LABORATORY MANUAL 
For 
New York State Health Officers 
Prepared by the 
DIVISION OF LABORATORIES AND RESE ARCH 
Augustus B. Wadsworth, M. D. 
Director 
ALBANY 
J. B. LYON COMPANY, PRINTERS 
1920 DIVISION OF LABORATORIES AND RESEARCH 
STATE DEPARTMENT OF HEALTH 
Augustus B. Wadsworth, M. D., Director 
Paul B. Brooks, M. D., Assistant Director 
Ila M. Dutton, Executive Clerk 
Diagnostic Laboratories 
Ruth Gilbert, Bacteriologist in charge 
Virginia H. Langworthy, Assistant Bacteriologist 
F. Constance Stewart, Assistant Bacteriologist 
Antitoxin, Serum and Vaccine Laboratories 
Mary B. Kirkbride, Bacteriologist in charge 
Analytical Chemical Laboratories 
Leonard M. Wachter, Chemist in charge 
F. Wellington Gilcreas, Wa/er Analyst 
3 CONTENTS 
PAGE 
Preface 7-8 
Introduction JL; 9 
Part I - Local public health laboratories 11 
Application for approval 11-12 
Questionnaire on methods used in the complement fixation test for 
syphilis 12-13 
Standard Methods 13 
Diphtheria ,. 13-14 
Tuberculosis 14 
Typhoid fever 14-19 
Gonorrhea 19-20 
Syphilis 20 
Records 20-21 
Bacterial count of milk 22-23 
Bacteriological examination of water 23-24 
Sanitary chemical examination of water 24-26 
List of approved laboratories 27-32 
Part II - The laboratory service of New York State in the diagnosis, 
prevention, and cure of disease 33 
Cancer 33-34 
Diphtheria 34-49 
Dysentery, bacillary 49-51 
Malaria 51 
Meningitis 52-54 
Miscellaneous examinations 55-5S 
• Ophthalmia neonatorum 58 
Pertussis (whooping cough) 58-59 
Pneumonia 59-66 
Rabies 66-69 
Smallpox 69-70 
Syphilis, gonorrhea and chancroid :.... 70-86 
Tetanus 87-90 
Tuberculosis 90-97 
Typhoid and paratyphoid fever 97-104 
Procedure of recording and reporting the results of laboratory examina- 
tions 104-106 
Administrative procedures 106-113 
The collection of samples of water, sewage and ice for bacterial and 
chemical examination 113-126 
Part III - Summary of laws and regulations relating to laboratories and 
laboratory specimens 127-131 
5 PREFACE 
Public health, work during the last decade has wonderfully 
broadened its scope. It now reaches out into new fields and 
gathers into its growing corps of workers all those who in any 
capacity whatever minister to the sick, protect individuals or com- 
munities from infectious or communicable disease, regulate per- 
sonal hygiene, or industrial sanitation, or safeguard workers 
against disabilities and incapacities. This public health work 
demands of all incomers to its ranks a wider vision in their work 
than is required in any of the chosen fields from which they have 
come. Physicians accustomed to cure individuals must assume 
the larger responsibilities of preventive medicine. Similarly the 
public health nurse accustomed to care for cases of illness, to 
relieve suffering and to expedite the recovery of patients, must 
extend her sphere of usefulness, cooperating with both physician 
and health officer. 
The early recognition of disease is the basis of all preventive 
medicine. It is largely for this very purpose that so many and 
such varied agencies 'have been marshalled to aid the expert in 
public health; but the most fundamental of all the agencies which 
have been developed is the laboratory. The laboratory is funda- 
mental and essential because accurate methods of analysis are 
used and definitely significant facts are elicited by them. 
It is not necessary for health officers, physicians or others 
interested in public health work to become experienced in the 
technical procedures of the laboratory, but they must be sufficiently 
well-informed to use the laboratory promptly and effectively 
whenever the occasion requires. 
In any district where public health officials are at work they 
should know definitely what laboratory facilities are available. 
In the State of New York the central laboratory of the Depart- 
ment of Health is located on New Scotland avenue in the city of 
Albany, and the branch laboratory is located in the building of 
the New York University and Bellevue Medical School, 338 E. 
26th Street, New York City. In various cities and counties of 
7 8 
Preface 
the State there are municipal laboratories maintained either by 
the city or the county, cooperating with the State laboratory at 
Albany. Standard methods for the various technical procedures 
have been agreed upon, making all the work done by these 
laboratories uniform throughout the State. Comparison of the 
efficiency of the services of different laboratories and the uni- 
formity of their reports is constantly made through their coopera- 
tion with the central laboratory in Albany. Specimens are sent 
in duplicate for examination and report. Nowhere else is there 
to be found a laboratory service for the civil population organized 
into such a complete unit. INTRODUCTION 
This manual has been written primarily for the physicians and 
health officers of New York State, but it contains information for 
others who must use the laboratory. It is only through complete 
cooperation that the service can be most effectively developed. 
Whoever uses it should not overlook the fact that the activities of 
the State laboratory are carried on by a large organization which 
is constantly being adapted to changing conditions and varying 
demands and that it is dependent upon postal, telegraph and trans- 
portation services; hence, the importance of reporting immediately 
any faults in the service whatever their nature and especially 
any suggestions for improvement. 
If physicians are to use the laboratory service of the State 
they must know what laboratories are available, where they are 
located, what they will and can do for them, and what standards 
of work are maintained. Finally, they must know how the laws 
of the State require them to use the laboratory. The manual is 
thus divided into three sections. The first section deals with 
the approved laboratories of the State. The second describes the 
work which they may be called upon to do in the diagnosis, pre- 
vention or cure of disease. In the third section state laws and 
regulations governing the use and operation of laboratories are 
abstracted so that any one who is interested may gain the neces- 
sary information, but these abstracts should not be regarded as 
authoritative interpretations. References to the law are given 
for those seeking complete and accurate information. 
Need for 
cooperation 
local 
laboratories 
Classlflcatfon) 
of Information 
in manual 
9 PART I 
In. certain, instances the laws of the State require examinations 
to be made in laboratories approved by the Commissioner of 
Health. Such examinations when made in other laboratories thus 
have no standing in the courts. The attached table (see pages 
27 to 32) gives a list of the approved laboratories and the extent to 
which their work has been approved. 
Many of the approved laboratories are limited in the scope of 
their work and are not equipped for all branches of laboratory 
work, but they can at all times refer specimens for examination 
to the central laboratory in Albany. A mobile unit has been 
prepared which it is hoped will always be ready in emergencies 
to support the local laboratories in the field. The laboratory at 
Albany should be notified promptly whenever there is any pros- 
pect that emergencies will arise. 
Certain steps must be taken in order to secure the approval of 
the Commissioner of Health, and there are certain minimum 
■standards of work to be maintained, before approval is issued. 
The approval is issued for one year. On or before January first 
of each year the person in charge of an approved laboratory is 
required to certify that the requirements have been fulfilled and 
the standards maintained before a reapproval is issued. 
In order that health officers and other physicians may know just 
what is required of these approved laboratories the application 
blanks, questionnaires and standard methods are presented below: 
LOCAL PUBLIC HEALTH LABORATORIES 
Mobile salt 
available la 
emergencies 
Application for the Approval of Public Health Laboratory Service 
(Health officer, or supporting board, director) 
hereby makes 
application for approval by the State Commissioner of Health of the public 
health work performed by 
located at 
(Name of laboratory) 
in charge of 
(Give full address) 
(Name and title of person in charge) 
11 12 
(Describe educational qualifications and experience) 
with a staff of. 
(Number of assistants, and whether on full or part time) 
This laboratory is located. 
(Describe where located, number of rooms occupied, etc.) 
and has the following equipment all of which is in good condition: 
Microscope 
Centrifuge 
Gas incubator 
Electric incubator 
.Dark field 
Autoclave 
Arnold sterilizer 
Hot air sterilizer 
The scope of the work of the laboratory includes. 
(Indicate by means of a cross (x) in which class your laboratory should be included) 
County 
Municipal 
Hospital 
Teaching institution 
Is county work also done?. 
Is municipal work also done? 
Private 
Institutional 
Is private work also done ?. . 
It is agreed that: 
1 The technique employed in the diagnostic examination of specimens from 
suspected cases of communicable diseases and in the examination of milk and 
water will be that approved by the laboratory of the State Department of 
Health. 
2 An accurate record will be kept of the daily work, and monthly reports 
filed with the laboratory of the State Department of Health on blanks pro- 
vided for the purpose. 
3 All stained microscopical preparations (slides) on which the reports are 
made will be kept on file for a period of six months. 
Date. 
(Official making application) 
Questionnaire on the Methods Used in Laboratories Throughout the 
State for the Wassermann Test 
1 What is your average number of tests per month? 
2 What is the average age of specimens tested? 
3 How frequently is the test performed? 
4 Do you use the reagents in the volume recommended by Wassermann, 
5 cc. in each tube, or %• or 1/10 of this volume? 13 
5 Give in detail your method of standardizing the hemolytic system, includ- 
ing the following points: Method of preparation of amboceptor; method of 
standardization of amboceptor; dilution used (give the amount and dilution, 
for example, 1 cc. of a 1-500 dilution) ; number of pigs bled for each day's 
work; length of time complement is kept before using; dilution of comple- 
ment; method of testing for hemolytic activity and nonspecific fixability; 
kind of red blood cells used (sheep, human) ; where obtained; length of time 
cells are kept before using; method of washing and diluting. 
6 How many antigens are used in your routine test? How are they pre- 
pared and standardized? How frequently are they standardized? 
7 Describe your test in detail, including the following points: Method of 
inactivating serum; number of units of each reagent used; amounts of 
patient's serum or spinal fluid used in the test; temperature and time allowed 
for fixation (ice-box, incubator, waterbath) ; controls used; antigen controls, 
serum controls (positive, negative and anticomplementary serum controls) ; 
controls on technical inaccuracies; tests for natural amboceptor; method of 
reading tests and reporting results. 
8 What methods are used in the washing and sterilizing of glassware? 
Agreement on Conditions to be Observed and Methods to be Followed, 
in Making Diagnostic Examinations in Diphtheria, Tuberculosis, 
Typhoid Fever and Other Communicable Diseases 
Laboratories undertaking examinations for the diagnosis of diphtheria,, 
tuberculosis, typhoid fever and other communicable diseases shall be properly 
equipped with standard apparatus and appliances for this work. Directors of 
laboratories, approved for these examinations, should preferably be graduates 
of medicine, or bacteriologists of sufficient education and experience to 
interpret the significance of the results of laboratory examinations. Members 
of the staff who make diagnoses shall have been trained under qualified experts 
and shall have had not less than one year's experience in a bacteriological 
laboratory. 
Diphthebia 
The results of direct microscopic examinations of spreads of material from 
disease processes may be reported when such examinations demonstrate the 
presence of morphologically characteristic diphtheria bacilli. The results of 
such examinations shall always be confirmed by the microscopic examination 
of cultures. 
Diphtheria cultures shall be made by transferring material or exudate from 
the disease processes on a sterile swab directly to coagulated blood serum 
medium (Loeffler). The surface of the medium is thoroughly inoculated with 
the culture material. Cultures which show liquefaction or other evidences 
of contamination, which are excessively dry, or which have not been taken 
properly, shall be considered unsatisfactory for examination. 
Cultures to be examined for diphtheria bacilli shall be incubated at 37° C. 
for a minimum period of ten hours before microscopic preparations are made. 
Microscopical preparations are to be stained with Loeffler's alkaline methylene 
blue stain for one minute. The absence of diphtheria bacilli shall not be so 
reported until the culture has been incubated for at least 15 hours and a 
preparation of it has been examined for at least one minute under a 1/12 
oil-immersion objective. 14 
The reports of the examination shall be: Diphtheria bacilli found; diph- 
theria bacilli not found; examination unsatisfactory; (a) medium contami- 
nated, liquefied or dried; (b) culture not properly taken; (c) results doubtful. 
In all cases giving a history of infection, in which diphtheria-like organisms 
are found, these organisms shall be regarded as true diphtheria bacilli unless 
they are tested and found nonvirulent. In cases not giving a history of 
infection distinction between Bacillus Hoffmanni, pseudo-diphtheria bacilli 
and the true diphtheria bacilli may be made by morphological examination. 
Tuberculosis 
Sputum which is to be examined for the presence of tubercle bacilli should 
be coughed up from the lung and collected in clean sterile containers. Speci- 
mens obtained on rising in the morning should be secured whenever this1 is 
possible. Spreads of a representative part of the specimen, the cheesy clumps 
of lung exudate being selected when present, are prepared, dried in the air 
and carefully fixed in the flame. They are then stained by the Ziehl-Neelson 
method, that is, stained for three to five minutes in steaming carbol-fuchsin 
or for twenty-four hours in carbol-fuchsin kept at room temperature, decolor- 
ized in acid alcohol containing 1-3 per cent hydrochloric acid and counter- 
stained with methylene blue. The method shall be tested by staining prepara- 
tions of sputum in which tubercle bacilli are known to be present. The 
absence of tubercle bacilli shall be reported only after the specimen has been 
examined under the microscope with a 1/12 oil-immersion objective for at 
least five minutes. *A positive diagnosis shall not be made unless several acid 
fast bacilli are found. 
Typhoid Fever 
Specimens of dried blood or of blood serum which are to be used in making 
the agglutination test are diluted 1 to 10, 1 to 20, and 1 to 40, using either 
distilled water or physiological salt solution. The dilutions of dried blood 
may be compared with standard dilutions of known quantities of blood which 
have dried and then been diluted with water. 
A culture of the Bacillus typhosus which agglutinates readily shall be 
selected for the test. This culture in broth shall be incubated at from 20° C. 
to 37° C. for not more than eighteen hours. The culture shall not be dis- 
turbed and only the surface used for the test, or if the growth is too heavy 
it may be diluted to correspond to a turbidity standard. If a suspension in 
saline of a fresh agar culture after eighteen hours' incubation at 37° C. is 
used, the clumps shall be allowed to settle. This culture or suspension shall 
be tested with anti-typhoid serum to prove its agglutinability. 
One loop of this culture and one loop of the 1 to 10, 1 to 20, and 1 to 40 
dilutions of dried blood or of blood serum are mixed on the cover glass. The 
hanging drops thus prepared, together with those of culture and salt solution 
or normal blood or blood serum for purposes of control, are examined after an 
Agglutination Test (Widal) 
* If other stains recommended for staining acid fast bacteria are preferred, 
describe in detail the technique desired. 15 
incubation period of one hour at 37° C. The readings of the agglutination 
reactions shall then be made in terms of the final dilutions of 1 to 20, 1 to 40, 
and 1 to 80. 
The reaction should not be considered significant unless there is loss of 
motility and a definite clumping in the 1 to 40 dilution in one hour. The 
reaction in the 1 to 20 and 1 to 80 dilutions shall also be studied for purposes 
of comparison.* 
Routine Procedube for the Isolation of Typhoid, Paratyphoid, and 
Dysentery Bacilli from Feces 
The examination shall be made immediately. Typhoid bacilli disappear 
from more than 10 per cent of the specimens of feces in twenty-four hours. 
Paratyphoid organisms do not degenerate so rapidly. If the specimens are 
sent to the laboratory emulsified in 30 per cent chemically pure glycerine, the 
typhoid bacilli are not so readily killed. 
I Preparation of specimen for plating 
When specimens are received undiluted, make a thin suspension of the feces 
in broth (using 10 parts of liquid to 1 part solid). Allow the emulsion to 
stand for about 10 minutes so that coarser particles may settle. When the 
specimens are received suspended in glycerine, they may be plated without 
further dilution. 
II Plating of specimens 
For each specimen at least six plates shall be used. Endo's medium, or 
Kendall's modification of Endo's medium, shall be used for at least part of the 
plates. Part of the plates used may contain brilliant green, or eosin blue 
medium if desired. (See preparation of media.) 
Place three or four loopfuls from the upper layer of the emulsion of feces 
upon the first plate and two or three loopfuls upon the fourth plate. With 
a sterile glass or wire plating rod spread the emulsion evenly over the sur- 
face of the plates. Starting with the first plate, all of the plates are seeded 
in succession. For purposes of comparison, control plates of each type of 
medium employed are made at the same time and inoculated with a pure 
culture of B. typhosus. Incubate plates 18-24 hours at 37° C. 
Ill Fishing of colonies 
After incubation the plates are examined under the microscope or hand lens. 
Typical or suggestive colonies (see table 1) are fished with a platinum wire 
and transferred to a slant of agar medium, containing the three sugars (1 per 
cent lactose, 1 per cent saccharose, 0.05 per cent dextrose) ; inoculating one 
tube from each colony. The medium is inoculated by deep puncture into the 
butt and along the surface of the slant. Incubate tubes 18-24 hours. 
Suggestive colonies may be emulsified in a drop of salt solution on a clean 
glass slide, and a loopful of this emulsion mixed with a drop of a 1-50 
dilution of the immune serum. When the side is tilted with the hand for 
a few minutes the bacilli from positive colonies should show definite agglutina- 
* The same methods may be used for paratyphoid agglutination tests. 16 
tion, while the bacilli from negative ones should be unchanged, the drop 
remaining homogeneous in appearance; the salt solution emulsion serves as a 
control. 
IV Motility tests 
The reactions of the triple sugar slants are recorded, and if any are typical 
of typhoid, paratyphoid or dysentery (see table 2), inoculations are made 
from the slants into sterile broth and the broth incubated. If after two 
hours the broth is cloudy, a hanging drop is made and examined under the 
microscope. B. typhosus and B. paratyphosus are motile, while all strains of 
B dysenteriae are nonmotile. 
V Agglutination tests 
If the organisms are motile, agglutination tests are made with typhoid or 
paratyphoid immune serum, depending upon the absence or presence of gas in 
the triple sugar slants (see table 2). If the organisms are not motile, agglu- 
tination tests are made with polyvalent dysentery immune serum, provided 
that the reaction of the triple sugar slant culture is typical. In these tests 
a serum of known specificity must be used, the titre having been previously 
tested.* 
(Immune sera for use in agglutination tests may be obtained from the 
State laboratory.) 
Positive control test 
With every agglutination test a positive control shall be made in the same 
manner as the regular test, except that a stock culture of the homologous 
organism is used in place of the culture that is being tested. 
VI Results of agglutination tests 
After tubes have been shaken, incubate two hours and let stand in icebox 
over night. If the reaction is positive, a flocculent precipitate should be 
present in the bottom of the tubes with the supernatant fluid clear; when 
gently shaken the precipitate persists in definite clumps. The negative control 
should show uniform turbidity. 
If an organism with characteristic morphology and staining properties, 
which has reacted typically on the sugars, fails to agglutinate, transfer it to 
plain agar, and, after making several subcultures, try the agglutination test 
again. This time positive results may be obtained, for it is a well-established 
fact that organisms freshly isolated from the body do not always agglutinate 
readily. 
VII Fermentation reactions 
If the motility is indefinite it is well to inoculate a series of eight carbo- 
hydrate serum water tubes with the culture to insure an accurate report. 
* Cultures which agglutinate in the polyvalent dysentery immune serum, 
may be sent to the State Laboratory at Albany for the determination of the- 
type. 17 
Make readings of these sugar reactions after 24 hours' and 48 hours' incu- 
bation. (See table 2.) 
VIII Reports of examinations shall be 
(1) B. typhosus, or B. paratyphosus A or B, or B. dysenteriae found. 
(2) B. typhosus, B. paratyphosus, B. dysenteriae, not found. 
(3) Examination unsatisfactory - not sufficient material sent - specimen 
spoiled, delayed in transit. 
IX Preparation of media 
(A) Endo medium, "Kendall's modification." 
To 100 cc. of melted sterile beef extract 3 per cent agar (reaction + 0.3 
phenolphthalein) is added 1 per cent lactose, 1 cc. of fuchsin indicator, 
and 0.2 cc. of N/l NaOH. 
(B) Brilliant green medium 
To 100 cc. of melted sterile beef extract 1.5 per cent agar (reaction + 0.1 
phenolphthalein) is added 1 per cent lactose 0.1 per cent dextrose and 
3 cc. of Andrade indicator. Test a sample of each new lot of medium to 
determine the reaction by cooling in a test tube, add enough N/l HC1 or N/l 
NaOH to make the medium a faint pink when cool. Just before pouring plates 
add a 0.1 per cent aqueous solution of brilliant green, the object of which 
is to inhibit the growth of B. coli. It is necessary to standardize the amount 
of this brilliant green solution to be used for every new lot of medium in 
the following way: Pour a series of 6 plates, 2 with 0.1 cc. of the green 
per 100 cc. of medium, 2 with 0.2 cc. of green per 100 cc. and 2 with 0.3 cc. 
of green per 100 cc. Each set of plates containing a different percentage of 
dye is then inoculated with stock strains of B. coli, B. typhosus, B. para- 
typhosus, and B. dysenteriae, only half a plate being used for each seeding. 
After incubation observe growth and choose amount of dye which best inhibits 
growth of B. coli without materially affecting the growth of the typhoid-para- 
typhoid group. Brilliant green usually inhibits the growth of B. dysenteriae. 
(C) Eosin methylene blue medium. 
To 100 cc. of melted sterile beef extract 2 per cent agar (reaction + 0.1 
phenolphthalein) is added 0.5 per cent lactose, 0.5 per cent saccharose, 
1% cc. of a 3 per cent aqueous solution of eosin and 2 cc. of a 0.5 per cent 
aqueous solution of methylene blue. 
It is advisable to use porous top plates for this work and after hardening at 
room temperature to keep them in the icebox until needed. Plates over a week 
old are not satisfactory for use. 
(D) Triple sugar medium 
Recent investigation has shown that Russell's double sugar medium, modi- 
fied by the addition of 1 per cent saccharose, offers certain advantages, 
especially when isolating members of the paratyphosus group. A considerable 
percentage of nonlactose fermenting organisms which produce gas in dextrose 18 
also produce acid on the slant by fermenting saccharose. This reaction sepa- 
rates these intermediates from the typhoid, paratyphoid and dysentery groups 
which do not produce acid on slants of this medium. 
X Preparation of dyes and indicators 
(A) Andrade indicator 
.5 per cent aqueous acid fuchsin 100 cc. 
N/l NaOH 16 cc. 
Prepare at least one hour before use. 
(B) Fuchsin indicator 
Saturated alcoholic solution of basic fuchsin 1 cc. 
10 per cent aqueous solution of anhydrous sodium sulphite 10 cc. 
(C) 0.1 per cent brilliant green 
Brilliant green 0.1 gm. 
Boiling distilled water 100 cc. 
(D) 0.5 per cent methylene blue 
Methylene blue 0.5 gm. 
Distilled water' 100 cc. 
(E) 3 per cent eosin yellow 
French pure eosin or anilin red 3 gm. 
Distilled water 100 cc. 
Table 1 
Tabulations of the Diagnostic Characteristics of the Typhoid, Paratyphoid, 
and Dysentery Bacilli 
Typhoid 
Para A and B 
Dysentery 
(Shiga) 
Dysentery 
(Mt. 
Desert) 
Dysentery 
(Flexner) 
B. Coli 
(Communis) 
Brilliant 
green. 
Colony colorless by di- 
rect light, translu- 
cent, greenish by 
transmitted light, 
border undulated, 
grape leaf, character 
marked. 
Colony similar to 
typhoid, except 
for rounded 
edges and lack 
of grape leaf 
character. 
No growth 
No growth. 
No growth. 
Greatly inhibited. 
Colonies pink- 
ish, regular bor- 
der. 
Endo 
Colony similar, less 
translucent, grape 
leaf character not so 
marked. 
Similar 
Colony color- 
less, translu- 
cent border 
regular; no 
granulation; 
no grape leaf 
character. 
Similar to 
Shiga. 
Similar to 
Shiga. 
Colonies pink or 
red nearly opa- 
que under low 
power granular 
and brownish 
border. 
Eosin meth- 
ylene blue 
Colony colorless, trans- 
lucent. 
Similar 
Similar 
Similar to 
Shiga. 
Similar to 
Shiga. 
Colonies colorless 
at edge, centers 
dark blue al- 
most black, opa- 
que, border reg- 
ular. 
Eosin green. 
Colony similar, grape 
leaf character 
marked. 
Similar 
No growth 
No growth. 
No growth. 
Colonies pinkish, 
dark centers. 19 
Tabulations of the Diagnostic Characteristics of the Typhoid, Paratyphoid, 
and Dysentery Bacilli 
Table 2 
Typhoid 
Para 
A and B 
Dysentery 
(Shiga) 
Dysentery 
(Mt. Desert) 
Dysentery 
(Flexner) 
B. Coli 
(Communis) 
Dextrose 
A 
A G 
A 
A 
A 
A G 
Leavulose 
A 
A G 
A 
A 
A 
A G 
Galactose 
A 
A G 
A 
A 
A 
A G 
Mannit 
A 
A G 
O 
A 
A 
A G 
Maltose 
A 
A G 
O 
0 
A 
A G 
Lactose 
0 
0 
O 
0 
0 
A G 
Saccharose 
0 
0 
0 
0 
Weak A 
0 
Dextrin 
A 
Weak A 
0 
o 
A 
Weak A 
Triple sugar slants. 
* 
i 
* 
* 
* 
§ 
Motility • 
Motile 
Motile 
Not motile 
Not motile 
Not motile 
Motile 
Gram stain 
Gram. neg. 
Gram. neg. 
Gram. neg. 
Gram. neg. 
Gram. neg. 
Gram. neg. 
* Acid in butt, colorless slant, no gas. 
t Acid and gas in butt, colorless in slant. 
§ Acid and gas in butt, acid in slant. 
Note.- Readings of the reaction in the sugar serum water are made after 24 and 48 hours 
incubation. 
A = acid. 
G = gas. 
O = no change. 
Gonorrhea 
The discharge shall be spread upon a slide, fixed in the flame and then 
stained by the method of Gram. One of the following methods shall be used.* 
A 1 Freshly prepared Koch-Ehrlich anilin-water gentian-violet for at least 
two minutes. 
2 Blot dry. Do not wash. 
3 Gram's iodine solution, one minute. Dry thoroughly. 
4 Decolorize with 95 per cent alcohol until the addition of fresh alcohol 
no longer removes any of the stain. Wash in water. 
5 Counterstain with freshly prepared 10 per cent dilution of a saturated 
aqueous solution of Bismarck brown. 
B 1 Carbol-gentian-violet, one minute. Blot dry. 
2 Gram's iodine, one minute. Blot dry. 
3 Decolorize and proceed as above. 
Note.- Koch-Ehrlich anilin-gentian-violet is prepared as follows: Satur- 
ated alcoholic solution of gentian-violet, one part, saturated solution of anilin 
water, nine parts. The anilin water is obtained by adding one part of anilin 
oil to nine parts of water. It is filtered through wet filter-paper until abso- 
lutely clear. 
Carbol-gentian-violet is prepared by adding one part of a saturated alcoholic 
solution of gentian-violet to nine parts of 5 per cent carbolic acid. Care 
should be taken to insure complete saturation of the alcoholic solution of the 
* If another modification of the Gram stain is preferred, give a careful 
description of the formula and technique desired. 20 
gentian-violet. This stain need not be freshly prepared as it keeps indefinitely. 
It is filtered before using. 
The nuclei of the polymorphonuclear leucocytes should be faintly stained 
with the gentian-violet. Other counter stains, unless greatly diluted, shall 
not be substituted as these may replace the gentian-violet in the Gram positive 
organisms. 
The morphological diagnosis is to be made when organisms are intracellular 
and the morphological characteristics, grouping, and staining reactions are 
typical. The reliability of the staining reagents shall in every case be con- 
trolled by testing them with smears of known Gram positive and Gram nega- 
tive bacteria. It is necessary to bear in mind the fact that the discharges 
from mucous membranes, commonly the site of infections with the gonococcus, 
not infrequently contain Gram negative cocci which are not gonococci. 
The spinal exudate obtained by spinal puncture under strictest aseptie 
precautions shall be centrifugalized, the sediment spread upon a slide, fixed in 
the flame and stained by the method of Gram. The morphological diagnosis- 
shall be made only when typical intra-cellular cocci in pairs or tetrads are- 
found. 
Epidemic Cerebrospinal Meningitis 
Syphilis 
The complement-fixation test for the diagnosis of syphilis shall be attempted' 
only by those who are especially trained and qualified to do the work. It is- 
undesirable for a laboratory to undertake the performance of the complement, 
fixation test for syphilis unless the number of specimens examined is sufficient 
to insure adequate control of the reagents and methods used. 
Blood serum shall be tested for complement-fixation by the method of 
Wassermann, or standard modifications of it, with not less than two antigens,, 
one of which shall be cholesterinized. All laboratories undertaking the per- 
formance of this test are required to file an accurate description of the- 
reagents and methods used with the laboratory of the Department at Albany- 
before an approval is issued. 
Direct Examination for Treponema Pallidum 
(The infectious agent of syphilis) 
Wash the suspected chancre with soap and water, rinse and dry. This should.' 
remove nearly all the contaminating organisms including the Spirochaeta 
refringens. Lightly curette the surface of the sore, wipe off the blood., then 
squeeze the surrounding tissues until a drop of serum, containing as little 
blood as practicable, collects. Transfer this drop to a clean slide, cover at 
once with a cover glass. Examine immediately over a dark field for charac- 
teristic organisms. 
Enlarged glands may be examined by aspirating a drop of serum from them- 
with a hypodermic syringe. 
Report of examination shall be, Treponema pallidum found, or Treponema 
pallidum not found. 
Accurate reports of all examinations shall be kept on file for permanent, 
records. The records of the examinations shall be made with ink. Every 
specimen received for examination shall be given an identification number as it 
Records 21 
is opened. The stained microscopical preparations (slides) on which the re- 
ports are made, shall be kept on file for a period of at least six months. All of 
these microscopical preparations shall be filed regardless of whether the results 
of the examinations were positive or negative. Each microscopic preparation 
shall be labeled at least with the identification number of the specimen and 
the date received. This data shall be put on the slide with a diamond point 
pencil, on a gummed paper label, or each slide kept in an envelope with the 
required data written on the outside. (Wax pencils are not satisfactory for 
labeling the slides.) Not more than three smears shall be made on a slide 
one inch by three inches in size. The immersion oil shall be removed before 
the slides are filed. 
" Whenever an examination for diagnosis by a laboratory or by any person 
other than the physician in charge of the person from whom the specimen is 
taken, if any specimen discloses the existence of a case of infectious and con- 
tagious or communicable disease, the person in charge of such laboratory or 
the person making such examination shall immediately report the same, 
together with all the facts in connection therewith, to the health officer of 
the city, town or village where srtch laboratory is situated and also to the 
health officer of the city, town or village from which such specimen came and 
shall keep a permanent record of all the facts in connection with such exami- 
nation, including the identity of the person from whom the specimen is taken 
and the name of the physician, if any, sending such specimen." (Extract from 
Sec. 25, Art. Ill, Public Health Law.) 
(The form of information blank and report slip now in use by the Labora- 
tory of the State Department of Health in Albany may be copied and adapted 
to the needs of the different laboratories throughout the State.) 
These laboratory records shall be kept on file where they will be available 
for inspection. 
Reports of all laboratory work for all districts of the State outside of the 
City of New York carried on by the laboratory shall be filed each month at 
the Laboratory of the State Department of Health in Albany. All doubtful 
results shall be reported and the slides or specimens referred to the central 
laboratory of the State Department of Health in Albany for confirmation. 
(For the purpose of determining standards of efficiency in the work, prepa- 
rations which have been studied or diagnosed by the staff of the central labora- 
tory in Albany will be sent to the different laboratories of the State for 
examination.) 
I hereby agree to fulfill all of the above specified conditions required in the 
diagnosis of 
and to certify in writing on January first of each year, to the Commissioner 
of Health at his request, that these conditions have been fulfilled in all the 
diagnostic examinations conducted in the laboratory of which I have charge. 
It is understood that in the event that the undersigned severs his or her 
connection with the laboratory, or is about to sever such connection, the 
Commissioner of Health will be immediately notified. 
(Signed) 
Date. 22 
Agreement on conditions and methods for the determination of the bacterial 
count of milk 
Specimens of milk must be forwarded to the laboratory packed in cracked 
ice and in no instance shall they be examined if the ice has completely melted.. 
Samples of milk received in proper condition should be examined immedi- 
ately or be kept packed in ice until they are examined. The interval between 
milking and plating should never exceed forty hours. The times of milkings 
sampling and plating should be recorded. 
When the examination of milk or cream is to be made, the sample should 
always be carefully mixed by shaking the container twenty-five times. All 
precautions against contamination should be observed in opening the sample 
and to avoid contamination sterile apparatus should be used. Standard 
methods of dilution and plating in agar and counting the colonies must 
be used. 
Note.- The standards of technical procedure contained in the Provisional 
Report of the Laboratory Section of the American Public Health Association 
October 24, 1916, are recommended. 
The dilutions of the milk should be made by transferring 1 cubic centimeter 
into 99 cubic centimeters of sterile water. As many subdilutions in 99 cc. or 
9 cc. of sterile water as are necessary to secure the desired final dilutions 
may be made preliminary to plating the milk. A separate sterile pipette 
should be used for making each dilution and also, a fresh sterile pipette for 
plating from each dilution. 
Record the temperature of the milk sample after withdrawing the portion 
for plating or have a duplicate sample that can be used for taking the tem- 
perature at the time of plating. 
The media used should contain 1,000 cubic centimeters of water, 12 grams, 
of oven dried agar or 15 grams of market agar (undried), 3 grams of beef 
extract, and 5 grams of peptone. The reaction of the finished media should 
be between + 0.5 .and + 1.0 to phenolphthalein indicator. Do not adjust 
the reaction if it lies within these limits. 
Ten cubic centimeters of agar media should be used for each plate. The 
agar should be melted and kept in a water bath at a temperature of 43° C. 
before pouring into plates. Incubate the plates for 48 hours at 37° C. 
From the different dilutions plated choose for counting those plates that 
come nearest to containing between 30 and 300 colonies. The whole plate 
should be counted. 
The average of at least two plates should be taken for computing the number 
of bacteria in the milk. 
Use a standard ruled counting disc for counting plates that contain a large 
number of colonies. Always use a hand lens magnifying 3% X. The counts 
should be computed in terms of a cubic centimeter and so recorded. 
Records of all examinations on the results of which milk or cream is 
graded should be kept on file and accessible in the laboratory making the 
examination. 23 
I hereby agree to fulfill all of the above specified conditions required in the 
examination of milk, and to certify in writing, January first, each year to the 
Commissioner of Health, at his request, that these conditions have been 
fulfilled in all the milk examinations conducted in the laboratory of which 
I have charge. 
Date. 
(Signed) 
Agreement on conditions and methods for the bacteriological examination 
of water 
Samples of water to be forwarded to the laboratory in shipping cases that 
make proper provision for keeping the samples cold by the use of ice. 
The temperature of the samples to be not higher than 10° C. at the time of 
arrival at the laboratory, and to be kept cold until examined. 
The sample bottles to be shaken twenty-five times before removing portions 
for examination. 
To determine the presence of intestinal bacilli of the colon group, inoculate 
at least two fermentation tubes containing lactose broth with each volume of 
the water that is tested, ten cc. one cc. and one-tenth cc. volumes of potable 
water to be tested. When examining grossly polluted water, also test smaller 
volumes in order to determine the volume that will give a negative test. 
Absence of gas after 48 hours' incubation at 37° C. indicates the absence 
of the colon group. If gas is produced before or at the end of 48 hours incuba- 
tion make a sub-culture on an azolitmin lactose agar or an Endo plate. Acid 
colonies (with or without gas) on the azolitmin lactose agar plates or 
colonies on the Endo plates are transferred to agar slants and incubated 
37° C. and identified by the reactions obtained in sub-culture of lactose broth, 
milk, nitrate solution, Dunham's solution and gelatin. Non-spore forming 
bacilli which ferment lactose broth, coagulate milk, produce nitrites and indol 
after four day's incubation, and do not liquefy gelatin in fourteen days at 
20° C., are classified in the colon group. 
The complete confirmative tests for the isolation of the colon group of the 
1917 edition of the Standard Methods of Water Analysis of the American 
Public Health Association may be used as an alternate method. This method 
gives a broader definition to the colon group. Thus, if the members of the 
colon group are not found by this method, they would not be found if the 
water was tested by the first method. 
Qualitative Examination 
Quantitative Examination 
If the water is known to contain 250 or a smaller number of bacteria per 
cubic centimeter, plate one cubic centimeter. If the water contains a large 
number per cc. dilute the sample with sterile water; one cc. of the sample to 
nine cc. or one cc. to ninety-nine cc. respectively, or similar further dilutions 
if necessary. 
The plating media are standard beef extract gelatin and standard beef 
extract agar, the reaction to be between + 0.5 and + 1.0 P. H. 24 
The total count on gelatin plates to be made after forty-eight hours' incuba- 
tion at 20° C. 
Counts on agar at 37° C. to be made after twenty-four hours incubation. 
Except when water contains less than twenty-five bacteria per cubic centi- 
meter, those plates should be counted that contain between twenty-five and two 
hundred fifty colonies. 
The average of at least two plates should be taken for computing the number 
of bacteria per cubic centimeter in the water. 
Note.-All counts to be made over a standard ruled plate with a standard 
lens magnifying 3.5 times as recommended by the Standard Methods of Water 
Analysis of the American Public Health Association, 1917 edition. 
Records of all examinations made on samples of water shall be kept on file 
and accessible in the laboratory making the examination. 
I hereby agree to fulfill all of the above specified conditions required in the 
■examination of water and to certify in writing, January first, each year, to 
the Commissioner of Health, at his request, that these conditions have been 
fulfilled in all the examinations of water from public supplies in New York 
State made in the laboratory of which I have charge. 
Date. 
Agreement on conditions and methods for the sanitary chemical examination 
of water 
Express results in parts per million. 
Color to be determined by the platinum cobalt standard. The water to be 
filtered through a small Berkefeld before determining the true color. 
Turbidity to be determined by the U. S. Geological Survey silica standard 
by comparison with standards in bottles or nessler jars. A properly standard- 
ized turbidimeter may be used. For field work the U. S. G. S. turbidity rod 
may be used. 
Odor (cold). Determine in a partially filled bottle after shaking. 
Odor (hot). Heat the water to nearly boiling in a partly filled tall beaker 
or an Erlenmeyer flask covered with a watch glass. Allow to cool and deter- 
mine the odor. 
Total solids. Evaporate a measured quantity of water in a weighed plati- 
num dish. Heat the residue at 105° C. for one hour; cool in a desiccator and 
weigh. 
Loss on ignition. Ignite the dish plus the total solid residue to dull redness 
in a radiator, cool in a desiccator and weigh. Loss in weight is the loss on 
ignition. 
Mineral residue. Total solids minus loss on ignition gives the mineral 
residue. 
Nitrogen as free or saline ammonia. Add a small amount of ignited sodium 
carbonate to 500 cc. of the water in a distilling flask. Distill off 3 tubes of 
50 cc. each. Xesslerize. If third tube contains more than a small amount 25 
of ammonia distill off one or more 50 cc. portions. Compare the nesslerized 
tubes with ammonium chloride standards or permanent standards adjusted to 
standard ammonium chloride. 
Nitrogen as albuminoid ammonia (total). Cool the residue from the dis- 
tillation of the free ammonia, add alkaline potassium permanganate, connect 
with the condenser and distill 5 tubes of 50 cc. each. Nesslerize and compare 
with the standards. 
Nitrogen as albuminoid ammonia (dissolved). When necessary to also 
determine the dissolved albuminoid ammonia, filter the water through ammonia 
free filter paper and proceed as above. 
Nitrogen as nitrites. Treat colored and turbid waters with aluminum 
hydrate and filter before testing. Add 2 cc. of sulphanilic acid and 2 cc. of 
a-napthylamine acetate to 100 cc. of the watei- in a nessler jar. Compare with 
standard nitrite solution treated with the same reagents in similar jars. 
Nitrates. Treat colored or turbid water with aluminum hydrate and filter. 
Evaporate 50 cc. or smaller volumes, depending on the nitrate content, in a 
porcelain dish on a water bath to dryness. Moisten residue with 2 cc. of 
phenol disulphonic acid. Rub with a glass rod. Dilute with distilled water 
and make distinctly alkaline with potassium hydrate. Wash into a 100 cc. 
nessler jar and dilute to 100 cc. Compare with standard solutions of potas- 
sium nitrate treated as above. 
If the water contains more than 20 parts per million of chlorine nearly 
neutralize the alkalinity with N/50 normal sulfuric acid, treat with silver sul- 
phate free from nitrates to remove all but 0.1 mg. of chlorine. Heat to boiling. 
Treat with aluminum hydrate, filter, wash with a small amount of hot water. 
Evaporate to dryness, moisten with 2 cc. of phenol disulphonic acid and 
proceed as above. 
Organic nitrogen. Boil off the ammonia from 500 cc. of sample. To the 
residue add 5 cc. of nitrogen free, concentrated sulfuric acid. Mix by shaking. 
Boil until copious fumes of sulfuric acid are given off and the liquid is color- 
less. Add crystals of permanganate until a heavy green precipitate persists in 
the liquid. Cool, dilute with ammonia free water. Make alkaline with 10 
per cent ammonia free sodium hydrate or carbonate. Distill the ammonia and 
nesslerize. 
Oxygen consumed. Place 100 cc. or when necessary smaller volumes of the 
water sample diluted to 100 cc. with distilled water free from organic matter 
in a flask, add 10 cc. of dilute sulfuric acid (1 to 3) and 10 cc. of standard 
potassium permanganate. Submerge the flask in boiling water for 30 minutes. 
Remove from bath add 10 c.c. of standard ammonium oxalate. Then titrate the 
excess of ammonium oxalate with the permanganate solution. 
Dissolved oxygen. Dissolved oxygen is determined by the Winkler method 
modified as recommended by the Standard Methods of the American Public 
Health Association (1917). 
Chlorine as chlorides. Turbid and colored samples to be first clarified with 
aluminum hydrate. Samples of water containing small amounts of chlorine 
to be concentrated by evaporation. Evaporate 250 cc. to a volume of 50 cc. 
in a 6 inch evaporating dish. Add 1 cc. of potassium chromate indicator and 
titrate with standard silver nitrate. Each cc.-.0005 grams of chlorine. 26 
Total hardness. Determine by the soap method. Standardize alcoholic soap 
solution against calcium chloride made from calc spar treated with hydro- 
chloric acid and evaporated several times to remove excess acid. 
Alkalinity. Titrate with N/50 sulfuric acid. If lacmoid is used, heat to 
boiling before completing the titration to remove CO2. Erythrosine may also 
be used in the cold. Methol orange may be used for waters that have not been 
treated with iron sulfate or aluminum sulfate. 
The 1917 edition of the Standard Methods of Water Analysis of the Ameri- 
can Public Health Association is recommended for details of technical 
procedure. 
Records of all examinations made on samples of water shall be kept on file 
and accessible in the laboratory making the examination. 
I hereby agree to fulfill all of the above specified conditions required in the 
examination of water and to certify in writing, January first, each year, to 
the Commissioner of Health, at his request, that these conditions have been 
fulfilled in all the examinations of water from public supplies in New York 
State made in the laboratory of which I have charge. 
Date. 27 
Location 
Laboratory 
Classification 
Director or person in charge 
Approved for following examinations 
Albany 
Bender Hygienic Laboratory.. 
Private, doing 
municipal work. 
Dr. Ellis Kellert, director 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test and the direct 
examination for Treponema pallidum), laboratory ex- 
amination of milk and water. 
Albany 
Albany Hospital Laboratory. . 
Hospital........ 
Dr. G. S. Graham, director 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, syphilis (complement fixaton test 
and the direct examination for Treponema pallidum), 
bacteriological examination of milk and water. 
Amsterdam 
Julius Wasserman Laboratory. 
County 
Dr. R. Halbach, director 
Miss L. Rider, bacteriologist. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal meningitis, 
direct examination for Treponema pallidum, pneumo- 
coccus type differentiation, bacteriological examination 
of milk and water. 
Amsterdam 
Private Laboratory of Dr. Lew 
H. Finch. 
Private 
Dr. Lew H. Finch, director 
Miss Dorothy Pease, bacteri- 
ologist. 
Diphtheria, tuberculosis, typhoid and paratyhpoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, bacteriological examination of milk and water. 
Auburn 
Cayuga County Laboratory. . . 
County 
Miss R. Stephens, bacteriologist. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test), pneumo- 
coccus type differentiation, bacteriological examination 
of milk and water. 
Auburn 
Laboratories of Chemical and 
Microscopical Diagnosis. 
Private 
Dr. H. Davenport, director 
Diphtheria, tuberculosis, typhoid fever (agglutination 
test), gonorrhea, epidemic cerebrospinal meningitis, 
direct examination for Treponema pallidum, bacterio- 
logical examination of milk and water. 
Batavia 
Genesee County Laboratory. . 
County 
Dr. F. D. Carr, director 
Diphtheria, tuberculosis, typhoid fever (agglutination 
test), gonorrhea, epidemic cerebrospinal meningitis, 
bacteriological examination of milk and water. 
Belmont 
Allegany County Hygienic 
Laboratory. 
County 
Miss G. L. Meade, bacteriologist 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentry, gonorrhea, epidemic cerebrospinal meningitis, 
bacteriological examination of milk. 
Binghamton 
Nelson & Lauder Laboratory.. 
Private, doing 
municipal 
work. 
Nelson & Lauder, directors 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, direct examination for Treponema pallidum, bac- 
teriological examination of milk and water. 
Binghamton 
Binghamton State Hospital 
Laboratory 
Hospital 
Dr. H. S. Gregory, director 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test). 
Binghamton 
Kilmer Pathological Lab- 
oratory. 
Private 
Dr. George H. Fox, director 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test), pneumococcus 
type differentiation, laboratory examination of milk 
and water. 
Public Health Laboratories Approved by the State Commissioner of Health to December 1, 1920* 
* This list is necessarily constantly undergoing revision. Important changes in and additions to this list are published from time to time in the Health News 
or Bulletins of the Department. 28 
Location 
Laboratory 
Classification 
Director or person in charge 
Approved for following examinations 
Buffalo 
Bureau of Laboratories, Health 
Department. 
Municipal and 
County. 
Dr. T. B. Carpenter, director. . . 
Diphtheria, tuberculosis, typhoid and paratyhpoid fever 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test and the direct 
examination for Treponema pallidum), pneumococcus 
type differentiation, laboratory examination of milk 
Buffalo 
Laboratory of Clinical Path 
ology. Buffalo General 
Hospital. 
Ontario County Laboratory.. . 
Clayton Laboratory 
Laboratory of the Clifton 
Springs Sanatorium. 
Hospital 
Dr. B. F. Hauenstein, director. . 
Dr. Byron D. Bowen, acting 
clinical pathologist. 
Dr. Wm. A. Bing, director 
Dr. James H. Stebbins, director. 
Dr. Walter S. Thomas, director. . 
Mrs. Margaret Schneider, bac- 
teriologist. 
and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, syphilis (complement fixation 
test and the direct examination for Treponema pallidum) 
pneumoceocus type differentiation, laboratory examina- 
tion of milk and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, bacteriological examination of milk and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, direct examination for Treponema 
pallidum, laboratory examination of milk and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test), pneumococcus 
type differentiation, laboratory examination of milk 
♦Canandaigua. . . . 
County 
Clayton 
Private 
Hospital 
Clifton Springs. . . 
Corning 
Steuben County Hygienic Lab- 
oratory. 
von Wedel laboratories (also 
at New Rochelle and White 
Plains). 
Elmira City Laboratory, De- 
partment of Health. 
Geneva City Laboratory 
Livingston County Laboratory 
Warren County Bacteriological 
Laboratory. 
Dr. H. E. Elwood, director 
Dr. H. von Wedel, director. 
Dr. Anna M. Stuart, director. . . . 
Miss Mildred Ross, bacteriologist 
Dr. R. S. Breed, director 
Prof. G. A. Bailey, director 
Dr. Morris Maslon, director 
and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, direct examination for Treponema pallidum, 
pneumococcus type differentiation, bacteriological ex- 
amination of milk and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebro spinal meningitis, 
syphilis (complement fixation test), pneumococcus type 
differentiation, laboratory examination of milk and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, pneumococcus type differentiation, bacteriological 
examination of milk and water. 
Laboratory examination of milk and water. 
Diphtheria, tuberculosis, typhoid fever (agglutination 
test), gonorrhea, bacteriological examination of milk 
and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, pneumococcus type differentiation, laboratory 
examination of milk and water, 
Dobbs Ferry 
Elmira 
Private, doing 
municipal 
work. 
Geneva 
Municipal 
County 
County 
Geneseo 
Glens Falls 
Public Health Laboratories Approved by the State Commissioner of Health - (Continued) 29 
Gloversville 
Jamaica 
Jamestown 
Kingston 
Mamaroneck 
Middletown 
Newburgh 
City Laboratory 
Jamaica Laboratories 
City Department of Health 
Laboratory. 
City Laboratory 
Cappus Laboratories 
City Department of Health... 
Pathological Laboratory, St. 
Municipal 
Private 
Municipal 
Municipal, doing 
county work. 
Private, doing 
municipal 
work. 
Municipal 
Hospital, 
Dr. Woodward Shaw, director.. . 
Dr. Henry F. Parker, director.. . 
Dr. John J. Mahoney, director. . 
Miss Eleanor Easton, bacteriol- 
ogist. 
Dr. Harry Cappus, director 
Dr. H. J. Shelley, director 
Dr. Adaline M. Wescott, director 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, laboratory examination of milk and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test), pneumococcus 
type differentiation, laboratory examination of milk 
and water. 
Laboratory examination of milk. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, bacteriological examination of milk and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test and the direct 
examination for Treponema pallidum), laboratory ex- 
amination of milk and water. 
Diphtheria, tuberculosis, typhoid fever (agglutination 
test), gonorrhea. 
Diphtheria, tuberculosis, typhoid fever, gonorrhea, 
New Rochelle.... 
New York City... 
New York City... 
New York City... 
New York City... 
New York City... 
Luke's Hospital. 
von Wedel Laboratories (also 
Dobbs Ferry and White 
Plains). 
Laboratory of the Hospital for 
Ruptured and Crippled. 
St. Mark's Clinical and X-ray 
Laboratories. 
Horstman Laboratory (Ford- 
ham University, College of 
Pharmacy). 
Clinical Laboratory of Frederic 
E. Sondern. 
Sero Pathological Laboratory. 
Private, doing 
municipal 
work. 
Hospital 
Hospital 
Teaching Institu- 
tion. 
Private 
Private 
Dr. H. von Wedel, director 
Dr. Ferdinand M Jeffries, di- 
rector. 
Dr. Byron C. Darling, director.. 
Dr. Gustave Horstman, director. 
Dr. Frederic E. Sondern, director 
Dr. Albert M. Pasca, director... 
epidemic cerebrospinal meningitis, bacteriological ex- 
amination of milk and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test), laboratory 
examination of milk and water. 
Diphtheria, tuberculosis, typhoid fever, gonorrhea, syphilis 
(complement fixation test and the direct examination 
for Treponema pallidum), bacteriological examination 
of milk and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test), laboratory 
examination of milk and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, direct examination for Treponema pallidum, 
pneumococcus type differentiation, laboratory examina- 
tion of milk and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test and the direct 
examination for Treponema pallidum), laboratory ex- 
amination of milk and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test and the direct 
examination for Treponema pallidum), laboratory 
examination of milk and chemical examination of water. 
* Director resigned. Reapproval under consideration. 30 
Location 
Laboratory 
Classification 
Director or person in charge 
Approved for following examinations 
New York City... 
T. S. Winslow, Laboratory... . 
Private 
Dr. Thomas S. Winslow, director 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test and the direct 
examination for Treponema pallidum), pneumococcus 
type differentiation, bacteriological examination of 
milk and water. 
Niagara Falls 
City Department of Health. . . 
Municipal 
Dr. W. A. Scott, director 
Mrs. Leah Cleary, bacteriologist. 
Diphtheria, tuberculosis, typhoid fever (agglutination test), 
gonorrhea, epidemic cerebrospinal meningitis, syphilis 
(complement fixation test and the direct examination 
for Treponema pallidum), bacteriological examination 
of milk and water. 
Olean 
City of Olean Laboatory 
Municipal 
Dr. J. P. Garen, director 
Diphtheria, tuberculosis, gonorrhea, epidemic cerebro- 
spinal meningitis, and the laboratory examination of 
milk. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
gonorrhea, epidemic cerebrospinal meningitis laboratory 
examination of milk and water. 
Oneida 
Madison County Bacterio- 
logical Laboratory. 
County 
Dr. R. L. Crockett, director. . . . 
Peekskill 
Lent Clinical Laboratory 
Private 
Dr. Frank 8. Lent, director 
Diphtheria, tuberculosis, gonorrhea, bacteriological ex- 
amination of milk and water. 
Pomona 
Rockland County Tuberculosis 
Hospital Laboratory. 
County 
Dr. E. H. Restin, director 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, direct examination for Treponema pallidum, 
bacteriological examination of milk and water. 
* Poughkeepsie.... 
Laboratory of City Depart- 
ment of Health. 
Municipal 
Miss Evangeline Moore, bacteri- 
ologist. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, direct examination for Treponema pallidum, 
pneumococcus type differentiation, laboratory examina- 
tion of milk and water. 
Poughkeepsie 
Vassar Brothers Hospital Lab- 
oratory. 
Hospital 
Dr. A. L. Peckham, director. .. . 
Diphtheria, tuberculosis, typhoid fever (agglutination test) 
gonorrhea, epidemic cerebrospinal meningitis, laboratory 
examination of milk and bacteriological examination 
of water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test), pneumococcus 
type differentiation, bacteriological examination of 
milk and water. 
Poughkeepsie 
Laboratory of Hudson River 
State Hospital. 
Institution 
Dr. Howard P. Carpenter, di- 
rector. 
Poughkeepsie 
Laboratory of Dr. Sanderson.. 
Private 
Dr. Raymond Sanderson, director 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, direct examination for Treponema pallidum, 
pneumococcus type differentiation, laboratory examina- 
tion of milk and water. 
Rochester 
City Health Department Lab- 
oratory 
Municipal 
Dr. George W. Goler, director. . 
Prof. C. W. Dodge and Miss 
Isabel Griswold, bacteriologists 
Diphtheria, tuberculosis, typhoid fever (agglutination 
test), gonorrhea, epidemic cerebrospinal meningitis, 
direct examination for Treponema pallidum, pneumo- 
coccus type differentiation, laboratory examination of 
milk and water, 
Public Health Laboratories Approved by the State Commissioner of Health - (Continued) 31 
Rochester 
Hahnemann Hospital Diag- 
Hospital 
Dr. R. Mellen, director 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test and the direct 
examination for Treponema pallidum), bacteriological 
examination of milk and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test and the direct 
examination for Treponema pallidum), laboratory 
examination of milk and water. 
Diphtheria, tuberculosis, typhoid fever (agglutination 
test), gonorrhea, epidemic cerebrospinal meningitis, 
syphilis (complement fixation test), bacteriological 
examination of milk and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test and the direct 
examination for Treponema pallidum). 
Diphtheria, bacteriological examination of milk and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, direct examination for Treponema pallidum. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever 
gonorrhea, epidemic cerebrospinal meningitis, syphilis 
(complement fixation test and the direct examination 
for Treponema pallidum), pneumococcus type differen- 
tiation, laboratory examination of milk, bacteriological 
examination of water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test), pneumococcus 
type differentiation, laboratory examination of milk 
and water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic ceiebrospinal menin- 
gitis, syphilis (complement fixation test and the direct 
examination for Treponema pallidum), pneumococcus 
type differentiation, laboratory examination of milk 
and water. 
Diphtheria, tuberculosis, typhoid fever (agglutination 
test), gonorrhea, epidemic cerebrospinal meningitis, 
syphilis (complement fixation test and the direct ex- 
amination for Treponema pallidum), pneumococcus type 
differentiation, bacteriological examination of water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test), chemical 
examination of water. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, direct examination for Treponema pallidum, bac- 
teriological examination of milk and water. 
Rochester 
nostic and Research Lab- 
oratory. 
Pathological Laboratory of 
Hospital 
Dr. Herbert R. Brown, director. 
Rochester 
Rochester Homeopathic Hos- 
pital. 
Private Laboratory of Dr. 
Boswell. 
Medical Laboratory of Dr. G. 
W. O'Grady. 
Rome City Laboratory 
Private 
Dr. Charles 0. Boswell 
Rochester........ 
Private 
Dr. George W. O'Grady, director 
Dr. W. Woglom, bacteriologist. . 
Municipal 
Saranac Lake.... 
Schenectady 
Sonyea 
Saranac Laboratory for the 
Study of Tuberculosis. 
Pathological Laboratory of the 
City and County. 
Craig Colony Laboratory. . . . 
Private, doing 
municipal 
work. 
Municipal and 
County. 
Institution 
Dr. Edward R. Baldwin, director 
Dr. Warren B. Stone, director.. . 
Dr. William T. Shanaha , M: d- 
Syracuse 
City Department of Health. . . 
City Laboratory 
Municipal 
cal Superintendent. 
Dr. Harold A. Patterson, Patho- 
logist. 
Dr. A. G. Gigger, director 
Municipal 
Dr. Harry W. Carey, director.. . 
Dr. S. A. Petr off, director.... 
Tuxedo Park 
Institution 
Trudeau 
and Clinical Laboratory. 
Tuxedo Laboratory 
Hospital, doing 
municipal 
work. 
Dr. Edward C. Rushrnorc, di- 
rector. 
* Director resigned. Reapprova lunder consideration. 32 
Location 
Laboratory 
Classification 
Director or person in charge 
Approved for following examinations 
Utiea 
City Laboratory 
Municipal 
Miss Margaret Upton, bacteri- 
ologist. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test), pneumo- 
coccus type differentiation, bacteriological examina- 
tion of milk and water. 
Utica 
Clarke Memorial Laboratory.. 
Hospital 
Dr. Philip L. Turner, director... 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, direct examination for Treponema pallidum, 
laboratory examination of milk and water. 
Watertown 
Calkin & Farmer Laboratory. 
Private 
Charles M. Rice, pathologist,. . . 
Miss M. P. Anthony, bact ri- 
ologist. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
< gitis, syphilis (complement fixation test and the direct 
examination for Treponema pallidum), pneumococcus 
type differentiation, laboratory examination of milk 
and water. 
Watertown 
Isabel M. Meader, Laboratory 
Private 
Dr. Isabel M. Meader, director.. 
Diphtheria, tuberculosis, typhoid fever (agglutination 
test) gonorrhea, epidemic cerebrospinal meningitis, 
direct examination for Treponema pallidum. 
White Plains 
von Wedel Laboratories (also 
at Dobbs Ferry and New 
Rochelle). 
Private, doing 
municipal 
work. 
Dr. H. von Wedel, director 
Diphtheria, tuberculosis, typhoid and paratyphoid fever 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test), laboratory 
examination of milk and water. 
White Plains 
Bloomingdale Hospital Lab- 
oratory. 
Hospital 
Dr. Karl M. Bowman, director.. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, syphilis (complement fixation test), laboratory 
examination of milk and water. 
Y onkers 
Laboratory of the Department 
of Health. 
Municipal 
Dr. C. W. Buckmaster, health 
officer. 
Mr. T. A. Walsh, bacteriologist. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, direct examination for Treponema pallidum, 
laboratory examination of milk and bacteriological 
examination of water. 
Y onkers 
St. Joseph's Hospital, Clinical 
Laboratory. 
Hospital 
Dr. Gustave Horstman, director. 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, pneumococcus type differentiation, bacteriological 
examination of milk and w'ater. 
Yonkers 
Sloan Laboratory 
Private 
Clark A. Sloan, bacteriologist. . . 
Diphtheria, tuberculosis, typhoid and paratyphoid fever, 
dysentery, gonorrhea, epidemic cerebrospinal menin- 
gitis, laboratory examination of milk and water. 
Public Health Laboratories Approved by the State Commissioner of Health-(Concluded') 
♦Bacteriologist resigns. PART II 
THE LABORATORY SERVICE OF NEW YORK STATE IN 
THE DIAGNOSIS, PREVENTION AND CURE OF DISEASE 
This section of the Manual describes very briefly what the 
laboratories of the State can do for physicians, health officials and 
citizens of the State in the diagnosis, prevention and cure of 
disease. This work, at present, is largely limited to the infectious 
diseases but there is no good reason why it should be so limited. 
The central laboratory at Albany aims to do any work the 
practical value of which is apparent. A brief statement of the 
scope and significance of laboratory service in the different 
diseases follows in alphabetical order. 
The essential clinical facts upon which is based the physician's 
diagnosis or request for a laboratory examination are of the 
utmost importance if the laboratory work is to be done intelli- 
gently and quickly. Often the character and extent of the 
examination and the necessity of confirmatory examination or 
repetition of the test are determined by these facts. Furthermore, 
much time is consumed in getting these facts if they are not sent 
with the specimens. If three or four minutes are required to 
write this essential information on the blanks, much more time 
is saved in the laboratory. For example, even in an examination 
seemingly so simple as that of sputum for the tubercle bacillus, 
the laboratory diagnostician might be required to devote a few 
minutes or an hour to his search or he might consired it necessary 
to get another specimen or inoculate a guinea pig. Once 
physicians appreciate the practical importance of giving the 
necessary clinical facts, the laboratories will not have any diffi- 
culty in securing their cooperation. 
Physicians should take special care to write their names and 
addresses legibly. 
All information concerning a specimen should be sent with the 
specimen and not by letter. 
Informatioa 
with 
specimens 
essential 
Cancer 
Upon the recognition of the malignant nature of tumors and 
new growths depends the possibility of eradicating diseases of 
this nature. Excepting small and superficial epitheliomata of the 
skin, which may be successfully treated by Roentgen rays or 
Prevention 
33 34 
thermocautery, if skilfully applied, there is no procedure by 
which cancer can be cured except that of complete removal. Com- 
plete removal can only be accomplished in the early stages of the 
disease. After a tumor has become malignant and spread beyond 
the reach of the knife there is not the slightest hope of effecting 
a cure or saving the life of a patient. The early diagnosis of 
malignant tumors can be made only under the microscope, and 
specimens of all such material should be submitted for examina- 
tion as early as the disease is suspected. These examinations are 
made by the New York State Institute for the Study of Malignant 
Diseases, at Buffalo, where specimens may be sent, put up in 
outfits obtained from the laboratory in Buffalo, or by making use 
of the miscellaneous outfit containing a sputum jar distributed 
by the State Department of Health. Directions for putting up 
such specimens are printed in a circular accompanying the infor- 
mation blank. A limited number of specimens have been examined 
at the laboratory in Albany. 
Laboratory 
specimens 
Although the appearance of the inflammatory processes in the 
throat is often suggestive of diphtheria, a bacterial diagnosis of 
the disease is necessary and is made by the examination under the 
microscope of cultures taken from the exudate in the throat. For 
this purpose an outfit containing a tube of culture medium and a 
swab with which to transfer the exudate to the surface of the 
culture medium, and an information blank on which to record 
clinical data concerning the case, is furnished. 
The bacterial examination of the inflammatory processes of the 
throat is extremely important because diphtheria in recent years, 
since the effective use of diphtheria antitoxin, has become often 
a mild disease in which all the characteristic clinical signs are 
absent. Furthermore, the presence of diphtheria bacilli in the 
secretions of healthy persons is now known to be not uncommon. 
The cultural examination of healthy persons is, therefore, neces- 
sary whenever cases of diphtheria are found, and especially is it 
necessary to take cultures from the throats of all 'healthy persons 
who in any way have come in contact with cases of diphtheria, 
not necessarily immediately after the exposure, but more particu- 
larly after a brief interval when it would be possible for the 
Diphtheria 
General 
considera- 
tion 35 
diphtheria bacilli to develop and become established in the secre- 
tions, thus giving rise to the carrier state. 
Diagnosis 
In every case of illness which there is reason to suspect is 
diphtheria, cultures should be made and submitted immediately 
to a laboratory approved by the State Commissioner of Health 
(Sanitary Code, chap. II, regulation 10). 
It should be borne in mind that not infrequently in cases of 
true diphtheria, as shown by laboratory tests, membrane and other 
classical symptoms are absent. In such cases the clinical picture 
may suggest tonsilitis or ordinary sore throat, yet the organism 
present in the patient's nose or throat, if transferred to the nose or 
throat of a susceptible person, may give rise to typical diphtheria. 
In cases which are clinically diphtheria, it is advisable to give 
antitoxin immediately, without waiting for laboratory reports), 
since antitoxin becomes less effective with each day's delay in 
administration. 
At times it is possible to confirm a diagnosis of diphtheria by 
demonstrating the bacilli in a smear made at the time of taking 
material for culture. A negative finding upon such a specimen 
is not reliable, since the organisms are less numerous and usually 
less typical than in specimens prepared from cultures after 
incubation. 
A negative report upon a culture from a case which is clinically 
diphtheria should not invariably be regarded as requiring a change 
in diagnosis. The question of the use of antiseptics, the possi- 
bility of the organisms having been missed in swabbing, or of an 
uncontaminated side of the swab having been applied to the 
culture medium and the possibility of exposure to extreme heat 
in transit, should be taken into consideration. 
Vincent's angina may at times present a clinical picture resem- 
bling that of diphtheria, although sloughing ulcers are more apt 
to occur and the membrane is more likely to involve the pillars, 
soft palate and buccal mucous membrane. When Vincent's 
angina is suspected prepare a smear upon a slide (from miscel- 
laneous outfit) and submit at the time of sending culture, asking 
for examination for the organisms of Vincent's angina. Tn pre- 
paring the smear, either use the swab accompanying the culture 
«W»wwu 
Atypiwii 
cm*e 
J>& - sasCti 
'cWtay *s9&- 
t®KS» 
K«aiJtaa- 
aSosa <«£ 
str.'Wtrs 
IrrteSjpne- 
tuTTon ««f 
negattve 
rvpctt 
VinceaS*® 
Ar«gS»a 36 
outfit (after inoculating the culture medium), using sufficient 
force to carry the swab through the membrane to its base, or 
curette lightly with a small sharp curette. 
In sending cultures from cases of suspected laryngeal diphtheria 
it should be borne in mind that throat cultures may not contain 
the bacilli early in the disease, owing to the location of the 
membrane. Later the organisms may be present in the throat. 
The presence of a profuse blood-stained nasal discharge should 
always be regarded with suspicion, especially after exposure to 
diphtheritic infection, and nasal cultures should be submitted for 
examination. 
Cultures In 
laryngeal 
cases 
Nasal 
diphtheria 
Place the patient in a good light. Depress the tongue. 
Collect the material on the cotton swab from the exudate or 
membrane, avoiding the tongue and taking care not to touch any- 
thing except the throat of the patient or the surface of the exudate. 
Material for examination from apparently healthy persons should 
be taken from the tonsils. 
In taking material from the nasal passages, place the patient 
in a chair and, if possible, have an assistant stand behind the 
patient and hold the head steady. Pass cotton swab upward a 
half inch, then directly backward to pharynx. Withdraw the swab 
and pass it through the other nostril. All manipulations should 
be made gently in order to minimize discomfort to the patient 
and to avoid injury to the mucous membrane. 
Inoculate the culture medium by rubbing the entire surface 
lightly and thoroughly with the swab, rotating the swab to be sure 
that the sides of swab which bear the secretions come in contact 
with surface of medium. Do not break the surface of the medium 
or push the swab into it. Contaminated, liquefied or dried tubes 
should not be used. 
Return the swab to its tube, insert the plug, return both tubes 
and the information blank to the container. Send at once, by 
the most direct route, to the State Department of Health, Division 
of Laboratories and Research, New Scotland avenue, Albany, 
N. Y., or to the nearest laboratory approved by the Commissioner 
of Health. (See pages 27-32.) 
Directions for Making and Transmitting Cultures 
Cultures 
from the 
throat 
Cultures 
from the 
nose 
Inoculation 
o£ medium 37 
With each culture outfit is au information blank which the 
health officer or other physician making the culture is required to 
fill out and return to the laboratory with the inoculated culture. 
All of the information asked for is needed either to comply with 
the laws, as a guide to laboratory workers or for statistical pur- 
poses. If complete information is at hand when a culture is 
being examined, it will at times mean a saving of time both to 
the laboratory worker and the physician. 
Health officers and physicians should be familiar with the 
appearance of culture medium which is in proper condition for 
use. The Loeffler medium (diphtheria outfit) should present a 
smooth, grayish white, and slightly moist surface. Culture tubes 
should never be used when the medium shows evidence of con- 
tamination or liquefaction or has dried and separated from the 
sides of the tube. 
Information 
required 
with cul- 
tures 
Condition 
of medium 
Form Used for Submitting Information to Accompany Cul- 
ture for Diphtheria Bacilli 
(Front) 
Diphtheria 
Number of culture, 1, 2, 3, 4, 5, 6, 7, 8, 9, etc 
Examination of Culture 
Results of previous examinations. 
Purpose of culture: 
For diagnosis 
For release 
To determine carrier. 
Clinical diagnosis made and antitoxin administered. Culture to confirm 
diagnosis 
Culture from throat 
Date of taking culture 
or nose. 
Time 
Name of patient 
Address 
Age. 
Sex. 
Occupation 
Color 
Clinical diagnosis 
Location of membrane 
Duration of disease 
How contracted 
.Date of onset 
Other information concerning specimen. 38 
Torm Used for Submitting Information to Accompany Culture for 
Diphtheria Bacilli - Continued 
Name and address of physician 
Name and address of health officer 
whom was this specimen taken?. 
Physicians and health officers are requested to answer all questions on the 
blank up to this point. 
Laboratory number. 
Examined 
Received 
Result of examination. 
Examiner 
Efforts Upon Examinations of Cultures for Diphtheria 
Bacilli 
" IWSfrr.a,"' 
When, organisms presenting the morphological characteristics 
rof diphtheria bacilli are fou^d, a report by mail or telegraph is 
sent to the attending physician and the local health officer. If 
the culture is the first one and there is no evidence that antitoxin 
'has been given, these reports are always sent by telegram, charges 
collect, unless otherwise directed on the information blank accom- 
jpanying the specimen. 
Form Used for Reporting Presence of Diphtheria Bacilli 
'Laboratory number 
In the examination of the culture from throat. 
, 19 
'Name 
Address 
'Taken on 
For or by 
Dr. 
Diphtheria bacilli were found. 
(This report is based upon morphological examination alone.) 
If the person referred to above is a " carrier " with no history 
of illness or contact with a case of diphtheria a culture' may be 
submitted for virulence tests immediately. 
AUGUSTUS B. WADSWORTH , M. D. 
Director 
Dr. 
Health Officer 
nose 39 
Form Used in Reporting Negative Finding in Examination of Culture 
for Diphtheria Bacilli 
, 19 
Laboratory number 
In the examination of the culture from throat. 
nose. 
Name 
Address 
Taken on 
For or by 
Dr. 
Diagnosis 
No diphtheria bacilli were found. 
Release 
. Carrier 
In an extremely small number of cases of true diphtheria, the diphtheria 
bacilli may not be found in the first culture, whereas in later cultures they are 
found. In laryngeal diphtheria the pharynx may not have become involved 
but diphtheria bacilli may be found in a second culture. 
In all doubtful cases, confirmatory cultures should be forwarded at once. 
AUGUSTUS B. WADSWORTH, M. D. 
Director 
Dr. 
Health Officer 
It not infrequently happens that specimens submitted are in 
such condition that a satisfactory examination can not be made. 
The following form is one used for " unsatisfactory " reporta 
upon all laboratory specimens, but it is included here because 
such reports are so often necessary in connection with cultures 
for diphtheria bacilli. 
Realizing that a definite report is usually a matter of great 
importance to the health officer and attending physician, a culture 
is never reported as unsatisfactory until every reasonable effort 
has been made to examine it and determine the presence or 
absence of diphtheria bacilli. 
" UnMUatac- 
tory " 
Repo eta 40 
Form Used for Reporting Upon Specimens Unsatisfactory for 
Examination 
(Front) 
Laboratory number 
, 19 
In the examination of the specimen for diagnosis of. 
from patient: 
Name 
Address 
Taken on 
For or by 
Dr. 
Was unsatisfactory for the following reason: 
(See reverse side) 
Another specimen should be forwarded at once for confirmation. 
AUGUSTUS B. WADSWORTH, M. D. 
Director 
Dr. 
Health Officer 
A- Received in poor condition 
I Serum medium dried, liquefied or contaminated. 
II Tube broken. Not properly packed. 
Ill Blood hemolyzed. 
IV Specimen spoiled or too old, delayed in transit. 
V Insufficient material for test. Specimen leaked out in transit. 
VI Specimen probably frozen in transit. 
VII Culture contaminated. 
{Back} 
B - Not properly taken 
I Insufficient material sent. 
II Culture medium not thoroughly inoculated. Insufficient growth 
obtained. 
Ill Smear not properly made - too thick. 
IV Not completely dried. 
V Proper outfit for specimen was not used; specimen spoiled. 
C-Result of examination doubtful 
I Organisms atypical, or their presence of doubtful significance. 
II Reaction partial. 
Ill Nonspecific reaction obtained; specimen " anticomplementary." 
D - Examination not made 
I See explanatory letter. 
E - Examination unsatisfactory 
I See explanatory letter. 41 
Not only is the receipt of an "unsatisfactory" report annoying 
to the physician waiting anxiously for definite information, but 
the receipt of a culture which is not in satisfactory condition for 
examination invariably means additional work for the laboratory 
staff. With these facts in mind, physicians about to prepare 
cultures should accept only culture medium which is in good con- 
dition and should familiarize themselves with the technique, as 
described in the circulars accompanying culture outfits. (See 
page 36.) 
A frequent source of annoyance is the contamination of medium 
with organisms which upon inoculation overgrow the culture and 
make a satisfactory examination impossible. Frequently the 
offender is a mouth organism which produces a slimy growth upon 
the culture medium. In a number of instances in which such an 
organism has appeared repeatedly in cultures from the same 
patient, irrigation of the nose and throat three or four times daily 
for several days with warm physiological saline solution has over- 
come the difficulty and made it possible to secure a satisfactory 
culture. 
Contaminated 
medium 
Use of the Schick Test 
After a diagnosis of diphtheria has been made in any case, and 
the patient isolated, it becomes necessary to ascertain what other 
persons have been exposed through contact with the patient and 
to determine whether or not it is advisable for such persons to be 
immunized. Histories of previous attacks of diphtheria are at 
times vague and unreliable and it is well known that an attack 
of this disease does not invariably confer immunity against a 
subsequent attack. 
The 'Schick test offers a means of determining whether an indi- 
vidual is immune or susceptible to diphtheritic infection. It is 
especially useful in institutions and special groups of individuals 
who are under close observation and control. 
The following experience is cited as illustrating the kind of 
situation in which the Schick test is particularly useful: 
In 1917 sixteen cases of diphtheria occurred among members 
of a student army training corps of approximately five hundred 
men. While these men were living in private houses and board- 
ing houses in a large city, they were under military control. All 
A means of 
determining 
susceptibility 42 
of the men who did not have diphtheria were examined by the 
Schick test and bv taking throat cultures. Those found to 
be carrying diphtheria bacilli were isolated and all giving 
positive Schick reactions immunized with antitoxin. A few giving 
both positive Schick reactions and positive cultures were given 
therapeutic doses of antitoxin. Those with negative Schick reac- 
tions and positive cultures were regarded as carriers. 
The following is part of the text of a special circular issued by 
the Division of Laboratories and Research: 
The Schick Reaction 
In 1913 Schick described the mild local skin reaction invariably induced in 
guinea pigs by the intracutaneous injection of very small amounts of diphtheria 
toxin. He stated that the same reaction could be obtained in persons who were 
susceptible to diphtheria but that it did not occur in persons who were not 
susceptible to the disease. Since that time, the Schick test has been used 
quite extensively for the purpose of ascertaining the presence or absence of 
sufficient diphtheria antitoxin in the blood and tissues of individuals to give 
active immunity against infection. It has been found that very small quanti- 
ties of antitoxin in the blood - probably not more than 1/30 unit - will 
adequately protect and thus make unnecessary the conferring of passive 
immunity through injection of diphtheria antitoxin. By the use of the Schick 
test, therefore, the unnecessary administration of antitoxin with its attendant 
serum reaction can be avoided in a number of instances. Furthermore, it also 
avoids sensitizing those persons unnecessarily against future treatment with 
horse serum and antitoxin. In the studies of Dr. W. H. Park approximately 
15 per cent of infants under 4 months are shown to be susceptible to diph- 
theria; this immunity, however, rapidly disappears until between 1 and 2 years 
75 per cent of children are susceptible. Between the ages of 10 and 20 years 
25 per cent are susceptible and about 20 per cent over 20 years. 
It appears that children in the same family frequently give the same 
reaction: thus if a young child is immune, that is, gives a negative reaction, 
the older children will also be found to possess immunity to diphtheria. Simi- 
larly, when an older child is susceptible, that is, gives a positive reaction, the 
younger children are also found to 'be susceptible. 
The Schick test has been used extensively by certain workers for four or five 
years. The results, when the tests have been properly given, indicate that very 
few, if any, variations in the natural immunity occur; a person giving a nega- 
tive Schick reaction will apparently possess this immunity indefinitely. 
Occasional mild cases of tonsilar diphtheria have been reported after a nega- 
tive Schick reaction. The Schick test may be of practical value in the diag- 
nosis of diphtheria. 
The Schick test depends on the local reaction or redness caused by the intra- 
cutaneous injection of extremely small amounts of diphtheria toxin when 
antitoxin is not present in sufficient quantity to neutralize the toxin. While 43 
the technique of the Schick test is in itself not difficult, experience has show® 
that for satisfactory and uniform results it is essential that the procedure be 
carried out with great accuracy and exactly as given in the directions, and 
that for an accurate reading of the reactions considerable experience is 
required. Physicians shorild bear in mind that the concentrated toxin sup- 
plied with the outfits is an extremely powerful poison and unless properly 
diluted may, when injected, cause slight necrosis and prolonged discomfortr 
and an overdose - death. 
Directions for the Use of the Outfit 
The special outfit prepared by the laboratory consists of two glass tubes 
each containing a standardized capillary pipette, a bottle containing 1 ce. 
of undiluted toxin, a bottle of sterile physiological salt solution and a small 
sterile test tube. 
An extra pipette is included so that the outfit may again be used if the 
bottle is rinsed under sterile conditions and refilled with sterile salt solutions, 
or cold boiled water to the graduation mark on the bottle. Rinsing may be 
done with sterile salt solution, sterile water, or better, by boiling the bottle and' 
stopper in water, after which it should be immediately restoppered. 
Precautions.- Do not use the outfit without first reading carefully the 
directions which should be followed exactly. Always make sure that the num- 
ber of the pipette given on the bottle of salt solution and the number on the- 
capillary pipette correspond. Keep the outfit in an ice box- the toxiffi- 
deteriorates rapidly in the light and unless kept at a low temperature. Do not. 
use a pipette the tip of which has been nicked or broken, as any change in the- 
tip of the pipette will alter the size of the drop. Always make a control test* 
with heated toxin on children over five years old and on adults. 
Never use the diluted toxin when it is over twenty-four hours old. 
Dilution.- Under sterile precautions remove the capillary pipette from its- 
container and by slight suction, draw up from the bottle of undiluted toxism 
enough toxin to half fill the pipette. Put exactly one drop of the toxin int® . 
the bottle containing the diluent as follows: holding the pipette with the • 
thumb and second finger, vertically, press gently on the top of the pipette 
with the first finger until a drop begins to form. At once remove the finger* 
and allow the drop, which should be discarded, to fall unaided. Discard th®' 
first drop, repeat the procedure and allow the second or third to fall into the 
bottle which contains the exact quantity of sterile salt solution necessary to 
make the proper final dilution. Cork the bottle and mix the contents 
thoroughly. (When many tests are to be made, on request, additional bottles 
of diluent are supplied, so that several bottles may be prepared with the 
same pipette at one time). Each 0.1 cc. of the dilution contains 1/50 of a 
minimal fatal dose of toxin - 1/50 of that quantity of toxin which will kill & 
250 grm. guinea pig in about 4 days. The dilution is not reliable afteir 
twenty-four hours. 
Test Dose.- Use, preferably, a 1 cc. " Record " tuberculin syringe with a 
fine, platinum-iridium or steel needle (gauge 26, % in.). An ordinary hypo- 
dermic syringe, unless graduated in 0.1 cc. is not satisfactory. Inject exactly 
0.1 cc. of the toxin dilution intracutaneously on the flexor surface of the left 44 
forearm or arm after cleansing with soap and water and then with alcohol. 
The insertion of the needle should be such that its opening is visible through 
the skin. The injection of the toxin should form a wheal-like, whitish, raised 
area. 
Control.- Transfer 2 or 3 cc. of the diluted toxin to the small sterile test 
tube by means of a sterile pipette, allowing no toxin to touch the upper part 
of the tube. Plug and immerse in boiling water for three minutes. Inject 
similarly on right forearm using the same dose and dilution as for the test. 
Thoroughly rinse and boil the syringe between the test and control injections 
or use a second syringe for the control tests. 
Readings should be made at the end of 24, 48, 72 and 96 hours. When a 
control injection has been made, the areas on both forearms should be care- 
fully compared. It is desirable to block out a card in squares in which the 
intensity and extent of the reactions are roughly sketched each day for com- 
parison for four days. 
Positive Reactions.- Usually toward the end of the first day a gradual red- 
dening appears, which becomes distinct in 24-48 hours. The maximum reaction 
occurs on the third or fourth day - the slight infiltration and redness cover- 
ing a circumscribed area of 1-2% cm. in diameter. The redness persists for 
some time, then gradually fades. The characteristic brownish pigmentation or 
bronzing remains for several weeks. 
Pseudo Reaction, Combined Reactions.- In older children and especially in 
adults, hypersusceptibility to the protein contained in the inoculum may not 
infrequently cause confusion and a misleading interpretation of the reactions 
unless carefully controlled and read in the light of considerable experience. 
Hence, the importance of the control inoculation with material in which the 
toxin has been rendered inert and the advisability of assuming susceptibility 
to diphtheria or repeating the tests immediately, if any doubt exists in regard 
to the reaction. 
The pseudo reaction differs from the true toxin reaction in that it occurs 
more promptly -■ urticarial-like reddening appearing within a few hours - 
it reaches its height in 36-48 hours and it subsides within 3 or 4 days. It 
usually shows a darker central core with a broad outer border which gradually 
merges into the surrounding tissue, or there may be a more uniform reddening 
considerably larger in diameter than the true toxin reaction. 
When the pseudo and the true toxin reaction are combined, the central core 
is usually larger and noticeably darker in hue than in the control in which 
the thermolabile substance of the toxin has been destroyed. The pseudo 
reaction rapidly disappears leaving the characteristic scaling and later pig- 
mentation of the true reaction. 
Persons showing no reaction may be considered immune to diphtheria pro- 
vided the test has been properly carried out. This, however, does not prevent 
their becoming carriers of virulent diphtheria bacilli. It is safest to consider 
all persons developing a very faint Schick reaction susceptible to diphtheria. 
Interpretation of Reactions 45 
Immunity against diphtheria may be obtained by the injection 
of diphtheria antitoxin or it may be induced by the injection of 
toxin-antitoxin mixture. 
The so-called " passive " immunity due to the circulation in the 
blood of diphtheria antitoxin (after injection of doses of approx- 
imately 1,000 units) is temporary, usually lasting from two to 
three weeks, but its effect is almost immediate. If an exposed 
and immunized person is promptly removed from contact with 
the infective case or carrier, the passive immunity continues 
sufficiently long to cover the period of incubation and, as a rule, 
affords adequate protection. Immunization with diphtheria anti- 
toxin is the method of choice in the presence of outbreaks or where 
exposures have presumably taken place and immediate protection 
is desired. 
An active and much more lasting immunity may be induced by 
means of the injection of toxin-antitoxin mixture. The following 
is, in part, the text of a special circular on this subject: 
The practical value of neutral or balanced mixtures of toxin and antitoxin 
for active immunization against diphtheria was first demonstrated by Dr. Theo- 
bald Smith in 1907 and 1909. Practical application of this principle has since 
been made on large groups of individuals. Persons who - as shown by the 
Schick test - lack specific immunity to diphtheria, may thus be immunized 
against the disease if treated with very small amounts of a properly balanced, 
mixture of diphtheria toxin and antitoxin. The material is prepared by add- 
ing to a ripened and accurately standardized diphtheria toxin just enough 
carefully standardized antitoxin to incite in the guinea pig slight local 
reactions and more marked but delayed affections of the nerves, indicating 
that complete neutralization has not taken place. 
Active immunization with diphtheria toxin-antitoxin mixture has proved 
especially valuable in institutions for young children and in schools where 
diphtheria is frequently present and difficult to eradicate. As most children 
between three months and two years are susceptible to diphtheria, it may, 
under special conditions, even be desirable without previous use of the Schick 
test, to treat all children between those ages, the local reaction caused by the 
injections being practically negligible in such young children. Where persons 
may be constantly exposed to diphtheria-as nurses and others in hospitals 
- active immunization of those individuals whom the Schick reaction has 
shown to be susceptible, is also of particular value. 
Treatment with toxin-antitoxin mixture has been introduced too recently 
for it to be possible as yet to know how long the immunity will last. There 
seems to be little doubt, however, that an active immunity persists for at 
least three years and probably for a considerably longer period, if not 
permanently. 
Immunization 
Passive 
immunity 46 
While the immunity conferred by active immunization is thus much more 
lasting than that obtained by passive immunization with diphtheria antitoxin, 
St is also much slower in developing - taking from 2 to 12 weeks. Injections 
diphtheria antitoxin - which give protection for 2' or 3 weeks - must, 
therefore, always be used where exposure has occurred and immediate protec- 
tion is necessary. In many outbreaks of diphtheria in schools and institu- 
tions the passive immunity thus conferred will last long enough to tide over 
the emergency. 
Directions for the Use of Toxin-antitoxin Mixture 
The mixture is distributed on special order in bottles containing 5, 10, and 
20 cc. The date of preparation and of return is marked on each bottle. It 
as essential that the material be kept in the dark and in an icebox at an even 
Jew temperature. In outdated material and in material which has not been 
kept under proper conditions the required balance between the toxin and anti- 
toxin may be destroyed, and the efficacy of the mixture as an immunizing 
-.agent lost. 
The injection is made subcutaneously, usually on the left arm at the inser- 
ition of the deltoid. The site of injection should first be cleansed with soap 
.-and water, then with alcohol or tincture of iodine. Children under one year 
-should receive 0.5 cc. of the undiluted mixture; older children and adults 
1 cc. Three injections are given at seven-day intervals, the same dosage being 
aised each time. 
Moderate swelling and soreness may develop at the site of injection in older 
children and adults; in very young children reactions seldom occur. 
After three months, the degree of active immunity which has been acquired 
should be tested for by repeating the Schick test. Dr. W. H. Park has esti- 
mated that approximately 90 per cent of persons will be found to give a 
.'negative Schick reaction- that is, to have developed an active immunity 
-■sufficient to protect against the disease. A second series of three injections 
will be - with rare exceptions - sufficient to produce an active immunity in 
..the remaining persons. 
The use of antitoxin in the treatment of diphtheria has so 
reduced the number and the fatality of the cases and so attenuated 
the severity of the disease in recent years that death from diph- 
theria is invariably due to delayed or faulty treatment with 
.-antitoxin.* 
Treatment 
The following is quoted from the special circular on the use of 
'diphtheria antitoxin issued by the Division of Laboratories and 
Research: 
Early use of antitonin is essential. An ample initial dose is more effective 
than .repeated small doses and is often sufficient, but when the initial dose is 
Inadequate, or its effect has disappeared and the disease persists, the dose 
•should be repeated, possibly increased. Immediate curative action is secured 
* Fatal complications such as pneumonia occasionally develop in diphtheria, 
'feut death in these cases is not directly due to the diphtheria toxin. 47 
by intravenous inoculation which is three to four times as effective as sub- 
cutaneous inoculation, but only physicians experienced in intravenous serum 
administration should practice it. 
Initial Dosage in Diphtheria 
Child under 15 years: Mild to moderate, 3,000-6,000 units, subcutaneous 
or intramuscular; severe to malignant, 6,000-18,000 units, intramuscular or 
intravenous. 
Adult: Mild to moderate, 3,000-9,000 units, subcutaneous or intramuscular; 
severe to malignant, 12,000-24,000 units or more, intramuscular or intra- 
venous. 
Physicians should bear in mind that since toxin which has become united 
to the cell substance is untouched by antitoxin, an early and liberal single 
injection is always preferable to smaller divided doses; which only delay the 
effect of the antitoxin on the free toxin in the system. Where sufficient toxin 
has combined with the body tissues to cause death no amount of antitoxin 
will bring about recovery, hence the importance of early treatment. 
A d ministration 
The antitoxin should be given by hypodermic injections made deeply into 
any suitable muscle from which absorption takes place rapidly. Injections 
may also be made subcutaneously. The skin over the selected area should be 
thoroughly cleaned with soap and water, and then washed with alcohol, or 
some disinfecting solution such as tincture of iodine. 
The physician's syringe should be boiled for at least five minutes and the 
antitoxin drawn up carefully and immediately injected to avoid possibilities of 
contamination. 
In severe cases, as in the emergencies of laryngeal diphtheria, if the 
physician is fully qualified to give an intravenous injection, this is advised as 
a primary dose. In order to safeguard against anaphylaxis by desensitizing 
the patient, 0.2 cc. of the dose should be allowed to circulate a few moments 
before the remainder of the dose is given and this should be injected very 
slowly. Whenever subcutaneous or intramuscular injections have preceded 
the intravenous injection by an hour or two this will suffice to desensitize. 
Physicians are cautioned to be on the alert for any symptoms suggesting an 
anaphylactic reaction and especially if the patient at any time has been 
treated with horse serum or is subject to asthma. 
Report Required from Physicians Using State Diphtheria 
Antitoxin 
Patient 
(Front) 
Address 
.N. Y. 
Treated at 
(Insert "home" or name of institution) 
. . Date of Earliest Symptoms 
Age. 
Sex. 
Bacterial Diagnosis 
Clinical Diagnosis 
Membrane Present ? 
To be returned to health officer or Division of Laboratories and Research, New 
Scotland Ave., Albany. 
Nares ? 
Pharynx?. 
.Tonsils? 
Larynx? 
(OVER) 48 
Date and Hours 
of Injections 
Units 
Injected 
Antitoxin 
Number 
Effect Complications and „ 
Produced Serum Rashes Operations 
(Back) 
Termination of Case (Recovery or Death): 
Date of Termination: 
M. D. 
Address. 
Release of Cases and Carriers 
Cases 
Regulation 36, Chapter II, Sanitary Code, provides that the 
minimum period of isolation in cases of diphtheria (including 
membranous croup) shall be until two successive negative cultures 
have been obtained from the nose and throat at intervals of not 
less than twenty-four hours, the first of such cultures being taken 
not less than nine days from the day of the onset of the disease. 
Under the rules and regulations for control of diphtheria car- 
riers (regulation 7) earners may be released when two successive 
negative cultures, taken at intervals of not less than twenty-four 
hours, have been obtained, or (regulation 6) when a virulent test 
upon a culture from the carrier has shown the organisms not to be 
virulent for guinea pigs. 
According to laboratory records, approximately 95 per cent of 
cultures from recovered cases and contact carriers tested for viru- 
lence up to three months from the date of onset have shown 
virulence. 
In making cultures from large groups of individuals who have 
not been in contact with cases, as in schools or institutions, where 
there is no diphtheria, organisms may be found in about 1 or 2 
Carriers 
Virulence 
tests 
Noncontact 
carriers 49 
per cent of all persons which closely resemble diphtheria bacilli, 
but which are not virulent for guinea pigs. They can be dis- 
tinguished from true diphtheria bacilli only by means of virulence 
tests upon these animals. 
In view of these facts, the laboratory will make virulence tests 
upon cultures from recovered cases (convalescent carriers) and 
contact carriers, under ordinary circumstances, only after three 
months from the date of onset (in cases) or discovery (carriers). 
This rule is necessary owing to the amount of time consumed in 
making virulence tests and the scarcity of laboratory animals. 
In special instances virulence tests are made before the three 
months' period has elapsed. When the health officer finds it 
necessary to have a virulence test made of a carrier, he should 
send a culture with his request for the virulence test on the infor- 
mation blank stating clearly whether or not the carrier is in his 
opinion a contact or a noncontact carrier or a convalescent carrier, 
together with reasons for making the request as indicated on the 
blank for this purpose. 
From noncontact carriers cultures may be submitted for viru- 
lence tests immediately. 
Convalescent 
and contact 
carriers 
Noncontact 
carriers 
Information Required of Physicians Requesting Virulence 
Tests 
Name of patient 
Record of Source of Culture for Virulence Test 
Age. 
Did patient have a clinical case of diphtheria? 
Is patient a contact carrier? 
Date of onset. 
A noncontact carrier ? 
Location of membrane. 
Was antitoxin administered?. 
General condition of throat and nose 
Condition of tonsils. 
Have any cases of diphtheria or carriers been traced to contact with this 
patient? 
Number of throat cultures reported positive. 
Number of throat cultures reported negative. 
Result of Schick test if it has been performed. 
Signature of attending physician. 
Date. 
Dysentery, Bacillary 
Bacillary dysentery is a disease incited by the dysentery bacillus Or8anisna 
and which not infrequently occurs in endemic and epidemic form 50 
in New York State. There are several types of dysentery bacilli 
and different types have been recognized in different outbreaks. 
These organisms are closely related to each other but vary greatly 
as to toxicity. During and following outbreaks, carriers are 
often discovered. They are occasionally discovered in the course 
of routine examinations of fecal specimens. 
Active immunity may be induced through the administration of 
dysentery vaccine. For therapeutic purposes the Department 
prepares and distributes a polyvalent serum. 
The following is quoted from a circular issued by the Division 
of Laboratories and Research: 
The State Department of Health, through the Division of Laboratories and 
Research, distributes to health officers and physicians qualified to administer 
it, polyvalent antidysentery serum obtained from horses immunized against 
organisms of the dysentery group. 
Carriers 
Distribution 
of serum 
Collection 
of specimens 
Directions for the Collection of Specimens for Diagnosis 
The methods of diagnosing dysentery and typhoid fever are similar. The 
clinical signs of diarrhea with blood and mucus in the stools require for an 
accurate bacterial diagnosis confirmation by a laboratory test of the blood 
and a bacterial examination of the feces, such as are necessary in typhoid 
fever. The agglutination or Widal test, however, in dysentery is not so 
reliable or so definitely standardized as it is in typhoid fever. Hence, the 
importance of examination of the feces in all cases of suspected dysentery. 
The outfits for specimens from typhoid fever cases should be used, but on 
the typhoid fever information blanks it must be clearly stated that a diag- 
nosis of dysentery is requested. 
Also state whether serum is desired. 
In severe cases where the immediate use of serum is desirable, its thera- 
peutic use may be commenced without waiting for the laboratory diagnosis. 
Directions for the Use of Antidysentery Serum 
It is advisable to give the serum early in the course of the disease and to 
continue its use if the signs of toxemia persist. 
A preliminary subcutaneous injection of 0.5 cc. serum should invariably 
be given at least 30 minutes before the initial therapeutic dose of 20 cc. to 
avoid anaphylactic shock. Special caution should be observed when the 
patient gives a history of being subject to asthma or hay fever. The desensi- 
tizing dose should always be repeated in the same manner if an interval of 
six or more days should elapse between injections. The skin over the selected 
region should be thoroughly cleansed with soap and water, and then washed 
with alcohol, or some disinfecting solution, such as tincture of iodine. Inocu- 
lation should be made subcutaneously, except in the emergency of the most 
acute toxemia, when in fully qualified hands the inoculation may be made 
intravenously. The serum when used intravenously should always be diluted 
at least one-half with warm fresh sterile physiological salt solution and care 
Administra- 
tion of serum 51 
should be taken that the mixture is at body temperature when injected. The 
administration of the serum must be under absolutely sterile conditions. 
Subsequent injections of serum -■ whether subcutaneous or intravenous - 
may be made from 12 to 24 hours apart, depending on the severity of the 
disease. 
Dysentery Vaccine 
A polyvalent dysentery vaccine can also be obtained on special request.* 
Dosage: Two subcutaneous injections of 1 cc. each are usually given, one 
every seventh day. For children, one-half of the above dosage should be given. 
Serum neutralizes free poison in the tissues, protecting them from injury so 
long as it is present; this is passive immunization. Vaccine acts on the 
tissues, stimulating them to an active immunity. The dysentery vaccines, 
therefore, should only be used for preventive inoculation or for the treatment 
of certain selected obstinate subacute or chronic cases. 
Active 
ImmuuixatiM 
Such a large number of disease reactions simulate the onset of 
malaria that an examination of the blood to determine the pres- 
ence of the malarial parasite or protozoon may be necessary. It 
is only since the discovery of the malarial parasite that it has been 
possible to distinguish true cases of malaria from other conditions 
which physicians from time immemorial have been accustomed to 
consider malaria. It is important to make the examination dur- 
ing the period of the exacerbation of the disease and not rely upon 
the results of examinations of specimens during intervals. 
The specimens may be sent in the miscellaneous outfit which 
consists of a small box containing two slides. Upon these slides 
a thin film of the blood may be spread according to the following 
directions: 
Malaria 
Examination 
of blood 
specimens 
Preparation 
of specimens 
Cleanse lobe of ear and prick it with a sterile needle. 
Collect a fraction of a drop of blood on one end of a slide. 
Place the second slide at an angle to the first slide in the small drop of 
blood, spread the blood in a thin film on the slide by a continuous sweep of 
the second slide across the first. 
Let the blood dry in the air without heating it. 
Spread another film of blood on the second slide, using the end of the first 
as a spreader. 
Replace the slides when dry, specimen sides together, and mail them to the 
laboratory. 
The film of blood should be thin, evenly spread, and extend over only half 
the surface of the slide. If the drop is too large, clean the slide and collect 
another smaller drop. 
* Prepared only during summer months. 52 
Meningitis 
Meningitis may be incited by a number of organisms and may 
occur as a primary and independent condition, or as a complica- 
tion or sequela of some other disease or condition. Epidemic 
cerebrospinal meningitis, which is of greatest importance from the 
standpoint of public health administration, is a specific disease, 
incited by the meningococcus. 
When meningitis occurs as a primary condition and in acute 
form, it is often difficult or impossible to make a positive diag- 
nosis without a laboratory examination of spinal fluid. The with- 
drawal of spinal fluid will, in itself, give temporary relief in 
many cases; in epidemic meningitis success of treatment depends 
upon early administration of serum; therefore, lumbar puncture 
should not be neglected or delayed. 
The following, with reference to serum treatment of epidemic 
cerebrospinal meningitis and to distribution of serum, is adapted 
from a circular prepared by the Division of Laboratories and 
Research: 
Antimeningococcus serum is distributed by the laboratory at Albany to 
main depots for laboratory supplies, lists of which will be published from 
time to time. A small stock of the serum will be kept in these depots for 
sanitary supervisors, health officers and physicians who are prepared to 
administer it. 
While this serum is of practical value only in cases of meningococcus 
meningitis it may not be harmful when the disease is caused by other organ- 
isms. Thus, if the exudate is cloudy, indicating an infectious process, the 
serum should be given without delay. 
As soon as a positive bacteriological diagnosis has been received a telegram 
asking for a fresh supply of antimeningococcus serum should be sent to the 
laboratory, New Scotland Avenue, Albany. The stock supply in the main 
depots should be used for the first injections or until the fresh supply from 
the laboratory is received. 
Examination 
of spinal 
fluid 
Serum 
treatment 
Procedure 
Spinal 
puncture 
Lumbar Puncture 
The serum is given subdurally; the subcutaneous introduction of it is of no 
value. Lumbar puncture is performed under strictly aseptic precautions 
in the third or fourth lumbar space without general anesthesia which should 
never be used. A local anesthetic may be advisable. Place the patient on 
the side with the back arched so that the spines of the vertebrae are separated. 
Select the notch nearest the line connecting the crests of the ilia. Introduce 
the needle in the midline and push it forward and a little upward. The needle 
should be introduced carefully, a distance of from one-half to three inches, 
depending upon the muscular development and age of the patient. When the 53 
needle enters the canal the cerebrospinal fluid will flow out until the pressure 
is so reduced that only three or four drops fall in a minute. If the fluid is 
cloudy, the serum can be injected immediately without waiting for the bac- 
terial diagnosis. But, if later it is found on bacterial examination to be due 
to other organisms, the serum treatment should be discontinued. 
Serum Injection 
The serum is warmed to body temperature and injected very slowly under 
the least possible pressure. A syringe may be used but a funnel with the 
tube arranged to allow the serum to run in by gravity is much the better 
method. The barrel of an ordinary syringe may be used as a funnel. The 
rubber tubing should be one-eighth to one-fourth inch in diameter and long 
enough so that the funnel may be raised twelve to fifteen inches. In adults, 
twenty to forty cubic centimeters may be introduced; in children, three to 
twenty cubic centimeters. The amount of serum which is introduced should 
be determined by the quantity of cerebrospinal fluid withdrawn and by the 
age of the patient. The dose should be five, ten or more cubic centimeters less 
than the cerebrospinal fluid withdrawn. When the serum apparently runs 
in freely after a dry tap, it is wise to proceed slowly and also to watch the 
patient carefully for the slightest change in pulse and respiration. When 
thick exudates will not flow through the needle gentle suction with a syringe 
may be tried. Occasionally the injection of a little serum will start the flow 
of such exudates. In very severe cases it is best to inject the serum every 
twelve hours until there is improvement. In moderate and mild cases it 
should be repeated each day for the first four days. Further administration 
depends upon the patient's general condition and the bacterial examination 
of the fluid. In prolonged subacute or chronic cases the administration must 
be continued. 
Alarming reactions occur only exceptionally after the injection of the serum. 
The respiration may cease or the pulse may become very rapid. These reac- 
tions to the introduction of the serum are not necessarily serious, but are best 
treated by the withdrawal of some of the serum if the needle is still in place. 
If the needle has been withdrawn, or, if after some of the serum has been 
removed the symptoms do not ameliorate, artificial respiration should be 
resorted to for the respiratory condition, and adrenalin or other stimulants 
administered hypodermically for the heart. Hospitals, and those having avail- 
able blood pressure apparatus, will find it of service in administering the 
serum. 
The following references will be of interest to physicians undertaking the 
treatment of meningococcus meningitis; Sophian, A., Jour. Am. Med. Assn., 
1912, 58, 843-845; Flexner, S., Jour. Exper. Med., 1913, 17, 553-576; Flexner, 
S., Jour. Am. Med. Assn., 1917, 69, 639-644; 721-724; 817-821. 
Technique 
of adminis- 
tratioa 
Reactions 
Report Required from Physicians Using State Antimeningo- 
coccus Serum 
(Front) 
Name of Patient. 
Report on the Use of Antimeningococcus Serum 
Address 
Treated at 54 
Occupation 
Clinical Diagnosis 
Age. 
Sex. 
Color 
Bacteriological Diagnosis 
Date of Onset 
How Contracted 
Duration 
Recovery 
Death 
Symptoms 
Remarks: 
Return to Health Officer or to Division of Laboratories, New Scotland 
Avenue, Albany, N. Y. (over) 
Injections 
(1st, 2nd, 
3rd) 
Date and 
Hour 
Amount 
Method of 
Injection 
Serum No. 
RESULTS 
(Back) 
Complications and Serum Rashes. 
Remarks: 
Date 
. Signed. 
Address 
Differential 
<lag>oaii 
In cases of tuberculous meningitis it is as a rule possible to 
demonstrate the presence of tubercle bacilli in the spinal fluid. 
In an obscure case showing meningeal symptoms, in which there 
is a possibility of syphilitic infection, a complement fixation test 
upon blood and spinal fluid and a cytological examination of a 
specimen of spinal fluid, may give information of value. 55 
Miscellaneous Examinations 
Aside from the procedures referred to under other heads, the 
State laboratory endeavors, in so far as possible, to meet the 
demands of physicians for special examinations, when these are 
related to public health problems. The diagnostic service, except 
in special instances, is necessarily limited to' procedures commonly 
resorted to in public health laboratories. Information form and 
directions for securing specimens of blood and body discharges, 
and of body tissues for section cutting, follow: 
Form for Submitting Information Accompanying Miscel- 
laneous Specimens for Examination 
(Front) 
MISCELLANEOUS EXAMINATION 
See accompanying circular " Directions for collecting miscellaneous specimens." 
Number of specimens, 1, 2, 3, 4, 5, 6, 7, 8, 9, etc 
Results of previous examinations 
Purpose of examination. 
Material 
Time 
Date of collection 
Name of patient 
Age 
Address 
Occupation 
Sex 
Color 
Clinical diagnosis 
Lesion, location, extent. 
Duration of disease 
How contracted 
Symptoms 
Date 
T 
P 
R 
Treatment 
Other information concerning specimen. 
Name and address of physician 
Name and address of health officer 
whom was this specimen taken?. 
Physicians and health officers are requested to answer all questions on the 
blank up to this point and return it with the specimen. 
Laboratory number 
Examined, 
Received 
Result of examination. 
Examiner 56 
Directions for Collecting Miscellaneous Specimens 
Collection of sputum for differentiation of pneumococcus types 
Local laboratory centers for type differentiation have been 
established in certain localities throughout the State. It is 
expected that additional centers will be organized as the 
laboratory facilities are increased. 
Select outfit with pink label containing sterile sputum jar.* 
Sputum coughed up from the deeper air passages and not saliva 
should be sent. If possible there should be at least 5 cc. of the 
sputum. When sputum can not be obtained, as so frequently 
happens with children, use a miscellaneous outfit with sterile 
tube and swab to collect as much secretion as possible from the 
pharynx. This may be facilitated by inducing the patient to 
cough, and swabbing just as the secretion is forced forward. 
The examination blank should be filled out carefully. The 
time of onset, location and extent of lesion, morning and evening 
temperatures and pulse rate should be given. If specimen is sent 
by messenger state on the blank whether antipneumococcus serum 
is desired; if by mail a letter should be sent at the same time 
giving this information. The specimen should be sent to the 
laboratory without delay. Reports will be sent by telephone or 
by telegraph if the diagnosis is Type I. 
When the diagnosis of Type I has been made, homologous 
serum should be given as soon as possible. Prompt diagnosis 
and early administration of serum is essential. 
Collection of specimens for other bacterial examinations 
Select outfit with pink label containing sterile tube and swab. 
The tube and the swab have been carefully sterilized. Remove 
the swab taking care not to touch anything with it. Collect on 
the swab enough of the discharge or exudate to be examined so 
that it will not dry in transit. Replace the swab in the tube, tak- 
ing all precautions against contamination. 
Enclose the information blank and forward by mail to the 
laboratory. 
* Sputum outfit bearing yellow labels should never be used for these speci- 
mens (see page 63). 57 
Preparation of smears for microscopic examination 
Collect a fraction of a drop of blood or discharge to be ex- 
amined on one end of a slide. 
Place the second slide at an angle to the first slide in the small 
drop, spread it in a thin film on the slide by a continuous sweep 
of the second slide across the first. 
Let the film dry in the air without heating it. 
Spread another film on the second slide using the end of the 
first as a spreader. 
The film of exudate should be thin, evenly spread, and extend 
over only half the surface of the slide. If the drop is too large, 
clean the slide and collect another smaller drop. 
Replace the slides when dry, specimen sides together, and mail 
them to the laboratory with the information blank. 
Preparation of material for section cutting 
Select outfit with pink label containing sterile sputum jar. 
Place bits of tissue or organs in 70 per cent alcohol or in 10 
per cent formalin (strong formalin 1 part diluted with water 
9 parts) in the sputum jar and cork tightly. To allow the har- 
dening fluid to penetrate, cut the large specimens with a sharp 
knife. The cuts should be parallel, half an inch apart, and deep 
but not so deep as to sever the slices. Use a volume of alcohol 
or formalin at least four times the bulk of the specimen. 
Slice tumors as above directed. Send all the material together 
with any lymphatic glands, removed at the operation. When 
the tumor is too large to send, cut a slice extending from the 
center through the periphery. 
Forward, the information with the specimen. 
The diagnostic facilities of the laboratory are designed 
primarily to render prompt assistance to health officers and 
physicians in the diagnosis and control of communicable diseases, 
and to provide laboratory service for all persons in the State for 
whom such service is not otherwise available. 
Physicians are especially urged to make use of the facilities 
of approved county, municipal and private laboratories when- 
ever such facilities are available in their vicinity. 58 
Form Used for Reporting Upon Examination of Miscel- 
laneous Specimens 
Laboratory number 
, 19 
Name 
Address 
Taken on 
For or by 
Dr. 
The following report is submitted. 
AUGUSTUS B. WADSWORTH, M.D. 
Director 
In the examination of. 
.from 
Ophthalmia Neonatorum 
The immediate application of silver preparations to the eyes 
of newborn infants for the prevention of ophthalmia neonatorum 
is a practice so universally established as to require little dis- 
cussion. The procedure should be followed as a routine without 
regard to the question of the probability of gonorrheal infection 
in the parent. 
The Division of Laboratories and Research distributes 1 per 
cent silver nitrate solution to health officers in individual wax 
ampules and also in a 15 cc. combined dropper and container. 
The latter can be used repeatedly and, it is believed, will offer 
a most convenient method for the use of the solution. 
Type of 
containers 
The laboratory prepares a vaccine which may be used either 
for prevention or treatment of whooping cough. While its value 
has not yet been definitely established, many observers have 
reported satisfactory results following its use, both in treatment 
of cases and as a preventive measure. Few reactions of clinical 
significance have been reported and its continued use would seem 
to be warranted. Only fresh vaccine should be used and for this 
reason it is not kept in stock by local supply stations, but is sent 
directly from the laboratory upon request. It should be borne 
in mind that success is most likely to follow its use as a preventive 
in any instance when the necessary number of immunizing doses 
have been given prior to exposure to infection. 
Pertussis (Whooping Cough) 
Use of 
vaccine 59 
The vaccine is injected with sterile hypodermic syringe, not 
too deeply into the subcutaneous tissue. The site of inoculation 
should be cleaned with soap and water and disinfected with 
alcohol, or by the application of tincture of iodine. 
Prophylactic Use 
Three injections are usually given, one every third day. 
For children and adults: 1,000 million, 2,000 million and 
3,000 million bacilli. 
Therapeutic Use 
Depending upon the clinical symptoms, at least four or five 
injections are given, one every second or third day. 
For children under one year: 500 million, 1,000 million, 
1,500 million, 2,000 million bacilli. 
For children over one year and adults: 500 million, 1,000 
million, 2,000 million, 3,000 million, 4,000 million bacilli. 
Pertussis vaccine is put up in outfits containing three doses 
for the immunization of one person, and in bottles containing 
ten cubic centimeters. The bottle should always be carefully 
shaken to mate sure that when doses are divided the sediment 
is suspended in the solution. In each cubic centimeter are 2,000 
million dead bacilli. The doses therefore are as follows: 
Technique 
Dosage 
500 million cc- 
1,000 million % cc. 
1,500 million % cc. 
2,000 million 1 cc. 
3,000 million 1^ cc. 
4,000 million 2 cc. 
Pneumonia 
Pneumonia is an acute exudative inflammation of the lung. 
Bronchopneumonia is a patchy involvement of the lung tissue 
about the bronchi and bronchioles, and more frequently develops 
as a secondary infection following other diseases. Although 
there is no fundamental difference, lobar pneumonia more fre- 
quently is a primary infection with more diffuse and extensive 
involvement. It is practically always in man a pneumococcus 
infection. Bronchopneumonia may be incited by many different 
species of pathogenic bacteria but chiefly by the pneumococcus 
or streptococcus. When effective methods of serum and vaccine 
therapy are developed pneumonia will be classified as pneumococ- 
Inciting 
agent 60 
cus pneumonia, streptococcus pneumonia and so on, according to 
the incitant. 
The earliest studies of pneumococcus infection and immunity 
follow the work of Roux, Yersin and von Behring on diphtheria 
antitoxin. Attempts to obtain an effective serum or antitoxin 
were not successful until Neufeld distinguished differences in 
the types of pneumococci and 'Cole, Dochez and Avery, at the 
Rockefeller Hospital, made their careful studies of the different 
types and of the therapeutic value of serum in the treatment of 
pneumonic infection of the different types. In their researches 
(see Health News, February, 1916) they classified the pneu- 
mococci into four groups, designated as " Types I, II, III and 
IV." It was found that these differed from each other in their 
immunological reactions, Type I organisms being agglutinated 
only by serum of an individual immunized against Type I 
organisms, etc. 
In Type IV were included a number of pneumococci which 
could not be included in either I, II or III, which differed from 
each other in immunological reaction, but which had certain 
characteristics in common. It is the organisms of this group or 
type which are found commonly in the mouths of normal indi- 
viduals. In the following summary are presented certain cogent 
facts with reference to the various types and their relation to 
prevalence, treatment, and mortality of pneumonia: 
Type I 
Mortality about 25 per cent in untreated cases, 3 to 10 per cent 
in treated cases. Homologous serum available for treatment. 
Type II 
Mortality about 33 per cent. No serum. 
Type III (Pneumococcus mucosus) 
Found occasionally in normal mouths (10M2 per cent). 
Mortality 45 per cent to 50 per cent. No serum. 
Type IV 
Includes several subtypes. Present in 40 per cent to over 50 
per cent of normal mouths. Cases frequently atypical. Mortality 
about 16 per cent. No serum. 
In the past there has been much uncertainty regarding the com- 
municability of pneumonia. While a large number of people 
were known to be carriers of pneumococci, it was observed that, 
Types of 
pneumococci 
Type IV 
Relation of 
types to 
diseases 
Communica- 
bility of 
pneumonia 61 
in most instances, neither they nor those who came in contact 
with them, developed pneumonia. On the other hand, it was at 
times noted, for instance, that following admission of a case of 
pneumonia to a hospital ward, other cases promptly developed. 
In cities and in more crowded communities pneumococci dur- 
ing the winter months and by early spring are very generally dis- 
seminated; from 20 to over 50' per cent of healthy persons may 
harbor the organism and nearly every person at some time probably 
■does harbor it for varying periods of time. The virulence of the 
pneumococcus fluctuates markedly, more so possibly than any 
other known incitant of infection. It may quickly be greatly 
exalted or may deteriorate rapidly. Outside the body it not 
only deteriorates but dies in a comparatively short time. Dif- 
ferent strains vary in these respects. 
Nearly everyone doubtless possesses some degree of immunity 
to pneumococcus infections; but many in a community are often 
■depleted by illness or other conditions of life which increase their 
susceptibility. In the light of these facts it is evident that com- 
plex conditions affecting the dissemination of the pneumococcus, 
changes in its virulence and the susceptibility of its various hosts 
determine the development and spread of pneumonia. Thus, it 
is not difficult to understand why it is that pneumonia does not 
always spread in households or hospitals and why occasionally it 
does, and finally why in the army camps its development and 
spread became such a serious problem. 
Although in general something of prognostic value may be 
gleaned from the statistics of the mortality in the four types of 
pneumococcus pneumonia, the prognosis in pneumonia should 
only be determined by clinical observation at the bedside of each 
case from day to day. It is not safe to give a definitely favorable 
prognosis early in a case of seemingly mild infection; nor is it 
wise to give an unfavorable prognosis early in a case of severe 
infection,- the former may die and the latter recover. For this 
reason if the case is a Type I infection and is to be treated with 
serum, the serum should be given promptly. 
It has been found possible to produce a serum which has given 
excellent results in the treatment of Type I pneumonias, when 
given under proper conditions. Thus far no serum has been pro- 
duced for the other types which is of sufficient value to warrant 
Prognosis 
Production of 
serum 62 
distribution. In view of the number of pneumococcus strains 
included in Type IV, the production of a serum for the treatment 
of Type IV pneumonias is not practicable. In view of this fact, 
it is fortunate that the case mortality is relatively low (16 per 
cent). 
Type I serum is specific for Type I pneumonia, and is not only 
of no value in the treatment of cases incited by other types, but 
may actually do harm. It should never be administered until 
the type of organism has been determined. From what has 
already been said, it will be self-evident that the use of " poly- 
valent" serums, said to be produced through immunization of 
horses against all of the various types of pneumococci, is not to 
be commended. 
In well-conducted hospitals the mortality has been greatly 
reduced. At the Rockefeller Hospital the mortality has been 
reduced to less than 7 per cent in the treated Type I cases. At 
Camp Wheeler seventy-two cases were treated with the N. Y. 
State serum with only two deaths and these were due to com- 
plications. The mortality of all cases treated and untreated was 
approximately 20 per cent, but in those treated with this serum 
less than 3 per cent. Although a marked reduction in mortality 
has occurred following treatment with the homologous serum 
under the carefully controlled conditions described above, unfortu- 
nately the results of its general use in the State have been much 
less satisfactory. Investigation of a large number of fatal cases 
in which State serum has been used has revealed the fact that 
in a vast majority one or more of the following conditions have 
prevailed: 
1 Serum has been given late. 
2 It has been given in too small doses. 
3 Only single doses have been given. 
For obvious reasons it has been considered necessary to restrict 
the distribution of State antipneumococcus serum to those com- 
munities in which laboratory facilities for the type diagnosis are 
available and in which qualified physicians have been appointed, 
usually upon recommendation of the local health officer, to admin- 
ister the serum. 
Specific 
action 
Restrictions 
upon distribu- 
tion 63 
A number of local laboratories are prepared to carry on type 
diagnosis. Revised lists of such laboratories will be published 
from time to time. Health officers of many municipalities to 
which such laboratory service is accessible have been furnished 
with emergency supplies of Type I serum. Additional serum 
may be obtained by telegraphing or telephoning either to the State 
laboratory at Albany or the State branch laboratory, 338 East 
Twenty-sixth street, New York City. 
It is important, in collecting sputum for laboratory diagnosis, 
to obtain, if possible, that which has been coughed up from the 
deeper air passages. When sputum can not be obtained, as so 
frequently happens with children, a miscellaneous outfit with tube 
and swab may be used, as much secretion as possible being col- 
lected from the pharynx. 
Collect sputum specimens in sputum jar outfits with pink infor- 
mation blanks and labels.* This instruction should be followed 
without fail, since at the State laboratory, specimens for examina- 
tion for tubercle bacilli (yellow label) are sterilized before the 
packages are opened, a procedure which would render pneumonia 
specimens useless. 
Information blanks should invariably be completely filled out. 
In each case the blank should contain the time of onset, location 
and extent of lesions, morning and evening- temperature and 
pulse rate. The physician should state whether or not serum is 
desired. 
Specimens should be sent to the nearest laboratory approved for 
this purpose with the least possible delay. When an examination 
shows the presence of Type I pneumococci, serum should be 
administered as soon as possible. As with the administration of 
antitoxin in diphtheria, the value of antipneumococcus serum 
becomes less with each day's delay in administration. 
In the administration of large amounts of foreign serum 
intravenously, moderate reactions, characterized by chill and eleva- 
tion of temperature and pulse, are not very unusual. These are 
usually evanescent and yield promptly to the hypodermic injection 
of adrenalin (epinephrin) or atropin sulphate. Reactions are 
less likely to occur when serum is properly diluted with warm 
saline and injected slowly by gravity. Serum rashes are fre- 
quently seen. 
Laboratory- 
centers 
Sources of 
supply 
Collection of 
sputum for 
diagnosis 
Send neces- 
sary data 
Avoiding 
delay 
Serum re- 
actions 
* See page 56. 64 
In persons especially sensitive to horse serum, unless proper 
precautions are taken, serious anaphylactic reactions may occur. 
Information should always be obtained regarding asthmatic ten- 
dencies or susceptibility to hay fever and also regarding previous 
administration of diphtheria or other immune serum. It should 
always be borne in mind that when a previous dose of serum has 
been administered and six or more days have elapsed, the patient 
may have become sensitized to horse serum. 
Whenever there is a suspicion that a patient may be hyper- 
sensitive to horse serum, every precaution should be taken to pre- 
vent a reaction. A skin test may give information of value 
(see directions in circular accompanying serum), although nega- 
tive results are not always dependable. 
In questionable cases it is advisable to begin the administration 
of serum by giving approximately .025 cc., following this after 
an interval by 1 cc. also given subcutaneously; after another 
interval approximately 2 cc. may be given intravenously and the 
amount doubled at half hour intervals until it has reached 25 
cc., after which the remaining serum may be given. 
A preliminary subcutaneous injection of 0.5 cc. of serum should 
he given two to four hours before the large dose, unless the patient 
has been completely desensitized as described above. The 
desensitizing dose should also be repeated whenever an interval 
of six or more days elapses between injections, since, as a result 
of the previous injections, the patient may be in a condition of 
extreme susceptibility. 
The initial therapeutic dose in adults should usually be 100 
cubic centimeters. This should ordinarily be followed in twelve 
hours, unless distinctly favorable results contraindicate, by a 
second injection of the same amount. A third and fourth injec- 
tion at the same intervals may be required before the desired 
response occurs. 
The technique of intravenous administration of serum is similar 
to that used in the administration of arsphenamine, and the same 
preparation of the Held of operation is required to maintain sur- 
gical asepsis. Preferably an infusion of 200 cc. of sterile physio- 
logical saline solution at a temperature of 45° C. (Ill0 F.) 
should be prepared, the serum being added after the injection of 
the saline solution has been begun. The serum should be poured 
Hyper- 
sensitivity 
from previous 
adminis- 
tration 
Precautions to 
be observed 
Administra- 
tion of serum 
Preparation 65 
carefully from the bottle, or transferred with a pipette, to avoid 
carrying over the small amount of sediment which is often present. 
Injection should be made intravenously by gravity and should 
be begun very slowly, the physician watching carefully for evi- 
dences of anaphylactic reaction. The diluted serum should be 
maintained constantly at body temperature. 
As the continuance of production of antipneumococcus serum 
depends upon the results obtained from its use, it is a matter of 
great importance that the State laboratory receive detailed infor- 
mation regarding results in each instance. Physicians using 
State serum are asked to cooperate in each case by filling out and 
returning the questionnaire shown below. 
Injection 
Value of data 
Report Required from Physicians Using State Antipneumo- 
coccus Serum 
(Front) 
Record All Following Data Possible. 
Chart P. R. T. on Opposite Side 
Name of Patient 
Occupation 
Age 
Address 
Sex 
Color 
Clinical Diag.: Original 
Date of Onset 
Duration 
Present 
Recovery 
Death 
How Contracted 
SYMPTOMS: Fever, chill, sweating, loss of appetite, strength, weight, 
emaciation, headache, general malaise, pain 
Hoarseness, cough, sputum rusty, hemorrhage, dyspnoea; 
Nose bleed, rose spots, diarrhea, mucus, bloody stools, gurgling, palpable 
spleen, liver, bladder, tumor 
Skin eruptions loss of hair, glandular enlargement, 
nocturnal headache; 
Paralysis - motor, sensory, facial, trunk, extremities (upper, lower), ascend- 
ing, descending, spastic, flaccid, tonic, clonic, tremor, convulsions, delirium, 
vertigo, vomiting, reflexes , rigidity, trophic changes , 
deformities ; 
Sensorium - clear, confused, coma. 
PHYSICAL SIGNS: (location and extent of lesions) 
Complications 
Remarks: 66 
Mo. 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 
Day Disease 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 I I 1 1 1 1 I I | I I I I 
P 
1 R 1 
T 
|M| E|M| 
E|M| E|M|E |M|E 
|M|E 
|M|E |M|E |M|E|M|E 
|M|E |M| E|M| E|M| E|M| E|M| 
160 
1 60 1 
107 
Illi 
1 1 1 1 1 1 
1 1 
1 1 1 1 1 1 1 1 
1 1 1 1 1 1 1 1 1 1 1 1 
150 
1 55 | 
106 
Illi 
1 1 1 1 1 1 
1 1 
1 1 1 1 1 1 1 1 
1 1 1 1 1 1 1 1 1 1 I 1 
140 
1 50 | 
105 
Illi 
1 1 1 1 1 1 
1 1 
1 1 1 1 1 1 1 1 
1 1 1 1 1 1 1 1 1 1 1 1 
130 
1 45 | 
104 
Illi 
1 1 1 1 1 1 
1 1 
1 1 1 1 1 1 1 1 
1 1 1 1 1 1 1 1 1 1 1 1 
120 
1 40 | 
103 
Illi 
1 1 1 1 1 1 
1 1 
1 1 1 1 1 1 1 1 
1 1 1 1 1 1 1 1 1 1 1 1 
110 
1 35 | 
102 
Illi 
1 1 1 1 1 1 
1 1 
1 1 1 1 1 1 1 1 
1 1 1 1 1 1 1 1 1 1 1 1 
100 
1 30 | 
101 
Illi 
1 1 1 1 1 1 
1 1 
1 1 1 1 1 1 1 1 
1 1 1 1 1 1 1 1 1 1 1 1 
90 
1 25 | 
100 
Illi 
1 1 1 1 1 1 
1 1 
1 1 1 1 1 1 1 1 
1 1 1 1 1 1 1 1 1 1 1 1 
80 
1 20 | 
99 
Illi 
1 1 1 1 1 1 
1 1 
1 1 1 1 1 1 1 1 
1 1 1 1 1 1 1 1 1 1 1 1 
70 
1 15 I 
98 
Illi 
1 1 1 1 1 1 
1 1 
1 1 1 1 1 1 1 1 
1 1 1 1 1 1 1 1 । 1 1 1 
60 
1 io I 
97 
Illi 
1 1 1 1 1 1 
1 1 
1 1 1 1 1 1 1 1 
1 1 1 1 1 1 1 1 1 1 1 1 
50 
1 5 | 
96 
Illi 
1 1 1 1 1 1 
1 1 
1 1 1 1 1 1 1 1 
1 1 1 1 1 1 1 1 1 1 1 1 
40 
1 1 
95 
Illi 
1 1 1 1 1 1 
1 1 
1 1 1 1 1 1 1 1 
1 1 1 1 1 1 1 1 1 1 1 1 
Urine | | | | I I I I I I I I 1 I I I 1 1 I I I 1 I 1 I I I I I I | | 
Feees 1 I I I I I I 1 I I 1 1 1 1 1 I 1 1 1 1 1 1 1 1 1 1 1 1 I 1 I I 
(Back) 
TREATMENT 
Serum, Vaccine 
(date, amount, time) 
Results 
Date 
Signed 
Address 
Return to Laboratory, State Dept, of Health, New Scotland Ave., Albany. 
Note: For directions for collection of sputum specimens for pneumococcus 
type differentiation, see under " miscellaneous specimens," page 56. 
Rabies 
Rabies is an acute, rapidly fatal disease. The infectious agent 
in the saliva of dogs suffering from the disease is commonly con- 
veyed to man through the broken or abraded skin. The virus 
follows the nerve trunks from the seat of injury to the spinal cord, 
thence to the medulla and brain. The period of incubation in 
man varies from 14 days to a year, the average being 40 days. 
The diagnosis of rabies in animals is made through micro- 
scopical examination of the brain. When a dog is suspected of 
having the disease, the head should be carefully packed in ice 
with sawdust and sent by through express routes to the New York 
State Veterinary College, Department of Pathology and Bacteri- 
ology, Cornell University, Ithaca, N. Y. 
When a dog, suspected of having rabies, has bitten a person or 
other animal, the dog should be isolated and observed for ten days. 
Diagnosis 
Observation of 
suspected 
animals 67 
If at the end of that time it is still alive and well, it can usually 
be safely assumed that it is not suffering from rabies. 
The method of treatment which Pasteur first used is an active 
immunization by inoculation with repeated doses of an attenuated 
virus. When a person has been bitten by a dog found to be 
suffering from rabies, immunization should be begun at once. 
The Research Laboratory of the New York City Department of 
Health, Sixteenth Street and East River, prepares this material 
for distribution to physicians in the city of Greater New York 
and is authorized to distribute it to physicians outside the city 
at a nominal cost. 
Through an arrangement between the State and the New York 
City departments of health, health officers and other physicians 
having occasion to administer the Pasteur treatment to persons 
unable to pay for the material can secure it free of charge by 
applying, by telegram or otherwise, to Dr. W. C. Noble, Branch 
Laboratory, New York State Health Department, 338 East 
Twenty-sixth street, New York City. 
" Pasteur 
treatment " 
Preventive Treatment 
Cauterization of the ivound 
The bite of a rabid dog should be immediately and thoroughly 
cauterized by a physician with strong carbolic acid, or nitric acid, 
or the actual cautery (Paquelin). This destroys and removes 
from the wound much of the virus. The period of incubation 
is thus prolonged, affording far greater chances of success from 
the preventive inoculation. 
Technique 
Preventive inoculation 
From seventeen to twenty-one days are required for the treat- 
ment with rabies vacqine. After careful cleansing of the skin 
with soap and water and disinfection with alcohol or iodine, the 
injection may be given with a sterile syringe of the capacity of 
3 cc. or 60 minims. If iodine is used to disinfect the skin it 
must be removed with alcohol. The syringe should be carefully 
boiled and if disinfectants are used these must be removed with 
sterile water because any disinfectant in the material which is 
to be injected destroys its potency and immunizing action. The 
injections are distributed in the subcutaneous tissues of the abdo- 
men. Widely separated spots are selected for injections. 68 
Doses to be inoculated 
Kabies vaccine should be kept on ice from the moment it 
arrives. The quantities to be inoculated will be forwarded daily 
by mail, double portions being sent on Fridays and Saturdays or 
the day before holidays, hence the importance of examining pack- 
ages for the presence of more than one bottle. The dose to be 
inoculated is marked on the bottle each day. During the first 
three or four days it is larger, 4 to 6 cc., according to the age of 
the patient, and should be given in two separate injections, one 
immediately after the other. The subsequent 2 cc. doses should 
each be given in one injection. As it is desirable that the virus 
be drawn into the syringe directly from the bottle, a little more 
than the exact dose will be sent each time. 
If, owing to the irregularity in the mail service, the treatment 
for two days should arrive simultaneously, the bottles should be 
used in the order of the dates, the first one should be given at once 
and the second midway between that time and the expected arrival 
of the next treatment. The bottles are labeled with the date on 
which they are filled and the doses should be given in the order in 
which they are sent. If, for any reason, the contents of any par- 
ticular bottle are not given, notice of the fact should be sent at 
once by telegram, identifying the bottle by its date. A careful 
record should be kept of each dose; record the dose by its date 
and the date of its administration. 
Care of the patient during treatment 
The bowels should be kept freely open and tea, coffee and 
alcoholic beverages used but sparingly. Ordinarily patients are 
able to attend to their work. Tenderness and erythema at the 
site of inoculation may develop. If these signs are marked and 
require treatment, the application of cold or a wet dressing of 
acetate of aluminum solution will be found useful. Some malaise 
may be present. Notice of other unusual symptoms should be 
sent promptly, especially those of neuritis. Exposure to cold, 
especially cold bathing, should be avoided during the course of 
treatment. 
Caution 
Physicians are cautioned against accidentally inoculating them- 
selves with virus of later injections. Although the larger early 
Precautions 
to be observed 69 
doses contain the virus in a greatly attenuated form, owing to pro- 
longed drying, this is not true of the later smaller doses which 
contain much more virulent material and should be promptly dis- 
posed of and never used except as directed. The empty vials 
should be burned or otherwise disinfected. 
Physicians must without exception keep the laboratory informed 
of the course of treatment and send without delay the following 
data: 
1 Name and age of patient. 
2 Location, date, and severity of bite. 
3 Treatment of bite, nature and extent of cauterization. 
4 Any information bearing on the diagnosis of the animal 
inflicting bite. 
5 Report on the condition of patient two weeks after the end 
of treatment, by postal, which is inclosed with circular. 
The treatment by means of this preventive inoculation should 
not be undertaken by physicians or health officers who are not 
familiar with it. The sanitary supervisor should be consulted 
in any emergency, but if any questions arise during the treatment 
communicate with the Branch Laboratory, 338 East Twenty-sixth 
street, New York City; telephone number, 8924 Madison Square. 
Unless all the directions and precautions are followed exactly 
the distribution of the material for the treatment will be imme- 
diately discontinued. 
Data 
required 
Smallpox 
The inciting organism in smallpox is not definitely known. 
The virus is regarded by some observers as belonging to the 
group of Chlamydozoa, organisms of uncertain classification pro- 
vided with a capsule supposed to be formed from the tissues of 
the host. The virus is passed through a Berkefeld filter with 
difficulty and, according to certain observers, loses some of its 
activity as a result of such filtration. 
Vaccinia is an infection developing in susceptible persons after 
vaccination with a virus obtained from cowpox. Experimental 
study of the immunity induced by cowpox and smallpox has 
demonstrated the fact that these diseases are incited by closely 
related organisms if not by the same species. The organism is 
Inciting or- 
ganism 
unknown 
Production of 
vaccine virus 70 
apparently so attenuated in the cow that it can safely be used to 
vaccinate man. Calves are used for the production of vaccine 
virus on a commercial scale. An effort has been made in the 
State laboratory to adapt the method of Noguchi, in which rabbits 
are used, to the production of virus on a large scale. It has been 
found impossible to produce a vaccine the potency of which can 
be depended upon in all cases. 
Since satisfactory vaccine virus can be obtained commercially 
at comparatively small expense, the State laboratory does not dis- 
tribute this product. K very satisfactory virus can be obtained 
from the New York City Department of Health, or from reliable 
commercial houses. 
In using any vaccine virus the physician should keep in mind 
the fact that its activity may be materially affected if it is stored 
or shipped under unfavorable conditions. Most of the unsuc- 
cessful vaccinations would undoubtedly be avoided if no vaccine 
were used other than that which had been kept constantly at 
ice-box temperature from the time of its preparation to the time 
of its use. In any instance, vaccine which has been kept for days 
and perhaps weeks upon a shelf at room temperature should 
never be accepted. 
Not dis- 
tributed by 
State labora- 
tory. 
Deteriora- 
tion 
Syphilis, Gonorrhea and Chancroid 
Laboratory 
tests essential 
Laboratory aids are essential in the diagnosis and treatment of 
syphilis, gonorrhea and chancroid. In cases of chancroid, a com- 
plicating syphilitic infection can not be excluded without labora- 
tory examination. The diagnosis of gonorrhea should always be 
confirmed by microscopic examination of the discharge. The 
cure of both syphilis and gonorrhea can only be ascertained by 
repeated examinations of the blood and discharges. 
Legal Requirements 
The requirements of the Public Health Law and Sanitary 
Code, with reference to the securing and submission for examina- 
tion of laboratory specimens, may be summarized as follows: 
Suspected persons 
When there is reasonable ground to suspect that any person 
within the jurisdiction of a board of health or health officer has 71 
an infectious venereal disease and is likely to be a source of 
infection to others, the board of health or health officer shall cause 
an examination to be made and the suspected person shall permit 
such specimens of blood or bodily discharge to be taken for labora- 
tory examination as may be necessary to establish the presence or 
absence of the disease or infection (with certain restrictions). 
Public Health Law, article 17-b, section 343-m. 
Convicted persons 
Every person convicted of vagrancy under certain laws (see 
"Laws and Regulations relating to Syphilis, Gonorrhea and 
Chancroid," issued by Department), or convicted of frequenting 
disorderly houses or houses of prostitution, shall be reported by 
the magistrate to the board of health or health officer of the dis- 
trict in which the offense occurs and shall not be released from 
the jurisdiction of the court until the convicted person has been 
examined as provided for in the preceding section (343-m). 
Public Health Law, article 17-b. 
Reports and information confidential 
All reports or information secured by a board of health or 
health officer under this article shall be absolutely confidential, 
except in so far as is necessary to carry out the purposes of the 
article. Public Health Law, article 17-b, section 343-r. 
Violations 
Any person violating any of the provisions of this article 
* * * shall be .guilty of a misdemeanor. Public Health Law, 
article 17-b, section 343-s. 
Results of laboratory examinations to be reported under certain 
conditions 
Whenever a laboratory examination by a laboratory or person 
other than the attending physician discloses the existence of a 
case of communicable disease, the laboratory or person making 
the examination shall report to the health officers of the munici- 
palities in which the laboratory is located and from which the 
specimen came. Public Health Law, article 3, section 25. 72 
Submitting specimens 
It shall be the duty of every physician attending a case of 
syphilis, gonorrhea or chancroid to submit to an approved labora- 
tory such specimens and data as may be prescribed in the special 
rules and regulations issued by the commissioner of health. (Sec 
page 73.) Sanitary Code, chapter 2, regulation 2-a. 
Records not to be disclosed 
Records relating to cases of syphilis, gonorrhea and chancroid 
shall not be made public so as to disclose the identity of the 
persons to whom they relate, except in so far as necessary for the 
enforcement of laws and regulations. Sanitary Code, chapter 2, 
regulation 29-b. 
Reporting persons violating laws and regulations 
If any person affected with syphilis, gonorrhea or chancroid 
shall violate any law or regulation and thereby, in the judgment 
of the physician, become a menace to the public health, the 
physician shall immediately report the name and address of the 
patient to the local health officer, and the latter shall forward a 
copy to the State Department of Health. The local board of 
health or health officer shall take all necessary steps to prevent the 
person reported from becoming a menace and to assist in his cure. 
Sanitary Code, chapter 2, regulation 29-d. 
Duties of physicians and others 
Under the Public Health Law concerning syphilis, gonorrhea 
and chancroid it shall be the duty of every physician or other 
person required to perform any duty or refrain from any act 
under article 17-b of the Public Health Law, as amended by chap- 
ter 264 of the Laws of 1918, providing for the regulation of 
syphilis, gonorrhea and chancroid ("venereal diseases"), to take 
all steps incumbent on him and necessary to carry into effect the 
provisions of the said law. Sanitary Code, chapter 2, regulation 
29-e. 
Duties of toion and city clerics 
Town and city clerks before issuing marriage certificates shall 
require from each of the applicants the following statement: " I 
have not to my knowledge been infected with any venereal disease, 73 
or if I have been so infected within five years I have had a labora- 
tory test within that period which shows that I am now free from 
infection from any such disease." Domestic Relations Law, 
article 3, section 15. 
Adopted by the State Commissioner of Health governing the 
collection and submission of specimens from cases of syphilis, 
gonorrhea or chancroid for laboratory examination. 
1 Syphilis. 
(a) Submission of specimens. 
(b) Collection of specimens. 
2 Gonorrhea. 
(a) 'Submission of specimens. 
(b) Collection of specimens. 
3 Chancroid. 
In accordance with the requirements of Regulation 2a, chap- 
ter 2 of the Sanitary Code, the following rules and regulations 
are hereby established relating to the collection and submission 
of specimens for laboratory examination: 
Special Rules and Regulations 
The Collection and Submission of Specimens for Labora- 
tory Examination 
In every case in which there is evidence of syphilis, gonorrhea 
or chancroid, the attending physician shall submit to the labora- 
tory of the State Department of Health, or to a laboratory 
approved for that purpose by the State Commissioner of Health, 
the specimens required for examination listed below, accompanied 
by the following data: Kame, address, age, occupation, and 
marital condition of the patient, clinical diagnosis, source and 
date of infection. 
Syphilis 
(a) Submission of specimens 
A physician attending a positive or suspected case of syphilis 
shall send, whenever possible, such case to a laboratory where a 
careful examination of the exudate from the chancre or other 74 
local lesion, with dark field illumination, shall be made. The 
physician shall also submit to a laboratory a specimen of blood 
for the complement fixation (Wassermann) test. 
When laboratory tests of the blood made during the first six 
weeks after the appearance of the lesion suspected to be a chancre 
are negative, a further specimen to test the diagnosis shall be 
submitted between the end of the sixth week and the end of the 
eighth week following the appearance of the lesion. 
A physician attending a case of constitutional syphilis (the 
so-called secondary, latent or tertiary stages of the disease) shall 
submit to a laboratory a specimen of blood of such case for the 
complement fixation (Wassermann) test. 
The above examinations shall be made in a laboratory or 
laboratories approved for this purpose by the State Commissioner 
of Health. 
(b) Collection of specimens 
Fresh specimens of exudate from the lesions of syphilis, 
especially from chancre, which are to be examined with the dark 
field illumination, shall be taken as follows: Remove a bit of 
the hard scab, sop the blood until bleeding stops, then squeeze 
the sore to express a drop of serum. All such specimens should 
be examined immediately. 
Specimens of blood for the complement fixation (Wassermann) 
test, consisting of not less than three cubic centimeters, shall be 
drawn into the sterile tube supplied for this purpose, as described 
on the blanks which accompany the laboratory outfits. 
Gonorrhea 
(a) Submission of specimens 
A physician attending a positive or suspected case of gonorrhea 
shall submit the specimens designated below to a laboratory. In 
those cases in which clinical evidence of the disease is present, 
and the first laboratory examination was negative, a second speci- 
men shall be submitted. These examinations shall be made in 
a laboratory or laboratories approved for this purpose by the 
state commissioner of health. 75 
(b) Collection of specimens 
In acute or active cases of gonorrhea, specimens of the urethral 
discharges shall be collected in the manner described on the blanks 
which accompany the laboratory outfits, furnished for this pur- 
pose. In the male, if no discharge is evident, specimens shall 
be obtained after careful massage of the prostate by compressing 
the urethra with the finger and stripping toward the meatus. 
In the female if no urethral discharge is evident, specimens 
shall be taken by compressing the urethra with the finger and 
stripping toward the meatus. Specimens of fresh exudate shall 
be taken from the cervix uteri, after careful cleansing of the os, 
and also from Bartholin's glands when it is evident that these 
are infected. 
All specimens of the discharge secured as above indicated shall 
be at once smeared on the glass slides as described on the blanks 
accompanying the laboratory outfits furnished for this purpose. 
Chancroid 
Without laboratory tests it is impossible to distinguish with 
certainty chancroid from chancre, hence all such lesions shall be 
considered chancre until the complement fixation (Wassermann) 
test of the blood is negative. 
A physician attending a positive or suspected case of chancroid 
shall send, whenever possible, such case to a laboratory where a 
careful examination of the exudate from the chancroid or other 
local lesion, with dark field illumination, shall be made. The 
physician shall also submit to a laboratory a specimen of blood 
for the complement fixation (Wassermann) test. 
When laboratory tests of the blood made during the first six 
weeks after the appearance of the lesion suspected to be a 
chancroid are negative, a further specimen to test the diagnosis 
shall be submitted between the end of the sixth week and the end 
of the eighth week following the appearance of the lesion. 
The above examination shall be made in a laboratory or labora- 
tories approved for this purpose by the state commissioner of 
health. 76 
Laboratory Tests for Syphilis 
The complement fixation test 
Principles 
involved 
Complement fixation was first nsed by Bordet and Gengou to 
identify the typhoid bacillus. Subsequently Wassermann adapted 
the reaction to the diagnosis of syphilis by using a preparation 
of the liver of a syphilitic fetus as a syphilitic antigen, but Was- 
sermann's original method has now been modified. 
In the course of infection or as a result of inoculation with 
the incitants of infection, the body tissues react and acquire the 
property of combining with the inciting agent of the reaction 
neutralizing its action. This peculiar property may be possessed 
in high degree by the tissue fluids and especially the blood serum. 
Any substance giving rise to this reaction of immunity is termed 
an antigen. When the red blood cells of the sheep are injected 
into the rabbit, the blood serum of the rabbit will not only com- 
bine with the red blood cells of the sheep in a test tube but it will 
also hemolyze (lake) them. After heating to 56 degrees C. the 
blood serum retains the property of combining with the sheep 
cells but loses its power to hemolyze them. The addition of a 
little fresh serum (complement) from a normal guinea pig 
restores the hemolytic power. By titration the exact quantities 
of rabbit immune serum (amboceptor for sheep cells) and of 
fresh normal guinea pig serum (complement) which will hemo- 
lyze (lake) a definite quantity of sheep's red blood cells can be 
determined. If this quantity of complement is added to a mix- 
ture of syphilis antigen and serum from a suspected case of 
syphilis, one of two' things happen: If the case is one of syphilis 
all three combine and the complement is fixed so that it can not 
hemolyze a mixture of sheep's cells and their immune serum; if 
the case is not one of syphilis no combination takes place and the 
complement is free to hemolyze the red blood cells mixed with 
their immune serum. It is impossible to determine whether or 
not complement and syphilitic antigen and patient's serum have 
combined because there is no visible change when they combine. 
Hemolysis (laking) of the red blood cells is readily seen and by 
measuring it the amount of complement free or fixed by the 77 
patient's serum can be determined. Four plus signifies complete 
fixation of the complement; three, two and one plus, diminishing 
degrees of fixation. Plus-minus indicates very slight and doubt- 
ful fixation. 
A single negative reaction does not necessarily preclude a 
diagnosis of syphilis. Not infrequently complement fixation can 
not be demonstrated before the second or third week following 
infection and the appearance of the reaction may be still further 
delayed. In cases which have been insufficiently treated, the 
Wassermann reaction may be absent for a time and reappear 
later. If the results of first tests are negative or uncertain further 
specimens should be submitted if there is reason to suspect that 
infection has occurred. 
After complement fixation has been demonstrated, periodical 
tests will give valuable information regarding the efficacy of treat- 
ment. Immediately after beginning treatment an intensification 
of the activity of the blood may be noted, but this should not be 
regarded as an indication for discontinuing or modifying treat- 
ment. The possibility of stimulating a positive reaction in cases 
of syphilis through administration of a "provocative" dose of 
arsphenamine may sometimes be taken advantage of in diagnosis 
of obscure cases. 
In certain stages of syphilis in which there is involvement of 
the central nervous system and in which no complement fixa- 
tion is obtained with the patient's blood serum, the test performed 
with large amounts of spinal fluid may be positive. The spinal 
fluid in some cases shows a positive reaction before the involve- 
ment of the central nervous system has become sufficiently 
extensive to be recognized clinically, making it possible to 
diagnose the specific nature of the condition and to institute 
treatment before irreparable damage to the central nervous 
system has occurred. 
In performing the complement fixation (Wassermann) test for 
syphilis, to insure accuracy of results, two antigens are used. 
The following forms are used for making reports upon specimens. 
Interpre- 
tation of 
negative 
results 
Value of 
periodic tests 
Tests upon 
spinal fluid 
Reports and 
their interpre- 
tation 78 
Forms Used for Reporting Upon Complement Fixation 
Tests for Syphilis 
When Partial Fixation of Complement Only Is Obtained With 
One or Both Antigens the Following Report Blank Is Used. 
(Front) 
Laboratory number , 19 
In the examination of the specimen from 
Name 
Address 
Taken on 
For or by 
Dr. 
Definite fixation of complement was not obtained with either of the antigens 
used in the complement-fixation test for syphilis. See below numbers. 
In the test of the specimen with PLAIN ALCOHOLIC ANTIGEN: 
1. No fixation of complement was obtained 
2. The fixation of complement was slight ± 
3. The fixation of complement was partial + 
In the test of this specimen with CHOLESTERINIZED ANTIGEN: 
4. No fixation of complement was obtained 
5. The fixation of complement was slight ± 
6. The fixation of complement was partial + 
For interpretation of results, see other side. 
AUGUSTUS B. WADSWORTH, M. D. 
Director 
(Back) 
The results of the complement-fixation test for syphilis should always be 
interpreted in the light of the clinical evidence. 
Unless there is, clinically, definite reasons to believe that the case is one of 
syphilis, a diagnosis of syphilis should not be based solely upon a slight (±) 
or partial (+) reaction. This is especially true if it is obtained of the 
cholesterinized antigen only. Experience has shown that the alcoholic antigen 
does not give slight or partial reactions with any considerable proportion of 
sera from persons free from syphilis. Cholesterinized antigen, on the con- 
trary, has been observed to give slight or partial reactions with 10% or less 
of sera from persons apparently free from syphilis, depending upon how 
sensitively the test is adjusted. 
In a case that has had no clinical signs of syphilis a slight or [ artial reac- 
tion, obtained only with cholesterinized antigen is usually considered nega- 
tive. In a known case of syphilis that has had specific treatment such a 
reaction, is considered to indicate that further treatment is required. 
It is recommended that confirmatory specimens be submitted in those cases 
in which the result of the first examination can not readily be interpreted in 
the light of the clinical evidence. If, in any case, a specimen is sent for 
confirmation, the physician is asked to note that fact on the accompanying 
history blank. 79 
When Definite Fixation of Complement is Obtained, the Follow- 
ing Report Blank is Used 
(Front) 
Laboratory number » 19 
In the examination of the specimen from 
Name 
Address 
Taken on 
For or by 
Dr. 
Definite fixation of complement was obtained with one or both of the 
antigens used in the complement-fixation test for syphilis. See below 
numbers - 
In the test of this specimen with PLAIN ALCOHOLIC ANTIGEN: 
1. No fixation of complement was obtained 
2. The fixation of complement was slight ± 
3. The fixation of complement was partial + 
4. The fixation of complement was definite 2+ 
5. The fixation of complement was nearly complete 3+ 
6. The fixation of complement was complete 4+ 
In the test of the specimen with CHOLESTERINIZED ANTIGEN: 
7. No fixation of complement was obtained 
8. The fixation of complement was slight ± 
9. The fixation of complement was partial + 
10. The fixation of complement was definite 2+ 
11. The fixation of complement was nearly complete 3+ 
12. The fixation of complement was complete 4-|- 
For interpretation of results see other side. 
AUGUSTUS B. WADSWORTH, M. D. 
Director 
(Back) 
The results of the complement-fixation test for syphilis should always be 
interpreted in the light of the clinical evidence. 
A reaction of marked intensity (2+, 3+ or 4+), if obtained with the plain 
alcoholic antigen, is usually considered to indicate syphilitic infection. 
Experience has shown that with a small proportion of known syphilitic sera, 
the alcoholic antigen may fail to react, or may react but weakly. In these 
cases the reaction may occasionally be stronger with cholesterinized antigen. 
A reaction with cholesterinized antigen is therefor considered to have 
specific significance and to indicate the necessity for further treatment in 
cases in which syphilis has previously been diagnosed. 
Although in our experience the cholesterinized antigen has given slight 80 
or partial reactions with a certain proportion of sera from persons apparently 
free from syphilis, it has not been observed to give reactions of marked 
intensity in any number of cases in which the possibility of syphilis could 
be excluded. In any case in which the result of the first test can not readily 
be interpreted in the light of the clinical evidence, it is recommended that 
confirmatory specimens be submitted. If, in any case, a specimen is sent 
for confirmation, the physician is asked to note that fact on the accompany- 
ing history blank. 
When No Fixation of Complement is Obtained with Either 
Antigen the Following Report Blank is Used 
Laboratory number , IS 
In the examination of the specimen from 
Name 
Address 
Taken on 
For or by 
Dr. 
No complement-fixation was obtained with either of the antigens used in the 
complement-fixation test for syphilis. 
In all doubtful cases, confirmatory specimens should be forwarded at once. 
If, in any case, a specimen is sent for confirmation, the physician is asked to 
note that fact on the accompanying history blank. 
AUGUSTUS B. WADSWORTH, M. D. 
Director 
Direct examination for Treponema pallidum 
An immediate diagnosis of syphilis in the primary stage can 
usually be made through demonstrating the treponemata in 
exudate from primary lesions, using the dark field method. Since 
it is necessary to take the material at the time of examination, 
the procedure can only be carried out when there is a laboratory 
near at hand. 81 
Form Used for Submitting Information Accompanying 
Blood Specimens for Complement Fixa- 
tion Test for Syphilis 
(Front) 
SYPHILIS 
See directions for collecting blood on other side 
Examination of Blood Serum 
Number of specimens, 1, 2, 3, etc 
Where examined 
.Date. 
Results of previous examinations. 
Results of examinations, T. pallidum 
Date of taking blood 
Name of patient. 
.Time 
Age. 
Address 
Occupation 
. Sex.. 
Color 
Married 
Children 
Date. 
Single 
Wid. 
How contracted: Acquired 
Initial lesion 
Treatment 
Hereditary 
Clinical signs: Primary 
Present symptoms 
Secondary 
Tertiary 
Duration of disease. 
Has arsphenamine been administered ? 
. Date. 
Has mercury been administered? 
.Date. 
Has patient taken alcohol within 24 hours ? 
Other information concerning specimen. 
Name and address of physician 
Name and address of health officer 
Physicians and health officers are requested to answer all questions on the 
blank up to this point and return it with the specimen. 
Laboratory number 
Examined 
Received 
Plain alcoholic antigen 
Examiner 
Result of examination: 
Cholesterinized antigen 
(Back) 
Scrub skin over median basilic vein with soap and water. Wash off the 
soap and disinfect the skin with alcohol 70%. 
Tie a bandage or place a tourniquet around the arm, just above the 
biceps and below the deltoid muscles, tight enough to constrict the venous 
circulation and yet not stop the pulse below. The distended vein ought to 
be visible or palpable. 
DIRECTIONS FOR COLLECTING BLOOD 82 
Pass the needle at a slight angle, nearly parallel to the long axis of the 
vein, through the skin, upward, into the vein. When the needle has entered 
the vein the point of it is free, meets no resistance, a fact which may quickly 
be detected if the needle passes easily through the skin. Immediately after 
the needle enters the vein, blood will flow. 
Taking all precautions against contamination, let the blood flow into the 
sterile test tube and cork it tightly when three-quarters full. At least two 
cubic centimeters of blood are necessary for the examination. 
With practice, blood may be drawn from the vein with a sterile hypodermic 
syringe introducing the needle as above described, provided the syringe is not 
too small and will hold a sufficient quantity of blood. The blood should be 
transferred to the sterile test tube immediately before it coagulates. 
Before withdrawing the needle the pressure on the arm above should be 
removed to avoid hemorrhage into the tissues. A sterile dressing should then 
be placed over the puncture. 
When handling the sterile glass tube and cork, avoid touching the inner 
surfaces with anything that is not sterile. 
The tube should be slanted for one-half hour at room temperature, until 
the blood has coagulated. 
Blood should preferably be taken about two hours after eating. 
The specimen should be sent to the laboratory as soon as possible. 
Please wrap used needle in piece of paper and return with specimen. 
The diagnostic facilities of the laboratory are designed primarily to render 
prompt assistance to health officers and physicians in the diagnosis and con- 
trol of communicable diseases, and to provide laboratory service for all 
persons in the State for -whom such service is not otherwise available. 
Physicians are especially urged to make use of the facilities of approved 
county, municipal and private laboratories whenever such facilities are 
available in their vicinity. 
Arsphenamine 
Distribution 
Arsphenamine for treatment of syphilis is distributed by the 
State laboratory in ampules containing 1.2, 0.6 and 0.4 grams. 
At present it is distributed only for use in authorized clinics, 
hospitals and institutions, by physicians who have been approved 
by the Commissioner of Health. Plans are now being made for 
more general distribution. Directions for administration accom- 
pany each package. 
When all necessary precautions are observed, marked reactions 
are rare. An unusual reaction occurring during or following 
injection of arsphenamine distributed by the Division of Labora- 
tories and Research should be immediately reported in detail to 
the laboratory. Otherwise report slips should be filled out and 
returned to the laboratory at the end of each month. 
Unusual re- 
actions 83 
Report Required of Physicians Using Arsphenamine Dis- 
tributed by the State Laboratory 
REPORT ON THE USE OF ARSPHENAMINE 
(Front) 
Name of patient. 
Address 
Age 
.Sex. 
.Date of earliest symptoms. 
Treated at 
Clinical diagnosis 
Complications 
Stage of the disease. 
Remarks 
Results of complement-fixation test or microscopic darkfield examination 
Date 
(Back) 
Mercurial treatment - previous, present. 
Arsenical treatment - previous. 
Other treatment. 
Date of 
Injection 
Dose in 
Grams 
Preparation 
No. 
Reactions following Injections of Arsphenamine 
(Underline words descriptive of symptoms) 
No reaction. Fever, chill, headache, nausea, vomiting, 
diarrhea, dyspnea 
Other symptoms 
Remarks 
I also certify that the purchase of the drug would be a hardship in this 
case. 
Date. 
Signed. 
M.D. 
Address. 
Physicians who fail to report promptly are liable to have the distribution of 
arsphenamine to them suspended. 84 
Laboratory Tests eor Gonorrhea 
In gonorrhea during the earlier stages of the disease the 
diagnosis is very readily made, but in the later stages of the 
disease it is not always possible to demonstrate the presence of 
the specific microorganism. After cleansing of the mucous mem- 
brane, however, an examination of the discharges from the deeper 
recesses often reveals the presence of the gonococci. In the male 
the prostate, the secretions of which may be exposed by massage, 
and in the female the urethra, the cervix, and the ducts 
of the glands of Bartholin most frequently harbor gonococci, 
whereas they are not readily found in the vaginal secretions. It 
is very important to send repeated confirmatory specimens when 
gonorrhea is suspected and the laboratory report is negative. 
Several smears may have to be carefully examined before gonococci 
are found. 
Form Used for Submitting Information Accompanying 
Specimens from Cases of Suspected Gonorrhea 
(Front) 
GONORRHEA 
Examination of Discharge or Blood Serum 
See directions on other side 
Number of specimen, 1, 2, 3, 4, 5, 6, 7, 8, 9, etc 
Results of previous examinations 
Date 
Date of collecting specimens 
. Time. 
From urethra 
Name of patient. 
Cervix uteri 
.Vagina. 
• Age. 
Address 
.Sex. 
Occupation 
Married 
Children. 
.Time in U. S. 
Single. 
. Color, 
Wid. 
When contracted. 
.Date first symptom. 
Duration of disease. 
Stage of the disease: Acute 
Number reinfections 
Chronic 
Amount discharge 
Character 
Treatment 85 
Other information concerning specimen. 
Name and address of physician 
Name and address of health officer 
whom was this specimen taken. 
Physicians and health officers are requested to answer all questions on the 
blank up to this point and return it with the specimen. 
Laboratory number 
. Examined 
Received 
. Examiner. 
Result of examination. 
DIRECTIONS FOR COLLECTING AND SPREADING DISCHARGE ON 
SLIDE IN ACUTE OR ACTIVE CASES OF GONORRHEA 
{Back) 
Collect a fraction of a drop of the URETHRAL DISCHARGE on one end of 
a slide. 
Place the second slide at an angle to the first slide in the small drop of 
exudate, spread it in a thin film on the slide by a continuous sweep of the 
second slide across the first. 
Let the film dry in the air without heating it. 
Spread another film of the discharge on the second slide using the end of 
the first as a spreader. 
Replace the slides when dry, specimen sides together, and mail them to the 
laboratory. 
The film of exudate should be thin, evenly spread, and extend over only half 
the surface of the slide. If the drop is too large, clean the slide and collect 
another smaller drop. 
IN CASES HAVING NO EVIDENCE OF URETHRAL DISCHARGE 
In the male the prostate should be carefully massaged and then the speci- 
men obtained by compressing the urethra with the finger and stripping 
toward the meatus. The drop of discharge should be collected on one end of 
a glass slide and smeared at once., according to the directions given above for 
smearing specimens from acute or active cases. 
In the female, if no urethral discharge is evident, specimens should be 
taken by compressing the urethra with the finger and stripping toward the 
meatus. Specimens of fresh exudate should be taken from the cervix uteri, 
after careful cleansing of the os, and also from Bartholin's glands when it is 
evident that these are infected. Specimens of discharge thus secured should 
be at once smeared on glass slides according to the directions given above 
for smearing specimens from acute or active cases. 
The diagnostic facilities of the laboratory are designed primarily to render 
prompt assistance to health officers and physicians in the diagnosis and control 
of communicable diseases, and to provide laboratory service for all persons 
in the State for whom such service is not available. 
Physicians are especially urged to make use of the facilities of approved 
county, municipal and private laboratories whenever such facilities are 
available in their vicinity. 86 
Form Used in Reporting Presence of Gonococci in Speci- 
mens Examined 
Laboratory number , 19 
In the examination of the specimen from 
Name 
Address 
Taken on 
For or by 
Dr. 
Gonococci were found. 
{This report is based upon morphological examination alone.') 
AUGUSTUS B. WADSWORTH, M.D. 
Director 
Form Used in Reporting Negative Findings in Examination 
of Specimens From Cases of Suspected Gonorrhea 
Laboratory number , 19 
In the examination of the specimen from 
Name 
Address 
Taken on 
For or by 
Dr. 
No gonococci were found. 
The failure to find gonococci in smears does not necessarily exclude the 
presence of gonorrhea, especially if the case is latent. The smears may not 
have been made from the infected area. 
Repeated confirmatory specimens should be sent if there is reason to 
believe the patient may be infected. 
AUGUSTUS B. WADSWORTH, M. D. 
Director 
Dr. 
Health Officer 87 
Tetanus 
The bacillus 
and its toxin 
Tetanus develops after injury, the tetanus bacilli being intro- 
duced either at the time of the injury or subsequently. The 
tetanus bacillus is an organism which does not grow readily in 
the air and for this reason penetrating and badly lacerated wounds 
afford the most favorable site for its growth. It is present in soil 
contaminated with animal excretion. In dirty wounds the 
organism finds favorable conditions for its development and pro- 
duces one of the most powerful toxins known. It is this toxin 
which gives rise to the disease processes. After its production 
in the wound it is absorbed along the nerve trunks and the spinal 
cord and central nervous system are very quickly affected. The 
tetanus toxin possesses a chemical affinity for the nerve tissues 
with which it enters into combination. 
The toxin is produced so rapidly and is so potent that the 
period between the development of symptoms and the stage of the 
disease when the prognosis is unfavorable is extremely short. 
It is only in this period of the acute cases that antitoxin treatment 
is effective. Treatment, in addition to appropriate surgical 
care of wounds, consists of the immediate intraspinal inoculation 
of 5,00'0 to 10,000 units, followed by intravenous administration 
of large amounts of antitoxin - 10,000' to 40,000 units, with 
subsequent repetition. The antitoxin combines with the free 
toxin in the central nervous system and in the tissues generally, 
but it does not combine with the toxin which has become fixed 
in the cells, especially the nerve cells. This accounts for the 
failure of antitoxin to cure the disease when it is administered 
too late. 
The administration of antitoxin in appropriate dosage at the 
the time of the receipt of injuries practically always affords pro- 
tection against the development of the disease. 
The following is quoted from a circular issued by the Division 
of Laboratories and Research: 
Treatment 
Protective 
inoculation 
Distribution of Antitoxin 
Tetanus antitoxin is distributed in packages of 20,000 and 10,000 units for 
therapeutic use and in packages of 1,500 units for preventive immunization. 
Antitoxin may be obtained by physicians from supply stations maintained 
by the health officers, who are responsible for the prompt distribution of all 88 
laboratory supplies from their own supply stations or, if it is unnecessary for 
them to maintain an independent station, from one near by. In emergencies, 
antitoxin may also be obtained from main depots in the county or municipal 
laboratories. Lists of such centers will be published from time to time or may 
be obtained upon application to the State laboratory. 
Physicians obtaining antitoxin must agree to report to the health depart- 
ment, within 60 days, the final results of its use, on the blank, which is en- 
closed in each package. (See page 89.) The blank should be filled out 
completely and returned to the laboratory. 
Experience has shown that the subcutaneous injection of an immunizing 
dose of tetanus antitoxin rarely fails to prevent the development of the 
disease. Whenever garden or street dirt, stable dust, manure, paper wads or 
powder from cartridges have been ground and forced into the injured tissues, 
a preventive dose of tetanus antitoxin should be given subcutaneously at the 
time the wound is dressed, or as soon thereafter as possible. This is especially 
recommended after Fourth of July injuries. 
While one injection is generally sufficient, if the wound continues to offer 
a site for possible infection, an additional subcutaneous injection should be 
given, and under exceptional circumstances, even a third. When repeated in- 
jections are given at intervals longer than a week or if at any time pre- 
viously the patient has been treated with horse serum or antitoxin, the pos- 
sible occurrence of anaphylactic shock should be guarded against by a pre- 
liminary injection of 0.5 cc. 
While the typical symptom complex of tetanus is unmistakable, the earliest 
evidences of the disease may be and frequently have been overlooked. Since 
to be of value it is essential that antitoxin be administered at the earliest 
possible moment, brief delay in diagnosis or in treatment may remove all 
possibility of recovery. By the time the first symptoms appear the disease is 
well advanced and all that can be reasonably expected of the treatment is the 
prevention of absorption of further amounts of active toxin by the nervous 
system. At the onset use intraspinally and intravenously any tetanus anti- 
toxin available, whether intended for immunization or treatment, and at once 
apply by telephone or telegram for an additional supply. 
Immuniza- 
tion 
Treatment 
Directions for the Use of Tetanus Antitoxin 
Immunizing dose. Fifteen hundred units of antitoxin should be injected 
subcutaneously if one injection only is given; one thousand units if repeated 
injections are given in two doses, 10-14 days apart; children 800 to 1000 
units. 
Therapeutic dose. The antitoxin may be administered in several ways, 
none of which precludes the use of any or all of the others. Recent experi- 
ence has shown, however, that the intraspinal method is by far the most 
effective, while the intravenous, owing to prompter absorption, is preferable 
to the subcutaneous. Since antitoxin should be administered promptly, the 
first dose in experienced hands is usually given intraspinally and followed 
immediately by an intravenous dose. Treatment should be continued depend- 
ing upon the clinical signs, using subcutaneous administration unless the 
severity of the symptoms requires continuance of the intraspinal and intra- 
venous treatment. 89 
(a) Inttaspinal injections of 5000 to 10 000 units repeated at 24 and 48 hour 
intervals. 
(b) Intravenous injections of 10,000 to 40,000 units repeated at 24 to 48 
hour intervals. 
(c) Subcutaneous injections of from 10,000 to 20,000 units. 
Administration 
Subcutaneous. The antitoxin should be given by hypodermic injection 
deeply into the muscles on the anterior surface of the body. 
Intravenous. The median basilic vein should be used. In order to safe- 
guard against anaphylaxis 0.2 cc. of the dose should be allowed to circulate 
for a few moments before the remainder of the dose is injected slowly. The 
antitoxin which should be one degree above rectal temperature, may be diluted 
in equal parts of warm sterile physiological salt solution. Physicians are 
cautioned to be on the alert for any symptoms suggesting an anaphylactic 
reaction and especially if the patient at any time has been treated with horse 
serum or is subject to asthma. 
Lumbar puncture. This must be performed under strictly aseptic precau- 
tions in the third or fourth lumbar space. An anesthetic may be advisable, 
Select the notch nearest the line connecting the crests of the ilia. Introduce 
the needle in the midline and push it forward and a little upward for the 
distance of from one-half to three inches' depending on the muscular develop- 
ment and age of the patient. When the needle enters the canal the cerebro- 
spinal fluid will flow out. Allow as much, or a little more of the spinal 
fluid to escape - if it will - than the amount of antitoxin to be injected. The 
antitoxin warmed to body temperature should be allowed to enter the canal 
by gravity by means of a funnel with a one-eighth to one-fourth inch dia- 
meter tube 12 inches long or an ordinary rubber catheter attached to the 
barrel of a glass syringe - the other end cut off for the attachment of the 
needle. 
Aseptic precautions. The skin over the selected regions should be thor- 
oughly cleansed with soap and water and then washed with alcohol or painted 
with tincture of iodine. The apparatus should be thoroughly sterilized by 
boiling for five minutes. When doses are given intravenously or into the 
nervous system, a strictly aseptic surgical technique should be observed. 
Report Required From Physicians Using State Tetanus 
Antitoxin 
By accepting antitoxins and serums prepared and distributed by the Depart- 
ment of Health, the physician assumes responsibility for reporting upon 
their use 
(Front) 
Patient 
Report on the Use of Tetanus Antitoxin 
Address 
N. Y. 
Age 
.Sex. 
Date of injury. 
Location and character of injury. 90 
Dirt or foreign bodies in wound. 
To be returned to health officer or Division of Laboratories and Research, 
New Scotland Ave., Albany. 
Surgical Treatment 
(Back) 
Dates and 
Hours of 
Injections 
Prophy- 
lactic 
Thera- 
peutic 
Units 
Injected 
Antitoxin 
Number 
Methods of administration 
(subcutaneous, intraspinous, intra- 
venous) 
Date._ 
Development'of tetanus within three weeks.. 
Termination of^case (recovery or death).. 
Date.. 
Address. 
M. D. 
Retain all report slips until expiration of three weeks period, or termination of case. 
Tuberculosis 
Examination 
of specimens 
Lacking specific curative and immunizing agencies in the treat- 
ment of tuberculosis, the early diagnosis of the disease is the 
essential factor upon which depends the care of the individual 
case and the prevention of the spread of the disease. In com- 
paratively few diseases is the bacterial diagnosis of greater prac- 
tical value to the physician and public health official. The find- 
ing of the tubercle bacillus in discharges leaves no question regard- 
ing the diagnosis. The tubercle bacillus is not found in the 
discharges of healthy persons. In suspected cases the examina- 
tion of discharge is, therefore, essential. The routine public 
health examination of such discharges is to a large extent limited 
to the examination of sputum, but the practical value of examin- 
ing other discharges is also manifest, although the great majority 
of tubercular infections are pulmonary, and from cases of pul- 
monary infection the spread of the disease is very largely confined. 
While the demonstration of the presence of tubercle bacilli 
is of positive value, failure to find the organisms in any case 
does not preclude the existence of tuberculosis. In cases of pul- 
Negative find- 
ings not con- 
clusive 91 
monary' tuberculosis it may not be possible to find the organisms 
in specimens of sputum until the disease is at least moderately 
advanced. In such cases, while successive specimens should be 
submitted for examination the diagnosis should not be delayed 
pending finding, but should usually be made from symptoms and 
physical signs. 
Specimens of Sputum 
Outfits for the examination of sputum specimens have been 
distributed throughout the State. The special outfit with yellow 
label for sputum includes a container and information blank 
with directions for collecting specimens, which are as follows: 
Form Used for Submitting Information Accompanying 
Specimens of Sputum to be Examined for Presence of 
Tubercle Bacilli (not to be Used with Specimen 
for Pneumococcus Type Differentiation) 
(Front) 
Examination of Sputum for Tubercle Bacilli Only 
TUBERCULOSIS 
(See other side for explanation and directions for collecting specimens of 
sputum.) 
Number of specimens from this patient, 1, 2, 3, 4, 5, 6, 7, etc 
Results of previous examinations. 
Date of collecting specimens 
Time 
Name of patient. 
Address. 
Age. 
Sex 
Occupation 
Clinical diagnosis 
Color 
Duration of disease. 
Symptoms (cross out those not observed) 
Fever, sweats, cough, loss of appetite, pulse rate.... ; hoarseness, 
emaciation, diarrhea, hemorrhage 
How contracted 
Other information concerning specimen. 
Name and address of physician 
Name and address of health officer 
whom was this specimen taken?. 
Physicians are requested to answer all questions on the blank up to this 
point and return it with the specimen. 
Laboratory number 
Received 
Examined. 
Examiner 
Result of examination 92 
CAUTION 
(Back) 
Send only specimens of sputum to be examined for tubercle bacilli in this 
container, as the specimens for this test are to be sterilized before they are 
examined and this procedure would render a specimen unsatisfactory for most 
other tests. 
If any other type of examination is desired, the specimen may be sent 
in a similar container with a pink label designed for specimens for mis- 
cellaneous examinations. 
Sputum should be collected in the special jars designed for this purpose. 
These are furnished in complete outfits for mailing by the State Department 
of Health free of charge to health officers and physicians. 
The specimen jar should be labeled with the name of the patient. 
The first sputum coughed up in the morning is preferred. When the 
sputum is scanty it should be collected for twenty-four hours. 
The tubercle bacilli are found most frequently during exacerbation of the 
disease and in purulent or cheesy sputa; less often, in pure mucus and blood. 
Following hemorrhage the purulent material should be selected for examination. 
Do not fill the jar more than three-quarters full. 
Cork securely to avoid leakage. 
The diagnostic facilities of the laboratory are designed primarily to render 
prompt assistance to health officers and physicians in the diagnosis and con- 
trol of communicable diseases and to provide laboratory service for all persons 
in the State for whom such service is not otherwise available. 
Physicians are especially urged to make use of the facilities of approved 
county, municipal and private laboratories whenever such facilities are avail- 
able in their vicinity. 
DIRECTIONS FOR THE COLLECTION OF SPUTUM 
Form Used for Reporting Presence of Tubercle Bacilli 
in Specimens of Sputum 
Laboratory number , 19 
In the examination of the sputum from 
Name 
Address 
Date collected 
For or by 
Dr. 
Tubercle bacilli were found. 
AUGUSTUS B. WADSWORTH, M. D. 
Director 
Dr. 
Health Officer 
(See other side) 
(Front) 93 
(Back) 
§ 32o. Reports of tuberculosis by physicians and. others. Tuberculosis 
is hereby declared to be an infectious and communicable disease, dangerous 
to the public health. It shall be the duty of every physician in the state 
of New York, to report by telephone or in person or in writing on a form 
to be furnished as hereinafter provided, the name and address, of every person 
known by said physicians to have tuberculosis, to the health officer of the 
city, town or village in which said person resides or may be, within twenty- 
four hours after such fact comes to the knowledge of said physician. It 
shall also be the duty of the chief officer having charge for the time being of 
any hospital, dispensary, asylum or other similar private or public institu- 
tion to report the name, age, sex, color, occupation, place where last employed 
if known and the previous address of every patient having tuberculosis who 
comes into his care or under his observation, within twenty-four hours there- 
after to the health officer of the city, town or village in which said patient 
resided immediately previous to admission to said institution; except that 
if such residence be outside of the state of New York then such report shall 
be made to the state commissioner of health. 
Any physician, nurse, employer, teacher, head of a family, landlord, or 
other person may report in writing the name and address of any person 
coming under his observation who appears to be suffering from tuberculosis 
to the health officer of the city, town or village in which such person is, and 
the health officer shall thereupon take such steps as may be prescribed by 
the sanitary code provided the person making such report signs his own name 
and address thereon. 
Each registrar of vital statistics shall promptly report to the health officer 
the name and address of every person reported to him as having died from 
tuberculosis. The health officer shall ascertain whether such person has been 
previously reported as having tuberculosis by the physician signing the 
death certificate, and if it appears that such physician has not so reported 
such person, the health officer shall call the attention of such physician to 
the provisions of this section. In case of repeated violations of the provisions 
of this section by any physician the health officer shall report such repeated 
violations to the board of health or other local health authorities, who shall 
cause such steps to be taken as may be necessary to enforce the penalty 
provided for such violation. 
§ 322. Protection of records. It shall be the duty of every health officer 
of a city, town or village to cause all reports made in accordance with the 
provisions of section three hundred and twenty, and also all results of 
examinations, showing the presence of the bacilli of tuberculosis, made in 
accordance with the provisions of section three hundred and twenty-one, to 
be recorded in a register, of which he shall be the custodian. Such register 
shall not be open to inspection by any person other than the health authorities 
of the state and of the said city, town or village, and said health authorities 
shall not permit any such report or record to be divulged so as to disclose 
the identity of the person to whom it relates, except as may be authorized 
in the sanitary code. 
PUBLIC HEALTH LAW 94 
SANITARY CODE 
Regulation 42. Duties of physicians and other persons concerning tuberculosis* 
It shall be the duty of every physician or other person required to perform 
any duty under sections three hundred and twenty to three hundred and 
thirty, both inclusive, of article sixteen of the public health law, providing 
for the reporting and control of cases of tuberculosis to take all steps incum- 
bent on him and necessary to carry into effect the provisions of the said law. 
Chapter II 
Form Used for Reporting Negative Results in Examina- 
tion of Specimens of Sputum for Presence of 
Tubercle Bacilli 
, 19 
Laboratory number 
In the examination of the sputum from 
Name 
Address 
Date collected 
For or by 
Dr. 
No tubercle bacilli were found. 
Failure to find the tubercle bacillus does not exclude the presence of tuber- 
culosis. In all doubtful cases specimens for confirmatory examinations should, 
be carefully selected and forwarded. Even though the sputum be negative, 
if, because of the clinical findings, you regard this case as one of tuberculosis 
it should be reported to the local health officer. 
There are cases of early or incipient tuberculosis and less frequently cases 
in more advanced stages which require several examinations of the sputum 
before tubercle bacilli are found microscopically. During exacerbations of the 
disease the bacilli are usually present in greater numbers. 
AUGUSTUS B. WADSWORTH, M. D., 
Director 
Dr. 
Health Officer 
Specimens Other Than Sputum 
Discharges 
Outfits for miscellaneous specimens may be used for the col- 
lection of other discharges for examination in the laboratory. 
These outfits consist of slides upon which smears of the exudates 
may be spread if the tubercle bacilli are likely to be numerous,, 
and another miscellaneous outfit with pink label containing a 95 
sterile tube and swab may be used for the collection of discharges 
and exudates, or even for smaller quantities of fluid, although 
the sputum jar would serve better for this purpose. 
In serous exudates, and in urine, tubercle bacilli are not 
numerous, and larger specimens must be sent so that specimens 
may be centrifugalized and examined by direct microscopic 
examination, or if necessary so that the inoculation of guinea 
pigs, an animal susceptible to the disease, may be made. The 
inoculation test requires five to eight weeks. 
It should always be borne in mind that in specimens of material 
from tubercular subjects the number of tubercle bacilli vary so 
greatly from time to time that they are not infrequently missed 
in one examination. Repeated examinations are necessary. 
Serous 
exudates 
and urine 
Reporting of Cases 
Health officers should report all cases of tuberculosis as required 
by law. For administrative reasons the submission of a labora- 
tory specimen and information regarding it does not constitute 
a case report. 
Tuberculin 
From time to time small quantities of old tuberculin - Koch's 
O. T. or crude tuberculin - are prepared by the Albany labora- 
tory for diagnostic use but this product is not distributed gen- 
erally. Tuberculin may be used on the scarified skin by the 
method of von Pirquet, or in dilutions injected intracutaneously 
(Mantoux) or subcutaneously (Koch). The last method, how- 
ever, in persons having active tuberculous lesions may be open 
to considerable danger through excessive reaction. The intra- 
cutaneous method is considered more delicate than that of von 
Pirquet. Tuberculin tests should be made only by experienced 
physicians and the results should not be considered as diagnostic 
unless carefully interpreted in the light of considerable practical 
experience of the tests. 
The following directions for uses of tuberculin are included in 
a circular issued by the Division of Laboratory and Research: 
Not generally 
distributed 
Cutaneous Method of von Pirquet 
Cleanse inner surface of left forearm with alcohol and ether. Make two 
small scarifications *4 inch long and about 3 inches apart, without drawing 
Tuberculin 
tests as 
diagnostic 
aids 96 
blood. On one scarification place one drop of undiluted tuberculin with a 
sterile needle or toothpick and allow it to dry. The second scarification acts 
as a control. 
Examine areas at the end of 12, 24 and 36 hours. The inflammatory reac- 
tion develops where the tuberculin was placed and should be distinct from any 
traumatic reaction as shown by the control area. 
Dilute the tuberculin with sterile physiological salt solution (1-10,000, 
1-100,000, 1-1,000,000, 1-10,000,000). Cleanse the inner surface of the left 
forearm with alcohol and ether. Holding the skin taut and using separate 
sterile tuberculin syringes and needles for each dilution inject into the skin 
(not subcutaneously) 0.1 cc. of each dilution of tuberculin. As a control for 
skin sensitiveness 0.1 cc. of sterile salt solution is injected similarly into a 
fifth area, noting well its relative position. A fine needle, preferably No. 26 
gauge, should be used and syringes and needles boiled up separately after 
use. 
The reaction is considered positive and possibly of diagnostic significance 
when an infiltration and hyperemia develops at the site of injection in 6-8 
hours, reaching a maximum in 24-48 hours and disappearing in 6-10 days. 
The control injection of salt solution may be followed by a definite traumatic 
reaction which however rapidly disappears after 24 hours. 
Intracutaneous Method of Mantoux 
Caution. The subcutaneous method should only be used with the greatest 
care and should be limited to cases without definite pulmonary lesions and 
to cases with inactive healed lesions. Extensive or definite pulmonary tuber- 
culosis should always be excluded by the x-ray examination of the lungs. 
Dilute the tuberculin with sterile physiological salt solution to which has 
been added 0.25% of pure carbolic acid (2.5 cc. of carbolic acid in 1,000 cc. 
of salt solution) to 1-10, 1-100, 1-1,000, 1-10,000, 1-100,000, etc. It is custom- 
ary to designate the dose of tuberculin in grams and milligrams, while the 
dilutions are made by liquid measurement. To administer one milligram, 
give 0.1 cc. of 1-100 dilution; 5 milligrams, 0.5 cc. of 1-100 dilution, etc. 
Pipettes, bottles and syringes should be sterile. 
The injections are made subcutaneously into any part of the body, but the 
region of the back below the angle of the scapula is the desirable situation. 
Often the arm will be found more convenient. 
A No. 23 gauge needle is used and syringe and needles should be boiled 
before use, and care should be taken that tuberculin dilutions remain sterile. 
The skin at the site of inoculation should be cleansed with iodine and 
alcohol. 
Reaction. Careful observations and records of subjective symptoms and 
objective signs of the disease together with the temperature are made pre- 
vious to the test for purposes of comparison, and an afebrile period should 
be selected. Body temperature is considered the most trustworthy index of 
the constitutional reaction and it is indispensable to have a correct record 
of its variations. In hospitals the temperature may be taken every two hours 
throughout the period of the test. Ambulatory eases must be instructed in 
taking temperatures. The average temperature reaction develops in 12 hours 
Subcutaneous Method 97 
reaching a maximum between 12 and 24 hours. Therefore, the injections 
should be given during the early morning hours or late in the evening. 
References. For full discussion of the tuberculin test in diagnosis of tuber- 
culosis, see Hamman and Wolman, Tuberculin in Diagnosis and Treatment, 
1912, Appleton Company. 
Typhoid and Paratyphoid Fever 
The early diagnosis of typhoid fever by clinical or laboratory 
methods is important bnt often difficult. Clinical methods are 
inaccurate. Many laboratory methods are not of value until 
after the disease has become well established. Cultural examina- 
tion of the blood for the presence of the typhoid bacillus is the 
only practical method in the very earliest stages of the disease. 
This is a difficult procedure and not always satisfactory. 
The examination of the blood by the method of Widal to 
determine its agglutinability with the typhoid bacillus is of value 
after the first week or ten days of the disease. The appearance 
of this agglutinability varies in different cases; it may be con- 
siderably delayed. 
Previous treatment with typhoid vaccine may develop agglu- 
tinins in the blood thus obscuring the results of the diagnostic 
procedure for typhoid fever; but, if a person has been treated 
with typhoid vaccine and as a result of that treatment the blood 
serum agglutinates the typhoid bacillus at the time the examina- 
tion for diagnosis is made, it is probable that sufficient immunity 
will be present in the tissues to prevent the development of the 
disease. 
It is not improbable that some of the cases reputed to have 
been typhoid fever developing in vaccinated persons were not 
typhoid fever, and that the error in diagnosis was due to the 
presence of agglutinins. 
It should be borne in mind that the agglutination reaction in 
typhoid fever is simply the development of a property of the blood 
normally present in health, and thus in degree only significant 
in diagnosis. 
The examination of feces in cases of typhoid fever is an 
extremely important procedure not only in the diagnosis of the 
disease, but in the detection of carriers of the disease. In the 
diagnostic 'examination of the feces the presence of the typhoid 
4 
Diagnosis 
of typhoid 
fevei 
Agglutina- 
tion reaction 
Examination 
of fecal 
specimens 98 
bacillus leaves no question about the nature of the disease. It 
is only in the later weeks and during convalescence that 
the typhoid bacilli appear and persist in the feces. During 
convalescence they are likely to be discharged intermittently so 
that frequent examination is necessary. The presence of typhoid 
bacilli in the feces of cases after three months of convalescence 
suggests a permanent carrier state, and such persons should be 
kept under observation, reporting for examination at intervals. 
Typhoid bacilli have been found in the urine in approximately 
25 per cent of cases of the disease. The examination of urine 
for these organisms is seldom of value before three weeks after 
the onset of the disease and is therefore more practical from a 
hygienic than a diagnostic standpoint. The bacilli may persist 
in the urine far into convalescence. In most instances where 
typhoid bacilli are found in urine, albumin is present in consider- 
able quantities. The bacilli usually appear and disappear with 
the albuminuria. 
Paratyphoid fever resembles typhoid fever so closely that 
laboratory examinations alone establish differential diagnosis. 
Agglutination of the blood serum in cases of paratyphoid fever may 
not be so marked as similar agglutinations with the blood serum 
of typhoid patients. The Widal reaction, therefore, may not be 
so definitely diagnostic. During the acute stages of the disease 
the blood culture often contains the bacilli which can be identified 
readily by cultural reactions. From specimens of feces the para- 
typhoid bacilli are isolated by methods similar to those used in 
the examination for typhoid bacilli. The methods of isolation 
and care of the patient and of convalescent and permanent car- 
riers correspond closely to those necessary in the care of the 
typhoid fever patient. 
Typhoid 
bacilli in 
urine 
Paratyphoid 
fever 
Collection of 
material 
Two outfits are distributed by the department, one for the col- 
lection of specimens of feces, blood and urine for the isolation 
of typhoid and paratyphoid bacilli, and one for the collection of 
blood for the agglutination test. Both of these outfits contain 
green information blanks with directions for the use of the outfit. 
When the physician submitting a specimen is in doubt as to 
Laboratory Specimens 99 
whether he is dealing with a case of typhoid or one of paratyphoid 
fever, he should make this fact known at the time of submitting 
the specimen, in order that agglutination tests may be made for 
both diseases. It is also more convenient for the laboratory 
workers if physicians would indicate at the top of the slip whether 
specimens of feces, blood or urine are being submitted by cross- 
ing out the words not applying to the specimen submitted. 
Form Used in Submitting Information Accompanying 
Specimens From Cases of Suspected Typhoid, Para- 
typhoid or Dysentery 
(Front) 
Examination of Feces or Blood, or Urine 
(See directions for collecting specimens on other side.) 
ENTERIC DISEASES 
Number of specimen from this patient 1, 2, 3, 4, 5, etc. 
Results of previous examinations: Stool. 
Widal 
Date of collecting specimen 
Urine 
Blood culture 
Time 
Address 
Name of patient 
Age 
. Sex 
Occupation 
Color 
Clinical diagnosis 
Time resident in present locality 
Absences 
Duration of disease. 
How contracted 
Has patient previously had typhoid or paratyphoid fever, or bacillary dysen- 
tery? 
When ? 
Has patient had vaccines? 
What? 
When? 
Symptoms (strike out those not observed) . 
Fever, nosebleed, rose spots, diarrhea, bloody stools, delirium, tenderness 
right iliac region, gurgling, palpable spleen, bronchitis, chills, sweating. 
Other information concerning specimen 
Name and address of physician 
Name and address of health officer 
By whom was this specimen taken? 
Physicians are requested to answer all questions on the blank up to this 
point and return it with the specimen. 
Laboratory number 
Examined 
Received 
Result of examination. 
Examiner 100 
Directions for Collecting Specimens of Feces 
(Back) 
With the enclosed swab emulsify in the glycerine (10 cc. of 
30% glycerine) a bit of the feces the size of a pea. Specimens 
of feces are more satisfactory for examination if fluid. If the 
clinical conditions warrant it may be advisable to give a cathartic 
before the specimen is collected. After the specimen has been 
transferred to the tube of dilute gylcerine burn the swab. Stopper 
tube tightly and pack carefully. Label tube with name of patient. 
Fill out the information blank and mail it with the specimen to 
the State Laboratory, New Scotland Avenue, Albany, N. Y. 
Directions for Collecting Specimens of Urine 
The feces outfit containing glycerine (10 cc. of 30% glycerine) 
may be used. 
Soak swab in urine that has been secured in as aseptic a man- 
ner as possible. Stir swab in glycerine. Burn the swab. Stopper 
tightly and pack securely. Label tube with name of patient. Fill 
out the information blank and mail it with the specimen to the 
State Laboratory, New Scotland Avenue, Albany, N. Y. 
Directions for Taking Specimens of Blood 
For Widal Test: 
Cleanse lobe of ear with soap and hot water. Rub lobe with a 
clean towel wet with alcohol. Prick lobe with sharp surgical 
needle and manipulate to secure free flow of blood. 
Allow one drop of blood to fall into the hollow of each aluminum 
plate. Allow this to dry in the air without heating it. Place the 
aluminum plates face to face in the small envelope. Label 
envelope with name of patient. Fill out the information blank 
and mail it with the Specimen to the State Laboratory, New Scot- 
land Avenue, Albany, N. Y. 
For Blood Culture: 
Cleanse lobe of ear as described above. 
Allow 10 drops of blood to fall into the tube of glycerine. 
Stopper tube tightly and pack carefully. Label tube with name 
of patient. Fill out information blank and mail it with the speci- 
men to the State Laboratory, New Scotland Avenue, Albanyr 
N- Y. 101 
Form Used in Reporting Presence of B. Typhosus, B. Para- 
typhosus or B. Dysenteriae in Specimens of Excreta 
, 19 
Laboratory number 
In the specimen of feces from 
Name 
Address 
Taken on 
For or by 
Dr. 
B. typhosus 
B. paratyphosus 
B. dysenteriae 
were found. 
AUGUSTUS B. WADSWORTH, M. D. 
Director 
Dr. 
Health Officer 
Form Used in Reporting Negative Results of Examination 
of Specimens of Excreta for Presence of B. Typhosus, 
B. Paratyphosus and B. Dysenteriae 
. 19 
Laboratory number 
In the specimen of feces from 
Name 
Address 
Taken on 
For or by . . 
Dr. 
B. typhosus 
B. paratyphosus 
B. dysenteriae 
were not found. 
Failure to find the bacilli of enteric disease in the feces does not necessarily 
exclude infection. The bacilli may be present in such small numbers that 
they could not be isolated. In all doubtful cases specimens of feces and urine 
should be sent for confirmatory examination, especially from convalescents 
and carriers. Specimens of feces are more satisfactory for examination if 
fluid. 
AUGUSTUS B. WADSWORTH, M. D. 
Director 
Dr. 
Health Officer 102 
Form Used for Reporting Presence of Agglutination 
Reaction in Blood From Cases of Suspected 
Typhoid Fever 
, 19 
Laboratory number 
The specimen of blood from 
Name 
Address 
Taken on 
For or by 
Dr. 
Gives the characteristic agglutination reaction with the typhoid bacillus. 
If the clinical manifestations are also typical the disease may be considered 
typhoid fever. 
If there are no other symptoms of typhoid fever and if typhoid vaccines 
have not been recently administered, the case may be a " carrier." Specimens 
of the feces and urine should be forwarded for special examination. Specimens 
of feces are more satisfactory for examination if fluid. 
AUGUSTUS B. WADSWORTH, M. D. 
Director 
Dr. 
Health Officer 
Form Used in Reporting Negative Results in Tests for 
Agglutination with Typhoid Bacilli 
, 19 
Laboratory number 
The specimen of blood from 
Name 
Address 
Taken on 
For or by 
Dr. 
Does not give the characteristic agglutination reaction with the typhoid 
bacillus. 
A comparatively small percentage of the cases of typhoid fever react typi- 
cally during the first week. During and after the third week of the disease 
only a comparatively small percentage fail to react. 
The absence of a positive reaction does not exclude typhoid infection. In 
all doubtful cases, specimens for confirmatory examination should, be for- 
warded at once. It is advisable, also, to send specimens of feces and urine for 
special examination. Specimens of feces are more satisfactory for examination 
if fluid. 
AUGUSTUS B. WADSWORTH, M. D. 
Director 
Dr. 
Health Officer 103 
Vaccination Against Typhoid and Paratyphoid Fever 
The administration of typhoid vaccine has proved to be an 
effective preventive against typhoid fever under ordinary condi- 
tions. Experience in the army, however, has demonstrated that 
it should not be expected to give absolute protection when other 
ordinary precautions are neglected. The immunity produced 
may not be sufficient to protect against repeated and massive doses 
of the infective agent. 
Beside a typhoid vaccine the department prepares a combined 
typhoid and paratyphoid vaccine, which is now very generally 
used. While the combined vaccine contains more bacteria, 
results indicate that the reactions from its use are but little more 
frequent or pronounced. The vaccines are not recommended as 
therapeutic agents to be used after the disease has developed. 
They should be kept in the cold. After six months the vaccines 
deteriorate and should be returned to the laboratory with other 
supplies semi-annually (January and July). 
The following directions for use of typhoid and paratyphoid 
vaccine appear in a circular issued by the Division of Laboratories 
and Research: 
TyphoK 
Typhoid-pan- 
typhoid 
vaceina 
The vaccine is injected with a sterile hypodermic syringe not too deeply 
into the subcutaneous tissues - usually over the insertion of the deltoid. 
The site of inoculation should be cleansed with soap and watex- and disinfected 
with alcohol or by the application of tincture of iodine. 
Three doses are usually administered at intervals of seven to ten days. 
For the first dose the number of dead bacilli is one-half that of the second and 
third doses. Although the dosage should not exceed the standard amounts 
given below in ordei' to reduce the severity of the reactions occasionally 
induced by the inoculation, slightly smaller doses may be given. If the dose 
is materially reduced, however, the number of inoculations should be corre- 
spondingly increased. The dosage for children should be reduced in propor- 
tion to the body weight as compared with that of an adult. In the treatment 
of carriers it is recommended that the treatment be continued for some time,, 
the dosage being gradually increased. 
The reaction induced by the vaccines varies; it may be practically negli- 
gible but usually consists of localized congestion with redness, swelling and 
tenderness. These local reactions may be accompanied by varying degrees of 
systemic disturbance, general malaise and fever. Pronounced systemic 
reactions are, however, rare and are transitory in character. It is advisable 
to give the inoculations late in the afternoon so that if a reaction occurs it 104 
will be at night. During the menstrual period and in case of illness, the 
injections should be postponed. 
Typhoid vaccine is prepared for distribution in outfits containing three 
separate doses for the immunization of one person, and in bottles containing 
10 cc. for the immunization of a number of persons at one time. Each cubic 
centimeter contains 1000 million dead bacilli. 
Typhoid-paratyphoid vaccine is also distributed in individual immunizing 
sets and in bottles containing 10 cc. of dead bacilli. Each cubic centimeter 
contains 1000 million typhoid bacilli and 750 million each of paratyphoid 
A and B. 
Initial dose (for adults) 
Typhoid vaccine 500 million bacilli (0.5 cc.) 
Typhoid-paratyphoid vaccine 1250 million bacilli (0.5 cc.) 
Second and third doses 
Typhoid vaccine 1000 million bacilli (1 cc.) 
Typhoid-paratyphoid vaccine 2500 million bacilli (1 cc.) 
The bottles should always be carefully shaken to make sure that when the 
doses are divided the sediment is suspended evenly in the solution. 
procedure of Recording and Reporting the Results of Laboratory 
Examinations 
iraportasce 
Iii a large laboratory the clerical procedure of recording the 
receipt of specimens and reporting the result of their examination 
becomes a complex problem of the utmost importance. Unless the 
greatest care is taken errors are certain to occur. Every labora- 
tory should keep an accession book in which every specimen should 
be recorded as soon as it is received. A system of numbering the 
specimens, keeping the original records of the examinations, send- 
ing the reports and checking against error is also essential in a 
well conducted laboratory. Every step in the work must be 
initiated by the worker in order to fix responsibility and trace 
errors if they occur. 
In the central laboratory in Albany, the procedure has been 
very carefully developed as a result of practical experience, and 
is essentially as described below. 
Stained specimen slides, after examination, are indexed and 
filed for future reference. Accession books are kept in the 
laboratory for the purpose of recording the receipt of every speci- 105 
men, and when the examinations have been made, the results are 
also recorded in these books - thus safeguarding against the loss 
or misplacement of any specimen in the laboratory. 
All specimens are examined and reported as promptly as 
possible after their receipt. With the exception of miscellaneous 
examinations, reports are sent to the physician sending in the 
specimen and to the health officer of the district in which the 
patient lives. Reports on miscellaneous examinations are sent 
to the health officer only on his special request and when they have 
reference to communicable diseases. Reports are not given to any- 
one except the physician sending in the specimen and to the health 
officer. Laboratory specimens arriving through the mails at night 
are collected periodically during the night and those requiring in- 
cubation are paced immediately in the incubators, in order that 
they may be ready for examination at the earliest possible moment 
on the following day. Physicians should send the specimens in 
the type of mailing case designed for them or indicate plainly on 
the outside of the mailing case the kind of specimen being sent, 
since it has not been thought advisable to allow the night watch- 
men to open the containers for fear the specimens might become 
mixed. Specimens from suspected cases of acute communicable 
diseases (tyhoid and paratyphoid, dysentery, diphtheria, etc.) 
received or becoming ready for examination (following incuba- 
tion) on Saturday afternoons, Sundays, and holidays, are ex- 
amined and reported upon immediately. 
When a first culture for the diagnosis of diphtheria is positive 
and apparently no antitoxin has been administered, a telegram 
is sent both to the attending physician and health officer, unless 
otherwise specifically directed on the information blank, in which 
case a telegram is sent only to the health officer; also when the 
information blank does not state whether or not antitoxin has 
been administered, telegrams are sent in the same way (cultures 
clearly marked for release are not considered primary cultures 
even though they may be the first culture sent to the laboratory). 
When physicians indicate on the history blank that the diag- 
nosis has been made and the culture sent to confirm diagnosis, 
telegrams are not sent. 
Mail report* 
Immediate 
attention to 
specimens 
Telegraphic 
reports 106 
When a telephonic report is requested on an information blank 
accompanying a specimen from any place outside of Albany or 
Rensselaer a telegram is sent instead, in order to save time and 
expense. All reports by telegraph and telephone are sent " col- 
lect," as the State has not provided an appropriation for this 
purpose. 
Complaints Regarding Service 
Constructive 
criticisms 
welcomed 
Health officers who have encountered apparently unnecessary 
delays in receiving laboratory supplies or reports upon diagnostic 
specimens, or who feel that they are not receiving satisfactory 
service, are urged to submit complaints to their sanitary super- 
visors or directly to the laboratory. All complaints received will 
be investigated and, so far as practicable, the health officers will 
be advised of the results. Constructive criticisms will be gladly 
received and will be given careful consideration. 
Distribution of Laboratory Supplies* 
To whom 
shipped 
Ordinarily supplies are sent to health officers, institutions and 
hospitals only. Physicians, nurses and laymen asking for sup- 
plies are referred to their health officers. If the records show 
that the health officer has not a sufficient stock on hand from 
which to fill the order, he is sent a supply with an explanatory 
letter. 
In order to insure prompt service and to reduce the possibili- 
ties of errors, all requests for supplies should be sent without 
exception directly to the Division of Laboratories and Research. 
Health officers on Long Island and in Westchester and Loch- 
land counties should obtain their supplies from the Branch 
Laboratory, New York State Department of Health, 338 East 
26th street, New York city. Any shipments made from the 
State laboratory at Albany to health officers in these districts 
contain labels addressed to the branch laboratory. 
When ordering supplies health officers should use Form 
No. 42, "Report on Laboratory Supplies." These forms may 
be obtained from the laboratory on request. (See page 109) 
Requisition should invariably state the exact amounts of each 
supply required. 
District 
served by 
branch 
laboratory 
Requisitions 
for supplies 
* See "Distribution of Laboratory Supplies, under New Law," p. Ill 107 
Laboratory supplies requested by health officers are sent within 
twenty-four hours of the receipt of orders, except when after 
January 1 and July 1 the orders are received in such large 
numbers that a delay of a few days is unavoidable. Telephonic 
and telegraphic orders are, so far as possible, shipped on the first 
express train leaving Albany after the receipt of the order. 
Supplies are given to health officers and other physicians call- 
ing at the laboratory, or sending properly accredited messengers. 
As applied to physicians who are not health officers, however, this 
is a matter of accommodation as it is preferred that they obtain 
their supplies from their health officers. 
Owing to the time and outlay required in the preparation of 
antitoxin and vaccine and the very large amount of unused and 
outdated material returned by health officers each year, it has 
seemed advisable to fill routine stock orders with some reference 
to the population to be served. 
In order to encourage the sending of further specimens a 
sputum container is sent to every physician (who is not a health 
officer), sending in a specimen of sputum which proves on 
examination to be negative. 
Certain supplies should be exchanged periodically, in accord- 
ance with the rules and regulations for supply stations. All 
perishable supplies, as they become outdated or old, should be 
returned to the laboratory and new material requisitioned. 
Exchange of supplies should be so arranged that the health officer 
will at no time be without sufficient supplies to provide for pos- 
sible emergencies. 
Health officers are required to sign and return for the labora- 
tory files the Rules and Regulations for Supply Stations which 
follow: 
Orders by 
mail, tele- 
phone, or 
telegraph 
Orders by 
messenger 
Population 
considered. 
Sputum con- 
tainers to 
physicians 
Return of 
old supplies 
Supply station 
agreement 
Rules and Regulations foe Laboratory Supply Stations * 
The term " Laboratory Supply Station " applies to any place, including the 
office or place of residence of the health officer, at which supplies furnished by 
the Division of Laboratories and Research are kept for distribution. 
In cities or districts in which it is not convenient for all physicians to 
secure supplies from one center, the health officer may, with the approval of 
the director of the laboratory, establish substations. When doing so, however, 
the health officer will be expected to assume full responsibility for the condi- 
* Attention is called to the fact that the following are not the rules and 
regulations referred to in chap. 620, Laws of 1920 (page 112). 108 
tions under which supplies are kept and to account for them periodically. A 
list of all substations shall be kept at the laboratory in Albany, which should 
be notified promptly of changes. 
It is important, from the standpoint of the protection of public health, that 
supplies be always adequate, easily available and in usable condition. 
In view of the cost and amount of materials used, economy is also an import- 
ant consideration. For the foregoing reasons, the department feels justified in 
requiring health officers in charge of supply stations to maintain proper 
standards and to comply with certain reasonable requirements: 
1. All supplies must be kept where they will be accessible to physicians 
at all times. Arrangements should be made so that, in the absence of the 
health officer, they may be dispensed by some other competent person 
designated for the purpose. 
2. Antitoxins, serums, vaccines, culture media and other perishable 
products should be kept in an ice chest. If this is impossible they should 
be kept in a cold dark place in a cellar.* They should never be kept at 
ordinary room temperature. 
3. Antitoxins and serums should be exchanged annually, or one year from 
date of test recorded on the label. Typhoid, paratyphoid and other bacterial 
vaccines should be exchanged half-yearly, or six months from date of 
preparation recorded on the label. All products bearing expiration dates 
should be exchanged on or before such dates. Culture tubes should not be 
used if the medium is contaminated or liquefied or after it has dried or 
separated from the sides of the tube. 
4. Tubes containing culture medium should be inspected periodically 
(once in two or three weeks), and any unfit for use set aside to be 
returned to the laboratory at Albany. 
5. The various therapeutic and preventive products are distributed for 
the treatment or immunization of inmates of State or charitable institu- 
tions and residents of the State unable to procure the remedy or to whom 
the purchase of it would be a hardship. These preparations may also be 
used in any emergency in which their use is likely to conserve life or 
health. 
6. Laboratory supplies distributed by the State are not to be sold under 
any circumstances. A violation of the above rule will subject the violator 
to the penalty prescribed by section 1740 of the penal code, which is as 
follows: 
"A person who wilfully violates any provision of the health laws, or 
any regulation lawfully made or established by any public officer or board 
under authority of the health laws, the punishment for violating which is 
not otherwise prescribed by those laws, or by this code, is punishable by 
imprisonment not exceeding one year or a fine not exceeding two thousand 
dollars, or by both." 
7. Laboratory supplies will be shipped, express charges collect. Sup- 
plies returned for exchange or specimens forwarded to the laboratory 
should be sent prepaid by express or by mail. 
* For convenience of health officers and others maintaining supply stations, the 
department has arranged with the Prison Department to furnish tin boxes in two 
sizes:-Size (10 x 10 x 8) at a cost of $1.10; size B (15% x 10 x 8) at a cost 
of $1.25. These boxes are painted white and marked " New York State Department 
of Health Supply Station." Send orders and remittances to " Warden Clinton 
Prison, Dannemora, N. Y." 109 
8. All specimens for examination should be mailed in time for the first 
outgoing mail. 
9. In ordering supplies, form No. 42 should always be used. In 
emergencies, telephone or telegraph and follow with the requisition form, 
which should be marked " Confirmatory." Order only such quantities as 
are likely to be used, with reasonable allowance for emergencies. 
10. Physicians, by accepting antitoxins, serums and other specified 
products, assume the obligation to report on the use of such preparations 
on the special form accompanying each package. These report forms 
should be filled out completely by the physician and returned by him 
directly to the State laboratory at Albany, or to the health officer, who 
should return such reports to the laboratory when ordering supplies or 
with the semi-annual report. 
11. The health officer, or person in charge of a supply station, should 
file a report with the Director of the Division of Laboratories and Re- 
search on the first of January and July of each year, using form No. 42. 
12. Any infringement of these rules and regulations may be considered 
sufficient reason for the removal of the Station. 
I hereby agree to make every reasonable effort to comply with and to carry 
out the foregoing requirements, thereby cooperating with the State Depart- 
ment of Health in promoting effective distribution and use of laboratory sup- 
plies in my district. 
Date. 
Name. 
Address. 
Sanitary District. 
Report on Laboratory Supplies 
.19. 
Town 
Village 
of. 
County of 
City 
Population Served by Supply Station. 
P. 0. Address 
The following shows the supplies on hand and the number of each needed: 
Diagnostic Outfits for Mailing Specimens: 
(Each outfit is designated by a color scheme and appropriate symbols on outside 
wrapper.) 
On Hand 
Needed 
Diphtheria, serum culture tube (blue label)-D 
(Specify with or without mailing cases) 
Typhoid fever, (feces) tubes containing glycerine 
(green label)-T 
Typhoid fever, (Widal) aluminum plates 
(green blank)-T 
[ Wassermann test 
Syphilis -J Outfit for blood serum }- (cherry red label)-V 
[ Sterile tube with needle J 
Gonorrhea, outfit containing slide 
(brown envelope)-V 
Tuberculosis, sputum jar..., (yellow label)-Tb 110 
Miscellaneous, glass jar for specimens 
(pink label)-M 
Miscellaneous, sterile swab tube for culture material 
<Suptum should be sent in this outfit for the bacterial diagnosis of pneumonia.) 
Miscellaneous, outfit of slides... (pink envelope)-M 
(pink label)-M 
Therapeutic and Prophylactic Preparations: 
Diphtheria antitoxin 
6000 units, therapeutic dose, bottles. 
3000 units, therapeutic dose, bottles. 
1000 units, prophylactic dose, bottles 
Tetanus antitoxin 
20000 units, therapeutic dose, bottles 
10000 units, therapeutic dose, bottles. 
1500 units, prophylactic, dose, bottles. 
Ophthalmia neonatorum, silver nitrate, 1 per cent 
(combined dropper and container of 15 cc.) 
solution (outfit for two treatments) 
(Bacterial vaccines are sent only on special request and should not be kept in 
■stock except in small quantities on account of deterioration.) 
Typhoid-paratyphoid vaccine (outfit for one person 
3 doses) 
(bottles of 10 cc.) 
Typhoid vaccine (outfit for one person, 3 doses) 
(bottles of 10 cc.) 
Pertussis vaccine (outfit for one person, 3 doses) 
(bottles of 10 cc.) 
Outfits for the Schick test, diphtheria toxin-antitoxin mixture and tuberculin are 
sent only on special application. 
Antimeningococcus serum is distributed from main depots, and from the labora- 
tory in Albany directly on application by telegram. 
Antipneumococcus serum for the treatment of pneumonia Type I is distributed 
through laboratory centers and is in charge of designated health officers. 
Dysentery vaccine, together with antidysentery serum for the treatment of 
bacillary dysentery, will be distributed for the present only on special application. 
Arsphenamine is distributed in ampules containing 2.4 grams, 0.6 grams and 0.4 
grams, for use in authorized clinics and institutions. 
Remarks 
I hereby certify that I have fulfilled all the conditions of my agreement 
with the Department, and further, that I have inspected all supply stations 
•established in my district. 
Health Officer 
Antitoxin (diphtheria and tetanus) should be exchanged at the end of a 
year: bacterial vaccines, antimeningococcus, antipneumococcus, and dysenterv 
serums every six months. 111 
Physicians and health officers are urgently requested to notify the labora- 
tory of any delay in receiving supplies or reports on specimens, of any defects 
in the outfits, and to offer any suggestions concerning improvement in the 
laboratory service to any district. 
The diagnostic facilities of the laboratory are designed primarily to render 
prompt assistance to health officers and physicians in the diagnosis and con- 
trol of communicable diseases, and to provide laboratory service for all per- 
sons in the State for whom such service is not otherwise available. 
Physicians are especially urged to make use of the facilities of approved 
cou/nty, municipal and private laboratories whenever such facilities are avail- 
able in their vicinities. 
Distribution of Laboratory Supplies Under New Law 
From Health Officers' Bulletin 
Chapter 620, Laws of 1920, which is presented below in full,, 
authorizes the State Commissioner of Health to establish labora- 
tory supply station districts and to appoint a custodian in each 
such district who shall have charge of the distribution of labora- 
tory supplies through a central station. 
In the past the Division of Laboratories and Research has dis- 
tributed antitoxins, serums, vaccines and various diagnostic 
specimen outfits, furnished for the use of physicians, through 
local health officers and a few special stations in local labora- 
tories and hospitals. Many of the thousand or more local health 
officers require supplies in small quantities, which has necessi- 
tated a vast number of small shipments and a large amount of 
clerical work in accounting for shipments and supplies exchanged.- 
Since health officers have received no extra compensation for this- 
service, it has been difficult to enforce the Department's require- 
ments regarding conditions under which laboratory supplies 
should be kept. The result has been a serious waste of perishable 
products, prepared at considerable expense, and health officers 
unexpectedly called upon for culture tubes or antitoxins for use 
in emergencies have sometimes found their supplies so seriously 
determinated as to be unfit for use. 
The new law makes the following provisions which it is hoped' 
will correct some of these conditions: 
It authorizes the -State Department of Health to prescribe con- 
ditions under which supplies -shall be kept and provides for the 
payment of necessary expense of maintaining supplies under 
ironer conditions. 112 
Custodians of district stations, appointed by the State Com- 
missioner of Health, are entitled to annual compensation, upon 
certification of the State Health Department that supplies have 
been maintained and distributed in accordance with its 
regulations. 
It authorizes the district custodian to designate necessary sub- 
stations in his district, subject to the approval of the State Depart- 
ment of Health. 
The law became effective when it was signed by Governor 
Smith on May 10; but since its operation involves a complete 
readjustment of procedure and many administrative details, and 
successful operation depends in large measure upon careful plan- 
ning of districts and wise selection of custodians, it will be some 
time before it will be fully operative * 
CHAPTER 620 
AN ACT to amend the public health law, in relation to the establishment of 
district laboratory supply stations. 
Became a law May 10, 1920, with the approval of the Governor. Passed, 
three-fifths being present. 
The People of the State of New York, represented in Senate and Assembly, 
do enact as follows: 
Section 1. Article two of chapter forty-nine of the laws of nineteen hundred 
and nine, entitled "An act in relation to the public health, constituting chap- 
ter forty-five of the consolidated laws," is hereby amended by inserting therein 
a new section, to be known as section five, and to read as follows: 
§ 5. Laboratory supply stations. The state commissioner of health may 
establish stations, to be known as district laboratory supply stations, for the 
distribution of laboratory supplies furnished by the state department of 
health. He may designate districts to be served by such district laboratory 
supply stations, each such district to include one or more municipalities. 
The term " municipality " as used in this article means a city, village, town 
or consolidated health district. The state commissioner of health may appoint 
the health officer of any municipality, the director or person in charge of 
any public health laboratory, or the director or person in charge of any 
health center, located in each such district, to serve as the custodian of the 
supply station thereof. The health officer or other person so appointed shall, 
with the approval of the state department of health, establish such sub- 
stations as may be necessary for the proper distribution of laboratory supplies 
to all physicians practicing in the district. Each district laboratory supply 
station and the substations thereof shall be maintained and operated in accord- 
ance with the rules and regulations of the state department of health and 
shall be subject at all times to inspection by authorized representatives of the 
*EstabIishment of district supply stations begun January 1, 1921. 113 
state commissioner of health.- The state commissioner of health may at any 
time discontinue any district supply station or substation or rescind any 
appointment previously made under this act, when in his judgment or that 
of his authorized representative such action will be in • the interest of the 
public health. The custodian of each district laboratory supply station estab- 
lished and operated under this act shall, upon certification of the state depart- 
ment of health that he has maintained and operated such station and the sub- 
stations thereof in accordance with its prescribed rules and regulations, be 
entitled to receive annually the sum of twenty dollars in consideration of 
services rendered in the administration of such district laboratory supply 
station, together with the sum of ten dollars for each substation established 
and operated in accordance with the provisions of this article, and the actual 
and necessary expenses of operation and maintenance of the district labora- 
tory supply station and substations thereof, such sums to be a charge upon 
the municipalities included in such district, such charges to be distributed 
among the municipalities so included upon the basis of population in accord- 
ance with the last federal or state enumeration.* 
§ 2. This act shall take effect immediately. 
The Collection of Samples of Water, Sewage and Ice for 
Bacterial and Chemical Examination 
The Department examines samples of water whenever the 
results of the examination are likely to be directly applicable to 
the prevention of disease and the protection of the public health. 
Samples from private wells are accepted for examination when 
accompanied by a statement of the results of a sanitary survey 
of such wells and their surroundings. (See form, page 125.) 
Bequests are numerous for examination of samples from wells 
on premises upon which single cases of typhoid fever have 
occurred. It should be borne in mind that the results of labora- 
tory examinations in such instances are of value only as they 
confirm previous epidemiological findings. The fact that a 
patient who has typhoid fever has used the water from a certain 
well in no sense proves that he thus received his infection, even 
though the water at the time of sampling may show evidences 
of fecal pollution. There is usually an interval of at least two 
weeks between the date upon which the patient receives his infec- 
tion and that upon which the sample is taken, with possibilities 
of material changes in conditions affecting the results of water 
When samples 
will be 
accepted 
Well water 
and typhoid 
* An endeavor will be made to secure an amendment making the fees and 
expenses, in districts including more than one municipality, county rather 
than municipal charges, with a view to simplifying administration. 114 
analysis. Fecal pollution, if found, may be of animal origin. 
Whether the source is from man or domestic animals can be 
determined only through investigation of local conditions. 
If the water has been responsible for the transfer of the 
infectious agent, the latter must have been discharged by a case 
or carrier. Every effort should be made to discover this case or 
carrier, the result of water analysis being regarded as another 
li link " in the chain of evidence. 
The health officer, whenever a laboratory examination is 
desired in his investigation of a water supply within his juris- 
diction, should advise the sanitary supervisor of the district of 
the existing conditions together with his reasons for requesting' 
the examination of samples. The sanitary supervisor, if in his 
opinion the laboratory analysis is required, will then send the 
proper containers or ask that they be sent from the laboratory. 
Health officers and sanitary supervisors should state in their 
requests for containers the number of chemical samples and the 
number of bacterial samples they wish to take in the course of the 
investigation of the water supply. Whenever a large sample for 
chemical examination is taken one bacterial sample should also 
be taken at the same point in the supply, although other bacterial 
samples may also be taken from other points in the supply. 
All containers are to be sent by express collect and returned 
to the laboratory by express prepaid. 
On receiving the containers, the health officer should select 
the information blank descriptive of the water to be examined 
and answer all the questions relating to the conditions which he 
has found in his inspection. 
No samples will be examined in the laboratory the sources of 
which have not been so inspected that all the inquiries can be 
answered. Having completed his inspection and made his report 
of it on the information blanks, the health officer should take the 
necessary samples following explicitly all directions. 
The, laboratory examination determines the presence or absence 
of pollution at the time of the sampling. 
The field inspection determines the sources and the nature of 
the pollution and thus the significance of its presence or absence. 
Select proper card; either ground water (well, spring, infiltra- 
tion gallery), light green; or surface water, untreated (stream, 
Securing con- 
tainers 
Information 
required 
Inspection 115 
pond or lake), pink; or treated water, blue. When, in describing 
a treated water', it is necessary to describe also the source of the 
raw water use two cards, one for the treated water and another 
for the raw water. 
After recording all data concerning the source of supply and 
the shipment of samples, the bacterial and chemical samples 
should be carefully marked and the markings recorded. For 
example: Samples are taken from each of several points in one 
system. Bacterial and chemical samples from the same point, 
marked with the same letter A, would therefore be taken from 
stream, tap or other point in the supply-A, as recorded on the 
descriptive card. 
Samples, bacterial or chemical, marked B from stream, tap 
or other point in the supply - B, as recorded on the descriptive 
card. The sources of chemical and bacterial samples taken from 
different points and marked with different letters would therefore 
be recorded after the corresponding letter on the descriptive card. 
Ground waters receive pollution, either from surface washings 
at the surface of the ground or from subsurface drainage through 
the soil or through fissures or channels in rocks. It is, therefore, 
necessary to inspect and record data descriptive of the well or 
spring or infiltration gallery as indicated on the card in order 
to show, first, whether or not the well is protected structurally 
from the access of pollution to it; and second, the nature and 
location of, and the drainage from, nearby sources of pollution. 
Surface waters receive pollution at different points from dif- 
ferent sources and through different tributaries. This pollution 
is altered by sedimentation, dilution, storage, and numerous other 
natural agencies. It is, therefore, necessary to record the num- 
ber, character, and size of the streams, ponds, or lakes, constitut- 
ing the supply, and the construction, capacity, and operation of 
storage reservoirs used in distributing the supply. Especially is 
it necessary to record, in so far as it is possible, complete data 
concerning the watershed and all probable sources of pollution 
and all safeguards against this pollution, as indicated on the card. 
Two cards are often required to record complete data concern- 
ing treated water supplies. In order that the raw water may be 
Description 
for identifica- 
tion 
Ground waters 
Surface 
waters 
Treated 
water 
supplies 116 
fully described, it should be described independently, as an 
untreated supply, on the appropriate card. 
Different methods of purification and different combinations 
of these methods are used in the treatment of water; hence, all 
the data on the card will not be required in describing any one 
purification plant. But owing to the fact that the efficiency of 
any method of purification or combination of methods is wholly 
dependent upon the accuracy with which each step of the process 
is carried out, it is necessary to have all structural and operative 
details accurately recorded, as indicated on the card. The 
technical details of construction and operation must be obtained 
from experts in charge of the plant. 
Having recorded all of the data requested on the card 
descriptive of the particular water under investigation, any 
further information elicited in the course of the inspection regard- 
ing conditions liable to affect the sanitary quality of the water, 
together with any further explanatory diagrams, should be noted 
under " remarks " or on the blank card furnished for this 
purpose. Except for the instance above mentioned, when the raw 
water of a treated supply is described, it is only necessary to fill 
out one descriptive card for each source of supply. The dif- 
ferent samples, bacterial and chemical, coming from different 
points of a source of supply, can be identified by the different 
letters, A, B, C, D, etc., used to label the samples, the respective 
points at which these samples were taken being noted on the 
descriptive card. 
All the cards should be replaced in the inner envelope, which is 
addressed to the laboratory, and from which they were taken. 
This envelope should be tied securely to the box containing the 
samples for shipment. 
General 
observations 
Directions for Taking Samples of Water for Bacterial 
Analysis 
The small bottles for bacterial samples in the insulated con- 
tainer have all been sterilized. They should be handled with the 
greatest care to avoid contamination. If by accident a bottle 
should become contaminated or there is any suspicion of its 
having become contaminated it should be so marked and a fresh 117 
bottle taken for the sample, leaving the contaminated bottle empty. 
The hands should be carefully washed and dried before taking 
the sample. 
Test the stopper to be sure that it is loose before removing the 
cloth. If necessary loosen it by gentle taps with a pocket knife 
or similai' object. Remove the cloth cover and loosen the edges 
of the tinfoil. Hold the bottle at or near the bottom with one 
hand and avoiding accidental pollution with the other remove 
the stopper still covered with the tinfoil. 
While collecting the sample be sure that the exposed stopper 
does not touch anything, that the neck of the bottle is not con- 
taminated by the hands and that the water does not flow over the 
hands into the bottle. The bottle should be tilled to within half 
an inch of the stopper, leaving only sufficient air space for 
expansion. Replace the stopper and the tinfoil, pressing it 
around the neck and tie the cloth securely. 
Label each sample A or B or C, etc., and be sure that the proper 
descriptions of these samples have been entered after the same 
letter on the green, pink or blue card on which is recorded the 
result of the inspection. (See pages 121-126.) 
Collection of Samples of Water 
Fig. 1 
Fig. 2 
Fig. 3 
Figure 1. Loosening edges of tinfoil. 
Figure 2. Taking a sample from a tap. Note that the tinfoil 
is not removed from the stopper. 
Figure 3. Pressing tinfoil around neck of hottie after replac- 
ing the stopper. 
Return the bottles to their places in the case. 
The tin box should be filled with ice mixed with a little sawdust 
and covered tightly. 118 
Special Precautions in Taking Samples from Different Sources 
Taps from which samples are to be taken should be located on 
a main which is in constant use and in no instance should a 
sample be taken from one placed on a dead end. 
The water should be allowed to run for ten minutes before the 
samples are taken. 
Wells should have at least five to ten pails of water pumped 
from them before the sample is taken.* 
In the absence of pumps when pails or buckets are used for 
taking samples they should be carefully cleaned, being careful 
not to touch their inner surface with the hands, and thoroughly 
rinsed with boiling water before they are used for this purpose. 
In ponds, reservoirs or streams the samples should be taken in 
a sufficient depth of water to avoid disturbing the sediment on the 
bottom or near the edges, or otherwise disturbing the conditions 
usually present. Grasping the bottle in the right hand near the 
bottom as above directed, plunge the bottle, mouth downward, 
well under the surface, keeping the hand on the downstream side 
of the bottle; then carry the bottle up stream under the surface 
and out of the water, all in one continuous motion. Great care 
should be taken to avoid having the water flow over the hand into 
the bottle and also to plunge the bottle quickly below the surface 
and remove it quickly to prevent any scum on the surface of the 
water from entering the bottle. In rapidly flowing water the- 
bottle may be allowed to fill, holding the neck up stream. In 
shallow waters the greatest care must be exercised to avoid dis- 
turbing the sediment. 
Directions for Taking Samples of Water for Chemical 
Analysis 
The large bottle for the chemical sample has been carefully 
cleaned and rinsed with distilled water, but it has not been 
sterilized. In selecting water for the sample precautions similar 
to those recommended for the collection of bacterial samples 
should be observed. The bottle should first be filled with the 
* If while pumping this water from a well there is any overflow or splash- 
ing of the water back into the well, this fact should be noted. 119 
water to be collected and then emptied. The bottle should then 
be refilled for the sample, taking all precautions against the 
■entrance of foreign material. The sample should be taken 
directly if possible without the use of a pail, dipper, funnel or 
other similar apparatus. When these are necessary they should 
be absolutely clean and thoroughly rinsed in the water which is 
to be sampled. The bottle should be filled to within two inches 
of the stopper, leaving only sufficient air space for expansion. 
The stopper* should be kept free from contamination as in tak- 
ing the bacterial samples and should be replaced after the sample 
has been taken. Finally the stopper and neck of the bottle should 
be covered with a piece of cloth and tied securely. The ends of 
the string may then be sealed but never seal the stopper. Label 
the bottle A or B or C, etc., and be sure that the proper descrip- 
tions of these samples have been entered after the same letter on 
the green, red or blue card on which is recorded the results of the 
inspection. 
Directions for Taking Samples of Sewage 
The procedure differs in no essential from that of taking 
samples of water except that it is necessary to have a composite 
sample for chemical analysis. To the large sample bottle add 
10 cc. or one-third of an ounce of chloroform. This bottle, dur- 
ing sampling and shipment to the laboratory, should be kept iced. 
At least every four hours, or in special instances, every hour or 
two during a twenty-four hour period, four or eight ounces of 
sewage, depending upon the number of fractional samples taken, 
should be added to the large sample bottle containing the chloro- 
form. The total composite sample should not be less than two 
quarts. All fractional samples added to the composite sample 
should be of equal volume. For very accurate determinations 
the volume of the fractional sample should be proportional to the 
* If by accident the stopper or the bottle should become soiled the bottle 
should be emptied, marked " used " and returned to the laboratory, the sample 
being taken in a fresh bottle. 120 
volume of sewage flowing at the time the fractional sample was 
taken, and so estimated; but this is rarely necessary and only 
when especially directed. 
All the precautions necessary to prevent the entrance of foreign 
material not actually present in the sewage, as described above 
for the collection of samples of water, must be observed. Samples 
of sewage for bacterial examination should not be sent to the 
laboratory except under special conditions, since this examination 
must be made very promptly if it is to be of any value. 
Directions for Taking Samples of Ice 
A cake of ice should be selected weighing about fifty pounds, 
but during the coldest weather a cake of twenty-five pounds will 
suffice. This should be packed with at least an equal bulk of 
sawdust in a box and forwarded to the laboratory. Cards for the 
description of ground water (green) or surface water (pink) or 
treated water (blue) should be used in recording the results of the 
field inspection of the water upon which the ice formed or from 
which it was made. 
Directions for the Shipment of Samples to the 
Laboratory 
Select through express routes and time the sampling to secure 
prompt shipment. 
Samples should reach the laboratory if possible within twenty- 
four hours after they have been taken and never later than forty- 
eight hours. 
Samples should be taken early in the week and not later than 
Thursday in order to avoid being in transit over Sunday. 121 
Private 
Institutional 
Public, Municipal, Corporate 
Samples from of 
(City, village or town) 
DESCRIPTION, SAMPLES Collected: Date 
Raptorial A 1 from R 1 from 
.County of. 
C 1 from 
What other municipalities supplied 
....Time. 
D 1 from .... 
Chemical A J B J C / D / 
Shipped via... express. Time..... 
DESCRIPTION, SOURCE OF SUPPLY: Name (stream, lake or pond) ' 
What other sources of supply used constantly - ...occasionally 
Does drought deplete supply -Do odors or tastes result from drought 
Does rainfall rapidly increase supply.. Does it render the supply turbid 
WATERSHED 
Yield of watershed or flow of stream if known - - 
Has the watershed precipitous 
.barren.... 
..forested. 
Approximate area of the watershed above intake 
Number of cities - villages 
Sewage, purified discharges from... 
Sewage, unpurified discharges from 
hamlets 
total population 
...total population - 
total population - 
TJaa waiorelipd hppn insnpnf.P.d DA trolled... 
bv whom 
how often..... 
Have rules and regulations been enacted for this watershed by this department -„ - - - - , - r- - 
Form for Sanitary Survey of Surface Waters 
Date received 
SURFACE WATERS (Untreated) 
(Front) 
Laboratory numbers. 
File number. 122 
I hereby certify that the samples of this water were collected by (name.. ) on (date 
.time ) and that I have followed explicitly all directions for packing in ice and immediate 
shipment by express; and further that I have inspected all conditions affecting the sanitary quality of this water and found them to be as above 
recorded. 
Sanitary Supervisor 
Health Officer 
appearance 
.capacity. 
.pumped or supplied by gravity to reservoir. 
Show by diagram 
.treatment.. 
.area less than 5 feet deep. 
Has much vegetation grown from bottom. 
Is there reason to suspect any connection between this water and the spread of typhoid fever or other disease. 
approximate average depth- 
.distributing. 
..taste... 
.diameter. 
.capacity in gallons. 
Is bottom paved. 
.elevation 
.elevation 
.elevation 
.elevation 
elevation 
.at what point. 
All containers are sent by express, collect; all samples must be sent, express prepaid. 
(Sac/c) 
Describe location of any of the following: 
..odor.. 
.height. 
.minimum. 
.distance.. 
.distance. 
.distance. 
.distance. 
distance 
LAKES OR PONDS: Give total area of lake or pond 
Are there complaints regarding sanitary quality. 
Trouble from algae or other microorganisms. 
Has the water a scum on the surface. 
.maximum.. 
Area greater than five feet deep. 
.number.. 
..number.. 
..number. 
..number. 
..number. 
Reason for requesting examination. 
Construction 
SOURCES OF POLLUTION 
Storage. 
RESERVOIRS 
STANDPIPES 
Are sides paved. 
Depth of water. 
A Privies. 
B Cesspools. 
E Barnyards. 
REMARKS:. 
C Sewers. 
D Drains. 
Area. 123 
Private 
Samples from. .of 
(City, village or town) 
DESCRIPTION OF SAMPLES 
Bacterial A \ f 
Collected: Date. 
B \ from 
Institutional Public, Municipal, Corporate 
..County of ...What other municipalities supplied 
Time 
. , from B ( from 
Chemical A J B J C J D J 
Shipped via._ .express. Time 
DESCRIPTION OF SOURCE OF SUPPLY: Source of the raw water (If necessary, describe on card for surface waters) 
Estimated capacity of the plant ( gals.) Daily consumption, gals. Maximum.. Minimum 
PRELIMINARY TREATMENT: Sedimentation:.. 1 .Basins / number construction 
( covered capacity 
Coagulation ...Coagulant .amount per gal 
Preliminary sterilization ..Chemical amount per gal.... 
Preliminary filtration -Type filter ..number of units 
Total area.. Rate per acre 
Bacterial efficiency of preliminary treatment, if known 
FINAL TREATMENT FILTRATION Type of filter 
Rapid Closed 
Rapid Open 
Slow (through sand) 
Number of units 
Pumped 
Gravity 
Pumped 
Gravity 
Area unit 
Total filtering area 
Working head or pressure 
Date received. 
Form for Sanitary S'urvey of Treated Water Supplies 
TREATED WATER SUPPLIES 
(Front) 
Laboratory numbers. 
Place. 124 
I hereby certify that the samples of this water were collected by (name . ....) on 
(date ....time ..) and that I have followed explicitly all directions for packing in ice and 
immediate shipment by express: and further that I have inspected all conditions affecting the sanitary quality of this water and found them to 
be as above recorded. 
Sanitary Supervisor 
Health Officer 
.Operating head. 
.Minimum. 
.How often.. 
.Appearance. 
.Air pressure. 
How often 
Method of application. 
Amt. per gal. water treated 
Is there reason to suspect any connection between this water and the spread of typhoid fever or other disease. 
.Uniformity coefficient. 
-Maximum 
How long. 
..Taste.. 
How often. 
..Size- 
Open or covered. 
Mechanical agitation. 
,By whom. 
All containers are sent by express collect; all samples must be sent express prepaid. 
(Back) 
By whom. 
.Rate gals, per acre per day. 
..Odor. 
Chemicals used 
Construction. 
Effective size. 
STORAGE RESERVOIR FOR PURIFIED WATERS 
CONSTRUCTION: Under drain or strainer system. 
Depth. 
Are there complaints regarding sanitary quality 
FINAL TREATMENT, STERILIZATION 
Reason for requesting the examination. 
Method by raw or purified water. 
plant 
watershed 
chemical, 
bacterial 
Efficiency of purification, if known 
Depth. 
Hours per day 
Head of water over sand. 
Is first effluent wasted. 
Laboratory examination 
Cleaned or washed 
Sanitary inspection 
OPERATION: 
REMARKS: 
Gravel. 
Capacity. 
Sand. 125 
Private 
Samples from.. ..of County of 
(City, village or town) 
DESCRIPTION, SAMPLES Collected: Date 
Bacterial A 1 from ...B ) from 
Chemical A / B / 
Owner of Property 
WELL WATER If public supply, number of wells... 
Depth of well Diameter 
Institutional 
Public, Municipal, Corporate 
What other municipalities supplied 
C \ from.... 
c/ 
Tenant..... 
Time 
D 1 from... 
DJ 
Dug, drilled or driven 
...Manner of drawing water 
Depth of water in well... Temperature of water in well 
Daily consumption ( Maximum. 
Does the water ever fail If so. under what conditions 
(gals, per day) Average. 
Is the water turbid after rainstorms 
Is the well curbed Is the curb tieht 
Distance of curb / ,ab.OVe SUr!aCe S™™? 
( nelow surlace ground 
Is the well covered. .' Is the cover tight 
Is there a metal casing ...Distance of casing ( , , f , 
° & ( below surface ground 
Does water which had been pumped flow into the well ........................................................................................................... 
Beeinninv at the surface, state character and thickness of the successive la.vers of earth and rock nenetrated 
Date received 
Do not describe well water as spring water or as an infiltration gallery or vice versa 
Form for Sanitary Survey of Ground Water 
GROUND WATERS 
(Front) 
Laboratory numbers. 126 
.Elevation of water surface relative to surface of stream or pond 
Show by diagram relation of well to sources 
of pollution and nearest surface water; indi- 
cate probable course of water drainage by 
arrows. 
Are there complaints regarding sanitary quality odor. taste... .....appearance. 
Is there reason to suspect any connection between this water and the spread of typhoid fever or other diseases 
Reasons for requesting the examination 
Remarks: 
I hereby certify that the samples of this water were collected by (name..... - ) 
on (date time... ... ..) and that I have followed explicitly all directions for packing 
in ice and immediate shipment by express; and furtiier that I have inspected all conditions affecting the sanitary quality of this water and found 
them to be as above recorded. 
Sanitary Supervisor 
Health Officer 
..temperature. 
proportionately how much. 
£ 
o 
c 
"o 
& 
.ra 
£ 
o 
in level ground 
Describe location, relative to well or spring, of the following 
sources of pollution: Record absence as well as presence 
of sources of pollution. 
.elevation 
.elevation 
.elevation 
elevation 
..elevation 
All containers are sent by express collect; all samples must be sent, express prepaid, 
(Back) 
..or diminish.. 
Distance from stream, lake or pond 
..in a steep slope. 
Is stream or pond probably polluted and to what extent. 
.distance. 
distance. 
.distance 
distance. 
.distance. 
Radius of area of the surface wash into the spring. 
Radius of the area of surface wash into the gallery. 
Surface or deep. 
How is the spring protected from this wash. 
SOURCES OF POLLUTION - 
.number. 
.number. 
.number. 
.number. 
number. 
During drought does flow cease. 
INFILTRATION GALLERY 
Situation: in a marsh. 
SPRING WATER 
B Cesspools. 
E Barnyards, 
stables, etc.. 
A Privies. 
C Sewers. 
D Drains. 127 
PART III 
* SUMMARY OF LAWS AND REGULATIONS RELATING TO 
LABORATORIES AND LABORATORY SPECIMENS 
Duties of Commissioner of Health with Respect to 
Laboratories 
The State Commissioner of Health authorized to establish 
laboratories or make contracts, within amount available therefor. 
Public Health Law, Art. II, Sec. 4-b. (P. H. Manual, p. 15.) 
Establishment of Laboratories 
Establishment and Operation of Institute for Study of 
Malignant Disease 
Establishment and control provided for and purposes defined. 
Public Health Law, Art. XVIII, Secs. 344-346. (P. H. 
Manual, p. 241.) 
County Laboratories 
Boards of supervisors authorized to establish county labora- 
tories or make contracts with other counties or cities for laboratory 
service. County Law, Secs. 43-44. (P. H. Manual, p. 405.) 
Supervision and Approval of Laboratories 
Registration and Supervision of Laboratories 
Laboratories where live pathogenic germs are handled or culti- 
vated required to be registered with the New York State Depart- 
ment of Health; conditions under which such germs or cultures 
may be transferred to others prescribed. Chapter 411, L. 1917. 
(P. H. Manual, p. 504.) 
Distribution of Cultures 
No person having in his possession cultures of pathogenic 
bacteria to sell or convey such cultures unless first approved by 
the State Commissioner of Health. Sanitary Code, Chap. II, 
Reg. 43-a. (P. H. Manual, p. 326.) 
Inoculation of Human Beings with Living Bacteria 
Prohibited until certain conditions have been complied with 
and until permission has been obtained from State Commissioner 
* The following summaries should not be regarded as interpretations. Those 
seeking accurate information should refer to the laws and regulations. 128 
of Health. Sanitary Code, Chap. II, Reg. 43. (P. H. Manual, 
p. 326.) 
Inspection of Laboratories 
State Commissioner of Health or his representative authorized 
to inspect laboratories doing work for the health authorities of the 
State or any county or municipality therein and to advise persons 
in charge as to methods employed. Sanitary Code, Chap. II, 
Reg. 44. (P. H. Manual, p. 327.) 
Laboratories to be Approved for Examination of Certain 
Specimens 
Laboratory specimens in syphilis, gonorrhea and chancroid 
(Sanitary Code, Chap. II, Reg. 2-a), diphtheria (Reg. 10), 
typhoid and paratyphoid fever (Reg. 10-a and Reg. 36). 
Regulation of Sale of Antipneumococcus and Antimenin- 
goccus Serum 
No such serum to be sold except in accordance with rules and 
regulations of State Commissioner of Health. Sanitary Code,. 
Chap. IX, Reg. 1. (P. H. Manual, p. 362.) 
Submission and Examination of Specimens 
Examination of Sputum 
Health officers required to have examinations made of sputum 
from suspected case of tuberculosis upon request. Tuberculosis 
Law, Sec. 321. (P. H. Manual, p. 2f5.) 
Syphilis, Gonorrhea and Chancroid 
Physician attending cases or suspected cases to submit such 
specimens and such data relating thereto as may be required by 
the special rules and regulations * of the State Commissioner of 
Health to the State laboratory or to a laboratory approved by the 
State Commissioner of Health for this purpose. Sanitary Code,. 
Chap. II, Reg. 2-a. (P. H. Manual, p. 306.) 
Suspected Persons 
Persons suspected of having syphilis, gonorrhea or chancroid 
and examined pursuant to this section, to permit such specimens- 
* See page 73. 129 
to be taken as may be necessary to establish the presence or 
absence of a suspected disease or infection, subject to certain con- 
ditions prescribed in this section including the right of the 
suspected person to apply to a magistrate for an order restrain- 
ing such examination and that before any such examination each 
suspected person shall be informed of his rights. Public Health 
Law, Art. XVII-B, Sec. 343-m. (P. H. Manual, p. 238.) 
Convicted Persons 
Not to be released from jurisdiction of court until examined 
as provided for in preceding section. Public Health Law, 
Art XVII-B, Sec. 343-n. (P. H. Manual, p. 240.) 
Laboratory tests in Connection With Marriage Licenses 
Duty of town or city clerk to require statement from applicant 
that he (or she) has not been infected with a venereal disease or 
if infected within five years, he (or she) has had a laboratory 
test showing freedom from infection. Domestic Relations Law, 
Art. Ill, Sec. 15. (P. H. Manual, p. 432.) 
Diphtheria 
In every case, or suspected case, material for culture to be 
taken by attending physician (or health officer, if local authorities 
so require) and submitted to an approved laboratory. Sanitary 
Code, Chap. II, Reg. 10. (P. IT. Manual, p. 309.) 
Release Cultures Required in Diphtheria Cases 
Two successive negative cultures required for release. Sani- 
tary Code, Chap. II, Reg. 36. (P. H. Manual, p. 321.) 
Release of Diphtheria Carriers 
May be released upon securing two negative cultures taken at 
intervals of not less than twenty-four hours. Rules and Regula- 
tions for Control of Diphtheria Carriers, Keg. 7. (See depart- 
ment circular No. 22.) 
Release of Diptheria Carriers by Virulence Tests 
Carrier may be discharged if virulence test shows organisms 
not to be virulent for guinea pigs. Rules and Regulations for 
5 130 
Control of Diphtheria Carriers, Reg. 6. (See department 
circular No. 22.) 
Epidemic Cerebrospinal Meningitis 
Case to be isolated until two weeks after temperature normal 
or until three successive cultures, at intervals of not less than five 
days, shall be found free from meningococci. Sanitary Code, 
Chap. II, Reg. 36. (P. H. Manual, p. 321.) 
Typhoid and Paratyphoid Fever 
In every case suspected of being typhoid or paratyphoid fever, 
sample of blood to be submitted to an approved laboratory by 
attending physician. Sanitary Code, Chap. II, Reg. 10-a. 
(P. H. Manual, p. 310.) 
Release in Typhoid and Paratyphoid 
When patient's occupation involves handling of milk, dairy 
products or other foods, two successive negative fecal specimens, 
at intervals of not less than seven days, to be submitted to a 
laboratory approved by State Commissioner of Health. Sani- 
tary Code, Chap. II, Reg. 36. (P. H. Manual, p. 321.) 
Milk, Certified and Grade A 
Bacteria counts required. Sanitary Code, Chap. Ill, Reg. 13. 
(P. H. Manual, pp. 337-340.) 
Milk, Grade B 
Bacteria count required, except as provided below. 'Sanitary 
Code, Chap. Ill, Reg. 13. (P. H. Manual, pp. 340-341.) 
Bacteria Counts ; Exception 
If impracticable to obtain bacteria counts, milk, except certi- 
fied and grade A, may be graded upon score. Sanitary Code, 
Chap. Ill, Reg. 13. (P. H. Manual, p. 343.) 
Laboratory Reports 
Examinations showing evidence of communicable disease 
When examinations by a laboratory or person other than the 
attending physician discloses evidence of communicable disease, 131 
report required to be made to health officer of municipality where 
laboratory is situated and health officer of municipality from 
which specimen came. Permanent record to be kept. Public 
Health Law, Art. II, Sec. 25. (P. H. Manual, p. 38.) 
Certain Records Confidential 
Protection of records in tuberculosis 
Records of results of examination showing presence of tubercle 
bacilli confidential. Tuberculosis Law, Sec. 322. (P. H. 
Manual, p. 215.) 
Tieports and Information Regarding Syphilis, Gonorrhea and 
Chancroid Confidential 
Reports or information secured by a board of health or health 
officer under the provisions of this article (XVII-B) confidential. 
Public Health Law, Art. XVILB, Sec. 343-r. (P. H. Manual, 
p. 240.) 
Records of Cases of Syphilis, Gonorrhea and Chancroid not to 
be Disclosed 
Records of State Department of Health or of any local depart- 
ment or local health officer relating to case, not to be disclosed 
except as provided in this regulation. Sanitary Code, Chap. II, 
Reg. 29-b. (P. H. Manual, p. 317.) 
Miscellaneous 
Shaving or lather brushes 
Hair or bristles used in manufacture to be treated, for purpose 
of destroying anthrax germs, in accordance with regulations of 
State Commissioner of Health. Sanitary Code, Chap. VII, 
Reg. 6-a. (P. H. Manual, p. 358; amendment in effect March 1, 
1919.) 
Method of Sterilization to be Approved 
Method of sterilization of second-hand material to be used in 
manufacture of mattresses, etc., to be approved or disapproved by 
State Department of Health. General Business Law, article 25-b, 
section 389-u. (P. H. Manual, p. 456.)