`
` A
`
` Study of the Relation of Diet to Pellagra Incidence in Seven Textile-Mill Communities of
`South Carolina in 1916
`Author(s): Joseph Goldberger, G. A. Wheeler and Edgar Sydenstricker
`Source: Public Health Reports (1896-1970), Vol. 35, No. 12 (Mar. 19, 1920), pp. 648-713
`Published by: Sage Publications, Inc.
`Stable URL: http://www.jstor.org/stable/4575517
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`Elysium Health Exhibit 1021
`Page 1 of 67
`
`

`

` March 19, 1920. 4:8
`
` A STUDY' OF THE RELATION OF DIET TO PELLAGRA INCI-
` DENCE IN SEVEN TEXTILE-MILL COMMUNiTIES OF SOUTH
` CAROLINA IN 1916.
`
` By JOSEPHt GOLDBERGER, Surgeon; G. A. WHEELER, Passed Assistant Surgeon; and EDGAR SYDEN.
` STRICKFER. Statistician, United States Public Health Service.
`
` J. Introductioii.
` II. Review of the studies of other
` workers.
` III. Plan and method of present study:
` Locality.
` Population.
` Pellagra incidence.
` Criteria of pellagra.
` Onset of attack.
` Assignment of cases to house-
` holds.
` Season.
` Dietary data.
` ITV Oomparison of diets:
` (a) Nonpellagrous v8. pel-
` grous households.
` (b) Nonpellagrous households
` of highest income vs..
` pellagrous households,
` each with at least two
` cases.
` (c) Nonpellagrous households
` of lowest income vs.
` pellagrous households,
` each with at least two
` cases.
`
` V. Relation of pellagra incideiice to
` variations in supply of "animal
` protein " foods.
` Milk.
` Freshl meats.
` Milk or fresh meats.
` Other "animal protein" foxods.
` VJ. Foods of the groups associated i ith
` increased pellagra incidence.
` Corn meal.
` Wheat flour.
` Dried legIuines.
` Other foods.
` VII. Dietary factors.
` Calories.
` Protein.
` Carbohydrate and lat.
` Sourcea of fat supply.
` vitamines.
` Inorganic constituents,
` VIII. Discussion.
` IX. Summary and(l conclusions.
` X. References.
` XI. Appendix.
` Explanation of articles and
` groups of articles of food pre-
` sented in Tables I et seq.
`
` I. INTRODUCTION.
`
` From the earliest history of pellagra a more or less important role
` has been assigned to diet inl its relation to the disease.. This has
` been forcibly expressed by Lavinder (1915): "Ever since Casal's day
` students are convinced that pellagra is associated with a poor diet,
` and volumes of research and arguiments have been offered on the
` subject. The Italianis have donle little more, Roussell somewhat
` sarcastically observed many years ago, than to ring changes on
` Casal's views. Yet they and all others must continue to study the
` relations between poor food and pellagra. For, among all the com-
` plexities and discordant things that surroun(d this disease, this is the
` one outstandingfact 2 that most urgently needs explanation."
` It was fundamentally with the view of finding the explaniation of
` thisfact, current theories being unacceptable, that a series of investi-
` gations of pellagra was begun in the spring of 1914 unider the direction
` of one of the present writers (J. G.).
`
` ' From Field Investigations of Pellagra. I Italics In original.
`
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`
`Elysium Health Exhibit 1021
`Page 2 of 67
`
`

`

` 649 MIarch 19, 1920.
`
` In a paper published June 26, 1914, Goldberger called attention to
` the significance of certain epidemiological observations which showed
` that at some institutions at which pellagra was either epidemic or
` had long been endemic among the inmates the nurses and attendants,
` drawn from the class economically identical with that most affected
` in the population at large, appeared uniformly to be immunie,
` although living in the same environment and under the same conidi-
` tions as did the inmates, and many of them also in frequent and
` intimate contact with cases of the disease. Neither conitact nor
` inseot transmission seemed capable of explaining this remarkable
` exemption of one of the two classes of residents. The suggestioi)
` was made that the explanation was to be found in a difference in
` the diet of the two groups, for it was observed that although the
` nurses and attendants appeared to receive exactly the same food as
` did the inmates, there was, nevertlheless, a difference in the diet of the
` two groups, in that the nurses and attendants, being in a favorable
` position to choose from what was provided, selected the best tor
` themselves. They were also free to supplement the institution diet
` in any manner they pleased. Furthermore, from a stuidy of the
` dietaries of certain institutions in which pellagra prevailed, the
` impression was gained that cereals anid vegetables formed a much
` greater proportion in these than they did in the dietaries of well-to-do
` people, that is, people who, as a class, are practically exempt from
` pellagra. Accordingly, the tentative suggestion was made that the
` prevention of the disease be attempted by improving the dietary of
` those among whom it is most prevalent by reducing the cereal and
` vegetable component and increasing the fresh animal foods (freslh
` meats, eggs, and milk) of the ration.
` The indications on which this suggestion was based were strikingly
` confirmed by other findings. Preliminary to an experimental test
` of the preventability of the disease by diet (Goldberger, Waring,
` and Willets, 1915; Goldberger, 1916) at an orphanage at Jackson,
` Miss., a study of the epidemiology of the disease was made at this
` institution and the singular fact was quickly discovered that the
` disease was practically exclusively confined to those between 6 andl
` 12 years of age. After a detailed inquiry the only significant difier-
` once that suggested itself as an explanation of the exemption of a
` considerable group of inmates unider 6 years and of another over 12
` years of age was a difference in the diet. 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. Subsequent inquiry at other institutions developed
` analogous conditions, and, as a whole, in the light of the then recent
` advances in our knowledge of beriberi, these findings strongly sug-
` gested the idea that the disease was dependent for its development
`
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`
`Elysium Health Exhibit 1021
`Page 3 of 67
`
`

`

` Marcli 19, 1920. 650
`
` on a diet that was for sovne reason fault,y,- atnd that this fault was in
` some wav elther pr-evenited or corrected by including in the diet
` larger propo:rt ionis of the fresh animal protein foods.
` The indicatio(nis for a possible method of prevention thus confirmed
` and mnore c learly dclfiieQI, were put to a practical test at two orphan-
` ages an-d at ani asylutm for the insane. At orphanages "M. J." and
` "B. J.," for several years endeinic foci of pellagra, the diet was
` modified in September, 1914, leaving hygienle and sanitar conditions
` unchanged. Followinig the change in diet, no recognizable evidence
` of a recurrence of the disease was observed at orphanage% "M. J."
` in aniy of the pellagrins of 1914, 67 of whom rem-ained uinder observa-
` tion at least tuntil the anniversary date of tlheir attack. Nor were any
` now cases observed among the nonpellagrin residents of 1914, 99 of
` whiom remainied under observation for niot less, than a year. At
` orphan-age "B. J.," subsequent to the change in diet, but a single
` case of a recurreniee was observed among the pellagrins of 1914, 105
` of whom remaiinedI u-nder observation at least until the anniversary
` date of their attack. At the same time, not a single- new case was
` observed among the inonipellagrin residents, 69 of whom remained
` under observation for not less thain one year.
` At the Georgia State Asvlum, an endemiiie focus of the disease, the
` diet of two. wards of pellagrins was mod1ified--one in October and
` the other in Decemiber, 1914--leaving unchanigedl hygien-ic and sani-
` tary coTnditionus anid tlhe institution routine. Following this change
` in diet and] up to October 1, 1915, the end of the period for which
` the report wa.s illade,i no recognizable evidence of a recurreniee in
` any of the pellagrin inM these wards was observed, although 72 (36
` colored and 36 white ferniales) remained ceitinuously under observa-
` tion througliout this period, or at least ut)itl the completion of the
` anniversary (late of their 1914 attackls. Whereas during the corre-
` sponding period not less than 15 (47 per cent') of 32 control female
` pella.grins preseitietled definite recurxrences.. This experimnent dearly
` showed that pellagra may be prevented by an appropriate diet
` vithout appreciable alterationl in the environment, hygienic or
` sanitary.
` While the experiments (lesigned to test the preven-tability of the
` disease by suitable addlition-s to the dliet were under way, another
` experimiienit vwas carried( outt to test the possibility of producing
` pellagra by meanlms of a presunuabl-y faulty diet in w-hich the foods
` whichl, for the reasontis stated,l -might be ass:umied to have preventive
` or corrective power,. we.re at a. nunniniu-ni. This experime,nt was car-
` ried out oin convxict voluinteers at the Miississippi State Peinitentiary
`
` These orphanage and asylum studies were otnti'inued to the end of 1916 and 1918, respectively, with
` results tiat ecincided with those :of thefirst year. A fuirther reportt on this study will appear in due time.
` (J. G.)
`
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`
`Elysium Health Exhibit 1021
`Page 4 of 67
`
`

`

` 651 Mlarch 19, 1920.
`
` Farm, near Jackson, Miss., between February 4 aind November I1
` 1915 (Goldberger and Wheeler, 1915; Goldberger, 1916; Goldberger
` and Wheeler, 1920). Of 11 mien subsisting on a diet conisisting of
` maize, wheat, rice, and pork fat witlh sweet potatoes, sugar, and
` soine green vegetables, not less than 6 developed clearly narked
` evidence of pellagra at the end of 5- to 6 m,onths; while of a large
` number of controls livin1g under poorer hygienic conditions and work-
` ing harder, but subsistinig on a differeint dlit, n onie showed any
` evidence of the disease.
` Thus, the results attainie(d by the end of 1915 clearly showed the
` controllngff influence of diet in both the prevention and the causation
` of the disease.' Accordingly, with the view of developing as broad
` a basis as possible for the eventual formulation of practical measures
` of control, it was plannied during the winiter of 1915-16 to supple-
` mnent these (in part epidemnologic, but chiefly experimental) investi-
` gations byr a sttudy, in different types of industrial and rural con-
` munities, of the relation of factors of a dietarv, sanitary, and economic
` character to the incidence of the disease.
` For various reasons it was decided to begin with a study of condi-
` tions in cotton-mnill villages, these villages representing one of the
` types of commiiunities in which pellagra was believed to be more than
` ordinarily prevalenit. The studly was begun in the spring of 1916
` and is still in progress. At this timre we desire to report the results
` of the first year's work with respect to the relation of household diet
` to the incidenee of pellagra. Some of these r-esults have already
` been presenited in a previous paper (Goldberger, Wheeler, and
` Sydenstricker, 1918).
`
` II. REVIEW OF THE STUDIES OF OTHER WORKERS.
`
` Before goilln on with ani account of our, work, it seeniis'desirable to
` review the studies of other workers il this field. Aul examination of
` the literature bearilngr onl the relationi of (liet to pellagra would involve
` practically all of the very volumlinous literature of the disease and
` would be beyond the scope of the presenit paper. We propose to
` confine ourselves, therefore, to a consideration of those recentt studies
` which may be regarded as in some senise conm-parable to- our own,
` particularly as it is planned to cons'iler the etiology of the disease in
` a separate patper subsequent to the publicatiao of the results- of the
` series of studies of which the- present is a part.
` To Grinmmi (1913) would seemii to belong, the- credit of the first
` attempt at a modern, comiiprcehensive, unbiased, epidemiological
` study of pellaggra. T[hisstudy was carried out during the summers of
` 1911 and 1912 in various localities in Kentucky, South Carolinia, and
`
` LDwi-g 1916, Goldherger attempted without success to transmit the disease by a series of inocilations
` in Ihunsau vehsuteers, with bbood,naso-pharyngeal secretions,lecesJ urine, and desquamat-ing epithelium.
`
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`
`Elysium Health Exhibit 1021
`Page 5 of 67
`
`

`

` March 19, 1920. 652
`
` Georgia. The inethod followed was to visit pellagrous communities
` and interview health officers anid physicians, and with their assistanice
` data were collected by initerviewing pellagrins, securing reports of
` cases and deaths and reports of facts and conditions pertaining to
` the disease.
` Grimim reports that upward of 20.0 physicians were interviewedl
` and iniforminatioin relatinig to a total of 1,426 cases was obtained. He
` himself visited 290 pellagrous houses and personally interv'iewed 323
` pellagrins. TIe founid that the collection of accurate and detaile(d
` data on the subject of food uised by pellagrinis previous to the onset
` of the disease preseinted insurmounitable difficulties. The systematic
` collection of information concerninig the items of food most com-
` monily used, hinds, sources, quantity, aind quality had to be aban-
` dioned, as it was found that this information could be obtained in too
` f-ew instances. "In many cases it was impossible to get even a
` mneager account of what had been eaten, as the memory and? powers
` of observation of these people seemiied extremely defective when the
` character of their diet was inquired into, * * *." The character
` of the data secured did not, in Dr. Grimmn's opinion, warrant any
` conclusions. So far as his observations went, however, no constant
` difference was found to have existed between the diets of the pellag-
` rous and the nonpellagrous Ineiebers of the families. In the closing
` remarks of the report of this pioneer investigation, Grimm states
` that from his observations "the relationship between food and pel-
` lagra seems to be a real one," but gives no indication of the evidence
` on which this opinion is based.
` In Junie, 1912, a commissioin (Tho.npson-McFadden), consistinig of
` J. F. Siler, P. E.: Garrison, and W. J. MacNeal, begani an elaborately
` planned study in South Carolina, whiclh has resulted in adding
` materially to our knowledge of the (lisease. We shall, in the present
` connection, concern ourselves only with the part of their investiga-
` tions (lealinig with diet.
` The study of the first year (Siler and Garrison, July, 1913), extend-
` inig from June I to October 15, 1912, carried out in Spartanburg
` CouInty, S. C., was of a preliminiary character. Their data were based
` oni informatioin obtained from statements of patients, physicians
` storekeepers, millers, and others. "IIn order to determine the rela-
` tive frequency vith -which the m3re important foodstuffs were used,
` patients and their families were closely questionied as to how often
` certain articles of food would appear on the family table, and with
` regard to the patient's particular fondniess for any particular dish."
` This information was of a general nature and dealt with the habitual
` dietary of pellagrins and their families. The tabulated data sub-
` mitted by them for the year studied represent, it would seem, the
` habitual dietary of the pellagrins occurring in three groups of the
`
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`
`Elysium Health Exhibit 1021
`Page 6 of 67
`
`

`

` 653 March 19, 1220.
`
` population of the c runty studied, namely, mitl village, urban, and ru-
` ral. Among the foods considered, it is interesting to note the finding
` that fresh beef was not a staple article of diet of any of these groups
` during the summer months. On the other hand, they report that
` fresh fowl was used quite extensively during the summer months in
` all three groups. The actual percentages of those using fowl, either
` daily or habitually, are reported to have been as follows: Urban cases,
` 66 per cent; rural cases, 65 per cent, andI mill village cases, 41 per
` cent. With respect to milk, it is reported that 72 per cent of thre mill
` village cases, 67 per cent of the rural cases, and 54 per cent of the
` urban cases used this food either daily or habitually. The interesting
` observation is a.lso recorded tnat, in the locality studied, in contrast
` to northern Italy, wheat flour is the principal breadstuff.
` Summarizin'g the results of this study, the commission states that
` "observations upon the habitual use of the more conmmon foodstuffs
` failed to discover any points of difference between pellagrins and non-
` pellag,rins in the county."' It does not appear, however, that the data
` presented relato to any but pellagrins, ant-d sO it is not clear o0n what
` this statement is based. They state further (S., G., and MacN.,
` 1914a) that careful consideration was given to the possible relation
` of an insufficient diet to the occurrence of pellagra, and that they
` are inclined to ascribe considerable importance to it, not as the sole
` or essential cause of pellagfra, but as a predisposing factor. They
` state that the foods riclh in animal protein, namely, meat, milk, and
` eggs, although apparently used in abundance by a few individual
` pellagrins in their series were, nevertheless, conspicuous by their de-
` ficiency in many of the cases.
` In evaluating the significance of this study one will have to take
` into consideration (1) the very general character of the data which
` apparently related only to the diet of pellagrins, and (2) the absence
` of any evidence of appreciation of the importance of the seasonal
` factor in relating diet to the incidence of the disease.
` This study was continued by the commission during 1913, when
` they undertook "a careful investigation of the dietary habits, not
` only of pellagrins an(d their families, but also of all the remaining
` population of the same class living under the same conditions, in
` certain selected industrial communities." Data were secured for
` each family by personal interview with a member of the family.
` The investigators recorded the diet served in the family as a whole,
` and each member of the household was considered as belonging to the
` dietary group of his family. In obtaining the data, a record was
` made of the frequency of use in the family of various foods, recog-
` nizing 7 classes of frequency: " First, daily use, which is self-explana-
` tory; second, habitual use, meaning as often as twice a week on the
` average; third, part time daily, which means daily use during certain
`
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`
`Elysium Health Exhibit 1021
`Page 7 of 67
`
`

`

` March 19, 1920. 65
`
` seasons of the year; fourth, part time, habitually, or habitual use
` during certain seasons; fifth, rarely, which means used less frequently
` than twice a week; sixth, part time rarely, and, seventh, never."
` In analyzing these data the population as represented first by the
` family as the unit and then by the individual as the unit was divided
` into several groups distinguished from each other by the frequency
` with wnich the particular food was used in the family, and then the
` relative number of cases of pellagra in the different groups was com-
` pared. As the data related to family and not to the individual use
` of various foods, the anialyses, using the individual as a unit, do not
` seem to us to have been permissible as involving danger of a confusion
` of ideas, of which, indeed, there is repeated evidence throughout the
` report of this interesting study. Thus, in discussing -the relationship
` of the frequency of use of fresh meat to pellagra they state that "'in
` the total population of the six villages the pellagra morbidity is
` actually highest in the group of 82 persons who used fresh meat
` daily," when all that could properly have been meant was that the
` morbidity was highest 'in the group of households (composed of 82
` persons) who used fresh meat daily.
` They analyzed their data in relation to corn meal, fresh meat,
` canned goods, milk, and eggs, and state that they found that the
` theory that pellagra is caused by the excessive use of corn meal, or
` that it is caused by a deficiency of fresh meat in the diet, was not
` supported. On the contrary, it appeared to them quite certain thaat
` in the population studied, those avoiding fresh meat contracted this
` disease the least.' Similarly, the, frequent, even daily use of fresh eggs
` afforded no relative protection from pellagra. With respect to canned
` goods they state that their study failed to discover any evidence that
` the use of canned goods causes pellagra. From the analyses presenited
` on the use of milk it seemed to them "evident that in the whole popu-
` lation those persons using milk daily contracted pellagra the least."
` "In every one of the six villages [studied], the group using milk daily
` showed a lower incidence thanl the average for that village, and the
` group never using milk showed a higher incidence than the average.
` Tlle correlation is quite inconsistent in the groups using milk habit-
` ually and rarely. The tendency toward correlation between the
` occurrence of new cases of pellagra and the deficiency of milk in the
` diet is nevertheless distinctly evident, on the whole, and suggests
` that the use of milk (including buttermilk) as a food has some value
` in the prevention of pellagra." Summarizinig this study, the commis-
` sion states (S., G., and MacN., 1914b) that a "house-to-house canvass
` of the homes of over 5,000 people living in six endemic foci of pellagra
`
` XItalics are ours. It is interesting to note in this connection that they state that the lowest morbidity
` from pellagra was observed by them in the two of the six villages in which the local market sold fresh meat
` throughout the year.
`
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`
`Elysium Health Exhibit 1021
`Page 8 of 67
`
`

`

` 655 March 19, 1920.
`
` failed to disclose any definite relation of the disease to any element of
` the dietary."
` In evaluating the significance of this, as of their preliminary inves-
` tigatioii, account must be taken of the fact (1) that the data are again
` of a very genieral character; (2) that there is no evidence of apprecia-
` tion on the part of these workXers of the importance of the seasonal
` factor in relating diet to the incidence of the disease; (3) that the
` data relate to family, not to indivicdual use of foods; (4) that the
` termn "pellagrini7" is niot de-finied, leaviing one in doubt whether, in
` sone of their analvses, this includes only active cases or whlether, as
` seems niot imp}robable, it also ineludes some quieseent cases; anid (5)
` that an error, the magnitude of which it is impossible to estimate from
` the data published, probably entered as the result of the relative
` incompleteness, for the purpose of such study, of the pellagra inci-
` dence data that is certain to arise unless cases are systematically and
` continuouslyM sought for by personal canvass (see also criticism by
` Vedder, 1916, p. 152). Finally, some account should perhaps also
` be taken of their methods of statistical interpretation, best il'lustrated
` in connection with tlle anialysis relating to the use of milk. Here, in
` considering the distributioni of families according to the frequency of
` use of this food, they point out (S., G., and MacN., 1914c, p. 357)
` that the} groups uLsing milk "habitually, rarely, and niever " wero wel
` represented, and thlat thie percentage table (Table 82) suggests "that
` pellagra was, on the whole, somewhat less common in families using
` milk daily."
` The table they cite (Table 82) actually shows that the rate of inci-
` dence for those families using milk rarely (13.6 per cent) was
` practically identical with those using it daily (13.5 per cent), and
` was therefore much lower than those using it habitually (22.5 per
` cent), the rate for the latter group being but little below that for the
` group using it never. This would seem to indicate that if the table
` under discussion suggests anything, it suggests that pellagra was, on
` the whole, somewhat less common in families using milk daily and
` rarely than in those using it habitually, etc., a paradox which
` would seem to point quite clearly to the need of extreme reserve in
` attaching significance to such indications if, indeed, any significance
` whatever can be attaehed to them.
` A consideration of the relation of pellagra to diet was included in
` a stuidy by Jobling and Petersen (1916 and 1917) of the epidemiology
` of the disease in Nashville, Tenn., during 1915 and 1916. During
` the first year's work, which was commenced August 1, 1915, "inquir-
` ies were made of the patients and of their friends as to whether there
` had been any definite change in the general character of food con-
` sumed during the two years previous to the onset of the disease, and
` whether there had been times during this period when they had not
`
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`
`Elysium Health Exhibit 1021
`Page 9 of 67
`
`

`

` Maich-li 19, 1920. 656
`
` had sufficienit food". Of 320 white people, 14.4 per cent, anid of 101
` colored, 11.8 per cent are reported to hlave stated that there had been
` times duiniig the two years preceding their first attack when they had
` not had sufficient food. These statements, it is pointed out, had
` reference, to a deficiency of all foods, not of any particular constituent.
` In only five inistances, they report, were they able to obtain informa-
` tion that there had beci a definlite change in diet for the worse durimg
` the two years previous to the onset of the disease. In the remaining
` inistance the patients and their friends are reported to have asserted
` that the food consumed had been the same or better in both qutality
` and quantity than they had been accustomed to previously.
` With reference to protein, Jobling and Petersen state that of the
` 421 patients considered, 66.8 per cent gave histories which indicated
` that they had been getting considerably more than 40 grams a day.
` They refer to the possibility that the deficiency in protein may be in
` quality, not in quantity. This, they state, was possibte in certain
` cases; but in the majority of the patients they considered the diet
` sufficieiitly varied to make it improbable.
` In discussing the results of their study they state that " tlle inhabi-
` tanlts of the South consume excessive amounts of carbohydrates, and
` fats," but no data on which this statement is founded are presented.
` In considering the theory of a vitamine deficiency advanced by Funk,
` and his suggestion that the disease might be prevented by the addi-
` tion of vitamine-containing substances, such as potatoes, milk, butter,
` fruit,+ etc., they state that people in their section eat a great deal of
` potatoes, fruits, and other green foods, both cooked and raw, during the
` spring and summer.i "It seems strange," they remark, "if this theory
` is correct, that pellagra should be rare in winter wheni green foods are
` scarce, and so frequent in the spring and summer when green foods
` and fruits are plentiful and cheap." It is evident that these workers
` have overlooked the significance of the strikingly similar seasonal
` behavior of endemic scurvy in relation to the availability of green
` foods and fruits-known prevenltives of the disease.
` In weighing the significance of this study it will be noted (1) that
` the dietary data are of a most general character, and (2) that, seem-
` ingly, it is the judgment of the. pellagrin, or that of his family, with
` respect to the pellagrin's diet, that constitutes the basic data, rather
` than quantitative statements or actual records of food supplies or
` of food consumption for a specific period or season of the year.
` The second year's study was an amplification of the first. Appar-
` ently the method of inquiry of the patient or of his family with
` respect to the pellagrin's diet was continued. In the second year's
` study it is stated that the pellagrins fell into two groups: One with
` active symptoms, acute skin changes, etc., "and one with chronic
` symptoms, in which the characteristic atrophy of the skin of the
`
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`Elysium Health Exhibit 1021
`Page 10 of 67
`
`

`

` 657 March 19, 1920.
`
` hands or feet, with occasional diarrhea, or in which evidence of de-
` generative changes in the central nervous system are apparent, cases
` in which the disease process is more or less quiescent." In a certain
` number of cases, constituting, in effect a third group, this information,
` it is stated, was not clearly obtained. Of the white cases, 42 per
` cent of the males and 33 per cent of the females are reported to have
` had active lesions, and 47 per cent of the males and 60 per cent of
` the females were classed as "more or less quiescent" cases. Their
` examiners, "from questions and observations, reported that a defi-
` ciency in quan-tity probably existed in 15 per cent of the whites and
` in 28 per cent; of tlhe colored cases."' Of 576 white pellagrins "90 per
` cent positively denied any deterioration in either the quantity or
` quality of the diet in the years immediately preceding the first attack
` (wvhich seemingly may have been several years before the date of the
` survey),,9.d only- 18 per cent of the colored cases had changed their
` diet in a manner that would indicate a lowering of its value."
` Furthermore, "in order to obtain an accurate idea of the balanicing
` of the diet" statements were obtained "as to tlhe variety of the foods
` consumed their quantity, and an average daily menu." "In this way"
` they are able, they state, "to approximate in a fairly satisfactory
` way the food value and the quality." flow the quantity of the food
` consumed was actually determined is not described, but would seem
` to have been by the simple statement of the patient or of a member
` of the family. What period this statement of food consumption
` covered or the average daily menu represented, is likewise not en-
` tirely clear; presumably it was either (1) for " tlle years immediately
` preceding the first attack" (which, in some instances, must have
` been several years anterior to the date of the survey), oir (2) for the
` current period at the time of the survey. In eithler event the as-
` sumption of accuracy in such data would imply, in view of Grimm's
` experience, unusual powers of observation and surprisingly good mem-
` ories in these people; furthermore, if these were statemenits of cur-
` rent consumption, approximately 50 per cent of the menus were those
` of "more or less quiescenit" cases-cases, that is, that from the point
` of view of diet may be considered as possibly subsisting on a diet
` favoring convalescence or recovery from the disease (see also p. 661).
` A classification of pellagrins on the basis of certain diets designated
` as high, medium, and low protein, and one on the basis of "partaking
` regularly" of certain protein foods, namely, eggs, meat, milk, and
` legumes, are given. No definition of the phrase, "partaking regu-
` larly" is presented. From the chart in which the latter analyses are
` presented it would seem that between 40 and 50