`
`The Prevention of Pellagra: A Test of Diet among Institutional Inmates
`Author(s): Joseph Goldberger, C. H. Waring and David G. Willets
`Source: Public Health Reports (1896-1970), Vol. 30, No. 43 (Oct. 22, 1915), pp. 3117-3131
`Published by: Sage Publications, Inc.
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`Elysium Health Exhibit 1020
`Page 1 of 16
`
`

`

` VOL. 30 OCTOBER 22, 1915 No. 43
`
` MARRIAGE OF TUBERCULOIJS PERSONS.
`
` A JUDICIAL DECISION ANNULLING THE MARRIAGE OF A PERSON WHO CONCEALED
` THE FACT THAT HE WAS SUFFERING FROM TUBERCULOSIS.
`
` The courts have held in a number of inistances that the marriage
` of a person suffering from a venereal disease might be annulled at
` the instance of the other party to the marriage when the existence of
` the disease had been concealed. The Supreme Court of the State of
` New York, in Sobol v. Sobol (p. 3175 of this issue of the Public
` Health Reports) carries this legal principle one step farther.
` The defendant (the husband) had been treated for tuberculosis
` and knew that he was suffering from the disease. He concealed this
` fact from his fiancee, and explained certain svmptoms by saying that
` he was suffering from a cold. After the marriage his wife discovered
` the nature of his illness and brought suit to annul the marriage.
` No issue resulted from the union.
` The court decided that, in view of the possible serious conisequences
` of such a marriage to the wife, to the children if any should be bornl,
` and to the community, the marriage contract should be annulled.
` The legal basis of the decision was the fraud of the defendant in
` concealing and misrepresenting the condition of his health.
`
` THE PREVENTION OF PELLAGRA.
`
` A TEST OF DIET AMONG INSTITUTIONAL INMATES.
`
` By JoEPII GOLDBERGER, surgeon; C. H. WARING, assistant surgeon, and DAVID G. WILLETS, assistant
` epidemiologist, UnIted States Public Health Service.
`
` INTRODUCTION.
`
` (By GOLDBERGER.)
`
` In a paper published June 26, 1914, attention was called to certain
` epidemiological observations relating to pellagra which appeared
` inexplicable on any theory of communicability. These observations
` showed that, at certain institutions at which pellagra was either
` epidemic or had long been endemic among the inmates, the nurse3
` 213 (3117)
`
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`
`Elysium Health Exhibit 1020
`Page 2 of 16
`
`

`

` October 22, 1915 3118
`
` and attendants, drawn from the class economically and socially
` identical with that miiost afflicted in the population at large, appeared
` uniformly to be immune, although living in the same environment
` and under the same conditions as did the inmates. Neither " contact "
` nor insect transmission seemed capable of explaining such a phe-
` nomenon. It was suggested that the explanation was to be found
` in a difference, which was believed to exist, in the diet of the two
` groups of residents.
` From a study of the dietaries of certain institutions in which
` pellagra prevailed the impression has been gained that cereals and vege-
` tables formed a much greater proportion in them than they did in the
` dietaries of well-to-do people; that is, people who as a class are
` practically exempt from pellagra. It was suggested, therefore, that
` it might be well to attempt to prevent the disease by reducing the
` cereals, vegetables, and canned foods and increasing the fresh animal
` foods, such as fresh meats, eggs, and milk; in other words, by pro-
` viding those subject to pellagra with a diet such as that enjoyed by
` well-to-do people, who as a group are practically free from the disease.
` In planning the field studies for 1914 it was proposed, with the
` approval of the bureau and the department, to put this suggestion
` to a practical test.
` In accordance with the original plan to carry on the test for at
` least two years, the experiment is still in progress. The results so
` far recorded are so striking, however, and of such profound practical
` importance that they are reported at this time.
` In planning the test of the preventive value of diet it was decided
` to take advantage of the universally recognized fact that "normally"
` pellagra tends to recur in the individual from year to year.
` In order to obtain significant and perhaps decisive results, it was
` decided to submit to the test as large a number of individuals as
` possible at some institution where the disease was endemic. After
` some search an orphanage with a high incidence of pellagra among its
` residents was found at Jackson, Miss.
` As a preliminary, a study was miade of the epidemiology of the dis-
` ease at this institution, and the singular fact was very quickly discov-
` ered that the disease was practically exclusively confined to those
` between 6 and 12 years of age. After a detailed inquiry the only
` explanation that couild be found for the remarkable restriction of the
` disease to this group was a difference in the diet of the resident
` grouips.
` In the diet of the affected group, as contrasted with that of the
` exempt groups, there was noted a disproportionately small amount
` of lean meat or other animal protein food, so that the vegetable com-
` ponent, in which biscuits (wheat flour), grits, meal (corn), and sirup
`
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`
`Elysium Health Exhibit 1020
`Page 3 of 16
`
`

`

` 3119 October 22, 1915
`
` were prominent and legumes relatively inconspicuous, formed a dis-
` proportionately large part of the ration. Inquiry at other institu-
` tions developed analogous conditions, and as a whole the findings,
` in the light of the recent advances in our knowledge of beriberi, very
` strongly suggested the idea that the disease was dependent upon a
` diet that was for some reason faulty and that this fault was in some
` way either prevented or corrected by including in the diet larger pro-
` portions of the fresh animal protein foods. These findings not only
` confirmed the writer's previous tentative deductions but helped in
` defining these deductions more clearly, and moreover made it possible
` more definitely to formulate plans, which were temporarily broad-
` ened to include a test of diet in the treatment as well as in the pre-
` vention of the disease.
` At the suggestion of the writer, Dr. W. F. Lorenz, special expert,
` Utnited States Public Health Service, who was at that time studying
` the psychiatric manifestations of pellagra at the Georgia State Sani-
` tarium, treated a series of 27 cases in the insane at that asylum exclu-
` sively by diet. Considering the class of cases with which he was
` (lealing, his results, as well as those of Dr. D. G. Willets, who for a
` time continued the work begun by Lorenz, were notably favorable.
` When the various recent methods of treatment, each warmly advo-
` cated by its author, are critically reviewed in the light of the test
` made by Lorenz and by Willets, one can not fail to be struck by the
` fact that the one thing they all appear to have in common is the so-
` called "nutritious" diet, and it is difficult to escape the conclusion
` that it is to this single common factor that the marked success, that
` is usually claimed for the "treatment" should properly be assigned.
` It is of much interest to note that fully 50 years ago Roussel (Rous-
` sel 1866, pp. 529-530), on the basis of long experience and from a
` critical review of the literature of his day, came to precisely the same
` conclusion. This is so much to the point that it is quoted herewith:
` "Without dietetic measures all remediesfail.' * * * when drugs
` and good food are simultaneously employed it is to the latter that the
` curative action belongs, the former exercises simply an adjuvant
` action and is without proved efficacy except against secondary changes
` or accidental complications."
` Important as the treatment of the individual case may be, it
` seemed to the writers of much more fundamental importance to
` apply their resources to the problem of prevention. Arrangements
` were therefore made to extend the preventive study to a second
` orphanage and later to two groups of insane at the Georgia State
` Sanitarium.
`
` I Italics are Roussel's.
`
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`
`Elysium Health Exhibit 1020
`Page 4 of 16
`
`

`

` October 22, 191; 3120
`
` ORPHANAGE STUDY.
`
` (By GoLDwBxam and WAtGa.)
`
` Both the orphanages at which the value of diet in the prevention
` of pellagra has been tested are located in Jackson, Miss.
` The first of these to be considered will be spoken of as orphange
` "M. J." Cases of pellagra have been recognized at this institution
` every spring for several years. During the spring and summer of
` 1914, up to September 15, 79 cases of the disease were observed in
` children at this orphanage. Although several of these were known
` to have had pellagra on admission or had developed it a short time
` after admission, a number appeared to have developed the disease
` for the first time after considerable periods of residence at this
` institution. The factor or factors causing pellagra and favoring its
` recurrence seemed, therefore, to be operative at this -orphanage.
` The second of the orphanages, which will be referred to as orphan-
` age "B. J.," is located about half a mile east of orphanage "M. J."
` Here, as at "M. J.," cases of pellagra have been recognized every
` spring for several years. The writers are informed by the superin-
` tendent that a condition which he can not distinguish from that now
` called pellagra has occurred every year among the children ever
` since his connection with the institution, a matter of some 12 to 13
` years. From his description it is believed that there can be but
` little doubt that pellagra has prevailed at this institution almost, if
` not quite, since its foundation in 1897.
` During the spring and summer of 1914, up to September 15,
` there were observed among the children at this institution 130 cases
` of pellagra. As at "M. J.," some of these were in recent admissions;
` a large proportion, however, occurred in long-time residents.
` There appears to be little if any reason to doubt that the factor
` or factors causing the disease and favoring its recurrence have been
` operative at this institution for many years.
` At both institutions the hygienic and sanitary conditions found
` left much to be desired. Both were much overcrowded.
` The drinking water at each is drawn from the public supply.
` One is equipped with a water carriage sewerage system connected
` with that of the city; the other has the unscreened surfaceprivy
` type of sewage disposal and, incidentally, we found here a great deal
` of soil pollution.
` At the very outset it was requested that no change be made in
` hygienic and sanitary conditions, and it is believed that these have
` remained as they were found and as they have been for several years.
` Since about the middle of September, 1914, the diet at both
` orphanages has in certain respects been supplemented by the Public
`
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`
`Elysium Health Exhibit 1020
`Page 5 of 16
`
`

`

` 3121 October 22, 1915
`
` Health Service. At both institutions a very decided increase was
` made in the proportion of the fresh animal and of the leguminous
` protein foods.
` The milk supply was greatly increased. Provision was made to
` give every child under 12 years a cup of about 7 ounces of milk at
` least twice a day. Those under 6 years had it three times a day.
` Until the spring of 1915 the milk used was all fresh sweet milk. In
` April of this year buttermilk was added to the diet. This was served
` at first only on alternate days to those over 12 years of age; later,
` when a sufficient supply became available, it was served daily at the
` niidday meal to all.
` Eggs, except in cooking or for the sick, had previously not entered
` into the regular diet of these children. The writers prescribed at least
` one egg at the morning meal for every child under 12 years of age.
` It had been the custom to serve the children with fresh meat but once
` a week; under the writers' direction it was increased to three or four
` times a week.
` Beans and peas, which had been conspicuous in the diet only during
` the summer and fall, were made an important part of nearly every
` midday meal at all seasons.
` The carbohydrate component of the institution diets was also
` modified. The breakfast cereal was changed from grits to oatmeal,
` partly because it was believed to be an advantage to reduce the corn
` element and in part because it was believed that the oatmeal wvould
` favor the increased consumption of milk. The corn element, though
` much reduced, was not wholly excluded. Corn bread was allowed
` all children once a week and grits to those over 12 years of age once
` or twice a week. Cane sirup or molasses, which it had been customary
` to serve freely at two or three meals each day, was for some weeks
` entirely excluded, and later allowed in small amounts at only three
` or four evening meals a week. The object in this was to reduce the
` proportion of the carbohydrate element. A more detailed idea of the
` character of the diet furnished may be obtained by reference to the
` menus herewith submitted.
`
` Orphanage, M. J.-January 1 to 7, 1915.
`
` BREAKFAST.
`
` All ages:
` Oatmeal, with sugar and milk, biscuit with butter, daily. Frankfurters (boiled), one morning, in
` place of fried bacon or eggs.
` Matrons and "big" boys:
` Fried bacon on six mornings.
` All under 12 years:
` Milk (about 7 ounces) as a beverage, daily; one egg (scrambled, fried, or boiled), six mornings.
`
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`
`Elysium Health Exhibit 1020
`Page 6 of 16
`
`

`

` Otober 22, 1915 3122
`
` DINNER.
`
` January 1: January 4-Continued.
` All- Matrons-
` Vegetable soup (tomatoes, Irish potatoes, Corn bread.
` corn, onions, rice). Hot biscuit.
` Baked sweet potatoes. January 5:
` Corn bread. All-
` Light bread. Vegetable soup, (tomatoes, rice, onions).
` Matrons- Roast beef.
` Biscuit. Baked sweet potatoes.
` January 2: Boiled lima beans.
` All- Light bread.
` Navy beans (boiled). Matrons-
` Baked sweet potatoes. Biscuits, corn bread.
` Light bread. January 6:
` Pie (blackberry, peach). All-
` Matrons- Roast beef.
` Hot biscuit. Boiled navy beans.
` Corn muffins. Baked sweet potatoes.
` January 3: Blackberry pie (five tables).
` All- Stewed pears (three tables).
` Roast beef. Light bread.
` Lima beans (boiled). Matrons-
` Layer cake. Biscuit.
` Matrons- Corn muffins.
` Baked sweet potatoes. January 7:
` Boiled rice custard. All-
` Blackberry preserves. Vegetable soup (tomatoes, rice, onions).
` January 4: Boiled frankfurters.
` All- Boiled lima beans.
` Vegetable soup (tomatoes, rice, onions, Baked sweet potatoes.
` navy beans). Light bread.
` Hash for three tables. Matrons-
` Baked sweet potatoes. Biscuit.
` Boiled navy beans. Corn muffins.
` Light bread.
` N. B.-Children under 6 years of age received about 7 ounces of milk each daily in addition to the above.
`
` SUPPER.
`
` January 1: January 5:
` All- All-
` Stewed prunes or pumpkin. Light bread.
` Light bread. Sirup.
` Over 12- Over 12-
` Boiled grits. Boiled grits.
` January 2: Fried fresh pork.
` All- January 6:
` Sirup. All-
` Light bread. Light bread.
` Over 12- Stewed apples.
` Boiled rice. Over 12-
` Fried bacon. Beef hash.
` January 3: Boiled rice.
` All- January 7:
` Cakes. All-
` Light bread. Light bread.
` Milk. Sirup.
` January 4: Milk.
` All- Over 12-
` Stewed apples. Fried bacon.
` Light bread. Boiled rice.
` Over 12-
` Fried bacon.
` Boiled rice.
` N. B.-All tulder 12 years received about 7 ounces of milk daily in addition to the bread and stewed
` fruit or sirup. The matrons and teachers were served with hot biscuits daily in addition to the other
` articles noted.
`
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`
`Elysium Health Exhibit 1020
`Page 7 of 16
`
`

`

` 3123 October 22, 1915
`
` Results.
`
` Orphanage "M. J."-Of the 79 cases of pellagra observed at
` "M. J." during the spring and summer of 1914, not less than 67 com-
` pleted at least the anniversary date of their attacks under the obser-
` vation of the writers. Of these not less than 9 have had at least 2
` annual attacks. In none of the 67, following the change in diet, has
` there been observed so far this year any recognizable evidence of a
` recurrence, nor have the writers been able to detect any evidence
` justifying a diagnosis of pellagra in any of the nonpellagrin residents,
` niumbering 99 children and adults, who have been continuously
` under observation for at least one year. In other words, barring,
` recent admissions, there has been no pellagra at this institution this
` year.
` Orphanage "B. J."-Of the 130 cases of pellagra observed in
` the children at "B. J." during the summer of 1914, not less than
` 105 have completed at least the anniversary date of last year's at-
` tack under the writers' observation. Not less than 14 of these have
` histories of at least 2 successive annual attacks. In only 1 of these
` 105 pellagrins, following the above change in diet, has there, so far
` this year, been recognized evidence justifying the diagnosis cf a
` recurrenc3,.
` Of the residents of this orphanage that did not present any definite
` evidence of pellagra in 1914, 69 have remained continuously under
` observation for at least a year; none has thus far developed recog-
` nizable evidence of the disease this year. Recent admissions aside,
` there has been but one case of pellagra at this institution this year.
`
` ASYLUM STUDY.
`
` (By GOLDBERGER and WILLETS.)
`
` Through the courtesy and with the very helpful cooperation of the
` board of trustees, superintendent, clinical director, and staff of the
` Georgia State Sanitarium, two wards were turned over to the writers
` for a test of the value of diet in the prevention of pellagra. To this
` asylum, the largest in the South, there are admitted annually a con-
` siderable number of cases of pellagra. Besides this, cases of insti-
` tutional origin are of frequent occurrence. This asylum must,
` therefore, be regarded as an endemic focus of the disease.
` Of the two wards placed at our disposal one is in the colored and
` the other in the white female service; the former was organized in
` October, the latter in December, 1914.
` Each ward has a capacity of about 50 beds. To each there were
` admitted about 40 adult pellagrins who had had attacks at one time
` or another during 1914. In organizing the wards and selecting our
` patients the list of female pellagrins that at that time were known to
` have had attacks in 1914 was practically exhausted. In selecting
`
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`
`Elysium Health Exhibit 1020
`Page 8 of 16
`
`

`

` October 22, 1915 3124
`
` the patients only one condition was observed, namely, that the pa-
` tient should, if possible, be of such a mental type as would give the
` highest degree of probability of remaining under observation for at
` least a year. In consequence a very considerable proportion of
` them were of a much deteriorated, untidy class. There were, never-
` theless, unavoidably included several in whom the mental condition
` improved to such a degree that we felt obliged to permit them to gc,
` when a request for their discharge was made. Not all, therefore, of
` our original patients remained under observation long enough to be
` included in the present discussion.
` Very few of the patients presenited active symptoms on admission
` to the writers' wards, the object so far as this test was concerned
` being not a study of the treatment of active symptoms but the pre-
` vention of recurrences. A very considerable number of the patients,
` however, presented marked residuals of a recent attack. Many of the
` colored patients had been dieted by either Dr. Lorenz or Dr. Willets
` during the acute stage of their attacks in the same ward prior to its
` organization for the purpose under consideration. A number of the
` white females had been dieted during the acute stage by Dr. Y. A.
` Lyttle, of the asylum staff, and formed part of a series reported on by
` him at the meeting of the Southern Medical Association in November,
` 1914. The writers are especially indebted to Dr. Lyttle for his
` courtesy in subordinating his own study and turning these patients
` over to them.
` The diet furnished the inmates of these two wards was prescribed
` by the writers, and instructions were given to the nurses to give more
` than ordinary care in supervising the feeding. As at the orphanages,
` a decided increase was nmade in the animal and leguminous protein
` foods. A cup of sweetr milk, about 7 ounces, is furnished each
` patient for breakfast and one of buttermilk at both dinner and
` supper. About half a pound of fresh beef and 2 to 21 ounces of dried
` field peas or dried beans enter into the daily ration. Oatmeal has
` almost enitirely replaced grits as the breakfast cereal; sirup has been
` entirely excluded. Corn products, though greatly reduced, have not
` been entirely eliminated.
` The meenu that follows will serve to give a, more detailed idea of the
` character of the diet furnished.
`
` Weekly menu for Ward 23.
`
` MONDAY.
`
` BREAKFAST.-Grits, sweet milk, sugar, broiled steak, hot rolls, biscuits, coffee.
` DINNsER.-Roast beef, gravy, peas, potatoes, rice, biscuits, buttermilk.
` SUPPER.-Stewed apples, light bread, coffee, buttermill-, sugar.
`
` TUESDAY.
`
` BREAKFAST.-Oatmeal, sweet milk, sugar, Hamburg steak, biscuits, hot rolls, cofree.
` DINNER.-Be.ef stew, potatoes, rice, bread, buttermilk.
` SUPPER.-Baked beans, light bread, coffee, sugar, buttermilk.
`
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`
`Elysium Health Exhibit 1020
`Page 9 of 16
`
`

`

` 3125 October 22, 1915
`
` BREAKFAST.-Oatmeal, sweet milk, sugar, beef hash, hot rolls, biscuits, coffeo.
` DINNER.-Pea soup, corn bread, gravy, potatoes, rice, bread, buttermilk.
` SuPPER.-Stewed prunes, light bread, coffee, sugar, buttermilk.
`
` WEDNESDAY.
`
` BREAKFAST.-Oatmeal, sweet milk, sugar, fried steak, hot rolls, biscuits, coffee.
` DI)IeER.-Beef stew, peas, potatoes, rice, bread, buttermilk.
` SuPPER.-Baked beans, bread, coffee, sugar, buttermilk.
`
` THURSDAY.
`
` FRIDAY.
`
` BREAKFAST.-Oatmeal, sweet milk, sugar, broiled beefsteak, hot rolls, biscuits, coffee.
` DINNER.-Pea SOUIP (puree), roast beef, potatoes, rice, bread, btittermilk.
` SUPPER.-Light bread, coffee, sugar, buttermilk, apples, baked beans.
`
` BREAKFAST.-Oatmeal, sweet milk, sugar, Hamburg steak, hot rolls, biscuits, coffee.
` DINNER.-Beef stew, potatoes, rice, bread, buttermilk.
` SUPPEB.-Bread, baked beans, buttermilk, coffee, sugar.
`
` SATURDAY.
`
` SUNDAY.
`
` BREAKFAST.-Oatmeal, sweet milk, sugar, mackerel, bread, coffee.
` DINNER.-Loaf beef and gravy, peas, potatoes, rice, bread, buttermilk, pudding.
` SUPPER.-Beef hash, bread, sugar, coffee, buttermilk.
` NOTE.-Green vegetables in season at irregular intervals. Milk and eggs, as a special diet, are furnished
` those patients who may require them.
`
` Aside from the change in diet and the increased watchfulness over
` the individual feeding enjoined on the nurses and attendants, no
` change in the habitual routine of the corresponding services was
` made. The patients were permitted and encouraaged to visit the yard
` and take the air as frequently as their physical condition and tho
` weather permitted.
` Results.-Of the pellagrins admitted to the writers' wards at the
` time of their organization, or shortly thereafter that is, not later
` than December 31, 1914-72 (36 colored and 36 white), have remained
` continuously under observation up to October 1, 1915, or remainied
` at least until after the anniversary date of their last year's attack.
` Of the 36 colored patients, 8 have histories of at least 2 amnual
` attacks; of the 36 white patients, 10 have histories of at least 2
` attacks. None of this group of 72 patients has presented recogniz-
` able evidence of a recurrence of pellacra.
`
` Significance.
`
` The significance of the results set forth naturally depends upon
` the rate of recurrence that may properly have been expected to occur
` in the groups studied under "normal" conditions; that is, without
` interference of any kind.
` The ideal form of the experiment would have been, of course, to
` retain for purpose of comparison a control group at each of the insti-
` tutions. This was impracticable at the orphanages. In estimating
` the significance of the results of the orphanage study, the writers are
` therefore obliged to depend on general observations and on experience
`
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`
`Elysium Health Exhibit 1020
`Page 10 of 16
`
`

`

` October 22, 1915 3126
`
` at other similar institutions. Satisfactory observations on the rate
` of recurrence either in children or adults are, so far as the writers are
` aware, not available in the accessible literature. There are to be
` found for the most part simply general statements that the disease
` tends as a rule to recur from year to year. Fortunately, Dr. H. W.
` Rice, of Columbia, S. C., has very kindly given a copy of his records
` of the cases of pellagra observed by him in children at anorphanage
` to which he has been attending physician. These records show that
` of 31 children who had pellagra in 1912, 18, or 58 per cent, had recur-
` rences in 1913; of the 21 who had it in 1913, 16, or 76 per cent, had
` it in 1914; and of 75 who had the disease in 1914, 56, or 75 per cent,
` had it again in 1915. The rate of recurrence in children at this insti-
` tution seems to have varied, therefore, between 58 per cent and 76
` per cent. These very valuable data enable one to form a definite
` conception of the frequency of recurrence that one might expect from
` year to year in children at such institutions as those at which the
` writers have worked.
` Taking 50 per cent, a rate somewhat lower than the lowest of the
` above rates, as being fairly and cojnservatively representative and
` applying it to the orphanages at Jackson, it is found that 33 recur-
` rences at "M. J." and 52 at "B. J." might reasonably have been
` expected this year, whereas, as already stated; there actually was
` none observed at the former and only one at the latter institution.
` Although not specifically so planned, conditions at the Georgia
` State Sanitarium have been such as to give a control group of pella-
` grins in both the colored and the white female service. This permits
` the makiiig of a direct comparison of the results observed in the
` writers' wards with those in other wards of the corresponding services
` at this institution.
` The control group of colored female pellagrins of 1914 consists of
` 17 who have remained under observation for a period comparable to
` that of the group on the special diet. Of these, 9, or 53 per cent,
` have already presented recurrences.
` The control group of white female pellagrins of 1914 consists of
` 15 individuals. Of these, 6, or 40 per cent, have had recurrences
` this year. Combined, the two control groups have thus far pre-
` sented an average of 47 per cent of recurrences. Besides the recur-
` rence rates in these control groups, the rates of recurrence in previous
` years in these services have been determined from a study of the
` records. It is found that in the colored female service the average
` rate for the four years 1911, 1912, 1913, and 1914 has been 52.5
` per cent, the rate in different years having varied from 40 to 70 per
` cent. In the white female service the average recurrence rate for
` the same period has been 37.5 per cent, the rate having varied between
` 22 and 48 per cent.
`
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`

` 3127 i October 22, 1915
`
` It must be quite evident, therefore, that on the basis of any of the
` foregoing rates a considerable number of recurrences in the groups of
` insane pellagrins subsisting on the modified diet might reasonably
` have been expected. On the basis of the average recurrence rate,
` 47 per cent, observed this year in the control groups, we might have
` expected some 34 recurrences, or on the basis of the average rate,
` 37.5 per cent, for four years, for the white female service, a rate lower
` than the average for the colored female service, we might have
` expected some 20 to 27 recurrences. As already stated, however,
` none has actually been observed.
` Vieowing the foregoing results as a whole, bearing in mind that
` three different institutions in two widely separated localities are
` involved, each institution beimg an endemic focus of the disease,
` and bearing in mind, also, that the number of individuals considered
` is fairly large, it seems to the writers that the conclusion is justified
` that pellagra recurrences may be prevented and, in view of the con-
` ditions of the test, that they may be prevented without the inter-
` vention of any other factor than diet.
` In this connection the question arises whether the conclusion is
` justified that the development of pellagra, apart from its recurrenice,
` may be prevented by diet. The character of the answer to the
` question will depend on the view held as to the nature of the pellagra
` recurrence.
` Among the epidemiologic features of pellagra none is more striking
` than the tendency for the disease not only to develop in the spring
` or early summer, but to recur year after year at about the same season.
` Various explanations of this singular phenomenon have been advanced.
` According to Sambon (1910, p. 49), "this peculiar periodicitv of
` symptoms can be explained only by the agency of a parasitic organism
` presenting definite alternating periods of latency and activity." A
` somewhat similar conception appears to be held by the workers of the
` Thompson-MacFadden Commission (Siler, Garrison, and MacNeal,
` 1914c), who distinguish between conditions favorable for the develop-
` ment of the disease, in the first place, and those that permit its subse-
` quent recurrence. Why Sambon and many other observers should
` consider this periodicity of symptoms as explicable only by the
` agency of a parasitic organism or of a virus or a toxin presenting
` definite alternating periods of latency and activity is rather hard to
` understand when it is recalled that in endemic scurvy' and particu-
` larly in endemic beriberi, diseases of well-known dietary origin, a
` strikingly similar periodicity is present. The following description
` of the clinical course of beriberi taken from Scheube (1903, pp. 199 to
` 200) well illustrates this point: "After developing the disease"
`
` 1 Lind, 1772, pp. 33, 84, 130, 306.
`
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` October 22, 1915 3128
`
` [beriberi], says Scheube, "the condition'of the patient may remain
` the same for months. Then, especiaRly on the appearance of the cold
` season, improvement sets in and recovery ensues. The predisposi-
` tion is not extinguished by recovery from the disease; on the other
` hand, he who has once had beriberi is 'apt to be attacked again. The
` relapses are sometimes milder, sometimes more severe than the initial'
` attack, and are repeated every year for shorter or longer periods,
` sometimes, 10, 20, or even 30 years. Sometimes the disease remains
` absent for one or several years, and then appears anew. Occasion-
` ally two or even three attacks occur during the co