PUBLIC HEALTH REPORTS.

VOL. XXVI.

SEPTEMBER 22, 1911.

No. 38.

THE CHOLERA SITUATION.

The extension of cholera in southern Europe continues. The presence of the disease has been officially reported in Roumania at Braila on the Danube River, and in Spain in the Province of Tarragona. In Italy cases have recently been reported in Milan city and Province. No case of cholera has arrived at a port of the United States since the one reported as arriving at New York on the steamship Re d'Italia August 18, 1911. The last cholera bacillus carrier detected among immigrants at quarantine also arrived August 18 on the same vessel.

NEW YORK.

Passed Asst. Surg. von Ezdorf reports that bacteriological examination of steerage passengers, for the detection of cholera bacillus carriers proved negative for the steamships Mendoza, from Genoa, Naples, and Palermo, which arrived at New York September 8; the San Giorgio, from Naples and Palermo, arrived September 12; the Oceania, from Trieste, Patras, Almeria, Spain, and Algiers, arrived September 12; and the Prinzess Irene, from Naples and Gibraltar, arrived September 13.

PELLAGRA: AN INVESTIGATION OF A LOCAL OUTBREAK IN KENTUCKY.

By R. M. GRIMM, Assistant Surgeon, United States Public Health and Marine-Hospital Service.

The following is a brief report upon an investigation of a "local outbreak" of pellagra, which occurred in southeastern Kentucky during the spring and early summer of 1911. The investigation was brought about by the appearance or by the recognition of a large number of cases of pellagra in this section of the State at this time. It was conducted under orders of the Surgeon General of the Public Health and Marine-Hospital Service and upon the request of the secretary of the State Board of Health of Kentucky and the Representative from the congressional district in which the cases occurred. The time spent upon the investigation was from August 12 to August 30, 1911, and during this time the pellagra situation was looked into in the counties of Whitley, Knox, and Bell.

These three counties are located in the southeastern portion of Kentucky along the Tennessee and Virginia lines, which is the most mountainous section of the State. Each county is traversed by the (1421)

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Cumberland River, which flows in a tortuous course through and around their many hills. The tributaries of this river and their numerous branches of creeks and runs form an irregular network of streams throughout these counties. A glance at a topographical map of this section will show the extreme irregularity of contour of the country and the scarcity of level land, which explains the presence of the multitude of small streams and the absence of many large ones. In addition to these permanently flowing streams, there are back among the hills many of the "wet-weather" type, which flow only during the winter, spring, and early summer. The country is dotted with numerous springs, some of which flow throughout the year while others become dry during the summer or have only a small flow. The water supply of the towns and rural districts is of course abundant, and in no instance does the water have to be conducted any great distance for use. Wells have been sunk at various places, but the majority of the people use surface water for general use.

The invesitgation was conducted with the help of the various county officials and of many local physicians, who rendered invaluable assistance in the collection of the following data:

WHITLEY COUNTY.

It was learned from Dr. E. S. Moss, of Williamsburg, health officer of the county, that pellagra had been present in Whitley at least since 1907, and that at that time a case of pellagra was recognized and diagnosed as such. Since 1907 the number of recognized cases of pellagra in this county has increased each year and the physicians are becoming more and more familiar with the disease and are on the lookout for it.

On account of the fact that the cases of pellagra in Whitley County are widely scattered and that many of them are in persons living in places difficult of access I was unable to visit all of them at their homes and had to depend largely upon the reports of physicians who had seen or treated them. The number of cases which were either seen by me or reported to me by physicians is as follows:

I was informed by Dr. J. S. Lock, of Barbourville, health officer of the county, that pellagra had been recognized by the physicians in Knox County only since the spring or early summer of 1911. The death of two women at this time from a disease which was not diagnosed brought on a discussion, which, considered with reports of cases of pellagra from other counties, led to the recognition of the disease in Knox County. It is certain, however, that pellagra existed in this county before the date of its recognition, as a number of the cases that I visited in the county gave histories dating back three or

1 Cases were diagnosed positive only when the three cardinal sets of symptoms were present or when there was a definite history of them.

It was learned that 12 deaths had previously been reported from this county, but definite information could be obtained of only 9.

four years. Dr. W. Burnside, of Barbourville, stated to me that he is confident that he treated a patient in 1901 for symptoms which he now recognizes to have been those of pellagra.

As far as I have been able to determine the number of cases of pellagra which have been recognized in Knox County up to the present time is as follows:

A. Cases of pellagra in Knox County:
(1) Diagnosis positive....

(2) Diagnosis probable..

B. Reported deaths of known pellagrins..

BELL COUNTY,

30

824

The exact date of the recognition of pellagra in Bell County is indefinite. It seems to have been first recognized there during the spring of 1911, although a number of physicians remember having treated cases before this date which they now know were cases of pellagra. A case was related to me by Dr. O. P. Nuckols, of Straight Creek, which was seen by him in the summer of 1910 and which had shown symptoms during the summer of 1909.

The first public recognition of the presence of pellagra in Bell County was made at the regular July meeting of the Bell County Medical Society, which was held at Cary on July 7, 1911, upon the invitation of the physicians of the Continental Coal Corporation at that place. The meeting was attended by a large number of county physicians and laymen. Five cases of well-defined pellagra were exhibited by Drs. Hendren and Hastings, of Cary, Ky., who had recognized and diagnosed them in their practice. Following this meeting a considerable amount of interest in the disease was shown by the profession of the county, and a number of cases were at once discovered at other places in the county. A pellagra conference was called by the secretary of the State Board of Health of Kentucky, and was held at Corbin, Ky., on August 9, 1911. This meeting was attended by a large number of physicians and laymen from the surrounding counties. A number of cases of pellagra were shown and the disease was generally discussed. Many cases of pellagra have been seen and recognized since these meetings by physicians who were before that time not familiar with the disease.

The majority of the cases of pellagra which have been recognized in Bell County have been in the mining camps around Pineville and around Middlesborough. The number of cases which have been recognized in Bell County up to the present time is as follows:

A. Cases of pellagra in Bell County:

(1) Diagnosis positive...

(2) Diagnosis probable.

B. Reported deaths of known pellagrins..

140

13

5

In regard to the number of cases of pellagra in Whitley, Knox, and Bell Counties, Ky., at the present time, my investigation shows the following grand total:

The report of 8 cases of pellagra and 1 death from Laurel County was made to me by Dr. M. W. Steele, health officer of Corbin, and 5 cases and 1 death were reported to me from the Tennessee line by Dr. J. G. Moss, of Hartranft, Tenn. The cases in these two reports are not included in the reports from Whitley, Knox, and Bell Counties. In the consideration of the whole series of 140 cases some generalizations can be made which may be of interest. Practically every case occurred in families in poor economic circumstances and living under rather unhygienic conditions. Many of them were in families of coal miners. On account of the topography of the country the most suitable locations for homes are along the streams, consequently a large percentage of the inhabitants live along watercourses. In every instance where I was able to visit the pellagrins at their homes I found them living within 500 or 600 yards from a stream. A number of them were living in houses situated literally on the banks of the streams. The question of diet was not gone into thoroughly, but in every instance where I was able to make inquiry regarding the diet of the pellagrin it was learned that corn products had been one of the main articles of diet. In fact corn products are used extensively by nearly all of the people in this section.

I was able to find only 16 pellagrins who were then living at the homes at which they were living when they first noted the symptoms of the disease. Upon inquiry as to the water supply in these instances it was found, with only one exception, to be either surface water from branches or creeks or water taken directly from neighboring mountain springs.

Regarding the race, sex, and age of the pellagrins in this series, I have constructed the following table from the data pertaining to these points:

Some other observations were made and some other data collected which are not included in the above report, but will probably be used in a subsequent paper on the epidemiology of pellagra.

In conclusion I wish to thank the health officers of Whitley, Knox, and Bell Counties for their valuable assistance and cooperation in this investigation. I am especially indebted to Drs. J. G. Foley, J. Harry Hendren, O. P. Nuckols, L. L. Robinson, and T. H. Curd, of Bell County; to Drs. J. S. Lock, Wilder, and W. Burnside, of Knox County; to Drs. E. S. and C. A. Moss and L. O. Smith, of Whitley County; and to Dr. M. W. Steele, of Corbin. Without their assistance very little could have been done..