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sylvania more skillful than Agnew and White? Who is a better techni-
cian at the University of Maryland than L. McLain Tiffany? Who
believes that Jefferson has a more skillful surgeon than W. W. Keen?
Richmond has not today a better man than Hunter McGuire, and New
York has no better man than W. T. Bull. And yet the mortality in
surgery has decreased each year. The surgeon no longer waits for a



FIFTH ANNUAL SESSION. 53

tumor to appear iu appendicitis, jaundice in gall-bladder disease, or for
the axillary lymph nodes to enlarge in tumor of the breast, before oper-
ating.

The low mortality in surgical diseases is due more to early recognition
than to great improvement in surgical technic.

If we will profit by this lesson and apply the same rule to pulmonary
diseases, and diagnose tuberculosis before tubercle bacilli are found iu
the sputum and before the clerk in the drug store suspects that the
patient who is taking cough medicine has consumption, then the mor-
tality from this disease will drop, for early diagnosis is the only hope of
effecting a cure. In addition, the patient is warned in time to take pre-
cautions preventing the infection of others Avith whom he comes in con-
tact.

Physicians should make a thorough physical examination of the lungs
of every patient. I will not take up the symptoms and physical signs in
tuberculosis. These will be found in any good text-book on medicine or
medical diagnosis. But I wish to emphasize a few points that we have
found of great help :

1. Do not be in a hurry about making a final diagnosis. Get an accu-
rate history of the development of the patient's condition, and especially
a history of exposure to infection.

2. If there is any doubt, go over the patient's lungs two or three times,
at intervals of a day or so, taking an hour for each examination, if
necessary.

3. Give the patient a tuberculin test. The von Pirquet test is good
and can be applied with little trouble. A positive tuberculin reaction,
though, does not necessarily mean that the patient has an active tubercu-
lous lesion.

It is possible in this way to diagnose many early cases which otherwise
would progress to a point beyond reasonable hope of recovery.

As a surgeon, I frequently see apparently surgical and gynecological
cases which are due really to some form of tuberculosis. For example :
I recently saw a patient, a girl of 20, who had never menstruated. Her
pelvic organs were normal, but she had an advanced pulmonary tubercu-
losis which had never been suspected. Such instances put us on our
guard and impress us with the importance of giving every patient we see
a thorough and complete examination, for only by an early diagnosis can
we hope to arrest the disease and at the same time warn the patient to
take such precautions that others Avill not be exposed to infection.

Dr. J. Howell Way, Waynesville : I want to thank Dr. Long per-
sonally, and also on behalf of the Health Officers' Association, for his
interest in preparing this paper. My only criticism of it is its brevity.



54 HEALTH officers' ASSOCIATION.

It was so good that it ought to have been longer. I want to thank him,
as a surgeon, and as one of North Carolina's great surgeons, for his
interest in this subject and for his coming today to be with us and to
read this paper. Certainly he is on the right line. When he was read-
ing that paper I sadly recalled having been summoned to a near-by town
last February to see a girl, beautiful, accomplished, a senior in one of
the leading schools of this State, and who would have graduated this
year. She was sent to Dr. Long's sanatorium, and he sent her home.
She gave me a history of having, in the autumn of last year, been in the
college infirmary with the diagnosis of having malaria. Malaria is a
common word ; I hear it a few score times each summer. Ofttimes it is
used in the summer to cover an incipient tuberculosis.

I was interested in what Dr. Nesbitt said this morning about Dr.
Wood of Wilmington, whom we all recognize as one of the most accom-
plished physicians in the State. Dr. Wood told Dr. Nesbitt that he had
only a very few cases of malaria in his practice in a given time ; these
cases being determined by routine blood examinations.

We talk about people going to a specialist to have their lungs exam-
ined. When you begin to think of 6,000 people dying in North Carolina
in one year from tuberculosis, it seems to me that if you consider it seri-
ously for a moment you will agree with me that every man who practices
medicine has to examine the chest almost every day, and if he has any
reason to suspect that any patient is at all possibly seriously sick, the
chest must be examined with precision. And, as Dr. Long says, don't be
in a hurry. Let the patient come back for another examination. If we
would all do that, we would diagnose tuberculosis very much oftener
than we do, and by diagnosing it early — early, I say — we would save
many of these cases from untimely graves.

Again, Dr. Long, we are very glad that you are with us, and we thank
you for this paper.

Dr. Long : I wish to thank Dr. Way for his kindly notice of my paper.

Sometimes one of the very first symptoms of tuberculosis in the young
female is menstrual disturbance, and they at once suspect pelvic disease
and consult a surgeon.

It is not easy to diagnose early tuberculosis. It is very hard to do
sometimes. I have kept patients at Statesville, where I have a small
hospital, for as long as ten days, knowing they had no other disease, and
trying to determine whether or not they had tuberculosis. It is not
always easy to detect tuberculosis, but it can be done, with patience and
labor, and it must be done if we cure our patients.



FIFTH AXNUAL SESSION. 55

WHAT THE STATE AXD YOU CXN DO FOR THE
COA^SUMPTIVE.



Thompson Feazek. M.I).. Asheville.



In recent years we have liad to change many of the vicAvs which we
once held on the subject of tuberculosis. With regard to the curability
of tuberculosis, you all remember the time when we looked upon the dis-
ease as a hopeless one. Not long after this — veering about to the other
extreme — we adopted a hopeful attitude, which, in turn, has been forced
to give way to the view which we now hold, and which maintains that
tuberculosis is curable, but curable only in the early stages and if prop-
erly treated.

In many other respects have we modified our opinions of former days.
N^one of our more recent views is of greater importance than that which
is implied in the title of this paper, ''What the State and You Can Do
for the Consumptive," which is tantamount to saying that the responsi-
bility for the cure of the disease does not rest on the patient and his
physician alone.

This conception is a somewhat new one ; for it has not been long since
we did look upon tuberculosis as the patient's own affair ; we hoped he
would get well, poor fellow; but if he didn't, it was scarcely our fault.

Happily, we have changed all this. We now realize that tuberculosis
is not simply the personal problem of the unfortunate sufferer, but a dis-
ease with vast sociological relations, and one whose eradication depends
upon the combined effort not only of patient and physician, but of State
and every individual as well. Xow, while the practicing physician has
a great responsibility to bear, in that an early diagnosis — so essential to
a cure — is demanded from him, it must be remembered that an early
diagnosis, though essential to a cure, does not spell cure. The physician,
no matter how willing, cannot work miracles. And while the patient, no
less, has it in his power to devote his will and determination to getting
well, there are some conditions inherent in the nature of the disease
which make recovery difficult of attainment.

In the first place, tuberculosis is a disease of early life. Secondly, it
is a disease which is most prevalent among those in moderate or strait-
ened circumstances. Thirdly, tuberculosis is a chronic disease, taking
months or years to "cure" or ''arrest." Who, I ask you, is to pay for a
course of treatment — which, first of all, consists of stopping work for a
period, let us say, of six months, for an early case? Not the sufferer;



56 HEALTH officers' ASSOCIATION.

when he stops Avork, his income stops with him. Who is going to teach
him to live so that he shall not be a source of danger to others ?

These are some of the questions which must be answered by the State
and by you. Before offering any suggestions on the solution of these
problems, I shall first attempt a brief review of some of the facts which
have a bearing on the subject of tuberculosis, believing that an apprecia-
tion of the conditions which underlie the disease will best serve to point
the path which we must follow.

There are two facts, fundamental to the proper understanding of
tuberculosis, that must be borne in mind. The fii'st of these is, that
tuberculosis is an infectious disease; the second, that it is a sociologic
problem.

It is, of course, known to all of you that tuberculosis is an infectious,
a communicable disease. Now, this does not mean that it is contagious
in the sense that measles and smallpox are contagious. Much of the fear
of consumptives is unwarranted ; at the same time Ave are safe in saying
that most cases of tuberculosis are the result of the taking into the body
of germs, the source of which is the dried-up sputum of consumptives.
We are also fond of saying that tuberculosis is preventable — and it is,
theoretically ; but as long as we do not destroy the infectious material it
is not preventable. I may be drawing down upon me the wrath of those
who maintain that tuberculosis is preventable ; the fact confronts us,
however, that as things stand today, it is not preventable. It should be,
it could be ; but, under existing conditions, it is not.

This is a sad commentary on our civilization, but the reason is not far
to seek ; for tuberculosis differs from most of the infectious diseases in
being of a long-draAvn-out nature. In typhoid fever, for instance, the
relation between infected food or Avater and an outbreak of typhoid feA'er
is more apparent ; cause and effect are close in time and space. In
tuberculosis, hoAvever, we don't so readily see the relation betAveen infec-
tion and the development of symptoms, for years may elapse betAA^en the
time that the individual is infected and the time that he breaks doAAm in
health; that is, the disease may exist for a long time in what is called
the latent stage, Avithout giving rise to symptoms. Indeed, Ave iioav regard
tuberculosis in the adult in many if not in most cases as the result of an
infection, which, taking place in childhood, was carried about for years
and did not cause symptoms until the strength of the body or, as we say,
the resistance Avas lowered as the result of unhygienic living or unsani-
tary conditions, such as hard work and long hours, insufficient sleep,
dark, unventilated quarters, poor food, and not enough of that.

This brings us to the second point Avhich I Avish to emphasize, viz., the
sociologic and economic aspect of tuberculosis ; for, though the tubercle



FIFTH AXNUAL SESSION. 57

bacillus is the actual exciting cause of the disease, equally important are
the conditions Avhich act as predisposing causes. These two causes, the
actual and the predisposing, often go, hand in hand, with poA'erty and
ignorance leading the way. It is no wonder tliat tuberculosis increases
as we go down the social scale; for in the dirty, overcrowded homes of
the poor Avho are ignorant of the most elementary rules of hygiene the
germs spit upon the floor by the untaught consumptive easily gain en-
trance into the bodies of other members of the family, especially the
children playing about the floor ; so that we may confidently look f orAvard
to the production of a new crop of consumptives in the coming genera-
tion, when — as the result of a scanty living wage or unsuitable quarters
or insuflieient food — the resistance to the infection is overcome. Thus,
poverty supplies both the seed and the soil.

This endless chain has been forged for countless centuries ; it is being
forged now. There is this difference, however : that we can no longer
plead ignorance of the fact.

With conditions as I have painted them, Avhat chance has the poverty-
stricken invalid for recovery? In the face of these facts, what can the
physician accomplish, unaided, in stopping the spread of infection ?
N^othing, or almost nothing. For Ave are not dealing with a disease alone,
but with a sociological condition — crime, if you will. It is only by united
efforts that we can get results. Each and every one of us must put his
shoulder to the wheel.

It Avould take us too far afield to discuss all the details AA-hich go to
make up the Antituberculosis Crusade. I shall attempt, hoAvever, to
indicate briefly the steps which should be taken by the State and by you.
From AA'hat has been said, it is plain that the problem Avhich confronts
us is really a double one, viz., the "cure" of those already affected, and
the prevention of the infection of others. Our efforts must embrace the

tAA'O.

AVHAT THE STATE CAN DO.

Looking at the matter from these tAvo angles, AA'hat can the State do?

1. To accomplish the "cure" of those already infected, there should be
established and maintained a clinic or free dispensary, so that the sick
individual may be examined by one familiar AAath the disease in order
that a diagnosis may be made at the earliest possible moment.

2. There should also be maintained by the State a sanatorium or sana-
toriums large enough and Avith a^^propriations sufficient to care for the
great numbers of indigent early cases Avho must otherAvise succumb to
the disease.



58 HEALTH officers' ASSOCIATION.

3. Bearing in mind the large number of children who are already
infected, the State should support a far-reaching policy of school inspec-
tion, with examination of suspicious cases ; this to be supplemented by
the institution of fresh-air schools for children whose physical condition
is found to be below par.

To check the spread of infection, which is as important as to attempt
to relieve those already diseased, there should be required :

1. Compulsory notification by physicians of cases of tuberculosis.
This is the only means by which we can even attempt to keep informed
of the number and location of cases.

2. In addition to laws looking toward this, there should be employed
a properly qualified, whole-time health officer whose duty it should be to
see that these and other laws are rigidly enforced.

3. The maintenance either by the State (or by some charitable organ-
ization) of the visiting nurse. This has been undertaken in many com-
munities, and cannot be too strongly recommended. Going into houses
in which tuberculosis has been reported, she becomes familiar with home
conditions, advises the patient to go to sanatorium or hospital, reports the
presence of other suspicious cases, gives instruction in hygiene, etc., etc.
She is of great service, therefore, as a means of discovering disease and
starting the educational campaign.

4. Valuable as the above measures have shown themselves to be, they
Avill not avail us much unless we have some means of caring for the
advanced cases who spread the infection. To this end a hospital where
the helpless, ignorant, careless, willful, and dangerous consumptive can
be taken care of must be looked upon as one of the most important meas-
ures of safeguarding the community.

WHAT YOU CAN DO.

One of the most important things you can do is to stand by the State,
for without support of the individual the State can do nothing. This,
however, is not the only thing that you can do : your sphere of influence
is a large one, if you wish it so.

We have seen that the economic aspect of tuberculosis is no less impor-
tant than the infectious aspect. We have learned that poverty is a great
predisposing cause of the disease. While I shall not suggest that you
attempt at once to abolish poverty, there is much that you can do in
seeing that child-labor laws are not only enacted, but enforced, and that
factory inspection results in better ventilation and better sanitary condi-
tions. While the assurance to the working classes of a living wage which
shall enable them to have enough to eat for themselves and their children.



FIFTH ANNUAL SESSION. 59

which shall provide better homes and protect them against the evils of
overcroAvding, darkness, filth, and other unsanitary conditions — this,
ultimately, rests upon the public, on you, individually and collectively.

By the organization of antituberculosis societies in your community,
acting in conjunction with the National Association, you could start an
educational campaign against ignorance, dirt, and disease that would
have wide-reaching results. A discussion of the early symptoms of tuber-
culosis, the means of prevention and treatment by mothers' clubs and
similar societies could not but prove helpful.

There is one thing more that you can do, and must do, and that is, con-
tribute to the cause; for, surely, common humanity demands that we
make provision for those who largely through no fault of their own have
become waste products of civilization.

Should humanitarian motives not prove strong enough, there is still
the driving power of self-interest which may spur us to action ; for it is
cheaper for the taxpayer to support an invalid in the early stages of the
disease than to withhold help until the disease is well advanced, at which
stage not only he must be taken care of, but those as well whom he has
succeeded in infecting during his career.

Whether we break the endless chain depends on you. The prevention
and the treatment of tuberculosis stand on a firm footing ; the knowledge
which has been obtained at great cost is useless, however, unless applied.
The final outcome of this war on disease depends on whether the sinews
of Avar are forthcoming. This again rests with you.

I believe you will rise to the task before you ; and I believe that the
present crusade is big with promise, in that you — the individual Avho
constitutes the State — are learning at last to realize to Avhat extent the
country's health, wealth, and prosperity have been held in check by the
greatest of scourges, tuberculosis.

Dk. C. y. Reynolds, Asheville : The question of tuberculosis is cer-
tainly a broad one. I don't knoAv of any preventable disease that is
before the medical profession today that is more important, or that
more good can be accomplished in its eradication, than tuberculosis.
I knoAv Dr. Frazer Avell, and I knoAV that Avhen he used the term ''cure"
he did not mean cure in the common acceptation of that term. I feel
and believe that he knoAvs there is no such thing as a real cure in tuber-
culosis. Tuberculosis is a chronic disease with a tendency toAvard arrest-
ment, but prone to relapses, and for this reason it is exceedingly danger-
ous to combat. Even in incipient cases we think that aa'c haA^e made a
"cure," and in the morning Ave Avake up and find that our patient had a
profuse hemorrhage, Avhich calls for a ncAv effort. The early treatment



60 HEALTH officers' ASSOCIATION.

of tuberculosis is certainly essential to tlie arrestment of the disease, but
the real benefit that we hope to get, I believe, is through education and
prevention — educating the people, as I said this afternoon, that the ser-
pent is in the sputum ; not fearing the patient, but fearing his sputum.
Educate them, then, to take care of the secretions, and we will in a short
period of time accomplish great results in controlling, modifying, and
limiting to a great extent this great scourge, tuberculosis.

Dr. Charles T. Nesbitt, Wilmington : Not only the tuberculosis
question, but the problem that presents itself, tuberculosis of childhood,
is an important question. Take measles and whooping-cough, for in-
stance. Thej are supposed to be the natural heredity of children, but
they are very much more important than you think. The doctor spoke
of encouraging open-air schools. I think the time will come when Ave
will have nothing but open-air schools. I think people will realize that
in the public school attended by little children, where they spend the
greater part of each day you have the most potent means of standard-
izing the health of the childhood of any community. The best way
to prevent them from exchanging their diseases is to teach them in the
open air or in a place unsheltered except above, where they will not
come into contact with each other and Avhere there will be the smallest
chance of getting droplet infection. I think this is a matter that we all
should think about. "We are all familiar with the ordinary schoolroom
and we are all familiar also with the tremendous outbreaks of the
so-called minor diseases that occur just as soon as school opens. This is
a matter that is certain to be one of the problems of the future, and I
think the sooner we adjust ourselves to the idea of sending our children
to open-air schools, where they will be wrapped up and protected from
cold in the winter-time, but out of doors, just that much sooner we shall
be able to control not only tuberculosis of the very young, but also scar-
let fever and the other infectious diseases of childhood.

Dr. D. E. Sevier, Asheville : I consider that Dr. Frazer has read one
of the most important papers that has come before us. I think a school
inspector should be able to make the diagnosis of a school child who is in
the earlier stages of tuberculosis; but Avhat are you to do with these
children? If you are in a schoolroom, as I have been, and find there a
little child suffering from tuberculosis, probably not in a run-down con-
dition, but seemingly strong and hearty, what more can you do than
instruct them to take the necessary precautions to keep them from infect-
ing their other classmates ? We do not want to handicap the children by
keeping them from school, but in the case of a child we know is run-down



FIFTH ANNUAL SESSION. 61

physically you could exclude them from school, but there is no law by
Avhich you can say to a child, "You have to give up joxw school and stay
at home." Again, gentlemen, it is the most heartrending sight that I
have ever seen to tell a child that he will have to go home on account of
his health. There is nothing that appeals to me more than this. ISTow,
I think Avliat Ave should do is to ask the State of North Carolina for a
fund to erect a school and a boarding-house to take care of all these chil-
dren. Outside of teaching them to take the necessary precautions,
coughing in their handkerchiefs and taking the little sputum box, I don't
see anything else that we can do, other than ask the State of JNTorth Caro-
lina to make an apj^ropriation to take care of these little boys and girls.



ELECTIOA^ OF OFFICEKS.

The report of the Committee on ]Srominations was presented by Dr.
C. V. Reynolds, as follows :

For President, Dr. D. E. Sevier, Asheville.

For Vice President, Dr. C. T. Nesbitt, Wilmington.

For Secretary-Treasurer, Dr. George M. Cooper, Kaleigh.

This report was adopted and these officers declared elected.



ADDRESS OF Dr. D. E. SEYIER, PRESIDENT-ELECT.

Mr. President. Ladies and Gentlemen : I Avish I could command appro-
priate Avords to express to you my sincere appreciation of the high
honor AA'hich you have so kindly conferred on me. I consider it a high
honor because it comes from the grandest organization, not only in the
Southern States, but of any State in the Union. Your officers as you
have selected them this evening can do but little alone; but, Avith the
assistance of each individual health officer of North Carolina, I feel that
Ave can carry this great organization on to success and do great health
Avork in the future. I thank you.



INDEX.

PAGE

Address of President Jt)nes 5

Address of rresident-elect Sevier 61

Address of Welcome — Mmjor T. J. Miirphii 3

response — Dr. B. K. Hai/s 5

Battle, r>r. J. T. J. : Interesting Communities in a General Community
Clean-up -i"

Committees named 30

Consumptive. What the State and You Can Do for the — Dr. Thompson

Frazcr 55

Contagious Diseases, the Problem of — Dr. M. T. Edycrton, Jr 33

Cooper, Dr. G. M. :

discussing Rural Sewage Problem 27. .30

Teaching Sanitation and Hygiene in the Schools IT

elected secretary-treasurer of the Association 61

Morbidity Reports. How to Secure 31



Online LibraryMedical Society of the State of North Carolina. AnTransactions of the Medical Society of the State of North Carolina [serial] (Volume 62 (1915)) → online text (page 57 of 58)