acteristically and so exhaustively that it is hardly worth while for me to say anything about it.

Any business depends for its success upon management. If that management is subject to municipal or state or national control, it is of necessity handicapped, perhaps disadvantageously. Red tape, iron clad rules, or the lack of rules, established for the guidance of management is disastrous and destructive.

That is the principal problem with which the health officer has to deal the passing of the buck, to use a classical expression, all the way from the mayor down to the chief of police in municipalities. The health department should be a separate and distinct department of municipal government. It should be presided over by a competent head, vested with the power to carry out the rules and regulations of the department as established by that department or the superior department of which it may be an integral part, the State or National department.

My idea of the personnel of the organization should be the commanding officer, the medical health officer, who should have as his lieutenant a sanitary officer, one or more inspectors according to the size of the community and sufficient clerical assistance to enable him to give such of his own time as may be required to the laboratory. That is the essential part of the health department and it is the only way in which communicable diseases can be controlled.

The organization must be entirely independent of politics and it should be subordinate to the state authorities and not be subordinate to the municipal authorities. The municipal authorities can establish their health department, but once established, it should be subject only to the state authority.

When we place a quarantine we can't release it, we can only ask the State to modify it.

I want to say just a word about smallpox. We have had our trouble with that. We have just gotten through with a little flurry of it and I want to make an appeal for the repeal of the quarantine laws on smallpox. How does it strike you? I want the quarantine laws on smallpox repealed. I want a smallpox patient privileged to walk the streets if he wants to to go and come as he likes.

There are two sides to that perhaps. I can only see one. You will admit there is only one way to control smallpox and that is by vaccination, successfully accomplished. If necessary, repeat it half a dozen times. You can't compel anybody to be vaccinated under the law. The only way you can compel them to be vaccinated is to let them rub noses with a case of smallpox and then I can assure you that 99 per cent of the Christian scientists, the chiropractors, the osteopaths, and all the other alienated individuals will be vaccinated as I have had an opportunity to demonstrate.

Dr. Weis is perfectly right about fumigation. It is an antiquated procedure. It has no merit and should be dispensed with, but you cannot make them

scrub; it would take the United States army to do that.

In regard to the venereal disease proposition: Dr. Weis, I am a little bit inclined to dispute the idea of publicity and not allowing ladies on the street after seven o'clock alone. We live in a factory town and most of the people that get down town after supper are ladies. They have to go at night, for they have no other time, and on certain nights you will find our streets crowded worse than State street with ladies, either singly or in groups, and I will concede that some of those ladies might bear investigation, but not all of them. We have no public source of venereal diseases of various forms, and yet we have plenty of it. Where does it come from? The treatment of the disease by druggists falls within the perview of our department and it is a big question which we must consider.

DR. C. ST. CLAIR DRAKE (Springfield): Dr. Mann has made an appeal for the revocation of rules for the control of smallpox. That is the Bracken idea, Dr. Bracken, the health officer of Minnesota, who advocated that a number of years ago. One of the great functions of the State Department of Public Health is to protect the individuals who will not take the trouble to protect themselves. If a man will not be vaccinated and protect himself against smallpox, it is our function to see that he is provided for if necessary.

On the disinfection proposition, I didn't hear all of Dr. Weis' paper. The State Department of Public Health for a number of years has abandoned fumigation. We do, however, recommend a thorough disinfection, to prevent the recurrence of the disease, by scrubbing, airing and sunning.

DR. ROBERTSON: May I follow with one point on disinfection? If this is money wrongly spent, I shouldn't be signing requisitions and vouchers for disinfection in Chicago. I don't propose to throw it down in Chicago. It is the best way we have of having our buildings aired. We go in and fumigate and make a big stink and they will then clean up to get rid of the stink. We get them aired all right.

DR. WEIS (closing discussion): I haven't anything further to say except to thank the Doctors for their consideration of this paper. Adjournment.

THE HABITAT AND DISTRIBUTION OF DANGEROUS STREPTOCOCCI IN THE BODY.*

DAVID J. DAVIS, M. D.

From the Department of Pathology and Bacteriology, University of Illinois, College of Medicine,

CHICAGO.

The habitat and distribution of bacteria outside of the body follow quite different rules.

*Read at the Annual Meeting of the Illinois State Medical Society, Section on Surgery, at Peoria, May 21, 1919.

There are soil bacteria, water bacteria, milk bacteria-all finding their optimum conditions in their respective mediums and dying out quickly when these conditions are essentially altered.

So, on and in the body of animals, the habitat and distribution of the bacteria follow similar rules. Staphylococcus albus lives in the skin and is always found there. In the large intestine live normally B. coli, B. welchii and others; in the stomach acidophiles, in the urethra diphtheroids, in the vagina acidophilic anaerobes; on the nasal mucosa white staphylococcus and often micrococcus catarrhalis, on the teeth and about the gums B. fusiformis and spirochetæ, on the buccal mucosa and pharynx streptococcus viridans and often varieties of pneumococci. The above mentioned organisms are the usual predominants in their respective localities. Other bacteria may less constantly occur. As a rule also the above organisms under certain conditions may be pathogenic and are, therefore, dangerous.

Dangerous streptococci, likewise, in habitat and distributition follow similar laws on and in the body. By dangerous streptococci I refer primarily to the hemolytic streptococci of the human type. Other non-hemolytic varieties are. dangerous but, on the whole, less so. These latter are principally concerned in causing respiratory infections and constitute a subject in themselves. I shall not discuss them now but will limit myself to the hemolysers.

The hemolytic type is the one primarily involved not only in respiratory disease, but in dangerous wound infections. It is the organism that the surgeon primarily fears. It has killed our soldiers by the score. These hemolytic streptococci are delicate organisms and evidently not widely distributed in nature. They are highly parasitic and usually die soon after leaving the body. They do not grow well on artificial media and are fond of blood, body fluids and tissues. On the human body they are not found normally. on the surface. If placed on healthy human skin they will disappear in from 24 to 48 hours without washing, sooner if the skin is cleansed. On filthy or pathologic skins they may obtain a foothold especially on hairy parts. (Schachter.) Normally in the vaginal tract they do not appear. In the stomach they cannot grow or live, the acid killing them quickly, thus also protect

ing the intestines and rendering the intestinal canal relatively free from this variety of streptococci. The appendix normally appears to be practially free of them. (Kraft.)

In the mouth and throat special conditions exist. Examinations we have made show that in the tonsil crypts occur potentially dangerous hemolytic streptococci in practically 100 per cent. This is true of both normal and abnormal throats. The surface of tonsils, however, gives hemolytic streptococci in only 60 per cent, the pharyngeal surfaces in 25 per cent. The farther away from the tonsil crypts we go the less often they are found. In the mouth and about the teeth they are practically absent except when pyorrhea and abscesses occur. After going over the entire body for hemolytic streptococci we are coming to conclude that there is normally only one natural habitat for them, namely, the crypts of the faucial tonsils. The facts point to this focus as a growth and distributing center for them. They live here just as the white staphylococci live in the skin or colon bacilli in the colon. From here by surface extension, by contact and by dissemination of buccal and throat secretions these cocci are distributed to various parts of the body and to other bodies where, should conditions permit, they may develop.

Moreover, we have shown that after tonsillectomy these streptococci in the throat are much reduced in numbers and frequency. While in throats with normal tonsils the streptococci were found in 58 per cent, in throats without tonsils they were found in only 15 per cent and then in small numbers. Nichols and Bryan' likewise report the disappearance of hemolytic streptococci from throats in 27 per cent of 31 patients 11 days after tonsillectomy. In the small percentage of positives after tonsillectomy their presence may be explained by tonsillar remnants and by chronic infections about the throat, teeth and sinuses. It is possible that hemolytic streptococci may grow in the adenoids and in the lymphoid tissue of the pharynx but observations do not point to these structures as important or common sources. It is difficult at times to differentiate between primary and secondary invasions of these regions.

1. Pilot & Davis, Jour. Inf. Dis., 1919, XXIV, 386, also Davis, Jour. Inf. Dis., 1912, X, 148.

2. Jour. A. M. A., 1918, LXXI, 1812.

These streptococci from the crypts or throat are always more or less virulent for animals. One to 2 cc. of broth cultures intraveinously will kill a rabbit; 1⁄2 cc. or less kill mice. The strains isolated from tonsils and even from the same tonsil vary some in virulence. Furthermore strains of lesser virulence may by animal passage increase their virulence. By making tonsil crypt cultures from time to time following acute streptococcus tonsilitis I have observed that though the streptococci remain following recovery their virulence decreases.

The idea has commonly prevailed that dangerous streptococci may be found almost any where about the body but this does not appear to be the case in the light of recent evidence. It may be that in addition to the tonsillar crypts other foci about the body, especially the various sinuses and folds of the upper respiratory tract, will show these organisms normally. But thus far such possible sources have not been found.

What I have said so far concerns what we may call body or endogenous streptococci. They are the streptococci that are constantly present in some focus ready to take advantage of conditions that permit further invasion of the body. They are the strains that commonly cause secondary infections in influenza, measles, scarlet fever, pneumonias, tuberculosis and many wound infections. In such cases the patients who die are presumably killed by their own hemolytic streptococci coming directly or indirectly from their throats.

There is another group of hemolytic streptococci which we may call exogenous streptococci. They include the so-called epidemic streptococci. They are quite like the first group in general properties but on the whole are of greater virulence, some strains acquiring very high aggressive properties. It is these streptococci that cause milk

epidemics of sore throat, epidemics of pneumonia

and empyema as occurred recently in military camps, outbreaks of erysipelas, epidemics of . puerperal sepsis and epidemics in surgical wards such as that recently described by Keegan in the U. S. Naval Hospital, Chelsea, Mass. This last mentioned epidemic is of peculiar interest to surgeons. It began in the nose and throat ward and spread by contact to other surgical

Jour. A. M. A., 1919, LXXII, p. 1434,

wards. Here it was manifested by sore throat, rise in temperature, leucocytosis, malaise, etc., and then by complications involving often regional lymph glands and sinuses and especially by metastatic infection in surgical wounds and joints. This epidemic was controlled by the suspension of all operations for a period of three weeks, immediate isolation of sore throat cases and elimination from surgical service of all carriers of hemolytic streptococci.

We have, then, the two sources of dangerous hemolytic streptococci, the exogenous which, through milk, contact, droplet infection and possibly in other ways, transmit an infection which is usually highly virulent and epidemic in character and the endogenes source which furnish so many of our secondary and terminal infections, on the whole not so virulent and not so contagious, at least for normal persons, but so often fatal to those whose resistance has been lowered by other diseases or by injuries.

We must also recognize the possibility that the endogenous may become more virulent and aggressive and thus start an outbreak or an epidemic by contact or otherwise. Perhaps this was the origin of Keegan's epidemic in the throat ward. It has been noted that in measles epidemics in military camps secondary streptococcus infections at first not so virulent may later become more virulent and ultimately give rise to primary streptococcus pneumonias and empyemas without measles or other infections as a predisposing factor.

Now a brief statement as to methods of con

trol. The exogenous source of streptococci leading to the epidemic outbreaks should be determined and by methods of isolation, control of milk supply and the like the spread of the infection may be controlled. Usually this can be quite readily accomplished and does not prevent

serious difficulties.

The endogenous source, however, is far more difficult to contend with. But now since we are finding that the dangerous hemolytic streptococci do not grow or are not even commonly found any and everywhere about the body but are confined largely to a definite focus the problem is somewhat simplified and does not appear so hopeless. The ultimate solution would seem to be the elimination of these streptococcus car

riers. Bacteriologically this means practically every person with tonsils and many without who have bad teeth, chronically inflamed throats or sinuses, middle ear infections, etc. Universal

tonsillectomy would perhaps go further than any other procedure. But, at least at present, this is impractical. It would greatly diminish the number of streptococci but would not in every case eliminate all the dangerous streptococci in the body. I do not propose-we do not know-at present the solution of the problem in a practical way. I merely now present the problem bacteriologically.

I wish to emphasize this point. Practically every one is harboring typical hemolytic streptococci in their tonsils which can not or have not been differentiated from many dangerous strains of streptococci, from pneumonias and other serious infections. Such streptococci may or may not be responsible for arthritis, iritis, or some other focal infection in the body. But finding hemolytic streptococci in the tonsils may mean nothing in relation to a possible systemic lesion. In fact we may take it for granted that if the examination is made properly hemolytic streptococci usually in large numbers will be found in every tonsil removed. Therefore we may spare our time and effort so far as this point is concerned. However should one find a definite abscess in the tonsils (and I do not mean crypts full of fatty debris and actinomyces-like granules) a bacteriological examination might be of value in deciding the organism involved in the systemic disease.

Finally, may I emphasize that the streptococcus carrier problem is squarely before us. It is assuming as definite form as is the typhoid carrier problem. It should be the aim of all of us, surgeons, medical men, bacteriologists, specialists in whatever line, to make a combined attack on this dangerous organism for too many streptococcus infections are occurring in all branches of medicine. While many difficulties still present themselves, since we are coming to know the habitat, distribution and natural history of this germ, the outlook appears not altogether hopeless. Thus far vaccination and serum therapy in this infection have been disappointing. Perhaps, if more emphasis is laid on the elimination of these organisms from the body, better results will follow.

DISCUSSION.

DR. MUNSON (Springfield): The past winter I have found in my cases of asthma that the recovery has been very slow and difficult. In all of these cases. we have found streptococcus hemolyticus, and because they were so slow to improve upon any form of treatment, I had vaccines made from these organisms in each individual case and especially my asthma cases, and I used the streptococcus hemolyticus vaccine. These were made by a very responsible laboratory in St. Louis, and it seemed to me that where this was the real cause, the cases improved.

I think that most all of you the past winter have noticed in your cases a great amount of hoarseness, tracheitis and laryngitis, and in many of these cases where the trouble was prolonged, in making cultures, we found the streptococcus hemolyticus. About the time the epidemic was at its height, I found myself expectorating some yellow sputum one morning, and when a culture was made, I found I had streptococcus hemolyticus. I had a vaccine made and took it. I thought I improved, but I can't prove it. I do believe that in my cases of asthma it was of material advantage.

AMERICAN STUDENTS AT FRENCH UNI

VERSITY

Two hundred and ninety-eight Americans in khaki are studying at the University of Bordeaux, sixty of them in the College of Medicine. They come from forty-four states of the Union, Canada, and Nicaragua, the New York delegation leading off with twenty-seven members, and they are alumni of universities from Harvard to Washington. There are 1,200 of them at the University of Toulouse, but the Journal de Medicine de Bordeaux comforts itself with attitbuting to the "tres sympathetique Lieutenant Wildermann,” in charge of athletics among his compatriots, the reflection that one American at Bordeaux is worth five at Toulouse, so that the advantage is with Bordeaux.

Meanwhile the Bordelais seems to be divided between friendliness for and amusement at the visitors. The American students had been at the university only two weeks when they had their own paper, which goes under the name of Voila. They conclude that the labyrinth of Crete had nothing on Bordeaux, and their opinion of the climate is summed up in the weather prediction from the first page of Voila: "Tomorrow, rain. Remainder of the week, rain"; the following issue, eight days later, bore the announcement: "No change."

The French universities are filled with youth again after the long emptiness of the war. It is appropriate that some of the American youth who helped save French culture should mingle with the returning throng. New York Medical Journal.