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+The Project Gutenberg EBook of Food Poisoning, by Edwin Oakes Jordan
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
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+
+Title: Food Poisoning
+
+Author: Edwin Oakes Jordan
+
+Release Date: November 1, 2010 [EBook #34189]
+
+Language: English
+
+Character set encoding: ASCII
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+*** START OF THIS PROJECT GUTENBERG EBOOK FOOD POISONING ***
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+Produced by Bryan Ness, Iris Schroeder-Gehring and the
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+
+  THE UNIVERSITY OF CHICAGO
+  SCIENCE SERIES
+
+
+
+
+ _Editorial Committee_
+
+  ELIAKIM HASTINGS MOORE, _Chairman_
+  JOHN MERLE COULTER
+  ROBERT ANDREWS MILLIKAN
+
+
+The University of Chicago Science Series, established by the Trustees of
+the University, owes its origin to a feeling that there should be a
+medium of publication occupying a position between the technical
+journals with their short articles and the elaborate treatises which
+attempt to cover several or all aspects of a wide field. The volumes of
+the series will differ from the discussions generally appearing in
+technical journals in that they will present the complete results of an
+experiment or series of investigations which previously have appeared
+only in scattered articles, if published at all. On the other hand, they
+will differ from detailed treatises by confining themselves to specific
+problems of current interest, and in presenting the subject in as
+summary a manner and with as little technical detail as is consistent
+with sound method.
+
+
+
+
+FOOD POISONING
+
+
+  THE UNIVERSITY OF CHICAGO PRESS
+  CHICAGO, ILLINOIS
+
+
++Agents+
+
+  THE BAKER & TAYLOR COMPANY
+  NEW YORK
+
+  THE CUNNINGHAM, CURTISS & WELCH COMPANY
+  LOS ANGELES
+
+  THE CAMBRIDGE UNIVERSITY PRESS
+  LONDON AND EDINBURGH
+
+  THE MARUZEN-KABUSHIKI-KAISHA
+  TOKYO, OSAKA, KYOTO, FUKUOSA, SENDAI
+
+  THE MISSION BOOK COMPANY
+  SHANGHAI
+
+
+
+
+FOOD POISONING
+
+  _By_
+
+EDWIN OAKES JORDAN
+
+  _Chairman of the Department of Hygiene and Bacteriology
+  The University of Chicago_
+
+[Illustration: emblem]
+
+  THE UNIVERSITY OF CHICAGO PRESS
+  CHICAGO, ILLINOIS
+
+
+
+
+  COPYRIGHT 1917 BY
+  THE UNIVERSITY OF CHICAGO
+
+  All Rights Reserved
+
+  Published May 1917
+
+
+
+
+  Composed and Printed By
+  The University of Chicago Press
+  Chicago, Illinois, U.S.A.
+
+
+
+
+CONTENTS
+
+
+  CHAPTER                                               PAGE
+
+  I. INTRODUCTION                                          1
+    The Extent of Food Poisoning
+    Various Kinds of Food Poisoning
+    The Articles of Food Most Commonly
+      Connected with Food Poisoning
+
+  II. SENSITIZATION TO PROTEIN FOODS                       9
+
+  III. POISONOUS PLANTS AND ANIMALS                       13
+    Poisonous Plants
+    Poisonous Animals
+
+  IV. MINERAL OR ORGANIC POISONS ADDED TO FOOD            26
+    Arsenic
+    Antimony
+    Lead
+    Tin
+    Copper
+    Various Coloring Substances
+    Food Preservatives
+    Food Substitutes
+
+  V. FOOD-BORNE PATHOGENIC BACTERIA                       44
+    Typhoid Food Infection
+    Asiatic Cholera
+    Tuberculosis
+    Various Milk-borne Infections
+    Possible Infection with _B. proteus_
+
+  VI. FOOD-BORNE PATHOGENIC BACTERIA (_Continued_)        58
+    Paratyphoid Infection
+      Typical Paratyphoid Outbreaks
+      General Characters of Paratyphoid Infection
+      Toxin Production
+      Sources of Infection
+      Means of Prevention
+
+  VII. ANIMAL PARASITES                                   79
+    Trichiniasis
+    Teniasis
+    Uncinariasis
+    Other Parasites
+
+  VIII. POISONOUS PRODUCTS FORMED IN FOOD BY BACTERIA
+    AND OTHER MICRO-ORGANISMS                             85
+    Ergotism
+    Botulism
+      Symptoms
+      Anatomical Lesions
+      Bacteriology
+      Epidemiology
+      Prevention and Treatment
+    Other Bacterial Poisons
+    Spoiled and Decomposed Food
+
+  IX. POISONING OF OBSCURE OR UNKNOWN NATURE             100
+    Milksickness or Trembles
+    Deficiency Diseases
+      Beriberi
+      Pellagra
+      Lathyrism
+      Favism
+      Scurvy
+      Rachitis
+    The Foods Most Commonly Poisonous
+
+  INDEX                                                  109
+
+
+
+
+CHAPTER I
+
+INTRODUCTION
+
+
+How frequently food poisoning occurs is not definitely known. Everybody
+is aware that certain articles of food are now and again held
+responsible for more or less severe "attacks of indigestion" or other
+physiological disturbances that have followed their consumption, but in
+many cases the evidence for assuming a causal connection is of the
+slightest. That convenient refuge from etiological uncertainty, "ptomain
+poisoning," is a diagnosis that unquestionably has been made to cover a
+great variety of diverse conditions, from appendicitis and the pain
+caused by gallstones to the simple abdominal distention resulting from
+reckless gorging.
+
+No doubt can be entertained, however, that intestinal and other
+disorders due to particular articles of food occur much more frequently
+than they are recorded. There are few persons who have not experienced
+gastro-intestinal attacks of moderate severity which could be reasonably
+attributed to something eaten shortly before. It is often possible to
+specify with a fair degree of certainty the offending food. The great
+majority of such attacks are of a mild character, are quickly recovered
+from, and are never heard of beyond the immediate family circle. Only
+when the attack is more serious than the average or when a large number
+of persons are affected simultaneously does knowledge of the occurrence
+become more widely spread. A small proportion of food-poisoning cases
+receives notice in the public press and a still smaller proportion is
+reported in the medical journals. Very few indeed are ever completely
+investigated as to their origin.
+
+Although most attacks of food poisoning are usually of a slight and
+apparently temporary nature, it does not follow that they are to be
+considered negligible or of trivial importance from the standpoint of
+public health. The human organism is always more or less weakened by
+such attacks, many of them, as we shall see, genuine infections; and, as
+is known to be the case with many infectious diseases, some permanent
+injurious impression may be left on the body of the affected individual.
+Under certain conditions it is possible that degenerative changes are
+initiated or accelerated in the kidneys or blood vessels by the acute
+poisoning which is manifested for a short time in even the milder cases.
+In yet greater degree these changes may follow those insidious forms of
+food poisoning due to the frequent ingestion of small quantities of
+mineral or organic poisons, which in each dose may cause little or no
+measurable physiological change, but whose cumulative effect may be
+vicious. In view of the grave situation evidenced by the increase in the
+degenerative diseases affecting early middle life in the United
+States,[1] the extent, causes, and means of prevention of food poisoning
+seem pressing subjects for investigation.
+
+
+THE EXTENT OF FOOD POISONING
+
+Since cases of food poisoning, "ptomain poisoning," and the like are not
+required by law to be reported, public health authorities in general
+possess no information respecting their occurrence. Very indirect and
+imperfect indications of the prevalence of certain kinds of food
+poisoning are afforded by casual press reports. Such as they are, these
+accounts are the only available material. Tables I and II summarize data
+I have gathered through a press-clipping bureau and other sources during
+the period October, 1913, to October, 1915. They serve to show at least
+the universality and complexity of the problem.
+
+The 375 group and family outbreaks together involved 5,238 persons.
+While it is not probable that all the instances reported as due to food
+poisoning can properly be so considered, there is no doubt that the
+number recorded in the tables falls far short of the actual occurrences.
+In the past few years the writer has investigated several large
+food-poisoning outbreaks which have never been reported in the press nor
+received public notice in any way. There is reason to think that the
+majority of cases escape notice. Probably several thousand outbreaks of
+food poisoning in families and larger groups, affecting at least
+15,000-20,000 persons, occur in the United States in the course of a
+year.
+
+The assignment of causes indicated in Table I is of limited value. The
+tendency to incriminate canned food is here manifest. Proper
+investigation of the origin of an outbreak is so rarely carried out that
+the articles of food ordinarily accused are selected rather as the
+result of popular prejudice and tradition than of any careful inquiry.
+
+TABLE I
+
+FOOD POISONING IN THE UNITED STATES, OCTOBER, 1913, TO OCTOBER, 1915
+
+  =================================================================
+          Assigned cause             |  Group   |          |
+                                     |and Family|Individual|
+                                     | Outbreaks|  Cases   |  Total
+  -----------------------------------+----------+----------+-------
+  Meat                               |    40    |    35    |    75
+  Canned fish                        |    29    |    35    |    64
+  Canned vegetables                  |    27    |    34    |    61
+  Ice cream                          |    31    |    22    |    53
+  Fish, oysters                      |    17    |    31    |    48
+  Cheese                             |    31    |     9    |    40
+  Sausage and canned meat            |    18    |    18    |    36
+  Milk                               |    14    |    13    |    27
+  Mushrooms                          |    12    |     7    |    19
+  Fruit                              |     8    |    11    |    19
+  Vegetables                         |    11    |     7    |    18
+  Fowl                               |    12    |     4    |    16
+  Salad                              |     9    |     5    |    14
+  Contact of food or drink with metal|    12    |     1    |    13
+  Miscellaneous                      |    29    |    55    |    84
+  -----------------------------------+----------+----------+-------
+                                     |   300    |   287    |   587
+  No cause assigned                  |   357    |    88    |   445
+  -----------------------------------+----------+----------+-------
+                                     |   657    |   375    | 1,032
+  -----------------------------------------------------------------
+
+TABLE II
+
+SEASONAL DISTRIBUTION OF FOOD POISONING CASES, 1914-15 (GROUP, FAMILY,
+AND INDIVIDUAL)
+
+  ==========================================
+  January | 90 ||May   | 63 ||September| 76
+  February| 66 ||June  |108 ||October  | 96
+  March   | 75 ||July  | 99 ||November | 96
+  April   | 79 ||August| 96 ||December | 88
+  ------------------------------------------
+
+There is no very striking seasonal incidence apparent in the figures
+here gathered (Table II). The warmer months seem to have a slight
+preponderance of cases, but general conclusions from such data are
+hardly warranted.
+
+
+VARIOUS KINDS OF FOOD POISONING
+
+Cases of poisoning by articles of food may be distinguished as: (1)
+those caused by some injurious constituent in the food itself, and (2)
+those caused by a peculiar condition of the individual consuming the
+food, by virtue of which essentially wholesome food substances are
+capable of producing physiological disturbance in certain individuals.
+The latter group includes persons, apparently normal in other respects,
+who are more or less injuriously affected by some particular article of
+diet, such as eggs or milk, which is eaten with impunity by all normal
+individuals. This is the so-called food sensitization or food allergy.
+
+Food poisoning, as more commonly understood, is due to the composition,
+contents, or contamination of the food itself. It is not within the
+scope of this book to consider any of those cases in which definite
+poisonous substances are added to food with criminal intent. The term
+food poisoning is here taken to include the occasional cases of
+poisoning from organic poisons present in normal animal or plant
+tissues, the more or less injurious consequences following the
+consumption of food into which formed mineral or organic poisons have
+been introduced by accident or with intent to improve appearances or
+keeping quality, the cases of infection due to the swallowing of
+bacteria and other parasites which infest or contaminate certain foods,
+and the poisoning due to deleterious substances produced in food by the
+growth of bacteria, molds, and similar organisms. As already pointed
+out, little is known about the relative frequency of occurrence of these
+different causes or the extent to which they are separately and
+collectively operative.
+
+
+THE ARTICLES OF FOOD MOST COMMONLY CONNECTED WITH FOOD POISONING
+
+In addition to the definitely poisonous plants or animals, certain
+everyday articles of food have been frequently associated with the more
+serious outbreaks of food poisoning. Meat in particular has been
+implicated so often that the term meat poisoning is used about as
+commonly as the term food poisoning in general discussions of this
+subject. Certain it is that the great majority of the best-studied and
+most severe outbreaks of food poisoning have been attributed on good
+grounds to the use of meat or meat products. Other animal foods, and
+especially milk and its derivatives, cheese and ice-cream, have likewise
+been held responsible for extensive and notable outbreaks.
+
+Perhaps the most significant feature of food poisoning attacks is the
+frequency with which they have been traced to the use of raw or
+imperfectly cooked food. The probable interpretation of this fact will
+be discussed in the later chapters. Especially have the use of uncooked
+milk, either by itself or mixed with other food substances, and the
+eating of raw sausage brought in their train symptoms of poisoning in a
+disproportionately large number of cases.
+
+Canned goods of various sorts have likewise been repeatedly accused of
+causing injurious effects, but the evidence adduced is not always
+convincing. The actual degree of danger from this source is far from
+being determined. The National Canners Association publishes in the
+annual report of the secretary a brief list of "libels on the industry"
+or instances in which canned foods of various sorts were regarded as the
+cause of illness. The 1916 report contains fifty-one cases of this
+character, none of which was considered by the investigator of the
+Association to be based on sound evidence. A still more searching
+investigation of all such cases would seem to be desirable, not with a
+view to incriminating or exculpating any particular product, but simply
+for the purpose of ascertaining and placing on record all the facts.
+
+
+FOOTNOTES:
+
+[1] Tables A and B show that the "expectation of life" for adults of
+forty years and over is shorter in New York City now than it was thirty
+years ago (Table A), and that this increase in the death-rate in the
+higher-age groups is manifested in recent years in a wide area in this
+country (Table B). This increased mortality is due chiefly to diseases
+of the heart, arteries, and kidneys, and to cancer.
+
+TABLE A[1a]
+
+APPROXIMATE LIFE TABLE, TRIENNA 1879-81 AND 1909-11, BASED ON NEW YORK
+CITY STATISTICS
+
+  ==================================================
+          |Expectation|Expectation|   Gain (+) or
+          |  of Life, |  of Life, |Loss (-) in Years
+     Ages |  1879-81  |  1909-11  |  of Expectancy
+  --------+-----------+-----------+-----------------
+  Under 5 |   41.3    |   51.9    |      +10.6
+        5 |   46.3    |   51.1    |      + 4.8
+       10 |   43.8    |   46.9    |      + 3.1
+       15 |   39.7    |   42.5    |      + 2.8
+       20 |   35.8    |   38.3    |      + 2.5
+       25 |   32.6    |   34.3    |      + 1.7
+       30 |   29.6    |   30.5    |      + 0.9
+       35 |   26.7    |   26.9    |      + 0.2
+       40 |   23.0    |   23.4    |      - 0.5
+       45 |   21.1    |   20.0    |      - 1.1
+       50 |   18.3    |   16.8    |      - 1.5
+       55 |   15.4    |   13.9    |      - 1.5
+       60 |   13.0    |   11.3    |      - 1.7
+       65 |   10.5    |    9.1    |      - 1.4
+       70 |    8.9    |    7.2    |      - 1.7
+       75 |    7.3    |    5.5    |      - 1.8
+       80 |    6.4    |    4.3    |      - 2.1
+       85 |    5.5    |    2.2    |      - 3.3
+  Balance |           |           |      +26.6
+          |           |           |      -16.6
+          |           |           |-----------------
+          |           |           |      +10.0
+  --------------------------------------------------
+
+TABLE B[1b]
+
+COMPARISON OF MORTALITY OF MALES AND FEMALES, BY AGE GROUPS. DEATH-RATES
+PER 1,000 POPULATION (REGISTRATION STATES AS CONSTITUTED IN 1900)
+
+  ============================================================
+  Ages        |   Males   |Percentage |  Females  |Percentage
+              |-----------|Increase or|-----------|Increase or
+              | 1900| 1911| Decrease  | 1900| 1911| Decrease
+  ------------+-----+-----+-----------+-----------------------
+  Under 5     | 54.2| 39.8|   -26.27  | 45.8| 33.3|   -27.29
+      5-9     |  4.7|  3.4|   -27.66  |  4.6|  3.1|   -32.61
+    10-14     |  2.9|  2.4|   -17.24  |  3.1|  2.1|   -32.26
+    15-19     |  4.9|  3.7|   -24.49  |  4.8|  3.3|   -31.25
+    20-24     |  7.0|  5.3|   -24.29  |  6.7|  4.7|   -29.85
+    25-34     |  8.3|  6.7|   -19.28  |  8.2|  6.0|   -26.83
+    35-44     | 10.8| 10.4|    -3.70  |  9.8|  8.3|   -15.31
+    45-54     | 15.8| 16.1|    +1.90  | 14.2| 12.9|    -9.15
+    55-64     | 28.9| 30.9|    +6.92  | 25.8| 26.8|    +0.78
+    65-74     | 59.6| 61.6|    +3.36  | 53.8| 55.1|    +2.42
+   75 and over|146.1|147.4|    +0.89  |139.5|139.2|    +0.22
+   All ages   | 17.6| 15.8|   -10.23  | 16.5| 14.0|   -15.15
+  ------------------------------------------------------------
+
+[1a] _Monthly Bull., Dept. of Health, City of New York_, III (1913),
+113.
+
+[1b] Dublin, _Amer. Jour. Public Health_, III (1915), 1262.
+
+
+
+
+CHAPTER II
+
+SENSITIZATION TO PROTEIN FOODS
+
+
+The first introduction under the skin of a guinea-pig of a minute
+quantity of egg-white or other apparently harmless protein substance is
+itself without visible injurious effect, but if this is followed by a
+second injection of the same substance after an interval of about ten
+days, the animal will die in a few minutes with symptoms of violent
+poisoning. Whatever be the physiological explanation of the remarkable
+change that thus results from the incorporation of foreign protein into
+the body, there can be no doubt that the phenomenon known as protein
+sensitization or anaphylaxis is relatively common.[2] Sensitization to
+proteins came to light in the first instance through the study of
+therapeutic sera, and has been found to have unexpectedly wide bearings.
+It is now known that not only the rash and other symptoms which
+sometimes follow the administration of horse serum containing diphtheria
+antitoxin, but the reaction to tuberculin and similar accompaniments of
+bacterial infection, are probably to be explained on the principle of
+anaphylactic change. The sensitiveness of certain individuals to the
+pollen of particular plants (hay fever) is also regarded as a typical
+instance of anaphylaxis, accompanied as it is by asthma and other
+characteristic manifestations of the anaphylactic condition.
+
+Among the reactions usually classed as anaphylactic are the occasional
+cases of sensitivity to particular food substances. It is a familiar
+fact that certain foods that can be eaten with impunity by most persons
+prove more or less acutely poisonous for others. Strawberries and some
+other fruits and some kinds of shellfish are among the articles of food
+more commonly implicated. Unpleasant reactions to the use of eggs and of
+cow's milk are also noted. The severity of the attacks may vary from a
+slight rash to violent gastro-intestinal, circulatory, and nervous
+disturbances.
+
+Coues[3] has described a rather typical case in a child twenty-one
+months old and apparently healthy except for some eczema. When the child
+was slightly over a year old egg-white was given to it, and nausea and
+vomiting immediately followed. About eight months later another feeding
+with egg-white was followed by sneezing and all the symptoms of an acute
+coryza. Extensive urticaria covering most of the body also appeared, and
+the eyelids became edematous. The temperature remained normal and there
+was no marked prostration. The symptoms of such attacks vary
+considerably in different individuals, but usually include pronounced
+urticaria along with nausea, vomiting, and diarrhea. The rapidity with
+which the symptoms appear after eating is highly characteristic.
+Schloss[4] has reported a case of an eight-year-old boy who evinced
+marked sensitiveness to eggs, almonds, and oatmeal. Experiments in this
+instance showed that a reaction was produced only by the proteins of
+these several foods, and that extracts and preparations free from
+protein were entirely inert. It was further found that by injection of
+the patient's blood serum guinea-pigs could be passively sensitized
+against the substances in question, thus showing the condition to be one
+of real anaphylaxis.
+
+Idiosyncrasy to cow's milk which is observed sometimes in infants is an
+anaphylactic phenomenon.[5] The substitution of goat's milk for cow's
+milk has been followed by favorable results in such cases.
+
+In very troublesome cases of protein idiosyncrasy a method of treatment
+based on animal experimentation has been advocated. This consists in the
+production of a condition of "anti-anaphylaxis" by systematic feeding of
+minute doses of the specific protein substance concerned.[6] S. R.
+Miller[7] describes the case of a child in whom a constitutional
+reaction followed the administration of one teaspoonful of a mixture
+composed of one pint of water plus one drop of egg-white, while a like
+amount of albumen diluted with one quart of water was tolerated
+perfectly. "Commencing with the dilution which failed to produce a
+reaction, the child was given gradually increasing amounts of solutions
+of increasing strength. The dosage was always one teaspoonful given
+three times during the day; the result has been that, in a period of
+about three months, the child has been desensitized to such an extent
+that one dram of pure egg-white is now taken with impunity."
+
+Many other instances of anaphylaxis to egg albumen are on record.[8] In
+some of these cases the amount of the specific protein that suffices to
+produce the reaction is exceedingly small. One physician writes of a
+patient who "was unable to take the smallest amount of egg in any form.
+If a spoon was used to beat eggs and then to stir his coffee, he became
+very much nauseated and vomited violently."[9]
+
+The dependence of many cases of "asthma" upon particular foods is an
+established fact. Various skin rashes and eruptions are likewise
+associated with sensitization to certain foods.[10] McBride and
+Schorer[11] consider that each particular kind of food (as tomatoes or
+cereals) produces a constant and characteristic set of symptoms.
+Possibly certain definitely characterized skin diseases are due to this
+form of food poisoning. Blackfan[12] found that of forty-three patients
+without eczema only one showed any evidence of susceptibility to protein
+by cutaneous and intracutaneous tests, while of twenty-seven patients
+with eczema twenty-two gave evidence of susceptibility to proteins.
+
+
+FOOTNOTES:
+
+[2] General agreement respecting the true physiological and chemical
+nature of anaphylactic phenomena has not yet been reached. For a
+discussion of the theories of anaphylaxis, see in Hans Zinsser,
+_Infection and Resistance_ (New York, 1914), chaps. xv-xviii; also
+Doerr, "Allergie und Anaphylaxis," in Kolle and Wassermann, _Handbuch_,
+2d edition, 1913, II, 947.
+
+[3] _Boston Med. and Surg. Jour._, CLXVII (1912), 216.
+
+[4] _Amer. Jour. Obstet._ (New York), LXV (1912), 731.
+
+[5] F. B. Talbot, _Boston Med. and Surg. Jour._, CLXXV (1916), 409.
+
+[6] See, for example, Schloss, _loc. cit._
+
+[7] _Johns Hopkins Hosp. Bull._, XXV (1914), 78.
+
+[8] See, for example, K. Koessler, _Ill. Med. Jour._, XXIII (1913), 66;
+Bronfenbrenner, Andrews, and Scott, _Jour. Amer. Med. Assoc._, LXIV
+(1915), 1306; F. B. Talbot, _Boston Med. and Surg. Jour._, CLXXI (1914),
+708.
+
+[9] _Jour. Amer. Med. Assoc._, LXV (1915), 1837.
+
+[10] Strickler and Goldberg, _Jour. Amer. Med. Assoc._, LXVI (1916),
+249.
+
+[11] _Jour. Cutaneous Dis._, XXXIV (1916), 70.
+
+[12] _Amer. Jour. Dis. of Children_, XI (1916), 441.
+
+
+
+
+CHAPTER III
+
+POISONOUS PLANTS AND ANIMALS
+
+
+Some normal plant and animal tissues contain substances poisonous to man
+and are occasionally eaten by mistake for wholesome foods.
+
+
+POISONOUS PLANTS
+
+Poisonous plants have sometimes figured conspicuously in human affairs.
+Every reader of ancient history knows how Socrates "drank the hemlock,"
+and how crafty imperial murderers were likely to substitute poisonous
+mushrooms for edible ones in the dishes prepared for guests who were out
+of favor. In our own times the eating of poisonous plants is generally
+an accident, and poisoning from this cause occurs chiefly among the
+young and the ignorant.
+
+According to Chesnut[13] there are 16,673 leaf-bearing plants included
+in Heller's _Catalogue of North American Plants_, and of these nearly
+five hundred, in one way or another, have been alleged to be poisonous.
+Some of these are relatively rare or for other reasons are not likely to
+be eaten by man or beast; others contain a poison only in some
+particular part, or are poisonous only at certain seasons of the year;
+in some the poison is not dangerous when taken by the mouth, but only
+when brought in contact with the skin or injected beneath the skin or
+into the circulation. There are great differences in individual
+susceptibility to some of these plant poisons. One familiar plant, the
+so-called poison-ivy, is not harmful for many people even when handled
+recklessly; it can be eaten with impunity by most domestic animals.
+
+The actual number of poisonous plants likely to be inadvertently eaten
+by human beings is not large. Chesnut[14] has enumerated about thirty
+important poisonous plants occurring in the United States, and some of
+these are not known to be poisonous except for domestic animals.[15]
+Many of the cases of reported poisoning in man belong to the class of
+exceedingly rare accidents and are without much significance in the
+present discussion. Such are the use of the leaves of the American false
+hellebore (_Veratrum viride_) in mistake for those of the
+marsh-marigold[16], the use of the fruit pulp of the Kentucky coffee
+tree (_Gymnocladus dioica_) in mistake for that of the honey-locust[17],
+the accidental employment of daffodil bulbs for food, and the confusion
+by children of the young shoots of the broad-leaf laurel (_Kalmia
+latifolia_) with the wintergreen.[18] One of the most serious
+instances of poisoning of this sort is that from the use of the
+spindle-shaped roots of the deadly water hemlock (_Cicuta maculata_)
+allied to the more famous but no more deadly poison hemlock. These
+underground portions of the plant are sometimes exposed to view by
+washing out or freezing, and are mistaken by children for horseradish,
+artichokes, parsnips, and other edible roots. Poisoning with water
+hemlock undoubtedly occurs more frequently than shown by any record.
+Eight cases and two deaths from this cause are known to have occurred in
+one year in the state of New Jersey alone.
+
+[Illustration: FIG. 1.--_Conium maculatum._ The fresh juice of _Conium
+maculatum_ was used in the preparation of the famous hemlock potion
+which was employed by the Greeks in putting their criminals to death.
+(From _Applied and Economic Botany_, by courtesy of Professor Kraemer
+[after Holm].)]
+
+An instance of food poisoning to be included under this head is the
+outbreak in Hamburg and some thirty other German cities in 1911 due to
+the use of a poisonous vegetable fat in preparing a commercial butter
+substitute.[19] In the attempt to cheapen as far as possible the
+preparation of margarin various plant oils have been added by the
+manufacturers. In the Hamburg outbreak, in which over two hundred cases
+of illness occurred, poisoning was apparently due to substitution of
+so-called maratti-oil, derived from a tropical plant (_Hydrocarpus_).
+This fat is said to be identical with oil of cardamom, and its toxic
+character in the amounts used in the margarin was proved by animal
+experiment. Increasing economic pressure for cheap foods may lead to the
+recurrence of such accidents unless proper precautions are used in
+testing out new fats and other untried substances intended for use in
+the preparation of food substances.[20]
+
+[Illustration: FIG. 2.--_Cicuta maculata_ (water hemlock); _A_, upper
+part of stem with leaves and compound umbels; _B_, base of stem and
+thick tuberous roots; _C_, cross-section of stem; _D_, flower; _E_,
+fruit; _F_, fruit in longitudinal section; _G_, cross-section of a
+mericarp. (From _Applied and Economic Botany_, by courtesy of Professor
+Kraemer [after Holm].)]
+
+Investigators from the New York City Health Department have found that
+certain cases of alleged "ptomain poisoning" were really due to
+"sour-grass soup."[21] This soup is prepared from the leaves of a
+species of sorrel rich in oxalic acid. In one restaurant it was found
+that the soup contained as much as ten grains of oxalic acid per pint!
+
+[Illustration: FIG. 3.--Fly Amanita (poisonous). (_Amanita muscaria_ L.)
+(After Marshall, _The Mushroom Book_, by courtesy of Doubleday, Page &
+Company.)]
+
+By far the best-known example of that form of poisoning which results
+from confounding poisonous with edible foods is that due to poisonous
+mushrooms.[22] There is reason to believe that mushroom (or "toadstool")
+intoxication in the United States has occurred with greater frequency of
+late years, partly on account of the generally increasing use of
+mushrooms as food and the consequently greater liability to mistake, and
+partly on account of the growth of immigration from the mushroom-eating
+communities of Southern Europe. Many instances have come to light in
+which immigrants have mistaken poisonous varieties in this country for
+edible ones with which they were familiar at home. In the vicinity of
+New York City there were twenty-two deaths from mushroom poisoning in
+one ten-day period (September, 1911) following heavy rains. The "fly
+_Amanita_"[23] (_Amanita muscaria_) in this country has been apparently
+often mistaken for the European variety of "royal _Amanita_" (_A.
+caesaria_).[24] Such a mistake seems to have been the cause of death
+of the Count de Vecchi in Washington, D.C., in 1897.
+
+  The Count, an attache of the Italian legation, a cultivated
+  gentleman of nearly sixty years of age, considered something of an
+  expert upon mycology, purchased, near one of the markets in
+  Washington, a quantity of fungi recognized by him as an edible
+  mushroom. The plants were collected in Virginia about seven miles
+  from the city of Washington. The following Sunday morning the count
+  and his physician, a warm personal friend, breakfasted together upon
+  these mushrooms, commenting upon their agreeable and even delicious
+  flavor. Breakfast was concluded at half after eight and within
+  fifteen minutes the count felt symptoms of serious illness. So rapid
+  was the onset that by nine o'clock he was found prostrate on his
+  bed, oppressed by the sense of impending doom. He rapidly developed
+  blindness, trismus, difficulty in swallowing, and shortly lost
+  consciousness. Terrific convulsions then supervened, so violent in
+  character as to break the bed upon which he was placed. Despite
+  rigorous treatment and the administration of morphine and atropine,
+  the count never recovered consciousness and died on the day
+  following the accident. The count's physician on returning to his
+  office was also attacked, dizziness and ocular symptoms warning him
+  of the nature of the trouble. Energetic treatment with apomorphine
+  and atropine was at once instituted by his colleagues and for a
+  period of five hours he lay in a state of coma with occasional
+  periods of lucidity. The grave symptoms were ameliorated and
+  recovery set in somewhere near seven o'clock in the evening. His
+  convalescence was uneventful, his restoration to health complete,
+  and he is, I believe, still living. On this instance the count
+  probably identified the fungi as _caesaria_ or _aurantiaca_.
+  From the symptoms and termination the species eaten must have
+  been _muscaria_.
+
+_A. muscaria_ contains an alkaloidal substance which has a
+characteristic effect upon the nerve centers and to which the name
+muscarin and the provisional chemical formula C{5}H{15}NO{3} has been
+given. The drug atropin is a more or less perfect physiological
+antidote for muscarin and has been administered with success in cases of
+muscarin poisoning. It is said that the peasants in the Caucasus are in
+the habit of preparing from the fly _Amanita_ a beverage which they use
+for producing orgies of intoxication. Deaths are stated to occur
+frequently from excessive use of this beverage.[25]
+
+The deadly _Amanita_ or death-cup (_A. phalloides_) is probably
+responsible for the majority of cases of mushroom poisoning. Ford
+estimates that from twelve to fifteen deaths occur annually in this
+country from this species alone. This fungus is usually eaten through
+sheer ignorance by persons who have gathered and eaten whatever they
+chanced to find in the woods. A few of these poisonous mushrooms mixed
+with edible varieties may be sufficient to cause the death of a family.
+Ford thus describes the symptoms of poisoning with _A. phalloides_:
+
+  Following the consumption of the fungi there is a period of six to
+  fifteen hours during which no symptoms of poisoning are shown by the
+  victims. This corresponds to the period of incubation of other
+  intoxications or infections. The first sign of trouble is sudden
+  pain of the greatest intensity localized in the abdomen, accompanied
+  by vomiting, thirst, and choleraic diarrhoea with mucous and bloody
+  stools. The latter symptom is by no means constant. The pain
+  continues in paroxysms often so severe as to cause the peculiar
+  Hippocratic facies, _la face vultueuse_ of the French, and though
+  sometimes ameliorated in character, it usually recurs with greater
+  severity. The patients rapidly lose strength and flesh, their
+  complexion assuming a peculiar yellow tone. After three to four
+  days in children and six to eight in adults the victims sink into a
+  profound coma from which they cannot be roused and death soon ends
+  the fearful and useless tragedy. Convulsions rarely if ever occur
+  and when present indicate, I am inclined to believe, a mixed
+  intoxication, specimens of _Amanita muscaria_ being eaten with the
+  _phalloides_. The majority of individuals poisoned by the "deadly
+  Amanita" die, the mortality varying from 60 to 100 per cent in
+  various accidents, but recovery is not impossible when small amounts
+  of the fungus are eaten, especially if the stomach be very promptly
+  emptied, either naturally or artificially.
+
+A number of other closely related species of _Amanita_ (e.g., _A.
+verna_, the "destroying angel," probably a small form of _A.
+phalloides_) have a poisonous action similar to that of _A. phalloides_.
+All are different from muscarin.
+
+[Illustration: FIG. 4.--Death-cup; destroying angel (_Amanita
+phalloides_ Fries); reduced; natural size: cap, 3-1/2 inches; stem,
+7-1/2 inches. (After Marshall, _The Mushroom Book_, by courtesy of
+Doubleday, Page & Company.)]
+
+The character of the poison was first carefully investigated by Kobert,
+who showed that the _Amanita_ extract has the power of laking or
+dissolving out the coloring matter from red blood corpuscles. This
+hemolytic action is so powerful that it is exerted upon the red cells of
+ox blood even in a dilution of 1:125,000. Ford[26] has since shown that
+in addition to the hemolytic substance another substance much more toxic
+is present in this species of _Amanita_ and he concludes that the
+poisonous effect of the fungus is primarily due to the latter
+("_Amanita_ toxin"). The juice of the cooked _Amanita_ is devoid of
+hemolytic power, but is poisonous for animals in small doses, a fact
+that agrees with the observation that these mushrooms, after cooking,
+remain intensely poisonous for man. Extensive fatty degeneration in
+liver, kidney, and heart muscle is produced by the true _Amanita_ toxin.
+In the Baltimore cases studied by Clark, Marshall, and Rowntree[27]
+the kidney rather than the liver was the seat of the most interesting
+functional changes. These authors conclude that the nervous and mental
+symptoms, instead of being due to some peculiar "neurotoxin," are
+probably uremic in character. No successful method of treatment is
+known. An antibody for the hemolysin has been produced, but an antitoxin
+for the other poisonous substance seems to be formed in very small
+amount. Attempts to immunize small animals with _Amanita_ toxin succeed
+only to a limited degree.[28]
+
+
+POISONOUS ANIMALS
+
+While the muscles or internal organs of many animals are not palatable
+on account of unpleasant flavor or toughness, there do not seem to be
+many instances in which normal animal tissues are poisonous when eaten.
+As pointed out elsewhere (chapter vi), the majority of outbreaks of meat
+and fish poisoning must be attributed to the presence of pathogenic
+bacteria or to poisons formed after the death of the animal. This has
+been found especially true of many of the outbreaks of poisoning
+ascribed to oysters and other shellfish; in most, if not all, cases the
+inculpated mollusks have been derived from water polluted with human
+wastes and are either infected or partially decomposed.
+
+In some animals, however, notably certain fish, the living and healthy
+organs are definitely poisonous. The family of Tetrodontidae (puffers,
+balloon-fish, globe-fish) comprises a number of poisonous species,
+including the famous Japanese _Fugu_, which has many hundred deaths
+scored against it and has been often used to effect suicide. Poisonous
+varieties of fish seem more abundant in tropical waters than in
+temperate, but this is possibly because of the more general and
+indiscriminate use of fish as food in such localities as the Japanese
+and South Sea Islands. It is known that some cool-water fish are
+poisonous. The flesh of the Greenland shark possesses poisonous
+qualities for dogs and produces a kind of intoxication in these
+animals.[29]
+
+Much uncertainty exists respecting the conditions under which the
+various forms of fish poisoning occur. One type is believed to be
+associated with the spawning season, and to be caused by a poison
+present in the reproductive tissues. The roe of the European barbel is
+said to cause frequent poisoning, not usually of a serious sort. The
+flesh or roe of the sturgeon, pike, and other fish is also stated to be
+poisonous during the spawning season. Some fish are said to be poisonous
+only when they have fed on certain marine plants.[30]
+
+There is little definite knowledge about the poisons concerned. They are
+certainly not uniform in nature. The _Fugu_ poison produces cholera-like
+symptoms, convulsions, and paralysis. It is not destroyed by boiling.
+The effect of the Greenland shark flesh on dogs is described as being
+"like alcohol." It is said that dogs fed with gradually increasing
+amounts of the poisonous shark's flesh become to some degree immune.
+Different symptoms are described in other fish poisoning cases.[31]
+
+
+FOOTNOTES:
+
+[13] _Science_, XV (1902), 1016.
+
+[14] _U.S. Dept. of Agric., Div. of Botany, Bull. 20_, 1898.
+
+[15] Among the plants that seem to be most commonly implicated in the
+poisoning of stock are the larkspur (_Delphinium._ _U.S. Dept. of
+Agric., Bull. 365_, September 8, 1916), the water hemlock (_Cicuta
+maculata_) and others of the same genus, the lupines (_U.S. Dept. of
+Agric., Bull. 405_, 1916), some of the laurels (_Kalmia_), and the Death
+_Camas_ or _Zygadenus_ (_U.S. Dept. of Agric., Bull. 125_, 1915). The
+famous loco-weed of the western United States (_U.S. Dept. of Agric.,
+Bull. 112_, 1909) is less certainly to be held responsible for all the
+ills ascribed to it (H. T. Marshall, _Johns Hopkins Hosp. Bull._, XXV
+[1914], 234).
+
+[16] Chesnut, _U.S. Dept. of Agric., Div. of Botany, Bull. 20_, 1898, p.
+17.
+
+[17] _Ibid._, p. 28.
+
+[18] _Ibid._, p. 45. The seeds of the castor-oil bean, which contain a
+very powerful poison (ricin) allied to the bacterial toxins, have been
+known to cause the death of children who ate the seeds given them to
+play with.
+
+[19] Mayer, _Deutsche Viertelj. f. oeffentl. Ges._, XLV (1913), 12.
+
+[20] Cf. an instance of palmolin poisoning, _Centralbl. f. Bakt._, I,
+Ref., LXII (1914), 210.
+
+[21] _Weekly Bull., N.Y. Dept. of Health_, September 16, 1916.
+
+[22] Seventy-three species of mushrooms known or suspected to be
+poisonous are enumerated in a bulletin of the United States Department
+of Agriculture, Patterson and Charles ("Mushrooms and Other Common
+Fungi," _Bull. 175_, 1915). This bulletin contains descriptions and
+excellent illustrations of many edible and of the commoner poisonous
+species.
+
+[23] Used in some places as a fly poison.
+
+[24] Ford, _Science_, XXX (1909), 97.
+
+[25] Another species of mushroom occurring in this country and commonly
+regarded as edible (_Panaeolus papilionaceus_) has on occasion shown
+marked intoxicating properties (A. E. Verrill, _Science_, XL (1914),
+408).
+
+[26] _Jour. Infect. Dis._, III (1906), 191.
+
+[27] _Jour. Amer. Med. Assoc._, LXIV (1915), 1230.
+
+[28] W. W. Ford, "Plant Poisons and Their Antibodies," _Centralbl. f.
+Bakt._, I Abt., Ref., LVIII (1913), 129 and 193, with full bibliography.
+
+[29] A. H. Clark, _Science_, XLI (1915), 795.
+
+[30] See W. M. Kerr, _U.S. Nav., Monthly Bull._, VI (1912), 401.
+
+[31] _Ibid._
+
+
+
+
+CHAPTER IV
+
+MINERAL OR ORGANIC POISONS ADDED TO FOOD
+
+
+Well-known mineral or organic poisons--"chemical poisons"--sometimes
+find their way into food, being either introduced accidentally in the
+process of manufacture or preparation, or being added deliberately with
+intent to improve the appearance or keeping qualities of the food.
+
+
+ARSENIC
+
+So powerful a poison as arsenic has been occasionally introduced into
+food by stupidity or carelessness. Arsenic has been found by English
+authorities to be generally present in food materials dried or roasted
+with gases arising from the combustion of coal, and in materials treated
+with sulphuric acid during the process of preparation. In both cases the
+source is the same: the iron pyrites, practically always arsenical,
+contained in the coal or used in making the sulphuric acid.
+
+A celebrated epidemic of "peripheral neuritis" in the English Midlands
+in 1900 was traced to the presence of dangerous quantities of arsenic in
+beer. About six thousand persons were affected in this outbreak and
+there were some seventy deaths. The beer coming from the suspected
+breweries had all been manufactured with the use of brewing sugars
+obtained from a single source, and these sugars were found to have been
+impregnated with arsenic by the sulphuric acid used in their
+preparation, some specimens of the acid containing as much as 2.6 per
+cent of arsenic.[32]
+
+The use of glucose, not only in beer, but as an admixture or adulterant
+in jams, syrups, candies, and the like, is open to serious objection
+unless the glucose is known to have been prepared with sulphuric acid
+freed from arsenical impurity. In fact, the use of any food material
+prepared by the aid of sulphuric acid is permissible only in case
+arsenic-free acid is employed.[33]
+
+
+ANTIMONY
+
+The cheaper grades of enameled cooking utensils in use in this country
+contain antimony, and this is dissolved out in noteworthy amounts in
+cooking various foods.[34] The rubber nipples used for infants' milk
+bottles also sometimes contain antimony.[35] Although the poisonous
+qualities of antimony are well known, there is little information about
+the toxic effect of repeated very minute doses. Recognized instances of
+chronic antimony poisoning are very rare. Further investigation is
+needed.
+
+
+LEAD
+
+The well-known poisonousness of lead and its compounds prevents, as a
+rule, the deliberate addition of lead salts to food substances, although
+it is true that lead chromate is sometimes used for imparting a yellow
+color to candy and decorating sugars.[36] Foods that are wrapped in
+foil, however, such as chocolate and soft cheese, contain traces of
+lead, as do the contents of preserve jars with metallic caps and the
+"soft drinks" vended in bottles with patent metal stoppers. Occasional
+ingestion of minute quantities of lead is probably a matter of little
+physiological importance, but since lead is a cumulative poison,
+frequent taking into the body of even very small amounts entails danger.
+Severe lead poisoning has been known to result from the habitual use of
+acid beverages contained in bottles with lead stoppers. Investigations
+made to determine the possible danger of poisoning from lead taken up
+from glazed and earthenware cooking utensils indicate that injury from
+this source is unlikely. The enameled ware in common use in this country
+is lead-free.
+
+Objection on the ground of possible contamination has been raised to the
+use of solder for sealing food cans. Such objections have less weight
+than formerly owing to changes in the construction of the container, so
+that any contact of solder with the food is now minimized and to a large
+extent done away with altogether.
+
+In consequence of the fact that many natural waters attack lead, the use
+of lead service pipes for wells, cisterns, and public water supplies has
+given rise to numerous outbreaks of lead poisoning. It is now generally
+recognized that water intended for drinking purposes should not be drawn
+through lead pipes.
+
+A special liability to take lead into the stomach exists in persons
+working at the painters' trade and other occupations involving contact
+with lead and its salts. It has been shown that the eating of food
+handled with paint-smeared hands brings about the ingestion of
+considerable quantities of lead and, when long continued, results in
+lead poisoning. The risk of contaminating food with lead in this way can
+be greatly lessened by thorough cleansing of the hands with soap and hot
+water before eating.[37]
+
+
+TIN
+
+Special interest has attached to the possibility of tin poisoning on
+account of the widespread use of canned foods.[38] It is established
+chemically that tin is attacked, not only by acid fruits and berries,
+but by some vegetables having only a slightly acid reaction. More tin is
+found in the drained solids than in the liquor, and the metal is largely
+in an insoluble form.[39] It has been the general opinion based on
+experiments by Lehmann[40] and others that the amounts of tin ordinarily
+present in canned foods "are undeserving of serious notice," and this
+view has found expression in the leading textbooks on hygiene.[41]
+Certainly there has not been any noticeable amount of tin poisoning
+observed coincident with the enormous increase in the use of canned
+foods. An instance of poisoning by canned asparagus observed by
+Friedmann,[42] however, is attributed by him to the tin content, and
+this view is rendered probable by the negative result of his
+bacteriological and serological examinations. Canned asparagus
+apparently contains an unusually large amount of soluble tin
+compounds.[43] There seems some ground for the assumption that certain
+individuals are especially susceptible to small quantities of tin and
+that the relative infrequency of such cases as that cited by Friedmann
+can be best explained in this way. Lacquered or "enamel-lined" cans are
+being used to an increasing extent for fruits and vegetables that are
+especially likely to attack tin.[44]
+
+Intentional addition of tin salts to food substances does not appear to
+be common, although protochloride of tin is said sometimes to be added
+to molasses for the purpose of reducing the color. The chlorides are
+regarded as more definitely poisonous than other compounds of tin, and
+for this and other reasons the practice is undesirable. Sanitarians
+insist that chemical substances likely to be irritating to the human
+tissues in assimilation or elimination should not be employed in food.
+Each new irritant, even in small quantity, may add to the burden of
+organs already weakened by age or previous harsh treatment.
+
+
+COPPER
+
+Danger is popularly supposed to attend the cooking and especially the
+long standing of certain foods in copper vessels on account of the
+verdigris or copper acetate that is sometimes formed, but Professor
+Long, of the Referee Board of Consulting Scientific Experts,[45] points
+out that this substance is far less toxic than it was once imagined to
+be, and he considers it likely that the cases of illness attributed to
+"verdigris poisoning" reported in the older literature should have been
+explained in some other way.
+
+The use of copper sulphate for imparting a green color to certain
+vegetables, such as peas, beans, and asparagus, is a relatively modern
+practice, having been started in France about 1850. Since the natural
+green of vegetables is in part destroyed or altered by heat, restoration
+of the color has appealed to the color sense of some consumers. It must
+be admitted that this aesthetic gratification is fraught with some
+degree of danger to health. The experiments by Long show that copper is
+absorbed and retained in certain tissues, and that even small amounts
+ingested at brief intervals may have a deleterious action. He concludes
+that the use of copper salts for coloring foods must be considered as
+highly objectionable. The United States Government now prohibits the
+importation of foods colored with copper and also the interstate trade
+in these substances.
+
+
+VARIOUS COLORING SUBSTANCES
+
+Copper sulphate is but one of a host of chemical substances applied to
+various foods for the purpose of altering the color which the foods
+would otherwise possess. In some cases perhaps it may be the general
+opinion that by special treatment the attractiveness of a food product
+is increased, as when dark-colored flour is bleached white with
+nitrogen peroxide, but in many instances the modification of color is
+based on preposterously artificial standards. The use of poisonous
+aniline dyes for staining candies all the colors of the rainbow must be
+defended, if at all, on aesthetic rather than on sanitary grounds. Some
+coloring matters in common use, such as the annatto, universally
+employed in coloring butter, are believed to be without harmful effect,
+but others are to be viewed with suspicion, and still others, like
+copper sulphate, are unquestionably dangerous. The whole practice of
+food coloration at its best involves waste and may entail serious danger
+to health. Broadly speaking, all modification of the natural color of
+foodstuffs is based on an idle convention and should be prohibited in
+the interest of the public welfare. Bleached flour, stained butter, dyed
+jelly and ice-cream are no whit more desirable as foods than the natural
+untreated substances; in fact, they are essentially less desirable. If
+the whole process of food coloration were known to the public,
+artificially colored foods would not be especially appetizing.
+Economically the practice is singularly futile. The artificial whitening
+of flour with the highly poisonous nitrogen peroxide seems hardly worth
+the extra tax of fifty cents to a dollar a barrel. Such bleaching with a
+poisonous gas certainly does not improve the nutritive or digestive
+qualities of flour; it may be insidiously injurious. The solution of the
+problem of food coloration seems to lie in a policy of educational
+enlightenment which shall make natural foods appear more desirable than
+those sold under false colors. Custom, however, buttressed by skilful
+advertising, offers a difficult barrier to reform in this field.
+
+
+FOOD PRESERVATIVES
+
+It is not only legitimate, but in every way most desirable, to keep food
+over from a season of superabundance to a season of scarcity. From time
+immemorial food has been preserved by drying, smoking, or salting, and,
+in modern times, by refrigeration and by heat (canning). These latter
+methods have come to play a large part in the food habits of civilized
+communities. Since food spoils because of microbic action, all methods
+of preservation are based upon the destruction of the microbes or the
+restraint of their growth by various physical and chemical agencies. The
+use of certain chemical preservatives such as strong sugar and salt
+solutions, saltpeter brines, and acid pickles has long been known and
+countenanced. In recent times the employment of chemical preservatives
+has acquired a new aspect through the increasing tendency of
+manufacturers to add to food products antiseptic chemicals in wide
+variety and of dubious physiological effect.
+
+It is not so easy and simple as it might appear to declare that no
+substance that is poisonous shall be added to food. The scientific
+conception of a poison is one involving the amount as well as the kind
+of substance. Common salt itself is poisonous in large doses, but, as
+everyone knows, small amounts are not only not injurious, but absolutely
+necessary to health. Well-known and very powerful protoplasmic poisons
+such as strychnine and quinine are frequently administered in minute
+doses for medicinal purposes, without causing serious results.
+
+How complicated the question of using food preservatives really is
+appears in the case of smoked meats and fish, which owe their keeping
+qualities to the creosote and other substances with which they are
+impregnated by the smoke. Although these substances are much more highly
+poisonous than chemical preservatives like benzoic acid, over which much
+concern has been expressed, but little if any objection has been made to
+the use of smoked foods.
+
+The use of benzoic acid (benzoate of soda) as a food preservative
+illustrates several phases of the controversy. Observations by Wiley in
+1908 upon so-called "poison squads" were thought by him to indicate that
+benzoate of soda administered with food led to "a very serious
+disturbance of the metabolic functions, attended with injury to
+digestion and health." On the other hand, the experiments of the Referee
+Board of Scientific Experts (1909), conducted with at least equal care
+and thoroughness, were considered to warrant the conclusions that:
+
+  (1) Sodium benzoate in small doses (under five-tenths of a gram per
+  day) mixed with the food is without deleterious or poisonous action
+  and is not injurious to health. (2) Sodium benzoate in large doses
+  (up to four grams per day) mixed with the food has not been found to
+  exert any deleterious effect on the general health, nor to act as a
+  poison in the general acceptance of the term. In some directions
+  there were slight modifications in certain physiological processes,
+  the exact significance of which modification is not known. (3) The
+  admixture of sodium benzoate with food in small or large doses has
+  not been found to injuriously affect or impair the quality or
+  nutritive value of such food.
+
+Still later experiments under the auspices of the German government
+(1913) showed that in the case of dogs and rabbits relatively large
+doses of benzoic acid (corresponding to sixty to one hundred grams per
+day for a man weighing one hundred and fifty pounds) were necessary in
+order to produce demonstrable effects of any kind. This finding may be
+considered to confirm in a general way the finding of the Referee Board
+that four grams per day is harmless.
+
+Probably the evidence respecting the effect of benzoic acids and the
+benzoates when used as food preservatives constitutes as favorable a
+case as can be made out at the present time for the employment of any
+chemical substance. Benzoic acid is present in noteworthy amounts in
+many fruits and berries, especially cranberries, and its presence in
+these natural foods has never been connected with any injurious action.
+In point of fact, substances present in many ordinary foodstuffs are
+converted within the human body first into benzoic acid and then into
+hippuric acid. Folin's masterly summing up is worth quoting:
+
+  We know that the human organism is prepared to take care of and
+  render harmless those small quantities of benzoic acid and benzoic
+  acid compounds which occur in food products or which are formed
+  within the body; we know how this is accomplished and are reasonably
+  sure as to the particular organ which does it. We also know that the
+  mechanism by means of which the poisonous benzoic acid is converted
+  into the harmless hippuric acid is an extremely efficient one, and
+  that it is capable of taking care of relatively enormous quantities
+  of benzoic acid. In this case, as in a great many others, the normal
+  animal organism is abundantly capable of performing the function
+  which it must regularly perform in order to survive. From this point
+  of view it can be argued, and it has been argued with considerable
+  force, that the human organism is abundantly capable of rendering
+  harmless reasonable amounts of benzoic acid or benzoate which are
+  added for purposes of preservation to certain articles of our food.
+  In my opinion this point of view is going to prevail, and the strife
+  will resolve itself into a controversy over how much benzoic acid
+  shall be permitted to go into our daily food.
+
+  But we ought to be exceedingly cautious about accepting any definite
+  figure, certainly any large figure, as representing the permissible
+  amount of added benzoic acid in our food. The very fact that we are
+  in possession of an efficient process for converting poisonous
+  benzoic acid into harmless hippuric acid indicates that there is a
+  necessity for doing so. It suggests that even the small quantities
+  of benzoic acid which we get with unadulterated food, or produce
+  within ourselves, might be deleterious to health except for the
+  saving hippuric acid forming process. And because that "factor of
+  safety" is a large one with respect to the normal benzoic acid
+  content of our food it does not follow that we can encroach on it
+  with perfect impunity. What the effect of a general, regular
+  encroachment on it would be cannot be determined by a few relatively
+  short feeding experiments. It is known that while certain chemicals
+  may be taken in substantial quantities for a month or a year without
+  producing demonstrably injurious effects, nevertheless the continued
+  use of the same substances, even in smaller quantities, will
+  eventually undermine the health. Perhaps the final solution of the
+  benzoic acid problem could be best obtained directly from the people
+  at large. If they were to consume benzoic acid as knowingly as they
+  consume, for example, sodic carbonate in soda biscuits, or caffeine
+  and theobromine in coffee and tea, it would not require more than a
+  decade or two before we should have a well-defined and well-founded
+  public opinion on the subject, at least in the medical
+  profession.[46]
+
+With respect to other familiar and more or less poisonous substances
+used to preserve foods, defense of their harmlessness is far more
+difficult. Formaldehyde, salicylic acid, sulphurous acid, and sulphite
+are compounds definitely poisonous in relatively small amounts, their
+injurious action in minute successive doses in animal experiments is
+quite marked, and their use in human food products practically without
+justification. Boric acid and borax are perhaps on a slightly different
+footing, but are never present in natural foods, and there is no good
+evidence that their long-continued ingestion in small doses is without
+injurious effect. It must not be forgotten that all such substances owe
+their preservative or antiseptic power to the poisonous effect they have
+upon bacterial protoplasm. It is fair to assume that, in general,
+bacterial protoplasm is no more easily injured than human protoplasm,
+and this raises at once the propriety of bringing into repeated contact
+with human tissues substances likely to produce injury even if such
+injury is slight and recovery from it is ordinarily easy. In every case
+the burden of proof should be properly placed on those who advocate the
+addition of bacterial-restraining substances to food intended for human
+consumption. It is for them to show that substances powerful enough to
+hold in check the development of bacteria are yet unable to interfere
+seriously with the life-processes of the cells of the human body.
+
+When this view of the situation is taken, not only the chemical
+substances mentioned previously fall under some suspicion, but also
+certain household preservatives long sanctioned by custom. Spices such
+as cinnamon, oil of cloves, and the like are, so far as we know, as
+likely to have an injurious physiological effect when taken in small
+recurring quantities as are some of the "chemical" preservatives whose
+use is debarred by law. The chemicals deposited by wood smoke in meat
+are of a particularly objectionable nature, and their continuous
+ingestion may quite conceivably lead to serious injury.
+
+One fact persistently comes to the front in any comprehensive study of
+the food-preservative question, namely, the need of further experiment
+and observation. We do not at present know what effect is produced in
+human beings of different ages and varying degrees of strength by the
+_long-continued_ consumption of food preserved with particular
+chemicals.
+
+  There is, I think, only one way to get at the facts with regard to
+  the various chemicals which have been used for the preservation of
+  foods, and that is by trying them and keeping track of the results.
+  To try them properly, on a sufficiently extensive scale and for a
+  sufficiently long time, is, however, more of a task than can be
+  undertaken by private investigators; for it is only by their
+  continuous use for many years under competent supervision and
+  control that we can hope to attain adequate information for final
+  conclusions. Work of this sort should be done and could very well be
+  done at large government institutions, as, for example, among
+  certain classes of prison inmates. I do not know how many life
+  prisoners or long-term prisoners may be available, but there must be
+  an abundance of them. They would make better subjects than students
+  on whom to try out a substance like boric acid. This, not because
+  they are prisoners whose fate or health is of comparatively little
+  consequence, but because they represent a body of persons whose mode
+  of life is essentially uniform and whose health record could easily
+  be kept for a long period of years. I am well aware that this
+  suggestion will impress many persons as heartless and brutal, but
+  such an experiment would be a mild and humane one when compared with
+  the unrecorded boric acid experiments which have been made by
+  manufacturers on all kinds and conditions of people. Prisoners are
+  unfortunate in not being able to render any useful service to
+  society. Probably not a few would be willing to co-operate in
+  prolonged feeding experiments, similar to the short ones conducted
+  by Dr. Wiley and by the Referee Board. Acceptable reward in the way
+  of well-prepared food of sufficient variety would attract
+  volunteers. If additional inducement were necessary, shortened term
+  of service would probably appeal to many. And in the face of the
+  fact that every civilized country is prepared to sacrifice thousands
+  of its most virile citizens for the honor of its flag (and its
+  foreign trade), the sentiment against endangering the health of a
+  handful of men in the interest of all mankind is not particularly
+  intelligent.[47]
+
+Until such information is forthcoming we do well to err on the side of
+caution. The desirability of adopting this attitude is especially borne
+in upon us by the facts already instanced (pp. 2-4) concerning the
+increased death-rates in the higher-age groups in this country. For
+aught we now know to the contrary, the relatively high death-rates from
+degenerative changes in the kidneys, blood vessels, and other organs may
+be in part caused by the use of irritating chemical substances in food.
+Although no one chemical by itself and in the quantities in which it is
+commonly present in food can perhaps be reasonably accused of producing
+serious and permanent injury, yet when to its effect is superadded the
+effect of still other poisonous ingredients in spiced, smoked, and
+preserved foods of all kinds the total burden laid upon the excretory
+and other organs may be distinctly too great. There can be no escape
+from the conclusion that the more extensive and widespread the use of
+preservatives in food the greater the likelihood of injurious
+consequences to the public health.
+
+The use of spoiled or decomposed food falls under the same head. It
+cannot be assumed that the irritating substances produced in food by
+certain kinds of decomposition can be continually consumed with
+impunity. We do not even know whether these decomposition products may
+not be more fundamentally injurious than preservatives that might be
+added to prevent decomposition!
+
+So far as our present knowledge indicates, therefore, effort should be
+directed (1) to the purveying of food as far as possible in a fresh
+condition; (2) to the avoidance of chemical preservatives of all kinds
+except those unequivocally demonstrated to be harmless. The methods of
+preserving food by drying, by refrigeration, and by heating and sealing
+are justified by experience as well as on theoretical grounds, and the
+same statement can be made regarding the use of salt and sugar
+solutions. But the use of sulphites in sausage and chopped meat, the
+addition of formaldehyde to milk, and of boric acid or sodium fluoride
+to butter are practices altogether objectionable from the standpoint of
+public health.
+
+The remedy is obvious and has been frequently suggested--namely, laws
+prohibiting the addition of any chemical to food except in certain
+definitely specified cases. The presumption then would be--as in truth
+it is--that such chemicals are more or less dangerous, and proof of
+innocuousness must be brought forward before any one substance can be
+listed as an exception to the general rule. Such laws would include not
+only the use of chemicals or preservatives, but the employment of
+substances to "improve the appearance" of foodstuffs. As already pointed
+out, the childish practice of artificially coloring foods involves waste
+and sometimes danger. It rests on no deep-seated human need; food that
+is natural and untampered with may be made the fashion just as easily as
+the color and cut of clothing are altered by the fashion-monger. The
+incorporation of any chemical substance into food for preservative or
+cosmetic purposes could wisely be subject to a general prohibition, and
+the necessary list of exceptions (substances such as sugar and salt)
+should be passed on by a national board of experts or by some
+authoritative organization like the American Public Health Association.
+
+
+FOOD SUBSTITUTES
+
+On grounds of economy or convenience familiar and natural articles of
+food are sometimes replaced or supplemented by artificial chemical
+products, or by substances whose food value is not so definitely
+established. I need refer only briefly to those notorious instances of
+adulteration in which chicory is added to coffee, or ground olive stones
+to pepper, or glucose to candy. On hygienic grounds alone some such
+practices are not open to criticism, however fraudulent they may be from
+the standpoint of public morals. It might be argued with some
+plausibility that chicory is not so likely to harm the human organism as
+caffeine and that sprinklings of ground cocoanut shell are more
+wholesome than pepper. But there is another group of cases in which the
+artificial substitute is strictly objectionable. The use of the coal-tar
+product saccharin for sweetening purposes is an example. This substance,
+whose sweetening power is five hundred times as great as that of cane
+sugar, has no nutritive value in the quantities in which it would be
+consumed, and in not very large quantities (over 0.3 gram per day) is
+likely to induce disturbance of digestion. As a substitute for sugar in
+ordinary foodstuffs it is undesirable.[48]
+
+The use of cheap chemically prepared flavors such as "fruit ethers" in
+"soft drinks," fruit syrups, and the like in place of the more expensive
+natural fruit extracts affords another well-known instance of
+substitution. Probably more important hygienically is the production of
+"foam" in "soda water" by saponin, a substance known to be injurious for
+red blood corpuscles.
+
+Among the many other familiar examples of food substitution,
+sophistication, and adulteration there are some of demonstrable hygienic
+disadvantage and others whose chief demerit lies in simple deception. Of
+practically all it may be said that they are indefensible from the
+standpoint of public policy since they are based on the intent to make
+foodstuffs appear other than what they really are.
+
+It is the opinion of some who have closely followed the course of food
+adulteration that, while the amount of general sophistication--legally
+permissible and otherwise--has greatly increased in recent years, the
+proportion of really injurious adulteration has fallen off. Be that as
+it may, it is plain that the opportunity for wholesale experimentation
+with new substances should not be allowed to rest without control in the
+hands of manufacturers and dealers largely impelled by commercial
+motives. So long as the motive of gain is allowed free scope, so long
+will a small minority of unscrupulous persons add cheap, inferior, and
+sometimes dangerous ingredients to foodstuffs. The net of restriction
+must be drawn tighter and tighter. The motives leading to the tampering
+with food fall mainly under three heads: (1) a desire to preserve food
+from spoiling or deterioration; (2) a puerile fancy--often skilfully
+fostered for mercenary reasons--for a conventional appearance, as for
+polished rice, bleached flour, and grass-green peas; and (3) intent to
+make the less valuable appear more valuable--deliberate fraud. Only the
+first-named motive can claim any legitimate justification, and its
+gratification by the use of chemical preservatives is surrounded with
+hygienic difficulties and uncertainty, as already set forth. From the
+unbiased view of human physiology the dangers of slow poisoning from
+chemically treated foods must be regarded as no less real because they
+are insidious and not easily traced.
+
+
+FOOTNOTES:
+
+[32] E. S. Reynolds, _Lancet_, I (1901), 166.
+
+[33] The sulphuric acid used in making glucose in the United States is
+authoritatively declared to be absolutely free from arsenic (report of
+hearing before Illinois State Food Standard Commission, June 21-23,
+1916; see _Amer. Food Jour._, July, 1916, p. 315).
+
+[34] E. W. Miller, _Jour. Home Economics_, VIII (1916), 361.
+
+[35] Phelps and Stevenson, _Hyg. Lab., U.S. Public Health Service, Bull.
+96_, 1914, p. 55.
+
+[36] Harrington and Richardson, _Manual of Practical Hygiene_, 5th ed.,
+p. 224.
+
+[37] See Alice Hamilton, "Hygiene of the Painters' Trade," _U.S. Bureau
+of Labor Statistics, Bull. 120_, 1913.
+
+[38] In 1909 the value of foods canned in the United States amounted to
+about $300,000,000 (_U.S. Dept. of Agric., Bull. 196_, 1915).
+
+[39] W. D. Bigelow, _Amer. Food Jour._, XI (1916), 461.
+
+[40] _Arch. f. Hyg._, XLV (1902), 88; _ibid._, LXIII (1907), 67.
+
+[41] See, e.g., Harrington and Richardson, _Practical Hygiene_, 5th ed.,
+p. 274.
+
+[42] _Ztschr. f. Hyg._, LXXV-LXXVI (1913-14), 55.
+
+[43] Bigelow, _loc. cit._
+
+[44] A. W. Bitting, _U.S. Dept. of Agric., Bull. 196_, 1915.
+
+[45] _U.S. Dept. of Agric., Report 97_, 1913.
+
+[46] Folin, _Preservatives and Other Chemicals in Foods_ (Harvard
+University Press, 1914), p. 32.
+
+[47] Folin, _op. cit._, p. 42.
+
+[48] See _U.S. Dept. of Agric., Report 94_, 1911.
+
+
+
+
+CHAPTER V
+
+FOOD-BORNE PATHOGENIC BACTERIA
+
+
+Many cases of so-called food poisoning are due to the presence of
+pathogenic bacteria in the food. In some instances, as in the typical
+meat poisoning epidemics, symptoms develop so soon after eating that the
+particular food involved is immediately suspected and laid hands on. In
+other cases the guilty article of food is difficult to trace. Certain
+cases of tuberculosis are undoubtedly caused by swallowing tubercle
+bacilli in the food, but the precise source and date of infection can be
+rarely, if ever, certainly established.
+
+The presence of pathogenic bacteria in food is usually due either to the
+contamination of the food by infected human beings during the process of
+preparation or serving, or to an infection of the animal from which the
+food is derived. The relative importance of these two factors is quite
+different in the various infections.
+
+
+TYPHOID FOOD INFECTION
+
+The typhoid bacillus does not attack any of the domestic animals;
+consequently all food-borne typhoid is caused more or less directly by
+human contamination. A remarkable instance of typhoid infection due to
+food was reported in 1914 in Hanford, California, where ninety-three
+typhoid cases were caused by eating Spanish spaghetti served at a public
+dinner.[49] Investigation showed that this dish was prepared by a woman
+typhoid-carrier who was harboring living typhoid bacilli at the time
+she mixed the sauce for the spaghetti before baking. Further laboratory
+experiments indicated that the ordinary baking temperature at which the
+spaghetti was cooked was not only not sufficient to sterilize the food,
+but afforded a favorable opportunity for the bacteria in the interior of
+the mass to multiply. The infection of the food was consequently heavy
+and involved a very large proportion (57 per cent) of those present at
+the dinner.
+
+Merited celebrity attaches to the exploits of the typhoid-carrier, Mary
+Malloy, who, in pursuing her career as cook in and about New York City,
+is known to have caused at least seven typhoid outbreaks in various
+families in which she worked and one extensive hospital epidemic.
+Similar cases of typhoid food infection by employees in restaurants and
+public institutions are by no means uncommon, and show the necessity of
+protecting food from contamination during the whole process of
+preparation and serving. Acting on this principle, the Department of
+Health of New York City has inaugurated a comprehensive examination of
+the cooks and waiters (approximately 90,000) employed in the public
+restaurants and dining-rooms in that city. Results have been obtained in
+the discovery of typhoid-carriers and of cases of communicable disease
+that amply justify this procedure as an important measure for protecting
+the community against the dissemination of infection.
+
+Some foods by their origin are exposed more than others to typhoid
+contamination. Such vegetables as lettuce, celery, radishes, and
+watercress, which are commonly eaten without cooking, are more likely
+to convey typhoid than peas, beans, and potatoes. A typhoid outbreak
+apparently due to watercress has been reported from Philadelphia.[50] At
+a wedding breakfast to forty-three guests on June 24, 1913, watercress
+sandwiches were served, and subsequent inquiry showed that nineteen of
+the guests partook of these sandwiches. Eighteen of this number became
+ill with typhoid fever within a month, the illness developing in most
+cases after the guests had scattered to their summer homes. Those who
+did not eat watercress sandwiches were not affected. Typhoid infection
+by uncooked celery has also been reported.[51]
+
+The practice of using human excreta as fertilizer in truck gardens is
+sometimes responsible for a dangerous contamination of the soil, which
+is communicated to the growing plants and persists for a long time.[52]
+Even scrupulous washing of vegetables is not sufficient to render them
+bacterially clean. In the future the danger to the community from this
+source is likely to become increasingly serious unless the growing use
+of this method of soil enrichment is definitely checked.
+
+In 1915 an increasing number of typhoid cases in South Philadelphia led
+to an investigation by the state health department.[53] This disclosed
+the fact that the majority of the cases were clustered in and about
+three public markets.
+
+  These are all curb markets--fruits, vegetables, pastry, clothing,
+  and miscellaneous merchandise of every description are dumped on
+  push-carts and pavements without regard for any sanitary
+  precautions. The patrons of these markets handle and pick over the
+  exposed foodstuffs, thus giving every opportunity for the
+  transmission of disease....
+
+  The greatest number of cases occurred in the immediate vicinity of
+  the Christian Street Market. This market is largely patronized by
+  the inhabitants of the section known as "Little Italy." The patrons
+  of the South Street Market are principally Hebrews, while the
+  Seventh Street Market is patronized in the main by Hebrews
+  and Poles.
+
+The following conclusion was reached regarding the particularly large
+number of cases among persons of one nationality:
+
+  Our inspectors have found that the different methods used by the
+  Italians and Hebrews in the preparation of their food are
+  responsible for the larger number of cases being found in the
+  vicinity of the Christian Street Market in Little Italy. It is the
+  custom of the Italians to eat many of the fruits and vegetables raw,
+  while the Hebrews cook the greater portion of their food. It is
+  presumably due to this custom that the members of the Italian
+  colony have suffered to a greater extent than the other residents
+  of the district.
+
+A bacterial examination of various kinds of vegetables obtained from
+push-carts and curb markets led to the finding of the typhoid bacillus
+upon some of the celery. It would naturally be difficult to determine in
+such cases whether the typhoid bacilli were derived from infected soil
+in which the celery was grown or whether the contamination occurred
+through improper handling.
+
+Bread, when marketed unwrapped, is subject to contamination from flies
+and from uncleanly handling. Katherine Howell[54] has shown that
+unwrapped loaves of bread sold in Chicago were more or less thickly
+smeared with bacteria and were coated on the average with a much larger
+number than wrapped loaves. In some cases typhoid fever has been
+directly traced to bread. Hinton[55] has recorded the occurrence of
+seven typhoid cases in the Elgin (Illinois) State Hospital, which were
+apparently due to a typhoid-carrier whose duty it was as attendant to
+slice the bread before serving. When this typhoid-bearing attendant was
+transferred to another department where she handled no uncooked food,
+cases of typhoid ceased to appear.[56]
+
+Food such as milk that is not only eaten customarily without cooking,
+but is also suitable for the growth of typhoid bacilli, needs to be
+particularly safeguarded. It is noteworthy that the compulsory
+pasteurization of milk in New York, Chicago, and other large American
+cities has been accompanied by a great diminution in the prevalence of
+typhoid fever. Until recent years milk-borne typhoid in the United
+States has been common and hundreds of typhoid epidemics have been
+traced to this source.
+
+[Illustration: FIG. 5.--Bacteria left by fly passing over gelatin plate.
+(By courtesy of Doubleday, Page & Company.)]
+
+One food animal, the oyster, frequently eaten raw, has been connected on
+good evidence with certain typhoid outbreaks.[57] The number of
+well-established oyster typhoid epidemics is not great, however, and
+the danger from this source has sometimes been exaggerated. The source
+of oyster contamination is in sewage pollution either of the shellfish
+beds or of the brackish water in which the oyster is sometimes placed to
+"fatten" before it is marketed. State and federal supervision of the
+oyster industry in the United States in recent years has largely done
+away with the taking of oysters from infected waters, and although
+oysters--and clams and mussels as well--must be steadily safeguarded
+against sewage contamination, the actual occurrence of oyster infection
+at the present time is believed to be relatively rare.
+
+Probably the most effective method of preventing typhoid food infection
+is to investigate every case of typhoid fever and trace it, so far as
+practicable, to its origin. In this way typhoid-carriers may be
+discovered and other foci of infection brought to light. Carriers, once
+found, may be given proper advice and warned that they constitute a
+danger to others; the complete control of typhoid-carriers who are not
+disposed to act as advised is a difficult problem and one not yet solved
+by public health authorities.
+
+
+ASIATIC CHOLERA
+
+With Asiatic cholera, just as with typhoid fever, domestic animals are
+not susceptible to the disease, all cases of infection having a direct
+human origin. Drinking-water is the usual vehicle of cholera infection,
+and even in countries where the disease is endemic, food-borne outbreaks
+of this disease are far less common than those of typhoid fever.
+Occasional instances of Asiatic cholera due to milk supply and to
+contaminated fruits or lettuce are on record, but these are exceptional
+and cannot be regarded as exemplifying a common mode of spread of this
+disease. The extent, however, to which dwellers in tropical
+countries--and indeed in all lands--are at the mercy of their household
+helpers is illustrated by the following experience of the English
+bacteriologist, Hankin. "I have seen," he says, "a cook cooling a jelly
+by standing it in a small irrigation ditch that ran in front of his
+cookhouse. The water running in this drain came from a well in which I
+had detected the cholera microbe. He cleaned a spoon by dipping it in
+the drain and rubbing it with his fingers; then he used it to stir the
+jelly."[58]
+
+
+TUBERCULOSIS
+
+Animal experiments have shown that both meat and milk derived from
+tuberculous cattle are capable of conveying infection. The precise
+degree of danger to human beings from the use of these foods under
+modern conditions is still in dispute. Since the tubercle bacillus of
+bovine origin differs from the tubercle bacillus of human origin in
+certain well-defined particulars, it is possible by careful study to
+distinguish the human infections caused by the bovine bacillus from
+those caused by the so-called human tubercle bacillus. Additional
+comparative investigations are needed in this field, and these may
+enable us to estimate eventually more fully than is possible at present
+the extent of human tuberculous infection derived from bovine sources.
+
+Meat is a less likely source of infection than milk, chiefly because it
+is rarely eaten without cooking. Opinion regarding the actual frequency
+of the transmission of tuberculosis by means of the meat of tuberculous
+cattle has been widely at variance in the past, and must even now be
+based on indirect evidence. There is no well-established instance of
+human infection from the use of the flesh of tuberculous cattle. The
+significance of this fact, however, is diminished by the observation
+that tubercle bacilli can pass through the intestinal wall without
+leaving any trace of their passage and can make their way to the lungs
+or to other distant organs where they find opportunity for growth. This,
+together with the long period which usually elapses between the actual
+occurrence of infection and the discovery of the existence of infection,
+makes the difficulty of securing valid evidence peculiarly great.
+Opposed to any very frequent occurrence of meat-borne tuberculosis are
+the facts that the tubercle bacillus is not commonly or abundantly
+present in the masses of muscle usually marketed as "meat," that the
+tubercle germ itself is not a spore-bearer and is killed by ordinary
+cooking, and that the reported cases of the finding of tubercle bacilli
+of bovine origin in adults over sixteen years of age are extremely rare.
+This latter fact is perhaps the strongest evidence indicating that
+tuberculous meat infection, although theoretically possible, is at least
+not of common occurrence.
+
+Most of the commissions and official agencies that have considered the
+precautions to be taken against possible tuberculous meat infection are
+agreed that the entire carcass of an animal should be condemned when the
+tuberculous lesions are generalized or when the lesions are extensive in
+one or both body cavities as well as when the lesions are "multiple,
+acute, and actively progressive." Any organ showing evidence of
+tuberculous lesions is obviously not to be passed as food. On the other
+hand, it is considered that portions of properly inspected animals may
+be put on the market if the tuberculous lesion is local and limited and
+the main part of the body is unaffected; in such cases contamination of
+the meat in dressing must be avoided. It is the general belief that
+when such precautionary measures are taken the danger of tuberculous
+infection through properly cooked meat is so slight as to be negligible.
+
+Milk is a much more likely vehicle than meat for the transmission of
+tuberculosis. Freshly drawn raw milk from tuberculous cattle may contain
+enormous numbers of tubercle bacilli, especially if the udder is
+diseased. Contamination of milk by the manure of tuberculous cows can
+also occur. Observers in England, Germany, France, and the United States
+have found tubercle bacilli in varying numbers in market milk, and have
+proved that such milk is infectious for laboratory animals. Although, as
+pointed out with reference to meat infection, the difficulties of
+tracing any particular case of tuberculosis to its source are very
+great, there are a number of instances on record in which the
+circumstantial evidence strongly indicates that milk was the vehicle of
+infection. Especially convincing are the observations on the relative
+frequency of infection with bovine and human tubercle bacilli at
+different ages as shown in the following tabulation:[59]
+
+  ====================================================================
+                      |Adults Sixteen|Children Five to|Children under
+                      | Years Old    | Sixteen Years  |  Five Years
+                      | and Over     |      Old       |
+  --------------------+--------------+----------------+--------------
+  Human tubercle      |    677       |      99        |     161
+    bacilli found     |              |                |
+  Bovine tubercle     |      9       |      33        |      59
+    bacilli found     |              |                |
+  -------------------------------------------------------------------
+
+The large proportion of bovine tubercle bacillus infections in children
+stands in all probability in causal relation to the relatively extensive
+use of raw milk in the child's dietary.
+
+The proper pasteurization of milk affords a safe and reasonably
+satisfactory means of preventing tuberculous infection from this source.
+The general introduction of the pasteurizing process in most American
+cities has ample justification from the standpoint of the prevention of
+infection.
+
+
+VARIOUS MILK-BORNE INFECTIONS
+
+The facts related in the foregoing pages indicate that of all foods milk
+is the most likely to convey disease germs into the human body. This is
+partly due to the fact that milk is sometimes obtained from diseased
+animals, and partly to the fact that unless great care is taken it may
+readily become contaminated during the process of collection and
+transportation; if milk is once seeded with dangerous bacteria these can
+multiply in the excellent culture medium it affords. It is also partly
+because milk is commonly taken into the alimentary tract without being
+cooked. For these reasons the amount of illness traceable to raw milk
+far exceeds that ascribable to any other food.
+
+There are several infections that may be communicated by milk, but are
+rarely if ever due to other foodstuffs. Diphtheria and scarlet fever are
+perhaps the best known of these. Both diseases have been repeatedly
+traced to the use of particular milk supplies, although various forms of
+individual contact also play a large role in their dissemination.
+Milk-borne scarlet fever and diphtheria seem to be generally, if not
+always, due to the direct contamination of the milk from human sources.
+It is considered possible, however, by some investigators that the cow
+may sometimes become infected from human sources with the virus of
+scarlet fever or diphtheria and may herself occasionally contribute
+directly to the infection of the milk.
+
+A serious milk-borne disease, which has lately been conspicuous in
+Boston, Chicago, Baltimore, and other American cities under the name of
+"septic sore throat" or "streptococcus sore throat," originates
+apparently in some cases from infection of the udder of the cow by an
+infected milker; in other cases the milk has seemingly been directly
+infected by a human "carrier." The specific germ is thought to have been
+isolated and its connection with the disease demonstrated in the
+laboratory. This disease, like diphtheria and scarlet fever, is
+sometimes due to contact. It is not known to be caused by any food
+except milk.
+
+Foot-and-mouth disease of cattle is transmissible to man through the
+milk of infected cattle, but this infection in man is not very common or
+as a rule very serious. So far as known, it is not communicated to man
+in any other way except through the use of uncooked milk.
+
+Such cases of infection or "poisoning" by milk may be prevented, as
+already stated, by the exclusive use of heated milk. The possible
+occurrence of nutritional disturbances (e.g., scurvy) in a small
+proportion of the children fed on pasteurized or boiled milk is
+considered by many physicians to be easily remedied and to possess much
+less practical importance than the avoidance of infection.
+
+
+POSSIBLE INFECTION WITH B. PROTEUS
+
+One widely distributed organism known as _Bacillus proteus_ has been
+several times held responsible for food poisoning outbreaks, but it is
+not yet certain how far this accusation is justified. _B. proteus_ is
+related to _B. coli_, but most varieties do not ferment lactose and are
+much more actively proteolytic than the latter organism, as shown by
+their ability to liquefy gelatin and casein. Like _B. coli_, they form
+indol and ferment dextrose with gas production. Varieties of _B.
+proteus_ are found widely distributed in decomposing organic matter of
+all sorts.
+
+The evidence upon which this bacillus is regarded as the cause of food
+poisoning is not altogether convincing. The outbreak described by
+Pfuhl[60] is typical. Eighty-one soldiers in a garrison at Hanover were
+suddenly attacked with acute gastro-enteritis four to twelve hours after
+eating sausage meat. The meat was found to contain _B. proteus_ in large
+numbers, although it was prepared with ordinary care and was entirely
+normal in appearance, taste, and smell. Rats and mice fed with the
+sausage became ill and _B. proteus_ was isolated from the blood and
+internal organs. But these animals sometimes die when fed with quite
+normal meat, and _B. proteus_ and other common intestinal bacteria are
+often isolated from the body after death. _B. proteus_, in fact, is
+found in many animal foods and in the apparently normal human intestine.
+Like _B. coli_, it frequently invades the internal organs after or
+shortly before death. Finding _B. proteus_ in food or in the internal
+organs does not therefore constitute definite proof of any causal
+relationship. The evidence attributing other outbreaks to infection with
+_B. proteus_ is similarly inconclusive.
+
+It is equally uncertain whether the production of a poison in food by
+this species can in any degree be held responsible for meat poisoning.
+_B. proteus_ is common enough in decomposing food material and under
+certain circumstances is known to generate substances that are toxic for
+man. It is possibly true that toxic substances are produced in the early
+stages of decomposition by this organism. In the opinion of Mandel[61]
+and others, if any injurious effect at all is to be attributed to _B.
+proteus_, it is in the nature of an intoxication and not an infection
+(see chapter viii). So far as the existing evidence goes, the question
+of the responsibility of this organism for food poisoning is still an
+open one.
+
+
+FOOTNOTES:
+
+[49] Sawyer, _Jour. Amer. Med. Assoc._, LXIII (1914), 1537.
+
+[50] _Eng. News_, LXX (1913), 322.
+
+[51] Morse, _Report of State Board of Health of Mass._, 1899, p. 761.
+
+[52] R. H. Creel, _Reprint from Public Health Reports, No. 72_,
+Washington, 1912.
+
+[53] _Health Bull. No. 76, Pennsylvania State Department of Health_,
+December, 1915.
+
+[54] _Amer. Jour. Public Health_, II (1912), 321.
+
+[55] _Institution Quarterly_, III (1912), 18.
+
+[56] See also a similar instance reported by Lumsden, _Hyg. Lab., U.S.
+Public Health and Marine Hosp. Service, Bull. 78_, p. 165.
+
+[57] For a discussion of the oyster question see G. W. Fuller, _Jour. of
+Franklin Institute_, August, 1905; _N.Y. City Dept. of Health, Monthly
+Bull._, November, 1913, and May, 1915; H. S. Cumming, _U.S. Public
+Health Service, Pub. Health Bull. 74_, March, 1916.
+
+[58] _Lancet_, II (1895), 46.
+
+[59] Park and Krumwiede, _Jour. Med. Research_, N.S., XVIII (1910), 363.
+
+[60] _Ztschr. f. Hyg._, XXXV (1900), 265.
+
+[61] _Centralbl. f. Bakt._, I, Orig., LXVI (1912), 194.
+
+
+
+
+CHAPTER VI
+
+FOOD-BORNE PATHOGENIC BACTERIA (_Continued_)
+
+
+PARATYPHOID INFECTION
+
+The most characteristic examples of "food poisoning," popularly
+speaking, are those in which the symptoms appear shortly after eating
+and in which gastro-intestinal disturbances predominate. In the typical
+group-outbreaks of this sort all grades of severity are manifested, but
+as a rule recovery takes place. The great majority of such cases that
+have been investigated by modern bacteriological methods show the
+presence of bacilli belonging to the so-called paratyphoid group (_B.
+paratyphosus_ or _B. enteritidis_). Especially is it true of meat
+poisoning epidemics that paratyphoid bacilli are found in causal
+relation with them. Huebener[62] enumerates forty-two meat poisoning
+outbreaks in Germany in which bacilli of this group were shown to be
+implicated, and Savage[63] gives a list of twenty-seven similar
+outbreaks in Great Britain. In the United States relatively few
+outbreaks of this character have been placed on record, but it cannot be
+assumed that this is due to their rarity, since no adequate
+investigation of food poisoning cases is generally carried out in our
+American communities.
+
+_Typical paratyphoid outbreaks._--Kaensche[64] describes an outbreak at
+Breslau involving over eighty persons in which chopped beef was
+apparently the bearer of infection. The animal from which the meat came
+had been ill with severe diarrhea and high fever and was slaughtered as
+an emergency measure (_notgeschlachtet_). On examination a pathological
+condition of the liver and other organs was noted by a veterinarian who
+declared the meat unfit for use and ordered it destroyed. It was,
+however, stolen, carried secretly to Breslau, and portions of it were
+distributed to different sausage-makers, who sold it for the most part
+as hamburger steak (_Hackfleisch_). The meat itself presented nothing
+abnormal in color, odor, or consistency. Nevertheless, illness followed
+in some cases after the use of very small portions. With some of those
+affected the symptoms were very severe, but there were no deaths.
+Bacilli of the _Bacillus enteritidis_ type were isolated from the meat.
+
+A large and unusually severe outbreak reported by McWeeney[65] occurred
+in November, 1908, among the inmates of an industrial school for girls
+at Limerick, Ireland. There were 73 cases with 9 deaths out of the total
+number of 197 pupils. The brunt of the attack fell on the first or
+Senior class comprising 67 girls between the ages of thirteen and
+seventeen. Out of 55 girls belonging to this class who partook of beef
+stew for dinner 53 sickened, and 8 of these died. One of the two who
+were not affected ate the gravy and potatoes but not the beef. Some of
+the implicated beef was also eaten as cold meat by girls in some of the
+other classes, and also caused illness. Part of the meat had been eaten
+previously without producing any ill effects. "The escape of those who
+partook of portions of the same carcass on October 27 and 29 [five days
+earlier] may be accounted for either by unequal distribution of the
+virus, or by thorough cooking which destroyed it. Some of the infective
+material must, however, have escaped the roasting of the 29th, and,
+multiplying rapidly, have rendered the whole piece intensely toxic and
+infective during the five days that elapsed before the fatal Tuesday
+when it was finally consumed." The animal from which the fore quarter of
+the beef was taken had been privately slaughtered by a local butcher. No
+reliable information could be obtained about the condition of the calf
+at, or slightly prior to, slaughter. The meat, however, was sold at so
+low a price that it was evidently not regarded as of prime quality. In
+this outbreak the agglutination reactions of the blood of the patients
+and the characteristics of the bacilli isolated showed the infection to
+be due to a typical strain of _Bacillus enteritidis_.
+
+An epidemic of food poisoning occurred in July, 1915, at and near
+Westerly, Rhode Island.[66] The outbreak was characterized by the usual
+symptoms of acute gastro-enteritis, and followed the eating of pie which
+was obtained at a restaurant in Westerly. All the circumstances of the
+outbreak showed that a particular batch of pies was responsible. About
+sixty persons were made seriously ill and four died. There was no
+unusual taste or odor to the pies to excite suspicion. The symptoms
+followed the eating of various kinds of pie: custard, squash, lemon,
+chocolate, apple, etc., that had been made with the same pie-crust
+mixture. _Bacillus paratyphosus_ B was isolated from samples of pie
+that were examined. No definite clue was obtained as to the exact source
+of infection of the pie mixture. It is possible that the pie became
+infected in the restaurant through the agency of a paratyphoid-carrier,
+but since there had been no change in the personnel of the restaurant
+for several months, this explanation is largely conjectural. Possibly
+some ingredient of animal origin was primarily infected.
+
+_General characters of paratyphoid infection._--The symptoms of
+paratyphoid food infection are varied. As a rule the first signs of
+trouble appear within six to twelve hours after eating, but sometimes
+they may come on within half an hour, or they may not appear until after
+twenty-four to forty-eight hours. Gastro-intestinal irritation is
+practically always present, and may take the form of a mild
+"indigestion" or slight diarrhea or may be of great severity accompanied
+with agonizing abdominal pain. Fever is usual, but is generally not very
+high. Recovery may occur quickly, so that within two or three days the
+patient regains his normal state, or it may be very slow, so that the
+effects of the attack linger for weeks or months.
+
+Investigators have noted the occurrence of at least two clinical types
+of paratyphoid infection, the commoner gastro-intestinal type just
+described and a second type resembling typhoid fever very closely, and
+occasionally not to be distinguished from it except by careful bacterial
+examination. It is not yet clear how these two clinical varieties are
+related to the amount and nature of the infecting food material. No
+difference in the type of paratyphoid bacillus has been observed to be
+associated with the difference in clinical manifestation. Possibly the
+amount of toxin present in the food eaten as well as the number of
+bacilli may exercise some influence. The individual idiosyncrasy of the
+patient doubtless plays a part.
+
+While there is still some uncertainty about particular features of
+paratyphoid infection, a few significant facts have been clearly
+established: (1) Certain articles of diet are much more commonly
+associated than others with this type of food poisoning. The majority of
+recorded outbreaks are connected with the use of meat, milk, fish, and
+other protein foods. Vegetables and cereals have been less commonly
+implicated, fruits rarely. (2) In many, though not all, of the cases of
+paratyphoid meat poisoning it has been demonstrated that the meat
+concerned has been derived from an animal slaughtered while ailing
+(_notgeschlachtet_, to use the expressive German term). There seems
+reason to believe that in such an animal, "killed to save its life," the
+specific paratyphoid germ is present as an infection before death. Milk
+also has caused paratyphoid poisoning and in certain of these cases has
+been found to be derived from a cow suffering from enteritis or some
+other disorder. (3) There is evidence that originally wholesome food may
+become infected with paratyphoid bacilli during the process of
+preparation or serving in precisely the same way that it may become
+infected with typhoid bacilli; the handling of the food by a
+paratyphoid-carrier is commonly responsible for this. In a few instances
+the disease is passed on from case to case, but this mode of infection
+seems exceedingly rare and is not nearly so frequent as "contact"
+infection in typhoid. (4) The majority of paratyphoid outbreaks are
+associated with the use of uncooked or partly cooked food. A selective
+action is often manifested, those persons who have eaten the
+incriminated food substance raw or imperfectly cooked being most
+seriously affected, while those who have partaken of the same food after
+cooking remain exempt.
+
+[Illustration: FIG. 6.--_Bacillus enteritidis_, Gaertner; pure culture;
+Van Ermengem preparation. (Kolle and Wassermann.)]
+
+The discovery of the connection of paratyphoid bacilli with meat
+poisoning dates from the investigation by Gaertner,[67] in 1888, of a
+meat poisoning outbreak in Frankenhausen, a small town in Germany. This
+epidemic was traced to the use of meat from a cow that was slaughtered
+because she was ill with a severe enteritis. Fifty-eight persons were
+affected in varying grades of severity; the attack resulted fatally in
+one young workman who ate about eight hundred grams of raw meat. Gaertner
+isolated from the spleen of the fatal case and also from the flesh and
+intestines of the cow a bacillus to which he gave the name _B.
+enteritidis_. Inoculation experiments showed it to be pathogenic for a
+number of animal species. Bacilli with similar characters have since
+been isolated in a number of other meat poisoning epidemics in Germany,
+Belgium, France, and England. One well-studied instance of food
+poisoning due to the paratyphoid bacillus has been reported in the
+United States.[68]
+
+The bacteria of the paratyphoid group are closely related to the true
+typhoid bacillus, but differ from the latter organism in being able to
+ferment glucose with gas production. They are more highly pathogenic for
+the lower animals than is the typhoid bacillus, but apparently somewhat
+less pathogenic for man. Most types of paratyphoid bacilli found in food
+poisoning produce more or less rapidly a considerable amount of alkali,
+and, if they are inoculated into milk containing a few drops of litmus,
+the milk after a time becomes a deep blue color. Several distinct
+varieties of paratyphoid bacilli have been discovered. The main
+differences shown by these varieties are agglutinative differences. That
+is, the blood serum of an animal that has been inoculated with a
+particular culture or strain will agglutinate that strain and also other
+strains isolated from certain other meat poisoning epidemics, but will
+not agglutinate certain culturally similar paratyphoid bacteria found in
+connection with yet other outbreaks. Except in this single matter of
+agglutination reaction, no constant distinction between these varieties
+has been demonstrated. The clinical features of the infections produced
+in man and in the higher animals by the different varieties seem to be
+very similar if not identical.
+
+The bacillus discovered by Gaertner (_loc. cit._) and known as _B.
+enteritidis_ or Gaertner's bacillus is commonly taken as the type of one
+of the agglutinative varieties. Bacilli with all the characters of
+Gaertner's bacillus have been found in meat poisoning epidemics in
+various places in Belgium and Germany. Mayer[69] has compiled a list of
+forty-eight food poisoning outbreaks occurring between 1888 and 1911 and
+attributed to _B. enteritidis_ Gaertner. These outbreaks comprised
+approximately two thousand cases and twenty deaths. In twenty-three of
+the forty-eight outbreaks the meat was derived from animals known to be
+ill at the time, or shortly before, they were slaughtered. Sausage and
+chopped meat of undetermined origin were responsible for eleven of the
+remaining twenty-five outbreaks. Two of the _B. enteritidis_ outbreaks
+were attributed to _Vanille Pudding_; one, to potato salad.
+
+In other food poisoning outbreaks a bacillus is found which is
+culturally similar to the Gaertner bacillus, but refuses to agglutinate
+with the Gaertner bacillus serum. Its cultural and agglutination
+reactions are almost, if not quite, identical with those of the bacilli
+found in human cases of paratyphoid fever which have no known connection
+with food poisoning. Mayer[70] gives a list of seventy-seven outbreaks
+of food poisoning (1893-1911) in which organisms variously designated as
+"_B. paratyphosus_ B" or as "_B. suipestifer_" were held to be
+responsible. The total number of cases (two thousand) and deaths
+(twenty) is about the same as ascribed to _B. enteritidis_. According to
+Mayer's tabulation meat from animals definitely known to be ailing is
+less commonly implicated in this type (ten in seventy-seven) than in _B.
+enteritidis_ outbreaks (twenty-three in forty-eight). Sausage and
+chopped meat of unknown origin, however, were connected with eighteen
+outbreaks.
+
+The bacillus named _B. suipestifer_ was formerly believed to be the
+cause of hog cholera, but it is now thought to be merely a secondary
+invader in this disease; it is identical with the bacillus called _B.
+paratyphosus_ B in its cultural and to a large extent in its
+agglutinative behavior, but is regarded by some investigators as
+separable from the latter on the basis of particularly delicate
+discriminatory tests. Bainbridge, Savage, and other English
+investigators consider indeed that the true food poisoning cases should
+be ascribed to _B. suipestifer_ and would restrict the term _B.
+paratyphosus_ to those bacteria causing "an illness clinically
+indistinguishable from typhoid fever." German investigators, on the
+other hand, regard _B. suipestifer_ and _B. paratyphosus_ B as
+identical. My own investigations[71] indicate that there is a real
+distinction between these two types.
+
+Bearing directly on this question is the discussion concerning the
+distribution of the food poisoning bacilli in nature. Most investigators
+in Germany, where the majority of food poisoning outbreaks have
+occurred, or at least have been bacteriologically studied, are of the
+opinion that _B. suipestifer_ (the same in their opinion as _B.
+paratyphosus_ B) is much more widely distributed than _B. enteritidis_
+and that it occurs, especially in certain regions, as in the southern
+part of the German Empire, quite commonly in the intestinal tract of
+healthy human beings. Such paratyphoid-carriers, it is supposed, may
+contaminate food through handling or preparation just as
+typhoid-carriers are known to do. A number of outbreaks in which
+contamination of food during preparation is thought to have occurred
+have been reported by Jacobitz and Kayser[72] (vermicelli),
+Reinhold[73] (fish), and others. Reinhold notes that in one outbreak
+several persons who had nursed those who were ill became ill themselves,
+indicating possible contact infection. In another outbreak also reported
+by Reinhold it was observed that those who partook of the infected food,
+in this case dried codfish, on the first day were not so severely
+affected as those who ate what was left over on the second day. A
+bacillus belonging to the paratyphoid group was isolated from the stools
+of patients, but not from the dried codfish. These facts were
+interpreted as signifying that the fish had become infected in the
+process of preparation and that the bacilli multiplied in the food while
+it was standing.
+
+There seems no doubt that certain cases of paratyphoid food poisoning
+are caused by contamination of the food during preparation and are,
+sometimes at least, due to infection by human carriers. The bacilli in
+such cases are usually (according to many German investigators) or
+always (according to most English bacteriologists) of the _B.
+suipestifer_ type. Other cases are due to pathogenic bacteria derived
+from diseased animals, and these bacteria are often, possibly always, of
+a slightly different character (_B. enteritidis_ Gaertner). It is still
+unsettled whether both types of food poisoning bacteria are always
+associated with disease processes of man or animals, or whether they are
+organisms of wide distribution which may at times acquire pathogenic
+properties. In certain regions, as in North Germany and England, such
+bacteria are rarely, if ever, found except in connection with definite
+cases of disease. In parts of Southwest Germany, on the other hand, they
+are said to occur with extraordinary frequency in the intestines of
+healthy men and animals. Savage[74] believes that there is some
+confusion on this subject owing to the existence of saprophytic bacteria
+which he calls "Paragaertner" forms and which bear a close resemblance
+to the "true" Gaertner bacilli. They can be distinguished from the latter
+only by an extended series of tests. The bacilli of this group show
+remarkable variability, and in the opinion of some investigators
+"mutations" sometimes occur which lead to the transformation of one type
+into another.[75]
+
+In spite of the present uncertainty regarding the relationship and
+significance of the varieties observed, a few facts emerge plainly from
+the confusion: (1) The majority of meat poisoning outbreaks that have
+been bacterially studied in recent years have been traceable to one or
+another member of this group and not to "ptomain poisoning." (2)
+Bacteria of the _paratyphoid enteritidis_ group that are culturally
+alike but agglutinatively dissimilar can, when taken in with the food,
+give rise to identical clinical symptoms in man. (3) Food poisoning
+bacteria of this group, when derived directly from diseased animals,
+seem more likely to be of the Gaertner type (_B. enteritidis_) than of
+the _B. suipestifer_ type.
+
+_Toxin production._--The problem of the production of toxin by the
+bacteria of this group and the possible relation of the toxin to food
+poisoning has been much discussed. Broth cultures in which the living
+bacilli have been destroyed by heat or from which they have been removed
+by filtration contain a soluble poison. When this germ-free broth is
+injected into mice, guinea-pigs, or rabbits, the animals die from the
+effects. Practically nothing is known about the nature of the poisonous
+substances concerned, except that they are heat-resistant. They are
+probably not to be classed with the so-called true toxins generated by
+the diphtheria and tetanus bacilli, since there is no evidence that they
+give rise to antibodies when injected into susceptible animals. In the
+opinion of some investigators the formation of these toxic bodies by the
+_paratyphoid-enteritidis_ bacilli in meat and other protein foodstuffs
+is responsible for certain outbreaks and also for some of the phenomena
+of food poisoning, the rapid development of symptoms being regarded as
+due to the ingested poisons, whereas the later manifestations are
+considered those of a true infection. Opposed to this view is the fact
+that well-cooked food has proved distinctly less liable to cause food
+poisoning than raw or imperfectly cooked food.
+
+A large proportion of the recorded meat poisoning outbreaks are
+significantly due to sausages made from raw meat and to meat pies,
+puddings, and jellies. This is most likely because the heat used in
+cooking such foods is insufficient to produce germicidal results. In
+milk-borne epidemics also it is noteworthy that the users of raw milk
+are the ones affected. For example, respecting an extensive _B.
+enteritidis_ outbreak in and about Newcastle, England, it is stated:
+
+  In no instance was a person who had used only boiled milk known to
+  have been affected. Thus in one family, consisting of husband,
+  wife, and wife's mother, the two women drank a small quantity of raw
+  milk from the farm, at the most a tumblerful, and both were taken
+  ill about twelve hours later. The husband, on the other hand,
+  habitually drank a pint a day, but always boiled. He followed his
+  usual custom on this occasion, and was unaffected.[76]
+
+When in addition it is taken into consideration that the ordinary
+roasting or broiling of a piece of meat is often not sufficient to
+produce a germicidal temperature throughout, the argument that a
+heat-resistant toxin is present in such cases is not conclusive. It must
+be remembered also that in some outbreaks those persons consuming raw or
+partly cooked meat have been affected while at the same time others
+eating well-cooked meat from the same animal have remained exempt; this
+would seem to indicate the destruction of living bacilli by heat, since
+the toxic substances formed by these organisms are heat-resistant. The
+view that a definite infection occurs, is favored, too, by the fact that
+the blood-serum of affected persons so frequently has an agglutinative
+action upon the paratyphoid bacillus. This would not be the case if the
+symptoms were due to toxic substances alone. Altogether the role of
+toxins formed by _B. enteritidis_ and its allies in food outside the
+body cannot be said to be established. The available evidence points to
+infection as the main, if not the sole, way in which the bacilli of this
+group are harmful.
+
+_Sources of infection._--The main sources of _enteritidis-suipestifer_
+infection are: (1) diseased domestic animals, the infected flesh or milk
+of which is used for food; (2) infection of food by human carriers
+during the process of preparation or serving. To these may be added a
+third possibility: (3) contamination of food with bacteria of this group
+which are inhabitants of the normal animal intestine. Considering these
+in order:
+
+1. Diseased animals: The majority of the meat poisoning outbreaks are
+caused by meat derived from pigs or cattle. Table III gives the figures
+for a number of British[77] and German[78] epidemics.
+
+TABLE III[79]
+
+  ====================================================================
+           |                    |                    |  BELONGING TO
+           |   B. ENTERITIDIS   | B. SUIPESTIFER     | THIS GROUP BUT
+           |                    |                    |UNDIFFERENTIATED
+           |--------------------+--------------------+----------------
+           |British|German|Total|British|German|Total|    British
+  ---------+-------+------+-----+-------+------+-----+----------------
+  Pig      |   1   |   1  |  2  |   3   |   5  |  8  |      4
+  Ox or cow|   3   |   9  | 12  |   2   |   3  |  5  |      5
+  Calf     |   0   |   7  |  7  |   2   |   2  |  4  |      0
+  Horse    |   0   |   1  |  1  |   0   |   1  |  1  |     ...
+  Chickens |   1   |   0  |  1  |   0   |   1  |  1  |     ...
+  --------------------------------------------------------------------
+
+Occasional outbreaks have also been attributed to infection through
+eating rabbit, sheep, goose, fish, shrimp, and oysters. Especially
+noteworthy is the relative rarity of infection from the meat of the
+sheep.
+
+More definite information is needed respecting the pathological
+conditions caused by these bacteria in animals and the relation of such
+conditions to subsequent human infection. A rather remarkable problem
+is presented by the relation of _B. suipestifer_ to hog cholera. This
+bacillus, although not now considered the causal agent of hog cholera,
+is very commonly associated with the disease as an accessory or
+secondary invader, and is frequently found in the internal organs of
+swine after death. It might be supposed that in regions where hog
+cholera is prevalent human infections would be more common than in
+other districts, but this seems not to be the case. No connection
+has ever been demonstrated between outbreaks of hog cholera--in which
+_B. suipestifer_ is known to be abundantly distributed--and so-called
+_B. suipestifer_ infections in man.
+
+Suppurative processes in cattle, and especially in calves, have
+given rise to poisoning from the use of the meat or milk of the
+infected animals. It has been often demonstrated that bacteria of
+the _enteritidis-suipestifer_ group are associated with inflammation
+of the udder in cows and with a variety of septicemic conditions in
+cattle and other domestic animals as well as with manifestations of
+intestinal disturbances ("calf diarrhea," etc.).[80] The frequency
+with which poisoning has occurred through the use of the meat of
+"emergency-slaughtered" animals has been already mentioned. K. F.
+Meyer[81] has reported an instance of accidental infection in a
+laboratory worker caused by handling a bottle of sterilized milk
+that had been artificially contaminated with a pure culture of
+_B. enteritidis_ for experimental purposes. The strain responsible
+for the infection had been isolated from the heart blood of a calf
+that had succumbed to infectious diarrhea.
+
+2. Human contamination: In a certain number of paratyphoid food
+infections there is some evidence that the food was originally derived
+from a healthy animal and became infected from human sources during the
+process of preparation. In addition to the instances already mentioned
+(Reinhold _et al._, p. 67) the Wareham (England, 1910) epidemic[82] was
+considered by the investigators to be due to infection of meat pies by a
+cook who was later proved to be a carrier of paratyphoid bacilli. The
+evidence in this case, however, is not altogether conclusive.
+Soederbaum[83] mentions a milk-borne paratyphoid epidemic occurring in
+Kristiania which was ascribed to infection of the milk by a woman
+milker. Sacquepee and Bellot[84] report an interesting paratyphoid
+outbreak involving nineteen out of two hundred and fifty men in a
+military corps. The patients fell ill on different dates between June 14
+and June 21.
+
+  It was found that an assistant cook who had been in the kitchen for
+  several months had been attacked a little before the epidemic
+  explosion by some slight malady which was not definitely diagnosed.
+  He had been admitted to the hospital and was discharged
+  convalescent. The cook, on being recalled and quarantined, stated
+  that some days before June 10 he was indisposed with headache and
+  anorexia. He had nevertheless continued his service in the
+  kitchen.... _B. paratyphosus_ B (_B. suipestifer_) was repeatedly
+  found in his stools in August, September, and October.... In all
+  probability, therefore, the outbreak was due to food contaminated
+  by a paratyphoid-carrier who had passed through an abortive attack
+  of the fever.[85]
+
+Bainbridge and Dudfield[86] describe an outbreak of acute
+gastro-enteritis occurring in a boarding-house; it was found that no one
+article of food had been eaten by all the persons affected, and there
+were other reasons for supposing the outbreak to be due to miscellaneous
+food contamination by a servant who was a carrier.
+
+There is, therefore, ground for believing that occasional contamination
+of food may be brought about by bacteria of this group derived from
+human sources. It is not clear, however, how frequent this source of
+infection is, compared to infection originating in diseased animals. It
+must be admitted, too, that English investigators are disposed to look
+upon outbreaks similar to those just described as infections with _B.
+paratyphosus_ B, an organism which they would distinguish from the
+"true" food poisoning bacilli, _B. enteritidis_ and _B. suipestifer_.
+
+3. Miscellaneous contaminations: Some investigators, especially certain
+German writers, regard the bacilli of the paratyphoid group as so widely
+distributed in nature that any attempt to control the spread of
+infection is like fighting windmills. According to this view the bacilli
+occur commonly in our everyday surroundings and thence make their way
+rather frequently into a variety of foodstuffs. Various German
+investigators have reported the presence of paratyphoid bacilli in the
+intestinal contents of apparently normal swine, cattle, rats, and mice
+and more rarely of other animals, in water and ice, in German sausage
+and chopped meat, and in the bodies of apparently healthy men. To what
+extent their alleged ubiquity is due to mistaken bacterial
+identification, as claimed by some English investigators, remains to be
+proved. There is no doubt that in some quarters exaggerated notions have
+prevailed respecting a wide distribution of the true paratyphoid
+bacteria. Savage and others believe that the hypothesis that food
+poisoning outbreaks are derived from ordinary fecal infection of food is
+quite unfounded. It is pointed out that there is good evidence of the
+frequent occurrence of intestinal bacteria in such food as sausages and
+chopped meat, and that consequently, if paratyphoid infections could
+occur through ordinary contamination with intestinal bacteria not
+connected with any specific animal infection, food poisoning outbreaks
+should be exceedingly common instead of--as is the case--comparatively
+rare.
+
+At the present time even those who maintain that these bacilli are of
+common occurrence admit that their abundance is more marked in some
+regions than in others. Southwest Germany, for example, seems to harbor
+paratyphoid bacilli in relatively large numbers. Possibly local
+differences in distribution may account for the discrepancies in the
+published findings of German and British investigators.
+
+A special case is presented by the relation of these bacilli to rats and
+mice. Among the large number of bacteria of the paratyphoid group is the
+so-called Danysz bacillus, an organism quite pathogenic for rodents, and
+now and again used in various forms as a "rat virus" for purposes of
+rodent extermination. Several outbreaks of food poisoning in man have
+been attributed on more or less cogent evidence to food contamination
+by one of these viruses either directly by accident, as in the case
+described by Shibayama,[87] in which cakes prepared for rats were eaten
+by men, or indirectly through food contaminated by mice or rats that had
+been infected with the virus.[88] The use of such viruses has not proved
+of very great practical value in the destruction of rodents, and is open
+to serious sanitary objections, since the animals after apparent
+recovery can continue to carry the bacilli of the virus and to
+distribute them on or near food substances.
+
+It seems possible that rats and mice may become infected with certain
+bacteria of this group without human intervention, and that these
+infected animals may be the means of contaminating foodstuffs and so
+causing outbreaks of food poisoning. Proof of the frequency with which
+this actually occurs is naturally difficult to obtain.
+
+There is no escape from the conclusion that in any given case of food
+poisoning the exact source of infection is often largely conjectural.
+Even when suspicion falls strongly on a particular article of food, it
+may not be possible to establish beyond a reasonable doubt whether the
+material (meat or milk) came from a diseased animal or whether it was
+infected from other sources (man or other animals) at some stage during
+the process of preparation and serving. The most definitely attested
+cases yet put on record are those in which it is possible to trace the
+infection to food derived from an ailing animal.
+
+_Means of prevention._--The most obvious and probably the most important
+method of preventing infection with paratyphoid bacilli is the adoption
+of a system of inspection which will exclude from the market as far as
+possible material from infected animals. To be most effective such
+inspection must be directed to examination of the living animal. The
+milk or the meat from diseased animals may give no visible sign of
+abnormality. In the Ghent outbreak of 1895 the slaughter-house
+inspector, a veterinary surgeon, was so firmly convinced that the meat
+which he had passed could have had no connection with the outbreak, that
+he ate several pieces to demonstrate its wholesomeness. The experiment
+had a tragic ending, as the inspector was shortly attacked with severe
+choleraic symptoms and died five days later, paratyphoid bacilli being
+found at the autopsy. Mueller[89] also has described a case in which
+paratyphoid bacilli were found in meat that had given rise to a meat
+poisoning outbreak although the meat was normal in appearance and the
+organs of the animal showed no evidence of disease to the naked eye. It
+is evident that inspection of the live animal will often reveal evidence
+of disease which might be missed in the ordinary examination of
+slaughter-house products.
+
+Although inspection of cows used for milking and of food animals before
+slaughter is highly important, it does not constitute an absolute
+protection. Emphasis must be repeatedly laid on the fact that meat, and
+especially milk that is derived from seemingly healthy animals, may
+nevertheless contain paratyphoid bacilli. To meet this difficulty in
+part the direct bacterial examination of the carcasses of slaughtered
+food animals has been proposed, but this seems hardly practicable as a
+general measure. In spite of all precautions taken at the time of
+slaughtering it seems probable that occasionally paratyphoid-infected
+meat will pass the first line of defense and be placed on the market.
+
+This danger, which is probably not a very grave one under a reasonably
+good system of inspection of live animals, may be met by thoroughly
+cooking all foods of animal origin. It is worth noting that some of the
+internal organs, as the liver and kidneys, are more likely to contain
+bacteria than the masses of muscle commonly eaten as "meat." Sausages,
+from their composition and mode of preparation, and chopped meat
+("hamburger steak") are also to be treated with especial care.
+Consumption of such foods as raw sausage or diseased goose liver (pate
+de foie gras) involves a relatively high risk. It is true of paratyphoid
+infection as of most other forms of food poisoning that thorough cooking
+of food greatly diminishes the likelihood of trouble.
+
+Whatever be the precise degree of danger from food infection by healthy
+paratyphoid-carriers (man or domestic animals), it is obvious that
+general measures of care and cleanliness will be more or less of a
+safeguard. As with typhoid fever so all outbreaks of paratyphoid should
+be thoroughly investigated in order that the sources of infection may be
+found and eliminated. The possible connection of rats and mice with
+these outbreaks should furnish an additional incentive to lessen the
+number of such vermin as well as to adopt measures of protecting food
+against their visits.
+
+
+FOOTNOTES:
+
+[62] _Fleischvergiftungen u. Paratyphusinfektionen_ (Jena, 1910).
+
+[63] _Rept. to Local Govt. Board_, N.S. No. 77 (London, 1913).
+
+[64] _Zeit. f. Hyg._, XXII (1896), 53.
+
+[65] _Brit. Med. Jour._, I (1909), 1171.
+
+[66] Bernstein and Fish, _Jour. Amer. Med. Assoc._, LXVI (1916), 167.
+
+[67] _Breslau aerztl. Ztschr._, X (1888), 249.
+
+[68] Bernstein and Fish, _Jour. Amer. Med. Assoc._, LXVI (1916), 167.
+
+[69] _Deutsche Viertelj. f. oeffentl. Ges._, XLV (1913), 58-59.
+
+[70] _Op. cit._, pp. 60-62.
+
+[71] _Jour. Infect. Dis._, XX (1917), 457.
+
+[72] _Centralbl. f. Bakt._, I Orig., LIII (1910), 377.
+
+[73] _Cor.-Bl. f. schweiz. Aerzte_, XLII (1912), 281 and 332.
+
+[74] _Jour. Hyg._, XII (1912), 1.
+
+[75] See Sobernheim and Seligmann, _Centralbl. f. Bakt._, Ref., Beilage,
+L (1911), 134.
+
+[76] _Report Med. Officer of Health_ (Newcastle-upon-Tyne, 1913).
+
+[77] Compiled from Savage, _Report of Local Gov't Board_, 1913.
+
+[78] Mayer, _Deutsche Viertelj. f. oeffentl. Ges._, XLV (1913), 8.
+
+[79] It must be noted that origin of the food from a diseased animal was
+not definitely proved in all the cases cited. Some of these cases should
+possibly be classed under human contamination (2).
+
+[80] Although not directly connected with the question of food
+poisoning, it is of interest to note that certain diseases of birds have
+been traced to infection with members of this group of bacteria. In a
+few cases, as in several epidemics among parrots in Paris and elsewhere,
+the infection has been communicated to man by contact.
+
+[81] _Jour. Infect. Dis._, XIX (1916), 700.
+
+[82] R. Trommsdorff, L. Rajchman, and A. E. Porter, _Jour. Hyg._, XI
+(1911), 89.
+
+[83] _Hygiea_, LXXV (1913), 1.
+
+[84] _Progres med._, 3d series, XXVI (1910), 25.
+
+[85] Ledingham and Arkwright, _The Carrier Problem in Infectious
+Diseases_, pp. 152-53.
+
+[86] _Jour. Hyg._, XI (1911), 24.
+
+[87] _Muench. med. Wchnschr._, LIV (1907), 979.
+
+[88] See, for example, H. Langer and Thomann, _Deutsche med. Wchnschr._,
+XL (1914), 493.
+
+[89] _Ztschr. f. Infektionsk. ... d. Haustiere_, VIII (1910), 237.
+
+
+
+
+CHAPTER VII
+
+ANIMAL PARASITES
+
+
+Not only pathogenic bacteria but certain kinds of animal parasites
+sometimes enter the human body in or upon articles of food. One of the
+most important of these is the parasite causing trichiniasis.
+
+
+TRICHINIASIS
+
+Trichiniasis or trichinosis is a disease characterized by fever,
+muscular pains, an enormous increase in the eosinophil blood corpuscles,
+and other more or less well-defined symptoms; at the onset it is
+sometimes mistaken by physicians for typhoid fever. The responsible
+parasite is a roundworm (_Trichinella spiralis_, formerly known as
+_Trichina_) which is swallowed while in its encysted larval stage in raw
+or imperfectly cooked pork.[90] The cysts or envelopes in which the
+parasites live are dissolved by the digestive fluids and the young
+larvae which are liberated develop in the small intestine to the adult
+worm, usually within two days. The young embryos, which are produced in
+great numbers by the mature worms, gain entrance to the lymph channels
+and blood stream, and after about ten days begin to invade the
+muscles--a procedure which gives rise to many of the most characteristic
+symptoms of the infection. It is estimated that in severe cases as many
+as fifty million embryos may enter the circulation. The parasites
+finally quiet down and become encysted in the muscle tissue and the
+symptoms, as a rule, gradually subside. Ingestion of a large number of
+parasites at one time often results fatally, the mortality from
+trichiniasis being on the average somewhat over 5 per cent and rising in
+some outbreaks to a much higher figure (30 per cent). On the other hand,
+many infections are so light as to pass unnoticed. Williams[91] found
+_Trichinella_ embryos present in 5.4 per cent of the bodies of persons
+dying from other causes. Such findings are considered to indicate that
+occasional slight _Trichinella_ infections even in the United States are
+quite common. This might indeed be expected from the frequent occurrence
+of infection in swine, about 6 per cent of these animals being found to
+harbor the parasite.
+
+[Illustration: FIG. 7.--Trichinae encysted in intercostal muscle of pig.
+(About 35x1.) (After Neumann and Mayer.)]
+
+The specific symptoms (such as the muscular pain) of trichiniasis may be
+due in part to mechanical damage of the muscle tissue, but it is also
+probable that they are partly due to toxic products exuded by the worms
+and partly to the introduction of alien protein material--the protein of
+the worm--into the tissues. Secondary bacterial infection is also a
+possibility, but there is little evidence to prove that this is an
+important factor in most cases of trichiniasis. The various stages
+observed in the progress of the disease are plainly connected with the
+different phases of the worm's development--the initial localization in
+the intestines, the invasion of the muscles, and the final encystment.
+
+Swine become infected with this parasite by eating scraps of infected
+meat, or the offal of their own kind, or by eating infected rats. The
+rat, through its cannibalistic propensities, becomes infected
+frequently, and is one of the chief factors in the wide dissemination of
+the disease. Human infection is practically accidental and self-limited;
+biologically speaking, man as a host does not enter into the
+calculations of the parasite.
+
+Treatment of established trichiniasis infection is palliative, not truly
+remedial. The parasites, once inside the body, cannot be materially
+affected by the administration of any drug. While cure of trichiniasis
+is thus difficult, if not impossible, prevention is very simple. The
+thorough cooking of all food is sufficient to preclude infection. This
+relatively simple means of destroying the larvae is a more certain as
+well as less expensive method of preventing infection than is the
+laborious microscopic examination of the tissues of every slaughtered
+hog. In Germany between 1881 and 1898 over 32 per cent of 6,329 cases of
+trichinosis that were investigated were traced to meat that had been
+microscopically examined and passed as free from trichinae.[92] On the
+other hand, thorough cooking removes all possibility of danger.
+
+
+TENIASIS
+
+Various tapeworm or cestode infections are contracted by eating meat
+containing the parasite. Particular species of tapeworm usually infest
+the flesh of specific hosts, as _Tenia saginata_ in the beef and _Tenia
+solium_ in the hog. The dwarf tapeworm, _Hymenolepis nana_, develops in
+rats, and the human infections with this parasite occasionally observed
+are probably caused by contamination of food by these animals.
+
+[Illustration: FIG. 8.--_Cysticercus cellulosae_ in pig's tongue. (After
+Neumann and Mayer.)]
+
+Sometimes the existence of the tapeworm in man is restricted to the
+alimentary tract and the symptoms vary from trivial to severe, but
+sometimes (_Tenia solium_) the larval stage of the tapeworm invades the
+tissues and becomes encysted in various organs (brain, eye, etc.),
+where, as in the case of cerebral infection, it may result fatally. The
+encysted larva of _Tenia solium_ was at one time regarded as an
+independent animal species and named _Cysticercus cellulosae_. The
+condition known as "measly pork" is produced by the occurrence of this
+encysted parasite.
+
+So-called hydatid disease is due to the cystic growth produced by the
+larva of a species of tapeworm (_Echinococcus_) inhabiting the intestine
+of the dog. Human infection may be caused by contaminated food as well
+as more directly by hands soiled with petting infected dogs. Several
+varieties of tapeworms infesting fish, especially certain fresh-water
+species, may be introduced into the human body in raw or partly cooked
+fish.
+
+Methods for the prevention of tapeworm infection include the destruction
+of the larvae by heat--that is, the thorough cooking of all meat and
+fish--and the minimization of close contact with those animals, such as
+the dog and cat, that are likely to harbor parasites. Cleanliness in the
+preparation and serving of food, and attention to hand-washing before
+meals, and especially after touching pet animals, are necessary
+corollaries.
+
+
+UNCINARIASIS
+
+Hookworm infection (uncinariasis, ankylostomiasis) is commonly caused by
+infection through the skin of the feet, but the possibility of mouth
+infection cannot be disregarded, and in regions where hookworm disease
+exists methods of guarding against food contamination should be
+practiced, as well as other precautions. Billings and Hickey[93] believe
+that hookworm disease is contracted by unconscious coprophagy (from raw
+vegetables) much more frequently than is generally supposed.
+
+
+OTHER PARASITES
+
+A number of other parasitic worms (e.g., _Strongyloides_, _Ascaris_ or
+eelworm, and _Oxyuria_ or pinworm) may conceivably enter the human body
+in contaminated food, and while, as in hookworm disease, other modes of
+infection are probably more important, the liability to occasional
+infection by uncooked food must not be overlooked.
+
+[Illustration: FIG. 9.--_Lamblia intestinalis._ (After Neumann and
+Mayer.)]
+
+Various forms of dysentery or diarrhea have been attributed to infection
+with _Giardia (Lamblia) intestinalis_. Observations made by Fantham and
+Porter[94] upon cases contracted in Gallipoli and Flanders have given
+support to this view. Strains of this parasite of human origin have been
+shown to be pathogenic for mice and kittens. It is considered possible
+that these animals may act as reservoirs of infection and spread the
+disease by contamination of human food.
+
+
+FOOTNOTES:
+
+[90] The consumption of raw sausage made with pig meat is particularly
+likely to give rise to trichiniasis.
+
+[91] _Jour. Med. Research_, VI (1901), 64.
+
+[92] Edelmann, Mohler, and Eichhorn, _Meat Hygiene_, 1916, p. 182.
+
+[93] _Jour. Amer. Med. Assoc._, LXVII (1916), 1908.
+
+[94] _Brit. Med. Jour._, II (1916), 139.
+
+
+
+
+CHAPTER VIII
+
+POISONOUS PRODUCTS FORMED IN FOOD BY BACTERIA AND OTHER MICRO-ORGANISMS
+
+
+In close relation to the cases of infection with animal or plant
+parasites which have been discussed, there are certain well-established
+instances of poisoning by substances that have been generated in food
+while it is still outside of the body. This is the common type of food
+poisoning in popular estimation, but in point of fact the proved cases
+of this class are much less frequent than the instances of true
+infection with bacteria of the _paratyphoid-enteritidis_ group (chapter
+vi). Thus far the best-known examples of poisoning by the products of
+micro-organisms are botulism and ergotism.
+
+
+ERGOTISM
+
+Ergotism or ergot poisoning is due to the use of rye that has become
+diseased through the attack of a fungus, _Claviceps purpurea_. It
+occurred frequently in the Middle Ages when in times of famine the ergot
+or spurred rye (O.Fr. _argot_, "a cock's spur") was often used in
+default of better food. In Limoges in 922 it is said that forty thousand
+persons perished from this cause. Improvement in the facilities for
+transportation of food into regions where crops have failed, and the use
+of special methods for separating the diseased grain from the wholesome
+have greatly reduced the prevalence of ergotism. In Western Europe
+poisoning from this cause has practically ceased, although Hirsch
+recorded some twenty-eight outbreaks in the nineteenth century; in
+parts of Russia the disease is said still to occur in years of bad
+harvest.[95]
+
+The poison ergot itself has long been used as a drug in obstetrics, but
+its composition is complex and is still not completely understood.
+Several constituents of ergot have been extracted, and these have been
+shown to possess different physiological effects.[96] The symptoms
+observed in the outbreaks of ergotism of mediaeval times are not wholly
+reproduced experimentally by the drug and are thought to have been in
+part due to the semi-starvation engendered by the use of rye from which
+the nutritious portions had been largely removed by the growth of the
+fungus.
+
+
+BOTULISM
+
+The best established case of poisoning by means of bacterial products
+taken in with the food is the serious malady known somewhat
+inappropriately as botulism (botulus, sausage).[97] This kind of food
+poisoning, which has a characteristic set of symptoms, seems to have
+been first recognized and described in 1820 by the German poet and
+medical writer Justinus Kerner. In two articles (1820-22) he enumerates
+174 cases with 71 deaths occurring in Wuerttemberg between 1793 and 1822
+and apparently in most cases connected with the use of insufficiently
+smoked sausage. Mayer[98] tabulates about 600 additional cases observed
+in various parts of Germany down to the end of 1908, the total mortality
+in the 800 cases being about 25 per cent. In France botulism is said to
+be very rare.[99] In Great Britain Savage[100] declares that he has been
+unable to trace the occurrence of a single outbreak. In the United
+States several instances of botulism poisoning are on record
+(Sheppard,[101] 1907, 3 cases, 3 deaths, canned pork and beans;
+Peck,[102] 1910, 12 cases, 11 deaths; Wilbur and Ophuels,[103] 1914,
+canned string beans, 12 cases, 1 death; Frost,[104] 1915, 3 cases, 3
+deaths). Professor Stiles[105] has given a graphic description of his
+own attack of probable botulism due in all likelihood to minced chicken.
+
+[Illustration: FIG. 10.--_Claviceps purpurea:_ 1, ergot on rye-grass; 2,
+ergot on rye; 3, section of a portion of the conidial form of fruit,
+x300; 4, a sclerotium or ergot; 5, head of ascigerous form of fruit; 6,
+an ascus, x300; 7, a single spore, x300. (After Massee, _Plant
+Diseases_, by courtesy of the Macmillan Company.)]
+
+_Symptoms._--The description of a case seen by Wilbur and Ophuels,[106]
+is so typical that it may be cited:
+
+  Girl, aged 23, Tuesday evening, Nov. 23, 1913, ate the dinner
+  including the canned string beans of the light green color together
+  with a little rare roast beef. The following day she felt perfectly
+  normal except that at 10:00 in the evening the eyes felt strained
+  after some sewing. Thursday morning, thirty-six hours after the
+  meal, when the patient awoke, the eyes were out of focus, appetite
+  was not good, and she felt very tired. At night she had still no
+  appetite, was nauseated, and vomited the noon meal apparently
+  undigested. Friday morning, two and one-half days after the meal,
+  the eyes were worse, objects being seen double on quick movement,
+  and it was noticed that they had a tendency to be crossed. A
+  peculiar mistiness of vision was also complained of. She was in bed
+  until late in the afternoon, when she visited Dr. Black. She had had
+  some disturbance in swallowing previous to this time and stated that
+  it felt as if "something came up from below" that interfered with
+  deglutition. The fourth day she remained in bed, was much
+  constipated, and noticed a marked decrease in the amount of urine
+  voided. There was at no time pain except for occasional mild
+  abdominal cramps, no headache, subnormal temperature, and a normal
+  pulse. The fourth and fifth days the breathing became difficult at
+  times and swallowing was almost impossible. The patient complained
+  of a dry throat with annoying thirst. The sixth day there were
+  periods of a sense of suffocation with a vague feeling of unrest and
+  as if there might be difficulty in getting the next breath. The
+  upper lids had begun to droop. The voice was nasal. When the attempt
+  was made to swallow liquids they passed back through the nose. The
+  patient felt markedly weak.
+
+  Physical examination at this time showed ptosis of both upper
+  eyelids, dilatation of the right pupil, sluggish reaction to light
+  of both pupils, apparent paralysis of the internal rectus of the
+  left eye, normal retina, inability to raise the head, control
+  apparently having been lost of the muscles of the neck, inability to
+  swallow, absence of taste. The tongue was heavily coated and the
+  throat was covered with a viscid whitish mucus clinging to the
+  mucous membrane. The soft palate could be raised but was sluggish,
+  particularly on the right side. The exudate on the right tonsil was
+  so marked that it resembled somewhat a diphtheritic membrane. The
+  seventh day there was some change in the condition; occasional
+  periods occurred when swallowing was more effective, and there was
+  less tendency to strangle. On the eleventh day there was some
+  improvement of the eyes, still strangling on swallowing, sensation
+  of taste was keener, and the general condition improved. The twelfth
+  day the patient was able to move her head, but was unable to lift it
+  except when she took hold of the braids of her hair, and pulled the
+  head forward. The eyes could be opened slightly, speech was less
+  nasal and more distinct, and improvement in swallowing was marked.
+  At the end of two weeks the patient was able to take soft diet
+  freely, and at four weeks she was up in a chair for a couple of
+  hours complaining only of general weakness and inability to use her
+  eyes. At the end of five weeks she was able to leave the hospital
+  and return to her home and later to resume her regular work.
+
+In all cases the nervous system is strikingly affected in this form of
+food poisoning. Dizziness, double vision, difficulty in chewing and
+swallowing, and other symptoms of nervous involvement occur with varying
+intensity and may persist for a long time after the first signs of the
+attack. Temperature, pulse, and respiration remain practically normal.
+In contrast with the traditional type of food poisoning
+gastro-intestinal symptoms may be slight or altogether lacking. Freedom
+from abdominal pain is usually noted; diarrhea is the exception and
+constipation the rule; vomiting sometimes occurs, but may be absent. In
+the cases described by Sheppard there was "an entire absence of the
+usual gastro-intestinal symptoms from first to last, no pain or sensory
+disturbance and no elevation of temperature." The visual disturbances
+are very characteristic. Stiles relates his own experiences as follows:
+
+  Vertigo and nystagmus developed [a few hours after eating] in a
+  startling degree, the car [in which he was being taken to his house]
+  seemed to be ascending an endless spiral, the stars made circles in
+  the sky, and the houses by the wayside reeled. The lighted doorway
+  of my house seemed to approach and surround me as I was carried in.
+  My bed for the moment presented itself as a vertical surface which I
+  could not conceive to be a resting place.... Whenever I opened my
+  eyes on this day [the next day] the impression of gyration of the
+  room was appalling.... To turn my head even very slowly from one
+  side to the other brought an accession of the overpowering
+  giddiness.... [eight days after the beginning of the attack]. The
+  nystagmus now became limited to momentary onsets, but in its place I
+  became aware of a peculiar diplopia. The image of one retina was not
+  merely displaced from the position of its fellow but was tilted
+  about 15 degrees from parallel.... This fantastic diplopia gradually
+  gave place to the familiar variety and this occurred less and less
+  often as my convalescence proceeded. From [this date] my recovery
+  pursued a course which was dishearteningly slow but free from any
+  setbacks. Among the persistent symptoms were ... the visual
+  difficulties mentioned. The left pupil was usually smaller than the
+  right and I thought I detected a slight failure to relax
+  accommodation with the left eye. Reading was difficult for several
+  weeks and the ability to write, as requiring closer fixation, was
+  still longer in returning.
+
+In the cases reported by Sheppard visual symptoms were the initial signs
+of trouble, double vision, mistiness, and inability to hit the mark in
+shooting being the first complaint.
+
+The time elapsing between eating the implicated food and the onset of
+the earliest symptoms is usually between twelve and forty-eight hours,
+but may be much less. In Stiles's case the interval was apparently less
+than three hours.
+
+_Anatomical lesions._--In fatal cases no characteristic gross changes
+are observed in the various organs. It has been stated by some writers
+that microscopic degenerative changes occur in the ganglion cells,
+involving especially the so-called Nissl granules, but in the carefully
+studied case reported by Ophuels[107] the Nissl granules were quite
+normal in size, arrangement, and staining qualities. There was, in fact,
+no evidence to substantiate the hypothesis of a specific action of the
+toxin on the nerve-cells. On the other hand, Ophuels found numerous
+hemorrhages in the brain-stem and multiple thromboses in both the
+arteries and veins. He holds, consequently, that the indications of
+severe disturbances of brain circulation associated with hemorrhages and
+thrombosis in medulla and pons are sufficient to explain the symptoms of
+botulism poisoning without having recourse to the assumption that the
+poison has a specific action on certain ganglion cells.
+
+_Bacteriology._--The cause of botulism poisoning was discovered by Van
+Ermengem to be the toxin produced by a bacillus which he named _B.
+botulinus_. This organism was isolated from portions of a ham that had
+caused fifty cases of poisoning (1895) at Ellezelles (Belgium), and also
+from the spleen and gastric contents of one of the three fatal cases.
+The bacillus grows only in the absence of oxygen (strict anaerobe),
+stains by Gram's method, forms terminal spores, and develops best at
+22 deg.C. Unlike most bacteria dangerous to man, it appears unable to grow
+in the human body, and its injurious effect is limited to the action of
+the toxin produced in foodstuffs outside the body. Botulism is an
+intoxication--not an infection. The fact that the bacillus can grow in
+nature only when the free oxygen supply is cut off explains in part at
+least the relatively rare occurrence of botulism since all the
+conditions necessary for the production of the botulism toxin do not
+commonly concur. Next to nothing is known as to how widely _B.
+botulinus_ is distributed. Except in connection with the cases of
+poisoning it has been reported but once in nature.[108] The botulism
+poison is a true bacterial toxin, chemically unstable, destroyed by
+heating at 80 deg.C. for 30 minutes, capable of provoking violent symptoms
+in minute doses, and possessing the property characteristic of all true
+toxins of generating an antitoxin when injected in small, non-fatal
+doses into the bodies of susceptible animals. In animal experiments the
+toxin formed by _B. botulinus_ has been found capable of reproducing the
+typical clinical picture of this form of food poisoning. Symptoms of
+paralysis are produced in rabbits, guinea-pigs, and other animals by the
+injection of so small a dose as 0.0001 c.c. of a filtered broth culture.
+
+[Illustration: FIG. 11.--_Bacillus botulinus_ with spores. Pure culture
+on sugar-gelatin. Van Ermengem preparation. (Kolle and Wassermann.)]
+
+_Epidemiology._--The conditions under which _B. botulinus_ occurs and is
+given opportunities for multiplying are not completely known. It is
+possible that there are localities where this bacillus is particularly
+abundant in the soil or in the intestinal contents of swine or other
+domestic animals, but on the whole it seems more probable that the
+organism is widely distributed, but that it does not often find suitable
+conditions for entrance into, and multiplication in, human food.
+Practically all the reported cases of botulism have been caused by food
+which has been given some sort of preliminary treatment, as smoking,
+pickling, or canning, then allowed to stand for a time, and _eaten
+before cooking_. Since both the bacillus, including the spore stage, and
+its toxin are destroyed by relatively slight heating, it is clear that a
+rather unusual set of factors must co-operate in order that botulism
+poisoning shall take place. These are evidently: (1) the presence of the
+bacilli in sufficient numbers in a suitable foodstuff; (2) the initial
+preparation of the food by a method that does not destroy the _B.
+botulinus_--inadequate smoking, too weak brine,[109] or insufficient
+cooking; (3) the holding of this inadequately preserved food for a
+sufficient length of time under the right conditions of temperature and
+lack of oxygen; (4) the use of this food, in which conditions have
+conspired to favor the production of toxin by _B. botulinus_, without
+final adequate cooking. It seems as reasonable to suppose that the
+infrequency with which these several factors coincide is responsible for
+the relative uncommonness of botulism as to suppose it due to the rarity
+of the specific bacillus. In the Belgian outbreak studied by Van
+Ermengem the poisonous ham had lain at the bottom of a cask of brine
+(anaerobic conditions) while the other ham of the same animal lay on top
+of it but was not covered with brine, and was eaten without producing
+any poisonous effect. In this instance the presence or absence of
+favorable conditions for anaerobic growth seemed to be the decisive
+factor.
+
+_Prevention and treatment._--The food in which _B. botulinus_ has grown
+does not seem to be altered in a way that necessarily arouses
+suspicion. In the case described by Roemer the incriminated ham showed
+bluish-gray areas from which _B. botulinus_ could be isolated, but this
+condition does not seem to have attracted attention before the poisoning
+occurred and was an observation made only after the event. So far as can
+be learned the meat that has caused botulism has always come from
+perfectly sound animals. In some cases the accused article of food is
+said to have had a rancid or acrid taste (due to butyric acid?), but
+there is nothing definitely characteristic about this, as the majority
+of anaerobes produce butyric acid. If, as in the Darmstadt[110] and
+Stanford University[111] epidemics, the food (canned beans) is served
+with salad dressing, a sour taste might pass without notice or even add
+to the relish. In the instance reported by Sheppard the canned beans
+were good in appearance, taste, and smell.
+
+The obvious precaution to take against poisoning of this sort is first
+the use of adequate methods of food preservation. To judge from the
+recorded outbreaks, domestically prepared vegetables and meats are more
+likely to give rise to botulism than those prepared commercially on a
+large scale. The general use of steam under pressure in the large
+canning factories affords a high degree of protection against the
+anaerobic bacteria and their resistant spores. Whatever the method of
+treatment, all canned or preserved food having an unnatural appearance,
+taste, or odor should be rejected. Reheating of all prepared foods
+immediately before use is an additional safeguard. Foods, such as
+salads, composed wholly or in part of uncooked materials should not be
+allowed to stand overnight before being served.
+
+If symptoms of botulism, such as visual disturbances, become manifest,
+the stomach should be emptied with a stomach pump, cathartics
+administered, and strychnine and other stimulants given as required.
+Since one of the noteworthy features of this disease is the paralysis of
+the intestinal tract by the toxin absorbed, the guilty food may lie for
+a long time in the stomach (cf. Stiles, _loc. cit._). Consequently,
+measures to empty the stomach should be taken even if the patient does
+not come under observation until several days after the poisonous food
+has been eaten.
+
+An antitoxic serum has been prepared at the Koch Institute in Berlin.
+This serum has given successful results in animal experimentation, but
+has not been used, so far as I can learn, in any human outbreak. It is
+not available at any point in this country.
+
+
+OTHER BACTERIAL POISONS
+
+The interesting case reported by Barber[112] shows that there are other
+possibilities of food poisoning by formed bacterial poisons. Acute
+attacks of gastro-enteritis were produced in several individuals by the
+use of milk containing a poisonous substance elaborated by a white
+staphylococcus. This staphylococcus occurred in almost pure culture in
+the udder of the cow from which the milk was derived. The milk when used
+fresh was harmless and the poison was generated in effective quantities
+only when the milk stood some hours at room temperature before being
+used. The symptoms were similar to those usually ascribed to "ptomain
+poisoning."
+
+
+SPOILED AND DECOMPOSED FOOD
+
+There is a general belief that food is unwholesome whenever the evidence
+of the senses shows it to be more or less decomposed. This opinion finds
+expression in civilized countries in many legal enactments forbidding
+traffic in decomposed meats, vegetables, and fruits. There is
+unfortunately lack of evidence as to what kinds or degree of visible
+decomposition are most dangerous. In fact, some foods of high nutrient
+value, notably cheeses, are eaten only after somewhat extensive
+decomposition processes (termed ripening) have taken place. The
+characteristic flavors or aromas of the various hard and soft cheeses
+are due to the substances formed by certain species of molds and
+bacteria and are just as properly to be regarded as decomposition
+products as the unpleasant stenches generated by decomposing eggs or
+meat. Indeed, some of the decomposition products formed in the ripening
+of Brie, Camembert, or Limburger are similar to, if not identical with,
+those which are associated with spoiled foods. Sour milk, again, is
+recommended and commonly used as a food or beverage for persons in
+delicate health, and yet sour milk contains many millions of bacteria
+and their decomposition products. Some of the bacteria commonly
+concerned in the natural souring of milk are closely related to
+pathogenic types. The partial decomposition of meats and game birds is
+often considered to be advantageous rather than otherwise. Even eggs, a
+food whose "freshness" is marred for most persons by the initial stages
+of decomposition, are ripened in various ways by the Chinese and eaten
+as a delicacy after the lapse of months or years. The preserved ducks'
+eggs known as pidan are stored for months in a pasty mixture of tea,
+lime, salt, and wood ashes. "They are very different from fresh eggs.
+The somewhat darkened shell has numerous dark green dots on the inner
+membrane. Both the white and yolk are coagulated; the white is brown,
+more or less like coffee jelly...."[113] Increase of ammoniacal nitrogen
+has taken place to an extraordinary degree in these eggs, indicating
+much decomposition of the egg protein. The ammoniacal nitrogen in pidan
+is considerably higher than in the eggs known by egg candlers as black
+rots.
+
+It is evident, therefore, that bacterial growth in substances used as
+food is not necessarily injurious and may in some cases increase the
+palatability of food without destroying its wholesomeness. Little or
+nothing is known about the correlation of visible signs of decomposition
+with the presence of poisonous products, and it is at present impossible
+to say at what point in the process of decomposition a food becomes
+unfit to use owing to the accumulation of poisonous substances within
+it. There seems to be no connection between the natural repugnance to
+the use of a food and its unwholesomeness. Under ordinary conditions the
+nauseous character of very stale eggs is proverbial, and yet few
+nitrogenous foods have so clear a health record as eggs or have been so
+infrequently connected with food poisoning outbreaks.
+
+It might seem tempting to conclude on the basis of the available
+evidence that spoiled or decomposed foods possess poisonous qualities
+only when certain specific bacteria, like the _B. botulinus_ already
+discussed, have accidentally invaded them and formed definite and
+specific poisons. But we have no right to assume that the everyday
+decomposition products of the banal bacteria are in all cases without
+injurious effects. Even though no sharply defined acute form of
+poisoning may be laid at their door, it does not follow that an
+irritating or perhaps slightly toxic action of the ordinary
+decomposition products is altogether absent. Our present knowledge of
+the nature and degree of danger to be apprehended from the use of
+spoiled food is imperfect and unsatisfactory. That fact, however, does
+not release us from the obligation to continue measures of protection
+based even to a limited extent on experience.
+
+
+FOOTNOTES:
+
+[95] Another species of _Claviceps_ (_C. paspali_) which attacks the
+seeds of a wild grass is believed to be responsible for certain
+outbreaks of poisoning among cattle and horses (_Science_, XLIII [1916],
+894).
+
+[96] Barger (_Jour. Chem. Soc._, XCV [1909], 1123) has shown that
+parahydroxyphenylethylamine is present in ergot and is in some degree
+responsible for the physiological action of the drug.
+
+[97] Although some of the early outbreaks were traced to the use of
+sausage, particularly in Wuerttemberg, the proportion of recent botulism
+poisoning attributed to this food is no greater than of sausage-conveyed
+infections with the paratyphoid bacillus (chap. vi), and a number of the
+most completely studied outbreaks of botulism have been traced to ham,
+beans, and other foods.
+
+[98] _Deutsche Viertelj. f. oeffentl. Ges._, XLV (1913), 8.
+
+[99] E. Sacquepee, _Progres med._, XXVI (1910), 583.
+
+[100] _Report to Local Govt. Board on Bacterial Food Poisoning and Food
+Inspection_, N.S. No. 77, 1913, p. 27.
+
+[101] _Southern Cal. Pract._, XXII (1907), 370.
+
+[102] _Ibid._, XXV (1910), 121.
+
+[103] _Arch. of Int. Med._, XIV (1914), 589.
+
+[104] _Amer. Med._, X (1915), 85.
+
+[105] _Jour. Amer. Med. Assoc._, LXI (1913), 2301.
+
+[106] _Loc. cit._
+
+[107] _Loc. cit._
+
+[108] In the feces of a healthy pig (Kempner and Pollock, _Deutsche med.
+Wchnschr._, XXIII [1897], 505).
+
+[109] _B. botulinus_ does not develop in media containing over 6 per
+cent of salt and should not be able to grow in meat properly covered in
+brine made with 10 per cent of salt (Roemer, _Centralbl. f. Bakt._, XXVII
+[1900], 857).
+
+[110] G. Landmann, _Hyg. Rundschau_, XIV (1904), 449.
+
+[111] Wilbur and Ophuels, _Arch. of Int. Med._, XIV (1914), 589.
+
+[112] _Phil. Jour. of Science_, IX (1914), B6, p. 515.
+
+[113] K. Blunt and C. C. Wang, _Jour. Biol. Chem._, XXVIII (1916), 125.
+
+
+
+
+CHAPTER IX
+
+POISONING OF OBSCURE OR UNKNOWN NATURE
+
+
+While many and diverse causes of food poisoning have been discussed in
+the foregoing pages, there remain certain affections definitely
+connected with food that are still of obscure or doubtful causation.
+
+
+MILKSICKNESS OR TREMBLES
+
+This disease, common to man and some of the higher animals, is
+characterized by a definite symptom-complex, the salient features being
+excessive vomiting and obstinate constipation accompanied usually by a
+subnormal temperature. Many cases result fatally. At the present time it
+is known to occur only rarely in some of the southern and central
+western states in this country, but during the period of pioneer
+settlement it was quite common in districts that are now seldom
+affected. A great many references to milksickness are found in the
+writings of the early travelers and physicians in the Middle West, one
+observer predicting that "some of the fairest portions of the West in
+consequence of the prevalence of this loathsome disease must ever remain
+an uninhabitable waste unless the cause and remedy can be discovered."
+In certain regions it is estimated that "nearly one-fourth of the
+pioneers and early settlers died of this disease." The mother of Abraham
+Lincoln fell a victim to this malady in 1818 in southern Indiana.
+
+The disease appears to be usually contracted in the first instance by
+grazing cattle or sheep that have access to particular tracts of land;
+"milksickness" pastures are, as a rule, well known locally for their
+dangerous qualities. Milksickness is communicated to man through the
+medium of raw milk, or butter and possibly of meat. Although some of the
+earlier observers make the statement that the disease is
+self-propagating and can be passed on without limit from one animal to
+another, later experiments cast doubt on this view.[114]
+
+Many different theories have been advanced to account for the origin of
+the disease. The belief that mineral poisons such as arsenic or copper
+might be taken up by grazing animals and eliminated in the milk finds no
+justification either in analytical or in clinical data. Many plants,
+known or suspected to be poisonous, have been accused of furnishing the
+substance that imparts the poisonous quality to the milk of animals
+suffering from trembles, but there is no agreement as to the responsible
+species. Feeding experiments with suspected plants have in no case given
+unambiguous results. While some facts have been supposed to indicate
+that living micro-organisms are the cause of milksickness, other facts
+are opposed to this view, and the most recent experiments in this
+direction did not lead to conclusive results.[115] The true cause of
+milksickness is at present quite unknown.
+
+
+DEFICIENCY DISEASES
+
+Although diseased conditions due to the absence rather than the presence
+of certain constituents in the food are not perhaps to be properly
+classed as food poisoning, they may be mentioned here to illustrate the
+complexity of the food problem. At least one disease,--pellagra--is
+attributed by some observers to the presence of an injurious substance
+or micro-organism in the food, and by others to the absence of certain
+ingredients necessary to the proper maintenance of life.
+
+_Beriberi._--One of the best established instances of a disease due to a
+one-sided or defective diet is beriberi. This affection is prevalent
+among those peoples subsisting chiefly or wholly on a diet of rice
+prepared in a certain way. As a matter of trade convention milled white
+rice has long been considered superior to the unpolished grain. The
+process of polishing rice by machinery removes the red husk or pericarp
+of the grain, and a diet based almost exclusively on polished rice
+causes this well-marked disease--beriberi--which was for long regarded
+as of an infectious nature.[116] It has been shown that if the husks are
+restored to the polished grain and the mixture used as food the disease
+fails to develop. Experiments upon chickens and pigeons show that an
+exclusive diet of white rice causes in these animals a disease
+(polyneuritis of fowls) similar to beriberi, which likewise can be
+arrested or prevented by a change in diet. From such observations the
+conclusion has been drawn that in the pericarp of the rice grain there
+are certain substances essential to the maintenance of health and that
+their withdrawal from the diet leads to nutritional disturbances. The
+name "vitamin" has been given to these substances, but little is known
+about their chemical or physiological nature. In a varied diet vitamins
+are presumably present in a variety of foodstuffs, but if the diet is
+greatly restricted, some apparently trivial treatment of the food may
+result in their elimination. It is uncertain how many and how various
+the substances are that have been classed by some writers under the
+designation vitamin. At least two "determinants" are thought to be
+concerned in the nutrition of growth, a fat-soluble and a water-soluble
+substance.[117]
+
+_Pellagra_ is one of the diseases attributed to an unbalanced diet,[118]
+and it has been suggested that the increased use of highly milled maize
+and wheat flour from which vitamins are absent may be responsible for
+the extension of this malady in recent years. Other observers, while
+admitting that a faulty diet may predispose to pellagra as to
+tuberculosis and other diseases, do not assent to the view that it is
+the primary factor.[119]
+
+_Lathyrism._--The name lathyrism has been given to a disease supposed to
+be connected with the use of the pulse and the chick pea. Nervous
+symptoms are conspicuous and sometimes severe, although the affection is
+of a milder type than pellagra. The disease is said to be associated
+with the exclusive or almost exclusive use of leguminous food and with
+generally miserable conditions of living. It is yet uncertain whether
+lathyrism is a deficiency disease like beriberi and possibly pellagra,
+or whether it is due to a mixture of foreign and poisonous seeds with
+the particular legumes consumed, or whether under certain conditions
+the legumes themselves may contain poisonous substances generated by
+some unknown fungus growths.
+
+_Favism_ (from _fava_, "bean") is an acute febrile anemia with jaundice
+and hemoglobinuria which occurs in Italy and has been attributed to the
+use of beans as food or even to smelling the blossom of the bean
+plant.[120] A marked individual predisposition to the malady is said to
+exist. Although the symptoms are very severe and seem to point to an
+acute poisoning, no toxic substance has been isolated from the
+implicated beans. It has been suggested by some that bacterial
+infection, and by others that a fungous growth on the bean, is
+responsible, but no evidence has been brought forward to support either
+assumption.
+
+_Scurvy_ in some forms is undoubtedly connected with the lack of certain
+necessary components of a normal diet. The development of scurvy on
+shipboard in the absence of fresh milk, fresh vegetables, fruit juice,
+and the like is a fact long familiar. Guinea-pigs fed on milk, raw and
+heated, and on milk and grain have developed typical symptoms of
+scurvy.[121] On the other hand, a form of experimental scurvy has been
+produced in guinea-pigs and rabbits kept on an ordinary diet of green
+vegetables, hay, and oats by the intravenous injection of certain
+streptococci.[122] The relative share of diet and infection in the
+production of human scurvy is consequently regarded by some
+investigators as uncertain.
+
+_Rachitis_ or rickets is a pathological condition in some way connected
+with a protracted disturbance of digestion which in turn leads to faulty
+calcium metabolism. It does not seem probable that rickets is caused by
+too little calcium in the food, but rather by the inability of the bone
+tissue to utilize the calcium brought to it in the body fluids.
+Experiments upon the causation of the disease have not given uniform
+results, and it does not seem possible at present to place
+responsibility for this condition upon any particular form of diet, such
+as deficiency of fat or excess of carbohydrates or protein. It appears
+to be true that the prolonged use of any food leading to nutritional
+disturbance causes an inability on the part of the bone cells to take up
+calcium salts in the normal manner.
+
+While there are many obscure points with regard to the origin of both
+scurvy and rickets, there is no doubt that some dietary shortcoming lies
+at their base, and that they can be cured or altogether avoided by
+maintenance of suitable nutritional conditions.
+
+
+THE FOODS MOST COMMONLY POISONOUS
+
+Certain articles of food figure with special frequency in the reports of
+food poisoning outbreaks. It is not clear in all cases why this special
+liability to inflict injury exists. For an example, vanilla ice-cream
+and vanilla puddings have been so often implicated that some
+investigators have not hesitated to ascribe a poisonous quality to the
+vanilla itself. But there is no good evidence that this is the case, and
+it has been suggested that the reducing action of the vanilla favors the
+growth of anaerobic bacteria which produce poisonous substances, an
+explanation highly conjectural.
+
+The conspicuous frequency with which the consumption of raw meat
+provokes food poisoning has already been set forth and in large part
+explained by the occasional derivation of meat from animals infected
+with parasites harmful to man. The even greater culpability of raw milk
+is due to the fact that milk is not only, like meat, sometimes obtained
+from an infected animal, but that it is a particularly good culture
+medium for bacteria, and in the process of collection or distribution
+may become infected through the agency of a human carrier. Foods such as
+ice-cream that are prepared with milk are also often connected with food
+poisoning. It seems probable that illness caused by ice-cream is much
+more commonly due to bacterial infection than to poisoning with metals
+or flavoring extracts. The responsibility of these latter substances is
+entirely problematic.
+
+Cases of cheese poisoning, which apparently are relatively numerous, are
+of quite obscure causation. Whether such poisoning is due more commonly
+to some original contamination of the milk, or to an invasion of the
+cheese by pathogenic bacteria in the course of preparation, or to the
+formation of toxic substances by bacteria or molds during the process of
+ripening which the cheese undergoes, is left uncertain in the majority
+of cases.
+
+Shellfish poisoning from eating oysters, mussels, or clams is
+unquestionably caused in some instances by sewage contamination of the
+water from which the bivalves are taken, and in such cases bacilli of
+the typhoid or paratyphoid groups are commonly concerned. It is a
+disputed question whether certain recorded outbreaks of mussel poisoning
+have been due to bacterial infection or whether sometimes healthy or
+diseased mussels taken from unpolluted water contain a poisonous
+substance. In a similar way it is uncertain whether a certain marine
+snail (_Murex bradatus_), sometimes used for food, contains under
+certain conditions a substance naturally poisonous for man, or whether
+it is poisonous only when it is infected or when toxigenic bacteria have
+grown in it.
+
+Potato poisoning has been attributed in some cases to bacterial
+decomposition of potatoes by proteus bacilli; in other cases, to a
+poisonous alkaloid, solanin, said to be present in excessive amounts in
+diseased and in sprouting potatoes. It is noteworthy that many instances
+of potato poisoning have been connected with the use of potato salad
+which had stood for some time after being mixed, so that the possibility
+of infection with the paratyphoid bacillus or other pathogenic organisms
+cannot be excluded. That solanin is ever really responsible for potato
+poisoning is considered doubtful by many investigators.
+
+These examples are sufficient to show that in a considerable proportion
+of cases of alleged food poisoning there is a large measure of
+uncertainty about the real source of trouble. Although the trend of
+opinion has been in the direction of an increased recognition of the
+share of certain bacteria, especially those of the paratyphoid group,
+there is an important residue of unexplained food poisoning that needs
+further skilled investigation. It is one of the objects of this book to
+point out this need and to draw attention to the numerous problems that
+await settlement. The first step is the regular and thorough
+investigation of every food poisoning outbreak.
+
+
+FOOTNOTES:
+
+[114] Jordan and Harris, _Jour. Infect. Dis._, VI (1909), 401.
+
+[115] _Ibid._
+
+[116] E. B. Vedder, _Jour. Amer. Med. Assoc._, LXVII (1916), 1494.
+
+[117] McCollum and Davis, _Jour. Biol. Chem._, XXIII (1915), 181.
+
+[118] Goldberger, _Jour. Amer. Med. Assoc._, LXVI (1916), 471.
+
+[119] MacNeal, _Jour. Amer. Med. Assoc._, LXVI (1916), 975; Jobling,
+_Jour. Infect. Dis._, XVIII (1916), 501.
+
+[120] Gasbarrini, _Policlinico_, November 14, 1915; abstract, _Jour.
+Amer. Med. Assoc._, LXV (1915), 2264.
+
+[121] Holst and Froelich, _Jour. Hyg._, VII (1907), 619; Moore and
+Jackson, _Jour. Amer. Med. Assoc._, LXVII (1916), 1931.
+
+[122] Jackson and Moody, _Jour. Infect. Dis._, XIX (1916), 511.
+
+
+
+
+INDEX
+
+
+  A
+
+  Acid pickles, 33
+
+  Adulteration, food, 41
+
+  Agglutination, 60, 64, 70
+
+  Alkaloid, 107
+
+  Allergy, food, 6
+
+  Almonds, 11
+
+  _Amanita_:
+    _aurantiaca_, 20;
+    _caesaria_, 18, 20;
+    _muscaria_, 18, 19, 20, 22;
+    _phalloides_, 21, 22, 23;
+    _verna_, 22
+
+  "_Amanita_ toxin," 22, 24
+
+  Anaphylaxis, 9, 10, 11
+
+  Aniline dyes, 32
+
+  Animal parasites, 79
+
+  Animals, 13, 14, 24, 44, 50, 67, 68, 70, 71, 72, 78, 93, 95, 100, 106;
+    emergency-slaughtered, 59, 62, 63, 65, 72
+
+  Ankylostomiasis, 83
+
+  Annatto, 32
+
+  "Anti-anaphylaxis," 11
+
+  Antimony, 27
+
+  Antiseptic chemicals, 33, 40
+
+  Antitoxin, 24;
+    diphtheria, 9
+
+  Appendicitis, 1
+
+  Arsenic, 26, 101
+
+  Arteries, 3
+
+  Artichokes, 16
+
+  _Ascaris_, 84
+
+  Asiatic cholera, 50
+
+  Asparagus, 30, 31
+
+  Asthma, 10, 12
+
+  Atropin, 20
+
+
+  B
+
+  Bacillus:
+    _botulinus_, 92-96;
+    _coli_, 56;
+    Danysz, 75;
+    _diphtheriae_, 69;
+    _enteritidis_, 58, 59, 60, 63, 64, 65, 66, 67, 68, 69, 70, 71,
+      72, 74;
+    _enteritidis-suipestifer_, 70, 72;
+    _paratyphoid-enteritidis_, 68, 69, 85;
+    _paratyphosus_, 58, 66;
+    _paratyphosus_ B, 60, 65, 66, 73, 74;
+    _proteus_, 55, 56, 57, 107;
+    _suipestifer_, 65, 66, 67, 68, 71, 72, 73, 74;
+    tetanus, 69;
+    tubercle, 44, 51, 52, 53;
+    typhoid, 44-47, 64, 106
+
+  Bacteria:
+    food-borne, 44, 58;
+    pathogenic, 44, 58
+
+  Bacterial products, 85
+
+  Balloon-fish, 24
+
+  Barbel, 25
+
+  Beans, 14, 31, 46, 86, 88, 95, 104
+
+  Beef stew, 59
+
+  Beer, 26, 27
+
+  Benzoate of soda, 34
+
+  Benzoic acid, 34, 35, 36
+
+  Beriberi, 102
+
+  Berries, 29, 35
+
+  Birds, game, 97
+
+  Biscuits, soda, 36
+
+  Blood vessels, 2, 39
+
+  Borax, 37
+
+  Boric acid, 37, 38, 40
+
+  Botulism, 86;
+    anatomical lesions, 91;
+    bacteriology, 92;
+    cases, 87;
+    epidemiology, 93;
+    prevention and treatment, 94;
+    symptoms, 88
+
+  Bread, 47, 48
+
+  Butter, 16, 32, 40, 101
+
+  Butyric acid, 95
+
+
+  C
+
+  Caffeine, 36, 41
+
+  Cakes, 76
+
+  "Calf diarrhea," 72
+
+  Candies, 27, 28, 32, 41
+
+  Canned foods, 4, 5, 7, 8, 29, 30, 95
+
+  Canning, 33, 93
+
+  Cap, metallic, 28
+
+  Cardamom, oil of, 16
+
+  Carriers, 55;
+    paratyphoid, 61, 62, 66, 67, 70, 73, 78;
+    typhoid, 45, 48, 50, 66
+
+  Cases of:
+    botulism, 87,
+      listed by Mayer, 88,
+      in U.S., 88-91;
+    dysentery, 84;
+    food sensitization, 10, 11, 12;
+    milksickness, 100;
+    mushroom poisoning, 20, 21, 22;
+    plant poisoning, 14;
+    poisoning from asparagus, 30;
+    trichiniasis, 80, 81;
+    tuberculosis, 53
+
+  Cat, 83
+
+  Cathartics, 96
+
+  Cattle, 10, 51, 53, 54, 55, 62, 63, 71, 72, 74, 82, 86, 96, 100
+
+  Celery, 45, 46, 47
+
+  Cereals, 12, 62
+
+  Cestode infection, 82
+
+  Cheese, 5, 7, 28, 97, 106
+
+  Chemicals, antiseptic, 33, 40
+
+  Chicken, 71, 88
+
+  Chick pea, 103
+
+  Chicory, 41
+
+  Chocolate, 28
+
+  Cholera microbe, 51
+
+  Chopped beef, 59
+
+  _Cicuta maculata_, 14, 16, 17
+
+  Cinnamon, 37
+
+  Clams, 50, 106
+
+  _Claviceps_:
+    _paspali_, 86;
+    _purpurea_, 85, 87
+
+  Codfish, 67
+
+  Coffee, 36, 41
+
+  Coffee-tree, 14
+
+  Coloring, artificial, 40
+
+  Coloring substances, 31
+
+  _Conium maculatum_, 15
+
+  "Contact infection," 62, 67
+
+  Cook, 44, 45, 50, 73, 74
+
+  Copper, 30, 101
+
+  Copper:
+    acetate, 31;
+    salts, 31;
+    sulphate, 31, 32
+
+  Cranberries, 35
+
+  Creosote, 34
+
+  _Cysticercus cellulosae_, 82, 83
+
+
+  D
+
+  Daffodil bulbs, 14
+
+  Danysz bacillus, 75
+
+  Death Camas, 14
+
+  Death-cup, 21, 23
+
+  Death-rates, 2, 3, 4, 39
+
+  _Delphinium_, 14
+
+  Diarrhea, 84
+
+  Diet, defective, 102, 103, 104, 105
+
+  Diphtheria, 54
+
+  Diseases:
+    deficiency, 101;
+    degenerative, 2;
+    milk-borne, 54;
+    skin, 12
+
+  Dog, 25, 83
+
+  Drying, 33, 40
+
+  Dyes, aniline, 32
+
+  Dysentery, 84
+
+
+  E
+
+  _Echinococcus_, 83
+
+  Eczema, 10, 12
+
+  Eelworm, 84
+
+  Eggs, 6, 10, 11, 12, 97, 98
+
+  Egg-white, 9, 10, 11, 12
+
+  Epidemics. _See_ Outbreaks
+
+  Ergot, 85
+
+  Ergotism, 85-86
+
+  "Expectation of life," 2
+
+  Extracts, flavoring, 106
+
+
+  F
+
+  Favism, 104
+
+  Fish, 5, 24, 25, 34, 62, 67, 71, 83
+
+  Flies, 47
+
+  Flour, 32, 43, 103
+
+  "Fly _Amanita_," 18, 19, 21
+
+  Fly poison, 18
+
+  Food:
+    adulteration, 41;
+    allergy, 6;
+    coloration, 32;
+    intoxication, 18, 57, 92;
+    preservatives, 33;
+    substitutes, 16, 41
+
+  Foods:
+    canned, 4, 5, 7, 8, 29, 30, 95;
+    cooked, 47, 51, 52, 53, 54, 60, 63, 69, 70, 78, 81, 94;
+    decomposed, 39, 97;
+    most commonly poisonous, 105;
+    protein, sensitization to, 9;
+    smoked, 34, 39;
+    spoiled, 39, 97;
+    uncooked, 7, 46, 47, 48, 55, 63, 69, 70, 79, 84, 94, 96
+
+  Foot-and-mouth disease, 55
+
+  Formaldehyde, 36, 40
+
+  Fowl, 5
+
+  Fruits, 5, 10, 29, 30, 35, 47, 50, 62, 97, 104
+
+  "Fruit ethers," 42
+
+  Fruit syrups, 42
+
+  _Fugu_, 25
+
+  Fungus, 85
+
+
+  G
+
+  Gallstones, 1
+
+  Game birds, 97
+
+  Gastro-enteritis, 56, 60, 74, 96
+
+  _Giardia (Lamblia) intestinalis_, 84
+
+  Globe-fish, 24
+
+  Glucose, 27, 41
+
+  Goose, 71;
+    liver, 78
+
+  Grain, 85, 104
+
+  Grass, wild, 86
+
+  _Gymnocladus dioica_, 14
+
+
+  H
+
+  _Hackfleisch_, 59
+
+  Ham, 86, 92, 94, 95
+
+  Hamburger steak, 59, 78
+
+  Hay, 104
+
+  Hay fever, 9
+
+  Heart, 3, 22
+
+  Heating, 40
+
+  Hellebore, 14
+
+  Hemlock, 13, 15;
+    poison, 16;
+    water, 14, 16, 17
+
+  Hippuric acid, 35, 36
+
+  Hog cholera, 66, 71
+
+  Honey-locust, 14
+
+  Hookworm infection, 83
+
+  Horse, 71, 86
+
+  Horseradish, 16
+
+  Hydatid disease, 83
+
+  _Hydrocarpus_, 16
+
+  _Hymenolepis nana_, 82
+
+
+  I
+
+  Ice, 75
+
+  Ice cream, 5, 7, 32, 105, 106
+
+  Infection:
+    accidental, 72;
+    Asiatic cholera, 50;
+    _Bacillus proteus_(?), 55;
+    bacterial poisons, 86, 96;
+    carrier, 44, 45, 48, 50, 55, 61, 62, 66, 67, 70, 73, 78;
+    cestode, 82;
+    _Giardia (Lamblia) intestinalis_, 84;
+    hookworm, 83;
+    laboratory, 72;
+    milk-borne, 54;
+    parasitic, 79;
+    paratyphoid, 58;
+    scurvy, 104;
+    secondary bacterial, 80;
+    soil, 46;
+    tapeworm, 82;
+    tuberculous meat, 51;
+      tuberculous milk, 53;
+    typhoid food, 44
+
+  Intoxication, food, 18, 57, 92
+
+  Iron pyrites, 26
+
+
+  J
+
+  Jams, 27
+
+  Japanese _Fugu_, 25
+
+  Jars, preserve, 28
+
+  Jelly, 32, 50
+
+
+  K
+
+  _Kalmia latifolia_, 14
+
+  Kidneys, 2, 3, 22, 24, 39
+
+  Kittens, 84
+
+
+  L
+
+  Larkspur, 14
+
+  Lathyrism, 103
+
+  Laurel, 14
+
+  Lead, 27
+
+  Lead:
+    chromate, 28;
+    foil, 28;
+    pipes, 28;
+    salts, 29
+
+  Legumes, 104
+
+  Lettuce, 45, 50
+
+  Liver, 22, 24;
+    goose, 78
+
+  Loco-weed, 14
+
+  Lupines, 14
+
+
+  M
+
+  Maize, 103
+
+  Maratti-oil, 16
+
+  Margarin, 16
+
+  Marsh-marigold, 14
+
+  Mary Malloy, 45
+
+  "Measly pork," 83
+
+  Meat, 5, 7, 24, 33, 37, 40, 44, 51, 52, 53, 57, 58, 59, 62, 63, 64,
+      65, 68, 69, 70, 71, 72, 75, 76, 77, 78, 79, 83, 95, 97, 101, 106;
+    jellies, 69;
+    pies, 69, 73;
+    puddings, 69
+
+  Meat inspection, 77, 81
+
+  Metals, 5, 106
+
+  Mice, 56, 74, 75, 78, 84
+
+  Milk, 5, 6, 7, 10, 11, 40, 48, 50, 51, 53, 54, 55, 62, 69, 70, 72,
+      73, 76, 77, 96, 97, 101, 104, 106
+
+  Milksickness, 100-101
+
+  Molasses, 30
+
+  _Murex bradatus_, 107
+
+  Muscarin, 22
+
+  Mushrooms, 5, 13, 18-24
+
+  Mussels, 50, 106
+
+  "Mutations," 68
+
+
+  N
+
+  Neuritis, 26
+
+  "Neurotoxin," 24
+
+  Nipples, rubber, 27
+
+  Nissl granules, 91
+
+  Nitrogen peroxide, 32
+
+
+  O
+
+  Oatmeal, 11
+
+  Oats, 104
+
+  Oil of cardamom, 16;
+    of cloves, 37
+
+  Olive stones, 41
+
+  Outbreaks due to:
+    beans, Darmstadt, 95,
+      Stanford University, 95;
+    beef, Breslau, 58;
+    beef stew, Limerick, 59;
+    beer, England, 26;
+    bread, Elgin, 48;
+    codfish, 67;
+    diseased animals, 71;
+    ergot, Limoges, 85;
+    gastro-enteritis carrier, 74;
+    group and family in U.S., 4, 5;
+    ham, Ellezelles, 92;
+    human contamination, 73;
+    list of, by:
+      Hirsch, 85,
+      Huebener, 58,
+      Mayer, 65,
+      Savage, 58;
+    margarin, Hamburg, 16;
+    meat, 65, 69;
+    Frankenhausen, 63,
+      Ghent, 77;
+    meat pies, Wareham, 73;
+    milk, 96;
+    Kristiania, 73,
+      Newcastle, 69;
+    miscellaneous contaminations, 74;
+    mushrooms, New York City, 18;
+    oysters, 48;
+    paratyphoid carrier, 73;
+    pie, Westerly, 60;
+    potato salad, 65;
+    public markets, South Philadelphia, 46;
+    rat virus, 75;
+    sausage, 65,
+      Hanover, 56,
+      Wuerttemberg, 86;
+    "sour grass soup," New York City, 18;
+    spaghetti, Hanford, 44;
+    typhoid carrier, New York City, 45;
+    _Vanille Pudding_, 65;
+    vermicelli, 67;
+    watercress, Philadelphia, 46;
+    water hemlock, New Jersey, 16
+
+  Oxalic acid, 18
+
+  _Oxyuria_, 84
+
+  Oysters, 5, 24, 48, 49, 50, 71, 106
+
+
+  P
+
+  Palmolin, 16
+
+  _Panaeolus papilionaceus_, 21
+
+  "Paragaertner" forms, 68
+
+  Parasites, 79, 84
+
+  Paratyphoid fever, 58-78;
+    carriers, 61, 62, 66, 67, 70, 73, 78;
+    diseased animals, 67, 71;
+    gastro-intestinal, 61;
+    general characters of, 61;
+    human contamination, 73;
+    means of prevention, 77;
+    miscellaneous contaminations, 74;
+    sources of infection, 71;
+    symptoms, 61;
+    toxin production, 68;
+    typhoid-like, 61;
+    typical outbreaks, 58
+
+  Parrots, 72
+
+  Parsnips, 16
+
+  Pasteurization, 48, 54
+
+  Pastry, 47
+
+  Pate de foie gras, 78
+
+  Peas, 31, 43, 46
+
+  Pellagra, 102, 103
+
+  Pepper, 41
+
+  Pericarp of rice, 102
+
+  Peripheral neuritis, 26
+
+  Pickling, 93
+
+  Pidan, 98
+
+  Pie, 60
+
+  Pigs, 71
+
+  Pike, 25
+
+  Pinworm, 84
+
+  Plant oils, 16
+
+  Plants, 9, 13-24, 25, 101
+
+  Poisons:
+    bacterial, 96;
+    chemical, 26;
+    mineral, 26;
+    organic, 26;
+    protoplasmic, 33
+
+  Poisoning by:
+    aniline dyes, 32;
+    animals, 24;
+    antimony, 27;
+    arsenic, 26;
+    Asiatic cholera infection, 50;
+    _Bacillus proteus_(?) infection, 55;
+    botulism intoxication, 86;
+    coloring substances, 31;
+    copper, 30;
+    defective diet:
+      beriberi, 102,
+      favism, 104,
+      lathyrism, 103,
+      pellagra, 103,
+      rickets, 105,
+      scurvy, 104;
+    egg-white, 9;
+    ergot, 85;
+    fish, 25;
+    food preservatives, 33;
+    food substitutes, 41;
+    lead, 27;
+    milk-borne infections:
+      diphtheria, 54,
+      foot-and-mouth disease, 55;
+    milksickness, 100;
+    scarlet fever, 54,
+      and septic sore throat, 55;
+    mushrooms, 18;
+    parasites, animal:
+      teniasis, 82,
+      trichiniasis, 79,
+      other, 84;
+    paratyphoid infection, 58;
+    plants, 13;
+    shellfish, 24;
+    tin, 29;
+    tuberculosis infection, 51;
+    typhoid infection, 44
+
+  Poisoning, food:
+    articles of food most commonly connected with, 7;
+    effects of, 2;
+    extent of, 3;
+    frequency of, 1;
+    kinds of, 6;
+    means of prevention, 2;
+    obscure, 100;
+    outbreaks of, in United States, 3, 4, 5;
+    reports of, 3, 4, 8;
+    scope of book, 6;
+    seasonal incidence of, 5;
+    unknown, 100
+
+  Poison-ivy, 14
+
+  "Poison squads," 34
+
+  Pollen, 9
+
+  Polyneuritis of fowls, 102
+
+  Pork, 79
+
+  Pork and beans, 88
+
+  Potatoes, 46, 107
+
+  Potato salad, 65
+
+  Preservatives:
+    chemical, 33;
+    food, 33;
+    household, 37
+
+  Proteins, 9, 11, 12, 62, 69, 80
+
+  Protochloride of tin, 30
+
+  "Ptomain poisoning," 1, 3, 18, 68, 97
+
+  Puffers, 24
+
+  Pulse, 103
+
+  Pyrites, iron, 26
+
+
+  Q
+
+  Quinine, 33
+
+
+  R
+
+  Rabbit, 71
+
+  Rachitis, 105
+
+  Radishes, 45
+
+  Rash, 10, 12
+
+  Rats, 56, 74, 75, 78, 81, 82
+
+  "Rat virus," 75
+
+  Refrigeration, 33, 40
+
+  Rice, 43, 102
+
+  Ricin, 14
+
+  Rickets, 105
+
+  Ripening, 97
+
+  Roundworm, 79
+
+  "Royal _Amanita_," 18
+
+  Rye, 85
+
+
+  S
+
+  Saccharin, 41
+
+  Salad, 5, 95, 107;
+    dressing, 95
+
+  Salicylic acid, 36
+
+  Salt, 33, 41, 94
+
+  Salt solution, 33, 40
+
+  Salting, 33
+
+  Saltpeter brines, 33
+
+  Sandwiches, 46
+
+  Saponin, 42
+
+  Sausage, 5, 7, 40, 56, 65, 69, 75, 78, 79, 86, 88
+
+  Scarlet fever, 54
+
+  Scurvy, 55, 104
+
+  Sensitization, food, 6, 9
+
+  "Septic sore throat," 55
+
+  Serum, antitoxic, 96;
+    blood, 11, 64, 65, 70;
+    therapeutic, 9
+
+  Shark, 25
+
+  Sheep, 71, 100
+
+  Shellfish, 10, 24, 106
+
+  Shrimp, 71
+
+  Smoking, 33, 93, 94
+
+  Snail, 107
+
+  "Soda water," 42
+
+  Sodic carbonate, 36
+
+  Sodium benzoate, 34
+
+  Sodium fluoride, 40
+
+  "Soft drinks," 28, 42
+
+  Soil, infected, 46, 47
+
+  Solanin, 107
+
+  Solder, 28
+
+  Sorrel, 18
+
+  "Sour grass soup," 18
+
+  Sour milk, 97
+
+  Spaghetti, 44
+
+  Spices, 37
+
+  Staphylococcus, 96
+
+  Stoppers, patent metal, 28
+
+  Strawberries, 10
+
+  "Streptococcus sore throat," 55
+
+  _Strongyloides_, 84
+
+  Strychnine, 33, 96
+
+  Sturgeon, 25
+
+  Substances, coloring, 31
+
+  Substitutes, food, 16, 41
+
+  Sugar, 26, 28, 41, 42
+
+  Sugar solution, 33, 40
+
+  Sulphite, 36, 40
+
+  Sulphurous acid, 26, 27, 36
+
+  Swine, 74, 80, 81, 82, 93
+
+  Symptoms:
+    cholera-like, 25, 77;
+    circulatory, 10;
+    coma, 22;
+    constipation, 89, 90, 100;
+    convulsions, 20, 22, 25;
+    coryza, 10;
+    diarrhea, 10, 21, 61, 90;
+    difficulty in swallowing, 20;
+    digestive, 1, 61, 105;
+    dizziness, 20, 90;
+    eyelids, edematous, 10;
+    febrile anemia, 104;
+    fever, 61, 79;
+    gastro-intestinal, 1, 10, 58, 61, 90;
+    hemoglobinuria, 104;
+    jaundice, 104;
+    mental, 24;
+    nausea, 10, 12, 88;
+    nervous, 10, 24, 90, 103;
+    pain:
+      abdominal, 21, 61, 89,
+      muscular, 79, 80;
+    paralysis, 25, 96;
+    rapidity of appearance of, 10, 44, 58, 61, 91;
+    rash, 10, 12;
+    sneezing, 10;
+    temperature, subnormal, 89, 100;
+    thirst, 21, 89;
+    trismus, 20;
+    visual, 20, 88, 89, 90, 91, 96;
+    vomiting, 10, 12, 21, 88, 90, 100
+
+  Syrups, 27, 42
+
+
+  T
+
+  Tapeworm, 82, 83
+
+  Tea, 36
+
+  _Tenia saginata_, 82
+
+  Teniasis, 82
+
+  _Tenia solium_, 82
+
+  Tetrodontidae, 24
+
+  Theobromine, 36
+
+  Tin, 29-30
+
+  Tin salts, 30
+
+  "Toadstools," 18
+
+  Tomatoes, 12
+
+  Toxin, 68
+
+  Trembles, 100
+
+  Trichina, 79
+
+  _Trichinella spiralis_, 79, 80
+
+  Trichiniasis, 79
+
+  Trichinosis, 79
+
+  Tuberculin, 9
+
+  Tuberculosis, 44, 51
+
+  Typhoid fever: 44-50, 78, 79;
+    carriers, 45, 48, 50, 66;
+    milk-borne, 48
+
+
+  U
+
+  Uncinariasis, 83
+
+  Urticaria, 10
+
+  Utensils, cooking, 27, 28, 30
+
+
+  V
+
+  Vanilla: 105;
+    ice cream, 105;
+    pudding, 65, 105
+
+  Vegetables, 5, 29, 30, 31, 45, 46, 47, 62, 83, 95, 97, 104
+
+  _Veratrum viride_, 14
+
+  "Verdigris poisoning," 31
+
+  Vermicelli, 67
+
+  "Vitamin," 102, 103
+
+
+  W
+
+  Water, 28, 50, 75
+
+  Watercress, 45, 46
+
+  Wintergreen, 14
+
+
+  Z
+
+  _Zygadenus_, 14
+
+
+
+
+Transcriber's Notes:
+
+
+Passages in italics are indicated by _underscore_.
+
+Passages in fracture style are indicated by +fracture+.
+
+This book contains 1 chemical formula on page 20: C{5}H{15}NO{3} the
+numbers in brackets should be read as subscripts.
+
+Illustrations have been moved from the middle of a paragraph to the
+closest paragraph break.
+
+The punctuation in the index was inconsistent, all semi-colons in
+listings for page numbers have been changed into commas, they are not
+specially mentioned/marked in the list of changes. Subentries are in
+general separated by semi-colons, these have been added or changed from
+other punctuation marks silently. Sub-subentries are in general
+separated by commas, these have been added or changed from other
+punctuation marks silently.
+
+Atropin and atropine have been retained in both versions in
+this project.
+
+Table A in footnote [1] contains a potential mathematical error, the
+2nd column (Expectation of Life 1879-81), row (Ages) 40 shows the value
+23.0, it should be 23.9 to add up correctly in the 4th column (Gain or
+Loss). The original value (23.0) has been retained.
+
+Footnote [2] "also Doerr, "Allergie und Anaphylaxis," in Kolle" is cited
+often as "also Doerr, "Allergie und Anaphylaxie," in Kolle". It has been
+retained in the version printed in the book for authenticity reasons.
+
+Margarin (pages 16 and 112) is in general spelled margarine, it has been
+retained in this book for reasons of authenticity.
+
+Maratti-oil (pages 16 and 112) is in general known as moratti-oil, it
+has been retained in this book for reasons of authenticity.
+
+Hydrocarpus (pages 16 and 111) is in general known as Hydnocarpus, it
+has been retained in this book for reasons of authenticity.
+
+Amanita caesaria (pages 18, 20, and 109) is also known as Amanita
+caesarea but retained for this project in the first form.
+
+Muscarin (pages 20, 21, 22, and 112) is in general spelled muscarine, it
+has been retained in this book for reasons of authenticity.
+
+Zygadenus (pages 25 and 115) is in general known as Zigadenus, it has
+been retained in this book for reasons of authenticity.
+
+The typhoid carrier in New York Mary Mallon (aka Typhoid Mary) mentioned
+on page 45 as well as on page 112 is spelled in this book as Mary
+Malloy, the original of the book has been retained.
+
+Other than the corrections listed below, printer's inconsistencies
+in spelling, punctuation, hyphenation, and ligature usage have
+been retained.
+
+The following misprints have been corrected:
+
+  added 0 to +.89 in table B footnote [1], second to last value
+  in 4th column.
+
+  changed "la face vulteuse" into "la face vultueuse" page 21
+
+  changed "Paneolus papilionaceus" into "Panaeolus papilionaceus"
+  page 21
+
+  the italic mark-up for "XLV" in "f. oeffentl. Ges., XLV" has been
+  removed, footnote [69]
+
+  changed "R. Trommsdorff, L. Rajchmann, and A. E. Porter," into "R.
+  Trommsdorff, L. Rajchman, and A. E. Porter," footnote [82]
+
+  changed "Paneolus papilionaceus" into "Panaeolus papilionaceus"
+  page 113
+
+
+
+
+
+End of the Project Gutenberg EBook of Food Poisoning, by Edwin Oakes Jordan
+
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