In the study of causes physicians are risking their lives daily, both at the bedside and in the laboratory, and the list of those who have perished in this work is by no means small.

Modern medicine is preventive medicine. To attain its objects, which are the protection of health and life, no effort is too arduous, no problem too difficult. Wherever disease prevails, wherever the death rate is high, it wants to know the cause in order that the remedy may be applied. It busies itself with water, milk, foods of every kind, even the air we breathe. It goes to the school, the mine, the factory, the shop, even to the very homes of the people to correct the faults that menace health and life through ignorance and neglect. It invokes the law that people may be protected from themselves and from each other. It is in the highest sense educational. It invites reasonable criticism of its methods and results. It would have the interested co

operation of those who reap the benefits of its work. There is and always will be plenty for it to do-always perhaps

until that millennium to which the ardent disciples of Metchnikoff looked forward when, infection being ended and the forces which make for senility minimized, there will be no sickness, old age will be enjoyable and death nothing more than a gentle turning over for a longer sleep.

A DISCUSSION OF CERTAIN FACTORS
RELATIVE TO THE ETIOLOGY
OF PELLAGRA.

BY C. C. BASS, M. D.,

NEW ORLEANS, LA.

Within the past two or three years several new theories as to the cause of pellagra have been advanced, among which may be mentioned, (a) that it

the similium reptans (Sambon); (b) that it is contagious and due to contact with Italians; (c) that it is due to ingesting cotton seed oil taken in its pure state or in the form of lard substitutes. Though such theories as this and others are not based on sufficient actual evidence and are at once disproven by the facts, they are likely to do incalculable harm by diverting attention from, and disturbing confidence in, the real cause or causes of the disease. This in turn results in less stress being laid upon the important part of treatment of the disease, viz., withdrawal of its real cause.

A great industry, corn growing, has no doubt suffered considerably in this country during the past three or four years, because of the recognition of pellagra here, and the theory that it is caused by eating spoiled corn. Though most medical writings have. indeed specified spoiled corn, quite at few o fthe newspaper articles and discussions by laymen have failed to specify or especially to emphasize, this quality. Again, the layman often fails to appreciate that spoiled corn signifies and development of the resultant toxic infection by and growth of bacteria substances, sometimes elaborated by such bacterial growth; especially on culture media of very complex composition, such as immature corn. examples of other food sources of disease we may cite the case of milk, which is a very wholesome and nutritious article of diet; but if it becomes infected with typhoid bacilli, it may be the source of typhoid fever. Water, in some form or other, is necessary to maintain life; but if it becomes infected with cholera bacilli, it may produce cholera. Likewise, meat enters into the dietary of the majority of people. in all lands; but if it becomes infected with certain bacteria and spoils, it will, if eaten, produce ptomaine poisoning.

As

Corn is a wholesome and nutritious article of diet; but if it becomes infected and is spoiled by certain bacteria, it may produce pellagra. Depending upon the dose of the toxin and the susceptibility of the individual, the severity of the disease will vary from the mildest to the most fatal, just as a small amount of ptomaine may give rise to mild symptoms while a sufficiently large amount will produce death. It therefore is not corn, but spoiled corn, that produces pellagra. Just what constitutes spoiled corn, what bacteria may elaborate in it this specific toxin, and the nature of the toxin, or toxins, have not been suc

cessfully worked out; largely because no disease has been produced in experimental animals that can be identified as pellagra. Corn, spoiled by a variety of bacteria, produces disease and death in experimental animals. Recently I have been able to produce a disease, with skin lesions exactly resembling those of pellagra in man, in a fowl; by feeding corn meal spoiled by inoculation with a pure culture ob

tained from a supposed source of pellagra. A preliminary note will appear in an early number of the Journal of the American Association. The illustration shows the distribution of the lesions on the legs of the fowl.

There would be no more justice in condemning all corn, or corn meal, as food because spoiled and infected corn produces pellagra, than there would be in condemning all milk, because infected milk may give rise to typhoid fever. This is true, however, only provided the sources of infection of each, and the infection itself, are equally recognized and controlled. I therefore desire to here point out some of the factors contributing to the spoiling of

corn.

It may be laid down as a rule that the susceptibility of corn to bacterial decomposition depends for one very important factor upon its moisture

content.

Moisture is one requisite of all bacterial growth. The amount of moisture. present in corn will depend upon the manner in which it is grown, harvested, stored, and, to some extent, upon the variety of corn. If grown where the season is short, such as in the northern part of the United States, it may fully mature and if harvested early will contain much moisture. If, on the other hand, the season is long, as in the Southern States so that the corn fully matures, and if it is allowed to remain in the fields until it is well dried, it may be of almost flint-like hardness and very dry. The practice of storing corn in open bins exposes it to the weather while the practice in most of the Southern States of storing it in covered houses after it is well matured and dried, reduces the moisture content to the minimum. The dampness in warehouses often contributes to the spoiling of corn and corn meal. Corn is sold by weight, and it is not always that the seller is scrupu

lous and sufficiently careful that water does not reach it and increase the weight. When corn, or corn meal, containing moisture is shipped over long distances and kept closed in dark, hot cars, the most favorable conditions are present for the development of bacteria, and it may result that corn, or corn meal that is sound and good for food before shipping; is spoiled and unfit for food upon arrival.

A hard, flint corn, which may be grown in a long season, can hold much less moisture than the softer' varieties that must be grown in the more northein sections, on account of the short seasons. It is a matter of common knowledge among southern farmers. that the immature northern and western grown corn can not be kept for long periods of time in the South during the warm season on account of its little resistance to the corn weevil; whereas the home grown corn is much more resistant.

2

As a result of the facts pointed out above, corn, or corn meal, when grown or produced where the season is short and shipped over great distances in tight, sometimes damp, hot cars, to warm, damp climates, frequently undergoes more or less decomposition either in transit or after arrival and before being consumed for food. As a matter of fact, the chief source of spoiled corn and corn meal in the Southern States is imported corn. If spoiled corn is the cause of pellagra, then the chief source of pellagra in the Southern States is imported corn. This is borne out by my observations in Louisiana and in South Mississippi, that the disease here occurs chiefly among the laboring class. in country towns and districts, who eat a great deal of corn or corn meal which is generally supplied from the store or commissary, which, in turn, imports from the corn growing sections. The lack of diversification by the cotton and sugar planters of these

two States, compels them to import much of their corn, and with this importation they supply their employees. Much of the pellagra of this section. develops among the employees on the cotton and sugar plantations, and especially among the employees on public works and saw mills in the towns and the country; and very frequently among those supplied from the commissary. The point may well be made that pellagra occurs, and in certain instances many cases are found, in the corn belt, for instance in Peoria, Illinois. To this I would reply that the disease has occurred chiefly in insane. hospitals, asylums and other institutions whose corn meal and flour are usually supplied by contract and bought and stored in considerable quantities. The supplies for several months or a year may be purchased at the same time. Whole corn does not spoil so rapidly as corn meal. In the Southern States the disease is more generally distributed, I believe; and is not confined to asylums, etc., as is the tendency in other States.

The apparent influence of the cotton boll weevil on the increase and decrease of pellagra in certain Southern States is interesting in this connection. From one to three years ago the States of Louisiana and Mississippi were overrun by the boll weevil and, cotton farming becoming unprofitable, the farmers turned to raising other crops and the yield of corn has been doubled and trebled, and as a result there has been very much less corn or corn meal imported.

In 1909 the type of pellagra diagnosed in New Orleans was very malignant and most of the cases died. In 1910, more cases were diagnosed, it is true, but the mortality was much lower. The cases diagnosed in 1911. are of a still milder type; and almost all have recovered or will do so. It is possible that as many will be diagnosed here

I have

in 1911 as in 1909, and it might at first be thought that the disease is increasing. Such is not the case. In 1909, when we first began to recognize the disease only the severe, well-marked cases were diagnosed and most of the cases we are now recognizing would have been passed unnoticed. no doubt that had we then possessed the same ability to diagnose mild cases, we would have recognized five. times as many cases in 1909, as we will in 1911. The first week in October the writer wanted some cases of pellagra for a clinic and after searching the New Orleans Charity Hospital (900 beds), found only one mild case and one doubtful. At any time during the summer and fall of 1909, several well-marked cases could have been selected. This change I attribute largely to the reduction of imported corn and corn meal and the increase of the home supply.

In Eastern Mississippi there is very little reduction as yet in the severity of the disease, and, of course, larger numbers are being diagnosed as the profession becomes more familiar with it. The influence of the boll weevil in its slow eastward spread is not felt. to the same extent that it is in a section like Louisiana, which was visited. by the pest two or three years earlier. In Georgia or the Carolinas, where the boll weevil has not reached, where the staple crop is cotton and the corn and corn meal supply largely imported, the disease is thought to be rapidly increasing. It would be interesting to know just how great the increase really is, however, after making due allowance for increased knowledge on the subject gained by the profession.

Briefly referring to the newer theories as to the cause of pellagra, I would point out that simulium does not exist in the southern United States where pellagra prevails to the same extent.

that it does in other States, like Idaho, where there is no pellagra.

With regard to contagiousness due to contact with Italians; I would say that I have studied over three hundred cases of pellagra in the past three years, and have not seen a single case of pellagra in the Italian. More than half of these cases have come from within a radius of one hundred miles of New Orleans, which section of country contains very many Italian laborers and inhabitants. A good number of the cases have been seen in the New Orleans Charity Hospital where many Italians are treated for other diseases. It would be passing strange if the Italians spread the disease by contact, but at the same time remained free from it themselves.

With regard to the theory recently suggested that pellagra is due to eating cotton seed oil or lard substitutes made therefrom, it may be set aside. with a few words. Pellagra has been known in Egypt, Spain, Italy and Roumania for from twenty-five to one hundred years before cotton seed oil or any of the lard substitutes into which it enters as an ingredient were used for food. Mixell (Journal-Record of Medicine, Vol. LVII), who proposes this theory points to the fact that the increase in the number of cases of pellagra diagnosed in the United States has augmented with the increase of the use of cotton seed oil for food. He could with equal justice accuse, as causative of pellagra, a score or more of other foods, etc., such as canned goods of all sorts, all kinds of breakfast foods, soft drinks and many other things, none of which has ever been conceived to have the slightest relation with the disease in question. If the claim of Mixell-that cotton seed oil and its products are responsible for pellagra-is at all tenable, why is it that the use of these food stuffs, which for years have had and are now having

enormously increased sale and consumption, in countries like France, Germany, Sweden, Denmark and Turkey, has not been productive of the disease? In the countries referred to, pellagra is little known. Why is it, also that enormously increased consumption of the prducts in the larger centers of population in the United States, like New York City, Philadelphia, etc., has not produced the disease? In these centers the disease is practically unknown.

One of the strong points argued by him in support of his new theory, is the fact, well known, of course, to the author, that pigs, or calves, when fed exclusively on cotton seed or cotton seed meal, accumulate fat and finally die. This is in striking contrast to the actual conditions in pellagra, in the majority of which emaciation is extreme before fatal termination. This is no more like pellagra than bloat in cattle, due to eating green clover, is like it.

In conclusion I would emphasize that it is not corn, but infected, or spoiled corn that produces pellagra;

That corn shipped long distances in tight, dark, damp cars, is more likely to become damaged than home grown

corn;

That corn grown in sections of the country where the seasons are short, may not fully mature and may therefore be more likely to spoil than that grown where the season is longer;

That sound, home grown corn is harmless and is to be commended as food for man.

I have written freely my opinions, many of which are formed from the study of the literature on pellagra, without referring to the many writings from which the ideas are derived. My indebtedness to these I acknowledge. The literature on pellagra is now too voluminous to permit of just abstraction on the points made in this paper in an article of this length.

Society Proceedings

MINUTES OF THE KY. MIDLAND MEDICAL SOCIETY, FRANKFORT KY., OCTOBER 12, 191Î.

In the absence of the President the meeting was called to order by the Vice

president, Dr. Geo. P. Sprague, of Lexington. Dr. Ben. Parrish was appointed to act as Secretary until the arrival of the Secretary.

A case was presented by Dr. Murdock, for diagnosis. A blacksmith had attacks resembling cardiac asthma. Dr. Curran Pope was appointed to examine the case. Dr. Pope's diagnosis was one of hysteria.

Dr. Sprague moved that Dr. Pope continue with the discussion and take up his paper which was along the line of dis

cussion.

Dr. Pope then delivered an address on "Dissociation of Personality," illustrating his remarks with charts.

The discussion of the address was opened by Dr. Sprague.

Dr. McClure (Lexington) then read a paper on "Tonsillectomy."

Dr. Willson (Frankfort) opened the discussion. He thought tonsillectomy should seldom be done. He believes in removing body of tonsil only. Thought the operation was attended with more danger from hemorrhage, as it is from the capsule that hemorrhage comes. Sometimes does partial tonsillectomy.

Dr. Pope (Louisville) : Sees many cases of sluggish mentality caused by tonsils and adenoids. Removal of tonsils in these cases gives splendid results.

Dr. Patterson (Frankfort): Didn't consider hemorrhage of such great importance as it could easily be controlled. by a few stitches.

Dr. Hill (Frankfort): Asked the question, "What operation is done more now, tonsillotomy or tonsillectomy?"