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s library of QIl)c Uutccrsity of Hortl] darolina COLLECTION OF NORTH CAROLINIANA ENDOWED BY JOHN SPRUNT HILL of the class of 1889 C(3(l\- 3V^fc^ \ This book must not be token from the Library building. ^v^^ «^\\,v^-^^^^'#AVWS!> Form No. 471 :B"criL,x^E:'xi3sr OF THE North Carolina Board of Health. Published Monthly at the Office of the Secretary of the Board, Raleigh, N. C. Geo. G.Thomas, M.D.,Pn's., Wilmington. I AV. P. Ivey, M. D Lenoir. S. Westray Battle, M. D...AsheviIle. ] IJkancis Duffy, M. D New Bern. Henry W. Lewis, M. D Jackson. i W. H. Whitehead, M. D Rocky Mt. J. L. Nicholson, M. D Richlanda. I J. L. Ludlow, C. E Winston. Richard H. Lewis, M. D., Secretary and Treasurer, Raleigh. Vol. XIX. APRIL, 1904. No. 1. Notice to Pliysicians. According to the jDrinted rules of the Biological Laboratory, it is closed during the month of June to allow the Biologist, who has no assistant, his well-earned va-cation. This year he will take his vaca-tion later, of which due notice will be given. So, physicians desiring labora-tory work can have it done without in-terruption until they receive such notice. Anunal Meeting of the State iMedical Society and of tlie Board of Healtlt. These bodies will meet in Raleigh on Tuesday, the 24th instant. At 12 M. on Wednesday the conjoint session of the two will take place. It promises to be unusually interesting and instructive, and it is earnestly desired that every superintendent of health 'who possibly can will attend. Such gatheriners are always helpful, and it is well for us to get together at least once a year and compare notes. Dr. Kriiext P. Foster, Dr. Abuer Alexander. It is with sincere regret that wc chron-icle the passing away of these two good men. Dr. Foster, at the time of his death, was Superintendent of Health of Franklin county. He was always the courteous gentleman and conscientious official.. The same can be said of Dr. Alexander. The latter was for several terms a member of the Legislature, and we wish to put it on record that the cause of the piiblic health and the medi-cal profession never had, in the writer's experience, a more earnest and, when his party was in power, a more efficient friend in the General Assembly. May they sleep well. / a \ •^ w-^ ^v^ . b ^..,. ^ ' h c •^ J . . * ' * no 1. ^ / c i^ a Z) y; ... f P'^ f a ^ d FIG 2 C e w «<.v y /V->^ ^v /% y k 0, Fio 3 o Plate 1.—Fig. 1. Parasite op Quartan Malaria. Fig. 2. Parasite op Tertian Malaria. Fig. 3. Parasite op Pernicious Malaria. BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. Tlie Kllolo$>;y of Malaria. BY GERALD MCCARTHY, Biologist N. C, Board of health. The disease variously called "Malaria,"' ''Chills and Fever," "Ague," and other names, was clearly recognized by physi-cians in the days of Aristotle. It was then as now the peculiar scourge of swampy regions, more especially in warm climates. But until comparatively recent times malaria was a common and fatal disease even in northern countries. Up to the beginning of the eighteenth cen-tury malaria of the chronic, pernicious type was epidemic and very fatal in England. During the same centurj', ow-ing to the great advances in hygiene and the improved condition of the houses of the common people, the disease lap-idly declined, and soon after the begin-ning of the nineteenth century became practically extinct in England. At the present time on the continent of Europe a line drawn along the tops of the Pj're-nees mountains and following the Lyo-nais mountains through Lyons and the upper Rhone valley, thence following the tops of the Alps and through the valley of the Danube by Vienna, thence along" the tops of the Carpathian moun-tains and northerly through Russia, un-til lost in the swamps of the Dneiper, will divide the continent into two parts, north of which line malaria is now rare and sporadic, while south of the line it is endemic, and like a smouldering fire ever ready, on the relaxation of hygienic measures, to burst forth. In the north-ern region of Europe ^only the tertian form is known. In the south the quar-tan form predominates, and in regions notorious for bad hygienic conditions the chronic and pernicious form is common. In North Carolina so far the Laboratory of the State Board of Health has received no blood sample showing the quartan parasite. Only the tertian form of ma-laria seems to exist in this State. In all legions of the north temperate zone the three winter months—December to Feb-ruary, inclusive — show the minimum prevalence of malaria. The maximum in the northern regions is from May to September. In the more southern re-gions the maximum occurs from August to October. THE CAUSE OF MALARIA. Up to the year 1880 the universal opinion, even among well-informed phy-sicians, was to the effect that malaria was an air-borne disease, due in some �� mj-sterious way to emanations from de-caying, water- soaked vegetation. In the year named Dr. LaA'eran, a French army surgeon, first clearly demonstrated the connection between the disease and a protozoan parasite, which is always found in the blood during acute attacks of malaria. Since 1880 numerous inves-tigators in Italy, Germany, America and England have verified and extended Lav-era n"s observations. The most recent and important advances in elucidating the etiology of the disease are due to the work of English physicians, among whom the more noted names are those of Man-son, MacCallum and Ross. Ross first clearly determined by the experimental method that the malarial parasite dur-ing different parts of its life-cycle lives in the bodies of humans and mosquitoes. Further he showed that only mosquitoes of the genus Anopheles act as malaria-carriers for humans. The common mos-quitoes of our houses, in both seacoast and upland regions, is not Anopheles but Culex. Culex acts as a disseminator of malaria among birds but not among hu-mans. BULLETIN OF THE NOETH CAROLINA BOARD OF HEALTH, THE LIFE HISTORY OF THE MALAKIA PARASITE. Tliere are two very distinct species of the malaiia organism. These are desig-nated HceinumoEha tertiaiia and H. quar- Uinu. They are directly correhited with the forms of malaria from which they take their specific names. The genus HcemariKjebu belongs to the natural order Sporozoa of unicellular animals, whicli order also includes the parasites causing malaria in birds and many animals and splenetic or "Texas" fever in cattle. Both species of the malarial organism are obligatory parasites and are known to exist only in the bodies of one or other of their hosts—mankind and mosquitoes. It is possible and probable that there is an as yet unknown segment in the life-cycle of these parasites. Many observations and conservative deductions point that way, but so far no one has discovered the missing link. The principal grounds for supposing the existence of an un-known segment of the life-cycle of the malarial parasites are as follows: Malaria is known to be endemic in poiticns of India and Africa where there are no human inhabitants. . The power of flight of the malaria mosquito is very slight and the creature rarely ever flies more than one mile from its place of birth. Yet it exists in uninhabited re-gions and seems able to convey malaria to chance visitors to such regions. It has long been known to physicians that the tearing up of the soil during the so-called malaria season frequently leads to malaria in an epidemic form. Finally it has been recently shown by Dr. J. M. Smith in New Jersey that the true mala-ria mosquito may exist in both of two nearby towns which, so far any one can see, have similar surroundings and same class of people, with constant intercom-munication. Yet in one town malaria may be epidemic and in the other origi-nal cases practically unknown, in Paris, France, no case of original malaria has developed within the memory of the oldest living physician. Yet the malaria mosquito. Anopheles iiiaculipennis, is not uncommon in Paris, especially in the parks and pul)lic gardens, where the pop-uliice frequently gather in large crowds. In Paris, too. t]ien> are numerous resi-dents who liad f(nnierly C(mtracted ma-lari: i in Algeria and otliei- notoriously malarious countries. Tliese persons are known to carry in their blood the resting or crescent spores of the p^irasite. From ou)- knowledge of the case and the theory, such persons must be frequently bitten by the .\nopheles. and tlieu the latter will suiely bite citi/ens wholly free from iiiabnia. (>nr present knowledge and the accepted theory of the disease wduhl require that every one bitten by the ma-laria- infected Anopheles sliould contract acute malaria, but the fact is. in Paris, at least, tliey do not. Yet this exception to the rule does not invalidati^ (he oft-proven fact that there can, under ordi-nary circumstances, be no acute malaria without the bite of an Anopheles mos-quito. :\Ialarial fevers are commonly classified into the following kinds: Quotidian, or paro.xysra recurring daily; Tertian, or paroxysm recurring every second day; Quartan, or paroxysm recurring every third day. There is also the so-called Estivo-autiunnal. or pernicious form. Finally, physicians recognize clinically two groups called' respectively benign , and malignant malaria. Biologists, however, recognize but two species of parasite, and therefore only two kinds of fever—tertian and quartan. BUI-LETIN OF THE NORTH CAROLINA BOARD OF HEALTH. Till' so-called quotidian fever is merely a double infection of the ordinary tertian and the so-called Estivo-autnmnal fever is teitiau in a chronic or specially viru-lent form. Plate 1, Fig. 1, shows the life-cycle of the quartan parasite as it exists in the human blood—« is the blood corpuscle just infected: b, c, d, e, f, show successive advances in the matui-ity of the parasite; g and /; show the beginning of sporulation. Figs. / and / are two extra-corporeal conditions of the fullj-- grown spore. One should be flagellated, but fiequently at this pait of the cycle the i^arasite seems to live an arrested life for a while and then degenerates and fall to pieces. Plate I, Fig. 2, shows the life-cycle of the tertian parasite; a, h, c, d, c and / show siiccessiA-ely maturing phases of the parasite Avithin a blood corpuscle; g and /( are the sporulating stages. In quar-tan fever the stage g resembles a sym-metrical daisy-like figure; in tertian fe-ver this phase resembles more a Ininch of grapes: / and _;' are extra-corporeal, sexual forms or "gametes" of the spore— - the llagellate form being the male. These coalesce and recommence the grand cj^cle, but only outside the human lx)dy, i. e., natnirally within the body of the mosquito, who lias abstracted the spores with blood from some malaria-infected person. In the liuman body alone the cycle ends at /(, where the non-sexual spores break from the corpuscle in which they had developed, and after being carried about in the blood .stream for awhile thej- find their way into new corpuscles and so begin again the cycle until the disease is checked by quinine or other causes. The bursting forth of the spore is con-commitant with the chill' stage of the disease, while the renewed attack of the spores upon the blood cells is the cause of the fever stajje. Plate I, Fig. 3, shows tiie life-cycle of tlie malignant or pernicious forms; a, b, c, d, e, /', are the successive stages as in the two preceding Hfiurcs; g shoMS a double infection of a l)lood corpuscle, conunon in malignant malaria; I and j are the sporulating stages; k is the cres-cent or '"resting- spore stage'' of the para-site within the human body; /, in, n, o, are stages of the development of the crescent into the flagellate form. These latter changes take place only otitside of llie human body, ('. c, in nature they occur only within the body of the mos-quito. But these changes also may take place in a sample of malarial blood kept tinder the microscope on a glass slide. 5a- __. Fig. 4 is another il-e?£ l N lustration of the life-gs^ bo.' \ cycle of the pernicious \ form of the malarial ; ; parasite within the hu- ^ ^'^ \ man body. 1 is the spcrozoit introduced ^^ba- . into the blood by a bite of Anopheles mos- ^ su' quito; 2 shows the original sporozoit mul- . / tiplied three fold; 3 ^ "" / shows a blood corpus- / cle invaded by one of -® * / the parasites. At 5a- I-VI the parasite com-j.^,.-'' pletes the cycle to the free-spore stage, when '^^ 1 it is ready to begin "T again, as at 3. Fig. 4.—Life Cycle of the Malarial Parasite IN THE Human Body. ^^'e have followed the successive phases of the cycle of the parasite within the himian luxly. \Ahen an Anopheles mos-quito sucks into its own body ])Io(mI containing tlic crescent or resting spores 6 BULT.ETIN OF THE NORTH CAROLINA BOARD OF HEALTH as previously shown, the crescents soon proceed to develop into the forms shown at i, j, Figs. 1 and 2, and at n, o, Fig. 3. In all of these figures the rounded form represents the female gamete and the flagellate form the male gamete or body. The result of the sexual fusion is the production of a slender, rod-like- form resembling 1 in Fig. 4, but wholly differ-ing from that form in physiological sig-nificance. The new form in the body of the mosquito soon penetrates the wall of the insect's stomach and attaches itself to the exterior surface of that organ. There it forms around itself a sort of cyst, and within this it develops a vast number of spores which soon in turn rupture the walls of the cyst and swim free for a time in the body cavity of the mosquito. Eventually, by some unknown attractive force, the new sporozoits gath-er into the salivary gland and duct of the mosquito and there remain ready to infect a new human victim as soon as the mosquito bites again. The mosquito injects the parasite with the venom that these insects always inject into the blood when they bite, in order to render the blood more fluid and easier to suck in. In each and every stage here described, those not illustrated as well as those pictured, the phases and changes in the complete life- cycle of the mosquito are described from actual specimens and dis-sections. There is no theory in it, nor is there anything taken for granted. Every stage as described is absolutely known to exist, and the fact may be verified by any one possessing the nec-essary apparatus, time and skill. The best time to find the parasite in the human blood is six to eight hours before or after a chill. The crescent forms are never found in acute cases until after some weeks of fever. The ear is the best organ to puncture. A new steel pen with one nib removed is the best lancet. This need not be steri-lized, nor is it necessaiy to wash the ear with alcohol. Stretch skin lightly over fingers and drive the lancet in one-eighth inch with a single rapid blow. Do not press or knead the part. Discard first few drops. Blood is best examined fresh and unstained with one-twelfth inch oil immersion lens. A lower power is not satisfactory. In pernicious ma-laria the destruction of blood corpuscles is rapid and very great—often four-fifths the normal number are destroyed by the parasites. THE DIFFERENT SPECIES OF MOSQUITOES. In the Eastern United States we have only two genera of mosquitoes of much economic importance. These are Culex, the common brown-legged, clear-winged mosquito, of which we have about twen-ty- two species, but only two of real im-portance. These are C. pipiens, the com-mon house mosquito of the upland coun-try, and C. sollicitans, the ring-legged salt-water mosquito, which is the more common species within twenty miles of the seashore. The malaria mosquito is Anopheles, of which we have three spe-cies, but one is quite rare. Of the other two, Anopheles maculipennis, the '"speck-led- winged mosquito," is the malaria species; the other species, A. punctipen-nis, "smoky-winged mosquito."' The lat-ter is suspected but not certainly known to convey the malaria germ when it bites. The other species has been proven beyond cavil to be a common carrier of the in-fection. Until we are better informed, however, we should, as a matter of safety, wage an uncompromising warfare against all Anopheles mosquitoes, and need not even spare Culex. Fig. 5. — Anopheles Maculipennis. (After Howard, Bull. 25, U. S. Dept. Agr. ). Fig. 6.—Eggs ok Anopheles. *: After Howard, Bull. 25 U. S. Dept. Agr. BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. Fig. 5 shows Anopheles maculipennis, and at the riglit a hirva or wriggler" male at left, female at right. Fig. 6 of Culex. Fig. 8 shows another view of shows the eggs of Anopheles as usually the same larva as they lie feeding in the laid l)y the insect upon water, and Fig. 7 shows at left the appearance of half-grown larva or 'wrigglers," two stages. water. Anopheles above lies just below the surface; Culex below lies in an ob-lique direction from surface. Fig. 7.—Larv^ Forms of Anopheles (at ( After Howard, Bull. These illustrations of mosquito larvae should be carefully .studied by every one living in a malarious neighborhood. As will be seen, the appearance of the An-opheles and Culex larva are very dis-similar, and it should be an easy matter to determine which genus we find in our rain-water barrels, or in chance pools, ponds or ditches within a lialf mile of the house. Whenever the narrow-headed, slender wriggler is found in any pond or other water, that water should at once be removed by drainage or the sur-face should be kept covered with a thin stratum of oil, as will be described fur-ther on. .As a general rule, the wrig-glers found in rain-water liarrcls and in left) and Culex (at right) Mosquitoes. 25, U. S. Dept. Agr.). foul or polluted ditches or ponds near houses belong to the genus Culex. But Anopheles is frequently founfl also in such places, though it prefeis remoter pools where green alga and water plants abound. Neither genus is likely to be found in ponds or vessels containing tad-poles, crabs or fishes. Ditches and pools having weedy or grassy margins are ex-cellent places to look for Anopheles lar-va'. I'he Anopheles thrives in salty or brackish watei', according to Dr. .J. ~Sl. Smith of New Jersey, who has for the last few years devoted much time to the study of the celebrated and fciocious mosquitoes of that State. BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. In addition lo minnows, wliicli are probably the best anti-mosqnito animals, the more important enemies of moscpiito arc water-beetles and bu<>s, which are nearly always carnixorons, frogs, tad-poles, drasfon-flics and insectivorous l)irds. Fig. 9.—Pupal Form of Anopheles. (After Howard, Bull. 25 U. S. Dept. Agr. I. Fi»'. fl sliows the pupal form of An-opheles, lliis is tlie stage intermediate between the larva and the winged forms. It usually lasts but a day or 1 wo. Fig. 10 shows the egg masses and hir\a of C'ulex. witli one enlarged wriggler at right. l-'ig. 11 shows the |)upal stage of Culex. .\s will be HDliceil, i1 is niuch snniller tli.ui the similar phase (if Anopheles. Fig. Li shows tlie mature form of ('iilc.v pijiicii.s. the (•<i)inn(in house mn-,(|nilii of (inr uplands. The female is pictured above, the male hclow. I"'cw ])ci's(ins excr sec a male mostpiito. The males iic\ci- hilc. They li\c up<m frnil juices .ilonc and as a iiilc ne\'cr come into linu-cs or .iliglil upon peo])le's hands or face. The female nn>sqnito 10 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. Fig. 10.—Egg Masses and (From Harward, Bull, alone is blood-thirsty. This particular and favorite beverage of the female mos-quito is supposed to be correlated with her egg-laying duties. It is imagined that mosquito eggs will not mature un-less stimulated by human blood, but as Fig. 11.—Pupal Form of Culex. (After Harward, Bull. 25 U. S. Dept. Agr. I. Larv^ form of Culex. 25 U. S. Dept. Agr. i. millions of mosquitoes live and propa-gate in swamps remote from human hab-itation, it is impossible that they can always secure blood to stimulate the activity cf the ovaries. It is important that every person ex-posed to punctures of the malaria mos-quito should be able to distinguish the mature or winged form of Anopheles from the winged fonns of the Culex mos-quitoes. The following are the more ob-vious distinctions: Culex is comparatively smaller and more heavily built; Anopheles is larger and lighter. Culex has comparatively short legs and when at rest is graceful in appearance; Anopheles has very long legs and appears clumsy when at rest. Culex has clear wings; Anopheles has black spotted or smoky wings. Culex when standing on a more or less level surface or biting lias the body nearly parallel with this surface and the head BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. 11 projects beyond the front legs; Anophe-les in a similar situation has the body oblique or nearly perpendicular to the supporting surface and the front legs are away beyond the head. The body of Culex is humped or bent at the tho-liibeinates in the holes left in trees and dry banks by swallows, squirrels and other wild burrowing creatures. Culex seems more tender than Anopheles, and always disappears early in the autumn. Anopheles may usually be found flying Fig. 12.—Mature Form of Culex (Female above). (After Howard. Bull. 25 U. S. Dept. Agr.). Tax; that of Anopheles is nearly a straight line from the tail to the beak. The upland Culex and Anopheles mos-quitoes pass the winter in the winged state. They lie hidden in cellars, stables, attics, and in the hollows of trees, etc. Anopheles also, according to Dr. Smith, as late as December in North Carolina, and in houses or cellars heated by a furnace these insects may remain active all winter and bite people, conveying malaria at any time. As we have said, the upland Culex breeds only in water not very .saltv, but it may be vei'v foul. 12 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. The seacoast mosquito breeds only in salt or bracki.sli water, never in fresh water. Anopheles can breed in water either fresh or salt, but is not usually found in streams or ponds grossly pol-luted, by sewage. The running of citj-pools, hollows of trees, and among water plants lining the margins of ponds, etc., make the extermination of this species in any given locality impracticable. We must lie content to repress it to keep its numbers down. The limits of practica- FiG. 13.—Resting Positions of Culex (above) and Anopheles (below). (After Howard, Bull. 25 U. S. Dept. Agr.). sewage into streams does not, therefore, tend to induce or increase malaria, as many seem to think. The facility with which the malaria mosquito can hide during the cold season and breed in any sort of water, and even in vcrv shallow jjle work are, however, quite important. We can at a coinparativelj- small cost reduce the prevalence of all the mosquito pests to from three-fourths to nine-tenths the ordinary uncontrolled numbers and annoyance. Drainage is the great and BULLETIN OF T]IK NORTH CAROLINA ROARD OF HEALTH. all-iuiiiortant leinedy for mosquitoes. The (Iniiiiaye must be tlioiuugli, so as to leave no hollows or pools. Even the depression made by the foot of a man walking o\er soft ground may ser\e to bleed hundreds of mosquitoes. Perma-nent bodies of water sliouM !)( stocked witli tish, especially the tup minnow — FuikIuIks in fresh and (lit inbHsiu in salt watei'. Pikes and other predacious fishes are not desirable in such ponds, as they destroy the useful insect-eating lishes. The margins of all ponds and sluggish creeks should be kept free from weeds and grasses. Sluggish wateis which caiuuit l)e stocked with tish should l)e oiled with crude petrolemu once every three or four weeks from June 1st to November 1st—one ounce of oil to fifteen square feet is suflficient. Fishes are better than oil. and as oil is liable to destroy the tish in a ]i(ind or stream, it should not be used wlicrc i1 is possible to stock the water with minnows. Aqua-tic water insects, crabs and frogs should never be harmed, as they do good work in reducing tlu' numbers of mosquitoes. Finally it must be said that mosquitoes breed only in stagnant or very slow-flow-ing and shallow waters. Bold streams with rapid currents, or lai'ge deep ponds with clean margins, will not breed these pests. There are every season advertisements of the wonderful anti-malarial effect of some new tree or plant when grown near houses. The only grain of truth in these stories is that all fast-growing plants cause the ex'aporation of a consideiable amount of water from the soil. One plant is ;is good as another f(n- this j)Ui]M;se if the same amount of leaf sui-face is exposed to the sun. Hut drainage by ditching and the otiier treatments above described are cheaper and far more effectual than soil-drying plants of any kind. There have been of recent years put upon the market by enterprising manufacturers many anti-nio.squito nos-trums of the usual patent, self-acting, miraculous kind. These nostrums are invariably "fakes" intended solely to convey money into the pocket of the atl- \'eitiser. There is no chemical treatment of water iov mosquitoes more etlectual or cheaper than crude petroleum. The salt-water mosquito is a daylight Hier, but the upland C'ulex and tiu' An-opheles mosquitoes are twilight tliers. Therefore to escape being iiitten by the malaria mosquito we have cnly to make our houses insect-tight with wiie screens and remain within from an hour l)efore sunset until an hour after suniise. This simple and practicable precaution is an' absolute protection against malaria, even in the most notorious uuilarial sections. Ijai-ge railroad construction gangs have in tliis way been jtrotected fiom malaria while building through swamps where malaria was known to be endemic among the natixes. In 1902 two English physicians were sent by the English war otiice to t^st the \alue of wii-e screens against malaria ity living in the district at the mouth of the Tiber in Italy. The district named has from time immemorial been noted f(n- the fatal and inveteiate type of ma-laria there endemic. The I'higlishmen took no ((uinine and went freely about among the malaiia-st ricken inhabitants, drinking swamp water t'ldiii a ditch which flowed past their door. They mide their house, whirh was ;in (irdiiiiiy st i-aw-thatched hut. insert -t ight liy hi:' ins of wire sci-eens. They weie careful lo be within doors one hour liefme >undowii and rei!iaine<l within until one hour afler NUUii^e. They kept u|) llii> life for the thi'ce most malarious month- nt' the rea-son and did not contract malaria, where- u BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. as all around them the natives were regularly shaking. This was a crucial test of the value of wire screens and is a lesson that should be remembered by physicians in malarious regions. ^\Tiere it is impossible for all persons to remain within doors during the dangerous hours as above described, the same end can and has on many occasions been attained by enclosing the head and neck in a mos-quito- proof veil and the hands in thick gloves. This veil should be of double thickness and should be carefully stitch-ed to the cap above and at bottom sewn to firm cloth flaps arranged to slip down over the shoulders and be tied under the arms. The hands must be encased in heavy leather gloves free from holes. The gloves must come well up on the arms and be tied there to prevent slip-ping off. The coat and pants should be thick enough to prevent the insect from 3)iercing through with her beak. The only other mosquito-repellant worth mentioning is oil of citronella. This oil is the commonly-used odor in cheap toilet soap. It can be bought at any drugstore. A few drops may be added to a teaspoonful of lard or a little vaseline and rubbed lightly upon the parts whicli must be exposed to insect bite. This protection is not satisfactory against Anopheles, but it is an almost certain preventative as against the sea-coast mo>quito and other Culex species. Visitors to the seashore and sportsmen in swamn^- regions, even where malaria is not feared, would do well to carry with them a small phial of oil of citonella. A few drops of this oil placed upon the pillow on retiring will prevent visita-tions from mosquitoes during sleep. Where oil of citronella may not be at "hand, a fair substitute is ordinary cheap scented toilet soap rubbed or smeared dry • on hands and other exposed parts. A fresh onion rubbed on the skin is a good repellant, as is oils of pennyroyal and lavender. But all these are inferior to oil of citronella. Review of Diseases for March, 1904. SEVEXTY-EIGUT COL NTIKS UEPORTIXG. Kinety-six counties have Superintend-ents of Health. Except in the case of the more con-tagious and dangerous diseases the Su-perintendent has, as a rule, to rely upon his own information alone, since few physicians can be induced to report cases of non-contagious diseases to him. Where the number of cases is not gi\eu, or the prevalence of a disease otherwise indicated, its mere presence in the county is to be understood as re-ported. For the month of March the following diseases have been reported from the counties named : [NLeasles.—Alleghany, in ;ill parts; Ashe, 20 cases; Bladen, 12; Burke, many; Caldwell, 20; Caswell, several; Catawba, 23; Chatham; Clay, in all parts; Cleveland, several; Cumberland; Davidson; Duplin. 10; Durham, a few; Edgecombe, several ; Forsyth ; Gaston, many; Pitt, .3; Polk, many; Rowan, 50; Rutherford, a few; Scotland, 10; Surry, a few; Swain; Union, 10; Vance, 16; Wake, 8; Watauga, 10 or 15; Wilkes, 2; Yadkin, many; Yancey, many—31 coun-ties. Whoopixg-cough.—Burke, in all parts; Craven, several; Durham; Edge-combe, a few; Forsyth; Gaston, a few; Granville, 15; Iredell, 4; Jackson, 10; Jones, a few; Martin, many; Mecklen-burg; Nash, many; Onslow, 10; Pitt, 6; Rutherford, a few; Surry, 20; Swain; Wake, 55; Wayne, a few—20 counties. BULLETIN' OF TH K XOKTH rAK<:>LINA BOARD OF HEALTil. 15 Scarlatina.—Davidson, 1 ; Forsyth, 15; Iredell, 1; McDowell, C; Randolph, a few ; Rockingham, a few ; Stanly Surry, 5; Wilkes, 1—9 counties. DiPHTiiEKiA.—Buncombe, 1; Cabarrus, 1; Cumberland, 1; Edgecombe, 2; For-syth, 4; Haywood; Lincoln, 1; New Han-over, 1; Perquimans, 1; Pitt, 3; Ran-dolph, 3; Stanly; Wake, 1; Wilkes, 1—13 counties. Typhoid Fevek.—Alamance, 2; Ashe, 2; Bladen, 1; Gates, 2; Iredell, 1; Jones, 1 ; ^ladison, 8 ; Xew Hanover, 4 ; Per-quimans, 2 ; Pitt, 1 ; Robeson, a few ; Union, 10; Wake, 7; Watauga, a few; Wilkes, 1; Yadkin, several—16 counties. Malakiai. Fever.—Chatham, Duplin, Jones, Pamlico and Pender—5 counties. ZklALARiAL Fever, Pernicious.—Chat-ham, 2. Malarial Fever, Hemorrhagic.— Pamlico. Influenza.—Alamance, general ; Cas-well; Clay; Cumberland, general; Curri-tuck; Davie, general; Gaston; Gates, Henderson, general; Hertford; Lincoln; ^Sloore ; Onslow, general ; Pender ; Person ; Rockingham ; Transylvania ; Vance, gen-eral; Wake; Warren, general; Watauga; Yancey—22 counties. Pneumonia. — Alexander ; Camden Cumberland, in all parts; Currituck; Davie, in all parts; Gates, 4; Harnett, a few; Henderson, some in all parts; Hert-ford, a few; Hyde, in all parts; Jones, 8; Martin; Onslow, in all parts; Pamlico, several; Person; Randolph; Wake, in manj' parts; Watauga—18 counties. Mumps.—-Caswell; Randolph, in many parts; Scotland; Swain; Vance, in all parts—5 counties. Roseola.—Caswell, Randolph. German Measles.—Rockingham, epi-demic. Varicella.—Clay, in all parts; Gas-ton; Scotland. Small-pox.—Alamance, 10; Anson,. 15; Ashe, 200; Bladen, 10; Cabarrus, 10; Caswell, 32; Catawba, 3; Cleveland, ti; Cumberland, 4; Davidson, 7; Davie, 7; Duplin, 7; Durham, 125; Forsyth, 23; Gaston, 4; Granville, 13: Greene, 30 or 40; Guilford, 14; Iredeil, 6; Mecklen-burg, 2; Xew Hanover, 7; Person, 1; Pitt, 4; Polk, 1; Randolph, 2; Rich-mond, 26; Robeson, several; Rowan, 2; Rutherford, 8; Scotland, several; Surry^ 12; Swain, 2; Vance, 42; Wake, 1; Wayne, several; Wilkes, 40 or more; Yadkin, 1—37 counties. Distemper, in Horses.—Burke and Clay. Xo diseases reported from Bertie, Car-teret, Dare, Johnston, Xorthampton, Pasquotank, Washington and Wilson. Xo reports received from Beaufort, Brunswick, Cherokee, Columbus, Frank, lin, Graham, Halifax, Lenoir, Macon, Mitchell, Montgomery, Orange, Sampson and Stokes. Summary of Mortuary Reports for .Tlareli, 1904. (twenty-five towns.) White. Col'd. Total. Aggregate popula-tion 8(5,150 50,550 145,700 Aggregate deaths . . 109 148 257 Representing tem-porary annual death rate per 1,000 15.2 29.8 21.2 Causes of Death. Tvphoid fever 2 2 Scarlet fever 1 1 Malarial fever 1 1 Diphtheria ] 1 Wliooping-cough .. Oil Measley 1 1 2 Pneumonia 16 28 44 Consumption 14 24 38 Brain diseases 7 4 11 Heart diseases 11 20 31 Neurotic diseases... 5 4 9 Diarrhoeal diseases 3 14 All other diseases.. 47 54 101 Accident 2 7 9 Violence 11 2 109 148 257 Deaths under five years 12 30 51 Still-born 4 11 23 16 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. Mortuary Report for March, 1904. Town? AND Reporters. Charlotte Ur. K. O. Hawley. Durliam Dr. N. JM. Johnson. Kdeutoii Dr. T. J. Hoskins. Elizabeth City Dr. I. Fearing. FayettevlUe Dr. A. S. Rose. Greensboro J no. S. Micliaux.C. C. Heiitlersoii Dr. .John H. Tucker. liaarlnbarg Dr. G. D. Everington. Lienolr Dr. S. W Shell. Lexington J. H. .vloyer,',Mayor. Marlon Dr. B. L. AshworUi. Monroe Dr. .Jno. M. Blair. Oxford Dr. S. D. Booth. Raleigh T. P. rfale, Clerk B. H. Rocky Monnt Dr.J.T.Shubrick.H.G, Salecu S. E. Butner, Supt. H Salisbury Dr. H. T. Trantham. Sonthport Dr. D. I. Watson. Tarboro Dr. Wm. J. Thigpen. Wadesboro , Dr. J. H. Bennett. Waynesvllle Dr. Thos.Stringfield, Weldon J. T. Gooeh, Mayor. Vfllmlngton , Dr. Cha.-<. T. Harper. AVllson Dr. W. S. Anderson. AVlnston Dr. J. L. Hane.s. Popula-tion. W. c. w. i;. w. c. w. c. w. c. w. c. w. c. w. c. w. c. w. c. w. c. w. c. 11,000 7,200 8,000 1,200 1,900 ."i.OOO' 3,000 2,500 2,300 6,10(1 4,000 2,100 1,700 900 6110 1,200 300 800 500 800 400 1,850 600 1,200 1,250 8,000 5,800 1,600 1,500 3,.300 Bin 3.900 2,.500 900 500 2,W0 500 1,000 700 1,600 400 700 750 Temporabt BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. 17 County Superintendents of Health. Alamance Dr. T. S. Faucette. Alexander Dr. C. J. Carson. Alleghany Dr. Robt. Thompson. Anson Dr. J. H. Bennett. Ashe Dr. Manlev Blevins. Beaufort Dr. D. T. tayloe. Bertie Dr. H. V. Dunstan. Bladen Dr. L. B. Evans. Brunswick Dr. J. A. McNeill. Buncombe Dr. D. E. Sevier. Burke Dr. J. L. Laxton. Cabarrus Dr. R. S. Young. Caldwell Dr. W. P. Ivey. Camden Dr. J. L. Lister. Carteret Dr. F. M.Clarke. Caswell Dr. S. A. Malloy. Catawba Dr. Geo. H. West. Chatham Dr. T. A. Kirkman. Cherokee Dr. B. B. Meroney. Chowan Dr. T. J. Hoskins. Clav Dr. P. R. Killian. Cleveland Dr. B. H. Palmer. Columbus Dr. I. Jackson. Craven Dr. Joseph F. Rhem. Cumberland Dr. A. S. Rose. Currituck Dr. H. M. Shaw. Dare .Dr. W. B. Fearing. Davidson Dr. Joel Hill. Davie Dr. M. D. Kimbrough. Duplin Dr. A. J. Jones. Durham Dr. N. M. Johnson. Edgecombe Dr. W. J. Thigpen. Forsyth Dr. W. O Spencer. Franklin Dr. E. S. Foster. Gaston Dr. H. F. Glenn. Gates Dr. W. 0. P. Lee. Graham Dr. V. J. Brown. Granville Dr. S. D. Booth. Greene Dr. C. S. IMaxwell. Guilford Dr. Edmund Harrison. Halifax Dr. I. E. Green. Harnett Dr. 0. L. Denning. Haywood Dr. J. F. Abel. Henderson Dr. J. G. Waldrop. Hertford Dr. C. F. Griffin. Hyde Dr. E. H. Jones. Iredell Dr. M. R. Adams. Jackson Dr. R. L. Davis. Johnston Dr. Thel Hooks. Jones Dr. N. G. Shaw. Lenoir Dr. C. L. Pridgen. Lincoln Dr. John W. Saine. McDowell Dr. B. L. Ashworth. Macon Dr. F. L. Siler. Madison Dr. W. J. Weaver. Martin Dr. W. H. Harrell. Mecklenburg Dr. C. S. McLaughlin. Mitchell Dr. V. R. Butt. Montgomery Dr. M. P. Blair. Moore Dr. Gilbert McLeod. Nash Dr. J. P. Battle. New Hanover Dr. W. D. McMillan. Northampton Dr. H. W. Lewis. Onslow Dr. E. L. Cox. Orange Dr. D. C. Parris. Pamlico Dr. H. P. Underbill. Pasquotank Dr. J. B. Griggs. Pender Dr. R. J. Williams. Perquimans Dr. C. C. Winslow Person Dr. J. A. Wise. Pitt Dr. Zeno Brown. Polk Dr. C. J. Kenworthy. Randolph Dr. W. J. Moore. Richmond Dr. F. J. Garrett. Robeson Dr. H. T. Pope. Rockingham Dr. Sam Ellington. Rowan Dr. W. L. Crump. Rutherford Dr. T. B. Twitty. Sampson Dr. John A. Stevens. Scotland Dr. A. W. Hamer. Stanly Dr. V. A. Whitlev. Stokes Dr. W. V. McCanlesB. Surry Dr. John R. Woltz. Swain Dr. A. M. Bennet. Transylvania Dr. C. W. Hunt. Tyrrell Union Dr. John M. Blair. Vance Dr. H. H. Bass. Wake Dr. J. J. L. McCullers. Warren Dr. M. P. Perrv. Washington Dr. W. H. Ward. Watauga Dr. C. W. Phipps. Wayne Dr. Williams Spicer. Wilkes Dr. W. P. Horton. Wilson Dr. W. S. Anderson. Yadkin Dr. T. R. Harding. Yancey Dr. J. L. Ray. BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. 19 [You are asked to fill out and mail one of these forms to the Superintendent of Health of your couDf.y on or before the third of each month, that he may use it in making his report to the Secretary of the State Board. Have any of the following diseases occurred in your practice during the month just closed. If so, state number of cases. Whooping-cough Typhoid Fever Measles Typhus Fever Diphtheria Yellow Fever Scarlet Fever Cholera - Pernicious Malarial Fever Smallpox Hemorrhagic Malarial Fever Cerebro-spinal Meningitis What have been the prevailing diseases in your practice? Has any epidemic occurred among domestic animals? If so, what? What is the sanitary condition of your section, public and private? General Remarks: M. D. 190 -- N. C. :B"C7IL.I-.E11:I2^T OF THE North Carolina Board of Health, Published Monthly at the Office of the Secretary of the Board, Raleigh, N. C. Geo. G. Thomas, M. D., Pres., Wilmington. S. Westray Battle, M. D...Asheville. Henry W. Lewis, M. D Jackson. J. L. XicHOLSox, M. D Richlands. W. P. IvEY, M. D Lenoir. Francis Duffy, M. D New Bern. W. H. Whitehead, M. D Rocky Mt. J. L. Ludlow, C. E Winston. Richard H. Lewis, M. D., Secretary and Treasurer, Raleigh. Vol. XIX. MAY, 1904. No. 2. House lufectiou of Tuberculosis. BY LAWRENCE F. FLICK, U. V., Director of the Phipps Institute for the Study, Prevention and Cure of Tuberculosis, Philadelphia. [We earnestly commend this admirable article by Dr. Flick, one of the highest authorities on tuberculosis, to our read-ers, and we hope that our physicians will transmit this knowledge to the fami-lies under their care, especially those having and predisposed to consumption ; and that they will be deeply impressed thereby with the great importance of the thorough ventilation of living and sleeping apartments and of the disinfec-tion of rooms occupied by consumptives. —Ed.] The kaleidoscopic phenomena of this earth as we see them around us are the result of a continuous alternation of life and death. In this beautiful pano-rama death is as necessary as life. Something is always dying that some-thing else may liA^e. Inorganic matter continuovisly is being changed into or-ganic matter and organic into inorganic. For changing organic matter into inor-ganic matter God has created the micro-organic world. A micro-organism which, perliaps, has slipped away from its natural place in organic nature, and in consequence has done much damage to man, is the tu-bercle bacillus. In the great division of organic matter it generally is cred-ited to the vegetable kingdom. In a classification of micro-organisms it is technically known as a facultative sapro-phyte. By this is meant that ordinarily it gets its living as a parasite on some higher organism, but that it may sub-sist on dead organic matter as a sapro-phj- te. In a sub-classification of micro- *Read at the Maryland Tuberculosis Exposition, January 26, 1904. From Maryland Medical Jour-nal, February, 1904. 22 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. organisms it is known as a facultative anaerobic parasite. By this is meant that ordinarily it grows in a tissue from which air is excluded, but that it may grow in some substances, under certain conditions, in the presence of air. When the tubercle bacillus giows in the tissue of a human being or of an ani-mal it gives rise to a condition which has forcibly arrested the attention of man because of the suffering, sorrow and misery which accompany it and follow in its wake. In the early history of medi-cine this condition, was named phthisis and consumption. In the more recent times it has been divided into two epochs, the earlier being called tuberculosis and the latter consumption. In ear-lier times, too, the condition was ^-iewed by mankind generally as a providential visitation, the punishment for sin, touch-ing not only the immediate offender, but reaching the offspring to the third and fourth generation. Science has dem-onstrated that it is a mere episode in nature subject to natural laws and abso-lutely under the control of man's will. Man is interested in tuberculosis be-cause it is a disease. The same pro-cesses and phenomena in other fields of nature give pleasure to man, but here they give discomfort, and are followed by sorrow and misery, because man him-self is the field of operation. Tlie word disease means want of ease. Quite natu-rally, man has given much thought to how to avoid getting tuberculosis and how to get rid of it when it afflicts him. By reason of his superior intelligence, man has always been able to control his organic foes so far as visible objects are concerned, but in his fight against the micro-organic world he is confronted with a much more serious problem. Much has been done, however, to throw light upon this newly-discovered enemy, and already it is demonstrated that men need no longer get tuberculosis, and that if he is so unfortunate as to get it, he need not die of it. Unfortunately, the knowledge which makes this new dispen-sation possible is still in the hands of a few. All diseases which are caused by mi-cro- organisms are communicable. This is a self-evident proposition. Whatever is living can only come from a parent, and phenomena which are due to the growth and development of living organ-isms cannot arise except by reason of the growth and development of those organisms. There is a difference, how-ever, in the manner in which parasitic micro-organisms are conveyed from one person to another. Some are conveyed through the instrumentality of insects, some by means of water and others by contact, direct or indirect. Some para-sites have two kinds of hosts, a major and a minor host; some can reproduce themselves outside of a host, and others always remain dormant when out of the host. Parasites which have two hosts and parasites which can reproduce them-selves outside of a host can be conveyed from one person to another over long distances, while parasites which are con-veyed by contact can only be conveyed within a limited, circumscribed environ-ment. Tlie yellow fever parasite, for instance, is conveyed through the mos-quito, the typhoid fever parasite by water, and the tubercle bacillus by con-tact. All diseases which are conveyed by contact are termed contagious. Conta-gious diseases are not necessarily alike, however. There is a great difference in the intensity of contagion. The acute contagious diseases are much more in-tensely contagious than the chronic con- BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. 23 tagioiis diseases. In principle the conta-gion of all is the same, but in practice the method differs widely. Small-pox, measles and scarlet fever, for instance, are contagious in exactly the same sense as tuberculosis, so far as the principle is concerned—that is, they are conveyed by contact—but the intensity of the con-tagion is so much greater with them than with tuberculosis that practical measures for the prevention of the for-mer would in no sense apply to the lat-ter. Small-pox, measles and scarlet fever affect the whole body, and contagion is rapidly given off from the entire body. Tuberculosis is a local disease, and con-tagion is given off from one or two points only. In smallpox, measles and scarlet fever the matter which carries the micro-organisms may be invisible; in tubercu-losis it always is gross and easily seen. In small-pox, measles and scarlet fever places and things soon become intensely contaminated; in tuberculosis it takes a long time to produce such a result. In-timate association, therefore, with a per-son suffering from small-pox, measles and scarlet fever without contracting the disease is impossible unless the person thus e.xposed has an immunity from A'accination or previous attack, while in-timate association with a consumptive without contracting the disease is quite feasible. The contagion of tuberculosis, indeed, is of a kind by itself. It differs some-what from the contagion of every other disease of which we have knowledge. It is so imique that writers have had some difficulty in finding an epithet descrip-tive of it. This is the reason why many writers object to calling tuberculosis con-tagious. Some would have us call it communicable, but this term is too gen-eric. Others have suggested the epithet infectious for it, and this does not fit at all, because it has a specific meaning which only applies to such diseases as malaria and yellow fever. The most striking feature about the communica-bility of tuberculosis is that it depends almost entirely upon the house. An in-elosure of some kind is so necessary for the conveyance of the disease from one person to another that contagion is im-practicable without it. It is, therefore, with good reason that we use the phrase house infection of tuberculosis when we speak of the practical manner in which the disease is spread in a community. The word infection, of course, is used in the broad sense of conveyance, and the word house in the broad sense of an inclosure. The phrase tells pretty nearly the whole story of the communicability of tuberculosis, and covers the entire proceeding from the beginning to the end—garnering the seed, preparing the soil, implantation, rearing the tender plant, nurturing the full-grown shoot, maturing and harvesting. The house is the granary of the tuber-cle bacillus outside of its host. Were it not for the house the tubercle bacillus would soon have to perish from the face of the earth. It could not be preserved. Sunlight, air and water are its natural enemies. The water dissolves it out of its cache, and the sunlight and air de-stroy it. How long tvibercular matter may remain vital in the open air has not been definitely determined, but all agree that the time is very sliort. Even when the bacilli in such matter are not killed they are weakened so that they will not readily take root when planted. In the house, on the contrary, tubercular matter may remain vital for a long time, because it becomes dry and the broken-down tis-sue serves as a cache for the bacilli. 24 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. Even ^vhen the matter becomes finely piil-rerized so that the bacilli no longer have so much protection, it remains vital for a long time, because the sun and air can-not get to it. Ordinarily the tubercle bacillus is de-pendent upon other micro-organisms for its exit from its host. These are the streptococcus and the staphylococcus. They are pus-producing organisms, and are very adept at destroying tissue. \Yhen they join forces with the tubercle bacillus they kill and soften the tissue which has been invaded by the tubercle bacillus, and then nature casts it out. A double purpose is served in this way, the tubercle bacillus is helped out of its host and is given a protective covering to-wards preservation while out of the host. The broken-down tissue which is thrown out forms the protective covering. In the transition of the tubercle bacil-lus from one host to another we have a beautiful illustration of nature's jeal-ous care of every form of life. The tu-bercle bacillus is a motionless, helpless niioro-organism, which can grow and reproduce itself only under certain con-ditions in a definite soil, and which re-quires during the interim between its exit from one host and its entrance into another special protection, and for ad-mission into a new host special oppor-tunities. Tliese are secured for it in-directly through its toxin and the toxins of its associates. By sensations set up in the neiwous system it lures its vic-tim into the veiy place where exist the best conditions for the preservation of its species and the best opportunities of finding a new host. Consumption is the autumn of tuberculosis, the blossom grown into ripe fruit. When it comes on the Aictim, by reason of his chilliness, malaise, and general feeling of helpless-ness, seeks shelter in some inclosure, and is deluded with the idea that the farther he can get away from sunshine and fresh air the better are his chances of recovery. The house thus becomes the harvest field of the ripe tubercle ba-cillus, and the seed quite naturally falls into the very place which by nature is intended for its granary. The house also prepares soil for the tubercle bacillus. We have every reason to believe that the bacillus cannot get a foothold in perfectly healthy, normal tis-sue. It is quite likely, indeed, that pri-mordially the tubercle bacillus was a saprophyte only, and that its function in the world Avas to change dead organic matter into inorganic matter. It is easy to conceive how gradually it may have evolved into a parasite by growing on tissue which, while not dead, was much debased. At any rate, even at the pres-ent time it does not seem to be able to invade tissue until the tissue has been injured in some way, either by malnu-trition, by traumatism, or through the agency of some other micro-organism. Malnutrition is one of the most common predisposing causes of tuberculosis. Tlie physical life of man and animals is a chemical process. There is a com-bination of certain elements through the instrumentality of a living cell, with evolvement of beings endowed with life. Food, air and water are the substances used in the process. In proportion as these substances are at hand in proi>er quantities the being evolved is a healtliy one, and in proportion as any of the substances are deficient or defective the being is an unhealthy one. Of the three substances required in this chemical p»o-cess, air is perhaps the most important, and certainly the most necessary. Life mav be maintained for some days without BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. 25 food and water, but for a few iiunutes only without air. The same is true of health. A person may keep fair health on a stinted supply of food and water for a long time, but soon succumbs to a stinted supply of air. This probably is due to the fact that air plays a double role in health. It not only carries in oxygen for cheraioal purposes, but it car-ries out poisonous products of chemical action. It is believed by some that re-breathed air produces soil for the tuber-cle bacillus more through the poisonous products of combustion Avhieh are dis-seminated in the air than by reason of deticiencj' of oxygen. Probably it does by both. At any rate, housed human beings and animals are very prone to tuberculosis. Deficiency of oxygen cer-tainly leads to malnutrition. Too much food and too little air not only lead to de-fective metabolism, but throw upon the organs of the body poisonous products which must be gotten rid of to the detri-ment of the whole system. Implantation of the tubercle bacillus is greatly facilitated by the house. For implantation prolonged intimate contact with a person, place or thing which has been intensely contaminated with tuber-cular matter is necessary. The mere pres-ence of a few tubercular bacilli is not sufficient. Everybody has some resisting power to tuberculosis, and with every one there is a minimal dose of tubercle ba-cilli which will give an implantation. Xo doubt this dose differs Avith diffei-ent people, but resisting power of some kind exists to some extent in every one. Even in inoculation experiments on animals a minimal dose has been found bolow whicli injections prove negative. This minimal dose in a sense measures the individual's fighting capacity against the disease. So long as the minimal dose is not reached. an implantation cannot take place. Fre-quent warfare against a dose below the minimal dose increases the resisting power of an individual and raises the minimal dose. With animals the mini-mal dose which can give an implantation gradually can be increased until an al-most complete immunity has been estab-lished. Experiments upon animals have been made by inoculation. It is quite probable that by the natural mode of entrance of the tubercle bacillus into the system the minimal dose is larger than by inoculation. The natural mode of entrance is by the alimentary canal or the respiratory tract. At both of these I>orts of entry there is strong opjxisition to admission. The gastric juice has some germicidal powers, and all along the respiratory tract there are devices for keeping out micro-organisms. Beyond the ports of entry lie the lymphatics and lymphatic glands, and beyond these the phagocytic bodies of the blood, all of \\hich wage war against micro-organisms that maj' pass the ports of entry. From what has been done experimentally on animals and from what we have been able to observe clinically on man, we have good reason to believe that the mini-mal dose of tubercle bacilli necessary for an implantation by the natural mode of entrance is quite large. This is not a mere speculation, either. Out of every five people who are intimately exposed to the contagion of tuberculosis for a long period of time under the most fa-vorable conditions for an implantation, only one person develops the disease. This shows that implantation is exceed-ingly difficult, even under most favorable circumstances. An inclosure is the one place in which contamination with tubercular matter can become sufficienth- intense to create 26 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. an environment capable of overcoming the resisting power of man and producing an implantation. It is only in an inclo-sure that vital tubercular matter can accumulate. In the open air, water, sun-light and air devitalize it nearly as rap-idly as it is given off. Tubercular mat-ter ejected in a house, unless immediately devitalized, artificially dries and is dis-tributed about in particles vai-ying in size from big chunks to impalpable dust. In these particles the bacilli are cached and preserved. Gradually all the parti-cles are reduced to dust, either by tritu-ration, oxidation, or the action of sapro-phytes. This tubercle-laden dust settles on the walls, on furniture, and on every-thing in the inclosure. In the course of time there is qviite an accumulation of vital tubercular matter in such a place, and every time the air is disturbed tuber-cle- laden dust is set in motion. Here, then, finally is an environment capable of giving an implantation of tuberculosis. Occupancy of such a room means con-stant inhalation and frequent deglutition of tubercular matter. Tubercle bacilli continuously find their way into the sys-tem, and it is only a question of time when more have gained entrance than can be successfully withstood by the guards and disease-fighters of the body. The re-sult is implantation of tuberculosis. The kind of inclosure which offers the best environment for the implantation of the tubercle bacillus is, first, the home, and second, the workshop. The home is of all places most prolific of new implan-tations of tuberculosis. It was on this account that in by-gone days tuberculosis earned for itself the reputation of being an inhei'ited disease. Tubei-culosis is a family disease. It can most easily be im-planted around the hearthstone. It fol-lows the family tree in its distribution, and when it once gets into a family it follows that family in all direc-tions until it either has exterminated the family or exhausted the soil, and has made what is left of the family immune. Tlie part of the home in which implanta-tions most frequently take place is the bedroom, and next to the bedroom the dining-room. The bedroom usually is the place where the victim of tuberculosis spends his last weeks or months— a period during which the disease is most intensely contagious. Among the very poor the dining-room often is used as a bunking-place for the stricken one until a day or two before death. Under such circumstances the dining-room becomes very much contaminated and becomes a prolific source of new implantation. The workshop is a very common means of spreading tuberculosis. By workshop, of course, is meant any inclosure in which one or more people are employed. Tuberculosis is an extremely chronic dis-ease, and usually runs a long course even in its contagious stage before its victim is incapacitated for his usual occupation. Some people work with the contagious stage of tuberculosis for the greater part of a working life-time, occasionally being thrown out of employment for a few weeks or months on account of an exacer-bation, and again returning with as much vigor as before. Unfortunately, habits of men and women in the matter of spitting make it easy for a consumptive to contaminate his immediate environ-ment in a shop, if not the entire shop. One consumptive, perhaps, cannot con-taminate a large shop so as to produce an infectious environment of the entire shop, but he can produce an environment around his own stand capable of implant-ing the disease in one or more of those next to him, and before long he has asso- BULLETIN OP THE NORTH CAROLINA BOARD OF HEALTH. 27 ciates in the task of polluting the shop. In a workshop in which a case of tuber-culosis exists careful investigation will reveal the presence of other cases in vari-ous stages of the disease. Deaths will occur from such a shop at regular inter-vals for an indefinite period so long as the shop is permitted to remain contami-nated. Inclosures such as hotels, churches, public halls, places of amusement, and public conveyances, in which people stop for a short time only, are not apt to give rise to many implantations of tubercu-losis for two reasons. First, because a consumptive rarely remains in them long enough to produce a contagious environ-ment capable of gi\dng an implantation, and secondly, because healthy people sel-dom remain in them long enough to get an implantation. There is some danger of contracting the disease in such places for people who are employed in them in the capacity of cleaners and caretakers, but for the casual visitor practically there is no danger. Things which have been intensely con-taminated by having been used for a long time by a consumptive may give the dis-ease to others when kept or used indoors. In the open air they may be harmless, unless worn upon the person. Contami-nated furniture, carpet, and hangings of various kinds, when taken into a per-fectly sterile house, may themselves con-taminate the house sufficiently to create an environment capable of implanting the disease. The tubercular matter adhering to such articles is distributed about and settles on Avails and floors. In the open air, on the other hand, tubercle-laden dust from such articles is apt to be scat-tered about over such a wide area as to make it impracticable for any one person to get enough of it to give rise to an im-plantation. The house nurtures the tubercular gro\A-th when an implantation has taken place. Mere implantation of the tubercle bacillus does not necessarily mean a de-devolpment of a full-fledged tuberculosis. The disease always begins in a very small way, and then attracts practically no at-tention. The first crop develops and runs through its course, and a second follows perhaps a little larger than the first. This is followed by a third and fourth, each a little larger than the preceding one, and thereafter another larger still, until finally so much tissue has been invaded and destroyed as to make death in-evitable. At any time during the prog-ress of the disease prior to the destruc-tion of tissue essential to normal func-tions of the body the economy has within itself the power of throwing off the dis-ease. Autopsies prove that this often is accomplished by nature unaided by medi-cine. It probably would be accomplished in all cases were it not for the house. In the beginning of the tubercular pro-cess the tendency to recovery is so great that the slightest aid to nature may turn the tide toward recovery. The process by which recovery takes place probably is healthy metabolism—that is, a perfect change of food into tissue. Implantation has taken place because the individual temporarily has been a little below par as a result of improper food, insufficient air, overwork, dissipation, an attack of some other disease, or some such matter, one or all. Under proper conditions the implantation is rooted up before it can grow into tuberculosis. All that may be needed is a little rest, a little extra food, and a little more fresh air. In some cases recovery might take place if a little 28 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. rest could be' had, even without extra food aud air; in others if better food could be had, even though no rest could be taken and the air supply could not be changed. But in all recovery would al-most surely follow a life in the open air, in spite of bad food supply and over-work. Life in the open air enables one to digest coarser food and to do more work without fatigue than is possible in-doors. This is probably due to the fact that in the open air the poisonous pro-ducts of combustion are promptly re-moved from the system, and thus are pre-vented from embarrassing the entire or-ganization. To cure tuberculosis we must have perfect metabolism, and this we only can have when enough fresh air is taken into the system night and day to oxidize the food and cleanse the blood. Imper-fect metabolism predisposes to tubercu-losis by debasing the tissues and making soil for the tubercle bacillus. House life undoubtedly plays an im-portant role througliout the entire course of tuberculosis to its culmination in con-sumption and death. With every re-curring crop of tubercle the organs of the body become more embarrassed, and the economy is less able to carry on the warfare against the disease. When the disease is in the lungs, as it frequently is, the air supply grows less with each destruction of lung tissue. Fortunately, nature has given all air-breathing crea-tures ample lung capacity, enough aud to spare, so that a great deal of lung tissue may be destroyed without interfering ^\-ith the functions of the body, provided the air supply is right. Under these cir-cumstances other organs, no doubt, sup-plement the lungs in their functions of elimination. Everything hinges upon an ample supply of fresh air, however. When this is at hand healthv metabolism may be maintained even when the disease is advanced, and through this health may again be reached. Tuberculosis makes its progress because its A-ictim is shut up in a house where he cannot get fresh air. Unfortunately for the poor, an ample supply of fresh air is impossible. Their homes, as well as their workshops, have been constructed on a mistaken idea that Avhatever shuts out air, heat and cold is conducive to health. The large death rate from consumption really must be ascribed in a great measure to bad venti-lation in home and workshop. The last scene of conflict in tubercu-losis between the victim and liis foe is the house. Tuberculosis develops into consumption because of the house. This does not mean that people could not get tuberculosis if they lived out of doors, for birds of the air and animals of the field get the disease. Tuberculosis, however, in itself would seldom prove fatal. Both animals and human beings may go through life with tuberculosis and reach old age without being seriously incon-venienced by it. Lots of animals and people do. Dr. Trudeau has shown by experiments on animals that life in the open air greatly retards the development of tuberculosis and promotes recovery. Rabbits which he inoculated and penned up died, while rabbits which he inocu-lated and permitted to run at large main-tained good health, although they de-veloped tuberculosis. In sanitoria where consumptives are made to live out of doors wonderful improvement sets in, even when the case is incurable. Frequently all the symptoms of consumption disap-pear, and the patient becomes comfortable even when so much tissue has l)een de-stroyed that recovery is physically impos-sible. In other words, even consumption in the open air loses all its most .serious BULLETIN or THE NORTH CAROLINA BOARD OF HEALTH. 29 symptoms. The house makes and main-tains consumption, and consumption kills. Consumption may be well termed a house disease. Without the house it can-not exist. It depends upon the house for its implantation, propagation, and for evolution of all its phenomena. The house is the place where the tubercle bacillus lies dormant in wait for its host; it is the place where the new host gets his implantation; it is the place where the tubercular subject gradually becomes a consumptiA^e, and it is the place where the consumptive dies. In studying the progress of civilization in the light of modern science one is struck with the egregious blunders into which man has been led by his desire for privacy and comfort. He has built his house to keep out his enemies, to protect himself from heat and cold, and to screen himself from the curiosity of his neigh-bor. He has sought to make his home his castle, but in reality he has made it the place wherein he courts death. If man desires to free himself from the great white plague, he will have to re-trace his steps from some of what he con-siders advanced points of civilization. He will have to learn, among other things, that fresh air is God's greatest gift on earth, and that whatever shuts out fresh air shuts out health and hap-piness. In house infection he will find the key to the entire problem of stamp-ing out tuberculosis. SUMMARY. 1.—Tuberculosis is a disease due to the parasitic growth of a micro-organism on the tissues of a .human being or ani-mal. Being due to organic life, it is communicable. 2.—Tuberculosis is contagious. The contagion of tubei'culosis is different from the contagion of acute contagious diseases, however. It is slow and can be avoided easily in the presence of a con-sumptive, while that of acutely conta-gious diseases is rapid and cannot be avoided in the pi'esence of those who have such diseases. 3.—The contagion of tuberculosis is closely associated with the house. An inelosure of some kind is necessary to make it effective. 4.—Tlie house is the granary of the tubercle bacillus. It is the place in which tuberculous matter is kept vital until the bacillus can find a new host. 5.—Out of doors tubercular matter be-comes devitalized in a short time through water, light and air. Enough cannot ac-cumulate in a vital state to create a con-tagious environment. 6.—Everyone has some resisting power to tuberculosis. Some have more than others. Practically all have sufficient re-sisting power to withstand occasional ex-posure to tuberculosis and exposure out of doors. 7.—For an implantation of tuberculosis prolonged intimate exposure and an in-tensely contagious environment is neces-sary to overcome resisting power. This is had in the home and the workshop. 8.—The house prepares soil for the tubercle bacillus. RevleAV of Diseases for April, 1904;. SEVEXTY-NIXE COUXTIE.S REPORTIXG. Xinety-six counties liave Superintend-ents of Health. Except in the case of the more con-tagious and dangerous diseases tlip Su- 30 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. perinteiident has, as a rule, to rely upon his own information alone, since few physicians can be induced to report cases of non-contagious diseases to him. Where the number of cases is not given, or the prevalence of a disease otherwise indicated, its mere presence in the county is to be understood as re-ported. For the month of April the following diseases have been reported from the counties named: Measles.—Alleghany, many cases; Bladen, 15; Burke, many; Caldwell, in all p^rts; Catawba, 5; Cherokee, 35; Cleveland, many; Cumberland, many; Davidson, many; Duplin, 4; Durham, a few; Edgecombe, in all parts; Franklin, a few; Gaston, a few; Granville, 8; Lin-coln, 6; McDowell, 5; Mecklenburg, 12; Nash, many; New Hanover, 167; Polk, 3; Randolph, a few; Rockingham; Rowan, 100; Surry, 14; Swain, several; Transylvania, several; Vance, many; Wake, 4; W\^tauga, 20 or 30; Wilson, many; Yancey, several—32 counties. Whooping-cough.—Cherokee, 40; Cho-wan, 1; Clay, several; Craven, a few; Duplin, 2; Edgecombe, several; Frank-lin, in all parts; Gaston, many; Gran-ville, 6; Haywood, in all parts; Hertford, ' 7 ; Martin, many ; New Hanover, 25 ; Onslow, 3 ; Pamlico, many ; Pitt, 6 ; Ran-dolph, a few; Sampson, many; Suriy, 50; Swain, several; Vance, a few; Wake, 21—21 counties. Scarlatina.—^Durham, 3; Forsyth, 15; Randolph, a few; Rockingham, a few. Diphtheria.—Chowan, 1: Durham. 2; Edgecombe, 7; Forsyth, 3; Iredell, 1; Mecklenburg, 2; New Hanover, 1; Ons-low, 3; Perquimans, 1; Pitt, 1; Stanly, 2; Wake, 2—12 counties. Typhoid Fever.—Bladen, 1; Chatham Craven, 1; Duplin, 1; Gaston, a few Gates, 1; Harnett, a few; Iredell, 1 Madison, 5; Onslow ,1; Pender, 2; Pitt 1; Randolph, 2; Rowan, 6; Stanly, 2 Wake, 5; Washington, 2; Wayne, 1 Yadkin—19 counties. Malarial Fever.—Caswell ; Duplin ; Gates, 12; Hertford; Pamlico; Sampson; Vance; Wake—8 counties. Malarial Fever, Pernicious.—Samp-son, a few; Wake, 1. Malarial Fever, Hemorrhagic.— Pamlico, 1. Influenza.—Anson, general ; Cald-well, general; Caswell; Cumberland; Currituck, general; Davie, general; Duplin; Gaston; Lincoln; Pamlico, gen-eral; Randolph, general; Scotland; Transylvania; Watauga, general; Yan-cey— 15 counties. Pneumonia. — Alexander ; Caswell ; Currituck, in all parts; Gates, 6; Hyde, in all parts; Pamlico, in all parts; Pen-der, 1; Pitt; Randolph, in most parts; Sampson; Transylvania; Watauga, in nearly all parts—12 counties. German Measles.—Craven, a few; Rockingham, in all parts. Mumps.—Caswell; Clay; Cumberland; Mecklenburg, 8; New Hanover, 24; Ran-dolph; Sampson; Scotland—8 counties. Varicella. — Camden; Cleveland; Mecklenburg. Small-pox.—Alamance, 17 ; Alleghany, 7; Anson, several; Ashe, 25; Bladen, 3; Buncombe, 5; Cabarrus, 24; Caswell, 3; BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. 31 Catawba, 1; Chatham. 3; Cumberland, 3; Da^adson, 7; Davie, 11; Durham, 100; Forsyth, 27; Gaston, 3; Granville, 1; Guilford, 14; Henderson, 46; Johnston, 1; Mecklenburg, 2; New Hanover, 10; Pender, 1; Pitt, 1; Randolph, 6; Rich-mond, 17; Rowan, 2; Rutherford, 6; Sampson, 8; Scotland, a few; Stanly, 4; Swain, 2; Wake, 13; Wayne, 6; Wilkes. 78—35 counties. Cholera, ix Hogs.—Clay, Hertford, Sampson, Washington. Distemper, in Horses.—Ashe, Burke, Lincoln. Rabies, in Dogs.—Sampson. No diseases reported from Bertie, Car-teret, Jackson, Northampton, Pasquo-tank, Robeson and Warren. No reports received from Beaufort, BrunsMdck, Columbus, Dare, Graham, Greene, Halifax, Jones, Lenoir, Macon, Mitchell, INIontgomery, Moore, Orange, Person, Stokes and Union. Summary of Mortuary Reports for April, 1904. (twextv-six towns.) ]Miite. CoVd. Total. Aggregate popula-tion 98,450 67,450 165,900 Aggregate deaths.. 87 129 216 Representing tem-porary annual death rate per 1,000 10.6 22.9 15.6 Causes of Death. Typhoid fever 2 2 Malarial fever 1 1 Whooping-cough.. Oil Pneumonia 12 20 32 Consumption • 8 28 36 Brain diseases 8 8 16 Heart diseases 6 5 11 Neurotic diseases... 3 7 10 Diarrhoeal diseases 7 18 All other diseases.. 42 51 93 Accident 14 5 Violence 1 1 87 129 216 Deaths under five years 16 34 50 Still-born 9 10 19 32 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. Iflortuarj Report for April, 1904. BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. 33 County Superintendents of Health. Alamance Dr. T. S. Faucette. Alexander Dr. C. J. Carson. Alleghany Dr. Eobt. Thompson. Anson Dr. J. H. Bennett. Ashe Dr. Manlev Blevins. Beaufort Dr. D. T. tayloe. Bertie Dr. H. V. Dunstan. Bladen Dr. L. B. Evans. Brunswick Dr. J. A. McXeill. Buncombe Dr. D. E. Sevier. Burke Dr. J. L. Laxton. Cabarrus Dr. R. S. Young. Caldwell Dr. W. P. Ivey. Camden Dr. J. L. Lister. Carteret Dr. F. M. Clarke. Caswell Dr. S. A. Malloy. Catawba Dr. Geo. H. West. Chatham Dr. T. A. Kirkman. Cherokee Dr. B. B. Meroney. Chowan Dr. T. J. Hoskins. Clav Dr. P. B. Killian. Cleveland Dr. B. H. Palmer. Columbus Dr. I. Jackson. Craven Dr. Joseph F. Rhem. Cumberland Dr. A. S. Rose. Currituck Dr. H. M. Shaw. Dare Dr. W. B. Fearing. Davidson Dr. Joel Hill. Davie Dr. M. D. Kimbrough. Duplin Dr. A. J. Jones. Durham Dr. N. M. Johnson. Edgecombe Dr. W. J. Thigpen. Forsyth Dr. W. 0. Spencer. Franklin Dr. R. F. Yarborough. Gaston Dr. H. F. Glenn. Gates Dr. W. O. P. Lee. Graham Dr. V. J. Brown. Granville Dr. S. D. Booth, Greene Dr. W. B. Murphv, Jr. Guilford Dr. Edmund Harrison. Halifax Dr. I. E. Green. Harnett Dr. 0. L. Denning. Haywood Dr. J. F. Abel. Henderson Dr. J. G. Waldrop. Hertford Dr. C. F. Griffin. Hyde Dr. E. H. Jones. Iredell Dr. M. R. Adams. Jackson Dr. R. L. Davis. Johnston Dr. Thel Hooks. Jones Dr. N. G. Shaw. Lenoir Dr. C. L. Pridgen. Lincoln Dr. John W. Saine. McDowell Dr. B. L. Ashworth. Macon Dr. F. L. Siler. Madison Dr. W. J. Weaver. Martin Dr. W. H. Harrell. Mecklenburg Dr. C. S. McLaughlin. Mitchell Dr. V. R. Butt. Montgomery Dr. M. P. Blair. Moore Dr. Gilbert McLeod. Nash Dr. J. P. Battle. New Hanover Dr. W. D. McMillan. Northampton Dr. H. W. Lewis. " Onslow Dr. E. L. Cox. Orange Dr. D. C. Parris. Pamlico Dr. H. P. Underhill. Pasquotank Dr. J. B. Griggs. Pender Dr. R. J. Williams. Perquimans Dr. C. C. Winslow. Person Dr. J. A. Wise. Pitt Dr. Zeno Brown. Polk Dr. C. J. Kenworthy. Randolph Dr. W. J. Moore. Richmond Dr. F. J. Garrett. Robeson Dr. H. T. Pope. Rockingham Dr. Sam Ellington. Rowan Dr. W. L. Crump. Rutherford Dr. T. B. Twitty. Sampson Dr. John A. Stevens. Scotland ....Dr. A. W. Hamer. Stanly Dr. V. A. Whitley. Stokes Dr. W. V. McCanlesB. Surry Dr. John R. Woltz. Swain Dr. A. M. Bennet. Transylvania Dr. C. W. Hunt. Tyrrell Union Dr. John M. Blair. Vance Dr. H. H. Bass. Wake Dr. J. J. L. McCuUere. Warren Dr. M. P. Perry. Washington Dr. W. H. Ward. Watauga Dr. C. W. Phipps. Wayne Dr. Williams Spicer. Wilkes Dr. W. P. Horton. Wilson Dr. W. S. Anderson. Yadkin Dr. T. R. Harding. Yancey Dr. J. L. Ray. BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. 35 [You are asked to fill out and mail one of these forms to the Superintendent of Health of your county on or before the third of each month, that he may use it in making his report to the Secretary of the State Board. Have any of the following diseases occurred in your practice during the month just closed. If so, state number of cases. Whooping-cough Typhoid Fever Measles Typhus Fever Diphtheria Yellow Fever Scarlet Fever Cholera Pernicious Malarial Fever Smallpox Hemorrhagic Malarial Fever Cerebro-spinal Meningitis What have been the prevailing diseases in your practice? Has any epidemic occurred among domestic animals? If so, what? What is the sanitary condition of your section, public and private? General Remarks: M. D. .190-— N. C. ZBTTILiIL^EITinsr OF THE North Carolina Board of Health. Published Monthly at the Office of the Secretary of the Board, Raleigh, N. C. Geo. G. Thomas, M. D., Pres., Wilmington. S. Westray Battle, M. D...Asheville. Hexry W. Lewis, M. D Jackson. J. L. Nicholson, M. D Richlands. W. P. Ivey, M. D Lenoir. Francis Duffy, M. D New Bern. W. H. Whitehead, M. D Rocky Mt. J. L. Ludlow, C. E Winston. Richard H. Lewis, M. D., Secretary and Treasurer, Raleigh. Vol. XIX. JUNE, 1904. No. 3. Annual Report of the Secretary of tlie IVorth Carolina Board of Health, May 1, 1903—May 1, 1904. [Read at the conjoint session of the State Board of Health with the State Medical Society, at Raleigh, May 24, 1904.] As must always be the case, the work of your Secretary during the past year has been largely of the usual routine character, dealing with the common every-day affairs of sanitation. These, however, are none the less important be-cause they are commonplace, as they practically cover the whole field of hy-giene. But we have one entirely new subject as applying to our State of great interest and importance, viz. : uncinariasis or hookworm di.sease. Inspired by the admirable address of Dr. Charles Wardell Stiles, Zoologist of the U. S. Public Health and Marine Hospital Service, at our last meeting at Hot Springs on the Uncinaria Ameri-cana, of which he was the discoverer,- and its prevalence in our Southern States, I promptly set to work to inter-est our physicians in the subject. In several issues of the Bulletin the mat-ter was called to their attention, a sum-mary of Dr. Stiles' official report and other articles being printed, and the medical reader was urged to send speci-mens of faeces from suspected cases to our laboratory for diagnosis. The re-sponse to this, I regret to say, has been discouraging, as only thirty-two applica-tions for the examination have been made during the year. This, however, does not represent, by any means, all the work done in relation to the hookworm disease. Dr. W. S. Rankin, of Wake Forest, in the early fall offered to give a month of his time to the Board with-out charge, other than his actual ex-penses, in making a personal investiga-tion, proposing to visit with his micro-scope the physicians in a number of our eastern counties and make the diagnosis for them on the spot. Authority was 38 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. obtained by correspondence Avith the members of the Board to accept Dr. Rankin's offer. He began his investiga-tion by a trip during Christmas week to Northampton and Edgecombe coun-ties. The results were so meagre and discouraging, as will appear in his re-port, which he will read, that we agreed that it would not pay to continue the personal work, and the spring tour of three weeks was accordingly abandoned. He has, however, done other work on this line by correspondence and among the students of the college, as he will detail to you. The physical signs of uncinari-asis are so striking and the diagnosis from the mere general appearance of a victim to it, taken together with his en-vironment, is so easy, that I have no doubt the diagnosis has been made in many instances without resort to the microscope and the proper remedy ad-ministered. From the facts in our possession it is certain that uncinariasis is very preva-lent in our State, and that it is not lim-ited to the sandy section, as Stiles sug-gests. It deserves and should receive the careful attention of all practition- <'rs. With the lights before me I would say unhesitatingly that every case of pronounced ana-mia, especially in young persons living in the country, should be investigated with a special view to this very harmful intestinal parasite. TUBERCULOSIS. Tuberculosis continues our most fatal disease. Experience has demonstrated that much can be done for its preven-tion. We should therefore make an earnest effort to check its ravages as far as possible. I therefore bring the mat-ter forward in order that it may be dis-cussed in the conjoint session, so that we may have the benefit of the wisdom that is said to appertain to a multitude of counsellors. The question of the prevention of tuberculosis is theoretically easy but practically most difficult, very much more so in our southern country than elsewhere on account of the large num-ber of negroes. The infectious principle being existent only in sputum and other discharges from tuberculosis cases and in the infected milk and meat of the lower animals, the thing to do, of course, is to destroy the sputum and pre-vent the sale and consumption of the tuberculous milk and meat. But how to accomplish this in actual practice to more than a most superficial extent is the question. The answer to this ques-tion is: By the thorough education of the public mind on the subject. So the practical problem is how to reach and influence the people, especially those having the disease and their immediate families who necessarily are in close and constant contact with them. The first step in the solution of this problem is to locate the tuberculous pa-tients. To accomplish this a few States and cities have resorted to legislation, requiring compulsory notification of tuberculosis as of other contagious dis-eases, so that the proper instructions may be given, inspections made and dis-infection practised. This looks well on paper, and in large cities with thor-oughly organized health and police de-partments and sufficient money to sup-port them it is no doubt of much prac-tical value. But in communities such as our State, the population of which is chiefly rural or resident in small cities, towns and villages without the full facilities for enforcement indicated, we cannot expect very much from this BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. 39 means. Especially is this true of the colored people. Their temperament, training, and environment make the so-lution of the problem in their case, to all intents and purposes, hopeless—for many years to come at any rate. And it is among them the disease is most prevalent, in the proportion of nearly three to one of the whites. That we cannot expect much is the more apparent when we call to mind the fact—the most discouraging fact—that a very large percentage of our physicians, although required to do so by law, will not report the more actively contagious diseases, such as scarlet fever, diph-theria and even small-pox, although the last named disease is, we believe, gen-erally reported, but not so much because the law requires it as because the doc-tor wants to get rid of it. In the pres-ent state of public sentiment the indis-position to rejwrt tuberculosis will be much greater. At the same time it is desirable to have this done if it can be brought about. We are glad to say that our own citj' of Raleigh has enacted stringent legislation on this line, and the results will be watched with much interest, as it is the first movement in tlie State for compulsory notification, although anti-spitting ordinances have been in force several years, first in Ashe-ville and later in Raleigh. The methods usually resorted to for the education of public sentiment are tul)erculosis congresses, the organization of anti-tuberculosis societies, public ad-dresses, newspaper articles, the distribu-tion to the individual of literature bear-ing on the subject and the establishment of special sanatoria. And this crusade has evidently borne fruit, for the de-crease in the death-rate from tuberculo-sis has been much more marked in the decade 1891-1900 than in any similar period previously. It is interesting to note, however, that the death-rate had been steadilj' diminishing in our larger cities before Koch's discovery of the bacillus and the demonstration of its contagious character. This is attribut-able to the improvement in the condition of the masses, better housing, better food, shorter hours of labor, the bicy-cle, athletic out-door games and the open-air life which has come to be the vogue, thereby begetting greater resist-ing power. In these respects the ad-vance has been much greater in the past decade than before and it is no doubt to no inconsiderable degree responsible for the decreased death-rate. In the prevention of infection with the tubercle bacillus there are three princi|>al objects to be sought: 1. The building up of greater resisting power in the individual; 2. The prevention as far as possible of the development of the bacilli; 3. The prevention of their dis-tribution by their prompt destruction. I. The dangers of the inspiration or ingestion of the bacilli are so great that it is a matter of doubt if any one living even a few years has not at one time or another taken them into his system, and yet only about one-ninth of the popula-tion, it is estimated, become fatally in-fected. This is due to the protective or resisting power inherent in every one to a greater or less extent. It is well es-tablished that this power to resist dis-ease, to repel it entirely, or to overcome it, is greatest in those who are in vigor-ous health. And this state of vigorous health is to be attained and preserved by living in accordance with the princi-ples of hygiene, special stress being laid upon the paramount importance of pure, fresli air in tlie greatest abundance an(? 40 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. at all times as near an ont-door life as possible. 2. The prevention of the development of the bacilli is to be accomplished chiefly by an early diagnosis, when the disease is a pure tuberculosis and before the de-generative changes which constitute con-sumption have taken place. In the for-mer the bacilli, being tied up in the un-broken tubercles, are not thrown off to any extent, while in the latter they are discharged in the sputum by the million. I would earnestly commend to your care-ful perusal a very able article, appearing originally in the Xew York Medical Jour-nal and reprinted in our January Bul-letin, on the subject of '"The Relation of Early Diagnosis and Treatment to the Prevention of Tuberculosis," by Dr. Pot-tenger, President of the Anti-tuberculosis League of Southern California. He esti-mates that from 75 to 95 per cent, of early cases with jiroper care should be cured, thereby preventing the develop-ment and distribution of the myriads upon myriads of bacilli from the same cases going on in the consumptive stage. Dr. Pottenger says that the expert in tu-berculosis "should be able to determine the presence of the disease in the vast majority of cases before bacilli appear in the sputum by the clinical history and physical examination. If not by these," he goes on to add, '"the tubercu-lin test can be used with confidence and safety." I beg to emphasize this last statement, for while I know that some object to the use of the tuberculin test in the human, claiming that it is some-times harmful, the early diagnosis in the tuberculosis stage is of such overwhelm-ing importance to both the patient and public, that inasmuch as it will enable the comparatively inexpert to make the diagnosis with cortaintv, tlie little risk. if there be any, should, in my judgment, be taken in doubtful cases. In any event, there can be no excuse for failure, to resort at once to the microscope in every suspicious case for the detection of the bacilli upon their first appearance in the sputiun, for tlie examination will be made free of charge for any phj-sician applying to the laboratory of the Board of Health. 3. The prevention of the distribution of the bacilli must be accomplished by the patient himself. He can do this by the invariable habit of expectorating only into spittoons partially filled with some disinfectant, or into the fire, when in the house, and by the use of a pocket spittoon, bits of cloth or paper napkin.s (never the handkerchief) tliat cm be burned, when out of doors. In a word, he must never let his sputum get away from him except into a disinfectant or the fire—never turn it loose to dry and assume the form of dust, especially in the house. Having thus outlined the problem very inadequately, but as fvilly as the limits of this report and your time permits, we now come to the all-important ques-tion as to how we can best solve it. The most conspicuous movement at present is towards the establishment by the State of special sanatoria for the tu-berculous. Experience has demonstrated their great success, not only in curing the disease in its incipient stage—-in over 50 per cent.—but chiefly as educa-tors of the people, for every patient returning to his home, thoroughly trained in the proper management of his case so as to prevent the re-infection of him-self and the infection of ethers, is an educator for his neighborhood. But at present, and doubtless for some years to come, we cannot liope for an apprcpria- BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. 41 tion by the State for this purpose. The other methods generally employed to educate the people and prevent the spread of disease by compulsory notification, distribution of literature, organization of societies, etc., have already been re-ferred to, but it seems to me that the most effective method of reaching and attacking the very citadel of the enemy has never been sufficiently emphasized. This method I believe to be through the family physician. It is the family phy-sician who first locates the case of tu-berculosis; it is he who is sought for advice by the patient and his friends, no one can get so near to the problem as he, and no one can have such influ-ence as he in securing the proper man-agement of the case on the part of both the patient and family. Xo health of-ficial nor organization can compare with him in the practical accomplishment of this work, if he can be induced to do it. Even if all the eases of the disease could be located and the proper instruc-tions for prevention furnished—a mani-fest impossibility without his aid—they would make but little impression unless re-inforced by his endorsement and earn-est personal advice. He is the medium — and the only medium in the vast majority of cases—through whom the principles of preventive management can effectively reach the individual case. It would be superfluous to argue this matter further. It is self-evident thot the solution of this great and difficult problem, the greatest health problem of this or any age, turns chiefly on the attitude of the attending physician. Tlie practical ques-tion before us, then, is: how can we arouse his interest and secure his cor-dial co-operation in the work. It is this particular question that I wish to hear discus.sed, that I may be helped in the performance of my official duty in the premises. I w ould respectfully suggest that this body, composed of a very large propor-tion of the leading physicians of the State, put itself on record by adopting some such resolutions as the following: Whereas, Tuberculosis, of all diseases the mo.st fatal, being the cause of death in about one-ninth of all who die, is a contagious and therefore preventable dis-ease, and Whereas, Its prevention depends upon the early diagnosis, upon the strict ob-servance of certain precautions in the relations between the patient and his as-sociates, and upon a mode of life in ac-cordance with the well-established prin-ciples of hygiene, and Whereas, These matters come within the immediate jurisdiction of the attend-ing physician, whose influence in secur-ing their observance is far greater than all other influences combined: therefore be it Resolved, That it is the sense of the iledical Society of the State of Xorth Carolina and of the Xorth Carolina Board of Health, in conjoint session as-sembled, that the spread of tuberculosis, the greatest scourge of mankind, can be most effectively prevented only with the active aid and cordial co-operation with the health authorities of the family phy-sician. Resolved, That not only every member of this body but every physician in the Slate is earnestly requested to use every effort, professional and personal, to pro-mote this great work for humanity. I would also suggest the propriety of adopting the following: Resolred, That it is the sense of the State Board of Health and of the State Medical Society, in conjoint session as- 42 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. se'mbled. that provision should be made in our hospitals for the insane and in the State's Prison, and in the county jails as far as practicable, for the sep-aration of tuberculous cases from the otlier inmates uninfected with the dis-ease. (Both resolutions were adopted unani-mously ) . SMALL-POX. As was anticipated in our last report, small-pox has continued with us to an increased extent. The total number of cases during our small-pox year—May 1 to May 1—is 5,370 as against 4,456 the year before. Of this number, 2,840 were white and 2,530 colored, with 35 and 34 deaths, respectively. It will be noted that for the first time the disease was more prevalent among the whites. The death-rate was the smallest in the history of the recent outbreak, being 1.23 per cent, among the whites and 1.34 per cent, among the colored. We have ex-perienced the same difficulties in the man-agement that have confronted us all along, due chiefly to the extreme mild-ness of the disease, although they have been somewhat less than heretofore. At the request of the authorities of the city of Durham, who were experi-encing much opposition to vaccination, I visited that city and addressed the people on the subject, with good results follow-ing. The general small-pox outlook seems to be the same it was a year ago. It will continue from year to year until all the people have been successfully vaccinated or had the disease. The following is a report in detail for the past year: BULLETIN' OF THE NORTH CAROLINA BOARD OF HEALTH. 43 REPORT OF SMALL-POX FROM MAY, 1903, TO MAY, 1904. Counties. 44 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. LABORATORY. The following is the rei)ort of Dr. McCarthy, the Biologist, in detail of the work clone for the Board of Health in the joint labi.iratory of the Department of Agriculture and the Board of Health, during the past year: REPORT OF BIOLOGIST. Raleigh, May 5, 1904. Dr. Richard H. Lewis, Secretary, y. C. State Board of Health, Raleigh, A'. C. Dear Sir:—I herewith submit a de-tailed report of the work done in the laboratory of the Board of Health during the twelve months included in the period from May 1, 1903, to April 30, 1904. Total number of anah^ses and deter-minations 522 (These include the following samples, to-wit ) : Public water supplies, monthly an-alyses 226 Analyses of water for physicians and health officers of counties 136 Examinations of sputum for physi-cians 57 Examinations of throat exudates, diphtheritic 53 Examinations of blood for Plasmo-dium malariffi 18 Examinations of fiBces for hook-wcrm 32 Total 522 The official examinations of public water supplies, under the law -passed by the last Legislature, was begun in May, 1903. Xo work was done in tlie laboratory during June. The full number of analy-ses required of the water companies un-der the law was therefore 11. Tliis number was actually taken by only four companies, the others, by carelessness or other causes, falling below the require-ments of the law, as shown by the an-nexed list : Xo. of Water Analyses Companies. Taken. Asheville 7 Concord 2 Charlotte 10 Dunn '. . . 1 Durham 10 Fayetteville (mimicipal) 8 Fayetteville (old system) Gastonia 9 Goldsboro 10 Greensboro 11 Henderson S Hendersonville 5 High Point 6 Lumberton 6 Monroe 8 Xew Bern 5 Raleigh 11 Reidsville 6 Rocky Mount 10 Roxboro 6 Salem 9 Sanfcrd 6 Salisbury . . .• 10 Southern Pines 9 Statesville 7 Tarboro 7 Waynesville 6 Washington 7 Wadesboro 3 Wilson 11 Wilmington 11 Winston 10 It must be said in ju.stice to a few of these water companies that they began business during the year and could not therefore take the full number of analy-ses. The companies included in this BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. 45 latter category are Dunn, Hendersonville, Eoxboro. The law directs the Board of Health to make these analyses for a charge of $5 each. The usual cost of biological analyses of water is $10 each. When we began this work it was with the idea of making only the biological analyses in tlie laboratory of the Board of Health, the chemical analyses to be made, if possible, by the Department of Agricul-ture. But in fact the chemical work was not done except in a very irregular way. The Department of Agriculture is supported by a special tax levied upon tlie farmers of the State. It is supposed to devote its energies entirely to strictly agricultural work. What work the De-partment can do in other lines must depend upon the chemists being unen-gaged. Water analyses, to be of much value, must be made regularly and systemati-cally. It was therefore determined to do the chemical as well as the biological work in the laboratory of the Board of Health. Soon after starting the chemical work we found that the larger part of the water companies were using too much alum in their filters and passing a part of this into the filtered water. The va-rious companies were notified of this fact, and though there was at first some indignation expressed upon the imputa-tion cast upon theif waters, the com-panies soon improved their services and apparatus, so that the last or April series of analyses showed for the entire State but two supplies giving the reaction for alum, and both these for onlj^ very min-ute (|ua;itities. We are now fully justi-fied in stating that no State or country anywhere has municipal water supplies superior to that of Xorth Carolina—so far as regards freedom from pollution and injurious chemical compounds. There are thirty public water companies in the State. The water of all is very soft, and, with a few exceptions, is free from organic matter. All of the supplies derived from deep wells, in number 5, contain much dissolved earthy matter, and a few approach the quality of min-eral waters. The deep waters are much harder than the surface waters. The quality and safety of the public or municipal water supplies of the State is enormously superior to the average qual-ity of the well waters sent to the labora-tory. So great is the difference that the Biologist, as the result of four years' work in this line in Xorth Carolina, is disposed to say that no incorporated town having 1,000 inhabitants can afford to permit its citizens to be supplied by pri-vate wells of the ordinary shallow type. The danger of typhoid hangs like the sword of Damocles over every community getting water from shallow wells. This danger is minimized for communities having a common supply wliich is closely guarded and the quality kept up to the standard by monthly analyses such as our State law requires. It would there-fore seem to be the duty of health offi-cers and physicians to advise even small towns to abandon shallow private wells for a common public water supply. As regards the samples of well water sent by physicians and county health superintendents, I am able to say that the average quality is superior to that received during the preceding year. There were fewer grossly polluted samples. Of the fifty-seven samples of sputum received, about one-third were free from bacillus tuberculosis. The samples show-ing the bacillus came from different parts of the State, but chiefly from the cen-tral and piedmont regions. 46 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. Of diphtheritic exudates, fifty-three were received and all but two showed the bacillus. Nearly all samples of exu-dates were described by attending physi-cians as "tonsillitis" or 'membranous croup." Determinations of diphtheritic exudates were given precedence over all other lines of work in the laboratory and the result is in all cases where the phy-sician can be reached by telegraph so transmitted, usually within one hour after sample reaches the laboratory. We could handle more of this class of work. In examinations of blood for the ma-laria parasite, our facilities are not yet appreciated by the medical profession, or else the type of malaria found in North Carolina is easily diagnosed clinically. Only eighteen samples came in and the larger part of these were free from the germ. Only the tertian parasite has been found. Of freces we have recived thirty-two samples and all but four contained the hookworm or its eggs. Most of the samples also showed large quantities of sand, indicating recent geophagism. The ages of the patients as given by physi-cians varied between six and sixty-one years. The larger part were under twen-ty- five years. The samples came from the following counties: Caldwell, Iredell, Granville, Johnston, New Hanover, Meck-lenburg, Nash, .Stokes and Wake. During the past twelve months, as in the preceding period, a few applications were received for the Widal test for typhoid fever. At considerable trouble and the expenditure of time and mate-rials, the Biologist stocked suitable cul-tures for this work at three different times in the two years, but the demand for this work proved too small to justify us in keeping up the cultures. Tlie average demand is only about four per year. For the Widal test the culture of bacillus typhosus must be virulent and not over four or five months at longest from the spleen of a person dead of ty-phoid. The culture must also be trans-ferred from tube to tube at least once a week, thus entailing much labor and eonsinnption of material. With so much other work pressing upon the laboratory, we could not afford for the small de-mand to keep up the typhoid culture as required, so at present we decline appli-cations for the Widal test. The clinical alternative is usually between typhoid and malaria, and an examination of the blood by microscope will determine whether or not it is malaria. A part of the Biologist's time is given lo the work of the State Department of Agriculture. The work of the Board of Health alone is more than enough to occupy the entire time of one ^man. Therefore until such time as the Legisla-ture sees fit to provide for the entire support of tlie laboratory no further ex-tension of the work is possible. Eespectfully submitted, Gerald McCarthy, D.Sc, Biologist. It will be observed that many of the public water supplies have been quite derelict in the matter of monthly analy-ses. The Act to protect Avater supplies requires every company selling water to the public to have an analysis made every month by the Board of Health, or in such laboratory as it may select, and j^et in a. total of 334 analyses required only 226 sent samples. I have tried faithfully to induce them by gentle means to send the samples regularly and promptly. My last letter has borne fruit, but there are some still that neglect this duty. While the law provides a penalty for failure to have the analyses BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. 47 made it is manifestly undesirable to resoi"t to the courts. Public opinion is the best lever to employ, and if the phj^- sicians living in cities and towns having public supplies would interest themselves in the matter the companies would be more apt to respond. It is of great importance that they should, not only as a guarantee to consumers of the jju-rity of the water sold them, but also as a means of support to the laboratory. Thanks to an enlightened, broad-minded Board of Agriculture and a Commissioner cordially in sympathy with this work for the people, we have been enabled to do the very creditable amount of work for the public health shown in the repoit, but times change and men change with them, and the support of the laboratory is extremely precarious. It should be sustained by a direct appropriation by the State for the purpose and it is to be hoped that it may be made by the next Legislature. While Dr. McCarthy, having no assist-ance, could hardly do more work than he has done, still it is discouraging to note how comparatively few of our phy-sicians avail themselves of the privileges offered free of cost beyond a few cents of postage. The number, however, is growing and will no doubt increase more and more as time passes. In conclusion, I appeal to the members of our noble profession to lend their in-terested support in this great work in which wo are engaged. While some are disposed to sneer, and wliile it must be admitted that the spirit of commercialism which pervades all callings at the present time has not left us untouclied, it still re-mains true that, excepting, perhaps, the sacred ministry, there is no body of men wliose hearts are so open to tlic cry of dis-tress or wliose minds and liands are so ready to administer to its relief without 2>ecuniary reward as the physicians of our country. It is a noble profession, and on the princiijle of noblesse oblige it is the duty of every physician, and should be his pleasure, not only to cure disease and suffering but also to aid in their prevention. Microbes and tlie Milk Supply. By GERALD MCCARTHY, D.Sc. Biologist. Milk is the first, most perfect and most generally used of all human food-stuffs. In its fresh state, or as butter, cheese or fermented drink, milk occupies the most important jilace in the dietaries of all civilized nations. But milk is also an almost ideal food for bacteria — those minute but formidable organisms which modern science has shown to be the chief cause of epidemics and prema-ture deaths among mankind. Not all species of bacteria are noxious—many are among our most useful servants, Init like other servants, these, when they get out of their proper sphere, are lia-ble to take on the characters of very obnoxious masters. The milk used in its natural or fresh condition, more es-pecially during hot weather, cannot be too pure or too free from bacteria. Bad milk is the cliief cause of infant mor-tality in summer. Tlie "fresh" milk delivered to consum-eis in cities is usually from 24 to 48 hours old, and is often as rich in putre-factive bacteria as the sewage which flows beneath the streets in the same cities, ^fore than this, the buctcria in the sewage and those in the milk are apt to be largely the same species. The following table shows the numbers of bacteria which have been found in the milk delivered to consumers in the cities 48 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. named. The measure used, cubic centi-meter, is equivalent to 16 minims or drops from an ordinary medicine dropper. Boston, Mass 4,577,000 Middletown, Conn 8.452,000 Madison, Wis 3.674,000 Naples, Italy 3,600,000 Wurzburg, Germany 7,330,000 Odessa, Russia 29,850,000 New York, N. Y 10,000,000 The average bacterial contents of fresh milk immediately after drawing, as found in the milk pails of careful dairymen, is about 10,000 per cubic centimeter. Under the average farm conditions, the number of bacteria so found is at least ten times as great. Bacteria increase in numbers only very slowly while the temperature of the surrounding fluid is below 40°F. Under the ordinary tem-perature of the barn or milk room, most bacteria connnonly found in milk double their numbers by the simple process of dividing their single-celled bodies every half-hour. It is therefore of the utmost impor-tance to the keeping qualities of the milk and to the health of those who consume the milk that the conditions surround-ing the cow and milker at the time of milking should be such as to insure the lowest possible bacterial contamination and further, it is very important that the milk, as soon as drawn, be cooled to below 40°F. and held there until con-sumed. The bacteria ordinarily found in milk are the same species found in excrement of cattle. The species vary according to the kind of food given the cows. The common bacteria are not particularly in-jurious, since they are normally found in the hinnan intestines as well in those of cattle, but when present in great num-bers, and more especially when the milk is more than twelve hours old, these bac-teria may excrete toxins which are more or less injurious. These toxins, the product of milk bacteria, arc without doubt one of the chief causes of intesti-nal diseases in children during hot weather ilany parents already recog-nize the connection between milk and diarrhceal diseases of children and seek to avoid the trouble by using instead of fresh milk condensed milk and the '"in-fants' foods" sold by druggists. But such substitution is rarely effective. Chil-dren do not thrive on condensed milk, and it is well known that those children fed upon the much- advertised "foods" are apt to develop rickets and to suc-cumb suddenly under the accidental strains to which all children are more or less exposed. Next to mothers' milk there is no food so well adapted for feeding children of tender age as fresh cow's milk having a low bacterial con-tent. There is in all food-stuffs an elusive but very important principle called "life." This principle is absent in canned and preserved foods of all kinds. Therefore no one thrives when fed largely or exclusively upon such "dead" foods. The New York Board of Health last summer made a very extensive study of the effect of feeding various grades of milk to the children of the tenement dis-tricts of that city. The results as re-ported by Dr. ^^'illiam H. Park in the Medical Yews for December, 1903, were substantially as follows : 1. The raw milk used by different families contained per cubic centimeter from 10,000 to 100,000,000 bacteria. Milk heated to 170°F. usually contained when used less than 500 bacteria per cc. After boiling milk contained less than 5 bac-teria per cc. Boiling milk usually de-stroys or attenuates the toxins already present in the milk. But boiling also BULLETIN UF THE NORTH CAROLINA BOARD OF HEALTH. 49 injures the digestibility of milk. Heat-ing to 140°F., unless continued for sev-eral hours, does not destroy such toxins. 2. During cold weather no apparent differences in health of children were traceable to the difi'erent qualities of milk. 3. During hot weather the kind of milk fed had a most important and easily detected influence on the health of children under observation. The worst results were obtained from condensed milk and the cheap milk of grocery stores. 4. One million bacteria per cubic centimeter of milk was found to be the limit of safety. When milk containing more than tliis was fed raw evil results followed promptly. When such milk was boiled before using not much injury fol-lowed. 5. Heating to ITO'F. for a short time seemed to destroy the toxins in milk unless the milk was very old and con-tained an excessively large Ijacterial con-tent. G. ]Milk pasteurized"' by heating to 140°F., or any degree short of boiling, and then kept under ordinary household conditions for thirty-six hours contained over 100,000,000 bacteria per cc, and was very deleterious. 7. Good bottle feeding of infants was found to be nearly as satisfactory as breast feeding. But good bottle feeding is rarely practiced. The feeding of fruit or ordinary table foods to children un-der two years was found to be one of the principal factors in the mortality of teneiiicnt-house children. ^Most druggists sell, or can ])rocuro. houscliohl milk-pa.steurizing outfits suit-able for ])reparing milk for children's use. Such outfits cost about $3. Much clieaper and equally effective apparatus can be improvised in most households. Ordinary four-ounce or six-ounce, wide-mouthed bottles with glass stoppers can be had from most druggists at about fifty cents per dozen. But in the ab-sence of such, common glass jelh' tum-blers or small fruit jars maj^ be used. Corks should be used to close such ,ves-sels. Rubber or glass stoppers kept scru-pulously clean or metal caps may be used or a clean sheet of glass may be laid down over the mouths of the ves-sels. The best results will be obtained by heating the milk to 140°F. for one hour, followed by heating to 18o°F. for two minutes. Where the milk is known to be reasonablj' fre.sh and where no pathogenic germs are suspected, the higher temperature is not necessary. After heating milk cool at once and keep as near 40°F. as possible until milk is consumed. Never keep the milk longer than twenty-four hours. Each vessel should contain only as much milk as will be consumed at one feeding. Any residue should be thrown away. The best way to heat milk is to place the vessels containing the milk in a basin of cold water, with the water at about the same level as the milk, and heat to the required temperature. The period of heating is to be reckoned from the time the temperature reaches the de-sired point. In this matter guess work will not do; a good dairy thermometer costing about fifty cents is necess;uy. Besides the ordinary saprophytic bac-teria found in milk, we may look for the germs of tuberculosis, typhoid, diphthe-ria and possibly scarlet fever. The most frequent and important pathogenic bacte-liuni liable to be disseminated in milk is bacillus tuberculosis. A recent in-vestigation into the milk supjilies of En-glish cities has shown that about 23 per cent of all the samples collected con-tained the germ of tuberculosis. Tlie tu- 50 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. beicular contamination of milk supplied to American cities is very much less than this, but it is still known to exist. The tuberculosis germ has also been fre-quently found in butter, and in cheese less than four months old. There can be no reasonable doubt that tuberculosis is more frequently disseminated in con-taminated milk, butter and cheese than has been commonly supposed. Probably very few persons could be induced to eat the flesh of an animal killed on account of infection by tuber-culosis. Yet such flesh is perfectly safe to eat if thoroughly cooked. The cook-ing destroys both the germs and their toxins. There is urgent need in North Caro-lina, as well as other States, of efficient hygienic oversight of dairy farms, to the end that tuberculosis-infected cattle may be excluded from herds supplying the public with milk, and also that all persons having consumption may be ex-cluded from handling the milk or uten-sils used by dairymen. Until we secure such oversight and control of the milk supply, we may expect tuberculosis to carry off each year, as it does at present, more human lives than war, flood and famine combined. Review of Diseases for May, 190-1:. SEVEXTY-SIX fOrXTIES REPORTING. Ninety-six counties have Superintend-ents of Health. Except in the case of the more con-tagious and dangerous diseases the Su-perintendent has as a rule to rely upon his own information alone, since few phj'sicians can be induced to report cases -of non-contagious diseases to him. Where the number of cases is not given, or the prevalence of a disease otherwise indicated, its mere presence in tlie county is to be understood as re-ported. For the month of May the following diseases have been reported from the counties named: Mea.sles.—Alleghany, several cases; Ashe, 12; Burke, many, Caldwell, many; Cherokee. 15; Craven, 3; Davidson, many; Durham, many; Edgecombe, epi-demic ; Forsyth ; Granville, 4 ; Guil-ford, 2 ; Henderson, several ; Hertford, 1; McDowell, 6; Macon, several; Martin, 10; Mecklenburg; Mitchell; New Hano-ver, 30; Person, several; Pitt, 3; Polk, a few; Randolph, in the western part; Richmond, a few; Robeson, a few; Rock-ingham; Rowan, 30; Transylvania, a few: Wake, 5; Watauga, 15 to 20; Wil-son, many—32 counties. Whoopixg-covgh. — Brunswick, 20; Cherokee, 40; Clay, 25; Craven, 2; Dur-ham; Edgecombe, a few; Forsyth; Hay-wood, in all parts; Hertford, a few; Iredell, 2; Macon, several; Martin, many: Mecklenburg; Pamlico; Pitt, 6; Randolph, a few; Sampson; Swain, in all parts: Union, 10; Wake, 6—20 coun-ties. Scarlet Fever.—Durham, 5; Fors}i;h, 3; Gaston, 1; New Hanover, 1; Rocking-ham, a few—5 counties. Diphtheria.—Chowan, 1 ; Craven, 1 ; Cumberland, 1 ; Edgecombe, 1 ; Ga.ston, 1 ; Haywood. 5, no physician attending, 3 deaths; Iredell, 4: Mecklenburg— 8 counties. Typhoid Fever.—Ashe, 3 ; Brunswick, 1; Caldwell, a few; Cleveland, a few; Craven. 2 ; Edgecombe, 2 ; Forsyth, many; Guilford, 1; Madison, 3; New Hanover, 4; Pamlico, 1: Pender, a few; Pitt. 3; Robeson, a few; Rockingham, BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. 51 very few; Rowan, 6; Scotland, 2; Union, 20; ^Ya^^en, 2; Washington, 1—20 coun-ties. ^Ialarial Fever.—Brims\\ ick ; David-son; Duplin; Gates, 10: Hertford, sev-eral; Martin, in all parts; Pamlico; Pitt; Vance, in all parts—9 counties. Malarial Fever, Perxicious.—Bruns-wick, 1 ; Davidson, 1 ; Pamlico, 1— 3 counties. Bowel Diseases. — Anson, several; Brunswick; Burke; Catawba; CleA'eland; Cumberland; Currituck; Duplin; Gates, 21; Harnett; Hertford; Martin, in all parts; Mitchell; Xorthampton ; Pender; Richmond; Robeson; Rowan; Sampson; Stanh". in all parts; Washington, in all parts—21 counties. Impetigo.—Burke. IxFLUEXZA.—Alamance, in all parts; Caldwell, in all parts; Cumberland; Gates; Lincoln; Madison; Randolph, in all parts; Transylvania, in all parts — 8 counties. Pneumonia.—Caswell; Gates, 3; Hert-ford, A-ery few; ]\IcDowell, in all parts; Martin, in all parts; Transylvania, sev-eral— 6 counties. Mumps.—Alleghany; Caswell; Clay; Xew Hanover ; Randolph, in western part; Scotland—6 counties. Small-pox.—Alamance, 2; Alleghany, 7; Anson, 3; Ashe, 60; Buncombe, 21; Catawba, 4; Chatham, 14; Cleveland, 3; Davidson, 2; Duplin, 1; Durham, disappearing, only one case in the city of Durham, June 2, the date of the re-port; Forsyth, 16; Gaston, 12; Guilford, 22, all well but 3 at date of report, June 6, and no danger of spread; Henderson, 1 ; Johnston, 2 ; Mecklenburg, 1 ; Mitch-ell, 1 ; Xash, 1 ; Xew Hanover, 1 ; Person, 6; Pitt, 2; Richmond, 4; Rutherford, 2; Stanly, 2; Swain, 8; Washington, 1, one suspect under guard, all exposed persons vaccinated and all infected ar-ticles burned; Wilkes, 8, now about free of it, two cases under guard. June 9 — 28 counties. Cholera ix Chickex's.—Pamlico. Cholera ix Hogs.—Clay; Sampson. Distemper ix Horses.—Ashe. Xo disease reported from Alexander, Bertie, Camden, Carteret, Davie, Hyde and Pasquotank. Xo reports received from Beaufort, Cabarrus, Columbus, Dare, Franklin, Graham, Greene, Halifax, Jackson, Jones, Lenoir, Moore, Onslow, Orange, Perqui-mans, Stokes, Surry, Wayne and Yadkin. Summary of mortuary Reports for May, 1904. (twenty-six towns.) mdie. Col'd. Total. Aggregate popula-tion 91,350 63,050 154,400 Aggregate deaths.. 112 158 270 Representing tem-porary annual death-rate per 1,000 14.7 30.1 21.0 Causes of Death. Typhoid fever 2 2 t^carlet fever 1 1 Malarial fever 2 2 Diphtheria 2 2 Whooping-cough.. 2 13 Measles 1 1 Pneumonia 8 13 21 Consumption 14 34 48 Brain diseases 12 9 21 Heart diseases 12 12 24 Xenrotic diseases... 2 6 8 Diarrhoeal diseases 21 IG 37 All other diseases.. 34 57 91 Accident 15 6 Suicide 1 1 2 Violence 1 1 112 158 270 Deaths under five years 34 51 85 Still-born 5 18 23 52 BULLETIN OF THE NOETH CAEOLINA BOARD OF HEALTH. Mortuary Report for May, 1904. Towns AND Repobteks Popula-tion. Burlington , Dr. C. A. Anderson. Charlotte Or. K. O. Hawley. Diirliain , Dr. N. M. Johnson. E^cleutoii , Dr. T. J. Hoskins. Elizabeth City Dr. I Fenring. Fayetteville Dr. A. S. Rose. O<»lil!4boro Ri)bt. A Creech, H. O. Green.sboro .Jno. .S Michaux.C.C, Heuderson Dr. .lohn H. Tucker. JLaiirliihnrg Dr. G. D. Everington. liexiugtou J. H. vioyer, Mayor. Marlon Dr. B L. Ashworth. Moiiroe Dr. .Ino. M. Blair. Oxford Dr. S. D. Booth. Raleigh T. P.8ale,Clerk B. H. Reidsvllle R.S. .Montgomery.Clk, Rocky Mount. Dr.J.T.Shubrick.H.O, Saleai , S. E. Butner, Supt. H Sallshnry , Dr. H. T. Trantham. Sonthport Dr. D. I. Watson. Tarhoro , Dr. \Vm. .J. Thigpen. Wadeshoro Dr. J. H. Bennett, liVaynesvllle , Dr. Thos. Stringfield WeldoM J. T. Gooch, Mayor. Wllinln^on Dr. Chas. T. Harper. Wilson Dr. \V. S. Anderson. Winston Dr. J. L. Hanes. 3,<i'>(i 500 n,()(K) 7,200 8,000 5,nu0 1,200 1,800 6,000 3,000 2,.500 2,;«xi 3,500 2,600 i 6,100 4,000 i 2,100 I 1,700 900 eoo 800 500 800 : 400 1,850 I 600 1 1,200 i 1,250 8,000 5,800 2,900 I l,.30O 1 1,600 I 1,500 I 3,.S0(> i 350 I 3,900 2,500 I 900 500 2,000 500 1,000 i 700 j 1,600 I 400 700 750 |ll,000 10,000 3,500 3,300 6,000 4,500 Tempobart Annual Death Rate PER 1,000. 3,500 I'l i8,20oj 2«;5 i3,ooo| i^;| 3,000| '^, ' 19 2 8,000| ^9.^ 19 2 4,800 ;^;^ 6,100: 13.7 27.7 lO'^oOj 33:0 3,800| 28:" 1 13 3 1,500, 'l-J^ 1,300 1,200 2,4.50 2,450 13,800 4,200 3,100 3,650 15.0 0.0 15.0 0.0 6.5 20.0 20.0 9.6 21.0 35.5 8.3 18.5 7.5 8.0 32.7 0.0 6,400 ll'l 13 3 ^M 0.0 1,700 ,?:? 2.000; 0.0 0.0 1 450' "•" ''*°"| 16.0 17 4 21,000 1^12 13 7 6,800 [gjg 10,500, ^ I 0.0 15.8 19.4 4.0 25.5 30.0 19.7 19.0 12.6 8.0 9.2 10.0 9.8 14.7 27.8 11.4 7.7 29.6 30,0 8.6 19.2 7.1 0.0 6.0 29.7 15.9 29.7 BULLETIN OF THE NOKTII CAROLINA BOARD OF HEALTH. 53 County Superintendents of Healtb. Alamance Dr. T. S. Faucette. Alexander Dr. C. J. Carsou. Alleghany Dr. Robt. Thompson. Anson Dr. J. H. Bennett. Ashe Dr. Manlev Blevins. Beaufort Dr. I > T. tayloe. Bertie Dr. H. V. Dunstan. Bladen Dr. L. B. Evans Brunswick Dr. J. A. McNeill. Buncombe Dr. D. E. Sevier. Burke Dr. J. L. Laxton. Cabarrus Dr. R. S. Young. Caldwell Dr. W. P. Iveyr Camden Dr. J. L. Lister. Carteret Dr. F. M. Clarke. Caswell Dr. S. A. Malloy. Catawba Dr. Geo. H. West. Chatham Dr. T. A. Kirkman. Cherokee Dr. B. B. Meroney. Chowan Dr. T. J. Hoskins. Clay Dr. P. B. Killian. Cleveland Dr. B. H. Palmer. Columbus Dr. I. Jackson. Craven Dr. Joseph F. Rhem. Cumberland Dr. A. S. Rose. Currituck Dr. H. M. Shaw. Dare Dr. W. B. Fearing. Davidson Dr. Joel Hill. Davie Dr. M. D. Kimbrough. Duplin Dr. A. J. Jones. Durham Dr. N. M. Johnson. Edgecombe Dr. W. J. Thigpen. Forsyth Dr. W. O. Spencer. Franklin Dr. R. F. Yarborough. Gaston Dr. H. F. Glenn. Gates Dr. W. O. P. Lee. Graham Dr. V. J. Brown. Granville Dr. S. D. Booth. Greene Dr. W. B. Murphy, Jr. Guilford Dr. Edmund Harrison. Halifax Dr. I. E. (ireen. Harnett Dr. O. L. Denning. Flaywood Dr. J. F. Abel. Henderson Dr. J. G. Waldrop. Hertford Dr. C. F. Griffin. Hyde Dr. E. H. Jones. Iredell Dr. M. R. Adams. Jackson Dr. R. L. Davis. Johnston Dr. Thel Hooks. Jones Dr. N. G. Shaw. Lenoir Dr. C. L. Pridgen. Lincoln Dr. John W. Saine. McDowell Dr. B. L. Ashworth. Macon Dr. F. L. Siler. Madison Dr. W. J. Weaver. Martin Dr. W. H. Harrell. Mecklenburg Dr. C. S. McLaughlin Mitchell Dr. J. Warren Bailey. Montgomery Dr. M. P. Blair. Moore Dr. Gilbert McLeod. Nash Dr. J. P. Battle. New Hanover Dr. W. D. McMillan. Northampton Dr. H. W. Lewis. Onslow Dr. E. L. Cox. Orange Dr. D. C. Parris. Pamlico Dr. H. P. Underbill. Pasquotank Dr. J. B. Griggs. Pender ..Dr. R. J. Williams Perquimans Dr. C. C. WMnslow Person Dr. J. A. Wise. Pitt Dr. Zeno Brown. Polk Dr. C. J. Kenworthv. Randolph Dr. W. J. Moore. Richmond Dr. F. J. Garrett. Robeson Dr. PL T. Pope. Rockingham Dr. Sam Ellington. Rowan Dr. W. L. Crump. Rutherford Dr. T. B. Twitty. Sampson Dr. John A. Stevens. Scotland Dr. A. W. Hanier. Stanlv Dr. V. A. Whitlev. Stokes Dr. W. V. McCanleee. Surry Dr. John R. Woltz. Swain Dr. A. i\L Bennet. Transylvania Dr. C. W. Hunt. Tyrrell Union Dr. John M. Blair. Vance Dr. H. H. Bass. Wake Dr. J. J. L. McCullere. Warren Dr. M. P. Perrv. Washington Dr. W H. Ward. Watauga Dr. C. W. Phipps. Wayne Dr. Williams Spicer. Wilkes Dr. W. P. Horton. Wilson Dr. AV. S. Anderson. Yadkin Dr. T. R. Harding. Yancey Dr. J. L. Ray. BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. 55 [You are asked to fill out and mail one of these forms to the Superintendent of Health of your county on or before the third of each month, that he may use it in making his report to the Secretary of the State Board.] Have any of the following diseases occurred in your practice during the month just closed. If so, state number of cases. Whooping-cough Typhoid Fever Measles Typhus Fever Diphtheria Yellow Fever Scarlet Fever Cholera Pernicious Malarial Fever Smallpox Hemorrhagic Malarial Fever Cerebro-spinal Meningitis What have been the prevailing diseases in your practice? Has any epidemic occurred among domestic animals? If so, what? What is the sanitary condition of your section, public and private? General Remarks: M. D. .190-— N. C. ^"crx^iL.E!a:i3^ OF THE North Carolina Board of Health, Published Monthly at the Office of the Secretary of the Board, Raldgh, N. C. Geo. G.Thomas, M.D.,Prf.?., Wilmington. W. P. Ivey, M. D Lenoir. S. Westr.w Battle, M. D...Asheville. Francis Duffy, M. D New Bern. Henry W. Lewis, M. D Jackson. \V. H. Whitehead. M. D Rocky Mt. J. L. Nicholson, M. D Richlands. , J. L. Ludlow, C. E Winston. Richard H. Lewis, M. D.,
Object Description
Description
Title | Bulletin of the North Carolina Board of Health |
Other Title | Bulletin of the North Carolina State Board of Health; Bulletin of the North Carolina Board of Health |
Creator | North Carolina. State Board of Health. |
Date | 1904; 1905 |
Subjects |
Diseases--Reporting Genealogy Mortality--Statistics Public Health--North Carolina--Periodicals |
Place | North Carolina, United States |
Time Period | (1900-1929) North Carolina's industrial revolution and World War One |
Description | Volume 19, Issues 1-12, April 1904-March 1905 |
Publisher | Wilmington, N.C. :Secretary of the Board, |
Agency-Current | North Carolina Department of Health and Human Services |
Rights | State Document see http://digital.ncdcr.gov/u?/p249901coll22,63754 |
Physical Characteristics | 61 v. :ill. ;23 cm. |
Collection | Health Sciences Library. University of North Carolina at Chapel Hill |
Type | text |
Language | English |
Format | Bulletins |
Digital Characteristics-A | 9,043 KB; 172 p. |
Digital Collection |
Ensuring Democracy through Digital Access, a North Carolina LSTA-funded grant project North Carolina Digital State Documents Collection |
Digital Format | application/pdf |
Related Items | Imprint varies: published later at Raleigh, N.C. |
Title Replaced By | Health bulletin** |
Audience | All |
Pres File Name-M | pubs_edp_bulletinboardofhealth190405.pdf |
Pres Local File Path-M | \Preservation_content\StatePubs\pubs_edp\images_master\ |
Full Text |
s
library of
QIl)c Uutccrsity of Hortl] darolina
COLLECTION OF
NORTH CAROLINIANA
ENDOWED BY
JOHN SPRUNT HILL
of the class of 1889
C(3(l\- 3V^fc^
\
This book must not
be token from the
Library building.
^v^^
«^\\,v^-^^^^'#AVWS!>
Form No. 471
:B"criL,x^E:'xi3sr
OF THE
North Carolina Board of Health.
Published Monthly at the Office of the Secretary of the Board, Raleigh, N. C.
Geo. G.Thomas, M.D.,Pn's., Wilmington. I AV. P. Ivey, M. D Lenoir.
S. Westray Battle, M. D...AsheviIle. ] IJkancis Duffy, M. D New Bern.
Henry W. Lewis, M. D Jackson. i W. H. Whitehead, M. D Rocky Mt.
J. L. Nicholson, M. D Richlanda. I J. L. Ludlow, C. E Winston.
Richard H. Lewis, M. D., Secretary and Treasurer, Raleigh.
Vol. XIX. APRIL, 1904. No. 1.
Notice to Pliysicians.
According to the jDrinted rules of the
Biological Laboratory, it is closed during
the month of June to allow the Biologist,
who has no assistant, his well-earned va-cation.
This year he will take his vaca-tion
later, of which due notice will be
given. So, physicians desiring labora-tory
work can have it done without in-terruption
until they receive such notice.
Anunal Meeting of the State iMedical
Society and of tlie Board of Healtlt.
These bodies will meet in Raleigh on
Tuesday, the 24th instant. At 12 M. on
Wednesday the conjoint session of the
two will take place. It promises to be
unusually interesting and instructive,
and it is earnestly desired that every
superintendent of health 'who possibly
can will attend. Such gatheriners are
always helpful, and it is well for us to
get together at least once a year and
compare notes.
Dr. Kriiext P. Foster, Dr. Abuer
Alexander.
It is with sincere regret that wc chron-icle
the passing away of these two good
men. Dr. Foster, at the time of his
death, was Superintendent of Health of
Franklin county. He was always the
courteous gentleman and conscientious
official.. The same can be said of Dr.
Alexander. The latter was for several
terms a member of the Legislature, and
we wish to put it on record that the
cause of the piiblic health and the medi-cal
profession never had, in the writer's
experience, a more earnest and, when
his party was in power, a more efficient
friend in the General Assembly. May
they sleep well.
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Plate 1.—Fig. 1. Parasite op Quartan Malaria. Fig. 2. Parasite op Tertian Malaria.
Fig. 3. Parasite op Pernicious Malaria.
BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH.
Tlie Kllolo$>;y of Malaria.
BY GERALD MCCARTHY,
Biologist N. C, Board of health.
The disease variously called "Malaria,"'
''Chills and Fever," "Ague," and other
names, was clearly recognized by physi-cians
in the days of Aristotle. It was
then as now the peculiar scourge of
swampy regions, more especially in warm
climates. But until comparatively recent
times malaria was a common and fatal
disease even in northern countries. Up
to the beginning of the eighteenth cen-tury
malaria of the chronic, pernicious
type was epidemic and very fatal in
England. During the same centurj', ow-ing
to the great advances in hygiene
and the improved condition of the houses
of the common people, the disease lap-idly
declined, and soon after the begin-ning
of the nineteenth century became
practically extinct in England. At the
present time on the continent of Europe
a line drawn along the tops of the Pj're-nees
mountains and following the Lyo-nais
mountains through Lyons and the
upper Rhone valley, thence following
the tops of the Alps and through the
valley of the Danube by Vienna, thence
along" the tops of the Carpathian moun-tains
and northerly through Russia, un-til
lost in the swamps of the Dneiper,
will divide the continent into two parts,
north of which line malaria is now rare
and sporadic, while south of the line it
is endemic, and like a smouldering fire
ever ready, on the relaxation of hygienic
measures, to burst forth. In the north-ern
region of Europe ^only the tertian
form is known. In the south the quar-tan
form predominates, and in regions
notorious for bad hygienic conditions the
chronic and pernicious form is common.
In North Carolina so far the Laboratory
of the State Board of Health has received
no blood sample showing the quartan
parasite. Only the tertian form of ma-laria
seems to exist in this State. In all
legions of the north temperate zone the
three winter months—December to Feb-ruary,
inclusive — show the minimum
prevalence of malaria. The maximum
in the northern regions is from May to
September. In the more southern re-gions
the maximum occurs from August
to October.
THE CAUSE OF MALARIA.
Up to the year 1880 the universal
opinion, even among well-informed phy-sicians,
was to the effect that malaria
was an air-borne disease, due in some
�� mj-sterious way to emanations from de-caying,
water- soaked vegetation. In the
year named Dr. LaA'eran, a French army
surgeon, first clearly demonstrated the
connection between the disease and a
protozoan parasite, which is always
found in the blood during acute attacks
of malaria. Since 1880 numerous inves-tigators
in Italy, Germany, America and
England have verified and extended Lav-era
n"s observations. The most recent
and important advances in elucidating
the etiology of the disease are due to the
work of English physicians, among whom
the more noted names are those of Man-son,
MacCallum and Ross. Ross first
clearly determined by the experimental
method that the malarial parasite dur-ing
different parts of its life-cycle lives
in the bodies of humans and mosquitoes.
Further he showed that only mosquitoes
of the genus Anopheles act as malaria-carriers
for humans. The common mos-quitoes
of our houses, in both seacoast
and upland regions, is not Anopheles but
Culex. Culex acts as a disseminator of
malaria among birds but not among hu-mans.
BULLETIN OF THE NOETH CAROLINA BOARD OF HEALTH,
THE LIFE HISTORY OF THE MALAKIA
PARASITE.
Tliere are two very distinct species of
the malaiia organism. These are desig-nated
HceinumoEha tertiaiia and H. quar-
Uinu. They are directly correhited with
the forms of malaria from which they
take their specific names. The genus
HcemariKjebu belongs to the natural order
Sporozoa of unicellular animals, whicli
order also includes the parasites causing
malaria in birds and many animals and
splenetic or "Texas" fever in cattle.
Both species of the malarial organism
are obligatory parasites and are known
to exist only in the bodies of one or other
of their hosts—mankind and mosquitoes.
It is possible and probable that there is an
as yet unknown segment in the life-cycle
of these parasites. Many observations
and conservative deductions point that
way, but so far no one has discovered
the missing link. The principal grounds
for supposing the existence of an un-known
segment of the life-cycle of the
malarial parasites are as follows:
Malaria is known to be endemic in
poiticns of India and Africa where there
are no human inhabitants. . The power
of flight of the malaria mosquito is very
slight and the creature rarely ever flies
more than one mile from its place of
birth. Yet it exists in uninhabited re-gions
and seems able to convey malaria
to chance visitors to such regions. It
has long been known to physicians that
the tearing up of the soil during the so-called
malaria season frequently leads
to malaria in an epidemic form. Finally
it has been recently shown by Dr. J. M.
Smith in New Jersey that the true mala-ria
mosquito may exist in both of two
nearby towns which, so far any one can
see, have similar surroundings and same
class of people, with constant intercom-munication.
Yet in one town malaria
may be epidemic and in the other origi-nal
cases practically unknown, in Paris,
France, no case of original malaria has
developed within the memory of the
oldest living physician. Yet the malaria
mosquito. Anopheles iiiaculipennis, is not
uncommon in Paris, especially in the
parks and pul)lic gardens, where the pop-uliice
frequently gather in large crowds.
In Paris, too. t]ien> are numerous resi-dents
who liad f(nnierly C(mtracted ma-lari:
i in Algeria and otliei- notoriously
malarious countries. Tliese persons are
known to carry in their blood the resting
or crescent spores of the p^irasite. From
ou)- knowledge of the case and the theory,
such persons must be frequently bitten
by the .\nopheles. and tlieu the latter
will suiely bite citi/ens wholly free from
iiiabnia. (>nr present knowledge and
the accepted theory of the disease wduhl
require that every one bitten by the ma-laria-
infected Anopheles sliould contract
acute malaria, but the fact is. in Paris,
at least, tliey do not. Yet this exception
to the rule does not invalidati^ (he oft-proven
fact that there can, under ordi-nary
circumstances, be no acute malaria
without the bite of an Anopheles mos-quito.
:\Ialarial fevers are commonly classified
into the following kinds: Quotidian, or
paro.xysra recurring daily; Tertian, or
paroxysm recurring every second day;
Quartan, or paroxysm recurring every
third day. There is also the so-called
Estivo-autiunnal. or pernicious form.
Finally, physicians recognize clinically
two groups called' respectively benign
, and malignant malaria.
Biologists, however, recognize but two
species of parasite, and therefore only
two kinds of fever—tertian and quartan.
BUI-LETIN OF THE NORTH CAROLINA BOARD OF HEALTH.
Till' so-called quotidian fever is merely
a double infection of the ordinary tertian
and the so-called Estivo-autnmnal fever
is teitiau in a chronic or specially viru-lent
form. Plate 1, Fig. 1, shows the
life-cycle of the quartan parasite as it
exists in the human blood—« is the blood
corpuscle just infected: b, c, d, e, f, show
successive advances in the matui-ity of
the parasite; g and /; show the beginning
of sporulation. Figs. / and / are two
extra-corporeal conditions of the fullj--
grown spore. One should be flagellated,
but fiequently at this pait of the cycle
the i^arasite seems to live an arrested
life for a while and then degenerates and
fall to pieces.
Plate I, Fig. 2, shows the life-cycle of
the tertian parasite; a, h, c, d, c and /
show siiccessiA-ely maturing phases of the
parasite Avithin a blood corpuscle; g and
/( are the sporulating stages. In quar-tan
fever the stage g resembles a sym-metrical
daisy-like figure; in tertian fe-ver
this phase resembles more a Ininch
of grapes: / and _;' are extra-corporeal,
sexual forms or "gametes" of the spore—
-
the llagellate form being the male. These
coalesce and recommence the grand cj^cle,
but only outside the human lx)dy, i. e.,
natnirally within the body of the mosquito,
who lias abstracted the spores with blood
from some malaria-infected person. In
the liuman body alone the cycle ends at
/(, where the non-sexual spores break
from the corpuscle in which they had
developed, and after being carried about
in the blood .stream for awhile thej- find
their way into new corpuscles and so
begin again the cycle until the disease
is checked by quinine or other causes.
The bursting forth of the spore is con-commitant
with the chill' stage of the
disease, while the renewed attack of the
spores upon the blood cells is the cause
of the fever stajje.
Plate I, Fig. 3, shows tiie life-cycle of
tlie malignant or pernicious forms; a, b,
c, d, e, /', are the successive stages as in
the two preceding Hfiurcs; g shoMS a
double infection of a l)lood corpuscle,
conunon in malignant malaria; I and j
are the sporulating stages; k is the cres-cent
or '"resting- spore stage'' of the para-site
within the human body; /, in, n, o,
are stages of the development of the
crescent into the flagellate form. These
latter changes take place only otitside of
llie human body, ('. c, in nature they
occur only within the body of the mos-quito.
But these changes also may take
place in a sample of malarial blood kept
tinder the microscope on a glass slide.
5a- __. Fig. 4 is another il-e?£
l N lustration of the life-gs^
bo.' \ cycle of the pernicious
\ form of the malarial
;
; parasite within the hu- ^ ^'^
\ man body. 1 is the
spcrozoit introduced
^^ba- . into the blood by a
bite of Anopheles mos-
^ su' quito; 2 shows the
original sporozoit mul-
. / tiplied three fold; 3 ^ ""
/ shows a blood corpus-
/ cle invaded by one of
-® * / the parasites. At 5a-
I-VI the parasite com-j.^,.-''
pletes the cycle to the
free-spore stage, when
'^^ 1 it is ready to begin
"T again, as at 3.
Fig. 4.—Life Cycle of the Malarial Parasite
IN THE Human Body.
^^'e have followed the successive phases
of the cycle of the parasite within the
himian luxly. \Ahen an Anopheles mos-quito
sucks into its own body ])Io(mI
containing tlic crescent or resting spores
6 BULT.ETIN OF THE NORTH CAROLINA BOARD OF HEALTH
as previously shown, the crescents soon
proceed to develop into the forms shown
at i, j, Figs. 1 and 2, and at n, o, Fig. 3.
In all of these figures the rounded form
represents the female gamete and the
flagellate form the male gamete or body.
The result of the sexual fusion is the
production of a slender, rod-like- form
resembling 1 in Fig. 4, but wholly differ-ing
from that form in physiological sig-nificance.
The new form in the body of
the mosquito soon penetrates the wall of
the insect's stomach and attaches itself
to the exterior surface of that organ.
There it forms around itself a sort of
cyst, and within this it develops a vast
number of spores which soon in turn
rupture the walls of the cyst and swim
free for a time in the body cavity of the
mosquito. Eventually, by some unknown
attractive force, the new sporozoits gath-er
into the salivary gland and duct of
the mosquito and there remain ready to
infect a new human victim as soon as
the mosquito bites again. The mosquito
injects the parasite with the venom that
these insects always inject into the blood
when they bite, in order to render the
blood more fluid and easier to suck in.
In each and every stage here described,
those not illustrated as well as those
pictured, the phases and changes in the
complete life- cycle of the mosquito are
described from actual specimens and dis-sections.
There is no theory in it, nor
is there anything taken for granted.
Every stage as described is absolutely
known to exist, and the fact may be
verified by any one possessing the nec-essary
apparatus, time and skill.
The best time to find the parasite in
the human blood is six to eight hours
before or after a chill. The crescent
forms are never found in acute cases
until after some weeks of fever. The
ear is the best organ to puncture. A
new steel pen with one nib removed is
the best lancet. This need not be steri-lized,
nor is it necessaiy to wash the
ear with alcohol. Stretch skin lightly
over fingers and drive the lancet in one-eighth
inch with a single rapid blow.
Do not press or knead the part. Discard
first few drops. Blood is best examined
fresh and unstained with one-twelfth
inch oil immersion lens. A lower power
is not satisfactory. In pernicious ma-laria
the destruction of blood corpuscles
is rapid and very great—often four-fifths
the normal number are destroyed by the
parasites.
THE DIFFERENT SPECIES OF MOSQUITOES.
In the Eastern United States we have
only two genera of mosquitoes of much
economic importance. These are Culex,
the common brown-legged, clear-winged
mosquito, of which we have about twen-ty-
two species, but only two of real im-portance.
These are C. pipiens, the com-mon
house mosquito of the upland coun-try,
and C. sollicitans, the ring-legged
salt-water mosquito, which is the more
common species within twenty miles of
the seashore. The malaria mosquito is
Anopheles, of which we have three spe-cies,
but one is quite rare. Of the other
two, Anopheles maculipennis, the '"speck-led-
winged mosquito," is the malaria
species; the other species, A. punctipen-nis,
"smoky-winged mosquito."' The lat-ter
is suspected but not certainly known
to convey the malaria germ when it bites.
The other species has been proven beyond
cavil to be a common carrier of the in-fection.
Until we are better informed,
however, we should, as a matter of
safety, wage an uncompromising warfare
against all Anopheles mosquitoes, and
need not even spare Culex.
Fig. 5.
—
Anopheles Maculipennis.
(After Howard, Bull. 25, U. S. Dept. Agr. ).
Fig. 6.—Eggs ok Anopheles.
*: After Howard, Bull. 25 U. S. Dept. Agr.
BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH.
Fig. 5 shows Anopheles maculipennis, and at the riglit a hirva or wriggler"
male at left, female at right. Fig. 6 of Culex. Fig. 8 shows another view of
shows the eggs of Anopheles as usually the same larva as they lie feeding in the
laid l)y the insect upon water, and Fig. 7
shows at left the appearance of half-grown
larva or 'wrigglers," two stages.
water. Anopheles above lies just below
the surface; Culex below lies in an ob-lique
direction from surface.
Fig. 7.—Larv^ Forms of Anopheles (at
( After Howard, Bull.
These illustrations of mosquito larvae
should be carefully .studied by every one
living in a malarious neighborhood. As
will be seen, the appearance of the An-opheles
and Culex larva are very dis-similar,
and it should be an easy matter
to determine which genus we find in our
rain-water barrels, or in chance pools,
ponds or ditches within a lialf mile of
the house. Whenever the narrow-headed,
slender wriggler is found in any pond
or other water, that water should at
once be removed by drainage or the sur-face
should be kept covered with a thin
stratum of oil, as will be described fur-ther
on. .As a general rule, the wrig-glers
found in rain-water liarrcls and in
left) and Culex (at right) Mosquitoes.
25, U. S. Dept. Agr.).
foul or polluted ditches or ponds near
houses belong to the genus Culex. But
Anopheles is frequently founfl also in
such places, though it prefeis remoter
pools where green alga and water plants
abound. Neither genus is likely to be
found in ponds or vessels containing tad-poles,
crabs or fishes. Ditches and pools
having weedy or grassy margins are ex-cellent
places to look for Anopheles lar-va'.
I'he Anopheles thrives in salty or
brackish watei', according to Dr. .J. ~Sl.
Smith of New Jersey, who has for the
last few years devoted much time to the
study of the celebrated and fciocious
mosquitoes of that State.
BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH.
In addition lo minnows, wliicli are
probably the best anti-mosqnito animals,
the more important enemies of moscpiito
arc water-beetles and bu<>s, which are
nearly always carnixorons, frogs, tad-poles,
drasfon-flics and insectivorous
l)irds.
Fig. 9.—Pupal Form of Anopheles.
(After Howard, Bull. 25 U. S. Dept. Agr. I.
Fi»'. fl sliows the pupal form of An-opheles,
lliis is tlie stage intermediate
between the larva and the winged forms.
It usually lasts but a day or 1 wo. Fig.
10 shows the egg masses and hir\a of
C'ulex. witli one enlarged wriggler at
right. l-'ig. 11 shows the |)upal stage
of Culex.
.\s will be HDliceil, i1 is niuch snniller
tli.ui the similar phase (if Anopheles.
Fig. Li shows tlie mature form of ('iilc.v
pijiicii.s. the (•sqnito
10 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH.
Fig. 10.—Egg Masses and
(From Harward, Bull,
alone is blood-thirsty. This particular
and favorite beverage of the female mos-quito
is supposed to be correlated with
her egg-laying duties. It is imagined
that mosquito eggs will not mature un-less
stimulated by human blood, but as
Fig. 11.—Pupal Form of Culex.
(After Harward, Bull. 25 U. S. Dept. Agr. I.
Larv^ form of Culex.
25 U. S. Dept. Agr. i.
millions of mosquitoes live and propa-gate
in swamps remote from human hab-itation,
it is impossible that they can
always secure blood to stimulate the
activity cf the ovaries.
It is important that every person ex-posed
to punctures of the malaria mos-quito
should be able to distinguish the
mature or winged form of Anopheles
from the winged fonns of the Culex mos-quitoes.
The following are the more ob-vious
distinctions:
Culex is comparatively smaller and
more heavily built; Anopheles is larger
and lighter. Culex has comparatively
short legs and when at rest is graceful
in appearance; Anopheles has very long
legs and appears clumsy when at rest.
Culex has clear wings; Anopheles has
black spotted or smoky wings. Culex
when standing on a more or less level
surface or biting lias the body nearly
parallel with this surface and the head
BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH. 11
projects beyond the front legs; Anophe-les
in a similar situation has the body
oblique or nearly perpendicular to the
supporting surface and the front legs
are away beyond the head. The body
of Culex is humped or bent at the tho-liibeinates
in the holes left in trees and
dry banks by swallows, squirrels and
other wild burrowing creatures. Culex
seems more tender than Anopheles, and
always disappears early in the autumn.
Anopheles may usually be found flying
Fig. 12.—Mature Form of Culex (Female above).
(After Howard. Bull. 25 U. S. Dept. Agr.).
Tax; that of Anopheles is nearly a
straight line from the tail to the beak.
The upland Culex and Anopheles mos-quitoes
pass the winter in the winged
state. They lie hidden in cellars, stables,
attics, and in the hollows of trees, etc.
Anopheles also, according to Dr. Smith,
as late as December in North Carolina,
and in houses or cellars heated by a
furnace these insects may remain active
all winter and bite people, conveying
malaria at any time. As we have said,
the upland Culex breeds only in water
not very .saltv, but it may be vei'v foul.
12 BULLETIN OF THE NORTH CAROLINA BOARD OF HEALTH.
The seacoast mosquito breeds only in
salt or bracki.sli water, never in fresh
water. Anopheles can breed in water
either fresh or salt, but is not usually
found in streams or ponds grossly pol-luted,
by sewage. The running of citj-pools,
hollows of trees, and among water
plants lining the margins of ponds, etc.,
make the extermination of this species
in any given locality impracticable. We
must lie content to repress it to keep its
numbers down. The limits of practica-
FiG. 13.—Resting Positions of Culex (above) and Anopheles (below).
(After Howard, Bull. 25 U. S. Dept. Agr.).
sewage into streams does not, therefore,
tend to induce or increase malaria, as
many seem to think. The facility with
which the malaria mosquito can hide
during the cold season and breed in any
sort of water, and even in vcrv shallow
jjle work are, however, quite important.
We can at a coinparativelj- small cost
reduce the prevalence of all the mosquito
pests to from three-fourths to nine-tenths
the ordinary uncontrolled numbers and
annoyance. Drainage is the great and
BULLETIN OF T]IK NORTH CAROLINA ROARD OF HEALTH.
all-iuiiiortant leinedy for mosquitoes.
The (Iniiiiaye must be tlioiuugli, so as
to leave no hollows or pools. Even the
depression made by the foot of a man
walking o\er soft ground may ser\e to
bleed hundreds of mosquitoes. Perma-nent
bodies of water sliouM !)( stocked
witli tish, especially the tup minnow
—
FuikIuIks in fresh and (lit inbHsiu in
salt watei'. Pikes and other predacious
fishes are not desirable in such ponds,
as they destroy the useful insect-eating
lishes. The margins of all ponds and
sluggish creeks should be kept free from
weeds and grasses. Sluggish wateis
which caiuuit l)e stocked with tish should
l)e oiled with crude petrolemu once every
three or four weeks from June 1st to
November 1st—one ounce of oil to fifteen
square feet is suflficient. Fishes are
better than oil. and as oil is liable to
destroy the tish in a ]i(ind or stream, it
should not be used wlicrc i1 is possible
to stock the water with minnows. Aqua-tic
water insects, crabs and frogs should
never be harmed, as they do good work
in reducing tlu' numbers of mosquitoes.
Finally it must be said that mosquitoes
breed only in stagnant or very slow-flow-ing
and shallow waters. Bold streams
with rapid currents, or lai'ge deep ponds
with clean margins, will not breed these
pests.
There are every season advertisements
of the wonderful anti-malarial effect of
some new tree or plant when grown near
houses. The only grain of truth in these
stories is that all fast-growing plants
cause the ex'aporation of a consideiable
amount of water from the soil. One
plant is ;is good as another f(n- this
j)Ui]M;se if the same amount of leaf sui-face
is exposed to the sun. Hut drainage
by ditching and the otiier treatments
above described are cheaper and far more
effectual than soil-drying plants of any
kind. There have been of recent years
put upon the market by enterprising
manufacturers many anti-nio.squito nos-trums
of the usual patent, self-acting,
miraculous kind. These nostrums are
invariably "fakes" intended solely to
convey money into the pocket of the atl-
\'eitiser. There is no chemical treatment
of water iov mosquitoes more etlectual
or cheaper than crude petroleum.
The salt-water mosquito is a daylight
Hier, but the upland C'ulex and tiu' An-opheles
mosquitoes are twilight tliers.
Therefore to escape being iiitten by the
malaria mosquito we have cnly to make
our houses insect-tight with wiie screens
and remain within from an hour l)efore
sunset until an hour after suniise. This
simple and practicable precaution is an'
absolute protection against malaria,
even in the most notorious uuilarial
sections. Ijai-ge railroad construction
gangs have in tliis way been jtrotected
fiom malaria while building through
swamps where malaria was known to be
endemic among the natixes.
In 1902 two English physicians were
sent by the English war otiice to t^st
the \alue of wii-e screens against malaria
ity living in the district at the mouth of
the Tiber in Italy. The district named
has from time immemorial been noted
f(n- the fatal and inveteiate type of ma-laria
there endemic. The I'higlishmen
took no ((uinine and went freely about
among the malaiia-st ricken inhabitants,
drinking swamp water t'ldiii a ditch
which flowed past their door. They mide
their house, whirh was ;in (irdiiiiiy
st i-aw-thatched hut. insert -t ight liy hi:' ins
of wire sci-eens. They weie careful lo
be within doors one hour liefme >undowii
and rei!iaine |