opaque white. If this drawback should be proved to be often a seri-
ous one, it might nevertheless be advisable to use the method, for the
growth is so much more rapid on these media that when the plating
is successful the reports can be made quite early. I have used the
media to a great extent for revivifying old cultures on ordinary
media. The meningococcus, for instance, can be kept alive practically
indefinitely if transplanted on to serum-glucose-agar for one day
and then back on serum-agar, etc. Bacteria which are inoculated on
these media for this purpose should be transplanted after twenty-
four to forty-eight hours, as many of them are not long-lived on these
media. I believe we will be able to make use of the media to a cer-
tain extent for the differentiation of bacteria and species of bacteria,
but more extended observations are needed before any rules can be
made.
VII. REMARKS ON THE ACID PRODUCTION.
This work seems to bring into greater prominence the acids produced
by bacteria. It has been occasionally stated that in infections of
various kinds there exists an acid intoxication. This has usually
been traced, however, to disturbances of cell metabolism such as occur
in diabetic coma and cancerous cachexia; but an attempt should be
made to determine what role may be played by the acids developed
by bacteria. It is known that in the body the bacteria always have a
sugar culture medium, and my figures (to be published later) show
that appreciable amounts of acid can be formed in the presence of
the amount of glucose which exists in diabetic or even in the normal
LIBMAN: GROWTH OP BACTERIA. 511
blood ; moreover, in the body there will be a new supply of sugar as
long as the circulation to a part invaded by bacteria is not cut off.
The acids generally produced by bacteria are the following* : The
most important and most widely distributed is lactic acid; in
traces formic, acetic, propionic, butyric, caproic, succinic, and valer-
ianic. Rarely lactic acid is absent and the others present. I shall not
now go into detail here as to the known effects of such acids. The
question is, are they formed in the human body? In the intestinal
canal it is known that some of them are formed. Theoretically we
are led to believe that they can also be formed in the tissues, for
Theobald Smith has shown that when sugars are present bacteria
in their growth first split up such sugars and acid formation results.
There is a small amount of proof that such acids are generated in the
body. Frosch and Kolle^ state that the staphylococcus aureus pro-
duces lactic acid and also isobutyric, valerianic, and propionic acids,
and that these acids have been found by several investigators in the
pus produced by this organism. These authors are inclined to be-
lieve that the acids play a role in suppuration.
From these remarks it is evident that we should endeavor to ascer-
tain whether acids are not produced in infectious processes. Their
effects upon the blood and their action in the gastrointestinal tract
are well worthy of study. Some attention has been paid to the latter
part of the subject. It is probable that they would play a greater
role in diabetics than in non-diabetics, for in the former they could be
generated in large amount. Is it not possible that some of the pe-
culiarities of infections in diabetics, especially local infections, may
be due in great part to them ? Is it not possible that some of the facts
developed in the course of our investigations may be of importance
in explaining the features of certain forms of thrombosis, the ex-
planation for the development of which has never been fully given ?
There are many facts which make such an occurrence very likely and
there are others which might be considered to militate against it.
I cannot at the present time go into any further discussion of the
subject, but I believe the question should be brought up so as to
indicate in what direction this line of work should be further con-
tinued. In one of his classic papers on acid production Theobald
Smith says: "It is prol)able that the presence of a small amount of
^Lehmann and Neumann: Atlas de Bakteriologie: 1896: Bd. ii.
"Flugge, Die Micro-organismen, 1806. vol. ii.. p. 189.
512 MOUNT SINAI HOSPITAL REPORTS.
fermentable carbohydrate in the intestinal canal and the body fluids
may be of the greatest significance as regards the attack on the body
by, and the development in it of, pathogenic bacteria," "and," I
might venture to add, "their mode of action."
[I wish to thank the members of the House Staff of the Mount Sinai
Hospital for much valuable assistance. I am also indebted to Dr.
Bookman for many kindnesses.]
[Contributions from the Pathological Department —
F. S. Mandlehaum, M.D., Pathologist.]
ON THE BACTERIOLOGIC STUDY OF A CASE OF PARA-
COLON INFECTION PROBABLY SECONDARY
TO TYPHOID FEVER,
WITH REMARKS ON SERUM REACTIONS IN PARACOLON INFECTIONS AND ON
THE THREAD REACTION.*
By E. Libman, M.D.,
ASSISTANT PATHOLOGIST, MOUNT SINAI HOSPITAL, NEW YORK.
NOTES ON THE HISTORY OF THE SUBJECT.
The subject of infectious by members of the group of organisms
intermediate to the typhoid bacillus and the typical colon bacillus of
Escherich— the so-called paracolon bacilli— is one of ever-increasing
interest. The name "paracolon" was first applied to the group by
Cilbert,^ who described five types of paracolon bacilli. He found mem-
bers of this group present in the intestinal canal of man and many
animals.
The first important casesf of infection by such organisms were de-
scribed by Achard and Bensaude^ in 1896, under the title of "Para-
typhoid Infections." Their cases were as follows:
Case I.— A case clinically resembling typhoid fever with an inter-
current relapse followed by a femoral phlebitis. During the course
of the patient's illness the writers twice isolated from the urine,
which had become purulent, a so-called paratyphoid bacillus which
was identical with the one found in the second case. A blood culture
made during the height of the fever proved negative. Aspiration
of the spleen revealed staphylococci only. The stools contained only
the usual forms of colon bacilli, typhoid bacilli being absent. The
*Read, March 28, 1902, at the Second Annual Meeting of the American Asso-
ciation of Pathologists and Bacteriologists, Cleveland, Ohio. Reprinted from
the Journal of Medical Research, vol. viii.. No. 1, 1902.
tin this summary of the cases we shall exclude the epidemics of meat
poisoning and cases of psittacosis.
514 MOUNT SINAI HOSPITAL REPORTS.
patient recovered after an illness lasting six weeks. During the
course of the disease the authors obtained a positive serum reaction
Avith the paratyphoid bacillus and with several cultures of typhoid
bacilli, the reaction with the typhoid bacillus persisting for less than
two months after defervescence.
The authors bring up the question whether or not the case was
one of typhoid fever complicated by a pyelonephritis due to the para-
typhoid bacillus, and cite a number of cases in which colon bacilli had
been found in cases of cystitis and pyelonephritis complicating
typhoid fever. They conclude that the illness was due to the para-
typhoid bacillus alone, because the serum of animals which had been
inoculated with their paratyphoid bacillus agglutinated not only the
paratyphoid bacillus, but also some varieties of the typhoid bacillus.
It is unnecessary to enter into any prolonged discussion of the sub-
ject, because, as Widal and Nobecourt^ very properly remark, the
serum reactions in this case are of no value, as the authors did not
make use of any dilutions of the serum.
Case II.— The second case was that of a female infant aged seven
months, who, after a febrile illness of almost three weeks' duration,
beginning with a bronchitis, developed a suppuration of the right
sternoclavicular joint. From the pus an organism was obtained re-
sembling that found in the first case. Both organisms closely resem-
bled the bacillus psittacosis. No other examinations were made in
the case, and, as the authors state, typhoid fever could not be ex-
cluded. The description of these organisms will be detailed later
in connection with the discussion of the bacillus isolated, from our
own case.
The next ca.se to be reported was that of Widal and Nobecourt^
in 1897. A phthisical patient, after being three weeks in the ward,
developed an abscess in the neck near the esophagus, with slight con-
stitutional symptoms. From the pus a paracolon bacillus was
isolated. (This case is considered by some authors as if it were the
sequela of an attack of typhoid fever, but the patient at the time of
observation was 31 years old and the attack of typhoid fever occurred
at the age of 9.)
Widal and Nobecourt state that they are opposed to the term ' ' para-
typhoid," because the organisms more closely resemble the colon
bacillus than the typhoid bacillus. They cite some observations of
Tavel and Lanz,* who found similar organisms in cases of peritonitis,
and they mention a case of suppuration in the spleen due to a related
organism.
LIBMAN : PARACOLON INFECTION, 515
In 1898 GAvyn^ reported the case of a man who suffered from a
typical attack of typhoid fever with intestinal hemorrhages. The
Widal reaction was absent. Three and a half weeks after the onset
of the disease Gwyn isolated from the blood a paracolon bacillus.
IMalherbe and JMounier'' isolated a paracolon bacillus from a case
of inflammation of the penis with induration of the corpus caver-
nosum.
Gushing 's' case is the most complete study among the various
papers on the subject. The history was in brief the following:
A man 27 j'-ears of age suffered for ten weeks with an attack of
fever described as typhoid. He had a relapse beginning with an
epistaxis. During convalescence he developed two foci of cos-
tochondral osteomyelitis. One of the foci disappeared, but the other
broke open six months later and discharged pus. Since that time
he had a sinus at the level of the fifth rib at the edge of the sternum.
From this focus, nine months after the onset of the fever. Gushing
obtained the paracolon bacillus in pure culture. The Widal reaction
was negative.
Gushing refers to the report of a case by Blumer^ in which the
latter stated that he found the bacterium coli in a post-typhoidal rib
abscess. As the organism produced alkali in milk and therefore proba-
bly did not ferment lactose, Gushing believed that it was probably a
member of the group of bacilli under discussion.
Schottmueller^ in 1900 reported a case of fever lasting twelve days,
beginning with reddening of the conjunctiva and the nasal mucous
membrane. A roseola and enlarged spleen were present. The
Widal reaction was absent. The blood culture made at the height
of the attack yielded a "typhoid-like" bacillus. Later'^ he reported
five cases occurring during a small epidemic of typhoid fever, in all
of. which the Widal reaction was absent and from the blood of each
of which he succeeded in isolating "typhoid-like" bacilli. The clin-
ical picture resembled typhoid fever. All of the patients recovered;
there were no complications and no relapses. (So the author states;
but his second case certainly must be looked upon as having had a
slight relapse.)
The report of only one Widal reaction is made. The blood of each
of the patients gave a positive reaction with the organism isolated
from the case and with some of those isolated from the other cases,
in high dilutions. The complete data will be given later. In the
516 MOUNT SINAI HOSPITAL REPORTS.
sixth, case he made the diagnosis on the basis of the serum reactions
alone.
Kurth/^ in a series of sixty-two cases of typhoid fever, found five
which did not give a positive Widal reaction. From the urine of one
ease and the stools of another he isolated a bacillus probably belong-
ing to the group under discussion, with which a positive reaction was
obtained with the serum of four of the cases. (The fifth was the case
with the bacillus in the urine ; no serum was obtained from this case. )
Although it is not my purpose to enter into the description of the
cases clinically in this paper, it is essential to refer to a few facts
concerning the cases of Kurth and Schottmueller. In five of Schott-
mueller's seven cases the duration was respectively twelve days, nine-
teen days, seventeen days, sixteen days, and thirteen days. In one
the onset was characterized by headache and sneezing; in three by
reddening of the face, conjunctivae, and the nasal mucous membrane.
In four of the cases there was constipation ; in one diarrhea. In one
case the roseola developed by the fourth day. All of the cases ended
by lysis.
Kurth 's cases lasted respectively three weeks, fifteen days, twelve
days, eighteen days, and two Aveeks. All had diarrhea. In one case
the roseola was present on the sixth day and in one on the fifth day.
In one case the temperature dropped by a distinct crisis.
These data are given to emphasize the mention of a paper published
by BrilP- in 1898 before Gwyn and Gushing reported their results.
Brill reported a series of cases which, though the}- were usually con-
sidered instances of typhoid fever, he believed should be placed in
a distinct group, and which he believed could be diagnosed by their
clinical appearances and the absence of the Widal reaction during
the duration of the fever and during convalescence. In none of Brill's
cases could the typhoid bacillus be isolated from the feces; in one
a variety of the colon bacillus was isolated from the blood aspirated
from the spleen. (The cultural characteristics are not detailed.)
Some of Schottmueller 's and Kurth 's cases resembled the clinical
picture described by Brill.
Because of the absence of indican, acetone, and diacetic acid from
the urine, Brill was not inclined to assume that the condition was
due to a toxic agent produced in the intestinal canal ; he suspected
that the cases might be due to an infection by colon bacilli. The
investigation of his own cases, as far as it went, did not seem to con-
firm this view sufficiently.
LIBMAN : PARACOLON INFECTION.
517
The last case to be reported was one presented by Buxton and
Coleman^^ to the New York Pathological Society in February of this
year. Clinically it resembled typhoid fever, and the paracolon
bacillus was isolated from the blood. The Widal reaction was prac-
tically negative, but a reaction was present with the paracolon
bacillus. All the cases thus far referred to recovered.
The clinical history of our case will not be given in full, because it
is to be made the subject of a special article by Dr. Berg and the
writer.^*
HISTORY OF OUR CASE.
C. I., 33 years of age, admitted to the Mount Sinai Hospital on
August 31, 1901. Previous history practically negative. Present
history: Ten days ago the patient was suddenly taken ill with nausea,
vomiting, and prostration. Temperature 100° by mouth. There Avas
abdominal distension and pain in the epigastrium. He remained in
bed only two days, but was too weak to return to his work. Three
days before admission he was seized with severe colicky pain located
in the epigastrium and right hypochondrium, vomiting and constipa-
tion; his skin was subicteric; temperature 103° F. On admission
the liver was not found enlarged, but there were friction rales heard
over it. Below the costal margin there was felt a very tender mass about
the size of a large lemon. Spleen enlarged to percussion. No roseola
present. Leucocytes, 15,000. Ehrlich reaction not present. On the
day after admission Dr. Berg performed an exploratory laparotomy,
suspecting either a cholecystitis or an abscess of the liver. The mass
felt was found to be a Riedel lobe. The gall bladder was distended ;
its contents could not be expressed. There was fibrin over the liver.
The gall bladder was aspirated and dark, thick bile obtained. After
the operation the temperature varied between 103° and 106° F. ; in-
tense jaundice was established, with marked cerebral symptoms. In-
cessant vomiting developed on September 9, and the patient died
on the following day. There was an agonal polymorphonuclear
leucocytosis.
BACTERIOLOGIC EXAMINATION.
On September 1 the fluid aspiration from the gall bladder was
plated, and a pure culture of an organism identical with that found
later in the blood and urine was found. On the following day I made
a blood culture to determine whether the presence of the bacilli in
the gall bladder might not be due to an excretion of organisms from
the blood. Eleven cubic centimetres of blood were used, part being
plated and part being gnnvn in fluid media. From both sources
was obtained a pure growth of a paracolon organism.
518 MOUNT SINAI HOSPITAL REPORTS.
On September 8 the urine was plated and a large number of colo-
nies of the paracolon bacillus was found, with a few colonies of the
staphylococcus albus.
On September 9, about twelve hours ante mortem, another blood
culture was made, eleven cubic centimetres again being used. There
were obtained numerous colonies of a paracolon organism and a few
colonies of the staphylococcus albus and streptococci.
A few hours after the fatal termination a culture was made from
the spleen. There were found colonies of the paracolon bacillus asso-
ciated with the staphylococcus citreus and albus and streptococci.
From the blood aspirated from the heart the same organisms were
recovered as were found in the blood the day before death. (The
staphylococcus albus and streptococci probably represent an agonal
invasion.)
A culture of the contents of the ileum, made at the time of the
postmortem examination, revealed two forms of colon bacilli (both
of which coagulated milk and produced indol), the bacterium proteus
vulgare, staphylococcus albus, and streptococci. There were no
typhoid bacilli and no paracolon bacilli found. For all these investi-
gations serum-glucose media were used.
DESCRIPTION OF THE PARACOLON BACn^LUS.
(All media sugar-free, except when otherwise mentioned.)
Titre of media one per cent, acid (with phenolphthale'in).
The organism is a facultative anaerobe.
Morphology. — The organism resembles the typhoid bacillus in
morphology. In glucose-sugar, after twenty-four hours, it appears
in larger forms, and after forty-eight hours shows some involution
forms and vacuolization. After two days on potato it shows rather
distinct bipolar staining. No capsules; no spores. It stains like the
typhoid and colon bacillus, being decolorized by the Gram procedure.
The organism is markedly motile in bouillon cultures at 35° C. and 37°
C, and retains its motility for several days. Six to twelve long
fiagella are present, arranged in peritrichal fashion. In gelatin and
agar, surface and stick cultures, and in glucose-agar (surface) it re-
sembles the typhoid bacillus, but the growth is more profuse and
whiter in color. Gelatin is not fluidified. Agar plates emit an odor
resembling that of the colon bacillus. Macroscopically, the surface
colonies are somewhat larger than those of the B. typhosus and
whiter. Microscopically, the smaller colonies show a densely granu-
lar centre, the colony becoming less and less granular toward the
periphery. The larger colonies have a brown, irregular nucleus
LIBMAN : PARACOLON INFECTION. 519
which is coarsely granular; the remainder of the colony is made up
of heaps of granules Avhich are browner near the centre and larger
in the clearer area at the periphery. The margin of a colony is
round or irregular. The deep colonies are brownish in color, oval
or whetstone-shaped; irregularly-shaped knobs are often present.
Bouillon.— Diffusely clouded in twenty-four hours. Turbidity in-
termediate between the B. typhosus and B. coli ; white, fine, powdery
sediment. After forty-eight hours there is a marked fluffy deposit.
There is no scum formed even after seventy-two hours. The cultures
emit an odor like cultures of B. coli, but less marked.
Reaction with CarhoJtydrates.— {One-half per cent, sugars used.)
Glucose is split up with the production of acid and visible gas. In
glucose-bouillon one and five-tenths per cent, acid produced in six
days. In fermentation tubes maximum gas produced in twenty-four
hours, amounting to thirty-three one-hundredths per cent. (Einhorn
tube). INIaltose is split up with the production of acid and visible
gas. Maximum acid one in twenty-five one-hundredths per cent. ; maxi-
mum gas after two days, fifty one-hundredths per cent. Lactose and
sucrose are not affected. In fermentation tubes there is no groAvth in
the branch ; in the bulb there is active growth with alkali production.
Amount of alkali produced same as in ordinary bouillon, being one
and five-tenths per cent, after one month.
Corresponding to its effect in the fluid media, the organism causes
precipitation and gas production in two per cent, maltose and two per
cent, glucose-serum-agar, but none in the corresponding lactose and
sucrose media.^'^
Plain Milk in Tw&es.— Unchanged for several days, then becomes
yellowish and more and more translucent, the change being very
marked after four weeks. The fat then floats on the surface and a
white deposit is seen at the bottom of the tube. Boiling causes
no coagulation.
Plain Milk in Fermentation Tubes. — In the branch a bubble of gas,
otherwise unchanged. Bulb same as milk tubes.
Litmus Milk in Tvbes.— After twenty-four hours distinct though
slight acid reaction. After a feAv days (varying from three to six),
reduction, and then ({uite marked progressively increasing alkali
production. (Tubes often again show reduction at the bottom after
three weeks.)
Litmus Milk in Fermentation Tubes.- AfXer twenty-four hours
bulb and branch slightly acid, bubble of gas in l)ranch. After forty-
520 MOUNT SINAI HOSPITAL REPORTS.
eight hours, reduction in branch ; later marked alkali production in
bulb ; the branch becomes blank white in color. Milk is never co-
agulated.
Potato. — A slight white shining growth is the rule. On the same
potato tubes the typhoid bacillus gives no visible growth. (Occa-
sionally a moderate yellowish-green growth was obtained with our
organism.)
Indol 7?f flr/iox. — Positive but slight in peptone water and sugar-
free broth, tested after eight days with sulphuric acid and one ten-
thousandth sodium nitrite. In some tests made in peptone water
with one-half of one per cent, sodium nitrite, a positive result was ob-
tained Avith our paracolon bacillus after three days, with the colon
bacillus in twenty-four hours, but was absent with the typhoid bacillus
even after eight days.
PATHOGENESIS.
The organism was pathogenic for guinea-pigs and rabbits, pro-
ducing peritonitis when inoculated intraperitoneally, and otherwise
causing septicemia with degeneration of the viscera and focal necroses
in the liver.
PROTOCOL OY" ANIMAL EXPERIMENTS.
(In all experiments twenty-four-hour bouillon cultures used.)
Guinea-pig i. — One cubic centimetre of culture of bacillus from
the blood, intraperitoneally. Death in sixteen hours. Seropurulent
fluid in the abdomen ; fresh fibrin on intestines and liver. Organism
recovered from peritoneum and heart blood.
Giiinea-jng 2. — One cubic centimetre of culture of bacillus found
in second blood culture, intraperitoneally. Died after fifteen hours.
The result as above.
Guinea-pig 5. — The same experiment with bacillus from gall blad-
der. Same result.
Guinea-pigs 4 and 5. — Same experiment with paracolon organisms
obtained from the urine. Result practically the same.
Guinea-pig 6. — One cubic centimetre of culture of bacillus isolated
from the blood, intraperitoneally. Death after eighteen hours.
Cloudy serous exudate with fibrin in peritoneal cavity, a few hem-
orrhages in mesentery. Organism recovered. Liver shows parenchy-
matous degeneration.
In the succeeding experiments the organism used was the paracolon
bacillus isolated in the first blood culture.
Guinea-pig 7. — One cubic centimetre subcutaneously. Death after
LIBMAN : PARACOLON INP^ECTION. 521
eight days. There was an indurated area at the site of injection,
not extending to the muscles or peritoneum. The peritoneum was in-
jected. There was a slight non-purulent exudate. The intestines
showed marked injection. The liver showed focal necroses with in-
filtration by leucocytes. There were also small areas in which there
was a collection of round cells and polynuclear leucocytes. In one
of the portal vessels a bacterial thrombus was found. Lungs con-