Jobling and Peterson,31 in their survey of pellagra in Nashville, came to practically the same conclusions as the Thompson Commission. Their observation that a close relationship exists between the sanitary condition of the different parts of Nashville and the incidence of pellagra, tends to strongly support the view that the disease is associated with poor sewage disposal. The sanitary conditions in those districts where pellagra is common are of the worst sort, in many instances there being little pretense made of doing anything with the excreta, which in summer is covered with flies. Screening was usually absent from those houses where the disease was found. Vedder, on the other hand, holds that the proofs offered in support of this theory are insufficient and susceptible of other interpretations.32 He says:

To accept this sone distribution of cases as pointing to an infectious agent as the cause of pellagra appears to involve an inconsistency. We must necessarily assume that the infectious agent is conveyed in some manner from house to house, and also from the frequency with which contiguous houses are at tacked that it is susceptible of being distributed with a considerable degree of certainty. In other words, we must assume that the organism causing the disease must be very highly infectious if it is capable of making it dangerous to live next door to a case of pellagra. Yet, in institutions, pellagra in a doctor, nurse or attendant is so rare as to be a curiosity. Here there is an infection so powerful that it often spreads from house to house, and yet which is powerless to attack attendants performing the most intimate of personal services. Such a peculiar incidence is conceivable in a disease carried by an insect, if the hospital attendants were protected from that insect. But as the method of transmission is unknown, measures to prevent insect transmission could not have been intelligently adopted in these institutions, many of which are infested with bedbugs, lice, biting flies and mosquitoes.

31 Jobling; and Peterson, J. Infect. Dis. 18, 501, 1016. 32 Vedder, 3rd Rep. Thompson Pell. Com.

Is there a tendency of pellagra to occur in that part of a community having a primitive system of disposal of excreta and to be absent in the portion having a proper sewer system? The commission has shown that pellagra in Spartanburg is much commoner in those sections of the city having privies than in those sections of the city having a sewer system. The sewer system runs throughout the business sections and better residence districts, while the poorer residence districts, including the several foci of mill workers, are not thus supplied. . . . The commission points to the epidemic of pellagra occurring in Peoria as an instance of the occurrence of the disease in a well-sewered institution, but thinks that the disease in this case may have been spread by contact. While freely granting this, we must see that the occurrence of such an extensive epidemic of pellagra in a well-sewered institution must necessarily detract from the importance of the sewer system alone as a factor in reducing the prevalence of pellagra in the sections of Spartanburg it supplies.

It should further be remembered that as pellagra in the Peoria institution disappeared after a radical change for the better had been made in the dietary, together with the enforcement of segregation of pellagrins, the disappearance of the disease cannot logically be attributed to the latter fact alone. Of course a brief discussion of one or two isolated instances can not do justice to the large number of observations accumulated by the commission on this point, but apparently the commission does not believe that they have any direct proof that pellagra has disappeared as the result of improved methods of conservancy alone.

It is to be noted in this connection that Boyd states that the sanitation and water supply was entirely satisfactory in the prison camps in Egypt in which the disease developed, and that an exhaustive search for any causative origin other than a faulty diet was without result.

Goldberger is the leading exponent of the theory of dietary origin for pellagra.33 Investigation has shown that the diet of pellagrins is almost invariably restricted and ill-balanced. Fat and carbohydrate predominate, and animal protein is low, as may be seen from the following diets taken from those reported by Vedder34 as typical:

Miss T., mill operative. Breakfast. Hot biscuit, butter and molasses; rice, occasionally; canned salmon frequently; eggs, a couple of times a week; coffee, glass of milk at times.

Dinner: Meat, usually bacon boiled with vegetables; had fresh beef once or twice a week, fried and usually overcooked; chicken or rabbit about once a month; had vegetables, such as Irish potatoes, sweet potatoes; in winter used canned vegetables, but in summer had string beans, corn, peas, onions, etc., cornbread made of shipped meal.

Supper: Cornbread and buttermilk; drank about a quart of milk daily (her estimate); ate a good deal of candy and always had plenty of fresh fruit.

33 Goldberger, Pub. Health Repto. 20, 1683, 1914; lb 30, 3117, 3338, 1915. Goldberger and Wheeler, lb., 30, 3, 1915. See also, Vedder, Arch. Int. Med. 18,137, 1916. Goldberger, Wheeler and Sydenstricker, J. Am. Med. Ass. 71, 944, 1918. 34 Vedder, 3rd Rep. Thompson Pell. Com.

This family (father and mother and seven children from 20 years of age to 13 months) purchased each month: 100 pounds of wheat flour, two bushels corn meal, one bushel Irish potatoes, hominy and rice as desired from time to time, and no account kept.

Mrs. H., housewife in mill village: Breakfast: Biscuits or bread; salmon twice a week, other mornings bacon; coffee, eggs rarely.