1

Of the outpatients, there were under treatment July 1, 1915, 12 patients; 28 were admitted during the year, 3 of them having been readmitted; 40 were, therefore, treated during the year. Of these, 15 were discharged improved (without having shown any return of active symptoms of pellagra), 5 were discharged unimproved. A total of 5,555 treatments (meals) have been furnished to these outpatients. Twenty remained under treatment June 30, 1916.

The treatment of 40 outpatients has consisted of serving at the hospital building each day one generous and well-selected midday meal. A more or less necessary placebo has also been given with this treatment. The outpatient department has served a twofold purpose to keep the hospital in touch with the local pellagra situation and to furnish data which will be of value from the standpoint of treatment and prevention of pellagra. While taking this daily meal at the hospital, none of these patients have shown any return of active pellagra symptoms, and although a few have been discharged unimproved the majority have been able to attend to their affairs throughout the period of treatment.

The care and treatment of the hospital and outpatients have been under the supervision of the medical officer in charge, assisted by Asst. Surg. W. F. Tanner until August 30, 1915, when Dr. Tanner was relieved and his duties were assumed by Asst. Surg. R. L. Allen. The cases have been followed carefully during treatment, and detailed clinical and dietary records have been obtained. clinical laboratory examinations have also been made.

Routine

While no definite conclusions have yet been drawn from the clinical work, it has been found, as a rule, that those patients who have continued treatment over a reasonable length of time have shown remarkable improvement. Relief from care, worry, and responsibility while in the hospital has undoubtedly been a factor in favor of the hospital patients. Analysis and comparison of the clinical and dietary data which are being collected at the station will probably be of great value in showing a definite relationship between certain articles of diet and the treatment of pellagra with maximum

success.

In addition to the hospital and outpatients who have been treated at the hospital building, a limited number of pellagrins living in Spartanburg and vicinity have received treatment at their homes. The treatment of these patients has consisted of the administration of special preparations made in the station laboratory under the direction of Prof. Voegtlin.

Dietary studies in pellagrous and nonpellagrous families.—In order to elucidate the question as to how diet leads to pellagra it was essential to obtain accurate information as to the qualitative and quantitative composition of the food consumed by persons suffering from pellagra. Twenty-two families in Spartanburg County, S. C., were selected for this purpose. These families were representative of the population of the cotton-mill villages where pellagra has been endemic for several years past. The families were divided into two groups: Group "A" included families in which there had not occurred any pellagra; group "B" was composed of families in which one or several members were affected with this disease. The general hygienic conditions of both groups were practically the same. The food supply of these families was computed during the whole year

and the families were examined from time to time as to the occurrence of pellagra. The families of The families of group "A" (nonpellagrous) remained free from the disease during the whole period of investigation (one year and a half).

The main result of the investigation was that the nonpellagrous families in every case had a more satisfactory supply of such foods as milk, eggs, and fresh meat than the pellagrous families. It was noted that the families of group "A" usually kept a cow, which, of course, meant that they were supplied with milk. This observation was made also in many other families living in this section of the country. The general economic condition of these people (group A) was also investigated. The results of these studies will be subsequently reported.

Without going into detail it may be said that the diet consumed by pellagrous families is deficient in certain food components, an observation which, together with other evidence, supports the so-called deficiency theory of pellagra.

Changes in vitamine content of bread.-A discussion of changes in the vitamine content of bread with reference to the occurrence of polyneuritis was published in the Public Health Reports during the year and issued as Reprint No. 333. On the basis of extensive animal experiments, it was shown that highly milled flour is deficient in vitamines and that, where these are not sufficiently provided in other parts of the diet, insufficient nutrition may result. It was also concluded that corn bread prepared by means of baking soda without the addition of buttermilk or sour milk is deficient in vitamines and that this deficiency is due to the destructive action of the alkali (baking soda) on the vitamines in these foods.

Metabolism in pellagra. This phase of the investigation was extended during the year, and it can now be considered as well advanced. The chemical composition of the blood, urine, and gastric contents from the patients at the hospital was carefully studied in detail. The milk secreted by pellagrins was also submitted to an extensive chemical analysis. The question of the occurrence of pellagra in early childhood received special attention. A collective manuscript including the results obtained in these studies was recently prepared.

Vitamine treatment of pellagrins.-In order to prove definitely that a disease is of dietary origin it is essential to determine the chemical character of the diet which gives rise to the disease. It has been suggested that pellagra is due to the consumption of a diet deficient in certain food elements (vitamines). It was therefore essential to determine the therapeutic effect of vitamines on the course of the disAs stated above, the diet of pellagrous families in Spartanburg County, and very probably elsewhere in pellagrous countries, is obviously deficient in vitamines. Preliminary therapeutic tests of such preparations were made during the past two years.

ease.

In order to continue these studies efforts have been made during the past year at the Hygienic Laboratory (see p. 93) and also at Spartanburg to obtain such physiologically active food components from various raw materials. A large number of vitamine preparations were accordingly obtained from brewer's yeast, ox liver, wheat bran, rice polishings, and field peas. These substances are now being tested as to their curative action on pellagrins,

Animal experiments.-Extensive feeding experiments of wheat and corn products were made in order to determine their content in socalled vitamines. The results conclusively show that the modern "patent" wheat flour and corn grits obtained from roller mills are deficient in vitamines. On the other hand, graham flour, whole-wheat flour, and rock-ground (whole) meal contain more of these elements. Food analysis.-The foods used at the Pellagra Hospital were analyzed for their content in protein, carbohydrates, fats, inorganic salts, and calories.

Dietary treatment of pellagra.-Several diets of different composition were tested out as to their curative action on the hospital patients. This work, which has been in progress since August, 1914, has now been completed.

MENTAL MANIFESTATIONS OF PELLAGRA.

An article by W. F. Lorenz, formerly special expert, Public Health Service, on "The mental manifestations of pellagra," was published in the Public Health Reports for February 4, 1916, and issued as Reprint No. 322. The article reports investigations made at the Georgia State Sanitarium during the spring and summer of 1914. Since this work has not been previously reviewed in the annual reports of the service, the following conclusions reached by Dr. Lorenz are given:

"The phychosis that accompanies pellagra has the characteristics of the toxic psychoses in 90 per cent of the uncomplicated cases admitted to an institution for the insane.

"It has great resemblance to the acute alcoholic psychoses.

"When pellagra develops in an individual already insane synchronously with the physical manifestation, a mental confusion or delirium may be added to the existing psychosis.

"Were an etiology to be suggested from the mental disturbances alone, the causes would fall among a group of agents similar to alcohol in that they are not products of bacterial or parasitic invasion of the body, but chemical intoxicants in the narrower sense."

PUBLICATIONS.

Of the publications of the service during the past fiscal year the following related to pellagra:

HYGIENIC LABORATORY BULLETINS.

102. II. Preliminary Observations on Metabolism in Pellagra. Hunter, Maurice H. Givens, and Robert C. Lewis.

By Andrew

103. I. Chemical Changes in the Central Nervous System as a Result of Restricted Vegetable Diet. By Mathilde L. Koch and Carl Voegtlin. II. Chemical Changes in the Central Nervous System in Pellagra. By Mathilde L. Koch and Carl Voegtlin.

REPRINTS FROM PUBLIC HEALTH REPORTS.

307. The Prevention of Pellagra. A test of diet among institutional inmates. By Joseph Goldberger, C. H. Waring, and David G. Willets. October 22, 1915.

308. The Prevalence of Pellagra. Its possible relation to the rise in the cost of food. By Edgar Sydenstricker. October 22, 1915.

311. Experimental Pellagra in the Human Subject Brought About by a Restricted Diet. By Joseph Goldberger and G. A. Wheeler. November 12, 1915.

322. Mental Manifestations of Pellagra. By W. F. Lorenz. February 4, 1916. 325. Vitamines and Nutritional Diseases. A stable form of vitamine, efficient in the prevention and cure of certain nutritional deficiency diseases. By Atherton Seidell. February 18, 1916.

333. Bread as a Food. Changes in its vitamine content and nutritive value with reference to the occurrence of pellagra. By Carl Voegtlin, M. X. Sullivan, C. N. Myers. April 14, 1916.

339. Pellagra. Laboratory Examinations in connection with the disease. By J. R. Ridlon. May 19, 1916.

PUBLIC HEALTH REPORTS.

March 31, 1916. Diet and pellagra. Rabbits and hares as a possible dietary factor in combating the disease. By C. W. Stiles.

PYORRHEA ALVEOLARIS.

An investigation of the curative effects of ipecac and emetin in pyorrhea alveolaris was conducted at the Fort Stanton Sanatorium for Tuberculosis and a report by Asst. Surg. John S. Ruoff published in the Public Health Reports and issued as Reprint No. 320. It was found that emetin is an amebicide, but alone will not cure pyorrhea aveolaris. Less confidence will hereafter be placed in the properties of this and other preparations of ipecac, although it is not denied that the drug does possess amebicidal properties. Just how much assistance is to be expected from the ipecac preparations used in conjunction with operative measures is a question upon which furtheir studies may be expected to throw some light.

TRACHOMA.

Trachoma work in the Appalachian Mountains.-As the establishment of small hospitals in known infected districts has proved the best method of eradicating and preventing trachoma, this work has been extended by the service along the same lines during the past year. The longer these hospitals are established the more the people appreciate their importance and necessity. Not only do they serve well the purposes for which they were established, but they act as centers for creating an interest in public health generally heretofore unknown. Many people living in rural and isolated districts previously skeptical or even antagonistic to sanitary measures have been taught by the doctors and nurses at these hospitals that trachoma and many other diseases are due solely to their way of living and are entirely preventable. By precept and example they are shown that prevention is better than cure and taught the simple rules of personal hygiene. Furthermore, the beneficial results obtained at the field clinics in old trachoma cases, many of whom have been practically blind for years, arouse the intense interest and enthusiasm of the community and insure a large attendance of persons eager to learn about health protection.

Location of hospitals.-During the past fiscal year, in addition to the three original trachoma hospitals in Kentucky, two others have been in operation in Coeburn, Wise County, Va., and Welch, McDowell County, W. Va. The Coeburn hospital was ready for the reception 63887°-H. Doc. 1493, 64-2-3

of patients on July 1, 1915, but the other was not opened until about October 1. This makes a total of five trachoma hospitals in operation at the close of the fiscal year. All arrangements have been completed for extending the work into Tennessee, and a trachoma hospital will be established at Tazewell, Claiborne County, Tenn., about August 17, 1916. The central office will remain at Lexington, Ky.

The original survey in 1913 showed Knott County to be heavily infected with trachoma and the first of these hospitals was therefore established in Hindman, the county seat, situated 20 miles from a railroad. In this manner treatment was given to hundreds of trachoma victims who would otherwise never have found relief. According to Surgeon McMullen, this county is now practically free of the disease and probably has less infection than any other county in Kentucky. The hospital will therefore be moved to another infected district in a short time.

Cooperation of State and local authorities.-The State and local authorities are cooperating in the work. The local authorities at London, Ky., Coeburn, Va., and Welch, W. Va., furnish suitable two-story buildings, rent free, for the use of the hospitals, while Breathitt County, Ky., contributes toward the rental of a building for the Jackson Hospital. The local authorities at Tazewell, Claiborne County, Tenn., are making extensive improvements on the house they have agreed to furnish for the use of the hospital to be placed there.

During the year just ended the State of Virginia contributed $1,200 toward the maintenance of the Coeburn Hospital and West Virginia $600 for the Welch Hospital. The State board of health of Kentucky proposes to contribute $500 to the work in the State during the next fiscal year.

The service endeavors to educate one or more of the local physicians to do the work at all of the trachoma hospitals, in this manner preparing the way for the establishment of similar hospitals by the local authorities after the discontinuance of service operations in these localities.

Eradication. These hospitals, with a capacity of only 15 or 20 beds, are often crowded, and unable to care for the numbers of patients seeking relief.

Persons treated.-During the past year the total daily attendance at the five trachoma hospitals was 19,530. Twenty thousand five hundred and forty-five treatments were given to dispensary patients. This, added to the 91.510 treatments given to the hospital cases, makes a total of 112,055 individual treatments given during the year by the doctors and nurses at these five hospitals. Nearly one-half of the number applying for relief for trachoma were found to have impaired vision. This ranged all the way from slight defects to total blindness as a result of trachoma. Many of these cases were among school children who were relieved of their trachoma while it was in the incipient stage and before the visual damage had been done.

A total of 1,880 persons were treated in the hospitals during the year. These were furnished subsistence and, as previously stated, given 91,510 individual treatments, an average of about 50 treatments per patient. There were 1,832 cases discharged from the hospitals,