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Chironomide should not be incriminated together with, or instead of, the Simuliida. Until quite recently practically nothing was known of the minute flies (Ceratopogon, Leptoconops, Culicoides) now falling under suspicion, and their larval stages had not been observed. However, their distribution was known to be, like that of the Simuliidæ, practically world-wide, and I had often found them together with the Simuliidæ.
Meanwhile, a Pellagra Commission had been appointed by the State of Illinois in October, 1909. It consisted of the following members: Dr. Frank Billings, of Chicago; Dr. J. L. Greene, Alienist of the State Board of Administration; Dr. Oliver S. Ormsby, of Chicago, Dr. H. Douglas Singer, of Kankakee, Illinois; Dr. Howard T. Ricketts, of Chicago; Professor W. S. Grindley, and Dr. W. J. MacNeal, of Urbana, Illinois. In its report, published in November, 1911, this Commission confirmed my findings. It is stated that "all work directed to ascertain whether there was any relation between maize and pellagra had yielded negative "our impression is rather that pellagra is due to infection results," and concluded, of the body with some micro-organism. It does seem possible, however, that a diet deficient in animal protein may so alter the body that the infecting organism has a better chance to grow.”
The West Indian Investigation.
In 1911, at the suggestion of Sir Patrick Manson, the. Colonial Office, in co-operation with Mr. Henry S. Wellcome, arranged that I should visit the British West Indian Islands, because pellagra, or a disease resembling pellagra, had been reported from some of the islands (Jamaica, Barbados), and appeared to be spreading The Colonial Governments were concerned on account of the gravity of the disease, and had asked that someone with a thorough knowledge of the disease should be sent out to investigate and advise.
Owing partly to other work, and partly to the discovery of endemic pellagra in the British Isles, my journey to the West Indies had to be postponed until the summer of 1913.
In June, 1913, Dr. Harris, of New Orleans, Louisiana, announced that he had succeeded in transmitting typical pellagra to three rhesus monkeys by means of a His experi- Berkefeld filtrate derived from the tissues of fatal pellagra cases. ments suggested that the causative agent of the disease is a filterable virus or a micro-organism capable of passing through the pores of certain Berkefeld filters.
On the 23rd August, 1913, I left for the West Indies, travelling via New York in order that I might avail myself of a most courteous invitation received from the Thompson-McFadden Pellagra Commission to visit their field of operation in South Carolina.
The Thompson-McFadden Pellagra Commission.
The Thompson-McFadden Pellagra Commission had been formed to investi- gate pellagra in the United States, and, since June, 1912, had been carrying out an extensive study of the disease in the County of Spartanburg, South Carolina. The Commission was composed of Captain J. F. Siler, Medical Corps, United States Army, Passed-Assistant Surgeon P. E. Garrison, United States Navy, and Dr. W. J. MacNeal, Professor of Bacteriology and Pathology, New York Post- Graduate Medical School. The biological, pathological, and chemical researches were carried out in the laboratories of the New York Post-Graduate Medical School by Dr. O. S. Hillman, Dr. R. M. Taylor, Dr. V. C. Myers, and Dr. M. S. Fine, under the supervision of Dr. Jonathan Wright, Director of Laboratories, and Dr. W. J. MacNeal, a member of the Commission. The entomological work was undertaken by Mr. A. H. Jennings and Mr. W. V. King, specially detailed by the Bureau of Entomology of the United States Department of Agriculture.
Pellagra Conference at Spartanburg,
On reaching Spartanburg, on 1st September, I was informed that a special Indeed, on the 3rd of Pellagra Conference had been convened in my honour. September, about two hundred physicians gathered in Spartanburg town from all parts of the United States. Among them were Dr. J. W. Babcock, Superintendent of the State Hospital for the Insane, Columbia, South Carolina; Dr. Stewart R. Roberts, Professor of Medicine, Atlanta College of Physicians and Surgeons. Atlanta, Georgia; Dr. E. Jenner Wood, of Wilmington, North Carolina; Dr. C. H. Lavinder, Passed-Assistant Surgeon, United States Public Health Service; Dr. J. J. Watson, of Columbia, South Carolina; Dr. Julius C. Sosnowski, of Charleston,
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South Carolina; Dr. George N. Miller, ex-President of the New York Post-Graduate Medical School, New York, and others who had already greatly contributed in one way or another to our knowledge of the disease.
As a result of the Conference it was agreed :---
"That no decision was reached as to the cause of pellagra, and no definite course of treatment was arrived at. Yet the theory was advanced, supported by almost incontrovertible facts, that the disease is not transmitted through direct contact, although probably infectious. The Lombrosian theory of maize was attacked, and the prevailing view was that Dr. Sambon's idea of a parasitic origin is correct."
Observations in South Carolina.
I spent ten days in South Carolina, travelling almost continuously day and night by train and motor car. Thus, in the short time at my disposal, under the able guidance of the members of the Thompson-McFadden Pellagra Commission, and thanks to the extreme kindness of the local authorities and medical societies, I was able to visit many pellagra centres about Seneca, Newberry, Union, Jonesville, Buffalo, Columbia, Charleston, and to make a most interesting excursion to John's Island. The observations I was able to make in South Carolina will be fully dealt with in my extended report. Here, however, I must say how greatly impressed I was by the thoroughness of the work carried out by the American Commission. Their plan of studying intensively a comparatively small area is excellent, and is certain. to yield very useful information, which, when compared with the data obtained from similarly investigated, but far removed and physiographically different, areas, should enable us to solve the obscure pellagra problem.
In a summary of their first Progress Report, published 3rd September, 1913, the Thompson-McFadden Pellagra Commission make the following statements:-
1. The supposition that the ingestion of good or spoiled maize is the
essential' 'cause of pellagra is not supported by our study.
2. Pellagra is in all probability a specific infectious disease, communicable
from person to person by means at present unknown.
3. We have discovered no evidence incriminating flies of the genus Simulium in the causation of pellagra, except their universal distribu- tion throughout the area studied. If it is distributed by a blood-sucking insect, Stomoxys calcitrans would appear to be the most probable
carrier.
4. We are inclined to regard intimate association in the household, and the contamination of food with the excretions of pellagrins, as possible modes of distribution of the disease.
5. No specific cause of pellagra has been recognized.
In transcribing these conclusions, I must point out that statement 4 is at variance with my own observations and with all previous experience. Statement 3 will be fully discussed farther on.
One of the most pleasant results of my visit to the United States was that both Captain Siler and Mr. Jennings decided to join me in the study of the pellagra conditions of the islands of Jamaica and Barbados.
Visit to the Panama Canal Zone.
I left New York on the 13th of September, 1913, and from that date to 6th January, 1914, when I returned to London, all my time was devoted to the visiting of the British West Indian possessions, with the exception of six days spent on the Isthmus of Panama. Here, very courteously invited by Surgeon-General W. C. Gorgas, United States Army, I had the opportunity of inspecting that wonderful feat of American-handled sanitation which had made possible the accomplishment of the great trans-oceanic canal, turned the deadliest tropical spot into a health resort, and proved the truth of an assertion I had made twenty years ago that parasitism and not climate was responsible for the unhealthiness of the tropics, and that, by overcoming parasitic disease, the white man could live, work, and rear his children in perfect health and happiness within the equatorial belt.
Distribution of Pellagra in the West Indies.
In the course of my journey I was able to visit the islands of Jamaica, Dominica, St. Lucia, St. Vincent, Barbados, Grenada, and Trinidad, the Colony of British Guiana, and, as already stated, the Isthmus of Panama. In all these places I either saw cases of indigenous pellagra, or was informed of their occurrence by the local health officers.
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