Pellagra




CHAPTER IX

PELLAGRA

This peculiar
disease is endemic in the maize-eating districts of Northern Italy, Roumania, Egypt
and the southern part of the United
States
, and is now grouped amongst diseases
due to a qualitative deficiency in the diet. Pellagra usually runs a chronic
course extending over many years. The disease is most active at certain
seasons, generally in the spring, but the actual time varies in different
regions; at the particular season a fresh outbreak occurs each year after a
quiescent period. Pellagra has appeared in all parts of the world, irrespective
of race or climate. People of all ages suffer from the disease; it has been
recorded in an infant of 5| months, in an old man of 99 and in a woman of 102.
Women suffer far more frequently than men.

The onset of the disease is often so gradual as to be imperceptible, and
the symptoms do not appear in any definite sequence. The disease in its fully
developed state makes such a typical picture, that when once seen it can never
be mistaken for anything else, but these cases form only a very small
proportion of the whole, and the recognition of less definite cases is not
simple. The pellagrin may succumb to some intercurrent infection. In
uncomplicated cases there is no fever. As the disease makes its slow progress
towards a fatal ending, flesh, strength and intellect fade away until the
pellagrin becomes as withered as a mummy, with bones protruding through the
yellow and blackened skin; death finally occurs from complete exhaustion. In
mild cases pellagra is confined to slight skin and digestive troubles, and many

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such
cases pass unrecognised.   Sometimes
these mild cases recover without treatment.

Symptoms.

The most characteristic features fall into three main groups:

(i) Severe disturbance of the whole digestive tract.—Obstinate
constipation is sometimes the first symptom, but later there is always
diarrhoea. The tongue is sore and inflamed and the entire digestive tract is
disordered. The hydrochloric acid secretion of the stomach is diminished, and
the powers of digestion and absorption generally are impaired. The stools are
liquid and exceedingly offensive and may contain mucous and blood.

 

(2)     

Skin eruption.—The rash is as a rule bi-laterally sym­metrical, i. e. appears
in corresponding positions on both sides of the body, on areas exposed to
sunlight or to friction or pressure. The redness may be so slight as to escape
notice or to be mistaken for sunburn or chaps. In a well-marked eruption the
skin appears shiny, red and tense; there is a sharply defined line between the
healthy and inflamed skin, which feels burning and irritable. The rash is
commonly seen on the back of the hands, on the neck and in a curious butterfly
shape radiating from the bridge of the nose, round the eyes and over the
cheeks. The severity of the skin lesions and the stage at which they are first
seen varies greatly. In communities in which pellagra is endemic, the rash
appears at the same season each year, generally in spring, and after a few
weeks dies away; the skin peels, leaving the underlying area pigmented a light
chocolate colour. After repeated attacks the skin becomes permanently dry,
shrivelled, pig­mented almost black and fissured by deep cracks. The name
pellagra was derived from Italian words meaning rough skin.

 

(3)     

Nervous and mental
symptoms.
—The onset of the disease is marked by
great mental depression, headache and sleeplessness, with much disinclination
for mental or physical effort. There may be vague pains in the spine and
joints, and attacks of cramp, giddiness, or faintness. With each seasonal
recurrence the nervous symptoms increase; depression deepens to acute
melancholia or delusions of persecution; many pellagrins become suicidal or
maniacal. On the other hand, many cases are sane and always remain so, but most
admit to a feeling of depression and impending disaster,



92   VITAMINS AND THE  CHOICE OF FOOD

There is no certain evidence that pellagra existed in Europe before Columbus introduced maize from America. The first accurate
description was written in Spanish by Pedro Gasal in 1707; he called it Mai
de la rosa
and described it as a new disease. From Spain pellagra spread to France, Lombardy
and eastwards, wherever maize became extensively used for food by a poor agri­cultural
population. At the present time the disease is no longer endemic in France and has greatly decreased in Spain. In Italy in 1881 there were over 104,000
pella-grins, nearly all in the northern
provinces
; in 1905, 53,000 cases were recorded. In
Roumania the disease has increased continually since its first appearance about
1836; in 1912 it was estimated that there were about 75,000 pellagrins out of a
population of 5,000,000, but the number has largely increased since the War. In
the United States
the disease was not recognised as pellagra till 1908. Since then the disease
has appeared to increase by leaps and bounds, but some of this increase is
fictitious; a better knowledge of the symptoms brought to fight many cases
previously unidentified. Many cases were also recalled which had escaped
diagnosis in the past. During the American Civil War (1861-65) there was heavy
mortality at Libby Prison, Richmond,
Virginia
. Maize was the principal
and sometimes the only food. The prisoners developed a kind of eczema, their
skin was rough and hard, their hands sore and cracked, their bowels chronically
loose, and they suffered from melan­cholia and dementia. The whole picture is
suggestive of pellagra, which was presumably responsible for the large number
of deaths.

There are no complete statistics of the prevalence of pellagra in the United States.
Notification is not compulsory in every State and many cases are concealed, for
it is considered a loathsome disease, and the motive for concealment is
strengthened by the fact that many hotels, hospitals and sanatoria exclude
pellagrins. Such figures as are available show that the pellagra problem



PELLAGRA



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in
the Southern States is very serious. In 1916 in Carolina this disease ranked
second highest amongst the causes of death; there were over 100,000 cases and
about 4000 deaths in all the Southern States; during 1917 the number of cases
increased by about 25 per cent. After 1917 the incidence of the disease began
to decline as a result of the measures taken to check it. In the Northern
States pellagra is much more rare; in both north and south Jews are practically
exempt.

An epidemic of pellagra broke out early in 1916 near Port Said at the American Gamp for Armenian
refugees. Later in the same year pellagra began amongst the Turkish prisoners
of war in Egypt,
and the disease con­tinued till the last prisoners were repatriated in 1920.
Altogether there were over 9000 cases amongst 105,000 prisoners. The German
prisoners of war in Egypt
suffered slightly from pellagra: 79 cases amongst 7608 prisoners.

Cases of pellagra may crop up anywhere, and from time to time have been
recorded in the British Isles. It is probable
that many isolated cases are not identified as pellagra.

The cause of the disease baffled many investigators. It seemed
impossible to track down every case to a similar origin. The association of
maize and pellagra was difficult to explain; for, although it is most prevalent
in maize-eating districts, yet in other parts of the world, e. g. Mexico,
maize is eaten largely but pellagra has not been recognised; again, pellagra
has often occurred in individuals who have not eaten maize. Funk (1913) was the
first to observe the parallelism of maize and pellagra to rice and beri-beri.
He pursued the analogy too closely in assuming that pellagra was caused by the
loss of some food-substance in the milling process of maize, and failed to
substantiate his theory.

Oasal, in his original description of the disease, had associated it
with a poor diet, and remarked that " the patients obtained great relief
when their food (which contained no meat) was replaced by other substances of



94   VITAMINS AND THE CHOICE OF
FOOD

a
more sustaining kind." Goethe in his Italian Journeys (1816)
mentioned the pitiful condition of the Tyrolese peasants, and thought it was
caused by their food, which was corn, fruit, green haricots and sometimes a
little cheese, " they ate no meat the entire year; " the symptoms he
described correspond with those of pellagra. Townsend in his Travels through
Spain
(1789) gave the first descrip­tion in English of this disease, and
said that it originated amongst people " who ate little flesh in their
food." Their diet was Indian corn (= maize), beans, peas, chest­nuts,
apples, pears, melons and cucumbers.

Towards the close of the nineteenth century the associa­tion of pellagra
with a diet poor in meat was lost sight of, owing to the growth of the new
science of bacteriology and the tendency to ascribe every disease of unknown
cause to some positive agent, such as a micro-organism or a toxin produced by a
micro-organism. Pellagra at one time was supposed to be due to a toxin formed
in maize by the action of moulds or bacteria, and at other times to be a direct
infection. The belief in its infectious nature was predominant at the time of
the discovery of pellagra in the United States. Various commissions
were formed to study the disease with the primary object of determining whether
it was caused by an infection or by an error in the diet.

Dr. Joseph Goldberger and his colleagues, who began their investigations
in 1914, found that it was not possible to reproduce the disease either in man
or animals by feeding or inoculating with secretions or with any sort of
material likely to contain infection from cases of pellagra. Goldberger drew
attention to observations made in European institutions for the segregation of
pellagrins, that the disease did not spread from the patients to the staff in
spite of the absence of any special precautions. He discovered the same freedom
from pellagra amongst the nurses and attendants in various orphanages and
lunatic asylums in the United
States
in which there were outbreaks of
pellagra.



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95



Two instances recorded by Willets were quoted by Goldberger:

In Georgia State Sanitarium, 7-65 per cent, of the patients remaining
over one year developed pellagra; there were no cases among 293 attendants who
had been in intimate contact with them all the time.

In the Orphanage at Jackson,
Missouri
, 68 out of 211 children
(32 per cent.) developed pellagra. Two cases were amongst children under six;
one case amongst children over twelve; [all the other cases were amongst
children aged six to twelve years. The housing and general conditions of life
were the same for children of all ages.

The exemption of the older and younger groups of children was as inexphcable
on the basis of infection as the exemption of the attendants in Georgia State
Sani­tarium. The only constant difference which could be detected was in the
diet. At both institutions those free from pellagra had a better diet
containing more meat, milk, eggs, etc.; those who contracted the disease had
little fresh animal food and a great deal of maize and syrup.

In some other institutions there was an obvious
difference
between the diet of the staff and of the
patients, whilst in those in which no difference was supposed to exist, a
minute examination showed that although the food was theoretically the same,
yet actually there was a difference. The nurses availed themselves of their
privilege of selecting the best and most varied food from the institu­tional
dietary, and also supplemented it from outside.

The prevalence of pellagra in the cotton-mill districts of South Carolina was also
found to be related to the diet. In the pellagrous households the food, though
satisfying the standards of energy value and of quantity of protein, which was
derived mainly from cereals, beans and peas, contained too little protein of
animal origin. In the non-pellagrous households more eggs, meat, milk and
cheese were used.   The pellagrous
households generally used



96   VITAMINS AND THE  CHOICE OF FOOD

rather
less carbohydrate food, thus excluding any con­nection between pellagra and an
excessive amount of carbohydrate. The prevalence of pellagra in this dis­trict
was directly associated with the poor supply of meat and milk : there were no
dairies or butchers' shops; little meat or poultry was produced locally, and
few cows were kept.

Additional evidence of the association of pellagra with an unbalanced
diet came from many sources. The dis­tribution of pellagra in Catto Parish, U.S.A.,
quoted by Dr. A. A. Herold, is a good illustration. Here agricultural and
mining districts lie side by side; the general hygienic conditions favour the
agricultural community, who are the sufferers from pellagra.

Mineral Oil District.         Agricultural District.

Bad sanitation, flies, mosquitoes.      
Better sanitation, fewer flies, etc.
Typhoid and malaria frequent.         Typhoid
and malaria less frequent.

Diet, thoroughly mixed and varied. Diet, chiefly fat pork, corn-meal
No pellagra.                            and
syrup.

200 cases of pellagra.

Goldberger concluded that pellagra was in no sense of the word a
communicable disease, but connected with the food. The chief foods of
pellagrous districts and institutions were vegetables and cereals. He therefore
suggested that the disease might be prevented by reducing the quantity of
cereals and increasing the amount of fresh animal foods such as meat, milk and
eggs. This recommendation was put into practice at two orphanages in Jackson, Missouri,
and pellagra was eliminated.

The cereal diet of the pellagrins is generally necessitated by poverty
and the high price of meat, milk, fish and eggs. In the winter the diet is
limited to the cheaper vegetables, cereals, carbohydrates and fats, such as
sweet-potatoes, maize, syrup and " sow-belly" fat. A rise-in the
price of food, especially of meat, poultry and eggs, as Syden-stricker (1915)
showed, was followed by an increase of pellagra. A fall in wages at the same
time had neces­sitated sacrifices in the variety, quality and quantity.



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97



In
the poorer asylums the prevalence of pellagra was due to fewer and less skilled
attendants, who were unable to care for the patients individually and to see
that each actually consumed his share of the food. There were more cases of
pellagra amongst the so-called " untidy " group of patients who could
not feed themselves properly, and who allowed their plates to be robbed by
other patients known as " stealers." In all parts of the world it is
the " untidy " class of asylum patients who suffer from pellagra,
scurvy, or beri-beri.

Goldberg therefore added to his earlier recommendation the caution that
it is necessary to see that the good food provided is actually eaten by each
individual. The need for this caution was endorsed by Colonel Vaughan, who had
difficulty in making the men of the Southern Army camps eat the good ration
provided. They had been accustomed at home to eating corn-bread, fat pork and
corn syrup, and if they could get these would eat nothing else.

In general, it was concluded that pellagra does not develop amongst
those who eat a varied and well-balanced diet. No cases have been described
either on the rations issued to the United States Army and Marine Corps or to
the Italian troops, though both in Italy and the States many of the
recruits come from pellagrous districts.

Goldberger, assisted by Wheeler, verified all his con­clusions by an
actual experiment. With the bribe of a free pardon from the Governor of
Mississippi, eleven healthy convicts, who had never suffered from pellagra,
were induced to volunteer for a feeding experiment to ascertain if the disease
could be produced in healthy white men by a one-sided, chiefly cereal diet. The
experiment was carried out at Rankin Farm belonging to the State Penitentiary,
where there was no previous history of pellagra. The hygienic conditions were
excellent and special precautions were taken to exclude flies and any infection
which they might carry. To reduce further the possibility of infection, the "
pellagra squad," as they

H



98   VITAMINS AND THE CHOICE OF
FOOD

were
called, were segregated and kept under observation for a preliminary period on
the ordinary prison diet. They were then given a diet of biscuits, white wheat
flour, various maize preparations, gravy, syrup, sugar, coffee, collards,
cabbage, sweet-potatoes, turnips and turnip greens, rice and fat pork. The
daily quantity per man had an energy value of about 3000 Calories per day,
sufficient considering the very light work done. As controls, thirty-five other
prisoners, four free women and two children, were kept on an ordinary mixed
diet con­taining some meat, eggs and buttermilk. They lived under inferior
hygienic conditions and no precautions were taken to protect them from any
infection. During the second month of the experimental diet all the pellagra
squad complained of weakness, headache, abdominal pain or some other
discomfort. After five months skin eruptions were noticed in six men; the
symptoms were pronounced by experts to be those associated with pellagra. The
experiment had to be discontinued at this stage, owing to the refusal of the
prisoners to continue. During the last four weeks all the prisoners on the
experi­mental diet had shown marked loss of body weight and all were out of health.
Pellagra thus developed in six out of eleven men, and would probably have
developed in all if the diet had been continued a little longer. Indeed Wilson, from his experiences with the outbreaks in Egypt during
the War, considers that four other cases might well have been included as
pellagrous from the peculiar intestinal and lingual symptoms described. There
was not a single case of pellagra amongst the controls; they remained in good
health.

Goldberger's work has been approved by Colonel Vaughan and Dr. Welch,
who were appointed by the Public Health Service to examine it. His results are
in accordance with the original observations of Casal, Townsend and Goethe,
that meat was seldom eaten in pellagrous districts, and exclude the possibility
of infection as the cause of the disease.  
Variation in the



PELLAGRA



99



composition
of the diet accounts for the seasonal epidemics of the disease. Lombroso's data
show the seasonal change in the diet in Italy:

 

 

Eight Winter
Months.

Four Summer Months

Polenta
(maize)

I.OOO

grms.

160 grms

per day

Bread
(partly maize)

IOO

Jf

600

II              II

Meat    ....

10

it

60     

II                1*

Cheese

5

 

20      

II                II

Beans

150

tt

40  

II                II

Milk
and eggs

0

"

0    ,.

"               n

Smaller quantities of meat and
cheese are used in the winter and more maize and beans.

The value of animal protein in preventing pellagra was again exemplified
by the distribution of pellagra during the War. All the troops with their high
meat ration were free from this disease, though they suffered at times from
beri-beri or scurvy. In Roumania the civilian population, whose chief food was
maize, were terribly afflicted with pellagra, but the Roumanian Army, which was
well supplied with meat, escaped the disease. The epidemics of pellagra in the
refugee and prisoners' camps in Egypt
were connected with the small ration of animal protein.

A diet containing meat, milk, fish and eggs will cure cases of pellagra
which have not progressed too far; a return to the former poor diet naturally
will cause a relapse. Advanced cases are very difficult to cure, as the
digestion may be so disordered that protein cannot be assimilated. Digestion is
greatly helped by the adminis­tration of hydrochloric acid (physiological
strength = 0-2 per cent.) in addition to good food. The diarrhoea which is so common in pellagra has been found to
be a sign
that the gastric secretion is deficient in hydrochloric acid.

Goldberger and his associates in America,
and Wilson and other workers in Egypt, have
proved beyond question that pellagra follows if the food for a long period has
been poor in animal protein, although the total amount of protein in the diet
satisfies the physiological standard and there is no shortage of vitamins. The
quality of the protein is the determining factor.

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