NEW YORK 
STATE DEPARTMENT OF HEALTH 
Edward S. Godfrey, Jr., M.D. 
Commissioner 
LABORATORY MANUAL 
FOR 
PHYSICIANS 
Aids in Diagnosis and Treatment 
Issued by 
DIVISION OF LABORATORIES AND RESEARCH 
ALBANY 
Augustus B. Wadsworth, M.D., Director 
1944 NEW YORK 
STATE DEPARTMENT OF HEALTH 
Edward S. Godfrey, Jr., M.D. 
Commissioner 
LABORATORY MANUAL 
FOR 
PHYSICIANS 
Aids in Diagnosis and Treatment 
DIVISION OF LABORATORIES AND RESEARCH 
ALBANY 
Issued by 
Augustus B. Wadsworth, M.D., Director 
Eighth Edition, June 1, 1944 “The development of laboratories connected with boards of health is one 
which is peculiarly American. The appreciation of the need of such labora- 
tories, of what can be accomplished by them and of the benefits which the 
general public derive from them, has been greater in this country than 
elsewhere. We have led in this particular direction. . . . The foundation of 
such laboratories has had a very important stimulating influence upon boards 
of health, both local and state. It has introduced a scientific spirit into the 
work; it has brought into connection with executive officers the younger men 
who are full of enthusiasm with reference to studies along these lines, and I 
think that we may say that the general tone of boards of health has been 
elevated and stimulated by the foundation of laboratories of this character.” 
—William H. Welch 
From “Relations of Laboratories to Public Health” 
“I like to think of the Laboratory to which is due the greatest credit and 
which has developed under the administration of the new [public health] law, 
as a living thing. It is true that a State Laboratory existed before the law 
went into effect but the old and the new laboratory are scarcely to be com- 
pared. Not only is the scale on which they were planned very different but 
the principles which animate their activities are entirely distinct. The older 
laboratory supplied a limited service consisting of a small number of routine 
duties. The present laboratory provides a multiplicity of services, many of 
which are highly elaborate and precise in nature and, besides being diagnostic, 
are also investigative, thus adding to the growing store of medical knowledge 
and improving the practical services rendered. I would also have you appre- 
ciate that this laboratory is so efficient because it is a living thing—a living 
organism, if you please, just as a true university is a living thing. Experi- 
ence has shown abundantly that a university fulfills its high purpose and is 
best when, besides communicating knowledge, it adds to the sum total of that 
knowledge through exploration and discovery. In its turn the State Labora- 
tory has directly and indirectly affected the character of the services it is 
able to give the medical profession and public of the state by discoveries and 
improvements in methods made by experiment within its own walls. It is 
a matter for real gratification that this new knowledge is made available for 
other states and other countries through publication in the accredited journals 
of scientific medicine.” 
—Simon Flexner 
Extract from an address, “Two Decades of Medical Research,” at 
the Annual Conference of Health Officers and Public Health Nurses, 
Saratoga Springs, New York, June 26, 1934. DIVISION OF LABORATORIES AND RESEARCH 
North I<agade Main Building, East and West Wings, New Scotland Avenue, Albany. Occupied successively 1919 1924, 
and 1929. 
Plate I DIVISION OF LABORATORIES AND RESEARCH 
Airplane View of Laboratories and Auxiliary Structures, New Scotland Avenue, Albany, 1939. 
1. West Wing: Antitoxin, Serum, and Vaccine Laboratories; 2. Central Building: Administration, General Services, and 
Research; 3. East Wing; Diagnostic Laboratories; 4. South Wing: Media Department, Library; 5. and 6. Animal Units; 
7. Power Plant, Carpenter and Machine Shops. 
Plate II DIVISION OF LABORATORIES AND RESEARCH 
NEW YORK STATE DEPARTMENT OF HEALTH 
Central Laboratory, New Scotland Avenue, Albany, 1 
Branch Laboratory, 339 East 25th Street, New York, 10 
Augustus B, Wadsworth, M.D., Director 
Mary B. Kirkbride, Sc.D., Associate Director 
Antitoxin, Serum, and Vaccine Laboratories 
Harold W. Lyall, Ph.D., Assistant Director in Charge 
Diagnostic Laboratories 
Ruth Gilbert, M.D., Assistant Director in Charge 
Fred W. Stewart, M.D., Principal Diagnostic Pathologist 
Branch Laboratory, New York City 
Edgar M, Maillard, M.D., Associate Diagnostic Pathologist 
Laboratories for Sanitary and Analytical Chemistry 
F. Wellington Gilcreas, Assistant Director in Charge 
Anna M, Sexton, Librarian 
Ha M. Dutton, Administrative Officer 
Lilian C. Smith, Secretary to the Director DIVISION OF LABORATORIES AND RESEARCH 
NEW YORK STATE DEPARTMENT OF HEALTH 
Fig. I. Chart of Organization CONTENTS 
PAGE 
Director and heads of laboratory departments v 
Introduction 1 
Part I—Public health laboratory service in New York State 
General organization; Approved laboratories; Registration of labora- 
tories 5 
Part II—Laboratory aids in the diagnosis and treatment of disease 
Submission of specimens; Specimen outfits; Preparation of speci- 
mens ; Postal laws and regulations 11 
Prophylactic and therapeutic preparations; Distribution of prepara- 
tions; Precautions against anaphylactic reactions; Administration 
of preparations; Severe or other unusual reactions following admin- 
istration; Reports on the use of products 15 
Laboratory aids in communicable diseases 19 
Miscellaneous examinations 85 
Part III—Examination of water, sewage, and sewage sludge 88 
Part IV—Examination of milk and cream 96 
Part V—Examinations concerned with eating, drinking, and cooking 
utensils 98 
Part VI—Recording and reporting results of laboratory examinations. . 99 
Part VII—Distribution of laboratory supplies 100 
Index 101 INTRODUCTION 
Modern medicine depends upon laboratory service. That disease 
is a reaction to injury—a biologic process rather than an entity— 
has been recognized only since the discoveries of Pasteur and his 
demonstration of the analogy between fermentation and infectious 
disease. This conception is not limited to any particular group of 
ailments but has become so broad that it is no longer possible to 
distinguish the border line between health and disease. The 
actions and reactions of the two states do not differ fundamentally; 
in fact the processes may be similar in nature, varying only in 
degree. The character and extent of the injury, in general, deter- 
mine the nature and severity of the disease. 
The internist often finds it difficult to differentiate the disturb- 
ances of metabolism that characterize certain diseases until, during 
their later stages, the abnormal extent of the changes becomes mani- 
fest. The psychiatrist often finds even greater difficulty in his 
field. 
The infectious diseases, perhaps, provide an opportunity for a 
sharper differentiation, because the injury is incited by a foreign 
agent, the presence of which may be detected. But often the infec- 
tious agent may lodge in the tissues and persist without giving rise 
to disease, or may continue an abated development after the morbid 
processes have subsided and health has been restored. The carrier 
state is, with but few exceptions, common to all infectious diseases. 
The ineitant of an infections disease gains access to the tissues 
through a portal of entry which varies with different species and 
depends, to some extent, upon exposure. Having gained access to 
the tissues, the parasite must develop in its new environment to 
produce substances that injure the tissues. The reaction of the 
tissues following this injury is the disease which we recognize by 
various signs, depending upon the nature of the processes. In the 
course of the disease the tissues develop activities that may not only 
inhibit and destroy the ineitant but also neutralize specifically the 
particular poisons produced by it—activities that are lacking or 
latent under normal conditions. 
Medical science has investigated and developed methods of 
detecting the poisons and determining the character and distribu- 2 
tion of the substances that incite injury, and also, within certain 
limitations, the character and extent of the reactive processes that 
constitute the disease. Thus it is that laboratory aids to diagnosis 
and treatment have been formulated as the investigations have 
progressed. 
The nature of the disturbances of metabolism in many of the 
constitutional diseases has not been adequately determined; only 
certain changes in the processes have been detected, as, for example, 
in diabetes, the increased percentage of sugar in the blood and its 
presence in the urine, resulting from the inhibition of the carbohy- 
drate metabolism of the tissues. In infectious diseases, on the con- 
trary, definite incitants have been recognized. In diphtheria, for 
instance, the diphtheria bacillus has been isolated in pure culture 
and fully identified, as has also the toxin it produces in the tissues 
and which incites the disease. The specific nature of the disease pro- 
cesses and the conservative effect of the immune reaction in neutral- 
izing the toxin of the foreign incitant, have been fully elucidated; 
preventive inoculation and antitoxin therapy have long been prac- 
ticed and, within certain limits, are specifically effective. 
The laboratory aids for the diagnosis and treatment of diabetes 
are, therefore, limited to chemical tests of blood and urine, but in 
diphtheria, the presence of the bacillus may be detected by bacter- 
iologic examination in any of the processes from which the disease 
arises. The degree of individual susceptibility to diphtheria may 
be determined by testing the activity of the tissues in neutralizing 
the toxins of the bacillus. The tissues of susceptible persons may 
be so immunized by the introduction of toxoid in graduated doses 
that they are no longer susceptible to diphtheria. Horses can be 
immunized and the blood serum from these animals, which contains 
antitoxin, may be injected into the tissues of a person suffering from 
diphtheria, and thus supplement the activity of these tissues in 
neutralizing the poison that is giving rise to the disease. Diph- 
theria thus strikingly illustrates the achievements that result from 
the laboratory study of infectious disease and the extent to which 
laboratory aids may figure in the diagnosis, prevention, and cure of 
the disease as it occurs in the individual or in epidemic form. 
Research on other infectious diseases has advanced our knowl- 
edge and developed many practical aids to diagnosis and treatment 
that are now essential to health officers in their administrative 
activities, and to physicians in their practice. Chemotherapy and 
the use of antibiotic agents are at present being extensively explored. 
Also, research in the closely related field of nutrition is laying a 3 
sound foundation and opening the more practical leads of the future 
that are not without significance in medical science. 
Obviously, according to present-day standards, any community 
that lacks laboratory service is seriously handicapped. The citizen 
ultimately benefits from the development of laboratory service. 
The application of these scientific methods has a far-reaching edu- 
cational influence that is essential to the maintenance of the high- 
est standards of medical practice in any community. PART I 
PUBLIC HEALTH LABORATORY SERVICE IN NEW YORK 
STATE 
The Division of Laboratories and Research in its present form 
began, as a successor to the earlier State Hygienic Laboratory, with 
the reorganization of the State Department of Health in 1913-1914. 
With a staff of less than twenty, the work was done in a small frame 
building and a remodeled stable on Yates Street, in sharp contrast 
to the modern, well-equipped buildings it now occupies in the pur- 
suit of its statewide activities. In 1919 the laboratory moved into 
the new main building on New Scotland Avenue; in 1924, the east 
wing was opened, chiefly for the use of the diagnostic laboratories, 
and in 1929 the antitoxin, serum, and vaccine laboratories were 
transferred to the new west wing. In that year a power-house and 
two new stable units were also constructed. Early in 1939 the south 
wing, which houses the media department and the library, was 
occupied. The laboratory farm, within a few miles of Albany, 
has. undergone a parallel development. The plant there now 
includes a large main unit and five additional buildings for 
separate phases of the work. This building program offers an 
excellent illustration of the expansion of the work year by year, 
for each addition has been a necessary step in the advancement and 
maintenance of efficient service. No appropriation has yet been 
made for work in virology. This is an urgent need and provision 
for it will doubtless be included in the postwar program, especially 
since it requires the construction of a separate building with com- 
plete isolation to safeguard against the spread of virus infection. 
There is only one branch laboratory of this Division, established 
in 1914 and now located at 339 East 25th Street, New York, 10, 
in close proximity to the important medical centers; it serves dis- 
tricts on Long Island and in the vicinity of New York which are 
less accessible to the Albany laboratory than are other parts of the 
State. The approved laboratories scattered throughout the State, 
serving the larger cities and most of the counties, provide close 
contact between the health officers and physicians and the central 
laboratory. Many technical diagnostic procedures must be per- 
formed at the bedside or in a laboratory nearby. The close contact 
thus afforded is an important factor in effective laboratory service; 
its development supplements the facilities offered by the central 
laboratory and the branch. 6 
The expanding laboratory service in New York State has pre- 
sented an interesting problem because of the uneven distribution of 
the population. The State now has a service that is unique in the 
extent to which it reaches the citizens of the various districts. The 
close cooperation between the approved laboratories and the 
Central Laboratory in Albany ensures uniform methods and reliable 
results. , 
This manual outlines the organization .and operation of the 
laboratory service offered by the State, and contains information 
on how physicians and health officers can avail themselves of it. 
The Public Health Law and the Sanitary Code should be consulted 
when there is any doubt concerning legal requirements or 
provisions. 
Approved Laboratories 
The function of the laboratory is to assist physicians, health 
officers, and, through them, the citizens of the State in the pre- 
vention, diagnosis, and control of disease. To attain the highest 
efficiency the laboratory must be developed to meet the neecls of 
the district served, and physicians and health officers should be 
thoroughly familiar with the facilities available. 
The regulations of the Sanitary Code of the State require phy- 
sicians to submit specimens from certain of the communicable 
diseases, as well as tissue removed at operation or at necropsy 
that requires laboratory examination as an aid in the diagnosis, 
prevention, or treatment of disease or to determine the cause of 
death, to a laboratory approved by the State Commissioner of 
Health for the examination of such specimens (Chap. II, Reg. 9; 
Chap. IV, Reg. 7). Specimens of blood from applicants for a 
marriage license and from pregnant women must also be submitted 
to an approved laboratory for serologic tests for evidence of syphilis 
(Domestic Relations Law, Art. II, See. 13-a; Public Health Law, 
Art. II-A, Sec. 18-d). There are approximately one hundred and 
twenty approved diagnostic laboratories in New York State, out- 
side of the city of New York; they include county, city, hospital, 
and private laboratories. Only a few of them have not received 
approval for the examination of specimens of tissue.* 
* The New York State Sanitary Code does not apply to the city of New 
York. Laboratories there whose directors wish to make official examinations 
of specimens from patients living outside of the city or to act as consultants 
in districts where the State Sanitary Code is effective are approved hy the 
state commissioner of health on the same basis as laboratories located else- 
where in the State. 7 
The Sanitary Code likewise requires the following sanitary 
examinations to be made in approved laboratories: bacterial milk 
counts for the purpose of grading (Chap. Ill, Reg. 5), samples of 
water in connection with control of the sanitary quality of public 
water supplies (Chap. V, Reg. 3d), and laboratory examinations 
of eating, drinking, and cooking utensils necessary to determine 
compliance with the Code (Chap. XIV, Reg. 3). Most of the 
laboratories approved for diagnostic procedures alfeo perform sani- 
tary examinations. From forty to fifty additional laboratories are 
approved for this type of work only. The Sanitary Code (Chap. 
Ill, Reg. 1) requires that bio-assays of vitamin D milk also be made 
in an approved laboratory. Six laboratories are approved for 
making such determinations. A pamphlet in regard to local 
laboratory service, which includes a list of laboratories and the 
examinations for which approval has been issued, is distributed 
annually to registered physicians in the State outside of the city 
of New York. 
When the need for local service has been realized in a com- 
munity, the first step is usually the appointment of a committee by 
the county medical society to ascertain the apparent and probable 
demand, and to determine the various and most feasible means by 
which laboratory service may be secured, and the approximate 
cost. Valuable information and advice may be obtained by con- 
sulting the district state health officer. State aid may be provided 
for county and city laboratories meeting certain requirements. If 
efficient laboratories are conveniently located, service may some- 
times be procured through contract. In most instances, however, 
the obtaining of service by contract is not as satisfactory as the 
establishment of a laboratory. 
Laboratories are maintained under such varying conditions, and 
the scope of the work and the size of the area served differ so 
widely that it is difficult to formulate a budget for general applica- 
tion. Salaries of workers depend upon training, experience, and 
skill. The amount offered must be sufficient to attract individuals 
competent to undertake the required work satisfactorily. A well 
qualified director, who must be a graduate in medicine with ade- 
quate training in pathology and bacteriology to comply with the 
provisions of the Sanitary Code, would seldom be attracted by 
a salary of less than $6,000 per year. The directors of some of 
the larger laboratories receive from $9,000 to $10,000. If a labora- 
tory serves a large institution or an extended area, the appointment 
of an associate director is essential. He should be a physician with 
adequate basic training in pathology and bacteriology and a salary 8 
of at least $4,000 should be provided. The larger laboratory may 
require the services of a trained biochemist, at a salary of $3,000 
or more. The number of technicians depends on the scope of 
the work. Senior technicians with a broad background of experi- 
ence generally receive from $1,800 to $3,000 per year; less 
experienced workers, at least $1,200; cleaners and helpers, a mini- 
mum of $900 or $1,000. Quarters, light, and heat ordinarily are 
a laboratory expense; when a county or city laboratory is located 
in a hospital, an estimate is made of the costs to the hospital and 
this sum is paid by the county or city treasurer directly to the 
institution. The hospital may, however, provide quarters without 
charge, in view of the benefits derived. In some instances, money 
for equipment and maintenance has been provided by public- 
spirited citizens. Office expenses and the cost of supplies and 
travel vary considerably. The Division of Laboratories and 
Research is glad to assist localities or institutions in estimating the 
probable expense of laboratory service to meet the particular 
need. 
The following are estimates of the probable cost, which varies 
according to the scope of the work and the size of the district 
served. 
Director (graduate in medicine with 
adequate training in pathology and 
bacteriology) $6,000 $7,000 $9,000 
Associate or assistant director (grad- 
uate in medicine) 4,000 6,000 
Chemist 3,000 5,000 
Technician 1,200 1,500 2,500 
Technician 1,200 1,800 
Technician 1,200 1,500 
Cleaner and helper 900 900 1,200 
Cleaner and helper 900 1,200 
Clerk 1,200 1,200 1,500 
Secretary or stenographer 1,500 1,800 
*Rent, fuel, light, water, etc 1,000 2,500 4,000 
Supplies 500 1,000 2,500 
Travel 150 300 500 
$10,950 $26,200 $38,500 
Cost of initial equipment 2,500 3,500 6,000 
$13,450 $29,700 $44,500 
* The amount for these items would depend upon the location of the laboratory. 9 
When the necessary data have been secured, the committee 
appointed by the county medical society should present the facts 
and the request for an appropriation to cover the desired service 
to the board of supervisors of the county or the common council 
of the city. 
The Public Health Law (Art. Ill, Sec. 20-e-h) authorizes boards 
of supervisors in counties, and the common council or any body 
exercising similar powers in cities, to establish laboratories or 
provide laboratory service, toward the support of which state aid 
may be granted: $2,500 for initial installation and equipment 
and one-half the cost of yearly maintenance not in excess of 
$7,500. A laboratory established under this act must have a board 
of managers consisting of at least five members representing the 
various interests in the district served, two of whom are physicians 
licensed to practice in the State. The board of supervisors may 
confer the powers and duties of the board of managers upon the 
county board of health if such a board exists. 
Before a laboratory can be approved for diagnostic procedures, 
the director must have the qualifications outlined in the Sanitary 
Code (Chap. XI, Reg. 18-24). 
On January 15, 1937, the Public Health Council adopted the 
following resolution relating to the approval of laboratories: 
“Resolved, that, diagnostic laboratory service being intimately 
concerned with the practice of medicine, the state commissioner 
of health be advised that a laboratory offering diagnostic service 
should not be approved unless, in addition to meeting other con- 
ditions which may be prescribed, the person actively in charge 
is licensed to practice medicine or eligible for examination for 
license to practice medicine in the State of New York.” 
Procedure of Approval 
Approval of a laboratory is considered by the Division of Laboratories 
and Research after an application has been made by the person in charge, 
and is issued only in case the applicant has qualifications that meet the 
requirements prescribed, has demonstrated his ability to perform the 
duties of the position satisfactorily, and agrees to conduct the work of 
the laboratory in an ethical manner and to maintain the technical 
standards required for laboratories approved under the authority of the 
Commissioner of Health. 
Four years of postgraduate training and experience in the department 
of pathology of a medical school recognized by the Regents of the 
University of the State of New York, including training and experience 
in pathology, bacteriology, and related departments, or an equivalent 
combination of training and experience have been considered as meeting 
the requirements for directors and pathologists outlined in Regulations 
21 and 22 of the Sanitary Code. 10 
Directors, pathologists, and bacteriologists shall either be on full time 
or devote the major part of their time and attention to the work of the 
laboratory. When they cease active laboratory work for a long period 
of years, their qualifications must be reviewed in the light of advances 
in knowledge in bacteriology and pathology that have taken place in the 
interim, before approval is issued. 
Persons responsible for the conduct of laboratories that are approved 
for sanitary examinations only shall have had adequate training and 
experience in the technical procedures involved and shall be thoroughly 
versed in the principles of sanitary science to enable them to interpret the 
significance of the laboratory findings. When sanitary chemical analyses 
of water are to be made, such persons shall also have had satisfactory 
training in chemistry, including analytical chemistry. Because of the 
value of the phosphatase test in control of the sanitary quality of milk 
supplies, approval for bacteriologic examinations of milk is granted only 
when the phosphatase test can be performed satisfactorily also. Similarly, 
in relation to approval for bio-assays of vitamin D milk, adequate train- 
ing and experience in the technical procedures and ability to interpret 
laboratory findings are essential. 
The facilities available, including space, lighting, and equipment, must 
be adequate for conduct of the work for which approval is desired. 
Certificates of approval are issued annually. They are valid until the 
end of the year in which issued unless sooner revoked. Approval termi- 
nates automatically with changes in the personnel in charge of work for 
which approval has been issued. The laboratory examinations for which 
approval is granted are specified. New appointees must qualify in the 
usual manner. 
Approval for any type of work may be withheld or withdrawn if exami- 
nations are undertaken that are required by the Sanitary Code but for 
which approval has not been granted, unless duplicate specimens are sent 
to an approved laboratory for official tests. 
Series of specimens are submitted for comparative examination from 
time to time to the different approved laboratories and also upon the 
request of a director. 
A person in charge of a laboratory seeking approval submits a 
formal application and signs agreements regarding the mainte- 
nance of standards of work. The laboratory is inspected by a 
representative of the Central Laboratory. Applicants for approval 
in pathology examine a series of approximately fifty sections of 
tissue that have been selected with special care. Only those sec- 
tions are used upon which the pathologists of the State Institute 
for the Study of Malignant Diseases in Buffalo and of the Division 
of Laboratories and Research are in complete agreement as to 
the character of the lesion and the suitability of the material 
for the purpose. 
Article XXIII of the Public Health Law requires the registration of 
places where cultures of pathogenic microorganisms or viruses are handled. 
This law has no bearing on the approval of laboratories but provides for 
the compilation of a list of addresses where strains of the incitants of 
disease are maintained. PART II 
LABORATORY AIDS IN THE DIAGNOSIS AND TREAT- 
MENT OF DISEASE 
With the development of laboratory service, the scope of the 
work is gradually being extended to include all types of examina- 
tions that are helpful in the diagnosis and treatment of disease. 
In every case, however, the results of laboratory examinations 
must be interpreted in the light of clinical observations; the 
ultimate diagnosis rests with the physician. If studies of a 
medicolegal nature are desired, the director of the laboratory to 
which specimens are to be submitted should be consulted in 
advance to determine whether he is prepared to undertake this 
type of work. The procedure for handling the volume of speci- 
mens received at the Division of Laboratories and Research can- 
not conform with medicolegal requirements and no provision has 
been made for medicolegal investigation. 
Submission op Specimens 
Every effort should be made to avoid the possibility of an inter- 
change of specimens before mailing and to ensure their prompt 
delivery to the laboratory in a satisfactory condition. 
Specimen Outfits 
Much time and effort have been expended in an attempt to pro- 
vide suitable outfits so that specimens will reach the laboratories 
in the best possible condition. The importance of selecting the 
proper outfit cannot be too strongly emphasized. The labels on 
the mailing cases used by the Central Laboratory and by many 
of the approved laboratories are marked to indicate the type 
of examination desired, as “D” for diphtheria. This not only 
facilitates the sorting of the specimens at the laboratory, and their 
distribution to the various groups for examination, but also ensures 
proper handling when they are received after working hours. For 
example, a mailing case labeled “D” for diphtheria, if received 
after 5 :00 p. m., is placed in the incubator by the night janitor, 
together with a record of the time it was received. The reporting 
of the results of the examination are thus facilitated because there 
is no delay in incubation. 12 
The Central Laboratory in Albany provides outfits designed espe- 
cially for the collection of specimens to be examined for evidence 
of diphtheria, enteric diseases, gonorrhea, syphilis, and tubercu- 
losis. Miscellaneous outfits are designed for the collection of 
material from conditions other than those mentioned. All of these 
outfits may be secured from the district laboratory supply stations 
maintained throughout the State. In districts where approved 
laboratory service is available, the supply stations distribute out- 
fits furnished by the approved laboratories for the submission of 
specimens to them; in addition, a limited number of the State out- 
fits is also available in the event that the physicians wish to sub- 
mit duplicate specimens to the Central Laboratory. 
In order to facilitate handling the large volume of specimens 
received for serologic tests for evidence of syphilis and to guard 
against possible delay that may render the specimens unsatisfactory 
for other desired examinations, the following procedure is 
recommended in sending specimens either to the Central Laboratory 
in Albany or the Branch Laboratory in New York: 
Use the outfit with a white label and red lettering marked “V,” when 
blood is to be examined for evidence of syphilis. 
When blood from the same patient is also to be subjected to another 
type of examination, such as an agglutination test for evidence of typhoid 
fever, submit, if possible, a separate specimen in the appropriate outfit. 
If for some reason this cannot be done, always place in the outfit accom- 
panying the specimen two forms giving adequate data relating to the case, 
one, a white, syphilis history form, the other, a pink, miscellaneous form. 
A supply of the miscellaneous history forms is available in all laboratory 
supply stations. 
Blood-letting needles. The outfits furnished to physicians by the 
Division of Laboratories and Research for the submission of 
specimens for serologic tests contain blood-letting needles. They 
are not included in outfits sent to clinics and institutions. The 
needles are expensive and, in order that their distribution may be 
continued, physicians are asked to return them to the laboratory 
with the specimens, for reconditioning. A small envelope is 
furnished with each outfit, in which the needle can be placed after 
use; sufficient space is provided in the mailing case for enclosing 
the envelope with the specimen for mailing to the laboratory. 
Since the blood-letting needles have, in general, proved more 
satisfactory than syringes for collecting specimens, physicians are 
urged to cooperate in the maintenance of this service. (See 
Plate VII, p. 70.) 13 
Information or history forms. An information or history form 
and directions for collecting specimens accompany each diagnostic 
outfit. The physician should give pertinent data on the history 
form so that it will be possible to determine the types of labora- 
tory examinations that will be most helpful; for example, if a 
patient has been in the tropics, various tests might need to be 
made that would not be undertaken as a routine procedure. 
Some of the information is required by law; some is needed for 
the guidance of laboratory workers; all of it, studied collectively 
with large numbers of records at hand, furnishes valuable data 
regarding the relative efficiency of the procedures commonly used. 
Inconvenience and loss of time for the physician, patient, and 
laboratory worker may result from lack of sufficient information. 
To avoid the possibility of an interchange of specimens and 
information forms, either before mailing or during transit, the 
identification of the patient should always be written on the cul- 
ture tube or other specimen container, as well as on the history 
form. Eesults of examinations can be reported only when the full 
name of the patient is given or, in the case of chancroid, gonorrhea, 
and syphilis, the patient’s initials and date of birth. Physicians 
should take special care to record such data legibly. All informa- 
tion regarding a specimen should accompany it if possible. If a 
letter is written separately, it should include the identification of 
the patient, a description of the specimen, the date of collection, 
and the type of examination desired. 
Preparation of Specimens 
In the preparation of specimens, it is exceedingly important 
that certain simple rules and precautions be observed. Directions 
for the collection and the preparation of specimens that accom- 
pany the outfits should be read and followed. Moreover, the per- 
son preparing specimens for examination should be so familiar 
with the appearance of the outfits and material that he will know 
when they are not satisfactory for use. 
The following precautions are among those to be observed; care- 
ful packing of specimens to avoid breakage and leakage; the use 
of medium that is neither liquefied nor dried; in the prepara- 
tion of cultures, proper application of the swab to the surface of the 
lesion and thorough inoculation of the medium; careful handling 
of the swab used in collecting a specimen to prevent its coming 
in contact with surfaces other than those to be cultured; the prepa- 
ration of thin films of blood or discharge so that they will be suffi- 14 
ciently translucent for microscopic examination; the submission of 
sufficient material, as in the case of specimens of blood for sero- 
logic tests; the proper care of syringes used in collecting blood, 
in order to avoid hemolysis of the specimen. The method of pre- 
paring thick blood films is described under Malaria, p. 41. 
After specimens have been prepared, they should be mailed or 
delivered to the laboratory promptly, for many are spoiled because 
of delay in mailing or length of time in transit. If kept at room 
temperature, blood specimens may become hemolyzed, throat cul- 
tures overgrown with contaminating microorganisms, and, in the 
case of fecal specimens, bacillary incitants of enteric disease may be 
destroyed by the products of decomposition. 
Postal Laws and Regulations 
The observance of certain postal laws and regulations regarding 
the kind of specimens admitted to the mails, the containers to be 
used, and directions for packing will expedite delivery (U. S. 
Postal Laws and Regulations, Section 589). Specimens for labora- 
tory examination may be admitted to the mail only when enclosed 
in mailing cases constructed in accordance with this regulation. 
Upon the outside of every such package should be written or 
printed the words, “Specimen for bacteriologic examination. This 
package should be pouched with letter mail.” The packages are 
then handled as first-class matter, but are subject to third-class 
postage rates unless weighing over eight ounces, when the fourth- 
class rate applies. 15 
PROPHYLACTIC AND THERAPEUTIC PREPARATIONS 
Antitoxins, sera, and vaccines are prepared, tested, and distri- 
buted by the Division of Laboratories and Research. These prepa- 
rations may be obtained by physicians from local supply stations. 
Certain preparations such as silver nitrate solution, sulfonamide 
drugs for the treatment of certain infections, antianthrax serum, 
and rabies vaccine, prepared elsewhere, are purchased for dis- 
tribution. Besides these supplies, the central laboratory prepares 
for use in the local approved laboratories a large number of sera 
for diagnostic purposes. 
Under no circumstances are any of the antitoxins, sera, vaccines, or 
other preparations distributed by this department to be sold. A violation 
of the above rule will subject the violator to the penalty prescribed by 
Section 1740 of the Penal Code. 
Distribution of Preparations 
Provision is made by law (1920) for the establishment of district 
laboratory supply stations by the Commissioner of Health, who 
appoints the custodians. The latter may, with approval, designate 
substations. Stations are maintained and operated in accordance 
with prescribed rules and regulations. All actual operating 
expenses and a specific sum per station for custodial services are 
borne by the localities. 
The district supply stations and their substations are so located 
throughout the State as to afford the greatest facilities to health 
officers and physicians. Many of the stations are in the approved 
laboratories. The proper care of the prophylactic and therapeutic 
preparations in the stations is prescribed and monthly reports are 
sent to the laboratory in Albany, giving the name and address of 
the physician, the kind, amount, and lot number of the material 
obtained, and whether any was returned unused. The local sta- 
tions are expected to maintain an adequate supply of routine 
material, such as diphtheria antitoxin, outfits of silver nitrate solu- 
tion, etc., to meet the usual needs, and enough of certain products, 
such as tetanus antitoxin for therapeutic use and antimeningo- 
coccus serum, for the initial injections of one or two cases before 
a fresh supply from the State laboratory can be secured by tele- 
phone or telegraph. Still other products which are relatively 
unstable or seldom used, or new products upon the use of which 
further data are required before they are released for general 16 
distribution, can be secured only upon special request made through 
the local station or directly to the laboratory in Albany, 
According to an amendment to section 1262, subdivision 2, of the Educa- 
tion Law, osteopathic physicians who have heen certified by the State 
Board of Regents are granted the right to use antitoxins, sera, and vaccines 
but are not permitted to administer drugs (for example, arsenical and 
bismuth preparations). 
Health officers and physicians can be of great assistance in con- 
serving State supplies by limiting their requests to material actu- 
ally needed for current use, by keeping under proper conditions 
any material held for a time, and by returning all unused material 
promptly to their local supply stations or, in the case of special 
products, to the central laboratory. 
All biologic products should be kept in the dark at a low, even 
temperature; under no circumstances at room temperature or sub- 
ject to marked temperature changes. It is inadvisable to use any 
material that has been frozen; it should be returned with this 
information. Material that has been kept under improper condi- 
tions cannot be relied upon to give satisfactory results. Products 
should not be used after the return date that is stamped on each 
package. 
Precautions against Anaphylactic Reactions 
The injection of horse or rabbit serum, whether concentrated or 
unconcentrated, may, in rare instances, incite severe or even fatal 
reactions of an anaphylactic character in highly sensitive persons. 
Such reactions usually occur in persons who suffer from hay fever, 
asthmatic or other allergic symptoms, or who have previously 
received an injection containing the corresponding serum. Hence, 
it is highly important to obtain the previous history and to 
determine whether a condition of hypersensitivity exists. For this 
purpose both an intracutaneous and an ophthalmic test are used. 
The intracutaneous test on account of its greater sensitivity should 
be selected if only one test is made. Even in persons who fail to 
react to the tests, intravenous or intraspinous injection of serum 
may induce severe or fatal reactions. Absence of systemic reactions 
when skin sensitivity has been demonstrated has also been reported. 
Although rare, the possibility of reactions makes caution essential 
in all serum injections. A syringe containing 1.0 ml. of freshly 
prepared epinephrine (Adrenalin) solution, 1:1000, should be kept 
at hand for immediate use. 
Moderate or severe reactions characterized by chill and sharp rise in 
temperature that usually occur within from one-half to one hour after 17 
serum injection are not considered anaphylactic. This type of reaction 
rarely requires more than symptomatic treatment unless the hyperexia 
becomes excessive. 
Intracutaneous test. An area on the inner surface of the forearm is 
gently cleansed with soap and water, then with alcohol, and 0.1 ml. of a 
1:100 dilution of normal horse or rabbit serum in sterile physiologic salt 
solution is injected intracutaneously. If a wheal, with or without 
erythema, does not appear at the site of injection within from fifteen to 
twenty minutes, the injection of serum is usually a safe procedure. If the 
skin reaction is positive, serum administration is generally contraindi- 
cated unless every facility is at hand to treat a possible severe reaction. 
Ophthalmic test. One drop of a 1:10 dilution of serum is dropped into 
the conjunctival sac. If definite congestion of the conjunctiva develops 
within from fifteen to twenty minutes with a sensation of itching and 
burning of the eye, a dangerous sensitiveness to the homologous serum is 
indicated, and intravenous injection is contraindicated unless “desensitiza- 
tion” is practicable. Should the local reaction he marked, it may readily 
be controlled by prompt application of epinephrine (1:1000) to the eye. 
“Desensitization ” The procedure of “desensitization” and the thera- 
peutic administration of serum are not advised in the case of patients 
with a positive skin or ophthalmic test except under conditions such as 
may be found in a well-equipped hospital. Serum therapy even under 
these conditions must he considered hazardous. The following procedure 
has been used in attempted desensitization. Subcutaneous injections of 
the serum, beginning with 0.01 ml. or even less, are given at one-half 
hour intervals until 1 ml. is reached by doubling or tripling the dose if no 
reaction develops. If 1 ml. injected subcutaneously incites no reaction, 
0.1 ml. may be given intravenously one-half hour later. Should this give 
rise to no reaction, the doses may be increased very gradually until the 
desired amount has been administered. With a few individuals the limit 
of tolerance will soon be reached. When an interval of more than three 
days elapses between injections of serum, the danger of serious reaction is 
considerable and fatal results even after desensitization have been reported. 
Administration of Preparations 
In the administration of prophylactic and therapeutic products 
aseptic technic is essential. Each preparation before being 
released for distribution is subjected at the laboratory to rigid 
cultural and animal tests of sterility and harmlessness. Correspond- 
ing care should be taken by the physician at the time of injection. 
The directions given in the circulars accompanying the various pro- 
ducts should be followed closely. 
Preparations for injection. The skin over the selected area should be 
thoroughly cleansed with soap and water, then disinfected with alcohol or 
with tincture of iodine applied to the dry surface. Variations in procedure, 
when required, are indicated in the circulars accompanying the products. 18 
The syringe should be boiled for at least five minutes immediately 
before use. A separate, freshly sterilized needle should be taken for 
each injection. 
To remove material from a container through the special rubber stopper, 
the following procedure should be observed: 
Use a sterile syringe on which the needle fits with an air-tight joint. 
Wipe off the top of the rubber stopper with disinfectant. 
Draw up the plunger of the syringe to the graduation corresponding to 
the volume to be withdrawn from the bottle. 
Insert the needle straight through the center of the stopper so that the 
tip protrudes a short distance beyond the inner end of the stopper. 
Invert the bottle and force air from the syringe into it. Avoid too 
great pressure. 
Keeping the inverted bottle uppermost, release the pressure on the end 
of the plunger. If necessary, repeat the last two steps until approxi- 
mately the desired volume of material flows into the syringe. 
Holding the plunger firm at the desired graduation, withdraw the 
needle from the stopper. 
Severe or Other Unusual Reactions Following Administration 
Severe or other unusual reactions following the use of any of 
the State products should be reported immediately to the labora- 
tory in Albany, as should any defect in the container, unusual 
appearance of the material, etc. The information should always 
include the lot number of the preparation and the return date given 
on the package. 
Reports on the Use of Products 
It is of the utmost importance for the maintenance of high 
standards of production that the laboratory be kept informed as 
to the efficacy of the preparations distributed. The various labora- 
tory tests used in the standardization of biologic products afford 
important criteria regarding therapeutic values, but it is to the 
physician that the laboratory must turn for final proof based upon 
clinical experience. All the information indicated on the report 
forms that accompany many of the State preparations is required 
for the correct evaluation of results. Thus, by filling out the forms 
completely and returning them promptly, the clinician makes pos- 
sible for himself and his patients a more efficient laboratory serv- 
ice. The reports on the use of the various products are all of 
value to the laboratory; many, utilized in publications from the 
Division of Laboratories and Research, have contributed mate- 
rially to the progress of vaccine and serum therapy. The collabo- 
ration of many physicians in the State has already been obtained 
and is keenly appreciated; with further realization of the import- 
ance of these records the hearty cooperation of all physicians in 
supplying accurate reports is looked for. 19 
LABORATORY AIDS IN COMMUNICABLE DISEASES 
Amebiasis 
Although the incidence of clinical amebiasis in the district served 
by this Division is low, subclinical infection with Endamoeba his- 
tolytica may be more widespread than is commonly realized. 
Amebiasis is a disease of the tropics, but by no means all of the 
patients suffering from it give a history of having lived in tropical 
climates. The condition is much more prevalent among inmates of 
institutions for the insane and mental defectives, owing to the 
habits of this type of patient, than among the general population. 
Specimens for Laboratory Examination 
Examinations for End. histolytica should be made in a local 
laboratory. The specimen should be passed into a warm container 
and should be submitted immediately for examination. If the 
patient is ambulatory, he should go to the laboratory for the col- 
lection of specimens, since motile forms tend to lose their charac- 
teristic appearance shortly after the stool has been passed. Cysts, 
on the other hand, may retain their distinguishing characteristics 
for several days. Oily medication renders the specimen unfit 
for examination. If the stool is formed or semiformed, a saline 
purge may be necessary. Examination of from six to ten specimens 
may be required unless a purge has been given, in which case three 
stools should be sufficient. Every patient with symptoms sugges- 
tive of dysentery should receive a sigmoidoscopic examination when 
the inciting agent cannot be demonstrated in the stools. 
A bacteriologic examination of the feces should be made, since in 
some instances bacillary incitants of enteric disease will be found, 
as well as amebae, or the case may be one of bacillary rather than 
amebic dystentery. 
Anthrax 
Infections with the anthrax bacillus are usually incurred by 
handling certain animal products such as hides, hair, or wool, 
especially those that are imported. Before their manufacture 
and sale were prohibited in New York State' (Sanitary Code, 
Chap. IX, Reg. 4), shaving brushes containing horsehair repre- 
sented a particular hazard. Infection Usually takes place through 
the abraded skin and is followed by the formation of a character- 
tistic pustule, but the microorganisms may gain entrance through 20 
the alimentary or the respiratory tract. The primary lesion usu- 
ally occurs within from twelve to twenty-four hours after infection. 
Diagnosis must be based on the history, clinical manifestations, and 
the finding of large Gram-positive bacilli in films prepared from the 
pustule. Prompt laboratory examination is essential, since the 
nature of the infection should be determined as soon as possible. 
For purposes of confirmation, the anthrax bacillus should be 
isolated and its identity proved by cultural and animal tests. Since 
the spores of Bacillus anthracis are highly resistant, all contami- 
nated material should either be burned, or boiled in 10-per-cent 
cresol for one hour. 
Specimens for Laboratory Examination 
In accordance with the requirements of Chap. II, Reg. 9, of the 
Sanitary Code, the following material should be submitted for 
examination to a laboratory approved for the purpose: (1) exudate 
from the lesion on a sterile swab (tube outfit with swab) ; (2) films 
of the exudate on glass slides (slide outfit). 
If microorganisms having the morphology of B. anthracis are 
found in films from the lesion, a preliminary report can be made 
at once. Cultural and animal tests, which may be somewhat time- 
consuming, are required for complete identification of the anthrax 
bacillus. 
Product Supplied by the Laboratory 
Antianthrax serum. Serum therapy in human anthrax, or 
malignant pustule, has proved definitely effective. Prompt admin- 
istration of the serum is essential. In the early stages excision of 
the focus of infection is also indicated. A limited supply of a com- 
mercial antianthrax serum is maintained at the central laboratory 
in Albany for emergency distribution. The material can also be 
obtained through the Branch Laboratory, 339 East 25th Street, 
New York City. Requests for the serum should be made by tele- 
phone or telegraph. If the patient is able to pay for the material 
or the ease is Covered by compensation, it is expected that the 
amount supplied will be replaced promptly. Physicians obtaining 
the serum are asked to send a complete report to the central 
laboratory. 
Administration. The initial dose of antianthrax serum recom- 
mended is from 100 to 200 ml., depending upon the severity of the 
symptoms, given intravenously or intramuscularly in localized in- 
fections. In severe cases of systemic infection an initial dose of 21 
200 ml. given intravenously is advised. Additional doses of 50 
ml. at daily intervals may be administered in all cases until there is 
marked improvement. Beneficial results have been reported from 
the supplementary injection subcutaneously of from 5 to 10 ml. 
of serum distributed between 3 or more points around the base 
of the pustule. Detailed directions are given in an enclosed 
circular. 
Chancroid 
The inciting agent in chancroid, Hemophilus ducreyi, can some- 
times be demonstrated in films prepared from fresh exudate from 
the lesion, and stained with special stains designed to demonstrate 
the characteristic arrangement of the microorganisms. The ineit- 
ant can be isolated only when the condition of the lesion is 
favorable, and a specially prepared culture medium can be inocu- 
lated promptly after collection of the exudate. Failure to demon- 
strate the presence of H. ducreyi does not necessarily mean that 
the patient does not have chancroid; the diagnosis often must be 
made on the clinical findings alone. Thus, laboratory examinations 
have been required only for evidence of syphilis. 
Specimens for Laboratory Examination 
In accordance with the requirements of Chap. II, Reg. 9, of the 
Sanitary Code, the specimens specified under Syphilis, p. 64, should 
be submitted to an approved laboratory for examination, in order to 
detect concurrent syphilitic infection. 
Cholera, Asiatic 
The inciting microorganism, Vibrio cholerae, is found in the rice- 
water intestinal discharge from infected persons and also in the 
vomitus, and can be isolated from the feces of convalescents and 
carriers. It gains entrance to the body through the ingestion of 
contaminated food and water. The microorganisms usually disap- 
pear from the stools within three or four days. They may be 
found, however, for from seven to ten days, occasionally for as 
long as two weeks, and more rarely for three or four months. 
During an epidemic, the carrier rate may be from twenty to 
thirty per cent. 
Federal quarantine regulations at ports of entry have been highly 
effective in excluding cholera. Modern methods of transportation, 
however, may introduce a new hazard from tropical diseases. The 22 
full effects of the present world war as far as the introduction of 
tropical diseases is concerned may not be appreciated for some 
time after the cessation of hostilities. 
If a diagnosis of cholera is considered, the district state healtli 
officer should be notified at once by telephone. 
Specimens for Laboratory Examination 
In accordance with the requirements of Chap. II, Reg. 9, of the 
Sanitary Code, the following material should be submitted for 
examination to a laboratory approved for the purpose: (1) a 
specimen of feces in a sterile container without preservative (jar 
outfit) ; (2) 10 ml. of blood to be examined for evidence of typhoid 
fever (typhoid tube outfit). Also, a specimen of feces in 30-per-cent 
buffered glycerol (typhoid jar outfit) should be submitted to be 
examined for other bacterial incitants of enteric disease. If 
possible, the specimens should be delivered to a laboratory by 
messenger. 
The presence of actively motile, Gram-negative, comma-shaped 
spirilla can be determined promptly by microscopic examination 
of specimens of feces. The identification of V. cholerae requires 
data concerning morphologic, cultural, and serologic properties. 
Diarrhea 
Outbreaks of diarrhea are of frequent occurrence, particularly 
during the summer and autumn. Except in cases of acute enteritis 
incited by microorganisms of the salmonella group or by dysentery 
bacilli, comparatively little is known regarding the etiology of 
such outbreaks. Even when investigations are undertaken 
promptly, bacilli usually associated with enteric disease often 
cannot be demonstrated. The role of certain groups of micro- 
organisms such as the paracolon group in the etiology of diarrheal 
diseases has yet to be determined. The incidence of diseases of this 
type depends primarily on sanitation and methods of handling food. 
Specimens for Laboratory Examination 
Specimens of feces may be submitted (typhoid jar outfit con- 
taining 30-per-cent buffered glycerol). They should be supple- 
mented by blood specimens for agglutination tests (typhoid tube 
outfit) collected at the time the patient is acutely ill and also from 
two to three weeks after recovery. 23 
Diphtheria 
Diphtheria often occurs in epidemic form. The inciting micro- 
organism, Cory neb act erium diphtheriae, usually becomes localized 
in the throat, producing characteristic lesions on the mucous mem- 
brane of the pharynx, tonsils, or larynx, sometimes extending into 
the trachea. Similar lesions may occur in the nose and, in rare 
instances, the conjunctiva, the vagina, and in wounds. The possi- 
bility of diphtheritic gangrene should be considered when lesions 
on the skin fail to heal. Recent literature indicates that infection 
of the skin with diphtheria bacilli is not uncommon in the armed 
forces. 
Three classes of individuals may harbor morphologically typical 
diphtheria bacilli in the throat or nose: (1) those having, or con- 
valescing from, diphtheria; (2) those who, without having con- 
tracted the disease themselves, have acquired the microorganisms 
through contact with others (“contact” carriers) ; and (3) those 
who give no history of either having had the disease or having been 
in contact with patients or carriers (“noncontact” carriers). 
Diphtheria antitoxin should be given without delay to every 
patient having clinical diphtheria, whether or not diphtheria 
bacilli are found, as well as to patients with sore throat when diph- 
theria bacilli are present. 
The period of communicability lasts until virulent bacilli are no 
longer present in the secretions and lesions. The persistence of 
C. diphtheriae after the clinical symptoms of the disease have sub- 
sided is variable. In exceptional instances, virulent diphtheria 
bacilli remain in the throat or nose for nine weeks or more. The 
usual length of time, however, is from one to two weeks. In over 
90 per cent of all cases, the bacilli disappear after four weeks. 
Carriers of C. diphtheriae. Persons who become persistent car- 
riers of diphtheria bacilli are usually found to have some abnormal 
condition in the throat or nose, most often diseased tonsils. With 
few exceptions, however, the diphtheria bacilli disappear in the 
course of a few weeks without treatment. British workers have 
found that the carrier state is apparently prolonged in some indi- 
viduals who harbor appreciable numbers of hemolytic streptococci 
in the nose. In these instances, treatment with sulfanilamide has 
been effective. 
If cultures are taken among large groups of apparently normal 
individuals, as, for example, in a school or institution, approxi- 
mately 1 per cent will usually show morphologically typical diph- 
theria bacilli. More than three-fourths of these, however, are found 24 
to be avirulent, i.e., incapable of producing toxin. This type of 
microorganism is generally encountered in the group of so-called 
“noncontact” carriers. Since the carrier condition is often tempor- 
ary, the diphtheria bacilli being found in only one or two cultures, 
a request for a virulence test ordinarily should not be made until 
two or three specimens have been examined to determine whether 
the microorganisms are persisting. 
In the case of convalescent and contact carriers, the fact that 
diphtheria bacilli have incited the disease is presumptive evidence 
that they are virulent. Experience has shown that in these 
instances approximately 95 per cent of the microorganisms remain 
virulent for three months. In view of this and since the test is 
expensive and time-consuming, virulence tests upon cultures from 
convalescents and contact carriers should not usually be requested 
until three months after the patient has recovered: If, however, a 
health official believes that the circumstances warrant such a 
request within a shorter time, an explanation should accompany 
the specimen. 
Specimens for Laboratory Examination 
In accordance with the requirements of Chap. II, Reg. 9, of the 
Sanitary Code, a culture from the throat on Loeffler’s blood-serum 
medium, and, if symptoms of rhinitis are observed, a culture from 
the nose also (diphtheria culture outfit) should be submitted for 
examination to a laboratory approved for the purpose. When a 
virulence test is desired, it should be requested on the history form. 
In the preparation of cultures for laboratory examination, the 
following directions should he observed: only Loeffler’s medium 
that is in a satisfactory condition should be selected; a culture 
should not be taken immediately after the patient has used an anti- 
septic as a spray or gargle; the inoculum should be collected at the 
margin of, or from beneath the membrane rather than from the 
surface; separate specimens should be submitted from the nose and 
throat; the medium should be inoculated by rubbing the entire 
surface lightly and thoroughly with the swab without breaking 
the surface of the medium or pushing the swab into it. 
A frequent source of annoyance is the contamination of medium 
with microorganisms that overgrow the culture and make a satis- 
factory examination impossible. Often, this condition results from 
the presence of a microorganism in the nose or throat that pro- 
duces a slimy growth on the culture medium. Irrigation of the 
nose and throat with warm sterile physiologic salt solution may 
remove the exudate containing such bacteria. 25 
Cultures are incubated at from 35° to 37° C. for from eighteen to 
twenty-four hours. Morphologic examinations are then made for diph- 
theria bacilli. When a virulence test is undertaken, the microorganism 
is obtained in pure culture, its morphology and cultural characters are 
studied, and its virulence is tested. 
When sufficiently large numbers of morphologically typical diphtheria 
bacilli are present, a suspension of the culture may be tested by the 
intracutaneous method, thus making an early report possible in case 
virulent diphtheria bacilli are demonstrated. 
Products Supplied hy the Laboratory 
In addition to the laboratory aids in diagnosis, there are avail- 
able to the physician in the control of diphtheria, laboratory prepa- 
rations for determining susceptibility, for inducing active or 
passive immunization, and for effecting cure. 
Outfits for the intracutaneous test of susceptibility to diph- 
theria toxin (Schick). The intracutaneous test of susceptibility 
to diphtheria toxin (Schick) consists of the injection into the skin 
of 1/50 of the minimum dose of a diphtheria toxin fatal to a 
guinea pig. When there is insufficient antitoxin in the tissues to 
neutralize the toxin, a local reddening is induced at the site of 
injection; when sufficient antitoxin is present, there is no toxic reac- 
tion. The test, therefore, is designed to differentiate those who have 
from those who have not sufficient antitoxin in their blood to render 
them immune to diphtheria. Reliable results are dependent upon 
great accuracy in procedure, and the correct interpretation of the 
reactions requires considerable experience. A control injection of 
heated toxin dilution should always be made since some persons 
react to the protein in the material, especially after immunization. 
The percentage of individuals susceptible to diphtheria at differ- 
ent ages varies in different localities and under different conditions. 
In general, the rural population is more susceptible than that of 
crowded cities. Adults are less susceptible than children. When 
practicable, the test should be performed before active or passive 
immunization against diphtheria is undertaken, especially in the 
case of older children and adults. A retest is necessary after active 
immunization to determine definitely whether immunity has 
developed. 
In the outfits for the test are two bottles, one containing diluted 
diphtheria toxin for the test dose, the other containing diluted 
heated toxin for the control injection. The toxin in each bottle is 
so diluted with buffered salt solution that the required amount for 
the test is contained in 0.1 ml. The toxin in the control dilution 26 
has been heated to destroy its toxicity and is used to determine 
sensitivity to the protein present. The outfits are distributed in 
two sizes; one in which the bottles contain 5 ml., or sufficient for 
from twenty-five to forty tests, and the other, 2 ml., or sufficient for 
about ten tests. 
Since unfavorable temperature and exposure to air or light may 
cause deterioration of the toxin, the contents of individual con- 
tainers should be used only for tests made at one time. When 
many tests are to be performed, removal of the stopper and the use 
of a long, sterile needle (gauge 15, 2 inches) to till the syringe has 
been found convenient. Any water remaining in the needle should 
first be emptied and the syringe and needle rinsed with a small 
amount of the material for the test. When outfits are requested, 
the number of persons to be tested should be given, and if the work 
is to be done in different groups or on different days the number 
of persons in each group to be tested should also be stated. 
The test. One-tenth milliliter of the toxin dilution is injected 
intracutaneously on the flexor surface of the left forearm and 
a similar volume of the heated toxin dilution on the right fore- 
arm. Special syringe outfits with a separate syringe for the con- 
trol test can be purchased. Syringes and needles that have been 
previously employed for tuberculin tests should not be used. A 
freshly sterilized needle for each child is recommended. When 
only one reading is practicable, it should be made on the fifth, 
sixth, or seventh day after the injection. It has been found con- 
venient to make readings and give the initial immunizing dose to 
those showing positive reactions, on the seventh day. 
Detailed directions accompany each outfit for the intracutane- 
ous test. To secure dependable results it is essential that they be 
followed closely. 
Diphtheria Toxoid 
Active immunization. Since the incidence of diphtheria is 
highest in young children and the mortality greatest in those under 
five years of age, the active immunization of children of pre-school 
and school age is an important preventive measure. The immunity 
usually derived by infants from their mothers is lost during the 
first months after birth, so that it is desirable that the immunizing 
injections be given at the age of six months or shortly after. The 
fact that in children under six years slight, if any, reactions are 
induced is an added advantage of early administration. 
Most children are susceptible to diphtheria, hence the preliminary test 
of susceptibility {Schick) of those under ten years of age is often omitted. 27 
Since fewer adults are susceptible to diphtheria, and more react to the 
immunizing doses of toxoid, the preliminary test should always be made 
to determine the need for immunization. In order to ascertain whether 
immunity has developed, an intracutaneous test should be made from four 
to six months after the last immunizing injection. Protection against 
diphtheria cannot be assumed without a negative test. In the case of 
children who received toxoid before two years of age, a supplementary dose 
as an additional stimulus should be given when the child reaches school 
age or before. A retest to determine susceptibility may first be made. 
Diphtheria toxoid, both unprecipitated and precipitated, is 
prepared, tested, and distributed by the Division of Laboratories 
and Research for active immunization against diphtheria. 
Diphtheria toxoid, unprecipitated, which contains no horse or 
other serum, is prepared by subjecting potent diphtheria toxin 
to the action of formalin and heat until the material has become 
detoxified. The best response appears to be in children between 
one and six to eight years old. Infants under six months, owing to 
the temporary immunity usually derived from their mothers, do not 
respond well to immunization. 
Diphtheria toxoid is distributed in bottles containing 5 ml. and 
in smaller bottles containing sufficient material for the complete 
immunization of one person or for one immunizing injection of 
three persons. When toxoid is requisitioned, the number of chil- 
dren whom it is proposed to immunize should always be stated. 
Administration. Injections are given subcutaneously, alternately 
on the outer side of the upper arm, beginning with the left arm. 
Three doses of toxoid of 0.5 ml. each at 2- or preferably 3-week 
intervals are recommended. (Experience indicates that doses 
even up to 1 ml. may be given to young children without inducing 
undue reactions.) On account of the small volume, special care 
should be taken to inject the full amount and to prevent loss by 
oozing. For persons over 15 years a modified dosage, 0.2, 0.4, and 
0.4 ml. at 2- or preferably 3-week intervals, is advised. If the con- 
trol for the intracutaneous test of susceptibility indicates a high 
protein sensitivity, the size of the doses may be still further reduced 
and a fourth dose given. 
Diphtheria toxoid, precipitated, contains no horse or other 
serum. It is prepared by subjecting potent diphtheria toxin to the 
action of formalin and heat until it has become detoxified. The 
active principle is then precipitated by the addition of chemicals 
and the resulting precipitate washed and resuspended in physiol- 
ogic salt solution. The presence of the precipitate, which retards 28 
absorption, is considered an important factor in the favorable 
results reported with this purified, stable preparation. Reports on 
its use in children up to 15 years of age have not indicated a higher 
incidence of reactions than occurs following the use of unprecipi- 
tated toxoid. For older persons a modified dosage of the unpre- 
cipitated toxoid is, however, at present recommended. 
Precipitated toxoid is distributed in bottles containing 10 ml. 
and in smaller bottles containing sufficient material for two injec- 
tions. Requests for the material should always state the number 
of children to be immunized. 
Administration. In order to insure a correct dosage, it is essential 
that equal amounts of the suspension be injected. The bottle should 
be thoroughly shaken just before it is opened and rotated each time 
the syringe is filled. The syringe should be rotated similarly before 
each injection. One dose of 1 ml. or preferably two doses of 1 ml. 
each a month apart are recommended. Special care should be taken 
to insure the injection of the full amount and to prevent loss by 
oozing. The injection should be made subcutaneously on the outer 
side of the upper arm, the left for the first and the right for the 
second if given. Deep or intramuscular injections should be 
avoided. 
Diphtheria-tetanus toxoid, precipitated, combines the advantages 
of both preparations in a volume dose approximating that of either 
and induces no more reactions. The material is prepared by mixing 
equal parts of each precipitated toxoid. It is considered an effective 
prophylactic agent for the active immunization of children against 
diphtheria and tetanus. For older persons the unprecipitated tox- 
oids are recommended. (See pages 27 and 71.) 
Diphtheria-tetanus toxoid, precipitated, is distributed in 10 ml. 
and 2.5 ml. amounts. Requests for the material should be made to 
the Central Laboratory and should always state the number of 
children to be immunized. 
Administration. The same precautions as for precipitated diph- 
theria toxoid should be observed. Two subcutaneous injections of 
1 ml. each a month apart are required. In order to maintain an 
adequate level of immunity a stimulating dose of precipitated diph- 
theria-tetanus toxoid or of tetanus toxoid alone should be adminis- 
tered at the end of a year. A stimulating dose of toxoid at the 
time of an injury for which ordinarily a prophylactic injection 
of tetanus antitoxin would be given, is considered to be sufficient to 
protect against tetanus infection. In case of any doubt as to previ- 
ous active immunization with tetanus toxoid, a prophylactic dose 
of tetanus antitoxin should be administered. 29 
Diphtheria Antitoxin 
Passive immunization. Protection of contacts not previously 
shown by the intracutaneous test to be insusceptible to diphtheria 
may be effected by passive immunization with diphtheria anti- 
toxin. Concentrated diphtheria antitoxin produced by the State 
laboratory is distributed through supply stations in packages of 
1,000 units for prophylactic use. The dose for adults is 1,000 units 
given subcutaneously; for children, from 500 to 1,000 units, depend- 
ing upon body weight. Such persons will be protected for a period 
usually of about two weeks. 
Curative treatment. When the lesion in the throat is typical, 
and especially when in suspected laryngeal diphtheria croupous 
symptoms develop, antitoxin should be administered immediately 
and a culture taken for bacterial diagnosis. The harmful effects 
in diphtheria are due to the diphtheria toxin which diffuses 
through the body from the local lesion in the throat. Toxin that 
has become united with the cell substance is probably not affected 
by antitoxin. When sufficient toxin has combined with the body 
tissues to cause death, no amount of antitoxin will bring about 
recovery. Hence, it is of the utmost importance to begin treatment 
as early as possible in the course of the disease. An early and lib- 
eral single injection is always preferable to smaller divided doses. 
The initial dose should be sufficient but if the clinical symptoms 
persist the dose must be repeated, possibly increased. The anti- 
toxin for therapeutic use is distributed in packages containing 
5,000 and 10,000 units. Directions are contained in each package. 
Administration. Immediate curative action is best secured by 
intravenous injection which is from three to four times as effective 
as injection into the subcutaneous tissue, but only physicians 
experienced in intravenous serum administration should practice 
it. In late or in severe cases, as in emergencies of laryngeal diph- 
theria, it is much to be preferred. Intramuscular injection, because 
of more rapid absorption, is more effective than subcutaneous. 
Initial Dosage in Diphtheria 
Mild Moderate Severe to Malignant 
Children under 60 lbs. in weight 
3.000- 5,000-10,000 10,000-25,000 
Adults 
3.000- 5,000-15,000 20,000-50,000 
Intramuscular Intramuscular Intramuscular or 
Subcutaneous Intravenous 
(The smaller dose is usually adequate for Intravenous injection.) 30 
Intravenous injection is made into the median basilic vein, the 
antitoxin preferably being diluted with warm sterile physiologic 
salt solution. In infants, if necessary, the external jugular vein 
may be used. For precautions against anaphylactic reactions, see 
page 16. 
Dysentery, Bacillary 
At least five distinct types of B. dysenteriae have been recognized 
as incitants of bacillary dysentery—Shiga, Schmitz, Sonne, New- 
castle, and Flexner. Infections with the last four occur not 
infrequently in New York State, particularly among inmates of 
institutions, whereas infections with the Shiga type, in which the 
mortality is relatively high, are extremely rare. 
The dysentery bacillus usually enters the body by the mouth, 
although infection may result from the use of unsterile tubing or 
other instruments employed in the administration of enemas or in 
similar procedures. 
The microorganism is found in the feces, but seldom if ever in 
the blood stream or in the urine. When a person has recovered from 
bacillary dysentery, the incitant can usually be isolated from the 
stools for only a relatively short time. Occasionally, however, 
patients develop symptoms of colitis and remain carriers of dysen- 
tery bacilli for long periods. The results of serologic tests for 
evidence of bacillary dysentery have proved disappointing. Blood 
from many normal individuals has been found to agglutinate 
dysentery bacilli, while, on the other hand, the titer of serum from 
patients with dysentery, at least when the specimens are collected 
early in the course of the disease, may be no higher than that of 
persons who are not ill. Consequently, blood from patients with 
symptoms of dysentery is usually examined for evidence of typhoid 
fever, since the clinical manifestations in these enteric infections 
may sometimes be similar. 
Specimens for Laboratory Examination 
In accordance with the requirements of Chap. II, Reg. 9, of the 
Sanitary Code, the following material should be submitted for 
examination to a laboratory approved for the purpose: (1) a 
specimen of feces (typhoid jar outfit containing 30-per-cent buffered 
glycerol) ; and (2) 10 ml. of blood to be examined for evidence of 
typhoid fever (typhoid tube outfit). 31 
The intestinal discharge consisting of blood and mucous as 
obtained in early stages of the disease, especially when relatively 
free from fecal matter, is the most suitable for examination. 
Note: The value of antidysentery serum for the treatment of infections caused 
by types other than the Shiga bacillus is questionable. Infections due to this type 
rarely occur in New York State. In view of these facts and the infrequent 
requests for the material, the distribution of multivalent antidysentery serum has 
been discontinued. 
Epidemic Encephalitis 
There are a number of true epidemic encephalitides, namely 
equine encephalomyelitis, St. Louis encephalitis, Japanese type B 
encephalitis, Australian X disease, and Russian encephalitis, in 
all of which viruses have been shown to be the etiologic agents. 
The etiology of encephalitis lethargica, the incidence of which has 
declined markedly in the United States since 1926, is unknown. 
Laboratory examinations are often of assistance in differentiating 
this disease from epidemic cerebrospinal meningitis, tuberculous 
meningitis, or cerebrospinal syphilis. 
Specimens for Laboratory Examination 
No specific test for encephalitis is at present available. How- 
ever, the results of a cell count, protein determination, colloidal gold 
test, quantitative sugar determination, and bacteriologic tests made 
on specimens of cerebrospinal fluid may be helpful in evaluating 
the clinical manifestations. Directions for the collection of speci- 
mens are given under Syphilis, p. 66. 
Food Poisoning 
The term “food poisoning” is usually employed to designate 
any illness following the ingestion of food containing certain toxi- 
genic microorganisms or their products. 
Botulism. The most serious, but in this country the least com- 
mon, form of food poisoning is that known as botulism, which 
results from ingestion of food containing toxin produced by Clos- 
tridium hotulinum. Botulinus toxin is highly poisonous and is 
not destroyed in the stomach or intestine. Several types of the 
botulinus bacillus have been recognized, but those most commonly 
associated with botulism in man are types A and B. Strains of 
type E have been isolated in New York State from canned and 
also from smoked fish. The products, which had been imported, 
had not been sterilized by heat. In both instances, individuals 32 
who had eaten the fish developed symptoms of botulism; there were 
two deaths. 
The source of infection in North America has, in most instances, 
proved to be canned nonacid fruits and vegetables, while in Europe, 
contaminated ham, sausage, and fish have figured most prominently. 
Individuals engaged in home canning should be aware of the 
dangers of using improper methods. Heating in a pressure cooker 
is the most satisfactory way of destroying the spores of Cl. 
hotulinum. In the case of foods that are definitely acid such as 
most fruits, tomatoes, pickled beets, ripe pimentos, and rhubarb, 
the botulinus spores may be destroyed within a reasonable time 
at the temperature of boiling water. Provided nothing is added 
to reduce or counteract the acidity of these foods, processing in a 
pressure cooker is not necessary. The bland nonacid foods, how- 
ever—including all vegetables other than those mentioned above, 
such as asparagus, peas, beans, corn, beets, and greens, and also 
meats and poultry—can be rendered safe with speed and surety 
only at the high temperature obtainable in a reliable steam pres- 
sure canner. Physical evidence of spoilage is usually present in 
food contaminated with Cl. hotulinum, but fatal cases have resulted 
from the tasting of food in which signs of decomposition were 
scarcely noticeable and were unaccompanied by any unpleasant 
taste or odor. Botulinus toxin is destroyed by boiling, but the 
heating of the food must be sufficient to insure raising every por- 
tion to the boiling point and continuing the heating for an addi- 
tional fifteen minutes. 
In botulism, the disease process results from the affinity of the 
toxin for the nervous system, and death occurs as a result of 
respiratory paralysis. In characteristic cases, the symptoms include : 
gradual onset with visual disturbances, such as double vision, 
ptosis of lids; difficulty in swallowing; and constipation. The 
clinical picture closely resembles that following atropin poisoning 
and bulbar paralysis. The period of incubation is variable (less 
than twenty-four hours or as long as a week), and only relatively 
mild gastrointestinal symptoms (vomiting once or twice and con- 
stipation) may precede the development of the characteristic 
paralysis. 
Other types of food poisoning. Food poisoning of the more 
common type can usually be attributed to toxic products of certain 
common bacterial species, principally staphylococci. The illness 
is generally characterized by a short incubation period, sudden 
onset with abdominal pain, nausea and vomiting, and offensive 33 
diarrhea. Fever is low-grade; the temperature rarely exceeds 
102° F. or 103° F. In severe cases, there may be faintness, mus- 
cular weakness, and shock. Salmonella and dysentery bacilli may 
be conveyed by food and infections with these species are there- 
fore sometimes designated as food poisoning. 
Staphylococci and other types of bacteria that produce toxic 
substances in food may be derived from lesions on the hands or 
from the nose of the food handler, or from raw milk from cows with 
diseased udders. Certain foods, especially cooked meat with 
gravy or cream sauce and custard-filled pastries, offer an excellent 
medium for the development of this type of bacterium, but deter- 
mination of the incitant and the source of contamination is often 
difficult. Bakers and other distributors of cooked foods, and the 
general public, should realize the importance of storage at temper- 
atures unfavorable to bacterial growth. In all instances, the toxic 
food stuffs have been found to have been kept, for a few hours at 
least, at a temperature that favors the development of bacteria. 
Since rodents and fowls are known to harbor many species of 
salmonella, contamination of food with their feces is probably one 
of the most common means of disseminating these microorganisms. 
Human carriers or cases may be the source of salmonella and also 
of dysentery bacilli. The source of Cl. hotidinum is usually the soil. 
Specimens for Laboratory Examination 
After an investigation has been made to determine the articles 
of food consumed by all who are ill, the suspected material should 
be sent to an approved laboratory, together with the pertinent data, 
including clinical manifestations of the illness. If canned, a por- 
tion of the food taken from the same container or lot as that eaten 
by the patient should be collected. In the case of botulism, even 
washings from the can may be adequate for testing. Since the 
symptoms in botulism may appear at any time from within twenty- 
four hours to several days after ingestion of the food containing the 
toxin, any food eaten within that period should be considered. 
Food to be examined for Staphylococcus aureus or other micro- 
organisms producing enterotoxins is satisfactory only when it has 
been refrigerated to prevent bacterial growth subsequent to the 
time when portions of it were consumed. Strains of Staph, aureus 
that produce enterotoxins, and those that do not, cannot be differ- 
entiated with certainty. 
Specimens from the patients should also be submitted: 20 ml. 
of blood to be studied for the presence of the botulinus toxin, a 34 
specimen of feces without preservative to be examined for CL 
botulinum (miscellaneous jar outfit), and another specimen of 
feces in 30-per-cent buffered glycerol J[typhoid jar outfit) to be 
examined for salmonella and other bacillary incitants of enteric 
disease. Cl. botulinum and its toxic products, however, can be more 
readily demonstrated in food than in these types of material. 
Products Supplied by the Laboratory 
Botulinus antitoxic sera. Serum therapy in cases of human 
botulism has not been used sufficiently to warrant a definite state- 
ment as to its practical value; that is, how early the serum must 
be given to be effective or how late in the course of the disease its 
injection becomes useless. Experiments with animals indicate that 
the serum may be of value when given within from twenty-four to 
forty-eight hours after the ingestion of the food containing the 
toxin. Two types of Cl. hotulinum, designated as A and B, are 
most frequently associated with human eases. They produce 
different toxins. Since the immediate determination of the type is 
not practicable, a multivalent serum, or both types of univalent 
sera, A and B should be given. The two univalent sera may be 
combined or given separately. Univalent botulinus antitoxic sera 
of types A and B are produced by the State laboratory and 
distributed in packages containing 20 ml. for immediate use. The 
type A serum is of exceptionally high titer and unconcentrated; 
the type B serum is concentrated. Requests for the sera should 
be sent by telephone or telegram at the earliest possible moment 
after botulism is suspected to the Central Laboratory, Albany, or 
the Branch Laboratory, 339 East 25th Street, New York City 10, 
or to one of the following where a limited supply is maintained 
for immediate emergency use: the departments of health at Buffalo 
and Rochester, the Binghamton City Hospital, the district state 
health officers at Gouverneur, Hornell, Jamestown, Middletown, 
Saranac Lake, and Syracuse. 
Administration. An initial dose of from 60 to 120 ml. (two 
bottles of type B for each one of type A) should be given intra- 
venously by gravity at the earliest possible moment. The dose may 
be repeated in from 6 to 8 hours unless it is apparent that no bene- 
ficial result can be expected from further serum administration. 
A prophylactic dose of 10 ml. of antitoxin, multivalent or com- 
bined, given intramuscularly, has been recommended for persons 
who may have consumed some of the suspected food but have not 
yet developed symptoms. The appearance of any suggestive symp- 35 
toms should be followed by the administration of the full dose 
intravenously. For precautions against anaphylactic reactions, 
see page 16. 
Gas Gangrene 
Infection with gas-forming anaerobic microorganisms, desig- 
nated as gas gangrene, may develop in any dirty wound, especially 
when there has been extensive destruction of tissue, as in the case 
of compound fractures, crushing injuries, and gunshot wounds. 
The laboratory can be of little assistance in diagnosis, since the 
results of bacteriologic examinations are not available soon enough 
to be of value as a guide in treatment. Examination of a piece 
of traumatized muscle from the deeper portions of the wound, how- 
ever, may reveal the presence of Clostridium welchii or other gas- 
forming microorganisms. Therapy to be effective must be under- 
taken promptly on the basis of clinical and x-ray findings. 
Product Supplied hy the Laboratory 
Gas gangrene antitoxin. Clinical reports received have indicated 
the value of serum therapy in the treatment of cases of gas gangrene 
due to the presence in the wound of one or more species of anaerobic 
bacteria. Treatment should be commenced promptly. Further 
experience with the use of sulfonamide drugs in battle casualties 
should determine the value of these agents in the treatment of gas 
gangrene, either alone or in combination with serum and surgery. 
A small supply of gas gangrene antitoxin is purchased and held 
for emergency use at the State laboratory, Albany, the Binghamton 
City Hospital, and in the Kingston City Laboratory and the Bac- 
teriological Laboratory, Buffalo, in care of the district state 
health officers. Requests should be made by telephone or telegraph 
to the central laboratory, the Branch Laboratory, 339 East 25th 
Street, New York City, or to the nearest station. The antitoxin, 
which is multivalent, is produced against the toxins of Cl. welchii 
(B. perfringens) and certain other species of pathogenic anaerobes. 
If the patient is able to pay for the material or the case is covered 
by compensation, it is expected that the amount supplied will be 
replaced promptly. The material is not furnished for prophylactic 
use. 
Administration. An initial injection of the contents of one 
bottle up to that of four bottles is recommended to overcome as far 
as possible the general toxemia. Subsequent in jections of at least 36 
the minimum dose (one bottle) may be given at from 4 to 6 
hour intervals or longer depending upon the condition of the 
patient. Intravenous injection is advised until signs of definite 
improvement are noted; subsequent doses may be given subcutane- 
ously. Detailed directions are contained in each package. 
If a prophylactic injection of tetanus antitoxin has not already 
been given, from 1,500 to 3,000 units should be administered at once 
and the dose repeated if the wound continues favorable for the 
development of tetanus infection. 
Glanders 
Glanders, primarily a disease of horses, can be transmitted to 
man. The incitant, Bacterium mallei, is found in the nasal secre- 
tions, pus from nodules, blood, and at times in the urine, saliva, 
and milk. In man the mode of infection is usually through an 
abrasion of the skin, but may be through the mucosa of the mouth 
and nose. A nodule appears at the site of infection, accompanied 
by lymphangitis and swelling. A general pustular eruption may 
occur. While the disease is usually acquired from contact with 
horses, it may be transmitted from man to man. 
Specimens for Laboratory Examination 
In accordance with the requirements of Chap. II, Reg. 9, of the 
Sanitary Code, the following material should be submitted for 
examination to a laboratory approved for the purpose: (1) 10 
ml. of blood (typhoid tube outfit) ; (2) a specimen of discharge on 
a sterile swab (tube outfit with swab) ; (3) films of discharge on 
glass slides (slide outfit). 
So few eases of glanders occur in man that little opportunity has 
been afforded to evaluate the results of serologic tests. Thus, 
adequate material for cultural examination is desirable. 
Glandular Fever and Infectious Mononucleosis 
Until the etiology of glandular fever and infectious mononucle- 
osis has been established, their relationship will probably remain 
unsettled. While the clinical findings and the cytology of the blood 
may be similar, outbreaks of so-called glandular fever have been 
reported to occur largely among children and may involve a con- 
siderable number of individuals, while infectious mononucleosis 
is usually characterized by sporadic cases among young adults. 37 
A distinct aid in the diagnosis of infectious mononucleosis is an 
agglutination test using sheep red blood cells. Reports in the 
literature indicate that in this test agglutination is rarely observed 
in the epidemic form of the disease (glandular fever) among 
children. It might be mentioned incidentally that injections of 
horse serum, particularly when serum sickness occurs, and admin- 
istration of bacterial vaccines or other types of foreign protein may 
give rise to agglutinative properties for these erythrocytes. 
Specimens for Laboratory Examination 
Blood films (slide outfit) may be submitted for differential 
leucocyte counts and 10 ml. of blood (typhoid tube outfit), for 
serologic tests. 
Gonorrhea 
Laboratory aids in the diagnosis of gonorrhea have proved 
especially helpful. In acute or active cases of gonorrhea, the 
incitant, Neisseria gonorrhoeae, is nearly always demonstrated 
microscopically in large numbers in the discharge, and can usually 
be isolated if cultural examination is undertaken promptly after 
collection of the specimen. If the patient cannot go to the 
laboratory, a suitable culture medium should be procured and inoc- 
ulated by the physician. Cultural examination is especially valu- 
able in the study of specimens from female patients, in chronic 
infections, and for control of treatment. Film preparations should 
be examined in all cases, since microorganisms having the morphol- 
ogy of gonococci are sometimes found microscopically when they 
cannot be isolated. 
The results of serologic tests may be helpful or may be mislead- 
ing; they should be interpreted only in the light of the clinical 
diagnosis or in conjunction with the morphologic or cultural demon- 
stration of the presence of the gonococcus in the disease process. 
Serologic methods continue under investigation so that further 
information may be secured concerning the limitations in the 
practical value of these tests. 
Specimens for Laboratory Examination 
In the male, urine, prostatic secretion, or exudate from the 
urethra should be submitted for examination; and in the female, 
exudate from the urethra, cervix, and Bartholin’s glands, or, in 38 
vulvovaginitis, from the vagina. Specimens from adult females 
should be collected with swabs; in vulvovaginitis, preferably with 
a glass catheter. In extragenital infections, appropriate specimens 
such as blood, joint fluid, or cerebrospinal fluid should be sub- 
mitted. Whenever the gonococcus is suspected as the incitant of a 
conjunctivitis, specimens should be submitted as described under 
Ophthalmia Neonatorum, p. 45. 
Products Supplied by the Laboratory 
Sulfonamide drugs. Sulfathiazole in bottles of forty 0.5-gram 
tablets is distributed to physicians and clinics through most of the 
district laboratory supply stations. -A request form for the purpose 
may be obtained from custodians of these stations. In accordance 
with Rule 38 of the New York State Board of Pharmacy, the actual 
signature of the physician requesting sulfonamide drugs is re- 
quired. A prescription or a letter signed by a physician is accept- 
able. 
Granuloma Inguinale 
Experience during the past few years has shown that granuloma 
inguinale is relatively prevalent in this country, especially among 
negroes. Reports indicate that while early treatment of the infec- 
tion may be successful, management of chronic cases is much less 
promising. The disease is believed to be incited by the so-called 
Donovan bodies, probably protozoan in nature, which are present 
as inclusions in some of the large tissue cells in the lesions. The 
local laboratory is in an advantageous position to assist in the 
diagnosis. 
Specimens for Laboratory Examination 
Films prepared from macerated tissue from the edge of the lesion, 
after the superficial exudate and crusts have been removed, should 
be examined for Donovan bodies. If there is doubt whether a 
lesion is a syphilitic chancre or one of granuloma inguinale, the 
films to be examined for Donovan bodies should be made before 
the fluid from the lesion is collected for examination for Treponema 
pallidum, since, when the lesion is swabbed with gauze as is done 
in the latter ease, a large part of the cells containing the Donovan 
bodies in their most readily recognized form may be removed. 
Helminthiasis 
The ova and sometimes the larvae or adult forms of parasitic 
worms (helminthes) may be demonstrated in the feces. The ova of 39 
pin worms, Oxyuris (Enterohius) vermicular is, can most easily be 
found on the skin around the anus. 
Specimens for Laboratory Examination 
One or two milliliters of fecal material without preservative (jar 
outfit) may be submitted for examination for most types of 
helminthes and their ova, or, if the presence of pinworms is sus- 
pected, a specimen collected in accordance with the following di- 
rections can be submitted: 
“A piece of ‘Scotch Cellulose Tape’ of half-inch width and about 8 cm. 
long is folded down for about a centimeter at each end, adhesive surfaces 
together, to form two grips for handling. In use the ribbon of cellulose 
is held in forceps in a loop, adhesive surface on the outer side of the 
loop, and is patted down on the perianal skin. The extremely adhesive 
surface picks up epithelial scales, fecal particles, and ova if any be 
present. The tape is then placed lengthwise on a microscope slide, 
smoothed down with the side of the forceps and examined with a 16 mm. 
objective like any preparation under a coverglass. If desired the folded 
ends, which of course do not adhere to the slide, can be trimmed off with 
scissors so that the tape will lie completely flat on the slide, but this is 
not essential.” (Graham, C. F., Amer. Jour. Trop. Med., 1941, 21, 159.) 
Influenza 
Demonstration of the virus of influenza is not applicable as an 
aid in diagnosis, but it is useful in epidemiologic studies. Patients 
with influenza are particularly susceptible to pneumonia; exam- 
ination of sputum for significant microorganisms and cultural 
tests of the blood are thus desirable if symptoms of pneumonia 
develop. Leucocyte counts may be helpful also, since uncomplicated 
influenza is characterized by leucopenia, while a leucocytosis is 
expected in case the patient develops pneumonia. 
Jaundice 
Acute infectious jaundice. Severe types of acute infectious 
jaundice incited by Leptospira icterdhaemorrhagiae and Leptospira 
canicola are endemic in certain parts.of Japan and Europe, and 
sporadic cases have been reported in this country. Rats and dogs 
are carriers of the leptospirae; the microorganisms are present in 
the kidneys and excreted in the urine. Infection of human beings 
apparently results from contact with the urine of infected animals. 
The rare occurrence of cases of leptospiral jaundice, in spite of the 
wide distribution of the inciting agent, has been attributed to the 40 
fact that the microorganism is extremely sensitive to drying and 
sunlight. It probably survives but a short time after being excreted 
from the animals. 
Epidemic jaundice, the incitant of which has not been definitely 
established but is probably a virus, is relatively common. It fre- 
quently can be differentiated from spirochetal jaundice by a 
leucocyte count, which in the latter is usually well over 10,000. 
In epidemic jaundice, however, a leucopenia with lymphocytosis is 
the rule. Individuals may also develop jaundice following inocu- 
lations with homologous serum such as blood and plasma trans- 
fusions and with biologic products containing human serum. 
Specimens for Laboratory Examination 
Specimens of blood (tube outfit—swab or needle removed) and 
urine (jar outfit) may be submitted for examination. These should 
be collected aseptically and the purpose of the examination indi- 
cated upon the history form. 
Lymphogranuloma Venereum 
Lymphogranuloma venereum is incited by a virus. The disease 
is fairly prevalent and clinically may at times be confused with 
syphilis. It is acquired usually through sexual intercourse. 
An intracutaneous test (the Frei test) is a valuable aid in diag- 
nosis. Complement-fixation tests of blood may in future serve as a 
means of differentiating lymphogranuloma venereum and syphilis, 
but few laboratories at present are prepared to make such a sero- 
logic test for evidence of the former. The preparation of the 
antigens is still in the experimental stage. 
Product Supplied by the Laboratory 
Lygranum for making the Frei test is available on request to the 
Central Laboratory, Albany. 
Malaria 
Cases of malaria occurred only occasionally in New York State 
in the years just prior to World War II. When members of the 
armed forces return in considerable numbers from fighting zones 
in the tropics, the incidence will probably increase. The ano- 
pheline mosquito, which is the intermediate host, is found in var- 
ious parts of the State. Hence, human carriers who may be living 41 
here may serve as a reservoir from which the infection may be 
transmitted. Blood films to be examined for malaria parasites 
should be prepared if possible before the initiation of chemotherapy. 
Specimens for Laboratory Examination 
In accordance with the requirements of Chapter II, Regulation 
9, of the Sanitary Code, both thick and thin films of blood on 
glass slides (slide outfit), preferably taken from twelve to twenty- 
four hours after a chill, should be submitted for examination to a 
laboratory approved for the purpose. Repeated films may be 
necessary for demonstration of the plasmodia. In fulminating 
eases, prompt examination of films is of special importance, since 
delay in treatment may result in a fatal outcome. 
Directions for preparing thick films. A thick film should consist of 
from three to five average-sized drops of blood. These may be deposited 
on an area about three-quarters of an inch in diameter (the size of a dime) 
and promptly combined with a needle or the corner of another slide; or 
the surface of the slide may be touched to a large drop of blood and the 
slide moved in narrow circles until a preparation of the size mentioned is 
obtained. The film must be fairly thick in order to have sufficient blood 
for adequate examination, but must not be so thick that it will peel from 
the slide during staining. When the thick blood film is still wet, ordinary 
printing can just be read through it. 
In order to protect the specimen from dust during drying, the slide 
should be supported with the film side down. A wooden slide container 
may be used for the purpose. It is important to have the slide level, since 
otherwise the blood might collect at one side of the film and not be 
evenly distributed. From eight to twelve hours should be allowed for 
drying unless the process can be hastened by using an electric fan. In 
this procedure, the slide should be placed with the film side up in front of 
the fan. The distance from the fan should be such that the current of air 
will not pile the blood on one side of the film. 
The slide should not he mailed until the films are entirely dry, and each 
slide should be wrapped in soft paper or tissue. 
The incitant of measles has not been definitely determined, 
although evidence has been obtained that a virus is involved. 
Laboratory aids in diagnosis are, therefore, not available. However, 
should the patient develop symptoms of pneumonia, the examina- 
tion of specimens described under Pneumonia, p. 46 is desirable. 
Measles 
Products Supplied by the Laboratory 
Globulin solution (human). Globulin solution (human) pre- 
pared by the extraction of placentas with sodium chloride solution 42 
and subsequent precipitation and dialysis of the globulin fraction 
is distributed for modification or prevention of measles. Results of 
clinical trial of globulin solution indicate that its prophylactic 
activity compares favorably with that of convalescent serum. 
When administered to children within 4 to 6 days of exposure to 
measles, an attack is usually modified or prevented. A modified 
attack of measles induces an active immunity. 
Globulin solution prepared for distribution in bottles containing 
5 ml. may be obtained by direct application to the central laboratory 
for use in contact children under four years of age and in those in 
institutions when indicated. 
Administration. Injections should be made into the muscles of 
the lateral aspect of the thigh, into the upper outer quadrant of 
the buttocks, or between the scapulae. A dose of from 2.5 to 5 ml. 
is at present recommended, depending to some extent upon the age 
of the child and the length of the period since exposure. 
In order to secure data on the value of globulin solution, it is essential 
that reports be received on all cases in which it is used. A report form is 
enclosed in each package. It should be returned after three weeks to the 
Division of Laboratories and Research, New Scotland Avenue, Albany 1. 
Sodium citrate solution for use in the collection of parent’s 
blood. Published reports and those that have been received by the 
State indicate that whole blood taken from an adult with a history 
of measles is an effective prophylactic agent. It is used for pre- 
ventive treatment of contact children between three months and 
five years of age, the period in which most of the deaths from 
measles occur. It may also be given in the case of older children 
whose physical condition is such that an unfavorable prognosis 
would be anticipated should measles develop. 
Sterile sodium citrate solution for use in the collection of par- 
ent’s blood for the modification or prevention of measles is dis- 
tributed through the local supply stations. Each package contains 
sufficient solution for one preventive treatment, a circular giving 
detailed directions, and a report form. 
The blood from one of the child’s parents who has had measles 
should be used unless contraindicated. Blood grouping is unneces- 
sary. Only persons in good physical condition and free from 
symptoms of tuberculosis, syphilis, malaria, or any other communi- 
cable disease should be selected. The blood is taken from one of 
the veins at the elbow into a syringe into which the sodium citrate 
solution has previously been drawn. Aseptic precautions should 
be observed throughout the procedure. 43 
Administration. The eitrated blood is injected slowly into the 
muscles of the lateral aspect of the thigh, into the upper outer 
quadrant of the buttocks, or between the scapulae. It may be 
injected in two areas. The dose for children under five years of 
age is from 20 to 30 ml, of blood. In case the blood is given to 
children over five years of age double the amount has been advised. 
Physicians are urged to fill out and return after three weeks the report 
form contained in each package of sodium citrate solution to the central 
laboratory in Albany. 
Meningococcus Infections 
Meningitis. While many species of pathogenic bacteria have 
been reported as the occasional incitants of meningitis, in cases of 
purulent meningitis that do not follow an infectious process in the 
mastoid or elsewhere, the meningococcus (Neisseria meningitidis) 
is the microorganism most frequently encountered. Consequently, 
when the cerebrospinal fluid is cloudy, not as the result of a bloody 
tap, chemotherapy should be commenced promptly, in the absence 
of definite contraindications. The administration of serum depends 
upon the bacteriologic findings and the clinical manifestations. 
Since meningococci autolyze readily few may be found in the cere- 
brospinal fluid, and in some instances, when the examination can- 
not be made promptly, none can be demonstrated. Experience has 
indicated that when large numbers of polymorphonuclear leu- 
cocytes are present in the cerebrospinal fluid and no bacteria are 
found, the incitant is usually the meningococcus, which is often 
found in a later specimen from the patient. 
Meningococcemia (septicemia). Invasion of the blood stream 
by N. meningitidis may precede or occur independently of menin- 
gococcus meningitis. Chronic infection of the blood stream with 
this microorganism is not uncommon. Cultural examination of a 
blood specimen collected during a febrile episode, if the fever is 
intermittent, aids in establishing the diagnosis. 
Specimens for Laboratory Examination 
In accordance with the requirements of Chap. II, Reg. 9, of 
the Sanitary Code, a specimen of cerebrospinal fluid in a sterile 
container (tube outfit—swab or needle removed) should be sub- 
mitted for examination to a laboratory approved for the purpose. 
Directions for the collection of specimens are given under 
Syphilis, p. 66. 44 
In meningococcemia (septicemia), the Sanitary Code also speci- 
fies that blood cultural tests should, if possible, be made in a 
nearby approved laboratory. Otherwise, 10 ml. of blood should 
be submitted (typhoid tube outfit). 
Product Supplied by the Laboratory 
Antimeningococcus serum. Serum therapy has proved of definite 
value in the treatment of meningococcus meningitis. More recently 
the use of sulfonamides has been shown to be highly effective either 
alone or combined with serum treatment. 
Multivalent antimeningococcus serum is prepared by the Division 
of Laboratories and Research and distributed in bottles containing 
20 ml., on special request through the district laboratory supply 
stations. Since only a small supply is maintained at a local station, 
when serum is requested for a ease the station is expected to tele- 
graph immediately to the Central Laboratory for additional ma- 
terial so that an ample supply will be available for further treat- 
ment. 
Since a multivalent antimeningococcus serum is available, group differ- 
entiation is not essential. It is, however, of interest and may be of great 
importance to classify the particular strain, especially in refractory cases. 
In such instances, the local laboratory should be requested to send the 
strain isolated to the central laboratory for further study or, if local 
facilities are lacking, the spinal fluid should be sent directly. 
Administration. The serum may be given intraspinously or intra- 
venously under aseptic precautions. At present there is a definite 
trend toward the intravenous route. Both methods would appear 
to have a place in the serum therapy of meningococcus meningitis. 
Full directions concerning precautions against anaphylactic 
reactions will be found on page 16. These directions and the 
technic of administration of the serum are also given in the circular 
that accompanies each vial. 
For intraspinous injection in adults, from 20 to 40 ml. of the 
serum may be given; in children, up to 20 ml. or more. The 
amount that is introduced should be somewhat less than the 
quantity of cerebrospinal fluid withdrawn and should depend upon 
the ease with which the serum runs in by gravity. Injections of 
the serum at 24-hour intervals are usually adequate when intra- 
spinous administration is used. In severe cases, the serum may be 
injected every six or twelve hours for three or four doses and there- 
after every twenty-four hours. In prolonged subacute or chronic 
cases;, the administration must be continued. Intraspinous admin- 45 
istration of serum for too long a period may give rise to symptoms 
that suggest recurrent meningitis. Overtreatment should, therefore, 
be avoided. The number of injections will depend upon the 
patient’s general condition and the bacteriologic examination of 
the spinal fluid. Injections should, in general, be continued until 
at least two successive specimens are free from meningococci. 
For intravenous injection, from 20 to 40 ml. of the serum may- 
be given, occasionally more. Here also continued treatment depends 
upon the patient’s general condition and the bacteriologic exam- 
ination of the spinal fluid. The schedule of doses suggested for 
intraspinous injections may be used. 
Some of the published reports recommend an excessive dosage 
which appears not only to be unnecessary, if sera of high potency 
and broad valency are used, but possibly even harmful, especially 
if continued for any length of time. 
Ophthalmia Neonatorum 
Many eases of ophthalmia neonatorum, especially the severe ones, 
owe their origin to the gonococcus (Neisseria gonorrhoeae). Proper 
treatment of such infections must be begun promptly if the sight is 
to be saved. Unless laboratory service is available in the locality 
so that specimens can be examined immediately, the laboratory 
findings are of value only for purposes of confirmation of the 
clinical diagnosis. 
Specimens for Laboratory Examination 
In accordance with the requirements of Chap. II, Reg. 9, of 
the Sanitary Code, films of the exudate from the eye on glass slides 
(gonorrhea slide outfit) should be submitted for examination to a 
laboratory approved for the purpose. The fresh exudate on a 
swab should be rolled out on the slide to avoid distorting the 
leucocytes. A microscopic examination only can be made when 
the specimen is submitted by mail. If local laboratory service is 
available, cultural tests often prove helpful. 
Product Supplied by the Laboratory 
Silver nitrate solution. The immediate application into the eyes 
of new-born infants of a 1-per-cent silver nitrate solution, or other 
agent equally effective in preventing ophthalmia neonatorum, is 
required by the Sanitary Code. The central laboratory distributes 
the silver nitrate solution to physicians through district supply 46 
stations and their substations in outfits containing two wax 
ampoules. Each ampoule has sufficient material for the treatment 
of one baby. Full directions for use accompany each outfit. 
Plague 
Plague is primarily a disease of rodents, the incitant of which, 
Pasteurella pestis, is transmitted, except in the pneumonic form, 
by fleas and probably other blood-sucking insects. The microor- 
ganism is harbored chiefly by the rat, but ground squirrels and 
other rodents have also been shown to be the source of the infec- 
tion. Plague has been proved to be endemic in wild rodents in 
some districts in California, and infected animals are occasionally 
reported in other western states. Thus, the possibility of the occur- 
rence of the disease in New York State must be kept in mind. 
While suggestive findings may be obtained by morphologic exami- 
nation of exudate from a bubo, the results of bacteriologic and 
animal tests are necessary to identify Past, pestis. 
If a diagnosis of plague is considered, the district state health 
officer should be notified at once by telephone. 
Specimens for Laboratory Examination 
In accordance with the requirements of Chap. II, Reg. 9, of the 
Sanitary Code, the following material should be submitted for 
examination to a laboratory approved for the purpose: (1) a 
specimen of discharge or aspirated fluid, if a bubo is present (tube 
outfit with swab) ; (2) 10 ml. of blood (typhoid tube outfit) ; (3) 
in the pneumonic type of plague, a specimen of sputum (jar out- 
fit). If possible, the specimens should be delivered to a laboratory 
by messenger. 
Pneumonia 
In pneumonia, prompt diagnosis and early institution of thera- 
peutic measures are essential. Local approved laboratory service 
should be used whenever available for the examination of speci- 
mens. If serum is to be administered, this fact should be indicated 
on the history form and the specimen should either be delivered by 
messenger or sent by special delivery. Sputum coughed up from 
the deeper air passages should be secured. Specimens consisting 
chiefly of saliva or nasopharyngeal secretions are not satisfactory. 
When sputum cannot be obtained in the usual manner, as so fre- 
quently happens with children, the patient should be induced to 47 
cough and as the secretion is forced forward, some of the material 
from the throat should be collected on a sterile swab. Stomach 
contents of young children may also contain sputum that has been 
swallowed. 
In addition to the study of sputum, cultural tests of blood should 
be undertaken. The initial sputum specimen and blood culture 
should be obtained before serum therapy or chemotherapy is 
begun; otherwise it is often difficult, if not impossible, to determine 
the incitant. The blood can be collected in a tube containing a 
suitable sterile solution of an anticoagulant, such as sodium 
citrate, that will not inhibit bacterial growth; or it may be intro- 
duced directly into fluid medium in an outfit designed for the 
purpose. 
If the patient has received chemotherapy, blood culture medium 
containing approximately 5 mg. per cent para-aminobenzoic acid 
or its sodium salt should be used. This compound may be added 
to the medium as it is being prepared, or may be introduced subse- 
quently in the form of an 0.1-per-cent solution in distilled water 
that is autoclaved before use. 
The following information should accompany the specimens: 
the time and character of onset, that is whether or not the patient 
had an initial chill, pain in the chest, and coughing; the morning 
and evening temperatures; and the pulse rate. 
Products Supplied by the Laboratory 
The favorable results obtained in the serum therapy of type-1 
pneumonia have been approximated, according to available reports, 
in the serum treatment of cases due to a number of other types. 
Sulfapyridine, sulfathiazole, and other related drugs have been 
shown to be definitely effective in the treatment of pneumonia. In 
the absence of contraindications, chemotherapy should be instituted 
in every case of pneumonia as soon as the diagnosis has been estab- 
lished and specimens of sputum and blood obtained for bacteriologic 
tests. When the administration of serum is indicated, adequate 
doses of the homologous type should be given without delay. 
Antipneumococcus sera. Antipneumococcus sera, horse or rabbit, 
produced against all of the established pneumococcus types are 
distributed by the Division of Laboratories and Research. The 
horse sera and some of the rabbit sera are concentrated and purified. 
A small bottle containing normal horse or rabbit serum diluted 
1:10 with salt solution for use in the tests of sensitivity to the 48 
serum. is included in each -package of antipneumococcus serum. 
Sterile physiologic salt solution in 10-ml. amounts may be obtained 
for use in preparing the dilution for the intracutaneous test of 
susceptibility, for rinsing water from syringes and needles that 
have been boiled, and for diluting the serum for the preliminary 
injection. 
At present, antipneumococcus horse sera of types 1, 4, and 5, 
and rabbit sera of types 2, 7, 8, and 14 are distributed through 
certain district laboratory supply stations. The location of these 
stations and the various types of sera available may be ascertained 
from the district state health officer or the Division of Laboratories 
and Research, New Scotland Avenue, Albany, 1. Antipneumocoecus 
rabbit sera of the remaining types are supplied on request from 
the Central Laboratory, and from the Branch Laboratory, 339 
East 25th Street, New York City, 10. To provide service more 
quickly to physicians north and south of Rochester, these types 
of sera are also distributed from the Rochester Bureau of Health. 
When serum is obtained, physicians are required to fill in com- 
pletely and sign a request form with pertinent data regarding the 
patient and stating that bacteriologic examination in the laboratory 
designated has established the presence of microorganisms that 
correspond to the type of serum requested. This information facili- 
tates contacts between the physician and the laboratory and other 
cooperating agencies and promotes complete and accurate reporting 
of cases. 
Administration. To be effective the serum must be given intra- 
venously. Full directions concerning precautions against ana- 
phylactic reactions will be found on page 16. These directions and 
the technic of administration of the serum are given in the circular 
that accompanies each bottle. Directions for the treatment of 
serum reactions other than anaphylactic are also given in the 
circular. Caution should be observed to avoid overheating of 
the serum in preparing it for injection. 
A preliminary injection of 1 ml. of the therapeutic serum may 
be followed, if not contraindicated, in from one-half to one hour 
by the remainder of the first dose, the contents of two vials. A 
second dose should usually be given from two to four hours later. 
For the treatment of the average case of type-1 pneumonia, the 
contents of four vials are recommended; for type-2, about eight vials. 
The contents of from four to six vials is suggested for the other 
types. At least double the dosage may be required when treat- 
ment has been delayed, in older patients, in those with a positive 49 
blood culture and with complications, in patients who are preg- 
nant, and in those who fail to improve within twelve hours, pro- 
vided the type has been verified by the examination of a second 
specimen of sputum or a blood culture. Favorable clinical response 
is the most reliable index of adequate dosage. If chemotherapy is 
used in combination with serum therapy, smaller total amounts of 
both drug and serum may be required than are necessary when 
either is used alone. 
Sulfonamide drugs. Sulfathiazole and sulfapyridine in bottles 
of fifty 0.5-gram tablets are furnished through certain supply sta- 
tions to registered physicians and hospitals for the treatment of 
pneumococcus infections in patients for whom the purchase would 
be a hardship. In accordance with Rule 38 of the New York State 
Board of Pharmacy, the actual signature of the physician request- 
ing sulfonamide drugs is required. A prescription or a letter signed 
by a physician is acceptable. 
Poliomyelitis 
The incitant of acute anterior poliomyelitis, an ultramicroscopic 
virus, has been isolated from the upper respiratory tract and from 
the feces of infected persons, either cases or carriers. Monkeys 
have been infected by the intranasal introduction of material from 
the nose or mouth of human patients, and by intraperitoneal inocu- 
lation of extracts of feces. 
During the„preparalytic stage, the physician must depend upon 
clinical observation for his diagnosis. The findings in the exami- 
nation of cerebrospinal fluid may be helpful. For these to be of 
greatest value, the specimen should be examined in a nearby 
laboratory, promptly after collection. 
Specimens for Laboratory Examination 
No practical, specific diagnostic test is at present available. The 
results of a cell count, protein determination, colloidal gold test, 
quantitative sugar determination, and bacteriologie tests on speci- 
mens of cerebrospinal fluid, however, may be helpful in evalulating 
the clinical manifestations. Directions for the collection of speci- 
mens are given under Syphilis, p. 66. 
Psittacosis (Ornithosis) 
The virus of psittacosis (ornithosis) is usually acquired through 
contact with diseased birds, although nurses have occasionally 50 
developed the disease while caring for patients. Since the out- 
break in 1929-30, few cases of psittacosis have been reported in 
New York State. The Sanitary Code, Chap. II, Reg. 38 prohibits 
the importation, breeding, sale, or offer of sale of birds of the 
psittacine family, with the exception that the importation and 
breeding of such birds for scientific research or exhibition in 
public zoological gardens may be permitted subject to the approval 
of the State Commissioner of Health. Other types of birds in 
addition to those of the psittacine family, notably pigeons, have 
been shown to be infected with the virus. 
Specimens for Laboratory Examination 
Results of laboratory examinations are of little value in fur- 
nishing information that can be used in recommending treatment 
for patients with psittacosis. Demonstration of the virus in sputum 
or blood requires inoculation of mice, and the findings may not be 
available for a week or more. Specimens of sputum have been 
found the most useful for this purpose. 
When the examination of birds is desirable, if they are still 
alive, they should be chloroformed, soaked in 5-per-cent lysol, 
wrapped in cloth or absorbent cotton saturated with the same anti- 
septic, and shipped to the laboratory by express prepaid in a 
water-tight container. Cracked ice or dry ice should be used to 
prevent decomposition. Birds with psittacosis, if shipped alive, 
would endanger persons who might come in contact with them 
during transit. 
A complement-fixation test for evidence of psittacosis has been 
developed and its routine use in future might be considered if the 
prevalence of the disease warrants. 
Rabies 
Rabies is an acute and rapidly fatal infection of mammals, par- 
ticularly dogs. The incitant, a virus, is present in the saliva 
of animals suffering from the disease, and may be conveyed through 
the broken or abraded skin, most frequently by bites of dogs. 
The period of communicability for man is not known, but for the 
dog it may be as early as four days before the onset of clinical 
symptoms and throughout the clinical course of the disease. The 
incubation period in man is usually from six to nine weeks, but it 
has been known to be as short as twelve days. In dogs, the period 
of incubation is usually fourteen days or less. Since, however, 
this period is sometimes prolonged, an animal that has been bitten 51 
should be killed or isolated for four months. An animal which is 
apparently normal but which has bitten a person should not be 
killed, but kept under competent observation for one week. If it 
shows clinical symptoms of rabies, it should be killed at once and the 
head submitted for laboratory examination (Sanitary Code, Chap. 
II, Reg. 10). 
Since Negri bodies can usually be demonstrated microscopically 
in the dog’s brain but very little earlier than the appearance of 
clinical manifestations, it is best not to kill the animal before 
such symptoms are evident. When Negri bodies are not dem- 
onstrated, the microscopic examination must be confirmed by 
animal inoculation, which usually requires from ten to thirty days 
for completion. 
Specimens for Laboratory Examination 
Whenever any animal that has or is suspected of having rabies 
dies or is killed, it is the duty of the health officer to cause the 
head of the animal to be removed and sent immediately, properly 
packed, with complete pertinent data, to a laboratory approved 
for this purpose (Sanitary Code, Chap. II, Reg. 10). Great care 
should be taken to avoid infection from the dog’s saliva, which may 
fleck its entire body. 
It is important to avoid trauma to the brain tissue of 
animals to be examined for evidence of rabies. Strychnine or 
other chemical poisons that may interfere with the results 
of animal inoculation tests should not be used. The animals 
should preferably be killed by gas or by a shot through the 
heart. 
A most important factor in the examination of the brain is the 
arrival of the specimen at the laboratory in a satisfactory condition. 
Decomposition renders the results of the examination, in most cases, 
unsatisfactory. The head should be submitted to the most accessible 
laboratory approved for the examination. Information in regard to 
the location of these laboratories is furnished to health officers and 
other physicians annually. The specimen should be kept cold, and, 
whenever possible, should be delivered by messenger. If messenger 
service is not available, the head should be placed in a container 
that closes tightly. This, in turn should be put in a water-tight 
container and packed with cracked ice. The use of dry ice is not 
recommended, since freezing of the brain, which usually occurs, 
delays the examination and may affect the condition of the tissue. 
A limited number of outfits is available for shipment of animals’ heads 
to the Central or Branch Laboratory to be examined for evidence of rabies. 52 
They are supplied through the district state health officers in whose terri- 
tory rabies has occurred most widely. The outfit consists of a large outer 
container held tightly closed by two hasps fitted with key rings, and an 
inner 2-gallon, water-tight can for the head. There is sufficient space 
between the containers for ice. (See Plate III.) 
Record of the clinical symptoms shown by the animal and 
information as to whether persons or other animals have been 
bitten or exposed should accompany the specimen. 
Product Supplied by the Laboratory 
Rabies vaccine. Rabies vaccine is given for preventive purposes 
only. No effective therapeutic treatment is available. The prompt 
use of the vaccine is indicated in the case of all persons bitten by an 
animal with clinical or suspicious symptoms of rabies, of persons 
bitten by a stray animal that cannot be found, and in all instances 
in which the laboratory examination of the brain has shown the 
animal to have been rabid. 
Cauterization. Wounds caused by rabid animals should be immediately 
and thoroughly cauterized by a physician with fuming or concentrated 
nitric acid. In districts where rabies is present all wounds caused by 
animal bites should be cauterized. Laboratory experiments in this country 
have indicated that cauterization by heat is less effective than by nitric 
acid and that carbolic acid, iodine, etc., are much inferior. Nitric acid 
should be applied very carefully to all parts of the wound and edges of 
the skin; for this purpose a glass rod is convenient. 
Antirabic vaccine (Semple method), prepared commercially, is 
available to physicians in the State outside of New York City. 
Applications by telephone or telegraph should be made to the 
Branch Laboratory, 339 East 25th Street, New York City, 10. The 
name and age of the patient and the location of the bite should be 
given. It is expected that local boards of health in a position to 
pay for the vaccine will do so, or that they will arrange for reim- 
bursement by the patient. Otherwise, the vaccine will be furnished 
by the State. Under a Federal ruling, commercial manufacturers 
of biologic products cannot sell their preparations directly to 
physicians. Therefore bills for rabies vaccine obtained through 
this Division must be made out to city, county, or local health 
departments. Except in special emergencies, requests to this 
Division for vaccine should be made by the health officer. 
Sufficient vaccine for a course of fourteen daily injections is sent 
at one time. Immediately upon receipt the material should be 
placed in the cold. Each dose is of equal strength and contained 
in 2 ml. Children receive the same dosage as adults. In the ease 53 
Plate III 
Outfit for Shipment of Head of Animal to be Examined for 
Evidence of Rabies 54 
of extensive bites and those on the head or neck, especially when 
the wound has not been thoroughly cauterized with strong nitric 
acid, or when treatment lias been delayed, a course of twenty-one 
doses is suggested. The treatment should not be undertaken by 
health officers or other physicians who are not familiar with it. 
The district state health officer should be consulted in any emer- 
gency, but if questions arise during the treatment it is advisable to 
communicate with the Branch Laboratory. Physicians who obtain 
the vaccine treatments from the State are expected upon completion 
of the treatment to fill out and return promptly to the Branch 
Laboratory the report form on the use of the vaccine, which is 
forwarded to them ten days after the material. 
Administration. The injections are distributed in the sub- 
cutaneous tissue of the abdominal wall and the interscapular region. 
Since the virus is easily affected by temperature conditions and 
certain disinfectants, special care should be taken to follow the 
directions enclosed in each package. Some local soreness, together 
with erythema at the site of injection, may occur. Notice of other 
unusual symptoms, especially those of neuritis, should be sent 
promptly to the Branch Laboratory. 
Rat-Bite Fever 
Rat-bite fever usually follows bites by rats, although other 
animals occasionally are involved. It is now generally believed 
that two types of the disease may occur, incited by Spirillum minus 
or Streptothrix muris-ratti. The clinical manifestations of these 
two infections frequently resemble each other so closely that they 
can be differentiated only by isolating the inciting microorganism. 
In either ease, an indurated lesion usually develops at the site 
of the wound in from one to three weeks after the bite. It is 
followed by fever of a relapsing type and frequently by rash. 
Leucocytosis may occur, and a reaction may be obtained with the 
blood in serologic tests for syphilis. Both types of disease may 
respond to treatment with arsenicals, particularly that induced by 
Spirillum minus. Arthritis may be a predominant complication 
in the infection incited by Streptothrix muris-ratti. In rare 
instances, epidemics incited by the latter microorganism, unasso- 
ciated with rat bite, have been reported (Haverhill fever). 
Specimens for Laboratory Examination 
Spirillum, minus remains viable for only a very short time out- 
side the animal organism. Arrangements should be made to 55 
inoculate mice, rats, or guinea pigs with specimens of blood 
promptly after they have been collected. Serum expressed from 
the margin of the wound or from a skin macule, or fluid aspirated 
from the regional lymph node may also be examined. 
Blood from the inoculated animals is examined for spirochetes 
by dark-field illumination daily from the eighth to the fifteenth 
day after inoculation. Cultural examination is also made for 
Streptothrix muris-ratti in case the animals die. Since special 
freshly prepared media are required, the director of the laboratory 
where the cultural examinations are to be undertaken should be 
advised in advance so that they will be available. 
Smallpox 
The incitant in smallpox is a virus which passes with difficulty 
through a Berkefeld filter and, according to certain observers, 
loses some of its activity as a result of such filtration. 
Specimens for Laboratory Examination 
In most instances, the diagnosis can best be made on clinical 
and epidemiologic grounds. When the clinical findings are ques- 
tionable, however, the contents of a pustule, collected in capillary 
tubes (chancre fluid outfit) can be used for the inoculation of 
rabbits. The results will not be available in less than four days. 
Vaccination against Smallpox 
State regulations relating to vaccination against smallpox—on 
approved methods of vaccination, reportability, care of cases, and 
the principal points of differential diagnosis between this disease 
and chicken pox—are given in the Sanitary Code, the Public 
Health Law, the Administrative Rules and Regulations of the 
State Commissioner of Health, and in pamphlets distributed by 
the State Department of Health. 
State regulations prescribe that vaccine virus be kept at 40° F. 
or lower. The activity of the vaccine is materially affected by 
unfavorable storage conditions, and, undoubtedly, a majority of 
unsuccessful vaccinations might be traced to this source. The 
optimum temperature is about 10° below the freezing point. In 
no instance should vaccine that has been stored at room tempera- 
ture be accepted. 
A proper interpretation of the reaction following vaccination is 
essential. Vaccination properly performed with fresh, fully potent 56 
virus, will result in one of three types of reactions: (1) typical 
primary vaccination, the usual course in an unvaccinated indi- 
vidual; (2) vaccinoid reaction, occurring in previously vaccinated 
persons, in which the broadest redness is reached in from three to 
seven days; (3) the so-called reaction of immunity, indicating full 
protection against smallpox, which reaches its maximum in from 
eight to seventy-two hours after vaccination,, With vaccine that has 
lost any of its potency, however, varying reactions which may be 
confused with reactions of immunity occur, so that the proper 
interpretation can be made only by physicians thoroughly familiar 
with the several types of reactions, and when full potency of the 
virus used is definitely proved. A fully potent vaccine may be 
defined as one that gives one hundred per cent “takes” in pre- 
viously unvaecinated individuals. 
Product Supplied by the Laboratory 
As a wartime emergency measure, a commercial preparation is 
distributed by the Central Laboratory for use in clinics at the 
request of district state health officers. 
Snake Bite 
The presence of rattlesnakes and copperheads in certain districts 
of New York State has, with the increase of camping and outdoor 
travel, become a matter of considerable popular interest and con- 
cern. While relatively few cases of snake bite are reported and 
fatalities in this part of the country have been rare, health officers 
and physicians should become familiar with the methods of treat- 
ment and the facilities now available. 
Product Supplied by the Laboratory 
Anti-snake-bite serum. A multivalent antitoxic serum is pro- 
duced in horses against the venoms of the copperhead, water 
moccasin, and rattlesnake, three of the most poisonous snakes of 
North America. A limited supply of a commercial concentrated 
product is maintained at the Bear Mountain Headquarters of the 
Palisades Interstate Park, in the department of health at Copake, 
and at the district laboratory supply stations in Glens Falls, Port 
Jervis, and Nyack, The serum is distributed for emergency use 
in the treatment of actual cases of snake bite, not for stock. If 
the patient is able to pay for the material or it is a case covered 
by compensation, it is expected that the amount supplied will be 57 
replaced promptly. Physicians obtaining the serum are asked to 
send a complete report to the Central Laboratory in Albany. 
In cases of snake bite the following procedure has been rec- 
ommended: (a) the immediate application of a ligature or tourni- 
quet a few inches above the bite, which is usually on the leg or arm, 
applied at first just tightly enough to prevent absorption and not 
interfere entirely with the flow of blood; (b) avoidance of exertion; 
(c) avoidance of all alcoholic or other stimulants. The tourniquet 
is released when serum has been given. Incision and suction are 
advisable to withdraw as much venom as possible, especially if treat- 
ment with serum is delayed. A dressing of a strong solution of 
table salt or Epsom salt in water may be used. Cauterization or the 
use of potassium permanganate is not advised. Detailed directions 
for the use of the serum are contained in each package. 
Administration. The amount of serum in one package (10 ml.) 
is stated to be usually sufficient to protect an adult against the 
amount of venom injected by the bite of a moderate sized snake. In 
the case of children, however, double this amount is advised for 
the initial dose. After bites from large rattlesnakes and moccasins 
20 to 30 ml. or more of serum may be required. Injections are 
given preferably intramuscularly; a small amount of the serum 
may also be injected subcutaneously around the site of the bite. 
Intramuscular injection ensures more rapid absorption than sub- 
cutaneous. In late cases or in those in which puncture of a blood 
vessel at the time of the injury is suspected, the intravenous method 
is much to be preferred. It is highly important that the serum 
be given as early as possible. Under certain conditions, repeated 
injections at short intervals are recommended. 
Streptococcus Infections 
Hemolytic streptococci are associated with a variety of infec- 
tions, including scarlet fever, erysipelas, septic sore throat, and 
puerperal sepsis. Although it is impossible by laboratory proce- 
dures to establish a definite etiologic relationship between a spe- 
cific streptococcus and any of these conditions, the majority of 
cultures isolated from lesions in man belong to a single serologic 
group that has been designated A. Thus, the group-precipitation 
test is especially useful in the study of hemolytic streptococci isolated 
from cows when outbreaks of streptococcus infection occur among 
consumers of raw milk from a particular dairy. Information 
regarding the serologic types of strains, that is whether the cases 
have been incited by one or more types, is also frequently of im- 58 
portance in the investigation of outbreaks. It is hoped that the 
Central Laboratory will soon be in a position to offer this service. 
Experience is indicating that when hemolytic streptococci belonging 
to group A are isolated from milk, one of the milkers has a history 
of recent acute infection, such as sore throat, scarlet fever, or a 
lesion on his hand. Veterinary examination of the cows usually 
indicates that one or more has mastitis incited by streptococci from 
such a lesion. Occasionally the evidence points to the fact that 
the raw milk has been contaminated directly by pus from the 
human source. 
Specimens for Laboratory Examination 
In accordance with the requirements of Chap. II, Reg. 9, of the 
Sanitary Code with respect to epidemic or streptococcus (septic) 
sore throat, a culture from the throat on Loeffler’s 
medium, and the swab used in making the culture (diphtheria 
culture outfit) should be submitted for examination to a laboratory 
approved for the purpose. The diagnosis should be clearly indi- 
cated on the history form, as well as the fact that an examination 
for hemolytic streptococci is desired. 
Investigation of outbreaks of scarlet fever or septic sore throat 
among users of unpasteurized milk from a common source should 
include a study of cultures collected from lesions on the hands and 
from the noses and throats of all persons coming in contact with 
the cattle or the milk, and the examination of samples of milk col- 
lected from the individual quarters from any animals in the herd 
that show evidence of mastitis or have lesions on the udders or 
teats. Samples of milk may be satisfactorily preserved for this 
type of examination by combining two parts of milk with one part 
of glycerol of tested purity. 
Products Supplied by the Laboratory 
Antistreptococcus Serum 
Scarlet fever, erysipelas, etc. A streptococcus specific to scarlet 
fever has not been differentiated. If the streptococcus is the 
primary and not the secondary incitant, scarlet fever should not 
be considered a specific disease—simply one manifestation of 
streptococcus infection. The results of study in this country and 
abroad have not only modified premature conclusions but have 
also provided a sound basis for investigation of the practical value 
and limitations of serum therapy in streptococcus infection. Since 59 
it is not possible by present methods to distinguish a specific strep- 
tococcus associated with scarlet fever or any other form of strep- 
tococcus infection, serum therapy of all streptococcus infections is 
a rational procedure, the limitations of which should be determined. 
The serum supplied by the State laboratory is produced by the 
immunization of horses with representative strains of strep- 
tococcus in order to obtain a product of the highest potency and 
broadest valency practicable. The serum is distributed for thera- 
peutic use in packages containing 5,000 units. A circular giving 
detailed directions for the administration of the serum is enclosed 
in each package. 
Antistreptocoecus serum has been and still is used in the treat- 
ment of scarlet fever. It is of definite practical value, often com- 
pletely overcoming the toxemia. Mild cases may not require treat- 
ment, but it is not always possible to distinguish the mild case in 
advance. Complicated cases, in which the streptococci have become 
generalized, do not always respond strikingly to treatment. The 
prompt use of the serum in order to prevent complications is of 
the utmost importance. 
The treatment of erysipelas with antistreptococcus serum has also 
been considered effective in a considerable number of cases. Accord- 
ing to laboratory tests and clinical reports, the results obtained from 
the administration of the antistreptococcus serum distributed by the 
State laboratory are comparable to those obtained with special sera 
produced elsewhere for the treatment of erysipelas only. Reports 
have also been received of the effectiveness of the serum in acute 
hemolytic streptococcus infections other than scarlet fever or 
erysipelas. 
The value of sulfanilamide and other related drugs in the treat- 
ment of scarlet fever has not been established but it has proved to be 
an effective agent in certain other hemolytic streptococcus infec- 
tions. There is no conclusive evidence that sulfanilamide neutralizes 
the toxic products of streptococcal growth. It does, however, restrict 
the growth of the microorganisms and thus limits the amount of 
toxic material liberated. Hence, even though chemotherapy is 
instituted early and continued, it does not take the place of 
serum in the treatment of the toxemia. 
Passive immunization—the treatment of contacts with anti- 
streptococcus serum (horse)—is not recommended owing to the 
temporary nature of the immunity induced, the severe reactions 
that may occur, and the possibility of inducing hypersensitivity to 
later injections of horse serum. Careful supervision of contacts 60 
and early administration of a therapeutic dose of serum, should 
symptoms develop, is advised. Serum for prophylactic use is not 
distributed by the State laboratory. 
Administration. Early administration of the serum and adequate 
dosage are essential in all forms of streptococcus infection. Occa- 
sionally cases fail to respond even to intensive treatment. The first 
dose should be at least 10,000 units on account of the difficulty 
of determining the severity of the infection at an early stage. In 
extremely toxic cases or those in which complications have devel- 
oped, it may be necessary to continue the treatment by repeated 
doses of 10,000 or 20,000 units at intervals of twelve or twenty- 
four hours, depending upon the condition of the patient. For very 
young children the doses may be somewhat reduced. 
In scarlet fever usually one dose, if sufficiently large, suffices. 
Satisfactory results are reported with intramuscular injection, but 
in severe cases it may be preferable to give part or all of the dose 
intravenously. 
In erysipelas the initial dose, usually 10,000 units, irrespective 
of the age of the patient, is given intramuscularly and repeated 
at 24-hour intervals until the skin lesions are arrested and the 
edema commences to subside. In certain refractory eases in which 
no response is obtained, even after several injections, serum treat- 
ment should be discontinued. The serum may have little effect 
upon the development of complications or the recurrence of attacks. 
In other streptococcus infections serum therapy must be con- 
sidered in the experimental stage. Intramuscular or intravenous 
injections of large repeated doses at 12- or 24-hour intervals are 
suggested, following in general the method for the intravenous 
treatment of pneumonia. 
For precautions against anaphylactic reactions, see page 16. 
Streptococcus Toxiil 
Intracutaneous test of susceptibility. The intracutaneous test 
to determine susceptibility to a standard streptococcus toxin is per- 
formed similarly to the test for susceptibility to diphtheria toxin 
(Schick) and should be carried out with the same accuracy. 
The test consists of the injection into the skin of one skin test 
dose of a standard streptococcus toxin. When a skin reaction 
develops, susceptibility to the toxin is indicated; a reaction meas- 
uring 10 mm. or over is considered positive. When the test is 
performed to determine whether immunity has been established after 61 
active immunization with the toxin, the dose of toxin used is also one 
skin test dose. A control injection of heated diluted toxin should 
always be made since some persons react to the protein in the 
material, especially after immunization. 
The skin reaction appears much sooner with streptococcus than 
with diphtheria toxin and is usually much less marked. It devel- 
ops within from six to twelve hours, usually reaches its maximum 
between twenty and twenty-four hours, and fades within forty- 
eight hours. A strongly positive reaction may occasionally be fol- 
lowed by pigmentation with very slight or no scaling. The read- 
ings should be made in a bright light from twenty to twenty-four 
hours after the injection. A circular giving directions for its use 
and the interpretation of reactions accompanies each outfit. 
Active immunization. Streptococcus toxin for the active immun- 
ization of persons found by the intracutaneous test to be sus- 
ceptible to the toxin is distributed only on special request. There 
is evidence that an immunity may be developed within two weeks 
following the injections of the toxin, but how long this immunity 
will continue or how reliable it will prove is not known. More- 
over, the large number of immunizing doses apparently required 
and the relatively large amount of toxic filtrate contained in them, 
would appear to make the treatment impracticable for general 
use. Under certain conditions, however, such as in outbreaks of 
scarlet fever in institutions or in the case of nurses in training, the 
use of the toxin may prove of value. If the individual immunized 
later develops streptococcus infections such as scarlet fever or 
erysipelas, the fact should be reported. 
For purposes of immunization, five and possibly six subcu- 
taneous or intramuscular injections of increasing doses of toxin are 
given at 5- to 7-day intervals. Two weeks after the last injection, 
in order to determine whether active immunity has been established, 
the intracutaneous test of susceptibility should be repeated with 
one skin test dose of toxin. If the test still indicates susceptibility, 
the immunizing treatments may be continued. Directions for dosage 
and use accompany each outfit. 62 
Syphilis 
Laboratory tests are of the greatest importance in the diagnosis 
and evaluation of treatment of syphilis. Demonstration of the incit- 
ant, Treponema pallidum, is essential to early diagnosis. The direc- 
tor of a local laboratory is usually in the best position to collect fluid 
from the chancre for dark-field examination. When facilities are 
not readily available or the patient does not wish to be referred to a 
laboratory, the attending physician, if he is familiar with the pro- 
cedure, can collect a specimen in an outfit containing sterile 
capillary tubes (Plate IV) and submit it to an approved laboratory. 
If the lesion was treated with an antiseptic or for any other 
reason Trep. pallidum is not found, the aspiration of fluid from the 
enlarged regional glands should be undertaken. The study of such 
material is of particular importance when the primary lesion is in 
the mouth, since the morphology of certain of the mouth spirochetes 
resembles that of Trep. pallidum closely. 
Treponema pallidum can usually be found in the initial lesion 
or in the regional glands as soon as the chancre develops, while a 
serologic reaction often is not obtained until several weeks after 
infection. Thus, the importance of careful search for the inciting 
microorganism cannot be overstressed. 
In case Trep. pallidum is not demonstrated in a suspicious lesion, 
repeated dark-field examinations should be made on several con- 
secutive days, and blood for serologic tests should be submitted. 
During the secondary stage of a syphilitic infection, the blood 
reacts in almost one hundred per cent of cases. Thus at a time when 
the disease is especially communicable, serologic tests are most 
dependable as an aid in diagnosis. 
In the tertiary and latent stages, the percentage of reactions 
obtained is lower than in secondary syphilis. However, many such 
cases that would otherwise be overlooked are detected by means of 
serologic tests. Experience has shown that patients who require 
medical examination should have a serologic test for syphilis 
made. Legislation has been enacted that requires the submission 
of specimens from pregnant women (Public Health Law, Art. II-A, 
Sec. 18-d) and from applicants for a marriage license (Domestic 
Relations Law, Art. Ill, Sec. 13-a). 
Specimens for serologic tests for evidence of syphilis should not 
be collected when the patient is acutely ill with some other disease 
or has recently been vaccinated. 
The degree of reactivity in serologic tests is as important in 
syphilis as it is in other infectious diseases, and especially since 63 
clinical signs are so often lacking or indeterminate. Hitherto, the 
methods for precipitation and complement-fixation have not pro- 
vided a reliable titration of the specific reactivity. The quantita- 
tive complement-fixation test used in the Central and Branch 
Laboratories and in some of the approved laboratories titrates the 
reactivity of the syphilitic serum. The titer represents the degree 
of reaction. It is expressed as a ratio comparing the degree of 
complement fixation in the test (patient’s serum, antigen, and com- 
plement) with that in the control (patient’s serum and comple- 
ment). When the two are equal, that is, when no reaction has 
occurred, the titer is 1. When fixation is three times as great 
in the test as in the control, the titer is 3, etc. Slight variations in 
the titers, such as may be found in the examination of duplicate 
or confirmatory specimens, are of no significance. In the majority 
of instances, however, a titer that is more than 20-25 per cent 
greater or less than that found in the examination of a previous 
specimen represents an actual change in the reaction of the 
patient’s blood. 
Titers in this quantitative test bear no constant relation to the 
“2+,” etc., values of other tests. In order to form a 
basis of orientation, however, it may be pointed out that “comple- 
ment fixation 4-f-” formerly reported approximates a titer of 6 or 
greater. Titers as high as 2,000 have been obtained, but reports 
at the present time differentiate titers from 1.6 to 10, i.e., in the 
range of weak, moderate, and relatively strong reactivity. Higher 
titers are reported “greater than 10.” 
“No reaction” includes titers up to 1.5, which represent at the 
most mere traces of fixation. Obviously, absence of a reaction does 
not exclude syphilis. Titers of 1.6 to 3.5 represent relatively 
weak reactions, and in such instances the physician should not 
make a diagnosis of syphilis unless there is evidence of the disease 
in the history or physical examination. 
Titers of 3.6 to 10 represent moderate to relatively strong 
reactions. Under such circumstances, convincing evidence must be 
available if syphilis is to be excluded. If such a titer is obtained 
in the absence of a history and physical findings of syphilis, 
further specimens should be studied. Anticomplementary speci- 
mens particularly indicate the necessity of studying additional 
specimens. 
While the value of examining the blood is now almost univer- 
sally appreciated, the necessity for the study of cerebrospinal fluid 
may not be so generally recognized. The detection of beginning 64 
neurosyphilis, or the ability to assure a patient, after he has had 
adequate treatment, that his cerebrospinal fluid is entirely normal 
is of vital importance. Thus, the cerebrospinal fluid of every 
patient who has been found to have syphilis should be examined 
at least once after treatment and a period of observation. Of 
course, at any time, in case neurologic symptoms of syphilis 
develop or the blood of the patient continues to react after he has 
had intensive treatment (this not infrequently occurs when there 
is involvement of the central nervous system), the study of the 
cerebrospinal fluid is imperative. 
As in the case of early syphilis, the director of a local laboratory 
is in a strategic position to assist the clinician through the study 
of specimens of cerebrospinal fluid. Such a study should include: 
1. Macroscopic appearance 
2. Determination of the cell content 
3. Estimation of the protein content 
4. Serologic tests (the results obtained with the cerebrospinal 
fluid should be compared with those secured with a speci- 
men of blood collected on the same day) 
5. Colloidal gold reaction 
Outfits containing two tubes (Plate VI)—one with a pointed 
base for a specimen of cerebrospinal fluid and another with a 
rounded end for blood—are available in the district supply stations. 
The results of laboratory tests for evidence of syphilis should 
be interpreted in the light of the clinical signs and history. When- 
ever they are at variance with other data concerning the case, 
specimens for confirmatory examination should be taken. 
Specimens for Laboratory Examination 
In accordance with the requirements of Chap. II, Reg. 9, of the 
Sanitary Code, the following material should be submitted for 
examination to a laboratory approved for the purpose: (1) fluid 
from the lesion to be examined for Treponema pallidum (chancre 
fluid outfit containing capillary tubes, Plate IV) ; (2) 10 ml, of 
blood for the complement-fixation test (syphilis tube outfit) ; 
(3) when laboratory tests fail to disclose evidence of syphilitic 
infection, 10 ml. of blood for the complement-fixation test, taken 
at weekly intervals until eight weeks have elapsed following 
the appearance of the primary lesion, unless evidence of syphilis 
is obtained earlier. 65 
Methods for Collecting Specimens 
Chancre fluid. The lesion should be washed with sterile physiologic 
salt solution, and rubbed firmly with sterile gauze (a compress of 2 per- 
cent novocain applied for a few minutes will aid in obtaining the deep 
exudate). After the blood has been removed, the tissues at the base of the 
lesion should be gently compressed until a drop of clear serum exudes on 
the abraded surface. The specimen can then be collected by touching this 
drop with the end of the capillary tube, which should be held in a hori- 
zontal position with the opposite end open. The serum or plasma will 
then rapidly enter the tube by capillary action. It should be sealed by 
pressing each end into the wax in the amber glass vial accompanying the 
outfit. While this is done, the tube should still be held in a horizontal 
position. (See Plate V.) Repeated tests are desirable, since failure to 
demonstrate the spirochetes does not exclude syphilis. If an antiseptic 
or other local treatment has been administered, a salt-solution compress 
can be applied and the patient instructed to return on successive days for 
the collection of specimens or, in case the regional glands are enlarged, a 
specimen may be taken from them. A specimen should always be examined 
from the latter site when the chancre is located in the mouth, or when 
there is a question of mixed infection or balanitis. 
Fluid from lymph nodes. When material is to be collected from the 
regional lymph nodes, those which are indurated, shotty, and not tender 
should be chosen. A few drops of sterile salt solution should be injected 
into the gland while the point of the needle is rotated to break apart 
some of the tissue. A little of the fluid should then be withdrawn for 
examination. A 1—2 ml. syringe attached to a 22- or 24-gauge needle 
should be used. While collecting the specimen, the gland should be 
immobilized by grasping it so that the skin is drawn tightly over 
it. Care should be taken to have the point of the needle enter the 
gland and not the surrounding tissues. The aspirated fluid (which should 
contain very little blood) may then be deposited from the syringe upon a 
clean glass surface such as that of a slide or the side of a flat bottle, and 
collected in capillary tubes in the manner described for fluid from a chancre. 
Blood. Specimens of blood, approximately 10 ml., should be taken 
preferably in the morning before breakfast or at least not within three 
or four hours after a meal, or when alcoholic beverages have been used. 
If a blood-letting needle is used, the stylet should be removed and the 
needle attached to the sterile tube, precautions being taken to avoid 
contamination of the needle, the cork, or the inner surface of the tube. 
(See Plate VII.) The needle should be returned to the laboratory in the 
envelope provided for this purpose. 
Syringes for the collection of blood should be sterilized by heating and 
permitted to cool before use. If a syringe has been boiled, it should be 
rinsed in sterile physiologic salt solution (about one-half a teaspoonful 
of salt to a glass of water). The blood should be transferred to the 
sterile tube immediately, before it coagulates in the syringe or needle. 
The tube should be left undisturbed in a slanting position at room tem- 
perature for one-half hour. 66 
Cerebrospinal fluid. Proper collection of the specimen is of particular 
importance. The collection of no more than 5 ml. of fluid can be recom- 
mended as a routine procedure. 
Since determination of the pressure of the cerebrospinal fluid is not 
necessary in an examination for evidence of syphilis of the central nervous 
system, apparatus for this purpose need not be used, thus lessening the 
chance of contamination. When a lumbar puncture is made, two needles, 
thoroughly cleansed and sterilized in dry heat, should be available. They 
should have been carefully sharpened, since the use of a dull needle is 
usually responsible for admixture of blood in specimens of cerebrospinal 
fluid. If there is evidence of blood in the fluid, the tap should be discon- 
tinued and another puncture made with a fresh needle in the next inter- 
space above the one that has been entered. Blood, oil, or any other foreign 
material in the cerebrospinal fluid usually renders it unsatisfactory. 
Centrifugation of cerebrospinal fluid before submission for examination 
is most undesirable. In the case of a bloody tap, should most of the cells 
he thus removed, sufficient hlood serum may remain, undetected, to affect 
the result of the serologic test. In the event that the specimen is from a 
syphilitic who does not have syphilis of the central nervous system, a reac- 
tion might occur when negative findings would have been obtained had the 
cerebrospinal fluid been uncontaminated with blood; that is, a reaction is 
obtained with the reagin in the blood that has contaminated the cerebro- 
spinal fluid. Also, study of the cellular elements in cerebrospinal fluid may 
yield information of great value in diagnosis. Consequently, it is impor- 
tant that the whole specimen as collected be available for laboratory tests. 
Products Supplied by the Laboratory 
Arsenical and bismuth preparations. Arsenical and bismuth 
preparations are purchased and distributed to physicf ans and 
clinics through most of the district laboratory supply stations. The 
drugs are at present supplied in the following amounts: 
arsphenamine, 1.0-gram ampoules; oxophenarsine hydrochloride 
(mapharsen), 0.06- and 0.6-gram; neoarsphenamine, 0,6-gram; sulf- 
arsphenamine, 0.45-gram; dichlorophenarsine hydrochloride, 
0.068-gram; bismuth salicylate in oil, 30-ml. bottles. Distilled 
water is also distributed for use by physicians and small clinics when 
not otherwise available. 
When all necessary precautions are observed, marked reactions 
associated with the administration of these arsenicals are rare. 
Any unusual reaction occurring during or after injection should 
be reported immediately and in detail to the Central Laboratory. 
The kind of material given and the lot number should be specified. 
Instructions for the preparation of the solutions and the method 
of administration will be found in the circulars enclosed in each 
package. 67 
Chancre Fluid Outfit Containing Capillary Tubes 
PLATE IV 68 
Sealing Capillary Tube with Wax 
PLATE V 69 
Outfit fob Blood and Ceeebeospinal Fluid to Be Examined fob Evidence of Syphilis of the Centbal Nebvous System. 
PLATE VI 70 
PLATE VII 
A 
B 
Tube from Syphilis Outfit 
A. When Cork is Removed, Label is Broken 
B. Attachment of Blood-Letting Needle When Specimen is Collected 71 
Tetanus 
Tetanus, like diphtheria, is essentially an intoxication. The 
tetanus bacillus (Clostridium tetani) grows only at the site of 
inoculation, usually a wound into which some infectious material 
such as soil contaminated with animal excretions has been forced. 
In dirty wounds, the microorganism finds favorable conditions for 
its development and produces one of the most powerful toxins 
known. A certain latent (incubation) period, proportionate in 
length to the distance of the portal of entry from the central 
nervous system, elapses before symptoms appear. 
Specimens for Laboratory Examination 
As considerable time may be required for the demonstration of 
Cl. tetani in the exudate of an infected wound, the laboratory can 
be of little assistance in making an early diagnosis. 
Products Supplied by the Laboratory 
Tetanus Toxoid 
Tetanus toxoid is used extensively for the protection of members 
of the armed forces. Its general use among civilians is not indi- 
cated. However, active immunization of children and of farm 
laborers and workers in certain industries, who are subject to 
repeated injuries, may be of definite value. 
Tetanus toxoid, unprecipitated, is, at present, prepared and 
distributed. It may be obtained in 10 ml. vials for immediate use 
by application directly to the Central Laboratory, Albany. The 
number of persons to be injected should always be given. (See 
Diphtheria-tetanus toxoid, precipitated, p. 28.) 
Administration. It is recommended that 3 injections of 1 ml. of 
tetanus toxoid, unprecipitated, be given at 21-day intervals. The 
intervals between injections may be somewhat lengthened if more 
convenient, but a shorter interval is not advised. Injections are 
given subcutaneously, alternately on the outer side of the upper 
arm, beginning with the left arm. 
In order to maintain an adequate level of immunity, a stimulat- 
ing dose of 1 ml. of tetanus toxoid should be administered at the 
end of a year. A stimulating dose of toxoid at the time of an 
injury for which ordinarily a prophylactic injection of tetanus 
antitoxin would be given, is considered sufficient to protect against 
tetanus infection. In ease of any doubt as to previous active 72 
immunization with tetanus toxoid, a prophylactic dose of tetanus 
antitoxin should be administered. 
Tetanus Antitoxin 
Passive immunization. Experience has shown that the sub- 
cutaneous injection of an immunizing dose of tetanus antitoxin 
rarely fails to prevent the development of the disease. When 
injury, resulting in a lesion favorable for the growth of tetanus 
bacilli, has occurred, a preventive injection of the antitoxin should 
be given subcutaneously at the time the wound is treated or as 
soon thereafter as possible. This is especially important in the 
case of gun shot or similar wounds or wounds in which garden, 
street, or stable dust or dirt has come in contact with the injured 
tissues. While one injection is generally sufficient, if the condition 
of the wound continues favorable for the development of tetanus 
infection, an additional subcutaneous injection should be given 
within five days and, under exceptional circumstances, even a third. 
The concentrated and purified antitoxin prepared by the State 
laboratory is available through the supply stations in package* 
containing 1,500 units. 
Curative treatment. While the typical symptom complex of 
tetanus is unmistakable, the early evidences of the disease are fre- 
quently overlooked. Since to be of value it is essential that anti- 
toxin be administered at the earliest possible moment, brief delay 
in diagnosis or in treatment may remove all possibility of recov- 
ery. 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 any tetanus antitoxin avail- 
able in the local supply stations, whether intended for treatment 
or immunization, should be used and an additional supply requisi- 
tioned at once by telephone or telegraph from the Central Labora- 
tory or from the Branch Laboratory in New York City. The anti- 
toxin is distributed in packages containing 20,000 units for thera- 
peutic use, A circular of directions is contained in each package. 
Administration 
Prophylactic dose. The initial preventive dose is 1,500 units 
of antitoxin injected subcutaneously. For young children from 800 
to 1,000 units may be given. In the case of a deep-seated and necro- 
tic wound that has failed to heal, or a more superficial gun shot or 
similar wound, the injection should be repeated, from 1,000 to 
1,500 units being given within five days after the initial dose. 73 
When the condition persists, a third and even a fourth injection 
after a similar interval may be advisable. In especially bad wounds 
larger as well as repeated doses may be needed. Should more than 
three days elapse between injections, the danger of severe anaphy- 
lactic shock should be borne in mind. 
Therapeutic dose. The antitoxin may be administered in- 
traspinously, intravenously, and intramuscularly. The intraspin- 
ous and the intravenous methods are generally recognized as far 
superior to the intramuscular for the initial injections. There is 
considerable difference of opinion as to which is the more effective 
route. On the basis of reports received on eases treated in the 
State, combined intravenous and iutraspinous administration 
appears to possess an advantage. Antitoxin should be administered 
at the earliest possible moment and in adequate amounts. Treat- 
ment should be continued depending upon the clinical signs, using 
intramuscular administration unless the severity of the symp- 
toms requires continuance of the intraspinous and intravenous 
treatment. A large intramuscular dose distributed among several 
muscles should be given at once if the first intraspinous and in- 
travenous injections are unavoidably delayed. Administration by 
cisternal puncture has been recommended. 
(a) Intraspinous injections of from 10,000 to 40,000 units 
repeated at 24- and 48-hour intervals. 
(b) Intravenous injections of from 20,000 to 40,000 units 
repeated at 24- to 48-hour intervals. 
(c) Intramuscular injections of from 10,000 to 20,000 units. For 
precautions against anaphylactic reactions see p. 16. 
Trichinosis 
Trichinosis is incited by Trichinella spiralis and results from 
eating raw or improperly cooked meat, usually pork, occasionally 
bear meat, containing tbe living encysted larvae of tbe parasite, 
wbicb are readily destroyed by thorough cooking. The larvae 
have been found to remain alive for several weeks in certain 
kinds of smoked sausages that are eaten uncooked. 
The trichinella reaches the adult stage in the intestine, where 
breeding takes place. After from five days to three weeks, the 
embryos migrate to various parts of the body and, if not destroyed, 
become encysted in the muscle fibers. Trichinella larvae have, on 
occasion, been found in blood and cerebrospinal fluid, but the 
examination of feces is in most cases useless. Indications of 74 
infection are not usually evident, however, until the parasites 
have reached the muscles. 
Blood counts furnish information of material value in diagnosis. 
A leucocytosis with marked eosinophilia is the characteristic find- 
ing, and repeated examination for eosinophilia is of greatest im- 
portance. Skin tests and serologic tests have also been developed 
and it is hoped that in future provision for such diagnostic aids 
may be made. 
Specimens for Laboratory Examination 
Sections of muscle in 10-per-cent formalin may be submitted to 
be examined for tricbinellae, as well as blood films for a differen- 
tial leucocyte count. In case the work can be done in a nearby 
laboratory, a total leucocyte count is also desirable. 
If possible, a portion of the meat or meat product thought to 
be the source of infection should also be submitted for examina- 
tion. 
Tuberculosis 
The aid in diagnosis which the laboratory can furnish by demon- 
strating tubercle bacilli in sputum or other types of specimens is 
too generally recognized to require emphasis. Tubercle bacilli, 
however, will not be present in specimens unless the tuberculous 
process has progressed sufficiently to provide necrotic material 
which contains the bacteria. Thus, in pulmonary tuberculosis, 
evidence of the disease can usually be demonstrated by means of 
x-ray and clinical manifestations before tubercle bacilli can be 
found. 
The complement-fixation test is sometimes of value in aiding in 
the differential diagnosis of active tuberculosis. The reaction 
occurs in a high percentage of active pulmonary infections and in 
a smaller percentage of extrapulmonary forms of the disease. The 
infrequent and low-grade reactions obtained in inactive cases indi- 
cate that the reaction of the serum diminishes or disappears with 
healing of the lesions and apparent arrest of the disease. 
Reactions with tubercle antigens have been reported to occur 
in the sera of persons suffering from syphilis, malaria, and lep- 
rosy. Experience at the Central Laboratory with cases of malaria 
and leprosy has been limited. In the sera of patients with leprosy, 
reactions are frequently obtained and are usually marked in 
degree. In fact, the proportion of marked reactions is greater than 75 
is commonly observed in patients with tuberculosis. In syphilis, 
while reactions occasionally occur, they usually are of low degree. 
Serologic tests for syphilis are performed, as a control, on all 
specimens submitted for the complement-fixation test for 
tuberculosis. 
Specimens for Laboratory Examination 
Sputum coughed from the deeper portion of the respiratory 
tract, preferably in the morning, or exudate from lesions believed 
to be tuberculous, may be submitted in jar outfits without preserva- 
tive, to be examined for tubercle bacilli. For cultural examination, 
at least 25 ml. of sputum collected over a period of not less than 
forty-eight hours should be obtained. The examination of stomach 
washings, especially in the case of children, is sometimes desirable. 
Blood may also be sent for the complement-fixation test (tuber- 
culosis tube outfit). 
In tuberculosis of the intestines, examination of fecal specimens 
usually provides information of less diagnostic significance than 
clinical and x-ray findings. Patients with pulmonary tuberculosis 
often swallow sputum, and thus the finding of tubercle bacilli in 
feces may not be indicative of a tuberculous involvement of the 
intestines. 
When the patient has symptoms of tuberculosis of the kidneys, 
specimens of urine collected aseptically from each ureter should be 
examined. The results of laboratory examinations may be helpful 
in confirming the diagnosis when a patient has symptoms of tubercu- 
lous meningitis. In most instances, a fibrin web collects in cerebro- 
spinal fluid from patients with this disease. The web entraps 
nearly all of the tubercle bacilli present. If the specimen is sent 
through the mail, the possibility of finding tubercle bacilli by 
microscopic examination alone is materially lessened, since the web 
is usually broken and its remnants may adhere to the cork in the 
tube. The results of cultural examinations or of animal inocula- 
tions with specimens of cerebrospinal fluid from patients with 
symptoms of tuberculous meningitis are of value only for purposes 
of confirmation of the diagnosis. They would seldom, if ever, be 
available in time to provide information that might aid in the 
management of the case. The study of specimens of feces, urine, 
and cerebrospinal fluid should be undertaken in local laboratories 
where all of the factors concerned can be evaluated. 76 
Product Supplied by the Laboratory 
Old tuberculin (Koch’s 0. T.). The tuberculin test is designed 
to determine the presence of tuberculous infection. Physicians 
are cautioned, however, that although the results of the tuberculin 
test reveal the fact that the tissues have been sensitized by the 
tubercle bacillus, they should not be considered diagnostic evidence 
of clinical disease unless carefully interpreted in the light of con- 
siderable practical experience with the test and correlated with 
clinical findings. 
Concentrated old tuberculin for diagnostic use is prepared by 
the Division of Laboratories and Research and distributed through 
supply stations to physicians experienced in making the test. The 
number of individuals whom it is planned to test should always be 
stated. The test may be made by the intraeutaneous method (Man- 
toux), or by the cutaneous method (von Pirquet). Because of its 
greater accuracy, the intraeutaneous method is recommended. The 
directions enclosed in each outfit should be followed closely. 
Intracutaneous test. The tuberculin is diluted with sterile, 
freshly prepared salt solution so that the required dose is con- 
tained in 0.1 ml. Great accuracy should be observed in making 
the dilutions. For the initial test of children under eight years old, 
0,1 ml. of a 1:10,000 dilution is advised; for older children and 
adults, 0.1 ml. of a 1:1,000 dilution. The dose is injected intra- 
cutaiieously on the inner surface of the left forearm. The reaction 
is considered positive when an infiltration and hyperemia develop 
at the site of injection in from six to eight hours, reaching a 
maximum in from twenty-four to forty-eight hours and then 
gradually subsiding. Readings should be made at 24- and 48- 
hour intervals. If no definite reaction is obtained after the 
first injection, especially in a case that according to the history or 
clinical symptoms is suggestive of active tuberculosis, the injection 
should be repeated with a lower dilution. 
Cutaneous test. Two small scarifications one-fourth inch long 
and three inches apart are made, without drawing blood, on the 
left forearm. On one scarification a drop of the concentrated 
tuberculin is placed with a sterile needle, and is then spread gently 
over the surface. The second scarification is not treated and serves 
as a control. An inflammatory reaction developing where the 
tuberculin was applied and distinct from any traumatic reaction 
in the control area, constitutes a positive reaction. This usually 
appears in from twelve to twenty-four hours and subsides after 
from three to four days. 77 
Tularemia 
Bacterium tularense, the incitant of tularemia, is acquired by 
man from an animal source. Rodents, especially rabbits, appear 
to be particularly susceptible, although many other species of 
animals, as well as birds, have been found to have the infection. 
Bact. tularense is transmitted from animal to animal and from 
animals to man by blood-sucking insects, as well as by direct con- 
tact in handling and dissection of animals. Transmission from 
man to man by contact or by the bite of insects that have pre- 
viously bitten a patient has not been reported. 
Tularemia is relatively rare in New York State. Rabbits and 
other game animals native of the State have seldom been implicated, 
although muskrats in the northern and central sections have been 
indicated to be a source of infection. 
Specimens for Laboratory Examination 
In accordance with the requirements of Chap. II, Reg. 9, of 
the Sanitary Code, the following material should be submitted for 
examination to a laboratory approved for the purpose: (1) 10 ml. 
of blood (typhoid tube outfit); (2) if ulcerating lesions are present, 
films of discharge on glass slides (slide outfit), and a specimen of 
discharge on a sterile swab (tube outfit with swab). Dead animals 
or birds may also be submitted, in which case none of the organs 
should be removed. 
Typhoid and Paratyphoid Fevers 
The present sanitary environment of urban districts in New 
York State is such that the incidence of typhoid fever is very low. 
The source of the ineitant in most cases can be traced to carriers 
of typhoid bacilli. Carriers who are food handlers represent a 
particular menace. 
The Sanitary Code requirement (Chap. II, Reg. 15) which 
necessitates the submission of specimens from convalescents who 
have had typhoid or paratyphoid fever (infections with Salmonella 
paratyphi-A or Salmonella paratyphi-B) before release from 
observation, should result in the detection of most of the individuals 
who develop the carrier condition. Nearly all of these carriers have 
a focus of infection in the gall bladder. Gall stones or other 
evidence of cholecystitis are usually found when the gall bladder 
removed from a chronic typhoid carrier is examined. 78 
In hospitals and other institutions, the ease with which incitants 
of enteric disease can be transmitted with the rectum as the portal 
of entry must be kept in mind. Improperly sterilized rectal 
catheters may be the means of transmission. Merely washing 
enema tubes or soaking them in an antiseptic is not an adequate 
protection, since the inside of the tubing may remain contaminated. 
Typhoid fever. The results of serologic tests for evidence of 
typhoid fever are seldom of diagnostic value during the first week 
after onset of symptoms. When the clots of blood are cultured, 
however, the incitant is usually isolated, definite confirmation of the 
diagnosis thus being provided. After the patient has been ill for 
from ten days to two weeks, the blood usually agglutinates 
Bacterium typhosum markedly. Total and differential leucocyte 
counts are useful, since a leucopenia and the presence of a relatively 
high percentage of lymphocytes are characteristic findings in 
typhoid fever. 
Specimens of feces collected a day or two after onset of symptoms 
may not be found to contain typhoid bacilli, but the micro- 
organisms can usually be readily isolated from those collected 
later during the acute stages of the illness and they may be present 
for a considerable time after convalescence. When these bacteria 
are found in specimens from a person who has not suffered from 
typhoid fever within one year, he is considered a chronic typhoid 
carrier (Sanitary Code, Chap. II, Beg. 31). 
Typhoid bacilli are present in the urine of a fairly high per- 
centage of patients with typhoid fever. They are found .also in 
discharges from focal infections and occasionally in cerebrospinal 
fluid and sputum. 
If a cholecystectomy is considered desirable in order to free 
a typhoid carrier who has a focus of infection, duodenal contents 
should first be examined to prove that the bile contains these 
bacteria. Such specimens should also be studied after the gall 
bladder has been removed. Typhoid bacilli may be present in 
specimens of duodenal contents from three months to a year after 
removal of the gall bladder and yet the focus may later become 
inactive. 
Paratyphoid fever presents problems similar to those encountered 
in typhoid fever. Certain diseases of rodents and domestic animals 
are incited by strains of salmonella other than S. paratyphi-A and 
-B. Man is susceptible to infection with many of these micro- 
organisms. 79 
Specimens for Laboratory Examination 
In accordance with the requirements of Chap. II, Reg. 9, of 
the Sanitary Code, the following material should be submitted for 
examination to a laboratory approved for the purpose; (1) 10 ml. 
of blood (typhoid tube outfit); if this is not practicable, from two 
to four drops collected on a glass slide and allowed to dry (slide 
outfit); (2) a specimen of fluid feces (typhoid jar outfit containing 
30-per-cent buffered glycerol) and, if there is evidence of localiza- 
tion in the genitourinary tract, a specimen of urine (typhoid jar 
outfit containing 30-per-cent buffered glycerol). The 30-per-cent 
buffered glycerol inhibits fermentation and has thus proved efficient 
in preserving specimens of the type mentioned, when transmitted 
through the mail. 
When the gall bladder of a carrier is to be removed, the fol- 
lowing specimens should be examined: 
Before operation. Three specimens of duodenal contents taken 
on three different days. 
At the time of operation. (1) the gall bladder and its contents; 
(2) the appendix if it is removed; (3) about 10 ml. of blood for 
agglutination tests. 
After operation, while patient is still hospitalized. (1) three 
specimens of duodenal contents taken at intervals of not less than 
twenty-four hours; (2) a part of each of at least eight succes- 
sive specimens of liquid feces taken on successive days, the first 
three to be obtained the day after the collection of each duodenal 
specimen. The patient cannot be released from the restrictions 
imposed on typhoid carriers until the series of the specimens 
collected postoperatively has been found to contain no typhoid 
bacilli (Sanitary Code, Chap. II, Reg. 34). 
When state aid is granted toward the cost of hospitalization, 
all of the specimens should be sent to the Division of Laboratories 
and Research. If no state aid is given, the examinations required 
before operation should preferably be made in a local approved 
laboratory; specimens for release, however, must be submitted to 
the Division of Laboratories and Research. 
The inconvenience to the patient occasioned by passing the 
drainage tube warrants the collection of at least three specimens 
of duodenal contents at 15- or 20-minute intervals so that at least 
one of them will be satisfactory. Only fluid that is neutral to 
litmus or very slightly acid or alkaline is usually satisfactory for 
cultural tests. When acid, the typhoid bacilli, if present, may not 
remain viable. The introduction of sterile sodium bicarbonate may 80 
be desirable to neutralize the acid. After the tip of the tube has 
reached the duodenum, administration of magnesium sulfate will 
promote the flow of bile and thus improve the opportunity for 
the detection of Bact. typhosum. 
Product Supplied by the Laboratory 
Typhoid vaccine. The administration of typhoid vaccine has 
proved to be an effective preventive against typhoid fever. The 
duration of the protection afforded may be a year or possibly a 
considerably longer period. It should be borne in mind, however, 
that the immunity induced by this vaccine is only relative; it may 
not be sufficient to protect against frequent and massive doses of 
the infective agent. The vaccine is not recommended as a thera- 
peutic agent to be used after the disease has developed. 
Typhoid vaccine is prepared by the Division of Laboratories and 
Research and distributed through district laboratory supply sta- 
tions in bottles containing three doses for the immunization of one 
person, and in larger bottles containing 10 ml. for use when a 
number of persons are to be immunized at the same time. Each 
milliliter of the vaccine contains 1,000 million killed bacilli. 
Administration. The vaccine should be injected subcutaneously, 
usually over the insertion of the deltoid. Three doses are usually 
administered at intervals of from seven to ten days, the first dose 
being 0.5 ml,, the second and third doses 1 ml. each. Although 
the dosage should not exceed the standard amounts recommended, 
slightly smaller doses may be given in order to reduce the severity 
of the reactions occasionally induced by the injections. If the 
dose is materially reduced, however, the number of injections 
should be correspondingly increased. The dosage for children 
should be reduced in proportion to the body weight as compared 
with that of an adult. For reimmunization, indicated under special 
circumstances, annual injections of 0.1 ml. intracutaneously or 0.5 
ml. subcutaneously may be given. 
The reaction induced by the vaccine varies; it 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, relatively rare and are transitory in 
character. It is advisable to give the injections late in the afternoon 
so that if a reaction occurs it will be at night. The injections should 
be postponed in case of illness, after the fifth month of pregnancy, 
or during the menstrual period. Great care should be exercised in 81 
eases of cardiac disease and nephritis—conditions which should 
be considered contraindications. The same is true of tuberculosis 
in the active stages, although typhoid vaccination in the latent 
or inactive stages is considered a safe procedure. 
Full directions for dosage and administration are given in the 
circular that accompanies each bottle of vaccine. 
Typhoid-paratyphoid vaccine. Because of the apparently low 
incidence and usually mild type of reaction induced in New York 
State and the wide variations in the immunologic properties of 
the ineitants, the general distribution of the combined typhoid- 
paratyphoid vaccine was discontinued in 1937. A small supply of 
typhoid-paratyphoid vaccine is, however, maintained for the 
immunization of special groups. 
Typhus Fever and Rocky Mountain Spotted Fever 
Both typhus fever and Rocky Mountain spotted fever are incited 
by rickettsiae and are transmitted by eeto-parasites. Ticks are 
involved in Rocky Mountain spotted fever, and lice or other insect 
vectors in typhus fever. The history of tick bites or of the presence 
of fleas or lice is therefore of distinct value in differentiation. In 
spotted fever, the rash usually appears first on the extremities and 
spreads rapidly, often extending even to the palms and soles. In 
typhus fever, the rash is usually observed first on the chest and 
upper abdomen, frequently extending to the upper arms, and in 
severe cases may become generalized. Rocky Mountain spotted 
fever occurs most commonly in the west, but it has also been 
found in most of the eastern states. In New York State, nearly 
every year, a few cases are reported on Long Island. Differentiation 
of the incitant of Rocky Mountain spotted fever from that of 
typhus fever requires extensive laboratory work involving the 
use of animals or serologic tests with rickettsiae. As yet, no pro- 
vision has been made for these types of examinations in the Division 
of Laboratories and Research. In either of these diseases, how- 
ever, the blood of the patients has been found to agglutinate 
certain strains of Proteus X. The study of specimens collected at 
intervals of a few days is usually important since the titer of 
the reaction increases markedly during the course of the infection. 
In accordance with Chap. II, Reg. 9, of the Sanitary Code, when- 
ever typhus fever is suspected, the following material should be 
Specimens for Laboratory Examination 82 
submitted for examination to a laboratory approved for the pur- 
pose: (1) 10 ml. of blood (typhoid tube outfit); and (2) a specimen 
of feces to be examined for evidence of typhoid fever (typhoid jar 
outfit containing 30-per-cent buffered glycerol). 
A similar procedure can be recommended when a diagnosis of 
Rocky Mountain spotted fever is considered. 
Note. A limited amount of Rocky Mountain spotted fever vaccine has for several 
years been supplied by the National Institute of Health to the Central Laboratory 
in Albany for use in New York State. In view of the small supply, it is necessary 
to restrict distribution to persons who are definitely exposed to bites of ticks in 
known infected areas. It is only recommended for prophylaxis, not for therapeutic 
usA 
Undulant Fever 
Until about fifteen years ago, undulant fever was thought to be 
incited only by Brucella melitensis and to be restricted to districts 
where the milk of goats was used as a beverage. Man was believed 
to be immune to infection with Brucella abortus, the incitant of 
abortion disease in cattle, to which hogs are also susceptible. Inves- 
tigation has proved, however, the fairly close relationship of the 
strains of bacteria belonging to the abortus-melitensis group, and 
that all of them are pathogenic for man. In New York State 
the number of hogs and goats raised is not large and these animals 
are of negligible significance as sources of the incitant of undu- 
lant fever. In nearly all instances, patients with this disease have 
been- found to have used raw milk from cows with infectious-abortion 
disease or to have handled such animals. The very small number 
of cases of undulant fever reported in the city of New York where 
all but a very small percentage of the milk is pasteurized and few 
of the residents handle cattle, indicates that butter, cheese, and 
uncooked meat that may be handled by the housewife do not repre- 
sent a significant source of the incitant of undulant fever. Men in 
slaughter houses, however, who come in contact with the tissues 
of diseased animals frequently acquire Br. abortus infection. A 
considerable percentage of patients with undulant fever develop 
chronic foci of infection; for example, cholecystitis or spondylitis 
may be incited by Br. abortus, or these bacteria may remain viable 
in an ovarian cyst. 
The clinical manifestations of infections with members of the 
abortus-melitensis group of bacteria vary widely; in fact, cases 
may first be diagnosed as typhoid fever, malaria, influenza, tuber- 
culosis, melancholia, or neurasthenia. Thus, the results of labora- 
tory tests are of particular value. While the serum from most 
patients with undulant fever agglutinates Br. abortus in a 1:80 83 
or higher dilution, no reaction or one of low titer only may be 
obtained early in the disease. When chronic foci develop, a 
marked reaction sometimes occurs, but in such eases low titers 
are not unusual. 
Specimens for Laboratory Examination 
In accordance with the requirements of Chap. II, Reg.- 9, of the 
Sanitary Code, 10 ml. of blood (typhoid tube outfit) should be 
submitted for examination to a laboratory approved for the pur- 
pose. Blood may also be collected in citrate solution for cultural 
examination. 
Note. A limited supply of Br. abortus vaccine is prepared and maintained by the 
Central Laboratory in Albany. While published reports and those received by this 
Division indicate wide variation in the results of vaccine therapy, the data accumu- 
lated appear sufficiently encouraging to warrant its use in suitable cases. Requests 
for the vaccine, made directly to the Central Laboratory, should give the significant 
facts concerning the case. Recommendations relating to dosage and administra- 
tion are mailed to the physician. 
Vaginitis (Trichomonas) 
The most reliable laboratory aid in the diagnosis of vaginitis 
incited by Trichomonas vaginalis is the examination of moist dis- 
charge promptly after collection. If this cannot be done in a 
local laboratory, film preparations should be submitted. At least 
four films should be available so that examinations for both 
Trichomonas vaginalis and Neisseria gonorrhoeae may be made. 
Vincent’s Angina 
A diagnosis of Vincent’s angina must be based largely on the 
clinical manifestations. The spirochetes and fusiform bacilli 
found in lesions of Vincent’s angina are often present in other types 
of lesion in the mouth or throat. They are usually present in the 
necrotic material around the teeth of patients with pyorrhea. 
Films from the surface of the membrane in diphtheria may be 
found to contain large numbers of fusiform bacilli and spirochetes, 
Hence, the presence of these microorganisms requires careful 
evaluation. 
Specimens for Laboratory Examination 
In accordance with the requirements of Chap. II, Reg. 9, of 
the Sanitary Code, the following material should be submitted 
for examination to a laboratory approved for the purpose: (1) 
films of the exudate on glass slides (slide outfit); (2) a culture 84 
from the exudate on Loeffler’s blood-serum medium, to be examined 
for diphtheria bacilli and hemolytic streptococci (diphtheria cul- 
ture outfit). 
Whooping Cough 
Laboratory aids in the diagnosis of whooping cough are unneces- 
sary when the patient has characteristic symptoms. In the ease 
of children who have not yet developed the “whoop,” or adults 
in whom the manifestations may not be typical, bacteriologic find- 
ings may be very helpful. 
A special medium is necessary for the isolation of Hemophilus 
pertussis. The work can best be done in a nearby laboratory. 
When an examination for the presence of H. pertussis is desirable, 
the patient is induced to cough on suitable medium in a Petri plate, 
or freshly collected sputum can be washed in sterile physiologic 
salt solution and streaked on the medium. In small children, 
examination of cultures from the nasopharynx will often reveal 
the microorganism. 
Product Supplied by the Laboratory 
Pertussis vaccine. Pertussis vaccine is used as a prophylactic 
and therapeutic agent. While its value cannot be accurately 
determined from the conflicting reports in the literature, there 
appears to be sufficient evidence to warrant the use of the vaccine, 
especially when given for preventive purposes, provided a suffi- 
ciently concentrated preparation is employed. Few reactions of 
clinical significance have been recorded. 
The vaccine prepared by the Central Laboratory is distributed 
through district supply stations in bottles containing three doses, 
for the immunization of one person, and in larger bottles con- 
taining 10 ml. The vaccine contains 10,000 million microorganisms 
per milliliter. It should be kept at a low, even temperature. 
Administration. The vaccine is injected subcutaneously. Just 
before the vaccine is withdrawn, the bottle should be vigorously 
shaken to make sure that the bacilli are suspended evenly in each 
dose. When the vaccine is used as a preventive, three injections 
are usually given, three to seven days apart; for therapeutic treat- 
ment, at least four or five injections are given, one every second 
to fourth day, depending upon the clinical symptoms. Full direc- 
tions for dosage and administration are given in the circular 
contained in each package. 85 
Miscellaneous Examinations 
Microscopic, cultural, and chemical examinations of blood, urine, 
and other body fluids, secretions, excretions, exudates, and trans- 
udates, and histologic examination of tissues may furnish valuable 
aids in the diagnosis, prognosis, and subsequent treatment of many 
types of disease processes. The local laboratory is in the best 
position to make these examinations since, in most instances, 
proximity to the patient is an important factor. 
Blood 
Chemical examination. The chemical examination of blood is 
not undertaken at present as a routine procedure either in the 
Central Laboratory or in the Branch Laboratory, but is included in 
the service rendered by most of the approved laboratories. When 
planning to have such tests performed, the physician should first 
consult the director of the laboratory concerning methods for the 
collection and submission of specimens. 
Cultural examination. While the typhoid bacillus can often be 
isolated from the blood clot after the specimen has been in transit 
for a day or more, cultural examination of the blood in most 
types of bacteriemia should be undertaken promptly after collection 
of the specimen. Experience has demonstrated that in addition to 
the usual aerobic procedures, anaerobic methods and provision for 
from five to ten parts of carbon dioxide in the atmosphere in which 
the cultures are incubated, adds materially to the value of the 
work. Also, the opportunity to isolate the inciting microorganism 
is increased if at least 10 ml. of blood are cultured. The use of 
ten parts or more of culture medium to one part of blood is 
desirable. 
Microscopic examination and hemoglobin determination. With 
the exception of the examination of dried films, none of the 
laboratory aids in diagnosis that can be furnished by studies 
of the cellular elements and platelets in the blood are successful 
if the material is submitted by mail. Recent investigations in 
this field emphasize the importance in diagnosis and prognosis of 
the number and condition of the various types of cells found in 
the blood and their relationship to the hemoglobin content. Here 
again, the director of the local laboratory is in an advantageous 
position to assist the clinician and the surgeon in his district. 86 
Tissue 
Histologic examination. The services rendered by the director 
of a local approved laboratory are of invaluable assistance to 
physicians and surgeons in their daily practice, and specimens 
of tissue obtained at operation or at necropsy can be most satis- 
factorily examined by him. Such material should be sent to the 
Division of Laboratories and Research only when a question has 
arisen in regard to diagnosis, when there is a difference of opinion 
concerning the findings, or when a confirmatory examination is 
desirable. Pertinent data relative to the clinical manifestations, 
operative findings, and treatment of the patient should accompany 
all specimens. 
Tissues for histologic examination should be placed in fixative 
immediately after removal, since the most important step in their 
preparation is proper fixation. If this procedure is not followed, 
post-mortem changes often render the material unsatisfactory for 
examination. A 10-per-eent solution of formalin is the best fixa- 
tive for routine use; the volume should be at least ten times that 
of the tissue. Whenever possible, all of the specimen that is 
removed, rather than a portion of it, should be sent to the labora- 
tory. Large specimens should be shipped by express in containers 
of adequate size, such as fruit jars; they should be incised to per- 
mit proper penetration of the formalin. If, for any reason, the 
entire specimen cannot be sent, small pieces of the abnormal areas 
may be excised. Uterine curettings should be selected, separated 
from the blood, placed on a piece of gauze; and put in formalin at 
once. 
Occasionally, a cultural examination or an animal inoculation is 
desirable. Under such circumstances, some of the material should 
be collected on a swab, or the specimen should be divided and a 
portion sent in a sterile jar without preservative and the remainder 
in one containing formalin. 
Sections from material obtained at autopsy are not entirely 
satisfactory for determining the cause of death. When it is not 
possible, however, to have a pathologist perform the autopsy and 
make a gross and microscopic study of the tissues, representative 
pieces of each organ may be submitted as previously described, to 
the Division of Laboratories and Kesearch, provided a medicolegal 
problem is not involved. A detailed history of the case, including 
the gross necropsy findings, should accompany the specimens. 
In accordance with the provisions of the Sanitary Code (Chap. 
IV, Reg. 7), representative specimens, or sections for microscopic 87 
examination, of tissue removed at operation or at necropsy that 
require laboratory examination as an aid in the diagnosis, preven- 
tion, or treatment of disease, or to determine the cause of death, 
should be submitted to an approved laboratory. 
Urine 
Chemical and microscopic examinations. Since no preservative 
has been found entirely satisfactory in preventing decomposition 
in urine, chemical and microscopic examinations are essentially 
procedures that should be done in a local laboratory. The urine 
should be collected in a clean receptacle, free from acid or alkalis, 
and sent to the laboratory promptly. For quantitative sugar 
determination, a portion of a 24-hour specimen should be submitted. 
Cultural examination. In case of infections of the urinary tract, 
a specimen collected aseptically, preferably by catheterization, 
should be examined promptly after it has been obtained. 
Autogenous Vaccines 
Isolation of cultures. Since the first requisite for an autogenous 
vaccine is the incitant of the lesion, the cultural examination 
should be undertaken promptly after collection of the specimen to 
obviate the possibility of overgrowth by contaminating micro- 
organisms and of destruction of the pathogenic species. 
Autogenous vaccines are not prepared as a routine procedure 
by the Division of Laboratories and Research. Since the etiologic 
relationship of a particular microorganism to a subacute or chronic 
infection is often difficult to establish from bacteriologic study 
alone, work of this type, when required, should be undertaken in 
a local approved laboratory. PART III 
EXAMINATION OF WATER, SEWAGE, AND SEWAGE 
SLUDGE 
Water 
Samples of water are examined at the request of directors of 
the divisions of the State Department of Health, district state 
health officers, district sanitary engineers, and local health officers. 
Individuals are referred to the local health officer; if in his judg- 
ment examinations to determine sanitary quality are necessary or 
desirable, they are made, but only if he collects the samples in 
containers supplied by the laboratory, and furnishes a record of 
the sanitary conditions at the source of the supply. Samples 
for laboratory examination should not be collected from sources 
where the surroundings are obviously insanitary until the condi- 
tion has been corrected. Samples from private sources are examined 
only for the sanitary quality of the water; for mineral analyses 
the owner is referred to a private laboratory for a special study 
of the particular problem. 
The health officer should state his reason for requesting a labora- 
tory examination in his investigation of a water supply, and also 
the number of samples it is proposed to collect for chemical and 
bacteriologic examination. Since a single bacteriologic examina- 
tion may not reveal intermittent pollution, a sample for chemical 
analysis should be collected from all privately owned sources 
where previous examinations have not been made. If problems of 
taste or corrosive action are under investigation, or data concern- 
ing recently constructed public water supplies are desired, a 
sample for chemical analysis should in all cases accompany those 
submitted for bacteriologic examination. If a large sample for 
chemical analysis is taken, one for bacteriologic examination should 
be collected at the same point in the supply; bacterial samples may 
also be taken from other points if the results are likely to be of 
significance. 
On receiving the containers, it is essential that the health officer 
select the information form appropriate for the water supply to 
be examined and that he answer all questions relating to the condi- 
tions found in his inspection: the green card for untreated ground 
waters (well, spring, infiltration gallery); the cherry card for 
88 89 
untreated surface waters (stream, pond, or lake); the blue card for 
all treated waters. 
The laboratory examination determines the presence or absence 
of pollution at the time of sampling, but the field inspection 
determines the sources and nature of the pollution and thus the 
significance of its presence or absence. Reports are not made 
unless the sources of supply have been adequately inspected. If 
the descriptive forms are incomplete, they will be returned and 
the report of the examination held until the necessary data are 
furnished. 
Ground waters receive pollution from surface washings, from 
subsurface drainage through the soil, or through fissures and 
channels in rock strata. It is, therefore, necessary to inspect the 
well, spring, or infiltration gallery, and to record data to show: 
(1) whether the well is protected structurally from pollution; (2) 
the nature and location of, and drainage from nearby sources 
of pollution; and (3) the character of the soil penetrated. The 
location of all potential sources of pollution should be noted. If 
sewage disposal is by means of septic tank, the location of the 
drainage area or tile field in relation to the well should be indicated 
on the descriptive card. Although information concerning the 
geologic formations penetrated by the well may not be available, 
frequently an examination of the surface conditions will indicate 
the probable presence of rock strata, or in the ease of any but 
deep driven wells, that the soil penetrated is either silt, gravel, 
clay, or loam. 
Surface waters receive pollution at different points from various 
sources and through tributaries. This pollution is altered by 
storage and by sedimentation, dilution, and many other natural 
agencies. The number, character, and size of the streams, ponds, 
or lakes constituting the supply, and the construction, capacity, 
and operation of storage reservoirs used in distributing it should, 
therefore, be recorded. Especially is it necessary to give complete 
available data concerning the watershed and all probable sources 
of pollution, together with all safeguards against contamination. 
Treated waters. Various methods of purification and different 
combinations of these methods are used in the treatment of water; 
hence, all the data on the blue card are not required in describing 
any one treatment plant. Since the efficiency of any method, or 
combination of methods, is dependent upon the precision with 
which each step of the process is carried out, it is necessary to 
record the operative details, all of which can be obtained from the 90 
person in charge of the plant. Any further information regard- 
ing conditions that might affect the sanitary quality of the water, 
together with an explanatory diagram, should be added under 
“Remarks” or on the blank white card furnished with each outfit 
for this purpose. Samples, bacterial and chemical, from different 
points in a source of supply, should be identified by the letters 
A, B, C, D, etc., the respective points at which these samples were 
taken being noted on the descriptive cards. All the cards should 
be put in the envelope in which they are shipped, and the envelope 
replaced in the box with the sample. 
Containers for the submission of samples are shipped by express 
collect; samples should be sent to the laboratory by express prepaid. 
The sampling schedule should be timed, and direct shipping routes 
selected to ensure delivery within twenty-four hours, if possible, 
but never more than forty-eight hours after collection. Samples 
should be taken preferably early in the week and not later than 
Thursday. 
Swimming Pools and Bathing Areas 
Samples of water from swimming pools and bathing areas are 
ordinarily examined only when submitted by a member of the 
Department staff in connection with a special study. A sterile 
bottle containing a dechlorinating agent is supplied for the col- 
lection of samples of chlorinated water. (These bottles are dis- 
tinguished by a red string securing the protective cover over the 
stopper.) Any excess chlorine in the sample is thus neutralized 
and the examination will indicate the bacterial content of the 
water more nearly than if the residual chlorine were allowed to 
remain in the sample during transit. 
Public Water Supplies 
As an aid in supervision and to provide data on which the 
Division of Sanitation may base recommendations for improve- 
ment, samples from all public water supplies are examined at 
scheduled intervals. Chemical examinations are made at least 
annually; bacteriologie examinations four, six, and twelve or more 
times a year. In general, supplies from surface sources, or those 
in which treatment is essential for maintenance of sanitary quality, 
are sampled at monthly or even shorter intervals. The frequency 
of sampling depends upon the results of previous examinations 
and upon known sanitary and operating conditions. When local 91 
approved county or city laboratory service is available and reports 
of monthly or more frequent bacteriologic examinations at these 
laboratories are submitted to the Department, the supplies are 
listed for minimum sampling. Occasionally, the frequency of 
sampling is increased temporarily. Included in this routine sampl- 
ing schedule are the water supplies of state institutions and state 
parks, over which close supervision is necessary in the interests of 
the public health. Large central schools served by individual water 
supplies and other schools in which the supply is a potential public 
health hazard have been selected for sampling at two-month intervals 
during the school year. 
Samples from public supplies examined under this schedule are 
shipped without refrigeration by parcel post, special delivery, in a 
container of special design; in this way delivery within twenty- 
four hours is assured. Experience has indicated that in water 
nOt seriously polluted bacterial changes during unrefrigerated 
storage for twenty-four hours are of little significance. Samples 
without special delivery postage are not examined and another 
specimen is requested from the same source. 
The Central Laboratory ships the sampling outfit to the health 
officer or water department official according to the established 
schedule, advising him at the same time by postal card when the 
sample should be submitted. The sample should be collected as 
nearly as possible on the designated sampling date and should be 
submitted in the container furnished for that specific purpose. If 
unusual conditions interfere, collection may be postponed until 
the following week. If the sample is not received within two weeks, 
a second postal card is sent calling the collector’s attention to this 
fact; at the end of three weeks, a letter is written or the district 
engineer investigates the cause of delay. 
The outfit includes a brown descriptive card on which all identify- 
ing and descriptive data regarding the sample and the supply 
should be entered. In order to avoid confusion, the name of the 
supply sampled should be written on the descriptive card as it 
appears on the postal card notice. If the water is chlorinated, the 
residual chlorine value on the day of sampling should be recorded, 
since it is essential to an interpretation of the laboratory findings. 
This information can be secured readily from the operator in 
charge of the treatment. Incomplete descriptive cards are returned 
for detailed information before the results are reported. 
The laboratory findings are sent to the Division of Sanitation 
for interpretation and submission to the local officials. 92 
The information furnished by this sampling procedure has been 
of great value in the control of water quality and in the establish- 
ment of more satisfactory public supplies throughout the State. 
When the laboratory results indicate that the sanitary quality 
of a supply is questionable, an inspection is made promptly by a 
member of the staff of the Division of Sanitation. 
Samples for hacteriologic examination. Taps on a main that 
is in constant use should be selected as sampling points; never 
those on a dead end. Leaky taps and hydrants are not suitable 
as sampling points. The water should be allowed to run for ten 
minutes before samples are taken. The bottles for bacterial samples 
are sterile and should be handled with care to avoid contamina- 
tion. If by accident a bottle should become contaminated, or 
there is any question of its sterility, it should be so marked and 
returned to the laboratory and a fresh one taken or secured from 
the Central Laboratory if not available locally. 
Method of collection: Wash and dry the hands carefully. With 
one hand hold the bottle at or near the bottom; with the other, 
unwind the string around the cap and remove the stopper with 
the protective paper cap in place. One end of the string used to 
tie the cap is inserted between the glass stopper and the neck 
of the bottle to facilitate removal of the stopper. Do not replace 
string in the bottle when the sample has been collected. 
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. Fill the bottle to within half an 
inch of the stopper, leaving only sufficient air space for expansion. 
Replace the stopper and tie the hood down securely. 
Label each sample with an identifying letter and the name of 
the city, town, or village, and enter the corresponding identifica- 
tion on the descriptive card of inspection. When from two to five 
samples from a single source are submitted for bacteriologic 
examination, it is more convenient to ship them by express in 
the special outfit provided for the purpose. This is a wooden 
box containing a metal can for ice and five sample bottles. When 
this outfit is used the ice can should be filled with cracked ice to 
provide refrigeration during transit. In no case should the sample 
itself be packed in the ice in this can; the bottle should be returned 
to its container and placed in position adjacent to the can. The 
can should not be used for the submission of samples of water 
for chemical or other examination. 93 
Samples from newly constructed or recently cleaned wells should 
be identified as such; at least a week should elapse between the 
time water is first pumped and the collection of the samples. 
The well should be pumped frequently during the interim. From 
five to ten pails of water should be pumped before a sample is 
collected. If there is any overflow or splashing back into the 
well during sampling, this fact should be recorded. Pails or 
buckets that are used for taking samples should be carefully 
cleaned and thoroughly rinsed with boiling water. 
In ponds, reservoirs, or streams, samples should be taken in a 
sufficient depth of water to avoid disturbing the sediment or 
otherwise affecting the usual conditions. Grasping the bottle 
in the right hand near the bottom, plunge it mouth downward well 
under the surface, keeping the hand on the downstream side of 
the bottle; then carry the bottle upstream 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. The bottle should be plunged quickly below the surface 
and removed quickly to prevent entrainment of any surface scum. 
In rapidly flowing water the bottle may be held upstream and 
allowed to fill in this manner. 
Samples for chemical analysis. The large bottle for the chemical 
sample is clean but not sterile. It is shipped by express in a 
wooden box with inner side spring to hold the bottle firmly in 
place and protect against breakage. Selection of sampling points 
should be made with the same care as in the collection of bacterial 
samples. The bottle should first be rinsed with the water to be 
collected, then filled with the sample, and precautions taken against 
the entrance of foreign material. If possible the sample should 
be collected directly, without the use of a pail, dipper, or funnel. 
If such apparatus is necessary it should be clean and thoroughly 
rinsed in the water to be sampled. Unless otherwise directed, 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 taking the bacterial samples. 
If by accident the stopper of the bottle should become soiled, it 
may be washed thoroughly in the water being sampled and replaced 
in the bottle. The stopper and neck of the bottle should be re- 
covered with the cloth and tied securely. The ends of the string may 
then be sealed but not the stopper. The bottle should be labeled 
with the name of the city, village, or town and the letters A, B, C, 
etc., to conform with the identification of the bacterial sample 94 
collected from the same source. Care should be taken to enter 
the proper descriptions of these samples on the green, cherry, 
blue, or brown card on which are recorded the results of the 
sanitary inspection. 
Sewage 
Samples of sewage, sewage effluents, and industrial wastes are 
examined only when submitted by members of the Department staff 
in investigations of the operation of sewage treatment plants or of 
stream pollution. They must be accompanied by the necessary 
identifying and descriptive data regarding the source, type of 
treatment, and method of plant operation at the time of sampling, 
and the purpose of the investigation. 
Bacteriologic examination. “Catch” samples should be taken 
in the type of sterile bottle used for the collection of samples of 
water for bacteriologic examination. Samples of chlorinated sew- 
age effluents should be collected in sterile bottles containing sodium 
thiosulfate to neutralize the residual chlorine in the sample. All 
samples must be carefully refrigerated from the time of collec- 
tion and delivered to the laboratory as soon as possible. 
Chemical analysis. Sampling points should be so located as to 
permit the collection of representative samples. Precautions against 
contaminating the sample with floating scum or sludge should be 
observed. Samples should be composites of specimens taken at 
intervals of not more than two hours, preferably more frequently, 
over a period determined by the nature of the investigation; when 
possible they should be integrated according to the rate of flow 
of the sewage. They should be submitted in duplicate in the glass- 
stoppered bottles (1 gallon capacity) furnished by the laboratory; 
concentrated sulfuric acid, C.P., (specific gravity 1.84) in the 
proportion of 1 ml. to 1 liter should be added as a preservative to 
one sample, and 5 ml. of chloroform per liter, to the second. If 
the biochemical oxygen demand is to be determined, a third sample 
without preservative should be submitted. Samples must be 
refrigerated from the time of collection and delivered to the 
laboratory as soon as possible. 
Sewage Sludge 
Chemical analysis. Samples of sewage sludge are examined only 
when submitted by members of the Department staff in investiga- 
tions of the operation of sewage treatment plants. They should 95 
be submitted in wide-mouthed, glass-stoppered bottles or in pre- 
serve jars, and must be accompanied by complete identifying and 
descriptive data regarding the source of both sewage and sludge 
and the type of treatment at time of sampling. Methods that ensure 
the collection of representative samples must be used. Samples must 
be refrigerated from the time of collection and delivered to the 
laboratory as soon as possible. PART IV 
EXAMINATION OF MILK AND CREAM 
Samples of milk and cream are examined by the Division of 
Laboratories and Research only in special cooperative investiga- 
tions with other divisions of the Department, principally the 
Division of Sanitation. Health officers requesting examinations 
to assist in carrying out the provisions of the Sanitary Code (Chap. 
Ill, Reg. 5) are referred to a local approved laboratory. 
Bacteriologic examination. Before sampling, milk or cream 
should be thoroughly stirred with a sterile rod or by inverting the 
container several times. Samples of at least 25 ml. should be col- 
lected through sterile glass or metal tubes of a length sufficient to 
reach the bottom of the original container, and transferred to 
sterile screw-capped vials or glass-stoppered bottles protected 
against subsequent contamination and leakage. Containers should 
be not more than two-thirds full in order to permit adequate 
agitation before portions of the sample are removed for examina- 
tion. Bottled milk should be submitted in the original unopened 
container as distributed by the dealer. All samples should be 
packed in sufficient cracked ice to ensure constant refrigeration dur- 
ing transportation to the laboratory. They should be accompanied 
by a record of the identification marks on the original container, the 
source—name and location of the dairy, bottling plant, creamery, 
producer, or distributor—the grade, whether raw or pasteurized, the 
date and time of collection and of shipment, the examination 
requested, and any other pertinent information. 
The standard agar plate count provides information of value 
in the routine control of the sanitary quality of a milk supply and 
is essential to determine compliance with the standards of grad- 
ing given in the Sanitary Code. 
Direct microscopic examination detects unclean milk and that 
from cows with diseased udders. Since it yields valuable informa- 
tion concerning the bacterial and cell content and may reveal the 
presence of flora introduced in processing, this method should be 
used in conjunction with the agar count on all samples, both raw 
and pasteurized. The direct microscopic count is not satisfactory 
for the accurate grading of Certified or other grades of raw milk 
with low counts; marked deviations from these grades can be 
determined, however, and it is, therefore, a desirable auxiliary 
examination. 
Under the usual conditions of production and handling, milk 
or cream may become contaminated with bacteria of the eoliform 
96 97 
group. Since these microorganisms multiply in such a favorable 
milieu, their determination in raw milk is of little value. They 
are destroyed at the temperature of pasteurization and their 
presence in pasteurized milk thus indicates subsequent contamina- 
tion by faulty handling. The sanitary quality of all pasteurized 
milk and cream should, therefore, be checked by this examination. 
Phosphatase test. The addition of significant amounts of raw 
milk to a pasteurized product cannot always be detected by bac- 
teriologie examination, nor can variations in pasteurizing treat- 
ment. A laboratory procedure to detect irregularities of this char- 
acter is a valuable aid in the control of the processing of milk. 
The phosphatase test detects almost without failure a lowering 
of as little as 1°F. in the temperature of pasteurization, shorten- 
ing of the holding time by five minutes, and the addition of more 
than 0.1 per cent raw milk. It is thus exceedingly valuable in the 
control of pasteurization and should be made at frequent intervals 
to detect irregularities in treatment. 
In summary, the routine supervision of milk supplies should 
include the standard agar plate count and the direct microscopic 
count on all samples, both raw and pasteurized; and, in addition, 
the test for the coliform group, and the phosphatase test on all 
pasteurized products. 
The results of the examination of a single sample of milk or 
cream often do not fairly represent the character of a supply. 
If a particular sample has a high standard plate count and a phos- 
phatase value indicative of inadequate pasteurization, or shows 
the presence of bacteria of the coliform group, an investigation 
should be made to discover the cause. Additional samples should 
be examined to determine whether the results were indicative of 
a single faulty condition or whether the entire supply is intermit- 
tently or constantly below standard. 
Determination of the butterfat content, solids, and preserva- 
tives in milk or cream is not made by the Division of Laboratories 
and Research, since the laws and regulations that relate to food 
value and adulteration are under the direction of the Department 
of Agriculture and Markets. 
Bio-assay of Vitamin D milk. Regulation 1, Chapter III of the 
Sanitary Code requires that Vitamin D milk shall be examined 
at semiannual intervals in a laboratory approved for the purpose. 
Arrangements have been made whereby dealers who supply Vitamin 
D milk for sale are required to submit specimens for bio-assay to 
one of a group of laboratories that specialize in this determina- 
tion and have been approved by the State Commissioner of Health. PART V 
EXAMINATIONS CONCERNED WITH EATING, DRINKING, 
AND COOKING UTENSILS 
A standard of 100 microorganisms per utensil surface area is 
established in the Sanitary Code (Chap. XIV, Reg. 3) as a 
criterion of the satisfactory cleansing of eating, drinking, and 
cooking utensils. Investigation has shown that adequate washing 
in water at 120°F. in which there is a suitable detergent, followed 
by adequate rinsing in water at 160°F. or greater will satisfy this 
standard; and, further, that if such utensils are protected sub- 
sequently during storage against contamination by handling, they 
will be free from bacteria of the coliform group. 
Laboratory examination of these utensils, particularly of glass- 
ware, is usually not necessary, since the methods of washing and 
rinsing and the general cleanliness of an establishment ordinarily 
indicate whether the regulations of the Code are met. Occasionally, 
it is necessary to demonstrate that specific methods of washing 
and handling produce or fail to produce results that meet the 
standard, or to provide evidence regarding compliance with the 
regulations. When such examinations are required, the general 
sanitation of the establishment and information regarding the 
specific methods of washing and rinsing are necessary to an inter- 
pretation of the results, and should be furnished to the laboratory. 
The Code specifies that such examinations must be made in a 
laboratory approved for the purpose. 
98 PART VI 
RECORDING AND REPORTING RESULTS OF LABORATORY 
EXAMINATIONS 
The maintenance of accurate records of specimens received and 
the prompt and correct- reporting of results of examinations are 
procedures of the utmost importance. 
To facilitate handling and to eliminate any possibility of inter- 
change in the laboratory, only one specimen is opened at a time; 
it is given a serial number before another container is opened. 
As a safeguard against loss or misplacement of specimens, accession 
books are kept for recording their receipt and pertinent data 
concerning them. These books are also the source of statistics 
used in the compilation of monthly and annual reports. Typed 
reports of all examinations are sent to the physician by whom the 
specimen is submitted and, if the examination discloses the exist- 
ence of a communicable or malignant disease, to the local or state 
health official to whom the physician is required to report the 
case (Public Health Law, Art. Ill, Sec, 25 and 25-b). A similar 
procedure is required (Public Health Law, Art. Ill, Sec. 25) when 
results of examinations are needed for purposes of release from 
quarantine or observation. 
Copies of reports are sent to hospitals for purposes of record, if 
the physician makes such a request on the history form. 
While the interests of the patient are considered in all cases 
where there is occasion to divulge information in regard to labora- 
tory examinations, the Public Health Law (Art. Ill, Sec. 25) 
and the Sanitary Code (Chap. II, Reg. 26) require all records 
relating to suspected cases of syphilis, gonorrhea, or chancroid 
to be treated as strictly confidential. Copies of reports are there- 
fore given only to health officials and to the physician by whom 
the specimen is submitted, unless the patient furnishes a waiver 
stating to whom he wishes the information furnished. 
The Public Health Law (Art. Ill, See. 25, and Art. XYI, Sec. 
322) and the Sanitary Code (Chap. II, Reg. 28-29) require records 
relating to eases of tuberculosis to be considered confidential also. 
99 PART VII 
DISTRIBUTION OF LABORATORY SUPPLIES 
Article II, Section 5, of the Public Health Law empowers the 
State Commissioner of Health or his authorized representative to 
establish district laboratory supply stations, to prescribe the dis- 
trict to be served by each, and to appoint a custodian to have 
charge of each station. A health officer or person in charge of a 
public health laboratory or, when necessary, some other competent 
person may be appointed. The law also authorizes the establish- 
ment of substations by the custodians upon approval of the State 
Department of Health. Substations should be established only in 
large cities and in counties where there is a county laboratory or 
a county health unit. All other stations should be main stations. 
If substations are essential for the satisfactory distribution of sup- 
plies to physicians in such cities and counties, they should be 
established only with the approval of the district state health offi- 
cer and the central laboratory. The substations should be located 
where there are facilities for keeping supplies under proper condi- 
tions and should be placed in charge of qualified persons. 
The law provides that each custodian of a main station shall be 
entitled to receive annually certain fees and the actual and neces- 
sary expenses for maintaining and operating the district station 
and its substations, upon certification of the State Department of 
Health that such stations have been maintained and operated in 
accordance with its rules and regulations. 
District supply stations have been established throughout the 
State, and laboratory supplies, including outfits for diagnostic 
specimens and prophylactic and therapeutic preparations, with a 
few exceptions, are distributed through these district stations and 
their substations. 
Health officers and physicians should secure supplies required 
for immediate use from the station that serves the municipality in 
which they are located. In an emergency they should be procured 
from the nearest station. Laboratory supplies, especially the 
perishable products, should not be kept in quantity except in 
regularly established stations. If difficulties are experienced or 
delays occur, the matter should be taken up with the district 
custodian or, if necessary, with the Division of Laboratories and 
Research. 
100 INDEX 
Amebiasis, 19 
Anaphylactic reactions, 16-17, 18 
Anthrax, 19-21 
Antianthrax serum, 20 
Antidysentery serum, 31 
Antimeningococcus serum, 44-45 
Antipneumococcus sera, 47-49 
Antirabic vaccine (Semple method), 
52-54 
Anti-snake-bite serum, 56-57 
Antistreptococcus serum, 58-60 
Antitoxins, administration, 17-18 
distribution, 15-16 
reports on use, 18, 100 
see also names of specific antitox- 
ins, e.g.. Tetanus antitoxin 
Arsenical preparations, 66 
Asiatic cholera, 21 
Autogenous vaccines, 87 
Bacillus anthracis, 20 
Bacillus dysenteriae, 30 
Bacterium coli, see Coliform bacteria 
Bacterium mallei, 36 
Bacterium tularense, 77 
Bacterium typhosum, 77-81 
carriers, 79-81 
Bathing areas, 90 
Birds, psittacine, regulations of San- 
itary Code, 50 
Bismuth preparations, 66 
Blood, chemical examination, 85 
cultural examination, 85 
hemoglobin determination, 85 
microscopic examination, 85 
Botulism, 31-32 
Botulinus antitoxic sera, 34-35 
Brucella abortus, 82-83 
vaccine, 83 
Brucella melitensis, 82-83 
Budget, estimate for local laboratory, 
8 
Carriers, Bact. typhosum, 77, 79-80 
0. diphtheriae, 23 
Cauterization of wounds by rabid ani- 
mals, 52 
Cerebrospinal fluid, examination, in 
meningococcus infections, 43, 44 
in syphilis, 66 
Chancre, 38 
Chancre fluid, methods for collecting, 
65 
outfit, (Plates IV, V), 67, 68 
Chancroid, 21 
records, confidential, 99 
Cholera, Asiatic, 21 
Clostridium botulinum, 31-32 
Clostridium tetani, 71-73 
Coliform bacteria, contaminants, in 
milk, 96-97 
on eating, drinking, and cooking 
utensils, 98 
Clostridium welchii, 35 
Cooking utensils, examination, 98 
Corynehacterium diphtherias, 23 
carriers, 23-24 
Cream, bacteriologic examination, 96 
phosphatase test, 97 
Desensitization, 17 
Diarrhea, 20 
Diphtheria, 23-30 
intracutaneous test of susceptibil- 
ity to diphtheria toxin (Schick), 
25-26 
Diphtheria antitoxin, 29-30 
Diphtheria toxoid, 26-28 
precipitated, 27-28 
unprecipitated, 27 
Diphtheria-tetanus toxoid, precipi- 
tated, 28 
Directors in charge of approved lab- 
oratories, qualifications, 9-10 
District supply stations, 15-16, 100 
Division of Laboratories and Re- 
search, branch laboratory, 5 
chart of organization, vi 
history and organization, 5 
photographs. Plates I and II 
Domestic Relations Law, require- 
ments on submission of specimens, 
6, 62 
Donovan bodies, 38 
Drinking utensils, examination, 98 
Dysentery, bacillary, 30-31 
Eating utensils, examination, 98 
Education Law in relation to osteo- 
paths, 16 
Encephalitis, epidemic, 31 
Endamoeba histolytica, 19 
Enteric diseases, 19, 22, 30-35 
Erysipelas, 57-61 
Food, value and adulteration, 97 
Food poisoning, 31-35 
Frei test, 40 
Fusiform bacilli, in Vincent’s angina, 
83 
101 102 
Gas gangrene, 35 
Gas gangrene antitoxin, 35-30 
Glanders, 36 
Glandular fever, 36-37 
Globulin solution (Imman), in 
measles, 41-42 
Gonorrhea, 37-38 
chemotherapy, 38 
records, confidential, 99 
Granuloma inguinale, 38 
Haverhill fever, 54 
Helminthiasis, 38-39 
Hemophilus ducreyi, 21 
Hemophilus pertussis, 84 
History forms, 13 
Hypersensitivity, tests for, 16-17 
Infection and immunity, 1-3 
Infectious mononucleosis, 36-37 
Influenza, 39 
Intracutaneous test, for hypersensi- 
tivity to horse or rabbit serum, 17 
Jaundice, acute infectious, 39-40 
epidemic, 40 
Laboratories, approval, procedure for, 
9-10 
approved, 6-10 
budget estimates, 7-8 
directors, qualifications, 9-10 
pathologists, qualifications, 9-10 
recording and reporting of exam- 
inations, 99 
registered, 10 
sanitary examinations, qualifica- 
tions of person in charge, 10 
state aid, 7-9 
supplies, distribution, 15-16, 100 
Leptospira canicola, 39-40 
Leptospira icier oh aemorrhagiae, 39- 
40 
Lymphogranuloma venereum, 40 
Malaria, 40-41 
preparation of thick films, 41 
Mastitis in cows, 58 
Measles, 41-43 
Meningitis, meningococcus, 43 
Meningococcemia, 43-44 
Milk, bacteriologic examinations, 96 
bio-assay of vitamin-D, 97 
brucella infections, 82 
examinations, 96-97 
food value and adulteration, 97 
microscopic examination, 96-97 
phosphatase test, 10, 97 
streptococcus infections, 57-58 
Miscellaneous examinations, 85-87 
Mononucleosis, infectious, 36-37 
Mycobacterium tuberculosis, 74-76 
Needles, blood-letting, 12 
Negri bodies, 51-54 
Neisseria gonorrhoeae, 37-38, 45, 83 
Neisseria meningitidis, 43-44 
classification of strains, 44 
Nitric acid, fuming, for cauteriza- 
tion, 52 
Ophthalmia neonatorum, 45-46 
Ophthalmic test, for hypersensitiv- 
ity, 17 
Ornithosis (psittacosis), 49-50 
Osteopaths, Education Law in rela- 
tion to use of antitoxins, sera, vac- 
cines, and drugs, 16 
Outfits for submitting specimens, li- 
lt 
Oxyuris (Enterohius) vermicularis, 
39 
Paratyphoid fever, 77-81 
Pasteurella pestis, 46 
Pasteurization, phosphatase test, 97 
Pathologists in charge of laboratories, 
qualifications, 9-10 
Penal Code, violated by sale of pro- 
phylactic or therapeutic prepara- 
tions, 15 
Pertussis vaccine, 84 
Phosphatase test, 10, 97 
Plague, 46 
Pneumonia, 46-49 
Poliomyelitis, 49 
Postal laws and regulations, 14 
Prophylactic and therapeutic prep- 
arations, administration, 17-18 
anaphylactic reactions, 16-17 
distribution, 100 
reports on use, 18 
sale a violation of Penal Code, 15 
see also names of specific prep- 
arations, e.g., Typhoid vaccine 
Proteus X, 81 
Psittacosis (ornithosis), 49-50 
Public water supplies, 90-91 
Puerperal sepsis, 57-61 
Rabies, 50-54 
cauterization of wounds, 52 
shipment of animals’ heads, 51-52, 
and Plate III, p. 53 
vaccine, 52-54 
Rat-bite fever, 54-55 
Reactions, reports of severe or un- 
usual, 18 
Reactions, anaphylactic, precautions 
against, 16-17 
Registration of laboratories, 10 
Reports of laboratory examinations, 
99 
Restaurant sanitation, examination 
of utensils, 98 
Rickettsiae, 81 
Rocky Mountain spotted fever, 81-82 103 
Salmonella paratyphi-A, 77-81 
Salmonella paratyphi-B, 77-81 
Sanitary Code, regulations for sub- 
mission of specimens, 6-7 
Scarlet fever, 67-61 
Schick test, 25-26 
Septic sore throat, 57-61 
Sera, administration, 17-18 
distribution, 15-16 
reports on use, 18, 100 
see also names of specific sera, e.g., 
Antipneumococcus sera 
Sewage, examination, 94 
Sewage sludge, examination, 94-95 
Silver nitrate solution, 45-46 
Smallpox, 55-56 
Snake bite, 56-57 
Sodium citrate solution, 42 
Specimens, directions for submitting, 
11-14 
outfits, 11-12 
preparation, 13-14 
Spirillum minus, 54-55 
Spirochetes, in Vincent’s angina, 83 
Staphylococcus aureus, in food pois- 
oning, 32-33 
State aid to local laboratories, 7-9 
Streptococcus infections, 57-61 
Streptococcus toxin, intracutaneous 
test of susceptibility, 60-61 
Streptothrix muris-ratti, 54-55 
Sulfonamide drugs, in gonorrhea, 38 
in pneumonia, 47, 49 
in streptococcus infections, 59 
Supply stations, 15-16, 100 
Swimming pools, 90 
Syphilis, 62-70 
methods for collecting specimens, 
blood, 65 
cerebrospinal fluid, 66 
chancre, 65 
lymph nodes, 65 
outfits for the collection of speci- 
mens, Plates VI, VII, 69, 70 
records, confidential, 99 
Tetanus, 71-73 
Tetanus antitoxin, 72-73 
curative treatment, 72 
Tetanus antitoxin (Continued) 
passive immunization, 72 
prophylactic dose, 72-73 
therapeutic dose, 73 
Tetanus toxoid, unprecipitated, 71 
Therapeutic and prophylactic prep- 
arations, administration, 17-18 
anaphylactic reactions, 16-17 
distribution, 100 
reports on use, 18 
sale a violation of Penal Code, 15 
see also names of specific prepara- 
tions, e.g., Typhoid vaccine 
Ticks, 81 
Tissue, histologic examination, 86-87 
Treponema pallidum, 38, 62-70 
Trichinella spiralis, 73 -74 
Trichinosis, 73-74 
Trichomonas vaginalis, 83 
Tuberculin (Koch’s 0. T.), 76 
Tuberculosis, 74-76 
records, confidential, 99 
Tularemia, 77 
Typhoid fever, 77-81 
Typhoid vaccine, 80 
Typhoid-paratyphoid vaccine, 81 
Typhus fever, 81-82 
Undulant fever, 82-83 
Urine, chemical examination, 87 
cultural examination, 87 
miscroscopic examination, 87 
Vaccination against smallpox, 55-56 
Vaccines, administration, 17-18 
distribution, 15-16 
see also names of specific vaccines, 
e.g., Typhoid vaccine 
Vaccines, autogenous, 87 
Vaginitis (trichomonas), 83 
Vibrio cholerae, 21 
Vincent’s angina, 83 
Vitamin D, bio-assay of milk, 7, 97 
Water, examination, 88-94 
requirements for approval of lab- 
oratory, 10 
sampling, 91-94 
Whooping cough, 84 
Worms, parasitic, 38-39