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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..6833f05 --- /dev/null +++ b/.gitattributes @@ -0,0 +1,3 @@ +* text=auto +*.txt text +*.md text diff --git a/34189-8.txt b/34189-8.txt new file mode 100644 index 0000000..5c716f4 --- /dev/null +++ b/34189-8.txt @@ -0,0 +1,4811 @@ +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 + + +Title: Food Poisoning + +Author: Edwin Oakes Jordan + +Release Date: November 1, 2010 [EBook #34189] + +Language: English + +Character set encoding: ISO-8859-1 + +*** START OF THIS PROJECT GUTENBERG EBOOK FOOD POISONING *** + + + + +Produced by Bryan Ness, Iris Schröder-Gehring and the +Online Distributed Proofreading Team at https://www.pgdp.net +(This file was produced from images generously made +available by The Internet Archive/Canadian Libraries) + + + + + + + + + + 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 attaché 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. öffentl. 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 rôle 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. Hübener[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_, Gärtner; pure culture; +Van Ermengem preparation. (Kolle and Wassermann.)] + +The discovery of the connection of paratyphoid bacilli with meat +poisoning dates from the investigation by Gärtner,[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. Gärtner +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 Gärtner (_loc. cit._) and known as _B. +enteritidis_ or Gärtner's bacillus is commonly taken as the type of one +of the agglutinative varieties. Bacilli with all the characters of +Gärtner'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_ Gärtner. 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 Gärtner bacillus, but refuses to agglutinate +with the Gärtner 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_ Gärtner). 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" Gärtner 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 Gärtner 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 rôle 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. +Söderbaum[83] mentions a milk-borne paratyphoid epidemic occurring in +Kristiania which was ascribed to infection of the milk by a woman +milker. Sacquépée 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. Müller[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 (paté +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. öffentl. 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. öffentl. 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] _Progrès méd._, 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] _Münch. 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 35×1.) (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 Württemberg 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 Ophüls,[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, +×300; 4, a sclerotium or ergot; 5, head of ascigerous form of fruit; 6, +an ascus, ×300; 7, a single spore, ×300. (After Massee, _Plant +Diseases_, by courtesy of the Macmillan Company.)] + +_Symptoms._--The description of a case seen by Wilbur and Ophüls,[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 Ophüls[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, Ophüls 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 anaërobe), +stains by Gram's method, forms terminal spores, and develops best at +22°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°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 +(anaërobic 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 anaërobic 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 Römer 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 anaërobes 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 +anaërobic 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 Württemberg, 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. öffentl. Ges._, XLV (1913), 8. + +[99] E. Sacquépée, _Progrès méd._, 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 (Römer, _Centralbl. f. Bakt._, XXVII +[1900], 857). + +[110] G. Landmann, _Hyg. Rundschau_, XIV (1904), 449. + +[111] Wilbur and Ophüls, _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 anaërobic 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 Frölich, _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, + Hübener, 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, + Württemberg, 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 + + Paté 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. öffentl. 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 + +*** END OF THIS PROJECT GUTENBERG EBOOK FOOD POISONING *** + +***** This file should be named 34189-8.txt or 34189-8.zip ***** +This and all associated files of various formats will be found in: + https://www.gutenberg.org/3/4/1/8/34189/ + +Produced by Bryan Ness, Iris Schröder-Gehring and the +Online Distributed Proofreading Team at https://www.pgdp.net +(This file was produced from images generously made +available by The Internet Archive/Canadian Libraries) + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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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 + + +Title: Food Poisoning + +Author: Edwin Oakes Jordan + +Release Date: November 1, 2010 [EBook #34189] + +Language: English + +Character set encoding: ISO-8859-1 + +*** START OF THIS PROJECT GUTENBERG EBOOK FOOD POISONING *** + + + + +Produced by Bryan Ness, Iris Schröder-Gehring and the +Online Distributed Proofreading Team at https://www.pgdp.net +(This file was produced from images generously made +available by The Internet Archive/Canadian Libraries) + + + + + + +</pre> + + +<div class="center"> +<p class="ftsize120 marbot1"><span class="pagenum1"><a id="pagei" name="pagei"></a>[p.i]</span> THE UNIVERSITY OF CHICAGO +SCIENCE SERIES</p> + +<hr> + +<p class="ftsize105 martop1"><i>Editorial Committee</i></p> + +<p class="martop05">ELIAKIM HASTINGS MOORE, <i>Chairman</i></p> +<p>JOHN MERLE COULTER</p> +<p>ROBERT ANDREWS MILLIKAN</p> +</div> + +<p class="martop4 blockq1"><span class="pagenum1"><a id="pageii" name="pageii"></a>[p.ii]</span> 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.</p> + + + + +<h1><span class="pagenum1"><a id="pageiii" name="pageiii"></a>[p.iii]</span> FOOD POISONING</h1> + + +<div class="center"> +<p class="ftsize105 wosp05"><span class="pagenum1"><a id="pageiv" name="pageiv"></a>[p.iv]</span> THE UNIVERSITY OF CHICAGO PRESS +CHICAGO, ILLINOIS</p> + +<hr> + +<p class="fextra">Agents</p> + +<p>THE BAKER & TAYLOR COMPANY<br> +<span class="ftsize75">NEW YORK</span></p> + +<p>THE CUNNINGHAM, CURTISS & WELCH COMPANY<br> +<span class="ftsize75">LOS ANGELES</span></p> + +<hr> + +<p>THE CAMBRIDGE UNIVERSITY PRESS<br> +<span class="ftsize75">LONDON AND EDINBURGH</span></p> + +<p>THE MARUZEN-KABUSHIKI-KAISHA<br> +<span class="ftsize75">TOKYO, OSAKA, KYOTO, FUKUOSA, SENDAI</span></p> + +<p>THE MISSION BOOK COMPANY<br> +<span class="ftsize75">SHANGHAI</span></p> +</div> + + + + +<h1><span class="pagenum1"><a id="pagev" name="pagev"></a>[p.v]</span> FOOD POISONING</h1> + +<div class="center"> +<p class="ftsize95"><i>By</i></p> + +<p class="martop1 ftsize110">EDWIN OAKES JORDAN</p> + +<p class="ftsize75 marbot4"><i>Chairman of the Department of Hygiene and Bacteriology<br> +The University of Chicago</i></p> +</div> + +<a id="img001" name="img001"></a> +<div class="figcenter1"> +<img src="images/img001.jpg" width="121" height="150" alt="crest" title=""> +</div> + +<p class="center ftsize105 martop4 marbot4">THE UNIVERSITY OF CHICAGO PRESS<br> +CHICAGO, ILLINOIS</p> + +<div class="center"> +<p class="ftsize75 martop4 marbot05"><span class="pagenum1"><a id="pagevi" name="pagevi"></a>[p.vi]</span> <span class="smcap">Copyright 1917 By<br> +The University of Chicago</span></p> + +<hr class="sep1"> + +<p class="ftsize75 martop05 marbot05">All Rights Reserved</p> + +<hr class="sep1"> + +<p class="ftsize75 marbot4 martop05">Published May 1917</p> + +<p class="ftsize50 martop4">Composed and Printed By<br> +The University of Chicago Press<br> +Chicago, Illinois, U.S.A.</p> +</div> + + + + +<h2><span class="pagenum"><a id="pagevii" name="pagevii"></a>[p.vii]</span>CONTENTS</h2> + + +<div class="toc"> +<ul class="none"> + <li class="lsoff addm2em ftsize75">CHAPTER <span class="ralign1">PAGE</span></li> +</ul> + +<ul class="roman"> + <li class="martop05"><span class="smcap">Introduction</span> <span class="ralign1"><a href="#page1">1</a></span></li> + <li class="lsoff">The Extent of Food Poisoning</li> + <li class="lsoff">Various Kinds of Food Poisoning</li> + <li class="lsoff">The Articles of Food Most Commonly Connected with Food Poisoning</li> + + <li value="2" class="martop05"><span class="smcap">Sensitization to Protein Foods</span> <span class="ralign1"><a href="#page9">9</a></span></li> + + <li class="martop05"><span class="smcap">Poisonous Plants and Animals</span> <span class="ralign1"><a href="#page13">13</a></span></li> + <li class="lsoff">Poisonous Plants</li> + <li class="lsoff">Poisonous Animals</li> + + <li value="4" class="martop05"><span class="smcap">Mineral or Organic Poisons Added to Food</span> <span class="ralign1"><a href="#page26">26</a></span></li> + <li class="lsoff">Arsenic</li> + <li class="lsoff">Antimony</li> + <li class="lsoff">Lead</li> + <li class="lsoff">Tin</li> + <li class="lsoff">Copper</li> + <li class="lsoff">Various Coloring Substances</li> + <li class="lsoff">Food Preservatives</li> + <li class="lsoff">Food Substitutes</li> + + <li value="5" class="martop05"><span class="smcap">Food-borne Pathogenic Bacteria</span> <span class="ralign1"><a href="#page44">44</a></span></li> + <li class="lsoff">Typhoid Food Infection</li> + <li class="lsoff">Asiatic Cholera</li> + <li class="lsoff">Tuberculosis</li> + <li class="lsoff">Various Milk-borne Infections</li> + <li class="lsoff">Possible Infection with <i>B. proteus</i></li> + + <li value="6" class="martop05"><span class="smcap">Food-borne Pathogenic Bacteria</span> (<i>Continued</i>) <span class="ralign1"><a href="#page58">58</a></span></li> + <li class="lsoff">Paratyphoid Infection</li> + <li class="lsoff add2em">Typical Paratyphoid Outbreaks</li> + <li class="lsoff add2em">General Characters of Paratyphoid Infection</li> + <li class="lsoff add2em">Toxin Production</li> + <li class="lsoff add2em">Sources of Infection</li> + <li class="lsoff add2em">Means of Prevention</li> + + <li value="7" class="martop05"><span class="pagenum"><a id="pageviii" name="pageviii"></a>[p.viii]</span><span class="smcap">Animal Parasites</span> <span class="ralign1"><a href="#page79">79</a></span></li> + <li class="lsoff">Trichiniasis</li> + <li class="lsoff">Teniasis</li> + <li class="lsoff">Uncinariasis</li> + <li class="lsoff">Other Parasites</li> + + <li value="8" class="martop05"><span class="smcap">Poisonous Products Formed in Food by Bacteria and Other Micro-organisms</span> <span class="ralign1"><a href="#page85">85</a></span></li> + <li class="lsoff">Ergotism</li> + <li class="lsoff">Botulism</li> + <li class="lsoff add2em">Symptoms</li> + <li class="lsoff add2em">Anatomical Lesions</li> + <li class="lsoff add2em">Bacteriology</li> + <li class="lsoff add2em">Epidemiology</li> + <li class="lsoff add2em">Prevention and Treatment</li> + <li class="lsoff">Other Bacterial Poisons</li> + <li class="lsoff">Spoiled and Decomposed Food</li> + + <li value="9" class="martop05"><span class="smcap">Poisoning of Obscure or Unknown Nature</span> <span class="ralign1"><a href="#page100">100</a></span></li> + <li class="lsoff">Milksickness or Trembles</li> + <li class="lsoff">Deficiency Diseases</li> + <li class="lsoff add2em">Beriberi</li> + <li class="lsoff add2em">Pellagra</li> + <li class="lsoff add2em">Lathyrism</li> + <li class="lsoff add2em">Favism</li> + <li class="lsoff add2em">Scurvy</li> + <li class="lsoff add2em">Rachitis</li> + <li class="lsoff">The Foods Most Commonly Poisonous</li> + + <li class="lsoff martop05 addm2em"><span class="smcap">Index</span> <span class="ralign1"><a href="#page109">109</a></span></li> +</ul> +</div> + + + + +<h2><span class="pagenum"><a id="page1" name="page1"></a>[p.1]</span> CHAPTER I</h2> + +<h3>INTRODUCTION</h3> + + +<p>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.</p> + +<p>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 <span class="pagenum"><a id="page2" name="page2"></a>[p.2]</span> 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.</p> + +<p>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,<a name="FNanchor_A_1" id="FNanchor_A_1"></a><a href="#Footnote_A_1" class="fnanchor">[1]</a> the extent, causes, and means of prevention of food poisoning +seem pressing subjects for investigation.</p> + + +<h4><span class="pagenum"><a id="page3" name="page3"></a>[p.3]</span> THE EXTENT OF FOOD POISONING</h4> + +<p>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 <a href="#TabI">I</a> and <a href="#TabII">II</a> summarize data +I have gathered through a press-clipping bureau and other sources during +the period October, 1913, to October, 1915. <span class="pagenum"><a id="page4" name="page4"></a>[p.4]</span> They serve to show +at least the universality and complexity of the problem.</p> + +<p>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.</p> + +<p>The assignment of causes indicated in <a href="#TabI">Table I</a> 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 <span class="pagenum"><a id="page5" name="page5"></a>[p.5]</span> of food ordinarily accused are selected rather as +the result of popular prejudice and tradition than of any careful +inquiry.</p> + +<p class="center ftsize105 martop1"><a id="TabI" name="TabI">TABLE I</a></p> + +<p class="center"><span class="smcap">Food Poisoning in the United States, October, 1913, to October, 1915</span></p> + + +<table border="0" cellpadding="2" summary="Food Poisoning in the United States"> +<colgroup> + <col width="40%"> + <col width="20%"> + <col width="20%"> + <col width="20%"> +</colgroup> + +<tr class="td-center smaller bortop1 lihei1"> + <td class="borright1">Assigned cause</td> + <td class="borright1">Group and Family Outbreaks</td> + <td class="borright1">Individual Cases</td> + <td>Total</td> +</tr> + +<tr class="bortop2"> + <td class="td-left tdp-left1 borright1">Meat</td> + <td class="td-center borright1">40</td> + <td class="td-center borright1">35</td> + <td class="td-center">75</td> +</tr> + +<tr> + <td class="td-left tdp-left1 borright1">Canned fish</td> + <td class="td-center borright1">29</td> + <td class="td-center borright1">35</td> + <td class="td-center">64</td> +</tr> + +<tr> + <td class="td-left tdp-left1 borright1">Canned vegetables</td> + <td class="td-center borright1">27</td> + <td class="td-center borright1">34</td> + <td class="td-center">61</td> +</tr> + +<tr> + <td class="td-left tdp-left1 borright1">Ice cream</td> + <td class="td-center borright1">31</td> + <td class="td-center borright1">22</td> + <td class="td-center">53</td> +</tr> + +<tr> + <td class="td-left tdp-left1 borright1">Fish, oysters</td> + <td class="td-center borright1">17</td> + <td class="td-center borright1">31</td> + <td class="td-center">48</td> +</tr> + +<tr> + <td class="td-left tdp-left1 borright1">Cheese</td> + <td class="td-center borright1">31</td> + <td class="td-center borright1">9</td> + <td class="td-center">40</td> +</tr> + +<tr> + <td class="td-left tdp-left1 borright1">Sausage and canned meat</td> + <td class="td-center borright1">18</td> + <td class="td-center borright1">18</td> + <td class="td-center">36</td> +</tr> + +<tr> + <td class="td-left tdp-left1 borright1">Milk</td> + <td class="td-center borright1">14</td> + <td class="td-center borright1">13</td> + <td class="td-center">27</td> +</tr> + +<tr> + <td class="td-left tdp-left1 borright1">Mushrooms</td> + <td class="td-center borright1">12</td> + <td class="td-center borright1">7</td> + <td class="td-center">19</td> +</tr> + +<tr> + <td class="td-left tdp-left1 borright1">Fruit</td> + <td class="td-center borright1">8</td> + <td class="td-center borright1">11</td> + <td class="td-center">19</td> +</tr> + +<tr> + <td class="td-left tdp-left1 borright1">Vegetables</td> + <td class="td-center borright1">11</td> + <td class="td-center borright1">7</td> + <td class="td-center">18</td> +</tr> + +<tr> + <td class="td-left tdp-left1 borright1">Fowl</td> + <td class="td-center borright1">12</td> + <td class="td-center borright1">4</td> + <td class="td-center">16</td> +</tr> + +<tr> + <td class="td-left tdp-left1 borright1">Salad</td> + <td class="td-center borright1">9</td> + <td class="td-center borright1">5</td> + <td class="td-center">14</td> +</tr> + +<tr> + <td class="td-left tdp-left1 borright1">Contact of food or drink with metal</td> + <td class="td-center borright1">12</td> + <td class="td-center borright1">1</td> + <td class="td-center">13</td> +</tr> + +<tr class="borbot1"> + <td class="td-left tdp-left1 borright1">Miscellaneous</td> + <td class="td-center borright1">29</td> + <td class="td-center borright1">55</td> + <td class="td-center">84</td> +</tr> + +<tr> + <td rowspan="2" class="td-left tdp-left1 borright1">No cause assigned</td> + <td class="td-center borright1">300</td> + <td class="td-center borright1">287</td> + <td class="td-center">587</td> +</tr> + +<tr> + <td class="td-center borright1">357</td> + <td class="td-center borright1">88</td> + <td class="td-center">445</td> +</tr> + +<tr class="bortop2 borbot1 lihei1"> + <td> </td> + <td class="td-center borright1 borleft1">657</td> + <td class="td-center borright1">375</td> + <td class="td-center">1,032</td> +</tr> +</table> + + +<p class="center ftsize105 martop1"><a id="TabII" name="TabII">TABLE II</a></p> + +<p class="center"><span class="smcap">Seasonal Distribution of Food Poisoning Cases, 1914-15 (Group, Family, +and Individual)</span></p> + + +<table border="0" cellpadding="2" summary="Seasonal Distribution of Food Poisoning Cases"> +<colgroup> + <col width="22%"> + <col width="12%"> + <col width="22%"> + <col width="12%"> + <col width="22%"> + <col width="10%"> +</colgroup> + +<tr class="bortop1"> + <td class="td-left tdp-left1">January</td> + <td class="td-right tdp-right borleft1 borright2">90</td> + <td class="td-left tdp-left2">May</td> + <td class="td-right tdp-right borleft1 borright2">63</td> + <td class="td-left tdp-left2 borright1">September</td> + <td class="td-right tdp-right">76</td> +</tr> + +<tr> + <td class="td-left tdp-left1">February</td> + <td class="td-right tdp-right borleft1 borright2">66</td> + <td class="td-left tdp-left2">June</td> + <td class="td-right tdp-right borleft1 borright2">108</td> + <td class="td-left tdp-left2 borright1">October</td> + <td class="td-right tdp-right">96</td> +</tr> + +<tr> + <td class="td-left tdp-left1">March</td> + <td class="td-right tdp-right borleft1 borright2">75</td> + <td class="td-left tdp-left2">July</td> + <td class="td-right tdp-right borleft1 borright2">99</td> + <td class="td-left tdp-left2 borright1">November</td> + <td class="td-right tdp-right">96</td> +</tr> + +<tr class="borbot1"> + <td class="td-left tdp-left1">April</td> + <td class="td-right tdp-right borleft1 borright2">79</td> + <td class="td-left tdp-left2">August</td> + <td class="td-right tdp-right borleft1 borright2">96</td> + <td class="td-left tdp-left2 borright1">December</td> + <td class="td-right tdp-right">88</td> +</tr> +</table> + + +<p>There is no very striking seasonal incidence apparent in the figures +here gathered (<a href="#TabII">Table II</a>). The warmer <span class="pagenum"><a id="page6" name="page6"></a>[p.6]</span> months seem to have a +slight preponderance of cases, but general conclusions from such data +are hardly warranted.</p> + + +<h4>VARIOUS KINDS OF FOOD POISONING</h4> + +<p>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.</p> + +<p>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 <span class="pagenum"><a id="page7" name="page7"></a>[p.7]</span> 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.</p> + + +<h4>THE ARTICLES OF FOOD MOST COMMONLY CONNECTED WITH FOOD POISONING</h4> + +<p>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.</p> + +<p>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.</p> + +<p>Canned goods of various sorts have likewise been repeatedly accused of +causing injurious effects, but the <span class="pagenum"><a id="page8" name="page8"></a>[p.8]</span> 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.</p> + + + + +<h2><span class="pagenum"><a id="page9" name="page9"></a>[p.9]</span> CHAPTER II</h2> + +<h3>SENSITIZATION TO PROTEIN FOODS</h3> + + +<p>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.<a name="FNanchor_A_2" id="FNanchor_A_2"></a><a href="#Footnote_A_2" class="fnanchor">[2]</a> 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 <span class="pagenum"><a id="page10" name="page10"></a>[p.10]</span> +typical instance of anaphylaxis, accompanied as it is by asthma and +other characteristic manifestations of the anaphylactic condition.</p> + +<p>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.</p> + +<p>Coues<a name="FNanchor_A_3" id="FNanchor_A_3"></a><a href="#Footnote_A_3" class="fnanchor">[3]</a> 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<a name="FNanchor_A_4" id="FNanchor_A_4"></a><a href="#Footnote_A_4" class="fnanchor">[4]</a> has reported a case of an eight-year-old boy who evinced +<span class="pagenum"><a id="page11" name="page11"></a>[p.11]</span> 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.</p> + +<p>Idiosyncrasy to cow's milk which is observed sometimes in infants is an +anaphylactic phenomenon.<a name="FNanchor_A_5" id="FNanchor_A_5"></a><a href="#Footnote_A_5" class="fnanchor">[5]</a> The substitution of goat's milk for cow's +milk has been followed by favorable results in such cases.</p> + +<p>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.<a name="FNanchor_A_6" id="FNanchor_A_6"></a><a href="#Footnote_A_6" class="fnanchor">[6]</a> S. R. +Miller<a name="FNanchor_A_7" id="FNanchor_A_7"></a><a href="#Footnote_A_7" class="fnanchor">[7]</a> 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, <span class="pagenum"><a id="page12" name="page12"></a>[p.12]</span> the child has been desensitized to such an +extent that one dram of pure egg-white is now taken with impunity."</p> + +<p>Many other instances of anaphylaxis to egg albumen are on record.<a name="FNanchor_A_8" id="FNanchor_A_8"></a><a href="#Footnote_A_8" class="fnanchor">[8]</a> 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."<a name="FNanchor_A_9" id="FNanchor_A_9"></a><a href="#Footnote_A_9" class="fnanchor">[9]</a></p> + +<p>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.<a name="FNanchor_A_10" id="FNanchor_A_10"></a><a href="#Footnote_A_10" class="fnanchor">[10]</a> McBride and +Schorer<a name="FNanchor_A_11" id="FNanchor_A_11"></a><a href="#Footnote_A_11" class="fnanchor">[11]</a> 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<a name="FNanchor_A_12" id="FNanchor_A_12"></a><a href="#Footnote_A_12" class="fnanchor">[12]</a> 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.</p> + + + + +<h2><span class="pagenum"><a id="page13" name="page13"></a>[p.13]</span> CHAPTER III</h2> + +<h3>POISONOUS PLANTS AND ANIMALS</h3> + + +<p>Some normal plant and animal tissues contain substances poisonous to man +and are occasionally eaten by mistake for wholesome foods.</p> + + +<h4>POISONOUS PLANTS</h4> + +<p>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.</p> + +<p>According to Chesnut<a name="FNanchor_A_13" id="FNanchor_A_13"></a><a href="#Footnote_A_13" class="fnanchor">[13]</a> there are 16,673 leaf-bearing plants included +in Heller's <i>Catalogue of North American Plants</i>, 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 <span class="pagenum"><a id="page14" name="page14"></a>[p.14]</span> 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.</p> + +<p>The actual number of poisonous plants likely to be inadvertently eaten +by human beings is not large. Chesnut<a name="FNanchor_A_14" id="FNanchor_A_14"></a><a href="#Footnote_A_14" class="fnanchor">[14]</a> 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.<a name="FNanchor_A_15" id="FNanchor_A_15"></a><a href="#Footnote_A_15" class="fnanchor">[15]</a> +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 (<i>Veratrum viride</i>) in mistake for those of the +marsh-marigold<a name="FNanchor_A_16" id="FNanchor_A_16"></a><a href="#Footnote_A_16" class="fnanchor">[16]</a>, the use of the fruit pulp of the Kentucky coffee +tree (<i>Gymnocladus dioica</i>) in mistake for that of the honey-locust<a name="FNanchor_A_17" id="FNanchor_A_17"></a><a href="#Footnote_A_17" class="fnanchor">[17]</a>, +the accidental employment of daffodil bulbs for food, and the confusion +by children of the young shoots of the broad-leaf laurel (<i>Kalmia +latifolia</i>) with the wintergreen.<a name="FNanchor_A_18" id="FNanchor_A_18"></a><a href="#Footnote_A_18" class="fnanchor">[18]</a> One of the <span class="pagenum"><a id="page16" name="page16"></a>[p.16]</span> most serious +instances of poisoning of this sort is that from the use of the +spindle-shaped roots of the deadly water hemlock (<i>Cicuta maculata</i>) +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.</p> + +<a id="img002" name="img002"></a> +<div class="figcenter1 width450"> +<img src="images/img002.jpg" width="438" height="600" alt="Fig. 1." title=""> +<p> <span class="smcap">Fig. 1.</span>—<i>Conium maculatum.</i> The fresh juice +of <i>Conium maculatum</i> was used in the preparation of the famous hemlock +potion which was employed by the Greeks in putting their criminals to +death. (From <i>Applied and Economic Botany</i>, by courtesy of Professor +Kraemer [after Holm].)</p> +</div> + +<p>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.<a name="FNanchor_A_19" id="FNanchor_A_19"></a><a href="#Footnote_A_19" class="fnanchor">[19]</a> 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 (<i>Hydrocarpus</i>). +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.<a name="FNanchor_A_20" id="FNanchor_A_20"></a><a href="#Footnote_A_20" class="fnanchor">[20]</a></p> + +<span class="pagenum"><a id="page17" name="page17"></a>[p.17]</span> +<a id="img003" name="img003"></a> +<div class="figcenter1 width500"> +<img src="images/img003.jpg" width="470" height="600" alt="Fig. 2." title=""> +<p><span class="smcap">Fig. 2.</span>—<i>Cicuta maculata</i> (water hemlock); +<i>A</i>, upper part of stem with leaves and compound umbels; <i>B</i>, base of +stem and thick tuberous roots; <i>C</i>, cross-section of stem; <i>D</i>, flower; +<i>E</i>, fruit; <i>F</i>, fruit in longitudinal section; <i>G</i>, cross-section of a +mericarp. (From <i>Applied and Economic Botany</i>, by courtesy of Professor +Kraemer [after Holm].)</p> +</div> + +<p>Investigators from the New York City Health Department have found that +certain cases of alleged <span class="pagenum"><a id="page18" name="page18"></a>[p.18]</span> "ptomain poisoning" were really due to +"sour-grass soup."<a name="FNanchor_A_21" id="FNanchor_A_21"></a><a href="#Footnote_A_21" class="fnanchor">[21]</a> 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!</p> + +<a id="img004" name="img004"></a> +<div class="figcenter1 width500"> +<img src="images/img004.jpg" width="500" height="315" alt="Fig. 3." title=""> +<p><span class="smcap">Fig. 3.</span>—Fly Amanita (poisonous). (<i>Amanita muscaria</i> L.) +(After Marshall, <i>The Mushroom Book</i>, by courtesy of Doubleday, Page & +Company.)</p> +</div> + +<p>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.<a name="FNanchor_A_22" id="FNanchor_A_22"></a><a href="#Footnote_A_22" class="fnanchor">[22]</a> 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 +<i>Amanita</i>"<a name="FNanchor_A_23" id="FNanchor_A_23"></a><a href="#Footnote_A_23" class="fnanchor">[23]</a> (<i>Amanita muscaria</i>) in this country has been apparently +often mistaken for the European variety of "royal <i>Amanita</i>" (<i>A. +caesaria</i>).<a name="FNanchor_A_24" id="FNanchor_A_24"></a><a href="#Footnote_A_24" class="fnanchor">[24]</a> Such a mistake <span class="pagenum"><a id="page20" name="page20"></a>[p.20]</span> seems to have been the cause of +death of the Count de Vecchi in Washington, D.C., in 1897.</p> + +<p class="blockq1"> The Count, an attaché 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 <i>caesaria</i> or <i>aurantiaca</i>. +From the symptoms and termination the species eaten must have been +<i>muscaria</i>.</p> + +<p><i>A. muscaria</i> 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<sub class="ftsize90">5</sub>H<sub class="ftsize90">15</sub>NO<sub class="ftsize90">3</sub> has been +given. The drug atropin <span class="pagenum"><a id="page21" name="page21"></a>[p.21]</span> 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 <i>Amanita</i> a beverage which they use +for producing orgies of intoxication. Deaths are stated to occur +frequently from excessive use of this beverage.<a name="FNanchor_A_25" id="FNanchor_A_25"></a><a href="#Footnote_A_25" class="fnanchor">[25]</a></p> + +<p>The deadly <i>Amanita</i> or death-cup (<i>A. phalloides</i>) 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 <i>A. phalloides</i>:</p> + +<p class="blockq1">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, <i>la face vultueuse</i> 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 <span class="pagenum"><a id="page22" name="page22"></a>[p.22]</span> 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 <i>Amanita +muscaria</i> being eaten with the <i>phalloides</i>. 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.</p> + +<p>A number of other closely related species of <i>Amanita</i> (e.g., <i>A. +verna</i>, the "destroying angel," probably a small form of <i>A. +phalloides</i>) have a poisonous action similar to that of <i>A. phalloides</i>. +All are different from muscarin.</p> + +<a id="img005" name="img005"></a> +<div class="figcenter1 width400"> +<img src="images/img005.jpg" width="392" height="600" alt="Fig. 4." title=""> +<p><span class="smcap">Fig. 4.</span>—Death-cup; destroying angel (<i>Amanita +phalloides</i> Fries); reduced; natural size: cap, <span class="ftsize95">3</span><sup class="ftsize50">1</sup>/<sub class="ftsize50">2</sub> inches; stem, +<span class="ftsize95">7</span><sup class="ftsize50">1</sup>/<sub class="ftsize50">2</sub> inches. (After Marshall, <i>The Mushroom Book</i>, by courtesy of +Doubleday, Page & Company.)</p> +</div> + +<p>The character of the poison was first carefully investigated by Kobert, +who showed that the <i>Amanita</i> 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<a name="FNanchor_A_26" id="FNanchor_A_26"></a><a href="#Footnote_A_26" class="fnanchor">[26]</a> has since shown that +in addition to the hemolytic substance another substance much more toxic +is present in this species of <i>Amanita</i> and he concludes that the +poisonous effect of the fungus is primarily due to the latter +("<i>Amanita</i> toxin"). The juice of the cooked <i>Amanita</i> 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 <i>Amanita</i> toxin. +In the Baltimore <span class="pagenum"><a id="page24" name="page24"></a>[p.24]</span> cases studied by Clark, Marshall, and +Rowntree<a name="FNanchor_A_27" id="FNanchor_A_27"></a><a href="#Footnote_A_27" class="fnanchor">[27]</a> 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 <i>Amanita</i> toxin succeed +only to a limited degree.<a name="FNanchor_A_28" id="FNanchor_A_28"></a><a href="#Footnote_A_28" class="fnanchor">[28]</a></p> + + +<h4>POISONOUS ANIMALS</h4> + +<p>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 (<a href="#chapVI">chapter vi</a>), 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.</p> + +<p>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, +<span class="pagenum"><a id="page25" name="page25"></a>[p.25]</span> including the famous Japanese <i>Fugu</i>, 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.<a name="FNanchor_A_29" id="FNanchor_A_29"></a><a href="#Footnote_A_29" class="fnanchor">[29]</a></p> + +<p>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.<a name="FNanchor_A_30" id="FNanchor_A_30"></a><a href="#Footnote_A_30" class="fnanchor">[30]</a></p> + +<p>There is little definite knowledge about the poisons concerned. They are +certainly not uniform in nature. The <i>Fugu</i> 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.<a name="FNanchor_A_31" id="FNanchor_A_31"></a><a href="#Footnote_A_31" class="fnanchor">[31]</a></p> + + + + +<h2><span class="pagenum"><a id="page26" name="page26"></a>[p.26]</span> CHAPTER IV</h2> + +<h3>MINERAL OR ORGANIC POISONS ADDED TO FOOD</h3> + + +<p>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.</p> + + +<h4>ARSENIC</h4> + +<p>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.</p> + +<p>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 <span class="pagenum"><a id="page27" name="page27"></a>[p.27]</span> in their +preparation, some specimens of the acid containing as much as 2.6 per +cent of arsenic.<a name="FNanchor_A_32" id="FNanchor_A_32"></a><a href="#Footnote_A_32" class="fnanchor">[32]</a></p> + +<p>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.<a name="FNanchor_A_33" id="FNanchor_A_33"></a><a href="#Footnote_A_33" class="fnanchor">[33]</a></p> + + +<h4>ANTIMONY</h4> + +<p>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.<a name="FNanchor_A_34" id="FNanchor_A_34"></a><a href="#Footnote_A_34" class="fnanchor">[34]</a> The rubber nipples used for infants' milk +bottles also sometimes contain antimony.<a name="FNanchor_A_35" id="FNanchor_A_35"></a><a href="#Footnote_A_35" class="fnanchor">[35]</a> 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.</p> + + +<h4>LEAD</h4> + +<p>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 <span class="pagenum"><a id="page28" name="page28"></a>[p.28]</span> that lead chromate is sometimes used for imparting a +yellow color to candy and decorating sugars.<a name="FNanchor_A_36" id="FNanchor_A_36"></a><a href="#Footnote_A_36" class="fnanchor">[36]</a> 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.</p> + +<p>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.</p> + +<p>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.</p> + +<p><span class="pagenum"><a id="page29" name="page29"></a>[p.29]</span> 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.<a name="FNanchor_A_37" id="FNanchor_A_37"></a><a href="#Footnote_A_37" class="fnanchor">[37]</a></p> + + +<h4>TIN</h4> + +<p>Special interest has attached to the possibility of tin poisoning on +account of the widespread use of canned foods.<a name="FNanchor_A_38" id="FNanchor_A_38"></a><a href="#Footnote_A_38" class="fnanchor">[38]</a> 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.<a name="FNanchor_A_39" id="FNanchor_A_39"></a><a href="#Footnote_A_39" class="fnanchor">[39]</a> It has been the general opinion based on +experiments by Lehmann<a name="FNanchor_A_40" id="FNanchor_A_40"></a><a href="#Footnote_A_40" class="fnanchor">[40]</a> 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.<a name="FNanchor_A_41" id="FNanchor_A_41"></a><a href="#Footnote_A_41" class="fnanchor">[41]</a> +Certainly there has not been any noticeable amount of tin poisoning +observed coincident with the enormous increase in the use of canned +<span class="pagenum"><a id="page30" name="page30"></a>[p.30]</span> foods. An instance of poisoning by canned asparagus observed by +Friedmann,<a name="FNanchor_A_42" id="FNanchor_A_42"></a><a href="#Footnote_A_42" class="fnanchor">[42]</a> 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.<a name="FNanchor_A_43" id="FNanchor_A_43"></a><a href="#Footnote_A_43" class="fnanchor">[43]</a> 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.<a name="FNanchor_A_44" id="FNanchor_A_44"></a><a href="#Footnote_A_44" class="fnanchor">[44]</a></p> + +<p>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.</p> + + +<h4>COPPER</h4> + +<p>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 <span class="pagenum"><a id="page31" name="page31"></a>[p.31]</span> acetate that is sometimes formed, but +Professor Long, of the Referee Board of Consulting Scientific +Experts,<a name="FNanchor_A_45" id="FNanchor_A_45"></a><a href="#Footnote_A_45" class="fnanchor">[45]</a> 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.</p> + +<p>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.</p> + + +<h4>VARIOUS COLORING SUBSTANCES</h4> + +<p>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 <span class="pagenum"><a id="page32" name="page32"></a>[p.32]</span> 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.</p> + + +<h4><span class="pagenum"><a id="page33" name="page33"></a>[p.33]</span> FOOD PRESERVATIVES</h4> + +<p>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.</p> + +<p>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.</p> + +<p>How complicated the question of using food preservatives really is +appears in the case of smoked meats <span class="pagenum"><a id="page34" name="page34"></a>[p.34]</span> 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.</p> + +<p>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:</p> + +<p class="blockq1">(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.</p> + +<p>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 <span class="pagenum"><a id="page35" name="page35"></a>[p.35]</span> (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.</p> + +<p>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:</p> + +<p class="blockq2">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 <span class="pagenum"><a id="page36" name="page36"></a>[p.36]</span> 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.</p> + +<p class="blockq3">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.<a name="FNanchor_A_46" id="FNanchor_A_46"></a><a href="#Footnote_A_46" class="fnanchor">[46]</a></p> + +<p>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 <span class="pagenum"><a id="page37" name="page37"></a>[p.37]</span> 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.</p> + +<p>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 +<span class="pagenum"><a id="page38" name="page38"></a>[p.38]</span> are of a particularly objectionable nature, and their +continuous ingestion may quite conceivably lead to serious injury.</p> + +<p>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 +<i>long-continued</i> consumption of food preserved with particular +chemicals.</p> + +<p class="blockq1">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 +<span class="pagenum"><a id="page39" name="page39"></a>[p.39]</span> 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.<a name="FNanchor_A_47" id="FNanchor_A_47"></a><a href="#Footnote_A_47" class="fnanchor">[47]</a></p> + +<p>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. <a href="#page2">2</a>-<a href="#page4">4</a>) 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.</p> + +<p>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 <span class="pagenum"><a id="page40" name="page40"></a>[p.40]</span> 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!</p> + +<p>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.</p> + +<p>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 <span class="pagenum"><a id="page41" name="page41"></a>[p.41]</span> 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.</p> + + +<h4>FOOD SUBSTITUTES</h4> + +<p>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 <span class="pagenum"><a id="page42" name="page42"></a>[p.42]</span> (over 0.3 gram per +day) is likely to induce disturbance of digestion. As a substitute for +sugar in ordinary foodstuffs it is undesirable.<a name="FNanchor_A_48" id="FNanchor_A_48"></a><a href="#Footnote_A_48" class="fnanchor">[48]</a></p> + +<p>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.</p> + +<p>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.</p> + +<p>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 <span class="pagenum"><a id="page43" name="page43"></a>[p.43]</span> 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.</p> + + + + +<h2><span class="pagenum"><a id="page44" name="page44"></a>[p.44]</span> CHAPTER V</h2> + +<h3>FOOD-BORNE PATHOGENIC BACTERIA</h3> + + +<p>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.</p> + +<p>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.</p> + + +<h4>TYPHOID FOOD INFECTION</h4> + +<p>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.<a name="FNanchor_A_49" id="FNanchor_A_49"></a><a href="#Footnote_A_49" class="fnanchor">[49]</a> Investigation showed that this dish was prepared by a woman +<span class="pagenum"><a id="page45" name="page45"></a>[p.45]</span> 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.</p> + +<p>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.</p> + +<p>Some foods by their origin are exposed more than others to typhoid +contamination. Such vegetables as lettuce, celery, radishes, and +watercress, which are <span class="pagenum"><a id="page46" name="page46"></a>[p.46]</span> 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.<a name="FNanchor_A_50" id="FNanchor_A_50"></a><a href="#Footnote_A_50" class="fnanchor">[50]</a> 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.<a name="FNanchor_A_51" id="FNanchor_A_51"></a><a href="#Footnote_A_51" class="fnanchor">[51]</a></p> + +<p>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.<a name="FNanchor_A_52" id="FNanchor_A_52"></a><a href="#Footnote_A_52" class="fnanchor">[52]</a> +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.</p> + +<p>In 1915 an increasing number of typhoid cases in South Philadelphia led +to an investigation by the state health department.<a name="FNanchor_A_53" id="FNanchor_A_53"></a><a href="#Footnote_A_53" class="fnanchor">[53]</a> This disclosed +the fact that the majority of the cases were clustered in and about +three public markets.</p> + +<p class="blockq2"><span class="pagenum"><a id="page47" name="page47"></a>[p.47]</span> 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....</p> + +<p class="blockq3">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.</p> + +<p>The following conclusion was reached regarding the particularly large +number of cases among persons of one nationality:</p> + +<p class="blockq1">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.</p> + +<p>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.</p> + +<p>Bread, when marketed unwrapped, is subject to contamination from flies +and from uncleanly handling. <span class="pagenum"><a id="page48" name="page48"></a>[p.48]</span> Katherine Howell<a name="FNanchor_A_54" id="FNanchor_A_54"></a><a href="#Footnote_A_54" class="fnanchor">[54]</a> 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<a name="FNanchor_A_55" id="FNanchor_A_55"></a><a href="#Footnote_A_55" class="fnanchor">[55]</a> 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.<a name="FNanchor_A_56" id="FNanchor_A_56"></a><a href="#Footnote_A_56" class="fnanchor">[56]</a></p> + +<p>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.</p> + +<a id="img006" name="img006"></a> +<div class="figcenter1 width500"> +<img src="images/img006.jpg" width="500" height="504" alt="Fig. 5." title=""> +<p><span class="smcap">Fig. 5.</span>—Bacteria left by fly passing over gelatin plate. +(By courtesy of Doubleday, Page & Company.)</p> +</div> + +<p>One food animal, the oyster, frequently eaten raw, has been connected on +good evidence with certain typhoid outbreaks.<a name="FNanchor_A_57" id="FNanchor_A_57"></a><a href="#Footnote_A_57" class="fnanchor">[57]</a> The number of +well-established <span class="pagenum"><a id="page49" name="page49"></a>[p.49]</span> 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 <span class="pagenum"><a id="page50" name="page50"></a>[p.50]</span> 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.</p> + +<p>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.</p> + + +<h4>ASIATIC CHOLERA</h4> + +<p>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 <span class="pagenum"><a id="page51" name="page51"></a>[p.51]</span> 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."<a name="FNanchor_A_58" id="FNanchor_A_58"></a><a href="#Footnote_A_58" class="fnanchor">[58]</a></p> + + +<h4>TUBERCULOSIS</h4> + +<p>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.</p> + +<p>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 <span class="pagenum"><a id="page52" name="page52"></a>[p.52]</span> 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.</p> + +<p>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 <span class="pagenum"><a id="page53" name="page53"></a>[p.53]</span> 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.</p> + +<p>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:<a name="FNanchor_A_59" id="FNanchor_A_59"></a><a href="#Footnote_A_59" class="fnanchor">[59]</a></p> + + +<table border="0" cellpadding="2" summary="Infection with tubercle bacilli at different ages"> +<colgroup> + <col width="40%"> + <col width="20%"> + <col width="20%"> + <col width="20%"> +</colgroup> + +<tr class="bortop1 borbot1"> + <td> </td> + <td class="td-center borleft1">Adults Sixteen Years Old and Over</td> + <td class="td-center borleft1">Children Five to Sixteen Years Old</td> + <td class="td-center borleft1">Children under Five Years</td> +</tr> + +<tr> + <td class="td-left, tdp-left1">Human tubercle bacilli found</td> + <td class="td-center borleft1">677</td> + <td class="td-center borleft1">99</td> + <td class="td-center borleft1">161</td> +</tr> + +<tr class="borbot1"> + <td class="td-left, tdp-left1">Bovine tubercle bacilli found</td> + <td class="td-center borleft1">9</td> + <td class="td-center borleft1">33</td> + <td class="td-center borleft1">59</td> +</tr> +</table> + + +<p>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.</p> + +<p><span class="pagenum"><a id="page54" name="page54"></a>[p.54]</span> 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.</p> + + +<h4>VARIOUS MILK-BORNE INFECTIONS</h4> + +<p>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.</p> + +<p>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 rôle 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 <span class="pagenum"><a id="page55" name="page55"></a>[p.55]</span> infected from human sources with the virus +of scarlet fever or diphtheria and may herself occasionally contribute +directly to the infection of the milk.</p> + +<p>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.</p> + +<p>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.</p> + +<p>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.</p> + + +<h4>POSSIBLE INFECTION WITH B. PROTEUS</h4> + +<p>One widely distributed organism known as <i>Bacillus proteus</i> has been +several times held responsible for food <span class="pagenum"><a id="page56" name="page56"></a>[p.56]</span> poisoning outbreaks, +but it is not yet certain how far this accusation is justified. <i>B. +proteus</i> is related to <i>B. coli</i>, 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 <i>B. coli</i>, +they form indol and ferment dextrose with gas production. Varieties of +<i>B. proteus</i> are found widely distributed in decomposing organic matter +of all sorts.</p> + +<p>The evidence upon which this bacillus is regarded as the cause of food +poisoning is not altogether convincing. The outbreak described by +Pfuhl<a name="FNanchor_A_60" id="FNanchor_A_60"></a><a href="#Footnote_A_60" class="fnanchor">[60]</a> 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 <i>B. proteus</i> 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 <i>B. proteus</i> was isolated from the blood and +internal organs. But these animals sometimes die when fed with quite +normal meat, and <i>B. proteus</i> and other common intestinal bacteria are +often isolated from the body after death. <i>B. proteus</i>, in fact, is +found in many animal foods and in the apparently normal human intestine. +Like <i>B. coli</i>, it frequently invades the internal organs after or +shortly before death. Finding <i>B. proteus</i> 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 +<i>B. proteus</i> is similarly inconclusive.</p> + +<p><span class="pagenum"><a id="page57" name="page57"></a>[p.57]</span> 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. <i>B. proteus</i> 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<a name="FNanchor_A_61" id="FNanchor_A_61"></a><a href="#Footnote_A_61" class="fnanchor">[61]</a> and others, if any injurious effect at all is to be +attributed to <i>B. proteus</i>, it is in the nature of an intoxication and +not an infection (see <a href="#chapVIII">chapter viii</a>). So far as the existing evidence +goes, the question of the responsibility of this organism for food +poisoning is still an open one.</p> + + + + +<h2><span class="pagenum"><a id="page58" name="page58"></a>[p.58]</span> <a id="chapVI" name="chapVI">CHAPTER VI</a></h2> + +<h3>FOOD-BORNE PATHOGENIC BACTERIA (<i>Continued</i>)</h3> + + +<h4>PARATYPHOID INFECTION</h4> + +<p>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 (<i>B. +paratyphosus</i> or <i>B. enteritidis</i>). Especially is it true of meat +poisoning epidemics that paratyphoid bacilli are found in causal +relation with them. Hübener<a name="FNanchor_A_62" id="FNanchor_A_62"></a><a href="#Footnote_A_62" class="fnanchor">[62]</a> enumerates forty-two meat poisoning +outbreaks in Germany in which bacilli of this group were shown to be +implicated, and Savage<a name="FNanchor_A_63" id="FNanchor_A_63"></a><a href="#Footnote_A_63" class="fnanchor">[63]</a> 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.</p> + +<p><i>Typical paratyphoid outbreaks.</i>—Kaensche<a name="FNanchor_A_64" id="FNanchor_A_64"></a><a href="#Footnote_A_64" class="fnanchor">[64]</a> describes an outbreak at +Breslau involving over eighty persons <span class="pagenum"><a id="page59" name="page59"></a>[p.59]</span> 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 (<i>notgeschlachtet</i>). 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 (<i>Hackfleisch</i>). 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 <i>Bacillus enteritidis</i> type were isolated from the meat.</p> + +<p>A large and unusually severe outbreak reported by McWeeney<a name="FNanchor_A_65" id="FNanchor_A_65"></a><a href="#Footnote_A_65" class="fnanchor">[65]</a> 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 <span class="pagenum"><a id="page60" name="page60"></a>[p.60]</span> 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 <i>Bacillus enteritidis</i>.</p> + +<p>An epidemic of food poisoning occurred in July, 1915, at and near +Westerly, Rhode Island.<a name="FNanchor_A_66" id="FNanchor_A_66"></a><a href="#Footnote_A_66" class="fnanchor">[66]</a> 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. <i>Bacillus paratyphosus</i> B was isolated from samples of <span class="pagenum"><a id="page61" name="page61"></a>[p.61]</span> +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.</p> + +<p><i>General characters of paratyphoid infection.</i>—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.</p> + +<p>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. <span class="pagenum"><a id="page62" name="page62"></a>[p.62]</span> +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.</p> + +<p>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 +(<i>notgeschlachtet</i>, 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 <span class="pagenum"><a id="page63" name="page63"></a>[p.63]</span> +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.</p> + +<a id="img007" name="img007"></a> +<div class="figcenter1 width400"> +<img src="images/img007.jpg" width="397" height="400" alt="Fig. 6." title=""> +<p><span class="smcap">Fig. 6.</span>—<i>Bacillus enteritidis</i>, Gärtner; pure culture; +Van Ermengem preparation. (Kolle and Wassermann.)</p> +</div> + +<p>The discovery of the connection of paratyphoid bacilli with meat +poisoning dates from the investigation by Gärtner,<a name="FNanchor_A_67" id="FNanchor_A_67"></a><a href="#Footnote_A_67" class="fnanchor">[67]</a> 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. Gärtner +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 <i>B. +enteritidis</i>. 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 <span class="pagenum"><a id="page64" name="page64"></a>[p.64]</span> food +poisoning due to the paratyphoid bacillus has been reported in the +United States.<a name="FNanchor_A_68" id="FNanchor_A_68"></a><a href="#Footnote_A_68" class="fnanchor">[68]</a></p> + +<p>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.</p> + +<p>The bacillus discovered by Gärtner (<i>loc. cit.</i>) and known as <i>B. +enteritidis</i> or Gärtner's bacillus is commonly taken as the type of one +of the agglutinative varieties. Bacilli with all the characters of +Gärtner's bacillus have been found in meat poisoning epidemics in +various <span class="pagenum"><a id="page65" name="page65"></a>[p.65]</span> places in Belgium and Germany. Mayer<a name="FNanchor_A_69" id="FNanchor_A_69"></a><a href="#Footnote_A_69" class="fnanchor">[69]</a> has compiled a +list of forty-eight food poisoning outbreaks occurring between 1888 and +1911 and attributed to <i>B. enteritidis</i> Gärtner. 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 <i>B. enteritidis</i> outbreaks were attributed to <i>Vanille Pudding</i>; +one, to potato salad.</p> + +<p>In other food poisoning outbreaks a bacillus is found which is +culturally similar to the Gärtner bacillus, but refuses to agglutinate +with the Gärtner 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<a name="FNanchor_A_70" id="FNanchor_A_70"></a><a href="#Footnote_A_70" class="fnanchor">[70]</a> gives a list of seventy-seven outbreaks +of food poisoning (1893-1911) in which organisms variously designated as +"<i>B. paratyphosus</i> B" or as "<i>B. suipestifer</i>" were held to be +responsible. The total number of cases (two thousand) and deaths +(twenty) is about the same as ascribed to <i>B. enteritidis</i>. 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 <i>B. +enteritidis</i> outbreaks (twenty-three in forty-eight). Sausage and +chopped meat of unknown origin, however, were connected with eighteen +outbreaks.</p> + +<p><span class="pagenum"><a id="page66" name="page66"></a>[p.66]</span> The bacillus named <i>B. suipestifer</i> 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 <i>B. +paratyphosus</i> 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 <i>B. suipestifer</i> and would restrict the term <i>B. +paratyphosus</i> to those bacteria causing "an illness clinically +indistinguishable from typhoid fever." German investigators, on the +other hand, regard <i>B. suipestifer</i> and <i>B. paratyphosus</i> B as +identical. My own investigations<a name="FNanchor_A_71" id="FNanchor_A_71"></a><a href="#Footnote_A_71" class="fnanchor">[71]</a> indicate that there is a real +distinction between these two types.</p> + +<p>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 <i>B. suipestifer</i> (the same in their opinion as <i>B. +paratyphosus</i> B) is much more widely distributed than <i>B. enteritidis</i> +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 <span class="pagenum"><a id="page67" name="page67"></a>[p.67]</span> reported by Jacobitz and Kayser<a name="FNanchor_A_72" id="FNanchor_A_72"></a><a href="#Footnote_A_72" class="fnanchor">[72]</a> (vermicelli), +Reinhold<a name="FNanchor_A_73" id="FNanchor_A_73"></a><a href="#Footnote_A_73" class="fnanchor">[73]</a> (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.</p> + +<p>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 <i>B. +suipestifer</i> type. Other cases are due to pathogenic bacteria derived +from diseased animals, and these bacteria are often, possibly always, of +a slightly different character (<i>B. enteritidis</i> Gärtner). 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 <span class="pagenum"><a id="page68" name="page68"></a>[p.68]</span> 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<a name="FNanchor_A_74" id="FNanchor_A_74"></a><a href="#Footnote_A_74" class="fnanchor">[74]</a> 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" Gärtner 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.<a name="FNanchor_A_75" id="FNanchor_A_75"></a><a href="#Footnote_A_75" class="fnanchor">[75]</a></p> + +<p>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 <i>paratyphoid enteritidis</i> 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 Gärtner type (<i>B. enteritidis</i>) than of +the <i>B. suipestifer</i> type.</p> + +<p><i>Toxin production.</i>—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 <span class="pagenum"><a id="page69" name="page69"></a>[p.69]</span> 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 <i>paratyphoid-enteritidis</i> 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.</p> + +<p>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 <i>B. +enteritidis</i> outbreak in and about Newcastle, England, it is stated:</p> + +<p class="blockq1">In no instance was a person who had used only boiled milk known to +have been affected. Thus in one family, consisting of <span class="pagenum"><a id="page70" name="page70"></a>[p.70]</span> +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.<a name="FNanchor_A_76" id="FNanchor_A_76"></a><a href="#Footnote_A_76" class="fnanchor">[76]</a></p> + +<p>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 rôle of +toxins formed by <i>B. enteritidis</i> 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.</p> + +<p><i>Sources of infection.</i>—The main sources of <i>enteritidis-suipestifer</i> +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 <span class="pagenum"><a id="page71" name="page71"></a>[p.71]</span> 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:</p> + +<p>1. Diseased animals: The majority of the meat poisoning outbreaks are +caused by meat derived from pigs or cattle. <a href="#TabIII">Table III</a> gives the figures +for a number of British<a name="FNanchor_A_77" id="FNanchor_A_77"></a><a href="#Footnote_A_77" class="fnanchor">[77]</a> and German<a name="FNanchor_A_78" id="FNanchor_A_78"></a><a href="#Footnote_A_78" class="fnanchor">[78]</a> epidemics.</p> + +<p class="center ftsize105 martop1"><a id="TabIII" name="TabIII">TABLE III</a><a name="FNanchor_A_79" id="FNanchor_A_79"></a><a href="#Footnote_A_79" class="fnanchor">[79]</a></p> + + +<table border="0" cellpadding="2" summary="British and German epidemics"> +<colgroup> + <col width="17%"> + <col width="10%"> + <col width="10%"> + <col width="10%"> + <col width="10%"> + <col width="10%"> + <col width="10%"> + <col width="23%"> +</colgroup> + +<tr class="bortop1 borbot1"> + <td rowspan="2"> </td> + <td colspan="3" class="smaller td-center borleft1"><span class="smcap">B. enteritidis</span></td> + <td colspan="3" class="smaller td-center borleft1"><span class="smcap">B. suipestifer</span></td> + <td class="smaller td-center borleft1"><span class="smcap">Belonging to This Group but Undifferentiated</span> </td> +</tr> + +<tr class="ftsize95 borbot1"> + <td class="td-center borleft1">British</td> + <td class="td-center borleft1">German</td> + <td class="td-center borleft1">Total</td> + <td class="td-center borleft1">British</td> + <td class="td-center borleft1">German</td> + <td class="td-center borleft1">Total</td> + <td class="td-center borleft1">British</td> +</tr> + +<tr> + <td class="td-left tdp-left">Pig</td> + <td class="td-center borleft1">1</td> + <td class="td-center borleft1">1</td> + <td class="td-center borleft1">2</td> + <td class="td-center borleft1">3</td> + <td class="td-center borleft1">5</td> + <td class="td-center borleft1">8</td> + <td class="td-center borleft1">4</td> +</tr> + +<tr> + <td class="td-left tdp-left">Ox or cow</td> + <td class="td-center borleft1">3</td> + <td class="td-center borleft1">9</td> + <td class="td-center borleft1">12</td> + <td class="td-center borleft1">2</td> + <td class="td-center borleft1">3</td> + <td class="td-center borleft1">5</td> + <td class="td-center borleft1">5</td> +</tr> + +<tr> + <td class="td-left tdp-left">Calf</td> + <td class="td-center borleft1">0</td> + <td class="td-center borleft1">7</td> + <td class="td-center borleft1">7</td> + <td class="td-center borleft1">2</td> + <td class="td-center borleft1">2</td> + <td class="td-center borleft1">4</td> + <td class="td-center borleft1">0</td> +</tr> + +<tr> + <td class="td-left tdp-left">Horse</td> + <td class="td-center borleft1">0</td> + <td class="td-center borleft1">1</td> + <td class="td-center borleft1">1</td> + <td class="td-center borleft1">0</td> + <td class="td-center borleft1">1</td> + <td class="td-center borleft1">1</td> + <td class="td-center borleft1">...</td> +</tr> + +<tr class="borbot1"> + <td class="td-left tdp-left">Chickens</td> + <td class="td-center borleft1">1</td> + <td class="td-center borleft1">0</td> + <td class="td-center borleft1">1</td> + <td class="td-center borleft1">0</td> + <td class="td-center borleft1">1</td> + <td class="td-center borleft1">1</td> + <td class="td-center borleft1">...</td> +</tr> +</table> + + +<p>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.</p> + +<p>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 <i>B. suipestifer</i> to hog cholera. This +bacillus, although not now considered <span class="pagenum"><a id="page72" name="page72"></a>[p.72]</span> 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 <i>B. +suipestifer</i> is known to be abundantly distributed—and so-called <i>B. +suipestifer</i> infections in man.</p> + +<p>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 +<i>enteritidis-suipestifer</i> 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.).<a name="FNanchor_A_80" id="FNanchor_A_80"></a><a href="#Footnote_A_80" class="fnanchor">[80]</a> The frequency with which +poisoning has occurred through the use of the meat of +"emergency-slaughtered" animals has been already mentioned. K. F. +Meyer<a name="FNanchor_A_81" id="FNanchor_A_81"></a><a href="#Footnote_A_81" class="fnanchor">[81]</a> 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 <i>B. +enteritidis</i> for experimental purposes. The strain responsible for the +<span class="pagenum"><a id="page73" name="page73"></a>[p.73]</span> infection had been isolated from the heart blood of a calf that +had succumbed to infectious diarrhea.</p> + +<p>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 <i>et al.</i>, p. 67) the Wareham (England, 1910) epidemic<a name="FNanchor_A_82" id="FNanchor_A_82"></a><a href="#Footnote_A_82" class="fnanchor">[82]</a> 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. +Söderbaum<a name="FNanchor_A_83" id="FNanchor_A_83"></a><a href="#Footnote_A_83" class="fnanchor">[83]</a> mentions a milk-borne paratyphoid epidemic occurring in +Kristiania which was ascribed to infection of the milk by a woman +milker. Sacquépée and Bellot<a name="FNanchor_A_84" id="FNanchor_A_84"></a><a href="#Footnote_A_84" class="fnanchor">[84]</a> 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.</p> + +<p class="blockq1">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.... <i>B. paratyphosus</i> B (<i>B. suipestifer</i>) was repeatedly +found in his stools in August, September, and October.... In all +probability, therefore, the <span class="pagenum"><a id="page74" name="page74"></a>[p.74]</span> outbreak was due to food +contaminated by a paratyphoid-carrier who had passed through an +abortive attack of the fever.<a name="FNanchor_A_85" id="FNanchor_A_85"></a><a href="#Footnote_A_85" class="fnanchor">[85]</a></p> + +<p>Bainbridge and Dudfield<a name="FNanchor_A_86" id="FNanchor_A_86"></a><a href="#Footnote_A_86" class="fnanchor">[86]</a> 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.</p> + +<p>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 <i>B. +paratyphosus</i> B, an organism which they would distinguish from the +"true" food poisoning bacilli, <i>B. enteritidis</i> and <i>B. suipestifer</i>.</p> + +<p>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, <span class="pagenum"><a id="page75" name="page75"></a>[p.75]</span> 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.</p> + +<p>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.</p> + +<p>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 <span class="pagenum"><a id="page76" name="page76"></a>[p.76]</span> 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,<a name="FNanchor_A_87" id="FNanchor_A_87"></a><a href="#Footnote_A_87" class="fnanchor">[87]</a> 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.<a name="FNanchor_A_88" id="FNanchor_A_88"></a><a href="#Footnote_A_88" class="fnanchor">[88]</a> 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.</p> + +<p>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.</p> + +<p>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.</p> + +<p><span class="pagenum"><a id="page77" name="page77"></a>[p.77]</span> <i>Means of prevention.</i>—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. Müller<a name="FNanchor_A_89" id="FNanchor_A_89"></a><a href="#Footnote_A_89" class="fnanchor">[89]</a> 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.</p> + +<p>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 <span class="pagenum"><a id="page78" name="page78"></a>[p.78]</span> 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.</p> + +<p>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 (paté +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.</p> + +<p>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.</p> + + + + +<h2><span class="pagenum"><a id="page79" name="page79"></a>[p.79]</span> CHAPTER VII</h2> + +<h3>ANIMAL PARASITES</h3> + + +<p>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.</p> + + +<h4>TRICHINIASIS</h4> + +<p>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 (<i>Trichinella spiralis</i>, formerly known as +<i>Trichina</i>) which is swallowed while in its encysted larval stage in raw +or imperfectly cooked pork.<a name="FNanchor_A_90" id="FNanchor_A_90"></a><a href="#Footnote_A_90" class="fnanchor">[90]</a> 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. <span class="pagenum"><a id="page80" name="page80"></a>[p.80]</span> 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<a name="FNanchor_A_91" id="FNanchor_A_91"></a><a href="#Footnote_A_91" class="fnanchor">[91]</a> found <i>Trichinella</i> 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 <i>Trichinella</i> 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.</p> + +<a id="img008" name="img008"></a> +<div class="figcenter1 width400"> +<img src="images/img008.jpg" width="400" height="275" alt="Fig. 7." title=""> +<p><span class="smcap">Fig. 7.</span>—Trichinae encysted in intercostal muscle of pig. +(About 35×1.) (After Neumann and Mayer.)</p> +</div> + +<p>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 <span class="pagenum"><a id="page81" name="page81"></a>[p.81]</span> 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.</p> + +<p>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.</p> + +<p>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.<a name="FNanchor_A_92" id="FNanchor_A_92"></a><a href="#Footnote_A_92" class="fnanchor">[92]</a> On the +other hand, thorough cooking removes all possibility of danger.</p> + + +<h4><span class="pagenum"><a id="page82" name="page82"></a>[p.82]</span> TENIASIS</h4> + +<p>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 <i>Tenia saginata</i> in the beef and <i>Tenia +solium</i> in the hog. The dwarf tapeworm, <i>Hymenolepis nana</i>, develops in +rats, and the human infections with this parasite occasionally observed +are probably caused by contamination of food by these animals.</p> + +<a id="img009" name="img009"></a> +<div class="figcenter1 width500"> +<img src="images/img009.jpg" width="500" height="331" alt="Fig. 8." title=""> +<p><span class="smcap">Fig. 8.</span>—<i>Cysticercus cellulosae</i> in pig's tongue. (After +Neumann and Mayer.)</p> +</div> + +<p>Sometimes the existence of the tapeworm in man is restricted to the +alimentary tract and the symptoms vary from trivial to severe, but +sometimes (<i>Tenia solium</i>) 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 <i>Tenia solium</i> <span class="pagenum"><a id="page83" name="page83"></a>[p.83]</span> was at one time regarded as an +independent animal species and named <i>Cysticercus cellulosae</i>. The +condition known as "measly pork" is produced by the occurrence of this +encysted parasite.</p> + +<p>So-called hydatid disease is due to the cystic growth produced by the +larva of a species of tapeworm (<i>Echinococcus</i>) 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.</p> + +<p>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.</p> + + +<h4>UNCINARIASIS</h4> + +<p>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<a name="FNanchor_A_93" id="FNanchor_A_93"></a><a href="#Footnote_A_93" class="fnanchor">[93]</a> believe +that hookworm disease is contracted by unconscious coprophagy (from raw +vegetables) much more frequently than is generally supposed.</p> + + +<h4><span class="pagenum"><a id="page84" name="page84"></a>[p.84]</span> OTHER PARASITES</h4> + +<p>A number of other parasitic worms (e.g., <i>Strongyloides</i>, <i>Ascaris</i> or +eelworm, and <i>Oxyuria</i> 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.</p> + +<a id="img010" name="img010"></a> +<div class="figcenter1 width400"> +<img src="images/img010.jpg" width="400" height="277" alt="Fig. 9." title=""> +<p><span class="smcap">Fig. 9.</span>—<i>Lamblia intestinalis.</i> (After Neumann and +Mayer.)</p> +</div> + +<p>Various forms of dysentery or diarrhea have been attributed to infection +with <i>Giardia (Lamblia) intestinalis</i>. Observations made by Fantham and +Porter<a name="FNanchor_A_94" id="FNanchor_A_94"></a><a href="#Footnote_A_94" class="fnanchor">[94]</a> 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.</p> + + + + +<h2><span class="pagenum"><a id="page85" name="page85"></a>[p.85]</span> <a id="chapVIII" name="chapVIII">CHAPTER VIII</a></h2> + +<h3>POISONOUS PRODUCTS FORMED IN FOOD BY BACTERIA AND OTHER MICRO-ORGANISMS</h3> + + +<p>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 <i>paratyphoid-enteritidis</i> group (<a href="#chapVI">chapter +vi</a>). Thus far the best-known examples of poisoning by the products of +micro-organisms are botulism and ergotism.</p> + + +<h4>ERGOTISM</h4> + +<p>Ergotism or ergot poisoning is due to the use of rye that has become +diseased through the attack of a fungus, <i>Claviceps purpurea</i>. It +occurred frequently in the Middle Ages when in times of famine the ergot +or spurred rye (O.Fr. <i>argot</i>, "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 <span class="pagenum"><a id="page86" name="page86"></a>[p.86]</span> some twenty-eight outbreaks in the nineteenth century; +in parts of Russia the disease is said still to occur in years of bad +harvest.<a name="FNanchor_A_95" id="FNanchor_A_95"></a><a href="#Footnote_A_95" class="fnanchor">[95]</a></p> + +<p>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.<a name="FNanchor_A_96" id="FNanchor_A_96"></a><a href="#Footnote_A_96" class="fnanchor">[96]</a> 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.</p> + + +<h4>BOTULISM</h4> + +<p>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).<a name="FNanchor_A_97" id="FNanchor_A_97"></a><a href="#Footnote_A_97" class="fnanchor">[97]</a> This kind of food +poisoning, which has a characteristic set of symptoms, seems to have +been first recognized and described in 1820 by the <span class="pagenum"><a id="page87" name="page87"></a>[p.87]</span> German poet +and medical writer Justinus Kerner. In two articles (1820-22) he +enumerates 174 cases with 71 deaths occurring in Württemberg between +1793 and 1822 and apparently in most cases connected with the use +<span class="pagenum"><a id="page88" name="page88"></a>[p.88]</span> of insufficiently smoked sausage. Mayer<a name="FNanchor_A_98" id="FNanchor_A_98"></a><a href="#Footnote_A_98" class="fnanchor">[98]</a> 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.<a name="FNanchor_A_99" id="FNanchor_A_99"></a><a href="#Footnote_A_99" class="fnanchor">[99]</a> In Great Britain +Savage<a name="FNanchor_A_100" id="FNanchor_A_100"></a><a href="#Footnote_A_100" class="fnanchor">[100]</a> 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,<a name="FNanchor_A_101" id="FNanchor_A_101"></a><a href="#Footnote_A_101" class="fnanchor">[101]</a> 1907, 3 cases, 3 deaths, canned +pork and beans; Peck,<a name="FNanchor_A_102" id="FNanchor_A_102"></a><a href="#Footnote_A_102" class="fnanchor">[102]</a> 1910, 12 cases, 11 deaths; Wilbur and +Ophüls,<a name="FNanchor_A_103" id="FNanchor_A_103"></a><a href="#Footnote_A_103" class="fnanchor">[103]</a> 1914, canned string beans, 12 cases, 1 death; Frost,<a name="FNanchor_A_104" id="FNanchor_A_104"></a><a href="#Footnote_A_104" class="fnanchor">[104]</a> +1915, 3 cases, 3 deaths). Professor Stiles<a name="FNanchor_A_105" id="FNanchor_A_105"></a><a href="#Footnote_A_105" class="fnanchor">[105]</a> has given a graphic +description of his own attack of probable botulism due in all likelihood +to minced chicken.</p> + +<a id="img011" name="img011"></a> +<div class="figcenter1 width350"> +<img src="images/img011.jpg" width="350" height="550" alt="Fig. 10." title=""> +<p><span class="smcap">Fig. 10.</span>—<i>Claviceps purpurea:</i> 1, ergot on rye-grass; 2, +ergot on rye; 3, section of a portion of the conidial form of fruit, +×300; 4, a sclerotium or ergot; 5, head of ascigerous form of fruit; 6, +an ascus, ×300; 7, a single spore, ×300. (After Massee, <i>Plant +Diseases</i>, by courtesy of the Macmillan Company.)</p> +</div> + +<p><i>Symptoms.</i>—The description of a case seen by Wilbur and Ophüls,<a name="FNanchor_A_106" id="FNanchor_A_106"></a><a href="#Footnote_A_106" class="fnanchor">[106]</a> +is so typical that it may be cited:</p> + +<p class="blockq2">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 <span class="pagenum"><a id="page89" name="page89"></a>[p.89]</span> 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.</p> + +<p class="blockq3">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 <span class="pagenum"><a id="page90" name="page90"></a>[p.90]</span> 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.</p> + +<p>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:</p> + +<p class="blockq1">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 <span class="pagenum"><a id="page91" name="page91"></a>[p.91]</span> 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.</p> + +<p>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.</p> + +<p>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.</p> + +<p><i>Anatomical lesions.</i>—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 Ophüls<a name="FNanchor_A_107" id="FNanchor_A_107"></a><a href="#Footnote_A_107" class="fnanchor">[107]</a> 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, Ophüls <span class="pagenum"><a id="page92" name="page92"></a>[p.92]</span> 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.</p> + +<p><i>Bacteriology.</i>—The cause of botulism poisoning was discovered by Van +Ermengem to be the toxin produced by a bacillus which he named <i>B. +botulinus</i>. 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 anaërobe), +stains by Gram's method, forms terminal spores, and develops best at +22°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 <i>B. +botulinus</i> is distributed. Except in connection with the cases of +poisoning it has been reported but once in nature.<a name="FNanchor_A_108" id="FNanchor_A_108"></a><a href="#Footnote_A_108" class="fnanchor">[108]</a> The botulism +poison <span class="pagenum"><a id="page93" name="page93"></a>[p.93]</span> is a true bacterial toxin, chemically unstable, +destroyed by heating at 80°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 <i>B. botulinus</i> 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.</p> + +<a id="img012" name="img012"></a> +<div class="figcenter1 width300"> +<img src="images/img012.jpg" width="300" height="300" alt="Fig. 11." title=""> +<p><span class="smcap">Fig. 11.</span>—<i>Bacillus botulinus</i> with spores. Pure culture +on sugar-gelatin. Van Ermengem preparation. (Kolle and Wassermann.)</p> +</div> + +<p><i>Epidemiology.</i>—The conditions under which <i>B. botulinus</i> 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 <span class="pagenum"><a id="page94" name="page94"></a>[p.94]</span> allowed to stand for a time, and +<i>eaten before cooking</i>. 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 <i>B. botulinus</i>—inadequate smoking, too weak brine,<a name="FNanchor_A_109" id="FNanchor_A_109"></a><a href="#Footnote_A_109" class="fnanchor">[109]</a> 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 <i>B. +botulinus</i>, 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 (anaërobic 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 anaërobic growth seemed to be the +decisive factor.</p> + +<p><i>Prevention and treatment.</i>—The food in which <i>B. botulinus</i> has grown +does not seem to be altered in a way <span class="pagenum"><a id="page95" name="page95"></a>[p.95]</span> that necessarily arouses +suspicion. In the case described by Römer the incriminated ham showed +bluish-gray areas from which <i>B. botulinus</i> 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 anaërobes produce butyric acid. If, as in the Darmstadt<a name="FNanchor_A_110" id="FNanchor_A_110"></a><a href="#Footnote_A_110" class="fnanchor">[110]</a> and +Stanford University<a name="FNanchor_A_111" id="FNanchor_A_111"></a><a href="#Footnote_A_111" class="fnanchor">[111]</a> 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.</p> + +<p>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 +anaërobic 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, <span class="pagenum"><a id="page96" name="page96"></a>[p.96]</span> composed wholly or in part of uncooked materials should +not be allowed to stand overnight before being served.</p> + +<p>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, <i>loc. cit.</i>). 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.</p> + +<p>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.</p> + + +<h4>OTHER BACTERIAL POISONS</h4> + +<p>The interesting case reported by Barber<a name="FNanchor_A_112" id="FNanchor_A_112"></a><a href="#Footnote_A_112" class="fnanchor">[112]</a> 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 <span class="pagenum"><a id="page97" name="page97"></a>[p.97]</span> before +being used. The symptoms were similar to those usually ascribed to +"ptomain poisoning."</p> + + +<h4>SPOILED AND DECOMPOSED FOOD</h4> + +<p>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 +<span class="pagenum"><a id="page98" name="page98"></a>[p.98]</span> 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...."<a name="FNanchor_A_113" id="FNanchor_A_113"></a><a href="#Footnote_A_113" class="fnanchor">[113]</a> 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.</p> + +<p>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.</p> + +<p><span class="pagenum"><a id="page99" name="page99"></a>[p.99]</span> 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 <i>B. botulinus</i> 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.</p> + + + + +<h2><span class="pagenum"><a id="page100" name="page100"></a>[p.100]</span> CHAPTER IX</h2> + +<h3>POISONING OF OBSCURE OR UNKNOWN NATURE</h3> + + +<p>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.</p> + + +<h4>MILKSICKNESS OR TREMBLES</h4> + +<p>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.</p> + +<p>The disease appears to be usually contracted in the first instance by +grazing cattle or sheep that have access <span class="pagenum"><a id="page101" name="page101"></a>[p.101]</span> 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.<a name="FNanchor_A_114" id="FNanchor_A_114"></a><a href="#Footnote_A_114" class="fnanchor">[114]</a></p> + +<p>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.<a name="FNanchor_A_115" id="FNanchor_A_115"></a><a href="#Footnote_A_115" class="fnanchor">[115]</a> The true cause of +milksickness is at present quite unknown.</p> + + +<h4>DEFICIENCY DISEASES</h4> + +<p>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 <span class="pagenum"><a id="page102" name="page102"></a>[p.102]</span> 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.</p> + +<p><i>Beriberi.</i>—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.<a name="FNanchor_A_116" id="FNanchor_A_116"></a><a href="#Footnote_A_116" class="fnanchor">[116]</a> 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 <span class="pagenum"><a id="page103" name="page103"></a>[p.103]</span> 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.<a name="FNanchor_A_117" id="FNanchor_A_117"></a><a href="#Footnote_A_117" class="fnanchor">[117]</a></p> + +<p><i>Pellagra</i> is one of the diseases attributed to an unbalanced diet,<a name="FNanchor_A_118" id="FNanchor_A_118"></a><a href="#Footnote_A_118" class="fnanchor">[118]</a> +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.<a name="FNanchor_A_119" id="FNanchor_A_119"></a><a href="#Footnote_A_119" class="fnanchor">[119]</a></p> + +<p><i>Lathyrism.</i>—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 <span class="pagenum"><a id="page104" name="page104"></a>[p.104]</span> legumes consumed, or whether under certain +conditions the legumes themselves may contain poisonous substances +generated by some unknown fungus growths.</p> + +<p><i>Favism</i> (from <i>fava</i>, "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.<a name="FNanchor_A_120" id="FNanchor_A_120"></a><a href="#Footnote_A_120" class="fnanchor">[120]</a> 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.</p> + +<p><i>Scurvy</i> 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.<a name="FNanchor_A_121" id="FNanchor_A_121"></a><a href="#Footnote_A_121" class="fnanchor">[121]</a> 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.<a name="FNanchor_A_122" id="FNanchor_A_122"></a><a href="#Footnote_A_122" class="fnanchor">[122]</a> The relative share of diet and infection in the +production of human scurvy is consequently regarded by some +investigators as uncertain.</p> + +<p><span class="pagenum"><a id="page105" name="page105"></a>[p.105]</span> <i>Rachitis</i> 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.</p> + +<p>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.</p> + + +<h4>THE FOODS MOST COMMONLY POISONOUS</h4> + +<p>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 anaërobic bacteria which produce poisonous substances, an +explanation highly conjectural.</p> + +<p><span class="pagenum"><a id="page106" name="page106"></a>[p.106]</span> 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.</p> + +<p>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.</p> + +<p>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 +<span class="pagenum"><a id="page107" name="page107"></a>[p.107]</span> diseased mussels taken from unpolluted water contain a +poisonous substance. In a similar way it is uncertain whether a certain +marine snail (<i>Murex bradatus</i>), 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.</p> + +<p>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.</p> + +<p>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.</p> + + + + +<h2><span class="pagenum"><a id="page109" name="page109"></a>[p.109]</span> INDEX</h2> + + +<ul> + <li class="martop1h add5em">A</li> + + <li class="martop04">Acid pickles, <a href="#page33">33</a></li> + + <li class="martop04">Adulteration, food, <a href="#page41">41</a></li> + + <li class="martop04">Agglutination, <a href="#page60">60</a>, <a href="#page64">64</a>, <a href="#page70">70</a></li> + + <li class="martop04">Alkaloid, <a href="#page107">107</a></li> + + <li class="martop04">Allergy, food, <a href="#page6">6</a></li> + + <li class="martop04">Almonds, <a href="#page11">11</a></li> + + <li class="martop04"><i>Amanita</i>:</li> + <li class="martop01 add2em"><i>aurantiaca</i>, <a href="#page20">20</a>;</li> + <li class="martop01 add2em"><i>caesaria</i>, <a href="#page18">18</a>, <a href="#page20">20</a>;</li> + <li class="martop01 add2em"><i>muscaria</i>, <a href="#page18">18</a>, <a href="#img004">19</a>, <a href="#page20">20</a>, <a href="#page22">22</a>;</li> + <li class="martop01 add2em"><i>phalloides</i>, <a href="#page21">21</a>, <a href="#page22">22</a>, <a href="#img005">23</a>;</li> + <li class="martop01 add2em"><i>verna</i>, <a href="#page22">22</a></li> + + <li class="martop04">"<i>Amanita</i> toxin," <a href="#page22">22</a>, <a href="#page24">24</a></li> + + <li class="martop04">Anaphylaxis, <a href="#page9">9</a>, <a href="#page10">10</a>, <a href="#page11">11</a></li> + + <li class="martop04">Aniline dyes, <a href="#page32">32</a></li> + + <li class="martop04">Animal parasites, <a href="#page79">79</a></li> + + <li class="martop04">Animals, <a href="#page13">13</a>, <a href="#page14">14</a>, <a href="#page24">24</a>, <a href="#page44">44</a>, <a href="#page50">50</a>, <a href="#page67">67</a>, <a href="#page68">68</a>, <a href="#page70">70</a>, <a href="#page71">71</a>, <a href="#page72">72</a>, <a href="#page78">78</a>, <a href="#page93">93</a>, <a href="#page95">95</a>, <a href="#page100">100</a>, <a href="#page106">106</a>;</li> + <li class="martop01 add2em">emergency-slaughtered, <a href="#page59">59</a>, <a href="#page62">62</a>, <a href="#page63">63</a>, <a href="#page65">65</a>, <a href="#page72">72</a></li> + + <li class="martop04">Ankylostomiasis, <a href="#page83">83</a></li> + + <li class="martop04">Annatto, <a href="#page32">32</a></li> + + <li class="martop04">"Anti-anaphylaxis," <a href="#page11">11</a></li> + + <li class="martop04">Antimony, <a href="#page27">27</a></li> + + <li class="martop04">Antiseptic chemicals, <a href="#page33">33</a>, <a href="#page40">40</a></li> + + <li class="martop04">Antitoxin, <a href="#page24">24</a>;</li> + <li class="martop01 add2em">diphtheria, <a href="#page9">9</a></li> + + <li class="martop04">Appendicitis, <a href="#page1">1</a></li> + + <li class="martop04">Arsenic, <a href="#page26">26</a>, <a href="#page101">101</a></li> + + <li class="martop04">Arteries, <a href="#page3">3</a></li> + + <li class="martop04">Artichokes, <a href="#page16">16</a></li> + + <li class="martop04"><i>Ascaris</i>, <a href="#page84">84</a></li> + + <li class="martop04">Asiatic cholera, <a href="#page50">50</a></li> + + <li class="martop04">Asparagus, <a href="#page30">30</a>, <a href="#page31">31</a></li> + + <li class="martop04">Asthma, <a href="#page10">10</a>, <a href="#page12">12</a></li> + + <li class="martop04">Atropin, <a href="#page20">20</a></li> + + + <li class="martop1h add5em">B</li> + + <li class="martop04">Bacillus:</li> + <li class="martop01 add2em"><i>botulinus</i>, <a href="#page92">92</a>-<a href="#page96">96</a>;</li> + <li class="martop01 add2em"><i>coli</i>, <a href="#page56">56</a>;</li> + <li class="martop01 add2em">Danysz, <a href="#page75">75</a>;</li> + <li class="martop01 add2em"><i>diphtheriae</i>, <a href="#page69">69</a>;</li> + <li class="martop01 add2em"><i>enteritidis</i>, <a href="#page58">58</a>, <a href="#page59">59</a>, <a href="#page60">60</a>, <a href="#page63">63</a>, <a href="#page64">64</a>, <a href="#page65">65</a>, <a href="#page66">66</a>, <a href="#page67">67</a>, <a href="#page68">68</a>, <a href="#page69">69</a>, <a href="#page70">70</a>, + <a href="#page71">71</a>, <a href="#page72">72</a>, <a href="#page74">74</a>;</li> + <li class="martop01 add2em"><i>enteritidis-suipestifer</i>, <a href="#page70">70</a>, <a href="#page72">72</a>;</li> + <li class="martop01 add2em"><i>paratyphoid-enteritidis</i>, <a href="#page68">68</a>, <a href="#page69">69</a>, <a href="#page85">85</a>;</li> + <li class="martop01 add2em"><i>paratyphosus</i>, <a href="#page58">58</a>, <a href="#page66">66</a>;</li> + <li class="martop01 add2em"><i>paratyphosus</i> B, <a href="#page60">60</a>, <a href="#page65">65</a>, <a href="#page66">66</a>, <a href="#page73">73</a>, <a href="#page74">74</a>;</li> + <li class="martop01 add2em"><i>proteus</i>, <a href="#page55">55</a>, <a href="#page56">56</a>, <a href="#page57">57</a>, <a href="#page107">107</a>;</li> + <li class="martop01 add2em"><i>suipestifer</i>, <a href="#page65">65</a>, <a href="#page66">66</a>, <a href="#page67">67</a>, <a href="#page68">68</a>, <a href="#page71">71</a>, <a href="#page72">72</a>, <a href="#page73">73</a>, <a href="#page74">74</a>;</li> + <li class="martop01 add2em">tetanus, <a href="#page69">69</a>;</li> + <li class="martop01 add2em">tubercle, <a href="#page44">44</a>, <a href="#page51">51</a>, <a href="#page52">52</a>, <a href="#page53">53</a>;</li> + <li class="martop01 add2em">typhoid, <a href="#page44">44</a>-<a href="#page47">47</a>, <a href="#page64">64</a>, <a href="#page106">106</a></li> + + <li class="martop04">Bacteria:</li> + <li class="martop01 add2em">food-borne, <a href="#page44">44</a>, <a href="#page58">58</a>;</li> + <li class="martop01 add2em">pathogenic, <a href="#page44">44</a>, <a href="#page58">58</a></li> + + <li class="martop04">Bacterial products, <a href="#page85">85</a></li> + + <li class="martop04">Balloon-fish, <a href="#page24">24</a></li> + + <li class="martop04">Barbel, <a href="#page25">25</a></li> + + <li class="martop04">Beans, <a href="#page14">14</a>, <a href="#page31">31</a>, <a href="#page46">46</a>, <a href="#page86">86</a>, <a href="#page88">88</a>, <a href="#page95">95</a>, <a href="#page104">104</a></li> + + <li class="martop04">Beef stew, <a href="#page59">59</a></li> + + <li class="martop04">Beer, <a href="#page26">26</a>, <a href="#page27">27</a></li> + + <li class="martop04">Benzoate of soda, <a href="#page34">34</a></li> + + <li class="martop04">Benzoic acid, <a href="#page34">34</a>, <a href="#page35">35</a>, <a href="#page36">36</a></li> + + <li class="martop04">Beriberi, <a href="#page102">102</a></li> + + <li class="martop04">Berries, <a href="#page29">29</a>, <a href="#page35">35</a></li> + + <li class="martop04">Birds, game, <a href="#page97">97</a></li> + + <li class="martop04">Biscuits, soda, <a href="#page36">36</a></li> + + <li class="martop04">Blood vessels, <a href="#page2">2</a>, <a href="#page39">39</a></li> + + <li class="martop04">Borax, <a href="#page37">37</a></li> + + <li class="martop04">Boric acid, <a href="#page37">37</a>, <a href="#page38">38</a>, <a href="#page40">40</a></li> + + <li class="martop04">Botulism, <a href="#page86">86</a>;</li> + <li class="martop01 add2em">anatomical lesions, <a href="#page91">91</a>;</li> + <li class="martop01 add2em">bacteriology, <a href="#page92">92</a>;</li> + <li class="martop01 add2em">cases, <a href="#page87">87</a>;</li> + <li class="martop01 add2em">epidemiology, <a href="#page93">93</a>;</li> + <li class="martop01 add2em">prevention and treatment, <a href="#page94">94</a>;</li> + <li class="martop01 add2em">symptoms, <a href="#page88">88</a></li> + + <li class="martop04"><span class="pagenum"><a id="page110" name="page110"></a>[p.110]</span> Bread, <a href="#page47">47</a>, <a href="#page48">48</a></li> + + <li class="martop04">Butter, <a href="#page16">16</a>, <a href="#page32">32</a>, <a href="#page40">40</a>, <a href="#page101">101</a></li> + + <li class="martop04">Butyric acid, <a href="#page95">95</a></li> + + + <li class="martop1h add5em">C</li> + + <li class="martop04">Caffeine, <a href="#page36">36</a>, <a href="#page41">41</a></li> + + <li class="martop04">Cakes, <a href="#page76">76</a></li> + + <li class="martop04">"Calf diarrhea," <a href="#page72">72</a></li> + + <li class="martop04">Candies, <a href="#page27">27</a>, <a href="#page28">28</a>, <a href="#page32">32</a>, <a href="#page41">41</a></li> + + <li class="martop04">Canned foods, <a href="#page4">4</a>, <a href="#page5">5</a>, <a href="#page7">7</a>, <a href="#page8">8</a>, <a href="#page29">29</a>, <a href="#page30">30</a>, <a href="#page95">95</a></li> + + <li class="martop04">Canning, <a href="#page33">33</a>, <a href="#page93">93</a></li> + + <li class="martop04">Cap, metallic, <a href="#page28">28</a></li> + + <li class="martop04">Cardamom, oil of, <a href="#page16">16</a></li> + + <li class="martop04">Carriers, <a href="#page55">55</a>;</li> + <li class="martop01 add2em">paratyphoid, <a href="#page61">61</a>, <a href="#page62">62</a>, <a href="#page66">66</a>, <a href="#page67">67</a>, <a href="#page70">70</a>, <a href="#page73">73</a>, <a href="#page78">78</a>;</li> + <li class="martop01 add2em">typhoid, <a href="#page45">45</a>, <a href="#page48">48</a>, <a href="#page50">50</a>, <a href="#page66">66</a></li> + + <li class="martop04">Cases of:</li> + <li class="martop01 add2em">botulism, <a href="#page87">87</a>,</li> + <li class="martop01 add4em">listed by Mayer, <a href="#page88">88</a>,</li> + <li class="martop01 add4em">in U.S., <a href="#page88">88</a>-<a href="#page91">91</a>;</li> + <li class="martop01 add2em">dysentery, <a href="#page84">84</a>;</li> + <li class="martop01 add2em">food sensitization, <a href="#page10">10</a>, <a href="#page11">11</a>, <a href="#page12">12</a>;</li> + <li class="martop01 add2em">milksickness, <a href="#page100">100</a>;</li> + <li class="martop01 add2em">mushroom poisoning, <a href="#page20">20</a>, <a href="#page21">21</a>, <a href="#page22">22</a>;</li> + <li class="martop01 add2em">plant poisoning, <a href="#page14">14</a>;</li> + <li class="martop01 add2em">poisoning from asparagus, <a href="#page30">30</a>;</li> + <li class="martop01 add2em">trichiniasis, <a href="#page80">80</a>, <a href="#page81">81</a>;</li> + <li class="martop01 add2em">tuberculosis, <a href="#page53">53</a></li> + + <li class="martop04">Cat, <a href="#page83">83</a></li> + + <li class="martop04">Cathartics, <a href="#page96">96</a></li> + + <li class="martop04">Cattle, <a href="#page10">10</a>, <a href="#page51">51</a>, <a href="#page53">53</a>, <a href="#page54">54</a>, <a href="#page55">55</a>, <a href="#page62">62</a>, <a href="#page63">63</a>, <a href="#page71">71</a>, <a href="#page72">72</a>, <a href="#page74">74</a>, <a href="#page82">82</a>, <a href="#page86">86</a>, <a href="#page96">96</a>, <a href="#page100">100</a></li> + + <li class="martop04">Celery, <a href="#page45">45</a>, <a href="#page46">46</a>, <a href="#page47">47</a></li> + + <li class="martop04">Cereals, <a href="#page12">12</a>, <a href="#page62">62</a></li> + + <li class="martop04">Cestode infection, <a href="#page82">82</a></li> + + <li class="martop04">Cheese, <a href="#page5">5</a>, <a href="#page7">7</a>, <a href="#page28">28</a>, <a href="#page97">97</a>, <a href="#page106">106</a></li> + + <li class="martop04">Chemicals, antiseptic, <a href="#page33">33</a>, <a href="#page40">40</a></li> + + <li class="martop04">Chicken, <a href="#page71">71</a>, <a href="#page88">88</a></li> + + <li class="martop04">Chick pea, <a href="#page103">103</a></li> + + <li class="martop04">Chicory, <a href="#page41">41</a></li> + + <li class="martop04">Chocolate, <a href="#page28">28</a></li> + + <li class="martop04">Cholera microbe, <a href="#page51">51</a></li> + + <li class="martop04">Chopped beef, <a href="#page59">59</a></li> + + <li class="martop04"><i>Cicuta maculata</i>, <a href="#page14">14</a>, <a href="#page16">16</a>, <a href="#page17">17</a></li> + + <li class="martop04">Cinnamon, <a href="#page37">37</a></li> + + <li class="martop04">Clams, <a href="#page50">50</a>, <a href="#page106">106</a></li> + + <li class="martop04"><i>Claviceps</i>:</li> + <li class="martop01 add2em"><i>paspali</i>, <a href="#page86">86</a>;</li> + <li class="martop01 add2em"><i>purpurea</i>, <a href="#page85">85</a>, <a href="#page87">87</a></li> + + <li class="martop04">Codfish, <a href="#page67">67</a></li> + + <li class="martop04">Coffee, <a href="#page36">36</a>, <a href="#page41">41</a></li> + + <li class="martop04">Coffee-tree, <a href="#page14">14</a></li> + + <li class="martop04">Coloring, artificial, <a href="#page40">40</a></li> + + <li class="martop04">Coloring substances, <a href="#page31">31</a></li> + + <li class="martop04"><i>Conium maculatum</i>, <a href="#img002">15</a></li> + + <li class="martop04">"Contact infection," <a href="#page62">62</a>, <a href="#page67">67</a></li> + + <li class="martop04">Cook, <a href="#page44">44</a>, <a href="#page45">45</a>, <a href="#page50">50</a>, <a href="#page73">73</a>, <a href="#page74">74</a></li> + + <li class="martop04">Copper, <a href="#page30">30</a>, <a href="#page101">101</a></li> + + <li class="martop04">Copper:</li> + <li class="martop01 add2em">acetate, <a href="#page31">31</a>;</li> + <li class="martop01 add2em">salts, <a href="#page31">31</a>;</li> + <li class="martop01 add2em">sulphate, <a href="#page31">31</a>, <a href="#page32">32</a></li> + + <li class="martop04">Cranberries, <a href="#page35">35</a></li> + + <li class="martop04">Creosote, <a href="#page34">34</a></li> + + <li class="martop04"><i>Cysticercus cellulosae</i>, <a href="#page82">82</a>, <a href="#page83">83</a></li> + + + <li class="martop1h add5em">D</li> + + <li class="martop04">Daffodil bulbs, <a href="#page14">14</a></li> + + <li class="martop04">Danysz bacillus, <a href="#page75">75</a></li> + + <li class="martop04">Death Camas, <a href="#page14">14</a></li> + + <li class="martop04">Death-cup, <a href="#page21">21</a>, <a href="#img005">23</a></li> + + <li class="martop04">Death-rates, <a href="#page2">2</a>, <a href="#page3">3</a>, <a href="#page4">4</a>, <a href="#page39">39</a></li> + + <li class="martop04"><i>Delphinium</i>, <a href="#page14">14</a></li> + + <li class="martop04">Diarrhea, <a href="#page84">84</a></li> + + <li class="martop04">Diet, defective, <a href="#page102">102</a>, <a href="#page103">103</a>, <a href="#page104">104</a>, <a href="#page105">105</a></li> + + <li class="martop04">Diphtheria, <a href="#page54">54</a></li> + + <li class="martop04">Diseases:</li> + <li class="martop01 add2em">deficiency, <a href="#page101">101</a>;</li> + <li class="martop01 add2em">degenerative, <a href="#page2">2</a>;</li> + <li class="martop01 add2em">milk-borne, <a href="#page54">54</a>;</li> + <li class="martop01 add2em">skin, <a href="#page12">12</a></li> + + <li class="martop04">Dog, <a href="#page25">25</a>, <a href="#page83">83</a></li> + + <li class="martop04">Drying, <a href="#page33">33</a>, <a href="#page40">40</a></li> + + <li class="martop04">Dyes, aniline, <a href="#page32">32</a></li> + + <li class="martop04">Dysentery, <a href="#page84">84</a></li> + + + <li class="martop1h add5em">E</li> + + <li class="martop04"><i>Echinococcus</i>, <a href="#page83">83</a></li> + + <li class="martop04">Eczema, <a href="#page10">10</a>, <a href="#page12">12</a></li> + + <li class="martop04">Eelworm, <a href="#page84">84</a></li> + + <li class="martop04">Eggs, <a href="#page6">6</a>, <a href="#page10">10</a>, <a href="#page11">11</a>, <a href="#page12">12</a>, <a href="#page97">97</a>, <a href="#page98">98</a></li> + + <li class="martop04">Egg-white, <a href="#page9">9</a>, <a href="#page10">10</a>, <a href="#page11">11</a>, <a href="#page12">12</a></li> + + <li class="martop04"><span class="pagenum"><a id="page111" name="page111"></a>[p.111]</span> Epidemics. <i>See</i> <a href="#outbr">Outbreaks</a></li> + + <li class="martop04">Ergot, <a href="#page85">85</a></li> + + <li class="martop04">Ergotism, <a href="#page85">85</a>-<a href="#page86">86</a></li> + + <li class="martop04">"Expectation of life," <a href="#page2">2</a></li> + + <li class="martop04">Extracts, flavoring, <a href="#page106">106</a></li> + + + <li class="martop1h add5em">F</li> + + <li class="martop04">Favism, <a href="#page104">104</a></li> + + <li class="martop04">Fish, <a href="#page5">5</a>, <a href="#page24">24</a>, <a href="#page25">25</a>, <a href="#page34">34</a>, <a href="#page62">62</a>, <a href="#page67">67</a>, <a href="#page71">71</a>, <a href="#page83">83</a></li> + + <li class="martop04">Flies, <a href="#page47">47</a></li> + + <li class="martop04">Flour, <a href="#page32">32</a>, <a href="#page43">43</a>, <a href="#page103">103</a></li> + + <li class="martop04">"Fly <i>Amanita</i>," <a href="#page18">18</a>, <a href="#img004">19</a>, <a href="#page21">21</a></li> + + <li class="martop04">Fly poison, <a href="#page18">18</a></li> + + <li class="martop04">Food:</li> + <li class="martop01 add2em">adulteration, <a href="#page41">41</a>;</li> + <li class="martop01 add2em">allergy, <a href="#page6">6</a>;</li> + <li class="martop01 add2em">coloration, <a href="#page32">32</a>;</li> + <li class="martop01 add2em">intoxication, <a href="#page18">18</a>, <a href="#page57">57</a>, <a href="#page92">92</a>;</li> + <li class="martop01 add2em">preservatives, <a href="#page33">33</a>;</li> + <li class="martop01 add2em">substitutes, <a href="#page16">16</a>, <a href="#page41">41</a></li> + + <li class="martop04">Foods:</li> + <li class="martop01 add2em">canned, <a href="#page4">4</a>, <a href="#page5">5</a>, <a href="#page7">7</a>, <a href="#page8">8</a>, <a href="#page29">29</a>, <a href="#page30">30</a>, <a href="#page95">95</a>;</li> + <li class="martop01 add2em">cooked, <a href="#page47">47</a>, <a href="#page51">51</a>, <a href="#page52">52</a>, <a href="#page53">53</a>, <a href="#page54">54</a>, <a href="#page60">60</a>, <a href="#page63">63</a>, <a href="#page69">69</a>, <a href="#page70">70</a>, <a href="#page78">78</a>, <a href="#page81">81</a>, <a href="#page94">94</a>;</li> + <li class="martop01 add2em">decomposed, <a href="#page39">39</a>, <a href="#page97">97</a>;</li> + <li class="martop01 add2em">most commonly poisonous, <a href="#page105">105</a>;</li> + <li class="martop01 add2em">protein, sensitization to, <a href="#page9">9</a>;</li> + <li class="martop01 add2em">smoked, <a href="#page34">34</a>, <a href="#page39">39</a>;</li> + <li class="martop01 add2em">spoiled, <a href="#page39">39</a>, <a href="#page97">97</a>;</li> + <li class="martop01 add2em">uncooked, <a href="#page7">7</a>, <a href="#page46">46</a>, <a href="#page47">47</a>, <a href="#page48">48</a>, <a href="#page55">55</a>, <a href="#page63">63</a>, <a href="#page69">69</a>, <a href="#page70">70</a>, <a href="#page79">79</a>, <a href="#page84">84</a>, <a href="#page94">94</a>, <a href="#page96">96</a></li> + + <li class="martop04">Foot-and-mouth disease, <a href="#page55">55</a></li> + + <li class="martop04">Formaldehyde, <a href="#page36">36</a>, <a href="#page40">40</a></li> + + <li class="martop04">Fowl, <a href="#page5">5</a></li> + + <li class="martop04">Fruits, <a href="#page5">5</a>, <a href="#page10">10</a>, <a href="#page29">29</a>, <a href="#page30">30</a>, <a href="#page35">35</a>, <a href="#page47">47</a>, <a href="#page50">50</a>, <a href="#page62">62</a>, <a href="#page97">97</a>, <a href="#page104">104</a></li> + + <li class="martop04">"Fruit ethers," <a href="#page42">42</a></li> + + <li class="martop04">Fruit syrups, <a href="#page42">42</a></li> + + <li class="martop04"><i>Fugu</i>, <a href="#page25">25</a></li> + + <li class="martop04">Fungus, <a href="#page85">85</a></li> + + + <li class="martop1h add5em">G</li> + + <li class="martop04">Gallstones, <a href="#page1">1</a></li> + + <li class="martop04">Game birds, <a href="#page97">97</a></li> + + <li class="martop04">Gastro-enteritis, <a href="#page56">56</a>, <a href="#page60">60</a>, <a href="#page74">74</a>, <a href="#page96">96</a></li> + + <li class="martop04"><i>Giardia (Lamblia) intestinalis</i>, <a href="#page84">84</a></li> + + <li class="martop04">Globe-fish, <a href="#page24">24</a></li> + + <li class="martop04">Glucose, <a href="#page27">27</a>, <a href="#page41">41</a></li> + + <li class="martop04">Goose, <a href="#page71">71</a>;</li> + <li class="martop01 add2em">liver, <a href="#page78">78</a></li> + + <li class="martop04">Grain, <a href="#page85">85</a>, <a href="#page104">104</a></li> + + <li class="martop04">Grass, wild, <a href="#page86">86</a></li> + + <li class="martop04"><i>Gymnocladus dioica</i>, <a href="#page14">14</a></li> + + + <li class="martop1h add5em">H</li> + + <li class="martop04"><i>Hackfleisch</i>, <a href="#page59">59</a></li> + + <li class="martop04">Ham, <a href="#page86">86</a>, <a href="#page92">92</a>, <a href="#page94">94</a>, <a href="#page95">95</a></li> + + <li class="martop04">Hamburger steak, <a href="#page59">59</a>, <a href="#page78">78</a></li> + + <li class="martop04">Hay, <a href="#page104">104</a></li> + + <li class="martop04">Hay fever, <a href="#page9">9</a></li> + + <li class="martop04">Heart, <a href="#page3">3</a>, <a href="#page22">22</a></li> + + <li class="martop04">Heating, <a href="#page40">40</a></li> + + <li class="martop04">Hellebore, <a href="#page14">14</a></li> + + <li class="martop04">Hemlock, <a href="#page13">13</a>, <a href="#page16">15</a>;</li> + <li class="martop01 add2em">poison, <a href="#page16">16</a>;</li> + <li class="martop01 add2em">water, <a href="#page14">14</a>, <a href="#page16">16</a>, <a href="#page17">17</a></li> + + <li class="martop04">Hippuric acid, <a href="#page35">35</a>, <a href="#page36">36</a></li> + + <li class="martop04">Hog cholera, <a href="#page66">66</a>, <a href="#page71">71</a></li> + + <li class="martop04">Honey-locust, <a href="#page14">14</a></li> + + <li class="martop04">Hookworm infection, <a href="#page83">83</a></li> + + <li class="martop04">Horse, <a href="#page71">71</a>, <a href="#page86">86</a></li> + + <li class="martop04">Horseradish, <a href="#page16">16</a></li> + + <li class="martop04">Hydatid disease, <a href="#page83">83</a></li> + + <li class="martop04"><i>Hydrocarpus</i>, <a href="#page16">16</a></li> + + <li class="martop04"><i>Hymenolepis nana</i>, <a href="#page82">82</a></li> + + + <li class="martop1h add5em">I</li> + + <li class="martop04">Ice, <a href="#page75">75</a></li> + + <li class="martop04">Ice cream, <a href="#page5">5</a>, <a href="#page7">7</a>, <a href="#page32">32</a>, <a href="#page105">105</a>, <a href="#page106">106</a></li> + + <li class="martop04">Infection:</li> + <li class="martop01 add2em">accidental, <a href="#page72">72</a>;</li> + <li class="martop01 add2em">Asiatic cholera, <a href="#page50">50</a>;</li> + <li class="martop01 add2em"><i>Bacillus proteus</i>(?), <a href="#page55">55</a>;</li> + <li class="martop01 add2em">bacterial poisons, <a href="#page86">86</a>, <a href="#page96">96</a>;</li> + <li class="martop01 add2em">carrier, <a href="#page44">44</a>, <a href="#page45">45</a>, <a href="#page48">48</a>, <a href="#page50">50</a>, <a href="#page55">55</a>, <a href="#page61">61</a>, <a href="#page62">62</a>, <a href="#page66">66</a>, <a href="#page67">67</a>, <a href="#page70">70</a>, <a href="#page73">73</a>, <a href="#page78">78</a>;</li> + <li class="martop01 add2em">cestode, <a href="#page82">82</a>;</li> + <li class="martop01 add2em"><i>Giardia (Lamblia) intestinalis</i>, <a href="#page84">84</a>;</li> + <li class="martop01 add2em">hookworm, <a href="#page83">83</a>;</li> + <li class="martop01 add2em">laboratory, <a href="#page72">72</a>;</li> + <li class="martop01 add2em">milk-borne, <a href="#page54">54</a>;</li> + <li class="martop01 add2em">parasitic, <a href="#page79">79</a>;</li> + <li class="martop01 add2em">paratyphoid, <a href="#page58">58</a>;</li> + <li class="martop01 add2em">scurvy, <a href="#page104">104</a>;</li> + <li class="martop01 add2em">secondary bacterial, <a href="#page80">80</a>;</li> + <li class="martop01 add2em">soil, <a href="#page46">46</a>;</li> + <li class="martop01 add2em">tapeworm, <a href="#page82">82</a>;</li> + <li class="martop01 add2em">tuberculous meat, <a href="#page51">51</a>;</li> + <li class="martop01 add2em">tuberculous milk, <a href="#page53">53</a>;</li> + <li class="martop01 add2em">typhoid food, <a href="#page44">44</a></li> + + <li class="martop04">Intoxication, food, <a href="#page18">18</a>, <a href="#page57">57</a>, <a href="#page92">92</a></li> + + <li class="martop04">Iron pyrites, <a href="#page26">26</a></li> + + + <li class="martop1h add5em"><span class="pagenum"><a id="page112" name="page112"></a>[p.112]</span> J</li> + + <li class="martop04">Jams, <a href="#page27">27</a></li> + + <li class="martop04">Japanese <i>Fugu</i>, <a href="#page25">25</a></li> + + <li class="martop04">Jars, preserve, <a href="#page28">28</a></li> + + <li class="martop04">Jelly, <a href="#page32">32</a>, <a href="#page50">50</a></li> + + + <li class="martop1h add5em">K</li> + + <li class="martop04"><i>Kalmia latifolia</i>, <a href="#page14">14</a></li> + + <li class="martop04">Kidneys, <a href="#page2">2</a>, <a href="#page3">3</a>, <a href="#page22">22</a>, <a href="#page24">24</a>, <a href="#page39">39</a></li> + + <li class="martop04">Kittens, <a href="#page84">84</a></li> + + + <li class="martop1h add5em">L</li> + + <li class="martop04">Larkspur, <a href="#page14">14</a></li> + + <li class="martop04">Lathyrism, <a href="#page103">103</a></li> + + <li class="martop04">Laurel, <a href="#page14">14</a></li> + + <li class="martop04">Lead, <a href="#page27">27</a></li> + + <li class="martop04">Lead:</li> + <li class="martop01 add2em">chromate, <a href="#page28">28</a>;</li> + <li class="martop01 add2em">foil, <a href="#page28">28</a>;</li> + <li class="martop01 add2em">pipes, <a href="#page28">28</a>;</li> + <li class="martop01 add2em">salts, <a href="#page29">29</a></li> + + <li class="martop04">Legumes, <a href="#page104">104</a></li> + + <li class="martop04">Lettuce, <a href="#page45">45</a>, <a href="#page50">50</a></li> + + <li class="martop04">Liver, <a href="#page22">22</a>, <a href="#page24">24</a>;</li> + <li class="martop01 add2em">goose, <a href="#page78">78</a></li> + + <li class="martop04">Loco-weed, <a href="#page14">14</a></li> + + <li class="martop04">Lupines, <a href="#page14">14</a></li> + + + <li class="martop1h add5em">M</li> + + <li class="martop04">Maize, <a href="#page103">103</a></li> + + <li class="martop04">Maratti-oil, <a href="#page16">16</a></li> + + <li class="martop04">Margarin, <a href="#page16">16</a></li> + + <li class="martop04">Marsh-marigold, <a href="#page14">14</a></li> + + <li class="martop04">Mary Malloy, <a href="#page45">45</a></li> + + <li class="martop04">"Measly pork," <a href="#page83">83</a></li> + + <li class="martop04">Meat, <a href="#page5">5</a>, <a href="#page7">7</a>, <a href="#page24">24</a>, <a href="#page33">33</a>, <a href="#page37">37</a>, <a href="#page40">40</a>, <a href="#page44">44</a>, <a href="#page51">51</a>, <a href="#page52">52</a>, <a href="#page53">53</a>, <a href="#page57">57</a>, <a href="#page58">58</a>, <a href="#page59">59</a>, <a href="#page62">62</a>, <a href="#page63">63</a>, <a href="#page64">64</a>, + <a href="#page65">65</a>, <a href="#page68">68</a>, <a href="#page69">69</a>, <a href="#page70">70</a>, <a href="#page71">71</a>, <a href="#page72">72</a>, <a href="#page75">75</a>, <a href="#page76">76</a>, <a href="#page77">77</a>, <a href="#page78">78</a>, <a href="#page79">79</a>, <a href="#page83">83</a>, <a href="#page95">95</a>, <a href="#page97">97</a>, <a href="#page101">101</a>, <a href="#page106">106</a>;</li> + <li class="martop01 add2em">jellies, <a href="#page69">69</a>;</li> + <li class="martop01 add2em">pies, <a href="#page69">69</a>, <a href="#page73">73</a>;</li> + <li class="martop01 add2em">puddings, <a href="#page69">69</a></li> + + <li class="martop04">Meat inspection, <a href="#page77">77</a>, <a href="#page81">81</a></li> + + <li class="martop04">Metals, <a href="#page5">5</a>, <a href="#page106">106</a></li> + + <li class="martop04">Mice, <a href="#page56">56</a>, <a href="#page74">74</a>, <a href="#page75">75</a>, <a href="#page78">78</a>, <a href="#page84">84</a></li> + + <li class="martop04">Milk, <a href="#page5">5</a>, <a href="#page6">6</a>, <a href="#page7">7</a>, <a href="#page10">10</a>, <a href="#page11">11</a>, <a href="#page40">40</a>, <a href="#page48">48</a>, <a href="#page50">50</a>, <a href="#page51">51</a>, <a href="#page53">53</a>, <a href="#page54">54</a>, <a href="#page55">55</a>, <a href="#page62">62</a>, <a href="#page69">69</a>, <a href="#page70">70</a>, + <a href="#page72">72</a>, <a href="#page73">73</a>, <a href="#page76">76</a>, <a href="#page77">77</a>, <a href="#page96">96</a>, <a href="#page97">97</a>, <a href="#page101">101</a>, <a href="#page104">104</a>, <a href="#page106">106</a></li> + + <li class="martop04">Milksickness, <a href="#page100">100</a>-<a href="#page101">101</a></li> + + <li class="martop04">Molasses, <a href="#page30">30</a></li> + + <li class="martop04"><i>Murex bradatus</i>, <a href="#page107">107</a></li> + + <li class="martop04">Muscarin, <a href="#page22">22</a></li> + + <li class="martop04">Mushrooms, <a href="#page5">5</a>, <a href="#page13">13</a>, <a href="#page18">18</a>-<a href="#page24">24</a></li> + + <li class="martop04">Mussels, <a href="#page50">50</a>, <a href="#page106">106</a></li> + + <li class="martop04">"Mutations," <a href="#page68">68</a></li> + + + <li class="martop1h add5em">N</li> + + <li class="martop04">Neuritis, <a href="#page26">26</a></li> + + <li class="martop04">"Neurotoxin," <a href="#page24">24</a></li> + + <li class="martop04">Nipples, rubber, <a href="#page27">27</a></li> + + <li class="martop04">Nissl granules, <a href="#page91">91</a></li> + + <li class="martop04">Nitrogen peroxide, <a href="#page32">32</a></li> + + + <li class="martop1h add5em">O</li> + + <li class="martop04">Oatmeal, <a href="#page11">11</a></li> + + <li class="martop04">Oats, <a href="#page104">104</a></li> + + <li class="martop04">Oil of cardamom, <a href="#page16">16</a>;</li> + <li class="martop01 add2em">of cloves, <a href="#page37">37</a></li> + + <li class="martop04">Olive stones, <a href="#page41">41</a></li> + + <li class="martop04"><a id="outbr" name="outbr">Outbreaks</a> due to:</li> + <li class="martop01 add2em">beans, Darmstadt, <a href="#page95">95</a>,</li> + <li class="martop01 add4em">Stanford University, <a href="#page95">95</a>;</li> + <li class="martop01 add2em">beef, Breslau, <a href="#page58">58</a>;</li> + <li class="martop01 add2em">beef stew, Limerick, <a href="#page59">59</a>;</li> + <li class="martop01 add2em">beer, England, <a href="#page26">26</a>;</li> + <li class="martop01 add2em">bread, Elgin, <a href="#page48">48</a>;</li> + <li class="martop01 add2em">codfish, <a href="#page67">67</a>;</li> + <li class="martop01 add2em">diseased animals, <a href="#page71">71</a>;</li> + <li class="martop01 add2em">ergot, Limoges, <a href="#page85">85</a>;</li> + <li class="martop01 add2em">gastro-enteritis carrier, <a href="#page74">74</a>;</li> + <li class="martop01 add2em">group and family in U.S., <a href="#page4">4</a>, <a href="#page5">5</a>;</li> + <li class="martop01 add2em">ham, Ellezelles, <a href="#page92">92</a>;</li> + <li class="martop01 add2em">human contamination, <a href="#page73">73</a>;</li> + <li class="martop01 add2em">list of, by:</li> + <li class="martop01 add4em">Hirsch, <a href="#page85">85</a>,</li> + <li class="martop01 add4em">Hübener, <a href="#page58">58</a>,</li> + <li class="martop01 add4em">Mayer, <a href="#page65">65</a>,</li> + <li class="martop01 add4em">Savage, <a href="#page58">58</a>;</li> + <li class="martop01 add2em">margarin, Hamburg, <a href="#page16">16</a>;</li> + <li class="martop01 add2em">meat, <a href="#page65">65</a>, <a href="#page69">69</a>;</li> + <li class="martop01 add2em">Frankenhausen, <a href="#page63">63</a>,</li> + <li class="martop01 add4em">Ghent, <a href="#page77">77</a>;</li> + <li class="martop01 add2em">meat pies, Wareham, <a href="#page73">73</a>;</li> + <li class="martop01 add2em">milk, <a href="#page96">96</a>;</li> + <li class="martop01 add2em">Kristiania, <a href="#page73">73</a>,</li> + <li class="martop01 add4em">Newcastle, <a href="#page69">69</a>;</li> + <li class="martop01 add2em">miscellaneous contaminations, <a href="#page74">74</a>;</li> + <li class="martop01 add2em">mushrooms, New York City, <a href="#page18">18</a>;</li> + <li class="martop01 add2em">oysters, <a href="#page48">48</a>;</li> + <li class="martop01 add2em">paratyphoid carrier, <a href="#page73">73</a>;</li> + <li class="martop01 add2em">pie, Westerly, <a href="#page60">60</a>;</li> + <li class="martop01 add2em">potato salad, <a href="#page65">65</a>;</li> + <li class="martop01 add2em">public markets, South Philadelphia, <a href="#page46">46</a>;</li> + <li class="martop01 add2em">rat virus, <a href="#page75">75</a>;</li> + <li class="martop01 add2em">sausage, <a href="#page65">65</a>,</li> + <li class="martop01 add4em">Hanover, <a href="#page56">56</a>,</li> + <li class="martop01 add4em">Württemberg, <a href="#page86">86</a>;</li> + <li class="martop01 add2em">"sour <span class="pagenum"><a id="page113" name="page113"></a>[p.113]</span> grass soup," New York City, <a href="#page18">18</a>;</li> + <li class="martop01 add2em">spaghetti, Hanford, <a href="#page44">44</a>;</li> + <li class="martop01 add2em">typhoid carrier, New York City, <a href="#page45">45</a>;</li> + <li class="martop01 add2em"><i>Vanille Pudding</i>, <a href="#page65">65</a>;</li> + <li class="martop01 add2em">vermicelli, <a href="#page67">67</a>;</li> + <li class="martop01 add2em">watercress, Philadelphia, <a href="#page46">46</a>;</li> + <li class="martop01 add2em">water hemlock, New Jersey, <a href="#page16">16</a></li> + + <li class="martop04">Oxalic acid, <a href="#page18">18</a></li> + + <li class="martop04"><i>Oxyuria</i>, <a href="#page84">84</a></li> + + <li class="martop04">Oysters, <a href="#page5">5</a>, <a href="#page24">24</a>, <a href="#page48">48</a>, <a href="#page49">49</a>, <a href="#page50">50</a>, <a href="#page71">71</a>, <a href="#page106">106</a></li> + + + <li class="martop1h add5em">P</li> + + <li class="martop04">Palmolin, <a href="#Footnote_A_20">16</a></li> + + <li class="martop04"><i>Panaeolus papilionaceus</i>, <a href="#page21">21</a></li> + + <li class="martop04">"Paragaertner" forms, <a href="#page68">68</a></li> + + <li class="martop04">Parasites, <a href="#page79">79</a>, <a href="#page84">84</a></li> + + <li class="martop04">Paratyphoid fever, <a href="#page58">58</a>-<a href="#page78">78</a>;</li> + <li class="martop01 add2em">carriers, <a href="#page61">61</a>, <a href="#page62">62</a>, <a href="#page66">66</a>, <a href="#page67">67</a>, <a href="#page70">70</a>, <a href="#page73">73</a>, <a href="#page78">78</a>;</li> + <li class="martop01 add2em">diseased animals, <a href="#page67">67</a>, <a href="#page71">71</a>;</li> + <li class="martop01 add2em">gastro-intestinal, <a href="#page61">61</a>;</li> + <li class="martop01 add2em">general characters of, <a href="#page61">61</a>;</li> + <li class="martop01 add2em">human contamination, <a href="#page73">73</a>;</li> + <li class="martop01 add2em">means of prevention, <a href="#page77">77</a>;</li> + <li class="martop01 add2em">miscellaneous contaminations, <a href="#page74">74</a>;</li> + <li class="martop01 add2em">sources of infection, <a href="#page71">71</a>;</li> + <li class="martop01 add2em">symptoms, <a href="#page61">61</a>;</li> + <li class="martop01 add2em">toxin production, <a href="#page68">68</a>;</li> + <li class="martop01 add2em">typhoid-like, <a href="#page61">61</a>;</li> + <li class="martop01 add2em">typical outbreaks, <a href="#page58">58</a></li> + + <li class="martop04">Parrots, <a href="#page72">72</a></li> + + <li class="martop04">Parsnips, <a href="#page16">16</a></li> + + <li class="martop04">Pasteurization, <a href="#page48">48</a>, <a href="#page54">54</a></li> + + <li class="martop04">Pastry, <a href="#page47">47</a></li> + + <li class="martop04">Paté de foie gras, <a href="#page78">78</a></li> + + <li class="martop04">Peas, <a href="#page31">31</a>, <a href="#page43">43</a>, <a href="#page46">46</a></li> + + <li class="martop04">Pellagra, <a href="#page102">102</a>, <a href="#page103">103</a></li> + + <li class="martop04">Pepper, <a href="#page41">41</a></li> + + <li class="martop04">Pericarp of rice, <a href="#page102">102</a></li> + + <li class="martop04">Peripheral neuritis, <a href="#page26">26</a></li> + + <li class="martop04">Pickling, <a href="#page93">93</a></li> + + <li class="martop04">Pidan, <a href="#page98">98</a></li> + + <li class="martop04">Pie, <a href="#page60">60</a></li> + + <li class="martop04">Pigs, <a href="#page71">71</a></li> + + <li class="martop04">Pike, <a href="#page25">25</a></li> + + <li class="martop04">Pinworm, <a href="#page84">84</a></li> + + <li class="martop04">Plant oils, <a href="#page16">16</a></li> + + <li class="martop04">Plants, <a href="#page9">9</a>, <a href="#page13">13</a>-<a href="#page24">24</a>, <a href="#page25">25</a>, <a href="#page101">101</a></li> + + <li class="martop04">Poisons:</li> + <li class="martop01 add2em">bacterial, <a href="#page96">96</a>;</li> + <li class="martop01 add2em">chemical, <a href="#page26">26</a>;</li> + <li class="martop01 add2em">mineral, <a href="#page26">26</a>;</li> + <li class="martop01 add2em">organic, <a href="#page26">26</a>;</li> + <li class="martop01 add2em">protoplasmic, <a href="#page33">33</a></li> + + <li class="martop04">Poisoning by:</li> + <li class="martop01 add2em">aniline dyes, <a href="#page32">32</a>;</li> + <li class="martop01 add2em">animals, <a href="#page24">24</a>;</li> + <li class="martop01 add2em">antimony, <a href="#page27">27</a>;</li> + <li class="martop01 add2em">arsenic, <a href="#page26">26</a>;</li> + <li class="martop01 add2em">Asiatic cholera infection, <a href="#page50">50</a>;</li> + <li class="martop01 add2em"><i>Bacillus proteus</i>(?) infection, <a href="#page55">55</a>;</li> + <li class="martop01 add2em">botulism intoxication, <a href="#page86">86</a>;</li> + <li class="martop01 add2em">coloring substances, <a href="#page31">31</a>;</li> + <li class="martop01 add2em">copper, <a href="#page30">30</a>;</li> + <li class="martop01 add2em">defective diet:</li> + <li class="martop01 add4em">beriberi, <a href="#page102">102</a>,</li> + <li class="martop01 add4em">favism, <a href="#page104">104</a>,</li> + <li class="martop01 add4em">lathyrism, <a href="#page103">103</a>,</li> + <li class="martop01 add4em">pellagra, <a href="#page103">103</a>,</li> + <li class="martop01 add4em">rickets, <a href="#page105">105</a>,</li> + <li class="martop01 add4em">scurvy, <a href="#page104">104</a>;</li> + <li class="martop01 add2em">egg-white, <a href="#page9">9</a>;</li> + <li class="martop01 add2em">ergot, <a href="#page85">85</a>;</li> + <li class="martop01 add2em">fish, <a href="#page25">25</a>;</li> + <li class="martop01 add2em">food preservatives, <a href="#page33">33</a>;</li> + <li class="martop01 add2em">food substitutes, <a href="#page41">41</a>;</li> + <li class="martop01 add2em">lead, <a href="#page27">27</a>;</li> + <li class="martop01 add2em">milk-borne infections:</li> + <li class="martop01 add4em">diphtheria, <a href="#page54">54</a>,</li> + <li class="martop01 add4em">foot-and-mouth disease, <a href="#page55">55</a>;</li> + <li class="martop01 add2em">milksickness, <a href="#page100">100</a>;</li> + <li class="martop01 add2em">scarlet fever, <a href="#page54">54</a>,</li> + <li class="martop01 add4em">and septic sore throat, <a href="#page55">55</a>;</li> + <li class="martop01 add2em">mushrooms, <a href="#page18">18</a>;</li> + <li class="martop01 add2em">parasites, animal:</li> + <li class="martop01 add4em">teniasis, <a href="#page82">82</a>,</li> + <li class="martop01 add4em">trichiniasis, <a href="#page79">79</a>,</li> + <li class="martop01 add4em">other, <a href="#page84">84</a>;</li> + <li class="martop01 add2em">paratyphoid infection, <a href="#page58">58</a>;</li> + <li class="martop01 add2em">plants, <a href="#page13">13</a>;</li> + <li class="martop01 add2em">shellfish, <a href="#page24">24</a>;</li> + <li class="martop01 add2em">tin, <a href="#page29">29</a>;</li> + <li class="martop01 add2em">tuberculosis infection, <a href="#page51">51</a>;</li> + <li class="martop01 add2em">typhoid infection, <a href="#page44">44</a></li> + + <li class="martop04">Poisoning, food:</li> + <li class="martop01 add2em">articles of food most commonly connected with, <a href="#page7">7</a>;</li> + <li class="martop01 add2em">effects of, <a href="#page2">2</a>;</li> + <li class="martop01 add2em">extent of, <a href="#page3">3</a>;</li> + <li class="martop01 add2em">frequency of, <a href="#page1">1</a>;</li> + <li class="martop01 add2em">kinds of, <a href="#page6">6</a>;</li> + <li class="martop01 add2em">means of prevention, <a href="#page2">2</a>;</li> + <li class="martop01 add2em">obscure, <a href="#page100">100</a>;</li> + <li class="martop01 add2em">outbreaks of, in United States, <a href="#page3">3</a>, <a href="#page4">4</a>, <a href="#page5">5</a>;</li> + <li class="martop01 add2em">reports of, <a href="#page3">3</a>, <a href="#page4">4</a>, <a href="#page8">8</a>;</li> + <li class="martop01 add2em">scope of book, <a href="#page6">6</a>;</li> + <li class="martop01 add2em">seasonal incidence of, <a href="#page5">5</a>;</li> + <li class="martop01 add2em">unknown, <a href="#page100">100</a></li> + + <li class="martop04">Poison-ivy, <a href="#page14">14</a></li> + + <li class="martop04">"Poison squads," <a href="#page34">34</a></li> + + <li class="martop04">Pollen, <a href="#page9">9</a></li> + + <li class="martop04">Polyneuritis of fowls, <a href="#page102">102</a></li> + + <li class="martop04">Pork, <a href="#page79">79</a></li> + + <li class="martop04">Pork and beans, <a href="#page88">88</a></li> + + <li class="martop04">Potatoes, <a href="#page46">46</a>, <a href="#page107">107</a></li> + + <li class="martop04">Potato salad, <a href="#page65">65</a></li> + + <li class="martop04">Preservatives:</li> + <li class="martop01 add2em">chemical, <a href="#page33">33</a>;</li> + <li class="martop01 add2em">food, <a href="#page33">33</a>;</li> + <li class="martop01 add2em">household, <a href="#page37">37</a></li> + + <li class="martop04">Proteins, <a href="#page9">9</a>, <a href="#page11">11</a>, <a href="#page12">12</a>, <a href="#page62">62</a>, <a href="#page69">69</a>, <a href="#page80">80</a></li> + + <li class="martop04"><span class="pagenum"><a id="page114" name="page114"></a>[p.114]</span> Protochloride of tin, <a href="#page30">30</a></li> + + <li class="martop04">"Ptomain poisoning," <a href="#page1">1</a>, <a href="#page3">3</a>, <a href="#page18">18</a>, <a href="#page68">68</a>, <a href="#page97">97</a></li> + + <li class="martop04">Puffers, <a href="#page24">24</a></li> + + <li class="martop04">Pulse, <a href="#page103">103</a></li> + + <li class="martop04">Pyrites, iron, <a href="#page26">26</a></li> + + + <li class="martop1h add5em">Q</li> + + <li class="martop04">Quinine, <a href="#page33">33</a></li> + + + <li class="martop1h add5em">R</li> + + <li class="martop04">Rabbit, <a href="#page71">71</a></li> + + <li class="martop04">Rachitis, <a href="#page105">105</a></li> + + <li class="martop04">Radishes, <a href="#page45">45</a></li> + + <li class="martop04">Rash, <a href="#page10">10</a>, <a href="#page12">12</a></li> + + <li class="martop04">Rats, <a href="#page56">56</a>, <a href="#page74">74</a>, <a href="#page75">75</a>, <a href="#page78">78</a>, <a href="#page81">81</a>, <a href="#page82">82</a></li> + + <li class="martop04">"Rat virus," <a href="#page75">75</a></li> + + <li class="martop04">Refrigeration, <a href="#page33">33</a>, <a href="#page40">40</a></li> + + <li class="martop04">Rice, <a href="#page43">43</a>, <a href="#page102">102</a></li> + + <li class="martop04">Ricin, <a href="#page14">14</a></li> + + <li class="martop04">Rickets, <a href="#page105">105</a></li> + + <li class="martop04">Ripening, <a href="#page97">97</a></li> + + <li class="martop04">Roundworm, <a href="#page79">79</a></li> + + <li class="martop04">"Royal <i>Amanita</i>," <a href="#page18">18</a></li> + + <li class="martop04">Rye, <a href="#page85">85</a></li> + + + <li class="martop1h add5em">S</li> + + <li class="martop04">Saccharin, <a href="#page41">41</a></li> + + <li class="martop04">Salad, <a href="#page5">5</a>, <a href="#page95">95</a>, <a href="#page107">107</a>;</li> + <li class="martop01 add2em">dressing, <a href="#page95">95</a></li> + + <li class="martop04">Salicylic acid, <a href="#page36">36</a></li> + + <li class="martop04">Salt, <a href="#page33">33</a>, <a href="#page41">41</a>, <a href="#page94">94</a></li> + + <li class="martop04">Salt solution, <a href="#page33">33</a>, <a href="#page40">40</a></li> + + <li class="martop04">Salting, <a href="#page33">33</a></li> + + <li class="martop04">Saltpeter brines, <a href="#page33">33</a></li> + + <li class="martop04">Sandwiches, <a href="#page46">46</a></li> + + <li class="martop04">Saponin, <a href="#page42">42</a></li> + + <li class="martop04">Sausage, <a href="#page5">5</a>, <a href="#page7">7</a>, <a href="#page40">40</a>, <a href="#page56">56</a>, <a href="#page65">65</a>, <a href="#page69">69</a>, <a href="#page75">75</a>, <a href="#page78">78</a>, <a href="#page79">79</a>, <a href="#page86">86</a>, <a href="#page88">88</a></li> + + <li class="martop04">Scarlet fever, <a href="#page54">54</a></li> + + <li class="martop04">Scurvy, <a href="#page55">55</a>, <a href="#page104">104</a></li> + + <li class="martop04">Sensitization, food, <a href="#page6">6</a>, <a href="#page9">9</a></li> + + <li class="martop04">"Septic sore throat," <a href="#page55">55</a></li> + + <li class="martop04">Serum, antitoxic, <a href="#page96">96</a>;</li> + <li class="martop01 add2em">blood, <a href="#page11">11</a>, <a href="#page64">64</a>, <a href="#page65">65</a>, <a href="#page70">70</a>;</li> + <li class="martop01 add2em">therapeutic, <a href="#page9">9</a></li> + + <li class="martop04">Shark, <a href="#page25">25</a></li> + + <li class="martop04">Sheep, <a href="#page71">71</a>, <a href="#page100">100</a></li> + + <li class="martop04">Shellfish, <a href="#page10">10</a>, <a href="#page24">24</a>, <a href="#page106">106</a></li> + + <li class="martop04">Shrimp, <a href="#page71">71</a></li> + + <li class="martop04">Smoking, <a href="#page33">33</a>, <a href="#page93">93</a>, <a href="#page94">94</a></li> + + <li class="martop04">Snail, <a href="#page107">107</a></li> + + <li class="martop04">"Soda water," <a href="#page42">42</a></li> + + <li class="martop04">Sodic carbonate, <a href="#page36">36</a></li> + + <li class="martop04">Sodium benzoate, <a href="#page34">34</a></li> + + <li class="martop04">Sodium fluoride, <a href="#page40">40</a></li> + + <li class="martop04">"Soft drinks," <a href="#page28">28</a>, <a href="#page42">42</a></li> + + <li class="martop04">Soil, infected, <a href="#page46">46</a>, <a href="#page47">47</a></li> + + <li class="martop04">Solanin, <a href="#page107">107</a></li> + + <li class="martop04">Solder, <a href="#page28">28</a></li> + + <li class="martop04">Sorrel, <a href="#page18">18</a></li> + + <li class="martop04">"Sour grass soup," <a href="#page18">18</a></li> + + <li class="martop04">Sour milk, <a href="#page97">97</a></li> + + <li class="martop04">Spaghetti, <a href="#page44">44</a></li> + + <li class="martop04">Spices, <a href="#page37">37</a></li> + + <li class="martop04">Staphylococcus, <a href="#page96">96</a></li> + + <li class="martop04">Stoppers, patent metal, <a href="#page28">28</a></li> + + <li class="martop04">Strawberries, <a href="#page10">10</a></li> + + <li class="martop04">"Streptococcus sore throat," <a href="#page55">55</a></li> + + <li class="martop04"><i>Strongyloides</i>, <a href="#page84">84</a></li> + + <li class="martop04">Strychnine, <a href="#page33">33</a>, <a href="#page96">96</a></li> + + <li class="martop04">Sturgeon, <a href="#page25">25</a></li> + + <li class="martop04">Substances, coloring, <a href="#page31">31</a></li> + + <li class="martop04">Substitutes, food, <a href="#page16">16</a>, <a href="#page41">41</a></li> + + <li class="martop04">Sugar, <a href="#page26">26</a>, <a href="#page28">28</a>, <a href="#page41">41</a>, <a href="#page42">42</a></li> + + <li class="martop04">Sugar solution, <a href="#page33">33</a>, <a href="#page40">40</a></li> + + <li class="martop04">Sulphite, <a href="#page36">36</a>, <a href="#page40">40</a></li> + + <li class="martop04">Sulphurous acid, <a href="#page26">26</a>, <a href="#page27">27</a>, <a href="#page36">36</a></li> + + <li class="martop04">Swine, <a href="#page74">74</a>, <a href="#page80">80</a>, <a href="#page81">81</a>, <a href="#page82">82</a>, <a href="#page93">93</a></li> + + <li class="martop04">Symptoms:</li> + <li class="martop01 add2em">cholera-like, <a href="#page25">25</a>, <a href="#page77">77</a>;</li> + <li class="martop01 add2em">circulatory, <a href="#page10">10</a>;</li> + <li class="martop01 add2em">coma, <a href="#page22">22</a>;</li> + <li class="martop01 add2em">constipation, <a href="#page89">89</a>, <a href="#page90">90</a>, <a href="#page100">100</a>;</li> + <li class="martop01 add2em">convulsions, <a href="#page20">20</a>, <a href="#page22">22</a>, <a href="#page25">25</a>;</li> + <li class="martop01 add2em">coryza, <a href="#page10">10</a>;</li> + <li class="martop01 add2em">diarrhea, <a href="#page10">10</a>, <a href="#page21">21</a>, <a href="#page61">61</a>, <a href="#page90">90</a>;</li> + <li class="martop01 add2em">difficulty in swallowing, <a href="#page20">20</a>;</li> + <li class="martop01 add2em">digestive, <a href="#page1">1</a>, <a href="#page61">61</a>, <a href="#page105">105</a>;</li> + <li class="martop01 add2em">dizziness, <a href="#page20">20</a>, <a href="#page90">90</a>;</li> + <li class="martop01 add2em">eyelids, edematous, <a href="#page10">10</a>;</li> + <li class="martop01 add2em"><span class="pagenum"><a id="page115" name="page115"></a>[p.115]</span> febrile anemia, <a href="#page104">104</a>;</li> + <li class="martop01 add2em">fever, <a href="#page61">61</a>, <a href="#page79">79</a>;</li> + <li class="martop01 add2em">gastro-intestinal, <a href="#page1">1</a>, <a href="#page10">10</a>, <a href="#page58">58</a>, <a href="#page61">61</a>, <a href="#page90">90</a>;</li> + <li class="martop01 add2em">hemoglobinuria, <a href="#page104">104</a>;</li> + <li class="martop01 add2em">jaundice, <a href="#page104">104</a>;</li> + <li class="martop01 add2em">mental, <a href="#page24">24</a>;</li> + <li class="martop01 add2em">nausea, <a href="#page10">10</a>, <a href="#page12">12</a>, <a href="#page88">88</a>;</li> + <li class="martop01 add2em">nervous, <a href="#page10">10</a>, <a href="#page24">24</a>, <a href="#page90">90</a>, <a href="#page103">103</a>;</li> + <li class="martop01 add2em">pain:</li> + <li class="martop01 add4em">abdominal, <a href="#page21">21</a>, <a href="#page61">61</a>, <a href="#page89">89</a>,</li> + <li class="martop01 add4em">muscular, <a href="#page79">79</a>, <a href="#page80">80</a>;</li> + <li class="martop01 add2em">paralysis, <a href="#page25">25</a>, <a href="#page96">96</a>;</li> + <li class="martop01 add2em">rapidity of appearance of, <a href="#page10">10</a>, <a href="#page44">44</a>, <a href="#page58">58</a>, <a href="#page61">61</a>, <a href="#page91">91</a>;</li> + <li class="martop01 add2em">rash, <a href="#page10">10</a>, <a href="#page12">12</a>;</li> + <li class="martop01 add2em">sneezing, <a href="#page10">10</a>;</li> + <li class="martop01 add2em">temperature, subnormal, <a href="#page89">89</a>, <a href="#page100">100</a>;</li> + <li class="martop01 add2em">thirst, <a href="#page21">21</a>, <a href="#page89">89</a>;</li> + <li class="martop01 add2em">trismus, <a href="#page20">20</a>;</li> + <li class="martop01 add2em">visual, <a href="#page20">20</a>, <a href="#page88">88</a>, <a href="#page89">89</a>, <a href="#page90">90</a>, <a href="#page91">91</a>, <a href="#page96">96</a>;</li> + <li class="martop01 add2em">vomiting, <a href="#page10">10</a>, <a href="#page12">12</a>, <a href="#page21">21</a>, <a href="#page88">88</a>, <a href="#page90">90</a>, <a href="#page100">100</a></li> + + <li class="martop04">Syrups, <a href="#page27">27</a>, <a href="#page42">42</a></li> + + + <li class="martop1h add5em">T</li> + + <li class="martop04">Tapeworm, <a href="#page82">82</a>, <a href="#page83">83</a></li> + + <li class="martop04">Tea, <a href="#page36">36</a></li> + + <li class="martop04"><i>Tenia saginata</i>, <a href="#page82">82</a></li> + + <li class="martop04">Teniasis, <a href="#page82">82</a></li> + + <li class="martop04"><i>Tenia solium</i>, <a href="#page82">82</a></li> + + <li class="martop04">Tetrodontidae, <a href="#page24">24</a></li> + + <li class="martop04">Theobromine, <a href="#page36">36</a></li> + + <li class="martop04">Tin, <a href="#page29">29</a>-<a href="#page30">30</a></li> + + <li class="martop04">Tin salts, <a href="#page30">30</a></li> + + <li class="martop04">"Toadstools," <a href="#page18">18</a></li> + + <li class="martop04">Tomatoes, <a href="#page12">12</a></li> + + <li class="martop04">Toxin, <a href="#page68">68</a></li> + + <li class="martop04">Trembles, <a href="#page100">100</a></li> + + <li class="martop04">Trichina, <a href="#page79">79</a></li> + + <li class="martop04"><i>Trichinella spiralis</i>, <a href="#page79">79</a>, <a href="#page80">80</a></li> + + <li class="martop04">Trichiniasis, <a href="#page79">79</a></li> + + <li class="martop04">Trichinosis, <a href="#page79">79</a></li> + + <li class="martop04">Tuberculin, <a href="#page9">9</a></li> + + <li class="martop04">Tuberculosis, <a href="#page44">44</a>, <a href="#page51">51</a></li> + + <li class="martop04">Typhoid fever: <a href="#page44">44</a>-<a href="#page50">50</a>, <a href="#page78">78</a>, <a href="#page79">79</a>;</li> + <li class="martop01 add2em">carriers, <a href="#page45">45</a>, <a href="#page48">48</a>, <a href="#page50">50</a>, <a href="#page66">66</a>;</li> + <li class="martop01 add2em">milk-borne, <a href="#page48">48</a></li> + + + <li class="martop1h add5em">U</li> + + <li class="martop04">Uncinariasis, <a href="#page83">83</a></li> + + <li class="martop04">Urticaria, <a href="#page10">10</a></li> + + <li class="martop04">Utensils, cooking, <a href="#page27">27</a>, <a href="#page28">28</a>, <a href="#page30">30</a></li> + + + <li class="martop1h add5em">V</li> + + <li class="martop04">Vanilla: <a href="#page105">105</a>;</li> + <li class="martop01 add2em">ice cream, <a href="#page105">105</a>;</li> + <li class="martop01 add2em">pudding, <a href="#page65">65</a>, <a href="#page105">105</a></li> + + <li class="martop04">Vegetables, <a href="#page5">5</a>, <a href="#page29">29</a>, <a href="#page30">30</a>, <a href="#page31">31</a>, <a href="#page45">45</a>, <a href="#page46">46</a>, <a href="#page47">47</a>, <a href="#page62">62</a>, <a href="#page83">83</a>, <a href="#page95">95</a>, <a href="#page97">97</a>, <a href="#page104">104</a></li> + + <li class="martop04"><i>Veratrum viride</i>, <a href="#page14">14</a></li> + + <li class="martop04">"Verdigris poisoning," <a href="#page31">31</a></li> + + <li class="martop04">Vermicelli, <a href="#page67">67</a></li> + + <li class="martop04">"Vitamin," <a href="#page102">102</a>, <a href="#page103">103</a></li> + + + <li class="martop1h add5em">W</li> + + <li class="martop04">Water, <a href="#page28">28</a>, <a href="#page50">50</a>, <a href="#page75">75</a></li> + + <li class="martop04">Watercress, <a href="#page45">45</a>, <a href="#page46">46</a></li> + + <li class="martop04">Wintergreen, <a href="#page14">14</a></li> + + + <li class="martop1h add5em">Z</li> + + <li class="martop04"><i>Zygadenus</i>, <a href="#page14">14</a></li> +</ul> + + + + +<h2>FOOTNOTES:</h2> + + +<div class="footnote indent03"> +<p><a name="Footnote_A_1" id="Footnote_A_1"></a><a href="#FNanchor_A_1"><span class="label">1</span></a> Tables <a href="#TabA">A</a> and <a href="#TabB">B</a> 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 (<a href="#TabA">Table A</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 (<a href="#TabB">Table B</a>). This increased mortality is due chiefly to diseases +of the heart, arteries, and kidneys, and to cancer.</p> + +<p class="center ftsize105 martop1"><a id="TabA" name="TabA">TABLE A</a><a name="FNanchor_B_1" id="FNanchor_B_1"></a><a href="#Footnote_B_1" class="fnanchor">[1a]</a></p> + +<p class="center"><span class="smcap">Approximate Life Table, Trienna 1879-81 and 1909-11, Based on New York +City Statistics</span></p> + + +<table border="0" cellpadding="2" summary="Approximate Life Table, Trienna 1879-81 and 1909-11"> +<colgroup> + <col width="25%"> + <col width="25%"> + <col width="25%"> + <col width="25%"> +</colgroup> + +<tr class="smaller center bortop1 borbot1"> + <td>Ages</td> + <td class="borleft1">Expectation of Life, 1879-81</td> + <td class="borleft1">Expectation of Life, 1909-11</td> + <td class="borleft1">Gain (+) or Loss (-) in Years of Expectancy</td> +</tr> + +<tr> + <td class="td-right tdp-right1">Under 5</td> + <td class="td-center borleft1">41.3</td> + <td class="td-center borleft1">51.9</td> + <td class="td-center borleft1">+10.6</td> +</tr> + +<tr> + <td class="td-right tdp-right1">5</td> + <td class="td-center borleft1">46.3</td> + <td class="td-center borleft1">51.1</td> + <td class="td-center borleft1">+ 4.8</td> +</tr> + +<tr> + <td class="td-right tdp-right1">10</td> + <td class="td-center borleft1">43.8</td> + <td class="td-center borleft1">46.9</td> + <td class="td-center borleft1">+ 3.1</td> +</tr> + +<tr> + <td class="td-right tdp-right1">15</td> + <td class="td-center borleft1">39.7</td> + <td class="td-center borleft1">42.5</td> + <td class="td-center borleft1">+ 2.8</td> +</tr> + +<tr> + <td class="td-right tdp-right1">20</td> + <td class="td-center borleft1">35.8</td> + <td class="td-center borleft1">38.3</td> + <td class="td-center borleft1">+ 2.5</td> +</tr> + +<tr> + <td class="td-right tdp-right1">25</td> + <td class="td-center borleft1">32.6</td> + <td class="td-center borleft1">34.3</td> + <td class="td-center borleft1">+ 1.7</td> +</tr> + +<tr> + <td class="td-right tdp-right1">30</td> + <td class="td-center borleft1">29.6</td> + <td class="td-center borleft1">30.5</td> + <td class="td-center borleft1">+ 0.9</td> +</tr> + +<tr> + <td class="td-right tdp-right1">35</td> + <td class="td-center borleft1">26.7</td> + <td class="td-center borleft1">26.9</td> + <td class="td-center borleft1">+ 0.2</td> +</tr> + +<tr> + <td class="td-right tdp-right1">40</td> + <td class="td-center borleft1">23.0</td> + <td class="td-center borleft1">23.4</td> + <td class="td-center borleft1">- 0.5</td> +</tr> + +<tr> + <td class="td-right tdp-right1">45</td> + <td class="td-center borleft1">21.1</td> + <td class="td-center borleft1">20.0</td> + <td class="td-center borleft1">- 1.1</td> +</tr> + +<tr> + <td class="td-right tdp-right1">50</td> + <td class="td-center borleft1">18.3</td> + <td class="td-center borleft1">16.8</td> + <td class="td-center borleft1">- 1.5</td> +</tr> + +<tr> + <td class="td-right tdp-right1">55</td> + <td class="td-center borleft1">15.4</td> + <td class="td-center borleft1">13.9</td> + <td class="td-center borleft1">- 1.5</td> +</tr> + +<tr> + <td class="td-right tdp-right1">60</td> + <td class="td-center borleft1">13.0</td> + <td class="td-center borleft1">11.3</td> + <td class="td-center borleft1">- 1.7</td> +</tr> + +<tr> + <td class="td-right tdp-right1">65</td> + <td class="td-center borleft1">10.5</td> + <td class="td-center borleft1">9.1</td> + <td class="td-center borleft1">- 1.4</td> +</tr> + +<tr> + <td class="td-right tdp-right1">70</td> + <td class="td-center borleft1">8.9</td> + <td class="td-center borleft1">7.2</td> + <td class="td-center borleft1">- 1.7</td> +</tr> + +<tr> + <td class="td-right tdp-right1">75</td> + <td class="td-center borleft1">7.3</td> + <td class="td-center borleft1">5.5</td> + <td class="td-center borleft1">- 1.8</td> +</tr> + +<tr> + <td class="td-right tdp-right1">80</td> + <td class="td-center borleft1">6.4</td> + <td class="td-center borleft1">4.3</td> + <td class="td-center borleft1">- 2.1</td> +</tr> + +<tr> + <td class="td-right tdp-right1">85</td> + <td class="td-center borleft1">5.5</td> + <td class="td-center borleft1">2.2</td> + <td class="td-center borleft1">- 3.3</td> +</tr> + +<tr> + <td class="td-right tdp-right1">Balance</td> + <td rowspan="3" class="borleft1"> </td> + <td rowspan="3" class="borleft1"> </td> + <td class="td-center borleft1">+26.6</td> +</tr> + +<tr> + <td rowspan="2"> </td> + <td class="td-center borleft1">-16.6</td> +</tr> + +<tr class="borbot1"> + <td class="td-center bortop2 borleft1"> +10.0</td> +</tr> +</table> + + +<p class="center ftsize105 martop1"><a id="TabB" name="TabB">TABLE B</a><a name="FNanchor_B_2" id="FNanchor_B_2"></a><a href="#Footnote_B_2" class="fnanchor">[1b]</a></p> + +<p class="center"><span class="smcap">Comparison of Mortality of Males and Females, by Age Groups. Death-Rates +per 1,000 Population (Registration States as Constituted in 1900)</span></p> + + +<table border="0" cellpadding="2" summary="Comparison of Mortality of Males and Females"> +<colgroup> + <col width="22%"> + <col width="10%"> + <col width="10%"> + <col width="19%"> + <col width="10%"> + <col width="10%"> + <col width="19%"> +</colgroup> + +<tr class="smaller center bortop1"> + <td rowspan="2">Ages</td> + <td colspan="2" class="borbot1 borleft1">Males</td> + <td rowspan="2" class="borleft1">Percentage Increase or Decrease</td> + <td colspan="2" class="borbot1 borleft1">Females</td> + <td rowspan="2" class="borleft1">Percentage Increase or Decrease</td> +</tr> + +<tr class="smaller center borbot1"> + <td class="borleft1">1900</td> + <td class="borleft1">1911</td> + <td class="borleft1">1900</td> + <td class="borleft1">1911</td> +</tr> + +<tr> + <td class="td-right tdp-right1">Under 5</td> + <td class="td-center borleft1">54.2</td> + <td class="td-center borleft1">39.8</td> + <td class="td-center borleft1">-26.27</td> + <td class="td-center borleft1">45.8</td> + <td class="td-center borleft1">33.3</td> + <td class="td-center borleft1">-27.29</td> +</tr> + +<tr> + <td class="td-right tdp-right1">5-9</td> + <td class="td-center borleft1">4.7</td> + <td class="td-center borleft1">3.4</td> + <td class="td-center borleft1">-27.66</td> + <td class="td-center borleft1">4.6</td> + <td class="td-center borleft1">3.1</td> + <td class="td-center borleft1">-32.61</td> +</tr> + +<tr> + <td class="td-right tdp-right1">10-14</td> + <td class="td-center borleft1">2.9</td> + <td class="td-center borleft1">2.4</td> + <td class="td-center borleft1">-17.24</td> + <td class="td-center borleft1">3.1</td> + <td class="td-center borleft1">2.1</td> + <td class="td-center borleft1">-32.26</td> +</tr> + +<tr> + <td class="td-right tdp-right1">15-19</td> + <td class="td-center borleft1">4.9</td> + <td class="td-center borleft1">3.7</td> + <td class="td-center borleft1">-24.49</td> + <td class="td-center borleft1">4.8</td> + <td class="td-center borleft1">3.3</td> + <td class="td-center borleft1">-31.25</td> +</tr> + +<tr> + <td class="td-right tdp-right1">20-24</td> + <td class="td-center borleft1">7.0</td> + <td class="td-center borleft1">5.3</td> + <td class="td-center borleft1">-24.29</td> + <td class="td-center borleft1">6.7</td> + <td class="td-center borleft1">4.7</td> + <td class="td-center borleft1">-29.85</td> +</tr> + +<tr> + <td class="td-right tdp-right1">25-34</td> + <td class="td-center borleft1">8.3</td> + <td class="td-center borleft1">6.7</td> + <td class="td-center borleft1">-19.28</td> + <td class="td-center borleft1">8.2</td> + <td class="td-center borleft1">6.0</td> + <td class="td-center borleft1">-26.83</td> +</tr> + +<tr> + <td class="td-right tdp-right1">35-44</td> + <td class="td-center borleft1">10.8</td> + <td class="td-center borleft1">10.4</td> + <td class="td-center borleft1">-3.70</td> + <td class="td-center borleft1">9.8</td> + <td class="td-center borleft1">8.3</td> + <td class="td-center borleft1">-15.31</td> +</tr> + +<tr> + <td class="td-right tdp-right1">45-54</td> + <td class="td-center borleft1">15.8</td> + <td class="td-center borleft1">16.1</td> + <td class="td-center borleft1">+1.90</td> + <td class="td-center borleft1">14.2</td> + <td class="td-center borleft1">12.9</td> + <td class="td-center borleft1">-9.15</td> +</tr> + +<tr> + <td class="td-right tdp-right1">55-64</td> + <td class="td-center borleft1">28.9</td> + <td class="td-center borleft1">30.9</td> + <td class="td-center borleft1">+6.92</td> + <td class="td-center borleft1">25.8</td> + <td class="td-center borleft1">26.8</td> + <td class="td-center borleft1">+0.78</td> +</tr> + +<tr> + <td class="td-right tdp-right1">65-74</td> + <td class="td-center borleft1">59.6</td> + <td class="td-center borleft1">61.6</td> + <td class="td-center borleft1">+3.36</td> + <td class="td-center borleft1">53.8</td> + <td class="td-center borleft1">55.1</td> + <td class="td-center borleft1">+2.42</td> +</tr> + +<tr> + <td class="td-right tdp-right1">75 and over</td> + <td class="td-center borleft1">146.1</td> + <td class="td-center borleft1">147.4</td> + <td class="td-center borleft1">+0.89</td> + <td class="td-center borleft1">139.5</td> + <td class="td-center borleft1">139.2</td> + <td class="td-center borleft1">+0.22</td> +</tr> + +<tr class="borbot1"> + <td class="td-right tdp-right1">All ages</td> + <td class="td-center borleft1">17.6</td> + <td class="td-center borleft1">15.8</td> + <td class="td-center borleft1">-10.23</td> + <td class="td-center borleft1">16.5</td> + <td class="td-center borleft1">14.0</td> + <td class="td-center borleft1">-15.15</td> +</tr> +</table> + + +<p><a name="Footnote_B_1" id="Footnote_B_1"></a><a href="#FNanchor_B_1"><span class="label">1a</span></a> <i>Monthly Bull., Dept. of Health, City of New York</i>, III (1913), +113.</p> + +<p><a name="Footnote_B_2" id="Footnote_B_2"></a><a href="#FNanchor_B_2"><span class="label">1b</span></a> Dublin, <i>Amer. Jour. Public Health</i>, III (1915), 1262.</p> + +<p><a name="Footnote_A_2" id="Footnote_A_2"></a><a href="#FNanchor_A_2"><span class="label">2</span></a> 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, +<i>Infection and Resistance</i> (New York, 1914), chaps. xv-xviii; also +Doerr, "Allergie und Anaphylaxis," in Kolle and Wassermann, <i>Handbuch</i>, +2d edition, 1913, II, 947.</p> + +<p><a name="Footnote_A_3" id="Footnote_A_3"></a><a href="#FNanchor_A_3"><span class="label">3</span></a> <i>Boston Med. and Surg. Jour.</i>, CLXVII (1912), 216.</p> + +<p><a name="Footnote_A_4" id="Footnote_A_4"></a><a href="#FNanchor_A_4"><span class="label">4</span></a> <i>Amer. Jour. Obstet.</i> (New York), LXV (1912), 731.</p> + +<p><a name="Footnote_A_5" id="Footnote_A_5"></a><a href="#FNanchor_A_5"><span class="label">5</span></a> F. B. Talbot, <i>Boston Med. and Surg. Jour.</i>, CLXXV (1916), 409.</p> + +<p><a name="Footnote_A_6" id="Footnote_A_6"></a><a href="#FNanchor_A_6"><span class="label">6</span></a> See, for example, Schloss, <i>loc. cit.</i></p> + +<p><a name="Footnote_A_7" id="Footnote_A_7"></a><a href="#FNanchor_A_7"><span class="label">7</span></a> <i>Johns Hopkins Hosp. Bull.</i>, XXV (1914), 78.</p> + +<p><a name="Footnote_A_8" id="Footnote_A_8"></a><a href="#FNanchor_A_8"><span class="label">8</span></a> See, for example, K. Koessler, <i>Ill. Med. Jour.</i>, XXIII (1913), 66; +Bronfenbrenner, Andrews, and Scott, <i>Jour. Amer. Med. Assoc.</i>, LXIV +(1915), 1306; F. B. Talbot, <i>Boston Med. and Surg. Jour.</i>, CLXXI (1914), +708.</p> + +<p><a name="Footnote_A_9" id="Footnote_A_9"></a><a href="#FNanchor_A_9"><span class="label">9</span></a> <i>Jour. Amer. Med. Assoc.</i>, LXV (1915), 1837.</p> + +<p><a name="Footnote_A_10" id="Footnote_A_10"></a><a href="#FNanchor_A_10"><span class="label">10</span></a> Strickler and Goldberg, <i>Jour. Amer. Med. Assoc.</i>, LXVI (1916), +249.</p> + +<p><a name="Footnote_A_11" id="Footnote_A_11"></a><a href="#FNanchor_A_11"><span class="label">11</span></a> <i>Jour. Cutaneous Dis.</i>, XXXIV (1916), 70.</p> + +<p><a name="Footnote_A_12" id="Footnote_A_12"></a><a href="#FNanchor_A_12"><span class="label">12</span></a> <i>Amer. Jour. Dis. of Children</i>, XI (1916), 441.</p> + +<p><a name="Footnote_A_13" id="Footnote_A_13"></a><a href="#FNanchor_A_13"><span class="label">13</span></a> <i>Science</i>, XV (1902), 1016.</p> + +<p><a name="Footnote_A_14" id="Footnote_A_14"></a><a href="#FNanchor_A_14"><span class="label">14</span></a> <i>U.S. Dept. of Agric., Div. of Botany, Bull. 20</i>, 1898.</p> + +<p><a name="Footnote_A_15" id="Footnote_A_15"></a><a href="#FNanchor_A_15"><span class="label">15</span></a> Among the plants that seem to be most commonly implicated in the +poisoning of stock are the larkspur (<i>Delphinium.</i> <i>U.S. Dept. of +Agric., Bull. 365</i>, September 8, 1916), the water hemlock (<i>Cicuta +maculata</i>) and others of the same genus, the lupines (<i>U.S. Dept. of +Agric., Bull. 405</i>, 1916), some of the laurels (<i>Kalmia</i>), and the Death +<i>Camas</i> or <i>Zygadenus</i> (<i>U.S. Dept. of Agric., Bull. 125</i>, 1915). The +famous loco-weed of the western United States (<i>U.S. Dept. of Agric., +Bull. 112</i>, 1909) is less certainly to be held responsible for all the +ills ascribed to it (H. T. Marshall, <i>Johns Hopkins Hosp. Bull.</i>, XXV +[1914], 234).</p> + +<p><a name="Footnote_A_16" id="Footnote_A_16"></a><a href="#FNanchor_A_16"><span class="label">16</span></a> Chesnut, <i>U.S. Dept. of Agric., Div. of Botany, Bull. 20</i>, 1898, p. +17.</p> + +<p><a name="Footnote_A_17" id="Footnote_A_17"></a><a href="#FNanchor_A_17"><span class="label">17</span></a> <i>Ibid.</i>, p. 28.</p> + +<p><a name="Footnote_A_18" id="Footnote_A_18"></a><a href="#FNanchor_A_18"><span class="label">18</span></a> <i>Ibid.</i>, 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.</p> + +<p><a name="Footnote_A_19" id="Footnote_A_19"></a><a href="#FNanchor_A_19"><span class="label">19</span></a> Mayer, <i>Deutsche Viertelj. f. öffentl. Ges.</i>, XLV (1913), 12.</p> + +<p><a name="Footnote_A_20" id="Footnote_A_20"></a><a href="#FNanchor_A_20"><span class="label">20</span></a> Cf. an instance of palmolin poisoning, <i>Centralbl. f. Bakt.</i>, I, +Ref., LXII (1914), 210.</p> + +<p><a name="Footnote_A_21" id="Footnote_A_21"></a><a href="#FNanchor_A_21"><span class="label">21</span></a> <i>Weekly Bull., N.Y. Dept. of Health</i>, September 16, 1916.</p> + +<p><a name="Footnote_A_22" id="Footnote_A_22"></a><a href="#FNanchor_A_22"><span class="label">22</span></a> 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," <i>Bull. 175</i>, 1915). This bulletin contains descriptions and +excellent illustrations of many edible and of the commoner poisonous +species.</p> + +<p><a name="Footnote_A_23" id="Footnote_A_23"></a><a href="#FNanchor_A_23"><span class="label">23</span></a> Used in some places as a fly poison.</p> + +<p><a name="Footnote_A_24" id="Footnote_A_24"></a><a href="#FNanchor_A_24"><span class="label">24</span></a> Ford, <i>Science</i>, XXX (1909), 97.</p> + +<p><a name="Footnote_A_25" id="Footnote_A_25"></a><a href="#FNanchor_A_25"><span class="label">25</span></a> Another species of mushroom occurring in this country and commonly +regarded as edible (<i>Panaeolus papilionaceus</i>) has on occasion shown +marked intoxicating properties (A. E. Verrill, <i>Science</i>, XL (1914), +408).</p> + +<p><a name="Footnote_A_26" id="Footnote_A_26"></a><a href="#FNanchor_A_26"><span class="label">26</span></a> <i>Jour. Infect. Dis.</i>, III (1906), 191.</p> + +<p><a name="Footnote_A_27" id="Footnote_A_27"></a><a href="#FNanchor_A_27"><span class="label">27</span></a> <i>Jour. Amer. Med. Assoc.</i>, LXIV (1915), 1230.</p> + +<p><a name="Footnote_A_28" id="Footnote_A_28"></a><a href="#FNanchor_A_28"><span class="label">28</span></a> W. W. Ford, "Plant Poisons and Their Antibodies," <i>Centralbl. f. +Bakt.</i>, I Abt., Ref., LVIII (1913), 129 and 193, with full bibliography.</p> + +<p><a name="Footnote_A_29" id="Footnote_A_29"></a><a href="#FNanchor_A_29"><span class="label">29</span></a> A. H. Clark, <i>Science</i>, XLI (1915), 795.</p> + +<p><a name="Footnote_A_30" id="Footnote_A_30"></a><a href="#FNanchor_A_30"><span class="label">30</span></a> See W. M. Kerr, <i>U.S. Nav., Monthly Bull.</i>, VI (1912), 401.</p> + +<p><a name="Footnote_A_31" id="Footnote_A_31"></a><a href="#FNanchor_A_31"><span class="label">31</span></a> <i>Ibid.</i></p> + +<p><a name="Footnote_A_32" id="Footnote_A_32"></a><a href="#FNanchor_A_32"><span class="label">32</span></a> E. S. Reynolds, <i>Lancet</i>, I (1901), 166.</p> + +<p><a name="Footnote_A_33" id="Footnote_A_33"></a><a href="#FNanchor_A_33"><span class="label">33</span></a> 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 <i>Amer. Food Jour.</i>, July, 1916, p. 315).</p> + +<p><a name="Footnote_A_34" id="Footnote_A_34"></a><a href="#FNanchor_A_34"><span class="label">34</span></a> E. W. Miller, <i>Jour. Home Economics</i>, VIII (1916), 361.</p> + +<p><a name="Footnote_A_35" id="Footnote_A_35"></a><a href="#FNanchor_A_35"><span class="label">35</span></a> Phelps and Stevenson, <i>Hyg. Lab., U.S. Public Health Service, Bull. +96</i>, 1914, p. 55.</p> + +<p><a name="Footnote_A_36" id="Footnote_A_36"></a><a href="#FNanchor_A_36"><span class="label">36</span></a> Harrington and Richardson, <i>Manual of Practical Hygiene</i>, 5th ed., +p. 224.</p> + +<p><a name="Footnote_A_37" id="Footnote_A_37"></a><a href="#FNanchor_A_37"><span class="label">37</span></a> See Alice Hamilton, "Hygiene of the Painters' Trade," <i>U.S. Bureau +of Labor Statistics, Bull. 120</i>, 1913.</p> + +<p><a name="Footnote_A_38" id="Footnote_A_38"></a><a href="#FNanchor_A_38"><span class="label">38</span></a> In 1909 the value of foods canned in the United States amounted to +about $300,000,000 (<i>U.S. Dept. of Agric., Bull. 196</i>, 1915).</p> + +<p><a name="Footnote_A_39" id="Footnote_A_39"></a><a href="#FNanchor_A_39"><span class="label">39</span></a> W. D. Bigelow, <i>Amer. Food Jour.</i>, XI (1916), 461.</p> + +<p><a name="Footnote_A_40" id="Footnote_A_40"></a><a href="#FNanchor_A_40"><span class="label">40</span></a> <i>Arch. f. Hyg.</i>, XLV (1902), 88; <i>ibid.</i>, LXIII (1907), 67.</p> + +<p><a name="Footnote_A_41" id="Footnote_A_41"></a><a href="#FNanchor_A_41"><span class="label">41</span></a> See, e.g., Harrington and Richardson, <i>Practical Hygiene</i>, 5th ed., +p. 274.</p> + +<p><a name="Footnote_A_42" id="Footnote_A_42"></a><a href="#FNanchor_A_42"><span class="label">42</span></a> <i>Ztschr. f. Hyg.</i>, LXXV-LXXVI (1913-14), 55.</p> + +<p><a name="Footnote_A_43" id="Footnote_A_43"></a><a href="#FNanchor_A_43"><span class="label">43</span></a> Bigelow, <i>loc. cit.</i></p> + +<p><a name="Footnote_A_44" id="Footnote_A_44"></a><a href="#FNanchor_A_44"><span class="label">44</span></a> A. W. Bitting, <i>U.S. Dept. of Agric., Bull. 196</i>, 1915.</p> + +<p><a name="Footnote_A_45" id="Footnote_A_45"></a><a href="#FNanchor_A_45"><span class="label">45</span></a> <i>U.S. Dept. of Agric., Report 97</i>, 1913.</p> + +<p><a name="Footnote_A_46" id="Footnote_A_46"></a><a href="#FNanchor_A_46"><span class="label">46</span></a> Folin, <i>Preservatives and Other Chemicals in Foods</i> (Harvard +University Press, 1914), p. 32.</p> + +<p><a name="Footnote_A_47" id="Footnote_A_47"></a><a href="#FNanchor_A_47"><span class="label">47</span></a> Folin, <i>op. cit.</i>, p. 42.</p> + +<p><a name="Footnote_A_48" id="Footnote_A_48"></a><a href="#FNanchor_A_48"><span class="label">48</span></a> See <i>U.S. Dept. of Agric., Report 94</i>, 1911.</p> + +<p><a name="Footnote_A_49" id="Footnote_A_49"></a><a href="#FNanchor_A_49"><span class="label">49</span></a> Sawyer, <i>Jour. Amer. Med. Assoc.</i>, LXIII (1914), 1537.</p> + +<p><a name="Footnote_A_50" id="Footnote_A_50"></a><a href="#FNanchor_A_50"><span class="label">50</span></a> <i>Eng. News</i>, LXX (1913), 322.</p> + +<p><a name="Footnote_A_51" id="Footnote_A_51"></a><a href="#FNanchor_A_51"><span class="label">51</span></a> Morse, <i>Report of State Board of Health of Mass.</i>, 1899, p. 761.</p> + +<p><a name="Footnote_A_52" id="Footnote_A_52"></a><a href="#FNanchor_A_52"><span class="label">52</span></a> R. H. Creel, <i>Reprint from Public Health Reports, No. 72</i>, +Washington, 1912.</p> + +<p><a name="Footnote_A_53" id="Footnote_A_53"></a><a href="#FNanchor_A_53"><span class="label">53</span></a> <i>Health Bull. No. 76, Pennsylvania State Department of Health</i>, +December, 1915.</p> + +<p><a name="Footnote_A_54" id="Footnote_A_54"></a><a href="#FNanchor_A_54"><span class="label">54</span></a> <i>Amer. Jour. Public Health</i>, II (1912), 321.</p> + +<p><a name="Footnote_A_55" id="Footnote_A_55"></a><a href="#FNanchor_A_55"><span class="label">55</span></a> <i>Institution Quarterly</i>, III (1912), 18.</p> + +<p><a name="Footnote_A_56" id="Footnote_A_56"></a><a href="#FNanchor_A_56"><span class="label">56</span></a> See also a similar instance reported by Lumsden, <i>Hyg. Lab., U.S. +Public Health and Marine Hosp. Service, Bull. 78</i>, p. 165.</p> + +<p><a name="Footnote_A_57" id="Footnote_A_57"></a><a href="#FNanchor_A_57"><span class="label">57</span></a> For a discussion of the oyster question see G. W. Fuller, <i>Jour. of +Franklin Institute</i>, August, 1905; <i>N.Y. City Dept. of Health, Monthly +Bull.</i>, November, 1913, and May, 1915; H. S. Cumming, <i>U.S. Public +Health Service, Pub. Health Bull. 74</i>, March, 1916.</p> + +<p><a name="Footnote_A_58" id="Footnote_A_58"></a><a href="#FNanchor_A_58"><span class="label">58</span></a> <i>Lancet</i>, II (1895), 46.</p> + +<p><a name="Footnote_A_59" id="Footnote_A_59"></a><a href="#FNanchor_A_59"><span class="label">59</span></a> Park and Krumwiede, <i>Jour. Med. Research</i>, N.S., XVIII (1910), 363.</p> + +<p><a name="Footnote_A_60" id="Footnote_A_60"></a><a href="#FNanchor_A_60"><span class="label">60</span></a> <i>Ztschr. f. Hyg.</i>, XXXV (1900), 265.</p> + +<p><a name="Footnote_A_61" id="Footnote_A_61"></a><a href="#FNanchor_A_61"><span class="label">61</span></a> <i>Centralbl. f. Bakt.</i>, I, Orig., LXVI (1912), 194.</p> + +<p><a name="Footnote_A_62" id="Footnote_A_62"></a><a href="#FNanchor_A_62"><span class="label">62</span></a> <i>Fleischvergiftungen u. Paratyphusinfektionen</i> (Jena, 1910).</p> + +<p><a name="Footnote_A_63" id="Footnote_A_63"></a><a href="#FNanchor_A_63"><span class="label">63</span></a> <i>Rept. to Local Govt. Board</i>, N.S. No. 77 (London, 1913).</p> + +<p><a name="Footnote_A_64" id="Footnote_A_64"></a><a href="#FNanchor_A_64"><span class="label">64</span></a> <i>Zeit. f. Hyg.</i>, XXII (1896), 53.</p> + +<p><a name="Footnote_A_65" id="Footnote_A_65"></a><a href="#FNanchor_A_65"><span class="label">65</span></a> <i>Brit. Med. Jour.</i>, I (1909), 1171.</p> + +<p><a name="Footnote_A_66" id="Footnote_A_66"></a><a href="#FNanchor_A_66"><span class="label">66</span></a> Bernstein and Fish, <i>Jour. Amer. Med. Assoc.</i>, LXVI (1916), 167.</p> + +<p><a name="Footnote_A_67" id="Footnote_A_67"></a><a href="#FNanchor_A_67"><span class="label">67</span></a> <i>Breslau aerztl. Ztschr.</i>, X (1888), 249.</p> + +<p><a name="Footnote_A_68" id="Footnote_A_68"></a><a href="#FNanchor_A_68"><span class="label">68</span></a> Bernstein and Fish, <i>Jour. Amer. Med. Assoc.</i>, LXVI (1916), 167.</p> + +<p><a name="Footnote_A_69" id="Footnote_A_69"></a><a href="#FNanchor_A_69"><span class="label">69</span></a> <i>Deutsche Viertelj. f. öffentl. Ges.</i>, XLV (1913), 58-59.</p> + +<p><a name="Footnote_A_70" id="Footnote_A_70"></a><a href="#FNanchor_A_70"><span class="label">70</span></a> <i>Op. cit.</i>, pp. 60-62.</p> + +<p><a name="Footnote_A_71" id="Footnote_A_71"></a><a href="#FNanchor_A_71"><span class="label">71</span></a> <i>Jour. Infect. Dis.</i>, XX (1917), 457.</p> + +<p><a name="Footnote_A_72" id="Footnote_A_72"></a><a href="#FNanchor_A_72"><span class="label">72</span></a> <i>Centralbl. f. Bakt.</i>, I Orig., LIII (1910), 377.</p> + +<p><a name="Footnote_A_73" id="Footnote_A_73"></a><a href="#FNanchor_A_73"><span class="label">73</span></a> <i>Cor.-Bl. f. schweiz. Aerzte</i>, XLII (1912), 281 and 332.</p> + +<p><a name="Footnote_A_74" id="Footnote_A_74"></a><a href="#FNanchor_A_74"><span class="label">74</span></a> <i>Jour. Hyg.</i>, XII (1912), 1.</p> + +<p><a name="Footnote_A_75" id="Footnote_A_75"></a><a href="#FNanchor_A_75"><span class="label">75</span></a> See Sobernheim and Seligmann, <i>Centralbl. f. Bakt.</i>, Ref., Beilage, +L (1911), 134.</p> + +<p><a name="Footnote_A_76" id="Footnote_A_76"></a><a href="#FNanchor_A_76"><span class="label">76</span></a> <i>Report Med. Officer of Health</i> (Newcastle-upon-Tyne, 1913).</p> + +<p><a name="Footnote_A_77" id="Footnote_A_77"></a><a href="#FNanchor_A_77"><span class="label">77</span></a> Compiled from Savage, <i>Report of Local Gov't Board</i>, 1913.</p> + +<p><a name="Footnote_A_78" id="Footnote_A_78"></a><a href="#FNanchor_A_78"><span class="label">78</span></a> Mayer, <i>Deutsche Viertelj. f. öffentl. Ges.</i>, XLV (1913), 8.</p> + +<p><a name="Footnote_A_79" id="Footnote_A_79"></a><a href="#FNanchor_A_79"><span class="label">79</span></a> 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).</p> + +<p><a name="Footnote_A_80" id="Footnote_A_80"></a><a href="#FNanchor_A_80"><span class="label">80</span></a> 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.</p> + +<p><a name="Footnote_A_81" id="Footnote_A_81"></a><a href="#FNanchor_A_81"><span class="label">81</span></a> <i>Jour. Infect. Dis.</i>, XIX (1916), 700.</p> + +<p><a name="Footnote_A_82" id="Footnote_A_82"></a><a href="#FNanchor_A_82"><span class="label">82</span></a> R. Trommsdorff, L. Rajchman, and A. E. Porter, <i>Jour. Hyg.</i>, XI +(1911), 89.</p> + +<p><a name="Footnote_A_83" id="Footnote_A_83"></a><a href="#FNanchor_A_83"><span class="label">83</span></a> <i>Hygiea</i>, LXXV (1913), 1.</p> + +<p><a name="Footnote_A_84" id="Footnote_A_84"></a><a href="#FNanchor_A_84"><span class="label">84</span></a> <i>Progrès méd.</i>, 3d series, XXVI (1910), 25.</p> + +<p><a name="Footnote_A_85" id="Footnote_A_85"></a><a href="#FNanchor_A_85"><span class="label">85</span></a> Ledingham and Arkwright, <i>The Carrier Problem in Infectious +Diseases</i>, pp. 152-53.</p> + +<p><a name="Footnote_A_86" id="Footnote_A_86"></a><a href="#FNanchor_A_86"><span class="label">86</span></a> <i>Jour. Hyg.</i>, XI (1911), 24.</p> + +<p><a name="Footnote_A_87" id="Footnote_A_87"></a><a href="#FNanchor_A_87"><span class="label">87</span></a> <i>Münch. med. Wchnschr.</i>, LIV (1907), 979.</p> + +<p><a name="Footnote_A_88" id="Footnote_A_88"></a><a href="#FNanchor_A_88"><span class="label">88</span></a> See, for example, H. Langer and Thomann, <i>Deutsche med. Wchnschr.</i>, +XL (1914), 493.</p> + +<p><a name="Footnote_A_89" id="Footnote_A_89"></a><a href="#FNanchor_A_89"><span class="label">89</span></a> <i>Ztschr. f. Infektionsk. ... d. Haustiere</i>, VIII (1910), 237.</p> + +<p><a name="Footnote_A_90" id="Footnote_A_90"></a><a href="#FNanchor_A_90"><span class="label">90</span></a> The consumption of raw sausage made with pig meat is particularly +likely to give rise to trichiniasis.</p> + +<p><a name="Footnote_A_91" id="Footnote_A_91"></a><a href="#FNanchor_A_91"><span class="label">91</span></a> <i>Jour. Med. Research</i>, VI (1901), 64.</p> + +<p><a name="Footnote_A_92" id="Footnote_A_92"></a><a href="#FNanchor_A_92"><span class="label">92</span></a> Edelmann, Mohler, and Eichhorn, <i>Meat Hygiene</i>, 1916, p. 182.</p> + +<p><a name="Footnote_A_93" id="Footnote_A_93"></a><a href="#FNanchor_A_93"><span class="label">93</span></a> <i>Jour. Amer. Med. Assoc.</i>, LXVII (1916), 1908.</p> + +<p><a name="Footnote_A_94" id="Footnote_A_94"></a><a href="#FNanchor_A_94"><span class="label">94</span></a> <i>Brit. Med. Jour.</i>, II (1916), 139.</p> + +<p><a name="Footnote_A_95" id="Footnote_A_95"></a><a href="#FNanchor_A_95"><span class="label">95</span></a> Another species of <i>Claviceps</i> (<i>C. paspali</i>) which attacks the +seeds of a wild grass is believed to be responsible for certain +outbreaks of poisoning among cattle and horses (<i>Science</i>, XLIII [1916], +894).</p> + +<p><a name="Footnote_A_96" id="Footnote_A_96"></a><a href="#FNanchor_A_96"><span class="label">96</span></a> Barger (<i>Jour. Chem. Soc.</i>, XCV [1909], 1123) has shown that +parahydroxyphenylethylamine is present in ergot and is in some degree +responsible for the physiological action of the drug.</p> + +<p><a name="Footnote_A_97" id="Footnote_A_97"></a><a href="#FNanchor_A_97"><span class="label">97</span></a> Although some of the early outbreaks were traced to the use of +sausage, particularly in Württemberg, the proportion of recent botulism +poisoning attributed to this food is no greater than of sausage-conveyed +infections with the paratyphoid bacillus (<a href="#chapVI">chap. vi</a>), and a number of the +most completely studied outbreaks of botulism have been traced to ham, +beans, and other foods.</p> + +<p><a name="Footnote_A_98" id="Footnote_A_98"></a><a href="#FNanchor_A_98"><span class="label">98</span></a> <i>Deutsche Viertelj. f. öffentl. Ges.</i>, XLV (1913), 8.</p> + +<p><a name="Footnote_A_99" id="Footnote_A_99"></a><a href="#FNanchor_A_99"><span class="label">99</span></a> E. Sacquépée, <i>Progrès méd.</i>, XXVI (1910), 583.</p> + +<p><a name="Footnote_A_100" id="Footnote_A_100"></a><a href="#FNanchor_A_100"><span class="label">100</span></a> <i>Report to Local Govt. Board on Bacterial Food Poisoning and Food +Inspection</i>, N.S. No. 77, 1913, p. 27.</p> + +<p><a name="Footnote_A_101" id="Footnote_A_101"></a><a href="#FNanchor_A_101"><span class="label">101</span></a> <i>Southern Cal. Pract.</i>, XXII (1907), 370.</p> + +<p><a name="Footnote_A_102" id="Footnote_A_102"></a><a href="#FNanchor_A_102"><span class="label">102</span></a> <i>Ibid.</i>, XXV (1910), 121.</p> + +<p><a name="Footnote_A_103" id="Footnote_A_103"></a><a href="#FNanchor_A_103"><span class="label">103</span></a> <i>Arch. of Int. Med.</i>, XIV (1914), 589.</p> + +<p><a name="Footnote_A_104" id="Footnote_A_104"></a><a href="#FNanchor_A_104"><span class="label">104</span></a> <i>Amer. Med.</i>, X (1915), 85.</p> + +<p><a name="Footnote_A_105" id="Footnote_A_105"></a><a href="#FNanchor_A_105"><span class="label">105</span></a> <i>Jour. Amer. Med. Assoc.</i>, LXI (1913), 2301.</p> + +<p><a name="Footnote_A_106" id="Footnote_A_106"></a><a href="#FNanchor_A_106"><span class="label">106</span></a> <i>Loc. cit.</i></p> + +<p><a name="Footnote_A_107" id="Footnote_A_107"></a><a href="#FNanchor_A_107"><span class="label">107</span></a> <i>Loc. cit.</i></p> + +<p><a name="Footnote_A_108" id="Footnote_A_108"></a><a href="#FNanchor_A_108"><span class="label">108</span></a> In the feces of a healthy pig (Kempner and Pollock, <i>Deutsche med. +Wchnschr.</i>, XXIII [1897], 505).</p> + +<p><a name="Footnote_A_109" id="Footnote_A_109"></a><a href="#FNanchor_A_109"><span class="label">109</span></a> <i>B. botulinus</i> 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 (Römer, <i>Centralbl. f. Bakt.</i>, XXVII +[1900], 857).</p> + +<p><a name="Footnote_A_110" id="Footnote_A_110"></a><a href="#FNanchor_A_110"><span class="label">110</span></a> G. Landmann, <i>Hyg. Rundschau</i>, XIV (1904), 449.</p> + +<p><a name="Footnote_A_111" id="Footnote_A_111"></a><a href="#FNanchor_A_111"><span class="label">111</span></a> Wilbur and Ophüls, <i>Arch. of Int. Med.</i>, XIV (1914), 589.</p> + +<p><a name="Footnote_A_112" id="Footnote_A_112"></a><a href="#FNanchor_A_112"><span class="label">112</span></a> <i>Phil. Jour. of Science</i>, IX (1914), B6, p. 515.</p> + +<p><a name="Footnote_A_113" id="Footnote_A_113"></a><a href="#FNanchor_A_113"><span class="label">113</span></a> K. Blunt and C. C. Wang, <i>Jour. Biol. Chem.</i>, XXVIII (1916), 125.</p> + +<p><a name="Footnote_A_114" id="Footnote_A_114"></a><a href="#FNanchor_A_114"><span class="label">114</span></a> Jordan and Harris, <i>Jour. Infect. Dis.</i>, VI (1909), 401.</p> + +<p><a name="Footnote_A_115" id="Footnote_A_115"></a><a href="#FNanchor_A_115"><span class="label">115</span></a> <i>Ibid.</i></p> + +<p><a name="Footnote_A_116" id="Footnote_A_116"></a><a href="#FNanchor_A_116"><span class="label">116</span></a> E. B. Vedder, <i>Jour. Amer. Med. Assoc.</i>, LXVII (1916), 1494.</p> + +<p><a name="Footnote_A_117" id="Footnote_A_117"></a><a href="#FNanchor_A_117"><span class="label">117</span></a> McCollum and Davis, <i>Jour. Biol. Chem.</i>, XXIII (1915), 181.</p> + +<p><a name="Footnote_A_118" id="Footnote_A_118"></a><a href="#FNanchor_A_118"><span class="label">118</span></a> Goldberger, <i>Jour. Amer. Med. Assoc.</i>, LXVI (1916), 471.</p> + +<p><a name="Footnote_A_119" id="Footnote_A_119"></a><a href="#FNanchor_A_119"><span class="label">119</span></a> MacNeal, <i>Jour. Amer. Med. Assoc.</i>, LXVI (1916), 975; Jobling, +<i>Jour. Infect. Dis.</i>, XVIII (1916), 501.</p> + +<p><a name="Footnote_A_120" id="Footnote_A_120"></a><a href="#FNanchor_A_120"><span class="label">120</span></a> Gasbarrini, <i>Policlinico</i>, November 14, 1915; abstract, <i>Jour. +Amer. Med. Assoc.</i>, LXV (1915), 2264.</p> + +<p><a name="Footnote_A_121" id="Footnote_A_121"></a><a href="#FNanchor_A_121"><span class="label">121</span></a> Holst and Frölich, <i>Jour. Hyg.</i>, VII (1907), 619; Moore and +Jackson, <i>Jour. Amer. Med. Assoc.</i>, LXVII (1916), 1931.</p> + +<p><a name="Footnote_A_122" id="Footnote_A_122"></a><a href="#FNanchor_A_122"><span class="label">122</span></a> Jackson and Moody, <i>Jour. Infect. Dis.</i>, XIX (1916), 511.</p> +</div> + + + + +<div class="box martop4"> +<p class="center ftsize105"><b>Transcriber's Notes:</b></p> + +<p>Illustrations have been moved from the middle of a paragraph to the +closest paragraph break. Missing page numbers are connected to blank +pages and moved illustrations. The following illustrations have been +moved to other pages:</p> + +<ul class="tn"> + <li><a href="#img002">Fig. 1</a> was moved from page 15 to page <a href="#page16">16</a></li> + <li><a href="#img004">Fig. 3</a> was moved from page 19 to page <a href="#page18">18</a></li> + <li><a href="#img005">Fig. 4</a> was moved from page 23 to page <a href="#page22">22</a></li> + <li><a href="#img006">Fig. 5</a> was moved from page 49 to page <a href="#page48">48</a></li> + <li><a href="#img011">Fig. 10</a> was moved from page 87 to page <a href="#page88">88</a></li> +</ul> + +<p>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.</p> + +<p>Atropin and atropine have been retained in both versions in this project.</p> + +<p>Table <a href="#TabA">A</a> in footnote <a href="#Footnote_A_1">1</a> 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.</p> + +<p>Footnote <a href="#Footnote_A_2">2</a> "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.</p> + +<p>Margarin (pages <a href="#page16">16</a> and <a href="#page112">112</a>) is in general spelled margarine, it has been +retained in this book for reasons of authenticity.</p> + +<p>Maratti-oil (pages <a href="#page16">16</a> and <a href="#page112">112</a>) is in general known as moratti-oil, it +has been retained in this book for reasons of authenticity.</p> + +<p>Hydrocarpus (pages <a href="#page16">16</a> and <a href="#page111">111</a>) is in general known as Hydnocarpus, it +has been retained in this book for reasons of authenticity.</p> + +<p>Amanita caesaria (pages <a href="#page18">18</a>, <a href="#page20">20</a>, and <a href="#page109">109</a>) is also known as Amanita +caesarea but retained for this project in the first form.</p> + +<p>Muscarin (pages <a href="#page20">20</a>, <a href="#page21">21</a>, <a href="#page22">22</a>, and <a href="#page112">112</a>) is in general spelled muscarine, it +has been retained in this book for reasons of authenticity.</p> + +<p>Zygadenus (pages <a href="#page25">25</a> and <a href="#page115">115</a>) is in general known as Zigadenus, it has +been retained in this book for reasons of authenticity.</p> + +<p>The typhoid carrier in New York Mary Mallon (aka Typhoid Mary) mentioned +on page <a href="#page45">45</a> as well as on page <a href="#page112">112</a> is spelled in this book as Mary +Malloy, the original of the book has been retained.</p> + +<p>Other than the corrections listed below, printer's inconsistencies +in spelling, punctuation, hyphenation, and ligature usage have +been retained.</p> + +<p>The following misprints have been corrected:</p> +<ul class="tn"> + <li>added 0 to +.89 in table <a href="#TabB">B</a> footnote <a href="#Footnote_A_1">1</a>, second to last value + in 4th column.</li> + <li>changed "la face vulteuse" into "la face vultueuse" page <a href="#page21">21</a></li> + <li>changed "Paneolus papilionaceus" into "Panaeolus papilionaceus" + page <a href="#page21">21</a></li> + <li>the italian mark-up for "XLV" in "f. öffentl. Ges., XLV" has been + removed, footnote <a href="#Footnote_A_69">69</a></li> + <li>changed "R. Trommsdorff, L. Rajchmann, and A. E. Porter," into "R. + Trommsdorff, L. Rajchman, and A. E. Porter," footnote <a href="#Footnote_A_82">82</a></li> + <li>changed "Paneolus papilionaceus" into "Panaeolus papilionaceus" + page <a href="#page113">113</a></li> +</ul> +</div> + + + + + + + +<pre> + + + + + +End of the Project Gutenberg EBook of Food Poisoning, by Edwin Oakes Jordan + +*** END OF THIS PROJECT GUTENBERG EBOOK FOOD POISONING *** + +***** This file should be named 34189-h.htm or 34189-h.zip ***** +This and all associated files of various formats will be found in: + https://www.gutenberg.org/3/4/1/8/34189/ + +Produced by Bryan Ness, Iris Schröder-Gehring and the +Online Distributed Proofreading Team at https://www.pgdp.net +(This file was produced from images generously made +available by The Internet Archive/Canadian Libraries) + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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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 + + +Title: Food Poisoning + +Author: Edwin Oakes Jordan + +Release Date: November 1, 2010 [EBook #34189] + +Language: English + +Character set encoding: ASCII + +*** START OF THIS PROJECT GUTENBERG EBOOK FOOD POISONING *** + + + + +Produced by Bryan Ness, Iris Schroeder-Gehring and the +Online Distributed Proofreading Team at https://www.pgdp.net +(This file was produced from images generously made +available by The Internet Archive/Canadian Libraries) + + + + + + + + + + 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 + +*** END OF THIS PROJECT GUTENBERG EBOOK FOOD POISONING *** + +***** This file should be named 34189.txt or 34189.zip ***** +This and all associated files of various formats will be found in: + https://www.gutenberg.org/3/4/1/8/34189/ + +Produced by Bryan Ness, Iris Schroeder-Gehring and the +Online Distributed Proofreading Team at https://www.pgdp.net +(This file was produced from images generously made +available by The Internet Archive/Canadian Libraries) + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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