RELATION OF CERTAIN ECONOMIC FACTORS TO PREVALENCE OF PELLAGRA.

An analysis of economic data bearing on the possible connection between the increasing prevalence of pellagra and the rise in the cost of food was made by Public Health Statistician Edgar Sydenstricker and published in the Public Health Reports (Reprint No. 308). This analysis indicated that such a connection might be possible.

In the spring of 1916 there was accordingly organized and inaugurated a field study of the relation of certain factors of an economic character to pellagra prevalence in mill village communities. The headquarters of this investigation have been established at Spartanburg, S. C., with Asst. Surg. G. A. Wheeler in local charge.

The investigation includes seven cotton-mill villages, of which four are in Spartanburg County, two in Oconee County, and one in Chester County. About 850 family schedules have been obtained. Wherever practicable the family store accounts were also obtained. This study will be continued during the next fiscal year. It is anticipated that valuable data will be obtained relating to such factors as annual family income, availability of food supply, seasonal variation in food supply, and the relation of these to pellagra incidence.

SPECIAL STUDIES OF PELLAGRA AT SPARTANBURG, S. C.

The special studies of pellagra have been continued at the service hospital and laboratory at Spartanburg, S. C. The work there has been more extensive and intensive than during the previous fiscal year, but has been carried out along the same general clinical and laboratory lines. The personnel of the station has been 1 passed assistant surgeon (medical officer in charge), 2 assistant surgeons, 1 pharmacist, 3 clerks, 1 biochemist, 2 assistant biochemists, 1 organic chemist, 1 food analyst, 1 dietitian, 1 field nurse, 6 hospital nurses, and 12 attendants.

The laboratory work has been under the immediate supervision of Prof. Carl Voegtlin, while the clinical work has been under the direction of Passed Asst. Surg. R. M. Grimm, who has also been in administrative charge of the station.

Clinical work. The clinical work at the station has consisted of the treatment and observation of hospital and outpatients at the hospital building, and of a limited number of special patients at their homes in and around Spartanburg. During the year a large number of persons have applied at the hospital for examination and advice, and a number of consultations at the request of the local physicians have been granted.

The treatment of the hospital patients has consisted almost exclusively in the administration of well-selected diets. A few drugs have been used from time to time for minor complications, but none have been administered consistently as part of the treatment for pellagra.

On July 1, 1915, there were 31 patients under treatment; 120 were admitted during the year, 9 of whom were readmitted; a total, therefore, of 151 received treatment for a period of 8,969 days. Of these, 94 were discharged improved, 23 discharged unimproved, and 3 died. Thirty-one remained under treatment June 30, 1916.1

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1 It is to be noted that a number of those classified as discharged improved presented on discharge no active or residual symptoms of pellagra; but on account of the uncertain nature of the disease the more conservative term 'improved" has been employed instead of the words recovered" or cured."

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 improved1 (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. Routine clinical laboratory examinations have also been made.

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 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 disease. As 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.

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,

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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