  20.9  respiradones  por  minuto.  Como  se  ve,  los  dos  resultados  (el  del  cdlculo 
y  el  de  la  obeervaddn),  son  sensiblemente  iguales  y  se  acercan  tambidn  a  la  dfra 
de  20.3,  fijada  por  el  Dr.  Coindet  en  la  Mesa  de  An&huac. 

S^gt&n  el  mismo  autor,  el  ntimero  de  pulsadones  por  minuto  es,  en  la  altiplanide, 
de  83.  De  mode  que  si  no  hay  un  mecanismo  conpensador  reepecto  a  una  mayor 
saperfide  de  hemoglobina,  lo  hay  por  una  mayor  rapidez  en  la  renovacidn  de  las 
superficies  puestas  en  contacto  para  tomar  el  exfgeno  que  debe  ir  a  produdr  las  com- 
bustiones.  Lo  difidl  es  saber  si  este  mecanismo  alcanza  a  suplir  a  aqu^l;  si  lo  que 
lesulta  pkir  el  dUculo  matemdtico,  resuKa  tambi^n  en  cuanto  a  la  pr&ctica  de  las 
oombustiones  org&nicas,  o  si  en  definitiva  la  folta  de  superfide  hemoglobinica  ea  una 
de  las  causas  de  la  baja  de  la  temp«»tura  animal  en  la  altiplanicie. 

Begdn  mis  observadones  tomadas  en  Tunja,  no  se  llega  a  los  mismos  resultados. 

Vimos  atr^  que  la  temperatura  humana  me  da  un  promedio  de  36.24,  es  dedr, 
inferiOT  al  obtenido  por  los  Drs.  Pab6n  y  Corpas  en  Bogotd.  Ahora  bien,  estando 
esta  filtima  pobladdn  colocada  a  un  nivel  inferior  al  de  Tunja,  deberla  encontrarse 


64  PBOOEEDINGB  SECOND  PAN  AMEBIOAN  8CIENTIFI0  C0NQBE88. 

en  esta  una  polipnea  compensadora  y  una  mayor  frecuenda  del  pulso;  no  sucede  asf, 
sin  embargo,  sino  todo  lo  contrario,  puee  como  se  ve,  mis  promedioe  de  76  pulsacionea 
y  de  20  respiraciones,  son  inferioi-es  a  los  obtenidos  en  Bogot&  por  Corpas. 

Si  no  fuera  porque  el  ndmero  de  observaciones  es  todavia  insuficiente  paia  sentar 
una  conclusi6n  definitiva,  podrfamos  deducir  (agregando  estoe  dos  datos  al  de  la  dis- 
minuci6n  del  valor  globular  con  la  mayor  altura)  que  nuestra  raza,  dcbido  a  multiples 
circunstancias  que  enumerar^  al  final  de  este  estudio,  est^  ataoada  de  un  principio  de 
degeneracidn  fisiol6gica  que  la  incapacita  para  defenderse  contra  la&agreedones  de  la 
altura. 

Ya  se  vi6  c6mo  la  intensidad  de  las  combustiones  orgdnicas  estd  en  raz6n  directa  de 
la.cantidad  de  alimentos  ingeridos,  de  mode  que  paracompensar  las  p6rdidas  de  calor 
que  el  oiganismo  sufre  en  la  altiplanicie  por  efecto  de  la  altura,  del  estado  higrom^trico^ 
de  la  temperatura  ambiente,  etc.,  se  necesita  agregar  a  los  medios  de  defensa  de  que  ya 
se  ha  hablado,  el  de  una  alimentaci6n  muy  rica  en  materiales  nutritives. 

Me  extenderla  demasiado  si  me  pusiera  a  relatar  los  experimentos  que  se  ban  becho 
sobre  esta  cuesti6n  del  aiimento,  como  medio  de  defensa  contra  las  causas  de  enfiia- 
miento,  talea  como  los  de  Levy,  en  perros,*  las  de  Viault,  en  el  bombre,  las  de  Richet, 
en  curfes,'  las  de  Atwater  y  las  de  Rdbner  sobre  el  valor  nutritive  de  los  alimentos.' 

Bstas  consideraciones,  agregadas  a  que  la  observacidn  diaria  y  la  tesis  del  Dr.  Del 
Rio  *  dejan  comprender  que  hay  una  insuficiencia  de  eliminaci6n  de  la  urea  entre 
nosotros,  me  condujeron  a  bacer  investigaciones  sobre  la  alimentaci6n  y  luego  sobre  la 
eliminaci6n  azoada  de  la  altiplanicie.  En  los  capltulos  siguientes  se  ver4  el  reeultado 
de  estas  investigaciones. 

LOS   ALIMENTOS. 

En  el  capltulo  anterior  se  hizo  el  anillisis  de  uno  de  los  elementos  de  combu8ti6n,  o 
sea  el  oxfgeno.  En  el  presente  voy  a  hacer  algunas  observaciones  sobre  el  otro  ele- 
mento,  o  sea  el  combustible. 

Ya  se  ha  visto  que  la  caUdad  de  los  alimentos  iniluye  poderosiamente  en  la  intensidad 
de  las  combiistiones  orginicas.  Y  como,  por  otra  parte,  se  sabe  que  las  materias  ali> 
menticias  tienen  composiciones  distintas  segtin  la  zona  a  que  pertenecen,  babla  pen- 
sado  que  la  insuficiencia  de  eliminaci6n  de  la  urea  que  se  nota  entre  nosotros,  pudiera 
ser  debida  a  una  insuficiencia  de  materiales  azoados  en  la  alimentacidn.  Venian  en 
apoyo  de  esta  hipdtesis  la  consideraci^n  de  que,  por  una  parte,  el  aire  de  las  alturas  no 
tiene  la  misma  cantidad  de  4zoe,  en  peso,  que  a  nivel  del  mar,  y  por  otra  que  no  estando 
nuestro  suelo  cientlficamente  abonado  para  la  agriciiltura,  pudiera  adolecer  de  una 
nitrificaci6n  insuficiente.  De  modo  que  el  alimento  vegetal,  origen  de  todos  los 
materiales  alimenticios  (vease  pdgina  53),  resultaria  con  una  cantidad  de  6zoe  insufi- 
ciente para  abastecer  a  las  necesidades  del  organismo,  tal  como  sucede  a  los  cereales  de 
Egipto,  por  ejemplo. 

Es  verdad  que  el  estudio  de  la  eliminacidn  azoada  da  datos  suficientes  para  juzgar 
de  la  alimentaci6n  azoada,  pero  las  consideraciones  anteriores  me  ban  obligado  a 
agregar  este  capitulo  a  manera  de  contra  prueba. 

Los  andlisis  no  solamente  se  ban  referido  a  las  materias  azoadas,  sino  a  otras  materias, 
cuya  determinaci6n  puede  ser  de  grande  utiUdad.  Debo  confesar  que  el  nt!imero  de 
andlisis  no  ha  sido  suticiente  para  sacar  conclusiones  a  este  respecto;  la  falta  de  tiempa 
para  extender  mAs  este  trabajo  y  mi  impericia  en  estos  asuntos  (que  hizo  que  los  primeros 
andlisis  fracasaran  por  una  mala  tunica)  me  impidieron  hacerlos  m^  niimerosos,  pero 
los  pocos  que  voy  a  presentar,  servirAn  a  lo  menos,  para  dar  idea  del  poder  nutritive  de 
nuestras  materias  alimenticias. 

Las  materias  que  he  analizado  son  las  que,  en  mi  concepto,  forman  la  ba^ e  de  nueetra. 
alimentaci6n:  trigo,  maiz,  arvejas,  habas,  papas,  arroz,  came  y  leche.    Los  anilisis 

»  Lambling,  loc.  cit.  »  LabW,  Les  regimes  alimentaires. 

«rh.  richet,  Chaleur  anlmale.         *  Anastaslo  del  Rio.    Tesls  para  el  doctorado,  BogotA,  1892. 


PUBLIC  HEALTH  AND  MEDICINE.  65 

verean  sobre  los  siguientee  datos:  agua,  sales  mineralee,  materias  azoadas,  mateiias 
grasas  y  materias  azucaradas. 

Ti^CNIGA  DB  LOS  ANAlISIS, 

I.  Preparacidn  de  Uu  mueitras. — ^La  pulverizaci^n  de  los  granos  y  demis  materias 
destiiiadas  al  fm^lisis,  se  ha  hecho  en  im  pequefio  molino  de  discos  de  acero,  acana- 
lados.  El  producto  del  primer  paso  se  remuele  varias  veces  hasta  obtener  un  polvo 
homog^eo. 

II.  Domdo  del  agua. — Se  peean  en  una  balansa  de  precision,  en  una  cdpsula  previa- 
mente  tarada,  una  cantidad  cualquiera  de  la  sustanda  que  se  va  a  analizar  (5  gramos 
por  ejemplo)  se  Ueva  luego  a  la  estufa  a  unos  100^  y  se  mantiene  alU  durante  24  horas; 
se  vuelve  a  pesar  al  cabo  de  este  tiempo  y  la  diferenda  da  el  agua. 

III.  Cenizas  o  sales  minerdles. — La  dipsula  que  sirvid  para  dosar  el  agua  se  pone 
sobre  una  parriUa,  y  con  la  ayuda  de  un  soplete  de  gasolina  se  indnera  hasta  que 
no  queden  rastros  de  carb6n.  Se  pesa,  y  el  resultado,  menos  el  peso  de  la  cdpsula 
da  las  cenizas. 

lY,*  Materias  azoadas, — ^Balland  '  aconseja  el  m^todo  de  Kgedahl,  basado  en  que 
las  sustandas  azoadas,  calentadas,  en  preeenda  del  ^do  sulfdrico  concentrado,  se 
descomponen  en  ^Uddo  caibdnico,  agua  y  amoniaco.  Todo  el  &zoe  pasa  al  estado 
de  amoniaco,  y  despu^,  al  combinaree  con  el  iddo  sulMiico,  forman  sulfato  de 
amoniaco.  Basta  deecomponer,  por  un  41cali,  la  sal  formada;  separar  el  amoniaco 
por  destilacidn  y  dosalarlo  volumdtricamente. 

Para  eeto  se  pone  en  un  matraz  de  500  c.  c.  de  capaddad,  1  gr.  de  la  materia  que 
hay  que  analizar,  10  c.  c.  de  soluddn  al  80  por  dento  de  oxalate  neutro  de  potasio 
y  10  c.  c.  de  dddo  suIMrico  concentrado.  Se  calienta  el  matraz  directamente,  si  es 
de  vidrio  de  Jena,  o  si  no,  interponi^ndole  una  maUa  de  alambre  por  medio  de  un 
reverbero  Juwel  u  otro  semejante. 

£1  calentamiento  debe  ser  moderado  al  prindpio,  teniendo  cuidado  de  agregar 
unos  15  c.  c.  de  alcohol,  cuando  la  espuma  que  se  forme  alcance  a  llenar  las  dos 
terceras  partes  del  globo.  Una  vez  que  baje  la  espuma  se  aumenta  la  llama  y  se 
coloca  entre  el  cuello  del  frasco  un  embudo,  que  tiene  por  objeto  evztar  que  se  escapen 
muchos  vapores  e  indicar  la  presenda  del  vapor  de  agua  por  el  niido  particular  que 
produce  al  condensarse  y  caer  sobre  el  fondo  del  globo;  cuando  se  ha  eecapado  todo 
eete  vapor,  se  regula  la  llama  de  mode  de  obtener  una  ebullid<ki  tranquila.  Los 
vapores  de  dddo  sulfuroso  y  de  &ddo  sulftirico  se  escapan  entonces  y  producen  una 
iiritaddn  muy  molesta  en  las  mucosas  de  las  vlas  respiratorias.  Cuando  el  Ifquido  se 
deecolora  completamente  o  queda  con  un  tinte  ligeramente  ambarino  (esto  sqcede 
una  o  dos  horas  despu^  de  prindpiada  la  operad6n),  se  le  quita  la  llama  y  se  deja 
enMar.  Una  vez  enfriado  el  matraz,  se  agregan  unos  30  6  4M)  c.  c.  de  agua  tibia  y 
luego  se  alcaliza  con  lejla  de  soda,  hasta  colorad6n  rosada  bien  marcada  de  la  fenol- 
taleina. 

Despu^-se  pone  todo  el  llquido  en  un  globo  que  estd  en  comunicad6n  con  un 
aparato  destilador.  El  llquido  desfiUado  se  redbe  en  un  matraz  donde  hay  unos  50 
c.  c.  de  dddo  sulftiiico  decinormal.  Cuando  el  Uquido  destilado  no  coloree  una 
gota  de  reactivo  de  Neeler  (yodo-mercuriato  de  potasio),  se  suspende  la  operad6n. 

Despu^  de  agregar  unas  gotas  de  fenoltaleina,  se  dosa  por  medio  de  soda  decenormal, 
la  cantidad  de  dddo  que  ha  quedado  libre  y  de  este  dato  se  deduce  la  cantidad  de 
amoniaco  desprendido.  Sea  n  el  n(imero  de  centlmetros  ctibicoe  de  soda  empleados. 
La  diferenda  50  — n  es  igual  al  amoniaco,  y  ^sta  multiplicada  por  0.0014,  da  al  dzoe 
de  1  gramo  de  sustanda,  el  cual  multiplicado  por  6.25  da  la  cantidad  da  materia 
albuminoidea. 


1  BaUand,  Ti«R  ailments,  pdfina  2, 1907. 


66  PBOOEEDINGS  SECOND  PAK  AMEBIOAN  BCIBimPIC  00NGBE8S. 

Eflte  procedimiento  es  mejor  que  el  piimitivo  de  KgeWahl,  que  consiste  en  poner 
mercuiio  en  vez  de  oxalate  neutro,  "porque  el  meicurio  fonna  combinadones 
amoniaco-meictiricas  dificiles  de  deecomponer  que  impedii&n  la  libre  deetilaci6n 
del  amoniaco."  Para  impedir  que  estaa  combinadonee  se  fonnen,  se  agrega,  deepu^s 
del  enfriamiento  del  nuitnuB  en  que  se  ha  verificado  la  reacd^  monoaulfuro  o  hipo»> 
(oafito  de  aodio,  Buatancias  que  son  muy  diUcilea  de  conaeguir,  o  de  conaoguir  puiaa 
en  el  comerdo. 

Por  via  de  enaayo  he  hedio  comparativamente  la  deecomposicidn  del  sulfate  de 
amoniaco  y  dosado  del  6zoe  por  este  m^todo  de  destilacidn  y  por  el  m^todo  volum^trico 
de  Deniges,  del  cual  hablar^  al  estudiar  el  dosado  del  6zoe  total  en  la  orina;  s61o  me 
han  dado  dif  erencias  que  no  merecen  tenerae  en  cuenta  si  se  considera  la  simplificacidn 
que  sufre  el  procedimiento. 

Pero  todos  estos  procedimientos  adolecen  del  error  de  dosar  las  materias  albuminoi- 
deas  por  el  4zoe;  y  ya  se  dijo  que  hay  en  los  vegetales  cuerpos  azoados  que  no  son 
albuminoideos  y  que  hay  materias  albuminoideas  que  contienen  m^s  de  16  por  ciento 
de&zoe. 

V.  MaUrias  grtuaa, — Este  dosado  se  ha  hecho  agotando  por  el  6ter  doe  gramos  de  la 
sustancia  en  im  aparato  semejante  al  de  Soxhlet,  construldo  por  el  Dr.  Eduardo  Lleras 
Codazzi. 

La  sustancia  se  coloca  en  un  papel  de  filtro  previamente  humedecido  con  alcohol. 
Encima  del  tubo  que  la  contiene  y  en  comunicacion  con  ^1,  hay  un  reMgerador,  y 
debajo — ^tambi^n  en  comunicaci6n — ^hay  un  globito  previamente  tarado,  que  contiene 
unos  5  c.  c.  de  6ter  siilftirico  o  de  6ter  de  petr61eo.  Se  calienta  el  globito,  y  el  6ter,  al 
evaporarse,  disuelve  la  materia  grasa,  se  condensa  en  el  refrigerador  y  vuelve  a  caer 
al  globo.  Esta  operaci6n,  se  contin(!ia  por  una  hora,  poco  m^s  o  menos,  teniendo 
cuidado  de  no  calentar  demasiado  para  que  no  se  escape  el  ^ter. 

El  globo  es  colocado  en  la  estula  a  unos  100^,  y  despu^  de  unas  veinticuatro  horas, 
cuando  se  haya  evaporado  todo  el  ^ter,  se  pesa.  El  resultado,  menos  el  peso  del 
globo,  da  el  peso  de  la  materia  grasa  contenida  en  dos  gramos  de  la  sustancia  que  se 
analiza. 

VI.  Materias  axticaradoi, — Se  agotan  por  el  agua  5  gramos  de  materia,  se  hace  hervir 
el  agua  de  los  lavados,  filtradoe  con  algiinas  gotas  de  &cido  clorhldrico.  Se  defeca 
deepu^  por  el  subacetato  de  plomo  en  ligero  exceeo.  Se  filtra,  y  despu^  de  eliminar 
el  exceeo  de  plomo  por  fosfato  o  carbonate  de  sodio  se  vuelve  a  filtrar.  Se  lleva 
despu^  a  un  volumen  determinado,  y  se  doea  el  azdcar  por  los  procedimientos  ordi- 
naries, con  licor  de  Pasteur. 

Para  la  leche:  para  el  an&lisis  de  la  leche  estos  m^todos  tienen  ligeras  variaciones. 
El  estracto  seco  se  doea  sobre  1  c.  c.  Las  cenizas,  sobre  5  c.  c.  previamente  secadas 
alaestufa. 

La  lactosa  sobre  5  c.  c.  a  los  cuales  se  agrega  poco  a  poco  5  c.  c.  de  alcohol  a  65^, 
adicionado  de  1  por  1,000  de  icido  ac^tico.  Se  lleva  en  seguida  sobre  un  filtro  previa- 
mente tarado.  El  coi&gulo  que  quede  se  lava  con  alcohol,  y  el  If  quido  filtrado  se  lleva 
a  un  volumen  determinado  y  en  ^1  se  doea  la  lactosa  por  el  licor  de  Pasteur.'  En  el 
co^igulo  que  queda  en  el  filtro  se  dosa  la  materia  grasa;  deepu^  de  extrafda  ^ta,  se 
pesa  y  el  resultado,  menos  el  peso  del  filtro  y  el  de  las  sales,  da  la  caseina. 

Estos  tUtimos  procedimientos  son  los  que  emplea  el  Dr.  Eduardo  Lleras  Codazzi, 
quf  mice  ayudante  en  el  Laboratorio  Municipal,  a  quien  me  toc6  reemplazar  diu^mte 
varies  mesos. 

Ia  came:  En  la  came  que  es  otro  de  los  alimentos  animalee  que  he  analizado,  s61o 
he  dosado  las  materias  albuminoideas  sobre  2  gramos  de  sustancia. 

1  Para  el  efecto  de  doear  la  lactosa  debe  tenerae  en  ouenta  que  5  gramos  de  glucosa  equivalen  a  6.75  de 
laotosa. 


PUBLIC   HEALTH  AND  MEDICIKE. 


67 


RESimrADOS. 


Muestras. 

NAixLl. 

Nflm.2. 

NAm.  3. 

I.  TBIOO. 

Affua 

PoreierUo. 
11.10 
1.90 
1.95 
9.80 
2.50 

PoreierUo. 

11.20 
1.80 
2.00 

12.82 
2.60 

Porciento. 
11.20 

Scues  minerales 

1.68 

Materia  grasa 

2.19 

Mftt^*rlBS  asoAd  A9 ............                           . . . . « 

11.10 

Ax6c&res 

1.55 

Muestras. 

NOm.  1. 

N6m.2. 

NAm.  3. 

PoreierUo. 

12.10 
0.98 
4.85 

13.58 
1.80 

N6m.  4. 

n.  MAlZ  BLANCO. 

Agua 

Pordento. 

12.00 
1.70 
3.90 

11.10 
2.40 

Pordento. 
11.90 
1.90 
3.90 
8.64 
L56 

Pordento. 
12.00 

Sates  minerales 

1.65 

If atfnia  Erasa 

5.10 

\f at^riftfi  asoadas .....  .          . .  . . . . ,  ^ . . 

12.25 

Asticares 

1.90 

Muestras. 

NAm.  1. 

Ntim.2. 

m.  ▲BTKJA8. 

Apia.     ........     .....T.-r-ir...T....-.TT.T.... .....r.T-,-,...TT.....,.....TTr.T,T 

Pordento. 

12.20 

3.24 

.95 

20.26 

3.46 

13.98 

2.40 

.98 

21.78 
3.46 

Pordento, 
14.98 

fl^iW    in*TI«nUefl.    .. ^        ,r...    ,        ,    ,   r   r        t,..    .    .    . r r -        r 

3.40 

Materia  srasa 

1.50 

M<|t4frfa8   ftf/MUlft?.    ,    r   r    r   ,        ,    .    ,    T   ,        T    T  -   T    r             -   .   ,    .    r        T r        ,    .   T    .    r    T             ,    ,    .    r T        r   ,    r 

20.06 

Asdcares 

2.27 

• 

nr.  HABA8. 

Agllft  ...-.-    r    .,.   T   r  r  T t .             ,    ,    ,    t    .   .    r   .   ,    t    r r T        x   T        -   T        r        x        T    r   T 

13.50 

Bales  Tn^TiWfOfls . ,  r  .  ^      ,  x  ^    x , , , x  - . , , .     . .  ^ . . , .  r  - 

2.24 

Materia  grasa 

1.25 

Matflriaslwoadas 

20.40 

At&cares 

3.10 

T.  ABBOK 

Agua 

Sales  minerales 

Materia  grasa 

Materias  azoadas 

Aztkcares 

VI.  PAPAS 

Materia  grasa 

Materias  az<»da8 

AzAcares 


Muestras. 


Norte- 
ameri- 
cano. 


Pordento. 
8 

1.19 
1.60 
7.564 
.145 

NAULl 
1 

1.74 
20 


Del 
puis. 


PoreierUo. 
7.32 
.90 
1.50 
9.264 
2 


Materias  asoadas. 


Yn.  CABNB  DISBirOBASADA. 


Muestras. 


N6m.  1. 


Pordento. 
22.50 


N6m.2. 


PoreierUo. 
22.48 


68436— 17— VOL  x 6 


68 


PBOCEEDINOS  SECOND  PAN  AMBBICAK  SOIBNTIFIO  OONOBESS. 


ICoestras. 

Nrtm.  1. 

Ntlin.2. 

Nflm.8. 

Nllni.4. 

Ntlin.6. 

N(liii.6. 

VUI.  Lbchk. 
Manteqoilla 

PormiL 
30 
15 

7 

46 

128 

PormU. 
88 

44 
7.8 
80 
128 

PornUl 

84 

43 

7.2 

41 

125 

PormIL 

81 

42 

7.1 

42 

120 

PormiL 

80 

47 

7 

86 
120 

PormIL 
82 

Lactosa 

47 

Sales 

7 

Casefna 

87 

Extracto  seco 

128 

Reaoci<5n 

Anf. 
1,080 

Anf. 
1,081 

Anf. 
1,082 

Anf. 
1,082 

Anf. 
1,081 

Ant 

Densidad 

1,082 

Si  86  comparan  los  an^jlisis  anterioree  con  lo8  practicados  en  otroe  palaeB,  se  v^ 
que  mis  Boepechas,  reepecto  a  la  inBuficiencia  de  materialee  nutiitivos  y  eepedal- 
mente  de  materialee  azoados  en  nueetros  alimentos,  eran  infundadas.  Voy  a  tras- 
cribir  algunoe  de  eetos  an&liais,  para  que  ee  pueda  establecer  la  comparaci6n: 

Trigos  de  los  Estados  Unidos. — Eetos  tienen  una  compoeicidn  muy  variada,  a  causa 
de  la  diferencia  de  climae.  En  los  trigos  de  Francia  las  diferendas  son  menoe  mar- 
cadas.    He  aqul  los  dates  que  suministra  Balland :' 


Trigos  de  lof  Bstados 
Unidos. 

Trigos  de  Fraocia. 

MAxImtim. 

Mtnimtim. 

Minimum. 

IfAximnm. 

Jigatk r r T 

14.56 

18.96 

2.25 

1.96 

ia80 
7.48 
1.10 
1.42 

laio 

7.68 
LIO 
1.12 

15.90 

WftiftHas  asoadaSx . . » . .  ^ . . . .  ^ 

12.00 

(^asas 

2.00 

finnisas 

2.10 

Como  se  ve  por  estos  pocos  dates  comparativos  y  por  el  resultado  del  an^isis  de 
las  dos  muestras  de  arroz,  la  una  norteamericana  y  la  otra  del  pais,  habrla  mas  bien 
raz6n  para  pensar  que  nuestro  suelo  es  suiicieDtemente  rico  en  materiales  nutritivos 
y  que  nuestros  productos  alimenticios  nada  tienen  que  en vidiar  a  los  de  la  zona  templada . 

Hasta  las  mismas  leguminosas  que  toman  el  izoe  '  de  la  atmdsfera,  izoe  que,  como 
se  sabe,  es  insuficiente  en  las  alturas,  parece  que  dispusieran  de  un  mecanismo  com- 
pensador,  an^ogo  al  de  los  animales  para  el  oxigeno,  porque  su  proporci6n  de  dzoe 
estd  en  nuestras  habas  y  en  nuestras  arvejas  en  la  misma  proporci6n  que  en  Europa. 
Pero  repito  que  el  ntimero  de  mis  anAlisle  ha  side  muy  pequefio,  y  que,  por  consi- 
guiente,  no  pueden  hacerse  sobre  ellos  sine  meras  suposiciones. 

Los  an&lisis  de  eliminaci6n  azoada  que  se  refieren  a  observaciones  rnks  numeroeas, 
compensan,  en  parte,  las  deficiencias  de  aquellos. 


Euminaci6n  azo ad a-Gener alidades. 

Si  se  exceptda  una  pequefla  cantidad  de  dzoe,  que  proviene  de  la  desintegraci6n 
de  ciertos  elementos  no  ^buminoideos  de  la  alimentaci6n  vegetal,  todo  el  dzoe  que 
elimina  el  organismo,  proviene  de  las  materias  proteicas. 

Resumir^  en  el  presente  capftulo  algunas  generalidades  sobre  eliminacl6n  azoada, 
acompafiindolas  de  distintas  opiniones  de  autores  extranjeros,  a  fin  de  que  se  puedan 
apreciar  mejor  los  dates  que  dBi6  en  el  capltulo  siguiente,  sobre  la  eliminaci6n  azoada 
en  la  altiplanicie. 


>  Balland,  Loc.  cit. 

>  Reoherchessorlafijationdel'asoteparlesplantes.    Analesl'Inst'tutPasteor,  1892,  Nt^.  2; -A. Balland, 
Loc.  cit,  p&gs.  99  y  100. 


PUBLIO  HEALTH  AND  MEDIOINB.  69 

Ya  86  dijo  que  fu^  liebig  quien  descubri6  que  las  albuminoideas  tienen  izoe  y 
quien  Bugiri6  la  idea  de  que  la  cantidad  de  dzoe  ellmmado  podiia  ser  proporcional 
a  la  cantidad  de  albtimiDas  destruidas  en  el  oiganismo;  rnks  tarde  Bidder  y  Schmidt 
Iniciaron  experimentoe  sobre  este  aaunto. 

La  moltoila  albunilnoidea  aufre  en  el  organismo  un  estado  tan  avansado  de  demoli- 
ckmea,  que  siendo  su  peso  molecular  primitivo  de  500  a  600,  termina  en  cuerpos, 
oomo  la  urea,  cuyo  peso  molecular  es  igual  a  60.  Es  verdad  que  la  urea  no  ee  el  dnico 
prodncto  de  trasformaci6n  de  las  materias  proteicas,  pues  hay  otros  de  peso  molecular 
m4i  elevado;  sin  embaigo,  la  nutiicl6n  es  m^  perfecta  cuanto  mds  completamente 
se  trasforme  la  albtimina  en  urea. 

Parece  que  la  mayor  parte  de  las  albuminoideas  se  destruyen  en  e^l  organismo  por 
bidratacidn,  como  in  vitro  bajo  la  accidn  de  las  diastasas  proteicas  o  de  los  ^dos 
faertes,  es  dedr,  que  se  fra^entan  suministrando  icidos  aminados,  glicocola,  leucina, 
alamina,  etc.,  que  son  oxidados  en  seguida.  En  efecto^  los  fermentos  proteolfticos 
que  se  han  encontrado  en  los  jugos  de  expreu6n  de  los  te^idos  desdoblan  las  proteicas, 
a  la  manera  de  la  tripmna  y  hacen  dcidos  mono  y  diaminados;  por  otra  parte,  estos 
icidoe  diaminados  han  sido  encontrados  en  los  liquidos  del  organismo  y  en  los  6iganos 
nismos  (jglicocola  en  la  orina  y  en  la  bills,  taurina  que  proviene  de  la  cistina  en  la 
bilis,  arginina  en  el  bazo,  etc.)  ^Qu6  se  hacen  entoncee  estos  dcidos  aminados?  Sufren 
verdaderamente  la  desamidacidn  en  el  lugar.  En  el  curso  de  la  autolisis  del  hfgado  y 
de  otros  drsanos,  los  ^dos  aminados  agrc^ados  a  los  tejidos  pierden  su  grupo  A^H'  al 
estado  de  AzH*.  Se  sabe,  ademds,  que  &  alanina  ineerida  es  trasformada  en  icido 
lictico;  despu^  de  la  separacidn  de  su  grupo  AzH'  ai  estado  de  AzH'  el  amonfaco 
es  al  punto  trasformado  en  urea,  que  se  elimina  r&pidamente  mientras  que  el  ^do 
deeaminado  es  quemado  m^  lentamente.  (Magnus  I/evy.)  La  desa8imi]aci6n  de  las 
albuminoideas  se  haifa,  pues,  por  etapas:  (1)  Desdoblamiento  en  ^idos  aminados; 

(2)  Desamidacidn  de  los  dcidos  aminados  3'  tra8formacI6n  del  amoniaco  en  urea. 

(3)  Oxidaci6n  del  &cido  desaminado. 

Pero  puede  suceder  que  esta  dialocacidn  no  sea  completa  y  que  una  fracci6n  de 
albdmina  se  escape;  se  ha  pensado,  en  vista  de  la  preeencia  de  gruesas  mol6culas 
azoadas  en  la  orina,  que  ^stas  representarlan  fragmentoe  ligeramente  oxidadoe,  sin 
haber  sido  previamente  divididas,  como  las  que  resultan  de  la  hidrolisis  por  acci6n 
diast^ca.' 

La  trasformacidn  que  lleva  la  mol^ula  albuminoidea  hasta  el  conjunto  de  despojos 
eliminables,  y  en  especial  hasta  la  urea,  se  cumple  muy  rdpidamente.  Hacia  la 
s^ptima  bora  deepu^  de  las  comidas  alcanza  su  miximun,  y  entre  la  novena  y  la 
duod^ima,  ha  terminado  su  eliminaci6n. 

La  eliminaci6n  de  los  productos  no  azoados  de  la  trasformacidn  de  las  albuminoideas 
(icido  carb6nico  y  agua),  se  verifica  por  la  via  pulmonar. 

La  gran  via  de  la  eliminaci6n  de  los  productos  azoados  es  la  orina,  pues  la  excreci6n 
por  el  tubo  digestivo  no  representa  sino  im  2  por  ciento  del  dzoe  total  perdido  por  el 
organismo;  las  otras  p^rdidas  son  todavfa  m^  pequeflas,  de  aquf  que  casi  todoe  los 
experimentadores  no  hayan  tenido  en  cuenta  sino  la  eliminaci6n  urinaria  para  medir  la 
eliminaci6n  azoada. 

Azae  total, — ^En  99  adultos  que  eligen  libremente  su  raci6n,  Pluyer,  Bleitien  y 
Blilaud,  han  encontrado  en  la  orina  de  las  24  horas  14.95  gramos,  por  t^rmino  medio, 
de  dzoe  total,  o  0.227  gramos  por  kilogramo  de  peso  vivo,  lo  que  corresponds  a  un 
consume  de  96.467  gramos  de  albtimina,  o  1.464  gramos  por  kilo  de  peso  vivo;  para  los 
individuos  j6venes  bien  alimentados  que  no  suministran  sino  im  trabajo  mecdnico 
mediocre,  la  excreci6n  azoada  de  las  24  horas  fu6  de  14.37  gramos,  que  indica  la 
de6trucci6n  de  93.7  de  albumina.  En  fin,  en  27  individuos  que  sumimstraban  im 
trabajo  considerable,  el  dzoe  total  se  elev6  a  16.68  gramos,  o  sea  0.249  gramos  por  kilo 
de  peso  vivo,  lo  que  da  una  destrucci6n  de  albtunina  de  107.60  gramos  0  1.688  gramos 
por  kilo  de  peso  vivo  por  dla.? 

Lambling  cree  que  en  Francia  no  se  puede  adoptar  como  tannine  medio  los  ndmeros 
que  se  acaban  de  leer,  los  cuales  son,  en  su  concepto,  demasiado  elevados.    El  deter- 

1  Oley,  Ph78iolog;Ie,  1910.  *  Para  oomprender  eeta  reladdn  y^ase  piglna  — . 


70  PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC   CONGRESS. 

mind  sobre  79  sujetos  de  la  clase  media  de  Lille  y  de  loe  alrededoree,  donde,  segdn 
dice,  68  general  la  costumbre  de  las  grandes  comidas,  una  cantidad  total  de  13.91 
gramoe  en  los  hombres  (50  sujetoe)  y  de  11.74  gramos  en  las  mujeres  (29  sujetos)  para  el 
perfodo  de  las  24  horas;  la  alimentaci6n  era  elegida  libremente.  Sin  embargo,  se  veri 
adelante  por  los  andlisis  hechos  tiltimamente  en  Francia  que  esta  cifra  ee  muy  superior 
a  las  que  da  Lambling. 

La  repartici6n  del  dzoe  en  laa  orinas,  en  caso  de  alimentaci6n  mixta,  es,  poco  m&  o 
menos,  la  siguiente,  segiin  el  mismo  autor: 

En  urea,  84  a  87  por  ciento.  En  amoniaco,  2  a  5  por  ciento.  En  dcido  tirico,  2  a 
3  por  ciento.    En  materias  extractivas  azoadas,  7  a  10  por  ciento. 

Estos  ntimeros  varfan  en  limites  muy  extensos,  cuando  se  pasa  de  la  alimentaci6n 
vegetal  a  la  alimentacidn  animal,  como  se  verd  por  el  cuadro  siguiente:^ 


Urea 

Amonfaco 

Otros  materlalesazoados.. 


R^men  mixto.  R^gimon  animal.  R^glmcn  vegetal. 


S6.8  (de  79.2  a  88.2)  i  80..5  (de  76.9  a  83.41 

)  I  4.29  a-    .     _        , 

8.39  (dell     a  8.2)  15.7  (de  10.5  a  17.6) 


4.84  (de   3.5  a   5.6)  |  4.29  (do   3.4  a   8.6) 


Khegnie  ha  notado  que  cuando  se  da  pan  a  un  perro,  la  secreci6n  gdstrica  es  m^a 
abundante  que  cuando  se  le  da  leche.  Partiendo  de  este  hecho,  Rjasawzeff  ha 
suministrado  a  un  perro  la  misma  cantidad  de  ^izoe  (4  gramos)  primero  en  forma  de 
pan  y  luego  en  la  de  leche;  la  cifra  de  la  excreci6n  azoada  fu^,  en  el  ensayo  del  pan 
dos  o  tres  yeces  mayor  que  en  el  ensayo  de  la  leche.  Parece,  pues,  que  existe  una 
relaci6n  directa  entre  la  intensidad  del  trabajo  secretor  impuesto  al  e8t<Smago  y  la 
cantidad  de  despojos  azoados.  El  trabajo  de  secreci6n  del  tubo  digestive,  serfa,  segtin 
eeto,  una  de  las  causae  de  la  necesidad  de  albtimina. 

Las  observaciones  sobre  eliminaci6n  azoada  deben  referiise  de  preferencia  a  la 
urea,  el  amonfaco,  el  ^do  tirico  y  las  bases  ptlricas,  el  dzoe  de  las  bases  precipitablee 
por  el  ^ido  sflicotdngstico,  y  adem^  diferentes  relacionee  de  estos  elementos  entre 
si  y  con  otros  materiales  de  eliminaci6n  urinaria.  Para  comprender  su  importanda, 
es  precise  hacer  el  resumen  del  origen  de  cada  uno  de  ellos. 

Urea. — ^La  doctrina  de  la  combusti6n  hacfa  considerar  la  urea  como  resultado  de 
la  oxidacidn  de  las  albuminoideas,  a  pesar  de  la  imposibilidad  de  producir  la  in  vitro 
por  medio  de  los  cuerpos  oxidantes,  pero  en  1856,  Beauchamp  pareci6  haber  llenado 
definitivamente  este  vaclo  con  el  descubrimiento  de  la  producci6n  in  vitros  de 
pequenas  cantidades  de  urea  por  la  oxidaci(5n  de  las  materias  albuminoideas,  en 
presencia  del  permangamato  de  potasio.  Al  aiio  siguiente  Saedeler  y  luego  Sub- 
botise  objetaron  las  conclusiones  de  Beauchamp.  El  debate,  planteado  nueva- 
mente  por  una  publicaci6n  de  Beauchamp  y  de  Ritter,  fu6  luego  considerado  defini- 
tivamente cerrado  por  los  resultados  negatives  de  !]^aen  y  de  Tapeiner. 

Se  empez6  luego  a  dar  grande  importancia  a  las  reacciones  orgdnicas  de  desdobla- 
miento  y  de  hidrataci6n,  y  bajo  la  influencia  de  los  trabajos  de  Schutzemberger, 
referentes  al  desdoblamiento  de  la  albdmina  en  presencia  del  hidrato  de  barita,  se 
lleg6  a  considerar  la  urea  como  proveniente  de  las  albuminoideas  por  simple  hidro- 
lisis.  Sobre  este  punto  los  trabajos  de  Schutzemberger  han  side  confirmados  por  loe 
de  Drechsel,  quieu  ha  podido  separar  de  la  caseina,  por  medio  del  dcido  clorhldrico, 
hirviendo,  bases  azoadas  complejas:  la  lisina  y  la  lisalinina  que  el  agua  de  barita 
desdobla  en  caliente  con  produccion  de  urea.  Por  otra  parte,  la  arginina,  una  de 
las  bases  ex6nicas,  suministrada  por  la  hidrolisis  de  las  albuminoideas,  es  igualmente 
desdoblada  por  la  barita  con  formaci6n  de  urea.  Pero  Drechsel  reconoci6,  al  mismo 
tiempo,  que  de  esta  manera  no  se  explicaba  sino  la  formacidn  de  una  pequena  canti- 
dad de  urea  en  el  organismo.    En  efecto,  en  los  experimentos  de  Schutzemberger  la 

I  Ouimiioih. 


PUBLIC   HEALTH  AND  MEDICINE.  71 

albtimina  ee  desdoblada  en  urea  y  oxiamida  (o  m^  exactamente,  en  dcido  carlxSifico 
y  amoniaco  en  las  proporciones  de  la  urea  y  de  la  oxiamida),  por  una  parte,  y  por 
otra,  en  una  mezcla  de  dcidos  aminados.  Se  puede  calcular  que  la  urea  asl  separada 
por  hidroliflis,  no  representa  sine,  aproximadamente,  un  10  por  ciento  del  dzoe  total 
y  que  86I0  los  icidos  aminados  representan  el  75  por  ciento  del  &zoe  de  la  mol^ula 
albuminoidea,  de  donde  se  deduce  que  otroe  fen6meno6,  fuera  de  la  hidrolisis,  inter- 
vienen  en  la  formaci6n  de  la  urea. 

Por  loe  experimentos  cl^icoe  de  Schultzen  y  Nenki,  se  sabla  desde  1867,  que  estos 
icidoe  aminados  pueden  constituir  un  producto  hacia  la  urea:  la  glicocola,  la  leucina, 
ingeridas,  se  trasforman  integramente  en  urea;  en  esta  observaci6n  Von  Kmerin  com- 
prendi6  el  icido  asp&rtico.  Pero  hay  que  notar  que  los  icidos  aminados  no  tienen 
aino  un  solo  dtomo  de  Az,  y  la  urea  tiene  dos;  es  necesario  admitir  entonces  la 
fijaci6n  de  otro  resto  de  Az.  Schultzen  y  Nenki  habfan  pensado  en  el  dcido  cidnico 
y  Salkowski  demostr6  que  una  parte  de  dicho  icido  se  fija  fdcilmente  in  vitro  sobre 
los  icidos  aminados,  para  dar  lugar  a  uramidos,  que  son  en  realidad  ureas  sustituidas, 
y  que,  por  otra  parte,  en  el  organismo  muchos  dcidos  aminados  se  trasforman  en 
^idos  uramfdicos  por  fijaci6n  de  dcido  cidnico  £s  este  el  ptmto  de  partida  de  otra 
teorfa  de  fonnaci6n  de  la  urea;  la  teorla  del  dcidociinico,  queexplica  laformaci6n  de  la 
urea  por  sfntesis,  semejante  a  la  sfntesis  hist6rica  de  la  urea  por  Woehler,  por  medio 
del  icido  ciinico  y  el  amoniaco.  E^sta  teorfa,  desarrollada  sobre  todo  por  Hoppe 
Seyler,  no  tiene  base  experimental  directa  en  el  sentido  de  que  jamis  se  ha  logmdo 
aialar  el  t^rmino  ciinico  como  punto  de  partida  de  toda  constituci6n. 

He  aquf ,  segdn  Gley,  los  mecanismos  por  los  cuales  los  icidos  aminados  simiinis- 
tran  urea: 

I.  Ya  se  vi6  que  se  han  encontrado  en  todos  los  6rganos,  y  principalmente  en  el 

hfgado,  diastasas  que  separan  el  dzoe  de  los  dcidos  aminados  bajo  la  forma  de  amoniaco. 

Esta  de8amidaci6n  comprende,  pues,  &zoe  del  aminodcido,  el  cual  queda  desde 

entonces  reducido  a  la  condici6n  de  un  simple  ^ido  graso,  cuyo  destino  se  confunde 

con  el  de  los  ^idos  grasos  y  las  grasas.    En  cuanto  al  amoniaco  producido,  va  a  en- 

gendrar  urea,  uni^ndose,  eegCoi  Schmildeberg,  con  el  icido  carb6nico  y  dejando  agua 

en  libertad: 

A7TT 
Urea:  2AzH,4-CO,=CO  ^^h'"*"^^"^ 

Segtin  otroB  la  urea  se  deriva  del  carbonate  de  amoniaco,  previamente  formado: 

En  loB  doB  08800  hay  Bfntesis  total  de  urea  con  deshidratacidn. 

II.  Por  otra  parte,  se  ha  obtenido  in  vitro  carbamate  de  amonio  por  oxidacidn  de 
los  icidos  aminados.  Es,  pues,  pooible  que  estos  den  por  oxidaci6n  en  el  higado, 
carbamato,  de  donde  proviene  en  seguida  la  urea  por  deshidrataci6n: 

Podrfa  suceder  tambi^n  que  sobre  el  grupd  COAz  H,  de  un  aminodcido  se  fijara 
otro  AzHa  y  que  por  una  oxidaci6n  concomitante  se  formaia  urea  (sfntesis  parcial ' 
COB  oxidaci6n).    8e  ha  mostrado,  por  ejemplo,  que  el  oxiamato  de  sodio  da  in  vitro 
urea  oxid&ndolo  por  el  permanganato  de  potaaio. 

Lambling  da  grande  importancia  a  la  primera  de  estas  teorfas  (formacidn  de  la  urea 
por  combinaci6n  de  dcido  carb6nico  con  el  amonfaco  dejando  el  agua  en  libertad)  la 
cual  ha  llamado  la  atenci6n,  dirigido  los  esfuerzos  de  los  experimentadores  y  tiene 
en  0U  favor  la  explicaci6n  de  hechoe  muy  trascendentales,  a  saber: 

1.  En  los  herbfv(»os,  la  ingestidn  de  las  sales  amoniacales,  sean  de  dddoe  fuertes, 
como  el  cloruro  de  amonio,  o  de  ^idoe  oig^cos  combustiblei,  como  el  citrato,  es 


72  PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC   C0NQBE8S. 

s^^da  de  un  aumento  de  la  urea  excretada.  En  los  camlvoroe  y  en  el  hombre  eete 
mismo  resultado  no  es  obtenido  claramente  sino  con  las  sales  amoniacales  de  ^dos 
orgdnicos,  como  el  carbonato  de  amonlaco.  La  raz6n  de  esta  diferencia  se  ver&  td&b 
adelante. 

Esta  teorfa  y  los  dos  6rdenes  de  hechos  que  se  acaban  de  sefialar,  encuentran  una 
veiificaci6n  notable  en  una  serie  de  fen6menos  relatives  a  la  acci6n  de  los  ^dos 
sobre  la  excreci6n  de  la  urea,  y  del  amoniaco.  Si  el  amonfaco  y  el  dcido  carb6nico 
son  realmente  los  precuirBores  de  la  urea,  la  presencia  de  los  ^idos  fuertes — es  decir 
de  cuerpos  capaces  de  fijar  s61idamente  el  amonfaco— debe  impedir  la  formacidn  de 
la  urea  y  aumentar  la  proporci6n  de  sales  amoniacales  en  la  orina,  esto  es  lo  que  la 
experiencia  demuestra  claramente. 

2.  Se  ha  visto,  en  efecto,  que  en  el  camivoro  el  carbonato  de  amonfaco  ingerido 
pasa  en  la  orina  al  estado  de  urea;  el  cloruro  de  amonio  pasa  inalterado  a  la  orina, 
porque  el  amonfaco,  fuertemente  retenido  por  el  dcido  clorhfdrico  no  puede  entrar 
en  reacci6n  con  el  dcido  carb6nico.  Si  en  el  herbivore  el  cloruro  de  amonio  contribuye 
a  la  formaci6n  de  la  urea,  esto  se  debe  a  que  la  alimentaci6n  vegetal  lleva  consigo 
una  superabundancia  de  bases  alcalinas  que  transformadas  en  el  organismo  en  car- 
bonate de  potasio  o  de  sodio,  hacen  la  doble  de8Compo8ici6n  con  el  cloruro  de  amonio 
y  le  transforman  en  carbonato. 

3.  Adem^,  en  el  perro  y  en  el  hombre  la  inge8ti6n  de  dcidos  minerales  aumenta 
la  cantidad  de  amonfaco  de  las  orinas  y  disminuye  la  de  la  urea  porque  el  &cido 
introducido  fija  y  retiene  fuertemente  el  amonfaco. 

Inversamente,  la  ingesti6n  de  dlcalis  en  el  hombre,  reduce  al  mfTiimiinn  la  excreci6n 
de  las  sales  amoniacales. 

Esta  neutralizaci6n  de  los  dcidos  por  el  amonfaco,  asf  sustrafdo  al  proceso  formador 
de  la  urea,  constituye  el  mecanismo  por  el  cual  el  oiganismo  de  los  camfvoros,  o  del 
hombre,  resiste  la  intoxlcaci6n  por  los  ^idos  y  preserva  de  los  accidentes  graves  que 
se  producirfan  si  las  bases  necesarias  para  el  f uncionamiento  normal  de  los  protoplasmas 
vinieran  a  ser  arrancadas  a  las  c^lulas. 

En  los  herbfvoros  este  mecanismo  regulador  no  existe.  Asf  se  ve  que  en  esos 
animales  la  intoxicaci6n  por  los  ^idos  termina  rdpidamente  en  accidentes  mortalee. 

Los  dcidos  que  se  forman  en  el  organismo,  en  el  curso  mismo  de  la  desasimilaci6n, 
producen  los  mismos  efectos  que  si  fueran  introducidos  experimentalmente.  Como 
estos  dcidos  resultan,  sobre  todo,  de  la  de8agregaci6n  de  las  albtiminas,  se  ve,  en  lo 
que  concieme  a  la  excreci6n  del  amonfaco,  que  la  alimentaci6n  animal  obra  como 
la  ingestidn  de  dcidos,  y  la  vegetal,  como  la  de  ilcalis.  Asf,  Caranda  ha  encontrado 
en  sf  mismo,  para  una  alimentaci6n  vegetal,  0  grms.  0.3998  de  amonfaco  por  dfa; 
para  una  alimentaci6n,  sobre  todo,  animal,  grms.  0.875,  y  para  una  alimentaci6n 
mixta,  grms.  0.6422. 

La  inanici6n  (que  es  una  alimentacidn  animal)  y  el  ejercicio  (que  disminuye  la 
alcalinidad  de  la  sangre)  producen  un  aumento  de  la  excreci6n  del  amonfaco,  el  que 
se  ha  visto  llegar,  en  la  inanicidn,  al  10  por  ciento  del  dzoe  total,  en  vez  de  2  a  5  por 
ciento  que  es  la  suma  normal. 

4.  Los  estados  patol6gicos,  que  causan  un  aumento  de  producci6n  de  ^dos  en  el 
oiganismo,  aumentan  la  excreci6n  del  amonfaco  por  las  orinas.  En  el  curso  de  la 
diabetes  y  especialmente  en  el  perfodo  de  coma,  la  orina  contiene  propoiciones  con- 
siderables de  amonfaco,  de  3  a  6  gramos  por  dfa,  y  en  un  case  de  Stadelmann,  hasta 
de  12,  en  vez  de  1  a  1.50,  cifra  normal.  Este  hecho  es  debido  a  la  fundicidn  r&pida  y 
anomud  de  los  protoplasmas  celulares  y  a  la  producci6n  de  cantidades  considerablee 
de  dcidos  anormales,  tales  como  el  ^ido  acetilac^tico  y  el  dcido  Boxibutfrico,  que 
inundan  literalmente  el  organismo  del  diab^tico;  y  es  precisamente  despu^  de  haber 
notado  la  presencia  de  cantidades  considerables  de  amonfaco  en  la  orina  de  los  dia- 
b6ticos,  cuando  Stadelmann  dedujo  por  este  hecho  una  intoxicaci6n  dcida  y  enconthS 
de6pu69  el  ^ido  Boxibutfrico.    Las  cantidades  de  este  dcido  son  frecuentemente. 


PUBLIO  HEALTH  AND  MEDICINE.  73 

en  la  orina  de  los  diab^ticoe,  de  30  a  50  gramoe.    Este  grado  de  intoxicacidn  &cida 
da,  pues,  la  explicacidn  de  la  amoniuria  diabetica. 

Se  sabe  que  eetas  reacciones,  que  dan  lugar  a  la  {onnaci6n  de  urea,  se  verifican, 
cad  en  su  totaUdad,  en  el  hiigado. 

Loe  experimentoe  por  medio  de  Ice  cualee  se  demuestra  que  eete  ee  el  lugar  de  tal 
fonnaci6n,  son  suficientemente  conocidoe,  para  no  detenerme  a  relatarlos. 

Amomaco, — ^Al  lado  de  la  urea  debe  hacerse  menci6n  especial  del  amoniaco,  que 
se  encuentra  siempre  en  la  orina  en  pequefias  cantidades  (1.11  gramos  en  24  horas, 
9egtin  Maillard);  esta  cantidad  representa  la  parte  del  amoniaco  que  no  se  ha  empleado 
en  la  formaci6n  de  la  urea. 

En  sua  investigaciones  cMsicas  sobre  los  efectoe  de  la  fistula  de  Eck,  Nenky  y 
Pawloff  ban  visto,  con  su  colaborador  Zaleski,  que  el  hfgado  recibe  por  la  vena  porta, 
aproximadamente,  6.6  gramos  de  amoniaco  por  100  c.  c.  de  sangre;  en  la  vena  supra- 
hepdtica  no  se  encuentran  m^  de  1.4  gramos,  de  donde  se  ha  calculado,  segtln  la 
velocidad  de  la  sangre  al  trav^  del  hljgado,  que  este  6rgano  retiene,  en  las  10  boras 
que  siguen  a  una  comida,  en  un  perro  9.5  de  kilos,  aproximadamente,  5  gramos  de 
amonlikco,  lo  que  correeponde  a  jd&b  de  8  gramos  de  urea.  Al  hablar  del  origen  de  la 
urea  se  vi6  cual  es  el  origen  del  amoniaco;  se  vi6  c6mo  y  por  qu6  la  eliminacidn  de  las 
sales  amoniacales  aumenta  o  disminuye,  segdn  que  la  alimentaci6n  sea  animal  o 
vegetal,  6cida  o  alcalina. 

M^  adelante  hablar^  del  Indice  de  imperfecci6n  urogen^tica  de  Maillard,  basado 
sobre  la  relaci6n  entre  el  &zoe  del  amoniaco  y  ^te,  mis  el  &zoe  de  la  urea. 

Acido  iirico  y  hates  piincaa. — Las  nucleo-proteidas  constituyen  un  grupo  muy  im- 
portante.  Son  estas  siistancias  las  que  forman  la  mayor  parte  de  los  grupos  celulares. 
No  hay  que  conlundirlas  con  las  nucleo-alb(iminas  o  peeudonucleinas,  entre  las 
cualee  se  encuentran  la  vitelina  y  la  caseina. 

Oomo  las  nucleo-proteidas,  las  pseudo-nucleinas  contienen  fdsforo,  pero  no  encierran 
purinas;  eetos  cuerpoe  parecen  ser  los  caracterlsticos  de  las  nucleo-proteidas,  o  a  lo 
menoe  del  ^do  nuclelnico  que  entra  en  su  con8tituci6n.^ 

Las  nucleo-pioteidas  son  esendalmente  formadas  por  la  uni6n  del  icido  nuclelnico 
con  diferentee  mateiias  proteicas,  y  como  estas  son  extremadamente  variables,  se 
condbe  que  las  nuclo-proteidas  sean  muy  numeroeas. 

Bajo  la  influencia  de  ciertos  reactivoe  qulmicos  por  la  accidn  del  jugo  g^istrico  en  el 
oiganiamo,  las  nucleo-proteidas  abandonan  un  grupo  proteico  y  queda  un  cuerpo 
llamado  nucleina,  que  se  deecompone,  a  su  tumo,  en  albtimina  y  en  ^ido  nucleico. 
Este  tiltimo  suministra  cuatro  especies  de  cuerpoe:  ^do  fosf6rico,  derivados  piriml- 
dicoe,  bases  x^ticas  e  hidratos  de  carbono. 

Pero  algunas  de  las  proteidas  son  mds  complejas  de  lo  que  indica  esta  f6rmula;  la 
nucleina,  adem^  de  la  albtimina  y  del  dcido  nucleico,  puede  contener  hipoxantina 
y  bases  diferentes,  tales  como  creatina,  camadna  ignotina,  novaina. '  Eptos  cuerpos, 
que  no  son  unidos  al  &cido  nucleico,  son,  sobre  todo,  abimdantee  en  las  nucleo-proteidas 
sacadaa  de  loe  m(!i8culos. 

£n  el  tube  digestive,  las  albtiminas  puestas  en  libertad  por  el  jugo  g^trico,  son 
trBsformadas,  segdn  el  i^oceeo  habitual,  por  la  clorhidro-pepsina,  y  en  cuanto  al 
^kddo  nuclelnico,  es  deecompuesto  por  un  fermento,  muy  extendido  en  el  organismo; 
la  nucleasa,  en  sua  componentes,  que  son:  ^do  fosf6rico,  un  azdcar,  adenina,  guanina, 
citoeina  y  elurina. 

El  icido  fosfdrico,  que  es  ^undo  ortofosfdrico,  proviene  del  ^do  tlmico,  el  cual 
encierra  todo  el  fdsforo  de  las  nucleo-proteidas.  El  azticar  no  es  conocido  sine  por 
8U8  productos  de  desdoblamiento.  La  citosina  y  la  timina,  derivados  primaries  del 
^tcido  nucleico.  La  uracila  es  un  derivado  secundario.  Estos  tres  dltimos  cuerpos 
son  semejantes  a  la  pirimidina. 

Los  cuerpos  pirimidicos  parecen  muy  inestablee;  en  el  organismo  se  destruyen 
ripidamente,  abandonando  ^do  carb6nico  y  urea. 

1  ProL  0.  H.  Rogert,  Digestion  at  Nutrition,  p&g.  518, 1910. 


74  PBOOEEDINOS  SECOND  PAN  AMEBICAN  SCIENTIFIC  CONQBESS. 

Mds  importante  es  el  eetudio  de  la  adenina  y  de  la  gnanina.  Estaa  doe  sustanciaa 
pertenecen  a  las  bases  ptiricas,  de  las  que  hace  tambi^n  parte  el  ^do  <!irico. 

Fu^  Fischer  quien  e8tableci6  la  eetructura  definitiva  de  la  punna.  Todas  per- 
tenecen a  una  misma  serie,  que  encierra  este  nticleo: 

(1)  Az-0  (6) 

(2)  0  (5)— Az  (7) 
0(8) 

(3)  Az— (4)  0— Az  (9) 

La  numeraci6n  que  se  ha  adoptado  ^  ^Molita  el  estudio  de  loe  derivados.  Basta, 
en  efecto,  indicar  para  cada  cuerpo  el  ntimero  correspondiente  a  los  productoe  de 
Bustituci6n,  para  comprender  la  poeici6n  exacta. 

£1  compuesto  hidrogenado  fundamental  ha  redbido  de  Fischer  el  nombre  de 
purina.  Conociendo  la  con8tituci6n  de  ^ste,  se  puede  comprender  Mdlmente  cuil 
es  la  de  loe  derivados. 

(^)  ^'=^^  W  AzH  (7) 

(^)  g^-^  (^)  CH  (8) 

(3)  AzC  (4) 

Purina  C»H*-Az*  ^*  ^^^ 

La  adenina,  por  ejemplo,  se  llama  (6)  amido-purina,  porque  resulta  de  la  sustitucidn 
del  gnipo  (6)  CH  de  la  purina  por  un  radical  amido  (AzH,),  de  tal  manera  que  la 
formula  queda:  CgHsAzg. 

De  la  misma  manera  se  puede  comprender,  por  el  simple  nombre,  la  constituci6n 
de  todos  los  dem^  derivados;  (6)  oxipurina  o  hipoxantina,  reemplazando  un  H  del 
grupo  6  por  un  0  (C*H*Az*0)  2  amido,  6  oxipurina,  o  guanina  (C'H'Az'O)— 2,  6 
dioxipurina  o  xantina  (C^*Az*0")-6  amido  2,  8  dioxipurina  (C»H»Az*0»)-2,  6,  8 
trioxipurina  (CH^AzH)')  icido  tirico,  etc.  Siguen  luego  hadendo  las  sustitudones 
los  otros  derivados  metilados  (monometilxantina,  paraxantina,  teobromina,  teofilina* 
cafeina),  cuyos  nombres  qufmicos  no  doy  por  no  alaigarme  demasiado. 

Las  purinas  del  oiganismo  provienen:  (1)  De  la  desintegrad6n  de  las  nudeo- 
proteidas  de  loe  alimentos;  (2)  de  la  desint^raci6n  de  las  nudeo-proteidas  de  los 
tejidos.  A  estas  dos  fuentes  hay  que  agregar  una  tercera:  la  que  resulta  de  la  intro- 
ducci6n  de  derivados  pdricos,  tales  como  teobromina,  cafeina,  etc.,  una  parte  de  las 
cuales  es  eliminada  por  las  orinas.  Los  fermentos  que  descompomen  las  nucleo- 
proteidas  y  ponen  el  dddo  nucl^ico  en  libertad,  son  abundantemente  extendidoe; 
pues  no  solamente  los  jugos  digestives,  sine  todos  loe  6rganos  y  tejidos,  son  capacee 
de  producir  tales  desdoblamientos.  Este  es  un  proceso  indispensable  para  el  juego 
natural  de  la  desasimilacidn. 

El  fermento  que  deecompone  el  dcido  nud^nico,  la  nucleasa,  se  encuentra  en  el 
time,  el  bazo,  el  ptocreas,  la  mucosa  del  intestino  delgado,  como  tambi^n  en  los 
m(isculos,  los  gl6bulos  nucleados  de  las  aves;  en  una  palabra,  la  nucleasa  existe  donde 
quiera  que  existan  nucleo-proteidas. 

El  jugo  pancre&tico  no  descompone  el  dddo  nuclefnico;  le  hace  solamente  perder 
su  car&cter  coloidal  y  lo  vuelve  dializable;  es  lo  que  algunos  autoree  expreean  diciendo 
que  cambia  el  ^ido  nudeinico  a  en  iddo  nuclefnico  b.  Esta  trasformad6n  permite 
al  &cido  nudefnico  difundirse  en  la  pared  intestinal.  Allf  se  encuentra  con  la  nucleasa 
y  a  favor  de  esta  acci6n  pone  en  libertad  sue  diversos  componentee. 

El  t^rmino  dltimo  de  la  t3*asformad6n  de  las  bases  ptiricas  es  el  dcido  drico,  para 
lo  cual  interviene  la  acd6n  sucesiva  de  dos  espedes  de  fermentos:  uno  desamidante 
y  otro  oxidante. 


1  Prof.  C.  H.  Roger,  Digestion  et  nutrition,  p&g.  621, 1910. 


PUBLIC  HEALTH  AND  MEDICINE.  75 

Los  fermentoB  desamidantes  trasfonnan  la  adenina  y  la  guanina — o  sean  los  pro- 
ductos  piimarioe  que  provienen  del  dcido  nucleinico — el  primero  en  hipoxantina  y 
el  8^:undo  en  xantina.    Un  simple  proceso  de  hidraci6n  da  cuenta  del  fen6nemo 

Adenina.  Hipoxantina. 

C^^Az'-fH'O^C^H^Az^O-fAzH' 

Guanina.  Xantina. 

C»H»Az»0+H20=C«H*Az*0+AzH» 

Como  88  ve,  el  amido,  que  ocupa  la  poeici6n  6  en  la  adenina  y  la  posicidn  2  en  la 
guanina,  se  elimina  al  estado  de  amonlaco. 

Los  fermentos  desamidantes,  adenasa  y  guanasa,  descubiertos  en  el  bazo,  se  encuen- 
tran  en  la  mayor  parte  de  los  6rgano8. 

Los  fermentos  oxidantes  son  tambi6n  en  ndmero  de  dos:  la  xantoxidasa,  que  oxida 
la  xantina  y  la  trasforma  en  dcido  tirico  y  la  hipoxantidasa,  que  hace  lo  mismo  con  la 
hipoxantina.  Estos  fermentos  oxidantes  no  son  tan  extendidos  como  los  precedentes; 
se  les  encuentra  solamente  en  el  bazo,  el  hfgado,  el  intestino,  los  rifiones,  los  pulmones 
y  los  mtisculos. 

Una  pcurte  del  icido  (irico  es  trasformada  en  el  hfgado  en  urea,  segun  lo  creen  todavfa 
algunos  autores.  Pero  esto  no  quiere  decir  que,  como  se  crefa  antiguamente,  el  dddo 
tanco  sea  un  producto  hacia  la  lurea,  pues  jra  que  se  conocen  bien  todas  las  trasforma- 
dones  de  los  nucleo-proteidos  y  las  de  las  bases  ptiricas,  se  ha  visto  que  todos  estos 
cuerpos  terminan  en  el  &cido  tirico,  que  es  el  tannine  final  de  la  serie,  como  la  urea 
es  el  t6rmino  tUtimo  de  las  trasformaciones  que  sufren  las  albdminas.^  Esto  me  ha 
•ugerido  la  idea  de  un  nuevo  coeficiente  urol6gico,  de  que  hablar^  m^  adelante. 

Asoe  nlicot&ngsiico, — Se  sabe  que,  sdemia  de  los  cuerpos  azoados  de  funci6n  dcida, 
como  el  dcido  drico,  o  de  funci6n  d^bilmente  b&sica,  como  la  urea,  la  orina  encierra 
ciertas  substancias  suficientemente  b&sicas  para  formar  con  el  dcido  silicottingstico 
combinacionee  muy  poco  solubles  o  priUrticamente  insolubles,  an^ogas  a  las  com- 
binadones  silicotdngsticas  alcal6idicas  estudiadas  por  R.  Grodefoy  y  por  G.  Bertrand. 

Un  eetudio  cuantitativo  de  estas  bases  urinarias  fu^  hecho  por  Guillemard,'  quien 
encontnS  variadones  importantes,  segtin  el  estado  normal  o  patol6gico  de  los  individuos, 
y  diferencias  apreciables  segtin  el  sistema  alimentido.  Posteriormente  MaiUard  ' 
hizo,  a  este  respecto,  observadones  muy  interesantes  y  encontrd  ima  eliminaci6n 
media  de  0.60  c.  c,  en  las  24  horas,  de  este  dzoe  que  para  abreviar  se  ha  llamado 
incorrectamente  dddo  silicottingstico,  por  ser  este  dcido  el  que  sirve  para  precipitarlo. 

De  las  relaciones  urol6gicas  hablar^  en  el  capitulo  siguiente. 

EuMiNAadN  AzoABA  SN  LA  Ai;nPLANiciE — ^Procbdimientos  Empleabos — Resulta- 

D08  ObTENIDOS. 

Es  el  andlisis  qui mico  de  ias  orinas,  dice  Marcel  Labb^,^  lo  que  simiinistra  datos  m&s 
numeroeos  y  mis  precisos  en  el  estudio  de  la  nutrici6n.  Desde  la  m^  remota  antigQe- 
dad,  los  medicos  lo  ban  utilizado  en  la  solucidn  de  los  problemas  m^  complicados. 
Los  m^todos,  muy  rudimentarios  al  principio,  han  ido  perfecciondndose  poco  a  poco. 

La  importancia  de  este  estudio  adquiere  mayor  inters  desde  que  se  trata  de 
materiales  azoadoe,  puesto  que,  segtin  se  vi6  atrds,  la  gran  via  de  eliminacidn  de  estos 
productoe  es  la  orina. 

Mis  observaciones  sobre  esta  materia  se  iundan  sobre  96  andlisis  de  orinas  de  indi- 
viduos en  estado  fisiol^gico.  Todos  los  sujetos  fueron  examinadoe  previamente,  y 
hasta  donde  es  posible  afirmar,  despu^  de  im  examen  detenido,  en  ninguno  de  ellos 
se  descubrid  nada  que  hiciera  pensar  en  una  alterad6n  de  la  salud.    Hasta  donde 

1  Roger,  Loc.  dt. 

s  Quillemard,  Contribution  &  r6tude  des  alcaloides  de  Torine,  thtee  de  Paris,  10Q2. 

s  Msillard,  Joorn.  de  Phys.  et  de  Pat.  06n.,  15  nov.  9Q6.-15  mars  1909. 

« H.  LabMy  Des  rfiglmes  alimentaires. 


76  PBOOEEDINQS  SEOOKD  PAN  AMEBIOAN  SOIBNTIFIO  C0KGBB88. 

me  fu^  poBible,  vigils  la  colerci6n  de  las  oiiiias,  y  a  aquellos  en  quienes  no  se  pudo 
verificar  esta  vigilanda,  se  lee  dieron  las  inetrucciones  necesarias  a  fin  de  que  se  recogie- 
ran  con  el  mayor  cuidado  colectando  winas  de  las  24  hotas,  y  nada  m&B  que  las  de  las 
24hoias. 

Con  tal  objeto,  las  orlnas  se  debfan  recoger  en  vasijas  lo  mejcv  lavadas  que  fueia 
posible.  Una  primera  mixi6n  serla  ejecutada  a  una  bora  cualquiera,  y  de  esa  hoza 
en  adelante  se  empezarfa  a  recoger  la  orina  basta  el  dfa  siguiente  a  la  mismabora,  eai 
que  se  recogerla  la  tiltima  porcidn  que  bubiera  en  eee  momento  en  la  vejlga,  t^endo 
cuidado  de  no  dejar  perder  la  que  se  emitiera  durante  las  deposiciones. 

Si  se  consideran  las  dificultades  para  conseguir  orina  en  estas  condiciones  y  si  se 
tiene  en  cuenta  que  para  bacer  eetos  an^disis  tuve  que  empezar  por  preparar  y  titular 
desde  el  primero  basta  el  tiltimo  de  los  reactivos,  teniendo,  algunas  voces,  que  preparar 
materiaB  primas  que  no  se  encuentran  en  Bogota,  se  comprenderd  por  qu^  gast^ 
una  cantidad  de  tiempo  increfble  en  verificar  estoe  anAlisis  y  por  qu4  no  alcanc6  a  Uegar  al 
ndmero  de  100,  que  me  bab(a  fijado  como  mfnimim  cuando  principi^  mis  observaciones. 

Las  orinas  de  los  andlisis  becbos  en  Bogota,  pertenecen,  unas  a  obreros  o  a  sirvientes, 
algunos  de  ellos  asistentes  del  bospital  y  otras,  las  provenientee  de  la  clase  acomodada, 
pertenecen,  en  su  mayor  parte,  a  estudiantes  y  m^icos  y  a  algunos  pocoe  comerci- 
antes.    Estas  dltimas  fueron  mia  escasas  por  la  mayor  dificultad  paia  conseguirlas. 

Los  anjjliflis  de  Timja  pertenecen  mucbos  de  ellos  a  individuos  de  clase  social 
acomodada  cuyas  orinas  be  podido  conseguir  y  recoger  minuciosamente,  como  m^ico 
que  soy  de  algunas  compafiias  de  seguroe;  otras  de  estas  orinas  pertenecen  a  soldados 
de  la  unidad  del  ej^rcito  que  presta  la  guamicidn  en  esta  ciudad. 

Estos  tiltimos  individuos  est&n  alimentadoe  con  el  r^imen  que  se  indicari  m^s 
adelante,  regimen  que  por  ser  algo  superior  al  usado  generalmente  por  nuestras  clases 
trabajadoras,  no  me  ba  parecido  l(5gico  incluir,  por  lo  que  a  sus  anAlisis  de  bus  orinas 
respecta,  entre  estaa 

Por  esta  circunstancia  y  por  ser  relativamente  pequefio  el  ndmero  de  mis  observa- 
ciones de  Tunja,  be  resuelto  no  dividir  en  doe  partes  los  cuadros,  como  los  de  Bogot4, 
sine  sacar  un  promedio  general  de  todos  ellos. 

MfrroDos  Emflsados. 

Los  andlisis  de  las  orinas  se  ban  dirigido  a  los  siguientes  puntos:  volumen  de  la 
orina  emitida  en  24  boras;  densidad,  acidez  (expreeada  en  bidr6geno),  amonfaco, 
urea,  purinas  totales  (expreeadas  en  dcido  tirico),  dcido  tirico,  bases  puricas  (expre- 
sadas  en  xantina),  dzoe  total,  dzoe  amoniacal,  4zoe  de  la  urea,  &zoe  purico  total, 
(nticleo  purico  solamente)  ^oe  del  dcido  tirico,  dzoe  de  las  bases  puricas,  anbfdrido 
fo8f6rico  para  efectos  de  la  relaci6n  at6mica.    P:  Az.  Belaciones  urinarias. 

Para  inveetigar  estoe  diversos  elementos  be  querido  emplear  los  m^todos  mia  exactos 
y  al  mismo  tiempo  los  menos  complicadoe.    He  aqui  la  de8cripci6n  de  ellos: 

Acidez. — Slguiendo  el  precepto  de  Maillard  respecto  a  la  acidez  de  la  orina,  de  que 
no  bay  m^todo  que  no  adolezca  de  empirismo,  be  resuelto  emplear  el  m6todo  directo 
con  fenoltaleina,  porque  segdn  el  mismo  autor,  no  es  menos  bueno  que  los  otros,  y  por 
que,  segtin  se  verd  m4s  adelante,  constituye  la  primera  operaci6n  paia  la  dosificacidn 
del  amonfaco. 

Se  toman  10  c.  c.  de  orina  y  se  colocan  en  un  globo  aforado  a  100  c.  c.  se  completa 
el  volumen  basta  la  Ifnea  del  globo,  con  agua  destilada.  La  mezcla  se  coloca  en  una 
fiola  de  Erlenmeyer  y  se  ie  agregan  imas  tres  o  cuatro  gotas  de  soluci6n  alcob61ica  de 
fenolteneina  al  1  por  ciento;  despu6s  se  vierte  gota  a  gota,  con  una  bureta  de  Gay 
Lisac,  soluci6n  decinormal  de  soda  basta  la  aparici6n  del  tinte  d^bilmente  rosado. 

Para  obtener  la  acidez,  en  gramos,  de  bidrdgeno  por  litre,  se  multiplica  por  0.01 
el  ntimero  de  c.  c.  que  se  bayan  gastado  de  la  soluci6n  de  soda.^ 

>  AlgnnoB  ftatora  aoonaejan  agregar  6  grms.  de  oxalato  de  jwUsio  para  preolpitar  las  sales  de  oaloio 
las  que  obrarlan  sobre  los  f  osDatos  ouando  se  agrega  la  soda. 


FUBUO  HEALTH  AKD  MEDIdKB.  77 

Atoe  total.— Ei  mismo  procedimiento  de  Ejeldahl  de  que  ya  hsihU  atr^  con 
algunas  variaciones. 

La  reacoidn  se  efecttia  con  20  c.  c.  de  orina,  5  c.  c.  de  Boluci6n  al  30  por  ciento  de 
oxalato  neutro  de  potado  y  5  c.  c.  de  &cido  sulMrico  puro.  La  eepuma  que  se  fonna 
baja  casi  siempre  espont&neamente  y  es  raro  que  haya  que  agregar  alcohol,  como 
cuando  se  trata  de  materias  alimenticias. 

Una  vez  descolorado  el  Ifquido,  se  deja  enfriar,  como  de  coetumbre,  agregindole 
unos  30  c.  c.  de  agua  tibia. 

Se  pone  luego  unas  gotas  de  soluci6n  de  fenoltaleina  y  se  agrega,  gota  a  gota,  una 
lejfa  de  soda  exenta  de  carbonato  y  de  1.15  de  densidad,  hasta  que  aparezca  la  colo- 
raci6n  d^bilmente  rosada;  tan  d^bilmente,  que  desaparezca  con  3  6  4  gotas  de  icido 
sulMrico  al  d^cimo;  despu^s  se  completa  el  volumen  a  100  c.  c.  en  un  globo  aforado. 

Para  averiguar  la  cantidad  de  dzoe  en  eete  licor,  se  opera  por  comparaci6n  con  una 
soluci6n  titulada  de  cloruro  de  amonio,  al  7.65  por  ciento,  de  tal  manera  que  5  c.  c.  de 
eeta  solucidn,  al  deecomponerse  por  el  hipobromito  de  sodio,  dan  exactamente  0.1 
gramo  de  &zoe.  Se  introducen,  pues,  en  el  ure6metro  5  c.  c.  de  esta  soluci6n,  como  si 
se  tratara  de  medir  urea  y  luego  se  hace  lo  mismo  con  5  c.  c.  del  Uquido  que  resulta 
de  la  reacci6n,  que  equivalen  alec,  de  orina.  Una  simple  relacidn  respecto  a  los 
Yoltimenes  ocupadoe  en  cada  operaci6n  por  el  &£oe  desprendido,  mostrar&  el  dzoe 
contenido  en  1  c.  c.  de  orina. 

Amoniaeo. — Se  sabe  que  todoe  los  m^todos  que  consisten  en  destilar  la  orina  en 
preeencia  de  dlcalis,  de  cal  o  de  magnesia,  de  carbonatos  alcalinoe  o  atin  terroeoe,  dan 
resultadoe  err6neoe,  por  exceso,  a  causa  de  una  hidrolisis  parcial  de  la  urea.  Y  no  es 
verdad,  segtin  Maillard,  que  la  deetilacidn  en  presencia  del  carbonato  de  sodio  o  de 
magnesio  en  el  vado  y  a  45^  o  50^,  est^  al  abrigo  de  estas  causae  de  error.  Los  otros 
m^todoB,  si  no  son  susceptibles  de  erroree  quimicoe,  lo  son  de  erroree  biol6gicoe. 

£1  m^todo  de  Ronchese,  uno  de  los  m&s  recientes,  es  justamente  elogiado  por  Mail- 
lard,  Jones  y  por  Guiard  y  Grimbert;  ^  tiene  la  inmensa  ventaja  de  ser  muy  exacto, 
muy  senciUo  y  muy  rdpido. 

Se  sabe,  desde  los  trabajos  de  Detepine  y  de  Cambier  y  Brodiet,  que  las  sales  amonia- 
cales  son  trasformadas  por  al  aldheida  f6rmica  en  sales  de  una  nueva  base,  la  exame- 
tileneamida;  como  esta  no  suire  la  influencia  de  la  fenoltaleina,  los  ^idos  primitiva- 
mente  combinados  al  amonfaco,  se  comportan  con  este  indicador  como  si  estuvieran 
libree;  de  modo  que  para  encontrar  la  neutralidad  a  la  fenoltaleina,  previamente 
comprobada,  hay  que  agregar  una  8oluci6n  decinormal  de  soda,  precisamente  equiva- 
lente  a  la  cantidad  de  amonfaco.  Este  m^todo  tiene  adem^  la  inmensa  ventaja  de 
dosar  al  mismo  tiempo  los  dcidos  aminados. 

Diez  c.  c.  de  orina  se  aumentan  con  agua  destilada,  recientemente  hervida  para 
que  no  contenga  carbonatos,  hasta  completar  el  volumen  de  100  c.  c,  y  se  neutraliza, 
como  ya  dije  al  hablar  de  la  detenninaci6n  de  la  acidez.  Por  otra  parte,  se  neutralizan 
de  la  misma  manera  20  c.  c.  de  aldheida  f6rmica  al  20  por  ciento  (formol  del  comercio 
dilufdo  de  su  volumen  de  agua).  Se  mezclan  entonces  estas  dos  soluciones,  y  como 
se  verifica  entonces  la  reacci6n  que  pone  en  llbertad  los  ^idoe  de  las  sales  amoniacales, 
los  Ifquidos  pierden  instantdneamente  el  color  roeado.  Basta  entonces  neutralizar 
de  nuevo  estos  dcidos  con  soda  decinormal,  para  saber  la  cantidad  de  amoniaco  em- 
pleada  en  cada  litre  de  orina,  pues  no  hay  sine  que  multiplicar  por  0.17  el  ntimero 
de  c.  c.  de  Boluci6n  de  soda  empleados.  Pero  como  las  sales  amoniacales  hacen  retardar 
un  poco  la  aparici6n  del  tinte  roeado,  hay  que  agregar  0.1  por  cada  3  c.  c.  de  soda 
gastadoe  en  la  neutralizaci6n  final. 

Urea. — ^Mail]^,  en  un  trabajo  citado  antes,  emple6  para  medir  la  urea  en  la  orina, 
el  m^todo  de  Folin,  que  estd  fundado  en  la  hidrolisis  de  la  urea  por  el  cloruro  de 
magnesio,  fundido  a  160^.  Se  dosa  luego  el  amonfaco  por  destilaci6n  sobre  el  dcido 
sulfdrico  cuartonormal.    Del  resultado  hay  que  deducir  el  amonfaco  de  la  orina, 


t  Qaiart,  at  Qrlmbert,  Diagnostiqae  ohimique,  1912,  HaiUard,  loo.  oit. 


78  PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC   CONGRESS. 

previamente  medido.  L.  G.  de  Saint-Martin  prefiere  al  cloruro  de  magnesio  el  de 
litio.  El  m^todo  de  la  descomposicibn  y  dosado  por  la  ureasa  es  bastante  precieo 
aunque  lento. 

El  dosado  gaaom^trico  ha  sido  objeto  de  graves  crlticaa;  sin  embargo,  estas  crfticas 
ban  sido  quiz4  exageradas,  como  lo  prueba  la  concordancia  de  los  resultados  obtenidos 
por  Maillard  y  los  obtenidos  por  Desgrez  y  Ayrignac.*  En  favor  de  la  rehabilitaci6n 
de  este  m6todo  estd  tambi^n  la  tesis  de  Ronchese.' 

Resolvl  emplear  el  m^todo  gasom^trico,  porque  si  es  verdad  que  adolece  de  muchos 
errores,  ellos  pueden  corregirse  fdcilmente. 

Este  m6todo  estd  fundado  en  la  de8compo8ici6n  de  la  urea  por  el  hipobromito  de 
soda,  en  dzoe,  dcido  carb6nico  y  agua;  el  dcido  carb6nico  ee  retenido,  si  se  opera^ 
con  un  exceso  de  soda,  y  el  volumen  del  dzoe  puesto  en  libertad  es  proporcional  a  la 
cantidad  de  urea  contenida  en  la  orina  empleada. 

Los  aparatos  destinados  a  medir  el  dzoe  son  muchos;  yo  emple^  para  estos  andlisis, 
como  para  el  dosado  del  dzoe  total,  uno  construido  por  el  sefior  R.  Ferreira,  segdn  el 
modelo  de  Mercier  o  del  doctor  Montoya,  compuesto  de  un  tubo  en  U,  con  un  Ifquido 
en  su  interior  y  una  de  sus  ramas  en  comunicaci6n  con  un  frasco  donde  se  efectua  la 
reacci6n.  La  graduaci6n  es  arbitraria,  m^  adelante  se  comprenderd  por  qu^.  Laa 
uniones  son  muy  herm^ticas  para  evitar  el  menor  escape  de  gas.. 

Uno  de  los  inconvenientes  de  este  m^todo  consiste  en  que  los  resultados  son  variables, 
como  son  variables  la  pre8i6n  y  la  temperatura.  Psura  subsanarlo  se  emplea  una 
soluci6n  tenue  de  urea  al  2  por  mil  (adicionada  de  unos  4  a  6  por  1,000  de  fenol  puro 
para  asegurar  su  conservaci6n)  con  la  cual  se  hace  un  an&lisis,  inmediatamente  antes 
del  de  la  orina.  Sabiendo  que  5  c.  c.  de  la  soluci6n  equivalen  a  O.OI  de  urea,  se  puede, 
por  cdlculo,  deducir  la  cantidad  de  urea  contenida  en  el  volumen  de  orina  empleado. 
La  correcci6n  que  se  hace  de  esta  manera  respecto  a  la  presidn  y  a  la  temperatura  es 
tan  considerable,  que  sobre  una  misma  orina  hice  el  mismo  andlisis  por  el  m^todo  de 
Folin  y  lu^o  por  el  m^todo  gasom^trico,  operando  comparativemente  con  la  soluci6n 
de  urea  en  un  aparato  calculado  para  0.560  c.  c.  de  presidn  y  15^  de  temperatura,  cifras 
que  se  consideran  como  medias  en  Bogotd.  El  resultado  fu^,  en  el  primer  case, 
4.998  gramos  por  litro,  en  el  segundo  5.8  gramos  por  litro,  y  segun  el  ndmero  que 
correspondfa  al  c&lculo  del  aparato,  8.50. 

Otra  causa  de  error  consiste  en  que  la  urea  no  desprende  todo  el  4zoe;  para  reme- 
diar  esto,  muchos  au tores  emplean  una  pequefia  cantidad  de  glucosa;  pero  haciendo  el 
anAlisifl  por  comparaci6n  con  la  solucidn  de  urea,  el  inconveniente  queda  subsanado. 

Por  otra  parte,  el  hipobromito  no  obra  solamente  sobre  la  iirea  sine  tambi^n  pone 
en  libertad  el  dzoe  del  dcido  tirico,  de  la  creatinina  y  de  las  sales  amoniacales.  Para 
eliminar  el  error  debido  al  dcido  tkico,  se  defeca  previamente  la  orina  por  el  subace- 
tato  de  plomo;  otros  emplean  el  ^do  fosfotilnt^co.  El  error  debido  al  amoniaco  se 
subsana  dosando  el  amoniaco  por  el  procedimiento  de  Ronchese  y  relacionando  la 
cifra  urea,  segtin  la  f6rmula:  Az  H'X0.1764 — ^Urea.  En  cuanto  al  error  debido  a  la 
creatina,  es  muy  pequeno  para  que  merezca  tenerse  en  cuenta. 

Acido  iirico. — A  causa  de  los  muchos  m^todos  que  hay  actualmente  en  boga  para 
dosar  el  icido  drico,  hube  de  escQger  varios  para  emplear  el  m^  preciso.  El  primero 
que  emplee  fu^  un  procedimiento,  tamhi^n  de  Ronchese,  que  est&  fundado  sobre  la 
precipitaci6n  del  dcido  tirico  al  estado  de  urato  de  amoniaco,  por  el  cloruro  de  amonio; 
este  precipitado  se  lava  con  una  soluci6n  de  amoniaco  y  de  cloruro  de  amonio  y 
luego  se  disuelve  a  favor  de  un  poco  de  ^do  ac^tico  adicionado  de  biborato  y  de 
bicarbonate  de  sodio.    En  el  Ifquido  asf  preparado,  se  agrega  poco  a  poco,  soluci^n 


t  A.  Desgres  j  J.  Ayrignac,  De  rinfluence  da  regime  alimentaire  sur  la  valeur  des  ooefiQcfcnts  urologiques 
3,  R.  Acad.,  1906,  pag.  162. 

*  A.  D.  Ronchese,  Mdthode  de  dosage  de  quelquee  compost  asot^  Thdses  de  pharm.,  Paris,  pags. 
43-49. 


PUBLIC   HEALTH  AND  MEDICINE.  79 

decinonnal  de  yodo  con  agua  de  almid6n  como  indicador  hasta  la  coloraci6n  azul. 
Cada  centlmetro  ctibico  de  8oluci6n  empleada  equivale  a  0.0084  de  dcido  ilrico. 

Este  m^todo  Uene  sus  causas  de  error  por  la  descomposicidn,  a  veces  muy  rdpida, 
del  yodiiro  de  alinid6n,  que  hace  que  ee  agregue  un  exceso  de  solucidn  de  yodo. 

El  m^todo  del  uric6metro  con  sulfuro  de  carbono  como  indicador,  es  tambi^n  muy 
poco  preciso,  pues  a  causa  de  la  falta  de  sensibilidad  del  indicador,  se  cometen  errores 
por  exceso. 

Mltodo  de  Folin  Schoffer. — Despu^s  de  la  defecaci6n  de  la  orina  por  el  reactive  de 
Folin  (sulfate  de  amonio  y  acetate  de  uranio)  se  precipita  el  urate  de  amoniaco  sobre 
100  c.  c;  el  precipitado  se  recoge  sobre  un  filtro,  ee  lava  y  se  disuelve  en  un  medio 
sulMrico  donde  se  dosa  el  dcido  Virico  por  una  solucidn  titulada  de  permanganate  de 
potasio  hasta  la  no  descoloraci6n;  1  c.  c.  de  la  soluci6n=0.000375  de  dcido  Virico.  Este 
m6todo  tiene  el  grave  inconveniente  de  que  la  soluci6n  de  permanganate  se  altera 
muy  r&pidamente  y  hay  necesidad  de  titularla  con  frecuencia. 

El  procedimiento  que  elegf,  por  parecerme  el  m^  exacto,  fu6  el  de  Gamier,  que  es 
el  mlsmo  que  se  emplea  para  las  piurinas  y  de  que  hablar6  en  seguida: 

Purinas  totales.  Procedimiento  de  Hycraff  Deniges  Gamier. — Las  bases  ptiricas 
tiatadas  por  el  nitrate  de  plata  amoniacal  en  presencia  de  una  sal  de  magnesio  dan  un 
urato  doble  de  plata  y  de  magnesio  perfectamente  definido.  Si  se  emplea  para  esta 
precipitaci6a  unlicor  de  plata  titulado,  se  puede,  midiendo  el  exceso  de  plata  no  com- 
binado,  deducir  la  que  se  combin6  en  laa  purinas,  y  por  consiguiente,  el  peso  de  ^stas. 

A  100  c.  c.  de  orina  defecada  por  26  c.  c.  de  reactivo  de  Folin,  agrdguese  una  solu- 
ci6n  de  partes  iguales  de  soluci6n  decinormal  de  nitrate  de  plata  y  de  otra  que  con- 
tenga  350  c.  c.  de  amoniaco,  150  gramoe  de  cloruro  de  amonio  y  50  gramos  de  cloruro 
de  magnesio.  Ffltrese,  rec6ja0e  100  c.  c,  agr^esele  10  c.  c.  de  una  soluci6n  titulada 
de  cianuro  de  potasio  (equivalente  a  la  de  nitrato  de  plata)  y  1  c.  c.  de  soluci6n  al 
un  d^imo  de  yoduro  de  potasio.  Vidrtase  gota  a  gota  8oluci6n  decinormal  de  nitrato 
de  plata  hasta  obtener  un  Hquido  permanentemente  turbio.  La  soluci6n  argdntico- 
magnesiana  da  la  combinaci6n  de  que  ya  se  habl6,  con  las  purinas.  El  cianiuro  de 
potasio  se  comljina  con  el  nitrato  de  plata  que  qued6  libre  y  como  son  equivalentes, 
basta  dosar  con  otra  soluci6n  aigdntica-decinonnal,  el  cianuro  que  no  se  cQmbin6  con 
la  plata,  con  KI  como  indicador,  para  saber  la  cantidad  de  la  8oluci6n  primitiva  de 
nitrato  de  plata  que  se  combin6  con  las  purinas;  ^ta,  multiplicada  por  0.21  da  el  peso 
de  purina  por  1,000  c.  c.  de  orina:  pero  a  causa  de  la  disminuci6n  de  volumen  que  se 
efectu6  al  verificarse  la  defecaci6n  de  la  orina,  hay  que  multiplicar  este  resultado 
por  1.25. 

Como  el  ^ido  urico  es  una  purina,  basta  aislarlo,  precipit^ndolo  de  la  orina  defe- 
cada, por  el  amoniaco,  al  estado  de  urato.  Este  precipitado  se  lava  con  sulfato  de 
amoniaco  al  10  por  ciento,  se  disuelve  por  medio  de  una  pequetia  cantidad  de  soda  al 
2  por  ciento  en  un  volumen  determinado  de  agua  destilada,  y  en  esta  soluci6n  se 
veriHca  el  dosado  como  para  las  purinas  totales: 

Bases  pdricas  (expresadas  en  xantina). — Si  en  la  precipitaci6n  de  las  bases  piiricas  la 
relaci6n  de  la  plata  al  niicleo  pdrico  fuera  la  raisma  que  en  la  precipitaci6n  del  dcido 
drico,  bastarfa,  para  obtener  la  cifrade  las  bases  pdricas,  restar  simplemente  la  cifra  del 
dcido  tirico  de  las  cifras  de  las  purinas  totales  y  despuds  multiplier  esta  diferencia  por 
la  relaci6n  entre  el  peso  molecular  de  la  piuina  elegida  como  tipo  (xantina,  por  ejemplo) 
y  el  peso  molecular  del  dcido  tirico.  Pero  como  en  el  case  de  las  bases  cada  nticleo 
ptirico  fi  ja  dos  dtomos  de  plata  mientras  que  el  ndcleo  del  dcido  tirico  no  fi  ja  sine  uno> 
la  misma  cantidad  de  plata  que  corresponde  168  partes  (una  mol^ula)  de  dcido 
lirico,  no  representa  sine  152:2=76  partes  (media  mol6cula)  de  xantina,  la  diferencia 
de  las  cifras  experimentales  multiplicada  por  la  relaci6n  76:168=0.454  expresa 
exactamente  en  xantina  el  conjunto  de  bases  puricas. 

Para  obtener  una  expresi6n  inequivoca  delas  bases  piSricas  hay  que  elegir  una  de 
las  doe  mds  abundantes  la  adenias  (151)  o  la  xantina  (152),  lo  que  da  la  misma  cifra, 


80  PBOOEEDIKGS  8B00ND  PAN  AMBBICAN  80IBKTIFI0  00KGBE88. 

vista  la  igualdad  prdctica  de  los  peaoe  moleculares.  El  error  proveniente  de  la  infe- 
rioridad  de  loe  pesos  moleculares  de  la  adenina  (135)  y  de  la  hipoxantina  (136)  debe  ser 
compensado  en  gran  manera  por  la  preeenda  de  la  metilxantdna  (166)  y  de  la  dime- 
tilxantina  (180);  se  puede,  pues,  considerar  como  satufactoiia  la  expresidn  de  las 
bases  puricas  en  xantina. 

Azoe  iiliootungstico, — ^Por  haberme  side  imposible  consegair  el  reactivo,  no  pude 
verificar  este  anilisis.  Las  materias  a  que  ^1  se  refiere  no  tienen  ademis  grande  impor- 
tancia  puesto  que  apenas  principian  a  conocearse,  y  su  importanda  ee,  per  con- 
siguiente,  muy  discutible. 

FSsforo  urinario  {en  dddo  fosfSnoo), — ^El  m^todo  estd  fundado  en  que  ai  se  vierte 
una  8oluci6n  de  una  sal  de  uranio  (nitrate  o  acetate),  en  un  liquido  que  contenga 
fosiatos  en  medio  ac6tico,  sin  icidos  minerales  y  de  una  temperatura  prdxima  a  la 
ebullici6n,  se  obtiene  un  precipitado  insoluble  de  fosfato  de  uranio.  El  fin  de  la 
reacci6n  se  conoce  por  medio  de  la  tintura  de  cochinilla,  con  la  cual  forma  la  sal  de 
uranio,  cuando  ya  no  encuentre  fosfatos  para  combinarse,  una  laca  verde  esmeralda, 

0  tambi^n  con  el  forrocianuro  de  potasio,  que  da  con  la  sal  de  uranio  un  precipitado 
rojo. 

Para  hacer  m^  c6moda  la  reacci6n,  he  titulado  la  solucidn  de  uranio  de  tal  manera 
que  1  c.  c.  sea  equivalente  a  0.05  c.  c.  de  dcido  fo6f6rico  por  litre  de  orina. 

La  reacci6n  se  verifica  en  una  cdpsula  de  porcelana  en  la  cual  se  pone  la  cantidad 
mencionada  de  orina  con  unas  gotas  de  tintura  de  cochinilla  y  1  c.  c.  de  soluci6n  al 

1  por  ciento  de  acetate  de  sodio  cristalizadoj  adicionada  de  5  por  ciento  de  acido 
ac6tico  cristalizable.  En  una  bureta  de  Mohor  que  estd  sobre  la  cdpsula  se  coloca  la 
soluci6n  de  urinario.  Una  vez  que  la  orina  calentada  por  una  Idmpara  de  alcohol, 
principia  a  desprender  vapores,  se  deja  caer,  poco  a  poco,  la  soluci6n  titulada,  hasta 
obtener  el  tinte  verde  oscuro. 

Ademds  de  estos  elementos,  y  a  pesar  del  examen  clfnico,  bu8qu6  en  las  orinas  en 
experimento  sustancias  anormales  para  asegurarme  del  estado  fisioldgico  de  los  indi- 
viduoe. 

RELACI0NE6   UR0l6GICAS. 

Se  sabe  que  los  diatintos  elementos  que  encierran  las  orinas  normales  son  variables 
con  la  alimentaci6n,  la  edad,  el  sexo,  el  clima,  etc.  Por  osta  raz6n  se  ha  dicho  que 
no  hay  orinas  normales  absolutas  sine  orinas  normales  particulares  a  cada  individuo. 

Sin  embargo,  loe  diferentes  elementos  de  la  orina  guardan  entre  si  relaciones  que 
son  independientes  de  su  cantidad,  y,  que  por  ser  bastante  fijas,  dan  muchas  ense- 
fianzas  respecto  del  funcionamiento  de  la  nutrici6n. 

He  buacado  las  siguientes  relaciones  uroldgicas: 

1.  Relaci6n  uzodrica:  Coeficiente  de  oxidaci6n  (Robin)  o  relaci6n  de  la  utilizaci6n 
de  dzoe: 

'"aIt   ^^OiT  ^-^^  *  ^-^  ^^^^  Robin). 

Ya  se  ha  visto  que  la  urea  es  el  t^rmino  final  de  la  trasfonnaci6n  de  las  albumi- 
noideas,  de  tal  manera  que  cuanto  m^s  perfecta  sea  la  nutrici6n,  habrd  menos  inter- 
medios  y  la  relaci6n  Az  U:Az  se  aproximar^  m^  a  la  unidad. 

P*  O*     1      10 

2.  Relaci6n  del  dcido  fosf6rico  a  la  urea  o  al  dzoe  total  —^ — ™in™T()o"*^*^^   ^ 

p2  0*     18 

1 — ^rir=T7r;^=0.18  esta  relaci6n  es  de  una  constancia  notable  (I von)  cuando  se  eleva 

Az  1      100 

considerablemente  se  puede  deducir  que  hay  fosfaturia.    Esta  es  relativa  cuando  la 

cifra  P*  0*  no  pasa  en  mucho  la  media  (2  por  60  en  24  horas),  ea  esencial  en  el  case 

p2Q5 

contrario.    La  relaci6n  P'  0*  tiene  la  misma  significaci6n;    t— 7p* 

3.  Relacidn  del  dddo  urico  coeficiente  de  trasformaci6n  de  las  nucleoproUidas. 


FUBLIO  HEAUTH  AND  MEDIOIKB.  81 

Dije  antes  que  el  icido  tirico  y  la  urea  no  tienen  un  origen  comtin,  y  aunque  una 
parte  del  icido  tirico  es  trasformado  en  urea  en  el  hfgado,  no  veo  que  ensefianzas  prdcti- 
cas  pueda  dar  la  relaci6n  entre  el  icido  drico  y  la  urea.  Porque  suponiendo  que  haya 
una  gran  trasformacidn  de  las  ndcleoproteidas,  puede  estar  aumentando  el  ^ido 
drico  al  mismo  tiempo  que  la  urea,  y  entonces  la  relaci6n  no  podrd  ensefLamos  nada 
respecto  de  las  trasformaciones  en  las  ndcleoproteidas;  o  si  la  urea  estd  disminuida 
por  una  d^bil  alimentaci6n  de  albuminoideos  propiamente  dichos  y  el  ^ido  drico 
aumentado  por  aumento  de  ndcleoproteidos,  esto  no  querda  decir  que  hubiera  un  mal 
funcionamiento  hepdtico  a  pesar  de  que  la  relaci6n  asf  lo  indicara.  Si  hay  una  d^bil 
trasfonnacidn  de  ndcleoproteidos  o  diBnnnuci6n  de  trasfonnaci6n  de  las  albiuni- 
noideas,  el  coeficiente  tami>oco  nos  ensefiard  nada  ni  respecto  a  un  funcionamiento 
hepdtico,  en  el  primer  caso,  ni  respecto  a  una  mala  trasformaci6n  de  ndcleoproteidos, 
en  el  segundo  grado.  De  manera  que  a  mi  modo  de  ver,  las  dos  razones  de  ser  del 
coeficiente  indicado  ban  perdido  mucho  de  su  importancia  desde  que  se  sabe  que  el 
iddo  drico  no  es  un  producto  hacia  la  urea. 

Yo  me  atreverla  a  proponer  que  se  adoptara  una  relaci6n  entre  el  dzoe  del  ^ido 

drico  y  el  dzoe  de  las  purinas  totales:  j — P~t»  ^  <l®<^^i  ^^  ^^^  ^^  l^s  ndcleoproteidos 

que  ha  llegado  al  dltimo  grado  de  desintegracidn  fisiol6gica,  y  el  que  ha  debido  llegar 
aUl. 

La  investigacidn  del  dzoe  de  cada  uno  de  los  cuerpos  que  entran  en  el  segundo  factor 
de  esta  relacidn,  complicarla  demaaiado  las  operaciones,  complicacidn  que  no  traeria 
quizd  mayores  ventajas,  una  vez  que  se  tienen  cantidadee  de  dzoe  propordonales. 

Las  cantidades  que  han  servido  para  la  relaci6n  de  que  hablo  son,  por  una  parte, 
la  proporci6n  de  dzoe  del  ^do  diico  por  ciento  de  izoe  total  y  por  otra  parte,  la  de 
iaoe  pdrico  total  por  ciento  de  dzoe  total.  Esta  dltima  cifra  no  representa  sino  el 
iasoe  del  ^do  drico  m^  el  izoe  de  las  purinas  b^cas  expreeadas  en  xantina;  es  decir, 
que  en  ellas  no  figura  el  dzoe  aminado  de  la  adenina  y  de  la  guanina;  pero  sf  repreeentan 
una  cantidad  que  es  siempre  proporcional  al  dzoe  pdrico  total  propiamente  dicho. 
Multiplicando  el  cociente  por  ciento,  el  resultado  indicar&  la  cantidad  de  dzoe  pdrico 
que  para  cien  partes  de  la  dira  global,  llega  al  t^rmino  normal  de  su  desintegraci6n 
fifliol^ca.  Gomo  se  verd  mia  adelante  si  en  vez  de  tomar  el  tanto  por  ciento  del  dzoe 
total  se  toman  las  clfras  directas  del  AU  y  de  las  BP,  el  resultado  es  muy  semejante. 

El  coeficiente  que  me  atrevo  a  proponer  podrfa  tener  grande  importancia  para  el 
estudiodeladesintegracidn  azoada,  de  las  oxidaciones  y  desamidaciones  orginicas  en 
general,  y  de  la  de8integraci6n  de  las  ndcleoproteideas,  en  particolar; '  tendrfa  respecto 
de  estas  quizd  la  mlsma  importancia  que  el  coeficiente  de  utilizaci6n  del  dzoe,  o 
mejor  que  el  coeficiente  de  que  hablar6  en  seguida,  tiene  respecto  de  las  albuminoideas 
propiamente  dichas. 

4.  Imperfeeci6n  itroginica — coeficiente  de  oxidacidn  verdadero  o  de  los  dcidos  ffrasos: 
81  se  tiene  en  cuenta  la  teoria  generalmente  aceptada  hoy  sobre  la  formaci6n  de  la 
urea,  se  verd  que  es  hasta  cierto  punto  il(5gico  hacer  intervenir  el  dzoe  total  en  el 
coeficiente  llamado  **de  utilizaci6n  del  dzoe."  Cbnsiderando  pues  que  hay  cuerpos 
azoados  que  no  son  productos  hacia  la  urea,  Arthus '  propuso  el  siguiente  coeficiente: 

Az  azubba;  az  amoniacal,  Acidos  aminados. 

Eete  coeficiente  fu6  estudiado  por  Maillard  quien  lo  llam6  coeficiente  de  imper- 
feccidn  urog^nica  y  mostrd  su  importancia  como  que  indica  adem^  de  la  intensidad 
de  la  fimci6n  uropoi^tica,  el  poder  de  oxidaci6n  del  organismo  sobre  los  &cidos  grasos 
o  cadenas  carbonadas  vecinas,  previamente  puestas  en  libertad. 

1  Veose  pAgina,  00.  *  M.  Arthus,  Prtete  de  chlmie  physiologique,  1906,  p&g.  390;  nota. 


82 


PROCEEDINGS  SECOND  PAN  AMEBIOAN  8CIENTIFI0  CONGRESS. 


Hay  que  notar  que  para  medir  el  amonfaco  Malllar  emple<S  el  procedimlento  de 
Bonchese,  que  ee  el  mismo  que  he  empleado  yo,  el  cual  dosa  al  misino  tiempo  el 
amonlaco  y  los  ^idos  ausinadoe.  Lazemberg  insiste  sobre  esta  neceeidad  de  medir  al 
mismo  tiempo  loe  icidos  aminadoe  productores  mediatoe  de  urea,  como  el  amonlaco  ^ 
fu6  el  quien  le  di6  al  cocficiente  la  forma  notada  arriba. 

RE8ULTAD08  INDIVIDUALES   DE   L08  ANAlISIS. 

En  la  primera  parte  de  loe  cuadros  que  se  ver^  an  seguida,  se  encuentran  loe  aniilifliB 
hechoB  en  Bogota,  divididos  en  dos  aeries  que  comprenden  la  eliminaci6n  azoada  y 
loeforada  y  luego  la  repartici6n  del  &zoe  y  la  relacl6n  del  f6sforo  al  dzoe.  En  la  primera 
eerie  se  encuentran  para  cada  cuerpo  dos  columnas  que  representan  la  eliminacl6n 
tanto  por  litro,  como  en  24  boras. 

En  la  segunda  parte  se  encuentran  los  20  andlisis  de  Tunja  repartidos  de  la  misma 
manera,  8<51o  quenoeet^  divididos  como  los  Bogotd,  "en  clase  obrera  "  y  ^'clase  acomo- 
dada"  tanto  porque  su  ntimero  es  muy  reducido  como  porque  se  refieren  a  individuoe 
alimentados  casi  todos  de  la  misma  manera. 

Por  dltimo,  los  andlisis  de  cada  localidad  est^  s^uidos  de  sub  promedios  y  al  final 
Be  encuentran  los  promedios  genorales. 

CuADRO  I  (Serie  !•). — Clase  obrera — Eliminacidn  del  dzoe  y  deljdsjoro, 

[An&lisis  de  BogotA.] 


Ntim. 


1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 


Alios  de 
edAd. 


23 
25 
20 
22 
21 
28 
28 
22 
23 
25 
25 
22 
21 


Profesidn. 


Jornalero.. 

Asistente.. 

Sirviente.. 

Albafiil. . . 

Sirviente.. 

Carpintero 

Jornalero.. 

Gendarme. 

Latonero. . 

Gendarme 

Asistente. 

Sirviente. . 

do 


Densidad 
dela 
orina. 


1,010 
1,022 
1,018 
1,015 
1,016 
1,027 
1,016 
1,027 
1,017 
1,012 
1,016 
1,013 
1,018 


Voliunen 

en  24 

boras. 


Aeidoc  en  H. 


Asoe  total. 


For 
litro. 


2,950 
1,460 
1,850 
2,120 
1,720 
1,660 
1,650 
1,075 
2,250 
1,550 
2,000 
3,300 
1,600 


0.013 
.051 
.035 
.025 
.027 
.031 
.035 
.036 
.018 
.019 
.024 
.005 
.012 


En  34 
boras. 


Por 
litro. 


■r 


0.038 
.048 
.065 
.053 
.046 
.051 
.047 
.038 
.040 
.029 
.048 
.016 
.019 


4.67 
6.60 
8.77 
6.20 
7.63 
8.09 
6.95 
ia89 
5.35 
5.10 
8.00 
8.47 
5.58 


En  34 
boras. 


12.0 

9.63 

16.33 

13.40 

13.13 

13.43 

11.46 

1L70 

12.00 

7.90 

16.00 

11.45 

8.93 


Amonlaco  y 

&cido8 

aminados. 

NAm. 

Por 

En  24 

litro. 

boras. 

1 

0.391 

1.15 

2 

.408 

.59 

3 

.714 

1.32 

4 

.918 

1.94 

5 

.969 

1.06 

6 

.935 

1.55 

7 

.068 

.11 

8 

.561 

.60 

9 

.204 

.50 

10 

.255 

.40 

11 

.68 

1.13 

12 

.119 

.89 

13 

.51 

.82 

Urea. 


For 
litro. 


En  24 
boras. 


5.50 

14.00 

13.00 

8.70 

10.00 

11.20 

10.94 

14.21 

7.87 

6.53 

11.23 

7.00 

7.52 


16.22 
20.44 
24.00 
18.44 
17.20 
18.59 
18.05 
14.27 
17.70 
10.12 
22.46 
23.10 
12.00 


Pminas  totales 
(en  &cido 
t&rico). 


For 
litro. 


0.675 
.721 
.84 
.803 
.709 
.966 
.729 

1.190 
.735 
.735 
.756 
.667 
.735 


En  24 
boras. 


0.93 
1.05 
1.55 
1.70 
1.22 
1.60 
1.20 
1.27 
1.65 
1.14 
1.51 
1.87 
1.17 


Acido  t!irico. 


Por 

litro. 


0.30 
.22 
.50 
.583 
.630 
.240 
.227 
.403 
.332 
.084 
.412 
.239 
.294 


En  24 
boras. 


0.88 
.32 
.92 
1.23 
1.08 
.40 
.37 
.43 
.14 
.13 
.82 
.97 
.47 


Bases  pAricas 
(en  xantina). 


For 
litro. 


0.168 
.320 
.090 
.099 
.035 
.320 
.220 
.350 
.180 
.390 
.15 
.12 
.20 


En  24 
boras. 


Acido 
fosfdrico. 


For 
litro. 


0.40 
.32 
.16 
.20 
.06 
.53 
.35 
.37 
.40 
.45 
.30 
.39 
.33 


1.00 

1.40 

1.50 

1.00 

1.30 

1.60 

1.10 

1.60 

.70 

.50 

1.20 

.60 

1.50 


En  24 

boras. 


3.05 
3.04 
3.77 
3.12 
3.06 
2.66 
1.89 
1.73 
1.57 
.77 
3.40 
1.98 
3.40 


I  Lacembdrg,  L'amoniaque  et  I'urine;  ^tude  d'un  nouveau  coefficient  urlnaire;  tb^  de  Paris,  1913. 


FUBLIO  HBALTH  AIXD  MBDIGOnL 


83 


OuADBO  II  (Serie  1*). — Cla$e  obrera--EHmiinaei6n  dd  dgoe  y  ddfdiforo. 


NAni. 

Aflofde 
edad. 

1 

» 

14 

30 

15 

32 

16 

21 

17 

24 

18 

28 

19 

24 

ao 

24 

21 

34 

23 

22 

28 

28 

24 

32 

25 

30 

26 

38 

Proleaidn. 


Oendarms. 
Cartero.... 
Sinriento.. 
AlbaflO... 
Citrpiiiteio 
Aflistozito . 
Albaflfl... 
Cftrpinteio 
Zapateio.. 
Oendarme. 
Jomatoro.. 
Oendanne. 
Jomatoro.. 


DoMldAd 
dela 
orioft. 


1,021 
l,OBl 
1,018 
1,012 
1,021 
1,026 
1,010 
1,012 
i,Q20 
1,020 
1,015 
1,022 
1,020 


Volamen 
en  24 
horas 

(en  Co.)* 


1,890 
020 
1,060 
1,680 
1,270 
1,320 
1,840 
1,500 
1,260 
1,500 
1,470 
1,420 
1,450 


AoidesenH. 


Par 
litro. 


0.024 
.037 
.011 
.025 
.040 
.037 
.031 
.020 
.048 
.012 
.012 
.011 
.060 


En  24 
horas. 


0.031 
.084 
.027 
.042 
.060 
.048 
.041 
.080 
.060 
.018 
.017 
.015 
.078 


Amo  total. 


Par 
litro. 


6.424 

14.24 

6.61 

5.60 

0.00 

10.416 

7.118 

4.30 

11.12 

5.00 

5.80 

0.24 

8.60 


En  24 
horaa. 


8.47 

13.20 

13.08 

11.08 

11.43 

17.02 

0.63 

6.45 

13.00 

7.50 

8.66 

13.12 

12.47 


NAni< 


14 
15 
16 
17 
18 
10 
90 
21 
32 
33 
34 
35 
36 


Amonlaooy 

Aoidos 
aminados. 


Par 
litro. 


0.502 

1.275 
.442 

1.182 
.765 

1.513 
.730 
.204 

1.470 
.104 
.272 

1.275 

1.324 


En  24 
horas. 


a66 

i.l7 
.87 

1.08 
.07 

1.99 
.99 
.31 

1.84 
.29 
.39 

1.82 

2.20 


Ursa. 


Por 
litro. 


0.60 
20.20 
11.645 

8.47 
15.058 
24.20 
12.00 

5.235 
16.66 

6.66 

7.293 
16.82 
13.91 


En  24 
horas. 


12.54 
18.58 
23.06 
14.22 
19.12 
31.04 
16.06 

7.83 
20.82 

9.99 
ia72 
23.88 
20.17 


Pnrinas  totaiss 
(enAeido 
tkrioo). 


Por 
litro. 


0.696 
1.365 
.504 
.441 
.840 
.819 
.603 
.388 
.714 
.420 
.483 
.766 
.462 


En  24 
horas. 


0.92 

1.25 

.98 

.74 

1.06 

1.07 

.03 

.58 

.89 

.63 

.71 

1.07 

.67 


XoidoMoo. 


Por 
litro. 


0.204 
.777 
.336 
.252 
.399 
.525 
.399 
.20 
.462 
.231 
.204 
.525 
.350 


En  24 
horas. 


0.38 
.71 
.66 
.40 
.51 
.60 
.53 
.30 
.58 
.34 
.43 
.74 
.51 


Bases  ptkricas 
(en  zantina). 


Por 
litro. 


0.18 
.26 
.06 
.085 
.20 
.13 
.132 
.065 
.113 
.065 
.085 
.104 
.050 


En  24 
horas. 


a23 
.23 
.11 
.14 
.25 
.17 
.17 
.12 
.14 
.12 
.12 
.14 
.07 


Icido 
fosfcrioos. 


Par 
litro. 


1.40 
1.00 
1.10 
1.30 
1.30 
1.60 
1.40 

.50 
1.20 

.70 
1.00 
1.10 

.70 


En  24 
horas. 


1.84 
.02 

2.06 
2.57 
1.64 
2.11 
1.87 
.75 
1.50 
1.05 
1.47 
1.56 
1.01 


CuADRO  III  (Serie  1*). — CUue  obrera-^Miminaeidn  del  dtoe  y  ddf69foTo, 


N4ni« 


27 
28 
20 
30 
31 
32 
38 
84 
85 
36 
87 


Afiosde 
edad. 


24 
80 
28 
22 
30 
23 
85 
36 
85 
28 
30 
22 
27 


Profcsi6n» 


llte)deoordel 

Carmo... 

Sastre 

Jomalero 

....id.. 

Horraro ....... 

Albafln 

Q«ndarme 

Jornalsro. 

Oendanne 

Herrero....... 

Jornalero 

Alhaflfl. 


Densidad 
dela 
orlna. 


1,015 
1,021 
1,015 
1,017 
1,016 
1,016 
1,012 
1,015 
l,0l2 
1,030 
1,015 
1,016 
1,014 


Vdumen 
en  24 
horas 

(en  Co.). 


1,450 
1,920 
2,115 
1,730 
2,115 
2,400 
1,800 
2,100 
1.450 
1,100 
1,470 
1,700 
2,740 


AoidesenH. 


Por 
litro. 


0.008 
.000 
.010 
.000 
.000 
.013 
.021 
.015 
.027 
.016 
.016 
.013 
.012 


En  24 
horas. 


a004 
.017 
.040 
.015 
.019 
.031 
.087 
.046 
.080 
.018 
.023 
.030 
.083 


Aioe  total. 


Por 
litro. 


5.00 

5.10 

6.50 

5.73 

6.00 

5.93 

5.60 

5.68 

7.722 

0.29 

8.771 

3.80 

4.30 


En  24 
horas. 


7.25 

0.60 
18.74 

9.89 
iO.75 
14.20 

0.90 
i7.45 
11.10 
10.22 
12.00 

6.46 
11.78 


68486— 17— VOL  x- 


84 


PB00EEDIKG8  SBOOND  PAK  AMWBrOATT  SOIBlfrTIFIO  00KGBE88. 


OuADBO  III  (Serie  1*). — Cla»€  abrera-^BHminaa&n  del  dtoe  y  dd  foBforo, — Ccntmiia, 


Amontaooy 

Addos 
amlnados. 

Una. 

Porinastotalw 
(enAoido 
Moo). 

loldo 

Moo. 

Bans  ptirioas 

Acldo 
ioafdrioo. 

N4m. 

Por 

En  24 

Por 

En  24 

Por 

En  24 

Por 

Bn24 

Por 

En  24 

Par 

En  24 

• 

litre. 

horn. 

litro. 

horai. 

Utro. 

horai. 

litro. 

horai. 

litro. 

horaa. 

lltio. 

horaa. 

27 

0.90 

L80 

5.70 

8.26 

0.899 

0.57 

0.105 

ai5 

0.132 

0.19 

0.60 

0.87 

28 

L270 

8.44 

6.00 

11.52 

.682 

L22 

.221 

.42 

.188 

.36 

LIO 

8.11 

20 

.635 

1.34 

9.571 

20.24 

.680 

1.33 

.200 

.42 

.104 

.41 

1.80 

2.74 

80 

1.118 

1.92 

7.77 

13.44 

.689 

L19 

.252 

.48 

.199 

.34 

1.00 

1.78 

81 

1.270 

2.78 

5.00 

10.75 

.700 

1.50 

.200 

.48 

.230 

.49 

1.00 

2.11 

82 

.890 

.96 

10.00 

24.00 

.680 

1.51 

.178 

.42 

.104 

.24 

1.20 

2.68 

83 

.578 

1.04 

9.90 

17.82 

.872 

.60 

.210 

.87 

.028 

.05 

.60 

1.08 

84 

.840 

.96 

9.219 

28.58 

.671 

8.08 

.252 

.78 

.190 

.58 

.75 

8.82 

85 

.685 

.92 

10.00 

14.50 

.467 

.68 

.815 

.46 

.068 

.09 

1.60 

2.32 

86 

.850 

.98 

17.20 

18.92 

.176 

1.29 

.260 

.27 

.418 

.46 

2.10 

2.31 

87 

.476 

.69 

10.454 

15.86 

.588 

.85 

.378 

.55 

.009 

.14 

1.20 

1.76 

88 

.282 

.48 

7.40 

9.18 

.756 

L29 

.550 

.98 

.92 

.15 

.60 

1.02 

80 

.800 

.82 

6.40 

17.54 

.525 

1.44 

.180 

.49 

.156 

.48 

.80 

2.19 

CuADBO  IV  (Serie  1*). — CUue  obrera — EUminad&n  del  dzoe  y  delfSsforo, 


NAm. 

Afioade 
edad. 

40 

26 

41 

82 

42 

28 

43 

30 

44 

20 

45 

20 

46 

26 

47 

26 

48 

23 

ProfDsidn. 


Sirviente 

Jomalero 

id 

Carrero 

Mozo  de  Cordel 

AlbaftU 

Jomalero 

Pintor 

Sirviente 


Aoidei 

lenH. 

Aioe 

Densidad 
dela 
orina. 

Volumen 
en  24 
horas 

(en  CO.). 

Por 

En  24 

Por 

litro 

horaa. 

litro. 

1,012 

1,430 

0.018 

0.027 

7.00 

1,020 

1,170 

.040 

.046 

7.80 

1,020 

1,250 

.028 

.035 

8.00 

1,030 

1,470 

.053 

.078 

9.57 

1,021 

1,460 

.034 

.049 

7.20 

1,020 

1,400 

.025 

.085 

7.56 

1,014 

2,380 

.015 

.085 

4.10 

1,021 

2,150 

.020 

.048 

7.82 

1,022 

1,870 

.036 

.049 

10.00 

En  24 
horas. 


10.00 
9.13 
10.00 
14.07 
10.40 
10.58 
9.76 
16.81 
13.70 


Amoniaooy 

Acidos 
aminados. 

Urea. 

Purinas  totales 
(enAcide 
drioo). 

Aoido 

drioo. 

Bases  ptSrioas 
(en  xantina). 

Aoido 
foafdrkx). 

NAm. 

Por 

En  24 

Por 

En  24 

Por 

En  24 

Por 

En  24 

Por 

En  24 

Por 

En  24 

litro. 

horas. 

litro. 

horas. 

litro. 

horas. 

litro. 

horas. 

litro. 

horas. 

litro. 

horaa. 

40 

0.221 

0.32 

11.00 

15.73 

0.839 

1.20 

0.450 

0.54 

0.175 

0.25 

L50 

2.14 

41 

.425 

.50 

10.00 

11.70 

.654 

.77 

.200 

.28 

.200 

.23 

2.00 

2.30 

42 

.697 

.87 

6.50 

8.12 

.885 

.48 

.180 

.22 

.092 

.11 

1.20 

1.50 

48 

1.250 

1.84 

11.95 

17.57 

.785 

1.08 

.400 

.50 

.151 

.22 

1.00 

1.47 

44 

.700 

1.01 

13.40 

19.48 

.420 

.61 

.170 

.25 

.113 

16 

2.00 

2.90 

45 

.909 

L36 

9.17 

12.84 

.567 

.79 

.214 

.30 

.159 

.22 

1.00 

1.40 

46 

.255 

.61 

5.00 

1L90 

.523 

1.24 

.180 

48 

.155 

.86 

.90 

2.14 

47 

1.105 

2.37 

10.00 

2L50 

.751 

1.61 

.201 

.42 

.249 

.58 

1.20 

2.58 

48 

1.168 

1.60 

10.10 

17.94 

.799 

1.08 

.856 

.49 

.109 

.15 

2.00 

2.74 

PX7BU0  HEALTH  AKD  MEDIOIKB. 


85 


GuADBO  V  (Serie  !•). — Close  aamodada'^Miminad6n  del  dzoe  y  ddfSsforo. 


Htm. 


1 
2 
3 

4 

5 

6 

7 

8 

0 

10 

11 

12 

13 

14 


Afio8d« 
edad. 


ao 

22 
24 
24 
26 
27 
26 
27 
26 
26 
26 
25 
24 
24 


PrafB8i6ll. 


Estudiante. . 
Comeroiaate 
Bstadiante.. 

id 

id 

MMico 

Estudiante.. 

MMico 

Estudiante.. 

id 

id 

Medico 

Estudiante.. 
MiUtar 


Densidad 
dela 
orloa. 


1,022 
1,018 
1,016 
1,020 
1,021 
1,030 
1,020 
1,020 
1,021 
1,021 
1,020 
1,022 
1,022 
1,021 


yolamen 
en  24 
horas 

(en  CO.). 


1,660 
1,400 
2,680 
8,100 
1,300 
1,600 
1,000 
1,800 
1,880 
1,820 
1,800 
2,000 
1,360 
1,230 


Aoides  en  H. 


Por 
litre. 


0.032 
.046 
.020 
.012 
.065 
.027 
.047 
.034 
.027 
.044 
.033 
.012 
.026 
.028 


En  24 
horas. 


0.063 
.062 
.054 
.037 
.071 
.043 
.047 
.061 
.058 
.058 
.051 
.024 
.035 
.027 


JLsoe  total. 


Per 
Ittro. 


6.00 
9.223 
5.25 
4.00 

10.00 
7.10 

16.21 

11.00 
6.75 
9.50 

11.60 
6.20 
5.648 
9.58 


En  24 
horas. 


8.30 
12.91 
14.07 
12.40 
13.00 
11.36 
16.21 
19.80 
12.09 
12.54 
20.88 
12.40 

7.68 
11.78 


Amoniacoy 

Acidos 
aminados. 

Urea. 

Purines  totales 
(en  Acldo 
drioo). 

Aoido  trico. 

Bases  ptb-icas 
(en  xantina). 

AcJdo 
osfdrico. 

NAm. 

Pot 

En  24 

Pot 

En  24 

Por 

En  24 

Por 

En  24 

Por 

En  24 

Per 

En  24 

litre. 

horas. 

litre. 

horas. 

litro. 

horas. 

litro. 

1 

horas. 

litro. 

horas. 

litro. 

horas. 

1 

a60 

1.00 

8.10 

13.46 

asoi 

1.33 

a262 

a43 

a944 

a40 

1.30 

2.16 

2 

.680 

.95 

11.90 

18.06 

.727 

1.03 

.332  . 

.46 

.178 

.25 

1.50 

2.10 

8 

.621 

1.39 

8.72 

23.40 

.302 

.81 

.148 

.40 

.060 

.18 

LOO 

2.68 

4 

.641 

L68 

6.90 

18.29 

.688 

1.26 

.300 

.96 

.190 

.40 

.80 

2L48 

6 

L290 

1.67 

13.00 

16.90 

.839 

1.08 

.501 

.65 

.148 

.19 

.96 

1.35 

6 

.646 

1.03 

12.00 

19.20 

1.076 

1.72 

.850 

.53 

.328 

.62 

1.00 

1.60 

7 

L211 

1.21 

25.00 

26.00 

1.0825 

1.08 

1.556 

.66 

.240 

.24 

2.40 

2.40 

8 

.  noo 

1.69 

16.00 

28.80 

.850 

1.63 

.243 

.44 

.274 

.49 

.76 

L36 

0 

.644 

L02 

12.00 

21.66 

.904 

1.81 

.301 

.66 

.300 

.66 

.60 

1.13 

10 

.612 

.81 

16.10 

21.25 

.7576 

L07 

.180 

.24 

.261 

.34 

1.06 

1.40 

11 

.816 

1.47 

18.00 

32L20 

.640 

.97 

.168 

.30 

.168 

.30 

L60 

2.88 

12 

.225 

.46 

7.20 

14.40 

.840 

1.68 

.261 

.62 

.282 

.56 

1.80 

1.60 

13 

.558 

.75 

7.18 

9.76 

.903 

1.23 

.420 

.57 

.118 

.16 

1.00 

1.36 

14 

.367 

.44 

16.40 

20.17 

1.023 

1.26 

.742 

.91 

.125 

.16 

1.80 

2.21 

CuADRO  VI  (Serie  1»). — Close  ocomodado — Eliminacidn  del  dzoe  y  delfSsforo. 


Stm. 


16 
16 
17 
18 
19 
20 
31 
22 
23 
34 
25 
26 
37 
28 


Afiosde 
edad. 


23 
24 
34 
25 
23 
24 
35 
25 
33 
36 
28 
27 
26 
26 


ProfesUtn. 


Qulmico 

Estudiante... 
Hacendado... 
Estudiante... 

id 

id 

id 

Militar. 

Estudiante... 

id 

Comerciante.. 

MMico. 

Estudiante... 
id 


Densidad 

Volumen 

dela 

en  24 

orina. 

horas 

(en  CO.). 

1,030 

1,300 

1,021 

1,340 

1,022 

1,800 

1,030 

980 

1,025 

1,250 

1,017 

1,500 

1,014 

1,680 

1,014 

3,740 

1,032 

850 

1,031 

1,000 

1,020 

1,450 

1,020 

1,560 

1,024 

1,260 

1,014 

1,760 

Aoldez  en  H. 


Por 
litro. 


a  051 
.027 
.020 
.055 
.037 
.015 
.024 
.012 
.040 
.035 
.006 
.050 
.032 
.006 


En  24 
horas. 


0.063 
.036 
.086 
.053 
.072 
.022 
.038 
.083 
.034 
.036 
.009 
.001 
.037 
.009 


Axoe  total. 


Por 
litro. 


13.23 

6.27 
10.70 

6.00 
11.30 

9.53 
ia84 

4.85 
13.82 

8.10 

laoo 
laoo 
ia86i 

9.35 


En  24 
horas. 


17.20 
7.06 
19.26 
16.68 
14.13 
14.29 
16.48 

2.63 
11.88 

8.10 
14.50 
16.60 
18. 6S 
16.46 


86 


PBOCEEDINGS  SECOND  PAN  AMEBIOAN  SCEBNTIFIO   CONGRESS. 


CuADRO  VI  (Serle  !•). — Ckue  acomodad(i-—Elim%naci6n  del  6zoe  y  del  /6s/oro — Con. 


Amoniaooy 

&cidos 
sminados. 

Uree. 

Purinas  totales 
(enAddo 
trkso). 

Addo 

tkrioo. 

Bases  p^rfcas 
(en  xantina). 

Aoido 
foBfdrloo. 

Nt^. 

Por 

En  24 

Por 

En  24 

Por 

En  24 

Por 

En  24 

Por 

En  24 

Por 

En  24 

litro. 

horas. 

IHro. 

horas. 

litro. 

horas. 

litro. 

horas. 

litro. 

horas. 

litro. 

-  horas. 

15 

L279 

LOO 

20.00 

20.78 

LOSO 

L86 

a508 

a65 

a  247 

a32 

1.80 

%U 

16 

.505 

.80 

8.70 

11.06 

.603 

.93 

.273 

.36 

.190 

.25 

.90 

L21 

17 

.510 

.92 

17.72 

31.90 

.553 

.99 

.231 

.41 

.145 

.27 

ZOO 

3.60 

18 

1.193 

1.17 

25.887 

25.87 

1.701 

1.67 

.609 

.60 

.492 

.48 

LOO 

L86 

19 

.980 

1.23 

2a  66 

25.83 

LOSO 

L31 

.315 

.30 

.826 

.40 

XIO 

2.26 

20 

1.00 

1.50 

14.73 

22.15 

.945 

1.42 

.470 

.70 

.215 

.32 

L30 

LOS 

21 

.949 

1.50 

14.72 

23.26 

.399 

.61 

.150 

.24 

.12 

.18 

L50 

X40 

22 

.440 

1.20 

7.40 

2a  27 

.425 

1.15 

.160 

.88 

.119 

.33 

.70 

L92 

28 

1.453 

1.25 

19.60 

16.86 

.632 

.54 

.401 

.42 

.064 

.05 

2.10 

L80 

24 

1.031 

1.03 

12.22 

1Z22 

1.356 

1.36 

.636 

.64 

.326 

.82 

LOO 

LOO 

25 

.551 

.80 

15.686 

2a  74 

.462 

.67 

.211 

.30 

.113 

.16 

L90 

L88 

25 

.754 

1.17 

16.49 

24.01 

.462 

.72 

.357 

.55 

.047 

.07 

LOO 

L55 

27 

1.072 

1.34 

19.296 

24.12 

.681 

.85 

.506 

.63 

.078 

.10 

2.10 

X62 

28 

.732 

L20 

15.00 

26.40 

.509 

.80 

.wOv 

.67 

.067 

.10 

L20 

2.11 

BLIMINACI6n  del  AZOB  Y  del  f6sFORO— ANILISIS  DB  TtJNJA. 


Nrtm. 

Aftosde 
edad. 

1 

30 

2 

44 

3 

29 

4 

42 

6 

29 

6 

38 

7 

20 

8 

45 

9 

24 

10 

22 

Profesldn. 


Abogado.... 

Comerclante 
Ingeniero... 

Medico 

Saoerdote... 
Sirviente.... 
Institutor... 

Soldado 

id 


Densidad 

Volumen 

dela 

en  24 

orina. 

horas. 

1,019 

1,340 

1,016 

1,700 

1,016 

2,000 

1,018 

2,090 

1,021 

1,230 

1,017 

1,930 

1,012 

2,600 

1,015 

2,000 

1,015 

2.900 

1,010 

2,800 

AddesenH. 


Por 
litro. 


En  24 
horas. 


a  031 
.012 
.021 
.012 
.028 
.028 
.010 
.094 
.027 
.013 


a  041 
.020 
.043 
.085 
.027 
.054 
.026 
.048 
.078 
.036 


JLxoe  total. 


9.22 
3.80 
7.32 
4.83 
9.58 
8.20 
3.60 
4.50 
4.13 
2.06 


12.35 

6.46 

15.07 

iao9 

1L78 

14.12 

9.36 

9.00 

ILOe 

5.77 


Amoniaco  y 

Aoidos- 

aminados. 

Ntim. 

Por 

En  24 

litro. 
0.74 

horas. 

a99 

.28 

.48 

.51 

LOS 

.36 

.75 

.36 

.44 

.52 

LOO 

.40 

L04 

8 

.68 

L36 

9 

.24 

.70 

10 

.20 

.56 

I 


Urea. 


Por 
litre. 


12.00 
7.40 

12.90 
7.90 

16.40 

1L30 
5.80 
5.10 
4.86 
8.43 


En  24 

horas. 


16.08 
9.18 
26.57 
16.52 
2a  17 
2L81 
15.08 
ia20 
13.93 
9.60 


Purinas  totales 
(en  Acido 
thrico). 


Por 
litro. 


En  24 
horas. 


a  70 
.76 
.46 
.  29 

L02 
.52 
.34 
.76 
.44 
.41 


a93 

L29 

.95 

.61 

L26 

LOO 

.88 

L52 

L27 

L16 


Addotbrico. 


Por 
litro. 


a40 
.55 
.35 
.24 
.74 
.32 
.18 
.41 
.31 
.23 


En  24 
horas. 


a53 
.93 
.73 
.50 
.91 
.42 
.47 
,S2 
.90 
.64 


Bases  puricas 
(en  xantina). 


Aoido 
fosfdrieo. 


Por 
litro. 


a  132 
.090 
.051 
.020 
.013 
.091 
.070 
.151 
.059 
.061 


1  En  24 

Por 

horas. 

litro. 

a  17 

L40 

.14 

L20 

.10 

LOS 

.05 

.64 

.15 

L80 

.17 

LIO 

.18 

.60 

.30 

.60 

.17 

.90 

.18 

.60 

En  24 
horas. 


L87 
L76 
2.22 
L33 
2.21 
2.02 
L66 
L20 
2.61 
L68 


PUBUG  HEALTH  AND  MEDICINE. 


87 


ANJLLISIS  DE  TUNJA—ELUONAClbN  DEL  IZOB  Y  DEL  F6sFORO. 


NAm. 

Afiosde 
edad. 

11 

•21 

12 

21 

13 

22 

14 

22 

15 

24 

16 

22 

17 

21 

18 

21 

19 

22 

20 

22 

ProfBBkSn. 


Boldado 

....id. 

....W., 

....W. 

....Id.. 

....Id. 

....Id-. 

....id. 

....id. 

....Id., 


Densidad 
dela 
orina. 


,016 
,012 
,014 
,015 
,006 
,010 
,014 
,011 
,014 
,012 


Volumen 
en  24 
horas. 


2,450 
3,300 
3,150 
2,950 
3,100 
3,240 
3,020 
2,900 
3,200 
3,000 


Acides  en  H. 


Por 
litro. 


0.022 
.021 
.021 
.023 
.018 
.021 
.022 
.026 
.021 
.024 


En  24 
boras. 


a054 
.069 
.066 
.06S 
.055 
.068 
.066 
.065 
.067 
.072 


JUoe  total. 


Por 
Utro. 


2.94 
3.33 
3.80 
4.10 
3.81 
2.86 
4.44 
4.84 
4.30 
4.60 


En  24 
horas. 


7.30 
10.90 
1L97 
12.00 
11.81 

9.26 
13.51 
14.04 
13.44 
13.80 


Amoniacoy 

Purines  totales 

iddos- 

Urea. 

(en4oido 

Acldo 

tkrioo. 

aminados. 

Arico). 

Nt^. 

Por 

Por 

En  24 

En  24 

Por 

En  24 

Por 

En  24 

litro. 

horas. 

litro. 

horas. 

litro. 

horas. 

litro. 

horas. 

11 

a20 

a  49 

4.86 

11.81 

a55 

1.59 

a32 

0.78 

12 

.27 

.89 

4.77 

15.54 

.45 

1.48 

.11 

.36 

13 

.23 

.72 

5.10 

18.07 

.46 

1.45 

.20 

.63 

14 

.20 

.59 

4.90 

14.46 

.42 

1.24 

.18 

.53 

15 

.21 

.65 

6.71 

16.03 

.42 

1.30 

.28 

.87 

16 

.31 

1.00 

3.43 

11.11 

.45 

1.45 

.19 

.62 

17 

.44 

1.33 

5.14 

15.42 

.22 

.66 

.11 

.33 

IS 

.68 

1.58 

5.57 

16.15 

.46 

1.33 

.26 

.75 

19 

.43 

1.53 

4.80 

16.36 

.48 

1.53 

.18 

.68 

20 

.24 

.72 

5.00 

15.00 

.44 

1.32 

.16 

.45 

Bases  puricas 
(en  xantina). 


Acido 
fosfdricos. 


Los  cuadros  de  la  8^:unda  serie  eetin  tambi^Ji  divldidos  en  ires  partes  y  cada  uno 
de  los  ndmeros  corresponde  a  los  mismos  individuos  que  figuran  en  los  cuadros  ante- 
riores.  En  los  cuadros,  que  se  verAn  en  seguida,  se  encuentra  la  repartici6n  del 
dzoe,  segdn  los  distintos  materiales  eiiminados  en  24  horas. 

El  c&lculo  del  &zoe,  que  corresponde  a  cada  uno  de  los  materiales,  fu^  hecho  de  la 
manera  siguLente: 

Az      14 
Paraobtener  el  dzoe  amoniacal  basta  multiplicar  el  amoniaco  por  r£H5~T7~^'^24. 

Az'       28 
El  dzoe  de  la  urea  se  obtiene  multiplicando  por  la  urea  a  r«ol~Tfx4=^=0.4667.    El 

Az*  56 

dzoe  de  la  xantina,  multiplicando  a  esta  poT  7^^.YAK~iQt^\t^2^^'^^^'    ^^  ^^^  ^®^ 

Az*  56 

&cido  drico  es  igual  a  p5jT4r""4o*™ir8**^-^^*^^/^'  ^®  modo  que  para  obtener  el  4zoe 

del  dcido  drico  basta  multiplicar  la  cifra  obtenida  de  este  dcido  en  las  24  horas  por 
.334,  o  sacarle  la  tercera  parte. 

El  dzoe  purico  total  es  la  suma  de  los  dos  aoteriores.  Representa,  como  ya  dije,  el 
ndcleo  pdrico  solamente,  y  no  comprende  el  dzoe  aminado  de  la  adenina  y  de  la 
guanina. 

En  estos  mismos  cuadros  se  encuentra  tambi^n  el  tanto  por  ciento  del  dsoe  coix 
que  cada  uno  de  estos  cuerpos  contribuye  a  la  cifra  del  dzoe  total. 

La  suma  de  6stos  tantos  por  ciento  representa  la  cantidad  de  dzoe  determinado, 
por  opoeici6n  lo  que  se  llama  en  el  cuadro  fracci6n  de  izoe  indeterminado;  es  decir, 
de  todas  las  sustancias  que  no  han  sido  dosadas  individualmente. 

En  las  dltimas  Ifneas  de  los  cuadros  se  encontrari  el  f6sforo  de  los  fostatos  el  cual 

P*       62 
se  obtiene  multiplicando  la  cifra  de  P*0*  por  p^'^jgo"^*'*^^' 


88 


PROCEEDINGS  SEOOND  PAN  AMBBIOAN  SOIENTIFIO  CONOBE8S. 


Hech  0  eeto  basta  dividir  la  cifra  del  &zoe  total  por  la  del  ideioro  para  obtener  la 

Az 
Telaci6n  ponderal  del  dzoe  al  f6sfoio  -p  .    Multiplicando  esta  relaci6n  ponderal  por  la 

31 
relaci^i^inversa  de  los  peeoe  at6micoe  7^=2.214  se  obtiene  el  ndmero  de  dtomos  de  4zoe 

que  corresponde  a  un  dtomo  de  fdsforo. 

Esta  relaci6n  at6mica  del  dzoe  al  fdsforo  es  interesante,  porque  el  denominador 

ijxdica  el  ntimero  de  dtomoe  de  dzoe  que  deja  el  oi^ganiBmo  mientras  se  elimina  un 

dtomo  de  f6sforo.    Esta  representaci6n  seria  perfecta  si  se  hubiera  doeado  al  mlsmo 

tiempo  que  el  f68foro  de  los  fosfatos,  todo  el  que  pueda  acompafiarle  en  formas  dife- 

rentes.    Se  sabe,  sin  embargo,  que  esta  excreci6n  del  f6fiforo  es  muy  pequeila;  de 

p 
manera  que  si  la  relaci6n  v-  del  cuadro  no  es  de  una  rigurosa  exactitude  sf  se  acerca 

mucho  a  la  realidad. 

Cuadro  I-II  (Serie  2*). — Close  ohrera — RepartieiAn  del  dzoe  y  reHadAn  del/ds/oro  al  dzoe. 


NAmeroB. 


^soe  amoniaoal 

Lsoedelaurea 

isoe  del  Acido  tuioo 

^soe  de  las  bases  pArloas 

^soe  ptUloo  total 

^soc  total 

parte  del  Axoe  amoniaoal  por 

100  de  ^Izoe  total 

Parte  del  Azoe  de  la  urea  por 

100  de  ^Izoe  total 

Parte  del  &soe  de  las  bases  ptii- 

oas  por  100  de&Eoe  total , 

Parte  del  4soe  del  ijcido  tkrioo 

por  100  de  Axoe  total 

Parte  Aioe  pOrioo  total  por  100 

de  Atoe  total 

Fraoci6n  de  Aioe  determinado 

por  100 

Fraocidn  de  iioe  indetenni- 

nadopor  100 

Anhldndo  fosfdrioo 

Fdsforo  de  los  fosfatos 

ReIaoi6n  ponderal 

RelacU^n  at<5mica 


1 

2 

0.06 
7.68 
.204 
.180 
.474 
12.00 

0.40 
0.64 
.106 
.118 
.224 
0.63 

7.02 

6.06 

63.17 

83.26 

1.60 

1.22 

2.46 

1.10 

3.06 

2.32 

76.04 

00.66 

24.06 
0.06 
1.20 
0.30 

20.60 

0.86 

2.04 

.80 

10.82 

23.00 

8 

4 

6 

6 

7 

1.06 
11.20 
.306 
.060 
.366 
16.32 

1.60 
8.61 
.411 
.073 
.484 
13.40 

1.30 
8.08 
.361 
.022 
.383 
13.12 

1.30 
8.68 
.134 
.101 
.326 
13.43 

aio 

8.42 
.123 
.002 
.266 

11.46 

6.43 

11.04 

10.62 

0.68 

1.16 

(B.60 

64.26 

61.10 

64.62 

73.47 

.86 

.64 

.17 

1.42 

.80 

1.87  307.00 

2.76 

1.00 

107.00 

2.23 

3.61 

2.92 

2.42 

1.87 

71.16  ;  79.80 

74.64 

76.72 

76.43 

28.84 

2.77 

1.21 

13.49 

29.00 

20.20 

2.12 

.03 

14.41 

31.90 

26.46 

2.06 

..90 

14.68 

32.30 

28.28 

X66 

L16 

11.68 

26.60 

23.67 

1.80 

.82 

13.97 

30.00 

8 


0.40 
6.66 
.144 
.136| 
.280] 
1L70 

4.10 

66.92 

1.16 

1.23 

1.39 

62.60 

37.60 

1.72 

.76 

16.60 

34.60 


0.41 
8.26 
.247 
.147 
.394 
12.00 

3.42 

66.83 

1.22 

2.06 

3.28 

75.63 

24.47 

1.67 

.60 

17.30 

38.60 


10 


0.33 
4.71 
.043 
.166 
.200 
7.90 

4.18 
59.63 

2.10 
.54 

2.64 

66.44 

33.56 

.77 

.84 

23.23 

61.40 


Ntimeros. 


^soe  amoniaoal 

itoo  de  la  urea 

Lsoe  del  ^do  6rioo 

itoe  de  las  bases  piMcas 

^soe  pArioo  total 

^soe  total 

parte  del  &soe  amoniaoal  por 

lOOde&zoe  total 

Parte  del  isoe  de  la  urea  por 

100  de  &Boe  total 

Parte  del  Axoe  del  Acido  t!^co 

por  100  de  Azoe  total 

Parte  de  &soe  de  las  bases  ptbi- 

cas  por  100  de  &£oe  total 

Parte  &soe  pi^rioo  total  por  100 

Aioe  total 

Fraooldn  de  Asoe  determinado 

por  100 

Fraoddn  de  Asoe  indetermi- 

nado  por  100 

Anhldrido  fosfdrioo 

Pdsforo  de  los  fosfotos 

Relaoi<5n  ponderal 

Relaoidn  atdmica 


11 


0.92 
10.48 
.273 
.110 
.383 
16.00 

5.75 
65.37 

1.71 
.60 

2.40 

73.52 

26.48 

2.40 

1.05 

15.24 

33.70 


12 


0.32 
10.78 
.322 
.143 
.465 
11.45 

7.79 

73.  n 

2.81 

1.25 

4.06 

85.62 

14.38 

1.06 

.86 

13.31 

20.50 


13 


0.67 
5.70 
.157 
.118 
.275 
8.02 

7.54 

62.78 

1.76 

1.33 

3.09 

73.31 

26.00 
2.40 
1.05 
8.49 

18.80 


14 


0.54 

5.88 
.127 
.065 
.212 

8.47 

6.37 

60.08 

1.60 

1.00 

2.50 

77.95 

22.05 

1.84 

.80 

10.50 

23.40 


15 


0.06 
8.f>7 
.237 
.085 
.322 
13.26 

7.27 
65.83 

1.79 
.64 

2.43 

75.53 

24.47 

.92 

.40 

33.00 

73.00 


16 


17 


0.72 
10.7f» 
.220 
.040 
.260 
13.20 

5.50 
82.26 

1.68 
.31 

1.99 

89.75 

ia25 

2.06 

.91 

14.37 

31.70 


1.63 
6.64 
.164 
.051 
.215 
11.06 

14.75 

50.93 

1.48 
.46 

1.94 
76.58 

23.42 
2.57 
1.12 
9.89 

21.90 


18 


19 


0.80 
8.02 

.i7o; 

.092; 
.262 
11.43 

6.08 
78.04 

1.40 
.81 

2.30 

87.32 

12.68 

1.64 

.72 

17.26 

38.20 


1.64 
14.01 
.230! 
.062 
.292 
17.92 

9.15 
83.20 

1.29 
.84 

L63 

93.98 

6.02 

2.11 

.92 

18.39 

40.70 


20 


0.81 
7.50 
.177 
.063 
.239 
9.48 

8.50 
78.70 

1.75 
.66 

X41 

80.61 

ia39 

1.87 

.82 

11.62 

25.70 


PUBLIO  HEALTH  AND  MEDIOIKE. 


89 


CuADBO  lU-IV  (Serie  2*).~02aM  obrerch-ReparUei&n  dd  dgoe  y  rdaei&n  ddfdrforo  al 

dzoe. 


NADuraf* 


^loe  amoniaoftl 

delanreft 

I  del  Addo  Moo 

iioe  do  las  bas6S  pAiioM 

lIOo  pAiloo  total 

^100  total 

parte  del  Aioe  amoniaeal  por 

100  de  Aioe  total 

Parte  del  &Eoe  de  la  urea  por 

100  de  ^Izoe  total 

Parte  del  Aioe  del  Addo  tkrloo 

por  100  de  Aioe  total 

Parte  del&xoe  de  las  bases  p6- 

fioas  por  100  de  Aioe  total. . . 
Parte  Aioe  pMoo  total  por  100 

AaoetoUl. 

Fraodte  de  Aioe  determinado 

por  100 

Fraooite  de  Aioe  indetermliia- 

do  por  100 

Anhldrido  fosfdrioo 

FMbro  de  los  fosfatos 

Relaeidn  ponderal 

Belaeidn  attf  mioa 


21 

22 

23 

24 

26 

26 

27 

28 

29 

0.26 
8.68 
.IOC 
.044 
.144 
6.46 

1.62 
0.72 
.193 
.061 
.244 
18.90 

0.24 
4.66 
.118 
.044 
.157 
7.60 

0.82 
6.00 
.143 
.044 
.187 
8.66 

1.60 
11.14 
.247 
.061 
.298 
13.12 

1.81 
9.41 
.170 
.026 
.196 
2.47 

1.07 
8.86 
.060 
.070 
.120 
7.26 

2.01 
6.88 
.140 
.182 
.272 
0.60 

1.11 
9.44 
.140 
.161 
.291 
13.74 

3.47 

11.63 

3.19 

3.70 

11.42 

14.63 

14.77 

20.74 

8.06 

66.28 

60.92 

62.18 

67.73 

88.99 

76.46 

68.10 

66.62 

68.70 

1.66 

1.39 

1.61 

1.66 

1.88 

1.36 

.09 

1.44 

1.10 

.68 

.87 

.60 

.61 

.89 

.20 

.99 

1.34 

1.10 

2.23 

1.76 

2.10 

2.16 

2.27 

1.66 

1.68 

2.78 

2.29 

61.98 

88.81 

67.42 

68.60 

97.68 

01.66 

69.56 

79.04 

79.06 

88.02 

.76 

.33 

19.54 

43.80 

16.60 

1.60 

.65 

21.38 

47.30 

82.68 

1.06 

.46 

16.30 

36.00 

86.41 

1.47 

.64 

13.63 

29.90 

2.32 

«  1.66 

.68 

19.22 

42.60 

8.46 

1.01 

.44 

28.34 

62.70 

30.46 

.87 

.38 

18.06 

41.90 

20.96 

2.11 

.92 

10.63 

23.80 

20.96 

2.74 

1.20 

11.45 

25.80 

80 


1.68 
6.27 
.143 
.126 
.268 
9.89 

16.99 

68.40 

1.44 

1.25 

xeo 

82.08 

17.02 

1.06 

.47 

21.04 

46.60 


Nomsfos. 

81 

82 

83 

34 

85 

86 

87 

88 

89 

40 

4^floe  MnoiriacaK 

X25 
5.02 
.144 
.180 
.824 
10.75 

20.98 

46^70 

1.34 

1.67 

8.01 

60.80 

80.70 

2.11 

.92 

11.47 

25.4 

a  18 
11.20 
.140 
.068 
.222 
14.20 

5.49 

78.87 

.98 

.62 

1.60 
86.96 

14.04 
2.68 
1.17 

12.14 

26.9 

a86 
&32 
.123 
.018 

9.90 

&69 

84.04 

1.24 

.19 

1.48 

94.16 

5.84 

1.08 

.47 

21.06 

46.6 

.078 
18.84 
.260 
.216 
.475 
17.46 

4.47 

76.45 

1.49 

1.29 

2.78 
83.70 

16.80 
2.82 
1.01 

17.23 

8&1 

0.76 
6.77 
.154 
.038 
.187 
11.19 

6.79 

6a50 

1.88 

.20 

L67 
68.96 

81.04 
2.82 
1.01 

11.08 

24.5 

a77 
8.88 
.090 
.160 
.269 
11.22 

6.86 

78.68 

.80 

L51 

2.81 
87.85 

12.15 
2.81 
1 

11.22 

24.8 

a58 
7.17 
.196 
.061 
.246 
12.90 

4.60 

55.58 

1.51 
.40 

1.91 

n.99 

28.01 

1.76 

.77 

19.27 

42.7 

0.80 
4.28 
.811 
.065 
.866 
6.46 

6.04 

66.25 

4.88 

.85 

5.68 

76.97 

28.08 

L02 

.44 

14.40 

82.5 

a67 
&18 
.164 
.168 
.822 
11.78 

5.68 

69.44 

1.89 

1.84 

2.78 

77.85 

22.15 

2.19 

.96 

1L12 

24.6 

0.26 

Asoe  de  la  nraa 

7.84 

A.aoe  del  Acklo  dHoo 

.180 

Aaoe  de  las  bases  p^blcas 

Axoeptlrloo  total 

.002 
.272 

JLsoeiot&l 

10. 

parte  del  4aoe  amoniaoal  por 
100  deisoe  total 

2.60 

Parte  del  Asoe  de  la  urea  por 
100  de  Axoe  total 

Parte  del  4soe  del  4cido  drloo 
por  100  deisoe  total 

Parte  del  4soe  de  las  bases 
pOiicas  por  100  de&soe  total. 

Parte  4soe  poiloo  total  por 
parte  Asoe  porloo  total  por 
lOO&soetotaL 

por  100 

74.40 

LOO 

.08 

2.72 
08.72 

Fraoddn  de  Aaoe  Indetermi- 
nadopor  100 

21.28 

Anhidrfdo  Ibsfonoo 

2.14 

Fdsforo  de  los  fo3hit08^  X 

.08 

Rdaddn  ponderaL 

10.75 

Relarl<!^n  at<Ttni<ni     

28.8 

GuADBO  V-VIII  (Serie  2*). — Cla$e  aeomodadar—RepartiMn  del  dioe  y  relaei&n  dd 

/6$/oro  (U  dzoe. 


Ndmeros. 

41 

42 

48 

44 

46 

46 

47 

48 

r'  ^K>e  amoniaical  

0.U 
5.46 

0.71      1.52 
8.70  .    8.20 

0.88 
0.07 
.083 
.060 
.142 
10.40 
7.98 
87.21 
.80 

.67 
L45 

96.64 
8.86 
1.27 
&19 

8L1 

1.12 
6.99 
.100 
.081 
.181 
ia68 
10.64 
66.62 
.96 

.76 
LH 
68.92 
81.08 
.61 
17.84 
8&4 

0.61 
5.66 
.143 
.133 
.276 
0.76 
6.02 
66.86 
1.47 

1.86 
2.88 

64.71 

85.29 
.98 

10.49 

28.2 

1.96 
11.71 
.140 
.196 
.836 
16.81 
11.60 
60.66 
.83 

1.16 
1.99 

88.26 

16.75 
1.13 

14.88 

82.9 

1.82 

J  kioe  de  la  urea. 

8.87 

-  Ltoe  dd  icido  ilrioo 

1.076      .078      .197 
.084      .040      .081 
.160      .113      .278 

0.13     10          14.07 

.168 

J  kioe  de  las  bases  Ddncas 

.006 

Aioe irtlrioo totAl ^ ^  .s^^.s. 

.218 

Asoe  totAi T , 

18.70 

Parte  del  4soe  amoniaeal  por  100  de  4soe  total. 
Parte  del  &soe  de  la  urea  por  100  deisoe  total. 
Parte delAxoedeiddo  Moo  por  lOOdeAsoe total 
Parte  del  &soe  de  las  bases  ptiricas  por  100  de 
4ioe  total , . .    .  .  ..... 

4.47       7.10 

69.80    37.90 

.88        .78 

.90  '      -40 

10.80 

58.28 

1.40 

.67 
1.97 
71.06 
28.96 
.64 
2L98 
48.7 

0.08 

61.00 

1.19 

.40 

Parte4ioepmioo  total  por  100  &M>e  total 

Frarf!i<)ii  de  4ioe  detflrmlruido  por  100 

1.78 
66 

0.18 
20.2 

1.13 
46.13 
58.87 
.66 
16.88 
84 

1.60 
72.81 

PraccUSnde&soeindetennliiadoporlOO 

Anhidrfdo  fwf^W^    . 

27.60 
L20 

Rela(d6n  ponderal 

L43 

Rftefitfn at^^to^ .  ... 

SL4 

90 


PBOOEBDIKGS  8E00KD  PAK  AMBBIOAK  80IBKTIFI0  OOKOBEBS. 


GuADBO  V-VIII  (Serie  2*).— CIom  ocomodadtt-'ReparHeiAn  dd  dzoe  y  relaei&n  del 

fdsforo  al  6xo€ — OontiQiia. 


Ntbneros. 


ksoe  amonlacal 

i.so6  de  la  urea 

kioc  del  Aoido  flrioo 

i.foe  de  Ifls  bases  pdiioas 

Lioepdnoo  total 

Lxoe  total 

parte  del  &toe  amooiacal  por 

100  de  4soe  total 

Parte  del  &«>e  de  la  area  por 

100  del  &aoe  total 

Parte  del  &soe  del  4cido  drlco 

por  100  de  &«>e  total 

Parte  &£oe  pOnoo  total  por  100 

del  &soe  total 

Parte  &zoe  pt^rioo  indetermi- 

nado  por  100  de  &toe  total. . , 

Anhidrldo  fosfdiico 

Fitaforo  de  los  fosratos 

Belacidn  ponderal 

Relacidn  atdmica. 


a82 
6.38 
.144 
.147 
.291 
8.80 

9.88 
76.87 

1.77 

90.25 

9.75 

2.16 

.95 

8.69 

29 


0.79 
8.48 
.154 
.092 
.246 
12.91 

0.13 

65.22 

.80 

73.83 

26.67 

2.10 

.92 

14.06 

3L1 


8 


1.14 
10.52 
.134 
.066 
.200 
14.07 

8.10 

74.77 

.47 

84.31 

16.60 
2.68 
1.17 

12.01 

26.1 


L88 
&54 
.821 
.147 
.468 
12.40 

11.13 

68.87 

1.10 

83.36 

16.64 
2.48 
1.08 

11.44 

25.5 


1.38 
7.89 
.277 
.070 
.347 
13 

10.61 

60.19 

.64 

78.69 

26.41 
1.25 
1.54 

23.85 

62.8 


6 


086 
&96 

.1771 
.191 
.3681 
11.36 

7.48 
78.88 

1.68 
89.60 

10.40 
LOO 
1.70 

16.26 

36 


1 

11.67 
.184 
.088 
.272 

16.21 

6.17 

71.99 

.64 

79.83 

20.17 
2.40 
1.05 

15.45 

34.3 


8 


1.21 
13.44 
.147 
.180 
.327 
19.80 

6.62 

67.88 

.01 

76.16 

23.86 

1.36 

.60 

33.56 

74.3 


10 


084 
10.06 
.187 
.206 
.393 
12.09 

6.62 
79.27 

1.62 

88.98 

11.02 

1.13 

.49 

26.90 

57.3 


0.07 
0.93 
.080 
.125 
.205 
12.64 

6.34 
79.11 

1 

86u07 

13.93 

L40 

.61 

20.62 

46.4 


NtUneros. 


isoe  amoniacal 

^Koede  la  urea 

del  ^ido  drico 

.toe  de  las  bases  pdrlcas 

ksoepdrlco  total 

Parte  del  axoe  amoniacal  por 

100  de  &soe  total 

Parte  del  Asoe  de  la  urea  por 

100  de  izoe  total 

Parte  del  &Eoe  de  Aoido  drioo 

por  100  de&zoe  total 

Parte  del  &soe  de  las  bases 

ptkioas  por  100  izoe  total... 

Parte  ilsoe  purloo  total  por  100 

de&£oe  total 

Fracoidn  de  Aioe  determinado 

por  100 

FriBccidn  de  Asoe  Indetermln- 

ado  por  100 , 

Anhidrldo  fosfdrioo 

Fdefbrode  los  fosfatos 

Relacidn  ponderal 

Relacidn  atdmioa 


11 


1.21 
15.03 
.100 
.110 
20.80 

6.72 

72.46 

4.70 

6.26 

10.06 
88.22 


11.78 
2.88 
1.25 

16.70 

37 


12 


0.79 
6.72 
.174 
.200 
12.40 

6.21 

64.19 

1.40 

1.66 

3.06 
63.46 


36.64 

1.60 

.70 

17.71 

39.2 


13 

14 

16 

16 

0.63 
4.55 
.190 
.059 
7.68 

0.36 
9.41 
.304 
.055 
11.78 

1.37 
12.50 
.217 
.108 
17.20 

0.66 
5.44 
.130 
.092 
7.06 

8.22 

3.06 

7.96 

9.35 

69.24 

70.88 

72.74 

76.49 

2.46 

2.68 

1.26 

1.69 

.77 

.47 

.63 

1.30 

3.22 
70.66 

3.06 
85.99 

1.89 
82.50 

2.99 
88.83 

29.32 
1.36 
.59 
13 
28.8 

14.01 

2.21 

.96 

12.37 

27.4 

17.41 

2.34 

1.02 

16.86 

37.3 

11.17 

1.21 

.53 

13.21 

29.2 

17 


0.76 
14.89 
.137 
.099 
19.26 

3.05 

77.81 

.71 

.51 

1.22 
82.68 


17.42 

3.00 

1.57 

12.27 

27.2 


18 

19 

0.96 

11.84 

.200 

.177 

15.68 

0.91 
12.05 
.130 
.147 
14.12 

6.12 

6.44 

75.45 

86.34 

1.27 

.92 

1.29 

1.04 

2.56 
84.13 

1.96 
93.74 

16.87 

1.86 

.81 

19.26 

42.6 

0.26 

2.28 

.99 

14.28 

31.6 

20 


1.24 
10.33 
.284 
.177 
14.39 

8.68 

73.31 

1.64 

.81 

3.46 
83.34 


16.66 

1.96 

.85 

16.81 

37.3 


Ndmeros. 


Lsoe  amoniacal 

ksoede  la  urea 

dellUsido  drioo 

itoede  las  bases  pdricas 

isoe  ptMoo  total 

Lsoe  total 

Parte  del  &soe  amoniacal  par  100  de  &soe  total 
Parte  del  Azoe  de  la  urea  por  100  de  Asoe  total. 
Parte  del  Aioe  del  Aoido  orico  por  100  de  &Eoe. 
Parte  del  &soe  de  las  bases  pdrioas  por  100  de 

<Lsoe  total 

Parte  &zoe  purico  total  por  100  &Eoe  total 

Fraocidn  de  Azoe  determinado  por  100 

Anhidrldo  fosfdrioo 

Fdsforo  de  los  fosfotos 

Relaoldn  ponderal 

Relacidn  atdmioa 


31 


1.24  ! 
10.85 
.060 
.066! 
.146 
16.48 
7.62 
65.84 
1.47 

.40 

.87 

74.23 

2.40 

1.05 

15.69 

34.7 


22 

28 

24 

0.99 

1.03 

0.85 

9.46 

7.86 

6.70 

.137 

.140 

.214 

.121 

.018 

.117 

.248 

.158 

.331 

12.62 

11.88 

8.10 

7.91 

8.67 

10.49 

75.56 

66.17 

70.37 

1.01 

1.18 

2.64 

.97 

.15 

1.44 

1.98 

1.33 

4.06 

85.45 

23.83 

15.06 

1.92 

1.80 

1 

.84 

.78 

.44 

14.67 

16.23 

18.41 

32.6 

33.7 

40.8 

25 


0.66 
9.68 
.10(^ 
.059 
.159 
14.50 
4.55 
66.76 
.60 

.41 

1.10 

27.59 

1.88 

.82 

17.68 

39.1 


26 

27 

0.96 

0.10 

11.20 

11.27 

.196 

.210 

.026 

.087 

.221 

.247 

15.50 

13.58 

6.19 

8.10 

72.26 

82.90 

1.25 

1.54 

.17 

.27 

1.42 

1.81 

20.13 

7.19 

1.55 

2.62 

.68 

1.14 

22.79 

11.91 

50.4 

36.4 

38 


1.06 
13.33 
.324 
.037 
.361 
16.46 
6.44 
74.85 
1.36 

.22 

1.68 

17.13 

3.11 

.93 

16.80 

37.3 


FUBLIO  HEALTH  AND  MEDIOIKE. 


91 


CuADRO  I'll  (Serie  2).—R€partici6n  dd  dzoe  6  rilacidn  ddfdsforo  al  dzoe. 

[AnAUsis  hoohos  en  TuQja.] 


Ntkmeros. 


amoninoal 

de  la  area , 

del  Acido  Ailoo 

de  las  bases  pAiioas 

Asoe  pdrlco  total 

Azoe  total 

Parte  del  4xoe  amonJacal  por 

100  de  &ioe  total 

Pftrte  del  &soe  de  la  urea  por 

100  de  &zoe  total 

Parte  del  &soe  del  Addo  tirico 

por  100  del  4«>e  total 

Parte  del  4soe  de  las  bases 

ptaicas  por  100  de  &ioe  total . . 
Parte  del  azoe  pt^rico  total  por 

100  de  &zoe  total 

FraockSn  del&ioe  determinado 

por  100 

Fraocidn  del  &soe  indetermina- 

do  por  100 

Anhidro  fosfdrlco 

F<toforo  de  los  fosftitos 

Relacidn  ponderal 

Relacidn  atdmtca 

Ndmeros. 

ksoe  amoniacal 

de  la  urea 

ksoe  del  &cido  Arico 

^soedelas  bases  pdrlcas 

^zoe  pt^rico  total 

Lsoe  total 

Parte  del  &soe  amoniacal  por 

lOOdeisoe  total , 

Parte  del  &soe  de  la  urea  por 

100  del  &zoe  total 

Parte  del  4soe  del  Addo  Arico 

por  100  de  &ioe  total 

Parte  del  4zoe  de  las  bases 

pAricas  por  100  de&zoe  total. . 
Parte  del  acoe  pArico  total  por 

100  de  6.toe  total 

Fracddn  del&soe  determinado 

por  100 

Fracddn  del  &soe  indetermina- 

do  por 100 

Anhidro  fosfdrloo 

Fdsforo  de  los  fosfatos 

Reladdn  ponderal 

ReiackSn  atdmica 


0.81 

7.50 

.18 

.062 

.242 

12.35 

6.56 
60.73 

1.46 
.50 

1.96 

77.75 

22.25 

1.87 

.82 

14.90 

11.1 


0.89 

4.28 

.81 

.0601 

.37 

6.46 

6.04 
66.25 

4.83 
.85 

5.68 

76.97 

23.03 

1.02 

.44 

14.40 

32.5 


8 


0.87 
13.40 
.243 
.087 
.280 
15.07 

5.77 
82.28 

1.59 
.25 

1.84 

89.89 

10.10 

2.22 

.97 

15.55 

34.4 


0.62 

7.n 

.167 
.018 
.185 
10.09 

6.14 
76.41 

1.68 
.18 

1.86 

86.27 

13.73 

1.33 

.58 

17.33 

38.5 


0.36 
9.41 
.804 
.055 
.350 
11.78 

8.06 
79.88 

2.58 
.47 

3.05 

85.99 

14.01 

2.21 

.90 

12.37 

27.4 


0.30 

10.18 

.14 

.062 

.202 

14.12 

2.12 

73.10 

.08 

.44 

1.42 

76.64 

23. 3C 

2.12 

.93 

14.10 

51.2 


0.86 

7.04 

.16 

.0701 

.23 

9.36 

11.32 

75.21 

1.70 
.75 

2.45 

88.98 

11.02 

1.56 

.69 

15.30 

33.9 


8 


0.93 

4.75 

.27 

.1101 

.38 

9.00 

10.33 

52.74 

3.00 

1.22 

4.22 

67.29 

32.71 

1.20 

.52 

17.30 

38.3 


0.58 

6.41 

.30 

.060 

.36 

11.95 

14.85 

52.89 

2.61 
.52 

3.13 

60.87 

39.13 

2.61 

.93 

12.85 

28.4 


10 


0.46 
3.31 
.31 
.001 

.88 
6.77 

7.80 

57.37 

3.64 

1.12 

4.76 

69.93 

30.07 

1.49 

.65 

8.88 

12.3 


11 

12 

0.39 

0.73 

5.92 

7.26 

.23 

.12 

.93 

.185 

.323 

.305 

7.20 

10.99 

5.36 

6.64 

82.22 

66.05 

4.55 

1.09 

1.29 

1.68 

6.84 

3.77 

93.42 

75.46 

6.58 

24.54 

1.47 

1.49 

.64 

.65 

11.35 

16.91 

24.09 

37.04 

13 


14 


15 


0.59 

7.51 

.21 

.131 

.341 

11.97 

4.97 

66.26 

1.75 

1.18 

1.93 

73.15 

26.84 

1.58 

.60 

17.35 

35.3 


0.49 

6.75 

.18 

.118 

.298 

13.09 

4.05 
55.00 

1.49 
.98 

3.47 

60.52 

39.48 

2.36 

.63 

11.72 

25.9 


0.54 

7.49 

.26 

.070 

.330 

11.81 

4.57 

63.42 

2.20 

.593 

.793 

70.78 

29.22 

3.17 

.94 

12.56 

27.8 


16 


17 


18 


19 


a82 

5.19 

.20 

.134 

.339 

9.26 

8.96 

56.72 

3.31 

1.506 

3.718 

69.39 

30.61 

1.94 

.85 

10.76 

23.8 


1.09 

7.19 

.11 

.053 

.163 

13.46 

8.13 

53.73 

.82 

.895 

1.215 

74.07 

25.93 

1.20 

.52 

25.77 

57.00 


1.38 

7.54 

.25 

.072! 

.322 

14.04  , 

9.83  I 
53.53  I 

1.85  i 
.513 

2.363 

65.72 

34.28 

1.20 

.52 

27.38 

60.6 


1.26 

7.17 

.19 

.106 

.296 

13.44 

9.37 
53.34 

1.41 
.79 

2.20 
64.91 

35.09 
2.56 
1.12 

12.00 

26.6 


20 


0.59 

7.00 

.15 

.263 

.413 

13.80 

4.23 

51.23 

1.09 

1.18 

2.27 

57.73 

42.27 
2.70 
1.18 

11.69 

25.9 


Promedios  de  Bogotd, 


Clase 
obrera. 

Clase 
acomodada. 

Promedios 
genoraks. 

Densidad 

1.018 
1.727 
.037 
11.29 
1.37 
16.84 
1.12 
.52 
.26 
1.18 
7.86 
.174 
.006 
.270 
10 
69.71 

1.021 
1.590 
.044 
13.69 
1.16 
21.21 
1.12 
.62 
.26 
.95 
9.90 
.174 
.092 
.6226 
6.99 
72.11 

1.019 

Volumen  en  24 

1.668 

Aoides(enH) 

.040 

Asoe  total 

12.44 

AmnnfAiV>  V  A'HdOfl  ftJOifV^doil .  .  . , „ . , 

1.26 

TTrea 

19.02 

Burlnas  totales  (en&ddoilrioo) 

1.12 

Acido drico .a -  T 

.62 

Bases  nOricas  (•!>  zantlna) ,  -  -  r  -  -  , . . . . 

.26 

>«<>©  aim>nlacal  ^ r  -  r  r , . , . . . 

1.04 

.mthf  A»  la  urea 

8.88 

>soe  del  Arldo  Aflco 

.174 

.Boede las  b^um i>(lri'^a9 .s. 

.004 

.loepftrlno  total! 

.368 

Parte'del  Asoe  amoniacal  por  iOO  de  Asoe  totie^l.^  

8.49 

Parte  del  Asoe  de  la  urea  por  100  deAioe  total 

7a  91 

92 


PROCEEDINGS  SECOND  PAN  AMBBICAN  SCIENTIFIC  CONGRESS. 


Promedios  de  BogtM — Contin6a. 


Parte  del  &«>e  del  &oido  Arico  por  100  de  Asoe  total . . 
Parte  del  &soe  de  las  bases  pdnoas  por  100  Axoe  total. 

Parte  del  Aoldo  tlrico  total  por  100  de  Asoe  total 

Fiaccidnde&soedeterminadoporlOO 

Fracddn  de  Azoe  indetermlnado  por  100 

Indlce  de  imperfeocidn  ureog6nica  por  100 


Coeflciente  de  trasformacidn  de  los  ntideoproteldeos  por  100. 

Anhldrido  fostdrico 

Fdsforo  de  los  (osratos 

Relaoidn  ponderal 

Relaoi6n  at^mioa 


Oaie 

Claae 

obrera. 

AOOTnodada. 

1.54 

1.28 

.86 

.68 

2.30 

1.96 

82.10 

81.00 

17.99 

18.94 

12.64 

8.86 

04.48 

65.8 

1.91 

1.97 

.76 

.86 

14.86 

15.80 

1:32.9 

1:35 

Promedios 


1.41 

.76 

2.17 

81.58 

18.42 

10.09 

1:64.82 

n:02.90 

1.94 

.81 

15.82 

1:33.9 


{ 


Promedios  de  Tunja. 


Densidad 1014 

Volumen  en  24  horas 2548cc 

Acidez  (en  H) 068 

Azoe  total 11. 19 

Amoniaco  y  dcidos  aminados 89 

Urea 15.40 

Purinas  totales  (en  ^ido  drico) . .     1. 22 

Acido  tirico 56 

Bases  ptiricas  (en  xantina) 229 

Azoe  amoniacal 75 

Azoe  de  la  urea 7.10 

Azoe  del  dcido  tirico 18 

Azoe  de  las  bases  ptuicas 11 

Azoe  ptuico  total 29 

Parte  del  4zoe  amoniacal  por  100 

de  dzoe  total 6. 70 

Parte  del  4zoe  de  la  urea  por  100 

dedzoe  total 63.44 


Parte  del  4zoe  del  dcido  tirico  por 

lOOdedzoe  total 1.62 

Parte  del  &zoe  de  las  bases  ptuicas 

por  100  de  dzoe  total 98 

Parte  del  &zoe  pdrico  total  por 

100  de  dzoe  total 2. 60 

Fracci6n   de    dzoe   determinado 

por  100 72.74 

Fracci6n  de  izoe  indeterminado 

por  100 27.26 

Coeficiente  de  trasfonnacidn  de  los 

nucleoproteidos  por  100,  1 60. 23 

Coeficiente  de  trasformacidn  de  los 

nucleoproteidos  por  100,  II 60. 07 

Anhidrico  fosf6rico 1.86 

F^sforo  de  los  fosfatos 81 

Relaci6n  ponderal 21. 22 

Relaci6n  at^ica 1:46. 9 


Promedios  geneniUi. 


Densidad 1. 016 

Volumen  en  24  horas 2.103 

Acidez  (en  H) 054 

Azoe  total 11. 81 

Amoniaco  y  dcidos  aminados 1. 07 

Urea 17.41 

Purinas  totales  (en  dcido  drico). .    1. 17 

Acido  tirico 54 

Bases  ptiricas  (en  xantina) 27 

Azoe  amoniacal 89 

Azoe  de  la  urea 7. 99 

Azoe  del  ^ido  tirico 096 

Azoe  de  las  bases  ptiricas 102 

Azoe  pdrico  total 148 

Parte  del  dzoe  amoniacal  por  100 

de  4zoe  total 7. 59 

Parte  del  dzoe  de  la  urea  por  100 

dedzoe  total 67.17 


Parte  del  &zoe  del  dcido  tirico  por 

100  de  dzoe  total 

Parte  del  dzoe  de  las  bases  pdri- 

cas  por  100  de  &zoe  total 

Parte  del  ^oe  pdrico  total  por 

100  de  &zoe  total 

Fracci6n  de  &zoe  determinado 

Fraccidn  de  ^oe  indeterminado. . 
tndicede  imperfecci6nureog6iiica. 
Coeficiente  de  trasformaci6n  de  los 

ndcleoproteidos  por  100,  I 

Coeficiente  de  trasformaci6n  de  los 

ndcleoproteidos  por  100,  II 

Anhidrido  fo8f6rico 

F6sforo  de  los  fosfatos 

Relaci6n  ponderal 

Relacidn  aUSmica 


1.51 
.87 

2.38 
72.76 
22.84 

9.92 

62.52 

62.48 

1.90 

.81 

18.27 

36.56 


PUBLIC  HEALTH  AKD  MEDICINE. 


93 


Di8cusi5n  db  LOS  Rbsultados  Obtbntoos. 

Si  86  quiere  sacar  alguna  ensefianza  del  cuadro  de  promedioe  de  los  noventa  y  seis 
an^isis  en  general,  de  cada  clase  social  en  particular,  es  indispensable  conocer  el 
lesultado  de  an^lisis  hechoe  redentemente  en  Europa  y  tenidos  sdll  como  precisoe. 

La  comparaci6n  posterior  entre  loe  resultadoe  obtenidos  en  Bogotd  y  los  obtenidos 
en  Tunja,  noe  dar&  preciosas  ensefianzas  sobre  el  metabolismo  azoado  entre  nosotros. 

Antes  de  hacer  comparaciones  y  como  punto  de  partida,  voy  a  permitirme  trascribir 
el  cuadro  de  resultadoe  medios  obtenidos  por  Maillard,  el  cual  es  considerado  en 
Francia  ''como  uno  de  los  documentos  m^  completos  que  se  poeee  en  la  hora  actual 
sobre  la  orina  del  hobre  con  regimen  mixto,  puesto  que  los  andlisis  se  hicieron  por  loe 
procedimientoe  m^  precisos  conocidos  hasta  entonces  y  que  cada  una  de  las  cifras 
del  cuadro  representa  el  promedio  de  sesenta  determinaciones/'  Tiene  ademds,  en 
el  caso  presente  la  inmensa  ventaja  de  que  los  resultados  fueron  obtenidos  casi  en  su 
totalidad  y  con  ligeras  variaciones,  por  los  mismos  m^todos  de  andlisis  empleadoe 
por  mi. 

He  aquf  estoe  promedios  de  eliminaci6n  en  veinticuatro  horas: 

Parte  del  ^oe  del  ^do  tirico 

por  100  de  izoe  total 1.43 

Parte  del  &zoe  de  las  bases  ptiri- 

cas  por  100  de  dzoe  total .22 

Parte   del    dzoe    silicottigstico 

por  100  de  dzoe  total 57 

Fracci6n  determinada  de  4zoe 

por  100 88. 86 

Fracci6n     indeterminada     de 

&zoepor  100 11.15 

Anhidrido  fosf^rico 2.19 

Fdsforo  de  los  fosfatos 96 

Relaci6n  at6mica 1:37.9 


Volumen 

1.810 

Addez  (en  hidr6geno) 

A  moniftco .  . .  t  t .,,,,,,- 

.045 
1.11 

Urea 

27.64 

Purinftfl  biiflicM 

.10 

A  zoe  total 

15.87 

Azoe  amoniacal 

Azoe  de  la  urea 

Azoe  ptirico  total 

Azoe  del  4cido  tirico ; . . . 

.91 
12.09 
.262 
.227 

Azoe  de  las  bases  pMcas 

Azoe  silicottingstico 

Parte  del  izoe  amoniacal  por 
100  de  izoe  total 

.035 
.090 

5.73 

Parte  del  dzoe  de  la  urea  por  100 
de  izoe  total 

81.29 

Si  se  comparan  estos  resultados  con  mi  cuadro  de  promedios  se  observan  diferendas 
considerables  en  la  mayor  parte  de  las  dfras:  diferendas  que  no  pueden  atribuirse  a 
errores  de  ttoiica  porque,  como  ya  dije,  los  an^isis  se  hideron  por  los  mismos  m^todos 
que  emple6  MaHlard  y  algunos  procedimientoe  mia  precisos  no  conoddos  en  la  6poca 
en  que  hizo  sus  an&lisis  este  distinguido  fisidlogo.  Adem&s,  los  reactivos  fueron 
titulados  con  el  mayor  escruptilo  y  usando  medidas  de  las  m^  precisas  conoddas, 

Analicemoe  separadamente:  1^.  Los  productos  de  desintegrad6n  albiuninoidea. 
2^.  Los  de  de8integrad6n  ndcleo  proteica:  (3°)  dzoe  total.  (4^)  izoe  indeterminado. 
(5**)  fdsforo.    (6**)  addez. 

I.  Productos  de  denntegraci&n  albuminoidea. — ^Lo  primero  que  llama  la  atend6n  al 
hacer  la  comparad6n  de  los  dos  promedios  es  que  hay  en  los  mfos  una  disminud6n  de 
la  urea  (de  10.23)  disminud^n  m^  considerable  que  la  encontrada  por  el  Dr.  del  Rfo 
pues  61  encontr6  en  algunos  casos  hasta  36  gramos  en  las  24  horas.  Es  posible  que  esta 
deeproporci6n  de  cifras  obtenidas  en  la  misma  localidad  sea  debida  a  que  el  Dr.  del 
Rio  al  medir  la  urea  por  el  procedimiento  gasom^trico  no  elimin6— o  no  lo  hizo  hasta 
donde  es  posible  hoy — ^las  causas  de  error  debidas  a  las  variadones  de  temperatura  y  de 
pred6n  atmosf^ca  asi  como  las  causadas  por  el  icido  drico,  las  bases  pdricas  y  el 
amoniaco. 

Esta  disminud6n  de  la  excred6n  de  la  urea  entre  noeotros  en  parte  relativa 
porque  hay  al  mismo  tiempo  una  disminud6n  del  izoe  total  diferenda  que  es  de  4.06 
en  las  24  horas.    Pero  se  ver4  que  la  primera  es  tambi^n  real  si  se  compara  la  dira 


94  PROCEEDINGS  SECOND  PAN  AMEBICAN   SCIENTIFIC  C0N0BE8S. 

que  representa  la  relaci6n  entre  el  dsoe  de  la  urea  y  den  partes  de  &zoe  total  que  es 
entre  noeotros  de  67.17  y  en  Eiuropa  81.29  segdn  Maillard:  y  eegtin  DeQg[rez  y  Aysignac, 
quienes  se  fundan  en  un  gran  ndmero  de  an&lisis,  ee  como  eigne  para  loe  diferentes 
regfmenes: 

Regimen  l&cteo  absolute  86,  regimen  mixto  (leche  nuevoe  vegetalcs)  86,  regimen 
mix  to  (lacto-vegetariano)  81,  regimen  mixto  d^bilmente  cameo,  82,  regimen  mixto 
(vegetariano  absoluto)  78. 

Comparando  abora  loe  andlisis  de  Tunja  con  loe  de  Bogota,  observamoe  una  diferen- 
cia  en  favor  de  6etoe  de  3.62  para  la  cifra  de  la  urea  y  de  7.47  para  la  relaci6n  entre 
el  dzoe  total  y  la  urea.  Dato  muy  intereeante  que  debe  tenerse  muy  presente  para 
las  conclusiones  de  este  estudio. 

Es  verdad  que  para  dosar  la  urea  emplee  m^todoe  diferentes  de  los  del  experimen- 
tador  cuyos  datos  estdn  sirviendo  de  comparaci6n  pues  61  emple<5  el  de  Folin  en  tanto 
que  yo  emple6  el  gasom^trico;  pero  las  causas  de  error  de  que  adolece  este  tiltimo 
fueron  corregidas  en  gran  parte;  por  otra  parte  el  error  si  existi6  debi6  ser  por  exceso 
por  falta  do  una  completa  precipitaci6n  del  dcido  drico  y  de  las  bases  pdricas;  por 
dltimo;  existe  el  antecedente  de  la  igualdad  de  los  resultados  obtenidos  por  Desgrez 
y  Ayrignac  con  el  m^todo  gasom^trico  y  los  de  Maillard  con  el  de  Folin. 

En  cuanto  al  amonlaco,  se  observa,  en  los  anilisis  de  Bogotd  un  aumento  de  0.15 
con  respecto  al  cuadro,  lo  que  estd  de  acuerdo  con  la  disminucidn  de  la  urea. 

En  los  andlisis  de  Tunja  se  observa  al  contrario  una  disminuci6n;  pero  si  en  vez  de 
tener  en  cuenta  la  sola  cifra  del  amonfaco  se  considera  la  del  dzoe  amoniacal  con  rela- 
ci6n  al  dzoe  total,  se  ver&  que  esta  diBminuci6n  no  es  sino  aparente  pues  hay  en  favor 
de  los  an&lisis  de  Tunja,  un  aumento  de  1.07  con  relaci6n  al  cuadro  que  sirve  de 
patr6n. 

Hay  pues  siempre  una  relaci6n,  mis  o  menos  exacta  entre  la  disminucidn  de  la 
urea  y  el  aumento  del  amonfaco. 

Es  de  notar  que  para  medir  el  amonfaco  emple^  el  procedimiento  de  Ronchese,  con 
las  mismas  correcciones  con  que  lo  emple6  Maillard. 

Como  se  hace  m^  patente  esta  diferencia,  es  comparando  los  fndices  de  inperfec- 
ci6n  urog^nica  que  son,  segtln  el  cuadro  del  autor  copiado  arriba,  de  6.58  por  ciento. 
Aplicando  el  calculo  a  los  an&lisis  de  Donze  y  Lambling,  se  encuentra  6.12. 

Estas  cifras  varfan  segtin  Lauzenberg^  con  el  regimen  alimenticio:  El  r^lmen 
licteo  da  valores  mis  d^biles  (4.28)  y  el  camoe  miis  fuertes  (6.31).  (Es  decir  menores 
que  los  obtenidos  por  VaQlard  con  regimen  mixto).  El  vegetariano  da  valores  medios 
(5.21). 

Cualquiera  que  sea  el  valor  que  se  atribuya  a  loe  resultados  que  menciono,  es  precise 
observar  que  existe  entre  nosotroe  un  aumento  de  este  coeficiente,  mucho  mayor  para 
las  clases  pK)bre8  que  para  las  clases  acomodadas.  Y  que  el  promedio  de  Tunja  que 
se  refiere  a  individuos  m^  mal  que  bien  alimentados,  es  mayor  que  el  de  la  clase 
acomodada  de  Bogotd. 

Es  verdad  que  todavfa  no  se  c<fnocen  bien  las  variaciones  fisiol6gicas  de  este  coefi- 
ciente, pero  dada  la  desproporci^n  que  existe  entre  las  cifras  apuntadas  y  las  obtenidas 
por  mf ,  es  precise  concluir  que  existe  entre  nosotroe  (y  quizi  un  poco  m^  en  Tunja 
que  en  Bogotd)  una  imperfecci6n  en  la  transformaci6n  de  las  albuminoideas  o  sea  una 
insuficiencia  de  la  actividad  global  del  oiganismo  para  el  conjunto  de  estos  tres  fen6- 
menos:  separaci6n  reductiva  o  hidrolftica  del  amonfaco,  oxidaci6n  de  los  4cidos  grasoe 
y  deshidrataci6n  del  carbonato  de  amonfaco,  lo  que  se  comprenderi  fdcilmente  si 
se  recuerdan  las  trasformaciones  que  su&en  los  amino^idos  que  llegan  hasta  la  urea; 
de  aquf  que  este  fndice  haya  side  llamado  tambi^n  coeficiente  de  oxidaci6n  verdndero 
o  de  los  ^idoe  grasos. 


1  Tesis  de  Paris,  1812. 


PTTBLIO  HEALTH  AND  MEDICINE.  95 

Eete  aumento  de  la  imperfecci6n  urog^ca  puede  ser  debido:  a  la  calidad  del 
regimen  alimenticio,  a  una  inmificiencia  hepdtica,  a  una  lentitud  de  laa  oxidacionee  o 
del  metaboliflmo  en  general,  laa  qua  a  su  tumo  pueden  depender  de  otras  tantas  causaa 
qua  analizar^  m&B  adelante. 

(a)  El  regimen  cameo  aumenta  y  el  regimen  vegetaiiano  disminuye  el  coeficiente 
en  cuestidn:  eeto  porque,  como  se  vi6  atr&B  los  dcidos,  que  se  fonnan  en  el  organismo, 
icidoB  que  reeultan  sobre  todo  de  la  deeintegraci6n  de  los  albuminoideos  animalee, 
retienen  fuertemente  el  amoniaco  y  le  impiden  seguir  su  tranirfonnaci6n  hada  la 
urea. 

Entre  noeotroe  no  parece  que  se  deba  atribuir  a  esta  causa  el  aumento  del  coefi- 
ciente  I^  porque  la  observacidnnos  ensefia  que  nuestras  clases  acomodadas  consumen 
mucha  menos  came  que  la  que  se  consume  en  los  palses  latinos  de  Europa  (menos 
camlvoros  que  los  sajones). 

8egtin  se  deduce  de  los  autores  que  he  podido  consultar  a  este  respecto,  la  cifra 
media  de  came  consumida  por  cada  individuo  en  Paris  es,  como  se  ver4  m^  adelante, 
superior  al  miximum  de  nuestras  clases  acomodadas:  (2°)  Porque  el  aumento  es  mayor 
en  las  clases  pobree  cuya  alimentaci6n  es  especialmente  vegetaiianae  bidrocarbonada 
y  (3^)  porque  los  mismos  andlisis  de  las  orinas  dejan  ver  que,  al  menos  en  Bogotd, 
no  hay  un  aumento  de  la  acidez  pues  esta  cilra  es  inferior  la  obtenida  por  Maillard, 
lo  que  indicarfa  mis  bien  un  predominio  del  regimen  vegetariano. 

(b)  Podria  mis  bien  pensarse  en  una  insuficiencia  hepdtica,  teniendo  en  cuenta 
que  el  Indice  de  imperf  ecci6n  iurog6nica  es  mucho  mayor  en  nuestras  clases  trabajadoras 
las  que,  como  se  sabe  ingieren  una  gran  cantidad  de  alcohol  en  la  chicha,  bebida  que 
constituye  en  muchos  de  estos  individuos  casi  la  totalidad  su  alimentaci6n. 

(c)  Pero  puesto  que  la  cifra  es  tambi^n  elevada  en  las  clases  acomodadas,  fuerza  es 
concluir  que  si  la  causa  de  que  acabo  de  hablar  existe  o  puede  existir  por  la  insufi- 
ciencia  de  la  alimentaci6n  animal  que  obligarfa  a  recargar  las  vfas  digestivas  con  un 
exceso  de  alimentos  vegetalee  lo  que  serfa  causa  de  insuiiciencia  hepdtica  hay  otros 
datos  consignados  en  el  curso  de  este  estudio  que  no  podrfan  pasar  inadvertidos  como 
son:  la  baja  de  temperatura,  de  gl6btilos  rojos  y  de  hemoglobina,  lo  que  obliga  a  creer 
en  una  lentitud  entre  nosotros  de  todas  las  trasformaciones  orginicas  quizi  por  insu- 
ficiencias  glandulares  que  traen  consigo  insuficiencias  de  fermentos. 

Ahora:  llevando  las  cosas  hasta  donde  es  posible,  al  terreno  de  un  r^^en  alimenticio 
semejante,  podrfan  como  ya  dije,  considerarse  los  sujetos  de  mis  experimentos  en 
Tunja  como  pertenecientes  a  la  '^clase  obrera"  de  Bogot4. 

Hay  en  aqu^llos  un  aumento  con  relaci6n  a  6stos,  aumento  que  no  estarfa  en  rela- 
ci6n  con  la  ligera  disminuci6n  de  gl6bulos  rojos  y  de  temperatura.  Adelante  se  veri 
alguna  explicaci6n  a  este  fen6meno,  pero  serla  imprudente  f ormular  conclusidn  alguna 
dado  el  pequefio  ntimero  de  mis  observaciones  de  Tunja  con  relaci6n  a  los  de  Bogotd. 

II.  Producios  de  desintegraddn  ndcleo  proteidica:  Indice  de  su  trQns/ormaci6n. — 
Obs^rvese  que  las  cifras  que  repreeentan  el  acido  drico  y  las  bases  ptiricas  son  casi 
id^nticas  en  el  cuadro  de  Bogotd  (0.78)  y  en  el  de  Maillard  (0.77).  Muy  ligeramente 
aumentados  en  el  de  Tunja  (0.81):  lo  que  indica  que  la  alimentaci6n  nucleo-proteica 
es  casi  la  misma  entre  nosotros  y  los  individuos  que  sirvieron  de  ob8ervaci6n  a  Maillard. 
Pero  hay  mis:  comparando  las  dos  cifras,  en  que  estdn  divididos  los  promedios  de 
Bogoti  se  ve  que  casi  son  id^nticas  en  la  *'clase  obrera''  y  en  la  clase  acomodada  lo 
que,  dada  la  diversidad  de  regimenes  alimenticios,  parece  a  primera  vista  inex- 
plicable; pero  si  es  verdad  que  nuestros  obreros  no  consumen  todo  el  caf^,  el  te  y  el 
cacao  que  consumen  las  clases  acomodadas,  consumen  en  cambio  chicha,  la  que  por 
sus  levaduras  da  gran  cantidad  de  purinas  y  por  su  alcohol  y  sus  toxinas,  destmye 
probablemente  una  gran  cantidad  de  nticleoproteidas  orginicas. 

Si  se  comparan  las  cifras  que  representan  el  porcentaje  en  reladdn  con  el  izoe  total, 
se  veri  que  nosotros  ingerimos  o  destruimos  una  mayor  cantidad  de  ndcleo  proteidas,  en 


96  PBOOEEDINGS  SECOND  PAK  AMBBIOAN  SOIBlfrnFIO  C0KGBES8. 

relaci6n  con  las  albuminoideas.    Pero  a  pesar  de  la  igoaldad  de  las  cifras,  el  desa- 

cuerdo  vuelve  entre  mis  anilisis  y  los  que  ban  servido  de  comparacidn  con  los  europeos, 

si  se  divide  la  dfra  de  las  purinas  en  sus  dos  factores:  icido  drico  y  bases  ptiricas,  hay 

para  el  primero  un  deficit  en  mis  anAlims  de  0.16  en  los  anjUims  de  Bogota  y  de  0.12  en 

los  de  Tunja,  y  para  la  8eg:unda  un  aomento  de  0.17  en  los  de  Bogota  y  de  0.19  en  los  de 

Tunja. 

Despu^  de  observar  que  mis  anAlisiH  de  estas  sustancias  fueron  hechos  por  los  mismos 

procedimientos  que  emplearon  Donze  y  Lambling,  Maillard  y  Boudrez  con  algiinaa 

variaciones  respecto  al  icido  drico  por  procedimientos  mis  modemos  y  por  un  estudio 

detenido  de  los  distintos  m^todos  (veise  pig.  78-79)  es  precise  concluir  que  hay  entre 

nosotros  un  aumento  de  los  t^rminos  intermedioe  de  la  tranflformaci6n  de  los  nticleoe 

proteidas,  a  expensas  del  tannine  final  de  estas  transformaciones;  sucede,  por  consi- 

guiente,  algo  muy  semejante  a  lo  que  pasacon  la  deeintegraci6n  de  las  albuminoideas 

con  la  sola  dif  erencia  de  que  en  el  case  presente  (probablemente  por  la  menor  interven- 

ci6n  del  higado)  la  dif  erencia  no  existe  entre  la  clase  acomodada  y  la  clase  obrera,  pero 

al  estudiar  larelaci6n,  veremos  que  hay  entre  los  anilisis  de  Bogoti  y  los  de  Tunja,  una 

dif  erencia  en  contra  de  6stos. 

Queda  pues,  desde  este  punto  de  vista,  justificado  mi  coeficiente  detran8{ormaci6n 

de  las  ndcleoproteidas  que  podrf  a  llamarse  tambi^n  de  oxidaci6n  o  de  de6amidaci6n 

vistoB  los  distintos  grados  de  deeintegraci6n  porque  pasan  estoe  cuerpos  (v6anse  pig. 

73  y  siguientes). 

^  ^  .         Az  A.  U. 

Este  coeficiente  ^^  p  >p 

es,  segdn  mi  cuadro  de  anilisis  de  Bogoti,  de  64.87  por  ciento  con  mha  dif  erencia  de 
0.80  en  favor  de  la  clase  acomodada  y  de  60.23  en  los  promedios  de  Tunja;  es  decir, 
que  hay  una  dif  erencia  en  favor  de  Bogoti  de  4.64. 

Para  poder  juzgar  del  valor  de  este  coeficiente,  voy  a  hacer  dgunas  comparaciones: 
aplicando  el  cilculo  a  los  promedios  de  Maillard  resulta  80.84  es  decir  ima  cifra  que 
difiere  de  las  mfas  (promedios  generates)  En  18.32  desigualdad  muy  proporcional  a  la 
que  existe  entre  los  indices  de  imperfecci6n  ureog^nica. 

Si  en  vez  de  tomar  el  porcentaje  del  izoe  total  se  toman  las  cifras  directas  de  izoe 
del  icido  drico  y  de  purinas  totales  los  resultados  son  naturalmente  muy  semejantes 
y  dan:  Guadros  de  Tunja,  60.70;  cuadros  de  Bogoti,  62.90.  Cilculo  aplicado  a  los 
resultados  de  Maillard,  86.64. 

Esta  segunda  forma  es  la  que  se  encuentra  en  los  promedios  marcada  con  el  Ndmero 
II. 

Y,  continuando  las  comparaciones:  si  se  aplica  ahora  el  cilculo  a  los  restiltados 
obtenidos  por  Bouchez  ^ — quien  hizo  anilisis  de  su  propia  orina — poni^ndose  dif  erentes 
reglmenes  de  alimentaci6n — se  encuentran  cifras  un  poco  superiores  a  las  de  Maillard 
como  se  veri  en  s^uida.  Pero  antes  debo  advertir  que,  para  los  promedios  que  copio, 
he  tenido  que  prescindir  de  algunos  anilisis  cuyos  dates  no  tenia  completes  en  el 
estudio  mencionado: 

Regimen  mixto  ordinario,  86.36;  regimen  mixto  con  nucha  came,  91.86;  regimen 
licteo,  91.02;  alimentaci6n  disminuida,  84.05;  regimen  licteo  vegetariano  rico  en 
hidratos  de  carbono,  88.41. 

Podria  sacarse  en  conclusi6n  de  las  cifras  anteriores — que  quizi  por  provenir  de  un 
individuo  sujeto  a  un  regimen  alimenticio  mis  rico  que  los  sujetos  en  quienes  experi- 
ments Maillard  dan  cifras  un  poco  superiores  a^tas — que  el  regimen  animal  aimienta 
el  valor  del  coeficiente  y  los  regfmenes  vegetariano  ehidrocarburados  y  la  alimentaci6n 
insuficiente  lo  disminuyen:  ensefianzas  que,  al  ser  confirmadas  con  un  mayor  ndmero 

1  A.  Bouchez,  Recherches  sur  la  composition  de  I'urlne  normal  de  I'homme,  Jour,  do  Phys.  et  de  Path. 
O^.,  enero  1912. 


PUBUO  HEALTH  AND  MEDIOINE.  97 

de  observaciones,  concordarfan  con  lo6  estudios  hechos  tiltiinamente  aobre  las  oxida- 
sas  de  la  came  y  en  general  con  el  de  las  citadas  de  las  albuminoideas  de  origen 
animal. 

No  pnede  negarae  tambi^n  que  hay  cierta  proporci6n  de  dif  erencias  con  los  anilisis 
de  Maillard  y  con  los  mfos,  entre  el  cuadro  sacado  de  los  estudios  de  Bouchez  y  el 
copiado  anteriormente  de  Desgrez  y  Aiiignac  ref erente  este  tiltimo  a  la  relaci6n  entre 
la  urea  y  el  dzoe  total. 

Goncordarfan  tambi^n  los  datos  apuntados,  con  las  observaciones  de  que  habl6  hace 
poco  de  las  insuficienciade  la  alimentacidncamea  en  la  altiplanicie  de  Bogotd  alimen- 
taci6n  que  es  casi  nula  en  las  clases  pobree.  Pasaria,  en  suma  aJgo  semejante  a  lo 
que  pasa  con  el  coeficiente  de  utilizacidn  del  &zoe. 

III.  Azoe  total  que  es  en  el  cuadro  modelo  15.87,  en  nds  promedios  generates  alcanza 
apenas  a  11.81  y  en  los  cuadroe  de  Bogotd  se  nota  una  dlferencia  de  2.30  a  favor  de  las 
clases  acomodadas.  Si,  por  un  error  imprevisto,  no  se  bubiera  hecho  figunur  entre  los 
obreros  a  airvientes,  que,  son  por  lo  regular  individuos  bien  alimentados,  esta  dife- 
lencia  serla  mucho  mayor. 

Las  cifras  apuntadas  representan  para  los  promedios  generales,  segtin  los  cdlculos 
que  quedaron  anotados  atrds  (vedse  pag.  57)  de  73.71  de  albdmina  por  cada  individuo, 
o  sean  353.81  calorfa  y  en  los  cuadros  de  Bogotd:  77.75  de  albtimina  o  373.20  calorias 
para  las  clases  obreras  y  de  84.94  de  albtimina,  o  sean  407.71  calorfas  para  las  clases 
acomodadas. 

Aplicando  el  cilculo  a  los  andliflis  de  Maillard  se  obtiene  una  diferencla  en  contra  de 
mis  sujetos  de  ob8ervaci6n  de  122.30  calorfas.  En  cuanto  a  los  andlisis  practicados  en 
Tunja,  se  aproximan  las  cifras  siendo  inferiores  a  las  de  la  clase  obrera  de  Bogota. 

Queda  pues  demoetrado,  que  bay  entre  nosotros  un  deficit  de  mateiiales  albumi- 
noideos  aun  en  nuestras  clases  acomodadas. 

lY.  Azoe  iruieterminado  por  dento  de  dzoe  total. — Entre  todos  los  estudios  que  se 
ban  consultado  no  he  encontrado  otros,  siquiera  citados,  a  este  respecto  que  los  de 
Maillard  y  Dans^  y  Lambling  y  Bouchez.  Los  resultados  del  primero  dan  11.15  por 
ciento  y  los  de  Dans^  y  Lambling  11.71;  los  de  Bouchez  dan  una  cifra  muy  inferior, 
en  tanto  que  los  mlos  dan:  en  los  promedios  generales  22.84,  en  los  de  Tunja  27.26, 
y  en  los  de  Bogotd  18.42,  con  un  pequefLo  aumento  para  la  clase  obrera.  La  desigual- 
dad  de  estos  resultados  se  debe  en  primer  lugar,  a  que  los  dltimos  de  los  autores  citados, 
midieron  la  creatinina  y  el  primero  las  bases  predpitables  por  el  dcido  silicotdngstico 
BUBtancias  que  no  figuran  en  mis  andlisis.  Pero  aun  hadendo  esta  correcci6n  hay 
dempre  en  mis  promedios  im  aumento  de  la  cifra  en  cuesti6n;  veamos  como  puede 
ser  explicado  este  aumento: 

El  dzoe  indeterminddo  pertenece,  sobre  todo,  a  la  creatinina  a  los  dcidos  uropro- 
teicofl  (con  el  urocromo)  al  dcido  hipurico  y  a  las  bases  predpitables  por  el  dddo  sill- 
cotdngsticD.    Recordemos  algo  sobre  el  origen  de  estos  cuerpoe. 

P.  La  creatinina  es  im  hidrato  de  la  creatina  de  la  cual  proviene,  y  este  queda  en 
Ubertad  en  la  tra8formaci6n  de  muchas  nucleo-proteidaa  en  cuya  compoeiddn  entra,^ 
de  mode  que  habiendo  un  aumento  de  purinas,  es  natural  que  haya  tambidn  un 
aumento  de  la  creatinina  y  aiendo  68ta  el  prindpal  factor  de  la  fracddn  de  dzoe  inde- 
terminado,  x>odriamo8  de  esta  manera  explicamos  el  paralelismo  entre  el  aumento  de 
esta  f racci6n  y  la  de  las  purinas  tanto  en  mis  andlisis  con  relad6n  a  los  europeoe, 
como  en  los  de  Tunja  respecto  a  los  de  Bogotd. 

Loe  vegetales  contienen  tambidn  creatina;  de  mode  que  el  regimen  vegetaiiano 
aumenta  la  proporddn  de  la  creatinina  en  las  orinas. 

S®.  Guando  la  dislocad6n  de  las  albuminoideas  es  imperfecta,  cuando  el  desdobla- 
miento  o  la  de8amidaci6n  de  los  dddos  aminados  o  la  oxidad6n  del  dddo  desaminado 
no  es  completa  se  encuentra  en  la  orina  mayor  cantidad  de  dddo  oxiprotdco  asf  como 

1  Professor  C.  H.  Roger,  Loo.  dt.  pig.  250. 


98  PBOOEEDINGS  BEOOND  PAN  AMEBIOAK  80IENTI7I0  OOKOBESS. 

de  &cido8  aloxiprot^co  y  urog^nico  ^  es  dedr  que  el  aumento  de  eetOB  dddos  eetk  en 
raz6n  directa  del  Indice  de  imperfecci6n  urog^nica. 

3®.  La  oiina  de  veinticuatro  horas  del  hombre  normal  no  contiene  por  tannine 
medio  sino  un  gramo  de  icido  hipdiico  (bajo  forma  de  hipnratos).  Loe  hipuratos  son 
mis  abundantes  en  la  orina  de  los  herbfvoros  que  en  la  de  loe  camlvoros  y  estos 
aumentan  con  la  alLmentaci6n  vegetal.  Sabiendo  que  el  dcido  benzoico  entra  en 
la  sinteais  del  icido  hipdrico  se  comprenderd  fdcilmente  la  influencia  del  alimento 
vegetal  en  este  aumento  y  si  como  ya  lo  inainu6  atr^  y  como  se  demostrard  m&s  ade- 
lante,  nuestra  alimentaci6n  es  muy  poco  camea  y  casi  totalmente  vegetariana  tam- 
poco  serfa  rare  que  los  hipuratos  estuvieran  en  mayor  proporci6n  en  la  oiina  del 
hombre  en  la  antiplanide.  Ademis,  como  la  glicocola  (que  como  se  sabe  es  un  4cido 
monoaminado  de  la  serie  alif^tica)  entra  tambidn  en  la  composici6n  del  &cido  hipti- 
rico,  quiz&  pudiera  explicarse,  en  parte,  de  esta  manera,  la  correlaci6n  entre  el  aumento 
del  &zoe  indeterminado  y  la  diszninuci6n  de  la  urea  con  el  r^^imen  v^getariano.  Si 
se  tiene  en  cuenta  la  importante  participaci6n  de  los  icidos  aminados  en  la  f  onnaci6n 
de  este  (iltimo  cuerpo. 

No  estd  por  dem&s  advertir  que  el  dddo  hiptkico  es  una  de  las  sustandas  cuya  to- 
maci6n  se  atribuye  a  encimas  de  trabajo  negative  es  decir  de  cuya  influencia  resulta 
una  reacci6n  con  ab8orci6n  de  calor.  Encimas  que  operarlan  por  consiguiente, 
segdn  Duclux  y  Lambling,  slnteeis  an^ogas  a  las  de  la  granulaci6n  clorofiliana.  La 
sfntesis  del  icido  hiptirico  parece  que  tenga  lugar  en  el  rifL6n. 

4®.  Ya  dije  todo  lo  que  se  sabe  respecto  a  las  bases  precipitables  por  el  4cido  silico- 
tdngstico.  Respecto  a  bus  variaciones  en  la  orina,  nada  cierto  se  sabe  hasta  el  pre- 
sente. 

SerCa  interesante  aveiiguar  cual  de  estos  cuerpos  que  forman  la  dfra  de  &zoe  inde- 
terminado estd  en  mayor  propord6n,  desgraciadamente  (quizd  excluyendo  uno  o  doe 
de  ellos)  no  se  conocen  todavia  procedimientos  para  medirloe  exactamente. 

5®.  Fds/oro. — En  cuanto  al  fdsforo  de  loe  fosfatos  se  encuentra  una  cifra  id^dca  en 
los  anilisb  de  Bogotd  y  en  los  de  Tunja,  a  pesar  de  una  ligera  disminucidn  en  los  pro- 
medioe  de  estos  tiltimos  del  anhidrido  fosfdnco.  Comparando  los  promedios  geneiales 
de  mis  andlisis  con  el  cuadro  modelo,  hay  a  primera  vista  una  disminud6n  en  los  pri- 
meros;  pero  si  se  reladonan  estos  resultados  a  los  del  dzoe  total,  hay  al  contrario,  un 
aumento  por  lo  cual  la  relad6n  ponderal  y  la  reladdn  at6mica  son  mavores  en  el 
cuadro  adoptado  como  punto  de  comparad6n;  la  tiltima  relad6n  es  de  36.05  en  mis 
promedios  y  37.09  en  el  cuadro  modelo. 

Esto  querrfa  dedr  que  nuentras  se  elimina  im  dtomo  de  f6sforo  se  ftliminR  entre 
nosotros  una  cantidad  un  poco  menor  de  &zoe,  lo  que  estd  de  acuerdo  con  la  mayor  can- 
tidad  de  purinas  en  relad6n  con  el  dzoe  total,  pues  se  sabe  que  la  mayor  parte  del  f6s- 
foro  urinario  proviene  de  la  desintegrad6n  de  las  nucleo-protddas. 

Esto  dltimo  explicaria  tambi^n  por  qu6  el  fdsforo  eetk  relativamente  en  mayor  can- 
tidad en  los  promedios  de  Tunja  que  en  los  de  Bogotd. 

6^.  Acidez, — Hay  un  aumento  de  la  addez  en  los  andlisis  de  Tunja,  probablemente 
porque  estos  an&lisis  se  refieren  a  individuos  sujetos  en  su  mayor  parte  a  ejerdcios 
musculares  continuados  y  mds  camfvoros  que  a  los  que  se  refieren  los  an^isis  de 
Bogota.  En  estos  tUtimos  hay  una  pequefLa  dlsminud6n,  la  cual  podria  ser  atiibuida 
al  predominio  de  la  alimentad6n  vegetal;  este  aumento  y  esta  disminuci6n  respecto 
de  la  addez,  son  por  lo  dem^  muy  pequefilos  para  darles  mayor  importanda. 

Como  consecuencia  final  y  resumen  de  estas  interpretaciones,  se  desprende  el  hepho 
de  que  eziste  en  la  altiplanide  de  Bogotd  una  insuficienda  de  la  utilizad6n  del  dzoe 
tanto  en  la  forma  albuminoidea  como  en  la  nucleo-protdca,  insufidencia  que  se  tra- 
duce en  las  orinas  por  un  exceso  de  los  tdrminos  intermedios  del  metabolismo  a 
expensas  de  los  t^rminos  finales;  conclusi6n  que  concuerda  con  la  baja  de  la  tempera- 
tura  y  la  disminud6n  de  la  superfide  hemoglobfnica. 

>  Profesor  E.  Qkj,  Loo.  dt. 


FUBLIO  HEALTH  AND  MEDIOINB.  99 

Quiere  esto  dedr  que  hay  entre  nosotros  una  inactividad  en  las  trasfonnaciones 
orginicas  y  eepecialmente  en  las  oxidaciones. 

^A  qu6  es  debida  esta  inactdvidad? 

Vimoe  atr&s  que  el  oi^ganismo  animal  no  es  como  un  homo  cuya  temperatura  puede 
elevarae  a  volimtad  con  uxia  mayor  cantidad  de  combustible.  De  manera  que  si  las 
combustdones  bajan  en  personas  que  tienen  recuraos  para  proporcionarse  toda  clase  de 
alimentofl — siendo  estos  alimentos  de  compoaicidn  qufmica  igual  a  los  empleados  en 
otras  regiones  como  lo  he  demostrado  por  mis  an&lisis — es  forzoeo  concliiir  que,  al  menos 
el  factor  mds  importante  de  esta  deficiencia  de  combustiones  no  ee  la  cantidad  de 
combustible  aino  se  debe  a  otras  causas  que  dependen  probablemente  de  una  dege- 
neraci6n  fisLol^gica  en  los  individuos. 

Hay  casi  s^^uramente  entre  nosotros  una  disminuci6n  de  los  fermentos  encaigados 
de  verificar  estas  trasformaciones  y  especialmente  de  oxidasas. 

La  insuficiencia  de  estos  fermentos  debe  provenir  de  una  falta  de  actividad  de  las 
gUndulas  encargadas  de  secretaries:  hip6te8is  que  seria  muy  interesante  confirmar 
y  sobre  la  cual  dejo  adelantados  los  hechos  demostrados  con  este  estudio. 

En  un  estudio  muy  bien  elaborado  y  documentado  que  presents  el  Dr.  Luis  Felipe 
Galder(5n  al  Segundo  Gongreso  Medico  Nacional,  sobre  sindromos  poliglandulares  en 
la  antiplanicie  y  que  fu^  justamente  elogiado,  Uega  entre  otras  a  las  siguientes  con- 
clusiones:  (1^)  Son  frecuentes  en  la  altiplanicie  los  sindromos  poliglandulares  y  pre- 
dominan  en  ella  los  causados  por  hipofunci6n;  (3^)  existe  en  la  altiplanicie  un  infan- 
tiliamo  visceral  hep&tico,  de  origen  hipofisiario,  compatible  con  la  integridad  funcional 
del  higado,  pero  que  lo  predispone  a  la  insuficiencia  y  lo  inhabilita  para  la  superac- 
tividad  que  suscitan  los  climas  c^dos;  (5^)  las  cardiopatias  de  las  menopausia,  fre- 
cuentes en  la  altiplanicie,  implican  el  tratamiento  por  la  opoterapia  ovariana. 

Las  causas  de  la  disminucidn  de  la  actividad  org^mica  pueden  ser  m(Utiples,  861o 
hablar6  de  tres,  para  no  extenderme  demasiado,  que  son  en  mi  concepto  las  que  merecen 
mib  atencidn;  es  la  primera  la  influencia  de  la  zona  de  que  me  ocupar^  en  las  con. 
clufliones,  y  las  otras  dos  son  ambas  reladonadas  con  nuestras  costumbres:  la  vida 
sedentaria  y  la  clase  de  alimentaci6n. 

El  hombrede  la  antiplanicie,  sobre  todo  el  hombre  pertenedente  a  clase  social  un  poco 
elevada,  pasa  su  vida  en  una  quietud  casi  abeoluta  y  entr^gado  a  un  ejerdcio  intelectual 
permanente y forzado.  Desde muy tempranaedad  concurre alaescuelapiimaiia, donde 
s61o  se  le  dejan  algunas  horas  de  descanso,  y  el  resto  del  dla  lo  pasa  en  un  recogimi- 
ento  absolutOy  dedicando  muy  poco  o  ning^  tiempo  para  atender  a  desanollo  flsico. 

Nuestros  colegios  de  educacitfn  secundaria  son  todos  escasos  de  espacio  y  si  en 
algunos  de  elloe  se  distrae  algdn  tiempo  para  los  juegos  y  la  gimnmria  no  se  les  dedica 
el  tiempo  neceeario  ni  se  hacen  con  m^todo.  Por  otra  parte,  todavfa  no  se  han  acli- 
matado  entre  nosotros  los  m^todos  modemos  de  instroccidn,  con  los  cuales  se  aprende 
mucho  y  se  trabaja  poco  intelectualmente:  todavfa  se  fatiga  el  cerebro  de  los  j6venes 
con  una  cantidad  excesiva  de  estudios,  muchos  de  los  cuales  estto  aichivados  por 
indtiles  en  todo  pais  civilizado. 

Y  si  esto  se  dice  de  los  hombres  otro  tanto  podrfa  decirse  de  las  mujeres  en  cuanto 
a  la  vida  sedentaria  se  refiere. 

De  aquf  que  el  Dr.  Galder6n  diga  en  la  tiltima  concluaidn  del  estudio  meneionado: 
''La  higiene  escolar  de  la  altiplanicie  debe  velar  por  los  piogresos  del  desanollo  ffsioo 
y  proveer  a  su  deficiencia  con  cambios  de  clima  adecuadoe  a  la  actividad  fisioldgica 
de  las  glindulas  que  lo  rigen."  ' 

A  las  concluaiones  del  Dr.  Calderdn  sobre  insufidencias  poliglandulares  paedo  agre- 
gar  que  en  mi  pr&ctica  de  laboratodo  he  tenido  ocasidn  de  encontrar--«n  eximenea 
hechos  para  la  compafilas  de  seguros— az6car  en  las  orinas  de  individuos  cuyo  examea 
clfnico  no  d^a  sospechas  de  perturbaci6n  de  salud  alguna. 

1  libro  del  8«giiiido  CoDgntD  ICMloo  NMioiHa  Colombtew 
68436— 17— VOL  x- 


100       PB0GEEDIK6S  SEOOND  PAN  AMEBIOAN  80IENTIFI0  COKOBE8S. 

Seria  inteiesante  praoticar  a  este  respecto  en  individuoB  en  aparente  estado  fisiold- 
gico,  experimentos  semejantes  a  loe  que»  en  enfermoB,  practiqu^  respecto  de  insafi- 
ciencia  hepdtica,  bajo  la  direccidn  del  profesor  Roberto  Franco  y  que  condenad  en 
un  estudlo  que  fu6  enviado  al  Seg^undo  Gongreeo  Medico  Nacional  Colombiano. 

Un  hecho  interesante  en  la  alimentacidn  conaiBte  en  que  el  habitante  de  Bogota 
consume  menos  came  que  im  europeo,  aun  haciendo  la  comparaci6n  con  palses  de 
raza  latina  que  como  se  sabe  son  menos  camlvoios  que  los  sajonee.  En  efecto  aeg&n 
estadlsdcas  citadas  por  Labb^,^  cada  habitante  de  Paris  consume,  por  t^rmino  medio, 
260  gramos  de  came  en  las  veinticuatro  horas;  y  por  datos  que  he  podido  recopilar 
tanto  en  la  Plaza  de  Games  como  en  la  Oficlna  de  Higiene  y  Salubridad,  se  ver&  que 
en  Bogotd  este  consumo  es  mucho  menor. 

En  el  afio  de  1912,  afio  en  que  el  consumo  ha  Uegado  al  mdximo,  se  expendieron 
en  Bogotd,  aproximadamente  y  por  t^rmino  medio,  a  raz6n  de  1,188  arrobas  por  dia, 
k)  que  corresponde  para  120,000  habitantes  a  124  gramos  por  persona.  El  milximum 
de  este  consumo  no  alcanza,  segtin  se  ha  podido  averiguarlo,  entre  las  clasesacomodadas 
a  160  gramos  por  persona;  es  decir  a  igualar  siquiera  las  cilras  medias  de  Paris;  y  en  la 
mayor  parte  de  los  trabajadores  Uega  a  cero. 

Esto  se  debe,  en  parte,  a  la  falta  del  uso  entre  nuestras  clases  pobres,  de  cames  baratas 
como  las  de  caballo,  etc.,  que  tanto  consumo  tienen  en  Europa. 

Pero  hoy  no  alcanzaria  a  dar  el  promedio  apuntado  arriba,  pues  parece  que  cada 
dia  van  haciendo  m^  mella  entare  nosotros  las  teorias  sobre  culpabilidad  del  regimen 
cameo  en  la  producci6n  de  la  arterio-esclerosis  y  de  la  vejez  prematura:  asi,  el  ntimero 
de  reses  sacrificadas,  que  venla  como  en  todas  partes,  aumentando  con  el  aumento  de  la 
poblaci6n,  y  que  de  22,954  que  fu^  en  1910  babfa  ll^;ado  en  una  progreei6n  no  inte- 
mimpida,  a  25,659  en  1912,  no  ha  sido  en  el  afio  de  1913  hasta  fines  del  mes  de  junio 
sino  de  11,530,  es  dedr,  que  probablemente  no  alcanzard  ni  a  24,000  o  sea  a  una  clfra 
inferior  a  la  del  afio  anterior. 

Yo  s^  de  muchas  familias  bogotanas  que  han  proscrito  la  came  de  su  alimentacidn, 
impresionadas  por  temores  que  muchos  medicos  contdbuyen  a  fomentar,  con  lo  cual 
hacen  un  grave  mal  en  mi  concepto.  Pues  si  se  exceptdan  muchas  enfermedades  en 
las  cuales  debe  prdubirse  la  came  por  tiempo  m^  o  menos  largo,  todo  ser  humane  ne- 
cesita  comer  came,  y  necesita  comerla  en  mayor  cantidad  de  la  que  entra  en  nuestra 
alimentaci6n,  como  lo  voy  a  demostrar: 

£1  oiganismo  necesita  de  albuminoideas;  las  causas  de  esta  necesidad  todavia  no 
son  bien  conocidas,  pero  sf  estk  bien  demostrado  que  ellas  existen. 

81  se  examinan  los  an^jlisis  de  alimentos  que  figuran  en  el  capftulo  tercero,  se  verd 
que  hay  algunos  vegetales,  sobre  todo  entre  las  leguminosas,  que  contienen  casi  tantos 
materiales  albuminoideos,  como  la  came.  P^ro  las  cifras  dadas  en  estos  anilisis, 
como  las  dadas  en  todos  los  an&Usis  de  alimento,  tienen  el  grave  Inconveniente  de  ser 
deducidas  del  dzoe  total,  procedimiento  que  como  ya  dije,  no  es  exacto,  porque  hay 
en  los  vegetales  olzas  materias  azoadas  (iddo  azoico,  amonlaco,  creatina„  etc.)  que  no 
son  albuminoideas;  de  modo  que  para  subvenir  a  stis  necesidades  de  albdmina,  tiene 
el  oiganismo,  a  regimen  vegetaiiano,  que  ingerir  una  gran  cantidad  de  alimentos,  lo 
que  recaiga  en  sumo  grade  las  vfas  digestivas.  Es  quizd  este  imo  de  los  motives  pcnr 
los  cuales  casi  todos  los  que  van  de  aquf  a  Europa,  notan  que  all!  se  come  una  mucho 
menor  cantidad  de  alimento.  ''Adem^,  la  experiencia  nos  ensefia,''  dice  Roeeer 
lutblando  de  los  vegetales  licos  en  albdmina'  ''que  no  podemos  hacer  uso  s61o  de 
^stos  en  muestra  alimentacidn.  Contienen  una  gran  masa  de  cerulosa  y  ademis  de 
que  esta  masa  indigesta  es  nociva  por  su  volumen  hay  que  agregar  que  su  presencia  tiene 
respecto  al  jugo  gdstiico,  un  papel  de  inhibicidn.  Un  alimento  albuminoideo  debe 
presentarse  al  estado  de  pureza,  es  dedr,  desprovisto  de  sus  envolturas  menos  atacables, 
para  que  sea  ^Udlmente  digerible,  para  que  pfovoque  una  secrecidn  gdstdca  dtil. 

>  M.  Labb^  1m  r^gtmes  aliniMitalrM. 

*  P.  T.  Roeser,  La  6hlml«  aUmentain,  Etudes  de  physlolosie  gdiidcale,  1005. 


PUBLIC   HEALTH  AND  MEDICINE.  101 

Hay  que  notar,  ad^mis,  que  el  almid6n  contenido  en  grandes  proporciones  en  los 
vegetales,  favorece  en  el  intestino  la  pululaci6n  del  bacilus  amilobacter,  agente  de 
una  fermentaci6n  dcida  cuyoe  productos  no  quedan  sin  acci6n  sobre  la  economla"  y 
m^  adelante  agrega:  '^  Loe  despojos  de  la  nutrici6n  son  numerosos  aun  cuando  se  haga 
uao  de  la  came,  pero  ee  predso  reconocer  que  en  este  dltimo  caso  son  menoe  nocivos." 
M.  Bikel  demo6tr<S  en  un  estudio  citado  por  Boruttau '  que  los  procesos  de  putre- 
facci6n  produddos  en  el  intestino  del  perro  son  tanto  mis  intensos  cuanto  mds  rica 
en  vegetalee  sea  la  alinientaci6n  y  que  Uegan  al  mfnimun  con  el  r^men  cameo 
abeoluto. 

Por  otra  parte,  la  came  es  el  6nico  alimento  que  tiene  acci6n,  especffica  sobre  la 
8ecreci6n  g&strica.  Cuando  se  introduce  en  el  e8t6mago,  evitando  toda  excitaci6n 
psfquica,  pan  papilla  de  almid6n  y  albdmina  de  huevo  crudo  o  cocido,  *  'estas  sustancia 
se  muestran  inertes  en  presenda  de  la  mucosa  g^trica,  y  pueden  permanecer  as!  por 
varies  dfas  sin  otra  modificaci6n  que  una  fermentaci6n  ptitrida. 

''La  mezcla  de  came  y  de  almid6n,  el  caldo,  el  extracto  de  came  y  con  mayor  raz6n  la 
came  pura,  provocan  la  aparici6n  de  un  jugo  dotado  de  un  jxKier  digestive  real  y  la 
dige8ti6n  asl  comenzadase  contindaautom&ticamente.''^  Este  efecto  muy  notable 
ee  producido  por  una  acci6n  especlfica  refleja  sobre  los  centros  nerviosos,  y  puede 
ser  aprovechado  con  ^xito  para  estimular  el  apetito  de  los  convalecientes  cuando  la 
excitaci6n  psfqiiica  inicial  hace  falta. 

Pero  hay  una  cuesti6n  que  intereea  de  mode  mds  directo  el  hecho  que  se  estd  tra- 
tando  de  interpretar  y  son  los  estudios  hechos  en  estos  tiltimos  aflos  sobre  la  impor- 
tancia  de  la  came  en  el  estlmulo  del  metabolismo  celular,  por  la  presencia  en  ellos  de 
fermentos  activos,  sobre  todo  de  peroxidases  y  de  catalasas  que  no  son  destruidas  por 
el  calor.  La  leche  contiene  tambi^n  muchos  de  estos  fermentos;  pero  algunas  razonee 
referentes  a  la  digestibilidad,  la  hacen  menos  recomendable.  H.  Busquet,'  dcepu^ 
de  experimentos  muy  cmdadosos  y  muy  interesantee,  en  los  cuales  alimentaba  ranas, 
mantenidas  en  equilibrio  ponderal,  unas  con  came  de  ranas  otras  con  came  de  vaca 
y  otras  con  cari^e  de  cordero,  dedujo  que  la  raci6n  de  mantenimiento  so  realiza  mejor 
en  la  rana,  con  la  ingesti6n  de  came  de  rana  que  con  la  de  vaca  o  la  de  cordero,  y  que 
en  las  ranas  en  inanici<5n,  un  aumento  pondend  determinado  se  obtiene  con  un  aporte 
de  albdmina  menor  con  la  ingestuSn  de  una  came  especifica,  que  con  la  de  cames 
extrafias. 

''Estas  nodones  nuevas  relatlvas  a  la  asimilacidn  azoada  permiten  la  comprensidn 
i&cil  de  hechos  muy  conocidos  en  le  fisiologfa  de  la  nutrid6n;  la  variabilidad  de  la 
necesidad  de  alblimina,  segtin  el  alimento  ingerido,  se  desprende,  como  consecuencia 
inmediata,  de  estos  experimentos.  Mientras  la  albtimina  se  aleja  mds  de  las  albtiminas 
especfficas,  mayor  ser&  la  cantidad  neceearia  para  el  mantenimiento  del  equilibrio 
aeoado."  De  mode  que  al  tratar  de  mantener  este  equilibrio  solamente  con  alimentos 
v^;e tales,  serfa  ^ta  una  causa  mis,  agr^ada  a  las  que  ya  mendon^  atr&s,  para  aumentar 
la  rad6n  alimentida  con  perjuicio  de  las  vfas  digestivas. 

Las  albtiminas  que  m^a  convienen  al  hombre  son,  en  consecuencia,  las  que  provienen 
de  los  mamiferos. 

Estos  datos  concuerdan  admirablemente  con  lo  que  a  eete  respecto  dice  Ardelbalden 
sobre  la  cuesti6n  de  la  necesidad  de  albtimina. 

Si  es  verdad  que  la  proteolisis  diG:e8tiva  consiste  en  una  demolici6n,  mis  o  menos 
profunda,  del  e£fido  molecular  de  las  albdminas,  seguida,  en  la  mucosa  intestinal  y 
quizi  en  el  hfgado,  de  una  recon8tituci6n  en  proteicas  sangafneas  especfficas,  propias 
para  determinado  organismo,  esta  reconstmcci6n  implica  un  primer  desperdicio,  que 
puede  ser  considerable.  Esta  reedificaci6n  debe  hacerse,  en  efecto,  por  la  ley  del 
minimum,  es  decir,  que  la  proporci6n  entre  los  di versos  productos  de  la  hidrolisis  aiges- 

1 H.  Bonittaa,  Jonr.  de  Fhys.  et  Path.  Ofo.,  1012,  enero. 

*  Estracto  pablicado  en  el  Jurtial  ottado,  Tumo  IX,  1907. 

•  Bosqtiet,  Contrlbotion  k  raode  de  la  valeur  nutritive  eomparte  dee  albmnines  ^trangteee  et  dee 
albnmlnei  ipedflqoes  ches  la  grenoalle,  Joor.  de  Fhys.  et  de  Path.  Q4n.,  16  de  mayo  de  1009. 


102       PROCEEDINGS  SECOND  PAN  AMEBICAN  SCIENTIFIC  CONGBESS. 

tiva  que  puede  ser  empleado  en  la  recoiistrucci6n  del  nuevo  proteico,  debe  regularse 
segiin  la  cantidad  de  aqu^l  cuyos  f ragmentoe  eetdn  en  menor  cantidad .  Cuando  luego 
las  proteicaa  sangulneas,  asl  construiaas,  se  ofrecen  como  alimento  a  las  diversas  espe- 
ciesque  tienes  necesidad  de  las  materias  azoadas,  volverd  a  comenzar  la  misma  opera- 
ci6n  de  demolici6n  y  recon8tarucci6n,  naturalmente  con  un  nuevo  desperdicio. " 

Asf  se  comprenderia  como,  para  hacer  frente  a  la  reconstruccidn  o  al  sostenimiento 
de  esos  protoplasmas,  el  organismo  tiene  necesidad  de  disponer  de  una  cantidad  con- 
siderable de  albtimina,  tanto  mds  considerable  cuanto  mds  se  aleje  de  las  albuminas 
especlficas. 

Por  dltimo  si  la  came  fuera  nociva  para  el  organismo,  las  razas  sajonas  no  tendrian 
ya  el  vigor  superior  que  conservan. 

Si  86I0  el  regimen  carneo  fuera  la  causa  de  la  arterio-escleroslB,  no  existirfa  esta 
enfermedad  en  los  mamlferos  herbivores. 

En  resumen:  para  una  mejor  utilizaci6n  del  dzoe  alimenticio  y  una  mejor  marcha 
de  las  transformaciones  orgdnicas,  el  hombre  necesita  de  una  alimentaci6n  rica  en  al- 
buminoideas  animales  especialmente  en  came. 

Pero  no  quiere  esto  decir  que  el  regimen  alimenticio  humane  deba  ser  solamente 
carneo.  Hay  en  los  vege tales,  fuera  de  las  materias  azoadas,  hidratos  de  carbono  y 
sales  minerales  que  son  de  suma  utilidad;  la  celulosa  misma  contribuye,  en  gran 
manera,  a  mantener  despejadas  las  vfas  digestivas,  preparando  asf  el  campo  para  una 
mejor  absorci6n. 

El  hombre  no  es  un  animal  solamente  carnivore,  como  no  es  solamente  herbfvoro. 
La  conformaci6n  misma  de  su  aparato  masticador,  desde  la  di6posici6n  de  su  articula- 
ci6n  t^mporo-maxilar  hasta  la  forma  y  disposici6n  de  su  sistema  dentario,  indican  que 
estd  constituido  para  el  regimen  mixto.  De  mode  que  los  que  en  estado  fisioldgico 
(entendiendo  por  fisiol6gico  el  organismo  cuyas  partes  funcionan  normalmente)  pre- 
tendan  someterse  a  un  regimen  absoluto,  sea  vegetariano  o  cameo,  pecan  contra  la 
misma  naturaleza. 

Y  continuando  sobre  el  mismo  tema  de  nuestro  regimen  alimenticio:  tiene  la 
cMcha  alguna  influencia  en  el  retardo  de  los  procesos  del  metaboKsmo  org4nico? 

El  asunto  me  ha  pareddo  de  tanta  importancia  que  lo  he  hecho  objeto  de  un  estudio 
especial. 

RBSUMBN  Y  C0NCLU8I0NB8. 

En  general,  en  un  sujeto  en  buenas  condiciones  higi^nicas  las  funciones  de  nutrici6n 
alcanzan  un  nivel  normal,  cualquiera  que  sea  la  cantidad  de  comburente  de  que  dis- 
ponga  el  organismo,  y  cualquiera  que  sea  la  temperatura  atmosf^rica,  a  favor  de  ciertas 
funciones  orgdnicas  de  compensacidn  (hiperglobulia  o  hiperhemoglobinuria  y  mayor 
frecuencia  de  la  respiraci6n  y  del  pulso)  y  a  favor  de  un  aumento  del  combustible 
(alimentos). 

Por  otra  parte  parece  demostrado: 

I.  Que  en  la  altiplanicie  de  Bogotd  la  nutrici6n  sufre  un  retardo  el  cual  se  re  vela: 

1.  Por  un  descenso  de  la  cifra  media  de  la  temperatura  humana. 

2.  Por  una  insuficiente  transformaci6n  de  los  materiales  azoados  en  el  organismo, 
insuficiencia  que  se  traduce  a  su  tumo. 

(a)  En  una  disminucidn  de  la  relaci6n  entre  el  dzoe  de  la  urea  y  el  dzoe  total. 

(b)  En  un  aumento  del  fndice  de  imperfecci6n  ureog^nica  0  de  loe  dcidos  grasos. 

(c)  En  un  aumento  de  los  tannines  intermedios  de  transformaci6n  de  los  nticleo- 
proteidos  (bases  pdricas)  a  expensas  del  tannine  final  de  estas  mismas  transformaciones 
{icido  drico). 

La  relaci6n  que  he  encontrado  entre  este  tiltimo  fen6meno  y  los  diferentes  grades  de 
nutrici6n  me  ha  inducido  a  proponer  un  nuevo  coeficiente  urinario  cuya  explicaci6n 
detallada  se  encuentra  en  diferentes  capftulos  de  este  trabajo. 

(d)  En  un  aumento  de  la  cifra  del  Az  indeterminado. 

II.  Este  retardo  de  la  nutrici6n  no  se  debe  a  una  disminuci6n  de  combustible  porque, 
adem^  de  que  se  encuentra  tanto  en  las  clases  pobres  como  en  las  clases  acomodadas, 


PUBLIC   HEALTH  AND  MEDICINE.  103 

una  cantidad  normal  de  izoe  en  las  orinafl,  se  ve  por  los  andlisis  que  hice  de  los 
principios  alimenticios,  que  ^stoe  son  por  lo  menoe  tan  ricoe  en  nueetra  altiplanicie 
como  en  la  zona  templada. 

Pero  esto  no  excluye  el  que  en  las  clases  no  acomodadas  pueda  tener  influencia  la 
insuficiencia  de  la  alimentaci6n  y  el  uso  de  la  chicha,  bebida  que  parece  ejercer  una 
acci6n  depresora  sobre  la  nutrici6n  general. 

III.  La  causa  de  este  retardo  es  probablemente  una  deficiencia  oig^ca  en  la 
elaboraci6n  de  los  fermentos  encargadoe  de  verificar  el  metabolismo  celular,  especial- 
mente  de  oxidasas.  Y  como  se  sabe  que  estos  fermentos  son  elaboradoe  por  diwtintag 
gUndulas  del  organismo,  pudi^ramos  decir  en  otras  palabras:  insuficiencia  poliglan- 
dular  a  este  respecto. 

IV.  Todas  estas  manifestaciones  de  un  retardo  en  la  nutricidn,  parecen  m^  bien 
aumentar  que  disminuir  con  la  altura,  como  se  ve  por  la  comparaci6n  de  las  observa- 
ciones  tomadas  en  Bogoti  y  en  Tunja,  ciudades  de  alturas  un  poco  diferentes. 

Pero^  cu&l  es  la  causa  eficiente  de  esta  deficiencia  org^inica? 

£1  problema  es  demasiado  dlKcil  para  x>oderle  dar  actualmente  una  Boluci6n  y 
serfa  petulancia  pretender  hacer  mis  que  formular  teorlas  m^  o  menos  aceptables  y 
dejar  que  otros  le  den  la  solucidn  sads&M^toria. 

Algunas  consideraciones  me  inducen  a  creer  que  la  causa  en  cuesti6n  tiene  una 
relaci6n  con  la  zona  en  que  vivimos,  entre  ellas  la  observaci6n  hecha  por  todo  viajero 
de  la  depresidn  volitiva  de  la  apatla  muscular  de  los  habitantes  de  la  zona  inter- 
tropical. 

Pero^  cudl  es  esa  causa?    Teorlas  y  teorias  pueden  emitirse. 

Quizd  no  deje  de  tener  alguna  influencia  la  pobreza  de  nuestra  alimentacidn  en 
albuminoideos  animales  asf  como  lo  eedentario  de  nuestra  vida;  aunque  esto  Ultimo 
puede  ser  m^  bien  efecto  que  causa. 

Algunos  creen  que  la  {alta  del  cambio  de  estaciones,  la  constante  repetici6n  de 
una  misma  sen8aci6n,  enerva  los  sentidos  e  influye  sobre  la  nutrici6n  general,  a  la 
manera  que  una  luz  igualmente  coloreada  acaba  por  producir  perturbaciones  visuales 
e  intele  .*tuales  o  que  la  repetici6n  del  mismo  manjar  que  no  se  cambia  acaba  por 
producir  perturbaciones  digeetivas. 

En  alguna  otra  parte  he  lefdo  la  teorla  de  que  la  tierra  en  su  movimiento  de  rotacidn 
acumula  mayor  cantidad  de  icido  carb6nico  en  el  ecuador,  lo  cual  parece  encontrar 
una  confinnaci6n  en  la  diferencia  de  dcido  carb6nico,  a  ftivor  de  loe  thSpicoe,  si  te 
coroparan  ani^lisis  (como  los  del  Profesor  Lewy  practicadoe  en  Bogotd)  de  la  atm6^ 
fera  intertropical  con  loe  de  la  zona  templada. 

Si  esto  es  asf,  quizd  pudiera  este  fen6meno  damos  la  explicaci6n  de  porqu^  la  vida 
vegetal  adquiere  mayor  robustez  en  los  tr^picos  y  porque  las  razas  animales  degeneran 
aUf. 

*' Porque  el  icido  carb6nico/'  segtin  Bobor,  Hasselbaalch  y  Erogh,  ''influye  sobre 
las  oxidaciones  orgdnicas  aun  dentro  de  loe  Hmites  fisioliSgicoe.*'  **E8,"  dice  Burder- 
man,  **un  depresor  morboso,"  y  pudiera  ser,  por  su  exceso  entre  nosotroe,  lo  que 
Luciani  llama  *'acciones  permanentes  que  producen  retardos  en  la  nutricidn." 

Finalmente,  ^debemos  considerar  como  consecuencia,  o  m43  bien  como  causa  inme- 
diata  de  enta  insuficiente  elaboraci6n,  la  disminuci6n  de  la  superficie  hemogl6bica, 
o  sea  la  di8minuci6n  del  ntimero  de  gl6bulos  rojos  sin  aumento  de  la  carga  hemo- 
globfnica? 

I  iene  el  enrarecimiento  del  aire  influencia  sobre  el  retardo  de  nuestras  combus- 
tiones?  T.a  respuesta  categ6rica  es  demasiado  diffcil,  pero  se  pueden  hacer  algunas 
anotariones  al  reded  or  de  ella. 

Parece  por  una  parte  demostrado,  en  estudios  experimentales  hechos  por  distintos 
autores,  que  a  medida  que  se  asciende  hay  una  hiperglobulia  o  hiperhemoj^lobinuria 
compensadora  del  enrarerimiento  del  aire. 

Por  otra  parte,  otras  observaciones  hechas  en  la  zona  t6rrida,  concuerdan  con 
las  mfas  en  esta  falta  de  compensaci6n. 


104        PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIO  CONGRESS. 

En  efecto,  el  Dr.  Joe^  G.  Hem&ndez  de  Caracas  ^  encontr6  en  aquella  ciudad, 
893  metros  sobre  el  nivel  del  mar,  un  promedio  en  25  individuoB  de  3,840,000  gl6buloe 
rojoe  por  milimetro  cdbico. 

Ouatro  afios  despu^s,  el  Dr.  Joige  Vaigas  encontr6  en  Bogotd  en  33  obeervadones 
un  promedio  muy  semejante  al  mfo  y  anot6  la  relaci6n  entre  sua  obeervacionee  y  las 
de  Del  Rfo  sobre  di8minuci6n  de  la  urea,  asf  como  el  descenso  de  la  temperatuia 
humana  en  Bc^td. 

Esta  falta  de  compensacidn  trae  como  consecuenda  un  aporte  menor  de  oxlgeno 
y  por  consiguiente,  una  disminuci6n  de  las  oxidaciones. 

Pero  recu^rdese  que  loe  autoes  que  ban  encontrado  la  compensaci6n  ban  experi- 
mentado  en  individuos  sometidos  por  corto  tiempo  a  la  influencia  de  la  altura  y  que 
en  extranjeros  reci^n  llegados  a  nuestra  altiplanicie  si  se  ba  encontrado  esta  com- 
pen8aci6n. 

Por  otra  parte,  tan  to  los  estudios  de  los  doctores  Hernandez  y  Vargas  como  los 
mios,  se  refieren  a  individuos  que  ban  vivido  la  mayor  parte  de  su  vida  en  la  altura 
o  al  menos  en  la  zona  t6rrida. 

Cualquiera  dirla  que  no  se  cumple  en  nosotros  esta  ley  fisiol6g:ica  puesto  que 
falta  la  compensacidn  de  que  bablo;  pero  compengaddn  que  implica  en  este  caso 
hiperfuncidn — qmere  decir  aumento  de  trabajo  y  el  aumento  de  trabajo  trae  consigo 
el  cansancio  precoz.  ^No  podria  suceder  que  a  la  maneracomo  el  coraz6n  se  fatiga 
mis  fdcilmente  en  las  grandes  alturas,  pudiera  venir  tambi^  una  bipofunci6n  de 
los  6rganoB  bematopoieicos,  bajo  la  influencia  prolongada  de  un  aire  enrarecido? 

Adem^  el  oxlgeno  es  un  gran  excitante  de  las  funciones  de  nutrici6n  como  lo 
I»^eban  sus  excelentes  resultados  y  los  del  aire  pure  en  los  enfermos  con  biponu- 
trici6n.  De  aqul  que  no  861o  las  oxidaciones  se  encuentren  disminuldas  en  nosotros, 
sine  casi  todas  las  reacciones  del  metabolismo. 

Abora  bien:  existe  en  la  zona  templada,  por  lo  menos  durante  medio  alio  una 
doble  condici6n  que  bace  la  atm6sfera  mucbo  m^  densa:  baja  temperatvra  y  bajo 
nivel  sobre  el  mar.  Mientras  que  en  nuestra  zona  tropical  bay  una  condici6n  per- 
manente  de  encarecimiento:  en  las  regiones  Mas  por  la  altura  y  en  las  partes  bajas 
por  el  calor. 

He  abf,  en  mi  concepto,  una  posible  influencia  favorable  del  cambio  de  estaciones, 
sobre  las  funciones  del  metabolismo  celular. 

Esta  diferencia  en  la  accividad  del  metabolismo  explica  por  qu6  se  siente  menos 
intense  el  frio  en  las  zonas  templadas — aun  con  estados  bigrom^tricos  i5:uales  y  con 
temperaturas  mis  bajas — ^y  por  qu6,  utiUzdndose  mejor  los  principios  alimenticios 
se  ve  mds  vida  en  los  individuos  adn  con  mds  pequefias  cantidades  de  alimentos. 

En  todo  caso  el  becbo  de  la  insuficiente  nutrici6n  entre  nosotros  parece  demos- 
trado;  falta  buscar  la  explicacidn  y  probarla  experimentalmente. 

Pero  entre  tanto  algo  puede  bacerse  para  remediar  el  mal: 

1.  Dar  grande  importancia  a  la  educaci6n  flsica  de  loe  nifios,  porque,  como  dice 
Bedict,  ''el  trabajo  muscular  es  un  estfmulo,  no  s61o  inmediato  sine  sostenido  de  la 
actividad  celular"  y  dar  la  preferenda  a  aquellos  ejercicios  que  desarrollan  la  capa- 
ddad  tordcica. 

2.  Lucbar  :ontra  el  uso  de  la  cbicba. 

3.  Quitar  de  la  mente  del  pueblo  la  idea  de  que  la  came  es  perjudicial  para  el 
bombre  sano,  a  fin  de  bacer  la  alimentaci6n  mds  rica  en  albuminoideos  animales  que 
son  un  gran  estlmulo  de  la  nutrici6n  general. 

1  J.  Q.  Horn&Ddes.    The  Number  of  the  red  oeUs.    Pan  Amerioan  Medical  Congress,  1895. 


PUBLIO  HEALTH  AND  MBDIOnTB.  105 

INFLUENOU  DE  LA  CHICHA  SOBRB  EL  BfETABOUSMO  AZOADO. 

Por  CALIXTO  TORRES  UMASA. 

La  chicha  es  la  bebida  ordinaria  de  nuestro  jmeblo;  es  una  especie  de  cerveza  que 
proviene  de  la  fermentaddn  del  mafs  pero  hay  dos  drcunstacias  que  hacen  de  ella 
una  bebida  infinitamente  mis  nociva  para  el  ofganiBmo  que  la  cerveza. 

Efl  la  primera  que  el  malz  no  contiene  sino  menos  de  la  mitad  de  la  glucosa  que 
enderra  la  cebada  y  la  seg^unda  que  ee  muy  diffcil  desamdlar  en  el  grano  el  fermento 
que  debe  trasftmnar  el  almid6n  en  azt&car.  For  eataa  razonee,  la  industiia  ha  tenido 
que  apelar  a  on  im>cedimiento  tan  laigo  que  convierte  la  fermentacidn  en  una  ver- 
dadera  putrefacci6n;  pues  ademds  del  alcohol  tienen  tiempo  de  deearrollarBe  otraa 
■uatancias  mucho  m6m  nocivae  que  ^ete. 

Debemos  al  ilustre  profeeor  colombiano  Dr.  Liborio  Zerda,  el  primero  y  mSm  com- 
plete estudio  de  los  divereoe  productoe  de  f  ermentaci6n  a  que  da  lugar  el  procedimiento 
que  hoy  se  emplea  para  la  preparaci6n  de  la  chicha. 

'*E8te  eetudio  lo  hizo  el  Dr.  Zerda  hace  ya  cercadeSO  alios  y  aunque,"  segdn  lo 
hace  notar  muy  juiciosamente  el  Dr.  Pablo  Garcia  Medina,^  ''en  este  espado  de 
tiempo  la  quimica  biol6gica  ha  hedio  grandes  adelantos  y  modificado  muchas  teorfas, 
fu6  este  tribajo  tan  complete,  priv6  en  61  un  criterio  tan  seguro  y  un  m^todo  tan 
rigurosamente  dentifico  que  hoy  parece  hecho  a  la  luz  de  esos  adelantos. '' 

Es  en  el  dltimo  perfodo  de  la  fermentaddn  de  la  chicha,  perfodo  que  puede  llamarse 
de  putrefetcci6n,  cuando  se  desarroUa  una  tomaina  que  encQntr6  el  Dr.  ISerda. 

£1  Dr.  F.  J.  Tapia  lo  ha  demostrado  de  una  manera  muy  sendlla.  Toma  un  poco 
de  maiz,  sufidentemente  reblandeddo  para  que  pueda  formarse  lo  que  se  ha  llamado 
masato,  cuyo  verdadero  olor  estd  casi  oculto  por  el  de  los  Uteres  que  se  desarrollan 
simultdneamente.  Galentando  este  mazato,  de  manera  que  los  Uteres  se  evaporen, 
queda  una  masa  de  olor  pdtrido  intense  como  de  cad&ver  en  descompo8ici6n,  lo  cual 
da  una  idea  de  las  diversas  alteradones  que  sufriri  el  mafz  durante  este  dltimo  perfodo 
de  verdadera  putr^acd6n. 

He  aqul  la  compo8ici6n  de  la  chicha,  al  terminarse  esta  fermentaci6n,  segdn  los 
anilisifl  del  Dr.  Zeida: 


Oiamos. 

Alcohol 65.00 

AddoUctico 4.30 

Otros&ddos L85 

Azticar  (sacarosa,  glucosa  y  azdcar 
invertida) 10.65 


Ormmot. 

Almid6n 10.80 

Materias  azoadas 6.27 

Glicerina 7.70 

Acdte  que  contiene  la  sustancia 
t6xica L60 


Pero  la  chicha  asf  compuesta  no  se  da  al  consume  sino  mezclada  con  agua  y  miel, 
con  lo  cual  se  forma  un  Ifquido  que  por  sufrir  la  fermentad6n  alcoh61ica  viene  a 
quedar  con  mayor  cantidad  de  alcohol  que  d  primero  jMfo  con  mucho  menos  sustandas 
nutritivas. 

En  tres  litres  de  chicha  que,  m^  o  menos,  consume  un  trabajador  de  la  sabana  de 
Bogota,  hay  340  gramos  de  alcohol  es  dedr  como  si  tomara  media  botella  de  aguardiente 
mis  una  gran  cantidad  de  los  elementos  t6xicos  propios  de  la  chicha. 

Las  alteradones  espedales  que  produce  la  chicha  en  el  oiganismo,  estudiadas  per 
el  Dr.  Jos6  Gomez  '  alteradones  distintas  de  las  del  alcoholismo  ordinario,  y  que 
son  casi  id^nticas  a  las  de  la  pelagra;  los  experimentos  practicados  por  el  Dr.  Zerda 
en  aninudes  y  d  anilimw  mismo  de  la  chicha,  me  hideron  penaar  que  esta  l>ebida 
puede  tener  alguna  influencia  inmediata  en  d  retardo  de  la  nutrid6n  de  nuestro 
pueblo  de  la  altiplanide. 

Con  d  objeto  de  investigar  esta  influencia  me  dirigf  al  Mlnisterio  de  la  Guerra  para 
solidtar  que  se  pusieran  a  mi  dispo8ici6n  seis  individuos  de  tropa  y  tuve  la  fortuna 

iSesloiiesolBnafioM  del  oentfloarlode  Colombia,  lOia  tJot6aoiiiei,tlehlelil8iiio. 


106       PROCEEDINGS  SECOND  PAN  AMEBICAN  SCIENTIFIC  CONGRESS. 

de  aer  debidamente  atendido  tanto  por  el  Sefior  Miniatro  como  por  el  Sr.  Coronel 
Baldlzar,  Jefe  de  la  6uarnici6n  de  Timja,  y  por  el  Dr.  Acevedo,  ofidal  de  sanidad 
de  la  misma,  quienes  confxibuyeron  en  gran  manera  a  que  los  experimentos  se  llevaran 
a  cabo  con  absoluta  preci6i6n. 

En  la.  dnica  parte  en  donde  eetos  enaayos  pueden  llevarse  a  cabo  con  la  abacduta 
exactitud  que  el  case  requiere,  ee  en  el  cuartel  donde  los  eujetos  est&n  aometddos  a  una 
rigurosa  diaciplina  y  por  consiguiente  obaervan  exactamente  el  regimen  y  las  instnic- 
ciones  bajo  la  vigilanda  de  sua  auperiorea. 

Para  hacer  mia  inveetigacionea  mnplee  un  m^todo  aemejante  al  que  emple6  el  Profea(»r 
MaiUard  en  el  ej^rcito  francos,  cuando  eetudi6  la  influencia  del  vino  sobre  la  excreci6n 
del  4zoe  y  del  f6eforo. 

Elegi  aeia  aujetoa  bien  conformadoa,  en  buen  eetado  de  aalud  y  entregados  a  su  vida 
ordinaria  de  cuartel. 

Todoa  ae  aometieron  a  un  regimen  conatante  que  obaervaron  cada  uno  aeia  dfaa,  dividi- 
doa  ^stoa  aeia  dfaa  en  dos  perfodoa  de  a  trea:  en  el  aegundo  perfodo  agregaron  a  su 
alimentaci6n  200  c.  c.  de  diicha  al  almuerzo  y  otroe  200  a  la  comida. 

Como  por  lo  demda  el  regimen  era  exactamente  el  miamo,  laa  variacionea  que  ae 
obaervaran  en  este  61timo  perfodo  representarlan  la  influencia  de  la  chicha  en  la  elimi- 
naci6n  urinaria;  pero  como  eata  bebida  tiene  cierta  cantidad  de  matenales  azoadoa 
los  individuos  ingerfan  ^atos  en  mayor  proporci6n,  dato  que  debe  tenerse  en  cuenta  al 
hacer  la  comparaci6n  de  los  promedios. 

Como  era  ifhposible  practicar  seis  andlisis  de  orinaa  completas  en  menos  de  cuatro  o 
cinco  dlas,  reaolvf,  para  que  no  se  produjera  una  fermentacidn  de  las  orinas  que  altera- 
Ha  los  resultados,  dividir  los  sujetos  en  dos  grupos,  cada  uno  de  los  cuales  se  someti6 
durante  los  seis  dias  al  mismo  regimen  no  s61o  alimenticio  sine  de  ejercicios  (estos  eran 
los  ordinarios  del  cuartel  sin  salir  al  terrene). 

El  r^orimen  alimenticio  era  el  siguiente,  es  decir  casi  el  ordinario  del  cuartel: 

Desayuno:  Agua  de  panela,  300  c.  c;  pan  de  munici6n,  90  gramos.  Almuerzo: 
Sopa,  1.500  c.  c;  came,  60  gramos;  pan,  45pramos.  Comida:  Mazamorra,  1.600  c.  c; 
came,  60  gramos;  papas,  960  gramos;  panel  a,  90  gramos.  Lo  que  da  por  dia  y  por  in- 
dividuo  las  siguientes  cantidades  de  materiales  utilizables: 


Allmentos. 

Canti- 
dades por 
homhre. 

Materias 
proteicas. 

Qrnsas. 

Hidratos 

de 
earbono. 

Panela 

Oramos. 
110 
135 
130 
150 
960 

09.00 

Pan 

8.70 
22.32 
16.76 
16.00 

0.19 

23.35 

6.00 

9.60 

76.20 

Came 

Malz 

2  86 

Paoas 

192.00 

Total 

64.37 

39.14 

368.85 

Estos  cdlculos  ban  sido  deducidos  de  mis  an&lisis  personales  de  alimentos,  cuyoa 
resultados  son  casi  id^nticos  a  los  de  Band  y  a  los  de  Alquier. 

Si  se  quiere  conocer  la  cantidad  de  energla  puesta  a  diflposici6n  del  organismo  por 
esta  raci6n,  hay  que  multiplicar  cada  uno  de  estos  elementos  por  los  coeficientes  calo- 
rfficos:  he  aqui  el  valor  de  la  raci6n: 

Materias  proteicas 64. 37X4. 4=    283. 23 

Grasas 39.14X9.4=    367.92 

Hidratos  da  earbono 368.85X4.1=1,512.29 

Total  de  calorlas 2,163.44 


PUBLIC  HBALTH  AND  MEDICINE. 


107 


Lo6  anilisis  de  las  onnsia  han  sido  piacticados  por  los  miamos  procedimientos  y  con 
las  mifimas  precauciones  de  los  aTiiJIims  del  estudio  sobre  NtUriddn  en  Bogotd. 

Los  cuadros  que  se  verdn  en  seguida  representan  para  cada  individuo  el  promedio  de 
los  tres  andlisis  de  cada  perfodo  y  al  fin  de  cada  serie  de  cuadros  se  encontrar&n  los  dos 
promedios  generates  que  servirdn  de  comparaci6n:  el  del  perfodo  de  ab8tenci6n  de 
chicha  y  el  del  perfodo  de  chicha. 

Las  orinas  fueron  recogidas  con  todas  las  precauciones  necesarias  para  impedir  la 
fermentaci6n  amoniacal  y  ademis,  para  mayor  seguridad  se  medfa  la  acidez  tan  to  a  su 
llegada  al  Laboratorio  como  en  el  memento  del  andlisis;  este  se  principiaba  por  aquellas 
sustancias  mis  ^iles  de  descomponer. 

Periodo  de  abstenddn  de  chicha — elvminaddn  del  dzoe. 


N6m. 


Aftos 

de 
edad. 


1 
2 
3 
4 
6 
0 


24 
22 
21 
21 
22 
22 


Tem- 
pera- 
luia. 


36.6 
36.6 
36.7 
36.5 
36.9 
37.0 


Polso. 


88 
84 
74 
82 
76 
78 


Res- 
pira- 

CwDOS. 


20 
18 
18 
20 
19 
20 


Densi- 

dadde 

laorlna. 


1,015 
1,010 
1,016 
1,013 
1,014 
1,015 


Volu- 
meii  en 

24 
boras. 


2,900 
2,800 
2,450 
3,300 
3,150 
29,502 


Acldex  eo  H. 


Por 
Utro. 


0.027 
.013 
.023 
.021 
.021 
.023 


En  24 
horas. 


0.78 
.036 
.054 
.060 
.066 
.068 


Azoe  total. 


Por 
Utro. 


4.13 

2.06 
2.94 
3.33 
3.80 
4.10 


En  24 
horas. 


11.95 
5.77 
7.20 
10.99 
11  97 
12.09 


Nfim. 


1. 
3. 
3. 
4. 
5. 
6. 


Amonlaco 

y  4cidos 

aminados. 

Urea. 

Purinas 

totales(en 

&cido  t^co). 

Acido  tiico. 

Bases  ptirlcas 
(enxantina). 

Por 

En  24 

Por 

En  24 

Por 

En  24 

Por 

En  24 

Por 

En  24 

litros. 

horas. 

Utro. 

horas. 

Utro. 

horas. 

Utro. 

horas. 

Utro. 

horas. 

0.24 

0.70 

4.86 

13.93 

0.44 

1.37 

0.31 

0.90 

O.a'iO 

0.171 

.20 

.66 

3.43 

9.60 

.41 

1.16 

.23 

.64 

.081 

.179 

.20 

.49 

4.86 

11.81 

.65 

1*59 

.32 

.82 

.104 

.355 

.27 

.89 

4.71 

15.54 

.45 

1.48 

.11 

.36 

.151 

.508 

.23 

.72 

6.10 

16.06 

.45 

1.45 

.20 

.63 

.114 

.359 

.30 

.59 

4.90 

14.46 

.42 

1.34 

.18 

.53 

.109 

.333 

Acldo 
fosTdrico. 


For 
Utro. 


0.90 
.60 
.60 
.45 
.50 
.80 


En  24 
horas. 


3.61 
1.68 
1.47 
1.49 
1.58 
3.36 


Periodo  de  abstenddn  de  chicha — eliminaciSn  del  dzoe  y  relaci6n  delfdsforo  al  dzoe 

(Cuadro  I). 


Ntimeros. 

1 

1 

2 

3 

4 

5 

6 

ktoe  amoniacal 

Axoe  de  la  urea 

0.58 

6.41 

.30 

.062 

11.95 

4.85 

52.89 

2.61 

.52 

3.L3 

60.87 

39.13 

2.61 

.93 

12.85 

28.4 

0.46 

3.31 

.21 

.065 

6.77 

7.80 

57.37 

3.64 

1.12 

4.76 
69.93 
30.07 

1.49 
.65 

8.88 
12.3 

0.39 

6.92 

.23 

.093 

7.20 

5.36 

82.22 

4.56 

1.29 

5.84 

93.42 

6.58 

1.47 

.64 

11.25 

24.9 

1 

0.73 

7.26 

.12 

.185 

10.99 

6.64 

66.05 

1.09 

1.68 
2.77 

75.46 

34.54 

1.49 

.65 

16.91 

37.4 

0.59 

7.51 

.31 

.131 

11.97 

4.97 

65.26 

1.75 

1.18 
7.93 

73.16 

26.84 

1.58 

.69 

17.35 

35.3 

0.49 
6.75 

Azoe  Acl'^o  rtrico, 

.18 

Asoe  de  las  bases  pdricas 

.118 

Azoe  pfirico  total 

13.09 

Part,  del  Ac.  amoniacal  porJ.00  de  &zoe  total 

4.05 

Part,  del  Az.  de  la  urea  por  100  de  Azoe  total 

55 

Part,  del  As.  del  &cido  por  100  de  Arico  total 

1.49 

Part,  del  Az.  de  las  bases  ptiricas,  por  100  de  &zoc 
total 

.98 

Part,  del  Az.  ptirico  total,  por  100  do  Axoe  total 

Fraccldn  de  A  z.  determlnado  I'.or  100 

2.47 
60.52 

FnM*ci<^n  'le  a  z,  indetenniTH^do  por  ino . 

39.48 

Anhidrido  fosfdrlco 

2.36 

Fdsforo  de  los  fosfatos 

.63 

Relacidn  ronderal 

11.72 

Relacidn  atdmica 

26.9 

108       FBOCEBDINOS  SECOND  PAK  AHBBIOAN  SOlEIJTlFiO  00NGBB88. 

Periodo  de  cAtcfto — elvmnaeiSn  del  dtoe  y  de  purina. 


Afios 

de 
ed»<L 

T«m- 

Polso. 

R«s- 

pirs- 

oiones. 

dAdde 
laoriiUL 

Volo- 
menon 

24 
boras. 

Addesenh. 

lioetoteL 

Ntkm. 

Per 
Utio. 

En  24 
bom. 

Per 
Utio. 

En  24 
boras. 

1 

24 
22 
21 
21 
22 
22 

86.2 
86.4 
86.5 
86.6 
36.8 
36.7 

88 
82 
72 
76 
76 
74 

20 
17 
18 
10 
10 
20 

1,008 
1,010 
1,014 
1,011 
1,014 
1,012 

2,100 
8,240 
8,020 
2,000 
8,200 
8,000 

0.018 
.021 
.022 
.026 
.021 
.024 

0.065 
.068 
.066 
.066 
.067 
.072 

8.81 
2.86 
4.44 

4.84 
4.20 
4.60 

11.81 

2 

0.15 

8 

18.40 

4 

14.04 

5 

15.44 

6 

18.80 

NUm. 

Amoniaoos 

7&cido8 

amliiadoB. 

Urea. 

Pnrinas  tota- 

lesenioido 

tkrioo. 

Aoidotlnoo. 

Bases  jpAri- 
cas(en 

AcidofDS- 
fdiioo. 

Pot 
litio. 

En  24 
boras. 

Por 
Utio. 

En  24 
boras. 

POT 

Utro. 

En  24 
boras. 

Por 
Utio. 

En  24 
boras. 

Por 
Utro. 

En  24 
boras. 

Por 
Utio. 

En  24 
boras. 

1 

0.21 
.81 
.44 
.58 
.48 
.24 

0.66 
LOO 
L33 
L68 
L53 
.72 

6.71 
3.43 
5.14 
5.57 
4.80 
5.00 

16.03 
U.U 
15.42 
16.15 
15.36 
15.00 

0.42 
.45 
.22 
.46 
.48 
.44 

L80 
L45 
.66 
L33 
L53 
L82 

0.28 
.19 
.11 
.26 
.18 
.15 

a87 
.62 
.83 
.75 
.58 
.45 

0.068 
.118 
.048 
.091 
.091 
.132 

0.196 
.382 
.145 
.201 
.291 
.806 

a70 
.60 
.40 
.40 
.80 
.90 

2.17 

2 

1.04 

8 

1.20 

4 

1.20 

5 

2.66 

6 

2.70 

Periodo  de  Mcha — Repartici^n  del  dzoe  y  rdaci&n  ddfdeforo  al  dzoe. 


NtUneros. 

1 

2 

3 

4 

5 

6 

A,coe  Amoniaeal 

0.54 
7.49 
.26 
.070 
.330 
1L81 
4.57 
63.42 
2.20 
.593 
2.793 
70.78 
29.22 
2.17 
.94 
12.56 
27.8 

0.82 
5.19 
.20 
.139 
.389 
9.15 
8.96 
56.72 
2.21 
L508 
3.718 
09.39 
30.61 
L94 
.85 
10.76 
23.8 

LOO 

7.19 

.11 

.053 

.163 

18.40 

8.13 

53.73 

.82 

.395 

L21 

74.07 

25.93 

L20 

.52 

25.77 

57.00 

L38 
7.54 
.25 
.072 
.322 
14.04 
9.83 
53.53 
L85 
.513 
2.36 
65.72 
34.28 
L20 
.52 
27.38 
00.6 

L26 

7.17 

.10 

.106 

.296 

18.44 

9.37 

53.34 

L41 

.790 

2.20 

64.91 

35.09 

2.56 

L12 

12.00 

26.57 

0.50 

Acoedela  area 

7.07 

Azoedel  Aoido  drico 

.15 

Azoe  de  las  bases  nArioas .• 

.263 

A  soe  ptbrioo  total 

.418 

A  aoe  total 

13.80 

Parte  del  Asoe  amoniaoal  pcv  100  de  AsT 

4.28 

Parte  del  &zoe  de  la  urea  por  100  de  AsT 

5L28 

Parte  dol  4zoe  del  Acido  mloo  por  100  de  AeT 

1.00 

Parte  del  &«>e  de  las  bases  pAncas  por  100  de  AsT 

Parte  del  &zoe  pflrioo  total  nor  100  de  AsT 

L18 
2.27 

FVft/»ri<Sn  d«  A*0«  rtflfrmlnftdo .  ^ ,    ... 

57.73 

Fnvvti^ndeAso^indetennJnado 

42.27 

Anhidrido  fos(<5rlco 

2.70 

F6sforo  delos  fosfatos 

L18 

Rel^ido  ponderal 

11.60 

Relacidn  £U<)mloa 

25.0 

PROMEDI08. 


I.  Periodo    de    abstencidn    de 

chicha: 

Denaidad 1. 013 

Volumen  en  24  horas  (c.  c . ) .      2. 925 

Acidez 061 

Azoe  total 10.41 

Amonlaco  y  4cido8  amina- 

doe 70 

Urea 13.20 

Purinas  totalee 1. 32 

Acido  drico 67 

Basespdricas 270 


I.  Periodo    de    abstencidn    de 

chicha — Gontinda: 

Anhidrido  fosf 6rico 1. 87 

Azoe  amoniaoal 58 

Azoe  de  la  urea 6. 16 

Azoe  del  ^ido  drico 25 

Azoe  de  las  basee  pdricas. .        .  161 

Azoe  pdrico  total 41 

Parte  del  &zoe  amoniacal 

por  100  de  &zoe  total 5.57 

Parte  del  &zoe  da  la  urea 

por  100  de  &zoe  total 59.03 


PUBLIC  HEALTH  AND  MEDICINE. 


109 


PB0MBDI08 — continda. 


I.  Perlodo    de    ab8tenci6n    de 

chichft — Continda: 
Parte  del  dzoe  ^ido  drico 

por  100  de  &zoe  total 2.04 

Parte  del  dzoe  de  las  bases 
pdricas  por  100  de  &zoe 

total LOS 

Parte  del  dzoe  pdrico  total 

por  100  de  izoe  total 3. 09 

Fraccidn  de  &zoe  determi- 

nado  por  100 67. 64 

Fracci6n  de  dzoe  indeter- 

minado  por  100 32. 36 

F6eforo  de  los  foafatos 81 

Ilelaci6n  ponderal 12. 85 

Relaci6n  at6mica 1:28. 5 

Indice  de  imperfecci6n  urog^ 

nica 8. 71 

Indice  de  transformacidn  de  los 
ndcleo  proteidos 60.09 

II.  Perfodo  de  chicha: 

Denaidad 1.  Oil 

Volumen  en  24  horas 3. 076 

Acidez 055 

Azoe  total 12.60 

Amonlaco  y   icidos   ami- 

nados 1.15 

Urea 14.84 

Purinas  totalee 1.26 

Acido  drico 60 

Bases  pdricas 30 


II.  Perfodo    de    chicha — Con- 
tin  da: 

Anhidrido  fosfdrico 1. 96 

Azoe  amoniacal 95 

Azoedelaurea 6.93 

Azoe  del  dcido  drico 20 

Azoe  de  las  bases  pdricas.        .  11 

Azoe  pdrico  total 31 

Parte  del  izoe  amoniacal 

por  100  de  dzoe  total. . .      7. 39 
Parte  del  dzoe  de  la  urea 

por  100  de  dzoe  total 55 

Parte  del  dzoe  del  ^ido 
drico  por  100  de  dzoe 

total L59 

Parte  del  izoe  de  las  bases 
pdricas  por  100  de  dzoe 

total 87 

Parte  del  dzoe  pdrico  total 

por  100  de  dzoe  total....      2. 46 
Fraccidn  de  dzoe  determi- 

nado  por  100 64. 85 

Fraccidn  de  dzoe  indeter- 

minado  por  100 35.15 

Fdsforo  de  los  fosfatos 86 

Relacidn  ponderal 15. 06 

Relacidn  atdmica 33. 34 

Indice  de  imperfeccidn  urog^nica    10. 20 
Indice  de  transformacidn  de  los 
ndcleo  proteidos 57.92 


DBDUCCI0NB8    DB    LOS  PR0MEDI08. 

Comparando  los  promedios,  de  los  doe  perfodos  vemoe  que  hay  en  los  s^undoe  (perfodo 
de  chicha)  con  relacidn  a  loe  primeros,  no  dando  mayor  importancia  a  la  pequefia  baja 
de  temperatura: 

Una  diaminucidn  de  ladensidad  de  la  orina,  de  la  acidez,  del  dcido  drico,  del  dzoe 
de  la  urea  en  relacidn  con  el  dzoe  total;  del  dzoe  del  dcido  drico,  y  del  de  las  bases 
pdricas  con  relacidn  al  dzoe  total,  del  dzoe  determinado  y  del  indice  de  trasformacidn 
de  los  ndcleoB  proteidos. 

Un  aumento:  del  volumen  de  la  orina,  del  dzoe  total,  del  amoniaco,  de  las  bases 
puricas,  del  anhidrido  foafdrico,  del  dzoe  amoniacal  con  relacidn  al  dzoe  total,  y  de  la 
imperfeccidn  urogdnica. 

Nada  mds  elocuente  que  estos  resultados  para  establecer  la  concluaidn  franca,  de 
que  la  chicha  produce  una  inhibicidn  sobre  los  procesos  nutritives. 

Esta  influencia  retardante,  quizd  no  sea  debida  al  alcohol  por  la  pequefia  cantidad 
que  ingirieron  loe  sujetos  de  mis  experimentos,  porque  no  se  verificaron  los  cambioe 
en  el  pulao  y  en  la  respiracidn  que  producen  pequefias  cantidadas  de  alcohol,  y 
porque  el  Profesor  Maillard  tuvo  que  concluir  un  trabajo  semejante  al  mfo,  con  el 
dicho  vulgar  de  que  un  vaso  de  vino  no  hace  dafio. 

No  sucede  lo  mismo  con  el  vaso  de  chicha,  la  coal  debe  muy  probablemente  su 
accidn  retardante  sobre  la  nutricidn,  a  la  tomaina  descubierta  por  el  Dr.  Zerda  y  que 
a  la  manera  del  fdsforo  del  dxido  de  carbono,  del  arsdnico,  de  la  morfina,  etc., 


110       PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC  CONGRESS. 

determina  variaciones  inmediatas  en  el  funcionamiento  qufmico  normal  del  organismo 
en  lo6  procesoB  de  nutricidn  general,  y  por  consiguiente,  en  las  excreeiones  urinarias 
en  particular. 

No  tengo  la  pretensi6n  de  creer  que  mis  reeultados  sean  de  una  infalibilidad  absoluta, 
pero  sf  que  los  experimentos  han  aido  hechos  con  el  m^  escrupuloso  cuidado  y  por  los 
mejores  procedimientos  hasta  hoy  conocidos. 

Es  esta  una  prueba  m^  de  que  la  chicha  es  un  veneno  y  de  que  el  Gobiemo  debe 
propender  por  cuantos  medios  est^n  a  su  alcance  para  impedir  su  uso. 

Si  es  verdad  que  todos  los  ej6rcito8  usan  el  alcohol  a  dosis  moderadas  como  alimento 
energ6tico  (el  aguardiente  en  Rusia,  el  vino  en  Francia  y  Espaiia,  la  cerveza  en  Ale- 
mania,  etc.)  deberia  elegirse  para  nuestros  soldados  una  chicha  en  que  la  fermentaci6n 
no  Uegara  al  estado  de  putrefacci6n  a  que  generalmente  llega,  o  una  cerveza  barata. 
De  esta  manera  el  cuartel  serla  una  escuela  para  ensefiarles  a  los  hombres  de  nuestro 
pueblo,  ya  que  no  a  dejar  la  bebida,  cosa  punto  menos  que  imposible,  al  menos  a 
cambiarla  por  una  menos  dafLosa  y  a  hacer  uso  de  otras  sustancias  alimenticias,  deri- 
vadas  tambi^n  del  mafz,  pero  no  dafiosas  como  la  chicha. 

The  Chairman.  It  is  very  difficult  to  follow  this  paper  into  all 
the  complete  details  that  are  given.  He  brings  into  the  paper  evi- 
dence of  nutritive  retardation  in  the  highland  of  Bogota.  Body 
temperature  is  lower.  The  amount  of  urea  in  the  urine  is  less.  The 
number  of  red  cells,  instead  of  being  increased,  as  it  is  stated  to  be 
in  the  highlands,  is  diminished  in  that  table-land  of  Bogota.  The 
pulse  is  somewhat  accelerated  and  the  respiration  also,  as  a  sort  of 
compensatory  respiratory  and  circulatory  function.  There  is,  there- 
fore, a  diminution  of  exudation  of  nitrogen  and  the  utiUzation  of 
nitrogen  also.  He  behoved  for  a  time  this  might  be  due  to  the 
difference  in  the  composition  of  the  foods,  since  the  nitrogen  com- 
ponents of  foodstuffs  were  found  to  be  less  than  in  other  climates. 
He  found  that  this  was  not  so;  that  the  composition  of  foods  in  the 
table-land  of  Colombia  is  exactly  the  same  as  in  the  Temperate  Zones. 
As  a  side  issue,  but  working  in  the  same  direction,  he  investigated 
the  action  of  the  common  beverage  of  the  country,  chicha,  of  which 
he  spoke  when  the  question  of  pellagra  came  up,  and  he  finds  that 
this  chicha,  an  alcohoUc  beverage  from  the  fermentation  of  maize, 
exerts  also  evidently  a  retarding  action  upon  this  nutritive  function, 
which  he  thinks  may  bo  duo  to  the  action  of  the  ptomaine  it  was 
found  to  contain  by  one  of  his  colleagues. 

I  do  not  quite  understand  his  theory  of  this  retarding  function. 
One  of  his  points  (there  are  two)  I  imderstood  weU.  He  believes, 
suggesting  without  giving  it  as  a  positive  opinion,  that  the  rapid 
rotation  of  the  earth  increases  the  amount  of  carbonic  acid  in  the 
atmosphere  in  the  Tropics,  thus  causing  this  retardation  of  nutritive 
function.  The  other  point  is  the  absence  of  seasonal  changes;  that 
is,  that  there  is  a  monotony  in  the  landscape,  a  monotony  in  every- 
thing about,  that  in  the  same  manner  there  is  a  monotony  of  Ught, 
a  monotony  of  sound,  which  may  produce  serious  disturbance  in 
the  nervous  system. 


PUBLIC   HEALTH  AND  MEDIOIKE.  Ill 

The  CHAiBBfAN.  The  following  papers,  largely  previously  presented 
conference  papers,  have  been  courteously  submitted  to  Section  VIII 
by  their  writers.  As  a  matter  of  record  they  will  be  included  in  the 
proceedings  of  the  section : 

Tratamiento  de  la  coqueluche,  by  Rodolfo  Kraus. 

Ingerto  testicular,  by  Antonio  F.  Celesia. 

Vacunoterapia  de  la  conjimtivitis  granulosa,  by  E.  B.  Demarfa, 
Salvador  Mazza,  y  Hector  Rebay. 

Tratamiento  de  las  apendicitis  agudas,  by  Ekirique  J.  Corbellini. 

The  Chaibman.  I  beg  to  state  that  through  the  courtesy  of  the 
authors  the  following  printed  pamphlets  have  been  presented  to 
the  Congress  through  Section  VIII : 

Investigaciones  sobre  el  cultivo  de  la  rabia  por  el  m6todo  de  No- 
guchi,  by  R.  Kraus  and  B.  Barbara.  Las  Ciencias,  Libreria  y  Casa 
Eklitora  de  A.  Guidi  BuiFarini,  Buenos  Aires. 

El  carb6n  animal  en  la  terap^utica  y  en  la  higiene,  by  R.  Kraus 
and  B.  Barbara.  Las  Ciencias,  Libreria  y  Casa  Editora  de  A.  Guidi 
Buffarini,  Buenos  Aires,  1915. 

Terap6utica  heterobacteriana,  by  R.  Kraus  and  S.  Mazza.  Las 
Gencias,  Libreria  y  Casa  Editora  de  A.  Guidi  Buflfarini,  Buenos  Aires, 
1914. 

Contribuci6n  al  estudio  del  tratamiento  operatorio  de  los  quistes 
uniloculares  vohuninosos  y  extrasinusales  del  maxilar  superior,  by 
Diogenes  Massa.  Talleres  Gr&ficos  de  Juan  Perrotti,  Buenos  Aires, 
1915. 

Profilaxia  de  la  tif6idea  por  la  vacunaci6n  en  la  Reptiblica  Argen- 
tina, by  Salvador  [Mazza.  Las  Ciencias,  Libreria  y  Casa  Editora  de 
A.  Guidi  Buffarini,  Buenos  Aires,  1915. 

Adjournment  at  1.20  p.  m. 


GENERAL  SESSION  OF  SECTION  Vm. 

New  Ebbitt  Hotel, 
Monday  afternoon,  Jarmary  5, 1916. 

Chairman,  J.  D.  Gatewood. 

The  session  was  called  to  order  at  2  o'clock,  by  the  chairman. 

The  following  papers  were  presented: 

Changes  in  the  food  supply  and  their  relation  to  nutrition,  by 
Lafayette  B.  Mendel. 

A  safe  and  sane  milk  supply,  by  John  Weinzirl. 

Proyecto  de  ordenanza  reglamentaria  del  comercio  de  leche  de 
consumo  en  Buenos  Aires,  by  Ricardo  Sarmiento  Laspiur. 

CHANGES  IN  THE  FOOD  SUPPLY  AND  THEIR  RELATION  TO  NUTRITION. 

By  LAFAYETTE  B.  MENDEL, 

Professor  of  Physiological  Chemistry ,  Sheffield  Scientific  School,  Tale  University. 

In  the  type  of  civilization  with  which  we  are  most  familiar  there  are  two  fundamental 
elements — supplies  of  food  energy  and  supplies  of  mechanical  energy.  Since,  at 
present,  partly  because  of  geographical  conditions,  these  do  not  necessarily  (or  even 
in  general)  occur  together,  there  is  a  third  essentisd  factor,  the  line  of  transport.* 

A  comprehensive  consideration  of  any  one  of  these  factors,  such  as  the  food  supply, 
can  not  be  completely  dissociated  from  its  relations  to  the  others.  The  development 
of  commerce  among  nations  having  adequate  means  of  communication  has,  for  exam- 
ple, rendered  the  distribution  of  food  materials  easy  and  developed  a  sense  of  security 
(under  normal  conditions)  against  failure  of  food  supplies.  The  growing  organiza- 
tion of  transportation  facilities  has  encouraged  the  introduction  of  dietary  changes 
never  thought  possible  or  even  contemplated  a  few  generations  ago.  Incidents 
associated  with  the  altered  distribution  of  wealth  have  improved  the  nutrition  as 
well  as  other  conditions  of  living  among  that  large  group  of  our  population  which  has 
been  termed  the  "healthier  well-to-do  classes." 

The  supply  of  food  energy  and  its  availability  where  needed  are  interrelated  closely 
with  a  variety  of  factors,  the  bearing  of  which  upon  the  problem  at  hand  is  not  always 
evident  upon  the  surface.  Some  of  these  features  may  be  classified  superficially  as 
follows: 

1.  Food  production. 

2.  Food  preservation  and  food  conservation. 

3.  Transportation  facilities. 

4.  Customs  in  diet. 

5.  Changing  industrial  and  social  conditions,  and  other  economic  and  hygienic 
factors. 

I  Dickson,  U.  N.:  The  Redistribution  of  Mankind.  Presidential  Address  to  Section  E  (Geography)  at 
the  Birmingham  meeting  of  the  British  Association,  September,  1913.  Report  British  Association  for  the 
Advancement  of  Science,  Birmingham  1013,  pp.  536-546.    London  1014. 

112 


PUBLIO  HEALTH  AND  MEDIGIKE.  113 

Food  production, — ^The  problem  of  food  production  is  the  fundamental  concern  of 
agriculture.  How  profoundly  its  practices  are  being  changed  by  the  progress  of  science 
and  the  mechanic  arts  is  familiar  to  every  observant  person.  The  food  supply  has 
been  increased  in  part  through  more  intensive  methods  of  agriculture,  in  part  through 
the  enormous  extension  of  areas  suitable  for  cultivation.  In  view  of  the  increase  of 
population  it  has  been  a  favorite  pastime  for  scientists  to  calculate  the  possibilities 
of  the  food  supply  of  the  future  and  to  venture  prophesies  involving  the  prospect  of 
impending  failures.  A  forecast  by  Sir  William  Crookes  of  the  relatioms  between  the 
probable  increase  of  the  world's  supply  and  demand  of  wheat,  ''the  most  sustaining 
food  grain  of  the  great  Caucasian  race,''  was  widely  discussed  when  his  estimates  were 
published.  In  a  Presidential  Address  to  the  British  Association  for  the  Advancement 
of  Science  in  1898  Crookes  said: 

Should  all  the  wheat-growing  countries  add  to  their  (producing)  area  to  the  utmost 
capacity,  on  the  most  careful  oilculation  the  yield  would  ^ve  us  only  an  addition  of 
some  100,000,000  acres.  stippl3dng,  at  the  average  world  yield  of  12.7  bushels  to  the 
acre,  1,270,000,000  busnels,  just  enough  to  supply  the  increase  of  population  among 
bread  eaters  till  the  year  1931.  ♦  ♦  ♦  Thirty  years  is  but  a  day  in  the  life  of  a 
nation.  Those  present  who  may  attend  the  meeting;  of  the  British  Association  30 
years  hence  will  judge  how  far  my  forecasts  are  justified. 

Fifteen  years  later  Prof.  Dickson  said: 

Half  the  allotted  span  has  now  elapsed,  and  it  may  be  useful  to  in<]uire  how  things 
are  going.  Fortunately,  this  can  be  easily  done,  up  to  a  certain  point,  at  any  rate, 
by  reference  to  a  paper  published  recently  by  Dr.  j.  F.  Unstead,  in  which  compari- 
sons are  given  for  the  decades  1881-1890,  1891-1900,  and  1901-1910.  Dr.  Unstead 
shows  that  the  total  wheat  harvest  for  the  world  may  be  estimated  at  2,258,000,000 
bushels  for  the  first  of  these  periods,  2,575,000,000  for  the  second,  and  3,233,000,000 
for  the  third,  increases  of  14  per  cent  and  25  per  cent,  respectively.  He  points  out 
that  the  increases  were  due  "mainly  to  an  increased  acreage,"  the  areas  being 
192,000,000,  211,000,000,  and  242,000,000  acres,  but  also  "to  some  extent  (about  8 
per  cent)  to  an  increased  average  yield  per  acre,  for  while  in  the  first  two  periods  this  was 
i2  bushels,  in  the  third  period  it  rose  to  13  bushels  per  acre." 

If  we  take  the  period  1891-1900.  as  nearly  corresponding  to  Sir  William  Crookes's 
initial  date  we  find  that  the  succeeaing  period  shows  an  increase  of  658,000,000  bushels, 
or  about  half  the  estimate  increase  required  by  1891,  and  that  attained  chiefly  by 
"increased  acreaffe. "  But  signs  are  not  wanting  that  increase  in  this  way  will  not  go 
on  indefinitely.  We  note  (alro  itom  Dr.  Unstead's  paper)  that  in  the  two  later  periods 
the  percentage  of  total  wheat  produced  which  was  exported  from  the  United  States 
fell  from  32  to  19,  the  yield  per  acre  showing  an  increase  meanwhile  to  14  bushels. 
In  the  Russian  Empire  the  percenta^  fell  from  26  to  23,  and  only  in  the  youngest  of 
the  new  countries — Canada,  Australia,  and  Argentina — do  we  find  lar^  proportional 
increases.  Again  it  is  sigpiificant  that  in  the  United  Kingdom,  which  is,  and  always 
has  been,  the  most  sensitive  of  all  wheat-producing  coimtries  to  variations  in  the 
floating  supply,  the  rate  of  falling  o£f  of  home  production  shows  marked  if  irregular 
diminution. 

Looking  at  it  in  another  way,  we  find  (still  from  Dr.  Unstead 's  figures)  that  the  total 
amount  sent  out  by  the  great  exporting  countries  averaged  in  1881-1890,  295,000,000, 
bushels;  1891-1900,  402,(500,000;  1901-1910, 532,000,000.  These  quantities  represent, 
respectively,  13,  15.6,  and  16.1  per  cent  of  the  total  production,  and  it  would  appear 
that  the  percentage  available  for  export  from  these  regions  is,  for  the  time  at  least, 
approaching  its  limit — ^i.  e.,  that  only  about  one-sixth  of  the  wheat  produced  is  avail- 
able from  surpluses  in  the  r^ons  of  production  for  making  good  deficiencies  elsewhere. 

There  is,  on  the  other  hand,  abimduit  evidence  that  improved  agriculture  is  begin- 
ning to  raise  the  yield  per  acre  over  a  large  part  of  the  producing  area.  Between  the 
periods  1881-1890  and  1901-1910  the  average  in  the  United  States  rose  from  12  to  14 
bushels;  in  Russia,  from  8  to  10;  in  Australia,  from  8  to  10.  It  is  likely  that  in  these 
last  two  cases  at  least  a  part  of  the  increase  is  due  merely  to  more  active  occupation  of 
tresh  lands  as  well  as  to  the  use  of  more  suitable  varieties  of  seed,  and  the  effect  of 
improvements  in  methods  of  cultivation  alone  is  more  apparent  in  the  older  countries. 
Diuing  the  same  period  the  average  yield  increased  in  the  United  Kingdom  from  28 
to  32  bushels,  in  France  from  17  to  20:  Holland,  27  to  33;  Belgium,  30  to  35;  and  it  is 
most  marked  in  the  German  Empire,  for  which  the  figures  are  19  and  29. 

In  another  important  paper  Dr.  Unstead  has  shown  that  the  production  of  wheat 
in  North  America  may  still  in  all  likelihood  be  very  largely  increased  by  merely 


114       PROCEEDINGS  SECOND  PAN  AMEBIOAN   SCIENTIFIC  CONGBESS. 

increasing  the  area  under  cultivation,  and  the  reasoning  by  which  he  justifies  this 
conclusion  certainly  holds  good  over  large  districts  elsewhere.  It  is  of  course  impos- 
sible, in  the  present  crude  state  of  our  Imowledge  or  our  own  plant,  to  form  anv  accu- 
rate estimate  of  the  area  which  may  be  the  use  of  suitable  seeds  or  otherwise,  become 
available  for  extensive  cultivation.  But  I  think  it  is  clear  that  the  available  pro- 
portion of  the  total  supply  fnnn  *' extensive"  sources  has  reached,  or  almost  reached, 
its  maximum,  and  that  we  must  depend  more  and  more  upon  intensive  farming,  with 
its  greater  demands  for  labor. 

The  average  total  area  under  wheat  is  estimated  by  Dr.  Unstead  as  192,000,000  acres 
for  1881-1890,  211,000,000  acres  for  1891-1900,  and  242,000,000  acres  for  1901-1910. 
Making  the  guess — ^for  we  can  make  nothing  better — that  this  area  may  be  increased 
to  300,000,000  acres,  and  that  under  ordinary  agriculture  the  average  yield  may  even- 
tually be  increased  to  20  bushels  over  the  wnole,  we  get  an  average  Imrvest  of  6,000^- 
000,000  bushels  of  wheat.  The  average  wheat  eater  consumes,  according  to  Sir 
William  Orookes's  figures,  about  4}  bushels  per  annum;  but  the  amount  tends  to 
increase.  It  is  as  much  (according  to  Dr.  Unstead)  as  6  bushels  in  the  United  King- 
dom and  8  bushels  in  France.  Let  us  take  the  British  figure,  and  it  appears  that  on 
a  liberal  estimate  the  earth  may  in  the  end  be  able  to  feed  permanently  1,000,000,000 
wheat  eaters.  "If  prophecies  based  on  population  statistics  are  trustworthy,  the 
crisis  will  be  upon  us  before  the  end  of  this  century. "  * 

Interesting  as  such  speculations  are,  despite  the  number  of  uncertain  variables  with 
which  they  necessarily  deal,  they  fail  to  take  into  consideration  the  altered  pros- 
pects arising  out  of  the  modem  increasing  knowledge  of  the  science  of  nutrition.  It 
is  by  no  means  improbable  that  progress  in  food  chemistry  and  the  study  of  metabolism 
will  point  the  way  to  substitutes  for  what  is  now  regarded  as  a  staple  foodstuff.  We 
shall  see  what  changing  customs  in  diet  have  already  brought  about  in  many  instances. 
If  corn,  for  example,  does  not  satisfy  the  requirement  of  a  staple  crop  for  human  con- 
sumption, it  is  not  at  all  unlikely,  in  view  of  information  already  available,  that  small 
addenda  of  other  foods  may  suffice  to  supplement  it  so  as  to  produce  a  more  perfect 
ration. 

One  may  appropriately  recall  here  that  evidences  of  adequate  nutrition  are  available 
from  people  nourished  in  most  diverse  ways  in  different  parts  of  the  world.  Even 
if  the  wheat  problem  were  to  become  one  of  urgency  within  an  appreciable  i)eriod,  this 
need  not  necessarily  be  construed  into  a  forecast  of  an  actual  shortage  of  food.  Within 
a  few  months  attention  has  been  directed  to  the  possibility  of  growing  in  the  United 
States  at  least  two  plant  products  which  may  serve  as  human  foods.  One  of  these  is 
proso  millet,  the  other  grain  soxghum  or  kaoliang,  both  of  which  have  long  been  known 
in  other  parts  of  the  world  as  constituents  of  the  diet  of  mankind .  Both  of  these  seeds 
can  be  milled  like  the  familiar  cereals  and  s^ved  Uke  these  or  transformed  into  culi- 
nary products  after  admixture  with  flour,  which  enables  them  to  be  prepared  for  baking. 
The  peculiar  agricultural  advantage  in  such  crops  lies  in  the  fact  that  they  are  drought 
resistant.  Proso  will  grow  when  and  where  the  staple  small  grains  that  require  moist 
regions  fail.  Kaoliang  represents  a  tropical  annual  plant  which  can  by  cultivation 
be  extended  north  as  far  as  Indian  com  on  this  continent.  The  dietary  possibilities 
of  both  proso  and  kaoliang  have  already  been  tested  in  a  semipublic  way.' 

Food  preservation  and  food  conservation. — ^The  preservation  of  food  affects  the  food 
supply  by  making  it  possible  to  utilize  in  times  and  places  of  relative  scarcity  products 
which  are  available  in  a  season  and  region  of  abundance.  From  an  early  period 
preservative  methods  have  been  employed.  Some  of  them  are  so  familiar  that  they 
are  frequently  not  even  recognized  as  belonging  in  the  category  of  food  preservation. 
Desiccation,  canning,  pickling,  salting,  smoking,  low  temperature,  freezing,  special 
chemicals — these  are  some  of  the  factors  that  enter  into  this  aspect  of  our  theme. 
The  significance  of  most,  if  not  all,  of  these  procedures  is  more  largely  economic  than 
hygienic. 

1  Dickson,  H.  N.:  kx^  cit.  p.  6S5. 

•  See  Hanaen,  N.  E.:  Proso  and  KaoHang  as  Table  Foods.  South  Dakota  Agrioultoral  Bxpariment 
Station  BuU.  158,  March,  1015. 


PUBLIC   HEALTH  AND  MEDICINE.  115 

The  cold  storage  methods  now  in  use  represent  a  comparatively  recent  development 
of  the  preservation  problem. 

According  to  Sherman,  only  since  about  1893  have  the  quantities  of  food  materials 
placed  in  cold  storage  been  large  enough  to  have  an  appreciable  effect  upon  market 
conditions.  As  an  illustration  of  its  efficiency,  recent  experiments  have  shown  that 
fresh  fish — a  food  product *notably  subject  to  speedy  deterioration — may  be  preserved 
frozen,  by  the  best  cold  storage  processes,  without  undergoing  any  important  change 
lor  at  least  two  years.  ^ 

Modem  bacteriology  has  placed  upon  cleanliness  a  preservative  value  which  may 

appear  surprising  in  respect  to  its  efficiency,  particularly  in  conjunction  with  low 

temperatures  which  inhibit  the  development  of  microorganisms  detrimental  to  foods. 

As  an  example  of  what  such  sanitary  precautions  can  accomplish  in  the  case  of  readily 

deteriiurating  milk,  Sherman  states: 

Three  American  dairy  farms  exhibited  raw  milk  at  the  Paris  Exposition  of  1900, 
one  of  them  sending  weekly  shipments  throughout  the  summer,  each  of  which  was 
kept  on  exhibition  m  the  raw  state  without  spoiling  until  the  next  shipment  arrived. 
It  was  difficult  to  convince  the  jury  of  European  experts  of  the  fact  tnat  cleanliness 
and  cold  were  the  only  preservatives  needed  to  accomplish  the  keeping  of  raw  milk 
in  a  fresh  sweet  condition  for  two  to  four  weeks  in  midsummer .^ 

Precisely  such  methods,  combined  with  modem  trsCnsport  facilities,  have  made  i  t 
possible  to  extend  the  range  of  milk  supply  in  our  laige  cities  literally  hundreds 
of  miles  and  to  bring  an  indispensable  food  at  a  reasonable  price  into  every  home. 
There  is,  indeed,  a  profound  difference  between  marketing  milk  in  the  familiar 
manner  now  practiced  and  the  older  mode  of  distribution  when  goats  or  cows  were 
driven  in  front  of  the  home  to  be  milked  there. 

Probably  no  single  preservation  device  excels  tiiat  of  desiccating  the  materials. 
In  the  absence  of  moisture  decay  is  arrested.  Where  the  ^ater  content  of  a  natural 
food  is  not  unduly  large  it  can  often  be  dried  readily  with  success.  Dried  meats, 
fish,  and  fruits  have  Icmg  belonged  to  the  list  of  preserved  foods.  In  the  case  of  prod- 
ucts comparatively  rich  in  water,  particularly  liquid  or  semiliquid  foods,  successful 
methods  of  desiccation  have  awaited  the  perfection  which  is  beginning  to  manifest 
itself  at  the  present  day.  Aside  from  the  element  of  cost,  the  use  of  heat  to  expel 
moisFture  has  the  objection  that  it  alters  the  product  in  some  cases  so  that  it  is  no  longer 
dietetically  acceptable .  Heat  also  may  remove  desirable  volatile  ingredients .  Flavors, 
which  play  a  very  important  rdle  in  rendering  a  food  acceptable  to  the  consumer 
are  not  always  thermostabile. 

Modem  industry  is  likely  to  oveitK)me  many  of  the  difficulties  by  the  device  of 
desiccation  at  lower  temperatures  either  in  a  vacuum  or  a  currait  of  air.  A  most 
Mtislactory  instance  of  this  ia  seen  in  the  case  of  milk.  Condensed  and  evaporated 
milks  are  likely  to  be  superseded  by  dried  milk  of  which  superior  grades  are  already 
being  manu&urtured.  The  successful  desiccation  of  milk— a  product  of  which  seven- 
eighths  is  water — with  the  retention  of  the  solubility  on  which  the  practical  appli- 
cations largely  depend,  and  with  its  nutritive  virtues  presumably  intact,  is  an  up-to- 
date  accomplidiment. 

The  possibility  of  a  satisfactory  outccone  of  the  efforts  now  being  made  in  the  milk 
industry  deserves  more  than  passii^  notice.  Milk  not  only  is  a  valuable  food ;  it  is  at 
present  an  indispensable  component  of  the  diet  during  growth,  and  no  entirely  satia&u^- 
tory  method  of  preservation  has  hitherto  been  devised.  With  one  American  brand  of 
dried  milk  as  the  chief  component  of  the  ration,  several  investigators,  including 
myself,  have  raised  small  animals  into  a  second  generation.    If  the  best  dried  milk 

I  Smith,  C.  S.:  A  Study  of  the  Infloenoe  of  Cold  Storage  Temperatures  upon  tbe  Chemical  Compodtioii 
and  Nutritive  Value  of  FUh.  Biochemical  Bulletin,  1913,  ill,  64;  Perteweig,  W.,  and  Gies,  W.  J.:  A 
Fartber  Study  of  the  Chemical  Composition  and  Nutritive  Value  of  Fish  Subjected  to  Prolonged  Periods 
ol  Cold  Storage.    Italdeai,  1918,  Ui,  09. 

t  siMrman,  H.  C:  Food  Prodoots.   New  York,  1914,  p.  fiS. 

68436— 17— VOL  X 0 


116       PBOCEEDINGS  SECOND  PAN  AMEBICAN  SCIBKTIFIO  00KQBES8. 

of  the  future  shall  be  shown  to  retain  eymi  the  more  subtle  physiological  properties, 
Buch  as  its  antiscorbutic  potency,  it  will  represent  good  achievement. 

The  expression  "food  conservation''  is  used  in  the  present  discussion  perhaps  not 
in  accord  with  a  strict  definition  but  rather  in  the  broader  current  sense  in  which  we 
speak  of  the  conservation  of  other  resources.  The  growing  use  of  by-products  finds  its 
exemplification  in  the  food  industries  as  well  as  in  other  branches  of  commerce;  and 
directly  or  indirectly  this  affects  the  problem  of  food  supply.  In  some  instances  the 
use  of  the  by-products  has  rendered  the  production  of  a  food  which  x>therwi8e  could 
not  be  marketed  advantageously  profitable  and  therefore  possible.  The  meat  industry 
presumably  afifords  instances  where  the  price  of  edible  parts  has  been  kept  within 
reasonable  limits  by  the  increasing  market  value  of  what  was  once  merely  worthless 
refuse.  Tankage  belongs  to  the  latter  category.  The  refinement  of  this  aspect  of 
modem  industry  impressed  itself  upon  me  in  seeing  the  fine  hairs  in  the  ears  of  cattle 
fattening  for  market  clipped  for  the  special  manufoicture  of  expensive  "camel's-hair" 
brushes;  and  likewise  in  observing  the  careful  removal  and  collection  of  the  seeds 
from  raisins  introduced  into  commercial  mince  meat.  From  these  supposedly  worth- 
less seeds  valuable  raisin  oil  was  subsequently  extracted.  The  by-products  of  the 
sugar  industries  are  notably  important.  Part  of  them  are  literally  used  to  get  gold. 
The  residues  from  the  desaccharification  factories  are  rich  in  nitrogen  which  is  in 
part  converted  into  sodium  cyanide.  Tons  of  this  have  been  exported  to  the  Trans- 
vaal where  it  has  been  used  for  extracting  the  precious  metal  by  the  well  known 
cyanide  process. 

For  tUe  food  supply  it  is  more  important  that  in  many  instances  what  was  in  the  past 
regarded  as  refuse  or  a  useless  dietary  constituent  has  been  converted  into  edible 
products.  Sometimes,  as  in  the  case  of  grain  products,  In  the  distilleries,  breweries, 
etc.,  by-products  now  s^rve  as  cattle  feeds  and  thus  indirectly  conserves  the  food 
supply  of  man.  In  other  instances  new  human  foods  have  been  devised.  Cotton- 
seed oil,  oleo  oils  from  beef,  and  other  fats  are  no  longer  despised  as  constituents  of 
the  diet.  In  some  cases  chemistry  has  aided  to  alter  the  &ts  into  a  suitable  texture 
and  consistency  for  culinary  purposes.  Slaughterhouse  blood  finds  its  way  into 
food  products.  Com  simps  and  glucose  sugars  artificially  prepared  from  cheap  sources 
of  starch  have  survived  the  propaganda  of  prejudice  and  now  represent  one  of  the 
cheapest  sources  of  wholesome  nutriment.  Deteriorated  products  such  as  old  butter 
are  * ' renovated  "  and  returned  into  the  food  treasury.  Hydrogenated  &ts  are  a  modem 
innovation. 

The  digestive  functions  of  man  offer  a  barrier  to  the  successful  use  of  certain  agri- 
cultural products  as  human  nutrients.  Complete  digestion  is  a  prerequisite  to  ade- 
quate nutrition.  Cellulose,  which  is  so  widely  distributed  in  plants,  is  unutilized 
by  man  because  it  is  indigestible.  It  is  theoretically  conceivable,  however,  that 
cellulose  can  be  converted  into  available  carbohydrate  by  chemical  procedures. 
Other  plant  constituents,  wholesome  in  themselves,  are  often  practically  unutilized 
in  the  alimentaty  tract  because  they  are  protected  by  impervious  coverings.  In 
such  cases  the  physical  texture  of  the  product  is  at  &ult.  The  alimentary  utilization 
of  the  foodstuffis,  particularly  the  indispensable  proteins,  in  conmon  foods  such  as  the 
legumes  and  cereal  grains  is  fax  below  what  potains  in  most  animal  food  products. 
Some  presumably  valuable  vegetable  proteins  can  not  be  used  as  food  by  man  because 
his  digestive  juices  can  not  get  at  them  in  the  condition  in  which  they  are  usuaUy 
exhibited  for  use.  Improved  culinary  methods  and  procedures  for  extreme  comminu- 
tion, particularly  after  desiccation,  may  alter  this  situation  in  coming  years.  A 
beginning  has  already  been  indicated  by  H.  Friedenthal  in  the  case  of  certain  green 
vegetables.  The  growing  use  of  nut  products  and  nut  pastes,  and  the  widespread 
popularity  of  the  readily  digested  peanut  butter,  prepared  from  an  article  which  is 
looked  upon  as  difficult  of  digestion  in  its  imperfectly  comminuted  form,  shows  what 
industries  can  do  to  overcome  dietary  prejudices  or  domestic  ignorance,  by  enhancing 
palatability  and  digestibility. 


PUBUC  HEALTH  AND  MEDICIll^.  117 

Of  all  the  foodstuffs,  the  proteins  offer  the  most  serious  problem.  They  represent 
the  Indispensable  staple  for  tissue  construction;  they  are  produced  at  the  greatest 
expense.  The  quantitative  aspects  of  the  protein  requirement  of  man  have  been 
warmly  debated  in  recent  years.  One  extreme  view  of  the  superiority  and  con- 
sequent liberal  need  of  protein  was  expressed  by  Liebig  ^  as  follows: 

Everyi^iiere  throughout  orguiized  nature,  where  animal  life  is  developed,  we  find 
the  phenomena  of  life  depending  on  the  presence  of  albumen.  The  continuance  of 
life  IS  indissolubly  connected  with  its  presence  in  the  blood;  that  is,  in  the  nutrient 
fluid.  In  so  far  as  the  notions  of  formation,  nutrition,  or  the  nutiitive  property  are 
inseparable  from  that  of  a  substance  whose  properties  and  composition  are  collected 
in  the  word  albumen,  only  those  substances  are  in  a  strict  sense  nutritious  articles 
of  food  which  contain  either  albumen  or  a  substance  capable  of  being  converted 
into  albumen  (p.  346). 

The  "plastic  foods''  of  Liebig  were  the  proteins.    Accordingly  he  says  again: 

All  these  orp;anized  tissues,  all  the  parts  which  in  any  wav  manifest  force  in  the 
body,  are  derived  hrom  the  albumen  of  the  blood;  all  me  albumen  of  the  blood  is 
derived  from  the  plastic  or  sanguigenous  constituents  of  the  food,  whether  animal  or 
vegetable.  It  is  clear,  therefore,  that  the  plastic  constituents  of  food,  the  ultimate 
source  of  which  is  the  vegetable  kingdom,  are  the  conditions  essential  to  all  production 
or  manifestation  of  force,  to  all  those  effects  which  the  animal  organism  produces  by 
means  of  its  oigans  of  sense,  thought,  and  motion  (p.  366). 

The  other  extreme  is  represented  by  the  modem  so-called  '4ow  protein"  advocates. 
From  the  debate  on  this  topic  it  has  become  probable  that,  although  some  views  as 
to  the  importance  of  protein  in  the  dietary  have  been  exaggerated,  a  liberal  factor 
of  safety  must  be  allowed.  In  any  event  protein  has  lost  the  special  significance 
which  it  assumed  in  Llebig's  day  as  the  unique  source  of  energy.  As  a  guide  in  the 
consideration  of  the  protein  supply  of  the  future  we  may  recall  the  attitude  of  Prof. 
Rubner,  an  expert  in  the  field  of  nutrition  study,  before  the  Fifteenth  International 
Congress  on  Hygiene  and  Demography  at  Washington  in  1912: 

Nutrition  in  the  cities  has  at  all  times  a  tenden<^y  toward  refinement,  but  in  former 
times,  when  the  classes  lived  strictly  separate,  the  food  materials  were  also  very 
different  within  the  city  walls.  The  food  of  the  nobility  was  different  from  that  of  the 
middle  class,  and  the  latter  from  that  of  the  poor  people.  Among  the  materials 
successfully  used  in  the  culinary  art  a  high  place  has  always  been  held  by  the  meat 
of  mammals,  fowls,  and  fishes.  These  meats  were  the  chief  part  of  the  meal,  other 
foods  of  vegetable  origin,  as  salads  and  vegetables,  sweets,  and  flour  foods  being  added. 
Bread  remained  in  the  background .  The  traditions  of  this  culinary  art  have  remained 
the  same  down  to  our  days.    This  diet  of  the  upper  classes  is  the  only  one  which 

Srovides  the  pleasures  of  me  table;  it  is  rich  in  proteid  and  fat;  it  is  not  voluminous, 
oes  not  overburden  the  stomach,  tends  less  to  ooesity  than  any  other  diet,  keeps  the 
body  even  of  a  lazy  man  in  good  condition,  and  does  not  overwork  die  digestive 
functions.  The  less  well-to-do  reduce,  of  course,  the  amount  of  meat,  but  they  use 
in  its  place  bread  and  potatoes.  This  is  called  a  mixed  diet.  When  the  barriers 
between  the  classes  fell,  the  middle  classes  gradually  rose  to  the  more  luxurious 
food  of  the  formerly  privileged  classes. 

It  is  a  fact  that  tlie  diet  of  the  well-to-do  is  not  in  itself  physiologically  justified: 
it  is  not  even  healthy^  for,  on  account  of  false  notions  of  the  strengmening  effect  ox 
meat,  too  much  meat  is  used  by  young  and  old  and  by  children,  and  this  is  harmful. 
But  this  meat  diet  is  pubUcly  sanctioned;  it  is  found  in  all  hotels;  it  has  become 
international  and  has  supplanted  almost  everywhere  the  characteristic  local  culinary 
art.  It  has  also  been  adopted  in  countries  where  European  culinary  art  was  unknown. 
Long  ago  the  medical  profession  started  an  opposition  to  the  exa^erated  meat  diet — 
long  before  the  vegetarian  propacimda  was  started.  It  was  maintained  that  flour- 
foods,  vegetables,  and  fruit  should  oe  eaten  in  place  of  the  overlarge  quantities  of  meat. 

The  descendants  of  those  well-noorished  classes  are,  on  account  of  many  influences, 
especially  the  school  and  the  indoor  life,  not  always  the  strongest  part  of  the  nation » 
but  since  in  recent  times  bodily  exercises  have  become  general  they  are  again  de- 
cidedly in  the  ascendency. 

iTonLiebig,J.' FmiiilUBrL«tt«noiiClitmi8try.   SdedUkm.   London,  18(1. 


118        PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC   CONGRESS. 

The  sanitary  condition  of  the  great  mass  of  industrial  workers  and  their  children, 
and  of  people  of  very  small  earnings,  are  different.  Keare  we  find  a  decided  deteri- 
oration of  the  body,  as  is  amply  shown  by  the  recruiting  for  military  purposes.  In 
spite  of  continuous  migration  from  the  country  to  the  cities,  conditions  are  little 
changed.  The  social  surroundings  of  a  great  city  are  decidedly  imfavorable  to  the 
maintenance  of  a  strong  race.  Among  the  many  factors  which  cause  this  decrease  of 
bodily  efficiency  nutrition  is  not  the  least. 

The  industrial  workers  coming  from  the  country  to  the  city  can  not  well  get  along 
with  their  former  simple  diet  because  the  cheap  food  materials  which  are  easily 
obtained,  as  bread  and  potatoes,  contain  too  little  proteid.  They  undoubtedly  need 
an  increase  of  proteid  material.  Neither  can  they  find  in  the  city  the  food  condi- 
tions to  which  they  had  formerly  been  used;  but  they  accommodate  themselves  rap- 
idly to  new  conditions,  coming  into  the  new  surroundings,  as  they  usually  do,  without 
a  family.  Just  as  under  the  doctrine  of  political  equality  the  lower  classes  try  to 
attain  the  luxurious  table  of  the  well  to  do,  so  it  is  not  8iu*pri6ing  that  industrial  work- 
ers coming  from  the  country  to  the  cities  accommodate  themselves  to  the  new  die- 
tary  forms. 

The  workingman  does  not  want  proteid,  leguminous  food,  milk,  etc.,  to  improve 
his  vegetable  diet;  he  wants  simply  meat,  not  because  he  needs  it,  but  because  it  b 
for  him  a  matter  of  pride  to  follow  as  best  he  can  the  other  classes  in  his  diet.  The 
difficulty  is  that  the  cost  of  meat  is  considerably  higher  than  in  the  country  where 
food  can  usually  be  obtained  without  the  aid  of  dealers,  and  where  many  foodstuffs 
are  raised  on  one's  own  land. 

The  importance  of  the  conservation  of  protein  has  led  to  numerous  investigations 
of  the  economy  of  this  food  stuff  which  need  not  be  discussed  here.* 

Transportation  facilities, — ^The  concentration  of  population  in  restricted  areas  is  nec- 
essarily limited  by  the  possibilities  of  the  food  supply.  The  latter  is  the  corollary  of 
finding  suitable  accomodations  for  increasing  numbers.  Within  less  than  a  century 
nearly  every  region  of  the  globe  has  been  tapped  by  railways  or  waterway  fecilities 
to  permit  the  more  uniform  distribution  of  things.  The  competition  of  the  different 
lines  of  transportation  has  been  an  interesting  phase  in  the  exchange  of  commodities, 
among  which  food  has  been  conspicuous.  The  end  is  not  in  sight,  for  with  the  added 
possibility  of  preserving  foods  at  reasonable  cost  a  new  chance  for  distribution  has 
arisen.  American  wheat  has  long  traversed  a  continent  by  train  or  crossed  an  ocean 
in  a  steamer's  hold,  but  the  sight  of  Australian  meats  in  the  London  market,  of  Call- 
fomian  fruits  and  vegetables  in  Boston,  of  eggs  from  China  in  Chicago,  or  of  Wisconsin 
milk  in  Manila  was  reserved  for  the  present  generation.  In  earlier  days  the  dietary 
habits  of  peoples  were  developed  on  the  basis  of  the  native  products  of  the  soil.  Now, 
when  the  means  of  transportation  are  no  longer  primitive,  specific  demands  can  read- 
ily be  satisfied  by  importation.  This  is  particularly  exemplified  where  certain  habits 
of  taste  have  persisted  longer  than  the  local  sources  of  supply. 

Customs  in  diet. — ^To  one  who  has  given  little  thought  to  the  subject,  the  dietary 
habits  of  a  community  or  nation  may  appear  as  something  fairly  fixed  from  generation 
to  generation.  This  is,  however,  far  from  a  correct  view.  Adequate  nutrition  may 
be  exemplified  alike  among  the  meat  and  blubber  eating  Eskimos  and  the  strictly 
v^etarian  Hindoos.  But  particularly  where  the  dietary  instincts  have  led  mankind 
to  adopt  a  more  div^sified  mixed  ration  one  may  discover  shifts  of  custom  and  changes 

1  The  following  is  a  partial  list  of  monographs  dealing  with  some  aspects  of  this  topic:  Chitten- 
den, R.  H.:  Physiological  Economy  in  Nutrition.  1904;  Chittenden,  R.  H.:  The  Nutrition  of  ICan, 
1907;  McCay,  D.:  The  Protein  Element  in  Nutrition,  1912;  Rubner,  M.:  Volksem&hrungslragen,  1908; 
Rubner,  M.:  Wandlungen  in  der  Volksem&hrung,  1913;  Hindhede,  M.:  Protein  and  Nutrition,  1918;  Men- 
del, L.  B.:  Theorien  dos  Eiwcissstoffwechselsnebstelnlgen  praktischen  Konsequenzen  derselben,  Ergeb- 
nisse  der  Physiologie,  19X1,  xi,  418-525;  Mendel,  L.  B.:  Nutrition  and  Growth.  Harvey  Society  Lectures, 
1914-15. 


PUBLIC   HEALTH  AND  MEDICINE.  119 

of  eatLQg  habits  within  comparatively  short  periods.  A  comprehensive  survey  of  this 
feature  of  dietetics  and  an  examination  of  the  underlying  causes  would  furnish  inter- 
esting physiological,  sociological  and  economic  details.  A  few  typical  illustrations 
must  suffice  to  indicate  these  interrelations  between  customs  in  diet  and  the  food 
supply. 

The  use  of  fresh  fruits  has  been  enormously  extended  among  the  progressive  peo- 
ples of  temperate  zones  within  the  past  two  decades.  Some  of  these  food  products, 
such  as  orchard  fruits,  have  long  been  favorites  in  the  dietary  and  because  of  their 
superior  keeping  qualities  have  been  avsiilable  over  long  periods  of  the  year.  The 
output  of  orchard  fruits  has  kept  pace  with  the  growth  of  population.  The  value  of 
the  products  of  the  orchard  in  the  United  States  in  1840  was  about  $8,000,000;  a 
recent  census  report  gives  the  figure  as  $140,867,000.  Among  other  types  of  fruits 
proportionately  greater  increases  are  noted.  '*  Small  fruits"  contributed  $30,000,000; 
grapes,  $22,000,000;  citrus  fruits,  $23,000,000;  other  tropical  and  subtropical  fruits, 
$2,000,000;  to  the  production  of  fruits  in  the  United  States  in  1909.  Many  of  these, 
like  the  orange  and  grapefruit,  have  become  prominent  in  the  diet  of  the  well  to  do 
because  of  the  readiness  with  which  they  can  be  obtained  at  a  reasonable  price  every- 
where during  most  of  the  year.  Science,  the  mechanic  arts,  and  business  organiza- 
tion have  combined  to  revolutionize  the  distribution  and  marketing,  as  one  may 
learn  in  studying  the  work  of  the  Califomia  Fruit-Growers'  Exchange.  The  once 
enormous  losses  from  decay  have  been  greatly  reduced  and  the  marketed  products 
are  of  a  superior  quality. 

There  is  a  physiological  justification  for  the  increasing  prominence  of  fruits  in  the 
diet  of  the  better  classes  and  its  extension  throughout  all  seasons  of  the  year.  With 
the  growing  use  of  highly  digestible  foods  and  the  exclusion  of  indigestible  food  resi- 
dues, with  the  widespread  employment  of  milled  cereals  largely  freed  from  cortical 
parts,  with  the  tendency  to  exclude  the  ''coarser''  vegetables  or  limit  their  inclusion 
in  the  menus  of  the  better  classes,  the  absence  of  ''roughage"  in  the  diet,  combined 
with  other  features  of  modem  living,  helps  to  induce  habitual  constipation  in  certain 
classes  of  society.  The  fruits  serve  a  useful  purpose  in  counteracting  this  tendency 
by  promoting  the  movement  of  the  bowel — hence  the  expression,  "An  apple  a  day 
keeps  the  doctor  away. ' ' 

The  familiar  adage  just  quoted  has  been  converted  into  an  advertising  slogan  in 
some  of  the  apple-growing  States  of  the  West.  This  leads  me  to  call  attention  to  the 
potent  force  ot  advertising  in  creating  a  demand  for  food  products  of  most  varied  sorts. 
The  same  agency  which  has  created  a  nation-wide  mania  for  chewing  gum  and  has 
initiated  in  all  ranks  of  society  a  senseless  habit  of  mastication  which  was  until  a  few 
years  ago  limited  to  the  overlooked  improprieties  of  childhood,  has  been  reflected  in 
the  food  market.  The  ready-to-eat  "breakfast  foods"  in  hi^y  advertised,  neat,  and 
attractive  packages,  have  replaced  the  less  expensive  cereals  long  sold  in  bulk.  The 
change  is  not  merely  one  of  the  container  or  package;  the  contents  no  longer  are  the 
nme.  Oatmeal,  for  example,  has  lost  some  of  its  former  popularity  as  a  breakfast 
dish  with  the  inroad  of  com  flakes  and  wheat  foods.  The  breakfast  staples  have  been 
changed  by  the  modem  advertiser;  and  illustrations  of  his  ingenuity  might  be  ex- 
tended to  include  numerous  food  products.  Except  from  the  standpoint  of  extreme 
economy  the  innovations  have  as  a  rule  been  wholesome  and  usually  in  the  interest 
of  food  hygiene.  The  purity  of  the  products  has  not  infrequently  siurpassed  the 
honesty  of  the  advertisement. 

Most  of  us  can  recall  the  days  when  meat  or  eggs,  or  both,  formed  an  indispensable 
part  of  the  early  meal  in  the  United  States.  At  present  there  are  signs  everywhere, 
at  least  among  those  classes  which  are  not  engaged  in  more  vigorous  muscular  work, 
of  a  simplification  of  this  meal  by  the  exclusion  of  meat  and  the  substitution  of  cereals 
and  fruits.    This  is  an  approach  to  the  traditional  breakfast  of  continental  Europe. 


120       PKOCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC   CONGRESS. 

It  is  not  easy  to  analyze  the  underlying  causes  for  such  dietary  changes;  they  are  not 
solely  physiological  nor  economic  in  origin.  Buhner  has  remarked  that  sometimes 
revolutions  occur  in  the  field  of  popular  nutrition.  The  introduction  of  the  potato  in 
many  extensive  regions  is  cited  as  an  illustration. 

It  might  be  supposed  that  bread,  ''the  staff  of  life,"  remains  essentially  what  it  baa 
been  in  days  gone  by.  This  food  product,  however,  furnishes  an  example  of  the 
evolution  of  a  food  indiistry.  Bread  making  is  gradually  becoming  a  factory  problem. 
The  magnitude  of  this  may  be  appreciated  from  the  statement  that  the  baking  indus- 
try is  to-day  capitalized  at  over  1270,000,000;  yet  housekeepers  still  make  70  per 
cent  of  the  product  used.^  With  increasing  efficiency  and  range  of  distribution  the 
use  of  bakers'  bread  is  certain  to  increase;  just  as  butter,  pickles,  mustard,  etc.,  are 
no  longer  exclusively  home-made  products.  As  soon  as  larger  corporate  interests  be- 
come involved  in  the  food  industries,  altered  methods  of  manufacture  are  likely  to  be 
introduced  when  they  seem  both  profitable  and  feasible.  Food  innovations  are  not 
readily  introduced  in  the  home,  but  in  the  factory  they  frequently  become  questions 
of  dollars  and  cents.  In  the  manufacture  of  baked  goods  the  cost  of  production  baa 
been  modified  by  the  substitution  of  dried  milks  for  fresh  milk  and  of  vegetable  fats 
for  the  more  expensive  butter.  The  manufacture  of  yeast  has  become  specialized  into 
an  important  industry  which  reacts  upon  the  public  with  the  cleverly  advertised 
admonition  to  ''eat  more  bread." 

Wheat  has  unique  properties  which  adapt  it  to  the  production  of  bread  as  we  now 
know  it.  Other  seeds  are  competing  for  recognition.  New  "flours"  are  proposed. 
The  proao  and  kaoliang  flours  already  mentioned  are  among  them.  Even  cottonseed 
"flour"  is  clamoring  for  recognition.  When  glutenous  adjuvants  are  supplied  to 
cereals  which  lack  them,  and  when  more  science  is  infused  into  the  art  of  baking,  new 
bakery  products  are  likely  to  arise. 

The  use  of  fats  in  the  diet  is  .doubtless  increasing  in  the  United  States.  It  is  esti- 
mated that  the  consumption  of  butter  alone  reaches  23  to  24  grams  (three-fourths  to 
four-fifths  of  an  ounce) ,  or  approximately  200  calories  per  person  per  day.  An  inspec- 
tion of  the  dietaries  in  the  public  establishments  of  half  a  century  ago,  as  they  are 
reported  in  the  treatises  of  that  period,'  reveals  the  important  part  taken  by  bread 
in  the  regimen.  Butter  was  often  entirely  omitted  in  the  daily  allowances  of  asylums, 
prisons,  military  groups,  and  other  typi<»l  institutions.  Frequently  the  diet  lists  of 
those  days  call  for  bread  and  molasses  or  bread  and  milk.  Bread  without  butter  or 
some  other  fat  is  now  the  rarity,  at  any  rate  in  American  homes.  Despite  the  dis- 
couragement which  the  oleomargarine  industry  has  received  from  legislation,  ofttimea 
unwarranted,  the  use  of  butter  substitutes  is  spreading  as  the  price  of  the  original 
product  is  increasing.  Here  too  the  advertising  billboards  are  already  pointing  out 
the  future  way.  Butter  substitutes  are  not  only  used  directly  in  the  meal,  but  are 
finding  a  wide  field  of  application  in  the  cooking  and  baking  processes  of  the  kitchen. 

Another  change  in  diet  customs  is  seen  in  the  growing  use  of  cheese  in  American 
homes.  This  wholesome  article  has  long  been  appreciated  at  higher  value  in  Euro- 
pean countries  than  in  our  own.  Nuts  and  nut  foods  are  becoming  more  popular,  in 
part  as  the  result  of  the  modem  vegetarian  propaganda  which  reconmiends  them  as 
''meat  substitutes.''  The  value  of  the  peanut  crop  is  about  $20,000,000.  Sherman 
remarks  that ' '  to  speak  of  nuts  as '  meat  substitute '  is  natural  under  present  conditions 
and  reflects  the  prominence  which  has  been  given  to  meat  and  the  casual  way  in 
which  nuts  have  been  regarded  for  some  generations.  Looking  at  the^matter  in 
evolutionary  perspective,  it  might  be  more  logical  to  speak  of  meats  as '  nut  substitute ' 
instead." 


>  These  statistics  and  related  statements  are  taken  (irom  Duncan,  R.  K.:  Some  Chemical  Problems  of 
To-day.   Chapter  on  Bread. 
*  For  example,  in  Pereira,  J  r  A  Treatise  on  Food  and  Diet.   New  York,  184S. 


PtraUC   HEALTH  AND  MEDICINE.  121 

The  cuirent  «zl«iiaiv«  uw  of  sucroM  in  the  bvm  of  refined  cuie  eupu  or  beet  augu 
exemplifies  what  the  cheapening  of  an  article  of  commerce  caa  accompliab  in  the  S»li 
ol  diet.  Althou^  sucrose  has  a  considerable  fuel  value  in  the  wganiam  its  dietary 
uae  is  (ntnitil)'  dictated  by  consideralaonB  of  flavor.  Opinioiu  are  occasionally 
divided  as  to  the  place  ol  tUs  sugar  in  the  dietary.  It  aeenu  as  if  the  extnmM  of 
refinement  which  have  made  commercial  suoose  in  a  chemical  sense  the  purest  <A 
aU  purchasable  foodstuffs  had  exceeded  all  requirements  of  nutrition  or  dictates  of 
the  palate.  The  addition  of  a  blue  dyeetuS  to  give  a  white  appearance  to  the  final 
product  rapreeents  one  of  the  peychological  vmluee  which  are  often  more  ridiculous 
than  costly.  Surely  for  most  uses  the  artificially  colored  white  sugar  has  nothing 
except  a  false  standard  to  recommend  it  in  place  of  tlie  natural  cream  colored  sugar. 

It  is  likely  that  the  succulent  vegetables  will  play  a  larger  part  in  the  table  of 
American  households.  Dr.  C.  F.  lAngwwthy,  Chief  of  Nutrition  Investigations  in 
the  Office  of  Experiment  Stations  at  Washington,  says; 

One  of  the  marked  differences  between  the  daily  fare  to-day  and  that  of  GO  years  igo 
consists  in  the  increased  supply  of  green  and  succulent  veKetablee,  a  clan  of  food 
used,  as  their  namee  imply,  for  their  refreshing  and  palatable  qualities  mwe  than  for 
their  total  nutritive  value.  Not  many  years  ago  the  winter's  supply  of  vegetables  in 
all  southern  countries  was  limited  to  root  crops  and  a  few  other  staples,  sud)  as  onions 


d  preservinff  industry,  have  made  succulent  vegetables 
tnd  available  in  one  fimn  or  another  foe  almost  every 

The  popularity  of  groan  v^etablee  is  beginning  to  be  reflectod  in  the  canning  indus- 
tries where  the  variety  of  such  products  is  being  extended  rapidly  and  the  f  nnfng 
procen  has  already  developed  into  an  impratant  enterprise.  To  the  m«e  familiar 
commercial  lists  including  tomatoes,  com,  peas,  and  beans,  there  are  being  added 
asparagus,  beets,  okra,  pumpkin,  sweet  potato,  rhubarb,  nuerkraut,  spinach,  and 
•qnaah.  The  extent  of  this  canning  industry  and  its  growth  in  a  single  decade  is 
shown  statislicaUy,  as  tollowa: 


ItOft 

•   I» 

CMta. 

V»U». 

Cmm. 

Vitm. 

at 

s 

Its 
OT 

u 
1 

Si 

l,tt!.HT 

I 

I  Lwcvtthf ,  C.  r.:  Onm  VtfMaUn  ud  Tbrir  ITi 
ISll,  p.  B. 

■  Finn  BttUoc,  A.  W.;  Kathodi  FaUn«d  In  tba  i 
Aptcnltm,  BulMtai  1«8,  WtrtdofUn,  IBll. 


itntlMStM.    AoHrioiB  PMd  locDiMl,  OM.  U 


122       PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC   CONGRESS. 

The  indirect  effects  of  the  antialcohol  campaign  now  vigorously  conducted  in  many 
countries  are  seen  in  the  stimulation  of  trade  in  so-called  temperance  drinks.  It 
comes  as  a  surprise  to  an  old-timer  to  see  buttermilk  retailed  over  the  bar  of  the 
American  saloon.  The  grape-juice  industry  has  grown  by  leaps  and  bounds;  and 
this  alcohol-free  natural  product  is  veritably  becoming  one  of  the  national  drinks. 
I  am  informed  from  expert  sources  that  the  production  of  American  unfermented 
grape  juice  in  the  year  1914  amounted  to  4,593,750  gallons  in  the  Chautauqua  belt 
alone.  Other  fruits,  also,  are  likely  to  figure  in  the  new  field  of  use  here  opened. 
It  is  stated  that  25  per  cent  of  the  apples  grown  in  American  orchards  never  enter 
into  the  food  supply  of  the  nation.  This  has  been  a  stimulus  to  the  food  conserva- 
tionists to  transform  the  unused  materials  into  new  forms  of  food.  Apple  sirup  and 
concentrated  cider  have  been  suggested  as  new  products  for  utilizing  surplus  and 
cull  apples.'    The  expert  of  the  Department  of  Agriculture  remarks: 

What  the  commercial  future  of  the  two  products  will  be  remains  to  be  determined 
under  actual  marketing  conditions.  The  department  has  every  confidence  in  the 
feasibility  of  making  tne  two  products  where  the  apple  supply  and  the  manufac- 
turiuR  conditions  are  suitable.  The  development  of  tnis  infant  industry  must  now 
be  left  in  the  hands  of  the  progressive  American  manufacturer.  A  process  which 
will  make  pure,  fresh  cider  available  as  a  summer  drink  at  our  soda  fountains  should 
open  up  a  new  and  valuable  market  for  the  juice  of  surplus  apples.  Whether  young 
America  will  eat  apple  sirup  on  his  bread  and  his  mother  use  it  in  her  kitchen  must 
be  decided  by  the  American  people. 

Similar  considerations  are  being  applied  to  other  fruits  now  wasted. 

The  *' dairy  lunch"  rooms  of  our  cities  and  larger  villages  represent  an  innovation 
in  dietary  practice.  The  dinner  pail  and  the  lunch  basket  filled  with  homemade 
food  have  given  way  to  "ready-made"  meals.  To  one  group  of  persons  the  lunch 
rooms  represent  a  welcomed  escape  from  the  more  expensive  luxuries  of  the  con- 
ventional restaurant;  likewise  a  possibility  of  substituting  old-fashioned  pastry  and 
cereal  dishes  for  the  usual  dining-room  meal  rich  in  meat.  To  another  increasing 
class,  however,  they  offer  a  means  of  reducing  the  labor  of  the  household  by  the 
device  of  a  public  eating  place.  The  recent  interesting  study  of  a  familiar  chain 
of  these  *' dairy"  restaurants,  published  under  the  auspices  of  the  Sage  Institute 
by  Gephart  and  Lusk,'  show  that  the  popular  sandwich  meal  of  the  lunch  counters 
is  by  no  means  a  cheap  diet  for  the  working  classes  who  have  a  limited  allowance 
to  spend  for  food.  Attractive  as  the  highly  profitable  service  of  the  "dairy  lunch" 
may  be,  with  its  congenial  environmental  features,  it  can  not  compete  with  "home 
cooking"  from  the  standpoint  of  economy.  This  lesson  needs  to  be  brought  home 
to  a  nation  which  is  continually  discussing  the  high  cost  of  living.  Domestic  arts 
should  not  become  relegated  entirely  to  corporate  enterprise. 

CJianging  social  and  indiistrial  conditions  and  other  economic  and  hygienic  factors. — 
Rubner  has  pointed  out  an  interesting  effect  of  commerce  in  food  on  nutrition: 

Most  conservative  as  to  the  food  question,  is  the  farmer,  though  in  the  country, 
too.  man^  changes  are  taking  place.  He  has  frequent  contact  with  the  city,  but 
he  has  still  plenty  of  food  material,  though  not  always  quite  suitable  to  the  purpose. 
I  have  noticed  a  very  unfavorable  influence  of  urban  food  requirements  on  the  milk- 
producing  districts  of  some  regions  of  Switzerland  and  Germanjr,  which  is  so  charac- 
teristic that  it  deserves  consideration.  The  milk-producing  resions  of  the  Bavarian 
highlands  and  of  Switzerland  had  formerlv  an  extremely  healthy,  strong,  and  tem- 
perate population.  Milk  was  largely  used  as  a  food,  and  the  excess  of  production 
was  placed  on  the  market.  In  the  course  of  years  the  communities  gradually  estab- 
lished central  diaries  in  which  the  fat  is  withdrawn  from  the  milk  by  means  of  cen- 
trifugal machines  to  produce  cream  and  butter.    The  impoverished  milk  is  partly 

1  See  Qore,  H.  C. :  Apple  Sirup  and  Concentrated  Cider:  New  Products  for  UtUiKing  Surplus  and  <  uU 
Apples.    Yearbook  of  the  Department  of  Agilculture  for  1914,  Washington,  1915,  p.  227. 

«  Gephart,  F.  C,  and  Lusk,  O.:  Analysis  and  Cost  of  Ready-to-Serve  Foods.  Press  of  the  America* 
Medical  Association,  Chicago,  1915. 


PUBUC   HEALTH   AND  MEDICINE.  123 

returned  to  the  fanners.  The  milk  produces  are  paid  in  cash  for  their  product, 
but  a  poor  and  insufficient  food  takes  now  the  place  of  a  former  hoalthy  one.  The 
money  now  goes  to  the  saloons.  The  potato  conquers  a  new  t  rritory.  Instead 
of  the  butter  which  was  formerly  used,  cheap  fats  are  now  bought;  in  short,  the 
change  of  diet  is  exactly  such  as  we  find  with  the  poorer  working  p<>pulation  in  the 
cities.  The  effects  are  exactly  the  same.  Physical  deterioration  in  such  districts 
becomes  more  and  more  pronounced,  reaching  finally  a  low  level.  This  is  a  very 
serious  condition,  which  attracts  attention  and  which  must  be  combated  f)y  all  pos- 
sible means. 

Rubner  believes,  further,  that  the  industrialization  of  nations  is  attended  by  a 
change  in  body  weight,  not  because  the  race  has  changed  in  itself,  but  because  the 
nutritive  conditions  have  changed  for  a  large  number  of  laboring  people  through 
migration  to  the  cities.  To-day  only  a  small  proportion  of  the  industrial  establish- 
ments are  in  rural  communities,  where  the  living  conditions  are  favorable.  The 
problem  of  the  underfed  is  thus  closely  related  to  the  distribution  of  the  food  supply. 

The  present  European  war  is  affording  an  opportunity  to  study  the  relation  of  the 
food  supply  to  unexpected  economic  and  territorial  conditions.  From  the  stand- 
point of  Germany  the  situation  is  unique  in  view  of  the  exclusion  of  food  normally 
obtained  in  large  amounts  from  abroad.  Russia,  America,  and  other  countries  have 
hitherto  furnished  wheat,  rice,  butter,  lard,  eggs,  and  many  other  foods,  along  with 
cruder  feeds,  which  in  turn  were  applied  to  animal  production.  These  sources  have 
been  threatened  or  entirely  cut  off.  With  true  scientific  acumen  the  German  nation 
has  started  a  public  propaganda  of  advice  intended  to  meet  the  situation  thus  imex- 
pectedly  created.*  The  export  of  native  products,  such  as  sugar  and  rye,  is  to  be 
restricted ;  the  feeding  of  materials  suitable  for  human  consumption  to  cattle  is  to  be 
greatly  decreased  and  conservation  of  food  values  ordinarily  lost  in  the  processes  of 
conversion  into  animal  tissue  accomplished;  unjustifiable  waste  is  to  be  avoided  not 
only  in  the  trade  at  large,  but  in  the  individual  kitchen.  The  elaborateness  of  the 
investigation  is  indicated  by  such  details  as  the  reminders  that  20  grams  of  fat  per 
capita  are  lost  in  the  sewage  waste  of  Berlin  every  day,  and  that  this  ought  to  be 
prevented.  The  people  are  assured,  on  the  authority  of  eminent  scientists,  that  they 
need  not  fear  intelligently  instituted  changes  of  dietary  r^me  as  something  inimical 
to  health. 

The  laws  of  nutrition  and  suitable  dietetic  advice  are  being  proclaimed  and  dis- 
tributed in  popular  form.^  The  more  liberal  use  of  plant  products  (rich  in  carbo- 
hydrates) in  place  of  meats  (rich  in  proteins  and  fats)  is  urged.  As  a  move  in  the 
direction  of  economy  in  nutrition  the  gradual  substitution  of  the  regimen  of  south 
German  households  in  place  of  the  excessive  meat  diet  of  the  northern  provinces  is 
urged.    Even  a  cookbook  for  war  times  is  freely  supplied.' 

The  experience  of  the  commissary  department  of  the  United  States  Army  in  Cuba 
during  the  campaign  of  1898  has  taught  the  mistakes  not  only  of  disregarding  local 
conditions,  but  also  of  falling  to  grasp  important  dietary  principles  and  to  inculcate 
them  where  the  lessons  are  needed. 

No  presentation  of  the  problems  of  the  food  supply  would  be  complete  without  an 
appreciation  of  what  the  growing  science  of  physiology  and  the  chemistry  of  foods  is 
contributing  to  mankind.  The  calorie  idea  in  nutrition,  the  outcome  of  an  imder- 
standingof  the  transformation  of  energy  in  the  living  body,  has  been  fruitful  in  more 
ways  than  one.  It  has  taught  people  to  think  of  the  uses  of  food  from  a  more  rational 
standpoint  and  has  furnished  an  intelligible  basis  for  constructive  institutional  die- 
tetics, as  well  as  the  nutrition  of  the  individual.    Food  is  beginning  to  be  regarded 

>See  ElUbAcher,  P.:  Die  Deutsche  Volksemahrtmg  tmd  der  Englische  Aoshungenmgsplan.  Ft. 
Vieweg  A  Sobn,  Braunsehweig,  191A. 

>  For  example,  in  pamphleU  such  as  "  Ernfthrung  in  der  Kriegsxeit,"  ein  Ratgeber  von  Prof.  Dr.  Paul 
Sltobacher,  Frau  Hedwig  Heyl,  Prof.  Dr.  Carl  Oppenhelmer,  Prof.  Dr.  Max  Rubner  und  Prof.  Dr.  Nathan 
ZonU.    Braunschweig,  1916,  pp.  16. 

»  For  example,  the  "Kriegskochbuch,"  von  Frau  Hedwig  Heyl.    Berlin,  1915. 


124       PBOCEEDINGS  SECOND  PAN  AMEBIOAN  SCIENTIFIC  CONQBESS. 

as  fuel  for  the  human  OTganiflm— -eomething  that  must  be  provided  in  determinable 
amoimts.  Malnutrition  and  imdemutrition  have  received  a  new  popular  significance 
in  the  discussion  of  human  efficiency. 

This  is  not  the  place  to  discuss  the  limitations  of  the  calorie  idea  in  nutrition  or 
of  some  of  the  current  conceptions  of  the  rdle  of  the  individual  nutrients— the  pro* 
teins,  fats,  carbohydrates,  and  inorganic  salts.  There  is  a  well-founded  growing 
belief  that  an  important  part  in  nutrition  is  played  by  substances  which  are  not 
identical  with  the  familiar  foodstuEfs  mentioned  and  which,  despite  the  minimal 
amounts  thereof  present  in  the  diet,  may  nevertheless  be  indispensable  for  growth 
and  the  maintenance  of  life.  They  have  been  called  ''accessory  diet  factors"  or 
<< vitamins.*'  We  may  conceive  of  them  as  stimulating  certain  ph3r8iological 
processes  and  as  essential  to  certain  functions. 

The  lubricant  is  quite  as  important  to  a  machine  as  is  the  energy-furnishing  fuel. 
So  these  diet  accessories  may  have  a  peculiar  usefulness.  They  are  apparently  some* 
times  easily  impaired  by  heat;  in  the  language  of  the  chemist,  they  may  be  thermo* 
labile.  Hence  the  use  of  heat  for  preserving  or  sterilizing  foods  suggests  new  diffi- 
culties. They  may  sometimes  be  lost  in  the  wastes  of  the  modem  technical  processes, 
as  in  the  milling  of  cereals.  This  has  been  demonstrated  in  the  case  of  '' polished" 
rice.  They  may  be  sensitive  to  other  agencies  involved  in  the  change  from  fresh  to 
salted  or  "prepared  "  or  preserved  foods. 

These  topics  represent  the  border  line  of  our  knowledge  of  to-day.  Enough  facts 
are  known,  however,  to  justify  the  interest  which  the  subject  is  receiving.  Scurvy 
has  long  been  recognized  as  a  disease  related  to  diet  and  the  antiscorbutic  and  curative 
virtues  of  certain  food  products  like  lemon  j  uice  were  early  learned  by  experience.  To 
these  so-called  "deficiency  diseases,"  beriberi  and  possibly  pellagra,  rickets,  and 
Barlow's  disease  may  be  added.  I  have  discussed  special  features  of  this  question 
elsewhere.'  They  help  to  explain  the  occasional  faUure  of  one-sided  dietaries,  and 
possibly  the  incidence  of  disease  in  groups  of  people  living  through  ignorance  under 
restricted  conditions  of  diet,  in  institutions,  on  expeditions,  on  shipboard,  during 
famine,  and  sometimes  amid  plenty. 

The  danger,  if  there  be  such,  of  a  lack  of  imrecognized  diet  accessories  is  probably 
greatest  in  the  exclusive  use  of  "artificial"  foods  which  have  experienced  extensive 
alterations  in  the  course  of  their  commercial  preparation.  In  the  present  stage  of  our 
knowledge  variety  of  food,  including  fresh  foods  of  many  descriptions,  may  be  wel- 
comed on  this  ground  alone.  Canned  goods,  glucose,  margarine,  refined  sugar,  highly 
milled  cereals — ^in  themselves  skillfully  produced  specimens  of  modem  technical 
progress — should  be  supplemented  with  fresh  foods  for  safety  until  our  knowledge  haa 
grown  to  supersede  the  uncertainty  of  present-day  ignorance  about  unappreciated 
deficiencies  of  the  diet.  If  the  factory  and  organized  business  have  introduced  "arti- 
ficial'' products,  modem  industrial  organization  and  transportation  have  likewise 
increased  the  possibilities  of  physiological  liberality  in  diet.  The  studies  of  the  past 
few  years  on  the  physiology  and  chemistry  of  the  ripening  of  fruits  is  only  one  indica- 
tion of  how  science  is  enlarging  the  possibilities  of  the  food  supply  through  an  under- 
standing of  underlying  factors.  Useful  investigations  on  the  date,  the  banana,  the 
apple,  and  other  fruits  have  already  been  instituted  by  our  Government. 

The  recent  progress  in  the  physiological  chemistry  of  the  proteins  illustrates  a  trend 
that  is  likely  to  affect  feeding  practices  in  the  future.  The  protein  molecule  is  com- 
posed of  a  group  of  unlike  chemical  units  many  of  which  appear  to  be  indispensable 
for  the  nutritive  functions.  The  animal  body  can  not  constmct  all  of  these  syntheti- 
cally, hence  it  is  dependent  upon  a  supply  thereof  in  the  diet.  The  proteins  of  com- 
mon foods  furnish  unlike  yields  of  these  essential  units  or  tissue  "building  stones." 

1  Ifendol,  L.  B.:  Natritlon  and  Qrowth.  The  Harvey  Society  Lectures,  1914-15.  Also  Joomal  of  the 
American  Medical  Association,  May  8, 1915,  p.  1539.  The  literature  of  the  subject  is  presented  there  in  soma 
detail. 


PUBLIC   HEALTH  AND  MEDICINE.  125 

It  is  accordingly  becoming  apparent  that  a  well-selected  ration  must  furnish  these  in 
both  quantitative  and  qualitative  sufficiency.  Com  and  the  by-products  of  the 
maize  kernel  are  notably  inadequate  for  good  feeding  results  unless  they  are  supple- 
mented by  other  protein-containing  foods.  The  relative  economy  of  the  addition  of 
supplementary  proteins,  such  as  are  preeent  in  dried  blood  or  milk  products,  to  a 
ration  that  is  inexpensive,  but  inefficient  by  itself,  suggest  new  standards  in  our  feed- 
ing practices.  A  small  addition  of  an  adequate  protein  may  be  far  more  advantageous 
for  producing  gains  in  animal  husbandry  than  large  amounts  of  cheaper  proteins  which 
supplement  the  deficiency  of  the  basal  ration  less  well . '  Our  agricultural  experiment 
stations  are  becoming  alive  to  the  opportunities  here  opened.  Fodder  analysis  has 
taken  a  new  turn.'  It  is  probable  that  protein  feeding  in  the  future  will  be  based  on 
the  known  chemical  structure  of  the  feeds  quite  as  much  as  on  the  results  of  past  feed- 
ing experiments.  Here,  as  so  often  before,  the  investigations  of  what  is  sometimes 
contemptuously  referred  to  as  "pure''  science  have  furnished  results  of  great  impor- 
tance to  practical  nutrition.  Sir  William  Crookes,  whose  f recast  of  the  failing  wheat 
supply  has  been  referred  to,  could  scarcely  foresee  that  the  progress  of  physiological 
chemistry  might  in  itself  nullify  the  contentions  which  he  vigorously  defended. 

A  corollary  of  a  better  understanding  of  the  principles  involved  in  the  field  of  human 
nutrition  is  the  improvement  of  household  science  and  the  domestic  arts.  Herein 
lies  the  significance  of  the  notable  "home  economics  movement"  of  the  preeent  time. 
Nutrition  and  its  relation  to  the  food  supply  are  in  no  small  measure  a  problem  of  the 
home.  Just  as  the  lessons  of  modem  science  are  permeating  the  practices  of  up-to- 
date  agriculture,  so  they  ought  to  influence  and  modify  the  periormance  of  the  house- 
hold. The  latter  has  been  described  as  a  social  institution  employing  certain  material 
agencies  which  include  the  provision  of  food  and  clothing.  Its  relations  to  other  social 
institutions  are  manifold.  Upon  industry,  for  example,  the  household  exerts  an 
influence  by  maintaining  the  physical  vigor  and  efficiency  of  the  worker;  and  industry, 
in  turn,  a£fects  the  home  by  the  character  of  the  supplies  which  it  furnishes.  We  are 
told  that  the  household  is  the  ultimate  agency  in  the  distribution  of  economic  wealth 
to  individuals. '  What  the  wage  earner  really  secures  and  the  wife  and  children 
secure  depends  upon  the  efficiency  with  which  the  household  turns  the  wage  income 
into  economic  good  and,  at  the  same  time,  supplements  it  by  the  income  equivalent 
of  household  work.  The  contribution  of  productive  housework  is  too  little  empha- 
sised. The  home  can  become  responsible  for  malnutrition  and  insanitary  living. 
An  appreciation  of  food  costs,  of  efficient  marketing,  of  the  "casual  sequence  of  food 
&om  the  farm  to  the  dining  room,  **  of  the  preparation  of  food  for  the  table,  surely  ia 
of  fundamental  import  in  every  home.  The  culinary  art,  upon  which  so  much  may 
depend,  is  in  danger  of  deteriorating  in  the  homes  of  this  country.  The  admonition 
to  "cook  at  home  "  should  be  passed  on  to  the  less  well-to-do  classes  and  the  education 
of  their  young  in  the  applications  of  domestic  science  should  be  warmly  defended. 
No  baker's  bread  equals  the  best  home-made  product.  Too  few  women  of  the  working 
classes  are  equipped  to  meet  the  demands  which  the  home  should  properly  make 
upon  them. 

>  CL  Osborne,  T.  B.,  and  Mendel,  L.  B.:  Feeding  Experiments  Hoisting  to  the  Kutritive  Value  of  the 
Proteins  of  liaise.  Journal  of  Biological  Chemistry,  1913,  xiv,  31;  American  Journal  of  Physiology,  1918, 
(a),  xxxl,  10;  Nutritive  Properties  of  Proteins  of  the  Maize  Kernel.  Journal  of  Biological  Chemistry,  1914, 
(b),  XTiii,  1.  Osborne,  T.  B.:  The  Nutritive  Value  of  the  Protehis  of  Maize.  Science,  1913,  xxxvii,  185. 
Osborne,  T.  B.,  and  Mendel,  L.  B.:  The  Comparative  Nutritive  Value  of  Certain  Proteins  in  Growth,  and 
the  ProUem  of  the  Protein  Minimum.  Journal  of  Biological  Chemistry,  1915,  xx,  351;  Protein  Minima  for 
Mahitenance.    Ibid,  1915,  xxii,  341. 

*  Cf.  NoUau,  E.  H.:  The  Amino-acid  Content  of  Certain  Commercial  Feeding  Stuffs  and  Other  Sources  of 
Protein.  Journal  of  Biological  Chemistry,  1915,  xxi,  611;  Orindley,  H.  S.,  Joseph,  W.  £.,  and  Slater,  M.  E. : 
The  Quantitative  Determination  of  the  Amino-adds  of  Feedingstufls  by  the  Van  Slyke  Method.  Joumai 
of  the  Amerioan  Chemical  Society,  1915,  xxxvii,  1778. 

*Ct  Andrews,  B.  B.:  A  Course  in  Hooiehold  Economics.  Joumai  of  Homo  Economics,  February, 
191S,  p.  2d. 


126       PROCEEDINGS  SECOND   PAN   AMERICAN   SCIENTIFIC   CONGRESS. 

Many  years  ago  Liebig  wrote,  in  hie  Familiar  Letters  on  Chemistry: 

Among  all  the  arts  known  to  man  there  is  none  which  enjoys  a  juster  appreciation 
and  the  products  of  which  are  more  universall>r  admired  than  that  which  is  concerned 
in  the  preparation  of  our  food.  Led  by  an  instinct,  which  has  almost  reached  the  dig- 
nity of  conscious  knowledge,  as  the  unerring  guide,  and  by  the  sense  of  taste,  whicn 
protects  the  health,  the  experienced  cook,  with  respect  to  the  choice,  the  admixture, 
and  the  preparation  of  food,  has  made  acquisitions  surpassing  all  that  chemical  and 
physiological  science  have  done  in  regard  to  the  doctrine  or  theory  of  nutrition.  In 
soup  and  meat  sauces  he  imitates  the  gastric  juice;  and  by  the  cheese  which  closes  the 
banquet  he  assists  the  action  of  the  dissolved  epithelium  of  the  stomach.  The 
table,  supplied  with  dishes,  appears  to  the  observer  like  a  machine,  the  parts  of 
which  are  harmoniously  fitted  together  and  so  arranged  that,  when  brougnt  into 
action,  a  maximum  of  effect  may  be  obtained  by  means  of  them.  The  able  culinary 
artist  accompanies  the  sangui^nous  matter  with  those  which  promote  the  process 
of  solution  and  sanguification  m  due  proportion;  he  avoids  all  kinds  of  unnecessary 
stimuli,  such  as  do  not  act  in  restoring  the  equilibrium;  and  he  provides  the  due 
nourishment  for  the  child,  as  well  as  the  old  man,  as  well  as  for  both  sexes. 

Even  Liebig,  the  great  scientist,  could  not  adequately  visualize  the  application  of 
science  in  the  kitchen .  Man  no  longer  depends  upon  his  instincts  alone  for  guidance  in 
the  affairs  of  life;  otherwise  progress  would  indeed  be  slow.  Instruction  in  domestic 
science  ought  to  become  a  means  of  solving  the  problems  of  applied  nutrition;  and  the 
best  interests  of  the  home — economic  as  well  as  social — call  for  better  domestic  service, 
a  discipline  into  which  woman  will  enter  "mit  Lust  und  Liebe. " 

We  have  seen  that  the  problem  of  food  supply  is  not  one  which  can  be  dismissed  by 
the  social  philosopher  or  solved  by  the  calculations  of  the  economist.  It  is  highly 
complex  with  its  involvement  of  factors  and  interests  in  agriculture,  commerce,  indus- 
try, and  nutrition.  Here,  as  in  other  domains,  there  is  opportunity  for  an  interplay  of 
science  and  the  arts,  of  experience  and  investigation.  To  attempt  to  foretell  the 
future  seems  more  like  an  act  of  ill-considered  rashness  than  a  keen  intellectual  venture . 
The  truth  can  only  be  approached  scientifically.  We  are  beginning  to  learn  what 
real  food  values  mean.  There  is  as  yet  no  ideal  ration.  The  world  menu  is  not 
in  sight.    Fitting,  indeed,  on  this  occasion  are  the  words  of  Prof.  Rubner: 

The  nutrition  of  the  great  mass  of  the  people  is  a  question  of  the  highest  importance, 
deserving  far  more  attention  than  it  has  hitherto  received.  All  the  great  countries 
ought  to  have  a  central  authority,  a  food  commission,  which  should  concern  itself 
exclusively  with  the  far-reaching  questions  of  the  well-being  of  the  people.  The 
material  as  it  lies  before  us  to-da>[  is  very  incomplete  but  sufiSces  to  indicate  the  main 
lines  of  useful  work.  The  nutrition  of  the  masses  has  so  far  been  mostly  studied  with 
regard  to  political  economy  and  according  to  methods  and  viewpoints  which  do  not 
always  withstand  the  tests  of  the  physiology  of  nutrition.  Only  by  means  of  the 
physiology  of  nutrition  is  it  possible  to  carry  on  exact  research. 

The  nutrition  of  the  masses  is  to  us  a  problem  which  may  be  approached  and  im- 
proved from  many  sides.  It  is  necessary  that  not  only  the  hygienists  in  the  narrower 
sense  take  up  the  stru^le  for  betterment  but  that  also  the  great  army  of  men.  who  are 
truly  humane  in  their  hearts,  shall  take  their  places  beside  us.  The  battle  which 
we  have  to  carry  on  is  not  only  against  unavoidable  and  natural  difficulties;  we  must 
not  for^t  that  human  society  includes  many  elements,  unwiUii^  to  make  the  least 
concession  to  a  humanitarian  movement,  persons  whose  prosperity  is  selfishly  held 
superior  to  the  welfare  of  their  neighbors  and  who  will  oppose  such  a  movement 
with  all  tiie  means  at  their  command.  Let  us  hope  that  our  opponents  will,  at  the 
last,  rejoice  with  us  in  a  triumph  of  the  Humane  Idea.  ^ 

1  Rubner,  M. :  The  NutriUon  of  the  People.    Journal  of  Home  Economicfl,  1913,  v.  1. 


PUBLIC    HEALTH  AND   MEDICINE.  127 

A  SAFE  AND  SANE  MILK  SUPPLY. 

By  JOHN  WEINZIRL, 
Univtrnty  of  Washington. 

There  are  three  large  phases  to  the  milk  problem  which  may  be  summed  up  in  three 
words — dollars,  dirt,  and  disease.  The  three  phases  must  all  be  solved  before  we 
have  solved  the  milk  question.  Nor  is  one  of  these  phases  more  important  than 
another  for  milk  which  does  not  pay  for  itself  will  not  long  be  produced,  dirty  milk 
will  not  be  used  when  the  people  are  informed,  and  milk  which  carries  disease  will 
eventually  be  barred  from  sale.  It  is  the  purpose  of  this  i)aper  to  consider  these  three 
phases  separately  and  collectively  in  order  to  discover,  if  possible,  a  sane  solution  of 
this  perplexing  question. 

THE   FINANCIAL   ASPECT. 

Until  quite  recently  milk  was  produced  under  primitive  conditions  at  a  moderate 
cost  which  was  roughly  proportional  to  its  food  value.  Although  the  food  value  has 
not  changed  materially  the  cost  has  increased  decidedly,  due  largely  to  the  increased 
cost  of  production.  A  certain  part  of  this  increase  is  due  to  economic  conditions  over 
which  the  dairyman  has  no  control;  another  part,  and  this  is  probably  the  larger,  is 
due  to  the  changed  methods  of  handling  the  product.  Formerly,  cheap  bams,  simple 
vessels,  and  common  labor  sufficed ;  now  certified  milk  is  produced  in  costly  stables 
under  a  sanitary  elegance  which  rivals  that  in  our  homes,  with  apparatus  that  is 
elaborate  and  expensive  under  expert  supervision  which  is  required  for  its  care  and 
management.  The  increase  in  price  from  5  cents  a  quart  to  10  cents,  then  15  cents, 
and  sometimes  to  20  cents  became  necessary,  and  even  now  certified  milk  is  not 
generally  profitable.  It  is  quite  obvious  that  certified  milk  is  essentially  a  luxury 
beyond  the  means  of  the  vast  majority  of  our  population,  and  can  only  be  indulged  in 
by  the  wealthy.  Evidently  certified  milk  as  a  solution  of  the  milk  problem  is  doomed 
to  fedlure.  It  is  probably  unnecessary  to  state  what  is  meant  by  certified  milk,  for  it 
has  been  adequately  described  in  many  sources.'  The  ideal  of  certified  milk  has  been 
of  inestimable  value  in  an  educational  way  for  it  has  taught  us  many  things.  It  has 
taught  us  what  clean  milk  means  and  how  dirt  can  be  eliminated ;  that  bacteriologically 
clean  milk  is  essential;  and  that  disease  germs  in  milk  can  and  must  be  eliminated. 
To  accomplish  this  task  has  been  eminently  worth  while,  and  we  diall  always  value 
this  service,  but  it  is  certain  that  simpler  means  must  be  foimd  to  accomplish  the 
ends  sought.  Fortunately  the  work  of  Harding  ^  and  of  North  *  has  shown  that  this 
can  be  accomplished  and  that  milk  of  an  excellent  quality  can  be  produced  without 
elaborate  equipment  and  at  reasonable  cost.  Intelligent  care  and  a  modest  bonus 
for  a  superior  product  are  the  essentials  for  accomf^iriung  the  end  in  view.  Beiate 
discussing  this  further  it  is  desirable  to  consider  the  question  of  diseases  carried  by 
milk. 

THE  PROBLEM   OF  DISEASE. 

That  milk  is  a  carrier  of  disease  germs  is  now  common  konwledge  and  many  well 
authenticated  epidemics  testify  loudly  to  the  fact.  The  problem  of  how  to  make 
milk  safe  as  food  has  been  attacked  in  a  number  ofVays;  all,  however,  fall  under  two 
principles,  viz,  either  prevent  the  entrance  of  disease  bacteria  to  the  milk  or  kill  the 
disease  bacteria  which  may  happen  to  enter.  Of  these  two  principles  the  former  is 
plainly  the  ideal,  and  acting  on  this  plan  inspected  milk  and  certified  milk  have  been 
produced .  Doubtless  dairy  inspection  and  milk  certification  have  done  much  to  lessen 
milk-borne  disease,  but  it  is  quite  obvious  that  inspection  will  not  detect  all  diseased 

>  Boa  M.    Ifilk  and  its  Relation  to  the  Public  Health.    U.  S.  Pub.  Health  A  Marine  Hospital  Service, 
s  Harding,  Roehle,  Wilton  and  Smith:  The  Effect  of  Certafai  Dairy  Operations  upon  the  Oenn  Content 
oflCilk. 
•  North:  The  Dairjrmao  v.  The  Dairy.    Am.  Jour.  Pub.  Health,  v.  0, 519,  1015. 


128       PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC  CONQBESS. 

animals  or  attendants  or  discover  and  close  all  the  avenues  by  which  disease  organ- 
isms may  enter  the  milk  supply.  The  epidemic  of  sore  throat  which  occurred  near 
Boston  ^  was  carried  by  one  of  the  superior  dairies,  and  doubtless  disease  germs  find 
their  way  into  certified  milk  more  often  than  we  are  wont  to  believe.  The  American 
ideal  of  certified  milk  fails  mainly,  however,  because  it  results  in  too  expensive  a 
product  for  common  use. . 

In  Europe  the  tendency  has  been  to  follow  the  second  principle,  viz,  to  kill  the 
disease  bacteria  which  may  enter  the  milk  supply.  This  was  done  empirically  for 
centuries  by  simply  boiling  the  milk  at  home ;  more  recently  pasteurization  has  been  re- 
sorted to,  and  this  method  is  rapidly  gaining  favor  in  America  as  well.  The  greatest 
objection  to  these  methods  is  the  cooked  flavor  imparted  to  the  product,  but  even 
this  is  largely  overcome  under  present  methods  of  pasteurization,  and  apparently  we 
are  slowly  outgrowing  our  prejudices  against  pasteurized  milk.  While  pasteurization 
adds  somewhat  to  the  expense,  this  factor  is  balanced  by  the  saving  affected  in  added 
keeping  qualities  of  the  product.  If  the  pasteurizing  has  been  properly  done,  we 
may  assume  that  the  problem  of  disease  citfried  by  milk  is  solved,  for  as  Rosenau  ' 
points  out,  '^  there  is  not  a  single  instance  on  record  in  which  a  milk-borne  outbreak 
[of  disease]  is  recorded  from  the  use  of  pasteurized  milk."  While  this  solution  may 
not  be  the  most  ideal  one  it  is  a  practical  solution  which  we  may  accept  for  the  pres- 
ent as  the  best  available  and  on  the  whole  as  quite  satisfactory.  If  an  occasional 
consumer  objects  to  paateiuized  milk,  the  certified  product  would  still  be  available. 

Many  sanitarians  have  objected  to  the  conclusion  at  which  we  have  arrived  on  the 
ground  that  pasteurization  is  practiced  on  milk  frequently  highly  polluted  by  manure; 
they  have  rightly  held  that  while  pasteurization  rendeied  such  milk  safe,  it  did  not 
chiuige  its  filthiness  and  unfitness  for  h\iman  food.  This  contention  must  be  granted, 
and  this  brings  us  to  the  third  aspect  of  the  milk  problem. 

THE  PROBLEM   OF  EUUINATINO  FH/TH. 

At  the  present  time  the  task  of  eliminating  dirt  from  milk  presents  the  most  serious 
difficulties,  and  is  the  most  important  phase  of  present  sanitary  endeavors.  This 
problem  resolves  itself  into  two  distinct  phases:  First,  the  problem  of  finding  the  most 
suitable  method  of  detecting  dirt  in  milk;  secondly,  bringing  the  evidence  home  to 
the  dairyman  and  making  him  respond  to  the  new  demands.  Let  us  first  consider  the 
methods  of  detecting  filth  in  milk. 

Three  methods  are  in  use  more  or  less  commonly,  viz:  (1)  Determining  the  total 
number  of  bacteria  present  in  the  milk,  assuming  this  to  be  an  index  of  its  cleanliness, 
and  fixing  a  limit  beyond  which  the  count  may  not  go,  otherwise  sale  ia  forbidden; 
(2)  determining  the  number  of  B.  coli  present  and  setting  a  similar  standard;  (3) 
determining  visible  dirt,  and  again  making  a  standard  for  purity.  To  these  the  writer 
now  desires  to  add  another:  (4)  Determining  B.  sporogenes  and  creating  a  standard 
of  purity. 

It  is  well  known  that  the  total  count  depends  upon  other  factors  as  well  as  upon 
dirt,  for  time  and  temperature  may  cause  a  high  count  in  an  otherwise  clean  milk; 
doubtless  such  milk  should  be  barred  from  sale,  but  it  does  not  reach  the  real  question, 
which  is  the  amount  of  dirt  present  in  it.  Again,  if  the  milk  is  pasteurized,  the  total 
count  fails  utterly  to  indicate  dirt.  Since  the  use  of  pasteurized  milk  is  rapidly 
increasing,  the  ultimate  failure  of  the  total  coimt  ia  obvious. 

As  to  determining  the  number  of  B.  coli  and  using  the  data  to  indicate  manure,  this 
method  will  fail  for  the  same  reasons  that  the  total  coimt  must  fail.  In  addition,  the 
determination  of  B.  coli  requires  rather  too  elaborate  a  technique  to  make  it  generally 
available.    Up  to  the  present  time  the  method  appears  to  have  gained  little  favor. 

1  Winslow:  An  Outbreak  of  Ttmsil  litis  or  Septic  Sore  Throat  in  Eastern  Massaohusetts  and  its  Relation 
to  an  Infected  Milk  Supply,  Jour.  Inf.  Dis.,  X,  1, 72, 1012. 
s  Rosenau:  The  Milk  Question,  1912. 


PUBLIC  HEALTH  AKD  MEDICINE.  129 

When  the  test  is  made  sufficiently  early  and  before  the  milk  is  pasteurized  it  has  been 
ahown  ^  that  the  method  is  an  excellent  one  for  the  purpose.  The  dairy  in  which  the 
method  was  applied  received  its  supply  from  a  comparatively  limited  area  and  from 
•nly  20  dairymen.    Special  endeavors  were  made  to  produce  only  superior  milk. 

At  present  the  determination  of  visible  dirt  appears  to  be  in  greatest  fovor  and  has 
proved  itself  a  valuable  asset  to  the  sanitarian  in  checking  up  supplies.  The  ease 
with  which  the  determination  is  made  and  the  telltale  nature  of  the  evidence  presented 
speak  highly  in  its  fttvor.  The  Wizzard  Sediment  Teeter  '  has  proved  very  satisbc- 
tory  in  our  hands.  Indeed,  the  method  leaves  little  to  be  desired  so  long  as  the  pro- 
ducer does  not  become  wise  and  adopt  clarification  methods  such  as  heavier  strainers 
or  centrifugation.  Obviously  the  method  will  fail  as  soon  as  better  clarification 
methods  are  adopted.  Such  clarification  can  not  lessen  the  number  of  manure  bactoria 
in  milk  or  the  soluble  portion  of  the  manure,  but  rather  aids  in  their  better  distribution. 
From  these  considerations  it  is  quite  clear  that  we  have  no  method  for  determining 
manural  pollution  which  does  not  fail  at  some  critical  point,  the  total  count,  and  B. 
coli  determinations  fail  in  milk  that  has  been  held  for  some  time  or  has  been  pasteur- 
ized, and  the  sediment  test  fails  after  clarification. 

To  overcome  these  difficulties  is  the  purpose  of  the  B.  sporogenes  determination  as 
an  indicate^'  of  manural  pollution  as  proposed  by  Weinzirl  and  Veldee.*  B .  sporogenes 
is  an  intestinal  organism,  and  hence  indicates  manure  when  found  in  milk;  it  does  not 
multiply  at  ordinary  temperatures  at  which  milk  ia  held,  and  so  it  truly  indicates  the 
pollution  even  of  milks  kept  for  varying  periods  of  time  and  at  varying  temperatures; 
it  produces  spores  but  these  are  not  killed  by  pasteurization  and,  finally,  the  oiganism 
can  be  easUy  and  quickly  determined. 

The  method  for  determining  B.  sporogenes,  as  we  now  use  it,  is  as  follows:  Milk  is 
dispensed  in  ordinary  test  tubes  and  solid  paraffin  sufficient  to  make  one-eighth  inch 
layer  is  then  added  and  the  whole  sterilized.  Five  cc.  of  milk  are  added  and  the  tubes 
heated  to  80^  G.  for  10  minutes.  The  tubes  are  rapidly  cooled,  the  paraffin  hardens 
and  produces  an  ansrobic  culture  in  which  the  B.  sporogenes  grows  when  incubated 
at  37^  C.  for  48  hours.  The  gas  produced  by  the  fermentation  of  the  lactose  lifts  the 
paraffin  plug  some  distance,  and  this  is  taken  to  indicate  B.  sporogenes  as  present. 

Thus  far  we  have  not  attempted  to  establish  a  standard  of  purity  or  limit  beyond 
which  the  presence  of  B.  sporogenes  would  condemn  the  milk  and  doubtless  the  line 
to  be  drawn  will  vary  for  different  localities.  In  1,088  samples  from  20  producers 
analyzed  by  Weinzirl  and  Folder  ^  it  would  appear  that  the  presence  of  B.  sporogenes 
in  5  cc.  samples  of  milk  would  condemn  about  20  per  cent  of  the  milk  under  compara- 
tively fttvorable  conditions.  Perhaps  2  or  3  positives  out  of  5  samples  of  5  cc.  each 
would  give  a  fairer  standard  and  a  broader  basis  for  judging  the  purity  of  the  milk. 
The  above  analyses  have  shown,  however,  that  B.  sporogenes  compares  very  fovorably 
with  B .  coli  as  an  indicator  of  manural  pollution  when  visible  dirt  is  taken  as  a  standard , 
and  both  are  superior  to  the  total  bacterial  count  when  the  latter  is  made  from  agar 
plates  incubated  48  hours  at  37"^  C. 

THE  MILX  PBOBLSM  AS  A  WHOLE. 

While  we  may  dissect  the  milk  problem  and  examine  each  part  separately,  to  really 
sdve  it  we  must  consider  it  as  a  whole.  We  have  made  exceUent  progress,  but  thb 
has  scarcely  been  jnropOTtional  to  the  work  done,  due  largely  to  the  failure  to  see  the 
pfoblem  in  its  entirety. 

We  must  have  cheap  milk,  clean  milk,  and  safe  milk.  Of  these  three  purposes,  the 
last,  safe  milk,  may  fairly  be  regarded  as  solved;  the  consumer  has  the  choice  of  two 

1  Wfliiisirl,  Jolm,  and  Fekter,  H.  A.:  UnpabUshed  dftta. 

*  Wisard  Sedimoit  Tettflr  The  Cnamerj  Paokago  UIg.  Co.,  Chicago,  U\. 

•  Wefaixirl  and  Veldee:  Am.  Joar.  of  Pub.  Health,  5:9*^02:1015. 


130       PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC   CONGRESS. 

possibilities,  either  pasteurized  milk  or,  if  his  purse  permits  the  indulgence,  certified 
milk.  As  to  cheap  milk,  this  problem  will  solve  itself  when  the  dairyman  is  not  com- 
pelled to  install  expensive  equipment;  when  care  is  made  superior  to  bams  and 
machinery;  when  demonstration  will  supersede  the  score  card.  If  the  score  card  is 
retained  at  all,  the  resulting  product  must  receive  at  least  nine-tenths  of  the  score, 
while  the  equipment  and  method  should  receive  perhaps  one-tenth  of  the  credit.  It 
is  doubtful,  however,  whether  the  score  card  should  be  retained.  A  rating  based 
upon  the  available  laboratory  tests  would  appear  to  be  the  better  plan.  Grading  the 
milk  on  the  basis  of  such  laboratory  tests  into  A,  B,  and  C  grades,  and  requiring 
these  grades  to  be  placed  on  the  bottles  or  containers,  will  come  nearer  to  solving  the 
cleanliness  problem  than  the  clumsy  and  costly  methods  now  in  vogue. 

SUMMARY. 

To  sum  up  the  problem  of  a  safe  and  sane  milk  supply,  we  find: 

(1)  That  pasteurized  milk,  when  the  ptoceea  has  been  properly  carried  out,  is  safe 
80  far  as  disease  is  concerned;  certified  milk  is  also  satisfactory  in  this  respect. 

(2)  That  a  sane  milk  supply  must  be  free  from  excessive  dirt.  To  eliminate  dirt, 
the  milk  should  be  rated  on  the  basis  of  laboratory  tests,  such  as:  (a)  Total  count; 
(6)  B.  coll  determination;  (c)  visible  dirt  test;  (d)  B.  sporogenes  determination. 

The  milk  should  be  graded  according  to  the  laboratory  tests  in  A,  B,  and  C  grades, 
and  these  placed  upon  bottles  and  containers  in  which  the  milk  is  sold. 

(3)  That  a  sane  milk  supply  must  be  cheap  enough  to  be  within  reach  of  the  com- 
mon people.  For  this  purpose  certified  milk  is  a  failiu^;  on  the  contrary,  if  dairy 
demonstration  supersedes  dairy  inspection,  and  laboratory  tests  the  score  card  in 
grading  milk,  when  care  is  made  sup^or  to  equipment  in  bams  and  machinery, 
then  a  clean  milk  may  be  had  at  a  reasonable  price  as  well. 


PROYECTO    DE    ORDENANZA    REGLAMENTARIA    DEL    COMERCIO    DE 
LECHE  DE  CONSUMO  DE  BUENOS  AIRES,  ARGENTINA. 

Por  RICARDO  SARMIENTO  LASPIUR, 
Secretario  de  la  Asiatencia  Pdblica  de  Buenos  Aires,  Argentina. 

CAPh-ULO  I. — CONDICIONE8  DB  LA.  LBCHB. 

ARTfcuLO  1.  La  leche  destinada  al  consumo  debe  ser  la  mezcla  perfecta  del  pro- 
ducto  del  ordefio  completo  de  por  lo  menoe  cuatro  vacas  sanas,  blen  mantenidas  y  cuida- 
das  y  que  no  se  hallen  en  los  dfas  inmediatamente  anteriores  ni  en  los  primeroe  dfas  pos- 
teriores  a  la  parici6n,  obtenido  y  tratado  en  condidones  higi^nicas  hasta  el  momento 
de  su  consumo  y  sin  agregados  ni  sustracciones  ni  alteraciones  de  ninguna  especie. 
A  fin  de  alcanzar  ese  deeiderdtum  en  la  medida  posible  en  nuestro  medio  y  propender 
al  mejoramiento  progresivo  del  producto,  la  leche  de  consumo  en  el  municipio  se  clasi- 
ficard  en  las  categorias  que  se  especifican  en  los  artfculos  siguientes,  y  su  producci6n, 
introducciiSn,  dep<3sito,  transporte  y  expendio  se  sujetar&n  a  las  prescripdones  de  la 
presente  ordenanza. 

Abt.  2.  Se  considerard  leche  de  piimera  calidad  certificada  y  s61o  se  permitir4  que 
en  tal  caiicter  o  bajo  tal  denominaci6n  se  introduzca  al  munidpio,  depodte,  trans- 
porte, venda  u  ofrezca  en  venta  dentro  del  mismo  la  leche  que  retina  los  siguientes 
requisites: 

1^.  Tener  por  lo  menos  3  por  ciento  de  materia  grasa  (goidiura). 

2®.  Tener  por  lo  menos  11.5  por  dento  de  sustanda  seca,  comprendida  la  materia 
grasa. 

3*.  Tener  un  grade  de  addez  no  menor  de  15  grades  Domic  ni  mayor  de  20  grades. 


PX7BLI0  HEALTH  AND  MEDIOIKB.  181 

4*.  No  coagulane  al  scmketerla  a  la  ebuUiddn,  ni  formar  copos  o  grumoe  ni  coagulane 
al  mezclarla  con  doe  voces  su  volumen  de  alcohol  a  70  voldmenee  por  dento. 

5^.  Sometida  a  cualquier  procedimiento  de  examen,  debe  mostnuBe  perfectamente 
limpia. 

6^.  No  content  en  nuM^  momento,  hasta  ser  entrogada  al  consumidor,  mia  de 
60,000  microbios  por  e.  c. 

7^.  Estar  edempre  a  una  iiemperatuia  de  10^  o  menos. 

8^.  Ser  entrogada  al  consumidor  dentro  de  las  20  horas  de  <xdefiada. 

9°.  No  haber  suMdo  modificadones  de  ninguna  espede,  debidas  a  la  intervenddn 
de  agentos  ffsicos  o  qui  micos. 

10^.  Ser  produdda,  envasada,  rotulada  y  transportada  en  la  forma  que  se  indica  m&B 
adelante. 

La  leche  que  no  llene  los  requidtos  1^,  2°,  o  3^,  caerd  en  comiBO,  sin  perjuido  de 
apUcaise  el  artfculo  8,  si  se  comprueba  que  ha  sido  adulterada.  Por  d  exeeeo  de 
addez,  se  apUcar&  en  cada  case  una  multa  de  50  pesos. 

La  infracddn  de  los  requisites  4^  o  5^  8er&  penada  con  multa  de  50  pesos  cada  ves. 
Ademis,  a  fin  de  que  el  Interesado  se  coloque  en  condidones  de  produdr  leche  in- 
objetable  a  esos  respectos,  se  prohibird  la  introducd6n  y  venta  de  la  leche  en  d  muni- 
dpio  durante  los  dnco  dlas  subsiguientes  a  la  comprobad6n.  La  leche  caerft  en 
comiso. 

Ouando  la  leche  presente  mis  de  60,000  microbios  por  c.  c,  se  avisaii  al  interesado 
a  fin  de  que  adopte  las  medidas  necesarias  para  evitar  el  inconyeniente.  £1  aviso 
se  repetiii  toda  vez  que  se  haga  la  misma  comprobaddn.  Pero  la  administraddn 
sanitaiia  podr&  prohibir  la  introducddn  y  venta  de  la  leche  en  d  munidpio,  si  se 
comprueba  que  con  irecuenda  tiene  mis  de  ese  ntimero  de  microbios,  d  d  ntimero  de 
microbios  supera  en  grandes  propordones  al  indicado  odd  interesado  no  adopta  las 
medidas  susodichas.    La  leche  caeri  en  comiso. 

La  iniracddn  dd  7^  requiaito  8er&  penada  con  multa  de  80  pesos.  Si  se  comprueba 
que  la  leche  no  tiene  la  temperatura  exigida  por  no  haberse  aplicado  a  los  medios 
necesarioB  para  cons^gulrlo,  la  multa  ser6  duplicada.    La  leche  caeri  en  comiso. 

Ladd  8^  requidto  ser&  penada  con  multa  de  50  pesos  cada  ves.  La  leche  caeri  en 
comiso. 

La  dd  9^  requidto  seri  penada  con.multa  de  100  pesos  la  piimera  vez,  de  200  pesos 
la  segunda  y  con  d  retire  definitivo  dd  permiso  paraintervenir  en  cualquier  forma 
en  d  comerdo  de  leche  de  primera  calidad  c^tificada  la  t^xfera.  La  leche  caer& 
en  comiso. 

La  dd  10^  requidto,  si  no  tiene  una  pena  espedalmente  establedda,  seri  penada 
con  multa  de  5  a  100  pesos,  seglin  la  gravedad  de  la  falta,  condder&ndose  como  dr- 
cunstanda  agravante  su  repetid6n.  Pero  la  administraddn  sanitaria  i)odr&  prohibir 
en  cualquier  memento  la  introducci6n  y  venta  de  la  leche,  d  conddera  que  ha 
d^ado  de  ofrecer  sufidentes  garantlas  de  salubridad. 

Art.  3.  Se  condderard  leche  de  primera  calidad  y  sdlo  se  permitlri  que  en  tal 
car&cter  o  bajo  tal  denominad6n  se  introducca  al  mimidpio,  depodte,  transporter 
venda  u  ofrezca  en  venta  dentro  dd  mismo  la  leche  que  redna  los  siguientes  requidtos: 

1°.  Tener  por  lo  menos  2.7  por  dento  de  materia  grasa  (gordura). 

2?,  Tener  porlo  menos  10.7  por  dento  desustancia  seca,  comprendida  la  materia  grasa. 

3^.  Tener  un  grado  de  addez  no  menor  de  15  grados  Domic  ni  mayor  de  20  grades. 

4^.  No  coagularse  al  someterla  a  la  ebullicidn,  ni  formar  copos  o  grumes  ni  coagularse 
al  mezclarla  con  im  volumen  igual  de  alcohol  a  70  voltimenes  por  dento. 

5"^.  Puesta  en  la  cantidad  de  un  litro,  despu^s  de  bien  revuelta,  en  im  redpiente 
cilfndrico  de  vidrio  incol(»x>  y  de  f  ondo  piano,  cuyo  diimetro,  sea  mis  o  menos  igual  a 
la  mitad  de  la  altura  de  la  columna  f ormada  por  la  leche,  no  debe  dejar  depodtar 
sedimento  apreciable  despu^  de  una  hora  de  repose. 

68436— 17— VOL  X 10 


182       PBOCEEDINQS  SECOND  PAN  AMBBIGAN   SCIENTIFIC  CONGBESS. 

6^.  No  contener  en  ningdn  momento,  hasta  ser  entrog&da  al  comsumidor,  m^  de 
500,000  microbioe  por  c.  c. 

7°.  liegar  a  la  ciudad  a  una  temperatura  de  15*^  o  menos. 

8^.  Estar  aiempre  a  10^  de  temperatuia  o  menos,  deepu^  de  dos  horas  de  su  entind* 
a  la  ciudad. 

9^.  Ser  entrogada  al  consumidor  dentro  de  las  veinte  boras  de  su  entrada  al  muni* 
dpio. 

10**.  Ser  introducida,  depositada,  envasada,  rotulada,  transp(»ladA  y  entr^gada  al 
consumidor  en  la  forma  que  se  indica  mis  adelante. 

La  leche  que  no  llene  los  requisitos  1*^,  2*^,  o  3^,  caerd  en  comlso,  sin  peijuicio  de 
aplicarse  el  artfculo  8°,  si  se  comprueba  que  ba  aide  adulterada.  Por  el  exceso  de 
acidez,  se  aplicari  en  cada  case  una  multa  de  30  pesos. 

La  in£racci6n  de  los  requudtos  4°  o  5**  seri  penada  con  multa  de  30  pesos  cada  vez. 
Si  la  comprobaci6n  ba  side  en  el  memento  dd  arribo  de  la  lecbe  al  municipio,  se  pro- 
bibiri  su  introducci6n  y  venta  en  el  mismo  durante  los  diez  dias  subsiguientes,  a  fin- 
de  que  el  interesado  se  coloque  en  condiciones  de  enviar  lecbe  inobjetable  a  esos  res- 
pectos.    La  lecbe  caeri  en  comiso. 

Guando  la  lecbe  contenga  m^a  de  500,000  microbios  por  c.  c.  se  avisaii  al  interesado, 
a  fin  de  que  adopte  las  medidas  necesaiias  para  evitar  el  inconveniente.  El  aviso 
se  repeturd  toda  vez  que  se  baga  la  misma  comprobaci6n.  Pero  la  administracidn 
sanitaria  podrd  probibir  la  intrbducci6n  y  venta  de  la  lecbe  en  el  municipio,  si  en 
tree  extoenes  sucesivos  efectuados  con  15  dfas  de  intervale  por  lo  menos  se  comprueba 
que  el  n6mero  de  microbios  supera  en  grandee  proporciones  al  indicado  o  si  el  interesado 
no  adopta  las  medidas  susodicbas.  La  lecbe  que  contenga  mis  de  500,000  microbios 
caeri  en  comiso. 

La  lecbe  que  llegue  a  la  ciudad  a  mis  de  15°  de  temperatura  caeri  en  comiso. 

La  infracci6n  del  requisite  8*^  seri  penada  con  multa  de  quince  pesos.  Si  se  com- 
prueba que  la  lecbe  no  tiene  la  temperatura  exigida  por  no  baberse  aplicado  los  medioe 
necesarios  para  conseguirlo,  la  multa  seri  duplicada.    La  lecbe  caeri  en  comiso. 

La  del  requisite  9*^  seri  penada  con  multa  de  veinticinco  pesos  cada  vez.  La  lecbe 
caeri  en  comiso. 

La  del  d6cimo  requisite,  si  no  tiene  una  pena  especialmente  establecida,  seri 
penada  con  multa  de  cinco  a  cincuenta  pesos,  eegta  la  gravedad  de  la  &dta,  conaiderin- 
doee  como  circunstancia  agravante  su  repetici6n.  Pero  la  administracidn  sanitaria 
podri  probibir  en  cualquier  memento  la  introducci6n  y  venta  de  la  lecbe,  si  conaidera 
que  ba  dejado  de  ofrecer  suficientes  garantias  de  salubridad. 

Art.  4.  La  lecbe  de  primera  calidad  podri  ser  pasteurizada.  En  tal  case,  salvo 
los  requisites  6^  y  9^  del  articulo  3,  deberi  reunir  antes  y  despu^s  de  la  pa8teurizaci6n 
todos  los  requisitoe  del  mismo  articulo  y  ademis  los  siguientes: 

V*,  No  contener  mis  de  2,000,000  de  microbios  por  c.  c.  antes  de  ser  pasteurizada. 

2^.  No  contener  en  ningtin  memento,  deepuis  de  pasteurizada  y  basta  ser  entregada 
al  consumidor,  mis  de  200,000  microbios  por  c.  c. 

3^.  Ser  entregada  al  consumidor  dentro  de  las  20  boras  de  pasteurizada. 

La  primera  in£racci6n  del  requisite  I*'  de  este  articulo  seri  seguida  de  un  aviso 
al  interesado,  la  segunda  seri  penada  con  multa  de  100  pesos,  la  tercera,  con  multa 
de  200  pesos  y  la  cuarta  seri  seguida  de  la  im)bibici6n  de  introducir  o  vender  lecbe 
pasteurizada  de  primera  calidad  en  el  municipio. 

La  primera  infracci6n  del  requisito  2^  de  este  articulo  seri  seguida  de  un  aviso 
al  interesado,  a  fin  de  que  adopte  las  medidas  necesarias  para  evitar  el  incon- 
veniente, y  las  infracciones  subsiguientes  con  una  multa  de  100  pesos  cada  vez.  Peio 
la  administracidn  sanitaria  podri  probibir  la  introducci6n  y  la  venta  de  la  lecbe 
en  el  municipio,  si  en  tres  eximenes  sucesivos  efectuados  con  quince  dlas  de  inlervalo 
por  lo  menos  se  comprueba  que  el  ntimero  de  microbios  supera  en  grandes  proporciones 
al  indicado  o  si  el  interesado  no  adopta  las  medidas  susodicbas.  La  lecbe  que  deepu^ 
de  pasteurizada  contenga  mis  de  200,000  microbioe  por  c.  c.  caeri  en  comiso. 


PUBUC  HEALTH  AND  MEDICINE.  133 

La  infnicci6n  del  requisito  3<*  de  este  artfculo  seri  penada  con  multa  de  25  pesos 
cada  vez.    La  leche  seri  comiaada. 

Las  indacciones  a  los  demis  lequiaitos  que  debe  llenar  la  leche  pasteurizada  de 
primera  calidad  tendr&n  las  penas  indicadas  en  el  artfculo  3. 

Art.  5.  Se  considerard  leche  de  segunda  calidad  y  b61o  se  peimitiri  que  en  tal 
caricter  o  bajo  tal  denominaci6n  se  introduzca  al  municipio,  defKwite,  tianspofte, 
venda  u  ofresca  en  venta  dentro  del  mismo  la  leche  que  redna  los  aiguientes  requisitos: 

1*.  Tener  una  denaidad  de  1,029  a  1,034,  inclusive,  a  15®  de  temperatura. 

2^.  Tener  per  lo  menos  2.5  por  ciento  de  materia  graaa  (gordura)  en  los  meses  de 
septiembre,  octubre  y  noviembre  y  2.7  por  ciento  en  los  otros  meses  del  afio. 

3*.  Tener  por  lo  menos  10.5  o  10.7  por  ciento,  respectivamente,  de  sustancia  seca, 
contada  la  materia  graaa,  segtin  se  trate  del  primero  o  segundo  periodos  indicados 
en  el  ptoafo  precedente. 

4?.  Tener  un  grade  de  acidez  no  menor  de  15  grades  Domic  ni  mayor  de  20  grados, 

5**.  No  coagularse  al  aometerla  a  la  ebullici6n,  ni  formar  copos  o  grumes  ni  coagularse 
al  mezclarla  con  im  volumen  igual  de  alcohol  a  70  voldmenes  por  ciento. 

6^.  Puesta  en  la  cantidad  de  medio  litre,  despu^s  de  bien  revuelta,  en  un  recipiente 
cilfndrico  de  vidrio  incoloro  y  de  fondo  piano,  cuyo  ditoetro  sea  mis  o  menos  igual 
a  la  mitad  de  la  altura  de  la  colunma  formada  por  la  leche,  no  debe  dejar  defKwitar 
■edimento  apreciable  despu^s  de  media  hora  de  repoeo. 

7®.  No  contener  en  ningdn  memento,  hasta  ser  entregada  al  consumidor,  m^  de 
5,000,000  de  microbios  por  c.  c. 

8^.  Llegar  a  la  ciudad  a  una  temperatura  de  20®  o  menos. 

9®.  Estar  aiempre  a  15®  de  temperatura  o  menos,  despu^s  de  dod  horas  de  eu  entrada 
a  la  ciudad. 

10**.  Ser  entregada  al  conaimiidor  dentro  de  las  24  horas  de  su  entrada  al  municipio. 

11<*.  Ser  introducida,  depositada,  envaaada,  rotulada,  tranaportada  y  entregada 
al  consumidor  en  la  forma  que  se  indica  mis  adelante. 

La  leche  que  no  llene  los  requisitos  1®,  2**,  3®,  o  4®  caerd  en  comiso,  sin  perjuicio 
de  aplicarse  el  articulo  8,  si  se  comprueba  que  ha  side  adulterada.  Por  el  exceso  de 
acidez.  se  aplicar^  en  cada  case  una  multa  de  15  pesos. 

La  infracci6n  de  los  requisitos  5®  o  6®  seri  penada  con  multa  de  15  pesos  cada  vez. 
Si  la  comprobaci6n  ha  side  en  el  memento  del  arribo  de  la  leche  al  municipio,  se  pro- 
hibir&  su  introducci6n  y  venta  en  el  mismo  durante  los  veinte  dfas  subsiguientes,  a 
fin  de  que  el  interesado  se  coloque  en  condiciones  de  enviar  leche  inobjetable  a  eeos 
respectoe.    La  leche  caerd  en  comiso  y  serd  inutilizada. 

Cuando  la  leche  contenga  mis  de  5,000,000  de  microbios  por  c.  c,  se  avisari  al 
interesado,  a  fin  de  que  adopte  las  medidas  necesarias  para  evitar  el  inconveniente. 
Las  tres  primeras  comprobaciones  en  tal  sentido  ser&n  seguidas  del  mismo  aviso. 
Pero,  si  despu^  de  esto,  en  tres  eximenes  sucesivos  efectuados  con  quince  dlas  de 
intervale  por  lo  menos,  se  comprueba  que  el  ndmero  de  microbios  supera  al  indicado, 
ae  prohibiri  la  introducci6n  y  venta  de  la  leche  en  el  municipio.  La  leche  que 
contenga  m^  de  5,000,000  de  microbios  por  c.  c.  caerd  en  comiso  y  seri  inutilizada. 

La  leche  que  llegue  a  la  ciudad  a  mis  de  20®  de  temperatura  caeri  en  comiso. 

La  inhracci6n  del  9®  requisito  serd  penada  con  multa  de  cinco  pesos.  Si  se  com- 
prueba que  la  leche  no  tiene  la  temperatura  exigida  por  no  haberse  aplicado  lee 
medios  necesarioe  para  conseguirlo,  la  multa  serd  duplicada.  La  leche  caerd  en 
comiso. 

La  infracci6n  del  10®  requisito  serd  penada  con  multa  de  15  pesos  cada  vez.  La 
leche  caerd  en  comiso  y  serd  inutilizada. 

La  infracci6n  del  requisito  11®,  si  no  tiene  una  pena  especialmente  establecida, 
serd  penada  con  multa  de  cinco  a  treinta  pesos,  segdn  la  gravedad  de  la  falta,  con- 
siderdndoee  como  circunstancia  agravante  su  repetici6n.  Pero  la  administraci6n 
sanitaria  podrd  prohibir  en  cualquier  memento  la  introducci6n  y  la  venta  de  la  leche, 
si  considera  que  ha  dejado  de  ofrecer  suficientes  garantias  de  salubridad. 


134       PBOGEEDINQS  SECOND  VJLN  AMEBICAN  8CIEKTIFIG  CONGBESS. 

Art.  6.  La  leche  de  segtinda  calidad  podrd  ser  pasteurizada.  En  tal  caao,  salvo  los 
requiaitos  6^,  7^,  8^,  y  lO''  del  articulo  5,  deberd  reunir  antes  y  despu^s  de  pasteurizada 
todos  los  requisitos  de  ese  mismo  articulo  y  ademis  los  siguientes: 

1^.  No  contener  m^s  de  300,000  microbios  por  c.  c.  despu^  de'pasteurizada  y  antes 
de  salir  del  establecimiento  donde  ha  suMdo  la  pasteurizacidn. 

2^.  Si  ha  side  pasteurizada  fuera  del  municipio,  no  contener  mia  de  400,000  micro- 
bios por  c.  c.  en  el  memento  de  llegar  a  ^1. 

3^.  Ser  entregada  al  consumldor  dentro  de  las  24  horas  de  la  pasteurizacidn. 

La  primera  infracci6n  de  los  requisitos  1*^  y  2^  de  este  articulo  serd  seguida  de  un 
aviso  al  interesado.  En  las  infracciones  subsiguientes  se  incurrLrd  en  multa  de 
100  a  500  pesos,  segdn  la  cantidad  de  leche  de  que  se  trate  y  la  gravedad  del  case, 
considerdndose  como  circunstancia  agravante  la  repetici6n  de  la  falta.  Si  la  leche 
ha  sido  pasteurizada  fuera  del  municipio,  en  lugar  de  las  multas  indicadas,  podr& 
prohibirse  su  introducci6n  y  venta  en  ^1  durante  1  a  30  dfas,  teniendo  en  cuenta  las 
mismas  circunstancias. 

La  infracci6n  del  requisite  3*^  de  este  articulo  serd  penada  con  quince  pesos  de 
multa  cada  vez.    La  leche  caerd  en  comiso  y  serd  inutilizada. 

La  de  los  otros  requisitos  dard  lugar  a  las  medidas  y  penas  indicadas  en  el  articulo  5. 

Abt.  7.  Se  prohibe  la  introducci6n  al  municipio  y  el  dep6sito,  transporte,  venta  u 
ofrecimiento  en  venta  dentro  del  mismo,  de  leche,  cualquiera  sea  su  categoria,  que 
tenga  color,  olor,  gusto  o  consistencia  anormales,  o  que  contenga  saugre  o  pus. 

Las  infracciones  del  presente  articulo  serdn  penadas  con  multa  de  15  a  100  pesos  o 
uno  a  seis  dias  de  arresto,  segdn  la  gravedad  del  case,  considerdndose  la  repetici6n  de 
la  falta  como  circunstancia  agravante. 

A  quien  incurra  dos  veces  en  las  penas  mds  graves  se  le  retirard  por  el  t^rmino  de 
un  afio  el  permiso  para  intervenir  en  cualquier  forma  en  el  comercio  de  lecheria.  La 
leche  serd  comisada  e  inutilizada  en  todos  los  cases. 

Abt.  8.  Igual  prohibici6n  que  la  expresada  en  el  articulo  7  rige  para  la  leche  de 
cualquier  categoria  a  la  que  se  haya  sustraido  en  cualquier  forma  una  parte  de  su 
crema  o  gordura  o  se  haya  agregado  agua  u  otra  sustancia  cualquiera,  comprendidas 
las  llamadas  ''conservadoras.'' 

Los  infractores  del  presente  articulo  incurrir^n  en  la  pena  de  cien  pesos  de  multa 
o  seis  dias  de  arresto  la  primera  vez,  doacientos  de  multa  o  doce  dias  de  arresto  la 
segunda  y  retire  definitive  del  permiso  para  intervenir  en  cualquier  forma  en  el 
comercio  de  lecheria  la  tercera.    La  leche  caerd  en  comiso. 

Art.  9.  Salvo  las  leches  de  que  se  trata  en  los  articulos  13  y  14,  se  prohibe  la  intro- 
ducci6n  al  municipio  y  el  dep68ito,  transporte,  venta  u  ofrecimiento  en  venta  dentro 
del  mismo  de  toda  leche  que  por  sus  condiciones  no  eet^  comprendida  en  alguna  de 
las  categorias  especificadas  en  los  articulos  2,  3,  4,  5  y  6,  respectivamente,  de  esta 
ordenanza,  bajo  pena  de  100  pesos  de  multa  a  la  primera  infracci6n,  200  a  la  segunda, 
retire  definitivo  del  permiso  para  intervenir  en  cualquier  forma  en  el  comercio  de 
lecheria  a  la  tercera  y  comiso  de  la  leche  en  todos  los  cases. 

Art.  10.  Se  prohibe  introducir  leche  al  municipio  y  depositarla,  transportarla, 
venderla  u  ofrecerla  en  venta  dentro  del  mismo  en  otro  car&cter  o  bajo  otras  deno- 
minaciones  que  los  indicados  en  los  articulos  2,  3, 4, 5  y  6  y  en  los  correlacionados  con 
ellos,  ni  en  forma  que  pueda  inducir  a  error  acerca  de  la  categoria  a  que  pertenece 
la  leche  sogdn  las  prescripciones  de  la  presente  ordenanza.  Se  excepttian,  en  lo 
que  se  refiere  al  caricter  y  denominaci6n  con  que  se  presenten,  las  leches  de  que  se 
trata  en  los  articulos  12,  13  y  14,  pero  estas  leches  y  todas  las  andlogas  que  puedan 
destinarse  al  consume,  cualesquiera  sean  su  mode  de  preparaci6n,  modificaciones, 
clases  o  uses,  deberdn  ser  introducidas  al  municipio  y  depositarse,  transportarse, 
venderse  u  ofrecerse  en  venta  dentro  del  mismo,  indicando  en  la  forma  establecida 
mia  adelante  a  qu6  categoria  de  las  esx)ecificadas  en  los  articulos  susodichos  per- 
tenecen  o  a  cual  de  esas  categorias  pertenece  la  leche  con  que  han  sido  preparadas. 


PUBUC  HEALTH  AND  MEDICINE.  135 

A  los  que  infrinjan  el  presente  artfculo  se  les  decomisard  la  leche  y  aplicardn  las 
penas  establecidas  en  el  articulo  9. 

Art.  11.  Las  leches  pasteurizadas,  ademis  de  las  condiciones  establecidas  en  lotf 
artfculos  4  y  6,  deber&n  satisfacer  las  siguientes: 

1^.  Haber  side  libradas  de  sus  impurezas  por  algdn  procedimiento  mecdnico  que 
no  separe  completamente  la  crema. 

2^.  Haber  side  sometidas  en  seguida,  en.toda  su  masa,  por  lo  menos  a  85*^  de  tem- 
pera tura  durante  un  minuto. 

3^.  Haber  sido  enfriadas,  inmediatamente  despu^s  de  calentadas,  a  10  o  15  grades 
de  temperatura  o  menoe,  segtin  se  trate  respectivamente  de  leche  de  primera  o  segunda 
calidad. 

4^.  Haber  sufrido  las  operaciones  antedichas  dentro  de  las  catorce  horas  de  orde- 
fiadas. 

5^.  No  haber  sido  calentadas  o  pasteurizadas  por  segunda  vez. 

6^.  Haber  sido  sometidas  a  esas  operaciones  en  aparatos  aprobados  por  la  adminis- 
traci6n  sanitaria. 

No  se  permitird  la  introducci6n  ni  venta  de  leche  pasteurizada  que  no  satisfaga 
estos  requisitos,  y  quien  infrinja  las  disposiciones  de  este  artfculo,  despu^  de  un 
primer  aviso,  incurrird  en  el  decomiso  de  la  leche  y  en  multa  de  100  a  200  pesos,  segdn 
la  gravedad  del  case,  consider&ndose  circunstancia  agravante  la  repetici6n  de  la 
falta. 

Art.  12.  S61o  se  tendrd  por  leche  esterilizada  la  que  despu^  de  limpiada  en  la 
forma  prescrita  en  el  articulo  11  haya  sido  sometida  dentro  de  las  catorce  horas  de 
ordeilada  a  algdn  procedimiento  de  esterilizaci6n  por  el  calor  de  reconocida  eficacia 
y  cuyo  envase  se  haya  cerrado  herm^ticamente  durante  el  calentamiento  y  se  man- 
tenga  igualmente  cerrado  hasta  su  entrega  al  consumidor. 

Se  prohibe  la  introducci6n  y  la  venta  de  leche  esterilizada  que  no  llene  las  con- 
diciones aquf  establecidas,  bajo  pena  de  comiso  del  producto  y  multa  de  100  a  200 
pesoe  cada  vez,  segtin  la  gravedad  del  caso,  considerdndose  como  circunstancia  agn^ 
vante  la  repetici6n  de  la  falta. 

Art.  13.  Las  leches  matemizadas  o  humanizadas  y  las  anilogas,  especialmente 
deetinadas  a  la  alimentaci6n  de  los  nifios  o  de  enfermos  o  convalecientes,  deberdn 
ser  preparadas  con  leche  que  satisfaga  por  lo  menos  los  cinco  primeros  requisites 
especificados  en  el  artfculo  5,  que  no  se  halle  comprendida  en  los  artfculos  7  y  8  y 
librada  de  sus  impurezas  en  la  forma  prescrita  en  el  artfculo  12.  Todas  estas  leches 
deberdn  ser  esterilizadas  en  la  forma  establecida  en  el  artfculo  12. 

Los  que  infrinjan  el  presente  el  artfculo  incurrirdn  en  las  penas  indlcadas  en  el 
artfculo  12  o  en  los  artfculos  7  u  8,  segtin  los  cases. 

Art.  14.  Las  leches  especiales  fermentadas  (Kefir,  etc.)  deberdn  ser  preparadas  con 
leche  que  satisfaga  por  lo  menos  los  cinco  primeros  requisitos  especificados  en  el  artfculo 
5,  no  se  halle  comprendida  en  los  artfculos  7  y  8  y  esterilizada  en  la  forma  prescrita  en 
el  artfculo  12,  correspondlendo  a  las  infracciones  de  lo  aquf  establecido  las  penas  indi* 
cadas  en  el  artfculo  13. 

Art.  15.  Se  prohibe  introducir  al  mimicipio  y  depoeitar,  transportar,  vender  a 
ofrecer  en  venta  dentro  del  mismo,  leche  que  sea  la  mezcla  de  distintos  ordefios  o  de 
partidas  de  leche  recibidas  en  horas  distantes  entre  si.  La  leche  ordefiada  o  recibida 
por  la  mafiana  no  debe  ser  mezclada  con  la  ordefiada  o  recibida  por  la  taide,  ni  in- 
versamente. 

Los  que  infrinjan  el  presente  artfculo  incurrirdn  en  el  comiso  de  la  leche  y  en  multa 
de  150, 100  o  50  pesos,  respectivamente,  cada  vez,  segtin  se  trate  de  leche  de  primera 
calidad  certificada,  de  primera  calidad  o  de  segunda  calidad. 

Art.  16.  Qnien  deliberadamente  o  sin  cerciorane  primero  de  la  calidad  a  que 
pertenece  la  leche  segtin  las  prescripciones  de  la  presente  ordenansa,  la  introdozca, 
deposite,  transporte,  venda  u  ofreeca  en  venta  en  el  municipio  como  de  mejor  calidad 


136        PROCEEDINGS  SECOND  PAN   AUBBICAN   SCIENTIFIC  C0NQBE3S. 

que  a  la  que  realmeate  p«rteiiece,  incuiriri  en  multa  de  100  pewe  U  primen  vez, 
doacientoB  peaoa  la  Begimda  y  en  el  retiro  definitivo  del  penniw  pus  intervenir  en 
cualquier  forma  en  el  comercio  de  lecherte  la  tercem  vet. 

Abt.  17.  Se  prohibe congeUr  la  leche o  agtegarle  leche  congelada,  bkjopenade  100, 
50  o  25  peeoe  de  multa,  leepectivamente,  segdn  se  trat«  de  leche  de  primen  calidad 
certificada,  de  primera  calidad  o  de  segunda  calidad . 


^^  ^ 


Kxt.  18.  S^vo los arttculoB 7, 8, 16 y  17,  loademiB del  presente cspftulo no se aplican 
a  la  leche  producida  en  loa  tambos  urbanoe  y  entregada  al  conaumidor  inmedistamente 
de  ordefiada. 


CApiruLO   ] 


CtiLKS,     AFABATOa, 


Dl     LOS     BNTABB8, 

H^airUIAS   KN   OENBBAL. 

Am.  19.  Pan  el  envaae,  medida  y  manipulacioues  de  la  leche  sdio  se  permitiii  el 
luo  de  recipientea  y  iltile«  de  hieiio  o  acero  con  eetafiado  gmeao  y  de  botellaa  devidrio 
incoloro.  8e  piohibe  expreeamente  unr  recipientee  de  cobre,  zinc,  latiin,  pLomo 
hieno  emplomado  o  nutdara. 


PUBUO  HEALTH  AND  MEDIOIKE.  137 

EsoB  recipientes  deber&n  ser  de  limpieza  y  deeinfeccidn  Mciles.  Los  met41ico8  ser&n 
am  cofltura  y  tendr&ii  sua  ftogukw  redondeados  y  lae  botellas  serto  de  fondo  piano.  LO0 
de  dofl  litioe  o  mis  de  capacidad  tendi^n  la  boca  suficientemente  ampHa  como  para 
pennitir  mtroducir  c6modameiite  la  mano  de  on  hombre  adulto.  LO0  mis  pequefios 
sef^n  de  tal  forma  y  dispoeicidn  que  su  intmor  pueda  limpiane  a  cepillo  ttcil  y  com- 
pletamente. 

L08  recipientes  usados  para  medir  la  leche  deben  estar  provistos  de  asa  o  mango 
apropiados,  de  tal  mode  que  la  mano  del  que  ks  maneja  no  se  ponga  en  contacto  con  la 
leche. 

AsT.  20.  Las  tapas  de  los  envases  y  recipientes  deben  Uenar  las  mismas  condiciones 
que  ^stos,  especificados  en  el  precedente  artfculo. 

Si  se  trata  de  envases  empleados  en  el  transporte  de  la  leche,  ser&n  de  cierre  herm6- 
tico  y  la  tapa  recubriri  los  hordes  de  su  boca  o  abertura.  Si  de  envases  especialmente 
destinados  a  tenerla  en  depdeito  en  locales  fijos,  las  tapas  deberto  recubrir  por  aniba 
y  por  fuera  la  boca  y  el  cuello  del  recipiente  y  podr&n  no  ser  ajustadas. 

Se  prohibe  expresamente  usar  trapos,  papel,  paja,  madera  o  materias  anilogas  y  aros 
de  goma  que  contenga  pbmo  o  est^n  agrietados,  para  tapar  los  recipientes  o  como  inter- 
mediaries para  cerrarioe. 

Para  ei  cierre  de  botellas  se  permite  el  uso  de  tapas  de  loza,  porcelana  y  vidiio  y  de 
placas  de  papel  especialmoite  preparadas  y  que  deberim  usarse  una  sola  ves. 

Abt.  21.  Los  recipientes  de  que  se  trata  en  el  articulo  19  y  las  t»puB  deben  hallane 
iempre  en  buen  estedo  de  conservaci6n,  es  decur,  en  condiciones  que  permitan  sua 
sidl  limpieza  y  desinfeccidn. 

Se  prohibe  ezinresamente  el  uso  de  los  que  tengan  su  superficie  interna  oxidada,  asf 
toomo  de  los  que  por  bus  abolladuras  u  otros  desperfectos  no  se  hallen  en  las  oondicione 
fusodichas. 

Abt.  22.  Las  cantillas  o  robinetes  de  los  recipientes  y,  en  general,  todas  las  que  se 
hallen  en  contacto  con  la  leche,  serin  metilicas  y  bien  cubiertas  interior  y  exterior- 
mente  por  una  capa  gruesa  de  estafio,  de  mode  que  en  ning^&n  case  pueda  formane 
caideniUo.  Interior  y  exteriormente  serin  peifectamente  lisas  y  dispuestas  de  tal 
manera  que  su  limpieaa  y  desinfeccidn  sean  ttciles. 

Abt.  ^.  Los  aparates,  miquinas,  grandes  dep6Bdtes,  etc.,  empleados  en  la  manipu- 
~~'^Kd6n  o  tratamiento  de  la  leche  deben  ser  en  todas  las  partes  que  entren  en  oontracto 
con  ella  de  material  impermeable  y  peifectamente  liso.  Se  prdbibe  expresamente 
emplear  en  esas  partes,  cobre,  sine,  lat6n,  plomo,  hienro  emplomado  o  madera. 

Abt.  24.  No  se  expedirin  pennisos  para  dedicane  en  cualquier  fonna  al  comerdo 
de  lecherfti,  sin  cerdorarse  primero  de  si  el  interesado  tiene  todos  los  elementos  indi- 
cados  en  este  capitulo,  y  que  deba  emplear,  en  las  condiciones  aqui  estableddas. 

Los  infractorea  de  loa  artfculoa  19,  20,  21  o  22  incurrixin  en  multa  de  5  a  20  peaoa, 
aegtin  la  gravedad  de  la  ftdta,  conaiderindoee  como  drcunatancia  agravante  au  repe- 
ticidn.  Ademis,  los  recipientes,  dtilea,  ti^Ms,  etc.,  mendonadoa  en  eeoa  articulos, 
aerin  marcadoa  la  primera  ves  que  ae  hallen  fuera  de  laa  condidonea  exigidaa  y 
deatruidoa  la  aegunda  ves. 

A  loa  infractorea  del  artlculoa  23  ae  lea  retirari  el  penniao  correapondiente  hasta 
tanto  ae  pongan  en  laa  condidonea  exigidaa. 

OAPItULO  m.  A8BO  DB  BBOIPIBNTBS,  tTILBS  T  OUIDADO  DB   hk  LBOHB   BN   GBNBRAL. 

Abt.  25.  Loa  redpientea,  tapaa,  miquinaa,  dtilea,  etc.,  a  que  ae  refiere  el  Capitulo 
II,  ddberin  hallane  aiempre  limpioa  por  dentro  y  fuera  y  no  uaaiae  para  tranaportar, 
goatdar  o  medir  otra  auatanda  que  la  leche,  ni,  en  general,  para  otroe  finea  que  aqueUoa 
a  que  eet&n  deatinadoa. 

Se  pn^be  eapedalmente  beber.  en  laa  medidaa  o  redpientea,  bajo  pena  de  dies 
peaoa  de  multa. 


188       PROOEEDINQS  8E00ND  PAN  AMEBIOAK  SCIBNTIFIO  C0KGBE8S. 

8e  deja  establecido  expresamente  que  se  coofiidenhL  sudo  todo  ledfttente,  dtil, 
etc.,  de  lo8  referidoe  en  este  articulo,  que  tenga  olor  a  leche  agna  o  cualquier  okr 
extnfio,  aunque  en  61  no  se  noten  reetos  de  leche  o  de  otras  sustandas. 

Abt.  26.  La  limjaesa  de  loi  recipientes,  utensilioB,  etc.»  a  que  se  refiere  el  articulo 
25,  debe  ef ectuane  tratindoloi  primero  con  una  sduddn  calienta  y  extendida  de  aoda 
o  con  lechada  de  cal,  enjuag&ndoloe  abundantemente  despu^  con  agua  caliente,  de 
manera  que  no  quede  resto  alguno  de  soda  o  cal,  y  anojando  finahn^ite  un  chono 
de  agua  hirviendo  aobie  toda  su  superficie  interna.  En  seguida  de  limpiadoe,  se  pon- 
dr&n  boca  abajo  ep.  un  sost^n  deetinado  a  ese  efecto  (escunidor)  y  en  un  lugar  libre  de 
moscas,  de  polvo  y  de  toda  otra  causa  de  sudedad  o  contaminacidn.  No  deben 
colocarae  boca  abajo  sobre  el  suelo.  Teniendo  vapor  de  agua  a  disposicidn,  en  lugar 
de  efectuar  la  estenlisacidn  con  agua  hirviendo,  puede  hacerae  con  un  chono  de  vapor . 
Lo  mismo,  si  se  dispone  de  cualquier  otro  medio  de  esterilizacidn,  6rte  puede  ser 
aplicado  en  lugar  del  agua  hirviendo. 

Art.  27.  Toda  penona  que  se  dedique  al  comerdo  de  ledieria,  que  redba  de  otra 
un  redpiente  con  leche,  esti  obligada  a  devolvteelo  limpio,  bajo  pena  de  dnoo  pesos 
de  multa.  Exlmese  de  esta  obligaddn  a  los  que  reparten  leche  a  domidlio  redbida 
de  comerciantes  o  empresas  con  establedmientoe  donde  pueda  hacerse  la  limpieaa 
instalados  en  la  capital  y  siempre  que  la  redban  en  los  mismos  envases  que  han  de 
servir  paia  el  reparte,  no  la  sometan  despu^  a  trasvasami^itoe  de  ninp^nit  eepede  y 
dsfvuelvan  a  los  mismos  los  tanos  vacfos  en  seguida  de  terminado  el  reparto.  De 
acnerdo  con  lo  que  antecede,  en  las  estaciones  fenoviarias  no  deberi  pcesentane  a 
embarque  ningdn  envase  que  no  est^  limpio,  ni  deben  transportarse  dentro  del 
munidpio  otros  envases  vacios  y  sin  limpiar  m^  que  los  que  se  vayan  vadando  o  se 
ha3ran  vadado  en  el  reparto  a  dcmiidlio. 

No  se  pennitir&  la  salida  de  la  Capital  de  ningtin  redpiente  sudo. 

Abt.  28.  Los  redpientes  que  contengan  leche  deber&n  estar  siempre  perfectamente 
cerrados  con  su  tapa  correspondiente,  salvo  durante  los  mementos  en  que  se  eche  o 
extraiga  leche,  bajo  pena  de  dnco  pesos  de  multa. 

Abt.  29.  No  se  permite  tiasvasar  la  leche  de  un  redpiente  a  otro,  ni  someteria  a 
manipulaciones  de  ninguna  espede,  en  la  via  pdblica,  en  las  estaciones  ferroviarias, 
en  comdones,  ni,  en  general,  al  aire  libre.  Estas  operaciones  deben  efectuarse  en  un 
local  espedalmente  destinado  a  ese  efecto.  Se  exceptdan  los  cases  en  que,  per  rotura 
del  redpiente,  sea  necesario  echar  su  contenido  a  otro,  a  fin  de  evitar  la  p^rdida  de 
la  leche. 

Los  iniractoree  de  este  articulo  incurrirdn  en  multa  de  diez  pesos. 

Art.  30.  Se  prohibe  soplar  con  la  boca  la  superficie  de  la  ledie  para  apartar  la  crema 
0  cualquier  cosa,  o  hacer  tal  operad6n  con  los  dedos. 

Abt.  31.  Los  redpientes  que  contengan  leche,  aunque  estdn  cerrados,  no  deben 
dejarse  expuestos  en  las  veredas  u  otros  lugares  de  la  via  ptiblica,  ni  al  polvo  o  a  las 
moscas,  ni  al  sol,  ni  a  cualquier  causa  de  nidedad  o  contaminacidn. 

Abt.  32.  De  los  tanques  o  depdsitos  provistos  de  canilla  la  leche  deberd  extraerse 
por  esta  dltima,  y  nunca  por  la  boca  o  abertura  superior. 

Abt.  33.  Al  lado  de  todo  tanque  con  canilla  debe  haber  un  soporte  especial  para 
colocar  el  redpiente  del  comprador  mientras  se  echa  en  dl  la  leche  que  se  va  midiendo. 

Abt.  34.  Con  la  ledie  no  deberd  guardarse  mis  que  manteca,  crema  y  otros  pre- 
jMurados  o  derivados  de  la  leche  incapaces  de  comunicarle  bus  olores. 

Art.  35.  Los  infractores  de  los  artfculos  28,  29,  30,  31  o  32  incunir&n  en  multa  de 
100  pesos. 

Art.  36.  Paia  mantener  fresca  la  leche  podrin  emplearse  cimaras  frigorfficas, 
aparatos  refiigeradores,  heladeras  o  cubas  con  hielo,  que  deberdn  ser  de  limpieza  y 
desinfecddn  Mdles  y  hallarse  siempre  en  buenad  condidones  de  conservaddn  y  de 
aseo. 


PUBLIO  HEALTH  AND  MEDICINE.  189 

Las  heladeras  y  cubas  deber&n  tener  revettimiento  met&lico  interior  inoxidable  y 
estar  bamizadas  o  pintadas  con  pintura  impermeable  y  blanca  o  de  color  claro. 

No  se  otoigar&n  los  permisoe  correspondientes,  a  quienee  no  tengan  eetoB  elementos 
de  refrigeraci6n  en  la  medida  neoesaria  para  la  cantidad  de  leche  con  que  operen  o 
comercien  y  en  las  condiciones  aqui  establecidas.  A  loe  que  infrinjan  el  preeente 
artfculo  se  les  aplicari  10  pesos  de  multa  y  no  se  les  permitir4  la  venta  de  leche  hasta 
que  se  coloquen  en  las  condiciones  exigidas. 

Art.  37.  En  todo  local  donde  se  limpien  redpientes  deberd  haber  un  servicio  de 
agua  caliente,  capaz,  por  lo  menos,  de  producir  en  una  sola  sesidn  o  en  un  chorro  con- 
tinue una  cantidad  de  agua  hirviente  igual  a  la  mitad  de  la  cantidad  de  lecbe  con  que 
se  opere  o  comercie.  Esta  proporci6n  no  regiri  para  las  f&bricas  o  usinas,  que  deber&n 
tener  instalaciones  especiales  para  la  limpieza  de  los  recipientes,  aprobados  por  la 
administraci6n  sanitaria. 

La  Mta  de  cumplimiento  de  este  artfculo  dar&  lugar  a  las  medidas  y  penas  indi- 
cadas  en  el  artfculo  36. 

Abt.  38.  Toda  el  agua  usada  en  los  establecimientos  de  lecherfa  deberi  ser  potable. 

Esta  disposicidn  comprende  atin  a  los  establecimientos  productores  o  remitentes  de 
leche  de  fuera  del  municipio,  a  quienes  no  se  les  permitird  introducir  sus  productos, 
so  pena  de  comisdrselos  a  su  lle^EKla,  mientras  la  administraci6n  sanitaria  no  se  cer- 
dore  en  lo  poeible  de  la  calidad  de  las  aguas  que  emplean. 

Abt.  39.  Los  redpientes  en  que  se  introduce  la  leche  al  municipio  deben  venir 
cenados  bajo  sello,  que  para  los  envases  met^icos  serd  de  plomo,  de  mode  que  no 
puedan  ser  abiertoe  sin  que  ello  se  note,  deede  el  memento  en  que  el  remitente  los 
entrega  a  quien  haya  de  transportarlos  hasta  aquel  en  que  loe  recibe  el  consignatario. 

La  leche  que  llegue  en  redpientes  no  sdlados  o  cuyo  sello  haya  side  violado  caerd 
encomiso. 

Abt.  40.  En  las  usinas  o  f&bricas  de  lecherfa,  las  leches  de  distintas  calidades 
deber&n  ser  tratadas  aparte,  en  locales  o  Becci6nes  especiales  y  separadas  para  cada 
una,  provistos  de  su  maquinaria  y  equipo  correspondientes  completes.  Lo  mismo 
para  la  fabricaci6n  de  manteca,  deberd  haber  en  ellas  un  local  o  Becci6n  especial  y 
aparte,  donde  se  har&n  todas  las  operaciones,  comprendido  el  descremado  de  la  leche 
y  el  depute  de  la  leche  destinada  a  descremaree. 

Los  infractoree  del  presente  artfculo  incurrir&n  en  multa  de  100  a  500  pesos,  segtin 
la  gravedad  de  la  fedta.    Si  loe  establecimientos  en  que  3  se  infrinja  se  hallan  fuera 
de  la  Capital,  no  se  les  permitird  la  introducd6n  de  leche  al  munidpio,  so  pena  de 
decomistoela,  por  uno  a  veinte  dfas,  segtin  la  gravedad  de  la  falta,  a  no  ser  que  pre 
fieran  abonar  la  multa  que  les  corresponderfa  si  se  hallaran  dentro  de  ella. 

Al  establecimiento  que  no  tenga  el  local  o  8ecd6n  especial  y  aparte  para  tratar  una 
determinada  calidad  de  leche,  no  se  le  permitird  vender  o  introducir  leche  de  esa 
calidad.  Al  que  fabrique  manteca  y  no  tenga  un  local  o  secd6n  especial  y  aparte 
para  ello,  no  se  le  permitird  la  introducci6n  o  venta  de  ninguna  clase  de  leche. 

OAPfrULO  IV.   CONDiaONES  ESPECIALES  DE  ENVA8E  T  ROTULADO  DE  LA  LECHE  SEOl^N 

8U  CALIDAD. 

Art.  41.  La  leche  de  primera  calidad  certificada  serd  entregada  al  consumidor  en 
botellas  Ilenadas,  cerradas  y  selladas  en  el  lugar  de  pioduccl6n  y  provistas  de  dlpsula 
que  proteja  la  tapa  y  la  boca  de  la  botella. 

Previa  solidtud  del  interesado,  la  administraci6n  sanitaria  podr&  permitir  el  use 
de  recipientes  meUUicoe,  cuando  se  trate  de  remitlr  a  un  mismo  consumidor  una  canti- 
dad de  leche  mayor  de  veinte  litroe  cada  vez. 

Botellas  y  redpientes  metdlicos  serin  entregados  con  el  derre  intacto  al  consumi- 
dor, es  decir,  con  su  sello  entero. 


140       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC   CONGRESS. 

Lo6  iDfractoree  de  eete  artfculo  incurriiin  en  multa  de  cincuenta  peeoe.  La  leche 
de  las  botelias  o  recipientes  metilicofl  que  se  hallen  con  el  sello  roto  antes  de  entre- 
garias  al  consumidor  caerd  en  comiso. 

Art.  42.  Los  recipientes  de  que  se  trata  en  el  artfculo  anterior  deber6n  Uevar 

impresa  en  las  c&psulas  o  en  etiquetas  pegadas  a  los  mismoe,  en  letras  negras  y  Mdl- 

mente  legibles,  la  slgulente  leyenda,  en  que  constari  el  dk  y  la  hora  en  que  ha  sido 

<ndefiada  la  leche: 

Leche  de  primera  calidad  certificada. 
Vigilada  deede  su  proaucdto  j>ar  la  AdministiaciiSn  Sanitaria. 

Especial  para  niiios  y  enfermos. 

Puede  consumirse  cruda. 
Ordefiada  el  dfa a  las  ... . 

Las  cipsulas  y  las  etiquetas  deberdn  ser  blancas. 

Art.  43.  Los  recipientes  en  que  se  introduzca  la  leche  de  primera  calidad  al  muni- 

cipio  deber&n  venir  provistos  de  una  etiqueta  atada  o  pegada,  respectivamente, 

8eg6n  sean  envases  met&licos  o  de  vidrio,  de  ocho  por  cuatro  centfmetros  de  dimen- 

8i6n  por  lo  menoe  y  de  color  bianco,  en  que  consten  en  letras  de  molde,  de  color  rojo 

y  bien  legibles,  la  calidad  de  la  leche,  el  ntimero  de  litres  que  contiene  el  recipiente, 

el  dla  y  hora  de  embarque  con  destine  a  la  capital,  el  nombre  y  apellido  de  su  pro- 

ductor,  el  de  la  estaci6n  fenroviaria  de  donde  la  leche  es  expedida,  el  nombre  del 

destinatario  y  la  direcci6n  de  su  establecimiento  en  Buenos  Aires,  en  la  siguiente 

forma: 

Leche  de  primera  calidad". 

Litros  

Embarcada  en ,  el  dfa a  las 

Productor 

Destinatario Calle ,  No.. . 

Cuando  el  remitente  sea  alguna  empresa  o  establecimiento  que  recoja  la  leche  de 
distintos  productores  para  enviarla  a  Buenos  Aires,  serd  su  nombre  el  que  deberi 
figurar  en  la  etiqueta,  en  lugar  del  del  tambero  o  productor,  precedido  de  la  palabra 
"Remitente." 

Cuando  la  leche  sea  pasteuriiada  o  esteiilizada,  deberi  constar  6sto  en  la  etiqueta, 
poniendo  en  su  primer  rengl6n,  respectivamente:  "Leche  de  primera  calidad  pas- 
teurizada"  o  "Leche  de  primera  calidad  esteiilizada." 

Art.  44.  Cuando  la  leche  de  primera  calidad  se  introduzca  al  municipio  para  ser 
pasteurizada,  la  etiqueta  de  que  se  trata  en  el  artfculo  43  ser&  amarilla  y  la  leyenda 
de  la  misma  estar&  impresa  en  letras  negras.  En  ^sta  deberi  constar  el  destino 
inmediato  de  la  leche,  poniendo  en  su  primer  rengl6n:  "Leche  de  primera  calidad 
paia  pasteurizar." 

Art.  45.  En  el  reparto  a  domicilio,  la  leche  de  primera  calidad  deber&  ser  trans- 
portada  y  entregada  al  consumidor  en  recipientes  met^cos  o  de  vidrio  cerrados  y 
sellados  en  el  lugar  donde  hayan  sido  Uenados. 

Los  envases  serdn  entregadoe  al  consimiidor  con  su  sello  intacto,  bajo  pena  de- 
veinticinco  pesos  de  multa. 

Art.  46.  Los  recipientes  de  que  se  trata  en  el  artfculo  precedente  deber&n  eetar 

provistos  de  etiqueta  blanca,  pegada  al  envase  en  lugar  visible,  con  la  siguiente 

leyenda,  en  letras  de  molde,  rojas  y  ficilmente  legibles,  donde  conste  el  nombre  del 

vendedor  y  la  direcddn  de  su  establecimiento,  o,  si  no  tiene  establecimiento,  su 

domicilio: 

I.>eche  de  primera  calidad. 
Ia»  nillos  y  enfermos  deben  consimiirla  hervida. 
(Aquf  ei  nombre  y  apellido  del  vendedor.) 
(Aquf  la  dlrecci6n  de  su  establecimiento,  o,  a  defecto  de  ^ste,  de  su  domicilio.) 


PUBUC   HEALTH  AND  MEDICINE.  141 

Cuando  la  leche  sea  pasteurizada,  deberd  cooBtar  dsto  en  la  etiqueta  y  adem&B  el 
nombre  de  la  Mbrica  o  iiaina  donde  haya  aido  pasteurizada  y  el  d(a  y  la  hora  en  que 
e  efectu6  la  operaci6n,  resultando  asi  la  leyenda  de  la  etiqueta  en  la  siguiente  tonna: 

Leche  de  primera  calidad  pasteuiuada. 
Lo6  nifios  y  enlennoB  deben  consumirla  hervida. 

Pasteurizada  pw  o  en el  d(a a  las  — 

(Aqui  el  nombre  y  apellido  del  vendedor.) 
(Aqu(  la  direcci6n  ae  su  establecimiento,  o,  a  defecto  de  6ete,  de  su  domicilio.) 

Los  dot  primeros  lenglones  de  la  leyenda  (dcmde  se  indica  la  calidad  de  la  leche 
y  la  manera  c6mo  debe  ser,  consumida),  tanto  para  la  leche  cruda  como  pasteurizada, 
0er6n  en  letras  de  doble  tamafto  que  el  resto  de  la  misma. 

Art.  47.  Previa  solidtud  en  cada  case  del  interesado,  la  Administraci6n  Sanitaria 
podrd  permitir  el  uso  de  tanques  con  canilla  para  el  transporte  de  la  leche  de  primera 
calidad  en  el  reparto  a  domicilio,  siempre  que  el  interesado  y  eeos  tanques  satisCagan 
todas  las  condiciones  establecidas  en  el  articulo  82  y  que  ademis  los  tanques  sean 
sellados  en  el  lugar  donde  se  llenen  y  esten  dispuestoe  de  tal  modo  que  la  leche  pase 
del  tanque  al  recipiente  del  consumidor  sin  ponerse  en  contacto  con  al  aire. 

En  tal  caBO,  los  tanques  llevar&n  en  la  forma  indicada  en  el  articulo  51  un  letrero 
indicador  de  la  calidad  de  la  leche  y  de  la  manera  c6mo  debe  ser  consumida. 

Si  se  trata  de  leche  pasteurizada  en  la  Capital,  los  tanques  deber^  ser  Uenados 
en  el  lugar  de  pasteuiizad^n. 

AsT.  48.  Los  recipientes  en  que  se  introduzca  la  leche  de  segunda  calidad  al  mu- 
nicipio  deber6n  venir  provistos  de  una  etiqueta  atada  al  envase,  de  echo  por  cuatro 
centimetres  de  dimensi6n  por  lo  menos,  de  color  verde,  y  en  que  consten,  en  letraa 
de  color  negro  y  bien  legibles,  los  dates  especificados  en  el  articulo  43  y  en  la  forma  de 
leyenda  allf  indicada. 

Si  se  trata  de  leche  esterilizada,  la  etiqueta  vendrd  pegada  a  las  botellas,  en  lugar 
visible,  y  seri  blanca,  con  la  escritura  en  verde. 

Abt.  49.  Cuando  la  leche  de  primera  calidad  se  introduzca  al  munidpio  para  ser 
pasteurizada,  la  etiqueta  de  que  se  trata  en  el  primer  pteafo  del  articulo  precedente 
ser4  amarilla  y  la  leyenda  de  la  misma  estari  impresa  en  letras  negras.  En  ^ta 
deberd  constar  el  destine  inmediato  de  la  leche,  poniendo  en  su  primer  rengl6n; 
"Leche  de  segunda  calidad  para  pasteurizar." 

Art.  50.  Paia  el  reparto  a  domicilio  de  la  leche  de  segunda  calidad,  la  leche  ser& 
transportada  en  tanques  con  canilla  o  robinete,  de  la  capacidad  que  se  quiera,  o  en 
redpientes  o  tazros  de  echo  litros  de  capacidad  como  mJTimum. 

Los  que  deseen  entregar  envasada  esta  leche  al  consumidor,  deberdn  usar  botellas 
e  envasee  metdlicos  cerrados  y  sellados  en  el  lugar  donde  hayan  side  llenados.  En 
tal  case,  los  redpientes  ser6n  entregados  al  consumidor  con  su  sello  intacto,  bajo 
pena  de  dnco  pesos  de  multa. 

Art.  51.  Los  redpientes  de  que  se  trata  en  el  primer  pteafo  del  artfculo  precedente 

deber&n  llevar  pintado,  estampado,  grabado  o  soldado  sobre  el  costado,  en  letras  de 

molde  de  tree  centfmetros  de  altura  y  medio  centimetre  de  grueso  por  lo  menos,  el 

siguiente  letreio: 

Segunda  calidad. 
Consdmase  hervida. 

Si  se  trata  de  leche  pasteurizada,  el  letrero  serd  asf : 

Segunda  calidad  pasteurizada. 
Consdmase  hervida. 

Estos  letreros  ser&n  de  color  que  resalte  sobre  el  del  redpiente,  y  por  su  forma  y  lugar 
deberdn  ser  bien  visibles  y  legibles.  En  los  tanques  o  redpientes  con  canilla  deberin 
hallaree  de  5  a  10  centfmetros  sobre  la  canilla. 


142       PROCEEDINGS  SECOND  PAN  AMBBICAN  SCIENTIFIC  CONGRESS. 

Abt.  52.  Loe  recipientes  de  que  se  trata  en  el  segundo  pimio  del  artfculo  50  de- 

ber&n  eetar  provistos  de  etiqueta  blanca,  pegada  en  lugar  visible^  con  la  fliguiente 

leyenda,  en  letras  de  molde,  verdes  y  I4cilmente  legibles,  donde  oonste  el  nombre 

del  vendedor  y  la  direcci6n  de  su  establedmiento,  o,  si  no  tiene  establedmiento,  su 

domidlio: 

Leche  de  eegunda  calidad. 

Consdmase  hervida. 

(Aquf  el  nombre  y  apellido  del  vendedor). 

(Aquf  la  direcci6n  de  su  eetablecimiento  o,  a  defecto  de  ^te,  de  su  domicilio.) 

Si  se  trata  de  ledie  pasteumada,  la  leyenda  seri  modificada  de  acuerdo  con  lo 
dicho  en  el  artfculo  46. 

Los  doe  primeros  renglones  de  la  leyenda  (donde  se  indica  la  calidad  de  la  leche  y 
la  manera  cdmo  debe  ser  consumida),  tanto  para  la  leche  creuda  conK>  pasteumada, 
ser&n  en  letras  de  doble  tamafio  que  el  resto  de  la  misma. 

Abt.  53.  La  leche  pasteunzada  no  debe  ser  guardada,  depositada,  <rfrecida  en  venta, 
ni  vendida  o  entregada  al  consumidor  en  recipientes  cerradoe  y  sellados,  a  menos 
que  haya  side  envasada  en  esa  forma  en  el  lugar  donde  ha  side  pasteuiizada. 

Art.  54.  La  administracidn  sanitaria,  cuando  lo  estime  necesario  para  el  mejor 
cumplimiento  de  esta  ordenanza,  y  preyiniendo  a  los  int^resados  con  cuatro  meses  de 
anticipaci6n,  podri  exigir  que  los  recipientes  met^icoe  Ueven,  adem^  de  loe  dia- 
tintivoe  aquf  estableddos,  una  raya  de  color  que  est^  de  acuerdo  con  esos  distintivos. 
Tambi^n  podrd  exigir,  previniendo  a  loe  interesadoe  con  cuatro  meses  de  anticipaci6n, 
que  loe  envases  de  otras  leches  o  derivados,  no  mencionadas  en  este  capftulo,  Ueven 
etiquetas  o  letreros  en  la  forma  que  mis  convenga  al  mejor  cumplimiento  de  la  preeente 
ordenanza. 

Abt.  55.  Las  etiquetas  atadas  de  que  deben  venir  provistos  los  envases  en  que  ae 
introduce  la  leche  a  la  capital  deber^  ser  guardadas  por  lo  menos  dunmte  dos  meses 
por  los  comerciantes  que  abran  los  recipientes  y  teneree  siempre  anegladas  en  orden 
cronol6gico.  Arregladas  en  eeta  forma  ser&n  pueetas  a  di8posici6n  de  loe  inspectores 
de  la  Admin]straci6n  Sanitaria,  toda  vez  que  ^stos  lo  soliciten. 

Abt.  56.  Todo  el  que  venda  leche  dentro  del  munidpio  deberd  llevar  un  libro 
foliado,  sellado  por  la  administraci6n  sanitaria  y  convenientemente  dispuesto,  en 
que  anotari  diariamente,  en  orden  cronol<5gico  y  sin  dejar  renglones  en  bianco,  en 
seguida  de  recibir  cada  partida  de  leche,  los  siguientes  dates  relatives  a  la  misma: 
fecha  y  hora  en  que  recibe  la  leche,  ntimero  de  litros  redbidos  y  ndmero  de  tarros  y 
botellas  en  que  la  recibe,  calidad  de  la  leche  (si  es  de  primera  calidad  certificada,  de 
primera  calidad  ode  segunda  segtin  las  disposiciones  de  la  presente  ordenansa,  y  si 
es  cruda,  pasteurizada,  etc.),  nombre  del  tambero,  productor  o  empresa  de  quien  la 
redbe,  estad6n  ferroviaria  donde  la  leche  es  embarcada  para  remitirla  a  Buenos  Aires 
y  ubicad6n  del  tambo  o  establedmiento  de  donde  se  le  remite  o  adonde  va  a  buscarla, 
si  la  compra  en  eeta  Capital. 

Este  libro  se  hallari  siempre  en  el  establedmiento  del  vendedor,  o,  si  ^ete  no  tiene 
eetablecimiento,  deberi  Uevarlo  en  el  carro. 

Art.  57.  Todo  el  que  dentro  del  munidpio  venda  leche  al  por  mayor  o  para  revender, 
deberd  llevar  un  libro  foliado,  sellado  por  la  administracidn  sanitaria  y  conveniente- 
mente dispuesto,  en  que  anotari,  en  orden  cronol6gico  y  sin  dejar  renglones  en  bianco, 
en  seguida  de  entregar  cada  partida  de  leche,  los  siguientes  datos  relatives  a  la  misma: 
fecha  y  hora  de  la  entrega,  ntimero  de  litros  de  leche  y  de  tarros  y  botellas  en  que  la 
entrega,  calidad  de  la  leche  (en  la  forma  indicada  en  el  artfculo  precedente),  nombre 
del  comprador  y  direcd6n  de  su  establedmiento,  o  de  su  domicilio,  si  no  tiene  estable 
dmiento. 

Este  libro  deberd  hallarse  siempre  en  el  establedmiento  del  que  vende  leche  al 
por  mayor  o  para  revender. 

Las  anotaciones  especificadas  en  este  artfculo  podr&n  Uevarse  con  las  de  que  se 
trata  en  el  artfculo  precedente  en  un  mismo  libro  convenientemente  dispuesto. 


PUBLIC   HEALTH  AND  MEDICINE.  143 

Art.  58.  Todo  tambero  o  productor  que  remita  a  la  Capital  leche  de  primera  cali- 
dad  cerdficada  o  leche  de  primera  calidad  y  toda  firma  o  empresa  que  remita  leche 
de  cualquier  dase  procedente  de  mis  de  un  productor,  o  pasteurizada  o  sometida  a 
otras  operacionee  despu^  de  redbida  del  productor,  deberd  Uevar  uu  libro  en  la 
fonna  indicada  en  loe  artfculos  56  y  57,  en  que  anotard,  en  la  forma  all!  tambidn  indi- 
cada,  cada  partida  de  leche  enviada  a  la  Capital  y  loe  siguientee  datoe  relativoe  a  la 
misma:  lecha  y  hora  en  que  remite  la  leche  a  la  estacidn  de  embarque,  ntimero  de 
litroe  remitidoe  y  n^ero  de  tarros  y  botellas  en  que  la  remite,  calidad  de  la  leche, 
nombre  de  la  persona,  firma  o  empresa  a  quien  la  remite  y  direcd6n  de  su  estableci- 
miento.  Cuando  remita  leche  a  varies  consignatarios,  la  leche  enviada  a  cada  uno 
se  considerard  como  una  partida  distinta  a  loe  efectos  de  las  anotaciones. 

Abt.  59.  La  leche  que  llegue  a  la  Capital  fuera  de  las  condidones  estableddas  en 
los  artlculos  43,  44,  48,  o  49  caerd  en  comiso. 

Los  infractoree  de  los  articulos  42  o  45  incurrirdn  en  multa  de  25  pesos  y  comiso  de 
U  leche;  los  del  artfculo  46,  en  15  pesos  de  multa  y  comiso  de  la  leche;  los  del  articulo 
50,  en  10  pesos  de  multa  y  comiso  de  la  leche;  y  los  de  los  artlculos  56  o  57,  en  50 
pesos  de  multa. 

Los  infractoree  de  los  artlculos  51  o  52  incurrirdn  en  cincuenta  pesos  de  multa  la 
primera  vez,  cien  pesos  la  segunda  y  en  el  retire  definitivo  del  permiso  para  intervenir 
en  cualquier  forma  en  el  comercio  de  lecheria  la  tercera.  La  leche  ser&  comisada  en 
todoe  loe  cases. 

A  los  infractores  del  articulo  53  se  lee  comisard  la  leche  y  se  les  apUcari  una  multa 
de  cincuenta  pesos,  si  se  trata  de  leche  de  primera  calidad,  y  de  25  pesos,  si  de  segunda 
calidad. 

A  los  del  articulo  55  se  les  comisard  la  leche  y  se  les  aplicari  una  multa  de  veinti- 
dnco  pesos  la  primera  vez,  50  la  segunda  y  100  pesos  la  tercera  y  las  sucesivas. 

A  loe  del  articulo  58  no  se  les  permitir&  la  introducci6n  de  leche  al  municipio  du- 
rante 5  a  15  dlas,  eeg&D.  la  gravedad  de  la  falta,  para  juzgar  la  cual  se  tendri  en  cuenta 
tambi^n  la  calidad  de  la  leche.  £1  interesado  podrd  cambiar  eea  pena  por  el  pago 
de  una  multa  de  50  a  150  pesos,  segdn  la  gravedad  de  la  falta. 

Art.  60.  La  administrad6n  sanitaria  no  otorgari  loe  x>emiiso8  correspondientes,  sin 
eomprobar  piimero  si  el  interesado  dispone  de  los  dementos  necesarios  para  dar  cum- 
plimiento  a  lo  estableddo  en  el  presente  capltulo,  en  las  partes  que  le  atafien. 

CApfrULO    V.      LOCAL   DE    MANIPULACIONE8,   DBPdSITO  T  PREPARACKSn  DE  LA  LECHE 

PARA  LA  VENTA. 

Art.  61.  Toda  persona,  firma  o  empresa  que  se  dedique  al  comercio  de  lecheria 
dentro  del  munidpio,  o  sea,  que  compre  o  que  venda  leche  para  comerdar,  estd  obli- 
gada  a  tener  un  local  especial  para  depositar  en  d  la  leche  y  para  efectuar  en  d  las 
manipulaciones  y  preparaci6n  de  la  leche  para  la  venta,  entendi^ndose  por  depositar 
a(in  el  simple  hecho  de  guardarla  por  cualquier  tiempo  y  por  manipulad6n  o  prepara-. 
d6n,  adn  el  simple  trasvasamiento  de  la  leche  de  un  recipiente  a  otro  o  la  simple 
operad6n  de  limpiar  un  tarro,  recipiente  o  (itil  de  cualquier  clase,  empleado  en  el 
comercio  de  lecheria. 

Cuando  esta  otdenanza  se  refiere  al  establecimiento  de  un  comerciante  de  lecheria 
dentro  de  la  Capital,  debe  entenderse  que  habla  del  local  de  que  se  trata  en  el  pre- 
sente articulo,  si  el  comerdante  no  tiene  otro  establecimiento.  Asimismo,  en  el 
cunBo  de  esta  ordenanza,  y  tratdndose  de  lo  que  est^  dentro  del  municipio,  se  llamanl 
aimplemente  local  de  manipulaciones  al  local  de  que  se  trata  en  el  presente  articulo. 

Art.  62.  £1  local  de  manipulaciones  no  podrd  estar  en  casas  de  inquilinato,  ni 
en  casas  antihigi^nicas. 

A  quince  metros  de  d  no  deberd  haber  caballerizas,  gallineros,  ni  ningunain8talaci<5n 
semejante  o  capaz  de  producir  males  olores,  de  atraer  las  moscas  en  gran  ntimero  o 
de  cargar  la  atm<3efera  de  polvos  que  puedan  llegar  hasta  el  local. 


144       PBOCEEDINQS  SECOND  PAN  AMEBICAN   SCIENTIFIO  CONOBESS. 

£1  espacio  libre  que  lo  rodea  etrtari  cubierto  de  piso  861ido,  de  material  impermeable 
y  Buperficie  lisa,  por  lo  meno6  en  un  ancho  de  tree  metroe. 

Art.  63.  £1  local  de  manipulaciones  congtaii  de  doe  piesaa  de  material  (obra  de 
fdbrica),  secas,  con  abundante  luz  natural,  bien  ventiladas,  freecas,  ain  maloB 
olores,  suficientemente  amplias  como  para  que  las  operadonee  a  que  eet6n  destinadas 
puedan  hacerse  c6modamente  en  buenas  condiciones  y  sin  amontonamiento  de  coBas, 
dispuestas  de  tal  modo  que  su  limpieza  y  desinfecci6n  sean  ttciles  y  que  la  leche  se 
exponga  lo  menos  posible  a  contaminaciones  y  mantenidas  siempre  en  buen  estado 
de  conservaci6n  y  aseo.  £n  cuanto  a  la  constnicci6n,  disposicidn,  utilaje  y  man- 
tenimiento  de  las  doe  piezas  que  constituyen  el  local  de  manipulaciones,  debeiin 
llenaise  por  lo  menos  las  siguientes  condiciones: 

1*^.  Tendrin  piso  sdlido,  impermeable  y  liso,  de  cemento,  baldosa,  mosaico  o  ma- 
terial an^ogOy  con  las  junturas  bien  tomadas  con  cemento,  y  provisto  de  desagtle 
dispuesto  de  manera  que  no  se  desprendan  emanadones  en  el  interior  del  recinto. 

2^ .  Las  paredes  estar^  re vestidas  hasta  dos  metros  de  altura  por  lo  menos,  de  baldosas 
esmaltadas  o  piedras  andlogas,  de  color  bianco,  con  las  junturas  bien  tomadas  con 
cemento  impermeable. 

3^.  £1  resto  de  las  paredes  serd  de  superficie  lisa  y  pintado  con  pintura  blanca  e 
impermeable. 

4**.  £1  cielo  raso  serd  s61ido  (no  de  papel),  liso  y  pintado  de  bianco. 

5^.  Los  dngulos  formados  por  las  paredes  entre  si  y  con  el  piso  serin  redondeados. 

6^.  Cada  pieza  tendri  por  lo  menos  una  ventana  o  una  puerta,  suficientemente  am- 
plias, abiertas  sobre  la  calle  o  un  patio  abierto  o  sobre  un  zaguin  que  d^  a  la  calle  o 
a  un  patio  abierto,  a  no  ser  que  tengan  claraboyas  que  aseguren  la  entrada  de  la  luz 
y  la  ventilaci6n  necesarias. 

7°,  Sus  aberturas  exteriores  estardn  provistas  de  tela  metdlica,  que  impida  la  en 
trada  de  las  moscas. 

8^.  Se  comunicardn  directa  e  inmediatamente  entre  si,  por  una  puerta  que  se 
cierrc  automiticamente  y  que  se  abriri  s61o  para  pasar. 

9**.  Las  piezas  no  estar&n  en  comunicaci6n  directa  con  letrinas. 

10^.  Si  se  comunican  directamente  con  alguna  habitacidn,  sea  ^ta  dormitorio  o 
no,  las  puertas  de  comunicaci6n  estardn  provistas  de  algdn  mecanismo  de  cierre 
automitico  y  s61o  se  abririn  para  el  paso  de  las  personas. 

11^.  No  serdn  usadas  como  dormitories,  ni  para  habitaci6n  de  enfermos,  ni  para 
ningdn  fin  dom^stico. 

12^.  Habrd  en  cada  pieza  una  escupidera  con  agua. 

13**.  Las  tapas  de  las  mesas  que  sea  necesario  tener  en  ellas  serin  de  material  sdlido, 
liso,  impermeable  e  inoxidable.  £1  resto  de  las  instalaciones,  apai)atos  y  muebles 
(mesas,  bancos,  estantes,  dispositivos  para  tener  los  recipientes,  escurridores,  etc.) 
0erin  del  mismo  material,  o,  en  su  defecto,  estarin  pintados  con  pintura  impermeable 
y  blanca. 

14^.  £1  pintado  del  local  y  de  sus  instalaciones,  muebles,  etc.,  se  renovari  en 
cuanto  se  halle  manchado  o  en  mal  estado  de  conservacidn. 

15^.  Los  recipientes  vacios  y  limpios  que  se  hallen  en  el  local  de  manipulaciones 
deberin  estar  siempre  tapados,  o,  si  estin  destapados,  colocados  boca  aba  jo  en  escu- 
rridores u  otros  dispositivos  apropiados. 

16^.  £1  local  seri  abundantemente  ventijado  todos  los  dfas,  y  ^1  y  todo  lo  que  hay  a 
dentro  de  ^1  estarin  siempre  libres  de  polvo,  telarafias,  tierra  y  reetos  o  resfduos  de 
residues  de  cualquier  especie. 

17^.  No  debe  echarse  o  extenderse  sobre  el  piso  ninguna  sustanda  pulverulenta, 
tal  como  aserrin,  arena,  etc. 

18®.  Para  la  limpieza  no  se  usari  nunca  la  eecoba  seca  ni  el  plumeio.  Debe  usarse 
el  trapo  y  el  lavado. 


PUBLIC   HEALTH  AND  MEDICINE.  145 

19®.  En  ningnna  de  las  piezas  dei  local  deben  pennanecer  nifios  ni  otras  personas  que 
no  tengan  que  hacer  en  el  manejo  de  la  leche. 

20®.  No  deben  entrar  a  ellas  animales  dom^sticoe  de  ninguna  eepe?ie. 

Abt.  64.  Una  de  las  piezas  del  local  seri  especial  y  exclusivamente  destinada  al 
depMto,  envase  y  preparaci6n  de  la  leche  para  la  venta. 

En  ella  no  se  procederd  a  la  limpieza  de  recipientes  ni  utensilioe. 

Deberd  estar  provista  de  los  elementos  necesarios  para  mantener  frla  la  leche  que  se 
guaide. 

En  ella  no  podrto  guardarse  mis  que  la  leche,  derivados  de  la  misma  incapacee  de 
comunicarle  olores  extrafios,  huevoe  frescos  y  otros  productos  de  granja  en  envases 
herm^ticamente  cerrados.  Ni  deberd  haber  en  ella  mis  que  lo  que  sea  necesario  para 
los  fines  a  que  est4  destinada,  ni  ningtin  dtil,  tarro  o  recipiente  vacfo  que  no  est^ 
limpio  y  seco. 

Art.  66.  La  otra  pieza  del  local  de  manipulaciones  seri  especial  y  exclusivamente 
destinada  a  la  limpieza  de  recipientes  y  utenailios. 

En  ella  no  se  guardard  la  leche,  ni  ninguno  de  los  productos  que  deben  y  pueden 
estar  en  la  otra,  segtin  lo  dicho  en  el  artfculo  precedente. 

f^stard  provista  de  una  pileta  para  el  lavado,  de  material  impermeable  y  liao,  de 
dimensiones  proporcionadas  a  las  necesidades,  convenientemente  dispuesta  para 
aquel  fin  y  con  servicios  de  agua  corriente,  caliente  y  frla. 

En  esta  pieza  no  deberd  haber  mis  que  los  elementos  necesarios  para  la  limpieza  y 
secado  de  los  recipientes  y  utensilios,  recipientes  y  utensilios  listos  para  limpiarse  y 
los  ya  limpios,  durante  el  tiempo  en  que  se  est^n  escurriendo. 

En  ella  habrd  guardado  siempre  un  delantal  limpio  de  repuesto  o  un  juego  de  ropa 
de  los  indicados  en  el  artfculo  66  por  cada  persona  de  las  que  intervengan  en  las  opera- 
ciones  que  se  efectden  en  el  local  de  manipulaciones. 

Abt.  66.  Las  personas  ocupadas  en  las  operaciones  que  se  efectdan  en  el  local  de 
manipulaciones  deberdn  usar  delantal  largo  o  pantalones  y  saco  o  blusa  limpios,  blan- 
cos  y  lavables. 

Art.  67.  En  el  local  de  manipulaciones,  si  61  no  estd  anexo  a  algdn  otro  estable- 
cimiento  de  lecheria  del  mismo  propietario,  donde  ya  se  tenga  el  libro  de  que  se  tiata 
en  seguida,  deberd  haber  un  libro  foliado,  sellado  por  la  Administraci6n  Sanitaria,  en 
que  los  inspectores  de  la  misma  dejardn  constancia  de  sus  inspecciones  y  de  las  obser- 
vaciones,  instrucciones,  avisos,  etc.,  que  hagan  o  den  a  su  propietario. 

En  las  tisinas  o  fdbricas  de  lecherfa  tambi^n  deberd  tenerse  el  libro  de  que  aquf  se 
trata. 

Art.  68.  Las  disposiciones  del  presente  capftulo  comprenden  tambi^n  a  las  usinas 
y  fdbricas  de  lecheria,  las  que  deberdn  darles  cumplimiento  en  cuanto  les  sean  apli- 
cables,  bajo  pena  de  cincuenta  a  cien  pesos  de  multa,  segtin  la  gravedad  de  la  falta. 

Art.  69.  Losinfractores  de  los  artfculos  61, 62,  63, 64, 65, 66  o  67,  incurrirdn  en  multa 
de  cinco  a  cincuenta  pesos,  segdn  la  gravedad  de  la  falta. 

No  se  otorgardn  por  la  Administracidn  Sanitaria  los  permisos  correspondientes,  sin 
comprobar  pnmero  si  el  interesado  dispone  de  todos  los  elementos  necesarios  para 
cumplir  lo  dispuesto  en  este  capftulo. 

CAPfrULO  VI.   VBNTA    DE  LECHE   EN  PUE8T08  FU08 — ^LBCHBRfAS. 

Art.  70.  Consid^rase  lecheria  todo  puesto  fijo  de  \  enta  de  leche  al  detalle  al  pu- 
blico consumidor,  adonde  ^ste  va  a  buscar  la  leche  que  compra. 

Art.  71.  Dichos  establecimientos  deberdn  tener  en  el  frente  un  letrero  que  diga 
** lecheria,'*  y  este  letrero  no  podrd  ser  usado  por  establecimientos  donde  no  se  venda 
leche  en  las  condiciones  indicadas  en  el  artfculo  precedente. 

Art.  72.  Las  lecherfaa  constardn  por  lo  menos  del  local  de  que  se  trata  en  el  capftulo 
y  y  del  local  de  venta  o  despacho  al  pdblico. 


146       PROCEEDINGS  SECOND  PAN  AMERICAN  SOIENTIPIO  CONGRESS. 

Art.  73.  El  local  de  despacho  deberd  estar  al  frente,  es  decir,  dar  a  la  calle,  y  toner 
por  lo  meuos  una  puerta  a  la  misma,  que  permita  el  acceso  inmediato  y  directo  del 
pdblico  que  va  a  comprar  leche. 

Estard  en  comunicacidn  directa  con  la  pieza  donde  se  depoaite  y  prepaie  la  leche 
(la  indlcada  en  el  art.  64),  pero  no  con  la  destinada  a  la  limpieza  (la  indicada  en  el  art. 
65). 

En  cuanto  a  su  consirucci6u,  dispo8ici6n,  utensilios  y  mantenimiento,  deber^  satis- 
facer  loe  requisitoa  indicados  en  loe  artfculos  62  y  63,  salvo  las  condiclones  5*,  6»,  ?•,  8», 
15*  y  19*  de  este  dltimo  artfculo,  y  con  la  diferencia  de  que  la  pintura  podr&  no  ser 
blanca,  bastando  que  sea  de  color  claro,  y  de  que  la  chapa  del  mostrador  debeht  ser 
blanca  o  de  color  claro. 

Art.  74.  En  las  lecberfas,  la  leche  de  primera  calidad  y  la  de  segunda  calidad 
podrdn  A  enderse  sueltas  al  consumidor,  es  decir,  serle  entr^ados  en  los  reclpientes  que 
lleve  a  ese  efecto. 

Art.  75.  La  leche  en  despacho  deber^  estar  en  depdsltos  o  tanques  sin  canilla, 
provistos  de  tapa  que  recubra  la  abertura  superior,  sus  hordes  y  el  cuello  del  recipiente, 
y  colocados  en  aparatos  refrigeradores,  heladeras  o  cubas  con  hielo,  si  la  temperatura 
amhiente  es  superior  a  la  que  debe  tenor  la  leche  segdn  su  calidad. 

Art.  76.  Los  tanques  o  depdsltos  mencionados  en  el  artfculo  precedente  se  hallar&n 
a  la  ^  Ista  del  publico  y  de  mode  que  los  clientes  puedan  leer  los  letreros  de  que  se 
trata  en  seguida. 

Los  que  contengan  leche  de  primera  calidad  Uevar&n  el  siguiente  letrero,  en  la 
forma,  lugar  y  dem^  condiclones  indicadas  en  el  artfculo  51: 

Leche  de  primera  calidad. 
Los  nifios  y  enfermos  deben  consumirla  hervida. 

Los  que  contengan  leche  de  s^^nda  calidad  llevarin  de  igual  manera  este  letrero: 

Leche  de  segunda  calidad. 
Consdmase  hervida. 

Si  la  leche  es  pasteurizada,  el  primer  rengl6n  de  esoe  letreros  dii&  como  sigue: 
''Leche  de  primera  calidad  pasteurizada"  o  ''Leche  de  segunda  calidad  pasteurizada," 
segdn  se  trate  de  una  u  otra  calidad  de  leche. 

Si  los  recipientes  estin  guardados,  encerrados  o  cubiertos,  de  tal  modo  que  no  se 
vean  sus  letreros,  ^tos  deberdn  ir,  en  la  forma  ya  indicada,  sobre  la  pared  de  la  heladera 
Cuba,  etc.,  donde  loe  recipientes  se  hallen  colocados.  Pero  6st06  llevar&n  siempre  los 
letreros  susodichos,  aunque  est^n  guardados,  encerrados  o  cubiertos. 

Art.  77.  La  leche  deberd  extraerse  de  esos  depdsitos  o  tanques  por  su  abertura 
superior,  a  la  vista  del  cliente,  por  medio  de  una  medida  provista  de  mango  lazgo,  a 
manera  de  cuchar6n,  y  despu^  de  remover  bien  el  Ifquido  con  la  misma,  a  fin  de 
quo  todos  la  reciban  con  igual  cantidad  de  gordura. 

Art.  78.  Cada  tanque  o  depdsito  estard  provisto  de  su  medida  especial  y  6sta  deberd 
permanecer  continuamente  dentro  del  dep6sito  respective,  colocada  de  tal  modo  que 
la  parte  del  mango  por  donde  se  toma  para  usarla  no  est6  sumeigida  en  la  leche. 

Art.  79.  El  dep6sito  y  su  correspondiente  medida  serdn  limpiados  por  lo  menos 
cada  veinticuatro  horas  y  ademds  toda  vez  que  se  vaya  a  echar  en  el  primero  leche  de 
otra  partida  (art.  15). 

Art.  80.  Al  lado  de  cada  tanque  o  dep6sito  habrd  un  soporte  o  una  percha  para 
poner  o  colgar  en  ^1  la  tapa  del  mismo  durante  las  operaciones  de  echar  o  extraer 
leche.    La  tapa  se  colocard  en  ellos  boca  abajo  siempre. 

Art.  81.  Los  depdsitos  deetinados  a  la  leche  de  primera  calidad  no  serdn  nunca 
usados  con  la  leche  de  segunda  calidad,  ni  los  destinados  a  esta  tUtima  con  la  de  pri- 
mera calidad. 


PUBLIC  HEALTH  AND  MEDIOIKE.  147 

Abt.  82.  La  Admini8traci6ii  Sanitaria  podr6  permitir  que  la  leche  en  despacho 
se  tenga  en  recipientes  con  canilla,  dempre  que  el  intereeado  disponga  de  loe  elementoa 
de  limpieza  y  esteiilizaci6n  necesarios  para  mantenerloe  en  perfectas  condiciones  de 
hjgiene  y  que  a  la  vez  eeos  recipientes  satifl&gan  Iob  requisitos  ya  eetablecidoe  en  esta 
ordenanza  y  adem^  loe  siguientes: 

1^.  La  canilla  deberi  eer  de  constituci6n  simple,  sin  rosea  y  ttdlmente  desmontable. 

2^.  El  recipiente  deberi  estar  dispuesto  de  tal  modo  que  no  se  pueda  extiaer  la 
leche  por  la  canilla,  sin  que  el  Ifquido  sea  agitado  de  tiempo  en  tiempo. 

3^.  El  mecaniBmo  para  agitar  la  leche  deberi  ser  tal  que  no  haya  ningimft  piesa 
que  se  mueva  en  el  interior  del  recipiente  ni  en  contacto  con  el  Ifquido. 

Para  usar  esta  clase  de  recipientes  loe  interesadoe  debedb  solicitar  en  cada  caso 
una  autoriaaddn  especial  de  la  Administraddn  Sanitaria. 

Art.  83.  Debajo  de  cuanto  letrero  se  coloque  en  las  lecherias,  relative  a  la  leche 
que  venden,  deber&  ponerse  siempre  el  aviso  ya  indicado  sobre  la  forma  en  que  debe 
ser  consumido  el  producto,  en  letras  de  igual  tamafio  y  color. 

Art.  84.  En  las  lecherfas  que  tengan  mesas  para  servir  leche  o  sus  derivadoe  o 
preparadoe  a  clientes  que  vayan  a  consumirlos  allf  mismo,  el  lugar  donde  se  hallen 
las  mesas  estari  separado  por  medio  de  una  baranda  por  lo  menos  del  despacho  de 
leche  al  publico  que  la  compra  para  llevtoela,  de  modo  que  los  clientes  que  conciuren 
a  las  mesas  se  hallen  a  una  distancia  de  tree  metroe  cuando  menos  del  mostrador  y  de 
los  depMtos  de  que  se  trata  en  el  artfculo  75  y  siguientes. 

El  acceso  al  lugar  de  despacho  s61o  se  permitiril  a  las  personas  que  vayan  a  comprar 
leche  para  llevtoela. 

Art.  85.  En  las  lecherfas,  adem^s  de  la  venta  de  leche,  s61o  se  permitiril  la  de 
huevos  frescos,  quesos  frescos  y  sin  olor  pronundado,  crema,  manteca,  cuajadas  y 
productos  an^ogoe  derivadoe  de  la  leche,  miel  y  otros  jmxiuctos  de  granja  conservadoe 
y  vendidoe  en  envasee  cerrados  en  el  lugar  de  producci6n,  todo  lo  cual  deberi  deposi- 
tarse  y  tenerse  en  condkdones  que  no  atndgan  las  moscas  y  no  puedan  comunicarle 
olores  eztrafios  a  la  leche. 

Tambi^n  podrin  tenerse  y  venderse  masas  secas  y  pan  para  ser  consumidos  en  las 
mesas  del  local. 

Pero  ni  loe  quesos,  ni  ninguno  de  loe  productos  no  derivadoe  de  la  leche  podrin 
ser  tenidoe  ni  vendidoe  en  las  lecherfas  en  cantidades  tales  que  hagan  perder  a  estos 
establecimientos  su  verdadero  car&cter  o  que  influencien  en  lo  m^  minfmo  el  cuidado 
y  las  condidones  de  la  leche. 

Art.  86.  Toda  lecheria  anexa  a  una  chocolaterfa,  confiterfa,  reetaurant  o  cualquier 
otro  negodo  deber&  estar  completamente  separada  de  ^l,  y  las  puertas  que  la  pongan 
en  comunicaci6n  con  €i  deberdn  ser  de  cierre  automdtico  y  abrirse  tinicamente  para 
pasar. 

Art.  87.  Las  personas  que  atiendan  el  despacho  usar&n  camisa  blanca  y  c(Hrbata  e 
indumentaria  exterior  como  la  indicada  en  el  artfculo  66. 

Art.  88.  En  toda  lecheria  se  llevar&  un  libro  como  el  indicado  en  el  artfculo  67. 

Art.  89.  El  permiso  que  otorgue  la  Administracidn  Sanitaria  a  las  lecherfas  deber& 
hallaiBe  en  el  local  de  despacho,  a  la  vista  del  ptiblico,  en  un  cuadro  con  vidrio. 

Art.  90.  No  se  otorgar&n  por  la  administraci6n  sanitaria  los  permisos  correspon- 
dientee,  sin  cerdorarse  primero  de  si  el  intereeado  dispone  de  los  elementos  neceearios 
para  satisfacer  las  prescripdones  contenidas  en  eete  capftulo. 

La  Administraddn  Sanitaria  podr&  prohibir  la  venta  de  leches  de  primera  calidad 
certificada  o  de  primera  calidad  a  las  lecherfas  que  por  su  mal  mantenimiento  u  otras 
causas  no  ofrezcan  garantias  sufidentee  de  entregar  esas  leches  al  consumidor  en  las 
condidones  exigidas  en  esta  ordenanza. 

Los  infractores  de  loe  artfculos  71,  84,  u  86  incurririn  en  dncuenta  pesos  de  multa. 
Se  les  clausurard  el  establedmiento,  si  deepu^  del  segundo  aviso  y  de  vencido  el 
plazo  que  les  sefiale  la  administrad6n  sanitaria,  no  se  colocan  en  las  condidones 
exigidas. 

684Se— 17— VOL  X 11 


148       PB00EEDIN6S  6E00NI>  PAK  AMEBIOAK  80IEKTIFI0  G0N0BE88. 

Los  de  lo6  articulos  73,  80,  85,  87,  88,  u  89  incunrir^  en  multa  de  cinco  a  dncuenU 
pesos,  seg^  la  gravedad  de  la  falta. 

Los  de  los  artfculos  75,  77,  o  78,  en  multa  de  treinta  pesos,  si  se  trata  de  leche  de 
primera  calidad,  y  de  quince  pesos,  si  de  segunda  calidad. 

Los  de  los  artfculos  76  u  83,  en  multa  de  dncuenta  pesos  la  primera  vez,  de  den 
pesos  la  segunda  y  retiro  definitivo  del  permiso  para  intervenir  en  cualquier  forma 
en  el  comercio  de  lecheria  la  tercera.  En  los  cases  de  infraccidn  del  artfculo  76, 
adem^  de  la  multa,  la  leche  caer&  en  comiso. 

Los  del  artfculo  79,  en  multa  de  treinta  pesos,  si  se  trata  de  leche  de  primera  calidad, 
y  de  quince  pesos,  si  de  segunda  calidad.  La  leche  puesta  en  el  depMto  que  do 
haya  side  limplado  previamente  serd  decomisada. 

Los  del  artfculo  81,  en  multa  de  dncuenta  pesos  y  comiso  de  la  leche  que  se  halle 
en  el  dep<3sito  o  tanque  destinado  a  leche  de  otra  calidad. 

OAFfruLo  vn.  ybnta  de  lbchs  a  domiciuo;  ysndbdobes  ambulantbs;  rbpabti- 

DORES;    CABROS  T  DBlCiS  VEHfCULOS  DB  RBPABTO. 

Art.  91.  Bajo  pena  de  den  pesos  de  multa  y  comiso  de  la  leche  que  transporte, 
no  se  usard  ningtin  carro  o  vehfculo  para  el  transporte  o  venta  de  ledie  a  domicilio 
que  no  haya  side  previamente  aprobado  y  registrado  por  la  Administraddn  Sanitaria. 
£1  carro  o  vehfculo  que  circule  en  la  vfa  ptiblica,  sin  estar  aprobado  y  legistrado, 
8er&  detenido  hasta  que  el  interesado  abone  la  multa  susodidia,  corriendo  por  su 
cuenta  los  gastos  de  dep^to,  y  sin  responsabilidad  para  la  admini8traci6n  sanitaria 
por  los  deterioros  que  pueda  sufrir  durante  su  detenci6n. 

Los  carros  y  dem^  vehfculos  de  reparto  o  venta  de  leche  a  domicilio  ser&n  con 
eldsticos,  completamente  cerrados,  con  paredes,  piso  y  techo  aisladores,  revestidos 
interiormente  de  chapa  met&lica  inoxidable  y  bien  unida,  y  estadin  provistos  de 
dep^tos  para  hielo  y  para  el  agua  de  descongelad6n,  de  manera  que  la  leche  pueda 
mantenerse  en  ellos  a  la  temperatura  que  corresponda  segtin  las  prescripdones  de 
la  presente  ordenanza  y  que  no  se  acumule  agua  en  el  interior  del  vehfculo.  Estardn 
totalmente  pintados  de  bianco,  salvo  las  ruedas,  que  podrin  ser  pintadas  de  cualquier 
otro  color.    La  pintura  serd  impermeable. 

Esos  vehfculos  serdn  de  limpieza  y  desinfeccidn  fddles  y  deberin  mantenerse 
siempre  en  buen  estado  de  con8ervad6n  y  aseo,  interior  y  exteriormente. 

Si  las  canillas  de  los  tanques  de  la  leche  salen  al  exterior  del  vehfculo,  estar^ 
ptovistas  de  una  cubierta  especial,  convenientemente  dispuesta  para  exduir  toda 
causa  de  contaminad6n. 

Los  vehfculos  podr&n  ser  de  tracd6n  humana,  animal  o  mecdnica. 

Art.  92.  Los  vehfculos  llevardn  pintado,  en  negro  y  en  caracteres  de  molde,  en 
una  de  las  paredes  laterales  o  en  la  posterior,  el  ndmero  de  su  registro  en  la  admi- 
nistrad6n  sanitaria,  precedido  de  las  inidales  A.  S.,  el  nombre  de  la  empresa,  firma 
o  persona  por  cuenta  de  quien  se  vende  la  leche  que  transportan,  la  direcd6n  del 
respective  establecimiento  o  del  domicilio  del  vendedor,  si  no  tiene  establedmiento 
alguno,  y  un  letrero  indicative  de  la  calidad  de  la  leche  o  de  las  leches  que  trans- 
portan y  de  la  manera  c6mo  deben  ser  consumidas. 

Para  la  leche  de  primera  calidad  certificada,  este  dltimo  letrero  serd  tal  como  se 
indica  en  el  artfculo  42,  suprimiendo  el  rengl6n  5^.  Para  las  leches  de  primera  calidad 
y  de  segunda  calidad,  tal  como  se  indica  en  los  artfculos  46,  y  52,  respectivamente. 

El  numero  de  registro  y  las  iniciales  que  lo  preceden,  asf  como  los  renglones  donde 
se  indica  en  los  letreros  la  calidad  de  la  leche  y  la  manera  c6mo  debe  ser  consumida, 
serdn  en  letras  de  echo  centfmetros  de  altura  por  uno  y  medio  de  grueso,  por  lo  menos, 
y  todo  el  reeto  de  lo  que  debe  ir  eecrito  sobre  el  carro,  en  letras  de  cinco  centfmetros 
de  grueso,  cuando  menos. 

La  leche  vendida,  ofrecida  en  venta  o  presentada  para  la  venta  como  de  una  calidad 
que  no  est^  indicada  o  anunciada  en  el  exterior  del  vehfculo  en  la  forma  establedda. 


PUBUC  HEALTH  AND  MEDICINE.  149 

caer&  en  comiso,  y  el  infractor  incurrird  en  multa  de  cincuenta  pesos  la  primera  vez, 
cien  peeoe  la  segunda  y  retiro  definitive  del  permiso  para  interveuir  en  cualquier  forma 
en  el  comercio  de  lecberia  la  tercera. 

Siempre  que  no  se  trate  de  maniobras  de  mala  fe,  que  tienen  penas  especialmente 
establecidas,  las  dem^  infracciones  del  presente  artfculo  serdn  penadas  con  multa  de 
cincuenta  pesos. 

En  los  cases  de  que  se  trata  en  los  dos  p&rrafos  precedentes,  el  veblculo  ser^  detenido, 
en  las  condiciones  establecidas  en  el  artlculo  91,  basta  tanto  se  abone  la  multa  im- 
puesta. 

Art.  93.  Se  prohibe  Uevar  en  el  pescante  recipientes  de  cualquier  clase,  sin  leche^ 
o  con  lecbe,  comprendido  el  jarro  xxmAo  como  medida,  que  tampoco  se  Uevard  colgado 
de  la  cintura,  bajo  pena  de  diez  pesos  de  multa  en  todos  los  cases  y  detenci6n  del 
veblculo,  en  las  condiciones  ya  establecidas,  basta  tanto  se  abone  la  multa. 

Recipientes  y  medida  ir&n  siempre  guardados  en  el  interior  del  veblculo. 

Abt.  94.  En  los  veblculos  de  reparto  no  se  llevari  agua  ni  ninguna  otras  sustancia 
o  cosa  mis  que  lecbe,  crema,  manteca  y  otros  derivados  de  la  leche,  siempre  que 
eatisfagan  ^stos  las  condiciones  indicadas  en  el  artlculo  85,  y  los  recipientes  a  ellos 
destinados. 

Se  probibe  tambi^n  llevar  en  ellos,  perros  o  cualquier  otro  animal  y  usarlos  para 
otro  destine  que  para  el  transporte  de  la  lecbe,  adn  fuera  de  las  boras  de  reparto. 

A  los  infractores  de  este  artlculo  se  les  aplicard  ima  multa  de  cinco  a  cincuenta  pesos, 
eegdn  la  gravedad  de  la  falta,  para  apreciar  la  cual  se  tendrd  en  cuenta  la  calidad  de 
la  leche  que  transporten  en  el  veblculo,  y  se  les  detendrd  ^te,  si  se  balla  en  la  via 
ptiblica,  en  la  forma  y  por  el  t^rmino  indi cades  en  el  artlculo  precedente. 

Art.  95.  Se  probibe  trasvasar  la  leche  de  los  recipientes  en  que  se  transporta  a  otros, 
con  objeto  de  bajarla  o  sacarla  del  veblculo  en  estos  dltimos  y  ecbarla  de  aqul  en  el 
recipiente  del  consumidor,  bajo  las  penas  establecidas  en  el  artlculo  93. 

La  lecbe  que  se  venda  o  reparta  suelta,  deberd  ser  ecbada  directamente  del  tanque 
0  tarro  en  que  se  transporte  a  la  medida  y  de  aqul  al  recipiente  del  consumidor. 

Art.  96.  Los  repartidores  y  los  vendedores  ambulantes  de  lecbe  usardn  la  indumen- 
taria  exterior  indicada  en  el  artlculo  66,  bajo  las  penas  establecidas  para  los  infractores 
de  este  artlculo. 

Art.  97.  Todo  repartidor,  por  su  cuenta  o  por  la  de  otro,  llevard  siempre  consigo  una 
libreta  numerada  que  lo  acreditar^  como  tal,  expedida  por  la  Administracidn  Sani- 
taria, mediante  el  page  de  su  costo.  Esta  libreta  llevard  el  retrato  del  repartidor  y  el 
texto  de  la  presente  ordenanza  y  ademds  constarin  en  ella  los  siguientes  dates:  nombre 
de  la  persona,  empresa  o  firma  por  cuenta  de  quien  se  hace  el  reparto  y  direcci6n  del 
respective  establecimiento,  nombre  y  apellido  del  repartidor,  ubicaci6n  de  su  eetable- 
cimiento,  o,  si  no  tiene  ninguno,  de  su  domicilio,  nacionalidad  y  edad  del  repartidor^ 
ndmero  del  permiso  del  establecimiento  respective  y  n(!imero  de  registro  del  carro 
que  usa  el  reparticor.  La  libreta  tendri  veinte  p^iginas  en  bianco,  donde  los  inspec- 
tores  de  la  Administraci6n  Sanitaria  anotardn  los  avisos  y  observaciones  bechas  al 
repartidor  y  las  infracciones  cometidas  por  ^te,  con  indicaci6n  de  causas  y  de  fecba. 

Al  repartidor  que  no  lleve  consigo  la  libreta  durante  el  reparto  se  le  aplicari  una 
multa  de  15  pesos  las  tree  primo-as  voces  y  de  50  las  suceaivas  y  se  le  detendrd  siempre 
el  carro,  en  las  condiciones  ya  establecidas,  basta  que  la  presente  y  abone  la  multa 
impuesta. 

Art.  98.  A  los  lecberos  ambulantes  o  repartidores  que  por  el  deficiente  manteni- 
mlento  del  veblculo  u  otras  causas  no  ofrezcan  suficientes  garantlas  de  entregar  al 
consumidor  la  lecbe  de  primera  calidad  certificada  o  la  lecbe  de  primera  calidad  en 
las  condiciones  exigidas  en  esta  ordenanza,  la  administraci6n  sanitaria  podrd  pro- 
hibirles  vender  o  repartir  esas  clases  de  leches,  so  pena  de  decomis&rselas,  aplicarle& 
una  multa  de  cien  pesos  y  detenerles  el  veblculo  en  las  condiciones  y  por  el  tormina 
indicados  en  el  artlculo  precedente. 


150       PBOCEEDIKQS  SECOND  PAN  AMEBIOAN  SOIENTIFIO  OONGBBSS. 

OAPtrULO    ym.     PBBSONAS    QUB   INTBBYIBNBN    BN    BL   COMBRCIO    DB   LBCHBRfA,    BN 

OBNBRAL. 

Art.  99.  Del  reparto,  venta  y  maiiipulaci6n  de  la  leche  no  se  ocupard  ninguna 
persona  afectada  de  enfennedades  contagiosas  que  puedan  trasmitirse  por  intermedio 
de  la  leche,  o  de  llagas  supurantee,  dlceras,  erupdoneB  o  eczemas  supurantes  o  hdmedoe 
de  los  brazos,  manos  o  cara,  ni  que  lleve  vendajee  en  estas  mismaa  partes. 

Art.  100.  Toda  persona  ocupada  en  el  reparto,  venta  o  maDipulaci6n  de  la  leche 
estari  provista  de  un  certificado  m6dico  expedido  por  la  administracidn  sanitaria  y 
que  deberd  ser  renovado  anualmente,  bajo  pena  de  cincuenta  pesos  de  multa. 

Art.  101.  Las  personas  de  que  se  trata  en  loe  precedentes  artfculos  deben  mante- 
nerse  siempre  aseados  y,  en  particular,  cuidarin  de  tener  sus  manos  limpias. 

CAPiTULO  IX.    produoci6n  db  la  lbchb  db  prdcbra  caubad  cbrtificada. 
1.  yACAS  tnoDvctoMAa;  sus  ooNDlcloirBa  t  bstaoo  samrabio. 

Art.  102.  El  lote  productor  de  leche  de  primera  calidad  certificada  constard  de 
cuatro  vacas  cuando  menos.    La  edad  de  los  animates  no  pasarA  de  doce  alios. 

Art.  103.  Las  vacas  destinadas  a  producir  esa  leche  seWoi  examinadas  individual- 
mente  y  tuberculinizadas  por  un  veterinario  de  la  administraci6n  sanitaria  antes  de 
entrar  a  formar  parte  del  lote  productor. 

Despu^,  serdn  examinadas  por  el  mismo  por  lo  menos  una  vez  al  mes  y  tubercu- 
linizadas cuantes  voces  ^1  lo  considere  necesario  para  descartar  cualqtder  sospecfaa 
de  tuberculosis. 

La  tuberculinizacidn  se  repetiri  por  lo  menos  cada  afio. 

Art.  104.  Las  vacas  que  reaccionen  como  tuberculosas  a  la  inoculaci6n  de  tuber- 
culina  o  que  presenten  signos  clfnicos  de  tuberculosis  ser&n  marcadas  a  fuego  con 
una  T  en  el  tercio  superior  de  la  tabla  izquierda  del  cuello.  Las  que  den  reacci6n 
dudosa,  con  una  D,  en  la  misma  forma  y  lugar.  Unas  y  otras  serin  immediatamente 
separadas  y  aisladas,  y  sacadas  del  establecimiento  dentro  de  un  plazo  de  48  horas. 
Aunque  dejaran  de  reaccionar  en  lo  suceeivo,  no  podr&n  nunca  formar  parte  del  lote 
productor  ni  volver  al  establecimiento. 

Las  que  al  examen  clfnico  o  bacteriol6gico  resulten  afectadas  de  cualquier  enfer- 
medad  serin  inmediatamente  separadas  y  aisladas,  hasta  que  el  veterinario  oficial 
las  considere  sanas  o  declare  que  su  leche  no  ofrece  inconveniente  ni  peligro  alguno 
Entre  tanto,  su  leche  no  seri  utilizada.  Si  considera  que  ellas  deben  ser  definiti- 
vamente  eliminadas  del  lote  productor,  serin  sacadas  del  establecimiento  en  el  plazo 
'  de  48  horas. 

Se  prohibe  expresamente  utilizar  para  la  producci6n  de  leche  de  primera  calidad 
certificada,  o  tener  dentro  de  los  establecimientos  que  la  producen,  vacas  que  no  tengan 
008  cuatro  mamas  fntegras  y  en  capacidad  de  funcionar  plenamente,  como  tambi^n 
dedicar  a  la  producci6n  de  tal  leche  o  tener  dentro  del  lote  productor  vacas  afectadas 
de  cualquier  trastomo  digestivo  acompafiado  de  diarrea. 

Art.  105.  Las  vacas  que  formen  el  lote  productor  serin  sefialadas  con  un  broche 
numerado  que  se  les  aplicari  en  la  oreja. 

Con  ellas  no  se  colocari  nunca,  en  el  establo,  ni  en  los  potreros,  ni  en  parte  alguna, 
ninguna  vaca  que  no  haya  sido  antes  tuberculinizada  y  examinada  por  el  veterinario 
oficial  y  declarada  sana  por  61.  Tampoco  podrin  estar  con  ellas  animates  de  otras 
especies  o  vacas  destinadas  a  producir  leche  de  otra  calidad. 

Art.  106.  Quince  dfas  antes  de  parir,  las  vacas  serin  separadas  del  lote  productor, 
colocadas  en  establos  o  potreros  especiales  y  mantenidas  aquf  hasta  despu^  de  ocho 
dfas  de  la  parici6n.  Durante  el  tiempo  de  separaci6n,  su  leche  no  seri  utilizada. 
Pasado  este  plazo,  y  previo  examen  del  veterinario  oficial,  podrin  volver  al  lote 
productor,  pero  sin  su  temero,  que  desde  ese  memento  no  tocari  mis  a  la  madre  ni 
estari  a  su  lado. 


PUBLIC  HEALTH  AND  MBDIOIKB.  161 

Abt.  107.  De  todo  traBtomo  de  la  salad  o  novedad  notadoe  ea  las  vacas  se  dar& 
aviso  inmediato  a  la  administraci6n  sanitaria,  que  dispondr&  en  seguida  su  visita  por 
on  veterinaiio.  Entre  tanto,  deede  el  primer  momento,  el  animal  serd  retdrado  del 
lote  productor  y  su  leche  no  serd  utilizada  hasta  que  el  veterinario  oficial  lo  ordene. 

Art.  108.  A  efectos  de  dar  ciunplimiento  a  lo  dispueeto  en  los  artfculos  anterioree, 
en  todo  establecimiento  dedicado  a  la  producci6n  de  leche  de  primera  calidad  certifi- 
cada  habr&  potreros  o  establos  especiales  para  el  lote  productor,  para  los  animales 
destinados  a  formar  parte  de  ^1  y  atin  no  examinados,  para  los  afectados  o  los  sospe- 
chosos  de  tuberculosis  o  que  por  cualquier  otra  causa  haya  que  retirar  definitivamente 
del  lote  productor  y,  finalmente,  para  colocar  la  vacas  durante  el  periodo  de  la  parici6n. 

Los  abrevaderos  de  eeoe  potreros  no  ser&n  comunes  ni  prdximos,  debiendo  haUarse, 
cuando  sea  posible,  a  distancia  de  por  lo  menos  cien  metres  unos  de  otros. 

Las  personas  dedicadas  al  cuidado  y  ordefio  de  las  vacas  del  lote  productor  o  que 
manejen  su  leche  no  atender^  los  animales  reaccionantes  o  sospechoeoe  de  tuber- 
culosis, y  s61o  podr&n  hacerlo  con  los  otros  cuando  el  veterinario  oficial  lo  permita. 

Abt.  109.  La  administraci6n  sanitaria  hard  examinar  desde  el  punto  de  vista  qulmico 
y  bacteriol6gico  una  vez  al  mes  por  lo  menoe,  muestras  colectivas  de  leche  del  lote 
productor,  recogidas  con  las  garantfas  necesarias.  Esas  muestras  se  recoger&n  de 
la  mezcla  de  la  leche  de  cincuenta  vacas  cuando  m&s. 

En  case  de  comprobarse  en  esas  muestras  agentes  infecciosos  que  puedan  proceder 
de  las  vacas,  se  hsxia  las  investigaciones  clfnicas  y  bacteriol<5gicas  individuales  nece- 
sarias para  descubrir  el  animal  infectante. 

Cuando  la  administraci6n  sanitaria  o  el  veterinario  oficial  lo  estimen  conveniente, 
podrdn  recogerse  muestras  colectivas  o  individuales  de  leche,  de  productos  patoldgicos, 
de  forrajes,  aguas  y,  en  general,  de  todo  lo  que  se  requiera  para  asegurarse  del  buen 
estado  sanitario  de  los  animales  y  de  las  condiciones  de  la  leche. 

Abt.  110.  Los  interesados  podrdn  hacer  asistir  sus  animales  por  el  veterinario 
particular  que  estimen  conveniente,  pero  el  veterinario  oficial  deberd  ser  enterado 
siempre  del  tratamiento  a  que  se  los  someta. 

Los  animales  enfermos  no  ser4n  tratados  por  ninguna  persona  que  no  tenga  el  tftulo 
de  m^ico  veterinario.  Ni  aun  medicamentos  caseros  (suUato  de  soda,  etc.)  podrin 
administrirseles  sin  la  intervenci6n  del  veterinario. 

Art.  111.  Las  vacas  del  lote  productor  no  serdn  tratadas  con  medicamentos  de 
acci6n  en^igica  o  capaces  de  pasar  a  la  leche.  Se  prohibe  eepecialmente  adminis- 
trarles  dloe,  irsenico,  em^tico  (tdrtaro  estibiado),  arcolina,  hel^boro  bianco,  prepara- 
dos  mercuriales,  yodo,  eserina,  pilocarpina,  estricnina  y  otros  alcaloides.  La  leche 
de  las  vacas  tratadas  con  estos  medicamentos  no  podrd  ser  utilizada  hasta  pasados 
cuatro  dias  de  ceeado  el  tratamiento. 

Art.  112.  Cuando  la  Administracidn  Sanitaria  lo  considere  necesario  podrd  exigir 
que  las  vacaa  sean  vacunadas  o  sometidas  a  tratamientos  prev^itivos  contra  determi- 
nadas  enfermedades  que  las  amenacen. 

Art.  113.  En  los  establedmientoe  productores  de  leche  de  primera  calidad  certifi- 
cada  se  llevar&  un  libro  dispuesto  en  la  forma  que  indique  la  administracidn  sanitaria, 
donde  se  anotard  respecto  de  cada  vaca  el  n(!imero  que  tenga,  su  reeefia  (rasa,  edad, 
pelaje,  sefias  particulares,  sefiales,  marcas,  etc.),  la  fecha  del  primer  examen  del  vete- 
rinario oficial  y  su  resultado,  fecha  de  instalacidn  en  el  lote  productor,  fechas  en 
que  fu^  servida  y  de  la  parici6n,  las  exclusiones  temporariaa  del  lote  productor,  con 
i2idicaci6n  de  fechas,  duraci6n  y  motives,  y  las  visitas  sucesivas  a  que  haya  side 
flometida  por  el  veterinario  oficial,  con  indicaci6n  de  fechas,  resultadoe  y  prescripcionee 
u  obeervaciones  a  que  haya  habido  lugar. 

Este  libro  estari  siempre  a  dispoeici6n  del  veterinario  inspects. 

Art.  114.  En  esoe  establecimientos,  por  lo  menos  dos  voces  por  semana  se  medlri  la 
cantidad  de  leche  que  d6  en  el  dia  cada  vaca  y  se  registrar^  el  dato  en  un  libro  especial, 
que  estari  siempre  a  di8poaici6n  del  veterinario  inspector.  Laa  anotaciones  ser^ 
conservadas  durante  seis  meses. 


152       PBOOEEDINGS  SECOND  PAN  AMEBIOAN  60IENTIFI0  CONGBESS. 

3.  ALnaNTAa6K  DK  las  YACAS  PBODUCTORAS  DB  UCBB  DB  PBIMBBA  CAUDAD  CBBTIFIGADA. 

Art.  115.  Los  potreroe  o  cuadros  donde  se  alimenten  las  vacas  a  pastoreo  serin 
altos,  libres  de  pantanos  o  charcos  y  de  todo  otro  dep<5eito  de  aguas  contaminadas  o  no 
potables,  no  inundables  por  las  aguas  superficiales  ni  subterr&neas  y  provistos  de 
buenos  pastos  naturales  o  artificlales. 

En  ellos,  ni  a  una  distancia  de  cien  metros  de  ellos,  no  habrd  chiqueros,  estercoleroe, 
ni  otras  habltaciones  de  animales,  dep<3sit06  de  residues  o  establecimientos  que  despi- 
dan  maloB  olores. 

Tampoco  habrd  en  ellos,  ni  a  cien  metres  de  ellos,  caddveres  de  animales,  carrofias, 
huesos  u  otros  restos  de  animates  muertos. 

Adem^,  la  ubicaci6n  de  esos  potreros  serd  tal  que  los  animates  no  est^n  en  ningdn 
case  obligados  a  transitar  a  distancia  menor  de  cien  metros  de  esas  habitacionee, 
dep<58ito8,  establecimientos  y  restos. 

Art.  116.  Ademds  de  la  alimentaci6n  a  pastoreo  podr&  administrarse  a  las  vacas  los 
siguientes  forrajes: 

(a)  Heno  (paste  seco)  de  buena  calidad,  bien  cosechado,  de  color  fresco  y  olor  ard- 
mitico ,  libre  de  plantas  t6xicas,  mohos  (no  serd  ardido)  y  polvo. 

(b)  Paja  de  cereales  de  la  misma  calidad  y  estado. 

(c)  Afrecho  de  centeno  y  de  trigo. 

(d)  Avena,  cebada,  centeno  y  mafz,  molidos,  rotos  o  aplastados. 

(e)  Harina  de  semilla  de  lino. 

Los  granos  y  harinas  serdn  de  buena  calidad  y  en  buen  estado  de  conservacidn. 

Quien  desee  administrar  otro  forrajes  pedird  previamente  autorizaci6n  a  la  admi- 
nistraci6n  sanitaria. 

No  se  permitird  en  ningdn  caso  que  los  animates  consuman  forrajes  capaces  de  pro- 
ducir  diarrea  u  otros  trastomos,  de  comunicar  a  la  leche  olor  o  gusto  extrafios  o  de 
disminuir  su  calidad. 

Art.  117.  El  agua  de  bebida  de  los  animates,  asi  como  toda  el  agua  usadacon  cual- 
quier  fin  en  los  establecimientos  productores  de  leche  de  primera  calidad  certificada, 
debe  haber  side  reconocida  potable  por  la  Administraci6n  Sanitaria. 

Cada  potrero  tendrd  su  abrevadero  especial,  separado  de  toe  que  pertenecen  a  toe 
potreroe  vecinos. 

En  los  abrevaderos  no  se  lavari  ropa,  ni  las  manoe,  ni  recipiente  alguno,  ni  se 
cumplird  ningdn  fin  domdstico,  ni  otros,  capaces  de  ensuciar  o  contaminar  el  agua. 

Se  hattardn  siempre  limpios  y  provistos  de  agua  limpia  y  fresca. 

Estardn  emplazados  en  lugares  altos  y  de  tal  mode  que  alrededor  de  ellos  no  se  formen 
charcos  o  barro,  donde  los  animates  puedan  echarse.  Tambi^n  se  evitard  que 
junto  a  ellos  o  a  su  alrededor  se  acumule  el  estidrcol  de  los  mismos  animates. 

Art.  119.  No  se  permitirdn  los  cambios  bruscos  de  rdgimen  alimenticio. 

£1  pasaje  del  rd^men  seco  at  de  paste  verde,  e  inversamente,  serd  gradual. 

En  la  dpoca  de  los  pastes  tiemos,  si  dstos  ocasionan  diarrea,  los  animates  mantenidos 
a  pastoreo  recibirdn  un  suplemento  de  paste  seco,  a  fin  de  evitar  ese  inconveniente. 
Lo  mismo,  se  adoptard  iguat  procedimiento,  si  la  alimentaddn  exdusiva  con  paste 
verde  de  cuatquier  clase  produce  ese  trastomo. 

Art.  119.  En  todo  eetabtecimiento  de  los  indicados  habrd  un  local  especiatmente 
destinado  at  depdsito  y  conservaci6n  de  los  forrajes,  de  dimensiones  proporcionadas 
ft  las  necesidades,  bien  ventilado,  seco,  limpio  y  emplazado  en  un  lugar  alto. 

S.  CAMPO  T  B8TABL08  DB  LAS  VACAS  PBODUCTOBAS  DB  LBCHB  DB  PBmBRA  CALTOAD  CEBTinCADA. 

Art.  120.  Los  animates  podrdn  ser  tenidos  en  establos  todo  el  aflo  o  en  ciertas 
dpocas  de  61,  pero  se  tes  dari  siempre,  salvo  que  el  mat  tiempo  no  lo  permita,  por  lo 
menoe  cinco  horas  diarias  de  soltura  at  aire  libre,  en  potreros  como  toe  indicados  eu  el 
artlculo  115. 


FUBUO  HEALTH  AND  MEDIODSTE.  158 

Art.  121«  Cuando  loe  animales  sean  mantenidos  continuamente  a  campo  y  no  haya 
6Btab1o6  para  eHos,  habr&  en  cada  potrero  por  lo  menos  un  tinglado  o  cobertizo  de  doa 
aguaSy  de  dimensiones  proporcionadas  al  ndmero  de  vacaa  que  haya  eo  ol  potrero,  con 
tabique  mediano,  piso  impermeable  y  idcil  de  limpiar,  y  orientado  y  dlapueeto  de  tal 
modo  que  loe  animates  puedan  protegeree  en  61  de  las  lluvias  y  del  viento. 

Be  evitari  que  en  61,  y  sus  alrededores  se  acomulen  deyecciones  o  el  agua  de  las 
Uuvias,  o  se  Idrmen  baches,  a  fin  de  que  los  animales,  en  lo  poeible,  no  se  ensucien, 
sobre  todo  al  echarse. 

Aht.  122.  Los  establos  se  hallarftn  emplassados  sobre  un  terrene  alto.  Sus  pisos 
ser&n  de  cemento  en  toda  sa  extensi6n  o  de  material  andlogo,  impermeable,  y  tendrdn 
una  inclinaci6n  que  permita  la  corriente  de  los  Uquidos  hacia  bocas  de  desajE^fle  cu- 
biertos  con  rejilla  y  en  conexi6n  con  el  sistema  de  drenaje.  La  superficie  del  piso 
se  hallard  a  20  centfmetros  por  lo  menos  sobre  el  nivel  del  suelo  que  rodea  el  establo. 

En  cuanto  a  lo  dero^,  los  establos  deberdn  satisfacer  las  condiciones  indicadas  en 
los  artfculns  siguientes. 

Art.  123.  El  sistema  de  drenaje  terminar&  en  pozos  adecuadamente  construidos  y 
estari  dispuesto  de  tal  modo  que  sus  emanadones  no  refluyan  al  establo. 

Art.  124  Las  paredes  del  establo*  hasta  dos  metros  de  altura  por  lo  menos,  ser&n 
de  material  (obra  de  ttbrica)  y  revestidas  de  cemento  impermeable  y  liso  o  de  baldosas 
o  azulejoB,  con  las  junturas  bien  tomadas  con  cemento. 

Los  ingulos  formados  por  las  paredes  entre  sf,  hasta  esa  altuia,  y  por  ellos  y  el  piso 
ser^  redondeados,  para  facilitar  la  limpieza. 

Art.  125.  El  resto  de  las  paredes  y  los  cielo  rasos  podr&n  ser  de  madera  cepillada. 
Si  son  de  material  (obra  de  f&brira),  tendrdn  su  superficie  lisa.  En  todos  los  casos, 
salvo  que  se  hallen  reveetidos  de  material  impermeable,  estar&n  pintados  con  lechada 
de  cal  o  alguna  pintura  impermeable  de  color  claro. 

Art.  126.  En  la  constniC€*i6n  del  establo  no  habrd  nada  de  madera  mds  que  lo 
indicado  en  el  artfculo  precedente  y  las  puertas  y  ventanas.  Los  parantes  o  columnaa 
de  sost6n  interiorps,  los  tabiques  de  separaci6n  de  los  animates,  las  rejillas  para  el 
pasto,  comederos,  bebederos,  etc.,  ser&n  de  hierro,  cemento  armado  o  material,  im- 
permeables,  con  sus  superficies  lisas  y  sus  aristas  y  hordes  redondeados. 

Art.  127.  El  establo  tendri  suficientes  dlmensiones  como  para  que  cada  vaca 
disponga  de  treinta  metros  ctibicos  de  espacio  libre,  cuando  menos. 

El  cielo-raso  se  hallarA  en  sus  partes  mis  bajas  a  5  metros  por  lo  menos  de  altura  sobre 
la  superficie  del  piso. 

Art.  128.  La  orientacldn,  construcci6n,  disposicidn  y  ventllaci6n  del  establo 
mtin  tales  que  el  aire  intmor  se  mantenga  tresco,  seco  y  agradable  y  que  no  haya 
corrientes  de  aire  en  el  recinto. 

La  temperatura  del  establo  se  mantendrd  entre  16  y  18  grados. 

Las  ventanas  serdn  de  dimensiones  y  en  ntimero  suficientes  para  que  haya  por  lo 
menos  12,600  centfmetros  cuadrados  de  abertura  por  cada  30  metros  cdbicos  de  espacio 
libre  interior.  Estar&n  situadas  en  forma  que  la  luz  se  distribuya  abundante  y  uni- 
formemente  en  todo  el  establo  y  se  abrir&n  hacia  adentro,  sobre  eje  horizontal  inferior, 
de  suerte  que  al  entrar  el  aire  vaya  hacia  arriba. 

£1  establo  estari  provisto  de  ventiladores  de  tiraje  interceptables  a  voluntad,  en 
ndmero  y  con  dimensiones  suficientes  para  que  por  c»da  30  metros  cdbicos  de  espacio 
libre  interior  haya  por  lo  menos  376  centfmetros  cuadrados  de  abertura  de  yentilaci6n. 

Ajbt.  129.  La  di8posici6n  interna  del  establo  serd  del  tipo  o  modelo  llamado  holand6s» 
en  lo  que  serefiere  a  la  forma  como  serin  tenidos  los  animales. 

La  superficie  ocupada  por  cada  vaca  serd  pequefia.  Tendrd  una  longitud  tal  que 
loe  excrementos  caigan  natundmente  en  la  canaleta  de  deyecciones  que  correrd  detrda 
de  los  pies  posteriores  de  los  animales.  Su  ancho  serA  tambi6n  reducido,  de  modo 
que  quede  espacio  para  los  pies  cuando  las  bestias  se  acuesten,  pero  que  sea  impoaible 
a  6stfi8  ladearse  y  alejar  los  cuartos  tiaseros  de  la  susodicha  canaleta. 


154       PBOOEEDINQS  3B00in>  PAN  AMEBIOAK  SCIBNTIFIC  G0NQBE88. 

Las  canaletas  de  deyecciones  tendr6n  diecis^  centimetros  por  lo  menos  de  pro- 
fundidad  en  todas  bob  partes,  ser&n  constaruidas  de  cemento  u  otro  de  lot  materiales 
indicados  para  el  piso  del  establo  y  adecuadamente  inclinadas  y  dr^iadas. 

Los  comedoxM  y  bebederos  ser&n  bajoe,  de  mode  que  los  animales,  al  echarse,  puedan 
extender  su  cuello  y  cabeza  pw  encima  de  elloe.  Su  fondo  no  estard  a  mia  de  15 
centfmetros  sobre  la  superficie  del  piso  circundante. 

Abt.  130.  En  los  establos  dispuestos  de  tal  manera  que  las  vacas  est^n  opuestas  por 
BUS  partes  posteriores  habdl  un  espacio  por  lo  menos  de  2.50  metroe  entre  los  border 
exterioree  de  las  canaletas  de  deyecciones  opuestas. 

El  establo  estari  provisto  de  pasillos  para  servir  los  alimentos  a  los  animales  sin 
tesnet  neceeidad  de  pasar  por  entre  ellos  ni  molestarlos. 

Los  pasUloB  y  caminos  y  todos  los  espacios  que  se  hallen  detr&s  de  las  vacas  serin 
p<v  lo  menos  tan  altos  como  los  lugares  ocupados  por  ellas. 

Art.  131.  Seri  preferible  que  cada  vaca  tenga  su  comedero  y  bebedero  aparte. 
Estos  ser&n  metilicos  o  de  otro  material  impermeable,  inoxidables  y  de  ficil  Umpiesa. 

Art.  132.  Todo  establo  tendri  su  servicio  de  agua  corriente  convenientemente 
dispuesto  y  que  baste  para  todos  los  prop<3sitos. 

Si  las  vacas  son  ordefiadas  en  el  establo,  en  un  lugar  adecuado  de  ^te  o  en  conexi6n 
con  ^1  habri  un  servicio  de  agua  caliente  con  todo  lo  necesario  para  lavarse  las  manos 
(pileta  o  gran  palangana,  jab6n,  cepillo  y  toallas  o  lienzos  limpios). 

Art.  133.  Se  tratari  por  todos  los  medios  posibles  de  que  el  establo  est6  siempre 
libre  de  moscas. 

Puertas  y  ventanas  estarin  provistas  de  tela  metdlica,  a  fin  de  impedir  su  entrada. 

Art.  134.  Todo  el  establo  estari  construido,  dispuesto  y  mantenido  de  tal  mode 
que  la  limpieza  y  desinfeccidn  sean  ttciles. 

Los  establos  se  hallarin  siempre  limpios,  libres  de  tiena,  polvo  y  telarafias. 

Si  las  paredes  y  cielo-raso  son  blanqueados  con  cal,  el  blanqueo  se  repetiri  cada  seis 
meees  por  lo  menos,  previo  raspaje  del  antiguo. 

Los  excrementos  ser&n  retirados  tan  frecuentemente  como  sea  necesario  para  evitar 
en  lo  posible  la  produccl6n  de  males  olores  y  que  las  vacas  se  ensucien.  Por  lo  menos 
serin  sacados  dos  voces  pw  dfa. 

Diariamente  se  haii  una  limpieza  completa  del  establo. 

Los  pilones  o  recipientes  donde  se  sirven  los  alimentos  a  los  animales  se  limpiarin 
despu^  de  cada  comida. 

Cada  cinco  dfas  por  lo  menos,  el  piso  de  todo  el  establo,  comprendidos  los  lugares 
donde  se  hallan  las  vacas  y  las  canaletas  de  deyecciones,  las  paredes  hasta  la  altura  de 
2  metres  y  todo  lo  que  est^  dentro  de  la  misma  altura,  serin  lavados  a  fondo,  a  cepillo 
y  con  abundante  agua. 

En  los  establos  no  habri  deshechos,  basuras,  ni  nada  que  no  sea  necesario  para  su 
buen  mantenimiento  o  para  el  cuidado  de  los  animales. 

Art.  135.  Si  el  establo  es  de  madera  en  sus  partes  superiores,  sobre  ^1  no  habri  de- 
p6sitos  de  forrajes,  ni  instalaciones  de  ninguna  especie. 

Ninguna  parte  del  establo  seri  usada  como  habitaci6n  de  personas  para  dormir,  ni 
para  ningtin  otro  fin  dom^ico. 

El  establo  tampoco  se  hallari  en  comunicacidn  con  habitaciones  ni  piezas  de  fines 
dom^sticos,  ni  con  caballerizas  u  otras  habitaciones  de  animales. 

Art.  136.  Los  excrementos  de  los  animales  serin  depositados  a  distancia  de  cien 
metres  por  lo  menos  del  establo,  en  direcci6n  contraria  a  los  vientos  predominantes 
y  en  condidones  de  impedir  en  lo  posible  el  desarrollo  y  acumulacidn  de  las  moscas 
y  la  producci6n  de  males  olores. 

Art.  137.  El  terrene  que  rodea  el  establo  eetari  nivelado  de  tal  mode  que  no  se 
acimiulen  en  ^1  aguas  superficiales  y  seri  mantenido  limpio,  seco  y  libre  de  residues, 
basuras,  trastos  viejos  o  cualesquiwa  otros  inconvenientes. 


PUBLIC  HEALTH  AND  MBDIOINB.  155 

Delante  de  las  puertas  habrd  un  vered6n  de  cuatro  metroe  de  fondo  y  dos  metros 
mia  ancho  que  la  paerta  correspondiente,  por  lo  menoe,  conBtruMo  de  material  861ido» 
liBo  e  impenneable. 

En  un  radio  de  cien  metros  del  establo  no  habr&  aguas  estancadas,  pantanos,  ba- 
rriales,  sumideros  o  depMtos  de  eeti^rcol,  ni  porquerizas. 

Art.  138.  No  habrd  letrinas  a  distancia  menor  de  veinte  metros  del  establo. 

Todas  las  letrinas  del  establecimiento  ser^n  cerradas,  de  material,  con  revestimi- 
ento  interior  impermeable  hasta  dos  metros  de  altura,  prot^das  contra  el  acceso 
de  las  moscas,  con  los  asientos  provistos  de  tapa  y  con  servicio  de  agua  corriente» 
Siempre  estardn  limpias,  en  condiciones  higi^nicas. 

4.  LIMPIEZA  DE  LAS  VACAS  PRODVCTOBA8  DK  LECHE  DS  PRIMSBA  CAUDAD  CSRTIFICADA. 

Art.  139.  Todo  el  establecimiento  productor  de  leche  de  primera  calidad  certifi* 
cada  estard  dispuesto  y  mantenido  de  tal  modo  que  las  vacas  se  expongan  lo  menoe 
posible  a  ensuciarse. 

Art.  140.  Cuando  se  use  cama  para  los  animales,  ellas  serim  de  paja  de  cereales  o  de 
paste,  Umpios,  sin  tierra  o  polvo,  ni  mohos,  ni  mal  olor.  Se  prohibe  utilizar  con  tales 
fines  paja  u  otras  materias  usadas  en  camas  de  personas  o  en  embalajes  o  en  cosaa 
anilogas. 

Art.  141.  Las  vacas  estardn  siempre  limpias,  sin  caspa,  ni  barro,  ni  esti^rcol  pega- 
doe  a  su  piel.    Se  les  podrd  pasar  la  mano  por  encima  sin  ensuci^rsela. 

£1  pelo  de  los  ijares,  del  vientre  alrededor  de  la  ubre,  de  la  ubre,  del  muslo  y  parte 
superior  de  la  piema  y  el  de  la  cola  ser^  mantenidos  cortos. 

Las  vacas  ser&n  completa  y  prolijamente  limpiadas  a  cepillo  una  vez  al  dia.  Las 
partes  sucias  de  esti^rcol,  barro,  etc.,  que  no  puedan  ser  limpiadas  a  seco,  se  lavarto 
con  agua  y  jab6n. 

Art.  142.  Para  la  limpieza  a  seco  y  lavado  de  las  vacas  mantenidas  continuamente 
a  campo  se  tendrd  un  tinglado  especial,  con  piso  impermeable,  drenaje  adecuado  y 
provision  de  agua  corriente. 

En  cuanto  al  emplazamiento  de  ese  tinglado  y  su  orientaci6n  y  8ituaci6n  reepecto 
de  otroe  lugares,  instalacionee  o  locales,  su  mantenimiento,  limpieza  y  usos,  deberin 
satififacerse  las  condiciones  de  un  establo,  en  la  medida  que  le  sean  aplicablee.  Estari 
ubicado  y  dis  puesto  de  tal  modo  que  el  viento  no  pueda  llevar  hada  otro^  locales 
(lecherla,  etc.)  los  pelos  y  el  polvo  que  se  desprendan  de  los  animales  al  limpiarlos. 
Podrd  estar  pr6ximo  al  local  de  ordefto,  pero  no  en  directa  comunicaci6n  con  ^1. 

Cuando  se  tengan  las  vacas  en  establos,  su  limpieza  podrd  hacerse  en  ellos;  pero 
se  considerard  en  mejoree  condiciones  higi^nicas  el  establecimiento  que,  teniendo 
establo,  disponga  tambi^n  de  un  local  especial  para  ese  objeto,  anexo  a  aqu61. 

5.  ORDEl^O  DE  LA  LECHE  DE  PRIMERA  CALIDAD  CSRTIFICADA. 

Art.  143.  Esta  operaci6n  se  efectuard  con  el  miximum  de  limpieza  que  sea  dado 
y  de  manera  que  la  leche  se  contamine  lo  menos  posible  con  microbios  del  exterior- 

Art.  144.  Se  hard  en  el  establo  o  en  un  local  especialmente  destinado  a  ese  objeto 
Este  tUtimo  existird  siempre  en  el  establecimiento  y  en  61  deberi  efectuarse  siempre 
el  ordefio,  si  las  vacas  son  continuamente  mantenidas  a  campo  (si  no  hay  establo). 

El  local  de  ordefio  serd  muy  abundantemente  ventilado,  seco  y  con  mucha  luz.  En 
cuanto  a  emplazamiento,  estado  y  mantenimiento  del  terrene  circundante,  ubicaci6n 
respecto  de  otras  instalacionee,  orientacidn,  naturaleza  del  piso,  paredes  y  cielo-raso, 
temperatura  interior,  servicio  de  agua,  drenaje,  conservaci6n,  limpieza,  defensa  con- 
tra las  mocas,  usos,  etc.,  deberd  llenar  las  condiciones  indicadas  para  el  establo,  en  la 
medida  que  le  sean  aplicables,  con  la  salvedad  de  que  la  ventilaci6n  y  la  luz  tendrdn 
que  ser  por  lo  menos  el  triple  que  las  del  establo.  Sus  dimensiones  estarin  en  rela- 
ci6n  con  el  n(imero  de  vacas  que  se  ordefien  a  la  vez  y  serdn  tales  que  permitan  la  ope- 


156       PBOGEEDINGS  SECOND  PAK  AMEBIOAN  SCIEKTIFIO  G0NGBES8. 

raci6n  del  ordefio  con  holgura.  En  61  habr&  un  servicio  para  lavaree  las  manoe  como 
el  indicado  en  el  artfculo  132. 

£l  Ber&  ocupado  por  las  vacas  (inicamente  en  el  momento  en  que  van  a  ser  orde- 
fiadas.    En  seguida  serd  limpiado  a  fondo. 

Habiendo  buen  tiempo,  bub  puertaa,  ventanaa  y  ventiladores  eetar&n  aiempre 
abiertos  durante  el  dia. 

En  61  no  deberd  hacerse  la  limpieza  general  de  los  animales. 

Art.  145.  Eb  indispensable  que  las  vacas  pennanezcan  tranquilas  durante  el  ordeilo. 
A  este  efecto  tendrdn  que  ser  animales  perfectamente  mansos  y  babituadoe  a  la  opera- 
ci6n  y  se  evitard  durante  ella  todo  lo  que  pueda  excitarloe. 

Art.  146.-  Las  vacas  que  en  el  momento  del  ordefio  se  ballen  mojadas,  por  haber 
estado  expuestas  a  la  lluvia  o  por  otras  causas,  serdn  perfectamente  cscurridas  antes 
de  comenzar  la  operaci6n,  de  tal  modo  que  de  su  piel  no  pueda  desprenderse  ninguna 
gota  Ifquida.  Esa  preparaci6n  del  animal  se  hard  en  el  local  de  limpieza  (articulo 
142)  0,  si  68te  no  existe,  en  el  establo. 

Art.  147.  Antes  del  ordefio  se  evitard  todo  lo  que  pueda  ocasionar  levantamiento 
de  polvo  y  desprendimiento  de  malos  olores. 

Las  limpiezas  generales  del  establo,  la  distribuci6n  de  las  comidas  o  forrajes  y  ^ 
cambio  y  removido  de  las  camas  se  efectuardn  inmediatamente  deepu^  de  terminar 
un  ordefto. 

La  remoci6n  de  excrementos,  las  limpiezas  pardales  de  las  canaletas  de  los  mismos, 
etc.,  no  se  hardn  tampoco  durante  la  bora  que  precede  a  aquella  operaci6n. 

La  limpieza  general  de  las  vacas,  cuando  se  haga  dentro  del  establo,  serd  efectoada 
tambi^n  en  seguida  de  terminar  un  ordefio. 

Si  se  trata  de  animi^es  continuamente  mantenidos  a  campo,  su  limpieza  general  se 
hard  inmediatamente  antes  de  comenzar  un  ordefio,  evitando  en  lo  posible  los  lavados 
extensos  de  las  partes  superiores  y  posterioree  del  cuerpo,  que  se  dejardn  para  despu^s 
de^l. 

En  todos  los  cases,  cuando  sea  de  eetricta  necesidad  lavar  esas  partes  antes  del 
ordefio,  deberdn  escurrirse  bien  las  regiones  mojadas  de  manera  que  mientras  ae 
efecttia  el  mismo  no  puedan  desprenderse  gotas  de  Hquido  capaces  de  llegar  a  las 
manos  del  ordefiador,  la  ubre,  las  tetas  o  el  redpiente  donde  se  recoge  la  leche.  En 
una  pal^bra,  no  se  ordefiard  ninguna  vaca  cuya  piel  est^  tan  mojada  que  de  ella  pue- 
dan caer  gotas  de  Hquido. 

Antes  de  comenzar  a  ordefiar  en  el  establo,  se  abrirdn  puertas  y  ventanas,  a  fin  de 
que  el  aire  se  renueve  y  se  evactien  los  males  olores. 

Art.  148.  Las  vacas  serdn  inmovilizadas  durante  el  ordefio.  Sus  colas  estardn 
sujetas. 

Art.  149.  Inmediatamente  antes  de  ordefiar  cada  vaca,  se  le  limpiard  la  ubre, 
las  tetas  y  las  partes  limftrofes. 

Esta  limpieza  se  hard,  sea  sacando  por  lo  pronto  las  grueeas  porciones  de  suciedad, 
lavando  despu^  con  agua  tibia  (a  temperatura  mds  o  menos  igual  a  la  del  cuerpo  del 
animal)  y,  finalmente,  frotando  y  secando  bien  con  un  lienzo  o  toalla;  sea  frotando  pri- 
mero  con  un  pafio  seco  o  Ugeramente  hdmedo  y  en  seguida  con  otro,  seco  o  apenas 
engrasado.  Los  trapes,  lienzos  o  toallas  serdn  blancos,  de  tela  suave,  lavables  y  limpios, 
debiendo  a  este  dltimo  efecto  haber  una  buena  provisidn,  para  que  puedan  cambiarse 
a  menudo.  La  materia  grasa  que  se  use  serd  pura  y  en  buen  estado  de  conservacida 
(no  rancia),  incapaz  de  irritar  la  piel. 

Serd  preferible  que  de  esa  limpieza  se  encargue  espedalmente  una  persona,  para 
que  el  ordefiador  pueda  operar  inmediatamente  con  sus  manos  limpias. 

En  case  de  volver  a  ensuciaise  durante  el  ordefio  las  partes  indicadas,  antes  de  prose- 
guir  habrd  que  limpiarlas  otra  vez. 

Art.  150.  El  ordefiador  Uevard  durante  el  ordefio  sobre-pantalones,  blusa  laiga  o 
delantal  de  mangas  cortas,  bien  cerrados,  y  gorro  que  contenga  y  recubra  los  cabeUos, 


PUBLIO  HEALTH  AND  MEDIOIKB.  157 

feodo  de  tela  bl«nca  y  lavable  y  en  perfecto  estado  de  limpieza.  8erd  preferible  que 
en  lugar  de  biiisa  y  sobre-pantalones  separados  use  una  combinaci6n  de  una  sola  piessa 
que  comprende  las  dos  cosas  y  especial  para  esos  fines. 

Para  cada  ordefiador  habri  siempre  diflpomble,  ademils  del  que  lleven  puesto,  tres 
juegos  de  la  ropa  susodlcha,  perfectamente  limpios. 

Art.  151.  El  ordeiLador  cumplird  su  tarea  con  las  manos  y  antebrazos  descubiertoe 
y  perfectamente  limpios. 

Antes  de  qpipezar  a  ordefiar  se  lavard  manos  y  antebrazos  con  agua  tibia,  jab6n  y 
eepillo,  operaci6n  que  repetiri  antes  de  ordeilar  cada  vaca,  y  a(in  durante  el  ordefio 
de  cada  una,  si  se  le  ensucian  entonces. 

Art.  152.  El  banquillo  del  ordefiadcM*  ser&  de  fidl  limpieza  y  estard  limpio  siempre. 

El  ordefiador  lo  llevari  sujeto  a  su  cuerpo,  a  fin  de  no  tener  que  tocarlo  con  sub  manos 
durante  el  ordefio. 

Abt.  153.  Durante  el  ordefio,  el  operador  evitari  tocar  con  las  manos  el  cuerpo  de 
la  vaca,  salvo  sus  tetas  ya  lunpias,  a  fin  de  no  ensucitoelas  o  contaminirselas.  Tnk 
tar6  de  mantener  el  animal  en  posicidn  conveniente  sin  tocarlo  con  las  manos. 

Art.  154.  £1  ordefio  se  hard  a  seco  (tetas  y  ubre  de  la  vaca  y  manos  del  operador 
eecas  durante  toda  la  operaci6n). 

Se  prohibe  ezpresamente  ponerse  saliva  en  las  manos,  o  mojteelas  o  mojar  las  tetaa 
oon  la  misma  leche  de  la  vaca.  Quien  haga  esto  incurrird  en  multa  de  den  pesos,  sin 
perjuicio  de  exigir,  si  se  estima  conveniente,  que  sea  eliminado  del  personal  del  esta- 
blecimiento. 

Abt.  155.  Los  tres  primeros  chorros  de  leche  de  cada  teta  ser&n  recogidos  aparte  y 
no  s^in  utilizados  en  ninguna  forma  para  el  consume  de  las  peraonas. 

Art.  156.  Los  recipientes  en  que  se  ordefie  la  leche  eetar&n  perfectamente  limpios 
y  esterilizadoe  a  seco. 

Su  boca  no  tendr&  nunca  mis  de  veinte  centfmetros  de  diimetro.  Se  preferirin  loe 
recipientes  con  embudo  y  filtro  de  algod6n  o  con  tapa  y  muy  pequefia  abertura  para 
la  entrada  de  la  leche. 

Abt.  157.  La  leche  que  se  haya  ensuciado  con  esti^rcol  o  en  otra  forma  cualquiera 
no  se  mezclar&  con  la  leche  limpia  ni  se  contar&  como  leche  de  primera  calidad  ceiv 
tificada. 

Abt.  158.  En  seguida  de  ordefiada  la  leche  se  echari  en  un  recipiente  colector,  a 
tiav^  de  un  filtro  que  le  serviri  de  tapa. 

La  leche  se  retirar&  prontamente  dd  establo,  para  evitar  en  lo  posible  que  se  con- 
famine  y  que  tome  el  olor  de  los  animales  o  del  esti^rcol.  A  estos  fines,  serd  preferible 
lener  el  redpiente  colector  fuera  dd  establo,  en  un  lugar  limpio  y  protegido  del  polvo 
y  de  las  moscas. 

Del  establo,  o  del  lugar  donde  se  halle  d  recipiente  colector,  la  leche  ser&  pasada 
inmediata  y  directamente  a  la  lecherfa.  A  ^sta  no  deberin  entrar  los  ordefiadores 
que  traigan  la  leche. 

Sn  todo  el  transcurso  desde  el  ordefio  hasta  su  llegada  a  la  lecherfa,  el  producto  seri 
protegido  contra  las  causas  de  contaminad6n. 

6.  LSCHXmtA  T  rREFARACl6N  DE  LA  LSCHX  DK  PBIMKBA  CALIDAD  CEBTlftCADA. 

Art.  159.  En  todo  cstablecimiento  productor  de  leche  de  primera  calidad  certifi- 
cada  habri  una  lecherfa,  o  sea  un  local  a  propMto,  donde  se  manipule  y  prepare  la 
leche  para  la  venta.  Ella  conssBtiii  por  lo  menos  en  dos  piezas  construidas  totalmente 
de  material  (obra  de  Mbrica),  una  destinada  a  la  limpieza  y  esterilizad6n  de  envases, 
redpientes,  Utiles,  etc.,  y  la  otra  a  la  mezda,  filtrado,  enfriamiento,  conservaddn  y 
envase  de  la  leche. 

Art.  160.  La  lecherfa  estari  pr6xima  al  establo,  pero  no  en  comunicaddn  con  d. 

En  cuanto  a  su  emplazamiento,  orientaci6n,  ubicaci6n  re8i)ecto  de  otras  instala* 
denes,  locales  o  lugares  y  estado  y  mantenimiento  del  terrene  drcundante,  habrd  que 
Uenar  las  condidones  indicadas  para  d  establo,  en  lo  que  le  sean  aplicables. 


158       PBOGEEDINGS  8E00ND  PAN  AMEBIGAN  SOIBNTIFIC  C0KGBB88. 

Ser6  amplia,  bien  ventilada,  soca,  fresca,  con  abundante  luz  natiml,  de  ttdl 
limpiesa  y  desinfeccidn  y  completamente  coimtniida  de  mamposterfo.  Todo  sa 
interior  estari  recubierto  de  revestiniiento  de  material  (obra  de  ttbrica),  liso, 
impermeable^  bianco  y  lavable.  Los  dnguloe  de  las  paredes  entie  sf  y  con  ei  piso  y 
cielo-raso  ser&n  redondeados.  Satisfoii,  por  lo  dem^,  todas  las  condiciones  eetableddas 
en  lo0  artfculos  63,  64  y  65,  en  cuanto  le  sean  aplicables. 

No  se  hallMrd  en  comunicaci6n  directa  jon  habitadones  de  personas. 

Oada  8ubdiyiBi6n  de  la  misma  estari  provista  del  equipo  y  Mementos  n^cesanos  pant 
lo8  fines  a  que  se  destina. 

En  ella  no  se  introdudii  ni  manipular&  otra  leche  m&B  que  la  de  {Hrimera  caHdad 
certificada,  ni  se  introduciid  ni  tendri  nada  que  no  sea  necesario  para  tiatar  esta 
leche. 

Abt.  161.  En  seg:uida  de  venir  la  leche  del  establo,  se  mezclard,  se  filtraii  nueva- 
mente,  se  enlriaiA  a  dies  grades  o  menos  y  se  envasari  en  lia  botellas  en  que  seriL 
entregada  al  coneunudor,  que  ser&n  inmediatamente  cerradas  y  selladas  en  la  fonna 
en  que  debe  redbirlas. 

Deede  entonces,  la  leche  serd  mantenida  continuamente  a  diez  grades  de  temperatnra 
o  menos. 

Art.  162.  No  de  mezclar&  la  leche  de  distintos  ordefios,  aunque  ^toe  sean  del 
mismo  dia,  debiendo  venderse  aparte  la  de  cada  uno. 

Art.  163.  La  leche  envasada  y  lista  para  la  venta  ser^  tratada  en  forma  que  loe 
envases  no  se  ensucien  exteriormente.  Las  botellas  o  redpientes  estar^n  perfecta- 
mente  limpios  al  entregarlos  al  consumidor. 

Art.  164.  Todos  loe  recipientes  usados  en  el  ordefio,  recolecci6n,  filtraci<5n,  mezda, 
enfiiamiento,  medida  y  envase  de  la  leche,  aef  como  los  filtros,  serdn  de  chapa  de 
hierro  o  acero  sin  costura  y  estafiados  en  capa  gruesa.  Los  refrigeradores,  m^quinas 
de  envasar,  etc.,  ser^  del  mismo  material  en  las  partes  que  entren  en  contacto 
con  la  leche. 

Recipientes  y  todos  los  Utiles  y  maquinaria  serin  de  fidl  limpieza  y  deBiniecci6n 
y  se  hallaiin  siempre  en  buen  estado  de  conservaci6n.  Se  consideiari  que  no  lo 
estin,  cuando  por  sus  condiciones  la  limpieza  y  desinfecddn  no  puedan  hacerse 
{4cilmente. 

Art.  165.  Los  redpientes,  utensilios  y  mdquinas  de  que  se  trata  en  el  precedente 
artfculo  serdn  mantenidos  siempre  en  perfecto  estado  de  limpieza. 

En  seguida  de  usarios  ser&n  limpiados  en  la  forma  indicada  en  el  articulo  26. 

Los  filtros,  tolas,  pafios,  toallas,  etc.,  usados  en  el  ordefio  y  para  el  secado  de  titiles 
y  redpientes  que  se  hallen  en  contacto  con  la  leche,  despu^  de  bien  lavados  y  some- 
tidos  a  la  ebullid6n,  serdn  esterilizados  a  seco  a  120°  de  temperatura  por  lo  menos. 

Despu^  de  lavados  y  limpios,  los  dtiles  y  redpientes  hasta  de  sesenta  litres  de 
capaddad  que  outran  en  contacto  con  la  leche,  ser&n  esterilizados  de  igual  manera. 

Todos  los  dtUes,  mitquinas  y  redpientes  de  mayor  tamafio,  despu^  de  limpiados 
en  la  forma  ya  indicada,  ser&n  esterilizados  con  agua  hirviente  o  a  chorro  de  va^ 
bajo  presi6n  y  despu^  secados  con  trapes  esterilizados. 

Todo  lo  mencionado  en  el  presente  artfculo,  despu^  de  esterilizado,  seri  resguardado 
de  contaminadones  hasta  el  memento  de  usarlo  nuevamente. 

Art.  166.  Durante  el  trabajo,  las  personas  ocupadas  en  la  lecheria  vestirin  panta- 
lones  0  sobre-pantalones,  saco  cerrado  y  largo  o  delantal  y  gorro,  todo  bianco,  lavable 
y  limpio.    Oada  persona  deberi  estar  provista  por  lo  menos  de  tres  mudas  de  esa  ropa. 

Mientras  est^n  ocupadas,  esas  personas  tendrin  sus  manos  y  antebrazoe  descubiertos 
y  perfectamente  limpios. 

7.  ABBO  T  SSTADO  SANTTABIO  DE    LAS  PSB80NAB  QUI   UlTZ*VIJOI|ltJI  BN   LA  PBODVOaON  DB  LBCHB  DB 

rSniBBA  CALIDAD  CBBTIflCADA. 

Art.  167.  Esas  personas  serdn  aseadas  y  observardn  en  todo  la  mayor  limpieza 
posible. 


PUBUO  HEALTH  AND  MBDIOIKB.  159 

La  adiiiinuitraci6n  samtaiia  podii  exigir  que  las  que  no  BatiBfagan  estas  condicioneB 
eean  excluidas  del  establecimiento. 

Art.  168.  Eetaiin  libies  de  enfermedadee  contagioeas  que  puedan  transmitine 
por  la  leche  y  de  las  que  se  mencionan  en  ek  artfculo  99. 

Antes  de  entarar  a  fwrnar  parte  del  personal  del  establecimiento,  tendr&n  que  pro- 
veerse  de  un  certificado  de reviBaci6n  m^ca  expedido  por  la administracidn  sanitaria. 
Ese  certificado  se  renovar&  cada  seis  meses. 

La  inobse^^acia  de  estas  disposiciones  ser6  penada  con  multa  de  cien  pesos,  sin 
peijuicio  de  prohibirse  la  introducddn  y  venta  de  la  leche  en  la  ciudad  mientxas 
ella  no  sea  cumplida. 

Art.  169.  No  estaiin  en  contacto  con  otras  personas  afectadas  de  enfermedades 
contagiosas  de  las  indicadas  en  el  articulo  precedente. 

Los  que  lo  lia3ran  estado  no  deber&n  intervenir  en  las  faenas  que  les  conrespondan, 
hasta  despu^  de  ser  autorizadas  por  la  administraci^n  sanitaria. 

La  infiacci6n  de  este  articulo  dar&  lugar  a  las  medidas  indicadas  en  el  articulo 
precedente. 

Art.  170.  El  propietario  est&  obligado  a  avisar  a  la  admmistraci6n  sanitaria  de 
todo  case  de  enfermedad  que  se  produzca  en  su  establecimiento  o  entre  las  personas 
del  mismo,  acompafiando  un  certificado  m^co  en  que  conste  la  enfermedad  de 
que  se  trata,  si  el  enlermo  no  puede  presentarse  a  ella  para  ser  examinado. 

La  inobservanda  de  esta  di8po8ici6n  S6r6  penada  con  multa  de  doscientoe  pesos, 
si  la  enfermedad  no  es  contagiosa,  y  con  la  prohibici45n  definitiva  de  introdudr  y 
vender  la  lecde  en  la  Capital,  en  case  de  tratarse  de  alguna  de  las  enlennedades  con- 
tagiosas indicadas  en  ek  articulo  168. 

S.  TlQILAirCIA  8AHRABIA    DE   LOS   S8TABL1CIMIENT08   PBODVCTOaSS    DE   LBCHX    DB   nUMXBA  CAUDAD 

CBBnnCADA  T  BSTllCULOB  PAKA  LOS  IflSMOS. 

Art.  171.  Un  veterinaiio  inspects  inspeccionarA  dichos  establecimientos  por  lo 
menos  una  vez  por  mes. 

La  administraci(Sn  sanitaria  podxi  disponer  que  tales  inspecdones  se  repitan  cuantas 
voces  lo  estime  conveniente  o  necesario. 

El  veterinario,  ademis  de  los  animales,  inspeccionaWl  el  campo,  los  edificlos  e 
instaladones,  los  forrajes,  las  aguas,  las  miquinas,  envases  y,  en  general,  todo  lo  que 
haya  que  tener  en  cuenta  en  la  producci6n  de  leche  higi^nica,  y  vigilari  asimismo 
el  aseo  y  estado  sanitario  de  las  personas  y  los  procedimientos  usados  en  esa  pro4ucci6n. 

Podrd  recoger  muestras  de  aguas,  leche,  forrajes,  etc.,  cuantes  veces  lo  estime 
necesario  o  conveniente. 

Los  gastos  de  viaje,  hospedaje  y  comida  del  veterinario  en  las  inspecdones  ser&n 
coeteados  por  los  propietarios  de  los  establecimientos.  En  case  de  negativa  a  abonar 
estos  gastos  en  la  forma  y  plazos  que  fije  la  administracidn  sanitaria,  ^sta  podii  prohibir 
la  introducci6n  y  venta  de  la  leche  en  la  Capital. 

Art.  172.  A  los  establecimientos  que  no  llenen  las  condiciones  prescritas  en  esta 
ordenanza  en  cuanto  a  instalaciones  e  implementos  no  se  les  permitiri  introducir 
ni  vender  en  la  Capital  leche  de  primera  csdidad  certificada. 

En  cuanto  a  su  estado  y  funcionamiento,  el  inspector  ela8ificar&  por  un  sistema  de 
puntos  que  fiijard  la  admLaistraci6n  sanitaria,  y  por  separado,  todos  y  cada  uno  de  los 
elementos  que  deben  tenerse  en  conaideraci6n  al  producir  leche  higi6nica.  Esa 
clasificaci6n  se  hard  en  cada  visita  o  inspecci6n  del  establecimiento  y  de  ella  se  entregard 
siempre  una  copia  al  interesado. 

Se  consideraii  en  condiciones  deficientes  el  establecimiento  cuyos  puntos  parciales 
no  sumen  en  total  el  85  por  clento  por  lo  menos  del  total  mdximo  fijado  por  la  admi- 
nistraci6n  sanitaria. 

Laclasificaci6n  de  defidente  serd  seguidade  un  aviso  al  interesado,  para  que  trate  de 
salvar  las  imperfecciones  existentes.    Un  mes  despu^  de  la  primera  cla8ificaci6n  de 


160       PROCEEDINGS  SECOND  PAN  AMEBICAN  SCIENTTPIO  C0NQBE8S. 

deficiente  se  procederd  a  una  nueva  inspecci6n  y  clasificacidn,  y,  si  el  resultado  de 
^9ta  68  el  mismo,  no  se  pennitird  la  introduccidn  y  venta  de  la  leche  respectiva  en  el 
mnnicipio. 

A  los  estableclmientos  cuya  claaificacl6n  total  no  pase  del  75  por  ciento  se  les  i»t>- 
hibird  InmediatameDte  esa  introducci6n  y  venta. 

Art.  173.  Los  interesados  podrdn  poner  en  las  etiquetas  de  los  en  vases,  en  loo 
lugares  de  venta,  en  los  avisos  en  que  ofrezcan  su  producto,  etc.,  las  claslficaciones 
obtenidas  por  stis  estableclmientos,  asf  como  las  proporciones  de  gordura  y  de  microbios 
de  la  leche  que  venden.  Pero  siempre  que  lo  hagan,  serdn  las  dltimas  clasificaciones 
obtenidas  a  esos  respectos  de  la  administraci6n  sanitaria  las  que  deberdn  bacer  coostar. 

La  adnilnistraci6n  sanitaria  podrd  publlcar  las  clasificaciones  obtenidas  por  loo 
estableclmientos  y  sus  productos,  a  fin  de  que  el  pdblico  sepa  cuilee  son  los 
mejores. 

Aniudmente  la  administracidn  sanitaria  discernird  un  premio,  consistente  en  mil 
pesos  m.  n.  y  un  diploma,  al  establecimiento  que  haya  conseguldo  mds  altas  claslfica- 
clones  eii  cl  afto  y  cuya  leche  durante  el  mismo  plazo  haya  sido  de  mejor  calidad. 
Para  estr*  se  tomard  en  consideracidn  las  duce  planillas  de  clasificaci6n  mds  alta  de 
cada  establecimiento  y  el  resultado  de  los  exdmenes  de  por  lo  menos  doce  muestraa 
de  leche  de  cada  uno,  tomadas  mds  o  menos  al  mismo  tiempo  en  todos  ellos.  No  se 
tendrdn  en  cuenta  las  planillas  de  claalficacidn  correspondientes  a  inspecciones  pedidas 
por  los  interesados  ni  los  exdmenes  de  leche  solicitados  por  ellos.  Se  considerard 
leche  de  mejor  calidad  la  que  supere  en  mayor  grade  las  condiciones  establecldas 
en  el  artfculo  2.  Este  premio  no  empezard  a  discemirse  hasta  despu^  de  pasado  un 
afio  de  existir  por  lo  menos  dos  estableclmientos  productores  de  leche  de  primera 
calidad  certificada. 

Art.  174.  Las  condiciones  enimciadas  en  este  capftulo  en  cuanto  a  los  establecl- 
mientos implementos  y  procedimientos  de  lecherla  son  las  mini  mas  que  deben  cum- 
pllrse.  Pero  los  interesados  podrdu  apartarse  de  ellas,  siempre  que  sea  para  mejorarlaa 
0  superarlas  del  pimto  de  vista  higi^nico,  sin  afectar  los  procedimientos  de  contralor 
sanitario,  y  previa  aprobaci6n  de  la  administraci6n  sanitaria,  quien  decidird  sin  apela- 

ci6n  sobre  el  cardcter  de  los  cambios  o  innovaciones  propuestos. 

CAPfnTLO   X.   TAMBOS  URBAN08. 

Art.  175.  Los  tambos  que  se  establezcan  en  la  capital  despu^s  del  dfa  de  promul- 
gaci6n  de  la  presente  ordenanza  estardn  constituidoa  cuando  menos,  por  el  establo, 
el  local  de  manipulacionee,  un  local  de  despacho  que  satisfaga  las  condiciones  espe* 
cificadas  en  el  Capftulo  VI,  el  dep6sito  de  forrajes  y  un  "paddock"  para  el  ejercicio 
de  las  vacas  y  estardn  provistos  de  un  dep6sito  adecuado  para  el  esti^rcol. 

Art.  176.  El  establo  serd  todo  de  mamposterfa  y  hierro.  No  x>odrd  haber  en  H 
otras  obras  de  madera  mds  que  las  puertas  y  ventanas. 

Estard  provisto  de  cielo-raso  de  acero  esmaltado  o  de  mamposterfa,  liso  y  de  color 
daro.  £n  sus  partes  mds  bajas,  ^ste  se  hallard  a  una  altura  de  5  metroe  sobre  el  piso 
por  lo  menos. 

En  todo  lo  demds  (construcci6n,  disposicidn  y  naturaleza  materialee  del  edificio 
y  de  sus  instalaciones  interiores,  ventilaci6n,  humedad,  temperatura,  mantenimiento, 
limpieza,  servicio  de  agua,  etc.)  habrd  que  satisfacer  en  cuanto  a  este  establo  las  con- 
diciones enundadas  en  los  artfculos  122  a  137. 

Art.  177.  El  local  de  manipulaciones  o  lecherfa  podrd  estar  en  comumcaci6n  con 
e)  puesto  de  venta  por  intermedio  de  una  puerta  que  se  abrird  s61o  para  pasar  y  provista 
de  mecanismo  de  cierre  automdtico,  pero  no  deberd  estarlo  con  el  establo,  ni  con  habita- 
ciones,  ni  con  el  dep6sito  de  forrajes.  En  todo  lo  demds,  la  lecherfa  responderd  a 
las  condiciones  enunciadas  en  los  artfculos  159  a  166  y  en  los  en  ellos  mencionadoe. 

Art.  178.  El  dep^sito  de  forrajes  serd  todo  de  mamposterfa,  interior  y  exteriormente 
revocado  y  de  acuerdo  en  todo  lo  demds  con  lo  estableddo  en  el  artfculo  119. 


PUBLIO  HEALTH  AND  MEDICINE.  161 

Abt.  179.  El  "paddock"  o  corral  de  ejerdcio  de  las  vacas  seri  al  aire  libre,  tendr& 
por  lo  menos  10  metros  de  di^etro  en  cualquier  sentido,  estard  provisto  de  piso  blando 
y  con  drenaje  y  rodeado  de  cerco  de  superfide  lisa  y  redondeada,  todo  de  f&cil  limpieza. 

8us  partes  de  madera  eetar&n  pintadas  de  bianco.  £1  blanqueo  se  renovard  toda 
vez  que  se  halle  en  mal  estado.    Si  es  con  cal,  se  repetiri  por  lo  menos  cada  seis  meses. 

Art.  180.  El  dep6sito  de  esti^rcol  serd  de  mamposterla,  recubierto  interior  y 
exteriormente  de  espesa  capa  de  cemento  impermeable  o  de  material  an&logo  y 
tendr&  tapa  metdlica,  cano  de  ventilaci6n  y  buen  drenaje. 

Art.  181.  Todo  el  terrene  libre  de  edificios  que  ocupe  el  tambo,  ezceptuado  el 
'' paddock, '^  estard  recubierto  de  piso  s61ido,  impermeablOi  bien  drenado  y  liso,  esto 
tiltimo  hasta  donde  lo  permita  la  estabilidad  de  la  marcha  de  los  animalee. 

Art.  182.  A  distanda  de  quince  metros  del  establo  y  de  la  lecherfa  no  habri  ester- 
coleros,  letrinas,  depiSsitos  de  residues,  gallineros,  caballerizas,  etc.,  ni  nada  que  d^ 
males  olores  o  atraiga  moscas  en  abundancia. 

Art.  183.  Las  vacas  permanecer&n  sueltas  en  el  "paddock  '*  de  ejercicio  por  lo  menos 
tres  horas  diarias,  salvo  que  el  mal  tiempo  no  lo  permita. 

Art.  184.  En  cuanto  al  estado  sanitario  de  las  vacas,  su  alimentad6n  y  ordefio, 
aseo  y  estado  sanitario  de  las  personas,  mantenimiento  y  limpieza  del  establecimiento 
y  de  los  animales,  manipulaciones  de  la  leche  y,  en  general,  en  cuanto  a  todo  aquello 
para  lo  cual  no  se  hayan  fijado  condiciones  especiales  en  este  capitulo,  los  tambos 
urbanos  Uenar^  todas  las  estableddas  al  respecto  para  los  establecimientos  produc- 
tores  de  leche  de  primera  calidad  certificada,  en  lo  que  le  sean  aplicables. 

Art.  185.  Los  tambos  que  se  abran  al  pdblico  despu^  de  la  promulgacidn  de  la 
presente  ordenanza  se  considerar&n  como  de  primera  categorla  y  deberdn  Uevar  en  el 
irente  el  siguiente  letrero,  en  grandes  caracteres  de  molde:  "Tambo  de  primera  cate- 
gorla." 

S61o  esos  tambos  podr&n  llevar  este  letrero. 

Despu^s  de  dos  meses  de  abierto  el  primero  de  esos  tambos,  todos  los  otros,  estableci- 
dos  antes  de  la  promulgad6n  de  esta  ordenanza,  deber&n  llevar  en  su  frente,  en  el  lugar 
m&a  visible  y  en  grandes  caracteres  de  molde,  el  siguiente  letrero:  "Tambo  de  segunda 
categorla. " 

Art.  186.  Todo  tambo  de  los  existentes  antes  de  la  promulgad6n  de  la  presente 
ordenanza,  que  despu^  se  reconstruya,  amplle  o  cambie  de  duefio,  serd  considerado 
como  establecimiento  nuevo,  y  regir&n  para  €i  las  prescripciones  de  este  capitulo, 
lelativas  a  los  que  se  estabiezcan  despu^  de  dicha  promulgaci6n. 

Art.  187.  Los  tambos  modelos  munidpales  arreglar&n  los  precios  de  sus  productoi 
en  forma  que  no  puedan  competjr  con  los  de  los  tambos  de  primera  categorla. 

capItulo  zi.  vigilancia  del  comercio  db  lechb. 

Art.  188.  La  aplicad6n  de  esta  ordenanza  y,  en  general,  todo  lo  relative  a  la  vigi* 
lancia  sanitaria  del  comerdo  de  leche  y  de  sus  derivados,  estard  a  caigo  de  la  Oficina 
Contralor  de  la  Leche  de  la  Administrad6n  Sanitaria. 

Art.  189.  Los  productores  o  tamberos  que  envlan  leche  de  primera  calidad  a  la 
capital  permitirdn  que  los  empleados  de  la  susodicha  oficina  recojan  muestras  de 
leche  en  el  mismo  tambo  rural,  en  las  estaciones  ferroviarias  de  embarque  o  en  cual- 
quier otra  parte,  fuera  y  dentro  del  municipio,  asl  como  de  las  aguas  usadas  en  sus 
establecimientos,  y  prestardn  a  esos  empleados  toda  su  cooperaci6n,  a  fin  de  que  la 
recolecci6n  pueda  hacerse  en  la  forma  y  con  las  garantlas  necesarias  para  deecartar 
cualquier  error  o  fraude  y  sin  molestias  personales  injustificadas.  Let  falta  de  co- 
operaci6n  en  este  sentido  serd  considerada  como  una  negativa  a  permitir  la  recolec- 
ci6n  de  las  muestras. 

Iguales  obligaciones  tienen  las  empresas,  establecimientos  o  personas  que  envfen 
leche  de  primera  calidad  a  la  capital,  procedente  de  distintos  tambos  o  establed- 
mlentos  productores,  corriendo  por  cuenta  de  ellos  el  asegurarse  de  que  estos  61timofl 


162       PB00EEDING8  SECOND  PAK  AMBBICAK  80IBKTIFI0  OONGBESS. 

cumplan  la  obligacidn  de  permitir  la  recolecci6n  de  las  muestraa  en  sub  tambos  o  en 
el  trayecto  de  ^stos  a  la  faictorfa  o  lugar  de  recibo  de  la  leche  por  dichas  empresas. 

Loe  inspectores  municipales  podr&n  presentane  sin  previo  aviso  a  tomar  las  mues- 
tras,  de  modo  que  los  interesados  debc^in  disponer  lo  necesario  a  fin  de  que  atin  en 
flu  ausencia  ellos  puedan  cumpllr  su  misi6n. 

Abt.  190.  Los  gastos  de  fenocarril,  coche,  hoqpedaje  y  comida  que  tengan  que 
hacer  los  empleados  encaigados  de  recoger  las  muestras  indicadas  en  el  articulo 
precedente  ser&n  abonados  por  los  tamberos  o  producU»es,  si  ^stos  envian  diiecta- 
mente  o  por  su  cuenta  la  leche  a  la  capital,  o  por  las  otras  empresas  o  personas  mencio- 
nadas  en  el  mismo  articulo,  en  case  de  ser  ^stas  las  que  remitan  la  leche. 

En  ningtin  case,  los  tamberos  o  productores  tendr4n  que  abonar  por  tales  conceptos 
m&B  de  250  pesos  anuales,  si  sus  eetabledmientos  se  hallan  a  100  kil<knetros  o  menoe 
de  la  capital,  o  m&B  de  350  pesos,  si  ^stos  se  hallan  a  m&B  de  100  ldl6metros  de  la  ca- 
pital, ni  las  empresas  o  las  personas  que  envien  leche  de  varies  productores  tendrin 
que  abonar  anualmente  m&s  de  esas  sumas  multiplicadas  por  el  ntunero  de  produc- 
tores de  qulenes  recojan  la  leche.    £1  exceso  8er&  costeado  por  la  municipalidad. 

Esos  gastos  ser&n  abonados  despu^  de  cada  intervenci6n  o  viaje  de  loe  empleados 
municipales,  en  la  forma  y  plazos  que  fije  la  admim8tiaci6n  sanitaria. 

La  adminiBtraci6n  sanitaria  dispondhl  que  se  recojan  muestras  de  leche  fuera  del 
municipio  s61o  cuando  sea  estrictamente  necesario  para  efectuar  an^Uisis  compani- 
tivos  con  muestras  de  las  mismas  leches  tomadas  antes  o  despu^  en  la  capital  y  tn^ 
tar&  de  que  los  gastos  que  deban  costear  los  producU»es  o  remitentes  se  reduzcan  at 
minimum  posible.  Las  muestras  de  agua  se  tomar&n  con  ocasi6n  de  la  recolecci6n 
de  las  de  leche. 

Las  in&acciones  de  este  articulo  o  del  precedente  ser&n  seguidas  de  la  prohibici6n 
de  introducir  leche  a  la  capital,  so  pena  de  decomisarla  a  su  arribo,  a  menos  que  loe 
interesados  abonen  una  multa  de  100  a  500  pesos,  segdn  la  gravedad  del  caso.  A  la 
tercera  infracci6n  del  articulo  189,  se  prohibiri  definitivamente  la  introducci6n  y 
venta  en  el  municipio  de  leche  de  primera  calidad  procedente  del  establecimiento 
respective. 

Art.  191.  Los  propietarioe  de  lecherfas  o  bus  representantes  permitir6n  en  cual- 
quier  memento  la  inspeccidn  de  sus  establecimientos  por  los  empleados  de  la  ad- 
cniniBtraci6n  sanitaria,  que  podrin  inspeccionar  todos  los  compartimientos  o  sec- 
ciones  del  establecimiento  y  todo  lo  que  se  halle  dentro  de  los  mismos,  asf  como  re- 
visar  los  certificados  mMicos  del  propietario  y  de  todo  el  personal,  y  a  quienes  debe- 
Hn  prestar  la  cooperaci6n  necesaria  para  que  puedan  desempefiarse  en  la  forma  que 
m&B  convenga  para  evitar  errores  o  fraudes  y  sin  sufrir  molestias  personales  injusti- 
ficadas.  La  fadta  de  cooperaci6n  en  este  sentido  se  considenu:i  como  una  negativa 
a  permitir  la  inspeccidn. 

Las  mismas  obligaciones,  tiene  toda  persona  que  se  dediqueal  comerciode  ledierfa 
o  que  venda  leche,  en  cuanto  al  local  de  que  se  trata  en  el  capitulo  V,  las  empresas 
o  firmas  que  se  dediquen  a  la  pasteurizaci6n  o  higienizaci6n  de  la  leche  o  a  cualquier 
otra  operaci6n  con  ella  o  sus  derivados,  en  cuanto  a  bus  respectivos  establecimientos  , 
y  los  lecheros  ambulantes,  en  lo  que  se  refiere  a  bus  vehiculoe  en  circulaci6n  o  en 
depdsito. 

Art.  192.  Toda  persona,  empresa,  sociedad  o  fiima  que  intervenga  en  cualquier 
forma  en  el  comercio  de  leche  dentro  de  la  Capital,  asi  como  bus  empleadoB,  permitiiin 
que  en  cualquier  memento  y  en  cualquier  parte  los  empleados  de  la  administraci6n 
sanitaria  examinen  la  leche  que  reciban,  tengan  o  lleven  y  tomen  muestras  de  la 
misma  y  de  tantos  recipientes  como  lo  consideren  conveniente,  sin  exigir  retribuci6n 
alguna,  y  les  prestardn  la  cooperaci6n  indicada  en  el  articulo  189,  cuya  &dta  serd 
considerada  como  una  negativa. 

Las  infracciones  de  este  articulo  y  las  del  precedente  tendr6n  las  mismas  penas 
que  las  del  articulo  8.    £1  establecimiento  serd  clausurado  en  cada  caso  o  no  se  per- 


PUBUO  HEALTH  AND  MEDIOINE.  168 

mitM  la  circulaci6n  del  vehfculo,  ri  se  trata  de  ^ete,  haata  que  el  intereeado  deponga 
eu  opodcidn  o  resistencia. 

Art.  193.  La  administracidn  sanitaria  podi&  eetablecer  servicioe  de  vigilancia  per- 
manentee  en  laa  usinas,  f&bricas,  etc.,  cuyos  productos  de  lecherfa  se  introduzcan 
o  vendan  en  el  municipio  para  consumo. 

Eee  servido  serd  coeteado  por  las  empresas  cuando  sns  usinas  o  f&bricas  se  hallen 
fnera  del  municipio.  En  eete  case  las  empreaas  estarto  tambito  obligadas  a  dar 
alojamiento  conveniente  a  loe  empleadoe  de  la  admini8traci6n  sanitaria. 

Cuando  ^sta  lo  juzgue  conveniente,  segtin  la  importancia  de  loe  establecimientos 
mencionadoe  en  este  artf  culo,  podri  exigir  que  se  habilite  en  ellos  un  local  para  labo- 
ratorio,  provisto  de  los  elementoe  necesarios  para  el  an^isis  qufmico  y  bacteriol6g;ico 
de  la  leche  y  sua  derivados. 

Art.  194.  Las  mueetras  de  leche  de  que  se  trata  en  los  artfculos  189  y  192  ser&n 
dobles  y  se  lacrar&n  y  sellar&n  en  presencia  de  los  interesados  o  sus  representantes. 

Oada  una  llevar&  una  etiqueta  con  todos  los  datos  necesarios  para  individualizarlas. 

Si  el  interesado  lo  pide,  se  le  entregari  una  tercera  mueetra  igual  a  las  dos  primeras, 
envasada  y  preparada  en  iguales  condicionee. 

En  s^:uida  se  levantar&  un  acta  por  duplicado,  en  que  consten  todas  las  circuns- 
tancias  y  detalles  necesarios  para  precisar  el  acto,  y  que  serd  firmada  por  el  inspector 
y  el  intereeado.  En  case  de  negarse  a  firmar  ^te  tUtimo,  se  dejard  constancia  de 
ello  en  el  acta  y  se  hard  firmar  ^ta  por  un  testigo.  Una  de  las  actas  se  entregar&  al 
interesado. 

Una  de  las  dos  primeras  mueetras  eeri  analizada  lo  mis  r&pidamente  posible  en  la 
ofidna  contralor  de  la  leche  y  la  otra  serd  convenientemente  conservada,  para  el 
caeo  en  que  el  interesado  promueva  un  peritaje  contradictorio. 

CAPfTULO  Xn.   PERMI808. 

Art.  195.  Nadie  podr6  vender  leche  en  la  capital  sin  previo  penniso  de  la  adminis- 
traci6n  sanitaria,  bajo  pena  de  cien  pesos  de  multa,  dausura  inmediata  del  estable- 
dmiento  respective,  detenddn  de  los  carros  de  reparto  que  se  hallen  en  circulaci6n 
y  comiso  de  la  leche  consjgnada  al  responaable,  o  que  ^te  tenga  o  intente  vender. 

Las  personas  que  so  propongan  vender  leche  en  la  capital  deber&n  presentar  una 
solidtud  de  penniso  a  la  admini8trad6n  sanitaria,  en  un  formulario  especial  que 
^ta  les  proveer&,  en  que  consten  su  nombre  y  apdlido,  su  edad,  nacionalidad  y 
domicilio,  la  ubicad6n  de  su  establecimiento,  el  ntimero  de  litros  de  leche  que  venden 
diariamente,  la  calidad  de  la  misma  seglin  las  dispoeicionee  de  esta  ordenanaa,  su 
procedenda  y  las  horas  en  que  la  redbe,  y  el  nombre,  apellido,  nadonalidad  y  edad 
de  cada  una  de  las  personas  que  tenga  empleadas  en  su  negodo,  y  en  que  se  compro- 
meta  a  respetar  y  a  cumplir  las  prescripdonee  de  la  preeente  ordenanaa  en  las  partes 
que  le  atafien.  Adem^,  el  intereeado  acompafiari  a  su  solidtud  su  cMula  de  identi- 
dad,  expedida  por  la  polida  de  la  capital,  y  con  un  retrato,  un  retrato  suyo  de  perfil, 
suelto  y  de  6  por  5  centimetroe  y  los  certificados  mMicos  de  la  administrad6n  sani- 
taria para  4\  y  cada  uno  de  sus  empleados. 

El  retrato  suelto  quedar&  archivado  en  la  administraddn  sanitaria,  juntamente 
oon  loe  datos  realtivos  al  causante. 

La  persona  que  adquiere  un  negodo  cualquiera  de  lecherla  est4  obligada  a  cumplir 
todas  las  disposiciones  de  eete  artfculo,  aun  cuando  el  que  se  lo  venda  ya  las  haya 
cumplido. 

Desde  que  entre  a  regir  la  presente  ordenanza,  toda  persona  dedicada  al  comercio 
de  lecherfa  en  el  munidpio  estari  provista  del  penniso  aqul  indicado. 

Art.  196.  Todo  cambio  de  domicilio  o  de  ubicad^  de  lot  establedmientoB  aeri 
comunicado  antidpadamente  a  la  Adminiatraddn  Sanitaria. 

Loe  cambioe  del  personal  onpleado  en  el  negodo  se  comunicarim  inmediatamente 
a  la  misma,  dando  los  nombres  y  apellidos  de  loe  onpleados  saHentes  y  de  los  que 
entren  a  reemplazarlos  y  acompafiando  los  certificados  m^cos  de  estos  tdtimos. 

6843e— 17— VOL  X 12 


164       PBOOEEDINGS  SECOND  PAN  AMEBIOAN  60IENTIFI0  C0N0BE6S. 

Todas  estas  comunicadones  se  har^  por  eecrito. 

Art.  197.  No  podri  habilltarae  o  tisarae  ningdn  carro  de  reparto  de  leche  dentro 
de  la  capital  que  no  se  halle  aprobado  y  registrado  en  la  adminiatracidn  sanitaria,  s 
cuyo  efecto  los  interesados  presentar^  con  antlcipaci6n  a  la  misma  la  solicitud 
correspondiente. 

No  86  aprobardn  ni  registrardn  los  carros  mientras  las  peraonas  o  empresas  por  cuenta 
de  quienes  se  hard  el  reparto  no  est^  provistas  del  permiso  establecido  en  el  articulo 
195. 

Si  la  administraci6n  sanitaria  lo  estima  conveniente,  podrd  esdgir  que  los  cairos 
Ueven  £ija  en  un  lugar  visible,  en  vez  del  ntimoro  de  registro  pintado  o  a  la  vez  que 
^ste,  una  chapa  con  dicho  ntimero,  que  ella  entregard  a  los  interesados  mediante^el 
pago  de  Bu  costo  y  que  tendr&  el  valor  de  un  certificado  de  registro. 

Art.  198.  Dentro  del  mtmicipio,  nadie  podrd  ser  repartidor  ambulante  de  leche, 
por  cuenta  propia  o  por  la  de  otros,  sin  previo  permiso  de  la  administraci6n  sanitaria, 
bajo  pena  de  100  pesos  de  multa,  comiso  de  la  leche  y  detenci6n  del  carro  por  cuenta 
y  rieego  del  interesado  (art  91)  hasta  que  la  multa  sea  abonada  y  aqu61  se  provea  del 
permiso  correspondiente. 

A  tal  efecto,  toda  persona  que  se  proponga  repartir  leche  a  domicilio  presentard  anti- 
dpadamente  una  solicitud  de  permiso  a  la  administracidn  sanitaria,  en  el  formulaiio 
que  ^sta  le  proveerd,  en  que  constar^  todos  los  datos  que  debe  Uevar  la  libreta  de 
que  se  trata  en  el  artfculo  97  y  en  que  ella  se  comprometeri  a  respetar  y  a  cumplir  las 
prescripciones  de  la  presente  ordenanza  en  las  partes  que  le  atafien.  Adem^,  acom- 
pafiar&  a  su  solicitud  una  cMula  de  identidad  como  la  indicada  en  el  artfculo  195, 
dos  retratos  sueltos  como  los  alll  tambi^n  indicados,  uno  para  ser  pegado  en  dicha 
libreta  y  otro  para  quedar  archivado  en  la  administraci6n  sanitaria,  y  un  certificado 
m^co  extendido  jKjr  la  ofidna  respectiva  de  esta  dltima. 

La  adminlstraci6n  sanitaria  extender^  el  permiso  en  la  libreta  mendonada. 

En  cuanto  entre  a  r^gir  esta  ordenanza,  todos  los  lecheros  o  repartidores  ambulantes, 
deber^  estar  provistos  del  permiso  aquf  eetableddo. 

Arj.  199.  Todo  product(»r  o  lechero  que  se  proponga  introdudr  o  remitir  leche  al 
mnnidpio  debe  solidtar  antidpadamente  permiso  a  la  administraddn  sanitaria,  en 
un  formulaiio  especial  que  Ma  le  proveeri.  En  su  solidtud  dari  su  nombre  y  apeUido 
o  la  firma  comercial  del  negodo,  su  edad,  nadonalidad,  dcnnidlio,  ubicad6n  del  tambo, 
tannine  medio  de  vacas  que  ordefle  diariamente,  raza  de  las  mismas,  tdrmino  medio 
de  producci6n  de  leche  por  cabeza,  horas  a  que  ordefle  las  vacas,  superfide  de  campo 
en  hectdreas  que  ocui>a  con  su  tambo,  superfide  al&d&ida  o  con  otros  f  orrajes  artifidales, 
superfide  de  campo  con  pastosnatuiales,  dir&siel  campoesde  supropiedad  o  lo  tiodeen 
aniendo,  dando  en  este  dltimo  case  el  nombre  del  propietario,  dedarard  el  nombre  de  la 
estaddn  ferroviaria  de  embarque  de  la  leche,  las  horas  en  que  embaica  en  ellas  el  pro- 
ducto  de  cada  ordefio,  el  nombre  de  la  estaddn  mds  pr6xima  a  su  tambo  o  por  donde  sea 
mds  f dcil  el  acceso  de  personas  a  su  establedmiento.  Al  mismo  tiempo  se  comprometeri 
a  respetar  y  a  cumplir  en  las  partes  que  le  atafien  las  disposidones  de  la  presente 
ordenanza.  A  su  solidtud  acompafiard  una  c6dula  de  identidad,  con  retrato,  ezp^ 
dida  por  la  policla  del  lugar  donde  tenga  su  tambo,  en  que  deberd  constar  su  pro* 
feei6n,  y  un  retrato  suelto  de  perfil  y  de  5  por  5  centfmetros  por  lo  menos.  Este 
retrato  quedard  archivado  en  la  administrad^  sanitaria.  El  permiso  que  se  expida 
al  tambero  Uevard  el  ndmero  de  su  registro  en  la  adminiBtrad6n  sanituia. 

8i  la  leche  que  se  ha  de  remitir  a  la  capital  es  de  primera  calidad,  tambi^  habri 
que  acompafiar  a  la  solidtud  una  o  varias  muestras  de  las  aguas  usadas  en  el  estable- 
dmiento, recogidas  y  transportadas  en  la  forma  que  indique  la  administraddn  sani- 
taria, y  una  descripd6n  del  establedmiento  y  de  los  procedimientos  aplicados  en  el 
mismo. 

Si  se  trata  de  leche  de  primera  calidad  certificada,  ademds  de  todo  lo  indicado  en 
los  dos  pfoafos  precedentes  y  de  los  que  deba  exigir  la  administraddn  sanitaria  de 


PUBLIC   HEALTH  AND  MEDICINE.  166 

acuerdo  con  lo  establecido  en  el  Capf  tulo  IX,  deberd  acompatiarBe  un  piano  del  estable- 
eimiento  y  de  sua  edificios  e  instalaciones. 

Los  permisos  de  los  establecimientoe  que  remitan  leche  de  primera  calldad  certifi- 
cada  o  leche  de  primera  calidad  ser^  renovadoe  anualmente. 

En  cuanto  entre  a  regir  esta  ordenanza,  todos  loe  remitentes  de  leche  a  la  capital 
deberdn  eetar  provistos  del  permiso  aqni  establecido. 

Art.  200.  Las  f&bricas,  udnas,  etc.,  de  lecherfa  no  podr^  funcionar  dentro  del 
mnnicipio  ni  vender  sus  productos  sin  previo  permiso  de  la  administraci6n  sanitaria, 
que  solicitar&n  anticipadamente  de  la  misma,  dando  los  siguientes  datos:  nombre  de 
la  firma  o  empresa,  ubicaci6n  del  establecimiento,  capaddad  productiva  del  mismo 
y  cantidad  de  leche  con  que  empezard  a  funcionar,  clase  de  productos  que  ha  de 
preparar  o  con  que  ha  de  operar  u  operaciones  a  que  ha  de  someter  la  leche  y  forma 
en  que  ha  de  vender  sus  productos  (si  por  intermediaries  o  directamente  al  consumi- 
dor,  etc.)  y  acompafLando  una  descripci6n  del  establecimiento  y  de  las  maquinarias 
y  sistemas  aplicados,  ilustrada  con  pianos. 

Las  que  se  hallen  fuera  de  la  capital  tampoco  podr&n  introducir  bus  productos  sin 
eee  permiso  previo.  Estas  deber^  presentar  para  conseguirlo  una  solicitud  igual  a 
las  otras,  pero  que  contendrd  adem^  los  siguientes  datos:  distanda  del  estableci- 
miento a  la  estaci6n  de  embarque  de  los  productos,  ntimero  de  tamberos  o  productores 
de  quienes  recibird  la  leche,  efectivo  total  de  vacas  productoras  de  la  misma  y  forma 
en  que  ha  de  transportar  sus  productos  a  la  capital. 

Unas  y  otras,  en  su  solicitud  de  permiso  se  comprometerdn  a  respetar  y  a  cumpiir 
las  disposidones  de  la  presente  ordenanza  en  las  partes  que  les  atafien. 

Al  entrar  en  vigencia  esta  ordenanza,  las  fdbricas  instaladaa  dentro  o  fuera  del 
municipio,  que  introduzcan  o  vendan  bus  productos  en  el  mismo,  deberdn  estar 
provistas  de  nuevos  permisos,  de  acuerdo  con  lo  estableddo  en  este  artfculo. 

AsT.  201.  Para  introducir  o  vender  en  el  munidpio,  para  el  consume,  leches  que 
hayan  sufrido  preparadones  o  transformadones  especiales,  tales  como  leches  esteri- 
lizadas,  matemizadas,  kefir,  koumis,  yogurt,  etc.,  deberd  tenerse  previamente  un 
permiso  especial  de  la  administrad6n  sanitaria. 

Abt.  202.  Desde  la  promulgad6n  de  la  presente  ordenanza,  antes  de  abrirse  un 
tambo  nuevo  en  la  capital,  o  de  proseguir  fundonando,  despu^  de  reconstrufdo, 
ampliado  o  haber  cambiado  de  duefio,  alguno  de  los  existentes,  deberd  solidtarse 
permiso  de  la  administraci6n  sanitaria,  en  un  formulario  especial  y  con  los  requisitoe 
indicados  en  el  artfculo  195  y  para  los  establedmientos  productores  de  leche  de 
primera  calidad  certificada,  en  cuanto  sean  aplicables  al  caso. 

Abt.  203.  La  administraci6n  sanitaria  podrd  exigir  ademis  a  toda  persona,  firma, 
empresa  o  compafifa  cuyos  productos  de  lecherfa  se  introduzcan  o  vendan  para  el 
oonsumo  en  el  munidpio,  o  que  intervenga  en  cualquier  forma  en  el  comercio  de 
leche  y  sus  derivados  destinadoe  al  consume  en  el  mismo,  cuantos  datos  o  requisites 
■ean  necesarios  para  a8^;urar  el  cumplimiento  de  esta  ordenanza,  comprendida 
la  presentaddn  de  tftulos  de  propiedad,  contratos  de  sodedad  o  arrendamiento, 
redbos  de  alquiler,  etc. 

AsT.  204.  La  adminiBtrad6n  sanitaria  podrd  prohibir  temporariamente  la  intro- 
ducd6n  de  leche  al  munidpio  procedente  de  establedmientos  o  regiones  donde 
exista  alguna  epidemia  o  epizootia  que  constituya  ima  amenaza  para  la  salud  de  los 
consumidores  del  producto. 

AsT.  205.  La  Administrad6n  sanitaria  podrd  seflalar  o  fijar  los  lugares  por  donde 
deber&n  ser  introduddos  la  leche  y  sus  derivados  destinados  al  consume  en  la  capital. 

Abt.  206,  incise  1.  No  se  otorgard  ningtin  permiso  sin  cerciorarse  primero  de  si  el 
eolidtante  tiene  en  las  condidones  establecidas  en  esta  ordenanza  todos  los  elementos 
necesarios  para  el  comerdo  o  trabajo  a  que  se  va  a  dedicar. 

Indso  2.  La  ledie  que  llegue  sJ  mimidpio  de  establedmientos  o  remitentes  sin 
pefiniso  o  a  los  cuales  se  les  haya  retirado  6Bte  temporaria  o  definitivamente,  caer& 
en  comiso,  en  cualquier  parte  donde  se  encuentre.  " 


166       PROCEEDINGS  SECOND  PAN  AMERICAN  SOIENTIPIO  CONGRESS. 

Inciso  3.  La  repetici6n  de  las  infraccionee  o  faltas  bo  coii8iderar&  siempre  como 
circunstancia  agravante. 

Inciso  4.  A  los  que  se  nieguen  abiertamente  a  dar  cumplimiento  a  cualquiera  de  lae 
dispodciones  de  la  presente  ordenanza,  se  les  retiiar&n  los  permisoe  correepondientee 
y  se  les  clausurar&n  los  establedmientoe,  si  se  hallan  dentro  del  municipio. 

CAPfTULO  Xra.     IN8TRU0CIONB8,  CONSULTAS  Y  ANXlISIS   GRATXTITOS. 

Art.  207.  La  admini8traci6n  sanitaria  preparar&,  hard  imprimir  y  di8tribuir&  gra- 
tuitamente  a  los  interesados  instrucciones  sobre  la  manera  de  produdr  leche  higi6- 
nica  y  de  tratarla  hasta  el  momento  de  ser  consumida,  atenderi  en  la  misma  forma 
cualquier  consulta  que  se  le  formule  respecto  de  esas  cuestiones  y  asesorard  sobre  el 
terreno  a  quienes  lo  soliciten  y  abonen  todos  los  gastos  del  t6cnico  que  a  ese  efecto  se 
comisione. 

Analizari  tambi6n  gratuitamente  toda  muestra  de  leche  que  se  le  envfe,  asf  como 
de  las  aguas  empleadas  en  la  alimentaci6n  de  los  animales  de  lecheria  o  en  la  limpieza 
de  recipientes  y  utensilios  usados  en  la  misma  industaia,  siempre  que  ellas  sean  toma- 
das  y  remitidas  en  las  condiciones  que  ella  indique,  a  cuyo  efecto  los  interesados 
deber&n  dirigirse  primero  a  ella,  por  escrito  o  verbalmente,  pidiendo  instrucciones. 

Todos  estos  servicioe  ser&n  prestados  a  las  personas  del  gremio  de  lecheria  que 
tengan  sus  establecimientos  en  la  capital,  a  las  que  los  tengan  fuera  de  la  misma 
y  dentro  del  radio  de  aprovisionamiento  de  la  ciudad  y,  en  general,  a  todas  aquellas 
que  puedan  contarse  entre  bus  posibles  proveedores. 

Art.  208.  A  las  personas  que  por  cualquier  motive  no  puedan  hacerlo  por  s(  mismas 
y  que  lo  soliciten,  se  les  redactardn  en  la  Ofidna  de  Contralor  de  la  leche  los  docu- 
mentos  eecritos  que  deban  presentar  al  dirigirse  a  ella  en  cualquier  sentido. 

CAPItULO  XIV.   DI8P08ICI0NB8  TRAN8ITORIA8. 

Art.  209.  Las  partes  de  esta  ordenanza  relativas  a  la  leche  de  primera  calidad 
certificada,  a  la  leche  de  primera  calidad  y  a  los  tambos  urbanos  entrar&n  a  regir 
desde  la  fecha  de  su  promulgaci6n.  Todo  lo  dem^  a  los  dos  afioi  de  la  fecha  de  su 
promulgaci6n. 

Art.  210.  £1  D.  E.  reglamentard  la  presente  ordenanza. 

Art.  211.  Der6ganse  todas  las  disposiciones  que  se  opongan  a  la  misma. 

The  Chairman.  These  papers  really  constitute  what  might  be 
called  a  symposium,  and  may  be  discussed  as  such  at  this  time. 
I  will  therefore  ask  if  any  one  here  desires  to  make  any  remarks 
in  regard  to  the  papers  that  have  been  read. 

Dr.  Sedgwick.  Mr.  Chairman,  there  are  one  or  two  small  points  in 
the  way  of  addition  that  it  seems  to  me  might  be  made.  In  the  first 
place,  it  has  not  been  pointed  out  that  by  changing  values  we  can 
add  materially  to  some  of  our  food  supplies.  It  has  lately  been 
noted  in  the  newspapers  that  in  New  York  horseflesh  is  being 
recommended,  or  at  least  allowed  for  sale — a  very  proper  procedure, 
as  it  seems  to  me,  and  I  personally  look  forward  to  the  time  when 
a  good  many  animals  not  now  eaten  will  be  regarded  as  good  food. 

Another  point,  it  seems  to  me,  is  very  illuminating,  and  that  is 
in  confirmation  of  Dr.  Laspiur's  statement  that  transportation  has 
done  so  much  for  us  that  it  may  be  said  to  have  conquered  famines. 
I  had  occasion  some  years  ago  to  write  for  a  youths'  journal  a  paper 
on  the  conquest  of  famine,  and  I  was  very  much  struck  with  the 


PUBLIC  HEALTH  AND  MEDICINE.  167 

fact  that  since  we  have  good  transportation  the  important  civilized 
and  accessible  portions  of  the  world  have  had  no  famine.  Of  course, 
we  all  remember  the  terrible  famines  in  Ireland  in  1846-7,  or 
1848,  or  thereabouts,  and  as  far  as  I  know  that  period  was  the  last 
period  of  terrible  famine  along  the  Atlantic  or  Pacific  coasts,  barring, 
perhaps,  certain  places  in  China  and  Japan.  I  suppose  that  if  in 
1847  they  had  had  the  means  of  transportation  which  we  have 
to-day — certainly  if  they  had  had  the  means  of  cold  storage,  can- 
ning, and  all  that  has  come  up  since  our  Civil  War — the  awful  mor- 
tality of  Ireland  would  never  have  happened.  So  that  this  pro- 
cedure of  canning  and  cold  storage  and  other  methods  of  food 
preservation,  added  to  transportation,  have,  for  the  time  being  at 
any  rate,  brought  about  a  condition  which  we  may  well  call  the 
conquest  of  famine.  On  the  other  hand,  that  man  would  be  foolish 
who  did  not  give  heed  to  the  predictions  of  Sir  William  Crook  or  to 
those  of  Malthus,  and  keep  his  eye  well  to  windward,  watching  for 
improvements  and  betterments  of  the  food  supply.  Famines  still 
occur,  but  they  do  not  happen  when  a  charitable  public  is  able  to 
send  food.  It  was  not  able  to  send  food  in  1847  to  Ireland;  it  would 
be  able  to  send  it  to-day  and  send  it  in  great  abundance.  Those 
are  very  small  points,  but  the  paper  is  so  interesting  I  could  not 
refrain  from  adding  them. 

The  Chairman.  Does  any  one  wish  to  speak  on  this  very  inter- 
esting subject?  If  not,  the  other  paper  on  the  program  will  be 
read  by  title,  as  the  writer  is  not  present. 


VULGARIZAaON  CIENTlFICA— HIGIENE  BUCAL. 

Por  JULIO  L.  CATONI. 
Buenoi  AireSy  Argentina. 

C(mtribuci6n  al  dtfundimiento  de  conocimientot  HiiUi.  Aunque  es  diffdl  com- 
parar  entre  s(  la  distinta  importanda  de  lo8  diferentes  6iganos  del  cuerpo,  pueeto 
que  cada  uno  de  ellos  ee  necesario  a  la  economfa  y  sa  falta  produce  una  perturbaci6ii 
en  8U  actividad  regular,  Bin  embaigo  bien  puede  dedne  que  la  boca  ea  el  6igano 
m^  6til  del  cueipo,  pues  a  ella  estdn  encomendadas  muy  nobles  fundoneo.  En 
ella  se  encuentran  loa  dientee  que  tienen,  a  su  ves,  importanda  grande,  pues  sig- 
nifican  caai  todo  para  la  digestidn  y  constituyen  una  parte  muy  esendal  de  la  cara 
como  est^tica.  Bien  se  sabe  qu^  encantos  pueden  dar  a  una  fisonomfa  que  sea  hasta 
repuMva,  una  hermosa  dentadura,  como  se  observa  tambi^  el  caso  contrario.  Sin 
entrar  a  enumerar  los  varios  6iganos  que  entran  en  la  formad6n  de  la  boca  dar^  un 
ligero  repaso  sobre  los  fen6menos  objetos  de  esta  cavidad.  La  masticad6n,  la  insaU- 
vad6n  y  la  gustad6n  se  efectdan  integralmente  en  la  boca  y  son  la  prim^a  fas  de 
la  digestidn  con  la  cual  est&n  en  reladdn  directa.  La  masdcaddn  produce  la  tri- 
toraddn  de  los  alimentos  que  son  de  este  modo  mezclados  m^  ttdlmente  a  la  saliva 
y  *  los  otros  jugos  digesdvos.  Las  primeras  modificadones  que  sufren  los  alimentos 
en  su  constituddn  qufmica  y  que  tienen  pcnr  c<msecuenda  rendir  los  aaimilables 


168       PBOOEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIO  CONGBESS. 

son  debidos  a  la  acci6n  de  la  saliva,  Ifquido  segregado  por  las  gUndulas  difeientes 
que  existen  en  la  boca.  En  la  Umacidn  desempefia  tambi^n  un  papel  importante 
aunque  el  verdadero  productor  de  la  voz  ee  la  laringe;  la  faringe  y  la  boca  constituyen 
un  tubo  adidonal  que  no  toma  parte  en  la  emisi6n  de  los  sonidos  que  vienen  direc- 
tamente  de  la  laringe,  pero  sirve  a  darles  articulaci6n.  Loe  fendmenos  de  masd- 
caci6n  que  acabo  de  mencionar  y  que  ae  efecttian  con  la  boca  y  los  dientee  son  la 
primera  faz  de  la  digestidn.  Ahora  bien,  ya  conoddos  a  grandes  raegos  el  objeto 
y  fin  de  la  boca  debemos  suponer  que  estando  en  buenas  condiciones  debe  Uenar 
su  cometido  en  forma  ventajosa  para  el  organismo,  siendo  por  lo  tanto  dtil  y  aprove- 
chable  para  el  estdmago  e  intestine  el  bolo  alimenticio  recibido,  los  cuales  podr&n 
asimilar  con  facilidad  el  alimento  bien  preparado  aprovechdndolo  en  su  caai  totalidad. 

En  el  cumplimiento  de  estas  operaciones  entra  el  valioso  concurso  de  los  dientes, 
factor  importante;  justo  es  pues  que  me  dedique  a  elloe,  verdadero  objeto  de  mi  artl- 
culo  y  que  demuestre  la  gran  importancia  de  su  buena  conservacidn  por  medio  de  las 
reglas  higi^nicas  tan  sencillas,  las  cuales  a  su  vez  redundan  en  beneficio  directo  de  la 
cavidad  bucal  a  la  cual  pertenecen.  El  nifio  nace  sin  dientes;  cuando  su  naturaleza 
adquiere  alguna  consistencia,  que  es  a  los  7  meses  mis  o  menos,  comienza  a  efectuarse 
en  61,  la  erupci6n  de  los  primeros  dientes,  los  cuales  en  los  sucesivos,  contintian  haciendo 
su  aparicidn  hasta  los  dos  afios,  y  algunas  veceshastadespu^dela^poca  en  que  el  nifio 
ya  es  apto  para  alimentarse  por  sus  propios  medios ;  la  primera  dentadura  del  nifio  que  ee 
temporaria,  consta  de  veinte  dientes  y  muelitas,  ntimero  suficiente  para  llenar  el 
espacio  reducido  de  la  boca  in&uitil.  Con  esa  dentadura  provisoria  el  nifio  tiene  que 
hacer  frente  en  la  edad  de  loe  continuos  cambios,  a  la  gran  tarea  de  la  alimentaci6n, 
pues  en  esa  edad  todoe  los  6rganos  se  desarrollan  y  exigen  del  cuerpo  gran  reserva  de 
elementos  constitutivos,  esos  dientes  desempefian  tambi^n  un  gran  papel,  el  de  la 
formacidn  de  los  dientes  permanentes.  Es  evidente  que  como  fendmeno  fisioldgico 
la  dentici6n  participa  de  ese  orden  y  concierto  con  que  la  naturaleza  reviste  todas  sus 
manifestadones  y  que  el  nuevo  ser  no  tiene  necesidad  de  masticar,  no  se  completa  su 
aparato  dentarlo.  Hasta  tanto  el  desarrollo  lo  exija,  no  de^gastaii  el  diente  perma- 
nente  al  temporario  para  expulsarlo  y  sustituirlo.  El  nuevo  germen  no  solo  tiene  por 
objeto  el  triturar  los  alimentos  como  parecerfa  a  primera  vista,  sine  que  tiene  tambi^n 
el  de  guard&r  el  sitio  a  su  sucesor;  el  diente  sustituto  que  en  el  fondo  del  maxilar  se 
desarrolla  socava  a  su  predecesor  por  las  ralces,  las  cuales  cabalgando  y  aprisionando  la 
corona  del  nuevo  germen  le  marcan  la  senda  que  invariablemente  debe  recorrer,  al  fin 
de  cuyo  dclo  el  diente  de  leche  ha  perdido  por  complete  su  rafz  por  cuyo  motivo  ae 
engendra  en  el  publico  la  falsa  idea  de  que  los  dientes  de  los  nifios  no  tienen  raiz. 
Cualquier  anomalfa  de  la  denticidn  temporal  se  trasmitird  de  una  manera  mis  o  menos 
pronunciada  a  los  dientes  definitivos  o  viceversa,  una  primera  dentid6n  normal  es 
seguida  de  otra  normal  tambi^n,  pues  muy  raras  vecee  esa  tiene  por  consecuenda 
anomalfas  de  la  dentadura  definitiva.  Esta  regla  fisioldgica  con  que  se  realiza  la 
evoluddn  dentaria,  tiene  numerosas  excepdones,  unas  debidas  a  enfermedades  intra 
o  extrauterinas,  y  la  mayor  parte  de  las  voces,  a  la  extracci6n  prematura  de  los  dientes 
de  leche. 

En  eetos  casos  la  mala  posiddn  dentaria  es  la  consecuenda  mis  frecuente  y  lament 
table,  puesto  que  el  que  extrae  la  muela  extemporineamente  es  el  ocasionador  de  on 
verdadero  desorden  en  la  boca.  Al  extraer  un  diente  temporal,  antes  de  su  cafda, 
se  deja  amplitud  al  sucesor  para  que  tome  cualquier  direcd6n,  puesto  que  se  le  quitan 
las  gulas  seguras  que  le  hubieran  conduddo  por  camino  recto  a  su  justo  lugar.  Quiere 
decir  que  es  a  todo  trance  indispensable  la  cQn8ervad6n  de  los  dientes  de  leche  en  el 
nifio,  puesto  que  su  extracd6n  no  s61o  perjudica  a  su  masticad6n,  sino  a  los  dientes 
permanentes  en  su  po6id6n,  evitando  asi  a  voces  su  erupd6n,  por  destruirse  o  arrastrar 
el  germen  con  ella. 

Despu^  de  los  seis  afios  hacen  su  aparid6n  las  primeras  grandes  muelas  Uamadas 
por  este  motivo  los  molares  de  seis  afios,  efectuindose  casi  simultineamente  el  cambio 


PUBUO  HEALTH  AND  MEDICINE.  169 

de  lo8  dientes  incisivos,  ee  dsta  una  edad  crftica,  pues  la  infancia  entra  en  la  edad 
eecolar,  edad  que  a  la  vez  ee  6poca  de  los  grandee  desgastee  og&nicos  exigidoe  tanto  por 
el  desarrollo  como  por  las  fatigas  de  las  tareas  eecolares,  que  aunque  proporcionadas  a 
la  edad ,  no  dejan  de  hacerse  sentir  en  el  organismo  infantil .   En  eete  perfodo  la  infancia 
necesita  del  concuieo  de  todos  sua  6rganoe  nutritivos  para  hacer  frente  a  los  procesos  de 
trans!ormaci6n,  como  asi  a  sua  mdltiples  enemigos.    Hasta  loe  12  afios  contindan 
los  cambioe  dentarios,  6poca  en  que  puede  decirse  es  ya  definitiva  y  estable  la  situa- 
ci6n  de  los  dientes,  salvo  pequefias  modificaciones  complementarias  de  crecimiento 
como  del  maxilar,  que  hasta  la  salida  del  tercer  molar  o  del  juicio  sufre  alguna  pequeff 
modificaci6n.    Este  molar  hace  erupci6n  entre  loe  18  y  25  afios  salvo  raras  voces  qw 
sale  antes  a  causa  de  haber  sufiido  la  boca  extracciones  tempranas  del  primer  o  segund' 
molar. 

Ahora  ya  conocidos  someramente  los  procesos  de  la  anatomia  dentaria,  debo  explicar 
que  no  es  suficiente  tener  dientes  en  la  boca  para  poder  masticar,  sino  que  a  eeos  dien- 
tes, cuyo  valor  es  inestimable,  se  les  debe  cuidar  con  esmero  para  que  la  utilidad  que 
presten  sea  maxima  y  no  minima,  y  para  ello  voy  a  describir  todos  los  efectos  posibles 
de  producirse  en  una  boca  descuidada,  pudiendo  aceptarse  deede  luego  que  la  mayorfa 
de  los  descritos  existen  en  alto  porcentaje  en  el  mundo. 

Los  hombres  de  ciencia,  actives  higiemstas,  nobles  de  coraz6n,  anhelosos  de  difundir 
ensefianzas  provechoeas  entre  el  pueblo  con  objeto  de  hacer  obtener  mayor  facilidad 
en  la  vida  y  mayor  aprovechamiento  de  las  energfas  humanas,  evitando  con  ello  los 
entorpecimientos  que  ocasionan  las  enfermedades  y  propendiendo  con  elloe  al  mejora- 
miento  de  nuestro  estado  social,  aconaejan  sabiamente  reglas  sobre  diferentes  r^- 
menes  de  vida  y  alimentaci6n;  pero  qu6  provecho  puede  sacar  de  esas  ensefianzas  el 
que  las  lea,  ai  antes  que  esas  nociones  debe  poseer  las  elementales,  o  aea  conocer  los 
medios  para  poder  llevar  a  cabo  con  buen  6xito  y  en  buenas  condicionee  aqu^llas, 
comenzando  por  poseer  una  boca  idealmente  limpia  y  dientes  (ntegramente  sanosT 
La  base  de  la  buena  alimentaci6n  estnba  sencillamente  en  eso. 

La  limpieza  de  la  boca  del  aer  humane  debe  practicarae  deade  aus  primeroa  dfaa, 
68  una  provechosa  prictica  de  las  madree  limpiar  las  encfas  y  lengtdtas  de  sus  hijos 
con  una  gasa  limpia,  hervida  y  humedecida  en  agua  hervida  tambi^n,  con  objeto  de 
deeembarazarle  de  las  aglomeraciones  saburrosas  que  se  forman  en  los  nifioa,  eapecial- 
mente  deapu^  de  laa  horaa  de  repoao:  ieea  pr^tica  evita  que  el  p&rvulo  ingiera  eaaa 
concredonee  nocivaa  airvi^ndole  a  la  v^z  de  t6nico  a  la  mucoaa  gingival,  sobre  todo 
cuando  comienzan  a  brotar  loa  primeroa  dientea,  evitando  aaf  laa  inflamadonee  y  la 
mayor  parte  de  loa  accidentee  de  la  dentici6n,  debidoa,  caai  siempre,  a  falta  de  higiene. 
Cudntaa  madrea  no  conocen  laa  bocaa  de  aua  hijitoa  aino  hasta  que  ae  lea  ha  llamado 
la  atenci6n  aobre  la  aalida  del  primer  diente,  el  cual  aiempre  ee  redbido  como  un 
acontecimiento;  al  rev^  de  otraa  madrea  que  ae  deaviven  por  verlea  dientes  a  aua 
hijoB  y,  anheloaaa  de  que  eao  suceda,  consultan  a  amigaa  y  vecinaa  qu^  medioa  aon  mia 
eficacea  para  favorecer  la  aalida  de  loa  dientea,  no  faltando  comedidaa  que  aconaejen 
pocionea  y  jarabes  de  dudosa  eficacia,  caai  aiempre  mal  aanoa  y  otraa,  menoa  teme- 
rariaa  aconaejan  hacer  chupar  al  nene  dientes  de  loa  animalee,  collares  de  Ambar  y 
colgar  al  cuello  de  la  criatura  amuletos  de  las  espedes  m^  variadas?  En  el  siglo  de 
hoy  deberfan  desaparecer  esas  ignorancias. 

Desde  que  los  dientes  se  van  colocando  en  sus  respectivoa  lugaree  aon  ya  acreedorea 
de  la  limpieza  mAs  minudosa  la  cual  ae  hard  con  el  concurao  de  cepilloa  fabricados 
exprofeso  para  nifios  con  objeto  de  desembarazar  loe  interstidos  de  los  dientes  y  la 
boca  de  los  residues  alimentidoe.  Estas  limpiezas  deben  hacerae  con  espedalidad 
en  la  noche  antes  de  acostarlos. 

Suponiendo  que  los  nifios  han  de  pennanecer  8  o  10  horas  durante  el  snefio  con  la 
boca  en  complete  repose  e  inmovilidad,  encontr&ndose  6sta  llena  de  reeiduos  de  los 
alimentos  ingeridos  durante  el  dla,  tienen  que  produdrae  fermentadones  y  deecom- 
poaidonea  altamente  favoreddaa  por  un  ambiente  htlmedo  y  tibio.    Eataa  altera- 


170       PBOOEEDINGS  SEOOITD  PAK  AMBBICAN  SCIEKTIFIC  00NGBB88. 

donee  del  contenido  bucal  son  casi  siempre  de  caricter  icido,  quedando  estacionadas 
en  f onna  de  papillae,  en  el  cuello  de  loe  dientes,  vestfbulo  de  la  boca  y  superficie  de  la 
lengua  acumuUndose,  noche  tras  noche.  hasta  formar  verdaderos  cdlculos,  enemigos 
de  las  encias  a  las  cuales  desalojan  de  los  dientes  imitdndola  en  alto  grado  y  dando  lugar 
a  la  apaiicidn  de  inflamaciones  de  di versa  Indole;  favorecen  la  acidez  constante  de  la 
saliva  pudiendo  esta  acidez  penetrar  en  la  primera  grieta  del  eemalte  de  los  dientes 
dando  origen  a  la  f  ormaci6n  de  la  cane  o  picadura  del  diente,  la  cual  arrastra  al  mismo 
fin  a  SUB  compaiieras,  determinando  en  poco  tlempo  la  p^rdida  o  inutilidad  cad  total 
de  esos  6rganoB. 

La  boca,  en  ese  estado,  puede  decirae  que  ya  es  albergue  de  una  regular  cantidad 
de  microbios,  los  que  estdn  en  acecho  de  cualquier  oportunidad  para  hacer  de  las 
Buyas;  debido  a  las  caries  comienza  la  inflamaci6n  de  las  glindulas,  que  no  es  otra 
cosa  que  la  infiltraci6n  s^ptica  de  microbios  en  esos  drganos,  originando  esto  un 
peligro  muy  grande,  pues  ellos  se  ven  debilitados  en  su  poder  ofensivo  contra  loe 
g^rmenee  nocivos,  y  quedan  completamente  impocdbilitados,  en  su  poder  defensivo 
dejando  en  el  mayor  desamparo  a  las  mucosas  bucalea  y  el  organismo.  Estas  miBmae 
gl&ndulas,  al  inflamaree,  pueden  comprimir  el  conducto  auditivo,  impidiendo  la  en- 
trada  del  aire  a  61,  originando  por  consecuencia  diversos  trastomos  en  los  ofdos;  pueden 
dar  lugar  tambi^n  a  la  formaci6n  de  vegetaciones  adenoideas  conocidas  por  la  mayor 
parte  del  pdblico  ilustrado,  tan  peligrosas,  pues  impiden  al  nifio  respirar  por  la  naiiz, 
obUg&ndolo  a  respirar  mdebidamente  por  la  boca;  la  nariz  no  es  s61o  un  adorno, 
tiene  por  objeto  atender  la  respiraci6n,  filtrando  los  g^rmenes  nocivos  y  calentando 
el  aire  antes  de  que  llegue  a  nuestros  pulmones;  en  cambio  la  respiraci6n  bucal  la 
priva  de  esos  beneficios,  esas  mismas  vegetaciones,  sobre  todo  las  nasales,  debido  a 
su  expansi6n,  modifican  y  comprimen  los  huesos  de  la  nariz,  estrechando  de  tal  modo 
los  canales  que  dan  paso  al  aire  que  luego  el  calibre  permanente  de  dichos  huesos  es 
insuficiente  para  dejar  pasar  el  aire  necesario,  dando  al  nifio  un  aspecto  corporal 
raquitico  e  impidiendo  su  expansi6n  tor^ca  debida. 

Estos  son  algunos  de  los  peligros  locales  de  la  boca;  ahora  veamos  los  peligroe  de 
la  mala  nutricidn.  Ante  todo,  un  nifio  con  dientes  cariados  no  puede  masticar  bien, 
puee  8US  dolores  y  la  lalta  de  integridad  de  aqu^llos  no  se  lo  permiten;  los  alimentoe 
que  ingeriri,  en  esas  condiciones,  aparte  de  estar  mal  masticados  iiixt  mezclados  con 
lo8  residues  nauseabundos  que  contiene  su  boca,  cuellos  de  sus  dientes  y  encias  in- 
fectando  el  alimento  y  neutralizando  la  acci6n  de  los  jugos  gistricos,  ese  nifio  tiene 
que  tener  forzosamente,  una  merma  enorme'debido  a  eea  forma  anormal  de  nutrirse 
y  en  lugar  de  abastecer  a  su  organismo  de  elementos  constitutivos,  lo  obliga  a  de- 
vorar  los  que  tiene,  creando  una  falta  de  equilibrio  orgdnico,  originario  de  un  estado 
an^mico  y  raquitico,  quedando  ese  organismo  predispuesto  en  cualquier  memento  a 
sucumbir  a  la  acci6n  de  loe  mtUtiples  enemigos  que  lo  acecban. 

La  falta  de  ese  equilibrio  lentamente  acaba  por  poner  triste  al  nifio,  priv^doee 
de  eea  al^rfa  tan  natural  en  la  infancia;  loe  doloree  acaban  por  initarle  los  nervioe  sen- 
sorioe  volvi^dolo  irritable  y  poco  acceeible,  ddndole  la  anemia,  debida  a  la  infecci6n 
de  Bu  sangre  un  aspecto  enfermizo;  perdiendo  el  brillo  de  sus  ojoe  y  presentando  un 
aepecto  p^lido  tan  desagradable  y  tan  poco  caracterlstico  de  la  nifiez,  la  cual  siempre 
ee  y  debe  ser  un  exponente  de  robustez  y  lozania. 

Puede  adquirirse  en  eee  peUgroeo  periodo  cualquiera  de  las  terriblee  enfermedades 
que  azotan  la  infancia,  como  son  la  difteria,  fiebre  tifoidea,  fiebres  g^tricas,  etc., 
cuyo  resultado  16gico  ee  el  empeoramiento  de  las  condiciones  orgdnicas,  hallindoee 
por  consecuencia  ese  cuerpo  mis  inhabilitado  para  lucbar  contra  la  devastaci6n, 
Es  entonces  que  la  terrible  tuberculosis  tiene  oportunidad  eepl^ndida  para  aduefiaiee 
de  eee  organismo,  no  se  neceeita  para  ello  mde  que  un  leve  reefrfo,  que  degenerari 
en  una  congeeti6n  pulmonar,  la  que  si  no  es  atacada  a  tiempo  se  eztiende  ocasionando 
los  verdaderos  estntgoe  de  una  pulmonia  infeccioea  muy  grave  de  por  sf,  y  que  si 
llega  a  curar  ipobres  pulmonesi,  quedan  casi  siempre  convertidos  en  el  palacio  mds 
apto  para  vivienda  y  asilo  seguro  de  los  bacilos  de  Koch,  loe  que  formar&n  sus  colonias 


PUBLIC   HEALTH  AND  MEDICINE.  171 

ain  impedimentos  de  ningdn  g^nero,  devorando  en  poco  tiempo  ese  pobre  organiBmo 
y%  cafii  indtil  por  todos  Iob  achaques  y  accidentes  sufridos,  exponiendo  con  tal  hecho 
el  inmerecido  y  triste  final  de  una  juventud  que  era  toda  una  promesa  para  el  future. 

Muchos  de  los  padres  que  lean  eetas  Uneas  no  habr&n  llegado  a  suponer  que  la 
responaabilidad  moral  que  tienen  sobre  sub  hijoe  se  extienda  hasta  estoe  Ifmites. 
Sin  embargo  es  asi. 

En  Europa  civilizada  existen  y  fimcionan  en  todas  las  ciudades  y  pueblos  cuerpos 
m^coB  escolares  bien  organizados,  donde  la  boca  ee  objeto  de  preferente  atenci6n 
y  estd  encomendada  al  cuidado  exclusivo  de  profesionalee  peritoe,  que  no  tienen 
otra  misi6n  que  prodigar  a  loe  que  necesitan  esos  cuidados  especiales,  se  ocupan  tarn- 
bi^  de  dar  peri6dicamente  conferencias  a  loe  nifios  sobre  la  gran  impcnrtancia  del 
cuidado  higi^nico  de  la  boca  y  dientes,  inculc&ndoles  conocimientos  y  m^JTimas 
suficientemente  poderosos  i>ara  que  esos  hombres  de  mafiana  se  preocupen  realmente 
de  cuidar  una  cosa  para  ellos  ignorada  y  de  gran  trascendencia  en  su  vida. 

Aquf  y  en  regiones  andlogas,  desgraciadamente,  no  ban  llegado  todavla  los  bene- 
ficios  de  esas  titiles  instituciones  y  parte  de  esa  enorme  labor  esta  encomendada  al 
medico,  que  en  medio  de  su  atareamiento  diario,  donde  se  ve  obligado  a  ejercer  todoe 
los  ramos  de  la  medicina  y  cirugfa,  no  le  queda  materialmente  tiempo  dedicarse  a  esa 
especialidad  de  la  higiene  y  s61o  lo  bace  en  cases  necesarios  donde  su  preeencia  ea 
exigida,  limitindose  cad  siempre  a  enviar  al  paciente  al  dentista  mejor  especiaUzado. 
Efl  entonces  donde  el  dentista  tiene  oportunidad  de  hacer  ver,  por  medio  del  case 
piictico,  al  paciente  o  a  sus  padres,  el  estrago  y  las  consecuencias  de  la  falta  de  hi- 
giene. Momentineamente  ^tos  aparentan  dar  importancia  a  la  cosa  bajo  el  peso 
de  las  circunstancias,  pero  como  esos  consejos  cayeron  al  azar  en  un  memento  acci- 
dental los  olvidan  con  facilidad;  en  cambio,  si  ese  nifio  hubiera  tenido  nociones  y 
sus  padres  hubieran  sabido  que  la  higiene  de  la  boca  tiene  importancia  trascendental 
en  el  sostenimiento  y  con8ervaci6n  de  la  vida  habrlan  dado  mds  importancia  al  acci- 
dente  sufrido  y  hubieran  tratado  de  evitarlo  en  lo  sucesivo.  Entonces  el  dnico  mode 
de  conseguir  algo  en  pro  de  estas  ensefianzas  es  comenzar  a  dictar  por  medio  de  la 
prensa  local  tan  empefiosa  y  decidida  en  la  obra  educativa,  una  cdtedra  de  higiene 
haciendo  conocer  el  objeto  de  determinados  6rganos,  consecuencias  distintas  e  inevi- 
tables de  la  falta  de  limpieza  y  cuidado  de  dichos  6rganos  y  medio  para  evitar  su  des- 
perfecto  y  alteramiento  propendiendo  con  ellos  a  su  verdadera  conservaci6n. 

En  resumen  definir^  en  pocas  palabras  todos  los  medios  y  cuidados  necesarios  para 
la  buena  conservaci6n  de  los  dientes,  evitando  oon  ello  y  por  consecuencia  el  altera* 
miento  de  loe  dem^  diganos  anexos. 

Como  he  dicho,  repito,  desde  la  m^  tiema  edad  se  debe  vigilar  la  lunpieza  de  la 
cavidad  bucal,  cuando  los  dientes  ya  ban  hecho  su  aparicidn  y  durante  todo  el  trans- 
curso  de  la  vida.  Esa  limpieza  debe  efectuarse  dos  veccs  por  dfa  a  la  mafiana  al 
levantarse  y  a  la  noche  antes  de  acostarse,  a  fin  de  que  el  ambiente  de  esa  boca,  sea  lo 
m&B  est^ril  posible;  un  cepillo  de  forma  y  dureza  especial  seri  el  encaigado  de  efec- 
tuarla  con  la  ayuda  de  determinados  agentes  bajo  forma  de  polvos  de  cualidades  de- 
finidas,  y  que  el  m^  indicado  a  prescribirlas  es  el  Dentista,  despu^  de  previo  examen 
de  la  boca  del  interesado.  Si  a  pesar  de  esos  cuidados  se  nota  dolor  o  alguna  pequefia, 
cariadura  a  veces  imposible  de  evitar,  se  debe  acuir  sin  p^rdida  de  tiempo  al  Dentista 
a  objeto  de  curarla  y  taparla,  lo  mismo  si  se  nota  que  los  dientes  salen  en  mala  po6ici6n 
o  torcidos  y  las  mandibulas  estan  proyectadas  hada  adentro  o  hacia  afuera,  se  debe  con- 
sultar  igualmente  al  odontdlogo. 

La  boca  a  pesar  de  esos  cuidados,  que  no  siempre  serin  efectuados  con  la  debida 
energia  y  esmero,  acumula  sarro  y  dep<5sitos  llamados  ddculos.  Igualmente  se  debe 
acudir  una'  vez  por  afio  a  los  buenos  oficios  del  Dentista  para  que  liberte  a  los  dientes 
y  encias  de  esos  temibles  enemigos. 

En  fin,  para  tenninar,  la  boca  debe  ser  objeto  de  la  mds  constante  atencidn  en  cual- 
quier  persona  y  durante  todos  los  perfodos  de  la  vida,  pues  en  todos  esos  perfodos  es 
igualmente  dtil;  pero  donde  tiene  mayor  importancia  la  buena  conservacito  de  la 


172       PB0CEEDIN08  SEGOKD  PAK  AMEBIOAK  8CIBNTIFI0  OOKGBESS. 

denfadura  es  en  la  inEancia,  vuelvo  a  repetirlo,  dn  cansarme,  por  ser  ella  la  esperanca 
de  un  pueblo  y  por  repreeentar  el  futuro  evolucioniata  de  una  raza  y  el  perfecciona^ 
miento  de  la  generaci6n  que  anhelamoe  todos. 

La  no  observanda  de  la  higiene  buco-dentaria  detennina  todas  y  muchas  mis  alte- 
racionee  que  las  deecritas,  trayendo  como  consecuencia  trastoraos  de  efectoe  terribles. 
en  la  nifiez,  con  su  inevitable  corolario  de  depre8i6n  mental.  Es  por  lo  tanto  neceeario 
hacer  un  llamado  a  los  padres  de  familia  sobre  la  activa  vigilancia  que  deben  ejercer  en 
eee  sentido  sobre  bus  hijoe,  constituyendo,  su  indiferencia  e  impa^dbilidad  al  conocer 
todos  eeos  peligros,  la  Banci6n  social  de  un  crimen  de  lesa  humanidad. 

Oreo  haber  usado  de  medioe  suficientee,  dentro  de  mi  inutilidad  literaria,  y  sin  la 
facilidad  y  claridad  que  lo  habrfa  hecho  un  hombro  de  letras,  para  demostrar  y  hacer 
resaltar  la  imperiosa  necesidad  de  aplicarse  en  la  higiene  bucal.  Si  algo  consiguiera 
con  dsto,  tendrfa  la  sati8facci6n  de  haber  side  dtil,  con  mi  modesto  y  pequefio  aporta- 
mjento  de  nociones  concemicntee  a  mi  profesidn,  a  muchoe  que  quiz&s  hubiesen  re- 
■ultado  perjudicadoe  con  su  desconocimiento. 

Through  the  courtesy  of  the  writer  there  was  presented  to  the  con- 
gress at  this  session  a  copy  of  the  following  printed  book: 

Higiene  dentaria  del  nifio,  por  Carlos  P.  Berra,  Dentista  del  ^'Cuerpo 
M6dico  Escolar.''    Cabaut  y  Cfa,  editores,  Buenos  Aires,  10J6. 

Adjourned  at  4.30  o'clock. 


JOINT  SESSION  OF  SUBSECTION  D  OF  SECTION  VDI  AND 

SUBSECTION  4  OF  SECTION  V. 

New  Ebbitt  Hotel, 
Tuesday  morning^  January  4, 1916. 

Ghairman,  J.  D.  Gatewood, 

The  session  was  called  to  order  at  9.15  o'clock  by  the  chairman. 
Papers  presented: 

Disposal  of  refuse.    Papers  by  George  A.  Soper  and  William  T. 

Sedgwick. 
Collection  and  disposal  of  municipal  refuse.    Papers  by  J.  T. 

Fetherston,  Morris  Enowles/  and  J.  W.  Paxton^ 

The  Chairman.  The  first  paper,  on  a  most  interesting  subject, ''  Dis- 
posal of  refuse/'  is  by  Dr.  George  A.  Soper,  president  of  the  Metro- 
politan Sewage  Commission,  New  York  City.  Dr.  Soper  will  please 
oome  forward  and  read  his  paper. 

AVAILABLE  METHODS  FOR  THE  SANFTARY  DISPOSAL  OF  REFUSE. 

By  GEORGE  A.  SOPER, 
ConniUing  Sanitary  Engineer^  New  York, 

The  intended  scope  of  this  paper  was  indicated  in  the  preliminary  program  of  this 
meeting  as  follows: 

VI.  Dis^sal  of  refine, — Under  this  topic  there  is  a  wide  range  of  topics  to  be  con* 
■idered,  viz,  (1)  sewage  disposal,  (2^  garbage,  (3)  ashes,  (4)  night  soil,  (5)  stable 
manure,  (6)  trade  wastes,  (7)  miscellaneous  refuse  of  the  household,  and  (8)  street 
cleanings.  The  collection,  transportation  and  ultimate  disposal  of  liiese  classes  of 
refuse  will  be  considered,  and  incidentally  the  purity  of  nvers  wad  other  bodies  of 
water. 

When  it  is  considered  how  small  a  topic  may  profitably  engage  one's  attention, 
and  how  various  and  complicated  are  the  chemical,  physical,  biological,  sociological, 
political,  economic,  engineering,  and  administrative  questions  with  ndiich  the  present 
subject  is  involved,  the  magnitude  of  the  undertaking  which  has  been  assigned  to  the 
author  of  this  paper  will  become  apparent.  No  attempt  at  thoroughness  could  be  war* 
ranted  within  dimensions  smaller  than  a  series  of  volumes.  Nor  would  such  an  effort 
be  pertinent  before  the  members  of  this  congress  had  been  given  an  opportunity  to 
relate  their  experience  and  opinions.  All  that  will  be  attempted  is  an  outline  of  some 
of  the  main  bearings  of  the  subject  as  related,  particularly  to  methods,  the  expecta- 
tion being  that  the  contributions  of  others  will  supply  many  details  of  present  interest. 

.  1  Paper  printed  tn  ToL  VI  of  tlM  ProoMdings  of  the  Beooiid  Pan  American  Soian^ 

173 


174       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  CONGRESS. 

The  tenn '  *  refuse  "  is  here  used  to  cover  broadly  all  liquid  and  solid  waste  substances 
produced  in  the  houses  and  streets  of  cities,  towns,  and  villages  under  ordinary  condi- 
tions of  occupancy. 

Refuse  is  divisible  for  consideration  into  two  general  classes:  I.  Solid  refuse,  and 
II.  Sewage.  This  division  leaves  something  to  be  desired  on  the  score  of  precision,, 
but  it  is  impossible  to  be  scientifically  accurate  in  the  use  of  terms  in  dealing  with 
the  disposal  of  refuse,  for  there  is  no  universal  agreement  among  sanitarians  with 
respect  to  them. 

Sewage,  which  is  the  material  customarily  carried  from  its  points  of  origin  in  under- 
ground pipes  and  drains,  usually  by  means  of  a  flow  of  water,  can  be  finally  disposed  of 
in  definite  and  effective  ways.  The  means  which  are  available  for  the  collection 
have  reached  a  point  of  perfection  which  leaves  little  to  be  desired.  The  processes 
which  are  available  for  final  disposition  have  received  a  great  deal  of  study  in  the 
laboratory  and  on  a  practical  scale  with  the  result  that  a  large  amount  of  infonnation 
exists  concerning  the  principles  which  must  be  followed  in  order  to  insure  successful 
results.  Sewerage  and  sewage  disposal,  therefore,  represent  a  rather  high  state  of 
development  considered  either  as  a  science  or  as  an  art. 

The  disposal  of  solid  refuse,  on  the  other  hand,  has  not  yet  emerged  &om  that  primi- 
tive state  of  development  in  which  the  experimental  generally  exceeds  the  certain  re- 
sult. Centuries  older  than  the  subject  of  sewage  disposal,  the  current  methods  of 
to-day  are  not  very  far  advanced  over  the  methods  which  were  in  force  in  the  time 
of  Moses.  Considering  the  fact  that  the  sanitary  disposal  of  refuse  has  materially 
affected  the  comfort  and  welfare  of  human  beings  ever  since  men  ceased  to  live  an 
uncivilized  and  nomadic  existence,  it  would  appear  that  the  methods  now  available 
for  the  removal  and  final  disposal  of  all  classes  of  solid  refuse  should  be  well  worked 
out  and  thoroughly  understood.  The  truth  is,  however,  that  modem  civilization 
has  but  recently  come  to  recognize  the  importance  of  the  subject  and  been  able  ta 
focus  the  scientific  attention  upon  it  which  is  necessary  in  order  that  well-developed 
methods  may  be  evolved. 

I.  THE  DISPOSAL  OF  SOLID  REFUSE. 

While  the  sewage  of  a  city  is  removed  from  the  houses  and  streets  where  it  is  pro- 
duced without  the  average  inhabitant  seeing  or  knowing  even  the  routes  which  it 
follows,  the  opposite  is  the  fact  with  regard  to  the  disposal  of  the  solid  wastes.  The 
garbage,  ashes,  papers,  stable  manure,  and  other  solids  are  stored  on  the  premises  until 
they  become  no  longer  tolerable,  then  placed  with  their  receptacles  in  the  highway, 
from  which  they  are  collected  in  a  noisy,  dusty,  odorous  manner,  hauled  in  foul  and 
leaky  wagons,  often  for  long  distances,  through  the  city,  and  finally  dumped  at  places 
which  are  offensive  in  the  extreme.  This  is  not  the  best  practice,  but  it  is  the  usual 
one;  there  is  hardly  a  city  to  be  found  which  is  not  guilty  of  some  or  all  of  the  offenses 
named.  It  is  unpleasant  to  mention  these  conditions,  but  it  is  necessary  to  recognize 
them,  if  more  correct  and  suitable  procedures  are  to  be  devised. 

There  is  need  of  improvement  in  the  manner  of  collecting  the  solid  wastes  and  of 
disposing  of  them.  The  first  is  laigely  a  matter  of  administration,  the  second  chiefly 
a  question  of  plant.  If  the  wastes  can  be  gathered  properly  to  suitable  points  for  dis- 
posal, it  will  be  within  the  range  of  scientific  e£fort  to  dispose  of  them  without  danger 
or  offense.  If  the  collections  can  not  be  made  suitably,  it  will  be  hopeless  to  attempt 
to  cope  with  the  problem. 

Suitable  collections  mean,  first,  appropriate  receptacles  and  a  correct  use  of  them 
by  the  householder.  This  is  always  a  difficult  thing  to  accomplish.  It  is  natural  te 
throw  refuse  away  carelessly  and  think  no  more  about  it.  This  course  has  been  made 
practicable  so  far  as  sewage  is  concerned ,  by  the  invention  of  the  water  carriage  system,, 
but  there  is  nothing  comparable  with  the  sewerage  system  which  can  be  used  for  the 
solid  wastes.    The  ashes,  papers,  floor  sweepings,  old  cloths,  bottles,  cans,  boxes^ 


FUBUO  HEALTH  AKD  MEDIOINE.  175 

and  kitchen  garbage  must  be  put  into  receptacles,  and  these  must  be  taken  out  of  the 
house  and  emptied  from  time  to  time.  Proper  receptacles  and  a  proper  use  of  them 
constitute  the  first  essential  for  the  householder. 

The  duty  of  the  municipality  begins  soon  aftw  the  waates  are  produced.  It  extends 
into  the  houses.  The  municipality  should  insist  upon  the  kind  of  receptacle  to  be 
provided  and  what  kinds  of  materials  may  and  may  not  be  put  into  them.  There 
should  be  r^ulations  specifying  where  and  when  the  receptacles  should  be  placed  to 
&cilitate  their  removal  and  emptying. 

In  some  well  sanitated  cities  the  solid  wastes  are  collected  together  in  mixed  con- 
dition; in  others  the  householder  is  required  to  keep  the  ashes  separate  from  the 
kitchen  swill  and  from  the  papers  and  other  materials.  The  regulations  in  respect  to 
thii  matter  should  depend  upon  the  way  in  which  the  wastes  are  to  be  disposed  of. 
It  has  not  been  found  that  any  appreciable  hardship  is  imposed  upon  householders  by 
such  requirements.  Separations  at  the  house  were  first  required  in  New  York  by  the 
late  Col.  Waring  many  years  ago,  and  are  still  infosted  on  in  that  dty  with  it«  5,500,000 
inhabitants.  The  householders  can  be  made  to  do  a  great  deal  of  work  which  will 
6ici1itate  the  disposal  of  the  solid  wastes  if  they  are  treated  Mrly,  and  it  is  desirable 
that  this  fact  be  made  use  of  to  the  full.  Experience  shows  that  it  L>  desirable  and 
feasible  to  insist  that  the  house  receptacles  shall  be  placed  for  collection  in  situations 
which  are  accessible  to  the  men  who  are  chaiged  with  the  duty  of  emptying  them,  and 
they  are  to  be  placed  there  on  those  days  and  at  those  times  when  the  collectors  are 
able  to  make  their  rounds.  Compliance  in  these  directions  will  be  the  more  effective 
if  there  ir  no  que^ion  as  to  the  authority  demanding  it,  and  confidence  that  the  collec- 
tors will  dn  their  part.  There  must  be  real  authority  and  the  public  must  be  treated 
fairly. 

One  of  the  secrets  of  success  in  all  branches  of  municipal  refuse  disposal  lies  in  the 
mutual  help  which  can  be  given  by  the  public  and  by  the  dty  officers.  No  cleaning 
department,  however  effldent  it  may  be,  can  keep  a  dty  clean  if  it  does  not  receive 
the  intelligent  help  of  the  dtizens.  The  health  department,  the  police,  and  the  clean- 
ing force  should  work  together  with  mutual  confidence  and  understanding.  In  no 
blanch  of  dty  work  is  cooperation  so  necessary  as  here. 

Contract  and  day  labor. — ^The  collection  and  disposal  of  solid  refuse  are  sometimes 
done  by  contract  and  sometimes  by  a  force  in  the  regular  employ  of  the  munidpality. 
In  many  cases  the  collections  are  made  by  the  dty  and  the  collected  materials  turned 
over  to  a  private  firm  for  final  disposition.  Carts  and  wagons,  too,  often  of  unsuitable 
form,  are  used  in  dther  event;  their  main  faults  are  that  they  are  too  high,  too  heavy, 
and  too  open.  There  is  a  good  field  for  the  employment  of  American  ingenuity  in  the 
perfection  of  carts  and  wagons  for  the  collection  of  solid  refuse. 

Traction  is  usually  effected  by  horses,  and  this  seems  to  be  the  cheapest  plan, 
except  when  the  vehicle  can  be  operated  for  unusually  long  periods  of  time,  or  is 
employed  on  long  hauls,  in  which  event  motors  are  the  more  economical.  The  partic- 
ular type  of  wagon  or  cart  to  employ  depends  a  good  deal  upon  the  material  to  be  car- 
ried and  the  topography  of  the  district.  Whatever  their  design,  the  vehicles  should 
be  iBOgOf  low,  covered,  and  tight. 

Carts  have  been  designed  for  household  receptacles  so  as  to  carry  off  the  refuse  in 
the  containers  in  which  it  was  first  put,  empty  receptacles  being  left  in  their  stead. 
Tha«  is  the  objection  to  this  practice  that  it  is  seldom  feasible  to  thoroughly  cleanse 
the  containers,  and  no  one  wants  to  receive  a  receptacle  which  has  previously  been 
used  in  a  house  where  sickness  has  occiured.  Wagons  are  sometimes  provided  with 
covers  and  a  mechanical  device  for  emptying  the  receptacle  without  causing  the 
dust  and  odors  to  escape.  This  appears  to  be  a  practicable  scheme  and  has  much  to 
recommend  it.  But  it  is  to  be  noted  that  such  vehicles  generally  require  the  house- 
holder to  employ  a  special  form  of  receptacle.  Perhaps  some  will  regard  thii  as  an 
advantage,  for  it  does  away  with  the  use  of  such  unsuitable  receptacles  as  boxes,  bas- 


176       PBOOEEDINOS  SECOND  PAN  AMEBIOAN   SCIENTIFIC  C0NGBES8. 

kets,  and  worn  out  cooking  utendb,  which,  in  spite  of  considerable  pressure,  are  to  be 
found  in  use  in  nearly  all  cities,  to  some  extent,  at  the  present  time.  The  standard 
receptacle  for  garbage  and  for  mixed  garbage  and  ashes,  in  American  cities  is  a  gal* 
vanized  iron  can  with  a  tight-fitting  cover. 

Collections  should  be  made  at  regular  intervals,  and  the  days  of  collection  should 
be  scrupulously  kept.  The  frequency  of  collection  for  garbage,  when  kept  separate 
from  ashes,  should  be  not  lees  than  twice  or  three  times  per  week,  according  to  the 
season  of  year  and  climate.  A  somewhat  longer  period  is  permissible  when  the  aahee 
and  garbage  are  mixed. 

Final  disposition, — ^The  most  conmion  methods  of  final  disposition  for  household 
refuse  are  diunping,  burning,  and  hog  feeding. 

In  spite  of  the  fact  that  the  feeding  of  hogs  with  the  garbage  of  cities  is  widely  prac- 
ticed, it  can  not  be  said  to  be  wholly  satisfactory.  The  idea  of  turning  useless  swill  into 
valuable  pork  has  attractions  for  the  economist,  but  it  can  not  be  accomplished  on  a 
laige  scale  in  a  way  that  is  satisfactory  to  the  sanitarian,  judging  by  the  efforts  which 
have  been  made  so  far.  A  few  years  ago  it  was  undertaken  by  a  Prussian  city,  and 
although  the  scheme  was  carried  out  with  characteristic  German  thoroughness,  the 
plan  was  eventually  given  up.  It  was  impossible  to  keep  the  hogs  healthy  and  their 
quarters  clean.    Hog  feeding  is  lees  objectionable  when  practiced  on  a  small  scale. 

Notwithstanding  its  bad  reputation,  the  dumping  of  household  refuse  on  land 
when  properly  carried  on  has  a  great  deal  to  recommend  it.  All  dumping  is  not  bad 
dumping,  by  any  means.  It  may  be  said  to  be  good  or  bad  according  to  the  place 
where  the  material  is  dumped  and  what  is  done  with  the  deposits.  Left  to  itself,  a 
refuse  dump  may  be  one  of  the  most  objectionable  nuisances  to  be  found  in  the  vicin- 
ity of  a  city.  Properly  cared  for  it  may  not  be  objectionable  at  all.  Garbage  alone 
can  not,  of  course,  be  suitably  disposed  of  in  this  manner,  but  garbage  and  ashes  in 
mixed  condition  may  be  dumped,  or  ashes  alone,  or  garbage,  ashes,  and  rubbish. 

It  is  a  mistake  to  suppose  that  land  whose  level  has  been  raised  by  deposits  of  refuse 
is  a  menace  to  health  or  unsuitable  for  any  use.  There  are  few  cities  of  considerable 
aise  parts  of  which  have  not  been  filled  in  and  built  upon  without  evil  consequences. 
In  some  of  our  great  cities  very  large  tracts  have  been  recovered  in  this  way  and  parks 
have  sometimes  been  made  of  the  districts  so  reclaimed. 

Dumps  should  be  drained  to  start  with  and  leveled  and  covered  with  earth  as  the 
work  of  dumping  progresses.  If  the  process  of  filling  is  carried  on  in  accordance  with 
correct  engineering  and  sanitary  principles,  it  will  not  be  objectionable. 

Garbage  can  be  composted  to  advantage,  a  fact  which  is  much  less  generally  under^ 
stood  in  America  than  in  Europe.  The  compost  heaps  need  not  be  especially  offensive 
nor  located  where  the  material  is  likely  to  cause  complaint;  the  resulting  material  is 
likely  to  be  of  considerable  value  as  fertilizer.  Unfermented  garbage  is  of  little 
service  as  a  manure. 

Reduction  and  burning. — One  of  the  most  approved  processes  for  the  conversion  of 
garbage  into  a  useful  commodity  is  known  as  reduction.  Essentially  this  method 
extracts  the  grease  by  means  of  heat  or  gasoline,  leaving  a  by-product  which  can  be 
used  as  a  basis  for  manure.  There  are  some  large  plants  which  dispose  of  garbage  by 
reduction;  in  fact,  this  method  seems  less  suited  to  small  cities  and  towns  than  to 
large  places.  Usually  the  works  are  owned  and  operated  by  a  corporation  which  takes 
the  city's  garbage  and  disposes  of  it  for  a  term  of  years  upon  the  payment  of  a  sum  of 
money  by  the  municipality. 

Burning,  or,  as  it  is  sometimes  called,  incineration,  is  generally  r^arded  as  one  of 
the  best,  if  not  the  very  best,  and  most  frequently  applicable  processes  for  the  final 
disposition  of  household  wastes.  It  has  the  advantage,  so  far  as  sanitary  considera- 
tions are  concerned,  that  it  utterly  destroys  whatever  it  deals  with.  Further,  burning 
is  capable  of  dealing  with  garbage,  ashes,  and  rubbish,  so  that,  unlike  reduction,  the 
entire  problem  of  disposing  of  these  three  classes  of  refuse  is  solved  at  one  stroke. 
Finally,  the  heat  produced  by  the  flames  can  be  turned  to  profitable  account  in  the 


PUBUO  HEALTH  AND  MEDICINE.  177 

production  of  steam  and  electric  power  and  light.  The  furnaces  which  are  suitable 
lor  this  work  may  be  of  a  size  to  accommodate  the  wastes  of  almost  any  municipality. 
For  good  results  they  must  be  skillfully  designed  and  operated.  In  Europe,  particu- 
larly in  England  and  Germany,  there  are  excellent  examples  of  refuse  destructors,  as 
they  are  properly  termed. 

Utilization  finds  an  encouraging  field  in  the  disposal  of  rubbish,  for  here  are  con- 
tained the  metals,  bottles,  pieces  of  cloth,  and  other  materials  which,  when  separated 
from  the  mass  in  which  they  are  cast  away  and  brought  together  in  quantities,  have  a 
market  value.  It  is  feasible  and  often  desirable  for  the  authority  which  is  charged 
with  the  duty  of  disposing  of  rubbish  to  have  it  overhauled  with  the  object  of  recov- 
ering the  salable  ingredients.  In  this  direction,  as  in  some  others,  useful  lessons  may 
be  learned  from  the  practices  of  private  scavengers. 

Private  scavenging. — In  practically  all  cities  of  the  United  States  there  aie  men  who 
make  a  living  by  taking  away  for  disposal  the  wastes  of  butcher  shops,  restaurants, 
and  the  garbage  and  ashes  of  private  dwellings.  Where  there  is  no  central  scavenging 
force  operating  at  the  expense  of  the  city,  and  this  applies  to  hundreds  of  small  cities 
and  villages  in  the  United  States,  the  employment  of  private  scavengers  affords  the 
only  means  which  the  householders  have  for  getting  rid  of  their  solid  refuse.  Some- 
times the  scavengers  operate  under  licenses  issued  by  the  health  authorities;  some* 
times  such  permission  is  not  required. 

The  operations  of  private  scavengers  are  various  and  seldom  sanitary,  except  in 
large  cities.  Depending  upon  the  value  of  the  material  which  is  taken  away,  the 
scavenger  either  receives  a  sum  of  money  for  his  services  or  gives  a  small  amount. 
The  work  of  collection  is  often  done  badly,  and  the  system  has  many  disadvantages, 
but  the  commercial  aspect  of  the  subject  is  developed  in  some  cases  to  a  surprisingly 
high  state  of  perfection.  The  garbage  is  usually  fed  to  hogs;  the  ashes  are  dumped; 
the  rubbish  is  overhauled;  and  the  salable  materials  are  carefully  collected  into  piles 
and  stored  until  enough  of  each  class  has  accumulated  to  be  marketed  to  advantage, 
when  it  is  shipped  away. 

The  tendency  of  the  times  is  to  insist  upon  more  frequent  collections  of  solid  house 
refuse,  a  better  disposition  of  it,  and  a  more  centralized  control  of  the  whole  subject. 
The  future  seems  likely  to  see  improvements  in  the  operations  available  for  collection 
and  disposal  in  small  communities  as  well  as  in  large  ones.  There  is  certain  to  be  a 
better  recognition  of  the  need  of  devoting  intelligent  care  to  the  whole  subject,  and 
in  view  of  the  remarkable  amount  of  attention  which  is  being  given  all  other  branches 
of  sanitary  work,  it  seems  not  too  much  to  expect  that  the  collection  and  disposal 
of  the  solid  refuse  of  municipalities  will  emerge  from  the  neglected  state  in  which 
it  exists  and  take  its  place  among  other  well  organized  mimidpal  enterprises. 

Encouragement  for  expecting  improvement  is  found  in  the  popularity  which  has 
recently  attended  the  periodical  cleaning  up  of  cities  of  all  sizes  in  the  United  States. 
In  these  ''clean  ups,"  as  they  are  called,  special  days  are  set  aside  for  the  thorough 
cleaning  of  houses,  yards,  shops,  alleys,  and  streets.  They  are  not  intended  to  be 
substitutes  for  the  routine  cleaning  which  is  desirable,  but  are  supplementary  to  it. 
Prizes  are  given  for  the  best  individual  work,  and  school  children  are  enlisted  to  act 
as  inspectors  and,  it  must  be  confessed,  as  educators.  The  campaigns  carried  on  in 
this  way  have  been  full  of  practical  value,  for  if  they  have  laid  what  to  some  would 
appear  to  be  unwise  emphasis  upon  an  occasional  cleaning  instead  of  upon  the  con* 
tinuous  care  which  a  city  should  have,  they  have  aroused  the  interest  of  many  persons 
who  could  not  have  been  persuaded  to  follow  the  better  course  at  once.  A  thorough 
cleaning  once  a  year  is  better  than  no  cleaning  at  all,  and  in  some  cases,  probably  in 
many,  the  good  b^:iiming  has  been  followed  by  sustained  and  productive  efforts. 

Night  ioil, — The  removal  of  night  soil  is  generally  carried  on  by  a  force  quite  inde* 
pendent  of  other  refuse  collecting  agencies.    Sometimes  this  work  is  done  by  a  health 


178       PBOOESDINGS  SECOND  PAN  AMEBIOAN  BOISKTIFIO  00NGBB88. 

department,  but  usually  by  small  contractors  licensed  by  tlie  city  and  operating 
under  more  or  less  careful  regulation.  The  material  is  removed  from  the  privies  and 
cesspools  either  by  shoveling  or  pumping.  Sometimes  the  work  is  done  by  so-called 
odwless  excavating  apparatus,  if  the  quantity  and  consistency  permit  of  it.  It  is 
customary  to  clean  cesspools  and  privies  when  they  become  so  full  as  to  necessitate 
empt3dng,  although  some  municipalitiee  provide  that  they  shall  be  cleaned  out 
periodically,  as  once  a  year,  for  example.  In  some  English  cities,  in  France,  and  in 
many  warm  countries  where  the  water  carriage  system  of  sewerage  is  not  used,  special 
receptacles  and  collecting  wagons  are  employed  and  the  excrement  is  taken  away  at 
frequent  intervals. 

As  generally  done  in  the  United  States,  the  removal  of  night  soil  is  costly,  imperfect, 
and  hi  bom  satisfactory  from  a  sanitary  standpoint.  But  with  careful  supervision  it 
can  be  carried  on  with  relatively  little  objection.  Barrels  and  wagons  can  be  made 
tight  and  kept  clean,  the  night  soil  can  be  excavated  without  destroying  the  shrubbery 
or  other  property  and  the  material  can  be  finally  disposed  of  by  applying  it  to  land. 
In  the  cleaning  of  over  1,000  privies  under  the  direction  of  the  author  of  this  paper 
there  were  no  complaints  from  property  holders,  no  illness  among  the  workmen  and 
the  material  was  disposed  of,  countlDg  all  expenses  from  the  privy  to  the  field  at 
about  1  cent  per  gallon.  The  material  was  buried  in  shallow  trenches  dug  by  a 
plough  and  at  once  covered. 

The  disposal  of  excrement,  in  such  condition  as  is  likely  to  be  met  with  in  cities 
and  towns  which  are  unprovided  with  sewerage  sjrstems,  is  an  important  field  for 
discussion,  since  the  methods  to  be  followed  apply  practically  to  all  villages  and 
towns  and  to  some  extent  to  most  cities.  Theoretically  the  material  is  highly  dan- 
gerous, containing,  as  it  often  does,  the  germs  of  many  infectious  diseases.  Practi- 
cally it  does  not  appear  to  be  so. 

The  disposition  of  night  soil  offers  opportimity  for  the  utilization  of  the  nitrogen 
and  other  manurial  ingredients  of  feces  which  in  sewage  is  highly  diluted  with  water, 
yet  science  shows  that  its  value  as  a  fertilizer  is  not  so  high-as  many  persons  suppose. 
The  custom  of  the  inhabitants  of  China  and  some  other  countries  in  hoarding  their 
excrement  for  the  purposes  of  agriculture  is  thought  by  some  to  mean  only  that  these 
people  are  very  thrifty.  Commercial  companies  which  have  been  organized  to  turn 
human  excrement  into  fertilizers  for  the  market  have  never  been  successful  for  long. 

The  trend  of  recent  effort  in  the  disposal  of  excrement  is  toward  better-built  privies 
and  cesspools  and  stricter  board  of  health  control  over  the  subject  and  the  construction 
of  sewerage  systems  wherever  practicable.  It  is  recognized  that  flies  and  other  insects 
must  not  have  access  to  the  material,  and  that  the  danger  that  food  and  drink  may 
become  contaminated  by  it  must  be  reduced  to  the  lowest  terms.  Properly  managed 
privies  and  cesspools  may,  in  certain  cases,  afford  the  best  means  of  solving  the  excre- 
ment problem.    Sewerage  systems  are  not  always  either  feasible  or  desirable. 

Strut  cleaning. — ^Turning  now  to  the  subject  of  street  cleaning,  another  division 
of  our  general  topic,  we  find  certain  standard  practices  and  on  the  whole  a  much  better 
stage  of  development.  But  even  here  there  is  considerable  diversity  of  procedure 
in  the  efforts  made  in  different  cities  for  the  accomplishment  of  the  same  object. 
It  must  not  be  overlooked,  however,  that  the  work  to  be  done  in  cleaning  a  pavement 
is  not  always  the  same.  Different  conditions  of  traffic  and  of  pavement  produce 
different  effects.  A  degree  of  cleanness  which  is  suitable  for  one  part  of  a  city  may 
not  be  appropriate  at  all  for  another.  The  best-cared  for  sections  are  usually  those 
which  are  most  difficult  to  keep  clean.  The  most  neglected  parts  of  cities  are  the 
outlying  districts.  These  often  appear  to  be  utterly  forgotten  by  the  street  cleaning 
authorities. 

In  no  case  should  there  be  imsightly  litter,  nor  the  excrement  of  animals,  except 
for  brief  periods  of  time.    Dust  should  be  prevented  as  far  as  it  reasonably  can  be. 


PUBUO  HEALTH  Ain>  KBDIOIKB.  179 

Not  that  the  duet  is  dangerous  so  much  as  because  it  is  disagreeable.  Dust  is,  moie- 
over,  costly  for  householders  to  remove  from  their  homes  and  injurious  to  fobrics  and 
other  things. 

The  trend  of  modem  practice  is  distinctly  toward  the  prevention  of  dust,  which 
means  the  collection  of  this  material  either  in  its  familiar  dry  ionn  or  as  mud,  which  it 
becomes  when  it  is  wet.  The  future  to  judge  by  the  efforts  which  are  now  being  made 
will  witness  more  distinct  improvements  in  this  direction  than  in  any  other.  Machines, 
as  yet  of  doubtful  efficiency,  may  be  developed  to  operate  on  the  vacuum  principle 
to  pick  up  street  dirt  and  store  it  in  a  suitable  receptacle  until  it  can  be  finally  dis- 
posed of. 

Hand  and  machine  work. — There  are  two  geneial  ways  of  cleaning  streets  whidi 
demand  consideration  here:  hand  and  machine  work.  Handwcnrk  is  the  more  mobile 
and  effective  method  and  is  to  be  preferred  where  the  pavement  is  poor  or  the  work 
difficult  for  other  reasons  or  the  beet  results  are  desired.  Machine  work  is  to  be  pre- 
ferred on  the  score  of  economy  and  speed. 

Under  handwork  is  to  be  mentioned  the  prompt  picking  up  of  litter,  including 
papers,  fruit  skins,  and  haree  droppings,  which,  if  sdlowed  to  remain  on  the  pavement, 
would  invite  to  a  fiuther  dirtying  of  the  street  and  would  become  ground  up  and  so 
made  more  difficult  to  remove.  The  labor  of  this  sort  which  is  entailed  in  most 
American  cities  is  very  large — ^it  is  unnecessarily  large.  A  great  deal  of  the  dirt  in 
our  city  streets  can  and  should  be  prevented  by  the  police  enforcements  of  suitable 
ordinances.  No  one  should  be  allowed  to  throw  papers,  house  sweepings,  ashes,  or 
other  refuse  into  the  streets.  It  is  forbidden  in  Grerman  cities  and  it  should  be  equally 
unlawful  elsewhere. 

With  the  best  of  care  some  littering  is  unavoidable  and  this  beet  can  be  taken  care 
of  by  what  is  known  as  the  orderly,  or  patrol,  or  block  sytem.  In  this  system  men 
or  boys  are  required  to  patrol  certain  districts  and  pick  up  the  laige  articles  of  refuse 
and  place  them  in  suitable  receptacles  for  final  removal  and  disposition.  In  the 
United  States  the  receptacles  are  generally  jute  or  canvas  bags  conveniently  hung 
on  two-wheeled  hand  carts,  or  barrel-shaped  cans  carried  in  a  similar  vehicle.  When 
a  receptacle  is  full  it  is  exchanged  for  an  empty  one,  the  full  receptacle  being  tem- 
porsrily  placed  where  it  can  be  seen  and  picked  up  by  men  with  carts  especially 
assigned  to  that  duty.  A  weak  2>oint  in  this  system  is  the  temporary  storage. 
The  receptacle  may  be  left  too  long  and  in  too  conspicuous  a  place.  Sometimes 
the  material  is  not  contained  in  a  receptacle,  but  is  simply  piled  up  near  the  gutter; 
under  such  circumstances  it  is  very  likely  to  get  scattered  about  by  passing  yehides 
and  by  winds. 

Sweeping, — ^Tbe  proper  function  of  sweeping  is  to  clean  pavements  of  the  finely 
ground  dirt,  which  is  dust  when  dry  and  mud  when  wet.  It  may  be  removed  in  either 
condition,  but  from  the  sanitary  standpoint  it  should  never  be  dealt  with  by  a  process 
which  raises  the  dust  into  the  air.  Brooms  of  special  design  and  of  standard  f(»rm  are 
are  usually  employed,  irrespective  of  the  kind  of  pavement  or  the  character  or  amount 
of  dirt  to  be  removed  from  it.    There  is  room  for  considerable  improvement  here. 

To  prevent  the  raising  of  dust  when  sweeping,  it  is  often  customary  to  sprinkle  the 
pavements;  this  is  usuaUy  done  by  means  of  a  horse-drawn  watering  cart.  Qood 
judgment  is  required  in  order  to  apply  the  right  amount  of  water,  for  if  too  little  is 
used  the  material  is  not  sufficiently  moistened  and  some  of  the  dust  rises  into  the 
atmosphene;  and  if  too  much  is  employed,  the  material  is  reduced  to  a  condition  of 
plaster  which  the  broom  smears  over  the  payment.  At  best,  hand  sweeping  is  expen- 
sive, far  the  hhcx  is  arduous  and  the  area  which  a  wivkman  can  properly  care  far  is 
relatively  small. 

The  material  which  is  swept  up  is  commonly  stored  on  the  pavement  in  pUee  until 
it  can  be  removed  to  the  place  of  final  disposal  in  carts.  This  practice  is  apparently 
unavoidable.    It  is  least  objectionable  when  the  dirt  is  collected  prconptly.    When 

684S6— 17— VOL  X 18 


180       PB00EEDINQ8  BECOND  PAN  AMERICAN  80IENTIFI0  C0NGBE88. 

the  piles  are  allowed  to  remain  long,  a  considerable  amount  of  the  dirt  may  become 
scattered  upon  the  pavements  again  by  the  wind  and  movements  of  vehicles. 

A  substitute  for  hand  sweeping  lies  in  the  use  of  the  revolving  broom  attached  to  a 
suitable  frame  and  drawn  by  one  or  more  horses.  Many  cities  use  the  horse  broom 
and  it  may  be  said  to  be  a  standard  piece  of  apparatus.  It  should  always  be  preceded 
by  a  sprinkling  wagon  when  the  material  to  be  removed  is  not  already  damp.  It 
could  be  used  to  great  advantage  during  and  inunediately  after  rain,  but  it  seldom 
make^  its  appearance  under  such  circumstances.  In  some  cities  where  there  is  a  great 
deal  of  work  to  be  done,  horse  brooms  travel  in  gangs,  the  broom  being  so  adjusted 
as  to  throw  the  dirt  to  one  side,  each  broom  taking  it  up  where  the  other  left  it  and 
carrying  it  nearer  and  nearer  to  the  side  of  the  street,  until  it  reaches  the  gutter. 
Here  the  dirt  is  shoveled  into  piles  to  be  collected  into  carts  for  final  disposition. 

Flushing. — The  most  recent  advance  in  street  cleaning  lies  in  the  use  of  a  stream 
of  water  to  cleanse  the  pavements.  The  object  is  to  secure  a  greater  degree  of  clean- 
ness than  is  possible  with  broom  work.  This  method  is  commonly  called  flushing, 
but  it  is  not  merely  flushing.  When  properly  done,  the  stream  sweeps  as  well  as 
flushes  the  material  away.  Before  the  water  is  applied,  the  material  to  be  removed 
should  be  thoroughly  lubricated  to  remove  its  adhesiveness  toward  the  pavement. 
This  is  beet  done  by  means  of  sprinkling  wagons  which  thoroughly  wet  the  pavements 
before  the  water  is  used  to  carry  the  material  to  the  gutters. 

Street  flushing  is  sometimes  done  by  means  of  a  fire  hose  and  sometimes  with 
wagons  which  carry  a  supply  of  water  and  direct  it  downward  under  pressure  upon  the 
pavements.  Under  favorable  circumstances,  good  results  can  be  obtained  by  either 
method,  but  where  the  pavements  are  irregular,  very  dirty  or  the  smallest  quantity 
of  water  must  be  used  or  the  cleanest  results  obtained,  no  automatic  apparatus  can 
take  the  place  of  intelligent  and  experienced  hand  workers. 

It  Ib  often  feasible  and  desirable  to  scrub  or  scrape  the  pavements  with  brooms 
or  rubber  squegees.  These  tools  may  be  used  in  the  hand  or  operated  mechanically. 
An  automatic  scraper  which  is  equipped  with  rubber  placed  spirally  upon  a  hori- 
zontal drum  has  been  found  to  be  one  of  the  most  serviceable  jneces  of  equipment  for 
this  service.    Like  flushing,  it  was  first  used  extensively  in  Europe. 

It  is  perhaps  unnecessary  to  point  out  that  in  selecting  the  method  to  employ  in 
any  case,  the  choice  should  depend  not  alone  upon  the  results  which  are  obtainable 
elsewhere,  but  under  the  particular  conditions  with  which  one  has  to  deal.  Before 
any  system  of  water  cleansing  or  sweeping  is  decided  on  as  the  best  for  any  case,  it  will 
be  desirable  to  consider  it  in  all  its  local  aspects.  Experiments  and  tests  of  appli- 
ances and  methods  may  be  exceedingly  helpful. 

Combinations  of  apparatus  have  been  invented  for  sweeping,  sprinkling,  picking 
up  dust  and  carting  it  away,  and  very  laige  pieces  of  apparatus  have  been  built  to 
clean  streets  on  the  vacuum  principle.  There  are  many  difliculties  in  the  way  of 
successful  machines  of  these  types  and  it  does  not  appear  that  they  have  all  been 
overcome.  One  of  the  main  obstacles  is  the  irregularity  in  the  surface  of  the  pave- 
ment, another  is  the  variety  in  the  consistency  of  the  dirt  to  be  removed.  In  time, 
perhaps,  such  automatic  apparatus  will  largely  supersede  hand  work,  but  that  time 
has  not  yet  arrived,  except  in  some  cities  where  the  conditions  are  decidedly  favorable. 

Final  disposition  of  street  dirt. — ^As  to  the  disposition  which  can  be  made  of  street 
dirt,  it  is  well  to  consider  that  the  main  object  should  be  to  get  rid  of  the  material 
in  a  sanitary  way,  and  attempts  to  extract  the  manurial  values  present  should  be  a 
secondary  consideration. 

The  manurial  value  of  street  sweepings  is  less  than  it  would  be  if  the  material  did 
not  lie  our  in  the  wet  and  air  and  become  mixed  with  useless  dust.  The  fresh  horse 
droppings  have  the  most  value,  and  it  is  often  more  economical  not  to  attempt  to  use 
them  tlum  to  gather  them  with  the  idea  of  putting  them  to  practical  use.  When 
horse  droppings  are  collected  promptly  and  removed,  the  pavements  are  to  that 


PUBLIC  HEALTH  AND  MEDICINIL  181 

extent  protected  from  objectionable  littering,  but  this  work  should  be  done  for  the 
sake  of  cleanness,  rather  than  for  profit.  Sometimes  street  sweepings  are  placed  in 
piles  and  allowed  to  ferment  like  compost.  This  is  an  admirable  procedure  wheu 
the  opportunities  are  favorable  to  it,  but  the  resulting  compound  is  not  of  much  value^ 

Snow, — The  removal  of  snow  is  one  of  the  most  costly  and  unsatisfactory  branches 
of  street  cleaning  for  the  reascm  that  the  amount  of  work  involved,  if  large  areas  of 
pavement  are  cleared,  is  very  large  and  its  occurrence  uncertain  and  irregular.  Most 
cities  do  little  to  clear  away  snow  except  upon  the  main  highways,  and  there  are 
few,  indeed,  where  even  this  result  is  accomplished  to  the  general  satisfaction.  For 
the  most  part  cities  allow  the  snow  to  lie  upon  the  pavements  until  warmer  weather 
occurs,  when  the  compacted  mass  is  picked  and  broken  and  the  natural  melting 
facilitated. 

Like  the  disposal  of  refuse  generally,  the  removal  of  snow  involves  three  processes : 
1,  Collection;  2,  cartimg;  and  3,  final  disposition.  For  collection  the  main  reliance 
is  hand  labor,  shovelSy  and  sometimes  when  the  snow  is  compact  and  frozen,  picks 
being  the  tools  most  often  employed. 

It  is  customary  to  shovel  the  snow  into  piles  located  at  convenient  distances  apart 
at  the  center  or  sides  of  the  carriageways.  Carts  and  wagons  of  the  largest  capacity 
available  are  then  driven  alongside  and  the  snow  is  shoveled  into  them.  The  carts 
are  hauled  to  dumping  places  which  should  be  as  accessible  as  possible,  rivers,  parks, 
and  empty  lots  often  being  utilized. 

Recent  improvements  in  snow  removal  have  been  made  by  the  employment  of 
plows  to  assist  in  the  collection  and  in  the  use  of  sewers  as  the  place  of  final  diBposi- 
tion.  It  has  been  found  that  large  sewers  are  capable  of  carrying  off  a  great  dcAl  of 
snow  without  injury  to  them,  provided  little  else  than  snow  is  put  into  them.  Fol- 
lowing European  custom,  great  improvement  has  been  made  in  perfecting  the  organi* 
sation  necessary  to  handle  the  snow.  The  largest  item  of  expense  being  in  the  Labor 
employed,  and  this  labor  being  necessarily  of  the  poorest  sort,  an  improvement  in 
the  organization  of  the  directing  force  of  permanent  employees  which  helps  to  direct 
the  auxiliary  laborers,  makes  for  efficiency  and  economy. 

In  future  the  work  of  removing  snow  is  likely  to  see  considerable  improvement  in 
the  organization  of  the  workers,  in  the  use  of  the  sewers  and  in  the  apparatus  designed 
to  supplement  the  large  amount  of  hand  labor  which  must  always  be  the  chief  reliance. 
The  use  of  salt  to  melt  the  snow  and  the  employment  of  streams  of  flushing  water  to 
carry  the  snow  into  the  gutters  and  sewers  appear  to  offer  some  promise  in  those 
situations  wherein  the  cold  is  not  excessive  and  the  water  is  available  at  no  great 
expense. 

n.  8BWAGK  DISPOSAL. 

According  to  statistical  information,  it  appears  that  most  of  the  cities  of  the  United 
States  are  provided  with  sewers,  to  some  extent,  at  least,  but  have  no  means  of  getting 
rid  of  their  sewage,  except  by  discharging  it  into  a  natural  body  of  water  in  the  vicinity. 
As  sewers  first  came  into  use  for  the  means  which  they  afforded  for  carrying  away 
lain  water  from  the  streets,  so  they  are  likely  to  be  built  in  the  small  and  growing 
municipality  for  the  same  purpose  to-day.  There  is,  perhaps,  little  objection  to  be 
raised  against  the  discharge  of  surface  water  to  the  rivers,  but  when  house  sewage  and 
the  drainage  of  factories  are  added,  grave  consequences  may,  and  often  do,  follow. 
These  consequences  are  of  two  general  kinds — danger  of  disease  and  risk  of  nuisance. 
The  nuisance  may  be  an  offense  to  the  sense  of  sight  or  smell.  The  danger  of  disease 
is  usually  through  the  pollution  of  drinking  water;  but  it  must  not  be  forgotten  that 
a  nuisance  may  have  a  prejudicial  effect  upon  health,  so  that  the  line  separating  the 
two  clases  of  objectionable  consequences  just  drawn,  should  not  be  regarded  as  a  very 

sharp  one. 

ExUnt  of  treatment  required. — ^Many  sanitarians  have  contended  that  the  proper 
function  of  sewage  disposal  works  was  to  i^event  nuisance  only,  and  that  the  proper 


182       PBOGEEDINGS  SBOOND  PAN  AMBBIOAN  SODSKTIFIO  CONGRESS. 

way  to  protect  a  community  from  polluted  riven  and  otlier  natural  bodies  ctf  water, 
was  to  avoid  the  use  of  the  unpurified  water  for  drinking  purposes.  Their  contention 
has  been  that  the  streams  were  natural  sewers  and  should  be  utilized  as  such;  that  it 
was  cheaper  to  purify  the  drinking  water  supplies  than  to  keep  all  natural  bodies  of 
water  clean  enough  for  domestic  uses  without  purification.  It  has  been  argued  that 
the  only  practicable  way  to  deal  with  the  problem  of  utilising  the  rivers  and  lakes  for 
sewage  disposal  and  water  supply  is  to  let  the  sewage  into  them  and  regard  all  water 
obtained  from  surface  sources  as  polluted  and  requiring  to  be  filtered  or  otherwise 
rendered  suitably  piure. 

This  is  the  status  of  the  subject  in  the  United  States  to-day. 

Sewage  should  be  discharged  only  in  such  quantity  and  in  such  places  as  will  not 
produce  a  nuisance  and  add  unreasonably  to  the  difficulty  and  cost  of  purifying  the 
water  for  such  purposes  as  it  may  be  required  to  serve.  Neariy  all  drinking  water 
supplies,  unless  from  underground  sources,  must  be  regarded  as  probably  unsafe  unless 
artificially  purified.  This  point  of  view  should  be  kept  in  mind  in  considering  the 
methods  which  are  available  for  the  treatment  of  sewage.  By  treatment  is  meant 
partial  purification. 

Exhaustive  experiments  as  well  as  experience  in  Europe  and  America  have  yielded 
a  great  deal  of  information  concerning  the  methods  which  can  be  successfully  employed 
for  the  purpose  of  relieving  sewage  of  its  offensive  ingredients,  and  there  is  little  doubt 
but  that  marked  progress  will  continue  to  be  made  in  this  important  field  for  some 
time  to  come. 

Objects  which  can  be  accompl'ished, — Few  sanitary  subjects  are  so  complicated  or 
require  so  varied  a  knowledge  of  science  for  their  mastery  as  sewage  disposal;  but 
once  the  principles  of  the  art  are  understood,  it  will  be  possible  to  proceed  with  con- 
siderable confidence  to  the  construction  of  the  necessary  works.  The  most  successful 
works  are  those  in  which  the  proper  principles  are  best  applied  to  the  local  conditions; 
no  single  process  of  sewage  disposal  exists  which  is  capable  of  dealing  satishictorily 
with  all  cases.  Sewage  varies  in  composition  and  is  not  of  the  same  volume  or  quality 
in  different  cities  or  different  sewers  in  one  city,  or  at  different  times  of  day  in  a 
given  sewer.  The  state  of  the  weather,  the  season  of  the  year,  the  character  of  the 
district  with  respect  to  residence  and  business  occupancy,  the  nationality  and  habits 
of  the  population  and  other  conditions  all  affect  the  quality  and  quantity  produced. 
Standard  methods  of  treatment  exist,  but  they  apply  only  to  standard  conditions. 
The  success  of  a  system  of  sewage  treatment  depends  upon  the  completeness  with 
which  it  is  suited  to  the  particular  situation  to  be  dealt  with.  To  many  persons  the 
repetition  of  this  fact  may  seem  unnecessary,  and  yet  it  is  to  its  continual  neglect 
thAt  most  of  the  failures  in  the  works  which  have  been  built  are  attributable. 

The  best  methods  for  the  treatment  of  sewage  have  for  their  immediate  objects  the 
removal  of  the  grit  and  other  relatively  large  and  solid  matters,  the  destruction  or 
abstraction  of  the  very  finely  divided  colloidal  and  other  semisolid  substances,  and 
the  oxidation  of  the  remaining  liquids. 

The  processes  may  be  said  to  be  mechanical  and  biological  and  chemical,  according 
to  the  principles  upon  which  they  operate.  The  mechanical  methods  aim  to  remove 
the  relatively  large  solids  and  some  of  the  colloids.  The  biological  undertake  to 
destroy  the  peculiar  molecular  structure  of  the  colloids  which  are  not  removed  mechan- 
ically and  to  carry  on  the  oxidizing  processes.  The  chemical  procedures  aid  the 
mechanical  and  biological  effects  and  sterilize  the  sewage  when  that  extreme  measure 
is  attempted.  No  one  of  these  processes  is  capable  of  adequately  treating  a  sewage 
except  where  a  partial  and  imperfect  effect  is  desired.  It  is  usual  to  employ  two  or 
more,  each  to  do  a  certain  share  toward  the  general  result  desired. 

MSCHANICAL  PROCESSES. 

a.  Screens  and  grit  chambers. — Mechanical  methods  include  grit  chambers,  which 
are  essentially  enlaigements  of  the  sewer  as  it  enters  the  disposal  plant.    As  the 


PUBLIC  HEALTH  AND  MEDIOINE.  183 

sewage  flows  into  the  chamber  the  velocity  of  the  ctnrent  is  retarded  and  this  slowing 
causes  the  solid  matters  to  settle  out.  Facilities  are  provided  in  the  form,  often,  of 
dredging  machinery,  for  removing  the  grit  from  the  bottom. 

In  connection  with  the  grit  badns,  there  are  generally  coarse  screens  composed  of 
heavy  bars  placed  an  inch  or  more  apart,  for  the  purpose  of  intercepting  large  floating 
substances.  * 

Fine  screens  are  sometimes  used  to  take  out  of  the  sewage  the  solid  matters  which 
are  not  heavy  enou^  to  sink  readily  in  the  grit  chambers.  If  not  removed,  these 
solids  become  more  and  more  comminuted  and  add  materially  to  the  difficulty  with 
which  the  more  refined  processes  of  treatment  can  be  carried  on.  The  fineness  of 
these  screens  and  the  ingenuity  with  whidi  they  are  constructed,  are  among  the 
most  recent  advances  which  have  been  made  in  the  whole  art  of  sewage  treatment. 
The  beet  screens  are  so  constructed  as  to  present  always  a  free  and  clean  surface  to 
the  sewage  stream.  This  result^is  accomplished  by  means  of  machinery  whidi  car- 
ries the  screening  surface  dowly  up  out  of  the  sewage  and  there  cleanses  it  before 
the  screen  automatically  revolves  back  for  a  new  load  of  soMd  matters. 

Fine  screens  have  reached  their  highest  development  in  Germany.  England, 
which  leads  the  workl  in  nearly  all  other  blanches  of  sewage  treatment,  possesBes  but 
few  examples  of  fine  screens.  The  Crermany  screens  are  standard  for  Grermany ;  nearly 
every  laige  city  is  provided  with  them  in  some  form.  The  forms  are  various;  it  is 
possible  to  find  one  to  suit  almost  any  requirsment.  The  difficulty  is  to  know  which 
is  the  best  for  the  particularly  case  in  hand,  and  Just  what  to  expect  of  it  under  Ameri- 
can conditions.  Again,  being  of  oompUcated  construction,  it  would  seem  necessary  to 
employ  a  conaidenble  amount  of  skill  to  operate  one  successfully.  But  this  objec- 
tion is  rather  a  general  one  and  can  not  be  escaped  in  sewage  disposal.  No  process 
is  capable  of  good  woric  without  good  attention. 

Between  the  complicated  fine  screens  of  the  Germans  and  the  conmion  bar  screens 
which  are  a  necessury  featinv  of  all  works  lies  a  large  variety  of  screens  of  varying 
degrees  of  efficiency.  Their  function  is  to  collect  such  relatively  large  substances 
as  leaves,  matches,  cloths,  paper  refuse,  and  whatever  else  will  gather  upon  them. 
Screens  of  these  kinds  are  often  employed  and  are  generally  inefficient,  being  poorly 
provided  with  cleaning  arrangements  and  too  coarse  to  gather  much  material. 

The  screenings  are  disposed  of  in  different  wajrs,  according  to  their  amount,  and  the 
natural  aptitude  of  the  people  to  turn  .such  material  to  account.  In  Germany  the 
screenings  are  often  used  as  manure,  sometimes  they  are  burnt.  In  all  cases  they 
are  exceedingly  offensive,  and  diould  not  be  stored  or  handled  any  more  than  is 
absolutely  necessary. 

h.  Settling  banm. — Settling  basins  are  regarded  as  one  of  the  most  useful,  as  they 
are  one  of  the  most  frequently  met  with  devices  used  for  the  treatment  of  sewage. 
They  are  of  various  types  and  perform  various  functions,  although  their  chief  useful- 
ness has,  until  recently,  been  considered  to  lie  in  the  removal  of  solids  which  will 
subside  if  given  a  chance  to  do  so. 

In  its  simplest  form  a  settling  basin  is  a  tank  of  such  size  as  to  permit  the  sewage 
to  flow  slowly  through  it  in  about  three  or  four  hours.  The  bottom  slopes  gradually 
toward  a  large  outlet  pipe  which  is  used  when  the  solid  matters  are  cleaned  out.  An 
inlet  and  an  outlet  for  the  sewage  are  provided  at  opposite  ends  of  the  tanks  near  the 
surfeice  of  the  liquid.  The  solids  are  deposited  as  the  pewage  flows  through  the  basin 
or  is  allowed  to  stand  quiescent  in  it,  according  to  the  method  by  'vdiich  the  operation 
is  conducted.  Sometimes  chemicals,  such,  for  example,  as  lime  and  iron,  are  applied 
to  the  sewage  to  increase  and  hasten  the  settlement;  this  method  is  termed  chemical 
precipitation.    It  is  not  so  much  used  now  as  formerly. 

Improvements  have  been  made  in  the  settling  basin  just  described  until  its  (Higinal 
functions,  as  well  as  its  appearance,  to-day  are  scarcdy  recognizable.  Among  the 
most  interesting  and  importaa  t  of  these  changes  were  those  which  were  brou  g^t  about 


184       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  CONGRESS. 

by  the  discovery  that  if  sewage  was  kept  in  a  settling  tank  for  a  period  of  eight  hours 
or  more  it  would  putrefy  and  much  of  the  solid  matters  which  gathered  upon  the 
bottom  would  become  liquid,  thereby  lessening  the  frequency  with  which  the  tank 
would  have  to  be  emptied  of  its  sewage  and  the  accumulations  at  the  bottom  removed. 
This  new  process  was  thought  capable  of  affording  a  nearly  complete  solution  of  the 
sewage  problem,  for  it  promised  to  do  away  with  the  troublesome  question  of  disposing 
of  the  settlings.  A  settling  basin  operating  upon  the  principle  just  indicated  was 
called  a  septic  tank.  At  first  the  limitations  of  the  septic  tank  were  not  recognized. 
To-day  it  is  probable  that  no  engineer  would  build  a  septic  tank  for  large  works,  even 
in  connection  with  other  devices,  except  under  unusual  circumstances. 

The  latest  development  in  settling  basins  is  the  Emscher  tank,  the  invention  of 
Karl  Imhof ,  of  the  Emscher  drainage  district  of  Germany.  The  Imhof  tank  possesses 
two  notable  features:  First,  great  depth  and  a  pointed  bottom,  which  causes  the 
depositing  solids  to  settle  toward  an  outlet  pipe,  from  which  they  can  be  withdrawn 
without  emptying  the  tank  of  its  sewage.  Second,  a  trap  through  which  the  solids 
settle  to  a  bottom  compartment  and  from  which  they  can  not  escai>e  to  the  flowing 
sewage  above.  The  sewage  passes  Xhrough  the  tank  too  rapidly  to  become  foul,  as  it 
does  in  the  old  septic  tank,  but  the  solids  imprisoned  in  the  trap  remain  long  enough 
to  undergo  a  complete  fermentation  with  a  result  which  is  truly  remarkable.  Whoreas 
the  accumulations  at  the  bottom  of  an  ordinary  ^ttling  tank  consist  of  a  very  watwy 
mud  which  can  be  dried  only  with  great  difficulty,  the  material  drawn  from  the  lower 
part  of  the  ImhoC  tank  quickly  parts  with  its  water  on  standing.  It  can  then  be  burnt 
or  used  for  filling  low  lying  land.  Immense  volumes  of  inoffensive  gas  are  produced 
in  the  process,  and  the  solids  taken  out  are  relatively  small  in  volume  and  practically 
inodorous.  Hundreds  of  new  tanks  have  been  built  on  this  principle  within  the  last 
few  years,  and  many  sewage  works  formerly  employing  plain  sedimentation  or  septic 
tanks  have  been  constructed  on  the  Imhof  principle. 

Processes  of  oxidation. — When  sewage  has  been  deprived  of  its  settleable  solids  by 
sedimentation  of  some  kind  or  the  solid  matters  have  been  removed  as  far  as  possible 
by  screening,  it  is  still  capable  of  produdng  offensive  odors  in  rivers  and  other  natural 
bodies  of  water  unless  the  diluting  power  of  the  latter  is  large,  and  for  this  reason  some 
further  process  of  treatment  frequently  becomes  necessary.  The  odors  are  due  to 
putrefaction,  or,  in  oiher  words,  bacterial  fermentation  in  the  absence  of  oxygen. 
Experience  has  shown  that  in  the  presence  of  a  proper  supply  of  oxygen,  objection- 
able odors  will  not  be  produced.  The  organic  matters  which  are  a  characteristic  of 
sewage  become  oxidized  and  so  converted  into  mineral  compounds  which  are  inoffen- 
sive and  incapable  of  becoming  so. 

It  has  been  found  practicable  to  cause  the  oxidizing  changes  to  take  place  in  arti- 
ficially prepared  beds  of  broken  stone  or  other  solid  media  through  which  the  sewage 
is  allowed  to  pass  very  slowly  with  an  abundant  supply  of  atmospheric  air.  Some- 
times the  beds  are  contained  in  water-tight  basins  and  the  sewage  is  allowed  to  flow 
into  them,  remain  in  contact  with  the  stone  for  a  period  of  two  hours  or  so,  and  then 
drawn  off;  in  this  case  the  device  is  called  a  contact  bed.  More  often  the  beds  are 
built  upon  an  impervious  floor  without  containing  sides.  The  sewage  is  sprinkled 
over  the  top  of  the  stones  and  allowed  to  drain  slowly  through  to  the  bottom;  in  this 
case  the  beds  are  known  as  sprinkling  filters  or  percolating  filters.  Both  contact  beds 
and  sprinkling  filters  are  capable  of  doing  excellent  work,  but  the  latter  are  by  far 
the  more  effective  for  a  given  amount  of  land.  Large  works  on  each  principle  exist 
and  have  proved  effective  even  in  cold  climates. 

The  oxidation,  like  the  putrefaction  of  sewage,  is  brought  about  by  the  activities 
of  special  types  of  bacteria,  and  it  is  by  providing  the  suitable  conditions  for  their  life 
processes  that  the  desired  results  are  secured.  When  suitable  conditions  for  the  par- 
ticular kind  of  bacterial  action  desired  are  not  provided,  the  whole  process  fails. 
Thus,  oxidizing  beds  are  able  to  ti^e  care  of  a  definite  amount  of  sewage  stuff  per  acre 


PUBUO  HEALTH  AKD  MEDIOINB.  185 

and  will  handle  no  more.    If  more  be  added,  or  the  supply  of  atmospheric  oxygen  be. 
diminished,  the  bed  becomes  sick  and  the  improvement  in  the  sewage  stops. 

The  latest  advance  in  sewage-disposal  practice  has  been  accomplished  by  doing 
away  with  the  stone  beds  and  giving  the  oxidizing  bacteria  their  proper  supply  of 
oxygen  directly  by  pumping  air  through  the  sewage.  This  process  can  apparently 
be  carried  on  in  tanks  like  the  old-fashioned  settling  tanks,  if  necessary.  Experi- 
ments made  at  the  famous  sewage  testing  station  at  Lawrence,  Mass.,  at  Milwaukee, 
Wis.,  Manchester,  England,  and  elsewhere,  give  promise  of  a  substantial  advance  in 
the  efficiency,  reliability,  and  economy  with  which  sewage  can  be  treated  in  this 
general  way. 

UtUizatian  of  the  manunal  value  of  sewage.— There  was  a  time  when  it  was  thought 
that  the  manurial  value  of  sewage  should  serve  as  an  incentive  for  the  employment  of 
this  kind  of  municipal  waste  as  fertilizer.  Economists  solemnly  warned  the  public 
that  millions  of  tons  of  nitrogen  were  being  wantonly  thrown  into  the  watercourses 
when  the  world's  supply  of  guano  was  showing  signs  of  depletion.  It  was  claimed 
that  the  heedless  pursuit  of  this  policy  was  certain  to  result  disastrously  in  course  of 
time.    The  sewage  should  be  returned  to  the  soil. 

Under  mistaken  ideas  of  conservancy  attempts  were  made  to  apply  sewage  to  agri- 
culture, and  these  efforts  were  persisted  in  in  England  until  the  subject  was  thoroug^y 
tried  out.  There  are  now  some  laige  farms  using  sewage,  not  only  in  England,  but  on 
the  Continent  of  Eiurope.  But  it  is  no  exaggeration  to  say  that  there  is  hardly  a  city 
which  would  not  willingly  give  up  its  sewage  farms  for  more  modem  and  intensive 
methods  of  disposal  if  it  could  do  so  without  sacrificing  the  money  which  is  invested 
in  the  existing  works.  Sewage  fanning  affords  a  good  way  to  get  rid  of  sewage  pro- 
vkling  the  climate,  soil,  and  agricultural  conditions  are  favorable;  but  it  can  rarely  be 
recommended  unless  the  water,  aside  from  the  manurial  ingredients,  is  needed  for  the 
crops. 

Such  fertilizing  value  as  sewage  contains  is  difficult  to  turn  to  practical  account.  For 
one  thing,  the  useful  materials  are  too  highly  diluted;  sewage,  as  ordinarily  produced 
by  the  cities  of  the  United  States,  is  about  998  parts  water  to  but  two  parts  of  solids, 
and  of  these  two  parts,  only  one-half  is  organic  matter.  Ordinarily,  land  does  not 
require,  nor  can  it  take,  a  great  deal  of  water  at  all  times,  and  yet  the  sewage  must  be 
gotten  rid  of  at  times  of  rain  and  frost  and  in  the  unproductive  period.  Furthermore, 
It  has  been  abundantly  shown  by  competent  agricultural  chemists,  that  such  fertilizing 
values  as  are  present  are  not,  for  the  most  part,  in  available  form  for  plant  food. 

The  most  promising  way  in  which  sewage  matters  can  be  utilized  for  the  manuring 
of  crops  is  in  the  form  of  a  dry  powder  produced  from  the  sludge  of  settling  basins. 
Filter  presses  and  other  drying  apparatus  can  be  employed  to  get  rid  of  the  water,  but 
the  undertaking  is  expensive.  Some  fertilizer  is  made  in  this  way;  the  amoiint  is  not 
laige.  Up  to  the  present  time  it  has  cost  too  much  to  sepsurate  the  useful  materials 
from  the  water.  The  subject,  in  spite  of  the  interest  which  has  been  taken  in  it  for 
more  than  a  generation,  still  lacks  practical  development. 

Sludge.— In  most  sewage-disposal  works  a  great  deal  of  mud  or  sludge,  as  it  is  called, 
is  produced,  and  the  final  disposition  of  this  material  offers  many  difficulties.  Some 
cities  carry  it  to  sea  and  dump  it  from  steam  vessels  constructed  for  the  purpose; 
others  discharge  it  into  lagoons  where  it  lies,  an  unsightly  and  malodorous  mass,  for 
long  periods  of  time  until  the  forces  of  luiture  eventually  consume  it.  In  order  to 
avoid  the  insanitary  conditions  which  sewage  produces  when  discharged  upon  land,  it 
is  often  ploughed  into  the  soil.  In  Germany  centrifugal  machines  are  used  to  express 
a  part  of  the  moisture,  after  which  the  sludge  is  further  dried  by  heat  and  burned. 
There  are  plants  in  England  and  America  where  the  material  is  passed  through  filter 
presses  and  then  dumped  upon  low-lying  land. 

Recently  it  has  been  found  that  sludge  will  ferment,  if  kept  stirred  up  and  mixed  in 
cotain  ways  with  fresh  and  stale  matoial,  and  after  this  change  takes  place  the  water 


186       PBOOEEDINOS  SSCOKO  PAK  AMBBIOAN  ddEKTIFIO  00NGBE88. 

will  easily  drain  away.   This  is  the  secret  of  the  Imhof  tank — ^the  Dickson  and  activated 
sludge  processes  and  other  methods  more  or  less  resemble  them. 

In  some  cases  where  the  sewage  is  particularly  rich  in  useful  ingredients,  special 
pfoceases  are  employed  to  recover  the  useful  materials.  Thus,  grease  can  profitably 
be  recovered  in  certain  cases.  We  are  here  approaching  the  field  of  the  industrial 
chemist.  Corporations  which  think  that  their  wastes  contain  valuable  substances 
which  it  is  shrewd  business  policy  to  recover,  are  often  compelled  to  employ  chemical 
ability  to  work  out  the  best  system  of  utilisation. 

Various  trades  produce  peculiarly  offensive  liquid  discharges,  as,  for  example,  gas 
making,  paper  making,  leather  tanning,  wool  scouring,  and  brewing .  Much  experience 
has  been  gained,  particularly  in  England,  in  utilizing  Industrial  wastes,  or  at  least,  in 
ridding  them  of  their  offensive  character,  and  the  steps  which  diould  be  taken  in  dis- 
posing of  them  are  still  the  subjecft  of  continuous  study.  Speaking  broadly,  the  undei^ 
lying  principles  for  the  disposal  of  trade  wastes  are  much  like  those  which  have  been 
described  in  this  paper  for  the  disposal  of  municipal  wastes.  Screening,  filtering,  set* 
tling,  precipitating  by  means  of  chemicals,  biological  treatment,  application  to  land, 
filter  pressing,  dumping,  burning,  and  dischaige  into  natural  bodies  of  water  are  all 
practiced. 

LiUrattare.'^The  literature  of  the  subject  of  waste  disposal  is  laige  and  scattered 
through  the  textbooks  and  journals  of  various  sciences  and  jvofesrions.  There  is  no 
comprehensive  work  which  deals  adequately  with  all  branches  of  the  subject.  The 
richest  literature  is  that  of  sewage  disposal;  the  poorest  is  that  which  relates  to  the 
aoHd  wastes.  England  and  Germany  have  been  the  greatest  contributors,  although 
America  is  conceded  to  have  prdduced  much  of  incalculable  value. 

A  feature  of  American  effort  has  been  the  making  of  exhaustive  investigations  and 
the  publication  of  coirespondiDgly  elaborate  reports  concerning  the  disposal  of  the 
aewage  of  particular  cities.  Of  special  interest  are  the  reports  ^ddch  deal  with  the 
sewage  of  New  York,  Chicago,  Philadelphia,  Boston,  Baltimore,  Worcester,  Cohunbos, 
Itilwaukee,  Plttdburgfa,  Gloversville,  and  Cleveland.  The  researches  of  the  Lawrence 
Experiment  Station  of  the  Massachusetts  State  Board  of  Health  into  the  dierposal  of 
sewage  and  the  purification  of  water  are  classic. 

In  England  the  reports  of  the  Royal  Commission  on  Sewage  Disposal,  which  was  ap- 
pointed in  1898  and  continued  until  1915,  easily  overshadow  all  other  work  of  this 
character  in  the  scope  and  practical  aspects  of  the  subjects  dealt  with.  Many  English 
cities  have  also  issued  reports  of  the  utmost  value  with  respect  to  their  sewage  diq)osal 
problems;  as,  for  example,  London,  Birmingham,  Manchester,  Leeds,  Sheffield,  Salftupd, 
and  Bradford.  The  reports  of  the  EngUsh  rivers  boards  are  interesting  and  instruc- 
tive. The  reports  of  the  Rivers  Pollution  Commission,  the  Health  of  Towns  Commis- 
sion, and  similar  bodies  are  regarded  as  having  laid  the  foundation  for  much  of  the  best 
work  which  has  been  done  in  all  countries  in  the  disposal  of  sewage.  In  G^ermany  the 
reports  of  the  Imperial  Sewage  and  Water  Testing  Station,  whose  headquarters  are  in 
Berlin,  and  the  reports  of  the  cities  of  B^^n,  Frankfort,  Hamburg,  Dresden,  Cologne, 
and  many  smaller  places  are  among  the  most  useful  by  way  of  reference. 

Wiih  regard  to  the  disposal  of  solid  wastes,  intersting  information  may  be  found  in 
reports  issued  by  the  cities  of  Boston,  New  York,  Philadelphia,  Chicago,  Baltim<n*e, 
Milwaukee,  and  Cleveland. 

The  periodical  literature  is  far  too  large  to  mention  in  detail.  The  student  should 
consult  the  proceedings  of  engineering  societies  and  chemical  associations  especially^ 
and  give  careful  attention  to  tiie  engineering  trade  papers  for  descriptions  of  the  most 
recent  developments  in  sewage  and  solid  waste  disposal.  Best  of  all,  in  order  to  get 
a  comprehensive  knowledge  of  the  subject,  will  be  a  tour  of  inspection  of  some  of 
the  great  cities  where  disposal  works  are  hi  operation  and  where  opportunity  may 
be  given  to  meet  the  splendidly  trained  and  intelligent  men  under  whom,  in  many 
cases,  the  ^Bsposal  works  have  been  constructed  and  to  whose  intelligent  efforts 
further  progress  is  to  be  looked  for. 


FUBUO  HIALXH  AJTD  KEDIGDrB.  187 

The  Chairman.  We  have  papers  on  this  same  subject  by  Prof. 
1/^Uiam  T.  Sedgwick,  of  the  Massachusetts  Institute  of  Technologyi 
and  Mr.  J.  T.  Fetherston,  commissioner  of  street  cleaning.  New  York 
CStj.    I  shall  now  call  for  their  papers. 


DISPOSAL  OF  BEFUSE. 

By  WILLIAM  T.  SEDOWIGK, 
MoitaehuieUi  IiuUluU  of  Technology. 

We  are  all  creatures  of  fashion,  followers  of  fttshion  in  sanitation  as  well  as  other 
ihatters,  but  I  am  inclined  to  think  that  the  pendulum  has  swung  too  ht.  We  can  not 
say  in  sanitary  matters,  as  we  may  in  the  law, '' De  minimis  curat  non  lex. ''  The  law 
does  look  after  the  least  things  in  sanitation,  and  will  forever  look  after  the  least  things, 
because  as  we  go  along  we  are  getting  the  big  things  looked  out  tar  and  have  to  attend 
to  the  little  things.  At  any  rate,  cleanliness  will  always  be  the  mother  of  sanitation 
and  hygiene;  and  in  dealing  with  these  wastes,  sewage,  garbage,  street  dirt,  and  all 
the  rest,  we  are  dealing  with  fundamentals  of  cleanliness,  and  if  we  ever  take  the 
standpoint,  as  some  people  are  taking  to-day,  rashly  and  without  thinking,  that  boards 
of  health  have  nothing  to  do  with  such  thii^  as  garbage  disposal  and  the  diEfposal  of 
street  dust  and  the  like,  because  they  at  the  moment  have  so  much  more  to  do  with 
infection  and  epidemics,  then  we  shall  make  a  very  serious  mistake,  and  boards  of 
health  will  find  themselves  by  and  by  having  a  certain  amount  of  disease  from  sources 
which  they  had  overlooked.  The  sanitary  chain  is  no  stronger  than  its  weakest 
link,  and  we  have  got  to  pay  attention  to  aO  these  things. 

Now,  Dr.  Soper  began  with  night  soil,  and  the  proper  disposal  of  night  soil  is  a  very 
•erious  matter.  If  it  is  put  on  cidtivated  fields  for  lettuce  and  cabbage  and  the  like 
to  grow  upon,  if  men  track  it  on  their  boots,  or  chickens  carry  it  on  their  feet  to  open 
wells,  then  it  becomes  a  serious  sanitary  menace.  In  rural  sanitation  the  disposal  of 
night  soil  is.  the  i»incipal  problem.  In  the  public  health  service  here,  Dr. 
Lumsden  is  showing  some  wonderful  results  that  he  has  accomplished  in  rural  sanita- 
tion in  several  of  the  counties  of  West  Virginia  and  Maryland  and  Indiana  and 
Kansas — marvellous  reductions  of  typhoid  fever,  laigely  by  attention  to  the  proper 
disposal  of  night  soil. 

While  in  a  laige  and  engineering  way,  the  board  of  health  may  be  said  to  have  very 
little  to  do  with  the  disposal  of  ni^t  soil,  to  take  very  little  interest  in  it  in  some 
cases,  in  other  cases  it  is  going  to  be  the  principal  work  of  the  future.  The  invention 
and  the  stimulation  of  the  use  of  sanitary  privies  is  one  of  the  most  important  subjects 
of  the  time.  There  is  one  at  the  hygienic  laboratory  now,  a  model  sanitary  privy, 
which  everybody  who  is  interested  in  rural  sanitation  or  in  tropical  sanitation,  where 
the  privy  is  wanting  or  too  rare,  should  get  acquainted  with.  It  is  a  most  interesting 
development. 

Again,  touching  on  a  matter  which  is  not  always  thought  of,  there  is  the  sanitary 
disposal  of  sewage  on  steamboats  and  railroads.  The  sanitary  disposal  of  the  waste 
from  these  sources  is  sometimes  a  serious  matter.  For  instance,  when  steamers  leave 
the  Chicago  River  and  go  out  near  the  intake  of  the  Chicago  water  supply,  great  excur- 
sion steamers  laden  with  thousands  of  people,  and  the  discharges  from  the  closets  go 
into  the  lake  near  the  intake,  it  can  not  help  being  a  serious  thing.  Just  how  serious 
the  scattered  disposal  from  a  moving  train  is  or  is  not,  no  one  knows;  but,  as  you  know, 
closets  are  still  locked  upon  trains  in  certain  parts  of  the  country  passing  over  certain 
watersheds,  and  while  that  is  a  barbarous  method  and  in  some  respects  absolutely  to 
be  disapproved  of,  it  is  better  than  none.    From  the  standpoint  of  personal  hygiene. 


188       PBOCEEDINOS  SECOND  PAN  AMBKEOAN  BClEMTliflO  OONGBESS. 

from  the  standpoint  of  efficiency,  it  is  all  wrong;  but  it  is  better  than  allowing  the 
excreta  to  go  into  a  public  water  supply  over  which  a  train  may  be  passing.  Within 
my  own  knowledge,  I  have  known  of  two  instances  in  which  human  excrement  from 
passing  railway  trains  was  found  right  in  a  public  water  supply  and  not  for  from  the 
intake. 

The  question  of  stable  manure  is  an  important  one  because  of  its  connection  with 
vault  building  and  flies,  and  the  health  officer  of  Brookline,  a  town  in  which  I  have 
been  living  for  some  time,  is  proposed  to  take  municipal  charge  of  this  matter  and  have 
municipal  disposal  for  a  more  satlBfactoiy  sanitary  treatment  and  control  of  the  vault 
nuisance. 

I  can  confirm,  and  heartily  confirm,  Dr.  Sopor's  statement  of  the  inefficiency  of 
many  street  "squeegees."  They  simply  pass  over  the  dirt,  allowing  it  to  dry  and 
blow  about.  I  have  had  my  mouth  partially  filled  with  pulverized  horse  dung  and 
other  refuse  for  so  many  years  that  I  hope  I  am  Immune,  but  it  is  not  pleasant* 
Boston,  for  instance,  in  a  windy  time,  has  an  atmosphere  of  pulverized  horse  dung 
and  other  dirt,  although  these  "squeegees ''  are  used  there  very  frequently.  Anyone 
who  has  seen  the  street  washing  in  Munich  and  then  watched  it  in  any  of  oiu*  American 
cities  has  noticed  the  difference;  there  it  is  efficient,  here  it  is  generally  very 
inefficient.  And  let  me  say  that  I  heartily  second  Dr.  Soper^s  suggestion  that  we 
hear  from  oiu*  Central  and  South  American  friends  in  regard  to  their  sanitary 
efforts  in  these  various  directions,  for  we  need  to  know  more  about  their  ways 
than  we  do. 

When  we  come  to  garbage,  we  have  again  a  variety  of  connections  between  sanita- 
tion and  engineering.  From  the  moment  the  garbage  leaves  the  kitchen  until  it  is 
either  destroyed  by  burning  or  by  reduction  or  by  hogs  or  something  else,  it  is  a 
nuisance  and  a  certain  source  of  danger;  probably  not  a  source  anywhere  near  ae 
important  as  sewage  or  some  other  things,  but  still  important.  The  handling  of 
garbage,  for  example,  from  tenement-house  districts  in  which  a  variety  of  diseases 
may  be  existent,  is  liable  to  infect  the  handlers;  and  even  if  no  infectious  disease  is 
carried  by  it  the  nuisance  which  arises  from  the  carting  of  the  garbage  through  the 
streets  by  those  that  generally  do  it  is  unpleasant  and  needless  except  under  our 
system — apparently  it  is  necessary  there. 

Then,  the  garbage  pail  in  the  back  yard,  or  the  garbage  can,  is  a  source  of  trouble. 
Dogs  and  cats  and  rats  by  day  and  by  night  scatter  things  about,  and  if  the  rat  prob- 
lem is  a  serious  one,  as  it  always  should  be  regarded,  then  the  garbage  can  is  a  most 
important  sanitary  appliance.  I  have  often  smiled  when  I  have  observed  that  the 
able  and  highly  trained  officials  of  the  United  States  Public  Health  Service  have 
sometimes  descended  from  their  lofty  level  to  invent  and  approve  garbage  cans. 
The  modem  medical  man  is  so  far  descended  from  ^culaptus  that  he  is  now  inventing 
and  approving  garbage  cans;  and  I  rejoice  in  this  fact,  for  it  shows  that  he  is  getting 
right  down  to  mother  earth  and  doing  fundamental  things.  When,  however,  he  goes 
further  and  invents  a  new  word,  "deratization,''  the  philologists  may  have  occasion 
to  quarrel  with  him  but  I  certainly  shall  not.  The  vermin  that  gather  around  the 
garbage  paU  and  make  the  back  of  the  house  a  nuisance  are  not  only  objectionable 
from  a  sanitary  point  of  view,  but  in  time  of  plague  become  very  dangerous;  un- 
pleasant always,  dangerous  occasionally,  and  yet  back  doors  are  neglected  in  your 
house  and  in  my  house.  As  a  rule  we  do  not  pay  much  attention  to  the  back  door, 
however  much  we  pay  to  the  front. 

As  to  the  sanitary  aspects  of  garbage  reduction  and  incineration  and  the  like,  so 
long  as  no  public  nuisance  is  produced,  I  see  on  objection  to  any  of  these,  excepting 
the  hog  disposal  method.  It  has  been  found  that  hogs  in  municipal  piggeries  are 
often  very  tuberculous,  and  that  is,  of  course,  a  serious  matter.  Moreover,  piggeries 
for  the  disposal  of  public  refuse  are  almost  always  public  nuisances,  because  the 
hog  is  not  a  sweet-smelling  animal  under  any  circumstances.    Municipal  piggeries 


PUBUG  HEALTH  AND  MEDICIKE.  189 

have  been  proposed,  but  I  do  not  think  that  the  idea  will  bear  serious  consideration 
because  of  its  nuisance  features. 

Garbage-reduction  plants  are  often  a  nuisance,  because  of  the  odors  they  produce, 
and  public  comfort  must  go  with  public  safety.  The  interpretation  of  public  we^hie, 
which  brings  sanitation  close  together  with  comfort,  is  too  often  overlooked. 

In  this  connection,  and  in  connection  with  sewage  and  its  sanitary  aspects  which 
are  so  well  known  to  us  all,  I  want  to  say  there  is  one  thing  in  this  country  which  is, 
at  any  rate,  fearfully  neglected,  and  that  is  the  establishment  of  public-comfort 
stations.  In  an  address  at  Rochester  two  on  three  months  ago  I  remarked  that  the 
most  flagrant  failure  in  American  sanitation  to-day  is  the  ahnoet  universal  lack  of 
public  convenience  or  comfort  stations  in  American  cities  or  towns.  Now,  this  is  a 
sanitary  matter  connected  with  the  disposal  of  personal  sewage  and  it  is  bringing  the 
thing  down  to  the  very  bottom.  The  stranger  within  the  gates  of  most  American 
communitieB  seeks  in  vaia  for  any  public  sanitary  conveniences.  If  he  is  well  dressed 
he  must  be  refenred  to  hotels  or  other  semipublic  buildings;  if  poorly  dressed,  to 
saloons  or  railroad  stations  or  other  semiprivate  or  public-service  stations.  In  sending 
out  my  abstract  to  the  authorities  of  the  Rochester  meeting  I  wrote,  as  I  have  just 
raid, ''  the  most  flagrant  failure; "  but  I  was  in  despair  to  find  on  arriving  that  it  had 
been  sent  out  to  the  press  all  over  the  country  as  '*  the  most  fragrant  failure,"  and 
I  am  afraid  that  that  was  quite  as  correct  as  the  other,  because  one  of  my  students 
came  to  me  the  other  day  and  said,  "  Professor,  I  thought  that  Boston  was  a  leader  in 
sanitary  matters,  but  if  there  is  a  worse  smelling  place  than  that  comfort  statkni  down 
on  the  Common  I  would  have  to  go  for  to  find  it." 

It  turned  out  a  little  later,  on  investigation  by  Dr.  Wilbiur,  of  the  New  York  State 
Board  of  Health,  that  in  Madison  Square,  New  York,  through  which,  as  you  know, 
tens  of  thousands  of  people  pass  every  day  there  is  no  public  comfort-station .  They  had 
one  about  a  year  ago,  but  it  was  so  filthy  that  they  decided  to  close  it  up.  That,  I 
think,  bears  out  what  I  have  been  saying,  that  the  most  flagrant  failiure  in  American 
sanitation  to-day  is  this  matter  of  the  failure  to  provide  public-comfort  stations,  and 
I  may  say  here,  by  way  of  parentheses,  that  Dr.  Wilbur  was  so  much  stirred  up  by  this 
discovery  of  his  in  New  York,  as  well  as  by  my  remarks,  that  he  has  established 
a  league  for  the  enforcement  of  the  common  decencies  of  Life,  which  is  to  be  known 
as  the  "Public  Comfort  League."  This  is  one  of  the  most  remarkable  things  that 
I  ever  heard  of,  for  the  constitution  provides  that  there  shall  be  no  officers,  rules, 
regulations,  annual  meetings,  or  dues.  Any  person  may  become  a  member  at  any 
time,  at  any  place,  by  helping  along,  etc.  You  see  what  an  admirable  thing  this  is, 
such  a  league  as  we  have  always  been  looking  for,  having  no  meetings,  no  officers, 
no  dues. 

Now,  banning  with  the  disposal  of  personal  sewage  in  comfort  stations  and  else- 
where, we  come  to  these  methods  of  which  Dr.  Soper  has  spoken  so  well  and  of  which 
Mr.  Featherston  will  have  much  to  say,  no  doubt,  although  his  subject  is  more  par- 
ticularly the  garbage  and  the  street  work.  We  do  not  need  to  dwell  on  the  need 
of  the  disposal  of  sewage.  That  has  been  proved  too  often  by  epidemics  and  in  sanitary 
science.  I  may  say  that  at  a  sanitary  laboratory,  of  which  I  am  director,  we  have  been 
experimenting  on  a  method  for  the  treatment  of  sewage  by  sulphurous  acid,  with 
recovery  from  the  sludge  of  grease,  and  to  oiur  surprise  have  found  it  much  better 
than  we  had  supposed,  so  I  think  I  may  say  here,  and  I  think  it  will  interest  all  the 
sewerage  people  as  being  somewhat  new,  that  there  is  a  possibility— I  can  not  say 
any  more  than  that — that  a  process  not  too  costly  and  perhaps  even  slightly  remun- 
erative may  be  devised  in  the  near  future,  by  which  domestic  sewage  and  certain 
trade  wastes  may  be  treated  by  sulphur,  in  this  case  preferably  sulphurous  acid, 
causing  a  precipitation  of  a  sludge  rich  in  grease,  rich  for  sewage.  Fnmi  that  the 
supernatant  liquid  can  flow  off,  practically  sterile  and  reasonably  clear,  so  that  it 
may  be  poured  into  a  harbor  or  lake  or  stream  with  little  sanitary  dang^.    The  proc- 


190       PBOCEEDINGS  SECOND  PAN  AMEBICAN  SCIENTIFIC  CONGRESS. 

en,  then,  involvet  the  extnctioa  of  &  specially  precipitated  shidge  for  the  grease 
which  it  has,  and  at  the  moment  it  looks  as  if  the  process  might  he  successful.  I  do 
not  want  to  say  much  about  it,  because  we  are  always  wary  about  these  new  processes 
and  we  have  had  so  many  failures  that  we  do  not  want  to  risk  anoth^,  but  careful 
and  repeated  experiments  which  have  lately  been  made  in  the  little  laboratory,  of 
which  I  have  had  the  direction,  upon  Boston  sewage  and  on  a  reasonable  scale  have 
led  us  to  the  point  where  we  want  to  make  experiments  on  a  large  scale  and  intend 
to  do  it  if  we  possibly  can. 

Anything  which  would  thus  sterilize  the  greater  part  of  the  liquid  of  sewage  and 
then  leave  us  to  deal  with  a  sludge  economically  valuable  would  be  a  very 
great  boon.  We  may  not  have  reached  this,  but  we  are  certainly  woridng  in  that 
direction. 

So,  from  the  sanitary  point  of  view,  I  want,  first,  in  the  way  of  recapitulation,  to 
protest  against  the  current  idea  in  some  sanitary,  and  more  particularly  medical, 
circles  and  boards  of  health  that  these  questions  of  sewage  disposal  and  garbage  dis- 
posal and  street  cleaning  and  the  rest  are  not  sanitary  questions,  that  they  are  not  to 
be  regarded  within  the  natural  purview  of  boards  of  health.  That  is  a  temporary 
fashion  which  must  pass.  I  have  explained  the  reason  for  it.  The  law  of  sanitation 
must  take  account  even  of  the  least  things  and  of  the  most  remote  things  dealing  with 
the  public  health,  and  we  must  give  attention  to  the  sanitary  aspects  of  garbage  dis- 
posal, of  street  cleaning,  of  sewage  disposal,  and  of  all  the  other  branches  of  waste  dis- 
posal .  Of  course  if  we  could  bum  everything  up  economically,  or  even  at  a  small  loss, 
it  would  be  well  to  do  so,  provided  it  could  be  done  without  producing  a  nuisance, 
but  at  present  in  most  cities  that  does  not  seem  to  be  practicable.  On  the  other  hand, 
principles  of  conservation  make  us  wish  to  get  what  we  can  out  of  these  wastes.  If  a 
ton  of  garbage  will  keep  75  hogs  a  day  and  turn  them  into  food  for  man,  that  is  a  very 
taking  proposition  on  the  face  of  it,  and  that  is  said  to  be  the  case;  but  if  the  keeping  of 
the  hogs  produces  a  public  nuisance  and  exposes  a  lot  of  people  associated  with  the 
hogs  and  with  the  garbage  to  the  contracting  of  infectious  diseases,  then  it  is  a  great 
deal  better  to  bum  the  stuff  up  and  get  rid  of  it  even  at  a  loss.  We  must  never  lose 
Bight  of  the  sanitary  side  of  the  case,  although  it  is  the  engineering  dde  tiiat  is  always 
put  first  because  of  the  economies  of  the  problem. 


COLLECTION  AND  DISPOSAL  OF  MUNICIPAL  REFUSE. 

By  J.  T.  FETHERSTON, 
Commissioner  of  Street  Cleaning  of  City  of  New  York. 

The  topics  discussed  in  this  paper  will  be  restricted  to  the  consideration  of  (1)  the 
quantity,  quality,  and  seasonal  variations  of  household  wastes  and  street  sweepings, 
and  (2)  the  cost  of  collecting  and  disposing  of  these  classes  of  refuse. 

Household  refuse  consists  of  ashes  from  furnaces  or  heating  appliances,  garbage  or 
oigamc  wastes  resulting  from  the  preparation  or  use  of  foodstuffs,  and  rubbish  or  arti- 
cles from  households  not  comjnrised  under  the  terms  ashes  or  garbage .  Street  sweepings 
consist  of  miscellaneous  mata-ials  removed  from  public  thoroug^aies. 

For  any  particular  municipality  there  is  one  most  suitable,  sanitary,  and  economical 
method  for  the  collection  and  disposal  of  refuse,  and  any  approach  toward  a  satisfac- 
tory solution  of  refuse  handling  can  only  be  attained  by  a  detailed  study  of  all  local 
conditions  bearing  on  the  problem.  Scientific  data  on  the  subject  until  recent  years 
have  been,  and  even  to-day  are,  genially  unsatisfacttny.  For  any  city  it  is  almost 
hopeless  to  expect  a  satisfactory  solution  of  the  collection  and  disposal  question  unless 


FUBUO  HBALIH  AND  MEDIOIKE. 


191 


the  amount,  character,  and  variationB  of  refuse  materials  are  definitely  known  for  a 
period  or  cycle  of  at  least  one  year.  With  such  data  the  next  step  usually  is  to  secure 
information  from  and  study  the  practice  of  other  cities,  and  the  results  therein  secured. 
In  all  cases  sanitary  efficiency  should  receive  primary  attention,  and  cost  or  expense 
should  receive  secondary  consideration.  More  often  than  not  these  items  are  con- 
sidered in  reverse  order. 

The  collection  and  disposal  of  refuse  from  a  sanitary  standpoint  involves  to  a  greater 
degree  the  comfcHrt  and  omvenience  of  dtisens  rather  than  the  actual  health  aspects 
of  the  community,  though  it  is  true  that  garbage  affords  a  breeding  place  for  flies; 
dust  from  ashes  affects  the  respiratory  organs,  while  rubbish  may  contain  discarded 
materials  from  the  sick  room,  carrying  pathogenic  organisms. 

From  the  cost  standpoint  it  is  apparent  that  the  enormous  volume  of  waste  produced 
in  municipalities  and  the  great  cost  of  collection  and  disposal  of  refuse  should  be  more 
forcibly  brou^t  to  the  attention  of  citizens  generally.  There  are  in  the  United  States 
184  cities  of  over  30,000  population,  aggregating  27,316,000  people.  The  expenditures 
for  the  collection  and  disposal  of  household  refuse  approximate  50  cents  per  capita 
per  annum.  Thus  the  total  expenditure  of  113,658,000  per  year  gives  a  clue  to  the  cost 
of  work  in  the  larger  cities  of  the  United  States. 

Local  conditions,  such  as  the  character  of  inhabitants,  geographical  location,  and 
and  the  nature  and  amount  of  food,  fuel,  and  accessories  necessary  for  urban  dwellers, 
determine  to  a  great  extent  the  volume  of  refuse  produced  per  capita  per  annum. 
Statistics  from  six  cities  in  the  United  States  and  one  in  Canada  show  an  average 
production  of  1,361  cubic  yards  of  housdidd  refuse  per  1,000  of  population  per  year. 
(See  table  No.  1.) 

Comparing  the  foregoing  statistics  with  similar  information  secured  from  cities  on  the 
continent  of  Europe,  it  is  shown  in  Table  No.  2  that  American  cities  produce  about 
2.7  times  more  househ<4d  refuse  per  capita  per  year  than  fcHreign  cities.  (See  Table 
No.  2.) 

The  foregoing  tables  indicate  the  necessity  for  discriminating  in  methods  of  refuse 
collection  and  disposal  on  the  basis  of  the  volume  of  materials  produced,  not  consider- 
ing at  all  the  nature  or  variations  in  the  materials  themselves. 

For  the  purpose  of  secunng  a  comparison  by  weight  of  refuse  in  foreign  and  American 
cities  Tables  Nos.  3  and  4  have  been  compiled,  and  here  also  American  cities  are  shown 
to  produce  about  twice  the  amount  of  material  discarded  in  foreign  cities.  Thediffer- 
mce  between  weight  and  volume,  comparing  foreign  with  American  cities,  is  undoubt- 
edly due  to  the  greater  amount  and  lower  weight  of  rubbish  discarded  in  American 
households. 

Tablb  I. — Household  refuse,  volume  per  annum,  seven  Am>er%can  cities,  19 IS, 


New   York:   Uanhattui,   Brookljm, 

Broix 

Washineton,  D.C 

Boston,  Mass , 

Trr^nt'^.  Ontark),  OaoadA 

New  Orleans.  la , 

Baltimire,  Md , 

PhiJadelphki,  Pa 


Avefage. 


Populatloii. 


ft, 118, 383 
353, 2»7 
72»,072 
475,575 
373,000 
558,485 

1,650,000 


Number 

ofool- 

lectors. 


Refuse 
collected 
per  year. 


1,878 
240 
056 
361 
180 
197 
600 


7,429,858 
440,368 
066,570 
845,908 
500,688 
647,951 

2,004,000 


Popula- 
tk>nper 
collector. 

Refuse 
per  col- 
lector per 
annum. 

Cu.ydi. 

2,725 

3,956 

1,472 

1,834 

1,111 

1,458 

1,248 

2,220 

2,072 

8,831 

2,835 

3,288 

2,760 

3,340 

2,030 

2,704 

Cubic 
yards  of 

refuse 
per  1,000 
popula- 
non  per 
annum. 


1,462 
1,244 
1,311 
1,780 
1,366 
1,160 
1,214 

1,361 


192       PROCEEDINGS  SECOND  PAN   AMERICAN  SCIENTIFIC   CONGRESS. 
Table  2. — Household  refuse^  volume  per  annum j  seven  European  citiei,  1912. 


Hamburg. . 
Nomberg.. 

Cologne 

Dusseldorf. 
Bannen.... 

Berlin. 

Paris 


Average. 


Population. 


976,000 
360,000 
516,000 
380,000 
150,000 
2,090,000 
2,846,966 


Nomber 

ofool- 

leotors. 


lU 
70 

150 
28 

400 

750 


Refuse 
collected 
per  year. 


Popular 
tionper 
collector. 


414,011 

125,931 

232,824 

175,272 

52,320 

1,700,400 

1,974,130 


3,243 
7,371 
2,533 
5,883 
5,225 
3,796 


3,752 


Refuse 
per  col- 
lector per 
annum. 


Cu,fi», 


1,135 
3,326 
1,168 
1,860 
4,251 
2,632 


2,397 


Cubic 
yards  of 

refuse 
per  1,000 
popola- 
non  per 
annum. 


J24.2 
349lS 
45L2 
461.2 
348.8 
813.  ft 
693.4 


606.2 


Tablb  3. — Household  refuse,  per  capita  per  annum,  by  weight,  10  European  cUie$,  1912^ 


Hamburg 

Numberg 

Cologne 

Dusseldorf. 

Barmen 

Berlin 

Paris 

Finsbury  Borough,  London. 

Manchester 

Sheffield 


Average, 


Popula- 


'opuJi 
tion. 


026,000 

360,000 

516,000 

380,000 

150,000 

2,090,000 

2,846,986 

87,923 

731,677 

471,662 


Tons 

mixed 

household 

refuse  per 

annum.1 


248,406 

75,558 

139,604 

105,163 

31,392 

1,020,200 

1,006,806 

20,403 

168,245 

121,103 


Pounds 

refuse 

per 

capita. 

per 
annum. 


50» 

41» 
541 
553 
418 
976 
707 
45» 
461 
5U 


5S0.ft 


t  Weight  of  mixed  household  refuse  assumed  to  be  1,200  pounds  per  cubic  yard. 
Tablb  4. — Household  re/use,  pounds  per  capita  per  annum. 


Pounds  per  capita  per  annum. 

Gar- 
bage. 

Ashes. 

Rub- 
bush. 

Total. 

Remarks. 

New  York: 

Brooklyn . . 

Bronx 

Philadelphia... 

Boston 

Milwaukee 

BulTalo 

217 
145 
119 
109 
235 
220 
137 

1,327 
496 
708 
1,112 
1,529 
476 
560 

108 
88 
51 
72 
43 
193 
120 

1,652 
729 

878 

1,293 

1,807 

880 

817 

New  York  Commission  on  Street  Cleaning,  1907. 

Do. 

Do. 
Municipal  Journal.  Nov.  11, 1915. 
X.  H.  Goodnough  (computed.) 
Rudolph  Hering,  1907. 
Municipal  Journal,  Nov.  11, 1915. 

Average.. 

169 

887 

169 

1,152 

PUBLIC  HBAUTH  AKD  MBDIOHrE. 


L«l([tho 
itreeU. 

■tnaU. 

Slmst 

rardspave- 

t,^ 

tfOa. 

StI 

I   s 

flO 

i;  s 

13,  «n 

•SS! 

■**« 

»:« 

■S! 

SS 

to 

131 

13.  a 

X.H 

Tablk  No.  6. — Street  HBeepmgi  r 


Loirthof 
Mceeti. 

Armor 

itnets. 

Strut 
«wwptan, 

street 

3t 

S 

71 

1           31 

9        m 
a        87 

«           3S 

7           M 
«           M 
11           45 

C^t^nrb 

"■"■■sit 

13! 

iS 

331 

SM 

1 

».I0 

Table  No.  7. — Monthly  vanation,  in  percentage*,  ofgarhage  produeed  antvaallf. 


ffir 

"Sir- 

Ckwfai- 

sgt 

& 

DatiXJit. 

Chfaxwo. 

miDd. 

Ptttnl. 

il 
■lis 

8.10 

T.n 

PtlttM. 

il 

0.70 

il 

13.31 

1 

Ptrcnt. 
0:30 

1 

ii-n 

1  .10 

1 

7  10 

il 

11.70 

1 

"1 
ll 

11 

'Ti 
11 

10.40 

!i 

S.30 

3.60 

IS 

10.  W 
1330 

''"Tl 

194       PB0CEEDIN08  SBCOVD  FAJS  AMBBIOAV  80IBKTIFI0  C0KQBB8S. 

Tablb  No.  8. — Monthly  voriaHonf  in  percmtaget,  o/oihet  and  rubbiMh  produced  an- 
nually. 


• 

Cleve- 
land, 
Ohio 
(State 
Board  of 
Health). 

Cindn- 

iiati.Ohlo 

(State 

Board  of 

Health). 

Mil- 
waukee 
(Herlng). 

Boston 
(Good- 
noogh). 

otmS- 

mood 

(Fether^ 

ftoo). 

JanoaiT .....^..r..-TTr- 

Peretnt, 
11.44 
7.97 
11.51 
9.56 
8.72 
8.36 
7.19 
7.66 
6.35 
7.39 
8.36 
5.50 

Percent. 

12.45 

11.46 

12.98 

8.17 

6.88 

6.  OB 

6.62 

5.28 

6.82 

6.19 

7.12 

18.35 

Percent. 

12.46 

10.81 

11.68 

7.16 

8.86 

6.27 

4.88 

5.89 

6.38 

6.47 

9.16 

11.64 

PereenL 

10.80 

10.62 

10.47 

9.94 

8.77 

6.76 

6.09 

6.36 

6.26 

7.13 

7.86 

9.46 

Percent. 
10.6 

Fehruary 

9.6 

ifawsh..'^.!.!.... 

11.8 

AdtU 

10.7 

M^::::::::::::::::::;:::::::: :.::: 

10.9 

June 

6.1 

July 

4.7 

Aamflt T  .  .  .  r  ,  r  ,       .   r  .  r  .  -  -  T  T -,  - 

4.6 

BeptetDDeT.  ■•••••.•.•••.••..•......••••....«...•..... 

4.7 

October 

6.2 

NoveiDDef  •  ••.••••••..•.•••............••.......... T. 

8.4 

December 

9.7 

Table  No.  9. — Monthly  variation,  in  pereentage$,  o/rubbiih  produced  anniMUy. 


Buffalo. 

Rochee- 
ter. 

Pitts- 
burgh. 

New 
York. 

January ..............r ■, 

Percent. 
8.62 
6.43 
7.78 
9.79 
11.97 
ia38 
7.69 
7.24 
7.30 
8.96 
6.54 
7.31 

Percent. 
8.50 
7.58 
8.06 
&78 
a90 
8.00 
9.35 
&67 
7.99 
8.94 
7.49 
7.75 

Percent. 
8.27 
5.83 
7.92 
9.44 
ia92 
9.63 
8.26 
7.84 
7.57 
9.48 
8.38 
6.49 

Percent. 
6.43 

Ffibmary 

6.28 

I'urch    '    V  -       '.   '. 

7.54 

April 

&26 

Ilay 

&81 

Jime T        ,.,.-..,,,-   T  r  r  ,  r  ,   r    ,.   T  r 

8L6S 

July 

&94 

An?u8t 

a64 

September , 

9.68 

October 

9.80 

November 

a77 

December 

7.83 

One  feature  shown  in  Table  No.  4,  compared  with  the  preceding  table,  is  the  separa- 
tion of  refuse  into  three  classes  as  generally  practiced  in  American  cities,  while  in 
foreign  municipalities  as  a  rule  all  wastes  are  placed  in  one  receptacle.  Here,  again, 
there  is  a  dew  as  to  the  trend  of  practice  regarding  the  collection  and  disposal  of 
wastes.  Foreign  cities  with  small  amounts  of  materials  have  practically  standardized 
their  methods  and  have  adopted  a  combined  collection  and  disposal  of  refuse,  while 
American  cities  require  the  separation  of  refuse  into  three  classes  and  disposal  of  each 
kind  separately.  Attention  may  be  called  to  the  variation  in  garbage  production 
among  tiie  borou^  of  New  York  Oity,  as  indicating  the  necessity  for  studying  even 
subdivisions  of  a  city  for  the  purpose  of  determining  the  most  suitable  methods 
adapted  to  localities  within  the  municipality. 

It  is  not  enough  to  provide  general  data  as  to  the  total  volume  or  weigjit  of  refuse 
produced  per  unit  of  population  or  per  year  when  considering  the  adoption  of  any 
method  of  refuse  collection  and  disposal.  The  peaks  and  valleys  of  refuse  production 
require  determination.  In  American  cities  climate  has  the  greatest  influence  in 
this  regard,  particularly  in  the  production  of  garbage  and  ashes.  Gcmaidering  only 
American  cities.  Table  No.  7,  shows  the  monthly  variations  in  the  amount  of  garbage 
produced  annually,  and  indicates  generally  an  increase  of  approximately  50  i>er  cent 
by  volume  during  the  summer  season  over  normal  production,  with  a  slightly  less  per- 
centage below  the  normal  during  the  winter  period.  The  same  condition  is  approx- 
imately true  among  cities  in  the  northern  part  of  the  United  States  for  ashes  and 


FUBLIO  HBALTH  A2n>  MENOINB. 


195 


rubbish  collected  together,  as  riiown  in  Table  No.  8.  Rubbish  separately  collected 
has  less  seasonal  variations  on  the  whole  than  garbage  or  adies,  as  indicated  in  Table 
No.  9. 

These  variations  in  the  quantity  of  material  produced  at  different  periods  of  the 
year  require  careful  consideration  in  the  design  of  plant  and  equipment  necessary 
for  the  economical  operation  of  a  collection  and  disposal  system. 

In  addition  to  the  amounts  and  seasonal  variations  of  the  various  classes  of  waste, 
scientific  methods  of  disposal  d^;»end  upon  the  mechanical  and  chemical  properties 
of  the  materials  to  be  treated.  Table  No.  10  presents  data  relating  to  the  mechanical 
analysis  of  mixed  household  refuse,  composed  of  fine  ash  or  material  passing  through 
a  three-eighths  inch  mesh  screen;  coal  and  dnders,  or  unbumed  or  partially  burned 
coal;  rubbish  or  generally  combustible  refuse;  garbage  (oiganic  waste);  and  metals, 
^asB,  crockery,  etc. 

In  foreign  cities  generally  the  amount  of  fine  ash  is  greater  than  that  shown  in  the 
analysis  of  mixed  refuse  in  one  of  the  borough  of  the  city  of  New  York,  where  tests 
were  carried  on  for  a  niunber  of  years,  and,  surprising  as  it  may  seem,  the  amount 
of  coal  and  dnders  wasted  is  apparentiy  less  in  New  York  City  than  in  foreign  cities, 
while  the  amount  of  rubbish  produced  is  decidedly  greater,  except  in  Melbourne, 
Australia.  It  is  interesting  to  note  the  relatively  small  proportion  of  garbage  pro- 
duced in  Cterman  cities,  and  the  larger  amounts  in  Great  Britain  and  New  York. 
The  variation  in  the  metals,  ^ass,  and  crockery  discarded  is  hard  to  explain. 

The  system  of  refuse  collection  depends  upon  the  metiiod  of  disposal  adopted. 
In  foreign  cities  with  few  exceptions  household  refuse  is  collected  in  a  mixed  condi- 
tion, while  in  tiie  United  States  garbage  is  generally  separated  from  other  dasses 
of  waste,  and  disposed  of  either  by  incineration  or  by  the  so-called  reduction  method. 

Where  combined  cdlections  are  in  vogue  great  progress  has  been  made  in  elimi- 
nating nuisances  due  to  the  escape  of  dust  and  odon  while  transferring  refuse  from 
the  householders'  cans  to  the  wagon  body.  This  is  particularly  true  in  the  German 
dties,  where  a  standard  type  of  receptacle  f<»r  holding  wastes,  having  an  attadied 
cover,  iB  so  designed  that  it  acts  in  conjunction  with  a  loading  device  on  the  vdude 
whereby  the  transfer  is  made  without  allowing  the  material  to  oone  into  contact 
with  the  air  or  to  be  scattered  about  the  ndg^bochood.  In  Great  Britain  and  the 
United  States  not  mudi  progress  has  been  made  in  collecting  refuse  so  as  to  eliminate 
odors  and  dust,  but  there  has  been  a  widespread  public  demand  for  improvements 
of  this  diaracter. 

Tablb  10. — Medumiieai  ono^ftet  cfimxtdhxnmkM  r^itm. 


Fine 

ash. 


Coal  and 
cinders. 


bish. 


Qar- 
l)age. 


orookery, 
etc 


Autborlty. 


Berlin,  Oermany 

Potsdam,  Qenuany 

Cliarlottenberg,  Qermany 

Kiel,  Germany 

Frankfort,  Oemiany 

St<dce  Newington,  England 

Ktaigs  Norton.  England 

Prahran,  Australia 

Melbourne,  Australia 

CUnon,  Boroogh  of  Rkflunoid,  N.  Y. .. 
West  New  Breton,  Borough  of  Ricb- 
mond,  N.  Y. 


Percent. 
46.73 
60.96 
30.58 
fia25 
49.25 


g 


.23 
42.81 
3L1 
34.7 


PereenL 
2S.77 
18.61 
37.00 
30.63 
43.14 
42.93 
46.4 
48.06 
20.66 
19.6 
28.6 


Percent. 

6.18 

2.28 

5.06 

2.21 

1.13 

16.4 

0.3 

9.26 

1L87 

10.80 

7.1 


Per  cent. 

20.0 

&25 

4.86 

LOS 

.58 

34.43 

39.60 

17.67 

14.31 

8L10 

24.90 


Per  cent, 
3.32 
ia87 
14.49 
6.88 
6i69 
7.36 
6.2 
3.87 
4.76 
7.6 
4.8 


68436—17— VOL  x- 


i  Inehided  In  ooal,  einder. 
14 


Dr.  Dfiir. 

Da 

Da 

Do. 

Da 
Leask. 

Da 
Calder. 

Da 
Fethenm. 

Da 


196       PB00BEDINQ8  SECOND  PAN  AMBBIOAK  SOISNTIFIO  00KGBE88. 


Table  No.  11.— 22^^  ditpomd  in  the  United  Statu. 


Matflrial  and  nMtbod  of  difpoMl. 


Oarbage: 

Redofliioo.. 

Incineratkm. 

Feeding  pigi 

LandflU:... 

Dumping  at 
Rnbblsh: 

Incineration 

Reclaniatioo  and  fills 

Landfills 

Dumping  at  sea 

Reolunation,  fills,  and  incineration 
Ashes: 

Landfills 

Incineration 

Dumping  at 
Street  sweepings; 

Landfills... 

Fertilizer... 

Dumping  at 


Number 

of  cities 

using 

this 

method. 


95 

41 

11 

7 

2 

33 
3 
6 
3 
1 

11 
7 
3 

17 
3 
4 


Total 
population 

oidties 
using  this 

method. 


16,093,000 

3,618,500 

1,960,000 

633,000 

905,000 

4.178,000 

2,035,000 

672,000 

730,000 

4,600,000 

8,093,000 

1,321,000 

765,000 

9,747,000 

645,000 

1,506,000 


Motor-driven  collection  vehiclee  have  replaced  horses  in  a  number  of  foreign  cities, 
and  it  is  claimed  that  the  cost  of  collection  by  this  method  is  less  than  that  by  horse* 
drawn  vehicles.  In  the  United  States,  however,  the  horse,  with  cart  ox  wagon  covered 
or  partly  covered,  still  remain  the  standard  types  of  i^paratos  for  collecting  refuse. 

Practically  every  city  uses  some  portions  of  refuse  for  land  fills,  and  smaller  cities 
use  this  method  almost  entirely  until  a  point  is  reached  where  the  cost  of  hauling 
to  land  fills  exceeds  the  cost  of  disposal  within  the  city  limits,  where  the  short  haul 
ofibets  the  increased  cost  of  disposal  by  a  scientific  process.  Table  No.  11  summarizea 
the  methods  of  refuse  disposal  practiced  in  cities  having  over  30,000  population 
in  the  United  States.  In  cities  of  over  100,000  population  a  separate  collection 
of  garbage  and  reclamation  of  grease  and  tankage  ox  fertilizer  base  is  apparently 
the  most  popular  practice,  mainly  from  the  standpoint  of  economy.  Twenty-six 
cities,  aggregating  over  15,000,000  people,  diq>ose  of  garbage  by  the  reduction  sys- 
tem, while  41  municipalities  with  about  one-quarter  the  population  incinerate  the 
garbage.  Feeding  garbage  to  pigs,  using  it  as  land  fills,  or  dumping  it  at  sea  is  prao* 
ticed  in  20  of  the  larger  cities  in  this  country.  Rubbish  generally  is  either  incin- 
erated or  placed  on  land  fills.  Ashes,  in  the  majority  of  cities,  are  placed  on  land 
fills.  Incineration  of  various  classes  of  refuse,  except  street  sweepings,  is  practiced 
generally  among  small  cities  and  towns  and  is  adaptable  to  all  classes  of  waste,  while 
reduction  can  only  be  applied  to  the  treatment  of  garbage.  Either  system  may  be 
made  sanitary  in  effect  by  proper  design  and  efficient  operation  of  the  disposal  works. 

Garbage,  when  separated  from  other  classes  of  waste  and  treated  by  the  reduction 
process,  provides  two  by-products:  (1)  Grease,  varying  from  3  to  8  per  cent  by  weight 
of  the  original  material,  depending  upon  the  location  of  the  city  and  the  character 
of  the  population.  This  grease  is  worth  from  3  to  5  cents  a  pound  and  is  used  mainly 
for  soap  making.  (2)  Tankage  or  fibrous  residue,  after  extracting  grease  and  mois- 
ture, averages  from  12  to  15  per  cent  by  weight  of  the  original  material  and  contains 
fertilizing  elements  of  value  (|6  to  |10  per  ton)  for  various  classes  of  crops.  Net 
revenues  from  the  treatment  of  garbage  indicate  the  possibility  of  obtaining  a  profit 
at  the  plant  varying  from  75  cents  to  $1. 50  per  ton  of  garbage  treated,  depending  upon 
the  process  used  and  the  efficiency  of  the  organization  and  management  of  the  works. 

Garbage-reduction  works  are  genmully  located  in  sparsely  settled  sections,  and 
as  most  of  the  plants  are  operated  by  private  companies  for  commercial  reasons, 
no  greater  attempt  is  made  to  eliminate  odors  than  necessity  demands.  As  a 
result,  such  plants  have  been  frequent  offenders  on  account  of  nuisances  created. 


FUBUO  HEALTH  AKD  MBDICIKB. 


197 


though  with  proper  design  and  management  this  drawback  can  be  entirely  eliminated 
or  minimized  to  a  point  where  the  odors  are  not  objectionable. 

Probably  the  most  sanitary  method  of  refuse  disposal  is  by  incineration,  as  naturally 
all  classes  of  waste  contain  some  portions  of  combustible  matter.  Two  methods  of 
incineration  are  practiced  in  this  country  and  abroad — (1)  incineration  of  mixed 
household  refuse,  where  all  wastes  are  collected  together  and  burned  by  the  aid 
of  forced  draft  at  high  temperature;  (2)  incineration  of  garbage  alone  or  with  portions 
of  rubbish  or  ashes.  By-products  from  high-temperature  incinerators  consLst  of 
steam  power  and  clinker.  Considerable  information  is  available  as  to  the  heat  values 
of  the  various  classes  of  refuse,  so  that  plants  may  be  designed  with  some  degree 
of  knowledge  concerning  the  proportions  of  the  furnace  required  and  the  tempera- 
tures necessary  to  prevent  the  escape  of  noxious  gases.  The  tables  which  follow 
summarize  the  available  tests  and  the  calorific  values  of  various  claBses  of  household 
refuse  in  this  country.  For  comparison  with  foreign  cities,  Table  No.  17  is  intro- 
duced. It  is  interesting  to  note  in  this  latter  table  that  the  incineration  of  mixed 
refuse  in  German  cities  deals  with  a  material  high  in  ash,  low  in  moisture,  and  gen- 
erally lower  in  calorific  value  when  compared  with  similar  materials  in  New  York 
City,  though  the  conditions  are  reversed  in  San  Francisco. 

Table  No.  12. — Analyses  of  garbage. 


CincinDati,  Ohio 

deretend,  Ohio 

Columbus,  Ohio 

Dayton,  Ohio 

Boro^h    of    Manhattan, 

ICilwaiilree,  Wis. 

Borough    of    lianhattan, 


Ether 
extract 
(grease). 


Percent. 
4.02 

8.85 

8.96 

8.88 

6.70 

8.77 
6.00 


Phos- 
phorie 
add. 


Percent. 
0.29 

.24 

.22 

.19 

.50 

X31 
L84 


nii 


Percent. 
0.04 

.64 

.59 

.51 

.94 

L61 
L76 


Potash. 


Peret. 
a28 

.30 

.25 

.20 

.37 


LOl 


Authority  and  remarks. 


Ohio  State  Board  of  Health  re- 
port, 10  samples. 

Ohio  State  Board  of  Health  re- 
port, 28  samples. 

Ohio  State  Board  of  Health  re- 
port, 31  samples. 

Ohio  State  Board  of  Health  re- 
port. 30  samples. 

Lederle  Laboratory,  4  samples. 

R.  E.  W.  Somers.  1  sample. 
Otto  H.  Klein,  4  samples. 


Table  No.  13. — Heat  values  of  garbage. 


Mois- 
ture. 

Ash. 

Com- 
bustible. 

B.  t.  u.  per  pound. 

Origfaial 
sample. 

Dry 
sample. 

Authority. 

Cindnnati,  Ohio 

Cleveland,  Ohio 

Columbus,  Ohio. 

Dayton.  Ohio 

Peret. 
76.7 

75.6 

76w4 

8a6 

74.4 

77.66 

78.5 
75.0 
82.3 

78.00 
73.26 

47.66 

07.0 

71.4 

Peret. 
3.66 

3.20 

3.30 

X57 

2.72 

8.15 

2.95 
3.50 
2.47 

13.614 
5.14 

26.35 

4.49 

3.72 

Percent. 
19.70 

21.16 

20.27 

1&82 

22.88 

19.20 

18.60 
20.91 
15.23 

8.386 
21.60 

25.99 

28.51 

24.88 

2,000 

2,057 

1,994 

1,712 

2,304 

1,832 

1,925 
2,100 
1,413 

8,553 
8,459 
8,448 
8,776 

Ohio  State  Board  of  Health  re- 
port. 10  samples.                  H 

Ohio  State  Board  of  Health  re- 
port. 28  samples.                  ^ 

Ohio  state  Board  of  Health  re- 
port, 31  samples.                   1 

Ohio  State  Board  of  Health  re- 

Dort,  30  samples. 
OdIo  State  Board  of  Health  re- 

KmiYfl^ld, Ohio 

port,  4  samples. 
Ohio  State  Board  of  Health  re- 

Marion, Ohio 

port,  2  samples. 
Do. 

Steuben  rllJe.  Ohio 

Do. 

ZanesviUe.  Ohio. 

Ohio  State  Board  of  Health  re- 

llUwaukee.Wis  

BorouKh  of  Richmond, 

N.  Y. 

Toronto,  Canada 

Boroosh  of  Manhattan, 
bol 

4,522 
8,351 

4,914 

8,723 

port,  3  samples. 
R.  E.  w .  Somers,  1  sample. 

2,233 
2,572 

B.  F.  Welton,  25  samples. 

Works  Department  Laboratory, 
45per  cent  rubbish,  4  sampka. 
D.  C.  Johnson,  3  samples. 

2,507 

Klein,  1910, 4  samples. 

198       PROCEEDINGS  SEOOSTD  PAK   IMBBIOAN  BCIENTIFIO  G0NQBB8S. 

Table  No.  l4.-^Heat  vdUi^i  o/itreei  »w€9pmg$. 


Mois- 
ture. 

Ash. 

CJom- 
busUbto. 

B.tu. 

pound 
(original 
sample.) 

Authority. 

Cfnclnill^tf 

Peret. 
43.0 

29.0 

Peret. 
42.30 

48.8 

82.1 

41.64 

36.69 
67.73 

Percent. 
13.9 

22.2 

17.9 

66.61 

36^86 

4L02 

1,446 
2,133 
1,680 

Ohio  State  Board  of  Health  report,  6 

Clft vftland .............  , 

samples. 
Ohio  State  Board  of  Health  report,  3 

Dayton 

samples. 
Ohio  Dtate  Board  of  Health  report,  1 

Do 

2.86 

S7.46 
L36 

sample. 
New    York   Commission   on    Street 

3,666 
3,730 

Cleaning,  1907, 4  samples. 
KMn.  1910. 4  sw^pieA- 

BorooRh    of    Richmond, 
N.  Y.,  dry  manure. 

Lederie  LaboratofT,  1906, 2  samples. 

Tablis  No.  15. — Heat  valuet  of  rubbish. 


Mois- 
ture. 

AOl 

Com- 
bustible. 

B.  to.  per  pound. 

sample. 

samiH** 

Authority. 

Borough  of  Richmond, 
N.  Y.,  West  New 
Brighton. 

Toronto,  Canada 

Borough  of  Manhattan, 

Borough  of  Richmond, 
N.  YV;cUfton. 

PereL 

6.78 

33.02 

11.50 

6.3 

PereL 
13.87 

7.82 
7.59 
11.6 

Percent. 
80.36 

50.16 
8a  91 
83.3 

6»833 

6,449 
6,701 
6,636 

7,351 

8,136 
7,673 
7,063 

B.  F.  Welton,  16  samples. 

Works  Department  Laboratory, 

Toronto,  3  samples. 
D.  C.  Johnson,  4  samples. 

A.  B.  HiU,  13  samples. 

Tabls  No.  16. — Eeai  value$  of  ashes  and  componmU  ofajikes. 


Cincinnati. 


Cleveland., 


Dayton.. 


Chicago. 


Do 

Borough   of  Rich- 
mond. West  New 
Brighion. 
Do 


Borough  of  Manhat- 
tan. 

Boroujdi   of  Rieh- 
mond.  Clifton. 
Do 


Description. 


Ashes. 


.do. 


.do. 


Fine  ash. 


Cinders 

Coal  and  cinders. 


Mois- 
ture. 


Fine  ash 

Coal  and  cinders. 

Fine  ash 


Peret. 
7.8 


14.1 
19i3 
L92 


1.16 
1.34 


1.20 
7.65 
3.8 
L9 


Ash. 


PerH. 
61.70 


63.9 
69.3 
77.76 


63.0 
39.93 


77.40 
3L83 
33.3 
7&6 


Com- 
busti- 
ble. 


Peret. 
3a6 


32.0 
21.6 
3a  33 


45.84 
6a  73 


21.40 
6a  63 
73.0 
36.6 


B.t.u.per 
pound. 


Origi- 
nal 
sample. 


3,087 
1,815 
1,680 
3,167 


6,941 
8,396 


3,846 

9,310 

10,946 

3,119 


Dry 
sample. 


Authority. 


3,348 
3,113 


8,610 
3,880 


11,360 
3,180 


Ohio  State  Board  of 
Health  report,  7 
samples. 

Ohio  State  Board  of 
Health  report,  6 
samples. 

Ohio  State  Board  of 
Health  report,  0 
samples. 

Bureau    of   Streets, 
Chicago,   30  sam- 
ples. 
Do. 

B.  F.  Welton,  96 
samples. 

B.  F.  Welton,  1  sam- 
ple. 

Otto  H.  Klein,  4  ssm- 
ples. 

A.  E.  HUl,  13 
pies. 
Do. 


PUBUO  HEALTH  AND  MEDIOIHB. 
Tablb  No.  n.— JlmtwUue*  of  mixed  n/we. 


'-~-"--""'"-^"""- 

AriL 

tun. 

a 

AuttOrtty. 

bon. 

Hrdn>- 

Callu- 

ToUl 
bdrtlUa. 

6&7S 
10.  (t 
UH 
MM 

■a.  to 

H-TS 
SbM 

11. « 

M.87 
U 

un 

3t.l3 
10.08 

10.11 
KLIO 
■.IT 

a.K 

13.96 

S!' 

ILIA 
<L00 
10.  BS 

i&«e 

XU 
II.(B 
».» 
30.31 

an 

.00 

.01 
.3> 
■M 

.30 
.43 
.« 

3.U 

8.10 

4.7S 
T.M 
LJ3 
3.73 

1.18 
J.H 
3.M 

1173 
17.10 
U.B 
10.00 
19.08 

n.si 

J0.01 

33.  S7 
M.B 

34.9 

1,(31 
t,03B 

1,877 
1,115 

i,»a 

3,981 

i,m 
i,m 
*,m 

1,873 
41141 

4,174 

1,410 

»■"£:  D, 

»m'"" 

WlMbadao. 

B  T  wetton. 

'ffi.ffiSSS: 

Tabli  No.  is. — Chewtieai  eompotilion  of  mixed  houseluild  refute. 


ss: 

■ran. 

Hydro-  Nltro- 

Bul- 

0.y- 

Adi. 

K^.. 

ci(tt^^.y..B«RKicb 

8«n^£>,0U 

19.74 

3&«8 
13.10 

Ptrtl. 
1.30 
L70 

.50 

PffCl. 

'li 

8.  SI 

17.x 

A.  E.  Hill,  11  Min- 

CompuM,  IWlher- 
■ton. 

Tablb  No.  10. — Cost  o/eotUeHon  and  ditpotal  ofhouMKold  refuMt. 


Poputati™. 

Amount 

'iS* 

Vl»h.        n««i>h    I.»»ln 

S7,«3B 

sss 

ill 

tmburs 

200       PBOGEEDINOS  BEOOKD  PAN  AMEBIOAK  SOIEKTIllO  C0KQBB88. 


Table  No.  20. — Co»t  of  eolUcHon  and  disposal  of  household  refuu. 


Washingtoii,  D.  C... 

Newark.  N.J 

CftmbrkiKe.  Mass 

Chicai;o,lu 

Buffalo,  N.Y 

New  Orleans,  La 

Loubvllle,  ICjr 

R ichmond ,  va 

Spokane,  wash 

Galveston,  T«x 

Manchester,  N.  H 

Salt  Lake  (%,  Utah 

Harrlsbure,  Pa 

Kansas  Citv,  Mo 

Augusta,  (Hk 


Popula- 
tion. 


353,000 

395,000 

110,000 

,142,000 

415,000 

334,500 

232,000 

115,000 

99,000 

37,000 

69,000 

87,330 

61,000 

241,767 

41,000 


Amount 
expended. 


$158,550 

190,605 

65,000 

1,231,065 

272,075 

169,635 

93,606 

54,62S 

50,036 

90,604 

22,534 

39,416 

26,520 

51,724 

14,968 


Per  optta 
cost  per 
annum. 


90.450 
.484 
.501 
.574 
.655 
.507 
.421 
.470 
.606 
.557 
.327 
.451 
.434 
.214 
.366 


Authority  and  remarks. 


Year,  19U. 

Do. 

Do. 
Bureau  of  Census,  year  1900. 

Do. 

Do. 

Do. 

Do. 

Do. 

Do. 

Do. 

Do. 

Do. 

Do. 

Do. 


Further  information  concerning  the  chemical  composition  of  mixed  household 
refuse  is  provided  in  Table  No.  18  for  one  borough  in  New  York  City,  also  San  Fran- 
cisco, Cal.,  where  differences  in  the  composition  are  again  apparent,  especially  in  the 
amount  of  moisture,  carbon,  and  ash.  It  is  evident  from  the  statistics  herein  pre- 
sented on  incineration  that  the  success  of  this  method  will  depend  to  a  Isif^  degree 
upon  the  preliminary  investigations  covering  the  heat  values  and  chemical  compo- 
sitions of  the  waste  in  conjunctiotn  with  the  amount  of  material  to  be  dealt  with  in  any 
locality.  Effective  organization  of  the  force  employed  and  efficient  management 
of  the  disposal  works  are  essential  in  any  type  of  plant  in  order  to  eliminate  nuisances 

The  amount  of  street  sweepings  or  cleanings  removed  from  pavements  in  any 
municipality  depends  almost  entirely  upon  local  uses  of  the  public  thoroughfares. 
Only  a  general  clue  can  be  given  as  to  the  volume  of  street  sweepings  removed  per  unit 
of  pavement  per  year.  Statistics  on  this  subject  are  not  always  satisfactory,  but  two 
tables  have  been  compiled,  one  covering  eight  foreign  cities,  compared  with  eight 
American  cities.  Abroad  about  29.6  cubic  yards  of  material  are  removed  per  1,000 
square  yards  of  pavement  per  year,  while  statistics  for  American  cities  show  the 
removal  of  only  24.9  cubic  yards.  To  one  familiar  with  the  use  and  abuse  of  streets 
in  this  country  and  in  foreign  cities,  it  would  seem  as  if  the  figures  should  be  reversed, 
and  it  is  interesting  to  note  that  one  of  the  cleanestcities  in  the  world,  Berlin,  accounts 
for  the  greatest  amount  of  material,  50.7  cubic  yards  removed  per  year  from  the  unit 
of  pavement  area. 

Two  cost  tables  are  presented  on  this  subject,  No.  19  covering  the  collection  and 
disposal  in  seven  foreign  cities,  and  No.  20  containing  similar  information  for  16 
American  cities.  The  average  cost  for  the  American  cities  is  approximately  48  cents 
per  capita  per  annum,  as  against  45  cents  per  capita  per  annum  in  foreign  cities,  where 
wages  generally  are  less  than  half  the  standard  rates  in  the  United  States.  Apparently 
the  refuse  collectors  in  the  United  States  are  harder  worked  men  than  the  foreign 
collectors. 

The  statistics  herein  presented  summarize  on  a  broad  basis  the  best  available  data 
on  the  subject  and  are  presented  in  concise  form  in  the  hope  that  those  interested  may 
find  them  of  value. 

BIBUOQRAPHY. 

Report  of  Commission  on  Street  Cleaning  and  Waste  Disposal,  New  York  City,  1907, 
by  H.  de  B.  Parsons,  Samuel  Whinery,  Rudolph  Bering. 

Report  of  a  Study  of  the  Collection  and  Disposal  of  City  Wastes  in  Ohio,  1910.  Ohio 
State  Board  of  Health. 

Report  on  Garbage  Disposal  for  the  City  of  Milwaukee,  Dec,  1907,  by  Dr.  Rudolph 
Bering. 


FUBUO  HSALTH  AVD  IfXDIOINB.  201 


Report  en  the  OoUeetiaii  and  DmpoBil  of  Rehiae  for  the  City  of  Chicago,  1914,  by 
I.  S.  Oabom  and  J.  T.  Fethenton. 

Report  of  the  Second  Special  CommiBsion  to  Inveatigate  the  Collection  and  Disposal 
of  Refuse,  City  of  Boston,  1910. 

Report  <m  Refuse  Collection  and  Diqixwd  for  City  of  Albany,  1908,  by  Wallace 
Greenalch. 

Report  to  President  of  Borough  of  Richnumd,  1906,  Test  of  West  New  Brixton 
Destructor,  by  J.  T.  Fetherston. 

Report  to  President  of  B<Ht>ug^  of  Richmond,  1914,  Summary  of  Results  of  Refuse 
Disposal  at  West  New  Brighton  and  Clifton  Plants,  J.  T.  Fetherston. 

Report  of  the  Bureau  of  Streets  Investigation,  Chicago,  1913. 

Report  for  year  1914,  Department  of  Street  Cleaning,  New  York  City,  by  J.  T. 
Fetherston,  Commissioner. 

Specifications  for  Garbage  Disposal  System,  San  Francisco,  1910,  Marsden  Manson, 
City  Engineer. 

Specifications  for  Refuse  Indneratiog  Plant,  Toronto,  1914,  by  I.  S.  Osbom,  En- 
gineer. 

Specification  for  Clifton  Destructor,  1910,  J.  T.  Fethenton,  Engineer. 

The  Collection  and  Disposal  of  Municipal  Wastes,  X.  H.  Goodnoug^  (Journal  ci  the 
Association  of  Engineering  Societies,  Vol.  XL,  1906). 

Municipal  Refuse  Disposal:  An  Investigation,  by  J.  T.  Fetherston,  Transactions 
Am.  Soc.  C.  E.,    Vol.  XL.    1908). 

Some  Notes  on  Municipal  Cleaning  and  Refuse  Destruction,  by  J.  T.  Fetherston, 
Proceedings  of  Municipal  Engineers,  N.  Y.  City. 

Final  Disposition  of  City  Refuse  by  Mixed  Recuse  Destruction,  etc.,  by  J.  T.  Fether- 
ston, Journal  of  the  Slociety  of  Chemical  Industry,  1908. , 

HaQsmQU  in  Strassenkehricht,  by  Dr.  Clemens  DOrr. 

Die  Strassenreinigung  in  Den  Deutschen  Stftdten,  by  Dr.  Ing.  Franz  Medner. 

Elektrizit&t  Aus  Kehricht,  by  Etienne  de  Fodor. 

Genmml  Statistics  of  Cities,  1909,  published  by  Bureau  of  Coisus,  1914. 

American  Society  of  Municipal  Improvement8--Statistics. 

Municipal  Journal. 

Engineering  News. 

Engineering  Record. 

The  Chairman.  The  papers  to  be  presented  at  this  session  have 
been  completed.  It  is  especially  desirable  to  have  some  formal 
debate  on  the  subject,  in  view  of  the  importance  of  the  subject  itself 
and  the  importance  of  the  papers  presented. 

Dr.  GuTFEBAS.  As  reference  has  been  made  by  some  of  the  gentle- 
men to  the  tropical  cities  and  the  request  has  been  made  directly 
that  information  be  given  with  r^ard  to  what  is  being  done  there, 
I  think  it  my  duty  to  inform  you  on  that  point,  although  we  are  all 
devoting  our  time  to  learning  all  that  we  can  about  it. 

In  the  last  two  years  a  system  of  separate  disposal  of  sewage  has 
been  completed  in  Habana.  The  discharging  place  for  this  sewage 
of  this  large  city  could  not  be  a  more  favorable  one.  The  sewage 
of  Habana  is  discharged  by  a  separate  system  into  the  Oulf  Stream. 
The  same  may  be  said  with  regard  to  the  garbage  and  street  and 
house  refuse.  Nothing  could  be  more  favorable  than  this.  Still, 
undoubtedly;  the  mani^ement  of  this  city  refuse,  the  handling  of  it 


202       PBOCEEDINOS  SOOOKD  PAN  AMBBIOAN  SOIEKTIFIO  00NGBE8S. 

in  the  city,  the  carrying  of  it  to  the  lighters  that  go  out  to  the  sea  to 
dump  it  into  the  Gulf  Stream,  i3  a  disagreeable  process  at  least,  and 
perhaps  accompanied  with^  some  danger.  Therefore  we  have  tried  to 
introduce  a  system  of  incineration  and  we  have  had  a  large  plant 
built  for  the  purpose  of  doing  away  with  the  carrying  out  to  sea.  I 
must  say  that  this  plant,  although  it  is  completed,  has  not  yet  been 
used,  because  it  is  supposed  to  be  expensive.  I  imagine  that  this 
means  that  the  other  system  of  dumping  into  the  Gulf  Stream  is 
not  so  bad  a  one  as  was  thought  since  we  are  not  willing  to  go  to  a 
little  more  expense  in  putting  into  operation  the  already  compiled 
incineration  plant.  It  may  be  true,  as  one  of  the  gentlemen  said, 
that  these  plants  must  be  perfectly  built  and  conducted.  Probably 
our  trials  with  the  plant  have  shown  that  it  was  not  properly  built 
and  that  perhaps  we  were  not  very  sure  that  we  were  going  to  handle 
it  in  a  satisfactory  manner. 

As  one  of  the  g^itlemen  has  said,  when  you  have  a  system  of 
sewage  disposal  in  large  cities  you  also  have  in  the  same  city  other 
systems.  This  means  that  we  have  still  in  Habana  cesspools,  espe- 
cially the  outlying  districts.  But  certainly  the  introduction  in  the 
last  three  or  four  years  of  this  enormous  system  of  sewage  disposal 
in  the  city  of  Habana  ought  to  have  made  a  striking  difference  in  the 
amount  of  typhoid  fever  in  the  city.  I  am  afraid  it  has  not,  and  that 
has  surprised  me  greatly.  It  is  one  of  those  subjects  difficult  to 
accoimt  for.  Our  typhoid-fever  rate  at  Habana  is  rather  high;  not  as 
high  as  in  some  American  cities,  but  higher  than  in  others.  We  do  not 
believe  that  this  is  due  to  our  water  supply.  The  manner  of  distri- 
bution of  typhoid  and  the  character  of  the  water  are  very  strongly 
against  the  idea  that  it  is  a  water-borne  disease;  but  at  any  rate  this 
very  radical  change  in  the  disposal  of  sewage,  the  doing  away  with 
an  enormous  niunber  of  cesspools  in  the  city  of  Habana,  has  not  had 
any  influence  upon  the  nimiber  of  cases  of  typhoid.  In  fact,  typhoid 
has  rather  increased  slightly  in  the  last  three  years  since  this  sewage 
system  is  in  operation.  We  believe  that  our  typhoid  fever  is  a 
contact  disease  and  that  the  distribution  of  it  in  the  city  of  Habana 
is  due  to  contact. 

I  was  very  much  interested  in  the  remarks  that  were  made  as  to 
whether  garbage  disposal  was  a  sanitary  question.  Of  course  it  may 
become  suddenly  a  sanitary  question  of  intense  importance,  as  it 
does,  for  instance,  when  plague  appears  in  a  city.  Disposal  of  gar- 
bage may  be  considered  almost  one  of  the  principal  sanitary  questions 
before  a  city.  At  a  time  of  plague  the  disposal  of  garbage  so  that  rats 
can  not  get  at  it  and  the  utilization  of  that  disposal  as  a  means  of 
doing  away  with  rats  by  removing  the  food  supplied  to  them  are  of 
the  most  extreme  importance. 


PUBUO  HEALTH  AKD  HEDICnTE.  208 

Of  C011IB6  I  have  been  speaking  of  a  large  city,  a  rich  city,  as 
Habana  is.  When  we  come  to  the  disposal  of  sewage  and  garbage 
in  the  rural  districts,  it  is  quite  different.  The  human  excreta  are 
▼ery  commonly  thrown  upon  the  surface  in  the  rural  districts  of 
Oaba,  yet  we  do  not  have  much  hookworm  th^re.  Cuba  is  very  far 
from  presenting  the  same  situation  that  Porto  Rico  does  with  r^ard 
to  the  numb^  of  cases  of  hookworm.  It  is  not  a  national  problem 
with  us.  llie  garbage,  etc.,  of  houses  is  usually  disposed  of  by 
dumping. 

Dr.  AoRAMONTB.  Perhaps  I  might  be  allowed  to  furnish  a  Kttle 
additional  information  to  Dr.  Guiteras'  remarks.  This  question  of 
sewage  and  r^use  disposal  in  Habana  is  in  the  hands  of  two  dif- 
ferent departments — the  sanitary  department  and  the  department 
of  public  works.  The  department  of  public  works  has  charge 
of  the  disposal  of  sewage  refuse  and  garbage  from  houses,  while 
the  sanitary  in  a  way  supervises  how  this  garbage  is  collected,  etc. 
We  have  a  national  health  organization,  as  you  probably  know. 
The  head  is  the  secretary  of  public  health,  a  member  of  our  cabinet. 
This  national  organization  takes  in  every  city  and  every  munici- 
pality in  the  Republic  of  Cuba.  Habana  is  only  different  from  the 
other  cities  in  having  a  special  service  in  that  direction.  The  ques- 
tion of  public  health  can  not  be  separated  from  the  sanitary  question 
in  its  engineering  or  medical  aspects.  We  have  sanitary  ordinances 
which  are  applied  to  all  the  cities,  all  the  mimicipalities  in  the  island 
of  Cuba,  and  they  must  all  obey  these  ordinances.  The  ordinances 
refer  to  the  disposal  of  garbage  or  its  collection  from  houses,  etc., 
providing  the  means  under  which  the  work  shall  be  done,  and,  by 
the  way, 'insist  that  it  should  always  be  collected  in  metal  pails 
or  barrels.  The  garbage  is  also  indirectly  under  supervision  of  the 
sanitary  department,  while  the  street  cleaning  is  in  the  hands  of  the 
department  of  public  works  in  Habana.  In  the  smaller  cities  of 
the  island  it  is  under  the  chaise  of  the  sanitary  officers. 

In  Habana  the  care  of  the  streets  is  divided  into  two  parts.  One 
is  really  the  street  cleaning  and  the  other  is  the  collection  of  manure 
from  the  streets.  This  is  in  the  hands  of  private  individuals,  who 
utilize  the  manure  for  fertilizing  purposes,  and  who  also  collect  the 
manure  from  the  large  stables,  public  hack  stables,  etc.,  and  sell 
it  to  tobacco  planters  in  the  eastern  part  of  the  island  mainly,  lliey 
coUect  it  in  huge  piles,  ferment  it,  and  then  carry  it  into  the  interior. 
The  manure  from  the  private  stables,  of  course,  is  carted  off  separ- 
ately from  the  garbage  and  house  refuse. 

As  I  said,  it  ia  difficult  to  conceive  how  the  medical  question  can 
be  separated  from  the  engineering  or  the  question  of  sanitation.  We 
have  a  particular  condition  in  Cuba  that  is  unlike,  of  course,  the  con- 


204       PB0CBEDIKQ6  BBOOKD  PAK  AMBBIOAK  SOIBKTIFIO  00KGBBS8. 

dition  in  large  countrieB.  We  have  no  inland  waterways.  Therefore 
the  question  of  poUution  of  streams  does  not  exist  with  us.  The  water 
employed  for  drinking  purposes  in  large  cities  is  not  surface  water, 
it  is  spring  water;  therefore  the  contamination  of  water  supplies 
from  streams  and  trains  does  not  concern  us.  Trade  wastes  engage 
the  attention  of  the  sanitary  department  particularly  lately  with 
r^ard  to  the  immense  amoimt  of  waste  produced  in  the  distilleriee 
of  the  large  plantations,  which  throw  their  waste  into  the  small 
streams,  as  we  have  no  large  rivers.  But  these  small  rivers  have 
fish  and  the  waste  kills  the  fish,  and  sometimes  a  very  unpleasant 
condition  arises.  This  question  is  now  being  attended  to.  I  believe 
Dr.  Guiteras  knows  better  than  I  do  about  this.  The  idea  is  to  have 
these  wastes  go  to  a  reservoir  of  some  kind,  remain  there  for  a  con- 
siderable period  of  time  until  they  are  self-purified,  and  then  dumped 

into  these  rivers,  when  they  would  do  less  harm. 

Dr.  Kebleb.  I  was  interested  in  some  of  the  remarks  made  by  Dr. 

Sedgwick,  particularly  that  feature  referring  to  the  inhalation  of 

street  filth.    Most  of  the  material  that  is  dropped  on  the  streets  or 

sidewalks  is  dried,  and  during  a  vdndy  day  is,  of  course,  wafted  into 

our  faces,  our  nostrils,  and  our  mouths.    I  have  frequently  wondered 

why  we  forbade  spitting  on  the  sidewalk  and  in  a  way  invited  spitting 

on  the  street.    To  my  mind,  there  is  not  very  much  difference. 

As  a  matter  of  fact,  the  material  dries  as  rapidly  in  the  street  as  on 

the  sidewalk.    It  is  considered  a  matter  of  inconvenience,  possibly, 

but  I  personally  have  never  been  able  to  see  why  such  a  distinct 

element  has  been  made  of  that  particular  feature. 

The  Chatbman.  As  there  is  apparently  no  further  business,  the 

chair  will  annoimce  this  session  adjourned. 

Adjourned  at  11.26  o'clock. 


GENERAL  SESSION  OF  SECTION  YIIL 

New  Ebbitt  HoteLi 
Ttiesday  afternoon,  January  4$  1916, 

Chairman,  Sam.  L.  Rogers. 

The  session  was  called  to  order  at  2  o'dock  by  the  chairman. 

The  Chairman.  The  program  opens  with  a  contribution  by  Dr. 
E2dwin  O.  Jordan,  department  of  hygiene  and  bacteriology,  University 
of  Chicago,  Chicago,  111.,  Dr.  Jordan  has  requested  Dr.  Ransdell  to 
kindly  read  his  paper. 

THE  PURIFICATION  OF  WATER  SUPPLIES. 

By  EDWIN  O.  JORDAN, 
Chairman  Department  of  Hygiene  and  Bacteriology ,  Univernty  o/  Chicago. 

DiflcuflBion  of  water  purification  in  this  paper  is  limited  to  the  hygienic  aspects  of 
the  subject.  Clarification  of  a  muddy  water,  removal  of  an  excess  of  iron,  softening 
of  a  hard  water  are  all  ends  desirable  in  themselves,  but  they  are  not  purification  in  the 
sense  in  which  that  term  is  here  considered.  Removal  of  turbidity  may  be  economic- 
aUy  and  esthetically  important;  installation  of  a  municipal  water-softening  plant  may 
be  demanded  by  considerations  of  convenience  and  economy,  but  softening  and 
clarification  of  water  are  never  matters  primarily  concerning  public  health.  If  a 
eommunity  desires  and  can  afford  to  pay  for  a  clear  or  a  soft  water,  it  can  get  it.  The 
degree  of  expense  in  this  direction  that  is  justified  in  comparison  with  oth^  needs 
is  a  question  to  be  determined  by  each  community,  bearing  in  mind  that  the  demands 
of  the  modem  city  are  many  and  urgent,  and  remembering  that  in  but  few  instances 
are  funds  available  to  carry  out  aU  the  measures  of  improvement  that  appeal  to  differ- 
ent groups. 

Most  citizens  would  agree  in  principle,  if  not  in  practice,  that  the  sanitary  purity 
or  direct  relation  of  a  water  supply  to  health  is  by  far  its  most  important  feature. 
Consideration  of  purification  of  water  may  therefore  be  here  consistently  restricted 
to  the  methods  of  rendering  a  contaminated  or  potentiaUy  dangerous  supply  safe  for 
use. 

WHT  PURIFICATION  »  NBCBSaARY. 

The  present  necessity  for  water  purification  in  civilized  countries  is  in  the  main  a 
consequence  of  two  Victors:  First,  the  greatly  increased  demand  for  water  under 
modem  conditions  of  life;  second,  the  increasing  density  of  population  on  most  parts 
of  the  earth's  surftu^e.  It  is  becoming  more  and  more  difficult  to  draw  for  a  water 
supply  of  any  size  upon  a  body  of  surface  water  that  is  uncontaminated  or  at  all 
events  not  liable  to  occasional  or  accidental  pollution;  as  is  well  known  infectious 
material  discharged  by  a  single  human  being  is  sufficient  to  poison  many  gallons  of 

206 


206       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIPIO  CONGRESS. 

water  and  to  cause  hundreds  of  cases  of  disease.  It  is  difficult  also  to  obtain  the 
volume  of  water  sufficient  for  a  large  and  rapidly  growing  community.  Many  of  the 
smaller  towns  and  villages  in  the  United  States  rely  on  deep  wells  as  a  source  of  sup- 
ply, and  from  a  sanitary  point  of  view  such  waters  are  usually  excellent.  In  many 
r^ons,  however,  the  amount  of  available  underground  water  is  limited  and  if  a  large 
amount  of  water  is  required  by  a  municipality,  surface  waters  more  or  less  exposed  to 
pollution  must  be  taken.  Where  surface  waters  are  resorted  to,  the  need  for  purifying 
them  is  so  plain  in  some  cases  that  there  can  be  no  question  of  its  imperativeness,  as 
with  the  Merrimack  River  used  by  the  city  of  Lawrence,  Mass. ;  the  Hudson  River, 
used  by  the  city  of  Albany,  and  the  Schuylkill  River,  drawn  on  by  Philadelphia. 
In  these  cities  simple  inspection  of  the  water  source  is  sufficient  to  show  that  the 
river  water  used  as  a  source  of  supply  is  contaminated  with  fresh  sewage  and  in  an 
untreated  condition  is  grosBly  unfit  for  drinking  purposes.  Water  purification  in 
these  cities  has  been  followed  by  a  marked  diminution  in  the  amount  of  certain  dis- 


On  the  other  hand,  the  need  for  purification  of  a  surface  water  supply  is  not  always 
so  obviously  urgent  to  the  untrained  judgment,  and  detailed  observation  of  disease 
prevalence  and  of  the  bacterial  character  of  a  water  is  necessary  before  general  agree- 
ment on  the  desirability  of  purification  is  reached.  This  has  been  the  water  supply 
history  of  some  cities  on  the  Great  Lakes.  The  city  of  Cleveland  hesitated  for  several 
years  before  undertaking  the  construction  of  a  filter.  Detroit  and  Buffalo  have  been 
rather  recently  convinced  of  the  desirability  of  protecting  their  water  supplies  by 
chlorination. 

Still  other  large  cities  are  so  fortunately  situated  in  respect  to  surface  water  sup- 
plies that  artificiBkl  purification  for  the  time  being  is  not  considered  necessary.  These 
are  practically  all  in  localities  where  the  water  e^ed  levied  on  is  owned  or  controlled 
by  the  municipality,  and  wheate  long  storage  of  impounded  wators  in  natural  or  arti- 
ficial reservoirs  can  be  trusted  to  effect  a  natural  purification.  New  York  and  Boston 
are  well-known  examples  of  cities  depending  on  protected  and  stored  surface  water. 

THB  DBVBLOPMBNT  OF  WATBR  PURIFICATION. 

Public  water  supplies,  although  not  unconmion  in  the  early  history  of  southern 
Ehirope,  were  practically  unknown  in  the  Middle  Ages,  and  the  large  modem  water 
supply  s3rBtems  have  been  developed  for  the  most  part  in  the  last  70  years.  Stor- 
age of  water  was  undoubtedly  practiced  in  antiquity,  but  was  not  consciously 
retorted  to  as  a  means  of  purification,  and  the  first  deliberate  attempt  at  purification 
of  water  on  a  laige  scale  seems  to  have  been  less  than  100  years  ago,  when,  in  1829,  a 
slow  sand  fiHer  was  built  by  one  of  the  London  water  companies.  Even  in  fhia 
instance  the  immediate  end  in  view  was  clarification  of  a  muddy  water,  and  it  wb» 
not  until  the  connection  between  drinking  water  and  disease  beotune  manifest  some 
20  yean  later  that  the  filtration  of  the  whole  London  water  supply  was  more  definitely 
undertaken  as  a  hygienic  measure.  Purification  of  public  water  supplies  became 
general  in  England  and  on  the  Continent  of  Europe  two  or  three  decades  earlier  than 
in  this  country,  owing  perhaps  to  the  greater  density  of  population  in  many  regions 
and  to  the  glaring  evidences  of  pollution  in  many  streams  serving  as  water  sources. 
European  cities  that  delayed  or  boggled  water  purification  often  suffered  severely 
from  water-borne  diseases,  as  did  the  wealthy  Glerman  city  of  Hamburg  in  the  cholera 
epidemic  of  1892-93. 

In  the  United  States,  as  in  Europe,  development  of  public  waterworks  has  taken 
place  almost  wholly  since  1850,  and  the  introduction  of  methods  of  purification  is 
yet  more  recent.  A  beginning  in  water  purification  had  been  made  at  Poughkeepsie, 
N.  Y.,  and  elsewhere  before  1890,  but  progress  has  been  much  more  rapid  since  that 
date,  owing  in  large  part  to  the  impetus  given  to  the  study  of  water  purification  by  the 
investigations*of  the  State  Board  of  Health  of  Massachusetts.    These  investigations^ 


PX7BU0  HBALTH  AND  BfEDICINB. 


207 


begun  in  1887,  were  soon  followed  by  tbe  conftnMtion  of  a  modem  sand  filter  plant 
At  Lawrence,  Maes.  (1893),  and  the  striking  sucoeas  et  this  filter  in  reducing  tyi^md 
lever  aerred  as  an  object  lesson  to  the  whole  country. 

It  was  calculated  by  Hazen  that  in  1900,  6.3  per  emit  of  the  urban  population  of 
the  country  (towns  ol  over  2, §00  population)  were  supplied  with  filtered  water,  while 
in  1911,  according  to  G.  A.  Johnson,  this  proportioa  had  arisen  to  over  20  per  cent. 
The  following  table  that  I  have  compiled  from  the  information  given  in  the  McGraw 
Waterworks  Directory  and  from  other  sources  of  information  shows  the  present  condi- 
tion in  the  larger  cities  of  the  United  States. 

Tablb  I. — CharaeUr  of  water  supplies  in  cUies  of  the  United  States  with  over  10,000 

population  in  1915, 


Wells  and  springs 

Riven  aod  streams. . . . 
Impounding  reservoirs. 

Wells  and  rivers 

Unknown , 


Total. 


Treated. 


Number 
of  cities. 


28 
141 

ao 
» 

15 


3S2 


Popula- 
tion. 


3,491,810 

10,780,M7 

1,993,035 

5,408,300 

571,566 


21,818,164 


Untreated. 


Unknown. 


Number  i    Popula- 
of  cities. 


76 
23 
19 


147 


>0pu]8 

tfon. 


3,215,168 
1,068,418 
5,360,524 
1,880,813 
93,801 


10,516,718 


Number 
ofdties. 


08 
35 
19 
16 
7 
83 


163 


PO 


opula- 

tlOD. 


1,705,500 
608,423 
843,536 
464,000 
458,813 
516,378 


4,645,288 


It  will  be  noted  that  while  over  60  per  cent  of  the  total  city  population  of  the 
United  States  is  at  present  supplied  with  water  treated  by  some  method  of  purifica- 
tion, the  actual  proportion  of  the  population  supplied  with  hygienically  sale  water  is 
ht  greater.  The  water  from  deep  wells  and  from  storage  reservoirs  is  unquestionably 
in  laige  part  of  excellent  quality,  even  if  not  subjected  to  artificial  purification.  It 
is  fair  to  assume  that  30,000,000  out  of  the  36,500,000  people  living  in  cities  with  over 
10,000  population  are  now  provided  with  water  initially  pure  or  more  or  less  effectively 
purified.  Taking  into  consideration  smaller  towns  and  villages,  it  seems  likely  that 
at  least  50  per  cent  of  the  total  populati<m  of  the  United  States  is  to-day  supplied 
with  water  of  a  high  degree  of  purity. 

Hasen  estimated  that  in  1904  water  of  a  more  or  less  unsatisfactory  quality  was 
supplied  to  approximately  52  per  cent  of  the  urban  population  of  the  United  States 
in  cities  of  more  than  25,000  inhabitants;  at  present^  1915,  this  statement,  as  to  as 
•anitary  quality  is  concerned,  would  hardly  hold  true  for  more  than  20  per  cent. 


MODERN  MBTHOD8  OF  PUBIFICATION. 

(a)  Storage, — ^A  high  degree  of  natural  purification  of  water  can  be  effected  by 
storage.  When  the  water  of  small  streams  is  impounded  in  a  reservoir  instead  of 
being  pumped  directly  into  water  mains  important  changes  occur.  Suspended  mat- 
ter in  part  sinkB  to  the  bottom  and  the  water  becomes  clearer,  the  color  of  the  water  is 
usually  lessened  owing  to  bleaching  by  the  sunlight,  and  the  total  number  of  bac- 
teria in  the  water  is  materially  diminished.  Most  impcvtant  of  all,  any  diseaee- 
pTodudng  bacteria  that  may  have  found  their  way  into  the  tributary  streams  tend  to 
perish  during  the  sojourn  of  the  water  in  the  reservmr.  A  cardinal  factor  in  bringing 
about  the  death  of  pathogenic  bacteria  in  water  is  time.  So  far  as  is  known,  disease 
germs  introduced  into  water  never  multiply  under  natural  conditions,  but  progrea- 
sirely  and  rather  rapidly  die  off.  The  longer  a  water  can  be  stored,  therefore,  either 
in  an  artificial  reservoir  <«  in  a  natural  lake  or  pond  with  protected  shores,  the  less 
liable  it  is  to  harbor  disease  germs.  This  principle  of  storage,  based  on  the  hi|^ 
mortality  of  typhoid  bacilli  and  allied  bacteria  suspended  in  water,  is  being  utilised 


208       PROCEEDIKOS  SECOND  PAK  AKKRTCAN  SCIENTIFIC  CONGRESS. 

apparoitly  with  high  succeas  in  the  treatment  of  many  large  svabnoe  water  supplies. 
New  York  and  Boston,  as  already  mentioned,  are  relying  mainly  on  this  method  (o 
insure  the  purity  of  their  sui^lies.  The  safety  of  the  London  supply  is  thought  (o 
depend  very  largely  upon  storage.  Adequate  storage  is  often  all  that  is  needed.  In 
cities  where  other  methods  of  purification  are  employed,  preliminary  storage  is  highly 
advantageous  rince  it  reduces  the  hurden  upon  filters  and  in  other  ways  fodHtateB 
the  application  of  special  purifying  treatment. 

(6)  Slow  Mtnd  fiUen.— The  use  of  beds  of  sand  carefully  superimposed  on  gravel  in 
water-tight  basins  and  through  which  water  flows  by  gravity  was  probably  the  first 
method  employed  for  water  purification  (London,  1829)  on  a  large  scale.  The  earlier 
European  filtration  plants  were  all  of  this  type.  In  this  country  slow  suid  filters 
have  been  installed  at  Albany,  N.  Y.;  Pittsburgh,  Pa.;  Washington,  D.  C;  Philadel- 
phia, and  other  cities.  Through  such  filters  water  may  be  commonly  passed  at  a 
rate  of  3,000,000  gallons  daily  per  acre  of  filtering  surface,  and  if  the  water  treated  is 
not  very  tiirbid  or  badly  polluted,  a  rate  of  6,000,000  gallons  or  more  daily  may  be 
permissible.  It  is  important  that  the  speed  at  which  the  water  passes  through  the 
sand  shall  not  vary  suddenly  or  in  different  parts  of  the  filter,  and  ingenious  devices 
for  regulating  the  flow  are  in  use  in  order  to  maintain  a  uniform  rate  of  filtration. 
Disturbance  of  the  filtering  surface  by  ice  also  impairs  the  eflldency  of  the  operation 
and  in  some  instances  has  been  followed  by  outbreaks  of  disease. 

One  of  the  principal  elements  of  expense  in  the  operation  of  slow  sand  filters  is  the 
necessity  for  removing  and  eventually  cleaning  and  replacing  the  thin  upper  layer 
of  sand  which  becomes  clogged  in  operation.  The  frequency  with  which  the  sand 
surface  must  be  scraped  and  renewed  depends  largely  upon  the  amount  of  suspended 
matter  in  the  water  treated  and  upon  the  rate  of  operation.  The  use  of  ample  pre- 
liminary settling  basins  or  storage  reservoirs  will  lessen  the  operating  cost,  as  well 
as  introduce  an  element  of  safety.  Taking  into  consideration  the  interest  on  the 
capital  invested  in  construction  and  other  proper  capital  charges,  together  with  the 
cost  of  maintenance,  the  average  cost  of  purifying  water  by  slow  sand  filters  is  about 
$8  per  1,000,000  gallons  under  present  conditions  in  this  country.  On  the  basis  of  a 
daily  per  capita  water  consumption  of  125  gallons  this  involves  an  annual  cost  of 
about  36  cents  per  capita. 

(c)  Rapid  sand  filtration, — Slow  sand  filters  are  not  adapted  for  use  in  many  parts 
of  the  United  States  because  the  amount  and  fineness  of  the  suspended  matter  in  many 
American  rivers  leads  to  premature  clogging  of  the  sand  and  a  total  obstruction  of 
operation.  A  somewhat  different  type  of  filter  known  as  the  mechanical  or  rapid 
filter  has  proved  to  have  marked  advantages  in  dealing  with  very  muddy  water, 
such  as  is  found  in  the  Ohio  and  Mississippi  Rivers.  If  a  turbid  water  is  first  treated 
with  some  coagulating  chemical,  such  as  sulphate  of  aluminum  or  sulphate  of  iron, 
it  can  be  passed  through  sand  at  a  much  higher  rate  than  is  possible  with  the  untreated 
water.  The  development  of  rapid  filtration  with  the  use  of  a  coagulant  has  been 
largely  a  matter  of  American  invention,  and  in  its  beginning  depended  to  a  great 
extent  on  the  use  of  patented  processes  and  mechanical  devices  protected  by  patent 
The  expiration  of  some  of  these  patents  has  opened  the  road  for  a  wider  appUcatioD 
of  this  method  and  has  been  followed  by  important  developments.  Experiments 
at  Louisville  and  Cincinnati  have  established  the  applicability  of  the  coagulating 
process  to  large  volumes  of  water,  and  at  present  rapid  sand  filters  are  in  operation 
at  Cincinnati,  Ohio,  Minneapolis,  Minn.,  St.  Louis,  Mo.,  an^  many  smaller  cities. 
Suitable  automatic  devices  for  controlling  the  application  of  the  coagulating  chemi- 
cal are  indispensable,  since  any  material  excess  or  deficiency  of  the  coagulant  is  fatal 
to  successful  or  economical  operation.  Many  of  the  earlier  installations  of  rapid 
filters  by  private  firms  were  not  properly  supervised,  and  in  some  cases  the  original 
plant  was  improperly  constructed  or  allowed  to  deteriorate  so  that  the  whole  process 
for  a  time  fell  into  a  measure  of  disrepute. 


PUBUO  HEALTH  AND  HEDIOIKS.  209 

The  cost  of  ooDstruction  of  rapid  mnd  filten  is  much  kiB  than  that  of  Bkrw  mod 
fihen,  but  the  cost  of  operation  is  greater.  Beckoning  all  charges,  the  total  cost  per 
miihon  gallons  of  water  purified  averages  distinctly  less  (about  |6  pw  million  gallons) 
by  the  rapid  than  by  the  slow  process. 

(d)  OermicUkd  treatment. — AlthousJi  ui  the  course  of  years  a  great  variety  of  chem- 
ical substances  have  been  proposed  for  the  disinfection  or  partial  sterilization  of  water 
supplies,  only  a  few  of  these  have  won  any  extended  practical  application.  The 
use  of  osone  for  water  sterilization  possesses  certain  theoretical  advantages.  Several 
small  plants  using  ozone  have  been  operated  in  European  countries,  but  in  practice 
the  relatively  high  expense  of  generating  the  ozone  and  bringing  it  in  intimate  con- 
tact with  the  water  to  be  treated  has  so  far  proved  an  obstacle  to  the  utilization  of 
this  mode  of  treatment  for  large  supplies.  It  is  possible  that  the  availability  of  cheap 
electric  power  for  generating  ozone  combined  with  othw  fiivorable  tectors  may,  under 
•ome  conditions,  render  ozonization  desirable.  The  development  of  cheapw  ger- 
micidal processes,  however,  has  diecked,  permanently  perhaps,  the  general  intro- 
duction of  ozonization. 

The  objection  of  high  cost  obtains  also  with  respect  to  the  use  of  ultra-violet  rays. 
These  rays,  which  are  conveniently  generated  by  specially  constructed  lamps,  have 
a  hig^  germicidal  power,  and  quickly  destroy  bacteria  in  clear  water.  Experimen- 
tally ultra-violet  stailization  has  very  desirable  qualities,  but  thus  far,  owing  to  the 
expense  of  operation  and  to  the  necessity  for  a  preliminary  clarification  of  v^ry  tur- 
bid waters,  it  has  not  been  used  in  this  country  for  large  soJe  installations. 

The  use  of  calcium  hypochlorite,  ''chloride  of  lime,"  or  "bleaching  powder''  has 
for  some  years  past  quite  overshadowed  other  methods  of  germicidal  treatment. 
Variations  in  the  character  of  the  water  and  in  the  composition  <A  the  conmierdal 
bleaching  powder  affect  the  amount  that  it  is  necessary  to  add  to  secure  germicidal 
efficiency,  but  in  general  the  quantity  of  the  powder  used  ranges  from  about  5  to  15 
pounds  for  each  million  gallons  of  water  treated.  The  cost  of  bleaching  powder  under 
normal  conditions  has  been  leas  than  2  cents  a  pound;  including  the  cost  of  appH- 
calion  hypochlorite  treatment  costs  not  more  than  one-tenth  as  mudi  as  filtration. 
The  action  of  the  hypochlorite  is  similar  to  that  of  ozone  and  depends  on  the 
strongly  oxidizing  powers  of  the  hypochlorous  acid  that  is  formed  when  the  bleadi* 
ing  powder  is  added  to  wat«r. 

The  advantages  of  the  hypochlorite  treatment  are  the  cheapness,  harmlessness, 
ease,  and  speed  with  whidi  it  may  be  employed.  The  diief  objection  is  the  liability 
to  the  production  of  disagreeable  tastes  or  odors  whidi  its  use  entails.  Chlorine  gaa 
itself  has  a  distinctly  unpleasant  odor  even  in  small  quantities,  and  the  action  of  the 
h}rpoch)orite  on  certain  organic  matters  present  in  water  also  generates  disagreeable 
tastes  and  smells.  Complaints  on  this  score  in  communities  where  hypochloritt 
treatment  of  the  water  is  practiced  are  especially  common  in  cold  weather.  Waters 
differ  in  respect  to  their  tendency  to  develop  objectionable  odors,  and  in  practical 
operation  some  waters  are  very  troublesome.  An  important  improvement  in  the  field 
of  water  disinfection  has  been  the  substitution  of  liquefied  chlorine  gas  (*' liquid 
chlorine  ")  for  calcium  hypochlorite.  The  gas,  which  is  generated  by  the  electrolyaia 
of  brine,  is  dried,  cooled,  and  comi^essed,  and  is  then  marketed  in  liquid  form  in 
portable  cylinders  under  pressure.  The  advantages  claimed  for  the  use  of  the  gaa 
indude  superior  economy  and  simplidty  in  regulation.  Liability  to  cause  unpleasant 
odors  is  said  to  be  much  less  by  this  mode  of  treatment.  Overdosing,  however,  may 
occur  both  with  liquid  chlorine  and  bleaching  powder. 

Rssm/ra  ov  water  PUBmcATiON. 

When  a  polluted  water  that  serves  ad  a  source  of  munidpal  supply  is  treated  by 
slow  sand  filtration  the  most  conspicuous  immediate  change  in  the  health  of  the 


210       PB0CEEDINQ3  SECOIH)  PAN  AMBBIOAK  SCIENTIFIC  CONQBESS. 


community  is  a  drop  in  the  typhoid  death  rate.  This  has  been  demonstrated  re- 
peatedly in  European  citiet,  as  in  Hambui;g»  for  example,  and  in  many  American 
cities.  In  Lawrence,  Albany,  Pittebiugfa,  and  Philadelphia,  Blow  sand  filtration  of 
%  hi^y  polluted  river  water  has  been  followed  by  a  reduction  in  the  reported  typhoid 
mortality  to  one-third  or  even  one-fourth  of  that  formerly  prevailing.  A  deciease 
in  water-caused  in^t  mortality  has  also  been  noted.^  It  is  yet  unknown  to  what 
extent  the  connection  between  in^t  m<»rtallty  and  sewage  polluted  water  supplies 
is  due  to  infection  with  the  typhoid  bacillus.  In  some  instances,  though  not  in  all, 
the  so-called  Mills-Beincke  phenomenon  has  been  observed,  namely,  a  decline  in 
the  general  death  rate  minus  the  tyj^oid  component,  and  in  the  reported  deaths 
from  certain  other  diseases,  such  as  tuberculosis  and  pneumonia,  not  onmmmily 
regarded  as  water  borne.' 

There  is  no  doubt  that  some  deaths  from  typhoid  infection  both  in  infants  and 
adults  have  been  and  still  are  reported  under  some  other  designation.  I  have  elsa- 
where  '  called  attention  to  the  decrease  in  reported  deaths  from  ''malaria"  in  Albany, 
N.  Y.,  following  the  installation  of  a  sand  filter.  It  is  unquestionably  true  that  in 
other  cities  some  of  the  deaths  in  the  past  reported  as  due  to  "malaria*'  or  ''typho- 
malaria*'  should  have  been  properly  classed  with  those  from  typhoid  fever.  Mis- 
taken diagnosb  may  explain  to  s(Hne  degree  such  decline  in  general  death  rates  as 
can  not  be  refierred  directly  to  the  diminution  in  deaths  epecifically  attributed  to 
typhoid  fever.  Thus,  in  St.  Louis,  a  correqxmdenoe  can  be  noted  in  some  years 
between  the  number  of  r^>orted  deaths  from  typhoid  lever  and  the  reported  deaths 
from  "malarial  fever." 

Tabls  2.— Dsfitlkt  reported  in  8i.  Lotitt. 


Year. 

Typhoid 

inotttoi 

Year. 

Typhoid 

IbJirUl 
fefrar. 

1800 

140 
105 
441 

216 

1818 

171 

184 

1891 

1804 

179 

1M2. 

In  mote  northern  cities,  where  for  various  reasons  the  diagnosis  of  death  from 
"malaria"  is  less  likely  to  be  made,  the  same  correspondence  can  yet  be  noticed 
under  certsin  conditions. 

Tablb  ^.—Deathi  reported  in  Chicago,  1891, 


Month. 

i 

Janottrj 

yebrusrr 

March 


Typhoid 


87 
61 
71 


MilMiA. 


7 

0 

16 


Ifontti. 


ApilL 
May. 

Tune. 


Typhoid 


188 
406 
167 


Matarls. 


18 

as 

7 


There  seems  no  escape  from  the  conclusion  that  at  least  some — probably  a  large 
proportion— H>f  the  deaths  recorded  as  due  to  "malarial  fever"  in  these  cities  were 
in  reality  caused  by  typhoid  infection. 

It  has  further  been  shown  by  Dublin  *  from  a  study  of  insurance  records  that  the 
normal  expected  mortality  is  doubled  among  typhoid  convalescents  during  the  first 
two  years  after  their  recovery  from  the  disease.  In  his  statistics  tuberculosis,  dis- 
eases of  the  heart  and  kidneys,  and  pneumonia  were  prominent  among  the  causes 
of  death  in  a  limited  number  of  typhoid  patients  subsequent  to  recovery.    If  this 

t  Moliai^lln,  R«priat  Irom  Pnblto  HMlth  Baports,  No.  H,  lOlB,  Wanhlnfton,  D.  C. 
<  Sedgwick  and  MacNutt,  Jour.  Infect.  ]>ia.,  1010, 7,  p.  480. 

*  Transactions,  Amar.  Soc  off  CiyO  Engineers,  Inter.  Eng.  Congress,  1006, 54,  D,  p.  306. 
«  Amer.  Tour,  off  Pub.  Health,  1016^  N.  8.  h,  p.  SO. 


PUBUO  HEALTH  AHD  MBDIdKB.     '  211 


conehision  proves  generally  valid,  there  must  alwaye  be  expected  eome  leeBening  of 
ihe  general  mortality  in  additk>n  to  that  due  to  the  typhoid  component,  and  perhi^ 
in  some  cases  a  measnn^le  diminution  in  the  death  rate  irom  tuberculosis  and 
other  diseases  accompanying  a  decrease  in  typhoid  fever  due  to  water  purification. 
In  a  word,  certain  individuals  appear  to  be  so  affected  by  the  typhoid  infection  that, 
although  surviviz^  for  a  time,  they  die  within  two  years  from  tuberculosis  or  cardiac 
lesions.  To  what  extent  the  Mills-Reincke  phenomenon  and  Hasen's  theorem 
are  explicable  on  this  basis  is  a  matter  for  further  investigation  to  determine. 

Granting  that  many  deaths  from  typhoid  fever  and  its  sequelae  are  prevented  by 
alow  sand  filtration,  the  question  may  be  raised  as  to  what  degree  of  safety  is  attained 
by  this  method,  whether  absolute  or  limited.  The  necessity  of  care  in  operation  is 
w^  known.  Bacterial  and  other  observations  clearly  show  that  dangerous  bacteria 
may  pass  through  the  sand,  if  there  is  any  '* accident''  to  the  filter  or  any  '* disturb- 
ance" of  its  normal  action.  The  epidemics  of  cholera  at  Altona,  Germany,  and 
typhoid  fever  at  Lawrence,  Mass.,  illustrate  the  way  in  which  the  formation  of  ice 
can  intoiere  with  the  safe  operation  of  a  filter. 

While  the  harm  from  such  unusual  intwruption  of  mnmal  filter  action  is  sufficiently 
demonstrated,  it  is  not  so  easy  to  measure  the  degree  of  danger  existing  under  more 
ordinary  conditions.  Reliance  on  bacterial  averages  of  effluents  may  be  misplaced, 
since  a  low  average  may  be  reached  ev^i  if  occasional  breaks  occur  in  a  long  series 
of  low  numbers.  Should  typhoid  bacilli  pass  through  a  filter  during  one  hour 
in  24,  or  for  one  day  in  the  year,  absolute  protection  is  plainly  not  afforded. 
While  the  data  for  a  final  judgment  on  this  point  do  not  exist,  it  must  be  admitted 
that  there  is  some  evidence  that  the  attempts  to  treat  a  highly  polluted  raw  water, 
place  at  times  too  great  a  burden  on  the  filter.  Intestinal  bacteria  of  the  B,  coli 
type  may  appear  in  the  effluent  in  such  cases  in  numbers  thought  by  some  observers 
to  indicate  danger.' 

Among  the  recent  attempts  to  establish  standards  for  safe  drinking  water  may  be 
noted  the  report  of  the  commission  appointed  by  the  United  States  Treasury  Depart- 
ment to  consider  standards  for  water  supplied  to  the  public  by  common  carriers 
engaged  in  interstate  commerce.^  The  commission  reported  as  follows:  "(1)  The 
total  number  of  bacteria  developing  on  standard  agar  plates,  incubated  24  hours  at 
37^  C,  shall  not  exceed  100  per  cubic  centimeter;  (2)  not  more  than  one  out  of  five 
10  cubic  centimeter  portions  of  any  sample  examined  shall  show  the  presence  of 
organisms  of  the  B,  coli  group."  A  study  of  the  records  of  filtration  plants  shows 
that  in  some  instances  the  application  of  such  a  standard  would  lead  at  times  to  the 
condemnation  of  filter  effluents.  It  has  been  suggested  that  the  standard  proposed 
is  too  severe  for  general  municipal  water  supplies,'  and  perhaps  this  is  a  just  criticism, 
but  in  any  case  it  is  clear  that  the  maigin  of  safety  in  some  filtration  plants  is  not 
very  great. 

Tlie  results  of  rapid  or  mechanical  filtration  are  essentially  similar  to  those  of  slow 
sand  filtration.  Tlie  percentage  bacterial  removal  reaches  practically  the  same 
height  as  in  the  slow  sand  filter,  and  a  marked  decline  in  typhoid  fever  has  been 
observed  in  many  cities  following  the  introduction  of  rapid  filters.  In  Cincinnati, 
Ohio,  Columbus,  Ohio,  Paterson,  N.  J.,  and  other  cities,  the  typhoid  death  rate  has 
sunk  to  low  figures  after  rapid  filters  were  installed.  The  necessity  for  careful  and 
unremitting  supervision  of  operation  is  quite  as  great  in  the  case  of  rapid  filters  as 
with  the  slow  sand  type.  The  safety  of  the  mechanical  filter  effluent  is  no  more  cer- 
tain or  absolute  than  that  of  slow  sand  filters. 

Excellent  results  as  regards  bacterial  efficiency  and  security  from  typhoid  infection 
are  achieved  by  bleaching  powder  and  by  liquid  chlorin  treatment.    The  chief 

1  McLaagtalin:  Reprint,  Pabtic  Hoftlth  R6ports,No.  204,  Jan.  26, 1914. 

>  BaoUriological  Standard  for  Drinking  Water,  Reprint,  232,  U.  8.  Public  Health  Reports,  1914. 

*  Fnller:  Jour.  Franklin  Institute,  July,  1915,  p.  42. 

68436— IT—VOL  x 15 


212       PR0CBEDIN6S  SECOND  PAN  AMBBICAN  8GIEKTIFI0  C0NQBB88. 


difficulty  experienced  in  this  mode  of  water  purification  lies  in  the  cloee  approxi- 
mation for  many  waters  of  the  limit  of  germicidal  efficiency  and  the  limit  of  inoffensive- 
ness.  If  unpleasant  odors  are  produced  by  the  chemical,  the  maintenance  of  an 
adequate  bactericidal  strength  often  proves  difficult  in  the  tece  of  complaints  from 
hundreds  of  water  consumers.  The  city  of  Cleveland  is  thought  to  have  suffered 
excessively  from  typhoid  in  1913  in  consequence  of  a  decrease  in  the  dosage  of  hypo- 
chlorite.^ Temporary  cessation  of  the  hypochlorite  or  reduction  to  an  amount  inade- 
quately germicidal  may  sometimes  be  followed  by  a  definite  typhoid  epidemic,  as  in 
the  outbreak  investigated  by  the  writer  at  Quincy,  111.,  in  1913.' 

A  remarkable  reduction  of  typhoid  has  been  observed  in  some  cases  to  acc<Hnpany 
the  hypochlorite  treatment.    The  experience  of  Milwaukee  is  in  point. 

Tablk  4. — DeathBfrom  typhoid  per  100,000  population^  Milwaukee,  Wis,* 

1906-1910  (average) 27 

1911  (hypochlorite  used  intermittently) 19 

1912  (hypochlorite  used  continuously  after  September,  1912) 25 

1913  (hypochlorite  used  continuously  after  September,  1912) 11 

1914  (hypochlorite  used  continuously  after  September,  1912) S 

1915  (estimated,  liquid  chlorin  treatment  begun  Mar.  31, 1915) 5 

Other  similar  instances  are  on  record  in  which  a  marked  typhoid  decrease  has  been 
chiefly  attributable  to  chlorin  treatment  of  the  public  water  supply.  In  such  cases 
it  is  interesting  to  note  that  although  clarification  is  not  effected  by  the  chlorin  treat- 
ment, the  sanitary  success  seems  at  least  as  great  as  when  filtratbn  is  practiced. 

One  noteworthy  development  of  the  chlorin  treatment  has  been  its  application 
either  to  the  raw  water  or  to  the  effluents  of  slow  sand  and  rapid  filters.  Hypochlorite 
dosage  of  the  water  applied  to  filters  or  of  the  filter  effluents  has  in  bet  become  an  almost 
universal  procedure.  (See  Table  5.)  It  does  not  yet  appear  that  this  practice  is 
accompanied  by  any  measurable  decline  in  typhoid  fever  in  cities  previously  served 
by  a  modem  well-operated  filter. 

Tablk  b,— Methods  of  toater  purifieatUm  in  ciUei  of  the  United  Statee  with  over  10,000 

population. 


Population 


- 

Slow  aand  flltratton. 

Rapid  saod  iUtntion. 

Chlorin 

• 

With 
(dilorin. 

Without 
chlorin. 

With 
chlorin. 

Without 
chlorin. 

treatnMot 
alone. 

Citi«8 

13 
2,886,233 

19 
1,073,200 

105 
7,343,087 

46 
8,835,980 

67 

5,793,419 

THB  OUTLOOK. 

A  few  probable  developments  in  water  purificatbn  in  the  United  States  can  be  fore- 
cast. It  seems  likely  that  the  public  demand  for  a  clear,  as  well  as  a  purified  water 
will  increase  and  that  sand  filtration  of  the  mechanical  type  will  become  more  genial. 
It  is  also  probable  that  the  increase  in  pollution  of  suribce  waters  consequent  upon 
growing  density  of  population  will  tend  to  overburden  filter  plants  and  that  If  the 
raw  water  can  not  be  protected,  chlorinatbn  will  be  resorted  to  as  an  adjunct  to 
filtration.  In  the  near  future  practically  all  surface  waters  not  adequately  purified 
by  protected  stcnrage  will  be  treated  by  some  purifying  process.  Already  approxi- 
mately 80  per  cent  of  the  population  of  cities  of  over  10,000  inhabitants  and  over  50 

I  Collins  and  Pflrklns,  Cleveland  Med.  Joor.,  1914, 13,  p.  786. 

s  Jour.  Infect.  Die.,  1913, 13,  p.  16. 

>  Prom  Information  kindly  tarnished  me  by  Dr.  Q.  C.  Ruhland,  health  oommisBloiMr,  Milwaukee. 


PUBLIC  HEALTH  AND  BCBDIOIKB.  213 

per  cent  of  the  total  population  of  the  country  are  supplied  with  purified  surfoce 
wvter  or  from  ground  water  sourcee  for  the  most  part  of  excellent  sanitary  quality. 
At  the  i»e0ent  rate  of  progress  water-borne  disease  in  the  cities  and  larger  towns  of 
this  country  '  will  within  10  years  be  relatively  rare. 

The  Chairmax.  If  I  am  not  mistaken  it  is  the  rule  in  this  section  to 
grant  a  limited  time  to  the  discussion  of  any  paper  under  consideration. 

Col.  HoFF.  I  move  that  the  discussion  be  postponed  until  after  the 
reading  of  other  papers  of  a  similar  character. 

Seconded  and  approved. 

The  Chairman.  The  next  contribution  is  by  Prof.  E.  M.  Chamot,  of 
the  laboratory  of  sanitary  chemistry,  Cornell  University,  Ithaca,  N.  Y. 
I  think  the  secretary  has  had  a  communication  within  the  last  few 
minutes  from  Dr.  Chamot. 

Secretary  Whttmore.  This  letter  is  from  Ithaca,  N.  Y.,  dated 
January  4,  1916: 

An  attack  of  rheumatism  and  neuritis  will  prevent  my  attendance  at  the  congress, 
and  therefore  the  reading  of  my  paper  on  Tuesday  afternoon.    £.  M .  Chamot. 

The  Chaibman.  We  are  sorry  that  the  doctor  is  not  present.  His 
paper  will  go  into  the  proceedings  if  there  is  no  objection.  Hearing 
none,  it  is  so  ordered. 


THE  APPUCABILITY  OF  MICROSCOPIC  METHODS  TO  THE  STUDY  OF 

WATER-SUPPLY  PROBLEMS. 

By  E.  M.  CHAMOT, 
Froftnor  of  Chemical  Mkro9Copy  and  SanUary  Chemistry ^  Cornell  University, 

The  great  desideratum  in  all  inveetigations  involving  the  quality  of  a  water  supply  or 
the  efficacy  of  a  system  of  water  purification  is  that  the  results  of  the  tests  or  analyses 
shall  be  avaUable  in  the  shortest  possible  time.  It  is  therefore  no  exaggeration  to  say 
that  the  most  serious  problem  which  confronts  the  water  analyst  and  water  works 
official  is  that  of  obtaining  information  concerning  the  quality  of  a  water  in  question 
before  such  water  can  have  reached  the  service  pipes  and  have  been  used  by  the  con- 
sumer. That  our  present  methods  are  in  the  great  majority  of  cases  too  slow  and  hence 
inadequate  will  be  gainsaid  by  but  few  analysts  and  sanitarians,  for  year  by  year  the 
increasing  number  of  water  purification  plants  of  the  rapid  American  type  which  are 
seldom  properly  operated  forces  upon  our  attention  the  fact  that  in  the  majority  of 
these  plants  the  true  quality  of  the  filter  effluents  can  not  be  known  until  some  hours 
after  the  water  has  been  drunk  by  the  public,  since  in  most  of  these  plants  the  rates 
of  filtration  are  very  high  and  the  capacity  of  clear  wells  or  distributing  reservoirs 
relatively  small. 

Granting  that  it  is  intelligent  supervision  of  the  plant  and  not  analytical  control 
which  is  of  the  greatest  value  and  all  important,  we  are  forced  to  recognize  that  the 
knowledge  gained  by  the  analyses  must  be  regarded  as  documentary  evidence  avail- 
able for  reference  and  study,  to  guide  in  the  future  operation  of  the  plant,  and  to  serve 
as  proof,  in  the  event  of  controversy,  of  the  quality  of  the  water  at  the  time  the  sample 
was  taken. 


>  Joar.  AiiMr.  Med.  Assoc.,  1915, 64,  p.  1322. 


214       PBOGBEDIKGS  SECOND  PAH  AMERIOAN  8CIENTIFI0  00KQBB88, 

Since  it  is  esBential  in  all  bacteriological  methods  that  time  be  allowed  for  the  growth 
and  development  of  bacterial  colonies  it  is  unlikely  that  any  culture  medium  can  be 
discovered  containing  materials  which  will  so  stimulate  and  accelerate  growth  as  to  ma- 
terially reduce  the  time  which  must  now  elapse  before  we  are  able  to  obtain  the  results 
we  need  in  order  to  pass  intelligently  upon  the  waters  in  question.  But  if  we  are  wil- 
ing to  recognize  the  quite  obvious  fact  that  essentially  that  which  we  are  striving  for 
is  always  in  reality  an  opinion  as  to  quality  and  not  very  accurate  numerical  results, 
then  we  may  hope  to  add  to  the  present  accepted  standard  methods,  supplementary 
tests  yielding  approximate  results,  easily  and  very  rapidly  obtainable.  The  develop- 
ment of  such  methods  will  enable  the  analyst  to  make  many  examinations  of  filter 
effluents  in  the  course  of  a  day.  On  the  other  hand  very  frequent  platings  of  effluents 
from  a  number  of  filter  beds  is  a  task  requiring  too  much  time,  labor  and  expense  to  be 
generally  practicable.  Few  water  purification  plants  indeed  are  financially  able  to 
perform  the  number  of  daily  examinations  of  water  that  good  management  and  oidi- 
nary  common  sense  require.  It  follows,  therefcnre,  that  there  is  but  one  system  of  very 
rapid  bacterial  enumeration  which  we  may  hope  to  successfully  develop  and  this  is  a 
direct  count  by  means  of  the  microscope  of  the  bacteria  present.  Al  though  a  numbtf  of 
such  direct  microscope  count  methods  have  already  been  proposed  they  have  attracted 
little  attention  and  have  never  received  the  study  and  trial  as  applied  to  routine  work 
which  they  deserve  and  to  which  they  are  entitled.  Most  of  these  direct  microscope 
count  methods  are  modifications  of  the  Hesse  suggestion  or  that  of  MQller.  In  the 
Hesse  *  method  the  bacteria  are  concentrated  by  filtration  through  a  bacteria  proof 
filter,  while  in  the  Mtlller '  method  sei>aration  of  the  bacteria  is  accomplished  by  the 
centrifuge.  A  portion  "of  the  concentrate  corresponding  to  a  known  volume  of  the 
original  sample  is  then  spread  upon  an  object  slide,  fixed,  stained,  and  examined.  By 
means  of  a  coordinate  rule  eyepiece  micrometer  adjusted  to  cover  a  known  area  of  the 
preparation  the  stained  bacteria  are  counted  and  from  these  counts  the  total  number  of 
bacteria  per  cubic  centimeter  can  be  calculated. 

These  methods  are  capable  of  yielding  results  bearing  a  very  Mr  approximation  to 
the  colony  counts  obtained  on  gelatine.  The  numerical  figures  are  usually  a  little 
lower  than  the  standard  coimt,  being  from  90  to  98  per  cent  of  the  latter.  It  is  not 
my  intention  to  here  discuss  the  details  of  these  microscopic  methods  nor  to  burden 
you  with  a  recital  of  modifications  and  improvements.  It  is  my  wish  to  point  out 
that  methods  exist  which  will  enable  us  to  obtain  an  idea  as  to  the  number  of  bacteria 
present,  with  little  labor  and  expense  and  a  total  expenditure  of  time  of  not  over  an 
hour.  In  actual  practice,  after  a  little  feimiliarity  with  the  technique,  we  may  obtain 
a  count  of  the  bacteria  present  in  from  30  to  45  minutes,  corresponding  to  94  to  95  per 
cent  of  the  counts  we  will  obtain  on  gelatine  at  the  end  of  48  hours. 

We  have  here,  therefore,  even  granting  its  inaccuracies,  a  means  at  our  command 
of  very  rapidly  estimating  the  number  of  bacteria  present  in  a  sample  of  water  with 
little  labor  and  no  disagreeable  after-cleaning  of  dishes  and  apparatus  and  no  appro- 
ciable  waste  of  material.  We  can  also  by  means  of  microscopic  methods,  make 
very  frequent  tests  of  filter  effluents  in  rapid  American  system  plants  and  obtain  an 
idea  of  what  the  filters  are  doing,  and  this  before  the  water  can  have  reached  am- 
sumers,  a  matter  of  prime  importance  when  dealing  with  questionable  efficiencies 
due  to  so-called  air-bound  filters,  filters  overtaxed  to  take  care  of  some  sudden  emec- 
gency,  filters  whoso  normal  run  has  been  greatly  shortened  through  clogging  by  the 
sudden  development  of  some  organism,  or  filters  in  which  the  upper  or  effective  part 
of  the  filter  bed  has  ruptured  through  sudden  changes  of  head  and  loss-of-head.  All 
of  these  conditions  are  apt  to  arise  in  any  and  every  plant.  The  quality  of  the  filter 
effluents  is  then  immediately  in  question.  If  the  number  of  bacteria  in  an  effluent 
rapidly  increases  and  the  raw  water  is  a  contaminated  one,  it  is  only  a  matter  of  a  short 

»  Hesse.  Ztschr.  f.  Hyg.  u.  Infekt.-Krankh.,  69,  522;  70, 310. 
•  Mttller,  An*,  f.  Hyg.,  75, 189;  82,  57. 


PUBUO  HEALTH  AKD  MEDICINE.  215 

time  before  this  effluent  will  contain  objectionable  species  of  bacteria.  It  is  rare 
indeed  that  oiganisms  of  the  B.  ooli  group  are  jMresent  in  numbers  in  a  raw  water  of 
low  count  and  still  rarer  in  filter  effluents  from  properly  washed  and  operated  filters, 
unless  these  effluents  run  relatively  high  in  bacteria.  To  this  rule,  however,  there 
are  exceptions.  One  interesting  and  very  unusual  case  of  this  sort  has  come  under 
the  speaker's  personal  experience.  A  new  unstripped  reservoir,  formerly  employed 
tt9  pasture  land,  was  flooded  in  the  spring,  then  followed  a  serious  drought  during  the 
summer  months.  During  the  latter  part  of  the  summer  the  water  in  the  reservoir 
became  very  low  and  stagnant.  The  coimts  on  gelatine  at  20^  and  on  agar  at  38** 
became  substantially  identical,  averaging  200  colonies  per  cc.  with  practically  every 
colony  one  of  the  B,  coli  group.  Filter  efflents  gave  from  10  to  30  colonies  per  cc. 
on  gelatine  at  20^  at  the  end  of  48  hours,  yet  with  this  low  count  it  appeared  that  from 
10  to  20  of  these  were  to  be  ascribed  to  the  B,  coli  group.  A  direct  microscopic  count 
in  such  a  case  would  give  information  of  little  value. 

No  doubt  many  other  less  striking  unusual  cases  could  be  cited,  yet  they  are  unusual, 
and  it  will  be  found  that  in  the  vast  majority  of  days  in  the  year  where  questions 
involving  the  doubtful  efficiencies  of  filters  arise,  direct  microscopic  counts  will  yield 
all  the  information  necessary  for  the  guidance  of  the  plant  superintendent.  Were 
such  methods  studied,  developed,  and  adopted  in  practice,  the  public  would  be 
insured  a  water  of  a  much  better  quality.  It  seems  to  me,  therefore,  that  we  can  not 
afford  to  longer  ignore  the  practicability  of  such  control  methods. 

There  is  also  another  valuable  application  of  the  method  of  direct  microscopic 
bacterial  count  which  is  worthy  of  note  and  trial.  A  daily  problem  of  the  water 
analyst  is  that  of  deciding  upon  the  dilution  of  a  given  water  under  examination 
which  will  yield  him  plates  with  not  over  200  colonies  developing  per  cubic  centimeter 
at  the  end  of  48  hours.  If  he  is  in  doubt,  several  dilutions  must  be  made,  involving 
a  loss  of  time,  labor,  and  culture  media.  A  direct  microscopic  count  gives  informa- 
tion with  little  loss  of  time  and  labor  which  may  be  utilized  to  good  advantage  in  sub- 
sequent  plating,  while  at  the  same  time  an  excellent  idea  of  the  bacterial  quality  of 
the  water  is  also  obtained. 

The  one  most  serious  drawback  to  direct  microscopic  counts  undoubtedly  lies  in 
the  little  evidence  diagnostic  of  species  which  it  affords.  We  need  in  all  cases  not 
only  an  enumeration  of  the  bacteria  present  but  also  information  as  to  their  species  or 
groups.  It  may  be  possible  that  the  method  can  in  the  near  future  be  improved  so 
as  to  afford  at  least  a  slight  diagnostic  value  over  and  above  the  information  yielded 
by  the  morphology  of  the  organisms  seen,  but  it  is  doubtful  whether  this  phase  can 
be  developed  to  any  satisfactory  degree.  In  spite  of  these  drawbacks,  the  water 
analyst  should  be  willing  to  recognize  the  fad  that  direct  microscopic  counts  are 
invaluable  in  the  majority  of  everyday  water  problems. 

There  is  only  one  type  of  water  where  such  an  examination  is  obviously  of  no  value 
and  this  is  in  the  analysis  of  * 'sterilized''  or  ''disinfected"  waters.  Here  we  meet 
with  the  question  of  not  how  many  bacteria  are  present  in  the  water,  but  how  many 
are  living.  Direct  microscopic  counts  give  us  only  the  bacteria  present — Hving  or 
dead  cells  are  alike  counted.  Plating  methods  give  us  only  the  count  of  those  living 
and  developing  at  the  end  of  a  given  period  of  incubation.  Both  methods  together 
carried  over  a  long  period  of  time  should  yield  data  of  inestimable  value.  Nor  is  it 
beyond  the  range  of  possibility  that  staining  methods  are  discoverable  which  will 
differentiate  between  living  and  dead  cells. 

'fhe  term  "microscopic  examination  of  water"  has  become  through  usage  so  closely 
associated  with  biologic,  limonologic,  or  planktonic  studies  that  its  broader  field 
of  usefulness  and  sanitary  applications  have  been  almost  lost  sight  of  and  generally 
neglected  in  America,  and  our  standard  methods  for  the  examination  of  water  (ail 
to  contain  a  single  statement  or  suggestion  as  to  the  microscopic  examinations,  save 
for  searching  for  odor  and  taste-fHXKlucing  organisms. 


216       PROCEEDINGS  SECOND  PAN   AMERICAN   SCIENTIFIC   CONGRESS. 

The  study  of  water  sediments,  of  suspended  mattere,  the  association  of  certain  species 
observed  in  large  numbers  with  that  of  a  suitable  environment  necessarj-  for  their 
development,  which  environment  is  of  an  insanitary  character;  the  presence  of  forms 
of  life  in  a  water  which  should  be  absent  and  could  not  possibly  exist  were  that  par- 
ticular source  free  from  pollution,  are  matters  which  no  modem  water  analyst  can 
afford  to  ignore.  Many  times  a  microscopic  examination  will  solve  a  difficult  problem. 
Permit  me  by  way  of  illustration  to  briefly  cite  several  cases  of  the  kind  of  application 
we  may  make  of  microscopic  sediment  examination. 

A  smiill  stream  flowing  through  the  grounds  of  a  large  corporation  developed  r!uring 
cue  summer  months  a  foul  odor.  In  order  to  abate  the  nuifiance  it  became  ne^  essary 
to  find  the  cause  of  the  trouble.  A  number  of  drains  from  laboratories,  shoy>B,  and 
houses  discharged  into  the  stream .  Qhemical  and  bacteriological  analyses  eliminated 
one  by  one  these  drain  lines  as  the  direct  cause  of  the  nuisance.  Samples  of  the  water 
of  the  stream  taken  above  these  drains  gave  on  chemical  analysif  evidence  of  grosB 
pollution^  while  the  bacteriological  examination  showed  the  presence  of  fecal  and 
intestinal  organisms.  The  analyst  held  that  the  water  was  receiving  sewage.  This 
was  denied  upon  the  basis  that  the  sediment  in  the  stream  was  not  of  the  character 
and  color  mot  with  in  small  brooks  which  are  sewage  polluted  to  an  extent  of  giving 
off  foul  odors,  and  moreover  the  presence  of  feral  and  intestinal  organisms  was  to  be 
cx]>ected,  since  a  large  stock  farm  was  located  upon  the  drainage  area  of  the  stream 
les '  than  a  mile  above  the  point  of  sampling.  It  should  be  explained  here  that  the 
bro  )k  flowed  through  a  relatively  long  line  of  tile  imder  a  roadway  sidewalk  and 
fillod-in  ground  and  the  samples  were  taken  at  the  lower  end  of  this  culvert.  The 
waier  analyst  insisted,  however,  that  the  cause  was  sewage  and  that  search  should 
be  matle  for  a  broken  sewer  line  or  an  overflowing  cesspool.  Another  factor  entered 
in  the  problem  in  that  the  stream  water  varied  greatly  in  character  at  different  times 
of  day,  seenrng  to  indicate  an  intermittent  sewage  discharge.  The  matter  rested 
here  through  the  winter  and  spring,  but  the  next  summer  the  odor  became  unbearably 
f(>ul.  Analyses  showed  a  greater  amount  of  contamination  than  before  and  again  of 
marked  variation  in  amount.  Microscopic  examination  was  resorted  to  with  most 
excellent  results.  It  was  possible  to  demonstrate  that  the  stream  carried  at  times 
relatively  large  amoimts  of  wood  pulp  and  that  this  wood  pulp  was  of  the  character 
of  that  of  the  toilet  paper  employed  in  the  water-closets  of  the  corporation,  and  further 
that  the  appearance  of  this  disintegrated  tissue  paper  coincided  with  the  periods  of 
maximum  odors.  This  was  evidence  of  a  character  not  to  be  ignored.  The  sewer 
line  was  traced,  found  to  cross  the  culvert  tile  above  referred  to.  and  excavated. 
The  culvert  tile  were  found  to  be  cracked,  the  sewer  tile  above  sunken  on  each  side 
where  it  crossed  the  stream  tile,  opening  up  the  sewer-tile  hubs.  Fine  material  was 
percolating  through  the  loose  soil  and  entering  the  little  stream. 

Here  we  have  a  very  striking  example  of  the  value  of  microscopic  examination  in 
aiding  in  locating  the  exact  cause  of  the  nuisance  in  a  water  known  to  be  grossly  pol- 
luted and  fiuther  of  pointing  out  the  remedies  which  should  be  applied  to  abate  a 
nuisance.  As  a  matter  of  fact,  the  microscopic  examination  alone  gave  all  the  infor- 
mation necessary,  and  had  it  been  applied  in  the  first  summer  it  would  have  solved 
the  problem  witliout  recourse  .to  either  chemical  or  bacteriological  analyses. 

Similarly  in  the  case  of  drinking  water,  ofttimes  both  chemical  and  bacteriological 
examinations  prove  a  water  to  be  unfit  for  household  use,  yet  the  cause  of  the  trouble 
is  obscure  or  indeterminate.  In  the  majority  of  such  cases  the  microscope  will  usually 
supply  the  missing  links  in  the  chain  of  evidence.  An  excellent  example  is  afforded 
in  a  problem  arising  in  the  case  of  a  drilled  veil.  The  facts  were  these:  Two  old 
people  died  under  circumstances  pointing  to  the  water  of  their  well  as  the  cause. 
The  small  farm  was  purchased  by  a  city  contractor  and  the  house  and  its  siuroundings 
cleaned  and  repaired.  The  well,  95  feet  deep,  drilled  in  the  rock  and  cased  for  some 
60  feet,  received  special  attention.     A  huge  slab  of  concrete,  10  fort  square  and  2  feet 


PUBUO  HSALTH  AND  BCEDIOIKB.  217 

thick  was  cast  about  the  well  casing,  a  small  catch  basin  with  tile  drain  for  leading 
ofif  the  water  was  provided  to  prevent  water  pumped  from  the  well  from  flowing  upon 
the  soil  in  the  vicinity  of  the  well  rasing  and  seeping  back  into  the  well.  Having 
thofi  improved  the  property  and  protected  the  well,  two  years  later  the  new  proprietor 
requested  an  analysis  of  the  water.  This  analysis  need  not  be  given  in  detail;  both 
chemically  and  bacteriologically  the  water  was  bad  and  the  microscopic  examination 
of  the  sediment  pumped  from  the  well  disclosed  a  remarkable  state  of  affairs,  in  that 
fragments  of  all  sorts  of  ordinary  articles  of  food  and  household  debris  could  readily 
be  detected  and  identified.  These  included  cereal  and  potato  starches,  cooked  and 
raw;  muscle  fibers;  fragments  of  human  hair  and  those  of  domestic  animals,  cotton, 
wool,  and  Hnen  fibers  dyed  and  undyed,  such  as  would  be  found  in  the  sweepings 
from  carpets  and  floors;  in  other  words,  all  the  material  normally  to  be  foimd  in  dish- 
waters and  laundry  and  household  wastes. 

It  was  obvious  that  dishwaters  and  slops  had  penetrated  into  the  well,  but  no  evi- 
dence as  to  just  how  this  had  taken  place  was  obtainable  for  some  time.    The  cesspool 
into  which  dish  and  laundry  waters  were  being  dlschaiged  was  water-tight  and  so 
situated  as  to  preclude  any  possibility  of  this  source  of  contamination.    The  nearest 
neighboring  farmhouse  was  over  3  miles  away.    Floor  sweepings  were  being  burned. 
The  surface  of  the  ground  round  about  the  well  and  the  house  afforded  no  possibilities 
of  surface  waters  entering  the  well.    There  existed  no  visible  drains.    It  was  there- 
fore surmised  that  the  pollution  must  date  back  to  the  time  before  the  improvements 
w^re  made  and  that  there  must  have  been  some  drain  line  from  the  kitchen  sink  past 
the  well .   Upon  investigation  this  supposition  was  found  to  be  correct.  There  formerly 
did  exist  a  subsoil  wooden  trough  passing  close  by  the  well,  but  the  manner  in  which 
the  water  of  the  well  became  befouled  was  not  that  anticipated,  namely,  a  break 
in  the  trough  and  a  leaky  well  casing,  but  proved  to  be  due  to  a  joint  in  the  shale 
rock  forming  the  precipitous  bluff  of  a  lake.    The  abandoned  drain  dischaiged  over 
the  edge  of  this  bluff  about  122  feet  high.    The  dirty  water  stnick  a  ledge  upon  the 
rocky  wall  some  70  feet  down  from  the  top.    This  ledge  was  formed  at  a  joint  in  the 
stiuta  and  the  inclination  of  the  strata  was  such  (so  far  as  could  be  observed)  as  to  allow 
a  percolation  of  water  to  a  level  just  below  that  of  the  water  table  of  the  well.    By  dig- 
tnng  into  the  joint  a  short  distance  material  was  found  of  the  same  sort  as  that  forming 
tho  sediment  in  the  well  water.    Inasmuch  as  two  years  had  elapsed  since  the  waste- 
water drain  had  been  abandoned  and  the  well  had  been  pumped  dry  on  many  occa- 
sions, it  was  evident  that  the  polluting  material  had  completely  filled  the  joint  and 
would  render  the  well  water  unsafe  for  an  indefinite  period.    The  more  the  well  was 
pimiped  the  more  the  putrefying  material  could  enter. 

It  iB  further  worthy  of  comment  that  the  water  of  this  well  was  long  regarded  as  a 
sulphur  water  because  of  its  hydrogen  sulphide  odor.  The  milky  turbidity  was  be- 
lieved to  be  precipitated  sulphur.  The  water  being  very  cold,  and  high  in  dissolved 
gases,  it  was  much  sought  after  in  the  neighborhood  as  a  mineral  water,  and  its  power- 
ful cathartic  effect  was  ascribed  to  purgative  salts  in  solution.  This  is  one  of  the 
only  moderately  deep-seated  waters,  cold  and  with  an  odor  of  hydrogen  sulphide 
which  the  speaker  has  yet  met  with  where  the  sulphiureted  water  derived  its  odor 
and  taste  from  putrefying  material. 

This  case  has  been  gone  into  at  length  because  it  is  an  exceptionally  good  example 
of  the  value  of  microscopic  examination  of  sediments.  It  is  to  be  especially  noted 
that  the  microscopic  examination  not  only  solved  the  problem  of  the  exact  nature  of 
the  polluting  material  but  eventually  led  to  the  discovery  of  its  source  and  demon- 
strated that  the  weU  water  must  be  indefinitely  abandoned.  We  must  not  foiget 
that  a  properly  conducted  water  examination  should  give  answers  to  three  questions: 
(1)  Is  the  water  fit  for  household  use;  (2)  if  unfit,what  is  the  trouble?;(3)  how  can  it 
be  permanently  improved?  To  these  three  a  fourth  sometimes  arises:  WiU  the  water 
probably  continue  to  remain  good  or  bad? 


218       PROGBEDIirGB  8BC0VD  PAV  AMEBKUK  60IBVTIFI0  CONQBESS. 

In  the  same  cUm  but  of  a  dififerent  type  fall  thoae  cases  of  microscopic  ezaminataoii 
of  sediments  and  8uq;>ended  matteis  disclosing  finely  divided  wood  palp  &t»i  chain 
pumps  having  wooden  pump  tubes,  or  an  emulsion  of  oOy  droplets,  etc.,  from  pumps 
lubricated  with  an  excess  of  oils  and  greases.  Such  waters  yield  high  oxygen  con- 
sumed and  high  loss-on-lgnition,  with  the  total  solid  residues  usually  blackening  on 
ignition  but  all  other  chemically  determined  constituents  low  and  usually  low  bac- 
teria. The  microscopic  examination  here  serves  to  elucidate  the  cause  of  these  hi^ 
results  and  renders  the  interpretation  of  the  entire  analysis  simple  and  certain. 
Without  the  microscopic  examination  the  analyst  is  apt  to  be  sorely  puzsled. 

Time  forbids  giving  other  examples  althou^  a  large  number  might  be  cited.  Yet 
it  is  remarkable  how  seldom  the  water  analyst  has  recourse  to  this  most  valuable  aid 
to  assist  him  in  forming  an  opinion  as  to  the  character  of  a  water  in  question  and  as 
to  the  means  for  improving  its  quality. 

The  examination  of  sediment  and  suspended  matters  in  waters  lor  the  possible 
presence  of  animal  parasites  is  also  too  often  neglected  as  a  matter  of  routine  work;  in 
at  least  two  instances  the  speaker  has  found  the  ova  of  the  common  iMpewixm  in  spring 
waters  submitted  to  him  for  analysis.  It  is  true  that  these  are  but  two  instances  in 
some  twenty-odd  years  of  experience  as  a  water  analyst,  yet  similar  examples  are  apt 
to  arise  at  any  time,  and  if  we  are  to  really  serve  our  clients,  we  must  be  prepared  to 
adopt  every  and  all  means  at  our  disposal. 

That  branch  of  microscopic  examination  devoted  to  the  detection  of  the  specific 
cause  of  bad  odors  and  tastes  in  impounded  waters  is  too  well  known  and  too  g«i- 
erally  employed  and  the  necessity  for  its  practice  too  firmly  established  to  necessitate 
any  consideration  by  me;  but  the  study  of  the  plankton  causing  rapid  clogging  of 
filters  in  rapid  American  systems  is  receiving  altogether  too  little  attention  by 
analysts  in  chaige  of  filter  installations.  It  is  not  uncommon  to  have  the  period  of 
ssrvice  between  filter  washings  cut  down  fuUy  95  per  cent  in  the  course  of  two  or 
three  days,  due  to  the  sudden  multiplication  of  organisms  of  one  species  or  another, 
thus  forcing  the  purification  plant  to  its  capacity  and  not  infrequently  rendering 
its  operation  almost  impossible.  A  knowledge  of  the  species  causing  the  clogging  is 
imperative  in  order  that  the  trouble  may  be  intelligently  fought.  Even  less  atten- 
tion is  being  paid  to  the  influence  of  certain  oiganisms  in  loosening  the  sand  beds 
or  at  least  in  some  way  lowering  efficiencies.  There  seem  to  be  good  reasons  for 
believing  that  some  of  the  lowering  of  efficiencies  due  to  the  pocketing  of  air  within 
the  filter  beds  may  be  due  directly  or  indirectly  to  the  action  of  organisms — directly 
when  the  oiganisn  efifects  a  liberation  of  gases  in  the  water,  indirectly  when  through 
their  action  in  forcing  sand  grains  away  from  one  another  they  form  a  space  where 
air  eventually  accumulates.  If  there  are  a  large  number  of  such  pockets  formed,  the 
available  filter  area  may  be  greatly  reduced  and  the  filter  finally  taxed  beyond  its 
capacity,  its  loss-of-head  rapidly  increased,  and  finally  the  pocketed  air  rising  loosens 
the  bed  and  we  have  an  airbound  filter  bed.  Actually  in  practice,  however,  we  fre- 
quently encounter  what  amounts  substantially  to  airbound  filters  without  the  air 
rising  as  in  typical  cases,  for  the  air  clings  tenaciously  to  certain  sand  grains  which  are 
coated  with  a  film  of  sudi  a  nature  as  to  hold  the  air.  In  such  an  event  the  filter  may 
not  "break,"  but  its  bacterial  efficiency  falls. 

In  our  purification  plants  we  have  paid  considerable  attention  to  the  effective  size 
of  the  sand  and  its  coefficient  of  uniformity,  but  we  have  absolutely  ignored  the  ques* 
tion  of  the  adsorptive  powers  of  sands  of  different  scurts  for  the  coagulants  we  are  to 
employ  in  the  specific  waters  to  be  treated.  Usually  a  newly  constructed  filter  bed 
does  not  yield  as  high  an  efficiency  as  after  it  has  been  in  use  tot  a  longer  or  shorter 
period,  or  until  it  has  become  "seasoned"  or  "ripened,''  as  it  is  sometimes  stated. 
It  is  the  commonly  accepted  theory  that  the  bed  becomes  efficient  as  soon  as  the  sand 
grains  acquire  a  thin  coating  of  coagulant  or  a  thin  film  of  protoplasmlike  material. 
This  surrounding  envelope  is  held  by  such  grains  of  sand  by  virtue  of  their  adsorptive 


PUBUC  HEALTH   AND  MEDICINE.  219 

power  for  the  particular  kind  of  colloidal  matter  iMreaent,  and  it  is  probably  largely 
by  reason  of  the  adsorptive  power  of  the  colloidal  matter  for  the  materials  which  we 
wish  to  remove  that  we  obtain  the  efficient  filtration  we  meet  with  in  practice.  It 
seems  reasonable  in  the  light  of  the  recent  develc^ments  of  colloidal  chemistry  to 
regard  the  mechanical  sand  analysis  expressed  in  terms  of  effective  size  and  uniformity 
coefficient  as  giving  us  information  only  of  the  rates  of  flow  we  may  expect  through  beds 
of  the  unclogged  (uncoated)  sand  bed,  but  the  purification  efficiency  of  the  bed  must 
be  measured  laigely  by  the  adsorptive  power  of  the  sand  for  the  colloidal  matter  and 
its  ability  to  retain  this  adsorptive  property.  If  we  take 'sand  from  seasoned  filter 
beds  and  examine  it  wet  under  the  microscope  just  as  it  is,  or  treated  with  an  aniline 
dye  (congo  red  or  benzo  orange  for  basic  aluminum  sulphate  treated  waters),  we  will 
find  a  relatively  large  number  of  sand  grains  with  no  colloidal  coating  whatever,  or 
with  colloidal  patches  instead  of  coatings,  and  we  will  further  find  that  the  relative 
proportion  of  coated  and  uncoated  grains  is  quite  different  in  sands  of  different  sorts. 
We  need,  therefore,  to  investigate  sands  with  respect  to  their  adsorptive  powers. 
There  is  little  question  that  the  differences  in  efficiencies  of  different  filter  plants  is 
a  matter  largely  of  adsorption  of  colloids  and  the  power  of  the  sand  grains  to  tenaciously 
hold  these  adsorbed  colloids  in  waters  containing  substance  which  through  their 
chemical  action  might  cause  the  colloidal  envelopes  to  loosen  and  disintegrate. 

It  is  safe  to  conclude  that  the  sanitary  engineer  in  writing  his  specifications  for 
sand  beds  ought  to  be  able  to  include  details  looking  toward  the  use  of  a  filter  material 
of  high  adsorptive  power.  Were  he  in  possession  of  this  knowledge,  much  progress 
could  be  made,  and  in  the  opinion  of  the  speaker  we  would  meet  i^ith  fewer  plants 
of  doubtful  efficiencies. 

Much  interesting  information  as  to  the  actual  condition  of  the  sand  in  the  filter  is  to 
be  gained  by  periodic  microscopic  examination  of  sand  before  and  after  washing  a 
filter  and  studying  the  sand  just  as  it  comes  from  the  beds,  staining  it  to  render  the 
film  m<Nre  easily  recognized,  and  also  through  examinations  of  sand  after  treating  it 
with  dilute  hydrochloric  acid.  In  many  waters  it  will  be  foimd  that  in  addition  to 
the  colloidal  coating  a  film  or  a  conglomerate  of  fine  crystals  of  calcium  carbonate 
coats  the  sand  grains,  and  this  when  no  lime  or  soda  ash  has  been  applied  to  the  water. 
It  is  not  clear  whether  this  lime  coating  is  beneficial  or  objectionable,  whether  it 
tends  to  cause  colloids  to  deposit  or  prevents  their  ads(»rption.  A  fertile  and  highly 
interesting  field  upon  which  considerable  work  should  be  done  is  here  open  to  the 
investigator.  In  one  filter  plant  with  which  the  speaker  is  familiar  this  tendency  of 
calcium  carbonate  to  deposit  upon  sand  and  gravel  has  been  at  times  so  great  as  to 
rapidly  lead  to  the  formations  of  patches  of  conglomerate  in  the  bed,  rendering  wash* 
ing  of  the  filters  inefficient  and  certain  areas  of  the  beds  impermeable. 

Occasionally  the  chemist  finds  it  important  to  ascertain  the  nature  of  the  salts 
deposited  during  evaporation  or  heating.  The  usual  method  consists  in  performing 
a  quantitative  analysis  of  the  solid  residue  and  then  computing  the  so-called  hypo- 
thetical combinations. 

Few  analysts  appear  to  be  aware  of  the  ^t  that  a  microscopic  study  of  the  properly 
obtained  solid  residue  will  in  most  cases  not  only  enable  him  to  identify  most  of  the 
salts  which  hare  separated  but  also  to  form  a  very  good  idea  of  their  relative  propor- 
tions with  a  certainty  that  is  as  surprising  as  it  is  simple  and  rapid. 

There  is  absolutely  no  question  whatever  that  microscopic  qualitative  analysis 
methods  are  the  simplest,  most  rapid,  and  most  certain  that  are  at  present  available 
for  the  detection  in  water  of  minute  quantities  of  copper,  lead,  zinc,  etc.  For  copper 
and  zinc,  volumes  of  from  one  drop  to  10  c.  c.  are  evaporated  to  dryness,  moistened 
with  dilute  nitric  acid,  evaporated  to  dryness,  taken  up  with  a  drop  or  two  of  distilled 
water,  and  a  portion  of  this  liquid  tested  upon  an  object  slide  with  ammonium  mercuric 
sulphocyanate.  In  the  case  of  lead  the  water  is  treated  exactly  as  above  and  the  lead 
made  evident  by  the  usual  inpLe  nitrite  reaction,  using  cesium  chloride  to  hasten  the 


:r20       PBOGEEDIKGB  SECOND  PAN  AMERICAN   SCIENTIFIC  C0NQBE8S. 

fonning  of  the  crystal  phase.  The  crystaLi  obtained  in  these  cases  are  abundant,  well 
formed,  very  characteristic »  easily  recognized,  and  not  liable  to  any  serious  interf^- 
ences  by  other  substances  which  may  be  present. 

With  two  microscopes  available  and  a  comparison  eyepiece,  quantitative  colori- 
metric  methods  can  be  employed  with  minute  quantities  of  water  and  yet  with  an 
accuracy  comparing  very  favorably  with  our  standard  methods  of  water  analysis. 
This  ifl  a  matter  of  vital  importance  when  the  taking  of  very  small  samples  of  water 
only  is  practicable. 

In  this  sh<Hrt  r^simi^  I  have  endeavored  to  point  out  that  microscopic  metliods  are 
capable  of  a  very  broad  application,  permitting  us  to  study  not  only  organisms  included 
in  the  general  term  of  plankton  but  also  enabling  us  to  estimate  the  bacteria  jxeeent 
with  ease  and  rapidity,  and  to  make  qualitative  or  even  quantitative  analyses  with 
an  economy  of  time,  material,  and  space  not  possible  by  any  other  method,  and  more 
important  still,  that  the  microscope  intelligently  employed  yields  inf(»rmation  of  a 
character  of  prime  importance  and  inestimable  value  in  the  sanitary  examination 
<  f  w^ter  and  even  in  the  operation  and  design  of  water-filtration  plants. 

Th<'  (^H AIRMAN.  Dr.  Edward  Bartow,  director  State  Water  Siirvey, 
rrl».aia,  111.,  is  the  next  on  the  program. 


THE  SIGNmCANCE  OF  CHEMISTRY  IN  WATER  PURinCATION. 

By  EDWARD  BARTOW, 
Director  StaU  Water  Survey,  Urbana,  III, 

When  water  purification  is  mentioned  one  thinks  first  of  water  for  drinking  pur- 
poses. It  is  a  fact,  however,  that  a  very  small  percentage  of  the  water  furnished  by 
a  municipality  to  its  citizens  is  used  for  drinking  purposes.  Water  purification  must 
include  treatment  of  water  for  drinking  purposes,  for  domestic  uses,  for  the  production 
of  steam,  and  for  manufacturing  processes.  The  value  of  an  abundant  supply  of  pure 
water  for  all  piuposes  is  becoming  more  generally  realized,  and  many  investigatc^s 
have  been  and  are  endeavoring  to  find  the  beet  means  for  judging  the  quality  of  a 
water  and  for  purifying  water.  The  chemist,  the  bacteriologist  and  the  biologist 
are  all  busy  investigating  these  problems. 

The  bacteriologist  rightly  considers  that  the  presence  or  absence  of  diseaae-pooduc- 
ing  bacteria  is  the  only  absolute  means  of  judging  whether  a  drinking  water  will  cause 
disease.  But  the  difficulties  in  determining  absolutely  the  presence  or  absence  of 
disease-producing  bacteria  and  the  uncertainty  which  negative  results  leave  with 
regard  to  possible  later  access  of  pathogenic  bacteria  make  it  necessary  to  use  some 
index  other  than  the  disease-producing  bacteria  themselves  by  which  to  judge  the 
piurity  of  a  drinking  water.  The  bacteriologist  has  the  nearest  approach  to  a  reliable 
index  in  the  bacteria  which  acccnnpany  pollution.  Bacteria  of  the  colon  group  are 
always  present  in  sewage,  and  their  presence  or  absence  in  a  drinking  water  is  very 
important  since  it  implies  the  jnreeence  or  absence  of  pollution  by  sewage.  There- 
fore, finding  the  colon  bacillus,  the  bacteriologist  would  condemn  the  water.  The 
biologist,  finding  organisms  that  impart  an  unpleasant  taste  or  odor,  would  condemn 
a  water.  The  sanitary  inspector,  from  a  survey  of  the  territory  surrounding  the  source 
of  a  water  supply,  finding  imfavorable  conditions,  would  condemn  a  water  without 
further  examination.  The  bacteriological,  biological,  and  inspection  approval  of  a 
water  is  not  sufficient.  Chemical  approval  in  addition  is  necessary  because  of  the 
possibility  of  unseen  undergroimd  contamination,  because  chemical  tests  reveal  the 
previous  history  of  a  water  and  may  indicate  possible  future  contamination,  because 
chemical  tests  determine  the  therapeutic  character  of  a  drinking  water. 


PUBLIC  HEALTH  AND  MEDICINE.  221 

Chemical  tests  are  used  to  4etennine  the  purity  of  water  and  to  control  the  treat- 
ment.   Chemicals  are  used  in  purification  and  disinfection  of  water  supplies. 

When  it  was  first  realized  that  a  polluted  well  water  might  spread  infectious 
diseases  chemical  tests  alone  were  relied  upon  by  the  water  analyst.  Because 
organic  waste  matter  contains  nitrogen  as  an  important  constituent,  Wanklyn  in  1868 
first  suggested  the  determination  of  nitrogen  as  an  index  of  the  character  of  a  water 
supply.  He  proposed  the  albuminoid  ammonia  test  and  while  it  has  had  consider- 
able criticism  it  has,  nevertheless,  served  a  good  purpose.  The  albuminoid  ammonia 
test  and  the  determination  of  oxygen  consuming  capacity  have  given  the  best  informa- 
tion concerning  the  character  of  a  water  supply,  until  the  introduction  of  bacteriological 
ter^ts.  For  many  years  the  sanitary  examination  of  a  drinking  water  consisted  of 
purely  chemical  tests  and  included  the  determination  of  residue,  chloride,  oxygen 
consiuning  capacity,  free  ammonia,  albuminoid  ammonia,  hardness,  dissolved  gases 
and  poisonous  metals.  Later,  owing  to  the  demand  for  a  clearer  water  free  from 
iron  and  manganese,  determinations  of  alkalinity,  carbondioxide,  iron  and  manga- 
nese were  added. 

When  bacteriological  tests  are  made,  it  is  surprising  to  note  the  amount  of  chemistry 
used  by  the  bacteriologist.  Even  in  determining  the  number  of  bacteria,  the  acidity 
of  the  media  must  be  accurately  adjusted  by  chemical  analyaiB.  The  determination 
of  the  colon  bacillus,  as  stated  before,  the  most  reliable  index  of  pollution,  depends 
upon  the  chemical  decomposition  of  sugars  in  media  whose  acidity  is  accurately 
adjusted.  Other  tests  for  the  colon  bacillus  depend  upon  the  chemical  reaction 
toward  litmus  lactose  agar  or  Endo's  media.  The  formation  of  indol  and  its  recogni- 
tion are  chemical  reactions  used  by  the  bacteriologist. 

At  present  in  the  analysis  of  drinking  waters  certain  chemical  tests  may  be  said  to 
supplement  the  bacteriological  tests.  These  are  the  tests  for  organic  matter.  They 
include  tests  for  ammonia,  albuminoid,  nitrite,  and  nitrate,  nitrogen,  and  the  oxygen 
consuming  capacity. 

The  inorganic  constituents  must  not  be  overlooked.  Some  serve  as  an  index  of 
pollution,  others  have  therapeutic  significance.  Chl(»ide  furnishes  an  example  of 
the  usefulness  of  a  chemical  test  as  an  index  of  pollution.  It  is  always  present  in 
sewage,  hence  in  regions  where  the  amount  of  chloride  present  in  normal  waters 
varies  with  the  distance  from  the  sea  coast  an  excess  of  chloride  above  the  normal 
arouses  suspicion.  It  must  be  remembered,  however,  that  in  other  regions,  especially 
r^ons  which  have  been  covered  by  the  sea,  the  normal  chloride  of  the  water  supplies 
is  so  high  and  its  variation  so  great  that  it  is  impossible  to  use  it  as  an  index  of  pollu- 
tion. The  chemical  analysis  of  the  inorganic  soluble  matter  shows  the  therapeutic 
significance.  Waters  containing  notable  amounts  of  the  sulfates  of  sodium,  or  mag- 
nesitun,  or  waters  containing  dis^jolved  gases,  especially  hydrogen  sulfide,  will  have 
a  physiological  action  on  those  who  drink  them,  especially  on  those  who  are  not 
accustomed  to  them.  Therefore,  these  waters  containing  large  amounts  of  sulphates 
or  hydrogen  sulphide  are  valuable  mineral  waters. 

The  chemical  tests  for  the  troublesome  metals,  iron  and  manganese,  and  the 
pQiBonous  metals — copper,  lead,  and  zinc,  must  not  be  overlooked.  Copper,  lead, 
and  zinc  are  found  in  waters  in  mining  regions  and  many  waters  will  dissolve  lead  or 
zinc  from  pipes.  The  drinking  of  these  waters  will  cause  serious  illnesses.  Iron  and 
manganese  if  present  in  sufficient  quantity  to  be  injurious  are  usually  precipitated 
on  contact  with  the  air  and  give  warning  against  the  use  of  the  water. 

To  determine  definitely  the  therapeutic  value  of  a  water  acciuHte  determinations 
of  the  chemical  composition  of  the  mineral  content  of  waters  are  needed.  These 
accurate  determinations  serve  also  to  show  the  value  for  use  in  boilers,  for  manufac- 
turing purposes  and  for  the  determination  of  methods  of  water  purification.  The 
tests  ordinarily  made  are  for  the  positive  ions,  potassium,  sodium,  iron,  aluminium, 
calciimii,  magnesiimii,  and  for  the  negative  ions,  chloride,  nitrate,  sulfate,  and  car- 


222       PB0CESDIKQ8  8B00FD  PAN  AMERICAN  80IBKTIFI0  C0NQBE88. 

bonate.  Sometimes  rare  ions  such  as  bromide,  iodide,  lithium,  and  i^osphate  are 
determined.  For  boiler  use  an  excessive  amount  of  calcium  and  magnesium  will 
cause  the  formation  of  scale.  Chloride  or  nitrate  ions  in  excess  will  cause  corrosion 
and  sodiiun  and  potassium  in  excess  will  cause  foaming.  Many  examples  might  be 
given  of  the  injurious  action  of  soluble  compounds  in  water  used  for  jnanuftu:taring. 
Suffice  it  to  say,  that  compounds  of  iron  and  manganese  by  their  color  interfere  with 
bleaching  processes;  calcium  and  magnesium  increase  the  amount  of  soap  required 
and  form  substances  that  can  be  with  difficulty  removed  from  ftibiics,  thus  interfering 
with  laundry  processes;  calcium  and  magnesium  when  present  in  water  used  in 
preparing  foods  give  an  inferior  product. 

Chemists  have  been  working  for  years  to  improve  methods  of  analysis  and  methods 
of  purification.  They  have  been  working  in  cooperation  on  methods  of  analysis  and 
individually  on  mediods  of  purification.  In  the  United  States  committees  have 
formulated  standard  methods  of  analysis.  The  first  attempt  to  obtain  uniform  methods 
was  made  by  the  chemical  division  oi  the  American  Association  for  the  Advancement 
of  Science,  which  presented  a  preliminary  report  at  the  meeting  in  Cleveland  in  1886.' 
This  committee  gave  standards  for  (1)  free  and  albuminoid  ammonia;  (2)  oxygen 
consuming  capacity;  (3)  nitrites;  (4)  nitrates,  and  implied  that  readue,  chloride,  and 
hardness  should  also  be  determined  but  gave  no  specific  directions  for  these  tests. 
The  American  Public  Health  Association  in  1894  took  its  first  step  toward  the  foimu- 
lation  of  standard  methods.'  The  committee  formed  at  that  time  made  eevend 
progress  reports  and  prepared  recommendations  for  bacteriological  examination  of 
water.  It  was  not  until  1905  that  they  published  the  first  report  <m  standard  methods 
of  water  analysis,  including  both  chemical  and  bacteriological  methods.  A  revised 
report  was  published  in  1912  and  a  second  revision  will  appear  during  1916.  This 
published  report  on  Standard  Methods  has  done  much  to  unify  the  chemical  procediue 
in  water  laboratories  and  to  promote  interest  in  investigation  of  methods  of  analyses. 

Having  by  analjrsis  found  a  water  impure  the  next  step  is  purification.  The  method 
ot  purification  depends  upon  the  proposed  use.  Drinking  water  demands  filtration  to 
remove  turbidity  and  bacteria  when  waters  are  turbid.  Impure  drinking  waters,  if 
clear,  demand  disinfection.  Slow  sand  filters,  imitating  nature's  process  were  first 
used  to  remove  turbidity  and  bacteria.  Owing  to  the  expense  oi  installation, 
especially  in  America,  the  so-called  mechanical  filters  have  been  substituted .  Chemi- 
csds  are  necessary  for  the  operation  of  mechanical  filters.  By  means  of  chemicals  a 
precipitate  is  formed,  which  in  settling  collects  colloids  and  bacteria  and  permits  the 
water  to  be  filtered  at  nearly  40  times  the  rate  possible  when  no  chemicals  are  used. 
Aluminium  sulfate  (filter  alum)  iron  sulfate,  and  lime  separately  or  in  combination, 
are  the  chemicals  added.  Aluminium  sulfate  reacts  with  the  bicarbonates  of  calcium 
and  magnesium  in  the  water  to  form  a  precipitate  of  alimiinium  hydroxide.  Iron 
sulfate  usually  added  with  lime  reacts  with  the  bicarbonates  of  calcium  and 
magnesium  to  form  a  precipitate  of  iron  and  magnesium  hydroxides,  and  calcium 
carbonate.  It  is  necessary  to  add  sufficient  lime  to  neutralize  any  free  carbon  dioxide 
present  or  set  free  by  the  iron  sulfate.  Lime  reacts  with  magnesium  salts  forming 
a  sufficient  precipitate  to  allow  filtration  without  aliuninium  or  iron  sul^te  or  with 
a  very  little  of  either  to  counteract  the  excess  of  lime.  Waters  with  an  excessive 
turbidity  like  those  in  the  Missismppi  River  Valley,  can  not  be  filtered  practically  by 
slow  sand  filtration  and  filtration  with  chemicals  is  used  exclusively. 

Each  year  the  public  is  demanding  better  water.  Standards  of  purity  are  being 
raised.  The  United  States  Public  Health  Service,  through  a  commission,  has  formu- 
lated standards  for  the  purity  of  drinking  water  to  be  used  on  interstate  carriers.'  A 
glance  at  the  literature  of  the  last  few  years  shows  how  investigators  are  endeavoring 

>  The  Journal  of  Analytical  Chemistry,  3, 808  (1887). 

s  Proceedings  of  the  American  Public  Health  Association,  20,  81  (18D4). 

>  Public  Health  Reports,  39, 2959  (IVM). 


PUBUO  HBALTH  AND  HEDIOINS.  223 

tft  comply  with  the  demand  for  better  water.    It  is  diflkult  to  conlorm  to  tlie  improved 
Blandarda  for  drinking  water  without  dianfection. 

For  disinfection,  ozone,  ultraviolet  rays,  bleaching  powder,  liquid  chlorine  and  lime 
ai6  uaed.  Osone  has  beoi  used  quite  extensively  in  Europe.  Plants  are  in  operation 
in  Europe  at  Wiesbaden,  Schierstein,  Paderbom,  Gosne,  Ghartus,  Nizza,  Dinard, 
Sulina,  Qinnekin,'  St.  Maur,'  Chemnitz,  Florence,  Spezia,  Genoa,  Bndla,  Paris,' 
Koenigsberg,*  Petrograd*  and  other  places. 

The  plants  which  have  been  constructed  in  the  United  States  *  have  not  been  very 
successful  and  it  must  be  considered  that  the  use  of  ozone  in  Ajserica  is  still  in  the 
experimental  stage. 

Disinfection  or  sterilization  with  the  ultraviolet  ray  was  first  proposed  by  Henri, 
Helbrunner,  and  Recklinghausen.^  Their  pioneer  work  has  been  followed  by  many 
investigators.  Plants  are  in  operaticm  in  Europe  at  Luneville,  St.  Malo,  and  Rouen.* 
No  large  installations  have  been  made  in  the  United  States  but  small  installaiticms  have 
been  used  with  evident  succeas. 

Bleaching  i>owder  (calcitun  hypochlorite)  was  first  used  in  1908  at  the  Union  Stock 
Yards  in  Chicago  and  at  the  Boonton  Reswoir  of  the  Jersey  City  supply.  The  process 
because  of  its  cheapness  is  being  widely  used  throughout  the  United  States.  In  1915 
Lon^ey  '  reported  that  240  water  supplies  were  being  treated  with  some  disinfecting 
i^eot;  about  80  per  cent  using  bleaching  powder  and  the  remainder  liquid  chlorine. 

Within  the  last  few  years  liquid  chlorine  has  been  made  available  and  several  forms 
of  apparatus  for  adding  liquid  chlorine  to  water  have  been  successful.  It  is  much 
easier  to  handle  the  liquid  chlorine  or  the  gas  from  it  than  to  handle  the  bleaching 
powder.    This  method  will  very  soon  replace  the  use  of  bleaching  powder. 

Investigations  by  Houston  ^^  in  London  have  shown  that  the  addition  of  lime  before 
storage  of  water  removes  the  bacteria  almost  completely.  Sperry  at  Qrand  Rapids 
and  Hoover  "  at  Columbus  have  shown  that  a  slight  excess  of  lime  when  used  as  a  pre  • 
dpitant  removes  the  bacteria,  serving  as  an  excellent  disinfectant.  For  the  disin- 
fection of  drinking  water  on  a  small  scale  potassium  permanganate,  bromine,  iodine, 
and  bleaching  powder  have  been  used.  Tablets  of  bleaching  powder  with  tablets  of 
sodium  thiosulfate  to  remove  the  excess  of  bleaching  powder  are  quite  satisfactory. 
In  brief  this  is  the  summary  of  chemical  methods  of  purifying  drinking  water. 

For  purifying  water  for  the  production  of  steam  and  for  manufacturing  processes  or 
"water  softening,''  lime  and  soda,  alone  or  in  combination  have  been  long  used, 
lime  is  used  for  the  removal  of  carbonates;  soda  for  the  removal  of  sulfates,  nitrates 
and  chlorides  of  calcium  and  magnesium.  Soda  may  be  replaced  by  other  sodium 
salts  BO  that  sodium  silicate,  sodium  phosphate,  sodium  hydroxide,  etc.,  are  used  in 
water  softening  and  boiler  compounds. 

A  new  method  for  softening  water  was  suggested  by  Crans.^'  It  had  been  known 
that  zeolites  would  soften  water  but  since  a  sufficient  quantity  of  the  natural  material 
could  not  be  obtained  Gans  prepared  an  artificial  zeolite  by  fusing  kaolin,  feldspar 
soda,  and  potash.  This  artificial  zeolite  called  by  the  trade  name  ''permutit,"  has  the 
power  of  removing  calcium  and  magnesium  from  a  hard  water,  delivering  a  water 

1  Ed  Imbeax  Wasser  n.  Abwasser,  7,  39.   (1015.) 

•  B.  Spftulding  Eng.  Mag.  45,  726.    (1913.) 

<  Q.  Brlwelii  Qesondh  lug.  36, 17.    (1013.) 

<  K.  Kisskalt  Oesumdh  log.  38, 195.    (1915.) 

•  F.  P.  Mann  Man.  J.,  82, 935.    (1912.) 

•  S.  T.  PoweU,  J.  Ind.  Eng.  Chem.  6, 050  (1914).    M.  W.  Franklin,  J.  Ind.  Eng.  Chem.  6, 959  (1914).    3. 
T.PoweU,  J.  N.  W.  W.  Assn.  29, 87  (1915). 

7  Ck>mpt.  Rend,  155,  852.    (1015.) 

•  ReckUnhauseo*  J.  Am.  W.  W.  Assn.,  1,  565.    (1914.) 
»  Longley,  J.  Am.  W.  W.  Assn.,  2,  679  (1915), 

10  Hooston,  8th  Research  Report  Metropolitan  Water  Board,  1912.   J.  Soc.  Chom.  Ind.,  31, 508.    (1012.) 
"  Hoover,  Eng.  Record  68,  257.    (1013.)    Sperry,  Mmi.  Eng.,  45,  343.    (1014.) 
><  Oans,  Chem.  Review,  Fett-Harc  Ind.,  16,  300  (1009).    Chem.  Ind.,  32, 197. 


224        FK0CEE1>INGS  SECOND  PAN   AMEBICAN   SCIENTIFIC  CONGRESS. 

with  zero  hardnees.  The  proceeB  is  well  adapted  to  soften  water  for  the  textile  indus- 
try, for  laundries,  etc.  Only  one  municipal  plant,  at  Hooten,  England,  has  beeu 
built.  As  yet  it  seems  too  expensive  for  municipal  water  supplies  but  very  probably 
efforts  will  be  made  to  lessen  construction  costs  so  that  it  can  be  made  available  for 
munidpalitieB. 

The  use  of  disinfectants  and  the  invention  of  permutit  are  the  most  important 
recent  improvements  in  water  purification.  Many  other  imiMrovements  of  minor  im- 
portance but  having  practical  value  have  been  recently  discovered.  Copper  sul&tte ' 
has  been  found  to  be  an  efficient  algsecide  and  is  widely  used  to  remove  al^ae  growths 
from  reservoirs.  Alum  has  been  made  from  sulfuric  acid  and  bauxite'  and  without 
refining  has  been  used  at  Columbus,  Ohio,  in  water  purification  with  a  great  reduction 
in  the  cost  of  purification.  In  Omaha  *  the  efficiency  of  filter  alum  is  said  to  be 
greatly  increased  by  passing  the  solution  of  alum  over  iron  filings  before  adding  it  to 
the  water  to  be  purified.  Analyses  of  chemicals  and  their  purchase  under  specifica- 
tions has  increased  the  efficiency  of  water  purification  plants. 

A  summary  of  this  pap^  on  Uie  "Significance  of  chemistry  in  water  purification" 
should  answer  the  question  often  asked:  What  does  water  chemistry  do? 

It  assists  in  and  supplements  bacteriological  tests. 

By  determining  the  mineral  content  of  a  water;  it  shows  the  therapeutic  character; 
it  shows  the  presence  or  absence  of  troublesome  metals,  iron  and  manganese;  it  shows 
the  presence  or  absence  of  poisonous  metals,  copper,  lead,  and  sine. 

It  controls  purification. 

It  formulates  standards  of  purity  and  improves  methods  of  purification. 

It  makes  filtration  of  turbid  water  possible. 

It  softens  water  for  many  purposes. 

Finally,  its  fundamental  purpose  is  to  furnish  and  conserve  pure  water  for  all 
purposes. 

The  Chairman.  You  have  heard  the  papers  on  "Water  Supply." 
I  would  like  to  ask  Prof.  Bartow  if  there  are  plants  in  this  country 
that  have  the  dual  water  supply,  such  as  they  have  in  some  Euro- 
pean cities  where  there  is  drinking-water  service  and  also  commercial- 
water  service. 

Dr.  Bartow.  Mr.  Chairman,  I  am  unable  to  answer  that  question. 
It  is  my  understanding  that  in  New  York  City  they  have  along  the 
water  front  hydrants  through  which  they  can  pump  water  for  fire 
protection. 

The  CHAiBBfAN.  I  mean  general,  throughout  the  city. 

Dr.  Bartow.  I  do  not  know  of  any  such  plant. 

Dr.  Sedgwick.  I  have  greatly  enjoyed  these  papers,  and  I  think 
that  Prof.  Bartow's  survey  of  the  situation  as  to  both  chemical  and 
bacterial  analysis  is  thoroughly  admirable  and  very  helpful.  I  re- 
member the  time,  however,  when  by  chemical  analysis  highly  pol- 
luted waters  were  allowed  to  be  drunk,  because  we  did  not  then  have 
the  notion  of  the  bacterial  content;  when,  for  instance,  the  Merrimac 
River  at  LoweU,  because  it  analyzed  well  chemically,  was  reputed 
to  be  good  for  drinking.  Of  course  that  is  many  years  ago,  but 
it  was  done  at  the  hands  of  excellent  chemists.     It  has  greatly 

>  ICooreand  KeUerman,  Bui.  64,  Bureau  of  Plant  Intl.,  U.  S.  Depl.  -Vgrlctiltnre. 
«  Hoovv^r,  Eug.  News,  72, 1239  (1914.) 
3  Jaoobson,  Eng.  Record,  71,  394  (1915). 


PUBLIC   HEALTH   AND  MEDICINE.  225 

strengthened  the  bacterial  side  to  be  able  to  bring  in  or  to  secure  the 
aid  of  the  chemists,  and  I  think  the  bacterial  side  in  its  turn  has  done 
something  for  the  chemists.  Certainly  no  bacteriologist  or  biologist 
would  ever  claim  that  his  science  is  anything  more  than  the  chemistry 
and  physics  of  living  matter,  and  biologists  and  bacteriologists  always 
rejoice  to  hear  of  the  progress  which  is  being  made  in  chemistry. 
We  know  what  the  water  survey  of  Illinois  has  done  to  help  us  in 
these  various  directions. 

One  point  in  Prof.  Jordan's  paper  interested  me  very  much,  and 
that  was  his  dealing  with  the  so-called  Mills-Reincke  phenomenon 
when  that  was  emphasized  some  years  ago  and  Hazen's  theorem  was 
formulated.  Some  of  you  may  not  know  what  these  things  were, 
but  the  gist  of  them  was  this,  that  for  every  death  from  typhoid 
fever  saved  by  the  purification  of  the  water  supply,  two  or  three 
deaths  from  other  diseases  were  likewise  saved,  and  this  numerical 
relation  was  named  Hazen's  theorem.  That  was  submitted  with  a 
good  deal  of  diffidence  by  the  authors,  who  said  that  it  seemed  to  be 
accounted  for  by  one  of  two  things:  Either  there  were  some  oigan- 
isms  capable  of  carrying  diseases  in  water  which  were  not  at  that 
time  recognized  as  thus  capable  (tubercidosis,  for  example),  or  eke 
that  the  vital  resistance  of  people  was  affected  unfavorably  by  pol- 
luted water.  Neither  explanation  seemed  then  wholly  satisfactory, 
but  the  former  has  some  support  to-day.  In  the  meantime  various 
critics  of  the  findings  have  arisen,  notably  Dr.  Chapin,  the  admirable 
authority  at  Providence,  who,  however,  is  always  skeptical  of  every- 
thing that  is  not  strictly  proved,  and  the  hardly  less  weU-known  Dr. 
Houston  in  chaige  of  the  London  water  supply.  There  appeared, 
however,  in  January  last — I  think  it  was — the  paper  by  Dr.  Dublin, 
which  was  referred  to  by  Prof.  Jordan,  in  which  the  experience  of  an 
insurance  company  with  typhoid  convalescents  was  recx)rded  with 
respect  to  their  susceptibility  to  other  diseases,  and  while  the  paper 
can  hardly,  perhaps,  be  considered  as  final  or  conclusive,  it  was  very 
interesting  as  far  as  it  went,  for  it  said,  as  Dr.  Jordan  stated,  that 
typhoid  recoveries  seem  to  be,  so  to  speak,  comparatively  temporary, 
dying  of  other  diseases  before  very  long,  or  at  least  before  others  in 
the  same  group  who  had  not  had  typhoid.  Col.  Woodruff,  the 
author  of  'Tropical  Life,"  who  has  studied  the  effects  of  tropical  life 
on  the  white  man,  was  also  very  much  interested  in  this  matter,  and 
he  had  figures  which  seemed  to  him  to  show  that  people  having  had 
typhoid  were  more  than  ordinarily  susceptible  to  tuberculosis,  etc* 

Dr.  George  A.  Sopbb.  With  respect  to  the  amount  of  protection 
afforded — ^referring  to  the  fact  stated  by  Prof.  Jordan  that  about  80 
per  cent  of  the  population  of  this  country  is  supplied  with  pure 
water — I  think  we  should  not  come  to  the  conclusion  that  the  pro* 
tection  against  typhoid  is  quite  as  great  as  the  figure  80  per  cent 


226       PROCEEDINGS  SECOVD  PAN  AMERICAN  SCIENTIFIC  OONQRESS. 

would  indicate.  We  must  know  more  of  the  20  per  cent  of  the 
unprotected  and  the  means  by  which  they  may  communicate  the 
disease. 

The  introduction  of  a  pure  water  supply  does  not  always  reduce 
the  typhoid  rate  so  much  as  is  expected.  We  have  an  instance  in 
the  city  of  Washington,  where  the  introduction  of  an  improvement 
in  the  existing  water  supply  was  expected  to  practically  eliminate 
typhoid  fever.  Very  much  to  our  surprise  there  was  littlei  if  any, 
reduction  in  typhoid. 

Throughout  several  cities  apparently  somewhat  similar  surprises 
have  resulted,  and  we  must,  I  believe,  recognize  that  diseases  which 
we  have  formerly  been  taught  to  regard  as  transmitted  chiefly  if  not 
exclusively,  through  water  are  also  transmitted  through  other  vehicles. 
It  has  witiiin  the  last  few  years  come  to  be  regarded  in  England  that 
contact  infection,  for  example,  in  typhoid  fever  plays  a  predominant, 
if  not  exclusive,  r61e  in  producing  high  death  rates  from  typhoid  fever. 

We  should  consider  these  matters  chiefly  from  the  standpoint  of 
the  latest  information  which  investigators  can  give.  Such  work  as 
the  United  States  PubUc  Health  Service  has  done  in  Washington 
should  by  all  means  be  reinforced,  indorsed,  and  the  proof  supple- 
mented, so  that  no  doubt  shall  remain  as  to  the  means  by  which 
these  so-called  water-borne  diseases  are  to  be  controlled. 

Dr.  KoBER.  It  may  be  of  interest  to  the  advocates  of  the  water- 
borne  theory  of  typhoid  fever  that  the  history  of  Washington  shows 
clearly  that  when  we  had  local  pump  supply  and  polluted  water 
supply  from  the  Potomac  River  there  was  an  ever-increasing  rate 
from  year  to  year.  In  1889  to  1890  we  had  a  typhoid  rate  of  104  per 
100,000  of  population.  It  was  during  that  year  that  I  dared  to 
assert  that  the  typhoid  (eveir  epidemic  at  Cumberland,  Md.,  would 
react  upon  our  typhoid  fever  rate.  My  suspicion  that  typhoid  fever 
germs  discharged  with  sewage  into  the  Potomac  River  at  Cumberland, 
a  distance  of  134  miles  away,  might  infect  consumers  of  Washington 
was  confirmed  by  studying  the  effects  of  the  Cumberland  epidemic 
upon  the  prevalence  of  the  disease  in  Washington.  The  records  of 
the  Health  Office  show  that  during  this  epidemic  from  December, 
1889,  to  April,  1890,  the  deaths  from  typhoid  fover  amounted  to  74 
as  compared  with  42  for  the  corresponding  months  of  the  previous 
year.  Indeed  we  had  almost  double  the  number  of  typhoid  deaths 
during  these  months  than  for  any  similar  perioH  either  before  or 
since  this  epidemic.  It  was  the  fact  of  caUing  attention  to  this 
coincident  event,  and  also  simultaneously  the  demonstration  made  by 
Dr.  Theobald  Smith  that  turbid  water  always  contained  a  large  num- 
ber of  colon  baciUi,  that  actually  aroused  an  interest  in  the  typhoid 
fever  situation  and  the  purification  of  the  water.  Steps  were  taken 
to  increase  the  storage  facihties  of  the  water  supply  of  Washington, 


PUBUO  HEALTH  AND  MEDICINE.  227 

X)^rmitting  of  longer  sedimentation;  city  pumps  and  box  priyies  were 
gradually  abandoned  and  with  these  improvements  there  was  a 
decided  reduction  from  year  to  year  in  the  prevalence  of  typhoid  fever. 

One  of  the  great  factors  before  filtration  was  actually  adopted  was 
the  installation  of  a  reservoir  which  permitted  longer  storage  for  our 
water;  and  everyone  familiar  with  the  subject  knows  that  sedimenta- 
tion alone  will  eliminate  about  87  per  cent  of  bacteria.  So  that  we 
really  had  a  marked  decrease  in  typhoid  fever  before  the  actual  com- 
pletion of  the  filtration  plant,  but  for  the  information  of  the  last 
speaker  I  will  say  that  it  is  a  very  different  thing  to  compare  a 
typhoid-fever  rate  of  104  per  100,000  of  population  in  1890  and  one 
of  about  15,  which  we  have  at  the  present  time.  I  feel  no  hesi- 
tation in  declaring  that  over  50  per  cent  of  all  the  typhoid-fever  cases 
in  this  city  before  the  completion  of  the  system  of  water  purification 
were  water  borne,  and  this  in  spite  of  the  fact  that  I  was  a  pioneer 
on  the  subject  of  milk-borne  typhoid  and  also  the  first  man  on  record 
in  this  country  to  direct  attention  in  1895  to  the  agency  of  flies  in 
the  transmission  of  typhoid  fever.  Those  who  are  interested  in  the 
subject  will  find  a  very  excellent  chart  prepared  by  me  in  Rosenau's 
recent  book  on  hygiene,  in  which  the  very  important  rdle  which  pol- 
luted waters  play  in  the  transmission  of  typhoid  fever  Ls  conclusively 
demonstrated. 

Dr.  Bartow.  Prof.  Sedgwick  has  spoken  of  the  water  which  was 
formerly  allowed  to  be  used  because  of  its  supposed  purity  after 
chemical  tests  were  made.  I  want  to  tell  of  one  which  was  con- 
demned because  of  the  chemical  tests,  although  it  was  bacteriologi- 
cally  pure.  The  central  part  of  Illinois  was  once  covered  by  glaciers. 
The  water  is  drawn  from  depths  of  150  to  200  feet  from  gravel  stratum 
that  contain  a  large  amount  of  nitrogenous  organic  matter. 

The  waters  are  imfit  for  drinking  purposes,  and  water  from  our 
wells  has  been  condemned  by  one  of  our  best  Illinois  authorities  on 
the  groimd  that  the  free  elements  were  too  high,  whereas  when  we 
analyzed  this  water  bacteriologically  it  was  practically  sterile. 

With  regard  to  the  reduction  of  typhoid  fever  by  the  introduction 
of  water  supply,  one  of  the  greatest  steps  in  this  direction  has  been 
the  introduction  of  a  filter  plant  at  Niagara  Falls.  The  typhoid  rate 
in  that  city  used  to  be  160  to  170  per  100,000.  After  the  introduc- 
tion of  that  plant,  the  typhoid  rate  dropped,  I  think,  to  15,  or  some- 
thing like  that,  and  one  can  hardly  conceive  what  improvement 
that  meant  in  the  conditions  all  over  the  country,  as  so  many  people 
visit  Niagara  Falls. 

The  Chaikman.  If  there  is  no  further  discussion  of  the  papers  we 
have  heard,  the  next  on  the  program  is  that  of  Dr.  Allan  J.  McLaugh- 
Kn,  United  States  Public  Health  Service,  on  the  subject  of  "  The 
control  of  Asiatic  cholera  along  int'emational  trade  routes.'' 

6843e— 17— VOL  X 16 


228       PBOOEEDINOS  SECOND  PAN  AMERICAN  8CIBNTIFI0  G0NQRB88. 

THE  CONTROL  OF  ASUTIC  0HOLER4  ON  INTERNATIONAL  TRADE 

ROUTES. 

By  ALLAN  J!  McLAUGHLIN, 
DhiUd  8tate$  Public  EeaUh  Service,  Commitiionir  of  Hecdtk,  MaeaadhueiU. 

General  principles  of  control  of  Atdatic  cholera  on  international  trade  routes  are 
the  same  for  overland  travel  as  for  travel  by  sea.  These  principles  demand  the 
restriction  of  travel  to  certain  definite  routes  which  pass,  at  the  frontier  or  on  the  sea 
coast,  through  well-equipped  modem  quarantine  plants. 

LAND  ROUTBS. 

An  international  trade  route  overland  may  involve  several  kinds  of  transportation, 
and  the  character  of  the  transportation  is  a  matter  of  vital  importance  in  the  spread 
of  Asiatic  cholera.  Asiatic  cholera  spreads  as  &st  as  man  can  travel,  so  that  it  can 
not  spread  as  fast  along  a  caravan  route  as  along  an  international  railroad  line. 

THB   ESTABLISHMENT  OP  FRONTIER  QUARANTINE   STATIOITS. 

When  a  country  is  menaced  by  Asiatic  cholera  on  its  land  frontier,  whether  the 
routes  over  this  frontier  are  caravan  routes,  ordinary  roads,  or  railway  lines,  passage 
of  the  frrontier  must  be  prevented,  except  at  certain  specified  quarantine  stations. 
In  the  interests  of  commerce  and  passenger  traffic,  these  stations  should  be  established 
on  all  important  points  through  which  passenger  or  freight  traffic  ordinarily  crosses 
the  frontier. 

These  quarantine  stations  or  detention  camps  on  a  frontier  should  not  be  essen- 
tially different  from  the  r^^ular  maritime  quarantine  stations  which  are  used  to  pro- 
tect against  Asiatic  cholera  carried  along  sea  routes,  and  for  that  reason  the  same  type 
of  quarantine  station  will  serve  for  either  land  or  wat^  quarantine. 

WATER  ROUTES. 

Lanes  of  ocean  travel  are  almost  as  definite  as  roads  for  land  travel,  and  great  steam- 
ship lines  run  on  a  schedule  with  the  regularity  of  railway  trains.  These  great  steam- 
ship companies  use  regular  terminals  in  the  large  seaports,  and  their  control  is  no 
more  difficult  than  that  of  regular  train  traffic  on  land.  There  are  in  addition  tramp 
steamers  and  sailing  vessds.  These  present  less  difficulty  than  irregular  traffic  across 
a  land  frontier.  Similarly,  water  routes  by  river  or  canal  ai^  controlled  by  a  quaran- 
tine station  at  the  frontier. 

Just  as  in  the  case  of  land  frontiers,  the  seaboard  of  a  country  may  be  closed  except 
certain  specified  ports,  provided  with  proper  quarantine  stations,  through  which  all 
traffic  must  pass.  In  the  interest  of  commerce  this  list  of  open  ports  should  include 
all  important  ports,  and  as  many  smaller  ports  at  which  quarantine  stations  can  be 
maintained  at  a  cost  commensurate  with  the  importance  of  the  port. 

THE  ESSENTIALS  OF  SUCCESSFUL  QUARANTINB. 

The  essentials  of  successful  quarantine  are  the  same  on  land  and  sea,  and  include: 

1.  Accurate  information  and  delimitation  of  the  infected  territory. 

2.  Efficient  frudlities  and  personnel  for  inspection  at  the  seaports  or  points  on 
frontiers  where  important  roads  or  water  routes  cross  the  frontier. 

3.  Modem  quarantine  stations. 

It  is  not  possible  within  the  limits  of  this  paper  to  discuss  all  the  details  of  these 
essentials.  I  will  omit  discussion  concerning  the  very  interesting  and  sometimes 
devious  methods  by  which  information  is  secured,  and  of  the  problematical  value 


PUBLIC  HEALTH  AND  MEDICINE.  229 

of  60-called  official  information.  I  shall  be  obliged  also,  because  of  lack  of  space,  to 
omit  detailed  description  of  what  constitutes  an  efficient  equipment  and  personnel 
of  an  inspection  service,  and  of  a  modem  quarantine  station. 

I  should  like  to  accentuate  the  necessity  of  giving  the  menaced  country  the  benefit 
of  the  doubt  in  attempting  to  delimit  the  infected  zone  in  a  neighboring  country, 
and  to  bring  out  certain  important  changes  of  technique  and  procedure  in  the  handling 
of  an  Asiatic  cholera  quarantine. 

DBLDCrTATION   OF  INFBCTBD  TBRSFTORY. 

The  delimitation  of  infected  territory  is  of  the  utmost  importance,  but  it  is  often 
extaremely  difficult  to  secure  accurate  information  of  the  exacta  rea  which  may  be 
dMsed  as  infected.  It  is  a  very  dangerous  procedure  to  assume  that  certain  portions 
of  a  country  are  cholera  free,  unless  a  representative  of  the  menaced  nation  is  on  the 
•pot,  whose  investigations  are  unhampered,  and  whose  reports  are  uncensored.  In 
1905,  for  example,  it  was  claimed  that  n<Hrthem  Russia  was  free  from  Asiatic  cholera, 
while  southern  Russia  was  infected.  The  writer  was  on  duty  in  Hamburg,  Germany, 
at  the  time  and  recommended  that  all  Russia  be  considered  infected,  in  view  of  the 
fact  that  all  trains  crossing  the  German  border  must  pass  through  infected  territory 
either  in  Poland  or  the  valley  of  the  Vistula,  and  that  owing  to  internal  disturbances 
in  Russia,  the  Russians  themselves  were  unable  to  delimit  accurately  the  infected  area. 
This  was  the  attitude  of  the  German  Imperial  Health  Office,  and  the  United  States 
sustained  its  representative,  ordering  that  all  Russians  be  detained  in  quarantine 
under  observation  in  German  ports,  before  embarking  for  United  States  ports. 

On  the  other  hand,  in  Germany,  because  of  unhamper(>d  investigation  and  ready 
access  to  accurate  information,  and  also  the  uncensored  us  3  of  the  cable,  it  was  possible 
to  delimit  the  infected  area  and  to  rpmove  restrictions  from  a  huge  part  of  the  empire. 
While  the  importance  of  exact  delimitation  in  avoiding  undue  restriction  can  not  be 
overestimated,  it  is  nevertheless  wise  to  err  on  the  side  of  safety,  and  a  country  menaced 
by  Asiatic  cholera  is  justified  in  imposing  its  quarantine  restrictions  upon  suspected, 
ae  well  as  infected,  territory. 

PERIOD  OF  DBTBNTION  IN   QUARANTINE. 

Formerly  cholera  quarantine  detention  was  at  least  five  days,  and  this  period  of  five 
days  under  observation  was  considered  a  sufficient  guaranty  for  safe  discharge  from 
quarantine,  provided  no  signs  of  illness  developed.  In  the  Philippines,  in  1908  and 
1909,  the  writer,  as  a  requirement  for  disduuge  of  contacts  from  quarantine,  substi- 
luted  a  negative  examination  of  the  intestinal  discharges  for  the  ordinary  five-day 
detention  period. 

In  October,  1910,  the  writer  recommended  to  the  Suigeon  (General  that  the  intestinal 
dischaiges  of  all  arrivals  at  United  States  ports  from  territory  infected  of  suspected  of 
being  infected  with  Asiatic  cholera,  should  be  examined  bacteriologically,  and  that 
discharge  from  quarantine  be  made  only  after  a  negative  result  of  the  stools  examina- 
tion. On  July  19,  1911,  the  Secretaiy  of  the  Treasury  promulgated  a  regulation 
providing  for  this  additional  safeguard. 

The  demonstration  of  carriers  who  discharged  vibrios  In  their  stools  for  weeks,  and 
even  months,  showed  that  no  mere  arbitrary  detention  alone  could  prevent  their 
passage  through  quarantine. 

Rapid  methods  of  technique  and  an  efficient  system  of  collecting  samples  and 
handling  the  specimens  make  it  possible  for  each  bacteriologist  to  examine  100  to 
ISO  stools  per  day. 

This  important  advance  in  our  methods  of  Asiatic  cholera  quarantine  not  only  gives 
us  an  additional  safeguard  in  preventing  the  entrance  of  vibrio  carriers,  but  makes 
ponible  the  shortening  of  the  period  of  detention  from  five  days  to  two  or  three  days. 


230       PROCEKDINGS  SECOND  PAN   AMXJEUGAX   SCIENTIFIC   CONGRESS. 

TECHNIQUE   OF   BACTEBIOLOGIC   BXAMINATIOV   OP  STOOLS  ON   A   TiARQB   SCALE   AT 

QUARANTIME  STATIONS. 

In  conBidering  the  problem  of  a  fvioob  examiiuttion  on  a  large  scale,  two  facton  must 
be  given  tbeir  proper  weight: 

1.  Proper  protection  of  the  public. 

2.  Minimum  restriction  of  commerce  consistent  with  No.  1. 

If  we  could  take  unlimited  time  in  the  matter  we  would  use  every  procedure  known 
for  the  detection  of  the  cholera  vibrio,  and  would  probably  detain  the  suspects  in 
quarantine  many  days  or  weeks,  but  as  quarantine  officers,  we  are  charged  by  law  wiih 
carrying  out  the  quarantine  fsguktienB,  and  especially  instructed  to  carry  them  out 
with  the  minimum  restriction  of  commerce.  This  noosssitatas  the  elimination  ol 
hanging  drop  or  other  dow  technical  procedurss,  dioleim  red  rsactions,  use  olgehUiAe 
media,  and  many  other  tests  whidi  are  inteiesting,  but  not  necessary  for  eholeta 
diagnosis  and  only  serve  to  increase  the  time  of  the  examination. 

SECURING  THE  SPBCDfEN. 

The  specimen  is  best  secured  by  the  administraticm  of  a  saline,  and  magnesinm 
tjulphate  serves  very  well.  It  is  best  administered  on  an  empty  stomach  about  6  a.  m. 
Suspects  with  diarrhea  and  children  may  be  exempted,  and  a  good  specimen  may  be 
obt^ned  from  these  by  passing  a  laige  catheter  or  rectal  tube  with  several  ''eyes*' 
<'ut  in  the  upper  end .  In  withdrawing  the  tube  the  "eye  "  scrapes  mucus  off  the  lining 
of  the  bowel  and  furnishes  a  very  good  specimen.  The  use  of  swabs  is  not  recom- 
mended, as  a  good  specimen  is  diffictilt  to  obtain  if  the  suspect  is  constipated.  The 
Hwab  has  a  great  deal  of  the  material  scraped  off  by  the  tight  sphincters  and  further 
may  cause  considerable  pain  and  injury,  especially  when  hemorrhoids  are  present. 
Dr.  Serrati,  the  Italian  royal  commissioner  at  New  York,  suggested  that  the  swabs  be 
ahuathed  in  glass  tubes.  The  tube  protects  the  swab  in  passing  the  sphincters  and  is 
also  lees  painful  in  passing. 

DISPOSAL  OF  THE   STOOLS   AFTER  PLANTING. 

The  specimen  should  be  passed  in  a  paper  sanitary  cuspidor  or  similar  receptacle 
which  is  cheap  and  may  be  burned.  After  planting  in  peptone  the  stool  and  con- 
tainer is  dropped  in  a  flour  barrel.  When  the  barrel  is  full  or  the  samples  all  taken 
the  cover  is  placed  and  the  barrel  with  its  contents  burned. 

The  specimens  are  planted  in  peptone  by  means  of  sterile  pieces  of  wood  (an  ordi- 
nary wooden  tongue  depressor  split  in  three  serves  very  well) .  This  obviates  the  neces- 
sity of  sterilizing  a  platinum  loop  or  other  metal  instrument  and  saves  much  time. 
After  planting,  the  stick  is  destroyed  with  the  specimen  in  the  barrel. 

PLANTING  AND  RBCORDINO  THE  SPBCDIENS. 

The  suspects  are  divided  into  groups  of  150  to  200,  each  group  designated  by  differ- 
ent-colored tags.  The  plants  are  made  on  a  table  convenient  to  the  latrines.  The 
specimens  are  brought  to  the  bacteriologists  at  the  tables  by  the  male  suspects  them- 
selves, under  the  supervision  of  orderlies  or  male  nurses.  The  specimois  from  the 
women  and  children  are  taken  by  trained  female  nurses  and  brought  to  the  tables. 
At  each  table  there  is,  besides  the  bacteriologist,  a  clerk,  who  records  the  name  of  the 
suspect  in  a  book  and  gives  him  a  number  in  consecutive  order.  This  number  goes 
on  the  suspect's  colored  tag  and  also  on  the  peptone  tube,  which  has  been  inoculated. 
The  amount  of  material  for  each  peptone  tube  should  be  about  equal  to  two  or  three 
large  loops.  After  inoculation  the  tubes  should  not  be  agitated,  ^id  agitation  should 
be  avoided  until  the  smears  are  made  after  incubation. 

INOXJBATION. 

The  best  temperature  for  incubation  is  from  35^  to  37^  0.,  and  the  tubes  should  be 
incubated  about  six  hours.  If  it  is  not  possible  to  examine  before  eight  hours,  soeond 
peptone  subculturea  should  be  made. 


I^UBUO  HEALTH  AND  MEDICINE.  231 

UAKTHQ  SM8AR0  AND  0TAININO. 

To  make  a  satiBfactory  smear  from  a  peptone  culture  is  not  easy.  Four  or  five  large 
loops  from  tiie  surface  (but  avoiding  the  pellicle)  are  placed  in  the  center  of  a  clean 
alidey  and  without  much  spreading  dried  slowly  and  fixed  by  heat.  This  gives  more 
concentration  and  more  organisms  in  a  field  than  if  one  drop  was  spread  upon  a  slide. 
The  stain  should  be  carbol-fuchsin  1  part  diluted  by  the  addition  of  9  parts  of  water.  ^ 
Stain  about  one  minute,  wash  carefully,  and  examine.  It  is  convenient  to  have  the 
numbers  cut  on  the  slides  with  a  diamond,  numbering  the  slides  consecutively,  in 
lots  of  50,  as  the  peptcme  cultures  come  in  in  racks  of  50.  The  slides  corresponding 
to  the  numbers  on  the  tubes  were  selected  and  used. 

BXAMm ATIONS  OV  TAB  0MEA1W. 

This  is  the  most  important  step  in  the  teclmic.  If  carelessly  done,  the  whole 
examination  is  valueless.  If  properly  done,  SO  to  90  per  cent  of  the  specimens  may 
be  rejected  without  plating.  The  observer  must  search,  using  a  mechanical  stage, 
kom  25  to  50  fields,  and  if  he  finds  no  suspicious  curved  organisms,  the  specimen  is 
marked  *  'negative.  ^*  If  he  finds  curved  organisms,  a  subculture  in  peptone  and  plates 
aie  made.  To  be  able  to  do  this  requires  acute  vision,  and  a  knowledge  of  vibrios  and 
other  curved  forms.  The  observer  at  first  finds  curved  organisms  in  nearly  every  speci- 
men, but  after  plating  these  out  he  finds  that  many  are  not  vibrios  at  all.  At  first 
the  beginner  will  plate  out  about  four-fifths  of  his  specimens.  After  training  and  the 
csperience  gained  by  studying  his  plates,  ho  will  not  find  it  necessary  to  plate  more 
than  10  per  cent.  The  differentiation  of  what  seem  to  be  curved  organisms  and  vibrios 
ean  only  be  learned  by  actual  experience,  and  safety  at  first  lies  in  plating  all  the 
4««btful  ones. 

PLATB8. 

The  |>l»te8  dumld  be  ordinary  nutrient  agar  (2  to  3  per  cent)  neutral  to  phenol- 
fhthalein,  the  attrlace  dried  an  hour  in  the  thermostat  at  37®  0.,  or  one  may  use  plates 
more  than  24  hours  old.    The  plates  should  be  examined  after  about  16  hours. 

AGGLUTINATION  TESTS. 

The  colonies  which  have  the  charactenstict  of  the  cholera  colonies  may  be  fished 
direct  to  drops  of  1  to  200  specific  cholera  serum  on  a  clean  glass  slide,  carefully  mark- 
ing tile  colony  on  the  piste.  Or  a  smear  may  be  made  from  the  colony,  stained,  and 
eamnined.  In  any  event,  the  colony,  if  a  vibrio,  must  be  fished  to  an  agar  slant  grown 
18  hours  and  a  quantitative  agglutination  made,  using  a  serum  of  a  titer  of  at  least 
1:4000  in  dilutions  ranging  from  1:50  to  1:1000.  Dilution  1:1000  should  be  positive 
beyond  question  after  one  hour  in  the  incubator  at  37®  0.;  1:200  should  give  an  in- 
stantaneous agglutination.  The  agglutination  test  should  be  controlled  by  test  with 
a  known  cholera  vibrio  and  with  dilutions  of  normal  serum  and  salt  solution. 

The  rapid  test  on  the  slide  with  an  instantaneous  reaction  in  a  dilution  of  1:200  may 
be  c<»npleted  by  drying,  fixing,  and  staining  the  clumps  in  situ.  Under  a  low  power 
the  clumps  will  show  very  well,  and  the  higher-power  lenses  will  show  the  character- 
istic morphology. 

mPBOVBMBNT  IN  MBDIA. 

One  other  advance  in  our  methods  of  handling  Asiatic  cholera  suspects  has  been 
made  by  Qoldbeiger,*  which  promises  to  increase  our  efficiency  in  detecting  Asiatic 
cholera  carriers  when  making  stool  examinations  on  a  large  scale. 

There  has  been  no  great  change  in  the  bacteriologic  methods  of  Asiatic' cholera 
diagnosis  in  the  past  10  years,  and  these  methods  are  based  upon  the  procedure  of 
tile  German  Imperial  Heftlth  Office. 

•  Ooldberger,  Joseph,  Some  ww  cholera  selective  media.    Hygienic  Laboratory,  Bulletin  No.  M,  Wash- 
i]«ton.  1914. 


232       PBOGEEDINGS  SECOND  PAN  AMEBIOAN  BdENTIFIC  C0NQRE88. 

As  a  time-saving  measure,  test  tubes  are  used  instead  of  large  flasks  for  the  peptone 
solution.  This  necessitates  that  the  amount  of  feces  added  to  the  tube  must  be  small, 
and  if  the  vibrios  are  very  scarce  a  carrier  might  be  recorded  as  negative.  Large 
flasks  and  many  platings  are  impracticable  on  a  large  scale  where  the  daily  examina- 
tions may  run  in  thousands.  Goldberger's  media  permits  the  planting  of  relatively 
laige  quantities  of  feces,  using  the  same  convenient  size  of  test  tubes. 

Goldberger  suggests  two  enriching  solutions,  an  alkaline  egg  peptone  and  an  alkaline 
meat  infusion  peptone.  The  cholera  vibrio  grews  well  in  both  solutions,  though  less 
luxuriantly  than  in  ordinary  cholera  peptone.  The  multiplication  of  the  ordinary 
fecal  bacteria  is  markedly  restrained,  especially  the  colon  bacillus.  Goldbeiger'a 
work  shows  that  in  his  media  the  vibrios,  if  present  even  in  small  numbers,  will 
increase  and  not  be  oveigrown,  even  after  72  hours.  Goldberger's  media  was  de* 
vised  after  a  careful  study  and  test  of  the  various  selective  media  suggested  by 
Dieudonn6,  Newfeld  and  Woithe,  Esch,  Pilon,  Crenderopoulo  and  Panayotatoa, 
Krumwiede,  Pratt  and  Grund,  Hoffmann  and  Kutscher,  Moldavan,  and  others. 

The  addition  of  Goldberger's  media  to  our  equipment  should  make  the  passage  of  an 
Aaatic  cholera  carrier  through  our  quarantines  still  more  imlikely.  It  is  true  that 
this  media  has  not  yet  been  tested  in  actual  field  work,  but  the  laboratory  tests  suggest 
that  it  is  the  most  valauble  addition  to  our  cholera  technique  which  has  been  made  in 
recent  years. 

CONCLUSIONS. 

1.  The  spread  of  Asiatic  cholera  in  international  traffic  is  largely  a  question  of  tiie 
travel  of  cholera  carriers. 

2.  Frank  cases  of  cholera  present  no  difllculty  in  diagnosis,  can  not  travel  fast  or  ter 
without  detection,  and  consequently  should  be  considered  a  lesser  menace  by  the 
quarantine  officer  than  the  carrier  without  symptoms. 

3.  An  arbitrary  period  of  detention  in  days  is  not  a  sufficient  safeguard  per.se  but 
should  cmly  serve  as  an  opportunity  for  detecting  cholera  in  the  intestinal  contenta 
of  the  suspects. 

4.  Model  quarantine  stations  upon  all  trade  routes  by  land  or  sea,  where  they  cross 
the  frontier  or  at  their  seaport  terminals,  are  a  necessity,  and  in  times  of  danger  all 
travel  from  infected  territory  should  be  restricted  to  routes  thus  equipped  and  con- 
trolled. 

5.  The  most  important  feature  of  a  model  quarantine  staticm  should  be  the  laboratory 
equipped  to  examine  and  report  on  not  less  than  100  stools  per  day  for  each 
bacteriologist. 

The  Chaibman.  Dr.  C.-E.  A.  Wiuslow,  Yale  Univei-sity,  New 
Haven,  Conn.,  will  now  present  a  paper  on  '*  Fresh  air  and  ventilation 
in  the  light  of  modem  research.^' 


FRESH  AIR  AND  VENTILATION  IN  THE  UGHT  OF  MODERN  RESEARCH 

By  C.-E.  A.  WINSLOW. 

Anna  M.  R.  fMuder  Professor  of  Public  Healthy    Yale  Medical  School^  and  chairman. 

New  York  State  Commission  on  Ventilation. 

The  problems  of  ventilation  might  at  first  sight  appear  to  be  of  so  universal  a  nature 
as  to  have  but  little  place  in  the  program  of  a  conference  laigely  devoted  to  the  com- 
parative problems  of  tho  different  countries  on  our  hemisphere.  Normal  air  has 
indeed  the  same  percentage  chemical  composition  wherever  we  may  sample  it. 


PUBUO  HBALTH  AND  MEDICIKB.  233 

JUtltode,  however,  strikingly  affects  physiological  reactions  by  its  influence  on  par- 
tial pressure;  and  the  extension  of  our  conception  of  air  conditioning  to  include  a 
consideration  of  the  physical  effects  of  the  atmoq>here  upon  the  body  brings  the  whole 
question  of  tomperature  and  humidity  and  climate  within  its  scope. 

The  evil  effects  of  bad  air  conditions  are  obvious  and  clearly  recognized.  In  a 
crowded,  ill-ventilated  room  we  experience  a  feeling  of  dullness,  deepiness,  and  under 
more  extreme  conditions  perhaps  nausea,  and  even  faintness;  and  there  are  several 
classic  instances  in  which  conditions  of  the  atmosphere  have  become  so  extreme  as  to 
result  fatally.  The  most  famous  of  these  examples  is  the  Black  Hole  of  Calcutta, 
which  Prof.  Lee,  of  Columbia  University,  has  described  in  the  following  sentences: 

On  one  of  the  hottest  of  the  hot  nights  of  British  India,  a  little  more  than  150  years 
ago,  Siraj-Uddaula,  a  youthful  merciless  ruler  of  Bengal,  caused  to  be  confined  within 
a  small  cell  in  Fort  William  146  Englishmen  whom  he  had  that  day  captured  in  a  siege 
of  the  city  of  Calcutta.  The  room  was  large  enough  to  house  comfortably  but  two 
persons.  Its  heavy  door  was  bolted;  its  walls  were  pierced  by  two  windows  barred 
with  iron,  through  which  little  air  could  enter.  The  night  slowly  passed  away,  and 
with  the  advent  of  the  morning  death  had  come  to  all  but  a  score  of  the  luckless  com- 
panv.  A  survivor  has  left  an  account  of  horrible  happening  within  the  dun(<eon,  of 
terrible  strugglings  of  a  steaming  mass  of  sentient  human  bodies  for  the  insufficient  air. 
Within  a  few  minutes  after  entrance  every  man  was  bathed  in  a  wet  perspiration  and 
was  searohing  for  wavs  to  escape  from  the  stifling  heat.  Clothing  was  soon  stripped  off. 
Breathing  became  difficult.  «rhere  were  vain  onslaughts  on  the  windows:  there  were 
vain  efforts  to  force  the  door.  Thirst  grew  intolerable,  and  there  were  ravings  for  the 
water  which  the  guards  passed  in  between  the  bars,  not  from  feelings  of  mercy,  but 
only  to  witness  in  ghoulish  glee  the  added  struggles  for  impossible  relief.  Ungovern- 
able confusion  and  turmoil  and  riot  soon  reigned.  Men  became  delirious.  If  any 
found  sufficient  room  to  fall  to  the  floor,  it  was  only  to  fall  to  their  deatii,  for  they  were 
trampled  upon,  crushed,  and  buried  beneath  the  fiercely  desperate  wave  of  frenzied 
humanity  above.  The  strougest  sought  death,  some  by  ]>raying  for  the  hastening  of 
the  end ;  some  by  heaping  insults  upon  the  guards  to  try  to  induce  them  to  shoot.  But 
all  efforts  for  relief  were  in  vain,  until  at  last  bodily  and  mental  agony  was  followed  by 
stupor.  This  tragedy  of  the  Black  Hole  of  Calcutta  will  ever  remain  as  the  most 
drastic  demonstratioin  in  human  history  of  the  bondage  of  man  to  the  air  that  surrounds 
him* 

On  the  other  hand,  the  beneficial  effects  of  good  air  are  equally  susceptible  of  demon- 
stration. Dr.  Edwud  Trudeau,  who  died  November  15  last,  went  to  Sarsnac  in  1878 
as  a  hopeless  victim  of  consumption.  All  his  friends  were  filled  with  horror  at  the  idea 
of  his  going  practically  alone  to  die,  as  they  believed,  in  the  Adirondack  wilderness, 
in  a  little  town  consisting  of  little  more  than  a  sawmill  and  half  a  doeen  cabins,  42 
miles  from  a  railroad.  Dr.  Trudeau  did  not  die  during  the  winter  of  1873,  but  grew 
very  much  better;  and  some  10  years  later,  as  a  result  of  his  experience,  he  founded 
the  Adirondack  Oottage  Sanatorium,  which  in  its  primitive  form  consisted  of  a  single 
house  in  which,  with  great  difficulty,  he  persuaded  two  consumptive  patients  to  live. 
That  was  the  beginning  of  the  demonstration  in  this  country  of  the  fresh-air  treatment 
of  tuberculosis,  which  Brehmer  and  others  had  introduced  on  the  other  side  of  the 
water.  To4ay  we  are  going  through  a  reaction  against  the  more  extreme  applications 
of  very  cold  air  to  sick  people  and  to  intots;  but  the  general  value  of  fresh  air,  if  not 
too  cold,  and  except  in  certain  diseases,  has  been  amply  demonstrated. 

What  are  the  factors  to  which  these  evil  effects  of  bad  air  and  these  boieficial  effects 
of  good  air  are  due? 

The  air  is  inade  up  of  78.1  per  cent  nitrogen,  20.9  per  cent  oxygen,  and  0.9  per  cent 
aigon,  with  0.03  per  cent  cari)on  dioxide,  and  traces  of  other  gases.  It  usually  contains, 
in  addition  to  these  gaseous  elements,  a  certain  amount  of  finely  divided  solid  matter 
in  the  form  of  dust  particles.  Analyses  made  undor  my  direction  during  the  past 
summer  have  shown  this  dust  to  be  present  to  the  amount  of  something  less  than  one- 
tenth  gram  per  million  liters  of  air,  or  5,000  dust  particles  per  liter,  in  the  air  of  New 
York  City  on  a  clear  day.  At  the  other  extreme  we  found  22 .2  grams  per  million  liters, 
or  250,000  dust  particles  per  liter,  in  a  mattress  factory,  and  still  luger  weights  in  a 


234       PBOGEKDINOS  SECOND  PAK  AMBRIGAN  8CIEKTIFI0  C0KQRE88. 

starch  foctory.    BacterUarapresentinofdinaryairtotlieBtimbOTof  1  to4p6rlit«r>- 
in  very  small  numbera  as  a  rule. 

Five  different  changes  take  place  in  this  normal  atmosphere  when  human  beings 
occupy  a  confined  space. 

1.  The  oxygen  is  reduced  by  respiration.  Tigerstedt  estimates  the  amount  of  oxy- 
gen absorbed  by  a  man  ci  average  weight  at  rest  as  764  grams,  or  634  Uters  per  24  hours. 

2.  The  carbon  dioxide  is  increased  by  the  same  process.  The  oxygen  consumption 
cited  above  with  a  respiratory  quotioit  of  0.80  would  equal  840  grams,  or  427  litecs 
per  24  hours. 

3.  There  is  given  off  into  the  air  a  greater  or  less  amount  of  oiganic  matter,  which 
is  perceived  by  us  as  odors--material  given  off  not  from  the  lungs  to  any  extent  but 
from  the  mouth,  from  the  teeth,  ddn,  and  clothing. 

4.  The  temperature  of  the  air  is  raised  by  the  heat  given  off  in  the  process  of  metab- 
olism. The  number  of  calories  produced  in  24  hours  corresponding  to  the  oxygen 
consumption  ol  634  liters  cited  above  would  be  2,563.2  cabries.  About  four-fiftha  of 
this,  say  2,000  calories,  is  given  off  from  the  sidn.  Ludc  and  his  associates  have 
recently  diown  that  the  heat  production  bears  a  direct  and  close  rehition  to  the  super- 
ficial area  of  the  body  and  amounts  for  a  resting  individual  to  953  calories  in  24  hours 
per  square  meter  of  body  surface  (corresponding  to  an  oxygen  consumption  of  108 
liters  per  square  meter  ol  body  surface).  # 

5.  The  humidity  of  the  air  is  increased  by  the  moisture  given  eff  in  the  breath  and 
from  the  skin .  The  amount  of  moisture  evaporated  has  been  estimated  as  in  the  neigh- 
boBlioodofl,400grams  in  24  hours  Turanian  at  rest.  All  of  these  values  may  be  greatly 
increased  by  active  exertion,  and  the  amount  of  water  given  off  in  particular  iatadi- 
oally  altered  by  the  heat  and  humidity  of  the  sunroonding  atmosphere. 

In  seeking  among  these  various  changes  for  the  cause  of  the  physiological  effects 
of  vitiated  air  it  was  perhaps  natural  that  the  mind  should  turn  to  lack  of  oxygen  as 
of  prime  importance.  When  a  mouse  is  confined  under  a  bell  jar,  it  dies  from  oxygen 
i9tarvation,  and  it  was  at  first  aasmned  that  the  same  thing  happens  to  a  less  degiee 
in  a  badly  ventilated  room.  As  a  matter  of  fact  men  do  sometimes  die  from  iMk 
of  oxygen  in  ckgged  sewer  manholes  (althoui^  poisoning  by  carbon  monoxide  is 
dten  at  fault  in  such  cases)  or  in  the  low  parts  of  mines. 

In  such  rooms  as  are  ordinarily  used  for  human  occupancy,  however,  the  changes 
in  oxygen  and  carbon  dioxide,  even  with  the  worst  ventilation,  are  found  to  be  com- 
parativ^y  slight.  The  oocygen  may  fall  from  21  per  cent  to  20  per  cent^  and  the 
carbon  dioxide  may  rise  from  0.03  to  one-half  per  cent;  greater  changes  than  this  are 
not  observed  even  in  the  most  crowded  and  worst  ventilated  room  on  account  of  the 
leakage  through  walls  and  ceiling  and  cracks  of  all  aorta.  These  values  are  very  te 
from  the  vahies  which  are  found  to  produce  harmful  physiokgical  effects.  In 
mines  the  oxy;gen  is  often  deliberatdy  kept  down  to  17  per  cent  or  less  in  the  hope 
of  avoiding  the  dust  expkoione  that  are  likely  to  follow  in  freely  ventilated  mines 
during  cold  weather. 

Some  of  the  most  interestiDg  work  along  this  Une  has  been  that  in  regard  to  the  phe- 
nomena of  mountain  sickness.  My  colleague.  Prof.  Hendersonf  with  the  English 
I^ysioIogistB  Douglas  and  Haldane,  made  a  most  important  series  of  studies  of  thi» 
kind  on  Pikes  Peak  two  or  three  years  ago.  On  Pikes  Peak  the  partial  pressure  of 
Cfsjg&n  present  corresponds  to  about  13  per  cent  at  ordinary  atmosph^c  pressitfe. 
Under  these  omditions  there  are  distinct  symptoms  of  mountain  sickness,  blueness  of 
lips  and  face,  loss  of  appetite,  nausea  and  vomiting,  intestinal  disturbances,  headache, 
fainting,  periodic  breathing,  and  great  difficulty  in  getting  breath  on  exertion.  But 
even  here,  with  only  13  per  cent  of  oxygen,  after  a  few  days  the  symptoms  b^gan  to 
lessen,  and  after  a  few  weeks  of  acclimatisation  the  extreme  conditions  disappeared, 
although  periodic  breathing  was  still  occaskmally  observed,  and  lips  became  blue  on 
vigorous  exertion.    The  investigators  found  that  at  least  three  th^igs  had  happened 


PUBLIC   HEALTH  AND  MBDICINE.  236 

in  this  adaptation.  In  the  first  place  the  cells  liDin^  the  alveoli  of  the  lungs  had 
acquired  the  power  of  secreting  oxygen  one  way  and  carbon  dioxide  the  other  more 
vigorously  for  the  same  gaseous  pressure  than  they  would  under  (vrdinary  conditions. 
In  the  second  place  the  alkalinity  of  the  blood  had  changed  so  as  to  stimulate  the 
respiratory  center  with  a  less  amount  of  carbon  dioxide.  And  finally  the  hemoglobin 
had  increased  so  as  to  supply  the  tissues  more  readily  with  the  needed  oxygen. 

Many  people  live  active  and  vigorous  lives  under  such  conditions  as  this.  In  the 
great  city  of  Potosi,  in  the  Andes,  for  instance,  the  partial  pressure  of  oxygen  is  very 
close  to  that  at  Pikes  Peak,  and  many  famous  health  resorts  at  an  altitude  of  5,000  feet 
have  a  lower  partial  pressure  of  oxjrgen  than  obtains  in  the  most  crowded  room. 

Much  the  same  thing  is  true  in  respect  to  carbon  dioxide .  Carbon  dioxide  may  reach 
one-half  per  cent  in  badly  ventilated  rooms.  In  certain  parts  of  many  breweries  it  is 
maintained  between  one-half  and  2  per  cent  without  serious  effects.  The  only  result 
of  a  concentration  of  2  per  cent  of  carbon  dioxide  is  an  automatic  50  per  cent  increase 
in  depth  of  breathing  such  as  occurs  with  moderate  exercise.  Only  when  ssdi  an 
excess  of  carbonic  dioxide  is  combined  with  vigorous  exercise  is  discomfort  experienced . 
By  observations  on  conditions  in  various  industries,  and  at  yarious  altitudes,  and  by 
detailed  physiological  experiments  of  many  observen,  it  has  been  shown  quite  con- 
chisively  that  oxygen  may  fall  as  low  as  at  least  17  per  cent  and  carbon  dioxide  may 
rise  as  high  as  1  per  cent  without  harmful  jdiysiological  effects. 

We  must  therefore  ttim  to  some  other  cause  than  changes  in  carbon  dioxide  and  oxy- 
gen to  account  for  the  sensation  of  discomfort  in  badly  ventilated  rooms.  This  fact 
has  been  recognized  for,  many  years.  Von  Pettenkoler  in  the  sixties  worked  the 
problem  out  broadly,  althou^  without  the  detail  which  is  now  available.  Hygienists 
turned  next  to  the  coganic  matter,  a  subject  much  harder  to  study.  It  was  simple 
to  try  out  various  percentages  of  carbon  dioxide  and  oxygen,  but  with  ofganic  matter 
of  a  hypothetical  nature  the  opportunity  for  m3r8tic  imaginings  was  mudi  greater. 

The  conception  of  subtle  organic  poisons  in  the  air  is  probably  due  to  Brown-S^quard 
mcH«  than  to  any  one  else — Brown-S^uard,  notable  among  biologists  because  he  had 
three  or  four  entirely  erroneous  opinions  on  important  points  which  he  ampported  by 
brilliant  and  apparently  convincing  experiments,  and  which  it  took  decades  to  dis- 
prove. He  believed  that  he  could  demonstrate  the  presence  of  organic  poisons  by 
condensing  the  material  from  the  breath  of  animals  and  injecting  it  into  other  animals, 
which  died  as  a  result.  It  was  later  shown  that  they  would  have  died  in  exactly  the 
same  way  if  the  same  amount  of  pure  water  at  the  same  temperature  had  been  injected . 
Then  he  placed  animals  in  jars  and  allowed  them  to  breathe  the  air  breathed  by  other 
animals,  once  more  with  fatal  results.  These  experiments  were  harder  to  control, 
but  it  was  finally  shown  that  the  animals  died  from  excessive  carbon  dioxide  or  from 
the  chilling  effect  of  excessive  moisture.  Many  others  have  repeated  these  experi- 
ments excluding  such  factors,  and  all  of  them  have  obtained  unif<»mly  n^^tive 
results. 

The  series  of  investigations  conducted  by  Prof.  Roeenau,  of  Harvard,  about  five 
yean  ago  approached  this  questicm  in  a  somewhat  different  way.  If  a  minute  amount 
of  some  foreign  protein  substance  is  injected  into  an  animal,  after  a  certain  time  the 
animal  will  become  highly  sensitive  to  that  particular  protein  and  will  die  in  a  few 
minutes  from  a  second  injection,  with  characteristic  symptoms.  This  anaphylactic 
reaction  is  a  test  for  the  specificity  of  proteins.  Rosenau  attempted  to  use  this  method 
for  the  detection  of  very  minute  quantities  of  oiganic  substances,  and  he  believed  that 
he  had  demonstrated  that  there  were  such  substances  present  in  the  expired  air.  He 
collected,  for  example,  the  matter  expired  in  the  breath  of  a  dog  and  injected  it  iuto  a 
guinea  pig,  and  later  injected  dog-blood  serum  into  the  guinea  pig,  when,  as  he 
believed,  the  guinea  pig  died  with  symptoms  of  anaphylactic  shock,  which  would  indi- 
cate that  there  was  a  specific  protein  substance  given  off  in  the  breath,  althou^  of 
course  not  necessarily  an  intrinsically  poisonous  one.    These  experiments  have  now, 


236       PROCEEDINGS  SECOND  PAN  AMSBICAN  SCIENTIFIO  C0KGBE88. 

however,  been  repeated  by  three  other  observers,  by  Leonard  Hill  in  England  and 
by  Weismann  and  Lucas  in  New  York  City,  the  latter  of  whom  worked  under  my 
direction.    All  three  entirely  failed  to  confirm  Rosenau's  experiments. 

There  has  been  one  series  of  investigations  carried  out  during  the  past  year  by  the 
New  York  State  Commission  on  Ventilation,  which  again  reopens  this  question  in  a 
different  form.  We  have  been  carrying  on  rather  extensive  experiments  for  the  past 
three  years,  to  which  I  shall  refer  in  more  detail  later  on,  in  which  human  subjects 
were  exposed  to  known  air  conditions  and  a  wide  variety  of  physiological  and 
psychological  observations  made  upon  them.  In  the  course  of  Uieee  experiments 
we  thought  it  would  be  interesting  to  see  whether  heat  had  any  effect  on  appetite 
for  food.  We  served  our  subjects  in  the  experimental  chamber  with  a  standard 
luncheon,  and  we  weighed  the  amount  that  they  left  on  the  plates  afterwards  so  aa 
to  see  how  much  they  had  eaten.  We  did  not  find  very  striking  results  due  to  the 
heat,  but  we  found  what  we  had  not  expected,  a  marked  effect  of  vitiated  air  aa 
compared  with  fresh  air  at  the  same  temperature.  We  gave  our  subjects  on  certain 
days  fresh  outside  pure  air  at  low  temperature;  on  other  days  fresh  pure  outside  air 
raised  to  a  high  temperature;  on  other  days  we  kept  the  same  air  in  the  room  all 
day,  allowing  it  to  become  chemically  vitiated,  but  regulating  its  temperature.  We 
found  to  our  great  surprise  that  comparing  the  fresh  air  and  vitiated  air  days  with 
the  same  temperature  and  humidity  there  was  a  distinct  difference  in  the  amount 
of  food  eaten.  One  series  of  experiments  showed  more  food  eaten  on  the  stale  air 
days,  4.9  per  cent  more  for  the  whole  squad  of  subjects;  but  this  series  had  been 
stopped  in  the  middle  before  calculating  the  results,  because  the  religious  prejudices  of 
the  subjects  had  entirely  destroyed  its  value.  We  happened  to  come  across  a  series 
of  fast  days,  and  these  subjects  were  women  who  were  very  orthodox,  and  we  found 
that  ritual  was  governing  the  amount  they  ate,  not  air  condition.  The  other  four  series 
which  were  completed  show  uniformly  an  excess  of  food  eaten  on  fresh-air  days,  the 
excesses  in  the  four  series  amounting  to  4.4,  6.8,  8.6,  and  13.6  per  cent,  respectively. 
There  were  from  71  to  160  meals  served  in  each  series,  and  we  believe  the  results  to 
be  significant.  We  have  tried  to  produce  the  same  effect  with  fresh  air  containing 
carbon  dioxide,  without  success.  We  have  tried  it  with  air  containing  artificial 
odors,  without  success.  My  personal  hypothesis  is  that  there  is  a  psychological  effect 
or  reflex  reaction  to  the  body  odor  which  had  that  subtle  effect  on  Uie  appetite.  At 
any  rate  it  stands  as  the  one  demonstrated  effect  of  the  chemical  constituents  of 
normally  vitiated  air. 

It  was,  I  think,  Hermann  who  in  1883  first  pointed  out  that  heat  and  moisture 
were  probably  the  factors  that  produced  the  bad  effects  of  bad  air  rather  than  its 
chemical  composition,  but  most  of  the  fundamental  work  on  the  subject  was  don^  in 
1905  or  thereabouts  by  FlQgge  and  his  pupils .  These  experiments  have  been  repeated 
by  Hill  and  Haldane  in  England,  and  by  Benedict  and  others  in  this  country,  and 
all  of  the  results  have  tended  to  show  that  Hermann  was  correct,  and  that  the  people 
in  the  Black  Hole  of  Calcutta  died,  not  of  oxygen  starvation,  but  of  heat  stroke. 

In  these  experiments  the  subjects  when  placed  in  carefully  controlled  closed 
chambers  experienced  the  symptoms  that  one  is  accustomed  to  associate  with  badly 
ventilated  rooms.  If  the  subjects  in  these  rooms  were  allowed  to  breathe  outside 
air  through  a  tube  they  were  not  relieved.  If  subjects  outside  were  allowed  to 
breathe  the  vitiated  air  through  a  tube,  they  did  not  experience  discomfort.  These 
two  simple  experiments  appear  to  be  entirely  conclusive  as  to  subjective  symptoms. 
The  feeling  of  uncomfortableness  affected  the  men  in  the  chamber,  not  the  men 
outside  the  chamber,  whatever  air  each  group  was  breathing.  It  was  the  heat  and 
moisture  produced  by  their  bodies  which  caused  the  feeling  of  discomfort,  by  its 
effect  not  on  the  lungs  but  on  the  skin.  Benedict  showed  that  a  man  could  live  for 
many  days  in  a  closed  chamber  without  damage  to  his  health  and  without  having 
any  idea  that  anything  was  wrong,  with  1  to  2  per  cent  of  carbon  dioxide  present, 
provided  the  chamber  was  cool  and  dry. 


PUBUO  HEALTH  AKD  MEDICINE.  237 

Leonard  Hill  comments  on  his  experimentB  in  England  as  follows: 

In  one  class  of  experiments  we  shut  within  the  chamber  seven  or  eight  students 
for  about  half  an  hour  and  observed  the  effect  of  the  confined  atmosphere  upon  them. 
We  kept  them  therein  until  tke  CO,  re»Ached  3  to  4  per  cent,  ana  the  oxygen  had 
fallen  to  from  17  to  16  per  cent.  The  ^et-bulb  temperature  rose  meanwhile  to  about 
80**  to  85**  P.  and  the  dry  bulb  a  degree  or  two  higher.  The  students  went  in  chattinj^ 
and  laughing,  and  by  and  b^  as  me  temperature  rose  they  ceased  to  talk  and  their 
faces  became  flushed  and  moist.  We  have  watched  them  trying  to  lif^it  a  cigarette 
(to  relieve  the  monotony  of  the  experiment)  and  puzzled  by  their  matcnes  going  out, 
borrowing  others,  only  m  vain.  They  had  not  sensed  the  percentage  of  the  diminu- 
tion of  oxygen,  whicn  fell  below  17.  Their  breathing  was  slightly  deepened  by  the 
high  percentage  of  CO3,  but  no  headache  occurred  in  any  of  them  from  the  short 
exposure  to  from  3  to  4  per  cent  CO,.  Their  discomfort  was  relieved  to  an  astonishing 
extent  by  putting  on  the  electric  fans  placed  in  the  roof.  Whilst  the  air  was  kept 
stirred  tie  students  were  not  affected  by  the  oppressive  atmosphere.  They  begged 
for  the  fans  to  be  put  on  when  they  were  cut  on.  The  same  old  stale  air  contaimng 
3  to  4  per  cent  CO3  and  16  to  17  per  cent  Oj  was  whirled,  but  the  movement  of  the 
air  gave  complete  relief,  because  the  air  was  80**  to  85**  F.  (wet  bulb),  while  the  air 
enmeshed  in  their  clothes  in  contact  with  their  skin  was  98**  to  99**  F.  (wet  bulb). 
The  whirling  away  of  this  stationary  air  cooled  the  body  effectually,  for  air  at  80** 
to  85**  P.  holds  considerably  more  water  vapor  when  heated  up  to  from  98**  to  99**  P. 

In  our  experimental  plant  in  New  York  we  have  been  repeating  these  experiments 
in  somewhat  more  detail  as  regards  the  special  physiological  reactions  involved. 
Our  observation  room  is  10  by  14  by  10  feet  high,  very  carefully  insulated  as  to  walls 
and  ceiling,  entered  by  passages  through  three  doors,  and  arranged  so  that  we  can 
control  with  a  high  degree  of  accuracy  the  temperature  and  humidity  and  air  flow. 
We  have  placed  in  that  chamber  from  four  to  eight  subjects  at  a  time,  each  squad  of 
men  or  women  being  observed  from  four  to  eight  hour?  a  day  for  a  period  of  two  to  eight 
weeks.  We  foimd  that  chemically  vitiated  air  of  a  comfortable  temperature  and 
humidity  had  no  effects  on  any  physiological  or  psychological  reaction  except  on 
appetite.  High  temperature  (86**  with  80  per  cent  relative  humidity)  produced  a 
slight  but  distinct  elevation  of  the  body  temperature,  an  increase  in  reclining  heart 
rate,  an  increase  in  the  excess  of  standing  over  reclining  heart  rate,  a  very  slight 
lowering  of  systolic  blood  pressure,  and  a  marked  fall  in  the  Crampton  value  (a  ratio 
between  the  change  in  heart  rate  and  the  change  in  blood  pressure  on  passing  from  a 
reclining  to  a  standing  position).  Broadly  speaking  a  high  Crampton  value  means 
that  the  vaso-motor  system  of  the  body  adjusts  itself  easily  to  the  work  of  standing  up 
after  lying  down. 

Moderately  high  room  temperature  (75**  with  50  per  cent  relative  humidity)  had 
the  same  effects,  although  of  course  in  less  d^^ree.  Even  the  extreme  room  tempera- 
ture of  86^  with  80  per  cent  relative  humidity  combined  with  high  carbon  dioxide 
showed  no  effect  on  the  respiratory  rate,  dead  space  in  the  lungs,  chemical  composi- 
tion of  the  blood,  or  the  rate  of  heat  production  or  digestion  or  metabolism  or  any 
other  physiological  reaction  studied. 

We  next  went  on  to  the  question  of  the  study  of  efficiency — ^the  ability  and  desire 
to  do  mental  and  physical  work.  We  found  that  even  a  temperature  of  86**  produced 
no  effect  on  the  power  to  do  mental  or  physical  work.  .When  subjects  were  working 
under  pressure,  accomplishing  all  they  could  in  a  brief  period  of  time,  they  did  Just 
as  well  under  bad  conditions  as  imder  good  conditions.  We  ought  not  to  be  surprised 
at  this.  It  is  our  own  experience;  on  a  hot  day  in  summer  we  play  tennis  or  do  a 
piece  of  absorbing  intellectual  work  just  as  well  as  in  colder  weather. 

We  had  therefore  to  adopt  other  methods.  Prof.  Thomdike,  of  Columbia,  devised 
tests  in  which  the  subjects  were  allowed  to  work  or  not  work  as  they  cho5>e,  and 
were  paid  a  small  amount  if  they  accomplished  a  certain  quota  of  work,  giving  a 
slight  but  only  a  slight  incentive,  imitating  the  condition  that  exists  in  schools  and  in 
factories  that  are  not  on  piecework. 

We  obtained  marked  and  striking  differences  from  these  option  tests.  The  amount 
of  physical  work  done  when  the  subject  had  the  choice  of  working  or  not  dropped 


238       PROCEEDINGS  SECOND  PAN   AMERICAN   SCIENTIFIC  CONORE88. 

15  per  cent  at  the  76°  temperature  as  compared  with  the  68**,  and  dropped  37  per  cent 
at  86"*  as  compared  with  eS"". 

We  found  no  such  effect  on  the  optional  tests  for  purely  mental  work.  On  the  con> 
trary  we  found  that  the  amount  of  mental  multiplication  done  optionally  was  A.9 
per  cent  more  at  75°  than  at  68°.  I  am  inclined  to  think  that  this  was  perhaps  due  to 
the  stimulus  of  the  slight  discomfort,  and  a  desire  to  keep  the  mind  off  the  outside 
conditions  by  working.  As  soon  as  we  got  to  typewriting,  involving  again  a  modicum 
of  physical  work,  6.3  per  cent  more  was  done  at  68°  than  at  75°.  I  think  these  experi- 
ments show  that  overheating  has  a  serious  and  important  effect  on  the  actual  output 
under  normal  working  conditions.  The  results  should  be  significant  for  the  school 
trustee,  and  for  the  office  manager  and  factory  manager.  They  show  definitely 
what  has  been  generally  assumed  without  any  quantitative  basis  of  proof,  that  there 
is  a  laige  loss  in  efficiency  due  to  overheating. 

Prof.  Ellsworth  Huntington,  of  Yale  Univereity,  carried  out  a  year  or  two  ago  some 
extremely  interesting  experiments  along  this  line  on  the  effect  of  season  upon  mental 
and  physical  work — phjrsical  work  of  operatives  in  Bridgeport  and  mental  work  of 
students  at  West  Point  and  Annapolis.  He  showed  that  there  was  a  distinct  foiling 
off  in  the  amount  of  work  when  the  outdoor  temperatures  went  above  65°  or  70°.  He 
found  that  there  was  a  still  more  marked  decrease  when  the  temperature  fell  below 
40°  to  50°.  There  was  thus  a  period  of  maximum  productivity  in  both  factories  and 
educational  institutions  in  spring  and  fall,  with  a  minimiun  period  in  winter  and 
another  minimum  in  summer.  Sudden  diangee,  on  the  other  hand,  in  either  direc- 
tion were  stimulating.  In  Prof.  Huntington's  book  on  Civilization  and  Climate  he 
connects  these  observations  in  a  most  interesting  and  suggestive  way  with  the  efficiency 
of  mankind  imder  the  various  climates  of  the  globe. 

A  word  should  be  said  as  to  one  other  important  effect  of  excessive  temperature, 
its  influence  upon  infant  mortality.  It  might  be  supposed  that  the  infant,  having^ 
more  surface  to  get  rid  of  the  heat  in  comparison  with  its  bulk,  would  not  suffer 
severely  from  heat,  but  this  advantage  is  much  more  than  overbalanced  by  the 
greater  sensitiveness  of  its  organization.  The  combined  effect  of  artificial  feeding 
and  high  atmospheric  temperature  is  what  causes  the  great  loss  of  infant  life  from 
summer  complaint.  A  young  baby  can  usually  live  in  cold  weather  even  when 
fed  with  cow's  milk;  a  baby  can  live  through  severe  summer  weather  if  it  is  fed  at 
the  breast.    The  combination  is  the  deadly  thing. 

Investigations  in  Berlin  and  elsewhere  have  shown  that  the  infant  mortality  in 
summer  is  of  two  distinct  types.  In  the  first  place,  diuing  early  summer  there  are 
deaths  among  infants  due  to  direct  heat  stroke,  sudden  short  illnesses  due,  primarily 
to  the  effect  of  heat,  but  occurring  almost  exclusively  among  infants  artificially  fed. 
Later  the  babies  die  from  summer  complaint,  from  long  drawn  out  diarrhea,  in  which 
the  milk  plays  a  somewhat  laiger  part,  but  in  which  the  lowering  of  the  vital  resistance 
by  heat  is  an  integral  factor. 

I  look  forward  to  the  day  when  there  will  be  not  only  artificially  cooled  hospital 
rooms  for  babies,  but  cool  day  and  ni^t  nurseries  in  the  crowded  tenement  districts 
where  babies  can  be  taken  when  a  severe  spell  of  weather  sets  in.  There  is  verj-- 
little  question  that  such  a  provision  is  quite  as  important,  if  not  more  important^ 
than  the  provision  of  warm  habitations  in  winter. 

Finally,  one  other  effect  remains  to  be  considered — ^the  effect  of  atmospheric  condi- 
tions on  the  membranes  of  the  nose  and  throat.  Benjamin  Franklin  said  ^'that  people 
who  live  in  the  forest,  in  open  bams,  or  with  open  windows,  do  not  catch  cold,  and 
that  the  disease  called  'a  cold'  is  generally  caused  by  impure  air,  lack  of  exerdse,^ 
or  from  overeating."  This  general  phenomenon  is  of  course  very  familiar;  yet  there 
has  been  little  exact  scientific  evidence  on  this  point.  This  is  a  subject  which  the 
New  York  State  Conmiission  on  Ventilation  has  been  taking  up  during  the  past  year 
in  a  series  of  experiments  under  the  immediate  direction  of  Dr.  James  Alexander 


PUBLIC   HEALTH   AND  MEDICINE.  239 

Miller.  With  our  experimental  rooms  we  were  able  not  only  to  expose  the  subject 
first  to  a  hot  condition  and  then  to  a  cold  condition,  and  vice  versa,  but  by  having 
them  bend  over  in  a  somewhat  uncomfortable  posidon  we  could  have  the  body  in  one 
room  exposed  to  one  atmosphere,  and  the  head  in  another  exposed  to  another  atmos- 
phere. 

These  experiments  confurmed  the  conclusions  of  Hill  and  Muecke  that  in  going  from 
a  hot  room  to  a  cold  room  the  membranes  of  the  nose  become  paler  and  less  moist, 
while  the  inferior  turbinates  contract. 

Wo  found,  however,  that  when  the  change  was  too  sharp,  when  the  subject  passed 
from  a  hot  room  into  a  cold  room  with  a  strong  draft  on  the  face,  it  frequently  happened 
that  while  the  redness  of  the  meml^ranes  decreased,  the  swelling  and  paleness  did 
not  deoreaae  but  often  increased,  so  that  the  membranes  were  swollen  and  bathed 
with  mucous  secretion,  but  without  an  ample  blood  supply — an  ideal  condition  for 
the  cultivation  of  disease  bacteria.  Apparently  this  is  the  phenomenon  which  Hes 
at  the  base  of  ''catching  cold  "  by  going  from  a  hot  room  into  the  cold  air. 

We  examined  a  number  of  workers  who  had  lived  under  skbnormal  conditions- 
furnace  men,  exposed  to  hot  dry  air;  laundrymen,  exposed  to  hot,  moist  air;  and 
truckmen  and  teamsters,  exposed  to  severe  outdoor-air  conditions.  We  found  abnor- 
mal reactions  among  these  subjects  in  much  greater  degree;  and  these  occupational 
groups  showed  much  more  chronic  nasal  disease  than  did  the  student  subjects.  About 
3  per  cent  of  the  students  had  chronic  diseases  of  the  nasal  passages,  19  per  cent  of  the 
outdoor  workers,  35  per  cent  of  the  furnace  men,  and  46  per  cent  of  the  laundrymen. 
Both  the  experimental  work  and  this  statistical  work  on  the  various  occupational 
groups  pointed  to  the  very  serious  effects  of  hot,  dry  air  upon  the  mucous  membranes, 
and  particularly  the  danger  of  passing  from  such  a  condition  into  chill  outdoor  air. 

These  are  the  things  we  know,  or  think  we  know,  sibout  air.  We  hear  a  great  deal 
about  other  subtle  and  mysterious  effects,  about  "canned  air,''  and  the  bad  effects  of 
bringing  in  air  through  ventilating  ducts  instead  of  through  windows.  I  have  never 
had  any  great  sympathy  with  this  phrase  or  with  the  idea  that  anything  harmful 
necessarily  happened  to  air  because  it  went  through  galvanised-iron  ducts  instead  of 
coming  through  a  window  frame.  Its  temperature  and  humidity  may  be  altered. 
Those  are  things  which  we  know  about  and  can  measure.  Whether  there  is  any  other 
factor  at  work,  I  do  not  know.  Our  own  observers  on  the  conmiission  staff  are  con- 
stantly reporting  to  us  that  window-ventilated  rooms  seem  fresher  than  those  ven- 
tilated by  mechanical-ventilating  systems.  I  suspect,  however,  that  these  differ- 
ences, when  more  carefully  analyzed,  will  be  found  to  be  due  either  to  odors  or  to 
variatiims  in  temperature  or  humidity  or  to  the  factor  of  air  movement. 

Air  movement  is  one  of  the  most  important  elements  in  the  problem,  since  it  largely 
controls  the  temperature  and  moistiu^  effects  upon  the  human  body.  The  body  is 
surrounded,  as  Prof .  Sedgwick  has  expressed  it,  by  an  ''aerial  blanket''  of  hot,  moist 
air.  Wind  breaks  up  this  hot,  moist  envelope  and  drives  it  away,  reducing  the  tem- 
perature of  the  body  to  that  of  the  surrounding  air.  Leonard  Hill  has  given  us  a 
useful  instrument  for  measuring  these  effects.  This  apparatus  consists  simply  of  two 
thermometers  graduated  from  86^  to  110'',  one  a  dry  bulb,  the  other  an  ordinary  wet 
bulb,  which  is  chilled  by  the  evaporation  fnnn  a  doth  surrounding  it.  These  ther- 
mometers are  first  heated  until  they  rise  to  about  110^,  and  the  time  taken  to  fall 
from  100'*  to  90"  is  noted.  This  measures  the  combined  effect  of  three  factors,  the 
temperature  of  the  outside  air,  the  humidity  of  the  outside  air,  and  the  air  move- 
ment; and  it  measures  these  three  factors  very  much  as  they  affect  our  own  body. 
I  have  been  making  observations  with  this  instnmient  during  the  past  summer.  The 
limits  of  comfort  set  by  Prof.  Hill,  and  which  I  think  are  reasonably  near  the  truth, 
are  three  minutes  forthefall  of  the  dry  bulb  and  one  minute  for  the  wet  bulb.  In  cme 
of  my  observations  in  a  room  before  a  fire  when  the  temperature  was  72",  the  dry  bulb 
took  4  minutes  37  seconds  to  fall;  the  wet  bulb  1  minute  18  seconds.    On  anoth^  day 


240       PBOCEEDINGS  SECOND  PAN  AMBBIOAK  8CIENTIFI0  G0NGBE8& 

outside  in  a  wind  the  thennometer  was  at  82^,  yet  it  took  only  3  minutes  for  tne  dry 
bulb  to  fall  and  42  seconds  for  the  wet  bulb.  This  ia  why  we  feel  so  much  more 
comf<»rtable  out  of  doors  in  summer,  with  a  high  temperature,  when  there  is  a  good 
wind,  than  we  do  in  a  closed  room  when  the  temperature  gets  a  very  little  over  70^. 

On  one  exceedingly  uncomfortable  day  in  September  in  my  laboratory  in  New 
York  at  a  temperature  of  79**  it  took  5  minutes  55  seconds  for  the  dry  bulb  to  fall, 
and  1  minute  35  seconds  for  the  wet.  We  turned  on  the  electric  fan,  and  it  took  1 
minute  58  seconds  for  the  dry  bulb  to  fall  and  29  seconds  for  the  wet  bulb.  This 
instrument  gives  at  last  an  opportunity  of  measuring  the  effect  of  air  movement, 
which  m  probably  one  of  the  most  important  things  in  determining  our  comfcnt. 

Prof.  Henderson  has  uiged ,  in  view  of  the  similarity  between  the  symptoms  of  moun- 
tain sickness  and  those  produced  by  bad  ventilation,  that  the  temperature  of  the  air 
may  produce  a  hitherto  unrecognized  change  in  respiratory  activity.  The  phenomena 
observed  have  however  to  do  primarily,  not  with  the  lungs  but  with  the  vaso-motor 
system,  which  regulates  the  temperature  of  the  body.  Our  bodies  maintain  their 
constant  temperature  of  98.6''  at  the  poles  and  at  the  Equator  by  an  exceedingly 
delicate  system  of  adjustments,  which  leads  to  the  dilation  of  the  blood  vessels  in  the 
skin  when  the  air  is  hot  and  their  contraction  when  it  is  cold.  Moderately  excessive 
heat  causes  the  expansion  of  the  skin  blood  vessels  and  robs  the  brain  and  internal 
organs  of  blood.  I  suspect  that  the  disinclination  to  do  physical  and  mental  work  ia 
laigely  due  to  deficient  blood  supply  in  the  brain.  Under  a  stimulus  we  may  over- 
come this,  but  ordinarily  when  the  blood  is  in  the  skin  we  are  sleepy  and  dull,  and  in 
extreme  cases  toxic  effects  result,  when  the  mechaniBm  of  the  body  is  seriously  de- 
ranged by  the  heat,  as  in  the  Black  Hole  of  Calcutta  and  in  the  case  of  heat  stroke  of 
infants  in  summer. 

Extreme  cold  on  the  other  hand  also  reduces  efficiency  as  shown  by  Prof.  Hunting- 
ton. It  lowers  the  vitality  and  may  form  an  important  contributing  factor  in  respira- 
tory and  other  diseases. 

Moderate  cold  exerts  a  tonic  effect,  training  the  blood  vessels  of  the  vaso-motor 
system  so  that  they  will  respond  promptly  to  external  changes.  This  system  needs 
to  be  exercised  just  as  any  oUier  system  of  the  body  does,  and  the  question  of  ventila- 
tion is  tied  up  with  the  problems  of  clothing  and  of  bathing.  The  judicious  airing 
and  clothing  and  bathing  of  the  body  so  that  the  vaso-motor  system  may  be  protected 
from  extremes  but  educated  so  that  it  will  meet  moderate  changes  of  temperature, 
with  success — ^these  are  among  the  most  important  tasks  of  personal  hygiene. 

If  the  concessions  drawn  by  Prof.  Ellsworth  Himtington  in  his  striking  book  are 
confirmed  by  future  study,  countries  whose  natural  climates  do  not  conform  to  the 
ideal  he  has  worked  out  may  find  it  possible  to  produce  and  maintain  on  an  extensive 
scale  those  artificial  conditions  of  coolness  and  changeablenees  which  he  finds  nec- 
essary to  stimulate  the  highest  human  efficiency. 

BIBUOOBAPHT. 

Benedict,  P.  G.,  and  Milner,  R.  D.  1907.  Experiments  on  the  Metabolism  of  Blatter 
and  Energy  in  the  Human  Body.    U.  S.  Dept.  of  Agric,  Bull.  No.  175. 

Billings,  J.  S.,  Mitchell,  S.  W.,  and  Bergey,  D.  H.  1895.  The  Composition  of  Ex- 
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Carrington,  T.  S.  1914.  Fresh  Air  and  How  to  Use  It.  National  Association  for 
the  Study  and  Prevention  of  Tuberculosis.    New  York. 

Cocks,  6.  H.  1915.  Experimental  Studies  of  the  Effect  of  Various  Atmi^heric 
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\ 


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geschloesenen  RaOmen.    Zeitschr.  f.  Hyg.  u.  Inf.,  XLIX,  363. 
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Heat  and  Ghemical  Purity  of  Glose  Air.    J.  of  Physiology,  XLI,  proc.,  p.  III. 
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Transactions,  American  Society  of  Heating  and  Ventilating  Engineers,  XXI. 
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1912.    111,504. 
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Inquiry  to  the  Board  of  Estimate  and  Apportionment,  New  York  Gity,  III,  670. 
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N.  8.,  XLII,  816. 
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Akad.  d.  ^^^ssensch.,  Mflnchen,  II,  88. 
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d.  Ghem.  u.  Pharm.,  Leipz.  u.  Heidelb.,  2  suppl.  dd.,  52. 
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242       PBOCEEDINGS  SECOND  PAN   AMBBICAN   SCIENTIFIC  C0NGBE8S. 

Weiaman,  C.  1913.  Bio-chemical  Studies  of  Expired  Air  in  Relation  to  Ventilation. 
Dissertation  submitted  to  Faculty  of  Pure  SddQce  of  Columbia  University.    1913. 

Winslow,  C.-E.  A.,  and  Palmer,  G.  T.  1915.  The  Effect  upon  Appetite  of  the  Chem- 
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mental Biology  and  Medicine,  XII,  141. 

Winslow,  C.-E.  A.,  and  Browne,  W.  W.  1914.  The  Microbic  Content  of  Indoor  and 
Outdoor  Air.    Monthly  Weather  Review,  XLII,  452. 

Winslow,  C.-E.  A.  1915.  Standards  of  Ventilation  in  the  light  of  Recent  Research. 
Science,  N.  S.  XLI,  625. 

Dr.  KoBEB.  I  wish  to  express  my  appreciation  of  the  very  scien- 
tific work  presented  by  Dr.  Winslow  and  to  utter  a  word  of  caution 
against  drawing  practical  deductions  which  might  perhaps  lead 
to  harmful  effects.  I  am  a  thorough  behever  in  pure  air  such  as 
nature  provides  in  the  average  composition  of  the  atmosphere.  It  is 
stated  that  in  the  question  of  ventilation,  the  temperature,  move- 
ment, and  amount  of  humidity  in  the  air  play  the  most  important 
part.  While  this  is  true,  I  believe  there  are  decided  differences  in  the 
purity  of  the  air  of  our  habitations  and  workshops  when  compared  with 
out-door  air,  especially  in  air  of  parks,  seashore,  mountains  and  in  the 
open  country.  I  think  it  can  be  shown  that  differences  exist  not  only 
in  the  amount  of  carbon-dioxide  and  oxygen,  but  also  in  the  organic 
and  inorganic  constituents,  as  demonstrated  by  the  presence  of  dust 
and  bacteria,  which  always  go  hand  in  hand.  So,  for  example,  Uffel- 
mann  foimd  that  while  the  outer  air  contained  only  250  germs  per 
cubic  meter,  the  air  of  his  library  contained  2,900,  of  his  sitting  room 
7,500,  of  his  bedroom  12,500,  and  the  air  of  a  living  room  of  a  work- 
ingman's  family  as  many  as  31,000  germs.  He  also  demonstrated 
that  they  increased  after  disturbing  the  dust  of  the  rooms  with 
feather  dusters  or  by  slamming  the  doors,  showing  that  they  actually 
cling  to  the  dust.  It  does  not  follow  that  because  laboratory  ex- 
periments failed  to  demonstrate  any  bad  effects  from  the  presence  of 
large  volumes  of  carbon-dioxide  and  a  corresponding  deficiency  of 
oxygen,  habitual  exposure  to  vitiated  air  is  harmless.  It  is  far 
better  perhajfe  to  assume  that  every  particle  of  impurities  over  and 
above  the  amount  normally  present,  must  of  necessity  influence  the 
physico-chemical  changes  in  respiration  and,  if  continued  for  any 
length  of  time,  health  will  be  impaired.  This  belief  is  also  in  har- 
mony with  nature's  beautiful  process  in  storing  up  the  excess  of 
carbon-dioxide  in  the  form  of  carbon  in  growing  vegetation. 

It  will  be  difficult  to  account  for  the  imdue  prevalence  of  tubercu- 
losis among  the  North-American  Indians  except  on  the  grounds  that 
the  change  from  the  tepee  with  its  copious  ventilation,  to  bad  housing 
conditions  with  insufficient  ventilation  has  estabUshed  a  peculiar  pre- 
disposition to  the  disease.  It  is  the  exf)erience  of  the  old  practitioners 
of  the  Southern  States  that  during  the  days  of  slavery  the  Negro  on 
the  plantations  enjoyed  as  good  health  as  the  average  white  people 


PUBUO  HEALTH  AKD  BfEDICIHB.  248 

among  whom  they  dwelt  and  that  consumption  was  very  uncommon 
among  them.  After  their  liberation  these  people  had  to  find  shelter 
as  best  they  could  in  shacks  and  shanties  wholly  unfit  for  human 
habitations.  Their  tuberculosis  rate  was  almost  treble  that  of  the 
white  population  in  the  city  of  Washington.  This  rate,  which  was 
690  per  100,000  of  the  colored  population  in  1878,  has  been  reduced 
to  359  in  1914. 

When  we  condemned  the  buildings  unfit  for  human  habitations, 
they  responded  promptly  to  improved  environments.  Even  hve- 
stock  shows  the  baneful  effects  of  impure  air,  for  tuberculosis  among 
the  range  cattle  of  the  far  west,  which  are  practically  without  shelter, 
is  comparatively  rare,  while  it  affects  from  15  to  25  per  cent  of  the 
dairy  herds,  which  are  housed  but  without  sufficient  regard  to  light 
and  air.  As  a  matter  of  fact,  an  abundance  of  pure  air  has  been  found 
a  most  important  factor  in  the  prevention  and  treatment  of  tubercu- 
losis, because  it  promotes  the  oxygenation  of  the  blood,  stimulates 
the  appetite  and  nutrition  and  thereby  increases  the  general  resisting 
power  of  the  system. 

Improved  ventilation  and  increased  air  space  have  lessened  every- 
where the  death-rate,  and  it  is  chiefly  by  just  such  measures  that 
the  rate  from  consumption  has  been  reduced,  according  to  Sir  Thomas 
Oliver  from  7.82  to  2.5  per  1,000  in  the  British  Army  during  the  last 
60  years.  The  tuberculosis  and  pneumonia  death  rate  in  the  United 
States  Army  has  been  reduced  respectively  from  0.95  and  0.48  in  1901 
to  0.49  and  0.28  in  1913,  and  similar  gratifying  reductions  have  been 
recorded  in  the  United  States  Navy.  It  is  to  be  presumed  that  then 
as  now  the  recruits  were  selected  with  great  care,  and  that  the  differ- 
ence is  simply  due  to  the  fact  that  they  were  subjected  to  impure  air, 
incident  to  limited  air  space  and  have  responded  to  improved  envi- 
ronments. 

The  influence  of  overcrowding  and  bad  air  on  diseases  of  the  respira- 
tory organs,  amounting  at  times  to  epidemics,  was  well  illustrated  on 
the  Isthmus  of  Panama.  By  scattering  the  colored  laborers  from 
crowded  dormitories  into  single  huts  or  rooms  with  not  less  than  50 
feet  of  floor  space  for  each  individual.  Gen.  Gorgas  reduced  the 
pneumonia  rate  in  a  single  year  from  18.4  per  1,000  to  2  per  1,000. 

It  is  also  well  known  that  pneumonia  is  more  prevalent  among  the 
cavalry  troops  than  among  other  arms  of  the  service.  Cavalry 
barracks  have  always  the  characteristic  odor  of  horses  and  stables 
about  them  and  it  is  not  improbable  that  apart  from  exposure  to  the 
inhalation  of  dust  during  the  grooming  process,  a  part  of  this  dust  is 
also  carried  to  the  quarters  and  contaminates  the  air. 

Personally  I  do  not  believe  that  the  dangers  of  habitual  exposure 
to  impure  air  have  ever  been  exaggerated  and  in  my  judgment  no  two 
factors  have  contributed  so  much  to  the  reduction  in  mortaUty  rates 

68436—17— VOL  x 17 


244       PBOCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC   CONGBESS. 

during  the  last  50  years  than  the  improvement  of  the  air  we  breathe 
and  the  water  we  drink. 

Lieut.  Col.  MuNSON.  I  want  to  thank  Prof.  Winslow  for  the 
extremely  interesting  paper  he  has  given  us.  The  subject,  it  seems 
to  me,  is  one  that  has  a  side  issue  as  well  as  a  direct  bearing  on  ven- 
tilation. I  mean  a  climatological  relation.  To  those  who  have  been 
in  the  Tropics  and  in  the  Philippines  there  has  lately  come  up  the 
question  of  how  long  men  should  serve  in  the  Tropics,  and  it  has 
been  decided  by  the  War  Department  that  probably  two  years 
would  be  sufficient.  The  question  was  considered  pro  and  con  as  to 
whether  physical  deterioration  did,  or  did  not,  occur  among  troops  in 
a  period  less  than  that  time.  We  know  from  the  experiments  which 
have  been  quoted  to  us  here  that  a  temperature  such  as  we  have  in 
Manila  means  approximately  a  one-third  decrease  in  the  physical 
efficiency  of  people. 

We  faiow  that  just  for  a  summer  day  or  a  week  or  two  of  hot 
weather  we  can  force  ourselves  to  work,  but  there  comes  a  time  when 
the  constant  pressure  of  unfavorable  environment  tends  to  reduce 
our  will  power  to  a  point  where  we  do  not  work  at  the  same  degree 
of  efficiency.  It  has  always  seemed  to  me  that  possibly  the  slug- 
gishness of  the  native,  his  unwillingness  to  work,  which  we  looked 
upon  with  some  contempt,  was  possibly  due  to  the  fact  that  he 
was  more  fit  to  Uve  in  that  environment  than  the  white  man.  The 
longer  that  we  Uved  there,  the  less  we  wished  to  do,  the  less  physical 
effort  we  wished  to  make,  mental  or  physical  effort.  At  the  outset, 
we  could  make  this  mental  effort  fairly  easily,  but  there  came  a  time 
when  this  was  reduced,  and  we  had  what  the  Army  knows  as  "  Philip- 
pinitis,"  a  mental  apathy  and  a  physical  sluggishness. 

In  these  experiments  of  Prof.  Winslow,  in  which  he  speaks  of  the 
psychological  effect,  I  would  rather  be  inclined  to  throw  out  the 
question  of  incentive,  because  the  incentive  is  not  the  same  to  all. 
A  dollar  looks  larger  to  one  person  than  to  another.  One  person 
will  work  harder  for  money  than  another.  But  the  point  is  this, 
that  np  one  willingly  went  along  and  did  physical  work.  I  should 
like  to  see  what  would  happen  if  such  experiments  as  Prof.  Wins- 
low's  were  continued  not  for  days  or  weeks,  but  for  months,  until 
one  got  what  we  find  in  the  Tropics,  a  physical  inertia,  graduiJ,  slow 
in  coining,  but  ultimately  arriving. 

In  regard  to  indoor  ventilation,  one  point  seems  to  me  to  need 
emphasis.  That  is  the  point  of  proper  humidifying  of  warm  air. 
You  will  never  find  that  worked  out  in  anything  but  the  most  elabo- 
rately ventilated  buildings.  In  Prof.  Winslow's  own  town,  which  is 
my  home,  the  people  have  no  conception  of  it,  and  they  overheat 
the  houses  at  the  same  time  they  batten  down  the  windows,  pre- 
paratory to  their  annual  six  months'  struggle  with  winter. 


PUBLIO  HEALTH  AND  MEDIOIKE.  245 

Dr.  GuiTERAS.  I  would  like  to  say  a  few  words  in  conneotion 
with  the  influence  of  heat,  especially  upon  mental  work.  I  am  not 
convinced  by  these  experiments.  I  have  Uved  one-half  of  my  Uf e  in 
a  cold  country  and  one-half  of  my  life  in  a  hot  country,  and  I  believe 
that  as  far  as  mental  work  is  concerned,  if  you  are  entirely  free  from 
the  prejudice  that  high  temperatures  make  work  impossible,  you  can 
do  as  much  work  in  a  hot  climate  as  you  can  in  a  cold  coimtry.  I 
think  we  forget  what  has  been  done  in  the  past,  how  great  civiliza- 
tions in  the  past  reached  their  height  in  hot  climates.  Even  the 
people  bom  in  cold  coimtries,  when  they  have  been  brought  into  the 
tropical  zone,  have  been  able  to  do  most  extraordinary  work.  I  do 
not  think  that  anything  the  Spaniards  have  done,  for  instance,  in 
their  own  country  or  throughout  Europe  could  equal  the  amount  of 
work  and  energy  displayed  both  physically  and  mentally  in  the  con- 
quest of  the  Tropics  in  America.  I  think  that  there  is  a  great  deal 
of  prejudice  in  education  that  makes  us  feel  that  we  can  not  do  work 
when  a  certain  degree  of  temperature  is  arrived  at.  I  have  always 
maintained  this  and  I  have  felt  that  I  could  do  as  much  work  in  the 
Tropics  as  I  could  in  a  cold  country. 

Prof.  Sedgwick.  It  is  not  many  years  since  we  were  all  taught 
that  the  proper  study  in  ventilation  was  the  question  of  space. 
We  must  have  so  many  cubic  feet  per  capita,  and  it  was  figured  out 
to  be  something  like  400  cubic  feet  per  capita.  I  have  for  some 
time  referred  in  my  classes  to  that  as  the  per  capita  of  fallacy, 
and  the  fact  that  Prof.  Winslow  has  omitted  all  reference  to  it  shows 
how  dead  it  really  is.  Yet,  if  you  pick  up  many  books  devoted  to 
air  and  ventilation,  you  will  find  these  figures  still  used,  i.  e.,  that  aU 
you  need  to  obtain  good  ventilation  is  400  feet  or  600  feet  per 
capita.  I  always  illustrate  the  fallacy  of  that  to  my  students  by 
saying  that  I  would  rather  have  my  head  inclosed  in  a  box  of  1  cubic 
foot  per  capita  with  a  good  breeze  going  through  the  box  than  to  sit 
in  the  biggest  room  in  the  world  where  there  was  no  motion  of  the 
air  at  all;  that  is,  I  would  rather  have  1  cubic  foot  per  capita  of  good, 
fresh  circulating  air  than  any  number  of  feet  per  capita  of  stagnant 
air.  Prof.  Winslow  has  rightly  concluded,  I  beUeve,  that  the  large 
part  of  this  question  is  the  question  of  stagnation — stagnant  air. 

The  Chairmak.  If  there  are  no  further  remarks  I  will  call  upon 
Dr.  Winslow  to  close  the  discussion. 

Dr.  Winslow.  There  are  a  few  things  I  wish  to  take  up.  In  the 
first  place,  Dr.  Guiteras,  as  far  as  our  experiments  went,  we  found 
no  diminution  in  the  mental  work,  but  rather  the  reverse.  We  foimd 
more  mental  activity  as  the  temperature  rose  above  76°.  We  foimd 
a  decrease  in  optional  phjrsical  work,  but  an  increase  in  optional 
mental  work. 


246       PBOOEEDIKGS  SECOND  PAN  AMBBIOAN  8CIENTIFIG  OONQBE88. 

I  may  say  with  regard  to  the  point  raised  by  another  speaker  that 
we  had  of  course  our  subjects  under  the  same  conditions,  so  that  I 
think  conditions  were  fair,  but  we  did  not,  of  course,  work  them  for 
long  periods  of  time.  Now  Prof.  Himtington's  work  on  students  at 
West  Point  and  Annapolis  in  classes  in  mathematics  showed  a 
diminution  imder  high  temperature,  and  these  results  show  very 
strongly  for  a  period  of  five  years  in  the  daily  marks.  Whether 
that  is  conclusive  remains  to  be  seen. 

As  to  the  question  of  dryness,  I  have  always  felt  personally  that 
very  dry  air  was  bad.  Many  people  say  dry  air  makes  them  nervous 
and  that  they  feel  badly.  All  I  can  say  is  that  our  work  has  failed 
to  show  any  effect  whatever  on  the  membranes  of  the  nose  and  throat. 
The  most  extensive  experiments  on  the  effect  of  dry  air  in  nervous- 
ness, interfering  with  very  delicate  reactions  have  been  made  by 
Prof.  Thorndyke.  These  results  so  far  are  negative.  I  think  we 
must  regard  the  bad  effects  of  dry  air  per  ae,  apart  from  heat,  as 
unproved. 

Col.  HoFF.  Prof.  Sedgwick  seemed  to  be  inclined  to  question  the 
effects  of  air  space,  cubic  feet,  etc.  Are  you  proposing  to  eliminate 
that  point  entirely?  Are  we  to  adopt  no  standard  of  air  space?  In 
the  Army  we  demand  a  minimum  of  600  cubic  feet  and  60  square 
feet  of  floor  space,  and  in  our  hospitals  we  require  a  larger  allowance. 
Are  we  to  eliminate  that  entirely  ?  There  is  no  doubt  that  movement 
of  the  air  is  an  extremely  desirable  thing.  For  example,  take  the 
Caribbean  Islands,  where  we  have  the  trade  winds  the  year  through. 
I  spent  a  couple  of  years  in  Porto  Rico,  and  it  did  not  seem  to  me 
that  it  was  at  all  troublesome  to  do  a  great  deal  of  hard  work  that 
had  to  be  done  down  there  at  the  time.  On  the  other  hand,  in  the 
Philippines,  where  wind  is  not  blowing  so  constantly  as  it  is  in  the 
Caribbean  Sea,  the  situation  seems  to  be  somewhat  different. 

Dr.  WmsLOw.  I  think  it  is  probably  true  that  there  is  a  lower  hmit 
below  which  it  is  difficult  to  get  motion  of  air  without  inconvenience. 
I  am  not  sure  that  that  l*foot  box  really  would  be  comfortable  with 
the  amount  of  air  going  through  it,  but  I  think  what  Prof.  Sedgwick 
meant  was  that  our  present  per  capita  standard  was  based  on  a 
wrong  conception  of  our  needs.  The  result  of  the  British  commis- 
sion on  factory  ventilation  was  that  there  was  no  relation  between 
the  actual  amoimt  of  air  and  the  per  capita  space  in  the  factory. 

The  CHAmMAN.  The  following  papers  will  be  read  by  title  before 
adjournment: 

Climatologia  dos  Campos  do  Jordfto  S.  Paulo,  by  Victor  Godinho. 

Nouveau  proc6d6  pour  la  transfusion  du  sang,  par  Louis  Agote. 


FUBUO  HEALTH  AND  MEDIOINE.  247 

CUMATOLOGU— CAMPOS  DO  JORDlO— S.  PAULO. 

For  VICTOR  GODINHO, 
Dvtdor  do  Hospital  de  Isolamento  de  8do  Paulo. 

Ha  dez  annos  que  00  Dree.  Emilio  Marcondee  Ribas  e  Victor  Godinho  esforyam- 
06  por  obter  dos  poderee  publicofl  do  Estado  de  Sfto  Paulo  e  do  Govemo  Federal  do 
Brasil  anxilios  afim  de  constmir  sanatorios  para  tuberculoeos  e  uma  villa  sanitaria 
para  peesoas  iracas,  convalescentee,  de  repouso  para  oe  individuos  enfraqueddoa  por 
qualquer  causa,  ou  simplesmente  veranistas. 

Em  1908  conseguiram  do  Gongresso  do  Estado  a  approva^So  de  uma  lei  que  Ihee 
garantia  uma  subven^&o  annual  de  Rs.  60:0001000  durante  20  annoe  para  construc^fto 
de  sanatorios.  Tratando  entfto  de  estudar  a  climatologia  das  differentes  localidades 
do  Estado  de  Sfto  Paulo,  reconheceram  que  a  situa^fto  deeejada  estava  situada  nos 
Campos  do  Joidfto  a  1,640  metres  de  altitude,  nas  vizinhan^as  da  villa  Jaguaribe. 
£  um  lugar  de  clima  privilegiado  e  gosando  \k  de  grande  fama  em  todo  0  paiz,  fama 
giangeada  por  innumeras  curas  alii  conquistadas,  deede  longa  data,  por  muitas  centenas 
de  tuberculosos. 

£  um  clima  de  montanha,  amenisado  pela  posi^So  geographica,  proxima  da  linha 
tropical,  ao  abrigo  de  ventos  tempestuosos. 

A  villa  Jaguaribe  fica  a  22^  44^  latitude  sul  e  45^  35^  de  longitude  a  oeste  de  Green- 
wich. PresB&o  barometrica  annual,  633.2  m.  m.,  notando-se  164  dias  por  anno  de 
dias  claros.  A  temperatura  media  annual  ^  de  13^  l^(centigTado),  sendo  os  extremes 
absolutos — 7^  e  28^  8^,  havendo  pois  uma  varia9&o  annual  de  35^  8^.  Nebulosidade 
media  annual  egual  a  3.3  e  humidade  relativa  variando  de  61  a  95. 

"&  pois  um  clima  temperado  situado  em  zona  quente  e  modificado  pela  altitude 
e  podpfto  geographica.  Quanto  aos  ventos  temos  uma  taxa  de  34  por  cento  de  fre- 
quenda  para  as  calmas,  27.4  por  cento  para  os  ventos  seccos  NE.  e  NW.  e  16.7  por 
cento  para  os  ventos  humidos  SW.  e  SE. 

Oonvenddos  que  os  sanatorios  para  tuberculosos  deviam  ser  construidos  nesse  clima 
ideal  dos  Campos  do  Jordfto,  oe  dois  medicos  tiveram  de  reconhecer  tambem  que 
a  viagem  era  extremamente  incommoda  para  aUi,  predsando-se  lugentemente  cons- 
tihiir  uma  estrada  de  ferro  que  ligasse  Pindamonhangaba  a  villa  Jaguaribe. 

Por  eesa  razfto  voltaram  a  solicitar  ao  Gongresso  Estadoal  favores  para  a  construcgfio 
para  a  referida  estrada  e  por  eesa  forma  a  concesrtU)  primitiva  para  construcySo  de 
sanatorios  foi  convertida  em  concessfio  para  a  Estrada  de  Ferro  dos  Campos  do  Jcxxl&o. 
A  sombra  doe  favores  officiaes  a  estrada,  que  era  0  primeiro  passo  para  conquista  de 
um  tfto  excellente  clima  e  para  a  construc^fto  posterior  dos  sanatorios,  foi  construida 
e  vai  ser  encampada  pelo  Govemo  do  Estado,  visto  os  embara^os  da  companhia  cons- 
tructora  em  ultimar  a  obra.  S6  folta  adquirir  o  material  rodante  e  electrificar  a 
tracy&o,  0  que  o  Govemo  far&.  Por  emquanto  o  trafego  provisorio  fitz-se  com  machinas 
a  vapor  e  automoveis  de  linha,  apezar  das  rampas  de  10  por  cento  na  Serra  da  Manti- 
queira. 

A  estrada  come9a  em  Pindamonhangaba,  quasi  a  meio  caminho  eatre  Rio  de  Janeiro 
6  Sfto  Paulo.  A  viagem  na  nova  estrada- offerece  pontes  de  vista  deslumbrantes,  mais 
belles  do  que  o  que  se  gosa  na  Serra  do  Mar  atravessada  pela  Sfto  Paulo  Railway. 
A  altitude  6  muito  maior,  1,750  metres  acima  do  nivel  do  mar,  no  ponto  mais  alto  da 
Serra  da  Mantiqueira,  0  horizonte  muito  mais  vasto  e  os  panoramas  mais  variados. 

Campos  do  J<HrdSo  ^  uma  regifto  de  campos  naturaes  em  que  sfto  muito  abundantes 
OS  pinheiros  {Araueana  hraaUientii),  Ha  l&  cerca  de  2,000,000  de  pinheiros  de  mais 
de  100  annos,  prestando-se  i  expl(»a$&o  da  madeira  e  sem  despir  os  mattes.  Todos 
OS  valles  sfto  cobertos  de  pinheiros,  todos  elles  cercados  de  campos  com  excellentes 
paetagens  para  a  creagfto  de  gado  cavallar,  bovine,  ovino  e  suino.     Estas  creayOes 


248       PROCEEDINGS  SECOND  PAN  AMEBIOAN   SCIENTIFIC   CONGRESS. 

teem  sido  ensaidas  com  muito  sueceflso,  mas  s&o  at^  agora  pouco  desenvolvidas  por 
causa  de  difHculdade  no  traoBporte. 

A  villa  Jaguaribe  desde  muitos  amios  6  procurada  por  tuberculoflos  que  na  sua 
grande  maioria  \&  encontraram  a  cura  ou  pelo  menos  uma  melhcMA  muito  accentuada. 
No  entanto,  nfto  ha  ainda  um  sanatorio  medelar  e  uma  villa  sanitaria,  com  todas  aa 
regras  da  hygiene,  como  projectam  construir  00  dois  facultativos. 

Uma  vez  realisados  esses  projectos,  a  esta^  climaterica  dos  Campos  do  Jordfto  esti 
destinada  a  attrahir  concorrentes  de  todo  0  Brazil  e  mesmo  dos  paizes  vizinhos, 
especialmente  0  Uruguay  e  a  Argentina. 

Oa  dois  medicos  fizeram  contracto  com  a  municipalidade  de  Sfto  Bento  do  Sapucahy 
para  construirem  na  villa  Jaguaribe  100  casas  e  gozam  dos  segumtee  favores:  isen^&o 
de  impostos  para  as  100  primeiras  casas;  luivilegio  para  abastecimiento  de  agua. 
luz  e  esgotos  e  para  for^a  electrica.  A  agua  6  abundante  e  purissima  e  as  cachoeiras 
numerosas  e  de  grande  forga.    Uma  dellas  produz  uma  for^a  de  12»000  cavallos. 

A  regiAo  presta-se  admiravelmente  para  cultura  das  fructas:  magans,  peras,  pecegos, 
figos,  etc.  Muitas  arvores  fnictiferas  est&o  }&  plantadas  e  dellas  se  tem  colhido  fructos 
abuntantes  e  deliciosos. 

Estd  em  discussfto  no  Congreeso  Federal  um  projecto  concedendo  garantia  de  juros 
de  6  por  cento  ao  anno  sobre  0  capital  de  Rs.  2,000:000$000  para  construcg^o  da  villa 
sanitaria  e  sanatorios,  isengio  de  impostos  aduaneiros  para  o  material  de  construc9^ 
e  rouparia  do  sanatorio  e  das  100  primeiras  casas. 

L'epende,  por^m,  da  resolug^  do  Congresso.  0  escriptor  deeta  pequena  com- 
muoica^  tem  esperanga  de  dotar  0  Brasil  de  uma  excellente  esta^  climaterica, 
procurada  como  fonte  de  sadde,  de  repouso  ou  simplesmente  de  recreio,  e  junto  da  qual . 
n^  distancia  de  6  kilometres,  serSU)  construidos  sanatorios  modelos  para  0  tratamento 
doB  tuberculoses.  Elle  6  proprietario  de  220  alqueiree  de  terra,  que  adquiriu  pam 
03  estabelecimentos  que  projecta,  garantindo  assim  0  come90  de  execu90  do  seu 
bonemerito  emprehendimento. 


NOUVEAU  PROCfiDfi  POUR  LA  TRANSFUSION  DU  SANG. 

Par  LOUIS  AGOTE, 

Pro/essewr  de  Clinique  MidicaU,  Bueno$  Ayres,  Argentina, 

La  transfusion  du  sang,  le  recours  pr^eux,  au  moyen  duquel  il  est  possible  de 
sauver  dee  milliers  de  personnes,  victimee  d'h^morragies  intenses,  n'aipu  dtre  utilise 
pratiquement  avec  Tamplitude  qu'on  pouvait  esp^rer  de  son  indlscutable  efficadt^; 
ceci  est  dQ»  non  seulement  aux  difficult^  d'une  manipulation  compliqu^  et  seule- 
ment  realisable  par  un  chirurgien  familiarise  en  chiruigie  vaaculaire,  mais  aussi  par 
les  mortifications  vraiment  douloureuses  souffertes  par  la  personne  donnant  du  sang. 
N^cessite  de  d^nuer  la  veine  dans  I'eepace  suffisant  afin  de  pouvoir  faire  la  suture  k 
la  veine  du  malade,  ce  qui,  en  reality,  constitue  toute  une  operation  chinirgicale. 
Ajoutez  &  tout  cela,  ce  qui  n'est  pas  depreciable,  le  danger  imminent  dee  embolies 
dans  le  syst^me  clrculatoire  du  malade,  graves  complications  difficiles  k  eviter  mal- 
gre  toutes  les  precautions  que  Pon  pourrait  prendre.  C'est  ce  h  quoi  Pon  doit  attri- 
buer  les  cas  de  mort  dej^  observes.  Comme  si  tout  cela  n'etait  pas  suffisant  pour 
restreindre  Pemploi  de  la  transfusion  parPanastomose  arterio-veineuse,  il  faut  compter 
encore  la  circonstance  aggravante  de  ne  pas  savoir  exactement  la  quantite  du  sang 
transfuse;  ceci  peut  ne  pas  avoir  d'importance  pour  celui  qui  le  reyoit,  mais  beaucoup 


PUBLIC  HEALTH  AND  MBQIOIKE.  249 

pour  celui  qui  le  doxme  (on  a  observe  dee  caa  de  d^faillance,  syncopea,  mort,  etc.):  1® 
danger  de  Pinfection  dee  blessures  produites  afin  de  dinner  lea  veines,  ^vit^  par  dee 
moyens  parfaitement  aseptiquee— par  exemple,  dans  une  salle  d'op^tiona — cela 
n'arrive  pas  ailleurs  et  sp^alement  dans  lee  hdpitaux  de  campagne,  en  cas  de  guerre 
oil  la  transfusion  aurait  un  champ  d'application  vaste  et  efficace. 

Tons  cee  inconv^nients  et  d'autrea  que  nous  vouloua  taire  afin  de  noua  r6f6rer  aeule- 
ment  aux  plus  forta,  experimental  demidrement  k  Toccasion  d'un  easai  de  tranafuaion 
par  lea  proc6d^  recommand^  ap^alement  par  lea  chirugienB  de  P  Am^rique  du  Nord, 
noua  ont  induit  &  6tudier  dana  Tinatitut  mod^e  de  clinique  m^dicale,  Tint^reaaant 
probl^me  afin  de  chercher  aa  aolution  partielle  ou  totale,  profond6ment  convaincua 
que  la  r^aliaer  actuellement  conatitue  un  recoura  vraiment  exceptionnel.  Noa  efforts 
r^lis^a  en  collaboration  du  docteur  Ig.  Imaz  Appathie,  mMedn  en  chef  dea  labora- 
toirea  de  Tinatitut,  ont  donn6  dee  r^aultata  favorablea,  permettant  d'aaaurer  que  la 
tranafuaion  du  aang,  c'eat-^ire  I'injection  de  ce  liquide  provenant  d'un  aujet  aain  a 
un  autre  aujet  malade,  comme  noua  le  conseillona,  aperdu  toua  ceadangera,  conatituant 
un  proced^  clinique  aimple  d'une  ex^ution  facile  et  &  la  port^  de  toua  lea  m6decina. 
II  remplU  alors  lea  conditUms  exigSes  par  la  clinique  nUdioale, 

Sana  vouloir  raconter  Thiatoire  de  noa  travaux,  eaaaia,  fracaa  et  vadllationa,  juaqu'it 
Parriv^  k  un  r^eultat  d^finitif  et  satiafaiaant;  sana  vouloir  diacuter  aur  lea  diveraea 
queationa  entrelac^  k  ce  probl^e  intdreasant  et  qui  aiirement  ae  pr^senteront  auaai  k 
Teaprit  du  lecteur,  il  nous  suffit  d'assurer  qu'elles  ont  6t6  ^tudi^es  et  r^eolues,  adit 
par  noa  proprea  travaux  soit  par  d'autres  observateurs.  Nous  nous  limiterons  k  la 
description  de  notre  proc^^,  tel  qu'il  r^sulte  de  nos  experiences  concluantes,  faites 
premi^rement  sur  des  animaux  et  ensuite  sur  des  hommes,  pouvant  assurer  sa  parfaite 
innocuite. 

Notre  precede  est  celui  de  la  transfusion  immMiate/  en  prenant  du  sang  de  la 
veine  du  pli  du  coude  du  donnant,  recueilli  dans  tm  recipient  ou  appareil  dermoclyse, 
contenant  une  solution  de  citrate  de  neutre  sonde  au  25%,  dans  la  proportion  d*un 
gramme  pour  cent  grammes  de  sang.  Ce  melange  rend  le  sang  incoagulable,  sans 
qu'il  perde  ses  qualit^s  vitales.  Comme  le  citrate  neutre  de  soude  est  absolument 
inoffensif  pour  Foiganisme  en  quantites  beaucoup  plus  grandes,  on  pent  injecter  ce 
mi'ilange  au  malade,  avec  toute  facility,  sans  aucun  danger,  dans  les  veines  de  Pavant- 
bios  au  moyen  du  mdme  appareil  et  comme  n'importe  quelle  autre  injection  endo- 
veineuse. 

Cette  merveilleuse  propriety  du  sel  de  soude  d'emp^cher  la  coagulation  du  sang, 
fait  de  la  transfusion  une  operation  tr^  simple,  k  la  port6e  de  tout  le  monde,  suppri- 
mant  d6finitivement  les  dangers  pr^sent^s  jusqu'ici,  gr&ce  k  ce  recours  d'un  effet  tr^ 
efficace.  D'autre  part,  elle  r^duit  Tacquisition  du  sang  a  la  simple  piqiire  d'lme 
aiguille  en  platine  (le  diam^tre  interieur  d*un  millimetre  est  suffisant),  suivant  le 
m^me  proc^eae la saign^e;  personne  ne  verra  d^inconvenients  k donner  une  quantity 
determinee  de  sang,  sans  s'exposer  k  souffiir,  durant  des  jours,  des  consequences 
comme  nous  le  sommes  de  son  innociute;  la  transfusion  sous  cette  forme  doit  entrer 
dans  la  pratique  courante  de  rasaistance  medicale,  dans  les  cas  indiques  et  durant  lea 
epoques  de  guerre  comme  actuellement  elle  constituera  le  recours  suprdme  pour 
combattre  les  grandes  pertes  de  sang. 

On  pourrait  objector  k  notre  precede  Temploi  du  sang  veineux  au  lieu  de  Tarteriel. 
Rappelons  que  Temploi  de  T anastomose  arterio-veineuse  n'a  pas  ete  faite  pour  la 
qualite  du  sang,  mais  afin  de  pouvoir  utiliser  la  forte  pression  arterielle,  indispensable 
au  moment  d'une  transfusion  directe. 

Librea  par  conaequent  de  cette  impoeition,  noua  pouvona  utiliaer  aans  danger  le 
aang  veineux,  d'autant  plus  lorsqu'il  appartient  k  la  circulation  peripherique,  mais 
toute  objection  reate  nulle,  noua  laiaaant  librea  d' utiliaer  la  circonatance  favorable  de 
I'avoir  k  notre  portee  au  moyen  d'une  aimple  piq(ire. 

1  Nous  avous  fait  la  premi^  transfasicm  le  14  de  novembre  de  1914. 


260       PBOOBEDIKQB  SBOOKD  PAH  AMKRIOAy  SOIBNTIFIO  00NGBB8S. 

Apr^  tout  cela,  le  liquide  injects,  en  p^n^trant  dans  la  cixculation  du  malade  va 
soufirir  la  mdme  depuration  pulnumaire  que  celle  k  laquelle  il  a  M  aoumiB  dans 
Poiganiflme  du  malade;  il  s'oxygtee  ainsi  dans  le  r^pient  comme  dans  le  pounu>n. 
L'observation  aurait  sa  raison  d'dtre  s'il  s'agissait  de  sang  pris  dans  une  veine  .  .  . 
d'une  visc^  (du  foie  ou  du  rein). 

MANliRI  DB  PBOOiniE. 

L'op^tion  n'offre  aucune  difficult^.  On  peut,  k  la  rigueur,  employer  Tappareil  de 
Potain  ou  n'importe  quel  autre  semblable,  utilise  pour  les  injections  endo-veineuses. 
Nous  conseillons  Pemploi  d'un  modMe  construit  par  la  maison  Lutz  y  Schuls  de 
cette  capitale,  d'aprds  noe  indications.  L'appareil  se  compose  d'un  r^pient  en 
verre  gradu6  k  deux  tubes,  avec  ouverture  relativement  laige.  On  cherche  que  le 
sang  tombe  directement  de  la  canule  au  r^pient  dont  le  fond  se  termine  en  pointe, 
afin  que  le  tube  injecteur  en  verre  arrive  au  niveau  plus  bas  du  liquide  et  permette 
ainsi  d'utiliser,  sans  que  Pair  entre,  la  plus  grande  quantity  de  sang,  dbrconstance 
tr^  importante  lorsqu'il  s*agit  de  cette  mati^re.  La  branche  la  plus  longue  porte 
I'aiguille  en  pladne  pour  Tinjection,  imie  au  moyen  d'un  tube  en  caoutchouc,  d'un 
calibre  int^eur  plus  ou  moins  ^gal  k  celui  du  tube  en  verre,  et  la  plus  courte  de 
laquelle  de  diam^tre  suflBsant  afin  de  pouvoir  le  tenir  en  position  verticale. 

Elu  le  donnant  et  qu'on  est  assure  de  sa  parfaite  sant^,  en  pratiquant  toujours,  si 
cela  est  possible,  la  reaction  de  Wassermann,  refusant  celui  dont  le  r6sultat  a  ^t^ 
poeitif  mtoie  quand  il  s'agit  d'un  malaise  sp6cifique  en  se  rappelant  des  diversity 
des  ipiroqiietes,  avec  see  consequences  pour  le  pronostic.  On  prendra  le  sang  dans  la 
veine  du  donnant,  sans  couper  la  pei^u,  au  moyen  de  TaiguiUe  en  platine,  apr^  avoir 
lie  le  bras  plus  haut  que  le  pli  du  coude,  ou  en  incisant  la  veine  par  une  incision 
comme  dans  n'importe  quelle  saign^e.  On  recueille  le  sang  dans  le  recipient  choisi 
dans  lequel  on  depoeera  prealablement  trois  grammes  de  la  solution  nommee  plus 
haut,  quantite  suffisante  pour  trois  cents  gnunmes  de  sang,  mdme  lorsqu'on  n'arrive 
pas  k  recueillir  la  dite  quantite,  puisque  etant  inofifensif  pour  Torgamsme,  ce  surplus 
n'a  aucime  importance.  II  est  convenable  d'agiter  doucement  I'appareil  pendant 
que  Ton  recueille  le  sang,  afin  de  fadliter  le  melange  des  deux  liquides  et  d'eviter 
la  coagulation  dans  les  parties  libres  de  son  contact.  Ceci  fait,  on  I'injectera  dans  la 
veine  du  malade,  suivant  le  procede  ordinaire  pour  les  injections  dans  lee  veines,  en 
prenant  les  precautions  du  cas. 

L'extraction  de  300  grammes  de  sang  chez  un  individu  normalement  robuste  est 
f  acilement  tolerable. 

Afin  d'eviter  une  syncope  ou  une  simple  defaillance  on  peut  lui  faire  prealablement 
une  enteroclyse  de  300  grammes  de  serum.  On  peut  ainsi  injector  apr^  avoir  pratique 
Pextraction  de  la  mdme  quantite  de  la  solution  saline  dans  la  veine  dennant.  L'ab- 
sorption  du  serum  par  le  rectum  est  presque  simultanee  avec  le  sang,  de  mani^re 
que  celui-Ui  conserve  en  tout  temps  son  equilibre  circulatoire. 

Apr^  la  transfusion  on  n' observe  pas  de  temperature,  ni  rien  de  particulier.  Nos 
affirmations  ont  ete  faites  aprds  avoir  analyse  soigneusement  les  urines  recueilliee  de 
deux  en  deux  heures,  ce  qui  montre  Tincorporation  complete  du  sang  injecte  dans  la 
masse  sanguine  du  malade.  Quant  k  Texamen  du  sang,  celui-ci  a  demontre  Paug* 
mentation  dee  elements  figures  et  de  I'hemoglobine,  comme  la  tension  sanguine  et 
la  reduction  de  la  tachycardie.  Consecutivement  k  ces  signes  retat  general  du  malade 
est  mieux. 

The  Chairman.  This  completes  the  program  of  the  afternoon,  and 
the  session  is  adjourned. 


SESSION  OF  SUBSECTION  B  OF  SECTION  Vin.> 

New  Ebbitt  Hotel, 
WednesdoA/  morning,  Januafy  5,  1916. 

Chairman^  Sam  L.  Rooebs. 
General  Topic: 

Pan  Amexloan  Theme:  Firogrees  of  Vital  StatiatieB  in  Pan  Amexiean 
Countries. 

The  session  was  called  to  order  at  9  o'clock  by  the  chaurman. 

TOOFOBMACION  DE  las  ESTADlSnCAS  DEMOGRlnCAS  Y  DE  LA  FECHA 
DE  LEVANTAMIENTO  DE  LOS  CENSOS  DE  POBLACION  DE  LOS  PAlSES 
PANAMEiaCANOS. 

Por  ALVARO  COVARRUBUS  ARLEGUI, 
Je/e  de  Section  de  la  Ofiama  Central  de  Estadisticaf  de  Chile. 

Introducci6n. 

En  el  presente  trabajo  no  aparecer&n  dfras  que  den  a  conocer  demogr^camente  los 
paiaes  panamericanoB,  ni  trataremoe  de  demostrar  la  neceeidad  de  que  cada  uno  de 
ellofl  organice  la  eetadlstica  del  ramo;  puee  ya  no  ee  dlscute  que  este  servido  fonna 
parte  integrante  de  la  admini0traci6n  y  que  oL  alguno  no  cuenta  aun  con  61,  no  ee 
porque  ee  deeconozca  su  importancia,  sine  x>or  causae  de  otro  orden  que  no  ee  del  caeo 
analizar. 

Por  lo  tanto,  el  presente  trabajo  tiene  por  objeto  proponer,  en  forma  eepedal,  la 
uniformaci6n  de  lae  Eetadfsticae  Demogr&ficae  para  bacerias  comparablee  entre  d 
proponiendo  a  la  yez,  entre  otras  coeae,  la  reducci6n  de  lae  mucbae  materiae  que  boy 
comprende  la  demografia  y  que  no  eet^  claramente  determinadae. 

Parte  I. — Definicidn  de  la  df!mograf\a, 

Etimoldgicamente  la  palabra  demografia  ee  deriva  de  la  griega  Demoe,  que  significa 
pueblo  y  Graptein,  deecribir;  o  sea,  deecripci6n  de  loe  puebloe. 

Se  puede  dedr  que  el  creador  de  eeta  palabra  fu6  el  doctor  en  dencias  y  eabio  bot4- 
nico,  Aquilee  GuHlard,  que  la  us6  por  primera  vez  en  el  Congreeo  de  BrueelaB  el  afio 
de  1853,  defini^dola  de  la  siguiente  manera:  "Es  la  bistoria  natural  y  social  de  la 
eepecie  bumana"  y  en  un  sentido  m^  reetringido:  ''  Es  el  conodmiento  matem&tico 
de  lae  pobladonee,  de  sue  movimientoe  genendee,  de  su  eetado  ffsico,  civil,  inte- 
lectual  y  moral." 

Deede  eea  fecba,  casi  todoe  loe  eecritoree  eobre  eetadletica  o  denciae  eocialee  y  lae 
pereonae  dedicadae  a  esta  clase  de  eetudioe  la  ban  definido  en  eentidoe  divereoe. 

E .  Lavaeseur,  en  su  libro  sobre  la  pobladdn  de  Francia,  la  define :  ' *  £s  la  dencia  de  la 
pobladdn:  ella  estudia  sue  movimientoe  y  prindpalmente  sue  nacimientoe,  matri- 
monioe,  defundonee  y  su  inmigrad6n;  ella  se  esfuerza  por  llegar  a  conocer  las  leyes 
que  los  rigen.    Ee  la  dencia  de  la  vida  bumana  en  eu  eetado  social." 

1  Then  wss  no  steDOgraphio  report  of  this  session. 

251 


252       PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC  CONGRESS. 

Ferraris  dice:  ^'Es  la  ciencia  de  la  pobladdn."  Meeadaglia:  ''Es  la  cienda 
estadistica  de  la  poblaci6n,''  y  Benini:  ''Es  la  ciencia  cuantitativa  de  la  poblaci6n/' 

Estas  definiciones  y  muchas  otras  ban  formado  algunas  sin  autores  conocidoe,  por 
ejemplo:  ^'Es  la  ciencia  del  hombre  comdderado  socialmente  y  en  cuanto  pueda  ser 
expresada  por  medio  de  cifras  num^ricas'';  otra:  ''Es  el  estudio  y  deecripci6n  de  loe 
pueblos,  teniendo  en  cuenta  la  edad,  profeei6n,  domicilio,  etc.,  de  loe  individuos." 

Las  definiciones  anteriores  nos  demuestran  doe  coeas:  que  eziste  discon- 
formidad  de  apreciaciones  y  que,  segtin  las  ^pocas,  se  restringen  o  ensanchan  las 
materias  que  debe  comprender  la  demograffa. 

Pabtb  II. — Materias  que  camprendia  la  demografia. 

Por  las  definiciones  anotadas  se  deduce  que  el  campo  de  acci6n  de  la  demografia 
es  casi  ilimitado;  pnes  abarca  la  mayorfa  de  las  estadisticas  que  se  relacionan  con  los 
hombres.  Ella  comprende la natalidad,  nnpcialidad,  mortalidad,  inst2iicci6n,  justicia, 
criminalidad,  migraci6n,  estaditicas  morales,  politicas,  religiosas,  etc. 

Sin  entrar  a  profundizar  cada  una  de  estas  materias,  se  ve  que,  aunqueligadas 
indirectamente  entre  si  forman  un  bloque  hetereog^eo  de  dificil  amalgamacidn. 

Parts  III. — SegregaMn  de  algunas  materias  que  comprendia  la  demografia. 

En  un  prindpio  no  present6  mayores  dificultades  el  estudio  de  la  demografia  en  la 
forma  amplia  en.  que  fu6  concebida;  pero  el  avance  de  las  ciendas  di6  a  conocer 
que  algunas  de  las  materias  comprendidas  en  ella,  debian  ser  investigadas  independi- 
entemente,  para  lo  cual  se  necesitaban  informadones  distintas  que  para  las  demib. 

Estas  nuevas  investigadones  trajeron  como  consecuenda  la  desmembrad6n  de  la 
demografia,  y  lentamente  los  Institutes  de  estadisticas  publicaron  trabajos  espedales 
sobre  muchas  de  ellas,  dejando  para  ser  tratadas  en  conjunto  s61o  aquellas  cuyas 
informadones  provenfan  de  una  misma  fuente. 

Parts  IV. — Materias  que  debe  comprender  la  demografia. 

Como  se  ve,  en  la  desmembraci6n  de  que  hablamos  no  ha  intervenido  directamente 
instituddn  o  persona  algiina,  66I0  ha  side  originada  por  la  fuerza  de  las  drcunstandas. 

De  aqui  que  en  la  actualidad  no  se  sepa  con  exactitud  las  materias  que  legltimamente 
le  corresponden;  imponi^ndose  pues  la  necesidad  de  eetablecerlo  de  una  manera 
categ6rica. 

La  prdctica  que  en  este  case  ha  representado  la  opini6n  de  la  mayorla  de  los  dem6- 
grafos,  ha  fijado  ya  casi  definitivamente  las  materias  que  debe  comprender  y  que  son: 
los  matrimonios,  nacimientos,  naddos-muertos  y  defundones. 

Existen  tambi^n  razones  de  otro  orden  que  concuerdan  con  las  fijadas  por  la  pr&ctica 
y  que  omitimos  anotarlas  aqul  para  hacerlo  en  el  capltulo  siguiente. 

Xo  contrariando  lo  establecido  por  la  pr&ctica  ninguna  dispo8id6n,  falta  para  darle 
fuerza  l^;al  un  acuerdo  intemacional. 

Por  tanto  se  entenderd  en  lo  sucesivo  por  demografia  la  ciencia  que  trata  exclusiva- 
mente  de  los  nacimientos,  matrimonios,  naddos-muertos,  defundones  y  bus  derivados. 

Como  la  palabra  derivados  encierra  la  mayorla  de  las  informaciones,  anotamos  las 
que  a  nuestro  juicio  debe  comprender:  derivados  de  los  matrimonios  son  los  divcnrdos; 
de  los  nacidos-muertos,  los  fetos  y  abortos  y  de  las  defunciones,  los  suicidios. 

Posiblemente  causard  extrafieza  que  la  migrad6n  que  estd  Intimamente  ligada  con 
el  aiunento  de  la  poblacidn,  haya  side  eliminada  de  la  demografia;  pero  para  obrar 
de  esta  manera  nos  hemes  apoyado  en  el  siguiente  aigumento: 

Cuando  los  medios  de  locomoci6n  no  hablan  alcanzado  el  desarroUo  actual  la  migra- 
d6n,  relativamente  redudda,  constitula  86I0  un  hecho  social  secundario  que  podia  ser 
tratado  en  conjunto  con  las  dem^  materias  demogrdficas.  Pero  actualmente  las 
cosas  ban  variado  en  absoluto  y  la  migrad6n  constituye  hoy  dla  un  problema  de  vital 
importanda  para  algunos  palses,  pues  de  61  depende  en  muchos  casos,  la  prosperidad 
futura. 


PUBLIC   HEALTH  AND  MEDICINE.  253 

For  esta  causa  loe  paiises  de  migracidn  intensa  hau  separado  las  estadlsticas  migra- 
torias  de  las  demogrdj&cas,  propiamente  dichas,  a  tin  de  poder  conocer  a  fondo  los 
muchoe  problemas  que  ella  encieira. 

En  consecuenda,  creemoe  que  la  demografia  no  debe  comprender  la  migraci6n  y 
que  su  programa  debe  eer  sdlo  el  que  anotamoe  anteriormente. 

Parts  V. — Conveniencia  de  adoptar  una  definici&n  de  la  demografia. 

A  pesar  de  existir  innumerables  deflniciones  de  la  demograffa  sin  embargo,  la 
mayorla  de  los  autores  estd  de  acuerdo  en  que  no  existe  ninguna  clara  y  preciaa. 

Recordando  las  muchas  materias  que  encerraba  se  comprender&  fdcllmente  que 
las  deflniciones  no  fueran  rigurosamente  exactas  y  que  no  expreearan  su  verdadero 
aignificado. 

Como  lo  hemes  tratado  de  demoetrar,  el  progreso  de  las  ciencias  en  general  y 
el  avance  de  los  estudios  sociales  en  particular,  ha  hecho  que  la  demografia  no  com- 
prenda  ya  el  gran  ndmero  de  materias  que  abarcaba  en  su  origen. 

De  aqui  que  las  definlciones  existentes  ademas  de  no  ser  concretas  no  expresen 
lo  que  es  hoy  la  demografia.  Por  esta  causa  es  necesario  crear  una  definici6n.que 
revele  con  exactitud  su  verdadero  significado. 

Estando  ya  los  limites  de  ella  perfectamente  delineadoe  no  es  dificil  encontrar  una 
definici6n  concisa,  clara  y  exacta  y  que  concuerde  con  la  etimologla  de  la  palabra. 

Para  esto  hay  que  dejar  establecido  que  los  acontecimientos  naturales  mds  impor- 
tantes  de  la  hiunanidad  son  los  nacimientos  y  las  defunciones,  puesto  que  constituyen 
el  principle  y  el  fin  de  la  vida,  y  que  todoe  los  demis  hechos  estdn  subordinados  a  elloe. 

Hemes  dicho  que  etimol6gicamente  la  palabra  demografia  significa  de6cripci6n 
de  los  pueblos.  Dejando  establecido  que  los  nacimientos  y  defunciones  son  sus 
acontecimientos  m^  importantes,  es  natural  que  la  descTipci6n  de  elloe  se  refiera  a 
eetoe  acontecimientos  principalee  y  no  a  otros  de  menos  importancia. 

(El  fondo  de  esta  argiunento  lo  hemes  tomado  tambi^n  en  consideraci6n  para  dejar 
reducida  la  demografia  a  las  cuatro  materias  anotadas  en  el  capitulo  anterior.) 

De  aqui  que  la  detinici6n  de  la  demografia  tomando  en  cuenta  su  etimologla  y  las 
materias  que  comprende,  serla:  "descripci6n  de  los  pueblos  segtin  sus  principales 
acontecimientos  naturales.'' 

A  esta  definici6n  hay  que  agregarle  algo  para  que  abarque  la  nupcialidad,  que  por 
no  ser  creaci6n  de  la  naturaleza,  no  es  acontecimiento  natural  y  por  tanto  estd  eliminado 
de  ella. 

Dada  nuestra  organizaci6n  social,  el  matrimonio  ha  pasado  a  formar  cad  un  aconte- 
cimiento natural  (a  i>e8ar  de  haber  side  creado  por  el  hombre)  pues,  es  el  que  legaliza 
la  reproducci6n  de  la  especie  humana  y  el  que  constituye  la  feunilia,  base  del  engran- 
decimiento  de  las  nadones. 

Por  tanto,  la  definici6n  anterior  podria  quedar  en  la  siguiente  forma:  "Enti^dese 
por  demografia  la  ciencia  que  trata  de  la  descripci6n  de  los  pueblos  s^;tin  bus  princi- 
pales acontecimientos  naturales  y  legales,  en  cuanto  a  la  nupdalidad  se  refiere.'' 

Parte  VI. —  Un'tfbrmidad  de  las  eetadUticas  demogrdficas  panamericana$. 

Es  un  principio  eetadfstico  que  todas  las  informaciones  de  una  misma  naturaleza, 
para  que  sean  delddamente  aprovechadas,  deben  ser  uniformee. 

Consecuente  con  este  principio,  casi  todos  los  Congresos  de  estadlsticas  han  tratado 
de  uniformar  las  demograflas  a  fm  de  hacerlas  comparables  entre  sf .  En  este  sentido 
ee  han  aprobado  diferentes  acuerdoe;  pero  pocos  han  side  los  que  se  han  Uevado  a  la 
pr^tica  en  la  forma  estricta  en  que  se  han  aprobado. 

De  estos  acuerdo  tal  vez  el  adoptado  por  el  mayor  ntimero  de  paises  panamericanos 
ha  side  el  de  la  nomenclatura  intemacional  de  causas  de  muerte,  pero  desgraciada- 
mente  no  ha  side  puesto  en  pr&ctica  en  la  forma  exacta  en  que  fu6  aprobado. 

Revisando  las  publicaciones  demogrdficas  se  \6  que  unoa  han  adoptado  sdlo  la 
n6mina  de  causas  de  muerte;  otros,  la  tabla  de  edades  y  por  tiltimo,  los  hay,  que  han 


254     PBOOBEDnros  beookd  pan  ambbioah  bgibktifio  ookobbss. 

ftdoptado  ambaa  coeaa,  pero  en  forma  tal,  que  con  las  edades  no  ae  pueden  fannu  loa 
grandea  gnipoa  de  que  trata  la  miama  nomendatora. 

Tot  eata  caoaa  laa  eatadfaticaa  demog^rificaa  pan  americanaa  no  ae  preatan  a  eatndioa 
comparatiToa. 

Eata  dificultad  para  cefiirlaa  a  un  miamo  plan  ae  debe  a  delectoa  de  loa  planea  pro- 
pueetoa  con  eate  objeto  y  a  la  forma  como  ban  aido  ai»obadoa,  aogdn  tiataremoa  de 
demoatrarlo. 

El  aervicio  de  eatadfatica  demogrdficahaaido  organizado  en  cadapafa  en  conlonnidad 
al  regimen  adminiatrativo  y  el  aiatema  de  inveatigacidn  y  pnblicaddn,  en  reladdn  a 
loe  problemaa  que  deaean  conocer.  De  aquf  que  cada  uno  tenga  an  aiatema  piopio' 
y  diferente  de  loa  demda,  aegt!in  ae  comprueba  por  laa  reapectivaa  publicadonea.  Aaf , 
por  ejemplo,  mientraa  un  paia  le  da  gran  deaarrollo  a  nupcialidad,  el  otro  apenaa 
la  mendona  y  mientraa  ^ate  uaa  la  palabra  var6n  y  bembra  para  determinar  Ice 
aexoa,  el  otro  emplea  el  de  bombre  o  mujer  o  maacuUno  y  femenino,  etc. 

Luego,  el  fracaso  de  la  uniformacidn  de  las  eatadfaticaa  demogrdficaa  ha  provenido 
de  que  loe  planes  propueetos  anulan  los  sistemas  en  uso,  y  como  ^stoa  ban  aido  creadoe 
aegtin  laa  necesidades  propias  de  cada  pafs,  los  nuevos  aiatemaa  no  lea  ban  reportado 
utilidad  mayor. 

En  consecuencia,  para  Uegar  a  conaeguir  que  se  uniformen  las  estadfatlcaa  demo 
gr^caa  de  los  pafses  panameiicanoe  es  necesario  que  los  acuerdos  que  en  este  sentido 
se  aprueben  no  envuelvan,  ni  directa  ni  indirectamente,  reforma  alguna  en  las  esta- 
(Ifsticas  existentes,  ni  tampoco  anulen  o  bagan  cambiar  loe  procedimientos  en  uso. 

Por  tanto,  para  llegar  a  este  resultado  y  obtener  ^xito  en  la  pr4ctica  respecto  a  la 
umformidad  de  ellas,  proponemos  la  aprobad6n  del  siguiente  acuerdo: 

''Los  pafses  panamericanos  formar&n  y  publicardn  bus  estadfsticas  demogr&ficas  en 
la  forma,  fecba  e  idioma  que  lo  estimen  por  conveniente;  pero  tendrto  la  obligaci6n 
de  bacer  figurar  en  un  capftulo  o  folleto  especial,  laa  informadonea  demogr&ficaa  en 
la  forma  e  idioma  acordado  por  el  Congreeo.  Eate  capftulo  o  folleto  ae  tituladL "  Infor- 
madonea demogr&ficas  acordadas  por  el  S^gundo  Congreso  Cientffico  Panamericano." 

Respecto  al  idioma  creemos  que  siendo  d  espafiol  el  de  la  mayorfa  de  loa  pafses 
panamericanos  deberd  ser  ^ste  d  que  se  adopte. 

Pabtb  VII. — Dates  gus  Comprenderdn  la$  Iriformaciones  Demogr^ficM  Poncrmmoanat. 

Habiendo  dejado  eatableddo  que  la  uniformaddn  propueata  no  se  refiere  en  ningtin 
case  a  laa  estadfstic&s  demogr&ficas  generales  de  cada  pafs,  sine  a  un  capftulo  especial 
de  ellas,  es  necesario,  por  tanto,  establecer  con  claridad  los  dates  que  el  dtado  capftulo 
o  foUeto  dd>e  comprender  y  la  forma  como  se  publicardn. 

Estoa  datoe  deber^  aer  de  interna  prindpal  y  general;  pero,  como  para  determinar 
ambaa  condidonee  se  necedtan  conocer  loe  problemas  aodalea,  econdmicoa,  noao- 
Idgicoa,  etc.,  de  cada  pafe;  y,  como  eato  aeria  materia  de  un  trabajo  largo  y  prolijo  y 
que  ae  preatarfa  a  apreciadonea  err6neaa,  noa  concretaremoa  a  anotar  nominatiyamente 
loe  que  a  nueatro  juido  pueden  aer  dasificadoa  como  de  interns  prindpal  de  cada 
pafe  y  general  para  todos,  badendo  solo  un  Ugero  andlisis  de  elloa  e  inaertando  al  final 
loa  formularioa  reepectivoe. 

P^ira  obrar  con  orden  anotaremoa  primero  los  dates  que  se  refieren  a  los  matrimonies, 
despu^s  los  que  se  refieren  a  los  nadmientos;  en  a^guida  los  de  naddos-muertos  y 
por  tiltimo  los  de  defundones. 

(a)  matrimonios. 

N(!bnero  total  de  matrimonies  y  proporddn  pcM*  mil  habitantea. 

N(!bnero  de  matiimonioa  daaificadoa  aogdn  el  grade  de  parenteaco  de  loa  contra- 
yentee  y  detalladoe  en  urbanoe  y  ruralea.    (Formulario  No.  1.) 

Ntimero  de  matrimonioe  daaificadoa  aegtin  la  nadonaUdad  de  loa  contrayentee  y 
detalladoa  en  urbanoe  y  ruralea.    (Formulario  No.  2.) 


PUBLIC  HEALTH  AND  MEDICINE.  255 

(b)  nagdobntos. 

Ntimero  total  de  nadmientoe  y  proporddn  por  mil  habitaiites. 

Ndmero  de  nacimientoe  ciaaificados  segtin  la  legitimidad  y  el  sexo  y  detalladoe 
en  urbanoB  y  rurales.    (Fonnulario  No.  3.) 

Ntimeio  de  nadmientos  claaificadoB  segiin  la  nadonalidad  de  loe  padres  y  la  legi- 
timidad y  Bexo  de  loe  naddoe,  detallado  en  urbanos  y  runJes.    (Fonnulario  No.  4.) 

Ntimero  de  nadmientoe  daaificadoe  seg6n  la  clase  de  loe  partes,  detalladoe  en 
nrbanoB  y  mralee.    (Formnlario  No.  6.) 

(O)    NAdDOS    ICUBBTOS. 

Se  comprenderd  en  eete  nibro  todoe  loe  que  la  nomendatura  intemadonal  de  caueas 
de  muerte  daeifica  como  talee  y  ademie  loe  abortoe,  fetoe,  etc. 

Ntimero  de  nacidoe  muertoe  daaificadoe  segrhi  la  legitimidad  y  el  eexo,  detalladoe 
en  urbanoe  y  rurales.    (Fonnulario  No.  6.) 

(d)    DBVUNCIONB8. 

Ntimero  de  defundonee  (deecontadoe  loe  naddoe  muertoe)  y  properdin  por  mil 
babitantee. 

Ntimero  de  defundonee  daeificadae  por  cauea,  edad  y  eexo,  detalladae  en  urbanae 
y  mralee.    (Formulario  No.  7.) 

Ntimero  de  defundonee  daeificadae  SQgdn  el  eetado  dvil  y  el  sexo,  detalladae  en 
urbanae  y  mralee.    (Formulario  No.  8.) 

Ntimero  de  falleddoe  menoree  de  un  afio,  dasificadoe  por  cauea,  edad  y  sexo,  detalla- 
doe en  urbanoe  y  mralee.    (Fonnukrio  No.  9.) 

Ntimero  de  fiJleddoe  menoree  de  un  afio  dasificadoe  por  cauea  y  agrapadoe  por 
meeee.    (Fonnulario  No.  10.) 

Ntimero  de  btlleddoe  menoree  de  un  afio  daaificadoe  por  edadee  y  agrapadoe  por 
meeee  del  afio.    (Formulario  No.  11.) 

Los  datoe  que  comprenderi  el  capitulo  o  folleto  de  estad£rtica  demogr&fica  Pan- 
americana,  deber&n  separarse  los  que  se  refieren  a  la  parte  urhana  de  loe  de  la  parte 
tural.  Far  ejemplo,  de  los  matrimonies  se  anotar&n  independientemente  los  cele- 
brados  en  las  dudades  de  los  cdebrados  en  los  campos,  etc.  Para  determinar  esta 
clasificaddn  se  emplear&n  las  abreviaturas  (TJ)  Urbane  y  (R)  Rural. 

Esta  8eparad6n  obedece  a  ]a  necesidad  de  conocer  la  forma  como  se  desarrollan  en 
loe  campoe  y  en  las  dudades  los  diferentes  problemas  sodales,  nosol6gicos,  etc.,  pues 
es  sabido  que  mientras  algunos  acontecimientos  son  antiguos  en  las  dudades,  en  los 
campoe  no  se  conocen,  o  vice-yerea. 

Adem&i,  la  vida  demogr&fica  de  las  dudades  tiene  caracterieticas  especiales  y  que 
si  las  informadones  de  ^stas  van  unidas  con  las  de  los  campos,  fale^anse  mutuamente 
bad^dose  impoeible  su  estudio. 

Respecto  a  la  edad  de  loe  falleddoe,  la  comiBi6n  interaadonal  encaigada  de  la 
revisi6n  de  la  Nomendatura  NoBol6gica  Interaadonal  reunida  en  Parfe  en  julio  de 
1909,  determin6  que  la  clasificadon  de  las  edades  debla  bacerse  tan  detallada  como 
sea  poeible.  Las  razones  que  se  dieron  sobre  el  particular  se  encuentran  en  las 
actas  de  dicha  comisi6n,  por  lo  cual  omitimoe  anotarlas  aquf . 

For  esto  las  edades  de  los  fallecidos  se  anotar&n  sin  formar  grapes  de  afios,  sine  los 
afios  continuando,  esto  es:  Menores  de  un  afio,  de  un  afio,  de  dos  afios,  etc.,  agrapando 
sdlo  los  de  den  afios  adelante. 

Biendo  los  estudios  nosol^gicos  de  ci^tal  importanda  para  la  humanidad,  estimo 
que  se  debe  aportar  a  ellos  el  mayor  ntimero  de  informadones  poeible  y  mis,  cuando 
se  trata  de  paisee  nuevos  como  los  panamericanos  que  en  este  sentido  tienen  muchos 
puntos  no  reeueltos  y  aun  desconoddos. 

Para  reforzar  nuestra  opini6n  anotamos  la  del  Dr.  norteame  ricano,  Carlos  V.  Cbapin . 
'*£1  registro  de  las  eetadfsticas  vitales  es  la  base  firme  sobre  la  cual  debe  descansar 


256       PROCEEDINGS  SECOND  PAN  AMEBICAN   SCIENTTPIC   CONGBESS. 

toda  la  estructura  de  la  ciencia  sanitaria  pr&ctica,  con  el  objeto  de  aprender  las  leyee 
de  las  enfennedades  y  buscar  sns  remedies.  Se  debe  tener  un  conocimiento  exacto 
del  movimiento  de  la  poblaci6n  y  de  las  causas  de  muerte.*' 

Partb  VIII. —  Vnijofrmaicidra  de  las  fechas  de  lo$  cengoi  generales  de  poblaci6n  en  lo9 

jxAsee  panamericanoi. 

Casi  sin  ezcepci6n  todas  las  materlas  que  fonnan  la  demografla  tienen  como  base 
la  poblaci6n  y  sus  deducciones  van  encaminadas  a  conocer  antecedentes  o  a  explicar 
fen6menoB  de  la  poolaci6n  misma.  Per  esto  se  encuentran  fntimamente  ligadoe 
entre  s(  el  censo  y  1*  demografia  y  es  lo  que  nos  ha  inducido  a  tratarlo  en  estetrabajo. 

Todo  lo  propuesto  es  relativamente  f&cil  de  llevar  a  la  pr^tica,  porque  depende 
casi  tinicamente  de  loe  Consejos  o  de  los  Directores  de  Estadistica. 

No  asi  lo  relatdvo  a  la  fecha  de  los  censos  que,  por  lo  que  a  Chile  se  refiere,  esti 
reglamentado  por  una  Ley  de  la  Repdblica. 

Analizando  este  asunto  con  algdn  detenimiento  se  ll^;a  a  la  conclusi6n  que  presenta 
dificultades  que  no  aparecen  a  primera  yista. 

En  primer  lugar  hay  que  tomar  en  consideraci6n  la  parte  econ6mlca  de  la  operacidn, 
que,  con  sus  trabajos  preliminares,  escrutinios  y  publicaci6n  demanda  un  desembolso 
pecuniario  considerable. 

Otro  factor  es  la  situacidn  de  normalidad  que  se  escoge  para  efectuar  el  censo, 
procur&ndose  que  no  haya  ningtin  problema  trascendental  que  agite  la  poblaci6n. 
Cierto  es  que  algunas  voces  se  efectda  sin  tomar  en  consideracidn  ninguno  de  estos 
factores;  pero  solo  por  circunstancias  especiales. 

Ahora  bien,  suponiendo  que  el  congreso  aprobara  la  uniformaci6n  de  las  fechas  de 
los  censos,  al  llegar  la  6poca  fijada,  habrla  palses  cuyo  estado  financiero  no  les  permitirfa 
en  ese  memento,  cumplir  el  compromiso;  a  otros  o  su  situadon  politica  o  social  les 
harla  imposible  la  ejucuci6n  del  trabajo,  o  habiendo  levantado  el  censo  poco  tiempo 
antes  de  la  fecha,  llam^osla  panamericana,  no  lo  repetirlan,  y  por  tiltimo,  Chile 
tendrla  el  Congreso  Nadonal  que  prestarle  su  i^robaci6n. 

Por  estas  causas  y  otras  que  serla  laigo  de  numerar,  la  fijacidn  uniforme  de  la  fecha 
de  los  censos  de  poblaci6n,  presenta  grandes  dificultades. 

Demostrados  ya  los  principales  inconvenientes  que  en  la  pr&ctica  se  presentarian  y 
estando  penetrado  de  su  utilidad,  considero  que  es  indispensable  encontrar  la  forma 
de  solucionarlos. 

Como  para  esto  se  neceeita  estudiar  cada  uno  de  estos  inconvenientes  a  fin  de  poderlos 
remediar,  estimo  que  la  manera  de  llegar  a  un  resultado  es  que  el  Congreso  apruebe 
por  el  memento  s61o  la  idea  de  la  unifcnrmidad  de  la  fecha  de  los  censos,  dejando  el 
detalle  o  sea  la  forma  concreta  del  asunto,  a  caigo  de  slguna  instituci6n  especial,  la 
Oficina  de  la  Uni6n  Panamericana  por  ejemplo,  paza  que  en  el  proximo  congreso 
cientffico  presente  un  proyecto  con  todos  los  antecedentes,  incluso  la  opini6n  de  los 
gobiemos,  respecto  a  la  uniformacion  de  la  fecha  de  los  censos  y  a  las  informaciones 
que  debe  contener. 

Concretando  la  idea  expresada  en  el  ptoafo  anterior,  el  acuerdo  serfa  el  siguiente: 

£1  Congreso  Panamericano  aprueba  la  idea  de  la  uniformaci6n  de  la  fecha  de  los 
censos  de  poblaci6n  y  encarga  al  Institute  de  la  Uni6n  Panamericana  presentar  en  el 
proximo  congreso  un  proyecto  complete  sobre  la  materia. 

CONCLUSIONES. 

En  vista  de  lo  expuesto  en  los  capitulos  respectivos,  el  Segundo  Congreso  Cientffico 
Panamericano,  aprueba  las  siguientes  conclusiones: 

1^.  Las  estadisticas  demogr4ficas  panamericanas  comprendedm  dnicamente  loe 
dates  que  se  refieren  a  los  matrimonies,  nacimientos,  nacidos — ^muertoe  y  defunciones. 
(Antecedentes  Parte  IV  del  texto.) 


PUBUC   HEALTH  AND  MEDICINE. 


267 


2^.  Se  adopta  la  aigmente  definicion  panamericana  de  la  demogiaffa.  '^Entd^ndese 
por  demografla  la  cienda  que  trata  de  la  descripcidn  de  Iob  pueblos  segtin  sus  princi- 
pales  acontecimientos  natuialee  y  legatee,  y  en  cuanto  estos  liltimos  a  la  nupcialidad  se 
refieren."    (Antecedentes  Parte  V  del  texto.) 

3^.  Los  palses  panamericanos  fonnar&n  su  estadfstica  demogi&fica  en  la  fonna  e 
idioma  que  lo  estimen  conveniente;  pero  tendr&n  la  obligaci6n  de  hacer  figurar  en  un 
capftulo  0  folleto  especial  las  informaciones  demogr&ficas  en  la  forma  e  idioma  acorda- 
dos  por  el  Gongreso.  Este  capitulo  se  titulard  **  Informadonee  demogr&ficas  acordadas 
por  el  Gongreso  panamericano.    (Antecedentes  Parte  YI  del  texto.) 

4^.  Los  datos  que  comfo^nderd  el  capftulo  o  folleto  titulado  informaciones  demo- 
gr&ficas  acordadas  por  el  Segundo  Gongreso  Gientffico  Panamericano  ser&n  las  que  se 
detallan  en  los  formiilarios  adjuntos.    (Antecedentes  Parte  VII  del  texto.) 

6^.  Se  aprueba  la  idea  de  la  uniformaci6n  de  las  fecha  de  levantamiento  de  los 
censos  de  poblaci6n  de  los  pafses  panamericanos  y  se  comisiona  al  Instituto  de  la 
XJni6n  Panamericana  para  presentar  en  el  pr6ximo  Gongreso  un  proyecto  complete 
sobre  la  materia.    (Antecedentes  Parte  VIII.) 

Informaeioirus  demogrdfieas  apropuestas  al  Segundo  Congreio  Cieniifico  Panamericano. 

MATRIM0NI08. 
FOBMITLABIO  1. 


Matrimoniofl  aeg6n  el  grado  de  parentesoo. 


Sntro  prlmo»tieniiaD08., 

Entre  if o  7  sobrina 

Bntre  tia  7  sobrlno 

Entre  otios  parlentes . . .. 
Entre  penonas  extniAas. 


Total. 


Nftmero  de  matrimonios. 


Urbana 

(enlae 

dada- 

dee). 


Roral 

(en  los 

oampoe). 


Total 

(reoni- 

dos). 


FOBMYTLABIO  S. 


Matrimonlos  mgAn  la  naotonaHdad. 


Entre  extrai^ieros... 

Entre  nadonales. 

Entre  esposos  naotonatos  j  esposas  extraqleras. 
Entre  esposos  extrai^eros  7  esposas  nadonales. 


Total. 


Niimero  de  matrimonlos. 


Urbana 

(en  las 

dada- 

des). 


Roral 

(en  los 

campos). 


Total 
(reiini. 

dos). 


Edad  media  de  los  esposos  7  esposas:  Parte  orbana Partemral 


258       PB00BEDIN06  BBOOKD  PAN  ABCBBIOAN  80IBNTIFI0  00N0BE88. 


Infimnaeioniidemoipr^lfieaiapropuaUu  CierU^fieo  Panamerieano^ 

Gontin6a. 


NACDOENTOS. 
rOBinTLABIO  8. 


Ntkmeio  de  naddos. 

Legitliiiidad. 

Url>aDa. 

Rural. 

TotaL 

Vaacn- 
lino. 

Feme- 
nino. 

Total 

Masca- 
Uno. 

Feme- 
nino. 

Total. 

IfatDu- 
Udo. 

nino. 

TAcrfHmna              . 

TiArftiinofl 

Total 

i 

rORlCITLASIO  4. 


Legitlmidad  legftn  la  naoio- 
nalidad  de  los  padrea. 


Ambos  padres  nadonales: 

Le^timos 

negitimos 

Total 


Ambos  padns  extranjeros: 

Legttlmos 

Hegltiinoa 


Total. 


Padrea  extraojaros  madres 
nadonales: 

Legftimos 

negitimos 


Total. 


Padres   nadonales.    IDadres 
eKtran}eras: 

Legitimos 

negitimos 


Total. 


Otras: 

Legitimos. 
negitimos. 


Total. 


Nflmero  de  naddos. 


Urbana. 


Maseu- 
lino. 


Feme- 
nino. 


TotaL 


RuraL 


Itasou- 
lino. 


afs'ss^ 


Feme- 
nino. 


TotaL 


Total  (remildoa). 


icaaeo- 
lino. 


a^ 


Fema- 
nino. 


PORMTTLARIO  6. 

Nflmero  de  naddos. 

Clase  de  partes. 

Urbana. 

Rural.                   Total  (reunldos). 

! 

Mascu- 
Uno. 

Feme- 
nino. 

Total. 

Mascu- 
lino. 

Feme- 
nino. 

Total. 

Mascu- 
llno. 

Feme- 
nino. 

Simples 

Dobles 

......... 

Triples 

......... 

Cti£ln]pka 

Total 

PUBLIC   HEALTH  AND  MEDICINE. 


269 


Informacwn€8  (Umogr^eoB  apropueitas  alSegundo  Congreio  deniifico  Panammcmuy— 

Contiii<ia. 


NACID08  MUEBT06. 


POBMULABIO  •. 


Ntlmero  de  nacidos  muertos. 

T^gitimidad. 

UrlMma. 

Bural. 

Total  (mmfdos). 

Ifasou- 
lino. 

F61I16- 

nino. 

Total 

Ifosou- 
lino. 

Feme- 
Dino. 

Total. 

Masou- 
lino. 

Fema- 
nlno. 

LegftimoB 

Ilegftimos 

• 

Total 

DEFUNCIONES. 

VOBMULABIO  7. 

[U—  parte  urbana.    R—  parte  rural.] 


Edady  sexo. 

Gansas  demoerte 
(nomenolatnra 
intemaoional). 

If  enoree  de  mi 
afto. 

De  un  afio. 

Dedos  alios. 

Detresalioa. 

De  coatro  alios. 

• 

ICasoa- 

lino. 

Feme- 
nino. 

Uascn- 
lino. 

Feme- 
nlno. 

Masoa- 
lino. 

Feme- 
nino. 

MawQ- 
lino. 

Fem»- 
nlno. 

Maaoa- 
lino. 

Feme- 
nino. 

1.  Fiebie    ttfoi-fU.. 

dea.            ^R.. 



2.  Etc <g"' 

1 

.: :....:::: 

•  •■••••-i_-____  — 

3.  Etc V^" 

. 

( 

i 

.. .   .J.   . .. 

i 

' 

■ 

1 

Edad  y  sezo. 

Cansas  de  mnerte 
(nomanolatura 
intemaoiona]). 

Dednoo  alios. 

Igoal  alio  per 

afio  basta  99 

aftos. 

DelOOafios 
adelante. 

No  dasiflcados. 

Total. 

Masca- 
lino. 

Feme- 
nino. 

Masoo- 

Uno. 

Feme- 
nino. 

KasoQ- 

lino. 

Feme- 
nino. 

Masca- 
lino. 

Feme- 
nino. 

Masca- 
lino. 

Feme- 
nino. 

1.  Flebre    tiM-fU.. 

dea.            iR.. 

2.  Etc <«*• 

3.  Etc |§** 

*•  E*c {ri: 

68436— 17— VOL  x- 


18 


260       PBOOEEDIKQS  SECOND  PAK  AMEBIGAK  80IENTIFI0  OONOBEBS. 

TnfcffmtuicmM  demogi^^fieaa  apropuatM  oZ  8egvmdo  Congruo  (XmtLJico  Panamencano^ 

Gontinda. 

DBFTTNCIONES-Oontiinia. 

rOUTOLABIO  a. 


Urbana. 

RnraL 

Total 

Bftttdo  oMl  do  ke  faUeeidos. 

Maaoa- 

Uno. 

Fama- 
nino. 

TotaL 

ICasca- 
lino. 

Fema- 
nino. 

TotaL 

Maaoa- 

lino. 

Fema- 
nino. 

BtMem 

Casados 

Vhidos 

Bin  MPMifloar 

Total 

MORTALIDAD  DB  MEN0RE8  DE  UN  AJ^O. 

FOBMTTLABIO  9. 

(U—  parte  urbana.    R—  parte  mral.] 


Edadyaezo.                 ^ 

Cauflaa  da  mniirte 
(nomanolatora 
intemaeional). 

Ifenores  de  nn 
mea. 

Deunmes. 

Dedosmeses. 

Detresmeses. 

Decuatro 
meaes. 

Masca- 
lino. 

Feme- 
nino. 

liaaoa-   Feme- 
lino,      nino. 

Masoa- 

lino. 

Feme- 
nino. 

Mawo- 
lino. 

Feme- 
nino. 

Mawo- 
Uno. 

Feme- 
nino. 

1.  Fiebre    tiioi-ru.. 

dea.           IR.. 

2.  Tlfos  ozante-  V.. 

1 

mAtioo.        R.. 

i 

3.  Fiebre    reoo-  V. . 

1 

*■*•*••• 

mote.  eta.   R. . 

....... .|.... .... 

1 

Edadysaxo. 

Osamiif  da  nrnart^  (nonanoiatara 

Daeino 

Dmaaea. 

Igoalmeaames 
basta  12  meaea 
manoe  on  dia. 

No  daaiflcados. 

Total. 

intemaniopal). 

Kaaon- 
lino. 

Feme- 
nino. 

Kaaon- 
lino. 

Fame- 
nino. 

Maaoo- 

lino. 

Feme- 
Dino. 

Masoa- 

lino. 

Fem^ 
nino. 

1.  Flelm tifoidea /5-* 

3.  Tiftia  ezantemitiai 
8.  Flabre  reoonante, 

, m- 

R.. 
•to la- 

........ 

\R.. 

i 

1 

rOBM  ULABTO  10. 


Meaea. 

Caoeas  de  moerte  (nomenclatara  intema- 
donal). 

Enero. 

Febfeco. 

Mano. 

Abril. 

Mayo. 

Igoal 

mesa 

mea 

baeta 

diciem- 

bre. 

PUBLIC  HEALTH  AND  MEDICINE. 


261 


Informadona  demogrdfietu  apropuestas  al  Segundo  CongreMO  Cientifico  Panamericano — 

Continda. 

MORTAUDAD  DE  MBN0RE8  DE  UN  AflO-Xontlnito. 

FOBMVLABIO  11. 


Meses. 

Edades. 

Enero. 

Febrero. 

Mano. 

Abril. 

Mayo. 

Igual 
mesa 

nun 

hasta 

dicJem- 

bre. 

Mffrwm  d6  on  fim. 

Dt  1  mee 

2me0e6 

3 nwMB...  ..      .  

4  Tnemii 

V  1I1Q90S. ............................... 

1 

De  adelante  mes  a  roes  hasta  12  meses 

1 

f^ip  clwrifloaci^n 

* 

(•■" 

Total 

1 

1 

> 

1 

INPORME  SOBRE  EL  DESARROLLO  DE  LA  ESTADlSTICA  DEMOGRlFICA 

EN  LA  REPtBUCA  DE  EL  SALVADOR, 

Por  PEDRO  S.  FONSECA, 
Director  General  de  Estadistica  de  El  Salvador. 

ANTBGBDENTB8  HI8T6rIC08. 

Durante  la  doininaci6n  espafiola,  poco  o  ninguna  ateiici6ii  mereci6  el  ramo  de 
eetadistica;  se  excepttia  el  censo  practicado  en  1778,  que  di6  a  conocer  que  las  Pro- 
vindas  de  San  Salvador  y  Sonsonate  tenfan  146,684  habitantes. 

Despu^  de  la  Independencia,  hubo  algunoe  indicioe  de  trabajos  estadfsticoB,  como 
loe  ordenados  en  1829,  1834  y  1837  sobre  censo  de  poblaci6n  y  riqueza  pdblica,  los  que 
se  publicaron  en  el  peri6dico  oficial  sin  orden  cronol6gico.  Antes  de  la  fundaci6n  de 
un  centro  directivo,  el  trabajo  m^  digno  de  consideraci6n  es  el  efectuado  por  el  Dr. 
Jos^  C.  L6pez,  en  1878,  levantando  un  censo  bastante  aceptable. 

En  1881  se  Iund6  la  Direcci6n  General  de  E8tadi8tica,su6pendida  algunos  alios 
despu^  y  reconstituida  formal mente  en  1901. 

Han  side  Directores  de  Estadistica  sucesivamente,  los  Sres.  Marcos  Alfaro,  Esteban 
Castro,  Rafael  Reyes,  Francisco  E.  Galindo,  Ram6n  Uriarte,  JuliAn  Escoto,  Santiago 
I.  Barberena  y  el  infrascrito.  Se  han  levantado  censos  en  los  siguientes  afios:  1778, 
1878,  1882,  1888,  1892,  1896  y  1901.  Algunoe  de  ellos  se  consideraron  inaceptables  y 
no  se  di6  a  conocer  su  resultado.  Es  indispensable  levantar  un  censo  con  plan  cienti- 
fico y  con  recursos  y  tiempo  suficiente  para  su  preparaci6n. 

B8TADO  ACTUAL. 

Deede  1901  se  ha  podido  llevar  sin  intemipcidn  la  estadistica  de  nacimientos, 
matrimonies  y  defunciones.  En  1911  se  modificaron  los  modelos,  procurando  en 
cuanto  es  posible,  seguir  las  pricticas  intemadonales.  Para  indicar  las  causas  de 
defiinci6n  tropezamos  con  el  inconveniente  de  que  la  roayoria  de  los  que  mueren  es 
sin  asistencia  mMica,  raz6n  por  la  cual  los  diagn<56tico8  no  deben  aceptarse  con  rigo- 
rismo  cientifico.    En  loe  cuadros  de  nacimientos  se  hace  constar:  El  sexo,  condici6n 


262       PROOEEDIKGS  BEGOKD  PAK  AMEBIOAK  SCIENTIFIC  CONGRESS. 


legal,  nacionalidad  del  padre  (cuando  el  nifio  es  l^timo  y  de  la  madre  cuando  es 
ilegltinio),  cd  es  parte  tinico  o  ii6,  si  naci6  vivo  o  muerto. 

En  las  defundones:  Sexo,  edad  (se  distribuye  per  perfodos),  estado  civil,  ocupaddn. 
causa  de  defunddn  (se  agrupan  conforme  la  cla8ificaci6n  de  Bertdllon),  nadonalidad, 
si  tuvo  o  no  asistencia  m6dica. 

En  los  matrimonios:  Edad,  estado  dvil  anterior,  nadonalidad  e  instrucd6n  de  cada 
uno  de  los  esposos. 

El  circuito  demogr&fico  es  el  Departamento;  agrupadoe  todos  los  de  la  Reptiblica 
^stos  se  totalizan. 

La  direcd6n  examina  parcialmente  cada  uno  de  los  informes  de  los  252  pueblos 
de  la  Reptiblica,  rectafica  errores  para  formar  el  cuadro  general  del  mes. 

Los  resultados  se  publican  en  el  Anuario  Estadlstlco. 

He  aquf  un  resumen  del  movimiento  demogrifico  en  El  Salvador,  durante  el 
perfodo  de  1899  a  1914: 


Afios. 

Nadmicntos. 

DflAmdones. 

Matri- 
monios. 

Varones. 

Mujeres. 

Totales. 

Varones. 

Majeres. 

Totales. 

No.  total. 

IHOO 

19.974 
21,612 
21,609 
20,788 
22,695 
22,978 
22,839 
21,731 
22,661 
24,396 
24,137 
23,846 
26,028 
25,408 
25,909 
26,374 

19,012 
20,340 
20,818 
20,217 
21,193 
21,581 
21,756 
21,093 
21,660 
23,256 
23,637 
23,021 
24,167 
24.601 
25,027 
26,485 

38,966 
41,952 
42,387 
41,005 
43,788 
44,664 
44,606 
42,824 
44,221 
47,661 
47,774 
46,866 
49,186 
49,999 
60,996 
61,859 

10,024 
9,229 
10,460 
11,456 
13,408 
11,624 
12,780 
12,384 
12,989 
12,644 
12,912 
18,886 
13.866 
12,788 
13,046 
13,046 

8,882 
8,286 
9,897 
10,907 
12,999 
11,061 
12,120 
11,606 
11,602 
12,147 
12,422 
13,467 
18,082 
12,137 
12,096 
12,367 

18,906 
17,464 
20,357 
22,363 
26,407 
22,685 
24,860 
24,080 
24,441 
24,091 
25,334 
27,353 
26.938 
24,926 
25,141 
25,413 

3,410 

I'JOO 

2,822 

imy 

3,774 

1W2 

3,402 

19:)3 

4,486 
4,483 

1 <>( )  1 

1^05 

4.280 

lf;-V, 

3.67S 

19)7 

3,878 

1908 

4,137 

lf>0(« 

4,362 

1910 

4,287 

1911 

4,445 

1912 

4,481 

1013 

4,762 

1914 

4,018 

371,889 

366,763 

728,642 

196,831 

186,017 

381,348 

64,649 

Media 

23,243 

22,297 

45,640 

12,270 

11,563 

23,834 

4,084 

Mediante  el  cdlculo  respective,  se  ha  podido  obtener  el  indice  de  natalidad, 
mortalidad  y  nupcialidad,  de  la  manera  siguiente:  Nadmientos,  por  1,000  habitantes, 
41.66;  defunciones,  por  1,000  habitantes,  21.00;  matrimonios,  por  1,000  habitantes, 
3.71. 

El  estado  dvil  de  los  nacidos,  por  t^rmino  medio  es:  Legitimes,  46.3  por  ciento; 
ilegltimos,  53.7  por  dento;  total,  100. 

El  TniJTimum  de  nadmientos  se  verifica  en  enero,  y  el  minimum  en  junio.    E 
maximum  de  defunciones  se  verifica  en  octubre,  y  el  mfmlmum  en  febrero. 

El  Oonsejo  Superior  de  Salubridad,  lleva  estadlstica  detallada  de  las  causas  de 
defundones.  correspondientes  a  la  Ciudad  de  San  Salvador  y  a  los  puertoe. 

Adjournment. 


GENERAL  SESSION  OF  SECTION  Vm. 

New  Ebbitt  Hotel, 
Wednesdm/  morning^  Janwiry  6, 1916. 

Chairman,  William  C.  Gobgas. 

The  session  was  called  to  order  at  9  o  'clock  by  the  chairman. 

The  Chairman.  Dr.  Weil,  I  think  you  are  to  start  this  program 
for  us. 

ANAPHYLAXIS. 

By  RICHARD  WEIL, 
CwfUU  UhivertUy,  MedkaL  ColUge,  New  York  CUy. 

I  have  been  asked,  in  the  unavoidable  abaence  of  Dr.  Anderson,  to  speak  on  the 
development  of  the  subject  of  anaphylaxis;  that 's,  to  g:ive  an  historical  oversight.  I 
will  attempt  to  sununarize  the  history  of  its  development  in  as  few  words  as  possible 
and  to  indicate  as  far  as  I  can  the  main  problems  which  have  presented  themselves  to 
the  men  who  were  active  in  the  study  of  anaphylaxis  at  the  various  stages  of  its  devel- 
opment. 

As  you  know,  the  entire  literature  of  anaphylaxis  does  not  go  back  more  than  15 
years.  It  started  with  a  series  of  observations  made  in  different  parts  of  the  world, 
which  curiously  enough  foreshadowed  the  various  phases  of  development  which  the 
history  of  anaphylaxis  has  taken  since  that  time.  In  the  first  place,  there  was  the 
observation  of  Roeenau  and  Anderson,  in  1906,  which  was  also  made  independently 
by  others,  that  guinea  pigs  which  had  been  given  a  preliminary  dose  of  foreign  pro- 
tein responded  to  a  subsequent  dose  of  that  foreign  protein  with  severe  and  often 
fatal  symptoms.  That  was  the  guinea  pig  phenomenon  and  represented  the  con- 
stitutional reaction  of  anaphylaxis.  The  first  experiment  of  this  t3rpe  had  been  per- 
formed on  dogs  in  1902  by  Richet. 

The  second  observation,  made  by  Arthus  in  Lausanne,  in  Switzerland,  involves  the 
principle  of  the  local  reaction.  He  found  that  rabbits  which  had  been  given  foreign 
protein,  such  as  egg  albumin  or  horse  serum,  over  a  period  of  days,  subsequently 
responded  to  later  injections  with  a  peculiar,  characteristic  reaction  at  the  site  of  injec- 
tion. They  developed  a  severe  local  reaction,  which  might  take  the  form  of  simple 
erythema,  but  might  go  on  to  abscess  formation  and  necrosis. 

The  third  observation  was  the  observation  of  Von  Pirquet  that  human  beings  who 
had  been  vaccinated  once  responded  to  a  second  vaccination  in  an  altogether  different 
way,  and  that  was  the  beginning  of  the  observations  that  led  Von  Pirquet  to  interpret 
the  various  manifestations  of  the  infectious  diseases  upon  the  basis  of  what  he  called 
allergy,  which  is  a  somewhat  broader  thing  than  what  we  call  anaphylaxis. 

The  very  first  problem  which  presented  itself  and  which  occupied  the  minds  of 
investigators  for  a  number  of  years  was  this:  What  is  the  character  and  what  is  the 
mechanism  of  the  reaction?  In  specific  terms  is  it  an  antibody  reaction  or  is  it  not 
an  antibody  reaction?    This  recalls  the  violent  i>olemic  which  occupied  the  earlier 

263 


264       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIO  CONGRESa. 

yean  and  in  which  Gray  and  Southard,  on  the  one  hand,  and  Roeenau  and  Anderson, 
on  the  other,  played  the  prominent  parts.  Gay  and  Southard,  as  you  remember, 
believed  that  when  a  foreign  protein,  say  horse  serum,  was  injected  into  a  guinea  pig, 
that  a  certain  part  of  it  remained  in  the  body  and  rendered  it  hypersusceptlble. 
They  called  this  fraction  anaphylactin,  Rosenau  and  Anderson,  on  the  other  hand, 
were  the  first  to  maintain  and  defend  successfully  the  theory  that  what  we  really  had 
in  anaphylaxis  was  nothing  but  an  immune  reaction.  In  other  words,  they  showed 
that  the  injection  of  the  foreign  protein  resulted  in  the  production  of  antibodies  in 
the  guinea  pig,  and  that  the  second  Injection  permitted  an  interaction  between  this 
newly  formed  antibody  and  the  reintroduced  antigen  in  the  body  of  the  animal.  I 
need  hardly  remind  you  that  this  controversy  raged  for  two  or  three  years.  It  was 
definitely  settled  not  only  through  the  work  of  Rosenau  and  Anderson,  but  with  the 
help  of  Otto,  working  in  Ehrlich's  laboratory,  and  of  others  in  f»voT  of  the  theory  of 
Rosenau  and  Anderson  that  the  anaphylactic  reaction  is  immime  reaction. 

The  second  question  naturally  involved  the  nature  of  this  antibody.  Was  it  an 
antibody  sui  generis,  different  in  nature  from  what  we  had  previously  worked  with, 
or  was  it  essentially  similar  to  the  various  precipitins,  agglutinins,  and  so  forth,  with 
which  men  were  already  familiar?  This  is  a  controversy  which  has  not  yet  been  en- 
tirely settled.  In  my  paper  to-day  I  hope  to  make  a  contribution  to  that  question. 
Friedberger  was  the  first  to  maintain  that  the  anaphylactic  antibody,  which  has 
been  called  by  various  terms,  "sensibilisin,"  etc.,  is  identical  with  the  precipitins. 
The  chief  argument  which  he  advanced  was  that  if  one  studies  the  sera  of  immun- 
ized animals,  one  finds  that  the  precipitin  content  goes  parallel  with  the  passively 
sensitizing  value  of  that  serum,  and  this  observation  was  confirmed  by  Doerr,  who, 
as  you  know  is  one  of  the  most  active  and  successful  workers  in  anaphylaxis.  It 
was  disputed  by  others.  Eraus,  who  is  now  in  Argentina,  attacked  the  theory  by 
showing  that  the  blood  of  guinea  pigs  which  have  been  sensitized  contains  no  pre- 
cipitins, so,  as  I  have  said,  at  this  time  the  nature  of  anaphylactic  antibody  is  still 
somewhat  in  doubt. 

The  third  main  problem  which  has  busied  the  workers  in  anaphylaxis  concerns 
the  site  of  the  reaction.  Where  does  the  anaphylactic  reaction  occur?  I  might  ex- 
plain this  question  more  in  detail  as  follows:  If  we  admit,  as  we  are  all  now  ready  to 
do,  that  anaphylaxis  is  the  result  of  a  reaction  in  the  living  body  between  antibody 
and  antigen,  where  do  these  two  substances  unite  in  the  body?  Thinkers  on  this 
problem  are  divided  into  two  schools:  First,  there  is  the  humoral  school,  which 
holds  that  the  reaction  occurs  in  the  blood.  This  theory  is  intimately  connected 
with  the  so-called  anaphylatoxin  theory,  because  those  who  maintain  that  the  reac- 
tion occurs  in  the  blood — and  I  think  that  Friedemann  was  practically  the  first  to 
advance  this  opinion,  although  it  has  been  developed  to  its  greatest  extent  by  Fried- 
beiger — maintain  at  the  same  time  that  this  reaction  results  in  the  production  of  a 
toxic  substance,  called  anaphylatoxin,  which,  by  its  irritant  action  upon  the  cells 
of  the  body  gives  rise  to  the  tjrpical  anaphylactic  symptoms,  the  convulsions,  etc. 
This,  then,  is  the  humoral  theory. 

The  second  theory  of  the  site  of  the  anaphylactic  reaction  is  what  might  be  called 
the  cellular  theory,  which  is  opposed  absolutely  to  the  humoral  theory  and  also  ex- 
cludes the  intervention  of  anaphylatoxin.  The  cellular  theory,  historically,  really 
goes  back,  I  should  say,  to  the  French  school,  to  Besredka,  who  maintained,  however, 
that  the  reaction  occurred  exclusively  in  the  brain  cells,  whereas  those  who  now 
accept  the  cellular  theory  include  the  cells  of  many  other  tissues  of  the  body.  This 
theory  is  based  very  largely  on  the  observed  response  of  the  muscle  cells  of  the  iso- 
lated uterus  to  antigen.  According  to  this  interpretation,  antigen-antibody  reactions 
occurring  in  the  blood  are  entirely  unproductive  of  symptoms,  and  are  only  effective 
when  mediated  by  the  cells  of  the  body. 


PUBUO  HBALTH  AND  MBBIOIKB.  265 

The  ceUular  theory  is  at  first  sight  not  in  itself  incompatible  with  a  belief  in  ana- 
phylatoxin.  It  is  perfectly  conceivable  that  within  the  cells  the  reaction  of  antibody 
and  antigen  should  give  rise  to  a  toxic  substance,  which  we  may  call  for  convenience 
anaphylatozin;  but  the  development  of  the  cellular  theory  has  precluded  such  an 
interpretation.  Dale  has  advanced  the  following  argument  on  that  aspect  of  the 
problem:  The  uterus  of  a  normal  guinea  pig  when  suspended  in  a  neutral  solutioui 
such  as  Locke's  fluid  or  Ringer's  fluid,  and  attached  to  a  writing  lever  which  runs 
upon  a  drum,  describes  a  regular  and  characteristic  series  of  rhythmical  contractionB, 
If  one  takes  the  uterus  of  a  guinea  pig  which  has  been  sensitized,  say,  to  horse  serums 
suspends  it  in  this  way,  allows  it  to  write  its  tracing,  and  then  adds  horse  serum  to 
the  bath,  the  uterus  at  once  executes  a  violent  contraction,  and  the  curve  shoots  up 
at  once.  Now,  there  are  several  reasons  for  believing  that  this  reaction  can  not  be 
due  to  the  production  of  a  chemical  substance.  Dale  himself  showed  that  the  reac* 
tion  had  no  determinable  latent  period.  He  concluded  that  it  is  inconceivable  on 
physiological  grounds  that  the  production  of  a  secondary  chemical  substance  by  fer- 
ment action  should  take  place  with  such  rapidity.  He  stated  also  that  the  result 
produced  in  the  living  animal  could  not  conceivably  be  due  to  a  chemical  substance 
formed  from  such  minute  amounts  as  one-ten  thousandths  of  a  gram  of  protein,  which 
we  know  will  produce  the  anaphylactic  reaction. 

These  views  of  Dale  have  been  accepted  by  physiologists.  Bayliss,  for  example, 
in  his  last  book,  Principles  of  General  Phjrsiology,  states  that  he  also  believes  that  it 
is  inconceivable  that  the  chemical  reaction  should  mediate  and  precede  the  anaphy- 
lactic response.  But  the  other  argument  is  very  much  stronger.  Doerr  has  shown, 
and  those  coming  after  him,  of  whom  I  am  one,  have  emphasised  the  fact  that  you 
can  not  get  the  anaphylactic  reaction  if  you  introduce  into  the  opposite  jugular  veins 
of  a  guinea  pig  antigen  and  antibody  simultaneously.  Now  there  you  have  the 
ideal  conditions  for  reaction  in  the  blood  stream,  antigen  and  antibody  coming 
together,  and  yet  nothing  happens.  On  the  other  hand,  the  uterus  of  a  guinea  pig 
which  has  been  washed  out  with  a  liter  of  solution  and  contains  no  blood  reacts 
violentiy  to  antigen.  If  one  accepts  the  cellular  theory,  one  is  practically  bound 
thereby  to  reject  the  anaphylatoxin  or  chemical  theory  and  to  accept  what  has  been 
called  the  physical  theory. 

And  that  brings  me  to  the  fourth  problem,  which  I  wish  to  sketchr— the  problem 
of  the  immune  mechanism.  When  I  speak  of  the  immune  mechanism  I  am  not 
speaking  of  the  gross  physiological  mechanism,  whether  it  be  spasm  of  the  bronchial 
muscles  or  what  not,  but  to  the  cellular  mechanism.  Are  we  dealing  with  a  chemical 
reaction,  in  which  the  reaction  of  antigen  and  antibody  results  in  the  production  of 
a  third  toxic  substance,  a  so-called  anaphylatoxin?  Or  are  we  dealing  with  what 
has  been  called  a  purely  physical  process—in  other  words,  something  like  an  electric 
shock,  whereby  the  sensitized  cell,  simply  in  virtue  of  the  presence  of  antigen, 
without  any  intermediate  change,  is  at  once  stimulated  to  the  discharge  of  its  normal 
activities— resulting  in  the  case  of  the  uterus  in  a  contraction,  in  the  central  nervous 
system  in  convulsions,  such  as  strychnin  produces,  and  so  forth. 

As  I  say,  those  two  theories  are  incompatible,  and  they  are  each  of  them  bound  up 
elthw  with  the  humoral  theory  or  with  the  cellular  theory.  I  do  not  wish  to  go  too 
far  into  a  discussion  of  this  subject,  in  view  of  the  fact  tiiat  there  are  to  be  several 
papers  which  bear  upon  it,  and  also  because  my  own  views  are  too  strong  to  allow  me 
to  give  you  a  perfectiy  impartial  historical  r^sum6  of  it. 

In  regard  to  the  practical  application  of  our  knowledge  of  anaphylaxis,  I  believe 
we  are  probably  at  the  very  beginning  of  our  understanding  of  the  relation  of  the 
phenomenon  to  disease.  The  boginnings  were  sketched  by  Pirquet  and  Schick, 
who  attempted  to  interpret  the  various  phenomena  of  the  infectious  diseases  upon 
the  theory  of  an  anaphylactic  reaction;   the  incubation  stage  corresponded  to  the 


266       PBOOEEDINOB  BBOOND  PAN  AMBRIOAN  SGIBNTIFIO  00NQBB88. 

peiiod  in  which  the  animal  was  developing  its  antibodies,  jtut  exactly  as  a  guinea 
pig  after  receiving  an  injection  of  horse  serum  is  apparently  unaltered  during  an 
Interval  of  10  or  more  dayB  and  then  makes  an  acute  response  to  the  reintroduced 
antigen.  If  the  production  of  the  antibodies  is  violent  and  in  large  amounts,  we  may 
have  an  initial  chill;  if  not,  a  gradual  onset.  Firquet  and  Schick  also  took  up  the 
question  of  the  local  diagnostic  response,  such  as  the  tuberculin  reaction,  and 
attempted  to  explain  it  upon  the  theory  of  the  anaphylactic  phenomenon— viz,  that 
the  immune  animal  responded  with  a  locally  excessive  response  to  the  introduction 
of  the  antigen. 

Those  theories,  although  they  have  been  rather  generally  accepted,  have  still  met 
with  a  good  deal  of  opposition,  and  require  a  good  deal  in  the  way  of  elucidation. 
If  we  come  to  the  most  prominent  problem,  we  might  say,  which  confronts  all 
medical  men— vis,  the  specific  diagnostic  reactions,  such  as  the  tuberculin  reaction 
or  even  the  secondary  vaccination  response— we  know  veiy  littie  as  to  the  mechanism. 
We  do  not  know  whether  that  response  is  due  to  the  cellular  reaction— whe^er  the 
cells  of  the  body  are  furnished  with  antibodies  and  mediate  the  response,  or  whether 
it  is  due  to  simply  the  presence  of  antibodies  in  the  blood.  The  same  holds  true  of 
the  interpretation  of  the  Arthus  phenomena.  Notwithstanding  these  difficulties,  the 
whole  fabric  of  the  infectious  diseases  is  by  many  believed  to  be  intopretable  upon 
an  anaphylactic  basis.  This  has  gone  so  hi  that  certain  observers  have  maintained 
that  the  evolution  of  even  the  chronic  infectious  diseases  is  essentially  refwable  to 
anaphylactic  laws.  For  example,  they  maintain  that  the  reason  tuberculosis  in 
infants  is  found  at  autopsy  very  laigely  to  take  the  form,  of  a  general  miliary  tubercu- 
losis, whereas  in  adult  life  it  generally  observes  an  altogether  different  distribution — 
namely  that  of  a  localized  process— is  simply  the  fact  that  the  infant  has  not 
developed  resistance  through  the  formation  of  antibodies  and  the  infection  conse- 
quentiy  spreads  through  the  system.  In  the  same  way  they  point  out  that  in  the 
secondaries  of  syphilis  one  has  generalized  manifestations  of  disease,  whereas  in  the 
late  stages  of  the  disease  one  has  some  localized  lesion,  and  they  maintain  that  the 
individual  infected  with  lues  develops  the  typical  secondaries  because  he  has  no 
antibodies,  but  as  the  disease  progresses  (just  as  in  the  case  of  an  adult  who  has  gone 
through  tuberculosis  early  in  life  and  has  a  second  infection  later  in  life),  the  reaction 
is  altogether  different,  owing  to  intervening  production  of  antibodies.  So  these  men 
maintain  that  in  the  development  not  only  of  the  acute  but  of  the  chronic  diseases 
we  are  dealing  with  conditions  that  have  been  produced  through  the  altered  reaction 
of  the  host  to  the  infecting  organism. 

One  might  really  go  on,  I  suppose,  almost  Indefinitely,  developing  the  various 
tendencies  in  the  interpretation  of  disease  through  anaphylaxis.  Of  course,  you  all 
know  that  certain  diseases,  such  as  the  food  idiosyncrasies,  hay  fever,  etc.,  are  now 
quite  thoroughly  explained  upon  the  anaphylactic  basis.  But  we  have  a  fairly  long 
program,  and  I,  unfortunately,  had  no  time  to  prepare  this  talk,  being  told  only  just 
before  the  meeting  began  that  I  should  have  to  give  it;  so  I  think  that  we  may  now 
conclude  this  general  resume,  and  proceed  to  the  special  papers  of  the  program. 

Dr.  Richard  Weil  took  the  chair  and  announced  a  paper  on  **The 
Argentine  biological  theory  of  immunity'*  by  Dr.  Julio  M6ndez. 
This  paper,  previously  printed  in  the  Revista  de  Filosofia,  alio  1, 
ntim.  V,  septiembre  de  1915,  was  submitted  to  the  congress  through 
the  courtesy  of  Dr.  Ricardo  Sarmiento-Lcspiur  and  read  by  him  at 
this  session. 


PUBUO  HBALTH  AND  MEDIOIKB.  267 

TEORiA  BIOLOGiCA  DE  LA  INMUNIDAD. 

Pot  JULIO  M^NDEZ, 
Eso-Prcfmaor  dela  Univerndad  de  Buenos  Aires. 

I. 

£1  ofganiBmo  animal  poeee  doe  grandee  grupos  de  hmdones.  Uno  corresponde  a 
loB  fen6meno6  de  la  vida  de  relaci6n.    El  otro  correeponde  a  loe  de  la  vida  vegetativa. 

Dentro  de  estoe  tiltimoB  encuadian;  loe  actoe  de  la  nutrici6n,  propiamente  dicha^ 
que  intervienen  en  la  aaimilacidn  o  adaptaci6n  de  las  subetandas  digeridas,  y  que 
tienen  por  objeto  la  regen6raci6n  de  nueetroe  diganoe  y  tejidos,  desgastadoe  constante- 
mente  por  el  hmdonamiento  vital;  y  loe  actoe  que  Intervienen  en  los  proceBoe  pato- 
Idgicoe,  que  al  contrario  de  los  anteriores  tienen  por  objeto  la  alterad6n  eetructural 
deeeoe  mismoe  diganos  y  tejidoe,  provocando  la  enfermedad  o  la  muerte. 

Hasta  hoy  no  noe  hemoe  preocupado  de  eetudiar  o  comprobar  el  lazo  de  uni6n  que 
exiate  entre  ambos  actoe,  atraidoe  por  loe  nuevoe  fen6menoB  descubiertoe  en  el  am- 
biente  patol6gico,  que  en  eetas  doe  dltimae  d^cadae  ha  realizado  progreeoe  incalculablee. 

Antee  de  empezar  a  tratar  de  elloe  en  el  preeente  artfculo,  conviene  saber,  a  manera 
de  orientad6n  para  eeguir  nueetrae  ideas,  que  el  sistema  vegetative  del  oiganismoy 
los  actos  que  ^1  rige,  o  sean  las  mutadonee  intra-oig^cas,  obedecen  a  un  solo  y  tinico 
proceeo,  sea  cual  fuere  la  via  por  la  cual  la  subetanda  se  introduce.  Eetas  vlas  son: 
la  enteral  o  gastro-intestinal  y  la  para-enteral  (drculatoria,  subcut^ea,  nerviosa  o 
linMtica). 

Que  la  substancia  sea  propiamente  alimenticia,  como  las  albtiminae  de  la  digeeti6n 
de  nueetroe  alimentoe,  o  sea  patoldgica,  como  los  g^rmenee  de  las  enfermedades  que 
nos  atacan,  el  acto  o  loe  fen6menoe  a  que  da  lugar  la  adaptad6n  de  ellas  por  el  oiganismo 
(para  que  lleguen  a  formar  parte  del  mismo  o  a  alterarlo  provocando  la  enfermedad) 
es  perfectamente  id6ntico,  diferend&ndose,  como  es  16gico,  en  bus  efectos.  Esta 
unidad  de  acd6n  dentro  del  orgamsmo  animal  no  ha  side  a(in  sancionada  por  la  denda, 
siendo  sin  embargo  una  realidad  demostrada  en  cada  uno  de  los  miles  de  experimentos 
que  se  realizan  y  que  vienen  a  satisfacer  la  16gica  del  bi61ogo,  deecubriendo  en  todos 
eeoe  actoe  fen6menoe  fisico-quimicoe,  sometidos,  como  las  reacdones  que  provocan, 
a  un  determininno  ineludible.  En  efecto,  no  es  dable  suponer  a  quien  conoce  el 
hmdonamiento  del  oiganismo  animal,  que  la  asimiladdn  de  las  albtiminas  digeridas 
de  came  de  pescado,  por  ejemplo,  sea  distinta  de  la  asimilaci6n  de  las  similares  de 
came  de  vaca.  O,  en  otras  palabras,  que  el  mecanismo  usado  por  el  organismo  se 
modifique  de  manera  distinta  para  la  adaptad6n  de  una  u  otra. 

Aparte  de  la  infinita  variedad  de  modificadonee  hmdonalee  que  exigirfa,  dada  la 
variedad  de  loe  productos  presentados,  tal  creenda  nos  llevaria  al  absurdo  de  pensar 
que  en  la  escala  zool(3gica  existen  m&a  grandee  diferendas  en  el  terreno  vegetativo 
que  las  que  evidentemente  existen  en  la  de  los  6rganos  de  la  vida  de  relad6n. 

Asf,  dentro  del  oiganismo,  los  actos  que  rigen  la  asimilad6n  de  las  albdminas  alimen- 
tidas  y  los  que  rigen  la  asimilacidn  de  las  albtiminas  pat6genas,  son  perfectamente 
id^nticoB.  El  oiganismo  se  deearrolla  y  se  mantiene  por  el  mismo  procedimiento 
que  se  enferma.    La  nutrid6n  y  la  enfermedad  son  procesoe  bioldgicos  id^nticos. 

II. 

Lo  que  acabamos  de  esbozar  interesa  sumamente  al  bi61ogo,  al  m^co  y  aim  a  los 
que  deseen  ten^  una  idea  de  esa  mecinica  fisiol^ca  que  significa  el  equilibrio  vital. 

Para  la  teorla  biol6gica  de  la  inmunidad,  es  la  base  que  ha  permitido  a  esta  teorfa 
adelantarse  pot  muchoe  afios  al  estado  actual  de  loe  conocimientoe  reepectivoe. 

Deede  que  el  juroceeo  de  la  nutrid6n  fntima  y  el  de  la  enfermedad  son  id^nticos 
como  actoe  biol6gicoe,  y  habiendo  la  inveetigaci6n  penetrado  o  detallado  mis  loe  con- 
cemientee  a  la  enf^medad,  estudiemoe  ^eta,  aunque  de  manera  somera,  para  acentuar 
el  detalle  mis  tarde,  al  tratar  de  la  inmunidad,  que  es  una  de  sus  consecuencias. 


268       PBOOEEDINGS  SECOND  PAN  AMBRIOAN  80IBNTIFI0  00N0BB88. 

Ouaado  un  individuo  ae  enferma,  de  enfermedad  infecdosa  (o  ai  quiere  por  catiaa 
venida  de  fuera  del  organismo),  necedta  que  el  agente  cauaante  o  micrtMnganismo 
haya  penetrado  en  sua  tejidoa  (contagio)  por  una  via  cualquiera,  ytk  enteral  o  ya  para- 
enteral.  Eate  microoiganiamo  o  gennen,  permanece  como  ''cuerpo  extrafio"  dentro 
del  oiganiamo,  haata  tanto  ae  vmfiquen  en  au  alrededor  loa  fen6menoa  que  van  a 
aaimilarlo,  para  que  el  portador  aufra  loa  traatomoe  de  au  eapecificidad. 

Ai  perfodo  latente  en  que  ae  deaarrollan  eeoa  fen6menoa  ae  llama  incubacidn,  y  est^ 
conatitufda  por  lo  que  Metchnikoff  ha  aido  el  primero  en  demoatiar  bajo  el  nombre 
de  "Fagocitoaia,"  que  conaiste  en  el  atrapamiento  de  loa  g^rmenea  por  loa  leucocitoa 
o  gl6buloB  blancoB  de  la  aangre,  atraidoa  al  aitio  por  el  acto  reflejo  que  motiva  la  pre- 
aencia  del  haata  eae  memento  ^'cuerpo  extrafio."  Loa  leucocitoa  ae  extravaaan  de  loa 
vaaoa  capilarea  de  la  regi6n  y  ae  dirigen  con  mia  o  menoa  atracci6n  hacia  41,  enviin- 
dolea  aua  paeudopodioa  o  prolongacionee  protoplaamdticaa,  que  concluyen  por  atra- 
parlo  e  introdudrlo  dentro  del  gl6bulo  bianco.  £1  fen6meno  ae  continda  gradual- 
mente  y  puede  aer  aeguido  en  preparacionee  microacdpicaa  coloreadaa,  en  todaa  aua 
faaea,  obaerv^doae  que  deapu^  de  un  tiempo  el  germen  comienza  a  colorearae  m^s 
difuaamente,  luego  pierde  au  forma  y  por  fin  deaaparece,  confundi^ndoee  con  el  pro- 
toplaama  del  leucocito,  que  aoporta  tambi^  cambioa  concomitantea  que  di9gregan 
au  protoplaama  haci^ndole  menoa  elective  a  laa  auatanciaa  coloreantea,  y  terminan 
por  la  deformaci6n  del  o  de  loa  ndcleoa  del  fagocito,  que  deaaparece  en  el  auero  ezudado 
al  trav^  de  loa  capilarea  (fagoliais). 

Otraa  vecea  la  incubaci6n  eetd  conatitulda  por  una  an&loga  tranafQnnaci6n  de  loa 
g^rmenea,  ain  la  preaencia  de  loa  leucocitoa,  por  el  auero  de  la  aangre  extravaaada  de 
loa  capilarea.  En  eate  caao  no  ae  obaerva  fagocitoaiB;  hay  deatrucci6n  por  el  Ifquido 
aolamente:  bacteriolyaiB  o  fen6meno  de  Pfeiffer. 

Tanto  la  &gocitoaiB  como  la  bacteriolyaia  exiaten  en  un  miamo  acto,  predominando 
una  u  otra  a^gtin  la  mayor  o  menor  virulencia  del  microorgamamo  que  ae  ha  intro- 
ducido;  aaf  lo  hemoa  demoatrado  en  un  experimento  fundamental,  el  afio  1900,  bajo 
el  nombre  de  '^Cuadroa  de  la  infecci6n"  y  que  ha  aido  el  primer  paao  de  nueatra  teorfa, 
logrando  al  miamo  tiempo  aaociar  laa  doa  doctrinaa  de  Metchnikoff  y  Pfeiffer,  refiidaa 
y  combatientea  por  largo  tiempo  en  aquella  ^poca  de  la  bacteriologfa. 

El  reeultado  de  eata  digeati6n  de  loa  g^rmenee,  como  ae  ha  dado  en  Uamarle,  ea  la 
deatrucci6n  de  unoa  y  otroa,  g6rmenee  y  fagocitoa,  parcial  o  total,  de  lo  que  reaulta  la 
producci6n  de  anticuerpoa. 

Haata  aquf  lo  cUaico.  Pero  ^c6mo  obran  eatoa  anticuerpoa?  ^c6mo  acttian  loa 
g^rmenea  para  producir  la  fiebre,  el  maleatar  oi^^nico,  la  alteraci6n  de  funci6n  y  de 
eatructura  de  tal  o  cudl  6rgano?    No  ae  aabe. 

El  adelanto  en  eata  rama  ae  ha  bifurcado  en  doa  direcciones.  La  una  inatigada  por 
loa  c^ebrea  trabajos  de  Ehrlich  que  abaorbieron  la  atenci6n  de  loa  obaervadorea,  y 
paralizaron  la  inve8tigaci6n  en  la  otra.  Eatoa  trabajos  lograron  demoatrar  laa  reac- 
cionea  que  individualizan  a  loa  anticuerpoa,  llegando  a  determinar  con  hip6tesiB  bri- 
llantea  tomadaa  del  concepto  qulmico,  la  compoaici6n,  o  mejor  dicho,  la  agrupaci6n 
de  aua  componentea.  Aaf  conocemoe  el  amboceptor,  loa  receptorea  y  el  componente, 
que  explican  el  encadenamiento  de  los  anticuerpoa  con  loa  g^rmenes  o  aubstanciaa 
que  le  dan  origen  y  cuyo  conocimiento,  juntamente  con  las  inveatigacionea  de  la  otra 
bifurcaci6n,  a  que  nos  hemoa  refehdo,  llegan  a  la  individualizacidn  de  loa  distintoa 
anticuerpoa  conocidos  con  el  nombre  de  aglutininaa,  precipitinaa,  opaoninaa  o  bacterio- 
tropinaa,  etc. 

Eatoa  anticuerpoa  existen  en  el  auero  de  la  aangre  de  aquelloa  animalea  que  han 
paaado  el  contagio  espontdneo  o  experimental  de  g^rmenee,  y  por  aua  propiedadea 
estrictamente  eapcclBcaa  poseen  la  cualidad  de  que,  pueatoa  en  presencia  de  dichoe 
g^nnonea  o  aubstancias  de  origen,  loa  aglutinan,  loa  precipitan,  loa  atraen,  etc.,  como 
ae  demueatra  por  reaccionea  in  vitro. 

El  conocimiento  de  laa  propiedadea  antedichaa,  con  cualidadea  eaencialee  y  por 
conaiguiente  perfectamente  eapecfficaa  reapecto  del  cuerpo  de  origen,  ha  deaarrollado 


PUBUO  HEALTH  AND  IfEDIOINE.  269 

Tinft  amplia  y  considerable  via  dentro  de  la  Medicina,  fundando  el  diagndstico  bioldgico 
•cad  matemitico,  que  tan  inconmensurables  servicioe  estd  prestando  a  nuestra  cienda, 
saduidola  del  estancamiento  en  que  la  habla  postrado  el  sfntoma  y  la  terap^utica 
flintom&tica. 

Para  ese  conocimiento  cUusico  modemo,  los  anticuerpos  no  prestan  otro  servicio  que 
^1  de  brillantes  y  seguros  medioe  de  diagndstico. 

ReclamamoB  aquf  la  atenci6n  del  lector  sobre  lo  que  dejamoe  dicho,  porque  al 
•desarroUar  m^  tarde  nuestra  teorla  tendremoe  que  relerimos  especialmente  a  ^sto. 
<}ueda  asf  un  gran  vacio  entre  los  conodmientos  cUsicoe  actuales  de  los  anticuerpos 
y  la  producci6n  de  las  antitoxinas,  cuerpoe  estos  tUtimos  que  evidentemente  exlsten, 
pero  cuya  formaci6n  no  ha  sido  hasta  hoy  explicada. 

III. 

En  el  pteafo  anterior  hemos  explicado  lo  que  es  la  incubaci6n;  ahora  veamos  el 
comienzo  de  la  enfermedad  o  lo  que  se  denominan  ''pr6dromo6.''  Se  llama  asf  a  las 
primeras  manifestaciones  subjetivas  de  malestar  para  el  enfermo,  y  a  los  sfntomas  que 
hacen  ostensible  para  el  m6dico  el  desequilibrio  de  la  salud. 

La  interpretaci6n  que  pasamoe  a  exponer  y  los  experimentos  que  relataremos  en 
otro  memento,  nos  pertenecen  en  absolute. 

A  esos  anticuerpos  que  provienen  de  los  g6rmenes  o  substancias  de  origen,  no  se  les 
reconoce  acci6n  bioldgica  dentro  del  organismo.  Nadie  sabe  qu^  es  lo  que  sucede 
despu^  de  la  destrucci6n  de  g^rmenes  y  leucocitos.  Para  Metchnikofif  y  Pfeiffer  el 
Tol  importante  del  oiganismo  es  destruir  el  agente,  y  ven  como  terminado  el  proceso 
por  su  solo  aniquilamiento. 

Para  noeotros,  al  contrario,  ese  acto  es  el  comienzo  de  la  infeccidn  del  individuo.  Los 
g^rmenes  transformados  en  su  d6strucci6n,  por  los  leucocitos  o  por  el  suero,  han  perdido 
su  forma,  si  se  quiere,  pero  no  sus  cualidades.  Transformindose  unos  y  otros  (g^rmenes 
y  fagocitoi)  en  albdminas  solubles,  se  ccHubinan  para  formar  los  anticuerpos  que  nos 
ocupan.  Ahora  bien,  dichos  anticuerpos,  como  estd  cUsicamente  demostrado,  y  en 
parte  confirmamos  ampliamente,  no  son  capaces  de  provocar  ningdn  fendmeno  pato- 
Idgico  dentro  del  organismo  que  los  contiene.  Sin  embargo  algo  aun  no  conocido  debe 
haber  que  sea  causa  de  la  enfermedad  o  muerte  del  sujeto.  Este  algo  m^  es  lo  que 
nosotros  hemos  descubierto,  denomin&ndolas  ^'Lysinas"  o  anticuerpos  tercianos,  para 
diferenciarlos  de  los  anteriores,  que  Uamamos  secundarios,  habiendo  tomado  estas 
dltimas  denominaciones  de  Ehrlich,  sin  que  se  equivalgan  absolutamente  con  las  de 
dicho  autor.  EUo  se  explica  porque  cuando  estudiibamos  estas  cuestiones  y  las 
publicamos,  en  1903,  no  teniamoe  la  orientaci6n  que  ahora  poseemos,  ni  la  nueva 
ciencia  era  rica  en  tannines  ad  hoc. 

Las  l3rBinas,  lo  mismo  que  los  anticuerpos  secundarios  o  haptinas,  constitufdas  por 
la  destrucci6n  del  g^rmen  y  del  leucocito — ^pero  de  partes  esencialmente  distintas  que 
las  que  sirven  paia  constituir  los  secundarios,  como  lo  conoceremos  luego — son  las  que 
circulando  en  el  organismo  a  medida  de  su  producddn,  se  adaptan  a  las  c^lulas  de  los 
tejidos  cuya  estructura  alteran  y  provocan  los  f  en6menos  funcionales  que  exteriorizan 
para  nosotros  los  sfntomas  de  la  enfermedad. 

IV. 

Durante  la  enfermedad,  los  tejidos  u  6iganos  que  por  su  afinidad  han  adaptado  las 
lysinas,  experimentan  en  perfodos  variables,  transformaciones  histoldgicas  conocidas 
desde  mucho  tiempo.  Las  c^ulas,  elementos  de  esos  tejidos,  se  preeentan  a  la  obser- 
vaci6n  micro6c6pica  en  diversos  estados  de  alteraci6n,  que  se  denominan:  tumefacci6n 
turbia,  infiltraci6n  grasosa,  degeneracidn  grasa,  etc.,  y  que  desde  Virchow  han  sido 
descritos  como  alteraciones  del  protoplasma  celular  que  manifiestan  el  padecimiento, 
y  respectivamente  la  muerte  de  la  c^ula. 


270       PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC  CONGRESS. 

Paralelamente  a  estas  alteraciones  estructurales  van  produci^ndofle  las  funcionales^ 
desde  que  el  6igano  celular  pierde  proporcionalmente  las  propledadee  de  su  par^n- 
quima  normal,  fuente  de  la  funcidn  que  le  est&  encomendada. 

La  fiebre,  el  dolor,  la  dispnea,  la  albuminuria,  la  hipotenfii6n  arterial,  etc.,  son  las 
consecuencias  de  este  ataque  de  las  lysinas  a  loe  elementos  celulaies  de  nuestros 
6rgano8. 

La  enfermedad  constituida  evoluciona  de  diversa  manera  SQgdn  sea  la  calidad  y 
cantidad  de  la  lysina,  SQgdn  sea  la  categoria  y  hincionamiento  de  las  c^ulas  atacadas. 

Aqui  se  vuelve  a  observar  un  fendmeno  an^ogo  al  de  la  fagocitosb,  es  dedr,  el 
complejo  que  se  constituye  entre  la  c^ula  y  la  lysina  es  el  mismo  que  el  del  germen  y 
el  fagocito  en  aqu^lla.  Pero  lo  que  en  este  case  es  f^kdl  de  demostrar  por  la  mor> 
fologia  de  los  cuerpoe  que  intervienen  (g^rmenes  y  leucocitos),  en  las  lysinas  no  se 
puede  demostrar  gr&ficamente,  porque  drculan  en  el  plasma  como  substancias  disuel- 
tas.  Y  es  por  esto  que  no  son  conoddas  por  los  observadores  y  que  nosotros,  habi^- 
dolas  concebido  en  1903  con  la  claridad  con  que  las  expondremos  mis  taide,  hemes 
pasado  nueve  afios  sin  poder  llegar  a  demostrarlas. 

Estas.  lysinas  y  las  c^lulas  de  tejido  constituyen  asf  nuevos  cuerpos  que  provocan  la 
alteraci6n  o  la  muerte  de  esas  c^ulas,  o  bien  la  formaci6n  de  otro  nuevo  anticuerpo 
con  cualidades  especificas  del  g^nero  de  la  lysina  que  le  ha  dado  origen:  o  sea  la 
antitoxina. 

La  curaci6n  o  8anaci6n  se  electda  por  la  regeneracidn  de  la  c^ula  que  ha  suMdo  la 
acci6n  de  la  lysina,  o  indirectamente  por  la  excreddn  de  la  antitoxina. 

Por  la  evoluci6n  de  este  proceso,  el  enfermo  sanado,  presenta  un  estado  bioldgico 
refractario  que  constituye  la  inmunidad. 

V. 

La  inmunidad  es  un  estado  oi^ginico  que  confiere  al  organismo  animal  la  resistencia 
para  soportar  una  infecci6n  dada,  sin  que  ella  le  provoque  alteracidn  en  su  salud. 

La  inmunidad  se  adquiere  casi  sin  excepci6n  por  el  paso  de  una  enfermedad .  Puede 
ser  temporaria  como  en  la  influenza,  la  neumonfa,  etc.,  o  persistente  por  toda  la  vida 
como  en  la  tifoidea,  la  viruela,  etc.    En  esos  casoe  se  llama  adquirida  natural. 

La  adquirida  artificial  es  la  que  logramos  provocar  por  la  introduccidn  de  g^rmenes 
a  volimtad  para  produdr  el  mismo  estado  que  en  la  natural,  y  que  como  ella  repre- 
senta  un  proceso  de  infecci6n  en  que  el  oiiganismo  (medio)  contribuye  como  parte 
principal  para  constituirlo. 

Eb  necesario,  antes  de  pasar  adelante,  conocer  bien  lo  que  entendemos  pat  infeccidn. 
Para  nosotros,  es  el  primer  acto  del  fen6meno  patol<5gico  que,  segdn  se  desarrolle,  puede 
llegar  a  provocar  la  inmunidad  o  la  muerte.  En  los  dos  cases  la  infecci6n  se  verifica 
efectuando  reacciones  id^nticas  que  sdlo  varian  en  graduacidn  y  que  demuestran, 
una  vez  mis,  c6mo  los  actos  biol6gico8  del  organismo  obedecen  a  una  sola  y  tinica  ley. 

Segdn  nuestro  mode  de  ver,  la  infecci6n  representa  actos  semejantes,  sea  que  el 
agente  infeccioso  estd  constituido  por  microrganismos  o  por  toxinas.  Esto  echa  por 
tierra  el  mode  de  ver  clisico  que  mantenfa  la  diferencia  entre  enfermedades  por 
septicemia  (ejemplo:  carbunclo)  y  enfermedades  por  toxemia  (ejemplo:  difteria).  En 
el  primer  case  el  agente  (microrganismo)  producirfa  la  enfermedad  por  la  multipli- 
caci6n  de  sus  g^rmenes  dentro  del  oiganismo.  En  el  segundo,  la  toxina  o  veneno 
soluble  producirfa  la  enfermedad  por  intoxicaci6n. 

Eeta9  ideas  pueden  ser  ficilmante  combatidas,  demoetrando,  como  lo  hemes  hecho 
en  los  '^CuadroB  de  la  infecci6n,''  que  toda  Bubetancia  urginica,  morfol6gica  o  no, 
introducida  en  el  organismo  se  comporta  como  materia  extrafia  e  innocua,  mientras 
no  haya  side  digerida  por  loe  fagocitos  o  el  suero  y  transformada  en  anticuerpos,  que  son 
los  tinicoB  elementos  que  por  sue  cualidades  bioldgicas  excitan  Ice  intercambios  orgi- 
nicoB. 


PUBLIC  HEALTH  AND  MEDICINE.  271 

El  hecho  medinico  de  la  CagocitOBis  ee  f&cdl  de  comprobar  al  microscopio  para  los 
elementos  morfoldgicoe  que  la  constituyen;  no  asi  el  de  las  toxinas,  Ifquidos  infonnes. 
Pero  la  simple  observacidn  de  la  imtaddn  local  que  provoca  la  inyecci6n  de  micror- 
ganismo  o  tozmas  bajo  la  piel  de  un  animal,  ensefia  a  ver  adn  a  Ice  menoe  avesados  lo 
que  pasa  despu^  de  algunas  horas:  un  edema  inflamatorio  doloroso  y  tuigente  que 
microecdpicamente  se  preeenta  en  ambos  casos  constitufdo  por  un  exudado  m£s  o 
menos  lico  en  leucocitos,  ofredendo  en  uno  el  cuadio  de  la  {agocitosis  de  los  g^rmenes 
aun  reconodbles,  y  en  el  otro  86I0  los  Cagodtos  sin  fonna  reconocible  en  su  interior. 
Besredka'ha  demostrado  que  soluciones  tdxicas  de  an6nico  inyectadas  al  animal,  se 
las  encuentra  en  mayor  cantidad  en  el  exudado  rico  en  leucocitos  que  en  el  suero,  lo 
que  se  comprueba  por  reacciones  quimicas  y  Gonfirma  en  consecuenda  que  los  leuco- 
citos se  apoderan  de  los  liquidoe  de  igual  manera  que  de  los  g^rmenes. 

Los  autores  ban  pasado  por  alto  esa  identidad  de  acddn  de  microrganismos  y  toxinas 

por  no  haberies  concedido  la  atencidn  que  se  merece  y  que  hemes  side  los  primeros 

en  sefialar  hace  16  afios. 

VI. 

Ahora  que  conocemos  en  bus  lineas  generales  lo  que  pasa  dentro  del  organismo, 
cuando  los  agentes  pat6genos  lo  contagian,  estudiemos  con  detalle  las  substancias  que 
toman  origen  por  este  contagio  y  los  efectos  que  producen. 

Los  anticuerpos  constitufdos  por  la  Agocitosis  o  la  bacteriolysiBson  de  dos  espedes: 
anticuerpos  secundarios  o  haptinas  y  anticuerpos  terciarios  0  lyainas.  . 

Segdn  la  deducci6n  analftica  a  que  nos  ban  llevado  estos  estudios  desde  bus  comien- 
zos,  guiados  como  hemos  estado  siempre  por  la  observaddn  del  hombre  enfermo  o  del 
animal  de  experiencia;  en  la  compo6ici6n  de  todo  microiganismo  o  substanda  oigdnica 
amorfa  (coloide)  existen  dos  cualidades:  una,  que  representa  las  particularidades  de 
su  estroma  o  estructura,  y  que  serla  como  la  pertonedente  a  su  membrana  de  envoltura 
o  a  su  esqueleto  de  Boston,  si  pudiera  expresarse  as!  (ectoplasma);  y  la  segunda  a  las 
particularidades  de^idas  a  la  estructura  y  funcionamiento  de  su  protoplasma  (endo* 
plasma). 

Eets8  dos  cualidades,  diliciles  de  evidenciar  pw  los  medios  fisicos  o  quimicos,  se 
hacen  ostensibles  por  sus  propiedades  bioliSgicas;  y  su  existenda,  demostrable  por  la 
experun6ntaci6n,  es  el  hecho  m£s  hmdamental  de  nuestra  teorfa. 

A  esos  dos  componentes  bioldgicos  del  gennen  o  toxina,  a  esas  albtiminas  extrafias 
al  oiganismo— <iue  se  denominan  con  el  nombre  gen^co  de  ''Antigeno'' — se  debe  la 
formaci6n  de  las  dos  dases  de  cuerpos  que  nos  ocupan. 

Para  los  haptinas,  el  ectoplasma  o  estroma;  para  las  lysinas  el  endoplasma  o  subs- 
tanda protoplasm&tica  del  antl^no.  Ambas,  en  raz6n  de  su  origen,  tienen  cualidades 
distintas  que  vamos  a  estudiar,  y  ambas  llenan  un  rol  diverse  en  el  proceso  de  la  inmu- 
nidad  y  de  la  enfermedad. 

Hemos  visto  que  las  haptinas,  despu^  de  constitufdas  y  circulando  en  la  sangre, 
gozan  de  propiedades  especificas,  caracteriaadas  por  la  atracd6n  hada  al  ant^feno  de 
origen.  Es  en  virtud  de  estas  propiedades  que  vuelven  de  nuevo  a  transformar  el 
antlgeno  reintroduddo  al  organismo  en  haptinas  id^ticas,  las  que  siguen  regener&n- 
dose  durante  un  tiempo  variable,  hasta  que  desaparecen  por  diversas  causas,  y  entre 
eUas  por  la  Mta  de  nuevo  ant^eno  reintroduddo. 

La  cualidad  de  destruir  el  antigeno  da  a  estos  cuerpos  doble  rol:  P,  aniquilar  el 
antigeno,  y  por  conaiguiente  evitar  su  multiplicad6n;  2^,  coadyuvar,  por  d  hecho 
de  fovorecer  ese  aniquilamiento,  a  la  limitad6n  en  la  producci6n  de  las  lysinas  que, 
constituldas,  tienden  fatalmente  a  producir  la  enfermedad. 

La  transformaddn  que  este  aniquilamiento  produce  es  el  fen6meno  biol<^co  indis- 
pensable que  sirve  para  hacer  adaptar  al  organismo  el  cuerpo  extrafio  que  representa 
el  antigeno,  y  que  hemos  denominado  "animalisacidn,"  a  falta  de  una  terminologfa 
m4s  adecuada  para  estos  actos  (ntimos  del  organismo. 


272       FBOOEEDIKOB  SECOND  PAN  AMBBIOAK  80IENTIFI0  OOKGBESS. 

De  todo  eeto  se  deduce  que  son  factores  primordiales  en  el  proceeo  de  la  inmoni- 
Bacidn  como  en  el  de  la  enfennedad.  Sin  ellos  el  antigeno  dejarfa  de  ser  cA  exdtante 
venido  de  faera,  y  el  ddo  ni6rbido  no  podrfa  deeanoUane. 

Pero  donde  m^Baltaavifltaeste  rol  primordial  de  las  haptinas,  es  enel  ddo  de  la 
nutriddn  de  nuestio  oiganismo.  ^G6mo  podrfan  eernos  Utiles  las  albuminas  de  loa- 
alimentos  despu^  de  la  digestidn  quimica  que  sufren  en  d  tube  gastro  intestinal, 
cuando  abeorbidas  por  la  sangre  y  por  d  qnimo,  no  fueraa  animaliKadaw  por  las  bap- 
tinas?  Vendrfan  a  ser  lo  que  d  ant%eno  no  tzansfonnado  en  el  ambiente  patoldgico  r 
"cuerpos  extrafios,"  incapaces  de  desanollar  d  ddo  evolutivo  de  la  nutriddn. 

La  ooncepd6n  de  las  baptinas  en  esta  fbnna,  ensandia  su  rol  en  el  organismo,  y 
▼ienen  a  ser  asi  los  factores  fisiol6gicos  de  la  nutrid6n  para  la  vida  del  indivfduo,. 
como  vienen  a  ser  los  factores  fidopatoldgicos  para  la  enfennedad  o  para  la  inmuni- 
saddn  dd  sajeto. 

Su  ddo  de  evoluddn  dentro  del  oiganismo,  se  reduce  al  leucodto  como  centro,  y 
son  sus  extremes,  d  antigeno  que  le  da  origen  y  el  antigeno  que  de  nuevo  lo  atrae. 
Ninguna  cdula  de  tejido,  ningdn  par6nquima,  en  una  palabra,  ningdn  6rgano  de  la 
▼ida  de  relacii6n  ee  atacado  por  las  baptinas. 

Este  rol  importantimmo  que  les  atribulmos,  y  sobre  d  que  se  basa  cad  excludva- 

mente  el  acto  inmunizatorio,  es  nogado  sin  reticenda  por  todos  los  autores,  que  66I0 

ban  prohmdixado  d  estudio  de  su  rol  de  reactivoe  especificoe,  evidenciados  pcft  tend- 

menos  in  vitro.    £1  estudio  de  eetas  reacdones  iniciado  por  Bordet  y  Ehrlicb,  con- 

tinuado  por  todos  investigadores  basta  hoy,  ba  despistado  la  atenddn  del  punto 

culminante  que  acabamos  de  establecer,  ocultando  asf  su  alto  rol  bioldgico  de  agentes 

fidopatol6gico6  del  oiganismo. 

VII. 

Como  ya  lo  bemoe  dicbo  anteriormente,  bemos  dado  d  nombre  de  "lysinas"  a  los 
anticuerpos  terdarios  que  se  constituyen  al  par  de  las  baptinas  durante  la  fagodtosis 
o  la  bacteriolysis  dd  endoplasma  dd  antigeno  introduddo  al  oiganismo. 

Hay  que  tener  bien  presente  que  la  palabra  lysina,  no  es  nueva  y  que  en  ciencia 
se  usa  frecuentemente  como  sin6nima  de  destrucddn. 

Asf  PffeifiFer  fnd  el  primero  que,  en  estos  estudios,  signified  la  disoluddn  o  destmc- 
ddn  de  los  badlos  con  d  nombre  de  bacteriolysis.  A  la  destmccidn  de  los  gl6bulos 
rojos,  se  llama  bemolysis;  a  la  de  las  cdulas,  drolysis,  etc. 

Nuestras  lisynas,  que  bemos  introduddo  por  primera  vez  en  la  patologfa  bioldgica, 
tienen  cualidades  propias  que  las  caracterizan  y  las  distinguen  hmdamentalmente 
de  todos  los  otros  cuerpos  biol6gicoe. 

Formadas  como  las  baptinas,  por  un  fendmeno  an&logo,  se  diferendan  desde  ese 
memento  mismo  porque  los  antigenos  capaces  de  darlas  son  mucbo  mis  virulentos  que 
loe  necesarios  para  dar  baptinas.  Tambidn  porque  su  formacidn  es  precedida  dempre 
por  una  etapa  de  formaci6n  de  baptinas  puras,  necesarias  para  excitar  la  fagodtosis 
de  aquellas,  al  comienzo  del  acto  fagodtario;  gracias  a  esa  preparaddn  para  la  trans- 
formaddn  de  las  lysinas  podemos  explicar  d  fen6meno  de  la  anafilaxia,  como  veremos 
luego. 

Su  dclo  de  acd6n  es  completamente  distinto  del  pequefio  dclo  en  que  se  forman 
y  actdan  las  baptinas.  Empieza  en  d  fagodto  como  aqudlas;  se  difunde  inmedia- 
tamente  de  constituidas  en  la  sangre  y  son  atrapadas  por  las  cdulas  de  nuestros 
diganos  con  avidez  sorprendente,  como  sucede  con  los  venenos  o  ponzofias  que  inme- 
diatamente  de  inoculadas  por  la  picadura  de  las  serpientes  0  arafias,  enferman  o 
matan,  a  causa  de  esa  difudbilidad  y  de  la  atracddn  de  las  cdlulas  por  ellas. 

La  acddn  de  las  lysinas,  como  nosotros  las  concebimoe,  se  limita  a  las  cdulas  de 
tejido,  dterando  su  estructura  y  por  consiguiente  su  hmdonamiento  (como  lo  bemos 
dicbo  al  bablar  de  la  enfennedad),  y  dan  un  producto,  en  los  casos  de  regeneraddn 
totd  de  la  cdlula,  o  sea  en  los  casos  de  sanaddn  que  es  lo  que  conocemos,  desde 
Behring,  por  antitoxina. 


PUBLIO  HEALTH  AND  MEDICINE.  273 

De  modo  que  la  lyaiiia,  nacida  en  la  ftigocitoeiB  o  bacteriolyEOs  del  antigeno,  tiene 
por  centro  la  c61ula  de  tejido  y  se  termina  por  la  fonnaci6n  de  antitoxina.  No  es 
como  la  haptina  que  termina  donde  empieza  y  preeenta  por  consiguiente  las  cuali- 
dades  reveraibles  de  Iob  fermentos.  La  lysina,  una  vez  fonnada,  ee  encadena  total- 
mente  a  la  c61ula  y  no  encuentra,  durante  su  existencia  como  tal,  ningdn  cuerpo  con 
propiedades  de  neutralizarla. 

Este  ee  un  hecho  importantlEdmo  para  nueetros  conocimientos  de  la  enfermedad  y 
de  la  sanacidn,  y  permite  explicar  el  rol  secundario  de  la  antitoxina  en  la  curaci6n  de 
la  enfermedad,  que  hasta  hoy  no  habla  side  detallado  en  todas  bus  fouses. 

Hemos  repetido  varias  voces  que  la  lysina  ee  el  factor  de  la  enfermedad  propia- 
mente  dicha,  explic&ndonoe  su  acci6n,  en  la  primera  ^poca  de  nuestros  trabajoe,  por 
simples  deducciones  de  observaci6n  clfnica  y  bacteriol<3gica. 

Pensdbamos  entonces  que  la  enfermedad  s61o  la  produce  el  antfgeno  virulento,  es 
decir,  seglin  lo  que  hemos  explicado,  el  antfgeno  que  ofrezca  mia  substancia  proto- 
plasmitica;  y  como  ^sta  es  la  que  contribuye  a  la  formaci6n  de  la  lysina,  a  mayor 
virulenda  coiresponde  m^  cantidad  y  eficacia  de  la  producci6n  de  lysina. 

Pero  esta  hip6tesis,  para  ser  aceptada,  necesitaba  ser  demostrada  por  hechoe  experi- 
mentales,  a  los  que  no  pudimos  ll^ar  durante  largo  tiempo,  atribuyendo  la  dificultad 
del  pioblema  a  la  difusibilidad  y  a  la  falta  de  atracci6n  de  las  lysinas  hacia  un  cuerpo 
que  pudiera  servimos  para  su  demostraci6n  in  vitro,  al  igual  de  las  reacdones  dee- 
cubiertas  por  Ehrlich  para  las  haptinas. 

Es  seguramente  por  esta  Jblta  de  atraccidn  a  todo  lo  que  no  es  c^lula  parenqoima- 
toea,  que  las  lysinas  han  pasado  inadvertidas  hasta  nosotros. 

El  estudio  del  fen6meno  de  la  anafilaxia  nos  ha  permitido  encontrar  las  reacdones 
demostrativas  de  la  existencia  de  estos  cuerpos,  que  pasamos  a  relatar  sumariamente, 
extractando  de  nuestros  trabajos  publicados  sobre  la  materia. 

VIII. 

Richet  ha  denominado  anafilaxia  al  fen6meno  que  ee  observa  cuando  un  animal 
inyectado  con  un  cierto  'antfgeno  es  reinyectado  despuds  de  algtin  tiempo  con  el 
mismo  antfgeno;  inmediatamente  de  la  reinyecci6n,  el  animal  presenta  un  cuadro 
de  sfhtomas  graves,  bien  caracterizados,  que  pueden  terminar  por  la  muerte. 

La  anafilaxia  se  piovoca  de  varias  maneras. 

Cuando  se  inyecta  a  un  animal  una  dosis  de  antfgeno  mucho  menor  que  la  necesaria 
para  producir  la  muerte,  de  modo  que  no  altere  su  salud,  y  se  inyecta  de  nuevo  canti- 
dades  aun  menores  del  mismo  antfgeno  algtin  tiempo  mia  tarde,  se  observa  que  inme- 
diatamente despu^  de  la  segunda  inyecci6n  el  animal  sufre  un  "choc"  que  produce 
la  muerte  casi  instant^nea.    Esto  es  lo  que  se  llama  anafilaxia  activa. 

Se  puede  producir  el  mismo  fendmeno  inyectando  a  un  animal  el  suero  de  la  sangre 
de  otro  que  ha  sido  inoculado  previamente  con  dosis  wifnifwo.  del  antfgeno.  El  animal 
asf  preparado  o  en  estado  pre-anafilictico,  al  ser  inyectado  dfas  despu^  con  el  antf- 
geno, sufre  el  ''choc"  id^ntico  al  del  ejemplo  anterior.  Se  tiene  entonces  la  anafi- 
laxia pasiva. 

Estudiando  estas  cuestiones,  en  1910,  tratamos  de  explicar  el  fen6meno  de  la 
anafilaxia  al  trav^  de  nuestra  teorfa,  y  para  hacer  m^  apreciable  la  idea,  imaginamos 
la  siguieinte  f6rmula: 

FORMULA   DE  LA  ANAFILAXIA. 

•n.  w         •  t       /Anticuerpossecundaiios+Chaptinas). 

Primera  inyeccion,  pnmera  faz..i  .^        '^     .      ..     ^  n    *      \ 
^  '  ^  lAnticuerpos  tercianos  0  (lysinas). 

„         J    .  .,  .    .      /Anticuerpo8  8ecundarios+++ (haptinas). 

Segunda  inyeccion,  segunda  faz.S  .^       *^     ^  iii/i'\ 

^  ^  '  ^  lAnticuerpos  tercianos+++Oyfli^**)' 

Interpretando,  tenemos:  que  la  primera  inyecci6n  dota  al  oiganismo,  despu^  de  un 
cierto  tiempo,  de  abundante  producci6n  de  haptinas  y  de  muy  pocas  o  ninguna  lysina. 


274       PBOOEEDINGS  SECOND  PAN  AMEBIOAN  SGIBNTIFIO  OONGBBSS. 

La  segunda  inyeccidn,  ea  virtud  del  e6tado  anterior,  es  transformada  r&pidamente  en 
ambos  anticuerpos;  y  como  de  ^stos  las  lyainas  son  los  tinicoe  pat6geno6,  a  ellas  se  debe 
el  fendmeno. 

De  mode  que  para  noeotros  el '  *  choc  **  anafildctico  se  debe  (inicamente  a  la  produccidn 
de  las  lysinaa  constituidas  instantineamente  por  las  haptinas  prefonnadas  de  la  primera 
inyecci6n.  • 

Para  demostrar  expeiimentalmente  esta  afirmacidn  tenlamos  que  busear  otroe 
ejemplos  que  los  de  la  anafilaxia  activa  o  pasiva,  con  objeto  de  penetrar  al  fondo  del 
fen6meno. 

Asf  tentamos  ezperimentos  nuevos,  a  fin  de  poder  eliminar  para  el  'choc"  ana- 
fiUctico  la  intervencidn  directa  del  antlgeno  y  aim  del  perfodo  pre-anafilictico,  es 
dedr,  prescindir  de  la  anafilaxia  activa  y  de  la  paaiva,  por  ser  por  sf  mismas  insufi- 
cientee. 

Y  es  lo  que  hemot  consegnido  y  demostrado  en  nuestro  trabajo  con  Ceballos. 

Oonsiste  en  tomar  una  gota  de  sangre  o  del  suero  de  nn  animal,  puesto  en  ''choc  " 
de  anafilaxia  activa,  e  inyectar  esa  sangre  o  suero  en  el  coras^,  a  otzo  animal  de  la 
misma  especie.  Etfte  tiltimo  entra  inmediatamente  en  "choc"  con  un  cuadro  de 
afntomas  id^ticos  al  animal  proveedor.  £1  fen6meno  se  obtiene  evidente,  ya  sea 
con  sangre  pura,  con  suero  active  o  con  suero  inactive. 

Por  esta  ezperienda  queda  suprimido  el  antigeno  en  el  animal  receptor,  y,  simpli- 
ficando  el  problema,  demuestra  que  por  el  hecho  de  la  d^gunda  inyecci6n  se  ban 
formado  cuerpos  delet^reos  en  el  animal  de  origen,  que  drculando  en  la  sangre  pueden 
ser  transmitidos  con  ella  a  otro  animal  no  preparado.  Tambi^  se  nota  que  este 
nuevo  mode  de  anafilaxia  transmitida  suprime  el  perfodo  pre-anafilfctico, 

Pero  aim  no  es  bastante  para  aislar  las  l3rBinas  de  otros  cuerpos  nuevos,  que  segdn 
Richet  y  otros  autores  se  f<^man  especialmente  por  la  re-inyecddn.  Estos  cuerpos 
sui  generis,  imaginados  ad  hoc  para  el  fen6meno  anafiUctico,  no  existen,  o  por  lo  menoe 
nadie  los  ha  descrito  en  el  proceso  espontdneo  de  la  enfermedad  o  en  el  artificial 
creado  por  la  inmunizacidn  conferida.  Son  puramente  hipot^ticos,  y  a  nuestro  mode 
de  ver  il<5gicos  en  el  encadenamiento  de  los  actos  fisiopatoldgicos  del  organismo,  que, 
como  lo  hemoe  dicho  mia  de  una  vez,  obedecen  y  se  desarroUan  dentro  de  una  ley 
tinica  e  inmutable. 

Para  eliminar  del  todo  la  t^cnica  de  los  autores,  a  la  que  parece  atribulrsele  la  forma- 
ci6n  de  esos  nuevos  cuerpos  especiales,  hemes  verificado  experimentos  publicados 
bajo  el  nombre  de  "Experiencias  de  las  lytanBB,**  que  consisten  en  inocular  de  una 
sola  vez  a  un  animal  una  dosis  del  antigeno  suficiente  para  producir  la  muerte,  como 
sucede  en  la  infeccidn  natural.  Extrayendo  una  pequefia  cantidad  de  sangre,  de  ese 
animal,  durante  el  perfodo  ag6nico,  e  inyect4ndola  inmediatamente  dentro  del 
coraz6n  de  otro  animal  normal  de  la  misma  especie,  provoca  en  6ste,  inmediatemente, 
los  di versos  sfntomas  del  "choc"  anafiiictico. 

^A  qu^  se  debe  el  "choc"  en  este  animal  receptor  7 

No  es  a  la  anafilaxia  cUisica,  que  exige  la  re-inyecci6n  del  antigeno.  No  es  tam- 
poco  a  la  transmitida,  de  M6ndez  y  Ceballos,  que  aun  pudiera  interpretarse  como  el 
transporte  de  los  cuerpos  sui  generis  elaborados  por  el  animal  proveedor. 

Aquf  no  se  trata  de  una  combinaci6n  del  antigeno  para  producir  esos  cuerpos  dis- 
tintos  del  proceso  inmunizante  comtin,  sine  simplemente  de  la  demostraddn  evidente 
de  la  existenda,  en  la  sangre  del  animal  ag6nico,  de  una  substancia  constituf  da  durante 
la  infecci6n  de  un  ant(geno  pat6geno.  Y  esa  substancia,  que  conocemos  en  su  manera 
de  formarse,  en  su  manera  de  actuar  y  aun  en  el  cuerpo  que  constituye  durante  el 
proceso  fiaiopatol6gico  de  la  enfermedad,  es  la  lysina. 

Si  aun  se  duda  de  que  el  anticuerpo  constitufdo  en  la  enfermedad  sea  el  mismo 
que  el  constitufdo  en  el  "choc"  anafiUctico,  porque  sus  efectos  parezcan  distintos, 
en  la  rapidez  de  acci6n,  seri  f&cil  convencerse  de  que  no  es  asf  si  tenemos  presente  la 
formula  de  la  anafilaxia  indicada  anteriormente. 


PU6LI0  HEALTH  AND  MEDICIKE. 


275 


be 

io 
a 


En  la  enfennedad,  natural  o  provocada,  la  formacidn  de  I3r8ina8  se  realiza  gradual- 
mente,  y  las  c^lulas  que  la  encadenan  van  recibi^ndola  poco  a  poco  y  produciendo 
con  su  iegeneraci6n  concomitante  la  antdtoxina;  de  modo  que  si  el  anibo  de  lysinas 
sobrepasa  la  actividad  regeneradora  de  la  c^ula,  ^sta  sufre  gradualmente  en  su  estruc- 
tura,  como  lo  hemos  ya  explicado,  y  caduca  al  fin  en  el  periodo  ag6nico. 

En  la  anafilaxia,  la  c^lula  de  tejido,  viigen  de  todo  contacto  anterior  con  .las  lysinas, 
sufre  sin  preparaci6n  previa  el  arribo  de  ^sta,  y  caduca  inmediatamente  por  falta  de 
actividad  regeneradora. 

La  rapidez  de  los  sfntomas  que  ha  sorprendido  a  los  observadores,  haci6ndolee  creer 
en  fen6menos  extraordinarios  del  organismo,  entra  tan  exactamente  en  nuestra  teoria 
que  viene  a  ser  la  reacci6n  buscada  para  demostrar  la  existencia  de  las  lysinas  (M^ndez) 
en  el  organismo. 

Dado  que  la  lysina  existe,  y  que  la  antitoxina  (su  producto  de  excreci6n)  es  tambi^ 
conocida,  estudiemos  someramente  el  rol  de  esta  tiltima  en  la  curaci6n  de  las  enferme- 
dades,  asunto  que  interesa  sobremanera  a  medicos  y  pacientes. 

IX. 

La  antitoxina,  descubierta  por  Behriag  para  la  difteria,  fu6  en  la  ^poca  de  su  descubri- 
miento  un  gran  paso  que  deslunibr6  a  los  estudiosos.  Faltos  de  conocimientos  sufi- 
dentes  entonces,  atribuiasela  a  un  simple  intercambio  del  organismo,  que  trans- 
formaba  la  toxina  inoculada  en  antitoxina  excretada;  y  contribuy6  adn  mis  a  esta 
creencia  el  hecho  de  que  ambos  compuestos,  mezclados  en  proporciones  adecuadas 
en  un  tube  de  ensayo  e  inyectados  conjuntamente  al  animal,  no  le  provocaban  malestar 
alguno.  Luego,  se  dedujo  que  la  antitoxina  era  el  remedio  especlfico  de  la  enferme- 
dad  respectiva. 

Efectivamente,  el  hecho  ostensible  es  ese;  pero,  despu^  de  lo  que  llevamos  dicho, 
sabemos  que  entre  la  toxina  inyectada  y  la  antitoxina  elaborada,  hay  en  el  organismo 
un  engranaje,  complejo  y  sencillo  a  la  vez,  que  permite  ampliar  el  conocimiento  de 
ese  reeultado. 

En  efecto,  si,  a  manera  de  resumen,  establecemos  un  cuadro  en  que  se  inscriban 
los  nombres  de  todos  los  cuerpoe  que  forman  y  constituyen  el  proceso  patol^co, 
relacion&ndolos  en  su  evoluci6n  y  i^nidadee,  tendremos: 

1.  Proceso  completo. 
Primera  fas;  segnnda  (as. 


Antfgeno. 

Fagooitoaiso 
bacteriolysis. 

Haptinas. 

Haptinas  y 
y  lysinas. 

Tejidos 
(drganos). 

Enferxnedad. 

Curaoitfny 
antitoxina. 

2.  Proceso  irirnunizarUe  (cido  haptmas). 
Primera  Cas;  segunda  fiaz. 

Antlgeoo. 

Fagocltosiso 
bacteriolysis. 

Haptinas. 

Noexiste. 

Antlgeno. 

3.  Enfermedad  (ciclo  lysinas). 
Primero  fiaz;  segunda  fas. 


Uaptinasy 
lysinas 


Tejidos 
(6rganos). 


Enfer- 
medad. 


Curaddny 
antitoxina. 


4.  (Cido  anUtoxinas,) 


Antitoxina. 


Antlgeno. 


68436— 17— VOL  x- 


19 


276       PBOGBEDINGS  SECOND  PAN  AMEBICAN  SCIENTIFIC  CONGBESS. 


5.  Arwfilaxia, 


Antlgeno. 

Fagooltosiso 
bacteriolysis. 

Prlmera 

faSfhap- 

tinas. 

Segunda  fki. 

T«jido8  (drganos). 

Choc 

Relnyeodtfn. 

Fagodtosiso 
baoteriolysls. 

Haptlnas  7 

El  primer  cuadro  ee  resumen  de  lo  tratado  en  eete  txabajo.  El  segundo  indica  el 
ciclo  de  las  haptinas  que  empieza  por  el  antlgeno  y  concluye  de  nuevo  en  ^.  El 
tercero  demuestra  que  la  lysina  constitufda  hace  8u  ciclo  medio  hasta  la  antitoxina. 
El  cuarto  confirma  lo  cl^co:  la  atiacci6n  de  la  antitoxina  por  la  toxina. 

Este  tiltimo  cuadro  exige  una  explicaci6n.  En  el  acto  patoldgico  loe  fen6menoe 
que  hemes  descrito  se  producen  concomitantee  loe  unos  con  loe  otroe,  o  bien  loe  unoe 
despu^  de  loe  otroe;  por  eeo,  en  un  memento  dado,  puede  encontrarse  dentro  del 
organismo  parte  del  antlgeno  aun  en  natura,  parte  transformado  ya  en  anticuerpos. 
Estos  pueden  eetar  predominando  en  su  primera  ^  o  en  su  segunda.  Las  lysinas: 
en  parte  atrapadas  por  las  c^lulas,  en  parte  aun  libres  en  la  sangre.  La  antitoxina, 
formindoee  y  excretada  por  las  c^lulas,  drculando  en  la  sangre,  en  presencia  de 
haptinas  0  de  lysinas,  con  las  cuales  no  tiene  ningdn  rol,  y  siendo  atralda  tinicamente 
por  el  antlgeno  al  que  neutraliza  en  el  sitio  de  su  producci6n. 

Tomamoe,  por  ejemplo,  un  enfermo  de  angina  dift^rica.  En  el  sitlo  del  contagio 
(gaiganta)  comienza  la  multiplicacidn  de  bacilos  que  al  mismo  tiempo  secretan  la 
toxina  respectiva.  Esta  es  fagocitada  o  bacteriolizada  para  constituir  loe  anticuerpos, 
etc.  La  antitoxina  al  fin  formada,  es  atralda  por  los  bacilos  y  por  la  toxina  nadente 
que  se  desarrolla  en  la  pseudo  membrana,  y  alll  la  neutraliza.  No  hay  mds  producci6 
de  toxina  dentro  del  oiganismo  y  por  consiguiente  el  contagio  queda  terminado.  El 
enfermo  puede  quedar  sano,  si  mientras  tanto  las  lysinas  drculantes  no  son  activas  o 
si  las  c61ulas  se  regeneran  acti vamente  a  su  excitaci6n .  En  case  contrario  el  individuo 
muere  a  pesar  de  su  antitoxina. 

Este  fendmeno  explica  lo  que  la  pr&ctica  confirma  dla  a  dla  cuando  se  aplica  el 
suero  antidift^rico  en  los  enf ermos  dlas  despu^  de  comenzada  la  enf ermedad .  Cuanto 
m4B  tarde  es  menoe  eficaz,  porque  las  lysinas  encadenadas  por  los  tejidos  han  destruldo 
gran  parte  de  las  c^ulas  y  la  regeneraci6n  no  es  ya  posible,  aunque  haya  la  cantidad 
milxima  de  antitoxina  introducida  circulando  en  la  sangre.  Por  la  misma  raz6n  es 
criticable  la  prdctica  en  boga  de  inyectar  dosis  m^ximas  de  suero  antidift^rico, 
creyendo  que  a  mayor  cantidad  corresponde  mayor  efecto,  cuando  una  dosis  media  es 
m^  que  suficiente  para  neutralizar  la  toxina  naciente  en  el  organismo  y  obtener  la 
curacidn  si  las  lysinas  no  han  alterado  el  protoplasma  0  las  c6Iulas  de  tejido. 

Seguramente  esta  teorla  no  merecerla  ser  expuesta,  si  no  fuera  m&a  que  una  cons- 
trucci6n  imaginativa.  Pero  ella,  adem^  de  ser  el  resultado  de  la  observaci6n  y  de 
la  experimentaci6n,  implica  una  serie  de  consecuencias  pr&cticas:  una  vez  confirmada 
y  aplicada  abriri  nuevas  vlas  a  la  curaci6n  de  las  enfermedades,  constituyendo  lo 
,  que  hemes  Uamado  la  '^Terap^utica  esencial.'*  De  ella  ya  poseemoe  algunos  jalones, 
como  son:  la  vacuna  carbunclosa  aigentina,  el  haptin^geno  gone,  el  haptindgeno 
neumo,  el  haptin^no  tlfico  y  otras  m^;  hijas  de  las  ideas  vertidas  en  estas  p&ginas, 
ejercen  su  acci6n  curativa  evidente  de  acuerdo  con  las  consecuencias  de  la  teorla. 

Despufo  de  lef  da  la  comunicaci6n  sobre  la  teoria  biol6gica  argcntina 
de  la  inmunidad  el  Dr.  Sarmiento  Laspiur  hizo  una  slntesis  en  f  ranc6s 
de  dicho  trabajo  y  explic6  con  eland  id  la  producci6n  del  chock 
anafil&ctico.  Al  terminar  su  dbertaci6n  hizo  constar  que  habfa 
escuchado  con  detenci6n  los  trabajos  presentados  sobre  anafilaxia  por 
los  delegados  americanos  y  manifestd  que  ellos  no  eran  otra  cosa  que 


PUBLIC  HEALTH  AUD  MEDICINE.  277 

la  repetici6n  de  experimentos  y  la  descripci6n  de  los  sintomas  de  ana- 
fil.vxia,  pero  que  en  ningimo  habia  escuchado  una  exp1icaci6n  original 
del  fen6meno,  mientras  que  la  teorfa  biol6gica  argentina  daba  una 
satisfactoria  explicaci6n  del  mecanismo  de  producci6n  del  "chock'' 
anafilftctico  absolutamente  personal  del  Dr.  M6ndez. 

The  Chairman.  The  paper  which  has  just  been  read  is  an  individual 
way  of  approaching  the  general  problem  of  anaphylaxis.  It  is 
difficult  to  discuss  it  owing  to  the  terminology,  which  though  in 
accord  with  terminology  generally  used  differs  somewhat  in  the  inter- 
pretation of  the  words.  As  far  as  I  can  make  out,  the  haptins 
and  lysins  are  considered  to  be  products  of  the  antigen.  The  thing 
that  specially  interested  me  was  the  statement  that  if  a  drop  of  blood 
or  serum  is  taken  from  an  animal  in  shock  due  to  active  anaphylaxis 
and  this  is  reinjected  into  the  circulation  of  another  animal  of  the  same 
species,  the  latter  animal  immediately  goes  into  shock  with  sjonptoms 
identical  to  the  first  animal. 

I  am  not  familiar  with  the  original  experiments  of  Dr.  Mendez 
which  led  him  to  that  conclusion.  Similar  experiments  were  reported 
a  few  years  ago  by  Thiele  and  Embleton,  of  London.  Now,  that 
observation,  if  correct  and  if  confirmed,  is  of  fimdamental  importance 
in  anaphylaxis  and  also  in  immunity,  because  if  it  is  correct  it  means 
that  substances  of  the  type  of  anaphylatoxins  are  actually  formed  in 
anaphylactic  shock  and  circulate  in  the  blood  as  such,  and  you  will 
see  at  once  that  that  commits  us  to  the  acceptance  of  the  humoral 
theory  and  to  the  acceptance  of  anaphylatoxin.  It  is  really  the 
one  fundamental  experiment  to  demonstrate  that  anaphylatoxins  are 
formed  in  shock  and  that  they  are  really  effective. 

Now,  the  question  is  whether  the  experiments  were  well  niade 
and  whether  the  observation  is  acceptable.  You  will  see  that  the 
statement  made  by  Dr.  Mendez  is  that  a  single  drop  of  blood  is  taken. 
In  the  experiments  of  Thiele  and  Embleton  they  practically  exsangui- 
nated animals  in  shock.  These  statements  as  made  here  are  not 
explained  in  detail;  we  do  not  know  whether  the  serum  was  used  or 
whether  the  blood  was  defibrinated,  or  whether  the  blood  was  taken 
into  citrate.  We  do  know  that  Thiele  and  Embleton  took  it  into 
citrate  and  injected  it  very  shortly  afterward.  Doerr  has  analyzed 
this  work  recently  and  declined  to  accept  it,  and  I  think  for  very  good 
reasons.  In  the  first  place,  he  states  a  fact,  which  is  really  fairly 
well  known,  that  blood  taken  from  an  animal  in  the  agonal  stages^ 
in  convulsions,  or  blood  taken  from  any  animal  if  fairly  fresh,  is 
highly  toxic  to  others  of  the  species.  Why  that  is  we  do  not  know, 
but  if  one  has  had  a  good  deal  of  experience  in  transfusing  animals 
one  comes  to  find  that  the  blood  of  animals  of  the  same  species  may 
be  highly  toxic.  It  is  not  necessary  to  take  an  animal  in  shock  or 
convulsions.     Now  Thiele  and  Embleton  made  no  controls  to  deter- 


278       PEOCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  CONQBESS. 

mine  whether  the  blood  they  got  from  theu*  anaphylactic  animals  was 
more  highly  toxic;  in  fact,  their  experiments  were  seriously  lacking 
in  control  experiments.  So,  as  Doorr  says,  we  can  not  accept  their 
conclusions. 

Now,  the  statement  is  made  here  that  a  drop  of  blood  produces 
the  result.  That  is  sometliing  entirely  new,  and  in  my  experience 
of  anaphylaxis  is  not  confirmable,  for  I  have  more  than  once  injected 
considerably  more  than  a  single  drop  and  have  never  obtained  the 
result.  So  there  must  be  other  factors  in  the  experiment  which  I 
should  like  to  hear.  It  seems  to  me  this  is  an  important  point  to 
analyze  correctly,  because,  as  I  said,  it  plays  an  essential  part  in 
the  question. 

Dr.  Clowes.  In  regard  to  what  Dr.  Weil  has  just  said,  in  the  first 
place,  relative  to  the  experiments  of  Thiele  and  Embleton,  citrated 
blood  is  toxic  at  sufficient  concentration  of  citrate.  I  do  not  know 
how  long  ago  it  was  originally  demonstrated,  but  three  years  ago  we 
demonstrated  that  .Ice  m  sodium  citrate  would  kill  a  mouse  weigh- 
ing 25  grams  with  all  the  symptoms  of  anaphylactic  shock  on  intra- 
venous injection.  In  the  second  place  I  should  like  to  point  out  that 
proof  of  the  existence  of  anaphylatoxins  is  absolutely  no  proof  that 
anaphylaxis  is  due  to  these  substances.  Anaphylaxis  may  well  be 
due  to  a  sudden  and  immediate  disturbance  of  colloidal  equilibrium, 
and  I  hope  to  demonstrate  that  point  in  the  course  of  my  work.  This 
would  correspond  with  the  views  of  Dr.  Weil.  The  subsequent  pro- 
duction of  disintegration  products  which  in  themselves  appear  toxic 
does  not  prove  at  all  that  the  original  cause  of  the  anaphylaxis  is 
these  disintegration  products. 

The  Chairman. — ^If  there  is  no  further  discussion  I  will  call  on 
Dr.  Bronfenbrenner. 


SPECIFIC  parenteral  DIGESTION  AND  ITS  RELATION  TO  THE 
PHENOMENA  OF  IMMUNITY  AND  ANAPHYLAXIS. 

By  J.  BRONFENBRENNER, 

DepartTnerU  of  Hygiene,  Harvard  Medical  School,  Boston,  Mase.,  formerly  of  the  Research 
Laboratories  of  the  Western  Pennsylvania  Hospital,  Pittsburgh,  Pa. 

While  it  ifl  generally  observed  that  repeated  injections  of  toxins  or  toxic  bacterial 
proteins  render  the  organism  resistant  against  even  a  multiple  lethal  dose  of  said 
toxic  substances,  certain  experiments  have  shown  that  under  certain  conditions  the 
leinjection  of  even  absolutely  inoffensive  substances  may  produce  very  severe 
phenomena  of  intoxication  and  even  death  of  experimental  animals.  It  is  this  exag- 
geration of  toxicity  which  is  the  most  striking  phenomenon  in  anaphylaxis. 

''Anaphylaxis  is  a  reveise  of  vaccination;  anaphylactic  animals  react  to  the  second 
injection  much  more  strongly  than  to  the  first,  which  is  the  more  surpriaing  because, 
in  the  majority  of  cases,  the  substances  used  are  not  toxic,  even  in  very  laige  doses," 


PUBLIC   HEALTH  AND  MEDICINE.  279 

wrote  Beeredka  in  1908.  Where  does  this  increased  toxiciiy  come  from?  Since  the 
substances  injected  may  by  themselves  be  inoffensive  to  normal  animals,  even  in 
very  laige  doses,  it  is  evident  that  conditions  in  the  body  of  anaphylactic  animals 
must  be  resi>onsible  for  the  change  in  tolerance  to  protein. 

Why  is  it,  then,  that  in  certain  cases  the  preliminary  injection  of  protein  raises  the 
resistance  of  the  animal  to  the  subsequent  introduction  of  the  same  protein,  whereas 
in  other  cases  it  destroys  even  the  natural  tolerance  of  the  animal,  making  it  incom- 
parably more  vulnerable  than  before? 

It  was  this  loss  by  the  animal  of  its  normal  degree  of  immunity  or  resistance  to  the 
parenteral  introduction  of  foreign  proteins  which  suggested  to  lUchet  the  name  of 
''Anaphylactic''  for  this  state  of  hypersensitiveness  of  the  experimental  animal, 
following  a  preliminary  inoculation  with  the  foreign  substance.  The  very  name 
given  to  this  phenomenon  by  Eichet,  who  was  one  of  the  first  investigators  in  this 
field,  shows  that  the  nature  of  the  anaphylactic  state  was  assumed  to  be  quite  the  oppo- 
site of  that  of  immunity  or  heightened  resistance,  in  spite  of  the  fact  that  both  condi- 
tions seem  to  be  brought  about  in  the  experimental  animal  by  a  very  similar  procedure. 

It  is  because  the  parenteral  introduction  of  foreign  protein  may  lead  in  one  case  to 
immunity,  and  in  the  other  to  hypersensitiveneBs,  that  some  authors  suggested,  as 
a  working  hypothesis,  that  the  introduction  of  foreign  protein  (antigen)  may  lead 
to  the  formation  of  two  independent  sets  of  antibodies,  one  responsible  for  the  height- 
ened resistance  and  the  other  for  the  heightened  vulnerability.  These  earlier  theories, 
however,  did  not  find  confirmation  in  subsequent  investigations. 

At  present  the  consensus  of  opinion  among  workers  in  this  field  of  scientific  endeavor 
seems  to  point  to  the  assumption  that,  in  the  measiue  in  which  the  development  of 
new  properties  in  the  blood  of  experimental  animals  is  responsible  for  the  establish- 
ment of  either  heightened  or  diminished  specific  resistance,  the  same  set  of  sub- 
stances is  supposed  to  confer  these  outwardly  contradictory  changes  in  tolerance  of 
animals,  to  reinjection  of  foreign  proteins. 

There  remains,  however,  an  open  question  as  to  the  nature  of  these  new  properties 
of  the  blood  serum,  as  well  as  to  the  mode  of  their  action.  Still  less  definite  is  infor- 
mation as  to  the  reason  why  these  changes,  brought  about  in  experimental  animals 
by  the  parenteral  introduction  of  foreign  protein,  should  produce  a  seemingly  opposite 
effect  on  the  natural  tolerance  of  animals  to  these  substances. 

The  changes  in  tolerance  to  a  given  protein,  following  a  single  or  a  multiple 
systematic  introduction  of  the  same  protein  Into  experimental  animals,  have  been 
studied  and  variously  interpreted  by  different  investigators.  But  for  very  slight  minor 
differences  all  the  theories  suggested  can  be  brought  back  to  two  fundamental  theo- 
retical conceptions.  One,  assuming  after  Ehrlich,  that  the  foreign  protein,  introduced 
parenterally  into  the  experimental  animal,  is  anchored  by  such  cells  of  the  body  as 
happen  to  possess  chemically  active  radicals  (receptors),  with  specific  chemical 
ftfl^ty  for  corresponding  chemically  active  radicals  of  the  protein  introduced  (anti- 
gen). The  union  of  the  respective  radicals  in  virtue  of  their  specific  chemical  afiinity 
is  followed  by  the  neutralization  of  the  chemical  avidity  of  the  cell  concerned,  and  by 
the  subsequent  restoration  and  overproduction  by  the  cell  of  the  radicals  saturated 
by  antigen.  This  phenomenon  (studied  and  described  by  Weigert)  leads  finally  to 
the  condition  in  which  the  cell  finds  itself  overburdened  with  the  radicals  in  question, 
and  at  a  certain  time  during  the  process  such  a  cell  casts  off  into  the  circulation  the 
excess  of  these  chemically  active  radicals.  Such  substances,  appearing  in  the  circu- 
lation, as  a  response  of  the  cells  to  the  introduction  of  a  foreign  body,  are  known  under 
the  name  of  antibody.  The  antibodies,  according  to  this  view,  retain,  while  free 
in  the  circulation,  their  power  to  combine  with  and  anchor  the  homologous  protein 
when  such  is  reintroduced  later.  Whereas  the  anchoring  of  antigen  by  the  specific 
BsceptoiB  of  the  c.ll  is  followed  by  incorporation  of  such  antigen  into  the  body  of  the 
cell  by  virtue  of  the  general  digestive  mechanisms  of  the  cell,  the  detached  receptors, 
circulating  in  the  blood  stream,  combine  with  such  specific  antigen  without  digesting 


280       PROCEEDINGS  SECOND  PAN  AMEBICAK  BGIENTIFIO  C0NGBE88. 

it,  but  merely  changing  such  antigen  in  a  manner  in  which  it  becomes  more  easily 
attackable  by  leucocytes,  as  well  as  by  the  complement,  which  is  supposed  to  be  the 
active  principle  directly  responsible  iot  "cytolytic"  as  well  as  ''albuminolytic*' 
properties  of  the  blood  serum. 

According  to  the  other  fundamental  theory,  represented  best  by  the  work  of  Vaughan 
and  his  collaborators,  the  parenteral  introduction  of  foreign  protein  stimulates  the 
production  of  specific  ferments  within  the  body  of  experimental  animals.  Such 
ferments,  circulating  in  the  blood  stream,  attack  and  digest  directly  the  homologous 
protein  when  it  is  reintroduced  later. 

Although  the  above  conceptions  differ  very  substantially  from  each  other  on  the 
question  of  the  intimate  nature  of  mechanisms  governing  the  physiological  processes, 
following  the  introduction  of  foreign  protein  into  the  animal  body,  both  theories,  in 
fact,  indicate  that  such  foreign  protein  undeigoes  parenteral  assimilation,  or  digestion 
in  the  broader  sense  of  the  term,  and  thus  eventually  is  eliminated  from  the  circula- 
tion. It  is  this  element  of  ridding  the  body  of  the  foreign  material  which  is  responsible 
for  the  view  of  the  whole  process  as  a  protective  mechanism,  especially  because  prac- 
tically all  the  protein  substances,  when  introduced  parenteraUy,  are  apt  to  exhibit 
different  degrees  of  toxicity,  if  the  amount  injected  is  sufficiently  great. 

Whichever  of  the  two  views  upon  the  mechanisms  of  parenteral  digestion  is  correct, 
the  careful  observers,  beginning  with  Jenner  in  1798  and  Magendi  in  1839,  have 
noticed  repeatedly  that,  parallel  with  the  apparent  development  of  specific  protective 
mechanisms,  the  parenteral  introduction  of  protein  foreign  to  the  body  may  give  rise 
also  to  other  mechanisms  detrimental  to  the  well-being  of  the  animal. 

According  to  the  views  of  the  school  following  in  the  footsteps  of  Ehrlich,  the  reason 
for  such  paradoxic  action  of  parenteral  introduction  of  protein  is  the  fact  that  during  the 
extracellular  specific  lysis  of  formed  as  well  as  unformed  protein  antigen  in  reinjected 
animals,  this  antigen  is  broken  down  through  the  action  of  complement,  and  the 
poisons  preexisting  in  the  unaltered  antigen  are  thus  liberated. 

Such  a  view  was  considered  especially  plausible  siuce  Vaughan  had  shown  that  any 
protein  can  be  broken  up  by  chemical  means,  so  as  to  yield  a  very  powerful  poison. 

Friedberger,  who  deserves  especial  credit  for  most  of  the  work  in  this  direction,  has 
shown  that  such  poisons  could  be  produced  in  the  test  tube  by  imitating  the  specific 
lysis,  supposedly  taking  place  in  the  body.  In  his  earlier  experiments  Friedberger 
obtained  from  normal  guinea-pig  serum,  which  had  been  allowed  to  stand  for  some 
time  with  the  washed  specific  precipitate  (formed  by  rabbit  serum  immunized  against 
sheep  serum  with  the  serum  of  the  latter),  very  strong  poisons,  which  killed  the 
guinea  pigs  instantly  with  symptoms  of  acute  shock.  He  named  the  poisonous  sub- 
stance anaphylatoxin,  and  assimied  that  it  arose  from  the  digestion  of  the  specific  pre- 
cipitate by  the  ferments  of  normal  guinea-pig  senun  (complement). 

According  to  the  views  of  Vaughan  and  his  followers,  toxic  phenomena  in  anaphy- 
laxia  are  due  to  the  split  products  of  direct  digestion  of  antigen,  by  the  specific  fer- 
ments present  in  the  blood  and  tissues  cf  sensitized  animals. 

More  recently  there  has  appeared  a  great  number  of  publications  concerning  the 
question  of  the  mechanism  of  the  specific  parenteral  digestion.  Abderhalden  and  his 
collaborators  M^ho  are  primarily  responsible  for  this  work,  have  taken  up  the  theory  of 
specific  ferments,  and  by  using  specially  devised  methods  ha\e  seemingly  demon- 
strated in  vitr )  the  presence  of  such  ferments  in  the  blood  of  prepared  animals.  These 
findings,  if  correct,  seem  to  offer  a  valuable  link  in  the  chain  of  reasoning  of  the  earlier 
supporters  of  the  theory  of  specific  ferments. 

Approaching  the  question  of  the  mechanism  of  anaphylaxis  at  this  stage  of  its  devel- 
opment, the  investigator  is  confronted  with  a  fimdamental  question:  Assuming  that 
the  anaphylactic  shock  is  due  to  the  liberation  of  poison  in  the  body  of  sensitized 
animals  through  the  specific  cleavage  following  the  reinjection  of  antigen,  what  is  the 
mechanism  of  this  cleavage?    In  order  to  answer  this  question  one  must  first  determine 


PUBLIO  HEALTH  AND  MEDICINE.  281 

the  nature  of  changes  ta^ng  place  in  the  normal  physiological  processes  of  the  animal, 
following  the  first  experimental  parenteral  introduction  of  the  foreign  protein. 

On  the  one  hand,  the  hypothesis  of  Ehrlich  suggests  that  such  parenteral  introduc- 
tion of  foreign  protein  is  followed  by  the  production  of  specific  antibodies.  On  the 
other  ha^d,  Vaughan  and  his  followers,  without  definitely  denying  the  production  of 
antibodies,  asstune  that  parenteral  introduction  of  foreign  protein  is  followed  by  the 
output  of  specific  ferments.  In  fact  Abderhalden  states  definitely  that  the  parenteral 
introduction  of  foreign  protein  is  followed  by  the  production  of  specific  ferments 
parallel  with  the  production  of  specific  antibodies,  but  independent  of  the  latter. 

If  the  interpretation  of  the  phenomena  observed  by  Abderhalden  is  correct,  the 
production  of  specific  ferments  seems  to  be  an  even  more  general  mechanism  than 
that  of  production  of  antibodies.  For  antibodies  have  been  thus  far  demonstrated 
only,  in  cases  of  parenteral  introduction  of  substances  of  animal  or  plant  protein 
origin,  provided  that  this  protein  is  foreign  to  the  species.  Specific  ferments,  how- 
ever, are  claimed  to  have  been  demonstrated  not  only  upon  the  parenteral  introduc- 
tion of  such  substances  but  also  upon  that  of  proteins  of  homologous,  and  even  auto- 
genous nature,  provided  these  substances  were  foreign  to  the  blood  ("blutfremd"). 
Moreover,  the  parenteral  introduction  of  substances  like  gelatin,  pepton,  cane  sugar, 
or  casein,  is  claimed  by  the  Abderhalden  school  to  produce  specific  ferments,  capable 
of  attacking  said  substances,  both  in  vitro  and  in  vivo.  Thus  the  group  of  substances 
which  can  play  the  part  of  antigen  in  the  production  of  antibody  is  included  in  that 
of  the  substances  capable  of  causing  the  production  of  specific  ferments,  but  is  only 
part  of  it. 

Such  a  conception  of  parenteral  digestion,  on  first  examination,  seems  very  useful 
as  a  working  hypothesis,  for,  if  it  is  possible  to  prove  the  presence  of  such  specific  fer- 
ments, all  findings  from  the  realm  of  immunity  can  be  brought  into  the  sphere  of 
biochemistry.  The  just  criticism  which  the  chemists  had  for  a  long  time  against  the 
conception  of  immimologists  who  dealt  with  * 'antibodies"  and  ''alexins" — terms 
which  seem  to  name  but  not  designate  the  still  unknown  substances — ^would  be  im- 
mediately answered. 

It  is  thus  that  a  nimiber  of  men,  familiar  with  phenomena  of  immunity,  and  anxious 
to  find  the  general  physiological  principles  underlying  this  very  important  mechanism, 
have  turned  their  attention  to  the  possibilities  offered  by  the  methods  of  investiga- 
tion enunciated  by  Abderhalden. 

In  repeating  the  work  of  Abderhalden  and  his  collaborators  in  this  laboratory, 
however,  we  came  to  doubt  their  conclusions.  Our  experiments  have  shown  that, 
although  under  certain  conditions  of  experiment  the  antigen  may  be  actually  di- 
gested by  the  ferments  of  the  blood  of  prepared  animals,  the  ferments  responsible  for 
such  digestion  are  not  specific.  In  fact,  as  others  have  shown  before  us,  the  digestive 
ferments  are  present  in  every  fresh  serum,  and,  if  set  free,  can  digest  any  suitably  pre- 
pared substratum  in  vitro  without  any  specific  predilection. 

According  to  the  findings  of  a  number  of  investigators,  the  activity  of  ferments 
normally  present  in  the  serum  is  usually  inhibited  by  a  simultaneous  presence  of 
antiferments  in  the  serum.  The  removal  of  the  latter  liberates  the  active  ferments 
and  allows  digestion  to  take  place.  Indeed,  Bordet,  Nathan,  Plant,  Flatow,  and 
others  have  demonstrated  quite  definitely  that  mere  mechanical  adsorption  by  any 
of  the  substances  like  agar,  kaoUn,  starch,  and  the  like,  may  free  serum  of  its  anti- 
ferments  and  thus  liberate  the  normal  ferments. 

On  the  other  hand,  as  Schwartz  and,  more  recently,  Jobling  and  Peterson  have 
shown,  serum  lipins  may  also  inhibit  the  activity  of  normal  ferments  of  the  serum, 
and  their  removal,  or,  as  we  found  it,  even  change  in  their  physical  state  may  result 
in  activation  of  the  normal  nonspecific  ferments  of  the  serum .  It  is  thus  that  a  number 
of  authors  tried  to  explain  the  digestion,  accredited  by  Abderhalden  to  the  activity 
of  newly  produced  specific  ferments,  by  assuming  that  it  was  due  to  the  mechanical 


282       PBOCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC  CONGRESS. 

adsorption  of  antiferments  by  the  substratum  and  subsequent  liberation  of  normal 
nonspecific  ferments.  Our  own  experiments,  however,  convinced  us  that  such  is 
not  the  case.  We  found  that  although  the  ferments  concerned  in  the  digestion  are 
not  specific  (inasmuch  as  they  can  be  made  to  digest  any  substratum),  the  phenomenon 
as  a  whole  is  not  devoid  of  a  certain  degree  of  specificity  and,  therefore,  could  not  be 
reduced  to  mechanical  absorption  of  antiferments. 

Our  systematic  study  of  this  question  brought  us  to  the  conclusion  that  the  element 
of  specificity  lies,  not  in  the  ferment  itself,  but  in  the  mechanism  of  its  activation; 
namely,  we  found  that  the  apparent  specificity  of  ferment  action  in  vivo,  assumed  by 
Vaughan  and  demonstrated  in  vitro  by  the  methods  of  Abderhalden,  is  due  to  the 
fact  that  the  combination  of  specific  serum  with  its  corresponding  antigen,  in  vivo 
as  well  as  in  vitro,  is  followed  by  a  radical  change  in  the  degree  of  dispersion  of  serum 
colloids.  This  physico-chemical  change  in  turn  is  followed  by  the  activation  of  a 
normal,  nonspecific  ferment  of  the  serum. 

If  such  a  conception  is  correct,  then  the  phenomenon  of  specific  parenteral  digestion 
may  be  explained  on  a  basis  very  similar  to  that  offered  by  the  chemical  theory  of 
Vaughan;  but,  instead  of  specific  ferments,  the  digestion  will  be  ascribed  to  normal 
nonspecific  ferments,  present  in  any  fresh  serum  (complement)  and  set  free  by  a 
specific  mechanism  of  combination  between  the  antigen  and  antibody  (very  similar 
to  that  recorded  by  the  meiostagmin  reaction  of  Ascoli.) 

As  was  mentioned  above,  the  toxic  phenomena  in  anaphylaxis  are  ascribed  by  the 
chemical  theory  to  the  action  of  the  split  products  of  antigen,  attacked  by  the  active 
principle  of  the  senun  of  the  sensitized  animal. 

This  hypothesis  is  based  on  observations  that  cleavage  of  the  antigen  in  vitro  by 
chemical  means  yields  poisonous  split  products;  that  combination  of  specific  serum 
with  its  corresponding  antigen  yields  toxic  substances,  identical  in  their  physiological 
action  with  those  produced  from  the  antigen  chemically;  and,  lastly,  that  the  actual 
cleavage  of  antigen  by  the  ferments  of  specific  senun  can  be  demonstrated  in  vitro. 

There  exists,  however,  another  view  of  the  origin  of  so-called  anaphylatoxin.  This 
view  represented  by  the  work  of  Nolf ,  Doerr,  Ritz  and  Sachs,  Bordet,  and  others  is 
known  as  ''physical  theory.''  In  the  main  this  theory  suggests  that  the  source  of 
anaphylatoxin  is  not  the  antigen,  but  the  protein  of  the  serum  Itself. 

As  mentioned  above,  in  his  original  experiments,  Friedbeiger  has  succeeded  in 
producing  the  toxic  substances  in  vitro  by  a  process  similar  to  that  which  was  sup- 
posed to  be  responsible  for  the  anaphylactic  shock  in  vivo.  Namely,  he  allowed 
antigen  to  combine  with  its  specific  antibody  and  added  the  complement  to  this  mix- 
ture. The  poisons  obtained  in  this  manner  in  vitro,  when  injected  into  normal 
animals,  were  able  to  produce  typical  anaphylactic  symptoms. 

In  his  later  experiments,  however,  Friedberger  succeeded  in  obtaining  similar 
poisons  from  bacteria  and  other  proteins  by  their  incubation  with  normal  guinea-pig 
complement,  without  the  concurrence  of  specific  antibody.  He  still  believed,  how- 
ever, that  in  these  experiments  also  the  poison  was  derived  from  the  protein  of  the 
substratum.  Even  when  Bordet,  Nathan,  Mutermilch,  and  others  have  been  able 
to  obtain  similar  poisons  by  the  incubation  of  normal  guinea-pig  senun  with  agar, 
starch,  or  kaolin,  and  have  decided,  therefore,  that  the  poison  must  originate  from 
the  serum,  Friedbeiger  still  objected  to  these  conclusions  on  the  basb  that  these 
substances  may  contain  a  small  amount  of  protein  impurities,  which  really  furnish 
the  substratum  for  the  formation  of  anaphylatoxin. 

In  studying  this  controversy  one  finds  two  really  independent  questions  involved 
in  it.  The  first  question  seems  to  be, ' '  What  are  we  to  take  to  be  the  anaph>  latozin? '' 
It  is  only  after  agreeing  as  to  the  exact  meaning  of  this  term  that  one  can  attack  the 
main  question,  "Which  is  the  soiu-ce  of  poisonous  substances  in  the  anaphylatoxin 
formation;  is  it  antigen  or  the  serum?" 


PXmUO  HEALTH  Ain>  MEDIOIHB.  283 

Oiigiiially  the  term  anaphylatoxin  was  applied  by  Friedberger  to  designate  the 
poison  which  was  supposed  to  be  identical  with  the  one  produced  in  vivo  during  the 
anaphylactic  shock.  This  poison  had  two  essential  characteristics,  making  it  possible 
to  assimie  its  identity  with  the  substance  causing  anaphylaxis:  First,  the  method  of 
its  production  from  pombination  of  antigen  with  antibody  and  complement,  and, 
second,  its  physiological  action  upon  normal  animals,  which  is  identical  with  ana- 
phylactic shock. 

In  discussing  the  question  of  the  origin  of  anaphylatoxin  different  authors  apparently 
used  as  criterion  in  their  terminology  only  the  second  characteristic  of  the  original 
anaphylatoxin — namely,  its  physiological  effect  upon  normal  animals.  Thus  many 
authors  have  called  anaphylatoxin  the  chemical  poisons  obtained  by  Vaughan  from 
bacteria.  Nathan,  Bordet,  and  Mutermilch  called  anaphylatoxins,  substances 
obtained  by  them  from  the  serum  by  adsorption  with  inert  substances,  etc.  Attempts 
of  these  authors  to  explain  the  nature  of  anaphylatoxin  seem  to  be  generally  inadequate 
because,  even  though,  as  my  experiments  have  also  confirmed,  by  digestion  of  senmi 
with  kaolin,  for  instance,  one  can  produce  from  senun  a  substance  which  is  similar  in 
its  physiological  action,  on  the  one  hand,  to  the  original  anaphylatoxin  of  Friedberger, 
and,  on  the  other  hand,  to  the  chemical  poison  of  Vaughan,  its  identity  with  one  or 
the  other  is  not  proved  by  this  similarity  alone.  The  identity  between  all  these 
substances  has  to  be  proven  before  the  experiments  above  could  be  taken  into  con- 
sideration in  discussing  the  probable  nature  of  anaphylatoxin. 

This  we  attempted  to  do  in  a  series  of  experiments  in  which  we  studied  the  actual 
mechanism  of  the  production  of  poison  in  each  instance.  These  experiments  have 
shown  that  in  the  poisons  arising  during  the  incubation  of  the  serum  with  kaolin  or 
starch,  as  well  as  those  arising  when  specific  serum  is  digested  with  its  antigen,  the 
s^rum  is  the  source  of  poisonous  products.  Moreover,  it  was  found  that  the  products 
of  such  autodigestion  of  senun  are  toxic  only  to  homologous  animals.  This  would 
indicate  that  during  the  anaphylaxis  in  vivo  the  toxic  split  products  originate  only 
from  the  digestion  of  serum  or  tissues  of  the  animal  and  not  from  heterologous  protein 
of  the  antigen  (though  the  latter  may  also  be  attacked  by  the  ferment  at  the  same 
time). 

Since  it  is  established  that  in  the  experiments  of  Bordet,  as  well  as  in  those  of  Fried- 
berger, the  formation  of  toxic  split  products  is  identical — ^namely,  that  it  is  due  to  the 
digestion  by  the  normal  senmi  ferments  of  autogenous  protein — ^the  similarity  of  the 
biologic  properties  of  the  respective  end  products  of  such  digestion  may  speak  for 
their  identity.  On  the  other  hand,  the  fact  that  in  Vaughan's  experiments  the 
poison  arises  from  heterologous  protein  shows  that  this  poison  is  not  identical  with 
anaphylatoxin,  in  spite  of  the  similarity  of  its  biologic  action  upon  animals.  These 
findings,  taken  in  connection  with  the  results  obtained  by  us  in  the  study  of  the 
mechimism  of  specific  parenteral  digestion,  referred  to  above,  suggest  that  the  nature 
of  anaphylatoxin  is  as  follows:  Fresh  serum  contains  normal  proteolytic  ferments 
whose  digestive  action  in  vivo  as  well  as  in  vitro  is  inhibited  by  the  simultaneous 
presence  of  some  antitryptic  elements.  This  antitrypsin  can  be  removed  from  the 
serum  in  vitro  by  two  independent  processes — one,  nonspecific,  a  simple  mechanical 
adsorption  by  means  of  excess  of  some  organic  as  well  as  some  inoiganic  substances; 
the  other  specific,  an  inactivation  of  the  antitryptic  properties  of  the  serum,  taking 
place  as  a  result  of  the  physico-chemical  changes  in  the  serum,  induced  by  the  specific 
interaction  between  the  antigen  and  the  antibody  of  the  immune  serum.  The 
removal  of  the  inhibiting  antitryptic  action  of  the  serum  by  either  method  is  followed 
by  the  restitution  of  the  activity  of  the  normal  proteolytic  enzyme,  which  may  attack 
both  the  protein  of  the  antigen  as  well  as  the  protein  of  the  serum  itself.  At  a  certain 
stage  of  this  autodigestion  the  split  products  of  the  serum  protein  exhibit  toxic  proper- 
ties.   Biological  properties  of  these  toxic  substances  indicate  their  resemblance  to  the 


284       PROCEEDINGS  SECOND  PAN  AMEBIGAN  SCIENTIFIC  CONGEESS. 

anaphylatoxin  and  suggest  that  the  anaphylatoxin  of  Fiiedberger,  whether  occurring 
in  vivo  or  produced  in  vitro,  is  a  result  of  the  autodigestion  of  serum  and  not  of  the 
protein  outside  of  the  serum. 

Our  findings  as  cited  above  showed  that  there  is  no  experimental  evidence  of  the 
existence  of  specific  ferments,  and  that  the  phenomena  of  parenteral  digestion  ascribed 
by  Vaughan  to  the  activity  of  specific  ferments  can  be  plausibly  explained  and 
experimentally  demonstrated  without  assimiing  the  existence  in  the  body  of  a  special 
specific  mechanism  outside  of  antibody  formation. 

Having  thus  answered  the  first  question  which  we  set  out  to  study  we  will  try  to 
answer  the  second  one — namely,  that,  assuming  the  above  mechanism  of  parenteral 
digestion  to  be  correct  why,  then,  in  some  cases,  the  introduction  of  protein  into 
normal  animals  results  in  the  establishment  of  heightened  resistance,  whereas  in 
other  cases  it  leads  to  heightened  vulnerability? 

As  we  have  stated  above,  the  activation  of  normal  ferments  present  in  specific  sera, 
through  the  changes  in  colloidal  dispersion  following  the  union  in  vivo  between  the 
antigen  and  antibody,  may  lead  to  digestion  of  antigen  as  well  as  to  that  of  the  serum 
itself.  When  the  antigen  mainly  is  digested  the  phenomenon  is  interpreted  by  the 
observer  as  that  of  protection.  When  the  serum  or  other  autogenous  elements  are 
digested,  the  split  products  being  toxic  to  the  animal,  the  intoxication  occurs  and  the 
observer  interprets  symptoms  as  a  sign  of  heightened  vulnerability. 

It  is  evident  from  the  above  that  the  actual  mechanism  of  parenteral  digestion  in  the 
body  of  the  animal  previously  injected  with  the  homologous  protein,  and  thus  possess- 
ing the  circulating  specific  antibody  is  the  same  in  both  cases — namely,  the  antigen 
upon  its  reintroduction  is  anchored  by  antibody  and  this  union  leads  to  the  liberation 
of  normal  proteolytic  ferments  of  the  serum.  It  is  only  at  this  point  that  the  difference 
may  come  in,  depending  upon  which  substratum  is  mainly  attacked  by  this  ferment. 

There  must  be  at  this  point,  therefore,  the  main  problem  of  the  situation,  What 
determines  the  direction  of  the  activity  of  the  ferments?  Is  this  activity  selective 
and  directed  exclusively  toward  sensitized  antigen  in  one  case  and  the  serum  protein 
in  the  other,  or  is  the  difference  in  two  cases  only  quantitative  and  not  qualitative? 
Our  experiments  point  to  the  second  as  a  correct  answer. 

It  is  true  some  of  our  findings  seem  to  show  that  sensitized  antigen  is  more  readily 
digested  by  the  ferment  in  "momentu  mascendi"  and  thus  there  m;ight  be  a  degree  of 
selective  action  on  the  part  of  a  ferment.  But  experiments  in  this  direction  are  very 
difficult  and  the  amount  of  work  actually  done  is  not  yet  sufficient  for  us  to  definitely 
claim  such  to  be  the  case.  On  the  other  hand,  and  in  the  majority  of  experiments, 
there  seems  to  be  no  selective  action  on  the  part  of  the  ferment.  Both  the  serum 
itself  and  the  antigen  seem  to  be  equally  subject  to  the  attack.  What,  then,  deter- 
mines the  degree  of  toxicity  developed  dining  this  process  of  parenteral  digestion? 
First  of  all,  of  course,  the  amount  of  the  autogenous  toxic  split  products  liberated 
during  digestion.  And  this  seems  to  be  in  direct  relation  with  the  amount  of  antigen 
introduced. 

It  is  well  established  experimentally  that,  no  matter  how  small  it  may  be  in  certain 
cases,  the  dose  of  antigen  introduced  into  a  sensitized  animal  must  be  sufficient  to 
produce  the  anaphylactic  shock.  If  the  amount  of  antigen  is  too  small  the  shock  does 
not  take  place,  although  the  experimental  animal  may  show  other,  milder  symptoms, 
due  to  partial  intoxication. 

It  is  thus  evident  that  the  amount  of  antigen  reintroduced  into  a  sensitized  animal 
is  a  very  important  factor  in  determining  the  degree  of  intoxication. 

On  the  other  hand  experiments  have  definitely  shown  that  exposure  of  sensitized 
animals  to  cold  or  starvation  may  reduce  the  toxic  effect  of  the  injection  of  a  lethal 
dose  of  antigen.  These  experiments  suggest  that  not  only  the  actual  amount  of  antigen 
introduced  but  also  the  rapidity  with  wldch  it  unites  witJi  the  antibody,  may  influence 
the  rapidity  of  liberation  of  ferments  and  resulting  intoxication.    This  relation  may 


PUBLIC  HEALTH  AND  MEDICINE.  285 

be  still  better  demonstrated  by  the  known  fact  that  if,  instead  of  injecting  at  once  a 
lethal  dose  of  antigen  into  a  highly  sensitized  animal,  one  would  inject  the  same  and 
even  a  larger  amount  very  slowly,  the  acute  anaphyl^tic  shock  might  be  averted. 
Thus  the  degree  of  toxicity  developed  during  parenteiul  digestion  in  sensitized  ftnimfr^ 
is  apparently  determined  by  the  amount  of  digestion  taking  place  in  a  unit  of  time, 
and  this  in  turn  depends  on  the  amount  of  antigen  injected  in  a  unit  of  time. 

Such  a  view  of  the  phenomenon  would  explain,  it  seems,  how  it  is  that  parenteral 
digestion,  following  reintroduction  of  antigen,  may  at  times  seemingly  protect  the 
animal,  whereas  at  other  times  it  injures  its  well-being.  If  the  amount  of  antigen 
reintroduced  into  a  sensitized  animal  is  small  or  introduced  very  slowly,  the  amount 
of  ferment  liberated  in  unit  of  time  is  very  slight,  and  the  amount  of  autogenous  split 
products  may  be  so  small  that  the  animal  may  show  no  apparent  symptoms  of  intoxi- 
cation. If,  however,  the  amount  of  antigen  is  sufficient,  and  if  it  is  introduced  rapidly, 
the  rate  of  activation  of  the  ferment  is  great  and  the  animal  succumbs  of  intoxication 
with  autogenous  split  products. 

In  case  of  natural  reinfection  with  pathogenic  microoiganisms  the  amount  of  antigen 
which  penetrates  into  the  body  of  sensitized  animals  is  usually  small  enough,  and 
even  if  it  multiplies  in  the  body  at  the  beginning,  the  process  is  so  slow  and  the  extent 
of  autodigestion  in  a  unit  of  time  is  so  slight  that  the  reaction  occurs  without  the 
visible  injury  to  the  host,  and  this  is  why  the  observers  called  the  process  ''protective" 
and  the  animal  ''immune."  If,  however,  the  same  animal  be  artificially  given  a 
large  dose  of  the  same  antigen,  a  large  amount  of  ferment  is  liberated  rapidly,  causing 
anaphylaxis,  and  we  call  the  same  animal  "hypersensitive." 

Howevw,  the  amount  of  the  antigen  and  the  rate  of  its  introduction  into  sensitized 
animals  is  a^^arently  not  the  only  mechanism  controlling  the  rate  of  parenteral 
digestion  as  judged  by  the  appearance  of  toxic  split  products.  It  is  observed,  for 
instance,  that  animals  receiving  systematic  injections  of  toxic  foreign  protein  at 
short  intervals  can  develop  their  resistance  to  Hie  given  toxic  substance  to  such  a 
degree  that  multiple  toxic  dose  of  toxic  antigen  may  be  injected,  no  matter  how 
rapidly,  without  producing  even  the  slightest  symptoms.  It  is  noticed,  however, 
that  a  similar  animal  inoculated  with  a  similar  dose  of  antigen,  the  only  difference 
being  that  between  the  time  of  the  last  serial  injection  and  the  test  injection  sufficient 
time  will  elapse,  will  succumb  with  anaphylactic  shock. 

In  both  cases  the  amount  of  antigen  and  the  rapidity  of  injection  being  the  same, 
it  is  evident  that  the  difference  in  time  elapsed  between  the  last  serial  injection  and 
the  test  injection  determines  the  difference  in  the  effect  of  the  respective  test  injections. 

Just  what  happens  in  the  sensitized  animal  dxiring  this  period  of  time,  called  "incu- 
bation period,"  is  differently  explained  by  different  authors.  Our  own  experiments 
lead  us  to  believe  that  the  reason  for  the  difference  in  the  response  of  the  sensitized 
animals  to  reinjection  in  the  two  cases  cited  above  is  as  follows: 

The  union  between  the  antigen  and  antibody,  as  we  have  suggested  above,  reduces 
the  inhibiting  power  of  the  serum-antitrypsin  and  thus  liberates  its  normal  ferments. 
Such  can  be  the  case  only  so  long  as  the  remaining  amount  of  antiferment  is  not  too 
great  to  interfere  with  the  action  of  the  ferment  as  it  is  liberated.  If  the  amount  of 
antiferment  is  too  great,  it  may  delay  or  altogether  prevent  the  digestive  action  of  the 
ferments.  When  antigen  is  introduced  parenterally  into  a  normal  animal  once  or  in 
serial  injections,  such  antigen  is  digested.  It  is  known  that  the  products  of  such  diges- 
tion are  strongly  antitryptic.  It  is  thus  that  as  the  digestion  progresses  there  is  going 
on  all  the  time  the  formation  of  new  antitryptic  split  products,  which  are  eventually 
either  assimilated  by  the  cells  in  the  constructive  process  of  the  body  or  are  elimi- 
nated. Such  removal  of  excess  of  antitryptic  elements  is,  however,  not  rapid,  and 
as  long  as  the  antitryptic  split  products  of  the  antigen  from  the  previous  injection  remain 
in  circulation  the  rapid  action  of  newly  formed  ferments  is  prevented  and  anaphy- 
laxis does  not  occur.    If,  however,  enough  time  is  allowed  to  pass,  usually  about  12 


286       PBOCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIO  OONGBESS. 

to  15  days,  before  the  test  injection  is  given  the  excess  of  antitryptic  products  of 
previous  parenteral  digestion  are  removed  and  a  rapid  action  of  ferments  is  thus 
made  possible.    Such  rapid  digestion  may  cause  the  shock. 

That  this  view  is  correct  also  follows  from  the  analysis  of  the  phenomenon  of  so* 
called  vaccination  against  anaphylaxis. 

It  was  my  good  fortune  to  study  the  phenomenon  of  anaphylaxis  in  Besredka's 
laboratory,  when  he  found  that,  if  the  treated  animal  should  be  given  a  second  in- 
jection of  antigen  before  the  expiration  of  full  incubation  time  after  the  first  injection, 
such  an  animal  does  not  respond  with  anaphylactic  shock  to  the  test  injection  at  the 
time  expected  (13  to  15  days  after  the  first  injection),  but  later.  Moreover,  the  larger 
the  dose  of  antigen  injected,  the  longer  is  the  state  of  hypersensitiveness  delayed 
and  the  period  of  resistance  prolonged.  This  phenomena  suggested  to  Besredka  the 
possibility  of  using  it  in  order  to  avoid  the  undesirable  reaction  in  anaphylactic 
animals.  Namely,  he  succeeded  in  preventing  anaphylactic  shock  in  animals 
having  passed  the  incubation  period  after  their  first  or  after  their  last  serial  injec- 
tion by  merely  injecting  a  sublethal  dose  of  the  antigen  some  short  time  previous 
to  the  following  test  injection  of  several  lethal  doses  of  antigen.  This  experiment 
was  laid  in  the  basis  of  the  method  which  is  used  every  day  now  for  the  prevention 
of  serum  sickness  in  children  receiving  more  than  one  injection  of  diphtheria  antitoxin. 

The  mechanism  of  such  ** vaccination  against  anaphylaxis'*  was  found  by  us  to 
be  that  of  retardation  of  ferment  action  by  the  circulating  split  products  remaining 
from  the  digestion,  following  the  vaccinating  injection  of  antigen,  and  not  to  ex- 
haustion of  antibody,  as  assumed  by  others.  Such  a  state  of  seeming  resistance  to 
anaphylaxis,  or,  as  it  is  called,  *'  the  state  of  antianaphylaxls,''  was  produced  by  many 
other  procedures  than  vaccinating  injection  of  antigen.  Thus  it  was  found  that 
administration  of  anesthetics,  sedatives,  and  many  other  toxic  substances  may  pre- 
vent the  subsequent  development  of  anaphylaxis.  The  mechanism  of  such  action 
of  the  substances  just  referred  to  was  never  adequately  explained. 

Having  convinced  ourselves  that  in  the  case  of  "vaccination"  against  anaphylaxis 
the  mechanism  involved  was  that  of  increase  of  antitrypsin,  we  tried  to  see  if 
the  same  could  also  be  true  in  the  other  cases.  Actual  measurements  have  shown 
this  to  be  the  case.  We  found  that,  without  exception,  the  administration  of  sub- 
stances known  to  have  the  effect  of  preventing  the  anaphylactic  shock  is  followed  by 
a  more  or  less  marked  increase  in  antitryptic  properties  of  the  blood.  Thus  we  sug- 
gest that  administration  of  poisons  causing  destructive  changes  in  the  cells  of  the 
body,  in  quantities  not  sufficient  to  kill  the  animal  outright,  is  followed  by  the  death 
of  the  tissues  immediately  a^ected  by  the  poison.  With  the  death  of  tissues  the 
intracellular  ferments  are  set  free.  These  ferments,  possibly  with  the  collaboration 
of  the  ferments  thrown  from  out  the  surrounding  fixed  cells,  as  well  as  from  the  blood 
serum  and  leucocytes,  proceed  to  dispose  of  the  dead  material.  Some  of  the  pro- 
tein split  products  of  such  digestion,  together  with  some  of  the  nonprotein  constituents 
of  the  destroyed  cells,  may  exert  antitryptic  action.  If  a  sensitized  animal  is  sub- 
jected to  such  treatment  previous  to  the  test  injection,  and  if  such  test  injection  is 
given  before  the  antitryptic  split  products  referred  to  above  are  eliminated,  they  may 
retard  or  stop  the  activity  of  proteolytic  ferments  liberated  upon  the  introduction 
of  antigen,  and  thus  prevent  the  anaphylactic  shock. 

The  view  of  specific  parenteral  digestion,  as  outlined  in  the  earlier  part  of  this 
paper,  offers,  it  would  seem,  a  plausible  basis  on  which  the  various  seemingly  contra- 
dictory phenomena  of  immunity  can  be  satisfactorily  explained.  Such  a  hypoth- 
esis suggests,  first  of  all,  that  the  terminology  used  in  connection  with  the  study  of  the 
reaction  of  the  living  organism,  following  its  invasion  by  biological  poisons,  is  not 
adequate. 

In  considering  the  question  in  the  light  of  its  historical  development  one  is  impressed 
by  the  fact  that  ever  since  the  first  observations  on  this  subject  the  apparent  increase 


PUBLIC  HEALTH  AND  MEDICINE.  287 

of  tolerance  to  biological  poIbodb,  following  their  repeated  introduction  into  experi- 
mental animals,  has  been  accepted  to  be  the  expression  of  nature's  protective  force. 
This  teleological  conception  of  the  reaction  on  the  part  of  animal  organism  upon  the 
I>arenteral  introduction  of  foreign  material,  however,  could  not  adequately  explain 
all  the  phenomena  observed.  The  work  of  Vaughn  especially  has  suggested  that  in 
dpite  of  the  difference  in  the  final  effect  the  reaction  of  the  animal  body  must  be  the 
same  in  case  of  heightened  as  well  as  diminished  resistance  to  poisons.  Although  our 
experiments  fully  confirmed  this  view,  the  intimate  mechanism  of  this  reaction 
seems  to  us  to  be  different  from  that  suggested  by  Vaughan.  There  seems  to  be  no  evi- 
dence of  the  existence  of  specific  ferments,  and  the  apparent  specificity  of  digestive 
processes  seems  to  be  due  to  the  presence  in  sensitized  animals  of  specific  antibodies 
in  the  sense  of  Ehrlich. 

As  to  the  difference  in  final  effect  following  the  specific  activation  of  serum  fer- 
ments, it  is  due  to  the  difference  in  rate  of  digestion.  Thus  "immunity  "  or  "anaphy- 
laxis'* can  be  nothing  but  different  forms,  in  which  a  greater  and  more  general  process 
of  specific  parenteral  digestion  expresses  itself  to  the  observer. 

The  Chairman.  The  next  paper  is  by  Dr.  John  A.  Kohner,  on 
''The  mechanism  and  dinical  significance  of  anaphylactic  and 
pseudo-anaphylactic  skin  reactions." 


THE  MECHANISM  AND  CLINICAL  SIGNinCANCE  OF  ANAPHYLACTIC 
AND  PSEUDO-ANAPHYLACTIC  SKIN  REACTIONS. 

By  JOHN  A.  KOLMER, 
Asnstant  Professor  of  Experimental  Pathology  in  the  University  of  Pennsylvania. 

Among  the  earliest  authentic  records  of  what  are  now  regarded  as  anaphylactic 
reactions  is  the  description  of  a  skin  reaction  by  Jenner  in  1798,  who  observed  the 
sudden  appearance  of  an  '^efilorescence  of  a  palish  red  color''  about  the  parts  where 
variolous  matter  had  been  applied  to  the  skin  of  a  woman  who  had  had  cowpox  31 
years  before.  Indeed  this  astute  observer  taught  that  the  '* disposition  to  sudden 
cuticular  inflammation"  following  the  application  of  smallpox  or  cowpox  matter  may 
be  '* effected  by  the  smallpox  or  cowpox"  and  that  when  this  sudden  local  reaction 
occurred  it  may  be  inferred  that  the  person  had  had  one  of  these  diseases  and  was 
not  now  susceptible  to  either.  Strangely,  these  observations  have  not  attracted  the 
attention  they  deserve,  and  even  at  the  present  day  many  physicians  fail  to  recognize 
or  consider  the  significance  of  this  "immediate  or  immunity  reaction"  following  cow- 
pox  vaccination  among  persons  who  are  immune  to  cowpox  and  smallpox,  as  recently 
emphasized  by  Force. 

The  modern  discovery  of  the  local  anaphylactic  reaction  is  accredited  to  Arthus, 
who  discovered  in  1903  that  the  subcutaneous  injection  of  normal  serum  into  sensi- 
tized rabbits  was  followed  by  a  local  reaction  at  the  site  of  injection  characterized  by 
inflammatory  phenomena,  of  which  edema  was  a  prominent  feature.  At  this  time 
Arthus  also  showed  that  this  local  reaction  was  probably  an  expression  of  anaphylaxis, 
inasmuch  as  these  animals  would  succumb  with  typical  anaphylactic  symptoms  fol- 
lowing the  intravenous  injection  of  the  serum.  Prior  to  this  time  Koch  had  observed 
the  local  reaction  following  the  subcutaneous  injection  of  tuberculin  into  tuberculous 
guinea  pigs,  but  did  not  suspect  the  true  nature  of  the  phenomenon.  In  1907  Von 
Pirquet  discovered  his  tuberculin  skin  reaction  and  presented  evidence  and  argu- 
ments indicating  its  anaphylactic  nature.  Since  then  various  skin  and  mucous- 
membrane  reartions  have  been  advocated  as  convenient  and  delicate  tests  for  the 


288       PBOGEEDINGS  SECOND  PAN  AMEBIOAN  SCIENTIFIC  CONQBESS. 

anaphylactic  state  to  various  bacterial  and  other  proteins,  in  the  study  of  a  wide 
group  of  pathological  conditions. 

While  the  earlier  investigations  in  anaphylaxis  were  mostly  concerned  with  the 
clinical  manifestations  and  lesions  of  the  condition,  more  recently  investigators  have 
been  mainly  interested  in  the  mechanism  of  the  phenomenon  and  its  relation  to  infec- 
tion and  immunity.  For  several  years  my  own  interests  in  anaphylaxis  have  been 
centered  upon  skin  reactions,  and  the  object  of  this  communication  is  to  present  our 
conceptions  of  the  nature  and  mechanism  of  anaphylactic  and  other  skin  reactions 
and  their  clinical  significance  as  indices  of  hypersusceptibility  and  infection  and  as 
indices  of  resistance  to  infection  or  reinfection. 

BTIOLOOY  OF  SKIN  REAOnONS. 

Skin  reactions  are  conducted  by  intradermal  injection;  by  application  to  an  abra* 
sion  of  the  skin;  by  rubbing  into  the  intact  skin  or,  as  on  mucous  membranes,  by 
mere  contact,  as  instillation  into  the  conjunctival  cul-de-sac.  In  the  first  and  second 
methods  trauma  due  to  the  operation  itself  is  a  factor  in  the  production  of  the  resulting 
inflammation;  likewise  the  intracutaneous  injection  of  practically  any  protein  or  non- 
protein substance  will  elicit  an  inflammatory  reaction,  providing  the  dose  injected 
is  large  enough.  The  causes  of  various  skin  reactions  may  be  summarized,  therefore, 
somewhat  as  follows: 

1.  The  true  or  specific  anaphylactic  reaction  due  to  the  interaction  in  the  skin  of 
specific  protein  antigen  and  specific  antibody. 

2.  The  pseudo  or  nonspecific  protein  reaction  due  to  the  interaction  in  the  skin  of 
general  protein  substances  and  nonspecific  proteolysins. 

3.  The  traumatic  reaction  consequent  to  the  operation,  or  to  the  irritant  qualities 
of  such  substances  as  preformed  bacterial  toxins  and  various  preservatives,  as  phenol 
and  tricresol,  contained  in  the  injected  material. 

The  intradermal  test  has  proven  the  most  delicate  means  of  eliciting  a  local  ana- 
phylactic response,  but  is  also  more  likely  to  yield  the  nonspecific  and  traumatic  reac- 
tions. 

THE  MB0HANI8M  OF  THB  8PBCIFI0  ANAPHTLAOTIO  SKIN  RBAOTION. 

While  the  symptoms  and  lesions  of  general  anaphylaxis  as  manifested  in  man  and 
the  lower  animals  are  fairly  well  understood,  the  mechanism  of  the  phenomenon  can 
not  be  regarded  as  definitely  established,  and  this  is  particularly  recognized  when  an 
attempt  ib  made  to  correlate  the  results  of  an  enormous  amount  of  research  work  in 
formulating  an  explanation  of  the  mechanism  of  the  cutaneous  anaphylactic  reaction. 

Furthermore,  an  acceptable  explanation  of  the  mechanism  of  cutaneous  anaphylaxis 
must  include  those  truly  wonderful  urticariaillke  reactions  which  follow  within  a 
few  minutes  the  application  of  a  very  minute  dose  of  ani^hylactogen  to  »n  abrasion 
of  the  skin,  as  in  those  exceptional  cases  of  bronchial  asthma  and  extreme  hyper- 
sensitiveness  to  horee  or  other  animal  protein,  and  in  hay  fever  to  the  protein  of  various 
pollens.  One  of  my  colleagues  who  is  hypersensitive  to  the  protein  of  the  rabbit, 
guinea-pig,  and  horse  and  who  suffers  with  acute  asthma  when  brought  in  contact 
with  these  animals,  yields  an  immediate  typical  reaction  on  the  skin  when  the  sera 
of  these  animals  are  applied  to  abrasions,  and  indeed  to  the  application  of  a  salt  solu- 
tion extract  of  lint  through  which  he  has  inspired  for  15  minutes  the  air  of  a  room  in 
which  a  few  of  these  animals  are  kept.  Similar  and  more  familiar  examples  of  extreme 
hypersensitlveness  to  a  protein  and  the  infinitesimal  amounts  which  may  produce 
an  anaphylactic  reaction  are  to  be  found  in  the  attacks  of  hay  fever  due  to  the  inhala- 
tion of  air  and  dust  carrying  the  particular  pollen.  An  acceptable  explanation  of  the 
mechanism  of  cutaneous  anaphylaxis  must,  therefore,  include  these  immediate  reac- 
tions to  very  small  doses  of  anaphylactogen  as  well  as  those  reactions  which  follow 
some  hours,  and  indeed  days,  after  the  intracutaneous  or  subcutaneous  injection  of 
much  larger  doses  of  protein. 


PUBLIO  HEALTH  AKD  MEDICINE.  289 

In  the  firat  place,  are  we  justified  in  aastuning  that  the  mechanism  of  general  ana- 
phylaxis and  cutaneous  anaphylaxis  are  identical?  This  has  been  the  subject  of  con- 
•iderable  research  over  a  period  of  several  years  in  attempts  to  transfer  the  specific 
antibody  in  animals  yielding  positive  skin  reactions  to  normal  animals;  by  testing 
animals  sensitized  at  the  same  time  and  in  the  same  manner  by  the  sJdn  test  and  others 
by  the  intravenous  injection  of  the  intoxicating  dose  of  protein;  and  by  first  implying 
the  skin  test  and  alter  24  hours  injecting  the  same  animals  intravenously.  The  major* 
ity  of  these  experiments  were  conducted  with  tuberculins  and  with  divergent  results 
and  interpretations,  but  there  i^pears  to  be  sufficient  evidence  at  hand  to  indicate 
that  a  local  skin  reaction  may  be  an  expression  of  an  anaphylactic  state  to  a  certain 
protein,  and  this  is  accepted  as  established  in  this  discussion,  although  there  is  not 
sufficient  data  at  hand  proving  that  the  mechanism  of  the  local  or  skin  anaphylactic 
reaction  is  identical  with  that  of  the  general  and  fatal  reaction  following  intravenous 
injection. 

At  the  present  time  two  main  theories  on  the  mechanism  of  anaphlaxis  are  promi- 
nentiy  before  us,  namely,  the  humoral  or  chemical  theory  which  maintains  that  the 
lesions  and  symptoms  of  anaphylaxis  are  due  to  a  poison  derived  from  a  protein  matrix 
through  the  interaction  of  anaphylactogen  and  its  antibody  or  a  ferment  in  the 
blood  and  variously  designated  proteotoxin,  anaphylatoxin,  and  serotoxin,  and  the 
physical  or  cellular  theory  which  denies  the  f(»ination  and  activity  of  this  protein 
poison  and  maintains  that  the  anaphylactogen  unites  with  its  antibody  in  the  cell  and 
that  this  union  results  in  a  disturbance  causing  shock  of  the  cell. 

The  two  schools  agree  at  least  in  two  points,  namely,  that  an  antibody  ib  concerned 
in  the  phenomenon  of  anaphylaxis  and  that  the  anaphylactogen  is  always  of  a  protein 
nature.  Neither  have  very  clear  conceptions  of  the  nature  and  mechanism  of  action 
of  the  antibody.  While  the  adherents  of  the  cellular  theory  maintain  that  the  foreign 
protein  constitutes  the  anaphylactogen,  the  adherents  of  the  chonical  theory  are 
divided  in  their  opinions  regarding  the  protein  matrix,  some  regarding  the  matrix  as 
the  foreign  protein  and  others  that  it  b  the  protein  of  the  patient's  own  serum. 

The  older  conception  of  the  antibody,  that  held  by  Friedberger  and  widely  accepted 
to-day,  is  to  the  effect  that  it  belongs  to  Ehrlich's  group  of  amboceptors  or  lytic 
antibodies  of  the  third  order.  As  is  well  known,  an  antibody  of  this  nature,  according 
to  Ehrlich's  theory,  is  produced  through  the  influence  of  the  antigen  (bacteria,  serum, 
egg  albumin,  pollens,  etc.)  upon  body  cells  and  is  specific  for  the  antigen  in  so  far  that 
it  will  unite  only  with  its  antigen  and  prepare  the  latter  for  the  disrupting,  digesting, 
or  lytic  action  of  a  fermentiike  substance  normally  present  in  the  blood  and  called 
complement.  In  this  manner  the  antibody  producing  the  protein  poison  of  anaphy- 
laxis has  the  same  structure  and  acts  in  the  same  manner  as  other  well-known  anti- 
bodies of  this  order,  namely,  the  hemolysins  and  bacteriolysins. 

According  to  this  view  we  must  concede  that  complement  plays  a  rdle,  indeed  a 
most  important  one,  in  the  production  of  anaphylaxis.  While  complement  has  prop- 
erties suggestive  of  a  proteolytic  ferment,  we  know  little  or  nothing  of  its  true  nature 
beyond  that  it  is  regarded  as  essential  for  the  cleavage  of  the  antigenic  molecule. 
Sleeswijk  (I),  Friedberger  and  Hartoch  (2),  Loeffler  (3),  and  others  have  shown  that 
complement  is  diminished  during  anaphylactic  shock;  likewise  Friedberger  (4), 
making  use  of  the  observations  of  Nolf  (5)  and  Hektoen  (6)  to  the  effect  that  comple* 
ment  is  not  bound  by  antigen  and  antibody  in  the  presence  of  hypertonic  salt  solu- 
tion, devised  experiments  which  appeared  definitely  to  establish  the  rdle  of  com- 
plement in  the  production  of  a  protein  poison  and  in  the  mechanism  of  anaphylaxis. 

Test-tube  experiments,  and  partictdarly  efforts  to  explain  anaphylaxis  on  the  basis 
of  the  Abderhalden  theory  and  technic,  seriously  question  the  rdle  of  complement 
in  the  mechanism  of  anaphyhuds.    Williams  and  Pearce  (7),^  Lange  (8),  Jobling, 

1  Figures  in  paraDttafises,  used  as  refwenoes,  rate  to  pabUcattons  bearing  identical  nomben  tinder  the 
bead  of  '*  Bibliograpby,"  at  the  end  of  this  piqper. 


290       PROCEEDINGS  SECOin)  PAN  AMEBICAN  SOIENTEPIO  CONGBESS. 

Eggstein,  and  Petersen  (9),  and  Kolmer  and  Williams  (10)  found  that  digestion 
occurred  with  activated  serum,  but  to  a  lesser  d^;ree  than  results  with  active  smun; 
on  the  other  hand  Stephen  (11),  Hauptmann  (12),  Bettencourt  and  Menezes  (13),  and 
Steisung  (14)  believe  that  a  complement  plays  a  very  important  rOle  in  Abderhalden's 
test.  Abderhalden,  himself,  while  believing  that  serum  complement  plays  some  part 
in  the  mechanism  of  his  reaction,  but  in  a  different  manner  than  in  hemolysis  or  other 
cytolytic  reactions,  offers  no  adequate  explanation  of  its  relation  to  these  processes. 

It  would  appear,  therefore,  that  if  we  attempt  to  explain  anaphylactic  reactions, 
either  general  or  local,  by  an  application  of  the  well-known  theory  of  antigen-ambo- 
ceptor-complement  production  of  the  anaphylactic  poison  on  the  basis  of  experiments 
in  vitro,  we  must  prepare  ourselves  to  believe  that  the  actiial  lytic  or  digestive  body 
in  the  serum  (call  it  complement  or  true  enzyme)  exists  in  both  a  themolabile  and 
themostabile  condition.  While  hemolysis,  bacteriolysis,  and  other  cytolytic  reactions 
will  occur  only  in  the  presence  of  fresh  complement  serum,  the  protein  poison  of 
anaphylaxis  may  be  produced  apparently  by  both  active  or  inactivated  serum; 
otherwise  it  would  appear  that  an  explanation  of  the  mechanism  concerned  in  the  pro- 
duction of  anaphylatoxin  must  be  withdrawn  from  the  field  of  amboceptor-antigen 
complement  activity  as  iinderstood  at  present. 

Vaughan  has  always  called  the  antibody  in  the  serum  concerned  in  the  mechanism 
of  anaphylaxis  a  "ferment";  likewise  Abderhalden  and  Jobling  and  Petersen  have 
used  this  term.  As  far  as  I  know,  these  observers  have  not  clearly  defined  the  meaning 
of  the  term  "ferment "  and  established  its  relation  or  lack  of  relation  to  the  amboceptors 
of  Ehrlich  or  sensitizers  of  Bordet;  apparently  they  regard  the  "ferment"  as  a  proteo- 
lytic enzyme  or  protease.  This  conception  of  the  enzyme  nature  of  the  "ferment" 
would  correspond  somewhat  with  the  nonspecific  alexin  of  Bordet  or  Ehrlich's  com- 
plement and  fail  to  harmonize  with  the  specific  nature  of  anaphylaxis.  Otherwise  it 
s  necessary  to  believe  that  the  entrance  of  a  foreign  protein  calls  forth  the  production 
of  a  specific  proteolytic  enzyme  or  ferment  capable  in  itself  of  attacking  and  disrupting 
a  protein  matrix,  and,  as  stated  above,  place  the  mechanism  of  anaphylaxis  out  of  the 
realm  of  amboceptors  and  complements  according  to  the  theories  of  Ehrlich  and 
Bordet. 

The  trend  of  more  recent  work  in  the  mechanism  of  anaphylaxis  by  Jobling  and 
Petersen  (15)  is  in  this  direction.  These  investigators  have  produced  the  protein 
poison  in  vitro  by  chemical  methods  in  such  manner  as  to  apparently  rule  out  the 
influence  of  the  thermolabile  and  easily  destroyed  complement  or  alexin;  according 
to  their  views  senmi  complement  and  normal  proteolytic  ferments  are  not  identical 
and  that  while  the  former  may  be  inactivated  by  heating  at  56**  C.  for  half  an  hour, 
the  latter  are  more  resistant,  the  increased  digestive  power  observed  following  the  addi- 
tion of  serum  complement  to  inactivated  pregnancy  serum  ascribed  to  the  amounts  of 
nonspecific  protease  thereby  added. 

It  is  clear,  therefore,  that  in  the  humoral  or  chemical  theory  of  anaphylaxis  tiie  true 
nature  of  the  antibody  is  unknown  and  in  dispute;  Friedberger  (16)  was  among  the 
first  to  maintain  that  the  antibody  is  identical  with  precipitin.  More  recently.  Lake, 
Osborne,  and  Wells  (17),  Doerr,  and  particularly  Weil  (18),  the  latter  being  an  ardent 
advocate  of  the  cellular  theory  of  anaphylaxis,  are  inclined  to  the  same  view  without, 
however,  offering  a  clear  explanation  of  its  action  in  vivo  in  the  mechanism  of  anaphy- 
laxis. \\Tule  the  rdle  of  precipitins  themselves  appear  to  have  been  excluded  as 
directly  participating  in  the  production  of  anaphylactic  shock,  recent  experiments  by 
Zinsser  (19)  and  others  would  tend  to  show  that  a  precipitin  possesses  the  nature  of  a 
protein  sensitizer  or  antibody  that  sensitizes  or  prepares  the  protein  antigen  for  lysis 
or  destruction. 

As  previously  stated,  the  chemical  and  cellular  theories  of  anaphylaxis  agree  that  the 
anaphylactogen  is  always  a  protein.  In  the  cellular  theory  the  anaphylactogen  is 
regarded  as  specific,  and  this  is  in  accord  with  accepted  facts  regarding  the  high 


FUBUO  HEALTH  AKB  MEDIOIKB.  291 

■pedfidty  of  the  anftphylactic  reaction;  in  the  chemical  theory,  howev^,  there  is  no 
agreonent,  some  maintaining  that  the  anaphyktozin  is  derived  from  the  foreign 
poison  or  anaphylactogen  and  others  that  it  is  derived  from  the  protein  of  the  patient's 
own  ienim. 

The  first  view  held  in  the  chemical  theory  is  that  in  the  anaphylactic  reaction  the 
antibody  acts  upon  its  protein  antigen  in  a  specific  manner  and  produces  in  the  reaction 
the  protein  poison  or  anaphylatoxin  responsible  for  the  lesions  and  symptoms  of  the 
anaphylactic  reaction.  For  example,  during  an  infection  with  spirocheta  pallida  an 
antibody  is  produced  which,  acting  upon  an  emulsion  of  dead  spirochetes  (luetin) 
injected  into  the  skin,  splits  the  protein  of  these  parasites  in  a  specific  manner  with  the 
|m>duction  of  a  poison  req>onsible  for  the  local  reactions  of  erythema  and  infiltration. 

An  anaphylactic  reaction  of  this  kind  employing  a  cellular  or  formed  antigen  is 
regarded  as  being  divided  into  twophases.  As  compact  structures  cells  can  not  enter 
into  direct  chemical  relations  with  the  fixed  tissue  cells  until  they  have  been  resolved 
or  disintegrated  into  ampler  constituents  by  ferments  or  antibodies  in  the  body 
fluids.  This  is  followed  by  the  second  phase  or  the  interaction  of  the  anaphylactic 
antibody  and  the  dissolved  antigen.  Anaphylactic  reactions  with  such  formed 
elements  as  erythrocytes  and  bacteria  may  occur;  usually  it  is  more  difficult  to  sen- 
sitize the  bbdy  ceUt  with  these  antigens  than  when  dissolved  proteins  as  in  blood 
serum  are  employed. 

The  experiments  of  Eeysser  and  Wassermann  (20),  Bordet  (21),  Jobling  and  Peter- 
sen (22),  Plant  (23),  Peiper  (24),  Freidemann  and  Schonfeld  (25),  Bronfenbrenner  (26), 
and  others  tend  to  show  that  the  mechanism  is  not  quite  so  simple  and  direct  and  that 
a  protein  poison  may  be  produced  in  the  absence  of  the  specific  antigen.  They  have 
demonstrated  by  experiments  in  vitro  that  such  inert  substances  as  kaolin,  barium 
sulphate,  agar  or  indifferent  bacteria  or  precipitates  may  replace  the  antigen  in  the 
production  of  a  protein  poison.  Since  the  presence  of  protein  substances  could  be 
excluded  as  with  such  inorganic  substances  as  kaoUn  and  barium  sulphate,  the  con- 
clusion was  naturally  drawn  that  the  matrix  of  the  poison  was  not  the  antigen  or 
subtract,  but  the  constituents  of  the  serum  itself.  Jobling  and  Petersen  advanced  the 
theory  that  the  proteolytic  ferment  was  held  in  check  by  antiferments  (largely  the 
unsaturated  fatty  acids  in  serum)  and  that  these  substances  as  kaolin  or  barium  sul- 
phate absorb  the  antiferments  uid  thereby  release  the  proteolytic  ferments  which 
proceed  to  digest  the  protein  of  the  serum.  For  this  reason  these  investigators  have 
applied  the  name  ''serotoxin''  to  the  protein  poison  as  indicating  its  source. 

Applying  these  observations  and  views  to  the  subject  undw  discussion,  it  would 
appear  necessary  to  infer  that  the  antigen  is  nonspecific  and  acts  as  it  were  in  a  purely 
mechanical  manner;  this  does  not  at  all  agree  with  great  mass  of  experim^ital  data 
showing  the  highly  specific  nature  of  anaphylaxis.  In  tertiary  syphilis,  for  example, 
the  reaction  in  the  skin  following  an  injection  of  an  emulsion  of  dead  spirochetes 
(luetin)  would  be  due  according  to  this  mechanism,  not  to  a  digestion  of  the  protein 
of  the  spirochetes  with  the  production  of  a  protein  poison,  but  the  luetin  would  act 
simply  as  a  local  adsorbent  of  the  antiferment,  releasing  thereby  proteolytic  ferments 
which  proceed  to  digest  the  patient's  own  serum  or  cellular  protein  in  loco  with  the 
production  of  a  poison  responsible  for  the  reaction,  and  if  this  were  true  the  reaction 
lacks  specificity. 

Bronfenbrenner  (27)  explains  the  specific  production  of  anaphylatoxin  by  non- 
si>ecific  ferments  or  antibodies  as  follows: 

Specific  antibodies  are  produced  which,  combining  with  the  antigen,  causes  a  falling 
out  or  inactivation  of  the  antiferments  of  the  serum  by  a  change  in  colloidal  conditions 
resulting  in  the  release  of  normal  or  nonspecific  proteolytic  ferments  which  disrupt 
<nr  digest  the  protein  of  the  serum.  In  other  words,  specific  antibodies  are  produced, 
but  instead  of  these  digesting  the  protein  of  the  antigen  or  of  the  serum  directly,  they 
act  by  uniting  with  the  antigen,  and  this  union  results  in  the  removal  of  antiensyme, 

68436—17— VOL  x 20 


292       PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC  CONGBESS. 

thereby  releasing  or  rendering  active  the  normal  and  nonspecific  enzymes  of  the 
serum  which  produce  a  protein  poison  or  anaphylatoxin  by  digesting  the  protein  of 
the  serum. 

Whether  or  not  the  results  of  a  study  of  the  mechanism  of  Abderhalden's  reaction, 
which  in  the  final  analysis  is  nothing  more  than  a  popularized  method  of  studying 
protein  digestion  in  a  manner  pregnant  with  opportunities  for  error,  can  be  applied 
to  unfolding  the  mechanism  of  anaphylaxis  is  uncertain;  but  it  is  certain  that  an 
explanation  of  the  mechanism  of  either  the  local  skin  or  general  anaphylactic  reaction 
must  satisfactorily  explain  the  high  and  uniform  specificity  of  these  reactions  before  it 
is  acceptable. 

The  above-mentioned  experiments  which  have  been  largely  conducted  in  vitro  are 
not  without  definite  value,  and,  as  I  shall  point  out  later,  have  a  greater  bearing  upon 
the  mechanism  of  the  pseudo  than  upon  the  true  anaphylactic  reaction  and  the 
phenomena  of  local  inflammation  in  general. 

Up  to  this  point  our  discussion  has  been  confined  to  present-day  conceptions  of  the 
nature  of  the  protein  matrix,  the  mechanism  of  action  of  the  antibody  or  ferment 
according  to  the  chemical  theory  and  the  effects  of  the  protein  poison  on  body  ceUs 
in  anaphylactic  phenomena. 

No  discussion  is  complete,  however,  without  particular  reference  to  that  peculiar 
change  on  the  part  of  the  cells,  probably  involving  the  colloidal  chemistry  of  theceUs 
themselves,  which  exerts  so  important  a  r^le  in  anaphylaxis  and  particularly  in  the 
local  reaction.  This  altered  reactivity[of  the  cells  or  their  unusual  and  exaggerated 
susceptibility  to  the  effects  of  the  products  of  digestion  of  foreign  proteins  was  early 
emphasized  by  Von  Pirquet,  Rosenau,  and  Anderson,  and  other  pioneers  in  this  field, 
and  on  account  of  the  importance  of  this  phase,  the  former  proposed  the  term '  *  allergy  " 
meaning  "altered  reactivity,"  as  describing  the  phenomena  more  concisely  than 
Richet's  term  " anaphylaxis, "  meaning  '* without  protection.''  The  term  "allergy" 
is,  in  our  opinion,  more  appropriate,  as  it  emphasizes  the  important  hypersensitivenees 
or  altered  reactivity  of  the  cells  regardless  of  any  theories  we  may  entertain  as  to  the 
manner  in  which  this  change  is  brought  about  or  manifested. 

Definite  information  on  the  nature  of  this  peculiar  cellular  change  is  lacking. 
When  one  bears  in  mind  the  intense  local,  focal,  and  general  reaction  in  tuberctdoeis 
that  may  follow  the  injection  of  a  mkiute  amount  of  tuberculin  or  the  minute  amount 
of  protein  that  suffices  to  induce  the  anaphylactic  reaction  in  the  classical  experiment 
with  horse  serum  and  guinea  pigs,  conditions  in  which  the  amount  of  protein  poison 
produced  must  be  very  slight  indeed  for  physical  reasons  alone,  the  supposition  is 
forced  upon  one  that  some  change  rendering  the  cells  highly  susceptible  to  the 
anaphylactic  poison  is  of  fundamental  importance  in  anaphylactic  reactions. 

Investigators  have  attempted  to  explain  this  peculiar  hyperactivity  of  the  body 
cells  on  the  basis  that  the  reaction  is  a  cellular  one,  that  is,  that  the  antibody  is  within 
the  cell  and  that  the  antigen-antibody  reaction  occurs  in  this  position  rather  than  in 
the  blood  stream  by  means  of  free  or  circulating  antibody  and  antigen.  According 
to  the  "cellular  theory, "  if  the  serum  of  an  immunized  animal  containing  the  anaphy- 
lactic antibody  is  injected  into  a  normal  animal  (passive  anaphylaxis)  followed  by  an 
injection  of  the  antigen,  an  anaphylactic  reaction  can  not  occur  before  the  elapee  of 
sufficient  time  for  the  antibody  to  become  anchored  to  cells.  According  to  the 
"humoral  theory,"  on  the  other  hand,  the  antigen  meets  the  antibody  in  the  blood 
stream  and  explains  the  time  required  between  the  injection  of  immime  serum  and 
antigen  in  passive  anaphylaxis  as  due  to  a  failure  of  rapid  union  between  antigen  and 
antibody  unless  quantitative  relations  between  the  two  is  accidentally  correct. 

The  early  theory  of  Friedberger  (16)  explaining  anaphylaxis  on  the  basis  of  "sessile 
receptors;"  the  experiments  of  Friedberger  and  Girgolaff  (28),  who  passively  sensi- 
tized normal  animals  by  transplanting  the  thoroughly  washed  organs  of  a  sensitized 
animstl;  the  transfusion  experiments  of  Pearce  and  Eisenbrey  (29),  who  transferred 


PUBLIC  HEALTH  AND  MEDICINE.  293 

the  blood  of  a  sensitized  animal  to  a  normal  animal  and  the  blood  of  a  nonnal  animal 
to  a  sensitized  one,  finding  that  the  latter,  but  not  the  former,  reacted  when  the  anti- 
gen was  injected  as  soon  as  the  transfusions  were  completed;  the  work  of  Coca  (30) 
who  found  that  sensitized  guinea  pigs  would  still  react  after  being  thoroughly  bled 
and  perfused  with  salt  solution;  of  the  investigations  of  Schultz  (31),  Dale  (32),  and 
particularly  of  Weil  (33),  showing  that  the  excised  and  washed  muscles  of  sensitized 
animals  would  react  in  vitro  in  a  bath  of  Ringer's  solution  when  the  antigen  was  added, 
support  most  strongly  the  cellular  theory  of  anaphylaxis  as  emphasized  also  in  the 
work  and  recent  communications  of  Doenr  (34). 

In  the  opinion  of  Weil,  Doerr,  Bayliss,  Coca,  and  others  the  '^ cellular"  theory  is 
the  only  tenable  one  to-day.  According  to  this  theory  of  anaphylaxis  the  antibody 
is  in  or  on  the  body  cells;  upon  imion  with  the  antigen  the  cells  undergo  a  physical 
shock  which  has  been  likened  to  an  electrical  shock,  and  this  constitutes  the  basis  of 
the  anaphylactic  reaction  without  the  formation  of  any  intermediate  or  chemical 
poison. 

As  emphasized  by  Weil  (36),  there  is  no  direct  evidence  of  the  production  of  a 
chemical  poison  or  anaphylatoxin  during  or  after  an  anaphylactic  reaction  in  the  living 
animal.  This  poison  has  not  been  satisfactorily  demonstrated  in  the  blood  and  in 
animals  recovering  from  a  general  anaphylactic  reaction,  the  phenomena  being  more 
suggestive  of  a  transitory  ''shock  "  than  an  intoxication  with  a  chemical  poison. 

On  the  other  hand  the  mass  of  experimental  evidence  indicating  that  the  anaphy- 
lactic reaction  is  not  purely  cellular,  but  at  least  in  part  an  intravascular  reaction,  is 
too  strong  to  be  discarded.  As  pointed  out  by  Zinsser  and  Young  (35),  the  necessary 
time  usually  required  in  passive  anaphylaxis  between  the  injection  of  immune  serum 
and  antigen  may  be  due  to  slow  union  between  antigen  and  antibody  in  the  blood 
stream  on  the  basis  that  the  anaphylactic  reaction  involves  the  interaction  of  colloids, 
and  that  a  protective  colloid  is  responsible  for  the  slow  union  of  antigen  and  antibody 
unless  its  influence  is  obviated  by  exact  quantitative  proportions  between  antigen 
and  antibody,  which  under  experimental  conditions  may  be  secured  in  a  more  or  less 
accidental  manner. 

As  antibodies  are  produced  by  the  body  cells,  it  is  reasonable  to  believe  that  they 
are  present  in  the  protoplasm  of  the  cells,  and  even  after  thorough  washing  of  the  tis- 
sues are  capable  of  union  with  their  antigen.  It  is  entirely  likely  that  these  attached 
or  sessile  antibodies  are  chiefly  concerned  in  the  phenomena  of  anaphylaxis,  but  I 
can  not  subscribe  entirely  to  the  cellular  theory  because  of  the  mass  of  experimental 
data  bearing  on  the  production  of  the  protein  poison,  particularly  in  vitro,  by  the 
free  antibodies  in  an  immune  serum.  The  reactions  in  vivo  of  hemolysis  and  bac- 
teriol3rsis  which  are  lytic  processes  apparently  similar  to  those  concerned  in  anaphy- 
lactic reactions  are  probably  intravascular  processes;  it  is  also  likely  that  in  anaphy- 
laxis to  formed  antigens  the  first  phase  of  the  reaction,  that  is,  the  disruption  of  the 
antigenic  cell,  is  intravascular,  showing  that  lytic  reactions  entirely  analogous  to  our 
conception  of  the  mechanism  of  the  production  of  the  protein  poison  in  anaphylactic 
reactions  may  occur  in  the  blood  stream.  For  these  reasons  alone  I  can  not  exclude 
the  free  antibodies  in  the  blood  from  playing  some  role  in  the  phenomena  of  anaphy- 
laxis. 

The  extreme  sensitiveness  of  the  body  cells  in  anaphylaxis  to  the  protein  suggests 
to  me  that  the  cells  acquire  the  property  of  union  with  the  protein  poison  to  an  extreme 
degree,  as  if  they  were  furnished  as  a  result  of  the  initial  dose  of  foreign  protein,  with 
an  increased  number  of  specific  and  sessile  receptors  for  the  protein  poison.  In  other 
words,  while  the  protein  poison  may  be  produced  in  the  cells  by  sessile  receptors  or 
in  the  blood  stream  by  free  receptors,  anaphylaxis  itself,  that  is,  the  hypersensitive- 
ness  of  the  cells  is  due  to  the  increased  binding  power  of  the  cells  for  the  protein  poison. 
In  our  opinion  this  in  part  explains  true  allergy,  that  is,  the  effects  of  local  or  general 
sensitization  (production  in  the  protoplasm  of  the  cells  of  increased  receptors  for  the 


294       PBOGEEDINGS  BBGOND  PAN  AMEBIGAN  80IENTIFI0  G0NQBE8S. 

protein  poison)  and  the  immediate  well  marked  w  even  violent  effects  following 
the  production  of  what  must  be  very  minute  amounts  of  protein  poison  as  in  the  cutan- 
eous tuberculin  reaction  or  in  the  classical  horse  serum  reaction  in  guinea  pigs  follow- 
ing the  intravenous  injection  of  the  intoxicating  or  second  dose  td  protein  in  every 
minute  or  infinitesimal  dosage. 

Personally  I  would  be  more  prepared  to  understand  and  accept  the  cellular  thearf 
in  the  strictest  sense  in  the  mechanism  of  anaphylaxis  were  my  studies  confined 
entirely  to  general  anaphylactic  shock;  in  the  local  reaction,  however,  the  slowly 
spreading  character  of  l^e  lesion,  the  erythema,  edema,  and  eosinophilic  infiltration 
strongly  suggest  that  a  diffusible  irritant  has  been  produced  similar  in  some  respects 
at  least  to  that  which  can  be  produced  in  vitro. 

As  far  as  I  am  aware  the  skin  or  local  anaphylactic  reaction  has  not  been  explained 
on  the  basis  of  the  cellular  theory  alone  in  its  strictest  sense.  These  reactions  have 
many  of  the  features  on  an  inflammatCHry  reaction  of  which  vascular  changes  (hypecw 
emia)  and  edema  are  prominent  features.  Intracutaneous  reactions  are  likely  to 
persist  for  several  days;  likewise  the  cutaneous  tuberculin  reaction,  although  the 
cutaneous  reaction  to  pollen  and  serum  may  reach  its  height  within  half  an  hour  and 
disappear  within  a  few  hours.  May  these  inflammatorylike  changes  be  ascribed  to 
a  temporary  and  physical  shock  of  the  endothelium  oi  vessels  in  the  skin  followed  by 
stasis  and  exudation,  and  of  the  connective  tissue  cells  at  the  site  of  injection?  Am 
previously  stated,  I  believe  that  the  cells  play  the  major  role  in  anaphylaxis  in  that 
the  formation  of  a  diffusible  protein  poison  occurs  largely  in  or  on  the  cells  by  reason 
of  the  fact  that  the  antibodes  are  largely  situated  in  the  cells  and  that  the  cells  beat 
the  brunt  of  the  change  and  undergo  shock  by  reason  of  the  poison  being  produced  in 
them,  but  that  a  poison,  nevertheless,  is  produced  which  may  escape  detection  by 
high  dilution  in  the  body  fluids  in  the  general  reaction,  but  which  appears  in  tiie  locdl 
reaction  as  a  diffusible  irritant  producing  the  phenomena  of  acute  congestion,  edema^ 
and  leucocytic  infiltration  (particularly  of  eosinophilee). 

It  is  my  opinion  that  the  source  of  the  protein  poison  in  true  anaphylaxis  is  always 
that  which  has  been  injected  and  for  which  specific  antibodies  are  present  mainly 
in  the  cells. 

I  regard  cutaneous  anaphylaxis  as  due  to  an  interaction  between  true  or  specific 
antigen  and  its  specific  antibody  with  the  production  of  a  diffusible  irritant  capable 
of  exciting  inflammation;  that  tikis  union  of  antigen  and  antibody  occurs  principally 
within  the  cells  and  that  the  cells  suffer  largely  by  reason  of  this  interaction  and  for- 
mation or  irritant  within  them. 

An  adequate  explanation  of  those  apparently  anaphylactic  reactions  to  drugs  has 
not  been  made.  It  is  generally  held  that  the  drug  alters  a  body  protein  with,  the 
formation  of  a  new  protein  compound  capable  of  sensitizing  and  producing  anaphy 
laxis. '  Recently  my  colleague,  Dr.  Fred  Boemer,  who  is  hypersensitive  to  quinine 
and  suffers  considerably  with  cutaneous  manifestations  if  even  minute  doses  are 
swallowed,  has  shown  a  marked  reaction  of  edema  and  erythema  in  his  skin  following 
in  few  minutes  the  application  of  powdered  quinine  sulphate  or  a  solution  of  the 
bisulphate,  to  an  abrasion.  He  has  shown  that  this  reaction  is  apparently  specific 
inasmuch  as  it  does  not  occur  among  persons  not  hypersensitive  to  quinine  and  a 
similar  reaction  occurred  in  the  skin  of  a  second  person  known  to  be  hypersensitive. 
The  occurrence  of  these  reactions  within  a  few  minutes  after  the  application  oi  quinine 
renders  the  theory  of  the  formation  and  activity  of  a  new  protein  compound  doubtfol* 

MECHANISM  OF  NONSPECIFIC  PROTEIN  AND  TRAUMATIC  SKIN  BEACTIONS. 

It  appears  well  established  that  the  blood  serum,  leucoc3rtes,  and  the  fixed  cells 
of  various  tissues  of  the  body  contain  proteolytic  ferments  capable  of  digesting  various 
protein  substances  in  vitro.  The  digestive  activity  of  these  ferments  can  be  studied 
and  determined  only  by  very  delicate  methods  and  are  apparentiy  nonspecific  in 


PUBUO  HBALXH  AHD  MBNOINB.  295 

chancier  (97).  la  vitro  they  apparently  are  capable  of  produciiig  toxic  substances 
which  may  be  regarded  as  protein  derivatives.  These  proteolytic  ferments  may  be 
reqxmsible  for  local  inflammatory  phenomena  and  in  an  attempt  to  corelate  these 
iQSults  with  the  mechanism  of  ^e  nonspecific  and  purely  inflammatory  reaction 
which  may  be  the  sole  reaction  in  the  skin  and  lead  to  misinterpretation  and  error,  or, 
occur  coincidently  with  the  true  anaphylactic  reaction,  the  following  explanationa 
have  been  oftered: 

1.  An  irritant  is  produced  through  the  inteiaction  of  general  proteolytic  ferments 
and  various  proteins  injected,  as  those  contained  in  broth,  agar,  or  ascites 
This  irritant  or  chemical  poison  is  responsible  for  the  lesion. 

2.  Trauma  caused  by  the  needle  or  trauma  plus  injury  to  the  cells  due  to  the  pres- 
ence of  a  preservative,  as  phenol  or  tricresol,  or  a  preformed  toxin  (as  diphtheria 
toxin  used  in  the  Schick  test),  or  bacterial  protcdn  of  irritant  nature,  may  destroy 
a  sufficient  number  of  cells  to  release  their  proteolytic  ferments  which  proceed  with 
a  process  of  digestion;  or  the  injection  mass  and  dead  cells  mechanically  absorb  the 
antiferment  and  thereby  activate  the  ferments  which  produce  from  the  injected 
|»otein  or  that  of  the  dead  cells  and  patient's  own  serum  sufficient  proteotozin  to 
produce  an  inflammatory  reaction. 

The  injection  into  the  skin  of  a  foreign  protein  (the  anaphylactogen),  as  that  pro- 
tein present  in  sterile  bouillon  or,  for  example,  the  protein  of  bouillon,  agar,  and 
q;Mrochet6s  as  present  in  luetin,  increases  the  production  of  protein  poison  by  more 
active  release  or  proteolytic  ferments  through  removal  of  the  antif erments  by  absorp- 
tion or  in  some  other  way,  followed  by  digestion  of  the  injected  protein  and  the 
|»otein  of  the  patient's  devitalized  cells  and  serum. 

Th|s  protein  poison  or  proteotoxin  is  an  irritant  and  excites  inflammation  of  vary- 
ing dcigrees  of  severity.  In  this  manner  we  have  a  ready  explanation  for  those 
pseudo  reactions  following  the  intracutaneous  injection  of  sterOe  broth  as  found 
by  Kolmer  and  Moshage  (38),  of  extracts  of  placental  cells  by  Engelhom  and  Wintz 
(39),  Falls  and  Bartlett  (40),  Eohner  and  Williams  (41),  of  agar  and  emulsions  of 
normal  and  pathologic  skin  by  Stokes  (42,  43),  of  heated  diphtheria  toxin-broth 
by  yiiTi^qr  (44)^  and  vfirlous  oilier  protein  substances  by  various  investigators. 

It  is  highly  probable  that  the  quantity  of  proteolytic  ferments  in  the  cells  and 
serum  of  different  persons  vary;  also  the  quantity  of  ferments  in  the  cells  of  the 
skin  of  the  same  person  in  different  areas  of  the  body,  and  in  this  manner  explain 
the  varying  d^;rees  of  pseudo  or  purely  inflammatory  reactions  in  the  same  person 
in  different  parts  of  the  body  or  among  different  persons,  with  the  injection  of  the 
same  protein  in  the  same  dosage.  Dr.  Moshage  and  I  have  foimd  that  the  skins 
of  persons  convalescent  from  scarlet  fever  and  measles  are  especially  prone  to  yield 
these  nonspecific  reactions. 

Any  protein  substance,  if  injected  into  the  skin  in  sufficiently  large  amoimt,  will 
elicit  a  nonspecific  or  inflammatory  reaction;  for  this  reason  the  material  used  In 
conducting  skin  tests  for  the  specific  anaphylactic  reaction  should  be  carefuUy  pre- 
pared and  admuiistered  in  such  amount  as  will  not  elicit  a  nonspecific  reaction 
among  a  large  number  of  controls,  and  the  injection  of  a  control  fluid  is  always  advis* 
able.  Outaneous  tests  are  much  less  likely  than  intracutaneous  tests  to  yield  non* 
specific  reactions  of  sufficient  degree  to  prove  disturbing;  they  are  less  delicate  testa 
for  the  anaphylactic  state  but  also  less  open  to  error. 

TUM  INVLUBNCB  OV  DBUCW  UPON  8KIN  RBAOnONB. 

Recently  Sherrick  (49)  has  reported  that  normal  persons  under  the  influence  of 
iodides  would  yield  positive  reactions  to  the  intracutaneous  injection  of  luetin. 
Broadwell,  Matsimami,  and  I  (50)  were  able  to  confirm  these  observations  in  that 
a  normal  person  who  reacted  negatively  to  luetin  in  the  preliminary  test  would 
frequentiy  react  to  a  well-marked  degree  when  the  test  was  applied  after  the  admin- 


296       PROCEEDINOS  SECOND  PAN  AMBBIOAN  SOIENTIFIO  GONQBESS. 

Istration  of  potaaeium  iodide.  We  also  observed  similar  results  among  rabbits  and 
guinea  pigs. 

During  the  past  year  these  studies  have  been  continued  with  the  cooperation 
of  Dr.  Immerman  and  Dr.  Montgomery  (51),  iising  various  iodides,  bromides,  chlo- 
rides, and  anesthetics  and  two  intracutaneous  tests,  namely,  the  liietin  test  and 
one  with  an  emulsion  of  B.  prodigiosis.  Both  tests  were  made  beforehand  upon 
Wassermann  negative  persons  and  repeated  after  the  administration  of  from  90  to 
170  grains  of  the  drugs  or  after  operation  under  ether  or  nitrous  oxide.  Iodides  and 
bromides  were  found  to  exert  considerable  influence,  while  the  influence  of  chlorides 
was  much  less  in  evidence,  and  ether  and  nitrous  oxide  were  without  demonstrable 
effect. 

According  to  Jobling  and  Petersen,  the  antiferment  of  the  serum  is  of  the  nature 
of  unsatmrated  fotty  adds  and  that  these  may  be  removed  by  the  halogens  and  the 
ferments  thereby  released  or  rendered  active.  The  influence  of  these  drugs  upon 
skin  tests  are,  therefore,  to  be  explained  upon  this  basis.  We  are  of  the  opinion 
that  they  do  not  influence  the  mechanism  of  the  true  anaphylactic  reaction,  but 
only  the  nonspecific  or  simple  inflammatory  portion  of  a  skin  reaction  by  facilitating 
the  release  of  nonspecific  ferments.  This  opinion  is  based  upon  the  observation 
that  the  influence  of  these  drugs  upon  skin  reactions  have  been  observed  in  persona 
who  were  not  anaphylactic  to  the  protein;  that  no  influence  was  observed  upon  true 
anaphylactic  reactions  to  the  cutaneous  application  of  tuberculin  and  that  the  greater 
the  amount  of  bacterial  protein  or  culture  mediiun  constituents  injected,  the  severer 
the  reaction. 

Since  the  nonspecific  element  may  always  play  a  part  in  skin  reactions  following 
intradermal  injections,  it  is  well  for  physicians  to  bear  in  mind  that  these  drugs 
may  so  favor  ^e  nonspecific  reaction  as  to  present  evidences  of  a  violent  reaction 
which  may  be  interpreted  as  anaphylactic. 

THB  CLINICAL  8IQNIFICANCB  OF  ANAFHTLACTIC  SKIN  RBACTIONS. 

1.  Aa  indices  of  hypersusceptibility  and  infection, — ^The  clinical  significance  of  a  true 
anaphylactic  skin  reaction  to  a  certain  protein  aside  from  establishing  the  t&ct  that  a 
person  is  hypersensitive  to  that  protein,  depends  upon  what  harm  may  be  done  with 
the  enteral  or  parenteral  introduction  of  the  protein.  It  is  not  my  purpose  to  review 
in  detail  the  many  clinical  conditions  which  appear  to  be  due  to  a  state  of  anaphy- 
laxis; this  phase  of  the  subject  has  been  recently  covered  in  a  thorough  and  excellent 
manner  by  Longcope  (52).  Here  it  may  be  recalled  that  examples  of  apparently 
true  spontaneous  hyx>er8ensitivenes8  to  various  foreign  proteins  are  not  uncommon 
and  indeed,  the  trend  of  recent  investigations  is  always  widening  this  field  and  estab- 
lishing hypersensitiveness  as  a  probable  basis  for  many  diseases  with  symptoms 
referable  to  the  respiratory  tract,  gastro-intestinal  tract,  and  the  skin.  In  the  minds 
of  not  a  few  physicians  the  term  "anaphylaxis"  means  a  brief  and  stormy  general 
reaction  following  the  administration  of  diphtheric  antitoxic  horse  serum,  a  reaction 
occupying  as  it  were  a  distinct  and  isolated  place  in  the  field  of  immunity,  whereas 
%h\iK  IB  but  one  manifestation  of  a  process  which  bids  fair  to  become  established  as 
the  basis  of  many  and  diverse  clinical  conditions,  as,  for  examples,  hay  fever,  ivy 
poisoning  and  similar  toxic  dermatoses,  bronchial  asthma,  serum  sickness  and  that 
wide  field  of  various  food  idiosyncrasies  due  to  the  ingestion  of  eggs,  milk,  and  various 
meats  as  studied  by  Schloss  (63),  Lesn6  and  Kichet  (54),  Talbot  (55),  Smith  (56), 
Strickler  (57),  Blackfan  (58),  and  others.  I  have  been  particularly  interested  in  the 
investigations  conducted  in  my  laboratory  by  Strickler,  which  show  the  very  impor- 
tant relation  of  hypersensitiveness  to  various  vegetable  and  animal  proteins  to  eczema 
and  other  skin  diseases. 

Further  researches  will  show  us  what  harm  may  be  done  by  the  anaphylactic  poison; 
at  present  we  know  that  grave  symptoms  and  even  death  may  result  from  the  paren- 


FUBLIO  HEALTH  AM)  MEDIOIHB.  297 

tend  injection  of  a  senim  to  vhich  a  person  is  highly  susceptible;  Longcope  and  his 
coworkers  have  shown  tiiat  the  poison  may  produce  slow  but  definite  degenerative 
lesions  in  the  kidneys;  the  ingestion  of  eggs  or  other  food  by  a  person  hypersusceptible 
to  their  protein  is  known  to  produce  symptoms  and  skin  manifestations  whidi  dis- 
appear or  ameliorate  upon  the  permanent  withdrawal  from  the  diet  of  such  foods. 
In  other  words  evidence  is  accumulating  to  show  that  hypersensitiveness  plays  an 
active  rdle  in  the  etiology  of  many  diseases  and  in  the  detection  of  these,  skin  reac- 
tions are  proving  of  great  value  and  indeed  may  prove  the  only  means  of  specific 
diagnosis. 

As  is  well  known,  anaphylactic  skin  reactions  may  be  elicited  in  various  bacterial 
and  protozoon  diseases  with  anaphylactogens  prepared  of  the  protein  of  the  respective 
microparasltes  particularly  in  tuberculosiB,  glanders,  typhoid  fever,  and  syphilis. 
Well-marked  and  specific  reactions  have  also  been  found  by  Amberg  (59)  and  Kolmer 
and  Strickler  in  ringworm  and  favus  and  isolated  repcurts  show  that  they  may  be 
elicited  in  various  other  diseases  with  the  proper  preparations. 

In  these  conditions,  however,  the  skin  reactions  are  not  always  elicited  and 
especially  during  the  early  and  acute  stages.  An  interval  of  time  is  required  for  the 
purpose  of  sensitization  and  during  the  acute  stages  antigen  and  antibody  may  both 
be  present  in  the  cells  and  body  fluids  as  shown  by  Weil  (60)  and  Denzer  (61)  with 
continual  interaction  expressed  in  the  symptom  complex  of  the  infection  and  thereby 
giving  no  response  when  the  protein  is  applied  or  injected  into  the  skin.  Further- 
more the  chemical  nature  of  the  protein  of  our  anaphylactogen  may  have  been  altered 
in  the  course  of  preparation  to  a  sufficient  extent  to  fail  to  elicit  an  anaphylactic 
reaction.  These  and  other  fakctors  not  understood  Himiniwh  the  practical  value  of  a 
skin  test.  At  present,  however,  it  may  be  stated  that  they  possess  a  diagnostic  value 
which  is  particularly  high  in  chronic  infections  and  that  no  other  satisfactory  clinical 
or  laboratory  test  for  the  state  of  anaphylaxis  to  a  particular  protein  and  for  the  ana- 
phylactic antibody,  has  been  discovered  except  that  by  which  the  protein  is  actually 
brought  into  relation  with  the  body  cells  as  in  the  parenteral  introduction  of  the 
protein.  Of  great  interest  in  this  connection  is  the  relation  of  the  intensity  of  the 
anaphylactic  skin  reliction  to  the  extent  of  the  infection.  Krause  (66)  has  recently 
studied  in  a  thorough  and  excellent  manner  the  tuberculin  skin  reaction  in  relation 
to  experimental  tuberculosis,  finding  that  cutaneous  hyx>erBensitiveness  to  tuberculo- 
jffotein  is  inaugurated  by  the  establishment  of  infection  and  the  development  of 
the  initial  focus;  that  the  skin  reaction  increases  with  progressive  disease;  is  dimin- 
ished with  healing  and  increased  by  reinfection. 

2.  At  indice$  of  immunUy, — Of  furtiier  importance  is  the  question  of  the  cliTiical 
significance  of  a  local  anaphylactic  reaction  as  an  index  of  immunity;  that  is,  resistance 
to  an  infection  or  reinfection.  Is  the  anaphylactic  antibody  capable  of  attacking 
and  destroying  the  antigenic  protein  in  a  living  state?  Are  protective  and  curative 
antibodies  produced  by  the  defensive  mechanism  of  the  body  while  the  cells  are  being 
sensitized  and  the  anaphylactic  antibody  produced?  In  other  words  is  hypersensi-. 
tiveness  to  be  regarded  as  an  index  of  resistance? 

In  1798  Jenner  wrote: 

It  is  remarkable  that  variolous  matter,  when  the  system  is  disposed  to  reject  it, 
should  excite  inflammation  on  the  part  to  which  it  is  applied  more  speedily  than 
when  it  produces  the  smallpox.  Indeed,  it  becomes  almost  a  criterion  by  which 
we  can  determine  whether  the  infection  will  be  received  or  not. 

In  other  words,  as  previously  mentioned,  this  astute  observer  noted  that  a  person 
who  presented  within  a  few  days  at  the  site  of  vaccination  an  '^efflorescence  of  palish 
color  "  was  probably  immune  to  smallpox.  Force  (62)  has  recentiy  drawn  attention 
to  this  *' immediate"  reaction  to  inoculation  with  cowx>ox  virus  as  an  evidence  of 
resistance  or  immunity  to  cowx>ox  and  smallpox  and  my  own  experience  supports 
his  conclusions.  Here,  indeed,  we  have  evidence  at  hand  indicating  that  an  anaphy- 
lactic state  is  an  index  of  the  coincident  presence  of  antibodies  and  resistance. 


298       PBOOEEDING0  8BG0ND  PAK  AMBBIOAK  SOOUfTIFIO  00NQBES8. 

Investigationa  bearing  upon  the  rdation  of  anax)]iylftxifl  to  immunity  in  other 
infections  have  not  generally  yielded  these  results.  Rosenau  and  Anderson  (68) 
sensitized  pigs  with  extracts  of  B.  typhosus  and  B.  coli  and  found  that  animals  so 
treated  were  immune  to  amounts  of  the  respective  microorganisms  fatal  to  nonnal 
pigs;  TComer  (64)  and  Sata  (66)  in  experiments  among  cattle  with  B.  tuberculosis 
reached  the  condusion  that  a  state  of  hypenensitiveness  meant  a  certain  degree  of 
redstance  while  Krause  (66)  and  Austrian  (67)  have  expressed  the  opinion  based  upon 
experiments,  that  sensitization  of  nontuberculous  animals  with  tubercle  im>tein  does 
not  raise  their  resistance  to  experimental  tuberculosis  infection  and  indeed  may 
lower  it. 

More  recently  Gray  and  Force  (68)  have  greatly  renewed  interest  in  this  subject  by 
advocating  l^e  skin  test  as  a  means  of  determining  defensive  activity  following 
typhoid  fever  or  active  immunization  by  means  of  vaccines.  Their  first  work  was 
conducted  with  a  ''tyj^oidin''  pr^>ared  in  the  same  manner  as  Koch's  old  tuberculin, 
by  cutaneous  inoculation;  later  Glay  and  Olaypole  (69)  prepared  typhoidin  by  pre- 
cipitating the  solution  with  alcohol,  washing  the  precipitate  with  alcohol  and  ether, 
drying  in  a  vacuum  and  suepending  the  resulting  powdor  in  phenolized  normal  salt 
solution  which  was  injected  intiacutaneously  and  implied  cutaneously;  a  control 
powder  was  prexNured  from  broth  and  used  in  the  same  maimer.  With  this  skin  teat 
Gkty  and  his  associates  have  studied  the  relative  value  of  various  vaccines  and  regard 
the  anaphylactic  reaction  as  indicative  of  a  state  of  immunity.  Nichols  (70)  has 
questioned  the  value  of  the  anaphylactic  ricin  test  as  an  index  of  ammunity  and 
regards  the  typhoidin  reaction  as  indicating  nothing  more  than  sensitization  of 
typhoid  protein  whidi  is  i^[>parently  less  lasting  and  less  specific  than  the  true  im- 
munity to  this  infection.  He  bases  this  opinion  on  the  fact  that  in  his  experience 
the  typhoidin  skin  gave  fewer  positive  reactions  (75  per  cent)  than  generally  expected, 
as  about  90  per  cent  of  persons  who  have  had  typhoid  fever  are  immune  for  many 
years  or  even  for  the  balance  of  life.  Furthermore,  according  to  Nichols,  expe- 
rience has  shown  that  protection  fdlowing  typhoid  fever  is  of  longer  duration  than  is 
indicated  by  the  typhoidin  test  and  while  a  large  percenti^  of  persons  who  have  had 
typhoid  fever  or  have  been  immunized  with  typhoid  vaccine  reiact  to  paratyphoidin 
recent  experiences  and  statistics  particulariy  in  Europe  have  indicated  that  these 
persons  are  not  immune  to  paratyphoid  fever. 

My  own  experiments  in  this  fidd  have  been  largely  tests  in  vitro  for  various  anti- 
bodies as  agglutinins,  bacterioiyains,  and  complement-fixing  substances  in  the  fresh 
sterile  blood  sera  of  persons  hypersensitive  to  various  proteins  in  ord^  to  determine 
whether  or  not  the  state  of  hypersensitiveness  to  a  particular  bacterial  protein  was 
accompanied  by  demonstrable  amoimts  of  these  antibodies.  I  am  wdl  aware  of  the 
diortcomings  of  such  tests  and  that  Ihe  weight  of  opinion  minimizes  their  value  as 
an  index  of  actual  immunity.  As  previously  mentioned,  Friedberger  (16)  was  among 
the  first  to  maintain  Ihe  identity  of  precipitin  and  the  anaphylactic  antibody;  Doerr 
and  RusB  (71)  independently  reached  the  same  conclusion  and  more  recently  Lake, 
Osborne,  and  Wells  (17)  and  Weil  (18)  have  brought  forward  considerable  evidence 
in  support  of  the  view  that  percipitins  are  frequently  persent  in  the  serum  of  the 
•ensitiBed  animal. 

The  experiments  conducted  by  Mr.  Berge  and  the  author  (72)  with  reference  to 
the  typhoidin  skin  reaction  showed  that  while  the  bactericidal  power  of  hmnan  serum 
over  B.  typhosus  is  increased  in  a  proportion  of  persons  following  typhoid  fever  or 
active  immunization  with  a  vaccine,  there  is  no  direct  relation  between  the  typhoidin 
skin  reaction  and  the  results  of  bactericidal  tests  in  vitro.  Likewise  no  definite 
relation  was  observed  between  the  presence  of  agglutinins  and  complement-fixing 
antibodies  and  the  skin  reactions. 

A  similar  study  in  syphilis  by  Broadwell  and  the  author  (73)  has  shown  that  in  hiunan 
syphilis  spirocheticidal  antibodies  for  culture  pallida  are  practically  absent  from  the 


FUBUO  mULXH  JOm  lODIOIKS.  299 

aefa  of  tihoae  penons  who  do  and  who  do  not  react  to  the  intiacutaneous  injection  of 
luetin.  likewiae  no  constmnt  relationihip  was  found  between  the  occurrence  of 
cutaneous  hypen«uitiyaieflB  to  luetin  and  the  presence  of  agglutinins  for  culture 
of  pallida  ard  ol  a  complement-ixing  antibody  with  an  antigen  of  luetin. 

Similar  studies  in  diphtheria  by  the  author  (74)  likewise  showed  an  absence  of 
any  relatJonship  betweoi  cutaneous  hypersensitiveneeB  to  a  pcdyvalent  and  detozised 
emulfdon  of  diphtiieria  bacilli  or  diphtherin  (76)  and  the  presence  of  such  antibodies 
as  antitoxin,  agglutinin,  bacteriolyan,  and  complement-fixing  substances  for  diph- 
theria bacilli. 

Additional  studies  by  HarloBS,  Matsunami,  and  the  author  (76)  along  the  same 
lines  in  canine  distemper  have  shown  that  the  sera  of  dogs  reacting  positively  to  the 
intracutaneous  injection  of  a  polyvalent  emulsion  of  B.  bronchisepticus  (77)  do  not 
show  the  presence  of  agglutinins,  bacteriolysinB,  and  complement-fixing  antibodies  for 
this  bacillus  in  any  constant  relaticmship  to  the  skin  reactions. 

In  a  strict  sense  the  question  whether  or  not  an  anaphylactic  skin  reaction  may  be 
taken  as  an  index  of  defensive  activity  can  only  be  answered  on  the  basis  of  actual 
protective  experiments.  Time  alone  will  tell  whether  or  not  the  person  presenting  a 
positive  reaction  to  typhoidin  is  actuaUy  immune  to  typhoid  fever  as  claimed  by  Gay 
and  his  associates.  Experiments  among  rabbits  with  cultures  of  spirocheta  jwdlida 
by  Npguchi  (78)  consisting  in  the  immunisation  of  the  animals  until  they  reacted 
to  the  intracutaneous  injection  of  luetin  followed  by  an  actual  test  of  their  immunity 
to  living  virulent  spirochetes  by  inoculating  the  testicle  have  given  Dr.  Noguchi  the 
impression  that  the  immunization  reduced  susc^tibility  in  some  rabbits  while  it 
had  no  effect  whatsoever  in  others  and  indeed  seemed  to  render  some  more  susceptible. 
Furthermore,  it  is  highly  probable  that  the  syphiUtic  is  open  to  reinfection  with 
spirocheta  pallida;  certainly  our  experiments  failed  to  show  the  least  evidence  of 
spiiocheticidal  antibodies  in  the  sera  of  tertiary  sylphilitics  reacting  positively  or 
negatively  to  the  intracutaneous  injection  of  luetin,  and  it  is  highly  probable  that  the 
luetin  reaction  does  not  indicate  resistance  to  reinfection  cm  the  "lighting  up''  of  a 
present  infection. 

Fortbermore,  I  have  seen  three  persons  presenting  perfectly  typical  reactions  to 
diphtberin  contact  diphtheria  and  dogs  which  have  reacted  to  bronchisepticin  have 
contracted  canine  distonper. 

The  sum  total  of  these  s^idies  indicate  that  while  antibodies  which  may  be  regarded 
as  possessing  protective  and  curative  properties  toward  a  certain  protein  may  be 
jHresent  in  the  body  fluids  of  persons  and  animals  hypersensitive  to  this  particular 
protein,  the  conditicm  of  hypersensitiveness  in  itself  is  no  direct  evidence  of  their 
pieeence  or  of  resistance  to  a  particular  infection,  although  these  antibodies  are  most 
likely  to  be  present  in  the  body  fluids  of  those  persons  who  are  hypersensitive.  The 
poative  anaphylactic  skin  test  is  therefore  evidence  of  infection  or  sensitization  to  a 
particular  protein  without  bearing  any  direct  relation  to  resistance  to  infection  or 
reinfection. 

The  clinical  significance  and  practical  value  of  skin  reactions  are  laigely  of  a  diag- 
nostic nature  for  the  detecticm  of  hypersensitiveness  to  a  protein  or  proteins  which 
may  when  introduced  into  the  organism  produce  various  acute  or  chronic  lesions  and 
symptoms  of  disease. 

CLINICAL   8IQNIFICANCB    OF  THE   PSBUDO    OR   NONSPECIFIC   PROTEIN   AND   TRAUMATIC 

SKIN  REACTIONS. 

At  the  present  time  the  chief  clinical  significance  of  the  pseudo  anaphylactic  and 
traumatic  skin  reactions  is  the  likelihood  of  mistaking  them  far  true  anaphylactic 
reactions. 

The  Schick  toxin  test  for  immunity  in  dii^theiia  is  regarded  at  present  as  due 
to  the  direct  irritant  action  of  diphtheria  toxin  upon  cells  at  the  site  of  injection;  if 


300       PROGEEDIKGS  SECOND  PAN  AMEBIOAN  SOIBNTIFIO  OONGBESS. 

antitoxin  is  present  in  sufficient  amount  the  toxin  is  neutralized  and  the  inflammatory 
reaction  does  not  occur.  Trauma  alone,  the  preservative,  the  interaction  between 
protein  constituents  of  the  broth  and  nonspecific  ferments  or  between  the  protein 
of  autolyzed  diphtheria  bacilli  and  specific  ferments,  may  induce  a  pseudo  reaction 
which  may  be  mistaken  for  the  true  reaction. 

It  is  probable  that  certain  conditions  accompanied  by  an  increase  of  cells  and  their 
destruction  as  in  cancer  and  pregnancy  may  result  in  the  temporary  increase  of  non- 
specific proteolytic  ferments  in  body  fluids  and  cells  and  increase  the  tend^icy  for  the 
production  of  pseudo  reactions  in  the  skin;  as  previously  stated  there  is  also  reason 
to  believe  that  certain  diseases  accompanied  by  skin  manifestaticms  as  scarlet  fever 
and  other  exanthemata,  increase  the  tendency  to  skin  reactions. 

SUMMART. 

1.  Skin  reactions  may  be  (1)  true  or  specific  anaphylactic  reactions;  (2)  pseudo  or 
nonspecific  protein  reactions,  and  (3)  traumatic  reactions. 

2.  A  nonspecific  or  traumatic  skin  reaction  may  occur  coinddently  with,  or  be  mis- 
taken for,  a  true  anaphylactic  reaction. 

3.  Intracutaneous  skin  tests  are  more  delicate  than  cutaneous  tests,  but  also  more 
likely  to  yield  the  nonspecific  and  traumatic  reactions. 

4.  The  traumatic  and  nonspecific  protein  skin  reactions  may  be  caused  (1)  by 
trauma  and  the  direct  injection  of  an  irritant  used  as  a  preservative  for  the  material, 
as  phenol,  or,  to  a  performed  toxic  and  irritant  substance,  as  diphtheria  toxin  in  the 
Schick  test;  (2)  to  the  production  of  a  protein  poison  of  irritant  qualities  by  the  action 
of  nonspecific  proteolytic  ferments  in  the  serum  or  derived  from  injured  cells,  upon 
the  protein  of  the  patient's  serum,  devitalized  cells,  injected  protein,  or  all  three. 

5.  The  true  anaphylactic  skin  reaction,  however,  is  a  specific  process  due  to  the 
interaction  of  specific  anaphylactic  antibody  and  specific  anaphylactogen,  largely 
within  or  upon  the  cells  and  with  the  formation  of  a  diffusible  irritant  similar  to  that 
produced  in  the  nonspecific  reaction,  capable  of  producing  acute  hyperemia,  edema, 
and  leucocytic  infiltration  of  the  skin. 

6.  Certain  drugs  as  potassium  iodide  and  potassium  bromide  increase  the  non- 
specific reaction  by  facilitating  the  activity  of  nonspecific  proteolytic  ferments  and  the 
production  of  protein  poison,  through  the  removal  of  antiferment;  these  drugs  probably 
have  no  direct  influence  upon  the  specific  anaphylactic  reaction. 

7.  The  specific  anaphylactic  skin  reaction  is  acceptable  as  a  delicate  index  of  hyper- 
sensitiveness  to  a  certain  foreign  protein  or  proteins,  the  enteral  or  parenteral  adminis- 
tration of  which  may  be  expressed  by  various  lesions  and  symptoms  of  disease. 

8.  The  severity  of  a  true  anathylactic  skin  reaction  appears  to  be  an  index  of  the 
degree  of  hypersensitiveness. 

9.  A  state  of  cutaneous  anaphylaxis  to  a  particular  bacterial  protein  is  not  of  itself 
an  index  of  resistance  or  immunity  to  the  living  microparaaite,  although  immunity 
principles  may  be  coincidently  present  with  the  anaphylactic  antibody. 

10.  At  present  the  main  clinical  significance  of  the  nonspecific  protein  skin  reaction 
is  the  likelihood  of  mistaking  it  for  a  true  anaphylactic  reaction. 

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Med.,  Chic,  1909,  3,  350-359. 

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72.  Kolmer  (J.  A.)  and  B^rge  (J.  H.).    The  relation  of  the  typhoidin  skin  reaction 

to  immunity  in  typhoid  fever.    Jour.  Immunology,  1916,  1,  409-428. 
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syphilis.    Jour.  Immunology,  1916,  i,  429-442. 

74.  Kolmer  (J.  A.).     The  relation  of  the  diphtherin  skin  reaction  to  immunity  in 

diphtheria.    Joiir.  Immunology,  1916, 1,  443-456. 

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304       PBOGBEDINGS  SECOND  PAK  AMEBICAN  SCIENTIFIC  CONGRESS. 

76.  Eolmer  (J.  A.),  Matsunami  (T.),  and  HftrkinB  (M.  J.).    The  relation  of  the 

bronchisepticin  skin  reaction  to  immunity  in  Canine  distemper,  including  the 
bactericidal  action  of  dog  serum  for  B.  bronchisepticus.  Jour.  Immunology, 
Balto.,  1916,  i,  571-686. 

77.  Eolmer  (J.  A.),  Harkinfl  (M.  J.),  and  Reichel  (J.).    A  cutaneous  reaction  isk 

canine  distemper.    Jour.  Immunology,  Balto.,  1916, 1,  601-611. 

78.  Noguchi  (H.).    Personal  communication. 

The  Chairman.  The  next  paper  is  by  Dr.  G.  H.  A.  Clowes  on  "The 
relation  of  hay  fever  to  anaphylaxis." 


THE  RELATION  OF  HAY  FEVER  TO  ANAPHYLAXIS,  TOGETHER  WITH 
A  THEORY  REGARDING  THE  NATURE  OF  ANAPHYLACTIC  PHE- 
NOMENA. 

By  G.  H.  A.  CLOWES, 

Biological'Chemical  Department  of  the  State  Institute  for  the  Study  of  Malignant  Disease , 

Buffalo,  N.   Y. 

Following  a  method  somewhat  analogous  to  that  adopted  by  Noon  and  Freeman  in 
the  treatment  of  the  European  form  of  hay  fever,  a  s&ciee  of  experiments  has  been 
carried  out  in  the  course  of  the  last  four  years  on  the  treatment  of  the  American  or 
autumnal  form  of  hay  fever  by  vaccination  with  the  extracts  of  plant  pollens.  The 
pollens  employed  for  this  purpose  were  first  dehydrated  by  means  of  a  mixture  of 
acetone  and  ether  and  subsequently  extracted  with  water. '  This  method  is  vastly 
superior  to  the  freezing  and  tiiawing  method  previously  employed  by  Dunbar,  and 
Noon  and  Freeman,  owing  to  its  greater  simplicity  and  the  greater  durability  of  the 
product  obtained. 

Sufferers  from  either  the  spring  or  autumnal  variety  of  hay  fever  exhibit  a  sensitive- 
ness to  one  or  more  varieties  of  plant  pollens  when  tested  by  means  of  the  ophthalmic 
or  cutaneous  method.  In  the  most  highly  sensitized  cases  a  flush  may  be  produced 
in  the  eye  by  introducing  a  drop  of  a  solution  containing  I  part  in  500,000  of  the  soluble 
constituents  of  the  pollen  to  which  the  individual  is  sensitive.  Group  reactions  are 
frequently  obtained;  for  example,  an  individual  sensitive  to  1  part  in  500,000  of 
ragweed  may  exhibit  a  sensitiveness  to  1  in  50,000  of  golden  rod  ox  other  members  of 
the  Compositse  family.  Similarly  an  individual  sensitive  to  1  in  500,000  of  timothy 
may  exhibit  a  less  marked  but  definite  sensitiveness  to  some  other  member  of, the 
Graminacese  family,  but  only  those  unfortunate  individuals  who  suffer  from  both  the 
spring  and  autumnal  varities  of  hay  fever  will  exhibit  a  sensitiveness  to  pollens  of 
plants  belonging  to  both  the  families  in  question. 

A  marked  alleviation  of  symptoms  and  reduction  in  senaitiveneeB  may  be  effected 
by  injecting  dilute  extracts  of  the  pollens  to  which  the  individual  is  sensitive,  at 
intervals  of  three  or  foiur  days,  starting  with  doses  as  small  as  I  cc.  of  1  in  5,000,000  and 
gradually  increasing  the  dose  until  a  maximum  dose  of  1  cc.  of  1  in  5,000  to  10,000  is 
attained.  If  the  treatment  is  suspended,  sensitiveness  develops  once  more,  and  in 
the  course  of  a  few  months  will  be  almost  equal  to  that  preceding  treatment,  but  it 
has  been  found  that  in  each  successive  season  of  treatment  the  symptoms  of  the  disease 
become  less  marked,  from  which  it  may  be  hoped  that  complete  cure  may  ultimately 
be  effected. 


I  Clowes,  A  preliminary  communication  on  certain  specific  reactions  exhibited  by  hay  Cever  cases,  i'roc. 
Society  (or  Bzperimental  Bicdogy  and  Medidne,  1018,  pp.  60-72. 

Clowes,  A  preliminary  commnnication  on  the  treatment  of  aotmnnal  bay  fever  by  vaooinatioo  with  an 
•qneoos  extract  of  the  poUen  of  ragweed.    Ibid. 


PUBLIO  HEALTH  AND  MEDICIKE.  305 

The  condition  is  certainly  not  strictly  analogous  to  anaphylaxis,  as  it  is  impossible 
to  secure  complete  relief  of  symptoms  by  the  use  of  a  single  deeensitiadng  dose.  The 
occurrence  of  a  cutaneous  reaction  at  any  point  in  the  body,  as  well  as  the  occasional 
occurrence  of  complement  deviation  in  the  blood,  indicates  that  the  reaction  is  sys- 
temic and  not  confined  purely  to  the  mucous  membranes.  All  attempts  to  induce 
hay-fever  symptoms  in  normal  individuals  by  introducing  into  their  eyes  pollen 
extracts  which  have  previously  been  incubated  with  the  serum  of  individuals  sensi- 
tive to  the  pollen  in  question  have  failed  of  result.  From  this  and  other  experiments 
to  be  reported  later  tibie  phenomena  exhibited  in  hay  fever,  asthma,  etc.,  appear  to 
support  the  conclusion  ^at  sensitization  phenomena  are  rather  attributable  to  dis- 
turbances in  the  colloidal  equilibrium  of  certain  constituents  of  the  cell  than  to  the 
production  of  split  products  as  a  result  of  peptization  of  antigen. 

That  the  immune  phenomena  developed  are  specific  was  demonstrated  by  immunis- 
ing certain  individuals  sensitive  to  two  widely  differing  pollens  against  one  only  of 
the  varieties  in  question.  A  reduction  in  sensitiveness  to  this  particular  variety  was 
noted,  accompanied  by  a  retention  of  the  fuU  measure  of  sensitiveness  to  the  pollen 
against  which  no  immunization  was  employed.  Within  a  single  group  of  closely 
related  plants,  immunization  by  means  of  one  member  of  the  group  will  confer  a  meas- 
ure of  immunity  against  other  members  of  the  same  group,  although  pos^bly  to  a  less 
marked  extent  than  is  obtained  against  the  pollen  of  the  plant  specifically  employed. 
A  nonspecific  immunization  or,  rather,  reduction  in  sensitiveness  may  be  effected  in 
certain  cases  by  administering  large  doses  of  calcium  salts.  It  is  worthy  of  note  that 
well-nourished  individuals  appear  to  respond  more  readily  to  treatment  with  calcium 
salts.  A  marked  variation  in  the  results  attained  from  vaccination  has  been  noted  in 
upward  of  100  cases  submitted  to  experiment.  In  25  per  cent  of  cases,  especially 
those  which  have  been  treated  for  several  years,  almost  complete  alleviation  of  symp- 
toms has  been  attained  by  means  of  repeated  vaccination.  In  a  further  40  per  cent  to 
50  per  cent  of  cases  a  partial  alleviation  of  symptoms  has  been  effected .  In  the  remain- 
ing cases  practically  no  results  have  been  obtained.  But  it  appears  probable  that  in 
spite  of  the  large  variety  of  pollens  employed  ihoee  cases  in  which  no  results  have 
been  obtained  owe  their  symptoms  to  causes  other  than  those  which  have  thus  far 
been  investigated.  Support  is  lent  to  this  point  of  view  from  the  observation  that 
those  showing  the  most  marked  sensitiveness  to  a  given  variety  of  poUen  are  most 
readily  treated.  Sensitization  to  a  certain  variety  of  flies  has  been  successfully 
treated  by  vaccination  with  the  soluble  extracts  of  the  flies  in  question.  An  inves- 
tigation of  the  sensitization  phenomena  of  plants,  animals,  and  a  variety  of  foreign 
proteids  indicates  that  the  condition  occurs  far  more  frequently  than  is  generally 
appreciated,  and  is  responsible  not  only  for  hay  fever  and  asthmatic  symptoms,  but 
also  for  certain  gastro-intestinal  and  other  disturbances  not  at  present  understood. 

Susceptibility  to  the  development  of  sensitization  phenomena  appears  to  be  an 
inherited  characteristic.  In  a  large  number  of  families,  data  regarding  which  has 
been  obtained  over  a  period  of  several  generations,  the  occurrence  of  one  or  another 
form  of  sensitization  follows  Mendelian  Unes  and  suggests  the  advisability  of  further 
study  in  this  direction.  If  sensitization  is  attributable  to  the  passage  of  colloidal 
aggregates  through  the  mucous  membrane  in  a  sufficient  state  of  aggregation  to  induce 
immune  reactions,  it  is  obvious  that  the  transmitted  characteristic  in  question  may 
be  simply  abnormally  low  or  impaired  resistance  or  lack  of  impermeability  of  the 
protoplasmic  membrane. 

In  conclusion  it  is  necessary  to  sound  a  note  of  warning  against  promiscuous  experi- 
mentation with  these  extremely  powerful  pollen  toxins.  The  administration  of  an 
overdose  may  readily  produce  serious  anaphylactic  symptoms,  and  the  employment 
of  mixed  vaccines  containing  not  only  the  pollens  to  which  the  individual  is  sensitive 
but  other  pollens  of  the  same  or  related  families,  is  obviously  to  be  deprecated.  The 
results  obtained  by  treatment  with  calcium  lactate  suggest  the  possibility  that  ulti- 


806       PROOEEDIKQS  SEOONB  VAX  AMSBIOAK  BOIEJiTlJfiO  CM)K0BB88. 

mately  some  better  procedure  than  that  of  yaccination  may  be  developed  for  coun* 
teracting  the  tendency  to  various  fonns  of  protein  sensitization,  which  under  the  con* 
ditions  of  modem  civilization  appear  to  be  increasing. 

Turning  now  to  the  question  of  the  nature  of  anaphylaxis.  Three  yean  ago  the 
writer  demonstrated  that  the  antagonistic  effects  exerted  by  electrolytes  in  biological 
systems  could  be  closely  paralleled  in  purely  physical  systems  and  are  dei)endent 
upon  the  relative  capacity  possessed  by  individual  electrol3rtes  or  their  component 
ions  to  promote  or  inhibit  the  dispersion  of  soap  films  in  water  as  compared  with  an 
adjacent  lipoid  or  fatty  phase,  or  of  other  concentration  films  formed  between  protein 
and  water  phases,  in  water  as  compared  with  the  protein  phase.  If  a  given  volume  of  an 
aqueous  solution  of  sodium  oleate  or  caustic  soda  is  allowed  to  flow  from  a  capillary 
pipette  through  oil  containing  a  certain  amount  of  fatty  acid,  the  number  of  drops  pro- 
duced will  depend  upon  the  strength  of  the  solution  of  soap  or  caustic  soda  employed. 
The  greater  the  concentration  the  larger  the  number  of  drops;  the  greater  the  dilution 
the  smaller  the  number  of  drops.  If  NaCl  is  added  to  a  system  of  this  sort,  the  number 
of  drops  will  be  greatly  increased.  If  OaCl,  is  added  the  number  of  drops  will  be  re- 
duced. NaCl  and  CaCl),  when  employed  in  those  ratios  in  which  they  exert  a  com- 
pensatory or  balancing  effect  upon  one  another  in  nature,  exert  no  effect  upon  the 
number  of  drops  produced  in  such  a  system.  These  results  are  attributable  to  the 
fact  that  a  surface  film  of  soap  is  formed  at  all  points  of  contact  between  water  and  oil. 
Alkalies  and  salts  of  the  monovalent  cations,  like  NaCl  and  KCl,  by  increasing  the 
dispersion  of  the  soap  film  in  water  as  compared  with  oil,  exert  a  destructive  effect 
on  the  film,  reducing  its  relative  resistance  to  the  passage  of  water  and  waternsoluble 
constituents,  consequently  causing  a  break  in  the  film  at  an  earlier  point  than  in  the 
system,  with  a  consequent  production  of  a  larger  number  of  drops.  Acids,  salts  of 
calcium,  barium,  strontium,  iron,  and  other  divalent  and  trivalent  cations  exert  on  the 
other  hand  a  protective  effect,  decreasing  the  relative  dispersion  of  the  constituents 
of  the  film  in  water  as  compared  with  oil,  thus  promoting  the  continuity  of  the  film, 
increasing  its  resistance  to  the  passage  of  water  and  water-soluble  constituents  with  a 
consequent  diminution  in  the  number  of  drops. 

Protoplasm  may  be  conceived  as  a  system  in  which  in  the  interior  fats,  lipoids, 
proteins,  etc.,  are  dispersed  by  means  of  concentration  films  of  soaps  and  other  sub- 
stances in  water  as  an  external  phase,  but  that  naked  protoplasm,  mhen  coming  in 
contact  with  water  containing  a  variety  of  salts,  tends  to  andergo  a  transformation 
with  the  formation  of  a  film  or  membrane  which  consists  essentially  of  a  dispersion  of 
water  in  oil,  water  in  lipoid,  or  water  in  concentiuted  protein,  a  type  of  a  jelly,  or 
more  probably  a  stage  intermediate  between  those  physical  systems  in  which  water 
is  the  diBpersed  and  the  continuous  phase.  The  extreme  outer  layer  consists,  pre- 
sumably, at  least  in  part,  of  a  mixture  of  soaps,  and  according  to  whether  the  soaps 
in  question  are  more  readily  dispersed  in  water  than  in  oil,  lipoid,  protein,  etc.,  the 
film  is  more  or  less  permeable  to  the  passage  of  water  and  water  soluble  substances, 
and  more  or  less  readily  dispersed  or  broken  up  and  removed  by  the  constituents  of 
the  external  water  phase. 

Salts  of  calcium  function  invariably  as  protective  agents  for  the  fflms  in  question, 
preventing  their  dispersion  or  disintegration  by  substances  present  in  the  environing 
aqueous  medium  and  interfering  with  a  too  great  permeability  of  the  protoplasm  or 
protoplasmic  film  which,  if  carried  beyond  a  certain  point,  would  necessarily  cause 
the  destruction  of  the  protoplasmic  system. 

The  salts  of  calcium  have  been  extensively  employed  by  Wright  and  others  to 
counteract  sensitization  and  anaphylactic  phenomena,  fot  example,  in  counteracting 
oedema,  urticaria,  herpes,  etc.,  induced  as  a  result  of  sensitization  to  foreign  proteins 
and  against  hay  fever,  asthma  and  other  sensitization  phenomena  as  in  our  experi- 
ments. In  this  and  numerous  other  cases,  calcium  appears  to  function  by  protectmg 
the  surface  film  and  preventing  a  too  free  passage  of  water  and  water  soluble  constitit- 


PUBLIC  HEALTH  AND  MEDIOIKE.  307 

J],  r        eskta.    In  the  opimon  of  the  writer,  not  only  protoplaon  but  all  colloidal  aggregates 

fi.  peeaent  in  the  blood  or  body  fluida  are  surrounded  by  stabilizing  films,  consisting  at 

least  in  part  of  a  mixture  of  soaps,  vhich  play  the  same  role  in  maintAinIng  the  equili^ 

^f  bniun  of  the  protoplasm  system  and  preventing  the  precipitation  of  proteins,  lipoids, 

i]  etc.,  by  salts,  as  is  played  by  the  stabilisdng  soap  films  in  emulsions  in  preventing 

^  I  the  aggregation  of  individual  globules  of  oil  wil^  one  another. 

t  '  Soaps  exhibit  an  antitryptic  reaction  vhen  present  in  the  serum.    Their  removal 

,  from  the  serum  by  means  of  extraction  with  organic  agents  caoses  a  reduction  in  the 

antitrjrptic  index.    It  has  been  demonstrated  by  Bronfenbrenner  and  others  that 

homologous  serum  extracted  by  means  of  oiganic  agents  is  toxic  for  animals  of  the 

same  species,  and  the  suggestion  has  been  put  forward  that  the  anaphylactic  reaction 

is  attributable  to  effects  brought  about  by  homologous  proteins.    In  the  opinion  of 

the  writer,  the  effects  in  question  are  attributable  to  the  removal  of  stabilising  films 

of  soaps  or  other  lipoid  disintegration  products  which  are  soluble  in  oiganic  agents 

and  the  consequently  more  ready  colloidal  aggregation  or  precipitation  of  proteins 

and  other  colloids  by  electrolytes  and  other  substances  nonnally  present  in  the 

system. 

The  writer  has  already  demonstrated,  in  experiments  which  will  be  published 
shortly,  that  the  antigen  antibody  combination  in  the  presence  of  complement  may 
fonction  as  a  dispersing  agent  for  fatty  or  soap  films  in  colloidal  systems  of  the  tjrpe 
described  above,  and  in  others  not  yet  described,  from  which  it  may  be  concluded 
that  an  anaphylactic  shock  represents  a  sudden  and  violent  removal  or  partial  destruc- 
ti^  of  certain  protective  colloidal  films,  thus  causing  a  more  free  ingress  of  water 
and  water  soluble  constituents  to  the  interior  protoplasmic  constituents  of  the  cell, 
with  consequent  destruction  of  the  working  mechanism  of  the  cell.  Effects  of  this 
t3rpe  would  obviously  be  produced,  but  with  varying  intensity,  at  different  points 
in  the  body,  and  not  only  the  cells  but  also  proteins  and  other  substances  dispersed 
in  the  blood  and  other  body  fluids  would  be  correspondingly  affected. 

The  protective  effect  exerted  by  salts  of  calcium  in  physical  and  biological  systems 
and  also  in  animalw  and  human  beings  exhibiting  phenomena  attributable  to 
sensitization  and  anaphylaxis,  is  a  strong  argument  in  support  of  this  point  of 
view,  and  in  a  series  of  experiments  published  three  years  ago,  the  writer  was  able 
to  demonstrate  that  the  influence  exerted  by  certain  mixtures  of  powerfidly  absorbed 
divalent  and  trivalent  cations  with  suitable  anions  exhibited  exactly  analogous  curves 
in  a  comparison  of  effects  produced  on  living  mice,  hemolysis  of  corpuscles  by  means 
of  complement  and  amboceptor,  the  state  of  diBperaion  of  colloidal  systems  in  water, 
I  blood  coagulation,  and  equilibrium  of  purely  physical  systems  of  the  type  described 

I  above.    Since  the  hemolysis  of  corpuscles  by  means  of  complement  and  amboceptor 

serves  in  a  sense  as  a  model  of  the  phenomena  presumed  to  occur  in  anaphylaxis,  and 
since  this  reaction  is  influenced  by  variations  in  the  proportions  of  powerfully  ab- 
sorbed x>ositive  and  negative  ions  in  a  manner  very  closely  resembling  the  influence 
exerted  upon  purely  physical  colloidal  systems  and  since  the  i^nimnlw  killed  by  intn^ 
venous  injection  of  the  salts  in  question  exhibited  symptoms  resemUing  those  of 
anaphylaxis  it  would  api>ear  probable  that  the  phenomenon  in  question  is  attributable 
to  variations  in  the  state  of  colloidal  aggregation  of  normal  constituents  of  the  body, 
under  the  influence  of  agents  capable  of  producing  sudden  and  violent  dispersiiig 
effects.  In  advancing  the  theory  that  sensitization  and  anaphylactic  i^ienomena 
are  due  to  a  sudden  and  violent  increased  dispersion  of  the  external  colloidal  film  of 
ptotoplasm  and  of  the  protective  films  of  other  colloidal  aggregates  in  the  body,  and 
that  the  specific  and  nonspecific  procedures  emjdoyed  to  counteract  these  ^ects 
function  by  diminishing  the  intensity  of  the  dispersion  in  question,  and  promoting 
aggregation  of  the  films,  we  do  not  deny  the  possibility  that  side  by  side  with  the 
reaction  in  question  and  the  exposure  of  naked  protein  to  the  influence  of  aggregating 
and  subsequently  of  dispersing  agents  that  a  variety  of  disintegmtioii  products  majr 

68486— 17— VOL  X 21 


308       PBOCEEDINGS  SECOND  PAN  AMBBIOAN  SCIENTIFIC  CONQBESS. 

well  make  their  appearance  in  the  serum,  but  we  are  inclined  to  believe  that  the 
primary  effect  in  anaphylaxis  and  the  one  that  causes  death  is  essentially  a  sudden 
disturbance  in  the  colloidal  equilibrium  of  the  protoplasmic  surface  film,  resulting 
in  too  great  permeability  of  the  protoplasm  and  a  consequent  irreversible  disturbance 
of  colloidal  equilibrium  of  the  protoplasmic  system. 

The  Chatkman.  Inasmuch  as  my  own  communication  is  next  on 
the  program,  I  will  ask  Dr.  Lung,  of  the  United  States  Navy,  to 
kindly  take  the  chair. 

The  Chairbcan  (Dr.  Lung  presiding).  Ladies  and  gentlemen.  Dr. 
Weil  has  already  been  presented  to  you  and  has  addressed  you.  He 
needs  no  further  introduction. 


anaphtlatoxin  and  the  mechanism  of  anaphylaxis. 

By  RICHARD  WEIL, 
Cornell  Medical  College,  New  York  City. 

I  shall  attempt  to  give  simply  an  informal  discussion  of  the  subject  of  anaphylaxis 
as  I  see  it  I  have  not  prepared  an  elaborate  paper,  because  I  do  not  think  the 
points  which  have  been  brought  out  lend  themselves  to  a  set  discussion.  They  have 
been  approached  from  a  variety  of  standpoints,  and  I  think  that  it  is  necessary  to 
consider  these  various  standpoints  in  a  manner  which  I  should  not  have  been  able  to 
follow  had  I  prepared  my  paper  as  I  saw  the  subject  before  listening  to  these  papers. 

Dr.  Bronfenbrenner  alluded  to  the  fact  that  I  should  probably  have  the  difficult 
task  of  defending  the  cellular  theory.  I  think  that  this  statement  is  largely  true. 
I  shall  indeed  have  that  task,  and  with  it  goes  the  task  of  showing  that  the  anaphy- 
latoxins  have  nothing  to  do  with  anaphylaxis,  because  the  two  standpoints  are 
entirely  incompatible.  Why  it  is  that  those  two  different  problems  have  come  to  be 
associated  in  that  way,  I  will  show  show  you  in  a  minute;  but  the  fact  is  that  they 
are  intimately  associated. 

As  regards  the  attitudes  of  the  scientific  world  on  the  subject  of  anaphylaxis,  I 
think  you  have  probably  gathered  that  it  is  not  entirely  harmonious,  but  it  has  taken 
a  peculiar  course  in  the  United  States.  At  the  present  time  there  is  a  tendency  to 
accept  the  anaphylatoxin  theory  witliout  question,  owing  laigely  to  Jobling  and 
others  who  have  done  so  much  work  on  anaphylaxis;  and  then,  too,  one  must  realize 
that  the  anaphylatoxin  explanation  of  anaphylaxis  is  very  enticing.  It  gives  us  a  sim- 
ile explanation  for  the  phenomenon.  A  chemical  toxin  is  said  to  be  produced,  and  we 
are  acquainted  with  the  action  of  chemical  toxins.  We  know  that  strychnin  causes  con- 
vulsions; well,  then,  in  anaphylaxis  they  tell  us  a  toxic  substance  is  produced  which 
acts  in  a  similar  way  on  the  cells  and  gives  rise  to  the  symptoms.  It  is  also  enticing 
from  the  foct  that  it  gives  us  a  uniform  explanation  in  that,  according  to  Vaughan^ 
the  same  toxic  substances  are  always  produced  when  antigen  and  antibody  come 
together  in  the  body,  and  therefore  we  always  get  the  same  exhibition  of  anaphylaxis. 

This  theory,  however,  is  not  universally  held.  For  instance,  Doerr  takes  exactly 
the  opposite  standpoint.  Contrary  to  his  previous  view,  inasmuch  as  he  originally 
was  a  believer  in  Friedberger's  theory  that  the  reaction  was  humoral  and  that  ana- 
phylatoxin played  a  r61e,  he  has  practically  concluded  in  his  last  review  to  accept 
the  cellular  theory  and  at  the  same  time  he  maintains  that  anaphylatoxin  plays  no 
r61e  in  anaphylaxis.  Then  there  is  Dale,  in  England,  who  holds  the  same  theory, 
and  Bayliss  in  his  recent  work  on  physiology,  which  I  Imagine  is  familiar  to  you  aU, 
uncompromisingly  accepts  this  explanation.    So,  while  this  is  a  question  of  very 


PUBLIO  HEALTH  AND  MBDIOINE.  309 

great  importance  for  the  general  interpretation  of  the  whole  subject  of  immunity,  and 
for  the  understanding  of  infectious  diseases,  it  is  one  which  at  the  present  time  has 
unfortunately  not  been  entirely  cleared  up. 

To  give  a  brief  view  oj  the  situation  and  to  simplify  it  if  possible,  the  following 
focts  should  be  considered.  The  data  of  anaphylaxis  and  immunity,  upon  which 
we  all  work  no  matter  what  our  interpretation  is,  are  essentially  two.  We  all  agree 
that  antigen  and  antibody  are  the  factors  involved.  We  all  agree  that  antibody  is 
present  either  in  the  cells  of  the  body  or  in  the  blood  of  the  body,  or  in  both.  We 
are  all  agreed  that  it  is  the  interaction  of  these  two  factors  which  results  in  the  phe- 
ncMnena  of  anaphylaxis  and  of  immunity,  strikingly  different  as  are  the  manifestations 
involved — ^in  one  case  an  apparent  protection  against  toxic  substances  and  in  the 
other  case  an  apparent  susceptibility  to  nontoxic  substances. 

Now,  there  are  two  questions  that  have  been  discussed  to-day  by  Dr.  Bronfenbrenner, 
Dr.  Kolmer,  Dr.  Clowes,  and  myself,  and  they  are  the  same  questions  which  I  tried 
to  bring  out  in  my  initial  discussion.  The  two  questions  are  these:  What  is  the  site 
of  the  reaction  in  the  body,  and  what  is  the  immune  mechanism?  These  are  two 
separate  questions,  and  yet,  as  you  will  see  in  a  minute,  the  view  which  we  take  of  one 
almost  necessarily  postulates  the  view  which  we  shall  take  of  the  other. 

As  regards  the  site  of  the  reaction,  we  are  accustomed  to  distinguish  between  the 
humoral  theory  and  the  cellular  theory,  to  which  we  might  add  an  intermediate 
standpoint,  which  Dr.  Kolmer  advocates,  viz,  that  the  reaction  may  occur  in  either 
place. 

If  we  look  at  the  problem  purely  from  an  experimental  standpoint,  what  facta 
are  there  in  favor  of  the  humoral  theory,  and  what  facts  are  there  against  it?  As  far 
as  I  know,  there  is  only  one  experiment  which  supports  the  humoral  theory,  namely, 
the  following:  It  has  been  maintained  that  if  one  introduces  antigen  and  antibody 
into  opposite  jugulars  of  the  same  guinea  pig  or  of  the  same  rabbit,  simultaneously, 
one  gets  anaphylactic  shock.  Now,  that  experiment  is  crucial.  If  the  observation 
is  correct,  it  is  perfectly  clear  that  the  reaction  in  that  instance  is  humoral  simply 
because  no  time  is  given  for  the  cells  to  anchor  the  antibodies;  the  reagents  are 
simultaneously  introduced,  the  reaction  is  instantaneous  and  must  therefore  take 
place  in  the  blood  stream. 

If  one  comee  to  analyze  the  literature  on  the  subject,  however,  one  finds  that  none 
of  the  authors,  with  the  exception  of  Gurd,  has  been  able  to  state  that  this  experiment 
has  resulted  in  anaphylaxis  with  any  frequency.  In  the  great  majority  of  instances 
the  experiment  has  apparently  no  definite  result.  One  can  do  it  ad  libitum,  varying 
the  relations  as  one  pleases,  yet  in  the  great  majority  of  Instances  one  does  not  get 
the  shock.  This  I  showed  some  years  ago.  Gurd's  experiments,  however,  seem  to 
diow  that  it  occurs  in  a  greater  proportion  of  cases  than  we  had  thought;  he  himself 
maintains,  indeed,  that  it  can  be  produced  with  considerable  r^;ularity. 

Accepting  the  fact  that  simultaneous  injections  do  occasionaUy  produce  immediate 
death,  how  is  this  result  to  be  interpreted?  What  is  the  result  if  one  perfonns  a 
control  experiment — that  is  to  say,  if  one  uses  an  antigen  and  an  antibody  which  are 
not  at  all  related?  Take  the  serum  of  a  rabbit  immunized  to  egg  albumin  as  antibody, 
and  horse  serum  as  antigen,  and  inject  them  simultaneously  into  opposite  veins. 
Even  by  this  procedure  one  will  kill  the  animals  occasionally.  'There  Is  here  no 
relation  of  antigen  and  antibody,  since  you  can  not  passively  sensitize  an  animal  by 
means  of  a  previous  injection  of  antiegg  albumin  serum  and  then  intoxicate  with 
horse  serum.  Therefore  it  seems  clear  that  death  in  these  cases  is  not  an  immimo- 
logical  phenomenon  but  is  due  simply  to  the  simultaneous  intravenous  injection  of 
any  two  foreign  proteins.  Unfortunately  Gurd  and  none  of  the  others  who  have 
worked  at  this  phase  of  the  problem  had  ever  made  this  experiment,  obvious  as  is 
the  necessity  of  a  "control'** to  their  results.  So  that  the  one  positive  piece  of 
evidence  which  has  been  advanced  in  fotvor  of  the  humoral  theory  appears  to  be 


310       PROCEEDINGS  SECOND  PAN  AMBBICAN  SCIENTIFIC  CONGRESS. 

utterly  inadequate.  Now,  on  the  othOT  hand,  the  positive  evidence  in  favor  of  the 
cellular  theory  is  very  convincing,  and  all  critics  have  accepted  it,  so  that  it  requires 
only  a  superficial  review. 

If  we  take  the  uterus  of  a  guinea  pig  which  has  been  sensitized  either  actively  or 
passively  and  suspend  it  in  Locke's  or  Ringer's  solution,  it  will  trace  a  series  of 
rythmic  contractions.  If  we  then  add  a  minute  amount  of  antigen,  it  at  once 
executes  a  tremendous  contraction.  Here  we  have  no  participation  by  the  circula- 
tion. The  reaction  occurs  even  if  we  have  washed  out  the  vessel  before  taking  out 
the  uterus.  We  have  a  response  from  the  isolated  cells.  Friedberger  made  the 
objection  that  in  spite  of  the  washing  out  there  was  still  enough  antibody  in  the 
circumambient  lymphatic  fluid  to  produce  the  reaction,  but  I  was  able  to  show  that 
this  was  not  the  case.  Further  studies  have  demonstrated  the  fact  that  during  the 
latent  period  of  passive  sensitization  the  cells  anchor  the  antibody;  until  this  has 
been  done,  they  fail  to  respond  to  the  antigen.  The  time  has  come,  therefore,  to 
accept  the  cellular  theory  in  toto.  There  is  no  reason  to  accept  in  the  smallest  part 
the  humoral  theory  of  anaphylaxis.  The  only  argument  that  keeps  us  still  tied  to 
the  latter  theory  is  the  fact  that  the  men  who  believe  in  anaphylatoxin  somehow 
feel  themselves  bound  to  support  the  humoral  theory  in  order  to  sustain  the  teet-tube 
experiment.  Yet  this  ib  an  unwarranted  assumption.  The  cell  might  conceivably 
functionate  as  a  test  tube  in  which  antigen  reacting  with  antibody  might  produce 
the  same  sort  of  changes,  whether  they  be  chemical  or  physical,  as  are  ordinarily 
ascribed  to  the  production  of  the  so-called  anaphylatoxin  in  the  test  tube.  It  is 
therefore  an  illogical  non  sequitur  which  Friedberger  originally  committed,  and  which 
seems  to  have  gone  down  through  the  years,  that  influences  men  who  accept  the 
anaphylatoxin  theory  to  believe  that  they  are  thereby  committed  to  the  humoral 
theory. 

This  brings  us  to  the  second  question,  the  question  of  the  immune  mechanism. 
Now  the  immune  mechanism  has  been  described  briefly  in  the  talk  which  I  gave  at 
the  outset.  There  aie  practically  two  theories,  the  physical  theory  and  the  chemical 
theory.  Both  of  these  theories  accept  the  fact  that  anaphylaxis  is  the  result  of  the 
reaction  between  antigen  and  antibody.  They  differ,  however,  in  one  respect.  The 
chemical  theory  maintAins  that  there  is  an  intermediate  process  and  that  when  these 
two  substances  interact  a  chemical  substance  is  formed  which  actually  produces  the 
toxic  symptoms.  The  physical  theory  ignores  any  such  intermediate  step  and  main- 
tains that  simply  in  virtue  of  the  attack  of  antigen  upon  the  antibody  of  the  cell  that 
cell  is  stimulated  just  as  it  would  be  by  an  electric  shock  or  by  any  other  sudden 
physical  change.  These  theories  are  not  of  merely  scholastic  interest.  The  entire 
phUoeophy  of  immunity  is  involved  in  the  choice  between  them.  The  school  that 
accepts  the  anaphylotoxin  theory  believes  that  the  mechanism  of  anaphylaxis  and  of 
immunity  ia  essentially  the  same  and  that  anaphylaxis  and  immimity  are  practically 
identical  phenomena,  which  differ  only  in  degree.  Those  who  originally  advanced 
the  chemical  theory  explained  the  difference  in  the  following  manner:  They  said 
that  antibody  in  the  presence  of  antigen  acts  on  the  latter  as  a  proteolytic  ferment 
and  breaks  it  down.  If  there  is  relatively  little  antibody,  as  after  a  single  injectum, 
the  breaking  down  of  the  antigen  is  incomplete  and  slow  and  results  in  the  produc- 
tion of  the  higher  proteoses  which  aie  toxic  and  which  kill  the  animal;  this  is  anaphy- 
laxis. If,  however,  the  blood  is  rich  in  antibodies,  as  after  repeated  injections,  the 
Inreaking  down  of  the  foreign  proteins  is  rapid  and  goes  to  the  limit  with  the  produc- 
tion  of  amino  acids,  which  are  not  toxic;  and  this  is  immunity. 

Now  Dr.  Bronfenbrenner  has  altered  the  terms  of  this  explanation  somewhat.  H« 
says  that  the  breaking  down  of  the  animal's  own  protein  results  in  anaphylaxis  instead 
of  the  breaking  down  of  the  antigen;  but,  as  you  see,  the  same  chemical  process  is 
involved  in  this  theory. 


PUBLIO  HEALTH  AND  MEDICINE.  311 

The  physical  theory  is  as  different  from  this  as  it  can  possibly  be.  According  to  the 
j^yaical  theory  anaphylaxis  results  when  the  antigen  attacks  cells  containing  anti* 
body.  On  the  other  hand,  when  there  is  sufficient  antibody  in  the  serum  to  ward 
off  the  antigen  from  this  attack  on  the  cells  immimity  results.  Thus  the  process  of 
aaaphylaxis  and  of  immunity  are  fundamentally  opposed;  there  is  the  union  of  anti- 
body and  antigen  in  the  serum,  which  protects  the  cells  against  the  antigen;  when  the 
two  mute  in  the  cells,  however,  we  get  the  explosive  and  the  unfortimate  symptoms 
of  anaphylaxis.  So  you  see  our  whole  conception  of  immunity  is  materially  affected 
by  our  interpretation  of  the  mechanism  of  anaphylaxis. 

To  come  to  the  evidence  in  favor  of  anaphylatoxin  and  the  evidence  against  the 
action  of  anaphylatoxin  in  the  animal.  We  all  know,  and  we  are  all  willing  to  admit, 
that  we  can  jHroduce  substances  which  are  toxic  by  the  incubation  of  sera  under 
various  conditions  outside  the  body.  These  substances  are  often  classed  together 
under  the  name  '^  anaphylatoxin. '^  Historically  speaking,  this  substance  should  not 
be  called  anaphylatoxin.  The  phenomenon  was  originally  observed  by  Richet,  who 
called  the  substance  apotoxin.  As  you  know,  anaphylatoxin  has  been  produced  by 
the  incubation  of  serum  with  a  great  variety  of  substances. 

Now  the  question  is,  does  this  effect  of  incubating  serum  with  various  substancet 
outside  the  body  justify  us  in  believing  that  the  same  process  occurs  in  the  body.  As 
a  matter  of  fact  it  does  not.  Agar  incubated  with  serum  produces  a  toxin,  but  agar 
injected  into  the  circulation  is  harmless.  The  only  way  to  prove  that  the  processes 
are  similar  is  to  take  the  blood  of  an  animal  in  anaphylactic  shock  and  determine 
whether  it  contains  such  toxic  substances.  Such  experiments  have  been  reported  by 
Thiele  and  Embleton  with  positive  findings.  Personally  I  have  been  unable  to 
reproduce  their  results,  and  Doerr  in  his  latest  review  has  shown  that  their  experi- 
ments are  open  to  serious  criticism.  Thus  there  is  no  experimental  evidence  that  any 
such  substance  as  anaphylatoxin  is  produced  in  the  body.  There  is  in  fact  every 
reason  to  believe  the  reverse.  As  a  matter  of  fact,  the  anaphylatic  phenomenon  is 
strikingly  unlike  the  effect  of  a  toxin.  An  animal  goes  into  shock,  into  convulsions; 
but  if  it  recovers  within  10  minutes  it  may  be  eating  its  food  just  as  if  nothing  had 
happened.  It  acts  as  if  a  violent  shock  or  stimulus  had  been  received,  not  as  if  poison 
were  circidating  in  its  blood.  It  is  the  same  with  the  experiment  of  the  suspended 
uterus.  You  can  get  it  to  contract  violently  by  adding  antigen  and  get  it  to  relax  by 
simply  p>iftn£ring  the  fluid;  and  at  the  end  of  such  a  series  of  anaphylactic  responses 
the  uterus  seems  as  normal  as  ever. 

There  are,  however,  additional  insuperable  objections  to  the  analogy  between 
anaphylaxis  in  vivo  and  the  production  of  anaphylatoxin  in  vitro.  In  the  first 
place,  there  is  the  matter  of  specificity.  We  know  that  anaphylaxis  is  a  specific 
phenomenon.  It  is  just  as  specific,  or  almost  as  much  so,  as  the  precipitation  or  the 
agglutination  reactions;  the  anaphylatoxic  substances  on  the  contrary,  can  be  pro- 
duced imder  the  most  varied  circumstances.  Incubation  of  serum  with  the  most 
diverse  substances  is  equally  effective  in  this  regard.  Then,  there  are  various  other 
conditions,  which  I  have  already  briefly  sketched,  when  anaphylatoxin  is  produced 
by  incubation.  The  process  requires  relatively  considerable  periods  of  time,  and 
the  proportions  of  antigen  and  antiboby  can  be  varied  only  within  narrow  limits. 
Now,  the  striking  thing  about  anaphylaxis  is  that  the  reactipn  does  not  require  time. 
In  the  living  animal  the  minute  the  injection  is  made  into  the  jugular  the  animal 
goes  into  convulsions.  As  Dale  has  shown,  in  the  uterus  the  reaction  also  is  imme- 
diate. Again,  as  regards  proportions  of  the  two  factors,  conditions  in  the  animal 
are  quite  different.  If  an  animal  is  passively  sensitized  against  horse  serum  by  an 
injection,  let  us  say,  0.1  cc.  of  rabbit,  immune  serum  can  be  killed  with  1  cc.  or 
0.01  cc.  or  0.001  cc.  of  horse  serum.  In  these  particulars,  therefore,  the  production  of 
anaphylatoxin  in  the  test  tube  has  no  resemblance  to  the  vital  reaction. 


312       PB0CEEDIN08  SECOND  PAN  AMERICAN  SCIENTIFIC  CONGRESS. 

Either  upon  the  cellular  or  the  humoral  theory,  then,  the  anaphylatozin  theory 
is  entirely  inadequate.  It  fails  to  satisfy  any  of  the  demands  of  the  problem.  There 
ia,  of  course,  no  question  that  anaphylatoxin  is  produced  in  vitro;  but  we  should  not 
blind  ourselves  to  the  fact  that  this  has  nothing  to  do  with  the  interpretation  of  ana- 
phylaxis. Such  a  conclusion  does  not  necessarily  detract  from  the  interest  or  tbe 
importance  of  the  work  that  has  been  done  on  anaphylatoxin,  but  it  does  suggeit 
the  idea  that  some  other  term  should  be  used  in  describing  these  toxic  products. 
Perhaps  the  term  originally  suggested  by  Richet,  ''apotoxin/'  is  as  good  as  could 
be  devised. 

As  bearing  upon  thb  problem  of  the  relationship  of  anaphylatoxin,  I  hope  that  you 
will  permit  me  to  describe  certain  new  experiments  which  are  designed  to  answer 
questions  in  the  mechanism  of  anaphylactic  shock.  In  the  first  place,  what  is  the 
antibody  concerned  in  anaphylaxis?  Originally  Friedbeiger  and  Doerr  maintained 
that  it  was  precipitin,  and  they  showed  that,  as  a  rale,  the  curve  of  predpitating 
antibodies  in  the  serum  runs  a  course  parallel  with  the  sensitizing  value  of  the  same. 
It  has,  however,  been  shown  that  this  parallelism  does  not  hold  in  active  anaphylaxis; 
that  guinea  pigs  might  be  highly  anaphylactic  and  still  have  no  precipitin  in  their 
serum.  The  following  experiment  seems  to  throw  light  on  this  question:  One  takes 
the  serum  of  a  rabbit  immunized  to  horse  serum  and  horse  serum,  mixes  them,  incu- 
bates them  for  a  short  time,  and  gets  a  precipitate;  centrifuges  the  precipitate,  pouis 
off  the  fluid,  and  retains  a  precipitate  entirely  free  from  the  supernatant  fluid.  If 
this  precipitate  is  taken  up  in  salt  solution  and  injected  intraperitoneally  into  a  guinea 
pig,  one  can  sensitize  this  guinea  pig  passively  with  that  precipitate.  If  one  waits 
three  days  and  then  injects  the  antigen,  the  animals  are  found  to  be  sensitised 
exactly  as  if  they  had  been  given  rabbit  vs.  horse  serum.  This  shows  that  the  pre- 
cipitin is  the  same  as  the  sensitizing  antibody.  I  will  not  go  into  the  controls  which 
were  used. 

The  next  question  which  arose  was,  Is  the  precipitating  function  necessary  for 
sensitization?  Now,  if  this  serum  is  heated  to  72^,  it  loses  its  precipitating  function, 
but  it  still  unites  actively  with  the  antigen.  That  has  been  proved  by  other  experi- 
ments. If  one  takes  a  serum  heated  in  this  way  to  72^,  although  it  has  lost  its  pre- 
cipitating function  entirely  in  the  test  tube,  it  retains,  although  slightly  diminished, 
its  sensitizing  value  for  the  guinea  pig.  Now,  I  think  that  proves  definitely  that  the 
precipitating  function  is  not  necessary  to  the  anaphylactic  phenomenon. 

This  leaves  us  simply  the  combining  group,  the  haptophore  group,  as  the  factor 
concerned  in  sensitization.  This  conclusion  harmonizes  with  the  so-called  physical 
theory  of  anaphylaxis — ^viz,  that  it  occurs  when  the  cell  possessed  of  an  antibody 
anchors  circulating  antigen.  The  vcr>'  fact  that  they  unite  stimulates  the  cell  to 
the  response. 

The  question  remains,  How  does  complement  enter  into  the  reaction?  You  know 
that  when  the  inrecipitating  antibody  unites  with  antigen  it  also  anchors  complement; 
we  find  that  when  serum  is  heated  to  72^  it  loses  the  power  of  binding  complement; 
when  it  is  heated  to  56^,  which  is  the  control  experiment,  it  still  binds;  and  yet, 
when  we  compare  the  sensitizing  value  of  serum  heated  to  56®  with  that  heated  to 
72®,  it  differs  very  slightly.  And  I  think  that  this  proves  that  complement  plays 
absolutely  no  r61e  in  the  reaction,  and  that  here  we  have  definite  proof  of  the  fact  that 
in  the  body  the  binding  of  complement  plays  no  rdle  in  the  anaphylactic  reaction. 
The  anaphylotoxin  theory  is  also  implicated  in  this  conclusion.  You  can  not  get 
anaphylatoxin  in  the  test  tube  by  incubating  antigen  and  antibody  unless  comple- 
ment is  present.  So,  here  is  another  aigiunent,  which  I  believe  is  final,  as  to  the 
inadequacy  of  the  anaphylatoxin  theory. 


PUBLIC  HEALTH  AND  MEDIOINE.  813 

The  other  questions  in  the  interpretation  of  anaphylaxis  and  immunity  are  sub- 
^diary  questions.  The  points  that  I  wish  to  impress  upon  you  are:  (1)  That  the 
theoretiod  evidence  and  the  experimental  evidence  are  absolutely  against  the  humoral 
theory;  (2)  that  it  is  no  longer  possible  to  straddle  the  problem  by  maintaining  that 
anaphylaxis  is  preeminently  cellular,  but  occasionally  humoral;  and  that  (3)  ana- 
phylatoxin  plays  no  rdle  whatever  in  anaphylaxis. 

The  Chairman  (Dr.  Weil  preeiding).  The  discussion  is  now  open  on 
these  papers. 

Dr.  Bbonfbnbbbnnbb.  Oentlmnen,  the  fact  alone  that  Dr.  Weil 
preferred  to  spend  most  of  his  time  to  criticize  the  humoral  theory 
of  anaphylaxis  instead  of  presenting  his  own  paper  shows  how  impor- 
tant he  considers  the  difference  between  this  and  the  cellular  con- 
ception of  anaphylaxis.  My  paper  was  not  intended  to  emphasize 
the  humoral  theory  at  the  expense  of  cellular,  though  the  material 
presented  by  me  does,  in  a  way,  illustrate  Uie  statements  made  by 
the  representatiyes  of  the  humoral  theory  of  anaphylaxis. 

Personally,  I  have  not  worked  in  anaphylaxis  much  and  my 
interest  in  the  subject  arose  from  the  work  on  abderhalden  reaction. 
Though  as  a  pupil  of  Prof.  Besredka  in  1909  I  have  been  engaged  in 
some  of  the  experiments  in  anaphylaxis  under  his  direction,  my  views 
as  to  the  mechanism  of  anaphylaxis  are  not  entirely  those  represented 
by  the  humoral  theory.  I  think,  however,  we  should  not  hurry  to 
discard  any  one  of  these  theories,  even  if  one  of  them  happens  to  be 
the  older  one.  Not  all  that  is  old  is  bad.  Insomuch  as  the  humoral 
tiieory  is  able  to  explain  all  the  phenomena  which  it  is  supposed  to 
explain  (many  workers  think  it  can),  there  is  no  need  of  discarding 
it  in  toto  and  replacing  it  witii  the  other,  even  if  certain  experi- 
ments, performed  by  its  adepts,  undoubtedly  demonstrate  the  pos- 
sibility of  cellular  response  being  an  int^ral  part  of  anaphylactic 
shock. 

As  Dr.  Clowes  has  remarked  a  few  minutes  ago,  the  phenomena  in 
anaphylaxis  are  very  general;  if  they  affect  one  structure  of  the  body, 
they  must  similarly  affect  other  structures  of  the  body,  as  there  is 
no  essential  difference  between  serum  and  the  tissues  which  the  serum 
envelopes. 

Although  there  are  many  phenomena  which  can  not  be  ade- 
quately explained  by  the  cellular  theory  of  anaphylaxis,  I  do  not 
intend  to  go  into  their  discussion,  for  it  would  take  again  as  much 
time  as  we  have  consumed.  The  experiments  quoted  by  Dr.  Weil 
undoubtedly  suggest  that  it  is  possible  to  demonstrate  cellular 
reaction  in  anaphylaxis.  Without  denying  that,  my  own  experiments 
surest  that  anaphylaxis  may  be  produced  as  a  result  of  the  combi- 
nation between  the  antigen  and  antibody  of  the  blood.  Of  course, 
as  Dr.  Clowes  has  stated,  the  cells  of  the  body  take  a  very  essential 


314       PBOCEEDINQS  SECOND  PAN  AMBBICAN  SCIENTIFIC  CONGBESS. 

part  in  the  reaction.  In  fact,  as  I  understand  it,  the  very  moment 
antigen  and  antibody  \inite  there  occurs  a  change  in  molecular  dis- 
persion (which  can  be  demonstrated  in  the  experiments  in  vitro.) 
In  the  body  Uiis  change  in  the  physical  state  of  serum  (through  its 
combination  with  antigen)  afFects  the  physiol<^c  functions  (permea- 
bility 1)  of  the  cells  so  that  a  number  of  cells  may  ev^i  die  as  a  result 
of  this  change.  Whether  in  this  process  there  is  formed  an  inter- 
mediate toxic  product  (anaphylatoxin)  which  is  a  distinct  chemical 
substance,  I  do  not  know.  I  think  anaphylatoxin  is  not  similar  to 
the  toxic  substances  of  Dr.  Vaughan.  I  am  more  inclined  to  view 
anaphylatoxin  merely  as  a  stage  in  the  physical  change  the  serum  is 
undergoing,  the  change  which  is  characterized  by  its  deleterious 
effects  on  the  life  of  the  cells  (possibly  by  affecting  the  permeabiUty). 

Beferring  to  Dr.  Kolmer's  discussion,  I  would  like  to  ask  whether  I 
understood  Dr.  Kolmer  correctly  ?  Dr.  Kolmer  thinks,  I  believe,  that 
there  19  no  doubt  of  the  specificity  of  the  ferment  in  pr^nancy.  If 
so,  I  disagree  with  him.  I  have  shown  in  my  published  work  that 
the  ferment  concerned  in  the  abderhalden  reaction  is  not  specific. 
The  apparent  specificity  of  the  reaction  is  due  to  the  mechanism  of 
the  activation  of  the  normal  blood  ferment  by  the  combination  of  the 
antigen  (placenta  tissue)  and  antibody  present  in  the  blood  of  preg- 
nant women. 

Dr.  Kolmer.  My  remarks  wiU  be  very  brief.  Like  Dr.  Bronfen- 
brenner,  most  of  the  work  that  I  have  been  doing  has  concerned 
the  mechanism  of  the  abderhalden  reaction  and  I  based  my  belief — 
tentative  belief — on  the  presence  of  a  specific  ferment  from  the  fact 
that  digestion  as  we  are  able  to  measure  it  by  all  methods,  except  the 
more  recent  one  of  Von  S  would  diiow  that  digestion  of  placenta 

by  the  serum  of  a  pregnant  woman  was  more  intense  than  of  non- 
pT^nant,  and  I  advanced  that  as  an  argument  against  the  purely 
chemical  theory,  as  it  were,  that  it  is  the  mere  absorption  of  antifer- 
ment  that  results  in  digestion. 

As  to  Dr.  Bronfenbrenner's  question  relative  to  nly  belief  in  the 
specificity  of  the  ferment,  I  may  say  that  I  put  this  reprint  to 
which  Dr.  Bronf enbrenner  refers  in  my  pocket  this  morning  with  the 
idea  of  asking  him,  if  I  had  a  few  minutes,  his  own  idea  about  it, 
because  I  find  in  the  same  reprint  the  statement  that  they  are  non- 
specific and  then  on  the  next  page  that  they  are  specific. 

As  I  wrote  my  paper  only  in  the  last  day  or  two,  it  was  my  object 
rather  to  review  the  present  opinions  particularly  in  reference  to 
abderhalden  reaction.  My  own  belief  is  that  there  is  in  pregnancy  a 
specific  ferment. 

Dr.  Bronfenbrenner.  According  to  my  findings  the  specificity 
lies  not  in  the  nature  of  the  ferment,  but  in  the  nature  of  its  activa- 
tion.    I  wish  to  make  it  very  plain.    The  ferment  is  not  specific. 


PUBUO  HEALTH  AND  MEDICINE.  315 

The  same  ferment  is  present  in  pregnant  as  in  nonpregnant  indi- 
viduals, but  it  may  be  made  active  in  the  serum  of  pre  .jnant  indi- 
viduals by  the  specific  process  of  the  imion  between  the  specific 
antibody  such  serum  contains  (in  addition  to  the  nonspecific  fer- 
ment) and  corresponding  antigen.  The  molecule  of  the  protein  of 
the  serum  having  a  certain  structure,  if  the  specific  combination  of 
antigen  and  antibody  will  change  the  degree  of  dispersion  of  the  par- 
ticles in  it,  would  be  broken  up — digested.  The  end  result  appears 
to  be  specific,  but  the  mechanism  is  not  that  of  the  action  of  a 
specific  ferment. 

The  Chairman.  We  come  now  to  the  paper  of  Dr.  A.  P.  Kitchens 
and  Dr.  C.  P.  Browne,  **Hay  fever  and  certain  other  local  anaphy- 
lactic phenomena  referable  to  the  respiratory  mucous  membranes.'' 

Dr.  HrroHENS.  On  account  of  the  lateness  of  the  hour  and  the 
length  of  our  paper,  I  should  like  to  suggest,  if  Dr.  Brown  will  agree, 
that  our  paper  be  read  only  by  title.  It  will  probably  be  pub- 
lished, and  I  think  every  one  may  get  as  much  from  the  abstracts 
possibly,  as  from  the  whole  paper.  Those  who  are  especially  inter- 
ested may  read  the  published  paper. 


HAY  FEVER  AND  CERTAIN  OTHER  LOCAL  ANAPHYLACTIC  PHENOMENA 
REFERABLE  TO  THE  RESPIRATORY  MUCOUS  MEMBRANES. 

By  A.  PARKER  HIT0HEN8  and  CLAUDE  P.  BROWN,  Oknolden,  Pa. 

In  reviewing  the  history  of  hay  fever  we  find  that  the  literature  naturally  falls 
into  five  fairly  distinct  periods: 

Fint  period, — In  the  earlier  bibliography,  long  before  the  first  accurate  description 
of  the  disease  by  Bostock  (1)  ^  there  are  numerous  references  to  periodical  attacks  of 
rhinitis  and  asthma  as  well  as  to  various  idiosyncrasies  associated  with  flowering 
plants.  Among  the  earliest  of  these  is  Botallus  (2) — "for  there  are  many  who  are 
attacked  with  sneezing,  by  the  slightest  thing  whatsoever,  others  by  merely  smelling 
a  rose.'''  Others  mentioned  by  Sticker  (3)  are  Binninger  (4),  Ledelius  (5),  Hdner^ 
wolf  (6),  and  Constant  de  Eebecque  (7).  Bostock  stated  that  the  earliest  reference 
to  which  his  attention  had  been  called  was  that  of  Heberden  (8).  The  quotation 
referred  to  is  probably  '*  Five  patients  were  attacked  violently  by  this  disease  for  a 
month  every  summer;  one  was  afflicted  annually  for  the  entire  summer;  another 
was  never  free  from  it  except  in  the  summer."  ^  These  references  are  sufficient  evi- 
dence that  hay  fever  existed  for  centuries  before  its  recognition  as  a  specific  disease 
and  all  attempts  to  estimate  its  antiquity  are  entirely  futile. 

1  Figures  In  parentheses,  used  as  references,  refer  to  publications  bearing  identical  numbers,  under  the 
head  of  "Bibliography,"  at  the  end  of  this  paper. 

s "Nam  plerl<iiie  sunt  qui  quaconque  re  levisslma  stemutationis  multis  agitabuntur,  ahi  ex  solo  rosae 
odoratu.'' 

>  "Qulnque  aegris  oontlgit  graviter  laborare  hoc  morbo  per  mensem  omnl  aestate;  aliimi  totam  aestatem 
afflixit  quotannis;  alius  nunguam  nisi  aestate  ab  eo  liber  fult.^'  In  a  translation  of  Heberden 's  work  pub- 
Udied  the  next  year  (9)  is  the  following:  "I  have  known  it  return  In  four  or  five  persons  annually  in  tha 
numths  of  April,  May,  June,  or  July,  and  last  a  month  with  great  violenoe.  In  one  a  catarrh  constantly 
▼Isited  him  every  summer:  and  in  another  this  was  the  <«ly  part  of  the  jrear  in  which  it  ceased  to  be  troo- 
bles<Mne." 


316       PBOCEEDINGS  SECOND  PAN  AMBBIOAN  SCIEVTIFIO  00KOSE88. 

Second  period.— In  1819,  Boetock  (1)  described  a  "Case  of  a  pmodical  afifection  of 
the  eyes  and  chest"  so  accurately  that  later  writers,  even  in  their  most  elaborate 
analyses  of  symptoms,  have  been  able  to  add  nothing  of  clinical  importance.  The 
attention  of  other  physicians  thus  being  called  to  this  affection,  reports  in  a  short  tune 
began  to  i4»pear  in  the  medical  publications  of  England,  France,  and  Germany.  Nine 
years  later  Bostock  (10)  himself  added  distinct  accounts  of  18  cases,  with  10  otheis 
''less  correctly  ascertained."  ElUottson  (13)  contributed  a  number  of  cases  and 
noted  many  interesting  data  with  regard  to  the  associatum  of  symptoms  with  the 
apparent  exciting  causes.  From  the  contributions  of  Gordon  (11)  and  MaccuUoch  (12), 
we  learn  that  the  term  ''  hay  fever"  was  probably  used  some  tune  before  its  recogni- 
tion as  a  disease  by  Bostock. 

Our  information  concerning  the  incidence  of  hay  fever,  its  relation  to  age,  sex,  and 
condition  of  life,  and  its  geographical  distribution  may  be  attributed  in  some  degree 
to  Elliottson  (13)  but  still  more  to  Phoebus  (14). 

With  r^;ard  to  the  etiology,  various  theories  were  held  and  practically  every  external 
agency  was  claimed  affirst  as  an  exciting  cause.  Bostock  believed  his  own  symptoms 
to  be  due  to  the  heat  of  summer,  while  other  writers  held  the  odor  of  flowering  plants 
chiefly  responsible.  The  proposal  of  a  bacterial  origin  by  Helmholz  (15)  never  gained 
much  headway.  Pirrie  (16)  suggested  that  the  disease  was  of  nervous  origin,  at  the 
same  time  admitting  emanations  from  plants  and  various  external  agencies  as  exciting 
causes. 

In  1859  Prof.  Phoebus  (14)  of  the  UnivenBity  of  Giessen,  sent  out  about  400  drculan 
to  physicians,  medical  societies,  etc.,  requesting  information  concerning  hay  fever. 
His  analysis  of  the  replies  received  remains  one  of  the  best  statistical  studies  of  the 
disease,  but  no  fundamental  ^ts  with  regard  to  etiology  were  ascertained.  One  of 
the  most  interesting  communications  quoted  by  Phoebus  (14,  pp.  136,  137)  was  that 
of  Eirkman,  who  disagreed  with  the  opinion  that  emanations  from  ArUhoxanOnum 
odoralum  were  a  cause  (probably  the  cause,  according  to  Gordon  (11 ),  because  **  I  am 
always  attacked  at  least  three  weeks  before  the  Anthoxanthum  is  in  blossom."  Later, 
in  his  hothouse,  he  noticed ,  a  day  or  two  before  Christmas,  a  single  ArUhoxanthum  odonir 
turn  in  blossom  and  well  loaded  with  pollen.  He  rubbed  the  flower  in  his  hand  and 
sniffed  it,  whereupon  all  the  symptoms  of  hay  fever  appeared  immediately,  continued 
for  an  hour,  and  then  left  him. 

In  1872  and  1876,  respectively,  Morrell  Wyman  (17)  and  Beard  (18)  published  sta- 
tistical investigations  similar  to  those  made  by  Phoebus.  Althou^  Blackley's  work 
had  appeared  three  years  earlier,  Beard  was  confident  that  his  theory  of  a  nervous 
diathesis  was  conclusive;  he  said  that  pollen  was  merely  one  of  the  "debilitating 
influences,  exciting  causes  purely,  and  of  themselves  are  powerless  to  induce,  or  at 
least  to  sustain  an  attack." 

Tfwrd  period, — ^The  chaotic  state  of  these  earlier  opinions  could  be  cleared  up  only 
by  actual  experiment.  However  little  serious  attention  it  attracted  at  the  time,  this 
necessary  elucidation  was  furnished  by  Charles  H.  Blackley  (19),  a  physidan  of  Man- 
chester, England.  In  1873,  he  published  the  results  of  one  of  the  most  complete 
researches  in  the  history  of  experimental  medicine.  Blackley,  himself  a  sufferer  from 
hay  fever,  was  at  first  inclined  to  agree  with  Bostock  that  summer  heat  was  the  cause 
of  the  disease,  but  he  was  led  to  question  the  correctness  of  this  view  by  circum* 
stances  connected  with  a  journey  to  the  sea  coast.  In  the  locality  of  his  home  at 
Manchester  the  hay  had  already  been  gathered  in  and  his  attacks  of  hay  fever  had 
ceased;  on  approaching  the  sea  coast,  however,  the  symptoms  reappeared,  and  later 
investigation  revealed  a  field  of  uncut  hay,  much  of  which  was  in  flower.  His  atten- 
tion was  directed  to  the  same  subject  by  an  incident  two  years  later.  Upon  examining 
a  bunch  of  grass  brought  indoors  by  one  of  his  children  the  cloud  of  pollen  scattering 
near  his  &ice  brou^t  on  violent  sneezing  in  two  or  three  minutes.  Blackley  dates 
his  experimental  work  from  this  time  (1859). 


PUBLIC  HEALTH  AND  MEDIOIKB.  317 

Alter  carefully  reviewing  all  the  current  opinions  concerning  the  etiology  of  hay 
fever  Blackley  asked  himself  the  following  questions: 

First.  Can  pollen  produce  the  symptoms  of  hay  fever? 

Second.  Does  this  property  belong  to  all  the  pollens  or  is  it  confined  to  the  pollen 
of  some  one  or  more  orders  of  plants?    And  if  so,  to  what  natural  orders  does  it  belong? 

Third.  To  the  pollen  of  which  natural  order,  or  of  which  speoBB  of  this  order,  are  the 
actual  attacks  of  hay  fever,  as  they  occur  in  early  summer,  due? 

Fourth.  Is  this  condition  or  property  found  in  the  dried  as  well  as  in  the  freeb 
pollen? 

Fifth.  To  what  special  substance  in  pollen  is  this  supposed  action  due? 

In  order  to  answer  these  questions,  Blackley  experimented  upon  the  pollen  in  five 
different  ways:  "  First,  by  applying  it  to  the  mucous  membrane  of  the  naies;  second, 
by  inhaling  it,  and  thus  bringing  it  into  contact  with  the  mucous  membrane  of  the 
larynx,  trachea,  and  bronchial  tubes;  third,  by  applying  a  decoction  of  the  pollen  to 
the  conjunctiva;  fourth,  by  applying  the  fresh  pollen  to  the  tongue,  lips,  and  fauces; 
fifth,  by  inoculating  the  upper  and  lower  limbs  with  the  fresh  moistened  pollen.'' 

Blacldey  (19,  p.  75)  tested  on  himself  the  pollens  of  the  grasses  and  of  plants  belong- 
ing to  35  other  natural  orders,  all  of  which  produced  symptoms.  He  studied  micro- 
scopically the  various  pollen  grains;  furthermore,  he  counted  the  grains  deposited 
within  a  given  time  upon  slides  coated  with  glycerine  and  carbolic  acid.  These 
studies  were  made  at  different  seasons,  indoors  and  out,  in  country  and  in  city,  at 
about  the  level  of  a  man's  head  and  at  higher  altitudes  by  means  of  kites.  Blackley 
demonstrated  that  symptoms  did  not  appear  until  the  pollen  grains  had  reached  a 
certain  number,  and  that  the  severity  of  the  symptoms  varied  in  direct  ratio  with 
the  amount  of  pollen  in  the  air.  He  also  showed  that  pollen  may  travel  enormous 
distances,  thus  accounting  for  the  fact  that  the  seashore,  or  even  the  ocean,  does  not 
always  afford  relief  to  susceptible  persons. 

In  all  this  work  Blackley  himself  was  the  subject  of  the  experiment.  At  that  time 
he  tried  in  vain  to  find  other  hay-fever  sufferers  who  would  submit  to  the  tests;  how- 
ever, the  opportunity  came  to  him  later  (20)  to  corroborate  his  findings  on  other 
patients. 

In  spite  of  the  evidence  presented  by  Blackley,  the  attention  of  his  contemporaries 
was  so  concentrated  upon  the  work  of  Pasteur  and  Koch  that  no  suggestion  regarding 
etiology  was  welcome  unless  founded  upon  bacterial  infection.  The  findings  of 
Helmholz  that  a  vibrio  was  the  cause  of  hay  fever  were  confirmed  by  Binz  (23)  and 
Fatten  (24).  Heymann  and  liatEuschita  (22),  howevw,  attempted  to  straddle  the 
question  by  suggesting  pollen  as  the  carrier  of  bacteria,  especially  of  streptococci. 

Furthermore,  the  fact  that  Blackley's  work  contained  no  ^ts  of  direct  therapeutic 
value  naturally  detracted  from  its  significance  for  clinicians.  Thus,  it  was  not  until 
the  successful  application  of  Noon's  method  of  vaccination  that  the  etiologic  rdle  of 
pollen  attracted  general  interest  and  found  final  acceptance  to  the  exclusion  of  all 
other  theories. 

Fourth  period, — ^In  1903  Dunbar  (21)  published  his  work,  built  upon  the  foundation 
laid  by  Blackley.  With  technique  similar  to  that  used  by  his  predecessor,  Dimbar 
experimented  upon  himself  and  other  susceptible  persons,  with  the  result  that  pollen 
was  established  as  the  cause  of  hay  fever.  Thus  the  findings  of  Blackley  were  con- 
firmed. Dunbar  believed  at  first,  however,  that  only  certain  pollens  were  in  ques- 
tion.   This  point  is  stiU  unsettled  and  needs  further  investigation. 

Dunbar  was  more  fortunate  than  Blackley  in  having  at  his  disposal  the  results  of 
all  the  later  achievements  in  both  organic  chemistry  and  immunology.  The  latter 
was  an  unknown  science  in  Blackley's  day.  Dunbar's  work  on  the  chemistry  of 
pollen  thus  constitutes  a  real  advance  in  our  knowledge  of  hay  fever.  In  the  field  of 
immunology  he  was  able,  by  serological  tests,  to  strengthen  the  evidence  in  favor  of 
the  etiologic  rdle  of  the  pollen  proteins.    He  was  the  first  to  establish  the  possibility 


818       PBOCEEDINGS  SECOND  PAK  AMEBICAN  SCIEKTEFIC  COKOBESS. 

of  actiye  immtmity  and  to  elAb<H»te  a  specific  thetvpy^  but  he  fell  into  error  by 
applying  to  hay  fever  the  diflcoreries  of  Bluing,  Kitasato,  and  othen  concerning 
bacterial  toxins  and  antitoxins.  Dunbar  maintained  that  hay  fever  was  caused  by 
a  true  toxin  existent  in  the  pcdlen,  and  that  the  serum  of  animals  (rabbits  and  hocses) 
injected  with  pollen  and  pollen  derivatives  possessed  true  antitoxic  power.  At  pres- 
ent we  regard  hay  fever  as  an  anafHiiylactic  i^enomenon,  and  consider  that  Uie  serum 
elaborated  and  patented  by  Dunbar  >  belongs  with  the  antibacterial  serums;  in  other 
words,  that  it  depends  for  its  activity  upon  amboceptor  and  not  upon  antitoxin. 

Fifth  period. — In  1911  Noon  (25)  reported  the  results  of  his  wwk  in  the  laboratory 
of  Sir  Almroth  Wright  on  the  treatment  of  hay  fever  with  subcutaneous  injections  of 
pollen  extracts  in  minute  doses.  Ourtis  (26)  and  Dunbar  had  previously  used  plant 
extracts  and  pollen  extracts,  but  neither  of  them  had  achieved  results  sufficiently 
promising  or  reliable  to  encourage  a  continuation  of  their  wo^.  Noon  injected  ex- 
tracts of  timothy  pollen,  controlling  the  doses  by  ophthalmo  reactions;  this  work 
interrupted  by  his  untimely  death,  was  continued  by  Freeman  (27). 

Preparation  of  pollen  extracU. — ^Dunbar  (28)  and  his  associates,  Prausnitz  (29),  Kam- 
mann  (30),  Weichardt  (81),  and  Liefmann  (32),  demonstrated  that  the  protein  which 
constitutes  about  40  per  cent  of  the  oiganic  substances  in  pollen,  is  the  active  agent 
in  causing  hay  fever.  Accordingly^  idl  methods  in  the  preparation  of  material  for 
vaccination  must  include  extraction  of  this  essential  protein. 

One  of  the  methods  used  by  Dunbar  for  the  preparation  of  his  '^poUen  toxin''  is  to 
extract  the  finely  pulverized  pollen  with  5  per  cent  sodium  chloride  solution  ccm- 
taining  0.5  per  cent  phenol,  incubating  the  mixture  at  87^  G.  The  undissolved  por- 
tion removed  by  centrifugation  consists  of  empty  pollen  membranes  and  inactive 
starch  rods.  The  supernatant  opalescent  solution  contains  the  dissolved  proteins; 
this  is  intensely  active,  even  in  high  dilution,  when  applied  to  the  skin  or  conjunc- 
tiva of  susceptible  persons.  For  use,  the  extract  is  diluted  with  physiological  saline 
solution.  He  suggests  further  purification  by  precipitation  with  eight  (8)  volumes 
of  absolute  alcohol  or  by  dialysis.  Only  the  cJbumens,  which  constitute  about  16 
per  cent  ot  the  total  proteins,  are  toxic,  tiie  globulin  fraction  being  entirely  inactive. 

Subsequent  investigators  have  made  their  extractions  with  distilled  water  and  with 
saline  solutions  of  various  strengths.    The  pollen  is  sometimes  ground  with  sand; 
Goodale  (43)  considers  grinding  unnecessary. 

There  are  other  modifications  in  technique  which  are  scarcely  worth  mentioning. 
In  many  instances  the  possibility  that  the  extract  is  not  sterile  can  not  be  eliminated. 
Standardization  is  generally  c(msidered  accomplished  by  noting  the  relation  between 
the  quantity  of  fluid  and  the  amount  of  pollen  extracted.  This  procedure  is  obvi- 
ously subject  to  great  variation.  Cooke's  (41)  method  of  standardization  seems  to 
be  the  most  accurate  so  far,  and  it  is  the  one  we  have  adopted. 

Recent  literature. — Among  the  recent  reports  of  Clowes  (35).  Lovell  (36),  Lowder- 
milk  (37).  Ub-ich  (38),  Koessler  (39),  Manning  (40),  Cooke  (41),  Wood  (42),  and  Good- 
ale  (43),  the  observations  of  Ulrich  regarding  intervals  between  doses  are  of  special 
interest.  He  noted  that  some  patients  were  relieved  for  much  long^  periods  than 
others,  and  because  of  this  variability  in  individuals,  he  suggested  that  the  intervals 
be  governed  in  each  case  by  the  date  of  return  of  the  symptoms. 

The  excellent  technic  of  Cooke  (41)  with  regard  to  standardization  has  already  been 
mentioned.  His  theories  regarding  the  mechanism  of  hay  fever  and  its  treatment 
are  in  accord  with  the  latest  views  of  anaphylaxis: 

1.  With  regard  to  antibody  formation. — It  must  be  borne  in  mind  that  any  form  of 
foreign  protein  parent  erally  introduced  within  the  living  body  gives  rise  to  the 
formation  of  a  specific  immune  or  antibody  which  exists  either  attached  to  certain 
cells  or  free.  When  union  takes  place  between  protein  and  free  antibody,  there  is 
no  clinical  evidence  of  a  reaction,  but  when  a  union  takes  place  between  protein  and 

»  D.  R.  P.  No.  1*2163. 


PUBLIC  HEALTH  AND  MEDICINB.  319 

fixed  antibody,  a  reaction  takes  place,  and  the  nature  of  this  reaction  is  determined 
by  the  type  of  cell  to  which  the  antibody  was  attached. 

2.  Relation  between  immunity  and  anaphylaxis. — ^They  are  aualitively  identical 
but  quantitatively  different.  In  other  woras,  when  there  is  a  large  excess  of  anti- 
body circulating  free  we  have  an  immune  state;  and  when  there  is  little  antibody, 
and  that  for  the  most  part  attached,  we  have  the  sensitized  state. 

3.  Duration  of  immunity. — Immunity  in  the  sense  that  free  excess  antibody  once 

E resent  is  always  present  does  not  exist.    WiUi  cessation  of  protein  injection,  the 
ody  returns  to  the  anaphylactic  state,  in  which  it  may  remain,  or  to  the  state  of  accel- 
erated capacity  to  form  antibody. 

The  attempts  of  Goodale  (43)  to  classify  the  susceptibility  of  patients  according 
to  natural  orders,  and  thus  to  study  this  part  of  the  problem  systematically,  opens  up 
many  interesting  possibilities  not  only  in  hay  fever  treatment  but  also  in  botanical 
classification. 

Work  of  the  writers. — ^For  obtaining  the  pollen  the  flowers  are  gathered  just  when 
pollination  has  started.  The  flowers  are  dried  and  the  pollen  collected  by  means  of 
fine  sieves.  The  pollen  itself  is  thoroughly  dried  immediately  and  preserved  in  the 
dry  state  until  it  is  to  be  extracted. 

1.  The  pollen  i3  mixed  with  sufficient  physiological  saline  solution  (0.85  per  cent) 
to  make  a  fairly  thick  paste. 

2.  The  paste  is  transferred  to  a  porcelain  ball  mill  and  ground  for  24  hours,  or 
until  microscopic  examination  shows  that  the  pollen  grains  are  broken, 

3.  Physiological  saline  solution  is  added  and  the  resultant  mixture  is  centrifuged 
to  remove  insoluble  debris. 

4.  The  extracted  protein  is  purified  by  precipitation  with  acetone. 

5.  The  precipitate  is  dried  and  thus  preserved  until  needed. 

6.  For  use,  the  precipitate  is  dissolved  in  physiological  saline  solution.  The 
amount  of  protein-nitrogen  in  this  solution  is  determined  by  the  Kjeldahl  method. 

7.  The  solution  is  then  diluted  so  that  each  cubic  centimeter  will  contain  certain 
fractions  of  a  milligram  of  protein-nitrogen. 

8.  The  lowest  dilution,  1  c.  c.  of  which  may  be  used  as  the  initial  dose  in  treatment, 
contains  0.0025  mg. 

9.  The  final  solutions  are  preserved  from  contamination  by  the  addition  of  0.25 
per  cent  three  cresols  and  sterilized  by  filtration.  Sterility  is  determined  by  careful 
aerobic  and  anaerobic  cultural  tests. 

The  treatment  may  be  continued  with  increasing  multiples  of  this  amount  ac curd- 
ing to  the  needs  and  the  sensitiveness  of  the  patient.  The  injections  are  first  given 
at  about  5-day  intervals,  but  as  soon  as  the  period  of  relief  has  been  found  these  inter- 
vals are  shortened  or  lengthened,  that  is,  if  ti-eatment  is  necessary  during  the  season. 

We  consider  this  better  technique  than  to  depend  upon  ophthalmo  reactions  which 
may  be  dangerous  or  upon  akin  tests  which  merely  complicate  the  procedure  for  the 
clinician.  In  other  words,  ophthalmo  reactions  and  akin  tests  bear  the  same  relation 
to  pollen  vaccine  dosage  that  the  opsonic  index  bears  to  bacterial  vaccine  dosage. 
By  the  ophthalmic  test  Noon  and  Freeman  were  able  to  place  pollen  vaccination 
upon  a  scientific  basis  similar  to  that  achieved  by  Wright  by  means  of  the  opeonic- 
index  technique.  At  present  by  starting  with  a  dose  (of  either  vaccine)  demon- 
strated to  be  sufficiently  small  to  do  no  harm  satisfactory  results  are  obtained  without 
the  same  control  of  dosage  that  was  necessary  at  the  beginning. 

Our  spring  extracts  contain  a  mixture  of  the  pollens  of  red  top,  timothy,  rye»  sweet 
vernal  grass,  and  orchard  grass;  the  autumn  type  con£dsts  only  of  ragweed. 

These  vaccines  have  been  used  by  ourselves  and  by  other  physicians  kindly  coop- 
erating with  us  in  the  treatment  of  61  patients. 

Of  these  61  cases  17  had  asthma  as  a  complicating  symptom,  of  which  3  gave  no 
report,  1  was  not  relieved,  2  were  considerably  relieved,  and  11  were  entirely  relieved. 
Of  the  44  remaining  cases,  3  gave  no  report,  2  were  not  relieved,  4  were  slightly 
relieved,  18  were  considerably  relieved,  and  17  were  entirely  relieved. 


820       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  CONGRESS. 

One  patient  has  apparently  been  cured.  He  was  treated  during  two  yean  in 
both  spring  and  autumn.  Another  patient,  who  was  only  partially  relieved,  was 
found  to  be  susceptible  to  wheat,  but  he  was  compelled  to  leave  tlio  vicinity  before 
a  special  extract  could  be  prepared  for  him. 

One  patient  not  completely  relieved  by  the  spring  vaccine  was  found  auaceptible 
to  daisy  pollen.  A  special  "daisy''  vaccine  was  prepared,  and  the  administration 
of  a  single  dose  brought  complete  relief. 

Our  results,  on  the  whole,  do  not  differ  greatly  from  those  obtained  by  others  since 
Noon's  first  report.  In  none  of  these  cases  have  we  considered  the  possibility  of  a 
superadded  or  even  possibly  of  a  primary  bacterial  infection.  This  point,  however, 
should  not  be  overlooked. 

Alexander  (34)  reports  two  patients  suffering  from  chronic  nasal  catarrh,  which  con- 
dition was  aggravated  by  pollen  during  the  hay-fever  season.  Treatment  with  Noon's 
pollen  vaccine  had  no  effect.  But  after  bacteriological  examination  and  the  admin- 
istration of  micrococcus  catarrhalis  vaccine  the  cases  were  cured. 

We  have  treated  one  asthmatic  patient  with  bacterial  vaccines  who  throughout 
one  winter  did  not  have  a  single  attack,  although  each  winter  previously  she  had 
experienced  many. 

Other  anaphyhctic  pJietwmena. — The  validity  of  the  so-called  idiosyncraciee  to  the 
emanations  from  animals  can  not  be  questioned.  Inquiry  into  the  cases  of  sudden 
death  following  the  injection  of  horse  serum  has  shown  that  many  of  these  persons 
had  previously  suffered  asthmatic  attacks  whenever  coming  in  contact  with  horses. 
The  manifestations  of  anaphylaxis  after  eating  certain  foods  are  now  well  recog- 
nized. All  these  facts  lead  to  the  deduction  that  any  protein  in  the  atmosphere 
may  find  hypersusceptible  individuals  who  react  with  sneezing  and  all  the  symptoms 
of  hay  fever  or  asthma,  or  possibly  with  other  more  obscure  symptoms.  A  case  in 
point  is  the  effect  of  bad  ventilation  (or  the  lack  of  ventilation)  on  certain  persons 
while  the  other  occupants  of  the  room  remain  unaffected.  Rosenau  and  Amoss  (33) 
have  attempted  to  demonstrate  the  presence  of  proteins  in  the  exhaled  breath,  and 
although  this  work  as  yet  lacks  confinnation  we  believe  it  is  a  line  of  research  worthy 
of  closer  attention. 

Discusnon, — ^We  feel  that  possibly  an  explanation  should  be  offered  for  consuming 
80  much  time  with  the  history  of  hay  fever.  However,  we  believe  this  review  to  be 
fully  justified  if,  by  clearly  outlining  the  work  already  successfully  completed, we 
may  thereby  indicate  the  departments  of  this  subject  actually  in  need  of  closer 
investigation. 

Hay  fever  at  present  is  a  problem  of  immunology  and  of  chemistry,  and  the  extension 
of  our  knowledge  is  limited  to  these  two  fields  unless  some  unsuspected  development 
may  lead  to  a  departure  from  the  present  trend  of  research — a  departure  such  as 
followed  the  investigation  of  anaphylaxis  by  Rosenau  and  Anderson. 

The  demonstration  made  by  Noon  that  injection  of  a  pollen  extract,  under  the 
rules  laid  down  by  Wright,  has  immunizing  and  therapeutic  value  in  hay  fever  suggests 
two  important  questions: 

1.  What  essential  constituent  of  the  pollen  should  be  contained  in  the  extract? 
This  is  practically  question  No.  5  asked  by  Blackley,  and  the  work  of  Dunbar  and 
his  associates  has  gone  far  toward  gi\ing  us  an  answer.  However,  the  lack  of  a  stand- 
ard method  for  preparing  an  extract  of  maximum  diagnostic,  immunizing  and  thera- 
peutic value,  clearly  indicates  the  intensive  investigation  needed  in  this  direction. 
Whether  or  not  the  same  constituent  would  possess  all  these  properties  would  be  one 
point  demanding  further  study. 

Although  the  method  adopted  by  us  is  not  the  best  poesible,  it  is  in  certain  re- 
spects superior  to  some  of  those  described  in  recent  reports. 

a.  Keeping  qualities. — Koepsler  (39)  among  others  found  his  extracts  to  be  worthless 
after  3  weeks.    An  extract  prepared  by  the  technique  given  above  \nelded  positive 


PUBUC  HEALTH  AND  MEDICINE.  321 

therapeutic  results  after  2  years;  chemical  tests  according  to  the  Kjeldahl,  biuret, 
and  Sflrenson  methods  showed  neither  any  change  in  protein-nitroj^on  content  nor 
decomposition  with  formation  of  peptones  or  amino  acids. 

b.  Uniformity. — The  Cooke  method  of  standardization  certainly  appears  more 
rational  than  that  used  by  Dunbar  and  others  who  estimate  the  strength  of  the  extract 
by  the  amoimt  of  pollen  submitted  to  extraction.  Lack  of  uniformity  in  the  strength 
of  his  vaccines  may  account  for  the  fear  of  anaphylactic  diock  expressed  by  Lowder- 
milk  (37).  None  of  our  patients  had  more  than  a  slight  local  reaction  which  caused 
no  inconvenience. 

2.  To  what  pollen  is  the  indi\idual  patient  susceptible?  This  is  Blackley's  Ques- 
tion No.  2.  While  certain  patients  are  susceptible  to  the  pollen  of  only  one  or  a  very 
few  plants  (or  at  least  to  a  single  natm^l  order),  others,  like  Blackley,  are  susceptible 
to  nearly  all  plants;  there  are,  of  course,  all  grades  between.  Goodale  has  attacked 
this  problem  from  a  practical  standpoint  by  classifying  the  various  pollens  with  a 
view  to  minimizing  the  number  requisite  in  treatment.  Freeman  reduced  his  vaccine  to 
an  extract  of  timothy  pollen  alone.  It  would  greatly  simplify  matters  for  the  clinician 
if  in  the  fall  the  pollen  of  a  single  member  of  the  Compositae  could  be  applied.  A 
sufficient  number  of  cases  has  been  reported,  however,  to  show  that  some  patients 
would  not  be  relieved,  even  assuming  that  timothy  pollen  extract  and  rag- weed 
pollen  extract  are  adequate  for  the  Gramineae  and  the  Compositae,  respectively. 
Persons  susceptible  to  rose  pollen  or  to  the  pollen  of  certain  trees  are  cases  in  point. 

Although  these  two  questions  are  the  most  important  at  the  present  time,  a  third 
problem  is  ever  present  with  the  practicing  physician. 

3.  In  the  present  state  of  oiw  knowledge  of  hay  fever,  how  can  this  knowledge  be 
best  applied  to  the  advantage  of  our  patients?  The  answer  to  this  question  may  be 
considered  in  two  sections:  (a)  Measures  to  be  taken  two  or  three  months  before  the 
hay-fever  season,  and  (h)  measures  to  be  taken  immediately  before  or  during  the 
hay-fe_ver  season. 

a.  Measures  to  be  taken  two  or  three  months  before  the  hay-fever  season.  When 
the  patient  can  be  studied  beforehand,  a  survey  of  his  habitual  surroundings  should 
be  made.  After  noting  all  the  flowering  plants  which  might  reasonably  come  into 
question,  skin  tests  should  be  made  with  pollens  of  each  of  these  plants  in  order  to 
determine  which  of  them  are  responsible.  In  this  connection  it  must  be  remembered 
that  pollens  may  travel  great  distances  (Blackley).  Accordingly,  a  field  of  grain 
even  several  miles  away  must  be  taken  into  consideration. 

It  seems  scarcely  necessary  to  mention  the  eliminations  that  could  be  made  according 
to  the  seasonal  incidence  of  the  attack.  The  Gramineae  in  the  spring,  the  Compositae 
in  the  fall  would  receive  first  consideration. 

b.  Measures  to  be  taken  immediately  before  or  during  the  attack.  If  the  attack 
has  already  started,  treatment  should  be  begun  at  once  with  a  vaccine  representing 
the  pollens  most  likely  to  be  responsible  for  the  attack.  If  the  treatment  does  not 
give  entire  roUef,  an  exact  diagnosis  may  be  made  quite  independently  of  the 
treatment. 

While  the  ordinary  seasonal  attacks  can  be  controlled  fairly  easily,  those  patients 
who  suffer  from  earliest  spring  until  latest  autumn  may  present  greater  difficulties. 
As  stated  above,  we  have  treated  one  patient  of  this  type  during  two  springs  and 
autumns  with  apparent  cure  as  the  result. 

As  regards  dosage  we  believe  that  the  placing  of  extracts  upon  the  conjunctiva 
should  be  unqualifiedly  condemned.  Skin  reactions  may  not  be  quite  so  exact,  but 
they  are  adequate  for  all  practical  piu^xwes,  if  indeed  any  such  control  is  needed, 
except  in  diagnosis. 

In  conclusion,  we  wish  again  to  suggest  that  those  persons  now  investigating  hay 
fever  first  familiarize  themselves  with  the  magnificent  research  of  Blackley,  as  well 
as  with  the  chemical  studies  of  Dunbar  and  his  associates.    Among  the  innumerable 


322        PROOEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIO  00N0RES8. 

publications  there  are  after  all  only  a  few  that  are  of  vital  importance — ^the  works 
of  Bostook,  Blackley,  Dunbar,  and  Noon.  Many  other  compilations  are  extremely 
interesting,  notably  the  reports  of  Phoebus  and  Sticker,  but  they  serve  merely  to 
confirm  or  elaborate  previous  knowledge  of  the  disease. 

BIBLIOGRAPHT. 

1.  Bostock:  Case  of  a  Periodical  Affection  of  the  Eyes  and  Chest,  Medico-Chi. 

Trans.,  1819,  x,  pp.  161-165. 

2.  Botallus:  Commentarioli  duo,  alter  de  medici,  alter  de  aegroti  munere,  p.  128. 

Lugduni,  Gryphium,  1565. 

3.  Sticker.    Das  Heufieber  und  Verwandte  Stdrungen,  Wien  und  Leipzig.    Holder, 

1912. 

4.  Binninger.    Observationum  et  curationum  medicinalium  centurifle  V.    Montes- 

beligard,  1673.    Argentorati,  1676. 

5.  Ledelius.    Odor  rosarum   visiu  nocivus.    Miscellanea  curiosa,   Decuriae  II. 

Annus  2,  Norimbergae,  1684;  odor  rosarum  rubrarum  nocivus,  Ibidem,  1691. 

6.  Hilnerwolf.    De  catarrho  ad  nares  ex  rosarimi  odore.    Ephemerides  naturales 

ciuios.    Decuriae  II.,  annus  quintus,  anni  1686,  Norimbergae,  1687. 

7.  Constant  de  Rebecque.    Atrium  medicinae  helvetiorum,  Obs.  92,  Genevae,  1691. 

8.  Heberden.    Commentarii  de  morborum  historia  et  curatione,  p.  120.    Londoni, 

Payne,  1802. 

9.  Ibid.    History  and  Cure  of  Disease,  pp.  135-136.    London,  Payne,  1803. 

10.  Bostock.    The  Catarrhus  Aestivus,  or  Summer  Catarrh.    Medico-Chi.  Trans., 

1828,  xiv,  pp.  437-446. 

11.  Gordon.    Observations  on  the  Nature,  Cause,  and  Treatment  of  Hay  Asthma, 

Lond.  Med.  Gaz.,  1829,  ix.,  pp.  266-269. 

12.  Macculloch.    An  Essay  on  Remittent  and  Intermittent  Diseases,  vol.  i,  pp.  394, 

397.    London,  1828. 

13.  EUiottson.    Hay  fever  (part  of  a  clinical  lecture).  Lancet,  1830-31,  ii,  pp.  370- 

373;  Lond.  Med.  Gaz.,  1831,  viii,  pp.  411-413. 

.    Principles  and  Practice  of  Medicine,  pp.  719-782.    London,  Joseph 

Butler,  1829. 

•.    Ibid.    First  Amer.  from  Sec.  Lond.  ed.  pp.  771-780.    Phila.,  Carey 


and  Hart,  1844. 

14.  Phoebus.    Der  typische  Fruhsommer-Eatarrh  oder  das  sogenannte  Heufieber, 

Heu-Asthma,  Giessen,  Ricker,  1862. 

15.  Helmholz.    Mentioned  by  Binz-Pharmazeutische  Studien  Qber  Chinin.    Vir- 

chows  Archiv,  1869,  xlvi,  pp.  100-105. 

16.  Pirrie.    On  Hay  Asthma  and  the  Affection  Termed  Hay  Fever.    London, 

Churchill,  1867. 

,    On  Hay  Asthma,  Hay  Fever,  or  Summer  Fever.    Med.  Times  and  Gaz., 

1867,  ii,  pp.  2-4:  30-32. 

17.  Wyman,  Morrell.    Autumnal  Catarrh,  New  York,  1872.    2d  edition,  1886. 

18.  Beard.    Hay  Fever  or  Summer  Catarrh,  New  York,  Harper,  1876. 

19.  Blackley.    Catarrhus  Aestivus,  London,  Bailli^e,  Tindall,  and  Cox,  1873. 

20. .    Bemerkimgen  Uber  Dr.  G.  T.  Patton's  Experiments  Qber  Heufieber, 

Virchows  Arch.,  1877,  Ixx,  pp.  429-433;  Med.  Times  and  Gaz.,  1877,  ii,  p.  243. 

.    Hay  Fever,  Its  Causes,  Treatment,  and  Effective  Prevention,  2d  ed. 

London,  1880. 

.    On  the  Treatment  and  Prevention  of  Hay  Fever,  Lancet,  1881,  ii,  p.  371. 

-.    New  Observations  on  Hay  Fever  with  New  Experiments  on  the  Quan- 


tity of  Ozone  in  the  Atmosphere.    London,  1889. 
.    ,  British  Med.  Joum.  1898,  i,  pp.  867-868. 


PX7BLI0  HEALTH  AND  MBDIOINE.  323 

21.  Dunbar.    Zur  Ursache  tmd  Spezifischen  Heilung  des  Heufiebero,  Mttnchen, 

Vorlag  Oldenbouig,  1903. 

.    Zur  Frage  betreffend  die  Atiologie  iind  spezifische  Therapie  dee  Heufie- 

bers,  Berl.  klin.  Woch.,  1903,  xl,  24,  pp.  537-639;  26,  pp.  569-672;  26,  pp. 
596-699. 

22.  Heymann  and  Matzuschita.    Zur  £tiolQgie  des  Heufiebers,  Zeit.  f.  Hyg.,  1901, 

xxxviii. 

23.  Blnz.    Heufieber,  Verchows  Archiv.,  1871,  li. 

24.  Patton.    Uber  Etiologie  und  Therapie  des  Heufieber,  Verchows  Archiv.,  1876, 

Ixix. 

25.  Noon.    Prophylactic  Inoculation  Against  Hay  Fever,  Lancet,  1911,  i,  pp.  1572- 

1573 

26.  Curtis.    The  Immunizing  Cure  of  Hay  Fever,  N.  Y.  Med.  News,  1900,  Ixxvii, 

pp.  16-18. 

27.  Freeman.    Fiuther  Observations  on  the  Treatment  of  Hay  Fever  by  Hypodermic 

Inoculation  of  Pollen  Vaccine,  Lancet,  1911,  vol.  ii,  pp.  814-817. 

.    Vaccination  Against  Hay  Fever:  Report  of  Results  During  the  Last 

Three  Years,  Lancet,  1914,  i,  pp.  1178-1180. 

28.  Dunbar.    Weiterer  Beitrag  zur  Ursache  und  spezifischen  Heilung  des  Heufiebers, 

Deut.  med.  Woch.,  1903,  xxix,  9,  pp.  149-162. 

.    Zur  Heufieberatiologie,  Deut.  med.  Woch.  1903,  Nov.  9. 

.    Ursache  und  Behandlung  des  Heufiebers,  Leipzig,  1905. 

—       .    Zur  Ursache  und  spezifischen  Heilung  des  Heufiebers,  Deut.  Med. 

Woch.,  J911,_xxxvii,  No.  1,  p£.  578^583 


.    The  Present  State  of  Our  Knowledge  of  Hay  Fever,  JToum.  of  Hyg., 
1913,  vol.  xii.  No.  2,  pp.  105-148. 

29.  Prausnitz.    Die  Heufiebei:gifte,  Handb.  d.  Tech.  d.  Immun.  Eraus-Levaditi, 

Jena,  1907,  Fischer,  i,  pp.  317-330. 

.    Zur  Behandlung  des  Heufiebers,  Munch,  Med.  Woch. ,  1905,  Ui,  pp.  1106- 

.    Heufieber  Antitixin,  Ibid,  ii,  pp.  263-278. 

30.  Kammann.    Hofmeisters  Beitrage  zur  chemischen  Physiologie  und  Pathologie, 

1905,  Bd,  v. 

.    Das  Heufieber  und  seine  Serumbehandlimg,  Berl.  klin.  Woch.,  1906, 

xliii,  26,  pp.  873-877. 

31.  Weichardt.    Ol>er  das  Heufieberserum  und  &hnliche  Sera,  Cent.  f.  Bakt.,  1906, 

Ref.,  xxxviii,  p.  493. 

.    Zur  Serumbehandlung  des  Heufiebers,  Berl.  klin.  Woch.,  1906,  xliii, 

pp.  1184-1186. 

-.    Zur  Heufieberfrage,  Berl.  klin.  Woch.,  1907,  xliv.  No.  21,  pp.  678-679. 


32.  Liefman.    Ein  Beitrag  zur  Frage  nach  der  ^tiologischen  Bedeutung  gewisser 

Pflanzenpollenkorner  fur  das  Heufieber,  Zeit.  f.  Hyg.,  1904,  Bd.  xlvii,  pp. 
153-178. 

33.  Rosenau  and  Amoss.    Organic  Matter  in  the  Expired  Breath,  JTour.  Med.  Res., 

1911-12,  N.  S.  XX,  pp.  35-84. 

34.  Alexander.    The  Specific  Treatment  of  Hay  Fever.    Liverpool,  Med.  Chir.  Jour- 

nal, 1914;  xxxiv,  pp.  260-266. 
36.  Clowes.    A  Preliminary  C(»nmunication  on  Certain  Specific  Reactions  Exhibited 
by  Hay  Fever  Cases,  Proc.  Soc.  Exper.  Biol,  and  Med.,  N.  Y.,  1912-13,  x,  pp. 
69,  70-72. 

36.  Lovell.    The  Vaccine  Treatment  of  Hay  Fever,  Lancet,  1912,  vol.  ii,  p.  1716. 
.    Hay  Fever.    Practitioner,  1914,  xcii,  pp.  266-273. 

37.  Lowdermilk.    Hay  Fever.    Joum.  A.  M.  A.,  1914,  vol.  Ixiii,  No.  2,  pp.  141-142. 

38.  Ulrich.    Some  Notes  on  Hay  Fever.    Joum.  A.  M.  A.,  1914,  vol.  Ixii,  No.  16,  pp. 

1220-1222. 

6843^—17— VOL  X 22 


324       PBOOEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  CONGRESS. 

39.  Eoessler.    The  Specific  Treatment  of  Hay  Fever  (PoUen  Disease) ,  in  Forscheimers 

Therapeusis  of  Internal  Diseases.    Billings  and  Irons,  vol.  v,  pp.  671-706,  N.  Y. 
Appleton,  1914. 
.    The  Specific  Treatment  of  BEay  Fever  by  Active  Immunization.    Illi- 
nois Med.  JToum.,  1914,  vol.  xxiv,  pp.  120-127. 

40.  Manning.    Hay  Fever,  Its  Treatment  by  Injection  of  a  Solution  of  Ragweed 

Pollen.    Joum.  A.  M.  A.,  1916,  bdv,  pp.  655-657. 

41.  Cooke.    The  Treatment  of  Hay  Fever  by  Active  Immunization.    Laryngoscope, 

1915,  vol.  XXV,  No.  2,  pp.  108-112. 

42.  Wood.    Hay  Fever  and  Asthma.    Chicago  Med.  Rec.,  1915,  vol.  xxxvii,  No.  8, 

pp.  453-459. 

43.  Goodale.    Pollen  Therapy  in  Hay  Fever.    Boston  Med.  and  Suig.  JToum.,  1915, 

clxxiii.  No.  2,  pp.  42-48. 

Dr.  Lung  presiding. 

Dr.  Weil.  Mr.  Chairman,  I  do  not  believe  you  can  combine 
incompatibles.  Either  one  of  the  two  things  is  correct,  and  I  do  not 
believe  that  it  amoimts  to  the  same  thing  to  say  that  it  occurs  inside 
the  cells  or  that  it  occurs  outside  the  cell.  If  it  occurs  within  the 
cell;  as  Dale  has  pointed  out  repeatedly,  and  as  Bayliss  has  confirmed 
— and  as  I  believe,  as  far  as  I  can  follow  the  discussion.  Dr.  Clowes 
also  beUeves — ^if  it  occurs  in  the  cell,  it  is  a  physical  phenomenon. 
If  it  occurs  in  the  serum  and  anaphylatoxin  is  part  of  the  mechanism, 
it  is  a  chemical  phenomenon  and  can  be  produced  by  incubation. 
Now,  it  does  not  do  to  try  to  combine  those  ideas.  One  of  them  is 
correct  and  the  other  one  is  wrong,  and  whichever  point  of  view  is 
eventually  accepted,  the  other  one  will  have  to  be  given  up.  I  am 
not  here  to  try  to  prove  to  anybody  that  one  is  absolutely  right  and 
the  other  absolutely  wrong.  Of  course,  my  own  conviction  has  been 
stated.  It  is  not,  Dr.  Bronfenbrenner,  that  the  humeral  theory  is 
conservative.  The  first  theory  was  the  cellular  theory,  advanced 
by  Otto,  accepted  by  Friedbeiger,  and  was  the  older  theory.  That 
was  given  up  later  by  Friedberger,  when  he  fell  in  love  with  anaphy- 
latoxin, and  subsequently  the  cellular  theory  has  been  advanced  by 
Dale  and  by  Doerr,  who  has  come  to  adopt  it. 

Dr.  Clowes.  I  just  want  to  make  it  clear  that  I  am  in  favor  of 
the  view  that  it  is  physical. 

The  Chairman.  If  there  is  no  objection  we  will  hear  from  Dr. 
Clowes. 

Dr.  Weil  took  the  chair. 

Dr.  Clowes.  We  have  studied  in  the  last  few  years  a  very  large 
number  of  cases  of  hay  fever,  some  hundred  or  so.  As  you  know, 
Dunbar,  Wright,  and  others  worked  on  the  subject.  I  think  that 
we  were  the  first  to  demonstrate  that  it  is  possible  to  immunize 
against  the  autumnal  form  of  hay  fever  by  injecting  extracts  of 
the  pollens  of  ragweed  and  goldenrod.  We  test  cases  by  the  ophthal- 
mic and  the  cutaneous  reactions.    To  those  who  would  like  to  see 


PUBLIC  HEALTH   AND  MEDICINE.  325 

a  demonstration,  I  may  say  that  I  happen  to  be  susceptible  to  rag- 
weed and  can  thus  far  show  the  tests  on  myself.  The  treatment  is 
successful  in  30  to  40  per  cent  of  individuals  when  they  are  immunized 
against  the  particular  form  of  pollen  to  which  they  are  sensitive. 

The  group  reactions  of  pollen  are  very  interesting.  The  Granie- 
nacesB  and  CompositaB  are  the  two  most  important  families,  the  pollens 
of  which  give  reactions.  In  the  CompositsB,  ragweed  and  goldenrod 
are  closely  related  and  the  dandelion  distantly  related.  If  you  are 
sensitive  to  one  pollen  you  are  liable  to  be  sensitive  to  another 
closely  related  pollen.  If  you  are  sensitive  to  ragweed  you  will  be 
sensitive  to  goldenrod,  but  the  degree  of  sensitiveness  may  vary 
considerably;  but  you  may  be  free  from  any  sensitiveness  to  dande- 
lion.   It  is  like  the  groups  reactions  exhibited  in  animals. 

It  is  perfectly  possible  to  be  highly  susceptible  to  ragweed  and  gold- 
enrod pollens  and  also  to  display  the  same  sensitiveness  to  grasses. 
Occasionally  we  find  an  unfortimate  individual  who  is  sensitive  to 
the  grasses  in  the  spring  and  to  the  autimmal  pollens.  If  you  inject 
such  a  case  with  pollen  extracts  of  one  of  the  groups  to  which  he  is 
sensitive,  it  leaves  him  just  as  sensitive  to  the  other.  As  regards 
asthma  it  is  interesting  to  note  that,  even  if  no  very  definite  hay 
fever  symptoms  are  exliibited,  cases  of  seasonal  asthma  will  fre- 
quently respond  to  treatment  with  specific  pollens  to  which  they 
are  sensitive. 

I  want  to  mention  the  fact,  too,  that  I  believe  the  great  majority 
of  us  are  subject  to  sensitization  phenomena.  Not  that  everyone 
of  us  is  afflicted  with  hay  fever  or  asthma,  but  we  have  a  lot  of  in- 
testinal and  other  disturbances  which  are  not  fully  understood, 
but  which  to  judge  from  blood  reaction  are  probably  attributable  to 
foreign  proteins  derived  from  foodstuffs,  etc.  Furthermore,  there 
is  a  hereditary  predisposing  tendency  to  develop  sensitization, 
which  I  consider  is  simply  due  to  the  fact  that  our  protoplasm  is 
more  or  less  permeable,  as  indicated  previously.  These  charts  repre- 
sent families  exhibiting  a  predisposition  to  sensitization,  and  you 
see  how  closely  analogous  they  are  to  Mendelian  theories.  You  see 
the  ratios  in  which  the  condition  tends  to  occur  in  certain  families. 
Owing  to  the  prevalence  of  weeds,  particularly  ragweed  and  golden- 
rod, in  Buffalo  and  vicinity  conditions  are  favorable  for  hay-fever 
development,  consequently  many  children  belonging  to  susceptible 
strains  develop  the  condition  who  might  escape  in  other  localities. 
Using  the  opthalmic  test,  the  rise  in  resistance  under  treatment  may 
be  noted.  But  I  want  you  to  note  the  immediate  drop  in  resistance 
afterward.  The  response  is  not  permanent,  but  there  is  this  to  be 
said,  that  the  individuals  who  are  treated  from  year  to  year  do 
apparently  acquire  finally  an  increased  immunity. 


326       PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC   CONGRESS. 

Another  important  point:  We  may  use  calcium  salts  with  great 
effect  in  certain  individuals  who  do  not  react  to  the  immune  pro- 
cedures, especially  fat  people,  and  that,  again,  fits  into  my  theory 
that  it  is  a  question  of  the  solubility  ot  calcium  salts  in  fat.  It  is 
a  fact  that  calcium  salts  act  very  well  with  fat  people  and  very 
badly  with  thin  people,  and,  again,  I  think  it  is  due  to  the  permea- 
bility of  the  protective  film. 

Another  point  I  want  to  bring  out  is  that  we  have  had  some  extraor- 
dinary cases  of  immunization.  A  lady  came  to  us  with  hay  fever. 
We  tried  her  with  every  possible  pollwi  and  she  gave  no  reaction. 
But  she  said  that  she  was  certain  she  was  sensitive  to  flies.  We 
collected  the  particular  flies  that  she  said  she  was  susceptible  to, 
obtained  a  solution  after  precipitation  with  acetone,  gave  her  two 
or  three  injections,  and  she  claimed  she  improved.  At  least  there 
was  a  reaction,  specific  and  not  simply  local — not  of  the  skin  alone 
but  systemic- 
There  is  occasionally  a  complement  deviation  in  the  blood. 
The  Chairman.  Have  you  anything  to  add.  Dr.  Kitchens? 
Dr.  Kitchens.  I  have  nothing  to  add,  Mr.  Chairman,  except  to 
state  that  we  have  observed  some  patients  who  have  been  suscep- 
tible all  the  year  around,  and  after  two  years'  treatment  have  been 
apparently  cured.  We  have  been  working  on  hay  fever  about  four 
years  and  we  have  had  62  cases.  I  have  forgotten  just  what  per- 
centage have  been  entirely  relieved  by  treatment.  One  very  inter- 
esting case  susceptible  to  this  pollen  has  been  relieved.  In  our 
paper  we  have  gone  into  the  history  of  the  problem.  We  have 
done  that  with  a  particular  end  in  view,  since  most  of  the  present- 
day  writers  are  apparently  ignoring  the  work  of  Blackley,  and  any 
one  who  will  take  the  trouble  to  read  his  little  work,  published  in 
1873,  will  see  that  he  has  done  all  the  work  that  one  could  do  up 
to  that  time.  Then  there  was  very  little  known  about  the  chem- 
istry of  proteins,  and  it  remained  for  Dunbar  to  clear  up  the  chem- 
istry of  the  proteins.  Active  or  passive  immunity  did  not  exist 
in  the  literature  at  that  time,  except,  of  course,  in  smallpox  vaccina- 
tion, so  that  all  we  have  added  since  Blackley  has  been  chemistry 
and  active  and  passive  immunization.  So  I  think  in  our  future 
work,  before  claiming  originality  for  anything,  we  should  be  pretty 
familiar  with  Blackley. 

Dr.  J.  Bronfenbrenner.  I  happened  to  have  a  patient  with  an 
idiosvncrasy  to  egg  white,  and  it  was  very  dangerous  to  immunize  her 
actively,  because  together  with  intestinal  disturbance  she  has  very 
severe  asthma  whenever  the  amount  of  antigen  injected  is  great 
enough.  Now,  we  began  by  injecting  her  with  dilutions  of  0.02 
c.  c,  1-8000,  and  we  have  come  inside  of  two  months  no  further 


PUBUC   HEALTH   AND  MEDICINE.  327 

than  tho  same  amount  Of  dilution,  1-2000 — just  four  times  as  much. 
What  is  your  prognosis  in  that  case  i 

Dr.  Lyster.  As  one  wlio  is  interested  principally  in  the  practical 
side  of  this  subject  I  wish  to  say  that  I  hope  it  will  not  be  lost  sight 
of  completely,  and  that  we  will  hear  something  more  of  the  prac- 
tical side  of  the  results  of  Dr.  Clowes's  and  Dr.  Hitchens's  work. 

Dr.  Tom  Williams.  I  would  like  to  ask  Dr.  Clowes  if  he  has 
observed  any  relationship  to  adrenal  administration  in  anaphylactic 
reactions  of  these  people,  also  in  regard  to  the  giving  of  morphine. 
The  reason  I  ask  is  because  I  have  had  cases  in  which  adrenal 
substance  has  diminished  this  tendency  and  in  which  the  taking  of 
morphine  has  diminished  it  or  caused  it  to  cease.  One  man,  I  think, 
became  a  morphine-maniac,  and  when  ho  took  morphine  the  condition 
ceased. 

Dr.  Kebler.  I  would  like  to  ask  the  doctor  if  he  has  had  any 
experience  with  the  product  containing  a  very  small  amount  of 
cocaine  which  has  recently  been  put  on  the  market. 

Dr.  Brown.  I  wish  simply  to  say  that  in  our  observations  we  find 
the  skin  reaction  entirely  satisfactory,  and  we  are  rather  inclined  to 
discountenance  the  use  of  the  ophthalmic  reaction  and  think  it  should 
be  eliminated  entirely.  We  believe  that  in  the  hands  of  the  general 
practitioner  there  may  be  some  dangerous  reactions.  The  skin  reac- 
tions are  very  satisfactory,  and  if  we  find  the  particular  protein  to 
which  the  patient  is  susceptible  we  will  be  able  to  relieve  all  their 
symptoms,  even  though  they  are  asthmatic. 

Dr.  Weil.  I  would  like  to  ask  if  anyone  has  ever  had  the  temerity 
to  inject  any  of  these  subjects  intravenously,  whether  there  is  then 
the  localized  reaction,  or  whether  there  is  a  generalized  reaction? 
Of  course,  if  one  used  small  amoimts  it  would  be  a  perfectly  harm- 
less thing.  I  do  not  know  that  it  has  ever  been  done.  I  believe 
injections  have  been  done  subcutaneously,  and  then  I  believe  there 
were  distinct  sjrmptoms  from  the  injecticm  of  the  antigen. 

Dr.  Brown.  We  have  injected  guinea  pigs  subcutaneously  and 
intraperitoneally  with  the  idea  of  sensitization,  and  later  gave  5  c.  c, 
both  doses  representing  1  milligram  of  protein.  No  symptoms 
occurred.  One  of  the  manifestations,  I  might  say,  of  the  subcu- 
taneous injection  of  human  beings  with  these  small  doses  of  protein 
is  that  within  5  to  10  minutes  the  patients  notice  a  distinct  drying 
of  the  mucous  membranes  of  the  nose. 

Dr.  Clowes.  So  far  as  I  am  aware  I  was  tho  first  to  experiment 
with  active  vaccination  against  the  autumnal  form  of  hay  fever 
by  injecting  the  extracts  of  ragweed  pollen,  and  I  was  the  first 
individual  tested.  I  would  not  for  one  moment  suggest,  of  course, 
that  I  was  the  first  to  take  up  this  general  problem.  There  was 
no  chance  in  the  limited  time  at  my  disposal  to  talk  about  previous 


328       PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC   CONGRESS. 

work,  with  which  I  presumed  you  were  well  acquainted.  It  has 
been  gone  over  very  extensively  by  numerous  investigators.  The 
originator,  of  course,  on  a  large  scale,  was  Dimbar,  followed  by 
Wright  and  his  pupils.  We  introduced  the  method  of  acetone 
precipitation,  which  has  given  satisfactory  results.  I  worked  up  the 
dosage  on  myself  and  have  also  given  myself  a  small  intravenous 
injection,  I  am  glad  to  say  without  result,  but  I  have  experienced  a 
mild  anaphylactic  shock.  In  order  to  keep  my  experimental  squad 
together  I  ran  up  my  dose  a  good  deal  ahead  of  theirs  and  got  an 
anaphylactic  shock.  I  have  since  used  that  dose  as  the  limit  and 
have  noted  that  a  slight  anaphylactic  shock  leads  to  suppression  of 
hay  fever  symptoms.  It  is  a  dangerous  thing  to  work  with,  so  we 
start  in  with  a  very  small  dilution  and  work  up.  We  have  worked 
up  to  1  c.  c.  of  1-1.000.  We  give  15  or  20  small  doses  at  an  inter- 
val of  two  or  three  days.  Dunbar  particularly  gave  up  any  attempt 
at  active  immunization,  because  he  started  in  one  of  his  cases  with 
10,000  times  the  dose  we  give,  and  it  took  him  several  days  to  pull 
his  case  through.  I  have  tried  all  sorts  of  antigen  and  antibody 
combinations,  taking  my  own  serum  and  the  serum  of  other  sensitive 
individuals  with  an  antigen,  and  tried  by  incubation  to  get  anaphy- 
latoxins  and  to  utilize  them  on  nonsensitive  individuals  with  abso- 
lutely no  result.  I  have  never  been  able  to  prove  anything  in  that 
way,  which  is,  I  believe,  in  support  of  Dr.  Weil.  With  regard  to 
drugs,  I  have  tried  morphine  and  other  drugs  with  absolutely  no 
results  excpt  temporary  alleviation.  Cocaine  was  mentioned.  It 
does  give  a  temporary  alleviation;  it  is  not  a  cure;  can  not  be  a  cure, 
and  simply  gradually  weakens  resistance  to  the  disease. 

My  condition  five  years  ago  had  reached  the  point  where  I  was 
incapacitated  during  the  hay-fever  season,  but  the  last  four  years 
I  have  been  able  to  carry  on  my  work  as  weU  as  I  can  now.  Those 
for  whom  we  can  do  nothing  are  generally  the  ones  for  whom  we 
can  not  at  present  find  the  particular  plant  or  protein  to  which  they 
are  sensitive.  I  do  firmly  believe  that  when  we  find  the  particular 
protein  we  shall  be  able  to  relieve  them.  As  regards  the  lady  Dr. 
Bronfenbrenner  could  not  work  on  for  egg  white,  I  should  advise  her 
to  keep  away  from  egg  white.  If  you  find  such  diflBculty  in  running 
up  resistance  against  pollens  or  food  proteins,  then  I  would  most 
undoubtedly  advise  the  person  to  go  to.  another  locality  or  to  give 
up  the  particular  protein  to  which  they  are  sensitive,  because  it  is 
probably  a  question  of  greater  permeability  of  the  intestinal  tract 
and  mucous  membranes  as  compared  to  other  people. 

Dr.  Bbonfenbbenneb.  If  she  just  goes  into  a  drug  store  for  a  glass 
of  soda  water,  drinking  from  a  glass  that  has  contained  egg  white,  she 
develops  the  marked  symptoms. 


PUBUG  HEALTH  AND  MEDICINE.  329 

Dr.  Clowes.  I  have  seen  innumerable  cases  like  that  with  fish,  etc.^ 
where  there  would  be  urticaria  and  other  most  distressing  symptoms. 
The  high  degree  of  sensitiveness  which  is  developed  is  really  extrar 
ordinary.  Dr.  Weil's  question,  as  to  whether  a  calcified  brain  is 
more  permeable  or  less  permeable,  is  most  important.  That  is  what 
old  age  would  seem  to  be.  In  old  age  there  is  the  ever-increasing 
effect  of  toxins  and  destructive  agents  upon  delicate  protective 
films,  tending  to  break  down  and  interefere  with  these  films. 

Calcium  is  mobilized  to  protect  the  film,  and  consequently  we  find 
increased  calcium  in  old  age,  arteriosclerotic  calcification  in  the 
brain,  etc.  It  might  be  possible  on  this  basis  to  produce  a  structure 
resembling  an  egg  shell.  I  have  a  chart  showing  calcium  coimter- 
aoting  many  himdredfold  the  amoimt  of  caustic  soda  and  oleate 
that  we  use  in  ordinary  drop  experiments.  Whenever  we  have  cal- 
cium deposited  in  huge  quantities  it  appears  to  have  been  mobilized 
to  counteract  the  destructive  effect  of  ferments  and  other  dispersing 
or  destructive  agents. 

Dr.  Keblbb.  Since  the  doctor  has  brought  up  this  question  of 
calcium  so  prominently  I  would  remind  him  that  there  has  been  a 
great  deal  of  work  done  on  the  value  of  calcium  compounds  in  the 
treatment  of  tuberculosis.    Has  the  doctor  any  views  on  that  point  t 

Dr.  Clowes.  Simply  that  calcium  increase  may  be  helpful  in 
coimteracting  toxic  agents.  Calcium  may  be  used  to  advantage  in 
counteracting  conditions  where  increased  permeability  of  the  tissues 
occurs.  It  acts  at  first  by  promoting  continuity  of  the  film  and  by 
preventing  its  destruction.    Ultimately  calcification  occurs. 

The  Chairman.  If  there  is  no  objection  the  following  papers  will 
be  read  by  title: 

Seroterapia  antipestosa  intensiva,  by  Jo86  Moreno. 

El  asma,  by  J.  A.  Rampini. 


SEROTERAPU  antipestosa  INTENSITA  (MfiTODO  DE  PENNA). 

Por  J0S6  MORENO, 

ProfuoT  SuplerUe  de  MaUria  Midica  y  Terapia  en  la  PacuUad  de  Mediemoy  de  Bumo$ 

Aim,  Argentina. 

I. 

La  peete  bub6nica  ha  sido  obaenrtda  por  primera  ves  en  la  Repdblica  Aigentina 
al  miflino  tiempo  que  la  epidemia  de  Oporto  en  1809. 

Segiin  ke  inveetigacioneB  de  Agote  y  Medina  (La  pesto  bubonique  dans  la  R6pubU> 
que  Aigentine  et  au  Panguay,  1901),  ella  habrk  ddo  diiectamente  importada  por  el 
paquete  ZeUr  cuyas  mercadeiiaB  infectadas  fneron  en  parte  tranabordadas  al  vapor 
CmUauro  de  la  Gimra  de  Montevideo  a  la  Aaunddn  (Capital  del  Puaguay).  En  eato 
ytipon  muzieion  ties  tripulantea  (abril  de  1899)* 


330       PBOCEEDINQS  SECOND  PAN  AMEBIGAN  SCIENTIFIC  CONQBESS. 

La  epidemia  tx>m6  cuerpo  en  la  ABunci6n  y  una  comiai6n  argentina  fu^  designada 
pan  Bu  estudio. 

Deecendiendo  por  el  Rio  Parand  doe  focos  principalee  se  deaarrollaron  en  los  puertos 
m^  importantes  de  este  rfo,  Roflario  y  San  Nicolis. 

Loe  piimeroB  cafloe  en  Buenos  Aires  fueron  internados  en  la  Gaaa  de  AlBlamiento  en 
enero  de  1900.  Provenian  del  Puerto  de  esta  Ciudad  y  fueron  adstidoB  y  obeervadoB 
por  el  Dr.  Jos^  Penna,  profesor  de  clfnica  epidemioldgica  en  nuestra  univeividad. 

Con  inlervalos  mia  o  meBoa  largoi  nuevoe  enfermoB  ban  sido  observadoe  y  algunas 
epidemias  ee  reproducen  de  1005  a  1912. 

Las  formaa  clinicas  mis  frecuentes  ban  aide:  V,  GangUonaree:  (a)  de  tipo  agudo;  (6) 
subagudas;  (c)  cr6nico.  2^,  Neum6nicaB:  (a)  neumonias  francas;  (6)  bronconeumo- 
nias.    3®,  Septlc^micas.    4^,  Carbunculares. 

II. 

llientras  Calmette  y  Salimbeni  en  Oporto  introdujeron  en  la  terapia  de  la  paste 
la  via  endovenosa  para  la  apMcacidn  del  suero  antipestoso  y  duplicaban  las  dosis  hasta 
entonces  empleadas,  Penna  aplica  tambi^n  en  Buenos  Aires  este  m^todo,  sin  cono- 
dmiento  previo  de  la  observacidn  de  aquellos  cuya  comunicaci6n  (Annales  de  Tlnsti- 
tut  Pasteur,  1899)  lleg6  a  Buenos  Aires  a  fines  de  enero  de  1900). 

Penna  habla  empleado  repetidas  voces  el  m^todo  de  la  inyecci6n  endovenosa  de 
divevsai  aolucionea,  pr^ctica  adquirida  durante  la  epidemia  de  c61era  de  1886  con  los 
Suexos  de  Hayem,  motivo  por  el  cual  la  via  sangulnea  fu6  tambito  elegida  por  41  para 
tratar  la  peste. 

Pero  aparte  de  esta  coincidencia  tx>n  el  m^todo  de  Calmette  y  Salimbeni,  una  modi- 
ficaci6n  fundamental  fu6  introdudda  poco  despu^  por  el  profesor  argentine  en  el 
tratamiento  de  los  nuevos  caaos  de  peste.  Con8iBti6  ella  en  el  aumento  progresivo  de 
las  dosis  de  suero  antipestoso  por  la  via  venosa,  hasta  llegar  al  doble,  triple  y  atin 
sextuplicar  las  cantidades  emi^eadas  por  aquellos  en  una  sola  inyecci6n. 

Este  procedimiento  francamente  intensive  constituye  un  progreso  excepcional  para 
la  ^poca,  tanto  m^  digno  de  menci6n  cuanto  que  las  observaciones  posterioree  en 
Bradl-Argentina  y  atin  en  la  India  actualmente  confirman  los  6xitos  de  las  grandes 
dosis.  Cuando  se  lee  la  comunicaci6n  de  Calmette  y  Salimbeni  y  se  hace  el  examen 
de  las  observaciones  x>or  ellos  efectuadas  en  Oporto  es  f^il  convencerse  de  que  el 
maximum  de  las  dosis  de  suero  empleadas  por  estos  en  las  inyecciones  endovenosas  no 
excede  de  20  c.  c.  en  una  sola  vez,  dosis  que  se  repite,  con  excesiva  prudencia  en 
los  dlas  subsiguientes,  altemadas  en  muchos  cases  con  dosis  subcut^eas  de  40  c.  c. 
como  maximum,  y  que  demuestran  no  solamente  prudencia  sino  relative  temor  al 
suero  por  via  endovenosa  como  lo  comprueba  la  observacidn  del  malc^rado  medico 
Dr.  C&mara  Pestana  fallecido  alll  y  quien  a6lo  en  los  liltimos  dlas  de  su  grave  infecci6n 
recibi6  moderadas  inyecciones  por  via  sangulnea. 

Penna  en  Buenos  Aires  aument6  muy  pronto  estas  dosis  que  Calmette  llamaba 
''Massives  "  sustituy^ndolas  por  otras  intensivas  primero  de  70  c.  c.  en  una  sola 
inyecci6n  endovenosa  (suero  antipestoso  del  Instituto  Pasteur)  y  m^  tarde  las  elev6 
hasta  100  y  120  c.  c.  del  mismo  suero,  que  se  repiteu  sin  inconvenionte  a  las  12,  24 
y  48  horas  despu^  si  es  que  los  slntomas  de  la  infecci6n  asl  lo  requieren. 

Esta  prictica  de  felices  resultados  constituye  esto  que  llamamos  en  la  Argentina 
Seroterapia  intravenosa  intenaiva  y  para  el  que  propongo  la  denominaci6n  de  m^todo 
americano  de  Penna. 

Las  observaciones  primeras  de  este  m^todo  fueron  consignadas  al  Profesor  Lignieres 
con  el  resumen  en  los  15  cases  iniciales  donde  Penna  escribe: 

Creo  que  la  mortalidad  de  21  por  ciento  habrla  side  mds  reducida  si  desde  el  prin- 
cipio  hubiera  sabido  manejar  mejor  el  suero,  pues  posteriormente  y  con  mds  expe- 
riencia  he  vlsto  curar  cases  m^  graves  que  los  que  fatlecieron  usando  el  medicamento 
a  dosis  masivas-intensivas.     En  efecto  la  observacidn  pronto  me  revel6  que  para 


PUBUC   HEALTH  AND  MEDICINE.  331 

lograr  ^xito  era  menester  como  en  la  difterla  emplear  doeis  suficientes  en  tiempo 
oportuno.  (Carta  a  Lignieree,  abril,  1000;  Pemia,  Lecciones  clinicas  eoVre  la  peete 
bub6nica,  1902.) 

Posteriormente  y  gracias  a  nuevoe  casoB  Penna  lleg6  a  perfeccionar  su  m6todo 
probando  la  inocuidad  de  las  alias  doos  de  saero. 

Noeotrofl  hemoe  empleado  este  procedimiento  llegando  hasta  inyectar  400  c.  c.  en 
tree  inyeccionee  con  12-24  y  48  hona  de  intervalo  sin  otra  consecaencia  que  los 
pequeftos  fen6menoe  de  la  llamada  ''Enlennedad  sMca  de  Von  Pirquet'*  loe  que 
per  otra  parte  861o  se  observan  en  un  ntimero  limitado  de  enfermoe. 

En  lo  que  se  ref iere  a  loe  resultadoe  noeotros  hemes  consignado  en  un  trabajo  sobre 
seroterapia  antipestoea  (tesis  de  prolesorado)  que  las  estadistdcas  en  las  epidemias 
americanas  tratadas  por  eete  m6todo  son  las  que  dan  menor  mortalidad;  Chodsky  en 
la  India  lo  emplea  (por  via  subcut^mea)  y  sobre  13,000  cases  ccmfinna  loe  buenos 
efectos  de  las  doeis  intensivas.  Adem^  la  obaervacidn  de  loe  casos  demuestra  una 
evoluci6n  m^  favorable  segtin  anotaremos  en  breve. 

Entretanto  sostenemos  que  la  seroterapia  antipestosa  intensiva  constituye  una 

ampliaci6n  fundamental  sobre  el  m^todo  masivo  de  Calmette  y  Salimbeni,  que  ai  en 

nada  amenglia  la  gloria  de  tan  eminentes  sabios,  merece  en  cambio  ser  aaotado  en 

honor  del  distinguido  clfnico  argentine  Profesor  Penna.    Y  con  tanta  mayor  justicia 

cuanto  que  en  la  6poca  en  que  dicha  modificaci6n  fu6  inidada  el  criterio  sobre  admi- 

nistracidn  de  sueros  por  via  endovenoea  y  a6n  subcut&nea  no  era  amplio  como  en  la 

actualidad. 

III. 

En  1906  y  1912  hemos  aplicado  la  seroterapia  intravenosa  intensiva  a  pestes  gan- 
glionares  neum6nicas  y  septic^micas  y  he  aquf  nuestras  comprobaciones. 

Pestes  ganglionares  agudas. — Nuestras  observaciones  se  refieren  a  casos  en  todoe 
los  cuales  la  presencia  del  bacilo  de  Yersin  ha  sido  revelada  por  el  examen  directo 
de  punci6n  de  ganglios  infartados  o  por  cultivos  o  inoculaciones  verificadas  en  el 
laboratorio  del  Hospital  Mufiiz,  dirigido  por  el  Profesor  Uriarte. 

En  las  formas  agudas  el  principle  brusco  se  acompafia  de  grandes  elevaciones 
t^rmicas  40**  y  41** — delirio — inyecci6n  conjimctival,  estado  tifoideo  con  infortos 
simples  o  multiples  visiblen  dolorosos  y  de  tumefacci6n  r&pida.  La  inyecci6n  intra- 
venosa de  100  a  120  centfmetros  cdbicoe  de  suero  produce  casi  inmediatamente  una 
mayor  elevaci6n  t^rmica  de  1^  y  atin  m^,  seguida  al  cabo  de  un  breve  intervalo, 
doe  o  tres  horas  de  un-descenso  que  llega  hasta  la  normal  37**  o  cerca  de  ella.  En 
muchos  casos  la  fiebre  no  reaparece  y  la  mayorfa  de  los  sfntomas  generales  incluso  el 
bub6n  se  atendan.  El  infarto  ganglionar  se  resuelve  a  vista  de  ojo  como  decla  Yersin, 
frase  oportuna,  porque  en  efecto  hay  bubones  cuya  tumefacci6n  dioninuye  notable- 
mente  en  pocas  horas,  por  la  acci6n  del  suero. 

En  otros  cases  una  nueva  elevaci6n  t^rmica,  casi  siempre  menor  que  la  primitiva 
indica  la  necesidad  de  una  nueva  dosis,  de  refuerzo  observdndose  que  efectivamente 
la  fiebre  desciende  como  si  se  tirase  la  temx>eratura  hacia  la  normal. 

Esta  evolucidn  ee  la  mds  favorable;  loe  enfermos  al  cabo  de  una  o  dos  inyecciones 
de  100  a  120  c.  c.  de  suero  curan  en  pocos  dfas. 

En  im  tcrcer  grupo  el  gran  ascenso  t^rmico  dominado,  sobrevienen  nuevas  tempera- 
turas  de  tipo  irreguliur  con  poca  alteraci6n  del  estado  general,  que  producen  remisiones 
irregulares,  acompafldndoee  este  estado,  con  infarto  doloroeo,  edematoso  y  tendencia 
a  la  supuraci6n.  El  abceso  ganglionar  se  forma  y  la  fluctuaci6n  indica  el  memento 
de  abrirlo  y  drenarlo  siguiendo  la  curaci6n  como  un  abceso  comdn. 

En  los  sujetos  inyectados  los  bubones  secundarios  no  presentan  la  agudez  ni  la 
gravedad  que  en  otros  en  donde  el  reblandecimiento  de  infartos  antiguos  llega  hasta 
produdr  una  septicemia  pestosa  aguda  y  la  muerte,  case  observado  una  vez  en  el 
Hospital  Mufiiz. 


332       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  CONGBESS. 

Infartos  ganglianares  suh-agtuhs  y  crdnicos. — ^Las  fonnas  ganglionares  subagudas  se 
caracterizan  por  una  defensa  del  oiganiamo  que  resiste  a  la  violencia  inicial  comdn 
y  localiza  la  infecci6n  a  loe  gnipos  ganglionares  sin  grave  repercuai6n  sobre  el  estado 
general.  Nosotros  hemes  visto  muchos  enfermoe  cuya  infecci6n  databa  de  dos  y 
tres  semanas.  La  temperatura  en  eetos  cases  no  eramuy  elevada  (38^,  38.5^),  losganglios 
doloroeos,  a  voces  edematizados  y  adheridoe  o  aislados,  ya  con  sfntomas  de  pronta 
supuraci6n  o  en  ciertos  cases  duros  adn. 

El  tratamiento  lo  efectuamos  con  el  mismo  m^todo  que  para  los  anterioree.  EstxM 
cases  y  los  del  tipo  cr6nico  presentan  esta  particularidad  que  los  sfntomas  de  infecci6n 
ceden  Mcilmente;  pero  el  infarto  es  mds  rebelde,  tienen  pues,  esto  de  paiad<5gico,  la 
infecci6n  mds  benigna,  y  la  enfermedad  m&s  larga.  Muchas  voces  hay  que  provocar 
la  resoluci6n  o  la  supuraci6n  ya  con  los  emolientes  continuos  o  por  inyecci6n  de 
sustancias  provocadoras  de  leucocitosis.  Hemes  empleado  en  algunoe  la  inyecci6n  en 
el  ganglio  de  una  soluci6n  de  nucleinato  de  soda  al  1/100  de  1  a  2  c.  c.  con  la  cual  se 
provoca  una  supuraci6n  r4pida. 

InfartoB  crdnicos. — ^E^tas  pestes  ambulatorias  se  confunden  a  menudo  con  adenitis 
diversas^  especialmente  tuberculosas.  Ellas  han  dado  origen  al  estudio  del  llamado 
tambi6n  '*bub6n  climdtico''  que  para  algunos  au tores  no  es  sine  la  variedad  de  peste 
atenuada. 

Nosotros  las  hemes  observado  en  sujetos  habitantes  de  r^ones  o  locales  infectadoe. 
El  principio  de  la  afecci6n  es  lento,  los  sfntomas  reaccionales  muy  benignos.  Las 
punciones  de  los  ganglios  dan  muchas  voces  resultados  negatives  en  el  examen 
bacterio]6gico  directo;  pero  insistiendo  en  la  investigaci6n  y  sobre  todo  con  los  cultivos 
e  inoculaciones  llega  a  encontrarse  el  germen  pestoso.  Hemes  hecho  referenda  al 
peligro  de  un  posible  reblandecimiento  ganglionar  tardlo  y  la  aparici6n  de  una 
septicemia  aguda.  El  Profesor  Penna  pudoobservar  un  case  de  ^stos;  el  sujeto 
portador  de  los  ganglios  durante  varies  meses  muri6  en  el  Hospital  Muiliz  y  la  autopsia 
confirm6  el  case.  Esta  ensefianza  determina  la  necesidad  del  tratamiento  especifico 
por  el  suero,  aunque  los  sfntomas  clfnicos  sean  poco  intensos.  Hay  cases  en  donde  el 
reblandecimiento  ganglionar  reviste  el  tipo  necr6tico  cuya  reparaci6n  es  lenta  y  la 
cicatrizaci6n  se  rodea  de  tejidos  duros  lefiosos .  El  tratamiento  de  la  forma  ganglionar 
cr6nica  puede  ser  menos  intensivo;  nosotros  hemes  hecho  grandes  y  moderadas  dosis 
120-100  y  hasta  80  c.  c.  en  ciertos  cases  intravenosas  en  otros  subcutdneas.  Aconse- 
jamos  no  emplear  la  via  endovenosa  si  previamente  se  ha  hecho  la  subcut&nea. 
Pueden  aaimismo  no  repetirse  con  poco  intervale.  A  voces  hacemos  una  inyeccidn 
cada  seis  dfas  hasta  tres  y  cuatro  inyecciones. 

Pestes  neumdnicas. — Las  formas  clfnicas  observadas  han  side  del  tipo  de  neumonia 
y  bronco-neumonia.  A  voces  los  tipos  septic6micos  se  agregan  a  los  neum6nicos  con 
tal  rapidez  que  es  diffcil  determinar  si  la  forma  es  pnmitiva  o  secundaria.  Esta 
invasi6n  sangufnea  y  las  degeneracionee  parenquimatosas  agudas  indican  la  necesidad 
de  las  inyecciones  intensivas  precoces  y  repetidas.  S61o  asf  pueden  justdficarse  los 
^xitos  relatives  en  las  epidemias  sudamericanas  frente  a  la  estadfstica  de  la  dltima 
epidemia  de  Mandchuria  cuya  mortalidad  ha  side  de  100  por  100  en  las  formas 
neum6nicas. 

En  Brasil,  Ferreyra  y  Tavares  de  Macedo,  han  salvado  cases  neum6nicos  de  peste 
por  las  grandes  inyecciones. 

En  Buenos  Aires  Penna  y  los  medicos  del  Hospital  de  Aislamiento  (Bonorino, 
Battaglia,  Barrio,  Mare,  Rioja)  han  tratado  neumonias  pestosas  con  este  m^todo 
consiguiendo  resultados  favorables.  Nosotros  lo  empleamos  tambi^n  en  varies  casos 
habidos  en  1912  sin  poder  aun  consignar  estadfstica  fi ja  por  las  variables  circimstanciafl 
de  cada  case  debidas  a  la  gravedad  de  la  infecci6n  que  no  tiene  en  esta  forma  tipoe 
uniformes. 

Argerich  y  Paasalacqua  (del  Departamento  Nacional  de  Higiene  de  Buenos  Aires) 
han  conseguido  tambi6n  6zitoe  paiciales  en  una  pequefia  y  mortffera  epidemia  pal- 


PtTBLIC  HEALTH  AKD  MEDICINE. 


333 


monar  que  asistieron  en  dos  localidades  campestres  de  la  provincia  de  Santa  Fe  ( Aigen- 
tina)  en  1912. 

Formas  septidmiau. — Las  miHmaa  consideraciones  son  aplicables  al  tratamiento  de 
las  septicemias  pestosas.  Primero,  per  la  gravedad  de  la  infecci6n  y  la  acci6n 
degenerativa  de  la  toxina;  segundo,  porque  en  muchos  cases  la  forma  aparentemente 
ganglionar  aguda  es  sintom&tica  de  la  infecci6n  generalizada.  La  inyecci6n 
endovenosa  intensiva  y  precoz  puede  evitar  la  muerte. 

Formas  carbunculares. — En  el  Hospital  Mufiiz  se  han  tratado  algunos  cases  de  forma 
carbunclosa,  con  buen  6xito  mediante  este  m^todo.  Nosotros  no  hemes  podido  observar 
casoe  de  esta  forma. 

IV. 

La  evoluci6n  de  la  seroterapia  antipestosa  queda  confirmada  por  el  6xito  que 
revelan  las  estadlsticas  generales  de  las  diversas  epidemias  frente  a  las  modificaciones 
de  los  distintos  m^todos. 

Los  resultados  m^  favorables  corresponden  a  las  epidemias  americanas  de  Brasil  y 
Argentina  en  donde  sistemdticamente  se  emplea  la  seroterapia  intensiva. 

Ohodsky  en  la  tiltima  estadfstica  de  las  epidemias  de  la  India  en  que  tan  impor- 
tante  actuacidn  ha  tenido  se  muestra  tambi^n  partidario  de  las  grandes  dosis  inten- 
sivas.  iA  prefiere  la  via  subcutdnea  e  invoca  para  ello  la  facilidad  y  rapidez  de 
acci^n.  No  concebimos  como  la  via  subcutdnea  pueda  ser  m^  r&pida  que  la  intn^ 
venosa. 

Las  consecuencias  de  la  seroterapia  intravenosa  intensiva  no  contraindican  su 
empleo.  Los  accidentes  s^ricos  inmediatoe  son  benignos  y  s61o  se  observan  en 
ntimero  limitado  de  casos.  Los  producidoe  por  reinyeccidn  tardfa  (anafilaxia)  no 
revisten  tampoco  gravedad. 

Nosotros  hemes  empleado  sueros  a  dosis  intensivas  s61o  hemes  visto  dos  casos  de 
schok  anafiUctico  ninguno  mortal.  Uno  de  elloe  con  suero  antitetdnico(  dosLs  intra- 
venosa intensiva,  m6todo  de  Penna)  y  otro  con  suero  normal  de  caballo  dosLs  mo- 
deradas  de  10  c.  c.  En  ambos  el  empleo  de  la  via  intravenosa  despu^s  de  haber 
empleado  la  via  subcutdnea  fu6  la  causa  del  accidente.  La  reinyecci6n  en  el  segundo 
case  fu6  a  las  tres  horas  de  la  inyecci6n  anterior,  el  sujeto  habla  recibido  antes  29 
inyecciones  de  suero  de  ciballo  en  siete  meees  con  intervales  breves  de  varies  dias 
(case  de  hemofilia). 

Expuesto  someramente  lo  que  antecede  nos  creemos  autorizados  a  anotar  las 
estadlsticas  y  conclusiones  que  siguen: 

Estadlstica  comparada  de  las  diversas  epidemias  de  peste  tratadas  con  los  diferentes 
m^todoe: 

Prdier  PerIodo. — MStodo  de  Yersin:  Inyecdanei  siLbciUdneai  de  suero  de  10  atO  c.  c. 


Autores. 


Yersin... 
Bimood... 

Zabototay 

Delay 

Thlrouz.. 


Birfdemtai. 


. s 


Canton  y  Amoy 

Bombay 

NaFrhttiK 

UaudYi 

Bombay 

Moontfa........ 

Kuratchl 

Mongolia.  Forma  natmKtaka 

MonU6  (China) 

Tamatave 


Aflos. 


ISM 
1807 
18W 
18W 
18PS 
ISM 
ISM 
18M 
18M 
ISM 


Bniermoa 
tratadoB. 


} 


M 

60 

3S 

186 

171 

76 
IS 
10 
20 


Mositoe. 


2 

17 
14 

m 
w 

87 

13 

4 

11 


MortaUdad. 


Poreiento, 

7.S 

84.0 

42.0 

66.0 

67.0 

49.8 
76.0 

4ao 

66.0 


334        PROCEEDINGS   SECOND  PAN   AMERICAN   SCIENTIFIC   CONGRESS. 

Seoundo  PbeIodo. — MStodo  de  Calmeiie  y  SalmibenL'  Inyecciones  Iniravtuosaa  de  10  a 
20  c.  c.  alternadas  con  inyerciones  subcutdneas  de  20  a  40  c.  c. 


Autores. 


Epldemias. 


Calmette  y  Salmlbenl 
Metin 

Primet 

Noe 

OswaldoCnu 

Agote  Medina 

Ciarac. 

RuflBandis 


Oporto 

Oporto 

Nomca 

Numca 

Rio  Janeiro 

Rosario  (Argentina) . 

GuaCunn 

TonTechow 

Tonkin 


Afio. 

Enfeimos. 

Muertofi. 

MortaUdad. 

PordetUo. 

1800 

142 

21 

14.7 

1800 

6 

1 

16.6 

/1800" 
\  1000 

} 

7 

2 

2&6 

1901 

17 

8 

46.9 

/100(K 
\  1001 

} 

278 

90 

85.6 

1000 

26 

11 

42.0 

1902 

71 

32 

45.0 

1002 

67 

34 

5ao 

1908 

72 

42 

58.3 

Tercer  PflRfoDO. — Mitodo  americano  de  Penna:  Inyecciones  InUnsivas  de  70  a  IBO  c  c. 

por  via  endovenosa  y  ntbcutdneas  repetidoa. 


Autoree. 


Penna 

Duprat 

Hotpltal  Faola  C^Uidfdo 

Hospital  San  Sebastian. 

Tavares  de  Maoedo 

Antonino  Ferrari 

Hofpltal  Mnmx 


Epldemias. 


Buenos  Aires , 

Rio  Grande,  M6U>do  subcuti- 

neo-tntensivo. 
Rio  de  Jaaeiro  (BrasU) 


Rio  Janeiro. 


Campos  (Brasil), 
Rio  Janeiro 


Boenos  Aires. 


Aflos. 


{ 


1900- 

1905 

1902 

1002 
1003 
1001 
1905 
1905 
1906 
1906 


1905 
1906 
1007 
1006 
1909 
1910 
1911 
1912 


Enfemos. 


} 


204 
45 

968 

641 

504 

149 

138 

187 

14 

09 

21 

11 

41 

04 

126 

60 

98 

47 

76 

68 


MuertoB.  iMortalldad. 


28 
7 

68 

124 

108 

25 

30 

54 

2 

5 

8 

2 

4 

22 
15 
7 
14 
7 
9 
5 


PordfiMo. 
14.3 
15.5 


96.6 
22.9 
ia4 
16.5 
21.7 
98.8 
14.0 

7.6 
38.0 
18.0 

0.0 
28.0 
12.0 
11.0 
15.0 
15.0 
11.0 

7.8 


^  Subcuttoeo. 


CONCLUSIONES. 

1^.  La  prictica  de  la  seroterapia  antipestoea  ha  demoetrado  la  necesidad  del 
aiimentx)  in  tens!  vo  en  las  dosis  de  suero. 

2*.  Lafi  inyecciones  intravenosas  deben  considerarse  de  especial  importancia  por 
la  rapides  de  su  acci6n  que  es  un  elemento  necesario  en  el  tratamiento  especialmente 
de  las  fonnas  agudas. 

3*.  £1  mitodo  de  las  dosis  intcnsivas  debe  considerarse  una  modiiicaci6n  funda- 
mental comparado  con  el  de  las  dosis  masiva  de  Calmotte. 

4*.  Esta  modificaci6n  debe  ser  denominada  mitodo  americano  de  Penna. 

6*.  Las  estadfsticas  mundiales  demuestran  que  el  mejor  tratamiento  de  la  peste 
bub6nica  lo  constituye  el  Mitodo  Intravenoso  Intensivo  de  Penna. 


PUBLIC   HEALTH  AND  MEDICINE.  336 

EL  ASM  A;  SUS  CAUSAS,  DEFECTOS  E  INCONVENIENTES  DE  UN  SOLO 
MfiTODO  EXCLUSIVO  PARA  CURARLA  COMO  EL  MfiTODO  DE 
EFRAIM.  NECESIDAD  DE  VARIOS  TRATAMIENTOS  CON  RELACION 
A  LAS  VARIAS  CAUSAS  ASMATOGENAS. 

For  JOSt  A.  RAMPINI. 
Montevideo,  Uruguay. 

Durante  diez  afios  de  clinica  asmdtica  que  vengo  haciendo  con  mis  enfermos  he 
estudiado  diversos  casos  de  asma,  especialidad  a  la  cual  me  dedieo  y  he  llegado  a  las 
fliguientes  concluaiones  que  oportunamente  ampliar^. 

El  asma  no  es  una  enfennedad,  sino  un  slndrome,  es  decir  que  los  asm&ticos  no  son 
todos  igualee,  pues  hay  diveraos  tipos  de  asmdticos. 

Ademds  del  drbol  respiratorio,  los  6rganos  mds  diversos  pueden  produclr  asma:  el 
ost(Smago,  el  higado,  el  intestino,  el  dtero,  los  ovarios,  el  rifi6n,  el  aparato  circulatorio 
pueden  producir  asma  todos  los  caracteres  del  asma  verdadera,  tfpica. 

Se  cita  un  reflejo  hepato-nasal  que  puede  producir  asma  nasal  sin  que  haya  nada  en 
la  nariz. 

He  visto  un  c6Uco  hepdtico  con  todos  los  caracteres  del  asma  pulmonar. 

He  visto  un  caso  de  embarazo  de  doe  meses  complicado  con  acceeos  de  asma  que  no 
cedieron  a  pesar  de  haber  empleado  los  calmantes  usuales  que  tan  buenos  resultadoe 
me  dieron  en  otros  casos.  Sospechando  que  el  asma  fuera  producida  o  por  lo  menoe 
deeempeilara  un  papel  importante  en  su  producci6n  la  intoxicaci6n,  por  insuficiencia 
6varica  hice  a  la  enferma  varias  inyecciones  de  ovocitina  Aster  fresca  y  obtuve  un 
excelente  resultado.  Continue  este  tratamiento  durante  todo  el  embarazo  con  el 
mismo  resultado. 

He  visto  un  caso  de  asma  con  bronquitis  catarral  en  un  sifilitico  terciario,  y  los 
acceeos  de  asma  y  la  bronquitis  curaron  con  el  tratamiento  mercurial. 

Eeto  demuestra  que  la  patologla  del  asma  es  m^  complicada  de  lo  que  a  primera 
vista  parece  y  que  cada  asm&tico  debe  ser  estudiado  detenidamente.  Para  conocer 
bien  el  asma  es  necesario  conocer  bien  la  patologla  de  todos  los  6rganos  y  el  tratamiento 
debe  variar  segtin  los  casos. 

Dr.  Jo86  Moreno,  profesor  suplente  de  la  facultad  de  medicina  de 
Buenos  Aires,  submits  the  following  '*Relaci6n  sint6tica  de  los 
trabajos  presentados  (por  61)  al  C!ongreso." 

Trabajos  presentados  al  Congreeo  Panamericano  de  W^ishington: 

Primer  trabajo:  Seroterapia  anHpe$to9a  tntenttva  {wUtodo  americano  de  Penna). 

Estudia  el  autor  el  origen  de  los  casos  de  peste  bulxkiica  en  la  Reptiblica  Argentina 
desde  su  primera  aparici6n  en  1900  hasta  la  fecha.  En  diversas  epidemias  de  1905-6 
y  12  a  formas  gangUonares  y  neum6mca8  ha  empleado  las  inyecciones  de  suero  anti- 
peetoso  por  via  intravenosa  siguiendo  el  m^todo  del  Profesor  Penna  de  Buenos  Aires 
conaistente  en  el  empleo  de  dosis  intravenoeas  de  100  y  120  c.  c.  de  suero  del  Institute 
Pasteur.  La  primera  inyecci6n  que  puede  ser  de  120  c.  c.  es  seguida  a  las  24  o  48 
horas  de  una  segunda  de  100  c.  c.  con  lo  que  ae  obtiene  un  ripido  descenso  de  las 
curvas  febrilee  y  los  sfntomas  de  la  intozicaci6n  pestoea  se  atentian  r^pidamente  en 
algunos  casos  de  forma  gangUonar. 

£1  estudio  de  los  casos  publicados  por  Calmette  y  Salimbeni  en  la  epidemia  de 
Oporto  en  1899  demuestra  que  las  dosis  intravenosas  de  20  c.  c.  empleadas  por  estos 
obeervadpres  en  aquella  epidemia  y  a  las  que  denominan  dosis  masivas  son  insufi- 
denies  como  se  observa  en  la  pendstencia  de  los  fen6menos  febriles  durante  24  horas 
mientras  que  par  el  m^todo  de  Penna  con  dosis  intensivoe  de  100  c.  c.  endovenosas 
loe  descensos  t^rmicos  son  muy  rdpidos  a  voces  desde  las  primeras  horas  que  siguen  a 
la  primera  inyecci6n.    £1  autor  jMropone  denominar  este  m6todo  seroterapia  intra 


836       PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC   CONGRESS, 

venosa  intensiva  o  m6todo  americano  de  Penna,  para  diferenciarlo  de  la  denomina- 
ci6n  "masiva'*  o  m^todo  de  Calmette. 

Para  mayores  detalles  ver  au  comunioaoi6n  y  bu  teas  actualmente  en  mpresi6a 
(Seroterapia  de  la  peste  bub6nica.  Imprenta  de  la  Semana  M6dica  Argentina,  Buenos 
Aires,  1915)  conteniendo  el  eetudio  comparative  con  numerosas  observaciones  y  la 
comiinicaci6u  a  este  Congreso. 

Scgundo  irabajo:  Climatologia  mSdica;  estaciones  invemales  argentinas. 

El  alitor  estudia  la  regi6n  argentina  situada  al  norte  del  31°  de  latitud  y  este  del 
61**  de  longitud  en  las  proximidades  del  Paraguay.  El  estudio  climatol6gico  de- 
muestra  la  uniformidad  climat^rica  apta  para  la  fundaci6n  de  Ciudades  Invernales,  su 
gran  similitud  con  loe  climas  invemales  europeos  y  la  conveniencia  de  la  creaci6n  de 
residencias  higi^nicas,  secas  y  hdmedas.  Las  proximidades  del  Rfo  Parand  y  de  las 
zonas  de  grandes  bosques  de  la  regi6n  subtropical  facilitan  la  humedad  atmoslMca 
para  el  equilibrio  de  las  temperaturas  y  la  moderaci6n  en  la  velocidad  de  los  vientos. 
Estos  factores  unidos  a  la  belleza  del  suelo,  a  la  latitud  pureza  de  aire  hacen  que  estas 
zonas  posean  un  clima  suave,  uniforme,  semejante  al  que  Lindsay  estudi6  en  las 
llanuras  de  Australia,  en  id^ntica  latitud  y  que  preconiz6  para  la  tuberculosis.  El 
autor  considera  que  las  formas  cr^ticas  y  hemoptoicas  son  beneficiadas,  mas  atin  que 
en  las  zonas  de  Montafia.  Su  estudio  data  de  1909  y  se  anticipa  asi  a  la  noci6n  de 
climas  complementarios  que  constituye  en  la  actualidad  la  tUtima  palabra  en  cues- 
tiones  de  climatoterapia.  A  61  se  debe  la  fundaci6n  de  una  primera  residencia  invemal 
llamada  **Ciudad  de  Inviemo." 

Tercer  trabajo:  Sobre  transformaciones  que  sv/re  el  *'606^*  en  el  organismo. 

Sin  ser  un  trabajo  experimental,  el  autor,  sometido  al  desarrollo  de  este  toma.  romo 
prueba  oral,  para  el  profesorado  universitario,  en  un  t^rmino  breve,  raciocina  sobre  la 
quimioterapia  del  "606  "  y  apoy&ndose  en  la  f6rmula  de  constituci6n  del  salvarsan,  en 
las  experiencias  hechas  en  el  servicio  de  Jeanselme  en  Paris,  en  los  hechos  cHnicos 
sostiene  que  debemos  aceptar  "que  el  edificio  molecular  del  "606",  una  vez  intro- 
ducido  este  cuerpo  al  organismo,  se  demimba  dejando  el  ars^nico  libre,  el  que  en  su 
mayor  parte  es  eliminado,  otra  parte  fijada  en  el  organismo  los  dtomos  amidados  serian 
transformados  en  el  hfgado  y  los  oxidnlos,  con  funci6n  fendlica  eliminados  por  la 
orina.  No  existiendo  bibliografla  sobre  el  tema,  el  autor  expone  su  doctiina  a  la 
consideraci6n  del  congreso. 

Cuarto  irabajo:  Pseiuio'tuberculons  ptUmonar  cocobacUar;  tesie  de  dodorado. 

El  autor  estudia  varies  cases  clinicos  en  donde  afecciones  pulmonares  con  sfntomas 
de  tuberculosis  pulmonar,  sin  bacilos  de  Koch  ban  presentado  en  los  esputos  y  aim  - 
en  cortes  histoldgicos  masas  zoogleicas  con  los  caracteree  morfol6gicos-culturales  y  de 
inoculaci6n  del  cocobadlo  de  la  pseudo-tuberculosis  zoogleica  de  Malassez  y  Vignal. 
Es  el  primer  trabajo,  conjuntamente  con  una  observaci6n  del  medico  argentine  Mario 
Acevedo,  en  que  se  establece  en  el  pulm6n  humane  la  existencia  de  n<5dulos  de 
reacci6n  al  cocobacilo  de  Malassez,  por  lo  que  el  autor  cree  en  la  posibilidad  de  confu- 
siones  de  diagn<5stico  clinico,  con  reacciones  negatives  a  la  tuberculina,  en  los  casos 
de  bronco-neumonias  cr6nic.as  y  esclerosis  pulmonares.  Las  investigaciones  bacterio- 
16gicas  y  andtomo-patol6gicas  rigurosas  podrian  aclarar  la  frecuencia  de  tales  pseudo- 
tuberculosis pulmonares. 

Quinto  trabajo:  Caso  de  tachipnea  hisUrica  simuJando  **coup  de  chaleur.** 

Estudia  un  caso  de  histeria  en  donde  la  enferma,  joven  de  18  atios  Simula  "coup 
de  chaleur"  durante  una  6poca  de  fuertes  calores.  Se  caracterizaba  por  conge0ti6n 
y  danosis  de  la  cara,  dispnea  intensa  con  movimientos  respiratorios  aparentes  basta 
130  por  minuto.  El  autor  ohserva  que  contra  las  deecripciones  hal  ituales  de  la  tachi- 
pnea el  ritmo  respiratorio  no  es  regular,  sine  que  aparece  asi  por  la  rapidez  de  loe  movi- 
mientos y  que  un  hdl  il  juego  respiratorio  permite  acumular  aire  para  dar  lugar  a  una 
serie  de  expiraciones  cortas.    Ademds  en  la  tachipnea  de  este  caso  nota  los  esfuerzos 


PUBUO  HEALTH  AND  MEDICINE.  337 

aparentes  de  la  enferma  para  simular  el  ahogo.  Gonsidera  de  interns  el  case  clfnico,  por 
no  encontrar  en  la  tachipnea  descrita  por  Iob  autores,  la  simnlacidn  del  ''coup  de 
chaleur." 

Sexto  trdbajo:  Hemofilia  familiar  de  tipo  hemoptoico  nstemdtico. 

Caeo  clinico  en  donde  la  herencia  hemofflica  es  doble.  El  enfermo  a  quien  eetudia 
con  todo  detalle,  para  excluir  confufiiones  de  diagn6etico,  ha  llegado  a  perder  haata 
14  litros  de  sangre  en  un  periodo  de  cinco  meees. 

Las  circunstancias  propias  del  caso  le  x>eiiniten  creer  en  que  de  las  teorlas  hemo- 
fflicaa  es  mis  probable  la  perturbaci6n  de  los  6rgano8  hematopoieticos  que  suminis- 
tran  una  sangre  anormal  por  pouss^.  Tiene  adem^  inters  por  haber  observado  iin 
"aihock"  anafiUu:tico  s^rico  despu^  de  29  inyecciones  de  suero  normal  de  caballo  y 
motivado  por  el  cambio  en  la  via  de  introducci6n  del  suero.  Las  inyecciones  ante- 
riores  habfan  sido  subcutdneas,  la  tiltima  tres  horafl  antes  de  la  endovenosa  que  fu^ 
practicada  por  un  colega  llamado  uigentemente.  El  ''shock"  anafiUctico  no  tuvo 
consecuencia  grave. 

SSptimo  trabajo:  Batallones  escolareSf  ediuxicidn  fitica. 

Estudio  presentado  al  primer  congreso  nacional  del  Nifto  en  la  Reptiblica  Argentina. 
Se  denominan  asf  agrupacionee  de  niilos  de  la  Sociedad  Sportiva  Argentina.  A  pesar 
de  su  nombre  los  batallones  escolares  no  encierran  concepto  de  milltarizacidn  infantil, 
dno  de  agrupacidn  con  fines  de  educaddn  flsica,  como  puede  verse  en  las  fotografias 
respectivas.  Estudia  el  origen  y  caracteres  del  nifio  argentine  y  la  necesidad  de  gra- 
dnar  los  ejercicios  progresivamente  empezando  por  la  gimnasia  sueca  antes  de  Uegar 
a  los  deportes  que  son  la  gimnasia  de  sfntesis.  Combate  la  gimnasia  durante  o  despu^ 
de  las  horas  escolares  por  el  surmenage  f  fsico  que  el  trabajo  intelectual  acarrea,  segtin 
demuestran '  los  trazados  con  el  erg6grafo  de  Mosso  y  preconiza  los  ejercicios  al  aire 
libre  las  fichas  individuales  del  Indice  torddco  terminando  con  la  importancia  en  la 
higiene  y  hominicultura  de  las  asociaciones  de  educaci6n  ffsica  racional. 

Octavo  trabajo:  ArUuepsia  digestiva  y  bacterio-terapia. 

Se  ocupa  el  autor  del  origen  de  las  inlecciones  y  autointoxicaciones  gastro-intestinales 
de  nifioB  y  adultos,  los  estudios  de  Fisher  y  Langenheim  sobre  descompoeici6n  de  albu- 
minoides,  la  necesidad  de  tener  presente  en  la  normalidad  de  los  procesos  digestivos 
los  estudios  de  Pawloff  para  explicar  las  autointoxicaciones  por  deficiencias  secre- 
torias,  la  relatividad  de  la  antisepsia  medicamentosa  la  importancia  de  la  bacterio- 
terapia  Uctica  de  Metchnico£F;  pero  hace  notar  que  las  preparaciones  tituladas  de 
bacterioe  Ucticos  son  frecuentemente  est^riles  por  lo  que  preconiza  el  empleo  de  las 
leches  fermentadas  recientemente. 

Noveno  trabajo:  Pervenidn  moral  (locura  moral  adqumda  de  Kraft'Ebing  y  Schule) 
de  origen  Baseedotoiano. 

En  un  informe  m6dico-legal,  el  autor  establece  el  diagndstico  de  perverai6n  moral 
(locura  moral  adquirida  de  Kraft-Ebing  y  Schfile)  en  una  enferma  de  mal  de  Bassedow. 

Se  trata  de  una  Bassedowiana  confirmada  en  perfodo  avanzado,  con  una  fuerte 
herencia  demencial,  la  que  con  toda  premeditaci6n  instiga  la  muerte  de  su  esposo 
ofreciendo  dinero  a  los  aseainos.  La  trama  del  delito  revela  una  premeditaci6n  larga. 
El  autor  estudia  la  esfera  intelectual  y  moral  de  la  procesada,  comprobando  que 
ademis  de  la  enfermedad  de  Baasedow  y  su  neiuosis,  la  enferma  en  cuesti6n  presenta 
las  caracterfsticas  de  una  locimi  moral  que  aparece  en  ella  concomitantemente  con  la 
enfermedad  de  Bassedow.  Siendo  la  lociira  moral  verdadera  congenita,  el  autor 
establece  que  los  sfntomas  corresponden  a  las  perversiones  morales  que  Ballet  con- 
sidera  episodios  de  afecciones  mentales  y  Kraft-Ebing  y  SchOle  denominan  locuraa 
morales  adquirldas. 

El  autor  determina  la  irresponsabilidad  de  la  enferma  basado  en  que  de  acuerdo  con 
Andr^  Thomas  "las  perturbaciones  de  la  emotividad  constituyen  el  fimdamento  de  la 


338       PROCEEDINGS  SECOND  PAN  AMEBICAN  SCIEKTIFIC  C0N6BESS. 

perversidn  Instintiva  "  y  la  enfennedad  de  Baasedow  es  ante  todo  una  afeccidn  que 
altera  eeencialmente  la  emotividad.  Es  ol  primer  case  descrito  en  la  bibliograiia  co- 
rriente  de  deUncuencia  premeditada  y  jactancia  del  delito  en  el  cuieo  de  una  enfer- 
medad  de  Bassedow  en  donde  en  general  los  delincuentes  lo  son  en  forma  impulsiva 
y  tranaitoria. 

Dicimo  trabajo:  Presenta  a  la  conaideracidn  del  congreso  varios  ejemplares  de 
lecciones  de  terapia  hlgi^nica  y  conferencia  inaugural  de  un  curso  libre  en  el  Centro  de 
Estudiantes  de  Medicina  de  Buenos  Aires,  independiente  de  la  ensefianza  oficial. 
Lecciones  de  sfnteaiB  sobre  temas  de  terap^utica  higi^nica,  entre  ellos  im  estudio 
sint^co  de  aguas  minerales,  en  especial  de  la  Reptiblica  Argentina  en  donde  se 
cumple  la  teoria  de  Gautier  sobre  la  distribucidn  geogrdfica  de  las  aguas  minerales  de 
origen  profundo  en  las  regiones  yolcdnicas.  Muestra  asimiamo  la  existencia  de  todaa 
las  variedades  de  aguas  minerales  en  la  Argentina  y  f  uentes  termales  en  las  mds  altas 
temperaturas  existentes  en  la  regi6n  andina. 

Estas  lecciones  dardn  ideas  sobre  la  generaUzaci6n  de  la  docencia  libre  incipiente 
atin  en  el  pafa. 

The  Chairman.  Before  adjournment  I  beg  to  state  that  a  copy 
of  the  following  printed  book  has  been  presented,  through  the  cour- 
tesy of  the  writer,  to  the  Scientific  Congress  and  is  herewith  reported 
by  section  VIII:  Las  Gl6ndulas  supra-renales  en  el  embarazo 
normal  y  patol6gico,  por  el  Dr.  Juan  A.  Gabastou.  Las  Ciencias, 
Libreria  y  Casa  Editora  de  A.  Guidi  Buffarini;  Buenos  Aires,  1915. 

Adjourned  at  2  o'clock. 


GENERAL  SESSION  OF  SECTION  Vm. 

New  Ebbitt  Hotel, 
Wednesday  nightj  January  5,  1916. 

Chairmaiiy  John  Van  R.  Hopp. 

The  session  was  called  to  order  at  8  o'clock  by  the  chairman. 

The  CHAiRBfAN.  The  meeting  will  please  come  to  order.  Before 
proceeding  with  the  regular  program  for  to-night  I  will  ask  Dr. 
Guiteras  to  read  by  title  several  papers  that  have  been  submitted  to 
the  section  by  Dr.  Genaro  Giacobini,  of  Buenos  Aires.  These  papers 
will  not  be  read  in  extenso. 

Hereupon  Dr.  Guiteras  read  the  titles  of  these  brief  papers.  The 
conclusions  of  two  of  these  papers,  previously  printed,  together  with 
the  author's  general  introduction,  follow: 

El  que  aba  jo  suscribe,  presenta  a  la  consideraci6n  del  2^  Congreso 
Cientifico  Panamericano  a  reunirse  en  Washington  en  Diciembre  de 
1915  las  siguientes  conclusiones  del: 

Estudio  de  la  pneumonia  en  la  infancia: 

lo.  Bxiste  on  signo  de  dolor  oolitlco  on  la  pneumonia  de  la  infanda,  signo  de  dolor  espont&neo  o  palpita- 
tono  de  la  residn  abdominal  correspondlente  al  colon  con  predomlnio  del  lado  derecbo  y  qoe  se  continOa  en 
la  tntenecddn  o  ingolo  qoe  forma  el  colon  ascendente  oon  el  transverao,  dolor  abdominal  que  no  oorres- 
poode  al  pnnto  apendicular  desdlto  por  Maaeolongo  y  nl<w!flfiado  con  la  denominacidn  de  "poendo* 
apendldtls  pneumdnloa  de  Massolongo/'  por  el  Congreso  Italiano  de  Pediatna  de  190L 

2*.  En  la  evolnddn  bacla  la  ouracKJn  de  la  enfecmedad  el  dolor  colltico  desaparece  antes  que  el  dolor  del 
costado  tor&cioo,  onando  ambos  se  presentan  al  ouadro  de  la  oorroboradto  dlagndstica. 

a».  El  panto  doloroao  ooUtico  de  la  pneumonia  en  la  infanda,  puede  presentarse  sin  el  dolor  tor&deo. 

Examen  anat6mico  comparative  del  sistema  nervioso  en  la  escala 
animal: 

1*.  La  Jerarquia  psiquica  de  los  anlmales  en  general  es  oonoordaote  oon  una  mayor  o  menor  reooncen- 
tiacidn  central  del  sistema  nervioso,  es  deoir,  oon  el  mayor  o  menor  volumenrelatiTO  del  oerebro  oomparado 
a  la  mMula  y  nendos  del  sistema. 

2*.  La  espeoie  humana  est&  regida  por  la  mi<ana  ley  de  la  fllogenia  que  gobiema  el  oonjunto  del  esealafdn 
looMgioo.    Supotenoiapsfquioacreceysureooncentraoldn  central  o  cerebral  ya  en  aumento. 

Ifin  oonseouenoia  si  establesoo  una  fraoddn,  a/b,  ouyo  numerador  represente  el  cerebro,  exponente  del 
de  la  eapecie  humana  en  la  aotualidad  y  el  denomlnador  a  la  mMula  y  nervios,  dedaoir6  el  aumento  pio- 
grealTo  del  i>rimero  con  respecto  al  segundo,  a  medida  que  la  vida  de  la  espede  humana  ascienda  en  poder 
psiquioo  ax/b. 

La  ontogonia  del  hombre  no  viola  la  ley  estableoida,  pues  no  es  m&s  que  una  modalidad  de  la  vida  de  la 
especie,  asf  oomo  teta  lo  es  del  oonjunto  animal. 

3*.  Las  leyes  que  las  gobieman  son  oonsecoencias  del  prlndpio  fllosdfloo  de  la  vida. 

The  remaining  papers  of  Dr.  Giacobini,  submitted  in  manuscript, 
are  herewith  printed,  together  with  the  author's  recommendations: 

Los  alienados  delincuentes  y  los  delincuentes  alienados — Creaci6n 
de  manicomios  criminales: 

El  concepto  de  la  delincuenda  del  aUenado  es  la  reeultante  de  la  interpretaddn 
jurfdica  de  Iob  actoe  del  mismo  en  funci6n  con  las  leyes  que  rigen  nueetras  actiyidadee 

68436— 17— VOL  x 28  339 


'  340       PBOGBEDINGS  SECOND  PAN  AMEBIOAN  8CIENTIPIG  00N6BBS8. 

Bodales  con  sua  preceptos  y  normas  de  conducta  individual  que  le  exigen  la  civilizacidn 
para  responder  a  la  ^tlca  de  loe  tiempos,  y  en  funci6n  de  la  paiquiatiia  el  alienado  que 
tiene  tendencias  al  delito  ee  una  entidad  que  lo  especdfica,  que  lo  caracteriza,  que 
le  da  un  cardcter  peculiar  dentro  de  la0  modalidades  psicoldgicas  de  loe  alienados 
comuneB.  Siendo  la  idioeincracia  del  alienado  delincuente  tender  a  los  actoe  delic- 
tuoeoB  dentro  de  las  r^las  de  un  determinismo  peicol<3gico,  ^por  qu^  n^arle  esa  eeped- 
ficidad?  ^porqu6  no  particularizarle  dentro  de  las  conquistas  grandee  de  la  paiquia- 
tiia lafl  reglas.  determinantes  de  una  conciencia  que  siente  dentro  del  ritmo  de  sub 
actoe  extra  sociales  una  tendencia  instintiva  a  las  leyes  que  rigen  la  individualidad 
en  la  sociedad  y  la  civilizaci6n? 

Glasificado  el  alienado  delincuente,  como  un  temperamento  dentro  de  la  cardtula 
del  deeequilibrado  mental,  ^no  es  por  acaso  particularizarle  y  claeificarle  de  los  comunes 
alienados  que  estudia  la  psiquiatria? 

La  locura  criminal  como  entidad  aut6noma  dentro  de  la  taxonomia  psiquidtrica  no 
existe. 

La  ciencia  paiquiitrica  no  ha  hecho  la  clasificaci^n  atin. 

Soetener  que  un  acto  delictuoeo  cometldo  por  im  alienado  en  un  memento  de  pa- 
roxismo  de  locura  sin  darle  la  particularidad  propia  y  especifica  de  locura  delictuosa, 
sea  un  error,  no  justifica  que  asf  se  califique  la  tendencia  instintiva,  repetida,  hada 
los  actos  delictuoeos  que  particularizan  y  clasifican  a  los  alienados  deiincuentes  y  a 
los  deiincuentes  alienados  cuyas  diferencias  dependen  por  la  raz<Sn  cronol6gica  de 
que  el  estallido  de  la  locura  sea  anterior  en  los  primeros  y  posterior  en  los  segundos. 

En  cuanto  a  la  jurisdiccidn  de  los  encargados  en  velar  por  la  8^;uridad  social,  entran 
a  participar  el  m^co  y  el  jurisconsulto,  desde  que  en  bus  actos  el  delincuente  necesita 
la  intervenci6n  facultativa  para  el  estudio  diagn6stico  de  los  procesos  cerebrales  del 
alienado,  y  para  la  terapia  del  mismo,  y  la  del  jiurisconsulto  como  tutor  y  salva- 
guardia  de  las  leyes  depoeitarias  de  la  defensa  legal  de  la  sociedad,  desde  que  los 
alienados  deiincuentes  y  los  deiincuentes  alienados  ban  Inlrigido  con  sus  actos  una 
ley  codificada  del  derecho,  su  acto  extra-legal  ha  inflingido  im  dano  de  una  manera 
dindmica  en  acci6n  violatoria  de  la  ley;  distingui^ndole  del  alienado  comtin  no 
delincuente  desde  que  sus  actos,  aunque  muchas  voces  en  latencias,  no  ban  infringido 
en  el  hecho  las  leyes  del  c6digo  escrito  de  la  jurisprudencia,  y  con  el  perjuido  social 
correspondiente. 

Dentro  del  movimiento  filos<5fico  y  cientifico  de  la  ^poca,  en  que  los  conodmientos 
humanos  tienden  a  la  especializaci6n,  los  estudios  de  la  psicoantropologfa,  m^co- 
legales  y  juridicos,  deben  tender  a  ese  movimiento  general  de  la  dencia  y  el  saber  y 
la  cread6n  de  manicomios  criminales  es  un  desideratum  que  responde  a  esa  tendencia 
del  esplritu  de  la  ^poca  y  de  la  dvilizaddn. 

Si  fu^  dable  refutdrsele  a  Lombroso,  en  lo  que  respecta  a  la  caracteristica  que  defini6 
al  loco  delincuente,  considerindolo  por  su  esplritu  de  asociad6n  y  su  espfritu  de 
rebeli6n,  con  la  cUsica  frase  'Ua  folie  c'est  Tisoloir  de  r&me,*'  porqu6  no  aceptar  el 
distingo  de  una  modaUdad  clinica  especial  del  alienado  delincuente  desde  que  sua 
actos  ae  inclinan  preferentemente  a  la  acd6n  delictuoaa  y  a  la  violaci6n  de  las  reglaa 
de  la  ley  protectora  de  la  ley  jurldica  y  moral  de  laa  sociedades. 

En  conaecuencia  debe  aceptarae  dentificamente  la  cread6n  de  inatitutoa  eepecialea, 
de  manicomioB  criminales  para  el  tratamiento  facultative  y  radonal  del  alienado  delin- 
cuente y  como  previsi6n  y  de  defenaa  social. 

Baaado  en  eataa  consideradonea: 

I.  El  Segando  Congreso  Cientffico  Panamericano,  reunido  en  Wiishington  en  didembre  de  1915,  patrodna 
lacreacidn  de  maoioomlos  criminales  en  las  naciones  americanas,  para  el  tratamiento  facultativo  y  raolonal, 
previsldn  y  defmsa  social  del  alienado  delincuente,  y  como  un  desideratum  de  la medlcina legal  y  dela  pslco- 
antropologla  criminal  oontempor&nea. 


PUBUC  HEALTH  AND  MEDICINE.  341 

Creacidn  de  tribimales  para  nifios: 

Entre  los  problemas  trascendentales  de  la  jurisprudencia  de  lo6  pueblos  contem- 
por&neos,  se  define  graadiosa  la  obra  de  la  redenci6n  moral  del  nifio,  por  una  sabia 
legiBlaci6n  previsora  del  delito. 

El  desenvolvimiento  de  los  factores  que  tienden  a  la  extiTpaci6n  de  las  tendenciaa 
delictuosas  de  la  nifiez  es  elevar  a  las  m^  altas  cincelaciones  del  ideal  humaao  y  redi- 
mirla  de  los  instintos  infeiiores  de  la  especie. 

Consecuente  con  las  ideas  de  r^eneraci6n  y  profilaxia  social  de  la  delincuencia, 
urge  considerar  el  problema  de  la  nifiez  desvalida,  y  la  creaci6n  de  tribunales  para 
nifios  en  los  paises  americanos,  salvaguarda  en  parte  la  deficiencia  del  medio  de  vida 
de  esos  seres  abandonados  al  acaso  en  los  embates  del  vicio  y  la  corrupci6n,  inclin&n- 
dolos  al  medio  purificador  de  los  m^todos  del  trabajo  y  de  la  escuela. 

Y  es  que  respecto  a  las  relaciones  de  la  codificaci6n  civil  americana  con  los  menores 
dellncuentes  deberia  modificarse  la  I^i8laci6n  en  el  sentido  de  quitarles  a  los  padres 
el  derecho  de  la  patria  potestad  para  los  menores  delincuentes  recidivistas  y  otoigar 
dicha  atribuci6n  legal  al  Estado  que  velaria  por  la  moralizaci6n  del  adolescente. 
La  funci6n  social  de  la  regeneracidn  tendrla  toda  la  caracterfsdca  de  una  disciplina 
pedag6gica-represiva  adoptada  a  los  principios  cientificos,  bajos  los  auspicios  y  fiscali- 
zaci6n  de  los  poderes  p(iblicos  amparados  y  sostenidos  por  la  ley. 

El  nifio  educado  en  una  6tica  purificada  es  un  ente  que  pugna  contra  los  medios 
comiptores  y  dellctuosos,  es  una  podeiosa  fuerza  de  h^gemonfa  moral,  vigor  y  din&- 
mica  activa  que  prepara  para  lo  futuro  la  vitalidad  misma  de  la  sociedad  humana 
en  el  incesante  torbellino  de  sus  evoluciones. 

Los  paises  sajones  ban  tributado  al  problema  del  estudio  y  de  la  terapia  de  la  crimi- 
nalidad  infantii  el  esfuerzo  del  espiritu  prictico  que  los  caracteriza. 

Y  al  fundar  y  en  la  creaci6n  de  tribunales  para  nifios  ban  querido  bacer  sentar, 
y  reposar  la  jurisprudencia  en  el  criterio  de  la  libertad  vigilada  y  que  debe  ser  la 
orientaci6n  esencial  de  nuestra  iniciativa  siempre  entendida  bajo  el  contndor  de  las 
escuelas  de  enmiendas  que  funcionan  en  la  actualidad  en  la  Gran  Bretafia  para  la 
correcci6n  de  la  infancia  delictuoea.  La  penalidad  del  nifio  desviado  por  la  senda 
del  delito  ha  side  la  preocupaci6n  de  los  estadistas  sajones  como  medio  de  previsi6n» 
correcci6n  y  enmienda,  pudiendo  hacer  reposar  el  mecanismo  de  la  represi^n  en  estos 
principios: 

1**.  Someterle  a  la  vigilancia. 
2^.  Libertarle  con  promesa  de  enmienda. 
3^.  Enviarle  a  una  escuela  industrial. 
4*^.  Enviarle  a  una  escuela  de  reforma. 

5^.  Multas  equivalentes  al  dafio  causado  y  hacer  responsables  de  la  infracci6n  a 
los  padres  o  tutores. 
6^.  Condenar  a  los  padres  o  garantizar  su  buena  conducta. 
7^.  Enviarle  a  un  lugar  de  atenci6n  reglamentado  legalmente. 

Y  preconizar  en  los  paises  americanos  la  creaci6n  de  escuelas  de  enmiendas,  divi- 
didas  en  tree  categorfas:  (1)  Para  la  correccidn,  Industriales  para  nifios  de^graciados 
0  abandonados  y  delincuentes  menores  de  12  afios;  (2)  las  de  reforma,  para  los  delin- 
cuentes especiales  de  2  a  16  afios;  y  (3)  las  escuelas  especiales  a  semejanza  de  las  de 
Borstal  para  los  de  16  a  21  afios.  La  acci6n  y  misi6n  de  estas  escuelas  patrocinarian 
la  misi6n  del  tribunal  para  nifios  y  serian  complementarias  del  espiritu  y  fondo  de 
esa  corporaci6n. 

Y  en  consecuencia. 

I.  Bl  Sagondo  Oongnso  Cientifloo  Panamerloano,  reonido  en  Wishlngton  en  dlotembre  de  1916,  patrodna 
la  reforma  de  la  legislacldn  penal  y  la  oreaoidn  de  tribunales  para  nilkM  en  las  naoiones  amfrtmnM,  y  «n 
el  oonoepto  de  previsldn,  oorreooidn  y  enmienda,  haoe  reposar  el  mecanismo  de  la  represidn  del  nifio  dettn 
ewnte  en  los  siguientes  prindplos; 
1*.  Someterle  a  la  yigilanoia. 
2*.  Libertarle  con  promesa  de  enmienda.- 


842       PBOOEEDINGS  SECOND  PAN  AMEBIGAN  SCIENTIFIO  CONGRESS. 

8*.  Enviarle  a  ana  eaciiela  industrial. 
4*.  Enviarle  a  ana  esouela  de  refonna. 

5*.  Malta  eqoivalente  al  daik>  oaosado  y  haoer  responsablM  de  la  infraooidn  a  los  padr«  o  tatorw. 
6*.  Condenar  a  los  padr«8  a  garantir  so  buena  oonduota. 
7*.  Enviarle  a  on  lugar  de  atenddn  reglamentado  legalmente. 
n.  Preoonixa  laoreaddn  en  los  palses  amerloanos  de  esooelas  de  enmlendas  divididas  en  tree  eatesorlM. 
1*.  Para  oorrecoi^n  (escnelae  indostrlales  para  niflos  deegraoiados  o  abandonados  j  dellnooeotes  me- 

nores  de  12  afios). 
3*.  Para  reforma  (escoelas  para  los  niftos  delinooentes  menores  de  12  a  10  afios). 
8*.  Espedales  (ewoelas  a  semejanxa  de  las  de  Borstal  para,  los  delincoentes  menores  de  10  a  31  aftos). 

Educaci6n  fisica,  moral  e  intelectual  del  niflo,  seg&n  la  ciencia 
p8icol6gica  contempor&nea: 

Entre  los  puntoe  de  capital  importancia  en  las  que  pudieran  plantearse  en  las  cues 
tiones  cientfficas  respecto  al  problema  infantil,  surge  el  enunciado  de  la  educacidn 
del  nifio  en  todos  sus  factores,  en  todas  sus  modalidades  de  la  educaci6n  fisica,  mora 
e  intelectual.     No  es  posible  desde  el  punto  de  vista  de  las  verdades  de  la  ciencia, 
Beparar  en  autonomfa,  esos  distintos  atributos  de  la  aotividad  individual. 

El  niiio  al  sei  lanzado  a  la  vida,  con  todos  los  atributos  de  la  existencia,  lleva  en  su 
ser  concentrado  en  estado  latente  todas  las  expresiones  de  las  modalidades  que  el 
medio  deber&n  estimular  para  dinamizarlas  en  el  ritmo  evolucionado  de  la  existencia. 

La  educaci6n  fisica  del  niiio,  debe  preocupar  la  atenci6n  de  los  hombres  estudioeoe. 
El  nifio  es  im  ente  en  plena  evolucidn  y  manif estaci6n  de  desenvolvimiento  orgdnico 
y  pslquico. 

Sus  6rganos  lanzados  a  la  ardua  complexidad  del  mecanismo  de  la  existencia,  dirigen, 
elaboran,  matizan  y  ritman  sus  palancas  din&micas  en  la  armonizaci6n  completa  de  la 
unidad  del  ser  en  el  conjimto  de  la  vitalidad. 

Y  en  el  acrecentamiento,  y  en  la  vigorizacidn,  en  la  solidaridad  y  la  armonla  de  todos 
estos  reeortes  del  oiganismo,  para  el  engranaje  fimcional  de  todos  sus  drganos  i)ara  la 
marcha  perfecta,  integral  y  fisiol6gica  del  conjunto  del  ser  'estd  el  veidadero  concepto 
del  cultivo  de  las  facultades  f  Isicas  en  que  reposa.  Gomo  veremos  luego  el  conjunto  de 
las  modalidades  morales  e  intelectivas  que  se  desprenden  Idgicaynaturalmentedeesoe 
foctoree  naturales.  El  cultivo  de  la  energfa  fisica,  deberd  por  lo  tanto  estimular  en 
una  eepede  de  euforia  vital,  que  invite  al  psiquismo  del  pequefio  ser  a  obrar  en  la  vida 
con  todos  los  entusiasmos  y  placeres  de  la  existencia  para  que  esos  mismos  atributos  de 
la  senaibilidad  del  alma,  refluyan  sobre  el  ejercicio  armonio^o  del  conjunto  flsico 
vigorizando  la  din&mica  funcional  de  la  vida  vegetativa  y  de  relaci6n  del  nifio. 

El  ejercicio  met^dico,  en  el  que  participan  en  el  estlmulo  los  distintos  6rganoe  de  la 
individualidad  fisica  sin  violencias  ni  brusquedades,  oxigenan  el  campo  energ^tico 
de  la  vida,  metabolizan  los  tejidos  en  la  vivificaci6n  de  las  reparaciones  org&nicaa  y 
■ientan  el  jal6n  luminoso  a  cuyo  resplandor  la  pedagogla  puede  y  debe  velar  por  la 
constitucionalidad  moral  e  intelectual.  Sobre  esa  base  fisica,  eduquemos  al  nifio  en 
■a  6tica,  con  el  sano  ejemplo,  con  las  buenas  costumbres,  honestidad  y  la  8atisfacci6n 
del  bien  cumplido. 

En  la  psiquis  del  nifio  predomina  el  esplritu  de  imitaci6n,  de  donde  se  desprende 
evidentemente  que  las  atenciones  pedag^cas  que  a  la  infancia  se  le  debe  un  gran 
atributo,  un  gran  factor  debe  considerarse  en  ese  sentido  y  elevar  a  la  sugesti6n  infantil, 
la  impreai6n  de  los  actos  llcitos  y  ^ticos  que  consagra  la  civilizacidn  y  el  progreeo  de 
las  costumbres. 

Y  en  consecuencia: 

1*.  El  Segondo  Oongreso  GieDtfflco  Panamerioano,  reanido  en  Washington  en  dldembre  de  1915,  insintia 
a  las  aotoiidades  edncaolonales  de  los  Estados  anMrioaiios,la  oonvenienda  oieatlflca  y  social  de  edooar  al 
nifio  integral  y  armrtnioamsnte  «n  todas  sos  faooltades  de  la  aotividad  fisica,  moral  e  intalectoal. 

3*.  Por  la  ednoaoidnf  isioa  oomo  medio  de  pflrfeooionamlento  y  desarrollo  org&nico  de  sos  elementos  vitales 
da  la  existMioiaflsloa,  en  el  ejenloio  mettfdioo,  radonal  y  diadplinado  de  sus  drganos. 


PUBLIC   HEALTH  AND   MEDICINE.  348 

3*.  Por  el  oultivo  de  los  piincipios  dtioos  asimilados  al  nifto  por  la  sabia  explicaoito  objeUva  del  ejemplo 
y  de  los  sanos  principios  7  oostumbres. 

4*.  Por  el  oultivo  integral  de  sus  facultades  intelectuales  por  la  objetividad  de  las  oosas  y  pnncipios, 
8ln  prejuicios  m  sectansmos  y  con  mdtodo  pedag<3gico  positive  y  de  uliUdad  prdctica. 

La  heredo  amoralidad  infantil  y  su  influencia  social  pedag6gica. 
Higiene  alimenticia  del  nifLo: 

El  nifLo,  68  un  exponente  de  las  idiosincracias  de  las  aptitudes  moralee,  intelectivaa 
y  sensitivas  de  sus  progenitoree  en  la  evoluci6n  peiquica  y  filo86fica  que  le  detenninan 
el  medio  ambiente  en  donde  reposa  la  incubadora  6tica  del  desarroUo  diniUnico  de  las 
facultades  int^grales  de  la  iniancia. 

Para. el  estudio  6tico  y  de  su  influencia  social  pedagdgica,  debemos  considerar  el 
agente  individual  como  factor  exponente  de  la  idiosincracia  propia  de  la  raza  en 
cuyo  modelo  bebe  la  savia  fluidiflcante  y  reparadora  de  pus  metabolismos  de  la 
vida  de  relacidn  y  la  complexidad  de  eee  medio  en  las  multiples  iases  de  su  vitalidad 
que'  crean,  dirigen,  neutralizan  infinitas  veces  las  disposiciones  innatas  de  la  estruc- 
tura  y  fundonamiento  individual. 

La  moral  del  nifLOy  hereda  de  sus  antepasados,  las  aptitudes  del  aprendizaje,  evoluci6n 
J  perfecci6n,  la  ensefianza  coordina  las  tendencias  6ticas  e  intelectivas  y  las  expreean 
con  las  cincelaciones  de  la  ciencia  pedag6gica  en  la  continua  a8censi6n  del  ser  humano 
hada  las  regiones  puras  de  la  raz6n  fundamental  de  la  existencia. 

La  amoralidad  en  la  iniancia  es  el  resultado  de  una  violad6n,  de  una  desorientacidn, 
de  un  deeequilibrio  del  factor  6tico-filo06fico,  y  en  eeta  enundaci6n  la  heredo  amondi* 
dad  infimtil,  abre  un  gran  capf  tulo  de  estudio  en  la  patologfa  de  la  pdcologfa  morboaa 
del  nifio. 

Se  me  n^ari  rotundamente  que  exista  el  factor  herencia  de  la  amoralidad  en  la 
infancia.  No  pretendo  entrar  en  una  disquisid6n  puramente  te6rica;  pero  si  admito 
que  d  bien  no  existe  una  herencia  de  la  amoralidad ,  de  una  imperfecci6n  de  la  6tica 
por  defidencia  similar  en  sus  progenitores,  como  semejante  comprobamos  en  el  pro- 
blema  de  la  herencia  de  la  tuberculosis  de  los  padres  a  los  hijos,  no  obstante,  las  apti- 
tudes del  mecanismo  psfquico-^tico  se  hallan  con  inverei6n  dindmica  adaptada  a  desen* 
volverse  por  la  senda  de  lo  malsano  y  antimoral  d  una  fuerza  de  pulimento  6tico 
no  viene  a  inhibirle  en  el  surco  generoso  y  bello  de  las  buenas  costumbres  y  de  los 
buenos  principios  de  la  vida  de  relaci6n. 

A  la  condderaci6n  del  problema  en  cuestidn,  hemes  planteado  la  influencia  evi- 
dente  del  medio,  del  agente  individual  del  nifio,  de  su  herencia  psfquica-^tica,  y 
como  premisa  se  desprende,  la  herencia  orgdnica  del  ser  infantil  de  sus  progenitoree* 
copiando  su  estnictural  constitucidn  de  la  existencia.  Los  multiples  factores  que 
explican  los  fen6menos  patoldgicos  de  los  actoe  sociales,  podrfamos  Uevarlos  a  la 
consideraci6n  de  lus  que  enuncian  y  consideran  los  de  la  infancia.  El  factor  econ6- 
mico,  el  ebtado  intelcctivo  de  una  comarca  0  poblaci6n  que  gula  y  dirige  la  aplica- 
d6n  inmediata  a  la  solucidn  y  consideracidn  de  los  problemas  de  la  existencia. 

Disdplinar  el  medio  en  el  que  se  deeenvuelve  las  acdones  del  nifio,  facilitando  todo 
loe  resortes  y  recursos  de  la  pedagogia  dentffica  para  que  las  factiltades  del  mismo  se 
desarroUen  en  la  plena  y  libre  expand6n  de  un  campo  embelleddo  en  las  galanuraa 
de  la  moralidad  y  de  los  principios  inmanentes  de  los  actos  de  la  justicia. 

Para  tal  fin,  el  nifio  deberd  redbir  el  nutrimento  fidol6gico  indispensable  para  que 
las  asimilaciones  org6nicas  se  hagan  de  acuerdo  con  las  leyes  fidol6gicas  que  rigen  los 
oiganismos  vivientes  en  las  plenas  expredones  y  manifestaciones  de  la  salud.  Esta 
enunciad6n  nos  lleva  a  la  condderaci6n  de  im  otro  problema,  cual  el  de  la  higiene 
alimenticia  dd  nifio,  capftulo  de  trascendental  importancia  para  el  estudio  de  la 
evolud6n  y  deearrollo  fidco. 

Desde  los  primeros  afios  de  la  vida,  alimentar  a  un  pequefio  ser,  es  un  problema  de 
dencia  pediitrica,  que  se  simplifica  cuando  el  fluido  matemo,  la  sangre  de  la  madre, 
basta  para  dotar  al  pequefio  nifio  la  asimilad6n  de  esas  neceddades  materiales,  pero  si 


844       PBOOEEDINQB  SECOND  PAN  AMEBIOAN  SOIENTIFIO  00NQBE88. 

eee  lecuno  de  la  natuialeza  sabia  y  providendal  no  existe,  el  nifio  peligra  su  alimen- 
taci6n  en  las  zozobras  de  un  nutrimento  antifisiol^gico,  deficiente  y  malsano. 

Resolver  el  complicado  problema  de  la  diet^tica  infantil,  es  solucionar  un  problema 
trascendental  de  la  salud  pdblica,  puesto  que  se  disminuye  con  tal  coea  el  porcentaje 
de  la  mortandad  infantil,  y  paralelamente  la  infancia  protegida  por  la  dencia  pedii- 
trica  y  de  las  leyes  de  la  alimentaci6n  racional,  seguiri  un  desarrollo  de  evolucidn 
ffsica,  con  vigor,  energfa  y  salud,  creando  una  adolescencia  fortalecida  y  apta  para 
resistir  a  los  embates  de  la  enfennedad  y  de  loe  mdltiples  y  complejoe  factores  socialee 
y  natuiales  que  predisponen  tambi6n  a  las  acciones  delictuosas. 

En  conclusi6n:  1^.  Debe  el  estado  velar  por  el  cumplimiento  de  las  leyee  pedag6- 
gicas  y  racionales  que  se  oponen  al  desarrollo  de  la  amoralidad  en  la  infancia. 

2^.  Extender  su  acci6n  protectora  en  el  sentido  de  una  amplia  consagraci6n  de  la 
moral  en  los  actos  que  se  desprenden  de  la  voluntad  y  actividad  del  nifio. 

3^.  Vigilar  y  difundir  los  preceptos  dentfficos  destinados  a  iluminar  al  pueblo  en 
el  sentido  de  una  dedicaci6n  racional  y  cientffica  de  la  higiene  alimenticia  del  nifio  • 

4^.  Con  el  cumplimiento  de  los  enunciados  resolverd  ventajoeamente  la  profilaxia 
de  la  delincuencia  en  la  infancia. 

Y  con  el  tercer  aserto  escribird  el  gran  capltulo  de  la  higiene  fisica  del  nifio  y  evi- 
tar&  la  crecida  mortandad  en  la  misma. 

Y  en  consecuencia: 

1*.  El  Segundo  Congreso  Ciontlfloo  PanamerloaDo,  reunldo  en  W&shington  eo  diciembre  de  1915,  inyitft 
ft  los  Estado3  americanos  a  qae  reglamenteo  j  velen  por  el  oumpUmiento  de  las  leyes  pedagdgicas  y  radol 
sales  que  se  oponen  al  desarrollo  de  la  amoralidad  en  la  infancia. 

2*.  Insintka  a  los  onerpos  esoolares  de  los  Estados  americanos,  la  indioaddn  de  intensiflcar  la  enseOanxa 
de  la  moral  en  el  niik>  como  medio  de  evitar  el  victo  y  la  oomipcidn  de  las  costunbres. 

8*.  In  vita  a  los  Estados  ameneanos  a  que  complementen  su  acddn  oflcial  en  ese  sentido,  por  su  actuaeidn 
eztraescolar  por  intermedlo  del  foUeto,  la  conferencla  pdbUca  y  otros  medlos  «xplicatiyos  y  de  aloanre 
popular. 

4*.  Invlta  a  los  Estados  americanos  a  que  reglamenten,  vigilen  y  difundan  los  preceptos  oientifloos  destl- 
nados  a  iluminar  al  pueblo  en  el  sentido  de  una  dedicaddn  racional  y  cientlfloa  de  la  higiene  alimenticia  dd 
nifio. 

6*.  Har&n  prActica  esta  dltima  proposioidn  por  los  medlos  indicados  en  la  proposiddn  tercera. 

La  delincuencia  y  el  crimen,  su  represi6n  cientifica: 

En  la  evoluci6n  de  la  jurisprudencia,  en  el  derecho  de  reprimir  los  actos  que  atenta- 
ban  con  las  leyes  del  consorcio  colectivo,  en  que  repoea  la  estabilidad  de  la  vida  del 
conjunto  social,  el  espfritu  penal  ha  ido  fluctuando  en  las  innumerables  teorfas  y 
transidones  del  esplritu  filoe6fico  y  cientifico  del  linaje  humano  al  trav^s  de  bu 
historia.  Observada  la  aurora,  loe  primeros  albores  del  derecho  codificado  en  funci6n 
a  las  leyes  de  la  penalidad  se  transparenta  di&fana  a  la  concepci6n  e  interpretaddn 
hist^rica,  la  base  movediza  en  que  reposaba  el  concepto  de  la  reprensi6n  del  acto 
delictuoso,  cuando  adn  se  hallaban  los  estudios  y  los  conocimientos  bioldgicos  en 
una  evidente  ruta  rudimentaria  en  la  evoluci6n  incesante  del  espfritu  cientifico  hada 
el  conocimiento  olfmpico  de  sus  consagraciones  hacia  el  ideal  del  saber  y  de  la  consa- 
grad6n  universal. 

La  humanidad  en  su  ruta  de  investigaci6n,  impregnada  su  conciencia  en  el  espfritu 
de  la  escol^tica,  preocupada  en  las  concepciones  trascendentales  de  la  vida  con 
prejuidos  extracientfficos,  explicaba  los  fen6menos  naturales  por  la  intervenci6n 
inmediata  y  directa  de  la  voluntad  divina,  anulando  la  crftica  de  la  raz6n  humana;  y 
eea  preocupaci6n  de  la  mentalidad  sin  la  oorroboraci6n  del  espfritu  de  la  naturaleza, 
fu6  Uevada  a  la  solucidn  de  los  problemas  de  la  criminalidad  y  de  la  delincuencia 
sancionando  preceptos  y  prindpios  de  reprensidn  segtln  f6rmulafi  en  los  prindpioe 
inmanentee  y  trascendentes  de  la  raz6n  filos<5fica,  teol6gica  y  metaffsica  que  se  des- 
prenden de  la  consideraci6n  del  radonalismo  de  la  6poca. 

Se  estudid  el  acto  delictuoso  en  sf ,  haciendo  abstracci6n  del  factor  intrfnseco  de  la 
personalidad,  del  agente  del  delito,  de  su  conformaci6n  antropol6gica  y  de  sus  expre- 


FUBUO  HEALTH  AND  MEDICINE.  346 

aionee  peicol^gicas  del  medio  ambiente  en  que  infinitfta  veces  es  la  incubadora  en  la 
que  se  deeenvuelven  las  modalidadee  eepecfficas  de  laa  idioeincrasias  delictuoeas  en 
la  expresidn  de  la  actividad  individual  y  social. 

El  desenvolvimiento  de  los  estudioe  biol^gicos,  la  concepci6n  cientffica  de  laa 
modalidades  de  la  vida,  en  la  que  laa  expresiones  de  la  actividad  mental  responden  al 
mecanismo  del  conjunto  peico-bioldgico,  a  la  eetructura  cerebral  como  palanca  de  la 
ideaci6n,  de  la  voluntad,  de  la  cerebracidn  consciente,  y  de  las  facultades  afectivas, 
encaminaron  el  problema  de  la  delincuencia  a  estudiar  el  agente  segtin  la  conformaci6n 
y  eetructura  p8ico-antropol6g:ica  como  base  del  criterio  de  la  imputabilidad. 

£1  fen6meno  del  conjunto,  como  determinante  de  la  acci6n  impuesta  por  la  compleja 
eetructura  del  hombre,  fu6  haciendo  cada  vez  m^  diffcil  la  solucidn  analftica  de  Iob 
iactores  eficientes  del  fen6meno  y  dando  al  estudio  del  problema  la  puntualizaci6n 
de  una  complexidad  m&xima. 

Se  desprende  de  esas  consideradones  que  el  acto  delictuoeo  emana  de  mtiltiplee 
determinantee  de  causae,  cuyo  estudio  debe  preocupar  la  mentalidad  de  la  cienda 
contempor&nea. 

La  vida  ffsica  de  la  raza,  la  salud  corp6rea,  la  eet&tica  y  la  dindmica  del  organiamo 
humano  como  fundamento  elemental  de  todo  acto  volitivo  y  de  toda  manifestaddn 
eensitiva  como  expresi6n  del  yo  como  individualidad  pensante  y  expre6i6n  afectiva 
con  todo  el  conjunto  de  modalidades  psicoldgicas  que  emanan  de  ese  postulado,  el 
eetudio  del  medio  social  6tnico  como  climat^co,  etc.,  la  herencia  espiritual  de  la 
tradici6n  y  de  la  historian  siguiendo  el  recorrido  parab61ico  que  toca  a  la  dvilizad6n 
recorrer  para  el  afianzamiento  de  sus  grandes  destinos. 

Basado  en  los  delineamientos  fundamentales  de  esas  concepdones  dentiflcas  en  lo 
que  reepecta  a  la  represi6n  radonal  de  la  delincuencia  y  del  crimen  en  las  nacionee 
americanas. 

El  que  abajo  suscribe,  presenta  a  la  considerad6n  del  Segundo  Oongreso  Cientffico 
Panamericano  a  reunirse  en  Washington  en  didembre  de  1915,  las  siguientes  proposi- 
dones  indicadas  paralarepresidn  cientlfica  y  radonal  de  la  delincuencia  y  del  crimen 
en  las  nadones  americanas. 

L  El  Segundo  Congreso  Cientlflco  PanamerioaDO,  rennldo  en  'WAahington  en  dloiembre  de  1916,  vota 
let  ilguientes  propostclones  indicadas  para  la  repreAdn  cientffloa  y  radonal  de  la  deUnouenda  y  del  crimeii 
en  las  nadones  americanas:  * 

1*.  El  Segondo  Oongreso  Clenttfleo  Panamericano,  rennldo  mWAshlngton  en  didembre  de  1916,  patrodoa 
la  ereaadn  en  las  nadones  americanas  de  dlspensarlos  para  los  nifios  nenriosos  en  donde  se  daiAn  ooidadot 
apfoplados  a  los  Jdveom  epil^tiros,  hisMrioos  f  neorastteicos,  a  los  nifios  tristes,  pereiosos,  a  fin  de  ylgo* 
rUar  la  vitalidad,  la  notricidn  de  so  cerebro  y  su  cohesidn  mental. 

3*.  El  Segondo  Congreso  Cientlfloo  Panamericano.  reonldo  en  W&shington  en  didembre  de  1916,  patro- 
etna  en  las  nadones  americanas  el  coltivo  y  el  desarrollo  intensivo  de  la  instmoddn  y  de  la  edncaddn, 
impregnando  el  esi^tn  del  nifio  en  los  prindpios  lomlnosos  de  las  verdades  y  de  la  moral. 

3*.  £1  Segundo  Congreso  Cieatlflco  Panamericano,  remildo  en  Wiahington  en  didembre  de  1916,  patrodna 
en  la9  nadones  americanas  la  investigaddn  m^co-legal  e  Inyestlgaddn  paiooldgica  del  inoulpeido,  oomo 
iwooedimiento  de  ley. 

4*.  El  Segondo  Congreso  Cieatlflco  Panamericano,  reonldo  en  WAshington  en  didembre  de  1916,patrodna 
en  las  nadones  americanas  la  creaddn  de  hospitales-c&roeles  para  los  criminales  aUenados  o  grandes  neord- 
patas. 

6*.  El  Segondo  Congreso  Cientlflco  Panamericano ,  reonldo  en  W&shington  en  dlciembre  de  1 916,  patrodna 
en  las  nadones  americanas  la  cread^Sn  de  colonias  penalee,  en  donde  se  redimirta  el  criminal  por  el  trabajo 
y  los  sanos  ejemplos. 

6*.  El  Segundo  ConjrresoCiontiflco  Panamericano,  reonldo  en  WAsbington  en  didembre  de  1916, patrodna 
en  las  nadones  americanas  la  Intensiflcacidn  de  la  locha  contra  d  alcobolismo. 

7*.  EI  Segnndo  Congreso  Cientlflco  Psaaniericano,  reonldo  en  Washington  en  dlciembre  de  1915,  patrodna 
en  las  naoiones  amenranas  In  intenslflcaddnde  la  locha  contra  las  enfermedades  mfeodosas. 

8*.  El  Segondo  Congreso  Cienttflco  Panamericano,  reonldo  en  W&shington  en  didembre  de  1916,  patrodna 
en  las  nadones  americanas  la  relbrma  de  la  legisladdn  penal,  adaptada  a  los  estodios  peico-antropddglooa 
y  sodales  contempor&neos. 


846       PBOGEEDINOS  SECOND  PAN  AMEBIOAN  80IEKTIFI0  00NQBE88. 

Defensa  profildctica  del  niflo  contra  las  enfermedades  infecciosas. 
Creaoi6n  do  un  Institute  Inter-Americano  de  Profilaxia  infantil  de 
las  enfermedades  infecciosas: 

El  nifio  e8t4  expueato  por  la  vitalidad  menor  de  su  resistencia  org^ca  a  loe  embates 
de  todos  lo8  factores  que  pugnan  con  la  estabilidad  fisioldgica  de  su  ser;  estd  colocado 
en  uno  de  los  eslabones  de  la  cadena  evolutiva  de  la  vida  al  pasar  por  todas  sub  fasee 
de  la  existencia.  Su  oiganismo  sufre  las  reacciones  paico-oigdnicas  mis  intensaa, 
deede  que  los  proceeos  del  intercambio  oig&nico  est&n  en  el  perfodo  del  acrecenta- 
miento  m^  progresivo,  cualquier  factor  que  venga  a  interrumpir  la  marcha  evolutiva 
del  complicado  engranaje  de  sub  intercambioB  org^cos  y  de  sus  manifestaciones 
psfquicas  se  traducir&n  con  caracteres  indelebles  en  Iob  procesos  ulteiiores  de  sa 
ser  en  las  caracteristicas  de  una  complexidad  patol^ca  y  enfermiza.  La  salud  del 
niflo  reposasobre  laperfectaarmonla  de  los  deberes  cumplidos  y  los  derechoe  adquiri- 
dos  que  la  sociedad  le  dispensa,  y  cudn  grande  es  ese  deber  desde  que  en  estado 
latente  la  civilizaci6n  humana,  Ueva  en  su  eneig^tica  y  din&mica  el  factor  intrfnseco 
de  la  modalidad  infantil  de  una  antigua  generaci6n  descentralizada  en  la  evolucidn 
de  los  seres  en  el  consorcio  colectivo.  Podrfa  decir  si  se  me  fuera  dable  expresanne 
en  una  terminologia  nietal6rica  que  los  microbios  patdgenos  tienen  en  la  infancia 
el  perfecto  caldo  de  cultivo,  que  necesitan  como  inoculaci6n  y  reproduccidn  deede 
que  en  ella  la  vida  tiene  los  encantos  de  una  oxigenaci6n  continua  y  perenne;  y 
que  los  agentes  patdgenos  se  adaptan  para  su  vivificaci6n  a  detrimento  de  la  salud  indi- 
vidual y  social .  Trascendental  es  la  soluci6n  del  complicado  f en6meno  de  la  profilaxia 
de  las  enfermedades  infecciosas  de  la  infancia,  es  im  problema  de  todos  los  6rdene8 
de  la  actividad,  si  bien  de  puntualizacidn  m^dica,  el  conjunto  de  los  factores  que 
entran  a  dirigir  la  sociedad  le  deben  no  obstante,  la  dedicacidn  mis  consagrada  como 
previfii<5n  y  terapia  de  esas  manifeetaciones  de  la  patologfa  pedi&trica. 

La  medicina  ha  comprobado,  corroborado  infinitas  voces,  la  precaria  situacidn  higi6- 
nica  en  que  se  halla  el  nifio  en  la  sociedad  para  resistir  a  los  embates  del  contagio  y  la 
enfermedad. 

En  las  primeras  etapas  de  la  civilizaci6n,  cuando  se  desconocfan  las  mdltiples  mani- 
festaciones  del  contagio  y  de  la  evoluci6n  de  1^  enfermedades,  el  problema  en  cuestidn 
permanecia  cual  inc6gnito  en  la  penumbra  metafisica  y  trascendental;  posteriormente 
el  desairollo  del  estudio  de  las  ciencias  naturalesy  de  la  biologfa,  vino  a  despejar  en 
parte  esa  obscuridad  y  en  la  clarovidencia  de  ^la  ciencia  de  la  experimentaci6n,  la 
gran  palabra,  el  gran  aserto  de  la  microbiologfa  a  cuyo  t^rmino  el  genio  de  Pasteur  se 
destacara  fulgurante  en  el  escenario  de  la  ciencia  se  conform6  el  determinismo  de 
causa  y  efecto  en  las  enfermedades  infeccioeas. 

El  problema  en  cuesti6n  sufri6  entoncee  una  gran  faz  en  su  evoluci6n,  la  ciencia 
triunM  sobre  la  antigua  filosofia  de  lo  trascendental  y  lo  Inmanente.  Las  autoiidades 
sanitarias  de  las  naciones  civilizadas  del  orbe  abrieron  un  gran  capftulo  a  su  estudio 
y  la  accidn  oficial  dej6  sentir  su  influencia  bajo  la  aseveracidn  de  la  palabra  cientffica. 

No  obstante  la  8oluci6n  del  problema  se  esboz6  mils  complicado  que  en  la  enuncia- 
ci6n  de  sus  principios,  algunos  resortes  del  engranaje  complicado  de  la  diniunica 
infantil  pasaron  desapercibidos,  y  esos  factores  descentralizados  de  la  conslderacidn 
cientffica  explicaron  la  deficiencia  de  algunos  pimtos  en  la  solucidn  del  problema 
sanitario. 

Como  dijera  anteriormente,  el  problema  debi6  solucionarse  en  los  multiples  factores 
convergentes  y  que  crean  el  campo  en  el  que  sedesenvuelven  las  aptitudes  vitales 
de  la  infancia. 

La  sltuaci6n  econdmica  de  la  familia  es  uno  de  los  puntos  de  capital  importanda, 

para  el  juicio  general  que  sobre  las  enfermedades  infecciosas  explican  muchas 

voces  la  accidentada  situacidn  higi^ca  de  la  familia  y  del  inmediato  peligro  para 

1  a  vida  de  los  pequefios  seres  evolucionando  dentro  de  un  medio  en  el  que  las  exi- 


PUBLIC  HEALTH  AND  MEDICINE.  347 

gencias  inmediatas  de  la  ixutrici6n  Oi^gdnica  se  hacen  con  la  deficiencia  de  la  carencia 
de  lo8  recursos  Indispensables  para  la  Batisfacci6n  floiida  de  la^  necesidades  mate- 
nales  de  la  vida. 

Serfa  el  punto  en  cuesti6n  el  factor  econdmico  de  la  miseria,  uno  de  los  que  pre- 
diisponen  al  contagio  de  las  enfermedades  infecciosas,  desde  que  eee  niflo  sobre  quien 
pesa  esasituacidn  aflictiva  del  hogar,  no  concentra  las  modalidades  de  resistencia 
orgdnica  propia  de  los  atributos  de  las  asunilaciones  nutritivas  de  los  intercambios 
vitales  de  la  existencia. 

A  la  consideraci6n  del  factor  econ6inico  debemos  definir  otra  cuesti6n. 

La  mentalidad,  el  estado  de  cidtura  de  las  familias,  el  desconocindento  de  las  nociones 
m&B  elementales  de  la  higiene  individual  y  colectiva,  hacen  y  determinan  en  laa 
famllias  asf  afectadas  ese  rasgo  de  deficiencia.  £1  fundamento  esencial  sobre  el  que 
reposa  la  vitalidad  del  ser  en  los  prim^ros  afLos  de  la  existencia  es  la  higienizaci6n  de 
los  medios  en  que  se  desenvuelven  los  factores  de  la  vida. 

Estas  dos  deducdones  las  he  podido  corroborar  en  mi  pr^Urtica  profesional,  en  donde 
en  cierta  y  detenninada  vivienda  de  algunos  barrios  apartados  de  la  capital,  la 
pobreza  m^  grande  impera  y  la  deficiencia  mils  grande  de  los  medios  higi^coe 
crean  y  predisponen  a  las  infecdones  pat6genas  mils  mortfferas. 

He  podido  comprobar  en  las  epidemias  que  anualmente  atacan  la  poblaci6n,  una 
d^adez  marcada  de  los  preceptos  de  la  higiene. 

La  lucha  por  la  profilaxia  de  las  enfermedades  infecciosas  en  la  infancia  dd>e 
llamar  en  consideraci6n  la  intervenci6n  ^e  los  Estados  en  una  sabia  disposid^n 
actuando  en  el  sentido  mSs  amplio  del  saneamiento  de  la  poblaci6n. 

£1  problema  en  cue6ti6n  ezige  legal  y  moralmente  la  constituddn  de  un  Instituto 
Inter-Americano  de  Profilaxia  de  las  enfermedades  inlecdosas  de  la  infancia: 

1*.  BI8<8midoOongreioCaflttt!flooPMi<mcrietno,femil^ 
la  ormci&a  de  an  lostitato  Inter-Ameriomo  de  Profilttds  de  las  enfcnnedadee  infeodoeas  de  la  Infaneht. 

2*.  El  Instf tato  Inter-Amerloaoo  de  Profilaxia  de  las  enfennedades  infeooiosas  de  la  Infanda,  haii  pcio> 
tteo  el  onmpliniiento  de  los  preoeptos  hlgi^oos  y  de  la  profilaxia  de  las  enfennedades  infecdosas  por  ana 
i«glaaeiitaeid&  legal  de  los  Estados  amerlcanos. 

8*.  For  eonteendas  pdbUoas  llamadas  a  ilostrar  a  los  pueblos  amerioanos  el  sentido  de  una  defsosa 
ndonal  y  dantlflca  oontra  el  viras  pat^geno. 

4*.  Por  la  pablioaddn  de  folletos  explicatlvos  f  Aciles  de  oomprenaidn  popular  y  oon  fotograbados  enunda* 
tiToe  de  las  oaosas  y  pi^genla  de  las  enfennedades  infecdosas  en  la  infiinda  y  el  modo  de  evitarlas. 

6*.  Rl  Institato  Ipter-Amerioano  de  Profilaxia  de  las  enfermedades  infecdosas  de  la  inlkaida,  enoomen- 
daiaatmaoomirfdBdentffloadeoadanaddnamflrioaiia  la  cooperaddn  efectiva  de  los  fines  y  mdviles  dal 
nUsmo. 

The  Chaibman.  The  symposium  on  cancer  will  be  opened  by  a 
paper  by  Dr.  Leo  Loeb  on  "General  tendencies  and  problems/'  I 
take  pleasure  in  presenting  Dr.  Loeb. 


GENERAL  PROBLEMS  AND  TENDENCIES  IN  CANCER  RESEARCH. 

By  LEO  LOEB, 
WdMngton  UnivtnUy  Medical  School, 

After  the  succeesful  continuous  transplantation  of  rat  sarcoma  and  mouse  carcinoma 
had  shown  that  we  possessed  a  method  suitable  for  the  study  of  the  biology  of  tumors, 
and  promising  a  rich  harvest  of  results,  the  decade  following  the  year  1901  was  to  a  great 
extent  devoted  to  the  study  of  propagated  tumors  rather  than  to  the  analysis  of  the 
first  origin  of  tumors,  although  this  latter  problem  had  never  been  entirely  neglected. 
Within  recent  years,  however,  much  attention  has  been  given  to  the  first  origin  of 
tumors.    The  so-called  endemic  occ\irrence  of  cancer  which  we  observed  in  the  cas» 


348       PBOOEEDINGS  SECOND  PAN  AMEBIOAN  SOIBNTIFIO  C0NQBB8S. 

of  cattle  and  rats,  and  which  other  investigators  observed  in  the  case  of  mice  and  other 
animals,  suggested  to  us  16  years  ago  the  possible  significance  of  heredity  as  an  etiologi- 
cal factor,  Some  years  later,  observations  which  we  made  in  a  mouse-breeding  estab- 
lishment in  Granby  confirmed  this  hypothesis;  but  it  is  only  during  the  last  six  years, 
following  the  observations  of  Tyzzer  and  Murray,  that  our  investigations  in  conjunction 
with  Miss  Lathrop  proved  on  a  very  broad  basis  the  very  great  significance  of  heredity 
in  the  transmission  of  cancer  in  mice,  the  distinctness  of  the  age  and  frequency  factors, 
the  correlation  between  cancer  frequency  and  structural  and  functional  characteristics 
of  the  animals.  The  results  of  hybridization  experiments,  which  we  carried  out  on  a 
large  scale,  do  not  seem  to  be  compatible  with  the  view  recently  expressed  that  the 
tendency  to  cancer  is  a  recessive  character. 

These  studies  and  the  methods  used  therein  have,  however,  a  much  wider  signi- 
ficance. On  the  basis  of  a  thorough  knowledge  of  the  cancer  incidence  in  certain 
families,  and  on  this  basis  alone,  will  it  be  possible  to  analyze  certain  other  factors  in 
the  etiology  of  tumors,  and  the  understanding  of  these  latter  factors,  as  well  as  of  hered- 
ity, will  perhaps  ultimately  provide  us  with  a  rational  basis  for  the  prevention  of 
cancer.  Without  a  thorough  knowledge  of  heredity,  conclusive  results  as  to  the  signifi- 
cance of  other  factors  could  not  be  expected.  Acting  on  this  principle,  we  found 
that  castration  in  sexually  mature  mice  at  the  age  of  3  to  6  months  reduces  the  cancer 
rate  in  a  very  pronounced  way. 

Prevention  of  pregnancy,  while  it  still  has  some  effect  in  reducing  the  cancer  rate, 
has  very  much  less  significance  than  castAtion.  These  results,  and  some  additional 
ones  to  be  mentioned  shortly,  permit  us  to  classify  the  causes  of  tumors  into  two 
main  divisions — internal  and  external  ones.  Heredity  belongs  to  the  former  class. 
The  point  of  attack  of  these  hereditary  factors  we  do  not  yet  know .  In  some  cases  they 
may  perhaps  stand  in  relation  to  some  other  internal  factors,  which  are  in  all  probability 
of  significance  in  certain  cases.  I  refer  to  the  spontaneous  parthenogenetic  develop- 
ment of  the  egg  within  the  ovary  and  perhaps  elsewhere  in  mammals — a  process  which, 
according  to  our  findings  in  the  guinea  pig,  is  not  a  rare  occurrence,  and  may  even 
normally  proceed  to  the  formation  of  the  anlage  of  the  central  nervous  system.  To 
this  class  of  factors  may  also  belong  developmental  errors  which  were  already  suspected 
by  Cohnheim,  and  which,  as  we  know,  may  appear  as  inheritable  mutations  in  varioue 
groups  of  animals. 

The  external  factors  may  be  further  divided  into  chemical  and  mechanical,  and  both 
may  be  derived  either  from  within  the  body  or  from  the  outside  world .  As  an  example 
of  a  chemical  factor  originating  within  the  body  we  may  cite  the  great  importance  of 
the  internal  secretion  of  the  corpus  luteum  in  the  origin  of  cancer  in  mice,  to  which  we 
referred  above,  but  other  internal  secretions  will  probably  be  found  to  be  of  similar 
significance.  External  mechanical  factors  can  be  recognized  in  the  well-known  effect 
of  chronic  irritation.  How  far  certain  parasites,  especially  those  in  the  class  of  vermes 
and  insects,  produce  cancer  through  chemical  and  how  far  through  mechanical  means 
is  not  certain.  Previous  observations  in  man  Id  the  case  of  cancer  of  the  bladder 
caused,  directly  or  indirectly,  by  bilharzia,  and  especially  the  recent  experiments 
of  Fibiger,  make  it,  however,  quite  certain  that  such  parasites  may  be  the  cause  of  can- 
cer. It  is  likewise  uncertain  how  far  Boentgen  ray  cancer,  frequent  in  Roentgen  ray 
operators,  and  also  apparently  experimentally  produced  in  a  few  rats  by  Marie,  is  due 
to  ulceration  subsequent  to  the  exposure  or  to  a  direct  stimulating  action  ol  the  rays. 
In  some  caees  perhaps  chemical  and  mechanical  factors  may  cooperate  in  producing 
tumors;  the  efliciency  of  such  a  combination  in  calling  forth  tumorlike  formations  has 
been  shown  by  us  in  the  case  of  deciduamata  of  the  uterus,  which  we  produced  experi- 
mentally— a  new  formation  which  we  included  in  a  class  designated  as  transitory 
tumors. 

There  are  observations  on  hand  which  indicate  that  growth  stimuli  may  be  espe- 
cially active  in  animals  with  a  hereditarily  determined  tendency  to  cancer.    Such  an 


PUBUC  HEALTH  AND  MEDIOIKE.  349 

observation  we  made  in  the  case  of  a  cancer  in  a  mouse  belonging  to  a  family  rich  in 
tumors,  where  ulceration  of  the  skin  near  an  adenoma  of  the  mammary  gland  led  to 
the  development  of  an  epidermal  carcinoma.  Further  systematically  conducted 
experiments  in  this  direction  might  lead  to  interesting  results. 

It  is,  however,  not  probable  that  in  order  to  obtain  the  production  of  cancer  the  quan- 
tity of  prerequisite  internal  factors  must  be  a  definite  one.  On  the  contrary,  there  is 
some  evidence  on  hand  which  makes  it  probable  that  internal  and  external  factors 
may  vary  in  inverse  ratio,  and  that  if  the  external  factors  are  quantitatively  very  strong, 
the  quantity  of  internal  factors  may  be  reduced. 

K  we  survey  briefly  the  various  tjrpes  of  growth  reactions  known  in  vertebrates,  we 
may  perhaps,  according  to  the  character  of  the  stimuli,  which  are  usually  in  each 
case  the  first  members  in  a  complicated  reaction  chain,  and  of  the  systems  on  which 
they  act,  provisionally  distinguish  the  following  types: 

1.  Various  stimuli  act  for  a  short  time  on  complex  systems,  the  egg  cells,  and  lead 
to  a  long  chain  of  growth  phenomena,  which  ultimately  cease.  The  experiments  in 
artificial  parthenogenesis  of  Jacques  Loeb  led  to  a  very  far-going  analysis  of  these 
phenomena. 

2.  Defects  lead  to  a  chain  of  growth  phenomena  which  are  of  a  temporary  character, 
and  come  to  a  standstill  after  a  certain  quantity  and  kind  of  new-formed  tissue  has 
more  or  less  completely  filled  out  the  defect. 

3.  Chemical  substances  stimulate  the  growth  of  certain  tissues  to  which  they  bear 
a  more  or  less  specific  relation. 

These  growth  phenomena  come  to  a  standstill  with  the  activity  of  the  stimulating 
substance  or  very  soon  afterwards.    (Corpus  luteum  and  mammary  gland.) 

4.  A  combination  of  factors  2  and  3  may  lead  to  tumor-like  growth  phenomena 
when  either  factor  alone  would  cause  only  a  slight  proliferation.  Here,  again,  the 
effect  is  temporary.    (Experimental  deciduomata  of  the  uterus.) 

5.  Chemical  (lipolytic?)  bodies  which  do  not  show  a  specific  relation  to  the  oigans 
affected  stimulate  various  tissues  to  a  temporary  proliferation:  Fat  soluble  staina 
(Bemhard  Fischer  and  others),  ether  (Reinke),  are  substances  that  under  certain 
oonditionB  seem  to  exert  a  stimulating  effect. 

6.  Chemical  and  mechanical  factors  produce  with  the  aid  of  a  large  quantity  of 
internal  factors,  or  in  certain  cases  apparently  without  such  aid,  an  increase  in  cell 
proliferation  that  persists  after  the  st^iuli  have  ceased,  which  is  permanent,  poten- 
tially eternal,  in  contradistinction  to  the  temporary  reactions  mentioned  above. 
This  is  the  cancerous  reaction  with  which  all  or  the  luge  majority  of  the  mammalian 
tissues  may  respond.  Characteristic  for  this  reaction  is  neither  potential  immortality, 
(some,  or  perhaps  all,  somatic  cells  are  potentially  immortal),  nor  the  power  of  con- 
tinued proliferation  which  in  all  probability  even  certain  ordinary  somatic  cell- 
possess;  but  it  is  the  increase  in  proliferative  power  which  is  characteristic  of  cancer, 
and  furthermore  the  permanency  of  the  reaction  in  response  to  a  temporary,  non- 
peimanent  stimulus.  We  have,  then,  to  assume  that  a  labile  cell  sjrstem  which 
responds  to  temporary  stimuli  with  a  temporary  reaction  is  transformed  under  the 
influence  of  certain  stimuli  and  often  with  the  aid  of  hereditaty  factors  into  a  stable 
system  which  shows  a  greater  proliferative  power  than  the  labile  system.  The 
stimulus  brought  thus  about  merely  a  transformation  of  the  cells  into  a  new  kind  of 
cell  system,  which  proliferates  indefinitely  at  a  more  or  less  increased  rate.  Such  a 
transformation  may  be  called  a  mutation.  Inasmuch  as  all  or  the  large  majority  of 
all  body  cells  are  liable  to  this  change,  they  must  have  from  the  beginning  in  their 
organization  a  mechanism  that  provides  for  the  possibility  of  such  a  mutation. 

According  to  this  conception  we  must  then  assume  that  all  or  most  ceUs  have 
potentially  two  equilibria — the  normal  one  and  the  cancerous.  They  begin  life  with 
the  normal  equilibrium,  but  \mder  the  influence  of  certain  stimuli,  with  or  without 
the  cooperation  of  hereditary  factors,  they  are  transferred  to  the  cancerous  equilibrium. 


350       PROCEEDINGS  SECOND  PAN  AMEBICAN   SCIENTIFIC   CONGRESS. 

Cells  in  the  normal  equilibrium  react  to  stimuli  in  the  manner  indicated  above 
(types  I  to  5).  Ultimately  they  return  invariably  to  the  normal  equilibrium  after 
the  stimulus  has  ceased  to  act:  Cancerous  cells,  on  the  other  hand,  may  perhaps 
be  exterminated,  but  they  are  not  known  to  return  to  the  normal  equilibrium.  There 
is,  however,  an  alternative  to  this  conception  which  would  eliminate  the  necessity 
for  assuming  a  new  equilibrium  for  cancerous  proliferation — an  assumption  for  which 
naturally  no  anology  can  exist.  If  we  assume  that  an  external  agent  associated  with 
the  ceU  rather  than  a  physical-chemical  mechanism  within  the  cell  produces  the 
cancerous  proliferation,  the  latter  would  no  longer  represent  a  peculiar  unique  con- 
dition, but  would  be  a  special  application  of  one  of  the  types  3  to  5,  in  whidi,  how- 
ever, the  stimulus  would  act  incessantly.  Such  a  stimulus  could  be  supplied  through 
multiplying  microoiganisms  which  essentially  represent  constantly  newly  formed 
external  chemical  stimuli.  We  know  that  microcHganisms  can  call  forth  cell  multi- 
pllcaticMi  in  plants  and  animals.  In  plants  certain  bacteria  can  produce,  as  especially 
Erwin  Smith  has  shown  in  the  case  of  the  crowngall,  tumor-like  proliferations— an 
effect  in  this  case  not  depending  merely  on  the  kind  of  stimulus,  but  also  <m  the  par- 
ticular system  on  which  the  stimulus  acts. 

In  this  connection  we  might  also  maition  a  number  of  extremely  interesting  cases 
in  which  various  investigators  saw  the  transformation  of  different  normal  into  can- 
cerous tissues,  after  a  preceding  contact  with  cancerous  tissue  of  another  kind,  but  in 
tissues  of  the  same  individual.  I  referred  above  to  an  observation  of  this  character 
in  which  we  found  skin  to  become  cancerous  under  the  influence  ci  an  adenocar- 
dnoma  of  the  mammary  ^and.  Similarly,  in  amtact  with  carcinoma,  connective 
tissues  may  become  sarcomatous.  Such  tumofs  we  called  combination  ooataci 
tumois.  In  such  a  carcinosarcoma  in  a  Japanese  mouse  which  we  studied  ezperi- 
msntaUy  we  found  the  carcinomatous  and  sarcomatous  components  to  loUow  the 
same  variation  curve  of  growth  energy  in  succeeding  generations.  This  suggests  the 
identity  of  the  agent  causing  the  proliieration  of  both  tissues  and  the  dependence  of 
the  variation  in  growth  on  the  variation  in  the  activity  of  the  agent.  The  agent 
tnosferred  from  one  tissue  to  another  mig^t  be  a  chemical  substance — an  explanation 
first  suggested  in  the  case  of  the  sarcomatous  transformation  of  the  stroma  by  EhrMch 
and  Apolant — or  it  mig^t  be  a  microoiganism.  There  exist  already  normally  indica- 
tions pointing  to  a  chemical  influence  exerted  by  one  tissue  upon  another.  We 
interpreted  in  this  manner  the  difference  in  ceU  activity  in  the  connective  tissue  of 
the  mucosa  in  certain  ocgans  near  the  epithelium  on  the  one  and  near  the  submucosa 
on  the  other  hand.  The  different  effect  exerted  by  the  tissues  of  different  individuals 
on  the  activity  of  the  fibroblasts  of  the  host  also  points  to  sudi  a  conclusion  (different 
effects  of  auto  and  homoiotransplantation). 

There  are  especially  to  be  considered  the  very  important  results  of  Peyton  Rous, 
who  succeeded  in  fowls  with  means  which  in  the  case  of  mammalian  tumors  had  not 
led  to  positive  results  in  the  hands  of  earlier  investigators,  to  separate  through  filtra- 
tion and  other  means  the  causative  agent  from  the  sarcoma  cells  with  which  it  was 
associated.  In  this  case  we  might  have  to  deal  either  with  filterable  microorganisms 
or  again  with  chemical  substances.  If  we  accept  the  latter  alternative,  we  would 
have  to  assume  that  the  same  substance  that  initiates  the  cancerous  cell  proliferation 
in  normal  cells  would,  alter  the  change  has  once  been  accomplished,  be  perpetually 
newly  formed  within  in  the  proliferating  cells.  This  condition  would  in  some  reqpects 
be  comparable  to  an  autokatalytic  process.  The  cancerous  equilibrium  would  rep- 
resent a  condition  in  which  this  growth  substance  is  either  produced  in  a  larger  quan- 
tity than  it  exists  in  normal  cells,  or  is  entirely  formed  de  novo.  It  seems,  further- 
more, that  no  antibody  is  produced  in  the  body  fluid  against  this  substance.  These 
substances  do  not  seem  to  be  separable  from  the  cells  in  all  fowl  tumors,  and  the 
kind  of  fowl  tumors  in  which  a  separation  can  not  be  accomplished  behave  in  this 
respect  like  the  mammalian  tumors.    There  seem  to  exist  different  substances  of 


PUBLIC   HEALTH  AND  MEDICINE.  351 

thjfl  kind,  and  different  substances  always  call  forth  a  specific  activity  of  connective 
tissue  cells  resulting  in  the  reproduction  of  the  original  kind  of  tumor  and  stimulating 
endlessly  the  production  of  the  same  specific  substance  within  the  fibroblasts.  Jint 
as  in  the  case  of  the  corpus  luteum  substance  responsible  for  the  production  of  decidu- 
omata,  the  cooperation  of  a  mechanical  factor  seems  to  be  essential  for*the  stimulation 
of  tumor  growth  in  fowl.  Thus  we  would  have  most  probably  to  interpret  these 
phenomena  if  the  observation  of  Casimir  Funk,  according  to  which  an  alcoholic 
extract  of  the  tumor  contains  the  active  agent,  could  be  confirmed  in  a  larger  number 
of  cases.  If  this  should  prove  correct,  we  may  expect  to  find  correepondilig  condi- 
tions in  mammalian  cancer.  A  study  of  heredity  in  cancer  of  the  fowl  would  close 
this  chain  of  investigations,  and  we  could  then,  with  the  analysis  of  internal  and  exter- 
nal factors  in  cancer  already  on  a  solid  foundation,  conclude  that  the  causes  of  cancer 
have  in  their  main  outlines  been  satisfactorily  analyzed.  Of  course  underneath  this 
first  plane  of  causes  connections  extend  further  into  fields  where  they  meet  with  other 
factors  determining  cell  and  tissue  life  in  its  dependence  on  physical  and  chemical 
laws,  and  thus  we  are  led  into  deeper  planes  of  caiisation.  But  here  the  problems 
have  become  identical  with  those  of  genera]  biology. 

In  this  connection  a  few  words  concerning  the  definition  of  cancer  might  not  be  out 
of  place.  It  might  be  assumed  a  definition  of  cancer  satisfying  past  and  future 
research  to  be  one  of  the  essential  requirements  for  the  fruitful  conduct  of  investigation 
on  the  contrary,  I  believe  that  at  the  present  stage  of  investigation  progress  may  be 
retarded  through  premature  rigidity  in  definition,  and  especially  through  insisting 
on  the  proof  that  secondary  tumors  originate  from  transplanted  cells.  In  the  case 
of  sarcoma  of  the  rat  and  mouse  this  proof  has  so  far  been  supplied  only  the  rat  sarcoma 
of  the  th3rroid  found  in  Chicago,  and  is  merely  based  on  analogy  in  the  case  of  the 
laige  majority  of  other  sarcomata.  Since  it  has  now  been  shown  that  in  sarcoma  of 
fowl  and  agent  associated  with  the  tumor,  but  separable  from  it,  may  just  as  well 
give  origin  to  new  growths,  we  may  well  hesitate  in  excluding  from  consideration  new 
formations  which  under  certain  conditions  take  in  all  probability  origin  from  trans- 
planted cells,  while  in  other  cases  they  may  perhaps  be  propagated  through  an  agent 
associated  with  the  tumor.  I  refer  especially  to  the  so-called  lympho-sarcoma  or 
small  round  cell  sarcoma  of  dogs,  which,  after  transplantation  in  dogs,  apparently 
grows  from  the  transplanted  cells,  while  in  the  fox,  according  to  von  Dungem,  the 
tumor  cells  are  composed  of  host  tissue.  May  we  not,  in  case  von  Dungem 's  view 
should  prove  correct,  have  to  consider  the  possibility  that  the  transplanted  dog  cells 
perished  in  the  foreign  species  and  that  the  associated  agent  stimulated  the  host  cells 
to  proliferate? 

With  the  factors  which  we  have  already  analyzed — factors  of  heredity,  of  internal 
secretion,  of  external  chanical  and  mechanical  stimulation — ^we  are  in  a  position 
to  control  to  a  great  extent  the  cancer  rate  in  certain  species  of  animals.  As  we  said, 
we  can  not  yet  exclude  with  certainty  the  other  alternative — namely,  microorgan- 
isms— ^as  an  additional  causative  factor. 

After  so  many  futile  attempts  at  a  direct  proof  of  their  presence,  further  efforts  of 
this  kind  do  not  appear  promising  at  present.  There  seem,  however,  ways  still 
open  to  approach  this  problem  in  an  indirect  manner. 

To  decide  between  the  two  alternatives  which  we  mentioned  does  not  only  con- 
cern cancer  research  in  the  more  restricted  sense,  but  is  of  the  greatest  importance 
for  general  biology.  In  return  for  much  that  it  received  from  neighboring  sciences 
cancer  research  has  given  something  important  to  biology.  The  serial  endless  experi- 
mental propagation  of  tumors  has  enriched  biology  with  a  valuable  instrument  of 
research  and  new  outlooks  on  the  life  and  character  of  somatic  cells  have  been  gained. 
We  may  briefly  mention  the  following  facts  established  or  very  strongly  suggested: 
In  the  course  of  our  early  transplantations  we  found  that  the  energy  of  tumor  growth 
can  be  experimentally  increased  as  well  as  decreased .    Ehrlich  explained  the  increase 


352       PROCEEDINGS  SECOND  PAN  AMEBIOAN  SOIENTIFIC  00NQBB88. 

as  due  to  a  selection  of  rapidly  growing  tumors.  We,  however,  believed  from  the 
beginning  that  it  was  partly  produced  by  a  mechanical  stimulation  of  the  tumor 
cells  and  in  addition  was  possibly  due  to  chemical  stimulation  caused  by  the  transfer 
in  to  a  new  host  with  a  different  constitution  of  the  body  fluids,  in  some  cases  perhaps 
processes  of  immiinity  may  enter  into  this  phenomenon. 

In  conjunction  with  M.S.  Fleisher  we  noted  that  chemical  bodies  which  inhibit 
tissue  growth  at  a  certain  period  in  the  life  of  tumors  do  not  have  this  power  at  other 
periods;  especially  are  they  powerless  in  the  case  of  very  young  timiors — an  obser- 
vation confirmed  by  Keysser;  but  we  found  that  such  early  injections  produce  an 
immunization  against  the  later  action  of  these  substances.  Our  experiments  suggest, 
furthermore,  very  strongly  that  this  immunity  is  of  a  twofold  character;  that  it  origi- 
nates in  the  host  as  well  as  in  the  tumor  cells  themselves.  That  this  cell  immunity 
can  be  transferred  to  a  certain  number  of  later  cell  generations  and  is  to  some  extent 
specific  for  the  substance  which  had  called  it  forth.  While  our  results,  based  on  the 
observation  of  a  very  large  number  of  animals,  strongly  suggest  these  latter  conclu- 
sions, we  nevertheless  think  it  desirable  to  add  new  evidence  in  order  to  guard  against 
a  complication  with  variable  factors. 

Do  we  have  in  all  these  cases  to  deal  with  indirect  actions  on  the  cells  and  with 
direct  actions  on  accompanying  microorganisms,  or  with  direct  actions  on  the  cells? 
I  rather  incline  to  the  latter  view,  and  we  would  suggest  that  an  increase  in  chemical 
activity  in  the  tumor  cells — ^an  increase  perhaps  restricted  to  certain  activities — 
render  the  latter  a  much  finer  balance  in  their  response  to  certain  environmental 
conditions  through  variations  in  growth  energy  than  are  the  normal  tissue  cells. 

As  we  pointed  out  in  1901,  on  the  basis  of  Moran's  and  our  own  experiments,  cancer 
cells  are  potentially  immortal  in  the  same  sense  in  which  protozoa  and  germ  cells  are 
potentially  immortal.  All,  or  at  least  the  large  majority  of  all,  normal  tissue  cells  are 
potentially  cancer  cells,  and  we  may  therefore,  with  full  justification,  conclude  that 
ordinary  somatic  cells  are  likewise  potentially  immortal.  Like  the  majority  of  tumors 
they  can  not  be  indefinitely  propagated  in  other  individuals  of  the  same  species 
because  of  the  injurious  action  of  what  we  may  term  ^'homoiotoxins. "  On  the  other 
hand,  thanks  to  their  increased  growth,  energy,  and  perhaps  a  lessened  sensitiveness  to 
homoiotoxins,  the  cells  of  certain  tumors  can  overcome  the  injurious  conditions  exist- 
ing in  other  individuals  of  the  same  species  and  be  propagated  indefinitely.  Tumor 
cells  and  ordinary  tissue  cells  do  not  differ,  as  Bashford  and  others  assumed  in  poten- 
tial immortality,  but  in  the  intensity  with  which  they  proliferate  and  in  their  destruc- 
tive power. 

Of  equally  great  biological  interest  are  the  defensive  reactions  called  forth  in  the 
host  through  the  growth  of  the  tumor  cells.  As  one  of  the  most  important  results,  we 
may  here  state  that  no  immunity  seems  to  be  produced  through  tumor  growth  in  the 
animals  in  which  the  tumor  originated.  We  foimd  that  in  the  case  of  rat  and  dog 
tumors  cells  remained  alive  and  grew  after  transplantation  into  the  animal  in  which 
they  originated,  while  they  died  in  other  individuals  of  the  same  species.  Tyzzer 
foimd  the  same  to  be  true  in  the  chicken,  and  Harland  and  Fleisher  and  ourselves  in 
the  mouse.  Harland !s  experiments  suggested,  furthermore,  that  the  own  tumor 
could  not  act  as  antigen,  and  by  proving,  in  addition,  that  the  own  tumor  does  not 
neutralize  immune  substances,  our  experiments  prove  the  correctness  of  Harland  *s 
suggestion  that  against  an  autochthonous  tumor  no  immunity  can  be  produced.  The 
greater  significance  again  attached  to  the  study  of  animals  in  which  tumors  originated, 
in  contradistinction  to  bearers  of  experimental  tumors,  is  one  of  the  characteristic 
tendencies  of  recent  cancer  investigation,  and  it  is  of  interest  in  this  connection  that 
our  experiments  indicate  that  animals  with  autochthonous  tumors  are  a  better  soil 
than  normal  animals  for  the  growth  of  other  spontaneous  tumors.  While,  therefore, 
in  the  own  organism  usually  no  reaction  takes  place  against  tumor  cells,  reactions  take 
place  after  transplantation  of  tumor  cells  into  other  individuals.    These  reactions 


PUBUO   HEALTH  AKD  MEDICINE.  353 

are  essentially  of  a  similar  character  in  the  case  of  tumors  and  of  normal  tissues.  Again, 
the  correlation  between  the  behavior  of  normal  and  of  cancerous  tissues  has  proven 
fruitful  in  this  case.  After  autotransplantation  of  a  piece  of  normal  tissue  it  may,  in 
the  same  way  as  a  piece  of  tumor,  at  least  in  the  case  of  certain  tissues,  apparently  live 
indefinitely,  while  after  homoiotransplaiitation,  as  we  observed,  the  tissues  die  as  a 
result  of  the  attack  by  lymphocytes  and  through  the  influence  of  fibre  blasts  of^the 
host,  producing  dense  fibrous  tissue,  which  strangulates  the  foreign  cells. 

There  exists  a  possibility  that  the  strange  body  fluids  may  also  directly  interfere 
with  the  metabolism  of  certain  transplanted  tissues  to  such  an  extent  that  they  are 
severely  injured.  After  heterotransplantation  the  indirect  injurious  action  of  the  body 
fluids,  which  are  imsuitable  for  the  metabolism  for  the  transplanted  cells,  is  more 
pronounced  and  leads  to  the  early  death  of  the  transplanted  cells,  and  we  found  in  the 
case  of  skin  imder  these  conditions  no  noticeable  activity  on  the  part  of  the  lympho- 
cytes and  fibro  blasts.  J.  B.  Murphy  showed,  however,  recently  in  very  ingenious 
experiments  that  also  in  the  case  of  heterotransplantation,  lymphocytes  may  be  of 
importance  as  a  defensive  mechanism  of  the  host  imder  certain  conditions. 

Likewise  in  the  case  of  tumors  against  which  an  immunity  becomes  established 
lymphocytes  play  a  distinct  r61e  in  the  destruction  of  the  tumor  tissue,  as  the  inves- 
tigations of  Burgess,  Baeslak,  Da  Fano,  Rous,  and  J.  B.  Murphy  have  shown.  This 
holds  good  in  the  case  of  tumors  already  established.  If  immunity  is  produced  before 
the  transplanted  tumor  has  united  with  the  host  tissues,  the  ingrowth  of  fibro  blasts 
and  blood  vessels  into  the  transplanted  tissue  may,  according  to  Kussel  (in  the  case 
of  tumors)  and  Peyton  Rous  (in  the  case  of  embryonic  tissues)  be  delayed  or  else 
diminished  in  amount. 

As  the  most  probable  explanation  for  these  phenomena  we  proposed  the  following 
theory:  The  chemical  incompatibility  between  the  body  fluids  of  one  individual  and 
the  tissues  of  another  lead  to  changes  in  the  metabolism  of  the  tissues,  with  the  pro. 
duction  of  homoiotoxins  and  heterotoxins,  which,  if  they  do  not  exceed  a  certain 
strength,  disturb  to  some  extent  the  normal  functions  of  the  transplanted  tissues,  with- 
out, however,  interfering  seriously  ^th  their  life;  but  the  abnormal  products  formed 
attract  the  lymphocytes  and  alter  the  reaction  of  the  fibro  blasts,  which  latter  are 
induced  to  produce  dense  fibrous  tissue.  If  the  poisons  become  more  active,  they 
may  directly  injure  tissues  to  such  an  extent  that  growth  and  life  become  impossible. 

These  conclusions,  as  we  believe,  also  throw  light  on  so-called  chronic  inflammatory 
processes  of  various  organs  where  a  changed  metabolism  of  the  cells  and  may  be  also 
poisons  produced  by  microorganisms  may  induce  fibro  blasts  to  form  bands  and  attract 
lymphocytes,  thus  leading  to  processes  of  cirrhosis.  In  a  similar  way,  in  the  case  of 
tumor  immunity,  which  exists,  for  instance,  in  the  case  of  the  retrogression  of  tiunors, 
as  Clowes  and  Gaylord  have  shown,  substances  produced  as  a  result  of  the  immuniza- 
tion and  circulating  in  the  body  fluids  alter  the  metabolism  of  the  tumor  cells,  which 
now  likewise  influence  the  activity  of  the  lymphocytes  and  fibro  blasts  in  a  similar 
way  as  normal  tissues  in  a  strange  host. 

It  remains  for  further  investigations  to  decide  how  much  the  presence  of  foreign 
tissues  leads  to  the  direct  production  of  what  we  could  call  primary  homoio  and  hetero- 
toxins, and  how  much  it  leads  as  the  result  of  immune  reactions  to  the  production, 
secondary  homoio  and  heterotoxins,  the  immune  substances.  At  present  it  appears 
probable  that  both  these  substances  play  a  rdle.  Apparently  in  vitro  the  toxicity 
of  body  fluids  of  foreign  spedee  is  less  marked  than  is  vivo.  We  must,  however,  con- 
sider tiiat  the  amount  of  body  fluids  and  of  toxin  acting  on  the  tissues  in  vitro  is  ex- 
tremely small  as  compared  with  the  quantity  acting  in  the  living  body.  In  the  case 
of  both  types  of  substances  those  preformed  and  those  produced  through  immuniza- 
tion, we  are  able  to  point  to  the  existence  of  analogous  substances  existing  elsewhere — 
namely,  the  preformed   species   speciflc  tissue  coagulins  and  the  secondarily,  arti- 


854       PEOCEEDINGS  SECOND  PAN  AMEEIOAN  SCIENTIFIC  CONGBESS. 

ficially  produced  antibodies  of  various  kinds.  It  also  remains  further  to  be  determined 
how  far  the  metabolic  products  of  foreign  cells  exert  a  direct  influence  upon  each  other 
and  how  much  of  this  effect  is  dependent  upon  the  interaction  between  cells  and  for- 
eign body  fluids. 

In  addition  to  the  effect  of  toxic  substanceS)  mere  lack  of  common  foodstufb  can 
als^  retard  tumor  growth,  as  the  retarded  growth  of  transplanted  tumors  in  pregnancy 
and  the  feeding  experiments  of  Moreechi,  Peyton  Rous,  Beebe,  Sweet,  Corsen  White, 
Saxon,  Robertson,  and  Burnett  have  shown.  Whether  an  immunity  caused  through 
the  lack  of  specific  substances  in  contradistinction  to  the  common  food  and  growth 
stuffs  of  cells,  whether  an  athreptic  immunity,  as  Ehrllch  called  it,  exists,  is  however 
very  doubtful.  Such  an  athreptic  immunity  certainly  would  not  explain  the 
phenomena  referred  to  above. 

In  connection  with  the  studies  in  metabolism  to  which  we  have  just  referred^  we 
may  look  forward  to  interesting  results  through  further  analysis  of  the  chemical  con- 
stitution of  tumor  tissue. 

I  am,  however,  inclined  to  regard  differences  so  i&T  found  between  normal  and  tumor 
cells  in  a  similar  light,  as  differences  observed  in  the  case  of  the  mitotic  division  in 
normal  and  tumor  cells,  both  being  probably  the  result  and  not  the  cause  of  the  changes 
in  the  growth  energy  characteristic  of  tumor  cells. 

Having  arrived  at  the  end  of  our  survey  we  must  confess  that  much  remains  still 
to  be  done  before  these  investigations  can  in  anyway  be  considered  near  completion. 

On  the  other  hand,  I  believe  to  have  indicated  that  there  are  ways  still  oi)en  for 
further  attack  of  the  problems  of  cancer  and  tissue  growth,  and  I  hope  also  to  have 
been  able  to  convey  the  impression  that  the  work  of  so  many  investigators  in  this 
field  has  not  been  in  vain,  and  that  not  only  this  special  branch  of  science  has  been 
built  up,  but  that  also  biology  and  pathology  in  general  have  been  stimulated  and 
enriched  as  the  result  of  their  labors. 

The  Chairman.  We  will  continue  the  papers  and  discuss  them  en 
bloc  at  their  conclusion.  I  have  the  picture  of  introducing  Dr.  Maud 
Slye,  of  the  University  of  Chicago,  who  will  read  to  us  a  paper  on 
**  Experimental  studies  in  heredity." 


EXPERIMENTAL  STUDIES  IN  HEREDITY. 

By  MAUD  SLYE. 
Univergiiy  of  Chicago. 

1  wish  to  give  to-night  a  condensed  report  of  my  work  of  the  last  10  years  along  two 
lines — the  inheritabiHty  of  tumor  and  a  few  points  on  its  etiology.  The  material 
for  this  study  has  been  in  my  hands  for  10  years.  Diuing  the  first  five  years  I  was 
engaged  in  studies  on  general  problems  in  heredity,  in  which  the  main  line  of  attack 
was  on  the  inheritability  of  coat  color,  the  inheritability  of  coat  pattern  and  the 
inheritability  of  what  I  may  call  general  metabolic  condition  as  manifested  in  siie, 
shape,  coat  quality,  pigment,  reproductive  capacity,  and  length  of  life.  During 
these  five  years  strains  of  mice  were  established  which  had  resulted  from  these  various 
Hues  of  study  and  from  this  material  as  a  basis  I  began  the  work  on  the  inheritability 
of  cancer.  The  stock  therefore  shows  many  things  of  great  interest  outside  of  its 
cancer  potentiality — ^viz,  the  relation  or  nonrelation  of  cancer  to  these  various  factors 
that  I  have  mentioned,  coat  color,  general  metabolic  condition,  etc. 

There  are  many  opportimities  for  error  in  the  study  of  any  problem  in  heredity, 
because  individuals  that  are  poorly  housed  or  poorly  fed  never  produce  their  full 
quota  of  young,  and  it  is  impossible  to  base  any  conclusions  on  one  or  two  litters  of 


PUBLIC  HEALTH  AKD  MEDIOIKE.  356 

three  or  four  mice  each.  It  is  necessary  therefore  for  any  conclusive  study  in  heredity 
that  a  laige  percentage  of  the  mice  should  live  to  old  age,  producing  their  full  quota 
of  young  with  a  variety  of  mates,  since  the  progeny  of  any  hybrid  individual  will 
depend  upon  its  mate  and  not  alone  upon  itself;  lor  example,  a  first-generation  albino 
mouse,  derived  from  red,  if  mated  with  a  gray  will  produce  red  in  the  first  genera- 
tion. It  is  the  mating  here  with  the  gray  which  determined  the  production  of  that 
red  young,  since  if  an  albino  had  been  mated  with  any  other  albino  it  never  would 
have  produced  any  other  than  whites. 

Again,  many  of  the  mice  are  eaten  or  killed  at  birth.  There  is  only  guesswork  to 
tell  what  they  might  have  been.  Again,  it  is  impossible  to  base  any  conclusionB  on 
small  numbers,  since  what  happens  for  ten  times  may  fail  in  the  next  ten.  And  still 
again,  as  I  have  already  pointed  out,  a  variety  of  mates  is  necessary  to  show  from  any 
given  hybrid  all  the  possible  offspring. 

Especially  are  these  errors  likely  to  obtain  in  the  study  of  cancer,  since  this  disease 
does  not  occur  in  early  life  and  a  mouse  which  dies  before  showing  cancer  must  be 
classed  as  noncancerous,  no  matter  what  its  potentialities  may  have  been.  It  is  only  by 
breedingout  theoffspring  of  such  mice  that  we  can  determine  whether  or  not  they  carried 
tumor  possibilities.  The  full  potentialities  of  cancer,  therefore,  in  any  strain  can  never 
be  fuUy  known  until  every  individual  lives  its  full  term  with  a  full  output  of  offspring. 

This  report  to-night  is  based  on  12,000  autopsies  performed  during  the  last  six 
years,  which  include  a  thousand  cases  of  tumor,  involving  over  2,000  malignant 
growths.  The  experiments  at  the  present  time  are  being  carried  on  with  a  living 
stock  of  some  12,000  mice,  which  in  its  present  state  is  producing  a  steady  output  of 
from  75  to  100  cancer  patients  all  the  time. 

My  tumor  stock  came  from  three  original  lines  of  wholly  unrelated  mice.  The 
first  was  a  strain  of  Japanese  white-footed  mice,  a  piebald  gray-white,  from  which  I 
have  in  process  of  making  at  the  present  time  Japanese  waltzing  mice.  Through  the 
first  five  years  of  work  it  was  hybridized  with  mice  of  all  possible  coat  colors,  thus 
giving  these  piebald  mice  of  various  pigments.  It  carried  a  heavy  percentage  of 
cancers  through  a  great  many  of  the  different  organs,  and  is  represented  in  the  charts 
by  strain  90  (I  will  make  this  clearer  in  demonstrating  the  charts).  The  second 
stock  of  mice  was  an  albino  stock,  very  nearly  depleted  at  the  time  the  cancer  worib 
began.  It  carried  tumors  of  the  mammary  gland  and  of  the  lung  and  did  not  produce 
any  tumors  in  other  organs.  The  third  stock  was  secured  from  the  Granby,  Mas., 
breeding  establishment.  This  stock  included  albinos,  red,  black,  blue,  gray,  choco- 
late, and  practically  every  tfolor  of  mice  known  to  modem  work  of  this  type.  Through- 
out the  entire  stock  it  carried  very  little  outside  of  mammary  gland  and  lung  tumorv. 

In  demonstrating  the  charts,  which  I  have  to  do  very  hurriedly  indeed,  there  are 
two  things  to  be  shown.  First,  the  general  feet  of  the  transmission  of  cancer; 
second,  the  transmission  of  types  and  locations  of  cancer;  for  these  stocks  of  mice  and 
their  hybrid  offspring  have  been  so  far  manipulated  at  the  present  time  in  breeding 
that  they  will  produce  practically  any  type  of  tumor  desired. 

Sftrain  139  was  some  of  the  Granby,  Mass.,  albino  stock,  inbred  for  23  generations; 
6  generations  in  my  hands.  This  chart  represents  all  that  was  left  of  it  when  my 
work  in  cancer  began.  Every  mouse  in  the  femlly  at  that  time  that  lived  to  cancer 
age,  with  the  exception  of  male  No.  553,  ^owed  tumor  at  death,  nearly  aU  of  them 
tumor  of  the  lung.  This  mouse  (male  No.  553)  died  of  pulmonary  infection  when  he 
was  barely  6  months  old.  Throughout  all  the  study  of  cancer  in  my  laboratory  we 
have  found,  and  particularly  in  these  lung  tumors,  all  stages  of  a  chronic  condition 
frequently  eventuating  in  tumor.  This  mouse  showed  a  chronic  condition  very  com- 
mon in  the  lungs  of  mice  which  later  develop  limg  tumor.  It  is  a  fair  inference  that 
he  would  have  developed  timior  of  the  lungs,  but  at  any  rate  the  strain  shows  90  per 
cent  of  tumor;  wherever  it  was  hybridized  it  produced  a  very  high  percentage  of  tuminr . 

68436— IT—VOL  x 24 


356       PKOCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC   CONGRESS. 

I  have  a  strain  now  (strain  65)  carried  out  in  two  branches.  If  you  glance  through 
it,  you  will  note  that  the  parent  female  came  from  strain  139,  the  parent  male  from  strain 
90,  the  strain  of  the  Japanese  piebald  mice  that  I  spoke  of.  This  is  an  extracted  gray- 
white  piebald  strain.  In  respect  to  coat  color  and  coat  pattern  it  follows  the  male; 
in  respect  to  tumor  tendencies  it  follows  the  female,  since  this  strain  throughout  all 
the  time  that  I  have  handled  it  has  never  shown  anything  but  mammary  gland  and 
lung  tumors.  I  could  reproduce  that  type  of  chart  very  extensively,  but  I  have  not 
brought  these  with  me  because  I  wished  to  show  to-night  this  later  work  on  the 
transmission  of  liver  tumors. 

In  the  literature  there  have  been  few  reported  liver  tumors,  either  in  mice  or  in 
the  human  species;  or,  for  the  matter  of  that,  in  any  other  animal  species.  This 
strain  90  carried  a  heavy  percentage  of  liver  tumors,  and  I  wish  to  show  you  some  of 
the  results  of  hybridization  of  that  strain.  Let  us  start  with  this  large  chart,  which 
shows  you  how  these  strains  are  derived.  The  main  emphasis  to-night  I  wish  to 
place  on  strain  338,  which  you  will  see  on  the  other  side  of  the  room.  It  has  been 
bred  out  in  a  great  many  other  branches  beside  these  shown  here.  This  chart  shows 
the  history  of  strain  338.  Groing  back  three  generations,  the  female  was  derived  trom 
strain  138,  Granby,  Mass.,  red  stock.  This  red  strain  did  not  breed  true  in  color. 
It  carried  only  cancers  of  the  mammary  gland  and  of  the  lung,  and  it  never  showed 
any  sarcoma;  it  showed  only  carcinoma.  This  parent  female  was  mated  with  a  male 
from  strain  90,  which  was  that  Japanese  white-footed  strain  which  carried  both  sar- 
coma and  carcinoma  involving  tumors  of  the  mammary  gland,  lung,  testicle,  kidney, 
mediastinum,  and  lymph  glands.  The  resulting  strain  from  this  cross  (strain  21) 
carried  both  sarcoma  and  carcinoma;  these  tumors  being  located  in  the  mammary 
gland,  lung,  liver,  testicle,  and  jaw.  This  female  of  strain  21  was  mated  with  a  male 
from  strain  135.  The  latter  strain  came  from  crossing  strain  151  again  with  strain  90. 
The  resulting  strain,  strain  135,  showed  only  mammary  gland  and  lung  tumors.  In 
its  ancestry,  however,  was  strain  90  carrying  tumors  of  the  mammary  gland,  lung, 
liver,  testicle,  ovary,  mediastinum,  and  lymph  gland.  A  double  dose  of  this  combi- 
nation, then,  was  bred  in,  since  it  ran  in  both  the  male  and  female  ancestry. 

From  this  cross  the  resulting  strain  in  the  maternal  ancestry  was  strain  112,  which 
cairied  cancers,  both  carcinoma  and  sarcoma  of  the  mammary  gland,  lung,  liver, 
kidney,  face,  pelvis,  and  1^,  practically  duplicating  the  list  with  one  or  two  excep- 
tions and  one  or  two  additions.  On  the  male  side,  going  three  generations  back, 
strain  94,  the  old  albino  strain  that  I  spoke  of,  some  of  the  original  stock,  carried 
carcinoma  and  leukemia.  The  tumors  were  located  only  in  the  mammary  gland  and 
lung.  The  mating  here  was  with  a  male  of  the  same  stock,  carrying  in  again  the  same 
thing.  The  female,  then,  two  generations  back  was  from  inbred  stock.  The  same 
thing  is  true  on  the  paternal  side  of  this  branch  of  the  family,  where  strain  90  came  in 
in  a  double  dose,  giving  an  inbred  member  of  strain  90  as  the  ancestor. 

The  mating  of  this  male  of  strain  90  inbred,  with  this  female  of  strain  94  inbred,  pro- 
duced strain  124,  which  carried  carcinoma  and  sarcoma;  of  the  mammary  gland,  lung, 
liver,  and  jaw.  The  mating  of  this  male  from  strain  124  with  the  female  from  strain 
112  produced  this  strain  338,  which  I  wish  to  demonstrate  more  in  detail.  It  carried 
leukemia  and  showed  carcinoma,  sarcoma  and  lymphoma;  involving  tumors  of  the 
mammary  gland,  liver,  lung,  back,  jaw,  chest,  ribs,  testicle,  body  wall,  lymph  glands, 
mediastimun,  pelvis,  hand,  and  preputial  gland.  From  these  matings  which  I  have 
detailed,  there  is  produced  a  strain  which  is  absolutely  riddled  with  cancer,  in  which 
there  is  scarcely  an  organ  which  does  not  carry  tumor.  I  may  say,  in  passing,  that  this 
strain  carries  a  great  many  tumors  into  any  strain  with  which  it  is  hybridized.  Strain 
3S8  was  started  by  the  individual  male  represented  over  here  in  strain  124,  Branch  1. 
You  will  notice  here  that  the  parent  female  of  strain  124  carried  adenoma  of  the  mam- 
mary gland  and  adenoma  of  the  liver  in  connection  with  liver  cyst.  There  do  not 
appear  in  this  chart  any  further  liver  tumors,  but  the  tumors  are  represented  in  the 


PUBUC   HEALTH  AND  MEDICflNE.  357 

lung  only  in  this  part  of  the  family.  Strain  124,  Branch  2;  here  neither  the  female 
nor  the  male  developed  tumor.  They  nevertheless  transmitted  it  in  the  first  genera- 
tion in  a  percentage  which  is  rather  striking,  for  this  represents  all  of  their  progeny 
which  lived  to  cancer  age.  The  mating  here  of  selected  males  and  females  in  two 
different  branches  gives  us  in  both  cases  the  perpetuation  of  cancer.  In  this  strain 
the  male  that  I  wished  to  emphasize — viz,  this  male  No.  7736,  died  when  he  was  3 
years  and  3  months  old  with  a  beginning  papilloma  of  the  lung  and  arterio-scleroais. 
If  the  mouse  had  died  at  any  time  within  a  reasonable  age — any  of  you  who  know 
about  the  breeding  of  mice  recognize  that  this  is  quite  an  exalted  age — if  he  had  died 
at  any  previous  time,  he  would  have  been  called  strictly  nontumorous.  This  male 
was  the  parent  of  strain  338. 

The  female  which  headed  this  strain  338,  the  indiWdual  female,  is  shown  in 
strain  112  of  which  she  was  a  member.  This  is  the  female  No.  5417  which  heads 
strain  338.  She  belongs  in  the  third  generation  in  strain  112  and  had  two  carcinomas 
of  the  mammary  gland  and  a  carcinoma  of  the  pelvis  (which  is  not  put  down  here), 
with  metastases  in  the  lungs.  Her  grandmother  had  an  adenoma  of  the  liver,  and  her 
grand&ther  a  beginning  lung  nodule,  like  those  frequently  observed  in  connection 
with  lung  cancer.  Here  is  a  sarcoma  of  the  liver,  and  here  a  carcinoma  of  the  lung, 
here  three  carcinomas  of  the  mammary  gland  with  metastasis  in  the  lung,  and  a 
squamous-celled  carcinoma  of  the  neck. 

Now,  bearing  in  mind  how  rare  liver  tumors  are,  for  I  am  laying  the  emphasis 
to-night,  from  brevity  of  time,  upon  tumors  of  that  particular  organ— remembering 
how  rare,  they  are — will  you  please  look  over  these  charts.  This  parent  female  did 
not  express  tumor  of  the  liver,  but  she  came  from  a  hunily  with  many  cases  of  it  and 
whose  ancestral  strain  and  its  later  derivatives  carried  liver  tumor.  The  male,  as  I 
showed  you  over  there,  did  not  express  tumor  of  the  liver,  but  he  came  from  a  family 
which  carried  in  its  ancestry  a  high  percentage  of  tumor  of  the  liver.  There  went  into 
the  strain,  strain  338,  then,  from  both  sides  of  the  family  a  heavy  percentage  of  1  ive 
tumor  in  addition  to  the  other  tumors  bred  in  at  the  same  time. 

Branch  1 ;  this  is  the  parent  female  No.  5417.  The  parent  male  No.  7736  here.  This  is 
the  parent  generation  which  heads  all  these  branches  of  strain  338.  The  female  had  two 
carcinomas  of  the  mammary  gland,  and  a  carcinoma  of  the  pelvis  of  an  entirely  different 
type  from  either  of  the  mammary  gland  cancers;  the  male  had  a  papilloma  of  the 
lung  and  he  was  this  old  male  3  years  and  3  months  old.  The  daughter  of  that  mating 
had  two  carcinomas  of  the  mammary  gland  and  an  adenoma  of  the  liver.  This  is  the 
female  selected  for  the  mating  in  this  branch.  In  the  next  generation  there  is  a 
sarcoma  of  the  body  wall  and  the  lymph  glands  and  a  papilloma  of  the  lung,  almost  a 
replica  of  the  grandfather's  papilloma.  And  in  the  next  generation,  again,  two 
carcinomas  of  the  mammary  gland  here,  a  carcinoma  of  the  lung  with  lung  metastases, 
and  again  three  carcinomas  of  the  mammary  gland. 

Branch  2  is  not  represented.  Branch  3  shows  here  one  of  these  beginning  lung 
nodules.  In  the  next  generation  a  sarcoma  of  the  back  and  further  down  carcinoma 
of  the  lung  and  of  the  mammary  gland. 

Branch  5  is  one  of  the  interesting  charts,  from  the  point  of  view  of  the  liver 
tumors.  Here  again  are  these  same  parents  female  No.  5417  and  male  No.  7736, 
and  here  for  the  parents  in  this  mating  there  were  selected  a  female  with  two 
carcinomas  of  the  mammary  gland  and  a  male  with  adenoma  of  the  liver.  I  may 
say, what  I  omitted  to  say  before,  that  all  the  offspring  of  female  No.  5417  repre- 
sented in  these  charts  were  produced  after  the  appearance  of  her  tumor.  There  are 
none  of  her  young  here  represented  who  were  produced  before  the  appearance  of 
her  tumor.  The  mating  of  this  female  with  two  carcinomas  of  the  mammary  gland 
and  this  male  with  adenoma  of  the  liver  gives  a  founily  in  which  cancer  is  wide- 
spread; a  male  with  carcinoma  of  the  lung,  a  female  with  two  carcinomas  of  the  mam- 
mary gland,  a  squamous  carcinoma  of  the  tskce  and  abscess  of  the  jaw  (which  looked 


358       PKOOEEDINGS  SECOND  PAN  AMEBIC  AN   SCIENTIPIC  CONQBBSS. 

more  like  an  entirely  necrotic  tumor  but  which  was  diagnosed  as  abscess),  two  car- 
cinomas of  the  mammary  gland,  a  carcinoma  of  the  pelvis,  metastases  in  the  lungs, 
etc.  Here  were  two  carcinomas  of  the  mammary  gland.  From  the  individuals 
selected  for  breeding  in  the  next  generation  of  those  who  lived  to  cancer  age  two 
showed  carcinoma.  Of  those  selected  for  breeding  here,  among  their  seven  o£f8pring 
there  were  four  cases  of  carcinoma;  in  the  fourth  generation  two  cases  of  carcinoma  of 
the  mammary  gland  out  of  three  (we  have  had  to  date)  that  have  lived  to  cancer  age. 
There  were,  as  I  recall  it,  seven  cases  of  liver  tiunor  in  this  one  branch  of  the  strain. 

In  Branch  7,  from  these  same  parents;  there  are  no  tumors  in  the  first  generation 
male  or  female  ciiosen  for  the  mating,  but  as  I  have  emphasized  repeatedly  it  is  only 
by  breeding  these  out  that  you  can  tell  what  their  cancer  potentialities  are,  since  they 
are  not  necessarily  expressed  and  since  many  of  these  mice  die  before  six  months, 
which  has  been  taken  as  the  lower  limit  of  cancer  age.  But  in  the  second  generation 
here,  out  of  five  which  have  died  to  date,  having  lived  to  tumor  age,  there  were  three 
cases  of  carcinoma;  and  in  the  next  generation  out  of  six  offspring  there  were  three 
cases  of  carcinoma. 

In  Branch  11  we  see  how  multiple  tumors  persisted  in  this  branch.  This  female 
had  two  carcinomas  of  the  mammary  gland.  There  are  two  carcinomas  of  the  pelvis 
in  the  next  generation — a  female  with  four  carcinomas  of  the  mammary  gland  and 
metastases  in  the  lung.  In  the  next  generation,  out  of  five  who  lived  to  cancer  age 
four  had  cancer.  One  has  developed  an  adenoma  of  the  liver.  In  the  next  generation , 
in  both  the  matings  carcinoma  of  the  mammary  gland,  and  in  this  case  there  is  again 
carcinoma  of  the  pelvis. 

In  Branch  12  of  this  same  strain,  in  the  first  hybrid  generation,  there  are  several 
cases  of  cancer.  In  the  next  chart,  the  parents  selected  for  the  mating  did  not  show 
cancer;  but  in  the  next  generation  cancer  came  out  in  startling  manner.  Here  a 
carcinoma  of  the  mammary  gland,  with  metastases  in  the  lung,  again  two  carcinomas, 
a  testicle  tumor,  a  malignant  tumor  of  the  preputial  gland,  and  again  a  carcinoma  of 
the  mammary  gland. 

In  the  next  generation  here  is  a  carcinoma  of  the  mammary  gland  with  metastases 
in  the  lung,  and  here  an  adenoma  of  the  liver  and  an  adenoma  of  the  limg;  and  wher- 
ever that  strain  has  been  crossed  in  it  has  carried  not  only  cancer  but  it  has  carried 
these  specific  tyx)e6  of  cancer.  In  the  mice  who  are  dying  now  in  those  hybrid  strains 
that  have  lived  to  cancer  age  I  am  getting  almost  a  duplicate  of  these  things  which 
appeared  sometimes  many  generations  before  them. 

There  are  other  charts  here  that  show  this  predominance  of  liver  tumors  wherever 
strain  90  went  in.  Thus,  as  you  see,  the  parent  female  from  strain  90  and  the  parent 
male  from  albino  strain  94,  both  of  them  tumor  strains;  here  the  carcinoma  of  the 
mammary  gland,  metastases  in  the  lung,  here  carcinoma  with  multiple  metastases 
in  the  liver,  etc.,  besides  the  various  other  tumors. 

I  have  one  or  two  other  interesting  charts.  Strain  196,  on  the  maternal  side, 
came  from  strain  90,  and  the  parent  male  came  from  strain  94.  The  percentage  here 
of  tumor  is  extremely  high,  and  this  seems  to  be  a  branch  of  the  family  which  got  most 
of  the  ovarian  tumors,  for  out  of  the  entire  2,000  tumors  in  my  stock  only  14  are  ovarian 
tumors.  Of  these  14  all  but  4  were  in  this  strain  and  its  hybrids  and  allied  strains. 
The  other  4  were  scattered.  You  will  notice  the  predominance  of  ovarian  tumors  in 
this  one.  There  bilateral  malignant  tumor  of  the  ovaries,  here  carcinoma  of  the 
mammary  gland,  general  sarcomatosis  of  nearly  the  entire  system,  bilateral  endo- 
thelioma of  the  ovaries,  squamous  carcinoma  of  the  skin,  and  carcinomatous  cyst  in 
the  ovary  which  ^^as  just  beginning  to  proliferate  in  a  papillomatous  ^hion,  here 
bilateral  ovarian  carcinoma,  and  down  there  a  cardnoma  of  the  left  ovary. 

Strain  104,  which  was  a  strain  of  wild  mice,  Peromyscus  Califomicus,  local  in 
the  Santa  Clara  Valley,  the  stock  had  been  in  my  hands  some  six  years.  Carcinoma 
and  sarcoma  are  both  rather  rare  in  wild  mice,  at  least  rarely  reported.    Female  2999 


PUBUC  HEALTH  AND  MEDIGINE.  359 

had  a  squamous  carcinoma  of  the  jaw.  She  had  a  son  with  what  was  diagnosed  ati 
an  abscess  of  the  jaw,  because  no  tumor  cells  were  left,  but  it  had  every  appearance  of  a 
necrotic  tumor.  The  mating  of  these  two  produced  a  third  with  squamous  carcinoma 
of  the  jaw.  That  is  rather  interesting  as  showing  the  transmission  of  the  type  of 
tumor  within  a  strain,  since  in  all  the  Peromyscus  stock  that  I  have  had  in  my  labo- 
ratory in  10  years  there  has  never  been  another  case  of  it. 

In  strain  164  we  have  a  wild  house  mouse  male  mated  with  an  albino  female.  This 
albino  female  belonged  to  a  hybrid  strain  derived  from  strain  139.  The  first  hybrid 
generation  showed  no  tumor.  It  has  never  shown  any  tumor  anywhere  throughout 
the  entire  stock,  which  has  been  bred  out  in  several  branches.  In  the  second  hybrid 
generation  there  is  a  lympho-«arcoma  of  the  thymus,  two  spindle-cell  sarcomas  of 
the  &ce,  two  carcinomas  of  the  mammary  gland;  and  again,  in  the  fourth  generation, 
carcinoma  of  the  mammary  gland.  Up  here  I  have  charted  some  human  strains  for 
the  interest  they  may  have.  In  this  white  strain  the  tumors  are  entirely  abdominal; 
in  this  colored  strain  where  uterine  tumors  came  in  on  both  sides  of  the  fondly  in  the 
later  generation  no  tumors  occurred  but  uterine  tumors.  It  has  been  said  in  criti- 
dsm  of  that  chart  that  the  uterine  tumor  is  the  common  tumor  in  the  colored  race, 
but  I  think  it  would  be  a  fair  reply  to  make  to  tiiat  statement  that  that  is  a  com- 
mon tumor  in  the  colored  race  jaMy  because  the  tendency  to  that  type  of  tumor  has 
been  so  commonly  bred  in.  Here,  for  example,  where  it  occurs  on  both  aidee  of  the 
family,  it  comes  out  in  3  cases  out  of  4  in  the  later  generation. 

These  charts  do  not  represent  picked  results.  They  are  typical  of  what  has  hap- 
pened throughout  my  entire  work  with  cancer  wherever  cancer  has  been  bred  in. 
It  has  been  objected  that  since  inbreeding  doee  not  characterize  the  human  race 
then  results  have  no  application  to  man.  Nothing  could  be  further  from  the  fact. 
The  method  of  the  laboratory  in  getting  fixed  strains  must  alwa3rB  be  that  of  inbreed- 
ing; tiiere  is  no  other  way  to  tell  what  went  into  a  cross,  but  in  the  matter  of  the  general 
incrstfle  of  tumors  outbreeding  will  do  far  more  to  increase  it  than  inbreeding  could, 
as  you  eee  by  all  these  hybrid  strains,  for  inbreeding  if  jMndsted  in  destroys  the 
strain.  This  female  (No.  529)  mated  with  her  brother,  never  produced  any  young 
at  all  that  lived  to  cancer  age;  mated  with  an  albino  from  a  nonrelated  strain  she 
IHToduced  an  enormous  family,  which  has  been  bred  out  and  which  has  been  hybridized 
into  many  strains  carrying  cancer  with  it.  Again,  her  mother  (female  No.  293), 
mated  with  her  brother,  produced  only  three  young  that  lived  to  cancer  age,  but 
mated  over  here  in  strain  65,  this  hybrid  chart  that  I  showed  you,  she  produced  a 
laige  number  of  progeny  and  started  up  a  whole  line  of  cancerous  mice  that  has  carried 
cancer  into  every  strain  with  which  it  has  been  hybridized. 

It  has  been  suggested  also  that  inbreeding,  which  weakens  the  strain,  renders  it 
more  susceptible  to  cancer.  My  cancer  strains  are  strong  by  every  criterion  of  strength 
in  the  banning.  Ab  I  have  already  said,  they  can  be  bred  out  by  inbreeding, 
eventually  destroyed  by  inbreeding,  just  as  every  strain  of  mice  that  I  have  ever 
handled  can  be  destroyed  by  persistent  inbreeding;  but  in  the  beginning  it  is  the 
strong  mice,  it  is  the  strong  strains,  which  show  cancer,  and  it  is  the  strong  members 
of  strong  strains  that  are  the  individuals  that  develop  cancer. 

And  this  brings  me  to  a  few  of  the  points  in  the  etiology  of  cancer  which  I  wish  to 
suggest.  I  have  found  that  reduction  of  feeding  to  a  point  which  produces  general 
amadation  reduces  the  amount  of  cancer  in  a  strain  and  holds  back  the  neoplastic 
growth  in  the  individual.  I  have  underway,  at  the  present  time,  experiments  on 
strains  of  mice  where  cancer  has  practically  been  starved  out  by  a  diet  too  low  to 
sustain  it.  Cancer  is  a  disease  of  middle  and  late  life,  when  growth  processes  are 
largely  reproduction  and  regeneration.  Infections  are  diseases  of  early  life,  when 
growth  processes  are  largely  accretions  in  quantity  and  in  complexity.  The  most 
careful  experiments  in  my  laboratory  have  foiled  to  produce  the  spread  of  cancer  by 
any  of  the  means  which  spread  any  infection  common  in  the  laboretorj.    If  one  of 


360       PBOCBEDINGS  SECOND  PAN  AMEBICAN  SOIENTIFIO  G0NQBE8S. 

the  common  infections  gets  into  a  section  of  the  laboraton',  unless  the  individuals 
carrying  it  are  immediately  isolated,  the  entire  family  and  all  the  neighbors  will  be 
wiped  out,  because  the  infection  will  spread  not  only  through  the  cage  but  through 
all  the  adjacent  cages.  The  most  careful  and  long-continued  effort  to  spread  cancer 
in  this  way  has  never  met  with  a  single  case  of  success.  I  have  had  the  young  of 
cancer  mothers  fed  and  reared  from  the  moment  of  birth  by  noncancerous  females; 
I  have  had  the  young  of  noncancerous  females  fed  and  reared  from  the  moment  of 
birth  by  females  with  exuding  cancers  of  the  manmiary  gland;  I  have  never  found 
that  these  experiments  modified  in  the  least  the  occurrence  of  cancer  in  cancer  strains, 
nor  have  they  introduced  it  in  the  noncancer  strains. 

I  find  that  vigorous  growth  is  necessary  for  tumor  growth .  As  I  have  said,  the  mem- 
bers of  my  laboratory  that  showed  cancer  are  the  strong  members  of  strong  strains. 
Vigorous  growth  processes  militate  against  infections.  A  very  slight  infection  will 
kill  a  pregnant  female.  It  is  amazing,  frequently,  at  autopsy  to  find  out  how  very 
slight  an  infection  has  produced  death  in  a  pregnant  female.  This  female  (No.  5417) 
who  heads  strain  338  had  her  tumor  a  year  before  it  killed  her  and  during  that  time  she 
produced  six  litters  of  young.  I  have  shown  those  that  lived  to  cancer  age  in  the 
charts  presented  to-night.  All  these  young  were  bom  after  her  tumor.  Ewy 
mouse  in  my  laboratory  that  has  been  strongly  reproductive  after  the  appearance  of 
tumor  has  had  the  tumor  growth  greatly  delayed  during  pregnancy  and  the  rearing  of 
young,  whereas  a  young  female  of  vigorous  reproductive  age,  if  not  mated,  will  die 
within  about  6  weeks  after  the  appearance  of  the  tumor,  the  tumor  frequently  being 
larger  than  the  mouse  itself. 

Whatever  the  ultimate  natxire  of  cancer  may  prove  to  be,  whether  infectious  or  not, 
it  has  one  quality  which  no  mouse  infection  that  I  have  handled  in  the  laboratory 
has,  it  follows  the  laws  of  heredity  with  an  exactness  which  makes  it  a  character  that 
can  be  manipulated.  It  can  be  bred  into  strains  where  it  has  never  before  occurred, 
and  it  can  be  drawn  out  in  extracted  strains  which  carry  cancer  into  every  line  with 
which  they  are  hybridized  and  these  hybrid  offspring  of  strains  where  cancer  has 
been  bred  in  will  carry  cancer  again  into  every  strain  with  which  they  are  hybridized; 
or  it  can  be  bred  out  of  a  strain  which  originally  carried  100  per  cent  of  cancer. 

Hereupon;  the  chairman  announced  the  reading  of  the  following 
papers: 

Factors  in  immunity  to  cancer^  by  James  B.  Murphy  and  John  J. 
Morton. 

Immunity  to  transplantable  neoplasms,  by  William  H.  Woglom. 

Tumor  immunity,  by  E.  E.  Tyzzer. 

Chemotherapeutic  experiments  on  rat  tumors,  by  Richard  Weil. 

The  application  of  chemical  methods  to  the  study  of  cancer,  by 
Casimir  Funk. 


FACTORS  IN  IMMUNITY  TO  CANCER. 

By  JAMBS  B.  MURPHY  and  JOHN  J.  MORTON. 
Laboratoriei  of  the  RockefeUer  Institute  for  MedUxd  Reeeardt. 

It  has  been  shown  in  previous  communications  that  the  resistance  to  heteroplastic 
tissue  giafts  apparently  depends  on  the  activity  of  the  lymphocyte.  The  facts  on 
iddch  this  conclusion  is  based  are  briefly  as  foUows:  The  chick  embryo,  which  nor- 
mally lacks  the  ability  to  destroy  a  heteroplastic  tissue  graft,  if  supplied  with  a  bit 


PUBUC   HEALTH  AND  MEDICINE. 


361 


of  adult  lymphoid  tissue,  becomes  as  resistant  as  the  adult  in  this  respect.  Further- 
more, an  adult  animal  deprived  of  the  major  portion  of  its  lymphoid  system  by  repeated 
small  doses  of  X-ray,  no  longer  has  the  i>ower  to  destroy  a  graft  of  foreign  tissue  and 
this  tissue  will  grow  actively.  The  chief  characteristic  of  a  failing  heteroplastic 
graft  in  the  unsuitable  host  is  a  marked  local  acounulation  of  lymphocytes.  The 
histological  picture  is  identical  in  a  foiling  cancer  graft  in  an  immune  animal  of  the 
same  species.  Synchronous  with  the  establishment  of  the  cancer  immunity  and 
during  the  period  in  which  the  lymphocytes  are  accumulating  around  the  cancer 
graft,  there  is  a  lymphocytic  crisis  in  the  circulating  blood.  This  is  foimd  in  the 
actively  immunized  animals  as  well  as  in  those  possessing  a  natural  immunity,  but  is 
totally  lacking  in  animals  susceptible  to  the  cancer  graft.  If  the  l3anphoid  crisis  be 
prevented  in  Immunized  animals  by  a  previous  destruction  of  the  lymphoid  ele- 
ments with  X-ray  the  potentially  immime  animal  is  changed  to  a  susceptible  one. 

We  have  noted  that  while  repeated  exposures  to  X-ray  wiU  destroy  the  lymphoid 
elements  of  an  animal,  one  small  dose  will  stimulate  these  same  cells.  With  this 
artificial  method  of  producing  a  lymphocytosis  we  have  attempted  to  study  the  rela- 
tion of  this  condition  to  the  resistance  of  mice  to  their  own  spontaneous  tumors.  For 
evident  reasons  it  was  necessary  to  rule  out  the  complicated  question  of  the  direct 
effect  of  X-ray  on  the  cancer.  In  order  to  do  this  we  have  removed  the  cancer  at 
operation  and  with  the  cancer  out  the  animal  has  been  subjected  to  a  stimulating 
dose  of  X-ray.  Immediately  after  this  a  graft  of  the  original  tumor  was  replaced  in 
the  groin  of  the  animal.  As  a  control  the  same  procedure  was  carried  out,  but  with 
X-ray  treatment  omitted.  As  a  further  check  to  these  results  cancers  of  spontane- 
ous origin  were  removed  from  a  number  of  animals  and  in  this  set  the  cancers  were 
exposed  direct  to  the  same  amount  of  X-ray  as  the  animals  in  the  first  group  had 
received.    After  this  a  graft  of  the  tumor  was  returned  to  the  original  host. 

The  results  of  these  three  experiments  are  to  be  judged  by  two  criteria:  Fiist, 
whether  or  not  there  is  a  return  of  the  disease,  either  at  the  site  of  removal  of  the  cancer, 
ar  at  the  point  of  inoculation  of  the  returned  graft;  and,  second,  the  time  at  which  the 
returned  graft  starts  in  active  growth,  if  at  aU.  The  figures  on  these  points  are  given 
in  the  following  table: 


Series!.. 
Series  II. 
Series  in. 


Immune. 


Per  cent, 

50.0 

3.4 


Suscep- 
tible. 


Percent. 

50.0 

96.6 

100.0 


Local  re- 
currence 
of  tumor. 


Per  cent. 
2L2 

48.3 

4ao 


Average  time  for 
appearance  of  graft. 


5  weeks  and  4  days. 
1  week  and  5  da3rs. 
1  week  and  3  days. 


Series  I  was  composed  of  52  animals  with  spontaneous  cancer  treated  by  X^ay 
while  the  cancer  was  outside  of  the  body,  with  later  a  return  of  a  graft  of  the  tumor. 
Series  II  was  made  up  of  29  control  animals  in  which  the  cancer  was  removed  and  a 
graft  returned  without  treatment  to  either  animal  or  tumor.  Series  III  was  made  up 
of  10  animals  from  whom  the  cancer  was  removed  and  the  cancer  subjected  directly 
to  the  same  amount  of  X-ray  as  the  animals  received  in  the  first  series,  and  later 
a  graft  of  this  X-rayed  cancer  returned  to  its  original  host.  * 

It  will  be  seen  from  these  figures  that  an  X-ray  dose  which  produced  a  lymphocytosis 
when  administered  directly  to  the  animal  was  sufficient  to  render  60  x>er  cent  of  the 
mice  so  treated  immime  to  returned  graft  of  their  own  tumor  and  in  the  other  50  per 
cent  to  greatly  retard  the  return  <^  the  disease.  A  similar  dose  of  X-ray  given  directly 
to  the  cancer  outside  of  the  body  did  not  influence  the  subsequent  growth  of  a  graft 
of  this  tumor  when  returned  to  its  original  host.  The  contrast  between  these  figures 
and  those  of  the  control  series  is  striking,  as  is  also  the  number  of  local  recurrences  in 
the  two  series.    If  this  effect  is  obtained  with  one  stimulating  dose  of  X-ray  it  is  prob- 


362       PEOCEEDINGS  SECOND  PAN  AMEBIOAN  BOIENTIPIC  CONGBESS. 

able  that  a  more  pronounced  result  might  be  obtained  by  a  second  exposure  to  X-ray 
after  a  suitable  interval. 

For  a  comprehensive  review  of  the  literature  on  cancer  resistance  see: 

Woglom,  W.  H.:  The  Study  of  Experimental  Cancer.  A  Review.  Studies  in 
Cancer  and  Allied  Subjects.    New  York,  1913,  i,  128. 

Murphy,  James  B.:  Transplantability  of  Tissues  to  the  Embryo  of  Foreign  Species. 
Jour.  Exper.  Med.,  1913,  xvil.  No.  4,  482. 

The  Ultimate  Fate  of  Mammalian  Tissue  Implanted  in  the  Chick  Embryo. 

Jour.  Exper.  Med.,  1914,  xix.  No.  2, 181. 

Factors  of  Resistance  to  Heten^lastic  Tissue  Grafting.    Joxa.  Exper.  Med., 

1914,  xix.  No.  5,  613. 

Heteroplastic  Tissue  Grafting  Effected  through  Roentgen-ray  Lymphoid 

Destruction.    Jour.  Am.  Med.  Assn.,  1914,  Ixii,  1459. 

Murphy,  James  B.,  and  Morton,  J.  J.:  The  Lymphocyte  in  Natural  and  Induced 
Resistance  to  Transplanted  Cancer.    Jour.  Exper.  Med.,  1915,  xxii.  No.  2,  204. 

The  Effect  of  Roentgen  Rays  on  the  Rate  of  Growth  of  Spontaneous  Tumon 

in  Mice.    Jour.  Exper.  Med.,  1915,  xxii,  No.  6,  800. 


IMMUNITY  TO  TRANSPLANTABLE  NEOPLASMS. 

By  WILLIAM  H.  WOGLOM, 
George  Crocker  Special  Research  Fundj  Columbia  University, 

It  is  customary  to  divide  immunity  into  two  types,  natural  and  acquired,  and  to 
subdivide  the  latter  into  active  and  passive. 

Natural  immunity  to  a  transplantable  tumor  is  present,  as  a  rule,  in  old  animals, 
and  in  species  other  than  that  in  which  the  neoplasm  primarily  arose;  thus,  with  an 
occasional  exception,  the  transplantable  new  growths  of  mice  are  not  transferable  to 
rats.  To  this  statement,  however,  the  following  important  exception  has  been  dis- 
covered. Murphy  ^  has  shown  that  the  embryo  chick  is  susceptible  to  rat  tumc^n 
until  about  the  time  of  hatching,  and  that  the  resistance  which  supervenes  after  this 
period  is  connected  in  some  way  with  the  maturation  of  the  spleen  and  the  bone 
marrow.  From  this  point  he  '  has  gone  on  to  demonstrate  that  mouse  sarcomata  will 
proliferate  in  rats  after  the  lymphoid  system  has  been  injured  by  exposure  to  X-rays 
or  by  the  administration  of  benzol,  for  a  longer  period  than  in  control  animals.  Hence 
it  appears  that  the  resistance  obtaining  in  foreign  species  may  be  abrogated  by  inter- 
fering with  the  lymphocytic  activity. 

Under  natural  imimunity  may  be  discussed  also  the  I'esistance  of  the  spleen  to  meta- 
static tumors,  and  the  reputed  insusceptibility  of  the  testis  to  inoculation  with  a  cer^ 
tain  neoplasm.  Both  von  Hansemann  *  and  Kettle  ^  have  recently  asserted  that  the 
immunity  of  the  spleen  is  not  so  efficient  as  had  formerly  been  supposed;  and  as  it  ia 
known,  furthermore,  that  grafts  of  transplantable  neoplasms  are  able  to  proliferate 
without  embarrassment  in  the  spleen  of  animals,  whatever  freedom  from  metastatic 
growths  this  organ  enjoys  is  probably  referable,  not  to  an  antagonism  against  the 
cell  higher  than  that  opposed  by  the  other  organs,  but  chiefly  to  some  mechanical 
factor.  Such  an  explanation  has  been  advanced  by  the  latter  of  these  two  authors^ 
who  has  suggested  that  the  contractions  of  the  spleen  force  tumor  emboli  out  of  tJie 
organ  again,  and  even  prevent  the  growth  of  a  large  number  of  those  that  have  becoBke 
impacted  in  its  capillaries. 

1  Jour.  Exp.  Med.,  1914,  xix,  513.  •  Deutsoh.  ICed.  Wchnschr.,  1015,  xli,  683. 

I  Jour.  Am.  Med.  Assoc,  1914,  bdi,  1459.  <  Joor.  Path.  &  Bacteriol.,  1912-13,  xvll,  40. 


FUBUO  HEALTH  AND  SiEDIOINE.  363 

In  other  words,  it  ia  probable  that  wherever  the  tumor  cell  comes  to  rest  in  the  tissues 
there  it  will  grow,  for  no  organ  in  the  mouse  has  proved  resistant  to  inoculation.  Even 
the  testis  of  the  rat,  formerly  said  to  be  almost  or  quite  immune  to  the  Flexner-Jobling 
carcinoma,  has  been  proved  by  Woglom  '  to  offer  very  nearly  as  favorable  a  soil  as  the 
subcutaneous  tissues. 

However,  in  comparing  natural  with  artificial  metastasis,  that  is,  with  inoculation 
into  the  various  organs,  one  distinction  must  not  be  overlooked;  in  the  former  process, 
the  tumor  cells  come  to  rest  in  a  blood-  or  a  lyfhph-channel,  while  in  the  latter  they 
are  deposited  directly  in  the  tissues,  where  the  conditions  for  growth  are  much  more 
favorable  in  many  instances;  for,  as  Takahashi '  has  found,  the  cells  of  certain  tumors 
are  unable  to  establish  vasctdar  connections  with  the  vessel  wall  soon  enough  to  per- 
mit their  survival. 

One  further  ^tor,  and  an  indefinite  one,  must  be  taken  into  account:  This  is  the 
chemistry  of  the  tissues  in  which  the  tiunor  embolus  settles.  In  how  far  metastasis 
is  encouraged  by  favorable  chemical  surroundings  is  still  an  imsettled  question, 
though  it  can  at  least  be  said  that  this  factor  does  not  appear  to  be  as  important,  in 
general,  as  the  mechanical  influences  emphasized  by  von  Recklinghausen  and  his 
pupils.    On  the  other  hand,  it  can  not  be  summarily  dismissed  from  consideration. 

To  recapitulate  the  essentials  of  metastasis,  it  appears  that  this  process  is  governed 
by  several  factors.  If  a  secondary  tumor  is  to  be  produced,  the  cells  of  the  primary 
neoplasm  must  have  the  povrer  to  establish  vascular  connections;  secondly,  they 
must  remain  undisturbed  in  the  vessel  long  enough  for  the  union  to  be  completed; 
and,  finally,  if  these  two  conditions  have  been  fulfilled,  the  organ  in  which  they 
happen  to  lie  is  probably  a  matter  of  indifference  in  the  great  majority  of  caaes. 

Acquired  resistance  is  conferred  by  unsuccessful  inoculation  with  a  tumor  or  even 
by  treatment  with  normal  tissues.  In  both  cases,  however,  the  cells  must  be  derived 
from  the  species  of  animal  which  it  is  desired  to  immunize.  The  most  potent  material 
is  embryo  skin,  which  will  effect  resistance  to  carcinoma  in  nearly  100  per  cent  of 
treated  animals.  The  refnCctory  condition  so  evolved  lasts  for  about  80  days,  as 
Woglom  '  has  shown  (fig.  1).  Less  active  is  kidney,  and  still  less  active  are  emulsions  of 
spontaneous  tumor,  though  the  immunity  to  which  the  two  latter  give  rise  lasts  for 
a^ut  the  same  length  of  time  as  that  produced  by  embryo  skin. 

Acquired  resistance  to  sarcoma  has  not  been  so  extensively  studied,  chiefly  because 
this  type  of  neoplasm  grows  too  irregularly  to  lend  itself  to  such  an  investigation. 
The  Imperial  Cancer  Research  Fund,  however,  possesses  a  mouse  sarcoma  of  foirly 
uniform  growth  energy,  so  that  Tsurumi  *  has  been  able  finally  to  approach  the  ques- 
tion. He  found  that  mouse  embryo  skin  would  immunize  against  sarcoma  also,  and 
that  the  time  and  rate  of  development  of  the  resistant  state  were  about  the  same  as 
in  the  case  of  carcinoma  (fig.  2).  Sarcomata  which  were  able  togrowinspite  of  attempts 
to  immunize  the  host,  evidently  owed  this  power  to  their  hig^  initial  proliferation, 
for  when  their  cells  were  damaged  by  incubation  at  37^  C.  they,  too,  became  sus- 
ceptible to  immunity. 

We  have  tri§d  at  the  Crocker  Fund  '  to  immunize  fowls  against  the  Rous  chicken 
sarcoma  by  treatment  with  chicken  embryo,  but  have  been  imable  to  make  them 
refractory  (fig.  3).  Had  the  attempt  succeeded  the  result  could  have  been  regarded  as 
evidence  in  favor  of  the  true  neoplastic  nature  of  this  peculiar  growth,  but  its  failure 
can  not  be  employed  to  support  the  opposite  side  of  the  argument,  and  for  two  rea- 
sons. In  the  first  place,  it  is  not  even  known  whether  the  phenomena  of  immunity 
characteristic  of  the  mouse  and  rat  can  be  duplicated  in  fowls,  and,  in  the  second, 
the  sarcomata,  in  mice  at  least,  are  not  so  susceptible  to  artificial  resistance  in  the 
host,  as  has  been  indicated  in  the  preceding  paragraph. 

I  Jour.  Exp.  Med.,  lOlS,  zxlil,  U9.  « Joor.  Path.  A  Baoterlol.,  1915,  xz,  1. 

*  Jour.  Path.  A  BactarloL,  1016,  xz,  76.  » Joar.  Bzp.  Mad.,  1016,  zxii,  164. 

>  Jour.  Bzp.  Med.,  1013,  xrl,  820. 


864       PROCEEDINGS  SECOND  PAN  AMEBICAN  SCIENTIFIC  C0NQBE88. 


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WiQ.  1.— Curves  showing  the  extent  Fio.  2.— Immunity  to 
•nd  duration  of  the  resistance  in-  sarcoma  produced  by 
dooed  in  mice  with  embryo  mouse  treatment  with  em- 
ildn  and  spontaneous  adenooar-  bryo  moose  ikin  one 
olnomata  of  the  mammary  gland  week  before  inocula-  Fio.  S.— No  immunity  to  the  Rous  chlekMi  saroomft 
of  the  mouse,  respeotlrely.  tion.  produced  by  treatment  with  fowl  embryo. 


■Mdforkelh 


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I.  _J 1 

Fio.  4.— Mice  in  frtileh  the  tumor 
to  the  left  has  grown  for  about  10 
days,  are  immune  to  retnocula* 
tloiiy  even  after  it  has  been  re- 
moved. Reinooulations  into  the 
left  axilla  were  all  negative  (— ), 
and  the  tumor  did  not  recur  in 
the  right  (— ),  showing  that  extir- 
pation was  complete.  Adapted 
from  KusselFs  article. 


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• 

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r  0     -4     -fc 

— •...       1 

Fio.  6.— The  tumor  to  the  left  (solid)  does  not 
immunize  during  its  growth.  The  barred 
tumors  are  the  result  of  reinoculation  tn  tbt 
left  axilla  after  removal  &om  the  rl^t  of  tbt 
growths  primarily  inoculated.  Reonrrenoe 
did  not  take  place  (— ),  showing  that  extirpa- 
tion was  complete.  Adapted  from  RusselFt 
article. 


PUBLIC  HEALTH  AND  MEDICINE.  365 

A  type  of  acquired  resistance,  first  described  by  Ehrlich,  and  by  him  called  "ath- 
reptic  immunity/*  still  remains  for  discussion.  Here  the  resistance  to  reinocuiation 
which  he  found  in  animals  with  rapidly  growing  neoplasms,  was  referred  to  a  with- 
drawal from  the  body  of  growth  stuffs  indispensable  for  the  proliferation  of  tumor 
cells,  and  the  consequent  unfavorable  circumstances  amidst  which  the  second  graft 
was  placed.  Russell  *  has  demonstrated,  however,  that  there  are  two  distinct  types 
of  tumor,  one  of  which  immunizes,  diuring  its  growth,  against  a  second  inoculation,  the 
other  of  which  lacks  this  power.  (Figs.  4  and  5.)  It  is  plain,  therefore,  that  those 
investigators  who  have  substantiated  the  occurrence  of  athreptic  immunity,. have  been 
working  with  the  first  type,  while  those  who  have  been  unable  so  to  do  have  been 
dealing  with  the  second.  A  final  proof  of  the  identity  of  athreptic  immunity  with  the 
ordinary  type  of  acquired  immunity  was  advanced  by  Bashford  and  Russell  *  in  their 
demonstration  that  athreptic  resistance  depends  upon  the  same  factor  responsible  for 
other  types  of  immunity — namely,  upon  the  absence  of  a  stroma  reaction. 

The  converse  of  immunity  to  transplantable  neoplasms  is  hypersusceptibility,  a 
condition  which  can  be  brought  about  by  treatment  with  body  juices  or  killed  tissues. 
It  has  been  asserted  recently  that  a  diet  rich  in  lactose  will  also  produce  a  state  of 
heightened  receptivity,  but  we  have  been  able  to  demonstrate  at  the  Crocker  Fund  • 
that  the  statement  does  not  hold  for  the  majority  of  carcinomata.  The  apparent 
hypersu8(!eptibility  must  have  been  due,  therefore,  to  some  one  of  those  experi- 
mental errors  which  it  is  so  difficult  to  avoid  in  cancer  research. 


TUMOR  IMMUNITY. 

ERNEST  EDWARD  TYZZER, 
Cancer  Commission  of  Harvard  University. 

In  a  consideration  of  tumor  immunity  it  appears  desirable  to  discuss  resistance  to 
spontaneous  tumors  and  to  implanted  tumor  separately.  Although  results  obtained 
with  experimentally  implanted  tumors  have  contributed  to  the  biology  of  tumors, 
these  results  can  not  be  applied  directly  to  spontaneous  tumors,  and  this  is  especially 
ti:ue  with  respect  to  immunity.  It  has  long  been  recognized  that  immunity  to  im- 
planted tumor  gives  no  assurance  against  the  subsequent  development  of  spontaneous 
tumors.  It  is  quite  impossible  to  present  within  reasonable  space  a  comprehensive 
review  of  all  investigation  in  tumor  immunity,  so  that  in  the  attempt  to  furnish  an 
adequate  explanation  of  the  phenomena  relating  to  tumor  immunity,  such  data  as 
appear  to  bear  directly  on  the  subject  will  be  discussed  and  correlated  as  far  as  possible. 

BB8I8TANGB  TO  SPONTANBOUS  TUMORS. 

The  individual  who  is  without  any  form  of  tumor  may,  in  a  certain  sense,  be  re- 
garded as  immune,  and  the  mechanism  for  regulating  the  growth  of  tissue  as  one  of 
immunity.  The  normal  individual  may,  however,  develop  a  tumor  at  any  time 
and,  with  the  limitation  of  active  growth  to  a  relatively  small  group  of  cells,  it  appears 
improbable  that  there  is  any  abnormality  of  the  growth-r^^ulating  mechanism  but 
rather  a  local  derangement  of  the  group  of  tissue  cells  from  which  the  tumor  arises. 
This  view  is  supported  in  that  Haaland  has  observed  that  tumors  may  be  transplanted 
to  a  normal  animal  as  readily  as  to  one  in  which  a  tumor  has  devleoped  and  also  in 
that  it  is  found  that  young  healthy  animals  are  more  favorable  to  the  growth  of  im- 
planted tumor  than  older  ones.    Since  natural  resistance,  once  a  malignant  tumor 

1  Fifth  Sd.  Report,  Imperial  Cancer  Research  Fund,  Tendon,  1912, 1. 
1  Proc.  Roy.  Soc,  Series  D,  1900-1010,  Ixxxii,  208. 
^  »  Jour.  Exp.  Med.,  191.5,  xxU,  766. 


366       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIPIC  CONGRESS. 

has  become  efltablished,  appears  to  be  usually  ineffective,  many  attempts  have  been 
made  to  increase  it  through  various  artificial  procedures. 

Spontaneous  regression. — Recovery  from  a  tumor  which  has  shown  malignant 
characteristics  is  rare.  A  number  of  such  recoveries  have,  however,  been  recorded 
and  Incomplete  excision  has  in  a  few  rare  instances  been  followed  by  complete  cure. 
That  there  is  also  spontaneous  recovery  from  certain  border  line  conditions  appears 
probable.  E\ddence  of  local  disappearance  of  tumor  is  more  frequently  met  with; 
for  example,  a  scirrhous  carcinoma  of  the  breast  may  disappear  in  certain  regions 
while  actively  growing  in  others. 

Reaction  of  tissues  to  tumor, — ^The  histological  study  of  tumors  also  discloses  reac- 
tions of  the  surrounding  tissue,  some  of  which  are  unquestionably  favorable,  others 
distinctly  unfavorable  to  the  growth  of  the  tumor  tissue.  Certain  uterine  carci- 
nomata,  for  example,  excite  a  pronounced  infiltration  of  eosinophiles,  and  in  such 
cases  the  reactionary  tissues  may  exceed  in  amount  the  essential  tissue  of  the  tumor.' 
Certain  carqinomata  of  the  lip,  as  well  as  the  border  line  conditions  in  this  region, 
show  marked  inflammation  in  the  tissue  near  the  abnormal  epithelium,  and  degen- 
erative changes  in  the  contiguous  con|iective  tissue  are  frequently  prominent.  In 
other  instances  proliferative  changes  in  the  supporting  tissues  are  most  marked. 
This  is  seen  in  adenomata  of  the  breast  and  in  the  papillary  tumors  of  the  ovary. 
The  proliferation  may  be  present  in  such  a  degree  as  to  give  the  appearance  of  mixed 
tumor  or  of  sarcoma.  Such  a  degree  of  connective  tissue  proliferation  has  attended 
the  transplantation  of  certain  carcinomata  in  mice  as  to  constitute  at  first  a  mixed 
tumor  and  later  on,  after  the  elimination  of  the  epithelial  elements,  a  sarcoma.  Thus 
Ehrlich,  Ix)eb,  and  Haaland  have  each  produced  sarcomata  experimentally  by  the 
inoculation  of  epithelial  tumors.  With  certain  carcinomata  a  dense  scar-like  tissue 
is  formed,  which  tends  to  bring  about  the  atrophy  and  disappearance  of  the  tumor 
epithelium  through  pressure  and  interference  with  nutrition.  Accordingly,  it  is 
possible  to  distinguish  a  great  variety  of  reactions  on  the  part  of  the  supporting  tissue 
in  response  to  the  influence  of  tumor  cells.  Some  are  distinctly  antagonistic,  others 
indifferent,  others  favorable  to  the  growth  of  the  tumor.  It  is  obvious  that  unless 
the  neoplastic  tissue  is  of  such  nature  as  to  stimulate  a  reaction  in  some  degree  favor- 
able to  its  support  and  nutrition,  its  continued  growth  will  be  impossible.  Such  re- 
actions furnish  definite  evidence  of  the  biological  variation  of  the  tumor  from  the 
somatic  tissue  from  which  it  arises,  a  subject  which  will  be  further  discussed  later  on. 

Relaiion  of  resistance  to  metastasis. — In  the  distribution  of  metftstasis  there  is  con- 
siderable evidence  of  oiganal  immunity.  Certain  organs  may  be  free  from  secondary 
tumors  in  cases  in  which  there  is  every  indication  of  a  general  dissemination  of  the 
tumor  cells,  and  emboli  of  tumor  cells  have  been  found  undeigoing  degeneration. 
Certain  tumors  are  widely  distributed  in  certain  tissues — ^for  example,  lymphomata 
which  grow  profusely  throughout  the  lymphoid  tissue — ^while  other  tissues  are  for  the 
most  part  exempt  from  invasion.  On  the  other  hand,  epidermoid  carcinomata  are 
observed  which,  while  infiltrating  the  tissues  diffusely,  are  at  the  same  time  being 
reduced  to  inert  masses  of  comified  epithelium  wherever  their  cells  have  lodged  in 
the  lymph-nodes.  However,  on  the  whole,  it  is  impossible  to  ascertain  in  most  cases 
whether  the  distribution  of  the  tumor  is  determined  by  its  biological  peculiarities 
with  respect  to  the  invasion  of  vessels  or  by  the  imfavorable  conditions  furnished  it 
by  certain  organs  and  tissues.  Adequate  vascularization  is  probably  an  essential 
^tor  in  the  nutrition  of  most  tumor  metastases.  A  more  definite  knowledge  of  the 
principles  governing  organ  or  tissue  exemption  from  metastasis  will  be  acquired 
when  the  experimental  method  is  more  generally  applied,  and  animal  tumors,  since 
they  are  available  in  considerable  numbers,  are  suitable  for  this  problem. 

>  Noted  in  a  case  from  the  colleotion  of  the  Department  of  Pathology,  Harvard  Medical  School;  also 
noted  by  Uallory. 


PUBLIC  HEALTH  AND  MEDICINE.  367 

The  opinion  has  been  expressed  that  metastasis  is  to  some  extent  governed  by  the 
resistance  of  the  individual.  Sticker  recognizes  a  premetastatic  period  in  the  growth 
of  tumors  during  which  the  resistance  of  the  body  is  sufficient  to  destroy  all  cells 
which  may  enter  the  circulation.  Gay,  on  finding  that  a  certain  proportion  of  rats 
bearing  the  Flexner-Jobling  tumor  recovered  if  reinoculated  during  this  period, 
adopted  Sticker's  views  views  in  the  explanation  of  his  results.  The  author  has  found 
that  by  the  forcible  manipulation  of  a  tumor  of  the  Japanese  waltzing  mouse,  metas- 
tases may  be  produced  experimentally,  and  it  is  not  only  possible  in  this  way  to 
reduce  artificially  the  premetastatic  period,  but  also,  by  ascertaining  the  time  re- 
quired for  the  tumor  emboli  to  become  visible  nodules,  to  show  that  the  natural  pre- 
metastatic period  is  actually  considerably  shorter  than  it  had  appeared.  It  has  been 
repeatedly  shown  that  animals,  on  developing  tumors  from  transplants,  frequently 
become  more  unfavorable  to  the  growth  of  subsequent  implants.  Although  it  is  not 
improbable  that  the  presence  of  a  local  tumor  may  stimulate  a  reaction  which  is 
unfavorable  for  the  development  of  tumor  emboli,  experimental  evidence  of  this  is 
lacking,  and  the  peculiarities  of  the  individual  tumor  with  respect  to  its  ability  to 
disseminate  its  cells  should  be  taken  into  consideration.  Tumors  which  metastasized 
in  the  individuals  in  which  they  ori^^inated  have  a  greater  tendency  than  others  to 
metastasize  during  propagation. 

Certain  points  with  respect  to  conditions  governing  the  growth  of  tissues  are  readily 
determined  in  human  beings.  The  following  observations  were  made  with  respect 
to  the  persistence  of  transplants  of  the  abnormal  tissue  in  myelogenous  leukemia  an  d 
Hodgkln's  disease  during  the  course  of  certain  procedures  that  were  undertaken  by 
the  members  of  the  staff '  of  the  Himtington  Hospital  with  the  view  of  testing  the 
efficacacy  of  autologous  vaccinations  which  was  at  that  time  on  trial  in  the  treatment 
of  tumors. 

Myelogencms  leukemia. — Case  C.  I.  12.  5.  This  patient,  a  woman  37  years  of  age, 
showed  marked  enlargement  of  the  spleen  and  a  white  coimt  varying  from  91,000  to 
496,000  while  under  observation;  duration  at  least  two  years. 

June  3,  1912.  A  cubic  centimeter  of  leucocytes  collected  from  dtrated  blood  was 
injected  subcutaneously. 

June  5,  1912.  Slisiht  tenderness  and  indication  at  site  of  iaoculation.  This  had 
entirely  disappeared  at  the  time  of  the  next  observation  several  days  later. 

Luger  quantities  of  leucocytes  were  employed  in  subsequent  Injections — 15  cubic 
centimeters  being  used  in  one  instance — but  theae  were  always  quickly  absorbed. 

June  29,  1912.  One  cubic  centimeter  of  blood  was  drawn  from  a  vein  and  injected 
immediately  beneath  the  skin  of  the  upper  arm. 

June  30,  1912.  The  blood  has  been  almost  wholly  absorbed  and  there  was  no  dis- 
coloration present. 

Hodghin's  disease. — Case  I.  12.  43.  A  girl,  17  yean  of  age,  with  enlargement  of  the 
glands  of  the  neck,  axilla,  and  mediastinum;  duration  of  disease,  4i  years. 

March  10^  1912.  A  small  nodule  was  excised  for  dia^osis.  A  small  portion  of  this 
was  inmiediately  Inoculated  subcutaneously  near  the  insertion  of  the  deltoid  muscle 
b^  means  of  a  trochar.  Following  this  the  implant  was  palpable  and  the  overlying 
skin  slightly  reddened. 

March  13,  1912.  No  reddening  and  the  implant  had  diminished  in  size. 

March  19,  1912.  No  trace  of  the  implant  remained. 

These  observations  show  that  the  abnormal  cells  in  these  two  diseases  do  not  find 
the  conditions  furnished  by  the  subcutaneous  tissues  favorable  for  their  development. 

Diagnostic  tests  and  curative  sera. — A  considerable  portion  of  the  work  on  immunity 
to  spontaneous  tumors  has  been  done  in  connection  with  human  cases  and  falls  nat- 
mrally  into  two  divisions;  first,  the  reactions  which  might  serve  as  diagnostic  or  prog- 
nostic tests,  and  second,  measures  which  have  been  carried  out  with  the  view  of 
efifecting  a  cure  by  sume  general  form  of  treatment.  Among  the  proposed  diagnostic 
methods  may  be  mentioned  Freund's  reaction,  the  meiostagmin  reaction,  the  hemo- 
lysis test,  Abderhalden's  test,  the  cobra  venom  test,  and  complement  fixation.    As 

1  Thomas  Ordway,  Ellis  KeUert  and  the  author. 


368       PKOCEEDINGS  SECOND  PAN   AMERICAN   SCIENTIFIC  CONGRESS. 

poeaible  ciirative  agents,  trypain,  sera  from  resistant  human  cases,  living  tumor  used 
as  an  autologous  vaccine,  tumor  extracts  and  cell  ferments,  dried  animal  tumon, 
and  the  transfused  blood  of  normal  individuals  have  been  employed.  Since  the 
various  tests  each  require  separate  consideration  no  discussion  of  them  will  be  under- 
taken. It  is  notable,  however,  that  up  to  the  present  time  these  have  in  general 
been  found  either  unreliable  or  impractical.  The  general  failure  of  the  long  list  of 
therapeutic  measures  for  which  claims  have  been  made  is  also  a  matter  of  common 
knowledge. 

IMMUNITY  TO  TRANSFLANTED  TUMOR  TISSUE. 

The  subject  of  immunity  to  transplanted  tumor  tissue  has  been  extensively  inves- 
tigated. Although  the  transplanted  tumors  of  rats  and  mice  are  especially  favorable 
for  experimentation,  there  has  been  more  or  lees  discrepancy  in  the  results  obtained 
by  different  investigators.  Explanation  for  this  is  found  both  in  differences  in  the 
biological  character  of  the  various  tumon  employed  as  well  as  in  differences  in  the 
character  of  the  animals  with  which  these  are  tested.  Russell  has  employed  in  his 
investigations  a  great  number  of  tumors,  the  immunizing  qualities  of  which  he  has 
determined  by  testing  them  upon  mice  of  the  same  breed  with  adequate  ccmtrols 
with  respect  to  age  and  weight.  The  author  has  attacked  the  problem  from  the 
diametrically  opposite  side  and  has  tested  the  reaction  of  different  varieties  of  mice 
to  a  single  tumor.  Thus  while  in  the  expenments  of  one  a  stock  of  tame  mice  was 
taken  as  thb  Indifferent  or  constant  and  the  tumor  as  the  variable  factor,  in  the  expen- 
ments of  the  others  a  single  tumor  served  as  the  constant  and  different  varieties  of 
mice  and  their  hybrids  as  the  variables. 

General  featuret. — Immunity  to  transplanted  tumor  has  as  its  basis  the  reaction  of 
the  organism  to  a  foreign  cell.  It  has  been  shown  that  animals  treated  with  normal 
cells  may  manifest  an  increased  resistance  to  implanted  tumor  and  also  that  animals 
treated  with  tumor  tissue  may  subsequently  show  pronounced  immunity  to  the 
same  tumor  or  to  other  tumon.  The  condition  of  resistance  to  implantaticm  of  various 
types  of  tumon  by  the  previous  injection  of  a  single  tumor  has  been  termed  pan- 
immunity  by  Ehrlich.  Differences  in  the  immunizing  qualities  of  various  tumon 
has  been  definitely  established  by  Russell,  who  has  foimd  that  in  general  the  poorly 
growing  tumon  serve  as  the  more  '* efficient  antigens."  Loeb,  Haaland,  and  the 
author  have  each  shown  that  tumon  may  be  readily  reimplanted  in  the  individuals 
in  which  they  arise — autoplastic  grafting.  When  a  tumor  is  transferred  to  other 
individuals  of  the  same  race,  a  variable  nimiber  of  failures  of  growth  usually  occur, 
and  greater  difficidty  is  encountered  in  the  successfid  implantation  of  tumor  tissue 
in  other  races  and  varieties — homololastic  grafting.  Practically  invariable  failure 
follows  the  implantation  of  tumor  in  other  species — ^heteroplastic  grafting.  The 
degree  of  the  immunity  which  develops  thus  depends  apparently  on  the  foreignness 
of  the  immunizing  cell  with  respect  to  the  organism  into  which  it  is  introduced. 
The  more  foreign  cells  accordingly  serve  as  the  more  effective  and  the  more  closely 
related  cells  as  the  less  effective  antigens. 

Antigen. — Immunity  to  tumor  tissue  is  evidently  excited  by  some  subtle  product 
of  cell  metabolism  eliminated  in  small  amount,  but  over  considerable  periods  of  time. 
Repeated  attempts  have  been  made  to  immunize  with  dead  tumor  or  other  tissue 
products,  but  notwithstanding  several  unconfirmed  reports  of  success  such  procedures 
have  in  general  proved  imsuccessful.  The  great  majority  of  those  who  have  investi- 
gated the  subject  have  thus  found  that  the  injection  of  living  cells  is  essential  in  the 
production  of  immunity.  While  such  treatment  may  serve  to  prevent  the  growth 
of  subsequently  implanted  tumor,  it  does  not  bring  about  the  retrogression  of  estab- 
lished tumors.  The  regression  of  implanted  timiors  of  large  size  may,  however, 
occur  spontaneously,  and  the  animals  are  then  immune  to  further  implantation. 
Tumore  have  been  fotmd  which  grow  in  practically  100  per  cent  on  implantation  but 
which  subsequently  all  retrogress  if  left  for  a  sufficiently  long  time. 


PUBLIC  HEALTH  AKD  MEDICINE.  369 

Histology  of  the  tissue  reactions  to  transplanted  tumor. — ^When  a  tumor  such  as  the 
carcinoma  (J.  w.  A.)  of  the  Japanese  waltzing  mouse  is  implanted  into  a  series  of 
common  mice — i.  e.,  into  individuals  of  an  alien  race — its  continued  growth  is  inva- 
riably prevented.  If  these  mice  are  killed  at  different  intervals  after  inoculation 
and  a  histological  study  is  made  of  the  implants  and  the  surrounding  tissue  it  is  foimd 
that  the  tumor  grows  for  a  period  of  six  or  seven  days  as  readily  as  in  the  Japanese 
waltzing  mouse,  the  variety  in  which  it  originated  and  in  which  implants  invariably 
continue  to  grow.  During  this  time  the  common  mouse  provides  stroma  and  blood 
vesBels  for  the  implant.  At  the  end  of  this  period,  an  inflammatory  reaction  appears, 
evidently  as  the  result  either  of  a  slight  injury  to  the  surrounding  tissue  or  of  some 
chemotactic  substance,  and  the  cellular  exudate  accimiulates  in  amount  sufficient 
to  interfere  with  the  blood  supply  and  to  isolate  the  tumor  from  all  healthy  supporting 
tissue  so  that  its  destruction  is  accomplished.  If  common  mice  in  which  this  reaction 
has  taken  place  are  subsequently  reinoculated  with  the  same  tumor,  the  inflamma- 
tory reaction  appears  several  days  earlier  and  the  implant  is  thus  disposed  of  much 
more  promptly  than  in  similar  untreated  common  mice.  Such  nonsusceptible 
common  mice  are  not,  therefore,  strictly  speaking,  naturally  immune,  but  develop 
an  immunity  which  first  manifests  itself  six  or  seven  days  after  inoculation.  They 
thus  develop  a  quality  not  present  in  the  untreated  mice,  in  other  words  an  active 
immunity. 

NonsuseeptibilUy  versus  immunity, — ^To  ascribe  nonsusceptibility  to  '^  natural 
immunity"  is  confusing,  if  not  inaccurate,  for  there  is  ample  evidence  to  show  that 
this  quality  is  based  on  an  ability  to  acquire,  under  artificial  conditions,  an  active 
immunity.  Russell  states  that  the  natural  resistance  of  animals  may  be  considered 
as  nothing  more  than  an  ability  to  develop  readily  an  active  immunity.  It  appean 
preferable  to  use  the  terms  nonsusceptibility  and  susceptibility,  the  former  to  indicate 
ability  to  develop  effective  immunity  to  a  given  tiunor  so  as  to  make  its  continued 
development  impossible,  the  latter  to  indicate  failure  to  develop  effective  immunity 
in  response  to  an  implant  of  tumor.  The  two  terms  find  application  with  respect  to 
both  individuals  and  races.  While  Japanese  waltzing  mice  furnish  an  example  of 
an  uniformly  susceptible  and  common  mice  of  an  uniformly  nonsusceptible  race, 
with  respect  to  a  single  tumor,  with  other  races  and  other  tumors  varying  proportions 
of  susceptible  and  nonsusceptible  individuals  are  found.  There  are  various  degrees 
of  susceptibility,  and  this  character  is  also  subject  to  variation  in  individuals,  since 
certain  animals  in  which  tumor  implants  would  ordinarily  grow  may  be  rendered 
immune  and  thereby  nonsusceptible  by  the  injection  of  normal  tissue  or  poorly  grow- 
ing tumor.  Other  animals  which  are  nonsusceptible  may  be  made  nonresistant 
through  appropriate  treatment. 

Hypothecs  in  explanation  of  tumor  immunity. — Since  active  immunity  to  implanted 
tumor  is  recognized  as  an  established  fact,  the  question  next  arises  as  to  the  nature 
of  this  immunity.    A  number  of  hypotheses  have  been  offered  in  explanation. 

The  body  fluids  of  immune  mice  have  not  been  observed  to  have  any  direct  cytolytic 
action  on  tumor  cells  either  in  the  test  tube  or  in  the  body  of  the  immune  animals. 
Immunity  to  homoioplastic  implants  thus  appears  to  differ  from  that  produced  by 
the  injection  of  the  tissue  of  a  foreign  species  in  which  cytolysins,  precipitins,  opsonins, 
etc.,  are  readily  demonstrated. 

The  possible  importance  of  intercurrent  bacterial  infection  in  tumor  immunity  has 
been  emphasized  by  Pitzman,  who  claims  that  infected  tumors  confer  protection, 
whereas  noninfected  tumors  do  not.  This  is  not  in  accordance  with  many  well  estab- 
lished isucta,  and  it  is  especially  difficult  on  this  basis  to  account  for  the  constant 
appearance  of  an  inflammatory  reaction  around  implants  in  one  variety  and  its  absence 
arotmd  implants  in  parallel  series  of  another  variety  of  mice.  It  is  likewise  difficult  on 
the  hypothesis  of  imnmnity  through  concomitant  infection  to  explain  the  occurrence 


\ 


370       PBOCEEDIKGS  SECOND  PAN  AMBBIOAN  80IENTIFIG  00NQBE88. 

Gf  an  inflammatory  reaction  only  around  living  tumor,  its  prompt  subeidence  as  soon 
as  the  latter  becomes  wholly  necrotic,  and  also  the  failure  of  necrotic  tumor  to  pro> 
duce  immunity.  In  order  to  put  this  hypothesis  to  further  test  a  tumor  infected 
with  a  nonpathogenic  bacillus  was  ground  in  salt  solution  and  filtered  through  filter 
paper.  The  filtrate  was  inoculated  subcutaneously  into  a  series  of  mice  and  later 
these,  together  with  an  equal  number  of  controls,  were  inoculated  with  timior  con- 
taminated with  the  same  bacillus.  Implants  taken  twenty  and  twenty-six  hours 
after  inoculation  showed  in  the  treated  mice  more  polymorphonuclear  leucocytes  in 
foci  around  the  tumor  than  was  the  case  in  the  controls.  After  48  hours,  however, 
the  implants  in  the  treated  animals  showed  practically  no  infiltration  and  were  devel- 
oping under  more  favorable  conditions  than  the  controls.  These  findings  are  not, 
therefore,  in  accord  with  the  vi^w  that  tumor  immunity  is  brought  about  through 
bacterial  infection. 

Athrepsia,  or  deficiency  on  the  part  of  the  body  fluids  with  respect  to  certain  sub- 
stances essential  for  the  nutrition  of  the  tumor,  fails  to  accoimt  for  both  the  vigorous 
temporary  growth  in  nonsusceptible  animals,  and  also  the  inflammatory  reaction 
which  precedes  the  destruction  of  the  tumor. 

The  hypothesis  that  something  is  produced  in  the  immune  animal  which  renders 
inert  the  products  of  the  tumor  and  so  inhibits  the  proliferation  of  stroma  and  blood 
vessels  has  been  advanced  by  Kussell  and  others.  While  this  would  not  account 
for  the  retrogression  of  large  established  tumors,  we  have  no  evidence  to  disprove  that 
this  mechanism  applies  to  certain  cases  in  which  there  is  no  active  inflammatory 
process  about  the  implant.  Theoretically  it  would  appear  quite  probable  that,  in 
instances  where  the  tumor  cells  were  less  foreign  in  nature,  the  immune  body  pro- 
duced may  call  forth  no  excessive  reaction  on  the  part  of  the  host  tissue  and  neverthe- 
less be  sufficient  to  inhibit  the  stimulating  effect  of  the  tumor  on  the  growth  of  blood 
vessels  and  connective  tissue. 

From  the  observations  already  alluded  to  it  appears  evident  that  a  large  proportiim 
of  tumor  implants  in  nonsusceptible  mice  are  at  first  provided  with  boUi  stroma  and 
blood  vessels,  but  later  on  become  isolated  from  healthy  supporting  tissue  by  an 
inflammatory  reaction  manifested  by  abundant  cellular  exudation  and  degenerative 
changes  in  the  tissue  around  the  tumor.  This  delayed  reaction  of  the  host  tissod  is 
difficult  to  explain  except  on  the  hypothesis  that  an  immune  body  has  been  pro- 
duced. Since  there  is  no  available  evidence  indicating  the  plurality  of  immune 
substances  in  tumor-immune  animals,  and  in  view  of  the  failure  to  demonstrate 
lysins,  precipitins,  or  any  of  the  recognized  immune  bodies,  it  appears  justifiable  for 
purposes  of  discussion  to  speak  of  the  protective  material  present  as  a  single  substance 
or  immune  body.  With  an  immime  body  present,  the  tumor  products  are  rendered 
strongly  chemotactic  so  that  the  surroimding  tissue,  as  well  as  the  implant,  becomes 
infiltrated  with  leucocytes.  The  reaction  is  not  merely  exudative  in  character  but  is 
proliferative  as  well,  for  there  is  a  great  increase  in  the  number  of  fibroblasts  in  the 
surroimding  tissue,  and  these  increase  in  size  as  in  granulation  tissue.  That  others 
have  attached  so  great  importance  to  lymphocyte  infiltration  may  be  due  in  part 
to  difference  of  material,  to  the  period  at  which  the  process  was  studied,  or  to  a  failure 
to  recognize  all  the  constituents  of  the  reaction.  From  both  the  material  on  whidi 
the  present  study  is  based,  and  from  the  illustrations  of  other  authors,  it  is  evident 
that  we  have  in  general  to  deal,  not  with  an  infiltration  of  a  single  type  of  cell,  but  with 
an  inflammation  which  may  vary  somewhat  with  the  material,  though  more  especially 
with  its  duration.  Thus  in  immunized  mice  the  reaction  is  more  prompt  and  poly- 
nuclear  leucocytes  are  more  numerous,  while  in  untreated  nonsusceptible  mice  the 
reaction  appears  later— not  earlier  than  the  seventh  day— and  here  the  lymphocytes 
occur  in  greater  numbers.  In  both  instances  the  reaction  manifests  itself  in  the 
formation  of  granulation  tissue  in  which  proliferative  as  well  as  exudative  activity  is 
evident. 


PUBLIC  HEALTH  AND  MEDICINE.  871 

The  pale  staining  and  vacuolation  of  the  cytoplasm,  the  swelling  of  the  nuclei,  and 
the  absence  of  cell  division  are  taken  as  indices  of  degeneration  in  the  tumor  epithe- 
lium. Such  degenerative  changes  are  of  frequent  occurrence  in  implanted  tumor 
epithelium,  even  in  susceptible  animals,  and  they  usually  occur  in  those  portions  of 
the  epithelium  farthest  from  the  host  tissue,  i.  e.,  from  the  source  of  nutrition.  From 
the  fact  that  the  features  of  tumor  cell  degeneration  are  the  same  in  both  susceptible 
and  immune  animals,  from  the  gradual  progress  of  this  degeneration,  and  from  the 
visible  evidence  of  a  reaction  which  tends  to  is(date  the  tumor  from  healthy  tissue, 
it  is  evident  that  the  destruction  of  the  tumor  is  accomplished  by  the  formation  of  an 
immune  body  which  modifies  the  response  of  the  host  tissue. 

The  number  of  lymphoid  cells  in  the  inflammation  around  the  tumor  implant  was 
regarded  as  significant  by  Da  Fano,  who  has  concluded  that  it  is  through  the  agency 
of  the  lymphocytes  that  immunity  is  produced.  Murphy  has  arrived  at  similar  con- 
clusions after  having  found  that  a  rat  tumor  may  be  grown  in  chick  embryos  in  the 
absence  of  lymphoid  tissue,  and  that  the  introduction  of  certain  adult  tissues,  such 
as  spleen  or  lymphnode,  is  sufficient  to  prevent  this.  Baeslack  has  ^own  a  relattve 
increase  in  the  number  of  lymphocytes  in  the  blood  in  the  course  of  the  retrogression, 
and  a  relative  decrease  during  the  active  growth  of  timiors.  Murphy  and  Morton, 
idio  have  made  a  study  of  the  blood  counts  in  artificially  immunized,  naturally  non- 
susceptible,  and  susceptible  mice,  have  also  demonstrated  a  very  marked  absolute 
increase  in  the  number  of  lymphocytes  during  the  retax>gre6sion  of  implanted  tumors. 
In  neither  of  these  articles  has  the  possibility  of  dififerences  in  the  leucocyte  content 
of  the  blood  of  the  tail  vessels  and  that  of  the  heart  in  rats  and  mice  been  discusMd. 
That  the  white  count  from  the  blood  of  the  tail  vein  may  vary  within  wide  limits 
has  been  pointed  out  by  Klienebeiger  and  Karl,  and  this  has  been  the  experience  of 
the  author.  Since  the  white  count  of  the  blood  of  the  tail  vein  may  vary  more  than 
100  per  cent  and  is  usually  much  higher  than  that  of  the  heart's  blood,  and  since 
differential  counts  show  that  the  lymphocytes  are  approximately  20  per  c^it  more 
numerous  in  blood  from  the  tail,  the  indicated  increase  in  the  number  of  lymphocytes 
in  the  blood  of  immune  mice  is  probably  greatly  exaggerated.  The  charts  presented 
by  Murphy  and  Morton  show  no  increase  in  the  lymphocyte  count  of  the  immunined 
mice  except  on  the  introduction  of  tumor  tissue.  Thus  the  lymphocyte  count  in  the 
immunized  mouse  is  shown  at  precisely  the  same  level  before  and  after  the  immuniz- 
ing injection,  and  yet  it  would  not  be  denied  that  an  animal  so  treated  now  poeMses 
qualities  which  were  previously  absent,  or,  in  other  words,  had  become  immune— a 
point  of  considerable  significance.  This,  together  with  the  fact  that  these  authors 
were  able  to  lower  the  resistance  of  immunized  animals  by  exposure  to  the  X-^rays, 
which  are  known  to  have  a  destructive  action  on  lymphoid  cells  and  other  leucocytes, 
lends  additional  support  to  the  hypothesis  already  outlined — ^i.  e.,  that  resistance  to 
transplanted  tumor  is  dependent  upon  (1)  the  presence  of  an  immune  body  which, 
in  the  presence  of  the  tumor,  either  produces  injury  or  otherwise  renders  the  implant 
chemotactic,  and  (2)  an  ability  of  the  tissues  to  respond  to  this  with  an  inflammatory 
reaction  which  isolates  and  destroys  the  implant. 

Although  it  may  be  possible  by  repeated  X-ray  radiation  in  appropriate  amoimts 
to  render  both  naturally  nonsusceptible  and  artificially  Immunized  animals  favorable 
for  the  growth  of  implanted  tumor,  there  is  in  the  physiological  mechanism  thus 
destroyed  nothing  specific  to  tumor  immunity.  It  is  inconceivable  that  there  should 
be  sufficient  differences  in  the  lymphocyte  content  of  various  classes  of  mice  to  account 
for  their  differences  in  susceptibility  to  a  given  tumor.  In  fact,  other  publications 
by  one  of  these  authors  tend  to  show  that  X-ray  radiation  tends  to  lower  resistance  to 
a  variety  of  disease-producing  agents.  The  X-ray  may  evidently  destroy  the  ability 
of  the  organism  to  respond  to  a  certain  type  of  injury  with  a  corresponding  type  of 
inflammatory  reaction  and,  applied  to  tumor  immune  animals,  it  in  this  way  de- 
creases their  resistance. 

68436— 17— VOL  X 25 


872       PB00BEDIK6S  SBCOND  PAN  AMEBIOAK  SCIENTIFIC  C0KQBES8. 

It  thus  appears  most  probable  that  at  least  three  factors  are  concerned  in  the  process 
of  the  elimination  of  implanted  tumor.  First,  antigen,  which  diffuses  from  living 
tumor  cells;  second,  antibody,  which  in  the  presence  of  antigen  renders  the  implant 
positively  chemotactic;  and  third,  in  reeponse  to  this,  an  inflammatory  reaction. 
With  the  formation  of  this  immune  body  tumor  products  which  had  previously  pro* 
duced  a  mild  proliferation  of  the  sunounding  host  tissue  are  now  made  strongly  chemo- 
tactic to  leucocytes,  and  probably  slightly  injurious  to  the  surrounding  tissue. 
Whether  another  substance  such  as  complement  is  necessary  in  this  reaction  has  not 
been  demonstrated.  With  the  material  at  hand  there  is  no  evidence  of  a  specific 
chemotactic  influence  on  the  lymphoid  cells,  for  diff^ent  varieties  of  wandering 
cells  are  attracted  and  other  cells  stimulated  to  proliferate.  The  character  of  the 
Inflammatory  reaction  varies  here  as  elsewhere,  both  with  the  degree  of  excitation  and 
with  the  duration  of  the  process.  The  lymphoid  cells  preponderate  in  the  milder  and 
more  prolonged  reaction,  polymorphonuclear  leucocytes  and  endothelial  phagocytes 
in  the  more  prompt  and  pronounced  reactions,  and  the  reaction  of  the  connective 
tiflme  is  also  an  important  factor. 

Pamve  immunity, — ^Following  the  recognition  of  the  immunity  of  mice  in  which 
lazge  implanted  tumors  had  retrogressed,  attempts  were  made  to  produce  passive 
immunity  and  through  the  use  of  the  serum  of  such  immune  mice  to  cure  other  mice 
of  their  tumors.  Although  success  was  at  first  reported,  a  further  trial  of  such  sup- 
posedly immune  serum  was  attended  with  no  more  frequent  retrogression  than  oc- 
curred naturally.  In  the  light  of  the  difficulty  in  curing  established  tumors,  it  is 
remarkable  that  no  greater  effort  has  been  made  to  demonstrate  passive  immunity 
with  respect  to  subsequently  implanted  tumcn*.  While  Gaylord,  Clowes,  and  Baes- 
lack  found  that  the  treatment  of  mice  with  immune  serum  appeared  to  have  the  effect 
of  lowering  the  number  of  takes  from  subsequent  implants,  Weil  found  that  the 
similar  treatment  of  rats  with  immune  serum  failed  not  only  to  influence  the  growth 
of  established  tumors,  but  also  to  prevent  the  growth  of  subsequent  implants  ol  sar- 
a»na.  He  was  also  unable  to  demonstrate  the  presence  of  an  immune  body  by  pas- 
sive sensitization  of  guinea  pigs  with  the  serum  of  tumor-immune  rats.  In  this  instance 
both  the  immune  plasma  and  the  tum(nr  were  derived  from  a  single  q>ecies,  the  rat, 
80  that  lees  pronounced  results  might  be  expected  than  in  immunity  to  a  foreign 
proteid.  In  fact,  these  results  are  not  inconsistent  with  the  presence  of  an  immune 
body  which  influences  the  reaction  of  the  host  but  does  not  directly  destroy  the  tumor 
ceils.  It  has  appeared  probable  that  by  histological  study  reactions  may  be  detected 
which  are  not  demonstrable  in  the  gross  phenomena  attending  the  experiment.  The 
object  of  the  following  experiment  was  to  ascertain  whether  the  injection  of  immune 
serum  at  the  time  of  the  implantation  of  tumor  in  susceptible  mice  would  jwevent 
or  in  any  way  influence  growth  and  also  whether  this  in  any  way  modified  the  reaction 
of  the  host  tissue  to  the  implant: 

With  a  view  of  conferring  a  passive  immunity  to  carcinoma  J.  w.  A  on  Japanese 
waltaing  mice,  an  immune  serum  was  obtained  irom  nonsusceptible  mice  which  had 
been  previously  immunized  by  implants  of  Japanese  waltzing  mouse  tumors.  The 
srouij  of  nonsusceptible  mice  employed  consisted  of  eight  F,,  two  Ft,  and  seven  F4 
nybnds  which  had  been  inoculated  on  July  27,  1915,  with  sarcoma  J.  w.  B  with 
negative  result.  These  were  inoculated  again  on  October  11,  1915,  with  carcinoma 
J,  w.  A.  On  bacteriological  examination  of  this  tumor  no  organism  was  found  either 
in  smear  or  culture.  Fifteen  days  later  (Oct.  26)  the  blood  of  these  mice  was  collected 
and  defibrinated.  With  the  exception  of  one  mouse  which  showed  a  consolidation 
of  a  portion  of  the  lung,  all  appeared  in  a  healthy  condition.  The  blood  was  kept 
at  a  low  temperature  for  about  one  hour,  then  centrifugated  and  the  serum  used  im- 
mediately. That  the  serum  was  somewnat  tinged  with  red  may  possibly  have  been 
due  to  pooling  the  bloods  of  so  many  animals. 

October  26,  1915.  Thirty-eix  Japanese  waltzing  mice  were  employed  for  the  test 
and  these  were  srouped  in  three  series  and  treatea  as  follows: 

Series  I.  Twelve  controls  each  received  an  implant  of  tumor  J.  w.  A.  beneath  the 
■kin  just  posterior  to  the  fore  leg. 


PUBLIC   HEALTH  AND  MEDICINE.  373 

Series  II.  Twelve  mice  received  each  a  subcutaneous  injection  of  0.3  c.  c.  of  the 
immune  serum  and  immediately  following  this  an  implant  of  timior  J.  w.  A.  The 
serum  was  injected  into  the  back  just  anterior  to  the  tail,  while  the  tumor  was  im- 
planted behind  the  fore  leg  as  in  the  controls. 

Series  III.  The  bits  of  tumor  used  to  inoculate  the  remaining  12  mice  were  first 
placed  for  about  one  hour  in  the  small  amount  of  serum  left  over  from  tiie  preceding 
series. 

At  fixed  intervals  an  animal  from  each  of  the  three  series  was  killed  in  order  to 
obtain  the  tissues  for  histological  study.  Six  from  each  series  were  killed  and  the 
others  left  to  observe  an^  differences  in  the  growth  of  the  implants.  (A  nonpatho- 
genic bacillus  was  found  in  cultures  from  the  tumor  here  employed.) 

Although  the  implants  were  smaller  at  the  end  of  the  first  week  in  certain  mice  of 
the  two  series  in  which  inmiune  serum  was  used,  the  subsequent  rate  of  growth  of  the 
tumor  was  more  rapid  in  these  than  in  the  controls,  so  that  at  the  end  of  four  weeks 
•  all  were  larger  than  the  laigest  tumor  of  the  controls  series.  Since  the  numbers  were 
small,  these  results  are  only  significant  in  showing  that  the  immune  serum  adminis- 
tered at  the  time  of  implantation  did  not  prevent  the  development  of  the  tumor  in 
susceptible  mice,  and  that  after  a  short  interval  it  may  have  had  a  stimulating  rather 
than  a  retarding  effect  on  its  growth. 

No  marked  histological  differences  in  the  reaction  of  the  tissues  of  the  animals  of 
the  control  series  and  of  those  which  had  received  serum-soaked  tumor  were  oboenred. 
Readily  distinguishable  differences  with  respect  to  reaction  to  the  tumor  implant 
were  noted,  however,  in  the  animals  treated  with  immune  serum.  The  tomcnr  epithe- 
lium of  the  24  and  26  hour  implants  in  the  serum-treated  series  showed  few  mitotic 
figures,  although  these  were  numoous  in  the  control  implants  at  this  time.  Th«re 
was  in  all  implants  of  the  treated  animals  an  exttt:isive  degeneration  of  the  tumor 
epithelium  and  the  living  renmants  were  scattered  in  isolated  islands,  whereas  in  the 
controls  the  living  tumor  formed  a  more  or  less  continuous  peripheral  layer.  The 
swelling,  pale  staining,  and  vacuolation  of  cells  may  be  taken  as  evidence  of  degenera* 
tion,  since  such  changes  are  ordinarily  found  in  the  living  portions  of  implants  bor- 
dering cm  the  necrotic  interior  and  farthest  from  the  source  of  nutrition.  Although  the 
degeneration  of  the  implanted  tumor  in  the  treated  mice  appeared  to  be  of  the  same 
general  character  as  in  the  untreated,  it  was  more  pronounced  in  the  former,  and  this 
difference  with  respect  to  the  extent  of  the  degeneration  increased  for  at  least  &fB 
days.  Infiltration  of  the  interior  of  the  implant  with  polym<»phonuclear  leucocytes 
appeared  early— 26  hours— and  persisted  for  at  least  four  days.  The  interior  of  the 
control  implants,  although  necrotic,  was  not  in  any  case  markedly  infiltrated.  For 
three  days  the  amount  of  collagen  in  and  around  the  implants  was  the  same  in  all 
three  series.  There  was,  however,  a  marked  excess  of  this  material  within  the  four 
and  five  day  implants  of  the  serum-treated  mice.  The  tumor  appears  to  require  a 
somewhat  cellular  connective  tissue  for  its  growth,  and  the  abnormal  intercdlular 
substance  which  appeared  in  the  serum-treated  mice  was  evidently  unsuitable  in 
this  respect. 

From  these  observations  it  is  evident  that  the  injection  of  immune  serum  modified 
the  reaction  of  the  tissues  of  the  implant  and  host,  although  not  sufficiently  to  prevent 
the  later  development  of  the  tumor.  It  is  possible  that  the  immune  serum  injected 
contained  a  constituent  which  was  slightly  toxic  for  the  tumor  epithelium,  as  was 
indicated  by  the  absence  of  mitotic  figures  for  a  time,  and  by  a  degeneration  which 
continued  for  several  days,  although  it  is  to  be  noted  that  similar  degenerative  changes 
were  commonly  found  in  portions  of  implants  at  a  distance  from  the  source  of  nutri- 
tion. It  is  clear,  however,  that  the  immune  serum  has  rendered  the  implant,  espe- 
cially its  necrotic  and  degeneratiDg  portions,  positively  chemotactic  to  polynuclear 
leucocytes.  Appearing  somewhat  later  (four  days  after  inoculation)  there  was  an 
increase  of  collagen  within  the  implant,  and  phagocytic  cells  also  appeared.  The 
implanted  tumor  thus  encountered  in  the  serum-treated  animals  conditions  which, 
although  transitory  and  not  sufficient  to  accomplish  passive  immunity,  were  never- 


874       PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC   CONGRESS. 

theless  definitely  unfavorable  to  its  development.  It  should  be  noted  that  the  trans- 
plantable tumor  for  which  the  immune  serum  was  prepared  encounters  conditions  in 
the  Japanese  waltzing  mouse  unusually  favorable  for  its  growth  so  that  it  is  not  im- 
probable that  effective  passive  immunity  with  respect  to  subsequently  implanted 
tumor  may  be  produced  by  employing  other  material. 

Specificity. — ^The  fact  that  blood  and  other  normal  tissue  may  be  employed  as  well 
as  tumor  tissue  in  the  production  of  immunity  to  the  latter  indicates  that  there  is  no 
marked  degree  of  tissue  specificity  in  the  immunity  which  develops,  but  it  is  prob- 
able that  there  is  a  considerable  degree  of  racial  specificity  with  respect  to  the  genetic 
origin  or  foreignness  of  the  antigens.  That  certain  tumors,  however,  show  greater  dif- 
ferences in  their  immunizing  qualities  than  the  embryonic  tissues  from  which  they 
have  arisen  will  be  diown  later  on  by  the  results  obtained  in  the  transplantation  of 
hybrid  tumors  to  the  parental  stocks. 

Fbreignness  of  tumor  toith  respect  to  host  a  requisite  of  twnwr  immunity  and  an  expUma- 
tion  of  the  inheritance  of  susceptibility  to  impUmted  tumor. — A  carcinoma  which  origi- 
nated in  the  Japanese  waltzing  mouse  is  found  to  grow  in  practically  every  individual 
of  this  variety  in  which  it  is  implanted.  On  the  contrary  it  fails  to  grow  in  every 
instance  on  implantation  in  the  common  mouse.  By  cross-breeding  these  two  varieties 
saccessive  generations  of  hybrids  have  been  obtained,  the  first  of  which  has  been 
back-crossed  with  both  parent  stocks.  The  results  obtained  from  the  implantation 
of  this  tumor  into  mice  of  the  various  filial  generations,  and  into  mice  derived  from  all 
other  matings,  are  shown  in  the  accompanying  chart.  The  susceptibility  of  each 
class  has  been  tested  by  the  simultaneous  inoculation  of  comparative  series  of  mice 
with  a  single  tunuM'.  The  material  here  considered  collectively  includes  that  which 
has  bem  jMrevioudy  presented  by  the  author,  as  well  as  that  collected  recently  in 
collalxxfttion  with  Little. 

It  ia  quite  appar«it  from  these  data  that  susceptibility  is  not  inherited  as  a  single 
BMOodelizing  factor,  for  both  in  the  successive  filial  generations  and  in  the  back-croeses 
between  the  first  filial  generation  and  the  parent  stocks,  the  results  do  not  furnish  a 
ratio  characteristic  of  single  factor  inheritance.  There  is  no  blending  inheritance, 
to  the  results  are  not  intennediate  but  correspond  closely  with  those  obtained  in  one 
or  the  other  of  the  parent  stocks.  The  only  hypothesis  upon  which  we  can  explain 
Ifaeae  results  is,  that  susceptibility  or  nonsuscepibillty  is  dependent  upon  the  pres- 
ence of  a  complex  of  independently  inherited  unit  factors.  Upon  the  number  of 
imcUas  necessary  for  susceptibility  will  d^>end  the  results  obtained  in  the  second  filial 
generation.  If  a  few  fact<Mrs  are  necessary,  a  condisorable  proportion  of  the  indivudalB 
of  this  generation  should  prove  susceptible;  if  a  larg^  number  of  factors  are  neces- 
sary, then  a  smaller  proportion  of  the  individuals  of  this  generation  should  be  sua- 
eeptible.  In  the  Fi  hybrids,  all  the  inheritable  factors  of  each  parent  will  presum- 
ably be  present  in  a  single  repre8entati<m.  On  the  principle  that  these  factors  will 
be  sQgr^gated  in  the  germ  cells  of  this  generation,  it  is  possible  to  compute  the  results 
of  the  random  combination  of  any  nuimber  of  factors  which  will  occur  in  the  mating  of 
tiie  Fi  animals.  Although  the  nature  of  the  material  employed  makes  large  numbers 
requisite  for  an  accurate  estimation  of  the  number  of  factors  involved,  the  results 
obtained  indicate  that  susceptibility  to  this  tumor  is  dependent  on  the  presence  of  a 
large  number  of  independently  inherited  factors.  Our  results  with  the  two  stocks  of 
common  mice  recently  employed  are  such  as  would  be  obtained  if  the  presence  of  from 
12  to  14  such  factors  were  necessary  for  susceptibility. 

The  effect  of  a  single  representation  of  factors  on  susceptibility. — ^Although  the  factors 
from  both  susceptible  and  nonsusceptible  parent  stocks  must  necessarily  be  present 
in  the  Fi  hybrid,  it  is  i^parent  that  those  necessary  for  susceptibility,  although  here 
only  singly  represented,  are  in  the  greater  part  of  our  material  as  effective  as  when 
doubly  represented  in  the  Japanese  waltzing  mouse.  Conversely,  the  factors  necee- 
sary  for  nansusceptibility ,  although  all  present  in  the  same  Fi  hybrids,  are  ineffective 


PUBLIC   HEALTH  AND  MEDICINE. 


375 


when  siiigly  represented  or  in  half  dose.  That  this  will  not  hold  true  in  the  cross-breed- 
ing of  every  stock  of  the  common  with  the  Japanese  waltsdng  mouse  is  clearly  indi- 
cated in  certain  earlier  experiments.    The  difference  between  the  percentage  of 

CHART  1. 

SUSCEPTIBILITY  TO  CARCINOMA  J.WA. 


Stock 

Stock 

1' 

'f 

Com. 

J.W. 

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FT  from  Lab.  Stock  -  ^S^S^ 

^  ^  BrAg.  »  -lOQO^ 
n  i»  d.Br.  n  -95.3'' 
»»    »   Alien    M     -69.2" 


F^  from  Lab.  Stock  —  5.0^ 
w     »»   BrAg.  »»    -~  17" 


poflitiye  results  obtained  in  the  Fj  hybrids  and  In  the  Japanese  waltzing  mice  in 
recent  experiments  might  possibly  be  attributable  to  faulty  technic,  since  only  one 
F|  animal  (1.6  per  cent)  failed  to  grow  the  tumor.    In  a  previous  investigation  a 


876       PBOCEEDIKQS  SECOND  PAN  AMBBIOAN  SCIENTIFIC  00NQBE88. 

Blighty  higher  proportioii  of  failures  occurred,  and  the  in/ct  that  most  of  these  were  in 
Fi hybrids  (''alien"  Fi  hybrids)  which  were  derived  from  another  stock  of  cOTimon 
mice  indicates  that  a  single  representation  of  the  factor  complex  of  nonsusceptibility 
may  in  some  instances  prove  effective.  The  nonsusceptibility  of  certain  of  these 
negative  Fi  hybrids  was  established  by  the  negative  results  of  reinoculation. 

The  effect  of  tingle  representation  of  factors  on  the  rate  of  growth. — ^Notwithstanding 
the  presence  of  the  factors  of  nonsusceptibility  in  the  Fj  hybrid^  the  rate  of  tumor 
growth  is  usually  more  rapid  than  in  the  Japanese  waltzing  mouse.  This  fact  was 
established  in  the  earlier  experiments  by  weighing  the  tumors  after  equal  periods  of 
growth  in  comparative  series  of  mice.*  Subsequent  experience  has  also  shown  that 
the  tumor  grows,  on  the  average,  more  rapidly  in  the  F|  hybrids.  It  is  probable 
that  this  increase  in  the  rate  of  tumor  growth  is  due  to  certain  factors  furnished  by 
the  nonsusceptible  parent  stock.  While  we  are  unable  to  recognize  the  individual 
Victors  concerned,  it  might  be  exi>ected  that  the  more  rapidly  growing  and  laiger 
hybrids  supply  the  tumor  with  more  abundant  nutrition  than  is  the  case  with  the 
more  slowly  growing  and  smaller  Japanese  waltzing  mice.  It  is  found,  however,  that 
the  tumor  grows  more  rapidly  than  in  Japanese  waltzing  mice,  not  only  in  young 
growing  but  also  in  full-grown  Fi  hybrids.  The  presence  of  certain  singly  repre- 
sented factors  of  nonsusceptibility  evidently  calls  forth  a  greater  growth  of  stroma 
and  blood  vessels,  so  that  they  in  this  way  appear  to  have  a  stimulating  effect  on  the 
growth  of  the  tumor.  The  injection  of  the  serum  of  immunized  mice  also  has  been 
shown  to  have  a  transitory  retarding,  but  a  later  stimulating,  effect  on  the  growth 
of  tumor  J.  w.  A.  in  the  susceptible  Japanese  waltzing  mouse. 

FaOor  representation  in  retarded  growth. — ^Although  in  recent  experiments,  3  of  183 
hybrids  of  the  second  filial  generation  have  shown  progressively  growing  tumors,  the 
rate  of  growth  has  been  much  slower  than  in  the  Japanese  waltzing  or  Ft  hybrid 
mice.  From  this  it  appears  probable  either  that  not  all  of  the  factors  found  in  the 
Japanese  waltzing  mice  are  present  even  in  a  single  representation,  or  that  certain 
of  the  factors  of  nonsusceptibility  become  effective  through  double  representation  in 
these  positive  Ft  mice,  for  otherwise  there  is  nothing  to  account  for  a  rate  of  growth  so 
comparatively  slow.  In  addition  to  these  individuals  in  the  F^  generation  in  which 
the  tumor  grew  progressively,  there  were  certain  others  in  whidi  the  tumor  grew  for 
a  time,  but  eventually  disappeared.  For  these  it  is  necessary  to  assume  a  still  more 
limited  representation  of  certain  factors  with  a  correspondingly  greater  representi^ 
tion  of  others. 

These  results  having  been  interpreted  from  the  viewpoint  of  genetics,  it  is  now 
important  to  consider  them  in  the  light  of  what  is  established  for  tumor  inmiunity. 
It  has  already  been  pointed  out  that  nonsusceptibility  of  a  class  of  animals  to  implanted 
tumor  is  to  be  regarded  as  an  ability  to  acquire  an  active  immunity,  and,  conversely, 
susceptibility  as  an  inability  to  develop  active  immunity  to  a  given  tumor.  If  a 
single  tumor  be  employed  as  a  constant  with  which  to  test  various  groups  of  mice, 
it  may  be  found  that  the  race  in  which  it  originated  is  susceptible  whereas  another 
race  is  nonsusceptible.  Nonsusceptibility  is  thus  based  on  foreignness  or  unlike- 
ness  with  respect  to  races,  so  that  when  the  tissue  of  one  is  introduced  into  the  other 
active  immunity  is  developed.  The  science  of  genetics  has  already  established  a 
series  of  independently  inherited  unit  factors  for  a  considerable  number  of  species, 
including  the  mouse.  In  the  consideration  of  foreignness  or  unlikeness,  what  else  could 
be  possible  than  that,  in  the  comi)arison  of  individuals  or  races,  some  should  differ 
with  respect  to  few  factors  and  others  with  respect  to  many  factors?  Thus  the  con- 
ception of  foreignness  or  unlikeness  not  only  furnishes  a  basis  for  tumor  immunity, 
but  also  makes  more  comprehensible  the  inheritance  of  susceptibility  to  implanted 
tumor. 

Foreignness  as  a  basis  of  certain  biological  differences  in  tumor. — If  groups  of  mice  of 
known  character  are  used  as  constants  with  which  to  test  various  tumors,  differences 


PUBLIC  HEALTH  AND  MEDIOIKB.  877 

in  the  behavior  of  the  latter  are  detected,  even  though  they  may  have  arisen  in  a 
single  inbred  race.  It  asedsts  materially  in  the  explanation  of  results  if  these  bio- 
logical differences  are  recognized.  Certain  tumors  occur  which  are  transplantable  in 
only  a  small  proportion  of  cases,  even  in  closely  related  animals.  The  conditions 
requisite  for  their  growth  are  raiely  found  apart  from  the  individual  in  which  they 
arise,  i.  e.,  a  slight  degree  of  foreignnees  on  the  part  of  the  host  tissue  is  fatal  to  them. 
For  other  tumors  fewer  conditions  or  factors  are  necessary,  and  such,  since  they  are 
able  to  withstand  a  higher  degree  of  foreignnees  on  the  part  of  the  host,  develop  on 
transplantation  in  a  greater  proi>Qrtion  of  cases.  Such  differences  in  the  capacity 
of  a  number  of  tumors  for  growth  in  various  classes  of  mice  are  shown  in  the  following 
toble. 


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PUBLIC  HEALTH  AND  MEDICINE.  379 

The  biological  difference  or  foreignnees  of  tumors  with  respect  to  one  another  and 
to  the  normal  somatic  tissue  from  which  they  arise,  is  a  point  of  considerable  signifi- 
cance. To  illustrate:  A  tumor  (H.  F.)  which  arose  spontaneously  in  an  Fj  hybrid 
has  been  implanted  into  other  individuals  of  the  same  generation,  and  into  the  parent 
stocks  of  common  and  Japanese  waltzing  mice.  Now,  the  animal  in  which  this  tumor 
appeared  grew  as  an  embryo  upon  the  uterine  mucosa  of  its  common  mother,  with- 
out the  appearance  of  any  incompatibility  between  the  embryonic  and  maternal 
tissue.  Since  the  tumor  which  has  arisen  from  the  somatic  tissue  of  this  mouse  fails 
to  grow  in  either  of  the  parent  stocks,  it  would  appear  probable  on  this  basis  that  it 
differs  from  the  soma  with  respect  to  its  ability  to  grow  on  a  given  ^il.  Loeb,  how- 
ever, has  already  called  attention  to  the  absence  of  antagonistic  reaction  in  utero 
between  the  maternal  and  the  somewhat  foreign  embryonic  tissue.  This  Fj  tumor 
appears  to  have  required  factors  for  its  growth  which  were  not  all  furnished  by  either 
the  conmion  or  the  Japanese  waltzing  mouse  nor  by  all  Fi  hybrids.  It  might  be- 
exi)ected  that  in  the  cells  of  this  tumor,  as  in  other  somatic  cells  of  the  F^  hybrid, 
there  would  be  an  equal  representation  of  factors  of  both  parents.  The  only 
alternative  would  be  to  consider  the  hybrid  tumor  as  a  manifestation  of  mosaic  inher- 
itance and  thus  corresponding  more  closely  in  its  character  to  the  soma  of  one  or  th» 
other  parent  stock.  If  such  were  the  case,  however,  it  would  be  expected  that  this 
tumor  would  grow  in  one  of  the  parent  stocks,  at  least  as  well  as  in  the  Fi  hybrids, 
but  the  results  are  otherwise.  The  Japanese  waltzing  mice  in  which  it  fuled  to* 
grow  were  all  found  to  be  susceptible  to  tumor  J.  w.  A.,  J.  w.  B.,  or  J.  w.  G.,  so  that 
its  failure  is  to  be  attributed  to  feeble  growth  power— i.  e.,  inability  to  grow  in  the- 
preeence  of  even  a  few  foreign  factors,  rather  than  to  any  unumi^  imnninifang 
property. 

Another  tumor  (H.  G.)  which  arose  in  a  back-cross  hybrid  from  the  mating  of  an 
F|  hybrid  with  a  common  mouse,  failed  to  grow  in  common  as  well  as  Japanese 
waltzing  mice,  although  closely  related  to  the  former. 

Differences  in  behavior  with  respect  to  transplantability  are  found  not  only  in 
tumors  arising  from  heterogeneous  stocks,  such  as  the  Jensen  and  Ehrlich  Stamm  11 
cardnomata,  but  also  in  tumors  arising  in  inbred  stocks  such  as  the  Japanese  waltzing- 
mouse.  The  behavior  of  the  tumors  arising  in  the  Fi  hybrids  can  not  be  accoimted 
for  on  the  basis  of  characters  derived  either  from  one  of  the  parents  or  from  both,  but 
only  on  the  basis  of  the  appearance  of  modifications  or  new  characteristics.. 

From  the  evidence  in  the  biological  character  of  tumors  of  a  permanent  modification 
of  somatic  tissue,  it  appears  logical  to  regard  a  tumor  as  a  manifestation  of  somatic 
mutation.  As  a  basis  for  this,  there  may  be  modification  in  the  relative  value  either 
by  loss  or  addition,  or  in  the  nature  of  foctors,  any  of  which,  if  continuously  trans- 
mitted thereafter  in  successive  cell  generations,  will  constitute  a  type  of  mutation. 
This,  imlike  the  mutations  which  may  affect  the  germ  plasm,  is  maintained  only 
throu£^  artificial  transplantation  from  one  individual  to  another.  The  tissue  of  a  new 
growth  has  thus  in  certain  respects  become  foreign  to  the  other  tissues.  Its  growth  is 
no  longer  controlled  by  the  normal  inhibiting  influences  which  constitute  a  regulating 
mechanism,  but  it  behaves  more  or  less  as  a  parasite  living  at  the  expense  of  its  host; 
and  it  may  excite  a  reaction  of  the  surrounding  tissue  which  is  in  some  cases  more 
faivorable,  in  other  cases  less  favorable,  to  its  continued  growth.  Malignant  tumora 
must  have  feeble  antigenic  power  as  well  as  sufficient  resistance  to  the  normal  inhibit- 
ing influences  to  provide  for  continued  growth  in  the  animal  in  which  they  originate, 
otherwise  reactions  sufficient  to  destroy  them  would  occur  more  frequently. 

Conclusions. — The  results  of  the  experimental  investigation  of  tumors,  as  well  as  of 
clinical  and  pathological  observation,  appear  to  favor  the  following  conception  of  the 
nature  of  tumors  and  their  relationship  to  the  other  tissues. 

The  interreactions  of  the  normal  tissues  are  mutually  beneficial  so  that  their  relation- 
ship is  one  of  symbiosis. 


380       PBOCEEDINGS  SECOND  PAN  AMEBIOAN  SCIEKTIFIC  GONQBESS. 

The  anomalies  and  benign  growths,  while  not  distinctly  harmful,  are  usually  of  no 
benefit  to  the  individual;  the  relationship  is  one  of  commensalism. 

The  malignant  tumors  are  in  many  respects  parasitic  in  nature,  especially  since  they 
develop  at  the  expense  of  the  other  tissues  of  the  body.  They  are  so  adapted  for 
growth,  once  they  have  become  established,  that  they  seldom  arouse  any  effective 
resistance  on  the  part  of  the  body.  There  is  some  evidence,  however,  of  a  local  reac- 
tion of  tissues  imfavorable  to  the  growth  of  many  different  types  of  tumors. 

Immunity  to  transplanted  tumor  is  based  on  foreignneas  or  incompatibility  of  tumor 
and  host.  This  holds  true  whether  the  tumor  or  the  animal  is  taken  as  the  constant 
&ctor  with  which  to  test  the  other.  Althou^  the  degree  of  foreignneas  is  not  sufficient 
for  the  production  of  markedly  cytotoxic  or  cytolytic  sera,  as  when  different  spedee 
are  employed,  it  appears  probable  that  an  immune  body  is  formed  which,  in  the 
presence  of  the  antigen — or  living  tumor — excites  an  inflammatory  reaction  in  the 
tissue  around  the  tumor  so  that  the  latter  is  isolated  and  eventually  destroyed. 

Both  susceptibility  and  nonsusceptibility,  or  the  ability  to  acquire  immunity,  aie 
inherited,  not  as  a  single  unit  factor  but  apparently  as  a  complex  of  mendelizing 
factors.  Nonsusceptibility  and  susceptibility  are  apparently  based  on  factor  differ- 
ences, or,  in  other  words,  on  unlikeness  or  foreignness.  Nonsusceptibility  may  thus 
depend  with  one  tumor  on  a  difference  with  respect  to  few  factors,  and  with  another 
tumor  on  a  difference  with  respect  to  many  factors.  In  the  comparison  of  a  stock  of 
Japanese  waltzing  and  several  stjDcks  of  common  mice,  the  nonsusceptibility  of  the 
latter  to  a  carcinoma,  J.  w.  A.,  is  based  on  a  difference  with  respect  to  a  laige  number — 
probably  12  to  14 — of  independently  inherited  factors. 

Susceptibility  is  in  this  material  a  dominant  character,  since  it  is  manifested  when 
its  factors  are  present  in  a  single  representation,  as  in  the  F^  hybrid.  The  presence  of 
a  single  representation  of  the  factors  of  nonsusceptibility  in  the  F^  hybrid  api>arently 
stimulates  the  growth  of  the  tumor,  for  its  rate  of  growth  is  more  rapid  than  in  the 
Japanese  waltzing  mouse  in  which  the  factors  of  susceptibility  are  doubly  represented* 

There  are  marked  differences  in  the  behavior  of  various  tumors  oh  transplantation 
in  given  classes  of  mice.  Even  tumors  arising  in  homogeneous  races  show  such  differ- 
ences, and  this  may  be  attributed  to  the  acquisition  of  new  characteristics  by  the 
soma  whidi  are  nuuiifested  in  the  developiment  of  the  tumor.  The  tumor,  since  it 
breeds  true  with  respect  to  these  characteristics  in  the  course  of  artificial  propagation 
may  be  regarded  as  a  modification  of  the  somatic  tissue  which  may  be  termed  somatic 
mutation. 

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Immunitatsforsch.  u.  exper.  Therap.,  1911,  x,  103. 
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Bashford,  E.  F.,  JSfurray,  J.  A.,  and  Haaland,  M.:  Resistance  and  susceptibility  to 

inoculated  cancer.    Third  Sc.  Report,  Imperial  Cancer  Research  Fund,  London, 

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Buigess,  A.  M.:  The  nature  of  the  reaction  of  the  tissues  of  susceptible  and  nonsus- 

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miinity.    Jour.  Med.  Research,  1909,  xx,  175. 
Gaylord,  H.  R.,  Clowes,  G.  H.  A.,  and  Baeslack,  F.  W.:  Preliminary  report  on  the 

presence  of  an  immune  body  in  the  blood  of  mice  spontaneously  recovered  from 

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New  York  State  Cancer  Laboratory,  1904-5,  11. 
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Annual  Report,  New  York  State  Cancer  Laboratory,  1905-6,  11. 
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Haaland,  M. :  Contributions  to  the  study  of  the  development  of  sarcoma  under  experi- 
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1908,  175. 
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malignant  timiors.    Jour.  Exper.  Med.,  1911,  xiv,  148. 
Little,  C.  C,  and  Tyzzer,  E.  E.:  Further  experimental  studies  on  the  inheritance  of 

susceptibility  to  a  transplantable  tumor,  Carcinoma  (J.  w.  A.)  of  the  Japanese 

waltzing  mouse.    Jour.  Med.  Research,  1916,  xxxiii,  393. 
Loeb,  L.:  Ueber  Sarkomentwicklung  bei  einem  drtisenartigen  Mftusetumor.    Berl- 

klin.  Wchnschr.,  1906,  xliii,  781. 
Loeb,  L.,  and  Leopold,  S. :  On  differences  in  the  results  obtained  after  inoculation  of 

tumors  into  the  individual  in  which  the  tumor  had  developed  spontaneously  and 

into  other  individuals  of  the  same  species.    Jour.  Med.  Research,  1907,  xvii,  299. 
Loeb,  L.:  Ueber  Enstehung  eines  Sarkoms  nach  Transplantation  eines  adenocar- 

cinoms  einer  japanischen  Maus.    Ztschr.  f.  Erebsforsch,  1908,  vii,  80. 
Loeb,  L.:  The  influence  of  changes  in  the  chemical  environment  on  the  life  and 

growth  of  tissues.    Jour.  Am.  Med.  Assn.,  1915,  Ixiv,  726. 
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Jour.  Exper.  Med.,  1914,  xix,  181. 
Murphy,  J.  B.,  and  Morton,  J.  J.:  The  lymphocyte  in  nattu^  and  induced  resistance 

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Murphy,  J.  B.,  and  Morton,  J.  J.:  The  effect  of  X-ray  on  the  resistance  to  cancer  in 

mice.    Science,  New  York,  1915,  xlii,  842. 
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Ztschr.  f.  Krebsforsch.,  1914,  xiv,  57. 
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cancer.    Fifth  Sc.  Report,  Imperial  Cancer  Research  Fund,  London,  1912,  1. 
Sticker,  A.:  Transplantables  Rundzellensarkom  des  Hundes.    Ztschr.  f.  Krebsforsch. 

1906,  iv,  227,  307. 
Tyzzer,  E.  E.:  A  study  of  inheritance  in  mice  with  reference  to  their  susceptibility 

to  transplantable  tumors.    Jour.  Med.  Research,  1909,  xxi,  519. 
Tyzzer,  E.  E. :  Factors  In  the  production  and  growth  of  tumor  metastases.    Jour.  Med. 

Research,  1913,  xxviii,  309. 


382       PROCEEDINGS  SECOND  PAN   AMERICAN  SCIENTIFIC  CONGRESS. 

Tyzzer,  E.  E. :  The  importance  of  inflammation  in  the  immunity  of  mice  to  implanted 

timior.    Jour.  Med.  Research,  1915,  xxxii,  201. 
Tyzzer,  E.  E.:  The  tumors  of  the  Japanese  waltzing  mouse  and  of  its  hybrids.    Jour. 

Med.  Research,  1915,  xxxii,  331. 
Weil,  R.:  A  study  of  the  blood  in  rats  recovered  from  impluited  sarcoma.    Jour. 

Exper.  Med.,  1913,  xviii,  390. 

Weil,  R.:  The  intravascular  implantation  of  rat  tumors.    Jour.  Med.  Research,  1913, 

xxviii  497 

DESCRIPTION  OF  PLATE  1. 

Fio.  1.  Carcinoma  (J.  w.  A.)  98  hours  after  implantation  in  a  normal  control 
Japanese  waltzing  mouse  (no.  5417).  Living  tumor  is  distributed  at  the  periphery, 
forming  a  layer  with  only  occasional  breaks  in  its  continuity.  The  necrotic  central 
portion  of  the  implant  is  free  from  infiltration. 

Fig.  2.  Carcinoma  (J.  w.  A.)  98  hours  after  implantation  in  a  Japanese  waltzing 
mouse  (no.  5423)  which  was  injected  with  immune  serum.  Living  tumor  is  found 
in  scattered  islands  and  is  absent  from  large. portions  of  the  implant's  surface.  The 
necrotic  interior  shows  extensive  infiltration  with  polymorphonuclear  leucocytes. 


CHEMOTHERAPEUTIC  EXPERIMENTS  ON  RAT  TUMORS. 

By  RICHARD  WEIL. 

Prom  the  Huntmgton  Fund  for  Cancer  Research  and  the  Department  of  Experimental 
Medicine  of  the  Cornell  University  Medical  College^  New  York  dbg. 

In  discuasing  a  subject  of  such  extent  as  the  chemotherapy  of  tumors  it  is  quite 
evident  that  only  isolated  features  of  the  problem  can  be  touched  on.  In  the  present 
paper  I  shall  attempt  to  discuss  certain  phases  of  the  work  which  I  have  been  carrying 
on  for  several  years,  in  their  bearing  on  the  general  problem. 

1.  The  penetrability  of  the  living  tumor  cells. — There  is  at  the  present  time  consid- 
erable unanimity  on  the  subject  of  the  intravitam  staining  of  cells.  Goldmann  (3), 
who  was  one  of  the  first  to  study  the  distribution  in  the  cells  and  tissues  of  dyes  which 
were  introduced  into  the  circulation,  reached  certain  conclusions  which  have  largely 
served  as  the  point  of  departure  for  subsequent  study.  He  found  that  certain  of  the 
cells  took  up  these  dyes,  which  could  then  be  identified  as  characteristically  colored 
granules  distributed  through  the  cells.  Goldmann  considered  that  these  granules 
were  preformed  elements  of  cell  structure,  which  had  been  stained  by  the  dyes. 
It  is  possible  that  this  explanation  holds  true  of  certain  basic  dyes  (such  as  janua 
green,  methylene  blue,  neutral  red).  Upon  this  theory  it  is  clear  that  a  staining 
of  granules  is  simply  an  alteration  of  paraplasm,  or  deuteroplasm,  and  that,  in  the 
absence  of  a  diffuse  staining  of  the  cytoplasm  we  can  not  speak  of  a  true  vital  stain 
of  the  cells.  Indeed,  Fischel  (2)  in  Ehrlich's  Encyclopadie,  holds  that  there  is  no 
such  thing  as  a  vital  stain  in  the  latter  sense. 

On  the  other  hand,  it  is  now  widely  believed  that  staining  of  preformed  granules 
is  not  the  correct  explanation  in  the  case  of  the  dyes  used  by  Goldmann,  which  be- 
long almost  entirely  to  the  benzidine  group.  Evans  and  Schulemann  (1)  have  argued 
quite  convincingly  that  the  presence  of  the  intracellular  granules  in  the  cells,  in  the 
case  of  this  group  of  dyes,  is  due  solely  to  phagocytosis.  The  cells  take  the  circulat- 
ing particles  of  dye  out  of  the  circulation,  and  they  then  appear  as  densely  stained 
particles  within  the  cell  body.  In  harmony  with  this  view,  it  is  found  that  only 
certain  definite  types  of  cells,  whicli  act  as  phagocytes-" -the  'scavenger  cells"  as 
Evans  calls  them,  can  take  up  these  dyes     The  living  cells  of  tumors  do  not  belong 


TUK08  IMMUNITY 


I  t 

I   ] 
1 


PUBLIC  HEALTH  AND  MEDICINE.  383 

to  this  category,  hence  it  is  impossible  to  stain  them  in  vivo  with  the  benzidine  dyes. 
Indeed,  I  have  not  been  able  to  stain  them  with  any  dyes  whatever.  The  cause  of 
this  differentiation  between  cells  is  probably  biological  rather  than  physical.  The 
scavenger  cells  are  differentiated  to  pick  foreign  substances  out  of  the  blood  for  the 
pttpose  of  elimination.  They  are,  so  to  speak,  a  widely  disseminated  excretory  organ. 
This  view  is  borne  out  by  some  instructive  experiments  carried  out  by  Kite  (6).  He 
found  that  certain  dyes  (such  as  azolitmin,  congo  red,  tropeolin  000  No.  1,  alizarin 
solphonate,  indigo-carmin),  which  t&il  to  penetrate  amoeba  proteus,  diffuse  freely 
throughout  the  organism  when  injected  into  it.  In  other  words,  the  surface  of  the 
cell  offers  an  obstacle  to  its  entrance;  once  in,  the  color  is  taken  up  diffusely  by  the 
protoplasm.  Again,  he  states  that  *4f  the  egg  of  Asterias  be  punctured,  the  add 
dyes  used  penetrate  the  swollen  area  for  varying  depths,  but  never  enter  the  normal 
unswollen  protoplasm.  ** 

Consequently  it  is  found  that  dead  or  injured  cells  behave  quite  differently  toward 
the  benzidine  dyes.  Their  peripheral  resistance  is  gone  and  they  take  up  the  dyes 
rapidly,  presenting  a  uniform  stain.  Thus  the  cells  of  the  kidneys  of  rabbits  treated 
with  sublimate  or  cantharidin  (Gross  (4)),  and  the  anterior  horn  cells  in  experimental 
poliomyelitis  (MacCurdy  and  Evans  (7))  may  be  strikingly  stained  by  these  dyes. 

In  this  connection  the  claims  of  Wassermann  and  Keysser  (10)  with  reference 
to  the  staining  of  living  tumor  cells,  are  worthy  of  attention.  They  asserted  that 
the  eosin  penetrates  all  the  cells  of  the  body,  and  therefore  used  it  as  a  carrier  ("  cyto- 
trochin'^)  for  selenium.  Their  facts,  however,  do  not  bear  out  this  assertion.  Hiey 
never  succeeded  in  staining  tumors  smaller  than  a  cherry  pit  in  size — ^in  other  words, 
tumors  in  which  central  necrosis  had  not  occurred.  Benign  spontaneous  tumors, 
which  have  no  tendency  to  undergo  necrosis,  they  invariably  failed  to  stain.  Internal 
implantations,  which  have  an  infiltrative  mode  of  growth  and  are  well  supplied 
with  vessels,  Keysser  (5)  was  never  able  to  stain.  It  seems  quite  clear,  therefore, 
that  they  did  not  succeed,  as  they  thought,  in  staining  the  living  cells,  but  only  the 
necrotic  areas.    In  a  recent  paper  (11)  I  have  critically  smalyzed  these  results. 

2.  Staining  of  necrotic  areas, — Inasmuch,  therefore,  as  the  conditions  do  not  permit 
of  staining  the  living  cells  of  the  tumor,  one  is  perforce  driven  to  a  study  of  the  staining 
reactions  of  the  necrotic  parts  of  tumors.  It  is  this  phase  of  the  problem  to  which  I 
have  chiefly  devoted  my  attention.  The  literature  which  bears  on  the  subject  is  to 
be  found  almost  exclusively  in  the  remarkable  series  of  studies  which  have  been 
published  in  the  last  few  years  from  the  Sprague  Memorial  Institute  (8)  under  the 
direction  of  H.  G.  WeUs,  dealing  very  largely  with  the  staining  reactions  of  tuberculous 
tissue. 

The  first  question  which  was  studied  in  my  work  concerns  the  distribution  of  crystal- 
line substances  in  necrotic  tumors,  as  compared  with  the  normal  tissues  of  the  body. 
Rats  bearing  necrotic  tumors  received  intravenous  or  subcutaneous  injections  of 
solutions  of  sodium  iodide.  After  varying  intervals  of  time  the  animals  were  killed, 
and  the  various  tissues  of  the  body  were  smalyzed  for  their  iodine  content.  The 
chemical  work  was  carried  on  by  Dr.  Van  Alstyne,  to  whom  my  thanks  are  due.  It 
was  found  that  the  blood  regularly  contained  the  largest  proportion,  and  after  this 
came  the  tumors  and  the  liver.  The  other  tissues,  except  the  kidney,  have  regularly 
shown  very  much  less  iodine.  If  the  tumor  was  small  and  nonnecrotic,  its  proportion 
of  iodine  was  very  small.  These  findings  are  entirely  in  harmony  with  those  recently 
published  by  Wells,  DeWitt,  and  Corper  (12)  on  the  distribution  of  potassium  iodide 
in  tuberculous  tissue.  They  interpret  their  results  as  indicating  that  *'the  large 
amount  of  iodine  present  in  necrotic  tissues,  whether  tuberculous  or  otherwise,  is 
dependent  on  purely  physical  conditions— i.  e.,  the  destruction  of  the  semipenetra- 
bility  of  the  cells.'' 

3.  LocaliuUion  of  dyes  in  tumon. — ^The  relation  of  the  dyes  to  the  necrotic  tissues  of 
tumors  is  of  considerable  interest.    Wells,  DeWitt,  and  Corper  arrived  at  the  conclu- 


384       PBOGEEDINGS  SECOND  PAN  AMEBIOAN  SOIENTIFIO  G0NGBE8S. 

edon  that  ''necrotic  tissues,  whether  tubercles  or  other  lesions,  behave  like  any  non- 
living colloidal  mass  into  and  from  which  crystalloids  diffuse  readily  and  rapidly, 
while  colloids  enter  very  slowly  or  not  at  all."  In  support  of  this  view  they  showed, 
by  a  very  ingenious  application  of  anaphylactic  methods,  that  egg  white  does  not 
penetrate  the  caseous  tubercle.  However,  their  theory  does  not  appear  to  ttice 
account  of  all  the  facts.  Thus  Dr.  DeWitt  (13)  herself  has  shown  in  another  paper 
that  caseous  tubercles  can  be  thoroughly  penetrated  and  stained  by  trypan  red  and  by 
trypan  blue.  Both  of  these  dyes,  however,  are  colloidal.  As  an  actual  fact,  tl^ 
relationship  between  foreign  colloids  in  the  circulation  and  necrotic  tissues  are  very 
much  more  complex  than  might  be  inferred  from  the  hypothesis  above  outlined. 
In  illustration  of  this  fact  I  might  instance  the  following  observation: 

During  the  period  in  which  I  was  studying  the  distribution  of  dyes  in  tumors  the 
rats  in  oiur  laboratory  fell  a  prey  to  a  very  serious  epidemic.  The  disease  manifested 
itself  as  a  progressive  caseating  inflammation  of  the  lungs.  Macrosopically  and  micro- 
scopically the  lesions  presented  a  striking  resemblance  to  human  phthisis,  without, 
however,  showing  cavity  formation.  Very  frequently  I  autopsied  animals  in  which 
not  only  necrotic  tumor  tissue  but  also  these  caseous  areas  in  the  lungs  were  present. 
If  such  animals  had  previously  been  injected  intravenously  with  appropriate  dyes 
of  the  benzidine  series,  it  was  almost  invariably  possible  to  make  a  very  striking 
observation.  The  dyestuff  (e.  g.,  congo  red)  regularly  produced  intense  discoloration 
of  the  necrotic  tissue  in  the  tumon,  but  in  no  instance,  over  dozens  of  observations, 
did  it  produce  the  slightest  staining  of  the  caseous  areas  in  the  lungs.  Congo  red,  it 
may  be  added,  is  a  hi^y  colloidal  dye.  This  statement  is  based  on  the  fact  that  the 
dye  does  not  diffuse  throu^  membranes.  Certain  other  properties  of  its  solutions 
seem,  however,  to  range  it  among  the  hi^y  dissociated  electrolytes.  Such,  for 
instance,  are  the  effects  upon  the  boiling  and  freezing  points,  and  the  fact  that  its 
solutions  are  optically  clear.  Therefore  one  may  conclude  that  the  relation  of  colloids, 
or  of  colloidal  dyes  at  least,  to  necrotic  tissues  is  not  uniform. 

As  a  matter  of  fact,  the  diffusibility  of  dyes  into  a  colloidal  mass  depends  upon  a 
varieity  of  circumstances.  As  regards  the  djre,  not  only  its  degree  of  diffusibility 
throu^  animal  membranes  which  determines  its  value  as  a  colloid,  but  its  electrical 
charge,  its  chemical  reaction,  and  its  chemical  composition  all  play  a  rdle.  As  regards 
the  colloidal  mass  again,  its  physical  composition  is  of  importance,  as  is  also  its  electri- 
cal  chaige  and  its  chemical  composition.  A  knowledge  of  these  factors  permits  of  a 
fair  guess,  but  no  more,  as  to  the  result.  Thus  Teague  and  Buxton  (9)  found  that 
agar,  which  is  supposed  to  carry  a  negative  charge,  was  easily  i>enetrated  by  acid 
dyes,  anilin  blue  diffusing  as  actively  as  the  much  more  slightly  colloidal  eosin. 
Of  the  basic  dyes,  only  the  slightly  colloidal  ones  diffused  in  any  amoimt.  Even 
moderately  colloidal  basic  dyes  showed  littie  capacity  to  invade  the  agar.  The  basic 
dyes,  however,  stain  the  agar  intensely,  whereas  the  acid  dyes  leave  it  imcolored. 
Congo  red  and  azo  blue  constitute  an  exception  to  the  latter  rule,  and  although  they 
are  add  dyes,  diffuse  only  slightly  but  stain  intensely.  Thus  it  will  be  seen  that  no 
generally  valid  law  for  the  diffusion  of  all  colloids,  or  colloidal  dyes,  into  necrotit 
tissues  can  be  formulated.  The  same  dye  may  react  quite  differently  to  differene 
types  of  necrosis  even  in  the  same  individual. 

4.  Localization  of  the  benzidine  dye*. — Of  the  benzidine  group,  a  considerable  number 
of  dyes  have  been  tested,  starting  with  congo  red.  In  all  over  20  dyes  have  been 
included  in  the  present  study,  all  of  which  are  well-known  chemical  individuals  of 
the  benzidine  group,  representing  substitutions  either  in  the  benzene  or  in  the  naph- 
thalene nucleus  by  sulphuric  acid,  hydroxyl,  methyl,  salicylic  add,  and  other  groups. 
In  general  these  dyes  tend  to  localize  first  in  the  peripheral  zone  of  the  central  necrotic 
area.  If  repeated  Injections  are  made,  they  gradually  penetrate  the  entire  necrotic 
Eventually,  with  the  use  of  very  large  amounts,  some  of  these  dyes  may 


PUBLIC  HEALTH  AND  MEDICINE.  385 

slightly  discolor  even  the  healthy,  actively  growing  rim  of  tumor  tissue,  owing  to  the 
presence  therein  of  minute  foci  of  necrosis.  For  the  other  tissues  of  the  body  the 
stains  have  a  varying  degree  of  aflinity,  depending  on  the  degree  to  which  they  are 
taken  up  by  the  scavenger  cells.  Superficially  it  would  appear  that  certain  dyes  have 
a  relatively  specific  tropism,  if  one  may  use  this  term,  for  the  necrotic  areas  of  the 
tumor.  It  is,  however,  not  safe  to  judge  of  the  localization  of  the  dyes  by  the  dis- 
coloration of  the  skin.  Animals  which  have  been  treated  by  intravenous  injections 
may  on  autopsy  present  no  apparent  evidence  of  discoloration,  either  in  the  skin  or 
in  the  internal  tissues.  If,  however,  the  liver  be  boiled  for  a  few  minutes — a  procedure 
long  ago  suggested  by  Ehrlich — ^the  masked  discoloration  at  once  becomes  evident. 
Observing  this  precaution,  I  have  never  yet  found  discoloration  in  the  tumor  which 
was  not  accompanied  by  some  discoloration  in  the  liver,  either  alone  or  with  other  of 
the  parenchymatous  viscera.  On  the  other  hand,  many  of  the  dyes  appear  to  lodge 
in  far  greater  amoimt  in  the  necrotic  area  of  the  tumor  than  in  any  other  tissue,  and 
also  to  remain  there  for  a  longer  period.  Whether  they  are  actually  present  in  greater 
amount  there  than  in  the  liver  is,  however,  very  doubtful,  owing  to  the  fact  that  the 
underlying  colors  make  an  ocular  comparison  extremely  fallacious.  In  some  experi- 
ments, equal  weights  of  liver  and  of  necrotic  tissues  were  suspended  in  equal  volumes 
of  water,  and  the  colors  of  the  resulting  solutions  were  compared.  It  did  not  appear 
that  the  liver  contained  less  than  the  tumors  in  any  instance;  indeed,  it  occasionally 
contained  more.  Thus,  it  is  probably  correct  to  say  that  none  of  the  benzidine  dyes 
manifests  more  than  a  relative  specificity  for  the  necrotic  tumors.  And  it  is  not 
unlikely  that  even  this  apparent  specificity  is  actually  nothing  more  than  the  expres- 
mon  of  a  retarded  rate  of  absorption  from  these  poorly  vascularized  areas.  It  is  interest- 
ing to  note  that  these  dyes  manifest  the  same  predilection  for  the  necrotic  areas  of 
human  tumors.  A  solution  of  congo  red  was  injected  intravenously  into  a  patient 
with  cancer  of  the  breast  in  the  hope  o(  helping  in  the  detection  of  the  carcinomatous 
areas  at  the  subsequent  operation.  When  the  breast,  with  the  axillary  contents,  was 
removed,  it  was  found  that  the  necrotic  areas  of  the  tumor  foci,  both  in  the  breast  and 
in  the  axillary  nodes,  were  stained  an  intense  red.  The  living  areas  of  tumor  tissue, 
as  well  as  the  normal  tissues  of  the  breast,  appeared  to  have  their  normal  coloration. 
It  seems  unlikely,  however,  that  this  method  will  ever  prove  of  any  clinical  value. 

6.  MeUuhromMia. — ^An  interesting  phenomenon  is  the  changes  of  color  undergone 
by  some  dyes  after  they  enter  the  necrotic  areas.  This  color  change  has  been  de- 
scribed as  metachromasia,  adopting  the  terminology  of  pathologists.  The  cause  of 
the  phenomenon  is  somewhat  obscure.  It  is,  of  course,  well  known  that  some  of  the 
benzidine  dyes  are  markedly  affected  in  coIot  by  the  mineral  acids.  Indeed,  congo 
red  has  on  this  account  been  adopted  as  an  add  indicator.  But  the  organic  acids 
have  this  effect  only  in  high  concentration  and  in  minor  degree.  Moreover,  the  coIot 
changes  are  not  similar  to  those  induced  by  mineral  acids,  but  resemble  more  the 
changes  induced  by  tiie  localization  of  dyes  in  amyloid.  In  seeking  to  determine  the 
cause  of  these  changes  I  was  led  to  test  the  effect  of  solutions  of  various  polypeptids 
on  the  benzidine  dyes.  I  found  that  they  effect  changes  quite  similar  to  those  pro- 
duced in  vivo  by  the  necrotic  tissues.  Thus,  if  solutions  of  congo  red  be  mixed  with 
solutions  of  various  amino-aclds,  a  series  of  changes  in  color  can  be  produced,  slight, 
for  example,  in  the  case  of  ^ycyl-glydne,  more  marked  with  leucyl-asparagine  and 
ftlanyl-g^ydne,  and  pronounced  in  the  case  of  glycyl-g^ycyl-leudne.  The  color  does 
not  change  to  blue,  as  it  does  with  mineral  acids,  but  rather  to  a  deep  mahogany  brown. 
Mr.  Carruth  has  suggested  to  me  that  color-changes  in  dyes  like  congo  are  to  be  ex- 
plained by  a  separation  of  the  base  (Na)  from  the  acid  radical,  which  make  it  possible 
for  the  dye  to  assume  the  isomeric  quinone  form.  Although  the  free  congo  acid  may 
exist  in  a  red  form  (azoid),  this  form  is  not  stable  in  aqueous  solutions  and  passes 


386       PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC   CONQBESS. 

instantaneously  into  the  blue  fonn  (quinoneimide).     Intermediate  shades — brown 
violet,  etc. — must  represent  the  presence  of  certain  amounts  of  each  form: 

NHj  NHj 


R-N=N- 


R-NH-N: 


SaH(Na) 


(Na)  80, 

At  all  events,  it  appears  that  the  chemical  conditions  present  in  the  necrotic  tissues 
resiilts  in  the  production  of  some  change  in  the  character  of  the  dye  compound.  In 
the  same  animal  the  normal  tissues,  such  as  the  skin,  which  take  up  the  dye,  present 
it  in  an  imaltered  form.  This  fact  led  to  the  hope  that  the  necrotic  areas  might  am- 
ceivably  be  competent  to  break  up  compounds  of  these  dyes  with  toxic  substances, 
freeing  the  latter  for  attack  upon  the  surroimding  healthy  tumor  cells. 

6.  Therapeutic  effects  of  certain  compounds. — ^The  method  of  study  followed  in  de- 
termining the  effect  of  the  dyes  upon  tumor  growth  and  a  typical  result  are  illustrated 
by  the  following  protocol.  In  this  case  the  dye  used  was  Columbia  violet  R,  supplied 
by  the  Berlin  Aniline  Works.  It  is  a  diphenyl-disazodi-amino-naphthol-sulphonic 
add. 

A  rat,  series  A,  X,  weighing  170  grams,  has  a  sarcoma,  the  Buffalo  strain,  inoculated 
27  dajrs  previously,  now  measuring  i  by  H  inches,  firm,  not  ulcerated. 

April  24,  subcutaneous  injection:  3  cc.  0.5  per  cent  C.  v.  R.  No  constitutional 
effects;  no  discoloration  except  at  site  of  injection. 

April  25,  the  same  dose. 

April  26,  the  same  dose. 

April  27,  no  general  discoloration.  Exploratory  section  of  tumor:  center  necrotic, 
peripheral  necrotic  rim  shows  a  violet  discoloration.  Two  pieces  removed  from 
nealthy  margin  and  planted  in  10  rats,  in  all  of  which  ''takes "  occurred.  Skin  sewed 
up  and  soon  nealed. 

May  11,  1^  cc.  1  per  cent  C.  v.  R.,  intravenously.  Tumor  has  grown  to  1  by  2^ 
inches. 

May  13  and  14,  2  cc.  1  per  cent,  intravenously. 

May  17,  animal  died. 

Autopsy:  Tumor  unstained  in  growing  margin.  Necrotic  core  shows  all  transitioiiB 
in  color  from  salmon  yellow  at  center  to  violet  at  margin.  Infiltration  of  lungs,  with 
severe  caseation.  No  discoloration.  Liver  and  kidney  on  boiling  show  slight  dis- 
coloration. 

A  series  of  compoimds  analogous  to  congo  red  were  made  for  me  by  Mr.  Carruth, 
working  imder  Prof.  Omdorff  in  Ithaca.  In  determining  the  compound  to  be  made 
we  were  perforce  guided  by  largely  speculative  considerations  as  to  their  probable 
effects  upon  the  living  cells.  Unfortunately  the  data  upon  which  such  calculations 
can  be  based  are  few  and  inadequate.  Aside  from  this  consideration,  however,  it  ia 
evident  that  chemotherapeutic  compoimds,  to  be  of  any  possible  service  in  the  treat- 
ment of  tumors,  must  possess  certain  other  properties.  They  shoiild  not  be  highly 
toxic  to  the  organism.  They  must,  of  coiirse,  be  soluble.  They  should  be  fairly 
stable  in  solution,  yet  should  be  dissociable  in  the  necrotic  areas  of  the  tumors.  These 
properties  are  not  such  as  can  be  foretold  of  any  given  compound  with  certainty,  hence 
the  investigation  resolved  itself  into  an  empirical  study  of  such  of  the  compounds  as 
seemed  most  favorable. 

The  compoimds  which  were  tested  out  on  the  rat  tumors  are  comprised  in  the 
following  list: 

In  soluiion, 

1.  Ortho-diselenide  dye. 

2.  Congo-formaldehyde  compoimd.  No  free  formaldehyde  present.  Ten  grams 
congo  red  per  liter;  0.43  grams  of  formaldehyde  per  liter. 

3.  P^-arseno-aniline  dye,  1  per  cent. 

4.  Mercury  congo  blue,  0.5  per  cent;  probably  a  mercuramino  compound. 


PUBUC  HEALTH  AKD  MBDIOIKB.  387 

In  powder  form. 

5.  Recrystallized  congo  red. 

6.  Recrystallized  bordeau  extra. 

7.  Barium  salt  of  congo  red. 

8.  Potassium  salt  of  congo  red. 

9.  Zinc  salt  of  congo  red. 

10.  Copper  salt  of  congo  red. 

11.  Copper  salt  of  bordeau  extra. 

12.  Congo  di-triazine. 

<Sulphanilic  acid. 
Beta-naphthol. 
14.  Thio-aniline  dye. 

<Atoxyl. 
Beta-naphthol. 
xAtoxyl. 

16.  Benzidine<^ 

^Naphthionic  acid. 

17.  Soluble  selenium  congo  red. 

18.  Salmon  red,  thiazol  derivative.  ^ 

The  exact  composition  and  probable  formulae  of  these  compounds  will  not  be  here 
discussed.  Consideration  of  solubility,  toxicity,  and  other  properties  will  also  be 
deferred  to  a  futiu'e  publication.  The  present  paper  is  concerned  only  with  the  analy- 
sis of  their  therapeutic  effectiveness. 

All  the  compoimds  appeared,  judging  by  the  gross  discoloration  of  the  tissues,  to 
localize  electively  in  the  necrotic  areas  of  the  tumors.  All  the  injected  animals  in 
which  tests  were  made,  however,  showed  discoloration  of  the  boiled  livers.  The  locali- 
zation was  further  controlled  by  chemical  analysis  of  the  oigans  which,  at  least  in  the 
case  of  the  arsenic  compound,  could  be  considered  to  give  reasonably  accurate  results. 
The  maximum  yield  of  arsenic  per  gram  of  substance  was  obtained  from  the  liver, 
while  the  tumor  and  the  kidney  came  next.  The  arsenic  content  of  the  other  organs 
and  tissues  was  low.  From  these  results  it  would  appear  that  localization  in  the  tumors 
was  only  relatively  specific.  It  is,  however,  possible  that  the  arsenic  reached  the 
liver  only  after  the  compound  had  been  dissociated  in  the  necrotic  areas  of  the  tiimors. 

In  judging  of  therapeutic  effects,  three  criteria  were  employed,  namely,  the  rate  of 
growth  of  the  tumors,  their  transplantability,'and  the  number  of  retrogressions.  The 
details  of  the  method  have  already  been  illustrated.  None  of  these  three  criteria  has 
an  absolute  value  in  the  type  of  tumor  which  formed  the  basis  of  this  study,  inabmuch 
as  they  all  vary  to  a  remarkable  degree.  At  times  the  tumor  ''takes''  in  a  laige 
percentage  of  the  inoculations,  while  at  other  times,  for  no  ascertainable  reason, 
this  percentage  is  greatly  reduced.  The  rate  of  growth  and  the  percentage  of  retro- 
gressions also  vary  strikingly  in  different  generations  of  the  tumor.  For  this  reason 
it  is  always  necessary  to  plant  a  considerable  series,  of  which  at  least  half  are  kept  as 
controls,  while  the  remainder  are  reserved  for  the  purposes  of  the  experiment.  The 
conditions  are  unfortimately  such  as  to  preclude  the  determination  of  small  effects; 
on  the  other  hand  a  definite  and  considerable  influence  on  the  life  history  of  the 
tumors  could  certainly  not  escape  detection.  Judged  by  these  standards,  the  results 
obtained  were  not  encouraging.  In  only  three  out  of  the  entire  list — ^namely,  niim- 
bers  3,  4,  and  14 — were  any  effects  ascertained,  and  these  three  proved  so  hi^^y 
toxic  to  the  rats  when  given  in  therapeutic  amounts  that  it  seemed  questionable 
whether  the  effects  on  the  tumors  were  attributable  to  the  specific  action  of  the  drug 
or  to  the  general  effect  upon  the  health  of  the  animal.  At  all  events,  none  of  the 
substances  possessed  that  combination  of  properties  which  would  make  them  avail- 
able for  the  effective  treatment  of  the  rat  tumor.  The  principal  object  of  the  investi- 
gation, therefore,  failed  to  be  accomplished. 

I  wish  to  acknowledge  the  constant  help  and  advice  of  Prof.  Omdorff  and  of  Mr* 
F.  £.  Camith,  without  which  this  work  would  have  been  impossible. 

68486—17— VOL  x 26 


888       PBOCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC   CONGRESS. 

CONCLUSIONS. 

1.  living  tumor  cells  are  not  penetrated  by  colloidal  dyes. 

2.  The  necrotic  areas  of  tumors  contain  a  lai^ger  amount  of  iodine  than  do  the  other 
tissues  of  the  body  after  the  intravenous  injection  of  sodium  iodide. 

3.  The  necrotic  areas  of  tumors  present  an  intense  discoloration  after  the  intraven- 
ous or  subcutaneous  administration  of  dyes  of  the  disazo  group. 

4.  The  discoloration  of  these  tumor  areas  is  very  frequently  associated  with  some 
discoloration  of  the  liver,  while  the  other  tiasues  of  the  body  remain  macroscopicaUy 
unstained. 

6.  The  staining  of  the  necrotic  areas  of  tumors  is  not  due  solely  to  the  death  of  the 
cells,  inasmuch  as  areas  of  pulmonary  caseation  in  the  same  rats  do  not  present  any 
discoloration. 

6.  The  localization  of  colloidal  dyes  in  necrotic  tiBsues  is  not  a  simple  physical 
phenomenon,  subject  to  the  laws  of  diffusion  of  fluids  into  nonliving-colloidal  material. 
The  diffusibility  of  the  dyes  through  membranes,  as  also  the  electrical  charge,  the 
chemical  reaction,  and  the  chemical  composition  of  both  colloids  influence  the  result. 

7.  A  peculiar  alteration  in  the  color  of  dyes  of  the  benzidine  group  occius  in  necrotic 
areas.    This  has  been  described  as  metachromasia. 

8.  A  series  of  new  synthetic  compounds  analogous  to  congo  red  were  injected  into 
tumor-bearing  rats.    No  definite  therapeutic  effect  could  be  determined. 

BIBLIOGRAPHY. 

(1)  Evans  and  Schulemann:  Science,  1914,  xxxix,  443. 

(2)  Fischel:  Ehrlich's  Encyclopftdie  Mikroekopischen  Technik,  Urban  and  Schwar- 
zenbeig,  Berlin,  1903,  i,  349. 

(3)  Goldmann:  Beitr.^.  Klin.  Chir.,  1908,  Ixiv,  192. 

(4)  Gross:  Beitr.  z.  path.  Anat.,  etc.,  1911,  li,  528. 

(5)  Eeysser:  Ztschr.  f.  Chemotherap.,  1914,  Orig.,  ii,  188. 

(6)  Kite:  Biol.  Bulletin,  1913,  xxv,  1. 

(7)  MacCurdy  and  Evans:  Berl.  Klin.  Wchnschr.,  1912,  xlix,  1695. 

(8)  Studies  from  the  Sprague  Memorial  Institute,  Chicago,  1914,  vol.  ii. 

(9)  Teague  and  Buxton:  Ztschr.  f.  physikal.  Chem.,  1907,  Ix,  464. 

(10)  Wassermaim,  Keysser,  and  Wassermann:  Deutsch.  med.  Wchnschr.,  1911, 
xxxvii,  2389;  Berl.  klin.  Wchnschr.,  1912,  xlix,  4;  Ztschr.  f.  Chemotherap.,  1914, 
Orig.,  ii,  110. 

(11)  Weil:  Jour.  Am.  Med.  Assn.,  1915,  xUv,  1283. 

(12)  Wells,  de  Witt  and  Corper:  Ztschr.  f.  Chemotherap.,  1914,  Orig.,  ii,  110. 

(13)  De  Witt:  Jour.  Infect.  Dis.,  1914,  xiv,  498. 


THE  APPUCATION  OF  CHEMICAL  METHODS  TO  THE  STUDY  OF  CANCER. 

By  CASIMIR  FUNK. 

The  aim  of  the  author  in  presenting  this  paper  is  to  indicate  the  chief  lines  of  bio- 
chemical research  for  the  study  of  cancer  and  to  discuss  the  results  obtained.  This 
branch  of  chemistry  dates  only  10  or  15  years  back  and  the  results  so  far  obtained  are 
only  the  first  attempts  to  throw  light  on  the  etiology  of  tumors  from  chemical  point 
of  view.  The  reason  why  so  few  results  were  obtained  can  be  very  likely  explained 
by  the  fact  that  so  long  as  Cohnheim's  theory  was  accepted  for  the  explanation  of  the 
tumor  etiology,  there  has  been  very  little  scope  for  the  application  of  chemistry  to 
this  branch  of  medicine.  This  theory  explained  the  origin  of  tumors  by  the  pro- 
existence  in  the  adults  of  embryonic  cells  which  had  the  power  to  resume  unlimited 


PUBLIC   HEALTH  AND  MEDICINE.  889 

growth  as  the  result  of  injury  or  irritation.  At  the  present  time  this  and  other  theories 
based  more  or  less  on  the  litalistic  conception  of  cell  energy  have  found  a  serious 
rival  in  the  parasitic  theory  and  recently  in  the  chemical  theory  of  cancer.  As  the 
hjrpothetical  parasite,  however,  must  stimulate  cells  by  chemical  means,  as  a  simple 
presence  of  a  parasite  could  not  explain  the  sudden  multiplication  of  cells,  both 
heories  need  for  their  final  deductions  of  serious  chemical  studies. 

THE  DETERMINATION   OF  VARIOUS  SUBSTANCES  IN  THE  TUMORS. 

The  analyses  were  carried  out  usiially  in  this  way  that  the  amount  of  the  different 
tiunor  constituents  was  compared  with  this  of  the  tissue  where  the  tumor  originated . 
Here  the  question  arises  whether  it  is  correct  to  compare,  for  instance,  a  sarcoma  of 
the  breast  with  the  tissues  of  the  normal  breast,  which  no  doubt  must  be  chemically 
different  from  another,  and  this  diminishes  the  ultimate  value  of  such  determinations. 
More  promising  would  be  to  hunt  for  substances  which  are  only  present  in  tumors 
and  not  in  normal  tissues.  As  these  investigations  are  the  only  ones  which  give  us 
an  idea  on  the  nature  of  chemical  processes  going  on  in  tumor  cells,  their  results  may 
be  shortly  recorded. 

THE  INORGANIC  CONSTITUBNTS. 

Beebe  studied  the  relationship  between  sodium  and  x>otassium  to  calcium,  which 
he  found  larger  in  quickly  growing  tumors;  in  young  tumors  only  potassium  was  found 
and  no  calcium;  this  work  was  confirmed  by  Clowes  and  Frisbie.  Medigreceanu 
investigated  the  quantity  of  manganese  in  experimental  tumors. 

THE  ORGANIC  CONSTTTUENTP. 

Proteins. — Petrv  determined  the  amount  of  nucleo-albumins  in  tumors  and  he  found 
in  a  breast  carcinoma  this  latter  protein  making  50  per  cent  of  the  total  protein,  whereas 
in  the  normal  breast  it  is  only  30  per  cent.  Beebe  found  a  nucleohistone  in  metastases 
of  a  carcinoma  of  the  breapt,  but  none  in  the  primary  tumor,  which  indicates  a  chem- 
ical difference  between  these  two  tissues.  Wolff  and  Blumenthal  have  recorded  an 
increase  of  albumen  in  tumors  at  the  expense  of  globulin.  Wolff  has  isolated  from 
ascites  fluid  of  a  cancer  patient  a  protein  giving  on  hydrolysis  35  per  cent  of  glu- 
tamic acid. 

Aminoadds. — Bergell  and  DSrpinghaus  have  hydrolysed  tiunor  proteins  and  have 
found  an  increase  of  glutamic  acid,  alanine,  phenylalanine,  aspartic  acid,  but  espe- 
pecially  of  diamonadds,  this  latter  fact  being  recently  confirmed  by  Kocher.  On 
the  contrary,  Neuberg  did  not  find  any  differences  between  the  metastases  of  a  carci- 
noma of  the  stomach  as  compared  with  the  somatic  tissue.  Abderhalden  and  Medi- 
greceanu have  analyzed  a  carcinoma  of  a  cow's  liver,  a  rat  sarcoma,  and  a  mouse 
carcinoma  on  their  content  of  tyrosine,  glutamic  acid,  and  glycine,  and  have  obtained 
nearly  identical  results.  Fasal  has  determined  tryptophane  in  several  ttunors  and 
Eppinger  the  same  aminoacid  in  a  melanosarcoma. 

OTHER  CONSTTTUENTS. 

Beebe  and  Schaffer  have  found  an  increased  amoimt  of  pentose  in  a  breast  carcinoma. 
Wolter  found  the  phosphatide  content  of  the  liver  tumors  diminished  and  the  protein 
phosphorus  increased. 

No  attention  so  far  was  paid  to  protein-free  filtrates  from  the  tumor  extracts — 
a  problem,  as  we  will  see  later,  of  particular  interest.  This  research  is  now  proceeding 
in  the  laboratory  of  the  author,  the  spindle  cell  and  the  osteo-chondro-sarcoma  of  the 
fowl  being  compared  with  the  normal  muscle  of  the  same  animal. 

FERMENTS  IN  CANCER. 

This  study  was  initiated  by  Blumenthal  and  Wolff  and  continued  by  Bergell  and 
D5rpinghaus  and  also  by  Neuberg,  these  authors  have  found  that  the  timaors  are  more 


890       PBOOBEDINQS  SECOND  PAN  AMEBIOAN  SCIENTIFIO  G0NGBE88. 

resistant  to  pepsin  than  nonnal  tissues.  This  resistance  is  destroyed  by  heat  and  is 
not  due  to  antifermenta.  An  increased  autolysis  in  tumors  was  first  described  by 
Petry;  the  tumor  extracts  were  not  only  found  to  break  down  proteins,  but  also 
albumoses,  into  simple  aminoacids.  Following  Blumenthal  and  Wolff  the  addition 
of  tmnor  extracts  is  able  to  activate  also  the  autolysis  of  other  tissues.  Abderhalden 
and  his  collaborators  (Medigreceanu  and  Koelker)  have  investigated  the  behavior  of 
tumor  extracts  toward  certain  polypeptides  and  peptones  by  means  of  the  optical 
method.  In  summarizing  the  results  of  these  extensive  studies  we  may  state  that  no 
marked  difference  so  far  was  observed  between  normal  tissues  and  tumors  as  regards 
their  action  on  polypeptides,  but  a  difference  was  noticed  by  using  silk  peptone. 
Serum  of  dogs  with  Sticker's  tumor  showed  the  presence  of  peptolytic  ferment  in 
difference  to  normal  dog  serum.  Abderhalden  and  Pincussohn  by  using  d-Alanyl- 
glycyl-glycine  made  the  observation  that  normal  tissue  splits  off  alanine  first  from 
this  tripeptide  whereas  the  tumor  extracts  separate  glycine  first.  These  studies  were 
also  applied  for  the  diagnosis  of  tiunors. 

SERUM  DIAONOBI8  OF  TUMORS. 

The  most  important  methods  used  are  the  dialysis  and  optical  methods  of  Abder^ 
halden,  the  reaction  of  Freund-Kaminer,  the  meiostagmin  reaction  of  AscoU,  and  the 
complement  deviation  method  of  v.  Dungern.  The  reaction  of  Abderhalden  is  based 
on  the  alleged  property  of  the  organism  to  destroy  substances  foreign  to  them  which 
appear  in  the  blood.  Assuming  for  the  present  that  the  theoretical  basis  of  theee 
studies  is  correct,  which  is  not  certain,  the  results  obtained  by  most  of  the  workers, 
including  the  author,  were  not  satisfactory.  By  using  the  micro  Kjeldahl  or  the  micro 
van  Slyke  method  no  increase  of  amino-nitrogen  was  obtained  by  action  of  the  tumor 
serum  on  tumor  substrates;  the  same  negative  results  were  obtained  with  the  optical 
method:  The  reaction  of  Freund-Kaminer  is  based  on  the  assumption  that  nonnal 
serum  is  able  to  destroy  cancer  cells — a  property  lacking  in  tumor  serum.  The 
meiostagmin  reaction  observes  the  diminution  of  viscosity  of  tumor  sera  under  the 
influence  of  certain  fatty  acids.  This  method  was  extensively  tried  by  the  author, 
and  by  using  cod  liver  oil  instead  of  fatty  acids  slightly  better  but  still  unsatisfactory 
results  were  obtained.  As  the  v.  Dungern 's  method  also  met  with  much  criticism, 
we  can  say  that  at  present  we  do  not  possess  a  single  method  for  a  successful  diagnosis 
of  tumors.  It  seems  that  the  most  promising  way  would  be  an  intimate  knowledge 
of  the  chemical  constituents  of  normal  and  tumor  sera.  By  analyzing  the  sera  of 
chicken  with  sarcoma,  I  was  able  to  demonstrate  a  very  marked  diminution  of  nitrogen 
in  the  serum,  with  a  tendency  of  this  difference  increasing  with  the  time  elapsed 
since  inoculation.  It  is  therefore  probable  that  the  diagnosiB  of  tumors  will  shift 
from  unknown  factors  to  a  determination  of  chemical  constituents  easily  recognizable 
and  easily  tested. 

CH  EM  OTHER  APBUTICB  OP  CANCER. 

The  infectious  nature  of  the  tumors  being  imcertain,  the  chemotherapeutical  treat- 
ment of  cancer  does  not  appear  to  be  promising.  Positive  results  so  far  obtained  with 
colloidal  metals,  selenium  and  tellurium  compounds,  and  arsenic  were  all  obtained 
with  rats  and  mice  and  failed  when  applied  to  man.  The  cause  of  this  feilure  is  that 
theee  tumors,  which  show  very  often  spontaneous  absorption,  are  not  well  adapted 
for  these  studies.  Chicken  tumors  seem  to  be  more  suitable  for  these  experiments; 
so,  for  instance,  a  number  of  arsenic  compounds  were  tried  by  the  author  on  chicken 
sarcoma,  with  no  visible  effect. 

INFLUENCE  OF  DIET  ON  THE  GROWTH  OF  TUMORS. 

We  are  able  to  influence  the  growth  of  tumors  by  using  a  diet  either  insufiicient  in 
quantity  or  in  quality.  Such  experiments  were  performed  by  Cramer  and  Pringle 
and  Rous.    Sweet,  Corson-White  and  Saxon,  Hopkins,  and  the  author  have  used  for 


PUBLIC  HEALTH  AND  MEDIOIKB.  391 

this  purpose  a  diet  lacking  in  vitamines,  and  have  observed  a  very  marked  inhibition 
of  tumor  growth.  Ab  apparently  the  affinity  of  the  tumor  cells  to  the  substance  neces- 
sary for  growth  is  greater  than  the  affinity  of  the  somatic  cells,  no  complete  inhibition 
of  tumor  growth  could  be  obtained  by  this  method.  Similar  experiments  were  per- 
formed by  Beebe  and  van  Alstyne  on  the  influence  of  the  addition  of  lactose  to  a 
casein  and  lard  diet.  Nothing  could  better  demonstrate  the  influence  of  diet  on  tumors 
than  the  experiments  of  the  author  on  the  successful  transplantation  of  foreign  tumors 
by  feeding  the  animals  on  the  tumor  used  for  inoculation. 

GROWTH  OF  TUMORS  AND  THB  BODY. 

The  results  of  Osborne  and  Mendel,  Hopkins  and  McCollom,  and  Davis  have  dem- 
onstrated the  fact  that  young  animals  require  for  their  growth  process  a  special  sub- 
stance, which  in  the  light  of  the  results  of  Gasimir  Funk  and  Macallum,  seems  to  belong 
to  the  class  of  vitamines.  For  these  experiments  yeast  has  proved  to  be  an  excellent 
starting  material,  and  a  chemical  fractionation  will  show  whether  the  growth  of  the 
body  and  of  the  tumors  requires  the  same  or  different  snhfitances. 

SnOLOOT  OF  TUMORS. 

The  discovery  by  Rous  of  tumors  in  chicken,  which  are  transplantable  by  means 
of  cell-free  filtrates,  opens  a  new  possibility,  namely,  that  they  are  propagated  by  an 
unstable  chemical  substance.  The  causative  agent  is  so  hig^y  unstable  that  heating 
over  50^,  and  even  drying  in  vacuum,  will  destroy  it.  As  a  preliminary  experiment 
toward  the  elucidation  of  the  etiology  of  these  interesting  tumors,  it  was  tried  to 
transplant  the  spindle  cell  sarcoma  by  means  of  an  alcoholic  extract  of  this  tumor, 
and  on  several  occasions  a  positive  result  was  obtained.  In  fact,  it  is  quite  conceiv- 
able that  tumors  are  produced  by  a  chemical  substance  in  a  similar  way  like  the  coi- 
entation  of  the  tissues  in  an  embryo  and  the  growth  of  animals  are  directed  in  a  chem- 
ical way.  Cancer  is  possibly  a  metabolism  disease,  in  which  the  metabolism  of  the 
growth  promoting  substance  is  affected.  The  age  at  which  the  tumors  usually  appear 
supports  this  view. 

All  the  problems  recorded  in  this  paper  render  the  collaboration  of  the  physiological 
chemist  toward  the  elucidation  of  the  etiology  of  cancer  hi^ly  desirable.  The  patho- 
logical research  in  cancer,  so  successfully  started  by  Jensen,  Ehrlich,  Bashford,  and 
others,  gave  us  an  enormous  amount  of  valuable  data,  but  it  appears  doubtful  whether 
the  pathological  line  alone  will  solve  the  cancer  problem.  The  necessity  of  a  new 
chemical  technique  and  extensive  facilities  calls  for  establishment  of  special  research 
places  for  the  chemical  study  of  cancer  which  would  supplement  the  studies  of  path- 
ologists in  this  direction. 

The  Chairman.  We  will  now  proceed  wil  h  the  discussion  of  the 
general  subject  of  the  evening. 

Dr.  WoGLOM.  I  think  that  Miss  Slye  is  to  be  heartily  congratu- 
lated on  having  so  fully  confirmed  the  findings  of  Tyzzer  in  our 
country  and  of  Murray  in  London.  Murray  has  been  publishing 
work  along  this  line  for  the  last  10  years.  His  last  paper,  I  think, 
came  out  two  or  three  years  ago.  Murray  finds  that  in  lines  of  can- 
cerous ancestry  there  is  an  incidence  of  something  like  15  per  cent  of 
mammary  cancers  in  mice  that  live  to  be  more  than  a  year  and  a 
half  old.  In  the  control  mice,  on  the  contrary,  there  is  about  8  per 
cent  of  mammary  cancer.  The  control  mice  are  those  that  lost 
neither  a  grandmother  nor  a  mother  from  mammary  cancer.  Now, 
Murray,  being  a  cautious  man,  submitted  his  figures  to  an  expert 


892        PEOCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIO  OONGRESS. 

Statistician  who  found  that  the  chances  were  three  to  one  in  favor  of 
Murray  8  results  being  correct.  It  seems  to  me  that  Miss  Slye  has 
here  invaluable  material  and  that  these  results  ought  to  be  analyzed 
by  a  statistician  in  exactly  the  same  way  that  Miuray's  work  was 
analyzed,  in  order  that  we  may  have  some  basis  of  comparison  be- 
tween the  two  stocks  of  mice.  In  the  meantime  I  think  some  pro- 
test should  be  made  against  including  the  lung  tumors  of  mice  with 
tumors  which  are  undoubtedly  cancerous.  I  do  not  think  any  of  us 
feel  sure  that  these  lung  tumors  are  really  carcinomata.  Perhaps 
Dr.  Tyzzer  has  seen  more  of  them  than  any  of  us  and  he  possibly  will 
express  an  opinion  on  this.  I  do  not  think  people  are  so  sure  about 
it.  Then,  in  the  second  place,  I  do  not  think  it  is  wise  to  count  a 
mouse  as  cancerous  that  dies  before  it  develops  a  cancer;  to  count 
that  •mouse  as  cancerous  because  his  descendants  developed  cancer. 
I  do  not  speak  as  a  biologist  nor  as  a  statistician.  I  speak  as  a 
pathologist.  I  think  only  a  board  of  statisticians,  biologists,  and 
pathologists  could  decide  on  the  justice  of  such  a  course. 

Dr.  Tyzzee.  I  would  like  to  make  a  few  comments  on  the  in- 
heritance of  spontaneous  tumors.  There  are  certain  well-known 
Mendelian  factors  which  are  concerned  in  the  production  of  tumors. 
I  refer  to  the  inheritance  of  sex.  Sex  is  a  perfectly  well-known  in- 
herited factor.  The  sex  factor  may  act  in  two  ways.  The  two  sex 
factors  may  act  in  the  following  manner:  In  a  restrictive  manner 
with  respect  to  certain  tumors — that  is,  they  are  sex  limited.  For 
example,  the  ovarian  tumor  is  limited  to  the  female;  the  testicular 
tumor,  to  the  male.  Then  there  is  the  liberative  action  of  these  factors. 
We  have  in  mice,  probably  more  than  in  human  beings,  the  mam- 
mary txunors,  restricted  to  the  female;  it  is  rather  rare  to  get  a  mam- 
mary tumor  in  the  male  mouse.  There  is  something  in  the  develop- 
ment of  the  female  sexual  organs  which  in  a  way  is  liberative,  so  that 
in  the  development  of  the  mammary  gland  we  get  more  tiunors  of  the 
mammary  gland  in  the  female.  I  do  not  believe  that  the  develop- 
ment of  tumors  can  be  shown  to  be  based  on  any  single  factor.  There 
must  be  multiple  factors  present  in  the  development  of  spontaneous 
tumors,  just  as  in  the  development  of  the  inheritance  of  susceptibility. 
The  pathologist  will  say  that  environment  is  the  essential  factor,  but 
I  would  like  to  point  out  here  that  environment  of  the  cells  is  to  a 
large  extent  inherited.  The  environment  of  the  female  mammary 
gland  is  to  a  large  extent  subjected  to  internal  secretions  which  are 
not  found  in  the  male. 

The  Chairman.  Dr.  Loeb,  will  you  be  kind  enough  to  close  the 
discussion  ? 

Dr.  Leo  Loeb.  Dr.  Woglom's  remarks  in  regard  to  Dr.  Slye's 
experiments  concern  my  own  experience  just  as  well  as  that  of 
Dr.  Slye,  so  I  might  perhaps  answer  Dr.  Woglom.    Dr.  Murray's 


PUBUO  HEALTH  AKD  MEDICINE.  393 

experience,  I  think,  does  not  hold  good  on  the  strict  basis  of  the 
ordinary  scientific  work  in  heredity.  Murray  found  differences 
between  8  and  18  per  cent,  if  I  remember  correctly,  for  he  had  two 
strains  of  mice.  He  selected  mice  whose  ancestry  had  tumors, 
cancers,  and  those  whose  direct  ancestry  did  not  have  cancer;  but 
those  whose  direct  ancestry  did  not  have  cancer  had  cancer  some- 
what further  back.  Now,  if  we  take  a  strain  very  poor  in  tumors 
and  select  as  ancestors  a  mother  who  had  accidental  tumors,  and  take 
another  strain  very  rich  in  tumors  and  select  as  ancestor  a  mother 
who  accidentally  did  not  have  tumors,  then  we  should,  according 
to  Murray's  procedure  and  method,  find,  if  we  persisted,  that  mice 
from  a  strain  rich  in  tumors  had  less  tumors  thnn  mir«  from  a 
strain  poor  in  tumors.  If  the  method  gives  correct  results  these 
results  can  only  be  accidental — at  best,  probably  three  to  one;  but 
that  is  not  an  actual  scientific  result. 

On  the  other  hand,  if  we  proceed  as  Dr.  Slye  and  myself  have 
done  for  quite  a  lai^e  number  of  years,  and  breed  a  lai^e  number 
of  generations,  have  thousands  of  mice  carefully  recorded,  and  find 
that  in  one  strain  there  is  always  present  70  to  80  per  cent  of  tumors 
in  various  generations,  and  that  in  another  strain,  maybe  abso- 
lutely imder  the  same  conditions,  only  2  to  3  per  cent  show  tumors, 
it  is  absolutely  impossible  that  any  objection  can  be  made  to  con- 
cluding that  there  is  hereditary  condition  since  the  environmental 
condition  is  absolutely  the  same.  On  the  other  hand,  I  think  Mur- 
ray's experiments  are  very  open  to  criticism. 

Tyzzer  is  the  first  one  who  really  tried  to  carry  out  experiments 
in  heredity  on  a  large  basis,  but  he  used  the  same  method  which 
Murray  used,  and  therefore  his  experiments  could  not  give  definite 
results.  I  want  to  say  a  few  words  concerning  Dr.  Tyzzer's  ex- 
periments in  regard  to  serum  in  cancer.  I  find  these  exceedingly 
interesting.  These  experiments  which  Dr.  Tyzzer  reported  to-night 
seem  to  prove  that  the  combination  of  serum  with  the  tumor  cells 
actually  causes  a  metabolic  product  to  be  produced  by  the  cancer 
cells  which  causes  a  contraction  of  the  lymphocytes.  There  are  the 
same  conditions  which  are  foxmd  in  normal  tissues;  and  on  the  basis 
of  a  lai*ge  number  of  experiments  I  came  to  the  same  conclusion  with 
respect  to  normal  tissues  and  suggested  that  in  the  case  of  tumor 
tissues  the  same  thing  would  hold  true.  Dr.  Tyzzer's  experiments 
provided  experimental  proof  for  these  suggestions. 

Dr.  Hoffman.  At  a  meeting  of  the  statistical  committee  of  th» 
American  Society  for  the  Control  of  Cancer  and  of  the  statistical 
revising  board  of  that  committee  a  number  of  matters  were  discussed 
more  or  less  pertinent  to  the  discussion  of  this  evening.  As  Dr. 
Woglom  has  pointed  out,  a  considerable  amount  of  statistical  aid 
might  possibly  be  rendered  to  Miss  Maud  Slye  in  her  very  admirabel 


894       PBOOBEDINGS  8E00ND  PAN  AMEBIOAN  SCIENTIFIC  C0NGBES8. 

work,  and  I  desire  to  assure  ber  on  behalf  of  the  committee  that 
they  are  most  willing  to  aid  her  in  any  way  to  make  the  interpreta- 
tion of  her  data  in  so  far  as  they  are  purely  statistical.  No  one  who 
has  had  much  experience  with  statistical  work  fails  to  realize  the 
enormous  number  of  pitfalls,  the  ever-present  liability  to  error  arising 
not  only  from  the  inadequacy  or  the  limitation  of  the  facts,  but 
partly  because  of  bias,  partly  because  of  the  inadequacy  of  our  judg- 
ment, and  largely  because  of  faulty  methods  of  statistical  analysis. 
The  resolution  which  the  committee  adopted  and  which  they  would 
like  to  have  this  section  adopt  in  behalf  of  Section  VIU  of  the 
Second  Pan  American  Scientific  Congress,  reads  as  follows: 

Whereas  cancer  is  one  of  the  leading  causes  of  death  in  adult  life  throughout  the 
Western  Hemisphere;  and 

Whereas  the  mortality  from  cancer  in  the  principal  countries  and  cities  <^  the 
Pan  American  Union  is  actually  and  relatively  on  the  increase;  and 

Whereas  the  statistical  study  of  cancer  is  of  great  practical  importance  to  the  cause 
of  cancer  research  in  all  its  scientific  aspects;  be  it 

Resolved  by  the  Second  Pan  American  SeientifU  CongresSy  That  they  most  respect- 
fully and  iu:gently  suggest  to  all  the  Governments  of  the  Pan  American  Union  that 
they  adopt  without  needless  delay  uniform  methods  of  cancer  classification  and 
statistical  tabulation  with  a  due  regard  to  the  age,  sex,. and  race  of  the  deceased,  of 
the  organs  and  parts  of  the  body  affected  by  malignant  disease,  in  conformity  to 
the  principles  of  the  Bertillon  international  classification  of  the  causes  of  death  as 
employed  and  standardized  by  the  Division  of  Vital  Statistics  of  the  United  States 
Census. 

I  move  the  adoption  of  the  resolution. 

The  Chairman.  You  have  heard  the  resolution.    What  is  the  pleas- 
ure of  the  section  in  regard  to  the  disposition  of  this  resolution  ? 
Dr.  Whitmore.  I  move  it  take  the  usual  coTu^e. 

Seconded  and  approved. 

The  Chairman.  The  following  papers  will  be  read  by  title: 
Linfocitosis    sanguinea    en    los    sifiUticos,    by    Ctodido    PatifLo 
Mayer  and  Augusto  Celestino  Gourdy. 
Granuloma  venSreo,  by  Federico  Susviela  Guarch. 


UNFOcrrosis  sanguInea  en  los  sifilIticos  (SIGNO  dugnOstico 

Y  PBONOSTICO). 
Pot  CANDIDO  PATISO  MAYER  Y  AUGUSTO  CELESTINO  GOURDY, 

Buenoi  Aireiy  Argentina. 

m&tOBlL, 

La  sffilis  es,  sin  duda,  una  de  las  enfennedades  infecciosas  m^  espaicidas  y  la  que 
cuenta  por  consigoiente  con  uno  de  los  porcentajes  mis  subidos  de  enlennos;  nada 
extrafio  tiene,  pues,  que  haya  mereddo  la  atenci6n  de  muchos  observadores  de  varias 
generaciones;  pero  su  conocimiento  mis  profundo  y  sus  mejores  adelantos^  no  'se 
alcanzaron  tanto  en  los  laigos  afios  transcurridos,  como  en  los  pocos  que  pasan  deede 
el  memento  en  que  se  descubre  el  espiroquete  pilido  por  Schaudinn  y  Hoffinan 
0111905. 


PUBLIC   ETEALTH  AND  MEDICINE.  395 

Justo  es  que  hasta  entonces,  una  enfennedad  tan  difundida,  fuera  objeto  de  consi- 
deraciones  mis  que  todo  de  orden  esencialmente  clfnico  y  que  a  partdr  de  eee  momento 
recibiera  una  atenci6n  mis  fundamental  y  cientlfica  por  la  contribucidn  del  labora- 
torio. 

£1  periodo  experimental  iniciado,  algo  antes,  por  NicoUe  y  Hamonic  y  continuado 
JMV  Metciinikoff,  Roux,  Bertarelli,  etc.,  sefiala  una  nueva  era  caracterizada  pOT  dos 
6rdenes  de  hechos:  el  diagn68tico  y  el  tratamiento  del  lues.  Este  tiltimo  recibe  un 
gran  impulso  con  los  compuestos  aisenicales  de  Ehrlich  que  permiten  intentar  la 
esterilizacidn  de  la  sifilis  mediante  el  tratamiento  abortivo. 

DiAGNdsnco. 

El  diagn<36tico,  merece  tambi^n  una  especial  atenci6n,  y  es  asi  como  se  descubren 
una  serie  de  procedimientos  biol6gico6  que  tienden  a  ese  objeto: 
(a)  Comprobaci6n  de  la  existencia  del  treponema  en  el  chancre. 
(6)  Intradermo  y  cuti-reacci6n  con  la  sifilina  de  Nicolas,  Fabre,  Gautier  y  Charlet. 

(c)  La  8uero-reacci6n  de  Wassermann  (principalmente  de  la  sangre  y  del  llquido 
c^falo-raquideo) . 

(d)  La  luetina-reacci6n  de  Noguchi. 

(«)  El  estudio  del  Ifquido  c6falo-raquideo:  examen  citol6gico,  quimico  y  biol6gico. 
(/)  La  reacci6n  de  Nonne  y  Apelt. 
(g)  La  reacci6n  de  Landau. 

(h)  La  coagulo-reacci6n  de  L.  Hirschfeld  y  R.  Klinger. 

Estos  son  los  procedimientos  que  hasta  nuestro  estudio  han  side  sefialados  para 
poder  diagnosticar  la  sifilis. 

NUEVO   SIGNO. 

Con  nuestro  trabajo  hemes  querido  agregar  un  nuevo  signo:  el  de  la  linfocitosis 
sangulnea,  que,  descuidado  por  los  observadoree,  ha  merecido  de  nuestra  parte  un 
estudio  especial,  dindole  todo  el  valor  que  debe  tener  no  s61o  en  el  diagn6stico,  sine 
tambi^n  en  el  prondstico  del  lues. 

Ya  el  Dr.  Gourdy  en  su  tesis  sobre  la  suero-reacci6n  de  Wassermann  tuvo  oportu- 
nidad  de  referirse  a  la  linfocitosis  de  la  sangre  de  los  lu^ticos,  y  ahora  nosotros  al 
estudiar  detenidamente  el  punto,  lo  hacemos  con  im  criterio  mis  amplio,  Uegando 
tambi^n  a  conclusiones  nuevas  e  interesantes. 

LINFOCITOSIS   SANGUfNEA. 

Entendemos  por  Linfocitosis  sangulnea,  la  proporci6n  de  linfocitos,  por  cientOi 
superior  i  la  cite  normal.  E^ta  linfocitosis  normal  segtin  los  diversos  autores  oscila ' 
entre  20  por  ciento  y  25  por'ciento  y  hasta  28  por  ciento  para  JoUy,  excepci6n  hecha 
del  nifLo  de  primera  infancia,  en  el  cual  la  proporci6n  normal  es  mucho  mayor,  pu- 
diendo  llegar  hasta  70  por  ciento  y  que,  como  se  comprende,  no  ha  side  considerado 
en  este  trabajo. 

Ahora  bien;  esta  linfocitosis  normal  se  halla  aumentada  en  los  sifilfticos  y  es  esa 
linfocitosis  patol(%ica  sifilltica,  la  que  nosotros  pretendemos  hacer  valer  en  la  sffilis 
como  signo  de  diagn6stico  y  adn  de  pron6stico. 

8IONO  patoonom<5nioo. 

S^rla  quererse  encerrar  dentro  de  llmites  muy  estrechos  y  alejarse  asf  del  criterio 
clfnico,  el  pretender  pensar  que  la  linfocitosis  es  dnicamente  patrimonio  del  lues, 
como  sorla  absurdo  sostener  que  por  el  hecho  de  pertenecer  a  un  grupo  de  enferme- 
dades  no  puede  tener  valor  diagn<5stico  en  la  sifilis. 

El  signo  patognomdnico  no  pertenece  ni  a  la  cUnica  ni  al  laboratorio;  hasta  un  mismo 
gennen  puede  producir  por  su  localizaci6n  diferente,  por  su  virulencia,  pOT  las  aso- 
ciaciones,   procesos  anat6micos  diversos.   Tambi^n  quisi^ramos  recordar  en  este 


396       PROCEEDINGS  SECOND  PAN  AMEBIC  AN   SCIENTIFIC  C0NGBE8S. 

momento  que  la  8uero-reacci6n  de  Waasennann,  de  valor  inestimable  en  el  diag- 
n<38tico,  pertenece  a  un  cierto  grupo  de  enfermedades,  como  la  frambueaia,  fiebre 
recurrente,  lepra,  satumismo,  peoriaaiB,  lupus  eritematoso,  algunos  palddicos,  eacar- 
latinosos,  y  estados  caqu^ticos;  a  veces  en  periodos  po6t-clorof6nnico6,  peste,  beri- 
beri, en  los  tripanosomiMcos  y  colesterin^micos;  algunos  ban  pretendido  hallarle  en 
eujetos  normales.  Sin  embaigo,  ^quien  se  atreverfa  a  restarle  su  inmenao  valor  en  el 
4iagn6stico  de  la  sifilis? 

LA  UNFOCrrOSIS  SANOUlNEA   EN  OTRAS  ENFERMBDADE8. 

Estos  comentarios  nos  los  sugieren  la  presencia  de  la  linfocitosis  en  otros  procesoa  no 
aifiliticos:  asf  per  ejemplo,  se  le  encuentra  en  un  porcentaje  subido  en  el  paludiamo, 
<*omo  el  Dr.  Patifio  Mayer,  entre  otros,  lo  ba  becbo  notar,  estableciendo  la  linfocitoaifl 
palMica  transitoria  y  la  permanente;  se  la  halla  tambi^n  en  estados  escrofuloaoa  c<a 
bipertroffa  de  loa  ganglios  y  de  las  amigdalas;  en  la  persistencia  del  time  y  en  el  bocio 
exoftdlmico;  en  la  diabetes;  en  la  obesidad;  en  el  mixedema  y  estados  bipotiroideoa;  en 
la  acromegalia;  en  algunos  neunSpatas;  en  la  tuberculosis;  en  algunos  procesos  cr6nico8 
y  enfermedades  de  la  sangre;  en  la  tripanosomiasis  y  leishmaniosis. 

Como  acabamos  de  ver,  la  linfocitosis  sangufnea  se  halla  en  un  cierto  grupo  de 

enfermedades,  pero  esto,  como  se  comprende,  no  le  quita  impcvtancia  en  el  diagn6etico 

del  lues;  f^il  aeri  establecer  el  distingo  por  los  caracteres  clfnicos  y  los  dates  hema- 

tol^cos  en  cada  case. 

sIfilis. 

Por  otra  parte  la  linfocitosis  sangufnea  del  sifilftico  es  generalmente  elevada,  pu- 
diendo  llegar  en  ocasiones  hasta  70  y  80  por  ciento.  Dentro  de  la  f6rmula  cit61ogica,  ae 
presenta  bien  caracterfstica,  la  linfocitosis  elevada,  acompafidndole  ima  cif ra  normal 
de  leucocitos  y  de  hematfes  (estos  pueden  estar  disminuidos  en  las  graves  infecciones). 
La  linfocitosis  sangufnea  tendrfa,  pues,  segtin  nuestra  manera  de  ver,  una  gran  impor- 
tancia  en  la  sffilis,  importancia  que  no  ba  llamado  la  atenci6n  hasta  el  presente  a  loa 
aifil6grafos,  ni  a  los  dedicados  al  estudio  de  la  hematologfa,  sin  embargo,  dada  nuestm 
larga  observaci6n,  de  varies  afios  a  esta  parte,  y  que  comprende  m^  de  500 '  obaerva- 
clones  de  distintos  periodos  del  lues,  nos  creemos  autorizados  para  darle  toda  la  impor- 
tancia que  merece  como  contribuci6n  a  su  diagndstico  y  a(in  a  su  pron6stico. 

INFECCIONES  ACCIDENTALES. 

Debemos,  no  obstante,  llamar  la  atenci6n  sobre  algunos  resultados  de  ex&menee  de 
aangre,  en  aparente  contradicci6n  con  la  f^mula  general  propia  del  sifilftico,  donde 
se  ve  una  leucodtoeis  con  predominio  de  los  polinucleares  neutr6filos;  se  trata  aquf, 
de  infeccionea  accidentalea,  concomitantea  y  que  enmascaran  asf  la  linfocitosis  del 
especffico,  que  vuelve  a  preeentarae  tan  pronto  deaaparecen  aqu^llas.  Las  observa- 
cionee  ntimeroa  13,  27,  28,  47,  y  494  que  citamoa  en  nueatro  trabajo,  aon  ejemplos  de  lo 
que  acabamos  de  decir. 

DiPOBTANOIA. 

Del  estudio  de  todas  las  observaciones  que  presentamos  se  deduce  que  la  linfocitoaia 
sangufnea  reviste  una  excepcional  importanda  como  signo  que  acompafia  al  eepe- 
cffico,  su  presencia  se  hace  evidente  deede  el  comienzo  de  la  infecci6n,  para  acompafiar 
al  lu^tico  en  su  segundo  y  tercer  perfodo.  La  existencia  constante  nos  ha  llevado 
al  convencimiento  de  que  au  determinaci6n  en  la  aangre,  debe  constituir  deade  aquf 
en  adelante  una  investigaci6n  que  se  impone  al  medico  en  su  examen  clfnico.  La 
linfocitosis  en  su  manifestaci6n  creciente,  habiendo  side  m^  o  menos  pronunciada 
antes  del  tratamiento,  Uega  a  un  Ifmite  m^ximo.  Cuando  el  enfermo  es  tratado  con- 
venientemente,  tiende  a  descender  hasta  llegar  a  una  cifra  casi  fija,  siempre  por  en- 

1  Son  solamente  500,  las  que  citamos  en  el  trabajo  original. 


PUBLIC   HEALTH  AND  MEDICINE.  397 

cima  de  la  cantddad  normal  Este  desceiiBO  puede hacerse  en  forma  gradual  y  m^  o 
menos  r&pido,  o  bien  experimentar  ciertas  osdlacionee  en  la  curva  deecendente,  hasta 
Uegar  en  su  disminuci6n  a  una  cilra  casi  invariable. 

VALOR. 

La  linfodtoeiB  tiene  mucho  valor,  en  ocasionee,  para  hacer  Boepechar  sifilis;  nos 
referimoB,  entire  otroe,  a  aquelloe  casoe  en  que  una  parturienta  da  a  luz  un  hijo  con 
«aero-reacci6n  de  Waaaermann  positiva,  en  tanto  que  ella  la  presenta  negativa.  En 
^stas  drcunstandas  hemos  podido  ver  que  la  linfodtoeiB  sangulnea  elevada,  por  arri- 
ba  de  la  normal  en  la  madre,  demoetraba  que  ella  era  una  especffica,  capaz,  por  lo  tanto, 
de  engendrar  un  heredo-eifilltico.  El  tratamiento  anti-lu^tlco  matemo  nos  ha  moe- 
trado  a  poeteriori  que  tenia  raz6n  de  ser  la  linfocitoeis  sangulnea  elevada,  desde  que 
era  capaz  de  reactivar  la  8uero-reacci6n  de  Wassermann  oculta. 

En  ocasionee,  la  linfocitoeis  se  presenta  en  una  forma  casi  aislada,  de  tal  modo  que 
fli  no  tuvitomos  otros  indicios  sobre  su  naturaleza  podrf a  pasar  como  un  hecho  banal 
o  por  lo  menos  sin  explicaci6n  satisfactoria.  Se  hallan  en  este  caso  las  observaciones 
496  y  498,  por  ejemplo. 

HBRBDO-SiFIUS.' 

Su  importanda  es  evidente,  en  la  contribud6n  que  puede  aportar  al  diagn<5stico  de 
la  heredo-sffilis  terdaria  tardfa,  hasta  hacer  desaparecer  dudas  en  algunos  casos  poco 
salvables  y  donde  ella  hard  soepechar  la  etiologla  de  las  alteraciones  elf nicas  observadas, 
espedalmente  en  aqueUos  en  quienes  los  antecedentes  hereditarioe  son  poco  ilustra- 
tivos  y  las  distroffas  no  muy  aparentes.  Desearlamos  recordar  aqul  un  trabajo  de 
Gaucher  en  el  cual,  para  llegar  al  diagn(5stico  de  la  heredo-sf fills  se  vale  en  unos  cases 
de  los  antecedentee  y  en  otros  de  las  taras  distr6ficas,  ayudado  una  que  otra  vez  por  la 
8uero-reacd6n  de  Wassermann  y  donde  en  todos  los  casos,  el  tratamiento  espedfico 
instituido  sirvi6  para  confirmar  la  herenda  sifilitica.  Las  dificultades  del  diagndstico, 
serian  mucho  menoree  si  se  hubiera  investigado  la  linfocitosis  sangulnea. 

En  aquellos  casoB  en  que  la  lesi6n  inicial  se  manifeeta  con  caracteres  poco  precisoB, 
pero  que  hacen  sospechar  el  lues  a  punto  de  justificar  un  tratamiento  abortive,  fedtando 
todos  los  signos  de  lainfecd6n,  la  linfodtosis  sangulnea,  por  su  precoddad  y  constancia, 
autoriza  la  prosecud6n  del  tratamiento  ante  la  poeibilidad  de  ima  8uero-reacd6n  de 
WasBermann  retardada  y  en  tal  sentido  es  digno  de  recordar  las  observadones  inte- 
reflantes  de  Grougerot,  que  dta  varies  enfermos  en  quienes  un  tratamiento  precoz  e 
intenflivo  hizo  retardar  la  suero-reacd6n  hasta  el  4^,  7^,  y  9^  mes. 

reactivaci<5n. 

Debemos  sefialar  como  un  hecho  interesante  en  el  estudio  de  la  linfodtosis  de  la 

sangre  de  los  sifillticos,  su  atunento  provocado  por  la  medicad<5n  especlfica,  lo  que  se 

hace  bien  evidente  cuando  la  propord6n  de  linfodtos  se  aproxima  a  la  cifra  normal, 

lo  que  denominamoB  (como  lo  hace  el  Dr.  Gourdy)  en  su  tesis  ''reactivaci6n  de  la 

linfodtoeis.''    Esto,  como  lo  hemos  podido  comprobar  ahora,  no  es  una  consecuencia 

del  medicamento,  pues  en  los  sujetos  sanos  y  aun  en  los  enfermos  no  especlficos,  no  se 

produce. 

PRON<5flrnco. 

Como  resultado  del  estudio  de  nuestras  observadones  hemes  adquirido  la  convic- 
d6n  de  que  la  linfodtosis  sangulnea  no  s61o  tiene  valor  diagn<5stico,  sine  que  a  la  vez 
lo  tiene  en  el  pron<5stico.  Opinamos  que  la  existencia  de  la  linfodtosis  sangulnea  es 
una  prueba  de  sffilis  no  curada;  el  hecho  de  que  no  existan  slntomas  cUnicos  nos  dir& 
tinicamente  sffilis  oculta  o  moderada  por  el  tratamiento,  pero  pocaa  voces  curada.  Se 
nospodripresentar,  sin  duda,  sifilfticoeque,  tratados  convenientemente,  no  presentan 

iDebemos  hao«r  presente  que  la  llnlxdtosis  sangufnea  en  la  heredo-sfflUs  s6\o  tiene  valor  dlagn^tlco  a 
partir  de  la  segimda  intencia. 


398       PBOGEEDINOS  SECOND  PAN  AMEBIOAN  8CIENTIFIG  GONGBESS. 

ya  manifeetaci6ii  cllnica  alguna,  durante  los  varioB  a&oe  en  que  pueden  tenerse  noticias 
de  tales  eoiennoe,  que  no  tienen  suero-reacciones  de  Wassermann  positivas,  pero 
tambi6n  no  hay  duda  de  que  tales  objeciones  no  dejan  de  estar  sujetas  a  crftica  y 
deede  luego:  ^No  es  verdad  que  un  sifilftico  que  se  hizo  tal  cierto  dia,  puede  pasar 
varies  afios,  diez  y  m&s,  ignorada  su  infecci6n,  ignorado  y  sin  tratamiento,  desde  la 
Ie8i6n  inicial  hasta  las  manifestaciones  de  tabes,  par&lisis  general  u  otras? 

RBINPECC16N. 

Para  los  que  sostienen  lo  contrario  y  consideran  curable  la  sifilis  es  argumento  im- 

portante  la  reinfecci6n.      Pero  hay  que  preguntarse  si  esas  pretendidas  reinfeccionee 

son  realmente  tales  o  lejos  de  serlo  son  simples  reavivaciones  de  la  enfermedad,  ador- 
mecida. 

No  es  nuestro  propdsito  entrar,  en  este  resumen,  a  considerar  los  detalles  que  ex- 
ponemoe  en  el  trabajo,  tan  solo  tendremos  en  cuenta  dos  drdenes  de  hechos,  unoe 
clfnicos  y  los  otros  experimentales.  Entre  los  primeros  debemos  recordar  los  tree 
interesantes  cases  presentados  d  la  "Soci^t6  Franyaise  de  Dermatologie ''  el  18  de 
Julio  de  1911  por  Bayet,  Deneaux  y  Dujardin,  en  los  cuales  habfa  aparecido  una 
segunda  sifilis  con  chancre,  adenopatia  y  roseola,  sin  que  hubiera  habido  nueva  con- 
taminaci6n. 

Por  lo  que  se  refiere  a  trabajos  experimentales,  citaremos  las  observaciones  de  varios 
autores  competentes:  Sandmann,  en  enfermos  que  hablan  side  intensamente  tratados 
con  mercurio  y  que  se  consideraban  clinicamente  curados,  abandonan  el  tratamiento 
y  despu^s  de  mes  y  medio,  y  atin  pasado  el  afio  no  habian  vuelto  a  aparecer  slntomaa 
algunos  de  especificidad ;  se  les  extirp6  porciones  de  tejidos  en  los  cuales  anteriormente 
habia  habido  localizaci6n  especifica  e  inyectdndoloe  a  ocho  monos,  ha  podido  ver 
el  desarrollo  de  la  sifilis. 

Hoffmann,  en  id^nticas  condiciones  de  experimentaci6n,  ha  llegado  a  las  mismas 
conclusiones.  Fischl,  en  virtud  de  bus  observaciones,  sostiene  que  las  nuevas 
manifestaciones  que  podrlan  considerarse  como  debidas  a  una  reinfecci6n  son  debidas 
a  multiplicaci6n  y  pululaci6n  de  los  focos  de  espiroquetes  que  quedan  en  los  tejidoe; 
ha  podido  demostrar  esto  por  bus  experiencias:  en  ellas  pone  a  contribuci6n  la  cura 
intensiva  combinsida  de  neosalvaredn  y  mercurio,  a  pesar  de  lo  cual  ha  podido  revelar 
la  existencia  de  espiroquetes  en  actividad  en  los  sitios  de  la  Ie8i6n  primera. 

TRATAMIENTO  ABORTIVO. 

En  nuestro  sentir,  pues,  el  tratamiento  abortive  no  implicarfa  la  esterilizaci6n  del 
organismo  a  pesar  de  la  excisi6n  precoz  del  chancro,  pues  no  librarfa  al  organismo  del 
proceso  de  infecci6n  general;  sabiendo  hoy  lo  que  significa  toda  infecci6n,  aunque 
demore  un  tiempo  m6s  o  menos  largo  en  aparecer  localizada,  ha  pasado  por  una  faz 
septic^mica.  La  sifilis,  como  todas  las  infecciones,  al  manifestarse  luego  en  sus  mani- 
festaciones secundarias  0  terciarias,  ha  side  previamente  una  septicemia;  tambi^n  el 
chancro,  clinicamente  expresidn  primera,  ha  dejado  transcurrir  antes  de  61,  im  tiempo 
necesario,  que,  dado  lo  que  dejamos  expuesto  en  el  concepto  general  de  la  patologfa  de 
las  infecciones,  serla  el  periodo  que  la  infecci6n  aprovecharia  para  generalizarse, 
mostrdndose  en  un  determinado  memento,  como  primera  aparici6n  de  enfermedad,  al 
cual  le  acompafla  la  linfangitis,  delatora  del  curso  que  aquella  ha  seguido. 

NO  CURABIUDAD. 

Los  autores  que  acabamos  de  sefialar,  al  presentar  experiencias  en  apoyo  de  la  no 
curabilidad  de  la  sifilis,  lo  han  logrado  merced  a  condiciones  especiales  que,  para  los 
que  piensan  de  otro  mode,  podrian  aparecer  como  excepciones;  pero  nosotros  llegamoe 
en  apoyo  de  aqu^Uos,  al  invocar  la  linfocitoeis  sangufnea,  que  al  manifestarse  deede 
el  memento  en  que  la  infecci6n  se  establece,  contintia  con  611a  y  no  abandona  al 
sujeto,  dejando  en  61,  el  estigma  indeleble  de  la  infecci6n  lu6tica  latente,  que  atenuada 


PUBUC  HEALTH  AND  MEDICINE.  399 

en  0a  virulenda  puede  estar  relegada  a  dertos  y  pequefioB  focoe  por  influencia  del 
tiatamiento,  esperando  el  momento  oportuno  para  exterioricane.  Eeta  maneia  de 
encarar  la  infecci6n  lu6tica  por  noeotros,  noe  Ueva  a  sustentar  atin  hoy,  la  manera  de 
pensar  del  viejo  maestro,  de  Foumier,  que  desconociendo  lae  reaccionee  biol^gicae, 
que  para  algunoe  serian  las  delatoras  de  la  infecci6n,  preconizaba  y  seguramente,  con 
verdad  todavla  para  noeotros,  que  la  sffilis  necesita  del  tratamiento  ar6nico  e  inter- 
mitente. 

CONCLUSIONES. 

El  estudio  detenido  del  tema  que  hemes  desarrollado  nos  permite  establecer  cierto 
orden  de  conclusiones  que  sintetizan  el  espfritu  de  nuestro  trabajo  y  que  exponemos  a 
continuaci6n: 

1^.  La  linfocitosis  sangufnea  es  el  dgno  m&s  constante  de  la  infeccidn  sifilltica;  es 
precoz;  comienza  con  la  infecci6n  y  acompafLa  la  vida  del  sujeto;  se  encuentra  en  el 
heredo — especffico  (a  partir  de  la  segunda  in&mcia). 

2**,  Loe  proceeos  infecdosos  concomitantes,  por  pequeflos  que  fueren,  enmasgaran 
moment&neamente  la  linfodtosis  sangufnea,  dando  polinucleosis;  desde  el  momento 
que  desaparecen,  nuevamente  se  presenta  aquella. 

3^.  La  linfocitosis  sangulnea  como  la  suero  reacd6n  de  Wassermann,  pertenece  a 
un  reducido  grupo  de  enfermedades.  Los  sintomas  dfnicos  y  las  dem&s  investiga- 
cionee  de  laboratorio,  permiten  excluir  los  otroe  procesos. 

4^.  Una  f6rmula  hematol6gica  propia  corresponde  a  la  linfocitosis  sangulnea  del 
sifilltico. 

5^.  La  0uero-reacd6n  de  Waasermann  es  mia  tardfa  en  aparecer  que  la  linfocitosis 
sangufnea. 

6^.  En  las  affilis  viejas,  no  tratadas,  la  suero  reacci6n  de  WasBermann  puede  perderse. 
La  linfodtoaiB  sangnfiiea  no  se  pierde. 

7^,  La  HnfodtosiB  sangufnea  se  reactiva  con  el  tratamiento.  Si  por  excepci6n,  no 
existe  desde  el  primer  momento,  la  medicad6n  la  hace  aparecer;  si  era  escasa,  la 
aumenta. 

8^.  La  reactivad6n  de  la  linfodtosiB  sangufnea  es  propia  del  especffico,  no  depende 
de  la  medicaci6n,  pues  6s^  por  sf  sola,  no  la  provoca  en  sujetos  no  espedficoe. 

9*.  El  tratamiento  espedfico  intense  y  prolongado  modifica  la  linfodtosis,  sin  Uegar 
nnnca  a  la  normal. 

10*.  La  linfodtosis  sangufnea  del  sifilftico  es  una  reacci6n  bioldgica  que  seguramente 
aigiiifica  i>erai8tencia  del  treponema  pdlido. 

11*.  La  linfodtosis  sangufnea,  entre  otros  signos  de  laboratorio,  impondrd  el  diag- 
n^stico  de  sffilis,  en  los  cases  en  que  los  sfntomas  clfnicos  ^tan. 

12*.  La  preeenda  de  la  linfocitosis  sangufnea,  en  ausencia  de  8uero-reacci6n  de 
Waasermann,  no  implica  la  negaci6n  de  sffilis,  antes  por  el  contrario,  hard  sospechar 
la  enfermedad,  e  insistir  en  su  investigaddn  para  aceptarla  o  excluirla  segtin  el 
resultado. 

13*.  La  linfocitosis  sangufnea  corrobora  que  las  afecdonee  tituladas  hasta  hace 
poco  parasifilf ticas,  son  de  naturaleza  eepecffica. 

14*.  Que  la  linfocitosis  sangufnea  del  especffico  se  reactive  con  el  tratamiento  anti- 
lu^tico  o  disminuya  con  ^1,  supone  que  su  etiologfa  es  funci6n  de  la  presencia  del 
treponema. 

15*.  La  persistencia  de  la  linfocitosis  sangufnea,  indica  que  la  sffilis  no  se  cura,  que 
diffdlmente  desaparece  o  bien  que,  producida  la  infecci6n  lu^tica  (aunque  menoe 
probable),  las  condidones  anatomo-patol6gicas  son  tales  que  queda  como  on  estigma 
de  sffilis  la  producd6n  anormal  de  linfodtos. 

16*.  El  aumento  espontdneo  de  la  linfocitosis  sangufnea  del  sifilftico,  que  caai 
siempre  se  observa  a  medida  que  nos  alejamos  del  sifiloma  y  durante  el  perfodo  se- 
cundario,  parece  demoetrar  que  depende  de  la  pululaci6n  del  eqpiroquete,  provocando 
una  reacci6n  oig&nica. 


^ 


400        PEOCEEDINGS  SECOND  PAN   AMEBICAN   SCIENTIPIC  CONGRESS. 

17<^.  La  linfocitoeifi  sanguinea  puede  ser  el  signo  tinico  de  la  sffilis  conyugal  en  la 
mujer  e  indicar  un  tratamiento  capaz  de  provocar  la  aparici6n  de  la  8uero-reacci6]i 
de  Waasennaim  oculta. 

18*^.  La  linfocitosiB  sanguinea  es  con  frecuencia  el  signo  linico  de  la  sf fills  latente. 

19*^.  La  linfocitosis  sanguinea  puede  ser  el  dnico  estigma  del  heredo-especifico  (a 
partir  de  la  segunda  infancia). 

20^.  La  linfocitosis  sanguinea  en  un  enfenno  sospechoso  de  sifilis,  tratado  preeoe- 
mente,  antes  de  la  aparici6n  de  la  suero-reacci6n  de  Wassennann,  pennite  continuar 
la  medicaci6n  sospechando  un  Wassermann  retardado. 

2P.  La  linfocitosis  sanguinea,  no  solo  tiene  el  valor  que  le  hemes  asignado  en  el 
diagn6stico  del  lues,  sine  que  tambi^n  lo  tiene  en  la  profilaxia  social;  las  amas,  per 
ejemplo,  con  linfocitosis  sanguinea  elevada,  hacen  sospechar  el  lues  y  autorizan  a 
profundizar  la  inve8tigaci6n.  Si  puesto  en  pr&ctica  un  tratamiento  de  prueba  (a 
pesar  de  no  existir  suero-reacci6n  de  Wassermann  positiva)  la  linfocitosis  aumenta, 
las  probabilidades  de  infecci6n  son  mds  evidentes. 

22®.  La  linfocitosis  sanguinea  perdura  como  signo  indelebie  de  sifilis. 

23*^.  La  persistencia  de  la  linfocitosis  sanguinea,  a  pesar  de  los  tratamientos  m^ 
en^igicos  y  prolongados,  parece  indicar  que  (con  los  descansos  pertinentes)  no  debe 
abandonarse  nunca  la  medicaci6n. 

24<^.  La  linfocitosis  sanguinea,  despu^s  de  todo  nuestro  estudio,  resulta  ser  un  com- 
plemento  indispensable  de  la  suero-reacci6n  de  Wassermann  en  el  diagn6etico  y  una 
investigacidn  necesaria  para  el  pron68tico. 


GRANULOMA  VENSREO '--CONTRIBUCION  PROVISORU  A  SU  ESTUDIO 

mSTOLOGICO. 

Por  FEDERICO  SUSVIELA  GUARCH. 
Jtft  del  Laboratorio  de  Histologia  Patoldgica  del  InstittUo  de  Radiologia  de  Montevideo. 

di8tribuci6n  geoorAfiga. 

Con  el  nombre  de  granuloma  ven6reo  o  groin  ulceration,  sclerotising  granuloma  of 
the  pudenda,  chronic  venereal  sores,  granulome  ulcereux  des  organes  g^nitaux,  etc., 
se  ha  designado  en  los  tiltimoe  tiempoe  una  afecci6n,  limitada  a  los  6rgano8  geni tales 
o  a  SU  vecindad  m^  pr6xima,  ulcerosa,  cr6nica  y  contagiosa. 

La  enfermedad  ha  sido  descrita  primeramente  por  Conyers  y  Daniels,  en  el  este  de 
la  India,  en  la  Guayana  britdnica  y  por  el  Ultimo  y  m^  tarde  en  los  Melanesios  de 
las  Islas  Fiji,  de  las  Nuevas  Hdbridas  e  Islas  de  Salom6n.  Demproolf  describe  una 
enfermedad  de  los  Paptias  y  Melanesios  en  Nueva  Guinea,  que  probablemente  es  la 
misma  afecci6n.  Maitland,  MacLeod  y  otros  encuentran  el  granuloma  en  la  India 
(Madr^,  Calcuta,  Assam).  Goldsmith,  en  Palmerston  (Australia  del  Norte).  Lea 
miembros  de  la  expedici6n  de  la  malaria,  en  el  oeste  de  Africa. 

La  ulceraci6n  serpiginosa  de  los  6rganoe  geni tales  descrita  por  MacLeod  (Ind.  Med. 
(jaz.,  1889),  es  la  misma  afecci6n,  reconocida  por  Patrich  Masson,  en  el  sud  de  la 
China.  Taylor,  de  Nueva  York,  la  ha  encontrado  en  los  blancos  en  los  Estados  Unidos. 
Pietro  Sabela  describe  algunos  cases  en  Tripoli,  con  el  nombre  de  granuloma  ulceroso 
de  los  6rgano6  genitales. 

£1  doctor  Juan  A.  Rodriguez  (Hospital  Maciel,  Montevideo)  estudia  actualmente 
varies  cases  de  granuloma  ven^o,  que  hard  conocer  pr6ximamente. 


1  Naestra  oontnbucidn  provisoria  al  estndio  del  granuloma  veDdreo  oon  las  obaofvodoiigs  recogidas  en 
Montevideo,  que  nos  proponemos  ampliar  e  ilustrar  muy  prOximamente,  responde  a  aquella  honrosa 
dlstinci6n,  fnvitacIOn  del  ministro  de  relaclonea  ezterlores  y  al  propdslto  de  avansar,  si  (uara  posible,  el 
oonodmiento  de  un  tema  intoresante  de  la  petologfa  humana. 


PUBUC   HEALTH  AND  MEDICINE.  401 

E.  Rabello  Beaiirepaire  Arag^  y  Gaspar  Viana,  de  Rio  de  Janeiro,  ban  estudiado- 
detenidamente  el  granuloma  en  la  mencionada  ciudad. 

Segtin  esta  distribuci^n,  geogr4fica  se  ve  que  la  enfermedad  se  balla  extensamente 
repartida  en  loe  pafeee  tropicales  y  subtropicales. 

BDAD  Y  8BX0. 

El  granuloma  no  ba  sido  observado  an  tee  de  la  pubertad ;  se  le  ba  encontrado  despu^ 
de  los  13  o  15  y  haeta  loe  45  afios.  Ninguna  raza  parece  ser  exclufda.  Hombree  y 
mujeres,  pueden  ser  igualmente  afectados,  con  preferencia  la  mujer. 

CONTAOIO. 

Hay  ilgunas  razones  para  creer  que  la  enfermedad  es  frecuentemente  de  origen 
vendreo.  Maitland  la  ba  observado  en  la  boca  de  un  marido  y  de  su  espoea.  iA 
cree  que  pueda  ser  propagada  al  nivel  de  beridae  de  naturaleza  veneriana. 

Pietro  Sabella,  admitiendo  el  contagio  sexual,  lo  ba  encontrado,  sin  embargo,  fuera- 
de  allf ,  en  personas  de  menor  edad,  en  familiae  de  sus  cases  de  Tripoli,  lo  que  no  eo 
de  extrafiar  por  la  promiscuidad  impiura  e  impropia  de  la  vida  en  aquella  poblaci6n. 
Las  ropas  y  las  manoe  pueden  baber  sido  el  vector  de  trasn^isidn. 

Tambi^  Mense  cree  en  esta  autointoxicaci6n,  donde  la  ulceraci6n  viene  a  estar  en 
contacto  con  la  piel  sana,  como  por  ejemplo,  en  los  pliegues  anales  y  escrotales. 

0ARACTBRB8  MACR08C<5pIC08  T  SINTOMATOLOOfA. 

Tratdndose  de  los  caracteree  macroec6pico6,  ad  como  de  la  sintomatologia  del 
granuloma  ven^reo,  noaotroe  traduciremos  a  contdnuacidn  la  descripci6n  de  Patrick- 
MasBon  y  de  Mense. 

Segdn  Patrick  Masson,  la  enfermedad  comienza,  en  la  mayorla  de  los  cases,  al  nivel 
de  los  6rganos  genitales,  o  del  ano  bajo  la  forma  de  un  espesamiento  o  elevaci6n  de 
la  piel,  nodulosa,  drcimscrita  e  insignificante.  La  zona  afectada  estd  recubierta  de 
un  epitelio  muy  delicado,  rosdseo  y  f&cil  de  ser  desprendido,  se  escoria  pronto  y  deja 
desnuda  una  superficie  que  tiende  a  sangrar  y  a  desollar,  p^ro  que  no  se  ulcera  de 
ordinario  de  una  manera  profunda.  La  enfermedad  evoluciona,  por  extensi6n  con- 
tinua  perif^ca  y  exc6ntrica  y  por  autoinfecci6n  de  ima  superficie  contigua.  En  su 
exten6i6n  ella  muestra  una  predilecci6n  por  las  superficies  calienies  y  bdmedas,. 
particularmente  los  replie^es  entre  el  escroto  y  los  muslos,  los  grandes  labios  y  los 
pliegues  del  ano.  Evoluaona  muy  lentamente  y  emplea  algunos  afios  para  recubrir 
ima  zona  ancba.  Conjuntamente  con  la  extensi6n  perif^rica,  se  forma  una  cicatriz 
densa  retralda,  desi^al,  que  se  desgarra  fdcilmente  sobre  la  superficie  recorrida  por 
la  activa  excrescencia,  m&B  o  menos  nodulosa,  que  constituye  el  contomo  de  la  forma- 
ci6n  patol<5gica.  A  voces,  algunos  islotes  de  la  parte  activa  del  timior  aparecen  en 
el  tejido  cicatricial,  pero  es  al  margen  de  la  zona  unplicada  aue  deben  ser  observadoe 
los  caracteres  especiales  de  la  enfermedad.  Cuando  se  trata  ae  un  tumor  al^  antiguo, 
encu^ntrase  ima  ancba  zona  de  tejido  cicatricial  bianco  o  irregularmente  pigmentado, 
algunas  veces  escoriado,  que  no  tiene  el  aspecto  de  la  piel  sana,  retraido.  plegado  o 
dense;  la  periferia  irre^;ular,  estrecba  y  serpiginosa  est^  constituida  por  tejiao  de  nueva 
formaci6n,  noduloso,  ligeramente  elevado,  rojo^  bamizado,  cubierta  de  una  delgada 
pelfcula  rosada,  superficialmente  ulcerada  o  agnetada. 

En  la  mujer^  la  enfermedad  puede  extenderse  a  la  vagina  sobre  los  labios,  y  a  lo 
largo  de  los  pliegues  del  ano. 

fin  el  bombre,  puede  invadir  el  pene  (comprendido  el  glande),  el  escroto,  y  la  parte 
elevada  de  los  muslos.  En  los  doe  sexoe  puede  extenderse  en  algunos  afios  al  pubis» 
al  perin6  y  posteriormente  basta  el  coxis  A  veces  corre  de  la  supemde  del  granuloma, 
un  Ifquido  abundante,  espeso,  que  ensucia  los  veetidos  y  emite  un  olor  particularmente 
deeaflradable.  En  estas  condidones  exti^ndese  la  enfermedad  lentamente,  diira  afios, 
y  da lugar  a  inconvenientes  y  a  veces  a  alteraciones  serias  de  parte  de  la  uretra,  de  la 
vafina  o  del  ano,  pero  sin  perjudicar  de  otra  manera  a  la  salua  del  enfermo. 

La  de0cripd6n  de  Mense,  no  difiere  de  la  anterior,  tan  bien  detallada.  Es  de 
anotar,  sin  embargo,  algnnas  particularidades  de  la  misma.  "No  rara  vez,  dan  loe 
bubones  8in>uradoe  o  cnancros  tlpicos,  blandoe  iniciales,  el  punto  de  partida  de  la 
afeeddn.    (Conyers,  Daniels,  Maitland.)    La  p^rdida  de  sustancia  conduce  a  la 


402       PROCEEDINGS  SBGOKD  PAN  AMEBIGAN  SGIENTIFIG  GONGBESS. 

ulceraci6n;  los  hordes  sinuosoB  avanzan  siempre  adelante  mientras  que  brotan  en 
el  fondo  granulaciones  que  sangrau  fdcilmente,  tdrpidae,  rojo  claras,  bnllantes,  o  gris 
mate,  las  que  sobrepasan  en  los  bordes  el  nivei  de  la  piel,  y  se  rehacen  m^  tarde  en 
el  medio.  El  proceso  contimia  y  ataca  las  mucosas  vecinas,  del  ano,  de  la  uretra  y 
de  la  vagina;  puede  producir  adn  mismo  una  neoplasia  heteropl&stica  en  la  profundidad 
y  abrir  la  vejiga  y  el  mismo  abdomen.  Las  gldndulas  linf&ticas,  en  lo  general,  no  son 
afectadas.    Los  dolores  son  moderados/' 

Cuando  la  ulceraci6n  alcanza  algdn  desarroUo,  se  retrae  en  al^unas  partes  el  tejido 
granular  y  proddcense  cicatrices  y  recubrimiento  cut^eo.  Las  cicatrices  suiren 
m^  tarde  una  considerable  retracci6n,  de  tal  manera,  gue  originan  estenosis  rectalee 
y  uretrales.  Pero  en  la  periferia,  avanza  siempre,  sin  cesar,  el  proceso  y  parece 
dudosa  una  curaci6n  espontdnea.  Se  ban  comprobado  persistencias  de  diez  afioe. 
Entretanto  el  estado  general  apenas  es  alterado  y  la  nutnci6n  se  conserva  bien.  En 
loe  cases  graves  puede  darse  la  muerte  por  anemia  y  p^rdidas  por  via  de  la  8ecreci6n. 

O^RHENES  DEL  GRANULOMA  VEN^REO. 

Siendo  nuestro  estudio  puramente  histoldgico,  no  noe  ocuparemos  de  la  Bacteriologfab 
del  granuloma  ven^reo. 

Resumiremos,  sin  embargo,  lo  conocido  hasta  la  actualidad: 

Markham  Carter,  describe  par^tos  que  considera  como  protozoarioe.  Elementos 
redondos  u  ovales.    Algunos  tienen  forma  de  frijol. 

Parece  que  estas  formas  son  id^nticas  a  las  encontradas  por  D6novan  en  1905,  en  seis 
cases;  61  cree  que  se  trata  de  protozoarios,  cuya  posicidn  definitiva  le  parece  dudosa. 
Loe  cuerpos  eran  de  1}  a  2  mm.  y  se  hallaron  en  c^lulas  epiteliales  de  la  red  de  Malpi- 
ghi  y  como  macr6fago6.  Siebert  ha  descrito  minuciosamente  la  forma  en  preparados, 
procedentes  de  allf ,  y  tambi6n  ha  demostrado  su  presencia  en  pieparadoe  de  Nueva 
Guinea;  los  toma  por  cocus,  o  c^lulas  fermentofl.  Flu  ha  visto  recientemente  las 
mismas  formas.  Describe  tambi6n  masas  pldsticas  que  se  asemejan  a  las  desciitas 
por  Carter. 

La  posici6n  definitiva  de  las  formas  cuyo  conocimiento,  sin  duda,  corresponde  a 
D6novan,  no  ha  side  fijada  definitivamente. 

El  germen  de  D6novan  ha  tenido  una  comprobaci6n  en  el  Brasil,  habiendo  sido 
encontrado  primero  por  E.  Rabelo  (1912),  y  despu^  por  BeaurepaiTe  Arag^  y  Gaspar 
Viana,  en  8  casos  de  su  observaci6n  en  ^o  de  Janeiro,  quienes  lo  han  aialado  y  culti- 
vado. 

Tr&tase  ya  de  pequefioe  cocus,  rodeados  de  una  c&psula,  o  de  baciloe  de  extremidades 
redondeadas,  rodeados  tambi^n  de  una  cdpsula  o  sin  ella.  El  germen  es  x>at6geno  pani 
los  animales  de  lalx^atorio.  No  se  comprueba  la  especificidad  por  el  desarrollo  experi- 
mental del  granuloma. 

M.  Lennan  describe  en  el  granuloma  ven^reo  un  espirilo  del  tipo  refringens  y  otra 
dase  todavla  desconocida.  Wise  encontrd  en  1907  espiriloe  del  tipo  de  la  palida,  lo 
que  indujo  a  Sabella,  en  Tripoli,  a  hacer  inoculadones  de  Salvars^  en  dos  casos  con 
6xito  curative.  Acland  y  Hickinbothan  vieron  espirilos  con  dos  o  tres  ondulaciones, 
acumuladas  a  voces,  diferentes  a  las  de  la  sffilis,  framboesia.  Ulcus  tropicum,  Ese 
espirilo  fu6  llamado  por  61  "Espirilos  aboriginales.*' 

No  se  consigui6  6xito  en  las  inoculadones  del  perro,  cuyo  animal  se  cree,  en  el 
vulgo,  ongioa  la  transmisi6n  a  las  mujeres.  Castellani  y  Chalmers  mencionan  que  en 
el  perro  se  han  encontrado  tumores  granuloses  con  espirilos.  Bosanquet  demostr6 
tambi^n  espirilos  en  cortes,  segfin  Levaditi,  en  el  granuloma  ven^reo,  en  los  naturales 
de  Australia,  numerosos,  3-4  milfmetros  bajo  la  superficie,  en  la  base  del  granuloma. 

El  valor  etioldgico  del  Sp.  aboriginalU,  no  est^  demostrado;  quizes  es  s61o  un  par&- 
sito.  Adem^,  diremos  que  Siebert  (1907)  y  Flu  (1911)  dan  como  causa  etioldgica  otros 
microorganismos  que  vi6  primero  D6novan. 

Por  lo  que  precede,  se  ve  que  el  problema  etiol(5gico  no  se  halla  resuelto  desde  el 
punto  de  vista  bacteriol6gico. 


PUBLIC  HEALTH  AND  MEDICINE.  403 

BXAMBN  marroLdoico  db  nubstro  caso.^ 

En  la  Qrientaci6n  general,  veee  afectada  la  epidennis,  el  cutis  y  el  subcutis,  lo 
mismo  que  loe  elementos  correspondienteB  en  la  forma  que  deecribiremos. 

Las  capas  aJBladas  de  la  epidermis  se  hallan  casi  siempre  m^  o  menos  reducidas, 
bajo  defonnaciones  del  conjunto,  a  la  capa  cdmea,  y  esta  misma  limitada  a  un  filamento 
frecuentemente  desprendido,  coloreado  de  amarillo  naranja.    Weigert  van  Giesson. 

Por  consiguiente,  las  capas  de  la  epidermis  no  presentan  sus  relacionee  reclprocas, 
ni  la  topograf(a  ordinaria.  Cuando  existen,  la  capa  germinativa,  filamentosa  y  granu- 
losa, y  esto  con  las  c^lulas  alteradas,  lo  mismo  que  modificadas  en  su  disposicidn, 
estructuia  y  granulaci6n,  penetran  a  voces  como  desprendidas  de  la  capa  Idcida,  en 
la  forma  de  pequefioe  actimulos  que  pudieran  tenerse  como  brotos  epiteliales  neo- 
pUudcos  por  debajo  del  llmite  epidermis-corion,  para  confundirse  con  una  infiltraci6n 
linfocitaria  vecina. 

Ademis  esas  capas,  en  el  caso  de  conservaci6n,  presentan  de  cuando  en  cuando 
espacios  que  contienen  restos  o  detritus  celulares.  Esos  espacios,  a  voces  muy  extendi- 
dos,  alterando  la  red  epitelial  a  la  que  dan  fonnas  caprichoeas,  encierran,  ademis,  del 
detritus,  infiltraci6n  de  linfocitos,  del  tipo  de  c^lulas  plasmiticas  linfocitarias,  sobre 
un  fondo  de  ligera  masa  de  tejido  colageno,  que  puede  reconocerse  como  tejido  con- 
juntivo  joven,  por  su  ddbil  constituci6n  fibrilar  y  sus  nticleos.  Toda  esta  alteraci6n 
de  la  epidermis  puede  demostrarse  muy  claramente  por  medio  del  azul  methylene 
X>olicromo  de  Unna. 

La  deformaddn  de  las  capas  de  la  epidermis  enunciada  y  su  alteraci6n,  hacen 
comprender  la  dificultad  de  poder  encontrar  alteraciones  regulares  en  las  c^ulas 
correspondienteB.  S61o  podemos  anotar  irregularidad  de  la  capa  germinativa,  des- 
provista  de  las  expansiones  protoplasmdticas,  dirigidaa  hacia  el  cutis,  penetraci6n 
de  sus  c61ulas  en  la  capa  filamentosa  alteracidn  de  la  estructura,  mitosis;  la  capa 
llicida  aparece  como  la  m^  conservada;  por  dltimo,  la  capa  c6mea  rara  vez  presenta 
sus  nticleos  ordinarios  alargados;  casi  siempre  se  ha  reduddo  a  un  filamento  des- 
prendido  coloreado  de  amarillo  anaranjado  por  Weigert  van  Giesson.  En  resumen, 
la  epidermis  parece  ser  el  asiento  de  un  proceso  invasor  y  destructor  dirigido  de  abajo 
aarriba. 

El  limite  epidermis-corium,  segtin  lo  precedente,  carece  de  Ifnea  regular,  y  es  el 
asiento  de  la  infiltraci6n  linfocitaria,  esparcida  hada  el  cutis  y  ocupando  el  lugar  de 
las  papilas.  Estas  h&llanse  dilatadas,  apenas  provistas  de  sus  fibras  ascendentes  de 
tejido  conjuntivo,  pero  ocupadas  por  la  infiltraci6n.  No  se  encuentran  vasos.  Por 
debajo  del  limite  epidermis-corium,  se  tiene  una  capa  madza,  ancha,  de  infiltraci6n, 
con  prolongadones  hacia  el  cuerpo  papilar.  La  masa  de  cdlulas  de  infiltraddn, 
comienza  mis  abajo,  en  montones  o  actlmtdos  en  el  cutis,  ocupando,  como  islotes, 
pequefios  o  grandes  espacios.  Estos  espacios,  pequefioe  o  grandes,  limitados,  de  1 
a  2  y  hasta  diez  d^cimos  de  milimetro,  por  el  tejido  conjuntivo,  se  propagan  hasta 
el  subcutis.  El  tejido  conjuntivo  mismo  del  cutis  y  subcutb  se  muestra  mis  espeso 
en  el  primero  que  en  el  segundo,  tiene  en  el  subcutis  disposicidn  ondulada  irregular, 
paralelo,  como  de  ordinario,  a  la  superfide,  presenta  sus  ntideos  mis  o  menos  defor- 
mados  grandes  o  vacuolizados.  Es  mis  bien  tejido  colageno.  El  tejido  conectivo, 
encerrando  lo  mismo,  en  el  cutis  que  en  el  subcutis,  linfodtos,  leucodtos  y  c^lulas 
plasmitlcas  linfodtarias. 

Los  vasos,  mis  grandes,  estin  espesados  y  prindpalmente  su  adventicia  desaparece 
en  la  formad6n  de  tejido  conjuntivo  espeso,  sin  infiltrad6n  colateral;  en  cambio,  la 
presentan  los  vasos  pequefios  (venas)  en  capa  espesa  circular.  El  semento  endote- 
lial,  muchas  voces  conservado  como  se  ve  en  los  vasos  cortados  longitudinalmente. 
El  lumen  contiene  restos  de  eritrodtos.  Una  acumulad6n  extravascular  de  estos 
dltimos,  s61o  se  encuentra  algiinas  pocas  voces  en  espados  de  tejido  conjuntivo. 

1  El  caso  pfooede  de  la  aala  0«niiin  Segora  d«l  Hosplto]  MMd,  oon  que  nos  ta^voncM  d  Dr.  Jnao  A. 
Rodxlgufls,  cajra  defenncia  agradaocmoB. 
68436— 17— VOL  x 27 


404       PROCEEDINGS  SECOIO)  PAN  AMEBIGAN  SCIENTIFIO  C0NQBE6S. 

Eb  dificil  encontrar  yb808  linMticos,  y  los  que  apArecen,  h^UlaiiBe  envueltOB  en  laa 
cdhilas  pequefias  de  infiltraci6n,  y  como  d  de  aqui  suigiera  ^sta. 

No  86  encuentran  otros  elementos,  oomo  peloe,  g^dulas  sudorffefas  y  aebiceaa. 
FUeden  percibiise,  laras  vecee,  restos  de  las  gl&adulas,  destrufdas  por  la  foimad^n 
de  tejido  conjuntivo. 

H^lanae  c61ulas  de  nticleo  polimorfo  (aerie  leucocitarla). 

Las  c^ulas  redondas  de  l]ifiltraci6n  que  figuian  en  nuestros  preparados  merecen 
una  consideraci6n  especial  por  ser  en  su  maycnrfa,  fuera  de  Hnfbdtos  y  pocos  leucodtos, 
cflulas  plasmilticas  linfocitanas  y  venir  a  ser  por  su  domlnio,  a  nuestra  manera  de  \er, 
una  caracterfstica  del  granuloma  yen^reo,  como  lo  acentuaremos  mis  adelante. 

Sabemos  que  las  c^lulas  de  orden  linfocitario  se  dividen  en  linfoblastos  y  linfoci- 
tOB.  £1  linfoblasto  (linfocito  no  adulto),  tiene  el  tamafto  de  un  mielocito,  un  proto- 
plasma  d^bilmente  basdfilo,  nticleo  bastante  grande  irregular,  con  una  membrana 
propordonalmente  espesa  y  un  nticleo  mis  o  menos  tingible.  Pegado  al  nticleo  pre- 
aentan  loe  linfoblastos  en  general,  una  zona  clara,  que  bajo  la  coloraci6n  de  Altman- 
Schiider  oirece  granulaciones  groseras,  de  forma  bacilar  y  color  rojo.  Estos  linfo- 
blastos que  representan  un  estado  de  divisi6n  de  loe  linfocitos,  presentan,  por  con- 
dguiente,  numerosas  mitosis.  Los  linfoblastos  aparecen  mis  bien  en  la  sangre,  como 
prueba  de  funcionamiento  exagerado  del  sistema  linfitico.  Los  linfocitos  son  pe- 
quefias  cilulas  con  un  nticleo  redondo,  rico  en  cromatina,  presentando  uno  y  hasta 
dos  nucleolos,  fuertemente  tingibles. 

Tambi^n  en  estas  c^lulas,  hillase  una  zona  ciaia  alrededor  del  ndcleo,  en  la  que 
ee  encuentran  granulaciones  como  en  los  linfoblastos. 

(Las  cilulas  grandes  mononucleares,  mostradas  por  Ehrlich  con  su  triicido,  son,  en 
pequefia  parte,  linfocitos  grandes,  adultos,  y  en  gran  parte,  formas  de  pasaje  con 
nticleo  poco  lobulado.) 

Ahora  bien :  las  dos  formas  anteriores,  loe  linfoblastos  y  los  linfocitos  pueden  engendrar 
en  los  estados  patoldgicos,  las  c^lulas  plasmiticas  linfoblisticas  y  Unfocitarias.  Las 
piimeras,  que  s61o  outran  en  consideraci6n  en  pocos  procesos  se  caracterizan  por 
tener  el  nticleo  propio  del  linfoblasto,  un  protoplasma  mis  fuertemente  bas6filo  y  una 
zona  mis  claia.  Las  segundas,  o  sean  las  cilulas  plasmiticas  linfocitarias,  son  mis 
importantes  que  las  primeras,  por  constituir  la  masa  principal  celular,  en  la  infiltra- 
cidn  de  pequefias  cilulas. 

Como  primer  caiicter  diferencial  entre  esas  dos  c61ulas  tenemos  en  la  cilula  plas- 
mAtica  linfodtaria,  la  fonna  de  rueda  del  nticleo  y  su  8ituaci6n  casi  siempre  mis 
inclinado  hada  el  polo  de  la  cilula,  la  que  es,  en  general,  oval. 

Ademis,  en  la  parte  del  cuerpo  celular  a  que  se  inclina  el  nticleo,  hillase  im  irea 
dara  muy  visible,  con  fuerte  aumento  y  p<Mr  la  col(Mraci6n  de  pyronina  o  de  azul  de 
methileno  policromo  de  Unna,  irea  que,  coloreada  por  Altman-Schride,  revela  las 
mismas  granulaciones  que  los  linfocitos.  No  es  raro  encontrar  en  las  cilulas  plas- 
miticaa  linfocitarias  varies  ndcleos  y  hasta  seis. 

Todas  las  c^ulas  del  orden  linfocitario  (linfocitos,  linfoblastos,  c61ulas  plasmiticas) 
tienen  la  propiedad  de  emigrar.  Sin  embargo,  parece  que  b61o  los  linfocitos  emigran 
en  los  vasos  capilares,  mientras  que  las  otras  c^lulas  emigran  en  el  tejido  conjuntivo  y 
al  trav^  del  epitelio. 

Ahora  bien:  como  avanzamos  antes,  son  las  c61ulas  plasmiticas  linfocitarias  las  que 
hallamos  en  gran  cantidad  en  la  infiltraci6n  del  granuloma,  no  s61o  esparcidas  hacia 
la  periferia,  vecindad  del  Ifmite  epidermis-corium,  no  861o  en  los  espados  lacunares 
anotados  de  las  capas  de  la  epidermis,  sine  tambi^n  como  actimulos  en  espacios  irregu- 
larmente  formados,  por  fuertes  fascicules  de  tejido  conjuntivo.  Encontrindose  esas 
masas  en  la  vecindad  de  los  vasos,  creemos  que  la  emigraci6n  se  da  para  el  granuloma 
en  el  tejido  conectivo.  De  todas  maneras,  el  ntimero  tan  considerable  de  cilulaa 
plasmiticas  linfocitarias,  y  su  vasta  distribucidn  par^enos,  al  menos  segtin  la  cons- 
tancia  del  fendmeno  en  nuestros  preparados,  una  caracterfstica,  no  consignada  hasta 


PUBUO  HEALTH  AND  MEDICINE.  405 

ahora,  segdn  nuettns  noticiat,  en  el  granuloma  ven^reo.  Mia  addante,  expiememotf 
nuertra  opinion  sobre  an  orig^i  y  la  influenda  primaiia  que  lee  asignamos  en  el  proceso 
estudiado. 

En  reeumen:  el  substractum,  consiste  al  xMrincipio  en  una  piolJieraci6n  inicial  de  la 
epidermis,  cuyoe  conoe  interpapilaree  se  prolongan  en  una  infiltraci6n  hasta  interc- 
pitelial  de  c^lulas  pequefias,  redondas,  que  vienen  del  ccnium  (c^lulas  plasmAticafl). 
Lo0  elementoe  ordinarioe  del  corium,  son  reemplazados  finalmente  por  c^lulas  redondas, 
las  que  en  su  mayorfa  tienen  el  car&cter  de  c61ulas  plasmiticas  linfodtarias,  algunas 
linfobUlsticas.  Los  vasos  del  cutis  se  encuentran  dilatados.  Por  dltimo,  el  epitelio 
superficial  se  atrofia  y  desaparece.  La  infiltraci^n  de  c^lulas  pequeflas  es  reemplazada 
por  tejido  conjuntivo  joven  y  bajo  formaci^n  activa  vascular  nace  un  tejido  conjuntivo, 
espeso,  granular,  caracterfstico,  que  no  presenta  tendencia  alguna  a  la  degeneracidn 
purulenta  o  caseosa,  no  encontr&ndose  c61ulas  gigantes,  ni  c^lulas  cebadas  (Mastzellen). 
La  acumulacidn  de  c^lulas  plasmdticas,  hace  recordar  al  Plasmocytoma,  tumor  de 
c^lulas  de  ese  orden,  descrito  por  Schridde  como  extrafia  formacl6n,  ajena  por  su 
ubicacidn  a  todo  origen  modular. 

diagn5btico  hi8tol6oico  difbrbncial. 

86I0  im  examen  superficial  ha  podido  conhmdir  el  granuloma  ven^reo,  con  el  Can- 
croid de  la  piel,  el  lupus  tuberculoso,  el  lupus  vulgar  y  las  formas  elefanti^cas. 

El  Cancroid  se  caracteriza,  desde  luego,  por  la  invasi6n  neopldaica  epitelial  y  por 
la  presencia  de  las  perlas  cancroideas.  El  lupus  tuberculoso,  se  revela  por  el  tub^rculo, 
cuyo  examen  bacteriol<5gico  basta  para  diferenciar  los  dos  procesos,  osi  como  las  ovinias 
gigantes.  El  lupus  vulgar  se  diferencia  por  sus  c^lulas  epiteloideas  y  c^lulas  gigantes. 
Puede  encontrarse  a  voces  el  bacilo  de  Koch.  Sobre  todo,  el  n6dulo  luposo,  sufre  la 
degeneraci6n  caseosa,  y  por  lo  mismo  ofrece  en  su  centre,  un  detritus  o  masa  finamente 
granulosa,  diffcilmente  tinglble,  con  restos  de  n6cleos  que  se  colorean  fuertemente. 
Las  formas  elefantifaicas  de  las  partes  genitales,  nacidas  a  expensas  de  estados  infla- 
matorios  cr6nicos,  diferentes  de  la  Elefantiasis  arahum,  formas  que  siguen  a  la  extirpa- 
ci6n  profunda  de  ganglioe  linf&ticos,  procesos  cicatriciales,  urogenitales  y  del  recto, 
dlcera  cruris,  asf  como  en  el  lupus  y  goma  de  la  extremidad  inferior,  se  distinguen  por 
la  formaci6n  en  masa  de  tejido  conjuntivo,  con  una  falta  casi  completa  de  fen6menos 
irritativos. 

Por  el  contrario  de  lo  que  pasa  respecto  de  estas  alecciones,  el  granuloma  ven^reo  que 
hemos  obaervado  presenta  relaciones  cercanas  con  las  lesiones  inflamatorias  de  la 
sffilis,  tales  como  el  condiloma  slfilftico,  el  chancre  dure  (Esclerosis  inicial),  el  goma 
sifilftico  o  sifiloma  de  Wagner.   Este  dltimo  en  su  primer  estado. 

Si  se  estudia  nuestro  examen  histol6gico  se  verd  que  ofrece  el  caricter  general  de 
las  lesiones  sifilfticas;  constante  infiltraci6n  de  elementos  j6venes,  en  el  seno  del 
tejido  conectio  y  perivascular,  sefialado  por  Rami6n  y  Cajal.  Haciendo  luego  la  compa- 
racidn  particular,  veremos  que  el  ordenamiento  del  tejido  conjuntivo,  tambi^n  peri- 
vascular, y  los  vasos  mismos  encontrado  en  nuestro  tumor,  se  acuerda,  con  igual 
disposicidn  sefialada,  i>ara  el  condiloma  sifilftico,  por  Ziegler  y  por  Rieder.  Tambi^ 
los  fascfculos  conectivos,  descritos  por  nosotros  pres6ntanse  rellenados  en  sus  espacios, 
por  las  c^lulas  embrionanas  mismas,  como  tiene  lugar  en  el  chancro  duro .  Por  Ultimo, 
en  el  goma  sifilftico,  como  en  nuestro  tumor,  nace  primero  una  formaci6n  neopUaica 
de  tejido  conectivo,  i>eriva8cular,  alrededor  del  cualse  forma  un  infiltrado  inflama- 
torio  muy  espeso.  Alrededor  de  esta  infiltracidn  se  dispone  el  tejido  conjuntivo  en 
liimmas  conc^tricas.  El  goma  se  compone,  i>or  consiguiente,  al  principio,  de  una 
envoltura  de  tejido  conjuntivo,  de  un  infiltrado  inflamatorio,  y  en  el  centre  de  ^ste, 
hiUase  nuevo  tejido  conectivo  ricamente  celular.  El  goma  tiene,  adem&s,  c^lulas 
epiteloidales  y  c61ulas  gigantes.    (Ehrman  y  Pick.) 

Si  se  sigue  el  estudio  de  nuestro  examen  histoldgico,  tambite  se  reconocer^  dos 
circunstancias  caracterlisticas,  de  gran  importancia  para  la  comparacl6n  de  nuestro 
tumor,  con  las  lesiones  inflamatorias  de  la  sffilis. 


406       PROCEEDINGS  SECOND  PAN  AMEBICAN  BCIENTIPIO  CONOSE8S. 

La  primera  se  refiere  al  tejido  conectivo,  que  ya  hemos  apreciado.  La  s^gunda, 
tiene  que  ver  con  la  naluralesa  de  las  c^ulas  que  coostituyen  en  su  mayoiia,  la  infil- 
traci6n,  dando  a  estas  leeianes  una  caracteristica  diferencial  de  la  mayor  impoitancia. 
Eaas  c^lulas  sobre  las  que  nos  hemos  extendido  antes,  y  a  que  hemot  Uamado  con 
Shride,  c^lulas  plasmiticas  linfoblisticas  y  linfocitarias,  reconocidas  en  nuestio  tumor, 
son  las  mismas  designadas  con  el  nombre  de  c^lulas  cian^filas  por  Cajal,  y  de  c^lulas 
plaam&ticas  por  Unna,  en  las  lesiones  inflamatorias  de  la  sifilis;  Hamad  as  tambi^  por 
680  c^lulas  especfficas. 

Tan  s61o  como  diferencia  pueden  anotaise  en  las  lesiones  inflamatorias  de  la  sifilis, 
y  el  granuloma  que  hemos  estudiado,  ausencia  en  este  dltimo  de  c^ulas  epiteloides,  y 
c^lulas  gigantes.  Pero  la  ausencia  de  esos  elementoe,  por  lo  demis  no  siempre  cons- 
tantes,  no  compromete  la  analogia  que  establece  la  presencia  de  los  otros,  indisponsa* 
bles,  como  estructurales  y  topogr&ficos. 

CONCLU8I6n. 

Nuestro  examen  histok5gico,  nuestro  diagn6stico  diferencial  histoldgico  y  la  com- 
paraci6n  del  proceso  observado  en  nuestros  preparados  con  las  formas  de  inflamacidn 
sifilftica,  nos  llevan  a  considerar  el  granuloma  ven^reo,  con  cuya  presencia  se  com- 
prueba,  en  numerosos  casos,  la  reacci6n  poeitiva  de  Wassermann,  como  una  forma  de 
inflamaci6n  sifilftica. 

BIBUOGRAYiA. 

Conyers  y  Daniels.    Brit.  Guiana  Med.  Ann.,  1889.    Citada  por  C.  Mense. 

Daniel,  C.  W.    Granuloma  of  the  pudenda,  1889.    Citado  por  Scheube,  Die  Krank- 

heiten  der  warmen  L&nder. 
Dempwolf.    Artzliche  Erfahruugen  in  Neu  Guinea.    Arch.  f.  Schiffs-  u.  Tropenhyg., 

1898. 
Le  Dantec.    Pr^is  de  pathologie  exotique.    Paris,  1900. 
Ehrman  y  Fick.    Speciellen  Histopathologie  der  Haut.    Wien,  1906. 
Flu,  P.  C.    Die  Etiolpgie  des  Granuloma  venereum.    Archiv.  f.  Schiffo-  u.  Trop. 

Hygiene,  Beiheft.  9. 
Hlrsch.    Handbuch  der  historisch  geographischen  Pathologie,  1886. 
Maibland  I.    Chronic  venereal  sores.    Indian.  Med.  Cras.,  1898. 
Scheube  B.    Erankeiten  der  warmen  L&nder,  1903. 
Mense,  C.    Handbuch  der  Tropenkrankheiten,  1905.    Leipzig. 
Memorias  do  Institute  Oswaldo  Cruz,  1913.    Rio  de  Janeiro. 
Ram6n  y  Cajal.    Anatomfa  Patoldgica,  1913. 

Kohle  u  Wasserman.    Handbuch  der  pathogenen  Mikroorganismen,  7ter.  B.,  1913. 
Sabella  Pietro.    Giomale  Italiano  delle  malattie  veneree,  1913. 

The  Chairman.  Before  adjournment  I  wish  to  announce  by  way 
of  record  the  title  of  the  following  reprint  presented  to  the  Congress 
through  Section  VIII : 

Profilaxia  social  del  delito,  por  Elnrique  Feinmann.  Buenos  Aires, 
Imprenta  y  casa  editora  de  Coni  Hermanos,  1913. 

Adjournment. 


SESSION  OF  SUBSECTION  C  OF  SECTION  VTO. 

New  Ebbitt  Hotel, 
Thursday  moTming,  January  6j  1916. 

Chairman,  George  M.  Kober. 
General  topic: 

Pan-American  Theme:  ^'Etiology  and  prevention  of  tuberculosiB  from 
a  sociological  standpoint." 

The  session  was  called  to  order  at  9  o'clock  by  the  chairman. 
Papers  presented: 

Contribuci6n  al  estudio  de  la  etiologia  y  profilaxis  de  la  tubercu- 
losis desde  el  punto  de  vista  sociol6gico,  by  Nicol&s  A.  Solano. 

La  tuberculosis  en  Bolivia;  su  etiologia  y  profilaxia,  by  N6stor 
Morales  Villaz6n. 

Profilaxia  de  la  tuberculosis,  by  Constancio  Castells. 

La  tuberculosis  en  el  Uruguay,  by  Joaquin  de  Salterain. 

*'  A  tooth  is  more  valuable  than  a  diamond,"  by  Felipe  Gkillegos. 

contribuciOn  al  estudio  de  la  etiologia  y  profilaxis  de  la 

TUBERCULOSIS  DESDE  EL  PUNTO  DE  VISTA  SOCIOLOGICO. 

Per  NICOLAs  a.  SOLANO, 
Miembro  de  la  Asociaddn  Midica  de  la  Zona  del  Canal. 

Parte  I. — EtioloqIa. 

HERENCIA. 

La  herencia,  atributo  esencial  de  la  vida  y  cuya  acci6n  sobre  la  con8tituci6n  del 
ser  es  tan  palpable,  ha  ejercido  a  trav^^s  de  los  siglo6  inmenBo  predominio  en  lo  que 
pudi^ramos  llanxar  la  genesis  patol6gica. 

Su  historia  en  la  enfermedad  que  nos  ocupa  ha  atravesado  fases  muy  diferenies  y 
contradictoriafl  que,  haciendo  doctrina,  explican  las  contradiccionee  que,  al  correr 
del  tiempo,  ha  habido  en  la  profilaxis  de  dicha  enfennadad.  Asi  vemoe  que  Hip6- 
crates  hacfa  de  ella  toda  la  etiologfa  de  la  tuberculosis  al  sentar  su  principio  absoluto: 
**Un  tfaico  nace  de  un  tisico,**  y  que  Brouasais  si^ruiendo  su  camino  definfa  la  tubercu- 
losis:  '^Es  una  enfermedad  orgdnica  diat^ca  y  hereditaria.'*  Esta  manera  de 
considerar  la  etiolop:fa  de  la  tuberculosis  (u6  un  poderoso  eneniigo  de  las  sabias  medidas 
profilacticas  dictadas  en  los  ailos  1751  y  1700  por  los  reyes  Fernando  VI  de  Espafia  y 
Felipe  IV  de  Ndpoles,  respectivamente,  y  a6n  hoy  forma  criterio  y  conserva  casi  todo 
su  vigor  en  la  humanidad. 

La  herencia  de  la  tuberculosis  ha  distrafdo,  pues,  la  atenci6n  de  la  clfnica  en  todo 

tiempo  y  al  advenimiento  de  la  bacteriologfa  los  trabajos  de  laboratorio  no  se  han 

most^ado  indifercnto««  a  la  solution  del  problemn. 

407 


408       PKOCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC  CONGBESS. 

Bien  cs  cierto  que  la  infecci6n  del  6vulo  por  el  espermatozoide  ha  aido  demostxada 
por  criadores  que  ban  logrado  obtener  temeros  tuberculoeo6  de  vaca  indemne  y  tofe 
contaminado,  probando  ad  la  tuberculosis  concepcional,  en  el  caao  raro  pero  podblo 
de  que  llegue  al  dtero  junto  con  el  g^rmen  fecundante  el  ndcrobio  patdgeno  y  que  este 
tome  alojamiento  en  el  embiidn.  Este  case  aunque  se  hayan  citado  ejemplos  en  la 
raza  humana  debe  ser  considerado  excepcional,  puesto  que  el  bacilo  tendrla  que 
alojarse  en  la  cabeza  del  espermatozoide,  y  disminuirfa  cuando  menos  la  vitalidad  de 
este  dadas  sus  dimensiones  respectivas:  4  por  3  micros  para  el  primero  y  5  por  3  micros 
para  el  segundo. 

El  case  de  madre  tuberculosa  y  padre  indemne  es  mucho  mis  frecuente  y  se  explica 
naturalmente  por  la  fntima  conexi6n  que  existe  entre  el  oiganismo  matemo  y  el  del 
embri6n  o  feto,  constituyendo  un  caso  de  generalizaci6n  de  la  tuberculosis,  ya  que 
existan  leaiones  patol^gicas  en  la  placenta,  o  porque  los  badlos  arrastradoe  por  loe 
leucocitos  fuera  de  su  foco  primitivo — digamos  el  pulm6n — ^atraviesan  la  red  pla- 
centaria  a  la  manera  de  los  otros  elementos  de  la  sangre  y  van  a  continuar  su  desarrollo 
en  un  punto  del  organismo  del  feto,  generalmente  el  higado,  produciendo  asf  la 
enfermedad  en  ^1.  En  amboe  casoe  no  hay  herencia  de  tuberculosis,  como  lo  expuse 
en  mi  tesis  de  grade,  aino  contagio  intrauterine  o  generalizaci6n,  que  impropiamente 
se  ha  llamado  herencia  del  grano  o  heredo-contagio. 

El  papel  que  desempefia  la  herencia  en  la  etiologfa  de  la  tuberculosis  no  es,  ain 
embargo,  despreciable,  ya  que  es  un  hecho  comprobado  que  esta  enfermedad  no  anida 
alii  donde  el  organismo  le  ofrece,  en  virt;udde  su  vitalidad  normal,  alguna  resistencia;  y 
que  naturalmente  un  ser  formado  por  la  fusidn  de  doe  c^lulas  (6vulo  y  espermato- 
zoide) en  que  ambas  o  una  de  ellas  estd  herida  de  decadencia  orgdnica,  del  mismo 
modo  y  por  el  mismo  efecto  que  lo  estdn  todas  las  c^lulas  del  organismo  de  un  tubercu- 
loso  de  que  provienen,  dar^  nacimiento  a  un  ser  d^bil  y  de  receptividad  mdrbida 
positiva.  El  conjunto  de  atributos  anat6micos,  qulmicos  y  dindmicoe  transmitidoe  por 
herencia  al  nuevo  ser  lo  har&n  apto  para  el  contagio,  el  cual  tiene  mayor  probabilidad 
de  ejercer  su  influencia  nefasta  que  en  cualquiera  otro  proveniente  de  organismos 
sanos.  Es  pues  una  herencia  de  predisposici6n  lo  que  contemplamos  en  la  mayorfa  de 
los  casos  seguida  de  un  contagio  por  el  modus  vivendi  actual.  Esto  se  llama  heredo- 
predispoaicidn. 

Alin  la  heredo-predisposici6n,  si  atendemos  a  los  datos  estadisticos  de  Pidoux,  quien 
deduce  de  elloe  que  la  tisis  no  nace  de  la  tisis  sine  en  20  por  ciento,  lo  cual  se  conforma 
tambi^n  con  las  opiniones  de  Hallopeau  y  Apert,  tiene  una  importancia  menor  que 
el  contagio  en  la  propagaci6n  de  la  tuberculosis;  mds,  adn,  generalmente  el  nifio  viene 
al  mundo  sin  manifestaciones  de  tuberculosis  y  la  enfermedad  en  estos  heredopredia- 
puestos  no  se  manifiesta  sine  en  6pocas  alejadas  de  la  del  nacimiento,  cuando  ya  no  se 
puede  seperar  la  idea  del  contagio,  puesto  que  ha  sido  lactado  por  su  madre  tubercu- 
losa y  se  ha  criado  en  un  medio  tuberculigeno  por  excelencia.  Y  es  que  en  este  caso 
particular  de  la  herencia,  como  en  ella  considerada  en  general,  el  medio  modifica  los 
caracteres  y  mds  aiin  las  receptividades  mdrbidas,  que  en  el  organismo  han  imprimido 
sus  ascendientes;  de  ahf  que  los  individuos  de  ascendenda  no  tuberculosa  eet^  m^ 
expuostos  a  contraer  la  enfermedad  cuando  se  uncuentran  sometidos  al  contagio,qae 
los  de  cepa  tuberculosa  a  los  cuales  se  sustrae  de  ese  contagio. 

Nuestra  idea  al  respecto  es,  pues,  que  la  herencia  tuberculosa  en  toda  la  acepci6n 
de  la  palabra,  es  decir,  que  el  tiaico  nazca  del  tlsico,  es  rara  y  que  la  herencia  de  pre- 
disposici6n  a  la  tuberculosis  es  muy  frecuente  y  la  que  se  observa  en  casi  la  totalidad 
de  los  casos. 

CONTAOIO. 

Historia. — El  bacilo  de  la  tuberculosis,  descubierto  por  Robert  Koch  (quion  lo  hizo 
conocer  el  24  de  marzo  de  1882  por  medio  de  su  comunicaci6n  titulada;  ''Notasobre 
la  investigacidn  y  cultivo  del  bacilo  de  la  tuberculosis,"  dirigida  a  la  Sociedad  Fido-  ^  ^ 
l^ca  de  Berlin,  y  que  contiene  la  descripci6n,  manera  de  aislar,  cultivar  y  diferendar 


PUBUO  HBALTH  AND  MBDIOINE.  409 

el  microoiganismo  de  la  enfermedad  que  no6  ocupa),  habia  ddo  presentido  por  Iob 
eabioe  de  mediadoe  del  siglo  XIX;  en  efecto  Villemin,  en  1865,  demo6tr6  la  posibilidad 
de  la  tranBtnieiiSn  de  la  tuberculosiB  por  inoctdaddn  y  con  eea  previBi6n  que  constituyd 
BU  ma3ror  gloria,  declar6:  "El  tub^rculo  es  el  resultado  de  la  preeenda  de  un  vinu  en 
el  oiganiamo  y  la  inoculaci6n  de  61  no  obra  por  la  materia  visible  y  palpable  que  entra 
en  el  producto  patol^gico,  sino  en  virtud  de  un  agente  mia  sutil  que  ee  encuentra 
contenido  en  61  y  que  eecapa  a  nuestros  sentidos/' 

Mas  la  idea  del  contagio  no  data  deede  los  tiabajoe  de  Villemin;  en  el  siglo  II  de 
nuestra  era  (xaleno  hablaba  de  tranBmi8i6n  de  la  tuberculosis  de  un  individuo  a  otro. 
Rhases  y  Avicenne  en  el  siglo  X  opinaban  de  la  misma  manera.  Silvius  deecubii6 
el  tub^rculo  en  el  afio  1555  y  sus  contemporineos  Fallope  y  Montano  aceptaban  el 
contagio  por  cohabitaci6n.  Fracastor  (siglo  XYI)  reconoce  el  contagio  y  es  el  primero 
en  tratar  el  asunto  de  manera  cientlfica  y  detallada.  Despdes  vienen  Morton,  Valsalva, 
Van  Swieten,  Frank,  Moigagni.  Moigagni  y  Valsalva  Uevaron  sus  ideas  hasta  creer 
nociva  y  peligrosa  la  autopeia  de  un  tlaico  y  no  la  practicaban  nunca.  Moigagni  sent6 
este  aforismo  "Phtisicorum  cadavera  fugi  adolescens,  fugio  etiam  senex"  y  de  dl 
hacia  partfcipes  a  sus  alumnoe;  precaucidn  que  decia,  parecerd  exagerada  pero  es  la 
m^  segura.  Baumes  y  Hufeland  participaban  de  esta  opini6n.  Esto  en  cuanto  al 
mundo  cientlfico. 

Oomo  iniciativa  gubemamental  encontnunos  la  de  Fernando  VI,  ya  citada,  la  cual 
reflejaba,  naturalmente,  la  idea  arraigada  del  contagio  en  el  pueblo  espafiol  en  em 
6poca.  He  aquf  el  decreto  fechado  el  6  de  octubre  de  1751  en  el  Palacio  del  Buen 
Retire  y  refrendado  por  el  primer  Ministro  Zen6n  de  SomodeviUa,  Marqu^  de  la 
Ensenada: 

Habiendo  demostrado  la  experiencia  cuan  peligroeo  es  el  uao  de  la  ropa  de  cuer^ 
muebles  y  objetos  que  ban  pertenecido  a  personas  atacadas  o  fallecidas  a  consecuencia 
de  enfermedades  6tica8,  tfsicas  y  otras  contagiosas,  ordenamoe  expresamente  a  todoa 
los  m^icos  de  hacer  conocer  las  enfermedades  o  muertes  de  tisis. 

De  mode  que  el  alcidde  haga  quemar  la  ropa  de  cuerpo,  los  veetidos,  los  muebles  jr 
todoe  los  objetos  al  servicio  personal  del  paciente  y  que  nubieran  quedado  en  su  habi- 
taci6n. 

Que  el  alcalde  ordene  tambi^n  que  la  habitacidn  donde  el  enfermo  hubiere  foUe- 
cido  sea  revocada  y  blanqueada:  que  el  piso  o  enlosado  de  la  pieza  o  de  la  alcoba  sea 
rehecho. 

Adem;&B  se  abrird  un  registro  en  el  cual  se  inscribird  la  procedencia.de  las  ropaa 
existentes  en  casas  de  cambalaches  o  mercaderes  de  ropa  vieja,  con  indicaci6n  de 
loe  nombree  y  domicilio  del  vendedor,  asf  como  de  aquellos  a  quienes  las  ropas  y  vea- 
tidos  hubieran  servido,  cambalacheros  y  ropavejeros  haciendo  el  comercio  ordinario 
de  efectos  contaminados. 

El  alcalde  entregaii  un  papd  atestando  que  las  susodichas  mercaderfas  estdn 
exentas  de  contagio:  lo  que  permitird  a  los  intereeadoe  retener  o  vender  las  merca- 
derias  de  ocasi6n. 

Todo  medico  que  no  declare  al  alcalde  de  su  cuartel  las  enfermedades  o  falleci- 
mientos  tisicos  incuirird:  por  la  primera  vez,  en  una  multa  de  200  ducados  y  soa- 
pensi6n  durante  un  afio;  par  la  segunda  vez  multa  de  400  ducados  y  la  pena  ae  dea- 
tierro  por  cuatro  afioe. 

Todas  las  personas  o  enfermeros,  criadoe  o  gentes  al  servicio  del  tfsico,  que  no  hagaa 
la  dedaracion,  incurririn  en  la  pena  de  30  dfas  de  encarcelamiento,  por  la  primera  ves; 
de  cuatro  afioe  de  presidio  por  la,  8^:unda. 

Las  autoridades  civiles,  religiosas  y  militares  tendr&n  que  hacer  quemar  en  loa 
hoepitales  civiles  y  militares  toda  la  ropa  de  uso  de  enfermos  y  soldados  tisicos. 

Mas  las  teorias  de  Broussais  desviaron  esta  corriente  de  preaervacidn  asf  como  laa 
poateriores  de  N4poles  ya  citadas,  coiriente  que  era  como  una  prediccidn  del  immortal 
deacubrimiento  de  Koch.  Laennec  al  contrario  aconsejaba  preaervarse  i>ara  evitv 
el  contagio.  Despu^  viene  Villemin,  quien  con  sus  trabajos  y  su  predicci6n  da  la 
nocidn  del  contagio  exacta,  confirmada  por  el  descubrimiento  del  bacilo,  que  clairiflca 
'la  tuberculoaia  al  lado  de  la  fiebre  tifoidea,  el  c61era,  etc.,  ea  deeir,  hace  de  ella  viMi 


410        PROCEEDINGS  SECOND  PAN   AMERICAN   SCIENTIFIC  CONGRESS. 

enfermedad  general  infecto-contagiosa  de  la  cual  ee  necesario  y  posible  preservaree  y 
a  lo  cual  se  tiende  hoy  universalmente. 

Vias  del  carUagio. — ^Ea  eete  otro  punto  que  ha  suscitado  discuedonee  numeroeae  y  en 
que  las  conclusioneea  que  han  llegado  los  diferentes  experimentadoree  eetdnlejos  de  un 
acuerdo  perfecto.  Para  noeotios  descartada  la  penetraci6n  del  microbio  por  la  herencia 
en  la  forma  que  dejamos  expuesta  al  tratar  de  ella,  el  bacilo  tuberculoso  puede  pene- 
trar  al  organismo  por  tree  vias,  la  sangufnea  por  la  inoculaci6n,  la  digest! va  por  la 
dige8ti6n,  y  la  a^rea  o  bronquio-pulmonar  por  la  inhalaci6n. 

La  tuberculosis  por  inoculaci6n  es  rara:  eUa  ha  permanecido  en  la  esfera  de  las  inves- 
tigaciones  de  laboratorio  y  presta  allf  preciosos  y  decisi  vos  servicios  a  la  clfnica.  Fuera 
de  esta  esfera  se  observan  raros  casos  de  tuberculosis  por  inoculaci6n  accidental, 
causadas  por  heridas  durante  las  autopsias  y  disecciones  anat<5niicas.  En  la  literatura 
m^ica  se  registra  el  caao  de  Laennec,  quien  se  hiri6  uno  de  los  Indices  aserrando  imas 
vertebras  tuberculosas,  lo  cual  di6  lugar  a  una  tuberculosis  local izada  que  luego  se 
generaliz6.  Estos  casos  se  hallan  localizados  entre  los  estudiantes  de  medicina  y  los 
mozos  de  moigue. 

El  contagio  por  inlialaci6n  e  ingesti6n  es  mds  frecuente,  casi  los  dnicos  medioe  que 
08  observan  en  la  vida  diaria;  se  discuten  atin  la  preponderancia  en  la  propagaci6n  de 
la  tuberculosis  y  a  sus  numeroeas  discusiones  se  han  consagrado  mia  de  una  vida  y 
m^  de  una  d6cada,  sin  que  al  preeente  inhalatorioe  e  ingestionistas  hayan  cejado  en 
solucionar  el  problema  del  lado  de  sus  contenedores  y  respondiendo  con  teorfas  y 
experimentos  a  las  teorias  y  experimentos  que  vienen  a  quitarles  su  preponderancia. 

Pasemos  una  rdpida  ojeada  sobre  unas  y  otras  ya  que  de  ellas  hemos  de  deducir 
necesariamente  las  medidas  preventivas. 

Tappeiner,  Reech,  Koch,  Nocard,  Fliigge,  Kuss  se  encuentran  entre  los  inhalato- 
rios:  asi  Tappeiner  nos  dice  que,  de  sus  investigaciones,  la  inhalaci6n  de  aire  conta- 
minado  produce  la  enfermedad;  Reech  refiere  una  observaci6n  clfnica  de  tuberculosis 
adquirida  por  insuflaci6n  de  aire  contaminado  en  el  reci^n  nacido:  Una  comadrona 
tuberculosa  tenia  la  costumbre  de  aspirar  las  mucosidades  de  los  reci^n  nacidos  de 
boca  a  boca  y  practicaba  de  igual  mode  la  insuf  aci6n  y  10  nifios  cuidados  por  ella 
miuieron  de  meningitis  tuberculosa;  Koch  inhala  cultivo  de  bacilo  tuberculoso  dilufdo 
en  agua  destilada  en  la  tr&quea  de  animales  y  todos  presentaron  leeiones  claras  de  tuber- 
culosis a  pesar  de  haberlos  colocado  en  las  mejores  condiciones  higi6nicas;  el  Prof esor  C. 
Fliigge  de  Breslau  concluye  de  sus  investigaciones  que  la  infecci6n  tuberculosa  por  las 
vias  respiratorias  es,  sin  duda,  m4B  fdcil  y  m&s  grave  que  la  infecci6n  por  via  digestiva. 
Apoydndose  en  estas  investigaciones  de  Fltlgge,  dice  la  Memoria  de  Maggoon  y  Bamet 
de  Cuba: 

Es  posible  producir  experimentalmente  la  tuberculosis  pulmonar  en  varios  animales 
(curies,  conejog,  cabras,  temeros,  perroe),  haci^ndoles  inhalaj  aire  mezclado  con  gotitas 
de  a.^ua  que  coateiigan  bacilos  de  Koch.  En  estas  condiciones  bastan  a  voces  pocos 
bacilos  (50  y  hasta  meiios)  para  provocar  la  aparicion  de  leaiones  tuberculosas  en  el 
pulm^n.  ta  inhalacion  tambi<5a  parece  ser  un  medio  de  infecci6n  superior  aun  en 
rapide^  a  la  irifecci(5n  subcutdnea  no  obstante  ser  ^sta  tan  eficaz.    Por  otra  parte,  se 

guede  demostrar  con  facilidad  en  estas  investigaciones  que  por  la  inhalaci6n  los 
acilos  han  penetrado  en  realidad  hasta  los  bronquios  mas  pequeflos:  para  ello  se 
inoculan  al  curi  en  seguida  de  la  inhalaci6n,  fragmentos  completamente  perlfericos 
del  puhnoti  del  animalque  haya  servido  para  el  experiraento.  Los  curies  sucumben 
con  mur'ha  rapidez  despu^^s  de  estas  inoculaciones.  Por  el  contrario,  cuando  los 
bacilos  se  introducen  en  el  organismo  del  animal  mezclados  con  los  alimentos  se  nece- 
sita  una  masa  enorme  de  bacilos  para  obtener  sfntomas  de  infecci6n  tuberculosa.  La 
infecci6n,  asi  como  el  resultado  nnal,  se  produce  mucho  mds  tarde. 

Es  errunea,  por  consiguiente,  la  opini6n  de  algunos  autores,  de  qu  e  los  bacilos  iuha 
lados  8(31(1  obran  cuando  una  parte  de  ellos  ha  podido  pasar  directamente  al  tubo  diges- 
tive por  la  faringe.  Pudiera  sostenerse  mejor  la  opini6n  opuesta,  esto  es,  que  los  ex- 
perimentos de  tuberculizaci6n  por  los  alimentos  que  han  sido  eficaces,  d^bense  a 
que  se  ha  producido  una  aspiracidn  de  partlculas  alimenticias  aiin  infinitesomales,  que 


PUBLIO  HEALTH  AND  MEDIOINB.  411 

ban  bastado,  pcur  loe  bacilos  que  contengan  para  provocar  una  infeccidn  bronquial 
mis  o  menoe  rapida.  Por  otra  parte,  el  Prof  esor  Fldgge  no  ha  podido  conseguir  nunca 
la  infecci6n  tuoerculoea  de  un  animal  cuando  le  introducfa  directamente,  por  medio 
de  una  tunica  especial,  los  alimentos  mezclados  con  baciloe  en  el  estiSniago  o  en  el 
intestino. 

Si  experimentalmente  los  peligros  de  infecci6n  por  inbalaci6n  eon  mucbo  mayores 
que  loe  de  iniecci6n  alimenticia,  no  ea  posible  sefialar  en  definitiva  sin  otras  investi- 
eaciones,  a  cual  corresponde  la  preponaerancia  de  uno  o  de  otro  de  estos  dos  modes 
de  infecci6n  en  la  tuberculosis  adquirida  espontdneamente.  Serfa  conveniente,  por 
el  contrario,  investi^  cuales  son,  en  las  condiciones  babituales  de  la  vida,  las  opor- 
tunidades  de  infecci6n  para  una  u  otra  via. 

Se  ve  que  la  tuberculosis  por  la  via  respiratoria  conserva  toda  su  importancia,  pues 
por  frecuente  que  sea  la  entrada  de  los  bacilos  tuberculoses  en  el  intestino^  no  sufre 
aqueUa  grandes  efectos  si  n6  se  ha  efectuado  al  mismo  tiempo  la  introduccidn  de  los 
mismos  por  medio  de  la  inhalacidn. 

Los  medios  de  infecci6n  son  muy  diversos  para  el  hombre  y  los  ani males  dom^ticos. 
Cuando  el  curi  o  el  temero  se  alimentan  con  leche  de  vacas  tuberculosas,  se  observa 
casi  constaatemente  que  La  infecci6n  se  verifica  por  via  intestinal;  pero  el  Prof  esor 
Flilgge  expresa  que  aun  asl  la  tuberculinizaci6n  ha  podido  producirse  por  la  respira- 
ci6n  directa  de  gotas  de  leche  baciliferas.  £n  estos  cases  puede  considerarse  como 
excepcional  la  contaminaci6n  por  el  aire. 

Los  animales  que  hayan  escapade  de  la  infecci6n  intestinal  pueden  adquirir  la 
tuberculosis  por  inhalaci6n,  en  la  proximidad  de  vacas  tuberculosas  que  lanzan 
partfculas  baciliferas. 

En  el  bombre  la  infecci6n  se  verifica  de  maneras  muy  variables,  debidoB  a  las 
coetumbres  de  loe  individuos.  Los  nifios  por  ejemplo,  pueden  ingerir  bacilcs  en 
la  leche,  la  mantequilla,  o  llevdndose  a  la  boca  los  dedos  sucioe  con  esputoe.  £1 
profesor  FlOgge  observa  y  con  raz<5n  que  el  pelifro  para  loe  nifios  aumenta  segdn 
la  proporci6n  mayor  de  vacas  afectadas  y  con  la  falta  de  cuidado  y  sefLala  la  incuria 
natural  de  los  tisicos,  por  lo  cual  se  cree  que  bastaria  tomar  precauciones  elementalee 
para  preservar  a  loe  ni&os  supuesto  que  fa  cantidad  de  bacilos  que  pudieee  Uegar  al 
mtestino,  serfa  insuficiente  en  la  gran  mayoria  de  loe  caeos  para  provocar  la  infccci6n. 

De  lo  expueeto  se  deduce:  que  la  inhalaci6n  de  aire  bacilffero  es  la  fuente  mds 
abundante  cle  la  infecci6n  y  que  basta  una  cantidad  muy  pequefLa  de  bacilos  para 
provocar  la  tuberculosis. 

Los  ingestionistas  ban  llevado  por  su  parte,  observaciones  clinicas  y  experimentos 
en  apoyo  a  la  primacia  de  la  infecci6n  por  las  vfas  digest! vas.  Tomemos  las  observa- 
ciones de  Calmette  de  Lille,  tanto  por  ser  las  m^  recientes  cuanto  por  haber  tenido 
en  cuenta  rodearse  de  las  mayores  precauciones  para  alejar  toda  causa  de  error.  Dice 
Calmette: 

*'  Desde  hace  muchos  afios  esta  cuesti6n  ee  el  objeto  principal  de  inveftipt.cionee 
de  laboratorio  que  prosigo  con  ayuda  de  mis  discfpulos  y  en  particular,  de  C.  Guerin. 
Ella  preooupa  igualmente  a  un  gran  ndmero  de  inveetigadoreti  en  todos  los  paises. 
Y  no  es  de  los  menos  apasionados,  asi  como  lo  atestiguan  lae  difccueiones  de  uut^tros 
conpesos. 

Hace  cuarenta  y  tree  afios,  Villemin  nos  en6en6  que  la  tuberculosis  es  inorulable 
y  contagiosa,  y  26  afios  nos  separan  de  la  ^poca  memorable  en  la  cual  Robert  Koch, 
al  deeciibrir  y  cultivar  su  bacilo,  hizo  la  demoetracion  de  su  espeiificidad. 

A  pesar  de  la  enorme  acumulacion  de  trabajos  publicadoe  en  cste  ultimo  cuurto 
de  aiglo.  no  hemos  fijado  sine  mu)^  imperfectamente  la  importancia  respectiva  de 
las  diversas  vlas  por  las  cuales  el  virus  tuberculoso  puede  penetrar  en  el  organif=mo 
del  hombre  y  de  los  animales  sensibles.  Hasta  en  estoe  ultimoH  tiempos  el  mavor 
ndmero  de  sabios,  cllnicos  y  experimentadoret^,  consideraban  como  dogma  intangible 
el  origen  re^piratorio  de  la  tuberculoei^  pulmonar  y  los  resonantes  debates  que  tuvieron 
lugar  en  las  conferencies  interna cionales  de  la  Haya  en  190*3.  Co  Viena  en  1907.  y 
desde  entonces  en  diversas  sociedades  de  sabios.  Critdu  muy  presentee  en  nuestro 
esplritu  para  que  haya  utilidad  alguna  en  recordarlas.  De  ellas  se  desprende  evi- 
dentemente  la  impretddn  de  que  un  acuerdo  definitive  etitd  pr6ximo  a  establet  erfe. 
y  que  oonio  siempre  la  verdad  no  se  encuentra  en  los  polos. 

Si  parece  innegable  en  ciertos  rafoe,  probablcmente  rartimos,  que  la  inf<'( cion 
directa  del  pulmon  por  el  aire  re^pirado  puede  efectuarse.  a  pcsar  de  1?8  multiples 
Ifneas  de  defensa  acumuladas  en  esta  via,  es  manifiesto  que  ei  camino  normalmente 
seguido  por  el  virus  tuberculoso  para  llegar  hasta  el  parenquima  pulmonar  e^,  lo 


412       PBOGBEDINGB  8B00ND  PAH  AMBBIOAN  SOIENTIVIO  OOKGBBSS. 

mia  a  menudo,  la  circulaci6n  linf&tica  o  sangufnea,  por  la  gran  puerta  de  entrada  del 
tubo  digestivo. 

La  experimentacidn  demueetra  que,  para  realizaree  la  tuberculizaci^n  ^rimitiva 
del  pulin6n  por  la  via  a^rea,  es  precise  colocaree  en  condiciones  extra  fisioldgicas, 
come  lo  ban  tiecbo  Nocard  y  Fltk^e  y  m^  recientemente  Kusa,  al  inmovilizar  ani- 
malee  para  obli^rlos  a  respirar  durante  largo  tiempo  una  atrndsfera  caigada  de  polvos 
infectadoH  Kquidoe  o  secos.  Los  polvos  Ifquidos  muy  finos  son  seguramente  ^li- 
grosoe,  sobre  todo  para  los  nifioe;  y  parece  evidente  que  las  neumonias  gaseosas  pnmi- 
tavas  y  las  tuberculosis  pulmonares  agudas  de  la  primera  edad  son  casi  siempre,  de 
origen  resplratorio.  Cuando  una  madre  o  nodriza,  afectada  de  tuberculosis  pulmonar 
cl&ca,  tose  o  estornuda  a  corta  distancia  de  los  labios  de  un  nifio  de  pecbo  que  respira 
con  la  boca  abierta  o  erita  en  espera  del  seno  que  debe  alimentarlo,  el  contagio  por 
inhalacidn  es  cAsi  fatal.  Pero  para  el  nifio  de  m6a  edad  y  para  el  adulto,  este  modo 
de  contaminaci6n  es  seguramente  excepcional. 

^  M&B  excepcional  adn  es  la  inlecci6n  por  los  polvos  secos  y  los  experimentos  posi- 
tivos  de  Comet,  como  los  de  Kuss,  efectuados  encerrando  animales  inmovilizados 
en  un  espacio  cerrado  lleno  de  una  nube  de  polvo  de  talco  o  de  restos  de  fibras  vege- 
tales  mezclados  con  esputos  secos,  no  niega  en  manera  alguna  los  resultados  negativos , 
mucho  mds  numerosos.  sefialados  por  Baumgarten,  T^ppeiner,  Cadeac,  Mallet,  Pater- 
son  y  por  ml  con  Vansteenberghe. 

La  asep?ia  de  la^i  vfas  respiratorias  i  no  atestigua  altamente  la  eficacia  protectora 
de  sus  medios  de  defeu'sa  cuando  4etas  no  est^  atacadaa  por  alguna  lesidn  preexis- 
tente  del  conducto  naso-faringeo,  de  la  laringe  y  de  los  gruesos  bronquios? 

La  adenopatfa  traqueo-bronquial  primitiva  que  ciertos  autores  consideran  siempre 
como  originaria  de  una  infecci6n  respiratoria,  no  puede  ya  ser  invocada  como  un 
aigumento  probatorio  en  favor  de  ^sta. 

oi  ee  exacto,  s^;tin  la  lev  de  Parrot,  que  es  siempre  acompaflada  o  precedida  por  uno 
o  muchos  tub^rculoB  puunonares.  naaa  ^nieba  que  ^tos  sean  de  origen  aer6genOy 
porque  se  presentan  con  extrema  nrecuencia  en  los  animales  artificialmente  infectados 
por  el  tubo  digestivo.  Por  mi  parte  lo  he  observado  regularmente  con  M.  Breton,  en 
un  gran  ntimero  de  curies  a  los  cuales  habfa  hecho  absorber  por  el  recto  o  ingerir  con 
la  sonda  esofagiana  una  pequefia  cantidad  de  emulsi6n  fina  de  cultivo  pure  <&  bacilos 
tuberculoses  bovinos.  A  menudo  estos  animales,  saciificados  despues  de  cuatro  o 
cinco  semanas  no  presentaban  otras  lesiones  que  uno  o  dos  tub^rculos  superfidalee 
del  tamafio  de  una  cabeza  de  alfiler,  ocultos  en  uno  de  los  16bulos  anteriores  del  pul- 
m6n  y  a  los  cuales  correspondfa  un  enorme  infarto  del  paquete  ganglionar  peribron- 
quial.  Un  observador  que  ignorara  las  condiciones  en  las  cuales  se  habfa  efectuado 
la  infecci6n  experimental,  habrfa  afirmado,  sin  duda  alguna,  que  se  trataba  de  una 
contaminaci6n  respiratoria. 

Es  pues  incontestable,  que  si  la  tubercullzaci6n  primitiva  del  pulm6n  o  de  los  gan- 
glios  traqueo-bronauiales  por  inhalaci6n  directa  de  polvos  bacilfferos  es  manifiata- 
mente  poeible  en  algunas  casos,  ella  es  excepcional. 

El  estudio  atento  del  conta^o  tuberculoso  en  los  animales  suministra  abundantes 
pruebas  clfnicas  del  predominio  de  la  infecci6n  por  las  vfas  digestivas. 

Se  sabe,  por  ejemplo,  aue  los  camfvoros,  tales  como  el  le6n,  el  tigre,  la  hiena  o  el 
chacal,  contraen  a  menuao  la  tuberculosis  de  forma  pulmonar  u  viscend  en  nuestros 
jardines  zool6gicos  cuando  se  les  alimenta  con  cames  tuberculosas,  mientras  que  estos 
animales  no  contraen  la  tuberculosis  en  estado  salvaje.  El  perro  se  tuberculiza  cuando 
inffiere  los  esputos  de  su  amo  tuberculoso;  el  temero.  el  gate  y  el  cerdo  contraen  la 
tuberculosis  cuando  se  les  alimenta  con  leche  rica  en  Dacilos. 

Se  ha  insbtido  con  justicia,  en  estos  tiltimos  tiempos,  sobre  la  ausencia  completa 
de  tuberculosis  en  los  cerdos  alimentadoe  exclusivamente  con  mafz  u  otras  subotan- 
cias  vegetales  sometidas  a  la  cocci6n,  mientras  aue  esta  enfermedad  es  extremada- 
mente  frecuente  Mi  donde  se  hace  consumir  a  los  cerdos  reeiduoe  no  pasteurizados 
de  las  lecherfas. 

Es  evidente  que  la  tubetculoeis  que  se  desarrolla  asf,  a  menudo  con  lesiones  primi- 
tivas  de  la  pleura  o  de  los  ganglios  bronquiales,  en  los  cerdos  alimentadoe  con  leche 
dejvacas  tucKurculosas,  resmta  de  la  absorci6n  de  bacilos  por  el  tubo  digestivo.  ^  Lo 
cual  es  debido  a  que  estos  bacilos  ingeridos  pueden  atravesar  las  paredes  del  intestino, 
entrar  en  la  clremacidn  linf&tica  y  sangufnea  y  ser  arrastrados  por  ella,  mis  o  menos 
tiempo,  antes  de  producir  en  el  organismo  los  desarreglos  caracterfsticos  de  la  infecci6n 
tuberculosa. 

Experimentalmente  ha  side  demostradoprimero  por  Chaveau,  de  1865  a  1876 
despu^  por  Vtllemin,  Aufrecht,  G^lach  Kleps,  Gunther  y  Harms  y  muchos  otios 
observadores,  entre  los  cuales  conviene  citar,  sobre  todo  a  Saint  Cyr,  Viseur,  Bol- 
linger, Orth,  Toussaint,  Baumgarten,  Ravinovitch,  Parrot,  Ravenel,  Schroeder  y 


PUBUO  HEALTH  AND  MEDICINE.  413 

Cotton,  etc.  Por  otra  parte  otros  hechoe  negativoB  reeonantee,  particulannente  los 
publicadoB  por  Colin  (ae  Alfort)  y  por  Moeller,  parecen  demoBtrar  que  los  animales 
pueden  tragar  impunemente  granaes  cantidades  ae  sustancias  tuberculosas.  Conoce- 
moe  hoy  la  raz6n  de  ello:  ea  que  la  infecci6n  artificial  del  tubo  dlgestivo  no  se  realiza 
con  seguridad  sino  cuando  se  toman  ciertaB  precaucionee  que  ne  predsado  con  G. 
Gu^rin;  ee  neceesario  hacer  absorber  loe  baciloe  en  eatado  de  divi6i6n  tal,  que  queden 
finamente  emulsionados  como  lo  estdn  en  los  esputos  o  en  la  leche.  En  escaa  condi- 
Clones,  una  sola  comida  infectante  basta  ordfnanamente  para  producir  lesionee  tuber- 
culosas que,  en  los  animates  j6venee,  permanecer&n  a  menudo  localizadas,  por  mayor 

0  menor  tiempo  en  los  ganglios  mesent^ricos  y  que,  en  loe  adultos  aparece  al  contiario 
primitivamente  en  los  pulmones. 

Al  estudiar  el  mecamsmo  de  la  absorcidn  de  poh  os  inertes  por  la  mucosa  intestinal, 
he  podido  comprol.ar  con  Vansteenberghe,  que  se  observan  los  mismoe  hechoe.  La 
iD^ti6n  de  pol  x  os  fines  de  negro  de  hiunOj  o  mejor  de  tinta  china  mesclados  con 
ahmentos,  produce  en  el  cmi  adulto  las  lesiones  tipicas  de  la  antracosis  pulmonar, 
mientras  que  en  el  curi  |o\  en  los  granos  coloreados  permanecen  mds  o  menos  tiempo 
en  los  ganglios  mesent^icos.  Los  cortes  de  fragmentos  de  intestine  delgado,  fijadoe 
durante  la  dijgesti6n,  permiten  entonces  reconocer  eetos  granos  coloieados  englobados 
en  los  leucocitos  y  en  los  a  asos  quilf feros  de  las  a  ellosidades. 

Al  repetir  nuestras  investigaciones  a  este  respecto,  Sir  William  Whitla  y  Sunmers 
han  hecho  recientemente  las  mismas  comprohaciones  y  estos  sabios  indican  un  pro- 
cedlmiento  ingenioso  que  les  ha  permitido  realizar  simult&neamente  la  tuberculosis 
y  la  antracosis  de  los  pulmones  o  de  los  ganglios  meeent^cos;  este  procedimiento 
consbte  en  hacer  absorber  a  los  curies  j5  enes  o  adultoe  una  emulsidn  mixta  de  baciloe 
tuberculoses  y  de  tinta  china  en  aceite  de  olivas. 

^  La  experimentaci6n  sobre  loe  ^ndes  bovideos  permite  establecer,  con  mayor  cer- 
tidumbre  atin,  el  tiayecto  que  siguen  los  bacilos  tuberculosos  para  llegar  hasta  los 
pulmones  ai  se  sacrifica  cada  aninud,  como  lo  he  hecho  con  C.  Guerin,  en  6pocas  m^ 
y  m&B  alejadas  de  la  dnica  comida  infectante.  Puede  imo  convencerse  entonces  que 
estos  bacilos,  asl  como  lo  habla  demostrado  Chauveau  y  despu^  Dobroklc^wski,  atra- 
viesan  la  mucosa  intestinal  aunque  est^  intacta,  y  que  no  dejan  en  ella,  en  la  generali- 
dad  de  loe  cases,  ninguna  hueua  de  su  paso.  Son  transportados  por  los  leucocitos 
polinucleares  deede  los  \  asos  quiliferoe  de  las  a  ellosidades  hasta  los  ganglios  mesen- 
t^ricos  m&B  vecinos. 

En  los  animales  que  atin  maman  y  el  nifio  de  primera  edad,  son  frecuentemente 
retenidos  en  eetos  ^iganos  linfdticos,  que  desempefian  respecto  a  la  linfa  el  papel  de 
un  filtro  casi  periecto.  Ya  loe  bacilos  acaban  por  destrufrse  alll  a  la  lar^,  ya  crean  en 
estos  6rgano6  lesiones  tuberculosas  que  evolucionan  hacia  la  caseificaci6n,  vertiendo 
SUB  microbios  en  los  canales  linfdticos  eferentes^  o  algunas  veces  en  el  peritoneo. 

£n  los  individuos  de  mstyor  edad,  cuyos  ganghos  mesent^ricoe,  como  lo  ha  demostra- 
do Weigc^  son  mucho  m&a  penneables,  los  bacilos — siempre  englobados  en  los  leuco- 
citos polinucleares—son  arrastradoe  en  la  linfa  del  canal  tor^ico  hasta  el  ventriculo 
derecho  del  coraz6n  y  propulsados  en  loe  capilares  del  pulm6n.  Si  loe  leucocitos 
parasitadqs  han  perdido  sus  movimientos  amiboideos  a  consecuenda  de  su  intoxi- 
caci6n  (que  resulta  de  la  tuberculina  secretada  por  los  bacilos),  son  incapaces  de  atra- 

1  esar  por  diapedesis  las  paredes  de  estos  capilares  y  crean  entonces  finas  embolias  que 
ll^aran  a  ser  el  punto  de  partida  de  otras  tantas  formacionee  tuberculosas  a  ezpensas 
de  las  paredes  endoteliales  \  asculares  (granulaciones  grises  de  Ladnnec). 

Las  lesiones  tuberculosas  asf  constituldas  evolucionan  en  seguida,  sea  hacia  calcific 
caci6n,  sea  hacia  la  caseificacidn.  En  la  segunda  altemativa,  los  tub^idos  se  ^  aclan 
en  los  alv^Ios  o  en  algunos  vasos  linf&ticos  o  venenoeos,  con  mayor  rareza  en  una  arte- 
riola.  Entonces  determinan  una  diseminaci^n  m^  o  menos  nlpida  y  m^  o  menos 
grave  de  virus  en  otras  regiones  del  organiamo. 

En  mis  in^  estigaciones  con  C.  Guerin  he  comprobado  siempre  la  extrema  frecuencia 
de  la  adenopatia  traqueo  bronquial  en  los  bovideos  de  poca  edad  cuando  los  bacilos 
han  franquoado  el  Itltro  ganglionar  mes^ntrico  y  eanado  los  pulmones.  Esta  adeno- 
patia eeta  en  relacidn  constante  con  una  o  muchas  lesiones  tuberculosas  subpleuriticas 
que  son  f^Udles  de  descubrir. 

El  origen  digeeti  o  de  estas  lesiones  es  del  todo  evidente.  Las  h^noe  reproducido 
muchas  \  eces  y  Vall^  (de  Alfort)  las  ha  obtenido  igualmente,  sea  alimentando  ter- 
neros  con  leche  de  a  acas  tuberculosas,  sea  inoculando  directamente  loe  bacilos  en  un 
ganglio  mesent^rico  despu^  de  laparotomla. 

Noe  ha  side  posible  obsen  ar,  aaem^,  en  algunoe  de  los  animales  infectadoe  por  las 
viae  digeti>as,  localizaciones  primiti\as  de  la  tuberculosis  en  otroe  6rganoe  que  loe 
ganglios  meeent^cos  o  el  pulm6n. 


414       PBOOBEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  CONGRESS. 

La  hemoe  viato  aparecer  bajo  forma  de  pleuresfa,  de  artiitis,  de  orquitis  y  en  un 
caso  muy  notable,  en  un  cabrito,  bajo  forma  de  iritis.  Estas  localizaciones  excep- 
cionales  no  sobrevienen  sino  en  animales  infectadoa  una  sola  vez  con  d^biles  cantidadee 
de  bacilos.  Se  puede  pensar  que  63tos,  en  raz^n  de  su  pequefio  ntimero,  ban  quedado 
largo  tiempo  en  circulaci6n  en  la  sangre,  arrastrados  por  algunos  leucocitos  polinuclea- 
res  y  ban  acabado  por  constituir  una  lesi6n  tuberculosa  solamente  en  el  6rgano  en 
que  estoa  leucocitos  se  encontraban  cuando  ban  side  heridos  por  la  muerte. 

Cualquiera  aue  sea  la  interpretacidn  ciue  se  d6  a  estos  hecboe,  permanece  cierto 
que  la  tuberculosis  pulmonar  llamada  primitiva  y  que  muchas  otras  formas  o  localiza- 
ciones de  la  infeccion  tuberculosa,  resultan  manifiestamente,  en  gran  ndmero  de  cases, 
de  la  penetraci6n  del  virus  por  la  via  digestiva. 

Los  partidarios  convencidos  del  predomio  de  la  inbalaci6n  sobre  todo  FlUgge  en 
Alemania,  Kuss  en  Francia,  objetan  que  para  producir  experimentalmente  la  tuber- 
culosis por  inge8ti6n  es  preciso  hacer  absorber  a  los  animales  roillares  o  millones  de 
bacilos,  mientras  que  algunas  unidades  de  ^stos  bastan  para  producir  lesiones  tuber- 
culosas  del  pulm6n  cuando  son  inhalados. 

Los  que  piensan  asi  se  olvidan  con  frecuancia  que  de  los  millones  de  bacilos  ingeri- 
dos,  s61o  un  pequefto  ndmero — algunas  unidades,  sin  duda— logran  atravesar  la  mucosa 
intestinal,  y  que  la  mayor  parte  de  los  que  la  franquean  son  destxufdos  ulteriormente 
en  los  gangiios  mesent^ricos.  Finalmente,  pocos  de  entre  ellos  son  arrastrados  por  loa 
leucocitos  al  torrente  linfdtico  del  canal  toracico  y  de  alii  a  los  capilares  del  pulm6n. 
Pero  aqu^Uos  que  llegan  basta  ^1,  determinan  entonces  esas  formaciones  tuberculosaa 
intravasculares  tan  bien  descritas  por  Borrel,  despu^s  por  Letrelle,  y  cuya  lenta 
evoluci6n,  por  accesos  sucesivoe,  acaba  por  crear  la  tisis. 

Si  tantos  medicos  se  obstinan  en  creer  que  frente  al  contagio  tuberculoso  el  hombre 
se  comporta  de  manera  distinta  que  los  ammales,  es  quizd  porque  las  viejas  ideas  sobre 
los  miasmas  pesan  aun  sobre  nuestros  cerebros. 

Sin  duda,  algunos  de  ellos  uos  ban  exagerado  la  importancia  y  la  frecuencia  de  la 
contarainaci6n  del  bombre  por  la  leche,  y  aquellos  que  sostienen  hoy  que  la  tubercu- 
losis se  contrae  por  el  intestine  con  mayor  frecuencia  que  por  las  vlas  respiratorias, 
^ufren  la  pena  do  estas  exageracioues. 

Asl^  debemoe  protestar  contra  esa  tendencia  a  identificar  el  origen  intestinal  con 
el  ongen  alimenticio.  Ciertamente,  para  nuestra  especie,  el  hombre  es — no  me 
cansar^  de  repetirlo  con  insistencia — el  principal  factor  en  la  propagaci6n  de  la  tubercu- 
losis. Pero  creo  que  es  preciso  afirmar  vigorosamente  gue,  si  el  hombre  puede  tomar 
excepcionalmente  la  tuberculosis,  sobre  todo  en  la  prmiera  edad,  por  inhalaci6n  de 
bacuos,  la  contrae  con  mayor  frecuencia  por  la  absorcidn  intestinal,  a  menudo  y  largo 
tiempo  r.^petida,  de  algunos  bacilos  acabados  de  expulsar  por  un  tuberculoso." 

Como  se  ve  de  lo  que  dejamos  transcrito,  de  las  tres  vlas  por  las  cuales  el  mibrobio 
tuberculoso  penetra  en  el  organismo,  la  sangulnea  por  la  inoculaci6n  es  la  menos 
frecuente  y  tambi^n  la  mds  fdcil  de  evitar;  y  de  las  otras  dos  consideramos  cierta  pero 
accessoria,  afortunadamente,  la  infecci6n  por  inhalaci6n,  y  decimos  afortunadamente 
porque  como  dice  Fltigge,  la  llegada  de  polvos  contaminados,  secos  o  htimedos,  al 
pulm6n  por  inhalaci6n,  no  861  o  produce  seguramente  la  tuberculosis,  sino  que  su 
forma  es  de  las  mds  graves;  y  si  la  inhalacidn  tuviera  el  predominio  en  la  etioloi^ia  de 
esta  enfennedad,  como  lo  quiere  ^ste,  la  proporci6n  de  la  morbilidad  y  mortalidad 
tuberculosa  serfa  en  extreme  alarmante  ^Qui^n  no  ha  estado  sometido  alguna  vez  a 
la  acci<jn  de  polvos  baciiferojs  diseminados  en  el  aire?  iLos  inismos  experimentadores 
podrfan  ponerse  al  abrigo  de  la  contarainaci6n  al  manejar  esos  polvos  secoa  casi  im- 
palpables  e  imperceptibles?  Ahora  la  experiencia  diaria  nos  presenta  casos  fre- 
cuentfsimoa  de  focos  tuberculosos  fainiliaros  en  que  la  mayorfa  de  los  convivientes  del 
tuberculoso  escapan  a  la  im'ecciou,  y  esto  no  obstante?  estar  todos  some  tides  a  la 
misna  aereaci6n.  Queda  pues  la  inQ:esti6n  como  la  mds  frecuente  de  la  viaa  de  la 
infecci6n  tuberculosa,  por  la  gran  puerta  de  entrada  del  tube  inU»stinal. 

Meciios  dc  cGul^igio- — De  una  manera  i  cneral,  todo  producto  de  twcre^ion  u  Cv  fecre- 
ci6u  que  contenc^a  elTai^io  de  iCorli,  es  nn  medio  de  contauo. 

Lo  contieuen  KeneralmentS.el  e-puto,  las  materias  estercorales,  la  orina,  la  esperma, 
etc.,  cuando  son  emitidos  por  unl^Sterculoso  de  las  vfas  respiratorias,  del  intestino,  del 
aparato  uro-genital,  etc.,  respectivam>4it^  y  el  pus  de  los  abeesos  tuberculosos.  El 
bacilode  Koch  arrastrado  al  medio  ambien!5S^o''^sta8sr^rTecionesoexrre-ioue3,  pacde 


PUBLIC  HEALTH  AND  MEDICINE.  415 

enoontnr  ocasLdn  de  penetrar  en  un  (nganismo  indemne  pero  receptivo  y  constituir  aaf 
iin  medio  de  rontagio. 

Oomet  dice:  ''el  esputo  y  especialmente  el  eeputo  seco,  ea  la  sola  causa  de  la  propa- 
g»ci6a  de  la  ttrberculosis  pulmonar; "  Villemin  habfa,  13  afios  antes  del  deecubrimiento 
de  Koch,  indicado  con  su  admirable  perspicacia  el  papel  que  deeempefian  los  esputos 
en  el  contag:io. 

Bl  esputo  bacillfero  es  el  medio  mis  frecuente  de  contagio,  ya  sea  que  desecado  y 
imlveriiado  venga  a  mezdarse  con  el  aire  ambiente  y  penetre  excepcionalmente  en 
los  bionquios  o  los  alveoles  pulmonares,  o  que  contamine  los  alimentos  o  que  de  cual- 
quiera  otro  mode  Uegue  en  estado  de  divisi6n  extrema  al  intestino. 

Dmante  laigo  tiempo  se  ha  considerado  la  opini6n  de  Comet  como  axiomitica. 
Hoyy  aegdn  las  nuevas  investigaciones,  6sta  pierde  su  predominio  en  favor  de  la  del 
espato  fresco,  acabado  de  expulsar: 

£1  Profesor  Fltkgge  insists  sobre  el  peligro  que  i^esentan  las  partfculas  de  la  ex- 
pectoraci6 1  de  los  enfermos  lanzadas  durante  la  tos,  y  las  considerft  como  la  fuente  de 
mfe^cidn  m^s  comdn,  sobre  tpdo  en  el  memento  en  que  se  arrojan.  S^dn  (A  es  mucho 
mds  rara  la  infecci6n  debida  al  polvo  de  los  esputos  desecados.  £1  pe&^  per  la  jmo- 
yecci6n  de  la  tos  de  gotitas  bacilfferas,  es  de  extrema  frecuenda;  adquiere  mayor  im- 
portanda  a<!in  en  las  reladones  de  madre  a  hijo,  de  enfermos  con  emermeros,  de  los 
c6nyuge6  eatre  sf.  de  los  obreros  con  bus  compafieros. 

I^  causa  mis  frecuente,  mis  eficaz,  de  la  propagaci6n  de  la  tuberculosis  es  el  pro- 
ducto  de  ]o8  tisicos  en  el  instante  mismo  de  su  emision.  (Maggoon  y  Bamet,  Memoria 
citada.) 

El  Tnieoon  Oalmette  es  de  opini6n  tambi6n  que  el  esputo  fresco  es  el  agente  prin- 
dipal  de  la  propagaci6n  de  la  tuberculosis,  y  a  ^1  debe  incriminarse  la  extensi6n  de  la 
enfermedad  por  sobre  cualquier  otro  medio  de  contagio: 

El  peligro  es  iufinitamente  mavor  v  mis  frecuente  por  los  bacilos  de  origen  humane 
recientemente  salidos  del  pulmon  de  un  enfermo,  cuando  son  transportados  de  los 
esputos  a  nuestros  alimentos  o  a  la  mucosa  bucal  por  el  oontacto  directo  o  indirecto  de 
laboca,  de  las  manos,  de  los  objetos  contaminados  o  de  las  moscas.  La  madre  tubercu- 
losa que  prueba  el  potaje  destinado  a  su  hijo  o  que  le  enjuga4a  cara  con  su  pafluelo, 
la  nodriza  que  lubnfica  el  seno  con  su  saliva,  el  nifio  que  toca  sus  alimentos  despu^ 
de  liaber  paseado  sus  manos  sobre  los  pisos.  el  adulto  que  moja  sus  dedos  llevinooloe 
a  la  boca  para  hojear  un  libro,  para  manejar  caracteres  de  imprenta  o  para  servirse  de 
instrumentos  que  pertenecen  a  tuberculoses  que  arrojan  bacflos,  ingieren  a  cada  ins- 
tante al<?unos  microbios  virulentos  y  los  riesgos  de  contaminad6n  son  para  ellos  tanto 
mis  graves  cuanto  que  estas  ingestiones  son  mis  abundantes  y  mis  repetidas. 

Los  bacilos  que  contiene  el  esputo  acabado  de  emitir  pueden  ser  transportados  a 
nuestros  alimentos  por  los  insectos.  La  mosca,  ese  insecto  casero  que  nos  acompafla 
por  doquiera,  que  pulula  alii  donde  nuestros  alimentos  se  encuentran,  que  Uena,  en 
ciertas  estaciones  del  afio,  de  una  manera  ins61ita  comedores,  cocinas,  odles  y  sobre 
todo  en  la  exposid6n  alimenticia  sin  abrigo  a  la  contaminaci6n,  que  llamamos  mer- 
cadoy  es  uno  de  los  elementos  mis  eficaces  para  la  propagaci6n  del  contagio:  ella  se 
posa  sobre  los  esputos,  ingiere  cantidad  de  ellos  y  parte  lleva  en  sus  patas  para  luego 
abandonarla  en  los  alimentos  y  contaminarlos  de  este  modo.  No  s61o  es  peligrosa  la 
mosca  por  que  acarree  el  bacilo,  sine  tambi^n  porque  al  morir  y  pulverizaree  puede 
dejar  un  residue  que,  contiene  el  bacilo  de  Koch  si  ha  ingerido  esputos  badlfferos,  y 
es  infectante.  Sus  excreciones  tambito  lo  contienen  y  pueden  obrar  a  la  manera 
de  SOS  cadiveres,  mezdindoee  al  aire  ambiente  y  contaminando  nuestros  alimentos 
o  los  objetos  de  nuestro  diario  y  reiterado  use.  Si  tenemos  en  cuenta,  ademis,  las 
laigas  excursiones  que  ellas  hacen,  se  comprende  el  amplio  papel  que  deeempefian 
como  medio  de  propagad6n  de  la  tuberculosis  y  de  otras  enfermedades  infecto-con- 
tagioeas. 

Si  bien  es  cierto  que  en  algunas  de  nuestras  dudades  de  la  AmMca  Hispana,  se 
han  dictado  medidas  sanitarias  para  contrarrestar  el  peligro  de  la  mosca,  en  la  gene- 


416       PBOOEEDINGS  SECOND  PAN  AMEBIOAK  80IENTIFI0  00KQBE8S. 

ndidad  de  ellas  no  ha  dado  el  resultado  apeteddo,  debido  a  que  no  ae  da  el  publico 
cuenta  exacta  de  lo  que  esas  medidae  signiiican  y  por  ello  son  mal  acogidas  per  IO0 
vendedores  de  siistancias  alimenticias,  los  cuales  desean  tener  siempre  a  la  vista  del 
pdblico  SUA  artfculoe  de  expendio. 

La  chinche,  tan  comdn  en  las  poblacionee  de  clima  tropical,  tambi6n  ha  side  ia-^ 
criminada  de  trasmitir  la  tuberculosis. 

Los  animales  dom^ticos  tambi^n  pueden  ser  contaminados  por  el  badlo  humano 
y  a  BU  vez  constituir  un  medio  de  contagio.  Tenemos  una  observacidn  del  Dr. 
Ta8c6n,  el  cual  la  tom6  en  el  Hospital  San  Jos^  de  Buga. 


Una  enferma  atacada  de  tuberculosis  pulmonar  aguda  tenia  una  inapetencia  abso- 
luta,  por  lo  cual  86I0  tomaba  poquitos  de  leche,  y  contra  mi  expresa  voluntad/  le 
daban  Us  sobras  a  un  gate  que  criaban  en  dicho  hospital  con  mucha  estimaci6n.  Poco 
tiempo  despu^s  cuando  atm  vivla  la  enferma,  aquel  pobre  animal  empez6  a  revelar 
los  sintomas  caracterlsticos  de  una  tuberculosis  pulmonar,  por  lo  cual  nube  de  sacri- 
ficar  el  animal  y  comprobado  el  contagio  hice  incinerar  el  cad&ver,  para  evitar  que 
a  su  vez  constituyera  un  encadenamiento  de  propagaci6n  de  la  enlermedad. 

Bien  conocida  es  esa  extrafia  manera  de  proceder,  de  las  mujeres  sobre  todo,  con 
los  animales  domdsticos,  ya  se  trate  de  im  falderillo,  de  un  gato,  de  un  loro,  etc.,  en 
qjie  la  extravagancia  las  lleva  hasta  besar  y  alimentar  de  boca  a  boca  a  dichos  animales. 

Esta  pr&ctica  trae  consigo  que  si  dichos  animales  contraen  la  tuberculosis,  como  en 
el  case  arriba  transcrito,  la  trasmiten  seguramente  a  sus  dueHos  o  allegados  de  ^tos. 
El  peligro  de  esta  convivencia  es  mucho  mayor  cuando  se  trata  de  gentes  de  baja 
clase,  pobres,  habitantes  de  bohardillas. 

La  observaci6n  que  hemos  transcrito  es,  adem^,  muy  l^rtil  en  ense£Lanzas,  y  nos 
indica  que  no  b61o  el  esputo  del  tuberculoso  es  nocivo,  sino  tambi6n  su  saliva,  ya 
que  restos  de  ^sta  fu6  la  que  infect6  la  leche,  y  no  puede  ser  de  otro  modo  puesto  que 
la  boca  es  el  camino  normal  y  reiterado  de  los  bacilos  que  salen  del  &rbol  aereo.  De 
ahf  que  la  opinion  del  Profesor  Flugge  sobre  la  importancia  de  ''las  particulas  de  la 
expectoraci6n  de  los  enfermos  lanzadas  durante  la  tos,"  la  hagamos  extensiva  a  las 
particulas  de  saliva,  producto  mis  flufdo  y  por  consiguiente  mis  ficil  de  pulverizaise 
por  la  corriente  de  aire  expirado. 

La  contaminaci6n  por  las  materias  estercorales  del  tuberculoso,  t<»na  amplia  parte 
en  el  contagio  en  nuestras  ciudades  y  aldeas  donde  estas  materias  son  arrojadas  a 
posos  ciegos  o  derramadas  sobre  el  suelo;  las  moscas,  y  los  animales  dom6sticos  que 
sinron  a  la  alimentaci6n  humana  pueden  contagiarse  y  continuar  los  eslabones  de  la 
cadena  de  contagio. 

El  bacilo  de  Koch,  hu6sped  de  un  individuo  tuberculoso,  penetra  a  voces  nueva- 
mente  en  su  organismo  despu^  de  haber  sido  expulsado  de  61,  e  infectar  un  aparato 
u  6igano  hasta  entonces  indemne;  es  lo  que  se  llama  auto-infecci6n.  En  el  estado 
actual  de  nuestros  conocimientos  y  en  consecuencia  con  las  opiniones  del  Profesor 
Galmette,  siguiendo  estos  bacilos  la  misma  via  que  sus  predecesores  se  localizan  en 
otro  punto  del  organismo,  porque  encuentran  alii,  ya  sea  por  un  estado  patol^co 
posterior  a  la  infecci6n  tuberculosa,  ya  por  que  herido  el  organismo  de  decadencia 
vital  por  la  acci6n  de  toxinas  del  bacilo,  un  locus  minorU  reaiBtentiae  o  se  deja  invadir 
en  cualquier  punto  atacado,  privado  como  se  halla  de  sus  medios  de  defensa. 

Esti  fuera  de  discuBi6n  que  el  bacilo  humano  produce  la  tuberculosis  en  los 
animales  no  refractarios  a  ella  y  con  tanta  rapidez  y  seguridad  en  algunoe  de  ellos, 
como  el  curf,  llamado  por  esta  raz6n  animal  reactive.  Los  animales  a  su  tamo  tras- 
miten su  tuberculosis  al  hombre. 

Sobre  el  tapete  cientlfico  se  encuentra  adn  la  cuestidn  de  identidad  o  dualidad  de 
los  bacilos  tuberculoses  en  el  hombre  y  los  animales  dom6sticoe.  Este  asunto  ha 
side  objeto  de  numerosos  trabajos  de  parte  de  los  experimentadores  y  el  angem  de 


PUBLIC  HEALTH  AKD  MBDIOINB.  417 

numerosas  discuaioiiefl  cientfficas  en  dlBtintas  corporaciomefly  sin  que  a  la  bofa  {Mreeente 
0e  haya  llegado  a  una  soluci^n  satisfiictoria  entie  las  opiniones  extremas. 

En  1901  el  ilustre  Koch  hacia  conocer  solemnemente  estas  doe  condusioneB:  (1)  La 
tuberculosis  humana  difiere  de  la  tuberculosis  bovina  y  no  puede  ser  traamltida  a  los 
ganados;  y,  (2)  la  trasmisidn  al  bombre  de  la  tuberculosis  bovina  por  la  lecbe  o  la 
came,  es  apenas  mis  frecuente  que  la  tuberculosis  b^reditaria:  por  consigpiente,  no 
ee  necesario  tomar  medida  alg:una  para  contrairestarla. 

Estas  conclusioneB  del  sabio  mis  endnente  en  materia  de  tuberculosis,  diecon  lugar 
a  numerosos  trabajos  contradictorios.  Youg,  Fibiger,  y  Arloing,  establecen  la  iden- 
tidad  de  la  tuberculosis  bumana  y  bovina  y  no  bacen  diferenda  entre  las  dos  que  la 
de  mayOT  virulenda  del  bacilo  bovino.  Gratia  declara  la  identidad  de  todas  las 
tuberculosis.  Bujwid  y  Perroncito  son  partidiarios  de  la  dualidad.  LOffler,  Kossel, 
Pfeiffer  y  Waserman  admiten  la  infeccidn  posible,  muy  rara  adem^  del  bombre  por 
el  bacilo  bovino,  pero  sostienen  la  teorla  de  su  maestro  Kocb. 

La  maycurla  del  Gongreso  Intemacional  de  Higiene,  reunido  en  Bruselas  en  1903, 
sin  estar  en  &vor  de  la  identidad  de  los  badlos  en  las  diferentes  espedes  animales, 
cree  necesario  prescribir  medidas  contra  los  peligros  de  contagio,  posibles  para  el 
bombre,  de  la  tub«x;ulosis  bovina. 

ligni^res,  quien  acepta  con  la  mayoria  de  los  experimentadores  el  peligro  del 
contagio  para  el  bombre,  de  la  tuberculosis  bovina,  termlna  en  su  estudio  titulado 
' '  La  tuberculosis  humana  y  la  de  los  animales  dom^stlcos, ' '  con  estas  concluslones,  que 
si  no  resuelven  el  punto  de  identidad,  si  merecen  tenerse  en  cuenta,  considerada  la 
cuestidn  desde  el  punto  de  vista  profiliU^tico: 

Las  tuberculosis  verdaderas  encontradas  en  el  bombre  y  en  los  animales  dom^sticos 
se  deben  a  badlos  pertenedentes  todos  al  mismo  grupo,  a  la  misma  especie:  al  badlo 
de  Koch,  que  sufre  la  ley  general  de  la  variedad  de  los  tipos. 

Asi  es  que  a  m^  de  las  vaiiedades  posibles  y  todavla  indeterminadas,  conocemos 
ya  los  tipos  diferentes,  a  saber:  el  badlo  tuberculoeo  tipo  bovino  que  861o  es  una 
variedad  del  tipo  humano,  o  viceversaj  los  badlos  tipo  aviario  y  tipo  pisciario,  que 
son  razas  dintintas  entre  sf  y  entre  los  tipos  humano  y  oovino. 

Ya  que  el  bacilo  tuberculoeo  del  bovfdeo  puede  infectar  al  bombre,  sobre  todo  a 
los  nifios  de  corta  edad,  y  aunque  esta  contamlnad6n  parezca  por  ahora  excepdonal, 
serla  una  culpa  grave  abandonar  la  lucha  tan  sabiamente  reglamentada  contra  la 
tuberculosis  bovina.  Es  preciso,  al  contrario,  proseguirla,  completarla  y  extenderla 
todavla  a  las  demds  tuberculosis  animales.  no  solo  para  contrarrestar  el  posible  contagio 
al  bombre,  sine  al  mismo  tiempo,  y  de  ello  se  olvidan  muy  a  menudo,  para  combatir 
las  tuberculosis  animales,  particularmente  la  bovina,  que  tiende  a  duundirBe  cada 
vea  xdAb  en  los  ganados. 

£1  Dr.  Gache,  en  su  libro  titulado  ''La  tuberculosis  en  la  Repdblica  Argentina," 
llama  la  atend6n  acerca  de  la  propagaddn  de  la  tuberculosis  por  la  came  de  los 
bovldeos,  y  Arloing  dtado  por  ^1,  hace  notar  que  la  disminuci6n  de  la  tuberculosis 
humana  en  Lyon  y  su  aumento  en  Burdeos,  por  ejemplo,  podrfa  muy  bien  deberse 
a  la  mayor  severidad  de  la  inspecd6n  de  cames  en  la  primera  dudad. 

El  mismo  Dr.  Gache  nos  dice  que  los  criadores  de  la  Argentina  ban  comprobado 
que  los  animales  tuberculoses  se  encuentran  dempre  entre  los  de  media  aangre,  es 
dedr,  que  resultan  del  cruce  de  animales  indfgeuas  con  importados: 

Durante  la  6poca  que  precedi6  a  la  importad^  de  animales,  la  tuberculosis  no  se 
encontraba  sino  excepdonalmente  en  el  rebafio  argentino,  pero  desde  hace  algunos 
afios,  desde  que  se  ha  comenzado  a  mejorar  la  raza Introduaendo  toros  y  vacas  Dur- 
ham y  Jersey,  etc.,  esta  enfermedad  esti  muy  espardda  y  su  difusi6n  prosresa  en  in- 
tima  relad6n  con  el  grade  de  afinamiento.  An  pues,  a  medida  que  el  cruce  hace  perder 
al  rebailo  aigentino  sus  oondidones  primitivas  para  darle  un  aspecto  bello  y  esbelto  de 
que  careda,  sus  cuididades  de  vitalidad  se  debilitan,  su  oiganismo  degenera,  su 
eneigia  y  su  resistenda  disminuyen.  Es  un  triste  privilege  que  los  animales  de  rsmgo 
elevado  haa  incoipoiado  a  nuestra  prindpal  fuente  de  nquesa,  al  mezclar  su  sangre 
azul  a  la  sangre  roja,  criolla,  de  los  de  las  praderas  argentinas. 


418       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  CONGRESS. 

Estas  comprobaciones  del  Dr.  Gache  han  eddo  observadas  tambi^n  en  algunos  otros 
puntos  de  la  America  Latiixa,  entre  otroe  en  Bogota  por  el  Dr.  Federico  Lleras  A. 

Pero  si  la  tuberculosis  bovina  no  es  frecuente  en  nuestros  pafses  y  por  consiguiente 
el  peligro  de  contaminaci6n  al  hombre  por  eUa  es  cast  nulo,  no  lo  es  que  41  existe  por 
la  contammaci6n  de  las  cames  y  sobre  todo  de  la  leche  por  el  bacilo  humano.  En  la 
generalidad  de  los  cases  la  came  y  la  leche  puede  contaminarse  por  el  bacilo  humano 
deede  el  matadero  o  el  establo  hasta  el  lugar  de  consume,  ya  que  o  no  hay  in6pecci6n 
sanitaria,  o  la  que  existe  es  tan  deficiente  que  a  veces  constituye  un  peligro  mayor, 
que  si  no  existiera.  Es  notorio  el  deeaseo  de  los  matanceros,  su  falta  absoluta  de  cono- 
dmientos  higi6nicos;  lo  mismo  sucede  con  los  acarreadores  de  came,  con  sus  vehfcolos 
y  acceeorios. 

Entre  este  personal  no  es  rare  encontrar  individuos  que  sean  tuberculoses  o  al  menos 
que  padezcan  de  enfermedades  del  irbol  a^reo  (poitrinaires,  que  dicen  los  m^icos 
franceses).  Puede  comprenderse  el  immense  peligro  que  existe  con  este  modus 
fjivendij  si  se  considera  ademds  que  el  personal  veterinario,  salvo  ligeras  excepdones 
es  de  una  incompetencia  absoluta.  Este  peligro  de  contaminaci6n  es  mayor  para  la 
leche,  medio  de  cultivo  por  excelencia  para  la  generalidad  de  los  micro-organismos, 
puesto  que  los  lugares  de  expendio  de  este  articulo  de  primera  necesidad  reunen  todas 
las  condiciones  para  una  fdcil  y  segura  contaminaci6n:  tienduchoe  donde  se  barre 
al  seco,  hay  aglomeraci6n,  y  adultos  y  nifios  con  enfermedades  del  pecho.  A(in 
para  las  ciudades  que  tienen  una  inspeccidn  de  cames,  existe  el  peligro  de  las  for&neas, 
ya  que  la  salaz6n  puede  disimular  y  disimula  en  ocasiones  a  las  cames  contaminadas, 
tal  como  el  expendio  de  ella  se  hace  en  la  generalidad  de  nuestras  ciudades.  Noso- 
tros  consideramoe  puee,  el  peligro  de  la  came  y  de  la  leche  no  deede  el  punto  de  la 
tuberculosis  bovina  sine  de  la  contaminaci6n  de  estos  artfculos  por  el  bacilo  humano, 
obrando  a  la  manera  de  vehfculos  trasportadores  del  bacilo  de  un  individuo  enfermo 
a  otro  sano,  del  mismo  modo  que  el  pan,  en  cuya  elaboraci6n  toma  parte  un  pergonal 
alcoh61ico,  que  trasnocha  constantemente  y  que  se  tuberculiza  f&cilmente. 

CONTAGIO  EN  LOS  DIVER808  MBDIOS  80CIALES. 

1.  La/amilia. — El  tuberculoso  cuidado  en  su  casa  es  hoy  el  mds  terrible  agente  para 
la  propagaci6n  de  la  tuberculosis,  no  861o  para  los  suyos,  sine  tambldn  para  todos  los 
que  Ueguen  a  tener  con  61  algimas  relaciones.  Cuando  se  presenta  en  un  miembro  un 
caso  de  tuberculosis  pulmonar,  se  llama  al  medico  en  los  ataques  agudos;  41  prescribe 
lo  necesario  para  contener  la  tempestad  del  memento;  alivia  mas  no  cumple  la  alta 
misi6n  que  le  estd  encomendada:  salvar  del  peligro  inminente  la  vida  de  los  allegados 
del  enfermo,  por  las  siguientes  razones:  o  cree  que  no  debe  alarmar  a  la  familia  del 
paciente  indicdndole  la  gravedad  del  mal,  present&ndole  el  cuadro  sombrio  que  estd 
en  gestaci6n,  aunque  no  le  sea  desconocido  el  valor  del  silencio;  o  si  asf  lo  hlciere  el 
hablar  de  cambio  total  de  vida,  de  separacidn  del  enfermo  y  sus  allegados  bajo  el 
peligro  de  contagio,  encontrari,  en  la  generalidad  de  los  cases,  resistencia  de  parte  de 
ambos:  del  primero  por  no  abandonar  su  vida  de  comodidad  o  de  lujo,  si  se  trata  de 
un  rico;  porque  es  menester  el  trabajo  diarlo  para  el  sustento  de  los  suyos,  si  no  lo 
es,  y  del  segundo  porque  puede  oponerse  a  conveniencias  sociales,  a  asuntos  de  interns; 
o  porque  un  altniismo  mal  entendido  hace  imposible  la  8eparaci6n,  juzgando  los  temores 
del  medico  exagerados  o  innecesarios.  Esto  hace  que  el  contagio  sea  un  hecho  inexo- 
rable. En  cases  muy  raros  el  medico  es  un  individuo  de  espiritu  recto,  altmista 
en  el  sentido  estricto  de  la  palabra,  entonces  puede  entablarse  la  lucha  entre  41,  la  familia 
y  el  paciente,  y  si  al  fin  logra  imponerse,  generalmente  es  ya  un  poco  tarde:  el  germen 
del  contagio  ha  tenido  tiempo  de  echar  sus  cimientos. 

El  m4dico  prescribe  durante  el  ataque  agudo,  la  escupidera  con  soluci6n  desin- 
fectante  o  sin  ella;  esto  tiltimo  es  la  r^la  general,  pero  despu^s  que  el  enfermo  se 
levanta,  que  vuelve  a  sus  quehaceree,  sus  esputos  van  a  enmiciar  elsuelo,  las  parades, 
etc.,    de   su   alojamiento,   de   su  gabinete  o  taller,   diseminaado   aquf   y    alii 


PUBLIO  HEALTH  AKD  BOSDICIKE.  419 

innumerablee  bacilos,  que  transportadoe  por  las  moecas  o  xdAb  tarde  por  la  pulveii* 
zaci6ii  de  los  esputoB  extendidos  en  capas  delgadas  por  los  piee  o  la  alcoba,  van  a 
infectar  a  otros  de  los  que  cohabitan  con  ^1.  El  tuberculoso  se  sienta  a  la  mesa  comtin 
sin  que  en  la  mayoria  de  los  casos,  haya  8eparaci6n  alguna  entre  los  cubi^rtos,  serville- 
tas,  etc.,  de  8u  uso  y  si  la  hubiere,  es  de  resultados  nulos  puesto  que  los  objetos  Benin 
lavadoe  en  comtin  con  los  dem^.  La  desinfecci6n  previa  es  cosa  que  nadie  conoce 
ni  se  preocupa  de  ello.  El  tuberculoso  cuidado  en  su  casa,  generalmente  vaga  de 
consultorio  en  consultorio  antes  de  que  se  le  haga  un  diagn6stico  positivo,  o  que  al 
menos  se  le  infcnrme  de  ese  diagn<38tico  y  de  los  peligros  que  su  enf ermedad  puede  traer 
a  su  familia. 

En  toda  familia  donde  existe  im  tuberculoso  adn  avanzado  6ste  recibe  de  sus  aUe- 
gados,  madre,  esposa  o  hija,  los  alimentos  que  prueban  con  el  mismo  cubierto  del 
enf  ermo,  muchas  voces  despu^  que  6ste  los  ha  lle\^o  a  la  boca,  imas  voces  para  haceile 
ver  que  estdn  bien  preparados  o  apetitosos  y  otras  para  hacer  ostentaci6n  de  que  mi 
estado  no  les  inspira  temor  o  repugnancla.  Los  niilos  de  la  casa  reciben  sus  cariciaa 
y  la  familia  en  general  permanece  algunas  boras  del  dla  en  su  cuarto,  a  voces  sentada  en 
la  misma  cama  del  enfermo  haci^ndole  compaflfa  en  medio  de  un  aire  contaminado 
por  las  partfculas  de  esputo  y  de  saliva  que  se  diseminan  en  el  ambiente  durante 
los  accesos  de  tos,  y  a  las  cuales  el  Profesor  Fltkgge  da  una  importancia  capital  en  la 
propagaci6n  de  la  enf  ermedad .  Para  el  ta^co  es  en  verdad  duro  piivar  a  un  individuo 
pr6ximo  a  abandonar  la  vida,  de  las  tiltimas  fruicionee  familiares:  ^pero  no  lo  es  mis 
contemplar  con  la  estoicidad  de  un  c6mplice  que  el  flagelo  extienda  sus  negras  alat 
sobre  un  grupo  de  seres  a  quienes  se  puede  salvar  de  sus  garras?  Rodeane  del  valor 
necesario  para  hacer  comprender  el  peligro,  es  la  tarea  del  mddico,  escabrosa  en  verdad, 
por  la  resistencia  que  encontraii  de  parte  de  la  familia  y  del  enfermo;  pero  del  cumpli- 
miento  de  la  elevada  misi6n  que  le  est&  enconwndada  por  magisterio  de  su  profe8i6n 
depende  el  6xito  de  ella.  De  esta  manera  se  ensefia  al  tuberculoso  a  hacer  profilaxia 
no  s61o  para  los  suyos,  sino  tambito  para  ^1  mismo,  evit&ndole  inf  ecciones  secundarias, 
y  con  la  esperanza  de  que  los  suyos  no  ser&n  contaminadoe,  debe  ademis  incuktoele 
f e  en  la  curabilidad,  en  algunos  casos,  porque  ello  sea  de  esperarse  dados  los  medios 
con  que  se  cuente,  y  en  otros  como  un  lenitivo  moral  indispensable;  es  seguro  que 
pondri  todo  su  contingente  al  servicio  de  la  ciencia  y  luchaiA  por  el  triunfo  de  ella, 
ya  que  luchar  es  un  sentimiento  innate  en  la  humanidad. 

"  El  medico,"  como  dice  el  ]m>fesor  Granchet,  **  debe  al  enfermo  la  verdad,  toda  la 
verdad "  y  creemoe  que  ella  solamente  d6  los  resultados  que  acabamos  de  anotar. 
Adem&B  dd  oontagio  directo  por  el  tuberculoso  cuyos  esputos  pulveriiados  van  a 
mezdane  con  el  aire,  impregnando  las  ropas  de  su  uso,  las  de  su  cama,  infectadas, 
ya  poique  escupa  en  ellas  o  porque  durante  los  accesos  de  tos  se  ensude  con  las  partf> 
culas  de  esputos,  ^stas  van  al  lavadero  con  las  de  los  individuos  sanos,  y  por  consi- 
goiente  serto  un  medio  de  ccmtagio  tanto  para  su  faonilia,  como  para  la  encaigada  de 
lavarlas;  poique  si  como  es  el  case,  generalmente,  la  lavandera  se  encuentra  agotada 
por  el  trabajo,  alcoholismo,  tabaquismo,  mala  alimentad6n,  tenemos  en  ella  un  candi* 
dato  seguro  para  la  tuberculosis  y  para  propagarla  entre  los  suyos  y  los  que  a  ella  ocupen. 

Gomo  se  ve  el  encadenamiento  de  este  orden  de  cosas  no  puede  ser  mejor  estableddo 
para  la  propagaddn  del  ccmtagio. 

El  aseo  en  las  habitadones  en  nuestras  dudades  se  hace  generalmente  por  medio 
del  barrido  al  seco  lo  cual  levanta  nubes  de  polvo  que  van  a  depositane  sobre  ka 
muebles,  libros;  si  se  trata  de  un  comedor  sobre  los  alimentos  que  eMn  desti^fMMloa 
o  mal  protegidos,  sobre  la  vajilla  o  resto  de  ella,  para  despu^  servirse  de  ellos  sin 
{Mrecauddn  alguna.  Ya  se  comprende  el  peUgro  que  esta  manera  de  proceder  acarrea 
pueslo  que  el  traumatismo  de  los  pulmones  por  el  polvo  absorbido  aun  no  badUleio 
crea  en  elloa  una  menor  resistenda  en  su  tejido  y  aomenta  el  peUgro  de  contagio  it 
las  alfombras,  pisos,  etc.,  se  encuentran  contandnados  por  esputos  badlflefos.    Ouando 

68486— 17— VOL  x 28 


420       PBOCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC  C0NQBB8S. 

el  tuberculoeo  muere  generalmente  no  se  prescribe  la  deemfecci6n  y  si  la  familia  no  ha 
sido  alecdonada  sobre  la  conducta  que  debe  obeervar  respecto  a  loe  objetoe  de  uso 
del  enfermoy  como  tambi^n  es  de  regia  general,  y  ademds  arraigada  la  idea  de  la 
herenda  morboea  siendo  casi  desconocida  la  manera  de  propagaci6n  por  el  contagio, 
loe  objetoe  propagadoree  de  ^ete,  sin  deeinfeccidn  previa  van  a  servir  a  loe  sobrevivienteB 
o  se  regalan  a  loe  menesteroeoe,  que  llevan  en  su  limnena  un  medio  de  acabar  mib 
prcmto  eu  existenda.  De  eeta  manera  ee  van  deearroUando  eeoe  focoe  que  la  humani- 
dad  llama  hereditarioe  y  que  en  verdad  no  eon  eino  contagio.  Caeoe  de  ^etos  eon 
obeervadoe  por  loe  m^dicoe  do  todoe  loe  paieee,  para  que  haya  inter^  alguno  en  citar 
^emploe. 

Eete  contagio  en  el  medio  familiar  ee  mucho  m^  frecuente  y  m4B  alarmante  cuando 
ee  trata  de  la  &unilia  obrera,  Y  la  raz6n  ee  obvia:  basta  echar  una  ojeada  eobre  la 
vida  del  obr^ro  en  casi  todas  las  ciudadee  de  alguna  importancia,  para  comprender 
que  son  aptoe  para  recibir  y  propagar  todas  las  epidemias  y  endemias. 

El  obrero  vive  generalmente  aglomerado  en  casas  donde  las  condiciones  higi^nicas 
biillan  por  su  ausencia:  generalmente  son  tugurioe  donde  se  respira  al  mismo  tiempo  el 
humo  de  la  cocinilla  mezclado  al  ambiente  de  excreciones  humanas  y  de  animales 
que  habitan  con  61,  perro,  gato,  gallinas,  en  hacinamiento  indescrifrable  de  penonas, 
animales  y  cosas;  el  salario  es  exiguo,  cuando  no  falta  del  todo,  y  de  ahf  la  miseria, 
el  alcoholismo,  causas  todas,  que  como  lo  veremos  m4s  adelante,  hacen  el  teireno 
oiginico  de  esas  ffamilias  de  una  receptibilidad  asombrosa  para  el  desarrollo  del  badlo 
de  Eoch.  Esto  lo  hemes  podido  comprobar  a  nuestro  paso  por  los  servicios  hospitalarios. 

2.  Hospital. — ^Los  hospitales  policllnicos  son  perjudiciales  desde  el  punto  de  vista 
de  la  tuberculosis,  no  861o  para  el  enfermo  atacado  de  ella  sine  tambi^n  para  los  otros 
enfermos. 

Los  hospitales  policUnicos  de  caridad  no  tienen  disposiciones  relativas  a  la  profi- 
laxis  de  la  tuberculosis,  hay  allf  generalmente  aglomeraci6n  y  no  est^  construfdos 
en  lugares  apropiadoe  para  la  cura  de  la  tuberculosis. 

La  mortaUdad  allf  por  esta  enfermedad  es  a  vecee  asombrosa:  en  el  Hospital  San 
Juan  de  Dios,  de  Bogota  alcanz6  en  el  afio  de  1896  el  terdo  de  la  mortalidad  adulta. 
La  hoepita]isaci6n  de  tuberculoeoe  en  promiecuidad  con  loe  enfermoe  atacadoe  de 
otne  lesionee  hace  que  aquella  enfermedad  tome  eeoe  caracteree  alannantee  que 
imp(men  impreedndiblemente,  un  cambio  radical  de  coetumbre,  ei  ee  que  algo  merece 
noeetra  atenddn  la  olaee  obrera  que  va  allf  en  busca  de  refugio  y  de  aHvio  a  las  dolen- 
das  de  la  vida. 

Estoe  hoepitalee  eon  un  contra  eentido  no  e61o  para  el  tuberculoeo  eino  tanbi^  para 
loe  enfermoe  atacadoe  de  otrae  leeionee,  pueeto  que  allf  encuentian  dieeminadoe  el 
badlo  de  Koch  que  germinari  en  eus  ozganiemoe  receptivoe,  como  lo  eon  todoe  loe 
de  ke  individuoe  que  buscan  un  refugio  en  estoe  eetablecimientos. 

Hay  mds,  el  tuberculoso  no  eiempre  ee  un  inv^lido;  ^1  no  busca  el  hospital  eino 
cuando  su  enfermedad  le  imjHde  trabajar  por  lo  muy  avaneada  o  por  un  ataque  agudo, 
frecuente  en  loe  cases  de  tuberculosis  pulmonar;  repueeto  de  dl,  eale  a  la  brega  por  la 
vida,  ain  haber  redbido  las  instrucdonee  convenientee  a  eu  eetado,  repartiendo  por 
doquiera  loe  productoe  del  laboratorio  que  lleva  en  eus  pulmonee  y  dejando  el  puesto 
infectado  al  que  Uega. 

Puede  darse  una  idea  de  ice  peligroe  que  eete  g^nero  de  hoepitalizaci6n  acarrea, 
ei  se  tiene  en  cuenta  que  de  eeoe  hoeintalee  ealen  individuoe  de  todas  las  profesionea 
y  (^doe  en  n(imero  no  deejMreciable,  el  cual  correeponde  en  eu  mayor  parte  al  grupo 
de  oficioe  dom^ticoe. 

3.  EjireUo  y  marina, — ^En  loe  pafsee  que  tienen  servido  militar  obligatorio,  loe  m6dicoe 
ee  encaigan  hoy  de  rechasar  loe  individuoe  que  preeentan  alguna  tara  oig^ca  y 
ezduyen  loe  que  eet^  afectadoe  de  tuberculoelB,  pero  en  loe  pafeee  en  quelarecluta 
•e  hace  de  manera  empfrica  ee  comprende  Mcilmente  que  el  eoldado  Ueve  al  cuartel 
lae  epidemias  de  eu  lugar  natal  y  que  al  obtener  eu  libertad  importe  a  ^ete  las  enferme- 
dades  que  reinen  en  el  cuartel. 


PUBLIC  HEALTH  AND  MEDICINE.  421 

Propiamente  hablando  Iob  cuarteles  no  se  han  constaruido  en  la  generalidad  de  los 

pafsee  latinoamericanos  teniendo  en  cuenta  loe  preceptoe  de  la  higiene.   El  personal  es 

en  general  analfabeta  y  la  vida  se  hace  alii  en  promiscuidad.    Y  no  ee  raro  con  este 

modus  Vivendi  que  ll^;uen  tuberculosoe  al  cuartel  y  propaguen  la  enfermedad  entre 
BUS  camaradas. 

La  generalidad  de  los  enfermoe  en  un  cuartel  son  atendidos  alii  en  enfermerias  o 
trasladados  a  un  hospital,  de  donde  vuelven  en  estado  de  convalecencia  nuevamente 
a  su  cuartel  entre  los  cuales  no  eo  raro  encontrar  enlermos  tuberculoses.  En  el  aflo 
de  1908  pasaron  en  este  estado  al  ej6rcito  acantonado  en  Bogotd  7  individuos  atacadw 
de  tuberculosis  pulmonar  y  12  de  otras  formas:  es  decir  enfermoe  en  Impotenda  de 
contagio  y  otros  loe  cuales  por  las  condicionee  de  medio,  aglomeraci6n,  la  disdplina 
que  los  obligar^  a  prestar  servidos  alii  donde  la  neceeidad  lo  exige,  poco  importa  que 
sea  de  noche  y  a  la  intemperie,  no  opondrian  mayor  resistenda  a  la  tendencia  invasora 
del  badlo  de  Koch. 

No  86lo  el  cuartel  es  perjudidal  al  soldado  tuberculoso,  6ete  tambi^n  es  perjudidal 
al  cuartel  y  en  mayor  escala,  ai  se  tiene  en  cuenta  el  ntimero  de  victimas  que  la  enfer- 
medad puede  hacer  por  la  acci6n  del  contagio. 

El  soldado  tuberculoso  lleva  al  cuartel  el  grano,  badlo  de  Koch,  que  ha  de  germinar 
en  un  terrene  apto  ya  que  el  reclutamiento  en  la  f<nrma  forzosa  lleva  al  ej^rdto individuos 
de  la  baja  clase  social  en  las  dudades  y  a  los  campesinoe,  habituadoe  al  aire  libre 
a  la  luz,  en  todo  a  un  g^nero  de  vida  totalmente  distinta  de  la  urbana  y  m^  atin  de  la 
de  cuartel,  que  lo  deprime  moralmente,  y  eete  decaimiento  de  dnimo  que  sufren  las 
gentes  del  campo,  asi  como  las  dem^  circunstancias  anotadas,  hacen  que  opongan 
una  menor  resistencia  a  las  enfermedades  infecto-contagioeas  en  general  y  a  la  tuber 
culoeis  de  manera  e6x>ecial  cuando  son  transplantadas  a  las  ciudades,  viniendo  a  ser, 
como  dice  el  Dr.  Cache  los  autores  de  esta  verdad  de  Lancereaux:  ''La  tuberculosis 
es  la  enfermedad  de  la  civilizaci6n.'' 

4.  Talleres. — Un  representante  dijo,  con  mucha  raz6n,  ante  el  Consejo  de  vigilancia 
de  Afiistencia  Pdblica  en  Paris:  "Hay  talleres  en  que  de  antemano  se  ha  estableddo 
el  lugar  del  tisico.  Cuando  uno  no  puede  ya  ocuparlo,  viene  un  sucesor  y  asi  se 
suceden  en  el  mismo  lugar  series  de  obreros  contaminados  por  bus  predeceeores.'' 

El  peligro  en  estos  medios  como  en  toda  colectividad,  es  el  esputo,  peligro  que 
hace  m&B  positive  el  estado  del  terrene. 

En  loe  talleres  no  hay  hasta  hoy,  escupideras  y  los  esputoe  lanzados  al  suelo  son 
luego  esparddoe  sobre  el  utilaje  por  el  barrido  en  seco  y  asi  como,  lo  hemes  visto, 
llevan  los  obreros  esos  Utiles  a  la  boca  o  sua  manos  son  ensuciadas,  el  contagio  no 
es  de  dejarse  esperar.  Esos  titiles  empleados  por  un  tuberculoso  lo  ser&n  despu^ 
de  su  retiro  del  taller  por  su  reemplazo,  cuando  no  son  de  uso  comdn,  como  sucede 
con  las  vasijas  del  agua. 

Estas  mismas  observaciones  tenemoe  que  hacer  respecto  a  las  oficinas  ptiblicas. 

5.  Escuelas  y  colegios. — Generalmente  lo  tinico  que  nos  preocupa  es  la  instrucddn 
y  poco  0  nada  la  educaci6n  fisica,  por  falta  de  conocimientoe  de  las  leyes  fisioliSgicas. 
El  organismo  es  im  todo  arm6nico  compuesto  de  partes  muy  diversas;  cada  una  de 
ellas  tiene  su  funci6n,  en  verdad  distinta,  pero  siempre  em  correlad6n  intima  con 
las  grandes  fundones  de  eee  todo.  Que  una  de  ellas  llegue  a  perder  o  simplemente 
a  alterar  su  estado  normal  y  el  todo  sufriril  necesariamente  la  falta  de  aquella.  Asi, 
sin  el  desarrollo  fisico  normal,  sin  la  integridad  de  las  funciones  de  la  vida  animal, 
las  de  la  vida  psfquica  no  podrdn  dar  el  trabajo  indispensable  que  en  el  estado  normal 
del  organismo.  De  ahi  que  en  las  agrupaciones  de  los  intemados  sea  poca  la  atenci6n 
que  la  higiene  se  merece,  siendo  alii  de  necesidad  imperiosa,  no  s61o  para  prcservar 
a  los  educandos  de  las  enfermedades  infecto-contagiosas,  sine  tambi^n,  y  he  aqui  el 
gran  papel  a  que  estd  destinada  en  la  prosperidad,  para  enseflarles  a  hacer  profilaxis 
individual  y  que  a  su  vez  la  establezcan  en  bus  hogares.    El  movimiento  antituber- 


422       PBOOEEDINOS  SECOND  PAN  AMERIOAN  SCIENTIFIC  C0NGBES8. 

culoso  del  mundo  cntero,  contard  en  el  porvenir  con  eee  grande  ej^rcitOi  ai  se  implan- 
tan  en  todoe  los  establecimientos  de  ensefianza,  las  medidas  contra  esta  enfennedad. 
La  vida  comdn  durante  varias  horas  o  varioe  meses  que  existe  entre  los  escolares 
hace  destacar  claramente  la  posibilidad  de  contagio  entre  ellos,  asi  como  tambi6n 
entre  los  maestros,  si  no  se  ha  tenido  cuidado  de  seleccionar  el  personal. 

6.  Teatros,  etc.— 1a  vida  urbana  noe  Ueva  buscar  en  loe  lugares  pdblicos,  teatros, 
caf6s,  cantinas,  salas  de  baile,  prostfbulos,  etc.,  un  cambio  de  dea»aci6n,  o  un  mayor 
ensanche  a  nuestras  viviendas  estrechas.  Sin  saber  que  en  la  mayoria  de  estos  lugares 
podemos  encontrar  un  contagio  por  la  falta  de  escupideras  y  la  comunidad  de  tidies. 

7.  LocomociSn. — Uno  de  los  giandes  beneficios  que  nos  ha  trafdo  el  creciente  pro- 
greso  de  la  mecdnica  ha  side  la  rapidez  y  facilidad  de  la  lomoci6n.  Lo  que  antes 
habria  necesitado  dias,  hoy  se  cuenta  hasta  por  minutos. 

Esta  facilidad  y  multiplicacidn  de  los  medioH  de  locomoci6n  hace  que  enfermos  y 
de  salud  admirable  se  entrecrucen  en  la  vida,  usando  reiteradas  vecee  los  mismos 
vehlculos  y  que  comarcas  salubres  reciban  frecuentemente  individuos  que  van  en 
busca  de  sus  aires  y  sus  aguas,  o  de  sus  paisajes  y  placeres  si  se  trata  de  lugares  de 
recreo.  En  las  ciudades  mismas  la  necesidad  nos  obliga  a  trasladamos  de  un  lugar  a 
otro  constantemente  y  para  ello  usamos  vehlculos  comunes,  no  siendo  raro  que  el  que 
acaba  de  servir  para  trasladar  a  un  enfermo  al  hospital  o  a  un  consultorio  m^oo, 
sirva  inmediatamente  a  un  individuo  que  aunque  vigoroso  puede  contaminarse  por 
la  repetici6n  de  esta  emergenda. 

Los  ferrocarriles  que  transportan  diariamente  nullares  de  personas  entre  ellos  tuber- 
culosos  y  que  ademis  necedtan  un  personal  crecido  que  se  tuberculiza  con  extrema 
frecuencia,  y  con  el  cual  tenemos  que  rozamos  y  ademis  va  transportando  el  bacilo  a 
laigas  distancias,  ya  que  ninguna  medida  se  ha  tomado  para  que  no  sean  infectados  y 
mucho  menos  para  que  una  vez  causada  esa  infecci6n  se  provea  lo  conducente  a  su- 
primir  los  males  que  puede  acarrear. 

TBRRBNO. 

Lo  que  dejamos  expuesto  acerca  del  contagio  muestra  claramente  que  estamos 
expuestos  a  la  absorcidn  del  germen  pat^geno  de  la  tuberculosis  en  una  proporcidn 
alarmante,  y  m^s  atin,  segtin  nos  dicen  las  investigaciones  de  Dieulafoy,  Lermoyez 
y  Strauss,  el  bacilo  se  encuentra  en  individuos  sanos. 

Nuestro  oiganismo  estd  pues  acechado  por  enemigos  de  potenda  variable,  en  que  la 
intensidad  de  bus  efectos  es  proporcional  a  su  ndmero  y  a  su  virulenda.  "El  ntlimeio 
de  los  microbios,''  dice  Bouchfuxi,  "tiene  su  importancia  desde  el  punto  de  vista  de 
la  transm]fli6n  y  de  la  gravedad  de  las  enf  ermedades  inf ecdosas,  puesto  que  aumea- 
tando  este  ntimero  se  puede  veneer  la  resistenda  que  un  oiganismo  determinado  qpone 
a  un  menor  ntimero  de  agentes  infecdosos;"  y  la  misma  observad6n  tlene  cabida 
respecto  a  la  virulenda,  puesto  que  un  agente  o  un  grupo  de  agentes  infecdosos  obiai&n 
OOQ  eneigfa  propordonal  a  su  vitalidad,  a  su  accidn  nociva  para  el  oiganismo,  es  dedr, 
a  su  grade  de  virulenda. 

^Por  qu^  no  somos  todos  tuberculosos?  Por  que  al  lado  del  gennen  y  no  Mo  en  la 
tuberculosis,  sine  en  toda  enfennedad  infecto-contagiosa,  hay  que  consideiar  el 
teneno;  o  en  otros  t&rmlnos,  porque  para  que  la  infecddn  tenga  lugar  se  necesita  no 
861o  el  badlo  sino  el  estado  leceptivo  del  oiganismo;  o  vali^dome  de  la  exptesl^ 
con  que  hace  sesenta  y  pico  de  alios  explicaba  el  Prof esor  Trousseau  la  maneia  de  obzar 
de  las  eolermedades  como  la  tuberculosis:  "Sembrad  sobre  la  roca  y  no  obtendr^ 
cosedia;  sembrad  sobre  teneno  fdrtil  y  la  tendr^  abundante,"  y  es  ese  teneno  fdrtil 
el  que  pnma  en  la  infeod^  tubeiculosa,  pues  como  dijimos  al  hablar  de  la  herenda, 
la  tubeicalosis  no  anida  allf  donde  el  oiganismo  le  ofrece  resistenda. 

El  oiganismo  humano  al  estado  normal  se  defiende  contra  los  g^nnenes  patdgenos  que 
tratan  de  invadirlo;  posee  medios  de  defensa  y  estos  medios  son  los  globules  blanoos, 
losfagodtos. 


PUBLIC  HEALTH  AND  MEDICINB*  428 

De  Fleury,  qulen  observa  esta  lucha  al  microecopio,  nos  la  deeciibe  asi: 

El  gl6bulo  bianco  encuentra  en  su  camino  al  pequefio  bastondllo.  fino,  neto,  casi 
elegante,  como  lo  ee  el  bacilo  de  Koch;  se  ponen  en  contacto  y  el  g]6bulo  bianco 
abeorbe  el  microbio;  se  le  distingue— intacto.  vivaz,  en  pleno  vigor,  en  plena  malign!- 
dad  por  consecuencia,  en  el  interior  de  la  c61ula  fagocitaria. 

Bale  la  influencia  de  verdaderos  ju^  digeetivoe  secretados  por  el  tiigocito,  el  bacilo 
ee  roido,  alterado,  se  i^ueca  aquf ,  se  infla  alld,  pierde  bu  forma  rectilinea,  viene  a  ser 
una  rama  nudosa,  que  se  agota,  despu^  desaparece  digerido,  aniquilado  por  el  gl6bulo 
vencedor. 

Pero  a  menudo  la  batalla  es  m4B  laiga,  la  victoria  m^  disputada. 

Aqui  el  ^jgocito  no  tiene  el  vigor  suficiente  para  digerir  al  microbio  y  al  mismo 
tiempo  el  microbio  no  lo  tiene  tampoco  para  hacer  de^nerar  la  c^lula,  para  hacerla 

1>6recer.  Entonces  el  microbio,  para  sustraeree  a  la  acci6n  de  loe  jugos  digestivos  que 
e  amenazan,  ae  rodea  de  envoi  turas  estratificadas,  que  ^1  mismo  secreta  y  que  vistas  al 
microecopio  semejan  a  las  envolturas  conc^tricas  de  un  bulbo  de  cebolla.  Ellas  le 
preservan  por  algun  tiempo,  mas  esta  coraza  acaba  por  serle  fatal,  nociva  y  muere  por 
inanici6n. 

El  gldbulo  bianco,  por  su  parte,  para  acabar  de  amurallarle,  secreta  en  tomo  de  la 
coraza  microbiana  capas  de  losfato  de  cal,  ^ue  le  airven  de  tumba;  tan  to  asf  que  la 
navaja  del  bacteri61oeo  se  mella  en  esoe  tejidos  caldureos  cuando  quiere  hacer  cortea 
para  encontrarloe  en  las  preparaciones. 

Pero  en  el  hombre  el  gl6bulo  bianco  es  casi  siempre  el  vencido. 

Cuando  curamos  de  la  tisis,  gradas  a  la  eficacia  de  la  hi^ene.  es  por  mecanismo 
an^o^  al  de  amurallamiento  del  microbio,  de  calcificaci6n  ae  las  lesiones.  El 
fasoato  mata  al  bacilo  y  lo  encierra  con  bus  venenos  en  una  tumba  s^lidamente  sellada. 

liOB  gl6bulos  blancoe  cumplen  esta  tarea  cada  vez  aue  tienen  la  fuerza  neceearia, 
cada  vez  que  nuestro  vigor  individual  estd  a  la  altura  de  su  faena. 

Pero  cuando  por  esta  o  aquella  circunstancia,  nuestro  organismo  se  encuentra 
debULtado  de  manera  transitoria  o  permanente,  el  bacilo  vencedor  hace  degeuerar 
la  c61ula  y  el  mal  es  dueilo  del  terrene. 

Hoy  es  innegable  que  el  bacilo  no  triunfa  sine  de  los  organismos  alterados  o  decafdos. 

Ahora,  la  resistencia  orgduica  puede  ser  vencida  y  lo  es  en  efecto  en  proporciones 
diversas,  y  de  ahi  proviene  la  predisposicidn  m6rbida,  la  aptitud  pam  contraer  la 
enfennedad,  el  terrene  f^rtil  que  dice  Trousseau. 

El  terreno,  con  sus  carac  teres  favorables  o  deafavorables  al  desarroUo  de  la  infecci6n, 
tiene  tal  importancia,  que  es  de  ^1  de  que  dependen  las  reacclones  cllnicas  y  las  diversas 
localizaciones  m6rbidas,  y  es  as(  como  se  explica  tambi^n  que  siguiendo  los  bacilos 
la  misma  via  para  penetrar  en  el  organismo — ^inhalatoria  como  lo  quiere  Flugge, 
•  intestinal  como  lo  demuestra  Calmette — ^no  sea  una  e  igual  la  intensidad  de  la  infec- 
ci6n  ni  uno  solo  tampoco  el  drgano  siempre  afectado. 

El  organismo  no  presenta  siempre  esa  aptitud  para  recibir  y  desarrollar  las  influencias 
mdrbidas,  que  es  lo  que  constituye  el  terreno,  sine  que  llega  a  ello  por  multitud  de 
causae  intensamente  depresoras  uuas  voces,  reiteradas  aunque  de  intensidad  mediocre 
otras,  que  vamos  a  esbozar  ligeramente. 

Al  hablar  de  la  herencia  de  la  tuberculosis,  hemes  sentado  que  ella  trasuiite  la 
decadencia  6rganica,  es  decir,  el  terreno  tuberculizable;  luego  tenemos,  en  tesis 
general,  que  hay  una  predisposici6n  hereditaria  o  mejor  una  predisposicidn  congenita. 
Pero  se  puede  llegar  al  mismo  estado  no  a6\o  sin  descender  de  padres  tuberculoses, 
sine  tambi6n  siendo  de  progenie  de  vigorosos. 

Las  endemias,  por  su  acci6n  debilitante  sobre  el  organismo  son  causas  de  predis- 
poeici6n  muy  marcada,  asf  podemos  ver  que  al  paludlsmo,  a  la  uncinariasis,  la  disen- 
terfa  amebiana,  etc.,  entre  nosotros,  preceder  o  mejor  preparar  el  camino  que  ha  de 
trillar  luego  la  tuberculosis.  Pero  entre  estas  endemias  hay  una,  la  social  llamada 
alcoholismo,  que  es  la  mds  temible  de  todas.  No  solamente  el  alcoholiamo  es  una 
causa  poderosa  del  deearroUo  de  la  tuberculosLs  en  loe  individuos  habituadoe  a  eete 
vicio,  sine  que  ejerce  una  influencia  f  uera  de  duda  sobre  la  progenie,  dando  nacimiento 
a  seres  congenitalmente  predispuestos,  tanto,  que  dice  Jousset,  que  ser  hijo  de  alco- 
h61ico  ee  tanto  como  ser  hijo  de  tfaico  y  apoya  su  aserci6n  sobre  la  encuesta  practicada 
en  loe  pafses  donde  impera  el  alcoholismo. 


424       PROCEEDINGS  SECOND  PAN   AMERICAN   SCIENTIFIC  CONGRESS. 

Desde  el  aAo  de  1868  present6  Lancereaux  un  trabajo  a  la  Academia  de  Medicina  de 
Fraucia  que  repoeaba  sobre  la  observacidn  de  numeroeos  casos  de  tiaa  en  alcoh61ico0; 
de  entonces  a  la  ^poca  presente  esoe  tiabajos  se  ban  multiplicado  en  todoe  los  paises 
y  es  un  acuerdo  general  el  que  reina  respecto  a  este  punto  de  etiologia.  Lo  demuestm 
claramente  que  de  la  mano  marchan  las  luchas  anti-tuberculosas  y  anti-alcotuSlicaa, 
y  que  eea  influencia  ne^ta  haya  hecho  decir  al  Profesor  Landouzy  que  el  alcohol 
prepara  el  lecho  en  que  anida  la  tuberculoeis,  y  al  Profesor  Hayem  que  la  tuberculosis 
se  toma  en  el  mostiador. 

Las  estadistdcas  sobre  consume  de  alcohol  y  m<vtalidad  por  tuberculosis  practicadas 
en  Francia  establecen  que  hay  una  relaci6n  constante  entre  el  consume  de  alc<^ol 
y  el  desarrollo  de  la  tuberculosis. 

En  la  memoria  de  1907  del  Henry  Phipps  Institute,  encontramos  consignada  tambi6n 
esa  acci6n  fovorable  del  alcdiol  en  la  propagaci6n  de  la  tuberculosis,  asi  como  tambi6n 
que  los  alcoh61icos  o  descendientes  de  tales  son  los  menos  influidos  por  el  tratamiento: 
el  alcoh61ico  permanece  en  estatu  quo  o  va  r6pidamente  a  la  muerte. 

No  citaremos  sine  para  dejar  constancia  de  su  error,  la  creencia  de  algunos  de  que 
tal  0  cual  alcohol  sea  favorable  o  preeervativo  de  la  tubarculosiB.  £1  akohol,  y  coando 
decimos  asf ,  comprendemos  todas  las  bebidas  espirituosas  cualquiera  que  sea  la  materia 
prima  de  que  se  extraigan,  obra  siempre  lo  mismo  en  nuestro  oiganismo;  produciendo 
alcoholismo  agudo  o  cr6nico  y  su  acci6n  sobre  el  de«noUo  de  la  tuberculosis,  es  el 
mismo,  como  lo  es  sobre  todas  las  enfermedades  infecto-contagioeas  sobre  las  endmnias 
y  epidemias:  son  los  alcoh61icos  los  que  pagan  mis  tributos  a  ellas,  como  lo  demuestran 
las  estadisticas  de  todos  los  hospitales  y  como  lo  comprob^  en  el  de  San  Juan  de  Dies 
de  Bogota  y  que  consign^  en  mi  tesis  inaugural,  ''Tuberculosis  en  Colombia. " 

He  aqui  los  dates  estadfsticos  de  Panami  que  sobre  esta  relaci6n  entro  tuberculosis 
y  alcoholismo;  corresponde  al  aflo  de  1914: 

Panami:  mortalidad  tuberculosa  229,  aloch61ica  10;  Col6n  mortalidad  tuberctilosa 
86,  alcoh61ica  4;  Zona  del  Canal  mortalidad  tuberculosa  74,  alcoh61ica  3. 

En  la  ciudad  de  Panamd  hay  inscritos  hoy  679  lugares  de  expendio  de  licores.  La 
producci6n  de  alcohol  de  cafia  de  33^  en  toda  la  Reptiblica,  fu4  durante  el  primer 
semestre  de  este  aflo  de  395,017  litres  con  6  decflitros. 

El  medio  social  tiene  influencia  notoria  sobre  la  preparaci6n  del  terrene  para  la 
germinaci6n  del  bacilo  de  Koch. 

£1  aire  libre,  la  vida  del  campo,  con  su  intensidad  solar  op<men  una  resistenda  vecda- 
dera  a  la  tuberculosis.  Los  arrendatarios,  los  Pescadores,  los  lefiadoree,  no  contraen  la 
enfermedad  sine  excepcionalmente,  dice  (lache.  En  Suiza,  la  tisis  hace  una  vfctima 
sobre  mil  habitantes  entre  los  selvicultores  y  agricultores,  y  en  Italia,  sobre  mil  muertes 
generales,  los  pastores  y  agricultores  no  tienen  sine  cuarenta  o  cincuenta  muertes 
causadas  por  esta  enfermedad. 

Entre  noeotros,  el  trabajador  de  las  regiones  indemnes  de  paludismo,  de  undnaiia 
americana  no  hace  excepci6n  a  la  regla  dtada;  pero  en  nueetros  climas  ardientes,  en 
las  hoyas  de  nuestro  rfos,  en  nuestras  selvas  vfigenes,  donde  el  anofeles  habita,  allf 
la  influencia  nefasta  del  paludismo,  aminorando  la  resistencia  (»ginica,  espera  solo 
que  un  case  importado  se  declare  para  que  el  contagio  se  extienda.  Cuando  las  plagas 
de  la  producci6n  agrfcola  obliga  a  los  agricultores  habituadoe  a  su  vida  de  campo,  a 
buscar  en  las  dudades  el  diario  sustento,  se  encuentran  reunidas  las  condidones  para 
llevar  el  contagio  ales  lugares  indemnes  de  tuberculosis;  puesto  que  Uegados  a  la  dudad 
en  malas  condidones  de  nutrid6n  y  produciendo  en  ellas  aglomeraddn,  se  tuberculizan 
bajo  las  influendas  que  hemes  anotado  al  hfiblar  del  ej^rdto  y  llevan,  al  regresar  a  sua 
hogares,  el  grano  que  ha  de  germinar  en  el  terrene  preparado  por  la  miseria  y  las 
endemias. 

En  las  dudades,  donde  el  excesivo  valor  del  terrene  hace  care  los  alquileres,  las 
condidcmes  de  habitad6n  insalubre  se  encuentran  reunidas,  mis  adn,  en  aquellas  que 
poco  o  nada  se  preocupan  por  el  aprovisionamiento  de  agua  potable  y  servicio  de  aseo. 


PUBLIC   HEALTH   AND  MEDICINE.  425 

La  clase  obrera  se  hacina  alii  en  cuartos  que  denen  una  sola  puerta  que  da  acceso  a 
la  via  pdblica  o  a  corredoree  eetrechoe,  oecuroe  y  htimedos;  la  cubicaci6n  es  eecasa,  a 
veces  el  piso  htimedo,  no  est4n  provistas  de  servicio  sanitaiio  aislado,  de  alii  que  mu- 
chas  excreciones  sean  guardadas  por  algunas  horas  para  despues  verterlas  en  laa  alcan- 
taiillas,  o  lo  que  no  es  muy  raro  sobre  el  suelo  en  los  patios  o  las  vias  pdblicas;  la  pro- 
viaUSn  de  agua  se  hace  del  surtidor  mds  cercano  y  se  mantiene  alii  sin  protecci6n 
alguna.  Al  hablar  del  contagio  en  la  familia  hemes  notado  que  en  estas  viviendas  hay 
promiscuidad  de  individuos  y  animales:  falta  alii,  pues,  el  aire  y  la  luz. 

Obran  tambi^n  como  causas  depresoras  predisponiendo  el  organismo  a  la  tubercu- 
losis alladode  la  aglomeraci6n,  lamiseria,  elalcoholismo,  la  habitaci6n  anti-higi^mca, 
la  agitaduSn  febril  de  las  ciudades,  con  su  vida  llena  de  continuas  necesidades,  mis  y 
mis  numerosas  y  apremiantes,  la  ambici6n,  las  contrariedades,  las  privadones,  etc. 

^La  edad  tiene  influencia  alguna  sobre  la  propagaci6n  de  la  tuberculosis? 

Algunos  autores  han  citado  la  pubertad.  Bien  que  ella  es  una  sacudida  violenta 
que  Bufre  el  organismo,  que  se  acompaiia  de  fen6menos  nerviosos,  contra  los  cuales 
reacciona  aqu61  segdn  circunstancias  que  se  nos  escapan,  no  puede  tener  otra  in- 
fluencia que  la  de  todo  debilitamiento  del  organismo  Asi  vemos  por  lo  general,  que  la 
pubertad,  que  pide  al  oiganismo  un  gasto  mayor  que  la  in&ncia,  puesto  que  ella  maica 
el  periodo  iniciativo  de  nuevas  funciones  y  correlativamente  el  aumento  de  <^lg!iw<m 
preezistentes,  pasa  sin  dejar  huellas  en  ^1;  mientras  que  en  otros  se  acompafia  de 
trastomos  que  si  las  dejar6n  perennes  o  transitorias,  que  indudablemente  obran  como 
aliadas  poderosas  y  eficaces  del  contagio.  Pero  tambi^  es  cierto  que  en  estas  dr- 
cunstancias  no  es  ese  periodo  de  la  vida  en  si  el  principal  factor,  sino  el  conjunto  de 
atributos  anat6micos,  quimicos  y  din^onicos  inherentes  al  ser  de  que  nos  habla  Koch: 
es  el  despertar  de  la  heredo-predisposici6n  bajo  la  influencia  del  aumento  de  trabajo 
del  organismo,  y  no  obra  la  pubertad,  en  este  case,  de  manera  distinta  a  cualquier 
causa  extrafia  en  un  organismo  predispueeto  de  antemano  por  los  yerros  o  privacioneB 
de  sus  antepasados. 

"Pubertad  y  virilidad,''  dice  Peter,  ''tal  es  en  efecto  el  periodo  de  la  vida  en  que 
la  tims  se  i^esenta  con  mayor  frecuencia  y  estas  nociones  hipocr&ticas  son  conocidas 
del  vulgo,  que  no  cree  en  esta  enfermedad  paaada  esa  edad,  y  muchoe  m^coB  son 
volgo  respecto  a  este  punto. ''  No  es  precise  que  sea  asi.  Lo  cierto  es  que  el  periodo 
de  la  tisis  es  el  de  la  tuberculizaci6n,  al  cual  se  ll^ga  por  predisposicidn  constita- 
cional  adquirida  o  hereditaria;  los  d^biles,  loe  lin^ticos,  los  hi  joe  de  tuberculosoe, 
padecen  de  enfermedadee  del  pecho  en  la  primera  o  en  la  s^gunda  parte  de  estaa 
edades,  segtin  la  intensidad  de  la  jHrediiqpoaicidn  y  de  las  causas  auziliares.  Peio 
aquellos  que  habian  nacido  fuertes  y  vigcmwos,  sin  tara  oig&nica  alguna,  que  parecen 
nacidos  para  no  ser  tuberculosoe,  pueden  llegar  a  serlo  a  cualquiera  edad  p<v  la  lenta 
y  continua  influencia  de  las  causas  tuberculigenas  y  mas  aiin  en  la  seniMdad,  que  por 
si  sola  constituye  una  causa  de  debilitamiento  org6nico.  Los  medicos  de  los  asUoi 
de  ancianos  conocen  este  hecho,  y  Fuller  ha  podido  decir  sin  exagenuodn  que  **km 
tiaicoB  son  casi  tan  num^oeos  a  los  70  como  a  los  15  afioe." 

£1  sexo  en  si  tampoco  tiene  influencia  en  la  tuberculosis. 

En  las  ciudades  en  que  la  mujer  trabaja,  solo  en  las  labores  caseras  y  en  los  campoB 
en  que  no  se  le  exige  m^  que  un  trabajo  proporcionado  a  sus  fuerzas,  la  tubercidoflouB 
es  menofl  frecuente  en  ella  que  en  el  hombre;  pero  en  los  centros  comerciales  y  iabriles, 
en  que  el  salaiio  del  hombre  no  alcanza  para  el  sustento  de  la  familia  y  la  mujer  as 
ve  obhgada  a  aportar  su  contingente  de  trabajo,  la  tuberculosis  es  tan  frecuente  o 
mis  en  ella  que  en  el  hombre.  Esta  influencia  de  la  propagacidn  de  la  tuberculosiB 
en  la  obrera,  es  palpable  en  las  ciudades  que  toman  un  ripido  desarrollo. 

Varias  causas,  que  no  dependen  de  su  constituci6n  misma,  si  no  del  medio  en  que 
se  agita  la  mujer  en  las  ciudades  populosas  es  lo  que  influye  en  su  tuberculizaei^; 
en  efecto,  obligada  a  tnibajar  en  oficios  sedentarios,  en  un  aire  confinado,  muchaa 
veces  en  aglomeracidn,  con  salario  exiguo  que  la  obliga  a  trabajar  no  b61o  durante  el 


426       PROCEEDINGS  SECOND  PAN  AMBBICAN  SCIENTIFIC  CONGRESS. 

dia  y  la  noche  aino  tambi^  en  estados,  como  la  prefiez  y  la  lactancia,  que  no  le  penniten 
flino  una  poici6n  de  tiabajo  como  uno  y  le  exigen  una  raci6n  alimoiticia  y  de  descanso 
como  do6,  8u  (urganismo  se  debiHta  y  ee  ^il  preea  del  contagio. 

Las  profesioneB  no  dejan  de  tener  su  influencia  por  el  medio  en  que  obligan  a  penna- 
necer  a  los  que  las  ejercen.  Las  estadlsticas  noe  dicen  que  las  enfermeras  y  los  enferme- 
roe,  sirvientee  de  morgue,  medicos,  etc.,  que  los  exponen  a  un  contagio  reiterado 
pagan  mayor  tribute  propoixdonalmente  a  la  tuberculosis.  Pero  lo  cierto  es  que 
en  materia  de  profesidn  sucede  lo  mismo  que  con  las  edadee,  se  llega  a  la  tuberculosis 
^or  efectoe  de  medio  y  de  contagio:  cuando  fijadas  definitivamente  y  llevadas  a  la 
pHLctica  las  medidas  profiUcticas,  las  estadlsticas  de  mortalidad  tuberculosa  por 
profesiones  no  presentaiin  predominancia  alguna  por  ^ta  o  aqu61]a.  En  apoyo  de 
nueetro  aserto  eetd  el  que  en  Bogoti  el  predominio  de  la  m<Ni>ilidad  y  mortalidad 
tuberculosa  coireepondende  a  la  clase  de  oficio  dom6stico,  lo  ciud  le  ser&  Mcil  com- 
prender  a  todo  aqu41  que  conozca  aquella  ciudad  en  que  las  condiciones  de  vida 
de  su  clase  pobre  se  encuentran  reunidas  todas  las  condiciones  antihigi^nicas. 

La  nutricidn  es  elemento  indispensable  al  mantenimiento  de  la  vida  y  como  tal 
de  defenaa  del  oiganismo;  cuando  ella  decae  bajo  el  imperio  de  una  acci6n  pato- 
l<$gica  o  de  una  causa  social,  el  organismo  eetd  preparado  para  la  obra  devastadora 
de  la  tub^xiulosis. 

En  una  palabra,  las  condiciones  favorables  a  la  evolucidn  del  bacilo  se  encuentran 
reaHzadas  por  todas  las  causas  capaces  de  producir  en  el  organismo  cierto  grade  de 
nutricidn,  sea  que  obren  como  causas  depresoras,  sea  que  debiliten  sus  defensas 
naturales;  excesos  de  toda  clase,  agotamiento,  fatiga,  disgustoe,  prefieces  repetidas, 
traumatismos,  intoxicaciones  crtSnicas,  etc. 

Parte  II. — Profilazis. 

La  profilaxis  de  la  tuberculosis  tiene  que  dirigirse,  como  l(5gicamente  se  desprende 
de  su  etiologfa,  sobre  el  bacilo  para  destruirlo  y  sobre  el  terrene  paia  pree^rvarlo: 
una  y  otra  de  estas  accionee  se  complementan.  Asf  es  que  para  ser  eficas  la  lucha 
anti-tuberculosa  no  debe  descuidar  ninguna  de  estas  doe  fases  del  problema. 

Destruir  el  bacilo  o  ponerlo  en  condiciones  de  ser  inofensivo,  esterllizar  la  humani- 
dad  para  el  bacilo  de  Koch,  por  decirlo  asf,  serfa  lo  ideal,  dado  que  por  muy  apto  que 
fuese  el  organismo  no  existirfa  la  enfermedad  si  faltase  el  agente  productor.  Incon- 
venientes  insuperables  en  la  prdctica  hacen  que  la  lucha  contra  el  bacilo  no  haya 
llegado  a  desempefiar  el  papel  que  la  teorfa  le  asigna  a  primera  vista;  sin  empargo, 
decfa  en  mi  tesis  inaugural  hace  seis  afios,  con  el  andar  del  tiempo,  vulgarizadas  las 
nociones  de  higiene,  esta  lucha  serd  un  baluarte  poderoso  en  la  defensa  de  la  humani- 
dad  contra  el  flagelo  de  la  tuberculosis,  y  cuan  poco  se  ha  avanzado  en  nuestros  pafsee 
en  este  sentido. 

En  nueetras  pequefias  nacionee,  donde  la  necesidad  de  la  higiene  no  ha  llamado  la 
atenci(3n  en  absolute  o  86I0  de  una  manera  mediocre  (Panamd  y  Col6n  no  son  obra 
nuestra),  la  tinica  fase  del  problema  que  puede  implantarse  por  doquiera  ee  profilaxis 
individual  contra  el  bacilo,  ensefiando  a  la  humanidad  los  peligros  del  contagio  y  Ice 
medios  de  preservarae  de  ^1. 

Expongamos  algunoe  de  los  medios  con  que  contamos  para  la  destrucci6n  del 
bacilo  alU  mismo  donde  se  produce. 

El  bacilo  de  Koch  es  muy  resistente  a  la  accidn  de  lo  agentes  f  fsicos,  como  lo  prueban 
los  siguientes  experimentoe: 

Los  esputos  pulverizados  y  mezclados  con  polvos  inertes  conservan  su  virulencia 
despu^  de  seis  meses:  la  congelaci6n  no  los  destruye,  lo  mismo  sucede  con  las  tem- 
peraturas  elevadas;  Grancher  y  Ledoux-Lebard  han  comprobado  que  los  cultivos  de 
DacUo  de  Koch,  previamente  aesecados  y  sometidos  al  calor  seco  a  70°  durante  siete 
horas,  conservan  su  virulencia;  sometidos  al  calor  hdmedo  a  100*'  durante  tree  horas, 
se  debilita  su  virulencia,  pero  no  se  extinjKue;  m^  adn,  Strauss  y  Gamaleia  han 
demostrado  que  sometidos  los  cultivos  no  solo  a  la  ebullici6n  repetida,  sine  al  auto- 


PUBUO  HEALTH  AND  MEDICINE.  427 

clave  a  115°  y  ISO*'  durante  varias  horas  (?}  e  inoculadoe  despu^,  se  produce  una 
reacci6n  local  un  abceso  que  contiene  el  baalo  con  8u  reacci6n  micro-quimica  carac- 
terlstica.  Es  pues  necesario  destruir  el  bacilo  con  agentes  m^  pr&cticos  y  m^  ener- 
gicofl  como  lo  son  las  soluciones  antis^pticas,  cuya  acci6n  ha  sldo  blen  estudiada. 

H.  Vincent  se  consagra  en  su  trabaio  tituliMio  **Sobre  la  desinfecddn  de  los  esputos 
tuberculoeoB,"  a  un  estudio  sobre  el  valor  comparado  de  algunos  desinfectantes 
qufmicos,  estudio  cuyas  conclusiones  pricticas  son  muy  interesantee  e  importantes 
para  el  asunto  aue  nos  ocui)a. 

El  escollo  de  la  de8infecci6n  oulmica  reside  en  el  hecho  siffuiente:  que  ee  necesario 
obrar  no  sdlo  sobre  el  bacilo  aislado  (desnudo),  sine  sobre  cd  bacilo  protegido,  en  los 
esputos,  contra  el  electo  de  los  antis^pticos  por  un  re  vestimiento  f  ormado  por  sustancias 
mucosas  y  albuminoideas.  Para  la  desinf  ecci6n  de  los  esputos  tuberculoses  ee  precise 
desecbar  las  sustancias  que  coagulen  rdpida  y  en^rglcamente  las  sustancias  albu- 
minoideas. 

El  mejor  de  los  ajenfces  de  desinf ecci6n  de  los  esputos  seria,  evidenteme^te,  aquel 
que  reuna  las  concuciones  siguientes:  acci6n  antis^ptica  absoluta  y  rdpida  sobre  el 
bacilo  de  Koch;  que  penetre  en  el  producto  de  la  expectoracidn  y  se  mezcle  fntima- 
mente  con  ^1;  que  no  sea  t6xico;  y,  en  fin,  que  su  valor  no  sea  excesivo. 

El  autor  ha  puesto  diferentes  sustancias  desinfectantes  durante  cierto  tiempo,  en 
contacto-  con  los  esputos  tuberculosos,  los  ha  lavado  con  agua  ester lllzada,  centrifu- 
gado  y  luego  inyectado  a  los  curies. 

De  estas  investlgaciones  resulta  que  se  pueden  eliminar  el  aceite  pesado  de  bulla, 
emulsionado  o  no,  la  cal  y  la  potasa,  cuya  acci6n  no  parece  satisfactoria.  El  lysol  al 
10  por  ciento,  la  soda  al  mismo  titulo,  los  hipocloritos  y  sobre  todo  el  hipoclorito  de 
cal  en  8oluci6n  concentrada  y  dilufda  luego  al  20  por  ciento,  son  los  desinfectantes 
m&B  actives  de  los  esputos  tuberculosos. 

Por  raz6n  de  su  a  alor  y  de  ser  inodora,  la  soda  al  10  por  ciento  merece  la  primacla. 
En  estas  condiciones,  ella  asegura  perfectamente,  a  la  temperatura  ordinaria,  la 
esterilizaci^n  de  los  esputos  al  cabo  de  seis  bona  y  adn  en  menor  tiempo;  a  este  tftulo 
no  es  ca(i8tica,  y  coloredndola  con  tintura  de  tomasol  se  e\itar4  cualquier  error;  di- 
sueh  e  y  fluidifica  los  esputos,  lo  cual  impide  que  se  adhieran  a  las  paredes  de  las 
eecupideras,  y  por  consiguiente  facilita  considerablemente  su  limpieza. 

Con  un  desinfectante  barato  y  exento  de  peligro  en  su  manipulaci6n  puesto  en 
cantidad  suficiente  a  disposicl6n  del  tuberculoso,  se  darla  un  gran  paso  en  el  sentido  de  la 
preser \  aci6n  de  sus  familiares.  Ese  desinfectante  del . e  ser  acompafiado  de  recept^ulos 
para  recibir  los  esputos  una  \  ez  salidos  de  su  lugar  de  producci6n:  las  eecupideras,  de 
las  cuales  existen  hoy  en  el  comercio  distintas  clases,  desde  la  de  lat<Sn  bamizado,  muy 
barata,  hasta  las  de  porcelana  y  terracota  esmaltadas;  lo  mismo  respecto  a  su  forma  que 
estd  de  acuerdo  con  el  lugar  de  colocaci6n:  de  boMllo,  para  el  piso,  y  las  llamadas 
colectivas,  especies  de  \  asijas  como  las  destinadas  a  colocar  flores  y  que  son  muy  con« 
venientes  para  jardines,  paseos,  corredores,  teatros,  y  en  general  para  todo  lugar 
concurrido. 

Con  estas  dos  pequefias  armas  bleu  se  puede  emprender  una  campafia  de  resultados 
satisfactorios.  El  uso  racional  de  la  escupidera  con  su  solucidn  desinfectante,  debe 
ser  \  ulgarizado  lo  m^  posible;  para  ello  es  necesaria,  la  educaci6n,  el  hdbito  de  no 
arrojar  los  esputos  fuera  de  ella,  est^  o  no  atacado  de  tuberculosis.  Esta  pr4ctica 
traerd  consigo  extender  la  profilaxis  a  los  indi^iduos  no  s61o  atacados  de  tuberculosis 
abierta,  sine  tambi6n  a  aqueUos  enfermos  del  pecho,  que  tienen  una  afeccidn  no 
tuberculosa,  pero  que  puede  llegar  a  serlo,  dados  los  medios  de  contagio,  de  un  me- 
mento a  otro  y  a  los  casos  no  diagnosticados,  como  sucede  en  el  comienzo  de  la  enforme- 
dad  cuando  no  hay  medios  para  un  examen  bacterioldgico,  case  muy  frecuente  en 
nuestras  ciudades,  en  las  cuales  se  dice  tuberculosis  ya  cuando  los  esputos  bacilfferos 
han  hecho  su  obra  de\  astadora. 

Debemos  propender  por  todos  los  medios  a  nuestro  alcance  a  que  la  escupidera  de 
bolsillo  ocupe  el  mismo  puesto  que  ha  alcanzado  el  pafluelo,  siendo  de  eficacia  mayor 
el  uso  de  aquella,  puesto  que  el  pafiuelo  es  un  medio  de  contagio  en  los  cases,  en 
verdad  raros,  de  tuberculosLs  naso-faringea.    ^No  es  miiado  comosigno  de  mala  edu- 


\ 


428       PROCEEDINGS  8B00N1)  PAN   AMERICAN   SCIENTIFIC   CONGRESS. 

caci6n  no  llevar  pafiuelo  para  sonarse?  Pues  hagamos  esfuerzos  por  que  otro  tanto 
su^eda  con  la  escupidera  de  bolsillo. 

Esta  medida  profil^tica  en  extreme  laudable,  quitaria  al  use  de  la  escupidera  de 
bolsillo  el  inconveniente  que  tiene  de  mostrar  de  modo  muy  visible  al  tuberculoBO, 
por  lo  cual  mlra  con  repugnancia  su  uso  y  deeoye,  en  detrimento  de  la  salud  pdblica, 
el  consejo  o  prescripcidn  del  m^co.    - 

Para  triunfar  en  esta  cruzada,  es  neceeario  que  todo  el  mundo  conozca  qu6  peligro 
existe  en  un  eeputo  tuberculoso  lanzado  libremente  al  suelo,  y  que  por  consecuencta 
cualquier  individuo  se  sienta  con  el  derecho  de  llamar  la  atenci6n  al  que  esputa 
cerca  de  ^1,  en  vela  de  su  salud  y  de  la  de  los  dem&a;  asi  como  comprendw  que  ese 
derecho  le  impone  el  deber  de  vigilarse  a  sf  mismo  para  no  incurrir  en  la  miama  fadta 
que  corrj^  a  otro.  Por  otra  parte,  el  m^co  debe  ad  vertir  al  tuberculoso  que  no  debe 
participar  libremente  de  la  vida  en  comunidad,  si  no  sigue  la  regla  de  usar  su  recept4- 
culo  para  esputoe,  a  lo  cual  se  mostrard  sumiso  si  al  mismo  tiempo  se  le  hace  conocer 
que  las  primeras  victimas  del  hibito  deplorable  de  escupir  en  los  pisos  son  sub  allegados. 
Indefectiblemente,  como  dice  P.  Brouaidei,  el  dia  en  que  haya  desaparecido  la 
desagradable  y  peligrosa  costumbre  de  escupir  sobre  el  suelo,  la  tuberculosis -decrececi 
r&pidamente. 

Nada  debe  ahurrarse  y  todoe  los  medios  son  buenos  para  llegar  a  este  fin.  Hoy 
vemos  poi  doquiera  los  avisos  de  ''  Prohfbese  escupir  sobre  el  piso/'  lo  que  nos  demuee- 
tra  que  el  consejo  del  Dr.  Bouiland,  en  su  relaci6n  a  la  AsociadkSn  MMica  Americana, 
ha  dado  sua  resultados.  Ese  aviso  diseminado  ipot  doquiera  ha  hecho  sub  progresos  ya, 
inculcando  en  el  pdblico  el  peligro  del  esputo.  Pero  es  precise  completario  poniendo 
al  lado  del  aviso  la  escupidera  para  aquellos  que,  por  sufrir  una  afecci6n  de  las  vias 
a^reas,  se  yen  en  la  necesidad  de  esputar  en  los  lugares  concurridos;  ademib,  ya  es 
tiempo  que  la  pidiibici6n  sea  s^;uida  de  correccidn:  los  agentes  encaigados  de  vigilar 
la  seguridad  pdblica,  quedan  impasibles  ante  un  individuo  que  arroja  sue  esputoa 
sobre  la  via  pdblica;  a  ese  se  le  debe  instruir  sobre  lo  que  eso  significa  e  imposerlee  el 
deber  de  vigilar  porque  la  prohlbici6n  no  sea  ietra  muerta,  e  imponer  penas  a  Ice  que 
asf  atentan  contra  la  salud  pdblica.  El  dIa  que  se  castigue  con  multas  a  los  que 
cometan  esta  falta,  no  habr&  m&B  infractores  de  esa  medida  sanitaria. 

Las  asociaciones  de  obreros,  el  periodismo,  las  conferendas  pdblicas,  prestar4n 
una  ayuda  eficaz  a  esta  profilaxis  individual.  Y  los  gobiemoe  por  su  parte  deben 
hacer  obligatoria  entre  el  personal  docente  la  ensefianza  anti-tuberculoea,  para  que 
ellos  a  su  vez  la  hagan  extensiva  a  los  nifios,  ya  que  elloe  van  a  ser  los  hombres  de 
mafiana. 

Eso  en  cuanto  a  lo  que  debe  hacer  el  individuo  aisladamente,  a  la  profilaxis  indi- 
vidual. 

Ahora,  colectivamente,  debemos  principiar  por  la  deeinfecci6n  obligatoria  y  reite- 
rada  de  las  habitaciones  de  los  tuberculosos,  sobre  todo  en  la  actualidad,  en  que  no 
promulgadas  adn  las  ensefianzas  arriba  indicadas,  la  habitacidn  en  comtin  con  estoe 
enfermos  es  muy  peligrosa.  Inclulda  como  eet&  la  tuberculosis  en  el  n(imero  de  las 
enfermedadee  de  declaraci6n  obligatoria,  ^sta  debe  ser  seguida  de  la  deeinfecd6n  del 
domicilio  del  enfermo  periddicamente. 

Incluir  entre  las  medidas  sanitarias  la  desinlecci6n  de  las  casas  de  alquiler,  antes 
de  ser  reocupadas  cuando  no  se  conozca  el  eetado  patol6gico  d^  inquilino  saliente. 
Los  eecrdpulos  que  esta  medida  traeri  consigo  al  prindpio,  ir&n  desapareciendo  con 
el  hdbito  y  con  la  convicci6n  radonal  de  que  el  servido  sanitaiio  deja  a  su  salida  de 
una  casa,  la  convicci6n  de  que  es  habitable  sin  temor  alguno. 

La  declaraci6n  de  los  cases  de  tuberculosis  en  su  prindpio  no  llenard  comideta- 
mente  su  objeto,  ya  sea  el  medico  de  cabecera,  la  &milia,  los  duefios  de  hoteles,  casas 
de  asistencia,  u  otros  an^ogos  los  encargados  de  haceria,  debido  a  la  aparente  repu- 
diad6n  que  el  sistema  tiene  de  atraer  sobre  el  enfermo  la  atend6n  pdblica;  pero  la 
propaganda  activa  por  medio  de  conferendas  pdblicas,  de  lecdones  objetivas  per 


PXJBLIO  HEALTH  AND  MEDICINE.  429 

medio  de  cuadroe  murales  y  la  voz  del  m^ico,  en  cada  case  particular,  llevard  a  los 
^imoe  la  convicci6n  de  la  neceddad  de  ^1  y  la  del  peligro  que,  para  la  fomilia,  las 
agrupaciones  industriales,  las  ciudades  y  los  palses  en  general,  trae  su  omisidn.  Asi 
llegar&  el  dfa  en  que  el  enfermo  mismo,  por  condiciones  de  interns  personal  bien 
entendido,  solicite  la  de8infecci6n  de  manera  imperiosa,  como  sucede  hoy  en  Panamd 
con  la  difteria,  la  escarlatdna,  etc. 

Para  que  esta  desinfeccidn  Uene  todo  su  cometido,  se  necesita  que  todos  los  casoe 
de  tuberculosis  sean  conoddos  de  la  oficina  de  sanidad  y  sobre  todo  las  tuberculosis 
al  prindpio.  Ninguna  instituci6n  puede  llenar  este  cometido  como  los  dispensarios 
antituberculosos  y  entre  estos  el  dispensario  tipo  Calmette,  que  tiene  la  ventaja  de 
controlar  los  cases  que  van  en  busca  de  auxilio  y  de  despistar  cases  que  no  se  habrlan 
presentado  sino  muy  tarde  y  que  adem^  va  inculcando  en  las  masas  la  confianza  y  la 
neces&dad  de  recunir  alii  apenas  se  siente  algtin  sfntoma  de  enfermedad  del  pecbo. 
Estos  dispensarios,  que  podremos  establecer  como  una  rama  de  nuestros  bospitales 
de  caridad,  dotados  de  personal  competente,  con  laboratorio  bacteriol<3gico  para 
ex&menes  de  esputos,  se  encaigarla  de  indicar  los  lugares  que  necesitan  de  la  desin- 
fecci6n. 

No  est&  de  m^,  dada  la  importancia  de  estos  dispensarios,  dar  aqui  una  idea  com- 
pleta  de  lo  que  son.    Dice  Calmette: 

Pienso  aue  en  lugar  de  esperar  que  el  obrero  tuberculoso  vensa  a  consultar  al  medico 
va  obli^^o  a  la  8uspen8i6n  de  trabajo  por  la  enfermedad,  debe  erigirse  en  prindpio 
la  neceodad  de  ir  a  el  v  de  prestarle  asistencia,  antes  de  que  se  aperdba  de  que  estd 
gravemente  atacado.  Quisiera  aue  fuese  posible  despistar  en  el  emermo  la  tuberculosis 
muy'al  jMindpio  de  su  evoludon  y  que  se  eeforzase  tambi^  en  darle  los  conseios  y 
cuidados  que  puedan  serle  dtiles  para  conservarlo  el  mayor  tiempo  eatie  su  medio  y 
sufomilia. 

He  aqui  como  es  posible  oiganizar  pr&cticamente  la  ludia  contra  la  tuberculosis 
en  la  clase  obrera: 

Se  crearia  primero  en  cada  dudad  un  n6mero  sufidente  de  dispensarios  de  barrio 
pm  que  cada  uno  de  ellos  pueda  f^Udlmente  atender  a  una  circunscripci^n  deter- 
minada. 

El  papel  de  los  dispensarios  consistiria: 

1^.  Ponerse  en  relaci6n  con  todos  los  jefes  o  capataces  de  Ericas  y  talleres  y  con 
todos  los  establecimientos  que  ocupen  obreros  protegidos  por  la  ley  de  aseguros  contra 
acddentes. 

2^.  Buscar,  gradas  a  los  dates  suministrados  por  los  jefes  o  capataces  de  las  f&bricas 
o  talleres,  los  obreros  sospechosos  de  tuberculosis;  atraerlos  al  dispensario  pant  darles, 
tan  a  menudo  como  sea  necesario,  consultas  gratuitas,  consejos  para  su  ftonilia;  dis- 
tribuirles  cuando  est^n  obligados  a  suspender  su  trabajo,  soanros  en  dinero  o  alimentosi 
vesddos,  medidnas,  libros. 

3c.  El  dispensario  de  cada  drcunscripddn  deber&  matricular  todos  los  enlermos 
de  su  dependencia,  hacerlosvisitar  frecuentemente  a  domidlio,  procurarles  ocupadones 
o  trabajos  en  relackki  con  sos  aptitudes  y  con  su  estado  de  salua;  hacer  desinfectar  sus 
aloj[amientos  toda  vez  que  esta  operad^n  pueda  ser  dtil;  suministrarles  las  escupdderas 
bigi^cas;  indicarles  como  se  deben  destruir  los  esputos;  esterilizar  sus  ropas;  dar 
en  una  palabra,  todas  las  instmcdones  necesarias  para  asegurar  las  mejores  condi- 
ciones higi^cas  en  su  domidlio  al  tuberculoso  y  jNreservar  del  contagio  a  aquellos  que 
lo  rodean  y  de  los  cualee  no  i>uede  ni  quiere  separarse. 

Querrfa  que  cada  dispensario  fuese  dSrigido  por  un  m^co  espedalmente  instruido 
en  vista  de  las  fundones  que  debe  Uenar  y  que  haya  hecho  un  curso  sufidente  en  los 
lab<»atorios  bacteriol6gicos,  para  tener  competencia  en  los  extoenes  regulares  de 
esputos  que  haga  a  los  enfermos  y  controlar  asi  la  eficada  de  las  desinfecdones  que 
haya  prescrito. 

Esta  por  de  wis  dedr  que  los  dispensarios  estar&n  piovistos  de  los  instrumentos  y 
dtiles  necesaiios  para  la  obs6rvaci6n  rigurosa  de  los  enfermos  (microscopio,  b^»cula» 
dinam6metro,  etc.)  y  que  cada  obrero  matriculado,  al  pasar  de  una  drcunscripcidn 
a  otra,  fuese  proyisto  de  su  ezpediente  dinico. 

La  adininis£raci6n  de  los  dispensarios  serfo,  en  mi  opinidn,  ventajosamente  confiada 
a  las  munidpalidades,  a  lo  menos  en  las  grandes  duoades,  con  un  control  del  Estado 
y  b«jo  la  reserva  de  que  una  ley  hideia  su  cread6n  obligatoria  en  todas  las  aglome- 
radones  obreras  de  algnpa  importanda. 

Los  gastos  de  instalad^n  senan  eiddentemente  poco  considerables,  pero  su  mante- 
nimiento  ezigiria  saaifidoe  peconiarios  importantes,  en  razdn  sobre  todo  a  subvenir 


430       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  OONQBESS. 

a  las  necesidadeB  de  laa  familiaB  de  los  obreros  enfermoe.  Segtin  mis  ddculoe  aproxi- 
mativos,  cada  obrero  cuidado  o  vigilado  por  el  dispensario,  comprendiendo  en  eUo 
loB  socorros  distribufdos  a  domicilio,  coBtarla  en  t6nnino  medio  3  francos  por  dla  de 
invalidez. 

En  Panami,  y  en  los  pafses  similares,  la  creaci6n  de  estos  dispensarioe  se  impone, 
ya  sea  aisladoe  o,  como  lo  dije  anterior  mente,  dependientes  de  los  bospitales  de  caridad 
ya  estableddos.  En  cuanto  a  sus  fondos,  ya  que  poco  o  nada  puede  esperarse  entre 
noeotros  de  la  iniciativa  particular,  tienen  que  emanar  del  tesoro  nacional  o  de  los 
municipios,  los  cuales  pueden  establecer  un  gravamen  o  contribuci6n  especial  sobre 
los  articulos  de  lujo  y  al  mismo  tiempo  un  seguro  obUgatorio  a  los  empleados  pt&blicos, 
contra  la  tuberculosis. 

Ahora  con  el  fin  de  hacer  llegar  sin  desconfianza  a  todos  los  enfermos,  esos  dispensa- 
rioe deben  ser  denominados  ''Dispensario  para  curar  las  enfermedades  del  pulm6n'' 
como  lo  propone  P.  Brouardel. 

Debo  consignar  aquf  el  ntimero  de  tuberculoses  existentes  boy  en  la  ciudad  de 
Panam^  y  en  la  Reptiblica  para  que  se  tenga  base  para  un  cdlculo  aprozimativo. 
Siguiendo  la  proporci6n  que  da  "La  comisi6n  permanente  contra  la  tuberculosis" 
en  Madrid  para  investigar  el  ntimero  de  tuberculosos  existentes  por  el  ntimero  de 
defunciones  causadas  por  esta  enfermedad  (cinco  eniermos  para  cada  defunci6n), 
tenemos  que  la  ciudad  de  Panamd  con  229  defunciones  en  el  afio  de  1914,  tendri 
1,145  enfermos  tuberculosos  y  que  la  Reptiblica  entera  con  504  defunciones,  tendrd 
2,520. 

A  los  hospitales  generales  de  hoy  U^an  tuberculosos  en  ntimero  no  despreciable  y 
esta  circumstanda  debe  aprovecharse  para  controlar  los  focos  de  donde  provieYien  y 
proceder  a  su  desinfecci6n. 

Al  hablar  del  contagio  en  los  hospitales,  dijimos  que  son  un  contra  sentido  los 
policllnicos  para  alojar  a  los  tuberculosos,  de  aquf  que  se  imponga  ya  sea  la  creaci6n 
de  eetablecimientos  adecuados,  ya,  como  medida  paliativa,  la  instalaci6n  de  salas 
espedales,  con  personal  competente,  instrufdo  profil&cticamente  para  que  a  su  ves 
instruya  a  los  enfermos  y  a  su  dalida  dejen  de  ser  un  peligro  para  sus  semejantes:  que 
esas  salas  sean  un  medio  de  vulgarizacidn  y  no  asilos  que  el  enfermo  solidta  cuando 
ya  sus  recursos  no  le  permiten  hacer  otia  cosa. 

Los  cuerpos  que  dependen  del  gobiemo,  ej^rcito,  gendarmerla,  polida,  deben 
redbir  instrucd6n  antituberculosa.  Asl  serd  f&cil  la  cruzada  por  la  profilaxis  indi- 
vidual. 

Indicadas  las  medidas  para  hacer  inofensivo  el  bacilo  de  Koch,  hasta  donde  sea 
posible,  y  que  Uevadas  a  la  prictica  el  tuberculoso  dejard  de  ser  un  peligro  para  sus 
semejantes,  reeta  indicar  los  medios  para  evitar  la  receptividad  del  organismo,  lo  cual 
complementary  los  buenos  frutos  obtenidos  por  aquellas.  Hemos  anotado  que  las 
causas  prindpales  que  hacen  el  organismo  receptive,  son:  el  alcoholismo,  la  habitad6n 
insalubre,  excesos  de  toda  naturaleza,  mala  o  deficiente  alimentaci6n  y  las  habita- 
dones  insalubres. 

El  alcoholismo  y  la  tuberculosis,  su  compafLera,  van  de  la  mano  diezmando  la  huma- 
nidad  y  contribuyendo  a  la  decrepitud  de  la  raza.  De  la  comprobaci6n  de  los  efectoe 
de  aqu^l,  ha  surgido  la  lucha  anti-alcoh61ica  que  se  propaga  por  el  mundo  bajo  auspi- 
dos  venerables. 

El  Profosor  Debove,  en  su  discureo  ante  La  Llga  Nacional  contra  el  Alcoholismo 
y  La  Uni6n  Francesa  Anti-alcoh61ica  en  Paris,  se  expree6  asi: 

El  alcohol  puebla  nuestros  hospitales,  nuestras  circeles,  nuestros  manicomios. 
Despuebla  nuestro  pais  merced  al  aumento  de  la  mortalidad,  a  la  disminud6n  de  los 
nacimientos  ^  a  la  procreaci6n  de  hijos  que  llevan  el  estigma  de  su  origen.  Su  acci6n 
mal^fica  se  ejerce  de  un  mode  desigual  en  nuestros  departamentos.  Es  f&cil  conocer 
cuales  son  los  mds  atacados:  los  que  registran  menos  nacimientos  y  mis  criminales, 
los  que  tienen  mds  hombres  rechazados  para  el  servicio  militar.  Si  siguen  asf  las  cosas, 
desaparecerd  nuestra  patria.    Serfa  intftil  mantener  un  ej^rdto  d  en  el  interior  tene- 


PX7BU0  HEALTH  AND  MBDIOIKE.  431 

mo6  un  enemigo  que  noe  deetruye  con  mis  aeguridad  de  lo  que  podria  hacerlo  una 
potenda  militar.  Serfa  indtil  intentar  eefuerzo  alguno  para  el  meiaramiento  material 
y  moral  de  un  pueblo,  cuyoe  dlas  de  existencia  eetuviesen  contaaoe. 

Meditando  las  palabras  del  ilustre  profesor  franco,  encontramos  en  ellas  consignada, 
al  par  que  los  inmensos  perjuidoe  del  alcoholismo,  la  imperioBa  necesidad  de  empren- 
der  la  lucha  contra  61,  en  el  mundo  entero,  porque  las  ensefianzas  que  encierran  no 
0on  tan  s61o  para  la  Francia,  ellas  traspasan  los  Ifmites  de  esa  naci6n  i)ara  hacerse 
universales. 

Hurguemos  en  ese  estercolero  social — el  alcoholismo — y  encontraremos  cuinta 
inmundida,  al  par  que  cu&ntos  reproches  para  los  que  miran  impasibles  los  males 
evitables.  Y  cuinta  execrad6n  para  los  que  convierten  el  envenenamiento  del 
organiBmo,  la  decrepitud  de  la  raza,  en  comercio  Hdto. 

La  lucha  antialcoh61ica  reviste  dos  fases:  la  acd6n  ofidal  y  la  inidativa  privada. 
En  los  pafses  en  que  esta  lucha  se  ha  instalado,  la  primera  de  bus  haee  ha  limitado  su 
acd6n  a  imponer  gray&menes  al  alcohol  deetilado,  dejando  de  este  modo  desarrollarse 
las  bebidas  fermentadas  que  producen  el  mismo  mal  que  el  anterior.  Entre  nosotros 
se  ha  hecho  lo  mismo,  creyendo  que  el  aumento  del  valor  de  la  primera  bebida  de- 
tendria  el  abuse  de  este  veneno,  y  hemes  observado  que  ha  aumentado  la  producd6n 
de  cervezas,  cuyo  consume  lleva  al  mismo  fin:  la  embriaguez  y  el  deterioro  del  or- 
ganismo.  En  algunos  Estados  de  la  Am^ca  del  Norte  el  consumode  bebidas  espiri- 
tuosas  estd  terminantemente  prohibido.  Esta  medida  nos  parece  la  mis  eficaz. 
M&B  ya  que  quizes  6ta  no  puede  llevarse  a  efecto,  creemos  que  la  acddn  ofidal  prestaria 
gran  apoyo  a  esta  obra  necesaria,  gravando  fuertemente  las  bebidas  destiladas  y 
fermentadas  (cervezas,  licores),  a  fin  de  acabar  con  la  industria  que  deprime  e  idiotiza 
a  la  humanidad  y  desplueba  las  nadones.  Las  munidpales  deben  gravar  ignalmente 
las  cantinas  y  demis  lugares  de  ezpendio  de  estas  bebidas,  dedicando  su  producto 
a  la  salubridad  ptiblica. 

La  segunda  es  mis  eficaz,  y  para  cumplirla  debidamente  debe  ser  mtUtiple  en  su 
acci6n:  debe  prindpiar  en  el  hogar,  proseguirse  en  la  escuela,  donde  al  par  que  la  edu- 
cad6n,  se  ensefien  las  nociones  de  higiene  individual  y  el  temor  al  peligro  alcoh61ico; 
las  escuelas  noctumas  para  artesanos  llevarfan  este  cometido  fidlmente  y  produdrfan 
benefices  resultados;  combatidas  allf  las  nociones  err6neas  del  alcohol  como  alimento 
de  ahorro,  como  rad6n  complementaria  de  la  vida,  se  prepara  al  dudadano  tempe- 
rante  de  mafiana;  completar  estas  nodones  con  conferencias  ptiblicas;  fomentar  las 
sociedades  temperantes  Iniciadas  ya  en  muchas  partes  del  mundo;  per  medios  de 
cuadroB  murales,  profusamente  repartidos,  que  sean  una  lecd6n  objetiva  de  los  males 
que  trae  consigo  el  alcohol;  del  r^lame  anti-alcoh61ico,  colocado  al  lado  del  reclame 
alcoh61ico,  al  cual  han  propendido  de  manera  eficaz  los  certificados  expedidos  a  las 
bebidas  llamadas  higi^nicas. 

Las  sociedades  de  obreros  y  religiosas  pueden  prestar  un  valioso  contingente  a  esta 
obra,  haciendo  figurar  en  sus  estatutos  la  prohibici6n  del  alcohol  y  oiganizando 
conferencias  para  que  sus  miembroe  lleven  al  espiritu  de  los  asociados  la  raz6n  de  eea 
medida,  tal  como  lo  hacen  sus  conferencistas  llevando  la  palabra  evang^lica,  predi- 
cando  la  8alvaci6n  de  las  almas;  asf  su  servicio  serfa  para  Dios  y  la  Patria:  al  primero 
devolviendo  al  rebaflo  las  ovejas  descarriadas  que  lavan  su  pecado  en  la  fuente  del 
arrepentimiento;  a  la  segunda,  devolviendo  al  trabajo,  a  la  industria  y  arrebatando  a 
la  miseria,  a  la  locura,  al  crimen,  multitud  de  descarriados,  que  son  hoy  una  caiga  paia 
sus  semejantes  y  procreadores  de  seres  de  miseria  moral  y  material,  que  mafiana  no 
podrin  contarse  como  unidadee  al  servicio  de  ella. 

La  habitacidn  anti-hlgi^ica,  de  cuyo  papel  etiol6gico  en  la  enfermedad  a  que  not 
referimos  ya  nos  hemes  ocupado,  cuenta  tambfen  para  su  deetruccidn  con  la  accidn 
oficial  y  la  iniclativa  privada. 

Las  municipalidades,  por  medio  de  su  inspeccidn  tdcnica  de  higiene,  deben  hacer 
desinfectar  las  contammadas,  contribuir  al  mejoramiento  de  la  habitaci6n  del  obrero, 


432       PB0GEEDIN08  SECOND  PAN  AMBBICAH  BOIBNTIFIG  CONOBBSS. 

y,  punto  importantisimo  para  nosotros,  que  contamos  con  ciudades  que  iniciaa  su 
desaiTollo,  imped*r  que  se  construyan  edificioe  sin  la  inspeccidn  higi6ncia,  para  lo 
cual  deben  ordenar  que  no  se  puedan  edificar  dichas  construcciones  sin  que  la  munici- 
palidad  apniebe  loe  pianos  correspond ientes,  mis  si  se  trata  de  pasajes  o  edificios  ani- 
logoe  para  arrendar.    De  esta  manera  se  previene,  tarea  mis  ^il  y  eficas  que  corregir. 

La  inlciativa  privada  ha  Uevado  a  Inglaterra  a  ocupar  el  primer  puesto  entre  laa 
nacionee  mejor  organizadas  para  la  lucha  contra  la  tuberculosis  y  tambi^n  la  que  ha 
obtenido  mejores  resultados.  Cerca  de  60,000,000  de  pesos  ban  invertido  los  capitalis- 
tas  de  Londres  en  la  construcci6n  de  casas  higi^nicas  a  bajo  precio  para  obreroa, 
que  les  producen  un  interns  m6dico  de  su  capital  y  al  mismo  tiempo  ban  contribuklo 
poderosamente  a  mejorar  las  condiciones  sanitarias  de  esa  ciudad. 

La  habitaci6n  higi^nica  a  bajo  precio  haril  desaparecer  el  tugurio  y  dari  una  ense- 
fianza  pr&tica  a  los  constructores  de  habitaciones  para  arrendar,  que  solo  se  ban 
preocupado  hasta  hoy  del  tanto  por  ciento,  a  mis  de  que,  inspeccionadas  debidamente, 
ensefiarin  el  aseo  al  pueblo;  su  bajo  precio  dari  un  aumento  a  la  raci6n  de  nutrici6n 
y  p<v  ^1  tendri  ella  una  doble  y  ben^fica  faz  en  el  mantenimiento  normal  de  la  resi»- 
tencia  orginica,  es  decir,  en  conservar  la  inmunidad  contra  loe  g^rmenee  de  las  enfer- 
madades  infecto^ontagiosas. 

Esta  obra  debe  ser  acogida  con  beneplicito  por  los  capitalistas  y  al  ayudarla  y 
prosQguirla  prestardn  un  precioso  contingente  al  servicio  de  la  Patria. 

Al  par  que  la  lucha  anti-alcoh61ica  y  la  habitaci6n  higi^nica,  se  ha  puesto  en  pr&ctica 
la  fundaci6n  y  explotaci6n  de  restaurantes  para  obreros,  cercanos  a  los  focos  indus- 
triales  y  fabriles.  en  Buenos  Aires,  debido  a  la  iniciativa  de  la  Sra.  de  Coni,  uno  de  los 
cerebros  femeninos  mis  culminantes  de  la  Amdr'ca,  quien  ha  unido  de  manera 
glorioea  su  nombre  a  la  lucha  anti-tuberculosa  de  su  patria. 

El  pensamiento  asi  expresado  dice  el  doctor  €^he  en  contestaci6n  al  proyecto  de 
la  Sra.  de  Ooni,  sefiala  por  ahora  el  primer  paso  en  el  sentido  de  mejorar  fundamental- 
mente  el  r^men  alimenticio  del  trabajador  para  hacerle  fuerte  y  colocarle  en  condi- 
ciones de  resistir  mejor  las  influencias  nocivas,  alejindole  al  mismo  tiempo  de  la  ta- 
bema  y  de  loe  sitios  peligrosos. 

£1  fomento  de  esta  obra  tendria  la  inconmensurable  ventaja  de  suprimir  o  a  lo 
menoe  de  restringir  el  restaurante-licorerfa,  donde  el  jomalero  consume  la  mayor 
parte  de  su  salario  en  la  bebida,  y  alimentindoee  por  ello  muy  deficientemente. 

La  influencia  nociva  de  loe  exceeos  fisicos  se  nota  tambi^n  casi  exclusivamente  en 
la  clase  obrera  sobre  todo  en  la  mujer,  que  lleva  sobre  sf  el  peso  de  la  escasez  de  au 
salario  y  en  ocasiones  trabaja  de  dia  y  de  moche,  a  pesar  de  la  matemidad  y  la  lactancia. 

Lo8  mia  expuestoa  al  deterioro  de  su  salud  por  los  exceeos  firacoe  son  la  mujer  y  el 
nifio  obreroe,  como  muy  bien  noe  lo  indica  la  Sra.  de  Goni,  de  la  Argentina:  en  aqu^lla, 
por  las  raaones  anotadaa;  en  ^ete,  porque  apenas  llegado  al  uso  de  rasdn  necesita 
ganarae  la  vida,  en  ocasiones  en  ofidos  fuertes  y  con  el  miamo  horario  de  trabajo  que 
el  adulto,  lo  cual  impide  el  desarrollo  normal  de  su  oiganismo. 

Laa  leyes  de  protecci6n  del  obrero  se  encuentran  en  vigencia  en  la  totalidad  de  las 
dudadee  europeas. 

La  obrera  que  aun  eetando  embarazada  neceaita  trabajar,  dari  al  mundo  hijoe 
raqufticos  y  predispuestoe  para  la  tuberculosis;  si  lacta  en  las  mismaa  condiciones,  au 
hijo  abandonado  en  el  tugurio  no  alcanza  generalmente  a  la  adolescencia,  vf ctima  del 
miamo  mal  o  de  alguna  otra  enfermedad  infecto-contagiosa.  Estudiadas  las  cauaaa 
de  la  crecida  mortalidad  infantil  en  los  centres  fabriles,  se  ha  llegado  a  la  fundaci6n 
de  asociaciones  para  preservar  al  hijo  intra  y  extra-uterino  de  la  obrera;  las  primeras, 
por  medio  de  casaa  de  matemidad  donde  ella  permaneceri  deede  cierto  tiempo  del 
embarazo  hasta  despu^  del  puerperio,  con  solo  pagar  una  pequefia  cuota  de  su  salario; 
la  segunda,  por  medio  de  casas  niileras,  donde  se  recibe  y  se  cuida  el  hijo  de  la  obrera 
mlentras  que  ella  esti  en  el  taller. 


PUBUC  HEALTH  AND  MEDICINE.  433 

Tuberculosis  y  matrinumio, — £1  hombre  tubeiculoeo  no  debe  caaarse,  no  solamente 
pcwque  agravarla  su  estado  de  salud  por  los  excesoe  y  fatigas  que  impone  el  primer 
pericdo  del  matrimonio;  no  86lo  porque  contaminarfa  a  su  esposa,  sino  porque  lo  que 
es  mis  grave  aiin,  procrearla  hijos  d^biles,  raqulticos,  que,  si  no  eetin  tuberculosos 
deede  su  nadmiento,  quedarin  en  circunstancias  favorables  para,  tarde  o  temprano, 
ser  presa  de  la  terrible  enfermedad  y  eeparcir  a  su  tumo  el  contagio. 

En  cuanto  a  los  nifios  hijos  de  mujer  tuberculosa,  son  a(hi  mis  raqufticos  y  estdn 
mis  predispuestos  a  la  enfermedad  que  los  de  hombre  tuberculoeo  y  mujer  indemne. 
Es  neceeario,  dice  Peter,  que  la  tuberculosa  no  se  case,  y  si  es  casEMia,  que  no  tenga 
hijos:  son  tan  intLtiles  a  la  sodedad  come  nodvos  a  su  madre;  son  nifios  cuya  vida  es 
un  problema  no  resuelto  atln. 

Para  toda  mujer  la  prefiez  es  una  fatiga,  y  la  tuberculoiis  la  exagera.  La  enfermedad 
queda  estacionaria  hasta  el  parte;  algunas  voces  la  enferma  se  sLente  mejor;  pero 
desptlies  del  parto,  la  enfermedad,  como  si  hubiese  recibido  un  empuje  poderoso,  toma 
una  marcha  fulminante  y  la  muerte  no  se  hace  esperar. 

Aai  pues  nos  dice  el  Profesor  Tamier,  es  precise  evitar  la  prefiez  en  una  mujer 
tisica.  '*En  caso  de  presentarse,  el  partero  cuya  intervenci6n  es  ineludible,  tiene 
que  Bometer  la  enferma  al  regimen  higieno-diet^tico  y  en  ocasiones  provocar  el  aborto, 
que  practicado  en  tiempo  puede  salvar  a  la  enferma.  Estas  consideraciones  bastan 
para  comprender  la  necesidad  de  aplicar  el  aforismo  de  Tamier.'' 

La lactancia  es  prohibida  por  la  ley  francesa,  que  dice:  ''toda  mujer  tuberculosa  o 
Bospechosa  de  estario  no  debe  lactar.  Hay  peli^^  en  ello  no  s61o  para  ella,  ya  que  la 
lactancia,  por  las  fatigas  que  trae  consigo,  agravari  su  estado,  sino  que  corre  peligro 
la  salnd  y  la  vida  de  su  nifio.'' 

^    Para  la  tuberculosa,  la  ley  de  Peter  es  de  aplicaci6n  rigurosa:  "soltera,  no  debe 
casarse;  casada,  no  debe  tener  hijos,  y  si  los  tiene,  no  debe  lactarlos." 

Independientemente  de  los  peligros  que  trae  consigo  el  matrimonio  entre  tubercu- 
losos: para  el  hombre,  las  reladones  sexuales  repetidas;  para  la  mujer,  la  prefiez; 
para  uno  y  otro,  la  hemoptisis  inminentes;  existe  el  peligro  de  la  contaminaci6n  a 
un  c6nyuge  sano  por  el  otoo  enfermo.  En  realidad,  los  besos,  la  vida  en  comtin,  son 
entre  nosotros  causas  casi  ftitales  de  contagio  descuidadas,  por  no  ser  conocidas  las 
reglas  que  pueden,  si  no  evitarlo  seguramente,  a  lo  menos  alejailo.  Y  este  contagio, 
segt&n  lo  ha  observado  Teutsch,  no  s61o  se  obsorva  entre  individuos  que  viven  continua- 
mente  unidos,8ino  tambiin  entre  aquellos  que  tienen  relaciones  espadadasocasuales. 

Como  regla  general,  resumiendo,  los  tuberculosos  deben  tener  relaciones  sexuales 
tan  cortas  y  alejadas  como  sea  posible;  para  evitar  el  contagio,  la  boca  debe  mantenene 
en  estado  de  aseo  perfecto  y  vigilar  con  cuidado  los  bigotes  y  la  barba;  lo  mejor  serfa 
efeitane  con  frecuencia;  seguir  estrictamente  las  reglas  de  la  profilaxis  individual. 

Loe  enfermos  cibiles  estin  condenados  a  no  casarse  nunca?  No,  pero  es  predso 
esperar  que  el  tratamiento  haya  producido  un  resultado  feliz  y  que  las  apariendas 
de  curad6n  se  mantengan  durante  varies  afios.  He  aqui  como  resuelve  la  cuesti6n 
Darembeig. 

Cuando  el  tuberculoeo  o  la  tuberculosa  estin  bien  curados,  desde  hace  cinco  o 
seis  afios,  pueden  casarse  si  tienen  recursos  sufidentes  para  no  estar  obligados  a 
trabajar  excesivamente  para  el  sustento  de  la  familia.  No  se  deberi  olvidar  que  los 
nifios  hijos  de  antiguos  tlsicos  son  delicados  y  que  deben  tener  no  solamente  una 
buena  aUmentaci^n,  sino  que  deben  vivir  al  aire  libre. 

Para  llegar  a  este  fin  ciurativo,  a  este  lindte  fijado  por  Darembeig,  la  necesidad  de  un 
diagn^stico  precoz,  elementario  sin  el  cual  el  tratamiento  no  alcanza  resultado  satis- 
factorio,  se  impone.  Este  diagndstico  precoz  comprende  el  perfodo  llamado  por  el 
Profesor  Grancher  "de  germinad6n  o  pretuberculoso.'' 


434       PBOOEEDINGS  SECOND  PAN  AMEBIOAN  SCIENTIFIC  CONGRESS. 

APiNDICE. 

Expuestas  las  medidas  preventivafl  de  la  tuberculodB,  debemoe  indicar,  para  com- 
pletar  eete  estudio,  que  debe  hacerae  con  loe  tuberculoeos  existentee,  ya  que  no  debe 
mirdrseles  como  pariafi,  mixime  cuando  au  crecido  ntimero  obedece  a  la  incuiia  en 
que  hemoB  vivido.  Hay  que  tener  en  cuenta  que  al  mejcmur  su  8ituaci6n|  al  colo- 
carloe  en  mejores  condiciones  noe  defendemoe  todos  del  flagelo  que  nos  amenaza 
cada  dia  m&s  y  m^s:  utilidad  com(hi  de  la  cual  debemoe  imponer  a  todoe,  para  que 
nadie  eacatime  bu  grano  de  arena  a  la  obra  anti-tuberculoea. 

Las  medidas  preventivas  nos  llevar&n  a  diamiinnr  o,  serla  el  ideal,  suprimir  loe 
tuberculoBOB  del  porvenir.  Pero  es  necesario  tratar  a  loe  enfermoe,  tanto  m^s  cuanto 
que  las  eetadisticaa  noe  dicen  que  la  enfermedad  es  curable  y  en  muchas  ocasiones 
curable  espontdneamente  como  se  ha  comprobado  millares  de  voces  en  las  autopsias. 

LfOfl  enfermos  que  no  tienen  recuieoe  para  ser  tratados  en  sus  domicilioe  debidamente, 
y  aquellos  para  quienes  el  dispensario  no  puede  servir,  por  lo  avanzada  de  su  enfer- 
medad o  durante  loe  ataques  agudos,  deben  ser  hospitalizados  lacionalmente  en 
eepera  de  una  mejoria  o  de  una  curaci6n  radical.  Estos  hospitalee  son  los  sanatorios, 
que  deben  ser  instalados  por  el  estado  o  las  municipalidades,  como  lo  son  los  hospitalee 
de  caridad,  sin  perjuicio  de  que  los  haya  particulares  para  las  clasee  pudientes. 

Lo  diffcil  de  estos  eetablecimientos  es  su  mantenimiento,  debido  a  su  costo,  pero 
esto  puede  allanarse  en  parte  con  el  establecimiento  del  sQguro  obligatorio  del  obrero 
y  del  empleado  civil,  lo  cual  ayudari  al  Estado  a  sobrellevar  la  caiga  que  su  creacidn 
le  impone. 

Este  seguro  es  m^  f^cil  de  establecer  en  loe  cuerpos  como  el  ejdrcito,  marina,  po- 
iioia,  etc.,  como  en  los  llamados  Monteplos  militares  fundados  con  fines  parecidos 
o  con  el  de  asegurarles  algtin  dinero  a  su  salida  de  servicio. 

Loe  niflos  tuberculosoe  no  deben  concurrir  a  las  eecuelas,  comunes,  pero  se  pueden 
establecer  escuelas  especiales  donde  al  par  que  desanollan  sus  funciones  psfquicas 
encuentren  medio  de  reponer  su  salud;  de  alii  volver^  muchos  sanos  y  vigorosos  a 
ser  iltiles  a  su  patria.  Estos  establedmientos  funcionan  hoy  en  varias  partes  del 
mundo  con  el  nombre  de  Golonias  agricolas  {lara  niflos  tuberculosoe. 

En  cuanto  a  los  nifios  no  tuberculosos,  pero  hijos  de  tales,  que  viviendo  al  lado  de 
ellos  Uegardn  a  serlo  indudablemente  debido  al  estado  receptivo  de  su  oiganismo,  se 
impone  el  tomar  alguna  medida  {lara  evitarlee  la  enfermedad.  Entre  las  que  se  han 
ideado  paia  ello,  noe  parece  la  m^  pr&ctica  y  la  m4B  fadl  de  llevar  a  cabo,  la  de  la 
obra  de  preeervacidn  de  la  tuberculosis  por  el  m^todo  del  Profeeor  Qrancher:  He 
aquf  como  lo  deecribe  De  Fleury. 

Su  objeto  predso,  es  sustraer  al  nifLo,  ileeo  de  la  enfermedad,  del  medio  tuberculoso 
en  que  crece,  expuesto  di&  y  noche  al  ccmtagio.  Est&  hov  aemoetrado  que  la  tisis 
no  es  hereditaria,  pero  si  muy  contagiosa,  y  todo  el  mundo  comi»endera  la  imp(»^ 
tancia  fundamental  de  esta  noci6n  actualmente  indiscutible. 

£1  medico  de  una  ofidna  de  beneficiencia  o  imo  de  esos  investigadores  de  la  tuber- 
culosis, como  los  ha  imaginado  el  Profeeor  Oalmette  para  sus  dispensarios,  avisarla  a 
los  agentes  de  la  obra  de  preeervaci6n  que  existen.  en  tal  o  cual  casa  insalubre  de  la 
dudad.  por  ejemplo,  dos  nifios  atln  sanos  cuyos  paoree  estin  enfermos  de  tuberculosiB. 
tin  medico  inspector  se  tiaslada  a  la  casa,  comprueba  aue  los  nifios  est&n  comple- 


tamente  Hesos  y  que  no  podr^,  pues,  contaminar  el  medio  a  donde  van  a  ser  trans- 
plantados.  La  obia  propone  entonces  a  los  padres  servirles  de  intermediaria  para 
colocar  a  sua  hijos  en  el  campo,  en  una  faunilia  de  labradores  parfectamente  sanos. 


AUi  crecer&  el  nillo  al  aire  libre.  l^os  de  todo  contM^io,  suficientemoite  alimentado, 
y  quedar&  pronto  vendda  su  debuidad  natural.  Al  mismo  tiempo  se  aligeran  los 
caiffos  del  padre  de  fomilia  y  el  trabajo  de  la  madre. 

<Sueda  bien  eetableddo  que  nunca  se  obligari  a  los  padres  a  separarse  de  sus  hiios. 
Conviene  que  se  imponsan  voluntariamente  este  sacrifido  necesario  y  que  la  obia 
b61o  le  sirva  de  intermecuaria.  AdemAs  los  padres  estarin  oblisados  a  IMgar  por  su 
hijo  una  cantidad  infima,  dos  o  tres  francos  por  afio,  que  se  les  adelantaraa  si  es  nece- 
sario, para  indicar  que  no  abandonan  a  su  hijo,  que  no  se  desinteresan  y  que  consenran 
contacto  con  41. 


PUBUC  HEALTH  AND  JIBDIOINB.  486 

La  obn  concebida  por  el  Dr.  Gianciier  Ueva  estampado  el  sello  de  su  eipfrita  tan 
neto,  tan  juicioeo  y  tan  perfectamente  clarividente.  Este  maestro,  aue  con0agr6 
mis  de  la  mitad  de  su  vioa  al  estudio  de  la  tuberculosis,  ha  contribuido,  mis  que 
nadie,  a  demostrar  su  unidad,  ha  descrito  loe  signos  que  permiten  hacer  el  diagndstico 
mecoe;  este  profesor  de  clmica  de  enfermedades  de  la  infoncia,  a  quien  no  ban 
laltado  las  ocasionee  de  conmoverse  ante  los  sufrimientos  de  los  pequefiuelos;  este 
bacteri61ogo,  cuyo  nombre  vivM  siempre  como  el  de  uno  de  los  primeros  y  mis 
eminentes  discfpulos  de  Pasteur;  este  hombre  estaba  particularmente  sefialado  para 
concebir  y  oimnizar  semejante  obra  de  preservad6n  que,  en  cualquier  sitio  donde 
funcione,  pondii  fin  a  la  propagaci6n  y  detendri  la  diBemiiiaci6n  ael  mis  atros  de 
los  azotes,  salvando  a  la  infaincia,  aliviando  a  la  familia  atacada,  de  todos  los  nstos 
y  pesares  que  cuesta  la  oblinci6n  de  criar  a  unos  inf elices  que  la  enfermedad  y  la 
miseria  hacen  sentir  haber  ediado  al  mundo. 

Se  recogen  los  nifios  entre  cinco  y  trece  afios  y  permanecen  en  el  campo  el  tiempo 
necesario  para  el  pleno  desanrollo  de  sus  fuerzas  y  el  saneamiento  de  la  casa  patema; 

Lsu  destierro,  suavizado  por  las  frecuentes  visitas  de  los  inspectoree  de  la  obra.  es 
:;undo  en  resultados  f^ues  para  ellos  mismos,  para  sus  padres  v  para  la  sociedaa. 

Toda  obra  de  beneficiencia,  de  pre8ervaci6n  y  de  asistencia,  ha  dicho  el  Profesor 
Grancher,  lo  mismo  si  vive  de  la  caridad  pdblica  o  con  el  dinero  del  Estado,  tiene  por 
deber  hacer  el  mayor  bien  posible  con  el  menor  g^Eisto.  Mis  que  ninguna  otra,  la  obra 
de  pre8ervaci6n  de  la  infancia  contra  la  tuberculosis,  parece  Uenar  estas  dos  condiciones. 

Hace  ya  tres  afios  que  se  fund6.  Algunas  cifras  van  a  decimos  lo  que  ha  reaUzado 
desde  entonces. 

£n  1904  asegurd  la  salvaci6n  de  27  nifios  amenazados  de  tuberculosis:  en  1905,  el 
ndmero  de  sus  pupilos  se  elev6  a  50,  y  en  1906,  a  223,  repartidos  entre  12  nogares;  cada 
uno  de  estos  hogares  esti  colocado  bajo  la  vigilancia  de  un  midico  de  la  comarca, 
afiliado  a  la  obra. 

Reconocida  de  utllidad  pdblica,  la  obra  del  Profesor  Grancher  recibe  ahora  del 
Estado  50,000  francos,  la  ciudad  de  Paris  le  concede  18,000  y  el  consejo  general  del 
Sena  7,000  por  afio. 

Los  adherentes,  fundadores  de  pensiones  o  plazas,  bienhechmas,  donantes,  etc., 
son  anualmente  1,048. 

El  valor  de  cada  nifio  se  ha  calculado  en  200  francos  anuales,  y  esto  hasta  los  10  o  12 
afios,  pues  de  dicha  edad  en  adelante  ya  no  costazi,  nada,  porque  su  trabajo,  de  acuerdo 
con  su  estado  de  salud,  dari  bus  gastos. 

Otras  ciudades  de  Francia  ban  seguido  el  ejemplo,  y  en  todas  ha  dado  los  mis 
halagfiefios  resultados,  y  de  Floury  noe  dice  que — 

Basta  con  que  continde  este  movimiento  para  que  dentro  de  pocos  afios  est^  en 
toda  la  Francia  los  hiios  de  tuberculosos  al  abrigo  de  un  mal  que  no  podfa  dejar  de 
alcanzarlos.  Se  habra  salvado  la  semilla,  como  decfa  Pasteur,  y  habri  dado  Francia 
al  mundo  una  incomparable  lecci6n  de  discemimiento,  de  sabidurUy  de  economla,  en 
materia  de  lucha  anti-tuberculosa. 

ooNOLuaioNsa. 

La  etiologfa  de  la  tuberculosis  se  basa  sobre  dos  puntos  capitales:  el  bacilo  de  Eoch, 
agente  especifico  de  dicha  enefermedad,  y  el  (wganismo  en  que  date  se  desarrolla. 

Antiguamente  era  dogma  la  herencia  de  la  enfermedad.  Hoy,  merced  a  los  pro- 
gresos  de  las  ciencias  bioldgica  y  fisi61ogica  y  a  su  ayudante  la  bacteriologfa,  ^sta  ha 
perdido  su  predominio  y  nosotaros  conclufmos  que  excepcionalmente  se  hereda  la 
tuberculosis,  rara  vez  es  congenital  por  contagio  intra-uterino,  y  que  la  herencia  no 
interviene  sine  predisponiendo  el  organismo  a  ella,  es  decir,  que  los  hijos  de  tuber- 
culosos nacen  d^biles  y  esto  los  hace  receptivoe. 

La  propagaci6n  de  la  enfermedad  en  el  mundo  se  debe  al  contagio. 

El  bacilo  de  Koch,  agente  del  contagio,  existe,  por  millares  en  los  esputos  de  los 
tisicoe.  Los  esputos,  tanto  al  estado  fresco  acabados  de  expulsar,  como  seco  y  reducidos 
a  polvo,  son  la  causa  primordial  de  la  exten8i6n  que  ha  tornado  la  enfermedad.  Fresco, 
puede  contaminar  las  manos,  libros,  objctos  de  uso  comdn,  etc.,  ser  llevado  por  las 
moscas  sobre  nuestros  alimentoe  y  de  ahi  pasar  a  nuestro  oiganismo  por  el  tube  digee- 
tivo.  Seco  se  pulveriza  y  esos  polvos  pueden  penetrar  en  nuestro  oiganismo,  deposi- 
tindoee  sobre  los  mismos  objetos  enumerados  y  penetrar  por  la  misma  via  o  en  cases 
ezcepcionaltt  con  el  aire  inq>irado. 

68486— 17--V0L  x 29 


436       PROCEEDINGS  SECOND  PAN  AMBBICAN  SCIENTIFIC  CONOBESS. 

Lo8  anlmales  tuberculosos  y  que  airven  a  iiueetz«  alimentaci6n  pueden  tambi^ 
Uevar  su  bacilo  a  nuestro  organismo  y  producimoe  la  enfermedad;  gracias  a  la  inspec- 
ci6n  de  cames,  ^tas  presentan  un  peligro  caai  depreciable;  no  asf  con  la  leche  que 
se  contamina  f&cilmente  por  el  esputo  humane. 

La  miseria,  toda  causa  que  debilite  el  oiganiamo,  lo  hace  receptive  para  la  tuberculo- 
sis y  en  muy  alto  grade,  el  alcoholismo,  Uamado  por  eso  el  gran  tisiiSgeno. 

I>a  habitaci6n  en  un  cuarto  o  casa,  con  gran  ntimero  de  personas  y  con  animaleB, 
sin  servicio  sanitario,  en  desaseo,  entra  en  el  ntimero  de  las  causas  m&9  poderosas  de 
debilitamiento  del  oiganismo  y  por  ende  de  la  propagaci<Sn  de  la  enfermedad. 

En  loB  medios  colectivos  en  que  estas  condidonee  se  encuentran  reunidas,  los  con- 
tactoe  entre  Ice  individuoe  son  frecuentes  y  las  ocasiones  para  el  contagio  son  tanto 
m&9  de  temer  cuanto  mayor  sea  el  ntimero  de  los  cohabitantes.  Sucede  asf  en  las  casas 
de  alquiler  por  cuartoe,  los  talleres  o  f&bricas,  los  asilos,  establecimientoe  de  castigo, 
los  hotelee,  el  ej^ito,  la  marina,  Ice  navlos,  los  trenes,  escuelas,  etc.,  y  en  algunos 
como  Ins  hoepitales  policlfnicos  de  caridad  que  se  encuentran  habitadoe  por  tuber- 
culosos en  ndmero  no  despreciable. 

En  todas  partes  donde  el  hombre  se  reune  para  su  trabajo  o  sub  placeres,  se  puede 
contraer  la  enfermedad  si  entre  los  reunidos  existen  tuberculosos  que  no  toman 
precauciones  con  sus  esputos. 

La  tuberculosis  es  una  enfermedad  que  se  propaga  no  tanto  por  ser  ella  inmlnente- 
mente  contagiosa,  sine  por  la  inciuria  en  que  vivimos  y  por  la  arraigada  idea  de  ocultar 
al  tuberculoso  su  estado  y  lo  que  es  para  los  dem^,  si  no  se  ajusta  a  las  prescripdonee 
de  una  higiene  individual  al  parecer  rigurosa,  pero  ben^fica  en  extreme  para  los 
seres  que  ama  y  para  quienee  desea  los  may  ores  bienes  posiblee. 

La  tuberculosis  es  pues  una  enfermedad  evitable  y  el  medio  mds  eficaz  y  ttcil  para 
ello  es  la  higiene  individual,  cuidando  al  mismo  tiempo  de  no  esparcir  los  esputos 
sobre  los  pisos,  ya  sea  de  la  habitaci6n  o  de  las  vias  ptiblicas,  con  mayor  razdn  en  1a 
proximidad  de  las  sustancias  que  sirven  a  nuestra  alimentaci6n.  Guerra  al  esputo 
debe  ser  el  lema  de  la  cruzada  antituberculosa. 

Las  mimicipalidades  no  deben  mostrarae  Indiferentes  a  eete  movimiento  preventive, 
dlctando  disposiciones  que  hagan  efectiva  la  prohiblci6n  de  escupir  en  los  lugaree 
ptiblicos  y  proveer  sus  edificios  de  escupideras  adecuadas  y  suficientes. 

Eptas  secundadas  por  el  Estado  deben  contribuir  a  la  fomentaci6n  del  servicio  de 
de8infecci6n  y  de  los  dispensarios;  al  mejoramiento  de  los  hospitales  policlfnicos  para 
evitar  que  sean  un  medio  de  propagaci6n;  creando  y  manteniendo  los  sanatorios  para 
alojar  a  los  tuberculosos  en  perfodos  curatives;  preservando  a  la  infancia  de  la  enferme- 
dad, contribuyendo  a  que  se  levanten  fuera  del  toco  tuberculfgeno  en  que  han  nacido. 

Las  aaociaciones  de  obreros;  las  grandes  fdbricas  y  talleres;  lasasociaciones  de  comer- 
do;  los  empleadoB  dviles  y  militares,  deben  establecer  el  seguro  obligatorio  contra 
la  tiflis.  Asf  se  hace  obra  de  preYend6n  y  se  pueden  ahorrar  muchas  penalidades  en 
lo  porvenir. 

En  estas  agrupaciones  humanas  como  en  las  escuelas  debe  llevarse  a  cabo  la  instmc* 
d6n  antituberculosa  para  que  sus  miembros,  comprendiendo  la  necesidad  de  ella  la 
practiquen  en  sus  hogares  y  por  doquiera. 

BIBfJOGRA^FiA. 

A.  Calmette.  Oonferencia  dictada  en  Harvey  Sodety  de  New  York.  La  Prone 
Medicale  No.  103,  Paris. 

Robert  Teutsch.    Tuberculosis  pulmonar. 

Paul  Brouardel.    La  lucha  contra  la  tuberculosis. 

P.  Jou8t9et     Profilaxis  de  la  tuberculosis. 

L.  de  Sohroter.    Higiene  de  los  pulmones. 

J.  Oourtmont.    Enfermedades  profesionales  infectantes. 

Louis  Martin.    Higiene  de  hoepitales. 

Pr.  Arloing.  Crftioa  a  las  ideas  de  Robert  Koch  sobre  la  profilaxis  de  la  tubercu- 
losis.   La  Lutte  antituberculeuse.    Paris. 


PUBLIC  HEALTH  AND  MBDICIKB.  437 

E.  de  Lavarenne.    Higiene  social  y  medicina.    T^a  Preflse  Medicale  No.  86,  Paris. 
Magoon  y  Bamet.    Memoria.    Alianza  de  higiene  social  No.  3  y  4.    Buenos  Aires. 
J.  Lignieres.    La  tuberculosis  humana  y  la  de  los  animales  dom^sticos. 
Samuel  Grache.    La  tuberculosis  en  la  Repdblica  Argentina. 
A.  Robin.    Terap^utica  usual  del  pr&ctico.    Tratamiento  de  la  tuberculosis. 
Hallopeau  y  Apert.    Patologia  general. 
G.  Dieulafoy.    Patologfa  interna. 
Del  Autor.    Tuberculosis  en  Colombia. 


LA  TUBERCULOSIS  EN  BOLIVIA;  SU  ETIOLOGiA  Y  PROFILAXU. 

Por  NlfeSTOR  MORALES  VILLAZ6N. 
Director  del  InstUiuo  Nadonal  de  Bacteriologia  de  Bolivia. 

El  tltulo  del  presente  estudlo,  parece  indicar  que  abarca  todo  lo  que  se  refiere  a  U 
tuberculosis  y  sus  caracteres  especiales,  en  las  distmtas  zonas  de  la  Repdblica,  pero 
como  un  tema  tan  vaato  requeriria  mis  tiempo  que  el  que  actualmcnte  dispongo, 
para  su  correcto  desarrollo,  b61o  me  ocupar^  por  el  momento  de  la  tuberculosis  en  la 
regidn  del  altiplano  y  muy  especialmente  en  los  departamentos  de  La  Paz  y  Gruro. 

La  tuberculosis,  cual  hacen  notar  con  razdn  la  mayor  parte  de  los  autores,  es  conocida 
desde  la  m^  remota  antigdedad,  confundida  al  principio  con  todas  las  enfermedades 
que  determinaban  intenso  desgaste  oiginico,  fu^  poco  a  poco  mejor  caracterizada, 
hasta  que  las  investigaciones  de  Peter,  Bonet,  Morton,  Sauvages  y  finalmente  Laenec, 
la  hicieron  conocer  en  su  integridad  clinica,  estableciendo  emds  la  anatomia  pato- 
l^ca  de  la  aleccidn. 

Lejos  se  encuentra  ya  de  nuestra  ^poca,  la  de  las  ardientes  discusiones  de  la  escuela 
dualista  con  Virchow  a  la  cabeza  y  la  unicista  cuyo  paladin  fu6  Villemin.  Sabido 
es  que  las  experienclas  de  inoculacidn  hechas  por  este  sabio,  el  5  de  diciembre  de 
1865  y  el  descubrimiento  del  bacilo  de  Koch,  el  24  de  marzo  de  1882,  vinieron  a 
sentar  sobre  bases  inconmovibles  la  absoluta  unidad  de  la  tuberculosis,  cuyas  modali- 
dadee  cllnicas  por  muchas  y  muy  variadas  que  fueran,  siempre  estaiin  en  dltimo 
t^rmino  producidas  por  el  mismo  bacilo. 

El  descubrimiento  del  agente  productor  de  la  enfermedad,  fu^  uniformemente 
aceptado;  los  mis  reputadoe  bacteridlogos  del  mundo  entero,  pudieron  comprobar 
que  en  todas  las  lesiones  verdaderamente  tuberculosas,  se  encontraba  el  bacilo  de 
Koch  a  exclusidn  de  cualquier  otro. 

Los  cultivos,  las  inoculaciones,  la  preparacidn  de  la  tuberculina,  los  ensayos  de  va- 
cunoterapia  y  sueroterapia,  no  hicieron  mis  que  afirmar  con  mayor  fuerza  si  es  posible, 
el  descubrimiento  de  Roberto  Koch. 

En  ^poca  muy  reciente,  algunos  autores  y  entre  ellos  Jaime  Ferrin,  niegan  la  especi- 
ficidad  de  este  organismo  microbiano,  creyendo  que  la  tuberculosis  es  un  complexo 
cUnico,  que  empieza  por  una  labor  quimica  lenta  y  silenciosa,  cuyo  agente  no  es  el 
bacilo  de  Koch. 

El  autor  arriba  mencionado  dice: 

La  tuberculosis  espontinea  comienza  casi  siempre  como  una  labor  quimica  lenta  y 
silenciosa  provocada  por  un  t6xico  bacilar  que  localiza  su  acci6n  en  los  eritrocitos 
partiendo  oe  la  red  liniitica.  Los  gldbulos  rojos  se  modifican  de  modo  que  se  muestraa 
mis  sejislbles  y  sucumben  mis  o  menos  fdcilmente  a  la  acci6n  destructora  de  los 
eritrdfagos  vis.?erale8. 

En  otra  parte  continda: 

En  rua^to  al  a^nte  de  estas  inflamaciones  cuando  son  espontineas,  en  vez  de 
ser  el  ba  ilo  de  lS)ch,  icido  resistente,  lo  es  un  ancestral  suyo  no  icido  reslstente, 
dotado  en  su  origen  de  aptitudes  saproflticas  y  por  lo  tanto  muy  ficil  de  cultivar. 


438       PBOCEEDINOS  8B00KD  PAH  AMBBIOAK  80IEHTIFIC  COKOBB88. 

El  Profeaor  Luis  Renon,  en  su  magnffica  obra  sobre  ks  enfermedftdee  popularee, 
participa  de  las  ideas  de  Ferr&n  y  hace  notar  que  ya  el  20  de  abril  de  1886  Duguet  y 
H6iicourt,  en  una  comunicaci6n  a  la  Academia  de  Medicina,  dudaban  del  caiicter 
especffico  del  bacilo  de  la  tuberculosis  y  se  preguntaban  si  no  era  este  microbio  otra 
cosa  que  una  de  las  fases  evolutivas  del  Microsporon  furfur.  Las  experiencias  de 
estos  sabios  no  merecieron  llamar  la  atenci6n  y  s61o  muchos  afioe  despu^,  ee  que  Piory 
y  Renoux,  volvieron  a  buscar  la  comprobaci6n  de  los  primitivos  estudios  y  conaigul- 
eron  mediante  la  inoculaci6n  de  las  escamas  de  la  pitiriaais  versicolor,  producir  en 
el  cobayo  una  tuberculosis  clisica. 

Otros  observadores,  Ernest  Lichtenstein,  Georges  Mayer,  Paul  Courmont,  encuentran 
en  la  manteca  y  en  lesiones  aparentemente  tuberculoeas,  bacilos  que  difieren  del  de 
Koch  en  algunoe  caracteres,  pero  que  participan  con  este  de  la  propiedad  de  ser 
icidos  resistentes.  Finalmente  el  Dr.  Santini  en  un  interesante  articulo  publicado  en 
la  Re  vista  de  Higiene  y  Tuberculosis  de  Valencia,  declara  que  habiendo  hecho  varias 
experiencias  con  el  bacOo  Fenin;  en  uno  de  los  cases  la  inyecci6n  repetida  de  bacterias 
aUSxicas,  determin6  un  proceso  tubercul6geno,  que  ocasion6  la  mucrte  del  aninutl,  en 
cuya  autopsia  se  encontraron  tub^rculos  verdaderos. 

Sin  entrar  a  un  estudio  m^  profundo  de  las  teorfas  del  Profesor  Ferr&n  y  reduci^n- 
dolas  a  su  mayor  sencillez,  podrfamoe  condensarlas  en  las  siguientes  palabras:  La 
tuberculosis  no  es  una  enfermedad  producida  por  un  solo  bacilo,  sine  por  toda  una 
familia  de  bacilos  sapr6fitos,  que  poco  a  poco  y  por  distintas  genesis,  adquieren  la 
propiedad  &cido  resistente. 

Respetando  las  opiniones  del  c^lebre  bacteri61ogo  espafiol,  al  que  tantos  y  tan  im- 
portantes  servicios  debe  la  ciencia,  debo  declarar  que  la  teorfa  saprofitaria  de  la  tuber- 
culosis, no  se  encuentra  de  acuerdo  con  las  investigacionee  de  laboratorio  y  que  en  los 
muchos  y  muy  variados  estudios  que  he  efectuado  sobre  esta  entidad  m6rbida,  siempre 
he  podido  comprobar  la  unidad  completa  del  bacilo  de  la  tuberculosis.  Es  evidente 
que  en  los  cultivos  ocurren  ciertos  fendmenos  que  conviene  mencionarlos  aunque  sea 
ligeramente  y  a  cuya  interpretaci6n,  sea  debido  quizd,  el  que  se  sospeche  de  la  completa 
unidad  del  bacilo  de  Koch.  Courmont,  Nicolle,  Marmorek  y  muchos  otros  expert- 
mentadores,  habian  hecho  notar  que  en  los  cultivos  se  encontraban  doe  especies  de 
organismos  bacterianos,  los  j6venes  y  los  de  mayor  edad.  Ahora  bien,  si  se  toma  un 
cultivo  de  20  o  25  dfas  y  se  le  somete  al  m^todo  Ziehl  Nelsen,  se  observa  que  mientras 
una  parte  de  los  bacilos,  es  dcido  resistente,  la  otra  se  decolora  en  su  totalidad  por  el 
^do  nitrico  al  tercio. 

Este  fen6meno  que  se  puedo  observar  en  cualquier  laboratorio,  ha  sido  posiblemente 
el  ongen  que  ha  hecho  suponer  que  el  bacilo  de  Koch  no  era  especifico.  En  este  punto 
conviene  hacer  notar,  que  la  propiedad  dcido  resistente  no  la  adquiere  el  bacilo  sino 
con  la  edad  y  constituye  uno  de  los  caracteres  de  su  completo  desarrollo;  pero  el  que 
en  las  preparaciones  existan  algunos  bacilos  que  se  decoloren,  no  puede  autorizar,  en 
mi  concepto,  a  negar  la  unidad  de  la  especie,  tanto  mds  cuanto  que  es  observacidn 
corriente  que  las  bacterias  segiin  la  edad  de  bus  cultivos,  adquieren  nuevas  propiedades 
o  pierden  las  que  tenian. 

Mucho  se  ha  insistido  sobre  las  manifestaciones  tuberculosas  que  se  han  logrado 
provocar  en  el  cobayo  mediante  la  inyccci6n  de  bacilos  saprofitarios.  Sin  negar  el 
hecho,  cabrfa  preguntar  si  en  estos  cases  las  inyecciones  repetidas  de  cultivos  bac- 
terianoe,  no  han  desempefiado  el  papel  de  causa  ocasional,  despertando  un  proceso 
baciloeo  latente.  No  tendrfa  nada  de  extraordinario  el  hecho  si  se  reflexiona  la  suscep- 
tibilidad  del  cobayo  con  respecto  al  bacilo  de  Koch. 

Origen  de  la  tubercuUms  en  el  altiplano  andino. — No  obstante  que  no  existen  docu- 
mentos  fehacientes,  en  los  cuales  pueda  fundar  conclusiones  de  car&cter  inamo\dble, 
basado  en  las  consideraciones  que  a  continuaci6n  expongo,  creo  que  antes  de  la 
conquista  de  la  America  Meridional  por  los  espafioles,  la  tuberculosis  en  esta  parte  del 
contiQente  era  o  sumamente  rara  o  totalmente  desconocida. 


FUBUO  HBALTff  AKD  MEI^IOIKS.  439 

ExaminMido  las  csuaas  que  originan  la  tuberculosis,  tenemoe  que  se  encuentran 
ocupando  lugar  de  preferenda  la  acci6n  del  aire  confinado  y  htimedo,  la  alimeiitaci6n 
defidente,  en  una  palabra  la  polreza  tal  como  la  conocemoe  hoy  en  las  grandes  ciudades, 
pues  tien,  examlnado  lo  que  aun  hoy  dia  ocurre  en  la  raza  indigena,  vemoe  que  su 
tendencia  es  vivir  en  chosas  separadas  en  las  que  rara  ves  existen  mis  de  cuatro  o 
dnco  penonaSy  pues  cuando  el  Ujo  o  la  hija  llegan  a  la  edad  adulta,  dejan  la  casa 
patema  para  constituir  lejos  de  ^ta  un  nuevo  hogar.  En  estas  condiciones  la  aglo- 
meraci6n  que  juega  un  papel  tan  importante  en  la  etiologia  de  la  enfermedad  de  que 
nos  ocupamos,  no  ha  podido  existir  en  el  altiplano,  en  cuyas  inmensas  llanuras,  los 
caserios  de  los  primiti^os  habitantes,  se  esparcian  quedando  entre  ellos  grandee 
distandas. 

Causas/itiau. — El  USrax  llamado  raquitico,  aplastado  por  las  partes  laterales  y  muy 
manil^esto  en  la  regi6n  del  eetenuSn,  que  Simula  la  quilla  de  barco  o  al  pedio  de  gailina, 
ha  flido  considerado  por  la  mayor  parte  de  los  tratadistas  como  siendo  el  terreno  abonado 
para  el  desarrollo  de  la  tuberculosis;  las  personas  asi  conformadas  tienen  reepirad6a 
defidente  y  basta  una  causa  ocasional  cualquiera,  para  que  la  enfermedad  se  produzca 
atacando  de  preferenda  los  ^  ^rtices  pulmonares. 

La  etidogfa  del  t^rax  raqultico,  es  miiltiple  y  las  causas  que  le  pro  ocan  son  dis* 
tintas  en  cada  case  particular,  existiendo  sin  embaigo,  algunas  de  caricter  general, 
entre  los  cuales  encontramos  la  falta  de  un  culaje  de  aire  respirable  sufidente,  la  falta 
de  ejercicio  y  la  alimentad6n  de  mala  calidad. 

Cubajt  de  aire  reepirable, — Los  higimiistas  de  un&nime  acuerdo,  declaran  que  cuanto 
mayor  es  la  superfide  que  pueda  disponer  cada  habitante,  la  salulridad  es  mejor. 
En  Francia  segtin  los  reglamentos  miU tares,  para  cada  soldado  existe  una  superficie 
de  3  metroe  y  75  centimetres,  en  Inglaterra  nue. e,  en  Alemania  cuatro  y  en  Paris 
Umiando  el  conjunto  de  la  dudad  46  metres.  La  cantidad  de  aire  respira)  le  por 
persona,  nunca  deberia  ser  menor  de  65  metres  ciilicos  dentro  de  las  hal  itaciones. 
Teniendo  en  cuenta  estos  dates,  nos  bastard  reflexlonar  que  los  primiti  os  hal  itantes 
del  Altiplano  Andino,  tenian  a  su  dispo6id6n  la  infinita  soledad  de  la  pampa,  la  cual 
si  se  hidera  el  c41culo  para  determinar  la  denaidad  de  la  pollaci^n,  tendriamoe  que 
quiz4  habria  un  habitante  por  cada  4  o  5  kil6metros.  Respecto  al  culaje  de  aire 
respirable,  debemos  sefialar  el  hecho  de  que  por  hdlito  el  indio  no  permanece  dentro 
de  su  choza  sine  para  dormir,  el  resto  queda  en  pleno  aire,  sea  ocui^ido  en  las  labores 
del  campo  o  en  los  pequefios  quehaceres  dom^ticos,  los  que  realiza  en  el  patio  de  la 
casa,  en  pleno  sol  y  al  aire  libre.  Como  consecuencia  l<3gica  de  lo  dicho,  se  deduce 
que  d  confinamiento  tan  temido  por  los  higienistas,  no  ha  podido  ser  la  causa  de  la 
bacilosis  en  la  raza  del  altiplano. 

La  alimentaci6n  intufidenU, — La  mala  nutrici6n  ocasionada  por  una  alimentad6n 
insuficiente,  es  tamli^  otra  causa  productora  de  la  tuberculosis,  ol  ra  dismlnuyendo 
las  defensas  orgdnicas  y  fiicilitando  en  consecuencia  la  in  asion  de  los  eleraentos 
bacterianos. 

Examlnando  la  histona  de  la  Am^ica,  es  fdcil  con  encerse  de  que  eeta  parte  del 
continente  gozaba  de  singular  lienestar,  la  carne  la  tenian  en  abundancia  de  la  llama  y 
la  alpaca,  ademis  la  papa,  la  oca  y  otros  a  egetalee  alimenticlos,  pro%  eian  ampliamente 
a  las  necesidades  de  los  primeros  habitantes.  Finalmente  siendo  el  aimara,  lo  mismo 
que  el  quechiia,  no  una  raza  n6mada  sino  sedentaria  y  agricultora,  no  se  condle 
que  existiendo  cuantos  terrenes  laboralles  se  podian  deeesr,  hubiera  indi .  iduos  que 
sufrleran  por  la  miseria. 

La  luz  cuya  acd6n  (itil  como  t6nico  del  organismo  ha  side  eetudiado  por  el  Dr. 
Joe^  Verdes,  Montenegro,  es  indudable  que  obra  en  estas  grandes  alturas  de  una 
manera  muy  eficaz.  Efectivamente  es  rare  que  en  la  altiplanlcie  andino,  existan 
dos  dias  sin  que  se  vea  la  luz  del  sol,  lo  ordinario  es  que  el  astro  rey  pennanentemente 
extienda  sus  rayos  sobre  la  inmensa  meseta  andina  y  que  sdlo  moment4neamente 
desaparezca  para  volver  a  presentarse  pasada  la  tormenta,  que  de  ordinario  es  de 
corta  durad6n.    Segdn  Schrroter,  la  luz  solar  aumenta  los  cambios  gaseosos  y 


440       PBOOEEDINOB  SEOOHD  PAN  AMBBIOAK  SdEHTIFIO  C0KQBB8S. 

naturalmente  la  actividad  orgdnica.  Moiin  le  atribuye  ima  real  influenda  sobre  el 
estado  pefquico,  lo  que  soeteniendo  la  moral  del  individuo,  lo  hace  mis  reeiBtente  a 
las  causas  patol6gica6. 

Hace  muchos  afioe  que  los  fisiologtstaB  ban  eentado  el  prindpio  de  que  la  funci6D 
bace  al  6rgaiio,  en  esta  yirtud  el  indio  obligado  a  reepirar  un  ntimero  mayor  y  mis 
amplio  de  vecee  para  evitar  la  acd6n  pemidosa  de  la  rarebkcd6ii  del  aire,  ee  indudable 
que  ha  desarroUado  bus  pulmonee  robusted^ndolos  en  tal  forma,  que  es  muy  difidl 
que  fueran  la  presa  fddl  de  la  invaai6n  badlar. 

El  desarroUo  considerable  del  aparato  reepiratorio  en  el  indio,  se  puede  boy  mismo 
comprobar  con  la  mayor  facilidad  y  bastard  dtar  lo  que  ocurre  con  los  indigenas  que 
se  presentan  a  los  cuarteles  para  cumplir  con  el  servicio  militar  obligatorio  y  que  son 
sometidoe  al  examen  medico. 

Segdn  la  mayor  parte  de  los  cirujanos  militares,  entre  elloe  Allaire,  Robert  Ham- 
nond,  Stolaroff,  la  aptitud  para  el  servido  se  puede  deducir  no  solamente  por  la 
talla,  sine  tambi^n  por  el  estado  de  desarrollo  pulmonar,  de  manera  que  un  buen 
Boldado  debe  tener  segdn  Seeland,  como  perfmetro  torddco  la  mitad  de  la  talla  del 
individuo  mis  2  o  3  centimetres. 

No  obstante  que  estas  medidas  ban  perdido  boy  algo  de  su  importanda  primi- 
tiva,  es  un  becbo  que  merece  llamar  la  atend6n  el  que  en  la  generalidad  de  los 
reclutas  ind^nas,  el  perimetro  toridco  es  mayor  con  seis  y  siete  centfmetros  de  la 
talla  media  del  individuo. 

Esta  amplitud  de  la  caja  torddca,  es  sin  g^nero  de  duda,  la  que  permite  al  soldado 
boliviano  en  alturas  que  varlan  de  3,000  a  4,000  metios  sobre  el  nivel  del  mar,  hacer 
marcbas  de  10  y  12  leguas  por  dia,  sin  fatiga  y  conservando  toda  la  aptitud  para  con- 
tinuar  el  viaje  al  siguiente  dia.  Teniendo  la  l^gua  4,225  metros,  resulta  que  un 
cuerpo  de  ej6rcito  en  12  boras  y  Irecuentemente  en  menos  tiempo,  puede  bacer  mia 
de  50  kil6metros  Uevando  todo  su  equipo,  sin  fatiga  para  la  tropa  y  sin  que  se  vean 
soldados  rezagados  por  el  cansando. 

Debo  advertir  que  no  ee  un  becbo  extraordinario  el  que  mendono,  sine  lo  que 
ocurre  babitualmente  y  en  la  Historia  Nadonal,  sobre  todo  durante  el  Gobiemo  del 
General  Melgarejo,  no  son  raros  los  ejemplos  de  marcbas  foTEadas  del  ej^rdto  que  en 
un  dfa  ba  becbo  basta  100  kil6metros,  entrando  inmediatamente  despu^  de  esfuerso 
tan  gigantesco  en  llnea  de  batalla. 

Riqueza  glolnUar. — ^Las  investigacionee  de  Metcbnikoff,  Ebrlicb,  Bordet,  Witte  y 
Nicoll,  ban  demostrado  el  papel  que  juegan  los  elementos  globulares  de  la  sangre  en 
la  defensa  del  organiamo  contra  las  enfermedades  infecdosas.  Estudios  llevados  a 
cabo  en  el  Instituto  Nacional  de  Bacteriologfa,  nos  ban  dado  las  siguientes  numera- 
dones: 


MUlmetro  cAbioo. 

O.N 6,083,470 

E.  R 6,553,863 

D.  F 7.146,666 


Milfmetro  cAbioo. 

CO 6,826,676 

N.  Q 5,435,505 

D.  LI 6,925.340 


Por  el  cuadro  que  antecede  se  ve  que  el  t^rmino  medio  de  gl6bulos  rojos  por  mill- 
metro  cdbico  en  La  Paz,  es  de  6,498,585  y  como  al  nivel  del  mar  este  ndmero  ee  861o 
de  5,000,000  por  miJimetro  cdbico,  resulta  que  a  3,629  y  a  4.000  metres  de  aitura  en 
que  se  encuentran  las  dudades  de  La  Paz  y  Oruro,  bay  un  aumento  de  riqueza  glob- 
ular de  1,498,585  por  milimetro  cdbico  sobre  la  propord6n  que  existe  al  nivel  del  mar. 

Papel  del  amtagio. — Cha  eau,  Puecb,  Gerlacb,  Gunther  aiirman  la  facilidad  con  al 
cual  la  tut  erculoeis  humana  puede  trasmitirae  a  la  especie  ho  ina  y  como  ee  justo, 
el  becbo  reclproco  tiene  que  ser  e  idente  o  lo  que  es  igual,  que  la  tuberculosis  bo  ina, 
puede  trasmitirse  a  la  especie  humana. 

Hoy  la  trasmisi^  ilidad  de  la  tuVerculosis  animal  al  homVre,  se  encuentra  perfecta- 
mente  estaVledda  y  ha  motivado  las  mtiltiples  medidas  bigi^nicas  que  los  Consejos  de 
Salubridad  de  todos  los  pafses  ban  dictado  para  e  itar  la  ^  enta  de  la  came  pro  eniente 
de  animales  enfennos. 


PUBLIC  HEALTH  AND  MEDIOINB.  441 

No  obstante  las  aiirmaciones  de  Koch  que  ante  el  Congreso  Intemacional  de  la 
Tuberculosis  reunido  en  Londres  el  22  de  julio  de  1901  sostUTO  que  la  tulierculosis 
humana  y  la  bovina  eran  atsolutamente  distintas  y  que  no  era  posible  la  trasmisidn 
de  la  enfermedad  de  una  especie  a  la  otra,  los  trabajos  del  profesor  Xocard,  prueVan 
hasta  la  evidencia  que  el  contagio  es  real,  siendo  bastante  {lara  demoetrar  este  hecho 
la  muerte  de  los  veterinarios  Moses,  Weimar,  Walley,  Jeusen  que  inoculados  acciden- 
talmente  al  hacer  la  autopsia  de  los  animales  enfermos,  muiieron  a  consecuienda  de  la 
tuberculosis. 

£s  indudable  que  probada  la  unidad  perfecta  del  bacilo  de  la  tuberculosis,  se  com- 
prenda  fdcilmente  la  importancia  del  contagio  producido  en  la  especie  humana  por 
los  productos  de  cnrigen  bo^ino.  Algo  mia,  el  profesor  Behring,  ante  el  Congreso 
celebrado  en  Caasel  en  1903,  sefiala  como  la  causa  etiol<3gica  m^  frecuente  de  las 
lesiones  bacilares  del  pulm6n,  a  lainfecci6n  del  intestino  contraf da  durante  la  ^poca 
de  la  primera  infancia  por  la  leche  infectada. 

Hecho  igual  sefiala  el  Profesor  Magburgo  y  los  autores  Gothan,  Ooppes  y  Priester 
afirman  haber  observ^ado  cases  de  tuberculosiB  intestinal,  provocada  por  la  ingesti6n 
de  leche  pro  eniente  de  animales  enfermos. 

No  me  extendi  mis  enestas  consideracionescuyo  objeto  no  es  otroqueprobarque 
no  haViendo  existido  en  la  AmMca  ganado  bovino  antes  de  la  conquista,  es  necesarlo 
tamlidn  eliminar  esta  causa,  cuya  importancia  hemes  puesto  suficientemente  en  claro. 

Respecto  a  los  medios  que  han  obrado  directamente  sobre  el  bacilo  impidiendo 
Bu  desarrollo  o  atenuando  su  virulenda,  mencionar^  en  primera  Unea  la  acci6n  de  la 
luz,  que  en  mi  concepto  desempefia  un  papel  preponderante. 

Las  experiencias  de  Candler,  Migneco,  Kamnonne  prueban  que  la  lui  obrando  sobre 
los  esputos  desecados  o  sobre  los  culiivos  vivos,  atentfa  la  vinilencia  de  Mos,  hasta 
el  punto  de  que  cincuenta  o  sesenta  dlas  despu^  de  una  expoeici6n  a  los  rayos  solares, 
el  bacilo  deja  de  ser  paUSgeno. 

La  influencia  de  la  luz  sobre  el  bacilo  tuberculoso  tanto  humane  como  aviario,  he 
podido  estudlarla  especialmente,  vali^ndome  de  cultivos  provenientes  de  los  labora- 
tories de  Francia  y  Norte  AmMca. 

El  resultado  de  mis  observaciones  es  el  siguiente:  Cultivos  en  patata  de  bacilo 
a  iario  expuestos  durante  10  dlas  a  la  acci6ndifusa  de  la  lus  solar  en  el  Laboratorio, 
han  dejado  de  desarrollarse  resembrados  en  nue^  os  medios. 

Culti  OS  en  patatas  de  bacilo  humane,  dejados  15  dlas  en  las  mismas  condiciones,  no 
se  han  desarrollado  ni  en  patata,  ni  en  caldo  glucosado,  ni  en  gelosa  glicerinada. 

Independientemente  de  la  acci6n  de  la  luz  cuya  importancia  no  me  parece  discu* 
tible,  es  e  idente  que  en  la  atenuaci6n  de  este  bacilo,  han  entndo  otios  elementos 
aun  no  bien  puestos  en  claro,  pero  cuya  existencia  esinnegable.  No  creo  que  la 
disminuckSn  de  presi6n  atmosf^ica,  haya  obrado  en  este  sentido,  pues  las  experiencias 
Uevadas  a  cabo  en  este  respecto  por  D'Arzonval  y  Charrin  han  demostrado  en  forma 
clara  y  palpable,  que  elaumentocomo  ladisminuci6nde  lapresi6n  atmosf^rica,  tienen 
escasa  influencia  sobre  el  desarrollo  de  las  especies  bacterianas.  Es  mis  posible 
que  la  raza  americana,  en  especial  la  del  altiplano,  haya  ofrecido  en  el  primer  memento 
y  por  las  razones  ya  apuntadas,  una  resistencia  organica  mis  grande.  El  hecho  de 
observaci6n  es  que  el  bacilo  de  la  peste  bub6nica,  el  bacilo  de  Koch  y  quizi  otroa 
mis,  en  el  continente  americano,  son  menos  temibles  sobre  todo  en  determinados 
puntos,  que  lo  que  son  en  Europa  o  Asia.  Asl  el  bacilo  de  Yendn,  a  pesar  de  existir  en 
forma  end^mica  en  casi  toda  la  coeta  del  Paclfico,  nunca  ha  pro ^  ocado  las  teniblee 
epidemias  que  siembran  el  pinico  en  la  India,  Rusia  y  otros  palses. 

Las  distintas  consideraciones  mendonadas  en  los  capltulos  que  anteceden,  creo  que 
me  autorizan  a  sentar  la  teoria  de  que  la  tuberculosis  humana  no  ha  existido  en  la 
altiplanide  andina,  hasta  la  6poca  de  la  conquista  espafiola. 

Junto  con  la  dvilizad6n  vinieron  a  la  America,  varias  enfermedades,  que  conslgo 
trajeron  los  espafioles,  pero  la  acd6n  del  dima,  la  natural  defonsa  globular  de  la 
hideron  que  estas  entidades  m6rbida8  se  propagaran  muy  poco. 


448       PB0CEEDIK08  SBOOKD  PAN  AMBBIOAN  BOOBirTIFIO  C0K0BB88. 


Ef  neceBftrio  en  mi  concepto,  llegar  a  una  6poca  relativamente  reciente,  para  enam. 
tear  el  origan  real  de  la  tuberculona  en  la  altiplanicie  ui  como  las  caiwaa  que  motlvaron 
0udifufli6n. 

Las  dudadee  ccmateuidaa  por  los  conquiatadOTes,  que  pooo  a  poco  lueron  aumen- 
tando  en  actividad  y  poblacidn,  eran  como  la  mayor  parte  de  las  fundadonee  espaftolaay 
inaalubree  bajo  todos  respectos,  faltas  de  alcantarillas,  con  callee  eetrechas,  algnnaa 
de  las  cuales  como  la  Calle  Linares,  el  callej6n  de  Tiquina,  la  calle  del  Inca,  la  caUe 
Mufiecas,  la  calle  Gatacora  y  muchfsimas  otras  que  aun  en  la  actualidad  eyisten, 
apenas  ed  miden  de  uno  a  tees  meteos  de  ancho.  AAAdaae  a  esto  que  las  casas  del 
Coloniaje,  eran  esteechas,  de  techo  bajo,  puertas  esendalmente  pequefias  y  &Jtas  de 
aire  y  de  luz.  De  estas  casas,  quedan  aim  muchisimas  y  al  respirar  el  aire  hAmedo  y 
jbrio  de  sus  habitadones,  uno  piensa  en  los  sdtanos  de  las  grandes  dudades  o  en  las  mal- 
sanas  prisiones  que  tanto  prodigaron  los  tiranuelos  de  la  Edad  Media.  Al  contanplar 
esas  casas  donde  b61o  de  tiempo  en  tiempo  asoma  temeroeo  un  rayo  de  lus,  es  casi  im- 
posible  explicarse  satisfatctcmamente,  el  por  que  de  tan  extrafias  construcdones.  Lo 
mis  radonal  es  suponer  que  para  resguardarse  del  frfo  y  de  los  vientos  helados  de  la 
Cordillera,  en  un  pais  donde  el  combustible  es  caro  y  dificil  de  conseguir,  los  primi- 
tiTos  pobladores  qukieron  defenderse  de  las  bajas  temperaturas  redudendo  hasta  lo 
inverosfmil  el  tamafio  de  las  puertas  y  ventanas  y  bajando  el  techo  hasta  el  punto  de 
que  se  lo  podia  tocar  con  la  mano.  Seguramente  pensaron  los  immitivos  pobladores, 
que  impedir  la  libre  enteada  del  aire,  era  disminuir  los  rigores  del  inviemo  y  conservar 
el  calor  que  da  flezibilidad  a  los  mtlsculos  y  alegria  al  contain;  Pero  a  que  predo  se 
pagaba  ese  poco  de  calorl 

Los  indios  habian  side  obligados  por  los  terratenientes  a  hacer  el  servido  en  las 
dudades  y  ya  sea  mensual  o  semanalmente  venia  uno  de  ellos  con  el  nombre  de  pongo 
a  La  Paz  u  Oruro  a  servir  a  los  patrones.  Encerrado  el  indio  en  un  medio  que  tan  poca 
armonia  guardaba  con  su  vida  libre  y  activa,  es  s^uro  que  empea6  a  sufrir  las  consecuen- 
das  de  esta  redusidn  y  como  numerosos  enfermoe  ven(an  ya  en  esas  6pocas  a  curarse  de 
sus  afecdones  pulmonares,  es  pues  ttcil  sup<mer  que  el  quichua  y  el  aimara  alejados 
de  su  medio  habitual,  oirederon  un  terrene  ficilmente  vulnerable.  6i  se  tienen  en 
cuenta  las  p^simas  condici<mes  higifaicas  de  la  mayor  parte  de  las  dudades  bolivianas, 
es  digno  de  llamar  la  atend6n  el  que  la  tuberculosis  no  hubiera  extendido  sus  estragos 
en  mayor  properdin  y  que  relativamente  la  mortalidad  por  esta  entidad  mdrbida  sea 
pocodevada. 

La  mortalidad  por  tuberculosis  en  los  distintos  estados,  seria  segdn  el  profesor 
Oalmette  de  LiUe,  la  que  se  mendona  en  el  siguiente  cuadro  tomado  dd  No.  83  de 
la  Revista  de  Higiene  y  Tuberculosis  dd  Dr.  J.  Chabis: 


Estados. 


Alemanla 

InglAterra 

Atntria 

B4(lgica 

Pinamarca 

Esooda 

Bspafla. 

Fraacla 

Grccia 

Hoiisjla 

Irlaiiaa 

Italia 

Noniega 

PalsesBaJos 

Portngal 

Rumania 

SiMoia ..., 

8alsa 


PoblacUSn. 


62,»t9,563 

35,348,780 

27,900,924 

7,386,444 

2,fi35,000 

4,826,587 

19,712,585 

39,196.328 

2,631,952 

20,786,278 

4,371,455 

34,129,304 

2,321,575 

5,784,232 

5,432,132 

6,771,722 

5,377,718 

3,554,672 


MortaU- 

Mortali- 

HortaU- 

dad  por 

dad  por 

dad  total 

tub«rcu- 

tub«rcii- 

por  10,000 
habl- 

losispor 
10,000 

losispor 
100,000 

tantes. 

habi- 

habl- 

tantes. 

tantes. 

186.6 

17.8 

15.4 

147.2 

15.9 

11.2 

225.0 
165.1 

30.4 
13.0 

10.1 

154.4 

17.6 

13.3 

161.3 

19.6 

12.6 

260.2 

18.5 

18.6 

190.0 

22.6 

18.7 

238.3 

33.9 

24.8 

244.4 
175.9 

37.0 
25.8 

19.5 

225.6 

16.6 

10.5 

142.9 

24.4 

18.8 

150.2 

16.2 

12.0 

226.4 

11.8 

0.9 

258.7 

30.9 

35.1 

141.1 

96.7 

3a7 

162.8 

24.1 

17.8 

Mortali- 
dad por 
tubercu- 
losis tior 
lOOdvitos 
detoda 
clase. 


10.1 
10.8 
18.5 

8.8 
11.7 
12.3 

7.4 
12.9 
14.4 
15.1 
14.8 

7.4 
19.8 
11.7 

7.8 
ILO 
19.0 
15.8 


FUBLIO  HSALTH  AHD  MEIHOIKB. 


448 


Lob  fallecimkntoe  por  tub«rcii]oflis  en  la  mayor  parte  de  las  grandes  capitalee, 
tomando  la  ptoporcidn  por  cada  10 ,000  habitaatee  ee  la  aiguiente  aegtln  el  aefkir  Abel  J . 
Olachea: 


Hambuigo 20.5^ 

Brealau 38.27 

Madrid 26.83 

Leipaig 23.61 

Munich 28.71 

Roma 17.63 

Venecia 19. 77 

Bmaelaii 17.29 

Stokolmo 23.42 

Piaga 33.40 


Londree 14. 43 

Buenoa  Aires 18.66 

New  York 2L66 

Berlin 24.70 

PlariB 38.02 

Viena 33.32 

Filadelfia 19.73 

Dresde 23.36 

Cologne 69.60 

Budapest 38.30 

Oopenbague 21.26 

En  La  Paz  segdn  los  dates  suministrados  por  el  Boletln  de  Higiene  y  Demograffa, 
el  ndmero  de  fallecidos  por  lesiones  tuberculosas  de  Ice  distintos  6iganos  ha  side  en  1913 
de  134.  Suponiendo  ahora  una  poblaci6n  total  de  100,000  habitantee,  no  tendrfamos 
Bin6  13.4  por  10,000,  cifra  seguramente  la  m^  baja  de  todas  las  que  registran  las 
eetadfsticas,  pues  aun  compar^dola  con  la  de  otras  ciudades  americanas,  como  por 
ejemplo  lima,  cuya  mortalidad  en  1906  fu^  de  72  por  10,000,  tendrfamos  que  ee  un 
hecho  indudable  que  las  lesiones  bacilosas  aunque  aclimatadas  en  La  Paz,  no  pro- 
ducen  los  destrozos  que  en  otras  capitales. 

Otra  de  las  causes  que  ha  motivado  el  aumento  de  la  tuberculosis  en  el  altiplano, 
es  la  inmigraci6n  de  individuos  enfermos,  que  han  venido  de  la  costa  del  Pacffico 
aprovechando  de  la  favorable  influencia  del  clima.  a  curarse,  y  como  con  ellos  no  se 
ha  tomado  ninguna  precauci6n,  que  sirva  de  garantla,  han  ido  esparciendo  los  g^rme- 
nes  del  mal  hasta  tal  punto,  que  a  continuar  las  cosas  como  hasta  hoy,  no  ser4  raio 
que  se  tenga  que  lamentar  la  m&d  funesta  influencia  en  nuestras  estadfsticas  sanitarias. 

La  tuberculosis  actualmente  en  La  Paz  como  en  Oruro,  ataca  de  preferencia  a  los 
adultos,  en  los  cuales  tiene  tendencia  marcada  a  localizarse  en  el  aparato  respiratoiio. 
Segtin  el  Boletln  arriba  citado,  tenemos  en  el  cuadro  de  defunciones  la  siguiente 
clasificaci6n  durante  el  afio  1903. 

Tuberculosis  pulmonar 97 

Tuberculosis  larlngea 18 

Tuberculosis  intestinal 7 

Tuberculosis  generalizada 10 

Mal  de  Pott 1 

Enteritis  tuberculosa 1 


Total. 


134 


Examinando  el  cuadro  que  antecede,  vemos  la  inmensa  preponderancia  de  la  tuber- 
culosis del  ai^arato  respiratorio  sobre  la  de  los  dem^s  6rganos. 

La  causa  de  este  fen6meno,  seHa  en  mi  concepto  la  siguiente:  La  mayor  parte  del 
elemento  joven  de  Bolivia,  muy  especialmente  en  las  regiones  mineras  de  Potosf, 
Oruro  y  La  Paz,  se  dedica  a  la  explotacidn  de  las  minas  de  plata,  cobre,  estafio,  wolfran 
y  otros  metales.  En  las  grandes  profundidades  a  que  Uegan  los  obreros,  las  minas  se 
hallan  deeprovistas,  en  su  inmensa  mayoHa,  de  todo  principio  de  higiene  y  van 
respirando  una  atmMera  permanentemente  cargada  de  partfculas  metilicas,  que 
deposit^uuiose  en  los  alveoloe  pulmonares  provocan  estados  bronquiales  agudos,  que 
repiti^ndoee  con  frecuencia,  finalizan  en  dilataciones  bronquiales  mis  o  menos  exten- 
sas,  que  son  el  terrene  abonado  de  la  tuberculosis. 

En  el  elemento  infantil,  las  lesiones  bacilosas  son  sumamente  raras  y  durante  el 
afio  que  me  encuentro  a  caigo  del  Gonsultorio  Publico  de  Nifios  y  del  Pabelldn  respec- 


444       PBOOEEDINGS  SECOND  PAN  AMBBICAK  80IEKTIFI0  00NGBES8. 

^vo  en  el  Hospital  Landaeta,  no  he  tenido  ocasidn  de  ver  nno  poqu<aimoe  caaos  de 
leaiones  tuberculosas,  que  se  las  podrian  claaificar  en  el  sigoiente  cnadro:  Calculando 
el  ntimero  de  nifios  asistidoe  durante  el  afio  de  1914  en  1,759  tendrfamos  que  sobre 
este  total  las  lesiones  tuberculosas  se  encuentran  representadas  como  sigue: 

Tuberculoma  del  cerebelo 1 

Artritis  tuberculosa 1 

Pleuresfa  purulenta  de  origen  bacilar 2 

Mai  de  Pott 1 

Enteritis  tuberculosa 1 

Total 6 

En  mi  pr&ctica  particular,  he  visto  de  igual  manera  muy  pocoe  nifios  con  lesiones 
bacOosas  y  entre  ^stos,  la  mayorfa  si  no  la  totalidad,  corresponden  a  loe  que  habfan 
permanecido  en  la  costa  o  venlan  con  el  objeto  de  curarse. 

Sabemos  bien  que  existe  una  ley  debida  a  Peter  que  ha  dominado  la  patologfa  de  U 
tuberculosis  y  es  la  que  dice  que  el  nifio  nace  tuberculizable  no  tuberculoeo;  en  esta 
virtud  la  excesiva  rareza  de  esta  enf ermedad  en  la  infanda,  conduce  a  pensar  que  los 
progenitores  se  encuentran  indemnes,  pues  hoy  se  conoce  el  mecanismo  del  contagio 
que  consiste,  en  que  estando  enfermos  los  padres  a  cada  memento  van  sembrando  el 
aire  que  respira  el  nifio  con  millones  de  organismos  patdgenos,  los  que  solamente  espe- 
lan  una  causa  ocasional,  para  desarroUarse  en  el  organismo  infantil. 

Las  tiltimas  investigaciones  respecto  a  la  tuberculosis,  tienden  a  quitar  a  la  f <kmu]a 
de  Peter,  su  car&cter  absolute  y  consideran  junto  a  los  nifios  tuberculizables,  los  que 
nacen  enfermos  y  han  recibido  por  intermedio  de  la  sangre  matema  el  gennen  del 
contagio. 

El  Piofesor  Landouzy,  Impresionado  por  la  frecuencia  con  la  cual  a  la  autopsia  de 
nifios  menores  de  dos  afios  se  encontraban  lesiones  tuberculosas,  pens6  que  era  raci<Hial 
Buponer  que  la  herenda  o  mejor  la  infeccidn  por  intermedio  del  organismo  matemo,  no 
era  indiferente  a  esta  miiltiplicidad  de  manifestaciones  badlosas.  Para  explicar  el 
contagio  del  feto,  los  autores  suponen  que  los  cuerpos  bacterianos,  pasan  por  la  vena 
umbilical  para  localizarse  en  el  hlgado  o  bien  franqueando  el  conducto  de  Aransi  se 
diseminan  por  toda  la  economfa,  dando  origen  a  las  formas  generalizadas,  cual  han 
tenido  ocasidn  de  observarlas  Facoli,  Lehmann,  Houl. 

La  trasmisidn  intraplacentaria  es  pues  e\  idente,  pero  conviene  hacer  notar  que 
es  a  todas  luces  rara  y  que  en  la  etiologfa  de  la  tuberculosis  no  juega  smo  un  papel 
secundario. 

A  las  numerosas  pruebas  acumuladas  en  capftuloe  anteriores,  aun  podriamos  afia- 
dir  otra,  cuya  significaci^n  es  no  menos  importante.  Todos  los  m6dicos  que  ejercen  en 
La  Pto,  Potoel  u  Oruro,  saben  que  los  indios  que  no  han  salido  de  sus  tierras,  llimenseles 
comunidad,  hacienda  o  sayafia,  nunca  presentan  lesiones  tuberculosas,  si^ido  al 
contrario  notable  su  robustez,  su  resistenda  a  los  m&s  duros  trabajos  y  su  increfble 
sobriedad.  El  indfgena  para  trabajar  doce  horas,  casi  sin  tomar  descanso,  no  necesita 
otro  alimento  que  un  poco  de  charque  o  chalona  (came  desecada  de  vaca  y  cordero 
respectivamente)  un  poco  de  maf z  coddo  o  tostado  y  200  o  300  giamos  de  hojas  de  coca, 
que  mastica  constantemente.  Con  una  racidn  nutritiva  de  tan  poco  valor,  el  natural 
del  pais  realiza  los  mayores  esfuerzos,  sin  que  su  organismo  sufra  el  menor  quebranto. 

Muy  distinto  es  el  porvenir  del  quechua  y  el  almara  que  se  radican  en  las  dudades 
e  que  dedicados  al  pequefio  comedo,  viajan  a  los  Yungas  (regiones  dUidas  de  la 
Repdblica,  donde  se  producen  el  caf4,  la  coca,  el  cacao,  etc.)  o  a  la  costa  del  PlM^fico. 
En  estos,  pronto  se  presentan  las  pruebas  inequf vocas  del  mal  y  raras  veces  se  logra 
detener  su  marcha  Invasora. 

Respecto  al  estudio  experimental  del  badlo  de  Koch,  poco  tengo  que  afiadir  lo 
que  dije  en  la  Memoria  presentada  al  D^dmo  qulnto  Gongreso  Intemadmia]  de  Hi- 


PUBLIO  HEALTH  AND  MEDICINE. 


445 


giene  y  Demografia  reunido  en  W^uihington  del  23  al  28  de  septiembre  de  1912,  al  que 
me  toc6  el  honor  de  asiBtir  como  delegado  ofidal  del  Qobiemo  de  Bolivia. 

En  dicho  estudio,  hice  notar  que  en  los  cobayos,  la  inoculaciiki  de  esputos  en  IO0  que  ek 
ezamen  microscdpico  habfa  pueeto  de  manifiesto  numeroeos  bacUos,  daba  lugar  a 
reacdonee  muy  diHtintaB  de  las  que  sefialan  como  nonnales  IO0  autores  que  se  han 
ocupado  espedalmente  de  este  g^nero  de  investigaciones. 

Mac6,  BesBon,  Miquel,  Oambier,  Dopter  y  Sacquep^  en  sua  obras  clisicaa,  mani- 
fiestan  que  para  el  estudio  de  la  virulenda,  de  los  productos  tuberculosoe,  el  animal 
de  eleccidn  es  el  cobayo,  en  el  cual  la  inoculaci6n  subcutinea  de  productos  bacUosoe, 
determina  fotalmente  la  tuberculosifl  y  provoca  la  muerte  en  un  plazo  que  varla  de 
tree  fwrnanaii  a  tres  meees. 

Inyectando  bajo  la  piel  un  producto  tuberculoeo  dilufdo  en  un  poco  de  agua,  hada 
el  d^imo  dfa  se  observa  en  el  animal  una  pequefia  induracidn,  que  se  ulcera  tomando 
el  tipo  t6ipido  y  al  mismo  tiempo  I06  ganglioe  inguinales  se  infartan. 

A  la  autopflia,  el  hfgado,  el  bazo,  la  superficie  de  loe  rifiones,  se  encuentran  cu- 
biertos  de  mdltiples  granulaciones  tubereulosas.  Si  se  siembran  loe  productos  soe- 
pechosoe  en  suero  glicerinado,  a  la  tercera  semana  se  pueden  ver  las  primeras  colonias 
que  bajo  el  aspecto  de  puntos  bianco  gris&ceoe,  de  superficies  d^eecadas,  empiezan  a 
desarrollarse. 

« 

Al  lado  de  esta  descripcidn  cUsica,  debo  hacer  notar  las  particularidades  que  la 
inoculaci6n  de  productos  tuberculosos  ofrece  en  estas  alturas. 

Desde  luego  la  muerte  de  un  cobayo  inoculado  por  la  vfa  subcut^ea,  solo  he 
podido  observar  una  0  dos  voces  sobre  mds  de  200  animales  en  experiencia,  lo  oidi- 
nario  es  que  despu^  de  ligera  reacci6n  local  con  infarto,  el  cobayo  recobre  su  peso 
primitivo  y  en  ocasiones  hasta  aumente,  como  ocurre  en  las  observaciones  3,  7  y  9. 
Ouando  el  animal  es  sacrificado  a  la  cuarta  o  quinta  semana,  se  encuentran  numerosoe 
foliciilos  en  la  superficie  del  hfgado,  en  el  bazo  y  en  los  rifiones,  pero  estos  productos 
sembrados  en  suero  glicerinado,  no  obstante  todas  las  precauciones  que  se  tomaren, 
es  muy  raro  que  den  origen  a  un  cultivo  positivo. 

La  interpretaci6n  de  este  fen6meno  serfa  en  mi  criterio  la  siguiente:  £1  bacUo  ya 
por  sf  m&s  fr&gil,  menos  virulento  que  el  de  otros  pisses,  no  habiendo  podido  produdr 
la  muerte  del  cobayo,  pierde  por  complete  sus  propiedades  vitales,  de  suerte  que  el 
cultivo  es  nulo. 

£1  siguiente  cuadro  que  abarca  las  observaciones  efectuadas  del  7  de  enero  al  18 
de  junio  de  1914,  es  particularmente  importante  y  su  examen  confirma  la  opinion 
quesostengo. 

Obtervaddn  de  cobayoi  tubereuIoBOi, 


Nttancro  7  eolor  de  la 
ooMya. 


L  Coteyaoaf^. 


a.  Oobaya  amarUlo  ol3t- 

txtn, 
a.  CoteyaamarUloelMo... 

4.  Cobaya  amiMlHo  obsetpo 

0.  Coteya  caf^  oon  blanoo . 

a.  Cobaja  bianco  oon  am- 

ariUo. 
7.  Cobaya   amarlllo   con 

bianco, 
t.  Oobaya  bianco  fnUno. . 
•.  Cobaya  blanoo  cabeza 

negra. 


Feoha  de  la 
tTiocnladdn. 


Enero  7  de  1014. 


<« 


Enero  Sde  1014 


u 


EQ«ro28del914. 


Natnralesa  del 
producto. 


Espoto    taberco- 

loso. 
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u 


n 


tt 


li 


AbrilMdelOU. 
Junio  18  de  1014. 


ii 


ti 


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Ora- 

moi. 

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540 

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675 

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Leslones  obew- 
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InfMtoa    gas^lo* 

naree.    ^^ ^ 

Infitftos  dlmtnuto^ 

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^Inocolado. 
ulcera  con  edema 

en  el  testiotilo. 
Un  d^bll  inOMto 

ranfclionar. 
Iiuartos    gan^io- 

nar69. 
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446       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  CONGRESS. 

Alcoholismo  y  iuberculosii. — Duclaux,  Renon,  Bertill6n  sostienen  la  relaci6n  fntiio* 
que  existe  entre  el  alcoholismo  y  la  tuberculods  y  el  segimdo  de  estos  autoies  dice 
textuahnente  "£1  alcoholismo  cr6nico,  ofrece  el  terreno  abonado  y  f^rtil  paxa  el 
desarrollo  del  bacilo  tuberculoeo/'  Teniendo  en  cuenta  la  relaci6n  intima  del  alco- 
holismo con  la  bacilosis,  es  indudable  pues,  que  alll  donde  menos  se  consuma  alcohol, 
aeri  tambi^n  donde  la  enfermedad  haga  menores  estragos. 

Sentado  este  principio  y  contra  lo  que  algunos  escritores  muy  a  la  ligera,  sin  obeer- 
variones  completas  y  guiadoe  por  el  examen  superficial  de  loe  hechoe,  han  soetenido, 
que  la  raza  indigena  es  alcoh61ica  en  grado  eminente,  debo  levantar  la  falsa  impu- 
taci6n  con  que  se  infama  gratuitamente  a  esta  pobre  raza,  declarando  con  ccmoci- 
miento  pleno,  que  el  indio  muy  lejos  de  ser  alcoh61ico  es  esencialmente  sobrio  y 
cuando  se  embriaga,  lo  hace  exepcionalmente  y  solo  en  las  grandes  fiestas,  en  las  que 
olvida  su  miserable  condici6n,  para  ahogar  un  momento  en  el  licor,  los  sufrimientos 
que  le  abruman. 

Investigando  con  criterio  sereno  lo  que  pasa  en  toda  poblaci6n  indigena,  cualquier 
escritor  imparcial,  no  podr&  menos  de  quedar  admirado  de  la  sobriedad  del  indio, 
que  en  un  afio,  es  excepcional  que  beba  mds  de  tres  o  cuatro  dias,  dedicando  el  resto 
al  trabajo. 

A  la  embriaguez,  por  accidente  y  en  tiempos  demasiado  alejados,  no  se  le  puede 
llamar  alcoholismo,  nombre  con  el  cual,  la  ciencia  designa  a  la  costumbre,  al  hdbito 
inveterado,  de  consumir  bebidas  fermentadas  o  destiladas. 

Antes  de  la  conquista,  el  indio  no  consumla  otro  licor  que  la  chicha,  que  la  obtiene 
haciendo  fermentar  el  maiz  y  cuyo  grado  alcoh61ico  es  demasiado  bajo  para  provocar 
lesiones  viscerales  graves  y  aun  la  chicha  cual  ya  hemes  dicho  en  otro  punto,  solo  la 
tomaban  en  sus  grandes  r^ocijos. 

La  ausencia  de  hibitoe  alcoh61ico8,  es  indudable  que  constituye  otra  nz6n  para 
suponer  que  la  tuberculosis  no  se  present6  en  el  Altiplano  sine  en  ^poca  posteri<»r^  j 
cuando  mediante  la  venta  de  alcoholes  de  p^sima  calidad,  la  civilizaci6n  empeod 
8U  labor  educadora,  por  destruir  esta  raza,  intoxic&ndola. 

Profilaxia. — La  profilaxia  contra  la  tuberculosis  deberla  ser  la  obra  comtin  de  todos 
los  gobiemoe  americanoe,  de  suerte  que  se  pueda  emprender  una  acci6n  en  conjunto, 
cuyos  reeultadoe  obren  en  bien  de  las  nacientes  sociedades  del  Nuevo  Mundo. 

£1  ejemplo  de  Alemania  me  parece  digno  de  ser  imitado,  en  ese  pueblo  cuyos  esta- 
distas  son  esencialmente  pricticos,  no  se  ha  puesto  el  menor  reparo  para  gastar  sumas 
casi  femt&sticas,  con  tal  de  disminuir  la  mortalidad  por  la  tuberculosis  reduciendo  sus 
estragos  a  la  menor  cifra  posible. 

En  la  America  Latina  no  obstante  de  que  tanto  en  las  nacionee  que  colindan  con  el 
Oceano  Paclfico,  como  aquellas  que  se  encuentran  a  orillas  del  Atldntico,  la  tuber- 
ciilosis  ha  tomado  un  desarrollo  alarmante,  pocas  son  las  reptiblicas  que  hayan  em- 
prendido  una  lucha  eficaz  contra  esta  enfermedad  social.  En  esta  labor  de  civiliza- 
ci6n,  tres  son  los  pueblos  que  hasta  hoy  se  han  distinguido  por  su  ben^fica  actividad: 
el  Uruguay,  la  repdblica  de  Cuba  y  la  gran  nacidn  aigentina.  En  Cuba  y  en  la  Repd- 
blica  Oriental,  la  oampafla  es  en^igica  y  ha  dado  hasta  hoy  muy  apreciable  frutos, 
merced  a  la  inteligencia  y  esfuerzo  de  notables  cientfficos,  entre  los  cuales  s61o  citar^ 
los  nombres  de  Juan  Santos  Femdndez,  Francisco  J.  de  Velasco,  Carlos  M.  Desvemine, 
Arturo  G.  de  Tejada,  y  Oscar  Jaime  de  la  Habana  y  Tomas  Hem&ndez  de  Sagua  La 
Grande.  En  el  Uruguay  los  Drs.  Sebastidn  B.  Rodriguez,  Arturo  Garabelli  y  Ernesto 
Fem&ndez  Espiro. 

En  la  Repdblica  del  Plata,  el  iniciador  de  la  campafia  contra  la  tuberculosis  fu^  el 
Dr.  Enrique  Tomu,  que  en  el  aflo  1898  traz6  un  plim  general  de  profilaxia  antituber- 
culosa. 

Poeteriormente  el  Dr.  Samuel  Gache,  Roberto  Wernicke  y  otros  mils,  se  propusieron 
fundar  la  Liga  contra  la  Tuberculosis.  Finalmente  el  Dr.  Emilio  R.  Coni,  fu6  el  que 
en  la  Argentina  ha  fundado  pr^ticamente  la  lucha  contra  la  tuberculosis,  creando 


PUBLIO  HEALTH  AKD  MEPICINB.  447 

en  mayo  de  1901  la  Revista  '*  Aliansa  de  H%iene  Social ",  que  tantos  benefickw  ha  pies- 
tado  a  la  cienda,  haciendo  que  su  director  meresca  la  gratitud  nadonal. 

A  tftolo  de  concluflionee  y  para  no  extender  m^  el  preeente  trabajo,  voy  a  proponer 
al  Segundo  Gongreso  Oientlfico  Fanamericano  que  n  cree  conveniente  adopte  laa 
aiguientes  resolucionee,  algunas  de  laa  cualee  formaron  parte  del  Primer  Congreso 
Latinoamericano  reunido  en  1901. 

1®.  LoB  Gobiemoe  de  Norte,  Gentro  y  Sud  America,  mediante  sua  delegados  se 
comprometen  a  organizar  con  caiicter  de  servicio  publico,  la  lucha  contra  la  tubercu- 
losis. 

2^.  Para  los  efectos  del  artfculo  precedente,  se  oiganizari  en  Washington  u  otra 
ciudad  que  designare  el  Gongreso,  un  comit6  central  que  fijahL  las  bases  de  la  lucha 
antitub^rculosa. 

3^.  Los  distintos  Gobiemos  contribuirto  mediante  sumas  proporcionales,  al  soste- 
nimiento  de  este  comit6. 

4^.  Cada  dos  afios  se  reunir&  una  asamblea  de  delegados  en  la  ciudad  en  que  fun- 
donare  el  comit6  central.  A  esta  asamblea  concurrird  cada  Gobiemo  mediante  sua 
delegados,  para  poner  de  manifiesto  las  medidas  que  se  hubieran  adoptado  en  cada 
pais,  para  la  lucha  contra  la  tuberculosis. 

5^.  El  comity  central  haoiendo  uso  de  los  medios  que  se  encuentren  a  su  disposi- 
ci6n,  procurar&  que  en  cada  Reptiblica  se  oiganicen  ligas  contra  la  tuberculosis. 

6^.  Para  mejorar  las  condiciones  higi^nicas  del  obrero,  el  comit6  dictari  los  regla- 
mentos  respectivos,  que  serin  sometidos  a  la  aprobaci6n  de  los  distintos  Gobienios. 

7^.  Pftra  facilitar  la  curaci6n  de  los  enfermos,  el  comit6  central  hari  que  se  estudien 
los  puntos  mis  apropiados  en  los  cuales  se  pueda  fundar  sanatorios  especiales,  para 
cuya  construccidn  los  distintos  Grobiemos  contribuirin  con  sumas  distribuidas  pru- 
dendalmente  segtin  los  recuisos  de  que  puedan  disponer. 

8^.  La  declaraci6n  de  las  tuberculosis  abiertas,  seri  obligatoria  para  el  medico. 

9^.  El  consume  de  la  leche  debe  ser  comprobado  por  veterinarios  oficiales,  que  in- 
vestiguen  la  sanidad  de  las  vacas  lecheras. 

10^.  Se  recomiendan  los  ejercicios  de  la  cultura  fisica,  como  un  medio  de  lucha  con- 
tra la  tuberculosis. 

11^.  Se  declara  obligatorio  en  los  establecimientos  de  instrucci6n  primaria,  el  uso 
de  una  cartilla  que  contenga  los  fundamentos  de  la  profilaxia  antituberculosa. 


PROFILAXU  DE  LA  TUBERCULOSIS. 

Por  CONSTANCIO  CASTELLS, 

MSdico  del  HoipUal  "Fermin  Ferreira,"  de  Uruguaif, 

"  La  aalad  del  paebh),  la  salad  de  los  hombrea,  es 
la  saprema  ley." 

Teniendo  trascendental  importancia  el  poner  en  prictica  el  mayor  n6mero  poeible 
de  medidas  profiUcticas  tendientes  a  prevenir  y  ^tar  el  progresivo  desarrollo  de 
la  tuberculosis,  bosquejaremos  en  breves  pirrafos  y  sin  profundisar  en  la  materia 
debido  a  la  indole  sint^tica  de  este  trabajo,  los  principales  puntos  que  abaica  dicho 
problema. 

Dichas  medidas  las  clasificamos  en  tres  grupos:  Del  primero  forman  parte  todas 
las  que  se  consagran  a  suprimir  el  contagio  directo  es  dedr  el  que  pueden  provocar 
los  enfermos  bacilares,  entrando  en  el  mlsmo,  las  medidas  higi^icas  y  por  medio 
de  antis^pticos  y  desinfectantes,  recomendados  para  destruir  los  bacdos  tubercu- 
Idgenos,  los  focos  purulentos,  esputos,  etc.,  neutralizacidn  de  toxinas,  etc.,  comente- 
mente  pueetos  en  prictica. 

El  contagio  volitil  segt&n  la  teoriade  las  gotitas  micr6bicas,  los  llamados  gases 
alimentos  de  bacilos,  las  neblinas  de  microbios,  s61o  visibles  al  ultramicroscopio 
y  que  se  acumulan  en  las  inmediaciones  de  un  contagioso  constltoyendo  aonas  peli- 


448       PBOOEEDINGS  SECOND  PAN  AMEBIOAK  80IEKTIFI0  CONGRESS. 

prons;  son  tambidn  tributarias  del  ueo  de  divereos  deeinfectuites  paia  su  deelnie- 
ci6n.  Se  ban  jH^conizado  para  ello  el  ueo  del  aerofiltro,  las  fumigaciones,  termova- 
porizaciones,  etc.,  a  base  de  digtintas  drogas,  {Mrocedimientos  todos  muy  recomen- 
dables  y  que  tienen  por  base  la  difuBi6n  de  sustancias  antis^pticas  a  la  par  que 
bals&micas  para  las  vias  respiratoias  del  enfermo. 

Se  recurrir&  a  las  fumigaciones  cuando  no  se  pueda  {Hracticar  el  aislamiento  del 
enfermo  y  tengan  que  atenderlo  de  cerca  otras  personas  sobre  todo  diirante  la  noche, 
proporcionando  asl  un  aire  purificado  aunque  artificialmente  evitando  o  disminu- 
yendo  loe  peligroe  de  la  auto-infecci6n  y  contagio. 

La  desinfeccidn  corporal  del  enfermo,  ropas,  muebles,  dtiles,  escupideras,  etc., 
las  recordamos  por  tener  suma  importancia  su  eecrupulosa  pr&ctfea,  asl  como  la 
destrucci^n  de  loe  portadores  de  g6rmenes,  insectos,  etc. 

En  el  segundo  grupo  hemes  reunido  todos  los  medios  de  que  disponemos  para 
reforzar  la  inmunidad  del  organismo  en  los  sanos  y  enfermos. 

El  conocimiento  etiol6gico  de  la  tuberciiloeis,  y  su  evoluci6n  permiten  fijar  los 
medios  prc^dcticos  ref(»rzadores  de  la  inmunidad  establed^ndolos  sobre  s61ida» 
bases:  el  tubdrculo  es  considerado  como  un  residuo  morboeo  y  la  enfermedad  tuber- 
culosis representada  org&nicamente  como  una  discrasia,  resultante  de  las  alteraclone» 
del  metabollsmo  bioqufmico  provocado  por  la  acci6n  toxi-infecdosa  de  las  bactenas 
no-^do-resistentes  (periodoe  pretuberculosos)  las  cuales  son  ancetras  del  bacilo 
de  Koch.  £s  pues  en  este  perfodo  que  debemos  reforzar  la  inmunidad  para  evitar  la 
formaci6n  de  tub^rculos. 

Loe  trabajos  clisicos  de  inmunoterapia  ban  demostrado  que  las  bacterias  aisladas 
del  perfodo  crdnico  de  esta  enfermedad  carecen  de  vacuna. 

La  profilaxia  ideal  pues  estarfa  representada  por  la  inmunizaci6n  del  oiganisma 
contra  las  bacterias  del  perfodo  agudo  o  tubercul<3genas  pero  en  los  trabajos  tendientes 
a  su  obtenci6n  est&n  preocupadoe  eminentes  bacteri61ogo8,  Ferr&n  de  Barcelona 
entre  ellos  y  no  es  posible  todavfa  formar  criterio  exacto  sobre  su  poeitivo  valw,  pero 
esperamos  que  un  feliz  ^ito  corone  bus  experiencias  y  no  se  malogren  las  esperanzas 
que  en  ellos  tenemos  depositadas. 

Triste  para  nuestro  aiglo  tenerse  que  esclavizar  a  un  bacilo .  Nada  en  verdad  reunirfa 
masror  ndmero  de  ventajas  para  hacer  buena  profilaxia  antituberculoea,  que  con- 
seguir  una  vacuna  especffica. 

La  discrasia  ffmica  tiene  el  gran  inconvenientae  de  ser  de  muy  diffdl  diagn6stica 
en  BUS  comienzos  y  se  confunde  generalmente  con  otros  sindromos.  Con  los  recursos 
ordinaries  de  la  exploraci6n  clfnica  se  diagnostican  las  formas  vulgares  de  tuber- 
culosis pulmonar  pero  son  infinidad  los  organismos  que  reaccionan  positivamente 
a  la  tuberculina  (tub^rculo  reacci6n)  a  pesar  de  no  sospechaise  cllnicamente  la 
existencia  de  tub^rculos. 

El  organismo  posee  alguna  inmunidad  (anticuerpos  de  los  extremes  globulares) 
pero  la  pierde  fdcilmente  segtin  variadas  circunstancias,  entre  las  mia  aceptadas 
cftanse  la  predi8poeici6n  humoral  del  terreno  por  inpregnaci6n  especffica  y  t6xica, 
la  llamada  aptitud  bio-qufmica,  desmineralizacl^n  y  deBcalcificaci6n.  La  accidn 
bioqufmica  de  las  sales  de  calcio  evitando  la  desmineralizaci6n  y  descalcificacidn 
reforzarfa  tambi^n  las  defensas  oigdnlcas  en  contra  de  la  infecci6n  tubercul6gena. 

Entre  las  circunstancias  ocasionales  de  la  p^rdida  de  inmunidad  tenemos  el  con- 
tagio directo  de  que  antes  hamos  hablado  y  el  indirecto  entrando  entre  ^stas,  la  edad, 
lactancla,  pubertad,  vida  genital,  desgastes,  enfermedades  intercurrentes,  etc. 

Mientras  no  sea  pues  un  hecho  la  aplicaci6n  de  una  vacuna  especffica  o  una  sus- 
tancia  bioqufmica  (Quimloterapia)  que  consiga  la  inmunidad  antituberculoea,  la 
profilaxia  toma  todo  el  cardcter  de  social  o  colectiva  y  es  en  este,  tercero  y  dltimo 
grupo  que  pasaremos  revista  a  los  interesantes  puntos  que  abarca.  Indudablemente 
hoy  por  hoy  el  problema  de  la  profilaxia  antituberculoea  es  sobre  todo  social. 

Se  ha  Uegado  a  la  afirmaci^n  (Grancher)  de  que  la  tuberculosis  es  de  las  enferme- 
dades cr6nicas  la  mis  curable,  dependiendo  tinicamente  de  la  resistencia  individual 


FUBUO  HEALTH  AKD  MEPICINB.  449 

y  de  lo6  cuidados  higio-diet^ticos,  pues  bien  con  mis  seguridad  afirmamos  noeotios 
que  es  la  mis  evitable  poniendo  en  juego  todoe  loe  resortee  de  cultura  profilictica, 
fomentando  la  in8trucci6n  prictica  y  haciendo  conocer  el  peligro  tubercnloso  que 
como  dice  Babinsky,  "es  univenal  y  avanza  lenta  pero  seguramente." 

Consultando  las  estadisticas  de  distintoe  paises  vemos  elocuentemente  demostrado 
que  la  mortalidad  por  tuberculosis  esti  en  raz6n  inveraa  del  grado  de  cultura. y  de 
[bb  medidas  de  profilaxia  social  que  en  ellos  se  toman. 

No  se  hace  profilaxia  donde  hay  analiabetos,  ^resultan  acaso  dtiles  para  dlos  los 
carteles  y  avisos  de  ''se  prohibe  eecupir'*  ''no  se  permite  fumar,"  etc.?  Se  generali- 
£an  acaso  entre  ellos  reglas  de  higiene?  Todo  lo  contrario.  Los  anallabetos  se 
trasmiten  sus  costumbres  y  ciertas  pricticas  que  ellos  quizis  creen  de  utilidad  pero 
que  estin  refiidas  con  las  mis  elementales  reglas  de  higiene  y  que  entrafian  serioe 
peligroe. 

Cuando  se  dan  cuenta  de  que  el  flagelo  ha  hecho  presa  de  ellos  acuden  a  loe  di^ 
pensarios  y  hospitales,  sociedades  ben^^cas,  etc.,  impetrando  un  socorro  pero  casi 
eiempre  Uegan  tarde  y  en  tales  condiciones  dichoe  establecimlentos  de  asistencia 
gratuita  no  pueden  llenar  las  sentidas  necesidades  de  los  que  a  ellas  acuden  acosadoe 
por  el  terrible  mal. 

En  el  Uruguay  funciona  desde  hace  algunos  afioe  persiguiendo  fines  profilicticos, 
la  Liga  Uruguaya  contra  la  V  uberculoeis,  meritoria  inBtituci6n  muy  bien  organizada 
pero  que  debido  a  la  enorme  cantidad  de  las  i>er8onas  que  acuden  para  benefidarse 
de  su  bienhechora  acci6n  no  le  alcanzan  loe  recursos  disponibles. 

^La  ley  de  seguros  contra  esta  enfermedad  remediaria  este  conflicto?  Puede  ser, 
dtil  la  ley  de  seguros  para  obreroe?  Segtbi  Loc»  dicha  ley  en  Alemania  donde  hace 
algunos  afios  se  implant6  empeor6  la  situacion  del  proletariado,  pues  se  aumentaron 
loe  impuestos,  creciendo  a  su  vez  las  caigas  para  loe  pjbres  que  son  quienesen  realidad 
las  pagan,  enfermindose  por  tener  que  trabajar  en  exceso  y  en  malas  condiciones  en 
los  talleres,  ^bricas,  minas,  etc.  ^ 

Hemes  dicho  en  malas  condiciones  de  trabajo  predsamente  por  que  vemos  por  las 
estadisticas  que  ^stas  y  no  el  trabajo  excesivo  es  lo  que  influye  en  el  aumento  de  la 
tuberculosis  pulmonar. 

La  ripida  ejeada  que  queremos  dar  a  todas  estas  cuestiones  no  nos  permite  entrar 
en  mayores  detalles,  haciendo  resaltar  que  el  ejercido  regulado  y  el  trabajo  regla- 
mentado  no  provoca  el  deearrollo  de  la  tuberculosis. 

Opuestamente  se  presentan  todos  los  dias  a  nuestra  observadon  esdermoB  en  cuyoe 
antecedentes  encontramos  un  exceso  de  trabajo  y  aun  malas  condiciones  del  mismo, 
por  ejemplo  madres  de  Emilia  que  estando  en  el  perfodo  de  lactanda  tienen  que 
trabajar  en  ttbricas,  talleres,  etc. 

Deben  pues  los  gobiemoe  proteger  el  trabajo  y  reglamentar  el  de  las  mujeres  y  nifios, 
ya  que  es  diffdl  refonnar  la  humanidad  y  mis  a6n  hacerla  perfecta,  se  conseguiri 
mis  fidlmente  mejorar  las  condidones  actuales  y  buscar  por  todos  los  medios  sa 
preeervaddn  y  contagio. 

La  denda  eug^nica  dedicada  al  estudio  de  las  influencias  capaces  de  perfecdonar 
el  desarroUo  de  la  raza  humana  para  obtener  el  desideritum  de  hombre  sano  se  halla 
ligada  intimamente  a  la  profilaxia  tuberculosa. 

Debe  evitarse  el  engendro  de  seres  enfennizos,  que  serin  el  dfa  de  mafiana  criminalesy 
d^enerados,  que  repreeentan  el  bald6n  de  la  humanidad,  convirti^ndoee  en  came  de 
presidio  u  hospital. 

La  tuberculosis  es  el  enemigo  hereditario  de  la  humanidad,  una  sangrla  continua, 
que  siembra  el  Uanto  y  la  viudez,  el  desamparo  y  la  horfandad  de  todoe  loe  paises. 

Se  nos  oprime  el  coraz6n  al  suponer  que  podemos  quedar  impasibles  contemplando 
ese  mal  tan  horrible  y  apooalfptico  de  la  peste  blanca,  capaz  de  prevocar  mis  vfctimas 
que  todas  las  guerras,  catistrofes  y  calamidades  reunidas. 


450       PBOOEEDIKG8  SECOND  PAN  ▲MJUUOAN  80IENTIVIG  00KGRE88. 

RMhmm  enumflEtf  las  cneeti^paB  que  encienmn  cftpitel  importsncia  como  factor 
individual  y  social  pan  la  profilaxia  tubsrculoM. 

Loe  pelig^  individuales  podemoa  daoificarloe  aai: 

La  ftdta  de  higieue,  corpoial,  dom^atica,  etc. 

La  piedispoaicidn  hereditaria. 

£U  retaido  de  deaairoUo  y  ciecimieiito. 

Falta  de  ejercicios  al  aire  libre. 

Falta  de  ejercidos  de  yinmairia  respiratoria. 

Habitaci6n  inaalubre.    Hadnamiento  en  la  vivienda. 

GoQtacto  con  otios  enlermoe,  exceaoe,  fatigaa,  ftdta  de  sufidente  alimentMidii. 

Tuberculizaddn  por  alimentos  aoepechoeoa,  leche  mal  hervida,  aduHeiadoa. 

El  aleoholiamo:  educar  aobre  el  inmenao  peligro  del  alcohd. 

Limitar  el  ntbnero  de  deapacho  de  bebidaa. 

Favorecer  en  cambio  el  oonaumo  de  bebidaa  sin  alcohd. 

Oaatigar  el  fraude;  aumentar  las  penas  a  los  ebrios. 

Estimular  a  los  que  no  beben  con  premios  o  mejorando  sus  Jornales. 

Pennitir  si^amente  el  consume  de  alcohol  pure  y  castigar  sevefamente  el  fraude  que 
se  comete  vendiendo  alcohol  de  orujo,  patata,  trapos  y  hasta  de  tierras,  que  son 
tdzicos  y  se  lucra  hoy  dia  con  su  fobricaddn. 

Ensefiar  pr6cticamente  estos  peligroes  a  los  anal&betos. 

Para  terminar  este  punto,  favorecer  por  todoe  los  medios  la  lucha  contra  el  alcoho- 
lismo. 

Gombatir  la  miseria,  fundando  las  cooperativas,  asodadones  de  socorros  mutuos,' 
cantinas  escolares,  restaurantes  populares,  etc. 

Dictar  leyes  contra  la  usura. 

Poner  contribudones  a  los  vidos. 

Proteger  a  la  mujer  embaraaada,  a  la  matemidad  y  a  la  tiema  infancia. 

Grear  cans  de  salud  destinadas  especialmente  a  los  oiganismos  f&cilmente  tuber- 
culisables  o  predispuestos  como  son  escrofulosos,  linf&ticos,  an^micos,  etc. 

Fomentaci6n  de  las  colonias  escolares,  escuelas  al  aire  libre,  estadones  campesties, 
siendo  de  gran  utilidad  las  plazas  de  ejerddos  ffsicos  que  actualmente  fundonan  ya 
en  Montevideo  con  enorme  ^to. 

La  profilaxia  por  lo  que  respects  a  la  higiene  urbana  es  tambi^  de  suma  impOTtanda, 
pues  de  aplicarse  bien  asegurarfan,  la  vida  normal  y  de  gran  reaistencia  a  todos  los 
trabajadoree  y  empleados  que  no  disponen  m6s  que  de  un  reduddo  espado  para 
habitad6n  con  ventilaci6n  insufidente,  exponi^dolos  a  los  graves  peligroe  del 
hadnamiento,  contagio,  etc. 

Inspecd6n  prolija  de  los  mataderos,  frigorfficos,  de  la  leche,  de  los  almacenes  de 
comestibles,  prohibir  la  venta  ambulante  en  malas  condidones.  Exigir  el  mis 
estricto  cumplimiento  de  las  medidas  de  deainfecd6n  a  las  empresas  de  tianvte 
camiajes,  autom6viles,  ferrocarriles,  etc. 

Evitar  el  matrimonio  entre  tuberculoeos  y  aobre  todo  tener  en  cuenta  que  de  los  dos 
progenitores  es  la  madre  la  que  de  mayor  predispodddn,  o  herenda  de  terrene,  y 
por  lo  que  respecta  al  padre  que  no  sea  un  alcohdlico,  sifilftico,  canceroso,  degenerado, 

etc. 

Protecci6n  a  la  infanda  ya  que  la  tuberculosis  del  adulto  se  considera  como  un 
despertar  de  una  infecdon  o  p^rdida  de  inmunidad  sufrida  en  los  primeros  alios. 

Recordaremos  tambi^n  la  profilaxia  de  todos  los  insectos  que  se  convierten  en 
portadores  de  g^rmenes. 

Algunos  otros  puntos  pudi^ramos  sefialar  pero  nos  contentamos  con  haber  sefialado 
los  principales  y  cuya  pr&ctica  es  necesaria  si  realmente  queremos  que  sea  un  hecho 
la  profilaxia  contra  la  tuberculosis. 

For  lo  expuesto  se  comprende  que  abarca  un  dilatado  campo  de  acd6n,  desde  la 
moralidad  de  coetumbres  hasta  el  sacrifido  material  impuesto  a  las  colectividades 
para  aliviar  a  los  pobres  y  desamparados,  que  se  impone  hacer  verdadera  educaci6n 


FUBUO  HEALTH  AND  MEDIOIKE. 


451 


antituberculoea,  por  medio  de  folletos,  conferencias,  etc.,  y  por  todas  las  pr&cticas 
imaginablee,  comprenaiblea  para  las  clases  anallabetas. 

En  esa  forma  sehardsentir  lainfuencia  sodalen  tanimportante  problema  int^rinamente 
se  resuelve  el  traecendental  de  la  inmunoterapia  o  de  la  quimioterapia,  encontzando  el  es- 
peclfico  ideal  para  imnunizar  al  organismo  desde  la  mis  tiema  infancia  contra  tan 
terrible  mal. 

£0  necesario  que  las  ciendas  m6dicas,  en  este  pimto  se  hallen  ami)aradas  por  loe 
gobiemos  y  colectividadeS)  porque  tinicamente  estd  al  alcance  de  bus  investigadores 
el  obtener  pr&cticamente  loe  trascendentalee  resultados  de  la  inmunidad  tuberculosa, 

Hay  que  desechar  de  nuestra  imaginaci6n  todo  prejuicio  y  esceptidsmo  al  respecto, 
hay  que  esperanzarse  de  que  su  obtenci6n  en  feqha  m^  o  menos  lejana  ser&  un  hecho, 
pero  interinamente  debemos  todos  con  nuestro  tribute  social  combatir  eea  piaga  y 
buscar  la  salud  favoredendo  y  eetimulando,  cuanto  la  acrezca,  y  combatiendo  y  eli- 
minando  cuanto  la  oprima. 


LA  TUBERCULOSIS  EN  EL  URUGUAY. 

Por  JOAQUlN  DE  SALTERAIN. 
Vicepreaidente  del  Consejo  General  de  EstadiiHea  del  Urugwxy. 

La  declaraci6n  obligatoria  de  las  enfermedades  infecto-contagiosas,  existe  en  vigen- 
da  en  el  Uruguay  desde  las  postrimerfas  del  afio  1896.  La  dentmcia  de  loe  cases  de 
taberculoeis  pulmonar  o  laringea,  debe  ser  elevada  ante  las  autoridades  correspon- 
dientes,  por  los  m6dicos,  en  las  24  boras  despu^  de  comprobada  la  enfermedad,  de- 
biendo,  asimismo,  los  ref eridos,  aconsejar  a  las familias  0  personas que  rodean  al  padente, 
las  medidas  necesarias  para  evitar  el  contagio  y  propagaddn  de  la  dolenda. 

En  la  prictica,  la  medida  en  sf,  no  ha  levantado  protestas,  ni  produddo  serias  difi- 
ciiltades,  sine  que  por  el  contrario  se  ha  incorp(»ado  a  las  costumbres,  merced  al  ihis- 
trado  concurso  del  cuerpo  medico  y  al  convendmiento  que  en  el  espfritu  del  pdbUco 
se  ha  difundido  por  medio  de  la  propaganda. 

Gradas  a  esos  factores,  puede  afirmarse  que  el  aislannehto  impuesto  en  la  mayoria 
de  los  cases,  a  nadie  repugna  ni  es  mirado  como  un  vejamen. 

En  este  sentido,  mucho  le  debe  el  pais  a  la  acddn  de  las  ligas  contra  la  tuberculosis, 
cuyos  padentes  desveloe  llevados  a  cabo,  con  encomiable  anhelo,  de  puerta  en  puerta, 
en  las  m&s  humildes  viviendas,  ban  ensefiado  al  obrero  y  al  menesteroso,  a  precaveae 
y  a  precaver  a  los  que  los  rodean,  asf  como  a  confiar  en  las  autoridades,  encargadas  de 
la  salud  ptiblica.  Con  tan' valioso  concurso,  la  luz  de  la  verdad  ha  penetrado  en  todos 
los  hogares;  los  conodmientos  relativos  a  los  i)eligros  del  contagio  se  han  vulgarizado 
en  todas  las  esferas  sodales,  pudiendo  as^^urarse  que  no  existe  asona  alguna  en  el  pais, 
atin  en  los  parajes  mis  apartados  y  desiertoe,  donde  se  ignoren. 

La  preparaddn  inidal,  indispensable,  existe  y  con  ello  el  terrene  propido  para  d 
desenvolvimiento  de  las  disdplinas  que  han  de  conjurar  numerosos  deeastres.  Desde 
la  promulgaddn  de  la  ordenanza,  hadendo  obligatoria  la  denunda  de  las  enfermedades 
infecto-contagiosas,  han  side  declarados  en  el  Departamento  de  Montevideo,  como 
tuberculoses,  los  siguientes  cases: 


1897. 
1898. 
1899. 
1900. 
1901, 
1902. 


71 

484 

742 

802 

740 

832 

1903 1,153 

1904 1,012 

1906 989 

68436— 17— VOL 


916 

883 

767 

766 

845 

1,166 

1912 1,374 

1913 1,724 

1914 1,266 


1906. 
1907. 
1908. 
1909. 
1910. 
1911. 


452       PBOCBEDINQ8  8BC0ND  PAK  AMEBICAK  80IENTIFI0  OONGBESa. 

La  profilftxifl  general  de  la  tuberculosis  humaaa  y  animal  estd  r^gulada,  excepdte 
liecha  de  la  acci6n  ejerdda  per  la  asisCenda  a  ks  hospitales  y  por  las  Ugas  contara  1* 
tuberculosis,  por  loe  siguientes  resortes: 

1.  TUBERCULOSIS  HUMANA. 

Declaraddn  obligatoria  de  la  tuberculosis  pulmonar  y  larfngea  (1896); 

FncepUm  generales  para  evitar  la  propagacidn  de  la  tuberculosis  por  los  enfermos  que 
padecen  de  la  forma  pulmonar  y  larfngea  (1898); 

Ftotecd^  escolar  contra  la  tuberculosis  (1906); 

Desinfecddn  por  loe  locales  habitados  por  los  tuberculosos  (190S); 

Prostitutas  tuberculosas,  curaciiki  y  aislamiento  (1906); 

Preparaci^,  venta  y  aplicaci^  de  la  tuberculina  (1911); 

Derinfecci^  obligatoria  de  los  muebles  y  enseres  usadoe,  que  se  voiden  particalar 
o  pdblicamente  (1893); 

Profilaxis  de  la  tuberculosis  en  el  Ej^ito  y  la  Policia  (en  proyecto),  1906; 

Protecci6n  a  los  maestros  de  esouelas  pdblicas,  afectados  de  tuberculosis  de  las 
Tfas  respiratorias.    (en  proyecto),  1909. 

2.  TUBBRCULOSIS  ANIMAL. 

Vigilancia  sanitaria  de  establos  y  lecherfas. 
Servicio  de  tuberculinizaci6n  e  inspeccidn  de  vetennaria. 
Intervencl6n  de  l%J)irecci6n  de  Cranaderfa,  en  loe  casos  de  tuberculosis  animal. 
Ley  de  la  policia  sanitaria  de  los  animales,  que  obliga  el  sacrificio  de  los  animales 
enfermos  y  acuexxia  indemnizaciones  a  los  propietarios. 

ASISTENCTA  AL  TUBBRCUL080. 

Ademis  de  esos  medios,  la  asistencia  pdblica  atiende  a  los  tuberculoeos  pobres,  en 
los  hospitales  que  diiige,  en  los  Departamentos  del  interior  y  en  la  capital  y  de  una 
manera  especial  en  esta  dltima,  en  pabellones  aislados,  construfdos  expresamente, . 
en  el  denominado  Hospital  Fermfn  Ferreim.    La  dltima  documentada  memoria  de  la 
Asistencia  Pdblica  Nacional,  y  que  alcanza  hasta  fines  de  1912,  decia  a  este  respecto: 

Hoy,  el  Hospital  Fermfn  Ferreira  tiene  habilitados  13  pabellones  para  la  asistencia 
de  tuberculosos  e  infecto-contagiosoB,  con  la  siguiente  distribucidn. 

Pabellones  de  madera,  Nos.  1,  2,  3  y  4  con  38,  40,  28,  y  24  camas,  respectivamente; 
tuberculoeos  mujeree. 

Pabell6n  de  madera  No.  5  con  24  camas,  dividido  en  cuatro  secciones,  para  aisla- 
miento de  infecto-contagiosos,  hombres  y  mujeres. 

Nos.  6  y  7,  j^bellones  de  mamposteiia,  ^melos,  con  36  camas,  resi)ectivamente, 
divididos  en  sois  secciones  cada  uno,  para  aislamiento  de  infecto-contagiosos  hombres 
y  mujeres.  Por  ser  suficientes,  en  las  condiciones  normalee,  los  otros  pabellones  de 
aislamiento,  el  No.  7  estd  casi  siempre  ocupado  por  tuberculosos  hombres. 

No.  8,  Pabelldn  Docker  con  24  camas  destinado  a  leprosos. 

Pabellones  de  mamposteria,  Nos.  9  y  10  con  capacidieui  para  50  enfermos,  cada  uno, 
ocupados  por  tuberculosos  hombres. 

Pabellones  Nos.  11  y  12,  de  madera,  con  25  y  28  camas,  respectivamente;  tubercu- 
losos mujeres. 

No.  13,  Pabell6n  Docker,  30  camas,  ocupadas  por  niflos. 

El  movimiento  del  referido  hospital,  en  d  aflo  de  1912,  fu6  el  siguiente,  por  la  tuber- 
culosis: Existencia  en  1  de  enero,  320;  ingresados,  1,178;  total,  1,498.  Fallecidos,  377; 
mortalidad,  por  ciento,  25.17.  La  proporcidn  de  25.17  por  ciento  de  mortalidad  por 
tuberculosis  en  el  Hospital  Fermfn  Ferreira,  no  es,  ni  con  mucho  excesiva,  pues  la 
casi  totalidad  de  los  enfermos,  acuden  al  establecimiento  cuando  el  trabajo  les  es 
imposible.  En  la  especie,  se  trata  de  casos  graves  en  el  tiltimo  perfodo  de  la  enfer- 
medad,  cuando  la  formacidn  de  las  cavemas,  la  fiebre  h^tica  y  el  aniquilamiento 
profundo  del  paciente,  dejan  pocas  o  ningunas  esperanzas  de  mejcn^. 


PUBLIC  HEALTH  AND  MEDICINE. 


453 


En  eBte  sentido,  la  experiencia  ha  demoetrado,  que  a  peear  de  la  propaganda  y  en- 
sefianza  antituberculosas,  difundidas,  como  hemos  dicfao,  por  loe  confines  del  pafe 
entero,  y  a  peear  del  conocimiento  que  el  pueblo  poeee,  acerca  de  las  probabilidades 
de  <mraci6n,  en  loe  piimeroe  perfodoe  de  la  tuberculoeie;  el  enfermo  se  reeiste  a  dejar 
Bu  hogar  y  abandonar  el  trabajo,  hasta  que  aquella  agota  sue  energlas.  Por  eso  la 
poblaci6n  de  nueetio  hoepital  de  tuberculoeos  eetk  fonnada,  caei  exclueivamente,  por 
individuoe  extenuadoe  ya  y  por  eeo  iambic  loe  reeultadoe  obtenidoe  y  que  oecUan 
eiempre  alrededor  de  las  proporcionee  transcritas,  deben  mirareei  relativamentei  como 
muy  ftkvorablee. 

Pueden  asimismo  consideraiee  como  elementos  coadyuvantee,  en  ft^vor  de  la  pro- 
filaxis  de  la  tub^x^uloeis,  los  siguientes: 

ASIL08  MATBRNALBS. 

La  aeistencia  ptiblica  cuenta  con  cuatro  eetablecimientos  de  esta  indole. 

AtUo  malemal  No.  1. — Situado  en  la  parte  sud  de  la  ciudad  nueva,  bastante  cerca 
de  la  coeta  marftima,  ocupa  una  superficie  de  930  metroe  cuadradoe.  Fu^  inauguiado 
en  1891. 

Anlo  maternal  No,  t. — ^En  la  parte  norte  de  la  ciudad  nueva.  Ocupa  una  exteneidn 
de  958  metroe  cuadradoe  en  1890. 

Aiilo  maternal  No.  S. — En  la  vieja  ciudad.    Extenei6n  1,095  metroe  cuadradoe,  1896. 

AMIo  maternal  No.  4- — En  loe  alrededoree  de  la  ciudad.  Funciona  conjuntamente 
con  la  Eecuela  del  Hogar  en  una  extenea  manzana  de  terreno. 

La  pob]aci6n  de  loe  aeiloe  matemalee,  en  el  afio  1912  fu^: 


Asilos. 


No.  I. 
No.  2. 
No.  3. 
No.  4. 


Promedlodiarlo. 


Dfasde 
dase. 


NIflosy 

nlfias 

(asisteocia 

total). 


231 

89,047 

203 

78,800 

204 

68,891 

192 

78,144 

1.472 


Eetoe  eetablecimientoe,  por  sus  finee,  y  por  su  excelente  organizaci6n,  deben  consi- 
deraree  como  factoree  poeitivoe  que  cooperan  en  beneficio  del  nifio,  cuyoe  padree 
no  pueden  atender  lae  neceeidades  del  hogar,  en  raz6n  de  sus  ocupaciones. 

Una  alimentaci6n  reparadora  y  eana,  contribuye  al  desenvolvlmiento  org&nico 
regular  y  una  ensefianza  met6dica,  en  relaci6n  con  loe  perfeccionamientoe  de  la 
moderna  pedagogia,  y  que  contempla  las  necesidades  complejas  de  la  infancia,  vigo- 
riza  sus  nacientes  energlas. 

COLONIA  DB  VAOAaONBS. 

Como  loe  anterioree  institutes  de  la  capital,  la  colonia  funciona,  desde  hace  afios, 
con  poeitivas  ventajas. 

Estd  situada  en  la  parte  Sud  de  la  ciudad,  a  orillas  del  mar,  en  un  terreno  de  algo 
m^B  de  15  hect^eas,  donde  abundan  las  plantaciones  de  pinoe,  eucaliptus  y  acacias, 
asf  como  las  de  diversas  hortalizas.  Los  asistentes  a  ella,  nunca  pueden  ser  enfennoe, 
sino  nifioe  d^bilee,  linfdticoe  y  predispuestos. 

Los  resultadoe  obtenidoe,  deede  la  ^poca  de  eu  hmdacidn,  hasta  la  actualidad,  ban 
sido  sumamente  satisfactorioe,  pues  segtin  la  autorizada  opinl6n  del  ilustrado  faculta- 
tivo  que  la  dirige,  se  ha  comprobado  siempre  en  loe  nifioe:  el  aumento  de  peso,  el 
mayor  incremento  de  la  talla,  como  la  amplitud  del  t6rax:  fndlces  prlncipales  que 
se  toman  como  elementos  de  comparaci6n.  El  niimero  de  asbtentee  en  los  tlltimoe 
afioe,  haeido:  1908  a  1911,  504;  1912,  81. 


454       PBOCEEDINGB  SEGOKD  PAN  AMBBIGAK  8GIENTIFI0  CONGBESSL 

CON8ULTORIO  OOTA  DB  LBCHB  NO.    1. 

Ttene  por  fines:  Fomentar  la  lactanda  materna,  ensefiar  loe  primeroe  cuidadoe  que 
las  madres  deben  poner  en  prdctlca,  vigilar  y  dixigir  el  crecimiento  nonnal  de  lo8 
nifloe,  prestar  asistencia  a  loe  menores  de  doe  afioe  que  concuiran  al  coDSultorio  y 
distribuir  leche  de  la  mejor  calidad,  entre  loe  nliioe  neceeitadoe  e  hijoe  de  madres 
meneeteroeas. 

Estd  instalado  en  uno  de  loe  prtncipalee  banioe  obreroe  de  la  ciudad,  poeeyendo 
todoe  los  aparatoe  neceearioe  para  la  eeterilizaci^n  de  la  leche,  envasee,  etc. 

En  el  aiio  1911  Ingresaron  1,146  nifioe  y  en  1912  la  cantidad  lleg6  haata  1,946. 

Excepci6n  hecha  de  loe  organismoe  a  que  hemoe  hecho  referenda,  pueden  aeimiemo 
considerarse,  como  elementoe  deetinadoe  a  preservar  y  amparar  a  loe  nlfioe,  el  Aailo 
de  Exp<5eitoe  y  Hu^rfanoe,  con  su  exteneo  eervicio  extemo,  numeroeo  pereonal  de 
nodrizas  y  cuna,  asf  como  el  Hospital  de  Nifioe  y  policlfnica  m^ca,  quirtkgica  y 
divereas  eepecialidadee. 

Tambi^n  debemoe  mencionar  el  eetablecimiento  de  la  nueva  Matemldad,  modelo 
en  su  g^nero,  que  acaba  de  Inaugurarse,  en  loe  momentoe  que  eecriblmoe. 

AOmNCIA  T  OURA  DBL  TITBBBCULOAO  FOB  LA   ''UOA  UBUOUATA." 

El  16  de  junio  de  1902,  por  inidativa  popular,  ee  conBtituy6  en  Montevideo  la 
' '  Liga  Uruguaya, '  *  la  cual  deede  eu  fundaci6n  emprendi6  una  lucha  acti va  y  pereistente 
para  el  triunfo  de  sue  prop<3eitoe.  A  pesar  de  no  eetar  preparado  el  ambiente,  la 
tenacidad  de  sue  iniciadoree  y  la  elocuencia  de  loe  hechoe  demoetradoe  por  una  pro- 
paganda tan  activa  como  eficaz,  abrieron  los  ojoe  de  las  multitudes,  que  bien  pronto 
comprendieron  la  importancia  del  problema  que,  por  primera  ves,  se  planteaba  en  el 
pals  con  la  serenidad  que  requiere. 

La  voz  de  alarma  se  propag6  por  los  clubs,  por  las  escuelas  y  por  los  cuarteles;  la 
I^ensa,  toda,  acogi6  la  inidativa,  apoy&ndola  sin  reticencias,  y  el  pdblico  entero,  de 
la  dudad  y  del  interior  contribuy6  al  ^xito  con  loable  inter^  a  punto  tal  que,  meses 
deepu^  de  constituirse,  celebraba  conferencias  pdblicas,  en  Montevideo  y  en  los 
departamentos,  publicaba  una  revista  y  fundaba  su  primer  dispensario  de  aelstenda 
a  loe  tubercidosos  necesitados. 

Para  darae  cuenta  exacta  del  inter^  despertado  par  la  inteneidad  de  la  propa- 
ganda, bastarla  recordar  que  entre  loe  centenares  de  donatives  espontineos  que  se 
repetfan  en  todoe  loe  momentoe,  figurd  el  de  un  generoeo  an6nimo  con  el  terrene  donde 
ttene  su  edificio  modelo  actualmente  la  instituddn.  Y  no  satisfecho  con  eso,  mis 
tarde,  don6  tambi^n  andnimamente,  la  cantidad  de  $100,000  oro  uruguayo. 

El  Gobiemo,  a  su  vez,  ddndoee  perfecta  ciienta  de  la  importancia  de  la  obra,  la 
alent6  con  su  vigoroea  ayuda,  subvencion&ndola  m&a  tarde  con  la  cantidad  de  $24,000 
anualee. 

Gracias  al  concurso  undnime  del  pueblo  y  de  sue  autoridadee,  inspiradoe  amboe  en 
nobiiisimoe  propiSsitoe,  la  liga  ha  podido  deeenvolver  con  eficacia  su  eefera  de  acci6n, 
obteniendo  en  varies  de  loe  concursoe  celebradoe  en  el  extranjero,  las  mia  altas  recom- 
pensas.  En  la  actualidad,  proeigue,  sin  lnterrupd6n,  la  tarea  emprendida,  siendo 
de  eeperar  que  en  el  p(»Tenir  ha  de  ampliar  y  mejorar  dia  por  dfa,  loe  servicioe  que 
de  ella  dependen. 

En  el  mes  de  enero  de  1914,  al  inaugurar  la  ''Primera  conferencia  encargada  de 
orientar  la  lucha  contra  la  tuberctiloeis,  en  el  interior  del  pals,"  oiganizada  por  la 
Comisi<5n  Directiva  de  la  Liga  Uruguaya  Contra  la  Tuberculoeis,  y  que  se  celebnS  en 
Montevideo,  del  18  al  23  del  mismo,  el  ilustrado  Presidente  decia: 

Nueetra  liga  gracias  a  los  perseverantee  eefuerzoe  de  sus  fundadores,  y  a  loe  de  eu 
abnegado  comit^  de  damas,  ocupa  un  puesto  de  primera  fila  entre  las  de  la  Am^ica 
Latina.  En  los  11  afios  trascurridoe  deede  su  fimaaci6n  ha  prestado  asistencia  a  3,774 
enlermos,  sometido  a  obeervacidn  a  15,096  y  dado  de  alta  por  curaci6n  o  notable 
mejoHa,  aptoe  para  el  trabajo  a  535.  Ha  distribufdo  600,000  iitroe  de  leche,  400,000 
kilogramos  de  came,  270,000  kilogramos  de  pan,  14,300  pesos  en  eubeidios  de  "' 


PUBLIC  HEALTH  AND  MEDICINE.  455 

jdases  y  sran  cantidad  de  camas,  colchones,  ropas  de  abrigo  y  de  vestir.  En  el  solo  afio 
1912-13  na  dado  33^162  bafio6  y  practicado  gran  ndmero  de  deeinfeccionee  a  domicilio 
y  en  el  desinfectorio. 

Hoy,  en  bus  tree  dispensarios  y  en  el  sanatorio  diumo,  tiene  bajo  su  protecci6n  y 
asistencia  692  enfennoe  y  por  la  escuela  al  aire  libre  y  la  *'Copa  de  leche/'  su  acci6n 
preventiva  alcanza  a  650  nifioe.  Como  se  ve,  en  la  capital,  laobra  de  la  liga,  es  tan 
amplia  como  lo  permiten  sus  recursos. 

£n  lo6  departamentos,  la  organizaci6n  de  las  ligas,  que  habia  empezado  a  deearro- 
llarse  con  la  creaci6n  de  dispensarios  en  Minas,  Salto,  raysandti  y  Treinta  y  Tree,  se 
detuvo  de  pronto  y  casi  se  paraliz6  en  1908  sobre  todo  por  falta  de  recurso.  sPocas 
comisiones  departamentales  daban  sefiales  de  vida  v  fue  necesario  reorganizarlas  en 
loe  tSltimos  afios  con  motivo  de  la  colecta  popular  del  Dia  de  los  Tuberculoses.''  £1 
resultado  de  estas  colectas  y  la  decisidn  de  la  comisidn  central  de  dejar  a  cada  departa- 
mento  el  producto  respective,  ha  despertado  nuevas  eneirgfas  y  en  la  actualidad  en 
todoe  los  departamentos  est&n  constituidas  las  comisiones  dele^adas  y  los  comit^s  de 
damas. 

C08T0  DE  LA  ASISTENCIA  AL  TUBBRCUL080. 

De  una  manera  matemdtica,  no  es  posible  comparar  exactamente  lo  que  cuesta  a  la 
asistencia  ptiblica  el  tuberculoso,  con  lo  que  gasta  la  liga  uruguaya,  pues  aunque  a 
primera  vista  no  parezca,  se  trata,  en  la  especie  de  elementos  heterog^neos.  La 
administraci6n,  casi  por  lo  general,  atiende  al  enfermo  en  el  dltimo  perfodo  de  su 
dolencia,  cuando  postrado  y  d^bil,  necesitando  un  exceso  de  alimentaci6n,  prolonga, 
a  esa  condici6n,  su  minada  existencia,  durante  largos  perfodos  de  tiempo,  si  es  que  no 
86  interrumpe  pocos  dlas  despu^  del  siempre  combatido  ingreeo  al  asilo,  el  epflogo  de 
su  agonfa. 

La  tarea  de  la  liga,  es  m&a  amplia,  pues  que  ensancha  su  esfera  de  acci6n  tomando  al 
sujeto,  desde  que  se  sospecha  pueda  estar  enfermo,  o  ballarse  en  condiciones  de 
susceptibilidad  morbosa.  Lo  ensefla  a  precaverse,  k>  ayuda  y  lo  sigue  dentro  de  la 
propia  vivienda. 

La  asistencia  acepta,  porque  no  puede  menos,  los  despojos  todos  de  la  marea,  por 
mis^rrimos  que  parezcan;  la  liga  clasifica,  y  separa  a  aquellos,  para  quienes  las 
esperanzas  de  mejoramiento  no  son  posibles  sine  probables  y  a  menudo  casi  realidades. 

Los  resultados  obtenidos  por  entrambos  medios,  asl  como  los  gastos  que  uno  y  otro 
demandan,  no  pueden,  por  tanto  equiparaise. 

No  obstante  y  b61o  a  tftulo  informative,  expondremoe  los  dates  siguientes: 

Durante  loe  dltimos  aflos  (1908-1912)  faUecieron  de  tuberculosis,  en  el  Hospital 
de  Infecto-Contagioeos  de  Montevideo  (Hospital  Fermln  Ferreira),  a  cargo  de  la  asis- 
tencia ptiblica; 

1908,  135  faUecidos;  1909, 128;  1910,  243;  1911,  291;  1912,  372;  total,  1,169  fallecidoe. 

Segtin  la  memoria  de  la  propia  asistencia  ptiblica,  1913,  la  mortalidad  de  Jf^  asilados 
por  tuberculosis,  en  el  referido  hospital,  durante  el  aflo  1912,  igual6  a  la  proporci<3n 
de  25.17  por  ciento.  Y  en  cuanto  al  costo  mensual  de  un  enfermo  de  loe  asilados, 
fu6  el  siguiente: 

1907-8,  $28.85;  1908-9,  $24,32;  190^10,  $28.29;  1910-11,  $30.65;  1911-12,  $31.29. 

La  Liga  Uniguaya  contra  la  Tuberculosis,  en  cambio,  en  el  solo  Departamento  de 
Montevideo,  atendi6,  desde  julio  de  1902  hasta  31  de  diciembre  de  1914,  en  los  tres 
dispensarios  que  poeee,  asf  como  en  el  sanatorio  de  cura  diuma  al  aire  libre,  el  ndmero 
de  enfennoe  siguiente  con  estoe  resultados: 

Ndmero  de  enfermos  asistidoe 3, 700 

(A)  Aparentemente  curados 910 

Proporci6n,  por  ciento 24. 69 

(B)  Notablemente  mejorados 328 

Proporcidn  por  ciento 8. 86 

A+B 1  238 

Proporcidn  por  ciento 33, 46 


456       PBOGEEDIKOS  SECOND  PAK  AMEBIOAN  80IBNTIFIG  C0NGBE8S. 

A  efte  reepecto  conviene  obwrvar  que,  a  peetr,  de  no  »dmitir  en  principio  1a 
Liga,  flino  loe  enfermos  curables,  en  la  pjtidicA  las  excepciones  son  frecuentes,  ingre- 
sando  en  los  dispenflarioe,  per  razones  de  caridad,  numevoeos  cases  de  tubereulosis 
en  los  periodoe  m^  avanzados  de  la  dolencia.  Y  por  lo  que  toca  a  loe  curados,  real- 
mente  pueden  considerarae  asi,  puee  segtin  las  pr^ticas  establecidas,  se  observa  du- 
rante afios  el  estado  ulterior  de  loe  dados  de  alta. 

EFICACIA  DE  LA  ACa6N  POPULAR  EN  LA  ASIfiTBNCIA  DEL  TUBERCULOSO. 

Durante  el  espacio  de  tiempo  de  mis  de  10  afios,  hemes  asistido  dla  por  dia  a  la 
ofganizacidn  de  la  liga,  desde  la  fecha  en  que  fu6  fundada. 

Adem^  del  mecanismo  administrativo  y  abeolutamente  nuevo  que  nos  fu6  dado 
estudiar  y  desenvolver,  adaptindolo  en  lo  posible  al  medio  ambiente,  las  exigendas 
del  cargo  nos  obligaron  a  estudiar,  en  sus  m&s  insignificantes  detalles,  la  vida  del  tuber- 
culoso,  sus  h&bitos,  sus  necesidades,  como  las  de  la  familia,  en  las  propias  moradas. 
S6lo  asf  nos  fu6  posible  damos  cuenta  de  su  ndmero,  consiguiendo  al  mismo  tiempo 
insinuamos,  en  el  espfritu  de  los  desgraciados,  escuchando  pacientemente  las  quejas 
que  la  amargura  y  la  miseria  provocan.  S61o  asl,  en  contacto  intimo  con  los  enfermos, 
llegamos  ainspirar  confianza,  vale  decir,  poseer  el  elemento  indispensable  para  la 
asistencia  y  sin  el  cual  ^ta  resulta  absolutamente  indtil. 

Observadores  mis  autorizados  que  nosotroe,  acaso,  nieguen  el  valor  de  lo  que  podria- 
mos  denominar  cura  moral  del  tuberculoso  y  sostengan  que  todo  debe  supeditarse  al 
cumpUmiento  de  una  disciplina  severa  y  rlgida.  Nuestra  modesta  experiencia, 
contradice,  en  absolute,  semejante  opinidn. 

Por  desesperante  que  parezca  el  estado  de  muchos  enfermos  y  por  decaido  que  eet6 
el  inimo,  de  continue  triste  entre  los  tuberculoses,  la  presencia  de  una  persona  que  se 
interese  en  semejantes  seres,  contribuye  tanto  o  mis,  si  cabe,  que  la  virtud  de  algunos 
remedies.  Y  si  esa  influencia  se  ejerce  de  manera  inteligentemente  consoladora  y 
persuasiva,  muy  rare  es  que  no  se  obtengan  benefices  resultados. 

La  acci6n  de  la  liga  poniendo  en  contacto  intimo  al  enfermo,  con  los  encaxgados  de 
su  asistencia,  facilitdndole  los  medios  de  hacer  frente  a  sus  necesidades  mis  apre- 
miantes,  dindole  techo,  abrigo  y  alimentos  y  ensefiindole  a  precaver  del  contagio  a  los 
seres  que  le  rodean,  ha  side  fecunda  y  esti  llamada,  si  la  oiganizacidn  de  sus  dispen- 
saries se  perfecciona,  como  es  de  esperarse,  a  desempefiar  el  principal  papel  en  la 
lucha  contra  la  tubercidosis.  Tal  es  nuestra  intima  convicci6n,  abonada  con  la 
experiencia  de  mis  de  diez  alios  de  observacidn  paciente  y  sincera. 

Por  supuesto  que  los  detalles  del  procedimiento  tienen  positive  valor,  pues  no  es 
lo  mismo  limitar  la  asistencia  a  lo  que  arrojan  el  estudio  clinico  del  enfermo,  el  peso, 
la  amplitud  del  t6rax  y  el  examen  de  los  productos  de  la  expectoraci6n,  que  ampliarla, 
vidtando  su  morada,  alentando  sus  cansadas  energlas  y  ayudindole  en  cuanto  necesita 
alivio  y  consuelo.  Todo  lo  que  se  diga,  en  este  sentido,  resulta  pilido,  ante  la  realidad 
de  los  hechos.  A  punto  tal  que  creemos  que  de  la  importancia  dada  a  estos  numerosos 
y  complejos  factores,  se  debe  caai  siempre  el  6xito  obtenido,  cuando  se  contemplan 
y  desenvuelven  convenientemente. 

MOBTALIDAD  POR  TUBERCULOSIS  PULliONAR,   AB80LUTA  T  PROPORCIONES. 

La  poblaci6n  del  Uruguay,  que  segtin  el  Ultimo  cense,  de  12  de  octubre  de  1908, 
sum6  la  cantidad  de  1,042,686  habitantes,  ascendi6,  segtin  cilculos,  en  31  de  diciembre 
de  1914,  a  la  de  1,326,506.  El  aumento  referido  se  debe,  en  primer  tannine,  al  aumento 
migratorio  (igual  en  los  afios  1909-1913  a  la  proporci6n  de  24.09  por  ciento;  y  en  segundo 
lugar,  al  crecimiento  vegetativo:  (igual  en  el  mismo  periodo,  a  la  proporci6n  de  18.23 
por  ciento).  La  poblaci6n  esti  formada  en  su  totalidad  por  uruguayos,  hijos  de  loe 
antiguos  colonos  europeos  y  por  extranjeros;  principalmente  italianos  y  espafioles. 


PUBUO  HEALTH  AND  MBDIGIKE. 


457 


La  pfopofci^  de  los  iinig:iUkyo6,  segAn  el  cenao  de  1908  fa6  igual  a  la  dira  de  82.62 
por  dento  y  la  de  extranjeros  a  la  de  17.38  por  dento.  Semejantee  ptopotciones  no  te 
han  alterado  senaiblemente  en  IO0  ^timoB  aHos. 

Durante  el  perfodo  comiMrendido  entre  loe  aHos  1895-1914,  entiamboe  incluaives, 
fallecieron  de  todaa  las  enfennedades,  la  cantidad  de  279,234  individuoe,  soma  que 
da  una  proporci6n  media  de  mortalidad  general,  en  veinte  afioe  de  obeervaddn,  igual 
a  12.18  por  1,000. 

Las  proporciones  medias  en  loe  19  Departamentoe  en  que  se  halla  dividida  la  Repd- 
blica,  fueron: 


Artigas 16.46 

Canelones 10. 32 

Gerro  Largo 12.44 

Colonia n.82 

Durazno 14. 49 

Flores ia06 

Florida n.66 

Maldonado 10. 81 

Minas 12.41 

Montevideo « 16. 05 


Paysandd 1L97 

Rfo  Negro 8.65 

Rivera 16.07 

Rodia 1L37 

Salto 15.03 

SanJos^ 1L93 

Soriano 14.07 

Tacuaremb6 14.56 

TreintayTres 1L67 


Durante  id^ntico  perfodo  de  20  afioe  fidlederon,  de  tuberculosis  pulmonar  en  el 
Uruguay,  la  cantidad  de  21,407  personasi  que  da  la  prqporci6n  media  de  5.38  por 
dento,  Bobre  las  defundones  genendes  y  la  media  tambi^n  propordonal,  de  0.69  pcnr 
cada  1,000  habitantes. 

La  proporci6n  media  de  folleddos  de  tuberculosis  pulmonar,  por  100  defundones, 
en  comparaci6n  de  las  proporciones  medias  sobre  la  mortalidad  general  en  los  Departa- 
mentos  fu6  c<Rno  sigue: 


Artigas 3.29 

Canelones 6. 49 

Gerro  Largo 6.59 

Gdonia 6/68 

Durazno 4.44 

Flores 4.47 

Florida 4.97 

Maldonado 3.19 

Minas 3.  79 

Montevideo 11. 55 


Fftysandd 8.41 

Rfo  Negro 4.56 

Rivera 4.35 

Rocha 5.79 

Salto 6.45 

SanJo66 7.70 

Soriano 7.10 

Tacuaremb6 4. 26 

TreintayTres 3.56 


Los  anteriores  guarismos  demuestran  que,  durante  ks  ^timoe  veinte  alios,  en  el 
Uruguay,  dentro  de  una  propotddn  media  de  la  mortalidad  general,  bastante  baja 
(12.18  por  1,000)  la  proporcidn,  tambi^n  media,  de  folleddoe  de  tuberculosis  pulmonar, 
por  ciento  de  defundones  generales,  tampoco  fu6  elevada  pues  igual6  a  la  de  5.38 
por  dento. 

No  obstante,  estudiando  paidal  y  comparativamente  los  cuadros  estadfsticos  que 
hemos  fonnado,  es  de  observar  y  tenerse  en  cuenta  para  ulteriores  investigaciones: 

Que  la  cantidad  absoluta  y  propoidonal  de  fidleddos  por  tuberculosis,  en  general, 
ha  ido  aumentando  paulatinamente.  Que  ese  aumento  es  bastante  mis  sensible  en  el 
Departamento  de  la  capital,  pudi^ndose  explicar  en  parte:  por  ser  de  regla  el  pre> 
dominio  de  las  afecciones  tuberculoses  en  centres  urbanos  de  poblaci6n  elevada; 
pofque  el  diagndstico  se  establece,  donde  los  servidoe  medicos  abundan,  en  mejofes 
condiciones  y  con  mayor  certeza  y  potque  muchos  enfermos  del  interior  acuden  a  la 
metrdpoli  en  busca  de  mejores  recursos. 

Finalmente:  que  la  propofci6n  de  defundones  de  tuberculosis,  sobre  el  ndmero  de 
habitantes,  en  loe  Departamentos  del  interior,  nunca  lleg6  a  la  cifra  de  2  par  1,000 


458       PBOCEEDINOS  SECOND  PAN  AMEBICAK  8CIBNTIFIQ  CONGRESS. 

elev&iidoae  86I0  la  de  Montevideo  (cuya  media  fu^  de  1.85  en  20  ados)  hasta  2.13  por 
1,000,  en  1911,  2.22  en  1912,  y  2.25  en  1914.  La  propoici6n  media,  en  el  Uniguay,  en 
loo  <iltimoe  20  afioe  fu4  de  0.69  por  1,000  habitantes. 

RB8UMBN. 

La  lucha  contra  la  tuberculosis  en  el  Uruguay  cuenta  con  elementos  diversoe  bae- 
tante  bien  oiganizadoe  en  su  conjunto.  En  el  interior,  como  en  la  capital,  la  aaistenda 
ae  Ueva  a  la  pr&ctica  con  el  concurso  de  I06  Hospitales  que  dependen  de  la  Asistenda 
Pdblica  y  el  de  las  Ligas.  Estas  iiltimas  tienden  a  deearrollarse  cada  vez  m&B,  con 
poaitivo  provecho. 

La  declaraci6n  obligatoria  de  la  tuberculosis  existe  en  vigenda  desde  1896.  La 
pr&ctica  de  la  de6infecci6n  se  Ueva  a  cabo  regularmente  en  la  Capital  y  tiende  a  regu- 
larizarse  en  el  interior. 

El  aislandento  del  enfermo  se  realiza,  en  Montevideo,  en  los  pabellonee  que  la 
administracidn  posee  y  en  algunos  departamentoe,  como  el  del  Salto,  en  las  instala- 
ciones  de  las  ligas. 

Adem&s  de  esos  instrumentos  de  cura  y  pre6ervaci6n,  deben  considerarse  como  &u> 
tores  coadyuvantes:  los  asilos  matemales  (tres  en  Montevideo);  la  Copa  de  leche  (una 
principal  con  siete  sucursales);  las  Colonias  de  vacadones,  concursos  de  lactantes; 
fundones  del  cuerpo  medico  escolar ;  Casa  de  matemidad ;  diversas  le3res  de  protecd6n 
a  la  infancia,  a  las  madres,  def^isa  de  menores,  etc.,  Hospital  de  nifios,  casa  cuna,  y 
servidos  intemo  y  extemo  de  hu^ifanos  atendidos  en  el  hospital  con  nodriza  y  ali- 
mentados  artificialmente. 

La  vigilancia  sanitaria  de  los  animales  se  Ueva  a  cabo  en  condidones  regulaiee, 
organizada  convenientemente  por  la  Direcd6n  de  Ganaderia  y  por  la  lnspecci6n 
Veterinaria. 

En  el  espacio  de  los  <iltimos  20  afios,  la  mortalidad  general  y  por  tuberculosiB,  en  el 
Uruguay,  lleg6  a  las  cifras  absolutas  y  propordonales  siguientes: 

Afios  1895  a  1914  (indusives):  MortaUdad  general,  279,234;  proporddn  media  por 
mil,  12.18;  mortalidad  por  tuberculosis  pubnonar,  21,407;  proporddn  media  por  mil 
habitantes,  0.69;  properdin  media  por  den  defnndones,  5.38. 

Alioi,  pohlacii6n,  mortalidad  general,  tuberculoiis  pulrrumar  y  proporeumes,  1895-1914, 

DEPARTAMBNTO  DE  ARTI0A8. 


Afioa. 

Pobla- 
ddii. 

Mortali- 
dad 
gantraL 

Ppopof- 
ddn 
media 
por  1.000 
habitan- 
tes. 

Mortali- 
dad  por 
taberou- 
losispul- 
monar. 

Propor- 

Oi&l 

media 

porl,000 

habitan- 

tet. 

media 
por  100 
defan- 
ciones 
ganarales. 

1896 
1896 
1897 
1808 
1899 
1900 
1901 
1908 
1908 
1904 
1906 
1906 
1907 
1908 
1909 
1910 
1911 
1913 
1918 
1914 

30,851 
31,174 

31,  no 

33,309 
33,904 
36,004 
87,001 
37,668 
38,364 
38,971 
80,574 
83,806 
86,480 
37,076 
38,719 
39,823 
81,380 
88,470 
35,151 
86,840 

437 
409 
849 
879 
375 
878 
436 
887 
469 
343 
410 
471 
499 
445 
530 
689 
548 
459 
445 
461 

90.98 
19.31 
10.06 
10.98 
13.00 
14.87 
15.77 
S.66 
16.50 
8.36 
U.41 
14.35 
18.80 
16.43 
18.45 
18.19 
17.80 

i8.n 

13.66 
13.68 

7 

6 

18 

18 

4 

10 

11 

17 

11 

4 

7 

11 

U 

11 

18 

30 

88 

37 

18 

83 

0.84 
.38 
.50 
.80 
.17 
.88 
.40 
.61 
.88 
.14 
.83 
.88 
.80 
.40 
.45 
.67 

1.31 
.80 
.61 
.88 

LOS 

1.46 
8.73 
4.74 
1.45 
3.88 
3.58 
3.71 
3.84 
1.66 
1.70 
3.38 
3.30 
3.47 
3.45 
3.71 
6.99 
5.88 
4.04 
6.94 

8,784 

15.46 

380 

.50 

8.39 

FDBLIO  HEALTH  AKD  HEDIOIHB. 


DBPABTAHBNTO  DE  CANBLONSfi. 


'"ST" 

AAOK 

s^ 

"2f- 

ss 

^100 

tea. 

i«i. 

l»«BiJei. 

UW 

M,ETG 

11.  TO 

0.71 

4.U 

aao 

18.»M 

10.39 

1,181 

.07 

t.« 

DBPARTAUSNTO  DB  CBRBO  LAKOO. 


mt 

tu 

10,  IM 

12.  M 

MR 

.10 

S.6S 

DBFARTAUBNTO  DB  COLONIA. 


S.4S 

1014 

7 

W7 

8.  SI 

44 

11,  »n 

11.81 

sw 

.7« 

a.  IB 

460       PBOOBBDINOe  SECOND  PAN  AHBBIOAN  SCIBimFIC  OONOBKBa. 


DBPAETAUENTO  DB  DITRAZNO. 


Alio*. 

Pobb- 

s 

HortaU- 

ha. 

tSH 

SW 
WO 

1 

904 

1 

KB 

i 

Ma 
vu 

i 

tS,«M 

t*,tao 

1 

SN 
EX 

m 

7U 

g 

4! 

37 

n 

31 

1 

S4 

.» 

.71 

lis 

.47 

1 
1 

'.n 

.» 
.97 

.7« 

.a 
.« 

^s 

.a 

J 

.79 
.a 

.M 

!u 

!07 

1I,S3I 

14. 4« 

tan 

1.44 

DEPARTAlfENTO  DE  F LORES. 


xa 

13. « 

13           D 

m 

fi.S4 

I4.se 

SI 

l.» 

I.M 

0.3G 

4, Ml 

13. 0« 

aM    1         .6S 

4.4T 

DBPARTAUENTO  DS  FLOUII>A. 


l»ft 

34  ITS 

13.83 

M 

3.n 

10,S»5 

ll.M 

537 

67 

4.97 

PUBUO  HEALTH  ABD  MEDIOIKE. 


461 


Aiioi,  poblaei6n,  morialidad  generalt  tub^rcuhiit  pubnonar  y  prt^pamoneij  189S^1914 — 

Gontinda. 


DEPARTAUENTO  DE  liALDONADO. 


! 
Afios. 

Pobla- 
dte. 

Mortall- 

dad 
Stneral. 

Propof^ 

ddn 

media 

por  1,000 

babltan- 

tee. 

Mortali- 
dad  por 
tuberoo- 
loslspul- 
monar. 

Propor 

d&i 

media 

por  1,000 

habitan* 

tes. 

Propor- 
don 
media 
por  100 
defun- 
dones 
generales. 

1805 
1806 
1807 
1808 
1800 
1900 
1901 
1902 
1903 
1904 
1905 
1906 
1907 
1908 
1900 
1910 
1911 
1912 
1913 
1014 

21,007 
22,425 
23,066 
23,835 
94,488 
26,430 
27,035 
27,720 
28,304 
28,068 
20,631 
31,419 
32,607 
20,276 
30,588 
31,818 
33,168 
34,704 
36,306 
37,125 

231 
460 
248 
301 
270 
305 
280 
277 
347 
261 
203 
307 
295 
333 
324 
348 
381 
367 
314 
330 

1L45 

90.51 

10.74 

12.71 

1L02 

11.58 

10.35 

0.08 

12.25 

0.00 

0.88 

0.77 

0.02 

11.37 

10.50 

10.03 

11.48 

10.57 

&64 

0.13 

10 

10 

13 

15 

14 

6 

7 

8 

8 

6 

3 

10 

10 

10 

7 

8 

11 

10 

11 

0 

0.73 
.44 

.56 
.62 
.57 
.22 
.25 
.28 
.28 
.20 
.10 
.31 
.30 
.34 
.22 
.25 
.33 
.54 
.30 
.24 

6.02 
2.17 
5.24 
4.03    1 
5.18    1 
1.06    1 
2.50    , 
2.88    ; 
2.30    1 
2.20    1 
1.02    1 
3.25 
3.38 
3.00 
2.16 
2.20    ! 
2.88 
5.17 
3.50 
2.65 

6,284 

ia8i 

201 

.34 

3.10 

DEPARTAMENTO 

DE  lilNAS. 

1806 

26,702 

418 

15.61 

18 

0.67 

4.80 

1800 

27,604 

528 

10.48 

13 

.47 

8.40 

1807 

28,401 

422 

14.85 

17 

.50 

4.08 

1806 

20,287 

445 

15.10 

16 

.54 

8.50 

1800 

80,360 

446 

14.68 

13 

.48 

8.01 

1000 

36,065 

520 

14.65 

17 

.47 

8.81 

1001 

37,152 

513 

13.80 

13 

.34 

8.63 

1002 

88,155 

545 

14.28 

13 

.34 

8.38 

1003 

30.306 

585 

13.35 

16 

.40 

3.04 

1904 

40,260 

420 

10.65 

13 

.80 

8.70 

1906 

41,426 

540 

13.03 

20 

.48 

8.70 

1906 

43,727 

080 

14.17 

36 

.88 

5.80 

1907 

45,334 

726 

16.01 

36 

.70 

4.06 

1906 

51,713 

583 

11.27 

28 

.48 

8.77 

1000 

63,300 

505 

11.14 

40 

.74 

6.73 

1010 

55,007 

617 

11.10 

81 

.38 

8.40 

1011 

57,036 

641 

11.23 

83 

.40 

3.58 

1012 

50,220 

581 

0.80 

17 

.88 

3.08 

1013 

61,470 

512 

8.32 

16 

.80 

8.18 

1014 

68,020 

582 

8.20 

30 

.46 

6.55 

10,737 

12.41 

406 

.47 

8.70 

DEPARTAMENTO  DE  MONTEVIDEO. 

1806 

858,000 

3,801 

15.02 

488 

1.06 

11.10 

1806 

861,183 

3,006 

15.20 

477 

1.83 

11.04 

1807 

864,838 

3,066 

15.06 

455 

1.71 

11.41 

1806 

864,704 

3,980 

15.03 

381 

1.43 

0.57 

1800 

865,578 

3.902 

14.65 

307 

1.40 

10.17 

1000 

868.334 

4,267 

15.05 

4tt 

1.70 

11.80 

1001 

873,666 

4.374 

15.08 

404 

1.80 

11.80 

1008 

876.034 

4,466 

16.17 

487 

1.76 

laoo 

1003 

888,680 

4,530 

16.02 

544 

1.08 

18.00 

1004 

880,018 

4.638 

16.04 

554 

1.01 

11.04 

1005 

806,538 

4.402 

14.74 

516 

1.73 

11.78 

1006 

807,482 

5,042 

16.80 

584 

1         1.80 

11.58 

1007 

800,004 

4,080 

16.07 

568 

1         1.81 

11.30 

1006 

318,016 

4,822 

15.40 

560 

,         1.78 

11.61 

1000 

881,834 

5,466 

17.01 

505 

'         1.85 

ia88 

1010 

380,888 

6,162 

18.67 

658 

1.00 

10.67 

1011 

388.353 

5,820 

17.88 

738 

8.13 

13.38 

1018 

355,017 

6.336 

17.84 

700 

8.88 

13.46 

1013 

874,006 

5,834 

15.57 

644 

1.74 

11.06 

1014 

375.135 

5,806 

15.71 

846 

8.85 

14.34 

06.788 

16.06 

11,181 

1         1.85 

11.56 

462       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIPIO  CONGRESS. 


AfioSt  po6tocw5n,  mortalidad  genemly  tuberculosis  puhnonar  y  propordoneSy  1895-1914- 

CoDtinda. 

DEPARTAMENTO  DE  PAYSANDlJ. 


Aftos. 

Poblar 
cldn. 

Mortali- 
dad 
general. 

477 
500 
625 
581 
401 
517 
507 
576 
554 
425 
517 
622 
608 
587 
543 
552 
608 
545 
581 
561 

Propor- 

don 

media 

por  1,000 

habitan- 

tes. 

Mortali- 
dad por 
tubercu- 
losis pul- 
monar. 

Propop- 

cion 

media 

por  1,000 

nabitan- 

tes. 

Propor- 
ci^n 
media 
por 100 
defun- 
ciones 
generales. 

1806 
1806 
1807 
1808 
1800 
1000 
1001 
1002 
1003 
1004 
1005 
1006 
1007 
1008 
1000 
1010 
1011 
1012 
1013 
1014 

36,448 
38,440 
40,431 
42,011 
44,344 
43,121 
44.411 
45,655 
47,086 
48,140 
40,784 
52,308 
54,007 
38,883 
42,143 
45,127 
48,410 
52,038 
57, 146 
60,512 

13.08 
15.34 
15.45 
13.63 
11.07 
11.08 
11.41 
12.61 
11.76 

8.82 
10.38 
11.87 
11.23 
15.00 
12.88 
12.23 
14.41 
10.47 
10.16 

0.27 

46 
28 
47 
36 
23 
36 
41 
30 
30 
32 
56 
57 
53 
38 
68 
54 
76 
50 
63 
57 

1.26 

.72 

1.16 

.83 

.51 

.83 

.02 

.85 

.82 

.66 

1.12 

1.06 

.07 

.07 

1.61 

1.10 

1.56 

.06 

1.10 

.04 

0.64 
4.74 
7.52 
6.10 
4.68 
6.06 
8.08 
6.77 
7.03 
7.52 

10.83 
0.16 
8.71 
6.47 

12.52 
0.78 

10.88 
0.17 

10.84 

10.16 

11,157 

11.07 

030 

1.00 

8.41 

DEPARTAMENTO   DE   RIo   NEGRO. 


1805 

20,771 

300 

10.06 

11 

0.63 

5.36 

1806 

22,100 

252 

11.35 

14 

.63 

5.55 

1887 

24,368 

246 

10.00 

11 

.45 

4.47 

1806 

25,888 

210 

8.43 

11 

.43 

5.03 

1880 

28,218 

228 

8.11 

11 

.38 

4.80 

1000 

21,202 

201 

0.48 

7 

.83 

3.48 

1001 

23,127 

344 

10.55 

16 

.60 

6.55 

1802 

25,157 

222 

8.83 

8 

.31 

3.60 

1803 

28,133 

223 

7.80 

13 

.43 

6.40 

1804 

31,103 

310 

6.75 

0 

.38 

4.38 

1806 

83,316 

340 

7.30 

10 

.30 

4.16 

1006 

36,025 

388 

8.00 

6 

.16 

3.00 

1007 

88,667 

344 

6.15 

14 

.35 

5.73 

1008 

20,565 

337 

11.53 

13 

.63 

6.48 

1008 

23,276 

321 

10.18 

8 

.84 

8.37 

1010 

25,452 

386 

8.68 

8 

.85 

4.07 

1011 

37,622 

263 

10.35 

13 

.48 

4.10 

1812 

28,631 

352 

8.87 

6 

.30 

3.38 

1813 

31,807 

387 

7.80 

10 

.31 

3.86 

1814 

83,528 

346 

7.33 

30 

.58 

8.13 

4,778 

8.65 

318 

.38 

4.66"" 

DEPARTAMENTO   DE   RIVI 

SRA. 

1885 

17,838 

415 

33.13 

4 

0.22 

0.86 

1886 

18,514 

300 

31.06 

18 

.70 

3.33 

1887 

18,767 

208 

11.13 

16 

.85 

7.66 

1886 

18,333 

334 

16.84 

16 

.83 

4.83 

1888 

18,820 

281 

14.17 

18 

.80 

6.40 

1800 

34,783 

368 

14.84 

15 

.60 

4.07 

1001 

35,348 

328 

13.87 

6 

.33 

L82 

1003 

35,807 

432 

.  16.67 

7 

.37 

1.62 

1008 

36,360 

416 

15.78 

11 

.41 

2.64 

1804 

36,556 

178 

6.74 

8 

.30 

4.46 

1005 

37,213 

461 

16.84 

13 

.47 

3.81 

1006 

28,831 

576 

18.87 

18 

.65 

3.38 

1807 

30,051 

470 

15.64 

33 

.76 

4.88 

1006 

36,063 

500 

13.86 

81 

.86 

6.30 

1000 

87,146 

586 

16.04 

31 

.83 

5.30 

1010 

38,227 

531 

13.62 

36 

.68 

4.08 

1811 

80,413 

783 

20.12 

30 

.76 

3.78 

1813 

41,030 

710 

17.20 

27 

.66 

3.80 

1813 

42,503 

670 

15.07 

42 

.88 

6.18 

1814 

43,342 

625 

14.42 

48 

1.10 

7.68 

8,374 

16.07 

404 

.70 

4.35 

PUBLIC  HBALTH  AND  MEDIOIKE. 


463 


Aiios,  pobladdrif  mortalidad  general^  tuberculosis  ptdmonar  y  proporciones,  1896-1914 — 

Oontinda. 


DEPARTAMENTO   D£    ROCHA. 


Afk». 

Pobla- 
ddn. 

Mortali- 
dad 
general. 

Propor- 

cion 

media 

por  1,000 

nabitan- 

tes. 

11.04 
16.47 
12.16 
13.25 
10.81 
11.03 
10.15 
11.03 
13.65 
10.03 
11.56 
10.70 
11.21 
11.60 
10.71 
10.00 
10.45 
10.08 
11.10 
0.05 

Mortali-     ^^^- 

tubercju-   ™YSo 

losispul-  gJ'J^ 

monar.     "^^^ 

1 

Propor- 

don 

media 

por  100 

defun- 

ciones 

generales. 

1805 
1806 
1807 
1808 
1800 
1000 
1001 
1002 
1003 
1004 
1005 
1006 
1007 
1008 
1000 
1010 
1011 
1012 
1013 
1014 

24,610 
25,251 
25,076 
26,704 
27,540 
20,560 
30,428 
31,167 
32,010 
32,608 
33,556 
!      35,582 
.      37,020 
34,543 
36,023 
37,438 
30,038 
40,705 
42,351 
43,300 

272 
416 
316 
354 
203 
326 
300 
372 
437 
328 
388 
381 
415 
404 
386 
412 
408 
447 
474 
431 

10 
20 
10 
16 
10 
14 
14 
22 
15 
10 
21 
25 
10 
26 
27 
27 
20 
28 
41 
87 

0.77 
.70 
.38 
.50 
.36 
.47 
.46 
.70 
.46 
.58 
.62 
.70 
.51 
.75 
.74 
.72 
.74 
.68 
.06 
.85 

0.06 
4.80 
3.16 
4.51 
3.35 
4.20 
4.53 
5.01 
8.43 
5.70 
5.41 
6.56 
4.57 
6.43 
6.00 
6.55 
7.10 
6.26 
8.64 
8.58 

7,674 

11.87 

430 

.65 

5.70 

DEPARTAMENTO  DB  8ALTO. 


1805 

35,881 

631 

17.58 

20 

a8o 

4.50 

1806 

36,801 

735 

10.07 

37 

1.00 

5.08 

1807 

37,586 

608 

16.17 

50 

1.33 

8.25 

1808 

38,320 

681 

17.76 

50 

1.30 

7.34 

1800 

30,451 

560 

14.10 

46 

1.16 

8.21 

1000 

44,675 

634 

14.10 

87 

0.82 

6.88 

1001 

45,754 

631 

13.70 

80 

0.85 

6.18 

1002 

46|703 

763 

16.30 

60 

1.06 

6.55 

1003 

47,615 

012 

10.15 

62 

1.00 

5.70 

1004 

48,326 

564 

11.46 

46 

0.05 

8.80 

1005 

40,646 

655 

13.10 

25 

0.50 

8.81 

1006 

51,661 

784 

16.17 

44 

a85 

6.61 

1007 

53,154 

877 

16.40 

.  53 

aoo 

6.04 

1006 

46,801 

740 

16.00 

80 

0.83 

6.30 

1000 

48,666 

753 

15.47 

62 

1.06 

6.00 

1010 

51,002 

783 

15.35 

80 

0.74 

4.06 

1011 

54,150 

788 

14.54 

61 

0.04 

6.47 

1012 

56,875 

700 

14.04 

58 

1.01 

7.26 

1013 

60,175 

744 

12.36 

73 

1.21 

0.81 

1014 

66,403 

780 

11.88 

62 

0.03 

7.86 

14,430 

15.03 

082 

0.07 

6:45 

DEPARTAMENTO  DB  SAN  JOSi. 


1805 

32,605 

474 

14.53 

41 

1.35 

8.64 

1806 

33,545 

480 

14.57 

81 

0.03 

6.38 

1807 

34,441 

510 

14.80 

60 

1.45 

0.80 

1806 

35,286 

580 

16.00 

00 

1.38 

8.31 

1800 

36,354 

516 

14.10 

48 

1.33 

0.80 

1000 

41,055 

640 

15.58 

86 

0.87 

5.63 

1001 

42,181 

480 

11.50 

26 

0.61 

6.31 

1002 

43,100 

406 

11.48 

87 

0.85 

7.45 

1003 

44,257 

514 

11.61 

40 

0.00 

7.78 

1004 

45,353 

472 

10.40 

38 

ass 

8.06 

1005 

46,866 

530 

11.43 

30 

0.63 

5.47 

1006 

48,671 

541 

11.11 

47 

0.06 

8.66 

10O7 

50,304 

615 

12.22 

48 

0.05 

7.80 

1006 

46,810 

571 

12.10 

44 

0.03 

7.70 

1000 

48,400 

585 

12.06 

53 

1.07 

6.88 

1010 

50,034 

615 

12.20 

41 

0.81 

6.66 

1011 

51,785 

626 

12.06 

46 

0.88 

7.34 

1013 

53,606 

533 

0.02 

31 

0.57 

6.81 

1013 

55,678 

400 

8.80 

53 

0.03 

10.61 

1014 

67,011 

430 

7.64 

41 

a7i 

0.40 

10,731 

11.08 

837 

0.01 

7.70 

464       PBOOEEDINQS  SECOND  PAN  AMEBICAN  SCIENTIFIC  CONGRESS. 


Aflotf  pchlaaAn,  mortoHdad  general,  tubereuloai*  pulmonar  y  propordoneSf  289&--t914 — 

Contintia. 

DBPARTAUENTO  DE  SORIANO. 


Aflos. 

Pobhh 
Gktei. 

liortali- 

dad 
CeneraL 

Propof- 

don 

media 

por  1,000 

habitan- 

tes. 

liortali- 
dadpor 
tubercu- 
losis pul> 

Ppopop- 

dOtk 

media 

por  1,000 

habitan- 

tea. 

Propor- 

media 
por  100 
defun- 

CiOIMS 

generalw. 

1806 
1806 
1807 
1808 
1800 
1000 
1001 
1002 
1008 
1004 
1005 
1006 
1007 
1006 
1000 
1010 
1011 
1012 
1013 
1014 

85,214 
36»072 
36,300 
37,451 
38,377 
38,047 
38,851 
30,861 
40,886 
41,768 
42,535 
44,487 
46,386 
30,077 
41,617 
42,758 
44,720 
46,010 
40,503 
61,413 

516 
481 
004 
483 

587 
«20 
616 
507 
603 
573 
584 
627 
638 
606 
613 
747 
641 
528 
547 
568 

14.65 
13.37 
10.07 
13.80 
13.73 
16.53 
15.85 
12.71 
14.74 
13.71 
13.72 
14.00 
13.75 
15.13 
14.72 
17.47 
14.33 
11.35 
11.02 
11.04 

40 
44 

38 
40 
41 
31 
45 
20 
46 
45 
35 
40 
57 
44 
36 
45 
48 
38 
56 
37 

1.13 
1.22 
1.04 
1.06 
1.06 

.81 
1.15 

.72 
1.12 
1.07 

.82 
1.10 
1.22 
1.10 

.86 
1.05 
1.07 

.81 
1.12 

.71 

7.75 
0.14 
6.47 
8.28 
7.77 
4.02 
7.30 
6.71 
7.62 
7.85 
6.00 
7.81 
8.03 
7.27 
6.87 
6.02 
148 
7.10 
10.28 
6.61 

11,727 

14.07 

844 

1.01 

7.10 

DBPARTAMBNTO  DE  TACUAREMBO. 

1805 

26,635 

661 

21.14 

39 

1.00 

6.16 

1806 

27,378 

688 

10.65 

10 

.00 

3.53 

1807 

27,020 

461 

16.50 

18 

.64 

3.00 

1806 

28,707 

447 

15.57 

33 

.80 

6.14 

1800 

20,608 

887 

13.07 

30 

.67 

6.16 

1000 

37,851 

470 

13.41 

15 

.30 

3.10 

1001 

38,780 

606 

13.04 

15 

.88 

3.06 

1003 

30,560 

641 

16.10 

31 

.78 

4.88 

1003 

40,412 

618 

15.30 

39 

.71 

4.60 

1004 

40,680 

803 

7.44 

13 

.30 

3.06 

1005 

42,104 

700 

16.83 

13 

.38 

1.00 

1006 

44,173 

748 

16.93 

86 

.81 

4.81 

1007 

45,580 

710 

16.77 

43 

.04 

5.06 

1008 

47,418 

664 

14.00 

34 

.50 

8.61 

1000 

48,787 

007 

14.38 

31 

.63 

4.44 

1010 

50,104 

700 

14.15 

30 

.50 

4.38 

1011 

51,506 

870 

16.80 

37 

.71 

4.36 

1012 

53,100 

750 

14.37 

30 

.54 

3.83 

1013 

55,285 

650 

11.75 

31 

.56 

4.76 

1014 

56,438 

661 

11.71 

33 

.58 

4.00 

12,118 

14.56 

517 

.63 

4.36 

DEPARTAMENTO  DE  TREINTA  Y  TRE8. 

1805 

31,732 

314 

14.44 

14 

a64 

4.45 

1806 

22,221 

250 

11.35 

7 

.31 

3.80 

1807 

22,615 

240 

10.60 

4 

.17 

1.66 

1886 

23,089 

361 

11.30 

4 

.17 

1.53 

1800 

23,567 

280 

13.36 

9 

.38 

3.11 

1900 

25,036 

336 

13.43 

7 

.37 

3.06 

1901 

25,800 

316 

8.37 

1 

.03 

.46 

1902 

26,360 

314 

11.90 

8 

.30 

3.54 

1903 

27,221 

306 

11.34 

1 

.03 

.33 

1904 

27,722 

131 

4.72 

3 

.10 

3.39 

1905 

28,495 

330 

11.80 

5 

.17 

1.47 

1906 

30,193 

438 

14.17 

16 

.49 

3.50 

1907 

31,360 

463 

14.73 

16 

.51 

3.46 

1908 

29,154 

334 

11.11 

13 

.44 

4.01 

1909 

30,318 

350 

11.84 

13 

.39 

3.34 

1910 

31,436 

407 

13.94 

17 

.54 

4.17 

1911 

32  897 

386 

11.73 

31 

.63 

5.44 

1913 

34,650 

410 

11.83 

34 

.69 

5.85 

1913 

36,284 

404 

11.13 

38 

.77 

6.93 

1914 

37,192 

380 

10.45 

35 

.67 

6.43 

6,565 

11.67 

234    i         .41 

1       3.66 

•••••••■•• 

1 

PUBUC  HEALTH  AKD  HEDICIlirE. 


465 


Ruwnen  dt  la  poMaciAn^  martalidad  general,  tubereuioiU  pulnwnar  y  proporeionee,  par 

DepartamefUoi  y  o/RMj  1896-1914- 


PoblaoMn 


MortalidMl 


Pitiponlte 


por  1,000 
hablttfitat. 


MortaUdad 


por 

tubcfODloeis 
pnlmonir, 


Pitiponlte 


por  1.000 
taabittfitot. 


Pitiponlte 


por  100 

fdnolooM 


ArtifM. 

CandoDes... 
C«rro  Largo. 
Cokmla  .... 
Dimmo.... 


Florida 

Maldooado.... 

Mlnas 

Mooterkleo.... 

PayauKKk. 

BloNogro 

RiTwa , 

Rooha 

Salto. , 

8anJo0« 

Toriano , 

Taeuarembo. . , 
TreintayTres. 


Total. 


38,000 
.88,189 
40,003 
64,843 
40,815 
17,401 
45,831 
30,047 
43,337 
801,870 
40,577 
37,007 
38,853 
33,378 
47,001 
44,051 
41,060 
41,000 
38,807 


8,784 
18,304 
10,134 
13,971 
11,831 

4,501 
10,506 

0,384 
10,787 
00,788 
11,157 

4,779 

9,374 

7,574 
14,430 
10,731 
11,737 
13,118 

0,505 


15.40 
ia83 
13.44 
1L83 
14.49 
13.00 
11.50 

lasi 

13.41 
16.06 
11.97 
&65 
10.07 
11.37 
15.03 
1L93 
14.07 
14.60 
1L57 


1,183 


807 
630 
904 

.  537 
301 
408 

11,181 


318 
404 


083 
837 
844 
517 
334 


379,334 


13.18 


31,407 


aoo 

.07 
.89 
.79 
.04 
.58 
.57 
.34 
.47 
1.85 
LOO 
.30 
.70 
.65 
.97 
.91 
LOl 
.03 
.41 


3.39 
0.49 
0.50 
Ob  06 
4.44 
4.47 
4.97 
3.19 
3.79 
1L66 
&41 
4.66 
4.36 
5.79 
6.45 
7.70 
7.19 
4.96 
3.56 


6i36 


««A  TOOTH  IS  MORE  VALUARLE  THAN  A  DIAMOND.*** 

By  FELIPE  GALLEGOS, 
Secretary  of  the  Dental  Faculty  of  Coeta  Rica. 

''In  the  lower  jaw,''  said  Sancho,  ''your  lordship  has  only  two  molars  and  a  half: 
and  above  neither  a  half  nor  a  single  one,  as  all  is  even  as  the  palm  of  the  hand.'' 
"Pity  on  me!"  said  Don  Quixote,  hearing  the  sad  news  that  his  squire  gave  him, 
"that  I  would  prefer  to  have  lost  an  arm,  excepting  the  one  with  wnich  fsway  my 
sword;  because  know  it^  Sancho,  a  mouth  without  teeth  is  as  bad  as  a  mill  without 
stone;  and  so  a  tooth  is  more  valuable  than  a  diamond." — From  the  Quixote  of 
Cervantes. 

This  lecture  on  oral  hygiene  has  been  written  so  as  to  help  all 
teachers  of  the  Costa  Rican  schools  in  their  efforts  to  promote 
hygiene  measures  of  aU  kinds .  My  aim  has  been  to  make  it  clear  to 
all  children,  avoiding  technical  names,  and  treating  in  detail  the 
more  important  questions  related  to  the  subject. 

Among  the  best  and  most  important  laurels  of  civilization  are  those  in  which 
scientific  research  finds  something  to  avoid  pain  or  to  prevent  the  diseases  that  make 
life  short  or  unbearable.  For  such  reason  civilised  countries  make  hygiene  something 
like  a  worship,  and  to  insure  efficiency  they  give  it  the  support  and  force  of  law. 

The  first  sociological  step  to  prevent  tuberculosis  and  most  infectious  diseases  ia 
oral  hygiene.  Children  have  seen  at  pubUc  places  billboards  which  say  "It  is  pro- 
hibited to  spit  on  the  floor,  since  tuberculosis  is  propagated  thereby."  You  see  now 
how  necessary  for  tiie  general  health  is  hygiene  of  the  mouth,  and  why  it  is  so  impor- 
tant that  dentists  become  apostles  of  it,  teaching  habits  of  cleanliness  to  the  rising 
generation. 

I  ConfBnDce  on  Onl  Hygtene  for  the  Sehoob  of  Costa  Rica. 


466       PBOGEEDINQS  SECOND  PAN  AMEBIOAN  SOIBNTIFIO  CONGBESS. 

The  care  of  the  teeth  is  necesBary  at  all  ages,  but  the  most  criticid  period  is  between 
the  sixth  and  fifteenth  years  of  age.  It  is  during  that  period  of  life  that  the  tem- 
porary teeth  are  shed  and  the  permanent  ones  appear,  with  the  exception  of  the  20^ 
year  molars.  In  childhood,  also,  the  teeth  are  more  prone  to  caries,  as  they  are  very 
soft.  Children  also  are  more  inclined  to  n^lect  their  teeth  in  this  growing  age. 
Many  of  them  are  also  very  poor  and  can  have  neither  good  food  nor  healthy  homes. 

The  necessity  of  having  healthy  teeth  is  evident.  To  enjoy  good  health  it  is  neces- 
sary to  digest  well  the  food  that  is  eaten,  and  that  can  not  be  accomplifihed  if  the  food 
is  not  masticated  slowly  and  strongly.  The  food  must  be  finely  groimd  and  mixed 
with  the  saliva  so  that  in  reaching  the  stomach  it  is  in  condition  of  being  immediately 
digested  and  assimilated.  We  must  bear  in  mind  the  axiom  that  says:  That  it  is  not 
the  quantity  of  food  eaten,  but  the  quantity  assimilated  that  is  of  vahie  and  gives 
strength  to  the  body. 

Parents  ought  to  see  that  their  children  acquire  the  habit  of  cleaning  their  teeth 
before  going  to  bed,  beginning  when  the  little  ones  are  3  years  old,  because  when  the 
temporary  teeth  begin  to  decay  and  give  them  pain  in  the  act  of  mastication  the 
children  acquire  the  habit  of  chewing  with  the  front  teeth  only  and  swallow  the  food 
unprepared.  The  jaws,  for  lack  of  exercise,  do  not  develop  well  and  properly  so  as 
to  accommodate  the  larger  permanent  teeth.  That  lack  of  exercise  in  mastication 
■and  the  premature  extractions  of  the  temporary  teeth  are  the  principal  cause  of  so 
many  irregularities  in  children's  mouths. 

When  3  years  of  age  the  child  has  20  pieces  in  its  mouth.  These  begin  to  change  at 
the  age  of  6.  but  before  beginning  to  change,  and  behind  the  milk  molar  teeth,  the 
first  permanent  molar  makes  its  appearance,  say  between  the  fifth  and  sixth  yeara 
of  age.  This  is  a  most  important  ^t  in  the  care  of  the  children's  teeth,  as 
unhappily  50  per  cent  of  them  lose  those  teeth  because  their  parents  confuse  them 
with  the  temporary  and  let  them  decay  beyond  recovery,  or  take  the  child  to  some 
ignorant  person  who  instead  of  saving  it  extracts  it,  causing  an  Irreparable  loss  to 
the  little  one. 

I  do  not  exaggerate  the  facts,  and  it  is  enough  to  say  that  the  first  permanent  molar 
is  the  laigest  of  all.  Its  premature  extraction  makes  the  others  appear  in  a  wrong 
place,  many  times  inclined  forward. 

There  are  few  things  so  interesting  as  the  human  dental  arch.  Only  man  has  his 
set  of  teeth  arranged  in  a  continuous  row  without  spaces  between  them,  and  articulat- 
ing perfectly  with  its  fellows  on  the  opposite  jaw.  And  it  is  that  wonderful  harmony 
that  is  broken  by  the  ignorant  who  extract  a  tooth  that  could  be  saved,  to  be  useful 
for  a  life  time. 

After  the  six-year  molars,  come  the  second  at  the  age  of  12,  and  the  wisdom  at  20; 
six  pieces  more  in  each  jaw,  making  in  all  32  pieces  in  the  mouth  of  an  adult  person. 

Children  should  observe,  in  cleaning  the  mouth,  the  following  simple  procedure : 
Immediately  after  eating  it  is  a  good  practice  to  use  (not  to  abuse)  a  quill  toothpick, 
or  floss  silk,  to  take  off  meat  fibres  and  the  like  which  may  become  pressed  between 
the  teeth.  Pins  and  matches  should  never  be  used  for  picking  the  teeth.  Matches 
sometimes  have  laige  amounts  of  poison  which  have  caused  violent  inflammations, 
many  times  with  very  serious  complications.  Select  a  good  toothbrush,  neither  too 
soft  nor  too  hard,  and  use  it  slowly,  with  a  movement  somewhat  downwards,  in  the 
upper  teeth,  and  somewhat  upward  in  the  lower  ones;  in  using  the  brush  only  hori- 
Bontally  as  it  is  generally  done,  you  can  not  clean  the  spaces  so  well,  uid  the  gums 
suffer.  Use  the  brush  on  the  inside  as  well  as  on  the  outside,  all  over  the  teeth.  It  is 
convenient  to  clean  the  teeth  after  each  meal,  but  absolutely  necessary  to  do  it  at 
night  before  retiring,  as  that  is  the  time  when  caries  progress  more.  The  child 
that  does  not  clean  his  mouth  at  that  time  will  be  alwajrs  suffering  with  bad  teeth.  If 
cold  water  is  unpleasant,  use  tepid  water  for  the  cleaning.  It  is  good  to  use  a  tooth 
powder  often,  to  avoid  stains;  the  tooth  soaps  are  not  to  be  recommended,  as  they 


PUBUO  HEALTH  AND  MEDIOIKB.  467 

make  the  brush  too  soft.  Use  what  your  dentist  recommends  for  you,  but  never 
use  dentrifices  of  unknown  formulfle,  as  they  may  contain  deleterious  substances. 
The  S.  S.  White  Dental  Manufacturing  Co.  makes  good  preparations.  I  use  to  a  great 
extent  listerine,  and  find  that  is  about  all  that  is  necessary. 

The  toothbrush  must  be  washed  well  and  made  dry  with  a  clean  towel  every  time 
it  is  used — otherwise  it  will  be  a  focus  of  infection;  then  keep  the  brush  in  a  clean 
place  where  it  can  not  be  confused  with  any  other. 

An  English  proverb  says:  '* Cleanliness  is  next  to  godliness.*'  The  breath  of  a 
young  girl  of  15,  who  has  always  taken  care  of  her  teeth,  is  sweet,  and  when  she  smiles, 
shows,  as  the  poets  say,  ''two  rows  of  pearls  in  a  ruby  case.''  But  if  it  has  been  other- 
wise; if  there  has  been  ignorance  and  neglect,  then  the  awful  caries,  working  little  by 
little,  will  be  found  making  ravages;  because  the  residues  of  food  accumulate  and 
become  decomposed,  forming  acids  which  attack  the  inoiganic  portion  of  the  teeth; 
and  then  also  millions  of  microbes  live  and  multiply,  and  attack  the  oiganic  portion 
of  the  same;  and  so  caries  multiply  and  progress,  destroying  the  enamel  first,  then 
the  dentine,  till  the  destruction  reaches  the  pulp,  or  nerve  of  the  teeth;  calcareous 
matter  forms;  the  gums  become  spongy  and  purulent;  the  breath  becomes  fetid,  and 
the  patient,  in  eating,  contaminates  his  food  with  those  microbes,  pus,  and  decom- 
posed matter;  and  then  will  soon  come  the  excruciating  pains,  the  neuralgias,  the 
stomatitis,  the  tonsilitis,  etc.,  because  a  mouth  in  such  state,  so  lamentable,  is  a 
bivorite  breeding  place  for  tuberculosis,  for  diphptheria,  and  all  infectious  diseases. 

From  what  has  been  said,  it  is  seen  clearly  that  the  parent  that  takes  due  care  of  the 
health  of  his  children  must  see  that  they  acquire  the  habit  of  cleanliness  at  an  early 
date;  and  must  also  take  them  frequently  to  the  family  dentist  to  have  their  mouth 
examined;  the  temporary  as  well  as  the  permanent  teeth,  and  not  wait  till  pain,  as  a 
protest  for  the  neglect,  obliges  the  foigetful  farther  to  take  his  boy  to  the  dental  office 
when  it  is  generally  too  late  to  save  the  aching  tooth. 

In  the  relations  between  the  client  and  the  dentist  each  receive  something:  the 
client  the  professional  services;  the  dentist  some  money.  When  the  operation  has 
been  performed  well,  it  is  the  client  who  receives  the  better  portion.  Good  dentists 
^ve  free  and  timely  advice,  which  many  times  is  worth  ten  times  the  amount  paid 
for  an  operation. 

As  a  contrast,  there  comes  to  my  mind  a  case  of  a  young  man,  20  years  old,  who 
went  to  see  a  surgeon-dentist  to  have  his  teeth  examined.  The  surgeon  found  enough 
to  be  done,  the  cost  of  which  he  put  at  a  reasonable  sum.  The  young  fellow  then  went 
to  see  a  quack,  who  for  half  price  extracted  all  his  upper  teeth  and  made  him  an  arti- 
ficial substitute.  But  the  fool  looked  very  happy,  showing  on  his  hand  a  very  valuable 
ring  with  precious  stones  as  an  adornment  of  his  body — that  same  body  that  had  been 
mutilated  by  a  false  idea  of  economy.  Oh,  if  that  young  man  with  such  a  narrow  mind 
had  been  able  to  comprehend  the  great  truth  said  in  the  immortal  phrase  of  Don 
Quixote,  ''A  tooth  is  more  valuable  than  a  diamond,"  he  would  have  saved  his  teeth 
instead  of  using  diamonds  on  his  fingers. 

The  light  of  better  times  is  beginning  to  shine,  and  the  more  cultured  nations 
have  begun  a  generous  and  eminently  altruistic  movement  by  founding  free  clinics 
to  care  for  the  teeth  of  poor  children  who  attend  the  schools.  Here  in  Costa  Rica  there 
are  many  dentists  who  want  to  begin  a  similar  movement;  and  it  is  to  be  hoped  that 
the  good  idea  will  soon  be  a  reality.  In  conclusion,  all  children  should  be  made  to 
imderstand  two  fundamental  things:  (1)  That  without  good  teeth  it  is  not  possible 
to  have  good  health,  and  for  that  reason  each  tooth  is  worth,  in  reality,  more  than  a 
diamond;  (2)  that  constant  care  and  cleanliness  of  the  mouth  is  indispensable  to  keep 
the  teeth  in  good  condition,  and  at  the  same  time  it  is  the  means  to  prevent  tubercu- 
0818  and  most  contagious  diseases. 

The  Chairman.  Dr.  Carter  will  open  the  discussion  on  the  general 
topic  of  this  session. 

6843e— IT—VOL  X 31 


468       PBOCBEDINQS  SE00191>  PAN  AMEBIOAN  SGIENTIFIO  CONQBESS. 

Dr.  Cabter.  I  have  only  a  few  remarks  to  make  on  what  Dr. 
Sagftmaga  read.  I  suppose  that  the  great  height  of  BoUvia  and  the 
high  clear  mountain  atmosphere  would  have  made  it  fairly  free  from 
tuberculosis,  but  there  are  some  factors  that  I  myself  had  not  appre- 
ciated. Among  others  is  the  large  Indian  population.  I  understood 
him  to  say  that  there  were  from  one  to  three  miUion  Indians  in  the 
country,  who,  in  the  first  place,  have  a  racial  susceptibility  to  tuber- 
culosis, although  they  are  naturally  out-of-door  people ;  that  when  they 
are  housed  they  are  very  much  crowded  together  so  that  infection 
among  them  is  very  great ;  that  they  U ve  in  a  good  deal  of  squalor,  have 
what  we  would  consider  insufficient  food,  and  it  is  among  them  that 
tuberculosis  so  greatly  extends. 

Again  he  calls  attention  to  what  we  in  North  America  and  Europe 
have  not  to  contend  with.  Our  heights  are  never  sufficient  for  maJ 
de  montafia.  The  higher  we  get,  the  better  we  Uke  it.  On  the  other 
hand,  as  I  have  said,  the  heights  in  Bolivia  are  so  great  that  he  speaks 
of  the  bad  effect  of  the  siroche  on  the  heart. 

Those  are  points  that  I  had  never  thought  of,  but  surely  are 
very  important. 

Dr.  SaoIbnaoa.  Dr.  Solano  says  in  his  paper  that  the  Indians  in 
BoUvia,  rather  contrary  to  the  native  Indians  in  North  America, 
are  not  susceptible  to  tuberculosis.  He  says  he  does  not  find  any 
cases  among  the  Indians,  and  that  the  ones  to  contract  tuberculosis 
are  the  middle-class  alcoholics.  He  has  seen  Indians  working  as 
high  as  15,000  feet  in  the  mines,  and  among  them  there  are  no  cases  of 
tuberculosis,  notwithstanding  the  fact  that  their  food  is  very  poor, 
as  they  eat  practically  nothing  but  cocoa  leaves. 

The  Chairman.  I  may  say  that  my  own  experience  with  the  Amer- 
ican Indian  15  or  20  years  ago  showed  me  that  they  were  singularly 
free  from  tuberculosis  until  they  were  actually  put  into  habitations 
unfit  for  human  beings.  At  the  time  I  knew  them  in  their  native 
state  in  the  States  of  Nevada,  Oregon,  and  Idaho,  and  in  northern  CaU- 
fomia,  occupying  their  native  tepees  with  copious  and  ample  ventila- 
tion, I  never  saw  a  case  of  tuberculosis  among  those  North  American 
Indians.  That  is  based  on  an  experience  of  several  trips  I  made  to 
that  country.  I  knew  of  no  cases  of  tuberculosis  among  them  imtil 
the  housing  movement  was  begun  and  they  were  encouraged  to 
bmld  houses.  On  account  of  necessary  economy  the  houses  were 
small,  about  12  by  15  feet,  with  two  or  three  small  windows  perhaps 
and  a  door,  and  a  whole  family  congregated  in  these  little  holes,  with 
deficient  ventilation  and  deficient  sunhght.  There  was  a  development 
of  tuberculosis  coincident  with  this  change  in  their  mode  of  housing. 
I  do  not  know  of  any  other  factor  that  predisposes  one  to  the  same 
extent  to  that  condition,  because  we  know  that  bad  housing  condi- 
tions favor  the  development  of  tuberculosis  and  other  so-called 


PUBUO  HEALTH  AND  MEDICINE.  469 

house  diseases.  It  is  notorious,  as  the  old  Germans  used  to  point 
out,  that  where  the  sun  does  not  enter  the  house  the  doctor  surely 
will.  They  appreciate  the  importance  of  sanitary  homes  for  good 
health,  and  haye  pointed  out  some  of  the  factors  that  are  inimical 
to  health,  particularly  dampness  and  darkness  and  gloomy  houses, 
all  fayoring  the  predisposition  to  tuberculosis.  We  can  understand 
very  readily  why  a  dark  house  and  a  damp  house  would  tend  to 
prolong  the  life  of  a  tubercular  bacillus  which  in  a  healtliful  house 
would  sooner  or  later  be  destroyed  by  nature's  agents. 

Dr.  Solano  spoke  in  Spanish,  which  was  interpreted  as  follows: 

Dr.  Solano  says  that  he  has  been  studying  tuberculosis  for  the 
last  10  years.  He  first  read  a  thesis  which  was  well  received  by  the 
Medical  Academy  of  Bogota,  in  Colombia,  where  he  studied.  He 
went  into  the  matter  as  thoroughly  as  possible;  he  studied  all  the 
statistics  that  he  could  get  hold  of  and  studied  the  subject  from  all 
points  of  view.  He  made  studies  in  the  Polytechnic  Hospital; 
there  was  an  epidemic  of  dysentery  at  the  time,  and  all  these  patients 
suffering  from  dysentery  were  ti^n  to  this  hospital.  They  would 
get  well  from  the  dysentery  but  would  unfailingly  take  tuberculosis, 
which  showed  that  there  was  contagion  taking  place.  There  were 
some  cases  of  tuberculosis  there,  and  these  patients  weakened  from 
dysentery  would  quickly  take  tuberculosis.  He  says  he  finds  that 
the  tubercular  bacilli  are  extremely  weak,  but  that  they  always  will 
attack  and  will  cause  disease  in  an  organism  that  is  weakened. 

He  says  that  tuberculosis  is  due  at  present  to  the  present  condition 
of  civilization;  that  is  why  he  thinks  it  can  be  combatted  if  these 
conditions  are  modified  and  proper  measures  taken  against  it. 

The  Chairman.  I  may  state  that  our  progress  in  the  combat 
against  tuberculosis  in  the  United  States  since  1880  has  been  very 
gratifying  indeed.  The  death  rate  from  the  disease  has  been  re- 
duced from  about  326  per  100,000  in  1880  to  147.6  in  1913,  which 
means  that  if  the  former  rate  of  mortality  had  been  continued  the 
number  of  deaths  from  this  disease  last  year  would  have  been  322,000 
instead  of  143,000.  This  is  equivalent  to  a  saving  of  179,000  lives 
during  1913  from  this  disease  alone. 

This  is  largely  due,  I  think,  to  improved  personal  sanitation,  and 
our  campaign  in  the  future  must  undoubtedly  continue  along  those 
lines,  apart  from  the  specific  measures  which  are  necessary  and 
essential  for  the  destruction  of  the  germs  wherever  we  encoimter 
them  and  for  the  protection  of  the  people.  Our  chief  aim  must  be  to 
build  up  the  power  of  resistance  of  the  individual  to  the  disease. 
The  germs  are  most  ubiquitous.  The  opportunities  for  contracting 
the  disease  are  so  general  that  it  is  a  question  of  a  battle  between  the 
microbal  invader  and  the  tissue  itself. 


470       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIPIO  C0NQBE88. 

Therefore  our  combat  should  begin  with  infancy  and  childhood, 
practically  even  with  the  prenatal  care  of  the  child,  so  that  it  may 
be  endowed  by  nature  with  a  stronger  resisting  power.  The  hygiene 
and  the  general  care  of  the  child  in  the  home  is  of  the  utmost  im- 
portance. Next  to  that,  the  hygiene  of  the  child  in  the  school,  its 
physical  development  by  agency  of  playgroimds — they  are  all  im- 
portant. 

Naturally,  then,  the  questions  of  habitation  and  food  are  essential. 
Anything  that  wiU  tend  to  develop  a  strong  vigorous  nation  wiH 
naturally  be  of  the  greatest  benefit  in  our  campaign,  not  only  against 
tuberculosis,  but  against  numerous  other  infectious  diseases.  The 
question  of  pure  lives,  the  question  of  temperance,  the  question  of 
freedom  from  vice  diseases,  are  all  important.  The  matter  of  factory 
sanitation  in  after  life  is  of  the  utmost  importance,  because  we  know 
that  the  people  who  are  exposed  to  the  dust  of  factories  are  50  per 
cent  more  predisposed  to  tuberculosis  than  those  not  so  exposed. 

So  all  our  efforts  hereafter  must  be  along  the  lines  of  personal 
and  pubhc  hygiene,  and  I  am  very  glad  that  our  Pan  American  col- 
leagues apparently  emphasize  that  same  line  of  campaign  in  their 
own  country. 

Personally  I  wish  to  thank  the  representatives  from  the  Latin- 
American  countries  for  taking  a  deep  interest  in  one  of  the  very 
serious  and  grave  but  decidedly  hopeful  problems,  because  I  believe 
that  if  all  our  knowledge  is  intelligently  applied,  and  faithfully  exe- 
cuted the  disease  will  be  actually  eradicated  between  the  next  15 
and  60  years. 

Dr.  Cabteb.  I  think  we  should  tell  Dr.  Solano  tiiat  a  condition 
such  as  he  describes  at  Bogota  would  not  be  possible  in  the  United 
States;  that  practically  no  hospital  treating  general  cases  treats 
cases  of  tuberculosis;  that  s^ch  cases  are  always  treated  either  in 
special  hospitals  or  in  general  hospitals  in  wards  isolated  from  the 
other  patiente.  How  much  risk  there  is  in  mixing  them  may  be  a 
question,  but  at  least  that  risk  is  not  taken  in  the  United  States; 
open  cases  of  tuberculosis  are  not  treated  in  wards  where  other 
patients  are  received. 

The  Chaibman.  Dr.  Solano's  experience  was  very  much  our  own 
in  years  gone  by  in  America.  Many  years  ago  patients  who  recov- 
ered from  measles  or  whooping  cough  or  typhoid  fever  or  dysentery, 
it  was  foimd,  were  peculiarly  susceptible  to  tuberculosis.  No  doubt 
many  of  those  cases  contracted  the  infection  in  their  weakened  state, 
possibly  by  contact  with  the  disease.  We  know  that  when  people 
are  as  much  as  3  feet  from  each  other  in  a  hospital  the  infectionn 
play  an  important  rdle  in  the  transmission  of  the  disease.  These 
contact  infections  were  pointed  out  10  years  ago  by  Dr.  Edsall,  of  the 
University  of  Pennsylvania.    He  made  a  strong  plea  for  what  he 


PUBLIC  HEALTH  AND  MEDICINE.  471 

called  medical  hygiene  in  our  ward  cases,  and  all  these  things  are 
being  appreciated  and  are  now  being  avoided. 

I  will  just  add  one  more  sentence.  It  is,  of  coiu'se,  quite  possible 
that  in  many  of  the  cases  where  these  infections  develop  the  weak- 
ened system  has  simply  permitted  some  latent  infection  to  develop. 
It  does  not  follow  always  that  a  recent  infection  has  taken  place, 
but  the  reduced  power  of  resistance  permits  the  developing  of  latent 
infections,  infections  that  may  have  been  contracted  years  and  years 
before. 

Dr.  Solano  made  some  further  remarks  in  Spanish,  which  were 
translated  as  follows  : 

Dr.  Solano  says  that  he  has  studied  different  kinds  of  tuberculosis, 
especially  in  Panama  among  the  poorer  classes  of  the  people.  The 
suburban  towns  are  populated  almost  altogether  by  these  poorer 
people.  These  houses  where  they  live  seem  to  be  infected  with 
tuberculosis.  He  says  he  has  often  observed  many  obvious  cases  of 
gastroenteritis  to  become  tubercular  on  subsidence  of  the  antecedent 
attack  of  gastroenteritis. 

The  Chaikman.  If  there  is  no  further  discussion  the  meeting  will 
stand  adjourned.  All  resolutions  will  go  to  the  committee  on  resolu- 
tions as  a  matter  of  course.  If  there  is  no  further  business  the  ses- 
sion will  adjourn. 

Adjournment. 


JOINT  SESSION  OF  SUBSECTION  E  OF  SECTION  Vm  AND  THE 
AMERICAN  ASSOCUTION  FOR  CANCER  RESEARCH. 

New  Ebbitt  Hotel, 
Thursday  morning,  January  6,  1916. 

Chairman,  Leo  Lobb. 

The  session  was  called  to  order  at  9  o'clock  by  the  chairman  of  the 
section. 

Papers  presented: 

Cancer  Problems  in  Special  Biological  Groups — 
Plant  tumors — Further  evidence  that  crown  gall  of  plants  is 

cancer,  by  Erwin  F.  Smith. 
Fish  timiors — ^Further  observations  on  so-called  carcinoma  of 
the  thyroid,  by  Harvey  R.  Gaylord. 
Tissue  cultures  in  cancer.     Papers  by  Robert  A.  Lambert  and 
Montrose  T.  Burrows. 
A  mechanistic  theory  of  cancer,  by  G.  H.  A.  Clowes. 
Radium  in  experimental  cancer,  by  Francis  Carter  Wood. 
Radium  in  the  treatment  of  cancer,  by  William  Duane. 
Pathological  aspects  of  some  problems  of  experimental  cancer 
research,  by  James  Ewing. 

Sero-diagnostic  methods  in  cancer — ^Reactions  of  Freimd  and  of 
V.  Dungom,  by  A.  F.  Coca. 
Teratoma  de  la  regi6n  del  tuber  cinereum,  by  Guillermo  A.  Bosco. 

The  Chaibman.  The  first  paper  is  on  'Tlant  tumors,"  by  Dr. 
E.  F.  Smith. 

FURTHER  EVIDENCE  THAT  CROWN  GALL  OF  PLANTS  IS  CANCER. 

By  ERWIN  F.  SMITH, 

Laboratory  of  Plant  Pathology y  United  Stain  Department  of  Agriculture. 

Tumors  without  visible  cause  are  the  subject  of  this  address.  They  have  been 
studied  most  numerously  in  man,  but  they  occur  also  in  the  domestic  animals,  in  wild 
animals  (mammals,  birds,  batrachians,  fish)  and  now,  as  we  know,  in  plants.  If  this 
paper  were  given  a  full  descriptive  title  it  would  read  as  follows:  Further  evidence 
that  crown  gall  is  cancer,  and  that  cancer  in  plants  because  of  its  variable  form  and 
its  bacterial  origin  offers  strong  presumptive  evidence  both  of  the  parasitic  origin 
and  of  the  essential  unity  of  the  various  forms  of  cancer  occurring  in  man  and  animalB. 
This  is  the  text  I  shall  talk  to,  and  in  passing  I  may  add  it  is  a  view  entirely  opposed 
to  the  current  views  of  cancer  specialists. 

To  make  plain  what  I  have  to  say  about  plant  tumors  of  this  type  it  will  be  neces- 
sary briefly  to  mention  similar  animal  tumors.    This  I  shaU  do  without  special  refer- 

472 


PUBLIC  HEALTH  AND  MEDIOINB.  478 

ence  to  medicine,  i.  e.,  simply  from  the  standpoint  of  a  biologist,  but  first  I  shall 
show  you  the  gross  appearance  of  a  few  animal  cancers. 

These  tumors  without  visible  cause  are  very  common  in  man.  They  have  been 
observed  in  every  organ  and  in  every  tissue  of  every  organ.  They  have  been  studied 
diligently  by  human  pathologists,  and  especially  by  morphologists,  for  many  yean 
and  there  is  now  a  great  volume  of  literature  respecting  their  structure  and  course  of 
development,  but  very  little  is  known  as  to  their  cause,'  and  nothing  as  to  the  occur* 
rence  in  them  of  any  causal  organism. 

Clinically  and  morphologically  they  are  divided  into  two  well-marked  groups— the 
benign  tumors  and  the  malignant  tumors.  All  of  these  tumors,  whether  benign  or 
malignant,  are  abnormal  overgrowths  (cellular  proliferations)  of  the  normal  tissues  ci 
the  body.  Every  organ  and  every  tissue  in  which  a  benign  tumor  has  been  observed 
may  also  become  the  seat  of  a  malignant  tumor.  Moreover,  benign  tumors  sometimes 
behave  like  or  become  converted  into  malignant  tumors.  Often,  in  early  stages  of 
growth,  it  can  not  be  foretold  whether  a  given  tumor  wiU  continue  benign  or  become 
malignant.  Benign  tumors  are,  therefore,  always  to  be  considered  as  a  possible  source 
of  danger,  and  their  interrelaticms,  il  any,  with  cancers  can  not  be  known  until  their 
causes  are  known. 

As  a  rule,  benign  tumors  grow  slowly,  although  often  eventually  they  reach  a  very 
large  size,  exceptionally  weighing  nuure  than  the  rest  of  the  body.  The  cells  com- 
posing them  approximate  in  form,  and  in  sise  (that  is,  in  maturity),  the  cells  of  the 
normal  tissues.  Owing  apparently  to  their  slow  growth,  there  is  also  a  body  reaction 
in  the  form  of  an  enveloping  capsule,  which  shuts  off  the  tumor  from  the  surrounding 
tissues.  These  tumors  are  called  ''benign*'  because  while  they  often  cause  great 
inconvenience  and  sometimes  death,  they  are  restricted,  usually,  to  the  locality 
where  they  first  appear.  That  is,  they  do  not  develop  destructive  daughter  tumors 
in  other  i>arts  of  the  body. 

On  the  contrary,  the  cancers,  or  malignant  tumors,  with  a  few  exceptions,  produce 
daughter  tumors  freely  (often  in  vital  organs),  grow  rapidly,  are  destitute  of  a  restrain- 
ing capsule — i.  e.,  become  invasive,  and  are  composed  of  cells,  which,  while  showing 
all  grades  of  transition  are  often  much  smaUer  and  more  embryonic  in  their  appear- 
ance than  cells  of  the  tissue  from  which  they  have  originated,  and  are  then  most 
malignant.  These  immature  cells  are  readily  distinguished,  however,  from  normal 
embryonic  cells  both  by  their  disturbed  polarity  and  by  their  reaction  to  stains.  In 
other  words,  they  are  not  genuine  embryonic  tissue,  because  they  do  not  possess 
either  the  fuU  structure  or  the  entire  capability  of  embryonic  tissue.  These  cance 
cells  proliferate  freely,  sometimes  with  astonishing  rapidity,  invade  and  destroy 
normal  tissues,  and  in  various  ways  act  like  a  foreign  organism,  that  is,  they  behave  in 
the  manner  of  a  parasite,  although  they  are  a  part  of  the  body. 

Without  including  all  of  the  forms  known,  or  going  into  a  swamping  multiplicity  ci 
details,  I  may  say  that  the  cancers,  or  malignant  tumors,  may  be  subdivided  into 
four  principal  groups:  (1)  The  sarcomas,  which  are  malignant  fleshy  proliferations  of 
the  various  types  of  connective  tissue;  (2)  the  cancers  proper,  or  carcinomas  (including 
the  epitheliomas)  which  are  destructive  (eroding)  proliferaticms  of  the  epithelium  of 
the  skin,  mucous  membrane,  and  glandular  tissues  generally;  (3)  the  so-called  mixed 
tumors  containing  proliferating  elements  from  two  germ  layers,  e.  g.,  the  chondro- 
sarcomas composed  of  proliferating  cartilage  and  connective  tissue,  the  adeno-sarcomaa 
composed  of  glandular  tissue  and  connective  tissue,  etc.;  and,  (4)  the  embryonal 
teratomas  which,  in  addition  to  the  cancerous  element  that  is  often  a  sarcoma,  contain 
teratoid  elements  representing  all  three  germ  layers — ^young  tissues  of  various  organs, 

1  Dass  das  Dimkel  auf  diesem  Oebiete  noch  nicht  erhellt,  des  RJUsels  Lfisoiig  noch  nicfat  gefanden,  das 
lelgt  did  noch  stetig  Eunchmende  Fehde  der  Streiter  auf  diesem  Felde.  Hie  embryonaler  Keim,  bio  par- 
aaitftrer  Urspnmg,  hie  lletaplasie,  hie  Anaplasie.  hie  Anarchie,  so  Isoten  die  Schlagvorte  der  Antoren 
Wibns). 


474       PBOCEEDIKQS  SEOOKD  PAN  AMEBIOAN   SCIEKTIFIC  CONGBESS. 

frequently  an  astonishing  mixture  of  teratoid  elements,  but  all  embryonic.  These 
are  also  known  as  atypical  teratoids  in  distincticm  from  monsters,  which  are  prenatal 
malformations,  and  from  typical  (ripe  or  adult)  teratoids  which  also  are  not  cancers, 
but  growths  due  to  prenatal  disturbances,  the  commonest  form  of  which  is  the  ovarian 
dermoid.  By  Wilms  they  are  called  solid  embryomas  or  embryoid  tumors  in  dis- 
tinction from  the  typical  teratoids,  which  he  calls  cystic  embryomas  or  simply 
embryomas. 

The  atypical  teratoids  grow  rapidly,  metastasize  freely  and  are  commonest  in  the 
early  decades  of  life.  In  the  typical  teratoids  the  fetal  fragments  have  grown  with 
the  growth  of  the  host.  Although  dwarfed,  they  are  as  old  as  the  individual  out  d 
which  they  have  come,  i.  e.,  they  contain  old  skin,  old  teeth,  old  bones,  long  hair, 
etc.  In  the  atypical  teratoids  the  fetal  fragments  are  always  very  embryonic  and 
probably  are  never  more  than  a  few  months  old,  or  a  few  years  old,  no  matter  how  old 
the  person  from  whom  they  have  been  removed,  i.  e.,  growth  goes  on  in  them  inde- 
pendently of  the  host.  Moreover,  these  atypical  teratoids  always  contain  cancerous 
elements.    It  is  this  latter  type  of  tumor  that  I  have  recently  produced  in  plants. 

In  the  benign  tumors,  to  return  to  animals,  the  tissues  are  arranged  in  a  nearly 
or  quite  normal  fashion  and  the  cells  are  full  grown,  only  much  more  abundant  than 
they  should  be.  In  the  malignant  tumors  the  tissues  are  not  only  more  embryonic, 
but  are  arranged  atypically,  the  cells  having  lost  a  part  or  the  whole  of  their  polarity, 
i.  e.,  their  orderly  arrangement.  Frequently  they  also  show  defective  mitosis,  and 
very  frequently  polynuclear  cells  (the  so-called  ''giant  cells")  appear,  owing  to 
fission  and  fragmentation  of  the  nucleus  without  any  corresponding  cell  division. 
Lobed  and  cleft  nuclei  are  very  common  in  cancers.  They  are  also  common  in  crown 
gall. 

Cancers  in  addition  to  the  malignant  cells  contain  a  stroma  or  framework  of  con- 
nective tissue  and  a  system  of  blood  vessels  and  lymph  channels  by  means  of  which 
they  are  nourished,  but  the  blood  flow  in  these  vessels  is  not  controlled  by  any  vaso- 
motor nervous  system.  OrdinarUy  cancers  do  not  contain  any  nerves,  the  associated 
pain  being  due  to  pressure  on  outside  nerves. 

All  of  these  tumors  are  imperfectly  provided  with  blood  vessels  and  are  subject  to 
early  decay,  the  resulting  cavities,  or  open  wounds,  being  exposed  to  various  harmful 
secondary  infections.  In  early  stages  of  growth  these  tumors  are  purely  local  and  may 
be  removed  surgically  with  good  prospect  that  they  will  not  return.  In  late  stages 
these  tumors  exert  a  markedly  detrimental  effect  on  the  whole  body,  which  is  visible 
as  atrophy,  anemia,  and  cancerous  cachexia,  and  surgical  interference  is  then  of  little 
or  no  avail. 

The  daughter  tumora  are  produced  frcm  the  mother  tumor  in  several  ways,  i.  e.,  by 
contact  of  a  diseased  area  with  a  healthy  area,  as  for  example,  by  tongue  against  lipsi 
or  cheek  against  jaw;  by  invadye  growth,  i.  e.,  tumor  strands  out  of  which  the  secon* 
dary  tumors  develop  as  in  cancer  of  the  breast;  by  motile  (creeping)  tumor  cells;  or 
finally,  by  cells  or  fragments  dislodged  by  the  blood  stream  or  the  lymph  stream  and 
carried  to  distant  parts,  where  they  multiply.  The  carcinomas  usually  invade  by 
way  of  the  lymphatics;  the  sarcomas  and  the  embryomas,  by  way  of  the  blood  yessels. 
When  a  tumor  strand  can  be  traced  from  the  daughter  tumors  back  to  the  mother 
tumor  they  are  called  invasive  growths;  when  no  such  connecting  link  is  visible  they 
are  called  metatsatic  (or  shifting)  growths.  Some  modem  writers,  however,  use  the 
word  metastasis  for  a  daughter  tumor  of  any  origin. 

As  I  have  said,  nothing  is  known  respecting  the  cause  of  these  human  tumors  and 
the  great  majority  of  cancer  workers  have  come  to  the  conclusion  (which  I  believe  is 
erroneous)  that  they  can  not  be  due  to  parasites. 

It  is  well  here  to  pass  in  review  some  of  the  objections  to  a  parasitic  theory  of  cancer: 
(1)  Because  many  authors  of  distinguished  reputation  (Bibbert,  for  example)  main- 
tain that  they  are  insuperable;  (2)  because  so  long  as  they  are  not  met  various  persons 


PUBUC   HEALTH  AND  MEDIGINE.  475 

will  be  discouraged  from  undertaking  active  researches  designed  to  uncover  the 
parasite;  and  (3)  because,  finally,  if  I  can  convince  you  that  crown  gall  is  a  cancer, 
3rou  will  then  be  ready  to  admit  that  what  requires  a  schizomycete  for  its  production 
in  the  plant  is  not  likely  to  be  produced  in  any  very  different  way  in  man  and  animals. 
Here  then  are  some  of  the  objections,  and  I  will  meet  them  as  isirly  as  I  can. 

1.  Nothing  definite  in  the  way  of  a  parasite  has  been  made  out  by  use  of  the  micro- 
scope. Answer:  This  is  admitted,  but  it  proves  nothing.  If  we  exclude  the  N^;ri 
bodies,  still  in  dispute,  the  same  is  true  for  rabies.  And  in  cancer  we  have  the  Plim- 
mer  bodies  and  other  cell  inclusions  of  a  doubtful  nature,  some  of  which  may  be 
bacterial  or  protozoan.  The  etiology  of  crown  gall  would  still  be  in  doubt  if  we  had 
depended  solely  on  the  microscope,  for  no  ordinary  staining  will  demonstrate  a  bac- 
terium in  the  cells,  and  yet  it  is  there.  For  the  final  analysis  recourse  must  be  had  to 
cultures  and  inoculations.  There  are  then  some  problems  in  pathology  which  never 
can  be  solved  simply  by  the  use  of  the  microscope. 

2.  From  cancer  no  parasite  has  been  isolated  in  spite  of  diligent  bacteriological 
search.  Innumerable  cultures  have  been  made  and  many  inoculations  and  all  have 
failed.  Answer:  The  same  is  true  of  yellow  fever.  No  parasite  has  been  found. 
Until  recently  the  same  was  true  of  syphilis.  Ten  years  ago  it  was  true  of  crown  gall. 
There  may  be  some  very  special  reason  (as  in  crown  gall,  or  in  certain  types  of  arthritis) 
why  isolations  have  failed;  or  the  right  organism  may  have  been  isolated  and  inocu- 
lations may  have  failed  simply  because  the  inoculated  animals  were  normal,  i.  e., 
fully  protected  by  their  leucocytes  and  therfore  not  susceptible.  We  must,  I  think, 
conceive  of  cancer  as  developing  only  in  a  weakened,  unprotected  condition  of  the 
body.  The  more  or  less  ready  growth  of  grafted  cancer  in  certain  animals  offers  no 
real  conlradiction  because  here  the  conditions  are  somewhat  different  from  what  they 
would  be  in  case  of  a  naked  bacterial  inoculation,  because  the  grafted  cancer  cells  are 
autochthonous  cells  and  are  introduced  into  the  mouse  or  other  experimental  animal 
in  a  considerable  compact  mass,  the  inner  cells  shielded  by  the  outer  ones  and  all 
developing  a  kind  of  protective  aura  under  the  influence  of  which  union  with  the  host 
tissues  takes  place  and  the  cancerous  growth  continues. 

8.  H^edity  is  a  sufficient  explanation.  Answer:  The  same  thing  was  said  repeat- 
edly of  tuberculosis  prior  to  1884.  Now  we  see  that  heredity  furnished  the  canvas 
but  could  not  paint  the  picture.  Miss  Maude  Slye's  work  on  heredity  of  cancer  in 
mice  is  astonishing  and  praiseworthy,  but  I  do  not  feel  sure  that  a  similar  picture 
could  not  be  obtained  by  breeding  together  tuberculous  animals,  indeed  I  am  quite 
certain  that  the  results  of  such  experiments  would  be  a  vastly  increased  number  of 
tubercular  animals,  and  if  we  knew  no  more  about  the  cause  of  tuberculosis  than  we 
do  about  the  cause  of  cancer,  the  interpretation  of  the  results  would  be  entirely  wrong, 
i.  e.,  they  would  be  ascribed  wholly  to  heredity,  whereas  we  know  that  two  factors 
are  involved:  (1)  H^edity,  (2)  infection.  I  do  not  think  Miss  Slye  has  established 
the  fact  that  cancer  follows  Mendel 's  law. 

4.  There  is  no  need  to  postulate  any  parasite,  since  the  cancer  cell  itself  is  the  all- 
sufficient  parasite  ancl  no  cancers  can  be  produced  in  the  absence  of  this  cell .  Answer : 
It  is  strange  that  the  authors  of  this  statement,  which  has  been  dinned  into  us  for  a 
generation,  can  not  see  that  it  is  no  answer  at  all,  but  only  a  makeshift.  As  well  say: 
Tetanus  is  due  to  tetanin.  Certainly,  we  all  admit  this,  but  what  originates  the 
tetanin?  and  what  originates  the  cancer  cell?  Moreover,  loath  as  these  objectors  are 
to  admit  it,  cancers  (sarcomas)  in  barnyard  fowls  can  now  be  induced  by  cancerous 
material  all  the  cells  of  which  have  been  removed  by  filtration,  or  have  been  killed 
by  heat,  by  freezing,  or  by  drying  (Rous).  And  how  should  anemias  and  cachexias 
arise  as  the  simple  result  of  the  proliferation  of  body  cells?  In  other  diseases  they  are 
the  direct  result  of  bacterial  or  protozoan  multiplication  in  the  body.  In  this  con- 
nection reflect  for  a  moment  on  what  goes  on  in  streptococcal  arthritis,  in  persistent 
agues,  or  in  yellow  fever  and  in  blackwater  fever  where  the  red  blood  corpuscles  are 


476       PBOCEEDINGS  SECOND  PAN  AMEBICAN  SCIENTIFIC  CONOBESS. 

destroyed  wholesale.  Even  pernicioiis  anemia  will,  I  believe,  be  traced  eventually 
to  a  blood-destroying  parasite.  All  that  we  yet  know  definitely  concerning  the  natural 
occurrence  of  anemias  (I  am  purposely  excluding  surgical  ones)  is  that  in  certain 
diseases  they  are  due  to  blood-destroying  parasites,  and  it  is  not  going  very  far  afi^d 
to  assume  that  anemia  is  so  produced  in  cancer. 

5.  The  idea  of  a  parasite  is  too  complex.  We  know  that  we  can  graft  cancer  only 
within  the  narrowest  limits,  and  also  that  within  the  same  species  each  scurt  of  cancer 
reproduces  its  own  kind.  We  must  therefore  postulate  not  only  as  many  different 
cancer  parasites  as  there  are  animals  subject  to  cancer,  and  that  is  probably  every 
kind  of  animal,  but  also  a  parasite  for  every  special  kind  of  cancer  in  each  particular 
animal  which  is  a  reductio  ad  absurdum.  Answer:  This  is  a  molehill  magnified 
into  a  mountain — an  unsubstantiated  and  unwarranted  hypotheaisi  The  history  of 
science  is  fuU  of  such  objections.  Against  the  plainest  evidence  it  is  always  easy  for 
certain  types  of  mind  to  raise  objections,  which  then  generally  are  left  to  some  <me 
else  laboriously  to  test  out  experimentally,  whereupon  they  vanish  into  thin  air,  the 
objections  not  having  been  well  grounded.  Some  people  are  good  only  as  objectoni 
They  can  not  do  anything  concrete.  It  is  less  than  20  years  since  certain  theoretical 
Germans  were  saying:  '*  There  are  no  bacterial  diseases  of  plants  and  can  not  be  any, 
for  the  reasons  we  have  given."  Yet  the  experimental  method  has  demonstrated  tht 
existence  of  nearly  a  hundred.  In  science,  no  theory  is  worth  a  picayune  that  does 
not  have  an  experimental  basis  under  it.  There  have  been  at  least  30  so-called 
explanations  of  cancer  origin  propounded  during  the  last  half  century,  not  one  of 
which  really  explains  or  has  any  experimental  basis  under  it.  Cohnheim  *s  theory  la 
one  of  these:  Bibbert's  is  another. 

From  the  behavior  of  the  cells  of  one  species  when  grafted  on  another  species  we 
can  postulate  nothing  as  to  what  a  naked  microofganism  would  do  under  the  same 
circumstances.  As  a  matter  of  fact,  plants  also  can  not  be  grafted  widely,  y^  the 
crown-gall  oiganism  is  widely  inoculable.  Moreover,  it  yields  one  result  when  inoca- 
lated  into  one  set  of  tissues  and  a  different  result  when  inoculated  into  another  set  of 
tissues.  In  malignant  neoplasms  in  man,  and  the  lower  animals,  why  then  may  we 
not  assume  for  experimental  purposes  an  intracellular  parasite  capable  of  producing 
sarcoma  when  infecting  connective  tissue  cells  and  other  types  of  tumor  when  infect- 
ing other  tissues — each  tissue  presumptively  developing  according  to  its  own  type? 
Theoretically  I  can  see  no  objection  to  this  view,  and  actually  we  have  this  very  tiling 
occurring  in  crown  gall. 

6.  Parasites  destroy  cells.  They  do  not  cause  them  to  prolifwate,  and  callng  can- 
cer a  cell  symbiosis  does  not  help  matters.  Answer:  The  world  progresses  and  new 
knowledge  modifies  or  supplants  the  old.  Menetrier,  of  Paris,  witiiout  knowing  any- 
thing about  our  experimental  work  on  crown  gall,  and  being  very  sceptical  as  to  the 
parasitic  origin  of  canc«r,  saw  clearly  in  1908  (and  so  stated  in  his  book)  that  there 
was  no  objection  theoretically  to  assuming  that  in  cancer  there  might  be  a  parasite 
which  did  not  destroy  cells,  but  continually  stimulated  them  to  divide,  only  he  said: 
What  is  the  use  of  speculating,  since  nobody  has  shown  any  concrete  example?  This 
may  have  been  true  of  that  time,  but  it  is  no  longer  true,  since  there  is  just  such  a 
cell  parasite,  or  cell  symbiont,  in  crown  gall. 

7.  In  cancer,  portions  of  the  body  grow  in -places  where  they  should  not,  having 
come  to  the  place  by  growth-extension  from  the  primary  tumor  cm:  having  been  trans- 
ported there  by  a  blood  stream  or  a  lymph  stream.  Nothing  like  this  occurs  in  any 
parasitic  disease.  Answer:  Formwly  this  statement  c(»responded  to  our  knowledge 
but  now  it  does  not,  because  just  this  thing  occurs  in  the  parasitic  plant  disease  of 
which  I  am  speaking,  viz,  invasion  or  growth-extension  from  a  primary  tumor  resulting 
in  the  occurrence  of  sec(mdary  tumors  in  what  previously  were  normal  parts  of  the 
plant. 


PUBUC   HEALTH  AND  MEDICINE.  477 

8.  Direct  stimulaUon  of  cell  growth  by  a  parasite  is  an  unknown  occurrence  in 
biology.  In  all  caaee  in  which  parasites  are  found  within  cells  the  effect  is  the  destruc- 
tion either  of  the  parasite  or  of  the  cell.  Answer:  Antiquated  information.  True  of 
many  things  but  not  of  all.  Theoretically  a  third  possibility  exists,  and  actually  we 
have  it  in  crown  gall.  Here  the  parasitized  cells  are  not  destroyed,  neither  are  all  of 
the  bacteria  within  them  killed,  but  only  meet  of  them.  There  is  a  very  delicate  bal- 
ance between  the  two,  which  results  not  in  death  of  the  host  cells,  but  in  an  increased 
tendency  to  cell-division,  a  tendency  strong  enough  to  overcome  the  physiological 
control  of  the  plant.  When  death  results  it  is  not  due  to  the  direct  action  of  the  bac- 
teria, but  to  other  factor^,  e.  g.,  nutritional  defects,  and  secondary  parasitisms. 

9.  Since  cell  proliferation  in  tumors  is  similar  to  cell  proliferation  under  normal 
conditions,  the  assumption  of  a  parasite  to  explain  it  is  qiiite  unnecessary,  and  makes 
an  explanation  of  tum<Nr-growth  more  difficult.  Answer:  Similar  is  not  necessarily 
the  same.  Conclusions  drawn  from  cultures  in  vitro  do  not  necessarily  apply  to 
growth  within  the  body.  Cell  proliferation  of  tumor  dssues  in  the  body  is  similar,  of 
course,  to  normal  cell  proliferation,  but  with  a  difference,  namely,  in  the  tumor  there 
is  an  unknown  something,  which  compels  these  cells  to  proliferate  in  opposition  to 
the  needs  of  the  body  and  in  spite  of  the  physiological  body  control.  Surely  some- 
thing very  foreign  to  the  body  is  required  to  explain  the  undifferentiation,  anaplasia 
we  call  it,  following  von  Hansemann,  and  the  excessive  vegetative  force  of  the  cancer 
cells.  Moreover,  so  far  as  it  is  able  to  do  so,  the  body  treats  individual  cancer  cells,  or 
groups  of  cancer  cells  (metastatic  fragments)  exactly  like  parasites,  that  is,  it  envelops 
them  in  a  blood  clot  and  destroys  them.  In  cancer,  therefore,  considering  what 
takes  place  in  crown  gall,  I  think  we  are  warranted  in  searching  for  an  intracellular 
parasite,  probably  some  common  oiganism,  as  the  unknown  factor,  necessary  to 
satisfy  the  equation  and  explain  the  phenomena.  Moreover,  I  fail  to  see  how  the 
assumption  of  a  parasite  makes  the  explanation  of  tumor  growth  ''more  difficult." 
These  objectors  are  here  dealing  with  one  of  their  many  assumptions  while  I  am  deal- 
ing with  a  fact.  I  insert  my  infected  needle  and  I  obtain  a  tumor.  I  insert  a  sterile 
needle  and  the  wound  heals  normally.  Into  one  branch  of  a  young  Paris  daisy  I 
set  my  infected  needle  50  times  and  obtained  50  tumors;  at  the  same  time  into  the 
twin  branch  I  set  a  sterile  needle  50  times  and  obtained  no  tumors  whatsoever,  but  only 
a  normal  healing  of  the  wounds.  Cell  proliferation  per  se  in  no  way  explains  cancer. 
Normal  cells,  also,  judging  from  the  way  they  behave  in  blood  serum  under  the  micro- 
scope, must  often  proliferate  into  the  plasma  of  the  body,  but  such  wandering  cells 
are  promptly  disposed  of  in  accordance  with  the  law  of  antagonism  or  of  physiological 
control,  or  whatever  you  please  to  call  it.  I  mean  the  action  of  the  body  as  a  whole. 
Otherwise,  we  should  have  occurring  continually  in  the  body  what  takes  place  when 
normal  tissues  are  cultivated  in  vitro,  that  is,  a  copious  cell  proliferation,  which  would 
be  disastrous.  This  we  do  have  in  cancer,  but  since  cancer  develops  in  opposition 
to  all  the  compelling  forces  of  the  animal  body  it  must  be  owing  to  a  profound  dis- 
turbance of  the  normal  (interior)  activities  of  the  cells  involved.  What  is  so  likely 
as  a  microorganism  to  produce  this  cell  disturbance  leading  to  the  formation  of  a 
tumor?    Especially  what,  since  in  the  plant  we  know  that  one  does  produce  just  that? 

10.  Cancers  are  due  to  long-continued  inflammatory  conditions.  They  begin  in 
bruises,  in  old  (unhealed)  wounds,  X-ray  bums,  charcoal  stove  bums  (Kangri  cancer), 
and  various  irritations  and  injuries  incident  to  special  trades  (chimney  sweeps '  cancer, 
paraffin  workers'  cancer,  etc.).  Answer:  The  second  statement  is  admitted.  They 
begin  in  all  of  these  places.  The  first  statement  is  a  non  sequitur,  a  post  hoc  eigo 
propter  hoc  argument.  Wounds  are  often  infected  with  visible  parasites,  why  not 
sometimes  with  invisible  ones?  Not  all  irritations  end  in  cancers.  Of  two  long-con- 
tinued irritations  one  may  become  malignant  and  the  other  not.  This  is  wholly 
inexplicable  on  the  theory  of  simple  irritation,  but  readily  interpreted  if  we  assume 
that  cancer  is  due  to  a  special  and  unusual  kind  of  parasite,  certain  long-continued 


478       PBOOEEDINGS  SBOONB  PAK  AMEBIGAN  SCIENTIFIC  OOKaBESS. 

irritations  having  paved  the  way  for  a  peculiar  infection  by  having  reduced  the  reflist- 
ance  of  the  body. 

11.  SurgeonB,  nurses,  and  relatives  do  not  contract  cancer.    It  therefore  does  nat 
behave  like  a  communicable  disease.    Answer:  Neither  does  malarial  fever;  neither 
does  arthritis;  neither  does  leprosy;  and,  finally,  neither  does  crown  gall.    We  must 
recognize  that  in  nature  there  are  aU  grades  of  parasitism  and  must  be  prepared  to 
welcome  forms  not  hitherto  recognized.    In  pathology,  as  everywhere  else,  the  open 
mind  is  after  all  the  beet  asset.    Closed  and  crystallized  minds  are  of  no  further  use  in 
the  world.    Certainly  cancer  is  not  an  acute  infection,  and  no  one  regards  it  as  such. 
It  may  be  due,  however,  to  a  parasite,  visible  or  invisible  as  the  case  may  be,  some 
feeble  parasite  against  which  the  normal  body  is  fully  protected,  some  common  organ- 
ism, living  saprophytically  on  the  body,  or  in  the  soil,  able  only  to  infect  a  depleted 
body,  and  destructive  only  when  through  wotmds  (very  slight  ones,  it  may  be)  it  has 
penetrated  into  the  interior  of  certain  ceUs,  which  neither  kill  it  nor  are  killed  by  it, 
but  where  it  depresses  functional  activity  while  at  the  same  time  enormously  stimu- 
lating vegetative  activity.    In  the  present  state  of  our  knowledge  no  one  can  say  that 
this  is  an  untenable  working  hypothesis.    Indeed  the  probabilities  in  favor  of  such  a 
view  are  much  stronger  to-day  than  they  were  five  years  ago,  when  I  first  discovered 
the  cancerous  nature  of  crown  gall  and  began  to  formulate  my  ideas. 

12.  We  might,  possibly,  concede  sarcomas  to  be  due  to  a  parasite,  but  not  carcino- 
mas, and  certainly  not  embryomas,  yet  whoever  proposes  a  parasitic  theory  of  cancer 
must  not  only  demonstrate  his  parasite  but  with  it  must  account  for  all  of  these  diverse 
forms,  and  especially  for  embryomas,  since  they  are  the  crux  of  the  whole  situation.* 
Answer:  This  is  admitted.  All  of  these  forms  hang  together,  and  the  claim  is  now 
made  that  embryonal  teratomas  and  gland  proliferations  can  be  induced  with  the  same 
Bchlzomycete  previously  used  to  produce  sarcomas.  As  a  negation  it  is  of  no  conse- 
quence whatever  to  say  that  I  have  only  produced  them  in  plants,  because,  little  aa 
it  is  yet  recognized,  plants  are  better  adapted  than  animals  to  certain  piurposee  of 
cancer  research.  In  due  time  and  in  the  same  way,  let  no  one  doubt,  they  will  also 
be  produced  in  animals.  Whatever  else  may  be  denied,  the  bold  fact  now  stands 
out  demonstrably  that  all  the  leading  types  of  cancerous  proliferation  can  be  pro- 
duced in  plants  with  one  microorganism.  If  anyone  doubts  it,  let  him  repeat  my 
experiments. 

13.  But  this  hypothesis  of  the  origin  of  cancers,  and  especially  of  embryonal  tera- 
tomas ujjsets  Cohnheim's  theory  of  "cell  rests.**  Answer:  It  does,  beyond  doubt, 
very  completely.  But  there  is  no  use  of  making  a  fetish  of  Cohnheim*8  theory.  It 
is,  after  all,  only  a  theory.  It  seemed  once  to  furnish  the  basis  for  an  explanation 
of  cancer  origin,  but  no  one  was  ever  able  to  build  a  superstructure  on  it,  for  no  one  can 
explain  why  some  "cell  rests"  grow  into  cancers  while  others,  and  by  far  the  larger 
number,  remain  dormant.  We  shall  simply  have  to  write  Hie  jacet  over  Cx)hnheim'8 
theory.  It  serves  well  enough  for  monsters  and  for  typical  teratoids,  but  it  does  not 
explain  cancers. 

14.  Plants  are  so  unlike  animals  that  no  comparison  can  be  drawn  from  diseases  of 
the  one  group  to  those  of  the  other  group.  Answer:  On  the  contrary,  fundamentally 
plants  and  animals  are  verj-  much  alike.  I  mean  the  resemblances  are  much  more 
basic  than  the  differences.  The  latter,  very  conspicuous  to  the  eye,  may  be  regarded 
as  differences  of  degree  rather  than  of  kind,  corresponding  to  differences  in  function. 
Such  an  objection  could  never  be  raised  by  a  biologist.  It  shows  perhaps  better  than 
any  other  argument  how  great  is  the  need  of  injecting  biological  concepts  into  cancer 
research.    The  cancer  problem  would  have  been  settled  long  ago,  I  believe,  had  it 

1  Oerade  in  diesem  Punkt  scheint  mJr  die  tnteressanteste  and  wlobtigste  Besiehung  der  Teratomen  la 
den  anderen  OescbwIUsten  zu  liegen,  dass  wir  in  den  Teratomen  eine  Gruppe  von  Produkten  vor  uns 
haben,  in  welcher  sich  die  Hauptfragen  dor  Oeschwulstlehro  wie  in  cinen  Bronnpunkt  vereinigen 
(Borst). 


PUBLIO  HEALTH  AND  MEDIOIKE.  479 

been  approached  commonly  from  this  angle  rather  than  &om  that  of  pure  morphology. 
Of  many  of  the  lower  forms  of  Ufe  it  is  still  very  difficult  to  say  whether  they  are 
plants  or  animals,  of  the  whole  group  of  bacteria,  for  example;  and  for  the  primitive, 
doubtful  forms  of  life  you  will  recall  that  Haeckel  created  the  special  kingdom  of 
Protista.  To  my  mind  a  fundamental  unity  runs  through  all  living  things  from  the 
lowest  to  the  hi^est,  like  the  gold  thread  through  a  tapestry.  For  one  thing,  all 
are  alive;  all  possessed  of  that  unstable  equilibriimi  of  forces  expressed  by  the  words 
growth  and  decay.  These  phenomena  are  the  properties  of  a  substance  called  pro- 
toplasm. In  both  plants  and  animals  this  substance  is  oiganized  into  the  form  of 
cells.  In  both,  usually,  it  is  the  outer  protoplasmic  membrane  that  controls  the 
passage  of  ions,  the  disassociated  electrically  charged  elements  of  water  and  other 
compounds.  The  same  wonderful  process  of  cell  multiplication  by  mitosis  occurs 
in  both  plants  and  animals.  In  both,  except  in  the  lowest  forms,  these  cells  are  organ- 
ized into  tissues  with  division  of  labor.  In  both  there  is  a  sexual  method  of  repro- 
duction. Plants,  indeed,  propagate  also  nonsexually  by  budding,  but  so  do  many 
of  the  lower  animals.  In  many  plants  there  is  regeneration  when  parts  are  cut  away, 
but  so  there  is  in  a  great  variety  of  animals.  Even  their  foods  are  not  different.  It 
is  true  the  plant  differs  decidedly  from  the  animal  in  possessing  an  apparatus  for 
elaborating  inorganic  substances  into  starch,  sugar,  and  proteids  which  the  animal 
consumes,  but  it  makes  these  substances  for  its  own  use.  not  for  the  animal.  It  is 
sometimes  assumed  that  the  inojganic  substances  of  earth,  air,  and  water  are  the 
food  of  the  plant,  but  such  is  not  the  case.  The  plant  depends  for  its  growth  on  the 
same  nutrient  substances  as  the  herbivorous  animals,  viz.,  on  starch,  sugar,  and  pro- 
teids, which  it  has  stored  in  every  seed  and  tmder  every  growing  bud .  The  phenomena 
of  birth,  growth,  and  decay  are  essentially  the  same  in  plants  and  in  animals;  but 
corresponding  to  higher  development  the  animal  has  many  special  oigans  either 
wanting  altogether  in  the  plant  or  greatly  simplified;  it  also  has  flexible  cell  walls 
while  the  plant  has  rigid  cell  walls;  but  both  plants  and  animals  respire;  both  assimi- 
late food  substances  and  oxidize  them  with  resultant  work;  both  require  about  the 
same  amount  of  water  and  mineral  salts;  both  have  a  circulation  of  fluids;  and  both 
secrete  and  excrete  a  variety  of  substances,  acid,  alkaline,  and  neutral.  The  response 
to  stimuli,  such  as  gravity,  heat,  lig^t,  radium,  X-ray,  electricity,  and  poisons,  is 
much  the  same  in  both  groups.  In  irritable  response  plants  and  animals  both  obey 
Weber's  law  (called  also  Fechner 's  law  and  the  psycho-physic  law),  that  is,  to  increase 
a  response  in  an  arithmetical  ratio  the  stimulus  must  be  applied  in  a  geometrical 
ratio.  There  is  a  suggestion  even  of  a  nervous  system  in  plants  since  stimuli  are 
passed  along  certain  channels  to  distant  organs  and  the  movement  can  be  slowed 
down  by  cold,  increased  by  heat,  or  inhibited  by  poisons  applied  midway,  the  response, 
according  to  Bose,  being  not  simply  hydromechanical.  Even  the  idea  of  locomotion 
does  not  distinguish  animals  &om  plants.  Many  of  the  lower  animals  are  rooted 
btsty  while  many  of  the  lower  plants  have  swimming  organs  and  are  actively  motile. 
Moreover,  all  of  the  higher  plants  change  position  more  or  less;  all  are  sensitive; 
all  show  rhythmic  movements.  Finally,  the  intimate  cell  chemistry  of  the  two 
gn)ui>s  (production  of  digestive  enzymes,  amino  acids,  etc.),  so  far  as  known,  is  much 
alike.  There  is  no  a  priori  reason,  therefore,  why  a  special  stimulus  to  cell  division 
in  plants  might  not  prove  to  be  of  the  highest  interest  to  students  of  cancer  in  man 
and  the  lower  animals.  It  is  a  matter  to  be  taken  up  like  any  other  and  tested  out; 
Researches  on  crown  gall  should  have  been  undertaken  long  ago  in  every  cancer 
laboratory  in  the  world  and  would  have  been  had  we  not  unfortunately  discovered 
a  parasite.  That  kiUed  the  whole  subject  in  the  eyes  of  the  orthodox.  Not  having 
found  a  parasite  themselves,  they  will  not  believe  that  anyone  else  can  do  it  or  that 
there  is  one;  and  this  in  spite  of  the  fact  that  the  history  of  parasitic  diseases  from 
Pasteur's  time  down  shows  clearly  enough  that  the  folly  of  one  generation  has  been 
the  wisdom  of  the  next. 


480       PBOCEEDINGS  SECOND  PAN  AMEBICAN  8CIENTEPIC  C0NGBE88. 

Von  HanBemann  has  said  *  that  crown  gall  has  nothing  in  ccmimon  with  cancer 
except  its  name  (Ejebs).  I  am  quite  willing  to  let  specialists  weigh  my  evidence 
and  decide  for  themselves,  if  only  they  will  wake  up  and  begin  to  do  so;  not  simply 
ignore  the  whole  subject  because  it  comes  to  them  from  an  unusual  quarter  and  is 
''too  botanical, "  as  another  German  editor  said  in  refusing  one  of  my  pax>erB. 

In  his  ''Principles  of  pathology''  ^  Dr.  Adami  gives  the  following  as  the  character- 
istics of  the  atypical  (malignant)  tumors:  (1)  Vegetative  (embryonic)  character  of  the 
tumor  cells;  (2)  rapidity  of  growth;  (3)  pesipheral  extenedon,  lack  of  capsule  snd 
infiltration  of  the  surrounding  tissues;  (4)  tendency  to  develop  metastases;  (5)  tendency 
to  central  degenerative  changes;  (6)  liability  to  recurrence  after  removal;  (7)  cachexia; 
(8)  anemia.  All  of  these  occur  in  crown  gall  except  (4)  and  (8).  There  is  nothing  in 
the  plant  corresponding  to  blood,  and  the  rigid  cell- wall  of  the  plant  prevents  metaa- 
tasis  in  the  true  sense  of  that  word.  But  if  we  use  the  word  metastasis  in  Ribbert's 
loose  way,  then  metawtasis  also  occurs  in  crown  gall. 

One  of  the  striking  things  about  cancer  and  one  separating  it  off  sharply  from  all 
other  animal  diseases,  is  the  fact  that  the  secondary  tumors  are  not  granulomatous  pro- 
liferations. That  is,  the  secondary  tumors  are  not  a  growth  response  of  local  tissues 
to  an  irritation,  and  hence  are  not  comparable  to  the  protective  granulations  formed 
in  the  healing  of  a  wound  or  in  such  a  disease  as  tuberculosis,  but  they  are  due  to  the 
migration  from  the  initial  tumor  either  of  infected  cells  or  of  deteriorated  cells  which 
continually  reproduce  their  own  kind  to  the  detriment  of  all  others.  The  cancer  cell 
is  a  lawless  entity,  different  in  its  tendencies  and  capabihties  from  any  other  cell  of 
the  body,  and  so  far  as  we  know,  it  al^^^ays  reproduces  its  kind,  the  daughter  ceUs 
being  cancer  cells  and  not  normal  cells.  Wliy  this  is  so  is  wholly  imknown  in  human 
and  animal  pathology,  but  that  it  is  so  admits  of  no  doubt  whatever.  To  illustrate: 
If  medical  men  were  able  to  reach  into  the  center  of  tubercle  nodules  or  syphilitic 
nodules  in  the  human  body,  and  kill  the  nest  of  pathogenic  bacteria  in  the  one  case 
and  of  pathogenic  ]Hotozoa  in  the  other  case,  without  injuring  the  unparasitiaed 
barrier  cells  forming  the  periphery  of  these  nodules,  then  these  cells  would  be  immedi- 
ately destroyed  and  removed  from  the  body  as  no  longer  of  use,  or  else  would  behave 
once  more  as  normal  body  cells  (scar  tissue).  In  cancer,  on  the  contrary,  as  every 
surgeon  knows,  if  any  cancer  cells  are  left  after  an  operation — even  the  least  number — 
they  are  likely  to  reproduce  their  evil  kind,  in  which  case  another  tumor  results  either 
in  the  old  locality  or  in  some  other  part  of  the  body.  In  other  words,  the  outermost 
cancer  cells  are  not  barricades  erected  by  the  body  to  prevent  further  encroachments 
of  the  enemy,  but  are  self-multiplying  outposts  of  the  enemy  himself.  However,  this 
does  not  militate  against  the  belief  that  some  of  the  elements  in  a  malignant  tuimn' 
aie  harmless  ones,  nor  that  the  body  often  reacts  against  the  tumor  as  a  whole  by 
the  formation  of  fibrous  tissue,  and  in  other  ways. 

Very  few  laymen,  I  believe,  have  any  clear  conception  of  the  exact  mechanism  of 
the  cancerous  process,  and  not  a  few  physicians  also  seem  to  be  ignorant  of  it.  Can- 
cers are  the  result  of  the  multiplication  in  the  body  of  certain  body  cells  which  have 
become  abnormal  and  dangerous  to  the  rest  of  the  body,  or  as  we  say  ''cancerous,"  a 
single  cell  or  a  few  cells  to  begin  with,  then  many.  \Miether  infected  or  only  degen- 
erate, these  cells  retain  their  hereditary  tendencies,  that  is,  liver  cells  to  reproduce 
Uver;  brain  cells,  brain;  connective  tissue  cells,  connective  tissue;  and  so  on;  but  all 
of  them  while  deriving  nourishment  from  the  body  have  become  more  or  less  emanci- 
pated from  body  control  and  exercise  their  freedom  by  an  unlimited  and  hasty  multi- 
plication very  destructive  to  the  other  tissues  of  the  body.  They  reproduce  their 
kind  first  in  the  primary  tumor  and  later  in  secondary  tumors.  I  can  make  this 
plainer  perhaps  by  another  illustration.  Following  tuberculosis  of  the  lungs  there 
sometimes  occurs  blood  infection  and  a  generalized  tuberculosis  of  every  oigan  in  the 
body,  but  in  such  cases  the  nodules  wherever  they  arise  are  due  to  local  bacterial 

1  Z«it80hrift  fOr  Krebsfondnmg,  me  Bd.,  1013,  p.  146.  •  Vol.  L,  p.  671. 


PUBUC  HEALTH  AND  MEDICINE.  481 

irritation,  and  are  always  built  up  out  of  local  tiasuee,  liver  tissue  in  the  liver,  spleen 
tissue  in  the  spleen,  and  so  on.  In  cancer,  on  the  contrary,  it  is  the  cancer  cell  which 
migrates  with  all  its  hereditary  tendencies  and  the  secondary  tumor,  therefore,  repro- 
duces more  or  less  perfectly  (or  imperfectly)  the  hereditary  cell  complex  of  the 
primary  tumor,  so  that  the  trained  pathologist  after  studying  sections  of  a  cancer 
can  usually  (but  not  always)  decide  whether  it  is  primary  in  the  organ  under  ezam^ 
inatioD,  or  secondary;  and  if  secondary,  then  in  what  other  organ  the  primary  tumor 
is  to  be  sought.  For  example,  if  a  primary  cancer  occurs  in  the  liver  and  there  are 
metastases  to  the  lungs  the  lung  tumors  will  contain  liver  cells;  so  if  a  primary  caiicer 
occurs  in  the  stomach  and  there  is  metastasis  to  the  liver,  the  liver  tumor  will  not  be 
formed  out  of  liver  cells  but  out  of  stomach  cells.  It  is  a  very  striking  thing  to  see 
under  the  microscope,  particularly  in  a  well-stained  section,  a  nest  of  malignant 
glandular  stomach  cells  in  the  midst  of  a  piece  of  liver.  I  do  not  know  that  it  has 
been  actually  proved,  but  undoubtedly  such  a  liver  tumor  must  have  the  power  of 
secreting  pepsin  or  at  least  of  mucin,  just  as  we  know  that  metastases  from  a  primary 
Uver  tumor  into  other  oigans  may  retain  the  power  of  secreting  bile. 

I  have  now  come  to  another  way  in  which  these  plant  tumore  res^nble  cancer 
in  man  and  the  lower  animals,  viz.  In  the  striking ftM^t  that  as  in  anlnuls  the  sec<mdary 
tumors  reproduce  the  structure  of  the  primary  tumor.  Thus  when  a  primary  tumor 
is  induced  on  a  daisy  stem  by  inoculation,  deep-seated  sacondary  tumors,  developed 
from  parenchymatic  tumor-strands,  often  arise  in  the  leaves,  and  these  tum<Hns  convert 
the  unilateral  leaf  or  some  portion  of  it  into  the  concentric  closed  structure  of  a  stem. 
(Slides  shown.) 

Having  now  reviewed  my  older  discoveries,'  I  come  to  details  of  mote  recent  ones 
also  bearing  directly,  I  believe,  on  the  etiology  of  cancer. 

I  have  referred  to  the  rapid  growth  and  eariy  decay  of  cancers  in  men  and  to  the 
common  occturence  of  atrophy  and  cachexia  in  connection  with  such  tumors.  Similar 
phenomena  occur  in  the  plant.  I  show  you  three  slides  from  photographs  of  galled 
sugar  beets.  They  were  grown  in  different  yean  (1907,  1913,  and  1916),  but  each 
showed  the  same  thing,  viz,  sound  control  plants  and  dwarfed,  sickly  (yellow),  and 
dying  inoculated  plants.  Each  inoculated  plant  bore  a  tumor  larger  than  itself 
and  the  time  from  inoculation  to  date  of  the  photograph  varied  from  2^  to  4(  months. 
This  year  I  have  obtained  the  same  results  on  ornamental  (white  flowered)  tobacco. 
At  the  end  of  five  months  all  of  these  inoculated  tobaccos  are  dead  or  dying  from 
large  tumon  of  the  crown,  whereas  the  c<mtrol  plants  are  healthy,  many  times  larger, 
and  now  in  blossom.  To  get  such  prompt,  disastrous  results,  the  inoculati<m  must  be 
fairly  early  in  the  life  of  the  plant  and  near  the  growing  point. 

Secondary  infections  due  to  other  organisms  are  also  as  common  and  as  disastrous 
in  crown  gall  as  in  cancer  in  man.  Just  now  in  the  hothouses  we  have  striking  ex- 
amples of  it  on  the  Paris  daisy,  and  I  will  show  you  a  few  slides.  (Slides.)  These 
secondary  Infections  may  be  either  fungous  ot  bacterial. 

Third,  let  me  show  you  some  examples  of  infiltration,  taken  from  sunflower  heads 
Inoculated  last  year.  The  first  three  slides  show  hard  greenish-gray  vascular  tumon 
which  have  developed  from  a  few  needle  pricks  made  into  the  extremely  vascular 
thin  layer  which  bears  the  seeds.  The  one  shown  in  vertical  section  is  from  the 
middle  of  the  flower  disk,  and  it  has  grown  downward  in  the  white  pith  f<H*  a  distance 
id  4  inches.  It  lies  in  the  pith  but  has  not  developed  out  of  pith.  The  fourth  slide 
from  another  tumor  shows  cancerous  cells  and  vessels  of  the  supporting  stnma  pushing 
out  into  the  sound  tissues  much  as  roots  do  into  a  fertile  soil.  The  fifth  slide  is  from 
the  cortical  pert  of  a  teratoma  on  Pelargonium.  Here  the  small-celled  blastomous 
tissue  has  crowded  in  between  coarse  cells  of  the  cortex. 

>  See  8ei0Dee  N.  8.,  VoL  zxxv,  p.  ISl. 


482       PEOCEEDINGS  SECOND  PAN   AMEBICAN   SCIENTIFIC  CONGRESS. 

Next  to  be  considered  are  examples  of  atypical  blastomous  tissue  taken  from  different 
parts  of  the  same  tumor  (a  yoimg  deep  inoculation  into  the  st^n  of  a  Paris  daisy). 
In  the  first  slide,  at  the  left,  is  a  part  of  the  supporting  stroma  (cortex  cells);  the  right 
side  shows  round  cells  of  the  same  type  that  have  become  cancerous,  i.  e.,  much, 
smaller,  more  embryonic,  rapidly  proliferating,  large  nucleate  and  deep-staining  ceils 
which  have  lost  their  polarity.  The  second  slide  shows  spindle-shaped  blastomous 
cells  from  the  outer  part  of  the  same  tumor.  This  tumor  b  the  ordinary  rough  gaU  of 
the  daisy  stem,  which  is  a  sarcoma  as  near  the  plant  can  make  one,  that  is,  a  sarcoma 
minus  the  intercellular  fibrils  which  are  wanting  in  plants. 

Now  let  us  consider  how  plastic  the  living  tissues  can  be  when  they  are  brought 
under  a  cancer  stimulus.  I  show  you  photomicrographs  of  tumors  (atypical  hyper- 
plasias) produced  by  inoculating  tlie  crown-gall  organism  into  the  extreme  outer  bark 
(living  cortex)  of  young  stems  of  Paris  daisy,  the  inoculated  cells  being  ordinary  c(»tex 
cells.  These  tumor  cells  which  conceal  the  bacteria  (there  are  none  in  the  intercel- 
lular spaces)  have  become  more  embryonic  than  the  tissue  out  of  which  they  have 
grown.  This  is  shown  by  their  size  (one-twentieth  that  of  the  ceUs  from  whidi  they 
have  developed),  their  large  nuclei,  and  their  avidity  for  stains,  as  well  as  by  the 
peculiar  way  in  which  they  fix  the  stains.  It  is  also  shown  by  the  fact  that  they  can 
produce  vessels  in  their  midst  (trachese),  whereas  the  iminjured  cortex  never  produces 
vessels.  The  embryonic  tissues  of  the  plant,  however,  have  this  vessal-producing 
power.  In  a  word,  these  tumor  cells  have  become  more  embryonic  than  the  tissue 
out  of  which  they  have  developed  and  have  lost  their  polarity,  and  this  is  exactly 
what  occiirs  in  cancer  in  man,  as  I  shall  show  you.  I  have  produced  these  super- 
ficial fine-celled  hyperplasias  out  of  coarse-celled  cortex,  not  once  but  a  number  of 
times,  and  in  sevend  different  kinds  of  plants. 

Thus  far  I  have  spoken  only  of  one  type  of  tumor,  the  common  crown  gall.  Until 
this  winter  (if  we  except  ludry  root)  I  did  not  know  of  the  existence  of  other  types. 
Now  I  believe  from  what  I  have  seen  that  all  the  leading  tyx>es  of  cancer,  viz,  (1) 
sarcoma,  (2)  carcinoma,  (3)  mixed  tumors,  and  (4)  embryomas,  occur  in  plants,  and 
that  all  are  due  to  one  and  the  same  organism.  I  certainly  have  abundant  material 
of  the  end  terms  (Nos.  1  and  4),  and  enough  of  2  and  3  to  convince  myself,  if  not  others. 

The  ''further  evidence"  alluded  to  in  the  title  of  this  paper  relates  more  especially 
to  the  embryomas  and  consists  of  the  discovery  of  an  entirely  new  type  of  plant 
tumor  due  to  the  crown-gall  organism,  in  which  tumor  there  are  not  only  (ordinary 
cancerous  cells  of  the  common  crown-gall  type,  but  also  entire  young  shoots  or  jumbled 
and  fused  fragments  of  leafy  shoots  and  of  other  young  organs,  thus  making  the  tumor 
correspond  to  the  highest  type  of  animal  cancer,  in  which  in  addition  to  the  blasto- 
mous element  there  are  fragments  of  vxurious  fetal  tissues,  sometimes  representing 
many  organs  of  the  body.  This  is,  I  believe,  the  first  time  this  type  of  tumor  has  been 
produced  experimentally,  and  it  has  been  done  with  the  bacterial  organism  cultured 
from  an  ordinary  rough  crown  gall  of  the  simpler,  well-known  type.  It  was  first  done 
by  inoculating  the  leaf  axils  of  growing  plants,  i.  e.,  the  vicinity  of  dormant  buds, 
in  other  words,  centers  containing  totipotent  ceUs.  Some  of  these  strange  tumon 
have  produced  daughter  tumors  in  other  parts  of  the  stem  and  in  leaves  and,  as  in  the 
embryonal  teratomata  in  man,  a  portion  of  these  secondary  tumors  have  the  full 
structure  of  the  primary  tumor. 

I  have  also  produced  these  teratoid  tumors  in  parts  of  plants  where  no  totipotent 
ceUs  are  known  to  exist,  but  only  young  plastic  cells  normal  to  the  parts  and  hitherto 
supposed  to  be  able  to  produce  only  one  kind  of  organ.  This  will  be  plainer  if  I  say 
that  by  needle  pricks  introducing  the  bacteria  locally  I  can  now  produce  atypical 
teratoid  tumors  in  intemodee  and  in  the  middle  of  leaves,  an  astcmishing  discovery, 
and  one  bound,  I  believe,  to  revolutionize  our  views  as  to  the  origin  of  these  tumors 
in  man.  I  do  not  here  deny  that  totipotent  cells,  hitherto  unsuspected,  occur  in  the 
places  I  have  inoculated;  indeed  they  must  so  occur,  but  I  only  cast  doubt  on  their 
abnormal  occurrence  in  such  places,  i.  e.,  as  the  result  of  early  embryonic  dislocations. 


PUBLIC  HEALTH  AND  MEDICINE.  483 

The  belief  that  I  have  also  produced  ''mixed  tumors/'  that  Is,  tumors  containing 
distinct  types  of  tumor  cells  originating  from  different  layers  of  the  plant,  rests  on 
stained  sections  of  tumors  from  several  different  kinds  of  plants.  The  evidence  here 
is  not  as  complete  as  in  the  case  of  the  embryonal  teratoma,  and  I  am  still  experiment- 
ing. What  I  think  I  have  in  one  part  of  the  tumor  is  sarcoma  originating  from  the 
deeper  connective  tissue  layers  and  in  another  part  of  the  tumor  carcinoma  derived 
from  the  skin  and  glands  of  the  plant.  However  thb  may  be,  it  is  now  beyond  question 
that  two  very  distinct  types  of  plant  tumor  (sarcoma  and  embryonal  teratoma)  corre- 
sponding to  similar  types  is  man,  as  nearly  as  plant  tissues  are  able,  can  now  be  pro- 
duced by  bacterial  inoculations,  using  the  same  organism.  To  get  one  type  of  tumor 
I  inoculate  one  set  of  tissues,  and  to  get  the  other  type,  another  set  of  tissues. 

Coming  to  the  details  of  my  newer  studies,  I  shall  first  take  up  the  question  of 
the  possible  existence  of  carcinoma  in  plants,  the  slides  I  shall  show  you  being  from 
photomicrographs  of  what  I  consider  to  be  ''mixed  tumors.''  All  are  due  to  pure- 
culture  inoculations,  but  they  show  a  diverse  internal  structure  suggestive  of  a  mix- 
ture of  epithelioma  (skin  cancer)  and  sarcoma  (connective  tissue  cancer).  There 
is  still,  perhaps,  some  doubt  as  to  the  interpretation  of  these  facts,  so  that  I  speak 
only  with  reserve  and  subject  to  revisions  due  to  further  experimentation. 

The  first  slide  I  show  you  is  from  a  teratoma  on  the  common  Pelargonium  or  house 
geranium,  but  in  this  connection  I  invite  your  attention  only  to  a  small  portion  of 
its  surface  (teratoid  part)  where  strange  phenomena  are  in  progress,  quite  like  what 
often  occurs  in  the  epithelium  of  human  teratoids.  Here  is  a  compact,  small,  surface 
tumor  showing  subepidermal  erosion,  an  effort  on  the  part  of  the  plant  to  protect 
itself.  Its  deeper  tissues  fuse  into  those  of  the  epidermis  in  such  a  way  as  to  suggest 
that  they  have  originated  from  the  latter — i.  o.,  there  are  no  epidermal  and  sub- 
epidermal differences,  although  these  differences  are  conspicuous  in  the  normal  plant 
and  also  in  other  parts  of  the  teratoma.  In  this  late  stage  of  development  it  is  im- 
possible to  tell  what  may  have  been  the  origin  of  these  queer  tumors,  but  what  appear 
to  be  much  earlier  stages  of  the  tumor  are  visible  in  several  places,  especially  on  their 
margins,  and  these  places  exhibit,  or  seem  to  exhibit,  all  stages  of  transition  between 
the  normal  one-layered  faint-staining  columnar  epidermis  (equivalent  to  an  epithe- 
lium), and  a  several-layered,  large  nucleate,  loosely  arranged,  deep-staining  tissue, 
the  cells  of  which  are  roimded  or  angular  and  have  lost  their  polarity;  that  is,  their 
orderly  relation  to  their  fellows.  Now,  this  is  exactly  what  takes  place  in  early 
ftages  of  carcinoma.  For  instance,  below  the  one-layered  epithelium  in  glandular 
tissues  of  breast,  of  stomach,  etc.,  irregularly  placed,  large-nucleate,  deep-staining, 
rapidly  proliferating  cells  make  their  appearance  as  shown  on  the  next  slide,  which 
is  from  a  cancer  of  the  lung.  This  kind  of  proliferation  is  rec(^;nized  as  the  begin- 
ning of  a  malignant  tumor,  and  surgeons  base  their  operations  on  its  presence  or 
absence.  If,  in  the  breast,  let  us  say,  this  displacement  of  cells  is  present,  then  the 
surgeon  does  a  major  operation,  but  if  it  is  not  present,  then  he  is  content  with  having 
removed  only  the  local  nodule.  These  surface  tumors  on  the  geranium  were  acci- 
dental discoveries,  but  I  have  now  begun  a  systematic  inoculation  of  the  skins  of 
plants  to  see  what  I  can  get. 

I  have  what  I  believe  to  be  the  same  phenomenon  (a  mixed  tumor)  on  tobacco. 
This  tumor  I  produced  out  of  young  cortex  in  1907,  but  it  has  been  properly  stained 
and  critically  studied  only  recently.  Its  outer  part  consists  of  blastomous  cells 
quite  different  in  shape  and  staining  capacity  from  the  cells  of  its  inner  part.  The 
outer  cells  are  more  or  less  compact  and  angular  and  the  protoplasmic  contents  stains 
uniformly.  The  inner  cells  are  round,  more  loosely  arranged,  and  stain  like  the 
ordinary  sarcoma  cells  of  this  tumor.  In  connection  with  the  last  slide  I  would  also 
call  special  attention  to  the  evidence  it  shows  of  the  appositional  transformation  of 
normal  cells  into  cancer  cells  (atypical  blastomous  cells).    I  refer  to  the  band  of 

6843ft— 17— VOL  X 82 


484       PEOCEEDINGS  SECOND  PAN   AMERICAN   SCIENTIFIC  CONGRESS. 

tissue  lying  between  the  normal  cortex  on  the  right  (out  of  which  the  tumor  has 
developed),  and  the  fine-celled  hyperplasia  on  the  left.  These  10  or  12  rows  of  cells, 
bordering  the  tumor,  have  the  same  arrangement  as  the  tumor  cells  and  stain  deeply- 
like  those  of  the  tumor,  but  are  several  times  as  large.  Occasionally  an  unchanged 
cortex  cell  is  buried  in  their  midst.  They  are,  I  believe,  a  transition  from  the  normal 
tissue  into  cancerous  tissue.^  The  same  phenomenon  has  been  seen  in  human  cancers 
by  several  good  observers  and  there  can  be  no  doubt  as  to  its  occurrence. 

Finally,  from  shallow  bacterial  inoculations  done  on  the  glands  of  Ricinus  last 
winter  I  have  also  obtained  what  appears  to  me  to  be  satisfactory  evidence  of  gland- 
ular proliferations — ^i.  e.,  rapid  multiplication  of  the  surface  layer  of  cells  with  loss 
of  form  and  polarity  and  entrance  into  the  subepidermal  region  as  an  invasive  hyper- 
plasia. The  punctures  were  deep  enough,  however,  to  have  infected  the  subglandular 
connective  tissue  which  is  also  proliferating.  The  secfions  were  cut  at  the  end  of  27 
days  and  show  transitions  from  a  columnar  (glandular)  epidermis  into  an  irregular, 
angular-celled,  large-nucleate,  deep-staining  mass  of  rapidly  multiplying  atypical 
cells  corresponding  to  an  epithelioma  (slides).  The  shape  of  these  cells  is  exactly 
that  of  proliferating  epidermal  cells  from  my  one-one  hundredth  millimeter  deep  72- 
hour  inoculations  on  tobacco  stems.  I  have  not  yet  obtained  metastases  from  such 
surface  growths,  but  I  am  only  now  beginning  my  studies  of  skin  and  gland  prolifer- 
ation and  there  is  much  to  learn. 

We  now  come  to  embryomas.  Before  describing  the  atypical  teratoid  tumors  I 
wish  to  make  some  general  remarks.  Conceiving  human  and  animal  cancer  to  be  due 
to  a  parasite,  I  have  been  greatly  interested  for  the  past  10  years  to  see  to  what  extent 
the  phenomena  of  such  cancers,  the  cause  of  which  is  unknown,  can  be  paralleled  by 
crown-gall  phenomena  the  cause  of  which  is  an  intracellular  schizomycete.  By  dis- 
covery of  a  tumor  strand  and  of  stem  structure  in  leaf  tumors  (in  1911)  my  interest 
received  a  tremendous  accession  from  which  it  had  not  yet  recovered  when  the  newer 
discoveries  of  this  winter  converted  it  into  a  white  heat.  I  am  now  persuaded  that 
the  solution  of  the  whole  cancer  problem  lies  in  a  study  of  these  plant  tumors.  At 
least  they  must  now  be  studied  until  the  matter  is  definitely  settled,  pro  or  con. 

If  cancer  is  due  to  a  microorganism,  bacterial  or  other,  we  are  not  obliged  theoret^ 
ically  to  conceive  of  all  such  new  growths  as  due  to  one  and  the  same  parasite,  nor, 
indeed,  on  first  thought,  is  such  the  more  probable  hypothesis.  The  first  thought  is 
that  probably  there  must  be  as  many  parasites  as  there  are  kinds  of  tumors,  jret  cer- 
tainly, on  further  reflection,  the  mere  cell  differences  between  a  sarcoma,  let  us  say, 
and  a  carcinoma  do  not  necessarily  involve  the  conception  of  two  parasites.  The  two 
tumors  can  be  explained  theoretically  just  as  well  by  the  postulate  of  one  parasite, 
and  in  the  light  of  our  researches  on  crown  gall  much  better  by  one.  If  the  tissue 
response  depends  on  the  kind  of  cell  or  cells  first  infected,  as  apparently  it  must,  on 
the  assumption  of  a  parasitic  origin,  then,  of  course,  if  connective  tissue  cells  only  are 
involved,  we  shall  have  sarcoma;  if  gland  cells  only  are  invaded  we  shall  have  carci- 
noma; or,  if  both,  then  a  tumor  containing  both  types  of  cancer.  Whichever  cell  was 
first  invaded  (the  bacteria  being  imprisoned)  would  be  likely  to  continue  its  pro- 
liferation as  a  tumor  of  a  pure  type,  but  other  elements  might  eventually  become 
infected  by  a  suigical  operation,  or  otherwise — e.  g.,  a  sarcoma  might  follow  a  carci- 
noma as  in  some  mouse  tumors,  and  also  in  man,  the  connective  tissue  stroma  becom- 
ing infected. 

I  now  think  the  human  embryonal  teratomata  are  cancerous  not  only  potentially 
but  actually  from  the  beginning.  Many  of  them  have  been  recognized  to  be  so  oil 
removal,  and  in  the  remainder  the  stimulating  blastomous  portion  may  have  re- 
mained undiscovered  owing  to  its  relatively  small  size,  as  was  the  case  in  hairy  root 
of  the  apple  (and  every  particle  of  such  a  tumor  would  have  to  be  sectioned  and 


1  8m  the  Jonmt]  of  Guioer  Researdi,  Aprfl,  1016,  PI.  xxUJ,  fif.  78. 


PUBUC  HEALTH  AND  MEDICINE.  485 

studied  before  one  could  deny  it),  or  it  may  have  receded  during  the  rapid  develop- 
ment of  the  nonblastomous  purely  teratoid  portions.  All  of  them,  whether  it  be 
assumed  that  they  have  developed  from  ''cell  rests"  or  parthenogenetically,  are,  I 
believe,  due  to  the  stimulus  of  a  microorganism,  but  not  necessarily  of  a  schizomycete, 
since  other  orders  of  parasites  may,  conceivably,  give  rise  to  the  same  chemical  and 
physical  stimulus.^ 

Wihns  in  his  book  on  ''Die  liischgeschwfllste"  (Heft  3,  Leipzig,  1902,  p.  242),  if  I 
understand  him  correctly,  considers  the  blastomous  portions  of  embryoid  tumors 
to  be  of  a  secondary  naturOj  as  do  other  writers,  but  in  this  assumption  they  are  probably 
wrong. 

To  the  statements  of  these  authors  claiming  the  cancerous  element  to  be  secondary, 
may  be  replied :  The  same  could  be  said  of  the  shoot-produdng  tumors  on  Pelargonium 
and  on  tobacco  did  we  not  know  experimentally  that  it  is  actually  the  infected  tumor 
tissue  which  is  the  earlier  and  which  has  stimulated  the  normal  tissues  to  develop. 
Moreover,  which  tissue  is  the  earlier  is  a  matter  that  can  not  be  determined  by  mere 
observation  of  sections  (Betrachtung  des  Wachstums — Wilms)  but  one  to  be  worked 
out  experimentally. 

To  condense  results,  I  may  say  that  during  the  past  winter  I  have  discovered  that 
when  the  crown-gall  organism  (Bacterium  tume^Kiens)  is  introduced  into  the  vicinity 
of  dormant  buds  on  growing  plants  atypical  teratoid  tumors  are  produced  quite  regu- 
larly. I  have  obtained  these  in  Pelargonium,  tobacco  (2  speceis),  tomato.  Citrus, 
Ricinus,  etc.  Apparently  what  happens  is  this:  The  bud  anlage  are  torn  into  frag- 
ments by  the  rapidly  growing  tumor  and  these  fragments  are  variously  distributed 
and  oriented  in  the  tumor  where  under  the  stimulus  of  the  parasite  they  grow  into 
abortive  organs  variously  fused  and  oriented,  some  on  the  surface  of  the  tumor,  others 
in  its  depths.  Surface  fosdation  occurs.  Also  in  the  depths  of  the  tumors  fragments 
of  organs  occur,  lined  by  membranes  bearing  trichomes  (hairs)  and  lying  upside 
down  and  variously  oriented  and  combined.  The  flower  shoots,  roots,  and  leaf  shoots 
on  the  surface  of  such  tumors  vary  greatly  in  number  and  size;  often  they  are  the 
merest  abortions,  and  in  that  case  there  may  be  a  hundred  or  more  of  them  (leafy 
shoots  or  flower  shoots)  on  a  single  tumor,  especially  on  the  Pelargonium.  Even  the 
largest  and  best  developed  surface  shoots  if  they  arise  out  of  the  tumor  tissue  and  not 
from  its  vicinity  are  feebly  vascularized  and  become  yellow  and  dry  up  within  a  few 
months  and  often  before  the  tumor  itself  decays.  Such  shoots  never  come  to  maturity, 
and  frequently  these  shoots  become  invaded  by  the  sarcoma,  especially  at  their 
base,  but  otherwise  their  starved  tissues  are  normally  arranged.  Immature  frag- 
ments of  what  I  have  interpreted  as  ovaries  and  anthers  also  occur  on  the  sur&u;e 
and  in  the  depths  of  such  tumors. 

These  teratomas  when  produced  in  leaf  axils  on  the  castor  oil  plant  reach  a  large 
size  and  perish  quickly,  i.e.,  often  within  two  months.  Frequently  in  this  plant  the 
neighboring  glands  on  the  base  of  the  leaf  stalk  are  also  invaded  (within  two  or  three 
weeks)  and  greatly  enlaiged.  This  is  one  of  the  striking  results  on  Ricinus  to  which  I 
would  call  special  attention,  since  it  is  very  suggestive  of  what  often  occurs  in  cancer  in 
man;  that  is,  of  the  malignant  enlargement  of  lymph  glands  in  the  vicinity  of  a  cancer. 
Following  inoculations  on  the  middle  part  of  the  leaf  blade  of  Ricinus  I  have  also 
traced  a  parenchymatic  tumor  strand  down  the  petiole  a  distance  of  11  centimeters. 
This  was  nearly  circular  in  cross  section,  large  enough  to  be  visible  to  the  naked  eye, 
and  composed  of  parenchyma  cells.  Corresponding  to  this  were  swellings  on  the  sur- 
ince  of  the  petiole  and  bulgings  into  the  petiole  cavity,  but  no  ruptured  tumors. 
No  teratoids  were  formed  on  the  Ricinus  leaves. 

Daughter  tumors  are  produced  freely  on  tobacco  if  the  inoculations  are  made  early 
enough,  and  these  often  reproduce  all  the  teratoid  elements  of  the  primary  tumor, 

1  Sae  Meebanlsm  of  Tumor  Growth  In  CrowD  Oall.  Journal  of  Agricultural  Research,  Oovemment 
Printing  Office,  Washini^ton,  D.  C,  January  39, 1917. 


486       PHOOEEDINGS  SECOND  PAK  AMEBICAK  SCIBKTIFIO  CONGBESS. 

e.g.,  daughter  tumors  10  inches  away  from  the  primary  tumor  may  bear  leafy  ahoota. 
These  secondary  tumors,  which  have  been  seen  both  in  stems  and  in  leaves,  are  con- 
nected with  the  primary  tumor  by  a  tumor  strand  which  is  lodged  in  the  outer  cortex 
and  is  vascular,  i.  e.,  has  the  structure  of  a  diminutive  stem  (stele). 

What  is  still  more  astonishing,  I  find  that  I  can  produce  these  teratomas  in  the 
leaves  of  tobacco  plants  where  no  dormant  buds  are  known  to  exist.  ^  To  get  these 
results  the  leaves  must  be  fairly  young,  i.  e.,  plastic.  They  will  then  produce  tumozs 
where  they  are  inoculated  (needle-pricked)  and  many  of  these  tumors  will  be  covered 
with  leafy  shoots  (tobacco  plants  in  miniature).  I  have  obtained  7  such  tera- 
tomas from  the  blade  of  a  single  leaf,  and  27  from  the  leaves  of  a  single  plant — ^too 
many  to  be  due  to  Gohnheim's  ''cell  rests. ''  They  must  have  originated,  I  think, 
from  groups  of  plastic  (totipotent)  cells  ncmnal  to  Hie  inoculated  parts  of  the  leaves 
and  probably  also  present  in  many  uninoculated  parts  of  such  leaves,  if  not  in  all 
parts.  I  have  more  recently  produced  them  readily  in  geranium  leaves  and  in  the 
middle  of  cut  intemodes  of  both  tobacco  and  Pelargonium  by  needle  pricks  intro- 
ducing Bacterium  tumefaciens. 

How,  then,  can  these  phenomena  be  explained?  The  teratoids  I  have  obtained 
being  essentially  like  the  embryonal  teratomas  in  animals,  I  believe  that  in  both 
plants  and  animals  they  must  have  the  same  origin,  i.  e.,  must  arise  from  an  identical 
chemical  and  physical  stimulus.  So  far  I  have  been  able  to  explain  the  embryonal 
teratomas  only  on  the  assumption  that  in  all  animals  and  in  all  plants  (except  the 
simplest)  certain  widely  dbtributed  normally  arranged  cells  or  groups  of  cells, 
possibly  all  cells  when  very  young  and  plastic,  carry  the  potentiallity  of  the  whole 
organism,  which  potentiality  is  not  ordinarily  developed  on  account  of  division  of 
labor,  but  which  comes  into  action  when  hindrances  are  removed,  i.  e.,  when  the 
physiological  control  is  disturbed  or  destroyed.  We  know  that  life  must  have  begun 
so  in  unicellular  plants  and  animals  and  there  is  no  good  reason  why  it  should  not 
have  continued  so  in  multicellular  ones.  Only  we  have  not  been  accustomed  to 
think  of  it  in  this  way,  yet  there  are  many  facts  respecting  r^eneration  of  lost  parts  in 
both  plants  and  animals  which  coincide  perfectly  with  this  view.  Coinciding  with 
this  view  as  to  the  origin  of  embryomas  in  various  organs,  i.  e.,  from  groups  of  normal 
but  very  young  undifferentiated  or  but  slightly  differentiated  cells  or  groups  of  cells 
multiplying  under  a  cancer  stimulus,  is  the  fact  that  I  have  been  able  to  produce  the 
teratomas  in  tobacco  leaves  only  by  inoculating  very  young  leaves.  When  older 
leaves  are  inoculated  they  either  do  not  respond  or  yield  only  the  ordinary  crown 
galls. 

Respecting  animal  inoculations  I  might  say  that  I  have  tried  this  organism  on 
fish  (brook  trout)  and  in  the  eye  cavity  and  elsewhere  have  obtained  small  nodules 
which  in  stained  sections  look  very  much  like  sarcoma,  but  in  no  case  have  I  seen 
metastasis  nor  do  I  know  that  the  nodules  would  not  have  been  absorbed  after  a 
time.  Most  of  my  inoculated  fish  recovered  or  died  early  of  septicaemias,  some  ol 
which  were  due,  I  have  reason  to  believe,  to  the  crown  gall  organism.  At  least 
from  the  dorsal  aorta  of  one  of  these  sick  fish  we  plated  the  crown  gall  organism  in 
practicaUy  pure  culture  and  with  subcultures  induced  crown  galls  on  healthy 
plants. 

I  may  be  permitted  a  few  general  remarks  in  conclusion,  premising  that  this  is 
the  way  the  cancer  problem  looks  to  an  experimental  biologist. 

With  some  praiseworthy  exceptions,  the  cancer  specialists  of  to-day,  following  the 
lead  of  the  Germans  and  their  English  imitators,  are  lost  in  a  swamp  of  morphology, 
and  it  is  time  that  an  entirely  new  set  of  ideas  should  be  promulgated  to  rescue  them 
from  their  self-confessed  hopelessness. 

When  a  pathologist  can  say:  ''Concerning  the  ultimate  nature  of  neoplastic  over- 
growth we  shall  never  have  more  than  a  de6cripti^e  knowledge,''  he  has  reached  the 

>  See  Jonmal  of  Agrlo.  Research,  Apr.  34, 1016,  PI.  xxlii. 


PUBUO  HEALTH  AND  MEDICINE.  487 

ead  of  the  road  iu  his  direction  and  the  limit  of  pesumism .  I  do  not  care  a  rap  whether 
I  am  caUed  orthodox  or  heterodox,  but  I  do  care  tremendously  to  keep  an  open  mind 
and  a  hopeful  spirit.  One  trouble  with  too  many  cancer  spedaHsts  is  that  they  are 
not  biologists,  whereas  the  cancer  problem  is  peculiarly  and  preeminently  a  biolog- 
ical problem.  These  cancer  morphologists  have  patiently  cut  and  stained  and 
studied  hundreds  of  thousands  of  sections  of  tumors,  fining  and  refining  their  defi% 
nitions  and  distinctions  and  building  up  high  walls  of  separation  where  nature  has 
made  none,  all  because  they  do  not  understand  the  plasticity  of  lining,  growing 
things.  I  do  not  mean  to  condemn  the  study  of  sections,  but  only  to  suggest  that 
there  are  also  other  ways  of  looking  at  this  problem,  which  is  one  of  growing  things. 
There  is  too  much  reasoning  in  a  circle  on  the  part  of  many  of  these  writers,  too  much 
argument  basing  one  assumption  on  another  assimiption  as  if  the  latter  were  a  well- 
established  and  solid  fact,  too  little  clear  thinking  of  a  biological  sort,  too  little  first- 
hand knowledge  of  living  plants  and  animals,  too  much  dogmatism,  too  much  ortho- 
doxy, and  not  enough  experimentation.  Hence  the  pessimism  and  the  discour- 
agement. 

Cancer  research  was  l^om  in  Germany  and  has  been  prosecuted  there  more  dili- 
gently than  anywhere  else  in  the  world,  and  they  have  done  wonders  in  the  study 
of  its  morphology,  but  etiologically  the  best  the  Germans  have  been  aMe  to  do  has  been 
to  cover  the  whole  situation  with  a  cloud  of  obscurity.  With  a  few  uninfluential 
exceptions  they  have  denied  the  parasitic  nature  of  the  disease  and  discouraged  search 
for  an  organism,  and  in  this  pessimistic  attitude  they  ha^e  been  ably  seconded  by 
their  English  followers.  These  strong  men,  chiefly  morphologists,  ha  ^  e  dominated 
the  situation  for  a^generation,  but  they  ha\  e  not  explained  cancer  and  they  can  not 
explain  it,  and  they  must  now  gi .  e  way.  Indeed,  from  Cohnheim  to  Ri])l  ert  there 
is  not  one  of  their  aigiunents  in  opposition  to  the  parasitic  nature  of  cancer  which  is 
not  as  full  of  holes  as  a  skimmer. 

Listen  to  Ribbert  in  his  last  great  book:  ^ 

Denn  wenn  auch  durch  Mikroorganismen  knotige,  tumorfthnliche  Wucherungen 
her  orgerufen  werden  kdnnen,  so  handelte  es  sich  doch  stets  nur  um  die  Bildung 
eines  entzOndlichen  Granulationsgewel  es,  das  hOchstens  mit  Tumoren  der  Binde- 
gewebsgruppe  eine  gewisse  Ahnlichkeit  haben  konnte  (p.  378). 

In  other  words,  the  most  that  parasites  can  do  is  to  produce  a  granulomatous  tumor 
superficially  like  a  sarcoma. 
Again  he  says: 

Aber  wenn  das  fremde  Lebewesen  die  2^11en  bewohnt,  mOssen  dieee  notwendig 
ffeschadigt  werden.  Das  folgt  aus  dem  Begriff  der  Parasiten,  der  selbst  erst^ndlicb 
der  Zelle  nur  Xachteil  bringen  kann.  Damit  ist  aber  die  den  Tumor  characterisie* 
rende  Steigerung  der  Wachstumsf&higkeit  der  Zelle  nicht  ^  ereinbar  (p.  384). 

In  other  words,  when  a  parasite  occupies  a  cell  that  cell  must  necessarily  be  injured. 
It  follows  out  the  ^  ery  concept  of  a  parasite  that  it  can  only  bring  injury  to  a  cell, 
and  the  characteristic  increase  of  cell  growth  in  timiors  is  incompatible  with  this 
idea.    Here  as  usual  he  just  misses  the  point. 

Ribbert  ends  his  great  book,  of  which  "seine  Entsehimg"  is  its  weakest  part, 
although  the  illustrations  are  also  to  be  criticized  because  they  are  all  ^  ague  wash  draw- 
ings when  they  should  ha\e  been  exact  photomicrographs,  as  follows: 

Das  Karzinom  entsteht  auf  Grund  einer  diurch  Epithelprodukte  bewlrkten  die  Dif- 
ferenzierung  des  Epithels  vermindemden  und  sein  Tiefenwachstum  auslfieunden 
subepithelialen  Entzflndung. 

In  other  words,  if  I  understand  him,  cancer  is  due  to  a  sul  epithelial  inflammation 
induced  l»y  substances  arising  in  the  epithelium,  which  sul  stances  cause  it  (or  which 
Inflammation  causes  it)  to  1  e  less  well  differentiated  and  to  grow  downward.  Thist 
etiologically  is  about  as  clear  as  mud. 

1  '<Das  Kaninom  des  Menschen  sein  Bau,  sein  Wachstum,  seine  Entstebung,"  Fr.  Cc^en,  Bonn,  1011. 


488       PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC  CONGRESS. 

Wilms,  abo,  at  the  end  of  his  book, '  sarcastically  inquires: 

Welches  Bakterium  soil  wohl  eine  Keimblattzelle,  Mesoderm-  oder  Mesenchyn.zolle 
producieren  kdnnen,  die  dann  embryonale  Gewebe  und  Organanlagen  bildet? 

To  which  may  be  replied  Bacterium  tumefaciens,  and  probably  others. 
This  is  his  additional  and  closing  sentence  designed  to  be  a  finality  of  in^  incible 
logic: 

Wer  diese  genannten  an^l)orenen  Sarkomaformen  als  durch  Bakterien  erzeugt 
betrachtet,  tibemimmt  damit  die  Verpflichtung,  auch  fiir  die  Bildung  seiner  eigenen 
normalen  Gewebe  und  Organe  eine  bakterielle  Infektion  nachzuweisen. 

To  which  may  be  answered:  Very  well,  and  why  not?  Since  a  bacterial  organism 
does  just  that  in  the  plant. 

I  believe  these  old  ideas  and  assumptions  must  be  sifted,  turned  and  o*.  ertumed, 
and  many  of  them  wholly  rejected  if  we  are  to  find  the  truth. 

Cancer,  according  to  my  notion,  is  a  problem  for  the  experimental  biologist  and 
the  bacteriologist.  The  morphologist  has  gone  as  far  as  he  can  go,  and  the  eneigy  of 
cancer  research  from  now  on  must,  1 1  elie  e,  be  turned  into  new  channels,  if  we  are 
to  expect  results  commensurate  with  the  needs  of  humanity. 

[For  Illustrations,  drawn  from  photographs  and  photomicrographs,  and  confirma- 
tory of  statements  here  made  respecting  crown  gall,  consult  '^  The  Journal  (A  Cancer 
Research,'*  April,  1916,  and,  especially  for  the  embryomas,  '^Bulletin  of  the  Johns 
Hopkins  Hospital,"  Sept.,  1917."] 

The  Chairman.  Are  there  any  questions  or  remarks? 

A  Delegate.  I  am  interested  to  learn  what  is  the  nature  of  the 
controls  used  in  the  work  on  trout.  Do  you  find  that  no  other  in- 
fection will  produce  this  kind  of  tumor  in  the  trout  ? 

Dr.  Smith.  I  can  not  say.  1  have  not  got  in  any  of  the  inoculated 
trout  tumors  enough  evidence  to  make  me  think  that  I  have  proved 
my  case.  The  work  is  still  going  on.  Until  I  can  get  metastasizing 
tumors  in  these  animals  and  from  them  can  produce  the  growth,  I 
do  not  think  I  have  made  out  my  case.  I  do  not  know  that  I  can  make 
it  out  in  animals,  anyway,  but  the  subject  is  interesting.  I  am 
working  on  lizards  now,  and  perhaps  after  a  time  I  may  have  some 
better  evidence  than  this.  But  I  have  got  here  in  plants  what  to 
my  opinion  parallel^  in  a  good  many  ways  what  takes  place  in  man 
and  many  animals.  I  know  it  is  due  to  an  organism,  but  it  does  not 
kill  the  cell.  It  grows  inside  the  cell  and  stimulates  it  to  proliferate, 
and  from  that  standpoint  I  think  it  well  worth  while  to  go  on  witii  the 

work. 

Dr.  Richard  Weil.  I  wonder  whether  Dr.  Smith  is  entirely  correct 
in  saying  that  he  does  not  get  metastasis.  Of  course,  he  gets  growth 
by  extension,  but  then  we  know  there  is  a  school  of  human  patholo- 
gists that  believe  human  metastases  are  very  largely  due,  if  not  ex- 
clusively— at  least  in  a  certain  type  of  cases,  e.  g.,  the  breast  cancers 
with  axillary  metastases — to  that  mode  of  growth — i.  e.,  extension 
with  eventual  destruction  of  intervening  strands  through  connective 


1 "  Die  MisctaciMObwaiste/'  p.  275. 


PUBUC   HEALTH  AND  MEDICINE.  489 

tissue  proliferation,  so  that  metastasis  according  to  that  belief  is  not 
caused  by  carriage  of  the  toxin  through  the  cells,  but  by  actual  pro- 
liferation. 

That  is  certainly  true  in  a  considerable  number  of  cases  of  metasta- 
sis. Whether  it  is  true  in  all  is  an  entirely  different  question,  but  I 
think  there  is  no  doubt  that  in  many  cases  of  human  breast  cancer 
we  get  just  that  method  of  extension  that  you  get  with  eventual 
destruction  of  intervening  strands.  As  far  as  I  could  make  out  from 
the  slides,  the  growth  was  partly  infiltrative,  and  I  wish  to  ask  whether 
there  was  true  infiltration  of  the  healthy  plant  tissue,  whether  the 
tumor  throws  out  feeders,  or  whether  it  only  extends  from  the  center 
and  destroys  the  surroimding  tissues  by  pressure  and  so  bursts  out  to 
the  surface. 

Dr.  Smith.  In  some  cases  it  sends  out  invasive  cell  growths,  at 
other  times  it  exerts  a  purely  crushing  effect. 

Dr.  Weil.  Does  the  plant  ever  recover  from  the  tumor  ? 

Dr.  Smith.  I  think  I  can  say  that  sometimes  recovery  occurs. 

Dr.  Weil.  Are  they  then  immune  ? 

Dr.  Smith.  We  have  worked  a  good  deal  on  that  point.  I  felt  a 
good  deal  more  certain  on  the  question  of  immimity  some  years  ago 
than  I  now  do. 

Dr.  H.  R.  Gatlord.  I  should  like  to  remind  Dr.  Smith  of  a  very 
interesting  occurrence  in  reference  to  this  subject  that  he  has  probably 
forgotten.  At  the  International  Cancer  Meeting,  in  Paris,  there  was 
presented  to  the  C!ongress  a  new  object  for  neoplasm  study,  a  genuine 
neoplasm  in  plants,  by  a  gentleman  who  stated  that  he  thought  it  waa 
of  great  value  to  human  study  because  it  could  be  demonstratea  by 
all  the  criteria  of  neoplasms  to  be  a  genuine  neoplasm.  What  he 
had  done  was  this:  He  had  this  tumor  in  sugar  beets,  and  he  had 
proven  by  transplantation  experiments  that  this  tumor  could  bo 
transplanted  from  one  type  of  beet  to  another  and  grow  by  ingrafting. 
In  other  words,  he  took  a  tumor  from  a  white  sugar  beet  and  trans- 
planted to  a  red,  or  the  reverse,  and  it  grew  from  the  transplant.  He 
proposed  that  here  was  a  very  simple  type  of  tumor  which  we  could 
use  for  transplantation  experiments.  One  of  the  criteria  which  he 
advanced  to  prove  that  it  was  neoplasm  was  that  no  one  had  ever 
been  able  to  cultivate  anything  from  it,  and  hence  that  definitely 
placed  it  in  the  neoplastic  growths.  He  was  very  much  surprised, 
we  know,  when  he  learned  about  Dr.  Smith's  growth.  Dr.  Smith 
had  at  that  time  accomplished  the  culture  of  this  organism  and  had 
inoculated  it.  Dr.  Smith  might  make  more  out  of  it,  I  think,  than 
he  does,  because  here  was  a  tumor  something  like  a  Rous  chicken 
tumor  which  was  passed  on  before  his  work  came  out  and  was  accepted 
as  a  type  of  neoplasm. 

The  Chairman.  We  will  pass  to  the  next  paper,  that  of  Dr.  Gaylord 
on  *'Fish  tumors." 


490       PEOOEEDINGS  SECOND  PAN   AMERICAN   SCIENTIFIC  CONGRESS. 

CANCER  PROBLEMS  IN  SPECIAL  BIOLOGICAL  GROUPS— FISH  TUMORS — 
FURTHER    OBSERVATIONS    ON    SO-CALLED    CARCINOMA    OF    THE 

THYROID. 

By  HARVEY  R.  GAYLORD, 

State  Institute  for  the  Study  of  Malignant  Disease^  Buffalo. 

Our  knowledge  of  the  various  types  of  neoplasms  in  fish  has  not  been  materially 
augmented  since  the  articles  of  Marianne  Plehn  in  1906,  1910,  and  1912.  It  is  well 
known  that  various  types  of  neoplasms  are  found  in  the  teleosts,  but  for  the  purposes 
of  cancer  research  the  descriptions  of  neoplasms  in  lower  animals  serve  only  to  extend 
our  knowledge  and  to  confirm  our  impressions  regarding  the  widespread  distribution 
of  the  neoplastic  processes.  Only  when  such  tumors  have  been  made  the  subject  of 
experimental  or  more  extended  study  is  their  significance  great. 

In  fish  the  particular  type  of  neoplasm  which  has  been  so  studied  is  the  so-called 
carcinoma  of  the  thyroid  in  the  salmondds.  Just  as  in  other  biological  groups  a 
certain  type  of  neoplasm  preponderates,  as  in  mice  carcinoma  of  the  breast,  and  In 
rats  and  chickens  the  sarcomas,  so  the  salmonoids  have  that  type  of  neoplastic  process 
which  even  in  mammals  bears  a  close  relation  to  the  problem  of  water  supplies. 
Therefore,  it  is  not  surprising  to  find  carcinoma  of  the  thyroid  in  fish. 

This  disease  was  first  described  by  Bonnet  in  1883.  Although  this  author  did  not 
recognize  the  nature  of  the  disease,  Scott,  in  1891,  described  it  as  cancer,  and  Plehn, 
in  1902,  recognized  it  as  a  neoplasm  of  the  thyroid  ^and.  In  the  same  year  it  was 
described  by  Gilruth  as  epithelioma  affecting  the  branchial  arches.  A  compre- 
hensive histological  study  based  on  some  ten  specimens  of  fish  was  made  by  Pick  in 
1905.  Our  interest  in  this  subject  began  in  1908  with  the  description  of  conditions 
existing  in  a  fish  hatchery,  in  which  hundreds  of  fish  were  affected.  The  disease 
was  also  studied  by  Marine  and  Lenhart,  beginning  in  1909,  these  authors  considering 
it  to  be  endemic  goiter.  Our  own  studies,  covering  a  period  of  six  years,  weue  pub- 
lished in  monograph  form  in  1914,  and  led  to  the  following  conclusions  regarding  the 
nature,  distribution,  and  significance  of  the  disease: 

1.  The  diuease  known  as  gill  disease,  thyroid  tumor,  endemic  goiter,  or  carcinoma 
of  the  thyroid  in  the  salmonidse,  is  a  malignant  neoplasm. 

2.  The  disease  occurs  in  fish  living  under  conditions  of  freedom  in  populated  areas. 

3.  When  introduced  into  fish-breeding  establishments  it  becomes  endemic  with 
occasional  epidemic  outbreaks. 

4.  Normal  fish  taken  from  the  wilderness  may  be  made  to  acquire  the  disease  when 
placed  in  fish-breeding  establishments  where  the  disease  is  endemic. 

5.  The  feeding  of  uncooked  animal  proteid  favors  and  the  feeding  of  cooked  animal 
proteid  retards  the  disease  as  compared  with  the  uncooked.  Feeding  alone  is  not  an 
efficient  cause.  It  must  be  combined  with  an  agent  transmitted  probably  through 
the  water  or  food,  or  both. 

6.  By  scraping  the  inner  surface  of  water-soaked  wooden  troughs  in  which  the  dis- 
ease is  endemic,  an  agent  may  be  secured  which  from  its  action  upon  the  mammalian 
thyroid  when  administered  through  drinking  water  is  no  doubt  the  cause  of  the  dis- 
ease in  the  fish  confined  in  these  troughs. 

7.  The  agent  is  destroyed  by  boiling. 

8.  Fish  in  all  stages  of  the  disease  are  favorably  affected  in  the  direction  of  cure 
by  the  addition  to  the  water  supply  in  suitable  concentration  of  mercur}%  arsenic  or 
iodine. 

9.  The  eff(;ct  of  mercury,  arsenic,  and  iodine  in  carcinoma  of  the  thyroid  in  fish 
and  the  siibsequent  positive  experiments  with  metals  in  mammalian  cancer  are 
probably  the  expression  of  a  therapeutic  relation  of  these  elements  to  carcinoma. 

10.  Certain  species  of  the  salmonidae  have  an  almost  complete  natural  resistance 
to  the  disease. 


PUBLIC   HEALTH  AND  MEDICINE.  491 

11.  Certain  lots  of  fish  of  susceptible  species  show  a  high  degree  of  immuiiity  to  the 
disease. 

12.  Spontaneous  recovery  occurs  in  a  considerable  percentage  of  individuals. 

13.  Removal  from  ponds  in  which  the  disease  is  endemic  to  natural  conditions,  or 
a  change  to  more  natural  food,  increases  the  percentage  of  spontaneous  recoveries. 

14.  Spontaneous  recovery  appears  to  confer  a  degree  of  immunity  against  recurrence. 

15.  The  percentage  of  spontaneous  recoveries  in  the  early  stages  of  the  disease 
i^pears  to  be  higher  than  in  the  later  stages  of  the  disease. 

16.  The  incidence  of  the  disease  increases  with  the  age  of  the  fieh,  at  least  up  to 
five  years. 

17.  Thyroid  enlargement  and  changes  presenting  at  the  end  of  five  months  a  picture 
of  diffuse  parenchymatous  goiter  were  induced  in  mammals  by  giving  them  water  to 
drink  in  which  had  been  suspended  scrapings  from  trou^  in  which  the  disease  was 
endonic.  Control  animals  which  received  the  same  water  boiled  failed  to  develop 
thyroid  changes.  That  these  enlargements  and  changes  are  the  first  stages  in  mam- 
mals of  the  same  disease  which  occurs  in  the  fish  inhabiting  the  troughs  from  which 
the  scrapings  were  obtained  is  an  inference  which  we  believe  further  experiments 
will  justify. 

18.  The  disease  is  endemic  in  a  very  high  percentage  of  all  trout  hatcheries  in  the  . 
United  States. 

19.  The  occurrence  of  the  disease  in  wild  fish,  its  introduction  into  fish-cultural 
stations,  its  localization  in  certain  troughs  or  water  supplies,  the  method  of  its  spread, 
its  transmission  to  mammals,  the  efficacy  of  three  well-known  Inorganic  germicides  in 
the  treatment  of  the  disease,  the  destruction  of  the  agent  by  boiling,  the  phenomena 
of  spontaneous  recovery  and  immunity,  strongly  indicate  that  the  agent  causing  the 
disease  U  a  living  organism. 

20.  No  evidence  has  yet  been  produced  to  indicate  the  direct  transmission  of  the 
disease  from  individual  to  individual. 

21.  In  many  of  its  phases  the  disease  is  identical  with  endemic  goiter.  As  there  is 
no  line  of  demarcation  between  what  is  called  endemic  goiter  and  what  we  believe  we 
have  clearly  shown  is  cancer  of  the  thyroid,  we  hold  that  endemic  goiter  and  carcinoma 
of  the  thyroid  in  the  salmonidee  are  the  same  disease. 

Since  the  publication  of  these  conclusions,  certain  new  facts  have  been  disclosed 
which  serve  to  extend  or  strengthen  some  of  our  conclusions  in  reg»d  thereto.  That 
the  disease  is  widespread  geographically  is  indicated  by  reports  we  have  received  of 
its  occurrence  in  India.  T.  Southwell,  director  of  fisheries  for  Bengal,  Bihar,  and 
Orissa,  wrote  "us  in  1914  and  later  sent  us  specimens  of  rainbow  trout  taken  in  the 
hill  waters  in  the  vicinity  of  Naini  Tal  with  visible  thyroid  tumors.  These  proved 
on  microscopic  examination  to  be  thyroid  carcinomata  of  the  usual  type.  Facts 
pertaining  to  this  observation  have  since  been  published  by  Southwell  with  two 
excellent  illustrations  in  the  records  of  the  Indian  Museum. 

In  the  literature  of  the  subject  there  is  but  one  reference  to  the  occurrence  of  visible 
thyroid  tumor  in  salt-water  fish,  and  this  only  in  Salmo  salar  Linnseus,  the  Atlantic 
salmon.  As  these  fish  at  certain  times  ascend  the  fresh- water  streams,  they  are  not 
strictly  salt-water  fish.  It  is,  therefore,  of  great  interest  to  learn  of  the  existence  of  the 
disease  in  four  examples  of  sea  bass,  Serranus,  in  two  species.  These  fish  were  found 
in  the  Naples  aquarium  by  Dr.  Paul  Vonwiller  and  will  be  later  published  in  detail  by 
Marsh  and  Vonwiller.  The  growths  are  in  general  like  the  process  in  the  salraonidss 
but  are  not  so  advanced .  Colloid  *is  found  in  all  sections  of  the  tumor.  The  epithelium 
is  in  all  stages  from  low  cubical  to  high  columnar,  and  not  greatly  infolded,  but  pre- 
sents an  appearance  of  adeno-carcinoma.  In  Serranus  there  is  very  little  evidence  of 
infiltration  and  no  metastases  are  demonstrable,  as  only  the  heads  of  the  fish  are 
available  for  investigation.    These  fish  were  always  in  sea  water,  and  they  were  fed 


492       PROCEEDINGS  SECOND  PAN   AMERICAN   SCIENTIFIC  CONGBESS. 

exclusively  on  marine  fish,  which  is  said  to  prevent  thyroid  overgrowth.    This  is  the 
first  observed  instance  of  thyroid  tumor  in  salt-water  fish  outside  the  salmonidse. 

Still  more  striking  is  the  observation  of  Cameron  and  Vincent  of  the  occurrence  of 
thyroid  tumor  in  an  elasmobranch,  squalus.    Squalus  is  a  dogfish,  or  small  shark. 
These  authors,  in  the  examination  of  217  specimens  of  dogfish  from  the  Pacific  coast, 
found  a  thyroid  which  was  enlarged  to  about  three  times  the  usual  size,  and  the  gland 
instead  of  being  leafiike  and  flat  as  normally,  was  paar  shaped  and  nodular.    The 
enlarged  gland  contained  cysts  and  under  the  microscope  cystlike  dilatations  of  the 
alveoli  with  cell  proliferations  projecting  into  them.    There  were  areas  of  normal 
vesicles  containing  colloid  in  parts  of  the  gland,  but  the  alveoli  in  the  more  charac- 
teristic portions  were  filled  with  solid  masses  of  cells.    In  some  places  all  alveolar 
structure  was  lost,  the  growth  being  made  up  of  irregular  masses  of  cells.    The  general 
appearance  of  the  growth  was  adenomatous,  but  in  certain  regions  infiltration  of  the 
interstitial  tissue  was  marked.    The  picture  described  by  these  authors  is  character- 
istic  of  the  disease  in  the  salmonidee .    The  point  of  especial  interest  is  that  the  thyroid 
in  squalus  is  an  encapsulated  gland.    Besides  this  one  example  of  gross  enlargement 
of  the  thyroid  in  squalus,  these  authors  describe  two  specimens  from  a  group  of  12 
examined  later  which  show  distinct  pathological  changes  on  microscopic  examination. 
In  these  glands  large  portions  of  the  thyroid  were  devoid  of  coUoid,  the  vesicles  being 
entirely  filled  with  epithelial  overgrowth.    The  sea  water  of  the  strait  of  Geor^da, 
where  the  squalus  was  obtained,  is  about  two-thirds  normal  ocean  salinity,  and  doubt- 
leas  two-thirds  normal  marine  iodine  content,  but  thb  is  much  above  the  concentration 
of  iodine  which  in  fresh  water  reduces  thyroid  hyperplasia. 

From  these  observations  the  evidence  which  has  been  collected  of  the  existence  of 
carcinoma  of  the  thyroid  in  fish  living  under  conditions  of  nature,  and  far  remoTOd 
from  questions  of  domestication,  overfeeding,  overcrowding,  etc.,  strengthens  the 
conclusion  that  the  disease  is  not  the  result  of  artificial  propagation.  The  occurrence 
of  the  disease  in  fish  whose  normal  habitat  is  sea  water  bears  rather  strongly  upon  that 
theory  of  th3rroid  hyperplasia  which  attributes  it  to  deficiency  of  iodine  in  the  food  or 
environment.  In  fact  so  far  as  fish  are  concerned  the  similar  results  obtained  with 
mercury  and  arsenic  would  seem  to  conclusively  show  that  idoine  acts  in  a  way  similar 
to  the  metals,  and  not  by  supplying  a  deficiency  of  iodine  in  the  gland.  The  observa- 
tion that  the  feeding  of  vegetable  food,  cooked  proteid,  or  chopped  sea  fish,  or  so-called 
natural  food,  such  as  maggots,  bugs,  etc.,  retards  the  progress  of  the  disease  in  hatch- 
eries, and  that  the  feeding  of  uncooked  animal  proteid  is  not  the  cause  of  the  disease 
but  a  contributing  factor,  has  been  strengthened  by  the  observation  of  the  occurrence 
of  the  disease  in  trout  fed  on  cooked  vegetable  food.  These  fish  came  from  a  com- 
mercial trout  hatchery  in  Pennsylvania.  The  first  food  of  these  fish  as  fry  was  beef 
liver  for  about  two  months.  Then  a  mush  made  from  wheat  flour  is  added  to  the  liver 
and  is  gradually  increased  in  relative  proportion  until  during  the  next  four  months  all 
liver  is  eliminated.  Subsequently  only  cooked  flour  mush  is  fed  to  these  trout. 
They  grow  slowly,  mature  and  breed,  and  are  sold  for  table  use  at  probably  a  record 
price  for  commercial  trout.  They  nevertheless  acquire  thyroid  tumors;  in  yearlings 
and  older  fish.  The  tumors  are  small ,  and  a  small  per  cent  of  fish  are  affected.  Micro- 
scopically, most  of  the  typical  appearances  of  carcinoma  in  the  salmonidae  are  seen. 
This  is  cancer  in  fish.  The  occurrence  of  the  disease  in  Serranus,  sea  fish  fed  exclu- 
sively upon  marine  fish  food,  also  strenghens  the  conclusion  that  feeding  is  not  the 
essential  cause  of  the  disease. 

The  observation  that  merciury,  arsenic,  and  iodine,  when  introduced,  even  in  small 
amounts,  into  the  water  containing  fish  with  thyroid  tumors,  bring  about  a  marked 
diminution  in  the  size  of  these,  develops  increased  significance  in  the  light  of  recent 
experiments  reported  by  McCarrison.  This  author  has  studied  the  prevalence  of 
goiter  in  the  Lawrence  Military  Asylum  for  children  at  Sanawa.  In  this  institution 
there  are  about  500  male  and  female,  European  and  Anglo-Indian  children .  About  two- 


PUBUC  HEALTH  AND  MEDICINE.  493 

thirds  of  the  children  are  of  pure  European  descent,  the  remaining  one-third  being  of 
mixed  parentage.  The  asylum  is  located  at  about  6,000  feet  in  the  lower  ranges  of  the 
Himalayas.  A  careful  study  of  the  records  in  this  asylum,  which  extended  over  some 
15  years,  showed  that  the  incidence  of  goiter,  with  Uie  exception  of  a  few  years,  was 
about  20  per  cent  of  the  inmates.  McOarrison  finally  traced  the  source  of  the 
endemic  to  the  drinking  water,  which  was  in  part  rain  water  and  in  part  spring 
water.  Both  sources  of  supply  were  open  to  fecal  contamination  and  showed 
abnormally  high  bacterial  content.  Beginning  April  19,  1913,  McOarrison  undertook 
the  exi>eriment  of  sterilizing  the  water  by  chemical  means  in  the  boys'  school  and 
barracks,  while  for  control  purposes  the  water  supply  of  the  girls'  school  and  barracks 
remained  as  before.  At  the  commencement  of  the  experiment,  there  were  284  boys 
in  the  school,  of  whom  57  were  goitrous.  There  were  216  girls  in  the  school,  of  whcnn 
57  were  goitrous.  On  the  25th  of  November,  1913,  when  the  experiment  was  com- 
pleted, the  number  of  cases  among  the  boys  had  been  reduced  to  27,  whereas  among 
the  girls  there  was  an  actual  increase  of  cases  above  the  57  first  recorded.  Pttrtial 
sterilization  of  the  water  was  carried  out  by  the  use  of  iodine  in  the  form  of  potassium 
iodide  and  iodate.  The  amotint  of  iodine  employed  equaled  1  part  in  70,000.  This 
method  was  used  to  purify  the  water  until  the  2d  of  July,  1913,  midway  in  the  experi- 
ment, and  from  July  3  on,  chlorine  was  largely  substituted  for  iodine,  with  the  con- 
tinuation of  the  results  observed  in  the  first  instance. 

In  the  latter  part  of  the  experiments  the  amount  of  iodine  per  parts  of  water  was 
reduced  to  1  in  911,000.  This  is  still  five  times  as  great  a  concentration  as  we  used 
in  treating  goiter  in  fish  by  the  addition  of  iodine  to  the  water.  McOarrison  considers 
the  question  of  whether  the  iodine  acts  in  this  case  as  a  purifier  of  water,  especially 
as  a  germicide,  or  whether  its  action  in  diminishing  the  number  of  cases  of  goiter  is 
to  be  attributed  to  its  supposed  physiological  action  upon  the  gland.  As  in  the  treat- 
ment of  goiter  McOarrison  has  obtained  equally  efficacious  results  with  thymol,  he  is 
not  inclined  to  attribute  to  iodine  a  distinctly  physiological  action  in  the  treatment 
of  goiter. 

McOarrison*s  experiments  do  not  conclusively  show  that  the  iodine  works  by  destroy- 
ing an  agent  in  the  water  supply.  It  is  still  possible  that  the  iodine  acts  as  a  germicide 
in  the  individui^  drinking  Uie  water.  It  is  to  be  regretted,  that  McOarrison  did  not 
entirely  substitute  chlorination  of  the  water  for  treatment,  with  iodine.  As  a  con- 
firmation of  the  results  obtained  with  iodine  by  Marine  and  by  ourselves,  hk  work 
indicates  a  very  valuable  application  of  this  method  in  the  practical  treatment  of 
goiter  in  human  beings. 

The  Chairman.  If  there  is  no  discussion,  we  will  proceed  to  the 
next  paper,  by  Dr.  Lambert,  on  "Tissue  culture  in  cancer." 


TISSUE  CULTURES  IN  CANCER.' 

By  ROBERT  A.  LAMBERT, 

Department  of  Pathology,  College  of  Phy$ician»  and  Surgeons y  Columbia  Univemtyf 

New  York  City. 

ABSTRACT. 

The  cultivation  of  tissues  in  vitro  forms  a  very  valuable  addition  to  our  methods  of 
investigating  cancer  problems.  Factors  may  be  introduced  and  controlled  to  an  extent 
not  possible  in  experiments  upon  the  living  animal.    One  may  observe  directly  the 

>  The  oommlttee  on  publication  regrets  that,  owing  to  the  absence  of  the  writer  in  Sooth  America,  only 
this  abstract  ol  Dr.  Lambert's  paper  can  be  printed. 


494       PEOCBEDINGS  SECOND  PAN   AMERICAN   SCIENTIFIC  CONGRESS. 

division  of  cellfi  and  follow  succeeding  generations  of  cells  under  variously  modified 
conditions  of  life. 

There  are  limitations  to  the  method.  Not  every  cancer  cell  or  normal  tismie  can  be 
cultivated,  and  when  cultures  are  successful  growth  is  by  no  means  comparable  to  ^lat 
observed  in  cultures  of  bacteria.  Some  tissues  merely  survive.  Human  tissues  offer 
special  difficulties,  although  modifications  in  technique  have  enabled  us  to  maintain 
an  active  multiplication  of  human  cells  for  more  than  a  month.  It  is  probable  ihnt 
growth  may  be  kept  up  indefinitely. 

The  method  of  tissue  cultures  has  been  used  by  us  chiefly  in  studying  the  nature  of 
cancer  immunity,  and  in  carrying  out  comparative  studies  upon  the  biology  of  cancer 
cells  and  normal  celb.  Further  evidence  has  been  obtained  to  show  that  canca*  im- 
munity is  not  a  serum  immunity,  that  circidating  antibodies  for  the  cancer  cell  do  not 
exist.  Tumor  cells  grow  actively  in  the  plasma  of  animals  which  are  naturally  or 
artificially  highly  resistant  to  tumor  inoculation.  They  even  grow,  as  do  also  nc^rmal 
cells  in  the  plasma  of  certain  foreign  species,  except  when  such  animals  have  been 
immunized  by  suitable  injections  against  the  tissues  of  the  species  to  which  the  tumor 
belongs.  In  other  words,  cytotoxic  immunity,  in  contrast  to  tumor  immunity,  is 
readily  demonstrable  in  tissue  cultures-. 

Interesting  differences  are  observed  in  the  behavior  of  cancer  cells  and  normal 
cells  in  cultures,  especially  when  the  cells  are  subjected  to  the  action  of  certain 
harmful  agents.  Cancer  cells,  particularly  sarcoma,  grow  very  actively  in  the  primary 
cultures,  but  continued  propagation  through  subcultures  is  difiicult,  often  impossible. 
The  reverse  is  true  of  normal  connective  tissue  cells  which  become  more  active  in 
subcultures.  This  observation  is  probably  significant,  indicating  either  that  tumor 
cells  are  less  hardy  or  that  in  cultures  some  necessary  substance  is  not  sufficiently 
supplied. 

To  some  physical  agents,  such  as  cold,  timior  cells  (mouse  and  rat  sarcomata)  apx)ear 
to  be  more  resistant  than  normal  tissues.  To  other  injurious  agents,  notably  heat, 
the  neoplastic  cell  is  clearly  less  resistant.  Recent  experiments  indicate  that  these 
results  apply  also  to  human  tissues.  It  is  suggested  that  the  problem  of  the  therapy 
of  cancer  may  be  profitably  attacked  by  this  method. 

Efforts  have  been  made  to  stimulate  in  various  ways  the  growth  in  vitro  of  cells, 
both  normal  and  malignant.  Work  in  this  direction  is  promising,  and  is  undoubtedly 
of  greatest  importance.  The  author  has  been  unable  to  confirm  some  of  the  positive 
results  reported  by  others.  Some  substances  which  stimulate  the  growth  of  cells 
in  the  body  appear  to  be  without  effect  in  cultures. 

Finally,  it  is  perhaps  interesting  to  note  that  normal  cells  grown  for  a  long  time 
outside  the  body  do  not  develop  as  the  result  of  their  freedom  from  the  restraint  of 
the  organism  any  tendency  to  malignant  lawless  growth.  This  is  shown  by  the 
entirely  negative  results  following  the  inoculation  of  subcultures  actively  growing  of 
normal  connective  tissue  cells. 

The  Chairman.  Before  proceeding  with  the  discussion  I  propose 
that  we  hear  Dr.  Burrows^s  paper,  which  is  of  a  similar  character, 
"The  tissue  culture  in  cancer,"  by  Montrose  T.  Burrows. 


THE  TISSUE  CULTURE  IN  CANCER.* 

By  MONTROSE  T.  BURROWS, 
Pathological  Laboratory^  The  Johns  Hopkins  University,  Baltimore^  Md. 

Cancer  considered  in  its  general  aspects  is  a  condition,  although  imique,  which 
must  be  understood  only  by  the  use  of  those  same  methods  by  which  we  are  to  even- 

1  Abstract  of  paper. 


PUBUO   HEALTH  AND  MEDIOINB.  495 

tually  understand  normal  and  other  pathological  processes.  The  important  problem 
in  pathology  and  in  biology  is  the  structure  and  metabolism  of  normal  body  cells.  The 
question  in  cancer  is  whether  the  cancer  cell  is  a  normal  cell  responding  to  a  peculiar 
environment  or  whether  it  is  a  cell  whose  metabolism  is  such  that  it  can  grow  in  an 
environment  where  other  cells  can  not  show  these  changes. 

At  one  time  it  was  supposed  that  the  cycle  of  the  life  of  the  organism  was  the  cycle 
of  the  life  of  the  cell.  At  the  present  time,  however,  this  particular  view  has  been 
largely  discarded  and  it  has  come  to  be  considered  that  the  body  is  not  only  controlled 
by  its  cells  but  that  the  cells  are  likewise  controlled  by  the  body.  There  is  a  mutual 
interrelation  between  the  whole  and  its  minute  parts.  Each  and  every  activity  of 
the  cell  is  a  response  on  its  part  to  some  external  stimulus.  Each  and  every  activity 
of  the  whole  is  the  result  of  the  coordinated  activity  of  its  parts.  The  cessation  of 
the  growth  of  many  cells  at  maturity  does  not  represent  a  loss  of  the  property  of  these 
cells  to  proliferate,  but  it  is  the  result  of  some  kind  of  a  change  either  in  the  organi- 
zation of  the  cell  or  in  the  parts  about  it. 

Although  it  has  been  assumed  that  this  peculiar  type  of  regulation  of  growth  and 
other  changes  in  the  body  cell  is  the  result  of  peculiarities  of  their  structure  and 
metabolism,  and  that  it  must  be  solved  by  direct  analysis  of  the  mechanisms  peculiar 
to  each  of  the  various  activities  of  these  cells,  up  to  the  time  of  the  development  of  the 
tissue  culture  method  no  means  for  such  direct  analysis  had  been  devised.  The  tissue 
culture  method  has  become  important  in  cancer  as  in  the  study  of  normal  and  other 
pathological  processes  in  that  it  allows  one  to  study  directly  the  reactions  of  these  vari- 
ous cells  in  a  restricted  and  analyzable  environment. 

Diuing  the  last  few  years  the  author  has  studied  by  this  method  several  different 
kinds  of  normal  and  cancer  cells.  Through  this  study  he  has  been  able  to  demonstrate 
directly  that  the  normal  cells  of  the  organism  are  essentially  fluid  systems  and  that 
the  organization  peculiar  to  their  various  activities,  such  as  growth,  movement, 
differentiation,  function,  etc.,  are  differential  surface  tension  phenomena,  regulated 
by  the  organization  of  the  environment  and  the  peculiar  properties  of  certain  of  the 
substances  formed  in  their  oxidation  reactions.  The  organization  peculiar  for  each 
of  these  activities  is  not  a  cellular  but  a  tissue  organization.  Thus  it  is  seen  how  these 
cells  may  under  the  influence  of  changes  in  their  environment  undergo  changes  in 
form  and  activity. 

A  fiurther  careful  study  of  oxidation  in  these  cells  has  been  made.  Oxidation  in 
these  cells  is  a  simple,  incomplete  chemical  reaction.  COj  and  another  or  other  sub- 
stances are  formed.  Certain  of  these  compounds  formed  are  insoluble  in  the  circu- 
lating body  fluids,  serum,  salt  solution,  etc.,  but  soluble  in  various  body  colloids, 
such  as  fibrin,  dead  cells,  etc.  In  the  presence  of  food  and  oxygen  this  oxidation  re- 
action can  continue  only  so  long  as  these  products  remain  below  a  certain  concentra- 
tion. When  this  concentration  is  attained  about  the  cells  all  activity  ceases.  For 
growth  to  take  place  in  these  cells  a  special  mechanism  for  removing  these  products 
must  be  available.  That  is,  it  can  take  place  only  when  the  cells  are  brought  into 
contact  with  certain  colloidal  materials^  having  the  property  of  absorbing  these  sub- 
stances and  it  continues  until  their  concentration  in  these  colloids  reaches  a  certain 
concentration ;  then  an  equilibrium  is  established .  Thus,  we  can  see  how  the  coaguable 
exudate  in  the  wound  forms  the  stimulus  for  growth  and  how  growth  ceases  at  the 
establishment  of  continuity  of  the  part  or  how  it  fails  through  a  failure  of  the  forma- 
tion of  the  exudate. 

A  careful  study  of  the  nail  shows  that  it  has  a  special  mechanism  for  supplying  col- 
loidal materials  and  removing  them  continuously  from  the  growing  cells.  The  rhyth- 
mically contracting  heart  muscle  cell  has  an  electromechanical  structure  capable  of 
splitting  these  substances  into  simpler  compound  which  are  soluble  in  the  circulating 
body  fluids.    The  energy  is  transformed  into  work  in  these  cells  through  the  fact 


496       PBOCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC  C0NQRE88. 

that  the  primary  oxidation  products  decrease  surface  tension  while  their  split  products 
increases  it. 

Cancer  cells  have  not  been  found  to  be  different  from  actively  growing  normal  cells. 
The  study  of  them  has,  however,  been  so  far  limited. 

The  Chairman.  There  is  an  additional  paper  by  Dr.  Clowes,  on 
"The  mechanistic  theory  of  cancer/^  which  is  very  similar  in  its 
contents  to  the  present  papers.  Tlie  papers  are  very  interesting 
and  I  hesitate  to  cut  them  short,  but  I  think  the  time  is  passing 
fast  and  we  have  to  be  as  brief  as  possible  in  these  communications. 


A  MECHANISTIC  THEORY  OP  CANCER. 

By  G.  H.  A.  CLOWES, 
Research  Hospital y  Buffalo,  N.  Y. 

While  investigating  12  yeard  ago  the  conditions  under  which  Bpontaneous  recovery 
from  cancer  occurs  in  mice,  and  the  phenomenon  of  immunization  against  subsequent 
transplantation  of  the  same  material,  we  had  an  opportunity  to  confirm  Beebe's 
observation  that  the  saline  constituents  of  tumors  appear  to  bear  a  direct  relation  to 
their  speed  of  growth.  We  carried  out  detailed  analyses  on  upward  of  80  carefully 
controlled  mouse  tumors  and  noted  an  extremely  high  K  and  low  Ca  content  associated 
with  rapid  growth  and  exceptional  \'irulence  of  these  tumors,  whilst  a  relatively  low 
K  and  extremely  high  Ca  content  was  associated  with  relatively  slow  growth  and 
tendency  to  spontaneous  recovery  on  the  part  of  the  tumors. 

While  analyses  carried  out  on  such  a  small  amount  of  substance  are  necessarily 
somewhat  inaccurate,  it  is  interesting  to  note  that  in  the  large  majority  of  cases  the 
speed  of  growth  and  probable  virulence  of  a  tumor  could  almost  be  determined  by 
reference  to  the  analytic  data.  A  high  K  content  is  commonly  associated  with 
rapidly  growing  embryonic  tissues  and  a  relatively  high  Ca  content  with  stationary, 
retrograding,  and  senile  tissues.  But  it  appeared  desirable  to  seek  some  further 
explanation  for  the  variations  exhibited  in  these  mouse  tumors,  particularly  the 
mechanism  underlying  the  mobilization  of  Ca  in  those  tumors  in  which  the  growth 
was  inhibited  and  spontaneous  recovery  occurred.  The  data  appeared  to  bear  some 
relation  to  experiments  being  published  at  that  time  by  Jacques  Loeb  and  his  asso- 
ciates on  antagonistic  effects  exerted  by  salts  of  monovalent  cations  against  salts  of 
divalent  cations,  particularly  in  so  far  as  they  might  apply  to  the  problem  of  increased 
or  diminished  permeability  of  the  protoplasmic  film  of  the  cancer  cell,  and  consequent 
accelerated  or  diminished  intake  of  foodstuffs  and  building  materials  capable  of 
causing  either  normal  or  pathological  cell  proliferation. 

Some  years  later  while  confirming  and  elaborating  the  work  of  other  investigators 
on  the  so-called  antitryptic  reaction  which  occiun  most  markedly  in  cancer  and  in 
pregnancy,  I  was  able  to  demonstrate  that  the  amount  of  these  substances  produced 
in  the  blood  appeared  to  bear  a  direct  relation  to  the  speed  of  growth  of  either  a  tumor 
or  a  fetus,  to  diminish  rapidly  following  an  operation  for  cancer  or  the  birth  of  a  child, 
only  to  increase  once  more  with  any  subsequent  recurrence  of  the  malignant  con- 
dition or  in  any  subsequent  pregnancy.  From  an  investigation  of  the  extent  to 
which  the  substances  in  question  were  influenced  by  treatment  with  organic  solvents, 
by  heating  and  the  action  of  physical  agents,  I  concluded  that  they  represented  prod- 
ucts of  the  destruction  of  lipoids  and  other  fatty  materials  which  are  believed  to  play  an 
important  rdle  in  the  protoplasmic  film  or  membrane,  and  subsequently  Jobling,  as 
a  result  of  fractionation  experiments  with  organic  solvents,  came  to  the  conclusion 
that  the  substance  causing  the  so-called  antitryptic  reaction  in  cancer  is  actually  a 


PUBLIC  HEALTH  AND  MEDICINE.  497 

■imple,  water-soluble  soap.  The  production  of  increased  proportions  of  soluble  soaps 
in  the  blood  appeared  to  support  the  conclusion  of  Shaw-Mckenzie  that  an  increased 
lipase  activity  is  to  be  noticed  in  cancer  and  suggests  the  possibility  that  the  mobili- 
zation of  Ca  is  a  protective  measure  calculated  to  counteract  the  increased  permea- 
bility of  the  protoplasm  resulting  from  the  disintegration  of  the  protoplasmic  film« 
the  soluble  soaps  produced  being  transformed  into  insoluble  Ca  soaps. 

There  was,  however,  no  satisfotctory  explanation  for  the  phenomenon  in  question 
until  Bancroft  made  the  observation  that  water-soluble  soaps,  like  Na  and  K  oleate, 
when  used  as  emulsifying  agents  for  oil  and  water,  promote  the  formation  of  emul- 
sions consisting  of  globules  of  oil  dispersed  in  water,  like  cream,  while  soaps  like  Ca 
and  Mg  oleate,  which  are  insoluble  in  water  but  soluble  in  fats,  when  used  as  emul* 
sifying  agents  promote  the  formation  of  emulsions  in  which  globules  of  water  are  dis* 
persed  in  oil,  like  butter. 

In  a  paper  published  in  1913  I  was  able  to  demonstrate  that  emulsions  of  oil  dis- 
persed in  water  may  be  transformed  into  emulsions  of  water  dispersed  in  oil  by  simply 
shaking  with  salts  of  Ca,  while  the  transformation  in  question  may  be  prevented  or 
the  reverse  transformation  effected  by  shaking  with  alkidies,  etc.  Now,  since  a  phase 
reversal  of  this  type  represents  a  transformation  of  a  system  analogous  to  islands  sur- 
rounded by  water  which  is  freely  permeable  to  water,  into  one  analogous  to  lakes 
surrotmded  by  land  which  is  impermeable  to  water,  it  is  obvious  that  by  simply 
varying  the  proportions  of  alkalies  and  salts  of  monovalent  cations,  on  the  one  hand, 
and  of  di  and  tri  valent  cations  on  the  other  hand,  it  is  possible  to  prepare  a  phjrsical 
system  having  any  desired  d^roe  of  permeability. 

A  careful  investigation  ^  of  the  effect  exerted  by  various  electrolytes  on  interfacial 
soap  films  by  means  of  the  drop  system  has  demonstrated  that  the  proportions  in  which 
given  salts  exert  an  antagonistic  e£fect  upon  one  another  in  these  purely  physical 
systems  correspond  exactly  with  the  proportions  observed  by  Loeb,  Lillie,  Osterhout, 
Matthews,  and  other  investigators  who  have  devoted  their  attention  to  the  phenomenon 
of  antagonistic  electrolyte  effects  on  cell  protoplasm.  From  Osterhout*8  observation 
that  NaCl  diminishes  the  resistance  of  the  tissues  of  certain  marine  organisms  to  the 
passage  of  an  electric  current  and  salts  of  Ca  exert  the  reverse  effect  increasing  the 
resistance,  while  properly  balanced  solutions  of  NaCl  and  CaCl2  exert  no  effect  upon 
the  resistance,  it  may  be  concluded  that  antagonistic  electrolytes  fimction  in  virtue 
of  their  capacity  to  induce  variations  in  permeability  of  the  tissues,  substances  of  the 
one  type  causing  an  increase  and  substances  of  the  opposing  type  causing  a  decrease  in 
permeability.  The  close  parallel  between  the  nature  and  proportion  of  salts  capable 
of  exerting  antagonistic  effects  in  such  purely  physical  systems  as  emulsions  and  the 
drop  system  on  the  one  hand  and  living  cells  on  the  other  suggests  the  extreme  proba- 
bility that  the  mobilization  of  soaps  of  monavalent  cations  in  rapidly  growing  normal 
or  cancerous  tissues  bears  a  direct  relation  to  increased  permeability  with  resulting 
increased  intake  of  foodstufb,  and  that  the  mobilization  of  Ca  in  stationary  or  retro- 
grading nomuU  and  cancerous  tissues  bears  some  relation  to  a  reaction  on  the  part  of 
the  system  against  such  increased  permeability  and  an  attempt  to  induce  a  com- 
pensatory effect. 

The  question  now  arises  as  to  how  such  changes  in  permeability  could  be  induced  in 
pregnancy  or  cancer,  as  to  what  forces  might  possibly  cause  abnormal  lipase  activity 
or  stimulate  the  lipase  normally  present  or  otherwise  lead  to  increased  soap  production 
or  increased  proportion  of  salts  of  monovalent  cations  as  compared  with  divalent 
cations,  thus  leading  to  an  increased  dispersion  of  the  "constituents  of  the  external 
protoplasmic  film  and  a  consequently  increased  permeability  of  the  protoplasmic 


1  Protoplasmic  Equilibrium,  by  G.  U.  A.  Clowes,  Journal  of  Physioal  Chemistry,  voL  30,  p.  407.    Aii> 
tagonistic  electrolyte  Effects  in  Physieal  and  Biological  Systems,  Science,  toI.  48,  p.  760. 


498       PROCEEDINGS  SECOND  PAN   AMERICAN   SCIENTIFIC  CONGRESS. 

system  to  water  borne  foodstufifs  capable  of  affording  thoee  building  materials  necessary 
for  cell  proliferation.  In  experiments  not  yet  published  we  have  noted  marked  ac- 
celeration of  lipase  action  on  fats  induced  by  a  variety  of  agents  which  may  well  be 
present  in  the  body  under  both  normal  and  pathological  conditions. 

It  is  well  known  from  the  experiments  of  Loeb  on  artificial  parthenogenesis  and  of 
Calkins  regarding  the  conditions  under  which  paramecia  may  undeigo  division  with- 
out the  intervention  of  the  sexual  cycle,  that  slight  variations  in  the  concentration  and 
proportions  of  certain  normal  salts  may  induce  cell  division  reaching  many  hifndred 
generations,  a  figure  far  in  excess  of  that  required  to  account  for  cancerous  develop- 
ment as  it  occurs  in  human  beings. 

While  it  is  perfectly  possible  that  toxic  agents  derived  from  parasites  may  under 
certain  conditions  play  an  important  rdle  in  inducing  changes  of  the  type  suggested, 
the  fact  that  physicochemical  phenomena  associated  with  cancer  and  pregnancy 
bear  such  a  striking  resemblance  to  one  another  as  indicated  by  a  large  variety  of  blood 
reactions,  raises  the  question  as  to  whether  both  conditions  may  not  be  induced  by 
similar  variations  in  the  colloidal  equilibrium  of  the  protoplasmic  system.  Cell 
protoplasm  apparently  represents  a  colloidal  chemical  adaptation  to  salts  and  other 
chemicals  originally  present  in  the  environmental  medium  in  which  protoplasmic 
material  first  came  into  being.  This  accounts  for  the  extraordinary  resemblance  in 
the  proportions  of  certain  electroljrtes  in  sea  water  and  the  blood  of  mammals.  With 
marked  variations  in  diet  the  cell  is  obviously  forced  to  exert  an  ever-increasing  selec- 
tive effect  in  order  to  maintain  its  equilibrium  and  ultimately  the  production  of  abnor- 
mal, suboxidized,  metabolic  products  exerting  a  cumulative  effect  taken  in  conjtinc- 
tion  with  an  abnormal  saline  environmental  medium  may  well  lead  to  changes  in 
colloidal  equilibrium  in  the  protoplasmic  cell  structure  of  thoee  tissues  which  exhibit 
an  hereditary  weakness  or  predisposition  to  cancerous  development. 

Peyton  Rous' s  observation  that  the  agent  inducing  chicken  sarcoma  may  be  filtered 
through  a  Berkefeld  bougie,  and  the  observation '  of  Simpson  and  the  writer  that  the 
agent  in  question  may  under  suitable  conditions  be  obtained  from  the  filtered  blood 
plasma  of  cancerous  chickens,  is  in  no  sense  incompatable  with  the  mechanistic  con- 
ception outlined  above.  It  may  be  demonstrated  by  experiments  with  purely  physi- 
cal systems  that  under  given  conditions  of  saline  equilibrium  an  agent  capable  of 
exerting  a  profound  effect  upon  the  surface  tension  of  dispersed  colloids  may  be  passed 
through  a  bougie  and  may  subsequently  induce  a  cycle  of  changes  resulting  in  the 
production  of  a  further  proportion  of  the  substances  in  question  and  subsequent 
further  development  in  liie  same  direction,  the  process  being  analogous  to  an  exo- 
thermic chemical  reaction  like  an  explosion  as  contrasted  with  an  endothennic 
reaction. 

While  biologists  have  generally  believed  that  the  temporary  intervention  of  pbysical 
or  mechanical  agents  could  not  induce  permanent  changes  in  protoplasmic  equilibrium 
which  would  find  expression  in  permanent  changes  many  hundreds  of  generations 
after  the  removal  of  the  cell  from  the  influence  of  the  agents  in  question,  it  must  be 
recognized  6rom  the  experiments  of  Ehrlich  regarding  the  action  of  certain  chemicals 
on  trypanosomes  and  from  the  experiments  referred  to  above  that  changes  of  this  type 
sufficiently  permanent  to  account  for  cancerous  proliferation  may  well  be  induced  by 
chemical  or  physical  forces.  In  the  present  state  of  our  knowledge  it  is  impossible  to 
determine  whether  a  para^te  pla3rs  any  direct  or  indirect  r61e  in  the  jHtKluction  of 
cancer,  but  it  is  perfectly  conceivable  that  the  filterable  agent  obtained  by  Peyton 
Rous  bears  a  direct  relation  to  substances  isolated  from  the  tissues  by  Robertson  and 
others  which,  even  when  emplo3red  at  extreme  dilution,  are  capable  of  inducing  mem- 
brane formation  in  the  eggs  of  certain  marine  organisms. 

>  Am.  MJd.  ASMO.  Vol.  64,  p.  1526. 


PUBLIO  HBALTH  AKD  MBDIOIKS.  499 

The  Chairman.  These  papers  are  now  open  for  discussion. 

Dr.  J.  Bbonfbnbbenneb.  The  paper  which  Dr.  Clowes  presented 
yesterday  broadens  out  a  good  many  questions  in  immunity.  I  have 
come  to  the  conclusion  that  at  least  a  part  of  anaphylaxis 
due  to  extra-cellular  phenomena  has  been  plainly  proven  in  our 
experiments  to  depend  on  physico-chemical  changes  in  these  media. 
If  t^e  experiments  of  other  investigators  are  correct,  it  is  easy  to  show 
that  by  dissolution  of  lipoids.  I  was  able  to  produce  the  phenomenon 
by  merely  passing  vapor  through  the  serum.  By  means  of  this 
method  I  was  able  to  dissolve  Upoids  and  spUt  up  the  particles  which 
probably  are  constructed  in  the  manner  illustrated  by  Dr.  Clowes. 
The  proteolytic  enzyme  digests  the  protein  of  the  serum  and  forms 
very  toxic  products.  I  do  not  mean  to  say  that  all  of  anaphylaxis 
is  taking  place  in  the  blood  serum,  as  I  am  sure  that  essentially  the 
same  elements  are  present  in  the  cells  as  in  the  serum,  and 
that  a  certain  amount  of  proteolysis  must  be  taking  place  also  in  the 
cells.  I  would  like  to  have  Dr.  Clowes  explain  the  fact  that  com- 
bination of  antigen  and  antibody  seems  to  be  doing  the  same  sort  of 
work  as  a  combination  of  calcium  and  sodium,  or  calcium  and 
potassium;  that  is  to  say,  how  does  it  happen  that  in  certain  quan- 
titative Umits  a  combination  of  specific  antigen  with  its  correspond- 
ing antibody  does  break  the  film  around  the  protein  molecule  and 
liberates  substances  within  f  That  combination  of  antigen  with  anti- 
body would  thus  break  up  the  outer  film  and  then  liberate  the  sub- 
stances. That  the  surface  tension  is  very  essentially  involved  in 
the  phenomenon  we  have  proven  in  experiments.  There  is  no  doubt 
that  the  phenomenon  is  entirely  physico-chemical,  as  we  tried  to 
emphasize  yesterday. 

Dr.  E.  F.  Smfth.  I  wish  to  say  a  word  about  some  work  that  has 
been  done  in  the  Department  of  Agriculture  on  the  effect  of  removal 
of  calcium  from  balanced  solutions  in  which  plants  are  grown.  Dr. 
Rodney  Drew  and  Mr.  Bartlett  made  a  long  series  of  experiments  by 
growing  certain  plants  in  balanced  solutions  from  which  calciiun  had 
been  withdrawn.  The  result  seems  to  be  that  the  membranes  become 
very  permeable  and  fluids  or  substances  pour  out  from  these  plants 
into  the  solution  as  soon  as  we  remove  the  calcium.  Ton  add  the 
calcium  and  the  membrane  becomes  more  impermeable.  The  results 
were  measured  electrically  by  the  electrical  apparatus  and  I  think 
that  there  can  be  no  doubt  about  that  result.  As  to  the  occurrence 
of  potassiiun  in  these  rapidly  growing  tumors,  I  think  it  may  be 
true  in  all  life  that  young,  actively  growing  parts  had  more  potassium 
than  the  older  parts.  It  is  certainly  true  of  some  plants  that  young 
actively  growing  normal  tissues  have  more  of  potassium  than  of  cal- 

68436— 17— VOL  x 88 


500       PBOOSEDIKGS  BBOOND  PAN  AMBSIOAK  SOIBNUFIO  OONGBEa& 

cium.  As  the  growth  becomes  more  mature  the  amomit  of  potassium 
decreases  and  the  amomit  of  calcimn  increases. 

The  CHAiBBfAN.  Will  you  close  the  discussion,  Dr.  Clowes  ? 

Dr.  Clowes.  The  experiments  which  Dr.  Smith  mentions  have  also 
been  made  by  Osterhaut,  showing  that  sodium  chloride  will  lower 
and  calcium  will  increase  the  resistance  of  certain  marine  substances, 
laminari»,  etc.  He  has  tried  it  out,  and  his  curves  with  aU  known 
elements  correspond  with  my  own  curves,  which  I  have  shown  here. 
Furthermore,  at  a  meeting  in  Boston  recently,  he  said  he  had  curves 
to  duplicate  my  own  which  he  had  not  yet  published. 

As  regards  the  question  of  antigen  and  antibody,  I  do  not  think  it 
belongs  in  this  discussion.  I  have  already  produced  results,  as  I 
explained,  in  which  I  have  duplicated  with  antigen  and  antibody  in 
various  ways  these  very  same  effects,  producing  an  increase  in  per- 
meability, in  the  drops,  by  means  of  an  antigen-antibody  combina- 
tion, and  coimteracting  them  by  means  of  calcium  in  the  specific  way 
we  mentioned  when  dealing  with  hay  fever  and  other  anaphylactic 
phenomena. 

As  regards  the  question  of  enzymes,  I  look  upon  enzymatic  effect 
as  simply  the  promotion  of  contact  between  the  otherwise  non- 
missible  phases,  thus  permitting  constituents  of  one  phase  to  exert 
chemical  or  physical  effects  on  constituents  of  the  other  phase.  If 
this  effect  is  dispersion,  it  is  simply  a  lowering  of  surface  tension, 
whereby  the  particles  more  readily  fly  apart;  if  aggregation,  a  height- 
ening of  surface  tension.  And,  of  course,  what  takes  place  is  that  the 
dispersion  or  breaking  up  of  any  stabilizing  film  around  the  cell  will 
render  the  passage  of  substances  contained  in  that  cell  more  easy. 

The  Chairman.  The  next  paper  is  by  Dr.  Wood. 


RADIUM  m  EXPERIMENTAL  CANCER. 

By  FRANCIS  CARTER  WOOD, 
Director  of  Cancer  Reiearch,  Oeorge  Crocker  Special  Research  Fund,  Columbia  Univerntjf. 

While  there  are  many  interesting  biol(^cal  problems  connected  with  the  action  of 
radium  on  tissues,  we  are  concerned  chiefly  in  determining  its  value  as  a  therapeutic 
agent  in  neoplasms  of  man.  It  is,  however,  extremely  difficult  to  apply  the  necessary 
scientific  criteria  to  the  investigation  of  human  tumors,  as  it  is  impossible  always  to 
obtain  satisfactory  specimens  for  microscopical  examination,  espedally  if  the  tumor 
is  in  the  internal  organs;  the  danger  of  overtreatment  with  resulting  severe  bums  is 
always  imminent;  and,  finally,  we  are,  in  this  country  at  least,  unable  to  obtain  any 
satisfactory  proportion  of  autopsies  on  persons  dying  from  any  cause  after  treatment. 
The  result  of  this  imsatisfactory  condition  is  that  the  medical  literature  is  filled  with 
practically  worthless  reports  of  the  effect  of  radium  on  tumors.  In  very  few  of  these 
reports  is  any  statement  made  as  to  whether  the  tumor  was  examined  microscopically, 
or  whether  the  patient  was  kept  under  observation  for  a  time  sufficient  to  warrant  any 
opinion  as  to  the  ultimate  cure.    In  fact,  many  cases  have  been  reported  a  few  weeks 


PUBUC  HEALTH  AND  MEDICINE.  501 

after  treatment,  when  any  opinion  is  absolutely  valuelees,  and  many  of  the  reports 
which  are  published  as  showing  that  benefit  has  resulted  from  the  treatment  concern 
patients  who  are  already  dead  from  the  disease.  Such  publications  are  worse  than 
useless,  for  they  are  misleading  as  regards  the  real  therapeutic  value  of  radium.  It 
is  much  more  important  for  us  to  know,  not  the  number  of  successes,  but  the  number 
of  failures  and  their  proportion  to  the  successes. 

It  is  my  opinion  that  the  percentage  of  cures  of  cancer — and  this  opinion  is  based 
not  only  upon  personal  experience,  but  upon  a  wide  survey  of  the  literature  of  the  last 
10  years — is  extremely  small  and  largely  confined  to  certain  groups  of  tumors,  among 
them  the  basal-cell  tumors  of  the  face,  the  epulides  of  the  jaw,  the  giant  cell  sar- 
comata of  the  long  bones,  the  adenocarcinomata  of  the  uterine  body,  and  certain 
lymphosarcomata.  All  of  these  tumors,  as  is  well  known  by  those  of  sufficient  expe- 
rience, either  may  undergo  a  spontaneous  disappearance,  at  least  for  such  perioda 
as  would  warrant  the  diagnosis  of  a  clinical  cure,  or  are  curable  in  some  instances 
by  the  mere  removal  of  the  main  mass;  although  later,  especially  in  the  case  of  the 
lymphosarcomata,  a  fatal  recurrence  is  frequent.  For  these  and  other  reasons  it  is 
necessary  to  turn  to  spontaneous  or  implanted  tumors  in  animals  as  a  means  of  scien- 
tificaUy  testing  the  therapeutic  value  of  radium. 

First,  it  is  important  to  know  what  the  minimal  lethal  doee  of  radium  is  for  cancer 
cells  outside  of  the  animal;  the  viability  of  the  treated  cells  being  tested  by 
inoculation  after  treatment.  Such  experiments  have  shown  that  when  the  alpha 
rays  are  removed  by  suitable  filters,  100  milligrams  of  radium  element  at  a  distance  of 
apjNTOximately  5  millimeters  require  one  hour  to  kill  carcinoma  or  sarcoma  cells  of 
the  mouse  or  rat  in  vitro.  If  the  filter  used  is  of  sufficient  thickness  to  remove  all 
of  the  bet%  rays  also,  the  time  required  is  increased  seven  or  eight  fold.  The  experi- 
ments have  shown  that  in  order  to  produce  these  effects  no  other  factors  are  in  play 
except  the  amount  of  radium,  the  length  of  the  exposure,  and  the  distance  between 
the  radium  and  the  tumor  cells.  This  fumishes,  then,  a  lethal  coefficient  which  can 
be  plotted  as  a  simple  rectangular  ciurve  and  by  means  of  this  anyone  can  deter- 
mine the  exact  length  of  time  required  to  kill  a  cancer  cell  at  a  given  distance  with 
a  given  amount  of  radium.  The  experiments  have  shown  also  that  sublethal  doses 
slow  the  growth  of  cancer  cells,  while  still  smaller  doses  stimulate,  and  they  confirm 
the  observations  made  on  human  beings,  that  with  sublethal  doses  healing  of  a  car- 
cinomatous ulcer  may  be  produced,  while  the  cancer  itself  keeps  on  growing  in  the 
lower  layers  and  is  either  slowed,  stimulated,  or  uninfluenced,  depending  upon  the 
amount  of  radiation  reaching  the  cells. 

These  phenomena  explain  the  sometimes  astonishing  increase  in  the  growth  rate 
which  has  been  observed  after  the  treatment  of  human  tumors  with  insufficient 
radium,  and  also  explains  the  very  late  recurrences  which  have  occasionally  been 
noted  after  treatment  with  radium  or  X-ray.  Some  of  these  recurrences  have  occurred 
some  years  aftw  treatment,  the  cells  remaining  quiescent  in  the  tissue  for  that  period . 

Second,  it  is  necessary  to  find  the  lethal  dose  of  radium  for  cancer  cells  when  these 
are  left  in  the  tianies  with  their  full  blood  supply,  and  experiments  carried  out  to 
determine  this  have  shown  that  the  amount  of  exposure  required  to  produce  the 
same  results  is  considerably  greater,  in  fact,  nearly  double  the  amount  required  in 
vitro.  Evidently  there  is  some  interference  with  the  destructive  action  of  the  rays 
caused  by  the  renewal  of  the  cell  substance  through  the  circulation. 

Third,  it  is  important  to  find  the  lethal  coefficient  for  human  cancer.  So  far  as 
clinical  experience  goes,  the  lethal  death  point  of  animal  and  human  tumor  cell» 
is  very  nearly  the  same,  and  there  is  no  reason  to  think  that  there  should  be  much 
difference.  Inasmuch  as  it  is  impossible  to  inoculate  human  cancer  cells  after  treat* 
ment,  it  has  been  necessary  to  grow  them  in  culture,  a  procedure  which  is  attended 
by  many  complications  and  tec-hnical  difficulties,  but  which  is  now  in  progress  in 
the  Crocker  laboratory.    There  is,  however,  another  factor  which  appears  in  the 


502       PBOCEEDINGS  SECOND  PAN  AMEBICAN   SCIENTIFIC   CONGRESS. 

treatment  of  human  material  and  that  is,  that  it  is  probably  not  necessar}-,  in  order 
to  produco  a  cure,  to  kill  all  of  the  cells;  but  that  if  a  certain  amount  of  radiation 
is  given,  the  closure  of  the  blood  vessels  by  the  endarteritis  which  the  radium  pro- 
duces and  the  new  growth  of  connective  tissue  induced  as  a  repair  process  fbllowinft 
the  arterial  thrombosiB  and  as  a  direct  effect  of  the  irritating  action  of  the  radium  on 
normal  tissues,  may  effect  a  choking  of  a  certain  amount  of  the  carcinoma,  and  pro- 
duce a  temporary  or  symptomatic  improvement  of  very  considerable  extent.  This 
may  explain  the  fact  that  in  some  cases  less  exposure  is  needed  to  cure  a  small  human 
cancer  of  low  virulence  than  to  kill  a  mouse  cancer  in  vitro. 

Experiments  in  treating  primary  tumors  of  animals  and  the  results  of  treatment  of 
human  cancers  of  high  malignancy  have,  however,  shown  that  in  thoee  portions  of  the 
growth  where  the  cells  of  the  ttunor  are  in  contact  with  normal  structures  it  is  eon- 
trem3ly  difficult  to  destroy  the  healthy  blood  vessels  and,  therefore,  to  influence  the 
diell  of  carcinoma  tissue,  which  still  remains,  even  though  the  main  mass  may  have 
disappeared  under  the  influence  of  the  radium.  It  is  from  this  shell  of  actively 
growing  neoplasm,  thin  as  it  may  be,  that  recurrence  takes  place,  and  this  is  the  diffi- 
cult phase  for  any  permanent  cure.  It  is  generally  stated  in  textbooks  and  held  by 
many  workers  that  a  cancer  cell  is  more  susceptible  to  any  destructive  agent  than  is  a 
healthy  cell.  This  is  very  doubtful ;  it  is  probable,  though  not  as  yet  decisively  duywn, 
that  a  rapidly  growing  epithelial  cell  is  just  as  susceptible  to  the  action  of  radium  as  a 
rapidly  growing  cancer  cell  derived  from  the  same  tissue.  We  must  always  remember 
that  the  blood  vessels  in  cancer  tissue  are  thin  walled  and  without  vasomotor  nerves, 
and  that  they  are  very  easily  injured,  or  even  destroyed,  by  toxic  agents,  such  as 
bacterial  toxins,  which  have  been  widely  used  in  the  form  of  the  toxins  of  streptococcus 
and  prodigiosus,  by  the  action  of  colloidal  metals,  and  even  by  adrenalin,  niiiich 
simply  raises  the  blood  pressure  and  causes  hemorrhages  throughout  the  tumor,  prob- 
ably by  mechanical  tearing  of  the  delicate  walls  of  the  capillaries.  Following  iay  of 
these  treatments  there  may  be  a  central  necrosis  of  the  tumor  with  a  loss  of  a  very 
considerable  portion  of  the  mass;  but  ultimately  recurrence  takes  place  from  the 
periphery. 

In  a  very  few  cases  unquestionaoly,  and  especially  in  tumors  of  the  vwiety  men- 
tioned in  the  first  part  of  this  paper,  the  balance  between  the  tissues  and  the  new 
growth  is  so  delicate,  so  easily  overthrown  spontaneously,  that  the  healthy  tissues 
may  be  victorious  and  all  the  cancer  cells  ultimately  destroyed,  but  in  the  vast 
majority  of  virulent  tumors  this  delicacy  of  balance  does  not  exist;  the  cancer  cells 
do  not  induce  any  reaction  against  themselves  by  their  growth,  or  at  least  sufficient 
reaction  to  be  of  any  therapeutic  benefit,  and  despite  a  certain  amount  of  central 
sloughing  a  continuation  of  growth  is  to  be  observed  with  ultimate  extension  of  the 
tumor,  the  formation  of  metastases,  and  the  death  of  the  patient. 

To  a  certain  extent  we  are  able  to  judge  the  type  of  tumor  which  may  be  influenced 
with  radium.  That  is,  any  tumor  rich  in  giant  cells,  especially  of  the  myeloplax 
type,  as  epulides  of  the  jaw  and  the  central  sarcomata  of  the  bone  epiphyses,  is  mcnre 
easily  influenced  than  any  other  type  of  sarcoma.  The  basal-cell  epitheliomata  of 
the  upper  portion  of  the  face,  and  tiie  adenocardnomata  of  the  body  of  the  utems, 
which  are  of  low  invasive  power  and  not  infrequently  cured  by  simple  curettage,  are 
especially  susceptible  to  radium  and  may  therefore  be  influenced,  but  exceptions 
occur  in  the  experience  of  everyone  who  has  used  this  agent,  and  therefore,  until  we 
have  much  more  knowledge  of  the  biology  of  these  tumors,  it  is  impossible  to  guarantee 
that  radium  will  in  all  cases  favorably  influence  them.  Until  we  know  exactly 
what  raditun  will  do  it  is  improper  to  apply  it  to  operable  tumon,  and  we  ought, 
therefore,  In  our  experiments  on  human  beings  still  to  use  only  such  tumofs  as  are 
decided  to  be  absolutely  inoperable. 


PUBUO  HEALTH  AND  HBIXIOINB.  503 

The  Chaibman.  I  take  pleasure  now  in  announcing  Dr.  William 
Duane,  the  writer  of  the  next  paper. 


RADIUM  IN  THE  TREATMENT  OF  CANCER. 

By  WILLIAM  DUANE. 

The  Cancer  Comimssion  of  Harvard  Univerrity. 

Soon  alter  iUnt0«i  diiooyered  X  vayB  in  1895,  Becquerel,  of  Paris,  fauncl  that  cer> 
tain  umaimn  aalta  produced  rays  similar  to  them.  About  two  yean  later  Moiiaieur 
and  Madame  Curie  micoeeded  in  extracting  from  pitchblende  two  new  elements, 
pc^nium  and  radium,  which  ponees  this  property  of  emitting  peculiar  types  of  rays 
to  an  exceptionally  marked  degree.  In  1809  Danlos  commenced  studying  the  effects 
of  vadium  ra3rs  on  certain  skin  lesions.  Thus  radium  thereapy  had  its  b^^inning  at 
the  close  of  the  last  century,  and  is  about  16  yean  old. 

In  the  early  history  of  the  subject  most  of  the  radium  treatments  conaieted  in  apply- 
ing to  the  lesions  oontainen  (umiaUy  glass  tubes)  with  radium  salts  in  them.  Some- 
times these  tubes  were  inserted  into  the  mass  of  the  tumor  itself.  Soon,  however, 
this  crade  method  gave  place  to  a  more  scientific  technique.  A  number  of  adentists, 
a  physicist,  a  che  <  ist,  a  pathologist,  a  cKnitian,  etc.,  grouped  themselves  together 
vnder  the  leadership  ci  Wickham  and  in  1905  began  a  thoroufl^  study  of  radium 
therapy.  They  invented  an  elaborate  instmm«itaiium  and  devised  several  methods 
of  tmntemt,  among  which  the  ''cross-fire"  and  "filtration"  methods  may  be  men- 
tisaed.  Radium  therapy  having  attained  some  success,  especially  in  the  treatment 
of  small  superficial  lesions,  a  number  ei  individuals  and  institutions,  both  in  Europe 
and  America,  underto<^  the  systematic  application  of  radium  to  a  great  variety  of 
pathological  conditions.  Among  these  institutiens  the  Radium  Institute,  of  London, 
may  be  mentioBed.  This  institute  has  several  grams  of  radium  at  its  disposal,  and 
was  the  first  actually  to  use  large  quantities  of  emanation  as  a  substitute  for  radium 
in  the  treatment  of  tusaon,  it  having  been  proved  yean  before  in  Paris  that  the 
emanation  of  radium  by  itself  and  apart  from  the  radium  produces  profound  physio- 
logieal  diaages.  At  Harvard,  in  tiie  cancer  commission's  hospital,  we  have  been 
using  several  methods  I  devised  lor  applying  the  deposited  activity  of  radium  (radium, 
A.  B.  C).  Radium  transforms  itself  into  radium  emanation,  and  the  emanation  in 
turn  transforms  itself  into  radium  A.  B.  C.  It  is  a  well-known  foct  that  the  rays  umially 
used  in  radium  therapy  come  from  radium  A.  B.  C.  and  not  from  radium  itself  or  its 
emanation.  The  first  treatments  by  Uiese  methods  were  made  by  the  author  in  collab- 
oration with  Dr.  Gieenoug^,  Dr.  Tyzzer,  and  Dr.  Ordway  in  1913.  The  methods  have 
proved  to  be  very  flexible  and  it  is  possible  by  them  to  obtain  very  intense  radiation 
ovw  a  sharply  defined  suHace  or  throughout  a  given  tumor  mass. 

The  fundamental  problem  involved  in  treating  a  tumor  with  radium  may  be  stated 
ttas.  Having  a  tumor  of  a  certain  sIeo  and  shape,  one  must  send  through  it  a  quan- 
tity of  radiation  sufildent  to  kill  all  the  tumor  cells  with  as  little  irritation  of  normal 
tissues  as  possible.  The  solution  of  this  problem  is  laigely  a  question  of  physical 
sdoKGe.  Hiere  are  more  than  80  known  radioactive  substances  emitting  in  different 
degrees,  one  or  more  of  four  different  kinds  of  rays,  and  one  must  choose  a  sufiicient 
amount  of  the  proper  substance,  place  it  in  the  right  position  in  or  near  the  tumor, 
aad  leave  it  there  for  a  sufiBcient  length  of  time.  Evidently  judgment  as  to  quantitive 
lelatiiHis  enten  as  an  important  factor  into  the  selection  of  the  proper  mode  of  pro- 
oedure. 


504       PB00EBDIKG8  8E00KD  PAK  AMEBIOAK  80IENTIFI0  00KGBE88. 

• 

Some  interestmg  principlee  underlie  the  metliodB  of  treatment  mentioned  above 
The  "cro09-fire"  method  is  based  on  the  geometry  of  radiation.  The  "filtiatioa" 
method  was  devised  for  the  purpose  of  cutting  out  those  easUy  absorbed  rays  that 
would  not  penetrate  fsa  enough  into  the  tissues.  We  know  that  the  radium  series  oC 
substances  emit  more  than  64  diff^ent  kinds  of  /9  rays  and  14  different  kinds  of  pene- 
trating y  rays.  These  differ  from  each  other  enormously  in  penetrating  power.  The 
more  easily  absorbed  kinds  of  the  /9  rays  are  completely  stopped  by  thin  layeis  oC 
tissue,  whereas  these  same  layers  absorb  only  a  very  small  fracticm  of  the  penetiatiog 
y  rays.  Thus  the  amount  of  radiation  absorbed  by  a  given  thickness  of  tissue  is  not 
at  all  proportional  to  the  amount  of  radiation  that  enters  it. 

Usually  radium  treatments  are  given  for  lengths  of  time  that  vary  in  differait  cases 
from  a  few  minutes  to  60  or  70  hours.  The  relative  value  of  the  small  dose  for  a  long 
time  and  a  large  dose  for  a  short  time  has  not  been  very  completely  investigated.  I 
propose  in  this  paper  to  present  some  observations  on  the  effects  produced  on  car- 
cinoma tissue  by  "  prolonged  radiation  *'  with  0  and  y  rays.  By  the  torms  "  pndonged 
radiation  "I  mean  radiation  lasting  continuously  for  a  month  or  six  weeks.  Of  course 
small  quantities  of  the  radioactive  substances  are  used,  whidi  is  a  great  advantage, 
considering  the  price  of  radium. 

The  technique  of  the  treatments  is  as  follows:  A  small  quantity  of  radium  emana- 
tion (from  3  to  10  millicuries)  is  extracted  from  the  radium,  purified,  and  compressed 
into  a  tiny  glass  tube  (length  3-5  mm.,  diameter  i  mm.).  A  brief  description  of  the 
method  of  doing  this  that  I  have  devised  may  not  be  out  of  place.  The  emanation  is 
a  chemically  inert  gas,  and  a  millicurie  is  the  quantity  of  emanation  that  is  associated, 
or  in  equilibrium,  with  a  milligram  of  radium  element. 

The  general  principles  of  the  method  of  purification  are  those  previously  employed 
by  Ramsay  and  Soddy,  Ruth^ford,  and  Debieme,  in  some  of  their  most  important 
researches.  The  advantages  of  my  method  described  below  are :  That  the  purification 
does  not  require  liquid  air;  that  a  large  number  of  millicuries  of  emanation  can  be 
purified  and  compressed  into  a  small  fraction  of  a  cubic  millimeter,  in  10  or  15  minutes 
of  time;  that  no  emanation  is  lost  except  that  due  to  its  natural  decay;  and  that  the 
process  may  be  repeated  a  great  many  times  without  renewing  parts  of  the  apparatus. 

The  drawing^  represents  the  arrangement  of  the  glass  tubes  and  reservoirs.  The 
bulb  A  contains  the  radium  salt  dissolved  in  water.  Radium  in  solution  continually 
decomposes  the  water  into  hydrogen  and  oxygen,  and  at  the  same  time  transforms 
itself  into  the  emanation,  which  is  set  free.  The  total  volume  of  the  hydrogen  and 
ox3rgen  amounts  to  more  than  two  hundred  thousand  times  that  of  the  emanation  at 
the  same  pressure  and  temperature.  In  addition  to  the  oxygen  and  hydrogmi  and 
emanation,  a  small  quantity  of  helium  appears  (the  volume  of  which  is  a  few  per 
cent  greater  than  that  of  the  emanation)  and  also  traces  of  other  gases,  probably  carbon 
dioxide  and  hydrocarbons  coming  from  the  decompoeiticm  of  (Hganic  impturities^ 
although  the  source  of  these  traces  of  gas  does  not  seem  to  be  thoroughly  understood. 
On  account  of  its  radioactive  transformation,  the  exact  proporticm  between  the  quan^ 
tity  of  emanation  and  the  gases  with  which  it  is  mixed,  depends  upon  the  length  of 
time  the  gases  are  allowed  to  accumulate.  In  the  ordinary  daily  routine  of  our 
laboratory,  however,  the  problem  resolves  itself  into  the  extraction  of  35  to  60  miUi- 
curies  of  emanation  having  a  volume  of  0.021-0.036  mm.  at  atmospheric  pressure 
and  ordinary  temperature,  from  a  mixture  of  gases,  having  a  volume  of  4.5  to  9  c.c.  at 
the  same  temperature  and  pressure. 

The  mixture  of  gases  collects  in  A  and  the  tube  B,  and  also,  if  the  passnge  is  open^ 
in  the  reservoir  C.  Allowing  the  gases  to  collect  in  C  apparently  increases  the 
efficiency,  probably  because  the  emanation  defuses  from  the  solution  into  a  large 
volume  more  freely  than  into  a  small  one.  The  tube  B  is  considerably  longer  than 
76  cm.  so  that  air  may  be  admitted  into  C,  if  desired,  without  its  finding  its  way  up 


FDBLIO  HKALia  AHD  MEUOUrK. 


505 


to  tli«  radium  Bdntion,  Tba  tnp  mt  B  protects  a^dnat  merctuy  spnrtiiig  up  into 
the  radium  aolutioD,  should  some  of  the  glan  appantua  break.  An  wdinarr  water 
aapiiator  witli  suitable  stopcocks  controls  the  flcpw  of  mercury  between  th«  reaervoin 
C  and  D.  On  admitting  the  air  into  D,  the  mercury  risea  in  C,  pushing  the  mixtun 
•  of  gaeee  through  the  mercury  trap  E,  into  tubes  F.  The  mercury  in  the  tnp  B  hirida 
back  all  but  a  very  small  quantity  of  the  water  v»por.  The  tubes  ^contain  a  copper 
wire  slightly  osidiied,  phoaphorpeatoxide  and  potasaum  hydroxide.   Although 


n  the  figure  in  a  vertical  postton,  the  copper  wire  really  lies  horiiontal. 
It  is  wound  on  a  quarts  rod  supported  by  feet,  ao  that  the  wire  doee  not  touch  the  inner 
iurbce  ot  the  tube  at  any  point.  The  diameter  of  the  wire  is  0.3  mm.  and  the  length 
of  the  coil  25  c.  m.  When  heated  red  hot  by  an  electric  current  of  5-10  amperea  it 
rapidly  combinea  the  oxygen  and  hydrogen,  the  phosphrapentoxide  absorbing  the 
water  vapw  formed.    A  small  amount  of  copper  oxide  on  the  wire  is  required,  becauaa 


506       PB00EEDIKQ6  8E00HD  PAK  AMBBIOAK  80IEVTIFI0  OOVOBBSS. 

the  mixture  of  gasee  contains,  at  least  at  first,  a  quantity  of  hydrogen  that  exceeds 
by  a  few  per  cent  the  proportion  required  by  the  chemical  formula  for  water.  Sooda 
oxygen  remains  in  the  ladium  solution  as  hydrogen  peroxide.  The  copper  wire  was 
heated  for  a  long  time  to  remove  as  much  d  the  occluded  gases  as  possible,  and  the 
phosphorpentoxide  was  distilled  into  its  present  position  from  a  tube  sealed  on  Jnet 
bdow  it,  and  afterwards  removed;  both  of  these  processes  taking  place  in  vacvum. 
The  potassium  hydroxide  is  for  the  purpoee  of  absorbing  any  carbon  dioxide  that 
may  be  present,  or  may  be  formed  by  the  hot  copper  wire  oxidizing  hydrocaibon 


After  the  purification  of  the  emanation  the  mercury  in  the  reservoir  6  is  drawn  into 
J7,  the  air  being  removed  from  H  by  the  water  aspirator,  and  the  emanation  and  helium 
pass  into  O.  The  gases  are  then  pushed  up  by  the  mercury  through  the  stopcock  / 
and  into  a  capillary  tube,  which  is  sealed  cm  at  N.  ThQ  volume  of  the  helium  being 
very  small  it  is  unnecessary  to  remove  it.  The  length  of  the  tube  connecting  B  with 
Q  should  be  so  great  that  air  may  be  admitted  into  O  without  forcing  the  mercury  up 
intof. 

The  stopcock  /  has  a  mercury  seal  and  contains  no  stopcock  grease.  A  few  maikB 
made  with  a  lead  pencil  on  the  stopper  allow  it  to  turn  freely.  It  will  be  noticed  thftt 
the  emanation  passes  througji  no  stopcock  except  the  one  at  J,  and  even  this  is  unnecea- 
sary  and  has  been  added  for  convenience  of  manipulation  only.  The  ^t  that  stopcock 
grease  and  many  other  organic  substances  are  decomposed  by  the  rays  from  the  emana- 
tion and  give  ofif  gases  is  well  known. 

The  system  of  tubes  and  bulbs  iT,  L,  Jf  is  for  the  purpose  of  removing  the  air  from 
the  oth^  tubes  and  reservoirs,  etc.,  by  means  of  a  pump  attached  at  M,  This  must 
be  done  at  the  beginning,  and  after  that  no  air  enters  the  reservoirs  except  occasionally 
when  it  becomes  necessary  to  rmiew  the  oxidised  copper  wire  (ht  the  phoepluvpent* 
oxide,  etc. 

The  apparatus  in  our  laboratory  has  been  in  continuous  daily  use  for  more  than  two 
years.  The  bulb  A  contains  over  220  miUigrams  of  radium  (element),  and  the  total 
quantity  of  emanation  purified  per  month  amounts  to  slighUy  more  than  one  curie 
of  emanation,  which  is  the  quantity  of  emanation  in  equilibrium  with  one  gram  of 
radium  (element). 

Afttf  the  emanation  has  been  pushed  up  into  the  capillary  tube  at  N  suitable  lengths 
of  it  containing  the  required  amounts  of  emanations  are  scaled  off  by  means  of  a  tiny 
gas  jet. 

In  making  a  treatment  several  of  these  tubes  are  inserted  through  a  small  trochar 
into  the  tumor  or  necrotic  tissue  and  left  there  indefinitely.  Great  care  must  be  taken 
in  placing  the  tubes.  They  should  not  lie  too  near  the  normal  tissues  but,  on  the 
other  hand,  they  must  be  so  distributed  that  all  parts  of  the  tumor  receive  adequate 
radiation.  I  have  seen  carcinoma  cells  destroyed  at  a  distance  of  2  c.  m.  from  one  of 
these  tubes,  whereas  normal  epithelium  may  continue  to  live  within  much  less 
than  1  c.  m.  of  one.  Several  of  the  tubes  properly  placed  produce  an  effective  croos- 
fire. 

As  stated  above,  the  emanation  transforms  itself  into  radium  A.  B.  0.  and  the  radium 
A.  B.  0.  produces  the  rays  that  penetrate  the  tissues.  Now  the  emanation  gradually 
disappears.  The  law  of  decay  is  such  that  one-hidf  a  given  quantity  will  have  trans- 
formed itself  and  disappeared  in  3.85  days.  Thus  at  the  end  of  four  days  about  half 
of  the  emanation  remains,  at  the  end  of  eight  days  only  one-fourth  renuuns,  and  at 
the  end  of  a  month  there  is  scarcely  any  left.  If  the  case  warrants  it  new  tubes  may 
be  inserted  at  the  end  of  one  or  two  weeks  so  as  to  keep  up  a  more  uniform  fiow  of 
/9  and  y  rays. 

The  treatment  produces  surprisingly  little  irritation  in  surrounding  healthy  tissues. 
This  was  contrary  to  my  expectations.  In  several  cases  tubes  have  been  placed 
within  2  or  3  cm.  of  the  eye  without  producing  an  effect  beyond  a  slight  increase  in 


FUBUO  HBALIH  AM)  MMfOIHa  607 

tke  ilow  of  lean.  Hie  side  of  t^  no0e,  too,  wm  not  bumed,  only  a  aliglit  orsrthema 
appearisf  there.  One  patient  ckune  to  have  been  conidoiit  of  a  aeniation  of  ligkt 
with  the  eyelidB  ckMsed  and  in  a  dark  room.  This  k  a  well-known  i^Mnomenon  and 
k  Mpposed  to  be  d«e  to  a  alight  plMq>horeeoence  produced  by  the  raye  in  tome  siib- 
Btance  in  the  eyeball. 

The  tect  that  the  rays  have  such  a  pronounced  destructive  effect  in  the  immediate 
nei^boihood  of  a  tube  and  exert  very  little  infiuence  a  short  distance  from  It  is  doe 
not  coaly  to  the  law  according  to  which  radiation  from  a  point  decreases  as  the 
square  of  the  distance  but  also  to  the  great  absorbibility  of  the  majority  of  the  fi 
rays.  No  effect  can  be  produced  by  rays  without  absorption  of  energy,  and  H  would 
seem  in  general  advisaMe  to  use  those  rays  a  large  fractkn  of  the  energy  of  which  is 
absorbed  by  the  tissues,  rather  than  those  rays  which  pass  through  without  producing 
much  change.  This  is  contrary  to  the  general  practice  of  so-called  deep  radium 
tiMrapy  in  which  the  easily  absorbed  rays  are  cut  off  by  screens.  In  the  method 
we  are  now  discusBing  the  deepei^lying  tissues  are  reached  by  actually  pladng  the 
source  of  the  rays  near  tham.  The  thinness  of  the  walls  of  the  glass  tubes  allows 
the  easily  absorbed  rays  to  pass  through  into  the  tissues. 

Some  experimental  evidence  has  besn  obtained  In  favor  of  the  yUm  that  radiation 
has  a  greater  effect  on  tissue  cells  during  certain  periods  of  their  life  history  than  at 
other  times.  If  this  is  true  in  general,  prolonged  radiation  will  catch  a  larger  pro- 
portion of  the  cdls  during  their  more  wlnefable  periods  than  radiation  of  short  dura- 
tion wUl. 

Some  details  of  the  destruction  of  cavdnomata*  and  of  subsequent  tissue  repair 
are  given  below. 

The  adjoined  reproductieBs  from  untondied  photografte  represent  the  first  three 
superficial  cardnomata  that  have  ever  been  treated  by  tiie  prolcmged  radiation 
method.  Bach  case  is  illustrated  by  a  scries  of  photographs  showing  the  destruction 
of  carcinoma  tissue  and  the  subsequent  repair. 

The  following  tables  contain  tiie  data  rdative  to  the  prolonged  radiation  treat- 
ments. In  addition  to  these  treatments  steel  tubes  containing  a  few  milUcuries  wsre 
occasionaUy  applied  for  a  diort  time  (one-half  to  t  hours)  to  portions  of  the  lesions, 
which  it  was  thought  had  not  received  sufficient  irradiation.  The  greater  part  of  the 
effect,  however,  was  undoubtedly  due  to  rays  from  the  tubes  inserted  and  left  in 
position  for  several  weeks. 

Cose  /. — ^In  April,  1914,  the  patient  presented  himself  to  the  Huntington  Hospital 
with  a  small  tumor  over  the  right  malar  Ixme  that  had  appeared  six  weeks  before. 
He  received  a  mild  radium  treatment,  but  was  advised  to  have  the  tumor  excised. 
He  went  elsewhere,  and  some  months  later  the  operation  was  performed.  Toward 
the  end  of  May,  1915,  however,  he  returned  to  our  hospital  with  marked  recurrence  and 
received  the  following  prolonged  radiation  treatments: 

liay  27  two  tubes  containing  a  total  of  8.3  millicuries  of  emanation  were  inserted 
near  the  outer  right-hand  border  of  the  lesion  and  left  there. 

June  2  two  tubes  contaii  ing  a  total  of  6.3  millicuries  of  emanation  were  inserted, 
respectively,  into  the  upper  and  lower  borders  of  the  lesion  and  left  there. 

June  7  the  emanation  tubes  were  still  in  position,  but  they  could  not  be  seen,  as 
they  lay  below  the  surface  of  the  necrotic  tissue.  No  appreciable  change  had  taken 
place  since  the  patient  returned  to  the  hospital  on  May  27.    (Case  la.) 

June  12  one  tube  containing  5.1  millicuries  of  emanation  was  inserted  near  the 
comer  of  the  lesion  below  the  inner  canthus  of  the  right  eye  and  left  there.  From  this 
tfane  on  a  gradual  but  marked  improvement  took  place.  Epithf'lium  gradually  grew 
over  the  base  of  the  hollow  but  never  quite  covered  it.  A  small  necrotic  area  still 
persisted  on  August  19.  During  September  a  marked  recurrence  took  place,  starting 
from  the  center  of  the  lesion  and  spreading  through  into  the  mouth.    It  appears  as  if 


508       PBOOEEDIKOB  SBOOKD  PAH  ABCBBIOAN  SOIBVTIFIO  00NQBE88. 

the  center  had  not  received  sufficiently  intense  radiation.  I  had  thought  that  the 
croflB-fire  radiation  received  at  the  center  from  the  tubes  Inserted  around  theborden 
would  have  been  sufficient,  but  the  facts  do  not  seem  to  verify  this.  During  October 
and  November  the  lesion  received  a  prolonged  treatment  somewhat  m(«e  intense  than 
the  first.  The  hollow  is  now  somewhat  deeper,  but  no  change  in  either  direction  has 
occurred  during  the  last  six  weeks.  It  is  interesting  to  note  that  although  the  rig|it- 
hand  side  of  the  nose  has  been  subjected  for  a  long  time  to  weak  fi  and  y  radiation,  no 
ulceration  has  resulted.  A  slight  erythema  appeared,  however,  which  does  not  show 
in  the  photograph.    (Oase  lb.) 

CoBe  f .— The  patient  was  referred  to  the  Huntington  Hospital  on  July  6, 1915,  with 
multiple  iSsratoses  on  his  face  and  hands,  some  of  which  were  of  10  yean*  standing. 
In  several  places  they  had  definitely  degenerated  into  carcinomata  and  had  ulcerated; 
notably  on  the  upper  lobe  of  the  left  ear.  All  these  lesions  were  tzeated,  but  only  thftt 
on  the  left  ear  received  prc^onged  radiation.  Tubes  containing  emanation  wen 
inserted  and  left  as  follows.    (Case  2a.) 

July  7,  one  tube,  2.1  millicuries;  July  14,  two  tubes,  7  millicuries;  July  21,  two 
tubes,  9.1  millicuries;  July  28,  two  tubes,  15  miUicuiies. 

Very  little  change  appeared  until  July  28,  and  about  this  time  ibib  tumor  began  to 
diminish  in  sise.  The  tumor  continued  to  meltaway  until  August  16.  As  the  lesion  did 
not  seem  to  be  improving  much  at  this  stage,  August  24,  two  tubes  containing  a  totnl 
quantity  of  7.4  millicuries  of  emanation  wera  inserted  and  left.  After  this  tieatment 
the  ear  swelled  up  to  four  or  five  times  its  natural  size.  The  swelling,  however,  and 
the  rest  of  the  tumor  gradually  disappeared  until  only  a  small  scab  ramained.  Asmall 
piece  of  the  edge  of  the  lesion  was  excised,  and  Dr.  Tyzxer  found  no  evidence  of  car- 
cinoma in  it.    Since  this  date  the  lesion  has  ramained  healed,  as  indicated  by  figura  2b. 

Although  some  ersrthema  appeared  on  the  skin  covering  the  side  of  ib»  head,  no 
ulceration  occurred  there,  except  where  the  tumor  was  actually  attached. 

CoBe  ^.— The  patient  presented  himself  at  the  hospital  on  October  8, 1915,  with  an 
epidermoid  carcinoma  over  and  just  below  the  right  malar  bone.  This  he  said  had 
developed  from  a  small  pimple,  that  had  appeared  eight  yean  before. 

Prolonged  radiation  treatment  began  several  days  later,  and  tubes  amtaining  ema- 
nation were  inserted,  fmd  left  as  follows: 

October  13,  two  tubes,  9.3  millicuries  total  dose,  in  the  upper  and  lower  bordem  of 
lesion,  respectively. 

October  27,  three  tubes,  10.1  millicuries  total  dose,  one  in  the  left-hand  and  two  in 
the  right-hand  border. 

November  3,  two  tubes,  4.4  millicuiies  total  dose,  in  the  upper  and  left  hand 
borden,  respectively. 

Scarcely  any  effect  had  been  produced  up  to  October  27,  at  which  time  the  photo- 
graph 3a  was  taken.  There  are  five  tubes  in  the  borders  of  the  lesion  as  represented 
in  this  picture.  About  this  time  the  tumor  began  to  disappear  and  by  November  23 
most  of  it  had  gone.  The  neighboring  skin  showed  considerable  erythema,  but  no 
ulceration  has  ever  occurred  beyond  the  edge  of  the  original  lesion,  although  some 
of  the  tubes  were  placed  within  a  short  distance  of  the  nonnal  tissue.  Since  Novem- 
ber 23  the  slow  healing  process  has  continued.  Figure  3b  represents  the  condition  on 
March  10  and  July  21, 1916,  when  the  patient  was  last  seen  at  the  hospital.  Exami- 
nation of  a  small  piece  of  tissue  excised  from  the  scar  showed  no  evidence  of  carci- 
noma. 

Every  action  that  takes  place  in  nature  is  not  only  qualitive,  but  also  quantitive; 
and  I  have  presented  the  foregoing  data  largely  for  the  purpose  of  calling  attention 
to  the  quantitive  relations. 

The  quantities  of  emanation  in  the  individual  tubes  varied  from  1.1  millicuries  to 
7.5  millicuries,  and  at  no  time  was  a  total  quantity  of  more  than  16  millicuries  left 


PtTBLIO  HEALTH  AND  MEmOINB.  509 

lor  a  long  period  in  a  tumor.  Tbe  tubes  lemained  in  position  loDg  enough  toutUize 
the  activity  of  the  emanation  during  practically  its  entire  life. 

Unfortunately  the  space  and  time  relations  can  not  be  accurately  measured.  The 
volumes  of  the  tumors  throughout  which  the  rays  destroyed  tumor  tissue  may  be 
estimated,  however,  as  lying  between  15  and  50  cubic  centimeters.  In  the  time 
relations  we  recognise  three  distinct  periods,  which  may  be  rou^y  estimated  (for 
the  dosages  given)  as  follows:  (a)  a  latent  period  of  10  to  14  days,  during  which  little 
apparent  change  takes  place;  (6)  a  destructive  period  of  3  to  4  weeks,  during  which 
the  tumor  tissue  disappears  as  such,  and  (c)  a  period  of  repair,  whidi  may  last  for 
several  months. 

The  word  ''specific  "  can  not  be  applied  strictly  to  radium  rays.  The  rays  however, 
have  a  certain  ''differential  *'  effect  on  many  kinds  of  tumor  tissue,  and  the  prolonged 
radiation  method  brings  this  out  quite  clearly.  Some  of  the  tubes  mentioned  above 
were  placed  within  a  few  millimeters  of  normal  tissue  without  producing  a  destruc- 
tive reacticm,  and  yet  the  rays  from  them  destroyed  carcinoma  tissue  at  a  distance 
of  considerably  over  1  centimeter. 

It  may  not  be  superfluous  to  add  that  the  |Mt)lQnged  radiation  method  offers  no 
guarantee  against  recurrence. 

We  hope  that  the  above  described  method  may  prove  useful  in  treating  internal 
malignant  growths.    Investigations  in  this  field  are  in  progress. 

The  Chaibman.  The  papers  by  Dr.  Wood  and  Dr.  Duane  are  open 
for  discussion. 

Dr.  EwiNG.  I  was  extremely  gratified  to  learn  from  Dr.  Wood's 
closing  remarks  that  he  believed  that  in  the  conrse  of  a  year  or  two 
methods  would  be  offered  to  the  dinician  to  enable  him  to  treat 
cancer  with  radium,  so  I  judge  that  he  anticipates  that  eventually 
the  agent  will  have  some  place  in  therapeutics.  I  think  the  doctor 
is  perhaps  not  thoroughly  familiar  with  the  extent  to  which  this 
agent  has  been  used,  nor  with  the  residts  which  at  least  careful 
observers  are  claiming  for  it.  I  have  here  an  extract  of  38  reprints, 
recent  ones,  on  the  therapeutic  effects  of  radium  from  different  lo- 
calities all  over  the  world.  They  cover  390  reported  clinical  cures 
of  cancers,  most  of  them  of  inoperable  type:  Fifteen  of  the  tongue, 
8  of  the  Up,  9  of  the  rectum,  17  of  the  prostate,  38  of  the  breast, 
254  of  the  uterus,  and  49  sarcomas,  among  which  were  3  of  the 
larynx,  5  of  the  oesophagus,  and  3  of  the  thyroid.  These  are  the 
reports  of  competent  men. 

Now,  of  course,  the  use  of  radium  in  cancer  is  like  every  other 
method  which  has  been  developed  for  the  profession.  It  is  simply  the 
beginning  of  perfection;  and  radiimi  is  not  a  perfected  product  in  the 
treatment  of  cancer  to-day,  but  it  is  probably  becoming  so  rapidly. 

One  should  be  very  cautious  about  making  any  statement  in  a  lay 
gathering  as  to  the  use  of  radium  which  might  reach  the  newspapers. 
But  at  our  meeting  of  the  American  Association  for  Cancer  Research 
I  do  not  think  we  ought  to  permit  ourselves  to  be  deceived  as  to  its 
possibilities.  We  ought  to  realize  that  we  expect  to  make  progress 
in  this  matter;  that  we  may  not  be  getting  to-day  as  good  results  as 
we  may  later;  and  on  that  point  I  wish  to  say  that  I  disagree  entirely 


510       PBOOEEDIKOB  SBOOJTD  PAN  AMBBIOAN  BOIBirTIFIC  C0KGBB88. 

with  Dr.  Wood  in  his  statement  thai  to  submit  to  radium  treatmeni 
any  operable  case  of  caneer  is  malpractice.  I  can  not  agree  with  that. 
When  one  considers  the  result,  for  instance,  as  in  the  case  Dr.  Duane 
presented,  of  a  small  rodent  ulcer  of  the  face,  and  sees  the  result  in  i^ 
f  ^w  weeks  of  the  radium  method,  and  then  compares  it  with  the  method 
Dr.  Duane  used,  I  think  one  has  erery  right  to  say  that  the  use  of  thiB 
method  is  not  malpractice.  As  a  matter  of  fact,  I  think  it  is  clearly  dem- 
onstrated that  the  treatment  of  cancer  by  radium  is  a  physical  prob- 
lem— that  there  is  an  energy  in  this  substance  which  destroys  cancer 
oeUs — and  that  if  you  get  enough  of  radium  applied  in  the  right  condi* 
tions  you  can  destroy  a  cancer  cell  wherever  it  can  be  reached.  I 
think,  therefore,  that  the  work  Dr.  Duane  is  doing  in  the  physical  con- 
trol of  the  agent  itself  will  reach  the  result  which  we  are  always  hoping 
will  be  reached. 

Dr.  Clowes.  I  was  particularly  impressed  by  Dr.  Wood's  experi- 
malts  with  radium,  going  through  a  series  of  goierations;  and,  as  I 
understand  Dr.  Wood,  he  appears  to  acquire  a  type  of  adaptation  of 
the  tissues  to  radium ;  that  is  to  say,  the  tissues  become  more  or  lesB^ 
resistant,  which  is  a  matter  of  immense  importance.  In  all  our  work 
with  cancer,  in  the  use  of  immune  serum,  chemicals,  colloidal  meth- 
ods, etc.,  we  have  very  frequently  encountered  conditi<»i8  in  which  a 
tumor  apparently  would  be  temporarily  relieved  and  then  the  same 
agent  would  under  no  circumstances  produce  a  result  again;  and 
furthermore,  we  have  every  reason  to  beUeve  that  that  condition  ean 
be  transmitted  from  generation  to  generation.  That  is  a  matter  ot 
the  greatest  importance,  because  if  that  is  the  case,  it  means  that  iriiat-^ 
ever  agents  we  employ  in  dealii^  with  cancer — chemical,  physical,  or 
biologieal — should  be  used  at  the  very  b^inning  in  the  exact  ana^ 
tomic  dose;  otherwise,  we  make  an  adaptaticm  of  our  tissues  to  anew 
environment  and  there  is  no  longer  response  to  any  sort  <3i  treatment.. 
I  think  that  point  is  very  important  from  a  biological  point  of  view, 
because  biologists  claim  that  all  cells  after  a  certain  time  revert  to 
type  and  lose  their  specific  adaptation  to  environment. 

I  beUeve  to-day  that  the  failure  of  ourselves  and  of  other  woricws 
to  reproduce  some  of  our  earlier  immune  experiments  and  some  of  our 
earlier  chemical  experiments  are  undoubtedly  due  to  the  same  propo- 
sition, and  I  would  point  out  that  colloids  can  be  adapted  to  the 
environment  and  that  the  surface  tension  can  be  changed  and 
adapted  to  environmait.  It  is  posuble  that  this  whole  matter  may 
be  a  matter  of  surface  tension. 

Dr.  Lambert.  Just  a  word  about  the  paper  and  the  remarks  of 
Dr.  Ewing.  Although  this  is  a  meeting  of  the  Ammcan  Association 
for  Cancer  Research,  I  fear  that  a  repetition  of  some  of  the  statements 
in  the  newspapers  is  capable  of  a  good  deal  of  harm.  I  would  like  to 
emphasize,  therefore,  one  thing  in  Dr.  Duane's  paper,  e.  g.,  that  these 


FUBUO  HBJkLTK  A2n>  lUUlOUNE.  611 

lesions  of  the  face  were  probably  ihe  rodent  ulcer  tjpe  of  a  rery  low 
grade  of  malignancy  which  do  not  metastasiae — many  have  been 
cured  by  X-ray  treatmmt — and  I  do  not  know  but  that  Dr.  Duane 
suggested  operative  procedures. 

Dr.  DuANS.  It  was  done. 

Dr.  Lambbbt.  Can  you  rouch  for  the  type  of  operation  that  was 
done? 

Dr.  Duane.  It  was  done  in  the  Boston  City  Hospital. 

Dr.  Lambbbt.  It  seems  to  me  in  regard  to  the  work  that  is  being 
-carried  on  by  Dr.  Loeb  and  others  who  are  trying  to  educate  the 
public  in  regard  to  these  matters  that  it  would  be  unfortunate  if 
statements  referring  to  rather  remarkable  cures  with  radium  treat- 
ment should  go  out  from  a  meeting  of  this  sort. 

Dr.  Wood.  I  seem  to  have  misled  Dr.  Ewing  in  my  views*  I 
have  not  changed  my  opinion  that  the  radium  treatment  of  an  oper- 
able tumor  is  at  the  present  time  not  justifiable  and  is  not  good 
practice.  I  am  also  not  unaware  of  the  reports  in  the  literature; 
for  instance,  there  are  three  cases  of  carcinoma  of  the  esophagus 
reported  cured.  I  autopsied  one  of  them.  The  other  two  I  know 
died  within  a  few  weeks  after  the  treatment  was  made.  The  amount 
of  radiimi  in  the  tube  was  probably  about  2  milligrams  of  the  ele- 
ment. Further  conunent,  you  see,  on  that  kind  of  cure  is  not  neces- 
sary. We  all  know,  for  instance,  the  cases  which  are  heralded  widely 
in  the  papers.  Take,  for  example,  the  case  of  famous  old  Uncle  John, 
who  after  a  few  months  has  had  his  picture  shown  as  a  great  cure — 
he  died  some  time  ago  with  metastasis  of  the  liver.  As  Dr.  Liam- 
bert  explained,  there  are  many  factors  which  make  a  case  operable 
or  not,  and  that  is  what  I  mean  when  I  speak  of  operable  cures.  A 
man  of  80  who  has  a  tumor  of  the  eyelid  which  would  destroy  his 
eye  and  has  perhaps  a  year  or  two  to  Uve,  I  do  not  consider  a  good 
operable  risk,  and  would,  of  course,  subject  him  to  radium.  But 
the  later  recurrences  which  we  see  following  radium  cxu'es  are  very 
extraordinary;  recurrences  which  happen  after  six  months,  one  year, 
two  years,  three  years — and  I  saw  one  of  eight  years  the  other  day, 
after  X-ray  treatment  of  epithelioma  of  the  lip,  a  recurrence  in  the 
glands  of  the  neck  which  was  the  size  of  a  melon.  Unfortunately, 
many  of  the  cases  reported  were  not  microscopically  examined;  un- 
fortunately, many  of  those  that  were  reported  as  cures  have  since 
died;  and  most  of  the  cures  are  tumors  that  are  relatively  benign, 
benign  tumors  that  are  removable  by  curette.  The  treatment  of 
epithelioma  of  the  face,  I  think,  is  justifiable  by  radium,  but  if  I  had 
one  I  should  prefer  to  have  it  cut  off. 

Dr.  William  Duane.  I  would  also  like  to  call  attention  to  the 
fact  that  I  never  used  the  word  ''cure.*'  I  never  use  the  word  ''cure" 
in  speaking  of  a  malignant  tumor.    In  regard  to  the  lip  cancer,  as 


512       PB00EEDINQ8  SECOND  PAN  AMBBIOAN  80IBNTIFI0  OONOBES8. 

a  matter  of  practice  we  always  operate  on  them;  and  in  one  or  two 
cases  where  the  patients  refused  operation,  we  have  refused  to  treat 
them  with  radium,  because  Dr.  Greenough,  who  is  our  surgeon,  feels 
that  those  lip  cancers  should  be  operated  on. 

Chairman.  '  This  concludes  the  discussion  on  these  papers  and  we 
win  now  take  up  the  paper  of  Dr.  Ewing  on ''  Pathological  aspects  of 
some  problems  of  experimental  research." 


PATHOLOGICAL  ASPECTS  OF    SOME    PROBLEMS  OF    EXPERIMENTAL 

CANCER  RESEARCH. 

By  JAMES  EWING, 
Department  of  Pathology t  Cornell  Univernty  Medical  College^  New  York  City. 

Although  the  great  poesibilitiee  presented  by  the  study  of  tranamissible  tumors  of 
lower  animals  were  fully  revealed  in  1894  by  the  systematic  observatioiis  of  Morau^ 
it  was  not  until  1901-2  that  the  work  of  Loeb  in  America  and  Jensen  in  Denmark 
attracted  universal  attention  to  this  field.  Especially  in  the  laet  decade  a  great 
number  of  observations  from  a  host  of  workers  have  produced  a  body  of  new  data 
which  is  of  first  importance  in  oncology.  From  this  extensive  field  it  is  my  purpose 
to  select  for  discussion  certain  problems  which  are  of  special  interest  to  the  general 
pathologist  and  to  attempt  to  evaluate  the  new  contributions  by  the  old  and  estab- 
lished pathological  criteria. 

Prominent  among  the  questions  raised  by  the  study  of  transmissible  tumors  of 
lower  animals  is  whether  these  processes  are  genuine  neoplasms.  ConBidering  that 
Virchow  once  said  that  no  one  even  under  torture  could  state  exactly  what  a  tumor 
is,  this  question  must  appear  somewhat  academic.  Yet  to  the  older  pathologists, 
thoroughly  saturated  with  the  conviction  that  a  neoplasm  is  viable  only  in  its  host, 
the  demonstration  of  successful  transfer  to  a  new  host  naturally  raised  a  lively  scepti- 
cism. Transmisaibility  implied  to  them  infectiousness  and  a  granulomatous  nature; 
the  transplantable  tumors  must  be  shown  to  grow  solely  from  the  transplanted  cells, 
after  the  manner  of  metastatic  tumors,  they  must  exhibit  infiltrative  growth,  and  pro- 
duce metastases;  the  striking  morphological  resemblance  to  tumors  was  not  univer- 
sally regarded  as  decisive  evidence.  All  these  essential  attributes  of  true  malignant 
tumors  have  now  been  demonstrated  for  many  of  the  transplantable  growths  in  lower 
animals. 

Personally  I  consider  the  morphology  alone  as  a  sufiicient  guaranty  of  the  neoplastic 
nature  of  many  of  these  tumors.  Doubts  of  its  significance  seem  to  result  from  a  some- 
what narrow  conception  of  the  very  variable  morphology  of  the  cancer  process,  and 
siinilar  doubts  have  arisen  regarding  the  cancerous  nature  of  certain  human  tumorp 
of  peculiar  character.  Thus  Borst  discusses  the  question  whether  primary  liver  cell 
carcinoma  is  a  true  carcinoma  because  the  infiltrating  cells  are  mechanically  forced 
into  the  hepatic  capillaries  and  do  not  actively  grow  into  them  as  do  some  tumor  cells. 
Yet  it  seems  somewhat  arbitrary'  to  demand  that  hepatic  carcinomas  should  behave 
exactly  as  do  mammary  carcinomas.  The  hepatic  cardnomae  have  many  peculiari- 
ties of  their  own,  but  all  the  essential  characters  of  malignant  tumors.  Similar  reserva- 
tions may  be  made  r^;arding  carcinomas  of  the  thyroid,  stomach,  adrenal,  and  other 
oigans,  in  which  morphological  details  are  not  cut  to  exactly  the  same  pattern.  More- 
over, cancer  morphology  does  not  always  appear  at  its  full  development,  but  is  pro» 
gressively  unfolding  its  potentialities. 


i 


FUBUO  HBALTH  A2n>  MBDIOIKB.  513^ 

Analyis  of  the  structtire  of  human  cancer  reveals  the  following  features,  any  one  oi 
which  may  dominate  the  pictiue  or  any  combination  of  which  may  be  exhibited. 

1.  Hypeiplasia,  surpassing  that  observed  in  other  conditions  occurring  in  the  same 
oigan.  A  sliding  scale  is  here  necessary  owing  to  the  great  variations  in  the  degree 
of  h3rperpla8ia  resulting  from  inflammatory  and  functional  changes  in  the  different 
oigans. 

2.  Atypical  qualities  of  the  cells.  This  feature  is  universally  recognized  as  perhaps 
the  most  significant  criterion  of  a  malignant  process,  and  when  sufficiently  pronoimced 
may  stamp  the  i^ocess  as  malignant  in  the  absence  of  other  changes  (early  carcinoma 
of  the  larynx). 

3.  Loss  of  polarity.  The  r^gidar  alignment  of  cells  in  relation  to  one  another  and 
to  basement  membranes  may  early  be  lost  in  adeno-carcinomas,  and  is  completely 
destroyed  in  diffuse  carcinomas. 

4.  Desmoplastic  properties.  The  capacity  to  excite  the  groVth  of  connective 
tissue  is  very  prominent  in  most  cardnomas,  but  entirely  lacking  in  others.  Mammary 
fibrocarcinoma  and  embryonal  carcinoma  in  children  represent  the  two  extremes. 

5.  Infiltrative  growth  is  a  late  property  of  most  carcinomas  and  the  time  of  its  iq»pear- 
ance  depends  much  on  the  accidents  of  position. 

6.  Metastases.  As  an  objective  sign  the  occurrence  of  secondary  tumors  is  most 
convincing  evidence  of  a  lawless  growth,  but  in  benign  metastasizing  struma  they 
occur  early,  in  an  otherwise  innocent  tumor,  and  in  some  t3rpes  of  malignant  hepatoma 
they  never  develop. 

Judged  by  these  main  criteria,  the  tumoru  of  lower  animals  take  their  places  as 
malignant  neoplasms,  with  certain  peculiarities  which  are  imi^essed  upon  them  by 
their  species. 

Metastases  were  observed  and  experimentally  produced  by  Morau,  and  Murray 
found  them  in  50  per  cent  of  his  mouse  tumors.  Their  relative  infrequency  as  com* 
pared  with  those  of  human  tumors  may  be  referred  largely  to  the  short  duration,  and 
the  peculiarities  of  the  circulation  in  small  animals.  Infiltrative  growth  is  frequently 
observed  under  suitable  conditions,  especially  when  the  tumor  meets  resisting  struc- 
tures. The  degree  of  cellular  hyperplasia  may  be  so  great  that  the  tumor  outweighs 
the  host,  and  in  general  it  probably  attains  a  larger  relative  volume  than  in  human 
tumors.  The  atypical  qualitiee  of  the  cells  are  almost  constantly  pronounced,  but 
while  this  feature  has  been  emphasized  by  some,  I  have  gained  the  impression  that 
the  variations  in  tumor  morphology  in  lower  animals  are  less  violent  and  less  extensive 
than  in  the  human  subject.  Extensive  overgrowth  of  connective  tissue  is  also  much 
less  notable  in  the  small  animals  for  reasons  which  are  not  entirely  clear. 

I  have  extended  this  analysis  to  some  length  because  the  study  of  lower  animal 
tumors  has  forced  the  pathologist  to  relax  to  some  extent  certain  rigid  notions  regarding 
what  a  tumor  may  do  and  how  it  may  look. 

The  comparative  studies  have  not,  however,  revealed  any  striking  variations  or  new 
morphological  properties  beyond  those  occasionally  exhibited  by  human  tumors.. 
The  same  fixity  of  form  and  clinical  behavior  reappear  in  the  different  examples  of 
the  same  type  of  tumor,  and  this  morphology  is  usually  maintained  throughout  many 
generations  of  transplants.  The  structure  may  vary  in  different  portions  of  the  same 
tumor,  and  metastases  may  be  more  or  less  atypical  than  the  original  growth. 

There  is  one  important  phenomenon  exhibited  by  lower  animal  tumors,  however^ 
which  is  at  variance  with  the  rules  deduced  from  human  oncology.  Certain  tran»» 
planted  tumors  of  mice  and  rats  are  said  to  excite  a  neoplastic  process  in  the  stroma 
of  the  host  so  that  in  the  course  of  transplantation  a  stromabom  sarcoma  may  arise 
and  even  outgrow  and  eventually  eliminate  the  original  carcinoma.  This  phenome- 
non was  first  observed  by  Ehrlich  and  Apolant  in  the  tenth  generation  of  an  ade- 
nocarcinoma of  the  mouse,  and  has  been  reported  in  both  rats  and  mice  by  Loeb^ 


614       PBOOEEDIKOB  BBOOVD  PAN  AMBBIOAK  80IBKTIFI0  OONGBMS. 

Lewin,.  Bashford,  Haaland»  Russell,  and  others.  The  change  i^pears  to  occur  rather 
suddenly  in  the  eighth  to  tenth  (nt  later  generations.  Russell  fixed  the  usual  period 
at  the  fifty-fifth  to  sixtieth  day  of  propagation  and  states  that  it  is  indepoident  of 
the  number  of  transfers. 

When  once  established  it  is  usually  progressive  and  both  tumon  persist  together,  or 
separate  strains  of  sarcoma  and  carcinoma  are  obtained  in  subsequent  transplants. 
The  rate  of  growth  of  the  mixed  tumors  is  usually  increased  and  the  sarcoma  is  usually 
more  active  than  the  carcinoma,  and  is  more  frequently  encountered  in  metastases 
(Haaland,  Glunot). 

The  idea  that  the  original  growths  were  mixed  tiunors  was  abandoned  lor  lack  of 
«ny  evidence.  It  is  generally  c<mcluded  that  the  sarcoma  represents  a  neoplastic 
transformation  of  the  stroma  of  the  host  caused  by  a  stimulation  of  cells  by  the  tumor 
epithelium.  Both  Haaland  and  Russell  describe  in  detail  the  i^peaiance  of  foci  of 
overcellular  stroma*  located  in  the  center  of  carcinoma  nodules,  the  increoEe  in  mitotic 
figures  in  the  stroma  cells,  the  survival  of  these  altered  c^ls  in  grafts,  and  their  rapid 
increase  until  they  overgrow  the  epithelial  elements. 

There  is  no  counterpart  in  human  pathology  lor  thia  rwnarkable  pvoceH.  In  no 
,CMe  has  the  stroma  of  a  human  tumor  during  vidnitudei  of  proloiiged  growth,  inflam- 
matory reaction  from  infection,  recuirenco  after  <^>eration,  or  spontaneooa  metaataaee, 
taken  on  a  neoplastic  growth.  It  ia  true  that  very  notable  grades  of  reactive  hjrper- 
plasia  may  be  excited  by  the  invasion  of  cancer  c^.  The  most  remarkable  is  prob- 
ably seen  in  the  bone  metastases  of  prostatic  carcinoma  (v.  Recklinghausen).  Here 
there  is  very  ext^isive  oveigrowth  of  bone  following  carcinomatous  invasion,  and 
histological  study  does  not  always  succeed  in  separating  tumor  ceUs  from  multif^jdng 
osteoblasts  in  the  new  tissue.  The  process  has  been  regarded  by  some  as  possibly 
sarcomatous;  and  secondary  osteosarcomatous  metastases  are  said  to  occur  in  the 
lung  (Schmorl,  Fischer-Defoy,  Axhausen).  Yet  it  is  not  clear  that  the  osteoblasta 
take  on  true  neoplastie  im)perties,  and  the  pulmonary  nodules  are  generally  regarded 
as  osteoplastic  carcinoma. 

It'is  perhaps  unreasonable  to  expect  that  there  should  be  a  human  paralM,  for 
human  tumors  do  not  experience  quite  the  same  insults  as  transplanted  tumon  receive. 
Yet  it  is  a  well  established  rule  that  the  stroma  never  participates  in  the  lawless 
growth  of  cancer  cells  except  in  mixed  tumors,  and  it  is  distinctly  anomalous  that  no 
trace  of  this  sarcomatous  transf  ormaticm  appears  in  man,  when  it  is  relatively  common 
in  mice.  Under  these  circumstances  it  may  reasonably  be  demanded  that  entirely 
demonstrative  evidence  should  be  furnished  before  its  occurrence  in  mice  can  be 
accepted.  Not  having  actively  engaged  in  this  study  I  am  not  in  a  position  to  deny 
the  claim  of  the  very  competent  investigators  on  whose  evidence  the  interpretation 
rests,  but  it  may  be  permissible  to  point  out  some  of  the  difiiculties  in  the  way  ol 
accepting  their  interpretation  that  the  stroma  of  mouse  cancer  becomes  sarcomatous. 

Human  carcinoma  never  exhibits  a  sarcomatous  transformati<A  of  its  stroma,  but 
its  polyhedral  cells  frequently  lose  all  their  epithelial  characters  and  grow  in  spindle 
form.  Epithelial  tumors  may  from  their  inception  appear  like  spindle  cell  sarcoma, 
as  in  the  spindle  cell  basal-cell  carcinomas  of  Krompecher,  in  q»ndle  cell  carcinoma 
of  the  thyroid,  and  in  melanoma.  It  is  becoming  more  and  more  i^parent  that  many 
ao-called  sarcomas  of  the  oigans  are  in  reality  spindle  c^  carcinomas.  Or  the  change 
to  spindle  cells  may  occur  in  one  portion  of  a  typical  carcinoma  as  is  frequently  seen 
in  tumors  of  the  thyroid  gland,  and  liv^ ;  or  spindle  epithelium  may  regularly  i^pear 
with  columnar,  as  in  glandular  adamantinoma.  This  tumor  is  notorious  for  its  remark- 
able changes  of  cell  form.  In  recurrences  after  operation  on  typical  carcinomas,  one 
frequently  encounters  pure  spindle  cell  growths.  I  have  traced  an  adamantinoma  re* 
curring  after  four  operations,  through  the  structures  of  adult  acanthoma,  plexiform 
opithelioma  without  squamous  cells,  spindle  cell  sarcoma,  and  finally  round  cell 


PUBUO  HBALTH  AND  MBmOIKB.  515 

8tt€omA.    Recentiy  I  have  found  spiiidle  cell  ]>eriva8Ciikr  aaicoma  in  a  utaro%  r»- 
flioved  riiortly  after  curettage,  revealing  typical  adenoma. 

l^pindle  tumor  cells  are  so  common  in  cardnoma  that  their  occupeace  in  any  carai- 
noma  is  very  strong  jHeeumptive  evidence  that  they  are  altered  epithelium. 

The  intrinsic  evidence  rating  to  the  transformation  of  the  stroma  is  not  «itirely 
satisfactory.  The  change  is  sudden  and  coincident  with  an  increased  late  of  growth 
of  the  tumor,  as  is  the  case  with  human  tumon  assuming  the  spindle  c^  Isrm.  A 
new  tumor  process,  affecting  the  stroma,  mig^t  be  expected  to  devdop  more  gradually. 
The  new  tumor  process  seems  to  outstrip  and  may  eliminate  the  old.  This  observa- 
ti<m,  that  an  <»riginal  carcinoma  diould  yidd  its  powers  to  the  stroma  c^b  and  ilsetf 
retire  from  the  scene,  seems  highly  paradoxical.  The  reverse  process,  vis.,  the  elimi- 
nati<m  of  spindle  cells  in  the  course  of  tranq^antation  of  a  carcinoma  has  been  ob- 
served by  Apofamt,  but  h&e  the  sinndle  cells  were  interpreted  as  altered  epitheliumf 
Tlie  fact  reported  by  Haaland,  that  the  carcinomatoiis  elemoit  in  the  mixed  tumor 
may  be  eliminated  by  heating  to  44^  C,  is  a  suspicious  circumstance  and  indicates 
that  the  spindle  ceUs  are  merely  the  more  resistant  as  well  as  the  more  nqpidly  growing 
form  of  epithelium. 

The  crucial  evidence  is  that  presented  by  obstfvations  tracing  the  actual  transfor* 
mation  of  stroma  cells  into  the  spindle  cell  sarcoma.  Not  all  authois  have  been  able 
to  convince  th^nselves  that  the  stroma  really  gives  origin  to  the  sarcoma  but  Russell 
and  Haatend  have  traced  this  origin  in  detail.  Haaland  pictures  peculiar  halos  o. 
large  pale  cells  surrounding  epithelial  groups.  They  are  intermediate  in  form  between 
stroma  and  tumor  cells  but  Haaland  derives  them  from  the  fcmner.  Y^  the  interpre- 
tation of  transitional  pictures  Lb  notoriously  hazardous  and  few  observers  have  been 
willing  to  trust  it  in  this  c<mnecti<m.  Orth  thought  that  Lewin's  sarcoma  represented 
granulation  tissue.  Through  the  kindness  of  Wog^om,  I  have  examined  two  cases 
purporting  to  show  the  sarcomatous  transformation  <^  stroma  cells,  but  have  beoi 
forced  to  draw  from  these  sections  the  opposite  c^Hiclusion,  namely  that  the  spindle, 
cells  are  derivatives  <d  the  epithelium.  In  view  of  all  these  difficulties  it  may  be 
urged  that  further  evidence  is  required  before  the  sarcomatous  transformation  of 
mouse  carcinoma  can  be  accepted  as  proven.  The  writer  would  not  deny  its  occur- 
rence but  merely  asks  for  more  evidence. 

The  experimental  studies  have  not  succeeded  in  defining  what  constitutes  a  tumor. 
They  have  shown  indeed  that  perhaps  the  most  essential  property  of  tumor  cdls  is  the 
capacity  for  unlimited  growth  in  a  wide  range  of  environments.  A  vast  number  of 
experiments  in  the  transfer  of  normal  or  proliferating  cells  of  embryonal  or  adult  tjrpe 
has  shown  that  these  cells  may  multiply  for  a  short  period  but  soon  differentiate  and 
become  quiescent,  or  atrophy  and  disappear.  Transplanted  tumor  cells,  however, 
continue  to  proliferate  beyond  the  life-time  of  the  host  from  which  they  were  derived. 

Yet  just  tills  conspicuous  tumor  character  is  exhibited  in  a  notable  degree  by  two 
diseases  the  exact  nature  of  which  has  not  been  fully  determined — ^the  so-called  infec- 
tious lymphosarcoma  of  dogs,  and  Rous'  chicken  sarcoma. 

The  infectious  lymphosarcoma  of  dogs  is  transferred  by  coitus  and  also  by  other 
methods  of  contact.  It  affects  primarily  the  genital  oigans,  skin,  kidneys,  and  some 
other  oigans,  and  produces  bulky  primary  tumors  as  well  as  milary  ar  massive  metar 
stases.  The  gross  anatomy  is  typical  of  a  malignant  neoplasm,  and  the  microscopical 
structure  also  is  that  of  an  extremely  active,  atypical,  infiltrative,  malignant  timoor. 
It  probably  arises  from  the  reticulum  cell  of  the  lymph  node.  No  microorganisms  are 
demonstrable  in  unulcerated  tumors.  Transplantaticm  is  succenful  only  under  tiie 
same  conditions  as  govern  the  transfer  of  mouse  tumors,  i.  e.,  the  inoculation  of  living, 
cells  into  closely  related  animals.  Doubts  regarding  its  true  neoplastic  nature  arise 
from  its  evident  relation  to  the  lymphocytomas.  Furthermore,  it  must  be  admitted 
that  at  some  point  in  the  history  of  its  development  a  parasite  may  enter,  though  there 

68436— 17— VOL  X 84 


616       PROOBEDIKGS  SECOITD  PAN  AMBBIOAN  BOIBlfTIFIC  C0HGBE8& 

Ifl  no  evidence  that  a  parasite  persists  throughout  the  disease.  Bashford  concfaided 
that  the  tumor  grafts  grew  in  part  at  least  from  the  host's  cdls  like  a  granuloma.  In 
serial  transplants  studied  by  Beebe  and  the  writer  it  grew  exclusively  from  the  trana- 
lerred  cells.  Bashl(»d,  on  examining  these  sections,  admitted  that  they  differed  from 
his  own,  and  I  am  forced  to  conclude  that  he  was  dealing  with  infected  material  or 
that  some  other  &ctor  caused  unnecesHury  inflammatory  reaction  about  the  grafts. 

V.  Dungem  claims  to  have  dealt  the  "coup  de  grace"  to  this  tumor  by  showing, 
through  the  absoice  of  ag^utinins  for  dog's  corpuscles,  that  the  tumors  lose  their  dog 
protein  when  transferred  to  foxes  and  accumulate  only  fox  protein.  His  hare  sar- 
coma, which  had  likewise  certain  granulomatous  features,  preserved  its  hare  protein 
while  growing  in  rabbits.  I  must  decline  to  accept  v.  Dung^rn's  conclusioDS,  based 
as  they  are  on  such  evidence  as  agglutination  and  h^nolysis.  The  tumor  can  be  seen 
to  grow  from  the  transplanted  cells,  and  in  comparison  with  such  direct  evidence  the 
significance  of  antibodies  for  a  specific  protein  is  of  quite  subordinate  value.  More- 
over it  appears  reasonable  that  a  few  dog  tumor  cells  multiplying  many  thousand  times 
in  fox  tissue  should  rapidly  acquire  the  fox  stamp.  Beebe  has  shown  that  mammary 
carcinoma  growing  in  lymph  nodes  acquires  the  nucleohiston  of  lymph  nodes  which 
is  entirely  missing  in  primary  tumors  of  the  breast. 

I  think,  therefore,  that  the  lymphosarcoma  of  dogs  may  safely  be  regsrded  as  a 
disease  sui  generis,  but  essentially  neoplastic.  It  may  be  complicated  by  a  parasite 
but  the  existence  of  thb  complication  is  not  proven.  Exactly  the  same  uncertainties 
surround  the  <»igin  and  nature  of  human  lymphossrcoma. 

Rous's  series  of  chicken  ssrcomas  is  one  of  the  most  interesting  and  obscure  develop- 
ments of  experimental  cancer  research. 

On  morphology,  one  would  accept  his  original  tumor  as  a  neoplasm.  It  presents 
excessive  hyperplasia  so  far  ss  may  be  judged  by  available  standards.  The  atypical 
qualities  of  the  cells  are  pronounced.  Th«re  is  infiltrative  growth  and  metastases 
are  ubiquitous.  It  was  at  first  transferred  with  considerable  difficulty  and  only  to 
the  same  strain  of  chickens,  but  its  viability  gradually  increased.  Yet  it  violates 
the  central  criterion  of  tunu»r  growth  by  being  transmissible  by  means  of  tumor  filtrate 
passed  through  a  Berkfeld  filter  (No.  5  medium).  The  active  agent  will  not,  how- 
ever, pass  a  Ghamberland  bougie  F.  Tumor  tissue  dried  for  some  months  remains 
active,  but  the  resulting  tumms  are  feeble.  Exposure  to  65^  G.  inactivates  the  agent. 
Cultures  are  negative. 

On  these  data  one  must  either  discard  the  process  from  the  group  of  neoplasms  or 
alter  the  experimental  criteria.    The  latter  course  seems  the  only  logical  choice. 

In  attempting  to  analyze  the  significance  of  this  tumor  we  are  handicapped  because 
the  principles  of  avian  pathology  are  not  well  understood.  One  must  hesitate  to 
apply  the  standards  of  human  pathology  to  the  tissue  reactions  of  the  chicken .  Exuda- 
tive inflammation,  functional  and  inflammatory  overgrowth,  meti^lasia,  etc.,  may 
follow  somewhat  different  laws  or  standards  in  such  widely  separated  species.  Hence 
one  may  be  in  error  in  too  closely  identifying  this  chicken  sarcoma  with  sarcomas  in 
other  animals.  It  may  be  an  infectious  granuloma  with  neoplastic  morphology.  But 
I  do  not  think  that  either  the  granulomatous  or  the  infectious  nature  is  probable. 
The  only  infectious  agent  meeting  the  requirements  would  be  an  extremely  labile 
protozoon,  of  the  actual  presence  of  which  tliere  ia  no  tangible  evidence.  It  has  been 
suggested  as  a  last  resort  that  fragments  of  cell  nuclei  capable  of  reproducing  the  cells 
may  pass  through  a  Berkfeld  filter.  While  the  data  are  still  inadequate  to  force  any 
conclusion,  I  have  received  the  impression  that  Rous's  sarcoma  is  a  genuine  neoplasm, 
occurring  only  in  the  chicken,  and  that  the  transmissible  virus  is  of  chemical,  and 
possibly  of  ferment  nature.  The  extensive  series  of  transplants  has  probably  inten- 
sified the  action  of  any  such  chemical  agent  present  in  the  original  tumor,  so  that  effects 
are  now  being  produced  with  this  tumor  which  were  not  possible  with  the  spontaneous 
growth  and  which  probably  have  no  counterpart  in  any  other  process  spontaneously 


PUBUO  HEiiLTH  AND  MEDIOIKB.  517 

occuning  in  nature.    At  any  rate,  the  principles  deduced  from  this  process  must 
for  the  present  be  appiled  to  this  disease  and  to  no  other. 

There  are,  howevw,  some  indications  that  chemical  agents  such  as  may  be  active 
in  the  chicken  sarccnna,  are  also  of  influence  in  some  human  tumors.  While  many 
tmnoro,  after  their  area  of  origin  is  defined,  grow  exclusiyely  from  their  own  resources, 
others  grow  by  progressive  inclusion  of  previously  normal  cells  in  the  tumor  sources. 
This  principle  comes  to  light  in  many  different  circumstances  and  may  be  employed 
to  account  for  diffusely  spreading  or  multiple  tumors  of  serous,  mucous,  or  cutaneous 
surfaces,  and  in  systemic  tumors  of  lymph  nodes.  In  a  lesser  degree,  it  may  account 
for  ctdlateral  hyperplasia  about  the  edges  of  some  tumcvs.  Paget 's  disease  covering 
much  of  the  chest  and  trunk  would  be  explained  thereby,  and  the  pigment  of  mela- 
noma is  said  to  have  excited  the  neoplastic  proliferation  of  liver  cells  about  hepatic 
metastases.  So  one  may  conceive  that  in  the  chicken  tumor  a  chemical  agent  may 
exist  which  is  remarkably  effective  in  inducing  neoplastic  hyperplasia,  and  that 
either  this  agent  alone  or  the  cells  that  contain  it  may  give  rise  to  the  tumor.  It  may 
here  be  recalled  that  the  filtrate  is  much  less  effective  than  are  the  living  tumor  cells. 
Perhaps,  also,  chicken  tissues  are  more  responsive  to  such  agents  than  are  othw  animal 
cells. 

It  would  be  interesting  to  know  if  carcinoma  in  the  chicken,  of  which  Ehrenretch  has 
described  several,  is  also  transmissible  by  means  of  its  filtrate. 

In  determining  the  effects  of  changes  in  the  mal  upon  the  growth  of  the  tumor,  ex- 
perimental studies  have  yielded  results  of  much  practical  value.  Spontaneous  varia- 
tions in  the  growth  of  tumors  are  quite  as  well  established  clinically  as  in  the  experi- 
mental field,  but  the  latter  seems  to  have  revelaed  some  of  the  reasons.  Racial  differ- 
ences in  susceptibility  have  been  practically  identified  with  changes  in  the  diet.  The 
importance  of  carbohydrates  in  the  nutrition  of  tumors  has  long  been  recognized 
among  clinical  writers  and  has  been  extensively  discussed  by  Brault,  Keating-Hart, 
and  many  others.  The  varying  glycogen  content  of  different  human  tumors  suggests 
the  caution  that  all  tumors  may  not  be  especially  dependent  upon  this  class  of  food- 
stuff, and  the  complexities  of  carbohydrate  metabolism  indicate  that  it  may  be  diffi- 
cult to  secure  satisfactory  experimental  evidence  in  the  field  of  tumor  diets.  Never- 
theless it  appears  that  rats  may  be  made  refractory  to  the  Buffalo  sarcoma  by  a  pre- 
vious course  of  carbohydrate-free  diet,  that  the  course  of  this  tumor  once  established 
is  retarded  by  such  diet,  whereas  it  is  accelerated  by  butyrates  among  the  fats.  Bene- 
dict saw  the  complete  regression  of  large  sarcomas  in  rats  rendered  completely  diabetic 
by  phloridzin.  By  substituting  foods  rich  in  lime.  Sweet,  Corson- White  and  Saxon 
rendered  rats  markedly  insusceptible  to  sarcoma,  and  saw  much  acceleration  in  growth 
<m  return  to  normal  diet.  Contrary  observations  show  that  all  tumors  do  not  react  to 
dietary  changes,  but  the  important  feature  of  this  work  consists  in  the  demonstration 
that  the  subject  is  susceptible  of  experimental  study  and  opens  up  one  of  the  most 
attractive  fields  in  experimental  cancer  research. 

Age  is  found  to  have  no  definite  influence  on  the  susceptibility  of  tumor  grafts. 
Both  young  and  old  animals  have  proven  suitable  for  experimental  propagation, 
although  most  workers  prefer  quite  young  subjects.  This  rule,  which  could  hardly 
have  been  established  except  by  experimental  studies,  has  an  important  bearing  on 
our  conceptions  of  the  relation  of  age  to  tumor  incidence.  Cancer  has  been  held  to 
be  a  disease  of  old  age  and  yet  young  animals  are  the  better  soil  for  growing  tumor  cells. 
Hence  it  is  not  constitutional  susceptibility  but  the  effective  action  of  inciting  factors 
which  belong  to  age.  The  problem  of  the  inception  of  cancer  is  quite  apart  from  the 
problem  of  its  continuous  growth.  Experimental  studies  have  had  little  concern  with 
the  histogenesis  of  tumors  and  only  to  a  slight  extent  with  their  general  etiology.  In 
the  transplantable  tumors  these  important  questions  have  suffered  some  neglect,  but 
work  in  this  field  has  been  of  great  value  in  defining  the  influence  of  age,  and  sepa- 
rating the  questions  of  inception  from  that  of  later  growth  of  tumors. 


518       PBOGEBDINOS  SECOND  PAN   AMBBIGAN   SCIENTIFIC  CONGBSSb. 

Immonily:  Although  Lauder  Brunton  once  said  that  Immunity  will  eventuiHy 
foe  found  to  be  a  function  of  the  liver,  the  serologist  will  doubtleas  claim  ezdufliTe 
fights  in  this  field.  The  pathologist  may  gladly  yield  this  territory,  pointing  out  that 
aerology  has  signally  Mled  to  produce  satisfactory  evidence  regarding  the  nature  of 
resistance  to  tumor  growth. 

AnimiJs  in  which  a  tumor  has  spontaneoody  regressed  are  often  actively  rasistant 
to  further  implantation,  but  the  resisting  factors  can  rarely,  if  ever,  be  tranaferred  to 
auaceptible  animals  and  specific  antagonistic  factors  in  the  blood  serum  have  not  bean 
satisfactorily  demonstrated.  On  the  contrary,  it  is  rather  dearly  apparent  Uiat 
immunity  to  tumora  ishistioid  and  cellular  and  reveala  itself  in  the  reactive  growth  of 
connective  tissue,  phagocytosis,  and  lymphocytic  attack  on  the  tumor  cells.  A  aofiip 
cient  stroma  reaction  has  been  emphasised  by  many  as  the  essential  element  in  sue- 
cessful  implantation,  but  abortive  grafts  are  often  found  sharply  inclosed  in  aliem 
connective  tissue.  Phagocytoila  is  very  frequently  observed  about  grafts  impiantad 
in  insu8cq[>tible  animals,  and  many  typea  of  cella  partidpate  in  thia  process. 

'Lymphocytosis  and  lymphocytic  invaaion  are  prominent  in  the  reaction  agsiaat 
grafts  in  renstant  animala  and  a^ut  rograsring  tnaaors.  There  have  been  numaroM 
observations  pointing  to  the  importance  of  lymphocytes,  large  and  small,  in  the  local 
and  general  reaction  to  tumor  growth.  Reoentiy  Murphy  has  shown  that  moose 
tumors  may  grow  in  chicken  embryos  until  the  time  when  the  production  of  lympho- 
cytes becomes  established,  that  tiiia  time  may  be  ahortened  by  implanting  apleen 
tiasue  in  the  embryo,  and  that  tumors  may  grow  in  alien  spedes  whose  lymphocyto- 
genic  function  is  pmdysed  by  the  X-ray. 

Most  of  these  obaervations  on  the  mechanism  of  tumor  immunity  must  be  valued  aa 
confirming  condusions  previously  drawn  from  human  pathology.  Schmidt  has  shown 
that  vagrant  tumor  cells  are  not  destroyed  in  the  drculating  blood,  but  are  lodged  m 
cai^laiiea,  coated  with  fibrin,  inclosed  by  endothelial  cells,  and  reduced  to  fibrous 
nodules.  It  is  hig^y  probable  that  many  tumor  cells  are  destroyed  in  the  Ijrmpli 
nodes  which  drain  tumor  areas.  The  function  of  lymphoc3rtes  in  limiting  tumor 
growth  is  extenedvdy  illustrated  in  human  material.  In  many  inatancea  ihey  form 
the  chief  barrier  against  the  initial  downward  invasion  of  epidennoid  cardnoma.  In 
many  mammary  carcinomas  one  may  see  islands  of  tumor  cdls  in  process  of  daatmc- 
tion  by  lymphocytes,  and  polyblasts  figure  prominentiy  in  the  active  fibrosis  which 
incarcerates  many  tumor  cdls.  It  is  a  wdl  founded  principle  of  pathology  that 
degenerating  or  alien  tissue  cdls  are  removed  by  phagocjrtosis.  Reactive  fil  rosia 
limits  the  growth  of  many  tumors  more  often  in  man  than  in  lower  animals,  and  may 
be  interpreted  as  a  form  of  dcatrcial  healing.  It  may  reach  very  extensive  propor- 
tions; thus,  I  have  seen  nearly  the  whole  liver  transformed  into  scar  tissue  in  which 
were  very  scanty  remnants  of  an  original  metastatic  carcinoma.  Lymphocytic  activity 
and  extensive  fibrosis  are  features  that  belong  to  the  so-called  clinically  resistant  caaaa» 
and  are  generally  wanting  in  the  more  rapidly  progressing  carcin<Mnas.  These  pro- 
cesses seem  to  be  particularly  prominent  in  very  old  subjects  in  whom  carcinoma  is 
of  slow  progress  and  often  takes  a  scirrhous  form.  Back  of  these  well  known  histo- 
logical signs  of  the  mechanism  of  immunity  are  doubtless  submeiged  constitutional 
and  local  influences,  in  the  duddation  of  which  tumor  serology  doubtiess  faces  a 
significant  future. 

On  the  therapeutic  side  experimental  cancer  research  still  presents  itself  practi- 
cally empty  handed.  The  exclusive  and  quite  energetic  pursuit  of  the  prindplea 
of  aerum  imnmnity  has  accomplished  practically  nothing  except  to  show  that  the 
malignant  tumor  process  can  probably  not  be  controlled  by  investigations  along  the 
lines  which  have  proven  effective  in  bacterial  diseases.  Vaccination  by  meane  ol 
tumor  derivatives  has  been  practiced  on  an  enormous  scale  all  over  the  world  and 
has  failed  to  justify  itself.  It  has  had  some  paradoxical  success,  but  has  probably 
done  more  harm  than  good.  No  one  has  been  able  to  improve  upon  Vidal's  feeUe 
showing  for  anticancer  sera.    Chemothen^y  has  never  had  any  tangible  basis  in  the 


PUBLIC  HEALTH  AND  MEDICINE.  619 

tumor  field,  and  from  Weil's  review  it  would  seem  to  have  even  less  claim  to  serioiiff 
notice  than  has  vaccination.  Under  these  circumstances  I  venture  to  raise  the  ques- 
tion whether  it  is  not  time  to  abandon  this  unprofitable  territory  and  seek  for  help 
in  entirely  different  directions.  It  may  be  that  artificial  alterations  in  the  course 
of  metabolic  processes  in  the  body,  as  suggested  by  recent  dietary  studies,  may  prove 
capable  of  influencing  favorably  the  course  of  some  malignant  tumors.  I  freely  con- 
fess the  hope  that  the  vegetable  kingdom  may  be  found  to  contain  some  agent  that 
wiU  specifically  affect  the  cells  of  some  tumors.  It  is  the  genius  of  vegetable  prod- 
ucts specifically  and  powerfully  to  affect  different  organs,  tisBues,  and  functions  of 
the  animal  body,  as  exhibited  by  digitalis,  strychnine,  morphine,  etc.  Why  should 
not  some  vegetable  agent  attack  the  delicately  balanced  nutrition  of  tumor  cells? 
It  would  be  extremely  disconcerting,  and  even  mortifying,  if  some  vegetable  alka- 
loid or  glucoside  were  found  to  do  more  for  cancer  than  all  the  theories  of  serum  immu- 
nity; but  the  demonstration,  if  made,  would  have  to  be  accepted. 

At  present  the  only  laurels  in  cancer  therapy  are  being  carried  off  by  physical 
agents,  X  ray,  and  radium,  and  it  seems  to  be  only  the  difficulties  of  accessibility 
and  dosage  which  stand  in  the  way  of  the  successful  application  of  these  agents  to 
all  localized  and  some  generalized  tumors.  Cancer  research  should  note  that  prog^ 
ress  in  the  development  of  the  X  ray  ib  almost  exclusively  in  the  hands  of  elaborately 
equipped  and  farsighted  business  corporations,  from  whom  one  department  of  medi- 
cine receives  orders  when  and  how  to  proceed.  This  situation  is  not  flattering  to  our 
dignity.  With  radium  the  situation  is  somewhat  different,  since  the  study  of  the 
physics  and  therapeutics  of  radium  rests  with  Government  organizations,  universi- 
ties, and  private  institutions  endowed  with  a  supply  of  this  precious  metal.  It  is 
not  too  much  to  hope  that  when  the  early  stages  of  cancer  are  recognized  as  a  proper 
field  for  the  use  of  X  ray  and  radium,  as  has  already  occurred  in  the  opinion  of  some 
competent  authorities,  much  of  the  present  fear  of  the  disease,  .especially  of  the  most 
deplorable  poet-operative  recurrences,  will  be  removed.  In  such  an  event  some  of 
the  present  problems  of  cancer  research  will  retain  only  an  academic  interest. 

In  the  department  of  special  etiology  experimental  cancer  research  has  secured 
some  of  its  most  significant  results. 

The  chicken  sarcomas  are  most  suggestive  from  the  point  of  view  of  their  probabie 
•tiology  and  pathogenesis.  Although  there  may  be  nothing  like  them  in  human 
pathology,  they  stand  as  a  specific  pathological  entity  and  raise  interesting  questions 
regarding  the  etiology  of  other  tumors.  Borrel's  consistent  pursuit  of  animal  para- 
sites in  tumors  has  enabled  him  and  others  to  uncover  the  main  factors.in  the  causa- 
tion of  several  tumors  of  lower  animals;  and  it  is  not  impossible,  although  as  yet 
unproved,  that  they  may  have  counterparts  in  man.  When  Fibiger  discovered  a 
nematode  worm  in  the  gastric  carcinoma  of  rats,  and  by  a  brilliant  analysis  identified 
and  located  this  parasite  in  nature  and  reproduced  the  disease  experimentally,  he 
established  the  existence  of  another  specific  disease  of  neoplastic  character. 

These  contributions  seem  to  me  to  point  to  the  necessity  of  regarding  all  forms  of 
neoplasms  as  specific  diseases,  connected  only  by  the  fact  that  they  are  neoplastic  in 
greater  or  less  degree,  but  differing  in  their  etiology,  clinical  course,  and  therapeutic 
possibiUtieB.  In  the  same  way  tuberculosis  and  bubonic  plague  are  infectious  dis- 
eases of  inflammatory  nature,  but  they  are  quite  as  closely  related  as  Fibiger's  gastric 
carcinoma  of  rats  and  pipe  smokers'  cancer  of  the  lip.  The  habit  of  regarding  cancer 
as  a  protean  disease  ol  uniform  significance  may  well  be  abandoned  in  the  intereete 
of  pTOgreie.  When  cancer  research  properly  occupies  itself  in  the  study  of  the  dis- 
tinctive features  of  differmt  cases  of  malignant  disease,  especially  when  it  abandons 
the  idea  of  a  universal  cure  for  cancer,  it  will  be  in  accord  with  sound  pathological 
sense.  It  will  then  not  be  necessary  to  talk  wisely  to  the  public  about  the  obscuri- 
tiee  of  cancer  etidogy  or  speculate  about  why  cells  grow  lawlessly.  Concerning  the 
ultimate  nature  of  neoplastic  overgrowth  we  shall  never  have  more  than  a  descrip- 
tive knowledge. 


520       PBOOEEDINQS  8BG0KD  PAN  AMERIOAK  80IENTIFI0  C0NQBE88. 

BIBUOOKAPHT. 

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The  Chairman.  There  are  many  points  in  this  paper  I  would  like  to 
have  discussed,  but  I  think  the  hour  is  late  and  I  must  now  call  on  Dr. 
Coca. 


8ERO-DUGNOSTIC  METHODS  IN  CANCER— REACTIONS  OF  FREUND  AND 

OF  V.  DUNGERN. 

By  A.  F.  COCA, 
Cornell  Univerntyy  New  York,  N.  F. 

I  have  prepared  no  special  paper,  because  the  field  of  sero-diagnosis  of  cancer  is  the 
most  unsatisfactory  in  cancer  research,  the  most  interesting  and  peculiar  fact  in  re- 
gard to  this  field  being  that  there  are  so  many  assumed  sero-diagnostic  methods  pub- 
lished, evidence  collected,  and  then  entirely  neglected.  I  would  like  to  confine  my- 
self to  an  account  of  my  experiences  with  the  Freund  reaction  and  the  complement 
fixation  reaction  of  Von  Dungem. 

About  two  years  ago,  thanks  to  the  generosity  of  the  trustees  of  the  Huntington 
Fund,  I  was  permitted  to  visit  the  laboratories  of  those  two  men  and  to  study  the  results 
of  these  reactions,  which  they  were  perfecting.  Freund's  reaction  was  based  upon  the 
proposition  that  normal  serum  destroys  cancer  cells,  whereas  cancer  serum  is  not  able 


FUBLIO  HEALTH  AND  MEDICINB.  521 

to  do  this.  The  reaction  is  not  only  of  clinical  interest,  but  touches  on  the  question 
of  etiology,  and  it  is  this  aspect  of  the  subject  that  interested  me  most,  because,  after 
all,  it  is  not  strange  that  serum  should  not  destroy  cancer  cells.  The  interesting  thing 
is  that  it  should  do  it  at  all.  'Pie  reaction  is  performed  with  an  emulsion  of  cancer 
cells,  best  taken  from  the  liver  at  postmortem.  The  emulsion  is  prepared  by  squeezing 
the  tissues  through  a  wide-meshed  towel  into  a  solution  of  acid  sodium  phosi^te,  in 
which  the  tissue  is  left  overnight  to  prevent  agglutination  of  the  cells;  by  centrifu- 
gization  and  washing  the  larger  clumps  of  cells  and  cell  debris  are  removed,  and  the 
isolated  cells  are  deposited,  so  that  at  the  end  an  emulsion  is  obtained  in  which  the 
cells  can  be  easily  counted.  In  the  laboratory  of  Freund  there  were  eight  such 
emulsions.  These  were  preserved,  with  the  addition  of  1  per  cent  sodium  fluoride,  in 
the  ice  box.  Three  of  the  emulsions  proved  to  be  satisfactory  for  counting  purposes, 
and  in  the  experiments  with  normal  human  serum  a  solution  was  obtained  of  the 
cells  in  the  way  described  by  Freund.  The  cells  are  counted.  There  should  not  be 
more  than  20  cells  in  16  small  squares  of  the  blood-counting  appantus,  and  after 
incubation  for  24  hours  this  should  be  reduced  to  50  per  cent.  Sodium  fluoride  should 
be  added  to  the  mixture  of  the  cell  emulsion  and  the  serum  in  order  to  prevent  bacte- 
rial growth.  In  most  of  the  succeeding  experiments,  however,  in  the  same  laboratory 
and  using  the  same  solutions  and  reagents,  no  solution  of  the  cells  could  be  obtained. 

I  used  rabbit  serum,  horse  serum,  and  normal  human  serum,  all  fresh,  and  in  very 
many  series  of  experiments;  no  further  solution  could  be  obtained,  excepting  in  one 
single  instance.  I  found  that  in  the  first  place  the  sodium  fluoride  did  not  prevent  the 
growth  of  bacteria  at  37^  G.  Freimd  himself  said  that  he  had  not  investigated  this. 
He  did  not  know  whether  it  was  actually  antiseptic  or  not.  He  said  that  he  was  using 
a  10  per  cent  solution  of  sodium  chloride,  whereas  that  substance  is  saturated  at  less 
than  5  per  cent.  In  his  publications  he  gives  this  percentage.  I  have  tried  other 
preservatives,  notably  boric  acid  and  borax,  in  a  mixture  and  have  found  that  this 
is  more  successful  in  reducing  the  growth  of  bacteria.  In  fact,  it  can  be  used  in  preser- 
vation of  blood  for  the  usual  purposes  of  complement  fixation,  but  applied  to  tumor 
cells  it  is  not  useful,  because  tumor  cells  are  agglutinated  in  it. 

In  many  subsequent  experiments,  both  in  Hamburg  and  in  America,  all  evidences 
of  a  dissolving  influence  of  normal  serum  on  cancer  cells  have  been  lacking. 

Von  Dungem's  reaction  is  one  that  depends  upon  the  usual  technique  of  comple- 
ment fixation.  He  got  his  idea,  practically,  from  the  published  experiences  of  Ascoli 
and  Izar  in  the  use  of  the  meiostagmine  reaction,  and  his  antigen  was  originally  an 
alcoholic  extract  of  tumor.  He  did  not  claim  to  have  found  a  specific  reaction  in  the 
sense  that  there  were  specific  antibodies  to  the  antigen,  nor  did  he  think  that  the  re- 
action was  an  organ-specific  one,  in  the  broader  sense — ^but  he  did  think,  and  I  believe 
he  still  thinks,  that  the  substances  producing  the  reaction  were  the  result  of  an  infec- 
tion by  a  parasite  which  may  under  favorable  drcumstances  result  in  the  formation 
of  a  tumor.  He  conceives  that  the  parasite  is  present  in  the  blood  of  individuals  long 
before  the  tumor  has  appeared.  This  experiment  is  made  with  an  antigen  in  which 
the  lipoids  were  isolated.  In  the  later  experiments  of  Von  Dungem,  instead  of  the 
extract  of  the  tumor  he  used  an  extract  of  blood  corpuscles.  In  one  experiment  I 
found  that  the  blood  lipoids  used  with  the  urine  of  cancer  patients  produced  a  reaction. 
The  same  substance  used  as  an  antigen  combined  with  urine  of  syphilitic  patients  did 
not  produce  the  reaction.  There  was  a  distinct  fixation  which  seemed  to  be  specific. 
The  urine  was  not  used  in  its  crude  condition,  but  an  alcoholic  precipitate  was  taken 
and  dialyzed  and  brought  up  to  a  certain  proportional  volume  in  each  case,  and  that 
was  used  in  place  of  the  patient's  serum. 

In  many  experiments  since  then,  both  in  von  Dungem's  laboratory  and  here,  no 
such  reactions  have  been  obtained.  In  fact,  during  the  time  that  I  was  in  von  Dun- 
gem's laboratory  his  laborant  was  not  able  to  produce  a  reaction.  The  reactions  at 
that  time  were  being  carried  out  by  an  assistant  as  had  been  the  case  for  sometime 


622       PB00EEDIKQ8  8B00HD  PA2f  AMBBIOAlf  80IBKTIFI0  CONGBESa. 

previouflly  and  von  Dimgem  had  not  been  controlling  the  teet,  but  an  exanunatioa 
of  them  flhowed  that  they  were  not  being  carried  out  according  to  the  usual  principlea 
ol  the  complement  fixation  teat.  I  have  apoken  with  other  men  who  have  tried  ih% 
reaction,  among  them,  Sachs,  in  Ehrlich's  laboratory,  and  these  men  have  failed  to 
obtain  anything  like  the  results  reported  by  von  Dungem.  The  confirmatory  work 
has  been  done  chiefly  in  von  Dungem's  laboratory.  One  of  those  who  obtained  con- 
firmatory results  in  his  laboratory,  Halpem,  has  not  been  able  to  use  the  test  at  all 
since  he  has  been  working  independently.  There  seems  to  be,  as  Sachs  expresses 
it,  an  uncontrollable  factor  in  the  tedmic  of  the  test  that  makes  it  not  valuable  for 
clinical  use. 

The  Chairman.  Is  there  any  discussion  of  Dr.  Coca^s  paper? 

Dr.  Bbonfenbbenner.  I  would  just  like  to  add  one  word  in  con- 
nection with  the  paper  by  Dr.  Clowes,  i.  e.,  it  would  bo  very  inter- 
esting if  it  were  possiUe  sometimes  to  prove  that  in  tuberculosis  and 
cancer  the  difficidty  of  serum  reaction  is  due  to  excess  of  calchim^ 
which  interferes  with  the  extent  of  the  reaction. 

The  Chairman.  I  will  now  state  that  the  paper  of  Dr.  Bosco  is  to 
be  read  by  title. 


TERATOMA  DE  LA  BEGION  DEL  TUBER  CINEREUM. 
P^  GUILLERMO  A.  BOSCO, 

Adtaripto  a  la  CdMra  de  CUmca  PropedkUiea,  Buenoi  Atr«f,  ArffenUna. 

Los  casos  dfnicos,  c^io  el  presente,  son  comuiies,  pcfo  la  naturalesa  anitomo- 
patol6gica'del  mal  es  de  las  mis  raras.  Esta  es  la  causa  que  nos  anima  a  publicar 
la  siguiente  observaci6n  y  desde  ya  podri  suponerse  el  caiActer  de  la  rniama. 
Revisando  la  historia  auitoiuo-patoLdgica  de  los  tumores  cerebralesy  s61o  hemoa 
enooatiado  seis  casos  semejantes  al  presente,  de  los  cuales  uinguno  ccNTesponde  a 
autoies  de  nuesUo  pais.  Greemos,  salvo  mejor  informaci6n,  que  el  twatoma  del 
tuber  cinereum,  objeto  de  este  tnbigo,  es  el  primero  que  se  describe  en  la  Aigentina. 
£1  enc^alo  no  es  asiento  oomto  del  teratoma;  su  proporcidn  es  minima  si  la  compa- 
ramos  con  el  nihnero  de  los  que  se  desarrollan  en  sua  regiones  de  predilecddn.  La 
raa6n  de  ello  se  encuentra  en  la  embriologia,  en  la  forma  como  se  organisan  los  dlv^aoa 
segmentos  de  nuestro  otganismo,  y  que  no  xecordamos  para  no  alejamos  demsaiado 
del  prop6aito  que  nos  hemos  propuesto.  M^  llamativo  es  peosar  en  la  causa  que 
da  lugar  a  la  produocidn  de  estos  tumores  que,  como  se  sabe,  son  embricd^cos.  BesiB 
diffcil  imaginar  algo  nuevo,  despu^  de  todo  aqu^o  que  se  ha  expresado  al  respecto. 
Oomparando  las  diatintas  opiniones  reinantes,  una  sola  queda  en  pie  y  es  aqudlla 
que  los  considera  como  una  defectuosidad  fonnativa,  una  reviviscencia  desviada  y 
monstruosa  de  restos  embiionarios  endavados  en  cualqider  punto  oiginico.  £s  m&» 
curioso  todavfa  preguntarse  qu^  es  lo  que  influye  en  la  animaci6n  de  esos  restos  en 
mementos  tan  opuestos  de  la  vida.  Nadie  hasta  ahora  ha  dado  una  respuesta  satis&c- 
toria  y  asf  debe  ser  por  poco  que  se  piense  en  ello,  y  si  hemos  recordado  a  nuestro 
tumo  estos  hechos  es  por  hibito  bien  entendido  m^  que  por  otra  cosa. 

Nuestro  enfermo,  argentine  agricultor,  de  SO  alios  de  edad,  carece  de  antecedentes 
patol<3gico6  hereditarios  y  peraonales.  Su  salud  ha  side  inalterable,  sua  oeupadones 
de  las  m^  sanas.  Ha  enfermado  una  sola  vez  que  ha  side  aqudlla  que  lo  condujo 
a  la  muerte.  £l  comienzo  de  su  enfermedad  data  de  un  afio.  M^s  que  61,  lu6  su 
kmilia  la  que  se  ap«rcibi6  de  ella.    No  se  inici6  en  una  forma  intensa  ni  se  hizo  visi- 


FUBUO  HBALTH  ASV  UMDIODSHL  62S 

Ut  por  BkanifeBtacicmes  eiztedoroB.  8u8  tlnUaatm  se  refirieron  a  modificscumeB  d^l 
caricter.  Estos  oomq>ondlaii  a  una  p^rdida  de  atenci^n,  memoria,  diacerntmiento, 
6t  dedr,  de  la  inteligenda,  a  una  disminud^n  de  la  voluntad,  y  a  la  aparici6n  de  una 
triatesa,  apatia,  indiferencia  y  deegano  crecientea.  Eate  cortejo  peiquico  Be  acompafi6^ 
de  ceialia  intennitente,  de  variable  intenddad.  Sub  all^adoi  creyeron  que  el 
enfenno  simulaba  una  afeccidn,  con  el  pcopMto  de  eludk,  qui^  Babe  porqu^  bu 
tabajo.  MaB  cemokB  pefturbacionea  cerebialeaiban  enaumentolacefalia  aumentaba 
y  aocrcaba  bub  acceaoB,  y  como  se  insinuaban  otraa  anarmalidadeB,  v.  i^.,  v6mitoB» 
convulflioneB  fruBtnui  de  Iob  miembroB,  anorexia,  diaDiinuci6n  de  la  visldB  en  el  ojo. 
derecho,  la  ^uaiilla  Be  reeolvid  bacerlo  examlnaT  Biendo  lipidamente  decidida  a  ello 
a  cauBa  de  una  Bede  de  ataqueB  que  tenninacon  par  una  hemiplegia  derecba. 

Alojado  en  nueetra  Bala  de  hoBpital,  Be  le  hizo  el  examen  de  bu  eBtado  y  ^  no  did 
datoB  de  mayor  importancia,  como  puede  vene  miB  abajo,  a  no  Ber  ke  que  bo  refieren, 
a  la  BBfera  nwvioBa  y  a  la  viBi^ 

£b  un  Bu|eto  en  buenaa  condicioneB  de  nutrici6n,  con  buen  deBanrollo  ^eeo  y  muacu* 
lar  y  regular  cantidad  de  paniculo  adipoea 

Cabesa:  El  sbtema  piloBo  y  el  cuero  cabeUudo  eon  normaleB.  El  crineo  ea 
mesoc^tiUo. 

Ojob:  No  hay  edema  de  Iob  p^rpadoe;  conjuntivaB  normalee. 

Naria  y  oidoe:  NormaleB. 

Boca:  Lengua  muy  BabunaL 

Ouello:  No  bo  yen  latidoB  arterialee  ni  bo  palpan  ganglioa. 

Tdraz:  Cilfndrico;  tipo  requratorio  coBtoabdominal,  14  reBpiracionai  par  minute. 

PulmoneB(por  detrtb):  EzcunLte  reBfdxaioria  normaL  ExJBten vibracioneB vocalea 
normaleB  deede  el  v^rtice  haBta  la  baee.  Sonoridad  normal  en  toda  la  Buperfide 
pulmonar.    MunnuUo  yeaicular  normal.    Por  dekmte:  iddnticoa  fendmenoB. 

Corasdn:  La  punta  ae  ve  y  ee  palpa  en  el  quinto  eq;Mcio  inteicoBtal,  siguiendo  la. 
linea  mamilar;  nada  de  particular  a  la  palpacidn  de  la  icgidn  precordial;  la  petcuaidii 
denota  que  el  area  cardiaca  ee  normal;  auBCultendo  bo  oyen  Iob  tonoB  nonnalee  en  ka. 
cuatro  focoB. 

PuIbo:  Frecuenda,  60  pulaadonee;  buena  tenai^  y  expanBidn,  regular,  igual. 

Abdomen:  Inapeccidn;  nada  de  particular. 

Palpacidn  (higado):  El  borde  Bupmor  bo  percute  en  el  quinto  eBpado  intercoBtal  en 
Ulinea  mamilar,  ocupando  el  reeto  del  bordeBUBitionornial;dbofde  inferior  Be  palpa. 
a  doB  traveBBB  de  dedo  por  debajo  del  reborde  coatal.  Eeta  hipertrofia  del  digano  ea. 
debida  a  la  preeencia  de  quistee  hid^ticoB  en  la  gKndnla. 

Baao:  La  perouaidn  deecubre  un  ligero  aomento  de  la  matitea;  bo  palpa  en  el  hipo-. 
cendrio  iaquierdo  durante  lae  profundaB  inapiracionea. 

RifUmeB:  No  bo  palpan. 

Nadade  particular  en  el  reeto  de  ke  vfBceraB. 

OiganoB  genitalea:  TeetkuloB  y  epididimoB  normalaa. 

MiembroB:  No  hay  edemaa. 

I^Btemanervioao(niotilidad):  La  motilidad  vduntaria  de  la  pienia  y  braao  derecbOv 
eeti  oompletamente  abolida.  El  braao  caa  doblado  Bobre  el  tronco  y  la  piema  exten- 
didaaobrelacama.  Lob  movimientea  activoB  eBtto  impoaibilitadoa,  no  puede  levantai 
el  braiOy  no  puede  caminar,  no  puede  aprovechar  el  primero  para  Iob  actoB  de  la  vida 
ordmaria  y  bo  vale  para  efectuarloe  del  biaao  y  piema  iaquierdoa.  La  maicha  ea 
dificultoea;  el  enkrmo  no  puede  permanecer  da  pie  y  cuando  camina  anaBtia  la  piema 
derecba.    De  pie  tiene  tendencia  a  caer  hada  atria  y  a  la  derecba. 

La  lengua,  dentfo  de  la  boca,  eeti  derecba,  pero  Bi  Be  la  hace  pioyectar  fuera  de  ella, 
Be  desvia  viriblemaite  hada  el  lado  deredio»  vale  dedr,  hacia  el  lado  paralisado. 

El  vek)  del  paladar  ae  encuentia  caido  unikrmemente  BC^re  la  lengua;  por  eeo  debe. 
alimentaiae  Imtamente  y  a6n  aai  Buelen  peaar  con  relativa  frecuenda  Iob  alimentea  a 
laa  loBBB  uMBleB,  a  conBecuenda  de  lo  cual  hay  BeiioB  traBtomoade  ladegluddn,    Laei 


524       PB00EEDINQ8  SEOOKB  PAN  AMBBIOAV  80IEKTIFI0  C0K0BE88. 

foucee  no  pueden  examinane  proliJAmente  porque  hay  contractura  de  lot  mas^Cefos, 
la  cual  p6iie8e  en  evidencia  ai  se  pretende  abiir  la  boca.  La  vos  del  enfermo  ea 
francamente  gangosa. 

Reflejne:  Los  reflejoa  cutineoe  eat^  exageradoa.  Hay  fen6meno  de  Babinaky; 
ai  ae  excita  la  planta  del  pie  del  lado  derecho,  ee  obeerva  que  loa  dedoa  ae  flezionaa 
bacia  la  planta,  excepto  del  dedo  gordo  que  ae  extiende. 

Loa  reflejoa  tendinoaoa  eat^  exageradoa;  la  percuaidn  del  tenddn  de  Aquilea  o  del 
tend6n  rotuliano,  produce  una  bruaca  extenai6n  del  pie  y  de  la  piema,  reapectiv*- 
mente.    Hay  ademte  clonua  y  trepidaci6n  epileptoidea. 

En  el  miembro  auperior  derecho  ae  obaerva  el  miamo  fendmeno;  la  percuaidn  de  los 
tendonea  en  coalquier  punto  que  Moa  eat^  a  flor  de  piel,  produce  la  exageraddn  de 
loa  movimientoa  fiaiol^coa  ccMreapondientea. 

Benaibilidad:  AI  tacto,  dolor  y  calor  conaervada. 

Atrofiaa  muacularea:  Laa  eminenciaa  tenar  e  hipotenar  de  la  mmo  derecba  ae 
prcaontan  deprimidaa,  debido  a  la  atiofla  de  loa  mtlbculoa  que  laa  conatitujren.  Ealaa 
atiofiaa  ae  obeervan  tambidn  en  el  antebraco  al  nivel  de  laa  eminendae  epitroclear  y 
epicondilea,  como  en  el  braso.    El  miembro  inferior  derecbo  eatd  igualmente  atrofiado. 

Acceeoa  epileptiformee:  En  ciertoe  momentoa,  al  practicarse  el  examen  clfnico,  el 
cuerpo  ee  aacudido  por  convulaionea  de  ritmo  y  mediana  intenaidad,  precedidaa  de 
on  grito  aemejante  a  un  chiUldo. 

ConUacturaa:  Exiate  contractura  de  la  mitad  derecba  del  cuerpo,  hay  ademia 
rigidez  de  la  nuca,  columna  vertebral  y  de  loa  maa^teroa  (triamua). 

Examen  de  loa  aparatoe  aenaorialea  (sentido  de  la  viata):  No  hay  traatomoa  motorea 
de  loa  pdrpados.  Hay  aniaocoria:  la  pupila  derecba  ea  mte  grande  que  la  izquierda; 
la  primera  no  reacciona  a  la  luz.  El  examen  del  fondo  del  ojo  deacubre  tma  atrofia  de 
la  pupila  complete  en  el  ojo  derecho,  menoe  pronunciada  en  el  opueeto.  A  conaecu- 
encia  de  eeto,  la  virion  no  exiate  en  el  primero.  El  ojo  izquierdo  preaenta  diaminuci6n 
conc6ntrica  del  campo  visual  y  la  vision  estd  redudda  al  d^cimo.  El  aentido  del 
olfato,  gusto  y  ofdo  es  normal. 

Examen  pafquico:  Su  estado  mental  ae  preaenta  profundamente  alterado.  Ha 
perdido  la  atencidn  y  la  memoria;  deeatiende  la  conversad^n  y  ha  olvidado  todo  cuanto 
ae  refiere  a  su  existencia.  Vive  en  una  perpetua  somnolencia  intemimpida  a  rates 
por  ligera  animad6n.  Estas  deficiendas  mentales  se  ban  ido  acentuando  progreaiva- 
mente  y  hubiera  sido  fdcll  seguirlas,  si  el  enfermo  se  hubiera  reclufdo  en  el  hospital 
desde  los  comienzos  de  su  afeccidn;  no  repreeentan  mia  que  loa  tUtimoe  gradoe  del 
estado  psfquico  que  hemos  descrito  en  los  prodromoe  de  su  enfermedad. 

Todoe  los  signoe  clinicoe  que  acabamos  de  enumerar  parecen  caracterizar  un  tumor 
de  la  fosa  cerebral  media.  Que  se  trata  de  un  tumor  ee  16gico  pensarlo,  por  la  cefalia 
persistente,  gravativa,  intensa,  los  v6mitos,  por  la  ambliopfa  y  la  ceguera,  por  loa 
trastomos  epileptiformea  y  hemipl^jicos  y  por  la  hipertenaidn  del  Ifquido  c^&do- 
raquideo.  Que  eet4  localizado  en  la  fosa  cerebral  media,  ea  lo  que  vamos  a  demostrar, 
valitodonos  de  algunos  de  esos  sfntomas  y  de  loa  que  caract^zan  a  los  que  tienen 
asiento  en  las  otraa  dos  fosaa.  Los  tumoree  de  la  fosa  cerebral  anterior  ae  distinguen 
por  la  anosmia,  la  ataxia  de  Bing  y  las  perturbaciones  psiquicas  y  la  ausencia  de 
atrofia  de  loa  nervios  dpticos,  mientraa  que  loa  de  la  fosa  cerebral  posterior  originan 
rigidez  de  Ja  nuca,  fen6menos  de  la  ataxia  cerebelosa,  falta  de  reflejo  corneal,  par&liaiB 
del  facial  y  del  auditive,  verdadera  triada  patognom6nica  y  ademte  falta  de  atrofia 
de  loa  nervios  6pticoe.  Por  este  r&pido  andHsis,  queda  suficientemente  demoatrada 
la  localizaci6n  mediana  del  tumor. 

Los  traatomoa  visualea  tienen  su  punto  de  origen  en  la  atrofia  deecendente  de  los 
nervioe  dptlcos  consecutiva  a  compreai^n  producida  por  el  tumor,  tma  de  cuyaa  por- 
donee  apoyaba  sobre  el  quiasma  y  los  nervios  6ptico8.  La  ceguera,  como  la  ambliopfa 
no  ban  sido  repentinas,  aino  que  se  ban  establecido  paulatinamente  y,  ea  poaible,  que 
loa  ojos  examinados  en  el  comienzo  de  la  enfermedad  hubieren  presentado  un  campo 


FiGUBA  2,^Zona  cortical  d»I  tiunor  ea  Is  qve  w 
«  BnoeUUca,  metUiidose  como  cavldsdes  pequeflas  e  Irtegulans. 


servado  cod  gran  aumcDlo.  Liu  CHvldodiis  ftUxi 
rpvestldas  por  UQB  OnamenibiBiiBcoUgpnB  y.por 
tuera  de  i%M,  la  cap*  basaU 


LAMINA  A. 

Incrustncioncs  cdmens  'Wnilole  cl  aipw'to  de  laminlllas  (fecaj. 
(i)  Conlfin  dc  ctflulas. 


PX7BLI0  HEALTH  AKD  HEDIOIKE.  525 

visual  con  algunas  de  las  modificaciones  hemiandpsicas  conocidas.  El  campo  visual 
del  ojo  izquierdo  es  el  de  una  estrechez  concdntrica  del  mjsmo  sumamente  avanmdo, 
tipica  de  la  atrofia  del  nervio  6ptico;  s61o  quedaba  respetada  la  visidn  macular  y 
eso  en  fonna  bastante  reducida  puesto  que  el  visum  era  igual  al  d^cimo  del  normal. 
La  midriasis,  como  la  ^ta  de  reacci6n  de  la  pupila  a  la  luz  del  ojo  derecho,  se  explica 
por  la  amaurosis  misma. 

Los  accesos  epileptiformee  tienen  su  explicaci6n  en  la  compresidn  indirecta  que 
han  sufrido  las  zonas  roUndicas,  precisamente  por  el  desarrollo  del  tumor  que  se  insinua- 
ba  cada  vez  m6a  entre  los  hemisferios  y  trataba  de  desplazar  lateralmente  su  masa. 

En  cuanto  a  la  par&lisis  vesical  y  rectal,  puede  admitirse,  de  acuerdo  con  ciertas 
teorfas  modemas,  que  sea  debida  a  compresiones  suMdas  indirectamente  por  los 
nucleos  grises  centrales,  donde  estarfan  localizados  los  centroe  motrices  de  los  esfin- 
teres. 

El  trismus  es  debido  posiblemente  a  una  compresi^n  directa  ejercida  por  el  tumor 
mismo  sobre  el  nervio  maxilar  inferior. 

Antes  de  bacer  la  deecripci6n  del  tumor,  sefialaremos  el  aspecto  de  una  serie  de 
cortes  bechoB  sobre  el  mismo,  uno  de  los  cuales,  el  m^  caracterfetico  de  todos,  es  el 
adjunto  (fig.  1). 

Primer  corte:  El  tumor  da  un  prolongamiento  qufstico,  cuyas  paredes  membra- 
noeasy  espesadasbans^uidoexactamenteelcaminodelacintaolfativa.  ensanchando 
el  surco  que  separa  las  circunvoluciones  por  donde  aqu^lla  camina,  alcanza  la  subs- 
tancia  gris  del  centre  oUativo  orbitario,  destruyendo  en  parte  la  substanda  gris  y 
desplazando  ligeramente  las  formacionee  locales  hacia  la  izquierda.  Los  cuemos 
frontales  est&n  dilatados;  las  venas  ventriculares  congestionadas. 

Segundo  corte:  En  la  cara  frontal  del  eegundo  corte,  la  prolongaci6n  qufstica  es 
m^  evidente,  es  m^  amplia  y  su  pared  membranosa  mds  espesada.  En  la  base  el 
cuerpo  del  tumor  posee  un  aspecto  mtUtiple  y  que,  por  otra  parte,  se  repetir&  en  el 
resto  del  mismo:  hay  zonas  de  aspecto  cartilaginoso,  gelatinoso,  bay  zonas  sdlidas, 
abuecadas,  qulisticas,  unas  revestidas  de  substanda  coloidea,  otras  encerrando  una 
substanda  blanquecina,  cuyo  aspecto  recuerda  al  de  la  cal  apagada.  Se  encuentran 
tambi^n  pequefios  focos  bemorr^cos.  En  la  cara  temporal  del  corte  se  ve  una 
cavidad  quiistica  de  paredes  muy  espesadas,  limitando  con  los  ventrfculos  laterales. 

Tercer  corte:  La  cavidad  qufstica  est4  m^  desarrollada  que  en  ninguna  otra  parte; 
tiene  una  capaddad  de  una  avellana.  No  ha  invadido  la  substancia  cerebral.  La 
membrana  que  es  m^  espesa  a  medida  que  nos  acercamos  a  la  base  del  tumor,  esti 
aplicada  sobre  aqu^lla  y  en  su  credmiento  se  ha  adaptado  exactamente  a  la  superficie 
cerebral,  de  modo  que  presenta  una  serie  de  dobleces  o  crestas  dirigidas  en  el  sentido 
anteroposterior.  Esa  cavidad  qufistica  se  ha  desarrollado  hacia  la  derecha  y  por 
consiguiente  ha  comprimido  la  masa  cerebral. 

Sobre  la  cara  ocdpital  del  mismo  corte,  se  ve  una  pequefla  cantidad  de  contenido 
coloideo,  revestida  de  una  membrana  que  tiene  el  aspecto  de  la  anterior,  indepen- 
diente  de  la  misma,  y  que  ha  rechazado  la  mitad  izquierda  de  la  comisura  blanca 
anterior,  y  que  hace  hernia  en  la  cavidad  del  ventrfculo. 

Cuarto  corte:  En  la  pord6n  m^  posterior  hay  una  membrana  qufstica  que  corn- 
prime  el  pie  del  peddnculo. 

En  resumen,  el  tumor  es  una  formaci6n  prismitica,  cuyas  dimensiones  son  las 
siguientes:  largo  4  centimetres,  ancho  2  centlmetros,  altura,  en  su  parte  media,  3 
centimetres.  Lateralmente  est&  limitado  por  los  lados  del  dngulo  que  fonnan  los 
pedfinculos  y  por  los  hordes  internes  de  los  16bulos  tempore  esfenddales;  por  su  cara 
inferior,  descansa  sobre  la  silla  turca;  por  su  cara  superior  llega  haeta  la  base  del 
tercer  ventrfculo.  En  su  credmiento  ha  alcanzado  a  destruir  las  formaciones  blancas 
y  grises  situadas  en  el  espado  cuadrangular,  delimitado  por  las  dntillas  6pticas  y  por 
los  pedtinculos  y  ocupado  por  los  tub^rculos  cuadrig^minos  y  tuber  dnereum.  Sus 
caras  son  mamelonadas,  tienen  el  color  de  la  substancia  cerebral,  estdn  recorridas  por 


526       PB00EEDIKQ8  SECOND  PAN  AMRBIOAK  80IBKTIFI0  00N0BBS8. 

escasos  capilares.  En  la  masa  del  tumor  hay,  como  se  ha  sefialado  m^  arriba  con 
mayores  detallet,  algunas  formacioneB  qufaticaa  de  vaiiado  aspecto,  con  incrustacionea 
bUuiquiscas,  4mpen»,  como  ad  fueran  de  polvo  calca^ro. 

Et  necesario,  para  comprender  Algunoe  sfntomas  cUnicos  que,  estando  el  limite- 
posterior  del  tumor  por  delante  del  origen  aparente  del  tercer  par  craneano,  ningtiff 
centre  nuclear  del  meeenc^falo  ha  eido  tomado  y,  como  el  tumor  se  ha  desarrollada 
bada  el  interior  de  la  masa  encef&lica,  meti^ndoee  como  una  cufia  entre  IO0  hemisferioa 
las  fibras  radiculares  de  los  nervios  en  especial  de  aqu^Uoe  que  se  dirigen  al  ojo,  ban 
side  respetadoe.  La  amaurosiB  de  uno  de  loe  ojoe  se  explica  por  la  compresidn  y  des- 
trucci6n  sufidda  por  el  quiasma.  La  parilisis  derecha  es  debida  a  la  compreei6n  del 
peddnculo  cerebral  del  Lado  izquierdo. 

El  estudio  histoldgico  de  la  neoplasia  nos  ha  dado  el  siguiente  resultado  (fig.  1). 

El  tumor  esti  constitufdo  por  cordones  de  c^lulas  de  espeeor  variable,  finoe  en  unoe 
lugaree,  gruesos  en  otros  y  que,  al  encontrarse  circunscrlben  cavidades  y  fisuias  de 
contomoe  y  yolumen  variables,  siendo  las  pequefias  corticales  y  las  mayores  centrales. 

Los  cordones  est&n  f cnrmados  por  cdlulas  de  forma  variable,  predonadas  mutuameate» 
sin  cemento  intercelular  y  unidas  entre  si  por  filamentos  que  recuerdan  las  que  yacea 
en  el  cuevpo  mucoso  de  Malpighi  (L^Unina  A).  Estos  cordones  eet&a  revestidos  en  su 
perileria  por  una  hilera  de  c^ulas  cdbicas,  de  ndcleo  central,  tapisadas  a  su  vea,  por 
una  membrana  anhista  unitome  y  delgada  (fig.  3).  Las  c^ulas  poseen  escaso  pn>- 
toplasma  cuyo  ndcleo  corresponde  a  la  forma  celular.  F^Udl  es  comprobar  que  la  nato-^ 
ndexa  de  las  c^ulas  cwdonales  y  de  las  cdbicas  es  epitelial.  Los  cordones  son  avascu- 
lares;  hay  uno  que  otro  esboso  de  vaso  generalmente  una  fisura  con  0  sin  gldbulos  rojos. 

Las  cavidades  que  delimitan  las  membranas  basales  contienen,  unas,  globes  eslMcoa 
de  substanda,  aspecto  y  reacddn  de  substanda  coloidea;  otras  tienen  substancia 
colidea  uniforme  0  vacuolada,  otras  poseen  ademis  de  esta  substancia  fines  filamentoa 
coligenos  en  contacto  con  la  basal;  otras  est&n  Uenas  de  tejido  hialino  atravesado  por 
vases  con  paredes  coUgenas  y  presentando  espacios  vados  que  enderran  grandes  c^u- 
las  mononudeadas,  de  ndcleo  pequefio.  En  algunos  puntos  estas  formadones  son  m4s 
densas;  las  c61ulas  est&n  dispuestas  en  cavidades  hechas  en  plena  substanda  hialina 
que  por  d  conjunto  toma  d  aspecto  de  cartflago;  sin  embaigo  las  cdulas  llenan  com- 
pletamente  las  cavidades  que  les  dan  alojamiento:  su  nddeo  es  pequ^o,  su  protoplasma 
estd  formado  por  una  fina  red. 

En  otras  aonas,  inmediatamente  per  dentro  de  la  membrana  basal,  hay  un  tejida 
conjuntivo  de  franco  caricter  coUigeno,  rico  en  c^lulas  redondas  y  fusiformes.  E^ 
resto  dd  tejido  esti  dispuesto  en  forma  de  areolae  que  recuerdan  d  grasoso. 

En  d  espesor  de  los  cordones  epiteliales  ndtanse  algunas  formadones  globulares, 
en  que  hay  dementos  aplanados  superpuestos  formando  capas  conc^ntricas,  coma 
globos  epid^nnicos,  por  aplanamiento  y  transformaddn  ccmea  de  los  elementos  de  loa 
cordones.    Tambi^n  en  ellas  se  encuentran  depMtos  caldureos. 

Exists,  por  dltimo,  en  menor  proporddn  que  las  dtadas  fcnrmadones,  un  tejido  espe- 
cial constituido  por  substancia  fundamental  hialina  en  partes,  y  en  otras  finamente 
granulosa,  que  enderra  cavidades  pequefias,  esfdricas  0  irr^ulares  por  pred6n  recf- 
proca,  dentro  de  las  cuales  encontramos  cdulas  de  protoplasma  esponjoso  y  nddea 
pequefio  en  reladdn  al  tamafio  celular.  Estas  cdulas  no  existen  en  todas  las  cavi- 
dades y  la  mayor  parte  no  alcanzan  a  colmarlas,  presentando  entonces  un  protoplasma 
retrafdo  o  dentellado  (fig.  4).  Pareceria,  a  primera  vista,  encontramos  en  presenda 
de  formaddn  cartilaginosa,  pero  el  examen  atento  y  las  reacdones  tintoiiales  noa 
demuestran  que  no  es  asf . 

8i  comparamos  esta  formad6n  con  los  datos  obtenidos  de  la  embriologf a,  y  recorda- 
mos  la  estructura  de  los  tumores  cong^tos  descritos  por  el  Profesor  Bibbert  con  d 
nmnbre  de  cordomas,  aceptamos  que  ella  estd  formada  a  expensas  de  restos  cordales. 
La  explicad6n  embriog^ca  precede  de  la  reladdn  que  tiene  la  extremidad  anterior 
de  la  corda  doisalis  con  la  membrana  fiuringea  en  la  base  del  enc^alo  para  formar  la 
bolsa  de  Rathke. 


L 


LAMINA  B. 


FiouRA  3.— CorIB  con  pan  numenlo  de  pordcnws,  mostnuido  ha  fllamcnlos  df  unlOn  snlre  los  cocdones. 

FiQURA  4.— TeJIilo  bialino  conlenlendo  csvldadrs  dealro  dp  las  cusIps  se  etxurnlrsn  mananucltadu  d« 

f spBJio  protoplasma  y  out  r«uf rdan  la  corda  dorealis. 

PrauBA  S.— Formacioncs  oiilcirFas  diapucslns  ea  tonna  lOnortitrioB  seracjando  al  colpstratoma. 


PUBLIC  HEALTH  AKD  MBDIOINB.  627 

Bcapecto  de  tea  fonnadoneB  ti<*HiiM  y  colt^deu  que  ae  inteiponen  entro  los  cordones 
-da  U  neoplau,  su  mtenpratKcidn  ee  lit  siguiente:  a  primer  golpe  de  visU,  parecetfo 
qae  ema  anbatanciaa  fnwen  una  aecrecidn  de  la  capa  de  c^hilaa  cdUcaa  qu«  ocnpon  la 
parte  mis  externa  de  los  cordonea,  recordasdo  el  aapecto  de  loa  cistmnaa  an  g«nentl; 
p«n»  la  franca  limjtaci<5n  de  loe  cordonea  qne  eattn  raveatldoa  por  una  membiana 
snhbtft  cny*  leacddn  coldgena  ea  evidente  7  qae  en  a^unoa  puntoa  eeti  constitufda 
par  on  acAmulo  de  fibrillas  de  igual  natoraleia,  aleja  eata  concepd^n. 

De  modo  puea,  que  pot  fueia  de  la  membrana  baaal  coiutitulda  por  laa  cAlnUa 
-cdUcaa,  exiate  como  d  dij jnince  on  dennia,  caj*  estructun  m  varia  y  qne  ha  auMdo 


■—oetodemia  qua  an  «l  punLo  xma 

»— brintg  D  Inlwltna  anUrlor. 

d— boln  a  dlTotleala  da  Rithk^ 

a— corda  dcnaUi  que  n  InslnAa  an  ri  extmnldad  u 


una  tranafonnaddn  biaUna  o  cololdea.  vitedoae  au  caKkter  flbrilar  en  pcNMa  luBarea. 
FUa  uit(9i«etar  la  histogtocou  de  wte  tumor,  hay  que  lemontuse  al  perf  odo  embrio- 
nario.  Ea  aabldo  qne  la  montwana  laringea,  antea  de  au  pertoacito  fmna  en  la  baoa 
c«ttlica  un  divertlcnlo  Uamado  la  bdaa  de  Rathke.  Eata  ha  de  conatituir  ulteaior- 
mente  la  hip6fida  y,  aqn^lla,  a  ozpenaaa  de  la  cual  ae  hace  el  divartlculo  de  que 
habUmm,  conata,  da  ectodermo  y  raidodenno.  Aboia  hien,  la  corda  donalia  fonna- 
cite  ectod6rmica  que  eeti  px  delante  del  neuro— eje  termina  en  an  porcidn  anterior 
juzta-^tonifndoae  a  la  capa  ectod^rmica  de  la  manfaraaa  famngeaeimnnnisdoaeentre 
M»yIacBpaendod6niuca.    Aal,  podiiamoaexplicar que elementoadetacmda donalia 


628       PBOGEEDINOS  SECOND  PAN  AKKRTOAN  SdENTIFIO  00N0BE88. 

puedan  ser  anaatrados  con  el  divertf culo,  e  induf dos  en  el  vftBtago  e  infundfbulo  de  Im 
hip6fi8i8,  den  lugar  a  este  tumor  complejo  que  estudiamos, 

£1  caao  que  eBtudiamos  es  andlogo  al  relatado  por  el  Prof eoor  Yutaka  Kohn  del  Inati- 
tuto  de  Anatomfa  Fatoldgica  de  Munich  y  claaificado  por  ^ate  con  el  nombre  de  teratoma, 
en  el  cual  habfa  ademia  formadones  cartilaginoflas  y  6aeaa  que  no  exiaten  en  el  nueatro. 

Se  trata,  entoncea,  de  un  tomat  de  naturaleaa  epitelial^  lormado  a  expenaaa  de  la 
membrana  fauingea,  cuando  ^ata  ae  Invagina  para  forma  la  hip6fiaia.  Algunoa  ele- 
mentoa  de  eata  membrana  unidoa  con  reatoa  de  la  corda,  cuya  reladdn  con  la  membrana 
iaringea  puede  apercibirae  en  el  eaquema  adjunto,  ban  quedado  aialadoe  y  alojadoa 
dentro  de  la  cavidad  craneana,  dando  lugar  al  deaarrollo  de  la  neoplaaia. 

El  tumor  eat4  formado,  en  conaecuenda,  por  elementoa  ectod^rmicoa,  meaoddrmicos 
y  endod^rmicoe;  loa  primeroa  conatituyendo  el  ectodermo  general  del  anbrkSn  que 
antra  a  forma  parte  de  la  membrana  faringea;  loa  aegundoa  por  loa  elementoa  con- 
juntivoa  que  ae  yen  en  dl;  y,  loa  terceroa,  conatitufdoe  por  laa  formadonea  cordales 
que,  como  ea  aabldo,  derivan  del  ectodenno. 

Adjournment. 


GENERAL  SESSION  OF  SECTION  Vm. 

New  Ebbitt  Hotel, 
Friday  morning,  January  7,  1916, 

Chairman,  B.  H.  Cabteb. 

The  session  was  called  to  order  at  9.15  o'clock  by  the  chairman. 

The  Chairman.  The  first  paper  this  morning  is  by  Dr.  Calkins,, 
of  Columbia  University,  on  "General  biology  of  the  protozoan  Ufe 
cycle.'' 

GENERAL  NOLOGT  OF  THE  PROTOZOAN  UFE  CYCLE. 

By  GARY  N.  CALKINS, 
Profeuor  ofPtoUmoolo^  in  Columbia  Univenity, 

For  five  decades  after  the  time  of  Ehrenbeig  the  peculiar  conceptdon  of  a  protosoan 
as  a  miniature  replica  of  a  metazoan,  held  by  this  gifted  observer,  influenced  the 
study  of  protozoa.  This  influence  gradually  wore  off  and,  so  far  as  morphology  is 
concerned,  ended  with  the  careful  observations  of  Stein,  Cliq[>arMe  and  Lachmann, 
Engelmann,  BQtschli,  and  Hertwig,  who  showed  that  various  structures  of  the  pro- 
tozoan body  are  not  beating  hearts,  brains,  ovaries,  and  stomachs,  but  are  simple 
differentiations  of  the  single-celled  organisms. 

A  more  lasting  influence  of  Ehrenbeig's  teaching,  seen  even  to-day,  is  the  habit  of 
regarding  a  single  protosoon  as  the  complete  expression  of  a  species  equivalent  to  an 
individual  worm,  mollusc  or  mammal.  The  individual  metazoon  dies,  while  the 
protoKoon  does  not  die,  but  grows  to  full  size  and  divides  into  two  or  more — facts 
which  led  Weismann  to  his  conclusions  regarding  mortality  in  metazoa  and  immortality 
in  protozoa. 

We  owe  to  Maupas  the  credit  for  dissipating  this  last  reminiscence  of  Ehrenberg's 
teaching,  and  for  showing  that  the  single  cell  is  not  the  final  representative  of  a  pro- 
tozoon  species.  We  are  accustomed  to  the  idea  that  many  individuals  of  a  polymorphic 
coelenterate  are  present  in  potential  in  the  fertilized  egg  of  the  coelenterate,  but  we 
are  less  accustomed  to  the  idea  that  polymorphic  individuals  are  present  in  potential, 
in  the  fertilized  cell  of  a  protozoon.  Research  in  recent  years  has  shown  that  suc- 
cessive generations  of  protozoa  may  be  more  or  less  progressively  differentiated,  so 
that  a  cell  picked  out  at  one  phase  of  the  life  cycle  is  quite  a  different  type  of  ind^ 
vidual  from  one  picked  out  at  another  phase.  Which,  for  example,  would  be  the 
''type''  individual  of  the  dimorphic  Foraminifera?  Which  would  be  the  type  in 
the  reproducing  flagellated  and  ameboid  stages  of  NUgUria  punetataf  of  different 
phases  in  the  life  history  of  Centropyxia,  ArcellOy  or  Diffiugiaf  or  of  intestinal  and  blood- 
dwelling  stages  of  PUumodiumt  The  morphological  differences  here  indicate  that 
the  protozoan  life  history  involves  differentiation  analogous  to  that  of  a  polymOTphic 
metazoon,  and  justify  the  comparison  of  the  whole  life  cycle  with  the  development 
and  differentiation  of  a  metazoon,  especially  that  of  a  metagenetic  type  such  as  co- 
elenterate or  trematode. 

529 


680       PBOOBEDIKOB  BECOVD  PAN  AMBBIOAK  BODUfXIFIC  00KQBB8B. 

The  importance  of  the  whole  life  cycle,  fint  demonstrated  by  Maupas,  waa  fully 
Tecognized  by  Schaudinn  and  applied  by  him  to  the  study  (A  parasitic  forms.  The 
monographs  resulting  from  this  study,  especially  those  on  Cocddnan  tehtdnrgi,  PUm^ 
moiiuiit  vivaXf  and  on  rhizopods,  are  classics  in  the  literature  of  protoooa,  and  modeb 
which  later  students  have  followed. 

Through  Schaudinn's  work,  and  by  later  researches,  the  sequence  of  events  in  dif- 
ferent parasitic  types  hae  been  made  out  with  painstaking  care  nntfl  to-day  we  know 
the  general  history  of  the  majority  of  injurious  human  protosoan  parasites,  the  modes 
of  transmission  from  host  to  host,  the  types  of  intermediate  hosts  and  what  happens 
in  them.  In  short,  we  know  enough  to  furnish  an  adequate  basis  for  public  and  private 
prophylaxis  which,  in  the  hands  of  sanitary  comnussioners  and  public-health  officer^ 
has  put  an  end  to  epidemics  at  yellow  fever,  malaria,  and  dysraitery ;  has  rehabilitated 
vasttractsof  land  ija  Italy;  saved  millions  of  dollars  in  South  Africa  and  in  our  Southern 
States;  and  has  made  the  Panama  Canal  possible. 

Such  are  the  fint  and  practically  the  most  important  results  of  our  knowled^  con- 
cerning protozoan  life  cycles;  quite  enough,  indeed,  to  justify  the  science  of  proto- 
loology.  Important  as  Uiese  results  are,  we  are  not  at  all  satisfied;  we  know  too  little 
about  the  conditions  of  development;  too  little  about  the  nature  of  the  vital  jMrocesses 
of  the  organisms  themselves  aad  their  varlaitioiis  in  strvotnre  and  function  under 
differing  conditions— ignorance  which  must  be  cleared  away  before  much  further 
practical  advance  can  be  made.  Further  advance  will  be  less  spectacular  and  must 
be  baaed  upon  the  biological  study  of  the  organisms  as  units  of  protoplasmic  substance, 
and  this  will  rest  upon  working  hypotheses  supported  by  experiment.  It  ii  along  such 
theoretical  lines  that  I  wish  to  direct  your  attention  for  a  few  minutes,  to  develc^  a 
conception  of  the  life  cycle  as  a  whole,  and  to  offer  a  thecMretical  interpretation  of  the 
different  phases  of  vitality  and  of  structural  variations. 

Let  us  consider  iot  a  moment  a  single  Ameba,  or  a  malaria  germ,  not  as  a  cause  of 
disease,  but  as  a  unit  mass  of  protoplasm  which,  like  a  free-living  ParaTnedum  at 
Didinium,  performs  all  of  the  fundamental  vital  activities  common  to  living  thinga— 
namdy,  nutrition,  excretion,  irritability,  and  reproduction.  The  chemical  compo- 
sition of  these  unit  masses,  so  far  as  I  know,  has  never  been  made  out,  but  there  is 
no  reason  to  doubt  that  it  agrees  with  that  of  other  living  substances,  since  the  accom^ 
panying  properties  of  protoplasm — metabolism,  growth,  and  reproduction — are 
obviously  performed,  and  probably  in  the  same  way.  In  such  unit  masses  of  proto- 
plasm we  assume  that  processes  of  hydrolysis,  synthesis,  oxidation,  and  reduction 
are  constantly  going  on  as  in  other  protoplasms,  and  not  in  any  h^>hasard  way,  but 
always  orderly  and  under  regulative  control  of  the  organism  as  a  whole.  The  appear- 
ance of  Ameba  shows  that  the  proU^lasm  is  made  up  of  alveoli  and  interalveolar 
substances  of  different  density,  representing  colloidal  and  crystalloidal  substances  in 
a  general  mixture  which  Ostwald  describes  as  an  emulsoid.  Between  these  different 
substances  constant  chemical  activities  are  in  progress,  and  the  orderliness  which 
distinguishes  these  processes  in  the  protoplasm  of  the  living  oiganism  from  similar 
processes  which  go  on  in  the  same  protoplasm  when  crushed,  are  possibly  due,  as 
Mathews  states,  to  the  physical  barriers  of  cellular  and  nuclear  membranes,  alveoU, 
and  the  colloidal  centers  of  activity.  The  speed  with  which  such  processes  take 
place  in  living  protoplasm,  which,  in  itself,  distinguishes  living  processes  from  chemical 
processes  in  lifeless  substances,  is  due  to  specific  enzymes  or  catalyzers  which  are 
manufactured  as  a  result  of  chemical  activities  in  living  protoplasm.  These  bring 
about  and  control  each  successive  step  in  the  long  chain  of  chemical  actions  involved 
in  destructive  metabolism,  the  action  in  each  event  being  conditioned  by  the  nature 
of  the  protoplasmic  substratum.  In  this  chain  of  destructive  processes  differmt 
substances  may  be  formed  which  undergo  no  further  oxidation  or  other  chemical 
change,  but  are  stored  up  in  the  protoplasm  until  disposed  of  by  excretion,  these  prod- 
ucts, leading  to  changes  in  the  protoplasmic  substratum — ^i.  e.,  to  protoplasmic 


FTJBLIO  KBU.1H  AlTD  UXDUHSM, 


chemical  d  i  Karen tUtioa—majr  or  aatf  not  b«  accompanied  by  vinble  •tructtiral  dlf- 
ferentiatioDB.    Such  products  of  deotmctlTe  mataboliam,  is  the  form  unudly  of  nucleo- 


.0 


ma.  a  Axn  ».  IndlvUiul  13  hoora  old  cat  m  ibown  In  a.    Put  A  tiad  a 
hoiin appaand la abava  ta2  A.    Part  B (atanaratnl  pofntlr  In M  boon. 

ruM.  *,l.t  UtD  7.  ImUrldsal  col  at  ■(■  of  M  honn  m  ibawn  tn  4.  ^  nnnaraMd  iiarlMItlr,  axoapt 
forabaanea  at  micnnDdaiii,  la  34  boun  liA);  B  divided  tliRait'>fia  oristnal  diiWcn  plana  (tndtaUad 
In  4),  wlthlD  a  faw  honn  tonolnc  a  mlnole  bnt  puclwl  IndlTldnal  «£'},  and  a  Dsrnial  talMu  lndl*ldaal 
tIB"). 

pToteina  w  their  derivatives,  may  act  as  poiaons  to  other  organiama,  as  melanin  doe* 
to  the  boat  in  malaria.,  or  aa  the  proteolytic  ferments  of  JBnioTn^a  Auto/jritoa  do  in 
68486— 17— vot  i 88 


532       PBOGEEDIKGS  BBOOND  PAN  AMEBIOAN  SCIBNTIFIO  00N0BE88. 

dysentery;  or  they  may  play  some  important  part  in  the  vital  activities  of  the  (Hgan- 
ism  itself,  as  in  phosphorescence  of  Noetiliusa  and  the  dinoflagellatea,  or,  more 
generally,  in  regeneration  and  reproduction. 

Let  me  illustrate  this  latter  point  by  some  experiments  made  on  Uronychia  trangfuga, 
a  ciliated  protozoon.  This  organism  has  rather  a  complicated  structure  with  nine 
giant  cirri  at  the  posterior  end.  Under  laboratory  conditions  it  divides  once  a  day 
approximately,  or,  more  exactly,  once  in  26  hours.  The  first  indication  of  division, 
is  the  precocious  formation  of  the  giant  cirri  in  a  central  region  of  the  body  which  we 
have  called  the  "division  zone.''  The  experiments  were  undertaken  for  the  purpose 
of  studying  the  relative  power  of  regeneration  of  the  single  cell  at  different  ages  between 
di\4aions,  it  having  first  been  determined  that  the  cell  regenerates  readily  after  being 
cut.  Celts  were  cut  with  a  scalpel  at  different  periods  subsequent  to  division;  some 
during  the  end  stages  of  division;  some  15  minutes  after  division;  some  one  hour 
after;  others  2,  4,  8, 12, 16,  and  20  hours  after,  and  some  were  cut  just  prior  to  the  next 
division  period — i.  e.,  24  to  25  hoiurs  after  division.  In  all  cases  of  record  the  cells 
were  so  cut  that  one  portion  contained  the  micronucleus  and  part  of  themacronucleus, 
the  other  portion  containing  only  a  part  of  the  macronucleus.  The  former,  or,  as  I  shall 
call  it,  the  nucleated  portion,  invariably  regenerated  after  some  hours,  forming  a  per- 
fect cell;  the  latter,  without  a  micronucleus,  which  I  shall  call  the  enucleated  portion, 
behaved  differently  as  regards  regeneration,  according  to  the  age  of  the  cell  when  cut. 
In  all  cased  this  portion  lived  from  three  to  five  days  after  the  operation.  If  the 
recently  divided  cell  were  cut  at  any  period  up  to  16  hours  after  division  the  result 
was  the  same;  no  regeneration  occurred,  the  fragment  merely  rounded  out,  swimming 
about  by  its  adoral  membranelles.  If  the  cells  were  cut  when  from  18  to  24  hours  old, 
regeneration  occurred  not  only  in  the  nucleated  portion,  but  in  the  enucleated 
fragment  as  well,  the  percentage  of  regeneration  increasing  with  the  increased  age 
of  the  cells  when  cut,  until  at  the  age  of  24  to  25  hours  the  enucleated  fragments 
regenerated  perfectly  in  100  per  cent  of  cases. 

These  results  indicate  a  gradual  chemical  differentiation  of  the  protoplasm  as  a 
result  probably  of  destructive  and  constructive  metabolic  processes.  The  giant  cirri 
whirh  are  regenerated  are  the  visible  expression  of  inherited  structures  characteristic 
of  the  species.  Since  the  enucleated  fragment  from  a  cell  cut  when  young  does  not 
regenerate  while  the  nucleated  fragment  does,  we  must  conclude  that  one  essential 
factor  at  least,  necessary  for  the  production  of  these  inherited  structures,  lies  in  the 
micronucleus. 

The  giant  cirri,  furthermore,  are  visible  differentiations  which  are  precociously 
formed  at  division.  This  must  mean  that  the  inherited  &LCtors  find  their  expression 
at  this  period,  and  it  follows  from  the  successful  formation  of  giant  ciiri  in  enucleate 
fragments  from  old  cells  that  whatever  may  be  the  direct  causative  agent  or  agents 
in  the  process  they  must  be  generally  distributed  throughout  the  protoplasm  at  this 
time.  We  have  no  direct  evidence  as  to  what  these  agents  may  be.  Possibly  there 
is  only  one,  and  that  of  the  nature  of  a  specific  enzyme,  or  perhaps  some  chemical 
body  analogous  to  hormones  formed  as  a  result  of  mutual  interaction  of  nucleus  and 
cytoplasm  when  the  latter  has  reached  a  certain  stage  of  chemical  differentiation 
through  normal  activities.  Or  it  is  possible  that  such  chemical  bodies  are  present 
at  all  times  and  are  activated  only  when  the  protoplasmic  substratum  reaches  some 
particular  stage  of  development.  Thus  it  is  possible  that,  with  continued  metabo- 
lism, the  acidity  if  the  protoplasm  gradually  increases  until  a  concentration  is  reached 
in  which  specific  enzymes,  not  able  to  act  befcnre,  are  now  activated. 

However  the<Mretical  the  interpretation  of  the  phenomenon  may  be,  the  periodic 
and  temporary  power  of  regeneration  is  an  observed  fact,  indicating  a  difference  in 
the  protoplasmic  make-up  at  different  age  periods,  a  difference  which  may  be  satis- 
factorily expressed  by  the  phrase  cumulative  chemical  differentiation. 


FUBUO  HEALTH  AND  MSDIdNB.  633 

Another  observed  tact  is  that  the  regenerative  power  is  exhausted  with  cell  divi- 
sion, for  young  enucleated  fragments  do  not  regenerate.  This  indicates  a  reduction 
of  the  differentiated  adult  protoplasm  to  the  condition  of  young  cells;  or,  at  least, 
the  protoplasm  is  restored  to  a  state  where  the  causes  underlying  regeneration  are 
inactive.  This  may  be  due  to  the  exhaustion  of  specific  substances  which  take  part 
in  the  reaction  of  regeneration,  or  it  may  be  due  to  the  chemical  and  physical  changes 
accompanyiug  cell  division. 

We  are  led  through  these  experiments  to  further  speculations  concerning  the  nature 
of  cell  division.  Chemical  differentiation  of  the  protoplasm  continues  even  after 
the  stage  is  reached  when  regeneration  is  possible.  This  is  shown  by  the  fokct  that 
formation  of  the  cirri  in  Uronychia  precedes  the  process  of  division  in  normal  cells, 
and  by  the  additional  fact  that  regeneration  of  cirri  occurs  while  ceil  division  does 
not  occur  in  enucleate  fragments  cut  from  old  cells.  I  would  interpret  cell  division 
as  due  to  cytolytic  action  set  up  by  enzymes  or  other  chemical  bodies  produced  as  a 
result  of  interaction  of  nucleus  and  cell  body  differentiated  chemically  by  age.  Cytol- 
ysis  may  then  occur  more  or  less  extensively  throughout  the  entire  protoplasmic 
mass,  but  it  is  most  active  in  the  division  zone  of  the  organism  which  is  more  highly 
differentiated  than  other  regions  (see  Calkins,  1911,  and  Peebles,  1912).  The  fnem- 
brane  of  the  cell  turns  in  at  this  cytolyzed  division,  and  the  constriction  results  in 
cell  division. 

As  a  consequence  of  the  activities  accompanying  cell  division  the  protoplasmic 
substratum  is  reduced  from  the  differentiated  adult  condition  to  the  condition  char* 
^acteristic  of  young  cells,  and  the  process  of  growth  and  chemical  differentiation, 
division,  and  dedifferentiation  recur  in  more  or  less  rhythmical  succession. 

Viewing  the  life  cycle  as  a  whole,  there  are  two  phases  which  must  be  taken  into 
account.  These  are,  first,  the  encystment  phase,  and,  second,  the  sexual  or  conju- 
gation phase,  both  widespread  and  almost  universal  in  protozoan  life  histories.  Lei 
us  first  consider  the  encystment  phase. 

Encystment  occurs  ordinarily  when  the  conditions  in  the  surrounding  medium 
are  adverse,  such  as  desiccation,  lack  of  food,  etc.,  such  encysted  forms  emerging 
from  the  cyst  when  suitable  conditions  are  restored.  In  some  cases,  also,  encystment 
occurs  during  the  digestion  of  food.  In  addition  to  these  casual  encystments  there 
is  another  form  of  encystment  which  involves  more  deeply  lying  activities  of  the 
protoplasm.  In  Didinium  nasiUum  I  have  foimd  that  encystment  occurs  at  periodic 
intervals  which  can  not  in  any  way  be  connected  with  adverse  conditions  of  the 
environment  or  with  feeding,  but  must  be  interpreted  as  a  normal  phenomenon  due 
to  internal  conditions  of  the  organisms.  Encystment  at  such  times  persists  for  from 
five  to  eight  days,  and  during  this  period  no  amount  of  coaxing  will  bring  the  organisms 
out.  During  such  encystment  the  macronucleus  fragments  into  himdreds  of  small 
chromatin  particles,  which  are  ultimately  absorbed  in  the  cytoplasm.  The  micro- 
nuclei  divide,  and  products  of  their  division  give  rise  to  a  new  macronucleus  and 
new  mirronuclei.  When  the  process  is  completed  and  the  organisms  emerge  from 
their  cysts,  they  possess  from  five  to  seven  times  the  vitality,  as  measured  by  the 
division  rate,  of  the  same  race  prior  to  encystment.  Fermor  was  the  first  in  1913  to 
describe  similar  happenings  during  the  encystment  of  Stylonychia.  In  this  case 
dissolution  of  the  old  macronucleus  and  absorption  of  the  fragments,  fusion  of  the 
two  micron uclei,  and  formation  of  new  macronuclei  and  micronuclei  from  the  fusion 
nucleus  were  described. 

It  is  well  known  that  Paramecium  does  not  enc3rst.  Nevertheless  Woodruff  and 
Erdmann  (1914)  have  shown  that  phenomena  similar  to  those  occurring  during  encyst- 
ment in  Stylonychia  and  Didinium^  and  which  they  refer  to  under  the  gen^^  term 
"endomixis,'*  recur  at  periodic  intervals  (about  once  a  month)  in  the  case  of  Pora- 
mecium  aurelia.    Here  also  the  old  macronucleus  fragments  and  the  fragments  are 


534       PROCEEDINGS  SECOND  PAN  AMEBICAN  SCIENTIFIC  00N0BB88. 

absorbed  in  the  cytoplaam,  while  a  new  macranucleus  and  micronudei  are  formed 
from  the  division  products  of  the  micronudei. 

The  interpretation  of  this  set  of  phenomena  in  the  life  histary  of  protozoa  is  a  per- 
plexing problem.  There  is  not  a  doubt  that  vitality,  as  measured  by  the  division 
rate,  is  restored.  Likewise  there  is  little  reasonable  doubt  that  a  complete  chemical 
and  physical  reorganization  of  the  protoplasm  takes  place.  The  renewal  of  vitality 
was  shown  both  in  Woodruff's  culture  and  in  my  Didinium  culture,  and  one  general 
problem  is  stated  in  the  query:  How  long  can  such  periods  of  reoiganization  continue? 
WoodniCf  believes  that  they  may  keep  on  indefinitely,  but  in  my  experiments  with 
Didinium  the  race  apparently  lost  its  power  to  encyst  and  ultimatdy  died  out  after 
six  months'  culture  without  encystment.  So  too,  in  my  ctilture  of  Paramtcium 
caudatum  (1902),  where  similar  reorganization  occurred  at  least  twice,  the  race  ulti- 
mately lost  the  power  to  reorganize  and  died  out.  I  may  have  had  unfavorable  forms 
to  start  with  and  so  lost  both  races  at  early  dates.  It  is  interesting  in  this  connection, 
however,  to  note  that  Whitney,  working  with  the  rotifer  Hydatina^  a  metazoon,  carried 
a  race  through  nearly  200  generations  by  parthenogenesis  when  the  individuals  lost 
their  power  to  reproduce  in  this  way,  and  many  of  his  lines  died,  while  others  produced 
sexual  individuals. 

The  general  bLoligical  effect  of  this  process  of  reoiganlzation  is  a  new  chemical 
combination  with  a  new  potential  of  metabolic  activity,  and  a  new  lease  of  life.  Not 
only  are  the  nuclei  restored  to  activity,  but  the  cytoplasm  is  likewise  completely 
reorganized  by  the  distribution  through  it  of  relatively  laige  quantities  of  nucleo- 
proteins,  giving  rise  to  successive  derivatives  (through  hydrolysis,  oxidation,  reduc- 
tion, etc.),  all  increasing  the  metabolic  processes  and  releasing  more  chemical  energy 
expressed  by  activity  of  movement  and  feeding,  and  leading  to  more  rapid  assimilation 
and  growth,  all  indicated  by  an  increased  division  rate.  In  short,  the  protoplasm  is 
rejuvenated. 

The  second  phase  in  the  life  history  to  be  considered — ^viz,  the  sexual  phase — 
involves  still  more  deeply  reaching  protoplasmic  activities.  The  protoplasm  of  the 
individual  cells  at  this  period  has  a  different  physical,  and  presumably  chemical, 
make  up  than  during  ordinary  vegetative  i>eriods.  In  free-living  forms,  such  as  the 
ciliates,  the  outer  protoplasm  becomes  sticky  or  glutinous,  so  that  two  cells,  on  touch- 
ing, fuse  together.  In  this  condition,  which  I  have  called  the  "miscible  state,"  con- 
jugation is  possible,  and  the  physical  condition  may  be  so  extreme  that  groups  of 
cells  get  stuck  together.  I  have  witnessed  the  fusion  of  nine  PaTairiecium  caudaJtum 
cells  in  a  single  amorphous  mass. 

In  other  forms — ^notably  the  parasitic  protozoa — ^protoplasmic  changes  at  this  stage 
follow  two  lines  of  differentiation.  Some  cells  store  up  metabolic  products  in  the 
form  of  reserves  of  nutriment  and  develop  into  female  gametocytes  or  macrogametes. 
Others  develop  into  more  active  male  gametocytes  and  microgametes.  In  both  of 
these  differentiated  types  if  union  or  fertilization  is  prevented,  the  cells  die  a  natural 
death. 

The  effects  of  conjugation  or  fertilization  are  almost  the  same  as  those  following 
asexual  reorganization  through  enc3rstment.  In  ciliates  cytolysis  of  the  old  macro- 
nudeus  takes  place  and  its  substances  are  absorbed— that  is,  undergo  chemical 
changes  in  the  cytoplasm.  The  majority  of  the  maturation  nuclei,  both  in  free- 
living  and  in  parasitic  forms,  meet  the  same  fate,  while  a  new  nuclear  apparatus  results 
from  the  products  of  the  fertilization  nucleus  or  synkaryon .  The  cytoplasm  is  renewed 
in  a  chemical  sense  and  metabolic  activities  recommence  with  renewed  vigor;  a  new 
rvce  is  started.  The  sole  difference  from  encystment  is  that  reorganization  occurs 
after  or  during  amphimixis,  and  a  new  hereditary  complex  is  formed  in  the  nucleus, 
while  even  this,  in  endogamous  conjugation  at  least,  can  not  be  very  different  from 
the  condition  after  asexual  reorganization.    It  is  obvious  that,  if  conjugation  is  the 


.J 


PUBUO  HEALTH  AND  BCEDICIKE.  535 

equivalent  of  fertilization  in  metazoa,  asexual  reoiganization  or  endomixis  is  the 
equivalent  of  parthenogenesiB. 

What  is  the  significance  of  these  two  important  phases  in  the  life  cycle  and  how  can 
they  be  interpreted  in  terms  of  metabolic  activities?  As  we  have  seen,  there  is  reason 
to  believe  that  the  cell  protoplasm  becomes  progressively  differentiated  in  a  chemical 
Bense  between  division  periods,  until  just  prior  to  division  processes  take  place  which 
do  not  occur  at  earlier  periods.  With  division  this  differentiated  condition  is  reduced, 
possibly  through  cytolysis,  until  a  more  labile  protoplasm  results.  Now  it  is  not  at 
all  improbable  that  such  reducing  processes  are  more  or  less  incomplete,  so  that  the 
protoplasmic  substratimi  in  the  second  generation  is  different  from  that  of  the  first. 
We  have  evidence  of  this  in  the  foraminifera  where  differences  in  the  protoplasmic 
•tnicture  and  in  shell  structure  characterize  the  second  generation .  Further  evidence 
is  seen  in  the  rhizopods,  where  increasing  quantities  of  chromidia,  and  in  some  cases 
differences  in  shell  structure,  are  morphological  indications  of  differentiation. 

Furthermore,  it  is  not  improbable  that  such  differences  are  cumulative  from  genera- 
tion to  generation,  just  as  chemical  differentiation  is  cumulative  with  inter-divisional 
age,  until  a  protoplasmic  substratum  b  evolved  in  which  processes  not  possible  before 
can  now  take  place.  We  have  show^  that  Paramecium  at  the  conjugation  phase  has  a 
different  physical  make-up  than  at  other  times,  the  cortical  plasm  becomes  mucilag- 
inous and  fusion  results  on  contact,  while  physiological  differences  are  manifested  by 
the  invariably  decreasing  division  rate  during  and  after  this  period  when  conjugation 
is  possible.  Here  the  protoplasmic  substratum  is  differentiated,  and  processes  occur 
which  are  not  possible  at  other  times.  So,  too,  in  Didinium,  Stylonychia,  etc.,  with 
successive  generations,  a  protoplasmic  substratum  is  gradually  evolved  (possibly 
hastened  by  adverse  conditions)  in  which  the  peripheral  zone  of  protoplasm  undergoes 
cytolysis  and  forms  an  impervious  membrane — the  cyst  membrane — analogous  to 
the  fertilization  membranes  of  metazoan  egg?*  Further  cytolytic  changes,  involving 
hydrolysis,  reduction,  and  other  chemical  activities,  are  set  up  in  the  cell  body, 
especially  in  the  cell  nuclei  which  divide  or  fragment.  As  a  result  of  these  activities, 
which  are  more  profound  than  those  accompanying  cell  division,  the  protoplasm  is 
•gain  restored  to  a  labile  condition,  vitality  is  renewed  and  a  de-differentiated  proto- 
plasm begins  a  new  cycle  of  metabolic  and  reproductive  phases. 

The  phenomena  of  conjugation  may  be  interpreted  in  a  similar  way  as  due  to  proc- 
esses possible  only  in  a  substratum  produced  by  cumulative  protoplasmic  differentia- 
tion. A  visible  expression  of  such  differentiation  is  seen  again  in  chromidia  formation 
of  Sarcodina  and  in  the  dimorphic  gametocytes  of  foraminifera  and  Sporozoa.  The 
reorganization  phenomena  are  quite  as  complicated  and  as  far  reaching  as  after  encyst- 
ment,  and  the  end  result  b  the  same,  a  de-differentiated  protoplasm  and  a  new  indi- 
vidual with  a  high  potential  of  vitality.  If  fertilization  is  prevented  the  differen- 
tiated macro  and  microgametes  die  as  do  metazoan  eggs  and  spermatozoa,  and  a  similar 
result  follows  the  continued  culture  of  free-living  ciliates,  in  which  conjugation,  or 
its  equivalent,  asexual  endomixis,  is  prevented. 

In  all  life  histories  we  find  more  or  less  regular  cycles  of  vegetative  and  sexual 
phases,  complicated  by  more  or  lees  active  asexual  and  sexual  reproduction.  In 
parasitic  forms  it  is  possible,  I  may  say  probable,  that  reorganization  and  renewal 
of  vitality  take  place  during  encysted  stages  as  Schaudinn,  Wenyon,  and  others  have 
held  for  the  genus  Entameba;  or,  as  in  Paramecium,  they  may  take  place  without 
encystment  in  types  like  Platmodium  as  described  by  Schaudinn.  The  proceeses 
of  autogamy,  so  called,  described  for  different  types  of  Entameba,  may  be  interpreted 
as  asexual  endomixis,  and  the  conflicting  views  as  to  the  significance  of  nuclear 
structures  in  EnUmuba  coU,  E.  kUtolytioa,  E.  tetragena,  and  E.  minuta  may  all  be 
reconciled  when  this  possibility  of  asexual  reorganization  is  applied  to  the  various 
parasitic  rhizopods. 


536       PSOOEEDIKOB  SECOND  PAK  ▲MBBIOAK  80IEKTI7I0  G0KQBBS8. 

With  Platmodium  the  principle  of  Mexual  reorganizatian  and  renewal  of  vitality, 
or  parthenogenesis,  has  long  been  called  upon  to  explain  malaria  reli^)8e.  The 
process,  as  described  by  Schaudinn,  is  too  familar  to  need  repetition  here.  Deqita 
the  objections  which  have  been  raised  in  recent  years  against  this  interpretation,  it 
must  be  admitted  that  no  a  priori  difficulty  stands  in  its  way.  It  is  evident  from 
experiments  that  the  protoplasm  of  an  old  race  is  more  stabile  than  that  of  a  young 
race,  possibly  due  to  accumulation  of  products  of  metabolism  in  the  former,  either 
for  a  useful  purpose,  as  in  the  storage  of  yolk  material  in  a  female  cell,  or  for  some 
harmful  purpose,  as  in  Parameeium  eaudaium  during  depression.  In  either  case 
if  a  labile  protoplasm  can  be  restored  resulting  in  chemical  activities  which  ulti- 
mately bring  about  dissolution  of  these  formed  products,  then  renewed  vitality  it 
the  outcome.  Asexual  reorganization  effects  this  result,  but  the  same  result  was 
produced  artificially  by  the  use  of  salts  in  my  experiments  with  Parameetum  eauda- 
tum  during  conditions  of  depression,  and  in  cases  where  the  cell  body  was  visibly 
loaded  with  products  which  it  could  not  automatically  dispose  of.  The  splendid 
results  which  Bass  has  obtained  in  cultivating  PUumodvum  in  vitro  and  in  the  pres- 
ence of  sugar  Indicate  the  possibility  of  malvria  organisms  while  in  a  stabile  condi- 
tion being  similarly  changed  into  a  labile  condition  by  changes  in  the  blood  content 
of  the  host.  Chaises  thus  set  up  mi^t  well  be  the  equivalent  of  asexual  reorgani- 
sation or  parthenogenesis,  or  the  equivalent  of  fertilizaticm  in  restoring  vitality« 

In  this  sketch  of  the  protozoan  life  cycle  I  have  endeavored  to  give  a  comprehen- 
sive, though  somewhat  speculative,  account  of  the  different  phases  of  vitality  whidi 
may  apply  equally  well  to  any  type  of  protozoa.  Cell  division,  reoiganizing  encyst- 
ment  or  its  equivalent,  and  conjugation,  are  all  regarded  as  phenomena  of  the  same 
general  character,  but  differing  in  degree,  the  effect  in  each  step  being  the  restora- 
tion of  the  protoplasm  to  a  condition  more  or  less  free  from  cumulative  metabolic 
differentiations. 

RBFBRBNCSB. 

Calkins,  G.  N.  19II.  Regeneration  aad  Cell  Division  in  Uronydda  transfuga. 
Jour.  Exper.  Zool.,  vol.  10.  No.  2. 

1911.  Effects  Produced  by  Catting  Paramecium  Cells.    Biol.  Bull.,  Vol.  XXI, 

No.  1. 
1915.  Didinium  nasutum.    1.  The  life  History.    Jour.  Exper.  Zool.,  vol.  19, 
No.  2. 
Peebles,  F.    1912.    Regeneration  and  Regulation  in  Paramecium.   Biol.  Bull.,  Vol. 

XXIII,  No.  3. 
Woodruff  L.  L.,  and  Erdmann,  R.    1914.    A  Normal  Periodic  Reorganization 
Process  without  Cell  Fusion  in  Paramecium.    Jour.  Exper.  Zool.,  vol.  17,  No.  4. 

Dr.  Gary  N.  Calkins  took  the  chair. 

The  Chairman.  The  second  paper  on  the  program  this  morning 
is  "Classification  of  parasitic  amoebe  of  man,"  by  Capt.  Craig,  In 
the  absence  of  Capt.  Craig,  an  abstract  of  his  paper  will  be  read  by 
Mr.  Bowles. 


THE  CLASSmCATION  OF  THE  PARASITIC  AMEBiG  OF  MAN. 

By  OHARLES  F.  ORAIG, 
MajcTf  Medical  Corpi,  United  Staiti  Armif, 

The  claasification  of  the  amebn  has  always  been  a  most  difficult  problem,  owing 
to  our  lack  of  knowledge  of  the  complete  life  cycle  of  many  of  the  so-called  species; 


FUBLIO  HEALTH  AHD  MXDIOIKS.  537 

the  simple  m<aphoiogy  of  theee  organismfl;  the  difficulties  inherent  in  tiie  study  of 
such  ddicate  cells  with  the  staining  methods  at  our  command;  and  the  conflicting 
opinions  of  protozoologists  as  to  the  data  upon  which  generic  and  specific  classifica- 
tion should  be  baaed.  However,  during  recent  years  enough  accurate  data  has  been 
collected  regarding  amebse  to  make  it  possible  to  divide  them  into  severpl  genera 
and  species  and  classifications  have  been  published  by  Ohatton/  Alexieff,*  Doflein,* 
Hartznann»^  and  Oalkins.* 

While  none  of  the  classifications  so  far  pubJiriied  can  be  considered  as  final,  for  all 
classification  must  remain  tentative  until  the  entire  life  cycle  of  every  organism 
contained  in  the  individual  classification  is  known,  I  believe  that  the  one  adopted 
by  Calkins  is  the  most  logical,  and  it  is  the  one  that  I  shall  employ  in  discussing  the 
subject  of  the  jiresent  paper.  Further  research  will  undoubtedly  render  it  necessary 
to  transfer  species  from  one  genus  to  another  and  probably  new  genera  will  be  dis- 
covered, but  OaUdns's  classification  furnishes  an  excellent  working  basis  for  the  differ- 
entiation  oi  amebie,  and  If  followed  will  result  in  great  good  In  clearing  up  the  chaotic 
condition  in  which  the  study  of  these  organions  has  r^nained  for  so  long. 

Calkins  divides  the  genus  .ime6a  into  seven  genera,  as  follows:  Ameba,  Vahlkampjia, 
Naglena,  OmgioL^  TriMfmoiligamdM,  Entamtha,  and  Parameha.  The  generic  name, 
ErUameha^  diould,  by  law  of  priority,  be  spelled  Endaan^^  for  the  reason  given  later 
in  the  discussion  of  this  genus. 

Of  the  seven  genera  mentioned  above,  only  three  are  of  interest  to  us  in  tiie  con- 
sideration of  the  parasitic  ameb»  of  man — ^i.  e.,  VahOsampfiaf  Craigia,  and  Endameha. 
Of  these,  Craigia  and  Endam^  contain  cmly  true  parasitic  species,  while  Vahlkampfia 
contains -species  which  may  beccmie  paiisitic  under  certain  conditions  and  for  a 
limited  period  of  time. 

eSNUS  VAHLKAMFVIA  GBATION  1013,  XMBND  0ALKIN8  1912. 

In  this  genus  are  placed  certain  species  of  ameb»  belonging  to  the  ''limax"  group 
«nd  which  have  no  flagellate  stage  of  development.  Calkins  thus  defines  the  char* 
acteristics  of  this  genus:  * 

Minute  free-living  or  commensal  ihixopods  moving  as  a  finger-formed  single  pseudo- 
podium  or  with  irregular  ectoplasmic  outbursts  to  form  a  local  or  general  hyaline 
ectoplasm.  The  nucleus  is  single  or  double,  with  finely  divided  chromatin  forming 
a  membrane  like  contour  and  with  a  definite  karyosome.  Reproduction  bv  simple 
division,  the  karyosome  dividing  first  like  the  nucleus-c^itrosome  of  Euglima,  the 
peripheral  chromatin  forming  the  nuclear  plate  (Promitosis  <3i  Nagler).  Cysts  uni- 
nucleate. Food  bacteria;  habitat  usually  fresh  water  in  ponds,  etc.,  but  many  tyx>es 
are  found  in  garden  earth  and  some  may  be  marine. 

To  the  characteristics  of  the  genus  given  above  the  following  may  be  added:  Most 
of  the  species,  if  not  all,  may  be  cultivated  upon  artificial  media,  and  upon  certain 
media  the  trophozoites  and  cysts  may  contain  several  nuclei,  as  proven  by  Calkins 
and  Williams.'  In  addition  to  the  habitats  given  by  Calkins,  it  is  now  well  demon- 
strated that  certain  species  belonging  to  this  genus  may  occasionally  be  parasitic  in 
man  and  other  animals  for  a  limited  period  of  time. 

This  genus  is  chiefly  of  interest  to  the  medical  piotosoologist,  because  certain 
spedesbelonging  to  it  may  often  be  cultivated  from  fecal  material  or  liver  abscess  pus 
obtajned  from  man,  and  hence  be  confused  with  the  true  parasitic  ameb»  or  enda- 

1  BalL  Soe.  ptth.  exol.,  1013,  ▼.  IS. 
t  BtOL  Soe.  Mol.  de  Fraooe,  1913;  y.  66. 

•  LehrbQcdi  dor  Protofocnkimd*.    Edit.  2, 1911, 660i 

«  Haadboeh  d«  FMlu  ProtoMMn.  V  ProwMck,  1913,  i,  61. 

•  Tr.  ISih  Intcrtat.  Cong.  Hyt.  sad  Donof .,  1913,  II,  387. 
•lUd. 

•  Ama.  Joqr.  Msd.  Biiwrriit  1911,  gd»>  tf. 


688       PBOOBEDIKOB  ABOOHl^  FAX  AMMOOQAJX  BOniKTIFIO  COKOBB88. 

mebtt.  However,  the  wwk  of  Hartmaim,^  Wkitmore,'  And  Walker,*  as  well  as  that 
of  many  other  obsenrecs,  liaa  proven  condiuively  that  these  cultivated  spedee  ava 
not  true  parasitic  amebie  and  should  not  be  included  in  the  genus  EmdamelM  er  ooa- 
iidered  as  identical  with  any  of  the  endamebn  so  far  described  as  occurring  in  man. 

The  following  q>ecies  belonging  to  this  genus  have  been  identified  as  oceuiring 
in  man: 

VaMkampJia  lobo9pino§a  Craig,  1912.^ 

VaOtampfia  witkmarH  Hartmann,  1912.*  (This  species  was  described  by  Maj .  Whii- 
more,  United  States  Army,  and  named  after  him  by  Hartmann,  but  the  specific  name 
is  misspelled  and  should  be  **i»hUmorei.**  It  is  probable  that  the  species  is  identical 
with  VaUoampfia  lobo»pino$a,) 

The  only  species  actually  identified  as  paiasitic  in  man  belonging  to  this  genus  is 
VaMkampJia  lobo$pmo9a,  an  oiganism  firat  described  by  Musgrave  and  Olegg*  as 
ameba  11524.  This  ameba  was  cultivated  by  them  from  a  dysenteric  stool  from  a 
patient  in  Bianila  in  1905,  and  a  culture  was  then  s^it  to  the  Army  Medical  Museum, 
in  Washington.  I  studied  this  species  in  cultures  directly  descended  from  the  Mus- 
grave culture,  and  in  1912  named  it  Ameba  loboipinota,  emending  the  name  in  1914 
to  VaMkampJia  lobospmoaa.  Other  authors  have  described  the  occurrence  ci  vahl- 
kampfiae  in  the  stools  of  human  beings  and  in  the  pus  from  liver  abscesses,  but  the 
species  concerned  were  not  clearly  identified. 

While  it  is  true  that  most  of  the  q[>ecies  belonging  to  this  genus  are  free  living,  it  is 
also  true  that  some  q;>ecies  are  apparently  true  parasites.  This  is  proven  in  the  case 
of  VaMkampJia  lac$rtm^  a  paraeite  oif  the  intestine  of  lisards,  while  VaMkampJia  mvdeola 
is  ectoparasitic  on  fish  and  VaMkampfia  pmdophthora  is  paraeitic  in  the  eggs  and  embryos 
of  crabs.  Several  authorities  have  claimed  that  typical  valkami^ie  aro  parasitic  in 
in  the  intestine  of  man  and  may  be  demonstrated  in  both  the  vegetative  and  cystic 
stages  of  devdopment  in  the  feces,  it  being  possible  to  observe  the  entire  cycle  of 
development  in  this  locality.  That  this  is  undoubtedly  true  in  some  instances  can 
not  longer  be  d«iied,  and  I.  myself,  have  had  the  opportunity  of  studying  prepara- 
tions sent  me  by  Dr.  W.  M.  James,  of  the  Canal  Zone,  obtained  from  the  feces  of  a 
patient  at  Panama,  which  contained  both  vegetative  and  cystic  stages  of  a  vahl- 
kampfia  which  is  indistinguishable  morphologically  from  VaMkampJia  lobospinoaa. 
This  patient  was  observed  for  a  considerable  poiod  of  time  and  liability  to  accidental 
contamination  of  the  feces  was  carefully  guarded  against.  It  is  imp<n'tant  to  note 
that  in  these  preparations  the  valkampfise  present  were  perfectly  typical  in  morph- 
ology of  the  same  (N^ganism  as  observed  in  cultures  and  that  they  could  be  easily 
distinguished  from  true  paraaitic  amebae,  as  Endameba  colt  or  Endameba  hiitolytim. 
This  observation  is  important  because  scHue  investigators  have  endeavored  to  prove 
that,  under  certain  conditions,  as  those  present  in  the  human  intestine,  valkampfiae 
may  so  change  in  morphology  as  to  be  ind istingiiiahable  from,  or  perhaps  identical 
with,  the  true  parasitic  amebae  or  endamebae. 

The  researches  of  Calkins  and  Williams,^  who  were  the  first  to  obtain  VaMkampJia 
lobospinosa  in  pure  culture,  have  shown  that  upon  certain  special  culture  media  this 
species  forms  trophozoites  and  cysts  containing  from  four  to  eight  or  even  more  nucl^, 
whereas  imder  normal  conditions  and  on  the  usual  culture  media  the  trophozoites 
never  contain  more  than  two  nuclei  and  the  cysts  are  uninucleate.  Owing  to  these 
very  marked  changes  produced  by  environment,  the  authors  mentioned  warn  against 
being  too  positive  regarding  the  distinctive  morphological  and  developmental  features 

>  Anna.  Jour.  lied.  ResearcJi,  1913,  xxix,  48. 

>  Arab.  (.  Protutenk,  1911,  xziil,  71. 

« PhUipplne  Jour.  Bcl.  see.  B.,  1911,  vi,  369. 
«  Arohiv.  Inter.  Med.,  1914,  ziii,  787. 

•  M.  Handbuob  der  Pathogenen  ICicroorganismen,  KoUe  and  Waasennann.    Bdtt.,  2, 1913,  vU,  OU. 

•  Musgrave,  W  .E.,  Bur.  Govt.  Lab.  BUA^  Manila,  1904,  No.  la 
'Ibid. 


P0BLIO  HBALTH  AHD  MSIHCnfB.  639 

claimed  for  the  endamebtt  of  man,  and  snggeflt  the  possibility  that  there  may  be  only 
one  spedes  of  amebce  parasitic  in  the  human  intestine  ''manifesting  different  forms 
under  different  conditions, "  and  indeed,  Oalkins  *  states  that  WilHams  has  been 
fttcceesful  in  cultivating  Endameba  coli. 

Now.  the  Endameba  cM  that  Williams  cultiyated,  as  stated  by  Oalldns,  is  Mu^grave 
and  Clegg's  ameba  No.  11524,  or  the  same  organism  I  have  studied  and  named  Vahl" 
hxmpfia  lobotpinosay  a  species,  which  when  introduced  into  man,  can  be  easily  recov- 
ered from  the  feces  in  cultures  and  which,  even  aftw  passage  through  the  human 
intestine,  retains  the  characteristic  morphology  of  a  typical  vahlkampfia.  Williams  * 
definitely  states  that  the  ameba  with  which  she  worked  is  identical  with  my  FoM- 
kampfia  lobospinosa  and  as  this  species  has  been  under  cultivation  since  1905  and  the 
cysts  resist  drying  for  years  (one  year  in  my  own  experience  and  three  years  accord- 
ing to  Williams),  it  is  very  evident  that  it  can  not  be  identical  with  either  Endameba 
coli  or  Endameba  histolytica,  for  the  cysts  of  these  species,  as  shown  by  several  obser- 
vers, notably  Walker,'  possess  comparatively  little  resistance  to  drying.  In  addition 
while  under  the  stimulating  conditions  present  in  certain  culture  media,  this  species 
does  produce  trophozoites  and  cysts  containing  several  nuclei,  the  photomicrographs 
illustrating  Calklna  and  Williams  paper  show  conclusively  that  these  multinucleate 
valkampfise  are  quite  different  in  morphology  from  the  endamebae  of  tbe  human  intes- 
tine, the  nuclear  structiu'e,  upon  which  much  stress  is  laid,  being  very  dissimilar  to 
that  of  either  Endamebe  coli  or  Endameba  hUtolytieay  in  either  the  vegetative  or  cystic 
stages  of  development. 

At  the  present  time,  while  it  must  be  admitted  that  certain  species  of  VahUtampJia 
may  live  a  parasitic  existence  in  man  for  a  limited  period  of  time,  and  while  such 
species  may  be  cultivated  from  the  feces,  there  is  no  real  evidence  demonstrating 
that  any  of  these  species  are  pathogenic  or  that  they  can  continue  a  parasitic  mode  of 
life  indefinitely.  The  evidence  of  many  investigators  has  proven  that  the  vahlkamp- 
fife  found  in  these  rare  instances  of  parasitic  existence  in  man  do  not  differ  in  mor- 
phology from  those  obtained  from  pond  water  or  the  air,  the  multinucleate  cysts 
described  by  Calkins  and  Williams  and  the  trophozoites  containing  more  than  two 
nuclei  never  having  been  observed  in  valkampfice  obtained  from  the  feces  or  other 
sources.  The  researches  of  these  authors  are  most  valuable  in  showing  the  enormous 
effect  of  environment  upon  the  morphology  and  development  of  an  ameba  belonging 
to  the  genus  Vahlkampfia,  but  they  are  far  from  demonstrating  that  this  ameba  is  a 
true  parasitic  species  or  identical  with  any  of  the  intestinal  endamebee  of  man. 

In  the  vast  majority  of  instances  the  valkampfise  reach  the  feces  or  other  material 
from  which  they  may  be  cultivated  by  way  of  the  air,  as  proven  by  Listen  *  and 
Wells,'  or,  in  the  case  of  the  feces,  by  passing  through  the  intestinal  tract  in  contam- 
inated food  or  water,  and  while  certain  species  may,  in  rare  instances,  become  para- 
sitic for  a  short  time  in  the  human  intestine,  this  is  an  abnormal  mode  of  existence, 
no  symptoms  of  disease  are  produced,  and  the  organisms  may  be  easily  distinguished 
from  the  endamebse  of  the  human  intestine  by  the  laige  karyoeome  of  the  nucleus; 
the  presence  of  at  least  one  contractile  vacuole;  the  uninucleate  cyst;  and  by  the  fact 
that  they  can  be  cultivated  upon  artificial  nutrient  media,  whereas  there  is  no  evi- 
dence demonstrating  that  any  of  the  endamebee  of  man  can  be  so  cultivated. 

GBMUS  CRAIOIA  CALKINS,  1012. 

This  genus  was  established  by  Calkins  *  in  1912,  to  include  the  ameba  described  by 
myself  under  the  name  Parameba  hominis,  in  1906.^    I  placed  this  parasite  in  the 

1  lIusgntTe,  W.  E.,  Bur.  GoYt.  Lab.  Biol.,  Manila,  1904,  No.  18. 

I  Studies  Research  Laboratories,  New  York  Board  of  Health,  1012,  vi,  208. 

«  PhiUppine  Jour.  Sd.,  Sec.  B,  1013,  vlii,  253. 

«  Quart.  Jour.  Mior.  ScL,  1011,  IvU,  270. 

•  Parasitology,  1011,  iv,  904. 

•Ibid. 

« Craig. C.F., Am. Jour. Med. BoL,  1906, ezzzii, 214.   AltoThaPaiMltto AmabaolMin.    ThSL,p,tl5. 


640       PBOOKEDINOS  SECOND  PAK  AMSBICAK  80IEKTIFIC  00N0BB88. 

genuB  Paramcba  because  of  its  resemblance  to  Parameba  eilhardi  Schaudinn,  but  Cal- 
kins rightly  states  that  the  fact  that  the  flagellated  stage  of  the  parasite  possesses  only 
one  flagellum,  while  Parameba  eilhardi  has  two,  is  sufficient  to  throw  it  out  of  the 
genus  Parameba,  while  he  doubts  if  the  accessory  nuclear  body  described  in  Parameba 
hamifdt  is  identical  with  the  Nebenkorper  of  Parameba  eUhardi,  On  these  grounds 
he  considers  that  this  parasite  should  be  placed  in  a  new  genus,  which  he  named 
Craigia.    Calkins  thus  describes  the  characteristics  of  this  genus:' 

Small  free-living  or  parasitic  ameb»  with  a  uniflagellated  swarmer  stage.  Ameba 
sta^  from  10  to  25m  with  little  differentiation  into  ectoplasm  and  endoplasm  when 
quiet,  but  with  clear  eotoplaam  in  movement.  The  endoplasm  with  or  without  an 
extranuclear  body  recalling  the  Nebenkorper  of  Parameba.  The  flagellated  stage  with 
a  single  flagellum. 

Four  species  have  so  far  been  described  as  belonging  to  this  genus,  all  of  which  are 
parasitic.  Two  species,  which  it  is  not  necessary  to  describe  here,  are  parasitic  in 
marine  worms,  while  two  are  parasitic  in  man.  These  are:  Craigia  hominU  {Parameba 
hominis)  Craig,  1906;  emend  Calkins,  1912;  Craigia  migrans  Barlow,  1915. 

Craigia  hominisj  the  type  species  of  the  genus,  was  first  noted  by  myself  in  the 
Philippines  in  the  feces  of  patients  suffering  &om  a  chronic  form  of  diarrhoea  and 
because  treatment  often  resulted  in  the  disappearance  of  the  parasite  and  in  the  ces- 
sation of  symptoms,  I  considered  that  it  was  probably  the  cause  of  the  condition 
present. 

The  parasite  is  characterized  by  an  amebic  and  flagellated  stage  of  development. 
In  the  amebic  stage  the  organisms  measure  from  10  to  25  m  while  the  flagellated  forms 
are  smaller  (3  to  20m).  Endoplasm  granular,  containing  a  nucleus  of  a  modified  Ztmax 
type  and  a  small  accessory  nuclear  body  noted  only  in  some  of  the  laiger  parasites. 
Flagellated  form  spherical  in  shape  and  possessing  a  single  flagellimi.  Multiplication 
of  the  flagellated  forms  occiu*  by  longitudinal  division  with  division  of  the  accessory 
nuclear  body  and  motile  organ.  The  amebic  form  encysts,  the  cyst  having  a  double 
contoured  membrane  when  fully  developed.  Reproduction  in  the  amebic  stage  by 
■imple  division  and  in  the  cystic  stage  of  the  amebic  form  by  swarmer  formation  within 
the  cysts,  the  swarmers  having  a  single  flagellum.  Habitat,  human  intestine  where  it 
causes  a  form  of  chronic  diarrhea  and  dysentery. 

More  recently  Barlow '  has  studied  this  parasite  in  Honduras  where  infections  with 
it  are  quite  frequently  observed  and  has  shown  that  it  not  only  causes  a  form  of  chronic 
diarrhea,  but  also  severe  ulcerative  conditions  of  the  intestine  resembling  endamebic 
dysentery.  He  was  able  to  study  five  infections  in  man  with  Craigia  hominis  and 
confirmed  my  own  work  concerning  its  morphology  and  cycle  of  development. 

Craigia  migrans,  a  new  species,  described  by  Barlow'  and  discovered  by  him  at  the 
time  he  was  studying  infections  with  Craigia  hominis,  in  Honduras,  is  characterized 
as  follows: 

There  is  an  amebic  and  flagellate  stage  of  development.  In  the  amebic  stage  the 
organisms  measure  from  12  to  30  Mt  average  about  20  m;  encysted  stage  measures  about 
18  M*  The  young  flagellates  measure  from  3  to  5  microns,  and  there  are  40  or  more  in  a 
cyst.  Endoplasm  granular  and  contains  a  nucleus  but  ho  accessory  nuclear  body. 
Flagellated  forms  are  circular  in  shape  and  have  a  single  flagellum.  Multiplication  of 
the  amebic  stage  is  by  simple  division  and  in  the  cysts  by  the  formation  of  swarms, 
which  are  flagellated,  and  the  cyst  may  contain  from  20  to  40  of  them.  No  multipli* 
cation  occurs  in  the  flagellate  stage,  Uie  flagellate  form,  as  soon  as  fully  developed 
becoming  an  ameba.  Habitat,  the  human  intestine,  where  it  produces  severe  dysen- 
teric lesions  and  in  some  instances  the  liver  is  invaded  and  abscesses  result. 

Barlow  studied  51  cases  of  infection  with  this  parasite  in  man  and  demonstrated  that 
it  was  the  cause  of  a  severe  dysenteric  condition  of  the  lower  bowel,  sometimes  accom- 

>Cralg,C.F.,  Am.  Jour.  Med.  8d.,  1906,  ODDdi,  314.    AImTIm  Pansitio  Ameba  of  Man.  PhiI.,p.Slft. 

•  Barlow,  N.,  Am.  Joar.  Trap.  Dbeaaas  and  PraranU,  Med.,  1015,  n,  880. 

•  Barlow,  N.,IMd. 


FUBUO  HSALTH  AKD  MJUUOIKB.  541 

panied  by  liver  abscess.  It  will  be  noted  that  this  species  differs  from  Craigia  Aomtnts 
in  that  the  flagellates  become  amebse  without  multiplying  as  flagellates,  and  for  this 
leason  Barlow  states  that  eventually  it  may  be  necessary  to  place  this  species  in 
another  genus. 

Infections  with  both  Craigia  hominis  and  Craigia  migmn$  are  probably  much  more 
widespread  and  numerous  Uian  is  generally  supposed,  owing  to  the  liability  of  con- 
fusing these  parasites  with  other  amebae  or,  during  the  flagellated  stage  of  development, 
with  cercomonads  or  trichomonads.  In  previous  papers '  I  have  considered  in  detail 
the  differential  diagnosis  of  Craigia  hominis  and  the  subject  has  also  been  treated  of  by 
Barlow  in  his  excellent  contribution,  already  quoted.  It  may  be  stated  that  a  differ- 
ential diagnosis  between  the  paraAtes  under  discussion  and  other  amebse  or  flagellates 
may  be  made  without  much  difficulty  by  attention  to  the  differential  characteristics 
«f  each  organism  outlined  in  these  papers. 

GENUS  ENDAMEBA  LEIDT,   1879. 

The  genus  Eniamebay  which  contains  only  parasitic  species  of  amebse,  was  estab- 
lished in  1879,  by  Joseph  Leidy  '  who  took  for  its  type  species  Endamtha  hlattx^  a 
parasitic  ameba  of  the  cockroach.  In  1897,  Casagrandi  and  Barbagallo  *  evidently  in 
Ignorance  of  Leidy 's  genus  Endameha,  established  for  the  parasitic  amebse  the  genus 
Mniameba  and  this  spelling  has  been  followed  by  the  majority  of  protosoologists  until 
%uite  recently.  However,  as  there  is  no  question  of  the  priority  of  Leidy 's  work  the 
proper  designation  for  this  genus  is  Endamuha  Leidy  and  not  BinUivMha  Casagrandi  and 
Barbagallo. 

The  general  characteristics  of  this  genus  may  be  outlined  as  follows: 

Size  comparatively  small,  from  5  to  80  microns.  Ectoplasm  and  endoplasm  distinct 
when  organisms  are  moving  and  sometimes  when  motionless;  ectoplasm  clear  and 
endoplasm  either  clear  or  finely  granular,  containing  a  nucleus  which  may  or  may  not 
be  visible  in  the  living  parasite;  contractile  vacuoles  generally  absent.  Nucleus  with 
•r  without  a  visible  karyosome  and  centriole;  reproduction  by  simple  division, 
schizogony,  and  cytX  formation  with  the  production  of  several  amebse  within  the  cyst. 
Habitat,  tiie  body  of  man  or  other  animals,  generally  in  the  digestive  tract.  Some  of 
Hie  species  are  commensal  while  others  are  pathogenic.  None  have  been  artificially 
cohivated. 

In  this  genus  have  been  placed  a  large  number  of  species  that  have  been  demon- 
strated to  be  parasitic  in  man  and  other  animals  but  at  the  present  time  it  is  believed 
that  many  of  the  species  described  are  not  entiUed  to  specific  rank  and  for  this  reason 
•uf  knowledge  as  to  their  exact  classification  is  in  a  very  unsatisfactory  condition. 
No  less  than  26  distinct  species  have  been  described  as  parasitic  in  man,  and  these 
species  are  named  in  the  following  list,  but  as  many  of  them  have  been  determined 
Id  be  identical  with  previously  described  species,  I  have  so  indicated  alter  the  spe- 
«fic  name.    For  convenience  of  reference  the  list  is  arranged  alphabetically: 

U8T  or  BNDAMBBiB  DBSOBIBBD  AS  PABASITIC  DC  MAN  AND  OTHBR  ANIMALS. 

Mndanuba  qfrieanoi  Hartmann,  1907;  identical  with  Endamuha  kittoliftka;  host, 

lan. 

M.  blaUm,  Leidy,  1879;  host,  cockroach. 

E.  aula$tami,  NoUer,  1912;  host,  eagle. 

B.  bavii,  liebetanz,  1905;  host,  cattie. 

E.  brasUieniii,  Baurepaire  Aragao,  1912;  host,  man. 

E.  huccaliB.,  von  Prowazek,  1907;  identical  with  Endameba  gingivaUi;  host,  man. 


*  Cndg,  C.  F.,  Am.  Jour.  Med.  Sd.,  1906,  cxxxli,  214;  ArchiT.  Inter.  Med.,  1910,  ▼!,  I;  Ibid.,  1914,  xitt,  7ST. 

*  Ltldy,  J.,  Rep.  U.  8.  Geol.  Sunr.,  1S79,  xli,  I. 

*  P.  Boll.  d.  Acoad.  Ofoento  di  nat.  sc.  in  Cataloola.,  N.  8.,  1895,  xzxiz,  4. 


642       PBOOEEDINOB  ffiOOKB  PAN  AMBEIOAK  80IEKTIFIC  C0N0BES8. 

E.  huttdiUi^  von  ProwaEek,  1912;  host,  man. 

E,  eohayx.  Walker,  1908;  host,  guinea  pig. 

E,  eoU,  Loesch,  emend  8chaudinn,  19CK3;  hoet,  man. 

E.  eonfuM,  Craig,  1916;  host,  man. 

E.  dintaHi,  Braun,  1883;  identical  with  E.  gingivaH$;  hoet,  man. 

E.  dubo0eqi,  llathias,  1913;  emend  Craig,  1913;  host,  monkey. 

E.  dif^mterise,  Councilman  and  Lafleur,  emend  Craig,  1905;  identical  with  E.  Mtii^ 
fytiea;  host,  man. 

E.  gingivalii,  €rro6,  1849,  emend  v.  Prowazek,  1907;  host,  man. 

E.  hartmannif  v.  Prowasek,  1912;  host,  man. 

E.  hutolyHca,  Schaudinn,  1903,  emend  Walker,  1911;  host,  man. 

E.  inU9tinal%s,  Walker,  1908;  host,  cat. 

E,  kartulitif  Doflein,  1901;  host,  man. 

E.  laeertXf  Hartmann,  1907;  identical  with  Vahlkampjia  tacerim;  host,  lisard. 

E.  lagopidis,  Fantham,  1910;  host,  moor-hen. 

E.  legerif  Mathias,  1913,  emend  Craig,  1914;  host,  monkey. 

E.  maxillaris,  Kartulis,  1906;  identical  with  E.  karhdin;  host,  man. 

E,  mtnuto,  ElmasBian,  1909;  identical  with  E.  hutolytioa;  host,  man. 

E.  miuraif  Ijima,  1898;  host,  man. 

E.  mortinatalium,  Smith  and  Wddman,  1910;  host,  man. 

E,  muriif  Grassi,  1881;  host,  mouse  and  rat. 

E.  nipponiea,  Koidzumi,  1009;  identical  with  E.  eoh',  host,  man.; 

E,  nuUalli,  Castellan!,  1908;  host,  monkey. 

E,  pfiagocytoides,  Gauducheau,  1907;  host,  man. 

E.  pithed,  v.  Prowazek,  1912;  host,  monkey. 

E.  poUcki,  V.  Prowazek,  1912;  host,  swine  and  man. 

E,  piUmonalu,  Artault,  1898;  host,  man. 

E.  ranerum^  Graasi,  1879;  host,  frog. 

E.  salpse,  Alexeleff,  1912;  host,  fish. 

E,  tchavdinni,  Lesage,  1908;  host,  man. 

E,  iuii,  Hartmann,  1913;  host,  swine. 

E.  testudinis,  Hartmann,  1910;  host,  turtle. 

E.  ietragena,  Viereck,  1907;  identical  with  E,  hutolytiai;  host,  man. 

E.  tropicalis,  Lesage,  1908;  identical  with  E.  colt;  host,  man. 

E.  undtdam,  Castellan!,  1904;  host,  man. 

E.  urogenUalis,  Baelz,  1883;  host,  man. 

E.  mlliamgi,  v.  Prowazek,  1911;  host,  man.    Identical  with  E,  coK. 

Of  the  large  number  of  species  mentioned  above  it  will  be  noted  that  about  one- 
third  have  already  been  proven  identical  with  previoudy  described  species,  and  it  is 
more  than  probable  that  further  research  will  demonstrate  that  the  vast  majority  of 
the  remainder  are  either  mere  variations  <^  well  known  species  or  identical  with 
them.  As  a  matter  of  fact,  there  are  only  three  epecies  of  endameb®  in  the  list  that 
are  of  great  interest  to  the  physician — ^i.  e.,  Endameha  ooli,  Endameba  kiitolytieaj  and 
Endameba  gingivals.  These  species  have  been  well  studied  and  their  specific  status 
demonstrated  beyond  any  reasonable  doubt. 

Endameha  coli^  Loesch,  1875;  emend  Schaudinn,  1903.  Endameha  coli  is  a  harm- 
less commensal  occurring  in  the  intestine  of  a  considerable  proportion  of  healthy 
individuals  in  almost  every  part  of  the  world.  The  species  was  first  definitely  sepa- 
rated from  Endameha  histolytica^  the  pathogenic  endameba  of  the  human  Intestine, 
by  Schaudinn,*  in  1903,  and  his  observations  were  confirmed  by  Craig,*  in  1905,  and 
later  by  Hartmann,'  Vedder,^  Werner,'  Whitmore,*  and  many  others.    Regarding 

>  Arb.  a.  d.  K.  Ocf undfatsamte,  1903,  jdx,  54T.  « Jour.  Am.  Med.  Assoc.,  1906»  xzri,  870. 

>  American  Med.,  1905,  U,  854,  837,  and  936.  •  Indian  Med.  Gazette,  1909,  xliv,  Ml. 
a  Aroh.  f.  Protistenk,  1909,  xviU,  307.                        •  Ibid. 


PUBUO  HBALTH  AKD  MEDICOni.  548 

the  occuirence  ol  thu  species  in  health  and  in  disease,  its  geographical  distdbutdon, 
and  its  life  cycle  and  differential  diagnosis  from  other  endamebie,  the  reader  is  referred 
to  the  pi^rs  just  quoted. 

Several  other  species  have  been  described  as  harmless  commensals  of  the  human 
intestine,  but  it  is  more  than  probable  that  they  are  all  identical  with  Endameba  eoli. 
This  is  certainly  true  of  Endameba  tropicalu,  described  by  Le  Sage;^  Endameba  nip- 
jKmtoa,  described  by  Koidzumi;'  and  Endameba  williamny  described  by  v.  Prowazek.* 

At  the  present  time  it  may  be  stated  that  Endameba  coli  is  the  only  species  of  enda- 
meba that  has  been  actually  demonstrated  to  be  a  harmless  commensal  in  the  human 
intestine. 

The  general  characteristicfii  of  the  species  are  as  follows: 

Size  varies  from  10  to  50  microns,  the  average  being  from  25  to  35  microns;  ectoplasm 
and  endoplflsm  only  well  differentiated  when  organism  is  in  motion;  movement 
sluggish  and  pseudopodia  blunt;  ectoplasm  very  slightly  refractive;  endoplasm  finely 
granular,  containing  one  to  several  noncontractile  vacuoles.  Nucleus  well  differen- 
tiated in  the  living  parasite.  Species  not  normally  phagocytic  for  red  blood  cor- 
puscles. Reproductioo  by  simple  di'N'ision;  schizogony,  with  the  production  of  eight 
young  amebte;  and  by  cyBt  formation,  with  the  production  within  the  cyst  of  from 
8  to  16  amebce,  the  normal  number  being  eight.  The  cysts  measure  from  10  to  30 
microns  in  diameter.  Habitat,  the  human  intestines,  where  it  is  a  harmless  com- 
mensal. 

Endameba  coli  is  of  great  practical  importance  to  the  physician  in  regions  where 
endamebic  dysentery  occurs  because  of  the  liability  of  its  confusion  with  Endameba 
histolyticay  the  cause  of  this  form  of  dysentery,  or  with  the  amebic  stage  of  Craigia 
Jiwninis  or  Craigia  migrans.  As  this  species  is  found  in  the  fecep  of  a  large  proportion 
•f  healthy  individuals,  especially  in  the  subtropics  and  Tropics,  as  well  as  in  indi- 
viduals suffering  from  diarrheal  conditions  not  endamebic  in  origin,  its  differentiation 
from  the  parasites  mentioned  is  essential  before  a  diagnosis  of  endamebic  dysentery  or 
infection  with  craigiie  can  be  made,  for  if  one  were  to  rely  only  upon  the  presence  of 
an  endameba  in  the  feces  in  the  dia&rnosis  of  these  infections  without  reference  to  the 
species  present,  it  is  evident  that  all  infections  with  Endameba  coli  would  be  diagnosed 
as  endamebic  dysentery,  and  this  is  just  what  occurred  prior  to  the  differentiation  of 
this  species  from  Endameba  histolytica.  It  has  only  been  within  a  very  recent  period 
that  care  has  been  exercised  in  differentiating  the  actual  species  of  endamebe  present 
in  cases  of  suspected  dysentery  and  even  to-day  this  very  important  procedure  is 
B^lected  by  many  clinicians. 

The  work  of  Walker  and  Sellards  ^  has  proven,  through  actual  experimentation 
npon  man,  that  Endameba  coli  is  a  harmless  parasite,  thus  confirming  the  results  ol 
the  animal  experiments  of  Craig,'  Strong  and  Musgrave,^  and  others,  so  that  it  follows 
that  any  diagnosis  of  dysentery  of  supposed  endamebic  origin  based  only  upon  the 
presence  of  an  endameba  in  the  stools  is  worthless  unless  the  species  of  endameba 
present  is  ascertained. 

Endameba  histolytica  Schaudinn,  1903;  emend  Walker,  1911.  Endameba  histobftiea 
is  the  proven  cause  of  a  severe  form  of  dysentery  prevalent  in  both  temperate  and 
tropical  regions,  but  especially  so  in  the  subtropics  and  tropics,  The  species  was 
first  clearly  differentiated  from  the  harmless  Endameba  coli  by  Schaudinn,'  in  1903, 
although  it  had  undoubtedly  been  described  in  part  by  almost  every  investigator 
of  this  form  of  dysentery,  especially  by  Kartulis,'  Councilman  and  Lafleur,'  Strong 
and  Mu^grave,*"  and  Craig. ^^    However,  Schaudinn  was  the  first  to  place  the  species 

>  Ann.  Inst.  Pasteur,  1905,  xvni,  9.  *  Ibid. 

>  Cflotralbl.  I  Bakt.,  1909, 1,  Orig.,  U,  650.  •  Virchow's  Arcfalv.  f.  path  Anat.,  1886,  oz.  631. 

•  ArchlT.  f.  ProtistMik,  1911,  zjoi,  945.  •  J.  Hopkins  Hotp.  Rep.,  18B1,  v.,  p.  80S. 
«  PhiUppine  Jour.  Bei.,  Sec  B,  1913,  viii,  288.                »  Ibid. 

» Ibid.  uAmerioan  Med.,  1906,  iz,  864, 807, 086. 

•  Annual  Rep.  Bury.  General,  U.  8.  Army,  1900,  p.  281. 


544       PBOGEEDIKGS  SECOND  PAN  AMEBICAK  80IEKTIFI0  OOKGBESCL 

upon  a  firm  basis,  and  although  some  of  his  interpretations  of  the  morphology  of  the 
parasite  were  erroneous,  his  work  has  been  confirmed  by  practically  every  student  of 
the  endamebee  of  man. 

An  element  of  confusion  arose  with  the  description  of  a  supposed  new  species  of 
pathogenic  endameba,  the  so-called  Endameba  Utragenaj  first  described  by  Viereck  ' 
and  afterwards  accepted  as  a  distinct  species  by  most  students  of  the  subject.  How- 
ever, the  recent  researches  of  Walker,'  Hartmann,'  Whitmore,*  James,  *  Darling,* 
and  Craig  ^  have  proven  that  Endameba  tetragena  is  merely  a  sta^  in  the  life  cycle 
of  Endameba  histolytica;  a  stage  erroneously  described  by  Schaudinn  and  others,  and 
first  correctly  described  by  Viereck  in  his  description  of  Endmneba  tetragena.  There- 
fore, it  follows  that  the  name  tetragena  has  no  longer  value  as  the  name  of  a  species  and 
can  only  be  correctly  used  to  designate  one  stage  in  the  development  of  Ehdamtba 
histolytica. 

Since  the  differentiation  of  Endameba  histolytica  as  a  distinct  species  certain  au- 
thorities have  described  other  endamoebae  occurring  in  diarrheal  conditions  and 
which  they  have  regarded  as  new  species,  but  all  that  have  been  carefully  studied 
have  been  proven  to  be  identical  with  Endameba  histolytica.  The  most  important  of 
these  so-called  species  is  Endameba  minuta^  described  by  Elmassian  '  as  a  cause 
of  dysentery  in  certain  localities  in  South  America,  but  recent  work  has  proven  that 
this  species  is  really  only  a  stage  in  the  life  cycle  of  Endameba  histolytica,  the  so-called 
minuta  stage,  in  which  the  trophozoites  and  cysts  are  smaller  than  those  observed  at 
other  times. 

The  general  characteristics  of  Endameba  histolytica  may  be  briefly  stated  as  follows: 

Size  varies  from  15  to  80  microns,  the  average  being  from  25  to  40  microns  in  diam- 
eter; ectoplasm  and  endoplasm  well  differentiated  when  organism  is  moving  and  fre- 
quently when  motionless;  ectoplasm  very  refractive  an  1  glass-like  in  appearance. 
Movement  active  and  pseudopodia  well  developed,  blunt  or  finger-like  in  shape. 
Endoplasm  finely  or  coarsely  granular,  containing  noncontractile  vacuoles  and  a 
well-defined  nucleus  when  the  symptoms  of  dysentery  are  subacute,  while  if  the 
symptoms  are  acute  the  nucleus  is  generally  invisible  in  the  living  specimen.  Nor- 
mally actively  phagocytic  for  red  blood  corpuscles.  The  nucleus  varies  markedly  in 
appearance  in  stained  specimens  at  different  stages  of  development.  Reproductlos 
occurs  by  simple  division;  schizogony,  with  the  production  of  four  daughter  amebse; 
and  cyst  formation,  with  the  production  within  the  cyst  of  foiur  amebae.  The  cysts 
measure  from  10  to  20  microns  in  diameter,  the  average  being  about  12  microns.  They 
contain  in  addition  to  from  one  to  four  nuclei,  characteristic  chromidial  bodies. 
Habitat,  the  intestine  of  man,  where  it  produces  the  symptoms  and  lesions  charac- 
teristic of  endamoebic  dysentery. 

This  species  of  endamobse  is  the  most  important  parasite  belonging  to  the  Ilhizopoda 
80  to  as  the  medical  profession  is  concerned,  as  it  has  been  definitely  proven  to  be  the 
cause  of  that  form  of  dysentery  known  as  amebic  or  endamebic  dysentery,  a  disease 
endemic  in  many  parts  of  the  world  and  which  may  occur  in  widespread  and  fatal 
epidemics  when  conditions  are  favorable.  Thus  the  recognition  of  the  parasite  is  of 
great  practical  importance  as  the  early  diagnosis  of  infection  with  it  as  almost  essential 
if  treatment  is  to  be  successful.  Many  very  excellent  descriptions  of  this  parasite 
have  been  published  by  the  authors  already  mentioned,  and  to  their  writings  the 
reader  is  referred  for  a  discussion  of  the  morphology,  life  cycle,  and  differential  diagno- 
sis of  this  interesting  and  important  species. 


>  Archiv.  f.  SctiifTs-u.  Tropen-HyR.,  Ifl07,  xi,  Beihest  1, 1-41. 

•  Philippines  Joar.  ScL,  See.  B.,  1911,  vi,  250. 
•Ibid. 

•  Am.  Jour.  Trop.  Dts.  and  Prevent.  Med.,  1913,  i,  197. 
» Ann.  Trop.  Med.  and  Hye.,  1914,  Ser.  T.  M.,  \ili,  133. 

•  Archiv.  Int.  Med.,  1913, 11,  495. 

T  Jour.  Infec.  Diseases,  1913,  xiil,  p.  28. 

•  Elmassian,  G.    Centralb.  f.  Bakt.,  etc.,  1909, 1,  Orig..  62, 335. 


PU6UC  HEALTH  AND  MEDICINE.  545 

It  may  be  stated  here,  however,  that  Endameba  hutolytka  is  peculiar  in  that  at  dif- 
ferent stages  of  its  development  the  morphology  of  the  parasite  varies  so  markedly  that 
one  might  easily  suppose  that  two  species  were  being  observed  and  it  was  this  fact 
that  lead  the  best  authorities  for  so  long  to  regard  one  stage  in  its  development  as  a 
distanct  species,  which  was  named  Endameba  Utraqena, 

The  relation  of  Efndameba  hiitolylica  to  dysentery  has  been  quite  recently  proven 
beyond  doubt  by  Walker  and  Sellards  *  by  experimental  work  upon  man,  and  while 
all  of  the  essential  points  in  their  work  had  been  perviously  proven  by  experiments 
upon  susceptible  lower  animals,  their  results  possess  the  advantage  of  having  been 
secured  upon  man,  the  natural  host  of  this  parasite.  These  investigators  performed 
twenty  feeding  experiments  upon  as  many  healty  individuals,  using  Pieces  containing 
cysts  of  Endameba  histolytica,  and  of  these  eighteen  afterwards  showed  the  endamebse 
in  their  faeces,  and  of  these,  four  or  22.2  per  cent  had  developed  typical  endamebic 
dysentery  at  the  time  of  the  publication  of  their  paper. 

Endam^M  gingivcUii  Gros,  1849;  emend  v  Prowazek,  1907.  This  species  of  en- 
dameba occurs  frequently  in  both  the  healthy  and  diseased  human  mouth,  especially 
around  the  teeth,  and  the  recent  attempts  that  have  been  made  to  prove  that  it  is  the 
etiological  factor  in  pyorrhea  alveolaris  have  made  it  a  species  of  considerable  interest 
to  physicians  and  dentists.  It  was  undoubtedly  first  described  by  Gros,'  in  1849,  who 
named  it  Amebia  genqivalis,  and  afterwards  studied  by  Steinberg  '  and  Grassi.*  In 
1904  V.  Prowazek'  gave  a  detailed  description  of  the  species  under  the  name  Endameba 
buecalit  but  as  there  is  no  doubt  that  the  endameba  described  by  the  latter  author  is 
idential  with  Endameba  gengivalis  the  name  ^'bucoalis  "  should  be  dropped  as  a  specific 
name  for  this  parasite. 

Size  varies  from  7  to  35  microns,  the  average  diameter  being  from  12  to  20  microns; 
ectoplasm  and  endoplasm  well  developed,  the  ectoplasm  being  visible  only  when 
motility  is  present.  The  ectoplasm  is  quite  refractive  and  movement  is  qrite  active, 
the  pseudopodia  being  well  developed  and  short  and  bli  nt  or  long  and  fingerlike 
in  shape.  The  endoplasm  is  granular,  contains  very  numerous  food  vacuoles,  non- 
contractile,  but  in  the  living  specimen  a  distinct  nucleus  is  not  ^iaible  in  most  in- 
stances. The  organism  is  actively  phagocyic  and  red  blood  corpuscles  are  often 
ingested.  Reproduction  apparently  occurs  only  by  simple  division  during  the  vege- 
tative stage  of  development.  Cysts  are  formed  containing  one  nrclevs,  but  no  repro- 
ductive changes  have  been  observed  within  these  cysts  and  it  is  probable  that  encyst- 
ment  In  this  species  is  a  purely  protective  phenomenon.  The  cysts  measi^re  from 
8  to  10  microns  in  diameter  although  larger  cysts  have  been  observed.  Habitat,  the 
human  mouth. 

There  is  no  question  that  Endameba  gingivalis  is  a  distinct  and  valid  species, 
although  some  authorities  have  endeavored  to  prove  that  it  i9  identical  with  E^da* 
meba  histolytica.  However,  the  differences  in  morphology;  the  fact  that  the  cysts 
formed  by  this  species  never  contain  more  than  one  nucleus,  the  four  nucleated  cyit 
of  Endameba  histolytica  having  never  been  observed;  and  the  absolutely  negative 
results  of  all  attempts  to  produce  dysentery  in  susceptible  animals  by  feeding  ex- 
periments, prove  that  Endameba  gingivalis  is  noc  identical  with  Endanuba  histolytica. 

As  regards  the  relation  of  this  parasite  to  the  etiology  of  pyorrhea  alveolaris  it  may 
be  stated  that,  at  the  present  time,  most  authorities  consider  that  it  is  not  the  cause 
of  this  condition.  )^l)ile  the  parasite  is  generally  present  around  the  teeth  and  in 
the  abscesses  of  the  dise^e,  it  also  occuni  in  a  large  proportion  of  perfectly  healthy 
mouths  and  there  has  never  been  the  least  proof  adduced  of  an  experimental  nature 
connecting  Endameba  gingivalis  with  the  production  of  pyorrhea.  TIMiile  it  is  at 
present  impossible  to  absolutely  deny  that  it  may  produce  the  disease,  it  is  certainly 

>n>ld.  4  0ai.  med  ItaJ-Lomb.,  1870,  xzxix,  44A. 

*  Bull.  8oc.  Imp.  de  oat.  de  Moscow,  1849,  xxil,  540.   •  Arb.  a.  d.  Kaiserl.  Uesundhtsamte,  lOM,  zzi,42. 

*  Sooremenaya  meditsina,  Kiev,  1902. 


546       PROGEEDIK08  ffiOOKD  PAN  AHBBIOAN  8CIBKTIFI0  C0NGBE88. 

true  thftt  we  have  no  experimeQtal  evidence  thai  it  does,  and  the  recent  work  of  both 
pbynciaDi  and  dentists  who  have  atudied  the  subject  is  amply  sufficient  to  lead  us 
to  conclude  that  this  species  ol  endameba  is  not  the  etiological  factor  in  pyorrhea 
alveolaris. 

The  Chaibman.  We  shall  go  on  to  the  next  paper  and  start  our 
discussion  after  Prof.  H.  S.  Jennings,  of  Johns  Hopkins  University, 
has  read  his  paper  on  the  "Origin  of  diverse  races  in  difflugia  corona.*'' 

I  woidd  like  to  ask  Dr.  Jennings  in  regard  to  the  method  of  repro- 
duction of  these  difflugia.  Was  it  invariably  by  the  so-called  budding 
division,  Dr.  Jennings  t 

Dr.  Jennings.  Yes,  Dr.  Calkins,  and  this  is  one  of  the  questions  on 
which  I  should  like  to  get  data.  I  have  examined  it  as  thoroughly  and 
as  far  as  I  was  able.  I  have  not  been  able  to  find  any  actual  observa- 
tion of  any  other  form  of  modification.  The  study  of  a  single  indi- 
vidual for  nine  months  with  respect  to  its  method  of  reproduction 
seems  a  pretty  fair  test  of  whether  the  other  form  of  reproducing 
itself  occurred,  because  if  a  young  individual  does  appear  on  your 
slide  you  can  always  tell  if  it  is  an  individual  that  does  not  belc  ng 
there.  You  can  teU  whether  it  is  a  contamination  or  not,  by  the  fact 
that  the  tail  gets  pink-red  as  it  gets  old;  and  there  was  absolutely 
no  appearance  of  an  individual  which  could  not  be  accounted  for  by 
simple  fission,  division,  whatever  you  might  call  it. 

The  Chaibhan.  I  am  still  tempted  to  ask  a  question,  and  that  is 
in  regard  to  the  chromatidiae.    Have  you  studied  them.  Doctor  % 

Dr.  Jennings.  I  have  not  studied  them.  As  you  know,  it  m  not 
possible  to  do  everything.  I  think  it  very  possible  that  the  dissimilar 
formation  that  happens  in  chromatidiae  may  very  well  have  some- 
thing to  do  with  this. 

The  Chaibman.  It  seems  to  me  from  what  I  have  been  able  to 
gather  as  you  went  along  that  there  is  a  possibility  that  this  forma- 
tion comes  with  the  dissimilar  development  of  chromatidiae  which  are 
here  the  bearers  of  hereditary  characteristics.  If  there  is  no  fiu'ther 
discussion,  we  will  pass  to  the  next  paper.  Dr.  Kofoid,  of  the  Uni- 
versity of  California  has  sent  his  paper  which  will  be  read  by  Dr. 
Metcalf. 


THE  BIOLOGICAL  AND  MEDICAL  SIGNIFICANCE  OF  THE  INTESTINAL 

FLAGELLATES. 

By  CHARLES  ATWOOD  KOFOID, 
Professor  of  Zoology,  University  of  California. 

A.  INTRODUCTION. 

The  growth  of  interest  in  the  flagellata  in  recent  years  has  been  stimulated  in  no 
small  degree  by  the  discovery  of  the  relation  of  trypanosomes  to  disease,  and  by  the 

>  At  the  author*!  request  this  paper  is  omitted  from  the  Proceedings.    The  complete  investigation  hat 
been  published  with  detaib  and  iilustralions,  hi  Qenstios,  vol  1,  pp.  407-A34,  Septamber,  101«. 


PUBUO  HBALTH  AlID  MEKOINB.  647 

steadily  increaeing  number  of  instancee  of  paraaitiBm  by  memben  of  this  group  in  the 
GtguiB  and  dflBues  of  both  vertebrates  and  invertebrates  with  occasional  instances 
of  pathogenic  consequences  to  the  host. 

In  the  field  of  comparative  cytology  this  group  has  of  late  yielded  data  of  prime 
interest  to  the  problems  of  the  evolution  of  nuclear  and  extranuclear  structures  of 
the  cell,  and  of  mitosis,  to  the  natiu«  and  behavior  of  chromosomes,  and  to  the  fun- 
damental problems  of  the  oi^gaoisation  of  the  living  substance. 

To  this  group  we  look  for  the  first  evidences  of  and  most  primitive  phases  of  sexual 
reproduction,  for  the  dawn  of  maturation  phenomena,  for  the  emergence  of  gametes 
and  their  sexual  differentiation,  and  for  the  unfolding  of  the  life  cycle,  but  we  have 
as  yet,  except  in  the  volvocidee,  which  are  hardly  typical  flagellata,  little  evidence 
which  can  be  regarded  as  final  that  true  sexual  reproduction  occurs  at  all  among 
flagellates. 

It  is  the  purpose  of  this  paper  to  review  recent  advances  in  th^s  field  and  to  assess 
their  value  and  significance  in  relation  to  current  conceptions  as  to  the  distribution  and 
parasitism  of  flagellates,  to  the  organization  of  the  flagellate  cell)  to  the  life  history 
of  flagellates,  and  to  the  processes  of  reproduction  in  the  group,  as  well  as  to  point 
out  certain  relations  of  theee  processes  to  the  interrelations  of  host  and  parasite  and 
to  disease. 

In  data  cited  in  this  paper  I  make  abimdant  use  of  results,  some  as  yet  unpublished, 
of  investigations  carried  on  under  my  direction  in  our  laboratory  at  the  Univeraity 
of  California.  I  am  especially  indebted  to  Misses  Christiansen  and  McCulloch  and 
Drs.  Swezy  and  Wilson  upon  whose  work  I  draw  freely  as  indicated  in  the  bibliog- 
raphy. 

B.   OCCURRENCE  OF  PARASITIC  FLAOELLATE8. 

The  flagellata  as  a  group  surpass  all  other  protozoa  in  numbers  of  individuals  and 
range  of  environments  successfully  occupied.  They  outnumber  the  rhizopoda  and 
ciUata  in  most  habitats,  and  vie  with  the  sporozoa  in  numbers  in  the  cavities  and 
tissues  of  their  hosts.  They  range  from  the  red  snows  of  the  polar  regions  and  Alpine 
summits  to  the  ooze  of  the  ocean's  depths.  They  swarm  in  all  seas  to  the  remotest 
shores,  occur  both  in  permanent  lakes  and  rivers  and  in  temporary  puddles,  and  even 
in  interstices  of  the  soil.  They  abound  in  decaying  organic  matter  and  play  a  large 
part  in  the  transformations  attendant  upon  putre&u;tion  and  decay.  They  run  the 
whole  gamut  of  nutrition  from  the  strictly  holophytic  dependence  upon  sunlight 
and  inorganic  materials,  through  the  saprophytic  or  saprozoic,  to  the  parasitic  and 
pathogenic  end  of  the  series.  As  parasites  they  infest  the  majority  of  species  of 
animalfl  and  some  plants,  and  enter  most  organs  and  tissues,  even  to  the  innermost 
recesses  of  man's  brain. 

This  great  adaptability  of  the  flagellate  stock  to  a  wide  range  of  environmental 
conditions  opens  the  door  to  a  large  development  of  parasitic  forms,  to  complicated 
and  irregular  life  cycles,  to  interchange  of  hosts,  to  transfer  to  new  hosts,  and  to  the 
causation  of  disease.  It  lends  itself,  in  many  forms,  to  a  degree  of  variability  within 
the  species  unsiupaased  among  other  organisms.  We  have  found,  for  example, 
that  Trichomonas  augusta  from  the  intestine  of  amphibians  lives  and  multiplies  for 
some  time  in  sterilized  enriched  tap  water  and  in  culture  slides  for  many  months 
quite  apart  from  its  normal  host.  Within  an  individual  host  it  will  sometimes  show 
a  very  wide  range  of  variation  in  size  and  proportions  at  comparable  phases  of  the 
life  history.  It  likewise  passes  through  not  only  the  flagellate  stage,  but  becomes 
amoeboid,  encysts,  and  loses  its  flagella. 

0.  PARASITISM  AMONG  lliAGBLLATSB. 

The  trancdtion  from  the  saprozoic  mode  of  life  to  that  of  a  parasite  In  the  intestine 
of  an  insect  or  a  vertebrate,  and  vice  vena,  ia  ^dently  easily  made  by  some  flagel- 
lates as  is  diown  by  the  present  exiatfliice  of  both  free  Hving  and  of  paraBitic  spedes 
68436—17— VOL  x 86 


548       PBOOBSDnSTGS  8B00VD  PAH  AlCBBIOAK  8CIBHTIFI0  00KGBB88. 


in  the  Mune  gemis,  aa  for  example  in  Axomiltu  and  Bodo^  and  by  the  ease  with  which 
aome  at  least  (Triehomonat  auffuita)  of  the  intestinal  flageJlatee  of  the  lower  verte- 
brates live  under  saprozoic  conditioDs  in  mixed  pure  cultures.  These  conditions 
thus  favor  the  polyph^^etic  origin  of  the  flagellates  found  as  parasites  and  accordingly 
we  find  species  or  genera  (which  are  parasitic)  in  most  of  the  groups  of  flagellates,  as 
for  example  in  the  protomonadina  ( TVypcmosoma,  Bcdo),  in  the  poljonastigina  (  TVi- 
(Aonunuu,  HexamUuit  Oiardia),  in  the  engkmoidina  (Copromomif),  and  in  the  dino- 
flagellata  (BUuiodmium). 

The  extent  of  the  occurrence  of  flagellates  as  parasites  among  animals,  especially  in 
the  invertebrates,  is  as  yet  very  imperfectly  known.  There  are  indications  that  care* 
ful  search  will  reveal  their  presence  in  most,  if  not  all,  species  in  which  there  is  a  well- 
developed  digestive  tract.  The  probability  of  the  continual  enteance  of  Uvlng  flagel- 
lates into  the  digestive  tract  with  food  and  water  is  apparent  to  anyone  at  all  familiar 
with  the  microfauna  of  natural  waters,  and  even  of  some  distilled  and  bottled  waters, 
as  well  as  of  the  more  favorable  nidus  provided  in  vegetable  and  other  foods  in  which 
the  initial  stages  of  decay  or  putrefaction  appear.  The  wonder  is  not  that  there  are 
intestinal  flagellates,  but  rather  that  there  are  not  more  of  them. 

The  frequency  with  which  they  may  be  found  is  illustrated  by  the  fact  that  in  the 
course  of  the  examination  of  829  vertebrate  hosts,  most  were  found  to  be  infected 
with  one  or  more  species  of  flagellates.  Less  than  2  per  cent  failed  to  yield  flagellates 
from  the  digestive  tract.  Amphibia,  5  species,  reptilla,  4  species,  and  mammalia,  6 
species,  were  included  as  shown  in  the  accompanying  list. 

LUtofhoiti  examined f or  flageUata. 

AMPHIBIA.. 

Diemyctylut  toronte 25 

RanahoyUi 13 

Rano  drayU)n% 24 

Rana  pipiene 20 

EylareffiUa 18 

ToUl  amphibia 100 

RSPnUA. 

EiUeniatvrtalU 2 

PUuopkis  eatentfer 5 

CroUilui  oregonut 1 

Python  retiadatui 4 

Total  reptilia 12 


Belgian  hare 12 

Culture  mice,  gray  and  white 98 

Culture  rats,  gray  and  white 42 

Peromyscus  maniculatus  gambelx 59 

Mierotui  oalifomicus  ealtfomicuB 4 

Canie  oekropue  ochropue 2 

Total  mammalia 217 

Grand  total  of  all  hosts 829 

The  variety  of  the  flagellate  intestinal  fauna  which  is  harbored  by  a  single  host 
•pedes  is  iUustrated  by  the  results  of  our  examinations  of  25  individuals  of  Di&' 


PUBUO  HEALTH  AITD  HEDIOIKB.  549 

myctylus  toronu.  In  this  host  species  we  found  no  less  than  10  genera  and  14  species 
•f  flagellates.  The  last  two  species  named  were  probably  derived  from  the  ali- 
mentary canal  of  insects  in  which  theyjire  normally  parasitic  and  are  not  digested 
with  their  host  by  the  salamander. 

PARASmC  FLAOELLATB8  FROM  DIGESTIVE  TRACT  OP  DIElfYCTTLUS  T0R08U8. 

1.  Trichomonas  augusta  Alexeieff. 

2.  Trichomonas  bfUrachorum  Perty. 

3.  Trichomonas  Bfp. 

4.  Tetratfichomonas  prowazeki  AlQiieieff. 
6.  Tnchomitus  parvus  Swezy. 

6.  Hexamitus  inteslinalis  Duj. 

7.  Hexamitus  batrachorum  Swezy. 

8.  Hexamitus  sp. 

9.  Chilomastix  mesnUi  Aleneie^. 

10.  Eutrichomastix  €ip. 

11.  Polymastix  hufonis  (Dobell). 

12.  Proumzehia  lacertae  (Grassi). 

13.  Monocercom/mas  melolonthae  (Grassi). 

14.  Rkizomastix  gracilis  Alexeieff. 

n.    EFFECT    OP   PARASrnC    ENVIRONMENT    UPON   THE    STRUCTURE    OF   THE    PARASITIO 

PLAQELLATE. 

In  two  very  important  particulars  the  flagellate  living  as  a  parasite  is  in  an  utterly 
different  environment  from  that  of  its  free  living  relatives  and  forbears.  In  the 
first  place,  it  is  subjected  to  new  and  different  chemical  conditions  created  by  the 
digestive  juices,  the  enzymes,  and  by  the  antitoxins  produced  by  its  host,  some  of 
them  in  response  to  its  own  chemical  defenses  and  accentuated  by  its  presence. 
These  are  biochemical  products,  and  as  such  have  a  unique  and  peculiar  facility  in 
gaining  access  to  t^e  innermost  structures  and  substances  which  enter  into  t^e 
organization  of  the  flagellate.  That  they  impose  new  adaptations  of  function  and 
structure  upon  successful  parasites  is  a  reasonable  hypothesis.  It  is  also  to  be 
expected  that  these  activities  will  manifest  themselves,  in  part  at  least,  in  the 
increased  functioning  of  the  nucleus  of  the  parasite  in  the  production  of  extranuclear 
substances,  hence* the  occurrence  among  parasitic  forms  of  diverse  chromidia  and 
extranuclear  chromatoidal  substances,  occurring  as  deeply  staining  clouds  about 
the  nucleus  or  of  chromatin  extrusions  therefrom  of  unusual  frequency  and  dimensions. 

The  second  new  and  potent  feature  in  the  environment  of  the  parasitic  flagellate 
is  the  denser  or  more  viscous  medium  in  which  its  body  is  constantly  bathed  in  the 
blood  or  lymi^  of  its  host  or  in  its  digestive  secretions  and  digesting  food.  This 
feature  of  its  surroundings  involves  at  once  an  increase  in  the  neuromotor  organs 
and  in  the  expenditure  of  energy,  and  this,  in  turn,  accelerates  the  metabolism  and 
activity  of  the  chemical  machine  formed  by  the  nucleus  and  cytoplasm. 

Structurally  it  results  in  increase  in  the  number  and  length  of  the  flagella,  in  their 
differentiation  into  undulating  membrane  and  axostyle,  and  in  increasing  complexity 
of  their  intracytoplasmic  parts,  as  for  example  in  Giardia. 

Functionally  it  leads  to  movement  on  the  substrate,  to  the  extensive  development 
of  ameboid  activities,  and  to  the  successful  penetration  of  the  epithelial  palisade 
and  other  defenses  of  the  host. 

The  extent  to  which  the  parasitic  habit  affects  life  history  is  as  yet  too  little  known 
even  to  speculate  thereon.  SuflSce  to  say  that  there  is  evidence  that  the  battle 
between  host  and  parasite  profoundly  affects  the  nature  and  rapidity  of  multipli- 
cative processes  and  fovors  cyst  formation. 


550       PBOGEEDINQS  SECOND  PAN  AMEBICAK  SCIENTIFIC  C0NGBE88. 

A  reoognitioii  of  the  potency  of  these  environmental  facton  in  the  evolution  of 
the  structure  and  life  history  of  the  flagellates  will,  in  the  opinion  of  the  writer,  tend 
to  clarify  our  morphological  interpretations  of  flagellate  structure  and  to  give  a  unity 
to  the  rapidly  increasing  revelations  of  their  diversity.  The  foilure  to  recognise 
these  factors  has,  I  believe,  led  us  far  astray  in  the  prevalent  conceptions  of  the 
extranuclear  organelles,  especially  in  the  case  of  the  so-called  kinetonudeus. 

B.    THE  MORPHOLOOICAL  AND  PHT8IOLOOICAL  SIONinCANCB  OF  THX  BO-CALLBD  '*  KIKB- 

TONUCLBUS." 

The  distinction  in  many  flagellates  of  two  types  of  nuclei,  the  kinetonudeus  and 
the  trophonucleus,  was  first  made  by  Schaudiim  (1904)  and  Woodcock  (1906)  and 
has  been  widely  adopted  in  the  subsequent  literature.  It  has  led  to  the  establish- 
ment of  the  order  of  protozoa,  known  as  the  binucleata,  by  Hartmann  (1907)  and 
the  adoption  of  this  system  of  classification  in  the  bibliographies  of  protozoology 
published  by  Field  in  the  Archiv  fOr  Protistenkunde.  It  has  also  given  rise,  or 
at  least  has  lent  support,  to  the  binuclearity  hypothesis  as  variously  elaborated  by 
Hartmann  (1907,  1911)  and  others.  This  conception  of  the  nuclear  organizjition  of 
the  flagellate  has  thus  been  ftkr-reaching  in  its  influence  on  protozoological  termi- 
nology and  ideas. 

This  view  was  founded  in  large  part  on  the  now  no  longer  accepted  life  history  of 
Trypanoiomaf  described  by  Schaudinn  (1904),  in  which  its  so-called  ookinete  gives 
rise  by  a  heteropole  mitotic  division  of  its  fertilization  nucleus  to  a  large  central 
nucleus  and  a  smaller  one  designated  by  Schaudinn  as  the  blepharoplast.  Woodcock 
(1906)  later  designated  these  as  trophonudeus  and  kinetonudeus,  respectively. 
Aocording  to  Schaudinn  the  latter  nucleus  by  a  seoond  mitotic  division  gives  rise 
to  the  basal  granule  from  which  the  flagellum  grows  out.  The  kinetonudeus  thus 
arises  as  do  other  nudei,  by  mitotic  descent  from  a  preexisting  nudeus. 

The  interpretation  presented  in  this  paper  of  this  so-called  kinetonudeus  is  wholly 
different  and  has  a  fundamental  significance  in  that,  if  true,  it  sweeps  away  the  basis 
for  the  group  binudeata  of  Hartmann,  and  also  the  grounds,  in  part,  upon  which  the 
binuclearity  hypothesis  rests. 

Without  attempting  in  this  connection  to  review  the  extensive  literature  pertain- 
ing to  this  subject,  I  will  pass  at  once  to  the  presentation  of  a  different  intopretation, 
based  on  functional  considerations.  The  main  thesis  of  this  is  that  the  loco- 
motor activities  of  the  flagellate  type  accentuated  in  parasitic  forms  by  the  increased 
expenditure  of  energy  demanded  of  them  by  life  in  a  denser,  more  viscous  medium 
than  that  of  their  free-living  relatives,  have  resulted  in  the  devdopment  of  an  extra 
nudear  neuromotor  apparatus  of  more  than  usual  complexity,  with  a  kinetic  reservoir, 
the  parabasal  body.  This  is  morphologically  associated  with  the  divmion  center  or 
centrosome  consisting  typically  of  a  chromatic  blepharoplast,  usually  containing  the 
division  center  (or  at  least  connected  with  it  by  a  rhizoplast)  from  which  the  flagella 
are  formed  by  outgrowth,  and  an  adjacent  structure  of  chromatic  substance,  the  para- 
basal  body,  which  is  a  sort  of  reservoir  of  substances  used  in  the  kinetic  activity  of  the 
motor  organelles  in  the  viscous  medium  in  which  the  parasite  lives. 

The  neuromotor  apparatus  in  nonparasitic  flagellates  usually  lacks  this  parabasal 
body.  It  is  not,  however,  everywh^e  absent — tor  example,  B^lftr  (1915)  describes 
in  Rhynchomoruu  naguta  from  the  scum  on  stagnant  swamp  water,  grown  in  cultures 
on  amoeba  agar  of  Hartmann,  structures  which  lend  themselves  to  the  int^^^retatioii 
above  outlined  though  not  so  interpreted  by  him. 

The  parabasal  is  lacking  in  some  of  his  figures  and  the  possibility  that  the  structure 
we  interpret  as  parabasal  is  a  daughter  blepharoplast  is  open.  If  not,  it  is  probable 
that  it  disappears  during  mitosis.  The  point  that  we  are  making  is  that  this  apparatus 
IB  excessivdy  devdoped  in  the  parasitic  flagellates  and  but  slightly,  if  at  all,  in  free- 
living  ones. 


PUBUO  HEALTH  AND  MBDIOINB*  561 

I.  Neuromotor    Apparatus    in    the    Protomonadina. 
1.  prowazekia  lacerta  (grassi). 

A  simple  and  very  instnictive  phase  of  ite  evolution  is  found  in  one  of  the  simpler 
protomonadina,  Prowazekia  loccrtx  (Grassi)  from  Dianyctylus  torosns.  In  this  form  the 
blepharoplast  at  the  base  of  the  two  flafrella  varies  greatly  in  size,  form,  and  evidently 
also  in  acti\'ity.  It  may  be  large  and  spheroidal,  surrounded  by  a  chromatic  halo,  or 
spreadini?  in  a  fan-shaped  suspensory  rhizoplast  passing  toward  the  parabasal  body. 
It  is  often  connected  with  the  nucleus  by  a  slender  rhizoplast. 

The  several  phases  of  the  parabasal  body  in  this  organism  and  the  accompanying 
changes  in  the  blepharoplast  and  nucleus  are  possibly  instructive  as  indicating  their 
interrelations  and  the  method  of  origin  of  the  parabasal.  In  stages  in  which  the 
nucleus  and  blepharoplast  both  contain  a  large  quantity  of  chromatin  or  deeply 
stainin?  material,  no  parabasal  can  be  found.  In  others,  apparently  premitotic  stages, 
the  central  karyosome  is  replaced  by  numerous  peripheral  granules,  and  coincidently 
the  blepharoplast  is  siurounded  by  a  zone  or  halo  of  stainable  substance.  In  other 
stacres  the  rhizoplast  is  spread  out  in  a  fan-shaped  structure  running  toward  the 
nucleus  and  the  parabasal  body,  and  small  masses  of  the  stainable  material  are  to  be 
seen  on  its  fibrous  strands  at  various  levels.  The  interesting  feature  of  the  parabasal 
is  that  it  has  various  shapes,  forms,  and  locations,  sugg^tive  of  a  highly  metabolic 
condition.  Moreover,  the  nucleus  and  blepharoplast  are  often  poor  in  chromatin 
when  the  parabasal  has  its  maximum  size  and  vice  versa.  Our  data  are  too  incom- 
plete to  give  a  clear  picture  of  the  process,  but  as  far  as  they  go  they  suggest  the  origin 
of  the  parabasal  at  the  expense  of  the  chromatin  of  the  nucleus  the  movement  of 
stainable  sibstance  on  the  rhizoplast  either  to  or  from  the  blepharoplast  at  the  base 
of  iJie  fiagella  and  the  wax  and  wane  of  the  parabasal. 

There  is  in  this  fluctuation  in  occurrence  and  structure  of  the  parabasal  of  Prowazehia 
a  striking  resemblance  to  the  form  and  behavior  of  mitochondria  of  the  cells  of  the 
Metazoa  (see  Lewis  and  Lewis,  1915).  The  fan-shaped  expansion  of  the  rhizoplast 
also  recalls  the  similar  structure  above  the  **kinetonucleus"  of  Crithidia  and  Trypano- 
$ama. 

A  feature  of  prime  significance  in  the  life-history  of  Prowazehia  is  the  fact  that  the 
parabasal  divides  at  mitosis  by  constriction  merely,  without  the  slightest  trace  of  a 
mitotic  phase  of  its  own. 

'  2.  crithidia  and  TRYPANOSOMA. 

The  nucleus  and  extranuclear  structures  of  Trypanosoma  are  so  well  known  that 
no  separate  discussion  of  them  will  be  undertaken  here  1  eyond  calling  attention  to 
the  fact  that  no  evidence  of  a  satisfactory  nature  has  ever  confirmed  Schaudinn's 
(1904)  account  of  the  origin  of  the  ^'kinetonucleus"  by  mitosis  from  any  nucleus  by 
heteropole  or  any  other  type  of  mitotic  1  ehavior.  In  their  recent  exhaustive  account 
of  the  life  history  of  Trypanosoma  levdsi  Minchin  and  Thompson  (1915)  give  no  data 
whatever  which  can  in  any  way  be  construed  as  justifying  the  use  of  the  term  mitotic 
to  deacri  e  the  divisions  of  the  so-called  ''kinetonucleus.*' 

The  close  relationship  of  Crithidia  (HerpetomonaSy  LepUmwnas)  with  the  trypano- 
somes  has  long  '  een  evident.  It  is  placed  beyond  all  question  by  the  discovery  of 
Sckizotrypanum  cruzi  by  Chagas  (1909)  and  especially  I  y  the  full  life  history  of  2Vy- 
pano!^oTna  letuisi  as  worked  out  by  Minchin  and  Thompson  (1915)  in  the  rat  flea. 
In  fuller  confirmation  of  the  close  relationship  stands  the  recently  pul  lished  outline 
of  the  life  history  of  Crithidia  leptocoridis  from  the  1  ox-elder  bug,  an  herlivorous 
hemipteran  insect,  ]>y  McCulloch  (1915). 

The  conditions  are  such  that  is  is  extremely  pro»  a'  le  that  the  whole  life  history 
of  this  parasite  is  passed  within  the  digestive  tract  of  this  insect  which  feeds  upon 
plant  juices.    Step  for  step,  the  life  history  and  morphology  of  Crithidia  leptocoridis 


552       FBOOESDnSTGS  SBCONB  PAK  AlCSBIOAN  80IBKTIFI0  C0KGBES8. 

and  of  Trypanosoma  Uwisi  up  to  the  trypaniform  phase  are  strUringly  fiimilar.  At  do 
time  in  the  life  history  of  either  doee  the  ''Icinetonucleus"  eithw  divide  Y  y  mitosia 
or  originate  from  the  nucleus  by  any  heteropole  mitotic  division.  On  the  othw  hand , 
there  is  some  very  significant  evidence  that  this  so-called  "kinetonucleus"  is  in 
reality  a  true  parabasal  1  ody. 

These  organisms  show  an  extranuclear  chromatic  mass,  the  para>  asal  body  or  ao- 
called  ''kinetonucleus/'  from  which  the  flagellum  proceeds  anteriorly  along  the 
maigin  of  the  undulating  membrane.  In  n^any  individuals  in  preparations  there 
runs  posteriorly,  apparently  directly  through  this  '^l^inetonucleus/'  a  chromatic 
thread,  the  rhizoplast,  to  the  nucleus  and  sometimes  to  its  karyosome.  From  the 
nucleus  or  from  Uie  blepharoplast  at  the  I  ase  of  the  flagellum  a'  ove  the  nuclena 
there  runs  posteriorly  a  slender  chromatic  thread  which  we  provisionally  call  the 
axostyle,  terminating  near  the  posterior  end  in  a  chromatic  granule.  This  appears 
to  lie  in  or  near  the  periphery  )  ut  differs  somewhat  from  the  adjacent  mycmeme  in 
size  and  undulations.  This  structure  proba'  ly  furnishes  the  mechanism  for  the  poe- 
terior  migration  of  the  '^Idnetonucleus''  in  the  trypaniform  phases  of  the  trypano- 
somidsB. 

Let  us  now  consider  more  particularly  the  morphological  relations  of  this  so-called 
"kinetonufleus."  In  the  first  place  it  lies  posterior  to  the  '  lepharoplast  which 
is  at  the  '  ase  of  the  flagellum;  secondly,  it  is  connected  with  this  blepharoplast 
by  a  fan-shaped  mass  of  suspensory  fibers  which  mijiht '  e  designated  as  the  para'  asal 
rhi7.oplaat;  and  thirdly,  its  appearance  in  the  chromatic  axis  running  posteriorly 
from  the  1  lepharoplast  to  the  nucleus  in  many  preparations  and  figiires  is  more 
apparent  than  real.  In  reality  it  lies  to  one  side  of  this  line.  A  study  of  the  figures 
of  Crithidia  Icptocondis  (McCulloch,  I9I5)  reveals  the  fact  that  this  triangular  ilol  ed 
^'kinetonucleus'*  lies  in  a  great  variety  of  positions  with  respect  to  the  nuclear 
rhizoplast  as  though  pendant  from  the  !  lepharoplast  and  aseuming  various  positions 
before  the  o  server  with  the  movements  of  the  \  ody  and  in  its  different  aspects  in 
the  preparations. 

These  facts  indicate  that  the  "kinetonudeus"  of  Crithidia  lepiocaridii  bears  the 
same  relations  to  the  *  lepharoplast  and  rhizoplast  as  does  the  parabasal  '  ody  of  the 
polymastigina,  as,  for  example,  that  of  Polymaslix  hvfonis.  These  considerations 
lead  us  to  conclude  that  the  '^  kinetonucleus  "  of  Criihidia  is  the  homologue  in  position 
and  structure  of  the  parabasal  body  of  the  polymastigina.  It  should  therefore  le 
called  the  para'  asal    ody. 

No  indications  of  its  origin  by  heteropole  mitosis  of  any  nucleus  nor  of  its  mitotic 
behavior  at  binary  fission  have  been  found.  It  rather  seems  to  be  connected  with 
the  blepharoplast  and  thence  vith  the  karyosome,  and  at  spore  formation  (McCulloch, 
1915),  to  come  into  intimate  relations  with  it.  Its  emergence  from  the  spore  has  not 
been  followed. 

At  binary  fission  in  Crithidia  leptocoridis  (McCulloch,  1915),  it  appears  to  di\'ide  by 
constriction  as  also  in  the  case  of  Schizotrypanum  crun  (Chagas,  1909)  and, in  TV;^- 
panosoma  /eu/m  (Minchin  and  Thompson,  1915).  There  is  no  evidence  that  it  under- 
goes mitotic  division,  or  passes  through  any  phase  ^hich  justifies  the  assignment  to 
it  of  nuclear  attributes  or  the  name  kinetonucleus  \sith  the  accompanying  morpho- 
logical connotation  of  the  word  nucleus. 

The  similarity  ot  the  structure  of  Crithidia  Uptocoridis  to  the  crithidial  stages  of 
Schizotrypanum  cruzi  and  to  those  of  Trypanosoma  Itwisi  gives  presumptive  evidence 
that  the  so-called  "kinetonucleus"  of  the  trypanosomidse  generally  is  in  reality  the 
parabasal  body. 

Confirmatory  c\idence  of  this  is  found  in  a  new  species,  Trypanosoma  triatomx, 
Kofoid  and  McCulloch  (1916)  found  by  us  in  Triatoma  protracta  Uhler,  a  reduviid 
bug  found  in  the  nests  of  the  wood  rat,  Neotoma  fusdpes  macrotus  Thomas.  The 
digestive  tract  of  the  bug  often  contains  blood.    We  have  not  as  yet  been  able  to 


PUBUO  HEALTH  AKD  MEDIOnfX.  553 

examine  the  blood  of  the  wood  mt  for  trypanoeomes.  PreBomably  the  flagellate 
parasite  which  is  found  in  the  digestive  tract  of  the  bug,  in  whidi  it  passes  through 
both  crithidlal  and  trypaniform  stages  with  remarkable  similarity  to  St^izotrypanum 
enai  in  its  invertebrate  host,  is  in  its  trypanosome  stage  to  be  sought  in  the  blood  of 
the  wood  rat. 

This  flagellate  which  is  an  undoubted  Trypanoioma  in  its  develo])mental  stages  as 
far  as  known  in  the  bug,  we  have  demonstrated  to  have  the  same  lateral  attachment 
of  the  so-called  "kinetonucleus"  to  the  blephaioplast  as  in  Crithidia  Uptocondu,  and 
the  same  fan-shaped  suspensory  structure  spreading  from  the  blephaioplast. 

The  morphological  considerations  set  forth  as  a  result  of  our  examination  of  CrUMdia 
leptocoridis,  a  trypanosomid  flagellate  which,  so  far  as  known,  occurs  only  in  the  in- 
testine of  Leptoeoris,  a  hemipt^ran  insect,  and  of  Trypanosoma  triatomx  in  both  its 
crithidial  and  trypaniform  phases  in  the  hemipteran  host  Triatoma,  lead  us  to  conclude 
that  tbe  so-called  ''kinetonucleus*'  of  these  organisms  is  the  homologue  of  that  in  the 
trypanosomidae  generally,  and  that  it  is  laterally  attached  to  the  blepharoplast,  a 
granule  at  the  base  of  the  flagellum,  from  which  a  rhizoplast  is  often  found  passing 
to  the  central  karyosome  of  the  nucleus  and  an  axostyle  passing  toward  the  posterior 
end  of  the  body.  The  striking  morphological  similarity  of  this  type  of  structure  to 
that  found  in  the  simpler  polymastigina  ^ill  be  apparent  when  we  come  to  consider 
the  organization  of  that  group.  We  hold  that  the  ''kinetonucleus'*  is  accordingly 
in  reality  the  parabasal  body. 

II.  Neuromotor  Appabatus  of  thb  Poltmastioina. 

In  the  polymastigina  the  neuromotor  apparatus  attains  a  much  higher  stage  of 
complexity  than  in  the  protomonadina.  This  is  seen  in  the  increase  in  the  number 
of  the  flagella,  in  the  development  of  a  powerful  intracytoplasmic  axostyle,  in  the 
various  specializations  of  the  parabasal,  and  in  the  integrating  structures  of  the 
diplozoic  hexamitidse. 

1.  POLTMABTIX  BUTONI8  (DOBSLL). 

The  simplest  condition  is  to  be  seen  in  one  of  the  lower  polymastigina,  Polynuutix 
bvfonis  (Dobell)  from  the  intestine  of  amphibians  which  has  four  very  long  equal  an- 
terior flagella,  a  fairly  rigid  body,  a  chromatic  blepharoplast  from  which  the  flagella 
spring,  located  constantly  at  the  extreme  anterior  end.  This  organ  is  also  the  division 
center,  leading  in  mitosis  but  not  taking  a  polar  position  on  the  intranuclear  spindle 
on  which  polar  caps  replace  the  usual  centrosome.  From  it  two  rhizoplasts  pass  cen- 
trally, one  to  the  chromatin-poor  spheroidal  nucleus,  the  other  to  the  chromatin-rich 
parabasal  body,  which  forms  a  curved,  club-shaped,  deeply  stained  mass  extending 
posteriorly  to  the  nucleus. 

The  most  instructive  features  of  this  parabasal  body  are  its  variable  form,  size, 
and  position,  its  connection  (often  apparently  lacking)  with  the  blepharoplast,  its 
diminution  during  mitosis,  and  its  division  by  simple  constriction,  without  mitotic 
activities  on  its  part. 

2.  TRICHOMONAS  AUGUSTA  ALEZEISFr. 

The  lateral  detachment  or  inclusion  of  one  flagellum  to  form  the  undulating 
membrane,  the  axial  inclusion  of  another  to  form  the  powerful  locomotor  axostyle^ 
and  the  almost  continuous  union  of  centrosome  with  the  blepharoplast,  is  character- 
istic of  many  of  the  trichomonidse  (see  Kofoid  and  Swezy,  1915,  b).  Trichomowu 
augtuta  Alexeieff,  a  parasite  of  amphibians,  serves  to  illustrate  this  tjrpe,  which 
for  purposes  of  description  may  be  regarded  as  typical  of  the  higher  polymastigina. 
In  these  trichomonad  flagellates  we  find  an  apparatus  which,  when  the  cytoplasm 
is  removed  by  maceration,  remains  intact.  It  consists  of  a  series  of  structures 
radiating  from  the  blepharoplast  which  is  attached  to  the  nuclear  membrane  by  a 


554       PKOGEEDINGS  8B00HD  PAN  AMEBIOAN  SCIENTIFIC  C0KGBE88. 

atonder  strand  of  stainable  material,  the  rhizoplaet.  From  the  blepharoplaet  there 
radiate  not  only  this  rhizoplast,  but  aim  (1)  the  three  anterior  flagella;  (2)  an  in- 
tracytoplasmic,  laterally  attached,  posteriorly  directed  flagellum  fonning  the  mar- 
ginal filament  of  the  undulating  membrane  and  projecting  po8teri<»ly  as  the  posterior 
flagellum;  (3)  the  axoetyle,  a  swollen  axial  intracytoplasmic  flagellmn  fonning  a  pow- 
erful motor  organelle  used  in  locomotion  on  the  substrate;  (4)  the  parabasal  body,  or 
kinetic  reservoir,  a  slender  chromatic  rod  l3ring  in  the  base  of  the  undulating  mem- 
brane, but  not  locomotor  in  function;  and  (5)  the  paradesmose  which  joins  the  polar 
blepharoplasts-centrosomee  at  mitosis  and  lies  outside  of  the  nuclear  membrane.  The 
blepharoplaet  which  contains  the  centrosome  initiates  the  process  of  mitosis.  The 
division  of  oiganelles  as  well  as  their  formadon  by  new  outgrowths  alike  proceed 
from  it.  The  centrosomes  may  leave  the  daughter  blepharoplasts  with  which  flagella, 
paradesmose,  and  parabasal  retain  their  connections,  while  it  remains  at  the  poles  of 
the  spindle.  This  separation,  however,  appears  to  be  temporary  in  this  organism 
but  a  permanent  one  in  Oiardia  (Lamhlia)  mun$.  The  permanent  extranuclear  loca- 
tion of  the  blepharoplaet  and  centrosome  in  flagellates  is  suggested  by  the  foct 
that  the  paradesmose  is  always  extranuclear. 

3.  GUBDIA.  MURIS  (GBASSI). 

A  more  highly  specialized  phase  in  the  evolution  of  this  neuromotor  apparatus  is 
to  be  found  in  Oiardia  mtcm,  a  parasite  of  Mils  and  Peromyscus  (see  Kofoid  and  Chris- 
tiansen, 1915,  a,  b).  This  is  a  binucleate  somatella  which  might  be  regarded  as  made 
up  of  two  individuals  of  Trichomonas  retaining  a  single  axostyle,  which  organelle, 
by  the  way,  is  the  last  to  divide  in  the  mitosis  of  TridMmonas  and  the  first  to  divide 
in  Oiardia,  The  permanent  condition  of  the  trophozoite  of  Oiardia  is  thus  that  of  a 
Trichomonas^  which  has  completed  all  of  the  steps  in  mitosis  except  division  of  the 
axostyle  and  plasmotomy.  The  early  phases  of  mitosis  in  Oiardia  have  given  rise  in 
the  previous  literature  to  the  belief  that  Oiardia  has  typically  two  axostyles. 

The  neuromotor  apparatus  of  CKardia  is  even  more  definitely  connected  with  the 
nucleus  than  Trichomonas.  In  nearly  all  individuals  a  chromatic  rhizoplast  runs  from 
the  blepharoplast  to  one  pole  of  the  elongated  nucleus,  expands  on  the  nuclear  mem- 
brane into  a  centrosome  (cent,)  and  continues  as  an  intranuclear  rhizoplast  into  the 
central  karyoeome.  The  connections  of  the  blepharoplast  with  the  flagella,  axostyle, 
and  parabasals,  are  less  distinct  than  in  Trichomonas,  owing  to  the  crowding  of  struc- 
tures about  the  head  of  the  axostyle.  From  or  near  the  blepharoplast  on  the  head 
of  the  axostyle  there  arise  in  addition  to  the  rhizoplast,  (1)  a  chronuitic  commissure 
joining  the  right  and  left  blepharoplasts;  (2)  the  antero-lateral  flagellum  which  ap- 
parently crosses  over  to  the  opposite  side,  runs  along  the  cytostome  posteriorly,  and 
emerges  at  a  lateral  basal  granule,  and  forms  in  the  median  line  a  node,  the  anterior 
chiasma  at  the  point  where  it  crosses  its  mate  from  the  other  blepharoplast;  (3)  the 
po.<)terolateral  flagellum  which  runs  an  intracytoplasmic  course  to  near  the  margin 
of  the  body  where  it  emerges  without  a  basal  granule;  (4)  the  free  ventral  flagellum; 
(5)  the  axostyle  attached  to  both  blepharoplasts  prior  to  the  early  phase  of  binary 
fission  of  the  somatella;  and  (6)  the  dorsally  located  rhizoplast  which  runs  to  the 
parabasal  body.  There  are  two  parabasal  bodies,  sometimes  partially  fused  into  one 
whii  h  are  subject  to  considerable  variation  in  size.  They  tend  to  disappear  at  mito- 
sis, in  both  binary  and  multiple  fission,  and  are  entirely  absent  in  encysting  stages 
when  locomotor  activities  cease. 

in  the  light  of  the  structure  of  the  extranuclear  organelles  of  both  the  protomonadina 
aii<1  the  polymastigina  we  hold  in  conclusion  that  the  parabasal  body  of  the  latter  and 
the  so-called  **kinetonucleu8"  of  the  former  are  homologous  organs,  that  there  is  no 
valid  evidence  for  the  derivation  of  this  organ  in  either  group  by  a  heteropole  or  any 
other  t>'pe  of  mitosis  from  any  nucleus,  and  equally  none  for  its  division  at  binary 
fission  by  any  process  to  which  the  adjective  mitotic  can  be  applied.    In  other  words, 


PXTBUC  HBAL3TH  AND  MEDICINB.  555 

there  are  absolutely  do  morphological  aanctiona  for  the  name  kinetODUcleus  for  this 
extranuclear  chromatic  structure.  It  is  rather  a  chromatic  extranuclear  kinetic 
reservoir,  and  the  noncommittal  morphological  designation  '* parabasal  body"  should 
be  applied  to  it  throughout,  or  the  functional  term  **  kinetic  reservoir.*'  The  term 
kinetic  or  division  center  is  wholly  inapplicable,  since  the  centrosome,  or  polar  caps, 
or  centrioles,  are  never  contained  within  it,  but  rather  in  the  blepharoplast  or  occur 
separately  from  both  blepharoplast  and  parabasal,  though  with  connecting  rhizoplast 
as  in  Qiardia, 

Til.  Obioik  of  thb  Extranttclbar  Nbubomotor  Appabatub. 

The  term  neuromotor  apparatus  is  used  by  us  here  and  elsewhere  to  designate  those 
organs  of  the  protozoan  body  which  carry  on  its  coordinated  motor  and  locomotor 
activities.  They  form  a  structurally  continuous  uoit  as  shown  in  Tnchomonas  and 
Qiardia  connected  by  a  rhizoplast  with  the  nucleus  as  in  Tnchomonas,  or  with  the 
central  karyosome  as  in  Qiardia,  On  maceration  of  the  cytoplasm  in  TWc^oTnoruuand 
Trichofmitna  this  apparatus  remains  stnicturally  intact  for  K)n<e  time.  It  includes  in 
Trichomonas  the  following  structures:  The  anterior  flagella,  marginal  filament  of  the 
undulating  membrane,  posterior  flagellum,  axostyle,  parabasal  body,  blepharoplast, 
and  rhizoplast.  In  Qiardia  there  are  added  the  anterolateral,  postero-lateral.  and  free 
ventral  flagella  and  an  axoetyle  terminating  in  the  posterior  flagella  the  intracytopla^ 
mic  parts  of  the  first  two  pairs  of  flagella  just  named,  a  rhizoplast  going  from  the 
parabasal  body  presumably  to  the  blepharoplast,  and  a  cross  commissure  joining  the 
right  and  left  blepharoplasts.  The  integration  of  these  parts  in  one  coherent  struc- 
tural system  and  its  intimate  relation  to  the  mobile  cytoetome  are  evident  on  an 
inspection  of  the  figure.  The  repeated  instances  of  the  attachment  of  the  blepharo- 
plast to  the  nuclear  membrane  by  a  rhizoplast  in  the  various  flagellates  which  we 
have  discussed  and  the  direct  connection  of  the  neuromotor  apparatus  with  the  karyo- 
some of  the  nucleus  in  Qiardia  give  premimptivp  evidence  of  a  fundamental  struc- 
tural and  functional  relation  between  the  nucleus  and  this  complex  of  extranuclear 
organelles.  The  fact  also  that  the  blepharoplast  and  its  outgrowths  and  connections 
are  basophileand  stain  more  or  less  deeply  with  iron  haemotoxylin  suggests  affinities 
if  not  similarities,  of  a  chemical  nature. 

Added  ground  for  regarding  the  extranuclear  neuromotor  apparatus  as  related  to  the 
nucleus  and  as  evolved  and  deriveo  from  it  is  to  be  found  in  the  results  of  Dr.  C.  W. 
Wilson's  (1916)  study  of  the  life  history  of  a  soil  amoeba  Naegleria  gruheri.  This  amoeba 
enflagellates  on  the  impact  of  various  environ nr en tal  factoTs  8i:ch  ae  access  of  oxygen, 
or  of  fresh  culture  medium,  and  exflagellatee  with  ef|ual  facility.  In  the  amoeboid 
phase  there  is  no  extranuclear  blepharoplast  rhizoplast  or  flagella,  and  no  chromatic 
extranuclear  organelles,  though  chromidial  formations  are  abundant  and  varied  at 
times  in  the  life  history.  As  enflagellation  approaches  a  chron  atic  process  grows  out 
from  the  central  karyosome  of  the  nucleus  forming  an  intrani  clear  rhizoplast  extending 
to  the  nuclear  membrane.  A  granule  appear?  at  its  tip  and  as  this  process  continues  its 
growth  peripherally  through  the  cytoplasm,  retains  iti»  terminal  position  until  it 
reaches  the  surface  where  it  forms  the  blepharoplast  connected  on  the  one  hand  with 
the  nucleus  and  on  the  other  giving  rise  to  the  two  flagplla.  In  exflagellation  the 
flagella  shorten  and  fusing  with  the  blepharoplast  and  rhizoplapt  appear  to  retreat 
again  into  the  nucleus.  In  this  connection  we  note  the  fact  that  no  instances  of 
mitoslB  were  discovered  in  the  flagellate  phase,  though  they  aie  to  be  expected,  and  in 
consequence  we  do  not  know  the  behavior  of  these  organelles  in  that  process.  The 
centrosome  or  centriole  is  contained  within  the  koryown^e  an(1  appears  here  as  in  other 
amoebas  at  mitosis,  at  the  ends  of  an  axial  chromatic  thrca<l  in  the  ceiiter  of  the  nuclear 
spindle.  Thus  in  this  amoeba  the  centrosome  within  the  central  karyoaome  of  the 
nucleus  originates  the  extranuclear  nduromotor  apparatus  of  the  flagellate  stage. 


556       PBOGEEDINGS  SECOND  PAN  AMBBIOAN  SOIENTIFIO  CONGBE88. 

F.  Thb  Lam  Ctclb  of  Intbstinal  Flagbllatbs. 

The  life  cycle  of  the  protos&oaD,  as  for  example,  of  Paramecium,  is  comparable  in  some 
of  its  aspects  to  that  of  the  metazoan.  It  starts  with  the  zygote  or  united  gametes. 
There  follows  a  period  of  binary  fission  in  the  protozoan,  or  of  cleavage  in  the  metazoan. 
Some,  at  least,  of  the  resulting  products  in  the  protozoa  become  gametocytes.  as  do 
some  of  the  cells  of  the  metazoa.  There  is  as  yet  no  critical  evidence  to  determine 
whether  or  not  all  individuals  in  the  line  of  descent  are  potential  gametocytes  in  the 
protozoa,  or  whether  only  a  part  of  them  are,  as  in  the  metazoa.  The  gametocytes  in 
both  protozoa  and  metazoa  undergo  a  matiutition  process  in  which  the  chromoeomee 
are  reduced  from  the  diploid  to  the  haploid  number  with  the  resulting  formation  of 
gametes. 

When  we  seek  to  apply  this  general  formula  to  the  data  at  present  a^'ailable  as  to 
the  life  history  of  intestinal  flagellates  and,  indeed,  of  flagellates  generally,  excluding 
the  phytomonadina,  we  find  a  serious  lack  of  conclusive  proof  as  to  the  occiurence  in 
them  of  this  life  cycle  as  above  outlined.  Asexual  reproduction  is  well  known« 
although,  as  we  shall  shortly  show,  one  important  phase,  that  of  multiple  fission,  has 
been  largely  overlooked  and  sometimes  denied.  Sexual  reproduction,  on  the  other 
hand,  is  less  clearly  established  among  flagellates  than  in  any  other  group  of  protozoa. 

I.  THE  SEXUAL  PHASE.  , 

The  occurrence  of  periodic  or  occasional  sexual  reproduction  among  the  parasitic 
flarellates  is  to  be  expected  on  a  priori  groimds.  It  has  long  been  known  among  the 
phytomonadina  in  Volvox  and  has  recently  been  demonstrated  by  Chatton  (1911)  in 
Fleodorina  oalifomica.  Among  other  groups  of  flagellates  Dobell  (1908)  has  given  an 
account  of  a  sexual  cycle  in  Copromonas  mbtilis  (Euglenoidina)  from  the  frog,  and  Gold- 
schmidt  (1907)  has  elaborated  a  very  full  description  of  a  sexual  cycle  in  the  free-liv- 
ing rhizomastigina  in  two  genera,  Mastigella  and  Mastiginay  of  rhizopod  aflfinlties 
with  a  cycle  of  the  rhizopod  type.  The  process  of  autogamy,  described  by  Prowazek 
(1904)  and  others,  and  rather  widely  accepted,  we  believe  to  be,  in  part  at  least, 
erroneous,  being  founded  on  the  inclusion  of  a  yeast,  BUuiocystia  (AlexeiefF,  1911) 
in  the  life  cycle  of  the  flagellate.    This  process  is  in  need  of  confirmation. 

The  difliculties  in  the  way  of  tracing  the  sexual  cycle  are  great.  Multiple  infec* 
tion  by  different  parasites  opens  the  door  to  confusion  of  different  species  in  one  life 
cycle,  a  pitfall  \^hich  trapped  even  the  fstr-sighted  Schaudinn.  Involution  phe- 
nomena, especially  nuclear  extrusions  of  chromatin,  simulate  maturation  phenomena. 
The  occurrence  of  stainable  products  in  the  cytoplasm  in  imiting  (or  di\dding?)  flagel- 
lates such  as  Dobell  (1908)  figures  for  Copromonas  is  hardly  to  bo  regarded  as  a  conclu- 
sive proof  that  maturation  has  taken  place.  Amoeboid  activities  of  the  still  attached 
sister  cells  at  the  close  of  mitosis  but  before  plasmotomy  in  binary  fission  afford,  in 
fixed  preparations,  most,  if  not  all,  of  the  stages  necessary  to  build  up  an  account  of 
the  fusion  of  gametes,  except  that  of  nuclear  fusion.  After  one  has  foUov^ed  the 
protean  changes  of  such  a  living  couple  he  approaches  the  subject  of  sexual  repro- 
duction and  especially  of  fertilization  stages  with  a  very  vivid  sense  of  the  diffi- 
culty of  securing  from  anything  but  the  li\ing  gametes  in  the  actual  process  of  sexual 
behavior  and  from  fusing  gametic  pronuclei  any  conclusive  evidence  of  sexual  repro- 
duction among  flagellates  without  morphologically  distinguishable  gametes. 

Another  uncertainty  of  considerable  import  arises  from  our  lack  of  knowledge 
regarding  the  nature  and  function  of  encystment,  and  the  condition  or  conditions 
which  induce  it.  We  have  as  yet  no  clear  evidence  that  this  process  is  in  these  flagel- 
lates necessarily  related  in  any  way  to  sexual  reproduction,  though  stages  suggestive 
of  it  are  found  in  the  so-called  '*  copulation  cysts  **  of  Giardia,  which  contain  two  binu- 
cFeate  individuals  in  a  definite  morphologiod  position  one  to  the  other;  that  is,  end 
to  end,  and  back  to  back.  Supplemental  to  this  is  the  discovery  in  Giardia  microti 
(see  Kofoid  and  Christiansen,  1915  b)  of  such  cysts  in  which  the  formation  of  reduc- 


PUBUO  HBALTH  Ain>  HEDIOIKB.  557 

itofi  nuclei  is  at  least  simiilated.  These  may  be  only  involutioii  phases,  with  degen- 
erating n(»mal  nuclei.  The  difficultiee  in  the  way  of  considering  these  true  copula- 
lion  cystB  are  great.  These  ''gametocytes''  are  binucleate.  This  does  not  preclude 
the  formation  of  uninucleate  gametes,  but  no  traces  of  such  a  condition  have  appeared 
in  eur  material.  There  is  no  evidence  of  reduction  in  the  number  of  chromosomes  in 
these  nuclei  under  suppicion  as  reduction  nuclei  by  reason  of  their  size  and  appear- 
ance in  ''copulation  cysts." 

On  the  negative  side  attention  must  be  called  to  the  failure  of  prolonged  and  inten- 
■iTe  investigation  on  the  life  cycle  of  trypanosomes,  such  as  that  of  Minchin  and  Thomp- 
son (1915)  on  Trypanoioma  lewisiy  in  bringing  to  light  the  least  evidence  of  the  occur* 
rence  of  a  sexual  phase  in  the  invertebrate  host,  the  flea.  The  discovery  of  the  so- 
called  sexual  reproduction  of  Trypanosoma  by  Prowazek  (1905)  in  the  louse,  is  as  yet 
without  adequate  confirmation.  It  rests  also  in  the  first  instance  on  isolated  occur- 
rences in  smear  preparations  of  fixed  material,  of  contiguous  so-called  anispgametes, 
and  not  on  continued  observation  of  the  sexual  behavior  of  living  gametes  and  of  the 
resulting  zygote. 

In  out  own  observations  (Kofoid  and  Swezy,  1915  b,  and  Kofoid  and  ChristianBen, 
1915  b)  on  the  life  history  of  four  genera,  Trichomonas,  EutrichomastiXf  Tetratncho* 
fnonas,  and  Giardiaf  and  Dr.  Swezy's  observations  (1915  a,  b,  and  1916)  on  Hexamitus, 
Polymastix,  Bodo,  and  Prov:a2ekia,  no  conclusi^'e  evidence  of  a  sexual  cycle  has  as 
yet  been  detected,  v,  hen  due  caution  is  observed  to  avoid  the  pitfalls  above  enumer- 
ated. The  sexual  cycle  is  to  be  sought  and  is  probably  to  be  expected,  but  the  evi- 
dence for  it  is  to-day  far  from  conclusive,  and  such  as  we  have  bears  no  comjMuison 
in  its  finality  with  that  available  in  the  case  of  the  ciliata. 

II.  THE  ASEXUAL  PHASE. 

This  phase  of  the  life  c:.'cle  as  we  have  found  it  Is  dividble  into  two  distinct  stages. 
(1)  binary  fission  with  mitosis  followed  by  dela:/ed  plasmotomy  and  yielding  two 
daughter  trophozoites,  and  (2)  multiple  fission  forming  by  three  successive  pervading 
mitoses  an  8-zooid  plasmodium  or  somatella,  which  by  a  process  of  disintegrative 
plasmotomy  later  gives  rise  to  eight  small  or  young  trophozoites.  In  the  binucleate 
flagellates  such  as  Giardia  and  Hexamitus  a  16-nucleate,  but  still  8-zooid  plasmodium, 
is  formed .  There  is  no  retmn  in  either  binar/  or  multiple  fission  in  these  forms  to  a 
uninucleate  condition,  at  least  in  so  far  that  at  each  succeeding  mitosis  the  growing 
somatella  is  composed,  not  of  4,  8,  and  lf>  separate  and  uniform  cells,  each  of  w'lich 
ultimately,  after  disintegration  of  the  temporary  phase  of  union,  forms  a  new  individual, 
but  rather  of  2,  4,  and  8  binucleate  potential  indi\'iduals  imited  in  a  common  cyto- 
plasmic mass,  but  each  fully  equipped  with  the  coordinating  neuromotor  organelles 
•f  the  individual. 

We  have  verified  the  occurrence  of  both  of  these  processes  of  asexual  reproduction 
in  12  species  belonging  to  6  genera.  Both  (except  as  noted)  have  been  found  in 
Trichomonas  augusta,  T.  muris  (Kofoid  and  Swezy,  1915  b),  in  T.  sp.,  and  T.  batracho- 
rum  (results  not  yet  published),  in  Eutrichomastix  serpentis  and  Tetratrichorrumas 
prowazeki  (Kofoid  and  Swezy,  1915  a,  b),  in  Hexamitus  muris ^  H.  intestinalis,  H.  ovatus, 
and  H.  hatrachorum  (multiple  fission  only),  in  Trichomitus  parvus  (Swezy,  1915  a,  c) 
and  in  Chiloinastix  mesnili.  Binary  fission  alone  has  thus  far  been  seen  in  Polymastix 
Vufonis  and  Prowazekia  lacertas. 

This  widespread  occurrence  of  these  processes  justifies  in  our  opinion  the  expectation 
that  both  binary  and  multiple  fission  will  prove  to  be  normal  phases  of  the  life  history 
•f  intestinal  flagellates  and  probably  of  most  flagellates.  It  will  suffice  for  present 
purposes  to  note  their  occurrence  in  the  protomonadina,  in  Trypanosoma  letoisi  as 
described  by  Minchin  and  Thompson  (1915),  and  to  briefly  outline  these  processes  in 
the  polymastigina  in  three  t^/pical  forms,  Polymastix  bvfonis  (Dobell),  Tiichom<mas 
augtuta  Alexeieff.  and  Oiardia  muris  (Grass!). 


658       PBOCEEDINQ8  8E00ND  PAN  AMEBICAN  80IENIIFI0  CONGRESS. 

I.   BINABT  FISSION  IN  INTESTINAL  FULGBLLATES. 

This  process  in  the  polymastigina  consists  of  two  distinct  phases:  (1)  Mitosis  involv- 
ing both  nuclear  and  extranuclear  structiires,  and  (2)  plasmotomy  resulting  in  the 
separation  of  the  daughter  individuals.  These  two  phases  are  far  leas  intimately  con- 
nected than  in  metazoan  cells,  and  a  considerable  interval  may  elapse  after  tiie  first  is 
completed  before  the  second  ensues.  Mitosis  is  of  the  premitotic  trpe  witli  tiie  nucle.^ 
membrane  remaining  intact  and  is  often,  but  not  always,  accompanied  in  the  poly- 
mastigina  by  the  formation  of  an  extranuclear  chromatic  thread  joining  the  sister 
blepharoplasts  at  the  poles  of  the  spindle,  but  lying  wholly  outside  of  ttie  nuclear 
membrane.  The  extranuclear  organelles  are  wont  to  initiate  the  mitotic  proc«B  a: id 
to  behave  rather  independently  of  the  intranuclear  phenomena.  Within  t*ie  nucleus 
an  intranuclear  chromidial  cloud  is  succeeded  by  a  skein  stage  from  which  twice  as 
many  chromatic  rods  (chromosomes)  emerge  as  later  appear  in  the  equatorial  plate, 
thus  giving  the  appearance  of  a  precocious  splitting  and  subsequent  fusion  of  tiiese 
structures.  It  is  also  noteworthy  that  the  chronolog*/  of  mitotic  phenomena  in  tne 
djxdding  oiganism  is  subject  to  many  variations  with  the  result  that  a  xer/  considerable 
variety  of  pictures  of  the  process  may  be  obtained.  This  is  to  be  expected  in  view  of 
the  parasitic  mode  of  life  and  the  peculiar  susceptibilif/  of  mitotic  phenomena  to  the 
subtile  influence  of  biochemical  factors.  Let  us  now  briefly  consider  binar-  fission 
in  three  t^'pes,  Polymastix  bufonis  (Dobell),  Trichomonas  augusta  Alexeieff,  and 
Giardia  muris  Grassi. 

(a)  Binary  fission  in  PoZy77ia«f to;  6w/o /lis  (Dobell):  The blepharoplast  initiates  binary 
fission  by  its  division,  each  daughter  taking  two  of  tlie  four  flagella.  No  paradesmose 
is  formed  between  them  and  they  are  at  no  time  located  at  the  poles  of  the  spindle. 
The  central  kar/osome  disappears,  an  intranuclear  chromidial  cloud  is  formed,  from 
which  four  chromosomes  emerge,  which  fuse  to  form  two  in  the  equatorial  plate.  In 
the  telophase  these  fuse  with  the  chromatic  polar  caps.  At  the  close  of  mitosis  the 
parabasal  body  whose  rhizoplast  appears  in  one  instance  to  be  split,  parts  by  simple 
constriction.  Neither  it  nor  the  blepharoplast  show  at  any  time  anv  features  which 
might  be  properly  designated  as  even  remotely  resembling  the  mitotic  processes  of 
the  nucleus.  Plasmotomy  ensues  progressively  from  the  anterior  end  posteriorly; 
that  is,  the  division  is  a  longitudinal  one. 

(6)  Binary  fission  in  Trichomonas  augusta  Alexeieff:  This  has  been  described  is 
full  elsewhere  (Kofoid  and  Swezy,  1915  a,  b)  so  that  a  brief  review  only  will  be  given 
here  of  its  most  salient  features.  It  is  initiated  by  the  division  of  the  blepharoplast 
and  of  the  attached  flagellum  or  chromatic  maigin  of  the  undulating  membrane,  and 
by  the  outgrowth  of  one  new  flagellum.  The  intranuclear  chromidial  cloud  emeiiges 
as  a  drcumnuclear  halo  and  later  both  cytoplasmic  and  axostylar  chromidia  increase 
in  number.  The  central  karyoeome  is  succeeded  by  a  chromatin  skein  and  this  in 
turn  by  the  emergence  of  10  or  twice  as  many  chromatin  masses  (chromosomes)  as 
appear  later  in  the  equatorial  plate.  The  chromosomes  are  differentiated  as  to  size 
and  behavior,  there  being  a  small  one  lagging  in  the  anaphase.  As  the  metaphase 
approaches,  the  daughter  blepharoplasts  migrate  to  the  poles  of  the  spindle,  spinning 
out  a  deeply  staining  paradesmose  between  them  which  persists  for  a  long  time 
as  a  sort  of  tether  between  the  daughter  nuclei.  It  is  always  extranuclear.  Each 
blepharoplast  takes  with  it  its  quota  of  old  and  newly  outgrowing  flagella  and  its 
undulating  membrane  and  parabasal,  a  new  parabasal  having  been  formed  by  out- 
growth from  the  blepharoplast  alongside  the  old.  At  the  metaphase  or  amphiaster 
stage  the  polar  blepharoplasts  may  be  temporarily  abandoned  by  the  centrosomes 
which  retain  a  polar  position  while  all  of  the  extranuclear  neuromotor  organelles, 
except  the  axostyle,  retain  their  attachment  to  the  blepharoplast. 

With  the  migration  to  the  poles  of  the  daughter  chromosomes  the  reorganization  of 
the  daughter  nuclei  i^  preceded  by  the  equatorial  constriction  of  the  parent  nucleus 
and  their  sudden  roxmding  up  and  separation.    This  latter  process  is  probably  aided 


PX7BU0  HBALTH  AND  MKDiOUNIt  650 

by  the  motor  activities  of  the  reattached  blepharoplast  with  its  flagella  which  again 
fusee  with  the  polar  centrosome.  The  connection  of  the  nuclei  and  blepharoplaste 
with  the  axostyle  is  apparently  lost  during  this  process  and  it  is  only  in  the  latest 
stages  of  mitosis  that  this  oigan  divides  lengthwise,  splitting  from  the  anterior  end  pos- 
teriorly. We  have  not  found  that  it  disappears  and  is  reformed  from  the  paradesmoee 
as  Dobell  (1909)  and  others  have  stated.  The  daughter  nuclei  become  attached  to  the 
heads  of  the  daughter  axostyles  and  in  this  condition  the  oiganism  remains  for  some 
time  while  imdergoing  protean  changes  in  form  as  the  two  daughters  struggle  persis- 
tently and  incessantly  to  sever  the  band  which  unites  them.  With  the  accomplish- 
ment of  plasmotomy  the  process  is  completed. 

(c)  Binary  fission  in  Giardia  murts  (Grass!):  The  process  of  binary  fission  in  this 
oiganism  is  complicated  by  the  fact  that  it  is  diplozoic  and  possesses  an  integrated 
neuromotor  apparatus.  We  have  elsewhere  described  this  process  in  detail  (see  Eofoid 
and  Christiansen,  1915  b)  and  will  review  it  briefly  here.  The  normal  trophozoite 
contains  but  a  single  axostyle.  Previous  accounts  of  its  structure  showing  two  axo- 
styles may  rest  on  early  stages  of  mitosis. 

Mitosis  is  initiated  in  Oitardia  by  the  division  of  the  blepharoplasts  and  is  followed 
at  once  by  that  of  the  axostyle  which  splits  longitudinally  from  the  anterior  end  pos- 
teriorly. The  centrosome  on  the  anterior  end  of  the  nucleus  divides  and  one  daughter 
moves  to  the  opposite  pole,  spinning  out  an  extranuclear  chromatic  paradesmose. 
Division  of  the  anterolateral  flagellum  progresses  distally  from  the  blepharoplast  to 
the  anterior  chiasma. 

In  the  meantime  an  intranuclear  chromidial  cloud  has  been  replaced  by  a  split 
•kein  and  this  in  turn  by  an  equatorial  plate  with  four  chromosomes  in  two  groups 
which  constrict  at  their  middle  and  the  daughters  migrate  to  the  poles.  Nuclear 
constriction  parts  the  daughter  nuclei.  During  mitosiB  the  parabasals  disappear  and 
reappear  later  in  the  daughter  oiganisms. 

Plasmotomy  is  a  slow  process  during  which  the  daughter  zooids  assume  many  dif- 
ferent positions  with  respect  to  one  another.  Before  they  finally  part  each  is  fully 
equipped  with  a  complete  set  of  organelles  and  phases  of  an  ensuing  mitosLs  may  even 
appear,  though  these  may  be  indications  of  an  impending  multiple  mitosis. 

in  closing  this  brief  discussion  of  binary  fission  and  mitosiB  attention  is  called  to  two 
main  points;  (1)  the  elaborate  system  of  extranuclear  neuromotor  organelles  inti- 
mately connected  with  karyosome  and  centrosome,  and  with  a  more  or  less  evanescent 
and  variable  parabasal  or  kinetic  reservoir,  and  (2)  that  there  is  no  second  nucleus  or 
other  structure  to  which  the  term  kinetonucleus  can  be  applied  by  reason  of  origin, 
structure,  or  function.  Th^re  is  no  mitotic  continuity  of  origin,  no  content  of  chromo- 
somes, no  mitotic  behavior  on  the  part  of  any  extranuclear  structure  in  either  the 
protomonadina  (Trypanosoma) ,  or  in  the  polymastigina  (Trichanunuu)  of  sufiSdent 
validity,  backed  by  indisputable  evidence,  to  justify  the  further  continuance  of  the 
term  kinetonucleus  in  protosoan  terminology.  There  is  now  in  hand  a  sufilcient  body 
ef  criticism  on  the  one  hand,  and  of  constructive  evidence  on  the  other,  to  seriously 
raise  the  question  if  it  is  not  in  the  interests  of  sound  protozoological  progress  to  rid 
ourselves  of  the  conception  of  nuclear  dualism  as  applied  to  the  flagellata  with  its 
resultant  consequences  in  our  ideas,  terminology,  and  classification. 

2.  MULTIPLB  FISSION  IN  INTESTINAL  FLAOBLLATE8. 

There  has  been  heretofore  much  doubt  (see  Jollos,  1913,  Alexeieff,  1914,  Prowazek 
and  Werner,  1914)  as  to  the  occturence  of  this  phenomenan  among  intestinal  flagel- 
lates. We  have,  however,  demonstrated  its  prevalence  fsee  Kofoid  and  Swezy,  1915 
b  and  Kofoid  and  Chrietiansen,  1915  b)  among  a  number  of  genera  and  species.  Its 
importance  as  a  feature  of  the  life  cycle  is  thus  established  but  its  significance  with 
respect  to  sexual  reproduction,  if  it  has  any,  is  as  yet  problematical.  It  is  not  accom- 
panied by  any  reduction  in  the  number  of  chromosomes  as  will  appear  on  an  inspec- 


660       PROOEEOIKQS  BBCOHD  PAN  AMERICAN  8CIEKTIFIC  C0N6BES8. 

tion  of  our  figures  (Keloid  and  Swezy,  1915  b)  of  the  process  in  EutndiomasHx  $erperUu 
in  which  there  are  four  chromoscHnee  throughout  both  binary  and  multiple  fission 
in  all  of  its  stages  through  the  8-nucleate  Plasmodium.  Possible  importance  of  the 
occurrence  of  this  phase  in  intestinal  flagellates  in  their  relations  to  their  hosts  is 
suggested  by  the  parallel  with  the  malarial  parasite,  but  there  is  here  no  cytoplasmic 
residuum  after  multiple  fission  to  release  endotoxins  as  in  Platmodiwm.  We  wil 
now  briefly  describe  this  process  in  intestinal  flagellates. 

(a)  Multiple  fission  in  protomonadlna:  It  has  been  definitely  established  that  it 
occuis  in  the  crithidial  phase  of  Trypano$oma  Uwisi  within  the  cells  of  the  stomach 
wall  of  the  flea  (Minchin  and  Thompson,  1915).  There  is  a  probability  that  it  alae 
occurs  in  the  cells  of  the  wall  of  the  midgut  of  Leptocorii  triviUatus  in  the  caee  eC 
the  minute  phases  of  Critkidia  UptocoridU  (see  McCulloch,  1915)  and  in  the  intestinal 
cells  of  Euryophthalmus  convivtis  in  the  life  history  of  Critkidia  euryophthalmi  (McCvU 
loch  manuscript,  1916),  but  the  details  of  the  process  are  inadequately  known.  There 
are,  however,  sufficient  Indications  to  justify  the  expectation  that  further  search  fer 
this  phase  among  the  ]HX>tomonadina  will  be  rewarded. 

(6)  Multiple  fission  in  the  polymastigina:  (1)  Trichomona$  augusta  Alexeieff.  Ws 
has  been  described  by  us  elsewhere  (Kofoid  and  Swezy,  1915  b)  in  full,  so  that  only 
a  brief  review  of  its  essential  features  will  be  given  here.  It  consists  of  three  rapidly 
succeeding  mitoses,  with  the  accompanying  formation  of  a  complete  set  of  new  extra- 
nuclear  neuromotor  organelles  accompanying  each  nucleus  as  in  mitosis  in  binary 
fission,  but  without  accompanying  plasmotomy.  This  results  in  the  successive  forma- 
tion of  a  2,  4,  and  8  nucleate  Plasmodium  or  somatella  of  amoeboid  form  and  activity, 
provided,  respectively,  with  6, 12,  and  24  flagella,  and  2, 4,  and  8  axostyles  and  undm- 
fating  membranes,  all  capable  of  motor  activity  and  vigorously  lashing  about. 

This  Plasmodium  or  somatella  then  proceeds  to  disintegrate  piecemeal  by  dropping 
a  single  zooid  at  a  time,  or  at  least  not  by  the  coincident  separation  of  all  the  zooidi. 
As  will  be  seen  in  the  figures  the  struggles  of  the  individual  zooid  ev«itually  free 
its  sister  and  cousin  zooids,  but  this  process  of  disintegrative  plasmotomy  is  a  prolonged 
one. 

(2)  Qiardia  mtarii  (Grassi).  The  process  of  multiple  fission  in  this  diplozoic  otgtm- 
ism,  is  not  the  formation  of  two  groups  of  eight  nuclei  descended  respectively  from 
the  right  and  left  nucleus  of  the  somatella.  but  the  establishment  of  bifurcating  t,  4, 
and  8  zooid  Plasmodia  by  three  succeeding  pervading  mitoses.  In  other  words  it 
is  a  Plasmodium  of  zooids  and  not  merely  of  cells.  At  each  step  of  its  fcnmation  the 
zooids  appear  to  be  quite  fully  equipped  with  the  extranuclear  neuromotor  oiganelles^ 
except  the  parabasals  which  disappear  early  in  the  i>rocess,  and  the  chromatic  border 
of  the  cytostome  which  is  but  partly  developed  in  its  anterior  r^on  only. 

Multiple  fission  in  the  free  stage  in  Oiardia  is  followed  by  dimntegrative  plasmotomir 
apparently  by  the  successive  detachment  of  individual  zooids.  Multiple  fissioA 
occurs  not  only  in  the  free  stage  but  also  in  cysts,  in  which  case  nuclear  multirlica- 
tion  proceeds  with  no  corresponding  divisions  of  the  extranuclear  structures  which 
more  or  less  disappear.  The  fate  of  such  cysts  with  16  nuclei  is  as  yet  wholly  un- 
known.   Thore  is  no  evidence  of  reduction  of  chromosomes  in  them. 

G.  Thb  Biological  Siqnificanob  of  ths  Lifb  Gtclb  of  Intbstinal  Flagellates. 

The  formation  among  flagellates  of  a  definite  Plasmodium  or  somatella,  as  a  regular, 
though  somewhat  brief  phase  of  the  life  cycle,  is  prophetic  of  the  organization  of 
the  more  permanent  multinucleate,  also  multicellular  body  of  the  metazoa.  In  al 
of  these  flagellates  mitosis  and  plaonotomy  are  two  distinct  processes  and  the  latter 
results  from  the  ceaseless  struggles  of  the  component  zooids  of  the  common  plasma- 
dium  which  finally  rend  asunder  the  viscous  plasma  and  thus  complete  the  estab- 
lishment of  their  separate  individualities.  The  component  zooids  of  Uiis  Plasmodium 
have  little  or  no  structural  or  functional  integration  to  bind  them  together  and  the 
disintegration  of  the  somatella  into  its  component  units  is  only  a  question  of  time. 


PUBUO  HBALTH  AND  MBDIOINB.  561 

It  is  a  matter  of  no  small  biological  significance  that  the  binucleate  genera  HtxamiivM 
(Octamiltu)  and  Gtardia  {^Lamhlia)  represent  structurally  an  integrated  pair  of 
flagellates  with  the  following  structural  evidence  of  such  integration,  bilateral  sym- 
metry, single  ventral  cytostome,  single  (not  double,  as  heretofore  described)  axial 
axostyle,  commissure  joining  the  two  blepharoplaets  across  the  head  of  the  axoetyle, 
and  a  union  in  the  median  plane  of  the  two  antero-lateral  fiagella  in  the  anterior 
chiasma,  thus  linking  together  the  neuromotor  apparatuses  of  the  two  component 
cells.  Functional  integration  is  seen  in  the  locomotor  behavior,  in  the  parallel  posi- 
tion and  common  stroke  of  the  free  ventral  fiagella  of  the  two  component  cells,  in  the 
fimrtioning  of  the  ventral  cytoetome  as  a  single  sucker  or  oigan  of  attachment,  and  in 
the  motor  activities  of  the  single  axostyle  or  of  the  paired  daughter  axostylee  during 
mitocis. 

From  the  evidence  in  hand  it  appears  that  in  the  hexamitidae  we  have  a  clear 
instance  in  which  a  multinucleate  body  in  its  lowest  possible  terms,  to  wit,  a  binu- 
cleate sonuitella,  has  been  evolved  from  an  already  highly  specialized  ancestral 
fiagellate  by  the  structural  and  functional  integration  of  its  already  complex  struc- 
tural features.  The  temporary  binucleate  somatella  occurring  in  the  interval  between 
mito  is  and  plasmotomy  in  other  fiagellates  has  in  Eexamtius  and  Gvirdia  become  the 
permanent  condition  of  the  organism.  This  union  fails  to  become  permanent  in  other 
fiagellates,  as  does  that  of  the  eight  zooids  in  the  somatellas  of  all  fiagellates,  becauee 
of  the  absence  in  them  all  of  the  essential  integrating  structural  bads,  and  the  absence 
in  these  stages  of  the  unified  behavior  of  its  component  parts. 

H.  The  Medical  Significance  of  the  Life  Cycle  of  Intestinal  Flagellates. 

The  relationships  of  these  parasites  to  an  absorbing  surface,  their  intense  locomotor 
acti\dty  on  the  mucus  substrate  of  the  intestinal  epithelium,  their  tendency  to  creep 
into  the  cryptB  and  their  ability  (Cfiardia)  to  traverse  the  intestinal  palisade  and  enter 
the  blood  stream  in  the  central  lacima  of  the  villi,  all  mark  them  as  probably  more 
than  mere  harmless  commensals.  In  cases  of  light  infection  and  in  perhaps  50  per 
cent  of  the  ho^ts  we  have  examined,  our  casual  inspection  has  detected  no  evidence 
of  lesions,  or  of  intestinal  modification  by  the  paraeite.  In  cafes  of  heavy  infection, 
however,  there  is  indisputable  evidence  that  they  are  associated  with  more  or  less 
breaking  down  or  thinning  out  of  the  intestinal  epithelium,  even  dropping  off  of  the 
villi,  and  considerable  local  dlBintegration  of  the  cells  of  the  inteetinal  epithelii  m. 
Bacterial  infection  is  heavy  in  such  localities.  Externally  the  region  of  infection 
can  usually  be  detected,  especially  in  the  lower  vertebrates,  by  the  flacddity  of  the 
wall,  often  accompanied  by  swelling  of  the  intestine  by  the  gelatinous  material 
which  is  there  localized  in  the  lumen. 

in  mice  an  infection  by  Giardia  mwris  is  accompanied  by  a  characteriFtic  yellowish 
translucent  color  of  the  intestine  which  is  brighter  in  tone  than  in  cases  of  infection 
by  Trich(ymx>na3i  ynturia,  and  the  contents  are  more  gelatinous  and  more  viscid.  These 
conditions  are  readily  detected  in  heavy  infections  upon  opening  the  abdominal 
cavity.  There  is  considerable  evidence  that  Giardia  is  far  more  pathogenic  in  its 
tendencies  than  are  the  other  genera.  It  occr^rs  as  G.  agilis  in  tadpoles,  bi.t  not  in 
frogs.  G.  muris  is  more  abundant  in  young  than  in  old  mice.  G.  lamblia  of  man 
{^LawhUa  intestinalis)  is  often  reported  from  children.  These  facts  suggest  that 
juvenile  infection  imparts  a  degree  of  immunity  to  the  adult. 

Certain  facts  derived  from  wild  mice  in  culture  suggcjtt,  but  as  yet  do  not  prove, 
that  infection  which  is  higher  among  culture  mice  may  be  a  cause  of  a  dwarfing 
of  wild  mice  imder  culti.ral  conditions.  Other  causes  are  operative  here  and  their 
relative  potency  has  not  as  yet  been  analyzed. 

Two  phases  of  the  life  cycle  brought  to  light  by  our  investigations  have  a  possible 
bearing  on  the  interrelations  of  host  and  intestinal  flagellate  parasites  and  sources  of 


562       PBOGEEDINOS  BEOOND  PAK  AMBBIGAK  8CIEKTIFI0  C0K0BE8S. 

pathogenicity  of  the  latter.  It  is  well  known  that  the  period  of  schizogony  in  the 
malarial  parasite  marks  the  climax  of  its  biochemical  assault  upon  its  host.  There 
is  some  very  incomplete  evidence  that  both  binary  and  multiple  fission  in  these 
intestinal  flagellates  is  periodic,  and  pervading,  though  none  that  this  periodicity  is 
regular.  Hosts  in  which  either  process  occurs  are  relatively  rare,  and  thoiigh  mitosis 
may  be  found  sparingly  in  many  host?  there  are  some  instances  in  our  records  in  whidi 
it  was  exceedingly  abundant  in  a  given  host. 

Multiple  fission  in  like  manner  is  restricted  to  a  few  host  individuals  among  the 
numerous  ones  examined  by  us.  In  the  case  of  Trickonuytias  augtuta  these  were  found 
mainly  in  the  months  of  July  and  August.  These  facta  point  toward  the  cyclic  occur- 
rence of  these  phenomena  of  reproduction  among  these  parasites.  A  second  phenom- 
enon of  interest  in  this  connection  is  the  occurrence  at  mitosis  among  these  parasitic 
forms  generally,  of  the  intranuclear  chromidial  cloud  followed,  in  some  cases  at  least, 
as  in  Trkhomonas  attgutta,  by  the  increase  in  the  number  of  extranuclear  chromidia, 
and  in  the  amount  of  extranuclear  chromatin  or  deeply  staining  substance  in  the 
cytoplasm.  Similar  conditions  attend  the  mitotic  phases  of  multiple  fission  in  this 
form.  In  some  other  flagellates,  as  in  Giardia  at  the  time  of  mitosis,  the  parabasal 
body  fades  away.  There  are  thus  indications  that  at  the  time  of  mitosis  the  metabolic 
processes  of  the  organism  involve  an  unusual  activity  on  the  part  of  the  chromidial 
and  extranuclear  stainable  substances  of  the  cytoplasm.  Moribund  individuals  with 
an  unusual  amount  of  such  cytoplasmic  inclusions  occur  in  hosts  in  ^diich  binary  or 
multiple  fission  is  in  progress.  There  is  a  possible  basis  here  for  a  climax  in  the  toxic 
effect  of  the  parasite  on  its  host  at  these  periods  of  reproduction. 

Still  another  feature  of  the  action  of  the  parasite  upon  its  host  is  to  be  recognized  in 
its  ceaseless  motor  activities  and  in  the  tendencies  for  the  fission  stages,  both  binary 
and  multiple,  to  creep  about  upon  or  into  the  intestinal  epithelium.  They  become 
at  these  periods  sources  of  stimulus  or  irritation  to  the  epithelial  cells  and  may  pos- 
sibly open  lesions  for  the  entrance  of  bacteria  into  the  blood  stream  of  their  host.  The 
enormous  numbers  of  Oiardia  in  the  mammal  and  of  Crithidia  in  h^niptera  are  sudi 
that  with  their  habit  of  attachment  to  the  intestinal  cells  they  form  a  veritable  living 
carpet  on  the  walls  of  the  infected  region  of  the  intestine. 

The  biological  data  regarding  intestinal  flagellates  thus  suggest  that  they  are  asso- 
ciated with  conditions  simulating  chronic  entoitis  and  that  they  may  be  sources, 
especially  at  reproductive  phases,  of  ectotoxins,  and  on  thdr  death  of  endotoxins, 
and  that  they  may  be  a  source  of  irritation  or  of  lesions  by  virtue  of  their  motor  activi- 
ties.   They  can  not  all  be  regarded  as  merely  harmless  coomiensals. 

I.  Summary. 

1.  Parasitic  flagellates  have  a  wide  distribution  in  the  digestive  tract  of  both  w- 
tebrate  and  invertebrate  hosts.  Many  different  species  (14  in  Diemyctyhu  toronts) 
may  occur  in  a  single  host  species,  sometimes  coincidently . 

2.  Most  subdivisions  of  the  flagellata  have  contributed  to  the  parasitic  faunas  of 
animals,  especially  the  protomonadina  and  polymastigina. 

3.  The  conditions  of  parasitic  life  in  a  denser,  more  viscous  medium  increase  the 
diflSculties  of  locomotion,  and  have  resulted  in  the  evolution  of  additional  motor 
organelles  and  the  establishment  of  a  highly  differentiated,  coordinated,  neuromotor 
apparatus.  They  also  cause  a  greater  expenditiu'e  of  eneigy,  with  accompanying 
increase  in  metabolism  and  development  of  extranuclear  chromatic  substances, 
especially  the  parabasal  body,  which  is  a  reservoir  of  such  substances  closely  related 
to  the  blepharoplast  at  the  base  of  the  flagella. 

4.  The  doctrine  of  nuclear  dualism  in  the  protozoa  advanced  by  Sdiaudinn,  Wood- 
cock, and  Hartmann,  which  recognizes  a  trophonucleus  and  a  kinetonucleus  rests  on 
an  erroneous  interpretation  of  this  parabasal  body  in  the  trypanoeomee  and  other 


PUBLIO  HSALTH  AND  MEDICINE.  568 

parasitic  flagellates.  The  so-called  kinetonucleus  does  not  arise  by  heteropole  mitotic 
division  of  a  parent  nucleus,  does  not  contain  chromosomes,  does  not  divide  by  mitosia, 
but  by  simple  splitting,  constriction,  or  outgrowth,  and  in  general  has  none  of  the 
attributes  of  a  true  nucleus  except  similar  stainability  with  certain  stains.  It  is  in 
reality  laterally  attached  to  the  blepharoplast  at  the  base  of  the  flagella  and  is  mor- 
phologically and  functionally  the  parabasal  body  or  kinetic  reservoir. 

5.  The  binuclearity  hjrpotiiesis  is  untenable  as  applied  to  the  flagellates,  the  binu- 
cleata  as  a  systematic  concept  should  be  abandoned,  and  the  doctrine  of  nuclear 
dualism  in  the  protozoa  should  be  restricted  to  the  dliata. 

6.  The  neuromotor  apparatus  is  derived  (in  Naegleria  gruhm)  from  the  karyoiome 
of  the  nucleuSi  centers  in  the  blepharoplast,  which  usually,  but  not  always,  ccmtains 
the  cytoplasmic  division  center,  and  includes  structures  attached  to,  or  growing  out 
from  the  blepharoplast,  such  as  flageUa,  axostyle,  maiginal  filament  of  the  undulating 
membrane,  parabasal  body,  and  rhizoplast.    It  is  mainly  baaophile  and  chromatic. 

7.  The  neuromotor  apparatus  is  an  integrated  structure  which  in  the  di|dosQic 
flagellates  (Qiardia,  Hexamiius)  forms  a  single  structural  and  functional  Bystem 
uniting  the  motor  oiganellee  of  the  two  cells  in  one  structural  unit. 

8.  Sexual  reproduction  among  intestinal  flagellatee,  and  flagellatee  genaraUy, 
except  the  volvoddse  (dose  to  the  metaphyta)  and  riiizomantigina  (dose  to  rhizopodi) 
is,  as  yet,  of  doubtful  occurrence.  "Autogamous  cysts"  belong  probably  to  a  yeait 
(Blattoeystis).  "Copulation  cysts"  have  not  been  proved  to  contain  gainetet.  Moie 
critical  investigation  is  needed  here. 

9.  Asexual  reproduction  is  of  two  types,  (1)  binary,  and  (2)  multiple  fission,  both 
of  wide  occurrence  among  intestinal  fiagellates. 

10.  Binary  fission  involves  mitosis  and  subsequent  plasmotomy.  Mitosis  is  of  the 
premitotic  type  with  nuclear  membrane  intact  throughout  the  process.  The  blepha- 
roplast may  or  may  not  contain  the  centroeomes  pennanently  or  tempocazily. 
Definite  chromosomes  of  constant  number  and  differentiated  form  and  behavior 
appear  in  the  equatorial  plate.  Precocious  splitting  or  doubling  occurs  after  the 
nuclear  skein,  but  the  chromosomes  reunite  in  the  equatorial  plate  and  pinch  apart 
without  evidence  of  any  relation  to  the  earlier  plane  of  fusion. 

11.  The  blepharopiasts  form  an  extranudear  paradesmoee  between  them.  This 
does  not  form  the  new  axoetyles  which  do  arise,  however,  by  longitudinal  splitting 
of  the  parent  axostyle.    The  axostyle  is  a  locomotor  not  a  dcdetal  organ. 

12.  PlasmotOTiy  is  a  slow  process  and  results  from  the  motor  activity  of  the 
daughter  zooids. 

13.  Multiple  fission  in  intestinal  flagellates  (polymastigina)  results  &om  three 
pervading  successive  mitoses  with  the  accompanying  formation  of  the  extranudear 
neuromotor  apparatus  for  each  nudeus.  It  results  in  the  successive  formation  of  a 
2,  4,  and  8  nudeate  Plasmodium  or  somatella.  In  the  diplozdc  fiagellates  it  forms 
a  4,  8,  and  16  nudeate  somatella,  but  these  are  primarily  2,  4,  and  8  zodd  somatellaa, 
since  each  zodd  is  fully  equipped  at  each  stage  (except  in  multiple  fission  in  cysti) 
with  the  normal  extranudear  organelles. 

14.  Plasmotomy  is  a  slow  process  of  progressive  detachment  of  individual  zodda 
from  the  common  somatella  which  lacks  integrating  structures  or  coordinated  bdiavior 
of  its  parts. 

15.  The  formation  and  prolonged  existence  of  the  Plasmodium  or  somateUa  anumg 
flagdlates  is  significant  as  indicating  a  tendency  to  form  a  multinudeate  body  as  in 
the  metazoa.  Such  a  body  in  its  lowest  possible  terms,  from  the  standpoint  d  cellu- 
lar components,  is  seen  in  the  two-celled  diplozoic  flagellates  such  as  Oiardia.  Theee 
are  evolved  by  the  persistent  union  of  the  component  cells  of  a  2-nudeate  Plasmodium 
and  the  development  of  an  integrated  neuromotor  apparatus,  and  accompanying 
integrated  behavior.  It  seems  probable  that  the  diplozdc  organism  is  derived  from 
the  highly  differentiated  uninudeate  type  resembling  Triehomonas. 

68486— 17— VOL  x 87 


564       PBOOEEDINGS  SECOND  PAN  AMBBICAK  80IEKTIFI0  OONGBESS. 

16.  The  intestinal  flagellates  are  not  all  harmless  commensalB.  Some  of  them 
accompany  inflation  of  the  intestine  locally,  the  acciimulation  of  a  viscid  yellowish 
gelatinous  mass  in  the  lumen,  the  thinning  out  and  breaking  down  of  the  intestinal 
epithelium,  and  they  may  even  create  lesions  and  enter  the  blood  stream. 

17.  Their  mobility  on  the  sur&M^e  of  the  intestinal  cells,  their  tendency  to  creep 
into  the  crypts  and  even  into  the  wall  itself  creates  a  source  of  local  stimulus  or  even 
of  irritation. 

18.  Their  cyclic  reproductive  processes  with  accompanying  fluctuations  in  meta- 
bolic activity  is  indicated  by  varying  amounts  of  chromatic  materials  in  the  cyto- 
plasm and  creates  a  basis  for  a  climax  in  their  biochemical  relations  to  their  hosts. 

J.  LrrBRATUBB  CrrBD. 
Alexeieff,  A. : 

1911.  Sur  les  ^'Eystes  de  Trichomonas  intestinal'U"  dans  intestine  des  batradens. 

Bull.  Sd.  France  et  Belgique,  44,  334-355,  pi.  3,  2  figs,  in  text. 

1914.  Notes  protistologiques.    Zool.  Anz.,  44, 193-213,  5  figs,  in  text. 
B^fir,  E.: 

1915.  Protistenstudien  I.  Arch.  Prot.,  36, 13-^1,  pis.  2-4,  3  figs,  in  text. 
Ghagas,  C: 

1909.  Eine  neue  TrypanosomaisiB  dee  Menschen.    Mem.  Inst.  Oswaldo  Cruz., 
1, 159-218,  pis.  9-13, 10  figs,  in  text. 
Cbatton,  E.: 

1911.  Pleodorina  calif omica  &  Banyuls-sur-Mer.    Bull.  Sd.  France  et  Belgique, 
44,  309-329,  pi.  7. 
Dobell,  C.  C. : 

1908.  The  autogamy  of  Bodo  laoertae.    Biol.  Gent.,  28,  548-555. 
Goldschmidt,  B.: 

1907.  Lebenogeschichte  der  Mastigamoeben.    Arch.  Prot.   Suppl.   1,  83-165, 
pis.  5-9,  20  figs,  in  text. 
Hartmann,  M.: 

1907.  Das  System  der  Protosoen.    Ibid.,  10, 139-157,  3  figs,  in  text. 
JoUofl,V.: 

1913.  **Darmflage11aten  des  Menschen"  in  Eolle  und  Waasermaim  ''Handbuch 
der  pathogenen  Mikrooiganismen,"  7,  687--702, 15  figs,  in  text. 
Kofoid,  C.  A.,  and  Christianwen,  E.  B.: 

1915a.  On  Qiardia  microti  sp.  nov.,  from  the  meadow  mouse.    Univ.  CSalif.  Pabl 

Zool.,  16,  23-29, 1  ^,  in  text. 
1915b.  On  binary  and  multiple  fission  in  Oiardia  mwrit  (Grassi).    Ibid.,  16, 
30-54,  pis.  5-8,  1  fig.  in  text. 
Kofoid,  0.  A.,  and  McCuUoch,  I.: 

1916.  On  Trypanosoma  triatomaet  a  new  flagellate  from  an  hemipteran  bug  from 

the  nests  of  the  wood  rat  Neotomafiudpes.    Ibid.,  16, 113-126,  pis.  14-15. 
Kofdd,  G.  A.,  and  Swezy,  O.: 

1915a.  Mitosis  in  Tridumumas.    Proc.  Nation.  Acad.  Sd.,  Washington,  1,  815- 

321,  9  figs,  in  text. 
1915b.  Mitosis  and  multiple  fission  in  tiichomonad  fiagellates.    Ptoc.  Amer. 
Acad.  Arts  &  Sd.,  Boston,  51,  289-378,  pis.  1-%,  7  figs,  in  text. 
Lewis,  M.  R.,  and  Lewis,  W.  H.: 

1915.  Mitochondria  (and  other  cytoplasmic  structures)  in  tissue  cultures.    Amer. 
Joum.  Anat.,  17,  339-401,  26  figs,  in  text. 
McGuUoch,  I.: 

1915.  Structure  and  life-hist(»y  of  Critkidia  leptoooridU  sp.  nov.    Univ.  Oallf. 
Publ.  Zool.,  16, 1-22,  pis.  1-4, 1  fig.  in  text. 
Minchin,  E.  A.,  and  Thomson,  J.  D.: 

1915.  The  rat-trypanosome,  T,  lewiti^  in  its  relations  to  the  rat-flea,  CeraiophifUm 
fasdatus.    Quart.  Joum.  Micr.  Sd.,  60, 464-^1,  pis.  36-45, 24  figp.  in  text. 


PUBUO  HEALTH  AND  MBIHOINB.  665 

Prowazek,  S.  von: 

1904.  Die  Entwickluiig  von  HetpeUmowu,    Aib.  Kais.  G«8nnd.,  20,  440-452,  7 

figs,  in  text. 

1905.  Studien  Qber  Saugertiertrypanoeomen.    Ibid.,  22,  351-394,  pis.  1-6,  4  figs. 

in  text. 
Prowazek,  S.  von,  and  Werner,  H. : 

1914.  Zur  EentniflB  der  SQg.    Flagellaten.    Arch.  Scbifis-u.  Tropenhyg.,  18, 
155-167,  pi.  10, 1  fig.  in  text. 
Schaudinn,  F.: 

1904.  Generation0-und  WirtBwechsel  bei   Trypano$oma  und  Spirochxta,    Arb. 
Kai0.  Gesund.,  20,  387-439,  20  figs,  in  text. 
Swesy,  O.: 

1915a.  Binary  and  multiple  fiaflion  in  HexamUui.    Univ.  Calif.  Publ.  Zool.,  16, 

71-68,  pie.  5-11. 
1915b.  On  a  new  trichomonad  flagellate  Trithomxtui  parvtu  sp.  nov.,  from  amphib- 
ians.   Ibid.,  16,  88-94,  pi.  12. 
1915c.  On  the  genera   Monocercomonas  and  Polymastix,    Ibid.,   16,   127-138, 
plfl.  16-17. 
Wilson,  0.  W.: 

1916.  On  the  life-history  of  a  soil  amoeba.    Univ.  Calif.  Publ.  Zool.,  16,  241-292, 
pis.  18-23. 
Woodcock,  H.  M.: 

1906.  The  HsemoflagellateB.    Quart.  Joum.  Micr.  Scl.,  50, 151-331, 65  figs,  in  text. 

The  Chairman.  Dr.  Kofoid^s  paper  furnishes  a  stimulating  record 
of  the  life  history  of  these  parasites.  Tlie  next  paper  on  the  pro- 
gram is  that  of  Dr.  C.  H.  T.  Townsend. 


DISCOVERY  AND  mENTIFICATION  OP  THE  STAGES  IN  THE  ASEXUAL 
CYCLE  OF  THE  CAUSATIVE  ORGANISM  OP  PERUVIAN  VERRUGA. 

By  CHARLES  H.  T.  TOWNSEND, 
Btareau  of  Entomology. 

For  the  benefit  of  those  who  may  not  be  acquainted  with  the  nature  of  the  disease 
known  as  verruga,  and  in  order  that  all  present  may  properly  understand  the  subject- 
matter  of  this  communication,  I  will  say  that  this  disease,  which  is  confined  to  certain 
deep  and  narrow  valleys  or  canyons  in  the  western  face  of  the  Andes  in  Peru,  is  believed 
by  practically  the  entire  Peruvian  medical  fraternity,  who  have  made  a  very  extensive 
study  of  the  subject,  to  consist  of  four  stages,  in  which  belief  I  concur. 

I.  An  incubative  stage,  without  visible  external  symptoms. 

II.  A  fever  stage,  with  slight  to  marked  rises  of  temperature,  type  intermittent  or 
remittent,  accompanied  by  more  or  less  marked  anemia,  with  more  or  lees  pronounced 
articulation,  bone  and  rheumatoid  pains,  and  more  or  less  marked  blood  changes, 
during  which  certain  bacilliform  bodies  occur  in  the  red  blood  corpuscles  and  other 
stages  of  these  bodies  occur  as  vascular  cell  inclusions  in  the  lymphatic  nodes,  spleen, 
and  other  organs. 

III.  A  quiescent  stage,  without  apparent  external  symptoms  other  than  general 
bodily  weakness. 

ly.  An  eruptive  stage,  during  which  a  more  or  less  wartlike  eruption,  consisting 
very  largely  of  vascular-cell  proliferation,  with  more  or  less  mononuclear  infiltration, 
i^pears  in  the  subcutaneous  tissues  and  often  in  the  internal  organs,  certain  vascular 
cell  inclusions  occurring  in  the  eruption  tissues. 


666       PBOCEEDINGS  SECOND  PAN  AMEBIOAK  SCIENTIFIC  CONGBESGL 

I  should  add  that  Dr.  R.  P.  Strong,  of  Harvard  medical  school,  and  his  associates 
have  recently  announced  their  firm  conviction  that  the  fever  and  eruptive  stages  just 
described  are  two  distinct  pathologic  entities,  or  two  separate  and  independent  dis- 
eases; the  fever,  which  they  call  Oroya  fever,  being  specifically  caused  by  the  bodies 
found  in  the  erythrocytes,  lymphatic  nodes,  and  other  organs;  the  eruption,  which 
they  call  verruga  peruviana,  being  caused  by  a  specific  virus  which  they  consider 
resident  in  the  eruption  tissues,  presumably  comprising  ultramicroecopic  organisms. 
The  paper  which  I  am  about  to  present  will,  I  believe,  prove  conclusively  that  such 
is  not  the  case,  but  that  the  fever  and  eruption  are  phases  or  stages  of  one  and  the  same 
disease. 

I  should  also  state  that  during  1913  and  1914  I  carried  out  in  Peru  an  investigation 
of  the  insect  transmission  of  verruga.  Without  going  into  details,  it  is  sufficient  for 
our  present  purpose  to  say  that  I  believe  that  I  have  fully  demonstrated  PkUhoUnmv* 
verrucamm,  a  small  and  delicate  bloodsucking  gnat,  the  only  strictly  crepuscular  and 
nocturnal  bloodsucker  confined  to  the  infected  zones,  as  the  vector  of  verruga. 

It  is  the  purpose  of  the  present  communication  to  interpret  correctly  the  stages  in 
the  asexual  cycle  of  the  causative  organism  of  verruga  from  the  findings  already  pub- 
lished, which,  however,  have  been  supplemented  and  verified  by  similar  findings  in 
my  own  material.  The  significance  of  these  was  first  pointed  out  by  me  before  the 
Biological  Society  of  Washington  on  December  4,  1916.  The  published  findings  will 
be  taken  up  in  chronologic  order. 

In  1909  Dr.  Albert  L.  Barton,  of  Lima,  Peru,  described  as  ''x-bodies"  the  mature 
gamete  stage  of  this  organism,  discovered  by  him  in  1905  in  the  erythrocytes  of  the 
peripheral  blood  of  verruga  cases  in  the  fev^  phase.  Drs.  Strong  et  al.  have  rede- 
scribed  the  same  stage  under  the  name  Bartonella  baeilltformis. 

In  1911  Dr.  S.  T.  Darling,  then  at  Panama,  figured  gametes  found  by  him  in  verruga 
blood  smears  from  Peru,  among  which  he  gives  a  figure  of  an  erythrocyte  filled  with 
minute  rods  which  he  termed  "young  x-bodies,"  and  which  will  be  referred  to  as 
Darling's  x-bodies.  These  are  the  immature  gametes  of  Barton^la,  shortly  after 
penetration  of  the  erythrocyte. 

In  September,  1912,  Drs.  Gastiaburu  and  Rebagliati,  of  Lima,  discovered  certain 
"cuerpos"  or  bodies  in  verruga  eruption  tissue  and  in  liver  of  vetmga  cases  in  the 
eruptive  stage,  which  they  figured  and  described  as  Leishmania-like.  These  are 
respectively  early  and  maturing  schizonts  oi  Barton^la,  before  they  have  begun  to 
break  up  into  merozoites.  Their  figure  of  the  eruption  smear  shows  a  cell  containing 
many  of  the  very  early  schizonts,  while  their  figure  of  the  liver  smear  shows  maturing 
schizonts  which  are  largely  free. 

In  April,  1913,  Drs.  Mayer,  Rocha-Lima,  and  Werner,  of  Hamburg,  fiigured  and 
described  certain  "Zelleinschluesse"  or  cell  inclusions  which  they  found  in  vascular 
endothelial  cells  of  the  greater  part  of  the  verruga  nodules  examined  by  them  from  a 
case  of  the  disease  just  arrived  from  Peru.  Their  figures  1  to  4  show  the  cell  induaions 
entire,  while  5  and  6  show  them  ruptured.  These  are  evidently  to  be  interinreted  as 
respectively  maturing  Bartonella  schizonts  and  Bartonella  merozoites  which  have 
resulted  from  the  breaking  up  of  schizonts. 

In  1915  Drs.  Strong  et  al.  figured  and  described  certain  ''spheres"  found  by  them 
in  vascular  endothelial  cells  of  lymphatic  nodes  and  spleen  of  verruga  cases  in  that 
phase  of  the  disease  which  they  term  Oroya  fever.  They  state  that  these  spheres 
apparently  break  up  into  a  large  number  of  minute  elements  each  containing  a  chro- 
matin granule,  these  becoming  elongated  and  finally  appearing  as  distinct  rods  con- 
taining at  one  end  a  minute  particle  of  chromatin.  The  spheres  shown  in  Strong's 
figures  1  and  2,  plate  X,  are  obviously  an  earlier  stage  of  Mayer,  Rocha-Lima,  and 
Werner's  cell  inclusions,  being  early  sdiizonts  of  Bartonella  and  in  more  or  less  nearly 
the  same  stage  of  development  as  Gastaiburu  and  Rebagliati's  eruption  smear  bodies. 
Figure  3,  plate  X,  corresponds  to  Mayer,  Rocha-Lima,  and  Werner's  figures  1  to  4,  and 


PUBUO  HBALTH  AND  MBIHOIHB.  567 

to  Gasdaburu  and  Rebagliati's  liver  smear  bodies,  being  the  maturing  schisonts  of 
Bartonella.  Figure  6,  plate  X,  shows  the  merosoites  of  Barton^la  largely  in  their 
early  stage,  before  elongation.  Figures  4,  5,  and  7,  plate  X,  show  the  elongated  stage 
of  the  meroBoites.  Drs.  Strong  et  al.  state  that  the  minute  rodlike  elements,  cft  elon- 
gated merosoitee,  are  identical  in  character  with  the  gametes  in  the  erythrocytes. 
After  entering  erythrocytes,  and  before  completing  their  growth,  they  are  evidently 
to  be  considered  immature  gametes,  and  are  the  same  as  Darling's  x-bodies.  The 
W(vk  of  Drs.  Strong  et  al.  has  thus  resulted  in  establishing  a  definite  connection 
between  Barton's  x-bodiee.  Darling's  x-bodies,  Oastiaburu  and  Rebagliati's  cuopos, 
and  Mayer,  Rocha-Lima,  and  Werner's  ZeUeinschluesse,  which  was  hitherto  not 
i^parent.  Drs.  Strong  et  al.,  however,  appear  to  have  suspected  no  connection 
between  their  vascular  cell  bodies  from  the  fever  stage  and  those  previously  announced 
from  the  eruptive  stage.  I  may  add  that  I  am  able  to  identify  these  bodies  in  my  own 
sections  and  smears  of  verruga. 

The  relationship  existing  between  all  of  these  bodies,  and  the  correspondence  of 
those  of  Drs.  Strong  et  al.  with  the  previously  announced  bodies,  can  be  seen  in  the 
diagram .  The  conclusion  is  obvious  that  all  are  stages  of  the  same  organism,  Bartonella 
haeUltformis,  The  schizogonic  cycle  of  Bartonella  in  warm  blood  can  be  easily  fol- 
lowed in  these  stages.  We  have  only  to  assume  the  existence,  in  the  salivary  glands  of 
Phlebotomus  vermearum,  of  the  sporozoites,  a  stage  as  yet  undetected  by  us  but  cer- 
tainly existing  by  analogy  with  the  life  cycle  of  similar  pathogenic  organisms. 

All  of  these  findings  indicate  conclusively  that  Bartonella  is  a  protozoan.  Several 
^ts,  which  are  easily  explained,  have  proved  stumblingblocks,  however,  in  the 
inteq>retation  of  the  asexual  development  of  the  organism.  It  has  been  repeatedly 
demonstrated  that  blood  containing  mature  gametes  of  Bartonella  fails  to  originate 
any  ssrmptoms  upon  injection  into  healthy  animals;  that  the  gametes  disappear  from 
the  erythrocytes  upon  the  advent  of  the  eruption;  that  it  is  impossible  to  grow  these 
gametes  in  ordinary  culture  media;  that  eruption-tisBue  inoculations  produce  localized 
proliferation  lesions  in  new  tissues  without  gametes  of  Bartonella  i^pearing  in  the 
erjrthrocytes;  and  that  such  lesions  may  be  produced  successively  in  series  of  animals 
by  such  inoculations.  These  and  related  facts  are  what  induced  Drs.  Strong  et  al. 
to  announce  the  fever  and  eruptive  stages  of  verruga  as  two  distinct  pathologic  entities. 
But  their  finding  in  Oroya  fever  cases  of  the  schizonts  and  merozoites  of  Bartonella, 
already  shown  to  be  characteristic  of  the  eruption  tissues,  appears  to  bind  inseparably 
their  Oroya  fever  and  verruga  peruviana.  The  explanation  of  the  several  facts  above 
mentioned  will  appear  below. 

It  is  evident  that  the  greater  numbers  of  the  Bartonella  sporozoites  introduced  by 
the  Phlebotomus  within  the  skin  of  susceptible  subjects  immediately  embed  them- 
selves in  the  cytoplasm  of  the  vascular  endothelial  cells  at  points  of  inoculation. 
Once  embedded,  they  devdop  into  schizonts,  which  upon  maturing  break  up  into 
merozoites,  the  latter  elongating  within  the  unruptured  host-cell  walls  and  penetrating 
such  er3rthrocytes  as  come  into  direct  contact  with  the  infected  cell,  whereupon  they 
become  immature  gametes.  The  fully  formed  rods  and  ovals  in  the  erythrocytes  are 
respectively  the  mature  male  and  female  gametes,  which  can  conjugate  only  in  the 
Phlebotomus,  or  at  least  in  cold  blood.  Hence  their  injection  into  a  healthy  warm- 
blooded animal  fails  to  originate  any  ssrmptoms  of  the  disease.  There  appears  to  be 
no  duplication  or  repetition  of  any  of  the  stages,  so  far  as  the  forms  already  found 
afford  any  index,  except  that  the  mature  male  gametes  may  increase  by  binary  trans- 
verse division.  But  there  is  some  reason  to  believe  that  the  merozoites  before  elon- 
gation may  under  certain  conditions  devdop  into  schizonts. 

The  endothelial  cells  of  the  capillaries  of  the  subcutaneous  tissues  are  evidently 
the  chief  seat  of  the  above-described  schizogonic  or  asexual  cycle  of  Bartonella,  and 
here  is  where  the  erythrocytes  mostly  become  infected.  The  fever  stage  follows  the 
extensive  breaking  up  of  the  schizonts  in  the  endothelial  cells  of  the  capillaries,  and 


568       PBOOEEDIKOS  SECOND  PAN  AMEBICAK  SCIENTIFIO  C0NGBB8S. 

its  iQception  coincides  with  the  extensive  penetration  of  the  erythrocytes  by  the 
merozoites.  The  toxin  resulting  from  the  multiplication  of  Bartonella  has  been  lib- 
erated in  quantity  into  the  blood,  causing  the  rise  of  temperature,  the  anemia  follow- 
ing through  hemolysis. 

The  eruption,  which  is  particularly  characterized  by  a  great  proliferation  of  vascular 
endothelial  cells,  is  the  direct  result  of  the  extensive  asexual  multiplication  of  Bar- 
tonella in  the  subcutaneous  tissues.  The  prolif^ation  of  vascular  endothelial  cells, 
incited  by  the  toxin  resulting  from  the  metabolism  of  Bartonella,  not  oidy  imprisons 
this  toxin,  thus  arresting  the  hemolysis,  but  also  prevents  the  erythrocytes  from 
coming  into  direct  contact  with  cells  containing  merozoites,  thus  cutting  short  the 
infection  of  the  erythrocytes.  As  the  natiural  result  the  fever  and  anemia  both  sub- 
side, and  the  gametes  of  Bartonella  are  no  longer  to  be  found  in  the  blood. 

Erythrocytes  can  evidently  become  infected  only  during  their  slow  passage  through 
the  capillaries  and  while  in  actual  contact  through  positive  chemotzopism  with  a 
Irving  infected  endothelial  cell  in  situ  in  the  capillary  wall.  Evidently  the  infected 
cell  is  positively  chemotropic  for  normal  freshly-oxygenated  erjrthrocytes,  attracting 
and  holding  them  in  contact  with  itself  until  transfer  of  a  certain  number  of  merozoites 
has  been  e£fected,  which  decreases  the  oxygen  tension  in  their  substance,  thereby 
transforming  their  tropic  qualities,  the  sufficiently  infected  erythrocytes  being  set 
free  through  negative  chemotropism.  Hence  eruption-tissue  inoculations  produce 
no  gametes  in  the  erythrocytes  of  the  subject  inoculated,  for  the  merozoites  contained 
in  such  material,  enveloped  as  they  are  by  masses  of  proliferation,  are  obviously 
unable  to  come  in  contact,  under  proper  conditions,  with  the  erythrocytes  in  the  new 
tissues.  Eruption-tissue  inociilations  are,  in  a  sense,  mere  transplantations  or  grafts, 
as  proved  by  the  fact  that  the  resultant  proliferation  is  strictly  localized.  They  are 
comparable  not  only  in  behavior,  but  also  to  a  considerable  degree  in  character,  to 
the  grafts  of  carcinoma  and  other  tumors  which  have  been  effected  within  recent  years. 

The  cause  which  leads  to  localized  proliferation  in  new  tissues  following  eruption- 
tiame  inoculations  appears  to  be  purely  physical  in  character.  The  new  proliferation 
results  from  a  specific  ch^nophyslcal  irritation  of  the  endothelial  cells  in  the  capillaries 
of  the  new  tissues  by  the  proliferation  substance  introduced,  and  is  not  due  to  any  new 
activity  of  a  living  organism.  It  is  toxin-indted,  not  virus-incited.  The  original 
proliferation  possesses  a  specific  chemophysical  reaction,  inherited  from  the  inciting 
toxin  and  transmissible  within  certain  limits  to  the  new  proliferation  which  it  induces. 
Such  new  proliferation  may  be  successively  repeated  in  verruga,  within  limits,  by 
inoculation  of  old  proliferated  cells  into  new  tissues.  This  explains  the  proliferation 
lesions  obtained  by  Drs.  Strong  et  al.  in  12  successive  series  of  monkeys,  which  lesions 
they  consider  due  to  a  virus  resident  in  the  proliferated  tissues  used  for  inoculation. 
However,  they  were  imable  to  obtain  the  lesions  by  injection  of  a  filtrate  from  these 
tissues,  the  reason  being  that  the  proliferated  cells  can  not  pass  the  filter;  they  found 
that  inoculation  of  these  tissues  upon  the  rabbit's  cornea  produces  no  lesion,  the  reason 
being  that  the  cornea  possesses  no  vascular  cells;  and  their  attempts  to  cultivate  the 
supposed  virus  resulted  in  failure,  the  reason  evidently  being  that  no  living  virus  in 
the  common  acceptation  of  the  term  exists  in  the  proliferation  tissues.  They  did 
succeed  in  determining  the  presence  in  the  eruption  tissues  of  a  hemolysin  which  they 
state  is  active  in  relatively  high  dilutions.  This  is  very  much  to  the  point.  This 
hemolysin  is  quite  certainly  the  toxic  by-product  of  the  reproductive  activity  of 
Bartonella  in  the  subcutaneous  tissues;  is  the  specific  cause  of  the  anemia  of  the  fever 
stage;  and  is  the  agent  which  directly  incites  the  proliferation  of  the  vascular  cells, 
thus  causing  the  eruption  lesions.  In  other  words,  this  toxin  is  able  to  destroy  ery- 
throcytes, to  irritate  vascular  cells  sufficiently  to  cause  their  proliferation,  but  has  no 
effect  on  such  dense  connective-tissue  cells  as  compose  the  cornea. 

Some  of  the  sporozoites  introduced  by  the  Phlebotomus  within  the  skin  must  reach 
the  lymphatic  nodes,  spleen,  bone-marrow,  and  liver,  as  well  as  the  capillaries  of  the 


PUBUO  HBALTH  AJSH)  MEIHCIKS.  669 

Bubmucous  tiflBues,  earned  thence  by  the  lymphatic  syst^n  on  their  failure  to  embed 
in  the  subcutaneous  tissues,  these  unembedded  sporozoites  being  picked  up  in  the 
serous  canaliculi.  If  this  happens  extensively,  internal  eruption  results.  This  ex- 
plains the  infarction,  necrosb,  and  other  pathologic  changes  in  the  internal  organs,  as 
weil  as  the  articulation  and  bone  pains,  all  so  commonly  noted  in  the  disease,  especially 
in  the  fever  stage.  In  most  cases  the  fever  and  visible  eruption  in  verruga  correspond 
very  faithfully  in  intensity.  When  this  cinrespondence  is  not  so  marked  it  is  prac- 
tically certain  that  infection  of  the  internal  organs  has  become  proportionately  greater, 
resulting  in  an  increased  internal  eruption. 

In  conclusion,  I  would  say  that  we  are  now,  for  the  first  time,  getting  some  tangible 
evidence  as  to  the  etiology  of  verruga.  Those  familiar  with  the  facts  so  far  known 
relating  to  this  unique  disease  will  at  once  see  how  perfectly  they  all  fit  together,  now 
that  we  interpret  the  cell  indusions  of  the  eruption  tissues  as  a  part  of  the  schiEOgonic 
cycle  of  Bartonella.  Incidentally,  the  unity  of  verruga  appears  to  be  established  by 
the  known  stages  of  its  specific  causative  organism. 

The  CHAntiiAN.  The  discussion  of  these  papers  is  now  open. 

Dr.  Tyzzee.  There  are  certain  points  in  these  papers  which  I 
would  Uke  to  comment  upon.  In  the  first  place  the  inclusions  which 
were  described  by  Gastiaburti  and  RebagUatri  in  the  internal  organs 
were  described  as  leishmania.  There  was  nothing  in  conmion  be- 
tween those  and  the  inclusions  which  we  found  in  the  endothelial 
cells  in  Oroya  fever.  I  do  not  see  that  there  can  be  any  connection 
between  these  inclusions  as  we  are  familiar  with  them.  There  were 
other  inclusions  found  in  verruga,  which  Rebagliatri  demonstrated  to 
us  as  clematozoa.  Neither  of  those  could  be  associated  with  the 
inclusions  which  we  found  in  the  endotheUimi  in  Oroya  fever.  I 
regard  those  observations  of  the  organism  in  the  endothelium  as 
observations  of  a  new  body  or  stage.  Of  course,  the  organism  in  the 
corpuscle  was  observed  by  Barton  and  by  Gastiaburti  previously. 

With  regard  to  the  basis  for  our  differentiating  two  diseases,  we 
studied  the  lesions  of  verruga  Peruana  at  all  stages.  These  tissues 
were  taken  from  the  human  being  and  studied  fresh  by  the  dark  field, 
in  stained  smears  and  stained  sections.  We  have  never  found  any- 
thing in  the  endotheUum  of  a  verruga  nodule  which  can  be  inter- 
preted as  an  oi^anism  or  which  is  in  any  way  similar  to  the  findings 
in  Oroya  fever.  I  may  say  that  our  material  is  abundant  and  was 
collected  under  the  be^t  of  conditions,  and  I  think  I  have  apphed 
most  of  the  valuable  methods  of  technique.  We  inoculated  monkeys, 
dogs,  and  rabbits,  and  also  one  hunum  being.  The  inmate  of  an 
institution  was  inocidated  with  the  verruga  nodule,  and  this  produced 
local  lesions  just  as  we  had  obtained  in  the  animals.  There  was  no 
Oroya  fever  which  followed  after  inoculation.  In  the  monkey  we 
produced  lesions  which  were  carried  on  for  successive  generations;  I 
have  forgotten  how  many,  but  I  should  say  it  was  10  or  12  successive 
generations.  That  this  can  not  be  transplantation  of  tissue  is  shown 
by  the  work  in  transplantation  of  tumors  with  which  I  am  quite 
famiUar. 


570       PB00BEDIKG8  SECOND  PAN  AMBBIOAK  80IBKIIFI0  OOKaBESS. 

In  transplantation  of  tumors  it  is  quite  out  of  the  question  to 
transplant  tissues  of  one  species  to  another  species  and  have  the 
tumor  continue  to  grow  for  any  length  of  time.  I  do  not  think  that 
the  transplantation  of  tissue  can  account  for  these  lesions  which  are 
produced.  We  are  firmly  convinced  that  it  is  a  disease,  a  transmis- 
sible disease,  which  is  transmitted  to  monke3rs  by  inoculation,  and 
in  the  dog  we  had  a  few  observations  of  lesions  which  corresponded 
with  those  of  the  human  verruga  lesions.  By  inoculating  the  test^ 
of  the  rabbit  in  a  manner  similar  to  that  in  which  syphilis  is  trans- 
mitted to  the  rabbit,  we  produced  lesions  here  also.  They  were  not 
of  the  same  type  as  those  found  in  the  human  lesion;  they  were  more 
exudative,  more  inflammatory,  and  there  was  not  a  proliferation  of 
the  endotheUal  cells. 

So  I  think  we  have  here  a  fairly  good  basis  for  the  differentiation 
of  Oroya  fever  and  verruga  as  two  distinct  diseases,  and  notwith- 
standing our  abundant  material  we  can  not  confirm  the  presence  of 
these  organisms  in  the  lesions  of  verruga. 

Dr.  Lung.  Mr.  Chairman,  I  have  nothing  to  contribute  to  the 
technical  knowledge  of  this  subject,  but  I  wish  to  call  the  atten- 
tion of  the  meeting  to  a  circumstance  in  connection  with  the  study 
of  this  disease  which,  at  the  present  time,  has  much  significance. 
Twenty-seven  years  ago,  in  the  course  of  my  joumeyings  as  a  naval 
medical  officer,  I  found  myself  in  the  harbor  of  Callao,  and  remained 
there  for  two  months.  Following  the  impulses  of  my  youth  and  my 
professional  instinct,  I  looked  into  the  diseases  that  prevailed  in  this 
locality,  and  my  attention  was  at  once  called  to  this  disease,  verruga. 
At  that  time,  it  was  of  great  moment  to  certain  commercial  interests 
of  Peru.  They  were  just  constructing  a  wonderful  railway  from  the 
city  of  Lima  to  the  top  of  the  Andes,  and  in  building  this  road  they 
had  encountered  this  disease.  The  conditions  attending  the  building 
of  the  road  had  apparently  increased  the  conditions  which  produce 
the  disease,  and  men  were  made  ill  by  the  hundreds,  incapacitated  for 
work,  and  many  died.  The  condition  was  a  parallel  to  that  prevail- 
ing in  the  building  or  the  attempt  to  build  the  Panama  Canal  by  the 
French.  In  consequence,  this  disease  gave  them  great  concern,  and 
in  the  light  of  the  Imowledge  we  had  of  such  diseases  some  study  was 
made;  and  I,  following  the  guidance  of  some  medical  officers,  accum- 
ulated a  good  deal  of  information  and  made  a  report,  published  in 
the  Surgeon  General  of  the  Navy's  record  the  following  year,  that 
was  of  necessity  immature  and  incomplete,  a  mere  compilation  of 
what  was  then  known. 

The  point  I  wished  to  speak  about  particidarly  was  this:  In  con- 
nection with  the  efforts  of  the  medical  men  of  our  sister  RepubUc, 
Peru,  to  determine  what  this  disease  was  and  what  caused  it,  there 
was  one  yoimg  man  who  had  not  only  the  enthusiasm  to  pursue  it 


PUBUO  HBALTH  AND  MBKOINB.  571 

vigorously,  but  he  inoculated  himself  with  the  exudate  or  one  of  the 
incrustations  which  appear  at  a  certain  stage  of  the  disease,  and  in 
consequence  contracted  the  disease  and  died.  We  love  to  think  of 
some  of  the  martyrs  of  our  profession  who  have  submitted  to  such 
procedures,  some  with  very  striking  and  good  results.  Here  was  a 
young  man  who  lost  his  life.  Unfortunately,  he  acquired  no  definite 
knowledge  or  imparted  no  knowledge  to  those  who  surroimded  him. 
But  at  this  particular  time,  when  we  are  endeavoring  to  promote  good 
feeling  and  professions  of  friendship  with  South  America,  we  should 
bear  in  mind  a  man  like  Daniel  Carrion,  who  was  willing  to  give  up 
his  life  to  science.  He  has  been  made  a  martyr  in  his  country,  and 
due  recognition  has  been  given  to  him  there. 

The  Chairman.  Is  there  any  further  discussion  ? 

Dr.  LuNO.  I  want  to  ask  a  question,  if  I  may.  After  being  in 
Peru,  I  went  to  the  Philippine  Islands,  and  there  I  saw  a  disease 
known  as  parangi  (yaws).  The  onset,  the  dinical  course  and  the 
results,  outwardly  at  least,  are  exactly  similar  to  those  of  verruga. 
I  would  Uke  to  ask  these  gentlemen  if  they  have  made  observations 
on  this  point.  I  believe  some  efforts  have  been  made,  but  so  far  as 
I  know  nothing  has  been  determined  conclusively. 

Dr.  TowNSEND.  I  can  only  say  that  Dr.  Strong  and  his  associates 
have  demonstrated  the  distinctiveness  of  verruga  peruviana  and 
parangi  (yaws) .  As  to  the  remarks  of  Dr.  Tyzzer,  I  do  not  wish  to 
prolong  the  argument,  but  I  simply  stand  on  the  arguments  in  my 
paper  and  would  invite  a  careful  comparison  of  the  figures  and  de- 
scriptions of  these  cells. 

Dr.  GuTTERAS.  I  would  like  to  ask  Dr.  Townsend  whether  there 
has  been  any  further  experiment  with  the  Phlebotomus  verrucarum. 
As  I  understand  it,  there  was  one  single  experiment. 

Dr.  TowNSBND.  There  are  no  experiments,  I  believe,  except  those 
I  carried  on,  and  I  performed  a  good  many  on  laboratory  animals 
and  one  on  man,  and  published  the  results  of  these.  I  used  great 
quantities  of  phlebotomus  in  the  different  experiments,  and  I  think 
that  my  published  results  will  contain  conclusive  proof  that  Phle- 
botomus verrucarum  is  the  vector  of  the  disease. 

Dr.  GoNZALEZ-RiNOONBS  hereupon  spoke  in  Spanish. 

The  Chairman.  Dr.  Guiteras,  will  you  kindly  translate  the  re- 
marks of  Dr.  Rincones  ? 

Dr.  GunsBAS.  Dr.  Rincones  has  called  attention  to  a  case  of  a 
German  who  had  gone  through  the  Oroya  Valley  and  afterwards 
came  to  Venezuela  and  there  developed  the  disease,  and  he  calls  atten- 
tion to  the  fact  that  they  saw  there  in  one  man  the  two  stages  of  the 
disease.  They  saw  the  fever  stage  and  afterwards  that  of  the  erup- 
tion.    Dr.  Rincones  says  that  they  were  not  able  to  find  the  parasite 


572       PBOCEEDINOS  BBOOKD  PAN  AMEBIOAK  SCIEKTIFIG  G0NGBE8S. 

in  the  dififerent  stages  that  have  been  described.  He  finally  calls 
attention  to  the  fact  that  parangi  (yaws)  in  the  Philippine  Islands  is 
an  entirely  distinct  disease,  the  microorganism  of  which  is  well  known. 

The  Chairman.  If  there  is  no  further  discussion,  we  will  proceed 
with  the  reading  of  the  papers  by  Dr.  L.  E.  Migone. 


UN  NUEVO  FLAGELADO  DE  LAS  PLANTAS  (LEPTOMONAS  ELMASSIANI). 

Pot  LUIS  E.  MIGONE, 
Prqfesor  de  Bacteriologia  de  la  Facultad  de  Medidna  de  Asund&ny  Paragtuty, 

En  una  exciir8i6n  practicada  el  afio  pasado  en  Iob  lugaree  pantanoeos  del  Rio  Salado, 
desagtiadero  de  la  Laguna  Ihpacaraf,  no  lejos  de  A8unci6n  (Paraguay),  con  motivo  de 
una  epidemia  de  mal  de  caderas  desarrollada  en  Iob  carpinchoB  {Hydrochcerua  capivara 
L.),  recordando  lo6  estudioe  de  Lafont  Bobre  ciertas  especies  de  Euforfolafl  en  la  Ma 
Mauricio;  los  de  Carrougeau  y  Lafont  en  Tamatave,  Diego  Suires;  Iob  de  Noc  y 
Stevenel  en  laa  Antillas,  me  detuve  a  examinar  el  jugo  o  savia  de  laa  plantas  que  con 
verdadera  exuberancia  crecen  en  oBas  regiones.  Una  de  ellas  resulta  intereBante,  una 
asclepiadasea:  la  Araujia  angustifolia  (Gris)  que  en  la  primavera  (septiembre  a 
diciembre)  cubre  con  sub  tenues  ramas  y  oBpeso  follaje  Iob  arbustoB  que  le  son  pr6ximoB. 

Examinando  al  microBcopio  el  jugo  lactescente  de  esta  planta,  con  una  buena  lente 
de  inmeni6n,  se  observa  que  las  finas  gianulaciones  emulsionadafl  en  el  Ifquido  gomoBo, 
estin  en  continuo  movimiento  ondulatorio,  comunicado  por  un  aer  completamente 
invisible  por  su  trasparencia.  Este  movimiento  puede  durar  en  la  preparaci6n  mia 
de  24  horas.  La  extensidn  del  latex  sobre  Idminas,  una  buena  fijaci6n  por  el  calor  y 
una  coloraci6n  lenta  de  12  gotas  de  la  Boluci6n  colorante  de  Giemsa,  en  30  gramoe  de 
agua  destilada,  durante  12  horas,  noB  demuestra  perfectamente  bien  que,  el  movi- 
miento vibratorio  observado  en  el  liquido,  es  efectivamente  producido  pOT  Beres  or- 
ganizadoB,  semejantes  a  los  encontrados  por  Lafont  en  las  Euforbias. 

Este  microorganismo  se  encuentra  en  general  en  toda  la  planta  y  en  todas  las  de 
la  misma  especie  que  habitan  la  regi6n.  Las  pequeflas  ralces,  el  tallo,  las  ramas 
juncoeas,  las  hojas,  ciliz  de  la  flor,  los  verdes  o  maduros  frutoe,  se  encuentran  invadidoe 
pOT  innumerables  leptomonas. 

En  el  inviemo  (junio  a  septiembre)  cuando  esta  planta  se  encuentra  reducida  a  su 
tronco  y  finos  tallos,  no  deeaparecen  bus  pahisitos.  Por  lo  general  las  curvaturas  de 
las  ramas  y  la  corteza  de  la  fruta  contiene  m^  pardsito  que  en  las  demis  partes. 

Esta  planta  trasportada  a  otro  lugar,  a  otro  suelo,  al  de  Asunci6n  por  ejemplo,  a 
pesar  de  la  focilidad  con  que  se  deearrolla,  pierde  paulatinamente  sus  par^itos.  Lo 
mismo  ocurre  con  las  plantas  nacidas  desemilla,  de  plantias  infectadas. 

Las  hojas  y  el  tallo  despiden  un  olor  desagradable  con  el  quebrantamiento  y  no  he 
podido  observar  que  ningtSn  animal  la  apetezca.  Ningdn  insecto  vive  sobre  ella.  El 
microorganismo  es  sumamente  tenue  y  fr^l.  Los  fijadores,  en  general,  no  le  con- 
vienen;  el  alcohol  parecedisolver  sus  cromatinas;  los  fijadores  de  Zenker  o  Schaudinn, 
que  requieren  largos  lavados  consecutivos,  tamx>oco  me  han  proporcionado  buenos 
^xitos  para  la  coloraci6n.  S61o  el  calOT  a  cien  grados  si  presta  gran  ventaja  sobre  los 
liquidoe  fijadores.  La  Boluci6n  colorante  mis  conveniente  es  la  de  Giemsa  como  ya 
lo  he  dicho. 

El  cuerpo  es  finamente  granulado,  con  la  extremidad  anterior  terminada  en  punta 
roma  y  la  posteriOT  en  una  punta  afilada  en  forma  de  cinta  retorcida  sobre  sf .  Presenta 
un  grueeo  ndcleo  coloreado  intensamente  del  b&sico;  el  centroeoma  o  blefaroblasto 
ocupa  ya  la  parte  media  entre  el  ndcleo  y  la  extremidad  anterior,  o  ya  mis  hacia  el 


PUBLIC  HEALTH  AND  MEDICINE.  573 

ndcleo.  Una  pestaiLa  o  flagelo  parte  del  blefaroblasto,  atraviesa  la  parte  anterior  del 
pardflito  pasando  por  su  parte  media  y  sale  al  exterior,  prolongdndoee  en  ondulaciones 
hasta  una  extensidn  de  las  tree  cuartas  partes  del  cuerpo  parasitario.  Este  flagelo  se 
colorea  debidamente  por  la  solucidn  colorante  de  Giemsa:  mejor  se  colorea  por  la 
violeta  genciana  anilinada. 

Este  flagelo  y  la  extremidad  posterior  acintada  le  sirven  de  6rganoB  de  locomoci6n  y 
con  ellos  producirfan  los  movimientos  vibratorios  en  diversos  sen  tides  observados  en 
las  finas  partfculas  amilaceas  emulcionadas  en  el  latex. 

Ningdn  borde  filamentoso,  ninguna  membrana  ondnlante  he  podido  comprobar, 
como  los  que  se  observan  en  los  trypanosomas,  pardsitos  como  sab^  muy  semejantes 
a  los  leptomonas.  La  multiplicaci6n  se  efecttia  por  divisi6n  longitudinal,  encon- 
trdndose  muchas  voces  dos  par&sitos  acolados  per  sus  extremidades  posteriores,  final 
de  una  divisidn. 

Los  primeros  indicios  de  una  divisi6n  en  el  engrosamiento  del  cuerpo  y  la  aparLci6n 
de  otro  blesfaroblasto.  Antes  de  completarse  la  divisi6n,  ya  se  ven  las  pestafias  que 
parten  de  los  sustrosomas. 

El  par&sito  mide  sin  su  flagelo,  14  a  15  milimetros  de  milimetro  y  de  1}  a  2  millmetros 
de  milimetro  de  ancho.  Las  formas  intermediarias  son  pocas,  siendo  la  piriforme  sin 
flagelo  la  m^  comtin. 

Ouando  se  trata  de  formas  regresivas,  todas  toman  la  forma  de  creciente,  pierden 
su  flagelo,  su  blefaroblasto  y  su  coloraci6n  se  toma  m^  dificultosa. 

He  tratado  de  practicar  inyecciones  hipod^rmicas  e  Intraperitoneales  en  anlmales 
del  latex  diluldo  en  suero  flsiol^co  con  el  fin  de  ver  si  era  o  no  posible  la  vida  de 
estos  par^tos  en  los  animales;  pero  mis  esfuerzos  fueron  infructuosos,  porque  septi- 
semias  de  otra  Indole  hacian  sucumbir  a  los  animales  pocos  dfas  despu^  de  las  inocu- 
laciones.  Este  par&sito  ee  m^  corto  que  el  Davidi,  descrito  por  Lafont  en  las  Eufor- 
bfas;  este  par&sito  es  permanente  en  toda  la  planta  y  en  todos  las  de  la  misma  especie 
de  la  regi6n  infectada;  este  microoiganismo  es  un  pardsito  de  otra  familia  de  planta 
muy  distante  de  las  Euforbfas,  ee  de  una  Asclepiadacea,  por  estas  razones  me  permito 
darle  el  nombre  de  Leptonu>na8,  por  los  caracteres  generales  del  par&aito,  y  de  Elmassi- 
ani,  en  memoria  de  mi  antiguo  profesor  y  compafiero  de  trabajo. 


PARASrrOLOGlA  DE  CIERTOS  ANIMALES  DEL  PARAGUAY. 

Por  LUIS  E.  MIGONE, 
Profesor  de  Bacteriologia  de  la  Facultad  de  Medidna  de  AsunciSn^  Paraguay, 

Permftaseme  presentar  en  este  certamen  cientlfico  un  resumen  del  estudio  siste- 
mdtico,  desde  el  punto  de  vista  parasitario,  de  la  sangre  y  de  los  6rganos  intemos  de 
ciertos  animales  del  Paraguay. 

He  examinado,  de  preferencia,  los  animales  que  viven  en  los  rios,  pantanos  y 
lugaree  ht&medos  o  anegables  de  mi  pais,  sean  ellos  aves  o  reptiles,  sean  peces  o  mamf- 
feros. 

Los  par&sitos  predominantes  son  las  hemogregarineas,  los  tripanosomas,  los  micro- 
filarias, los  myxosporideos  y  un  par^ito  bastante  mal  conocido  atin:  los  lingudtulas. 

AVES. 

Theristicus  candattis  (Bodd),  Ibidse,  huru-kdu  nombre  guaranf.  Esta  ave  que  se 
alimenta  y  vive  en  los  lugares  bajos  y  hdmedos,  presenta  bastante  tripanosomas  en  la 
sangre.  Este  tripanosoma  es  bien  largo,  mide  tres  voces  el  di&metro  longitudinal  del 
gl6bulo  rojo.  Sus  movimientos  son  rdpidos.  El  ndcleo  es  bastante  grueso,  rico  en 
ciomatina;  centrosoma  manifiesto,  neto;  el  protoplasma  granuloso  y  membrana  ondu- 
lante  envolviendo  dos  voces  el  cuerpo. 


674       PBOOEEDINOS  SfiCOlH)  PAN  AMEBIOAN  8CIENTIFI0  OOHGBESS. 

Fijaci6n  alcohol.    Coloraci6n  aistemitica  Giemsa. 

Butoridet  ttriata  (L.),  Ardeidae,  hoho-i,  Esta  ave  se  mantiene  en  loe  lugares  iranca- 
mente  pantanosos,  presenta  tambien  tripaooBoma  en  la  sangre,  muy  parecido  al 
anterior. 

El  TigrUoma  marmoratu  (Vieill.),  hoho-hovih  o  hoho-pcard  y  el  Syrigma  tibUatriz 
(Temma),  Ardeidaee,  hjutraihrmimbihf  que  tambi^  viven  en  los  lugares  pantanoeos, 
no  son  parasitados. 

He  eetudiado  con  mucha  detenci6n  la  sangre  de  los  m&s  comunes  Anatidaes:  Meto- 
piana  peposaca  (Vieill.),  yhpl-pepd-^akd;  Nettium  branliense  (gen.),  TAp^  o  yhpe-hu' 
tiri;  y  del  yhpi  Dendrocygna  viduata  (L.),  pero  ninguno  de  ellos  est4  paraaitado. 

£1  tuyuyHt  Tdntalvs  americanuB  (L.)  uno  de  loe  m^  grandee  sancudoe  tiene  tiipa- 
noeoma  en  eu  sangre.  Este  tripanosoma  ee  tal  yes  iin  poco  mis  gnieso  que  el  anterior 
pero  tan  largo  como  dl. 

PBCBS. 

Nueetroe  rfoe  y  lagunaa  son  muy  ricoe  en  diferentee  variedadee  de  pecee.  Muchoe 
de  elloe  se  alimentan  de  vegetales  o  reetos  oig^micos  de  todas  clases  sin  excepciiki. 

Los  peecados  sin  escamas  son,  en  general,  mis  parasitadoe. 

El  Prewhplaty^oma  wnucans  (Agass.),  Siluridse,  $wubi  o  pird  pard  en  guuanl, 
ee  un  peecado  sin  escama,  bastante  comtin  en  las  grandes  aguas,  tiene  la  sangre  inf  ectada 
de  hemogregarinea;  la  piel  est4  ataeada  de  myxosporideos  y  el  canal  intestinal,  la 
cavidad  peritoneal,  el  tejido  subpleural  y  loe  mteulos  coetales  eon  invadidoe  de 
lingu&tulas  o  quistes  de  lingu&tula. 

El  tagud  o  ytaugud,  tambi^  Siluridse,  Doras  amuUu$  Guv.  ee  muy  a  m^iudo  paia- 
sitado  como  cd  $wubi. 

Otro  Siluridse,  tal  vez  el  mis  grande  de  nuestros  pescados,  sin  escamas  igualmente 
el  ZHmgaro  mangtaroi  (Val.)  fnangurudyH  o  piragwuH,  ee  generalmoite  infectado  de 
hemogregarinea  de  myxosporideo  cutaneo  y  de  linguitula. 

De  los  dasyatidse,  el  Potamotrygon  humboldtiU  (RouUin)  o  dyavevikij  tambien  suele 
infectarse  de  myxoepolideoe. 

Entie  loe  charasidaee  eon  el  ProfhUodus  argenUm  (Agass.)  kihrihmbati  y  el  EopWu 
nuddbarieiu  (Bloch)  loe  que  preeentan  inlecdonee  mixtas  en  loe  diganoe  intemoe,  del 
baco,  del  higtAo  perit6neo  y'branquias  de  myxosporideos  y  lingu&tulas. 

RBPnLBS. 

El  dyaoari  hu,  Caiman  $cUrop8  (Schneid.)  es  el  mis  parasitado.  En  ^  se  encuentra 
hemogregarinea,  microfilaria  en  la  sangre  y  drganoe  intemoe;  en  la  cavidad  abdominal 
y  primerae  vlas  respiratorias  abundan  los  quistes  de  lingu&tulas. 

Todoe  eetoe  parisitoe  pueden  ser  encontradoe  sobre  un  mismo  animal. 

De  loe  Teiidse,  el  tedyH  hovih^  Ameiva  ameiva  (L.)  y  el  tedyH  guatd,  TupinamJbi$ 
Uginxm  (L.)  son  tambi^  parasitados  de  hemogregarineas. 

De  loe  amphisbaenidae  tiene  hemogregarinea  el  s61o  ejemplar  examinado:  AmphU" 
haena  alba  (L.). 

Entre  los  Ophideos  he  estudiado  la  sangre  del  tukwri,  EunecUr  murinxu  (L.);  del 
nyahanind  hi&,  SpiUoUi  pullatxu  (L.);  de  loe  mboi  boviha,  Phylodrias  tchoUi  y  olfenH 
licht;  del  hOinhS,  Lachesis  newmedi  (Wagl.),  y  todoe  parasitadoe  de  hemogregarineas. 

hahIfbbos. 

Los  mamiferos  infectados  de  microfilarias  son  el  aguard  guasiif  Canisjubatut  (Deem.); 
el  carpincho,  HydrochcmM  capibara  (L.);  el  kihdyd,  Myocastor  coyptis  (MoL);  el  agvmd 
popSf  Procyon  oancrivona  hrasilierms  (Yering.) 

Vemos,  que  en  el  centre  de  Am^ca  del  Sur  exlsten  parisitos  id^nticos  a  los  ya 
conocidos  en  el  viejo  continente  y  en  otras  naclones  amerlcanas. 

Gonozco  los  interesantes  trabajos  del  Profesor  Oarini,  director  del  Institute  Pasteur 


PUBLIO  HEALTH  AND  MEDIOIinB.  576 

de  SSo  Paolo,  Bobre  IO0  hamogregarineaa  del  Mti»  decumanxUf^  Bobre  las  del  Phylodias 
(Schotti);  '  del  Tupinambis  tegubdn  y  del  Oaimiii. 

Por  otra  parte  el  Profesor  Laveran  y  Mme.  y  Mr.  Phisalix,  se  ban  ocupado  redente- 
mente  de  una  manera  extensa  del  bemogregarinea  de  una  viperinea  americana, 
Lachem  aUemahis^ 

He  repeddo  todoB  estoe  estudios  en  Ice  animales  de  las  Tnimnafl  especiee  ezistentes 
en  mi  pals,  y ,  sirvi^ndome  ^stos  de  base,  be  seguido  investigando  en  las  dem^  especies 
enumeradas. 

La  sangre  del  ZHngaro  mangunUf  del  Dora  armattu  y  del  Pseudoplatystoma  pre- 
sentan  una  bemogregarinea  uniforme,  con  im  ndcleo  central  caracterfstico  que  ocupa 
todo  el  tamafio  del  par&sito,  con  muy  pocas  granulaciones  protopUsmicas  y  ima  tenue 
membrana  perif^ca.  Estos  pardsitoB  se  encuentran  alojados  en  loe  gl6buloB  rojos  y 
nunca  en  los  leucocitos.  8e  desarrollan  en  el  protoplasma  celular  deplasando  al 
nt&cleo  bacia  la  periferia,  y,  a  medida  que  el  pariisito  crece,  el  gldbulo  rojo  se  def(»ma 
y  Be  destruye.  La  gregaiinea  se  deearrolla  como  un  vermfculo  basta  abandonar  el 
gl6bulo  bemdtico. 

Cuando  se  observa  una  preparaci6n  btimeda  de  sangre,  se  ven  estOB  desplazarBe  en 
el  plasma  sangulneo,  con  un  movinuento  lento  vermicular.  En  este  estado,  estado 
eztraglobular,  toman  muy  diffcilmente  ima  buena  colcnracidn. 

En  el  blgado  y  bazo  de  estos  animales  se  encuentran  pequefios  quistes  en  cuyo 
interior  se  diseflan  las  fases  de  multiplicaci6n  e8qui8og6nica. 

Aparte  de  la  forma  vermicular  del  par^to,  se  encuentran  formas  esf^cas  con  ilea 
masa  cromdtica,  que,  probablemente,  son  individuos  de  sexualidad  distinta. 

En  los  gl6bulo6  rojos  no  se  encuentra  m&s  de  un  pai6sito,  no  ee  como  la  sangre  de  las 
LaeheHB  altemahja  (Laveran)  0  en  la  Laehens  neuwiedi  en  que  en  algunoe  gldbulos 
estdn  dos  o  tres  alojados.  Como  en  estos  peces  estudiados  son  bub  bemogregarineaa 
muy  semejantes,  creo  que  deben  ser  de  la  misma  especie. 

MTZOSPOBiDBOS. 

Los  myxosporkleos,  tan  extensam^ite  estudiados  pw  BuBchili  en  ciertos  peces  de 
Europa,  tambi^  se  encuentran  en  el  Paraguay. 

Forman  tubdrculos  subepid6rmicos  en  los  pescados  sin  escamas,  en  toda  la  pared 
ventral.  Se  consideraban  en  mi  pais  como  quistes  de  vermes,  pero,  disecando  cuida- 
dosamente  se  puede  extirpar  im  tub^rculo  blanquecino,  de  2  0  3  milimetros  de  di&- 
metro.  Con  \ma  ligera  presi6n  se  rompe  derramindose  un  Uquido  lecboso  lleno  de 
myxosp<Mrfdeos. 

Cuando  el  peecado  es  con  escamas,  estos  tub^rculos  se  encuentran  en  las  branquias, 
en  el  blgado,  el  bazo,  y  el  tejido  subpleural. 

La  sangre  y  el  tejido  muscular  no  son  invadidos  por  ellos. 

MIOBOnLARIAS. 

En  el  Caimdn  seUropif  en  el  Eydrockxnu  capibara  en  el  Canit  jubahju  y  en  el  My<h 
editor  coypus,  be  encontrado  numeroeos  microfilarias  en  la  sangre,  en  el  bazo  e  blgado. 

Por  lo  general  los  animales  atacados  de  microfilarias  scm  enfermos.  Muestran 
algunas  particularidadee  de  vida:  se  alejan  de  los  p6ntanoe,  enflaquecen  y  es  relati- 
vamente  f&cil  su  caza  p<»rque  se  defienden  poco. 

El  blgado  de  estos  animales  es  m&s  oscuro  que  lo  n<xmal  pero  sin  aumentar  de 
volumen.    La  bolsa  biliar  es  grande. 

La  sangre  y  frotis  de  loe  6rganos  intemos  presentan  abtmdantes  microfilarias, 
^ivueltas  en  su  bolsa  gelatinosa,  nialina  0  completamente  deanudos.  £1  par&sito  es 
anillado  y  granuloso  con  \m  ndcleo  perif^co  grueso  algunos  de  ellos. 

>  Rerbta  de  to  Sooledade  Solflotiflca  de  Sio  Pftolo,  ToL  6,  tcoeto,  1910. 

*  C.  0.,  Septlembre,  1910. 

I  Bulletin  de  pathologie  ezotlqiie,  191S. 


676       PBOOEEDIKOS  SECOND  PAN  AMEiaGAN  80IENTIFI0  COKaBBSS. 

Como  86  Uata  de  obflervaciones  practicadas  en  animalee  salvajes  y  agwradoe  con 
perroe  o  muertoe  a  fusil,  do  es  poaible  completar  las  muchas  fasee  del  estudio  de  loe 
microfilarias  y,  mucho  menos,  determinar  ens  especies. 

linouAtulas. 

Las  Iingu4tula8  muy  mal  conocidoe  ha^ta  ahora  es  bastante  comtin  en  los  peacadofl 
que  provienen  de  aguas  muy  contaminadas  de  materias  6rganicas  en  descomposicidn. 
£n  Asuncion  se  encuentra  muy  a  meuudo  en  los  que  vienen  del  Rfo  Confuso  u  otroe 
riflchos  pr6ximo6  y  en  los  mismos  pescados  del  Rfo  Paraguay  tambi^n  se  observa. 
No  solamente  se  encuentra  en  loe  pescadoe  sino  tambi^n  en  el  caimdn  y  otros  mamlferos 
sefialadoe. 

Cuando  se  abre  un  peecado  infectado,  salta  a  la  vista  en  la  cavidad  abdominal 
nmnerosas  linguitulas  y  questes  de  pequeflas  lingoitolas. 

El  peritoneo,  epipl6n  y  peritoneo  parietal,  albergan  comtuimente  eetos  pai^tos. 

Lo  particular  ee  que  parece  que  este  Ar^lgnido  penetra  por  el  canal  gastro-intestiiud. 
He  observado  repetidas  vecee  al  lingu^tula  atravesando  la  pared  intestinal  aiempre 
con  la  cabeza  hacia  la  cavidad  peritoneal. 

Asf  ccmio  hay  pardsitos  bien  desarrolladoe  de  1  a  3  centimetros  de  largo,  asf  tambi^n 
hay  nomeroeos  quistes,  de  1  a  3  milfmetros  de  didmetro,  conteniendo  un  poco  de 
liquido  y  un  pequefio  vermfculo  completamente  formado  con  sus  pseudoartzoe  y  sii8 
buenos  garfios. 

Pot  los  caracteres  generales  del  pardsito  me  parece  ser  Lingudtula  serrata. 

Como  he  dicho  este  pardsito  no  s61o  se  encuentra  en  los  peces  sino  que  tambi^n  en 
los  mamfferos  que  se  alimentan  de  peces  muertoe  que  encuentran  en  los  hordes  de  loe 
rlos  o  lagunas  secas,  como  en  el  Cani  jubatus  y  el  Proq/on  canarivonu  bmsUiensis. 

Posiblemente  los  ejemplares  de  lingudtulas  encontrado  por  Darling  y  Viana  tienen 
origen  alimentario,  de  pecee  mal  cocidos  o  mal  preparados  o  poca  propiedad  en  la 
alimentaci6n. 

Before  calling  for  the  paper  of  Dr.  Gonz&lez-Bincones  on  ''Asca- 
nio's  method  of  staming  parasites, "  I  wish  to  announce  that  Dr,  Gon- 
z&lez-Rincones  presents  to  the  Scientific  Congress,  through  Section 
Villi  a  reprint  with  the  following  title:  Revision  del  estudio  de 
nuestro  tripanosomas.    Caracas:  Tip,  Guttenberg,  1914. 


MflTODO  DE  ASCANIO  PARA  LA  COLORACION  DE  LOS  PARlSITOS  DEL 

PALUDISMO. 

Por  RAFAEL  QONZALEZ-RINOONES, 

Pro/esar  de  la  FaciUtad  de  Medicina  de  CaracoB,  Venezuela, 

Tengo  el  honor  de  presentar  algunas  preparacionee  de  sangre,  hechas  en  mayo  de 
1915  con  una  t^cnica  que  mi  compafiero,  el  Dr.  Ascanio,  de  Caracas,  conaidera  pn^ia. 
Consta  de  loe  tiempoe  siguientes: 

1«.  Fijaci6n  con  alcohol  metflico  durante  un  minuto  (o  mientras  se  cuenta  mental- 

mente  110). 

2**.  Colaraci6n  con  8oluci6n  de  eosina  en  alcohol  metOico  al  1  per  ciento,  un  minute. 

^,  Lavado  rdpido  con  agua  corriente  para  determinar  la  coloracidn  definitiva  de 
la  eosina. 


PUBUO  HBALTH  AND  MBDIOIHB.  577 

4®.  Coloraci6n  con  asul  de  metUeno  acuoeo  al  1  por  mil  (mientras  se  cuenta  un 
mlnuto  0 110,  mentalinente). 

5^.  Lavado  al  chorro,  secando  por  medio  de  agitaci6n  al  aire. 

Toda  la  tunica  dura  a  lo  sumo  cinco  minutos  y  loe  hematozoarios  se  muestran 
tefiidoe  de  asul  intenso,  siendo  muy  visible  el  pigmento  sobre  este  fondo  de  proto- 
plasma  parasitaris.    La  cromatina  no  se  title  de  rojo  rub!  como  con  el  ''Giemsa." 

Loe  elementoB  normales  de  la  sangre  perif6rica  se  coloran  asi: 

Gl6bulo6  rojos:  de  color  chocolate,  rojo  violdceo,  uniforme. 

Polinucleares  eo6in6filoe:  nticleo  azul  pdlido;  granulacionee  voluminoeas  rojas. 

Polinuclares  neutr6£Uoe:  nticleo  azul  mis  intenso  que  en  loe  eosin^filoe;  pequefLas 
granulaciones  roeadas  sobre  un  fondo  rosa  pdlido  de  protoplasma. 

Mononucleares  grandes:  protoplasma  azul  intenso  con  nticleo  apenas  coloreado  de 
azul  celeste  muy  pilido. 

Linfocitos:  ndcleo  azul  intenso  homog^neo. 

Aunque  la  coloraci6n  en  general  de  los  gl6bulos  blancos  es  bastante  parecida  a  la 
que  da  la  triacida  de  Erlich,  se  nota  que  los  mononucleares  se  coloran  en  sentido 
inverse. 

La  modificaci6n  aconsejada  por  el  Dr.  Ascanio  tiene  la  ventaja  de  su  rapidez  y 
puede  reemplazar  para  el  diagn(5etico  de  las  plaamodiosiB  las  soluciones  de  Roman- 
owsky,  Giemsa,  May-Grilnwald,  los  polvos  de  Jenner,  Leishman,  etc.,  que  comienzan 
ya  a  escasear  en  el  mercado  de  los  productos  qulmicos  europeos.  Sea  cual  fuere  su 
grade  de  originalidad,  me  ha  parecido  interesante  y  oportuna. 

The  Chairman.  I  would  like  to  ask  the  Doctor  if  this  method  has 
been  published  ? 

Dr.  (jONZALEz-RmcoNES.  No;  it  has  not  been  published. 

Dr.  GuiTERAS.  The  method  is  the  following:  Fixation  in  methylic 
alcohol  during  one  minute,  or  while  we  count  110  mentally;  second, 
staining  with  eosin  solution  in  methyhc  alcohol,  1  per  cent,  one  minute; 
third,  rapid  washing  with  running  water  to  determine  the  final  colora- 
tion of  the  eosin;  fourth,  staming  with  aqueous  solution  of  methylene 
blue,  1  per  thousand,  one  minute  or  while  we  count  110;  fifth, 
washing  freely  in  water,  drying  in  the  air  by  shaking  the  preparation. 
The  whole  technique  will  take  not  more  than  five  minutes,  and  the 
parasites  are  found  stained  intense  blue,  the  pigment  being  quite 
visible  upon  this  bad^round  of  the  protoplasm.  The  normal  ele- 
ments of  the  blood  are  stained  as  follows:  Red  cells,  chocolate  color, 
violet  red,  or  uniform  coloration;  polynuclears  eosinophile,  nucleus 
pale  blue,  granules  laige,  red;  polynuclears  neutrophile,  nucleus  blue, 
granules  small,  rosy  colored  on  a  background  of  pale  rose  of  the  proto- 
plasm, nucleus  more  intense  blue  than  in  the  eosinophiles;  large 
mononuclears,  intense  blue  protoplasm  with  a  nucleus  very  slightly 
stained  of  a  light  blue,  veiy  pale;  lymphocytes,  nucleus  intense  blue, 
homogeneous. 

The  Chairman.  Are  there  any  comments  on  this  paper  t  If  not, 
I  am  requested  to  announce  that  the  paper  of  Dr.  T.  Bayma,  on 
"Adrenalin  in  Amoebic  Dysentery,"  wiD  be  read  by  title. 


578       PBOOBEDINQS  SECOND  PAN  AMBBIOAN  SOIENTIFIO  CONGRESS. 

ADRENALIN  IN  AMERIC  DYSENTERY. 

By  THEODORO  BAYMA, 

Director  of  the  8do  PatUo  Bacteriologieal  In$tiUuU  (Braml)  and  CkUfPhytidan  of  the 
Medical  Clinic  cf  the  Santa  Com  de  Mieerioordia  Hoepital. 

"On  the  treatment  of  bacillary  dysentery  by  adrenalin  "  is  the  title  of  an  interesting 
article  by  Dr.  Franz  V.  G6en  in  ^e  Mdnchner  Medizinishe  Wochenachrift No.  14,  Apd!, 
1916. 

This  article  studies  the  effects  of  the  opiates,  of  atropine,  of  aspirin,  and  especially 
of  adrenalin  in  a  series  of  about  300  sufferers  from  bacillary  dysentery.  Tlie  cases 
are  from  the  author's  hospital  practice. 

He  concludes  that,  besides  Its  innocuousness,  suprarenin  has  a  epedfic  action  on  the 
syndrome  of  bacillary  dsrsentery,  especially  as  regards  the  pains,  the  rebellious  hic- 
coughs and  vomiting  in  grave  cases.  The  medicament  in  solution  of  one  to  a  thousand 
is  administered  per  os,  10  to  20  drops  in  a  little  water,  at  intervals  of  one  to  two  hours, 
and  in  grave  cases  large  intestinal  washings,  in  the  dilution  of  1:100,000  or  1:500,000, 
at  the  temperature  of  40^  C.  This  application  is  made  with  a  stomach  tube  1  meter 
long  and  not  very  thick  (8  mm.),  the  patient  being  in  the  lateral  decubitus  or  genn 
cubitus,  injecting  as  much  as  800  c.  c.  of  the  solution.  In  addition  to  its  action  on  the 
pains  and  the  disappearance  of  blood  from  the  feces.  Dr.  F.  CrOers  mentions  the  im- 
provement of  the  general  condition  of  the  patient  and  the  cessation  of  the  toxic  symp- 
toms, the  cure  being  manifest  in  less  than  6  or  10  hours. 

This  is  the  summary  of  Dr.  Frans  GOers's  work. 

Inspired  by  this  work  we  sought  to  verify  the  effects  of  adrenalin  in  the  treatment 
of  amebic  dysentery,  a  disease  observed  amongst  us  for  many  years,  as  may  be  veri- 
fied by  the  publications  of  Luts  >  (1888, 1889  to  1898),  Vital  Brazil,'  Diogo  de  Fatia, 
A.  Mendouga,'  and  recently  by  other  colleagues. 

We  threw  ourselves  more  rescdutely  into  these  experiments  after  knowing  the 
opinion  of  Eirschner,  who  sees  in  infectious  diseases  the  principal  therapeutic  indi- 
cation for  adrenalin,  as  well  as  the  observations  d  Pourcev^  (d  Moscow),  with  rela- 
tion to  the  existence  in  the  suprarenal  g^ds  of  hyperemia,  hemonhagic  effusions, 
diminution,  and  even  absence  of  the  amorphous  substance,  more  or  less  marked 
degeneration  and  diminution  of  the  fatty  element  in  cases  of  dysentery,  diphtheria, 
typhoid  fever,  etc. 

Tlie  results  of  the  observations  whidi  we  have  collected  have  brought  us  to  the 
conviction  of  its  specificity  perhaps  on  intestinal  and  hepatic  amebiasis. 

One  advantage  of  the  new  application  of  adrenalin,  and  which  is  not  to  be  despised, 
is  simplicity  of  administration,  as  it  is  not  repugnant  to  adults,  and  especially  children, 
as  happens  with  injections  of  emetin. 

The  patients  treated  by  us  are  not  yet  many  in  number,  there  being  only  a  few 
more  than  10  cases;  all  presented  the  complete  dysenteric  qrndrome,  and  besides 
this,  case  X  presented  a  suppurative  hepatitis  of  amebic  orig^,  proved  by  the  pres- 
ence of  amebas  in  the  pus  of  the  abscess. 

In  two  cases  the  clinical  cure  was  accomplished  within  the  first  6  hours  and  con- 
firmed by  microscopical  examination  of  the  feces  and  absence  of  blood  in  the  feces 
20  hours  after  the  b^;inning  of  the  treatment  (cases  VIII  and  IX) ;  in  another  (case  VII) 
24  hours  after  the  cure  was  complete,  clinical,  microscopical,  and  chemical 
proofe.    In  case  III  the  same  results  were  obtained  in  2  days;  in  cases  I  and  II  4 

1  Dr.  Adolpho  Loti:  "Report  on  tlio  wwk  of  the  Bacterlologioa]  InsUtate  dnrins  ttie  yean  1807  and 
1886."   SAo  Paolo  Medical  Beyiew,  1806,  p.  182;  1809,  p.  806. 

tDr.VitalBraiU:"Aoaaeofd78enterioalMeeaBoftheUTer."   Bfto  Paolo  liedioal  Review,  1806,  p.  6. 

* "  BoOetlii  of  the  Society  of  Medidne  of  SAo  Paolo,"  1807. 

« Pooroev:  "Pathogfoie  dea  glandea  sarrfinalee  et  leor  IMons  paHiologiqoea."  Joomal  dTJrologle 
Hedioale  et  Chirargicale,  1013,  p.  683. 


PUBUO  HBALTH  AKD  MENOINE.  579 

days  of  treatment  were  necessary;  case  V  required  5  days;  case  VI,  a  chronic  case, 
with  acute  remittance,  of  eig^t  months'  standing,  with  70  to  80  evacuations  daily, 
treated  previously  with  emetin  without  result,  was  enabled  to  return  to  work  after  10 
days'  treatment;  the  patient  with  abscess  of  the  liver  (case  X)  required  25  days  for  the 
cure  to  be  effected. 

Case  IV,  of  more  than  three  months'  diu^tion,  was  the  only  one  which  presented  a 
certain  rebelliousness  to  the  action  of  suprarenin;  however,  if  it  had  not  been  for  the 
systematic  examination  of  the  feces,  the  case  would  have  been  considered  clinically 
cured  after  some  days  of  medication  as  it  presented  no  vegetative  amebee.  We  did  not 
consider  it  so,  however,  in  view  of  the  presence  of  cystic  forms.  Without  acceding  to 
the  reiterated  solicitations  of  the  patient  we  detained  her  for  the  prosecution  of  studies 
as  to  the  action  of  the  medicament  per  os  and  in  intestinal  washings  on  that  resistant 
form  of  the  protozoon,  consequently  on  ameba  carriers—that  is  to  say,  on  the  rOle 
which  the  extract  of  the  suprarenal  capsule  may  play  in  the  prophylaxis  of  amebiasis. 
Having  given  three  intestinal  lavages,  with  a  four  days'  interval,  we  no  longer  observed 
the  cysts,  which  argues  in  favor  of  the  method  in  chronic  and  rebellious  forms  of  the 
disease. 

With  the  exception  of  this  case,  in  no  other  did  we  encounter  the  cystfc  forms  of  the 
protozoon,  a  ^t  encountered  with  some  frequency  in  individuals  submitted  to  treat- 
ment with  emetin. 

Are  we  dealing  in  this  case  with  a  strain  of  amebse  that  are  resistant  to  adrenalin 
as  has  abready  been  verified  in  the  case  of  the  alkaloid  of  ipecac?  And  when  the 
amebatropic  or  amebaddal  property  of  the  new  drug  does  not  make  itself  felt  on  the 
parasite,  will  an  ^'intermittent  treatment"  following  the  clinical  ciure  be  necessary, 
as  Baermann  and  Heinemann^  advise  in  such  cases  that  have  been  treated  with 
emetin? 

We  prudently  initiated  the  experiment  by  administering  5  drops  in  the  morning  and 
5  in  the  afternoon  of  the  solution  of  adrenalin  hydrochlorid  1:1000  of  Parke  Davis  &  Co. 

Gradually  and  cautiously  we  increased  the  dose  up  to  30  drops  or  1  milligram  of 
adrenalin  hydrochlorid  every  hour  or  every  two  hours  according  to  the  severity  of 
the  case. 

We  verified  Dr.  G5ers  results  as  to  the  complete  innocuousness  of  the  drug;  we  did 
not  observe  in  any  one  of  the  patients  the  least  symptom  or  phenomenon  of  intoxica- 
tion. Furthermore,  0.  Jo6u6,'  L^n  Bernard,'  and  Netter  had  already  demonstrated 
that  poisoning  accidents  should  not  be  feared  when  adrenalin  is  administered  per  oa 
or  in  the  subcutaneous  cellular  tissue.  Not  even  in  case  IV,  an  old  atheromatous 
woman,  did  we  have  any  fears  of  augmenting  the  arterial  lesions,  as  we  were  convinced 
by  Josu^'s  demonstrations  that  these  lesions  only  follow  intratracheal  and  intravenous 
administration  of  the  drug. 

In  acute  cases  treated  early  in  the  disease  a  large  dose  is  not  necessary  as  is  shown 
by  cases  I  and  II,  in  which  only  5  drops  twice  a  day  brought  about  the  cure.  In  the 
case  of  the  patient  of  case  III  we  administered  5  drops  every  three  hours.  In  that  of 
case  V 10  drops  every  two  hours  and  in  that  of  case  VII  the  same  quantity  every  three 
hours. 

Of  the  observed  cases  VIII  and  IX,  one  in  a  member  of  our  faunily  and  the  other 
in  a  servant  in  the  house,  we  were  enabled  to  follow  pari-passu,  from  the  first  mani- 
festations, the  effects  of  the  medicinal  action  of  adrenalin,  convincing  us  still  more 
of  its  high  therapeutic  value  in  amebic  dysentery,  and  even  of  its  specific  action. 
The  cure  of  these  two  cases  was  accomplished  within  six  hours  by  the  administration 
of  10  drops  of  the  solution  at  two-hoiur  intervals. 

>  Baannami-Heliieinaim,    "Dto   Behandioiig  der  Arndben-dysenterto  mlt  Emettn"— IftliiofaiMr  M. 
Wochemebrift,  1913,  p.  113^1210,  Band  21-23. 
•  O.  loBoA,  "RemarqtMfl  rar  Temploi  de  radrfeaUn  en  thenpentic.''   La  Presse  KedicalB  1910,  p.  IM. 
« Uon  Bernard,  "A  propoa  da  la  posologle  da  radrfeaUn."   La  Presae  Kedicale  1910,  p.  190. 

68486— 17— VOL  x 38 


680      FBOOBEDIKGB  8BC0KD  PAK  AMEBIOAK  BOlBHIUriO  OONQBBSCL 

Wiflihiiig  to  test  the  action  of  the  drug  by  mibcutaneous  ftdminifltntion,  of  which 
Dr.  F.  G{kn  did  not  cogitate,  we  experimented  on  a  patient  without  the  least  result, 
while  improvement  was  manifested  as  soon  as  the  gastric  route  was  used,  20  drops 
being  administered  every  two  hours. 

The  rapid  improvement  experienced  by  patients  after  the  fiist  doses  ol  the  drug 
impresses  one  greatly;  the  general  condition  is  improved,  the  colic  and  tenesmus  are 
lessened  immediately  or  even  disappear,  the  number  of  evacuationB  is  diminished. 
The  latter  in  a  few  hours  fail  to  reciur  (cases  VII,  VIII,  and  IX)  and  lose  their  muco- 
sanguinous  character,  becoming  pasty  or  even  normal,  without  the  characteristic  odor 
ol  rotten  leather,  free  from  blood,  amebee  and  cysts  of  this  protozoon. 

Case  VI  deserves  dose  attention,  the  chronidty  of  which  (8  months  duration)  proved 
the  high  curative  power  of  suprarenin  in  ascending  doses  (10  to  20  drops),  accom* 
pliflhing  a  cure  in  10  days,  while  months  of  treatment  with  emetin  brought  about  only 
an  insignificant  improvement. 

Also  in  case  IV,  the  interctirrence  of  a  pleuro-pneumonia  in  an  organism  impaired 
by  age  and  by  a  long  and  serious  illness,  causing  old  Isabel  to  succumb,  jvovided  us 
with  one  more  irrefutable  proof  of  the  pharmaco-dynamic  action  of  adrenalin  in  intes- 
tinal amebiasis. 

The  restitution  of  the  integrity  of  the  large  intestine  pictures  the  enei!gy  which  the 
drug  exercised,  for  about  a  half  dozen  small  open  ulcers  remained,  mere  vestiges  of  the 
myriads  which  were  present  and  which  healed  by  a  dcatrizing  process,  evidently 
very  recent.  The  histologic  examination  of  the  large  intestine,  made  by  Dr.  Dorival 
de  Camargo,  of  the  Butantan  Institute,  did  not  reveal  the  presence  of  ameb»'or  cysts 
in  the  sections. 

The  feces  following  the  first  administrations  of  the  drug  assume  at  times  a  dark  color, 
as  if  they  were  highly  bilious,  a  coloring  which  stains  intensely  the  bacilli  present, 
and  which  becomes  progressively  fainter. 

In  some  cases  (Nos.  VI,  VII,  and  VIII)  we  noted  strong  constipating  action  which 
required  the  use  of  a  purgative  to  render  the  intestinal  functions  normal. 

We  should  not  omit  one  fact  in  regard  to  adrenalin,  and  which  was  already  noted  in 
regard  to  emetin,  and  which  appears  to  be  connected  with  the  source  or  quality  of  the 
drug.  As  we  know,  there  is  synthetic  adrenalin  and  extractive  adrenalin,  the  latter 
more  active  than  the  former. 

It  is  thus  that  in  case  IX,  a  case  which  evolved  under  our  eyes,  we  first  employed  a 
Bradlian  solution  of  adrenalin  and  later  a  solution  sold  as  prepared  by  Clin  of  Paris, 
without  the  patient  experiencing  the  slightest  relief  from  the  colic  and  tenesmus  which 
were  severe  enough  to  bring  tears  to  the  patient's  eyes.  Substituting  these  preparations 
by  that  manu^tured  by  Parke  Davis,  all  symptoms  gradually  lessened  and  finally 
disappeared,  the  patient  attending  to  her  duties  within  a  few  hours. 

As  regards  case  IV,  we  must  note  in  passing  that  he  was  suffering  from  ankylos- 
tomiasis also  and  that  the  drug  had  no  effect  on  this  nematode,  as  the  ova  were  always 
found  in  the  feces. 

How  can  the  action  of  adrenalin  on  these  two  kinds  of  dysentery— badllary  and 
amebic — ^be  explained?  Dr.  F.  GOers  thinks  that,  in  the  former,  this  drug  exercises 
an  antitoxic  action  on  the  toxins  secreted  by  the  bacillus,  as  A.  Marie  had  shown  in 
the  case  of  diphtheria  and  tetanus  toxins. 

This  conclusion  of  Marie's  '  deserved  the  contradiction  of  Dr.  J.  M.  Stutzer  ^  who 
hdds  that  the  neutralizing  action  of  the  adrenalin  hydrochlorid  on  the  diphtheria 
toxin  is  due  to  the  free  hydrochloric  add  present  and  when  this  is  neutralized  the 
toxin  is  rendered  indifferent. 

1  aiandfls  sorrenaleB  et  toxHofBcttons,  dted  by  "Z«ittdulft  ffir  ImmmiltiUifbnoliiiiig  anil  Sxpeclmen- 
tdfe  Thenpie,"  1913,  Band  XLII,  p.  430. 

•  Ueber  die  Wtrkmig  von  Adrenattn  Mf  Bakterien^ond  Diphtecietozin,  «Z«it8cfailft  ftir  Immunlt&ts- 
fonohong  and  Ezperlmentelle  Thenple,"  1014,  Band  XXn,  p.  872. 


FUBUO  HBALTH  AKD  MBDIOINB.  581 

Such  an  interpretation  does  not  appear  to  be  acceptable  to  us  in  regard  to  amebic 
dysentery,  and  hence  we  venture  to  formulate  questions  which  subsequent  studiei 
may  succeed  in  answering. 

(a)  Will  adrenalin,  by  its  vaso  constrictor  action,  causing  an  ischaemia  of  the  vas- 
cular network  of  the  intestine,  withhold  from  the  protozoon  its  favorite  aliment — 
erythrocytes — causing  it  to  perish  by  inanition? 

(6)  Has  it  a  direct  parasitropic  action  on  the  vitality  of  such  a  frail  and  delicate 
organism,  as  Maurel  ^  thinks  is  the  case  with  emetin  and  which  Edward  B.  Wedder 
(1910)  and  Wherry  (1912)  demonstrated  in  vitro  in  as  high  dilutions  as  1  to  200,000? 

(c)  Are  we  confronted  with  cases  in  which  organotherapy,  stimulating  or  supplying 
the  functional  deficiency  of  the  supra  renal  glands,  organs  essential  to  life,  as  Brown- 
S^uard  showed  in  1856,  and  balancing  the  organism's  deficit  of  epinephiin,  thus 
reestablishing  its  protective  functions? 

(d)  Or  will  all  of  these  factors  act  simultaneously,  each  within  its  own  sphere,  on 
the  vital  conditioi^  of  the  parasite? 

CASE  REPOBTS. 

Case  L — Santa  Oasa  de  Bfisericordia  Hospital,  first  women's  ward,  case  card  No. 
4330.  Lucia  B.,  Italian,  45  years  old,  widow,  resident  in  the  capital.  Admitted  on 
the  25th  of  April,  1915.  She  had  been  ill  for  8  days,  having  10  to  15  evacuations  in 
24  hours.  Complete  dysenteric  syndrome.  The  examination  of  the  feces  under  the 
microscope  revealed  the  presence  of  blood  and  many  entamebss  histolytica  of  Schaudin 
in  active  motion  and  engulfing  many  erythrocytes.  Temperature  and  urine  normal. 
There  not  being  any  emetin  in  the  hospital's  pharmacy,  we  prescribed  a  saline  purga- 
tive, and  afterwards  a  mixture  of  syrup  of  ipecac,  with  eigotin  and  syrup  of  opium, 
a  prescription  which  she  continued  to  use,  with  slight  modifications,  until  May  25 — 
that  is,  for  one  month — ^without  showing  improvement.  May  26,  we  prescribed  for 
the  first  time  the  1  to  1,000  solution  of  adrenalin,  5  drops  in  the  morning  and  5  in  the 
evening.  May  27,  28,  and  29,  the  same  medication  was  continued  and  the  patient 
experienced  rapid  improvement  as  regards  the  colic  and  tenesmus.  May  30,  the  feces, 
of  normal  appearance  and  consLstency  were  examined  and  fo\md  nega^ve  for  blood 
and  amebffi  and  remained  so  until  the  day  the  patient  left  the  hoflpital.  Cured  by 
adrenalin  in  four  days. 

Ca$e  II. — Santa  Casa  de  Misericordia  Hospital,  first  women's  ward,  case  card  No. 
5409.  Estherina  M.,  Italian,  married,  42  years  old,  resident  in  the  capital.  Ad- 
mitted May  25,  1915.  Had  been  ill  for  15  days.  Temperature  normal.  Complete 
dysenteric  syndrome.  Under  the  microscope  the  stools  showed  many  amete  in 
motion,  and  blood,  also  eggs  of  ascaris.  May  26,  we  {nescribed  a  saline  purge.  May 
27,  we  beg^n  the  treatment  with  the  1  to  1,000  solution  of  adrenalin,  5  drops  in  the  nuffn- 
ing  and  5  drops  in  the  evening  and  this  was  kept  up  until  June  2,  when  amebse 
cysts  and  blood  were  no  longer  foimd  in  the  feces,  which  proved  to  be  normal. 
Cured  by  adrenaUn  in  four  days. 

Case  III, — Santa  Casa  de  Misericordia  Hospital,  first  women's  medical  ward,  case 
card  No.  5537.    Maria  da  L.,  Portuguese,  married,  35  years  old,  resident  in  the  suburb 
of  Belemzinho.    Admitted  May  26,  1915.    She  had  experienced  the  dysenteric 
syndrome  for  8  days.    Temperature  and  urine  normal.    May  2!d,  the  exaxmnaAion  ol 
the  feces  showed  blood,  entamebse  histol3rtica  in  motion  and  phagocytiaed  ery^uo- 
cytes.    We  prescribed  5  drops  of  the  1  to  1,000  lydreBS^  %cto!dQa  e^«rj  ^^msto. 
May  31,  feces  ncMmal,  negative  for  amebss,  bloo^        a  cytte,  •ndtcCD*^^^  ^^ 
subsequent  examinations.    Cured  by  adrenalii^  j  ^\-fO-^^** 


>  Contribution  k  Tetude  experimental  du  chlor  <*'*nietur^\  v^^ieaiCiooa  ^wa^  jijd^ 
I'Acadtoile  de  M6dicine  de  Parfs,  No.  12.  March,  1914.      ^^        ^o^^^  ^**V>^ 


^v^ 


582       PROCEEDINGS  SECOND  PAN  AMEBICAN  SCIENTIFIC  GONOBESS. 

C(ue  /F.-— Santa  Oasa  de  Misericordia  Ho6i»taI,  first  women's  medical  ward;  case 
card  No.  5968.  Isabel  A.  de  J. ,  Brazilian,  70  years  old,  widow,  resident  in  the  capital. 
Admitted  June  10,  1915.  A  saline  purgative  was  prescribed  for  her.  She  had  been 
iU  for  more  than  3  months,  and  experienced  successive  pouss^es  of  the  dysenteric 
syndrome,  frequently  expelling  muco-sanguinous  feces  of  very  bad  odor.  G^eral 
condition  bad;  great  impoverishment  and  profound  asthenia.  Tongue  covered  with 
a  thick  greasy  coating.  Belly  painful  to  touch.  June  11,  the  examination  of  the  feces 
flhowed  them  to  be  of  a  muco-sanguinous  character,  very  foul  smelling  and  \mder  the 
microscope,  ova  of  ankylostoma,  and  many  other  flagellates  besides,  a  large  amount 
of  pus  and  blood  and  many  amebse  histol3^ca  of  Schaudin  in  motion  and  with 
phagocytised  erythrocytes.  June  12  and  14,  I  prescribed  15  drops  of  adrenalin  seda- 
tion every  3  hours.  The  colic  and  tenesmus  disappeared  and  the  feces  became  leas 
fetid. 

June  15  we  increased  the  number  of  drops  to  20.  The  evacuations  became  less  fre- 
quent and  of  a  dark  color  and  the  amebse,  fewer  in  number,  w^e  immobile.  The 
patient  was  in  good  spirits,  manifesting  a  general  improvement.  June  22,  still  great 
quantity  of  pus,  very  little  blood,  and  very  few  amebse,  and  these  motionless  and 
with  granulur  endoplasm  and  without  phagocytised  erythrocytes,  which  we  had  noted 
since  the  15th.  Three  evacuations  a  day,  less  dark  in  color.  June  27,  no  evacuation. 
The  patient  feels  quite  well  and  asks  for  solid  food.  The  general  condition  has  im- 
proved very  much  and  the  tongue  is  completely  clean.  Abdomen  not  painful  to 
palpate.  July  1,  doughy  feces,  without  amebse  or  blood.  July  3,  a  laige  quantity 
of  cystic  forms  of  amebse  histoljrtica  appeared  in  the  feces.  The  medication  per  oe 
continued  until  July  7,  when  we  made  the  first  intestinal  lavage,  according  to  Dr.  F. 
GOers's  indication.  The  patient  expelled  the  solution  of  adrenalin  half  an  hour  after- 
wards, along  with  hard  feces,  of  a  normal  color  and  in  which  we  found  the  cysts. 
July  12,  one  doughy  stool  per  diem,  still  with  cysts.  We  gave  a  second  washing  and 
recommended  the  medication  per  os  suspended  on  July  7.  From  this  date  until  the 
16th  the  patient  only  had  one  evacuation.  July  16  we  gave  a  third  lavage.  July  17 
and  following  days  we  did  not  observe  any  more  cysts,  amebse,  or  blood  in  the  feces, 
the  patient  evacuating  naturally  on  alternate  days.  The  patient  feeling  well  and 
strong,  insisted  on  being  discharged,  but  this  was  not  permitted,  in  order  to  keep  her 
under  observation  for  further  study.  July  20,  the  patient  got  chilled,  developed  a 
cough  and  a  stitch  in  the  left  axillary  region.  Temperature,  37.8®  0.  July  21,  auscul- 
tation revealed  the  phenomena  of  a  left  pleuropneumonia.  Temperature,  38.4; 
feces  negative.  The  patient  got  worse  of  the  pleuropulmonary  affection,  dying  on 
the  24th  at  6  o'clock  in  the  morning. 

Autopsy:  It  was  not  possible  to  make  a  complete  autopsy,  so  that  only  the  large 
intestine,  the  appendix,  and  kidneys,  with  their  respective  suprarenal  bodies,  were 
taken  out.  Liver  and  kidneys  showed  no  macroscopic  alteration.  Appendix  and 
diverticulum  normal;  also  the  abdominal  ganglia.  The  large  intestine  was  opened 
and  we  removed  from  it  some  doughy  feces  of  normal  appearance,  which  we  examined 
for  amebse  and  cysts  according  to  Dr.  K.  Ujihara's  method,*  since  the  microscope 
did  not  reveal  them  to  us,  but  without  any  results.  The  whole  extension  of  the 
intestinal  tract  from  the  csecum  to  the  anus,  especially  in  the  lower  portion,  was 
riddled  with  small  lenticular  points,  with  the  surface  covered  with  a  thin  and  slimy 
epithelial  coat,  showing  that  there  had  been  a  very  recent  process  of  cicatrization  in 
these  healed  miliary  ulcers.  In  one  or  another  section  a  few  of  these  small  ulcers 
(half  a  dozen,  perhaps)  are  found  still  open,  the  largest  of  which  did  not  exceed  in  sise 
a  grain  of  rice,  round  or  oval  in  shape,  with  the  edges  mined  or  cut  perpendicularly 

1  Studfen  Qber  die  Arndbendysenterie,  Zeitsohrift  (Or  Hjrgiene  and  Infectlonskrankeiteii,  1914,  Band  77, 
p.  829. 


PUBUO  HEALTH  AND  MSDIOIHB.  583 

and  the  floor  constituted  by  the  muscular  coat.  Scraping  with  the  knife  point  under 
the  edges,  no  amebce  histolytica  were  found  in  the  material  thus  obtained. 

Sections  of  the  laige  intestine,  made  by  our  colleague,  Dr.  Dorival  de  Gamaigo, 
assistant  of  the  Serumtherapeutic  Institute  of  Butantan,  did  not  reveal  the  presence 
of  the  parasite,  either  in  its  vegetative  form  or  in  its  cystic  form. 

As  regards  the  suprarenal  glands,  macroscoplcally  altered,  let  us  await  the  results 
of  the  histopathological  examination  to  say  something  about  them  in  the  prosecution 
of  our  studies.  We  shall  then  treat  of  the  experiments  in  vitro  as  regards  the  action 
of  adrenalin  on  the  amebsB  and  of  its  degenerative  forms  observed  during  the  treat- 
ment, subjects  which  do  not  belong  to  the  properly  clinical  feature  of  this  work. 

Case  V, — Santa  Casa  de  Misericordia  Hospital,  first  women's  medical  ward;  case 
card  No.  6448.  Olympia  da  C,  Portuguese,  34  years  old,  married,  resident  in  tho 
suburb  of  Cambucy.  Admitted  June  26,  1915;  six  months  pr^;nant.  Urine  showed 
trace  of  albumen  and  much  pus.  Temperature  normal.  Suffering  from  dysenteric 
syndrome,  sometimes  more,  sometimes  less  intensely.  The  feces  under  the  micro- 
scope showed  a  great  deal  of  blood  and  many  amebse  in  active  motion,  and  phago- 
cytised  erythrocytes.  June  28,  began  to  use  10  drops  of  the  adrenalin  solution 
every  two  hours.  June  29,  evacuated  three  times  without  colic  or  tenesmus.  The 
feces  became  dark  in  color.  A  few  nonmotile  amebse  with  granular  protoplasm; 
very  little  blood.  July  1,  two  evacuations  with  few  amebse  and  small  amount  of 
blood.  July  3  and  4,  three  evacuations,  nearly  normal  in  appearance  and  without 
amebse  or  blood.  July  5,  a  t  the  patient's  request  she  was  discharged .  July  15,  exami- 
nation of  feces  failed  to  show  any  amebse,  blood,  or  cysts.  Cured  by  adrenalin  in  5 
days  of  treatment. 

Case  VI, — Antonio  R.,  Italian,  married,  32  years  old,  resident  in  the  capital.  On 
June  5  he  came  to  the  clinic  informing  us  that  he  had  been  sick  since  October,  1914. 
Creneral  condition  bad;  very  pale  and  thin.  He  presents  the  complete  dysenteric 
syndrome  with  70  to  80  muco-sanguinous  stools  daily.  He  could  not  even  sleep 
because  of  the  severe  coUc  and  tenesmus  which  torment  him.  He  was  treated  for 
several  months  by  another  colleague,  who  gave  him  some  injections  of  emetin,  with 
but  little  benefit,  and  for  this  reason  he  abandoned  the  treatment.  The  feces 
having  been  examined  on  the  same  day,  we  found  many  entamebse  histolytica  in 
motion  and  a  laige  quantity  of  erythrocytes.  We  prescribed  10  drops  of  1  to  1,000 
adrenalin  solution  (Parke  Davis)  every  three  hours.  June  6,  he  returned  and  said  that 
he  had  evacuated  30  times,  with  less  colic  and  tenesmus,  so  that  he  had  succeeded 
in  sleeping  some,  which  he  had  been  unable  to  do  for  a  long  time.  The  medication 
was  continued.  June  7,  feces  contained  less  blood  and  fewer  ameb».  We  Increased 
the  dose  to  20  drops  every  three  hours.  June  8,  had  17  evacuations  almost  without 
tenesmus.  June  9,  evacuated  only  10  times;  very  few  nonmotile  ameba  with  gran- 
ular ondoplasm.  Very  little  blood.  June  15,  only  evacuated  once.  No  amebse  or 
microscopic  or  occult  blood,  and  the  feces  remained  so  during  the  succeeding  days. 
July  22,  we  had  an  opportunity  of  examining  his  feces  on  this  date  and  found  no 
blood,  ameb»,  or  cysts,  the  latter  having  been  looked  for  by  Dr.  Martin  Picker 
according  to  Dr.  E.  Ujihara's  method.    Cured  by  adrenalin  in  10  days. 

Case  F7/.— Martiniano  Z.,  Brazilian,  single,  20  years  old,  resident  in  the  city. 
He  came  to  the  dispensary  on  June  3,  saying  he  had  been  sick  since  the  1st  of  the 
month  with  coUc,  frequent  muco-sanguinous  stools  accompanied  by  severe  tenesmus. 
The  microscopic  examination  showed  a  great  quantity  of  amebie  and  blood.  We 
prescribed  for  him  10  drops  of  adrenalin  solution  (1  to  1,000)  every  three  hours.  This 
he  began  to  use  on  June  4.  June  5,  feces  of  normal  appearance  and  consistency, 
without  ameb»  or  even  occult  blood.  The  following  ^Y  ^^  ^^  badly  constipated. 
July  2,  we  examined  the  feces,  which  was  negative.    Oiw^  ^7  adrenaAm  m  24  hours. 


i 


i 


584       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  CONGRESS. 

(^  VIIL—V,  R.,  angle,  Brazilian,  28  yeare  old,  resident  in  the  suburb  of  Santa 
Cedlia.  On  the  night  of  July  4  he  felt  the  first  colicky  pains  and  a  frequent  deaire  to 
go  to  stool.  The  stools  were  only  bloody  mucus  and  were  accompanied  by  severe  tenes- 
mus. July  5,  we  found  many  amebae  in  motion  and  large  amounts  of  blood.  At 
noon  we  began  to  give  10  drops  of  adrenalin  every  two  hours.  After  the  firstdose  of 
the  drug  he  experienced  immediate  improv^nent,  which  became  more  and  more 
marked.  Up  to  6  o'clock  in  the  evening  he  had  only  two  stools  and  these  painleas. 
No  more  passages  until  the  9th  of  July,  when  a  saline  purgative  was  given.  We  found 
AO  ftmebae,  cysts,  or  blood  in  the  feces.    Cured  by  adrenalin  in  six  hours. 

Com  JX.— Anna  M.,  Brazilian,  single,  18  years  old,  resident  in  the  suburb  of  Villa 
Buarque.  On  July  9,  at  night,  she  felt  the  first  colicky  pains  with  the  expulsion  of 
bloody  stools  every  10  minutes.  July  10,  we  found  laige  quantities  of  amebse  and 
blood.  The  treatment  was  begun  by  using  a  Brazilian  solution  of  adrenalin,  10  drops 
^very  two  hours.  The  patient  did  not  improve  and  on  the  following  day  we  substi- 
tuted this  preparation  by  one  made  by  Clm  &.  Co.,  but  still  without  result,  a  failure 
which  we  attributed  to  tiie  preparation  being  old.  We  were  disappointed  as  we  wece 
accustomed  to  record  immediate  improv^nent.  On  July  12,  we  prescribed  Parke 
Davis's  adrenalin.  After  the  first  dose  (20  drops)  the  patient  b^gan  to  improve  and 
at  the  end  of  six  hours  left  her  bed  and  tried  to  work.  The  examination  of  the  feces 
which,  after  the  use  of  National  and  French  preparations  of  adrenalin  showed  amelMe 
and  blood,  was  now  entirely  negative.  The  constipating  action  of  the  adrenalin 
continued  until  the  fifth  day,  when  after  a  purge  the  feces  examined  were  negative 
and  remained  so  subsequently.    Cured  by  adrenalin  in  6  hours. 

Oue  X. — Santa  Casa  de  Misericordia  Hospital  (Sfto  Paulo),  first  women's  medical 
ward,  case  card  No.  9672;  bed  No.  21.  Maria  Ramos,  Portuguese,  married,  30  yean 
old,  resident  in  the  capital.  Admitted  October  4.  Had  been  sick  for  8  months; 
presenting  at  all  times,  with  greater  or  less  severity,  the  complete  dysenteric  syndrome. 
General  condition  bad,  patient  very  thin  and  debilitated;  dimy  tongne;  the  ligjit 
lobe  of  the  Uver  enlarged  and  painful  on  pressure,  with  a  spot  of  maximum  tenderness 
in  one  of  the  intercostal  spaces.  Slifi^t  edema  of  the  overlying  chest  wall;  scapa- 
lodynia  on  the  same  side.  Tempefature  38^  C.  on  the  day  of  admission  to  the  hos- 
pital. She  states  that  there  is  an  exacerbation  of  symptoms  in  the  evening,  these 
being  preceded  by  chills  and  to?rard  night  followed  by  inrofuse  sweats.  Urine  Is 
normal.  Feces  are  muco-sanguinous  and  very  foul  smelling.  Under  the  microBc<^ 
great  numbers  of  histolytic  amebse  are  seen  and  these  show  red  blood  cells  which  they 
have  phagocytised« 

Treatment:  Ten  drops  of  Parke  Davis  &  Co.'s  1  to  1,000  adrenalin  solution  every 
two  hours,  and  this  dose  was  increased  to  30  drops  on  the  14th,  as  the  feces  still  con- 
tained blood  and  ameb»,  though  in  smaller  quantities. 

The  number  of  stools  became  progresrively  lees,  also  the  quantity  of  blood  and  num- 
ber of  ameb»  until  October  25,  from  whidi  date  on,  the  feces  were  of  a  pasty  con- 
sistency and  contained  no  amebse,  blood  or  cysts.  The  intestinal  coUc  and  tenes- 
mus ceased  after  the  first  few  doses  of  the  dnwr.  The  general  condition  of  the  patient 
continued  to  improve;  the  edema  of  the  chest  wall  disappeared,  also  the  tendemesi 
to  pressure  and  the  fever. 

The  day  following  the  admisrion  of  the  patient,  I  made  an  exploratory  pimctiiie 
of  the  liver  at  the  site  of  maximum  tenderness  and  withdrew  a  small  quantity  of  pus, 
chocolate  colored,  and  which  showed  the  presence  of  motile  amebse  when  examined 
under  the  microscope. 

On  November  6  I  stopped  the  medication,  discharging  the  patient,  who  left  the 
18th,  strong,  robust,  with  a  good  color,  and  without  having  shown  any  more  ameb» 
or  cysts  in  the  feces,  which  had  returned  to  normal. 


FUBLIO  HEALTH  AND  MEIXEOINB. 


585 


Cured  of  dysentery  and  of  »  Buppuratiye  heptttitis,  of  amebic  (»igin,  by  aiii-An^Hn 
in:25dayB. 

y  OONOLUaiON. 

Fust.  Beside  emetin«  and  periiaps  with  advantages  over  it,  there  exists  another  drag 
of^great  therapeutic  vahie  in  the  treatment  of  ameUc  dysentery— adrenalin. 

Second.  Adrenalin  appears  to  have  also  a  therapeutic  dfect  on  suppurative 
hepatitis  of  amebic  oiigui. 

The  Chatbman.  This  brings  us  to  the  end  of  our  scientific  program. 
Is  there  any  special  matter  to  come  before  the  section  t  If  not,  the 
session  is  adjourned. 

Adjourned  at  12.15  o'clock. 


GENERAL  SESSION  OF  SECTION  VIIL 

New  Ebbitt  Hotel, 
Friday  afternoon,  January  7,  1916. 

Qiairman,  H.  R.  Caeter. 

The  session  was  called  to  order  at  2  o^clock  by  the  chairman. 
The  Chairman.  The  first  paper  on  the  program  is  by  Dr.  Hoffman 
on  "The  Mortality  from  cancer  in  the  Western  Hemisphere." 

THE  MORTALITY  FROM  CANCER  IN  THE  WESTERN  HEMISPHERE. 

By  FREDERICK  L.  HOFFMAN, 
StatUtidanf  The  Prudential  Inmrance  Co.  of  Ammca, 

mTRODUCnON. 

The  progresB  of  eodety  is  laigely  measured  by  the  more  or  lees  effective  prevention 
of  poverty,  sickneaB,  and  premature  death.  Within  a  single  generation  a  veritable 
revolution  has  been  achieved  in  the  control  of  many  important  diseases,  and  some  of 
the  most  destructive  plagues  of  mankind  have  been  successfully  eliminated,  or 
mateiially  reduced  in  frequency,  in  the  principal  civilized  countries  of  the  world. 
Foremost,  in  the  order  of  importance,  are  the  diseases  attributable  to  infection  or 
contagion,  and  in  many  important  countries  plague,  cholera,  yellow  fever,  leprosy, 
smallpox,  typhoid  fever,  and  tuberculosis,  as  well  as  most  of  the  acute  infectious 
diseases  of  infancy,  are  now  measurably  and  effectively  under  sanitary  control.  By 
way  of  illustration,  attention  may  be  directed  to  the  balance  of  mortality  for  four  large 
American  cities  for  which  the  data  are  available  in  a  fairly  trustworthy  form  fer  the 
last  60  years.  The  cities  considered  are  New  York,  Boston,  Philadelpdiia,  and  New 
Orleans,  and  the  data  may  be  relied  upon  as  fairly  representative  for  at  least  the  urban 
centers  of  population  of  the  couotry  at  laige. 

DECLINE  IN  THE  DEATH  RATE. 

In  the  four  dties  under  consideration  Asiatic  cholera  and  yellow  fever  have  been 
practically  eliminated.  Smallpox  has  been  reduced  from  a  former  rate  of  39.5  to  a 
present  rate  of  only  2.4  per  100,000  of  population .  Scarlet  fever,  diphtheria  and  croup, 
typhoid  fever,  and  pulmonary  tuberculosis,  as  well  as  the  diseases  of  the  stomach  and 
intestines,  have  materially  decreased  diuing  the  last  quarter-century,  compared  with 
the  25  years  preceding  the  year  1889.  The  most  significant  exception  to  a  general 
decline  in  the  death  rate  is  the  increasing  mortality  from  cancer.    In  the  four  cities 

586 


PtJBUO  HEALTH  AND  MBDIOIVB. 


587 


under  consideration  the  cancer  death  rate  has  increased  from  46.4  to  72.1  per  100,000 
of  population.  In  other  words,  there  has  been  an  actual  increase  in  the  rate  of  25.7 
per  100,000  of  population,  equivalent  to  a  quarter-century  increase  in  the  rate  of  55.4 
per  cent. 

Balance  of  mortality  for  New  York,  Boston,  Philadelphia^  and  New  Orleans, 

1864rl888y  1889-1913, 

LBatas  per  IQOfiOO  of  popnlatton.) 


Smallpox 

Asiatic  cholera 

Yellow  fever 

Soerlet  fever 

Diphtheria  and  croup 

Tn>hoid  and  typhus  fevers. . . . 

Pnnnonary  tnbercutoeJs 

Pneamontt 

Stomach  and  intestiiia]  diseases 

Heart  diseases 

Nephritis 

Cancer 


1864-1S88 

1889-1913                                     1 

Deaths. 

Bates. 

Deaths. 

Rates. 

23,799 

39.5 

3,306 

2.4 

4,500 

7.6 

10 

.01 

8,4(>0 

14.0 

821 

.0 

39,983 

60.3 

26,500 

1SL8 

74,274 

123.2 

79,890 

58.3 

32,042 

58.1 

38,673 

24.7 

220,048 

3019 

308,802 

223.3 

113,712 

188.6 

816,048 

232.0 

164,698 

288.0 

200,901 

190.2 

62,505 

108.7 

223,991 

164.0 

47,479 
27^806 

78.7 

179,258 

131.7 

40.4 

98,085 

72.1 

INGBBA8B  IN  CANCER. 

In  the  regLBtration  area  of  the  United  States,  during  the  decade  ending  with  1912, 
the  death  rate  from  cancer  was  72.8  per  100,000  of  population,  or  55.7  for  males  and 
90.6  for  females.  In  the  registration  area,  which  now  includes  about  two-thirds  of 
the  entire  American  population,  the  cancer  death  rate  has  increased  from  62.9  per 
100,000  of  population  during  1900  to  78.9  during  1913.  On  the  basis  of  a  conservative 
estimate  the  annual  number  of  deaths  from  cancer  in  the  entire  United  States  is 
approximately  80,000.  It  is  therefore  not  jgoing  too  to  to  speak  of  cancer  aa  a  menace 
to  civilization  and  as  a  disease  of  the  very  fust  order  of  present-day  importance  in 
medicine,  surgery,  and  public  health. 

PROBLEMS  OP  CANCER  CONTROL. 

Largely  upon  the  basis  of  the  statistical  evidence  regarding  cancer  frequency  and 
cancer  increase  throughout  practically  the  ^itire  civilized  world,  a  movement  was 
inaugurated  within  very  recent  years  effectively  to  arouse  public  interest  in  the 
possibilities  of  cancer  prevention  and  cancer  control.    Chiefly  under  the  direction  of 
the  American  Society  for  the  Control  of  Cancer,  but  in  hearty  cooperation  with 
National,  State,  and  local  medical  and  surgical  societiee,  a  campaign  of  education  has 
been  carried  on  through  the  entire  country,  which,  in  the  opinion  of  those  beet  quali- 
fied to  judge,  has  been  decidedly  beneficial  and  warrants  favorable  anticipatioiis 
regarding  ultimate  results.    Under  the  auspices  of  the  American  Society  for  the  Con- 
trol of  Cancer,  the  American  Medical  Association,  medical  societiee.  State  and  muni- 
cipal boards  of  health,  etc.,  and  several  of  the  laige  American  life  insurance  com- 
panies, a  considerable  amount  of  well-conaidered  and  instructive  information,  on  the 
cancer  problem  in  its  relation  to  the  individual  has  b^H  pubUehod  and  maA^  av«a^\>\e 
to  many  who  otherwise  could  not  have  been  reacl^^  so  effectiveVy  «i3^^  ^  *^  ^™^  * 
period  of  time.    Since  the  appeal  to  the  pubUc  ^o^A^eVy  \i>«i^e  ©X»^«*aK«^  ^ 
of  the  cancer  situation,  conservatively  detema^^    vv  ^  ^V*^*»^&«^  eBBS^fo*  ^     ja 


hemisphere. 


^^>^^^fsni 


FBOOBBDIKOS  HBOOVD  FAN  AUEBIOAN  BOIEKTIFIC   OONOBESS. 


PUBLIC  HEALTH  AKD  MEDIOIKB.  589 

OBOORAPHICAL  INCIDENCE. 

The  frequency  of  cancer,  geographically  considered,  varies  enormously  throughout 
the  world,  but  the  mortality  rate  is  also  decidedly  affected  by  sex,  age,  race,  and 
marital  condition.  Apparently  lees  important  factors  are  climate  and  occupation. 
For  many  imp<»rtant  countries  no  trustworthy  data  are  at  present  available  and  lor 
most  of  the  States  of  the  Western  Hemisphere  the  acceptable  returns  are  limited  to 
large  cities.  When  all  the  available  statistics  for  the  civilized  world  are  combined, 
it  appears  that  during  recent  years  (1908-1912)  the  average  cancer  death  rate  was  65.7 
per  100,000  of  population  for  the  Western  Hemisphere,  which  compares  with  a  rate  of 
72.8  for  the  Eastern  Hemisphere.  In  the  Western  Hemisphere  the  country  of  most 
importance,  whether  considered  by  area  or  population,  ia  naturally  the  United  States, 
but  even  for  this  country  there  are  at  present  trustworthy  mortality  data  for  only  two- 
thirds  of  the  population,  and  40  per  cent  of  the  total  area.  It  is,  therefore,  not  feasible 
to  make  a  thorou^y  satisfoctory  presentation  of  the  facts  of  geograj^cal  incidence 
for  the  ^itire  Western  Hemisphere,  but  the  available  amount  of  information  is  suffi- 
cient for  the  inreeent  purpose.  Preliminary,  however,  to  a  discussion  of  the  varia- 
tions in  the  cancer  death  rate  throu^out  the  Western  Hemisphere,  certain  elementary 
statistical  considerations,  based  laigely  upon  the  cancer  mortality  statistics  of  the 
United  States  registration  area,  are  entitled  to  presentation. 

AGE   AND  SEX. 

The  table  following  exhibits  the  mortality  from  cancer  by  age  and  sex  in  the  United 
States  registration  area  for  the  decade  1908-1912.  According  to  this  table  the  death 
rate  is  practically  the  same  far  both  sexes  at  ages  under  5,  a  trifle  hifi^er  ior  males  at 
ages  5  to  14,  but  at  ages  15  to  44  the  male  rate  is  13.6  per  100,000  of  population  and  the 
female  rate  32.1;  or,  in  other  words,  the  female  rate  is  18.5  per  100,000  of  population, 
or  136  per  cent,  in  excess  of  the  male  rate.  At  ages  45  and  over  the  male  rate  is 
236.5,  against  366.4  for  females;  or,  in  other  words,  the  cancer  death  rate  of  females 
at  this  age  period  is  129.9  per  100,000  of  population,  or  54.9  per  cent,  in  excess  of  the 
male  rate.  This  excess  in  the  adult  cancer  death  rate  of  women  is  laigely,  in  the 
United  States  at  least,  due  to  cancer  frequency  in  organs  or  parts  peculiar  to  the 
female  sex.  The  table  on  the  following  page  exhibits  the  cancer  mortality  by  organs 
and  parts,  in  the  United  States  registration  area,  for  the  period  1903-1912,  with  an 
estimate  of  the  number  of  deaths  from  cancer  for  the  different  organs  and  parts,  accord- 
ing to  sex,  for  the  year  1915. 

Mortality  from  cancer,  by  age  and$ez,  United  States  regittration  area,  190S-J91t, 

[BttC0  pcrlOO,000  of  popolfttlioiL] 


Agfli. 

BMtm, 

IfUfli. 

rmuHm. 

Under  6 

t.8 

L7 

18.6 

836.5 

S.0 

5  to  14 

L8 

15  to  44 

83.1 

45  ftnd  flTur 

886.4 

OBOAN8  AND  PABT8. 


According  to  this  table  the  rate  of  mortality  from  cancer  (A  the  stomach  and  liver 
is  almost  the  same  for  both  sexes,  but  there  is  a  decided  excess  in  the  case  of  females 
in  the  mortality  rate  from  cancer  of  the  peritoneum,  intestines,  and  rectum.  The  rate 
of  mortality  from  cancer  of  the  skin  and  of  the  buccal  cavi^  is  higher  among  men 


690       PBOGEEDINGS  SECOND  PAN  AMEBICAN  SOIENTIFIO  C0NQBES8. 

than  among  women,  but  the  actual  number  of  deaths  from  this  group  of  malignant 
diseases  is  not  of  so  much  importance.  The  excess  in  the  female  cancer  mortality 
ifi  to  be  -found  chiefly  in  the  deaths  from  cancer  of  the  generative  organs  and  of  the 
female  breast,  accoimting  for  39.3  per  cent  of  the  total  mortality  from  cancer  among 
women,  and  35.6  per  100,000  of  population  of  females  separately  considered.  Elimi- 
nating cancer  of  the  generative  organs  and  of  the  breast,  it  is  shown  that  the  cancer 
death  rate  for  males  was  55.7  per  100,000  of  population,  against  55.0  for  females;  or, 
in  other  words,  the  actual  differences  in  the  rates  were  relatively  of  small  significance. 
As  will  subsequently  bo  shown,  these  differences  in  the  incidence  of  cancer  by  sex 
vary  widely  throughout  the  world,  and  it  is  in  the  directicm  of  geographical  pathology 
that  the  outlook  is  most  encouraging  that  future  statistical  research  will  add  mate- 
rially to  our  imderstanding  of  the  conditions  and  circumstances  accountable  for  a 
high  or  low  cancer  death  rate. 

Mortality  from  cancer^  by  organs  or  parts,  United  States  registration  area,  1903-1912,  and 
estimated  cancer  mortality  of  the  Continental  United  States,  1915. 

[Rates  per  100,000  of  population.] 


Males: 

Boocalcavitv. , 

Stomach  and  livtf 

Peritoneum,  intestines,  and  rectum 

Skin 

Other  or  not  spedfled  organs , 

Ages  45  and  over , 

Total  all  ages 

Females: 

Buooalcavitj 

Stomach  ana  liver 

Peritoneum,  intestines  and  rectum, 

Generative  organs 

Breast 

Skin 

Other  or  not  specified  organs 

Agee  45  and  over 

Total  all  ages 


Esti- 

Number 

Per 
cent. 

mated 

of  deaths 

Rates. 

number 

1903-1912. 

of  deaths 

1915.1 

9,652 

7.4 

4.2 

2,608 

64,049 

49.4 

27.5 

15,622 

16,615 

12.8 

7.1 

4,503 

7,722 

5.9 

3.3 

1,808 

81,746 

24.5 

13.6 

7,577 

111,884 

86.2 

236.5 

28,185 

129,784 

100.0 

65.7 

32,118 

2,163 

1.1 

1.0 

541 

64,685 

81.9 

29.0 

16,050 

23,137 

11.4 

10.8 

6,U0 

49,747 

24.6 

22.3 

12,848 

29.685 

14.7 

13.8 

7,285 

4.306 

2.1 

1.9 

958 

28,098 

14.2 

12.8 

4,640 

164,673 

81.4 

866.4 

89,456 

202,421 

100.0 

90.6 

47,882 

Per 
cent. 


8.1 
48.6 
14.0 

5.6 

28.6 

S7.6 

100.0 

1.1 

88.5 

12.8 

25.8 

15.1 

2.0 

9.7 

82.4 

100.0 


1  Estimated  on  the  basis  of  the  percentage  distrlbotioii  of  the  mortality  from  cancer  in  the  reglstnttloB 
area  in  1913. 

URBAN  AND  RURAL. 

In  the  redstration  States  of  the  United  States  during  the  decade  ending  with  1912 
the  urban  mortality  rate  from  cancer  was  79.2,  against  a  rural  rate  of  66.7,  per  100,000 
population.  The  urban  rate  is  partly  affected  by  cancer  deaths  in  hospitals  and 
Bpedal  institutions  for  cancer  treatment,  but  when  due  allowance  is  made  for  this 
fetctor  there  would  seem  to  be  no  reason  to  question  the  conclusion  that  cancer  is 
relatively  more  common  among  American  city  population  when  compared  with  the 
corresponding  population  of  the  country.  Important  exceptions,  however,  are  met 
with  in  different  coimtries  of  the  world,  and  the  present  conclusion  applies  only  to 
the  registration  States  of  the  United  States  r^jfistration  area.  Crude  death  rates  in 
this  respect  2Lje  quite  likely  to  be  misleading  in  that  the  proportion  of  aged  persons 
is  almost  everywhere  larger  in  the  country  districts  than  in  the  cities. 


RACE. 


During  the  period  1906-1912,  in  30  large  southern  cities  of  the  United  States  the 
cancer  mortality  rate  of  the  white  population  was  80.3  per  100,000  of  population,  and 
of  the  colored  population,  55.2.    All  the  available  statistics  for  the  United  States  and 


PUBUO  HEALTH  Ain>  MEDICINE. 


591 


other  countries  emphatically  sustain  the  conclusion  that  cancer,  generally  considered, 
is  relatively  rare  amoug  primitive  races.  In  the  case  of  the  American  negro,  for  more 
than  a  century  and  a  half  in  close  contact  with  the  white  race,  and  with  habits  of  life 
closely  conforming  to  those  of  the  Caucasians,  there  has  been  a  gradual  approach  in 
the  cancer  death  rate  toward  the  rate  common  to  the  white  population,  and  for  cancer 
of  the  uterus  the  rate  for  the  negro  population  of  at  least  certain  American  cities  is 
now  in  excess  of  the  corresponding  rate  for  white  women .  The  lesser  liability  to  cancer 
among  primitive  races  would,  therefore,  seem  to  be  rather  attributable  to  habits  of 
life  or  tiie  mode  of  living  than  to  racial  immurity.  Of  all  the  statistical  elements  of 
the  cancer  problem  the  racial  aspect  of  the  disease  is  extremely  interesting  and  most 
likely  to  prove  of  the  first  order  of  practical  importance.  Several  careful  investi- 
gations have  been  made  in  the  United  States  with  reference  to  the  occurrence  or  rela- 
tive frequency  of  malignant  diseases  among  North  American  Indians  and  the  EsMmoB 
of  Alaska  and  Labrador,  but  without  exception  the  results  have  been  negative.  In 
other  words,  there  are  no  reasons  for  questioning  the  statement  that  cancer  is  actually 
as  well  as  apparently  very  rare  among  North  American  Indians  and  Eskimos,  and 
that  the  explanation  for  the  infrequency  of  the  disease  is,  most  likely,  that  it  is  due 
to  habits  or  mode  of  life  rather  than  to  racial  immunity. 

The  possible  correlation  of  latitude  and  equivalent  climatic  conditions  to  cancer 
frequency  is  shown  in  the  table  following,  illustrating  the  mortality  from  cancer  in 
130  cities,  according  to  latitude,  for  the  Eastern  and  Western  Hemispheres,  for  the 
period  of  1908-1912: 

Mortality  from  cancer  in  otiM,  according  to  latitude,  Eastern  and  Western  Hemi$phere$, 

1908-1912, 


Eastern  Hemisphere. 

Western  Hemispliere. 

Degree  of  latatode. 

Nnmber 
of  cities. 

Rates  per 

ioo,o(n 

Index 
nnmber. 

Nombcr 
of  cities. 

Rates  per 

100,000 

Index 
number. 

60N.-60N 

86 
22 
6 
3 
1 
1 
1 

106.7 
10S.4 
66.9 
13.6 
11.6 
34.4 
90.1 

98 
100 
62 
13 
11 
82 
83 

60N.-40N 

26 
18 
4 
8 
6 
4 

77.3 
86.6 
77.2 
82.7 
38.2 
89.8 

100 

40N.-30N 

111 

30N.-10N 

100 

10N.-10  8 

107 

10S.-30S 

49 

80  8.-40  8 

116 

Total 

69 

9S.3 

, 

61 

78.0 

According  to  this  table  there  is  no  precise  degree  of  correlation,  partly,  no  doubt, 
because  of  the  fact  that  the  data  for  tropical  countries  are  too  insuJficient,  and  that 
such  cities  as  Calcutta,  Hongkong,  and  Singapore  are  not  strictly  comparable  with 
cities  like  New  Orleans,  Habana,  and  Paramaribo.  Furthermore,  60^  to  50^  north 
latitude  in  European  countries  corresponds  rather  to  50^  to  40^  north  latitude  in  the 
Western  Hemisphere,  as  regards  dimatological  conditions.  It  has  not  been  feasible 
for  the  present  purpose  to  establish,  on  the  basis  of  a  sufficient  amount  of  statistical 
information,  the  precise  correlation  of  temperature,  rainfall,  and  humidity  to  cancer 
frequency,  but  the  suggestion  may  be  made  here  that  such  a  study  would  add  a  useful 
contribution  to  cancer  knowledge. 

HABITS  AND  BCONOKIC  CONDniONS. 

The  question  may  also  be  raised  as  to  whether  the  observed  differences  in  the 
relative  frequency  of  cancer  between  civilized  and  primitive  man  are  not  primarily 
conditioned  by  habits  of  life,  chiefly,  of  course,  diet,  which  is  largely  a  matter  of 
material  well-being.    Native  races  are  generally  underfed,  at  least  with  regard  to 


692       PBOOEBDIKQS  8B00KD  PAN  AMBBIOAK  SOISNTDIO  00NGBE88. 

what  in  civilized  countries  is  nonnally  considered  a  nutritious  diet,  often,  however, 
eiToneously  confused  with  an  excess  in  food  consumption.  At  least  in  the  case  of 
the  native  American  Indians  it  is  a  safe  assumption  that  the  laige  majority  are  under- 
fed, which,  however,  is  not  necessarily  equivalent  to  the  conclusion  that  they  are 
undernourished,  for,  broadly  speaking,  that  is  seldom  the  case.  Such  investigations 
as  have  been  made  to  determine  whether  the  poor,  as  a  class,  are  as  liable  to  cancer 
or  more  so  than  the  well  to  do,  as  has  abundantly  been  shown  to  be  the  case  with 
tuberculosis,  have  all  been  in  the  negative.  In  other  words,  the  available  evidence 
is  rather  to  the  effect  that  cancer  is  chiefly  a  disease  of  the  well  to  do  and  by  inference 
a  disease  of  civilization,  which  broadly  speaking  is  measured  by  the  attained  degree 
of  material  well-being  or  widely  diffused  material  prosperity.  Exact  statistics  are 
unfcHTtunately  obtainable  with  difficulty,  but  a  most  important  contribution  to  our 
knowledge  has  recentiy  been  made  by  the  public  health  department  of  the  dty  of 
Eidinbuigh,  which  has  published  the  statistics  of  cancer  and  tuberculosis  according 
to  the  rental  of  the  houses  occupied  by  the  deceased.  It  is  shown  by  this  inquiry 
that  of  the  mortality  from  phthisis  36.4  per  cent  of  the  deaths  occurred  in  houses  rent- 
ing at  less  than  about  $50  per  annum,  34.6  per  cent  occurred  in  houses  renting  at  from 
$50  to  $100,  and  17.9  per  cent  occurred  in  houses  renting  at  over  $100  per  annum. 
The  remainder  occurred  in  lodging  houses,  or  the  information  was  not  given.  In 
contrast  of  the  mortality  from  cancer  only  21.8  per  cent  occurred  in  the  houses  with 
the  lowest  rental,  37  per  cent  in  the  houses  with  a  moderate  rental,  and  35.9  per  cent 
in  the  houses  with  a  rental  rather  indicative  of  the  prosperous  and  the  well  to  do .  Fur- 
thermore, while  6.9  per  cent  of  the  deaths  from  phthisis  occurred  in  lodging  houses, 
typical  of  the  very  poor,  only  0.9  per  cent  of  the  deaths  from  cancer  occurred  in  this 
dass  of  residences.  The  proportion  of  deaths  with  residences  not  stated  was  practi- 
cally the  same  for  both  diseases.  Restating  these  rather  important  conclusions,  it 
would  appear  that  the  frequency  of  cancer  deaths  was  about  one-third  less  in  the 
bouses  of  the  poor  but  nearly  double  in  the  houses  of  the  well  to  do  than  in  the  case 
of  those  who  died  from  phthisis,  which  is  generally  considered  a  disease  of  poverty. 
These  observations  suggest  the  great  practical  value  of  a  further  statistical  study  of 
the  relation  of  material  well-being  to  cancer  and  tuberculosis. 

MARITAL  OONDmON. 

Among  other  important  statistical  foctors  which  require  more  extended  considera- 
tion in  the  study  of  the  caiuier  problem  is  marital  condition.  A  recent  investigation 
by  the  registrar  general  of  England  and  Wales,  extending  over  a  period  of  three  years, 
seems  to  warrant  the  important  conclusion  that  cancer  of  the  breast  and  ovaries  is 
decidedly  more  common  among  single  than  among  married  women,  when  proper 
correction  is  made  for  variations  in  the  age  distribution.  In  contrast,  cancer  of  the 
uterus,  however,  is  decidedly  more  common  among  the  married  than  among  the 
unmarried,  but  there  are  reasons  for  believing  that  if  a  further  analysis  could  be  made 
of  the  precise  site  of  the  disease  it  would  be  shown  that  the  excess  in  the  mortality 
of  the  married  is  chiefly  limited  to  cancer  of  the  cervix. 

CANOBR  INOBEASB  IN  OLD  AOB. 

Of  all  the  factors,  however,  which  influence  the  cancer  death  rate  age  is  of  the 
first  order  of  importance.  Cancer  is  essentially  a  disease  of  adult  life,  and  of  the 
80,000  estimated  deaths  from  cancer  in  the  United  States  at  all  ages  for  the  year  1915, 
approximately  67,600,  or  84.5  per  cent,  occur  at  ages  45  and  over.  Since  the  age  dis- 
tribution of  the  population  varies  materially,  not  only  for  different  countries,  States, 
and  cities,  but  also  for  di^erent  periods  of  time,  it  is  imperative  that  as  far  as  prac- 
ticable, the  age  factor  should  alwa>^  be  taken  into  account.  Unfortunately  a  recal- 
culation of  crude  cancer  death  rates,  in  conformity  to  a  standard  basis  of  age  dis- 
tribution, is  frequently  quite  difficult  and  often  practically  impossible. 


PTTBUO   HEALTH  AND  MtJOOIXX. 


693 


The  most  useful  BtatiBticB  for  the  purpoee  of  illiurtiatiiig  the  influence  of  age  on  the 
cancer  death  i&te  and  the  changes  in  the  rate  are  those  for  England  and  Wales,  which 
lor  the  present  purpose,  however,  u«  limit«d  to  the  male  population  and  the  two  years 
ISOlandlSlS.    ThedataareMtforthinthe table  below: 


Mortality  fiam  a 


n  EngloTid  and  WaU$  accorAng  to  age,  1901  compared  with  IBOS? 


ACB. 

m 

,m 

bxlM 

PopoUlbn 

Dtathi. 

Batsi. 

Popnlitla). 

DMtbl. 

Batn. 

bo. 

1,<IM.SM 
3,MD,WS 

3,  no.  i«a 

109,333 

es 

i 

2.0W 

IS 

J! 

«as.s 

1    1 

1;    £ 

'i 

3« 

1,<M 

1 

3.S 

li 

11,734.813 

io,ni 

«.5 

17,789,001 

n.9w 

M.1 

<  Halts  00I7. 

According  to  this  table  the  cancer  death  nXa  for  malee  at  all  agee  increased  37  per 
cent,  but  the  moat  significant  incKseea  in  the  rate  occutred  at  ages  56  and  over,  having 
been,  respectively,  25  per  cent  at  ages  55-64,  27  per  cent  at  ages  65-74,  44  per  cent 
at  ages  75-84,  and  37  per  cent  at  ages  85  and  over.  The  table  warrants  the  conclu- 
aion,  which  is  fully  sustained  by  an  analysis  of  corresponding  statisticB  fur  the  United 
States  and  other  countries,  that  the  increase  in  the  cancer  death  rate  has  occurred 
largely  in  the  period  of  advanced  adult  life.  An  extended  statistical  study  of  the 
details  by  single  yean  reveals  the  foct  that  the  increase  has  been  tu  from  unifnm 
at  every  period  of  life,  but  that  there  have  been  many  important  fluctuations  and 
variations  suggestive  of  a  real  increase  rather  than  an  apparent  improvement  in  the 
rate  in  consequence  of  increased  accuracy  in  diagnosia  and  death  certification.  To 
illustrate  this  point  of  view  more  precisely  a  table  is  included,  giving  the  rates  by 
divisonaJ  periods  of  Ufe  for  the  male  population  by  single  years  for  the  entire  period 
1901-1913.    This  table  is  self-explanatory  and  requires  no  extended  discussion. 

MorUditgJnm  taneer  in  England  and  Watet  aecardiJig  U>  oge,  lS01-t91S.' 
IBatM  pa  loajno  oIpopaktkiii.| 


DDdtr 

^. 

^. 

(t-M. 

tt-74. 

TBind 

AH 
tgm. 

4.4 

t! 

4.7 

t\ 

1.1 

as 

li 

43:4 

P 

lfl«.S 

is 

li 
iTi! 
ii 

«lfl.« 

Si 

S4& 

fl7B. 

«e4. 

m. 

781. 

Tn. 

771. 
788. 

i 

ea.1 

694       PBOOEEDIKQS  SBGOKD  PAN  AMEBIOAN  SCIENTIFIC  C0NQBES8. 

MOBTAI«mr  OF  THB  WB8TERN  HBMI8FHBRE. 

The  present  state  of  intematioiud  vital  statistics  is  fBi  from  being  satisfactory  and 
conclusive.  Every  international  comparison  is  more  or  less  liable  to  serious  errors, 
but  particularly  so  in  the  case  of  the  countries  of  practically  the  entire  Western 
Hemisphere.  An  extended  discussion  of  the  local  cancer  death  rate  by  countries, 
States,  and  cities  throughout  this  vast  area  would  obviousily  be  impracticable  on  the 
present  occasion,  but  the  following  observations  are  presented  as  a  tentative  contri- 
bution toward  a  more  scientific  and  extended  study  of  the  geographical  distribution 
of  cancer  throughout  the  Western  Hemisphere.  Combining  the  available  statistics 
from  official  sources  for  the  period  1908-1912,  the  average  cancer  frequency  rates  for 
the  principal  geographical  divisions  were  as  follows: 

Latitude  50^  N.-40^  N.  includes  the  principal  cities  ot  States  of  British  North 
America  and  the  northern  tier  of  the  registration  area  of  the  United  States,  with  a 
population  of  approximately  14,400,000.  The  average  cancer  death  rate  for  this  area 
was  77.3  per  100,000  of  population. 

Latitude  40^  N.-30°  N.  includes  the  larger  portion  of  the  central  and  southern  tiers 
of  the  United  States  registration  area,  with  a  population  of  approximately  6,000,000. 
The  average  cancer  death  rate  for  this  area  was  85.5  per  100,000  of  population. 

Latitude  30^  N.-IO^  N.  includes  the  cities  of  New  Orleans,  Habana  (Cuba),  Mexico 
City,  and  Caracas  (Venezuela),  with  a  population  of  approximately  1,275,000.  The 
average  cancer  death  rate  for  this  area  was  77.2  per  100,000  of  population. 

Latitude  10^  N.-IO^  S.,  entirely  within  the  Tropics,  includes  the  cities  of  Parama- 
ribo (Dutch  Quiana),  Bogota  (United  States  of  Colombia),  and  Cruayaquil  (Ecuador), 
with  a  population  of  approximately  240,000.  The  average  cancer  death  rate  for  this 
area  was  82.7  per  100,000  of  population. 

Latitude  10^  S.~30^  S.  includes  the  principal  cities  of  Brazil,  and  Santiago  del 
Estero  (Argentina),  with  a  population  of  approximately  1,600,000.  The  average 
cancer  death  rate  for  this  area  was  38.2  per  100,000  of  population. 

Latitude  30^  8.-40^  S.  includes  the  city  of  Pelotas  (Brazil),  the  two  principal  citie^ 
of  the  Argentine  Republic,  and  the  dty  of  Montevideo  (Uruguay),  with  a  population 
of  approximately  2,000,000.  The  average  cancer  death  rate  for  this  area  was  89.8  per 
100,000  of  population. 

COMFARATIVB  RATE  OF  FRBQUBNCT. 

The  general  conclusion  would  seem  to  be  justified  that  there  is  a  decreasing  rate 
of  cancer  frequency  with  diminishing  distance  from  the  Equator.  How  far  this  result 
is  attributable  to  race  and  primitive  conditions  of  life,  rather  than  to  climatological 
effects,  can  not  be  stated  at  the  present  time.  In  a  general  way,  however,  it  would 
seem  safe  to  assume  that  the  effect  of  race  is  decidedly  more  pronounced  than  the 
result  of  more  obscure  climatological  conditions  such  as  temperature,  rainfall,  and 
humidity.  No  conclusive  investigation  has  as  yet  been  made  to  determine  the  pos- 
sible correlation  of  latitude  to  cancer  frequency,  but  the  general  evidence  available 
would  seem  to  suggest  that  latitude  is  not  a  pronounced  factor  in  determining  the 
cancer  death  rate.  The  following  five  tables  exhibit  the  cancer  death  rate  for  the 
period  1908-1912,  for  typical  cities  of  North,  Central,  and  South  America. 

The  first  table  is  for  the  northern  portion  of  North  America  and  includes  nine  cities, 
with  an  aggregate  population  estimated  for  1912  at  11,507,768,  and  a  range  in  the  cancer 
death  rate  from  50.6  per  100,000  of  population  for  the  city  of  Winnipeg,  to  105.7  lor 
the  city  of  Boston. 


li 


PUBLIO  HEALTH  AND  HBDIOINE. 


696 


J.  Moridiiijf  from  eoneer  in  dtUs  of  northern  North  Amerieaj  latitude  50^  N,-^^  N.^ 

1908-1912. 

[Rfttei  per  100,000  of  popaktioii.) 


WiDofpeg..... 

MoaUeAl 

Toronto 

Boston. 

Cbicaco....... 

NewYorV.... 

Ptftfttanh... 
rhUtdelphiA.. 


Total. 


Latttudo. 


40 
47 
46 
43 
42 
41 
40 
40 
40 


SON. 
SON. 
30  N. 
40  N. 
22  N. 
68  N. 
43  N. 
20  N. 
00  N. 


Fopniation 
(1912). 


169,280 

26«,600 

4M.400 

414.000 

716,711 

2,282,038 

6.082,m 

650.»t6 

1,000,072 


11,507,708 


Rata. 


60.0 
66.8 
06.4 

72.2 
106.7 
78.0 
77.1 
06.4 
8(Wt 


78.4 


The  second  table  is  for  the  eoutbeni  portion  of  Ncnrth  America  and  includes  10  cities, 
with  an  aggregate  population  estimated  for  1912  at  3,179,647,  and  a  range  in  the  cancer 
death  rate  from  50.8  per  100,000  of  population  for  the  city  of  Memphis,  to  109.7  for  the 
dty  of  San  Francisco.  In  the  caoe  of  the  more  southern  American  dtiee  the  race 
factor  is  of  considerable  determining  importance. 

//.  Mortality  from  cancer  in  dtiee  of  eovthem  North  America,  laHtude  40^  N,~SO^  N., 

1908'191t. 

[Ratal  p«rlOO,000  of  popolatloo.) 


Ratei, 


Peovor 

Baldmora.... 
Kansas  (  tty.. 

Bt.  I^Nlifl , 

8ao  Franeiiieo. 

llemnhbi 

Lob  An«^le9.., 
rbtrle«toa*.... 
Bavaooah*.... 
New  Orleans*. 


Total. 


Latitude. 

Popalation 
(1912). 

89    41  N. 

229, 2R7 

89    17  N. 

668,891 

89   06N. 

206,300 

88    8KN. 

709.887 

87    48  N. 

431,738 

86    08N. 

130,861 

84    06N. 

862.64] 

82    4AN. 

60.487 

82    06N. 

67,228 

30    OON. 

849,171 

8,179.647 

88.1 

89.6 
79.0 
81.0 

109.7 
60.8 

100.9 
68.8 
6&9 
84.9 


87.0 


>  In  1010  tb#  nerro  popalation  of  Memphis  was  40  per  cent  of  the  total;  of  Charleston,  62.8;  of  Sayannah, 
61.1,  and  of  New  Orleans.  26J. 

The  third  table  includes  the  West  Indies,  Mexico,  and  Central  America,  with  an 
agier^^te  population  estimated  for  1912  at  1,305,566.  To  increase  the  practical  value 
of  this  table  the  same  has  not  been  limited  entirely  to  cities,  but  includes  a  few 
islands,  since  in  the  West  Indian  island  communities  the  urban  and  rural  populations 
are  considerably  merged  on  account  of  the  tkct  that  the  larger  cities  have,  as  a  rule, 
the^only  available  facilities  for  institutional  treatment.  The  range  in  the  cancer 
death  rate  of  this  group  is  from  a  minimum  of  20.7  per  100.000  of  population  for  the 
island  of  Grenada,  and  20.9  for  the  island  of  St.  Lucia,  to  102.7  for  the  dty  of  Habana. 

68436—17— VOL  x 88 


696       PROCEEDINQS  SECOND  PAN  AMEBICAN  SCIENTIFIC  CONGRESS. 

UL  Mortality  frcm  cancer  in  the  West  Indies,  MexMO,  and  Central  America^  latitudi 

St""  N.-W  -Y.,  1908-191$ . 

(RatM  per  100,000  of  popnlatioii.] 


Bermtidft 

Habftna 

Mexico  City 

Danish  West  Indies 

St.  Lada 

Windward  and  Leeward  Islands. 

San  Salvador 

Grenada 


Total. 


Latitude. 


S2 
23 
19 
18 
14 
14 
13 
12 


00  N. 
OBN. 
2ft  N. 
20  N. 

01  N. 
00  N. 
44  N. 

02  N. 


Popola- 
tlon  (1912). 


19,892 

853.500 

401.500 

26  742 

49  205 

237.041 

AO.OOO 

68,177 


1,805,506 


54.1 
102.7 
40.5 
•1.0 
90.0 
970 
58.0 
20.7 


66.8 


The  fourth  table  is  for  the  northern  portion  of  South  America,  the  six  cities  repre- 
sented having  a  combined  population  for  the  year  1912  of  698,183.  The  lange  in 
the  cancer  death  late  is  from  a  minimum  of  21.8  for  La  Paz  to  a  maximum  of  104.8  for 
Caracas. 

IV,  Mortality  from  cancer  in  dUei  of  northern  South  America,  latitude  10^  N.-tO^  8,, 

1908-191i. 

(Bates  per  100»000  of  popnlatloo.] 


Latitude. 

Popula- 
tion (1912). 

Rates. 

Oaracas 

•     1 

10   81 N. 

5   SON. 

4    85N. 

2  11  8. 
13  00  8. 
16    80  S. 

75.000 
35.000 

121  257 
80.000 

800.000 
86.926 

104.8 

Panmiaribo 

95  6 

BoKota 

89.7 

Qq^yftnnilT 

59.6 

BahlaT. 

23.8 

La  Pas 

21.8 

Total 

606,188 

52.7 

The  fifth  table  is  for  the  cities  of  the  southern  portion  of  South  America,  the  seven 
cities  represented  having  an  aggregate  population  for  the  year  1912  of  3,257,569. 
The  range  in  the  cancer  death  rate  is  from  a  minimum  of  36.5  per  100,000  of  popu- 
latbn  for  Bello  Horizonte  to  a  maximum  of  116.9  for  the  city  of  Montevideo. 

F.  Mortality  from  cancer  in  citia  of  southern  South  America,  latitude  20^  S-40^  S.^ 

1908-1912. 

(Rates  per  100,000  of  popolatlon.] 


Bello  Horizonte.... 

Rio  de  Janeiro 

Sao  Panio 

Hsntheo  del  Bstero. 

Biirnos  Aires 

Montevideo 

Baaiiago  de  Chile  >.. 


Total. 


Latitude. 


20 
22 
23 
27 
34 
34 
35 


00  s. 
54  S. 
38  8. 
48  3. 
36  8. 
54  8. 
00  8. 


Popula- 
Uon  (1912). 


39.84.S 

36  5 

710,600 

42.6 

400.000 

45.4 

20  580 

87.5 

1,383  663 

85.5 

3S5.0I7 

116.9 

347.864 

71.1 

8,257,569 


Ratee. 


72.1 


iPo4'ulatloiLforl909:  rate  for  period  1905-1909. 


1 


FUBUO  HEALTH  AKD  MEDICIIfE. 


597 


The  foregoing  ratee  ftre  largely  in  the  nature  of  an  approximation  to  the  exact 
truth.  It,  however,  may  safely  be  aseerted  that  the  maigin  of  error  is  not  of  suffi- 
ciently serious  importance  to  invalidate  general  conclusions  based  upon  the  data 
presented,  which,  without  exception,  are  derived  from  official  sources.  It  is  prac- 
tically a  for^^ne  conclusion,  however,  that  in  the  case  of  communities  or  cities 
with  very  low  cancer  death  rates  the  chances  of  error  in  death  certification  and 
completeness  of  r^istration  are  more  serious  than  in  the  case  of  communities  or 
cities  with  high  cancer  death  rates,  but  the  range  in  the  rates  is  so  considerable  that 
there  can  be  no  question  of  doubt  but  that  underlying  local  causes  account  for  the 
differences,  which  are  too  pronounced  to  be  due  in  any  material  degree  to  errors  in 
clinical  diagnosis,  death  certification,  and  completeness  of  registration. 

These  data  are  illustrated  graphically  in  figure  2. 

VARIATIONS  BT  ORGANS  AND  PARTS. 

It  is  realized  that  this  statement  requires  some  amplification,  and  in  support  thereof 
the  following  observations  on  the  comparative  rate  of  cancer  frequency,  with  a  due 
regard  to  sex  and  oigans  or  parts  affected,  for  a  few  selected  cities  of  North,  Central, 
and  South  America,  are  presented: 

Mortality  from  eaneer  in  cities  of  North,  Central ,  and  SoiUh  America^  by  organs  and 

partSy  according  to  sex. 
[Rates  per  100,000  of  population.] 


North  America. 

Central  and  South  America. 

Organ  or  part 

New 
York. 

New 
Orleans.1 

San  Fran- 
cisco. 

atyof 
Mexioo. 

Riode 
Janeiro. 

Monte- 
video. 

Buenot 
Aires. 

Males: 

Buccal  cavity 

4.7 
80.0 

10.8 

1  « 

lft.1 

7.8 
27.5 

0.4 

1.5 

82.1 

10.6 
54.1 

18.7 

2.5 

20.9 

%7 
7.8 

X4 

1.8 
18.1 

8.9 

lao 

1.7 

2.0 

13.6 

5.5 
77.9 

7.8 

1.8 

85.0 

6.8 

Btomach  and  Hver 

Perltommm,  Intestlnet,  and 
rectum 

88.8 
4.8 

Bkin 

2.0 

Other  or  not  speelfled  orsani 

81.5 

All  orgMii  and  partf 

62.8 

75.8 

101.  K 

27.8 

81.8 

127.0 

1.2 
47.8 

8.7 

23.8 

7.2 

1.2 

21.1 

98.0 

Buccal  cavltv 

.0 
80.6 

12  1 

23.4 

13.7 

1.1 

9.8 

2.2 
23.2 

0.8 

85.6 

12.0 

.6 

16.9 

1.1 

40.1 

17.6 
82.6 
20.2 
2.1 
10.  A 

1.8 
9.4 

4.0 
86.8 

8  5 

.8 

13.3 

1.2 

4.1 

1.8 

15.4 

8.6 

.9 

18.8 

1.1 

6torai)ch  and  Uver 

reritonouni.  Intestines,  and 
recium 

28.4 
4.8 

18.4 

Brmst. 

4.8 

Bkln 

•8 

Other  ornot  spocifled  organs 

18.8 

All  organs  and  parts 

91.5 

97.3 

124.3 

68.6 

45.7 

110.0 

71.8 

1  The  data  for  New  Orleans  are  for  the  white  population  only. 

The  tahle  provides  sufficient  material  for  the  purpose  of  illustrating  the  very  wide 
degree  of  variation  in  the  local  incidence  of  cancer  according  to  oigans  or  parts  of 
the  body  affected.  It  can  not  well  be  questioned,  for  illustration,  that  the  status 
of  medical  practice  in  Buenos  Aires  is  not  so  very  much  different  from  the  attained 
degree  of  medical  and  suigical  proficiency  in  the  city  of  New  York.  The  table  shows 
that  the  general  cancer  death  rate  of  males  in  the  city  of  New  York  was  ^2.S  per 
100,000  of  population,  against  98.1  in  the  city  of  Buenos  Aires.  It  could  not  well 
be  maintained  that  the  physicians  of  Buenos  Aires  diagnose  malignant  disease  with 
much  greater  accuracy  than  the  physicians  of  the  city  of  New  York,  yet  cancer 
among  men  is  shown  to  be  approximately  50  per  cent  more  frequent  in  Buenos  Airei 
than  in  New  York  City,  and  upon  further  analysb  it  appears  that  most  of  this  excess 
is  due  to  the  higher  degree  or  rate  of  frequency  occurrence  in  the  case  of  cancer  of 
the  buccal  cavity,  stomach  and  liver,  skin,  and  ill-defined  or  nonspecified  oigaiif 


{ 


698       PBOOEEDINGS  BECOND  PAN  AMERICAN  8CIENTIFI0  CONGBESS. 


or  parts.  The  disease,  however,  is  less  frequent  in  Buenos  Aires  than  in  New  Yc^ 
City  in  the  case  of  cancer  of  the  peritoneum  and  intestines  and  rectum.  For  this 
group  of  cancers  the  death  rate  for  the  city  of  New  York  is  more  than  twice  the  nude 
corresponding  rate  for  the  city  of  Buenos  Aires. 

In  marked  contrast  the  female  cancer  death  rate  of  the  city  of  New  York  is  91.1 
per  100,000  of  population,  against  a  corresponding  rate  of  71.2  for  the  city  of  Buenos 
Aires.  Considered  in  detail,  it  appears  that  the  only  form  of  cancer  more  common 
among  the  women  of  Buenos  Aires  is  cancer  of  the  buccal  cavity,  but  the  excess  is 
very  slight.  The  excess  in  the  rate  for  ill-defined  or  not  specified  forms  of  cancer 
can  not  be  relied  upon  as  entirely  conclusive.  In  a  general  way,  all  important  speci- 
fied forms  of  cancer  are  less  common  among  the  women  of  Buenos  Aires  than  among 
the  women  of  New  York  City,  and  particularly  so  is  the  case  in  cancer  of  the  peri- 
toneum, intestines  and  rectum,  and  the  female  breast.  The  analysis  would  seem  to 
prove  that  the  differences  in  the  rates  are  due  to  local  conditions,  diiefly,  no  doubt, 
variations  in  habits  of  life  and  the  possible  effect  of  race  and  climate,  rather  than  to 
pronounced  or  numerically  important  errors  of  clinical  diagnosis  and  death  certifica- 
tion. 

These  data  are  illustrated  in  Figure  4. 

CANCBR  IN  THB  UNTTBD  STATES  AND  URUGUAY. 

As  a  further  contribution  to  this  very  interesting  aspect  of  the  geogra^iical  study 
of  cancer  frequency,  and  as  evidence  of  the  great  practical  value  of  an  extended 
statistical  analysis  of  the  official  returns,  the  following  comparative  table  is  included 
for  the  United  States  registration  area  and  for  Uruguay: 

Mortality  from  cancer  in  the  United  States  rcgietratian  area  and  the  Republic  of  Uruguay ^ 

by  organs  and  parts,  1906-1910, 


[RAtes  per  100,000  of  population.J 

Males. 

Females. 

Hales  and  females. 

United 
Stotes. 

Uru- 
guay. 

United 
States. 

Uru- 
guay. 

United 
States. 

Um 

Boooal  cavity 

4.2 

27.0 
7.1 

3.6 

44.4 

4.2 

0.0 
29.0 
10.5 
22.1 
13.3 

1.0 
12.4 

0.4 
20.5 

4.0 
12.2 

3.7 

.6 

10.2 

2.6 
28.3 

8.8 
10.8 

6..1 

2.7 
12.9 

2.0 

Stomach  and  liver 

86.0 

Peiitonenm,  intestine^t  ftQd  rectum. 

Female  generative  organs 

4.6 
6.0 

Female  bnwst 

1  S 

BMn 

3.4 
13.4 

1.0 
10.4 

1  1 

Other  or  not  specified  organs 

14  0 

AP onraosand  parts.. 

65.7 

73.2 

00.1 

50.4 

72.6 

66.0 

The  general  cancer  death  rates  of  the  two  countries  are  not  very  far  from  being 
about  the  same.  The  rate  for  Uruguay  was  66  p&r  100,000  of  total  population  during 
the  period  under  conmderation,  against  a  rate  ot  72.6  for  the  United  States  registra- 
tion area.  Considered,  however,  by  four  groups  of  specified  organs  or  parts,  it  appears 
the  the  rate  for  cancer  of  the  stomach  and  liver  was  28.3  per  100,000  of  total  popula- 
tion for  the  United  States  registration  area,  against  35.6  for  Uruguay.  It  could  not 
well  be  maintained,  without  the  risk  of  successful  contradiction,  that  cancer  of  the 
stomach'and  liver  is  less  accurately  diagnosed  in  the  United  States  than  in  the  South 
American  Republic.  The  mortality  from  cancer  of  the  skin  was  2.7  p^  100,000  of 
total  population  in  the  United  States  registration  area,  against  a  rate  of  1.1  for  Uru- 
guay. Since  this  form  of  cancer  is  the  most  easily  diagnosed,  it  is  reasonable  to  sup- 
pose that  the  differences  in  the  rate  can  not  be  attributed  to  the  serious  shortcomings 
d  medical  i»«ctice  in  the  South  American  Republic. 

These  data  are  illustrated  in  Figures  1  and  3. 


PUBUO   HEALTH  AKD  MEDICINB. 


600       PBOCEEDINGS  SECOND  PAN  AMEBIOAK  SCIENTIFIO  CONGEESS. 

FEMALE  GENERATIVE   GROANS  AND  BREAST. 

The  mortality  from  cancer  of  the  female  generative  organs  was  22.1  per  100,000  of 
female  population  for  the  United  States  registration  area,  against  a  rate  of  12.2  for 
Uruguay;  and  the  corresponding  rates  for  cancer  of  the  female  breast  were  13.3  for 
the  United  States  registration  area,  against  only  3.7  for  Uruguay.  No  evidence  is 
available  to  prove  that  cancer  of  the  female  generative  organs  is  less  accurately  diag- 
nosed in  Uruguay  than  in  the  United  States,  if  the  higher  rate  for  cancer  of  the  stomach 
and  liver  in  Uruguay  can  be  relied  upon  as  evidence  that  the  diagnosis  of  a  somewhat 
similar  group  of  generally  inaccessible  cancers  is  as  accurately  made  as  in  the  United 
States. 

The  very  low  mortality  from  cancer  of  the  female  breast  in  Uruguay  can  not  be 
accepted  as  proof  of  inaccuracy  or  incompleteness  of  diagnosis,  since  this  is  one  of  the 
most  easily  diagnosed  forms  of  malignant  disease.  By  way  of  further  iUustration,  it 
may  be  stated  in  this  connection  that  the  mortality  from  cancer  of  the  female  breast 
is  4.5  per  100,000  of  female  population  for  the  island  of  Cuba,  but  only  1.8  for 
Japan.  In  contrast,  the  rate  attains  to  extremely  high  proportions  in  England  and 
Wales,  where  it  is  17.9;  and  in  Scotland,  where  it  is  16.4.  Since  the  corresponding 
rate  for  the  United  States  registration  area  is  only  13.3,  it  would  follow  that  if  the 
low  rate  for  Uruguay  is  to  be  considered  evidence  of  inaccuracy  or  Incompleteness  ol 
diagnosis,  then  the  same  conclusion  applies  to  the  United  States  and  Japan,  and  a 
number  of  other  countries  for  which,  as  far  as  known,  the  registration  returns  are  as 
trustworthy  as  for  England  and  Wales,  Scotland,  Switzerland,  and  the  Australian 
Commonwealth.  In  fact,  it  may  be  said  further  in  this  connection,  that  the  mor- 
tality from  cancer  of  the  breast  for  Bavaria,  \^bere  the  general  accuracy  of  diagnosis 
can  not  be  questioned,  was  only  9.1  per  100,000  of  female  population,  and  for  Hol- 
land only  9.6,  against,  as  said  before,  corresponding  rates  of  17.9  for  England  and 
Wales,  and  15.4  for  Scotland. 

These  data  are  illustrated  in  Figure  4. 

ACCURACY  OP  DIAGNOSIS. 

The  foregoing  observations  are  called  for  in  defense  of  the  practical  use  of  the  gen- 
eral cancer  mortality  statistics  of  the  Western  Hemisphere  as  an  approximate  indica- 
tion of  the  geographical  distribution  of  the  disease  throughout  this  vast  area,  and  the 
modification  of  local  cancer  death  rates  by  population,  climatoiogical  conditions, 
habits  of  life,  etc.,  as  the  case  may  be.  Those  who  are  responsible  for  the  charge  that 
methods  of  death  certification  are  grossly  defective,  and  that  in  a  large  number  of 
cases  the  clinical  diagnosis  is  inaccurate  or  seriously  at  fault,  rely  upon  fragmentary 
data  and  not  upon  the  required  statistical  evidence  in  conformity  to  the  first  and 
fundamental  law  of  all  statistical  inquiries,  and  that  is  the  law  of  large  numbers. 
Most  of  the  contributions  to  the  medical  literature  on  accuracy  in  death  certification 
bear  intrinsic  evidence  of  superficial  consideration  and  indifi'erence  to  accepted 
principles  of  statistical  inquiry.  It  is  as  wrongful  a  procedure  on  the  part  of  a  physi- 
cian not  trained  in  statistical  methods  to  bring  forward  statistical  arguments  and  far- 
reaching  assertions  based  upon  mere  figures  or  data  not  conforming  to  the  require- 
ments of  statistical  science,  as  for  a  statistician  superficially  informed  concerning 
medical  matters  to  pass  judgment  on  involved  proplems  of  pathology  or  therapeutics. 
It  is  unquestionably  of  the  first  order  of  importance  that  the  clinical  diagnosis  and 
methods  of  death  certification  should  be  further  improved,  and  no  one  with  any 
knowledge  of  the  facts  but  will  admit  that  present  methods  throughout  the  world  are 
far  from  perfect  or  ideal;  but  the  strongest  possible  objections  lie  against  the  increas- 
ing practice  on  the  part  of  superficial  and  ill-informed  medical  writers,  to  indict  on 
the  one  hand  the  entire  practice  of  medicine  and  surgery  as  being  little  ehort  of  quack- 
ery, and  on  the  other,  the  statistical  method  in  medicine  as  a  delusion  and  fraud.  The 
cause  of  neither  medicine  nor  statistics  is  advanced  by  such  amateurish  contribu- 
tions, but  a  vast  amount  of  harm  is  done  to  both  medicine  and  statistics  by  their  pub- 
lication in  scientific  periodicals,  official  health  reports,  or  in  the  medical  press. 


PUBLIO  HEALTH  AND  UEDICEKE. 


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1 


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602      PBOOEEDINQB  BECOHD  PAK  AHBBtOAN  800X1010  OONOBBBB. 


FUBUO  HEALTH  AND  MEDICINE. 


608 


UROBNOT  OF  QUAUnSD  8TATI8TI0AL  RK8BARCH. 

The  foregoing  observations  are  chiefly  intended  to  emphasize  the  urgency  and 
practical  utility  of  further  statistical  research  into  the  geographical  incidence  of  cancer 
throu^out  the  Western  Hemisphere.  Conceding  the  rather  doubtful  accuracy  and 
completeness  of  the  returns  for  certain  countries  and  islands  largely  inhabited  by 
native  races,  it  nevertheless  seems  reasonable  to  maintain  that  if  malignant  disease 
were  actually  as  common  in  these  areas  as  in  the  more  civilized  portions  of  the  globe, 
the  recorded  rate  of  frequency  would  be  much  higher  than  is  actufldly  the  case.  Recall- 
ing  the  wide  disparity  in  the  comparative  rate  of  incidence,  by  organs  and  parts,  met 
with  in  such  cities  as  New  York  and  San  Francisco,  or  Chicago  and  New  Orleans,  it 
would  seem  utterly  incredible  that  these  differences  should  be  the  result  of  serious 
errors  in  diagnosLs  or  inaccuracies  in  death  certification,  instead  of,  as  is  more  probable, 
due  to  pronounced  variations  in  the  existing  conditions  of  life,  chiefly  habits  and  diet, 
which  in  part  at  least  are  the  equivalent  of  material  well-being  and  poverty.  *  While 
cancer  occurs  among  animals  under  domestication,  or  under  exceptional  laboratory 
ccmditions,  it  is  well  known  that  malignant  disease  is  relatively  infrequent  among 
wild  animals  in  captivity.  Conversely,  there  are  no  reasons  why  native  races  should 
be  peculiarly  or  exceptionally  liable  to  malignant  disease,  and,  as  a  matter  of  fact, 
the  most  careful  medical  observers,  living  for  many  years  among  primitive  peoplep, 
have  invariably  reported  cancer  to  be  of  comparatively  rare  occurrence  among  them» 
There  are,  therefore,  convincing  reasons  for  believing  that  a  thoroughly  specialized 
ftatistical  cancer  research  into  the  predae  geographical  incidence  of  malignant  disease 
throughout  the  Western  Hemisphere  would  prove  of  much  practical  value  and  possibly 
of  faur-reaching  importance  to  the  cause  of  cancer  control. 

In  contrast  to  the  comparative  rarity  of  cancer  in  many  of  the  countries  and  islands 
of  Central  and  South  America,  the  discusmon  draws  attention  to  the  excessive  fre* 
quency  (rf  the  disease  in  such  cities  as  Buenos  Aires  and  Montevideo,  where  it  has  been 
shown  that  cancer  is  even  more  common  than  in  cities  (rf  c<»responding  size  in  the 
northern  portion  of  the  Western  Hemisphere.  In  this  direction  also  the  outlook  is 
encouraging  that  further  statistical  research,  amplified  by  medical  and  anthropo- 
logical studies,  and  most  of  all  by  thoroughly  qualified  studies  of  metabolism  diet 
and  habits  of  life,  would  yield  results  of  considerable  practical  importance.  Accepting 
as  conclusive  the  recorded  rate  of  excessive  cancer  frequency  for  many  of  the  countries 
and  States  of  the  Pan  American  Union,  it  would  furthermore  seem  of  the  utmost 
urgency  that  the  attention  of  these  countries  should  be  directed  to  the  principles  and 
methods  of  the  American  Society  for  the  Control  of  Cancer,  as  a  first  step  in  the  direo- 
tion  of  an  effective  public  education  in  the  essential  cancer  facts  and  a  prerequisite 
lor  an  ultimate  reduction  in  the  mortality  from  malignant  disease  throughout  the 
entire  Western  Hemisphere. 

The  Chaisman.  The  paper  just  read  is  open  for  discussion. 

Dr.  William  Rodman.  I  was  very  much  struck  with  one  state- 
ment that  Dr.  Hoffman  made,  which  is  that  malignant  disease  is 
certainly  more  frequent  in  the  fleshy  than  in  those  who  are  under 
weight.  I  think  there  can  be  no  doubt  about  this.  Particularly  is 
this  so  in  patients  with  cancer  of  the  breast.  Sorae  oi  l\ift  sta\Aa\ic» 
that  the  writer  quoted  from  South  Atnetrica^  c\t\e<a  raVXiet  suipnaoA 
and  startled  me. 

Dr.  Truman  Abbe.  The  paper  that  W.  ^o^xsxsc^Yv^  ^^^  tSx 
tremely  interesting  and  brought  to  nx>^  ^  L^  v«n  V^tc'^^^^^XSx.^^ 
that  we  heard  two  days  ago  by  Dr.  1^    ^'^^^X'J^  ^^ V^t^Vrfis^.^^^  "^^ 
in  mice.    It  occurred  to  me  that  tV^^^   c^"^  ^^^^v^jjv 


604       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  CONGRESS. 

incidence  of  cancer  in  particular  organs,  in  various  portions  of  the 
body,  would  be  fully  explained  by  her  proof  that  cancer  is  definitely 
hereditary,  not  only  the  tendency  to  cancer,  but  the  tendency  of 
cancer  to  special  oi^ans.  This  would  account  for  the  increased 
frequency  of  cancer  of  the  special  organs  and  the  increased  fre- 
quency of  cancer  in  certain  localities.  I  would  like  to  ask  what 
Dr.  Hoffman  has  to  say  on  that  question. 

The  point  as  to  the  prevalence  of  cancer  in  people  of  overweight 
is  a  proposition  which  is,  again,  very  interesting  to  me,  because  I 
have  been  convinced  that  in  a  certain  number  of  cases  the  over- 
weight is  a  symptom  of  the  cancer  and  not  the  cause  of  the  cancer. 
It  is  perfectly  true  that  a  lai^e  number  of  the  cancer  cases  that  we 
operate  upon  and  do  not  cure  gain  remarkably  in  weight  before  a  re- 
currence appears.  The  same  thing  is  probably  true  in  the  early  stages 
of  our  cancer  development,  and  I  was  wondering  if  that  would  not 
perhaps  accoimt  for  the  overweight  suggestion  of  Dr.  Hoffman, 

The  Chairman.  Dr.  Hoffman,  will  you  close  the  discussion  ? 

Dr.  Hoffman.  The  question  of  overweight  in  relation  to  organs 
and  parts  has  not  been  statistically  studied  so  far  as  I  know.  It  ia 
a  line  of  study  that  I  hope  myself  to  take  up  in  the  near  future  in 
cooperation  with  the  advisory  board  of  the  statistical  committee  of 
the  American  Society  for  the  Control  of  Cancer  and  the  cooperation 
of  some  of  the  leading  life-insurance  companies  in  this  coimtry,  who 
will  be  requested  to  concentrate  their  attention  upon  cancer  of  the 
breast  in  women  and  cancer  of  the  tongue  in  men.  I  may  state, 
however,  that  according  to  the  best  information  which  I  have  been 
able  to  obtain  from  medical  sources  cancer  occurs  more  in  those  who 
have  always  enjoyed  robust  good  health,  those  who  represented 
apparently  a  better  physical  type,  as  measured  by  an  excess  in  nour- 
ishment. As  to  whether  overweight  is  a  symptom,  I  am  not  so  sure. 
Miss  Attley  in  Philadelphia  has  made  some  extremely  interesting 
investigations  regarding  weight  in  relation  to  cancer  of  the  uterus, 
and  her  conclusions  were  to  the  effect  that  a  loss  in  weight  had  been 
the  earlier  symptom  of  cancer  of  the  generative  organs;  but  her 
control  cases — that  is,  nonuterine  cases — seemed  to  prove  the  oppo- 
site. I  question  whether  any  data  at  present  available  permit  of  a 
categoric  answer  to  that  important  question;  but  it  suggests  a  line 
of  future  statistical  inquiry  which  will  differentiate  the  organs  and 
parts  and  possibly  the  forms  and  types  of  cancer.  No  progress 
was  made  in  the  study  of  malaria  until  fevers  were  resolved  into 
their  different  types. 

As  regards  heredity  I  regret  to  say  that  I  have  been  constrained 
to  take  an  opposite  view  to  that  of  Miss  Maud  Slye  and  her  conclu- 
sions based  upon  animal  experimentations  alone.  In  her  series  of 
charts  the  other  night  she  had  just  two  family  records  of  hiunan 


tIEOICINE.  605 

of  all  American  life  insur- 
ompany  is  to  the  effect  that 
in  the  family  have  slightly 
Q  cancer  in  particular  than 
itribution.    That  is  positive 

by  the  possible  doubtful 
iment  might  be  impeached, 
036  who  had  auth^ticated 
0  or  more,  the  frequency  of 

expected;  so  that  the  evi- 
)Osed  of. 

e  program  is  "The  relation 
f  bacterial  diseases  in  Pan 
Rosenau  has  sent  his  paper 
•.  Bowles. 


TO  THE  CONTBOL  OF  BAC- 
AMERICA. 
U.  D., 

larvard  Medical  Sdtoot;  Dwtetor, 
formarlg  Director,  Hygienic  Labor- 
ma  take  no  heed  of  luilionality  oi 
the  routes  of  human  intercoune. 
ast  najoiity  of  instancee  infection 

rather  than  on  things.  In  other 
eneficent  bleainga.  alao  carries  in 
MB  real  because  they  are  ioeidioua 
1  the  world's  history  have  died  of 
I  ie  tho  meeeage  of  hope  found  in 
spread,  and  means  of  prevention. 

growing  and  ie  bound  to  increase 
I  of  products  and  people  will  come 
ately,  our  methods  of  quarantine 
\  where  we  can  guard  against  the 
however,  is  only  a  makeehift  and 
n  fact,  is  an  admitaion  of  imperfect 
n  laugh  at  yellow  fevet  and  needa 
»ell  protected,  need  fear  iko  watai- 
r  built  with  regard  to  tats  wiU  not 
iUtiiul''  must  be  the  "city  cVcao," 
r,\Mme,aiidc\«Acts.,^«en.'i»^'*«« 


».mO'»  ,.         _A     «Qa'J'" 


606       PBOOEEDINGS  SECOND  PAN  AMEBIOAK  80IENTIFI0  00NGBE8EL 

burgh  and  Niagara  Falls,  which  served  as  endemic  fod  from  which  the  disease  radiated 
to  all  parts  of  our  country,  at  last  have  been  eliminated.  Many  of  the  cities  and 
States  in  our  fair  land  now  equal  the  best  records  of  European  cities  so  far  as  typhoid 
death  rates  are  concerned.  The  period  of  incubation  of  typhoid  fever  is  often  pro- 
longed— sometimes  three  weeks  or  more.  A  person  may  thus  drink  a  glass  of  infected 
water  or  contaminated  milk  in  the  United  States  and  travel  to  Brazil,  Aigentme 
Republic,  or  Chile  before  the  disease  breaks  out.  Quarantine  procedures  are  inef- 
fective against  typhoid  fever,  and  therefore  our  reliance  must  be  placed  upon  the 
resources  of  sanitation  and  personal  hygiene. 

The  brilliant  results  obtained  in  the  United  States  Army,  through  the  use  of 
typhoid  vaccines,  has  proved  that  this  is  a  useful  method  of  prevention.  This 
method  of  typhoid  prophylaxis  is  also  available  to  the  civil  population,  but  does 
not  take  the  place  of  hygiene  and  sanitation. 

The  story  of  cholera  Ib  an  exact  counterpart  of  that  of  typhoid  fever.  Cholera  is 
spread  in  precisely  the  same  way  that  typhoid  fever  is  spread,  and  bacillus  caniens 
play  the  same  insidious  roll  in  both  diseases.  "Flies,  fingers,  and  filth'*  are  illiter- 
ative  truths  in  both  infections.  Furthermore,  it  is  literally  true  in  both  cholera  and 
typhoid  fever  that  ''disease,  dirt,  and  diarrhea^  become  sadly  mixed. 

Bubonic  plague  has  found  a  foothold  on  the  American  Continent  and  will  be  difficult 
to  eradicate.  Plague  is  a  bacterial  disease,  but  is  an  exception  to  the  rule  in  that  it 
is  spread  not  so  much  from  person  to  person  as  through  the  intermediary  of  the  rat 
and  its  flea.  Plague  is  a  disease,  primarially,  of  rats  and  secondarily  of  man.  This 
exotic  pestilence  Ib  dragged  from  country  to  country  mainly  by  the  rats  on  board 
ships.  Quarantine  restrictions  against  plague  are  effective  but  cumbersome  to  trade 
and  travel.  A  rat-free  city  could  lighten  the  delays  and  expense  of  quarantiiie 
measures  against  plague. 

Nations  must  leam  the  lesson  that  it  will  pay  to  require  rat-proof  buildings,  rat- 
proof  markets,  wharves,  graneries,  and  slaughterhouses,  just  as  it  has  foimd  by  bitter 
experience  that  it  pays  to  have  other  restrictive  building  laws. 

Monumental  public  buildings,  beautiful  parks,  art  galleries,  libraries,  and  hand- 
some boulevards  do  not  make  the  "city  beautiful."  The  sanitarian  looks  deeper 
than  these  outward  expressions  of  prosperity  and  appreciation  of  fine  arts.  He 
requires  a  clean  dty  in  the  sense  of  biological  cleanliness — free  of  rats,  flees,  vermin, 
and  dust;  good  houses,  clean  from  garret  to  cellar;  tidy  back  yards — ^in  fact,  cleanli- 
ness of  the  food  we  eat,  water  we  drink,  air  we  breathe.  Cleanliness  of  home  and 
surroundings  is  the  foundation  stone  of  an  enduring  structure  in  preventive  medicine. 
The  greatest  blessing  to  man  is  health,  and  this  can  not  be  achieved  without  intelli- 
gent effort  and  the  expenditure  of  time  and  money.  "The  healthy  man  is  the  most 
meritorious  product  of  nature  as  far  as  he  goes.  A  soul  in  right  health  is  the  blessedest 
thing  this  earth  receives  of  heaven." 

The  Chairman.  This  paper  is  now  open  for  discussion. 

Mr.  James  T.  B.  Bowles.  I  had  the  pleasure  of  serving  in  Panama 
for  nearly  six  years.  My  mind  goes  back  to  the  nidus  of  the  infeo- 
tions  which  were  formed  by  trade  routes,  beginning  at  the  old  town 
of  Portobelo.  Sailing  vessels  first  stopped  at  Portobelo,  as  there 
were  markets  and  fairs  there.  Cargo  and  passengers  were  then 
transferred  to  small  sailing  vessels  for  the  village  of  Chagres,  which  in 
turn  became  a  new  center  of  infection  for  yellow  fever  and  malaria, 
and  so  it  continued.  Each  one  of  the  places  along  the  trade  route 
became  a  center  of  infection  for  yellow  fever  and  malaria,  and  as 
these  routes  were  traveled  by  the  people  crossing  Panama  the  centers 
of  infection  were  kept  up  by  the  new  blood  passing  through. 


PUBUO  HEALTH  AND  MBDIOIKE.  607 

The  point  was  brought  out  that  quarantme  is  only  a  makeshift 
and  is  not  a  true  method  of  prevention.  I  think  this  is  very  well 
illustrated  by  the  conditions  in  Panama.  With  the  present  sanitary 
conditions  there,  quarantine  would  not  be  necessary  if  it  were  not  for 
the  conditions  of  some  of  the  places  lower  down  in  South  America. 
That  is  easily  seen  from  the  fact  that  occasionally  it  has  been  neces- 
sary to  strengthen  the  quarantine  regulations  at  the  port  of  Panama 
City. 

Dr.  Rosenau  places  a  great  deal  of  stress  on  typhoid  fever.  The 
control  of  typhoid  fever  in  Panama  is  another  wonderful  thing.  I 
know  of  practicaUy  only  two  very  small  outbreaks  of  typhoid  fever. 
There  were  a  few  cases  at  two  different  times.  The  first  few  cases 
were  practically  water  borne  through  a  water  carrier  who  had  been 
infected  with  typhoid  fever.  The  second  series  of  cases  occurred  two 
or  three  years  ago,  through  the  infection  of  the  oyster  beds  in  the  bay 
by  the  sewerage  of  Panama  City.  There  were  only  a  very  few  cases 
then.  I  think  we  can  say  that  the  death  rate  in  Panama  from 
typhoid  is  practically  nil,  far  less  than  in  any  of  the  American  cities. 

The  typhoid  death  rate  in  the  Army  was  very  interestingly  brought 
out.  L^ist  year  when  we  were  in  Vera  Cruz  we  did  not  have  one 
case  of  typhoid  fever  in  the  Army.  This  certainly  vindicates  the 
prophylactic  use  of  vaccmation  against  typhoid  fever.  When  we 
went  iato  Vera  Cruz  we  found  a  great  deal  of  typhoid  and  tubercu- 
losis there. 

The  Chairman.  It  is  perfectly  true  that  to  have  a  city  in  such 
sanitary  condition  that  a  disease  can  not  spread  is  infinitely  better 
than  a  measure  to  keep  it  out.  At  the  same  time  the  economic 
question  plays  its  r61e  even  in  sanitary  affairs.  Sometimes  a  doUar 
will  do  more  in  keeping  disease  out  than  a  good  many  dollars  will 
iQ  preventing  its  spread,  and  if  you  can  keep  it  out,  as  a  makeshift 
at  least,  it  is  very  well  to  do  so. 

The  next  paper  on  the  program  is  that  of  Prof.  S.  J.  Meltzer,  Rocke- 
feller Institute,  New  York  City. 


ON  THE  INHIBITORY  PROPERTIES  OF  BfAGNESIUM  SULPHATE  AND 
THEIR  THERAPEUTIC  APPUCATION  IN  TETANUS. 

By  S.  J.  MELTZER. 
Department  of  Phytiology  and  Pharmacology  of  the  JtodufelUT  InstitiUe  /or  Medical 

Reeearchf  New  Yiori, 

INTRODUCTION 


The  object  of  my  communicatioD  10  chiefly  a  pt^^^^t^^.  \'^rMfi^\0^^^^^^^^?'^^ 
for  treatment  of  tetaDus,  but  1  doubt  that  mau^    ^^jwO  ^^^!^^  ^"^^^^^ 


way  how  magneeium  sulphate  should  be  uned  i|^^^^0^VCD«oX  ^  val^^^^*  \«c^\si«^ 
improbable  that  there  are  many  in  this  audiencw     Vv^  ^^o"^  'OwbX  >^^X^5csM83tf*o^ 


608       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  CONGBESS. 

action  of  this  salt  upon  which  this  method  of  treatment  is  based.  It  is  conceivable 
that  it  is  assumed  by  many  that  any  favorable  therapeutic  effect  Epsom  salt  may  exert 
upon  tetanus  rests  upon  its  well-knoA^ai  action  as  a  pui^gative.  Furthermore,  I  can  not 
free  myself  from  the  doubt  that  the  physiological  phenomenon  of  inhibition  is  generallj 
well  understood,  and  especially  that  the  term  "inhibitory  property,"  which  has  been 
used  in  the  title  of  this  paper  in  connection  with  the  action  of  magnesium  salts,  w*U 
be  properly  interpreted.  My  practical  statements  will,  therefore,  have  to  be  intro- 
duced by  a  discussion  of  a  theoretical  character.  In  this  discussion  I  shall  deal 
briefly,  first,  with  the  phenomena  of  inhibition,  as  I  understand  them,  and  then 
proc3od  to  discuss  the  Inhibitory  actions  of  the  salts  of  magnesiutn  which  we  observed 
in  our  exx)erimental  studies  and  which  led  up  to  the  use  of  magnesium  sulphate  in 
tetanus. 

THE  PHENOMENA  OF  INHIBmON  IN  BIOLOGY. 

The  beet  known  phenomenon  of  inhibition  is  the  action  of  the  vagus  upon  the  heart. 
The  heart  is  a  muscle  which  continually  performs  rhythmical  contractions.  When 
a  nerve  which  goes  to  a  muscle  is  stimulated,  the  muscle  gets  into  a  shorter  or  longer 
state  of  tetanus.  But  the  Weber  brothers  discovered  that  stimulation  of  the  peripheral 
end  of  the  vagus  nerve  stops  the  heart  in  diastole— it  inhibits  its  contraction.  The 
phenomenon  of  inhibition  was  thus  discovered.  In  the  past  70  years  a  great  many 
physiological  processes  were  discovered  which  had  to  be  interpreted  as  inhibitory 
phenomena.  I  shall  not  attempt  to  discuss  here  the  great  amount  of  the  corresponding 
data,  which,  by  the  way,  have  not  yet  been  sufiiciently  correlated.  I  shall  only  dia- 
CUBS  two  or  three  points  which  are  very  useful  to  keep  in  mind.  Many  yeare  after  the 
vagus  inliibidon  came  to  light,  nerve  fibers  were  discovered,  the  stimulation  of 
which  causes  an  acceleration  of  the  heart  beats;  it  was  further  established  that  when 
the  inhibitory  vagus  fibers  and  the  accelerator  nerve  fibers  are  stimulated  simul- 
taneously, the  effect  of  inhibition  prevails  during  stimulation  to  a  degree  that  the 
ftimulation  of  the  accelerators  can  no  t  be  well  recognized .  But  both  sets  of  nerve  fibeii 
differ  in  some  peculiarities,  among  others,  in  the  fact  that  stimulation  of  the  accelerator 
nerves  leaves  a  long  after  effect,  while  the  inhibitory  nerve  fibers  of  the  vagus  mauiifest 
only  a  short  after  effect.  This  leads  to  the  result  that  when  both  sets  of  fiben  art 
■timulated  simultaneously  a  considerable  acceleration  of  the  heart  beat  follows  soon 
after  discontinuation  of  the  stimolation.  By  this  phenomenon  the  presence  of  ac- 
celerators, or,  as  it  is  also  termed,  augmenting  nerve  fibers  in  a  nerve  trunk  are 
recognized.  In  other  fimctions  opposite  relations  prevail,  namely,  the  augmenton 
predominate  during  stimulation  and  the  inhibitors  possess  the  longer  after  effect. 

It  is  readily  conceivable  that  the  effect  of  stimulation  of  a  single  nerve  trunk  could 
be  interpreted  in  various  ways,  which,  of  course,  I  should  not  analyze  here.  I  need 
only  to  add  that  the  above-mentioned  antagonism  applies  not  only  to  the  motor 
sphere,  but  is  readily  adaptable  also  to  the  functions  of  secretion  and  sensation  and, 
furthermore,  is  appUcable  also  to  functions  in  which  the  augmenting  and  inhibitory 
processes  are  not  represented  by  well-defined  nerves  or  other  morphological  units. 

It  is  very  useful  to  have  another  consideration  well  fixed  in  mind.  By  our  daily 
habits  we  are  used  to  the  mode  of  thinking  that  any  action,  a  motion,  or  a  secretion, 
is  brought  about  by  a  positive  cause,  a  definite  stimulus.  The  absence  of  such  an 
action  seems  not  to  need  any  explanation;  a  thing,  for  instance,  does  not  move  sim- 
ply because  there  is  no  cause  for  its  motion.  This,  however,  is  not  true  even  in  the 
inorganic  physical  world.  A  thing  does  not  move  in  a  certain  direction  merely  be- 
cause it  is  prevented  by  an  opposing  force  of  exactly  similar  eneigy  which  works 
in  an  exactly  opposing  direction.  By  an  analysis  of  numerous  living  phenomena 
I  came  to  the  conclusion  that  all  living  functions  are  continually  controlled  by  two 
opposing  forces — augmentation  or  action  on  the  one  hand  and  inhibition  on  the  other 
hand.  The  state  of  every  function  at  every  moment  depends  upon  the  relation 
and  the  predominance  of  each  of  these  opposing  functions.    Taking  motion  as  an 


PUBLIC  HEALTH 

instance,  the  iw-Timnm  effect  of  the  Ktioi 
maximum  eflect  of  inhibition  is  complete 
preaant  an  intermediary  atate  in  which  on 
dominating.  Some  fomiB  of  abaolute  paral 
may  have  been  brought  aboiit,  indeed,  b 
flnl  decades  thia  theory,  and  especially  th 
factor  in  all  mantfestationa  of  life,  p'ayed  i 
«H  a  working  factor  in  my  inreatigationi 
tion  and  of  respiration. 

THB  INHIBITORI  ACTIOI 

Some  19  yeara  ago  I  studied  the  effect  o 
of  various  solu.  While  the  effect  of  neftrl; 
tion  of  a  more  or  leas  in  tense  and  chiraclerl 
intracerebral  injection  of  a  few  dropa  of  a  f 
Miimal  turned  on  one  side  and  remained  I 
the  influence  of  the  conception  that  inhibi 
of  the  living  body  the  question  arose  in  t 
between  the  magnesium  ion  in  the  body  a] 
■ion.  A  review  of  the  literature  revealed  t 
very  little  and  only  aitperflciaJly  studied, 
concerning  the  phenomena  of  inhibition; 
varioua  functional  activities  were  rarely 
It  was  mostly  the  various  forms  of  exciti 
tion  of  the  physiologist  and  were  inveetig 
basis  of  the  above-formulated  question  w< 
the  department  of  physiology  and  pham 
Dr.  John  Auer  and  other  associates  the  vor 
body.  After  a  long  experience  we  may  m 
nesum  salts  upon  the  living  body,  no  m 
that  of  (Uprtuion  or  inhibition. 

We  shall,  of  course,  not  enter  here  upon 
▼ery  briefly.  When  after  the  administrati 
dent  to  cause  anastheeia,  an  ine  Rcient  am 
tramuacularly,  a  profound  onastbeeia  follow 
Consciousness  is  the  first  thing  complete 
as  a  rule,  accompanied  by  a  great  musculi 
nearly  unafFected.  With  a  larger  dose  of : 
with  a  still  further  increase  of  the  magnes 
paralyzed— a  cumre  like  action— occomf 
found  central  action.  Thia  was  obesrved 
human  beings  by  Di.  Peck  and  also  in  ei 

Chemically  calcium  and  magnesium  arc 
however,  they  are  strikingly  anti^niatic  t 
animal  which  may  have  been  complete!; 
restored  within  a  fRiction  of  a  minute  by 
This,  however,  applies  essentially  to  cond 
the  effect  of  magnesium  for  a  comparatively 
with  magnesium  for  a  longer  period  the  an 
and  is  not  even  without  some  danger. 

At  the  last  meeting  of  the  International 
I  offered  the  following  hypothesis  in  ei 
As  it  is  well  known  the  var 
termed  by  Sherrington  "  synaptic  m 


610       PBOCEEDINOS  SECOND  PAN  AMEBIOAN  SOIEKTIFIO  00NGBE8B. 

and  muscle  is  also  not  of  a  very  solid  character  and  is  tenned  by  some  also  as 
synaptic  membrane.  My  theory  asmimes  that  the  magnesium  contained  in  the  Ijnnpli 
which  bathes  the  synaptic  membrane  enters  with  ease  into  these  spaces  and 
interrupts  the  passage  of  such  impulses  which  have  a  less  readily  prepared  path  than 
reflexes  for  their  transmission  from  neurone  to  neurone.  Again,  the  synaptic  mem- 
brane between  two  neurons  offers  less  resistance  to  the  entrance  of  the  magnesium 
than  the  more  solid  membrane  between  the  motor  nerve  and  the  muscle.  The  same 
applies  to  the  calcium.  When  it  is  present  in  the  lymph  in  a  quantity  larger  than 
normal  it  enters  readily  into  the  synaptic  membrane  and  displaces  or  neutralizes  then 
the  obstructing  or  inhibiting  magnesium.  When,  however,  the  magnesium,  by  its 
bng-lasling  presence,  manages  in  some  way  to  enter  into  the  inside  of  a  nerve  cell,  the 
calcium  is  incapable  to  didodge  or  neutralize  there  the  magnesium  readily.  This 
theoretical  view  may  have  some  bearing  upon  the  mode  of  the  therapeutic  action  of 
magnesium  salts  in  tetanus. 

THS  TRBATMBNT  OF  TBTANU8  BT  MAGNBSIUM  SULPHATE. 

The  effect  of  magnesium  salts  was  investigated  extensively  on  animals  and  in  m 
comparatively  moderate  degree  on  human  beings  by  different  modes  of  administtm- 
tion — ^by  intravenous,  intraspinal,  intramuscular,  and  subcutaneous  injections.  In  all 
modes  of  administration  the  character  of  the  effect  Ib,  as  stated  before,  unmistakably 
depressing  in  character.  In  intravenous  application  the  effect  is  rapid,  but  is 
comparatively  of  short  duration  and  it  must  be  guarded  against  possible  hannful 
incidents.  The  inhibitory  effect  of  an  intraspinal  injection  sets  in  fairly  early  and 
may  last  even  longer  than  24  hours.  Intramuscular  injections  have  a  fairly  early 
effect,  but  are  only  of  a  comparatively  short  duration.  Subcutaneous  injections  act 
slowly,  but  have  a  cumulative  action.^ 

I  shall  deal  here  exclusively  with  the  favorable  action  of  magnesium  sulphate  upon 
tetanus.  The  action  may  appear  to  some  as  a  merely  symptomatic  one ;  it  relieves  the 
convulsions.  But  even  if  this  would  be  indeed  its  only  favorable  effect,  it  would  be  of 
unestimable  value,  since  the  suffering  in  tetanus  and  the  fatal  outcome  of  this 
horrible  disease  is  nearly  exclusively  due  to  the  consequences  of  the  tetanic  symptoms. 
And  we  may  claim  that  there  b  no  other  remedy  which  is  capable  of  relieving  the 
furious  symptoms  to  such  a  satisfactory  d^^reeasthe  injection  of  magnesium  sulphate. 
But  on  the  basis  of  the  above-mentioned  theory,  we  may  expect  from  the  use  of  magne- 
sium sulphate  perhaps  even  more  than  a  symptomatic  action.  It  is  possible  thst 
the  magnesium  salts,  accumulated  in  the  lymph,  enter  into  the  synaptic  membrane 
between  two  nuerons  and  thus  prevent  the  wandering  of  the  tetanus  toxin  into 
higher  neurones  and  the  corresponding  nerve  cells. 

Soon  after  our  publications  on  the  inhibitory  action  of  magnesium  salts  clinical 
cases  of  tetanus  b^an  to  appear  in  the  medical  literature  in  which  magnesium  sul- 
phate was  used.  This  was  especially  the  case  after  the  favorable  report  published 
by  the  famous  surgeon,  Theodor  Kocher,  of  Berne.  At  the  outbreak  of  war  niimer- 
ous  cases  of  tetanus  were  treated  by  magnesium  sulphate.  I  shall  not  enter  here 
upon  an  analysis  of  the  extensive  literature  on  that  subject.  I  wish  only  to  say  that 
a  study  of  this  literature  convinced  me  that  in  many  instances  the  writers  were  neither 
familiar  with  the  pharroacolc^ical  principles  underlying  this  treatment  nor  with  its 
indications  or  contraindications,  and  some  of  the  conclusions  which  they  derive  from 
their  observations  were  hastily  drawn  and  without  proper  criticism.  Some  did  not 
know  enough  to  distinguish  between  the  symptoms  due  to  the  disease  and  those  which 
were  brought  about  by  an  improper  use  of  the  magnesium  salts. 

In  the  following  I  shall  try  to  lay  down  some  rules  for  the  use  of  magnesium  sulphate 
in  tetanus  as  I  learned  them  from  our  extensive  experimental  investigations  and 

I  Also  local  application  exerts  unmistakably  some  favorable  effect  upon  burns,  erysipelas,  etc.,  but  I 
ibaU  not  deal  here  wltb  this  side  of  the  subject. 


PUBLIO  HEALTH  Ain>  MEDICINE.  611 

from  an  unbiased,  critical  study  of  the  clinical  literature  of  that  subject.  However, 
in  employing  magnesium  sulphate  for  the  treatment  of  tetanus  and  in  drawing  con- 
clusions from  such  observations  there  are  a  few  things  which  one  has  to  keep  in  mind 
and  to  which  I  wish  to  call  attention  before  I  proceed  to  describe  the  methods  to  be 
used,  their  respective  advantages  and  disadvantages,  and  the  procedures  which  are 
necessary  to  meet  the  latter. 

There  are  advanced  and  dangerous  forms  of  tetanus  which  can  not  be  cured,  or  even 
relieved  temporarily,  by  any  method  of  treatment;  the  failure  of  magnesium  In  such 
cases  should  in  no  way  militate  against  the  possible  usefulness  of  this  method.  The 
treatment  of  tetanus  by  magnesium  does  in  no  way  preclude  a  simultaneous  treatment 
with  antitetanic  serum.  The  suffering  of  tetanic  patients  is  too  great  and  the  outlook 
is  too  grave  to  permit  the  experimental  method  of  treatment — i.  e.,  to  test  one  remedy 
at  one  time.  Even  if  magnesium  sulphate  would  do  no  more  than  relieve  the  most 
severe  symptoms,  the  convulsions  and  the  tetanus,  it  would  be  a  duty  to  use  it.  If 
properly  used  it  is  certainly  capable  of  reliably  relieving  severe  symptoms  in  many 
cases  better  than  by  any  other  remedy.  It  is  necessary  to  know  the  possible  dangers 
which  may  be  brought  about  by  the  use  of  magnesium  salts;  at  the  same  time  it  is 
necessary  to  know  well  the  incidents  of  tetanus,  in  order  not  to  look  upon  them  as 
effects  of  the  magnesium  injection.  This  confusion  occurred  in  many  instances.  Mag- 
nesium may  bring  about  a  temporary  reversible  paralysis  of  the  respiration.  We  shall 
discuss  later  how  to  avoid  this  incident  and  how  to  meet  it  when  it  occurs.  The 
circulation  is  not  readily  affected  by  the  injection  of  the  magnesium  salt  and  such  an 
an  incident  ought  never  to  occur.  Magnesium  salts  cause  a  temporary  appearance 
of  hyaline  casts  in  the  urine  (Peck,  Gates)  which  disappear  readily  and  early;  never- 
theless magnesium  injections  should  not  be  used  in  cases  of  outspoken  nephritis. 
Intravenous  injections  of  magnesium  salt  causes  a  definite  hyperglycemia,  with 
only  a  mild  glycosuria  (Kleiner  and  Meltzer).  It  is,  however,  a  merely  temporary 
phenomenon  and  is  no  contraindication  to  the  use  of  magnesium  salts. 

We  shall  now  proceed  to  a  description  of  methods  of  administration  of  magnesium 
salts  in  tetanus. 

I.  TniTOipinal  injection, — It  may  be  stated  that  for  adults  this  method  of  administra- 
tion gives  the  best  results.    The  sulphate  of  magnesium  (Epsom  salt,  MgS04+7H20) 
should  be  administered  in  a  25  per  cent  solution,  1  cubic  centimeter  of  the  solution  to 
each  20  pounds  of  body  weight.    In  cases  of  strong  opisthotoous  it  is  advisable  that  the 
injection  be  preceded  by  a  moderate  general  anesthesia,  ether,  or  chloroform,  which 
should  be  discontinued  immediately  after  the  injection  is  completed.    The  injection 
should  be  made  in  the  lumbar  r^on  at  the  usual  place  and  with  the  usual  precau- 
tions. The  patient  should  then  be  placed  on  the  back.  The  relief  may  begin  to  become 
manifest  in  a  short  time  after  the  injection,  and  leads,  as  a  rule,  to  a  complete  relaxa- 
tion lasting  24  hours  and  longer.    Duriog  this  period  the  patient  is  resting,  relieved, 
partakes  of  food,  and  may  fall  into  a  deep  sleep.    Sooner  or  later,  however,  stiffness  and 
convulsive  seizures  will  return.   A  second  injection  ought  to  be  given  before  the  tetanic 
conditions  attain  their  original  intensity.    The  second  dose,  however,  ought  to  be 
smaller,  for  instance,  about  0.8  cubic  centimeter  per  20  pounds.    The  repeated  injec- 
tions ought  to  be  adapted  to  the  conditions  of  the  patient,  which  mostly  do  not  demand 
a  complete  relaxation.    It  may  be  necessary  to  catheterize  the  patient.    This  and 
the  occasional  rise  of  termperature  do  not  present  coiitiaiiid\caXioiv»  ^»  ^^^^  mftt\iod 
of  treatment.    The  only  serious  phenomenon  whiclx  fl>W  coxopVvcaX;©  tXi^-^toeedux^  ta 
the  setting  in  of  a  weakening  or  a  temporary  standa^n  ol  ^^  t^as^vsa-^^^  ^^\^^\^^<a 
edly  to  a  paralysis  of  the  respiratory  center  by  ty^    w^^igaeaaxxssv.   \^  ^  ^.^^^^^^^^ 
above-described  procedure  is  followed  out  carelul^^  ^\^  6et\ft\xV\xv(i\^^^^,^-A3ss^^'^'^s^ 
in  adults.    It  is,  however,  well  to  know  how  to  j^^  \  ^^\  -^Ykfexx.  ^^fc^^^)^      xX^s?^"*"^^ 
its  appearance.    A  needle  should  be  introduced   vHvft^^  a  Vvsltc^^^      A  *» 


introduce^  t^.e^e^^^'^^^L^ 
jrmittedto    ^V     ^     ^^^^^'^i 


some  of  the  spinal  fluid  should  be  permitted  to     '^X^'     ^'^     ^x^A  ^^t^o^ 
68436— 17— VOL  x 40  ^^^^  a^^'  ^ 


^iSS^^^ 


0* 


612       PBOCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  C0NGBE8S. 

washed  out  several  times  with  a  Ringer  solution.  During  this  procedure  the  upper 
part  of  the  body  should  be  kept  elevated,  to  facilitate  the  escape  of  the  fluid  from  the 
spinal  canal;  also  artificial  respiration  should  be  instituted  with  air  or  oxygen,  for 
both  of  which  my  apparatus  of  pharyngeal  insufflation  which  I  describe  elsewhere 
is  the  most  suitable  one. 

Both  the  washing  of  the  canal  and  the  artificial  respiration  should  be  instituted  at 
an  early  stage;  that  is,  as  soon  as  the  respiration  becomes  slow  and  shallow.  The  re- 
covery will  follow  rapidly.  Action  should  not  be  delayed  until  the  respiration 
actually  ceases;  the  preceding  prolonged  asphyxia  may  be  a  hindrance  to  the  prompt 
recovery.  The  use  of  calcium  or  physostigmin,  which  we  shall  mention  in  describing 
the  other  methods  of  application,  are  of  no  avail  in  the  intraspinal  method.  Aa 
■tated  before,  the  occurrence  of  a  respiratory  complication  is  not  to  be  feared  when 
used  in  adults  according  to  prescribed  rules.  In  very  young  children  the  initial  dose 
thould  not  be  higher  than  0.5  cubic  centimeter  of  a  25  per  cent  solution  per  20 
pounds.  For  the  present  it  is  perhaps  better  not  to  use  it  as  a  routine  method  in 
children.  The  intracommunication  between  the  various  sections  of  the  intraspinal 
canal  is  probably  much  freer  in  very  young  children  than  in  adults. 

2.  Sttbcutaneom  injection, — ^This  method  is  incapable  of  relieving  severe  acute  attacks 
of  tetanic  conditions  imless  used  in  immense  doses.  On  the  other  hand,  small  doses 
used  three  or  four  times  a  day  undoubtedly  gradually  reduce  the  increased  irritability 
and  may  lead  even  in  severe  cases  to  a  final  recovery.  The  dose  should  be  for  adults 
about  1.2  cubic  centimeters  and  for  children  0.6  to  0.8  centimeter  per  kilogram  of  body 
weight  of  a  25  per  cent  solution  three  to  four  times  a  day.  It  should  be  begun  as  soon 
as  symptoms  of  a  local  tetanus  (drawing  of  the  muscles  in  a  slightly  wounded  extremity, 
slight  difficulty  in  swallowing,  slight  trismus,  etc.)  make  their  appearance  and  be 
continued  until  all  tetanic  symptoms  disappear.  The  use  of  a  moderate  local  or  gen- 
eral anesthetic  facilitates  these  injections,  which  should  be  made  imder  the  necessary 
aseptic  or  antiseptic  precautions.  It  should  be  borne  in  mind  that  such  injections 
are  incapable  of  offering  a  rapid  relief  in  acute  tetanic  attacks  and  their  value  should 
not  be  discredited  by  their  failure  to  relieve  satiafoctorily  acute  dangerous  seizures. 

3.  Tntravenoui  injection. — ^Magnesium  salts  disappear  rapidly  from  the  drculatioii; 
this  method  Is  therefore  inappropriate  for  the  purpose  of  bringing  about  a  complete 
cure;  besides,  under  prolonged  use  it  may  act  unfavorably  ui>on  the  circulation. 
In  a  previous  communication  I  advised*against  its  use.  However,  after  a  series  of 
experiments  with  Dr.  Auer  on  tetanic  dogs  and  after  the  clinical  communications  of 
Hans  Kobn  and  of  Walter  Straub,  I  b;K;ame  convinced  that  this  method,  if  used  prop- 
erty, may  save  life  in  severe  dangerous  tetanic  attacks  of  the  pharynx,  the  larynx,  or 
the  diaphragm.  It  should  be  used  in  a  6  per  cent  solution  2  to  8  cubic  centimeters  per 
minute,  and  it  should  be  discontinued  immediately  as  soon  as  the  respiration  becomes 
shallow.  As  a  rule,  the  respiration  improves  soon  after  the  infusion  of  magnesium  is 
discontinued.  If  the  improvement  is  not  prompt  enough  a  small  amount  of  CaCl] 
(2.6  per  cent)  should  be  slowly  injected  through  the  venoiu  cannula,  used  for  the 
infusion  of  magnesium,  until  the  respiration  shows  a  definite  improvement,  ^hich 
may  appear  in  leas  than  30  seconds.  The  calcium  injection  should  be  immediately 
discontinued;  otherwise  all  the  previous  tetanic  manifestations  may  make  their  rwp- 
pearance.  The  striking  favorable  effects  of  intravenous  injections  of  magnesium 
may  disappear  in  30  to  40  minutes,  but  the  actual  dangerous  symptoms  may  be 
obviated  for  a  much  longer  period. 

4.  Intramtueular  injection  plut  ether  inhalation, — In  experiments  of  Auer  and  the 
writer  it  was  established  that  an  injection  of  only  2.4  cubic  centimeters  of  a  25  per 
cent  solution  of  magnesium  sulphate,  given  intramuscularly  combined  with  a  tempo- 
fary  mild  ether  inhalation,  is  capable  of  bringing  about  a  considerable  relief  in  less 
than  half  an  hour,  and  may  last  for  several  hours.  The  method  is  inappropriate  for 
frequent  repetitions. 


PUBLIO  HEALTH  AND  MEDICINB.  618 

Should  it  by  unforwen  acddent  be  found  that  during  the  uae  of  one  of  the  three 
last-mentioned  methods  the  respiration  became  affected,  an  intramuscular  injection 
ot  a  2.5  per  cent  solution  of  2.5  i)er  cent  solution  of  Ca(1'  may  slowly  neutralize  the 
unfavorable  respiratory  effect  without  bringing  back  serious  tetanic  symptoms. 
An  Injection  of  about  1  milligram  of  physostigmin  is  also  capable  of  improving  the 
lespiration. 

Summary^^The  best  general  plan  for  treatment  of  tetanus  wotdd  seem  to  bs  as  follows: 
To  give  in  each  and  every  case  of  tetanus  by  subcutaneous  injection  1.2  cubic  centi- 
meters of  a  25  per  cent  solution  of  magnesium  siilphate  per  kilo  body  weight  three  times  a 
day  throughout  the  entire  disease.  When  the  disease  is  complicated  with  severe  tetanic 
attacks,  to  give  (in  adults)  by  the  intraspinal  method  1  cubic  centimeter  of  a  25  per 
cent  solution  for  every  10  kilograms  (20  pounds)  body  weight.  When  the  disease 
is  attended  by  immediately  dangeroiu  tetanic  complications,  to  give  by  intraven- 
008  injection  2  to  3  cubic  centimeters  per  minute  of  a  6  per  cent  soluticm  of  magne- 
sium salts  untU  the  dangerous  symptoms  subside,  or  the  respiratioQ  becomes  shal- 
low and  too  slow.  When  the  respiration  seems  to  become  impaired  in  consequence 
of  the  use  of  the  magnesium  salt  by  the  way  of  circulatory  apparatus,  to  inject 
intramuscularly  10  to  15  cubic  centimeters  of  a  2.5  per  cent  solution  of  calcium 
chloride.  It  is  advisable  to  have  at  hand  an  apparatus  of  intrapharyngeal  insufflation, 
ready  for  use  whenever  the  respiration  becomes  slow  and  shallow.  Finally,  not  to 
neglect  the  simultaneous  treatment  with  serum. 

Dr.  Bayer.  I  was  preGent  about  19  years  ago  at  a  meeting  of 
the  American  Physiological  Association  in  New  Haven  when  Dr. 
Meltzer  demonstrated  for  the  first  time  the  effect  of  intracranial 
injections  of  the  several  salts  which  he  has  mentioned,  among  which 
were  magnesium  chloride,  sodium  chloride,  and  potassium  salts.  We 
were  very  much  surprised,  but  it  meant  only  a  very  curious  and  as 
yet  unexplained  phenomenon,  and  it  is  due  to  the  fertile  mind  of 
Dr.  Meltzer  and  a  few  special  students  that  there  has  been  carried  on 
the  study  of  their  peculiar  and  most  important  effect  on  the  nerv- 
ous system.  It  happened  to  be  my  fortune  to  be  in  Germany  at 
the  outbreak  of  the  war,  and  my  further  good  fortune  to  assist 
one  of  the  famous  surgeons  in  Germany  diuing  the  first  eight  months 
of  the  war.  We  had  our  usual  number  of  tetanus  cases,  which  did 
not  respond  to  any  treatment  that  we  could  devise.  Some  of  these 
days  I  hope  that  we  may  save  oiu*  patients  that  are  now  dying  of 
tetanus  by  the  improved  method  which  Dr.  Meltzer  gives. 

Dr.  Brown.  I  should  like  to  ask  Dr.  Meltzer  whether  the  local 
injection  of  a  solution  of  magnesium  sulphate  has  any  effect  upon 
the  destruction  of  the  tetanus  toxin  from  its  location — that  is, 
near  the  place  of  injury. 

Dr.  Houghton.  I  woiild  Uke  to  ask  Dr.  Meltzer  if  he  li«ift  any  con- 
siderable data  showing  the  comparative  results  upon  aniTntAft  treated 


with  antitetanic  serum  by  itself  and   by  ^^^  ^5«taV)Vii^  \aftkOa.od. 
I  have  been  very  much  interested  in  th-.  AA^e\o\mifeTv\»  ^^  ^^  ^^>    . 

the  purpose  of  finding  out  how  mucK       ^*  ^  co\3\^  \^  ^ 


very  much  interested  in  tlw.  ^e^^'^^^^^'^^^  ^  v«A 

magnesium  sulphate,  so  much  so  that  ^        qx  ^^^u^  ^j^fd^'^  ^^       \ 
conducted  in  my  laboratory  a  series  o-^  ^      e^^^^^^^^xi^^^^^  N^ij^^ 


V' 


614       PROCEEDINGS  SECOND  PAN   AMERICAN  SCIENnFXO, CONGRESS, 

the  various  kinds  of  treatment  proposed.  While  I  can  not  give 
definitely  the  data — I  have  not  gone  over  it  lately — ^we  found  that 
the  use  of  magnesium  sulphate  did  not  show  a  diminution  in  the 
amount  of  tetanus  toxin  that  was  manifestly  present  in  the  blood 
of  the  sheep  when  drawn  from  the  animal  after  it  had  developed 
symptoms  of  disease  and  had  been  treated  with  magnesium.  The 
same  experiments  were  undertaken  with  tetanus  antitoxin.  In  each 
case  there  was  apparently  some  diminution  in  the  amount  of  toxin 
that  could  be  demonstrated  present.  Ether  and  trichlortertiary 
butylalcohol,  or  chloretone,  was  also  used,  but  with  none  of  them 
could  we  ever  firmly  establish,  with  the  possible  exception  of  the 
antitetanic  serum,  that  there  was  a  diminution  in  the  amount  of 
toxin  present  in  the  blood. 

From  this  I  believe  the  conclusion  might  be  drawn  that  the  use  of 
magnesium  sulphate,  the  use  of  trichlortertiary  butylalcohol,  chloral, 
or  any  other  anesthetic  of  that  series,  merely  assists  in  the  control 
of  the  symptoms  manifested  by  the  animak.  As  a  result  of  our 
studies,  which  covered  a  considerable  length  of  time  on  many  animals, 
we  arrived  at  the  conclusion  that  the  best  method  of  treating  tetanus 
in  the  lower  animals  was  through  the  use  of  antitetanic  serum  com« 
bined  with  the  use  of  an  anesthetic,  either  chloroform,  ether,  or  tri- 
chlortertiary butylalcohol.  It  was  rather  gratifying  to  note  in  a  recent 
number  of  the  Lancet  quite  a  lengthy  article  by  one  of  the  English 
surgeons  in  which  he  discussed  various  methods  of  treatment,  and 
gave  in  the  conclusion  of  his  article  what  he  believed  to  be  the  best 
method  of  treatment.  This  corresponded  very  closely  to  the  treat- 
ment we  had  determined  experimentally  in  the  laboratory,  viz,  the 
use  of  an  anesthetic  with  the  antitetanic  serum.  About  the  same 
time  I  received  a  communication  from  Prof.  Sims  Woodward,  a 
private  communication  (as  you  know,  he  is  professor  of  pathology 
in  the  University  of  Cambridge,  England),  in  which  he  congratulated 
the  medical  profession,  particularly  the  bacteriologists,  for  having 
been  able  to  devise  and  elaborate  a  product — antitetanic  serum — 
which  had  so  nearly  robbed  war  of  the  terrible  scourge  of  tetanus. 

The  Chairman.  Is  there  any  further  discussion?  If  not.  Prof. 
Meltzer  will  close. 

Dr.  Meltzer.  Dr.  Bayer,  I  think,  was  in  Hamburg.  They  did 
not  use  there  the  magnesium  sulphate,  although  they  had  used  it  exten- 
sively in  other  places  on  the  German  side  where  there  were  enormous 
n\imbers  of  cases  of  tetanus  at  the  beginning  of  the  war. 

In  regard  to  the  question  of  Dr.  Brown,  whether  the  injection  of 
magnesium  has  any  direct  effect  upon  the  tetanus  toxin,  I  would  an- 
swer negatively. 

As  to  Dr.  Houghton,  I  am  familiar  with  that  article  which  came  out 
from  the  Parke-Davis  Laboratory.    After  the  effect  of  magnesium  be- 


PX7BLI0  HEALTH  AND  MEDICINE.  616 

came  known,  this  laboratory  recommended  also  chloretone  which  is 
manufactured  there.  They  used  intraperitoneal  injections  and  I  am 
sure  that  they  were  not  justified  in  drawing  the  conclusions  they  have. 
Now,  does  magnesium  have  any  effect  upon  the  toxin?  We  do 
not  mean  to  influence  the  tetanus  toxin.  Then,  as  to  the  experi- 
mental work  on  animals,  I  can  say  that  the  only  sure  animal  on 
which  you  can  make  experiments  by  intraspinal  injection  is  tho 
monkey.  We  never  succeeded  in  doing  anything  by  intraspinal 
injection  in  other  animals. 

The  Chairman.  The  next  paper  is  by  Dr.  R.  Gonz&lez-Rincones , 
of  Venezuela,  on  "Tropical  parasitosis." 


OBSERYAaONES  SOBRE  PARlSITOS  TROPICALES. 

Pot  RAFAEL  GONZAlEZ-RINCONES, 
ProfaoT  de  la  Facultad  de  Medicina  de  Caracas,  Venezuela, 

AMearidiom, — El  Dr.  Ascanio,  de  Caracas,  ha  teaido  oportunidad  de  tratar  muchot 
casos  de  ascaridiosis  con  la  esencia  de  chenopodium,  86I0  o  asociada  a  la  eantonina  y 
al  calomel.  £1  Dr.  Ascanio  atribuye  gran  importancia  al  momento  en  que  se  ad- 
ministra  el  vermifugo,  baadndoee  en  una  creencia  popular  segtin  la  cual  loe  resultadot 
mis  probables  son  obtenidoe  tree  diss  antes  de  que  la  luna  entre  en  su  primera  Urn 
mensual  y  el  dia  antes  de  que  el  astro  entre  en  el  cuarto  menguante. 

Anquiloetomotie, — Timol  y  el  chenopodium.    Leche  de  higuerote,  Novo-timobensol. 

Bilhanione. — Los  primeros  casos  fueron  sefialados  en  Caracas  per  Rangel  y  Soto,  en 
noviembre  de  1906  (Sch.  Mansonl). 

El  Dr.  Ellas  Rodriguez,  de  Caracas,  aconseja  el  tratamiento  sigui^ite:  Tree  pastillas 
de  £1  Kossam  par  dfa  y  al  siguiente,  una  cipsula  de  helecho  macho,  por  la  noche,  al 
acostarse,  tres  a  cuatro  hoias  despu^  de  la  dltima  comida.  Coutinuar  iddntico  tiali^ 
mieiito  durante  meses,  ingiriendo  altemativamente,  las  tres  pastillas  y  la  cipsula. 
Segdn  observaciones  del  Dr.  Ascanio,  desde  el  vig^simo  dIa  los  buevos  de  Bilhania 
desaparecen  de  las  heces;  los  casos  que  ha  sometido  a  este  slstema  durante  cinco  meses 
seguidos,  parecen  estar  curados,  como  autorizan  a  suponerlo  las  observaciones  clfnicas 
de  esos  sujetos  y  los  ex&menes  de  heces  peri^dicos  practicadoe  durante  un  afio  por  li4)eof 
de  20  dfas. 

Por  mi  parte,  bas&ndome  en  la  presencia  de  los  paiisitos  en  la  vena  porta  y  bus  ramas, 
administro  dosis  fraccionadas  de  calomel  o  protoioduro,  bicloruro  o  bioduro  de  mercurio* 
Como  la  absorcidn  de  estas  sales  se  hace  por  el  sistema  porta  en  gran  parte  donde 
precisamente  viven  los  vermes,  parece  racional  el  empleo  del  tratamiento  mercurial, 
fliempre  que  se  establezca  con  el  nusmo  culdado  y  las  mismas  precaudones  de  doeift- 
caci6n  que  en  el  tratamiento  de  la  sffilis.  Para  activar  la  eliminaci6ii,  administro  da 
0.25  a  0.50  gramos  de  teobromina  durante  15  dlas,  al  mes  de  haber  iniciado  la  cuxa 
mercurial. 

Para  combatir  la  anemia  y  sostener  la  acci6u  ^w  ^canientcw^  ^Ac^^^stoo  w  t«tca 
mes  el  licor  de  Donovan  Ferrari.    Siempre  que  w  ^  ^  -^omVA^,  %OTiet^  ^  ^Akc^q  ^ 
irradiaci6n  de  una  ampolla  de  layos  X,  para  «8t^^. .  ^  Vob  P^^^s^Vfti^C**^'^^,^,^^^ 
que  se  hallan  en  la  vena  porta  y  sus  ramas  intr^  v^^^^^raa>^^*^^'^^'^  ^^^^c^X^  ^^-^M^oa^ 
conocida  que  ejercen  los  rayos  X  y  los  niy<w^^o6»*^  ^^  dA  '^^J^^^^^^^jcS&i.. 
germinativoe.    He  obtenido  ya  muy  bueno^  ^   ^  O^\oft  <^^^^  ^tt^^^^"^ 


Xi'^ 


616       PBOGEEDINGS  SECOND  PAN  AMEBICAN   SCIENTIFIO  C0NGBE8S. 

La  aplicaci6n  de  loe  rayoo  X  pars  el  tratamiento  de  las  bilhamosas  debe  cefiine  a  las 
reglas  de  la  radloterapla  profunda;  empleo  el  sistema  de  fuegoe  cnizadoa,  Bin  paaar 
nunca  del  tinte  II  del  radio-crom6metro  de  Bordier. 

La  emetina  no  ha  dado  resultadoe  en  esta  paraBitosis.  Tampoco  hemos  obtenido  lot 
resultadoe  que  se  esperaban  con  una  fdrmula  que  me  suministrd  el  Dr.  Robinson,  por 
haberle  escrito  el  Dr.  Andrew  Balfour,  de  Londres,  a  su  regreeo  de  una  ezpedici6n  por 
Granada,  Barbada,  Trinidad,  Venezuela  y  Colombia,  que  la  bilharziocdB  existia  en 
Venezuela,  seglin  pudo  verlo  en  preparaciones  que  le  mo0tr6  en  mi  laboratorio. 

Para  una  cipsula:  Timol,  0  gr.  60;  benzol,  1  gr.  80. 

La  admini0traci6n  del  timol  aaf  dimielto,  en  79  casos  de  bilharziosia,  no  ha  prodocido 
nunca  ningtin  accidente  t<5xico.  En  un  caoo  el  enfenno,  tom6  durante  doe  meset 
consecutivoe,  doe  cdpsulas  diariaa  de  timo-benzol  al  acoetane,  flin  el  m^ior  incon- 
veniente. 

La  f6rmula  precedente,  por  la  cual  doy  en  esta  ocasidn  las  gracias  a  su  autor,  Dr. 
Robinson,  a  cuya  intervenci6n  la  debo,  ha  servido  de  base  al  Dr.  Ascanio  para  un  nuevo 
tratamiento  contra  la  tenia  y  el  anquilostomo. 

El  Dr.  Ascanio  tiene  numerosas  observadones  de  sujetoe  a  quienes  ha  hecho  ex- 
pulsar  8U8  tenias  con  una  solucidn  de  timol  en  benzol,  saturada  de  alcanfor.  Se  ad- 
ministra  en  las  condiciones  que  se  exigen  para  la  admini8traci6n  del  timol  en  la  an- 
quilostomosis  y  el  resultado  es  ripido  y  absolutamente  exento  de  peligro  si  el  medica* 
mento  es  precedido  de  un  purgante  de  sul&ito  de  soda  y  seguido  de  otro  de  la  misma  sal. 
Las  tenias  son  expulsades  en  bloques  y  no  parsimonioeamente  como  sucede  con  el 
helecho  nacho,  cuyoe  fen6menos  t6xicos  son  demasiado  frecuentes  en  los  enfermoe  a 
quienes  se  administre  en  dosis  suficiente. 

El  Dr.  Ascanio  usa  tambi^n  la  formula  de  Robinson  modificada,  la  cual  denomina 
novo-timo-benzol,  en  el  tratamiento  de  la  anquilostomosis  y  hace  notar  que  el  ^to  es 
seguro  y  el  tratamiento  mucho  mejor  aceptado  por  los  enfennos  (cualquiera  que  sea  su 
estado)  que  el  timol  en  polvo  puro.  Cree  que  la  adici6n  del  alcanfor  modifica  la  acci6n 
irritativa  del  timol  sobre  la  mucosa  g^strica  y  al  mismo  tiempo  el  coraz6n  es  tonificado. 
Ha  seguido  comparativamente  en  varies  casos,  por  medio  del  eefigmo  man6metio  de 
Parhdn  y  del  eflfigm<3grafo,  la  tensidn  arterial  y  los  trazos  esfigmogrificoe  en  sujetoe 
diferentes  a  quienes  ha  administrado  el  mismo  dla  los  preparados  sif:uientes:  timol  s61o, 
en  sellos;  timol  con  azdcar,  tamhi^n  en  sellos;  timo-benzol  de  Robinson  y  novo-timo- 
benzol.  El  Dr.  Ascanio  conaidera  esta  dltima  fdrmula  como  tratamiento  de  eleccidn 
en  la  anquilostomosis  y  para  la  expul8i6n  de  teniados. 

Tricocefalotis. ^LoB  Dree.  Fonseca  y  Ascanio  han  obtenido  buenos  resultados  con 
la  asociaci6n  de  la  esencia  de  chenopodium,  santonina,  calomel  y  aceite  de  ricino.  Es 
muy  popular  el  uso  de  la  leche  de  higuerote  morado,  contra  este  par^to.  Se  administra 
como  en  Colombia  y  Centre  America,  durante  varies  dias,  y  luego  se  purga  al  enfenno 
con  un  salino.  Es  de  lamentarse  que  no  se  encuentre  todavla  este  producto  bajo  una 
forma  comercial  de  fdcil  adquisicibn. 

The  Cu airman.  Is  there  any  debate  upon  the  paper? 

Dr.  Hall.  The  treatment  of  parasites  is  being  taken  up  by  the 
United  States  Bureau  of  Anhnal  Industry  with  a  view  to  determining 
what  things  are  really  efficacious.  Clinical  treatments  are  often 
unsatisfactory  so  far  as  positive  results  are  concerned.  In  human 
parasites  we  are  limited  to  an  examination  of  the  feces,  and  while 
fecal  examinations  are  reliable  within  their  limits,  there  are  a  number 
of  factors  which  limit  the  findings.  In  the  experiments  which  we 
have  been  carrying  on  we  have  in  all  cases  followed  feces  passed  for 
four  days.  The  experiment  animal  was  then  used  for  post  mortem. 
The  animal  used  in  most  of  our  series  so  far  has  been  the  dog,  which 


PUBLIC  HEALTH  AND  MEDICINE.  617 

has  a  comparatively  simple  digestive  tract.  There  are  certain  things 
which  warrant  deductions  appUcable  to  the  case  of  man,  as  the  para« 
sites  found  in  the  dog  are  themselves  rather  closely  related  to  those 
of  man.  We  can  confirm  in  our  experiments  the  statements  of  Dr. 
Rincones  that  oleum  chinopodium  seems  especially  efficacious,  very 
frequently  having  an  efficacy  of  100  per  cent  for  a  single  treatment, 
which  is,  in  our  experience  with  anthelmintic,  exceptional.  The 
toxic  dose  for  oleum  chinopodium  in  the  case  of  the  dog  is  0.6  of  a 
cubic  centimeter  per  kilo  weight  of  dog.  We  have  used  it  0.01,  0.02, 
0.03  in  all  cases  where  repeated  doses  were  bringing  it  up  to  the  lethal 
do3e,  and  without  injury  in  most  cases  to  the  animal.  That  is  very 
much  in  excess  of  the  dose  for  man,  where  the  dose  runs  6  to  10  drops 
administered  three  times  at  hour  intervals,  and  I  ventiure  to  say  that 
the  dose  now  being  used  for  man  could  in  all  probability  be  safely 
increased.  However,  if  it  seems  sufficiently  efficacious  in  its  present 
dose,  there  would  be  no  object  in  increasing  it,  as  there  is  a  certain 
amount  of  irritation  to  be  expected.  Still,  chinopodium  is  in  the  main 
a  safe  drug.  It  is  constipating  and  demands,  of  course,  a  purgative 
treatment  following  it.  It  has  this  interesting  feature — that  its  admin- 
istration in  oil  and  the  administration  of  oils  following  it  diminishes 
the  toxicity  instead  of  increasing  it,  as  in  the  case  of  male  fern  and 
some  other  drugs. 

In  the  case  of  hookworms,  which  have  been  recently  stated  to  be 
quite  amenable  to  the  action  of  oleum  chinopodium,  we  have  not 
foimd  its  efficacy  as  great  as  it  is  against  ascaris.  It  seems  to  be 
only  moderately  efficacious  against  the  hookworm  of  the  dog,  but  it 
has  been  recorded  that  in  the  use  of  oleum  chinopodium  in  over 
100,000  cases  of  hookworm  treatments  in  various  parts  of  the  world 
it  has  been  found  more  satisfactory  than  thymol,  more  efficacious 
and  less  toxic.  Lane  finds  it  to  be,  roughly  speaking,  91  per  cent  in 
efficaciousness,  as  I  remember  the  figures,  as  against  87  for  thymol. 

Hookworms,  in  our  experience,  are  removable  only  by  accident, 
and  almost  any  anthelmintic  may  be  occasionally  efficacious  against 
hookworms.  It  seems  to  be  not  a  matter  of  whether  a  given  anthel- 
mintic can  kill  a  hookworm,  but  a  matter  of  whether  a  dose  of  any 
given  anthelmintic  will  make  the  journey  from  the  ileocecal  valve 
back  to  where  the  hookworm  is  located. 

I  have  been  very  much  interested  in  the  reports  from  Central 
America,  where  it  is  stated  that  they  are  using  various  species  of 
ficus  that  is  said  to  be  extremely  efficacious  against  hookworm.  I 
wonder  whether  in  this  we  have  something  which  can  be  depended 
upon  to  go  back  into  the  cecum  and  get  at  the  hookworm.  We  know 
so  Uttle  about  the  conditions  covering  the  course  of  the  ingesta  from 
the  ileocecal  valve — that  seems  to  be  a  subiect  upon  which  we  have 


618       PBOGEEDINQS  SECOND  PAN  AMEBIGAN  SCIENTIFIO  CONQBESS. 

comparatively  little  data.    Thymol  has  been  put  forward  lately  in 
many  publications  as  extremely  efficacious  against  hookworms. 

The  question  of  a  treatment  that  will  cure  bilharzia  is  rather  inter- 
esting. Of  course,  as  has  been  pointed  out,  that  disease  is  character- 
ized essentially  by  lesions  of  the  rectum  and  bladder,  and  the  mere 
killing  of  the  worm  in  the  portal  system,  for  instance,  or  in  the  pos- 
terior mesenteric  blood  vessels  does  not  necessarily  mean  the  cure  of 
the  disease.  If  you  can  kill  the  worm,  you  stop  the  production  of  the 
eggs  which  are  causing  the  trouble.  Another  phase  of  the  situation 
presents  itself  in  this :  Whether  relief  is  to  be  obtained  by  the  removal 
of  the  eggs  already  there.  Anything  which  claims  to  cure  that  disease 
will  need  careful  analysis  as  to  whether  we  really  have  what  can  be 
termed  a  cure. 

The  Chaibman.  The  Chair  would  like  to  add  one  word.  In  the 
Isthmus,  the  eggs  of  the  Schistosoma  munsoni  were  decidedly  common 
and  in  only  four  cases  was  the  parasite  found  to  be  pathogenic.  I 
saw  one  case  in  San  Jos6,  Costa  Rica,  dying  with  symptoms  of 
proctitis  and  colitis.  I  saw  three  cases  in  Santo  Tomas  Hospital, 
Panama,  in  the  same  condition.  The  syptoms  were  like  those  of 
amebic  dysentery,  the  lesions  being  imusually  low  down.  At  the 
autopsies  that  I  saw  on  two  cases  we  foimd  that  the  rectum  was 
riddled  with  xilcers,  due  to  the  spine  of  the  eggs.  No  treatment 
had  any  eflfect,  as  far  as  anyone  could  tell,  save  possibly  wash- 
ing out  with  ordinary  enemata.  The  point  is  that  all  of  these 
cases  were  from  the  uplands  of  Venezuela;  none  were  coast  men. 
Two  had  come  by  Chagres,  two  by  Trinidad,  and  one  from  Porto- 
belo,  but  all  were  men  from  the  mesa.  They  are  the  only  cases  that 
I  can  recall.  In  all  there  were  rectal  ulcers.  Also  autopsy  showed 
ulceration  of  the  lower  part  of  the  sigmoid,  due  to  the  spines  of  the 

eggs. 

The  Chatkman.  The  next  paper  upon  the  program,  "Method  of 

approach  in  teaching  sex  ethics  to  girls  and  young  women,"  is  by 

Dr.  William  R.  Manning,  University  of  Texas. 


A  METHOD  OF  APPROACH  IN  TEACHING  SEX  ETHICS  TO  GISLS  AND 

YOUNG  WOMEN. 

By  WILLIAM  R.  MANNING, 
Univernty  of  Texas. 

Along  with  many  other  educators  and  with  many  scientists  and  social  reformers  I 
believe  that  one  of  the  greatest  dangers  to  present  civilization  is  the  perversion  of 
the  sex  function  and  sex  life.  All  society,  including  the  State,  rests  on  the  home  and 
the  home  depends  on  the  sex  relation.  Owing  principally  to  the  sex  ignorance  of 
women  the  home  is  threatened  from  two  directions.  The  social  evil  and  commercial- 
ized vice  are  withdrawing  from  home  life  a  considerable  percentage  of  girls  and  young 


PUBLIC   HEALTH  AND  MEDICINE.  619 

women  who  are  by  nature  "fittest  to  survive"  if  considered  from  the  sexual  stand- 
point. The  dangerous  limitation  upon,  or  entire  avoidance  of,  childbearing  is  pre- 
venting the  increase,  if  it  does  not  actually  cause  the  decrease,  of  the  element  of  the 
population  that  is  "fittest  to  survive"  when  considered  from  the  intellectual,  the 
social,  and  financial  standpoint.  Thus,  the  sex  dangers  to  which  women  are  subject 
and  the  avoidance  of  sex  duties  by  women  threatens  to  result  in  a  "limitation  upon 
the  fittest,"  if  not  indeed  the  "elimination  of  the  fittest,''  even  if  they  should  never 
entirely  destroy  the  home. 

I  would  not  suggest  to  you  one  evil  thought  except  to  warn  you  against  its  danger. 
There  is  no  evil  in  a  full  knowledge  of  the  matters  which  I  am  going  to  discuss,  pro- 
vided that  knowledge  comes  from  a  wholesome  source.  But  much  evil  of  the  very 
worst  kind  results  from  ignorance  of  them,  or  from  partial  knowledge  imparted  with 
an  improper  motive.  I  would  not  frighten  you  unnecessarily  by  telling  of  one  danger 
that  is  not  real,  or  by  magnifying  dangers  that  are  real.  Hidden  dangers  are  the 
greater  because  they  are  concealed.  It  is  the  covered  trap  that  catches  a  wary  animal. 
It  is  the  hidden  pitfall  or  entanglement  that  involves  an  attacking  army  in  ruin.  It 
is  an  invisible  mine  or  a  submarine  boat  that  blows  a  ship  to  destruction. 

I  do  not  wish  to  cause  women  to  despise  or  fear  men.  I  would  have  men  and  women 
in  each  other's  company  more  than  they  are  rather  than  less.  But  I  would  have 
both  observe  proper  safeguards,  each  understanding  fully  the  sex  nature  and  sex 
difficulties  of  the  other,  and  each  realizing  the  dangers  to  which  unwise  conduct  in 
either  may  subject  both. 

I  would  have  all  girls  and  women  marry,  if  possible,  and  be  intelligent,  considerate, 
and  even  indulgent  wives;  and  I  wish  that  all  wives  could  and  would  become  mothers. 
For  no  other  life  can  entirely  satisfy  the  true  end  of  their  creation,  or  bring  to  them  so 
much  of  happiness  and  contentment. 

I  believe  that  a  full  understanding  of  the  overpowering  strength  of  men's  sex 
impulses  will  increase  the  respect  and  admiration  of  all  true  women  for  all  pure  men. 
No  woman,  not  even  a  wife,  dreams  of  the  effort  it  costs  a  man  or  boy  to  remain  entirely 
pure.  He  who  lives  a  perfectly  clean  sex  life  is  a  hero  of  10,000  battles — of  battles 
which  are  the  harder  to  fight  because  they  must  be  fought  absolutely  alone,  with  no 
praise  for  victory  and  little  if  any  shame  for  defeat. 

It  does  no  good  to  denounce  all  men  as  villains,  or  even  those  who  go  down  to  defeat 
dragging  innocent  girls  or  women  with  them.  It  is  not  enough  to  declare  that  many 
men  do  win  the  fig^t  and  stay  clean,  and  that  all  could,  if  they  would  live  up  to  the 
best  that  is  possible  for  them.  More  good  will  be  accomplished  in  teaching  them 
self-control  by  acknowledging  frankly  that  more  men  fail  in  the  battle  for  purity 
than  win,  and  that  the  struggle  is  so  great  that  even  the  strongest  and  best  remain 
pure  only  through  valiant  and  ceaseless  effort. 

In  spite  of  denunciations  and  moralizing  and  theorizing  it  is  hardly  likely  that 
man's  sex  nature  will  ever  be  materially  changed  or  the  strength  of  his  passions 
diminished.  Incidental  proof  is  afforded  by  authentic  writings,  both  sacred  and 
secular,  that  there  has  been  no  general  material  change  in  the  sex  nature  or  sex  habits 
of  man  during  the  past  4,000  years.  Since  there  is  little  if  any  hope  of  changing  his 
nature,  the  only  hope  is  to  change  his  habits  by  strengthening  his  self-control  and  by 
removing  as  far  as  possible  all  influences  which  stimulate  the  normally  quiescent  and 
controllable  instinct  into  the  all  but  irresistible  whirlwind  of  passion. 

In  the  meantime  the  men  of  the  present  must  be  lived  with  as  they  are;  and  the 
sooner  girls  and  women  understand  the  reason  for  and  the  nature  of  men's  sex  responses 
the  sooner  will  they  be  able  to  conduct  themselves  so  as  to  avoid  the  consequent 
dangers.  Girls  and  women  should  be  willing  to  make  whatever  effort  and  even 
sacrifice  may  be  necessary  to  do  this,  because  these  dangers  involve  not  only  themselves 
but  also  their  male  associates,  their  weaker  unprotected  sisters,  their  own  future  home 
life,  and  all  society. 


620       PBOGEEDINGS  SEGOND  PAN  AMERICAN  SCIENTIFIC  CONGRSSS. 

In  giving  these  very  plain  talks  I  have  in  mind  three  distinct  purposes. 

The  first  and  the  chief  is  to  promote  the  safety  of  girls,  and  of  women,  both  unmanned 
and  married,  by  pointing  out  the  dangers  to  which  they  are  necessarily  exposed 
because  of  the  sex  nature  and  sex  problems  of  men,  and  by  showing  how  they  imcoo- 
sciously  increase  these  dangers  and  how  they  can  consciously  diminish  them. 

My  second  purpose  is  to  increase  the  happiness  and  forestall  the  mental  angniah  of 
future  wives  (and  incidentally  of  their  huslMmds  as  well)  by  having  the  young  women 
of  the  present  understand  before  marriage  the  reason  and  the  apparent  necessity  in 
nature's  economy  for  the  almost  overmastering  strength  and  the  perpetual  preeence» 
but  perfect  propriety  and  harmlessness  when  rightly  used,  of  the  sex  impulse  in  men. 
By  this  means  I  hope  to  do  something  toward  removing  what  I  believe  to  be  one  of 
the  most  fertile  causes  of  domestic  discord  and  divorce. 

My  third  purpose  is  to  make  it  easier  for  men,  whether  married  or  unmarried,  to 
live  up  to  the  single  standard  of  virtue,  thus  doing  something  to  limit  the  spread  of 
the  social  evil  and  consequent  social  diseases,  which  together  are  threatening  the  veiy 
existence  of  the  home,  and  through  it  of  all  society,  including  the  State.  I  propose 
to  do  this  by  showing  to  girls  and  women  the  influence  which  unwise  conduct  or 
improper  clothing  has  on  the  sex  impulses  and  sex  life  of  the  men  and  boys  with  whom 
they  come  into  contact  and  by  appealing  to  them  to  do  all  they  can  to  remove  theie 
influences. 

I  shall  endeavor  to  make  these  talks  perfectly  simple  by  avoiding  all  technical  and 
abstruse  language.  I  shall  also  avoid  all  obscene  expressions  used  by  unthinking  at 
vicious  men  and  bojrs  in  their  all  too  common  conversation  among  themselves  con- 
ceroing  sex  matters.  But  I  shall  be  perfectly  plain  and  shall  neither  conceal  nor 
omit  any  facts  which  I  consider  necessary  for  a  f tUl  imderstanding  of  men's  sex  nature 
and  sex  problems  and  of  the  reasons  for  the  almost  uncontrollable  character  of  their 
pas3ioQS.  In  doing  this  I  shall  probably  say  things  for  which  most  men  would  criti- 
cize me  severely;  but  that  is  because  in  the  case  of  most  men  these  things  recall 
experiences  and  sensations  which  they  wish  had  never  come  to  them  and  wiiich  tfaejr 
would  like  to  forget.  It  has  been  my  experience  and  the  experience  of  other  men 
who  have  dealt  with  these  subjects  that  women  listen  to  wholesome  instruction  on 
them  with  much  less  perturbation  and  much  less  shamefacedness  than  men,  because 
most  women  have  not  had  experiences  of  which  they  should  be  ashamed;  and  their 
calmer  sex  nature  is  such  that  they  do  not  experience  anything  of  the  thrilling  sensa- 
tions that  come  to  men  when  they  read  or  listen  to  such  discussions. 

Because  prevalent  social  conventions  and  imperfect  ideals  of  chivalric  conduct 
protect  girls  and  women  of  the  so-called  respectable  classes  from  the  immediate  con- 
sequences  of  the  passions  which  they  unconsciously  arouse  in  the  men  and  boys  with 
whom  they  associate,  they  think  no  harm  is  done,  or  more  probably  most  of  them  think 
nothing  at  all  about  it. 

In  their  ignorance  they  do  not  realize,  and,  when  informed,  they  are  reluctant  to 
beUeve,  that  their  unwise  conduct,  their  insufficient  or  improper  clothing,  and  their 
undue  familiarity  have  much  to  do  with  driving  many  of  these  same  men  and  boys  to 
satisfy  the  passions  that  they  have  aroused  by  seducing  girls  of  a  supposedly  lower 
class,  who  are  not  protected  by  these  distort^  chivalric  ideals  and  false  sodal  dis- 
tinctions, or  by  visiting  the  houses  of  prostitution  that  are  continually  recruited  from 
these  unfortunate  victims  of  this  vicious  social  system. 

For  too  many  of  the  respectable  girls  and  women  their  respite  from  suffering  is  but 
a  brief  one.  In  nuirriage  many  of  these  same  men  bring  back  to  them  from  their 
fallen  sisters  the  terrible  social  diseases  to  cause  them  lives  of  suffering,  to  fill  operat- 
ing rooms  with  supposedly  innocent  victims,  and  to  render  homes  childless  or,  what 
is  far  worse,  bring  to  them  imbecile  or  defective  children.  These  diseases  are  spoken 
of  by  women  of  the  underworld  as  wedding  presents  which  they  send  to  brides. 


PUBLIC  HEALTH  AND  MEDIOIKB.  621 

It  is  almoBt  inconceivable  how  married  women,  who,  if  they  have  nonnal  husbands, 
know  the  effect  on  their  husbands  of  close  bodily  contact  or  the  exposure  of  any  con- 
dderable  portions  of  their  bodies,  will  still  expose  so  much  of  their  bodies  to  the  gase 
of  other  men,  and  invite,  permit,  and  even  urge  improper  familiarity  from  other 
men,  and  encourage  their  daughters  to  do  the  same. 

The  only  possible  way  to  account  for  or  excuse  such  conduct  on  the  part  of  clean 
wives  and  mothers  is  to  think  that  they  believe  their  own  husbands  abnormal  and 
other  men  not  subject  to  the  same  almost  uncontrollable  passions. 

If  a  husband  ventures  to  criticize  his  wife's  clothing  or  conduct  he  is  likely  to  get 
nothing  for  his  pains  but  derision  or  an  indignant  stormy  protest,  and  possibly  a 
scornful  reminder  that  to  the  impure  all  things  are  impure.  Unfortunately  many 
husbands  are  led  themselves  to  fear  that  they  may  be  abnormal;  and  nearly  all  of 
the  rest,  finding  criticism  worse  than  useless,  give  up  their  attempt  to  correct  what 
they  know  is  dangerous  and  accept  what  they  consider  inevitable. 

More  disastrously  still,  many  husbands  who  would  by  choice  lead  clean,  proper 
lives  accept  the  challenge  of  their  wives  and  indulge  in  the  same  improper  familiar- 
ities with  other  women,  not  only  of  their  own  social  set  but  of  the  underworld,  also, 
with  the  inevitable  results.  The  deluded  wife  merely  exults  in  thinking  that  she 
has  won  he>  point  and  had  her  way.  The  husband  does  not  tell  her  the  fearful  cost 
of  her  victory  until  some  gossip  or  some  too  bold  act  on  his  part  rouses  her  suspicion 
and  she  charges  him  with  unfaithfulness,  or  until  she  finds  that  he  has  brought  to 
her  one  of  the  dreadful  diseases  to  which  he  is  continually  exposed. 

Even  if  they  were  sharing  in  the  profits  of  organized  vice,  many  popular  and  repu- 
table but  socially  ambitious  women  could  hardly  do  more  to  stimulate  the  business 
than  they  are  now  doing. 

Girls  and  young  women  have  long  been  told  in  a  dogmatic  way  and  in  general  terms 
that  they  ought  not  to  do  or  permit  this  thing  or  another  thing  which  is  asserted  to 
be  dangerous  without  the  reason  being  given.  Lifferent  prophets  of  evil  who  utter 
these  warnings  disagree  concerning  almost  every  one  of  the  things  which  girls  are 
warned  against.  This  confiicting  advice  has  led  many  girls  to  feel  that  all  such  warn- 
ings are  but  expressions  of  the  f ooUsh  fears  of  old  fogies,  and  they  have  defied  all  advice 
and  abandoned  all  restraint. 

I  believe  it  will  be  far  better  for  girls  and  women  to  be  told  frankly  why  certain 
actions  in  them  necessarily  stimulate  certain  very  pleasurable,  very  alluring,  very 
powerful,  and  therefore  very  dangerous  impulses  in  boys  and  men.  With  this  knowl- 
edge I  believe  they  can  safely  be  left  to  choose  intelligently  whether  they  wish  to 
incur  the  inevitable  perils  to  themselves,  to  their  gentlemen  friends,  to  their  unpro« 
tected  sisters,  and  to  all  society.  I  believe  that  knowledge  will  be  a  more  effective 
shield  than  ignorance  to  protect  the  innocence  and  purity  of  our  girls  and  young 
women. 

The  old  notion  that  complete  silence  should  be  observed  concerning  sexual  mat- 
ters, that  even  fathers  and  mothers  should  never  mention  them  to  their  sons  and 
daughters,  is  now  condemned  by  most  enlightened  people.  It  is  feared,  however, 
that  few  parents  yet  have  the  courage  or  the  skill  to  Uve  up  to  their  convictions. 

It  is  certain  that  few  adults  of  the  present  generation,  and  few  of  the  young  people 
now  approaching  manhood  and  womanhood,  have  ever  had  any  proper  instruction. 
But  scientific  investigations  have  proved  that  practically  all  boys  before  they  reach 
adolescence  even  have  acquired  from  older  boys  a  large  amount  of  improper  knowl- 
edge concerning  sex.    Usually  little  else  enters  into  the  conversation  oi  adolescent 
boys  when  in  groups  unattended  by  girls  or  woia^n  ot  grown  men.    Knd  U)o  tre- 
quently,  it  must  be  said  to  their  shame,  m©ix  «ot  o^Y  ^^  ^^^  rec^lmn  Bvxch  talk 
among  boys  but  themselves  start  and  lead  it.      a  *id  ftOion^  "msti  t\^^  ^JwK.«ii^  xaXk  \a 
all  too  common.    But  most  young  women  stin        wv©  V>  ^ouaas^oo^  '^"^  ^laoeX  com- 
plete ignorance  of  the  mysteries  of  sex.    Seri^.  ^^>tvd««^^  •^^  ^j^o©^  ViQaX\}5^>a»tot. 


622       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  C0NGRE88, 

tunate  combination  of  ignorance  on  the  part  of  girls  and  young  women  and  viciom 
knowledge  on  the  part  of  boys  and  men  is  the  fertile  culture  in  which  the  social  evil 
germinates  and  flourishes  and  from  which  commercialized  vice  derives  its  supply  and 
fupport. 

It  is  almost  unbelievable  that  girls  should  for  so  long  have  been  kept  in  such  com- 
plete ignorance  of  those  matters  which  contain  so  much  of  present  peril  for  them  and 
80  vitally  affect  their  whole  future  welfare.  Because  of  this  ignorance  thousands  fall 
victims  e\'ery  year  to  dangers  which  they  could  easily  have  avoided  if  they  had 
known  of  their  existence.  The  only  serious  explanation  ever  given  for  this  conspiracy 
of  all  society  against  its  girls  is  that  it  is  improper  for  their  pure  minds  to  be  soiled 
with  thoughts  of  impiuity. 

Every  father,  while  he  knows  that  many  girls  are  led  astray,  hopes  and  believes 
that  his  daughter  many  be  fortunate  enough  to  remain  in  innocent  ignorance.  And 
the  chances  are  in  his  favor,  since  fortunately  an  overwhelming  majority  do  escape. 
But  each  of  the  thousands  who  do  go  down  every  year  is  somebody's  daughter  and 
might  be  anybody's. 

If  a  city  council  should  pass  an  ordinance  declaring  that  henceforth  all  children 
should  hold  their  hands  over  their  eyes  and  their  thumbs  in  their  ears  whjle  crossing 
the  principal  business  street,  it  would  be  thought  very  strange.  If,  when  the  reason 
for  such  an  absurd  regulation  was  demanded,  they  should  say  that  they  believed  it 
improper  for  children  to  be  frightened  by  knowing  the  many  dangers  to  which  thej 
were  exposed,  and  that  few  would  be  killed  an3rway,  since  nearly  all  motormen,  chauf- 
eurs,  and  drivers  would  try  to  keep  from  running  them  down,  that  council  would  be 
considered  better  fitted  for  an  insane  asylum  than  for  a  city  hall.  But  such  an  ordi- 
nance would  be  no  more  absurd  than  the  unwritten  social  law  that  hides  from 
nearly  all  girls  the  vitally  important  knowledge  concerning  matters  of  sex. 

It  is  my  desire  to  uncover  your  eyes  and  unstop  your  ears  that  you  may  see  and 
kear  and  know  and  escape  the  sex  dangers  that  you  are  likely  to  encounter. 

If  there  were  in  this  city  a  huge  recreation  park  where  each  evening  thousands  9t 
joiing  people,  and  you  among  them,  were  strolling  in  happy,  careless,  and  apparently 
innocent  freedom;  if  now  and  then  one  girl  mysteriously  disappeared  through  a  con- 
cealed trapdoor  never  to  reappear  or  be  mentioned  in  respectable  society;  and  if  I 
knew  where  the  trapdoor  was  and  could  tell  you  how  to  avoid  it,  would  you  want  me 
to  refrain  from  tolling  you,  even  if  the  door  had  an  unpleasant  name  and  it  would  be 
painful  for  you  to  know  what  became  of  those  who  had  disappeared  through  it?  De 
you  think  your  parents  would  neglect  to  tell  you  if  they  knew,  or  would  object  to  my 
telling  you?  Hitherto  most  of  them  have  neglected,  although  they  do  know,  and 
probably  many  would  object  if  they  knew  that  I  was  going  to  try  to  tell  you. 

Such  a  recreation  place  does  exist  in  this  city  and  every  other;  and  the  concealed 
trapdoor  frequently  opens  to  receive  its  victim  and  closes  forever  behind  her.  I  am 
going  to  try  to  explain  why  the  door  is  so  treacherous,  and  to  show  the  many  insidious 
approaches  along  which  it  is  so  easy  and  seems  so  harmless  to  start;  and  I  shall  endeavor 
also  to  explain  why  the  keeper  of  the  door  seems  so  pleasant  when  he  meets  you  at  the 
beginning  of  any  of  these  approaches,  but  is  so  utterly  heartless  when  he  drags  his 
victim  through. 

The  name  of  the  park  is  social  pleasure.  The  hidden  trapdoor  is  man's  pasedon. 
The  keeper  of  the  door  is  man  himself.  The  b^:innings  of  the  many  approaches  are 
collectively  known  as  sex  attraction,  or,  more  familiarly  and  politely,  feminine  charm 
in  women  and  gallantry  in  men.  No  one  wishes  to  or  can  escape  or  eliminate  these 
beginnings.  But  if  traveled  far  the  approaches  lead  by  imperceptible  d^prees  to  the 
all  but  irresistible  sex  stimulation  which  too  frequently  ends  only  beyond  the  trapdoor 
from  which  the  man  may  and  does  return  but  the  girl  almost  never. 

Parents  in  the  home,  teachers  in  the  public  schools,  preachers  in  the  churches,  and 
teachers  in  the  Sunday  schools,  all  give  much  time  and  thought  and  energy  to  the 


FUBUO   BKLL.TH   &KD  MEDICINE.  623 

monl  training  of  boys  and  young  men,  of  giib  imd  young  women.  All  other  moral 
dangen,  both  groat  and  gmall,  both  near  and  remote,  are  fully  and  frankly  explained, 
and  the  yoimg  are  told  why  they  should  and  how  they  can  avoid  them.  But  when 
anything  is  eacountered  in  reading  or  spoken  in  converaation  concerning  any  sex 
danger  or  any  sex  fact  it  ia  passed  over  in  shamelaced  ailence  or  cixidemned  as  indecent. 
Yet  every  normal  boy  or  young  man  is  continually  confnmted  with  many  most  serioui 
aez  problems,  fiaught  with  the  worst  sort  of  moral  and  phyaical  dangers  not  only  for 
himself  but  for  the  girls  and  young  women  with  whom  he  anodateB. 

Forgirlsand  youngwomeneepiecially,  no  other  dtmgersare  so  seriouaas  sex  dangers, 
andnootheroSensesareaofatalaseexoffuueB.  Almost  any  other  oSense.even  though 
oft  repeated,  may  be  forgiven  and  lived  down.  A  single  wi  mistake  in  a  girl  may  and 
often  does  hopelessly  condemn  her  to  a  life  of  social  oatracifan,  of  ahame,  and  of  suffer- 
ing; to  a  death  of  despair;  and  to  an  eternity  the  character  of  which  God  only  in  Eis 

wi*d«in  run  Irnnw  nr  in  Hin  mnrr'V  dntnrminR 

will  come,  when  these  matters  should 
in  company  composed  of  men  and 
:  they  should  never  enter  into  the  coa- 
less  they  be  husband  and  wife),  evaa 
y  seriously  whether  it  is  entirely  wiM 
g  from  the  lecture  platform,  the  stage, 
struction  is  far  better  than  no  instnic- 
audiences  by  careful  and  prayerful 
cte  are  far  better.  1  am  so  firmly  con- 
I  one  woman  alone  ought  never  to  di»- 
alone  to  ask  me  questions  concerning 
or  more  I  will  endeavor  to  answer  aujr 
le  may  come  to  my  home  and  we  will 
I  as  vitally  interested  in  these  matter* 

keriB 

a  surrounded  with  an  atmosphere  ol 
ir  traditions  and  teachinj^  have  made 

The  reproductive  function,  to  which 
en  degraded  from  its  high  purpose  to 
led  to  look  only  at  its  vicious  aspects, 
om  the  leg  of  asceticism  and  pruderj 
lace  among  the  subjects  deemed  most 
e  subject  oi  sex,  the  ever-recurring 
iFOrds  of  the  Rev.  Canon  Lyttleton, 
e  can  be  no  greater  satire  on  creative 
b  most  nearly  asBimilates  man  to  his 

the  creation  of  lite  is,  in  any  proper 

letter  of  President  Eliot,  saying: 

ion  ol  the  horrible  docUine  that  the 
ightest  degree  sintul  or  foul  processea. 
line  in  connection  with  theae  proceesea 
that  there  iftno»:hin%  oa  eaitti  «>  swreA 
^  AilA  iiiXo  tiie  ■woi\4  «i  ^^»*»- 


624       PBOOEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  C0N0BE8S. 

• 

to  this  knowledge  is  that  sex,  maternity,  and  children  constitute  a  larger  and  more 
important  part  of  woman's  existence  and  questions  relatlni^  to  such  important  facta 
of  her  life  seem  natural  and  proper.  Apart  from  considerations  of  sentiment  wom^ 
have  a  right  to  a  knowledge  of  the  facts  which  so  vitally  concern  their  own  and  their 
children's  health. 

The  American  Society  for  the  Prevention  of  Social  Diseases,  in  a  pamj^let  ad- 
dressed to  teachers,  declaied: 

The  need  of  popular  instruction  in  the  physiology  and  hygiene  of  sex  has  in  recent 
years  become  recognized  as  imperative  by  many  earnest  physicians  and  citizens. 
The  reasons  are  of  a  nature  that  specially  requires  instruction  of  the  young  between 
the  ages  of  10  and  20— i.  e.,  when  the  great  majority  are  in  school  and  college.  The 
ideal  is  for  all  parents  to  give  it.  ^  Since  this  is  impossible  of  realization  at  present, 
the  duty  falls  cniefly  upon  physicians  and  teachers. 

Another  pamphlet  issued  by  the  same  society,  in  discussing  the  problem  for  teaehena* 
nys: 

Sex  is  the  most  Important  fact  of  life — ^the  central  fact  as  reguds  the  existence  and 
the  relations  of  human  society.  *  *  *  So  far  as  we  can  apprehend  nature's  pur- 
pose in  the  scheme  of  the  universe,  the  chief  end  of  man  and  woman  is  not  simply 
to  live,  but  to  transmit  life,  and  from  this  point  of  view  all  other  functions  of  the 
body  exist  and  need  to  be  conserved  to  permit  of  the  accomplishment  of  the  creative 
function.  In  order  to  assure  the  perpetuation  of  life,  nature  has  implanted  in  all 
animals  the  sexual  instinct  which  incites  to  the  perfonnance  of  this  tunction;  man 
alone  is  endowed  with  reason  for  its  guidance  and  will  for  its  regulation. 


Still  another  pamphlet,  on  the  relations  of  social  diseases  to  marriage,  says: 

Evil  conditions^  like  manv  crimes,  flourifih  best  in  the  dark.  In  this  atmosphere 
of  ignorance^  in  disguise  ana  darkness,  wearing  the  protective  mantle  of  secrecy  and 
shame  and  silence,  with  absolute  exemption  from  all  sanitary  reception  or  control, 
these  diseases  infect  the  social  body,  unseen  and  unnoticed.  In  view  of  the  dangera 
which  menace  the  public  health  and  the  interests  of  the  family  and  society  from 
venereal  diseases,  it  is  time  to  break  down  these  barriers  of  concealment  and  silence 
behind  which  these  diseases  propagate  and  flourish,  to  dissipate  the  dense  ignorance 
of  the  public  by  tumins  on  the  purifying  light  of  knowledge,  to  do  away  with  ^e 
mystery  and  secrecy  which  have  always  surrounded  them,  and  to  put  aside  that 
ridiculous  prudery  which  regards  all  knowledge  of  sexual  matters  as  pro&me. 

Dr.  Winfield  S.  Hall,  in  an  address  on  the  teaching  of  social  ethics,  said: 

The  onljr  rational  cure  for  present  social  conditions  is  to  be  found  in  education. 
Wise  laws  justly  and  firmly  administered  will  help.  Public  institutions  for  reclaiming 
the  fallen  will  also  help.  These  two  measures  last  named  alleviate  in  a  superficiu 
way  only.  What  we  must  seek  to  accomplish  is  to  remove  the  cause  so  that  tnese  ills 
will  not  exist  and  therefore  not  need  alleviation.  In  the  social  evil,  as  well  as  the 
drink  evil,  it  is  necessary  that  the  education — the  rational  prophylaxis  of  the  evil — be 
beffun  in  youth.  It  is  very  much  easier  to  keep  a  youi^;  life  straight  than  it  is  to 
make  it  straight  once  it  has  become  bent  and  distorted.  *  *  *  A  very  sm^ 
proportion  of  the  present  j^eneration  of  parents  possess  either  the  requisite  informa- 
tion or  the  necessary  inclination  to  give  this  instruction. 

There  must  be  a  transitional  period,  during  which  educators,  social  workers,  and  ail 
the  constructive  forces  of  society  work  together  to  produce  a  generation  of  parents  who 
will  possess  both  the  information  and  the  inclination.  That  means  that  we  must  go 
into  the  schools  and  teach  the  great  truths  of  life  to  the  children  and  youth.  *  *  • 
The  education  of  the  youth  in  this  transitional  period  should  begin  in  colle^  and 
universities.  It  may  be  said  in  passing  that  a  considerable  number  of  our  institutions 
of  higher  learning  have  abeady  made  a  good  start  in  this  teaching.  We  may  lo<^ 
forward  with  assurance  to  a  time  in  the  near  future  when  all  these  institutions  will 
recognize  their  obligation  in  this  direction  and  wiU  have  this  instruction  given 
systematically. 

In  the  introduction  to  his  Sex  Education  Series,  Dr.  Hall  says: 

There  is  need  for  instruction  by  religious  teachers,  since  the  will  and  the  conscience 
must  be  appealed  to  if  right  habits  are  to  be  formed. 


FUBLio  health:  akd  mediciite. 

Dr.  Robot  N.  Wilran,  in  bia  Education  of  the  Young  in  Sei  Hygiene, 
the  girl'B  needs,  aava: 

It  is  the  pommon  statement  of  nuuried  women  consultine  with  their  phyraciana  that 
before  marriaee  they  Vnew  practicaHy  nothing  reRftrding  the  need  of  instruction  with 
reepert  to  their  own  or  their  Hie  partner's  physical  body.  No  one  prepared  them  Ua 
unnecensarv  blunders  and  dangere  before  they  entered  into  that  riche^  in  hanpiDeas 
and  peril  of  all  life's  ways.  On  the  ncore  of  indelicacy  and  diificulty  of  appniacn.  and 
because  of  a  modesty  as  false,  transparent,  and  fatal  as  the  affection  of  Judas  for  Christ, 
thousands  of  youn^  wivee  have  Been  brous^ht  ab-eady  sexless  from  disease  to  the 

r rating  table,  and  Ibouannds  more  have  there  been  rendered  stcaile.  •  *  •  If 
girl  of  the  twentieth  century  has  a  single  need  it  is  for  a  simple,  sane  underatanding 
of  her  physical  self,  of  her  greateet  physical  abject  in  living,  and  the  means  of  its 
fulfillment. 

The  American  Federation  for  Sex  Hygiene,  in  a  committee  report  on  sex  education, 
■ays; 

The  common  reluctance  even  of  educat«d  peo))1e  in  the  past  to  tolerate  discusnoD 
of  this  mibject,  outside  of  medical  circles,  must  give  way.  and  is  rapidly  giving  way. 
to  a  nobler  and  purw  sentiment,  which  will  recognize  that  whatever  is'  fiindamenlJti 
knd  vital  to  health  and  monls  in  the  individual  and  die  community  is  a  proper  sub* 
ject  for  serious  thought  and  discreet  discussion. 

In  order  to  reach  its  conclusions,  this  committee  ffMmuIated  a  dosen  or  more  propo- 
■itions  setting  forth  means  and  methods  of  giving  (wx  instruction  of  all  kinds  adapted 

.__!. J  _. ™..__    _.    ._..., bmltted  for  approval  or  disapproval 

public  schools,  colleges,  and  nni- 
proposition  was  approved  by  from 
Of  the  remainder,  few  disapproved, 
,-e  of  the  wonderful  and  wholesome 
le  educated  classes, 
id  an  Ancient  Evil,  mya: 
ktional  approach  to  this  subject  has 
Kiousnees  of  grown-up  people;  for 
ply,  their  parents  often  uike  alarm, 
ed  together  a  number  of  influential 
jie  root  of  the  social  evil  lay  in  the 
ickening  of  the  parental  conscience 


[  that  for  older  children  the  ii 
e,  but  may  come  auite  naturally  in 
the  havoc  WTOugnt  by  the  sexual 
when  directed  and  npiritu allied,  it 
na  and  sacrilicM.  Tne  youth  thus 
Dtial  to  the  continuance  of  the  race, 
la,  as  a  fundamental  factor  in  sociai 
his  mind  at  he  learns  that  his  own 
M  been  said  that  the  child  growing 
rents  and  teachers  something  of  the 
lubjecta  save  upon  that  of  sex.  On 
B  from  its  predecwaon. 

■  ^^  \A»  ^^witoa  •»*■  ^^""^  "'** 


^V 


626       PROCEEDINGS  SECOND  PAN  AMEBICAN  SGIENTIFIO  C0N0BE6& 

When  murder  or  some  other  serious  crime  has  been  committed  and  the  oimiiud 
has  escaped  without  being  observed  by  anyone  and  can  not  be  easily  found,  the 
police  or  detectives  always  raise  the  question,  To  whose  profit  could  it  have  been  that 
this  crime  should  be  committed?  This  clew  usually  fixes  suspicion  on  some  one,  and 
frequently  results  in  the  detection  of  the  criminal. 

Who  profits  from  this  conspiracy  of  silence  concerning  sex  knowledge,  in  wfaidi 
nearly  all  the  rest  of  society  joins  against  its  girls  and  unmarried  women? 

Certainly  the  girls  and  unmarried  women  get  no  profit  from  it.  The  most  that  cmn 
be  said  is  that  a  large  majority  of  them  fortunately  8u£fer  no  ill  from  it  so  long  as  they 
remain  unmarried.  But  no  one  knows  whidi  of  them  may  at  any  time  become  one  of 
the  small  minority  who  are  the  first  and  most  unfortunate  victims  of  it,  and  to  whom 
it  brings  far  worse  than  death,  for  it  means  a  life  of  infamy  to  end  in  a  death  of  despair. 

Neither  do  married  women  profit  from  it.  The  knowledge  of  sexual  matters  is 
inevitable  to  them.  When,  as  usual,  they  are  uninstructed  beforehand,  it  sometimee 
comes  even  to  those  who  marry  the  cleanest  and  kindest  of  men  with  such  a  shock  of 
dismay,  disgust,  and  fear  that  it  disrupts  the  marriage  at  once  and  ends  the  dream  ci 
hapfHness.  In  other  cases  the  wife  even  of  such  a  man  spends  the  early  weeks  or 
months  or  possibly  years  in  untold  agony,  thinking  she  is  wedded  to  a  man  who  it 
brutal  and  unlike  others.  She  could  have  been  saved  this  by  knowing  in  advance 
that  all  men  are  essentially  alike,  if  they  are  normal,  in  possessing  this  powerful  in- 
stinct, and  by  being  taught  that  there  is  nothing  shameful,  unholy,  or  injurious  in 
the  proper  sex  relation  oi  husband  and  wife.  More  especially  the  thousands  of  wives 
who  each  year  are  married  to  men  ^o  have  acquired  the  physical  and  moral  db- 
eases  inseparable  from  social  vice  (which  lives  principally  on  the  sex  ignorance  of 
girls  and  unmarried  women)  certainly  get  anything  but  profit  from  it. 

Neither  do  pure  men,  either  married  or  unmarried,  profit  from  this  conspiracy  of 
silence.  The  immodest  clothing  and  improper  conduct  of  so  many  women  due  to  their 
Ignorance  of  the  influence  these  have  on  men's  sex  impulses  make  much  harder  than  it 
need  be  the  struggle  in  which  clean  men  are  always  engaged  to  remain  pure  in  thought 
as  well  as  act. 

Those  ^o  profit  from  sex  igncnrance  in  girls  and  women  are  impure  men,  wiio  wisli 
to  prey  upon  them,  and  the  army  of  human  harpies,  both  men  and  women,  who  share  in 
the  spoils  of  commercialized  vice.  Should  parents  and  educators  still  continue  to  be, 
as  nearly  all  have  hitherto  been  through  their  silence,  accessories  to  this  crime? 

What  I  am  attempting  is  a  study  of  sex  ethics  rather  than  of  sex  anatomy  or  phjrsiology, 
or  even  of  sex  hygiene.  It  is  therefore  not  my  purpose  to  discuss  the  structure  or  uses 
or  care  of  the  sex  organs,  either  male  or  female,  or  to  study  the  subject  of  reproduction 
in  general,  although  I  consider  these  very  important  and  perfectly  proper  subjects  for 
discussion  or  study  before  classes  or  audiences  composed  of  women  and  girls  alone 
or  men  and  boys  alone.  Furthermore,  I  would  have  men  and  boys  know  all  there  is 
to  be  known,  not  only  concerning  the  male  sex  organs  and  functions,  but  the  female 
also;  and  I  would  have  all  women  thoroughly  instructed  not  only  concerning  their 
own,  but  those  of  men  as  well.  In  no  other  way  can  there  be  a  full  and  sympathetic 
understanding  by  each  of  the  sex  problems,  difficulties,  and  dangers  of  the  other. 
Without  such  full  and  sympathetic  understanding  it  is  hardly  possible  for  safe  and 
proper  relations  to  be  maintained  between  them. 

The  traditional  and  customary  habit  of  thinking  of  and  referring  to  these  portions 
of  our  bodies  as  the  secret  organs  is  not  only  absurd  but  vicious.  It  is  part  and  pared 
of  the  age-old  and  fatal  conspiracy  of  silence  concerning  sex.  I  hope  the  time  may 
come  when  these  will  be  thought  of  and  spoken  of  no  longer  as  the  secret  but  as  the 
sacred  organs.  This  would  help  to  inspire  a  much  to  be  desired  reverential  respect 
for  them  that  should  lead  to  their  proper  care  and  their  preservation  and  reservation 
for  holy  uses. 


PUBUO  HBALTH  AKD  MBDIODni.  627 

Fortunfttely  this  infonnation  conoerning  the  structure,  the  uses  and  the  care  of  ttie 
sex  organs,  and  concerning  reproduction  ahready  exkts  in  many  books.  For  a  simple 
and  readable  and  scholarly  study  of  the  most  important  facts  concerning  the  female 
oigans  and  female  share  in  the  reproductive  processes,  I  know  of  nothing  better  than 
Br.  Mary  G.Hood's  book, ''For  Girls  and  theMothers  of  Girls,"  pubUshedbytheBobbs. 
Merrill  Co.  A  similar  though  somewhat  technical  but  still  readable  study  of  the  male 
oigans  and  male  share  is  Dr.  Winfield  S.  Hall's  **  Reproduction  and  Sexual  Hygiene." 
His  more  recent  ''Sex  Education  Series "  presents  much  of  the  same  information  in 
simpler  form  in  several  small  books  adapted  to  various  ages.  I  wish  that  every  girl 
and  woman,  and  every  man  and  boy  as  well,  would  read  and  re-read  with  care  both  of 
the  first  two  books,  or  some  of  the  many  other  books  that  deal  with  the  same  subjects. 
Dr.  Hall's  latest  and  best  book,  called  "Sexual  Knowledge, "  published  by  The  ^ter- 
national  Bible  House,  gives  full  instruction  concerning  both  male  and  female  sex 
organs  and  processes,  in  easily  comprehensible  language.  Dr.  I.  D.  Steinhardt's 
"Ten  Sex  Talks  to  Girls,"  recently  published,  is  valuable,  simple,  and  wholesome. 
He  also  has  a  companion  book  on  "Ten  Sex  Talks  to  Boys. " 

I  shall  not  attempt  to  study  the  character  or  the  prevalence  of  the  terrible  diseases 
that  result  from  the  social  evil.  It  is  sufficiently  startling,  and  should  cause  every 
unmarried  woman  to  be  exceedingly  cautious,  for  me  to  say  that  the  consensus  of 
opinion  among  students  of  these  subjects  and  among  practicing  physicians  indicates, 
in  a  way  that  makes  it  practically  impossible  to  doubt  the  truth  of  their  statements, 
that  considerably  more  than  half  of  all  men  either  are  or  have  been  infected  with  one 
or  more  of  these  diseases.  In  cities  the  percentage  is  much  higher.  In  smne  cases, 
of  course,  infection  is  without  illicit  relations. 

I  will  dwell  long  enough  to  say  for  your  comfort  and  jHrotection  that  there  ii  a  practi- 
cal and  proper  and  almost  certainly  effective  way  to  exercise  this  caution.  It  is  for 
every  prospective  bride  (through  the  medium  of  her  parent  or  guardian  or  physician) 
to  require  from  the  man  she  is  to  marry  certificates  of  at  least  three  medical  examina- 
tions declaring  that  at  all  three  examinations  he  was  free  from  any  of  these  or  other 
communicable  diseases.  The  physician  should  be  chosen  each  time  not  by  the  man 
but  by  the  woman  or  those  who  speak  for  her.  The  times  of  the  examinatioas  should 
not  be  selected  by  him,  but  by  the  woman's  representatives,  and  should  be  unknown 
to  him  until  a  few  days  befcwe  each  is  to  be  made.  There  should  be  at  least  one  year 
between  the  first  and  the  last,  and  marriage  should  follow  shortly.  No  dean  man  will 
resent  or  object  to  the  requirement.  If  one  did  resent  it,  that  in  itsdf  would  be 
strong  presumptive  evidence  of  his  fear  that  he  could  not  give  a  dean  bill  el  health. 
It  would  also  be  proper,  and  strengthen  theevident  justice  of  her  causey  for  the  prespoo- 
tive  bride's  parent  or  guardian  to  give,  as  a  matter  of  course  (not  merely  te  offer),  to 
her  prospective  husband  similar  certificates  of  her  freedom  from  communicable 
disease.  At  least  one  such  certificate  for  each  is  required  by  law  in  some  States.. 
It  would  be  far  better  if  the  other  two  were  also  required,  or  vduntarily  given  as  joit 
described.  This  would  have  the  further  salutary  effect  of  making  hasty  manriage 
impossible. 

A  multitude  of  books  and  pamphlets  are  available  for  the  study  of  these  aodal 
diseases  and  their  relation  to  health,  to  marriage,  and  to  society  in  geneiaL    Periiapa 
the  most  easily  available  and  effective  are  the  numerous  and  inexpensive  pamphlets 
issued  by  the  Society  of  Sanitary  and  Moral  Fhyphylaxia.    T>v.  Bobest^.  ^Iten'a 
"Education  in  Sex  Hygiene"  is  one  of  the  best  geoetal  etudiea  «i  wpw^^^^^aonanAthe 
social  evil,  though  not  the  most  happily  oiganized  f^^  i^Ut«wn  « V)^«^^*»»^V=«»^^ 

I  will  do  hardly  more  than  to  mention  the  ^'wle^^^^  •^'biW^Jiari^lx*^^^  ~^]^^^ 
ized  means  of  recruiting  for  the  deplorable  "y^t^^^^l  coiSM"^«KaiiJ6*'®^  ^^^^V^cs^ 
makes  it  unsafe  for  any  girl  or  young  woman,  u^^     tg\  ^  ""^^cosAi  *^  ^eJs.'*^'^^^ 
in  the  company  of  any  man  who  is  not  an  *cq\J^^^va^^  ol  ^^^«^M^^^n*  >:%«»  ^^w^- 
months'  standing  and  of  irreproachable  cluit%^|!^\>^  A^fliK^  ^^^^t^t 
6848^-17— VOL  X 41 


628       PB0GEEDIN6S  SECOND  PAN  AMESIOAN  80IENTIFI0  C0NQBS88. 

science  and  an  Ancient  Evil/'  already  quoted  from,  is  a  dramatic  and  convincing 
presentation  of  the  extent,  the  danger,  uid  the  methods  of  this  nefarious  businesB. 
The  other  books  and  pamphlets  just  mentioned  study  this  also. 

My  discussions  will  be  confined  to  an  effort  to  give  an  adequate  apinreciation  of  the 
all  but  uncontrollable  strength  of  men's  sex  impulses  when  imder  the  influence  of 
sex  stimulation;  to  give  a  reasonable  explanation  of  the  almost  perpetual  presence 
and  easy  susceptibility  to  outside  stimulation  of  their  desire  for  sex  union;  to  show 
what  actions  and  conditions  in  women  stimulate  this  desire;  and  to  show  women  and 
girls  how  they  can  avoid  causing  this  stimulation  without  depriving  themselves  or 
their  gentlemen  Mends  or  relatives  of  any  legitimate  pleasures  that  come  from  the 
proper  companionship  of  the  sexes. 

Many  men  who  conscientiously  oppose  the  giving  of  sex  instruction  to  women  and 
others  who  do  not  oppose  all  instruction  but  think  it  should  not  be  given  so  fully  or 
frankly  as  I  am  giving  it,  fear  that  a  knowledge  of  so  seductive  a  danger  will  lead  some 
to  seek  it  who  might  through  ignorance  escape.  Think  for  a  moment.  If  there  were 
lying  in  an  out-of-the-way  comer  of  this  room  a  small  package  which  you  had  frequently 
passed  near  without  touching  or  paying  any  attention  to,  and  if  I  should  know  and  tell 
you  that  it  contained  dynamite  which  would  explode  with  fatal  results  to  yourself  and 
probably  to  others  if  you  should  strike  it  or  handle  it  carelessly,  would  you  deliberately 
go  and  kick  it?  Certainly  not,  if  you  believed  what  I  said .  If  there  were  on  this  table 
a  glass  containing  what  appeared  to  be  drinking  water,  but  what  I  knew  to  be  a  color- 
less, odorless,  and  tasteless  but  deadly  poison,  would  you  be  more  likely  to  kill  yourself 
by  drinking  it  after  I  told  you  its  real  nature,  or  before?  Are  the  young  and  middle 
aged  people  of  the  present  drinking  more  intoxicating  liquor  than  they  would  other- 
wise have  done  because  teachers  of  physiology  and  hygiene  in  the  schools  for  the  past 
two  generations  have  been  teaching  tbe  evil  effects  of  alcohol?  No;  it  is  this  very 
instruction,  and  that  imparted  in  other  ways,  that  seems  to  have  sounded  the  death 
knell  of  the  liquor  traffic.  And  this  has  come  about  in  spite  of  the  fact  that  this  instruc- 
tion has  not  endeavored  to  conceal  the  pleasure  and  exhilarating  stimulation  idiidi 
result  from  moderate  drinking,  but  has  dwelt  on  the  certain  idtimate  evil  from  even 
moderate  drinking  and  the  danger  that  moderate  drinking  will  lead  to  excessive  drink- 
ing with  its  shame  and  di4grace  and  its  moral  and  physical  and  financial  ruin. 

If,  then,  in  order  that  you  may  realize  how  powerful  and  seductive  the  dangers  are 
to  whidi  women  are  subjected  because  of  the  sex  passion  in  men,  I  explain  to  you  the 
almost  delirious  pleasure  which  practically  all  men  and  possibly  a  few  women  expe- 
rience when  under  the  influence  of  extreme  sexual  excitement,  is  that  going  to  make 
you  more  likely  to  incur  these  dangers  than  if  you  remained  in  ignorance  of  them? 
I  believe  it  will  not,  any  more  than  a  knowledge  of  the  pleasures  of  intoxication  or  of 
opium  eating  is  going  to  make  you  a  drunkard  or  an  opium  fiend. 

It  is  exactly  in  this  almost  insatiable  delirious  pleasure  that  the  strength  and  per- 
sistence of  the  masculine  passion  lies;  it  is  the  almost  uncontrollable  strength  of  that 
passion  that  makes  it  so  dangerous;  and  it  is  women's  ignorance  of  its  univerRality 
and  strength  which  leads  them  unintentionally  and  unconsciously  to  stimulate  it. 

The  sex  instinct  is  for  the  life  of  the  race  \diat  hunger  is  for  the  life  of  the  individual. 
Intense  ''gnawing  "  hunger  is  caused  by  violent  spasmodic  contractions  of  the  muscular 
waUs  of  the  stomach.  Nerves  in  the  stomach  convey  to  the  brain  the  sensations 
caused  by  these  movements,  and  a  craving  for  food  results.  The  sex  oigans  are  sup- 
plied with  very  numerous  and  very  sensitive  nerves.  As  the  continually  accumu- 
lating reproductive  sscretions  of  the  male  oigans  cause  pressure,  their  waUs  periodi- 
cally and  involuntarily  become  turgid  and  spasmodically  expand  and  contract.  The 
nerves  convey  this  agitation  to  the  brain  and  a  craving  for  sex  gratification  results, 
whether  the  boy  or  man  is  awake  or  asleep.  This  craving  is  far  more  insistent  than 
the  craving  for  fcx>d,  and  the  pleasure  accompanying  its  satis&uiion  is  immeasurably 
more  intense.    Just  as  hunger  grows  more  intense  in  the  presence  of  appetizing  food, 


PUBLIC  HEALTH  AND  MEDICINE.  629 

80  this  sex  longmg  becomes  more  intense  when  stimulated  by  conditions  to  be 
explained. 

In  men  who  persist  in  living  continent  lives,  that  is,  resolutely  resist  the  powerful 
temptation  to  satisfy  their  longing  in  any  improper  way,  this  **sex  hunger"  operates 
as  a  powerftd  force  impelling  them  to  marriage,  which  institution  has  been  ordained 
by  God  and  man  for  the  legitimate  satisfaction  of  this  longing  and  for  rearing  the  chil- 
dren which  normally  result  from  it.  It  is  thus  seen  that  this  instinct,  which  is  so  dan- 
gerously insistent,  is  necessary  and,  if  properly  controlled,  beneficent. 

If  any  woman  is  to  be  entirely  safe  she  must  imderstand  the  existence  and  the 
strength  of  this  instinct,  avoid  giving  occasions  for  its  stimulation,  and  keep  from  falling 
into  the  power  of  men  of  uncertain  character  or  impure  habits.  Woman*s  physical 
strength  is  useless  as  a  protection;  for  man,  always  the  stronger,  seems  to  possess  almost 
superhuman  strength  when  under  the  influence  of  sex  stimulation. 

It  is  in  order  that  you  may  understand  these  facts  and  conduct  yourselves  accord- 
ingly that  I  am  giving  you  these  perfectly  frank  explanations  of  the  serious  sex  prob- 
lems of  men.    Proper  precaution  will  enable  you  to  avoid  almost  every  danger. 

If  you  will  examine  with  care  a  fully  and  freshly  opened  peach  blossom  you  will  see 
just  above  and  within  the  circle  of  five  pink  petals  a  mass  of  tiny  stems  each  having 
its  top  enlarged  and  covered  with  what  seems  to  be  tiny  particles  of  yellow  dust, 
which,  if  you  shake  the  flower,  flies  off  in  a  miniature  cloud  or  which  clings  to  your 
nose  or  your  finger  if  it  touches  them.  In  the  middle  of  the  bunch  of  little  yellow- 
crowned  stems  you  will  see  a  single  one  slightly  larger  and  considerably  longer,  which 
also  has  its  end  slightly  enlarged,  but  very  different  from  the  others,  and  covered 
with  a  slightly  sticky  substance.  At  the  bottom  of  this  central  stem  you  will  find  a 
little  bulb-like  enlargement  which,  if  the  blossom  had  remained  on  the  tree  and  no 
mishap  had  befallen  it,  would  have  developed  into  a  peach. 

These  are  the  sex  organs  of  the  peach.  The  single  central  stem  with  its  tiny  enlarge- 
ment at  the  top  and  its  larger  bulb  at  the  bottom  are  the  female  organs.  The  smaller 
yellow-topped  stems  are  the  male  organs.  All  other  flowers  have  essentially  these 
same  organs,  though  they  may  differ  greatly  in  form,  in  relative  location,  and  relative 
numbers  in  different  flowers.  In  some  plants  the  female  organs  are  on  different 
twigs  or  different  boughs  from  the  male,  and  in  some  the  two  are  on  separate  plants 
or  trees. 

I  probably  do  not  need  to  inform  you  that  in  the  beginning  God  not  only  created 
man,  male  and  female,  and  ordained  that  each  should  be  a  helpmate  to  the  other,  but 
all  other  living  things,  both  animal  and  vegetable,  except  a  few  of  the  very  lowest 
forms  of  life,  were  sdso  created  male  and  female.  And,  barring  the  few  relatively 
unimportant  exceptions,  without  the  union  of  the  male  and  female  elements  of  any 
given  species  there  can  be  no  new  life  produced. 

Let  us  turn  again  to  the  peach  blossom  and  notice  that  there  ia  only  one  female 
stem.    This  is  called  the  pistil.    The  enlargement  at  the  top  is  the  stigma,  and  that 
at  the  bottom  the  ovary.    If  you  will  count  the  male  stems,  or  stamens,  as  they  are 
called,  you  will  find  that  there  are  20,  25,  or  30  if  the  flowers  are  normal  and  none  of 
the  stamens  have  fallen.    Each  little  enlargement,  or  anther,  as  it  is  called,  on  top 
of  the  stamen  contains  so  many  dust  particles,  called  collectively  the  poUen,  that  it 
is  almost  impossible  to  count  them.    There  are  probably  several  thoxisands  o!  tliem. 
for  a  conservative  estimate  let  us  say  there  are  a  thouaaxid  \j^  Qac\i.    "W^iAlV^VyVii^  tiAs 
by  the  number  of  anthers  would  give  at  least  2q  qQO  l^Wea  ^gra^s^  ^  ^^^  f^o^«t. 
Each  grain  contains  a  male  germ  cell  and  is  capaV^y'  ol  l«^^^^^Xl'^^^  \«as2ift  ^^^i  c^V 
and  starting  the  new  life.  ^^ 

In  the  single  ovary  at  the  bottom  of  the  siix^^  .^tJV  ^  V^^  ^\^e  ^^^''.^^^V^^^' 
If  this  be  fertilized  by  one  of  the  pollen  partj^^  y7  ^'^^  ^'^^^^'^^Is^^^^^'^'^^ 
subsequently  meets  with  no  mishap.    If  the  ^     Vv^ft  '^     \v^  "^^'^*^^v^  e^^ 


630       PBOOEEDINOS  SBOOND  PAN  AMEBICAN  SOIENTIFIO  CONOBE88. 

80  far  as  the  reproductive  process  is  concerned,  be  planted  it  will  come  up  and  grow 
^to  be  a  new  peach  tree. 

The  fact  that  I  want  to  impress  on  your  minds  concerning  the  sex  process  in  the 
peach  is  that  of  the  20,000  or  more  male  germ  cells  only  one  is  needed  or  can  be  used. 
All  the  rest  must  go  to  waste.  Certainly  in  the  peach  nature  is  prodigal  of  the  male 
element,  but  very  careful  to  make  sure  that  the  female  shall  not  lack  fertUlEaticm. 

In  many  other  plants,  perhaps  most  plants,  the  ovary,  instead  of  containing  only 
one  female  germ  ceil  and  developing  into  one  seed,  contains  many  female  germ  cells 
and  develops  many  seeds,  as  the  apple  and  most  berries  among  fruits,  or  peas,  beans, 
melons,  and  most  vegetables.  In  these  cases  as  many  pollen  particles  or  male  germs 
as  there  are  seeds  must  find  their  way  into  the  ovary,  each  coming  into  contact  with 
and  fertilizing  its  own  female  germ.  Even  in  such  cases,  however,  there  are  scores, 
probably  hundreds,  and  possibly  thousands,  of  male  cells  for  each  female  cell. 

The  reason  for  thb  prodigality  of  the  male  element  in  plant  reproduction  is  probably 
partly  due  to  the  fact  that  there  are  only  a  few  days,  possibly  only  a  few  hours,  in  the 
life  of  the  individual  flower  when  the  organs  are  in  such  a  condition  that  the  fertiliz- 
ing process  can  occur.  If  during  those  few  hours  or  days  the  male  germ  fails  to  find 
its  way  through  the  pistil  to  the  female  germ  in  the  ovary,  the  pistil  withers  and  drops, 
the  unfertilized  female  germ  ceases  to  grow,  and  the  entire  ovary,  which  would  nor- 
mally have  developed  into  the  fruit,  being  robbed  of  the  purpose  for  which  it  existed, 
also  atrophies  and  drops  from  the  tree. 

To  prevent  this  calamity,  or  reduce  its  occurrence  to  a  minimum,  nature  provides 
hundreds  or  thousands  of  male  germs  to  make  sure  that  one  of  them  will  perform  its 
mission.  She  seems  not  only  prodigal  of  the  male  germ,  but  careless  of  its  fate.  The 
lifetime  after  maturity  of  the  individual  male  cell  is  only  a  few  hours  or  a  few  days, 
unless  it  finds  new  life  in  union  with  the  female. 

This  brevity  of  life  of  the  unused  male  germ  is  common  to  animals  and  to  man,  as 
well  as  to  flowers.  The  prodigal  profusion  in  the  supply  of  male  germs  is  also  common 
to  them.  And  the  careless  waste  of  the  unused  germs  also  exists.  More  will  be  said 
a  little  later  concerning  these  facts  in  their  relations  to  animals  and  to  man. 

The  means  by  which  the  pollen  from  the  anther  is  conveyed  to  and  unites  with 
the  ovule  in  the  ovary  is  tlie  sex  process  of  the  flower,  or  fertilization.  I  have  said 
that  without  this  there  can  be  no  new  plant  life.  The  way  this  is  accomplished  is 
very  interesting  and  wonderful.  It  is  possible  that  the  pollen  from  one  flower  by 
merely  falling  may  drop  on  the  stigma  of  another,  or  it  ma^y  be  cani«d  by  the  wiad 
or  water  &om  one  to  the  other.  But  nature  has  provided  a  siurer  means.  In  most 
familiar  flowers  the  transfer  is  effected  chiefly,  and  in  some  entirely,  by  insects.  Each 
insect  is  wholly  imconscious  of  the  important  service  it  is  performing,  being  only 
intent  on  accomplishing  its  own  selfish  ends — ^that  is,  satisfying  its  appetite  for  food, 
or  for  enjoying  the  sweet  odors  or  gay  colors  of  the  flower — ^purely  sensual  pleasures, 
Those  features  which  so  please  us  about  the  flower — ^the  beautiful  color,  and  the  delicate 
odor — are  provided  by  nature  merely  to  attract  the  insects  to  the  nectarlike  liquid 
at  the  base  of  the  pistil,  which  constitutes  their  principal  food. 

By  various  ingenious  devices  nature  has,  in  nearly  all  flowers,  made  it  practically 
impossible  for  the  pollen  from  the  anthers  of  any  individual  flower  to  reach  the  stigma 
of  that  flower.  This  is  doubtless  for  the  same  reason  that  the  stock  raiser  brings  his 
male  animals  from  other  flocks  or  herds,  and  that  near  relatives  among  human  beings 
are  forbidden  to  marry. 

To  accomplish  this  purpose  in  the  peach  and  many  other  flowers  the  pistil  is  con* 
siderably  longer  than  the  stamens  and  the  stigma  is  thus  far  above  the  anthers. 
"While  the  bee  feeds  from  the  honey,  hidden  at  the  base  of  the  pistil,  its  legs  and  body 
become  dusted  with  pollen  &om  the  anthers.  It  flies  to  another  flower,  still  seeking 
honey,  but  it  also  carries  the  pollen,  which  is  brushed  against  the  pistil  of  the  second 
flower.'* 


FUBLIG  HEALTH  AKD  METOCINB.  631 

Dr.  Hood  in  her  book,  ''For  Girls  and  the  Mothers  of  Girls,"  already  mentioned 
and  just  quoted  firom,  describing  this  process,  especially  for  the  lily,  says  further: 

As  the  pollen  dust  is  blown  by  the  wind  or  brought  by  the  insect,  it  is  caught  bv 
the  sticky  fluid  upon  the  stigma.  The  sticky  substance  furnishes  just  the  food  which 
the  pollen  cell  finds  necessary  for  its  growth,  and  very  shortly  it  b<^;ins  to  grow  and 
to  send  down  a  fine  tube  through  the  pistil  to  reach  the  ovary.  When,  after  two  or 
three  days,  the  tube  is  ready,  the  [sex]  nucleus,  idiich  is  the  essential  part  of  the 
pollen  or  niale  cell,  escapes  into  the  tube  and  travels  down  to  meet  the  ovule,  or  female 
cell.  When  it  reaches  the  bottom  of  the  tube,  the  end  opens,  the  two  cells  come 
tc^ther,  the  ovule  absorbs  the  nucleus,  and  immediately  the  changes  b^:in  which 
end  in  the  formation  of  a  seed. 

• 

Hie  sex  process  in  animals  and  man  is  remarkably  analogous  to  this — ^that  is,  through 
the  tube  of  the  female  sex  oi'gans  b  inserted  the  tube  from  the  male  organs,  and  through 
the  latter  the  male  germs  pass  to  find  the  female  germ.  In  animals  and  man  the  sex 
organs,  instead  of  being  created  anew  for  each  act  of  union,  as  in  plants,  and  immedi- 
ately disappearing,  remain  as  permanent  parts  of  the  entirely  separate  male  and  female 
bodies.  I^e  most  important  difference,  however,  is  in  the  forces  which  bring  the 
male  and  the  female  germs  together. 

The  flower  has  neither  consciouaness  nor  volition;  hence  in  it  sex  anion  must  be 
effected  by  outside  forces.  Neither  is  the  insect  conscious  of  the  service  it  rendera 
the  flower  in  effecting  the  union,  any  m<m»  tlian  the  wind  is  conscious  when  it  renders 
the  service.  The  insect's  act  is  both  voluntary  and  oMiscious;  but  it  wills  only  to 
satisfy  its  own  appetite,  and  knows  only  that  it  is  being  satisfied.  In  fishes  and  frogp 
and  most  other  water  animals,  where  fertilisation  and  hatching  occur  wholly  apart 
from  the  body  of  the  parent,  there  seems  only  little  more  consciousness  or  volition  in 
effecting  the  union  tiban  in  plants.  But  in  the  higher  forms  of  animal  life  and  in  man, 
where  the  fertilized  ovum  must  spend  a  period  of  weeks  or  months  in  the  body  of  the 
female  before  its  expulsion  or  birth,  the  union  of  the  germs  must  occur  within  the 
female  body  and  can  not  be  left  to  chance  or  be  accomplished  by  forces  independent 
of  both  parents,  as  in  flowers. 

Sex  instinct  in  the  higher  forms  of  life  takes  the  place  of  the  color  and  odor  and 
nectar  in  the  flowers.  In  most  animals  both  the  male  and  female  sex  instincts  appear 
to  be  entirely  dormant  except  when  there  is  in  the  female's  body  an  ovum  in  the 
proper  stage  for  fertilization.  When  this  condition  exists,  certain  actions  or  sounds 
or  odors  always  make  known  the  fact.  The  instinct  of  the  male  always  responds 
instantly.  In  the  absence  of  any  influence  to  keep  them  apart  union  always  occurs, 
and  normally  fertilization  follows.  During  the  several  months  from  the  time  fertili- 
zation occurs  until  some  time  after  the  birth  of  the  yoiuig,  although  the  two  may  be 
continually  in  close  proximity,  neither  seems  conscious  of  the  sex  instinct. 

If,  however,  the  male  animal  should  at  any  time,  after  a  few  minutes  had  inter- 
vened, come  into  contact  with  another  female  of  the  same  species  that  was  ready  for 
union  his  instinct  would  again  respond.  Hence  one  male  domestic  animal  is  suffi- 
cient for  scores  of  females.  While  the  sex  process  in  animals  is  thus  both  conscious 
and  voluntary,  the  individual  animal  wills  only  to  satisfy  the  desire  of  the  moment 
and  is  conscious  of  nothing  but  its  satisfaction.  So  &r  as  being  wiUing  to  periorm, 
or  conscious  of  periorming,  a  necessary  part  in  reproducing  its  kind,  the  service  is 
probably  little  if  any  more  conscious  or  voluntary  than  that  of  the  inaect  tot  the  Ao^er. 

The  supply  of  the  male  germs  in  the  sex  procQes  oi  animala  is  almoBl,  li  not  quite, 
as  prodigal  as  in  flowers.    Instead  of  the  single  eenn  or  very  le^  ne^^^  ^onMnda 
passfromthebodyof  themaletothatof  thefena^^    at  ft  «^^^^  wtX  oi  >35sv<sii.  ^^^^^" 
tion  to  this  prodigality,  the  male,  among  don^^^  ^    ^ts^sAa  %X\Qd3^^  ^  ^^^^^^      'Jf  ^ 
though  his  service  is  needed  by  an  individu^^^    t^  otA^  ^si^j^  O^  ^^^"^^vT^^^^ 

This  fact  is  of  great  ec<momic  value.    Sino^    ^"^     tf\e  t»a^^  t^jisvso^  ^^^ 
is  needed  for  a  large  herd  or  flock,  and  sinc^      W  ^J^^pJ^x  ol  \xi^^  ^^'^^Sk^^^^'"^^' 
proximately  equal,  the  surplus  males  amoiuw   X^^    iV^'^*xtiv««Vi^T'^  jf^^^ 


n:^ 


632       PBOOEBDIKOS  SBOOKD  PAK  AMEBICAK  80IEKTIFI0  GOKOBE8S. 

after  the  few  are  reserved,  can  be  and  are  used  for  food,  in  case  they  are  edible.  In 
the  case  of  horses  and  some  others,  which  are  not  good  for  food,  the  males  are  preserved 
and  used  for  draft  animals.  But  it  is  necessary  for  them  to  be  unsexed,  since  they 
are  otherwise  almost  unmanageable,  so  irresistable  is  the  instinct  when  stimulated 
by  coming  near  a  receptive  female  of  the  same  species.  Even  in  many  wild  animals 
most  of  the  males  are  eliminated  so  far  as  their  service  in  reproduction  is  concerned. 
In  fighting  for  possession  of  the  receptive  females  the  weaker  males  are  killed  or 
driven  away  by  a  few  of  the  stnmgest.  In  a  few  species  of  animaLs  and  many  of 
birds  there  is  a  pairing-off  during  the  mating  season,  which  gives  to  practically  all 
liiales  an  equal  share  in  reproduction. 

Because  it  is  so  difficult  to  control  the  sex  instinct  when  stimulated,  the  male 
horses  that  are  reserved  for  breeding  purposes  are  seldom  seen  on  the  street  or  the  road 
or  in  the  field,  but  are  shut  away  in  the  rear  part  of  livery  stables  or  confined  within 
high  strong  fences.  When  taken  out  skillful  horsemen  must  keep  them  under  con- 
stant control  by  bridle  and  whip.  A  bull,  when  forcibly  restrained  under  such  cir- 
cumstances, although  tame  and  manageable  at  other  times,  often  becomes  so  infuri- 
ated that  he  attacks  and  kills  his  master. 

The  fierceness  of  the  sexual  passion  in  males,  when  under  the  influence  of  stlmu* 
lation,  is  not  confined  to  animals.  It  is  every  whit  as  strong  in  men;  but  the  power 
of  self-control  is  greater,  and  in  that  minority  of  men  who  remain  pure  is  always  effec- 
tive. Unfortunately,  however,  the  powet  of  self-control  in  most  men  is  far  from 
being  as  strong  as  it  should  be  and  is  sure  to  break  down  sometimes  if  temptation  is 
strong.  In  some  men  self-control  is  almost  wholly  lacking  at  aU  times.  There  are 
certain  physical  conditions,  of  which  the  most  serious  is  intoxication,  which  deprive 
even  the  strongest  men  of  the  power  to  control  this  instinct. 

Even  when  every  other  condition  is  most  favorable  for  exercising  this  self-control, 
continued  close  proximity  of  a  girl  or  woman,  and  her  apparently  yielding  famil- 
iarity (especially  if  these  occur  when  considerable  portions  of  her  body  which  should 
be  clothed  are  exposed)  may,  and  too  often  does,  entirely  break  down  the  strongest 
control.  This  is  why  such  dreadful  crimes  can  happen,  even  among  those  of  sup- 
posedly irreproachable  character,  as  are  frequently  reported  in  the  daily  press. 

When  this  stage  is  reached  in  man  there  is  no  strong  fence  or  halter  or  whip  or  ring 
in  the  nose  to  control  him.  Law  attempts  to  cast  some  safeguards  around  women  and 
apply  some  restraint  for  men,  but  the  law  is  of  very  little  value  for  protecting  the 
individual  girl  from  the  consequences  of  the  fatal  mistake.  It  affords  a  little  protec- 
tion for  society  in  general  by  punishing  the  worst  offenders  when  their  offenses  have 
become  the  most  flagrant.  Man's  reason  and  his  knowledge  of  the  cost  to  his  victim 
is  a  restraint  in  some  cases.  Social  conventions  and  notions  of  decency  restrain  a  few. 
But  in  too  many  cases  all  of  these  fail  in  the  presence  of  a  powerful  stimulus.  The 
only  safe  way  is  to  avoid  stimulation. 

There  is  one  important  difference  between  the  sex  instinct  in  man  and  in  male 
animals  and,  unfortunately,  this  increases  the  danger  to  women.  It  was  stated  above 
that  in  most  male  animals  the  sex  instinct  appears  to  be  entirely  dormant  except  in 
the  presence  of  a  female  of  the  same  species  that  is  ready  for  and  desirous  of  imion. 
But  in  the  absence  of  any  stimulation  from  girls  or  women,  and  even  in  the  entire 
absence  of  all  women,  all  normal  men  and  boys  at  some  times  and  some  men  and  boys 
at  nearly  all  times  are  conscious  of  a  powerful  sex  instinct  that  impels  them  to  Beek 
means  for  its  gratification.  This  feeling  is  stimulated  by  seeing  pictures  of  nude  or 
partially  nude  women,  or  women  in  immodest  attitudes  or  clothing,  or  even  by  seeing 
pictures  of  a  man  and  a  woman  in  each  other's  embrace,  such  as  imfortunately  have 
in  recent  years  become  all  too  common  on  the  covers  and  the  pages  of  what  are  con- 
sidered the  best  magazines.  Imagining  any  of  these  or  a  multitude  of  other  sensual 
facts  or  pictures  has  much  the  same  effect.  Talking  of  any  such  things,  or  obscene 
conversation  concerning  any  sexual  matters,  which  has  already  been  said  to  be  dis- 


PUBLIC  HBALTH  AND  ICBDIOIKB.  688 

treasingly  and  even  diflgracefully  common  among  men  and  boys,  also  strengthenB  tfais 
ever  present  dangerous  desire. 

Instead  of  saying  that  these  things  cause  this  desire  in  men  it  would  probably  be 
more  accurate  to  say  that  the  everpresent  powerful  instinct  is  what  causes  men  and 
boys  to  engage  in  obscene  conversation,  to  think  lewd  thoughts,  and  to  enjoy  sensual 
pictures.  But  it  is  certainly  true  that  such  pictures,  such  thou^ts,  and  such  con- 
versation strengthen  the  instinct  and  render  self-control  more  difficult.  Therefore 
they  should  be  avoided  as  far  as  possible. 

That  the  control  of  this  instinct  is  not  entirely  subject  to  the  will  even  in  the  absence 
of  any  or  all  of  these  or  other  stimulants  is  evident  from  the  fsuct  that  during  sleep  thb 
instinct  is  often  present  and  causes  the  mind  to  conjure  up  sensual  dreams.  The 
dreams  usually  pass  leaving  no  effect  other  than  the  memory.  But  in  normal  boys 
older  than  14,  and  normal  men  who  do  not  have  frequent  sex  union,  there  occurs 
during  sleep  about  once,  twice,  or  three  times  each  month  a  dischaige  from  the  sex 
oigans  of  the  fluid  which  they  are  continually  secreting,  accompanied  by  much  the 
same  sensations  as  sex  union.  This  usually  occurs  in  connection  with  the  dream,  and 
the  sleeper  usually  awakes  at  the  moment  of  completion.  These  nocturnal  emissions, 
sometimes  referred  to  as  visits  from  dream  wives,  are  often,  in  clean  boys  and  men,  the 
source  of  great  mental  disquietude,  and  not  infrequently  of  nervous,  and  sometimes 
physical,  injury,  since  few  realize  or  are  properly  informed  that  they  are  perfectly 
normal  and  are  experienced  by  practically  all.  They  resemble  the  regular  monthly 
discharge  from  the  organs  of  girls  and  women  in  both  their  periodicity,  which  is  apiNrox« 
imately  though  never  entirely  regultf  in  men,  and  in  the  mental  anguish  they  fre- 
quently occasion  because  proper  information  concerning  them  is  not  imparted  at  the 
proper  time.  Quack  doctors  and  venders  of  so-called  remedies  prey  upon  these  fears 
in  boys  and  sometimes  in  men,  leading  them  to  think  that  this  perfectly  natural 
function  is  a  loss  of  vitality  or  virility  or  an  evidence  of  approaching  depletion  of 
strength. 

When  regular  sex  relations  are  formed,  whether  in  wedlock  or  out,  these  night  mani- 
festations cease.  A  feeling  of  comfort  and  well-being  takes  the  place  of  uneasiness 
and  discomfort.  The  disposition  is  likely  to  become  more  cheerful,  and  the  general 
health  may  even  show  marked  improvement.  Under  these  circumstances  it  is  not 
strange  that  so  many  men  hold  to  tiie  popular  but  mistaken  notion  that  frequent  sex 
union  is  necessary  in  order  to  preserve  virility  and  health,  and  on  this  ground  justify 
themselves  for  visiting  &llen  women  until  they  find  it  convenient  to  marry.  But  the 
risk,  almost  amoimting  to  a  certainty,  of  acquiring  disease  is  a  fearful  price  to  pay  for 
the  comfort  and  temporary  feeling  of  well-being  that  they  enjoy.  The  occasional 
visits  from  dream  wives  described  above  seem  to  be  the  means  which  nature  has 
kindly  provided  for  relief  to  the  boy  or  unmarried  man  imtU  legitimate  and  safe 
relations  can  be  established  by  marriage.  These  nocturnal  emissions  are  entirely 
adequate  so  ^  as  preserving  health  or  virility  is  concerned.  They  may  even  be 
entirely  absent  in  many  cases,  and  no  other  means  of  relieving  the  desire  may  be 
practiced,  and  still  no  damage  be  done  to  health  or  virility. 

In  mentioning  these  serious  sex  problems  which  the  boy  or  unmarried  man  has  to 
contend  with  if  he  resolutely  refuses  to  engage  in  illicit  relations,  it  is  proper  to  men- 
tion the  fsLCt  that  many  boys  discover  for  themselves,  and  many  others  are  tau^t  by 
companions,  unnatural  methods  of  producing  at  will  the  discharge  ol  tiv^  tertalizing 
fluid,  with  its  accompanying  feeling  of  physical  pleasure,  'wvt3M>ui  '^^  MB^aaaco  ol 
any  woman.    The  undesirableness  and  certaiix  injury  of  tJaia  \iftV>^^»  "^^V^  cai\»a 
masturbation,  is  sufficiently  indicated  by  sayii^  AAt^^  ^^>^^nv^\>Y  '''^^'^^^^^^^"^iS^ 
known,  when  the  conversation  is  not  of  an  o\w^^0  dttwraucVj^  ^je  ''**^'*'  ^^^^^,5*^^ 
"secret  vice."    It  usuaUy  accompanies,  and  ^^j^^tf^  ^^"^^^^  '^^^^\fs%\>^^ 
and  insanity.    It  may  be  practiced  for  a  o^^^f^^lyAe  taxs^  >^<J^  Vi.m^s^^'^ 
conscious  of  its  wrongfulness  or  realizing  it^^^^^*|^«»*     ^j^^ 


634      PBOOBBDIKaB  BBOOUD  PAK  AMXUDAV  BOOKTIFIO  OOirGBBSS. 

trae  diuicter  and  endaftvon  to  break  tiiehaMtheimJiiesitsoveiiiiaateniigBtfeiigth 
and  in  hiB  apparently  vain  struggle  against  it  his  reason  may,  and  at  times  does, 
entirely  break  down.  As  long  as  it  is  practiced  the  night  disdbaiges  are  likely  to  be 
absent.  But  it  ii  nearly  sore  to  be  practiced  mudi  more  frequently  than  the  nonnal 
Boctumal  emiisions,  as  the  power  of  self-oontxol  is  gradually  undennined;  and  the 
continually  repeated  nervous  shock  would  be  nearly  sure  sooner  or  later  to  destroy 
health,  and  probably  virility,  and  possibly  reason,  even  though  no  effort  were  made 
to  break  the  habit. 

The  exiitence  in  men  and  boys  of  this  powerful  instinct,  the  almost  continual  desire 
for  gratification,  and  the  almost  insuperible  difficulty  of  resisting  the  desire  even  in 
the  absence  of  any  stimulation,  show  iHiy  so  many  men  respond  so  easily  and  quickly 
to  even  a  slight  stimulation  and  entirely  lose  the  little  self-control  that  ranains.  A 
knowledge  of  these  facts  diould  cause  idl  girls  and  women  studiously  to  avoid  d<nng 
anything  to  stimulate  this  instinct  in  the  men  with  irhom  they  associate,  and  to  be 
very  careful  to  keep  from  exposing  themselves  to  attach  horn  unknown  men  whose 
power  of  self-control  may  already  be  gone  and  who  may  be  lying  in  wait  to  victimize 
the  first  woman  that  comes  within  their  power. 

It  is  not  easy  to  tee  iHiy  nature  diould  have  found  it  necesmry  to  make  this  instiiict 
in  men  so  overpowering  and  so  neariy  perpetually  present.  It  does  seem  that  it  wouM 
have  been  te  better  if  it  couM  have  been  as  it  is  In  the  male  ardmalr-tfaat  is,  entir^ 
-dormant  except  in  the  presence  of  a  woman  in  whose  body  a  ftaiale  germ  was  ready  for 
fertilisation,  and  who  desired  sex  unkm. 

Some  think,  and  possibly  property,  that  the  real  cause  is  to  be  found  in  the  &ct  that 
women's  reason  has  led  them  to  realise  so  vividly  the  inconvenience  and  discomfort  of 
diild  bearing  that  they  refine  to  reveal  their  desire  when  they  have  any,  and  conceal 
the  f^bct  when  prepared  for  conception.  Women  having  practiced  this  deceit  for  so 
many  centuries  the  sex  instinct  in  many,  possibly  most,  is  almost  wholly  lacking 
even  when  conception  could  take  place.  The  individual  woman  seems  almost  uncon- 
scious of  having  mcfre  sexual  desire  at  one  time  than  at  any  other.  In  many  not  only 
is  there  an  absence  of  desire  practically  always  but  sex  union  with  their  husbands  is 
distasteful  or  actually  repellant  at  nearly  all  times,  and  sometunes  even  when  they  are 
willing,  or  actually  desire,  to  bear  children.  When  to  this  absence  of  desire  throu^ 
perversion  of  instinct  there  is  added  the  stress  of  economic  ctmditions  or  the  desire  in 
both  parents  to  limit  the  number  of  children  that  a  few  may  be  given  better  advantages 
than  would  be  possible  for  many,  the  danger  of  race  suicide  becomes  imminent,  at 
least  of  that  portion  of  the  race  that  is  best  fitted  through  intellectual  attainments  to 
survive.  If  sex  instinct  in  men  were  as  weak  as  in  women  the  danger  of  race  suicide 
would  be  far  more  imminent.  According  to  this  theory,  as  the  power  of  women's  seoc 
instinct  has  declined  that  of  men  has  become  stronger,  more  continually  active,  and 
more  uncompromisingly  persistent,  in  order  that  nature's  purpose  may  not  be  thwarted. 

Whatever  is  the  correct  theory  to  account  for  it,  or  whether  it  can  be  or  need  be 
accounted  for,  the  fttct  is  that  men's  instinct  is  almost  continuoueiy  present,  is  exceed* 
ingly  powerful,  and  in  some  almost  uncontrollable.  Any  girl  may  and  many  girls  do 
ftdl  victims  to  it  because  in  their  ignorance  of  these  facts  they  unintentionally  and 
unconsciously  stimulate  it. 

The  Chaibbcan.  The  next  paper,  ''Antirabic  vaccination  in 
Habana,  with  statistics  compared  witii  those  of  other  nations/'  by 
Dr.  Jnan  Santos  Femtodez,  of  Habana,  Cuba,  will  be  read  by  Dr. 
Ouiteras. 


FUBUO  HBALTH  AND  MBDIOIHB.  635 

ANTIRABIC  VACCINATION  IN    HABANA  WITH  STATISTICS  COMPARSD 

WITH  THOSE  OF  OTHER  NATIONS. 

By  JUAN  SANTOS  FERNiJ^DEZ. 
DvnOm  of  the  LaJbcfraiory  o/Antirabie  VdocmaHon  ofHabana, 

Antiiabic  vaccination  in  Habana  was  fint  uaed  in  1887  (1)  immediately  after  Faa- 
teur  discovered  it  in  Paris,  Cuba  being  one  of  the  first  countries  to  adopt  it  and  the 
first  in  America  to  make  use  of  it.  Since  that  time  in  vgit/b  of  the  great  diflkulties 
that  the  Island  of  Cuba  has  encountered,  Habana  and  the  country  at  laige  have  always 
had  at  their  diiq>osal  this  powerful  remedy  to  combat  certain  death,  for  that  was  what 
happened  to  the  person  who  was  bitten  by  a  rabid  dog. 

Until  1873  it  was  hard  to  ascertain  the  number  of  victims  of  rabies  in  Cubi^  but  in 
that  year  there  appeared  in  the  death  statistics  of  this  city,  the  first  deaths  by  hydro- 
phobia. We  have  to  agree,  says  Dr.  Acosta  who  was  in  chaige  of  theantirabic  treat- 
ment from  1887  untU  hif  premature  death  in  1913,  that  probably  there  were  many 
caaes  of  rabies  that  were  not  mentioned,  on  account  of  its  being  an  almost  unknown 
disease  and  not  of  easy  diagnosis.  The  first  statistics  of  antirabic  vaccination  in 
Habana  (2)  which  were  published  by  Dr.  Acosta  comprises  the  first  10  years  and  he 
«id  at  that  time:  Hydrophobia  has  been  known  in  Cuba  since  1838  accordioig  to  the 
facts  that  we  were  able  to  obtain  and  in  that  epoch  22  people  were  the  victims  of  the 
disease.  Later  on,  during  General  Tacon's  administration,  the  man  in  chaige  of  the 
keys  to  the  doors  of  the  dty  was  torn  to  pieces  by  mad  dogs  at  the  outskirts  ol  the  town. 
Tfads  abundance  of  dogs  can  only  be  compared  to  conditions  in  Constantinople  (S) 
where  there  are  more  than  80,000  dogs,  which  on  account  of  rdigious  prejudices  are 
not  molested  by  the  police.  In  spite  of  that,  rabies  are  rare  among  these  mongrels, 
probably  because  of  the  lack  of  conmiunication  with  dogs  of  other  countries. 

Since  the  foundation  of  the  laboratory  in  1887  it  has  been  known  that  rabies  was 
frequent  in  Habana  and  that  its  victims  necessarily  had  to  be  numerous.  The  num- 
ber of  patients  who  came  to  the  laboratory  in  order  to  be  injected  during  the  first  10 
years  of  its  establishment  was  1,721,  according  to  the  facts  gathered  by  Dr.  Acosta. 
Of  these,  995  were  adults  and  721  children,  and  from  them  only  543  adults  and  313 
children,  or  856  in  all,  were  innoculated  with  the  vaccine.  Adults  bitten  by  animals 
positive  of  rabies  numbered  134;  children,  179.  Adults  bitten  by  animals  suspected 
ai  being  rabid  numbered  134;  children,  366.  In  reference  to  the  place  of  the  wound: 
On  the  head,  12;  body,  5;  and  extremities  163.  From  this  total  there  have  ocurred 
14  deaths,  giving  a  percentage  of  1.63.  Of  these  9  were  adults  and  5  children,  a  per- 
centage of  1.65  for  the  adults  and  1.58  for  the  children. 

The  mortality  is  low  if  one  consid^s  the  fact  that  during  the  same  period  there 
occurred  the  deaths  of  40  persons  who  did  not  come  to  the  laboratory  to  be  treated. 
If  we  use  the  above  proportion,  we  would  see  that  those  40  deaths  would  correspond 
to  over  5,000  persons  who  were  bitten  without  having  come  to  the  institution,  a  thing 
that  could  not  have  been  so. 

Dr.  Acosta  believed  that  mortality  was  greatly  reduced  after  the  treatment,  while 
the  mortality  rate  of  those  not  treated  reached  50  per  cent.    Dr.  Acosta  concLudes 
by  stating  that  at  that  time  mortality  by  rabies  was  reduced  in  France  to  0.75  per 
cent;  in  St.  Petersburg,  to  2.65  per  cent;  in  Odessa,  to  1.41  per  cent;  and  in  Milan 
to  0.65  per  cent. 

We  shall  now  describe  the  statistics  of  antij^KiC  vacciaa^awi  u^ '^»^**^  ^*^**^  ^^\ 
to  1915,  during  the  28  years  of  its  existence  ixi  !;,Ka.    IxiVl^Mji^^^^^^"'*^^*^''^^ 
tiiose  of  Dr.  Acosta  and  one  can  obsenre  tiie^5^^)^tioii  Vii^^ 
called  attention.    Our  own  statistics  are  as  tM^^^^^^. 


686       PBOOBEDINQS  SBOOKD  PAK  AMEBIOAK  SOIEiniFIO  00K0BE88. 


Patients 
treated. 

Deaths. 

Mortal- 
ity. 

Patients 
treated. 

Deaths. 

Mortal- 
ity. 

1887 

86 

06 

260 

164 

116 

82 

45 

72 

187 

68 

80 

166 

44 

68 

10 

1 

Percemt, 
1.16 

1002 

18 

10 

22 

20 

12 

8 

16 

806 

848 

406 

168 

187 

220 

288 

Ptroent, 

1888 

1008 

1880 

8 

6 
8 

L16 
8.24 
2.60 

1904 

1880 

1006 

1801 

1906 

1802 

1007 

1808 

2 

4.44 

1906 

1804 

1900 

2 
2 
2 

0.60 

1806 

1910 

•0 

1806 

1011 

.^ 

1807 

1012 

1898 

4 

2.68 

1018 

1 
2 

1 

.6S 

1890 

1014 

.00 

1900 

1016* 

.86 

1001 

I  During  1015  there  oooorred  three  deaths,  bat  only  one  died  after  the  treatment.  Case  I  came  to  the 
laboratory  after  the  disease  was  estabUsbel,  dying  on  the  seoind  day  of  the  treatment.  Case  II  was  bitten 
on  the  fiaoe  by  a  rabid  dot;,  and  aft3r  having  torse  day's  treatment  did  not  continue,  dvlng  a  month  after- 
ward. Only  Case  III  recei/ed  the  fall  course  of  treatment  and  died  two  months  after  that.  That  we 
feel  we  are  right  in  Including  only  that  one  case  in  the  mortality  records. 

From  April,  1887,  to  this  tdme  there  have  been  4,438  cases  in  the  laboratory,  of  which 
3,360  received  treatment  and  1,075  were  not  treated  because  there  was  no  need  iixt  it. 
In  1,015  there  was  bacteriological  comprobation  of  rabies  in  the  brains  of  the  dead  ani- 
mals, and  of  the  others,  1,557  were  bitten  by  unknown  animals,  while  the  rest,  791, 
were  bitten  by  animals  that  had  been  killed  immediately  or  soon  after  the  occurrence. 
The  existence  of  the  disease  in  the  animals  was  proved  in  354  cases  in  this  laboratory , 
118  at  the  National  Laboratory,  and  543  according  to  the  reports  of  various  veterinary 
surgeons. 

Since  the  establishment  of  the  institution  65  persons  died  from  hydrophobia  who 
had  not  received  treatment  and  28  died  after  the  treatment,  which  gives  a  percentage 
of  mortality  of  0.85  per  cent,  this  per  cent  being  very  near  those  of  the  New  Y(xk 
Board  of  Health  and  the  Pasteur  Institute. 

Poateur  IiutUuU  staHstia. 


1886 
1887 
1888 
1880 
1800 
1801 
1802 
1893 
1804 
1806 
1886 
1897 
1896 


Patients 

innocu- 

lated. 


2,671 
1,770 
1,622 
1,880 
1,540 
1,650 
1,790 
1,648 
1,887 
1,620 
1,306 
1,621 
1,466 


Deaths. 

Pot  cent. 

26 

0.04 

14 

.70 

9 

.56 

.88 

.82 

.26 

.22 

.86 

.60 

.88 

.80 

.89 

.20 

1800 
1900 
1901 
1902 
1908 
1904 
1006 
1906 
1007 
1908 
1909 
1010 


Patients 

innooo- 

lated. 


1,614 

1,420 

1,821 

1,006 

628 

755 

721 

772 

786 

524 

467 

401 


Deaths. 


4 
4 

6 
2 
2 
3 
8 
1 
8 
1 
1 


Percent 


28 
58 
18 


41 
U 


19 


We  were  given  the  statisticB  for  three  years  of  the  New  York  Board  of  Health  whidi 
will  give  a  complete  understanding  of  the  work  done  there.  During  that  time  there 
have  been  Inoculated  2,050  persons  who  were  bitten  by  rabid  or  suspected  animals, 
and  10  cases  of  rabies  have  occurred,  7  of  which  were  of  rapid  incubation  and  3  casei 
that  resulted  in  death  after  treatment. 

The  laboratory  of  vaccination  is  under  the  direction  of  the  New  York  Department  of 
Health  and  in  one  of  its  departments  is  Dr.  Anna  Wessels  Williams,  who  is  in  diaige 
of  the  diagnosis  of  the  brains  of  rabid  animals.  Her  investigations  caused  her  to  believe 


FUBLIO  HEALTH  AND  MBNOINB.  637 

wbat  is  now  certain:  Negri's  bodies  are  positive,  if  present,  but  if  not  present,  one  can 
not  say  that  there  are  no  rabies. 

The  extraction  of  the  medulla  as  practiced  in  New  York  is  similar  to  our  method. 
The  spinal  canal  is  not  uncovered,  but  the  cord  is  pushed  with  a  wire  one-half  centi- 
meter in  diameter  with  a  cotton  swab  on  the  end,  that  is  introduced  in  the  anterior 
part  of  the  canal  while  the  cord  is  grasped  with  forceps,  and  after  dried  is  kept  in 
flasks  ad  hoc,  from  which  they  are  taken  for  the  preparation  of  the  virus. 

The  Chatrman.  Out  secretary  has  informed  me  that  the  foDowing 
papers  will  be  read  by  title  and  spread  upon  the  record: 

Ensayo  sobre  profilaxia  de  la  sifiilis  y  la  blenorragia^  by  Joaquin 
Travieso. 

Morbosidad  y  mortalidad  infecto-contagiosa  en  El  Uruguay,  by 
Alfredo  Vidal  y  Fuentes. 


ENSAYO  SOBRE  PROFILAXU  DE  LA  SfFILIS  T  LA  BLENORRAGU. 

Por  JOAQUIN  TRAVIESO, 
MSdico  AMtenU  de  la  Faeultad  de  Medicina  de  MonUvideo,  Montevideo,  Uruguay, 

El  problema  de  la  profilaxia  de  la  sifilis  y  dem6s  afecciones  ven^reas  estd,  sin  duda 
de  ninguna  especie,  adn  por  resolver. 

Tan  radonales  y  eficaces  ban  sido  las  medidas  tomadas  en  materia  de  profilaxis  para 
todas  las  otras  plagas  que  aquejan  a  la  humanidad,  como  incomplete  e  imperfecto 
es  lo  que  hasta  ahora  se  ha  hecho  en  la  higiene  sexual;  todo  el  camino  est&  por  andar 
y  si  bien  hay  paises  que  han  obtenido  resultados  no  despreciables,  ellos  son  mf nimos, 
sin  ningun  valor:  se  pierden  ante  la  inmensidad  de  los  que  ya  est^  enfermoe  y  de 
los  que  se  enferman  a  diario. 

La  profilaxia  de  la  sffilis  es  una  de  las  cuestiones  mils  serias,  m^  graves,  m^  terri- 
bles  y  m^  dificiles  de  resolver,  entre  las  mtiltiples  que  se  plantean  al  higienista  de 
nuestros  dfas. 

No  quiero,  no  debo  disertar  sobre  porcentajes  ni  hacer  estadfstica:  ya  hay  muchas; 
bastan  y  sobran.  No  puedo  ni  debo  decir  tampoco  en  este  trabajo,  que  es  la  sifilis,  ni 
cu^es  son  sus  consecuencias,  x>orque  todos  los  mMicos  lo  sabemos;  eso  si,  debo,  sin- 
t^ticamente,  como  hombre,  como  m6dico  y  como  especialista,  manifestar  lo  que  enti- 
endo  por  profilaxia  de  sifilis  y  demds  afecciones  ven^reas,  y  ciUdes  son  los  medios, 
que  de  acuerdo  con  mi  criterio,  pueden  llevar  a  la  soluci6n  del  problema. 

Ante  todo,  es  necesario  que  los  poderes  ptiblicoe  de  todas  las  nadones  del  mundo 
legislen  sobre  sifilis  y  blenorragia:  la  forma,  que  no  podrla  ser  6nica  para  todos  los 
pueblos,  serla  adaptada  a  cada  medio,  teniendo  como  fundamento  la  educaci6n 
sexual  de  las  generaciones  presentee  y,  sobre  todo,  de  las  futuras. 

Hay  necesidad  de  educar  a  los  que  son  ya  hombres;  hay  que  ensefiar,  que  dedr, 
que  hacer  ver,  en  todas  las  esferas  sodales,  lo  que  es  la  sifilis,  lo  que  es  la  blenorragia, 
como  se  pueden  evitar,  como  se  pueden  adquirir,  curies  son  sus  peli^^cos  inmediaUie 
o  lejanos;  y  a  los  que  son  ya  vlctimas,  dedrle^  ^^g  tesponaabVMadee  ^  YiacetVe*  com- 
prender  lo  que  significa  tener  una  sifilis  o  uin^  viAnon^^i^t  7*  •^■^  ''^^  ^^^  mssnica. 


ya  por  los  dem^.    Los  poderes  ptiblicos,  secu^^  ?  •ijv  *^^  mfe^ooa  «^ '*^'^ ^"wdT*^ 
a  4st08  corresponde  iniciarla  puesto  que  sou  |  ^^^cob  ca^^w^  ^®  ^^^>ks^Lw 


problema  de  un  mode  eficaz.    En  todas  las 

toda  entera,  las  responsabilidadee  son  a  m^^^(]^)>'^^^9X^^!^^^\^  !^"^\4i^3««k, 

que  si  hay  actoe,  y  a  veces  ideas  que  ni^r^H^    ^^  c^^'^^i^j^ \>^^ 


638       PBO0EEDIK68  SECOND  PAK  AMEBICAK  BCIEKTIFIC  CONGRESS. 

y  68t6  efl  unode  ellos,  en  que  la  hltA  de  valor  (ya  que  la  ausencia  de  conviccioneA  de 
podria  aigOine)  para  ejecutar  un  acto  o  defender  una  idea,  son  mucho  m^,  cien  mil 
veces  m&B  justiciables  de  caatigo  y  de  sanci^;  Be  delinque  obrando  y  hablando, 
pero  tambi6n  se  delinque  no  haciendo  y  callando.  Y  en  eeta  materia  eon  responsablee 
aquellos  que  callen  y  que  no  hagan,  loe  medicos  y  quienes  deban  secundarloe,  Ioa 
poderes  ptiblicoB.  Para  educar  al  pueblo,  a  la  juventud  de  maiiana,  es  indispenMble 
que  en  loe  alboree  de  la  Bexualldad  hiunana  intervenza  el  m6dico,  ^1  mbmo,  y  jam^ 
intermediarioe  que  ser^  laa  mds  de  las  veces  incompetentes. 

Cuando  la  primera  curioeidad  sexual  del  nifio  se  disefie  en  su  espiritu,  el  medico 
debe  tomar  la  orientaci6n  y  la  direcci6n  de  esa  importante  &&z  de  la  vida.  Debe 
iluBtrarlo,  ensefiarlo,  satisfecerlo  y,  al  mismo  tiempo,  dirigirlo  per  la  senda  de  la 
verdad  y  de  lo  titil,  y  no  por  el  error  y  por  el  engafio  como,  amaigamente  tenemoe 
que  reconocerio  todos,  se  hace  hoy  en  dia.  En  las  escueUus,  cutbob  e^pedales  deben 
ser  dictados  por  el  m^co  mismo  a  los  nifios  de  cierta  edad,  para  amboe  sexos,  separada- 
mente.  Es  indudable  que  no  se  debe  pretender  el  establecimiento  de  un  Ifmite  fijo  en 
la  edad  del  nifio,  para  empezar  su  educaci6n  sexual;  dicho  Ifmite  debe  variar  no 
Bolamente  para  cada  naci6n,  sine  hasta  para  cada  individuo;  y  por  tanto,  no  serfa 
diffcil  en  los  colegios  poder  establecer  una  especie  de  seleeci^n  entre  aquellos  que  a 
juicio  del  medico  y  del  maestro  fueren  capaces  de  retirar  fruto  de  esa  ensefianza.  En 
t^rminoe  generalee  podrfa  limitarse  entre  13  y  16  afioe  la  edad  mis  apropiada  para 
inculcar  al  nifio  las  primeras  nociones  sobre  cuestiones  sexuales.  Y  esa  educaci6n 
sexual,  tal  vez  diffcil  de  resolver  en  sus  detalles,  deber6  hacerse  en  una  fonna  dara, 
sumaria,  pero  lo  m&s  completa  posible,  quedando  sobrentendido  que  hay  que  adaptarla 
a  la  edad  de  los  auditores.  Y  en  todas  las  instituciones  a  donde  acuda  el  nifio  debe  de 
proporcionarsele  esa  educaci6n  especial  tan  necesaria  en  la  lucha  por  la  vida,  como 
la  del  mancjo  de  las  armas  en  la  guerra.  Pero,  si  asf ,  los  hombres  de  mafiana  conocerin 
esas  cosas,  nuestros  contempor^eoe  las  ignoran,  y  las  ignoran  de  la  manera  m^  com- 
pleta; pero  esto  no  serfa  nada  si  no  existiera,  como  corolario  de  ese  estado  de  cosas,  una 
serie  de  prejuicioe  e  ideas  falsas  que  son  tan  teniblemente  malos  como  la  ignorancia 
misma;  esos  prejuicioe  han  llegado  a  todos  los  medios  sodales;  esas  ideas  err6neas  se  ban 
infiltrado,  se  han  arraigado  como  se  arraiga  todo  lo  malo;  tenemos  que  ponerles  fin; 
tenemoe  que  destruirlos,  y  al  sustituirlos  por  la  verdad  habremos  cumplido  uno  de  los 
deberes  m^  sagrados  de  nueetro  apostolado  profesional. 

Tenemos  que  ir  a  las  escuelas,  a  los  talleres,  a  las  f&bricas,  a  donde  est&n  las  familias, 
al  campo,  al  ej^rcito  y  a  la  marina,  por  todos  lados;  tanto  al  hogar  del  pobre  como 
al  del  potentado,  porque  todos  necesitan  ig:ualmente  de  nuestra  ensefianza.  Al 
nifio  se  le  debe  ensefiar  la  verdad  a  fin  de  que  mafiana  no  sea  dominado  por  las  historias 
err6neas  que  a  veces  le  forjan  sus  mismos  progenitores,  ocult&ndoles  todo  lo  real,  lo 
titil  y  lo  pr^tico,  sino  prepardndolo  para  no  caer  f&cilmente  en  cualquier  oca8i6n, 
la  cual  algunas  veces  pueda  hacerlo  su  vfctima  en  la  primera  circunstancia. 

El  pudor  no  eetk  refiido  con  la  verdad  ni  con  la  higiene  o  la  conservaci6n  de  la 
especie  y  su  mejoramiento;  el  pudor  estA  en  pugna  con  los  degencrados  y  los  d^biles, 
porque  ellos  lo  ofenden  y  lo  mancillan;  estos  seres  son  a  menudo  vfctimas  de  una 
sffilis,  que  sus  antepasados,  gentes  de  \m  pudor  sin  m^ula,  les  legaron. 

Es  mucho  mds  f&cil  perderse  en  el  caos,  en  el  desierto  inmenso  de  la  vida,  siendo  un 
ignorante,  \m  hombre  de  prejuicios,  que  siendo  un  conocedor  en  cualquier  materia; 
y  si  al  nifio  no  se  le  ensefia  la  verdad,  61  aprenderd  la  mentira,  pagando  despuds  su 
tribute  a  ella. 

Yo  no  s6  pedagogfa;  como  profano  en  la  ciencia  de  la  ensefianza,  no  podrfa  ni 
querrfa  sostener  con  tesis  filos6ficas  m&B  o  menos  brillantes  y  acertadas,  las  opiniones 
y  creencias  que  profeso  en  materia  de  profilaxia.  No  s6  si  una  vez  impregnado  de  esa 
diffcil  ciencia  que  se  llama  "pedagogfa,''  y  en  la  m£s  terrible  de  todas,  la  filosoffa,  y 
si  se  quiere,  en  la  moral  mis  eetricta  y  absoluta;  no  s6,  repito,  si  ello  harfa  cambiar 
mis  convicciones  y  evolucionar  mi  conciencia  en  otro  sentido;  hoy  por  hoy  soy  creyente 


PUBLIC  HEALTH  AND  MBKOIKE.  639 

decidido,  un  budista  de  la  educaci6n  sexual  precosmente  inBtaiuada  en  todas  partes 
y  en  todos  los  paises.  La  juventud  que  vendrd  tiene  derecho  a  saber,  para  su  salva- 
guardia  personal  y  para  el  bien  colectiva  de  ella  y  los  suyos.  Hago  el  cargo  formal, 
severo  e  inflexible,  a  esos  criterios  filosdficos,  morales  y  pedagiSgicos,  que  por  mis  her- 
moeos  que  ellos  sean,  por  mis  bellas  que  fueren  las  concepoionee  que  representan,  no 
valen,  no  pueden  valer  s^uramente,  el  aniquilamiento  de  un  hombre,  de  una  btmilia 
y  tal  vez  de  una  generaddn  entera  llevado  a  cabo  por  la  sifilis.  Entiendo  que  debo 
declarar  que  si  hay  derechos  que  se  opongan  a  la  educaci6n  sexual  de  la  juventud,  yo 
gritarfa  que  ellos  son  absurdoe.  Hay  que  ensefiar  a  los  padres  para  que  ellos  ensellen 
a  SUB  hijos;  hay  que  cambiar  sus  eir6neos  conceptos  sobre  moralidad  y  decirlee  bien 
fuerte  que  si  no  noe  oyen,  ser^  culpables  mafiana.  Muchos  casos  podrla  citar,  y  lo 
bar^  en  un  libro  que  preparo  en  estos  momentos,  para  demostrarles  la  8inraz6n  de  su 
conducta  y  lo  torcido  de  su  educaci6n  moral  en  estas  cueetiones. 

A  las  masas  que  viven  en  las  urbee  inmensas  de  las  capitales,  hay  que  inculcarles 
los  conodmientos  indispensables  de  higiene  sexual;  son  y  ser^  sus  annas  eficaces  en 
la  lucha  contra  las  enfermedades  ven^reas.  Hay  que  hacerlo  con  la  palabra,  con  la 
imagen  y  con  el  ejemplo,  y  no  olvidar  tampoco  al  campesino,  cuyos  alcances  sabemos 
que  no  son  muy  grandes  en  ningdn  pais  del  mundo.  Habri  que  castigar — Im  leyes  se 
encargaiin  de  ello — a  los  que  conscientemente  contaminen  a  su  pr6jimo,  porque  una 
vez  coDseguido  el  desideratum  de  la  educaci6n  sexual,  todos  sabr^  lo  que  significa 
tener  una  sifilis  o  una  blenorragia,  y  no  podr&n  al^ar  ignoranda  en  esas  cosas.  HabrA 
que  impedir  que  se  engendren  hijos  degeneradoe,  exigiendo  certificados  m6dicos  en 
forma  seria  y  de  una  manera  general,  pues  los  extoenes  serol6gicoe  nos  permiten,  hoy 
en  dfa,  ponemoe  a  cubierto,  de  una  manera  casi  perfecta,  contra  las  gentes  de  mala  fe. 
Habri  que  exigir  una  reacci6n  negativa  antes  del  matrimonio  y  castigar  al  que  deso- 
bedezca  las  leyes,  o  legislar,  haciendo  obligatorio  el  examen  medico.  Yo  conozco 
varies  cases  de  sujetos  en  pleno  periodo  secundario,  que  han  contraido  matrimonio,  y 
uno  de  ellos  a  quien  amonest^  de  la  manera  m^  severa,  ya  ha  contaminado  a  su  esposa. 
En  casoe  como  ^te,  habri  que  librar  al  m6dico  de  su  secrete  profesional,  y  mils  a6n, 
darle  los  medios  de  impedir  la  consiunacidn  .de  tales  hechoe.  La  literatura  m^dica 
registra  casoe  de  m^cos  que  han  denunciado  a  uno  de  los  contrayentes  matrimonialee 
como  portador  de  una  sifilis  en  plena  potencia;  y  yo  los  justifico,  puee  entiendo  que 
no  puede  existir  ningdn  deber  profesional  que  oblique  a  hacerse  c6mplice  de  un  acto 
seooejante  ni  pueda  acallar  nuestra  conciencia  de  m^icoe  y  de  hcnnbres. 

Y  na  hay  que  creer  que  es  solamente  en  ciertas  clases  inferiores  de  la  sociedad, 
donde  existen  arraigadas  ideas  funestas  sobre  sexualidad  y  enfermedades  ven^reas 
es  en  todos  los  ambientes,  en  todas  las  esferas  donde  hay  tal  estado  de  cosas,  y  m^  adn, 
en  todos  o  casi  todos  los  paises  es  lo  mismo;  y  entre  los  que  hemes  tenldo  la  suerte  de 
conocer  algunos  paises  que  marchan  a  la  cabeza  de  la  civilizaci6n  del  mundo,  y  de 
vivir  en  ellos,  no  nos  faltarian  aiigumentos  y  casoe  para  probar  las  afirmaciones  que 
acabamoe  de  hao^ :  en  Europa — ^y  Mo  es  la  expre0i6n  mis  sincera  de  la  verdad — ^la 
edocacidn  del  pueblo  a  este  resp>ecto  no  es  superior  ni  mucho  mejor  que  la  nuestra,  y 
^por  qn6  no  decirlo  de  una  vez?    Es  completamente  nula;  no  existe. 

La  proBtituci6n  es  indudablemente  una  de  las  causas  principales  de  diBeminaci6n 
de  la  sifilis  y  la  blenorragia,  y  si  bien  tanto  reglamentaristas  como  aboUcionistas, 
tienen  y  hacen  valer  hermoeos  aiigumentos  en  ixvor  de  las  ideas  que  sostienen,  asi  de 
una  parte  como  de  otra,  han  desaprovechado  un  tiempo  que  hubiera  side  precioso. 

£1  reg^amentarista  dice:  revfseee  toda  mujer  con  la  trecuenda  neceearia,  y  a  la 
mis  minima  soepecha  redtSsrasela  en  un  lugar  apropiado,  el  sifilicwnio,  y  seri  ad 
imposible  que  ella  pueda  contaminar  a  alguien  mia.  Esto,  sin  dejar  de  reconocer  que 
es  eminent^nente  prictico  y  dtil  en  clertos  medios  especialee,  falla  fundamentalmente. 
por  doe  razones:  (a"  la  revision  debiera  hacerse  a  diarlo,  y  aunque  asi  tusca,  una 
pequefiisima  lesion  puede  escapar  al  ojo  mis  avetado;  Qo)  un  contact  ^gfcocfidontA,  m 
las  preecripciones  de  la  higiene  son  descuidadas,  ^joo  acontece  muy  t^monxido^  puede 


640       PROCEEDINGS  SECOND  PAN  AMEBICAN   SCIENTIFIC  CONGRESS. 

contaminar  al  que  siga  inmediatamente,  y  ^eto  adn  estando  la  mujer  sana.  Agi  m 
explicar&n  esos  casoe  en  que  doe  sujetos  ban  [estado  con  la  nusma  mujer,  con  muy 
poco  tiempo  de  diferencia,  el  uno  contrae  una  iniecci6n  venerea,  no  infect&ndoee  el 
otro:  el  primero,  en  general,  ee  el  que  enferma  con  mia  facilidad,  pero  amenudo sucede 
que  lo8  doe  enferman. 

Ia  reacci6n  de  WaaBermann,  hecha  siBtemdticamente  a  toda  proetitutai  y  un  trata- 
miento  llevado  hasta  obtener  la  n^ativa  completa  de  esa  sero-reacci6n  no  sdlo  en  la 
fsangre,  sino  en  el  Ifquido  c^falo  raqufdeo,  constitiiirfa  una  garantla  en  extremo  eficaz. 

For  otra  parte,  la  eecuela  abolicionista  arguye:  (a)  la  pro6tkiici6n  reglamentada  a  base 
de  reclufli6n  obligatoria  de  las  meretrices,  no  bace  mia  que  fomentar  la  i»t)6tituci6n 
clandestina  y  favorecer  su  dieeminacidn.  Y  ^sto,  no  bay  m^  remedio  que  reconocerlo, 
ee  perfectamente  cierto.  En  todas  las  ciudadee  que  be  visitado  y  en  algunas  de  ellaa 
donde  be  vivido  bastante  tiempo  se  obeerva  perfectamente  ese  becbo:  en  Paris  todos 
saben  lo  que  es  la  pro8tituci6n  en  qu6  forma  estd  reglamentada,  y  para  qu6  eirve 
eea  reglamentaci6n;  en  Montevideo,  puede  decirse  que  por  cada  proetituta  inscrita 
bay  10  que  no  lo  est&n;  y  es  lo  mismo  en  todas  partes.  En  Montevideo  be  podido 
comprobar  num^camente  la  exactitud  de  lo  que  digo.  La  mujer  que  ba  aide  recluida 
una  vez,  por  m^  dulce  que  se  quiera  bacer  su  encierro,  a  su  salida^  si  encuentra  una 
casa  no  inscrita,  lo  que  no  ee  dif  fcil,  cambia  inmediatamente,  o  de  lo  contrario  vive  en 
otra  forma  mds  peligrosa  todavla,  trabajando  en  rendezvous,  yendo  a  los  botelee  y 
casas  amuebladas  y  frecuentando  ciertos  pequefloe  clrculos  de  diversi6n  privados  y 
a  voces  acudiendo  a  boras  especiales  a  casas  de  citas  donde  elude  por  completo, 
asf  como  los  propietarios  de  ellas,  toda  responsabilidad.  Los  abolicionistas  agregan: 
nadie  tiene  el  derecbo  de  encerrar  a  una  mujer  porque  eet^  enferma:  pero  dado  que 
esta  medida  fuera  de  una  utilidad  de  car^cter  general  y  positive,  no  se  podrla  dejar 
de  argOir  que  la  mujer  que  comerda  con  sus  6iganos  genitalee,  constituye  una  pro- 
fesional  que  puede  preeentar  series  peligros  para  la  colectividad;  en  tales  casos  nadie 
dudar&  en  intemarla,  pero  si  bien  esa  medida  no  es  del  todo  instil,  estd  lejoe,  pero- 
muy  lejos  de  llenar,  ni  siquiera  medianamente,  las  necesidades  de  la  profilazia  y  la 
bigiene  severas  que  en  materia  de  sffilis  y  blenorragia  debieran  ser  de  rigor.  La  mejor 
enseflanza  la  tenemos  «in  nuestro  ambiente,  en  Montevideo,  donde  la  prostituci6n 
clandestina  constituye  una  verdadera  vergQenza  nacional.  Pero  los  reglamentaristas 
abogan  por  su  causa  diciendo  que  la  persecucion  tenaz  y  firme  de  la  proetituci6n  clan- 
destina, Bolucionarfa  el  problema.  Yo  me  permito  decir  que  el  pretender  extirparla 
de  cualquier  punto  ee  sencillamente  una  Utopia,  y  m&s  en  pafees  como  el  nuestro, 
donde  ciertas  influencias  y  causas  especiales,  que  no  pueden  escribirae,  lo  bacen 
imposible. 

La  educaci6n  sexual  del  bombre  y  de  la  mujer  becba  completa,  el  establecimiento 
de  dispensarios  especiales  sin  restriccionee  de  ningtin  g^nero,  donde  el  enfermo  pueda 
conservar  el  inc6gnito,  donde  no  tenga  el  m^  minimo  desembolso  que  efectuar,  donde 
se  le  aconseje  y  se  le  dirija;  cuando  esos  dispensarios  funcionen  en  forma  conve- 
niente,  cuando  su  abundancia  y  su  8ituaci6n  sean  juiciosamente  establecidas,  darin 
seguramente  bermosos  resultados.  En  Lieja,  en  Paris  y  en  algunos  puntos  de  Italia, 
bay  establecidos  ya  dispensarios  de  esta  fndole  y  parece  que,  sencillamente,  sub 
resultados  ban  side  magnfficos. 

En  slntesis,  cuatro  proposiciones  dignas  de  atenci6n  me  permito  preeentar  a  la 
consideraci6n  de  ese  Honorable  Congreso,  y  son  las  siguientes: 

1<^.  Educaci6n  sexual  amplia,  completa  si  es  posible,  a  los  nifioe  y  a  los  adultoe, 
becba  por  los  mismos  medicos  y  Uevada  a  todos  los  ^bitos  y  a  todas  las  eeferas  sodalea 
de  cada  pals,  y  educaci6n  becba  por  la  palabra,  por  el  libro  y  por  la  imagen. 

2<>.  Legislaci6n  sobre  sffilis  y  demds  enfermedades  ven^reas,  en  una  forma  adaptada 
a  las  necesidades  de  cada  pafs. 

3a.  Establecimiento  de  dispensaries  mtiltiplee,  en  todas  las  ciudades,  en  todos 
los  pueblos,  basta  on  las  pequefias  localidades. 


PUBLIC  HEALTH  AND  MEDIOIKB.  641 

4^.  Aboliddn,  en  t^rminoB  geneiales,  de  la  proetitacidn  reglamentada,  con  excep- 
ci6n  de  ciertos  medioe,  pero  debiendo  siempre  ser  conedderada  como  elemento 
secundario  ante  las  treB  propoeiciones  precedentes. 

Eflta  breve  expoeiddn  no  constituye  m^  que  la  sfnteBiB  de  un  extenao  trabajo  que  en 
eetoe  momentos  preparo,  y  en  el  que  eetudiar^  en  detalle  la  ofganizaddn  y  pr&ctica 
de  cada  uno  de  los  puntoe  fundamentales,  proponiendo  fdrmulas  generales  que  aehLn 
modificadas  de  acu^o  con  las  necesidades  de  cada  medio. 


MORBOSIDAD  T  MORTALTOAD  INFECTO-CONTAGIOSA  EN  EL  URUGUAY* 

Por  ALFREDO  VIDAL  Y  FUENTES, 
MantevtdeOf  Uruguaif. 

En  el  decenio  1905-1914  la  enfermedad  que  di6  m^  denuncias  en  la  Reptiblica, 
fu^  la  tuberculosis  pulmonar  y  laringea,  alcanzando  su  cifra  a  16,423.  Ella  fu6  tambi^ 
la  que  produjo  m^  defunciones  (12,630). 

Estaas  cifras  aterradoras  ban  convencido  a  los  poderes  ptiblicos  y  al  pueblo  del 
Uruguay,  de  la  neceddad  urgente  que  bay  de  combatir  ese  terrible  mal,  ensancbdn- 
doee  considerablemente  el  Hospital  Fermin  Ferreira,  destinado  a  la  asistencia  de  los 
tuberculosos;  coadyuvando  al  sostenimiento  de  las  ligas  contra  la  tuberculosis,  que 
contribuyen  con  su  accidn  eficaz  a  ayudar  a  los  mfseros  enfermos  badlares  y  creando 
numerosos  dispensarios  donde  se  asisten  los  enfermos  y  se  les  da  al  mismo  tiempo 
dates  dtilee,  que  contribuyen  a  la  profilazia  de  tan  terrible  mal. 

El  sarampidn  da  la  cifra  de  la  denunda  m&s  alta  despu^s  de  la  tuberculosis,  10,000 
cases.  La  mortalidad  por  esta  enfermedad  (326)  no  es  alta  y  serfa  mis  baja  atin, 
si  no  fuera  porque  en  campafia,  debido  a  la  escasez  de  asistencia  m^ca,  se  producen 
muchas  complicadones  bronco-pulmonares,  que  son  la  mayor  parte  de  las  voces 
las  causas  de  esas  defunciones. 

Viene  despu^  la  fiebre  tifoidea,  con  tma  denuncia  de  7,751  cases  y  2,009  defunciones. 
En  las  ciudades  del  interior  y  literal  del  Uruguay,  las  obras  de  saneamiento  estto 
proyectadas,  pero  aun  no  se  ban  realizado.  Esa  ee  la  causa  del  desanollo  de  la 
tifoidea  en  nuestro  pals,  que  tenderi  a  desaparecer  cuando  en  aquellas  ciudades,  se 
beba  un  agua  tan  pura  como  en  Montevideo. 

No  obstante  que  esta  multiplicidad  de  cases,  debiera  aprovecharse  para  la  prepac 
racidn  de  la  vacuna  antitifica,  pues  constituye  un  hermoso  material  para  ello,  el 
Institute  Nacional  de  Higiene,  no  ba  podido  aun  atender  el  pedido  que  le  bizo  el 
Consejo  Nacional  de  Higiene,  de  que  la  preparara  en  cantidad,  para  enviarla  a  lea 
delegados  sanitarios  departamentales,  con  el  objeto  de  usaria  en  la  campafia  como 
medio  de  profilaxia. 

La  difteria  y  la  escarlatina  son  las  enfermedades  m^  denimciadas  despu^  de  las 
anteriores.  En  nuestro  pals  se  usa  mucbo  el  suero  antidift^rico,  preparado  por  el 
Institute  Nacional  de  Higiene,  pero  se  usa  con  m^  facilidad  en  Montevideo,  donde 
la  asistencia  m^ca  es  rdpida  y  por  lo  mismo  eficaz;  mientras  que  en  la  campafia, 
cuando  la  autoridad  sanitaria  tiene  conodmiento  de  la  existencia  de  un  ioco  de 
difteria  y  acude  a  61  para  combatirlo,  el  terrible  n^  y^  ^^^  producido  tob  eiectoe 
destructores,  siendo  a  voces  mucbos  los  que  ban  fallecido  iah  aaf^eos^  ixL^d^c^ 
antes  de  la  llegada  del  delegado  sanitario  clep^i^^^^ixiaX. 

Puede  afirmarse  que  la  mortalidad  por  dift^^l*^T^eV  XSx^ig^Y  ee  ^^^^y^^n^'^^ 
en  la  campafia  que  en  Montevideo,  capital  d^  ?^   ^r){>VAi^-       '  x«fivasaa.^\b. 

La  viruela  produjo  violenta  epidemia  en  ^  ^H^^^q\0,  ^^^^^^i^-A^  ?^^vA^^^- 
cifra  de  1,838  y  la  mortaUdad  a  599.    Si  se  q^  W  ^^  cu^a.^^^^^^  ^ 


642       PBOOBEDIHQB  OCOMU  PAV  AMlBKUTf  BUIEJITIFIO  OOVCffiBflS. 

pcobar  que  esot  ndmeros,  alcmim  ropectiTaiiiaite  a  mib  de  la  mUad*  de  lat  cifraa 
oofrespondientes  al  decenio,  en  lo  que  ropecta  a  la  Tiniela. 

Eeta  enorme  epidemia  tomd  sa  origen  en  el  alio  aateiior  7  vino  a  pndndiBe  por  im 
enor  de  diigndetico.  8e  describid  una  p^ipma  hemofrigica  en  on  hoqatal,  cnando 
en  realidad  ae  trataba  de  una  viruda  hemofrigica.  Cuando  ae  ooinprendi6  el  enor, 
ya  la  chispa  habla  determinado  el  incendio. 

Debido  a  este  hecho  lamentable,  ea  que  deade  1911,  apaiecen  entie  loa  de  enler- 
medades  contagioaaa  en  el  Uruguay,  loa  caaoa  de  pdipma^  como  puede  vene  en  el 
cuadio  citado. 

Junto  con  eata  comunicacifai  va  la  Ordenansa  No.  136,  dictada  por  d  Oonaejo 
Nacional  de  Higiene,  el  16  de  aeptiembre  de  1910,  induyeDdo  a  la  ptftrpuia  hemocrtfigica 
entre  laa  enfennedadea  de  dedaracidn  obligatoria. 

(>meaani]aniafecliadict6deonaejolaOrd€oansaNo.lS5,  que  tambifa  la  agregamoa 
aeate  informe,  por  laqueae  eatableceladeclaraci6n  obligatoiiade  loa  caaoa aoapechoaoa 
de  viruela. 

Be  agregaigualmente  la  circular  de  26  de  abril  de  1911,  que  dirigi6  d  Oonaejo  Nadonal 
de  Higiene  a  sua  delegadoe  aanitarioa,  relacionada  con  ^  aialamiento  en  loa  caaoa  de 
viruela,  eacarlatina  y  difteria. 

Junto  con  todaa  eetaa  diapoeicionea  tendientea  a  evitar  la  propagaddn  de  la  viruda, 
la  Intendencia  Municipal  en  Montevideo  y  el  Oonaejo  Nadonal  de  Higiene  en  la 
campafia  practicaron  en  1910  una  intenaa  vacunaddn,  habi^ndoae  inoculado  en  la 
capital  45,000  peraonaa  y  en  el  reato  de  la  Repdblica  unoa  60,000. 

El  Uruguay  tenk  en  eae  afio  1,500,000  habitantea. 

El  6jiU>  de  eatae  medidaa,  bien  meditadaa  por  cierto  y  que  fueron  aplicadaa  con 
toda  energ(a,  no  ae  dej6  eaperar,  puea  en  loa  afioa  1912,  1913,  1914  y  baata  el  31  de 
octubre  de  1915,  no  ae  ha  i»oduddo  ni  un  aolo  caao  de  viruela  en  la  Reptiblica. 

Han  llegado  a  vecea  vaporea  de  ultramar,  con  algdn  enfomo  de  viruela,  pero  no  ae 
lea  ha  pennitido  deaembarcar  en  Montevideo,  llev6ndoaelea  para  au  ariatencia  y 
^ialamiento  al  Lasareto  de  la  lala  de  Florea. 

Laa  primeraa  denundaa  de  meningitia  cerebro-eapinal  epid^mica,  aparecen,  como 
puede  veiae  en  el  cuadro  adjunto,  en  el  afio  1913.  En  eae  afio  ae  dict6  la  Ordenansa 
No.  149,  que  va  agregada  a  eate  informe. 

El  tracoma  ae  eatableci6  que  era  obligatoria  au  declaracidn,  por  la  Ordenaaia 
No.  153  del  12  de  octubre  de  1914,  la  cual  va  tambi^n  agregada  nia  adelante. 

Se  denunciaron  de  eaa  enfennedad  7  caaoa. 

De  beri-beri  ae  ban  denunciado  en  eate  decenio  105  enf ermoa  y  4  defuncionea. 

Eaa  enfennedad  ea  completamente  ez6tica  en  nueatro  pafa,  aiendo  todoa  eaoa  caaoa 
iinportadoa,  no  habi^ndoae  obaenrado  jamiB  ningdn  caao  de  beri4>eti- ni  entre  el  peiaonal 
del  Lasareto,  donde  todoa  fueron  aaiatidoa,  ni  entre  loa  demia  habitantea  del  pafi. 

La  peate  bub6nica  da  63  denundaa  y  13  defuncionea  en  d  decenio,  habiendo  habido 
afioa  como  1905,  1906  y  1910  en  que  no  ae  produjo  ningdn  caao  de  eaa  enfennedad. 

La  peate  aiempre  noa  vino  del  Paraguay,  del  Braril,  de  la  Aigentina  y  alguna  vea 

quisil  de  la  India,  de  donde  ae  importa  la  arpillera,  en  cuyoa  fardoa  ae  ban  encontndo 

rataa. 
Loa  caaoa  ae  han  aaiatido  todoa  en  aialamiento,  en  el  Hoapital  Fermin  Ferreira,  en 

pabellonea  eapedalea  deatinadoe  a  eae  efectoa. 

El  suero  Jeraain  aplicado  al  principio  caai  aiempre  fu^  eficas.  8e  le  prepara  en  el 
Inatituto  Nacional  de  Higiene. 

Loa  caaoa  denunciadoa  de  lepra  ae  aaiaten  en  aialamiento  la  mayor  parte  de  elloa,  en 
una  pequefia  leproaerfa  que  funciona  en  el  Hoapital  Fermin  Ferreira. 

La  proporci6n  de  la  mortalidad  infecto-contagioaa  por  cada  1,000  habitantea,  da  una 
idea  de  que  el  eatado  aanitario  del  pafa  ha  aide  baatante  bivorable. 

y^aae  el  cuadro  adjunto  donde  eati  indicada  eaa  properdin  para  la  Itepdblica»  para 
Montevideo  y  para  la  campafia. 


644      PB00BBDINQ8  8B00KD  PAV  AMBBtOAN  80IBNTIFI0  OOHTGRBSB. 

ORDBNANZA  No.  186. 
MONTBTDBO,  SVBBMBBB  16  DB  1910. 

OMuMcrtiitfo;  Qne  durante  la  Mtoftl  opldemls  de  Tiniela,  fe  han  eonfoiidido  ■Igunos  otMs  de  forma 
iMmonAgloa  ooo  oatoa  de  pdrpura; 

C^iuUennio:  Qneoada  ano  de  elloi  ha  dado  lofw  a  repetidoe  oasos  de  vlniela; 

OfmtUermnia:  Que  habfa  neoeelded  de  evitar  la  repfodueoidn  de  eeoe  heehos  que  ban  oontribuldo  a  la 
difnsldo  de  eea  enfannedad,  y  tambMn  per  la  importaneia  que  tendila  eea  medida  del  punto  de  vitta  de  la 
proAlaxif; 

For  tales  oontideraolOBei,  el  Cooicilo  Naolonal  de  HUiene  en  uso  de  lus  atriboelones,  neuelve: 

AsrlcuLO  1*.  Deolarar  de  acuerdo  oon  el  artlculo  1*  de  la  Ordenania  No.  6,  Inchitda  la  pttrpon 
bemofricloa  antra  iae  eofvmedadet  de  deelaraddn  obllgatoria. 

Art  3*.  Pubifqueie  para  oonoolmiento  generaL 

Alhuedo  Vidal  t  FumtM,  PretUeuie. 
Joat  UAXtOMKt,  Seerdarlo, 

COKSWO  NAaOWAL  DB  HlOIBVB,  OKOBWAirSA  Na  1S5. 

MoMTBTiDBO,  SepiUmhn  19  ie  1BH>. 

Oomtiinanio:  Que  en  la  ofdenansa  sobre  deelaraddn  obUgatoda  de  iae  enennedadee  eontafloias,  de 
feoba  38  <ie  juUo  de  1896,  no  eette  Ineluldoe  kM  oaaos  eoipeeiioeoe  de  Tiruela; 

Ovfktiiefmio:  Qne  la  aooldn  praventt^a  de  la  antoridad  aanitaria  debeila  baoerie  sentir  tuito  en  lot 
oaeos  eosDedbosos  como  en  lot  oonflnnadot: 

OomidenMia:  Qne  hacMndoee  obllgatoria  la  deelaraddn  de  eeoe  oaeos  se  podila  intenrenir  eon  laantid- 
paeidn  neeesaria  para  establecer  Its  medldaa  de  proflbpds; 

Cbn<tf#raiidoi*  Qne  per  la  misma  rasdn  que  se  ha  obligedo  a  dechtfar  Ids  oasos  sospediosos  de  cdlera,  0^^ 
amarilla,  peste  y  difteria,  debiera  obUgarse  a  deehtfar  los  de  viruela; 

For  tales  oonsideraotones,  el  ConseiK>  Nadonal  de  Higiene  en  uso  de  sus  atrlbueionss,  resuelve: 

AbtIcolo  1«.  Deolarar  de  aouerdo  oon  lo  presortto  en  el  artSoulo  1«  de  la  Ordenania  No.  6,lne]ufdos  los 
oasos  sospeoboeos  de  viruela  entre  los  de  deolaraddn  obllgatoria  de  enfermedades  Infecto^ontagiosas. 

Abt.  3*.  Publlqusse  pen  oonoolmiento  gsneraL 

Altbbdo  VIdal  t  Fushtbs,  PntHnU. 
Jos*  Mabtibbk*,  Seerdtrio, 

CnCULAR. 

BabUnio  eonauUado  U  inspeeddn  dipartamental  de  higiene  ie  San  Joei,  enmnio  tiempo  iebia  mmnienene 
el  aielamiento,  tntAmioee  de  vimOa,  efcsristfaa  y  ^^^teris,  tate  eoniejo,  deapute  de  etr  •  ia  inepeodAn  de 

MoNTXYiDKO,  U  de  Abrii  de  mi. 

Bl  coQsaJo  en  sesldn  de  osta  feoba,  aprobd  el  infonne  preoedente,  exoepto  las  oonoluaiones,  que  se  acordd 
suprimirlas,  sustituytodolas  por  la  sigulente  resohiddn: 

1«.  Qilea  dabe  }usg%r  de  Is  daradda  del  alslamiento,  es  el  inspeotor  de  bigiene,ouyo  hinoionario  inter- 
veodrA  en  todos  Ids  oasos  qne  lo  estime  neoesario. 

3».  Bl  aislaalento  so  levantarft  pare  la  ▼iniola  y  pare  la  esearlatina  euando  baya  teiminado  el  perlodo 
de  eseamacidn,  y  en  la  dlfterla  a  los  15  diss  despute  de  inieiada  la  enfermedad. 

9».  BstaresoluoidQ  teQdr&oadU)ter  general  y  se oomunlcar&  alas inspeodonesdepartamentalesde higiene 
para  sn  conodmlento  y  observanoia. 

Cnmplido,  aroblvese. 

Bl  oriterio  que  infonna  la  primere  oonohisidn,  no  es  de  que  siempre  deba  intervenlr  el  inspeotor  de  higiene 
pare  levaatar  el  aislamiento,  no;  lo  que  se  pretende  es  fsoultarlo  pare  que  pueda  ctleroer  ese  oontralor  en 
to  Jos  los  casos  que  por  raiones  espeoiales  Jusgue  prematuro  el  cese  del  aislamiento,  o  ouando  tenga  motivoa 
de  otro  orden  pare  dudar  do  si  ha  llegado  o  no  el  momento  de  dejar  sin  efecto  la  ezpresada  medida 
pioflldetiea. 

Lo  que  partiolpo  a  Vd.  a  sus  efeetos. 

Sahkla  a  Vd.  atentamente. 

A.  Vidal  t  Fvbmtbs,  PretUenie. 

P.  Prado,  Seeretario. 

OBDBNANtA  No.  153. 

Montbvidbo,  It  de  Oetmhre  de  IBt^ 
Bl  GonsAjo  Nsdonal  de  Higiene  en  uso  de  Its  atribuciones  que  le  conflere  la  ley  de  31  de  ootubre  de  18iM, 
debidamente  autorisado,  resuelve: 

Artloulo  to  OeeUhase  el  "Traooma"  entre  las  enfermedades  inleotoHxmtagiosas  de  deolaracJdn  obllga- 
toria a  que  se  reflere  el  artloulo  1*  de  la  Ordenania  No.  6  del  Consejo  Nsdonal  de  Higiene,  promulgada 
por  el  Poder  BJeoutivo  oon  Ceoha  28  de  Julio  de  1806. 
Akt.  ao.  Publlquese  pare  oonoolmiento  general. 

A.  Vidal  t  Fvzmtbb,  PreeidetUe, 
lost  ICAnKUNOU,  5«erelsrfo. 


PUBUC  HBALTH  AND  MEDIGHfTE.  645 

OBDICNANZA  No.  149  DBL  CONSKJO  NaCIONAL  DB  HIQIXNB  fob  la  QUB  SB  INCLUTB  la  MENINQniB 
CBBBBBO-ESPINAL  EPIDtMICA  ENTBB  las  BmrBBMBDADBS  INTBCTOCONTAOIOSAS  DB  DECLABACI6M 
OBUOATOBIA— 28  DB  JUNIO  DB  1918. 

C<W8BK>  NACIONAL  DB  HIQIBNB. 

El  Consejo  Nadonal  de  Higlene,  en  uso  de  las  focoltades  que  le  cooflere  la  ky  de  31  de  octvbre  de  180S 
debidamente  autorixado,  resoelve: 

ABncuLO  1«.  Inchiir  la  meningitis  oerebro-espioal  epid^mica  entre  las  enfennedades  Iniitcto-coDtagioaa 
denunciables  de  oonformldad  oon  el  artfculo  2*  de  la  Ordenansa  No.  6  promulgada  el  28  de  Julio  de  1896 
7  del  artloulo  26  del  Re^amento  de  Sanldad  Teirestre. 

Abt.  2<».  La  meningitis  oerebn>e8pina]  epid6mica  queda  Inoorporada  a  las  enfpnnedades  mendonadas 
en  el  ntkmero  1  del  artlculo  102  del  Rcglamento  de  Sanldad  Terrestre. 

Abt.  3".  PubUqnese  para  oonodmiento  general. 

A.  ViDAL  T  Fuentbs,  PruUeHte. 
JoBt  Mabtibbnb,  SeereUTio. 

The  Chairman.  I  beg  to  announce  that  copies  of  the  foDowing 
printed  books  have  been  presented  by  the  authors  to  the  congress 
through  Section  VIII : 

Reorganizaci6n  del  Servicio  M6dico-L^al  en  Chile,  by  I.  Marcial 
Rivera. 

Essai  sur  les  Diptdres  Vuln^rants  du  Venezuela,  by  J.  M.  R.  Surcouf 
and  R.  Gonzalez-Rincones.    A.  Maloine,  ^diteur.     Paris,  1912. 

Manual  de  obstetricia,  por  los  doctores  Josu^  A.  Beruti  y  Domingo 
Iraeta.  Las  Ciencias,  libreria  y  Casa  Editora  de  A.  Guidi  Buffarini, 
Buenos  Aires,  1915. 

La  Nticleo-Prote{naGonoc6ccica  y  sus  aplicaciones,  por  los  doctores 
Silvio  Dessy  y  F.  L.  Grapiolo.  "La  Semana  M^dica'*  Imp.  de  obras 
de  E.  Spinelli,  Buenos  Aires,  1914. 

The  Chairman.  The  last  paper  on  our  program  is  ''A  historical 
r6sum6  of  the  investigations  of  yellow  fever  leading  up  to  the  findings 
of  the  Reed  board,"  and  is  by  the  late  Gen.  George  M.  Sternberg, 
United  States  Army,  paper  to  be  read  by  Col.  Hoff. 


A  HISTORICAL  RfiSUMS  OF  THE  INVESTIGATIONS  OF  YELLOW  FEVER 
LEADING  UP  TO  THE  FINDINGS  OF  THE  REED  BOARD. 

By  GEORGE  M.  STERNBERG, 
Surgeon  Qeneral^  United  States  Armyy  retired. 

[Gen.  Sternberg  died  in  Washington,  D.  C,  November  3,  1915,  and  this  paper  was 
read  by  Col.  John  Van  Hoff,  United  States  Army  Medical  Corps.] 

It  is  generally  recognized  that  the  demonstration  that  yellow  fever  is  transmitted 
by  mosquitoes  of  the  genus  St^omyia  is  one  of  the  greatest  achievements  of  modem 
science;  and  the  credit  for  this  demonstration  is  justly  given  to  the  c<»nmisBion  of 
which  Maj.  Walter  Reed,  suigeon,  United  States  Army,  was  preoident,  which  was  sent 
to  Habana  in  1900,  upon  the  recommendation  of  the  writer,  then  Surgeon  General 
of  the  Army. 

Dr.  Carlos  Finlay,  of  Habana,  had  long  before  conceived  the  idea  that  the  disr^ipi 
under  consideration  is  transmitted  by  mosquitoes,  and  fuU  credit  should  be  given  him 
for  persistently  advocating  this  theory,  although  his  own  experiments  failed  to  fumidi 


646       PROCEEDINGS  SECOND  PAN  AMERICAN   SCIENTIFIC  CONGRESS. 

Any  satisfactory  proof  that  his  theory  was  well  founded.  Indeed,  such  proof  waft 
wanting  Ln  the  earlier  experiments  of  the  Reed  board,  and  it  was  not  until,  as  a  final 
experiment,  the  mosquitoes,  after  filling  themselves  with  blood  from  a  yellow-fever 
patient,  were  kept  for  10  or  12  days  before  allowing  them  to  bite  a  susceptible  indi- 
vidual that  success  was  attained. 

In  a  report  published  in  May,  1901,  Maj.  Reed  says:  **We  have  thus  far  succeeded 
in  conveying  yellow  fever  to  12  individuals  by  means  of  the  bites  of  contaminated 
mosquitoes."  Confirmation  of  these  results  was  soon  after  afforded  by  the  experi- 
ments of  Dr.  John  GuLteras,  and  to-day  yellow- fever  prophylaxis  is  successfully  based 
upon  this  epoch-making  discovery. 

But  as  to  the  precise  nature  of  the  etiological  agent  or  "germ,"  we  are  still  uncer- 
tain, although  in  the  present  state  of  science  we  can  scarcely  fail  to  believe  in  a  living 
germ,  which  multiplies  in  the  blood  of  infected  individuals,  but  which  is  so  minute 
that  it  has  not  yet  been  demonstrated  by  the  highest  powers  of  the  microscope. 

I  have  no  new  facts  to  add  to  our  knowledge  of  yellow-fever  etiology.  But  it  has 
occurred  to  me  that  a  brief  account  of  the  investigations  which  led  up  to  the  demon- 
stration that  yellow  fever  is  transmitted  by  mosquitoes  might  be  of  some  interest  to 
the  members  of  the  Pan  American  Scientific  Congre^.  Such  an  account  must  begin 
with  the  Habana  Yellow  Fever  Oommission  of  1879. 

The  wide  extent  and  great  mortality  of  the  yellow-fever  epidemic  of  1878  led  to 
the  organization  of  a  United  States  National  Board  of  Health.  And  it  was  evidently 
expected  that  one  of  the  most  important  duties  of  this  board  would  be  to  attempt  to 
devise  methods  for  the  prevention  of  similar  epidemics. 

Among  the  members  of  this  National  Board  of  Health  was  Dr.  S.  M.  Bemis,  of  New 
Orleans,  who  no  doubt  had  much  to  do  with  the  selection  of  the  members  of  the  com- 
mission which  it  was  decided  should  be  sent  to  Habana  to  study  the  disease  in  one 
of  its  principal  endemic  foci.  The  membership  of  this  commission  was  as  follows: 
President,  Dr.  Stanford  E.  Chaill^,  of  New  Orleans;  secretary,  Suig.  George  M.  Stem- 
berg,  United  States  Army;  Dr.  John  Guiteras,  Marine  Hospital  Service;  and  Mr. 
T.  S.  Hardee,  civil  engineer,  of  New  Orleans.  Mr.  Rudolph  Matas,  of  New  Orleans, 
was  appointed  clerk  to  the  commission,  and  Mr.  Henry  Mancel,  a  Frenchman  living 
in  New  Orleans,  was  engaged  as  photographer. 

In  the  division  of  our  work  it  was  decided  that  Dr.  C^il16  should  make  investiga- 
tions relating  to  the  prevalence  of  yellow  fever  in  the  island  of  Cuba.  This  he  did  in 
a  most  comprehensive  manner,  as  is  shown  by  his  published  report  to  the  National 
Board  of  Health.  Dr.  Guiteras  undertook  the  search  for  microorganisms  and  for  path- 
olo^cal  changes  in  the  tissues  of  yellow-fever  cadavers.  This  he  did  secundem  artem, 
but  his  painstaking  labors  did  not  throw  any  new  light  upon  the  etiology  of  the  disease* 

To  me  was  assigned  the  examination  of  the  blood,  culture  experiments,  and  experi- 
ments upon  lower  animals.  It  would  be  tedious  to  attempt  to  give  details  of  my 
numerous  experiments  and  observations,  but  suffice  it  to  say  that  I  failed  to  find 
any  microorganisms  in  the  blood  of  living  patients  drawn  on  different  days  of  sick- 
ness and  did  not  succeed  in  producing  any  symptoms  resembling  yellow  fever  in  the 
lower  animals  subjected  to  experiment. 

I  may  say  that  in  advance  of  my  visit  to  Habana  I  had  strong  hopes  that  by  modem 
methods  of  research  the  germ  of  this  infectious  disease  might  be  found  in  the  blood, 
and  I  was  prepared  to  photograph  it  if  found.  I  was  provided  with^eiss  one-twelfth 
and  one-eighteenth  inch  homogeneous  oil-immersion  objective,  and  I  had  received 
instructions  in  the  art  of  making  photomicrographs  from  Surg.  J.  J.  Woodward,  United 
States  Army,  a  pioneer  and  recognized  expert  in  the  art,  at  the  Army  Medical  Museum. 
Ninety-eight  specimens  from  41  undoubted  cases  of  yellow  fever  were  carefully 
studied,  with  a  completely  negative  result  so  far  as  microorganisms  were  concerned. 
My  photomicrographs  were  mostly  made  with  a  magnifying  power  of  1,450  diameters, 
obtained  by  the  use  of  a  Zeiss  one-eighteenth  inch  objective  and  a  Tolles  amplifier. 


PUBUC  HEALTH  AND  MBmCINB.  647 

The  researches  made  by  me  subsequently  to  the  return  of  the  yelluw  fever  com- 
mission were  embodied  in  my  report  on  the  Etiology  and  Prevention  of  Yellow  Fever 
published  in  1890.    In  it  1  say: 

The  investigations  to  which  this  report  relates  were  made  in  the  city  of  Habana 
in  the  summers  of  1888  and  1889;  in  the  (ity  of  Decratur,  Ala.,  in  the  autumn  of  1888; 
and  in  the  laboratories  of  the  Johns  Hopkins  Univendty,  where  1  have  continued  my 
researches  during  the  intervals  between  my  visits  to  the  infected  localities,  ana 
ainr.e  my  return  from  Habana,  in  September,  1889,  up  to  the  present  date. 

My  bat^teriologioal  studies  have  been  made  with  material  obtained  from  43  yellow  - 
fever  cadavers;  from  "black  vomit'*  and  feces  of  patients  in  various  stages  of  the 
disease;  and,  for  comparison,  from  18  cadavers  in  which  death  occurred  Som  some 
other  disease  than  yellow  fever,  and  from  feces  of  healthy  individuals. 

After  the  extended  researches  in  this  report  I  state  my  conclusions  as  follows: 

The  experimental  data  recorded  in  this  report  show  that  the  specific  infectious 
agent  in  yellow  fever  has  not  been  demonstrated. 

The  m^«t  approved  ba(;teriol'»gical  methods  fail  to  demonstrate  the  constant  presence 
of  any  particular  microorganisms  in  the  blood  and  tissues  of  yellow  fever  Okdavers. 

The  microorganisms  which  are  sometimes  obtained  in  cultures  from  the  blood  and 
tissues  are  present  in  comparatively  small  numbers,  and  the  one  meet  frequently 
found  (Ba^.terium  coli  cdmmune)  is  present  in  the  intestines  of  healthy  individuals, 
and  consequently  its  oc*»sional  presence  can  not  have  any  etiologii  al  import. 

A  few  scattered  bar.illi  are  present  in  the  liver  and  probably  in  other  organs  at  the 
moment  of  death.  This  is  shown  by  preserving  portions  of  liver,  obtained  at  a  recent 
autopsy,  in  an  antiseptic  wrapping. 

A  t  the  end  of  24  to  48  hours  the  interior  of  a  piece  of  liver  so  preserved  contains  a 
large  number  of  lMu;illi  of  various  species,  the  most  abundant  being  those  heretofore 
mentioned  as  occasionally  found  in  fresh-liver  tissue — viz,  BacteriTim  coli  commune 
and  Bat.illus  cadaveris. 

Having  failed  to  demonstrate  the  presence  of  a  specific  ''germ''  in  the  blood  and 
tissues,  it  seemed  possible  that  it  is  to  be  foimd  in  the  alimentary  canal,  as  is  the  case 
in  cholera.  But  the  extended  researches  made  and  recorded  m  the  present  report 
show  that  the  contents  of  the  intestines  of  yellow-fever  cases  contain  a  great  vanety 
of  bacilli  and  not  a  nearly  pure  culture  of  a  single  species,  as  is  the  case  in  recent 
and  typical  cases  of  cholera. 

On  tne  other  hand  nonliquefying  bacilli  are  very  abundant.  The  one  most  con- 
stantly and  abundantly  present  is  tne  Bacteriiun  coli  commune  of  Escherich.  This 
is  associated  with  various  other  bacilli,  some  of  which  are  strict  anaerobics  and  some 
facultative  anaerobics. 

Among  the  faciiltative  anaerobics  is  one  (my  bacillus  X)  which  has  been  isolated  by 
the  culture  method  in  a  considerable  number  of  cases  and  may  have  been  present 
in  all.  This  bacillus  has  not  been  encoimtered  in  the  comparative  experiments  made. 
It  is  very  pathogenic  for  rabbits  when  injected  into  the  cavity  of  tne  abdomen.  It 
is  possible  that  wis  bacillus  is  concerned  in  the  etiology  of  yellow  fever,  but  no  satis- 
factory evidence  that  this  is  the  case  has  been  obtained  by  experiments  on  the  lower 
animals,  and  it  has  not  been  found  in  such  numbers  as  to  warrant  the  inference  that 
it  is  the  veritable  infectious  agent. 

All  other  microoif^anisms  obtained  in  pure  cultures  from  yellow-fever  cadavers 
appear  to  be  excluded,  either  by  having  been  identified  with  known  species,  or  by 
having  been  found  in  comparative  researches  made  outside  of  the  area  of  yellow-fever 
prevalen(.e,  or  by  the  fact  that  they  have  been  found  only  in  small  numbers  and  in  a 
limited  number  of  cases. 

It  will  be  seen  that  I  did  not  positively  exclude  my  bacillus  X  as  a  possible  etiologi- 
cal factor,  but  I  say  that  it  was  not  found  *'in  such  numbais  as  to  warrant  the  inference 
that  it  is  the  veritable  infectious  agenf  In  1902  I  was  appointed  Surgeon  General 
of  the  Army,  and  my  opportunities  for  personal  research  work  ceased.  My  published 
reports  had  apparently  satisfied  the  profession  that  the  various  daims  which  had 
been  made  for  the  discovery  of  the  specific  genn  of  yellow  fever  had  no  substantial 
foundation.  Among  these  were  the  claims  of  Domingoe  Freire,  of  BrazO;  of  Oannona  y 
Valle,  of  Mexico;  of  Carlos  Finlay,*  of  Habana;  and  of  Paul  Gibier,  of  France. 


1  His  "Micrococcus  tetragenos  febrls  flavae.'' 


648       PROCEEDINGS  SECOND  PAN  AMEBICAN  SCIENTIFIC  C0NQBB8S. 

Since  my  report  above  referred  to  was  published  a  new  claimant  appeared — viz, 
the  Italian  bacteriologist,  Sanarelli.  His  researches  were  made  in  Brazil,  and,  singu- 
larly enough,  he  found  in  the  blood  of  the  first  case  examined  by  him  a  baciUus.  It  was 
present  in  large  numbers,  but  this  case  ia  unique,  for  neither  Sanarelli  nor  anyone 
else  has  since  found  it  in  such  abundance.  It  has  been  foimd  in  small  numbera  in 
the  blood  and  tiasues  of  yellow-fever  cadavers  in  a  certain  number  of  cases  examined. 
For  a  time  I  thought  it  probable  that  Sanarelli's  bacillus  was  identical  with  n^y 
bacillus  X.  But  the  researches  of  the  Reed  board  identified  it  with  the  bacillus  of 
hog  cholera,  while  my  bacillus  X  appeared  to  them  to  belong  to  the  colon  gnup. 
The  badllus  of  Sanarelli  had  a  certain  amount  of  standing  for  a  time  because  two 
medical  officers  of  the  Marine  Hospital  Service,  who  had  been  sent  to  Habana  to  study 
yellow  fever,  made  a  report  favorable  to  the  claims  of  Sanarelli.  But  the  researches 
of  Reed,  Carroll,  and  Agramonte  >  have  demonstrated  conclusively  that  this  bacillus 
has  nothing  to  do  with  the  etiology  of  yellow  fever. 

At  the  present  date  Dr.  Arlstides  Agramonte  is  the  only  living  member  of  the  yellow- 
fever  commission  appointed  upon  my  recommendation  in  1900.  Maj.  Walter  Reed, 
surgeon,  United  States  Army,  was  selected  as  president  of  this  commission  because 
he  was  a  trained  bacteriologist,  and  at  the  time  of  his  appointment  was  in  charge  of 
our  bacteriological  laboratory  at  the  Army  Medical  Museum.  He  died  in  Washington 
from  appendicitis  November  23,  1902,  aged  51 .  Since  his  death  various  articles  pub- 
lished in  the  newspapers  have  stated  that  he  died  as  a  result  of  his  yellow-fever  in- 
vestigations. This  is  a  mistake.  Dr.  Reed  was  in  Washington  at  the  time  that  Dr. 
Carroll  made  upon  himself  the  first  successful  yellow-fever  inoculation  and  he  was 
not  inoculated. 

br.  James  Carroll  died  in  Washington  March  9,  1907,  of  myocarditis,  which  was 
believed  by  his  physicians  to  have  resulted  from  the  severe  attack  of  yellow  fever 
which  he  suffered  in  1900. 

Dr.  Jesse  W.  Lazear,  contract  surgeon.  United  States  Army,  was  appointed  a  member 
of  the  commission  because  he  had  had  special  training  as  a  bacteriologist.  He  died 
at  Camp  Columbia,  Cuba,  of  yellow  fever  on  September  25,  1900.  His  attack  was 
attributed  to  the  bite  of  a  mosquito  while  he  was  visiting  the  wards  of  a  yellow-fever 
hospital. 

The  written  instructions  given  by  me  to  this  selected  board  of  experts  were  as 
follows: 

You  will  naturally  give  special  attention  to  questions  relating  to  the  etiology  and 
prevention  of  yellow  ^ver.  As  you  are  familiar  with  what  has  &ead}r  been  done  by 
other  bacteriologists  in  this  field  of  investigation,  I  do  not  consider  it  necessary  to 
^ve  you  any  suggestions  or  detailed  instructions.  But  it  is  evident  that  the  most 
miportant  question  which  will  occupy  your  attention  is  that  which  relates  to  the 
etiology  of  this  disease. 

You  will  also  take  advantage  of  such  opportunities  as  may  offer  for  the  study  of 
other  infectious  diseases,  and  especially  of  the  malarial  fevers  prevailing  in  the  isumd 
of  Cuba.  An  important  question  in  connection  with  the  diseases  of  tropical  and 
semitropical  countries  relates  to  the  etiology  of  febrile  attacks  of  short  duration,  to 
which  strangers  are  especially  subject.  Should  you  have  time,  there  will  be  ample 
opportunity  for  the  study  of  leprosy  in  the  lepers'  hospital  in  the  city  of  Habuia. 
Attention  uiould  also  be  given  to  the  infectious  diseases  of  the  lower  animals,  in  case 
any  such  prevail,  the  etiology  of  which  has  not  been  definitely  determined. 

In  addition  to  these  vrritten  instructions  I  talked  freely  with  Maj.  Reed,  president 
of  the  commission,  and  gave  him  my  views  as  to  the  most  promising  lines  of  experiments 
relating  to  the  etiology  of  yellow  fever. 

>  Dr.  Agramonte  worked  on  this  problem  during  the  Santiago  campaign  in  1806  and  afterwards  with 
Reed  and  Carroll  in  the  bacteriological  laboratory  of  the  Army  Medical  Museum.  He  was  otdered  to 
Habana  in  December,  1808,  with  instructions  from  Oen.  Sternberg  and  power  to  do  all  that  might  be  neo- 
essary  to  dear  up  the  problem.  In  1800  Drs.  Qoddings  and  Wardin  submitted  a  report  afOnning  that 
Sanarelli's  bacillus  was  present  in  almost  all  the  cases,  while  Dr.  Agramonte  denied  that  it  had  such  specific 
character  and  showed  its  occurrence  in  cases  not  yellow  lever.  He  continued  his  researches  until  appointed 
a  member  of  the  commission. 


PUBUO  HEALTH  AND  MBIHOINE.  649 

I  tuiged  that  efforts  should  be  rntde  to  ascertain  definitely  whether  the  disease  can 
be  communicated  from  man  to  man  by  blood  inoculations.  Evidently  if  this  is  the 
ciMB  the  blood  must  contain  the  living  infectious  agent  upon  which  the  propagation 
of  the  disease  depends,  notwithstanding  the  fact  that  all  attempts  to  demonstrate 
the  presence  of  such  a  germ  in  the  blood,  by  means  of  the  microscope  and  culture 
methods,  had  proved  unavailing.  I  had  previously  demonstrated  by  repeated 
experiments  that  inoculations  of  yellow-fever  blood  into  lower  animals — dogs,  rabbits, 
guinea  pigs— give  a  negative  result,  but  this  negative  result  might  well  be  because 
theee  animals  were  not  susceptible  to  the  disease  and  could  not  be  accepted  as  show- 
ing that  the  germ  of  yellow  fever  was  not  present  in  the  blood.  A  single  inoculation 
experiment  on  man  had  been  made  at  my  request  in  the  city  of  Vera  Cruz,  in  1887, 
by  Dr.  Daniel  Ruiz,  who  was  in  charge  of  the  civil  hospital  in  that  city.  But  this 
experiment  was  inconclusive  for  the  reason  that  the  patient  from  whom  the  blood 
was  obtained  was  in  the  eighth  day  of  the  disease,  and  it  was  quite  possible  that  the 
specific  germ  might  have  been  present  at  an  earlier  period,  and  that  after  a  certain 
number  of  days  the  natural  resources  of  the  body  are  sufficient  to  effect  its  destruction 
or  in  some  way  to  cause  its  disappearance  from  the  circulation. 

I  was  especially  anxious  that  this  experiment  should  be  repeated  with  the  blood 
taken  from  a  case  in  the  early  stages  of  the  disease.  I  had  not  been  able  to  make  the 
experiment  upon  myself,  as  I  was  immune,  having  suffered  a  severe  attack  of  yellow 
fever  in  1875. 

The  Reed  Commission  made  this  experiment  with  success  after  having  demonstrated 
that  the  disease  could  be  transmitted  by  mosquitoes  which  had  been  kept  for  10  or  12 
days  after  biting  a  yellow-fever  patient.  It  is  evident  that  if  the  experiment  had 
been  made  at  the  outset  of  the  investijration  a  similar  success  would  have  lead  inevitably 
to  the  conclusion  that  yellow  fever,  like  malarial  fever,  is  transmitted  by  an  inter- 
mediate host,  and  that  this  intermediate  host  is  a  mosquito. 

So  far  as  I  am  concerned,  there  is  nothing  more  to  be  said  about  yellow-fever  etiology, 
and  my  excuse  for  writing  this  brief  paper  is  to  be  found  in  the  fact  that  the  present 
generation  of  physicians  had  not  appeared  upon  the  stage  when  Prof.  Chaille,  Dr. 
John  Guiteras,  and  myself  visited  Habana  in  1879  for  the  purpose  of  studying  yellow 
fever,  and  probably  few  of  the  members  of  the  profession  have  seen  my  published 
report  of  subsequent  investigations  made  by  me.' 

The  Chairman.  You  have  heard  the  paper.  It  is  now  open  for 
discussion. 

Dr.  AoRAMONTE.  I  need  hardly  say  how  gratified  I  am  for  the 
opportunity  of  hearing  this  paper,  prepared  by  Surg.  Gen.  Stem- 
berg  a  short  time  evidently  before  his  recent  death.  I  am  sure 
that  I  have  never  overestimated  the  great  value  of  his  investigations 
when  I  have  said,  as  I  frequently  have,  that  his  work  was  of  the 
utmost  importance;  that  he  blazed  the  trail  that  made  the  walking 
easier  for  those  who  came  after  him.  As  I  listened  to  the  reading 
of  his  paper  it  seemed  to  me  like  an  echo  of  a  voice  from  beyond  the 
grave  and  like  a  proof  that  the  lives  of  great  men  do  not  terminate 
with  their  earthly  existence. 

Dr.  OuTTEBAS.  I  rise,  of  course,  not  for  discussion,  but  in  memory 
of  this  kindly  gentleman,  Dr.  Sternberg. 

>  Thb  historical  rteim4  was  i>reparad  a  few  weeks  before  the  lamented  death  of  Qen.  Sternberg  and  Is 
an  important  contribatioo  to  the  history  of  the  moanentoos  period  treated  of ,  aU  of  which  the  writer 
knew  and  a  large  part  of  which  he  was. 


650       PROCEEDINGS  SECOND  PAN  AMERICAN  SCIENTIFIC  CONGRESS. 

Dr.  KoBER.  I  will  simply  state  for  the  information  of  the  section 
that  this  paper  might  not  have  been  presented  to  the  section  if 
Mrs.  Sternberg  had  not  noticed  in  one  of  the  daily  papers  a 
remark  that  was  made  by  Dr.  Agramonte  that  the  organism  of 
yellow  fever  had  not  yet  been  discovered.  She  was  reminded,  then, 
that  the  general  had  prepared  a  paper  on  this  subject.  She  placed 
the  paper  in  my  hands  only  four  days  ago — a  most  opportime  moment 
to  place  on  record  an  historical  rfeumfi  of  the  prelimmary  work 
which  led  up  to  this  brilliant  discovery.  It  is  very  evident  tliat  the 
paper  was  prepared  with  no  intention  of  detracting  in  the  slightest 
degree  from  the  brilliant  achievements  of  the  Reed  Yellow  Fever 
Coiomission,  but  to  recount  his  own  preliminary  work,  which  cer- 
tainly was  of  the  highest  scientific  value  and  has  enabled  future 
investigators  to  begin  where  he  left  off.  He  had  done  the  work, 
with  practically  nothing  more  to  be  added  than  absolute  experi- 
mentation on  the  human  subject.  This  fact,  gentlemen,  must  go 
down  in  history  in  justice  to  a  man  who  was  as  able  as  he  was 
modest. 

The  Chairman.  The  more  I  think  of  the  history  of  the  etiology 
of  yellow  fever,  the  more  surprised  I  am  that  we  could  not  see  what 
Finlay  showed  us.  I  can  take  a  little  credit  to  myself  that  after 
meeting  him  I  thought  his  view  was,  at  least,  reasonable.  In  the 
second  year  that  I  was  at  Habana  we  found  that  Las  Animas  Hos- 
pital, where  the  yellow-fever  patients  were  treated,  at  least  the 
hospital  proper,  was  practically  noninfectible  territory.  The  physi- 
cian who  had  been  there  a  whole  year  without  contracting  yellow 
fever,  did  contract  it  when  he  moved  into  town  the  next  spring. 
One  of  the  nurses  who  had  nursed  in  Las  Animas  the  whole  summer 
of  1899,  when  she  went  down  in  the  spring  of  1900  into  Habana 
contracted  yellow  fever.  It  was  fair,  then,  to  say  that  Las  Animas 
was  noninfectible  territory.  I  suggested  that  there  be  put  out  in 
both  the  lazareto  and  the  main  hospital,  bottles  to  get  the  larv»  of 
the  mosquito,  thinking  that  since  these  places  were  uninfectible 
territory  this  mosquito  was  not  the  factor  that  carried  it,  if  we 
found  it.  I  was  decidedly  disappointed  in  finding  some  of  these  larvs& 
hatched  in  the  bottles,  more  in  the  lazareto  than  in  the  hospital. 
I  did  not  think  of  finding  them  in  the  lazareto  because  it  was 
fumigated  with  sulphur  every  week  or  so.  I  suppose  the  reason  that 
the  fever  was  not  conveyed  into  the  hospital,  was  possibly  because  the 
patients  were  kept  imtil  the  diagnosis  was  very  certain  before  they  went 
in.  I  think  a  very  small  percentage  went  in  until  they  had  passed 
the  first  four  days  of  their  sickness,  when  we  believe  their  blood  is 
,  no  longer  infected  with  the  stegomyia.    Again,  Dr.  Guiteras  tells 

I  me  there  were  but  few  larvae.     We  found  some,  however.     But  Finlay 

was  that  close  to  proving  his  belief  of  conveyance  by  the  mosquito. 


PUBLIO  HEALTH  AND  MEDICINE.  651 

Sternberg  doubtless  must  have  suspected,  or  must  at  least  have 
considered  the  probability  of  conveyance  by  an  insect  host,  and  yet 
he  could  not  have  readily  accepted  it.  On  the  4th  of  July,  1900, 
I  was  dining  with  Stark,  at  that  time  a  captain  or  heutenant  in 
the  Medical  Corps  of  the  Army.  I  was  talking  to  Reed,  and 
Chains  while  waiting  for  dinner.  I  had  been  fairly  intimate  with 
Lazear  before  that.  The  question  came  up  of  the  mosquito  con- 
veyance of  yellow  fever,  and  I  asked  Reed  if  he  had  seen  the 
mosquitoes  that  Lazear  had  from  Finlay,  mosquitoes  the  larvae 
of  which  I  myself  had  carried  from  Finlay  to  Lazear.  We  were 
speaking  of  the  general  conveyance,  and  Chaillfi  asked  about  the 
conveyance  of  fomites.  I  asked  if  conveyance  was  by  clothing, 
and  Gen.  Stcrr)borg  stated  it  was  universally  admitted  that 
yellow  fever  was  carried  by  clothing.  I  think  then  he  must  have 
considered  the  possibility  of  insect  conveyance,  but  he  had  not 
suspected  the  mosquito,  at  any  rate,  or  Reed  could  scarcdy  have  so 
quoted  him.  I  told  him  that  the  difference  between  *' universally 
admitted"  and  proven  is  very  great,  that  *Hwo  years  before  it  was 
universally  admitted  that  malaria  was  simply  an  air-borne  disease. 
It  is  not  so  now,  and  I  am  one  who  does  not  believe  it  is  carried  by 
fomites,"  and  gave  him  reasons  for  my  thinking  so. 

I  say  this  to  show  that  I  suspect  the  result  was  almost  as  much 
a  surprise  to  Gen.  Sternberg  as  it  was  to  many  others.  Lazear  was 
probably  the  first  member  of  the  commission  who  entertained  the 
idea  of  the  disease  being  carried  by  the  mosquito.  Sometime 
before  Reed  came  down  he  said,  speaking  of  some  data  which  had 
been  given  him,  *^This,  if  true,  looks  as  though  it  were  carried  by  a 
living  host."  I  made  him  a  memorandum,  showing  that  there 
were  two  other  modes  of  conveyance,  which  seemed  to  me  also 
possible. 

Col.  HoFF.  There  were  two  objects  sought  in  reading  this  paper — 
one  to  record  that  the  general  had  this  congress  in  mind,  and  the 
other  to  bring  to  the  attention  of  the  members  of  this  section  the  fact 
that  there  is  probably  much  in  the  history  of  the  steps  that  led  up 
to  the  final  achievement  that  has  been  forgotten  in  the  course  of 
events. 

Mr  Chairman,  before  a  final  adjournment  of  this  section  I  have 
several  resolutions  and,  with  the  permission  of  the  section,  I  should 
like  to  introduce  them. 

The  Chairman.  There  is  no  reason  why  you  should  not  introduce 
them.  I  am  very  sure  the  section  will  agree  to  waiving  the  method 
we  have  used  because  there  is  now  no  committee. 

Col.  HoFF  (reading) ; 

Rcsolvedy  That  the  secretary  be  requested  to  send  a  set  of  reprints  of  the  valuable 
papers  read  before  Section  VIII  of  the  Second  Pan  American  Scientific  Congress  to  the 


652       PROCEEDINGS  SEOOND  PAN  AMEBIGAN   SCIENTIFIC   CONGRESS. 

following  libraries:  Library  Siuigeon  General's  Office,  United  States  Army, Washing- 
ton, D.  C,  Library  Harvard  Medical  School;  Boston  Medical  Library,  Bo6t<», 
Mass. ;  Library,  Academy  of  Medicine,  New  York  City;  Library  CoUege  of  Physicians, 
Philadelphia;  Library  University  of  Pennsylvania;  Library  Johns  Hopkins  Medical 
School. 

Dr.  Hinsdale.  I  have  no  doubt  that  these  papers  could  be  sent 
without  a  resolution  on  application  of  these  particular  bodies,  but  I 
think  periiaps  it  is  just  as  well  to  make  a  record  of  it. 

Seconded  and  approved. 

Col.  HoFF.  Another  resolution : 

Resolved^  That  the  Section  on  Public  Health  and  Medical  Science  indorses  the 
House  of  Representatives  bill  528  to  discontinue  the  use  of  the  Fahrenheit  thermometer 
scale  in  Government  publications. 

Seconded. 

Dr.  Hoffman.  May  I  speak  to  that  resolution  ?  It  seems  to  me 
that  it  is  too  radical  a  resolution  to  be  passed  without  serious  con- 
sideration. If  the  Fahrenheit  scale  is  to  be  discontinued  it  would 
seem  at  least  advisable  that  for  a  time  it  should  be  continued  in 
addition  to  the  others. 

The  Chairman.  I  will  read  from  the  bill.     (Read.) 

Dr.  Hoffman.  That  meets  the  objection. 

Motion  carried. 

Col.  HoFF.  A  further  resolution,  sir: 

Resolved,  That  the  thanks  of  the  section  are  due  and  that  they  be  extended  to 
Maj.  E.  R.  Whitmore,  our  most  efficient  secretary,  for  the  admirable  way  in  which 
he  has  performed  the  arduous  and  esba^ting  duties  of  his  office  and  wli^ch  has  resulted 
in  a  most  successful  meeting  of  our  section  on  public  health  and  medical  science. 

The  Chairman.  I  move  that  the  vote  on  that  resolution  be  taken 
standing. 

The  members  of  the  section  rose. 

Col.  Hoff: 

Renolved,  That  the  thanks  of  the  section  are  due  to  the  Latin  American  membere 
of  the  section,  and  especially  to  Drs.  Guiteras  and  Agramonte,  for  their  assistance  in 
promoting  the  efficient  conduct  of  the  section. 

The  Chairbcan.  All  in  favor  will  rise. 

The  members  of  the  section  rose. 

Col.  Hoff.  I  move  that  we  adjourn. 

The  Chairman.  It  is  moved  that  we  adjourn  sine  die. 

Adjournment  sine  die  of  Section  VIII. 

o 


HMHI 


Hate  Due 


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