^
LIBRARY
or TIIK
University of North Carolina
Eii(l(iwi'<l liy the Dialcclic and I'liilan-tlirni>
ic Societies
\^bq- "S
This book must not
be token from the
Librory building.
Form No. 471
TWELFTH BIENNIAL REPORT
OF THE
NORTH CAROLINA
BOARD OF HEALTH
1907-1908
RALEIGH
E. M. UzzELL & Co., State Peintees and Bindees
1909
i
MEMBEKS OF THE BOAED.
ELECTED BY THE MEDICAL SOCIETY OF THE STATE OF
NORTH CAROLINA.
George G. Thomas, M. D., President Wilmington.
Terra Expires 1911.
Thomas E. Anderson, M. D Statesville.
Term Expires 1911.
David T. Tayloe, M. D Washington.
Term Expires 1913.
James A. Burroughs, M. D Asheville.
Term Expires 1913.
APPOINTED BY THE GOVERNOR.
J. L. Ludlow, C. E., Engineer Winston-Salem.
Term Expires 1909.
J. Howell Way. M. D Waynesville.
Term Expires 1911.
W. O. Spencer, M. D Winston-Salem.
Term Expires 1911.
Edward C. Register, M. D Charlotte.
Term Expires 1913.
Richard H. Lewis, M. D., Secretary and Treasurer. .Raleigh.
Term Expires 1913.
COUNTY SUPERINTENDENTS OF HEALTH.
Alamance Dr. H. M. Montgomery.
Alexander Dr O. L. Hollar.
Alleghany Dr. Robert Thompson.
Anson Dr. E. S. Ashe.
Ashe Dr. M. Blevins.
Beaufort Dr. D. T. Tayloe.
Bertie Dr. H. V. Dunston.
Bladen Dr. L. B. Evans.
Brunswick Dr. J. Arthur Dosher.
Buncombe Dr. D. E. Sevier.
Burke Dr. J. L. Laxton.
Cabarrus Dr. R. S. Young.
Caldwell Dr. C. L. Wilson.
Camden Dr. C. G. Ferebee.
Carteret Dr. W. E. Headen.
Caswell Dr. S. A. Malloy.
Catawba Dr. Geoi-ge H. West.
Chatham Dr. J. H. Taylor.
Cherokee
Chowan Dr. H. M. S. Cason.
Clay Dr. P. B. Killian.
Cleveland Dr. T. E. McBrayer.
Columbus Dr. H. B. Maxwell.
Craven Dr. Joseph F. Rhem.
Cumberland Dr. A. S. Rose.
Currituck Dr. H. M. Shaw.
Dare -
Davidson Dr. Joel Hill.
Davie Dr. M. D. Kimbrough.
Duplin Dr. John A. Ferrell.
Durham Dr. N. M. Johnson.
Edgecombe Dr. W. J. Thigpen.
Forsyth Dr. S. F. Pfohl.
Franklin Dr. R. F. Yarborough.
Gaston Dr. L. N. Glenn.
Gates Dr. Geo. D. Williams.
Graham Dr. M. T. Maxwell.
Granville Dr. S. D. Booth. V Greene Dr. W. B. Murphy.
Guilford Dr. Edmund Harrison.
4 LIST OF SUPERINTENDENTS.
Halifax Dr. I*. E. Green.
Harnett Dr. J. W. Halford.
Haj^woofl Dr. J. F. Abel.
Henderson Dr. .J. G. Waldrop.
Hertford Dr. J. H. Mitchell.
Hyde Dr. R. E. Windley.
Iredell Dr. M. R. Adams.
.Jackson Dr. A. A. Nichols.
.Johnston Dr. Ij. D. Wharton.
.Jones
Lee Dr. J. P. Monroe.
Lenoir Dr. C. L. Pridgen.
Lincoln Dr. R. W. Petrie.
McDowell Dr. M. L. Justice.
Macon Dr. S. H. Lyle.
Madison Dr. W. J. Weaver.
Martin Dr. W. E. AVarren.
Mecklenburg Dr. C. S. McLaughlin.
Mitchell Dr. Virgil R. Butt.
Montgomery Dr. J. B. Shamburger.
Moore Dr. Gilbert McLeod.
Nash Dr. J. P. Battle.
New Hanover Dr. W. D. McMillan.
Northampton Dr. H. W. Lewis.
Onslow Dr. Cyrus Thompson.
Orange Dr. C. D. Jones.
Pamlico
Pasquotank Dr. J. B. Griggs.
Pender Dr. Robert H. Bradford.
Perquimans Dr. T. P. McMullan.
Person Dr. W. A. Bradsher.
Pitt Dr. Joseph E. Nobles.
Polk Dr. Earle Grady.
Randolph Dr. S. A. Henley.
Richmond Dr. N. C. Hunter.
Itobeson Dr. H. T. Pope.
Rockingham Dr. Sam Ellington.
Rowan Dr. I. H. Foust.
Rutherford Dr. E. B. Harris.
Sampson Dr. Frank H. Holmes.
Scotland Dr. Iv. A. Blue.
Stanly Dr. J. N. Anderson.
Stokes
Surrv Dr. John R. Woltz.
LIST OF SUPERINTENDENTS.
Swain Dr. J. A. Cooper.
Transylvania Dr. Goode Cheatham.
Tyrrell
Union Dr. Henry D. Stewart.
Vance Dr. John Hill Tucker.
Wake Dr. J. W. McGee, Jr.
Warren Dr. M. P. Perry.
Washington Dr. W. H. Ward.
Watauga Dr. J. M. Hodges.
Wayne Dr. T. L. Ginn.
Wilkes Dr. John Q. Myers.
Wilson Dr. W. S. Anderson.
Yadkin Dr. S. L. Russell.
Yancey Dr. W. B. Robertson.
LETTER OF TRANSMISSIO^t,
North Carolina Board of Health,
Office of the Secretary,
Raleigh, June 15, 1909.
His Excellency, W. W. Kitchin^
Governor of North Carolina.
Sir :—I have the honor to present herewith the Twelfth
Biennial Report of the ITorth Carolina Board of Health.
Very respectfully,
Richard H. Lewis, M. D.,
Secretary and Treasurer.
TWELFTH BIENNIAL REPORT
OF THE
NORTH CAROLINA BOARD OF HEALTH.
1907-1908.
The past two years, from the sanitary point of view, have
been uneventful. Beyond an outbreak of typhoid fever of un-usual
severity in the little village of Council, Bladen County,
extending through two seasons, but limited in extent because
of the small population, there has been no epidemic worthy of
the name. Smallpox has continued to croj) out at various
times and points, but has been decidedly less in extent than
for several years, and of the same extremely mild type.
The most noteworthy event of the past biennial period is
the establishment of the State Sanatorium for Tuberculosis.
The General Assembly of 1907 passed an act authorizing its
establishment, and appropriated $15,000 for the purchase of
a site and erection of buildings and $5,000 annually for its
sujDport. While the amount appropriated was altogether
inadequate, it was nevertheless the beginning of what we hope
and have reason to believe will develop into an institution of
great value in the crusade now waging all over the civilized
world against man's most deadly enemy. Considerable dif-ficulty
was found in securing a satisfactory site, but finally
an excellent location with a clear title, in the pine-clad sand-hills
at Montrose, on the Aberdeen and Eockfish Railroad,
eight miles from Aberdeen, just across the Moore County line
in Cumberland, was obtained. We doubt if a site more nearly
ideal for the purpose can be found east of the Mississippi.
With a capacity of thirty-four, it was opened for patients in
Il^ovember, 1908, and has already done good work.
For an account of the work of the Board in detail, the
reader is referred to the pages following.
MEETINGS OF THE BOARD.
MINUTES OF THE ANA^UAL MEETIjSTG AT
MOEEHEAD CITY.
MoKEHEAD City, June 12, 1907.
The annual meeting of the Board was held in the Atlantic
Hotel, President Thomas in the chair. Members present:
Drs. Thomas, Battle, Way, Anderson, Spencer, Register,
Lewis (R. H.), and Colonel Ludlow.
The minutes of the last meeting were read and approved.
Dr. McCarthy, Biologist of the State Laboratory of
Hygiene, read his report. On motion, its consideration was
temporarily postponed, with the understanding that a report
of the action of the Board thereon would be made to him at
the end of the meeting.
On motion of Dr. Spencer, Dr. C. A. Shore was elected
Director of the Laboratory of Hygiene, at an annual salary
of $2,000. beginning January 1, 1908. "
On motion, the Treasurer was instructed to pay Dr. Mc-
Carthy, Biologist of the State Laboratory of Hygiene, the
sum of $500 for the purchase of his typewriter and to cover
all claims against the Laboratory for fees for special analyses
and for all other claims, as set forth in his report of this
date; and it was further ordered that his services be con-tinued
until March 1, 1908, at the rate of $2,000 per annum,
beginning June 1, 1907. This was accepted by Dr. Mc-
Carthy.
On motion, the salary of the chemical assistant in the
Laboratory, Miss Daisy B. Allen, was made $75 a month.
beginning July 1, 1907.
The Secretary having called attention to the fact that the
terms of office of all the members of the Board of Embalming,
by limitation or by change in the personnel of the Board of
TWELFTH BIENNIAL KEPORT. 9
Health, had expired, Messrs. Harry and Simpson, embalmers,
having held over, the follovs^ing were elected as members from
the Board of Health
:
Dr. J. Howell Way, Waynesville; term expires 1909.
Dr. E. C. Register, Charlotte; term expires 1908.
Dr. E. H. Lewis, Ealeigh; term exj)ires 1912.
The Secretary was instructed to prepare resolutions of
appreciation oft the valuable aid extended to the Board of
Health in its laboratory work by the State Board of Agricul-ture
and to make them a part of these proceedings.
The President was requested to appoint, at his convenience,
the committees for the inspection of the public institutions
of the State.
Adjourned after midnight, to meet again in the morning.
EicHAED H. Lewis,
, Secretary.
MoEEHEAD City, June 13, 1907.
The Board reassembled with the same members present as
the night before.
On motion of Colonel Ludlow, the Secretarv was instructed
to obtain a United States Geological Survey field outfit for
water analyses, with the necessary su]3plementary apparatus
for the bacteriological examinations of water supplies, and to
employ in emergency a suitable man to make the examina-tions
whenever in the opinion of the Engineer and the Secre-tary
it might be deemed advisable.
On motion. Colonel Ludlow and the Secretary were elected
delegates to the American Public Health Association.
The term of office of the Secretary having expired at this
meeting by limitation. Dr. Way nominated the present in-cumbent
and moved that the Present be instructed to cast
the ballot, there being no other nomination. The motion
was carried, the President cast the ballot of the Board and
the present incumbent was re-elected for a term of six years.
10 NORTH CAROLINA BOARD OF HEALTH.
The Treasurer presented his reports, with vouchers, for
the Board of Health and for the Laboratory of Hygiene.
Colonel Ludlow and Dr. Anderson were appointed by the
President a committee to audit the same.
The engineer of the Board was requested to continue his
supervision of the public water supplies.
The auditing committee reported that they had examined
the accounts of the Treasurer and found thent correct.
On motion, the Board adjourned to meet at 12 M. to-mor-row
in conjoint session with the State Medical Society.
RiCHAKD H. Lewis,
Secretary.
CONJOINT SESSION
WITH THE
STATE MEDICAL SOCIETY AT MOREHEAD CITY,
JUNE 12, 1907.
The conjoint session of the State Board of Health with the
State Medical Society, according to custom, was held at 12 M.
on Jnne 12, the second day of the meeting of the Society.
Dr. George G. Thomas, President of the Board of Health,
in the chair.
REPORT OF THE SECRETARY.
The Secretary read his annual report, as follows
:
ANNUAL REPORT OF SECRETARY OF THE NORTH CAROLINA
BOARD OF HEALTH, MAY 1, 1906, TO MAY 1, 1907.
During the past year we have suffered uo special outbrealc of dis-ease
and the liealtb of our people in general has been about as usual.
A detailed statement of the work of the Board will be found in the
Eleventh Biennial Report, which has been for months and still is in
the hands of the printer. A copy will be sent to any one asking for
it as soon as it is published.
The work of your Secretary has been for the most part of the
usual routine character, special attention having been paid to the
further distribution of the pamphlets on the prevention of tuber-culosis.
The indications are that the wide circulation of this publi-cation
has made an impression upon our people and has been of real
assistance in the campaign against this most fatal of all our diseases.
I am satisfied that the plan adopted of sending the pamphlet direct
to the individual, with a letter urging him to read it and to assist
in its distribution, has added much to its effectiveness. Over 100,000
copies have been mailed to date, and I am confident that no expendi-ture
of our meager appropriation has brought forth better results
than that paid out for the postage on this pamphlet.
With January came the meeting of the General Assembly, which
is always a period of mingled hopefulness and anxiety. While the
attitude of the last Legislature was. perhaps, less friendly to our
license law than has been the case for many sessions, its interest
in the public health was more pronounced than usual—an interest
that was not simply academic, but one that did something worth
while. In The Bulletin for April I printed all the acts of general
12 NORTH CAROLINA BOARD OF HEALTH.
interest bearing on the iDublic health, both directly and indirectly,
but it may not be amiss to refer again in this place to the more im-portant.
The act creating the State Laboratory of Hygiene, which carried
no annual appropriation from the general fund for its support, was
so amended as to give it two thousand dollars annually ; at the same
time increasing the annual tax of sixty dollars upon water com-panies
by four dollars. This latter does not materially increase the
income of the Laboratory, but all the companies would not pay
expressage on water samples, and the four dollars were added to
cover that. With the tax from the water companies, nov.^ numbering
fifty-one and gradually increasing year by year, the income will be
sufBcient, with the money on hand, to adequately equip and conduct
an excellent laboratory without outside help. In this connection it
is proper to call attention again to the fact that without the generous
aid given us by the Board of Agriculture we, in all probability,
would not liave had any laboratory at all. It should be remembered
that at first the Board of Agriculture had biological analyses of
drinking-water made for us in their laboratory free of charge—
-
until the water tax was obtained four years ago—and that since
that time it has, in addition to furnishing the Laboratory with gas
and water, paid $750 a year towards the salary of the Director.
I hope suitable acknowledgment of the enlightened liberality of the
Board will be made by the conjoint session. The report of the Direc-tor
for the past year is appended.
In order to extend the benefits of the Laboratory as far as possible
to the people, an act was passed authorizing the preventive treat-ment
of rabies by the Director—who, in the reorganization, will
doubtless be a thoroughly trained medical man—when it can be
done without interfering with the legitimate work of the Laboratory
proper.
A decided advance in State medicine was marked by the enact-ment
of the bill establishing a sanatorium for tuberculous patients,
appropriating $15,000 for a plant and $5,000 annually for support.
The chief credit for this particular legislation is due to Dr. .J. E.
Brooks, of Greensboro, who was "the man behind the gun," and the
Hon. J. R. Gordon. M. D.. member from Guilford of the House of
Representatives, who was mainly instrumental in securing its pas-sage.
Acknowledgment of this was made by the Board of Directors,
of which the Secretary of the Board of Health is ex offlcio a member,
at their first meeting, in the election of Dr. Gordon Chairman of the
Board and Dr. Brooks Superintendent of the Sanatorium. While
the appropriation is very small, it will provide for a beginning, and
as the Superintendent is not only an intelligent and capable physician,
but an enthusiast on the subject. I feel confident that it will succeed.
As the competency of our physicians is of the highest importance
TWELFTH BIENNIAL KEPOKT. 13
to the public health, anything bearing upon our medical license
law is of importance to us. During the session of the Legislature
bills for the relief of physicians in Cherokee, Clay, and Graham
counties and in Chatham County were enacted into laws. In the
one case physicians having diplomas were allowed to practice without
license until May 1, 1909, and in the other simply to stand the exami-nation
for license without exhibiting a diploma. The reason given
for this legislation was the same in both cases—that in the remote,
sparsely settled, and physically rough regions physicians so well edu-cated
as to meet the requirements of our very high standard had not
settled, and that unless such action was taken the people in the
affected regions would be without medical aid. While actively op-posing
the first-named bill for fear it might be an entering wedge
threatening the integrity of our license law, I could not deny the
facts, nor iu my own mind deny the inherent reasonableness of the
contention in the light of those facts. It was indeed the realiza-tion
of what we have been anticipating, and I was thoroughly im-pressed
with the importance of devising some means of practically
lowering the standai-d to meet such conditions lest our license law
should be emasculated in the near future. As a means to this end
I approved, as Chairman of the Society's Committee on Legislation,
the passage of a bill authorizing the Board of Medical Examiners
to reciprocate with other States in their discretion. I welcomed this
bill the more gladly because it enabled me to secure the voluntary
suppression by its author of another bill requiring the Board of
Examiners to grant licenses to any one presenting a diploma from
the American Association of Medical Colleges and a license from any
State. As the standard of some States is extremely low, and in
nearly all lower than in ours, the passage of this bill would have
practically repealed our license law and have undone the work of
fifty years for the elevation of our profession and the protection of
the people against incompetent physicians. Before the present meet-ing
of the Board of Medical Examiners I addressed a circular-letter
to each member of the same, calling attention to the conditions
above set forth and to the importance of action on their part to meet
them as far as possible, suggesting reciprocation with the low-standard
States when the conditions for this concession demanded
it, and also that it would probably be well to lessen the rigor of the
examination somewhat by granting certificates on the branches
passed, and thereby encourage men to come a second time and finish
up successfully rather than give up in despair and take the chances
of practicing illegally. I was, therefore, much gratified to learn from
President Kent, who stopped over in Raleigh on his way to the meet-ing
for the purpose, that he had secured from the Assistant Attorney-
General an opinion to the effect that it would be legal for his Board
to grant a license and to require the recipient to sign a contract to
14 NORTH CAROLINA BOARD OF HEALTH.
restrict his practice to a certain county or section, the Assistant
Attorney-General writing out the form of the said contract. The
judicious use of this privilege will, I think, solve the problem.
SMALLPOX.
I am very glad to state that smallpox has been very much less
prevalent. In 1905 the total number of cases was 7,.37.5 with 31
deaths ; in 1906, 6.049 cases and 17 deaths, while during the year
ending May 1, 1907. the total number of cases was only 1,897 with
6 deaths. The following is a tabulated statement of the disease by
counties
:
SMALLPOX REPORT, FRO^NI MAT 1, 1906, TO MAY 1, 1907.
Counties.
Alamance —
Anson
Ashe*
Bertie
Bladen*
Brunswick -
Cabarrus
Carteret
Catawba
Chatham
Cherokee—
Chowan*
Cleveland —
Columbus -—
Cumberland -
Currituck --.
Davidson
Duplin
Durham
Forsyth
Franklin* —
Gaston
Granville
Guilford
Halifax
Number of Cases.
White. Colored.
24
10
15
5
12
5
1
2
1
12
2
100
4
1
19
22
6
64
24
9
10
2
5
2
74
10
11
3
30
6
15
1
200
1
4
7
12
50
*91
4
5
94
1
Total.
98
20
15
16
15
35
7
2
1
27
3
300
4
2
23
29
6
12
114
24
*100
14
7
99
3
Number of Deaths.
White. Colored. Total.
TWELFTH BIENNIAL REPORT. 15
SMALLPOX—Continued.
Counties.
Harnett
Hertford
Lincoln
Martin
Mecklenburg
Moore
Nash
New Hanover
Northampton
Orange
Person
Pitt
Randolph
Richmond*
Robeson
Rowan
Rutherford
Stanly
Vance
Wake*
Warren
Washington*
Wayne
Total in forty-eight counties -
Death rate, per cent.
Number of Cases.
White. Colored.
18
15
17
20
4
4
10
25
13
26
7
10
3
4
8
67
4
620
4
30
Total.
100
4
23
65
6
1
5
272
2
20
190
1,348
22
45
17
120
8
27
10
1
3
25
1
13
91
13
10
6
4
1
13
339
6
28
190
1,968
Number of Deaths.
White. Colored.
.003-;-
Total.
.002- .003-
' Estimated.
In compliance with the instructions given the Secretary
at the meeting of the Board the night before, he presented
the following resolutions of appreciation of the great serv-ice
rendered the cause of the public health by the State
Board of Agriculture in having made for the Board in its
laboratory sanitary analyses free of charge for two years and
upon payment by the Board of Health of half the salaries of
16 NORTH CAROLINA BOARD OF HEALTH.
the Biologist and his assistant for four years longer, the
Board of Agriculture defraying all other expenses of the
laboratory, which were unanimously adopted:
Resolved, by the North Carolina Board of Health and the Medical
Society of the State of North Carolina in conjoint session assembled:
1. That as the special custodians of the health and lives of our
people they desire to place on record their appreciation of the gener-ous
assistance in preventing disease, given by the State Board of
Agriculture in the use of its laboratory, including the services of its
bacteriologist, for making analyses of drinking-water suspected of
causing typhoid fever, and other hygienic analyses, bearing all the
expenses for two years and fully half for four years more, until funds
could be secured for its support.
2. That the benefit to our people in the prevention of typhoid
fever alone has, if computed in terms of dollars, exceeded many
times over the amount expended, and they owe a debt of gratitude to
the Board of Agriculture that should ever be remembered.
3. That these resolutions be spread upon our records and that a
copy be sent to the Commissioner of Agriculture, with the request
that he transmit it to his Board at its next meeting.
[Owing to the failure of the stenographer employed by
the Medical Society to furnish his report to the Secretary
of the same, there is no record of the discussions.]
Mli^UTES OF THE ANXUAL MEETING AT
WIXSTON-SALEM.
Wiis'ston-Salem^ jST. C, June 16, 1908.
Annual meeting. Present : Drs. Thomas, Anderson, Way,
Spencer, Register and Burroughs, Colonel Ludlow and the
Secretary,
The minutes of the last meeting were read and approved.
Dr. Shore, Director of the Laboratory of Hygiene, read
his report.
On motion of Dr. Spencer, the Secretary was authorized
to employ an assistant bacteriologist.
The Secretary stated that by allowing part of her time
to the Laboratory, he had reduced the cost of the stenographer
to the Board from $35 to $25 a month.
On motion of Dr. Way, the Secretary and such other mem-bers
as may attend were appointed delegates to the next
meeting of the American Public Health Association, their
expenses to be paid, if there should be money enough in the
treasury after meeting the regular charges thereupon.
The President was authorized to appoint, at his con-venience,
committees to make the regular inspections of the
State institutions,
Drs, Spencer and Register, who were appointed as auditing
committee, reported that they had examined the accounts of
the Treasurer and found them correct.
On motion, the Board adjourned, to meet in conjoint ses-sion
with the State Medical Societv at 12 M, to-morrow,
RiCHAED H, Lewis,
Secretary.
CONJOINT SESSION
WITH THE
STATE MEDICAL SOCIETY AT WINSTON-SALEM,
JUNE 17, 1908.
The State Medical Society was called to order at 3 :30
with the President, Dr. J. Howell Way, in the chair.
The Peesident: The Society will be in order. We will
now have the conjoint session of the State Medical Society
and the State Board of Health. Gentlemen, I present the
President of the State Board of Health, Dr. George G.
Thomas, who will preside over the conjoint session.
Dr. Thomas: The conjoint session is now open for bns^i-ness.
We will be glad to have the report of the Secretary.
ANNUAL REPORT OF THE SECRETARY OF THE NORTH CARO-LINA
BOARD OF HEALTH—MAY 1. inOT. TO MAY 1. 190S.
The health conditions of our State during the past year have been
marlvPd by nothing out of the common run, and the worlv of your Sec-retary
has been chiefly routine. There have been some small epi-demics
of typhoid fever, and an investigation by the Board was re-quested
by County Superintendent of Health Evans of one at Coun-cil,
in Bladen County, and by Mayor Montgomery, of Reidsville. of
an outbreak in that town. The former was investigated by President
Thomas and the latter by Engineer Ludlow. Their re.spective reports
are appended.
Tuberculosis has lost nothing in importance or interest. Our dis-tribution
of literature on the subject has. I believe, borne fruit in the
education of the people as to the best methods of preventing its
spread. In August last, at the request of the authorities, a committee
of the Board visited the State Hospital at Morganton and advised
with the management as to the location of special quarters for tuber-culous
patients. Their report is appended.
Although not under the control of the Boai'd of Health, its Secretary
is, ex offlcio, a member of the Board of Directors of the State Sana-torium
for Tuberculosis, and a review of the health conditions of the
State would not be complete without reference to it. Its establish-ment
was authorized by the last Legislature, hut it has been un-avoidably
delayed by the inability to secure a site suitable to the per-manent
establishment of so important an undertaking. Fortunately,
TWELFTH BIE:XNIAL REPORT. 19
the necessary abandonment of one or more locations fixed upon, owing
to the inability to secure a sound title, finally resulted in the selection
and purchase of as nearly an ideal site as can well be imagined.
Situated in the sandhills of Cumberland County, about eight miles
from Aberdeen, it is traversed by the Aberdeen and Rockfisb Railroad,
and is, therefore, easy of access. The purchase contains about nine
hundred acres, and its highest point, which has been selected for the
location of the buildings, overlooks a wide panoramic view of at least
three-fourths of a circle of miles upon miles of rolling pine forest.
Work has been begun on the buildings, and it is hoped, I am told by
Dr. Brooks, the Superintendent, that patients can be received in the
early fall.
The International Congress on Tuberculosis, which is to meet in
Washington, September 21st to October 12th. is an event of world-wide
interest and will well repay a visit. I hope that many of our
health oflicers and physicians will attend.
Smallpox has been slightly more prevalent than during the pre-ceding
year, the record being 2,011 cases, with 8 deaths, against 1,968
cases and 6 deaths in 1906-'07. During the past year the disease has
been much more prevalent among the whites than among the negroes,
which is just the reverse of the year before. To state it accurately
:
In 1906-'07 there were 620 white cases, with 2 deaths, and 1,348 col-ored
cases, with 4 deaths; while during the past year there were
1,168 white cases, with 6 deaths, and 843 colored cases, with 2 deaths.
The number of counties infected was just the same in each year—48.
Owing to its continued mildness, and the fact that it has become such
an old story—just ten years old—it produced little concern and prac-tically
no interference with business. The following is a tabulated
statement, by counties
:
SMALLPOX REPORT, FROM MAT 1, 1807, TO MAY 1, 1908.
Counties.
Alamance*
Alleghany -
Beaufort --
Bertie
Buncombe -
Burke
Cabarrus --
Catawba-—
Chatham --
Number of Cases.
White. Colored. Total
75
6
2
6
4
89
1
20
60
22
135
6
7
6
3
4
111
1
23
Number of Deaths.
White. Colored. Total,
20 NORTH CAROLINA BOARD OF HEALTH.
SMALLPOX—Continued.
Counties.
Chowan
Cleveland
Columbus
Cumberland --.
Currituck
Davidson
Davie
Durham
Edgecombe* —
.
Forsyth
Gaston
Gates
Guilford
Halifax
Harnett
Iredell
Jackson*
Johnston
McDowell
Madison
Mecklenburg
-
Mitchell
New Hanover
Nash
Orange
Pasquotank —
Pender
Randolph
Robeson
Rockingham—
Rowan
Rutherford
Sampson
Wake
Warren
Number of Cases.
White.
100
8
2
1
32
7
1
12
14
6
109
9
10
75
150
3
37
16
40
9
2
5
3
14
4
3
48
11
2
29
Colored.
100
17
55
1
192
5
72
1
4
75
19
25
2
59
45
5
1
51
6
Total.
200
8
3
1
49
7
55
2
12
206
6
5
181
1
13
10
75
225
3
37
21
40
28
2
30
2
3
14
4
62
93
16
3
80
6
Number of Deaths.
White. Colored. Total.
TWELFTH BIENNIAL KEPORT 21
SMALLPOX—Continued.
22 NORTH CAROLIIVA BOARD OF HEALTH.
a compptent assistant, as the diveolor. even now. has all his time
occupied in the general work ; but we can now afford it, and we recom-mend
it. The repoi't of the Director of the Laboratory accompanies
this. As the Laboratory is intended for the benefit of the people,
through the medical profession, it is hopetl that the physicians will
freelj' avail themselves of its help.
Dr. Thomas : Gentlemen, you have heard the report. Are
there any remarks thereon? Then, if there is no objection,
the report will go on file.
Gentlemen, it is my pleasure to introduce to you Dr.
Charles Wardell Stiles, Ph. D., Chief of the Department of
Zoology of the United States Public Health and Marine
Hospital Service, who will give you a special address on
"Soil Pollution, with special reference to Hookworm Dis-ease."
Dr. Stiles : Before passing to the reading of my i)a]ier
I wish to say that Surgeon General Wyman sends his l)est
regards to the Association, with his best wishes for a success-ful
meeting.
I have taken the liberty of changing my paper somewhat,
although I shall speak on the same general subject as in the
program. The title of my paper reads
:
THE MEDICAL INFLUENCE OF THE NEGRO IN CONNECTION
WITH ANEMIA IN THE WHITE.
Mr. Fkesident and Gentlemen:—In responding to your kind invi-tation
to return to North Carolina and to address your meeting, I
invite your attention to a certain phase of the same subject upon
which I spoke before you several years ago. In my former address
I discussed the general subject of hookworm disease. To-day I wish
to speak on the negi'o as a factor in the spread of this malady, and
his resulting influence upon the health of the white race. In bringing
this subject before you, it is needless for me to state that I appeal to
no race prejudice, but that I simply bring forward certain harsh, cold,
scientific facts, which must be faced, not only in the interest of the
white, but in the interest of the negro as well.
As many of you know, I have for some years past lieen especially
interested in studying medico-zoological conditions in the rural dis-tricts
of the South, and this work has led me to spend about a year
living among the tenant whites. During these studies I have made
TWELFTH BIENNIAL, REPOKT. 23
inquiries among all classes of people regarding their ideas relative to
the origin of the present impoverished financial and physical condition
of the "crackers," "sandhillers" and "harrenites," and the information
obtained, combined with my own investigations, has led me to a con-ception
of these people which is not altogether in harmony with the
general opinion entertained regarding them. So far as I can analyze
the subject, these people are the joint product of certain medical and
industrial conditions, as follows
:
In ante-helium days, if a man was wealthy enough to own slaves,
he was wealthy enough to own good plantation land. If not wealthy
enough to own slaves, it is not reasonable to assume that he could buy
the better class of farms. The latter people, therefore, would natu-rally
be forced into the poorer lands, if owners, or to serve as over-seers,
to become tenants and, in general, to compete with slave labor.
Such seems to me to be the most reasonable of the several explana-tions
I have heard regarding the origin of these people. In different
parts of the South they are known as "shad-bellies," "poor Bukra,"
"poor whites," "crackers." "sandhillers," "sand Billies," "barrenites,"
"poor .Johns," etc.
The old-time negro had a great contempt for the white man who
could not own a slave, and this contempt culminated in the expression,
'•poor white trash." This same contempt is reflected in the negro
song, "I'd rather be a nigger than a poor white man."
The expression, "poor white trash," has become very well known,
despite its offensive character, and, unfortunately, the average more
fortunate whites, both those who know these people and those who
have not seen them, have too commonly allowed their judgment of
these people to become somewhat clouded by the judgment formed by
the old slaves. In fact, very few persons have any sympathy -for
these people, who have been repeatedly referred to in my presence as
"lazy," "shiftless." "good for nothing." "indolent," "untrustworthy."
etc. One Southerner whom I recently met stated that he had had
twenty-five years' experience with them, and that he considered "they
were not worth trying to help." He was kind enough to inform me
that I was wasting my time in living among them and studying their
conditions. This reflects in an exaggerated form the average opinion
I have encountered during my studies among these people, now car-ried
on at various intervals for nearly six years, the total study-amounting
to about one year's time.
Actual experience among them for the purpose of scientific study,
and actual association with them, involving sleeping in their homes,
board with the "dirt eater" and "snufC dipper." playing with their
children, visiting their schools, seeing them on farms, in mines, in
mills, hospitals and orphanages, have led me to a conception of them
which is different from the opinions just mentioned, and I am forced
to take radical issue with any person who looks upon them as "lazy,"
24 NORTH CAROLINA BOARD OF HEALTH.
"iudoleut" 01' "good for nothiug," and I cannot refrain from expressing
surprise that any man should have twenty-five years' experience with
them and use so little intelligence and acumen as to come to the con-clusion
that tlioy are "not worth trying to help."
Since these people are peculiar to the South, in order to understand
them it is necessary to understand certain other factors which are
peculiar to this same region. There are three factors in particular
which come into consideration, namely: (1) the area under discus-sion
presents the most intense negro population of any part of the
country; (2) this area also presents the area of most intense hook-worm
infection; and (3) the same area presents the most intense
malaria infection of any portion of the country. The question now
arises
:
In what relation do these four factors (the tenant white people, the
negroes, hookworms, and malaria) stand to one another?
I need not argue to you the fact that both hookworm disease and
malaria are found both in the white and in the negro, for this is well
established. I may. however, invite your especial attention to an
important point, too often overlooked, namely, that these two great
anemia-producing diseases which are so severe on the white are rela-tively
less severe on the negro race. This fact, that the negro pre-sents
a relative immunity to the physical effects of these two infec-tions
which are so common to his race, is one of very great impor-tance,
for it points us to a conclusion from which there is no escape,
namely, that the negro va.ce, forms a great reservoir for the supply of
these infections.
Take malaria, for instance. It is a well-established fact that the
malaria parasite is exceedingly common in the blood of negroes. It is
a fact of common knowledge, which can be easily verified by any
doii])ting Thomas, that the negro does not trouble himself very much
to screen against mosquitoes. What is the result? Since the negro
does not suffer from the effects of this infection so severely as does
the white, the negro is not so likely as the white to come under medi-cal
treatment ; accordingly, he is more likely to form a source of
infection to the mosquito ; add to this the fact that he does not screen
against mosquitoes so much as does the white, and it is clear that rel-atively
he forms a greater source of infection to the mosquito than
does the white. Now. let a v\-hite man take what precautions he will
against malaria in his family, the mosquitoes in the negro's house on
the back street still form for this white man's family a source of
danger, over which he has practically no control. The conclusion is
evident : Theoretically and pi'actically. the negro race, living side by
side with the white race, is, when viewed from the standpoint of
malaria, a great and serious reservoir of infection.
Take next hookworm disease. A given infection with this disease
may put a white person in his grave or may make him so sick that
TWELFTH BIEX^'IAL REPORT. 25
he remains at home, and it is likely to bring him under medical treat-ment.
Tbus this infection is either brought to an end or it is more
or less confined to the immediate premises of this particular family.
That same infection will produce less serious phj-sical results on the
uegro, who will, therefore, not be so likely to be confined at home,
and he will not lie so likely to come under medical treatment. The
conclusion naturally is that, relatively, the negro is, and from theo-retical
conditions necessarily must be, a greater spreader of hook-worm
disease than is the white man.
The immense importance of this latter fact can be seen when we
compare the white and the negro as a soil polluter. In this connec-tion
I would state that I have collected statistics for 3G6 farmhouses
in North Carolina, South Carolina, Georgia and Alabama, and I find
that of these 366 cases only ll.j houses, or 31.4 per cent, were pro-vided
with jH-ivies of any sort ; in other words, 251 of these houses, or
68.5 per cent, had no privy, and on this account the soil pollution on
these premises reached a theoretical maximum. Of the 306 farm-houses
in question my records show that 73 were occupied liy whites
and 83 by negroes, but I have no record of the race of the occupants
of the remaining 210 houses. Of the 73 houses occupied by whites
56.1 per cent, or 41 houses, had privies, and 43.S per cent, or 32
houses, were without privies. Of the 83 negro houses 20.4 per cent,
or 17 houses, had privies, while 79.5 per cent, or 66 houses, had no
privy. In other words, the theoretical maximum of soil pollution was
reached in 43.8 per cent of the houses occupied by whites and in 79.5
per cent of the houses occupied by negroes. From these statistics it
would appear that the negro is nearly twice the soil polluter that the
white man is, and this conclusion is in harmony with what we know
of the generally poorer condition (jf the negro privy, when one is pres-ent,
and also with the complaints so often made regarding the pollu-tion
of alleys in cities by the negro.
Comparing the white and the negro, numerically, as an inhabitant.
we find that in the States of Virginia, North Carolina, South Carolina,
Georgia, Florida, Alabama. Mi.ssissippi and Louisiana the average
ratio is 1,000 whites to 833 negroes. The ratio in these States varies
between 1.000 whites to 494 negroes in North Carolina and 1.000
whites to 1,415 negroes in Mississippi.
From the foregoing data it is seen that in the area under discussion
we have the following combination
:
(1) Two races (whites and negroes) are living side by side.
(2) As inhabitants they bear the ratio of 1.000 whites to 833 negroes
(a proportion of negroes far in excess of what exists in other States).
(3) As soil polluters they bear the ratio of 438 (in whites) to 795
(in negroes).
(4) Two diseases (hookworm disease spread by soil pollution, and
malaria spread by mosquitoes) are present in high percentages.
26 NORTH CAROLINA BOARD OF HEALTH.
(5) Those anemia-producing diseases are especially' severe on the
white, hut relatively less severe on the negro.
To my mind, the foregoing combination of facts leads inevitably to
the conclusion that the white race in the South is living under a
hygienic handicap which is not paralleled in any other part of the
country, and, were it not for the greater intelligence and better finan-cial
condition of the whites, whereby they are able to protect them-selves
more or less against these diseases by sanitary measures, it
would be only a question of a few generations before this handicap
would exterminate the whites from those portions of the South which
are especially favorable to these infections.
The whites of higher education and in better financial condition are
able to protect themselves against this handicap, the burden of which
has, therefore, fallen more especially upon that class (namely, the
rural white tenant class) which has been kept in financial impoverish-ment
through generations of competition with negro labor ; and the
result is exactly what theory demands it should be, namely, the pres-ent
impoverished physical condition of so many thousands of the ten-ant
white people, especially those living in the sandy and mountainous
districts, where the sanitary arrangements are so inferior.
The physical condition of these people can be appreciated only by
persons who have been among them. Those of us who have lived
among them need not be surprised to find their blood from 10 to 70
per cent below normal, nor need we be surprised, upon entering a
poor farm hovel, to foresee death, in many instances, in 40 per cent
of the children (namely, 2 of the 5, or 4 of the 10 children of the
family) before they reach twenty-one years of age. I visited one
farm on which I found father, mother, five children, and fifteen chil-dren's
graves. I asked the physician what had killed these fifteen
children, and he replied : "I do not know what the disease is, but if
you can tell me what is killing fJiat girl there, you will know what
killed the other fifteen children." "That girl there" was a severe case
of hookworm disease, in the dirt-eating stage. Think of it. gentle-men
; 75 per cent of the rising generation of this family had already
paid the extreme penalty of soil pollution, and one further member of
the family already had one foot in the grave!
Gentlemen, let any one call me a theorist if he will, but, in all fair-ness
to the tenant white class of the rural sand and piney-woods dis-tricts
of the South, let him first see the sights I have .seen before he
makes fun of those people and before he jokes about their sick and
dying women and children. Before any man who claims to be hu-mane
considers these people "lazy," "good for nothing" and "not
worth trying to help," let him reflect upon the following statistics,
based on about 10,000 examinations I have recently made among this
class of people
:
TWELFTH BIENNIAL REPORT. 27
(1) At least 13 per cent (women over 20 years) to IS per cent
(girls 16 to 20 years) of these women of maternity age are suffering
from the anemia-producing hookworm disease, which prevents them
from properly nourishing their habes.
(2) Of the girls under 16 years, at least 18.7 per cent have this
same infection, which thus adds a serious strain upon their bodies (in
addition to the strain incident to their sex) and which tends to re-tard
their physical development, so that many of them reach maturity
two to five years late ; and even after they have reached maturity this
disease renders them irregular in their menstrual functions.
(3) Of the boys under 16 years, at least 24.9 per cent have this
same infection, which inliiliits both their physical and their mental
growth.
(4) Of the boys 16 to 20 years, 20.7 per cent, and of the males over
20 years, 5.8 per cent, show these same symptoms, which decrease
their labor capacity and their military efficiency.
Now, my friends, in all kindness, let me submit to you a question
for thoughtful consideration : Nearly half a century ago the country
freed the slaves, but in these decades that have elapsed since then
uhat has our couiitri/ done in order to hetter the conditions of the
tens of thousands of the rural tenant ichites xoho have been kept in
financial poverty through competition tcith negro lahor, and in physi-cal
poverty through the tico great anemia-producing diseases for
which the negro forms the great reservoir of infection?
All honor to the few noble men and women who, by great personal
sacrifice, are struggling to support efforts looking to a betterment of
their condition; all honor to the few physicians who have let it be
known that they will treat hookworm cases among thes-e people with-out
professional fee ; all honor to the Southern cotton mill which is
enabling thousands of these people to earn an honest living and thus
to uplift themselves. But think a moment. In comparison icifh what
this country is doing for the negro of the ^^outh, for the Chinaman in
Asia, and for other people of different races, ivhat is our country
doing in order to elevate these tens of thousands of people of our own
race in our own country?
Does it tend to elevate them if we refer to them as "lazy" and as
"good for nothing"? Would it not help them more if we could send
to the chain gang people who indulge in that kind of pseudo-wit?
Gentlemen, there is a rational solution to the problem before us, and
I submit to you for consideration a plan which I maintain is well
founded from a theoretical point of view, and feasible from a practi-cal
point of view. It is the same plan which I submitted a few days
ago to the Alabama State Medical Association, and which the Asso-ciation
has unanimously endorsed. It is this
:
Let us start out on the general principle that it is much easier to
teach children than adults. With this truth in mind, I propose the
28 NORTH CAROLINA BOARD OF HEALTH.
introfluftion of a "Public Health Week" into every schoolroom in the
South. During this week let us utilize the class in physiology, in
order to teach to the children the three great and fundamental princi-ples
of public health so important for the South. These principles
are:
First. Do not spit on the floor, for this habit spreads tuberculosis
and diphtheria.
Second. Do not pollute the soil, for this habit spreads typhoid fever
and ground itch, with its resulting hookworm disease.
Third. Protect against mosquitoes-, for mosquitoes spread malaria,
yellow fever, dengue, and elephant foot.
Besides working through the schools, let us use every other means
by which we can carry on a merciless campaign against soil pollution.
In the last analysis, soil iwllution is an evil in itself; it is in the
nature of "malum in se" ; it is an "aggravated offense against the pub-lic
welfare" ; hence it should be prohibited and made a crime, and any
person guilty of polluting a highway or back alley should be sent to
the chain gang.
Let us extend this campaign to the farms especially, and, if possible,
persuade, but, if necessary, compel, the farmer to build a sanitary
privy and to keep it clean.
Let us appeal to the clergy, to the lawyers, to the business men, and
especially to the school teachers and the mothers, to join in this cam-paign.
If I can gain the mothers of the South for this movement, and
be given a chance to do so, I will agree to practically eradicate hook-worm
disease from the South in one generation's time, and by this
eradication I will agree to elevate the condition of the rural tenant
whites.
In conclusion, gentlemen, let me emphasize a very important point
in the plan I propose, namely, that it is absolutely necessary to avoid
any distinction between the whites and the negroes in this campaign
of sanitary education, foi*
—
(a) The white man who fails to recognize the important necessity
of improving the sanitary conditions under which the negro is living
fails to go to the root of the evil, and he unconsciously invites disease
and death, especially to the women and children of his own race
;
while—
(h) The negro who fails to recognize the important necessity of
improving the sanitary conditions under which the negro is living
overlooks the fact that he is placing a very serious handicap in the
way of a higher mental development of his race ; for the point must
not be forgotten that hookworm disease, in addition to its physical
effects, to which the negro is relatively immune, has also a serious
effect upon the mentality, and it has not been shown that the negro is
immune to this latter effect.
TWELFTH BIENNIAL REPORT. 29
Dr. Thomas : I would like to say that I owe Dr. Stiles an
apology for my error in introducing him. He is well known
to this Society.
Db. Julian : I am sorry that I did not get here in time to
hear this very valuable paper of Dr. Stiles' ; but some years
ago Dr. Stiles came to my town and assisted me in eradicating
hookworm disease at the Thomasville Orphanage. At the
time he assisted me he was satisfied the box privy was the
source of the epidemic. I reported the matter to the trustees.
We pulled down the box privies, dug a deep well, have water
throughout the building, and after a few months we have
never seen a case of the disease.
Dr. Lewis : I wish to call to the attention of the Society
that the Laboratory, as it already knows, is ready to make ex-amination
of the faeces. All they have to do is to write the
Laboratory at Ealeigh for a container and send a sample of
the faeces to the Director of the Laboratory.
Dr. Julian : The examination is very easily made by any
doctor who is acquainted with the microscope, by introducing
the finger into the rectum, getting a small amount of the
fseces, placing it on the slide, and in a few drops of water.
Dr. Thomas : We will now have an address by Dr. Tait
Butler, State Veterinarian of IvTorth Carolina, on
OUR MILK SUPPLY AND SOME OF ITS RELATIONS TO
PUBLIC HEALTH.
In accepting the invitation of your Secretary, Dr. Lewis,, to read a
paper at this meeting on the public or marlcet millv supply of the State,
I did so with a distinct purpose in view. It is, perhaps, telling no
secret, and it is certainly not meant offensively, if I state that the
average practicing physician is none too familiar with the real prob-lems
involved in putting into the hands of consumers a wholesome
milk supply. But this, in my opinion, is not of great importance. It
Is not necessary, however desirable, that the physician possess expert
dairy knowledge or that he be capable of performing the duties of a
scientific dairy inspector. A much more important matter, as affecting
any effort for the improvement of our milk supply, is that he have a
full and accurate knowledge of the real importance of pure milk for
the consumption of those under his care.
30 NORTH CAROLINA BOARD OF HEALTH.
Many of those here have given special study to this suhject. Others
who are investigators have full knowledge regarding certain phases
of it, but the general practitioners have not given that attention to the
subject which its importance demands. Moreover, the general prac-titioner
gets closer to the public than any other man, and it is through
him that the general public can be best reached ; therefore, in this
paper I have decided to talk to the general practitioner and to assume
the part of an agitator rather than an educator.
All freely admit the importance of a wholesome milk supply as a
general proposition. But how many know fully and accurately the
awful results of our criminal neglect in the past along this line?
How many have an accurate knowledge of the quality, or lack of
quality, of the milk now being sold throughout the State? How many
i-ealize the full measure of filth which it carx-ies, and what that
means in misery and death to the innocent babes who must con-sume
it?
Gentlemen, it is not the ravings of a fanatic nor the extravagance
of a sensationalist, but a conservative statement of terribly serious
facts when I say to you that the almost total ignorance of dairy
science on the part of our milk producers, the lack of knowledge of
what constitutes first-class milk, and the care it should receive on the
part of consumers, and the almost criminal indifference and inertia of
the medical profession, who are the accepted guardians of the public
health, are seeds, the awful but legitimate harvest of which are ill
health, misery and death to hundreds upon hundi'eds of innocent con-sumers
during our long, hot summers.
The indifference of the public generally, and the indifference and
inactivity of the medical profession in particular, along the lines of
milk and meat inspection, are little short of tragic, and I wish I
might say something that would help, in a small way at least, to
arouse and increase interest in this long-neglected branch of sanita-tion.
There are three general ways in which the milk supply may have a
direct relation to the public health
:
1. It may be a means of carrying and transmitting disease from
man to man—such, for instance, as typhoid fever, diphtheria, scarlet
fever, cholera, etc. ; but of these phases of our subject I shall take for
granted you are better informed than I, and omit their discussion.
2. Milk may be a means of carrying and transmitting disease from
cows to man, such as tuberculosis, anthrax, foot and mouth disease,
eowpox, etc. Of these, one alone is common—tuberculosis—of which
I shall have something to say later.
3. Milk may cause disease in man by conveying disease-producing
agents or materials, such as filth and the conditions which it favors
for the growth of bacteria and the development of toxins and other
deleterious substances ; also the products of mammitis and other septic
troubles.
TWELFTH BIENNIAL REPOKT. 31
Of the distinct diseases affecting the cow, which also affect man and
which may be communicated from one to the other, tuberculosis is of
first importance.
When Koch discovered the bacillus of tubei'culosis and proclaimed
the identity of boA-ine and human tuberculosis, there was little hesi-tancy
in accepting a conclusion so closely in harmony with the experi-ence
and observation of scientific workers in both human and veteri-nary
medicine. Later investigators called attention to the difficulty
in transmitting human tuberculosis to bovines, and still later the fact
was pointed out that the bacilli from bovine and human sources often
possessed morphological and cultural peculiarities sufficient to differ-entiate
them ; but when Koch followed, in 1901, with the remarkable
declaration that bovine and human tuberculosis were different and not
intercommunicable, few scientific investigators were willing to accept
the (lictum on the insufficient evidence produced, and at once investi-gations
were started all over the civilized world to determine the truth
or falsity of Koch's declaration. In the meantime progress towards
preventing the communication of bovine tuberculosis to man received
a decided setback.
The results of the investigations, stimulated by Koch's dogma, indi-cate,
as clearly as the nature of the case will permit, that bovine
tuberculosis may be and is communicated to man.
It has been shown that the bacillus from human tuberculosis is
capable of producing tuberculosis in many animals, but for no animal,
unless man is the sole exception, is it so virulent as the bovine germ.
If the bovine bacillus is more virulent for all other animals, including
monkeys and apes, it very logically follows that it probably is also
more virulent for man than the hiunan bacillus.
Of course, Koch has not recanted. He still maintains the position
taken in 1901, but the fact is now pretty generally recognized that
bovine tuberculosis may be a source of danger to man.
The next question to arise was, naturally. To what extent is bovine
tuberculosis a source of infection to man'?
In their efforts to show that bovine tuberculosis was rarely com-municated
to man, the fact of the greater frequency of pulmonary
than abdominal tuberculosis was pointed out, and the claim that intes-tinal
tuberculosis of children, the greatest consumers of milk, was
rare, were made much of.
Recently much evidence has been developed showing that intestinal
or abdominal tuberculosis of children is not so rare as claimed by
those who maintain that bovine and human tuberculosis are not inter-communicable.
And still further to the dismay of those who cling to old beliefs
because they are old, even the time-honored assumption that the chief
mode of entrance of the infection agent is through the inhalation of
germ-laden dust particles has been challenged and met with an array
82 NORTH CAROLINA BOARD OF HEALTH.
of fjiels and reason which may wt'll receive serious consideration by
all those interested in the question of the relation of the milk supply
to the public health.
It has been clearly shown that the introduction of the bacillus into
auy part of the body—blood vessels, intestines, abdominal cavity, or
even a part so remote as the tail of the cow—is generally followed by
thoracic tuberculosis, instead of necessarily tuberculosis at the point
of entrance or of nearby organs.
Again, when tuberculosis of the intestines is found, especially in
children, the bovine germ, which may be recognized, is frequently
found in these cases of human tuberculosis. Is this not more than
passing strange if the bovine germ does not produce tuberculosis in
the human?
In short, recent investigations show plainly that not only is bovine
tuberculosis communicated to man, but that this is probably not so
uncommon as the comparative infrequency of abdominal tuberculosis
was thought to indicate.
To question the old inhalation theory of the entrance of the tubercle
germ from sputum, pulverized, is. I know full well, among the medical
men here, likely to lessen the respect which you will have for the
other statements I may make, but I cannot resist the temptation to
state that it never did have any scientific evidence worthy of con-sideration
to support it.
It is an old, well-known fact that drying and sunlight rapidly kill
tubercle bacilli. One hour of sunlight will kill tubercle bacilli in
transparent layers of sputum, while five hours exposure to sunlight
will kill the bacilli in thick opaque layers. Sputum is mixed with
mucus, is tenacious and hard to pulverize, unless thoroughly dried.
Yet we accept the statement that tubercle bacilli resist this drying
and pulverizing process to such an extent that this way, and this way
almost exclusively, is tuberculosis thought to be introduced into the
human system. The theory is not only not supported by facts, but is
most unreasonable. Furthermore, if the tubercle germs enter by way
of the air cells, why is it that tuberculosis starts in the capillaries
instead of in the air cells? Why is it that tuberculosis starts in the
apex of the lung, where there is a smaller proportion of air cells than
in the base of the lungs? ""
Another discovery has recently been made, namely, that probably
before the tubercle bacilli are expelled from the body in any con-siderable
numbers through other channels, they may exist in large
numbers in the manure. Years ago, I remember reading in Novy's
"Laboratory Work in Bacteriology" that there was a bacillus fre-quently
found in cow manure that stained like the tubercle bacillus
—
very much like it. indeed, because it probably was the tubercle bacil-lus.
Now, the chief filth in milk is cow manure. That cowy odor is
usually plain, vulgar, filthy cow dung.
TWELFTH BIENNIAL REPOKT. 33
lu the face of these facts, what is our position? We Icnow that
tuberculosis exists in our dairy herds ; we liuow that when tuber-culosis
exists iu a herd, owing to the passage of the bacilli through
the udder, and through the intestines and manure, which almost
always contaminates the milk more or less, milk from such a herd is
almost certain to contain tubercle germs. We know that infants, the
largest consumers of milk, have intestinal tuberculosis more fre-quently
than adults, and that the bacillus causing this disease is fre-quently
of the bovine type. In short, we know that our neglect to
exclude tuberculous cows from our herds is causing the death of many
human beings, and yet we are doing nothing, literally nothing, to
prove ourselves worthy the title of guardians of the public health.
The tuberculin test is the only means of detecting tuberculosis be-fore
the products of the cow are likely to be infective, but we are not
forcing the dairymen of the State to do what is to their own financial
interest to do—test their cattle and exclude the tuberculous animals.
Tuberculosis is not over common in this State, except in the dairy
herds, and is not as prevalent there as in many States, but it will
steadily increase unless controlled. Moreover, if we admit its exist-ence
even, and the possihUlty of its communication to the consumer of
milk, we have uo right to stand idly by and permit any human being
to take that chance, no matter how small the chance may be.
In my opinion, diseases of the udder and those conditions of milk
included under the general term "filthy" are the most fruitful source
of injurious effects upon the consumers of milk. All forms of garget,
mammitis or other diseases resulting in pus and other inflammatory
products entering the milk are unquestionably the source of much of
the diarrhreal troubles of infants resulting from the consumption of
impure milk. Filth, manure from the cows and stables, which is the
most abundant and common contaminating material of unclean milk,
has not, in my opinion, been given its full share of responsibility for
the high death rate from diarrho?al diseases, so fatal to young chil-dren.
Especially is this so in North Carolina.
In short, tuberculosis, diseased udders and filth are the three main
sources of danger to the consumers of milk in this State.
How are these conditions to be corrected? In the first place, clean
milk is worth more than dirty milk, and it costs more to produce it.
Are our people willing to pay for clean milk? I believe we are now
paying a price—eight to ten cents a (piart—which entitles us to a
fairly good quality of milk. If this is not enough to enable the pro-ducers
to put clean milk on the market, then you, the guardians of
the public health, must educate the public up to the point where it
will pay for good milk.
In the second place, few of our dairymen know sufticient of dairy
science and practice to enable them, unassisted, to put clean milk on
the market. The general supply of milk can be iniijroved. but for
34 NORTH CAROLINA BOARD OF HEALTH.
many years yet cannot be brought up to the standard necessary for
the feeding of infants and sick people. Comparatively few men any-where
are able to put such a quality of milk on the market. What is
to be done?
First, start here to-day such a campaign for pure milk as will
arouse public opinion, stimulate dairymen to greater efforts, and result
in a competent milk inspection and supervision in every town of 3,000
population in the State. This can be done, and will improve the gen-ei'al
condition of the milk supply. In evei'y town where the demand
will justify let a certified milk commission be established to encourage
some one or more men to produce and put upon the market a first-class
milk product. And, last, as a temporary and doubtful expedient,
if filthy milk must still be consumed by many, establish under munici-pal
control, where conditions render it practicable, a pasteurizing
plant, where all milk below a certain standai'd must be pasteurized
before being sold. Pasteurizing will not make unclean milk clean,
but it may lessen its injurious effects. If generally adopted, it is
likely to encourage filthy practices rather than correct them. It prob-ably
lessens the digestibility of the milk, and is only advisable as the
lesser of two evils. As between reasonably clean milk and pasteur-ized
milk, there is no question in my mind of the superiority of the
former, but if it is still necessary to put up with dirty milk, then by
all means pasteurize. The chief objection to it is that its us^e is likely
to prevent as great an effort to secure clean milk as would be made
were pasteurizing not practiced.
How is the general quality of the milk supply to he improved?
First, by a proper system of inspection. Three forms of knowledge
are requisite for competent milk inspection—first, a knowledge of
cows in health and disease—possessed by the veterinarian ; second, a
knowledge of dairy science and practice, which should be possessed
by the so-called practical dairyman, but in our State rarely is; third,
a knowledge of milk, bacteriologically. chemically and microscopically.
The milk inspection of a municipality may well be administered by
a milk commission ; but if ^o, it should he made up of men chosen for
their knowledge of the work. For such a commission a physician, a
practical dairyman and a veterinarian are logically competent men.
Or the administrative part of the work may be left to the city health
officer ; but the success and efficiency of any system of milk inspection
depends on the efficiency of the inspector and the quality of the labo-ratory
work done.
First, there should be a frequent and thorough veterinary inspection
of the cattle. The inspector should also be a practical, scientific
dairyman who has had experience in dairying. If it is claimed that
such a man cannot be employed, then the milk inspection will fall
short of a full success just to the extent that the inspector falls shoil
of these requirements.
TWELFTH BIEXNIAL REPORT. 35
Our dairyineu are not desirous of putting filthy milk on tLie market,
but they don't know. The inspector must be able to teach and lead,
rather than try to force rapid changes.
In most instances too much importance or reliance is placed on
laboratory examinations. These are essential, but they will not take
the place of frequent and competent inspections of the dairies and the
manner of handling the milk. Bacteriological examinations should be
made, for unquestionably a high bacterial content is indicative of a
high filth content. If there be a high bacterial content, then the
inspector must seek the cause and correct it. He must have accurate
dairy knowledge and practical experience to do this.
A microscopic examination may be made, for a high leucocyte and
streptococci content, with the presence of fibrin, which indicates in-flammation
of the udder, but this is of most value when examinations
are made of the milk of individual cows.
In the city of Raleigh we have a so-called milk inspection, which is
practically nothing more than a bacteriological examination and pub-licity
of the results or findings. No competent inspector is employed,
no tuberculin test is made of the cattle, and a violation of the regula-tions
does not usually mean any sort of punishment ; but, with all this,
good has been accomplished. For instance, in 1906, after a complete
neglect of duty for three months, the commission was forced to make
a pretense of doing its duty by public criticism through the press, and
from March 27 to April 27, 1906, fifty samples, the first taken after
this period of neglect, gave twenty with a bacterial count of over
1,000.000 per cc. From March 27 to April .
.
, 1907. fifty samples gave
seven with a bacterial count of over 1,000,000 per cc. From March 26
to April 28. 1908, fifty samples gave eight with a count of over
1.000.000. In September, 1905, ten samples gave an average bacterial
count of 3.111,500 per cc. In September, 1906, ten samples gave an
average count of 846,000 per cc. In September, 1907, ten samples gave
an average count of 164,000 per cc. In August, 1906, twenty-three
samples gave an average count of 2,570,000. In August, 1907, nine
samples gave an average count of 890,000 per cc.
An improvement, but what filth still exists ! Fancy, during the
months of March and April, milk from three to five hours old, in
which sixteen per cent of the samples have from one to two million
bacteria to the cc!
A bacteriological examination of milk is of importance, but its chief
value is lost unless supplemented by and done in co-operation with
an intelligent dairy and cattle inspection. A high bacterial count
means either age or filth, and large numbers of liqueflers mean in all
probability filth, and. where dairies are not of fairly good grade, dairy
practice rather than age influences most the bacterial count.
We must keep in mind that a healthy cow gives a wholesome
product of fairly uniform quality. If the milk is put on the market in
36 NOKTH CAROLINA BOARD OF HEALTH.
Icid condition or of greatly varyin'g composition, it means bad dairy
l)ractice. Very frequently I hear of tliis physician or that one who
insists that the cow shall receive no cotton-seed meal, or no silage, or
some other excellent food is tabooed. I have heard of this sort of
thing in our city of Raleigh, and yet our system of handling milk
makes it almost certain that the fat content of the milk from any one
dairy may vary from 2.5 to 8 per cent.
This has actually occurred, and is due to the fact that milk is sold
from a large can instead of being bottled at the dairy. The faucet
being at the bottom of the can, and the cream rising to the top, the
customers first served get the 2.5 per cent milk, while the last get
milk containing 8 or 10 per cent butter fat. No sort of feeding will
produce a change of over one-half of one per cent in the butter fat
content. In fact, it is doubtful if any effect on the fat content can be
regularly and consistently pr^oduced by any sort of feeding; therefore,
it will avail most to give more attention to the handling of the milk,
for it will certainly mean discomfort, if nothing more serious, to any
delicate infant to receive 2.5 per cent milk to-day and 8 per cent milk
to-morrow.
Good milk will not be put on the market until the dairyman is re-quired
to bottle it at the dairy, under proper sanitary and dairy con-ditions.
Some of the points that need attention in our North Carolina dairies
are:
1. Test all cows with tuberculin, and exclude the diseased ones.
The North Carolina State Department of Agriculture will do that
free of charge, on certain reasonable conditions.
2. Institute an intelligent inspection of the cows, and exclude all
those with any disease of the udder.
3. Prohibit the selling of milk except in bottles, and require that
the milk be kept below a certain temperature.
4. Prohibit feeding during or just before milking.
5. Compel dairymen to keep their cattle clean. Cows can be cleaned,
but milk cannot.
6. Compel dairymen to wear clean clothes and wash their hands
before milking.
7. Wipe the udders off with a damp cloth and use a covered milk
pail.
These can only be brought about by an inspector capable of lead-ing
and teaching. We cannot have entirelj^ clean milk at once, but
we might have cleaner milk with an intelligent effort.
As an illustration of how the cleanliness of milk is influenced by
dairy practice, as indicated by the bacterial coimt, I desire to present
the following charts, the data for which have been taken from bulle-tins
No. 42 and No. 48 of the Storrs (Connecticut) Agricultural Ex-periment
Station.
TWELFTH BIENNIAL REPORT. 37
It Lias been stated as an excuse for the filthy luilk which so many
of our dairymen are putting on the marliet that, from lack of knowl-edge,
capital or other facilities, they could not produce and put clean
milk on the market. These charts show that certain practices pro-duced
a wonderful improvement in the quality of the milk, as indi-cated
by the bacterial count, and yet all these things could be done by
our dairymen. They are all simple, practicable and inexpensive.
MILKED BEFORE FEEDING.
MILKED AFTER FEEDING.
Diagram showing relative bacterial content of milk drawn before
and after feeding hay and grain.
MILKED BEFORE FEEDING.
MILKED AFTER FEEDING.
Diagram showing relative bacterial content of milk drawn before
and after feeding dry corn stover.
38 NORTH CAROLINA BOARD OF HEALTH.
NOT BRUSHED.
BRUSHED.
Diagram showing relative bacterial content of milk drawn immedi-ately
after the cows had been brushed and when no brushing was
done at that time.
UDDERS AND FLANKS WIPED.
UDDERS AND FLANKS NOT WIPED.
Diagram showing relative bacterial content of milk drawn immedi-ately
after the udders and flanks of the cows had been wiped with a
damp cloth, and when they were not wiped.
TWELFTH BIENNIAL KEPOET. 39
EDUCATED MILKER.
REGULAR MILKERS.
Diagram showing relative bacterial content of milk drawn by an
educated dairyman and that drawn by regular milkers.
COVERED PAIL.
OPEN PAIL.
Diagram showing relative bacterial content of milk drawn into a
Stadtmueller covered pail and into an ordinary open pail, in a dairy
where extra care is given to cleanliness.
40 NORTH CAROLINA BOARD OF HEALTH.
COVERED PAIL.
OPEN PAIL.
Diagram showing relative bacterial content of milli; drawn into a
Stadtmueller covered pail and into an ordinary pail, in a dairy where
con.siderable care is given to cleanliness.
COVERED PAIL.
OPEN PAIL.
Diagram showing relative bacterial content of milk drawn into a
Stadtmueller covered pail and into an ordinary pail, in a dairy where
little care is given to cleanliness.
In all of the experiments furnishing the data upon which these dia-grams
are based, more than ordinary care was taken to follow correct
dairy practices. In all experiments, except in the ones comparing
open and covered pails, the Stadtmueller covered pail was used, and
all other conditions except those being tested were as near alike in
ail cases as it was possible to make them. In dairies where little
TWELFTH BIENNIAL REPORT. 41
regard is paid to cleanliness tbe results would still more forcibly
demonstrate the effects which the methods of handling the milk has
on its cleanliness and the bacterial count.
Dr. Silvio von Ruck, Asheville : I have listened to Dr.
Butler's paper with much interest, but he has made many
statements which are radical and not proven.
He tells us that tuberculosis is transmitted from cattle to
man with great frequency, and even that bovine tuberculosis
is the almost exclusive source of infection for man, while
human infection through sputum is of little importance.
He has misquoted Professor Koch, who did not state that
infection of man bv milk of tuberculous cows could not
happen at all. Koch announced at the London Tuberculosis
Congress in 1901 that he had not been able to produce infec-tion
in cattle with tubercle bacilli of human origin; that the
human and bovine type of bacillus were not identical ; that in
the light of the rarity of primaiy intestinal tuberculosis and
reasoning by analogy he did not believe that human infection
from bovine sources was of frequent occurrence. He did not
deny that it might never occur.
There are two sides to this question, one of which Dr. But-ler
has entirely ignored ; and aside from bacteriolooic investi-gations
and animal experimentation, we have much evidence
in support of Koch's position. This also requires consider-ation.
For example, it is well known that in Japan, before for-eign
cattle were imported, bo^•ine tuberculosis was not prev-alent.
Further, the number of cattle in proportion to the
population is so small that milk is not an ordinary article of
diet. Nevertheless, Japan has shown and continues to show
as great a pro rata mortality from tuberculosis as other coun-tries.
In Sweden and Norway, where almost all children are
nursed by their mothers, there is as great a j^ercentage of
tuberculosis mortality as in countries where cow's milk is
more commonly used for infant feeding.
42 NORTH CAROLINA BOARD OF HEALTH.
In Berlin records have been kept of the method of feeding
infants, and the number of deaths from tuberculosis is equally
divided, as shown by statistics cited by Fraenkel, between
those who were nursed by the mothers and those who were
fed on cow's milk.
There is much more evidence of like character which tends
to show that the tuberculosis of cattle is not the great source
of danger that has been asserted ; but an actual experiment on
man has been made, although at the time not with the view of
determining this question.
Baumgarten has given us the details of it. Based upon
Rokitansky's theory of the antagonism between tuberculosis
and cancer, a number of patients suffering from inoperable
malignant disease were inoculated with bovine tubercle bacilli
in the hope that their malignant disease might thereby be
favorably influenced. All eventually died of their malignant
disease, and Baumgarten performed the autopsies. He found
no evidence of tuberculosis, and even critical microscopic ex-aminations
failed to reveal tubercle or tubercle bacilli.
As Dr. Butler has stated, it has been found that primary
intestinal tuberculosis is not quite as rare as was supposed
at the time Professor Koch made his announcement in Lon-don,
but while the thoracic glands may become affected as a
result of ingestion of tuberculous material, this, according to
all results and investigations, is rare. It is generally con-ceded
that by whatever route the bacillus enters, be this by in-gestion
or by inhalation, the first localization occurs in the
nearest regional lymph gland. However, since 1901, the sub-ject
has been most carefully and painstakingly studied at
the Imperial Health Bureau in Berlin and elsewhere, and it
has been proven conclusively that in the majority of cases of
primary intestinal tuberculosis the tubercle bacilli isolated
from the intestine or mesenteric glands were of the human
type. Up to the present time the cases in which bovine in-fections
have been proven to have occurred in man are about
TWELFTH BIENNIAL REPORT. 43
33 in number, 18 of which have been examined at the Im-perial
Health Bureau, while 15 are reported by other ob-servers.
Apart from any danger to man from tuberculosis of cattle,
the question is of imjDortance from an economic standpoint
as well, and if, as appears, the danger to man is but little, it
should not be necessary to destroy hundreds and thousands of
cattle simply because they be shown to have acquired tubercu-losis.
Besides, as Professor Koch points out, we can protect our-selves
from such danger as may exist by boiling the milk and
cooking the flesh of such cattle as are or may be tuberculous.
With Dr. Butler's views as to the importance of cleanliness
in our dairies, I am heartily in sympathy. Irrespective of
the tuberculosis question, clean milk is essential, and for
many other reasons we should use our influence to obtain it.
Dr. Bukroughs, Asheville, ]S[. C. : Mr. Chairman, I have
listened to Dr. Butler's paper with interest. But there are
one or two points on which I think that the doctor, as our
State Veterinarian, has not been sufficiently explicit.
I wish to state that no tuberculous cow should be milked
nor is milked at any dairy that produces healthful milk. The
herds are usually tested every six months. And all additions
to herds are tested before being allowed to mingle with the
cattle already tested.
Dairy cattle of Asheville are under the direct supervision
of a veterinary surgeon ; and all milk is under the supervision
of one man, who tests milk a.t his will, with full authority to
act.
The cattle are kept on the hills and in the valleys a portion
of the day and also a part of the night. And the milk is col-lected
twice daily.
The cattle are driven to a large corral with a shed attached
to the stables where they are fed. In this shed the cattle are
brushed off, and while they are being fed their teats are
washed with an antiseptic solution. Following this come the
44 NORTH CAROLINA BOARD OF HEALTH.
immaciilatelj dressed milkers with strainer pails. The milk
is then carried to the chemist, with his assistants, where it is
standardized according to the requirements of Mr. Wilson in
the Department of Agriculture of the United States Govern-ment.
The milk is then iced and delivered in sealed glass
jars.
One statement made in Dr. Butler's paper I do not under-stand,
and I am certain that other members of the conjoint
session do not understand, which I wish the doctor to explain,
and it is this: that "thoracic tuberculosis is very frequently
contracted from the cow's tail." (Laughter.)
De. Butler closes: Just a word in reply to the gentle-man's
(Dr. Burroughs') thrust. I didn't say it.
I know I didn't cover this subject thoroughly. If I had
I would have kept you here until to-morrow morning, I
stated in the start I wasn't going to talk to the specialists and
investigators, but to the general practitioner.
I could meet Dr. Von Buck's statistics with statistics if
time would permit. I could tell you of investigators who
have found as high as 41 per cent of the abdominal tubercu-losis
of children of bovine origin, but I did not have time to
do it or to go into this matter fully.
I wanted to say further—and I thought I made that point
clear—that the old idea that you can tell the mode or channel
of entrance of the tubercle cerm bv the location of the lesion
is no longer tenable. It is nonsense to say, because you find
tuberculosis in the lungs, that the germ necessarily entered
through the air passages. I said you could put the germs in
the tail of the cow and the chances were the tuberculosis would
develop in the lungs, not in the tail. Why ? Because tuber-culosis
is primarily a disease of the lungs, and the germs go
to where they like to live. They find the most suitable place
for their development. You can inject the tubercle germs
into the abdominal cavity, and you may feed them through
the mouth ; you may put them into the circulation or into any
part of the system, in any way you like, and in the majority
TWELFTH BIENNIAL REPORT. 45
of cases you will get tuberculosis in the lungs. That is what
I meant to say. Thank you.
My paper is better exj^lained with the drawings given the
Secretary.
Dr. Thomas : Gentlemen, the next subject to be presented
is 'Tellagra," by Dr. E. J. Wood, of Wilmington, X. C.
PELLAGRA.
Pellagra is a disease supposed to be due to an intoxication derived
from diseased maize and characterized by a triad of symptoms
:
symmetrical erythema, gastro-intestinal disturbances, and various
nervous and mental manifestations.
Spain was the first country in which pellagra was recognized.
This was in 1735, and the disease was regarded as a vai'iety of
leprosy. The disease later appeared in Galatia, and later in Castilia.
Rome, and Aragon. To-day it is very prevalent in Navarre and
Galicia. The name lepra asturiensis was one of the many by which
it was known. Next the disease was noted in the northern provinces
of Italy. Trapalli. in Lombardy, gave the name pellagra (pelle and
agra, rough skin).
At the present time pellagra is very prevalent in Roumania. In
1882 there were 4,o00 cases ; iu 1888 there were 10,626 cases out of a
population of 5,339,650; in 1894, 6,694 cases; in 1896, 19,796 cases;
and a more recent estimate places the number above 50,000 cases,
who were affected with the disease in some stage. It also occurs
in the south of France. Since 1856 it has been present in Corfu.
The Asturias are still the chief seat of the disease iu Spain. One
sporadic case is said to have occurred in England.
When the disease first appeared in Italy it was in the neighborhood
of the Lago Maggiori. During the last century it extended into
Emilia and Tuscany. In central Italy it is little known and in south-ern
Italy and Sicily is unknown.
Bouchard describes the disease in Mexico. It has occurred also
in Brazil, Argentine Republic, and Uruguay. Many cases have been
reported in Egypt and some in South Africa.
The disease has almost disappeared from France, but there are
still small areas in the Pyrenees and in Garonne.
Sporadically cases have been seen in the Tyrol, Servia. Bulgaria',
Greece, and Asia Minor.
Italy and Roumania are considered the disease centers. In Italy
it is endemic. According to a reliable source tliere were 100,000 cases
or 10 per cent of the rural population affected with pellagra.
The disease was supposed not to occur in this country, and many
of the best text-books fail to mention it. Probably the first article
46 NORTH CAROLINA BOARD OF HEALTH.
on the subject appeared in the Jotinnil of the American Medical As-sociation
for July 6, 1907, by Dr. G. H. Searcy. The disease ap-peared,
according to this report, in 1901, in Tuscaloosa, Alabama,
but at the time was not recognized. In 190G there occurred in Mount
Vernon, Alabama, 88 cases of acute pellagra, with a mortality of
57 or 64 per cent.
In 190.5 the disease was present, unrecognized, in "Wilmington.
Certainly as far back as 1900 there was a case in Jones County.
Dr. James McKee, Superintendent of the State Hospital for the
Insane at Raleigh, has kindly furnished me with notes of three cases
under his care, and suggests the possibility of the disease having
been present in the institution for a number of years.
Dr. E. H. Bellamy, of Wilmington, at the recent meeting of the
American Medical Association reported ten cases.
Dr. J. C. Gilbert, of Hope Mills, in a letter to Dr. Bellamy reports
seven cases under his care.
Certainly there have been thirty cases in North Carolina. It is
probable, however, that the correct number will run into hundreds.
It is also probable that the disease is rapidly increasing. We have
many reasons to believe that the disease has existed in North Carolina
for some years, but that these cases were sporadic ; otherwise the
condition would long ago have been recognized. As there has been
an increase from a few sporadic cases to a number which is daily
increasing, the question of the disease becoming endemic with us must
be seriously considered.
Pellagra seems to be generally distributed throughout the South.
Merrill reports a case from Colorado, Texas, and Babcock reports
nine cases occurring in the Hospital for the Insane in Columbia. S. C.
SYMPTOMATOLOGY.
Weeks and even months before the appearance of the erythema
of pellagra there may be symptoms which, while usually very in-definite,
would lead one in a iwllagrous region to make the diagnosis,
provisionally, of the disease. There is often progressive weakness,
especially of the feet and legs, gastric disturbances and loss of ap-petite.
Roussel regards the loss of appetite and gastric disturbances
as complications, and dryness and burning of the mouth with a sen-sation
of heat in the stomach which may develop into a true pyrrhosis
as the first symptoms of the disease. Further, he considers voracious
appetite, vomiting, cardialgia and diarrhoea of purely nervous origin.
Besides these symptoms there are vagabond pains in the extremities
and back, tinnitus, weakness of vision, general malaise, especially
in the mornings ; sometimes pain in the joints. Headache, vertigo
and melancholia follow.
In many respects these symptoms are common to the whole group
of acute infectious diseases ; but still, when headache, vertigo, sensa-
TWELFTH BIENNIAL KEPORT. 47
tions of weakness, especially in the lower extremities, are present,
often accompanied by diarrhoea and occurring about the middle or
end of winter, our suspicions at least should be aroused.
According to Theodori, about four weeks after these pellagrous
symptoms occur the unmistakable signs of the disease appear. This
period is often mucla longer, in some instances being as much as a
year.
The first skin lesion almost always appears in the spring and the
parts affected are usually those parts exposed to the sun's rays.
Many of the best observers think that as an etiological factor the
rays of the sun have little effect. Among these are no less author-ities
than Procopiu and Tuczak. to whose works we are much indebted
for our information. Many other writers think that the violet rays
are certainly a predisposing cause of the skin lesions, if nothing
more. The last word on the subject has not been said. In our cases
we are disposed to belittle the solar influence: (1) Because the dis-ease
appears with us so early that we can exclude any very Intense
action; (2) in some cases it appears over the sternum, in the vagina,
and in patients who have been in bed for days and weeks with a
pellagrous lesion on the hands and face we see the extension to the
feet, even though previous to their admission to the hospital they had
not gone barefooted.
The skin lesions usually appear first on the back of the hands over
the metacarpal region, either with a swelling and a red spot in the
center or else with a diffuse redness. Oftentimes blebs appear.
The blebs contain clear, alkaline serum, which is sterile. After the
hands the face is usually more apt to be affected. Here the lesion
begins symmetrically either at the outer canthi of the eye or at the
angles of the mouth. It is common to have it symmetrically situated
on the forehead in two patches, which have a narrow vertical strip
of healthy skin between. Beneath the lower lids and at the back of
the neck are favorite places. In the latter situation tlie lesions ex-tend
auteriorlj' until they nearly meet in front, forming a collar
which is higher behind. In our limited number of cases we have
found the face and neclv lesions much more commonly in females,
and especially children. The next sj^ot selected is the top of the feet.
Our last case has the two varieties of lesions occurring simultane-ously.
Just below the external maleolus there is a bleb on both feet,
which began as two round, red spots about the size of a fifty-cent
piece. In ten days a bleb appeared which, after drying up. left a
raw surface. In the same case, over the crest of the tibia, extending
downward over the metatarsal region to the lower articulations of
the toes, is a diffuse redness much resembling a lymphangitis.
This lesion will probably go on to exfoliation without bleb forma-tion.
In some cases the lesion may appear over the sternum, and
in two of our cases the labia pudendi were affected by the typical
48 NORTH CAROLINA BOARD OF HEALTH.
lesion. The disease has been liuown to make its first appearance on
some covered portion of the body, but this is exceptional. In none
of our cases did it appear there until long after its more usual
appearance on the exposed parts. In the lesions with blebs there is
left a raw surface which either forms an ulcer or is covered by
crusts, which often are quite thick. The crusts and the weeping
ulcerated areas, together with the odor, make a loathsome patient.
With the beginning of healing, the skin of the face contracts so that
in one case there was a marked ectropion and also inability of
the lips to cover the teeth. The photograph shows the condition
well, but it became mucli worse as the disease progressed. Usually,
especially in the dry cases, exfoliation begins after three or four
weeks, and as the dead skin comes away a pigmented area is left.
This pigment varies from a slight yellowish tinge to a dirty brown
or even a chocolate color. The depth of color depends upon the
duration of the disease, that is, on the number of the attacks. In ad-dition
to tlie pigmentation, the skin is shining and atrophic. By
fall the skin regains more or less of its normal tone, only to be ready
for the next attack the following spring. With each attack the skin
becomes more atrophic and more pigmented.
INTESTINAL TRACT.
With the appearance of the erythema, or soon after, the mouth
becomes affected. The mucous membrane is red and swollen, the
lips may be covered with blisters, and later they become cracked and
seared. The tongue is intensely red and the papilla? enlarged, with
furrows between. The patient complains often of burning and salty
taste in the mouth, often with an increased flow of saliva.
Dr. McKee says the mouth suggests to him stomatitis materna.
Salivation is often intense, and in one of our cases we suspected
ptyalism. After the skin lesion the mouth condition is the most con-stant,
and in none of our cases was it absent. In some cases it
subsides after the first few weeks ; in others it persists throughout.
In all of our cases the stomach was not affected. Pyrrhosis, eructa-tions,
vomiting, anorexia or bulimia, often with extreme thirst, are
common symptoms. In some cases the gastric analysis shows an
absence of hydrochloric acid, while in others it is normal.
Much more commonly present is obstinate bloody diarrhoea, often
of a dysenteric type, usually attended with colic. This diarrhoea is
considered by many to be a neurosis, but it is often difhcult to be-lieve,
judging from the character of the stools.
NERVOUS SYSTEM.
Roussel considered the vertigo a very characteristic symptom, and
described it as being much like a gastric vertigo. Diplopia and
amblyopia are common, but were absent in all our cases. The pupils
TWELFTH BIENNIAL REPORT. 49
react acutely tu both light jukI accommodation, and the ophthal-moscopic
examination has revealed nothing to us. The patients
usually complain of a sensation of heat or cold in various parts
of the body. We have attempted to investigate the tactile sense,
the sense of heat, cold and pain, but our observations are inaccurate
because of the mental state of our patients. The complaint of pain,
especially in the shoulders and epigastrium, is quite common, and
noted by us.
Convulsions are quite common and often close the scene. In one of
our earlier cases this was so. Tetany is reported by some. We have
found a coarse tremor present in a number of our cases. In one,
just before death her ^vhole body was in a constant tremor, but could
not be accounted tetany.
The condition of the tendon reflexes is more variable. In many
of our cases thej' remained normal. In a few they were absent,
though there were no other symptoms of locomotor ataxia. In one
case where the reflex had been absent there was a return before
death in a rather exaggerated form. In one case it was much ex-aggerated,
and ankle clonus was present. In one case it was
present on one side and absent on the other. Usually, in the be-ginning
of the disease it is normal or decreased, but later, when the
lesion in the cord has extended, it is apt to be exaggerated. Station
is usually good. The gait becomes unsteady, but not ataxic. A
slight spasticity has been observed. Among the vaso-motor and
trophic disturbances is usually included the erythema itself. In ad-dition,
we often find paleness of the skhi, sensations of cold, "goose-flesh,"
and muscle atrophy in the shoulder, girdle muscles of the
hand, thorax and lower leg. This should not be confounded with
emaciation, which is often extreme. The alterations in the tongue
and the thickening of the nails may be included under this head.
In Europe "misery and poverty"' are counted the chief predisposing
causes of pellagra. Just those conditions occurring among the
peasantry in Europe are almost unknown with us. Certainly the
I'ichest and the poorest buy the same grade of corn-meal. The chief
difference here, as we all know, is that the poorer class have less
variety and often the food is poorly prepared. We are disposed
to think that pellagra with us is not so much a respecter of persons,
affecting the well-conditioned as well as the victims of previous dis-ease
and poor hygienic surroundings.
It has been shown, especially in Sandeith's Egjiitian cases, that
the parasitic disease seems to form a very definite predisposing cause.
Especially has it been noted that anchylostoma is often present. One
such case was noted by Harris in Georgia. Babes and Sion report
the occurrence of malaria in eight of their twelve cases. We have had
occasion to consider seriously this possible relationship. My first
case, which was erroneously reported in the Journal of the American-
50 NOKTH CAKOLINA BOARD OF HEALTH.
Medical Association, had a latent malaria and the unusual coiiditiou
of a mixed infection with tertian and quartan organisms. Much at-tention
has been paid to the occurrence of alcoholism and syphilis with
pellagra. This is unimportant except in so far as thef^e conditions
lower the resistance.
The course of pellagra is very variable, lu Italy it is no un-common
thing for the outbreak to occur each succeeding spring for
twenty years. Each year the patient becomes more wrinkled, more
atrophic and more melancholy until, finally, he dies from some in-tercurrent
disease, as broncho-pneumonia or of cachexia.
There recently came under our care a typical case of chronic
pellagra which is worthy of note.
Mrs. W. ; age 34 years ; Jones County. Family history negative,
save for malaria and typhoid. No history of miscarriages. In the
spring of lOOG she was affected with gastro-intestiual symptoms, one
month after the appearance of which the erythema appeared on her
hand and the lower third of her forearms. In the spring of 1907
the same condition recurred. In May. 190S, the condition made Its
third appearance, was diagnosed pellagra and reported to me by my
colleague. Dr. Thomas M. Green. Her condition was as follows
:
A poorly nourished woman, much older in appearance than the age
given. Symmetrically situated on her forehead were tvi'o patches of
desquamating erythema. These patches are about equal to the size
of two silver dollars. The same lesion surrounded both eyes. On
the upper lid the lesion was more recent, with the presence of crusts
and a weeping surface beneath. This lesion extended into the an-terior
nares. On the skin below the eyes the lesion was older and
there is a slight brownish pigmentation. On the backs of both hands
from the finger-nails to the middle of the forearms posteriorly is this
same condition of the moist variety. The lesions were especially
aggravated over the knuckles and tips of the ulna. The same con-dition
was present on the anterior sui'face, save for the palms, where
there was simple redness without exfoliation. Near the upper mar-gins
of the arm lesions was found considerable brownish pigmenta-tion.
On the back of the neck was a much older lesion, which had
caused a tawny pigmentation. Posteriorly this lesion is about two
inches in length, but as it extends anteriorly it becomes narrowed, al-most
meeting in front. The labia pudendi were affected with the
moist lesion.
Heart and lungs were negative.
Spleen and liver negative to palpation and percussinn.
Urine showed albumen and granular casts.
Blood showed a simple anemia of moderate degree.
No leucocytosis. Differential leucocyte counts showe<l no abnormal
variations. Blood cultures were taken.
TWELFTH BIENISriAL EEPOKT. 51
The patient's mental condition became rapidly worse ; slie refused
nourishment, and a I'estraining sheet had to be used. lu her mania
she would rub off the crusts, from the arm lesions especially, and
the picture that resulted was horrid, with the raw, bleeding surface
and the bedclothing covered with blood and pus.
She died of exhaustion.
Our knowledge of chronic pellagra is limited, fully 75 to SO per
cent of our cases being acute. It seems remarkable that Lombroso
should have had occasion to diflierentiate" this acute or "typhoid"
pellagra from typhoid fever. There is certainly no resemblance,
except possibly in some of the late nervous symptoms of both diseases.
Our acute cases ran a course from a few weeks to a few months.
As an example of this is the following
:
V. S. (colored) ; 12 years; Wilmington. Referred to us by Dr. W. J.
Bellamy.
Family and previous medical histories negative as far as we could
secure them, except that at this time she has a sister aged 6 years
recovering from the first attack of pellagra. This child is in my
care, and is strong and robust.
In February she had various vague digestive symptoms before she
noticed at the outer canthi of the eyes a small red spot. This
erythema increased in size rapidly, extending over the forehead. It
next appeared beneath the angles of the jaw and extended around
the neck, meeting behind. The gums were swollen and red and
the whole mucous membrane of mouth inflamed. The eruption next
appeared on the backs of the fingers and extended upward to the
middle of the forearms. The face and both arms were covered, giving
the appearance of a superficial burn. The contraction of the skin
of the face has been described. From the beginning the bowels
have been affected in the form of a persistent diarrhcea. The only
gastric symptoms have been anorexia and nausea. With the aid
of two doses of santonin during the past week she has expelled from
the bowels forty-six round worms and vomited one. When first seen
a week ago the feet and ankles were oedematous, but this has dis-appeared
and the erythema has taken its place.
Knee jerks were absent, but have reappeared. Skin sensations
normal. Pupillary reaction normal. She complains of cold sensa-tions,
weakness, and pain in right shoulder. She is now beginning
to be quite delirious at times and falls out of the bed repeatedly.
June 13. The appearance of the face is distressing. The skin
lesion seems really to have extended to the eyes. The cornea is dry
and there is a marked conjunctivitis. Mucopurulent material flows
from each eye. Both of the lids are so contracted that the eyes
have not been covered for over a week ; this condition is certainly
largely the cause of the terrible state of the eyes.
52 NORTH CAROLINA BOARD OF HEALTH.
Belmondo and a number of other observers state that typhoid
peUagra never occurs primarily, that it is always the exaggeration
of a recurrence in chronic cases. We have seen five cases die in the
first attack. The disease must be more malignant than in southern
Europe. It is difficult to explain why this sliould be, except that we
know when a disease appears in a new country the death rate at
tirst is always higher. We have examples of that in some of the
yellow-fever outbreaks, and better still in the outbreak of measles in
some of the Pacific islands, where the mortality was !)0 per cent.
The diagnosis of pellagra, after it is well established, is quite easy
and does not require yearly recurrences to establish it. In no disease
is an early diagnosis more important than in this, as our only hope
of effecting a cure is in removing the cause early in the disease.
Ergotism was the first thing thought of in our cases; it was ex-cluded
because of an absence of the characteristic numbness, tingling,
vascular stasis, and gangrene of the fingers and toes.
I have had to watch for several days simple sunburn suspiciously
in some cases because there is nothing more like it. The erythema
of pellagra is described as resembling sunburn almost exactly.
Usually, however, the diarrhoea and stomatitis precede.
Pellagra sine pellagra calls for our special attention. Right now
we have a number of cases under this suspicion, but we must agree
with the authority who rather questions the possibility of such a
diagnosis. That such cases have occurred there can be no question,
as the best authorities so state it.
The treatment of pellagra so far is not promising. Practically
all acute cases die regardless of treatment. In chronic cases that
are not far advanced the removal of all corn food, with tonic treat-ment,
together with improved hygiene, often brings about recovery
with or without mental deterioration, depending upon the stage of
the disease when arrested. Babcock is using successfully atoxyl
hypodermically in doses of one to one and a half grains every four
to seven days. In much larger doses in the acute afHiction it has
failed in my hands. Babcock is also using Soamin (Burrbughs,
Wellcome & Co.) in one grain doses three times a day. In Wilming-ton
we have exhausted the pharmacopceia without seeing any benefit
derived by the sufferers.
Dr. Thomas : "PellagTous Insanitj" will be discussed by
Dr. John McCampbell, Superintendent State Hospital for
the Insane, Morganton, N. C.
SOME OBSERVATIONS OF PELLAGRA IN THIS COUNTRY,
WITH SPECIAL REFERENCE TO PELLAGROUS INSANITY.
Pellagrous insanity, as the name implies, is so closely associated
with and dependent upon the general systemic disease that its con-
TWELFTH BIENNIAL KEPORT. 53
sideratiou separate and apart would be difficult and hardly profitable,
it being in reality only one of the late manifestations of the malady
known as pellagra, which has been comprehensively defined by Yau
Harlingeu as a "complex disease characterized by a class of symp-toms
:
"1. A squamous erythema confined to those portions of the skin
which are exposed to the action of heat and light.
"2. A chronic inflammatory condition of the digestive passages,
shown chiefly by obstinate diarrhoea.
"3. A more or less severe lesion of the nervous system, leading at
times to mental alienations and paralysis.
"The.se various symptoms are at first insignificant and in a certain
way periodic. They begin or recur in spring and diminish or disap-pear
in winter. Later they become persistent, more and more marked,
and finally terminate fatally."
Pellagra has been known to exist in Italy. Spain, and adjacent
countries for more than a century and a half, and was scientifically
investigated in Italy as far back as the year 1771 ; but until quite
recently there has been very little said in this country on the subject.
In fact, the existence of the disease has been denied by some of
the most eminent medical writers of recent years, the subject being
dismissed with brief mention and tlie statement that it is a disease
confined to certain European countries. It is true that cases simulat-ing
pellagra were reported in tlie early sixties by Dr. Gray, of New
York, and Dr. DeWolfe. of Nova Scotia ; but the genuineness of
these was questioned at the time and the disease either disappeared
or was overlooked (the former, most lilcely) until attention was
again called to it by the publication within the past year of the
observations of Drs. Searcy, of Alabama ; Babcock, of South Carolina
;
Wood, of this State, and possibly others, though some doubt ap-parently
existed in the minds of some of these observers, as is evi-denced
by the fact that Dr. Babcock presents his able, and to my
mind convincing paper, in the form of a query.
My own experience leads me to believe that we now have in this
country, probably a recent development, a grave and usually fatal
disease identical with the pellagra of southern Europe, and which
may, under favorable conditions, gain the proportions of an epidemic.
During the past four years I have, from time to time, encountered
mental cases presenting certain definite and ratlier uniform mani-festations
and associated with a peculiar skin eruption, which I was
unable to fit into any recognized classification ; yet I realized that
I was dealing with a distinct entity, and it was not until tlie earlier
of the last referred to papers came into my hands that I was con-vinced
that the disease in question was pellagra and the mental dis-turbance
present constituted pellagrous insanity pure and simple. In
support of this belief I wish to recount the chief etiologic and
symptomatic features as observed in twelve of these cases, with spe-
54 NORTH CAROLINA BOARD OF HEALTH.
cial reference to their mental aspect, since all of them were so far
advanced in the disease as to necessitate their commitment to a
hospital for the Insane.
The theory generally, if not universally, accepted is that ])ellagra
is in some way associated with the ingestion of Indian corn which is
diseased, harvested immature, or in some way damaged and conse-quently
containing a toxic substance, the exact nature of which has
never yet been very clearly defined. Ballardini considers it a parasitic
growth on mouldy and musty maize, while Lombroso suggests that
it is due to a fatty oil and an extractive substance, the product
of decomposition or bacterial action which are never present in sound
corn. At anj' rate, the disease is more in the nature of a ptomaine
poisoning than a direct bacterial infection. This would naturally
be supposed, since most of the corn and corn preparations which
are used as food have been cooked, and thereby subjected to a
sterilizing temperature. It is of interest to note in this connection
that I have recently had an opportunity to interview several native
Italians of the peasant class, who had some knowledge of the dis-ease,
and they invariably assigned as the cause the eating of polenta
three times a day ; and they attached considerable importance to the
fact that it was eaten three times a day. I am unable to determine
the exact character of diet previously used by any of my cases, but
there is good reason to suppose that corn was extensively eaten, and
it will be conceded that this prime etiologic factor was present.
Locality within the State seems to have no particular influence,
as the twelve cases were distributed impartially over the territory
extending from Robeson to Madison counties. All of these cases were
women, which fact is at variance with the common teaching, since
the two sexes are supposed to be equally susceptible. The negative
bearing of this circumstance is eliminated by the fact that at the time
these observations were made my service was confined to the wards
for women. In the epidemic occurring at IMouut Vernon, Alabama,
and reported by Dr. Searcy, eighty out of eighty-eight affected were
women. The average age was thirty-eight years. Nine out of the
twelve cases ranged from thirty-eight to forty-five, which is of no
special significance, unless it be that the nervous instability conse-quent
upon the approach of the climacteric in some way predisposes
to the disease. Eight, or two-thirds of the twelve cases, showed first
mental symptoms in either April, May, or June, and two others in
July and August. Allowing for the slight delay in the occurrence
of mental disturbance in these two cases, we have ten out of twelve
occurring in conformity with the usual seasonal incidence of the
disease, it being understood that most cases develop or recur in the
spring or early summer months. There was a total absence of
heredity in all but two cases, and in these it was remote—an insane
uncle in one and an insane niece in another. Neither was there any
instance of parental consanguinity.
TWELFTH BIENNIAL REPOET. 55
Absence of these factors, which are hnportant in the causation
of most insanities, points to the exogenous character of the disease
and renders it less likely that the ordinary insanities have been
confounded with this series of cases. All, with two exceptions, were
exceedingly poor, and most of them bore evidence of having undergone
extreme privation. These conditions, no doubt, contributed to the
development of the disease, both by the malnutrition consequent upon
an insufficient diet and also by the fact that poverty of that degree
usually necessitates the use of corn to a greater extent than is
customary with people in better circumstances.
All the cases under consideration having, before "coming under
observation, reached a condition of extreme mental alienation, it
naturally follows that we are dealing with latter stages of the dis-ease,
and data concerning the earlier symptoms are lacking. It
appears from the histories given in the commitment papers that in a
vast majority the mental symptoms were preceded by or associated
with ill health, being in all probability nothing more than the las-situde,
general debility and digestive disturbances common to the
earlier stages of the disease. In fact, a rundown condition, debility,
indigestion, general catarrhal condition of the intestinal tract and
like troubles are specified in several cases.
The beginning of the psychic disturbance was usually marked by
a period of anxiety and worry, undue importance was attaclied to
trivial affairs and misfortunes were apprehended. Occasionally un-usual
religious interest was manifested. Tins was followed by a
disturbance of perception and the development of hallucinations,
usually auditorj-, though occasionally visual as well. Judgment was
profoundly disturbed, giving rise to delusions, which were char-acteristic
ill that they were, with only one exception, depressive and
painful in nature, though they lacked the self-accusatory quality
of the usual delusions of simple melancholia, being rather of fear
and suspicion; or more specifically, one thought that she was to be
burnt up; another, that she was burning in torment and her child,
recently dead, was also in hell. Still others thought that poison
was put in their food or that they were to be hurt or injured in
some way.
At this stage tlireats and attempts at suicide were rather frequent,
and occasionally homicidal tendencies were present. Two cases
showed very decided emotional instability. As the disease progressed
memory became grossly defective and orientations as to time, place,
and persons was imperfect. Incoherence of speech was common
and was usually of the most desultory variety. Neither distractibility
nor true flight of ideas were observed at any time. There were in-stances
of mutism, the patient appearing dazed and failing to respond
to questions and orders of the simplest kind, due probably to clouding
of consciousness and a failure to comprehend.
56 NORTH CAKOLINA BOARD OK HEALTH.
Motor restlessness and insomuia were prominent, with a disposi-tion,
even when extreme wealiness was present, to get out of bed,
tangling and scattering the bedclothes about the room in the most
aimless manner, and a kind of senseless resistance was made to
efforts at examination. A total disregard for cleanliness soon ap-peared
and all became extremely untidy in habits; this from mental
hebetude and indifference rather than viciousness.
There was an early failure of appetite and frequently absolute
refusal of food (often due to delusion), necessitating forced feeding
with nasal tube.
These mental symptoms without remission steadily grew more and
more pronounced until a condition of complete armentia ensued,
and. coupled with the physical weakness present, was not unlike the
so-called typhoid condition, and especially so when the delirium as-sumed
a muttering character. Coexistent with the mental condition
described there was invariably present an eczematous involvement of
the skin, varying all the way from thickened, I'oughened and pig-mented
condition, with a tendency to fissure, to a typical exfoliative
dermatitis. These skin changes were distinctive in that they were
limited to exposed areas, the backs of the hands escaping in no in-stance,
and in this location the milder cases strongly suggested sun-burn.
The involved surfaces were uniform and ended abruptly,
usually at or just above the wrists. The line of demarcation was
very distinct and correspondingly close to the limit of protection
afforded by the sleeve or arm covering. The eruption occasionally
appeared on the face, especially at the angles of the mouth, and once
upon the forehead, but was not observed on the feet.
There was a tendency toward pigmentation and scaliness over the
bone prominences, even where protected by the clothing, and espe-cially
so where counter pressure was exerted. This was most marked
at the point of the elbows, the front of the knees, though at these
places it was never as severe as when exposed to the action of the
sun's rays.
The nervous disturbances consisted in exaggeration of the dual
reflex, coarse intention tremors, ataxic and choreic movements of the
extremities, especially the arms ; and later this inco-ordination fre-quently
involved speech, rendering it halting, slurring, and finally
inarticulate.
The pupillary disturbance was slight, variable and inconsistent.
As the end approached there was a general spastic condition of the
muscles, with marked retraction of the neck and head, and a mere
tap at almost any part of the body would excite a slight tetanic con-vulsive
movement. Diarrhoea was usually present, characterized by
obstinacy and an exceedingly offensive and putrescent odor of the
dejecta.
TWELFTH BIENNIAL REPORT. 57
All twelve cases terminated fatally. The course of the disease was
rather rapid. The average duration after the beginning of the mental
symptoms was three and one-half months. The average duration
after admission to the hospital was forty-four days.
The foregoing mental symptom-complex, although somewhat con-tradictory,
or at least inharmonious, might be to some extent as-sociated
with any of the toxic or exhaustion psychoses, since many
of the symptoms mentioned are common to most of these conditions.
without regard to the particular morbific influence in operation, and
it was only by the somatic disturbance invariably present, chief
among which were the skin lesions, that differentiation was possible.
I am aware that the number of cases studied is rather small and
the records from which the histories are taken too incomplete to
altogether justify a dogmatic statement, yet I believe that sufficient
has been said to show the similarity of these cases to the descrip-tions
of pellagra given in the classic writings on the subject.
And I would say. further, that this paper is not presented with a
view to adding anything to the literature of the subject, but rather
in the hope that I may. in some measure, at least, aid in directing
the attention of the profession in general to a danger which possibly
threatens us, since an early recognition is all-important, for it is
only by prophylactic measures that we can hope to accomplish any-thing.
To show that this danger is not altogether imaginary. I will say
that out of twenty deaths occurring among women in the State
Hospital at Morganton during the past year, five, or 25 per cent,
granting the correctness of diagnoses, were attributable to this dis-ease—
a number in excess of those assignable to any one cause,
tuberculosis included.
DISCUSSION,
De. W. p. Whittington, of Asheville, X. C. : Mr, Pres-ident,
I just want to add a few words in the report of a
case that I saw a few j'ears ago. A joung man in good physi-cal
condition went from Asheville to Pittsburg, Pa., and
while in Pittsburg, after being there two or three months, he
contracted what I now know to be pellagra. He went under
the treatment of different physicians there for about two
months, expecting to get well, but he got worse all the time.
He stopped at Greenville, in East Tennessee, abont a month,
where he was under the care of a physician he knew, expect-ing
to improve, but got worse all the time. He then returned
to Asheville, having had the disease about four months after
58 NORTH CAROLINA BOARD OF HEALTH.
be left Asheville. He called to see me after he got back, and
I knew there was something the matter with the intestinal
tract. He seemed to have gastro-enteritis. He bad that char-acteristic
erythematous condition on the hands, extending up
to the wrist, as far as the band was exposed to the sun. He
Avas very much emaciated and I thought he would die, but I
put him on treatment for the symptoms, not knowing ivbat
the true cause of the condition was.
I want to mention the treatment, not knowing whether his
coming back to North Carolina, where we have better corn,
cured him, or he got well from some other cause. I gave him
nitrate of silver, bismuth and opium. After that I put him
on arsenic, and in three or four months the man appeared to
be perfectly well, and is well to-day, five years, and has had
no' recurrence whatever.
Another case mentioned by Dr. McCampbell, of Morgan-ton.
It was a lady attacked with similar symptoms, but soon
after she was attacked her mind became involved and she was
sent to the asylum and there died.
I merely mention these cases. I did not know what they
were at the time, but afterwards learned that they were pos-sibly
pellagra.
One of these, I think, originated in Pittsburg, Pa., and the
other had not been out of Buncombe County, and was due,
perhaps, to the infection received there.
Dr. I. M. Taylor, Morganton, l!^, C. : I have seen in my
practice, I believe, five cases which I can account for as pel-lagra.
Of these, four have died ; the other seems to have
made a recovery. Three of these were men and two women.
Three were intemperate people, and I accounted for their
skin condition as the result of alcoholic abuse.
I confess that I have never made a diagnosis of the dis-ease,
and only since this discussion has ojDened in the journals
and since reading the paper of Dr. Babcock have I recognized
that I had been dealing with this condition.
TWELFTH BIENNIAL REPORT. 59
I accounted for the general skin and nervous symptoms as
malnutrition, and, in the case of two men and one woman,
directly due to alcoholic abuse.
Dk. Stiles : I have seen two cases, one in South Carolina
and one in Alabama, both recorded by the i^hysicians who
had them in charge. In one of these cases my examination
was made and coincident thereto parasitic infection was
found.
The question is raised. Is not pellagra of parasitic infec-tion
? If it is, it is something new to me.
The two cases that I saw, in Alabama and South Carolina,
one is totally different from any symptom I ever saw.
In connection with the alleged cause it is interesting to
note that it is particularly in Antwerp, Bremen and Copen-hagen
that complaints have been made regarding spoiled
corn ; and yet in that part of the world pellagra is unknown.
I mention this as an interesting fact—that spoiled corn
does not seem to cause the disease.
Dr. W. S. Rankin : I desire to report a case, that is in-teresting
in the light of this recent and valuable work on
pellagra.
The patient, a young man twenty-five years of age, a stu-dent
at Wake Forest College, has suffered every spring and
summer for the last three years with a peculiar skin lesion.
The lesion, svmmetrical in distribution, consists of an ab-normally
smooth, hairless, slightly red and sensitive skin,
about the size of a dollar, on the dorsal surface of the hands
just above the metacarpo-phalangeal articulation.
Knowing Dr. Wood's interest in the relation of malaria to
Raynaud's disease, and believing this case to bear some re-lation
to some of the varieties of Raynaud's disease, I referred
the case to him.
At his suggestion the patient began a course of Fowler's
solution, but was unable to note much change in his hands.
In April of this year the patient consulted my colleague,
Dr. Gaines, whose attention had been attracted by recent liter-
60 NORTH CAROLINA BOARD OF HEALTH.
ature to the relation of certain skin lesions to intestinal in-toxication
as evidenced hj well-marked indicanuria. and the
relief of the skin lesions hj medication addressed to his in-testinal
trouble.
On examining the urine a well-marked indicanuria was
evident.
The patient was given sodium phosphate enough to produce
two motions a day, with salol 5 grs. every four hours. Within
two weeks the skin lesions had almost disappeared.
Since Dr. Stiles has mentioned it, I am almost sure that
two years ago I found this man with a very light uncinariasis.
De. Dalton : I would like to make an announcement.
Over at ISTissen Park we have a supper prepared for the So-ciety
which will be ready at 7:30, and as soon as you can
adjourn you take the cars going south at once.
Dk. Thomas : Gentlemen, it is not necessary for me to
repeat such a pleasant invitation as that. I am sure it will
appeal to you.
If there is no more business before the conjoint session
we will now adjourn.
The session is now adjourned.
THE NORTH CAROLINA ASSOCIATION FOR THE PREVENTION
OF TUBERCULOSIS.
MINUTES OF THE SECOND ANNUAL MEETING,
MOREHEAD CITY, JUNE 12, 1907.
The second annual meeting of the North Carolina Associa-tion
for the Prevention of Tuberculosis was held at More-head
City on June 12, 1907. President M. L. Stevens w^as
in the chair. There were present about twenty members.
The minutes of the last meeting were read and approved.
The President read a report of the work accomplished
during the past year. Upon motion, the report was accepted.
Dr. Templeton moved that the present officers of the As-sociation
be re-elected for the coming year. The motion was
carried.
Dr. Benjamin K. Hays was elected delegate to the National
and to the International Association, to be held in Washing-ton
City next year ; Dr. I. M. Taylor, alternate.
A committee, composed of Drs. J. Howell Way, C. M.
Poole and J. R. Williams, was appointed to solicit member-ship.
A time for holding the meetings of the Association was
discussed. Dr. Way suggested that the Secretary arrange
with the Secretary of the State Medical Society for an hour
(or more) of the time of that body. Upon motion, this
was carried.
There being no further business, the Association ad-journed.
Benjamin K. Hays,
Secretary.
MINUTES OF THE THIKD ANNUAL MEETING,
WINSTON-SALEM, JUNE 18, 1908.
At 12 o'clock Dr. C. A. Julian, Vice President, called
the body to order in the lobby of the Hotel Zinzendorf, Win-ston-
Salem, N. G.
Dr. W, L. Dunn, of Asheville, N. C, was elected Presi-dent;
Dr. John Eoy Williams, of Greensboro, N. C, was
elected Vice President; Dr. C. A. Julian, of Thomasville,
N. C, was elected Secretary and Treasujer.
The following members of the Association were present at
the meeting:
Drs. L. B, Morse, John L. Williams, W. C. Bronson, H. C.
Weaver, W. L. Dunn, H. T. Bahnson, J. Howell Way, C. A.
Julian, Richard H. Lewis, William M. Jones, Isaac M.
Taylor, J. F. Highsmith, Hon. ClementManly, Drs. William
Bolton, P. E. McFayden, E. M. Summerell, D. A. Dees,
A. W. Knox, J. B. Smith. J. A. Turner, J. E. Reitzel,
Charles R. Wharton, E. C. Laird, W. P. Whittingion, J. C.
Grady, H. H. Briggs, W. S. Eanldn, A. B. Groom, J. L.
Hanes, J. P. Turner, F. O. Rogers, C. F. Harper, H. H.
Dodson, J. Allison Hodges, L. B. McBrayer, Philip Morris,
A. L. Flanders, Francis Duffy, R. G. Buchner, J. W. Long,
A. A. Kent, W. P. Beall, J. T. Burrus, G. E. Jordan, G. A.
Andrews, W. P. Reeves, J. M. Reese, H. A. Barnes and
D. A. Stanton.
The Association was organized May 30, 1906, by the com-mittee
appointed by the President of the North Garolina
Society, under resolution offered at the 1905 session. The
purpose of the Association, as stated in article 2 of the
Gonstitution of the Association, is the prevention of tubercu-losis
:
(a) By the study of the disease in all of its forms and
relations.
TWELFTH BIEI^^NIAL EEPOKT. 63
(h) Bj the dissemination of knowledge concerning its
cause, prevention and treatment, and by supplementing the
work of the State Board of Health in this cause.
(c) By such other means as may from time to time be
deemed advisable.
This