®SAGE
`
`A Study of the Treatment and Prevention of Pellagra. Experiments Showing the Value of
`
`Fresh Meat and of Milk, the Therapeutic Failure of Gelatin, and the Preventive Failure of
`
`Butter and of Cod—Liver Oil
`
`Author(s): .Toseph Goldberger and W. F. Tanner
`Source: Public Health Reports (1896-1970), Vol. 39, No. 3 (.Tan. 18, 1924), pp. 87—107
`
`Published by: Sage Publications, Inc.
`Stable URL: http://www.jstor.org/stable/4577015
`Accessed: 16—05—2017 17:13 UTC
`
`JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted
`
`digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about
`
`JSTOR, please contact support@jstor.org.
`
`Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at
`
`http://ab0ut.j stor.0rg/terms
`
`Sage Publications, Inc. is collaborating with J STOR to digitize, preserve and extend access to Public Health
`Reports (1896-1970)
`
`
`
`Elysium Health Exhibit 1006
`This content downloaded from 38.111.59.10 on Tue, 16 May 2017 17:13:59 UTC
`P
`1
`f
`All use subject to http://about.jstor.org/tenns
`
`age
`
`0
`
`Elysium Health Exhibit 1006
`Page 1 of 22
`
`

`

`PUBLIC HEALTH REPORT
`
`
`No. 3
`JANUARY 18, 1924
`VOL. 39
`
`A STUDY OF THE TREATMENT AND PREVENTION OF
`PELLAGRA.
`
`Experiments Showing the Value of Fresh Meat and of Milk, the Therapeutic Failure
`of Gelatin, and the Preventive Failure of Butter and of Cod-Liver Oil.
`
`By JOSEPH GOLDBERGER, Surgeon, and W. F. TANNER, Surgeon, United States Public Health
`Service.
`
`It will be recalled that a preventive feeding experiment begun in
`1914 by Goldberger, Waring, and Willets, and carried out among
`institutional inmates, resulted in demonstrating the complete pre—
`ventability of pellagra by means of diet (1). The test was of such
`a character, however, that it did not in itself reveal what food or
`foods were to be credited with the favorable result. At most it sug-
`gested that the fresh meat and milk of the diet were concerned in
`bringing about the protective effect. This indication was strength.-
`ened by the results of a study of the relation of diet to pellagra inci-
`dence among households of certain South Carolina cotton mill vil-
`lages (2).
`In this study it was found not only that pellagra occurred
`less frequently or not at all in households having a daily minimum
`average supply of approximately a pint of milk or of 30 grams of
`fresh meat per adult unit, but also that an increasing supply of each
`of these foods independently of the other was definitely associated
`with a decreasing pellagra incidence. These indications of
`the
`presence in both meat and milk of the essential pellagra preventive
`factor or factors gain additional support from a further study of
`these foods, the results of which study, with certain incidental obser-
`vations, we desire to report at this time.
`
`FRESH MEAT.
`
`Our study of the value of fresh meat apart from milk or other
`animal protein food has been limited to its use as a therapeutic agent
`in the treatment of active cases of the disease at the Georgia State
`Sanitarium. We have, up to the present time, not attempted to test
`its value prophylactically.
`Eight well—marked, though not very severe (mainly dermal), cases
`have so far been treated with fresh beef as the only known thera—
`peutic element in the diet. The meat was lean round steak. Seven
`ounces (200 grams) of this meat, chopped fine, seasoned with salt,
`
`76091°~24
`l
`(87)
`
`Elysium Health Exhibit 1006
`This content downloaded from 38.111.59.10 on Tue, 16 May 2017 17:13:59 U C
`All use subject to http://about.jstor.org/terms
`Page 2 of 22
`
`Elysium Health Exhibit 1006
`Page 2 of 22
`
`

`

`January 18, 1924.
`
`and baked in its own juice, was offered daily as a supplement to the
`diet which the patient had been receiving when the attack developed
`(which diet already included a small amount of meat) or, in the case
`of newly admitted patients, as an addition to a diet approximating
`that which it is believed they had had before admission and of a type
`in association with which intramural cases had been observed to
`
`develop.
`The following is a summary of the significant clinical features of
`these cases:
`
`Case 1.‘ A 16-year—old colored girl who was admitted to the sani-
`tarium July 21, 1922.
`I’ellagra was diagnosed August 14, 1922.
`There was no history of a previous attack.
`She came under our ob—
`servation August 19, 1922, at which time she presented characteristic
`dermal lesions on the back of the hands, sides of the neck, and over
`the inner malleolus of the left foot. The bowels tended to slight over—
`activity.
`She was confused and delirious.
`Treatment with the beef diet shown in Table I was begun on August
`19, 1922. This she ate well from the first. Within two weeks im-
`provement began to be perceptible, and thereafter continued progres—
`sively. By October 26, except for some residual marks of the derma-
`titis, she presented no recognizable evidence of pellagra. Between
`August 21 and December 31-the end of the period of treatment——
`her weight increased from 34.5 to 44 kilos.
`Case 2: A white woman, 37 years old, who was admitted to the
`sanitarium May 6, 1922, with active pellagra, came under our 0b-
`scrvation on the same date. She presented a rather severe derma-
`titis of the hands and lower part of the forearms, and considerable
`keratosis of the forehead and bridge of the nose. The bowels were
`slightly loose. There was marked mutism.
`She was weak and in
`bed.
`After three days on the mineral—and—vitamine—enriched ward diet
`shown in Table II, treatment was started with the beef diet shown
`in Table III. On May 12 the mineral and vitamine supplements
`were discontinued, making her diet as shown in Table IV. Her ap—
`petite, at first only fair, soon improved, and she ate more and more
`of the food offered her. By May 17 her condition showed a well-
`marked change for the better, but she continued as mute as when
`she came under our observation. By the end of the month, how—
`ever, she was respondinor to simple questions and was up and about.
`In another two weeks her skin lesions had entirely cleared up, and
`by the end of June her mental condition shOWed marked improve—
`ment. During this period of eight Weeks she gained approximately
`5 kilos in weight.
`She left the institution on furlough September 8,
`1922.
`like case 1, showed very clear evidence of prompt
`This patient,
`and marked improvement on 200 grams of beef, although the diets
`(Table I and Table IV) otherwise were relatively low (as compared
`with the diet shown in Table II) in minerals and known vitamines.
`
`The preceding were patients who had pellagra on admission to
`the sanitarium. Those next to be considered developed the recur-
`rences for which they were treated while inmates of the institution,
`
`CElysium Health Exhibit 1006
`This content downloaded from 38.111.59.10 on Tue, 16 May 2017 17:13:59 U
`All use subject to http://about.jstor.org/terms
`Page 3 of 22
`
`Elysium Health Exhibit 1006
`Page 3 of 22
`
`

`

`89
`
`January 18, 1924.
`
`and in spite of having subsisted for periods of not less than about
`two and one-half months on the mineral—and—vitamine-enriched diet
`shown in Table II.
`
`Case 3: A white woman 40 years old who had pellagra in July,
`1921. About March 15, 1922, a mild pellagrous erythema, marking
`the beginning of a recurrence, made its appearance. This was ac-
`companied by a slight stomatitis and was soon follOWed by some loose-
`ness of the bowels.
`On April 7 treatment with a gelatin diet (Table V) was begun,
`but this was taken so poorly that on April 13 a change was made to
`the beef diet shown in Table VI. One week later the allowance of
`meat was reduced to the standard 200 grams by discontinuing the
`ortion allowed by the institution, leaving the diet as shown in Table
`II. The appetite of this patient continued poor to the end of the
`month, but she relished the meat, of which she ate practically all
`that was offered. During May her appetite improved. On May 12
`the mineral mixture and the supplementary vitam’ine—rich foods were
`discontinued, leaving the diet as shown in Table IV. Her appetite
`continued to improve so that by the beginning of June she was eat-
`ing practically all the food offered.
`By about the middle of May all evidence of the dermatitis and
`gastrointestinal disturbance had cleared up. Her general ap ear-
`ance had very definitely improved. Her weight, which had een
`tending downward, began to go up after the beef treatment was in-
`stituted; between April 11 and July 4 it increased from 35.2 to 42.2
`kilos.
`
`Thus the change in diet on April 13, consisting of an increase in
`the fresh meat, was followed by improvement in her general appear—
`ance, by clearing up of the skin lesions, of the stomatitis, and of the
`bowel disturbance, and by a gain in appetite and weight.
`It is
`worthy of note that this improvement continued in s ite of the re—
`duction in minerals and Vitamines resulting from the orange on May
`12 from the diet shown in Table III to that shown in Table IV.
`Jase 4: A white woman 34 years old who had pellagra in 1913
`and recurrences in 1914, 1920, 1921, and 1922. The recurrence in
`1922 began about March 29 with the appearance of an erythema on
`the hands and neck and some looseness of the bowels.
`Treatment was begun on April 7, and, as in case 3, with the gela-
`tin diet shown in Table V. Unlike case 3,
`this patient’s a petite
`was good; she ate this diet well. The skin lesions passed t rough
`the normal cycle of changes so that they had quite cleared up by
`about April 19. The bowels, however, continued loose, and about
`May 10 a slight stomatitis was observed to have appeared.
`On May 13 the daily offering of gelatin was increased, the allowance
`of cod—liver oil reduced, and that of tomatoes slightly increased, so
`that the diet became as shown in Table VII. She continued to eat
`well; nevertheless, about 10 days later—~that
`is, about May 24—~a
`fresh dermatitis appeared on the hands and forearms. Her bOWels
`continuing loose, it was thought that it might be advantageous to
`replace the cod—liver oil with butter. This was done on May 27, the
`diet thereafter having the composition shown in Table VIII. Her
`appetite and food consumption continued excellent
`in spite of a
`slight stomatitis.
`
`CElysium Health Exhibit 1006
`This content downloaded from 38.111.59.10 on Tue, 16 May 2017 17:13:59 U
`All use subject to http://about.jstor.org/terms
`Page 4 of 22
`
`Elysium Health Exhibit 1006
`Page 4 of 22
`
`

`

`January 18, 1924.
`
`90
`
`ateh appeared on the neck; on
`On June 9 a pellagrous dermal
`ave developed about the knees;
`June 29 an erythema was found to
`and on July 5 the skin on the back of the feet was found to be affected.
`Since the relapsing dermal lesions seemed to indicate a failure of
`gelatin to favorably influence the progress of the disease, a change
`was made on July 7 to the beef diet shown in Table IX. Within a
`month after this change the patient’s condition had definitely im-
`proved. By the end of the first week of August she no longer pre-
`sented evidence of the attack except, possibly, that her bOWel actions
`were soft. She continued to improve in general appearance and
`strength during a further period of observation ending, January 2,
`1923, although her bowels continued to act
`irregularly. A fecal
`examination on October 12 revealed Ascaris ova, whipworm ova, and
`Strongyloides embryos which, in part, at least, probably explained the
`loose and irregular bowels. U to about the middle of October this
`patient’s weight was maintaine at a level of between 41 and 42 kilos.
`After this it went up, so that by January 2, 1923 (the end of the period
`of treatment), she had gained 4.5 kilos.
`In summary it appears that during the six months (July 7, 1922,
`to January 2, 1923) following the inauguration of the treatment with
`200 grams of beef (Table IX), this patient’s condition underWent
`definite improvement
`in marked contrast with the unsatisfactory
`progress on the gelatin (and mineral—and—vitamine-enriched) diet
`(Tables V, VII, and VIII) during the immediately preceding/period
`of three months.
`Case 5: A white woman 46 years old who had pellagra in 1913 and
`recurrence in 1914, 1918, 1921, and 1922.
`The recurrence in 1922 began to develop about March 29 with the
`appearance of an erythema on the hands and forearms.
`Treatment with a gelatin diet (Table V) was begun April 7, but
`this was taken so poorl
`that on April 13 a change was made to the
`beef supplemented war diet (Table VI).
`A week later the beef was reduced to 200 grams by omitting the
`institution portion (Table III), and on May 12 the mineral mixture
`and supplement of certain vitamine—rich foods were discontinued, so
`that thereafter the diet was as shown in Table IV.
`She took the meat quite well, but her appetite for the remaining
`portion of her diet continued poor through April and May. During
`June her food intake became much improved. Up to April 13 her
`weight had tended downward; after this, this trend was arrested and,
`if anything, turned in an upward directlon. Between April 13 and
`July 4 her weight showed but slight change—a rise from 45.8 to 47.2
`kilos.
`Within a month after be inning the beef, the dermatitis had cleared
`up, and during the remainc er of the period of treatment, ending July
`6, 1922,
`the patient remained free from recognizable ev1dence of
`pellagra.
`I
`Case 6‘: A white woman 52 years old who had pellagra in 1914 and
`recurrence in 1918, 1921, and 1922.
`The recurrence of 1922 began between March 29 and April 5 with the
`appearance of a dermatitis on the hands. Treatment was begun
`April 7 with. a gelatin diet
`(Table V).
`She took this Well. On
`May 13 the gelatin was increased to a daily offering of 85 grams, the
`allowance of cod—liver oil was reduced, and that of canned tomatoes
`
`CElysium Health Exhibit 1006
`This content downloaded from 38.111.59.10 on Tue, 16 May 2017 17:13:59 U
`All use subject to http://about.jstor.org/terms
`Page 5 of 22
`
`Elysium Health Exhibit 1006
`Page 5 of 22
`
`

`

`91
`
`January 18, 1924.
`
`somewhat increased, the resulting diet being that shown in Table VII.
`She continued to eat well, actually consuming a daily average of
`approximately 80 grams of gelatin during the period May 13—31,
`and 79
`rams during the period June 1~26.
`The
`ermatitis which began between March 29 and April 5 and
`which, at its height, involved the hands, forearms, and feet, passed
`through the ordinary cycle of pigmentation, keratosis, and desquama-
`tion,reaching by June 14 the stage where there remained but a residual
`keratotic fringe on the foot.
`Two weeks later, however,
`there
`appeared a fresh erythema on the back of each forearm, and by July
`5 the knuckles and back of the hands were also involved. There was
`present no other recognizable disturbance. Throughout the period
`January 3 to July 5 the weight oscillated between 53.5 and 56.5
`kilos.
`'
`
`roved inadequate to prevent
`The gelatin diet having, as in case 4,
`a relapse of the dermatitis, a change to t e beef treatment (Table IX)
`was made on July 7. She continued to eat well, and by the middle of
`September was free of active pellagra, and so remained to December
`26, the end of the
`eriod of treatment. Between August 1 and De-
`cember 26 her weig t rose from 53.5 kilos to 61.5 kilos.
`Case 7: A white woman 39 years old who had pellagra in 1917 and
`recurrence in 1918, 1921, and 1922.
`The recurrence in 1922 began about April 5 with the appearance of
`an erythema on the right forearm. By May 10 the pellagrous
`dermatitis had affected the hands, forearms, and forehead, and a mild
`stomatitis was present.
`On May 13 treatment was begun with gelatin (Table VII). Her
`appetite being excellent, she consumed practically all of the food
`offered, it being estimated that during the
`eriod May 13 to June 30
`her consumption of gelatin a proximatedp an average of 83 grams
`daily. Notwithstanding this,
`owever, a fresh erythema developed
`during June, slight mental confusion became perceptible, and toward
`the close of this month the bowels developed a slightly increased
`activity. Accordingly, on July 7 the treatment was changed to beef
`(Table IX). Following this change, improvement set
`in, and all
`recognizable evidence of the attack disappeared by about the close of
`Au ust. Up to about the middle of September her weight tended
`slig 1tly downward, but after this time, to the end of the year, she
`maintained her weight with but negligible oscillations.
`There was in this case, therefore, a clearing up of the evidence of a
`recurrent attack of pellagra following upon the inauguration of the
`beef‘treatment, although during the immediately preceding period of
`about eight weeks, on a liberal gelatin diet, the attack had shown a
`tendency to increased severity.
`It is worthy of note, also, that the
`improvement asssociated with the beef diet took place, as in case 4,
`in spite of the reduction in the minerals and known Vitamines coinci—
`dent with the change from the gelatin (Table VII) to the beef diet
`(Table IX).
`Case 8: A white woman 31 years old who had pellagra in 1914: and
`recurrence in 1918, 1920, and 1922.
`The 1922 recurrence began some time between about May 3 and
`May 10 with the appearance of a
`ellagrous dermatitis on the feet.
`Treatment was inaugurated on
`,ay 13 with the gelatin diet shown
`in Table VII. This she ate well. The dermatitis cleared up during
`
`CElysium Health Exhibit 1006
`This content downloaded from 38.111.59.10 on Tue, 16 May 2017 17:13:59 U
`All use subject to http://about.jstor.org/terms
`Page 6 of 22
`
`Elysium Health Exhibit 1006
`Page 6 of 22
`
`

`

`January 18, 1924.
`
`the month, but the bowels, which had been somewhat irregular even
`before the appearance of
`the dermatitis, continued loose. Fecal
`examination made in May showed Trichuris ova, and, in June, some
`Ascaris. She maintained her weight with, perhaps, a slight gain
`during this period. Her condition having seemingly improved on
`the gelatin diet, it was thought that the indication in favor of gelatin
`would be strengthened if the small allowance of beef in the basic diet
`were excluded. This was accordingly done on July 7, at the same
`time compensating for the calories by an increase in the allowance
`of butter (Table X).
`During the period July 7 to July 31 her food consum tion continued
`well nigh complete, so that it
`is estimated that s e ingested an
`average of approximately 83 grams of gelatin daily. Notwith-
`standing this, however, a relapse of the dermatitis on her feet devel-
`oped between July 15 and July 19, which, after subsiding somewhat,
`flared up anew on August 2 and again on August 9. During this
`latter period there was also some falling off in appetite.
`This failure to maintain the seemingly favorable progress noted
`early in July led to a change, on August 18, to the beef diet shown
`in Table IX. The change was followed by a return of appetite, a
`slight change for the better in bowel activity, gain in Weight, and
`clearing up of skin lesions. Between August 22 and December 5
`her Weight increased from 38.5 to 44.5 kilos. On January 7, 1923,
`the close of the period of treatment, this patient presented no recog-
`nizable evidence of her recurrence, unless a persistent though reduced
`irre ularity 0f the bOWels is to be so regarded.
`Tius, as in cases 4, 6, and 7, a liberal daily intake of gelatin
`failed to prevent a relapse of the dermal manifestations of the disease,
`but definite clinical im rovement was noted following the change
`to the treatment with
`eef.
`It is worthy of note,
`too, that this
`improvement took place in spite of the reduction in minerals and
`known vitamines associated with the change from the gelatin
`(Table X) to the beef diet (Table IX).
`
`It is seen, then, that in all eight cases well—marked and progressive
`clinical
`improvement
`followed the inauguration of
`the treatment
`with fresh beef. This is particularly significant
`in the four cases
`(Nos. 4, 6, 7, and 8) in each of which the treatment with beef had
`been preceded by a considerable period of treatment with gelatin
`which, though coupled with a mineral and vitamine enriched basic
`diet, had failed to arrest the progress of the attack. This contrast
`tends to emphasize, on the one hand,
`the inadequacy of gelatin,
`and, on the other, the therapeutic potency of fresh beef.
`Taken by itself, so restricted a therapeutic test can hardly be more
`than suggestive; but when coupled with the available evidence of
`the preventive value of fresh meat,
`it strengthens the indications
`that fresh beef contains the pellagra preventive factor or factors.
`MILK.
`
`Although the available evidence already strongly supported the
`inference that milk, when a generous element in the diet, operated
`
`CElysium Health Exhibit 1006
`This content downloaded from 38.111.59.10 on Tue, 16 May 2017 17:13:59 U
`All use subject to http://about.jstor.org/terms
`Page 7 of 22
`
`Elysium Health Exhibit 1006
`Page 7 of 22
`
`

`

`93
`
`January 18, 1924.
`
`to prevent pellagra, nevertheless it seemed highly desirable to put
`this inference to direct
`test. This was done at the Georgia State
`Sanitarium during 1922.
`In the rural areas of the South, milk is most commonly consumed
`as buttermilk. We therefore chose buttermilk as the form of milk
`
`locally produced, and of fair
`It was fresh,
`to use in this study.
`quality. Analysis of a sample in the division of chemistry of the
`Hygienic Laboratory shOWed it to contain 2.88 per cent of protein
`(Nx 6.38). A daily allowance of approximately 1,200 grams (40
`fluid ounces) of this milk was offered each one of a group of 29 colored
`female inmates of the sanitarium.
`It was Well taken as a beverage
`at each one of the meals. The approximate composition of the diet
`so supplemented is shown in Table XI.
`Of the 29 patients constituting the group, 19 were pellagrins and
`10 nonpellagrins. Of
`the pellagrins, 16 remained in the test for
`one year, to its termination on January 2, 1923. Three dropped out
`and passed from observation after shorter periods (6%, 8, and 10
`months, respectively) by reason of the development of intercurrent
`illness necessitating transfer to other wards. Of the 10 nonpellagrins,
`9 remained throughout, 1 passing from observation on July 22, after
`a period of over 6% months, on account of pulmonary tuberculosis.
`None of the group of 29 patients developed any evidence of pellagra
`at any time during the observation period which, for 16 of the pellag—
`rins and 9 of the nonpellagrins, lasted one year.
`Since our rather extensive experience with this class of patients
`has convinced us that without the buttermilk (or equivalent supple-
`ment) upward of 40 or 50 per cent of the group would with certainty
`have developed pellagra within a period of from three to seven or
`eight months, the complete absence of any indication of the disease
`in any of this group is, in our judgment, conclusive evidence of the
`preventive action of the buttermilk.
`We have here, then, and for the first time, a direct demonstration
`of what heretofore has been an inference from indirect evidence—
`
`namely, that milk contains the essential pellagra preventive factor or
`factors.
`
`DISCUSSION.
`
`In
`The results herein reported are of interest in several respects.
`the first place they emphasize anew the importance of fresh meat and
`milk in the treatment and prevention of pellagra. This does not
`mean, as Hindhede (4) has taken it to mean (in the face of repeated
`warnings to the contrary (5)) that these are the only foods possessing
`pellagra-preventive value. On the contrary, not only is it possible,
`but we think it probable, that other foods will prove equally or even
`more potent. Unfortunately their identity remains to be determined.
`
`CElysium Health Exhibit 1006
`This content downloaded from 38.111.59.10 on Tue, 16 May 2017 17:13:59 U
`All use subject to http://about.jstor.org/terms
`Page 8 of 22
`
`Elysium Health Exhibit 1006
`Page 8 of 22
`
`

`

`January 18, 1924.
`
`Judging by our observation of a very high incidence of the disease
`associated with such diet as that which was supplemented by the
`beef in Tables I, III, IV, VI, and IX, and by the buttermilk in Table
`XI, it would seem as if this basic diet included but insignificant, if
`any, preventive elements. Our results with the beef and milk
`supplements are also of interest, therefore, in that they afford some
`idea of the effective quantity of these foods.
`The determination of the quantity of beef to be used in our study
`was largely arbitrary. We Were guided in a measure by the observa-
`tion that at the sanitarium the allowance of meat which, so far as
`we are able to judge, has in the past been the principal if not the sole
`preventive element in the general diet, has not been adequate to
`prevent all recurrences of the disease. We reasoned that, since the
`vast majority of the inmates seemed to be protected, that is, showed
`no evidence of the disease, this quantity of meat is presumably only
`a little short of being fully adequate.
`It seemed reasonable to assume,
`therefore, that twice this allowance—that is to say, an allowance of
`an equivalent of about 100 grams of round steak-—w0uld suffice to
`prevent all but very exceptional cases. But since for the treatment
`of active cases, particularly recurrences in patients of the dilapidated
`physical and mental type with which we were dealing, a quantity
`in excess of that sufficient for prevention would probably be desirable
`if not necessary, we doubled the quantity we judged might be ade—
`quate for prevention, thus arriving at 200 grams as the quantity to
`be tried in treatment.
`
`While it is possible that for purposes of treatment even larger
`quantities may in exceptional instances be necessary, it seems highly
`probable, if not certain, that for preventive purposes a smaller quan-
`tity will be ample.
`Indeed, the experience at the sanitarium, already
`referred to, suggests that the small quantity allowed as part of the
`general diet of that institution is well—nigh sufficient, and, as has been
`mentioned, we think it probable that not more than about twice this
`allowance—that is, about 100 to 125 grams—would be found entirely
`adequate in all but very exceptional instances.
`In deciding upon the allowance of buttermilk to use in our test
`of this food, we were guided by our experience with it in the treat-
`ment of active cases. We had found that 32 to 40 fluid ounces as a
`supplement to the basic diet did not always seem adequate to arrest
`the progress of symptoms which cleared up following an increase to
`48 ounces.
`It is not certain that even this larger quantity will inva-
`riably suffice to arrest an attack, for in a recent instance, unique in
`our experience, there was a relapse of symptoms following a period
`of apparent improvement in spite of a faithful trial of a milk diet
`containing 32 ounces of fresh whole milk and 24 ounces of butter-
`milk. Since it seemed that, for preventive purposes, a quantity
`
`CElysium Health Exhibit 1006
`This content downloaded from 38.111.59.10 on Tue, 16 May 2017 17:13:59 U
`All use subject to http://about.jstor.org/terms
`Page 9 of 22
`
`Elysium Health Exhibit 1006
`Page 9 of 22
`
`

`

`95
`
`January 18, 1924.
`
`smaller than the maximum needed for treatment would be adequate,
`we decided to try 40 ounces. As has been seen, this proved to be
`adequate in the group studied by us, and it is not improbable that
`a somewhat smaller quantity might have served equally well. Con-
`sidering the restricted basic diet and the type of individual1 with
`which we were dealing, it seems probable that no more than this
`quantity will suffice in all but very exceptional instances.
`In this connection the question arises, How doesfresh whole milk
`compare with buttermilk in potency? We have made no direct com—
`parison. But it is of interest to note that our experience with butter
`as the therapeutic and preventive element in the diet has been very
`disappointing. Although we have tried it repeatedly and in increas-
`ing quantities, the consumption in several recent instances having
`equaled a daily average of approximately 135 to 145 grams of fresh,
`locally produced butter (estimated as representing 100 to 110 grams
`of butterfat) from cows largely pasture fed, for periods of
`from
`three to upwards of five months (the patients weighing between 51
`and 57.5 kilos), it has practically invariably failed to prevent recur-
`rence of the disease. And in passing it may be remarked that the
`results of similar trials with cod—liver oil have been equally disap-
`pointing. Consumed in quantities of 128 grams (that is, in propor—
`tion of over 2 grams per kilo of body weight) daily for periods as long
`as three, four, and five months, no preventive efiect on the recurrence
`of the disease was appreciable. Since it would thus appear that the
`pellagra—preventive factor is not present (in appreciable amount) in
`butter, it is perhaps permissible to infer that whole milk is not ma—
`terially, if at all, more potent than buttermilk.
`So far, then, as the
`treatment and prevention of pellagra (in the specific sense) is con-
`cerned, fresh'milk and buttermilk may be assumed to be quantita-
`tively interchangeable.
`Our experince with meat and with milk has naturally suggested a
`comparison of their value. Unfortunately our data are not of such a
`character as to permit us to form anything more than an impression
`with regard to this question.
`Our experience with these foods has not afforded us entirely com-
`parable quantitative data of their value in treatment, and, as already
`stated, we have not made a direct study of the preventive value of
`meat by itself. Nevertheless, this experience and the rough estimates
`which have already been discussed may be taken as affording at least
`a suggestion of the comparative value of meat and buttermilk. Thus
`we have found 200 grams of lean round steak (42 grams protein) to
`be very efficient in arresting the progress and clearing up the symptoms
`1 It may be well to keep in mind that our observations were on insane pellagrins, many of Whom had
`had repeated attacks of pellagra, in consequence of which their nutritional needs (quantitative) were
`probably relatively higher than the normal.
`
`CElysium Health Exhibit 1006
`This content downloaded from 38.111.59.10 on Tue, 16 May 2017 17:13:59 U
`All use subject to http://about.jstor.org/terms
`Page 10 of 22
`
`Elysium Health Exhibit 1006
`Page 10 of 22
`
`

`

`January 18, 1924.
`
`of an attack. We have had similar though, we have thought, not
`quite so prompt effects from 48 ounces of buttermilk (43 grams
`protein). And we have estimated that approximately 125 grams of
`lean round steak (27 grams protein) would probably be as efficient in
`prevention as the 40 ounces of buttermilk (36 grams protein) were
`found to be. These considerations lead to the suggestion that gram
`for gram, on the basis of protein content, fresh beef is somewhat more
`efficient than buttermilk.
`
`Notwithstanding the possibly greater potency of fresh beef, milk,
`for purposes of treatment at least, must be regarded as the more
`valuable, since, among other reasons, it has the practical advantage
`that it needs no mastication, and can therefore be readily taken by
`patients in whom the condition of the mouth may render mastication
`painful or impossible and can be easily given by tube in cases refusing
`nourishment.
`
`Our study is of interest, finally, as it bears on the problem of the
`identity of the essential preventive dietary factor or factors. Here
`it may be worth recalling that six of the cases treated with fresh beef
`had developed their attacks under our observation in spite of having
`subsisted for periods of not less than about two and one—half months
`on the mineral—and—vitamine-enriched sanitarium diet
`shown in
`
`Table II. These cases formed the principal subject of a previous
`report (3). As was there stated, it would seem as if this diet must
`have yielded an abundance of the known vitamines and minerals,
`thus excluding deficiency of these and leaving the protein (amino
`acid) mixture of the diet, some as yet unrecognized dietary complex
`(possibly a vitamine), or some combination of these, for consideration
`in relation to the development of the disease.
`This interpretation is supported and strengthened so far as con-
`cerns the antiophthalmic and the antirachitic complexes by the
`failure of butter and of cod—liver oil as preventives, and as concerns
`the antineuritic and the antiscorbutic complexes by the therapeutic
`efficiency, particularly under the conditions of our study, of a food
`(muscle tissue of beef) known to be relatively quite poor in these
`factors (9). With respect to protein it may be observed that the fail-
`ure of gelatin in the treatment of the cases in which beef was subse—
`quently tried with markedly beneficial effect, would seem to ind