Pellagra

“ Pellagra is a slow but usually progressive disease occurring chiefly in Italy, due, it is thought, to the continued ingestion of decomposed or fermented maize. It is characterized by cutaneous symptoms, at first upon exposed parts, of an erythematous, desquamative, vesicular and bullous character, and by general constitutional disturbance of a markedly neurotic type. A fatal ending, if the disease is at all severe or advanced, is to be expected.
Treatment is based upon general principles. ”

“ Blood or gland-lymph examination, or, if this be negative, hepatic or splenic puncture, should establish the diagnosis.
In pellagra the erythema is of a characteristic type. It is not ringed or fugitive as that of trypanosomiasis, and it affects principally the exposed parts of the body; the disease is of a much more chronic character, and, instead of lethargy, the mental condition, if implicated, is more that of insanity melancholia alternating with mania and terminating in dementia. Further, in pellagra, the symptoms are aggravated at particular seasons spring and autumn. ”

“ The evidence at hand to date indicates that acute anterior poliomyelitis, or infantile paralysis, is transmitted by contact with infected persons. Under certain conditions insects may be agents in spreading the disease, but their rôle is a subordinate one. [Pg 246]
Pellagra
Pellagra is an endemic and epidemic disease characterized by a peculiar eruption or erythema of the skin (figs 144 and 145) , digestive disturbances and nervous trouble. Insanity is a common result, rather than a precursor of the disease. The manifestations of pellagra are periodic and its duration indeterminate. ”

“ Sambon goes farther than this. He has advanced the hypothesis that the hitherto unrecognized protozoal cause of pellagra is insect-borne, and probably by some blood-sucking midge belonging either to the Chironomidæ or to the Simuliidæ. In favour of this hypothesis he adduces not only the analogy of malaria and trypanosomiasis, but the facts that pellagra is a rural and not an urban disease; that it affects principally field -labourers ”

“ In contemplating the fungus theory of pellagra it is interesting to note that of all the diseases known to be caused by fungi, such as thrush, ringworm, pinta, tinea imbricata, mycetoma, actinomycosis, pneumonicosis, not one in any way resembles pellagra.
Of the more recent etiological theories concerning pellagra the following may be mentioned: Dr. Licorish of Barbados believes that the disease is due to an excessive sugar diet; Auld ascribes it to a magnesium infiltration from the ingestion of maize; Dr. Pixley of South Carolina incriminates rancid fats ”

“ Although pellagra occurs most frequently in rural labourers living from hand to mouth, it does attack people in good circumstances. This has long been recognized in Italy, and the figures given by Gruner for the southern States of the United States— 258 cases had lived in poverty, 59 in comfort, 6 in affluence— show that the same remark applies to America.
Season.— Of all diseases with marked seasonal connection, pellagra is one of the most striking. As in the case of malaria, the pellagra season varies in different localities, but is always the same in the same locality. ”

“ But the peculiar symptoms and anatomical lesions of pellagra, together with its epidemiology, seasonal habit, and geographical distribution, show very clearly that the disease must have one specific cause and cannot be brought about by each, or all, or any of the numerous aforementioned nematodes, protozoa, fungi, bacteria, and chemical products. It would be unwise, therefore, to place much reliance on these experiments. The interpretation of experiments is often as fallacious as the interpretation of ordinary natural facts. ”

“ Micro-organisms found on maize.— Ballardini, in 1845, was the first to attribute pellagra to a living organism, a mould (Sporisorium maydis}, which he found in the greenish stain (verderame) frequently seen in the germ-groove of maize grains. Experiments gave rise to gastritis and diarrhoea in man, loss of feathers and general wasting in fowls. Lombroso pointed out that Sporisorium maydis, on account of its rarity, could not be the cause of pellagra, and that Ballardini had probably confounded the Sporisorium with Penicillium glaucum. ”

“ Goldberger states that mental disturbances sufficient to require institutional care do not occur in more than 2 or 3% of cases.
In the second stage the urine shows rather marked indicanuria and the faeces contain an excess of skatol. Loss of weight is as marked a feature of pellagra as of tuberculosis. Well nourished pellagrins are the exceptions.
Third Stage.—With the setting in of a confusional insanity and a terminal cachexia we have the third and last stage of the disease. On account of so many of the victims of pellagra becoming inmates of insane asylums the disease is peculiarly dreaded. ”

“ Usually, where a mixed diet with meat is possible, pellagra never appears. In other places, as in Italy, where the peasants live on a porridge of corn meal cooked in great potfuls, a week's supply at a time, and during the week exposed to dirt and flies and often spoiled before eating, pellagra is most common. Experiments have shown that in these districts, by excluding corn from the diet and furnishing a substantial fare, the disease has been banished. ”

“ In a later work Ceni, together with Besta, ascribes pellagra not to the organisms themselves, but to elaborated toxins. More recently Ceni and Besta describe two special varieties of Penicillium glaucum as' the true cause. According to these authors the toxic properties of one variety are excitative and therefore cause the acute forms of the disease ; those of the other, being narcotic, give rise to a more chronic type. ”

“ No case should be regarded as cured until the patient has been absolutely free from all symptoms for at least two years.
In its advanced stage the disease is practically incurable. In Italy the Government, basing its action on the maize theory of pellagra, has provided grain drying appliances for bakeries, and other hygienic advantages, including better house accommodation, also special asylums (pellagrosari) for the treatment of the disease in its earlier stages. ”

“ In examining the numerous observations that have been made, there is one fact which stands out very prominently, and that is that each investigator claims to have reproduced true pellagra, either in animals or man, sometimes in himself, by inoculating beneath the skin, injecting into the veins, or administering per os the special organism or toxic product which he happens to have isolated. ”

“ I would repeat with emphasis that it is inconceivable that a fly of the appearance and habits of the prevalent species of Simulium could be present in such a region, especially about the haunts of man and attack him with sufficient frequency and regularity to satisfactorily account for so active and prevalent a disease as pellagra without being a well-known and recognized pest. ”

“ Age.— Hitherto pellagra was considered to be a disease of middle age, the majority of cases occurring between 20 and 50. Sambon has shown that within the endemic centres children are attacked, and that no age is exempt, he having seen the characteristic symptoms in a woman over 100 years old and in infants of barely 3 months.
Occupation.— The disease is most prevalent among field-labourers. The inhabitants of towns, even of those in the very heart of intensely pellagrous districts, enjoy an immunity similar to that of town-inhabitants as regards malaria. ”

“ In Venetia the lives of the small proprietors and of the salaried peasants are often extremely miserable. There and in Lombardy the disease known as pellagra is most widely diffused. The disease is due to poisoning by micro-organisms produced by deteriorated maize, and can be combated by care in ripening, drying and storing the maize. ”

“ The absence of skin lesions and mental symptoms differentiates sprue from pellagra.
Prognosis is good for recent cases, provided proper treatment is carried out. It is bad for patients over 50, for long-standing cases, for careless and injudicious patients, and for those who cannot or will not take a purely milk diet.
Treatment.— Importance of early and thorough treatment. If treatment be undertaken sufficiently early in sprue, and be thoroughly and intelligently carried out, it is generally marvellously successful. ”

“ The report of the American Pediatric Society includes two cases of eczema as a complicating condition. This symptom is of special interest in view of the fact that a similar skin lesion constitutes one of the typical signs of pellagra. In a case of infantile scurvy we have seen an eruption at the nape of the neck which was symmetrical and greatly resembled that of pellagra. Andrews refers to the occurrence of eczema in his description of infantile beriberi. ”

“ Sun disease " was an old popular name, and certainly the skin manifestations of pellagra are influenced by the action of the direct rays of the sun. This was proved experimentally, first by Gherardini, who varied the limits of the eruption by systemati- cally displacing parts of the clothing ; and later by Hameau, who obtained differently shaped patches of erythema by means of gloves fenestrated in different ways. In smallpox and also in other exanthemata we notice a decided influence of light, more particularly of the actinic rays, on the production of their skin eruptions. ”

“ The Urine.—There is rarely any increase in albumin. The most important urinary finding is in connection with indicanuria, 96.4% of Ridlon’s cases showing this finding. As convalescence comes on indicanuria tends to lessen.
The Temperature Chart.—We expect a normal temperature in an uncomplicated case of pellagra but in typhoid pellagra and in the terminal stages of the disease a fever of from 101° to 103°F. is generally noted. Fever makes for a bad prognosis. There is nothing special about the circulatory system other than low blood pressure and a tendency to vasomotor disturbances. ”

“ There are some indications that infection may be the immediate cause, but the strong evidence is that a faulty diet is the chief predisposing cause of the disease. Certain it is that pellagra is both prevented and cured by a diet containing liberal amounts of milk, eggs and leafy vegetables. On the other hand, those who live during the winter months on a diet chiefly derived from bolted white flour, degerminated cornmeal, polished rice, starch, sugar, molasses and fat pork, furnish the victims of this dreaded disease in the spring. ”

“ These flies are widely distributed throughout the world, always occurring in proximity to rapidly flowing streams of water in which the larva? live. The adults, though small, are vicious biters. They appear mainly in the spring, more rarely in the fall, and agree in seasonal distribution with the incidence of pellagra. The causal organism has never been found and is evidently an ultramicroscopical or filterable virus. ”

“ Reviewing the group as a whole, we find that its species are essentially "wild" and lack those habits of intimate association with man which would be expected in the vector of such a disease as pellagra. Although these flies are excessively abundant in some parts of their range and are moderately so in Spartanburg County, man is merely an incidental host, and no disposition whatever to seek him out or to invade his domicile seems to be manifested. Critically considered, it is nearer the fact that usually man is attacked only when he invades their habitat." ”

“ While Simulium pictipes does not attack man, there are a number of the species which are blood-sucking and in some regions they are a veritable scourge. In recent years the greatest interest in the group has been aroused by Sambon's hypothesis that they transmit pellagra from man to man. This has not been established, and, indeed, seems very doubtful, but the importance of these insects as pests and the possibility that they may carry disease make it urgent that detailed life-histories of the hominoxious species be worked out. ”

“ The two diseases are closely allied in the insidious approach of their symptoms, in their implicating the tissue-nutrition through the nerves, or the nervous functions through the nutrition, in their cumulating and incurable character, and in their transmissibility by inheritance. Thus nosologically allied, they may be reasonably suspected of having analogous causes; and as we know the cause of modern pellagra to be something noxious in the habitual diet of the people, we may look for the cause of medieval leprosy in something of the same kind. ”

“ Collective investigations are being made of the prevalence of pellagra, infantile paralysis and leprosy.
A compilation has been prepared of state laws bearing upon reporting diseases, with a view to increasing the collection of morbidity statistics and bringing about improved methods and greater uniformity in their collection. ”

“ An obstinate chronic disease endemic in Ceylon. It has a superficial resemblance to syphilis; the whole body being covered with ulcers, while the sufferer rapidly declines in strength. It seems to arise from insufficient diet, and to be analogous to the pellagra which causes havoc among the peasants of S. Europe. The word is apparently firinghee, 'European,' or (in S. India) 'Portuguese' ”