MORTALITY-FOREIGN AND INSULAR-COUNTRIES AND CITIES (Untabulated). CHILE-Punta Arenas.-Month of July, 1911. Population, 12,000. Total number of deaths from all causes 28, including tuberculosis 1. FRANCE-Calais.-Month of August, 1911. Population, 75,000. Total number of deaths from all causes 202, including diphtheria 1, measles 2, scarlet fever 1, tuberculosis 28. JAPAN-Formosa.-Two weeks ended July 29, 1911. Population, 3,290,186. Total number of deaths from all causes not reported. The deaths include diphtheria 1, typhoid fever 10. By authority of the Secretary of the Treasury: WALTER WYMAN, Surgeon General, United States Public Health and Marine-Hospital Service. PUBLIC HEALTH REPORTS. VOL. XXVI. SEPTEMBER 29, 1911. No. 39. THE CHOLERA SITUATION. Cholera continues prevalent in Italy. Cases of the disease are being reported in Russia, especially in the southern Provinces. According to last advices the disease is still present at Marseille, France, and in the Province of Tarragona in Spain. The disease is present in Turkey in Europe and Asia. Six cases were reported among pilgrims at Beirut. On August 30 cholera was reported present at Kobe and Osaka in Japan, and on September 26 at Tunis in Northern Africa. After a lapse of a considerable period in which no cases were reported a case of the disease occurred in Manila, P. I., during the week ended July 29, and a small number of cases are being reported from the Philippine provinces. A point of interest in connection with the case of cholera reported in Manila is that of seven contacts, all upon examination proved to be harboring the cholera organism and to be cholera carriers. All were isolated, and during a period of 10 days' detention none had developed clinical symptoms of the disease. Emigrants from Italy are bacteriologically examined by medical officers of the Italian Government for the presence of cholera carriers before embarkation. Out of a total of 9,557 such examinations made 40 carriers have been found at Naples and one at Palermo. No cholera carrier nor case of cholera has arrived at a port of the United States since August 18, 1911. To meet the possible detouring of Italian immigrants to ports in other European countries orders have been issued requiring bacteriological examination of all Italian steerage passengers on arrival at a port in the United States without regard to the port from which they sailed in conformity with department circular No. 47, July 19, 1911. THE SALIENT EPIDEMIOLOGICAL FEATURES OF PELLAGRA. By C. H. LAVINDER, Passed Assistant Surgeon, United States Public Health and Marine-Hospital Service. The developments of modern medicine have repeatedly shown the great value which is to be attached to epidemiologic studies as an aid in the elucidation of the etiology of disease. It seems remarkable that such studies are lacking for pellagra. Many important epidemiologic facts have been observed and recorded for this disease, but anything like complete and detailed studies do not as yet exist. 114 1459 The only modern work of this kind which we possess is that of Sambon and that of Alessandrini. Both of these authors have made important contributions to the subject, but each was striving to establish his own hypothesis of the etiology of the malady. Their contributions therefore are necessarily wanting a certain judicial point of view which would have much increased their value. It is to be observed, moreover, that the studies of these two authors were made exclusively in Italy, and that practically all recorded epidemiologic observations refer, if not to Italian pellagra, at least to the pellagra of southern Europe. Such observations are lacking for many places where the disease is known to be endemic, and we have none for the United States. If careful studies of this nature, both extensive and intensive, could be made for many places, a comparison of results would establish on a firmer basis many points of importance which are now obscure and might serve at least to give us a more definite idea as to the direction of our future work on the all important question of the etiology of this disease. Ultimately of course such studies must lead us back to the individual patient for completion. It is intended to assemble in this paper, without very much discussion, the epidemiologic data we already possess regarding pellagra with the idea of trying to make some estimate of how incomplete these data are, and what indications they may perhaps show. First with regard to prevalence and geographic distribution, it may be noted that the statistics of pellagra are for many reasons notoriously inaccurate, and the general geographic distribution of this disease is in all likelihood uncertain. Sambon's expression that our knowledge of its geographic restriction very likely represents only the limitations of our information as to its extent should be borne in mind. At present in a general way the disease is probably most prevalent in Northern and Central Italy, Southern Roumania, the Austrian Tyrol, Southeast Hungary and the Southeast United States. Lower Egypt might, perhaps, be included. It has now been reported from various parts of the world, both in the Eastern and Western Hemispheres, but on the whole displays at least certain geographical limitations, although these are not easy to define with any degree of accuracy. Roussel (1865) wrote as follows concerning the geographic distribution of pellagra: "Recently this malady has invaded new countries, and to-day it is found to the south of 47 degrees of north latitude, between 10 degrees of longitude west and even beyond 25 degrees of longitude east, meridian of Paris, extending over a long zone of the temperate region of Europe, from Cape Finisterre to the banks of the Sereth, across the Pyrenees provinces of Spain and of France, Upper and Central Italy, and, in the basin of the Danube, upon the eastern and southern slopes of the Carapathians, even to the frontiers of the Russian Empire.' Since this date the disease has been much more extensively reported, and may be even much more widely prevalent than present reports show. It may in a general way be said that pellagra is confined to tropical, southern north temperate, and northern south temperate zones, and perhaps nothing more definite can now be said in a general statement. Its local geographic distribution presents more striking peculiarities. In Italy, for example, it has for generations been endemic in the northern and central parts of the peninsula, but has definitely spared southern and insular Italy, though endemic in the island of Corfu, just across the Adriatic. In recent years, however, it appears to be slowly advancing southward. In Roumania, on the other hand, long endemic in the south, it now appears to be slowly traveling northward. It is endemic in Northern Italy and in the Austrian Tyrol, yet contiguous Switzerland and Germany have always escaped. Again, endemic and quite prevalent in Lower Egypt, it is comparatively rare and sporadic in Upper Egypt. In the United States, also, there seems a certain geographic restriction to the southeastern States. Such sharp limitations are not constant, however. From Roumania it has apparently invaded neighboring parts of Russia and of Austria-Hungary, and is scattered along the Danube. Without attempting any exhaustive statement of these peculiar and sharp limitations a glance at a map will show that such peculiarities are evident and striking. One other fact may be noted here, and that is the practical disappearance of the disease from France where it was once endemic and rather widely prevalent. In Spain, too, the disease has never seemed to spread widely. It is not to be forgotten in this connection that the "zeist" idea of the etiology of pellagra has been so widely accepted that practically all pellagra literature bears more or less the coloring of this theory. Geographical observations have likewise not escaped this bias, and conclusions are not infrequently drawn which a strict estimation of facts do not entirely warrent. The statement that pellagra occurs only in those countries which grow and to a large extent subsist on maize products is, in itself, not only a statement of a very general nature, but is so wide as to include perhaps too much. Corn is grown and used as an article of food so extensively over the earth's surface that it might, with similar reason perhaps, be adduced as an etiologic factor in other diseases as well as pellagra. In other words, a premise of this character is so broad that it weakens the conclusion. Among other general factors climate seems to exert no especial influence, though, as noted above, the disease seems to be confined to the tropical and the warmer parts of the temperate zones. The influence of climatic factors on the spoiling of corn are important, as is well known. Seasonal influences to the "zeists" are also of great importance for similar reasons. The relation between symptomatology and seasons is discussed later. Meteorologic and telluric conditions, outside of their well-known re'ation to the corn theory, appear to present nothing noteworthy; although many of the older writers have paid a good deal of attention to excessive moisture, dryness, etc. The relation of the erythema to sunshine is mentioned later. The topographical distribution of the disease has, in the opinion of most observers, furnished no facts of importance. In the recent work of Sambon, however, in support of his simulium theory of pellagra, great stress has been placed on topographic distribution. This forms an essential feature of this hypothesis. His observations go to show that the disease is linked to the swiftly running streams of hilly territory in which the simulium breeds. |