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Biennial report of the North Carolina State Board of Health
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^ LIBRARY or TIIK University of North Carolina Eii(l(iwi'<l liy the Dialcclic and I'liilan-tlirni> ic Societies \^bq- "S This book must not be token from the Librory building. Form No. 471 TWELFTH BIENNIAL REPORT OF THE NORTH CAROLINA BOARD OF HEALTH 1907-1908 RALEIGH E. M. UzzELL & Co., State Peintees and Bindees 1909 i MEMBEKS OF THE BOAED. ELECTED BY THE MEDICAL SOCIETY OF THE STATE OF NORTH CAROLINA. George G. Thomas, M. D., President Wilmington. Terra Expires 1911. Thomas E. Anderson, M. D Statesville. Term Expires 1911. David T. Tayloe, M. D Washington. Term Expires 1913. James A. Burroughs, M. D Asheville. Term Expires 1913. APPOINTED BY THE GOVERNOR. J. L. Ludlow, C. E., Engineer Winston-Salem. Term Expires 1909. J. Howell Way. M. D Waynesville. Term Expires 1911. W. O. Spencer, M. D Winston-Salem. Term Expires 1911. Edward C. Register, M. D Charlotte. Term Expires 1913. Richard H. Lewis, M. D., Secretary and Treasurer. .Raleigh. Term Expires 1913. COUNTY SUPERINTENDENTS OF HEALTH. Alamance Dr. H. M. Montgomery. Alexander Dr O. L. Hollar. Alleghany Dr. Robert Thompson. Anson Dr. E. S. Ashe. Ashe Dr. M. Blevins. Beaufort Dr. D. T. Tayloe. Bertie Dr. H. V. Dunston. Bladen Dr. L. B. Evans. Brunswick Dr. J. Arthur Dosher. Buncombe Dr. D. E. Sevier. Burke Dr. J. L. Laxton. Cabarrus Dr. R. S. Young. Caldwell Dr. C. L. Wilson. Camden Dr. C. G. Ferebee. Carteret Dr. W. E. Headen. Caswell Dr. S. A. Malloy. Catawba Dr. Geoi-ge H. West. Chatham Dr. J. H. Taylor. Cherokee Chowan Dr. H. M. S. Cason. Clay Dr. P. B. Killian. Cleveland Dr. T. E. McBrayer. Columbus Dr. H. B. Maxwell. Craven Dr. Joseph F. Rhem. Cumberland Dr. A. S. Rose. Currituck Dr. H. M. Shaw. Dare - Davidson Dr. Joel Hill. Davie Dr. M. D. Kimbrough. Duplin Dr. John A. Ferrell. Durham Dr. N. M. Johnson. Edgecombe Dr. W. J. Thigpen. Forsyth Dr. S. F. Pfohl. Franklin Dr. R. F. Yarborough. Gaston Dr. L. N. Glenn. Gates Dr. Geo. D. Williams. Graham Dr. M. T. Maxwell. Granville Dr. S. D. Booth. V Greene Dr. W. B. Murphy. Guilford Dr. Edmund Harrison. 4 LIST OF SUPERINTENDENTS. Halifax Dr. I*. E. Green. Harnett Dr. J. W. Halford. Haj^woofl Dr. J. F. Abel. Henderson Dr. .J. G. Waldrop. Hertford Dr. J. H. Mitchell. Hyde Dr. R. E. Windley. Iredell Dr. M. R. Adams. .Jackson Dr. A. A. Nichols. .Johnston Dr. Ij. D. Wharton. .Jones Lee Dr. J. P. Monroe. Lenoir Dr. C. L. Pridgen. Lincoln Dr. R. W. Petrie. McDowell Dr. M. L. Justice. Macon Dr. S. H. Lyle. Madison Dr. W. J. Weaver. Martin Dr. W. E. AVarren. Mecklenburg Dr. C. S. McLaughlin. Mitchell Dr. Virgil R. Butt. Montgomery Dr. J. B. Shamburger. Moore Dr. Gilbert McLeod. Nash Dr. J. P. Battle. New Hanover Dr. W. D. McMillan. Northampton Dr. H. W. Lewis. Onslow Dr. Cyrus Thompson. Orange Dr. C. D. Jones. Pamlico Pasquotank Dr. J. B. Griggs. Pender Dr. Robert H. Bradford. Perquimans Dr. T. P. McMullan. Person Dr. W. A. Bradsher. Pitt Dr. Joseph E. Nobles. Polk Dr. Earle Grady. Randolph Dr. S. A. Henley. Richmond Dr. N. C. Hunter. Itobeson Dr. H. T. Pope. Rockingham Dr. Sam Ellington. Rowan Dr. I. H. Foust. Rutherford Dr. E. B. Harris. Sampson Dr. Frank H. Holmes. Scotland Dr. Iv. A. Blue. Stanly Dr. J. N. Anderson. Stokes Surrv Dr. John R. Woltz. LIST OF SUPERINTENDENTS. Swain Dr. J. A. Cooper. Transylvania Dr. Goode Cheatham. Tyrrell Union Dr. Henry D. Stewart. Vance Dr. John Hill Tucker. Wake Dr. J. W. McGee, Jr. Warren Dr. M. P. Perry. Washington Dr. W. H. Ward. Watauga Dr. J. M. Hodges. Wayne Dr. T. L. Ginn. Wilkes Dr. John Q. Myers. Wilson Dr. W. S. Anderson. Yadkin Dr. S. L. Russell. Yancey Dr. W. B. Robertson. LETTER OF TRANSMISSIO^t, North Carolina Board of Health, Office of the Secretary, Raleigh, June 15, 1909. His Excellency, W. W. Kitchin^ Governor of North Carolina. Sir :—I have the honor to present herewith the Twelfth Biennial Report of the ITorth Carolina Board of Health. Very respectfully, Richard H. Lewis, M. D., Secretary and Treasurer. TWELFTH BIENNIAL REPORT OF THE NORTH CAROLINA BOARD OF HEALTH. 1907-1908. The past two years, from the sanitary point of view, have been uneventful. Beyond an outbreak of typhoid fever of un-usual severity in the little village of Council, Bladen County, extending through two seasons, but limited in extent because of the small population, there has been no epidemic worthy of the name. Smallpox has continued to croj) out at various times and points, but has been decidedly less in extent than for several years, and of the same extremely mild type. The most noteworthy event of the past biennial period is the establishment of the State Sanatorium for Tuberculosis. The General Assembly of 1907 passed an act authorizing its establishment, and appropriated $15,000 for the purchase of a site and erection of buildings and $5,000 annually for its sujDport. While the amount appropriated was altogether inadequate, it was nevertheless the beginning of what we hope and have reason to believe will develop into an institution of great value in the crusade now waging all over the civilized world against man's most deadly enemy. Considerable dif-ficulty was found in securing a satisfactory site, but finally an excellent location with a clear title, in the pine-clad sand-hills at Montrose, on the Aberdeen and Eockfish Railroad, eight miles from Aberdeen, just across the Moore County line in Cumberland, was obtained. We doubt if a site more nearly ideal for the purpose can be found east of the Mississippi. With a capacity of thirty-four, it was opened for patients in Il^ovember, 1908, and has already done good work. For an account of the work of the Board in detail, the reader is referred to the pages following. MEETINGS OF THE BOARD. MINUTES OF THE ANA^UAL MEETIjSTG AT MOEEHEAD CITY. MoKEHEAD City, June 12, 1907. The annual meeting of the Board was held in the Atlantic Hotel, President Thomas in the chair. Members present: Drs. Thomas, Battle, Way, Anderson, Spencer, Register, Lewis (R. H.), and Colonel Ludlow. The minutes of the last meeting were read and approved. Dr. McCarthy, Biologist of the State Laboratory of Hygiene, read his report. On motion, its consideration was temporarily postponed, with the understanding that a report of the action of the Board thereon would be made to him at the end of the meeting. On motion of Dr. Spencer, Dr. C. A. Shore was elected Director of the Laboratory of Hygiene, at an annual salary of $2,000. beginning January 1, 1908. " On motion, the Treasurer was instructed to pay Dr. Mc- Carthy, Biologist of the State Laboratory of Hygiene, the sum of $500 for the purchase of his typewriter and to cover all claims against the Laboratory for fees for special analyses and for all other claims, as set forth in his report of this date; and it was further ordered that his services be con-tinued until March 1, 1908, at the rate of $2,000 per annum, beginning June 1, 1907. This was accepted by Dr. Mc- Carthy. On motion, the salary of the chemical assistant in the Laboratory, Miss Daisy B. Allen, was made $75 a month. beginning July 1, 1907. The Secretary having called attention to the fact that the terms of office of all the members of the Board of Embalming, by limitation or by change in the personnel of the Board of TWELFTH BIENNIAL KEPORT. 9 Health, had expired, Messrs. Harry and Simpson, embalmers, having held over, the follovs^ing were elected as members from the Board of Health : Dr. J. Howell Way, Waynesville; term expires 1909. Dr. E. C. Register, Charlotte; term expires 1908. Dr. E. H. Lewis, Ealeigh; term exj)ires 1912. The Secretary was instructed to prepare resolutions of appreciation oft the valuable aid extended to the Board of Health in its laboratory work by the State Board of Agricul-ture and to make them a part of these proceedings. The President was requested to appoint, at his convenience, the committees for the inspection of the public institutions of the State. Adjourned after midnight, to meet again in the morning. EicHAED H. Lewis, , Secretary. MoEEHEAD City, June 13, 1907. The Board reassembled with the same members present as the night before. On motion of Colonel Ludlow, the Secretarv was instructed to obtain a United States Geological Survey field outfit for water analyses, with the necessary su]3plementary apparatus for the bacteriological examinations of water supplies, and to employ in emergency a suitable man to make the examina-tions whenever in the opinion of the Engineer and the Secre-tary it might be deemed advisable. On motion. Colonel Ludlow and the Secretary were elected delegates to the American Public Health Association. The term of office of the Secretary having expired at this meeting by limitation. Dr. Way nominated the present in-cumbent and moved that the Present be instructed to cast the ballot, there being no other nomination. The motion was carried, the President cast the ballot of the Board and the present incumbent was re-elected for a term of six years. 10 NORTH CAROLINA BOARD OF HEALTH. The Treasurer presented his reports, with vouchers, for the Board of Health and for the Laboratory of Hygiene. Colonel Ludlow and Dr. Anderson were appointed by the President a committee to audit the same. The engineer of the Board was requested to continue his supervision of the public water supplies. The auditing committee reported that they had examined the accounts of the Treasurer and found thent correct. On motion, the Board adjourned to meet at 12 M. to-mor-row in conjoint session with the State Medical Society. RiCHAKD H. Lewis, Secretary. CONJOINT SESSION WITH THE STATE MEDICAL SOCIETY AT MOREHEAD CITY, JUNE 12, 1907. The conjoint session of the State Board of Health with the State Medical Society, according to custom, was held at 12 M. on Jnne 12, the second day of the meeting of the Society. Dr. George G. Thomas, President of the Board of Health, in the chair. REPORT OF THE SECRETARY. The Secretary read his annual report, as follows : ANNUAL REPORT OF SECRETARY OF THE NORTH CAROLINA BOARD OF HEALTH, MAY 1, 1906, TO MAY 1, 1907. During the past year we have suffered uo special outbrealc of dis-ease and the liealtb of our people in general has been about as usual. A detailed statement of the work of the Board will be found in the Eleventh Biennial Report, which has been for months and still is in the hands of the printer. A copy will be sent to any one asking for it as soon as it is published. The work of your Secretary has been for the most part of the usual routine character, special attention having been paid to the further distribution of the pamphlets on the prevention of tuber-culosis. The indications are that the wide circulation of this publi-cation has made an impression upon our people and has been of real assistance in the campaign against this most fatal of all our diseases. I am satisfied that the plan adopted of sending the pamphlet direct to the individual, with a letter urging him to read it and to assist in its distribution, has added much to its effectiveness. Over 100,000 copies have been mailed to date, and I am confident that no expendi-ture of our meager appropriation has brought forth better results than that paid out for the postage on this pamphlet. With January came the meeting of the General Assembly, which is always a period of mingled hopefulness and anxiety. While the attitude of the last Legislature was. perhaps, less friendly to our license law than has been the case for many sessions, its interest in the public health was more pronounced than usual—an interest that was not simply academic, but one that did something worth while. In The Bulletin for April I printed all the acts of general 12 NORTH CAROLINA BOARD OF HEALTH. interest bearing on the iDublic health, both directly and indirectly, but it may not be amiss to refer again in this place to the more im-portant. The act creating the State Laboratory of Hygiene, which carried no annual appropriation from the general fund for its support, was so amended as to give it two thousand dollars annually ; at the same time increasing the annual tax of sixty dollars upon water com-panies by four dollars. This latter does not materially increase the income of the Laboratory, but all the companies would not pay expressage on water samples, and the four dollars were added to cover that. With the tax from the water companies, nov.^ numbering fifty-one and gradually increasing year by year, the income will be sufBcient, with the money on hand, to adequately equip and conduct an excellent laboratory without outside help. In this connection it is proper to call attention again to the fact that without the generous aid given us by the Board of Agriculture we, in all probability, would not liave had any laboratory at all. It should be remembered that at first the Board of Agriculture had biological analyses of drinking-water made for us in their laboratory free of charge— - until the water tax was obtained four years ago—and that since that time it has, in addition to furnishing the Laboratory with gas and water, paid $750 a year towards the salary of the Director. I hope suitable acknowledgment of the enlightened liberality of the Board will be made by the conjoint session. The report of the Direc-tor for the past year is appended. In order to extend the benefits of the Laboratory as far as possible to the people, an act was passed authorizing the preventive treat-ment of rabies by the Director—who, in the reorganization, will doubtless be a thoroughly trained medical man—when it can be done without interfering with the legitimate work of the Laboratory proper. A decided advance in State medicine was marked by the enact-ment of the bill establishing a sanatorium for tuberculous patients, appropriating $15,000 for a plant and $5,000 annually for support. The chief credit for this particular legislation is due to Dr. .J. E. Brooks, of Greensboro, who was "the man behind the gun," and the Hon. J. R. Gordon. M. D.. member from Guilford of the House of Representatives, who was mainly instrumental in securing its pas-sage. Acknowledgment of this was made by the Board of Directors, of which the Secretary of the Board of Health is ex offlcio a member, at their first meeting, in the election of Dr. Gordon Chairman of the Board and Dr. Brooks Superintendent of the Sanatorium. While the appropriation is very small, it will provide for a beginning, and as the Superintendent is not only an intelligent and capable physician, but an enthusiast on the subject. I feel confident that it will succeed. As the competency of our physicians is of the highest importance TWELFTH BIENNIAL KEPOKT. 13 to the public health, anything bearing upon our medical license law is of importance to us. During the session of the Legislature bills for the relief of physicians in Cherokee, Clay, and Graham counties and in Chatham County were enacted into laws. In the one case physicians having diplomas were allowed to practice without license until May 1, 1909, and in the other simply to stand the exami-nation for license without exhibiting a diploma. The reason given for this legislation was the same in both cases—that in the remote, sparsely settled, and physically rough regions physicians so well edu-cated as to meet the requirements of our very high standard had not settled, and that unless such action was taken the people in the affected regions would be without medical aid. While actively op-posing the first-named bill for fear it might be an entering wedge threatening the integrity of our license law, I could not deny the facts, nor iu my own mind deny the inherent reasonableness of the contention in the light of those facts. It was indeed the realiza-tion of what we have been anticipating, and I was thoroughly im-pressed with the importance of devising some means of practically lowering the standai-d to meet such conditions lest our license law should be emasculated in the near future. As a means to this end I approved, as Chairman of the Society's Committee on Legislation, the passage of a bill authorizing the Board of Medical Examiners to reciprocate with other States in their discretion. I welcomed this bill the more gladly because it enabled me to secure the voluntary suppression by its author of another bill requiring the Board of Examiners to grant licenses to any one presenting a diploma from the American Association of Medical Colleges and a license from any State. As the standard of some States is extremely low, and in nearly all lower than in ours, the passage of this bill would have practically repealed our license law and have undone the work of fifty years for the elevation of our profession and the protection of the people against incompetent physicians. Before the present meet-ing of the Board of Medical Examiners I addressed a circular-letter to each member of the same, calling attention to the conditions above set forth and to the importance of action on their part to meet them as far as possible, suggesting reciprocation with the low-standard States when the conditions for this concession demanded it, and also that it would probably be well to lessen the rigor of the examination somewhat by granting certificates on the branches passed, and thereby encourage men to come a second time and finish up successfully rather than give up in despair and take the chances of practicing illegally. I was, therefore, much gratified to learn from President Kent, who stopped over in Raleigh on his way to the meet-ing for the purpose, that he had secured from the Assistant Attorney- General an opinion to the effect that it would be legal for his Board to grant a license and to require the recipient to sign a contract to 14 NORTH CAROLINA BOARD OF HEALTH. restrict his practice to a certain county or section, the Assistant Attorney-General writing out the form of the said contract. The judicious use of this privilege will, I think, solve the problem. SMALLPOX. I am very glad to state that smallpox has been very much less prevalent. In 1905 the total number of cases was 7,.37.5 with 31 deaths ; in 1906, 6.049 cases and 17 deaths, while during the year ending May 1, 1907. the total number of cases was only 1,897 with 6 deaths. The following is a tabulated statement of the disease by counties : SMALLPOX REPORT, FRO^NI MAT 1, 1906, TO MAY 1, 1907. Counties. Alamance — Anson Ashe* Bertie Bladen* Brunswick - Cabarrus Carteret Catawba Chatham Cherokee— Chowan* Cleveland — Columbus -— Cumberland - Currituck --. Davidson Duplin Durham Forsyth Franklin* — Gaston Granville Guilford Halifax Number of Cases. White. Colored. 24 10 15 5 12 5 1 2 1 12 2 100 4 1 19 22 6 64 24 9 10 2 5 2 74 10 11 3 30 6 15 1 200 1 4 7 12 50 *91 4 5 94 1 Total. 98 20 15 16 15 35 7 2 1 27 3 300 4 2 23 29 6 12 114 24 *100 14 7 99 3 Number of Deaths. White. Colored. Total. TWELFTH BIENNIAL REPORT. 15 SMALLPOX—Continued. Counties. Harnett Hertford Lincoln Martin Mecklenburg Moore Nash New Hanover Northampton Orange Person Pitt Randolph Richmond* Robeson Rowan Rutherford Stanly Vance Wake* Warren Washington* Wayne Total in forty-eight counties - Death rate, per cent. Number of Cases. White. Colored. 18 15 17 20 4 4 10 25 13 26 7 10 3 4 8 67 4 620 4 30 Total. 100 4 23 65 6 1 5 272 2 20 190 1,348 22 45 17 120 8 27 10 1 3 25 1 13 91 13 10 6 4 1 13 339 6 28 190 1,968 Number of Deaths. White. Colored. .003-;- Total. .002- .003- ' Estimated. In compliance with the instructions given the Secretary at the meeting of the Board the night before, he presented the following resolutions of appreciation of the great serv-ice rendered the cause of the public health by the State Board of Agriculture in having made for the Board in its laboratory sanitary analyses free of charge for two years and upon payment by the Board of Health of half the salaries of 16 NORTH CAROLINA BOARD OF HEALTH. the Biologist and his assistant for four years longer, the Board of Agriculture defraying all other expenses of the laboratory, which were unanimously adopted: Resolved, by the North Carolina Board of Health and the Medical Society of the State of North Carolina in conjoint session assembled: 1. That as the special custodians of the health and lives of our people they desire to place on record their appreciation of the gener-ous assistance in preventing disease, given by the State Board of Agriculture in the use of its laboratory, including the services of its bacteriologist, for making analyses of drinking-water suspected of causing typhoid fever, and other hygienic analyses, bearing all the expenses for two years and fully half for four years more, until funds could be secured for its support. 2. That the benefit to our people in the prevention of typhoid fever alone has, if computed in terms of dollars, exceeded many times over the amount expended, and they owe a debt of gratitude to the Board of Agriculture that should ever be remembered. 3. That these resolutions be spread upon our records and that a copy be sent to the Commissioner of Agriculture, with the request that he transmit it to his Board at its next meeting. [Owing to the failure of the stenographer employed by the Medical Society to furnish his report to the Secretary of the same, there is no record of the discussions.] Mli^UTES OF THE ANXUAL MEETING AT WIXSTON-SALEM. Wiis'ston-Salem^ jST. C, June 16, 1908. Annual meeting. Present : Drs. Thomas, Anderson, Way, Spencer, Register and Burroughs, Colonel Ludlow and the Secretary, The minutes of the last meeting were read and approved. Dr. Shore, Director of the Laboratory of Hygiene, read his report. On motion of Dr. Spencer, the Secretary was authorized to employ an assistant bacteriologist. The Secretary stated that by allowing part of her time to the Laboratory, he had reduced the cost of the stenographer to the Board from $35 to $25 a month. On motion of Dr. Way, the Secretary and such other mem-bers as may attend were appointed delegates to the next meeting of the American Public Health Association, their expenses to be paid, if there should be money enough in the treasury after meeting the regular charges thereupon. The President was authorized to appoint, at his con-venience, committees to make the regular inspections of the State institutions, Drs, Spencer and Register, who were appointed as auditing committee, reported that they had examined the accounts of the Treasurer and found them correct. On motion, the Board adjourned, to meet in conjoint ses-sion with the State Medical Societv at 12 M, to-morrow, RiCHAED H, Lewis, Secretary. CONJOINT SESSION WITH THE STATE MEDICAL SOCIETY AT WINSTON-SALEM, JUNE 17, 1908. The State Medical Society was called to order at 3 :30 with the President, Dr. J. Howell Way, in the chair. The Peesident: The Society will be in order. We will now have the conjoint session of the State Medical Society and the State Board of Health. Gentlemen, I present the President of the State Board of Health, Dr. George G. Thomas, who will preside over the conjoint session. Dr. Thomas: The conjoint session is now open for bns^i-ness. We will be glad to have the report of the Secretary. ANNUAL REPORT OF THE SECRETARY OF THE NORTH CARO-LINA BOARD OF HEALTH—MAY 1. inOT. TO MAY 1. 190S. The health conditions of our State during the past year have been marlvPd by nothing out of the common run, and the worlv of your Sec-retary has been chiefly routine. There have been some small epi-demics of typhoid fever, and an investigation by the Board was re-quested by County Superintendent of Health Evans of one at Coun-cil, in Bladen County, and by Mayor Montgomery, of Reidsville. of an outbreak in that town. The former was investigated by President Thomas and the latter by Engineer Ludlow. Their re.spective reports are appended. Tuberculosis has lost nothing in importance or interest. Our dis-tribution of literature on the subject has. I believe, borne fruit in the education of the people as to the best methods of preventing its spread. In August last, at the request of the authorities, a committee of the Board visited the State Hospital at Morganton and advised with the management as to the location of special quarters for tuber-culous patients. Their report is appended. Although not under the control of the Boai'd of Health, its Secretary is, ex offlcio, a member of the Board of Directors of the State Sana-torium for Tuberculosis, and a review of the health conditions of the State would not be complete without reference to it. Its establish-ment was authorized by the last Legislature, hut it has been un-avoidably delayed by the inability to secure a site suitable to the per-manent establishment of so important an undertaking. Fortunately, TWELFTH BIE:XNIAL REPORT. 19 the necessary abandonment of one or more locations fixed upon, owing to the inability to secure a sound title, finally resulted in the selection and purchase of as nearly an ideal site as can well be imagined. Situated in the sandhills of Cumberland County, about eight miles from Aberdeen, it is traversed by the Aberdeen and Rockfisb Railroad, and is, therefore, easy of access. The purchase contains about nine hundred acres, and its highest point, which has been selected for the location of the buildings, overlooks a wide panoramic view of at least three-fourths of a circle of miles upon miles of rolling pine forest. Work has been begun on the buildings, and it is hoped, I am told by Dr. Brooks, the Superintendent, that patients can be received in the early fall. The International Congress on Tuberculosis, which is to meet in Washington, September 21st to October 12th. is an event of world-wide interest and will well repay a visit. I hope that many of our health oflicers and physicians will attend. Smallpox has been slightly more prevalent than during the pre-ceding year, the record being 2,011 cases, with 8 deaths, against 1,968 cases and 6 deaths in 1906-'07. During the past year the disease has been much more prevalent among the whites than among the negroes, which is just the reverse of the year before. To state it accurately : In 1906-'07 there were 620 white cases, with 2 deaths, and 1,348 col-ored cases, with 4 deaths; while during the past year there were 1,168 white cases, with 6 deaths, and 843 colored cases, with 2 deaths. The number of counties infected was just the same in each year—48. Owing to its continued mildness, and the fact that it has become such an old story—just ten years old—it produced little concern and prac-tically no interference with business. The following is a tabulated statement, by counties : SMALLPOX REPORT, FROM MAT 1, 1807, TO MAY 1, 1908. Counties. Alamance* Alleghany - Beaufort -- Bertie Buncombe - Burke Cabarrus -- Catawba-— Chatham -- Number of Cases. White. Colored. Total 75 6 2 6 4 89 1 20 60 22 135 6 7 6 3 4 111 1 23 Number of Deaths. White. Colored. Total, 20 NORTH CAROLINA BOARD OF HEALTH. SMALLPOX—Continued. Counties. Chowan Cleveland Columbus Cumberland --. Currituck Davidson Davie Durham Edgecombe* — . Forsyth Gaston Gates Guilford Halifax Harnett Iredell Jackson* Johnston McDowell Madison Mecklenburg - Mitchell New Hanover Nash Orange Pasquotank — Pender Randolph Robeson Rockingham— Rowan Rutherford Sampson Wake Warren Number of Cases. White. 100 8 2 1 32 7 1 12 14 6 109 9 10 75 150 3 37 16 40 9 2 5 3 14 4 3 48 11 2 29 Colored. 100 17 55 1 192 5 72 1 4 75 19 25 2 59 45 5 1 51 6 Total. 200 8 3 1 49 7 55 2 12 206 6 5 181 1 13 10 75 225 3 37 21 40 28 2 30 2 3 14 4 62 93 16 3 80 6 Number of Deaths. White. Colored. Total. TWELFTH BIENNIAL KEPORT 21 SMALLPOX—Continued. 22 NORTH CAROLIIVA BOARD OF HEALTH. a compptent assistant, as the diveolor. even now. has all his time occupied in the general work ; but we can now afford it, and we recom-mend it. The repoi't of the Director of the Laboratory accompanies this. As the Laboratory is intended for the benefit of the people, through the medical profession, it is hopetl that the physicians will freelj' avail themselves of its help. Dr. Thomas : Gentlemen, you have heard the report. Are there any remarks thereon? Then, if there is no objection, the report will go on file. Gentlemen, it is my pleasure to introduce to you Dr. Charles Wardell Stiles, Ph. D., Chief of the Department of Zoology of the United States Public Health and Marine Hospital Service, who will give you a special address on "Soil Pollution, with special reference to Hookworm Dis-ease." Dr. Stiles : Before passing to the reading of my i)a]ier I wish to say that Surgeon General Wyman sends his l)est regards to the Association, with his best wishes for a success-ful meeting. I have taken the liberty of changing my paper somewhat, although I shall speak on the same general subject as in the program. The title of my paper reads : THE MEDICAL INFLUENCE OF THE NEGRO IN CONNECTION WITH ANEMIA IN THE WHITE. Mr. Fkesident and Gentlemen:—In responding to your kind invi-tation to return to North Carolina and to address your meeting, I invite your attention to a certain phase of the same subject upon which I spoke before you several years ago. In my former address I discussed the general subject of hookworm disease. To-day I wish to speak on the negi'o as a factor in the spread of this malady, and his resulting influence upon the health of the white race. In bringing this subject before you, it is needless for me to state that I appeal to no race prejudice, but that I simply bring forward certain harsh, cold, scientific facts, which must be faced, not only in the interest of the white, but in the interest of the negro as well. As many of you know, I have for some years past lieen especially interested in studying medico-zoological conditions in the rural dis-tricts of the South, and this work has led me to spend about a year living among the tenant whites. During these studies I have made TWELFTH BIENNIAL, REPOKT. 23 inquiries among all classes of people regarding their ideas relative to the origin of the present impoverished financial and physical condition of the "crackers," "sandhillers" and "harrenites," and the information obtained, combined with my own investigations, has led me to a con-ception of these people which is not altogether in harmony with the general opinion entertained regarding them. So far as I can analyze the subject, these people are the joint product of certain medical and industrial conditions, as follows : In ante-helium days, if a man was wealthy enough to own slaves, he was wealthy enough to own good plantation land. If not wealthy enough to own slaves, it is not reasonable to assume that he could buy the better class of farms. The latter people, therefore, would natu-rally be forced into the poorer lands, if owners, or to serve as over-seers, to become tenants and, in general, to compete with slave labor. Such seems to me to be the most reasonable of the several explana-tions I have heard regarding the origin of these people. In different parts of the South they are known as "shad-bellies," "poor Bukra," "poor whites," "crackers." "sandhillers," "sand Billies," "barrenites," "poor .Johns," etc. The old-time negro had a great contempt for the white man who could not own a slave, and this contempt culminated in the expression, '•poor white trash." This same contempt is reflected in the negro song, "I'd rather be a nigger than a poor white man." The expression, "poor white trash," has become very well known, despite its offensive character, and, unfortunately, the average more fortunate whites, both those who know these people and those who have not seen them, have too commonly allowed their judgment of these people to become somewhat clouded by the judgment formed by the old slaves. In fact, very few persons have any sympathy -for these people, who have been repeatedly referred to in my presence as "lazy," "shiftless." "good for nothing." "indolent," "untrustworthy." etc. One Southerner whom I recently met stated that he had had twenty-five years' experience with them, and that he considered "they were not worth trying to help." He was kind enough to inform me that I was wasting my time in living among them and studying their conditions. This reflects in an exaggerated form the average opinion I have encountered during my studies among these people, now car-ried on at various intervals for nearly six years, the total study-amounting to about one year's time. Actual experience among them for the purpose of scientific study, and actual association with them, involving sleeping in their homes, board with the "dirt eater" and "snufC dipper." playing with their children, visiting their schools, seeing them on farms, in mines, in mills, hospitals and orphanages, have led me to a conception of them which is different from the opinions just mentioned, and I am forced to take radical issue with any person who looks upon them as "lazy," 24 NORTH CAROLINA BOARD OF HEALTH. "iudoleut" 01' "good for nothiug," and I cannot refrain from expressing surprise that any man should have twenty-five years' experience with them and use so little intelligence and acumen as to come to the con-clusion that tlioy are "not worth trying to help." Since these people are peculiar to the South, in order to understand them it is necessary to understand certain other factors which are peculiar to this same region. There are three factors in particular which come into consideration, namely: (1) the area under discus-sion presents the most intense negro population of any part of the country; (2) this area also presents the area of most intense hook-worm infection; and (3) the same area presents the most intense malaria infection of any portion of the country. The question now arises : In what relation do these four factors (the tenant white people, the negroes, hookworms, and malaria) stand to one another? I need not argue to you the fact that both hookworm disease and malaria are found both in the white and in the negro, for this is well established. I may. however, invite your especial attention to an important point, too often overlooked, namely, that these two great anemia-producing diseases which are so severe on the white are rela-tively less severe on the negro race. This fact, that the negro pre-sents a relative immunity to the physical effects of these two infec-tions which are so common to his race, is one of very great impor-tance, for it points us to a conclusion from which there is no escape, namely, that the negro va.ce, forms a great reservoir for the supply of these infections. Take malaria, for instance. It is a well-established fact that the malaria parasite is exceedingly common in the blood of negroes. It is a fact of common knowledge, which can be easily verified by any doii])ting Thomas, that the negro does not trouble himself very much to screen against mosquitoes. What is the result? Since the negro does not suffer from the effects of this infection so severely as does the white, the negro is not so likely as the white to come under medi-cal treatment ; accordingly, he is more likely to form a source of infection to the mosquito ; add to this the fact that he does not screen against mosquitoes so much as does the white, and it is clear that rel-atively he forms a greater source of infection to the mosquito than does the white. Now. let a v\-hite man take what precautions he will against malaria in his family, the mosquitoes in the negro's house on the back street still form for this white man's family a source of danger, over which he has practically no control. The conclusion is evident : Theoretically and pi'actically. the negro race, living side by side with the white race, is, when viewed from the standpoint of malaria, a great and serious reservoir of infection. Take next hookworm disease. A given infection with this disease may put a white person in his grave or may make him so sick that TWELFTH BIEX^'IAL REPORT. 25 he remains at home, and it is likely to bring him under medical treat-ment. Tbus this infection is either brought to an end or it is more or less confined to the immediate premises of this particular family. That same infection will produce less serious phj-sical results on the uegro, who will, therefore, not be so likely to be confined at home, and he will not lie so likely to come under medical treatment. The conclusion naturally is that, relatively, the negro is, and from theo-retical conditions necessarily must be, a greater spreader of hook-worm disease than is the white man. The immense importance of this latter fact can be seen when we compare the white and the negro as a soil polluter. In this connec-tion I would state that I have collected statistics for 3G6 farmhouses in North Carolina, South Carolina, Georgia and Alabama, and I find that of these 366 cases only ll.j houses, or 31.4 per cent, were pro-vided with jH-ivies of any sort ; in other words, 251 of these houses, or 68.5 per cent, had no privy, and on this account the soil pollution on these premises reached a theoretical maximum. Of the 306 farm-houses in question my records show that 73 were occupied liy whites and 83 by negroes, but I have no record of the race of the occupants of the remaining 210 houses. Of the 73 houses occupied by whites 56.1 per cent, or 41 houses, had privies, and 43.S per cent, or 32 houses, were without privies. Of the 83 negro houses 20.4 per cent, or 17 houses, had privies, while 79.5 per cent, or 66 houses, had no privy. In other words, the theoretical maximum of soil pollution was reached in 43.8 per cent of the houses occupied by whites and in 79.5 per cent of the houses occupied by negroes. From these statistics it would appear that the negro is nearly twice the soil polluter that the white man is, and this conclusion is in harmony with what we know of the generally poorer condition (jf the negro privy, when one is pres-ent, and also with the complaints so often made regarding the pollu-tion of alleys in cities by the negro. Comparing the white and the negro, numerically, as an inhabitant. we find that in the States of Virginia, North Carolina, South Carolina, Georgia, Florida, Alabama. Mi.ssissippi and Louisiana the average ratio is 1,000 whites to 833 negroes. The ratio in these States varies between 1.000 whites to 494 negroes in North Carolina and 1.000 whites to 1,415 negroes in Mississippi. From the foregoing data it is seen that in the area under discussion we have the following combination : (1) Two races (whites and negroes) are living side by side. (2) As inhabitants they bear the ratio of 1.000 whites to 833 negroes (a proportion of negroes far in excess of what exists in other States). (3) As soil polluters they bear the ratio of 438 (in whites) to 795 (in negroes). (4) Two diseases (hookworm disease spread by soil pollution, and malaria spread by mosquitoes) are present in high percentages. 26 NORTH CAROLINA BOARD OF HEALTH. (5) Those anemia-producing diseases are especially' severe on the white, hut relatively less severe on the negro. To my mind, the foregoing combination of facts leads inevitably to the conclusion that the white race in the South is living under a hygienic handicap which is not paralleled in any other part of the country, and, were it not for the greater intelligence and better finan-cial condition of the whites, whereby they are able to protect them-selves more or less against these diseases by sanitary measures, it would be only a question of a few generations before this handicap would exterminate the whites from those portions of the South which are especially favorable to these infections. The whites of higher education and in better financial condition are able to protect themselves against this handicap, the burden of which has, therefore, fallen more especially upon that class (namely, the rural white tenant class) which has been kept in financial impoverish-ment through generations of competition with negro labor ; and the result is exactly what theory demands it should be, namely, the pres-ent impoverished physical condition of so many thousands of the ten-ant white people, especially those living in the sandy and mountainous districts, where the sanitary arrangements are so inferior. The physical condition of these people can be appreciated only by persons who have been among them. Those of us who have lived among them need not be surprised to find their blood from 10 to 70 per cent below normal, nor need we be surprised, upon entering a poor farm hovel, to foresee death, in many instances, in 40 per cent of the children (namely, 2 of the 5, or 4 of the 10 children of the family) before they reach twenty-one years of age. I visited one farm on which I found father, mother, five children, and fifteen chil-dren's graves. I asked the physician what had killed these fifteen children, and he replied : "I do not know what the disease is, but if you can tell me what is killing fJiat girl there, you will know what killed the other fifteen children." "That girl there" was a severe case of hookworm disease, in the dirt-eating stage. Think of it. gentle-men ; 75 per cent of the rising generation of this family had already paid the extreme penalty of soil pollution, and one further member of the family already had one foot in the grave! Gentlemen, let any one call me a theorist if he will, but, in all fair-ness to the tenant white class of the rural sand and piney-woods dis-tricts of the South, let him first see the sights I have .seen before he makes fun of those people and before he jokes about their sick and dying women and children. Before any man who claims to be hu-mane considers these people "lazy," "good for nothing" and "not worth trying to help," let him reflect upon the following statistics, based on about 10,000 examinations I have recently made among this class of people : TWELFTH BIENNIAL REPORT. 27 (1) At least 13 per cent (women over 20 years) to IS per cent (girls 16 to 20 years) of these women of maternity age are suffering from the anemia-producing hookworm disease, which prevents them from properly nourishing their habes. (2) Of the girls under 16 years, at least 18.7 per cent have this same infection, which thus adds a serious strain upon their bodies (in addition to the strain incident to their sex) and which tends to re-tard their physical development, so that many of them reach maturity two to five years late ; and even after they have reached maturity this disease renders them irregular in their menstrual functions. (3) Of the boys under 16 years, at least 24.9 per cent have this same infection, which inliiliits both their physical and their mental growth. (4) Of the boys 16 to 20 years, 20.7 per cent, and of the males over 20 years, 5.8 per cent, show these same symptoms, which decrease their labor capacity and their military efficiency. Now, my friends, in all kindness, let me submit to you a question for thoughtful consideration : Nearly half a century ago the country freed the slaves, but in these decades that have elapsed since then uhat has our couiitri/ done in order to hetter the conditions of the tens of thousands of the rural tenant ichites xoho have been kept in financial poverty through competition tcith negro lahor, and in physi-cal poverty through the tico great anemia-producing diseases for which the negro forms the great reservoir of infection? All honor to the few noble men and women who, by great personal sacrifice, are struggling to support efforts looking to a betterment of their condition; all honor to the few physicians who have let it be known that they will treat hookworm cases among thes-e people with-out professional fee ; all honor to the Southern cotton mill which is enabling thousands of these people to earn an honest living and thus to uplift themselves. But think a moment. In comparison icifh what this country is doing for the negro of the ^^outh, for the Chinaman in Asia, and for other people of different races, ivhat is our country doing in order to elevate these tens of thousands of people of our own race in our own country? Does it tend to elevate them if we refer to them as "lazy" and as "good for nothing"? Would it not help them more if we could send to the chain gang people who indulge in that kind of pseudo-wit? Gentlemen, there is a rational solution to the problem before us, and I submit to you for consideration a plan which I maintain is well founded from a theoretical point of view, and feasible from a practi-cal point of view. It is the same plan which I submitted a few days ago to the Alabama State Medical Association, and which the Asso-ciation has unanimously endorsed. It is this : Let us start out on the general principle that it is much easier to teach children than adults. With this truth in mind, I propose the 28 NORTH CAROLINA BOARD OF HEALTH. introfluftion of a "Public Health Week" into every schoolroom in the South. During this week let us utilize the class in physiology, in order to teach to the children the three great and fundamental princi-ples of public health so important for the South. These principles are: First. Do not spit on the floor, for this habit spreads tuberculosis and diphtheria. Second. Do not pollute the soil, for this habit spreads typhoid fever and ground itch, with its resulting hookworm disease. Third. Protect against mosquitoes-, for mosquitoes spread malaria, yellow fever, dengue, and elephant foot. Besides working through the schools, let us use every other means by which we can carry on a merciless campaign against soil pollution. In the last analysis, soil iwllution is an evil in itself; it is in the nature of "malum in se" ; it is an "aggravated offense against the pub-lic welfare" ; hence it should be prohibited and made a crime, and any person guilty of polluting a highway or back alley should be sent to the chain gang. Let us extend this campaign to the farms especially, and, if possible, persuade, but, if necessary, compel, the farmer to build a sanitary privy and to keep it clean. Let us appeal to the clergy, to the lawyers, to the business men, and especially to the school teachers and the mothers, to join in this cam-paign. If I can gain the mothers of the South for this movement, and be given a chance to do so, I will agree to practically eradicate hook-worm disease from the South in one generation's time, and by this eradication I will agree to elevate the condition of the rural tenant whites. In conclusion, gentlemen, let me emphasize a very important point in the plan I propose, namely, that it is absolutely necessary to avoid any distinction between the whites and the negroes in this campaign of sanitary education, foi* — (a) The white man who fails to recognize the important necessity of improving the sanitary conditions under which the negro is living fails to go to the root of the evil, and he unconsciously invites disease and death, especially to the women and children of his own race ; while— (h) The negro who fails to recognize the important necessity of improving the sanitary conditions under which the negro is living overlooks the fact that he is placing a very serious handicap in the way of a higher mental development of his race ; for the point must not be forgotten that hookworm disease, in addition to its physical effects, to which the negro is relatively immune, has also a serious effect upon the mentality, and it has not been shown that the negro is immune to this latter effect. TWELFTH BIENNIAL REPORT. 29 Dr. Thomas : I would like to say that I owe Dr. Stiles an apology for my error in introducing him. He is well known to this Society. Db. Julian : I am sorry that I did not get here in time to hear this very valuable paper of Dr. Stiles' ; but some years ago Dr. Stiles came to my town and assisted me in eradicating hookworm disease at the Thomasville Orphanage. At the time he assisted me he was satisfied the box privy was the source of the epidemic. I reported the matter to the trustees. We pulled down the box privies, dug a deep well, have water throughout the building, and after a few months we have never seen a case of the disease. Dr. Lewis : I wish to call to the attention of the Society that the Laboratory, as it already knows, is ready to make ex-amination of the faeces. All they have to do is to write the Laboratory at Ealeigh for a container and send a sample of the faeces to the Director of the Laboratory. Dr. Julian : The examination is very easily made by any doctor who is acquainted with the microscope, by introducing the finger into the rectum, getting a small amount of the fseces, placing it on the slide, and in a few drops of water. Dr. Thomas : We will now have an address by Dr. Tait Butler, State Veterinarian of IvTorth Carolina, on OUR MILK SUPPLY AND SOME OF ITS RELATIONS TO PUBLIC HEALTH. In accepting the invitation of your Secretary, Dr. Lewis,, to read a paper at this meeting on the public or marlcet millv supply of the State, I did so with a distinct purpose in view. It is, perhaps, telling no secret, and it is certainly not meant offensively, if I state that the average practicing physician is none too familiar with the real prob-lems involved in putting into the hands of consumers a wholesome milk supply. But this, in my opinion, is not of great importance. It Is not necessary, however desirable, that the physician possess expert dairy knowledge or that he be capable of performing the duties of a scientific dairy inspector. A much more important matter, as affecting any effort for the improvement of our milk supply, is that he have a full and accurate knowledge of the real importance of pure milk for the consumption of those under his care. 30 NORTH CAROLINA BOARD OF HEALTH. Many of those here have given special study to this suhject. Others who are investigators have full knowledge regarding certain phases of it, but the general practitioners have not given that attention to the subject which its importance demands. Moreover, the general prac-titioner gets closer to the public than any other man, and it is through him that the general public can be best reached ; therefore, in this paper I have decided to talk to the general practitioner and to assume the part of an agitator rather than an educator. All freely admit the importance of a wholesome milk supply as a general proposition. But how many know fully and accurately the awful results of our criminal neglect in the past along this line? How many have an accurate knowledge of the quality, or lack of quality, of the milk now being sold throughout the State? How many i-ealize the full measure of filth which it carx-ies, and what that means in misery and death to the innocent babes who must con-sume it? Gentlemen, it is not the ravings of a fanatic nor the extravagance of a sensationalist, but a conservative statement of terribly serious facts when I say to you that the almost total ignorance of dairy science on the part of our milk producers, the lack of knowledge of what constitutes first-class milk, and the care it should receive on the part of consumers, and the almost criminal indifference and inertia of the medical profession, who are the accepted guardians of the public health, are seeds, the awful but legitimate harvest of which are ill health, misery and death to hundreds upon hundi'eds of innocent con-sumers during our long, hot summers. The indifference of the public generally, and the indifference and inactivity of the medical profession in particular, along the lines of milk and meat inspection, are little short of tragic, and I wish I might say something that would help, in a small way at least, to arouse and increase interest in this long-neglected branch of sanita-tion. There are three general ways in which the milk supply may have a direct relation to the public health : 1. It may be a means of carrying and transmitting disease from man to man—such, for instance, as typhoid fever, diphtheria, scarlet fever, cholera, etc. ; but of these phases of our subject I shall take for granted you are better informed than I, and omit their discussion. 2. Milk may be a means of carrying and transmitting disease from cows to man, such as tuberculosis, anthrax, foot and mouth disease, eowpox, etc. Of these, one alone is common—tuberculosis—of which I shall have something to say later. 3. Milk may cause disease in man by conveying disease-producing agents or materials, such as filth and the conditions which it favors for the growth of bacteria and the development of toxins and other deleterious substances ; also the products of mammitis and other septic troubles. TWELFTH BIENNIAL REPOKT. 31 Of the distinct diseases affecting the cow, which also affect man and which may be communicated from one to the other, tuberculosis is of first importance. When Koch discovered the bacillus of tubei'culosis and proclaimed the identity of boA-ine and human tuberculosis, there was little hesi-tancy in accepting a conclusion so closely in harmony with the experi-ence and observation of scientific workers in both human and veteri-nary medicine. Later investigators called attention to the difficulty in transmitting human tuberculosis to bovines, and still later the fact was pointed out that the bacilli from bovine and human sources often possessed morphological and cultural peculiarities sufficient to differ-entiate them ; but when Koch followed, in 1901, with the remarkable declaration that bovine and human tuberculosis were different and not intercommunicable, few scientific investigators were willing to accept the (lictum on the insufficient evidence produced, and at once investi-gations were started all over the civilized world to determine the truth or falsity of Koch's declaration. In the meantime progress towards preventing the communication of bovine tuberculosis to man received a decided setback. The results of the investigations, stimulated by Koch's dogma, indi-cate, as clearly as the nature of the case will permit, that bovine tuberculosis may be and is communicated to man. It has been shown that the bacillus from human tuberculosis is capable of producing tuberculosis in many animals, but for no animal, unless man is the sole exception, is it so virulent as the bovine germ. If the bovine bacillus is more virulent for all other animals, including monkeys and apes, it very logically follows that it probably is also more virulent for man than the hiunan bacillus. Of course, Koch has not recanted. He still maintains the position taken in 1901, but the fact is now pretty generally recognized that bovine tuberculosis may be a source of danger to man. The next question to arise was, naturally. To what extent is bovine tuberculosis a source of infection to man'? In their efforts to show that bovine tuberculosis was rarely com-municated to man, the fact of the greater frequency of pulmonary than abdominal tuberculosis was pointed out, and the claim that intes-tinal tuberculosis of children, the greatest consumers of milk, was rare, were made much of. Recently much evidence has been developed showing that intestinal or abdominal tuberculosis of children is not so rare as claimed by those who maintain that bovine and human tuberculosis are not inter-communicable. And still further to the dismay of those who cling to old beliefs because they are old, even the time-honored assumption that the chief mode of entrance of the infection agent is through the inhalation of germ-laden dust particles has been challenged and met with an array 82 NORTH CAROLINA BOARD OF HEALTH. of fjiels and reason which may wt'll receive serious consideration by all those interested in the question of the relation of the milk supply to the public health. It has been clearly shown that the introduction of the bacillus into auy part of the body—blood vessels, intestines, abdominal cavity, or even a part so remote as the tail of the cow—is generally followed by thoracic tuberculosis, instead of necessarily tuberculosis at the point of entrance or of nearby organs. Again, when tuberculosis of the intestines is found, especially in children, the bovine germ, which may be recognized, is frequently found in these cases of human tuberculosis. Is this not more than passing strange if the bovine germ does not produce tuberculosis in the human? In short, recent investigations show plainly that not only is bovine tuberculosis communicated to man, but that this is probably not so uncommon as the comparative infrequency of abdominal tuberculosis was thought to indicate. To question the old inhalation theory of the entrance of the tubercle germ from sputum, pulverized, is. I know full well, among the medical men here, likely to lessen the respect which you will have for the other statements I may make, but I cannot resist the temptation to state that it never did have any scientific evidence worthy of con-sideration to support it. It is an old, well-known fact that drying and sunlight rapidly kill tubercle bacilli. One hour of sunlight will kill tubercle bacilli in transparent layers of sputum, while five hours exposure to sunlight will kill the bacilli in thick opaque layers. Sputum is mixed with mucus, is tenacious and hard to pulverize, unless thoroughly dried. Yet we accept the statement that tubercle bacilli resist this drying and pulverizing process to such an extent that this way, and this way almost exclusively, is tuberculosis thought to be introduced into the human system. The theory is not only not supported by facts, but is most unreasonable. Furthermore, if the tubercle germs enter by way of the air cells, why is it that tuberculosis starts in the capillaries instead of in the air cells? Why is it that tuberculosis starts in the apex of the lung, where there is a smaller proportion of air cells than in the base of the lungs? "" Another discovery has recently been made, namely, that probably before the tubercle bacilli are expelled from the body in any con-siderable numbers through other channels, they may exist in large numbers in the manure. Years ago, I remember reading in Novy's "Laboratory Work in Bacteriology" that there was a bacillus fre-quently found in cow manure that stained like the tubercle bacillus — very much like it. indeed, because it probably was the tubercle bacil-lus. Now, the chief filth in milk is cow manure. That cowy odor is usually plain, vulgar, filthy cow dung. TWELFTH BIENNIAL REPOKT. 33 lu the face of these facts, what is our position? We Icnow that tuberculosis exists in our dairy herds ; we liuow that when tuber-culosis exists iu a herd, owing to the passage of the bacilli through the udder, and through the intestines and manure, which almost always contaminates the milk more or less, milk from such a herd is almost certain to contain tubercle germs. We know that infants, the largest consumers of milk, have intestinal tuberculosis more fre-quently than adults, and that the bacillus causing this disease is fre-quently of the bovine type. In short, we know that our neglect to exclude tuberculous cows from our herds is causing the death of many human beings, and yet we are doing nothing, literally nothing, to prove ourselves worthy the title of guardians of the public health. The tuberculin test is the only means of detecting tuberculosis be-fore the products of the cow are likely to be infective, but we are not forcing the dairymen of the State to do what is to their own financial interest to do—test their cattle and exclude the tuberculous animals. Tuberculosis is not over common in this State, except in the dairy herds, and is not as prevalent there as in many States, but it will steadily increase unless controlled. Moreover, if we admit its exist-ence even, and the possihUlty of its communication to the consumer of milk, we have uo right to stand idly by and permit any human being to take that chance, no matter how small the chance may be. In my opinion, diseases of the udder and those conditions of milk included under the general term "filthy" are the most fruitful source of injurious effects upon the consumers of milk. All forms of garget, mammitis or other diseases resulting in pus and other inflammatory products entering the milk are unquestionably the source of much of the diarrhreal troubles of infants resulting from the consumption of impure milk. Filth, manure from the cows and stables, which is the most abundant and common contaminating material of unclean milk, has not, in my opinion, been given its full share of responsibility for the high death rate from diarrho?al diseases, so fatal to young chil-dren. Especially is this so in North Carolina. In short, tuberculosis, diseased udders and filth are the three main sources of danger to the consumers of milk in this State. How are these conditions to be corrected? In the first place, clean milk is worth more than dirty milk, and it costs more to produce it. Are our people willing to pay for clean milk? I believe we are now paying a price—eight to ten cents a (piart—which entitles us to a fairly good quality of milk. If this is not enough to enable the pro-ducers to put clean milk on the market, then you, the guardians of the public health, must educate the public up to the point where it will pay for good milk. In the second place, few of our dairymen know sufticient of dairy science and practice to enable them, unassisted, to put clean milk on the market. The general supply of milk can be iniijroved. but for 34 NORTH CAROLINA BOARD OF HEALTH. many years yet cannot be brought up to the standard necessary for the feeding of infants and sick people. Comparatively few men any-where are able to put such a quality of milk on the market. What is to be done? First, start here to-day such a campaign for pure milk as will arouse public opinion, stimulate dairymen to greater efforts, and result in a competent milk inspection and supervision in every town of 3,000 population in the State. This can be done, and will improve the gen-ei'al condition of the milk supply. In evei'y town where the demand will justify let a certified milk commission be established to encourage some one or more men to produce and put upon the market a first-class milk product. And, last, as a temporary and doubtful expedient, if filthy milk must still be consumed by many, establish under munici-pal control, where conditions render it practicable, a pasteurizing plant, where all milk below a certain standai'd must be pasteurized before being sold. Pasteurizing will not make unclean milk clean, but it may lessen its injurious effects. If generally adopted, it is likely to encourage filthy practices rather than correct them. It prob-ably lessens the digestibility of the milk, and is only advisable as the lesser of two evils. As between reasonably clean milk and pasteur-ized milk, there is no question in my mind of the superiority of the former, but if it is still necessary to put up with dirty milk, then by all means pasteurize. The chief objection to it is that its us^e is likely to prevent as great an effort to secure clean milk as would be made were pasteurizing not practiced. How is the general quality of the milk supply to he improved? First, by a proper system of inspection. Three forms of knowledge are requisite for competent milk inspection—first, a knowledge of cows in health and disease—possessed by the veterinarian ; second, a knowledge of dairy science and practice, which should be possessed by the so-called practical dairyman, but in our State rarely is; third, a knowledge of milk, bacteriologically. chemically and microscopically. The milk inspection of a municipality may well be administered by a milk commission ; but if ^o, it should he made up of men chosen for their knowledge of the work. For such a commission a physician, a practical dairyman and a veterinarian are logically competent men. Or the administrative part of the work may be left to the city health officer ; but the success and efficiency of any system of milk inspection depends on the efficiency of the inspector and the quality of the labo-ratory work done. First, there should be a frequent and thorough veterinary inspection of the cattle. The inspector should also be a practical, scientific dairyman who has had experience in dairying. If it is claimed that such a man cannot be employed, then the milk inspection will fall short of a full success just to the extent that the inspector falls shoil of these requirements. TWELFTH BIEXNIAL REPORT. 35 Our dairyineu are not desirous of putting filthy milk on tLie market, but they don't know. The inspector must be able to teach and lead, rather than try to force rapid changes. In most instances too much importance or reliance is placed on laboratory examinations. These are essential, but they will not take the place of frequent and competent inspections of the dairies and the manner of handling the milk. Bacteriological examinations should be made, for unquestionably a high bacterial content is indicative of a high filth content. If there be a high bacterial content, then the inspector must seek the cause and correct it. He must have accurate dairy knowledge and practical experience to do this. A microscopic examination may be made, for a high leucocyte and streptococci content, with the presence of fibrin, which indicates in-flammation of the udder, but this is of most value when examinations are made of the milk of individual cows. In the city of Raleigh we have a so-called milk inspection, which is practically nothing more than a bacteriological examination and pub-licity of the results or findings. No competent inspector is employed, no tuberculin test is made of the cattle, and a violation of the regula-tions does not usually mean any sort of punishment ; but, with all this, good has been accomplished. For instance, in 1906, after a complete neglect of duty for three months, the commission was forced to make a pretense of doing its duty by public criticism through the press, and from March 27 to April 27, 1906, fifty samples, the first taken after this period of neglect, gave twenty with a bacterial count of over 1,000.000 per cc. From March 27 to April . . , 1907. fifty samples gave seven with a bacterial count of over 1,000,000 per cc. From March 26 to April 28. 1908, fifty samples gave eight with a count of over 1.000.000. In September, 1905, ten samples gave an average bacterial count of 3.111,500 per cc. In September, 1906, ten samples gave an average count of 846,000 per cc. In September, 1907, ten samples gave an average count of 164,000 per cc. In August, 1906, twenty-three samples gave an average count of 2,570,000. In August, 1907, nine samples gave an average count of 890,000 per cc. An improvement, but what filth still exists ! Fancy, during the months of March and April, milk from three to five hours old, in which sixteen per cent of the samples have from one to two million bacteria to the cc! A bacteriological examination of milk is of importance, but its chief value is lost unless supplemented by and done in co-operation with an intelligent dairy and cattle inspection. A high bacterial count means either age or filth, and large numbers of liqueflers mean in all probability filth, and. where dairies are not of fairly good grade, dairy practice rather than age influences most the bacterial count. We must keep in mind that a healthy cow gives a wholesome product of fairly uniform quality. If the milk is put on the market in 36 NOKTH CAROLINA BOARD OF HEALTH. Icid condition or of greatly varyin'g composition, it means bad dairy l)ractice. Very frequently I hear of tliis physician or that one who insists that the cow shall receive no cotton-seed meal, or no silage, or some other excellent food is tabooed. I have heard of this sort of thing in our city of Raleigh, and yet our system of handling milk makes it almost certain that the fat content of the milk from any one dairy may vary from 2.5 to 8 per cent. This has actually occurred, and is due to the fact that milk is sold from a large can instead of being bottled at the dairy. The faucet being at the bottom of the can, and the cream rising to the top, the customers first served get the 2.5 per cent milk, while the last get milk containing 8 or 10 per cent butter fat. No sort of feeding will produce a change of over one-half of one per cent in the butter fat content. In fact, it is doubtful if any effect on the fat content can be regularly and consistently pr^oduced by any sort of feeding; therefore, it will avail most to give more attention to the handling of the milk, for it will certainly mean discomfort, if nothing more serious, to any delicate infant to receive 2.5 per cent milk to-day and 8 per cent milk to-morrow. Good milk will not be put on the market until the dairyman is re-quired to bottle it at the dairy, under proper sanitary and dairy con-ditions. Some of the points that need attention in our North Carolina dairies are: 1. Test all cows with tuberculin, and exclude the diseased ones. The North Carolina State Department of Agriculture will do that free of charge, on certain reasonable conditions. 2. Institute an intelligent inspection of the cows, and exclude all those with any disease of the udder. 3. Prohibit the selling of milk except in bottles, and require that the milk be kept below a certain temperature. 4. Prohibit feeding during or just before milking. 5. Compel dairymen to keep their cattle clean. Cows can be cleaned, but milk cannot. 6. Compel dairymen to wear clean clothes and wash their hands before milking. 7. Wipe the udders off with a damp cloth and use a covered milk pail. These can only be brought about by an inspector capable of lead-ing and teaching. We cannot have entirelj^ clean milk at once, but we might have cleaner milk with an intelligent effort. As an illustration of how the cleanliness of milk is influenced by dairy practice, as indicated by the bacterial coimt, I desire to present the following charts, the data for which have been taken from bulle-tins No. 42 and No. 48 of the Storrs (Connecticut) Agricultural Ex-periment Station. TWELFTH BIENNIAL REPORT. 37 It Lias been stated as an excuse for the filthy luilk which so many of our dairymen are putting on the marliet that, from lack of knowl-edge, capital or other facilities, they could not produce and put clean milk on the market. These charts show that certain practices pro-duced a wonderful improvement in the quality of the milk, as indi-cated by the bacterial count, and yet all these things could be done by our dairymen. They are all simple, practicable and inexpensive. MILKED BEFORE FEEDING. MILKED AFTER FEEDING. Diagram showing relative bacterial content of milk drawn before and after feeding hay and grain. MILKED BEFORE FEEDING. MILKED AFTER FEEDING. Diagram showing relative bacterial content of milk drawn before and after feeding dry corn stover. 38 NORTH CAROLINA BOARD OF HEALTH. NOT BRUSHED. BRUSHED. Diagram showing relative bacterial content of milk drawn immedi-ately after the cows had been brushed and when no brushing was done at that time. UDDERS AND FLANKS WIPED. UDDERS AND FLANKS NOT WIPED. Diagram showing relative bacterial content of milk drawn immedi-ately after the udders and flanks of the cows had been wiped with a damp cloth, and when they were not wiped. TWELFTH BIENNIAL KEPOET. 39 EDUCATED MILKER. REGULAR MILKERS. Diagram showing relative bacterial content of milk drawn by an educated dairyman and that drawn by regular milkers. COVERED PAIL. OPEN PAIL. Diagram showing relative bacterial content of milk drawn into a Stadtmueller covered pail and into an ordinary open pail, in a dairy where extra care is given to cleanliness. 40 NORTH CAROLINA BOARD OF HEALTH. COVERED PAIL. OPEN PAIL. Diagram showing relative bacterial content of milli; drawn into a Stadtmueller covered pail and into an ordinary pail, in a dairy where con.siderable care is given to cleanliness. COVERED PAIL. OPEN PAIL. Diagram showing relative bacterial content of milk drawn into a Stadtmueller covered pail and into an ordinary pail, in a dairy where little care is given to cleanliness. In all of the experiments furnishing the data upon which these dia-grams are based, more than ordinary care was taken to follow correct dairy practices. In all experiments, except in the ones comparing open and covered pails, the Stadtmueller covered pail was used, and all other conditions except those being tested were as near alike in ail cases as it was possible to make them. In dairies where little TWELFTH BIENNIAL REPORT. 41 regard is paid to cleanliness tbe results would still more forcibly demonstrate the effects which the methods of handling the milk has on its cleanliness and the bacterial count. Dr. Silvio von Ruck, Asheville : I have listened to Dr. Butler's paper with much interest, but he has made many statements which are radical and not proven. He tells us that tuberculosis is transmitted from cattle to man with great frequency, and even that bovine tuberculosis is the almost exclusive source of infection for man, while human infection through sputum is of little importance. He has misquoted Professor Koch, who did not state that infection of man bv milk of tuberculous cows could not happen at all. Koch announced at the London Tuberculosis Congress in 1901 that he had not been able to produce infec-tion in cattle with tubercle bacilli of human origin; that the human and bovine type of bacillus were not identical ; that in the light of the rarity of primaiy intestinal tuberculosis and reasoning by analogy he did not believe that human infection from bovine sources was of frequent occurrence. He did not deny that it might never occur. There are two sides to this question, one of which Dr. But-ler has entirely ignored ; and aside from bacteriolooic investi-gations and animal experimentation, we have much evidence in support of Koch's position. This also requires consider-ation. For example, it is well known that in Japan, before for-eign cattle were imported, bo^•ine tuberculosis was not prev-alent. Further, the number of cattle in proportion to the population is so small that milk is not an ordinary article of diet. Nevertheless, Japan has shown and continues to show as great a pro rata mortality from tuberculosis as other coun-tries. In Sweden and Norway, where almost all children are nursed by their mothers, there is as great a j^ercentage of tuberculosis mortality as in countries where cow's milk is more commonly used for infant feeding. 42 NORTH CAROLINA BOARD OF HEALTH. In Berlin records have been kept of the method of feeding infants, and the number of deaths from tuberculosis is equally divided, as shown by statistics cited by Fraenkel, between those who were nursed by the mothers and those who were fed on cow's milk. There is much more evidence of like character which tends to show that the tuberculosis of cattle is not the great source of danger that has been asserted ; but an actual experiment on man has been made, although at the time not with the view of determining this question. Baumgarten has given us the details of it. Based upon Rokitansky's theory of the antagonism between tuberculosis and cancer, a number of patients suffering from inoperable malignant disease were inoculated with bovine tubercle bacilli in the hope that their malignant disease might thereby be favorably influenced. All eventually died of their malignant disease, and Baumgarten performed the autopsies. He found no evidence of tuberculosis, and even critical microscopic ex-aminations failed to reveal tubercle or tubercle bacilli. As Dr. Butler has stated, it has been found that primary intestinal tuberculosis is not quite as rare as was supposed at the time Professor Koch made his announcement in Lon-don, but while the thoracic glands may become affected as a result of ingestion of tuberculous material, this, according to all results and investigations, is rare. It is generally con-ceded that by whatever route the bacillus enters, be this by in-gestion or by inhalation, the first localization occurs in the nearest regional lymph gland. However, since 1901, the sub-ject has been most carefully and painstakingly studied at the Imperial Health Bureau in Berlin and elsewhere, and it has been proven conclusively that in the majority of cases of primary intestinal tuberculosis the tubercle bacilli isolated from the intestine or mesenteric glands were of the human type. Up to the present time the cases in which bovine in-fections have been proven to have occurred in man are about TWELFTH BIENNIAL REPORT. 43 33 in number, 18 of which have been examined at the Im-perial Health Bureau, while 15 are reported by other ob-servers. Apart from any danger to man from tuberculosis of cattle, the question is of imjDortance from an economic standpoint as well, and if, as appears, the danger to man is but little, it should not be necessary to destroy hundreds and thousands of cattle simply because they be shown to have acquired tubercu-losis. Besides, as Professor Koch points out, we can protect our-selves from such danger as may exist by boiling the milk and cooking the flesh of such cattle as are or may be tuberculous. With Dr. Butler's views as to the importance of cleanliness in our dairies, I am heartily in sympathy. Irrespective of the tuberculosis question, clean milk is essential, and for many other reasons we should use our influence to obtain it. Dr. Bukroughs, Asheville, ]S[. C. : Mr. Chairman, I have listened to Dr. Butler's paper with interest. But there are one or two points on which I think that the doctor, as our State Veterinarian, has not been sufficiently explicit. I wish to state that no tuberculous cow should be milked nor is milked at any dairy that produces healthful milk. The herds are usually tested every six months. And all additions to herds are tested before being allowed to mingle with the cattle already tested. Dairy cattle of Asheville are under the direct supervision of a veterinary surgeon ; and all milk is under the supervision of one man, who tests milk a.t his will, with full authority to act. The cattle are kept on the hills and in the valleys a portion of the day and also a part of the night. And the milk is col-lected twice daily. The cattle are driven to a large corral with a shed attached to the stables where they are fed. In this shed the cattle are brushed off, and while they are being fed their teats are washed with an antiseptic solution. Following this come the 44 NORTH CAROLINA BOARD OF HEALTH. immaciilatelj dressed milkers with strainer pails. The milk is then carried to the chemist, with his assistants, where it is standardized according to the requirements of Mr. Wilson in the Department of Agriculture of the United States Govern-ment. The milk is then iced and delivered in sealed glass jars. One statement made in Dr. Butler's paper I do not under-stand, and I am certain that other members of the conjoint session do not understand, which I wish the doctor to explain, and it is this: that "thoracic tuberculosis is very frequently contracted from the cow's tail." (Laughter.) De. Butler closes: Just a word in reply to the gentle-man's (Dr. Burroughs') thrust. I didn't say it. I know I didn't cover this subject thoroughly. If I had I would have kept you here until to-morrow morning, I stated in the start I wasn't going to talk to the specialists and investigators, but to the general practitioner. I could meet Dr. Von Buck's statistics with statistics if time would permit. I could tell you of investigators who have found as high as 41 per cent of the abdominal tubercu-losis of children of bovine origin, but I did not have time to do it or to go into this matter fully. I wanted to say further—and I thought I made that point clear—that the old idea that you can tell the mode or channel of entrance of the tubercle cerm bv the location of the lesion is no longer tenable. It is nonsense to say, because you find tuberculosis in the lungs, that the germ necessarily entered through the air passages. I said you could put the germs in the tail of the cow and the chances were the tuberculosis would develop in the lungs, not in the tail. Why ? Because tuber-culosis is primarily a disease of the lungs, and the germs go to where they like to live. They find the most suitable place for their development. You can inject the tubercle germs into the abdominal cavity, and you may feed them through the mouth ; you may put them into the circulation or into any part of the system, in any way you like, and in the majority TWELFTH BIENNIAL REPORT. 45 of cases you will get tuberculosis in the lungs. That is what I meant to say. Thank you. My paper is better exj^lained with the drawings given the Secretary. Dr. Thomas : Gentlemen, the next subject to be presented is 'Tellagra," by Dr. E. J. Wood, of Wilmington, X. C. PELLAGRA. Pellagra is a disease supposed to be due to an intoxication derived from diseased maize and characterized by a triad of symptoms : symmetrical erythema, gastro-intestinal disturbances, and various nervous and mental manifestations. Spain was the first country in which pellagra was recognized. This was in 1735, and the disease was regarded as a vai'iety of leprosy. The disease later appeared in Galatia, and later in Castilia. Rome, and Aragon. To-day it is very prevalent in Navarre and Galicia. The name lepra asturiensis was one of the many by which it was known. Next the disease was noted in the northern provinces of Italy. Trapalli. in Lombardy, gave the name pellagra (pelle and agra, rough skin). At the present time pellagra is very prevalent in Roumania. In 1882 there were 4,o00 cases ; iu 1888 there were 10,626 cases out of a population of 5,339,650; in 1894, 6,694 cases; in 1896, 19,796 cases; and a more recent estimate places the number above 50,000 cases, who were affected with the disease in some stage. It also occurs in the south of France. Since 1856 it has been present in Corfu. The Asturias are still the chief seat of the disease iu Spain. One sporadic case is said to have occurred in England. When the disease first appeared in Italy it was in the neighborhood of the Lago Maggiori. During the last century it extended into Emilia and Tuscany. In central Italy it is little known and in south-ern Italy and Sicily is unknown. Bouchard describes the disease in Mexico. It has occurred also in Brazil, Argentine Republic, and Uruguay. Many cases have been reported in Egypt and some in South Africa. The disease has almost disappeared from France, but there are still small areas in the Pyrenees and in Garonne. Sporadically cases have been seen in the Tyrol, Servia. Bulgaria', Greece, and Asia Minor. Italy and Roumania are considered the disease centers. In Italy it is endemic. According to a reliable source tliere were 100,000 cases or 10 per cent of the rural population affected with pellagra. The disease was supposed not to occur in this country, and many of the best text-books fail to mention it. Probably the first article 46 NORTH CAROLINA BOARD OF HEALTH. on the subject appeared in the Jotinnil of the American Medical As-sociation for July 6, 1907, by Dr. G. H. Searcy. The disease ap-peared, according to this report, in 1901, in Tuscaloosa, Alabama, but at the time was not recognized. In 190G there occurred in Mount Vernon, Alabama, 88 cases of acute pellagra, with a mortality of 57 or 64 per cent. In 190.5 the disease was present, unrecognized, in "Wilmington. Certainly as far back as 1900 there was a case in Jones County. Dr. James McKee, Superintendent of the State Hospital for the Insane at Raleigh, has kindly furnished me with notes of three cases under his care, and suggests the possibility of the disease having been present in the institution for a number of years. Dr. E. H. Bellamy, of Wilmington, at the recent meeting of the American Medical Association reported ten cases. Dr. J. C. Gilbert, of Hope Mills, in a letter to Dr. Bellamy reports seven cases under his care. Certainly there have been thirty cases in North Carolina. It is probable, however, that the correct number will run into hundreds. It is also probable that the disease is rapidly increasing. We have many reasons to believe that the disease has existed in North Carolina for some years, but that these cases were sporadic ; otherwise the condition would long ago have been recognized. As there has been an increase from a few sporadic cases to a number which is daily increasing, the question of the disease becoming endemic with us must be seriously considered. Pellagra seems to be generally distributed throughout the South. Merrill reports a case from Colorado, Texas, and Babcock reports nine cases occurring in the Hospital for the Insane in Columbia. S. C. SYMPTOMATOLOGY. Weeks and even months before the appearance of the erythema of pellagra there may be symptoms which, while usually very in-definite, would lead one in a iwllagrous region to make the diagnosis, provisionally, of the disease. There is often progressive weakness, especially of the feet and legs, gastric disturbances and loss of ap-petite. Roussel regards the loss of appetite and gastric disturbances as complications, and dryness and burning of the mouth with a sen-sation of heat in the stomach which may develop into a true pyrrhosis as the first symptoms of the disease. Further, he considers voracious appetite, vomiting, cardialgia and diarrhoea of purely nervous origin. Besides these symptoms there are vagabond pains in the extremities and back, tinnitus, weakness of vision, general malaise, especially in the mornings ; sometimes pain in the joints. Headache, vertigo and melancholia follow. In many respects these symptoms are common to the whole group of acute infectious diseases ; but still, when headache, vertigo, sensa- TWELFTH BIENNIAL KEPORT. 47 tions of weakness, especially in the lower extremities, are present, often accompanied by diarrhoea and occurring about the middle or end of winter, our suspicions at least should be aroused. According to Theodori, about four weeks after these pellagrous symptoms occur the unmistakable signs of the disease appear. This period is often mucla longer, in some instances being as much as a year. The first skin lesion almost always appears in the spring and the parts affected are usually those parts exposed to the sun's rays. Many of the best observers think that as an etiological factor the rays of the sun have little effect. Among these are no less author-ities than Procopiu and Tuczak. to whose works we are much indebted for our information. Many other writers think that the violet rays are certainly a predisposing cause of the skin lesions, if nothing more. The last word on the subject has not been said. In our cases we are disposed to belittle the solar influence: (1) Because the dis-ease appears with us so early that we can exclude any very Intense action; (2) in some cases it appears over the sternum, in the vagina, and in patients who have been in bed for days and weeks with a pellagrous lesion on the hands and face we see the extension to the feet, even though previous to their admission to the hospital they had not gone barefooted. The skin lesions usually appear first on the back of the hands over the metacarpal region, either with a swelling and a red spot in the center or else with a diffuse redness. Oftentimes blebs appear. The blebs contain clear, alkaline serum, which is sterile. After the hands the face is usually more apt to be affected. Here the lesion begins symmetrically either at the outer canthi of the eye or at the angles of the mouth. It is common to have it symmetrically situated on the forehead in two patches, which have a narrow vertical strip of healthy skin between. Beneath the lower lids and at the back of the neck are favorite places. In the latter situation tlie lesions ex-tend auteriorlj' until they nearly meet in front, forming a collar which is higher behind. In our limited number of cases we have found the face and neclv lesions much more commonly in females, and especially children. The next sj^ot selected is the top of the feet. Our last case has the two varieties of lesions occurring simultane-ously. Just below the external maleolus there is a bleb on both feet, which began as two round, red spots about the size of a fifty-cent piece. In ten days a bleb appeared which, after drying up. left a raw surface. In the same case, over the crest of the tibia, extending downward over the metatarsal region to the lower articulations of the toes, is a diffuse redness much resembling a lymphangitis. This lesion will probably go on to exfoliation without bleb forma-tion. In some cases the lesion may appear over the sternum, and in two of our cases the labia pudendi were affected by the typical 48 NORTH CAROLINA BOARD OF HEALTH. lesion. The disease has been liuown to make its first appearance on some covered portion of the body, but this is exceptional. In none of our cases did it appear there until long after its more usual appearance on the exposed parts. In the lesions with blebs there is left a raw surface which either forms an ulcer or is covered by crusts, which often are quite thick. The crusts and the weeping ulcerated areas, together with the odor, make a loathsome patient. With the beginning of healing, the skin of the face contracts so that in one case there was a marked ectropion and also inability of the lips to cover the teeth. The photograph shows the condition well, but it became mucli worse as the disease progressed. Usually, especially in the dry cases, exfoliation begins after three or four weeks, and as the dead skin comes away a pigmented area is left. This pigment varies from a slight yellowish tinge to a dirty brown or even a chocolate color. The depth of color depends upon the duration of the disease, that is, on the number of the attacks. In ad-dition to tlie pigmentation, the skin is shining and atrophic. By fall the skin regains more or less of its normal tone, only to be ready for the next attack the following spring. With each attack the skin becomes more atrophic and more pigmented. INTESTINAL TRACT. With the appearance of the erythema, or soon after, the mouth becomes affected. The mucous membrane is red and swollen, the lips may be covered with blisters, and later they become cracked and seared. The tongue is intensely red and the papilla? enlarged, with furrows between. The patient complains often of burning and salty taste in the mouth, often with an increased flow of saliva. Dr. McKee says the mouth suggests to him stomatitis materna. Salivation is often intense, and in one of our cases we suspected ptyalism. After the skin lesion the mouth condition is the most con-stant, and in none of our cases was it absent. In some cases it subsides after the first few weeks ; in others it persists throughout. In all of our cases the stomach was not affected. Pyrrhosis, eructa-tions, vomiting, anorexia or bulimia, often with extreme thirst, are common symptoms. In some cases the gastric analysis shows an absence of hydrochloric acid, while in others it is normal. Much more commonly present is obstinate bloody diarrhoea, often of a dysenteric type, usually attended with colic. This diarrhoea is considered by many to be a neurosis, but it is often difhcult to be-lieve, judging from the character of the stools. NERVOUS SYSTEM. Roussel considered the vertigo a very characteristic symptom, and described it as being much like a gastric vertigo. Diplopia and amblyopia are common, but were absent in all our cases. The pupils TWELFTH BIENNIAL REPORT. 49 react acutely tu both light jukI accommodation, and the ophthal-moscopic examination has revealed nothing to us. The patients usually complain of a sensation of heat or cold in various parts of the body. We have attempted to investigate the tactile sense, the sense of heat, cold and pain, but our observations are inaccurate because of the mental state of our patients. The complaint of pain, especially in the shoulders and epigastrium, is quite common, and noted by us. Convulsions are quite common and often close the scene. In one of our earlier cases this was so. Tetany is reported by some. We have found a coarse tremor present in a number of our cases. In one, just before death her ^vhole body was in a constant tremor, but could not be accounted tetany. The condition of the tendon reflexes is more variable. In many of our cases thej' remained normal. In a few they were absent, though there were no other symptoms of locomotor ataxia. In one case where the reflex had been absent there was a return before death in a rather exaggerated form. In one case it was much ex-aggerated, and ankle clonus was present. In one case it was present on one side and absent on the other. Usually, in the be-ginning of the disease it is normal or decreased, but later, when the lesion in the cord has extended, it is apt to be exaggerated. Station is usually good. The gait becomes unsteady, but not ataxic. A slight spasticity has been observed. Among the vaso-motor and trophic disturbances is usually included the erythema itself. In ad-dition, we often find paleness of the skhi, sensations of cold, "goose-flesh," and muscle atrophy in the shoulder, girdle muscles of the hand, thorax and lower leg. This should not be confounded with emaciation, which is often extreme. The alterations in the tongue and the thickening of the nails may be included under this head. In Europe "misery and poverty"' are counted the chief predisposing causes of pellagra. Just those conditions occurring among the peasantry in Europe are almost unknown with us. Certainly the I'ichest and the poorest buy the same grade of corn-meal. The chief difference here, as we all know, is that the poorer class have less variety and often the food is poorly prepared. We are disposed to think that pellagra with us is not so much a respecter of persons, affecting the well-conditioned as well as the victims of previous dis-ease and poor hygienic surroundings. It has been shown, especially in Sandeith's Egjiitian cases, that the parasitic disease seems to form a very definite predisposing cause. Especially has it been noted that anchylostoma is often present. One such case was noted by Harris in Georgia. Babes and Sion report the occurrence of malaria in eight of their twelve cases. We have had occasion to consider seriously this possible relationship. My first case, which was erroneously reported in the Journal of the American- 50 NOKTH CAKOLINA BOARD OF HEALTH. Medical Association, had a latent malaria and the unusual coiiditiou of a mixed infection with tertian and quartan organisms. Much at-tention has been paid to the occurrence of alcoholism and syphilis with pellagra. This is unimportant except in so far as thef^e conditions lower the resistance. The course of pellagra is very variable, lu Italy it is no un-common thing for the outbreak to occur each succeeding spring for twenty years. Each year the patient becomes more wrinkled, more atrophic and more melancholy until, finally, he dies from some in-tercurrent disease, as broncho-pneumonia or of cachexia. There recently came under our care a typical case of chronic pellagra which is worthy of note. Mrs. W. ; age 34 years ; Jones County. Family history negative, save for malaria and typhoid. No history of miscarriages. In the spring of lOOG she was affected with gastro-intestiual symptoms, one month after the appearance of which the erythema appeared on her hand and the lower third of her forearms. In the spring of 1907 the same condition recurred. In May. 190S, the condition made Its third appearance, was diagnosed pellagra and reported to me by my colleague. Dr. Thomas M. Green. Her condition was as follows : A poorly nourished woman, much older in appearance than the age given. Symmetrically situated on her forehead were tvi'o patches of desquamating erythema. These patches are about equal to the size of two silver dollars. The same lesion surrounded both eyes. On the upper lid the lesion was more recent, with the presence of crusts and a weeping surface beneath. This lesion extended into the an-terior nares. On the skin below the eyes the lesion was older and there is a slight brownish pigmentation. On the backs of both hands from the finger-nails to the middle of the forearms posteriorly is this same condition of the moist variety. The lesions were especially aggravated over the knuckles and tips of the ulna. The same con-dition was present on the anterior sui'face, save for the palms, where there was simple redness without exfoliation. Near the upper mar-gins of the arm lesions was found considerable brownish pigmenta-tion. On the back of the neck was a much older lesion, which had caused a tawny pigmentation. Posteriorly this lesion is about two inches in length, but as it extends anteriorly it becomes narrowed, al-most meeting in front. The labia pudendi were affected with the moist lesion. Heart and lungs were negative. Spleen and liver negative to palpation and percussinn. Urine showed albumen and granular casts. Blood showed a simple anemia of moderate degree. No leucocytosis. Differential leucocyte counts showe<l no abnormal variations. Blood cultures were taken. TWELFTH BIENISriAL EEPOKT. 51 The patient's mental condition became rapidly worse ; slie refused nourishment, and a I'estraining sheet had to be used. lu her mania she would rub off the crusts, from the arm lesions especially, and the picture that resulted was horrid, with the raw, bleeding surface and the bedclothing covered with blood and pus. She died of exhaustion. Our knowledge of chronic pellagra is limited, fully 75 to SO per cent of our cases being acute. It seems remarkable that Lombroso should have had occasion to diflierentiate" this acute or "typhoid" pellagra from typhoid fever. There is certainly no resemblance, except possibly in some of the late nervous symptoms of both diseases. Our acute cases ran a course from a few weeks to a few months. As an example of this is the following : V. S. (colored) ; 12 years; Wilmington. Referred to us by Dr. W. J. Bellamy. Family and previous medical histories negative as far as we could secure them, except that at this time she has a sister aged 6 years recovering from the first attack of pellagra. This child is in my care, and is strong and robust. In February she had various vague digestive symptoms before she noticed at the outer canthi of the eyes a small red spot. This erythema increased in size rapidly, extending over the forehead. It next appeared beneath the angles of the jaw and extended around the neck, meeting behind. The gums were swollen and red and the whole mucous membrane of mouth inflamed. The eruption next appeared on the backs of the fingers and extended upward to the middle of the forearms. The face and both arms were covered, giving the appearance of a superficial burn. The contraction of the skin of the face has been described. From the beginning the bowels have been affected in the form of a persistent diarrhcea. The only gastric symptoms have been anorexia and nausea. With the aid of two doses of santonin during the past week she has expelled from the bowels forty-six round worms and vomited one. When first seen a week ago the feet and ankles were oedematous, but this has dis-appeared and the erythema has taken its place. Knee jerks were absent, but have reappeared. Skin sensations normal. Pupillary reaction normal. She complains of cold sensa-tions, weakness, and pain in right shoulder. She is now beginning to be quite delirious at times and falls out of the bed repeatedly. June 13. The appearance of the face is distressing. The skin lesion seems really to have extended to the eyes. The cornea is dry and there is a marked conjunctivitis. Mucopurulent material flows from each eye. Both of the lids are so contracted that the eyes have not been covered for over a week ; this condition is certainly largely the cause of the terrible state of the eyes. 52 NORTH CAROLINA BOARD OF HEALTH. Belmondo and a number of other observers state that typhoid peUagra never occurs primarily, that it is always the exaggeration of a recurrence in chronic cases. We have seen five cases die in the first attack. The disease must be more malignant than in southern Europe. It is difficult to explain why this sliould be, except that we know when a disease appears in a new country the death rate at tirst is always higher. We have examples of that in some of the yellow-fever outbreaks, and better still in the outbreak of measles in some of the Pacific islands, where the mortality was !)0 per cent. The diagnosis of pellagra, after it is well established, is quite easy and does not require yearly recurrences to establish it. In no disease is an early diagnosis more important than in this, as our only hope of effecting a cure is in removing the cause early in the disease. Ergotism was the first thing thought of in our cases; it was ex-cluded because of an absence of the characteristic numbness, tingling, vascular stasis, and gangrene of the fingers and toes. I have had to watch for several days simple sunburn suspiciously in some cases because there is nothing more like it. The erythema of pellagra is described as resembling sunburn almost exactly. Usually, however, the diarrhoea and stomatitis precede. Pellagra sine pellagra calls for our special attention. Right now we have a number of cases under this suspicion, but we must agree with the authority who rather questions the possibility of such a diagnosis. That such cases have occurred there can be no question, as the best authorities so state it. The treatment of pellagra so far is not promising. Practically all acute cases die regardless of treatment. In chronic cases that are not far advanced the removal of all corn food, with tonic treat-ment, together with improved hygiene, often brings about recovery with or without mental deterioration, depending upon the stage of the disease when arrested. Babcock is using successfully atoxyl hypodermically in doses of one to one and a half grains every four to seven days. In much larger doses in the acute afHiction it has failed in my hands. Babcock is also using Soamin (Burrbughs, Wellcome & Co.) in one grain doses three times a day. In Wilming-ton we have exhausted the pharmacopceia without seeing any benefit derived by the sufferers. Dr. Thomas : "PellagTous Insanitj" will be discussed by Dr. John McCampbell, Superintendent State Hospital for the Insane, Morganton, N. C. SOME OBSERVATIONS OF PELLAGRA IN THIS COUNTRY, WITH SPECIAL REFERENCE TO PELLAGROUS INSANITY. Pellagrous insanity, as the name implies, is so closely associated with and dependent upon the general systemic disease that its con- TWELFTH BIENNIAL KEPORT. 53 sideratiou separate and apart would be difficult and hardly profitable, it being in reality only one of the late manifestations of the malady known as pellagra, which has been comprehensively defined by Yau Harlingeu as a "complex disease characterized by a class of symp-toms : "1. A squamous erythema confined to those portions of the skin which are exposed to the action of heat and light. "2. A chronic inflammatory condition of the digestive passages, shown chiefly by obstinate diarrhoea. "3. A more or less severe lesion of the nervous system, leading at times to mental alienations and paralysis. "The.se various symptoms are at first insignificant and in a certain way periodic. They begin or recur in spring and diminish or disap-pear in winter. Later they become persistent, more and more marked, and finally terminate fatally." Pellagra has been known to exist in Italy. Spain, and adjacent countries for more than a century and a half, and was scientifically investigated in Italy as far back as the year 1771 ; but until quite recently there has been very little said in this country on the subject. In fact, the existence of the disease has been denied by some of the most eminent medical writers of recent years, the subject being dismissed with brief mention and tlie statement that it is a disease confined to certain European countries. It is true that cases simulat-ing pellagra were reported in tlie early sixties by Dr. Gray, of New York, and Dr. DeWolfe. of Nova Scotia ; but the genuineness of these was questioned at the time and the disease either disappeared or was overlooked (the former, most lilcely) until attention was again called to it by the publication within the past year of the observations of Drs. Searcy, of Alabama ; Babcock, of South Carolina ; Wood, of this State, and possibly others, though some doubt ap-parently existed in the minds of some of these observers, as is evi-denced by the fact that Dr. Babcock presents his able, and to my mind convincing paper, in the form of a query. My own experience leads me to believe that we now have in this country, probably a recent development, a grave and usually fatal disease identical with the pellagra of southern Europe, and which may, under favorable conditions, gain the proportions of an epidemic. During the past four years I have, from time to time, encountered mental cases presenting certain definite and ratlier uniform mani-festations and associated with a peculiar skin eruption, which I was unable to fit into any recognized classification ; yet I realized that I was dealing with a distinct entity, and it was not until tlie earlier of the last referred to papers came into my hands that I was con-vinced that the disease in question was pellagra and the mental dis-turbance present constituted pellagrous insanity pure and simple. In support of this belief I wish to recount the chief etiologic and symptomatic features as observed in twelve of these cases, with spe- 54 NORTH CAROLINA BOARD OF HEALTH. cial reference to their mental aspect, since all of them were so far advanced in the disease as to necessitate their commitment to a hospital for the Insane. The theory generally, if not universally, accepted is that ])ellagra is in some way associated with the ingestion of Indian corn which is diseased, harvested immature, or in some way damaged and conse-quently containing a toxic substance, the exact nature of which has never yet been very clearly defined. Ballardini considers it a parasitic growth on mouldy and musty maize, while Lombroso suggests that it is due to a fatty oil and an extractive substance, the product of decomposition or bacterial action which are never present in sound corn. At anj' rate, the disease is more in the nature of a ptomaine poisoning than a direct bacterial infection. This would naturally be supposed, since most of the corn and corn preparations which are used as food have been cooked, and thereby subjected to a sterilizing temperature. It is of interest to note in this connection that I have recently had an opportunity to interview several native Italians of the peasant class, who had some knowledge of the dis-ease, and they invariably assigned as the cause the eating of polenta three times a day ; and they attached considerable importance to the fact that it was eaten three times a day. I am unable to determine the exact character of diet previously used by any of my cases, but there is good reason to suppose that corn was extensively eaten, and it will be conceded that this prime etiologic factor was present. Locality within the State seems to have no particular influence, as the twelve cases were distributed impartially over the territory extending from Robeson to Madison counties. All of these cases were women, which fact is at variance with the common teaching, since the two sexes are supposed to be equally susceptible. The negative bearing of this circumstance is eliminated by the fact that at the time these observations were made my service was confined to the wards for women. In the epidemic occurring at IMouut Vernon, Alabama, and reported by Dr. Searcy, eighty out of eighty-eight affected were women. The average age was thirty-eight years. Nine out of the twelve cases ranged from thirty-eight to forty-five, which is of no special significance, unless it be that the nervous instability conse-quent upon the approach of the climacteric in some way predisposes to the disease. Eight, or two-thirds of the twelve cases, showed first mental symptoms in either April, May, or June, and two others in July and August. Allowing for the slight delay in the occurrence of mental disturbance in these two cases, we have ten out of twelve occurring in conformity with the usual seasonal incidence of the disease, it being understood that most cases develop or recur in the spring or early summer months. There was a total absence of heredity in all but two cases, and in these it was remote—an insane uncle in one and an insane niece in another. Neither was there any instance of parental consanguinity. TWELFTH BIENNIAL REPOET. 55 Absence of these factors, which are hnportant in the causation of most insanities, points to the exogenous character of the disease and renders it less likely that the ordinary insanities have been confounded with this series of cases. All, with two exceptions, were exceedingly poor, and most of them bore evidence of having undergone extreme privation. These conditions, no doubt, contributed to the development of the disease, both by the malnutrition consequent upon an insufficient diet and also by the fact that poverty of that degree usually necessitates the use of corn to a greater extent than is customary with people in better circumstances. All the cases under consideration having, before "coming under observation, reached a condition of extreme mental alienation, it naturally follows that we are dealing with latter stages of the dis-ease, and data concerning the earlier symptoms are lacking. It appears from the histories given in the commitment papers that in a vast majority the mental symptoms were preceded by or associated with ill health, being in all probability nothing more than the las-situde, general debility and digestive disturbances common to the earlier stages of the disease. In fact, a rundown condition, debility, indigestion, general catarrhal condition of the intestinal tract and like troubles are specified in several cases. The beginning of the psychic disturbance was usually marked by a period of anxiety and worry, undue importance was attaclied to trivial affairs and misfortunes were apprehended. Occasionally un-usual religious interest was manifested. Tins was followed by a disturbance of perception and the development of hallucinations, usually auditorj-, though occasionally visual as well. Judgment was profoundly disturbed, giving rise to delusions, which were char-acteristic ill that they were, with only one exception, depressive and painful in nature, though they lacked the self-accusatory quality of the usual delusions of simple melancholia, being rather of fear and suspicion; or more specifically, one thought that she was to be burnt up; another, that she was burning in torment and her child, recently dead, was also in hell. Still others thought that poison was put in their food or that they were to be hurt or injured in some way. At this stage tlireats and attempts at suicide were rather frequent, and occasionally homicidal tendencies were present. Two cases showed very decided emotional instability. As the disease progressed memory became grossly defective and orientations as to time, place, and persons was imperfect. Incoherence of speech was common and was usually of the most desultory variety. Neither distractibility nor true flight of ideas were observed at any time. There were in-stances of mutism, the patient appearing dazed and failing to respond to questions and orders of the simplest kind, due probably to clouding of consciousness and a failure to comprehend. 56 NORTH CAKOLINA BOARD OK HEALTH. Motor restlessness and insomuia were prominent, with a disposi-tion, even when extreme wealiness was present, to get out of bed, tangling and scattering the bedclothes about the room in the most aimless manner, and a kind of senseless resistance was made to efforts at examination. A total disregard for cleanliness soon ap-peared and all became extremely untidy in habits; this from mental hebetude and indifference rather than viciousness. There was an early failure of appetite and frequently absolute refusal of food (often due to delusion), necessitating forced feeding with nasal tube. These mental symptoms without remission steadily grew more and more pronounced until a condition of complete armentia ensued, and. coupled with the physical weakness present, was not unlike the so-called typhoid condition, and especially so when the delirium as-sumed a muttering character. Coexistent with the mental condition described there was invariably present an eczematous involvement of the skin, varying all the way from thickened, I'oughened and pig-mented condition, with a tendency to fissure, to a typical exfoliative dermatitis. These skin changes were distinctive in that they were limited to exposed areas, the backs of the hands escaping in no in-stance, and in this location the milder cases strongly suggested sun-burn. The involved surfaces were uniform and ended abruptly, usually at or just above the wrists. The line of demarcation was very distinct and correspondingly close to the limit of protection afforded by the sleeve or arm covering. The eruption occasionally appeared on the face, especially at the angles of the mouth, and once upon the forehead, but was not observed on the feet. There was a tendency toward pigmentation and scaliness over the bone prominences, even where protected by the clothing, and espe-cially so where counter pressure was exerted. This was most marked at the point of the elbows, the front of the knees, though at these places it was never as severe as when exposed to the action of the sun's rays. The nervous disturbances consisted in exaggeration of the dual reflex, coarse intention tremors, ataxic and choreic movements of the extremities, especially the arms ; and later this inco-ordination fre-quently involved speech, rendering it halting, slurring, and finally inarticulate. The pupillary disturbance was slight, variable and inconsistent. As the end approached there was a general spastic condition of the muscles, with marked retraction of the neck and head, and a mere tap at almost any part of the body would excite a slight tetanic con-vulsive movement. Diarrhoea was usually present, characterized by obstinacy and an exceedingly offensive and putrescent odor of the dejecta. TWELFTH BIENNIAL REPORT. 57 All twelve cases terminated fatally. The course of the disease was rather rapid. The average duration after the beginning of the mental symptoms was three and one-half months. The average duration after admission to the hospital was forty-four days. The foregoing mental symptom-complex, although somewhat con-tradictory, or at least inharmonious, might be to some extent as-sociated with any of the toxic or exhaustion psychoses, since many of the symptoms mentioned are common to most of these conditions. without regard to the particular morbific influence in operation, and it was only by the somatic disturbance invariably present, chief among which were the skin lesions, that differentiation was possible. I am aware that the number of cases studied is rather small and the records from which the histories are taken too incomplete to altogether justify a dogmatic statement, yet I believe that sufficient has been said to show the similarity of these cases to the descrip-tions of pellagra given in the classic writings on the subject. And I would say. further, that this paper is not presented with a view to adding anything to the literature of the subject, but rather in the hope that I may. in some measure, at least, aid in directing the attention of the profession in general to a danger which possibly threatens us, since an early recognition is all-important, for it is only by prophylactic measures that we can hope to accomplish any-thing. To show that this danger is not altogether imaginary. I will say that out of twenty deaths occurring among women in the State Hospital at Morganton during the past year, five, or 25 per cent, granting the correctness of diagnoses, were attributable to this dis-ease— a number in excess of those assignable to any one cause, tuberculosis included. DISCUSSION, De. W. p. Whittington, of Asheville, X. C. : Mr, Pres-ident, I just want to add a few words in the report of a case that I saw a few j'ears ago. A joung man in good physi-cal condition went from Asheville to Pittsburg, Pa., and while in Pittsburg, after being there two or three months, he contracted what I now know to be pellagra. He went under the treatment of different physicians there for about two months, expecting to get well, but he got worse all the time. He stopped at Greenville, in East Tennessee, abont a month, where he was under the care of a physician he knew, expect-ing to improve, but got worse all the time. He then returned to Asheville, having had the disease about four months after 58 NORTH CAROLINA BOARD OF HEALTH. be left Asheville. He called to see me after he got back, and I knew there was something the matter with the intestinal tract. He seemed to have gastro-enteritis. He bad that char-acteristic erythematous condition on the hands, extending up to the wrist, as far as the band was exposed to the sun. He Avas very much emaciated and I thought he would die, but I put him on treatment for the symptoms, not knowing ivbat the true cause of the condition was. I want to mention the treatment, not knowing whether his coming back to North Carolina, where we have better corn, cured him, or he got well from some other cause. I gave him nitrate of silver, bismuth and opium. After that I put him on arsenic, and in three or four months the man appeared to be perfectly well, and is well to-day, five years, and has had no' recurrence whatever. Another case mentioned by Dr. McCampbell, of Morgan-ton. It was a lady attacked with similar symptoms, but soon after she was attacked her mind became involved and she was sent to the asylum and there died. I merely mention these cases. I did not know what they were at the time, but afterwards learned that they were pos-sibly pellagra. One of these, I think, originated in Pittsburg, Pa., and the other had not been out of Buncombe County, and was due, perhaps, to the infection received there. Dr. I. M. Taylor, Morganton, l!^, C. : I have seen in my practice, I believe, five cases which I can account for as pel-lagra. Of these, four have died ; the other seems to have made a recovery. Three of these were men and two women. Three were intemperate people, and I accounted for their skin condition as the result of alcoholic abuse. I confess that I have never made a diagnosis of the dis-ease, and only since this discussion has ojDened in the journals and since reading the paper of Dr. Babcock have I recognized that I had been dealing with this condition. TWELFTH BIENNIAL REPORT. 59 I accounted for the general skin and nervous symptoms as malnutrition, and, in the case of two men and one woman, directly due to alcoholic abuse. Dk. Stiles : I have seen two cases, one in South Carolina and one in Alabama, both recorded by the i^hysicians who had them in charge. In one of these cases my examination was made and coincident thereto parasitic infection was found. The question is raised. Is not pellagra of parasitic infec-tion ? If it is, it is something new to me. The two cases that I saw, in Alabama and South Carolina, one is totally different from any symptom I ever saw. In connection with the alleged cause it is interesting to note that it is particularly in Antwerp, Bremen and Copen-hagen that complaints have been made regarding spoiled corn ; and yet in that part of the world pellagra is unknown. I mention this as an interesting fact—that spoiled corn does not seem to cause the disease. Dr. W. S. Rankin : I desire to report a case, that is in-teresting in the light of this recent and valuable work on pellagra. The patient, a young man twenty-five years of age, a stu-dent at Wake Forest College, has suffered every spring and summer for the last three years with a peculiar skin lesion. The lesion, svmmetrical in distribution, consists of an ab-normally smooth, hairless, slightly red and sensitive skin, about the size of a dollar, on the dorsal surface of the hands just above the metacarpo-phalangeal articulation. Knowing Dr. Wood's interest in the relation of malaria to Raynaud's disease, and believing this case to bear some re-lation to some of the varieties of Raynaud's disease, I referred the case to him. At his suggestion the patient began a course of Fowler's solution, but was unable to note much change in his hands. In April of this year the patient consulted my colleague, Dr. Gaines, whose attention had been attracted by recent liter- 60 NORTH CAROLINA BOARD OF HEALTH. ature to the relation of certain skin lesions to intestinal in-toxication as evidenced hj well-marked indicanuria. and the relief of the skin lesions hj medication addressed to his in-testinal trouble. On examining the urine a well-marked indicanuria was evident. The patient was given sodium phosphate enough to produce two motions a day, with salol 5 grs. every four hours. Within two weeks the skin lesions had almost disappeared. Since Dr. Stiles has mentioned it, I am almost sure that two years ago I found this man with a very light uncinariasis. De. Dalton : I would like to make an announcement. Over at ISTissen Park we have a supper prepared for the So-ciety which will be ready at 7:30, and as soon as you can adjourn you take the cars going south at once. Dk. Thomas : Gentlemen, it is not necessary for me to repeat such a pleasant invitation as that. I am sure it will appeal to you. If there is no more business before the conjoint session we will now adjourn. The session is now adjourned. THE NORTH CAROLINA ASSOCIATION FOR THE PREVENTION OF TUBERCULOSIS. MINUTES OF THE SECOND ANNUAL MEETING, MOREHEAD CITY, JUNE 12, 1907. The second annual meeting of the North Carolina Associa-tion for the Prevention of Tuberculosis was held at More-head City on June 12, 1907. President M. L. Stevens w^as in the chair. There were present about twenty members. The minutes of the last meeting were read and approved. The President read a report of the work accomplished during the past year. Upon motion, the report was accepted. Dr. Templeton moved that the present officers of the As-sociation be re-elected for the coming year. The motion was carried. Dr. Benjamin K. Hays was elected delegate to the National and to the International Association, to be held in Washing-ton City next year ; Dr. I. M. Taylor, alternate. A committee, composed of Drs. J. Howell Way, C. M. Poole and J. R. Williams, was appointed to solicit member-ship. A time for holding the meetings of the Association was discussed. Dr. Way suggested that the Secretary arrange with the Secretary of the State Medical Society for an hour (or more) of the time of that body. Upon motion, this was carried. There being no further business, the Association ad-journed. Benjamin K. Hays, Secretary. MINUTES OF THE THIKD ANNUAL MEETING, WINSTON-SALEM, JUNE 18, 1908. At 12 o'clock Dr. C. A. Julian, Vice President, called the body to order in the lobby of the Hotel Zinzendorf, Win-ston- Salem, N. G. Dr. W, L. Dunn, of Asheville, N. C, was elected Presi-dent; Dr. John Eoy Williams, of Greensboro, N. C, was elected Vice President; Dr. C. A. Julian, of Thomasville, N. C, was elected Secretary and Treasujer. The following members of the Association were present at the meeting: Drs. L. B, Morse, John L. Williams, W. C. Bronson, H. C. Weaver, W. L. Dunn, H. T. Bahnson, J. Howell Way, C. A. Julian, Richard H. Lewis, William M. Jones, Isaac M. Taylor, J. F. Highsmith, Hon. ClementManly, Drs. William Bolton, P. E. McFayden, E. M. Summerell, D. A. Dees, A. W. Knox, J. B. Smith. J. A. Turner, J. E. Reitzel, Charles R. Wharton, E. C. Laird, W. P. Whittingion, J. C. Grady, H. H. Briggs, W. S. Eanldn, A. B. Groom, J. L. Hanes, J. P. Turner, F. O. Rogers, C. F. Harper, H. H. Dodson, J. Allison Hodges, L. B. McBrayer, Philip Morris, A. L. Flanders, Francis Duffy, R. G. Buchner, J. W. Long, A. A. Kent, W. P. Beall, J. T. Burrus, G. E. Jordan, G. A. Andrews, W. P. Reeves, J. M. Reese, H. A. Barnes and D. A. Stanton. The Association was organized May 30, 1906, by the com-mittee appointed by the President of the North Garolina Society, under resolution offered at the 1905 session. The purpose of the Association, as stated in article 2 of the Gonstitution of the Association, is the prevention of tubercu-losis : (a) By the study of the disease in all of its forms and relations. TWELFTH BIEI^^NIAL EEPOKT. 63 (h) Bj the dissemination of knowledge concerning its cause, prevention and treatment, and by supplementing the work of the State Board of Health in this cause. (c) By such other means as may from time to time be deemed advisable. This
Object Description
|Biennial report of the North Carolina State Board of Health
|Other Title
|Report of the North Carolina State Board of Health.
|North Carolina. State Board of Health.
|1907; 1908
North Carolina. State Board of Health--Statistics--Periodicals
Public health--North Carolina--Statistics--Periodicals
Public Health--North Carolina
|North Carolina, United States
|Time Period
|(1900-1929) North Carolina's industrial revolution and World War One
|Report covers two calendar years (13th-18th); (19th) covers Dec. 1, 1920-June 30, 1922; thence each covers July 1-June 30 years.; Printer: 13th (1909/10)-18th (1919/20) by Edwards & Broughton; 19th (1921/22)-20th (1923/24) by Bynum; 21st (1925/26)-<44th (1970/72)> unnamed.
|Raleigh :The Board,1911-
|North Carolina Department of Health and Human Services
|State Document see http://digital.ncdcr.gov/u?/p249901coll22,63754
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|v. ;24 cm.
|Health Sciences Library, University of North Carolina at Chapel Hill
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|158 p.; 8.81 MB
|Biennial report of the North Carolina State Board of Health
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North Carolina Digital State Documents Collection
N.C. Public Health Collection
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|Printer: 13th (1909/10)-18th (1919/20) by Edwards & Broughton; 19th (1921/22)-20th (1923/24) by Bynum; 21st (1925/26)-<44th (1970/72)> unnamed.
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University of North Carolina