CORNELL UNIVERSITY LIBRARY GIFT OF Hauck Memorial Fund Pellagra, 3 1924 012 173 252 Cornell University Library The original of tliis bool< is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924012173252 EOYI'TIAN PlSLLAGIlA. Courtesy of Dr. F. M. Sandwith. PELLAGRA BY DR. A. MARIE Physician to the An/lunu, ^efartment of the Seine, Editor-in-Chief, Archives de J^euroJogie, and director of the Lahoratory of Pathological Psychology, Ecole des Hautes Etudes, Paris, France \(/ith Introductory J^otes ly Prof. Lomhroso Autborized Translation From the French BY C. H. LAVINDER, M. D. Passed Assistant Surgeon XJ. S. Public Health and y^arine Hospital Service AND J. W. BABCOCK, M, D. Physician and Superintendent State Hospital for the Insane, Columbia, S. C. 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The average of all the experiments in this period of the disease was 36.72 degrees. In one case only, consequently 16 per cent., was there no febrile tem- perature. In the 35 cases of the second period, there were 6.01 per cent, above the normal, or twice as many as in the cases of the first period. In one case the TEMPERATUEE 213 temperature rose to 39.4 degrees, in another to 39 degrees; in 14 cases it oscillated between 38 and 38.9 degrees; in 19 cases it was below 38 degrees. The average of all was 36.81 degrees, or 0.09 of a degree higher than the average of the cases of the first period. There were ten cases without a trace of febrile temperature, that is 28.57 per cent. The tendency to a febrile state is more accentuated in the third stage. Of these there were 59, and the temperature was found above normal 1,745 times, which is 10.12 per cent, of the total observations, being nearly double that of the second stage. The highest temperature observed was 41.5 degrees; the others were as follows: 40 degrees and above in 11 cases ; 39-40 degrees in 23 cases ; 38-39 degrees in 17 cases ; below 38 degrees in 8 cases. The average of all the observations was 37.06 degrees ; it was, therefore, more elevated by a quarter of a degree than the average of the cases of the second stage. A single case, that is 1.7 per cent., showed no fever, but still it ought to be stated that this case reached the max- imum of the normal temperature, that is 37.4 degrees. An observation which may have a certain prog- nostic interest, is that the twelve patients whose tem- peratures had not been above normal during their stay at the hospital, left it cured with one exception, and this one case showed no improvement. Analo- gous results are obtained by observing the cases at different stages. The temperature increases during the passage from the first to the second or from the second to the 214 PELLAGRA third stages. For example, in one case the highest temperature in the first stage was 37.5 degrees with an average of 36.98 degrees ; in the second stage the highest was 38.1 with an average of 37.14 degrees. So, in another case, the second stage was afebrile, ■with an average of 36.60 degrees, while in the third stage there was a maximum of 40 and an average of 36.82 degrees. But even in the course of a single stage in a febrile case, Alpago-Novello was able to assure himself that the improvement of the patient proceeded fari passu with a gradual decline of the temperature. And he was able to state that vice versa, the aggravation of the disease proceeded step by step with the rise of the temperature. This accords with the experiments on dogs in which the aggrava- tion of the symptoms of intoxication occurred at the same time with the maximum of temperature and minimum of weight. Of the 38 pellagrins who died of the disease, 28 had in their last days a febrile temperature ; nine did not. Likewise with dogs, temperature elevation runs parallel with diminution in weight, and increases at the approach of death. The course of pellagrous fever is absolutely irreg- ular. It is rarely continuous, is often remittent, almost always with an evening rise; it is frequently intermittent (the rise usually occurring in the even- ing), and there is always a great irregularity both in course and in elevation. Often there is a fever disturbance at varying intervals. In the cases of typhoid pellagra Lombroso and iBelmondo have noted some rare conditions of subnormal temper- ature (33 degrees) in the last days of the malady. Plate XIII. Illinois case. I'ellagrous '%^auntlet" and unusual localization on arms. Courtesy of Dr. G. A. Zeller. TJRINE 215 Eoncoroni and Lombroso followed attentively three patients for five days and the difference in the sides was almost regularly .1 to .2 of a degree, and in two cases especially a higher temperature was noted »n the left axilla. In another series of observations of 12 pellagra patients the tempera- times on the left; twice only it was equal. [See charts.] Urine : Of 100 pellagra patients the quantity of urine in twenty-four hours showed an average of 900 c. c, with a minimum of 500 c. c. and a maximum of 1,900 c. c. The quantity is, therefore, less than normal. Calderini also found in 35 per cent, of his pellagra patients a great diminution of the quantity of urine. The reactions of the urines of pellagra patients show a marked difference from the normal. In 100 cases the urine was: 76 times slightly acid; 14 times neutral ; 10 times alkaline. It is in the most severe cases that the urine is more often alkaline (paralytics and aged patients) ; but also in young patients having cataleptiform or epileptiform attacks Calderini has made the same observation. Also in an examination of 33 cases, he found 21 per cent, of the urines strongly acid, 57 per cent, of slight acidity, 12 per cent, neutral, and 9 per cent, alkaline. Verga found 11 per cent, of the urines alkaline and 21 per cent, neutral. The color of the urines is constantly pale yellow, never passing the numbers 3 and 4 of the Vogel scale. The specific gravity is always less than the normal; it varies between 1,005 and 1,010, and between 1,018 and 1,025. 216 PEIiDAGHA A remarkable peculiarity of the secretion of urine is its constancy; even at the approach of death pellagra patients show very little change in the quantity, color and reaction of the urine. And in pellagrous meningitis and typhoid pellagra one finds, with a pulse of 120 and a temperature of 39 to 41 degrees, the specific gravity of the urine is often less than normal. Roncoroni has exanuned the constituents of the urine in three cases, partic- ularly with regard to the urea (by Esbach's method), the phosphates and the chlorides. As a means of control the urine of three epileptics, while free from attacks, was taken. The persons under observation were placed under the same regimen. They were put on a daily diet equivalent to 147.41 grams of albumen and casein, 567.27 grams of fats and carbohydrates, 22.891 grams of proteids, and 48.913 grams of urea. The observations were con- tinued for ten days. The average results were: a a Ul a o -«1Z CQ as II Ends of fingers 54 59 60 92 94 46 54 35 41 35 90 90 29 39 19 Forearm (Internal surface) .... Forearm (external surface) .... Forehead 18 25 2 Nose 4 Palms 17 Back of hand 15 The diminution of the sensibility to pain observed among pellagrins is not found in the other insane, among whom it is generally increased, or, at least, normal. Out of thirty severe cases, Tonnini found five times a profound analgesia extending from the feet 232 PELLAGRA even to the face, but greater in the lower extremities ; he found more or less analgesia fourteen times, and hyperalgesia four times. In forty pellagrins less severely affected Tonnini found two-thirds analgesic, and only two hyperalgesic. Hyperalgesia in pellagra is more common in florid types, and is accompanied by a decided ele- vation of the temperature. The cases are numerous in which, if they are touched, principally on the stomach or on the thorax, they begin to cry out, and at the least noise they start; others have painful parsesthesise, as if water were thrown on their heads, or as if they were pricked on the legs by thousands of pins; they complain also of burning in the eyes, in the nose and in the face. Insensibility to pain is often shown by their voluntary exposure to cold as well as to burning or scorching to which they repeatedly expose themselves. Tonnini found the sensibility to heat better preserved in the face than in the extremities. But sometimes cryesthesia is found. Vision. In five cases of pellagra observed by Roncoroni and Ottolenghi the sight was normal. Among ten the study of the visual field did not disclose anything worthy of note. In two other cases there was partial vertical homonymous hemiopsia. In five cases color vision was entirely normal. Taste and Smell. The sense of taste is little diminished ; four pella- grins being examined with strychnine sulphate ANOMALIES Or SENSATIOK 233 could, on the average, detect the bitter taste in a 1 to 243,000 solution (healthy individuals 1 to 500,- 000). Saccharine was detected in solution of 1 to 37,000 (healthy individuals 1 to 80,000). These same persons noticed perfumes in very dilute solu- tions (1 part of oil of carnations to 50,000 of water) . They distinguished readily also quantitative differ- ences in solutions of perfumes but could not describe their nature. Anomalies of Sensation. A subjective sensation experienced with few exceptions always in the beginning of the disease, and lasting frequently to the end, is that of burning on the hands and legs, sometimes over the entire body. Others, on the contrary, experience a sensa- tion of cold or of heat internally and of cold in the extremities. Then there is frequently pruritus in the groin or on the back and arms ; some patients have abnormal sensations in the genital organs and in the anus, just as do some alcoholics; others believe that they feel hot water running down the back, or on the head, or have burning and itching at the nipples and in the inguinal region; when they are touched they think they feel prickings and twitchings, principally between the shoulder blades, in the thumb and on the soles of the feet. Sometimes this sensation extends all along the vertebral column, so that the patients cannot be covered in bed or dressed with- out great distress. Often they feel neuralgic pains in the arms, in the groin or in the thighs, and shoot- 234 PELLAGRA ing pains which injections of morphine do not relieve. Frequent are the cases of cephalalgia, which increases if the sick remain on their feet or are exposed to the light of the sun. Once persistent hemicrania was noted, with increase of temperature on one side of the face and enlargement of the pupil of the same side. An intelligent female pellagrin, subject to fre- quent attacks of crying and continuous insomnia in the five or six days which preceded these attacks, had an invincible desire to sleep. Another lay down in the fields in order to sleep, and remained thus two or three days; she became angry when they wished to interrupt her sleep. This somnolence is sometimes persistent, and in one case it lasted two years. Insomnia, however, is more common even among pellagrins not mentally affected. CHAPTER VII Psychic and Paretic Phenomena, Complications, Heeeditt. It is not easy in the study of the psychic phe- nomena of pellagra to distinguish those symptoms produced directly by the disease from mere coinci- dences or accidental complications, more especially insanity. There are depressed mental states which arise from the pitiful and wretched condition of these pariahs of upper Italy, This condition can frequently be explained as a melancholia analogous to the melancholia ab miseria of Lasegue. A notable peculiarity among pellagrins, even when not mentally affected, is an increasing irrita- bility; at the least inconvenience or on the slightest emotional disturbance they quickly display temper, although ordinarily they appear quite normal. This is a characteristic common to alcoholics and to paralytics in the early stages of their malady; and this can be explained by the law that any enfeebled organ is readily irritated and easily suffers. The laity, who consider these external signs only, frequently attribute pellagra to moral causes. Perversions of feeling are generally rare. Very often the patients complain of a loss of memory and of mental weakness, which diminish when they are in bed or lying down. Certain others indulge in introspection and analyze very acutely their mental troubles. The poor wife of a fisherman, ordinarily taciturn and apparently rather dull, 236 PELLAGRA caused surprise in the course of her attacks by some rather remarkable observations, for instance: "Notice, now, these invalids, they have no hearts, they are full of superstitions, they use cards to learn whether their husbands will be true, as if the chance of cards could have such influence; then from the accidental fall of a -card they draw conclusions by which they are irritated and plunged into quarrels. Is not this sickness rather than insanity?" Chronic pellagra is often accompanied by a hypo- maniacal state with a tendency to sarcastic speeches and caustic observations, a thing often seen among other insanities. Frequently the pellagrous psy- chosis appears under the form of a special melan- cholia, more often in the form of an insanity with systematized delusions. This last form may be observed in hereditary pellagra; vagaries of mem- ory, self-accusations, nosophobia, apprehensions of personal violence, delusions of pregnancy, loss of personality, and concealment of sex have all been noted. A woman of Seronno, 38 years old, confided mys- teriously to the judge that she had been violated and had become pregnant. She believed that she had given birth to a child, and then, with the help of her seducer, had buried it alive; for three months she led the officers of justice to many places in search of the little corpse ; when finally a medical examina- tion revealed that she was a virgin suffering from pellagra. In another case a male pellagrin imagined himself affected with venereal disease. He dosed himself PSYCHIC AND PARETIC PHENOMENA 237 with remedies advertised in the newspapers, and at last complaining that all the world was pointing the finger of scorn at him, he threw himself into the water. Another sufferer, of sufficient intelligence to be employed in the care and instruction of convales- cents, imagined that he was going to marry in a short time a young and wealthy marchioness, and dissimulated his delusion with a finesse which is sometimes seen in the paranoiac state. A pellagrin in the hospital at Milan, besides the usual symptoms of pellagra, suffered from a cardiac affection accompanied by edema ; he displayed a true monomania of avarice, rigidly economizing his own food, at the same time striving to prevent others from eating. But these are exceptional cases, and, as Verga has noted, are probably only examples of a psychosis engrafted upon pellagra. In general, even when pellagrous mania assumes a type, it is rather that of systematized delirium than of paranoia. In almost all cases of pseudo-monomania there is associated a well nourished body, and this is another analogy with general paralysis. Another characteristic in pellagrous insan'ty, is a real or, more often, apparent stupidity or an obsti- nate mutism. The sick stay motionless iu a crouched position, as if they sought to avoid not only social contact with other people, but even the light itself. When this apathy ceases, it may be succeeded by attacks of psychic epilepsy or often followed by an 238 PELLAGRA active delirium ending in a ceaseless torrent of words. In other cases, instead of these depressed and sluggish phenomena, there may be observed a persistent gaity or an exaggerated activity. The patients repeat, without weariness, certain appeals, chants, phrases, sometimes with an insupportable tenacity, and resemble in this the stereotypy of dementia precox. Cases of hallucination are numerous, especially those having a strain of cenesthesia, and these have a certain dependence upon an abnormal state of the viscera. They burn, they have dogs in their stomach, they see water on all sides, and hear voices commanding them to drown themselves ; or, perhaps, they are aggressive, believing themselves insulted. The psychoses of pellagra do not show persistent paroxysms without interruption, they are rather short recrudescences and fleeting disturbances. The anarthria or brief aphasic attacks which are found in certain paralytics, alcoholics or epilep- tics, are not met with in pellagra. There is, how- ever, often an embarrassment of speech with a ten- dency to repeat certain words, and to pronounce phrases without connection. Two peculiarities which are more characteristic of pellagrous psychosis are sitophobia and hydromania. The most frequent form of psychosis in pellagra, according to Eegis, is mental confusion with depres- sive states or with delirium. It exists, more or less marked, in most of the cases. It manifests itself by inertia, passivity, indifference, torpor, frequently very marked; by insomnia, often with terrifying PSYCHIC AND PAHETIC PHENOMENA 239 hallucinations both of sight and hearing; by depressed delusional states with fixed ideas of despair, of damnation, of fear, of anxiety, of per- secution, of poisoning, of possession by demons and sorcerers (Warnock) ; by refusal of food, and a ten- dency to suicide, especially to suicide by drowning, so much so that Strambio has designated this feature of the disease by the name of hydromania. This melancholic depression, which may go in certain cases as far as stupor, is always accompanied by, or founded on, a certain mental obtuseness, even intel- lectual dullness, and considerable general anesthesia (Morichon, Beauchamp and Courtellemont), which finally becomes permanent and culminates gradually in a dementia which deepens in proportion, as the pellagrous cachexia progresses. It may be accom- panied by polyneuritis (Righetti). One may observe also in every severe chronic intox- ication a morbid state resembling general paralysis (pellagrous pseudo-paresis). This occurs especially in those cases in which, instead of the habitual melancholic ideas, the patients present ideas of satis- faction and wealth (Warnock, Marie). "Stupor," says Girma, "has been often mentioned, as well as ideas of suicide; in two cases the disease developed with alternations of agitation and depres- sion; twice there was an intellectual torpor, like dementia; three times trembling of the hands and of the tongue was noted, as well as difficulties in walking, difficulties of speech, and once paraplegia; these cases furnished a symptomatology somewhat similar to that of paralysis and we even make use of 240 PELLAGRA the term pellagrous pseudo-general-paralysis; once there were spinal and abdominal pains. "Deaths in pellagra have resulted: three times from cerebral congestion ; four times from pellagrous marasmus with diarrhoea; four times from pul- monary tuberculosis. These deaths followed upon a rather short stay — some months at the most — ^in the Asylum of Pau. "The cases which recovered progressed favorably rather than rapidly under a tonic regimen and their discharge took place in .the course of the first year. Only two hereditary cases, with mental aberration, had to be detained longer; one developed dementia; the other, originally defective, was discharged at the end of three years 'improved.' " Refusal or Food. In many cases refusal of food is the result of per- verted innervation of the stomach, which shows itself by anorexia or voracious appetite. Such patients often say they feel a lump in the epigas- trium, and cannot swallow food (dysphagia). A female patient obstinately refused all nourishment during her insanity, and upon recovery ate on request, but with great repugnance. "It seems to me that I am filling up a body already full ; I am full up to the neck." Constipation may sometimes explain this sensation of repletion. Repugnance for food may also be explained by other somatic causes or delusional ideas — fear of injury, of indignity, of culpability, etc. In other cases it may be due to hallucinations, such as visions of the host on plates PSYCHIC AND PARETIC PHENOMENA 241 or fear of poison, but it is then only a partial sito- phobia. Eepugnance to food is sometimes due to negativism and resistance; if no notice is taken of such patients and they are left to themselves, they eat better. Suicide. The other condition, characteristic of pellagra, hydromania, has also variable and complex causes. In many cases there exists a real passion for water; and this is justified by the continuous burning sensa- tions which are relieved by effusions of cold water. "See," said a patient, "this water is my only salva- tion, if I were not able to bathe myself constantly these burning sensations would drive me to suicide. I would not give this water for all the treasures in the world." In rigorous winter weather some may even break the ice in order to plunge into the water. In other cases this tendency does not spring from sensations of burning, but seems due to the pleasure evoked in patients by the attraction of the shimmer- ing surface of the water. This peculiarity is related to certain modifications in the retina, and is seen at times in children and in some paralytics. On some pellagrins fire produces impressions similar to those of water; they may throw their effects into it, and even burn their own hair or beard. A gardener, forty-five years old, who suffered from pellagra with pruritus and a muscular feebleness, which compelled him to rest at least two days each week, used to say : "Nothing in the world gives me more pleasure than a little stream; when I take a walk I go alongside of it and look at it always as 242 FEUiAOKA long as I can. In the night I dream of seeing water," On the other hand, others have a great repugnance to water; the sight of it terrifies them. This repugnance is poorly interpreted by many observers. It may lead to suicide by drowning from a para- doxical attraction against which, at first, the patients try to struggle. For an accurate comprehension of this phenomenon it is necessary to analyze their con- fessions. "When I see water," said one patient, "my eyes are blinded and I am nauseated. If I cross a bridge, I am obliged to close my eyes, and try to walk in the middle, otherwise I should fall." "If I look into the water," said another, "I am obliged to close my eyes, and to hold on to a stake or to a tree ; if I do not, I feel myself attracted by the water and am likely to fall." "If I do not close my eyes at sight of water, it forces me to turn my head in its direction, and I cannot withdraw my gaze from it," etc. These two contradictory phenomena of attraction and fear are really not irreconcilable. Certain of these "hydrophobias" are marked by a fear of flow- ing surfaces because of photophobia. For others, however, actual contact is sometimes necessary, while still others cannot endure to drink any but hot liquids or the opposite. These sufferers certainly do not go into the water because of any predilection for it, quite the con- trary. Indeed, water, as does a mirror in certain delicate women, causes in some an overwhelming impression of disgust, or of repugnance or a vertigo. PSYCHIC AND PAEETIC PHENOMENA 243 One day, in fine weather, a patient being placed in front of a turning mirror, hid his eyes, drew back his head, and did not wish to look again, saying that it produced on him the same effect as water. Another patient, when placed before a mirror which reflected the rays of the sun, feU a few minutes afterwards in an attack and was nauseated. Many patients have a repugnance for water, notwithstanding the fact that it does not cause them to feel stupefied. Here again is seen evidence of the contradictory phe- nomena which are so often found in chronic intox- ications, especially in pellagra. Some even feel repugnance to cold water, and are obliged to heat it in order to drink. In Tuscany, pellagra is often the cause of many people not being able to endure hydrotherapeutic treatment. Many sufferers drown themselves not from disgust of life, but in obedience to hallucinations which probably arise in recollections of former agreeable impressions, associated with water. Suicides by drowning are numerous also by reason of a kind of motor automatism or instinctive impul- sion, similar to attacks in epileptics. They do not know why they throw themselves into the water, and if they survive, they can not explain their attempt. Certain patients throw themselves into the -water not to drown themselves, but to find some relief from their torturing paresthesias, and being seized with vertigo, they are drowned. One pellagrin could neither go to stool nor urinate anywhere except in a ditch, the water of which alone could stimulate his enfeebled reflexes. 244 PELLAGRA Finally, frequent suicides occur from a fixed reso- lution to escape from the sufferings of the malady. In the execution of their attempts they derive aid from a profound perversion of sensibility, which, while it makes them painfully aware of certain impressions, arising from the stomach and heart, renders them, on the other hand, less sensitive to trauma and other more painful things. Thus a pellagrin, who suffered intolerable pains in the epigastrium, cut his throat with a sickle, and then dragged himself 100 metres to his house with his sickle in his hand. It appears, then, that when death by drowning occurs among pellagrins, there is always doubt as to whether it is accidental or suicidal. . Statistics show that in those provinces of Italy where pellagra is prevalent, suicides by drowning, voluntary or accidental, are more numerous than in the provinces whose inhabitants, by the nature of their work, or by the mere situation of their habita- tion near the water (Naples, Sardinia, Liguria), are more exposed to drowning. It follows that in dis- tricts like Lombardy and Emilia, where there is much pellagra, almost half of the suicides occur by drowning. On the contrary, Tuscany, Romagna, Naples and Sicily, which have a numerous popula- tion of fishermen, and are half surrounded by the sea, have a small number of such suicides in com- parison to population. These facts would become still more obvious if the deaths by accident are compared with those by drowning in various regions or provinces, though there are exceptions. psychic and paretic phenomena 245 Intermissions. A remarkable peculiarity of pellagra, that is well known, is the intermittent appearance of the psychic symptoms. The rare attacks during cold weather are almost doubled in the months of spring. They become par- ticularly numerous in the month of March, and increase with the heat up to July. The number is small in the spring and increases again in autiunn (September). For more exact observation a record was kept of severe psychic exacerbations in 100 pellagrous insane during a period of five years ; the averages are given in the table below : Dec. Jan. Feb. Mch. April May June July Aug. Sept. Oct. Nov. Attacks 33 34 27 50 64 67 77 88 46 81 66 48 There are two causes for this. The influence of the elevation of temperature, but still more, the rapid thermometric and barometric changes. The attacks of autumn are those which demonstrate this. Other observers, as Calderini, have remarked that in many cases of pellagra, the relapse of psychic troubles took place in the autumn instead of in the spring. Spring recrudescences are also observed in endemic alcoholism. It is possible that these symptoms depend on the deficiency of certain mineral salts in the blood, for example the phosphates, which are diminished in the first cold months, more exactly in the proportion of 0.569 to 1.064, in comparison with the winter months. 246 PELLAGRA In six cases a tertian type of recrudescence was noted. For example, M. G., thirty-seven years old, refused nourishment for a day, pulse 90 and tem- perature 37.5 C. degrees; the following day she was entirely herself, pulse 80 and temperature 36; the third day she was delirious again, with increased temperature and pulse rate. Another periodicity common in pellagra is of a diurnal type with recrudescences at certain hours. Almost all the patients say that their headaches are more violent between midday and three o'clock, during the hours of the greatest heat. Others declare that they have vertigo all night, and hallucinations before falling asleep, whereas during the day they feel well. Development. From the standpoint of the evolution of the indi- vidual, certain pellagrous psychoses are character- ized by an arrest of development (denied by Fer- rario) ; a kind of hebephrenia with genital and gen- eral insufficiency; numerous examples of this have been cited (hereditary pellagra and infantile degen- erations). Complications. Pellagra may be complicated with many other dis- eases, which sometimes mask it completely. The most common of these is alcoholism. (a) Alcoholism. The question whether certain symptoms come from alcoholism or from pellagra, is, at times, very .i^?. /^jO PSYCHIC AND PARETIC PHENOMENA 247 difficult to decide. This arises in part from the fact that many incipient pellagrins, like paralytics, seek a passing solace in alcohol. Others are obliged by their expenditures in alcohol, to buy for food spoiled com, which is, of course, cheaper. Small quantities of alcohol used by others, already predisposed to the disease by the poisons of com, easily precipitate the malady just as might be done by other secondary causes. These two factors are often coincident, and the sufferer, not willing to con- fess his vice, leads the physician into error. A pellagrin of Verona said he made from five to six francs per day as workman in a factory, and was obliged to quit his work because of his malady; he was, as a matter of fact, sent away for drunkenness and was obliged to beg his bread; he was a hardened drinker who sold the bread he begged in order to buy brandy and spoiled polenta. Since then he has suffered from muscular feebleness, trembling, diarrhea, pruritis, epileptic attacks, weakness, want of appe- tite and dilatation of the capillary vessels of the face. Another drunkard, who also ate spoiled polenta in order to be able to procure brandy, suffered, at fifty-four years of age, with severe headaches, marked feebleness of the legs, vertigo, constipation, desquamation of the hands, burning pains on the soles of the feet, and, later, ptosis, trembling and convulsions of the right hand with slow pulse and atheroma. The Piedmont Commission, as well as Paolini at Bologna, noted frequently the coincidence of pellagra and alcoholism. It is remarkable, how- ever, that in the years of rich wine harvests pel- lagra is rare. This contradiction disappears when one recalls that small quantities of wine are help- ful, while large quantities are injurious; and 248 PELLAGRA that a lack of wine in many places means an absence of prosperity, and the necessity of eating poor com. In general the cases in which alcoholism and pel- lagra are coincident seem less severe than those of pellagra alone; and all of these cases have been found in the cities. [According to Nicolas and Jambon, three classes of persons are subject to pellagra: those who eat corn, the insane and alcoholists. A similar idea is entertained by some Italians who call their cases true pellagra in persons who eat com products, ethylic, in those who use alcohol and mixed in those who use both.] (b) Tuberculosis. A disease often complicated with pellagra is tuberculosis. It is very rarely found among the pellagrins of Venetia and Lombardy, but DeUa Eosa found numerous cases of it in the southern Tyrol. He f oimd in fifteen fatal cases of pellagra ten cases of tuberculosis. The. rarity of a tuberculous compli- cation in upper Italy has been atttributed to an antagonism between tuberculosis and the cardiac affections to which pellagrins are often subject. Perhaps the old writers have confounded tubercu- losis with croupous pneumonia, which is frequent in pellagrins, as are also pulmonary edema and emphysema, especially in those with mental aliena- tion. (c) Syphilis. In Eoumania, Felix found numerous syphilitic pellagrins, but this complication has not often been found in Italy. It is worthy of note, however, that PSYCHIC AND PARETIC PHENOMENA 249 syphilis in certain parts of Eoumania is very wide- spread in consequence of insufficient prophylactic measures. (d) Thyeoid Disease. In the Lombardy districts where goitre and cre- tinism prevail, pellagra is widely spread; so much so that often relatives and physicians regard the one disease as the cause of the other. Atrophy of the thyroid gland is met with in the pellagrous, but it is still more frequent in the here- ditary cases with arrest of development. This seems to show the easy vulnerability of this gland to the poisons of corn, and helps to explain the dystrophic and myxedematus phenomena some- times observed. It may be added that this alteration of the thyroid seems of much consequence in aggra- vating certain symptoms of the pellagrous intoxica- tion. Pellagrous psychoses accompanied by thyroid disturbances are marked by signs of stupor; sito- phobia is also frequent in such cases, and cures are more rare. (e) Uterine Complications. Among the numerous complications there are also utero-ovarian diseases, and it is often impossible to distinguish whether these are accidental complica- tions, or are really essential phenomena of the dis- ease. [This subject is more fully discussed else- where.] (f) Marasmatic Degeneration. A very common complication is marasmatic degeneration, and a theory of pellagra has been based on it. The sufferers, especially if poorly nourished, even on full diet waste rapidly, and 250 PELLAGRA finally show a great degree of emaciation, with a reduction in weight even as low as 28 kilograms. This emaciation, however, ceases in the winter months. It is generally accompanied by hydro- mania, persistent mutism, and rather frequently by hyperinosis. [Malaria, by some writers, is spoken of as a rather frequent and very important complication of pel- lagra. It has not been common in our experience even in the southern United States. Wood, from North Carolina, has, however, reported interestingly on this complication. Hookworms, round worms and other intestinal parasites have, in the South, been very common in our experience ; and, of course, add to the gravity of the outlook at times. The question of intestinal protozoa in pellagrins attracted much attention at the National Conference on Pellagra at Columbia, South Carolina, 1909. Much possible importance was attributed by Siler and Nichols to amebiasis, which they found very frequently present among insane pellagrins in Illi- nois. Allen also reported the frequent presence of amebse in the stools of pellagrins in North Caro- lina, as has Long, in South Carolina and Pennsyl- vania more recently. The opinions of these observers generally was that amebiasis should be regarded as a serious complica- tion of pellagra, and that such intestinal protozoa might have important effects by increasing intestinal irritation and modifying the absorption of endoge- nous toxines. Some recent students of pellagra seem to regard amebse as a possible cause of the disease. PSYCHIC AND PARETIC PHENOMENA 251 In our experience, while we have fouad protozoa not infrequently in the stools of pellagrins, ame- biasis has been comparatively rare.] Diagnosis. So far as concerns the differentiation of true pel- lagra from alcoholism and from paralysis in its last stages, it is important to note that in pellagra there are wanting marked disturbances of speech; arterial atheroma is rare; the ambitious or melan- cholic delirium of paralytics is very rare. The urine does not show the density and abundance of phos- phates seen in that of alcoholics and paralytics, and the visual and tactile hallucinations of the drunkard do not occur. Alcoholics do not have hydromania nor atrophy of the heart nor the earthy complexion and faces observed in pellagra. Heeeditaky Pellagra. There are, however, forms of pellagra, or of pseudo-peUagra, most difficult to diagnose because the disease does not show itself in its full symptom- atology. This is designated as hereditary. Like hereditary syphilis there may be two types, one very severe, another very benign and mild. The first manifests itself about the second year of life. It is rarely accompanied by desquamation; most often there are epigastric pains, pyrosis, sito- phobia, unsteady gait, fears, diarrhea, yellowish complexion, as in malarial cachexia, retardation and arrest of development; later may be seen the com- 252 PELLAGRA plete phenomena of a pellagra which resists all ther- apy. In some there are noted marked brachycephalia or dolichocephalia, with receding brow, ears badly set, facial asymmetry, anomalies of the genital organs or other physical stigmata of degeneration. In the districts where this form prevails, the benign form is also seen, and merits more study from the prophylactic and hygienic point of view. It is a true ^^pellagra sine pellagra.'''' Many of these unfortunates are seen in certain sections of Venetia, and of Trentino, even among the well-to-do classes. They complain of burning at the extremities, of pains in the back, and of pyrosis. The women suffer from leucorrhea, uterine heaviness, amenorrhea, flatulence, vertigo, constipa- tion or diarrhea, and a yellowish color of the skin, but desquamative skin lesions and delirium are wanting. These complications move me more to compassion than does true pellagra, because they indicate how misfortune may occur through hereditary infiltra- tion into the germ of an entire population. It hap- pens with pellagra, as with cretinism, that the dis- ease once scattered in a group of families, predis- posed by locality, misery, etc., displays its taint even among families which might have been exempt, bequeathing them, if not the body, at least the livery, as Verga has well said, of this endemic malady. (Lombroso.) In Favrio it seems undoubted that heredity acts directly. All the alliances of the Franceschinelli and Lorenzi, for example, being afflicted with peUagra, PSYCHIC AND PARETIC PHENOMENA 253 while the Briosi family, who live with equal par- simony, if not misery, are entirely exempt. Atavism. Many times hereditary influence, on the other hand, is not so evident, for atavism is displayed in the weak attention and the labile memory of the poor peasant, and may be indeed a preponderating force over paternal heredity. For Instance, a young pellagrous girl, 16 years old, suffer- ing from typhoid pellagra, had had chronic diarrhea at the age of two years, and at eight years vertigo, later tjfphoid pellagra and insanity; she had healthy parents, but her grandfather had died of a pellagrous diarrhea at an ad- vanced age. In another case a boy of 12 years, of retarded develop- ment, with scaphocephalous cranium, suffered from a con- tinous diarrhea, with a tendency to bite; he also had the habit of striking his head against a wall, indeed so often as to cause an osteoma to form on the left side of the cranium, and he displayed an exaggeration of his sensory and motor reflexes. The father and mother were healthy, intelligent and sound, brothers pellagrous. The grandfather at a certain age, however, suffered from a tendency to bite, and would fall to the ground at the least noise ; he also had the habit of beating his head against the wall just as his grandson had. "The descendant of the pellagrous is recognized by his vacillating and uncertain step; his muddy, yellowish sclerotics, his fixed look, the pale and ashy color of his face, his reddish eyelids, his hare- lip, the scant hair on his head, his brow prematurely furrowed, his flabby muscles, his stupid and apa- 254 PETT.AGRA thetic appearance. This general aspect is found in children of ten to twelve years and is the appearance presented by the children of pellagrous parents." (Sacchi.)^ The pellagrous intoxication of antecedents, and especially of the pregnant mother, is capable of pro- ducing in the offspring early and rapid exhaustion of vitality, degenerative changes and especially arrest of organic development. In hereditary pellagra there is a very high per- centage of mortality. The stigmata of degeneration are common, especially anomalies of the cranium, arrest and retardation of bodily development, even veritable dystrophic infantilism, myxedematous dwarfism, or the exhaustion of the procreative power. "I remember very well that when wretched, scrof- ulous children presented themselves at my home, my father would say: 'It is the offspring of a pella- grin.' " (Sacchi.) Especially prominent among the descendants of old pellagrous families, are peculiar nervous troubles, manifested by sadness, depression, and suicidal tendencies most often carried into execu- tion by hanging. Hereditary pellagra may also be combined with an acquired pellagra. In France, pellagrous insanity, now almost un- known, still manifests itself under the form of hereditary pellagra, as the recent work of Eegis shows. According to the statistics, the asylums of Pan and Montpellier are almost the only ones in 'Piedmont Oommisnon, 1847. PSYCHIC AND PARETIC PHENOMENA 255 which this affliction exists. This shows that pellagra is only possible where corn is consumed. This cereal must needs enter into the daily food, a thing which happens only exceptionally in France, and then in the back country, among the miserable and desolate. It is not the same in Spain, where pellagrous intoxication persists in certain regions and affects sometimes even 20 per cent, of the population. In Italy, in spite of the valiant struggle of Lom- broso during all his life, the regions of Bergamo, Brescia, Venice, Padua, still number 35 to 50 pella- grins to 1,000 inhabitants. Treviso, Vicenza, Cre- mona, Pisa number 10 to 20 each per 1,000. At Milan the writer examined, some months ago, several insane cases of pellagra. The total number of cases in Italy is estimated at 72,000. [The esti- mate of E. A. C. WoUenberg (op. cit.) July, 1909, of the total number of pellagrins in Italy is less than 50,000.] In Eastern Europe pellagra prevails, also in Rou- mania, Servia, Bosnia, Macedonia, Albania and the Turkish countries, as well as in Greece. The fine work of Babes and Marinesco in Rou- mania on the neuro-pathology of this intoxication is supplementary to that of the Italian school to which we owe the prophylactic measures of the law of July 21, 1902, which originated in the Anti- pellagra Congresses of Bologna, Padua and Milan. (See Appendix I.) In Egypt pellagra is spreading as in other Turk- ish countries, where corn is largely eaten. There, one can say that almost all the fellaheen are, to some 17— p. 256 PELLAGRA degree, tainted by the poison of pellagra. In the hospital of Kasr el Ainy at Cairo, in ten years more than a thousand pellagrins have been treated. Each year, out of this number, forty cases complicated with mental disease are successively turned over to the asylum of Abbassia, where the writer has been able to study them. Outside of the hospitals, the study of pellagra among the population of the country districts has been undertaken by Sandwith (Egyptian Congress, p. 485). He makes an average estimate that more than 36 per cent, of the Egyptian peasants are affected. In the less wretched districts the propor- tion may fall as low as 15 per cent., but elsewhere rises to over 62 per cent. In lower Egypt the average would be greater, even in young women. The considerable rate of still births would not be properly explained without reference to this scourge. In upper Egypt the greater dryness and the use of millet as food diminishes the danger; and prob- ably also, the countries further removed from the seacoast consume less imported com, which is the more dangerous because of spoiling during trans- portation. The number of pellagrous insane is continually on the increase; and yet only those are counted who show the definite physical stigmata, such as those whose photographs were presented to the Academy of Medicine in 1907, for the hereditary pellagrins do not always show these stigmata so definitely. PSYCHIC AND PARETIC PHENOMENA 257 The erythema varies in appearance according to the stage under consideration, though the location may be the same. Racial characteristics are manifest in relative peculiarities of pigmentation; it is thus that old scars, instead of presenting a dark color, as in case of the white man, show, on the contrary, more of a gray tint in the Arabs, in consequence of the scaly thickness of the dry and hypertrophied skin. The climate and the Arab costume produce also certain local peculiaritites of this erythema; thus the short and large sleeves cause the pellagra gaunt- let to be more extended; the gandoura, freely open at the breast, cause the dermatitis to extend to the neck and sternal region. (See Frontispiece.) On the legs the boot erythema can extend often above the knee and the bare foot is involved, as is the hand. One can observe either increase of pigmentation at the beginning, or the final depigmentation with a dystrophic state of the epidermis which becomes like parchment, dried and scaly. Scars of old ulcer- ations frequently occur in these people and make further changes in the aspect of the skin on the most exposed parts. The ulcerous stage is sometimes preceded by a phase of desquamation which occurs in strips of pig- mented epidermis leaving cracks and fissures. We have made various photographs of these different phases. In the negro the erythema, especially on the face, may take the appearance of pigmented grains of millet, apparent on the brow, the neck, the cheeks and around the lips. 258 PELLAGRA It is unnecessary further to discuss either the well-known skin lesions with their seasonal recur- rences or the prominent visceral troubles which accompany them (diverse gastro-intestinal troubles, gastralgia, diarrhea, etc.). We will restrict our- selves to the mental and nervous peculiarities, whose manifestations are generally consecutive to the pre- ceding symptoms, although they may precede or even replace them entirely. The mental state of these patients generally is characterized, after the initial stage of feebleness and irritability, by an apathy with physical and mental depression and diverse phobias. Sitophobia is frequent and coincides with the gastro-intestinal troubles, gastralgia, cramps, nausea, seborrheal con- dition, constipation and diarrhea. Mutism is usually associated with sitophobia; the patients become excited and frightened, seclude themselves and seek dark corners (photophobia, hyperthermia, painful, cutaneous paresthesias). Mental stupor is accompanied by amnesia and by spasms, including vertigo and epileptic convulsions, or their psychic equivalents. In the first rank of the latter phenomena must be noted ambulatory auto- matism, a frequent cause of unconscious suicide by precipitation into, or drowning in the canals of the Nile. Autoaccusations or nosophobic, hypochondriac preoccupations are not rare, being associated with vague ideas of persecution. Stupor is interrupted by automatic raptus and various spells with or with- out confused dreamy states. PSYCHIC AND PAKETIC PHENOMENA 259 Sitophobia may be due to dysphagia and anor- exia, and the apathy may be confined to katatonia. It yields sometimes to sitomania at a later phase, for pellagrous insanity frequently assumes the chronic form with or without intermissions. That is easily understood, for convalescent patients returning to a dietary of spoiled corn, the same causes then repro- duce their same effects. Relapses are frequent, and the chronic states also; complications, furthermore, through other etiological factors of psychosis are not rare. In Egypt the pellagrous intoxication at times occurs with hashish intoxication. Then there is the possible combination of various infections, especially of malaria and of syphilis, and such endemic para- sitism as ankylostomiasis, which is found very prev- alent among Egyptian insane as well as among the native population in general. With regard to syphilis, attention has already been called to the frequent occurrence of general paralysis among the Egyptian Arabs. The question is, does pellagrous pseudo-general-paralysis exist among them, or is this a simple specific general paralysis modified by the pellagrous intoxication? The question is not a new one, and it was raised by the French school at the time when the academic debates started by Baillarger in 1847,^ were attract- ing attention. ^The point was with regard to addressing a programme of in- quiry, proposed by Roussel, to the Minister of Commerce — an inquiry to be made In Spain as to the causes and manifestations of pellagra, which was then wide-spread in the southwest of France. M. Gibert, member of the Academy, expressed an opinion con- 260 PELLAGRA An examination of the pellagrous lunatics among the Arabs at the asylum in Abbassia show that true pellagra is very frequent among them, as it is among the population from which they conie. In addition to the insane who have become pellagrous, there are cases of insanity consecutive to pellagra and in strict causal relation therewith. Such cases show their pellagrous origin by typical phenomena united with characteristic physical stigmata. A certain number of paralytic insanities coincide with pellagra in their essential phenomena, and con- firm the opinion of Baillarger that the ultimate paralytic stage of pellagra may represent a condi- tion identical with paresis both clinically and path- ologically. These cases do not weaken in any respect the character of specific general paralysis, from which they are distinct, and which is, of course, ascribed to syphilis. The two forms, however, may be associated, that is, one may observe Arabs suffer- ing from general paralysis who are at the same time syphilitic and pellagrous. trary to the corn theory, resting for support on the cases observed by him at Paris in the Hospital Saint Louis. He probably had before him hereditary pellagra, analogous to the case mentioned by Efigis of a patient that had never eaten spoiled corn, nor even good corn, but was the daughter and grand- daughter or niece of confirmed alienated pellagrins. CHAPTER Vni Pathological Anatomy. The researches of Babes, Sion and Marinesco, as well as those of the Italian investigators Rossi, Righetti, Grimaldi, made by the method of Nissl, have shown that there occurs in pellagra consider- able cellular change. Parhon and Papinian noted (1905) in a case of pellagra, alterations of the neuro- fibrils predominating in the large cells. The giant cells show a red-mahogany coloration of their cyto- plasm and a complete absence of neurofibrils. The nucleus is, according to the stage of the process, vesicular, atrophied or invisible. The nucleolus takes a stain with difficulty in the most altered cells. The appearance of the large cells of the anterior horn resemble very much the giant cells of the Rolandic area (Regis). The pathological changes seen in 113 autopsies, seventy of which were done by Lombroso and his students, in their essential details, are given in the pages which follow. Meninges and Brain. — ^Milky opacity of the pia mater and thickening of the pia mater and arach- noid, often circumscribed, more frequently diffuse, were found thirty-three times; four times with a purulent exudate ; five times with hemorrhagic extra- vasations under the arachnoid; twenty-four times extensive or partial edema of the brain, sometimes with edematous softening around the pillars of the fornix or at the foot of the hippocampus; five 262 PEIiAGRA times hardening of the cerebellum was seen; on the other hand, in 8 cases it was found soft and edema- tous ; eleven times atrophy of the brain, especially in the cortical substance. The weight of the brain was found diminished in 18 out of 28 cases examined, while in 7 cases it was increased above normal; twice it was found hardened; five times hyperemia of the brain was noted, twice of the corpus striatum, in one of which cases it was more marked on the right side than the left ; four times, on the contrary, there was seen anemia of the brain. Other observers have likewise noted similar changes. Nardi, Fanzago and Strambio report injection of the membranes, with thickening of the arachnoid and congestion of the sinuses. In almost all of his autopsies, Liberali found inflammatory changes in the arachnoid. In 21 out of 41 cases Verga found adhesions of the dura mater to the superior cranial bones; twice thickening of the dura mater; three times opacities of the arachnoid; and once only adhesions of the pia mater. In 16 autopsies Rizzi found the pia mater always involved. Morelli often found extravasations of blood under the meninges. Verga found in eight cases hydrops of the ventricles, and in four soft- ening of the cerebral substance. Microscopic examination showed 11 times fatty or pigmentary degenerations, 4 times both combined, in the walls of the cerebral capillaries, three times with calcareous degeneration; once sclerotic changes in the brain ; once dilatation of the brain capillaries. In twelve examinations of the sympathetic ganglia Plate XVI. South Carolina case. "Wot" dermatitis of hands, face and lips. Note characteristic facial exprossion. Courtesy of Dr. J. J. Watson. PATHOLOGICAL ANATOMY 263 marked pigmentation of the ganglionic cells was found eight times. Spinal Meninges. — Still more important were the alterations of the meninges found by Lombroso, Tonnini and Belmondo in 71 autopsies. Tonnini found hemorrhage under the arachnoid 4 times in 51 cases, of which two cases were scor- butic ; in other cases no hemorrhage was found, but a decided circumscribed pigmentation in certain parts of the spinal meninges. Anemia of the membranes was found in 8 cases out of 51 with concomitant anemia of the spinal cord also. Hyperemia of the membranes was found 17 times, the arteries and veins being tortuous, and the in- ternal face of the dura mater sometimes mottled by dark red spots. In these cases the cerebrospinal fluid was increased as well as turbid and reddish in color. In 34 out of 71 autopsies Tonnini and Belmondo found, besides the thickening of the membranes, osteomata (ossifying arachnoiditis) in addition to senile alterations. Out of 14 autopsies Tamburini found osteomata in 9 cases where the age exceeded 50 years, but all were paralytics. Spinal Cord. — Omitting older writers, Liberali, Verga, Labus, Nardi, Marce, Billod, Brunetti and Bouchard, have studied the spinal lesions in pel- lagra. In an examination of the two halves of the gray axis Tonnini found in six out of fifty-one cases, granular and pigmentary degenerations with cellular atrophy. He observed changes in the left dorsal seg- ments in one individual who had muscular atrophy 264 PELLAGRA of the thorax and the inferior extremities. The amyotrophy was on the left side while on the right there were signs of anterior poliomyelitis. In this case, microscopically, there were observed cellular atrophy in the anterior horn of the left side, granu- locellular degeneration on the right and incipient degenerations in both lateral columns. In twenty-two out of fifty-three cases he found softening of the cord in the dorsal region ; in fifteen, softening in the cervical region along with similar changes in the dorsal and lumbar regions. The cen- tral canal may be dilated (Syringomyelia). Eleven times out of fifty cases he found anemia of the cord, a condition more marked in the substance of the cord than in its membranes. Microscopic examination of the cord by Golgi's method showed in places many nerve fibres poor in myelin, and demonstrated numerous round or oval nucleated bodies, thirty to sixty micra in diameter, many of which were surrounded by a fine stroma of granular protoplasm with proliferations. Tonnini in eight of thirteen cases found marked pigmentation of the cells of the anterior and poste- rior horns with disappearance or alteration of their nuclei. From these and other lesions Tonnini thought the microscopic anatomy very similar to that found by Tuczek in ergotism. Hieronimis noted small-cell infiltration of the gray and white substance of the cord, and around the ependyma with dilatation of the perivascular and pericellular lymph spaces. Marchi noted altera- tions in the vessels of the gray matter. PATHOLOGICAL ANATOMY 265 Belmondo, in his very important researches on twenty cases, distinguished two kinds of changes, the acute and the chronic: The first were noted exclusively in cases terminating with so-called typhoid pellagra, and consisted in an abundant infil- tration by leucocytes of the meninges and of the cord, and in a great dilatation of the vessels, which were filled with blood; in other words, there existed an acute meningo-myelitis. The alterations of a chronic nature existed, on the other hand, also in cases of severe pellagra in which death had been due to an intercurrent malady. In all cases he found varying degrees of degener- ation of the crossed pyramidal tracts, from slight changes with loss of myelin up to an actual sclerosis. The posterior columns, those of GoU and Burdach, exhibited also degenerative changes. These lesions of the posterior cord resembled in many cases those of incipient tabes, but in the pellagrous the posterior columns were more involved in the superior dorsal and cervical regions. Other less important changes were noted occasion- ally in the white substance of the cord; as well as certain alterations in the ganglionic cells, which were frequently atrophic and, even in the youngest cells, filled with pigment. This increased pigmentation, found constantly by Lombroso in the sympathetic and spinal ganglia, is regarded by him as of much importance, being an indication of profound nutritional disturbances occurring in the central nervous system. 266 PELLAGRA Belmondo, from these researches, concluded that severe cases of pellagra are accompanied constantly by systemic degenerations of the lateral and pos- terior columns of the spinal cord in the form of a combined sclerosis. According to Italian authorities, combined scleroses are more usual. These cord lesions of pellagra, like those of ergot- ism, are not indeed essentially progressive in their nature; advance in the process is due to renewed poisoning by the toxic agent, and often it is only with the appearance of other intercurrent morbid conditions, especially a cachectic state, that the pro- cess shows any advancement; and such progress is always slow. Since 1894, Pierre Marie has made several investi- gations of the alterations of the cord in pellagra; and he has undertaken to compare the cord lesions of tabes and of pellagra. He says : "Thus it is that in pellagra, where there exist most often combined lesions of the posterior and lateral coliunns one can, according to Tuczek's recent work, show that the degeneration in the posterior columns has a locali- ization different from that of tabes. Indeed there does not exist in pellagra, contrary to what is found in tabes, any lesion either of the posterior roots or of their intramedullary prolongations (zone of Lissauer and Clarke's column). The degeneration of the posterior columns must then be attributed to a mechanism other than that of tabes. Indeed while the degeneration of the posterior columns in tabes is exogenous, that is, arises especially from the lesion PATHOLOGICAL ANATOMY 267 of the posterior roots ; that of pellagra — at least in typical cases — is endogenous, that is, it takes its origin in consequence of the alteration of certain cells of the gray matter of the cord known under the name of 'cells of the posterior columns.' This alteration would be produced by a poliomyelitis especially marked in the upper median dorsal region, but extending almost all the length of the spinal axis. With regard to degeneration in the lateral columns, this would be due to this same poliomyelitis acting on the 'cells of the lateral columns.' " In all probability it is necessary to consider the process in the cases of pellagrous myelitis as an intoxication in which the vessels of the gray matter play the prin- cipal role. Dide and Leborgne have described in certain cases of non-pellagrous dementia precox, lesions iden- tical with those noted by P. Marie in paretic pella- grins. They also found them in old epileptics. With Dide, the author presented to the Anatomical So- ciety spinal cords of patients who died of dementia precox with analogous lesions, whereas the spinal cords of pellagrins, collected by him, in Italy at Tessin, did not present characteristic alterations. It appears, therefore, that certain insane pellagrins present cord lesions relatively independent of pella- gra, which arise from secondary auto-intoxications, not characteristic of their pellagrous intoxication. Duse^ found in a great number of pellagrins a marked frequency of the Babinski reflex. Galesesco ^Arcliiv. dl Psychiatria, January, 1904. 268 PELLAGRA and Slatineano,^ of Bucharest, have made examina- tions of the cerebro-spinal fluid with practically negative results, but when this is from cases of paretic pellagra or general paralysis associated with pellagra, one may conceive the possibility of a diag- nostic change in the albumen of the spinal fluid, and of an increased number of lymphocytes due to a concomitant general paralysis. Lungs. — The frequency of edema, pleurisy, hyper- emia, emphysema, and pneumonia in the autopsies on pellagra in Lombardy is established ; tuberculosis, however, seems rare there. Still at Trent in fifteen autopsies nine cases of tuberculosis were found. Heart. — ^The examinations of the heart showed twelve times hypertrophy, sixteen times atrophy (Baruffi, Verga), thirty-three times softening of the myocardium; seven times hydropericardium ; eleven times aortic atheroma. Verga found once aneurism of the aorta, and twice hypertrophy of the heart. Labus found, in one hundred autopsies, fifteen cases of hypertrophy and atrophy of the heart in advanced and old pellagrins. With the microscope very notable changes were found: most frequently brown atrophy of the muscle with cellu- lar infiltration (twenty-eight cases in thirty-five) or fatty degeneration. Liver. — The lesions of the liver are very common ; it is sometimes small, again enlarged and friable, and brown atrophy occurs. Verga noted cirrhoses and Chiarugi found in twenty-nine autopsies, nine fatty livers. The weight of the liver is often sensi- iSocletfi de Blologle, 2 Aout, 1907. PATHOLOGICAL ANATOMY 269 bly diminished, sometimes by half; fatty infiltra- tion also is found and congestion or granulo- fatty degeneration. Spleen. — The spleen is also frequently atrophied, forty-one times to twelve hypertrophies. Labus and Verga likewise reported atrophy of the spleen even in cases of typhoid pellagra. Kidneys. — These are often fatty, atrophied, cir- rhotic or cystic (once uric acid calculus). Very rarely they appear normal. In forty out of fifty- two cases the weight of the kidneys was found diminished; almost always renal sclerosis is asym- metrical. Gianelli notes the frequency of Bright's disease in pellagra, and fatty degeneration of the epithelium of the tubules is observed with or with- out interstitial sclerosis (Festler). Vassale and Belmondo have described in cases of pellagra a form of chronic nephritis with fatty degeneration and desquamation of the epithelium of the tubules. Intestines. — For many years muscular atrophy has been described; also hyperemia and ulceration of the rectum, to which too much importance has been accorded. Rarely anemia or hyperemia of the gastric and intestinal mucosa have been noted (twice in seventy autopsies), as well as chronic enteritis with or without cicatricial constriction, thickening of Peyer's patches and cystic degeneration of the sub-mucuous glands. The examination of the suprarenal capsules, of the pancreas and of the testicles offered nothing notable. 270 PELLAGRA The female sexual organs, however, showed various alterations, hyperemias, polyps, tumors, fibromata of the uterus, calcarious bodies in the ovaries, etc., etc. Muscular System. — In forty-four cases the mus- cular system was found atrophied twenty-one times ; normal or well developed twenty times; athletic once ; affected with fatty degeneration twice. Skeleton. — Fragility of the ribs was met with in eighteen cases out of forty-two. These persons weighed from forty-nine to fifty-three kilograms, were not of an advanced age, and had, in part, craniums more solid and heavier than normal. In a single one of the cases the cranium was also fragile ; in eleven the bones of the skull were thin. Fragility of the bones was long ago observed, but without special importance being attached to it (Bouchard, Orsolato, Villergois, Strambio, the elder). This fragility depends on the eccentric atrophy of the compact substance with hypertrophy of the medullary substance, which the microscope demonstrates. In the tubular bones, as in the spleen, numerous cells were found, in which were included red cor- puscles, one part of which was well preserved, and the other part transformed into granular pigment. Skin. — Griifini has made a comparative study of the alterations of the skin in pellagra with the skin of healthy subjects, young and old. He found marked atrophy of the stratum corneum, copious desquamation, active reproduction in the Mal- pighian reticulum and marked sclerosis of the ves- sels of the papillary layer and the derma. PATHOLOGICAL ANATOMY 271 Lombroso thus sums up the pathology of pel- lagra : There are found irritations, exudations and hyper- emias localized more commonly in the membranes of the brain, spleen, liver, kidneys, inferior portions of the intestines and above all in the spinal cord and its coverings. Atrophy of many organs occurs; especially those innervated by the pneumogastric : heart, kidneys, spleen, liver, intestines and lungs ; besides these, the ribs and the muscles. Brown atrophy of the heart with cellular infiltration and diminution of weight was found frequently in the absence of general marasmus and this, with other visceral atrophies, is common even in well nourished individuals. Fra- gility of the bones is ordinarily confined to the ribs. Fatty degeneration of the muscles is infrequent and then usually confined to certain muscle groups. Fatty degenerations are common, and such changes are observed in the kidneys, liver and at times in the heart ; and, what is of more import, in the spinal and cerebral vessels. Very characteristic of pellagra is the great fre- quency of pigmentary degenerations. Thus, as noted, one finds brown atrophy of the heart, which is an atrophy with pigmentation; pig- mentation of the liver cells and sometimes pigmen- tation of the cerebral vessels and of the spinal and ganglionic cells, with or without fatty degenera- tion. In one case was seen a general pigmentation of the kidneys, the heart, the liver, and the vessels of the brain (hemolytic cellular disintegration). 272 PELLAGRA There are rarely also other forms of anatomic degeneration, as calcareous degeneration of the cerebral vessels and at times aneurysmal dilatations. These alterations, together with the thickening of the membranes of the brain and of its vessels, suffice to explain the psychic troubles so frequently met with. To be noted finally is the tendency to precocious senility, with atheroma, a great number of amylace- ous bodies in the spinal cord and in the sympathetic ganglia, precocious baldness and scleroses and pig- mentation of the ectodermic structures. [Tuczek's well-known studies on the pathology of pellagra are thus summarized by himself :* "Putting on one side appearances incidental to the general constitutional disturbance, and those due to intercurrent disease, etc., found in pellagra — e. g., general nutritional derangements which are not con- stantly present, such as wasting of the adipose and muscular tissues, fragilitas ossium, degeneration of the cardiac muscular tissue, fatty degeneration and atrophy with a slight degree of sclerosis of the liver, spleen and kidneys, we have to consider the more important post mortem results obtained in pella- grous patients. These are: (1) Changes in the intestinal tract — attenuation of the intestinal wall in consequence of atrophy of the muscular coat, with occasional hyperemia and ulceration of the lower •Tuke, D. H. — A Dictionary of Psychological Medicine — Phlla., 1892. PATHOLOGICAL ANATOMY 273 parts of the canal; (2) abnormal pigmentary de- posit, such as is usually met with only in senility, is commonly found, especially in the ganglionic cells, the muscles of the heart, the hepatic cells and in the spleen; (3) changes in the nervous system; these are by far the most important and constant post mortem signs. The hyperemic and anemic conditions, or the edema of the central nervous system, though frequently present, are by no means the char- acteristic changes, neither are those inflammatory conditions such as pachymeningitis and cerebral and spinal leptomeningitis, or the obliteration of the spinal canal by granulations, or ossific arachnitis, at all peculiar to this malady, they being common to many chronic nervous aflfections; the most note- worthy and constant lesion, and one that may be taken as peculiar to this disorder, is an affection of the spinal cord, and especially of its lateral columns. The brain when examined furnishes generally negative results, apart from the occasionally found pigmentary deposits in the cortical cells, and in the adventitia of the smaller vessels, with fatty degeneration or calcification of the intima; atrophy of the cerebrum and its cortex has been found in cases of long standing mental derangement. The cord lesion, though mainly one of the lateral col- umns, frequently implicates also the posterior columns; in the former the pyramidal tracts are generally affected with partial involvement of the anterior columns; in the latter the postero-lateral columns are generally left free. The lesion of the lateral columns is shown most prominently in the 274 PELLAGRA dorsal regions of the cord, while that of the posterior columns is limited to, or rather most distinctly- marked in, the cervical and dorsal regions. "Microscopically, the affection seems to be a pri- mary degeneration of the nerve fibres, with sec- ondary proliferation of the neuroglia, the walls of the vessels not being necessarily implicated; some- times granular cells, and more frequently amylace- ous corpuscles, are met with in the degenerated areas. Degeneration of the anterior root fibres along the anterior cornua has also been demon- strated, while there is to be found in addition a more or less considerable degree of pigment atrophy of the ganglion cells in the anterior cornua, with sclerosis of the matrix and atrophy of the nerve roots. Besides the excessive pigmentary deposit found in the peripheral ganglia, both spinal and sympathetic, there are no characteristic microscop- ical evidences in other parts of the nervous system. "Typhus pellagrosus furnishes us with definite post mortem results — chronic gastro-enteritis with formation of ulcers and swelling of the mesenteric glands, and well marked changes in the central nervous system, associated with secondary affection of the kidneys, lungs, pleurae, etc., being the main features on examination. It is to be noted that the spleen is usually involved in the general visceral atrophy, and is never enlarged." He draws a strong analogy between pellagra and ergotism both etiologically and pathologically. [Complete and detailed reports on the pathology of pellagra in the United States are as yet wanting. PATHOLOGICAL ANATOMY 275 It has, however, been shown by several writers that the pathology of the disease, in a general way, shows no essential deviation from Italian pellagra. The most detailed report has been made by Harris, who has confirmed, in their usual features, the customary skin and visceral changes. With regard to the cen- tral nervous system he has found in the brain the alterations described by Babes and Sion and con- firmed by Marinesco and others. These are in the nerve cells, especially in the large chromophilic cells of the cortex, the presence of unmistakable degenerative changes. The tigroid bodies fail to stain with basic dyes, and the cell becomes swollen and vacuolated. The nuclei are frequently pushed to one side, show swollen nucleoli and will not take basic stains, the pigment is also scattered through- out the cell body. The processes of the cells often appear broken and seem swollen. The pericellular, lymph spaces are dilated, and the walls of these cavities often lined with yellow pigment. In the brain tissue, small collections of lymphoid cells are frequently encountered, and the neuroglia cells in the vicinity of the blood vessels are swollen. Harris further states :* "In addition to the changes mentioned, I would remark that in all of my cases the small vessels of the brain seemed unusually filled with blood, and the perivascular lymph spaces were quite uniformly dilated. There were no collections of lymphoid cells anywhere in the tissue. The nerve ceUs showing degenerative changes usually measured less than the normal ones, and always contained a greater or less •Trans. Nat'l. Pellag. Conference 1909, p. 91. 276 PELLAGEA amount of acidophilic protoplasm. The cells suffer to a varying degree in different parts of the brain. Parhon and Papinian have demonstrated, as might have been expected, that the neuro-fibrils of the cells show degenerative changes. "Alterations similar to those found in the cere- brum have been observed by me in the nerve cells of Purkinje. The cell protoplasm loses its aflSnity for basic stains, and the nucleus undergoes a sim- ilar change. The cells contain a finely granular protoplasm that takes acid stains, and in many of the cells only the nucleolus retains its power of absorbing basic dyes. The nucleus does not seem to be dislocated in these cells so often as in the pyra- midal cells. In all of my cases it was quite evident that many cells of Purkinje had undergone degen- eration and entirely disappeared. In one instance this change was most striking ; in this case the mole- cular and granular layers were in many places sepa- rated by microscopic spaces that probably existed during life, and having the same significance as the dilated lymph spaces. These cerebellar alterations probably explain the ataxic forms of the malady. So far as I am aware, no one has previously observed these alterations in the cerebellum." With regard to changes in the spinal cord, Harris observed the ordinary degenerative lesions usually described, and, in one instance, noted the "meningo- myelitis acuta" described by Belmondo. In the spinal and sympathetic ganglia he noted changes similar to those found in the central nervous system, though usually not so marked. PATHOLOGICAL ANATOMY 277 He also says: "From the results of the work of Bietti, it is not improbable that circulatory changes are frequent in the central nervous system in pella- gra, as he has shown that in quite a proportion of the cases the retina is anemic, and in about the same percentage the opposite state of hyperemia occurs."] CHAPTER IX DIAGNOSIS, PROGNOSIS, PEOPHVLAXIS AND TREATMENT.* The diagnosis of pellagra in pronounced cases — with the so-called pellagrous triad of cutaneous, gastro-intestinal and nervous phenomena — ^presents no diflSculty, but cases are not uncommon in which the diagnosis is often involved in much doubt. Out- side of the erythema, which some authorities regard as pathognomonic, there is no distinctive lesion of the disease, and the diagnosis must depend "on the lights and shadows" of the clinical picture. Early diagnosis is a matter of much importance. Camurri has recently said: "The most important medical problem now occupying the pellagrologic field is, without doubt, that of establishing an early diagnosis. Without this, it is impossible to arrest or ameliorate the harmful effects of pellagra which seem fatally inevitable." And, of course, such a diagnosis is all too frequently involved in doubts and difficulties. Many times, of course, the diagnosis must be of a tentative nature, and treatment begun accord- ingly. So far as the clinical picture is concerned, we may take into consideration the history of the case; mild mental disturbances, usually of a depressed type; gastro-intestinal disturbances, such as dyspep- sia, change in appetite, thirst, diarrhea or consti- pation; vertigo and insomnia with headache; various paresthesias, such as burning in the mouth, esopha- gus and stomach, or on the hands and feet, formica- tion, bands around the body, etc.; changes in the •This Chapter Is by the Translators. I'late XVII. South Carolina caso. Saiuti as I'late XVI. Conva- losccnt and sliowin,u' pin'mentation of hands and arms. Courtesy of Dr. J. J. Watson. DIAGNOSIS 279 knee jerks, with usual exaggeration; pupillary phe- nomena, especially of a unilateral character ; general malaise with muscular weakness, especially in the lower extremities ; possible tender spinal points ; per- haps loss in weight with a generally lowered physi- cal, nervous and mental vigor. A tentative diagno- sis made on such grounds must frequently await the appearance of more conclusive symptoms, especially the erythema. The importance of this early diagnosis has led to a search for some positive laboratory method for recognizing the disease at an early stage, and there is not an inconsiderable literature on certain blood serum reactions, thought to be of importance in this connection. These methods include the toxicity of pellagrous serum as tested on animals, and the appearance of a "maize-precipitine" in the blood of pellagrins. Camurri in a recent discussion of this subject, with a review of his own experimental work, states that the toxicity of pellagrous serum is incon- stant, and hence not to be depended upon for diagnosis. The "precipitine" test, in a general way, is made by adding a small quantity of the sus- pected serum to a standard infusion of corn; the mixture is placed at 37 degrees C. for a few hours, and if positive, a precipitate makes its appearance. With regard to the specificity of such a reaction, and its value in diagnosis, Camurri thinks that its only value is to show. that the individual is an eater of corn, and that there has been, within a short period, some lesion of the gastro-intestinal tract. From other experimental work, he deems the urine of early 280 PELLAGRA pellagra to show very constantly hypoacidity with increased chlorides; and he concludes that an indi- vidual from a section where pellagra is endemic, who shows a positive "maize-precipitine" reaction in his blood serum, and who, for a brief period of time, under a constant diet, shows a urinary hypoacidity with increased chlorides, is a pellagrin in the initial stages of the malady. These methods, in their present state, do not ap- pear to us of much value; and even if found of value, they are now too complex for general use, and must remain restricted to the laboratory. Naturally inquiry is made regarding the skin lesions and their value in diagnosis. The question not infrequently arises whether the disease may be recognized without skin manifestations {pel- lagra sine pellagra), or whether cutaneous lesions alone are sufficient for the recognition of the disease. The answer to such questions is not with- out uncertaiaty. On the dermatological side we have the opinion of Merk that the skin symptoms alone suffice for a diagnosis ; and that the cutaneous lesions of pellagra possess the same value in diag- nosis as do those of scarlatina, measles, variola and varicella in the respective diagnosis of these diseases. Eoussel expressed grave doubt as to the existence of a real pellagra sine pellagra, and Lombroso, as we have seen, calls certain hereditary types the only true pellagra sine pellagra. There seems doubt as to the existence of a pellagra without skin manifestations at some stage of the dis- ease. Certainly such a diagnosis may be made DIAGNOSIS AND PKOGNOSXS 281 tentatively, but in the present state of our rather limited experience with this disease, it would seem wise for us to use great care in doubtful cases. The diagnosis of pellagra has become fashionable of late, and it has been pointed out by more than one ob- server that we are at present far more likely to rec- ognize pellagra in too many patients than in too few. With riper experience we shall be able to advance with more assured step. Typhoid pellagra and certain acute manifestations may at times be very confusing, especially in the ab- sence of a distinct erythema. The history of such cases, and a careful search for poorly marked skin manifestations, may be of much importance in diagnosis. In the differential diagnosis many conditions de- mand some consideration. In the first place, there are some diseases thought to be allied to pellagra on its etiological side, which may display some similar- ity in their symptomatology, such as ergotism from rye, lathyrism from chick peas and acrodynia. Ergo- tism is rare abroad and probably is seldom seen in this country ; the history and course of the case with the spasmodic and gangrenous phenomena should serve to differentiate it. Lathyrism is lacking in skin manifestations, is usually sudden in onset, and dis- plays a characteristic palsy. Acrodynia seems to sim- ulate pellagra at times very closely. It is an epidemic disease, the etiology of which is doubtful, but it is thought to be similar to ergotism and pellagra. It has been observed in France, Belgium, Turkey, Persia, Algiers and Mexico, always in epidemic 282 PELLAGRA form. There are gastro-intestinal symptoms, hyper- esthesias, anesthesias, edemas, and an erythema, principally confined to hands and feet. Spastic phenomena sometimes occur. The course is afebrile and recovery is the rule. Fatalities are rare. Scurvy, leprosy and beri-beri are often mentioned but should be easily recognized. Various skin lesions, such as solar erythema, lichen, eczema and erythema multiforme may be im- portant. Erythema multiforme may at times be a real cause of confusion. Its recognition must de- pend on its characteristic cutaneous lesions, the course of the disease and the general symptomatol- ogy. A solar erythema may for a time cause doubt, especially when occurring among the insane. Lichen and eczema must be excluded on local appearances and general course. Functional neuroses, especially neurasthenic phe- nomena, may for a time remain in doubt, but they are usually cleared up by the appearance of the erythema. Sprue is said to occur in the United States and may cause confusion; the course of the disease and the absence of skin manifestations must suffice for diagnosis. Typhoid pellagra may be mistaken for an acute infectious disease or uremia or diabetic coma. The history of the case under such circumstances may be of much importance. The character of the tem- perature, condition of internal organs and general symptomatology should usually serve for differen- tiation after a short time of observation. PROGNOSIS 283 PROGNOSIS. There are two factors, with regard to pellagra in the United States, which should not be overlooked in dealing with prognosis. These are, first our com- paratively brief experience with the disease; and, second, the fact that even this experience is based very largely on the treatment of asylum cases, admittedly the most hopeless type of the disease. It is manifestly unfair to expect improvement from any treatment when it is applied to cases not only far advanced, but likewise victims perhaps of many serious secondary organic changes. Nevertheless, even when these factors are given due consideration, it may undoubtedly be safely said that in this country all physicians who have treated this disease regard the outlook in individual cases as one of great gravity with respect to complete and final recovery. The statistics in existence, all based on asylum cases and only a small number at that, will give a case mortality of from 35 per cent, to 65 per cent. Such figures should really not be quoted, for they certainly give a very erroneous estimate as to the gravity of the disease in this country, and justify no definite conclusions whatever. In the existing state of our knowledge definite information is not available, and the opinions of those with widest experience must be accepted as our only present criterion. This opinion is practically unan- imous that the prognosis is grave in all cases. AUbutt has said, "When the disease has recurred for three or four seasons, and especially if the mind be affected, the prognosis is very bad. I gathered 284 PETTiAGRA from the physicians of Italian lunatic asylums that recovery of patients once arrived at the asylum stage of insanity is almost unknown. Still these are extreme cases ; the mentally afflicted in their earlier phases may recover; only too often, however, the advance of death is inexorable," and this doubtless expresses very fairly the view generally entertained in this country at the present time. A study of Italian statistics, however, certainly leaves one to infer that the Italians have no such mortality as we have apparently had ; and it is prob- ably safe to assert that the average Italian case mortality, as given in their statistics, will not exceed that usually accepted for typhoid fever, that is 10 per cent. In many cases it will fall even lower than this. The nature of the disease, however, with its chronic course and seasonal recrudescences, and the notorious unreliability of many statistics on pel- lagra, leaves the matter in much doubt. At the same time it would certainly seem that the Italian physi- cians do not view the matter in the hopeless light that is common among so many American medical men. The Roumanian observers, who with the Ital- ians have perhaps the widest experience, likewise do not take this gloomy view with regard to prognosis. From a consideration of all these facts, we are forced to conclude either that the disease is much more severe and hopeless with us; or, what is far more likely, that our experience has been largely confined to the hopeless type of the disease, the asylum cases. It seems to us reasonable to think that as our knowledge broadens and our experience DIAGNOSIS AND PEOGNOSIS 285 develops we will probably come to a clearer com- prehension of the matter ; and we will finally, in all likelihood, conclude that while the prognosis in all cases is grave, it is by no means hopeless. There are certain considerations of much weight in prognosis, and among these one of the more im- portant is an early diagnosis. It seems to be a fairly unanimous opinion, throughout pellagra literature, that early cases offer the greatest returns from treat- ment, and, of course, the most hopeful prognosis. The disease is essentially chronic in its character, but, untreated, advances inexorably until finally with marked involvement of the central nervous system little can be hoped for from treatment. It does not seem unjust to draw some parallel between this disease and tubercle of the lungs, both chronic, advancing states. But we have, through much misery and suffering, learned how early to diagnose, to treat and to counsel the tuberculous. Can we not apply this lesson, at least to some extent, with regard to pellagra? Pellagra is subject to sudden acute manifestations, and these conditions are of the utmost gravity. The condition of typhoid pellagra is practically hopeless. Occasionally a case recovers, but this is very rare. The chronic type of the disease, without mental involvement, is, as a rule, the most hopeful type, especially if early treat- ment is begun. Certain symptoms are worthy of note with regard to prognosis. As a rule pellagra is a disease of little fever, and it is fairly generally acknowledged that fever, especially if high or constant, must be 286 peUjAGra regarded as a danger signal. (See p. 214.) The char- acter and extent of the erythema, since the time of Strambio, has been regarded as no index of the con- stitutional disturbance, but we are convinced that extensive, moist dermatitis is always accompanied by grave general conditions. This opinion has like- wise been expressed by Merk in his recent admirable study of the skin lesions. Whether such erythemas mean some secondary invasion we are not in a posi- tion just now to say. Mental involvement always adds to the seriousness of the outlook, and such nerv- ous disturbances as subsultus, marked tremor, retrac- tion of the head, can, as in other affections, be inter- preted as an index of severe intoxication. In mental cases periods of excitement are not rare and they do much to help exhaust the patient. Severe recru- descences of the acute phenomena sometimes occur during the same season after the patient seemed to be on the road to recovery. Steadily progressing emaciation, especially if accompanied by an invet- erate diarrhea, which is usual, very often ends fatally. On the contrary, a tendency to take on fat is usually a favorable sign. Much of this might be summed up in a general way by saying that in advanced cases, with serious involvement of the central nervous system, and the appearance of what Roussel calls various consecu- tive conditions, offer a far less hopeful prognosis than cases of the first or early second stage before such events have occurred. Certain complications are also of importance in prognosis, and should always be kept in mind. By PROPHYLAXIS 287 some malaria is regarded as a very serious compli- cation. Then we may have intestinal parasites, such as thread worms, round worms, hookworms and amebas. Marked nephritis may also occur as well as acute bronchitis, pneumonias, decubitus gangrene (often difficult to avoid), possibly tubercle, and, of course, sudden acute manifestations like typhoid pellagra. All these complications may add greatly to the gravity of the situation. Finally, if the patient is carried safely through the acute manifestations of one season, a recrudes- cence of them must be watched for during the next season, more especially if anything should intervene to lower the general resistance, such as acute illness, childbirth, etc. Being a chronic disease, pellagra demands long, continued oversight and treatment much the same as does syphilis. It may be added that an hereditary taint may prove of much importance in prognosis, as has already been pointed out elsewhere. Prophylaxis. In any discussion of pellagra we must of course recognize the paramount importance of prophylaxis. The disease is first of all a public health problem; and while the treatment of the individual case must necessarily appeal to many medical men, yet preven- tive measures should, and do, occupy first place. Governments have usually displayed much concern at the invasion of their territory by this disease, and medical men, sanitarians and legislators have joined hands in attempts at its limitation or eradication. The gravity with which the disease is regarded, both in the individual case and in its relation to pub- 19— p. 288 , PELLAGRA. lie health, becomes much more evident when certain facts are brought into prominence. Pellagra has al- most invariably been found associated with wretch- edness and poverty, and the disease has In conse- quence been often regarded as an indication of the economic conditions obtaining among certain classes of people in the country involved ; and thus through motives of patriotism or for reasons of policy, or even from a sense of shame, publicists have felt urged to grapple with the problem. Pellagra, more- over, largely involves the laboring classes and so menaces the physical integrity of a very important part of a nation's population, a part which usually forms an essential element of strength and produc- tivity. Through its hereditary influences the disease also saps the strength of the people in a peculiarly hopeless manner, and throws its burden upon coming generations, ever spreading wider in its vicious cir- cle. Furthermore, the chronic nature of the disease, its seasonal recurrences, its too often steady advance, with possible years of invalidism and not infrequent mental alienation — all result, not only in the loss of productive years to the nation, but likewise often to the assumption of the greater burden of caring for useless mem- bers of society, frequently at public expense in a public institution, for long periods of time. These, in a general way, are the peculiar reasons why pel- lagra is regarded as a public health question of no small importance ; and why this disease, less import- ant numerically than some other well-known, pre- ventable diseases, has yet frequently attracted the at- PROPHYLAXIS 289 tention of sanitarians and public health officials, and demanded the support of legislators in the enact- ment of laws and in the appropriation of money. Now, the prophylaxis of any disease must neces- sarily depend upon its cause, and with equal neces- sity the efficiency of prophylactic measures must be in ratio to the definiteness of our knowledge regard- ing such cause. The etiological ideas of pellagra from a scientific viewpoint are, it may be admitted, at least in an unsatisfactory state. Yet, despite this, men of the widest experience and the broadest study seem convinced that there is some definite etiological relation between pellagra and the use of spoiled corn as a food stuff. On this assumption they have estab- lished extensive prophylactic measures which appar- ently in great part have often met with success. Under present conditions we must, it would seem, try to profit by their example. Of all such work, perhaps none deserves more attention or study from us than that of the Italians. They have labored long and earnestly in this matter, and they are beginning to believe that their success is almost assured. There is one fact, however, of immense importance in the United States which must not be overlooked, and which has been commented on by many observ- ers, and that is the absence among us, relatively speaking, of the poverty-stricken classes among which pellagra occurs. It has been said that Ameri- cans do not know what poverty is, and certainly we have no such wretchedness and poverty in our coun- try as is found in many places in the old world. This fact adds a hopeful gleam to an otherwise dark out- 290 PELLAGRA look, and it may not be too much to say that for this reason alone pellagra will never secure the hold here which it has in other places. But we could hardly sit with folded hands depending upon this fact for the solution of so serious a matter. We must at least be awake to the possibilities which may lie in the ap- pearance among us of a disease of such character as pellagra. As for the methods adopted by the Italians and the results, so far of their struggle, no better idea could be given than in a brief review of some por- tions of the report of Mr. Cutting, elsewhere cited in this volume. He personally visited many districts in Italy and saw not only the men engaged in the fight against pellagra, but was able in many places to judge also of local conditions for himself. He says: "How shall the people be prevented from eating mouldy corn? This is the problem which confronts the legislator and philanthropist of today. For its clear realization and for the chief measures adopted to solve it, we are indebted to the Zeist School, and in particular to Lombroso. * * * The Zeists have compelled general recognition of the obvious truth that prevention is better than cure ; and at the same time, by the very dogmatism of their monistic creed, have given unity of object to the work of prevention." He then reviews Italy's early efforts against pellagra, notes the establishment by Joseph II of Austria in 1784 of a special hospital for the study of the disease at Legnano with Gaetano Strambio as director; and the important census of pellagrous sufferers made by national authority in PROPHYLAXIS 291 1879, the consequences of which were renewed inter- est in the disease and much activity on the part of various provincial governments against its further spread. The way was thus finally smoothed for the great national law of 1902, under which the present apparently successful struggle is being waged against this disease. (This law and the regulations made under it are given in Appendices I and II.) The important dispositions of this act, according to Cutting's analysis, are of two kinds, curative and preventive; the former include distribution of salt, administration of food, either at the patient's homes or at sanitary stations (locande sanitarie), treatment of severe cases in hospitals, pellagrous hospitals (pellagrosari) and insane asylums. The preventive measures include the inspection and testing of all corn or meal brought in at the frontiers or seaports or offered for sale or brought to the mills; the ex- change of good corn for bad; dessicating plants, cheap co-operative kitchens; improvement of agri- cultural methods ; and the education of the people as to the danger of bad corn. In addition, cases of pellagra must be reported. There are some practical methods authorized by the bill and in general use in Italy which deserve a brief discussion, since they are in a measure novel to us in the United States, and are deemed of much importance. The free distribution of salt is due to the fact that salt is a government monopoly in Italy and its price is frequently high. Besides being considered an es- sential part of a healthy diet, salt is also by many 292 PELLAGRA considered beneficial to pellagrous sufferers. It is stated that the national government in Italy dis- tributed over 3,000,000 pounds of salt in this way during 1906-07. Under the law of 1902 the distribution of a "cura- tive diet" is made obligatory, and it is provided that such diet shall be distributed for two periods of at least forty days each per annum. This diet is ap- proved by the provincial Pellagrologic Commission, and medicines are also included. These provisions are carried out by means of a house to house distribution, by economic kitchens, or by sanitary stations, all dependent upon the practical conditions to be met in various places. The economic kitchen is a place where good, plain food is supplied to rural populations at a low cost, or even gratuitously. Such places are conducted by the commune or by charitable organizations or they are co-operative. The sanitary station {locanda sanitaria) is a de- velopment of the economic kitchen in accordance with special conditions, and is a place where pel- lagrins come once or twice a day, during a stated period, to receive food which is consumed at the sta- tion. The food consists of soup, bread, meat, wine, cheese, milk and vegetables. The general idea is to furnish good nutritious, non-maidic food to pel- lagrous sufferers during the seasons when pellagra is most virulent, spring and fall. Along with the diet, in many such stations a course of medical treat- ment including hydrotherapy, is given as well. PROPHTIiAXIS 293 The value of these stations, according to Cutting, is a subject of much discussion. The time of treat- ment is too brief, but a large number of sufferers are reached, and more than 80 per cent, go away distinctly improved, while a large number of incip- ient cases, especially among the young, are per- manently arrested. For incipient cases it is regarded as a valuable curative agent in the fight against pel- lagra. In 1907 there were over five hundred of such stations in Italy. The best results are obtained where the sanitary stations are numerous and are kept open for considerable periods of time. The pellagrosari are special hospitals for the treat- ment of pellagrins. They are intended primarily for cases too acute, or too grave, for treatment at sanitary stations. The treatment in these institu- tions is along the same general lines as elsewhere^ dietetic, hydrotherapeutic and medicinal. There seems a tendency to make use of these institutions as a prophylactic measure, admitting thereto prin- cipally the young and the incipient cases. The insane asylums receive a large number of alienated pellagrins, and the tendency is to send as many of these unfortunates as possible into the asylums, rather than allow them to linger in the villages and rural districts. The inspection of corn and the prohibition of the spoiled grain is conducted by a corps of men acting under the sanitary authorities. The distinction between sound and spoiled corn is not always easy, and several tests are in use. Such tests include the general physical characteristics of the grain, dis- 294 PELLAGRA coloration, presence of moulds, loss of lustre, bitter taste and peculiar odor. The chemical tests include the determination of the proportion of ash, sound corn being said not to give more than 4 per cent, of ash; Gosio's phenolic reaction, a greenish or purple color with ferric chloride ; the reaction of the grain, spoiled corn having a higher degree of acidity; the germination test, spoiled corn of course losing a cer- tain part of its germinating power; and finally the use of animals. These tests are not regarded as entirely satisfactory, but in practice the sound and spoiled grain are said to be differentiated with a fair degree of readiness, especially at the frontiers and seaports. But meal from home-grown grain, at the mills, or on the markets, has given much trouble ; and the detection of a spoiled article is said to be almost impossible. It has even been urged by many that all mills be placed under governmental supervision, or be owned and operated by the muni- cipalities. "Every province of Italy," says Cutting, "has a commission for the encouragement of improved methods of agriculture." Thus are established the Cattedre Ambulanti (moving chairs) or "Farmers' Institutes," the activity of which is far-reaching, and the influence of which has been notable in the progress of agriculture in Italy during the past decade. By precept and example these "institutes" have taught the peasant how to grow better corn, or to replace this crop with some other more profit- able one, as potatoes, millet, etc. Cutting thinks it no small triumph for these institutions that in many Plate XVIII. South Carolina case. "Wpt" form. Dcrmatilis of hands, elbows, face and lips. Superficial ulceration of hands. PROPHYLAXIS 295 places they have induced the Italian peasant to abandon a traditional crop for one unfamiliar to him. The influence of such work is thought to be one of the important factors in the restriction of pellagra. The dessicating plants for the artificial drying of corn are of comparatively recent introduction into Italy, but are regarded as of the greatest importance in the prophylaxis of pellagra. The peasantry not infrequently object to the use of the dessicator, alleging that during the process the corn loses in weight, later it will not germinate and that the cost amounts to something. These objections do not all hold good, for the loss in weight from the spoiling of the grain is also considerable, the best dessicators do not impair the germinating power of the grain, and the question of cost has been met by a provision of the law which allows dessication of corn for family consumption at no cost, and the rest at nom- inal rates. These dessicators are of two types, fixed and port- able. The portable are very convenient, but the fixed are far more efficient and are preferable. Cutting, in describing the Cattaneo type of the fixed dessicator, says: "Air heated by a furnace is forced by a ventilator into a chamber of seven stories. Each story is a circular, revolving tray, containing about 1,390 pounds of corn. The top tray is filled from above. After a certain time its contents are emptied, by pressing a lever, into the tray below, in such a way that they are thoroughly remixed. The com thus passes gradually to the 296 PELLAGRA bottom tray, whence it goes to a receptacle where it is cooled by means of a ventilator, and thence out of the machine by an inclined plane. The first tray load of corn takes seven hours to pass through the machine; after that 1,400 pounds come out each hour. The cost of the machine is about $540, and the power required to run it about 2^ H. P. . . . The air is forced through the trays in both an upward and a downward direction, and that which has absorbed dampness from the corn is replaced constantly by dry air; the temperature is kept low (about 104° F.), with economy of fuel and without risk of injuring the corn. The mechanism is so simple that the machine can be handled by any laborer of ordinary intelligence." There are also good portable dessicators which are less elaborate and less costly, but, as stated, far less satisfactory. The low temperature at which the grain is dried does not suffice to kill mould spores, and it is, there- fore, considered of much importance not to place spoiled corn in the dessicators. Their use is to dry good grain for preservation. Public dessicators are now numerous in Italy, the number in 1907 being given as 461, and the quantity of corn dried by them during that year as 54,747,000 pounds. The necessity of properly storing corn, and the unhygienic and unsanitary methods in use among the peasants for preserving the grain, have been the subject of much comment. In recognition of the importance of this matter, the law of 1902 provides PROPHYLAXIS 297 for public store houses, but for the present the cost of construction and maintenance has been prohib- itory. Cutting thinks there is no doubt, however, that public store houses will ultimately come into general use. In the further effort to eliminate from the diet of the peasants bread made of corn, there has been established another institution known as the rural bakery {fomo rurale). In this institution good wheat bread is furnished at a very low price. In- stitutions of this kind are comparatively recent, but their number has increased from 77 in 1904 to 591 in 1907. Another effort has been made in the establishment of corn exchanges where the peasant may exchange spoiled grain for a smaller quantity of good meal, some deduction being made for cost of milling, etc. The plan is approved by many as a good one, and has not proven very costly in comparison with the benefit conferred, but it has not been very successful. Numerous other expedients of less importance have been suggested or even adopted in the struggle against pellagra. "In general," says Cutting, "the object is to get at the children; to prevent pellagrous mothers from nursing their babies, or if this cannot be done, to see that the mothers are well fed ; to treat a child the moment he or she shows the slightest symptoms of pellagra, and to send such children to other surroundings." Of course while legislative restrictions have their importance, yet in this, as indeed in all such strug- gles, the education of the people is of paramount im- 298 PELLAGRA portance. The restriction of corn, the change in a national taste, the introduction of a varied diet and better living conditions, these are the cardinal things in such a campaign. "And this is not neglected. The indefatigable Permanent Committe& of the Interprovincial League against Pellagra edit a magazine, the Revista Pellagrologica Italiano^ devoted to the struggle against the disease; popular pamphlets are distributed in great numbers; popu- lar lectures are held everywhere ; colored lithographs representing the healthy laborer fed on sound corn and the pellagrous laborer fed on spoiled corn hang on the walls of public lecture halls; and the pella- grologic and agricultural commissions of the dif- ferent provinces multiply instructions by precept and example." (Cutting.) The results of such work seem on the whole very encouraging, but their interpretation is difficult by. reason of other contemporaneous developments. They coincide with a marked rise in general pros- perity. The laborers and peasants can now eat bet- ter food than ever before; numbers of the rural population are employed in industrial institutions, where they receive a varied diet; temporary emigra- tion has reflexly widened the view of the peasant class, and they demand and get better food and living conditions; the consumption of meat is in- creasing, and wages are higher. Such things must, of course, in a disease like pellagra, have a very profound effect. Statistics undoubtedly show a decrease in pel- lagra; but for many reasons statistics are not COMMUNICABILITY 299, entirely satisfactory and do not serve to show the actual state of the case. The opinions of those actively engaged in the work and in close touch with the situation, are, in general, that pellagra in Italy is notably decreasing both in numbers and in inten- sity. Strange as it may seem, however, the disease is apparently increasing its area, and parts of Italy previously free from pellagra are now developing the disease. The cause of this is not apparent. Communicdbility. The question of the contagi- ousness of pellagra, early in its history, aroused inuch discussion. The idea of contagion was advo- cated by many able men, and opposed just as strongly by others. With the courage of conviction and with the zeal of enthusiasts, several voluntarily submitted themselves to inoculation with pellagrous material in order to prove their contention of its non-contagiousness. The inability of those favoring contagion to bring forward any satisfactory reasons or observations to sustain their view, and the numer- ous observations and the extended experience of others against the idea of contagion, at last served entirely to discredit any doctrine of communica- bility; and the advocates of contagion abandoned their views. Since then this subject seems to have received but scant attention at the hands of writers on pellagra, the question being regarded as defin- itely settled. Eoussel, as early as the middle of the nineteenth century, wrote: "It can be said of the contagion of pellagra, that it is a question fully determined, . . . pellagra is not contagious." 300 PELLAGRA This question has very naturally arisen again in the United States, and observations have been brought forward in support of conununicability ; measures of isolation and quarantine even having been adopted. Such views seem to us now wanting in proper evi- dence to support them. Of course we must realize that the medical profession has many times been led into error through what appeared to be sound de- ductions from extensive observations ; and so long as the etiology of pellagra remains in its present state it can not be denied, beyond all doubt, that communi- cability in some form may be a possibility. This is, however, too severe a test to apply to a great deal of accepted medical opinion. In the present state of our knowledge, the idea of communicability seems to us indefensible; and the hardships and severity always implied in quarantine and measures of iso- lation appear equally unjustifiable, either on theoret- ical or practical grounds. Treatment. ESegarding the medical treatment of pellagra, Holland, as long ago as 1817, wrote: "In short, it appears certain that mere medicine has done very little for the relief of pellagra; and Strambio frankly confesses that he never saw a case distinctly cured by the remedies that were employed." This gloomy outlook has been shared by others, and here in America most clinicians who have had experience with the disease seem inclined to take a very discouraging view of treatment. TREATMENT 301 Certainly we must admit at the outset that we have no specific for the disease, but this is far from admitting that treatment is hopeless. In great part, the present therapy of pellagra is founded on Lom- broso's teaching, and while he, and his followers, may by many be regarded as too sanguine, still his enormous experience certainly entitles his views to the greatest attention and respect. In discussing the treatment of pellagra in accordance with ideas advanced by him, he says that the therapy of this disease, which was at first desperate and could be summed up in baths barren of result, can now be undertaken more confidently and rationally, as the treatment of a chronic intoxication, analogous to alcoholism or morphinism, and curable by antidotes, when the use of the toxic material has been sus- pended. These antidotes, he thinks, are to be found in arsenic and chloride of sodium. Lombroso's teaching has had a profound effect, and his ideas on therapy have been very generally adopted. No account of treatment, therefore, would be complete without at least a brief review of the measures advocated by him. He recommends as a rule a liberal diet, including meats especially, but points out that this alone is insufficient. He also remarks that in well-nourished pellagrins this is of course not so much indicated, and adds that such cases are rebellious to treatment. He speaks of baths and cold douches, which he thinks benefit especially paretic states, the skin man- ifestations and the painful burning sensations bo common in pellagrins; and further says that, while 302 PELliAGRA they do not cure, they at least prolong existence or render it more tolerable. In some patients, however, there is a true aversion to baths, and in such they should not be tried. Of drugs in a general way he condemns the use of iron, for the reason that he has seldom seen bene- fit from its use and has often seen it cause exacer- bations of intestinal and other symptoms. In some cases, especially in the young and those with arrested development, he states that he has obtained magnifi- cent results with simple salt rubs or frictions. He has experimented extensively with acetate of lead, but finds it of little use except in pellagra of the aged, in those who suffer acute articular pain, in cases of incipient paresis, and in cases of general tremor. The dose used was 0.01 to 0.05 gram in 300 c. c. of water. In typhoid pellagra he tried numerous remedies without avail. Finally in his search for a remedy (through some reports of Coletti and Perugini) he got the idea of using arsenic, and he says, after experience with the drug, that the results exceeded by far his expecta- tions. He does not seem to regard arsenic as a true specific for pellagra and admits that it does not cure all cases, but he thinks it is a very valuable remedy, and that it acts in a certain sense as an antidote for the toxines of spoiled maize. As an antidote he compares it to the action of opium in alcoholism and mercury and the iodides in syphilis. Sodium chloride he seems to think has probably an equally powerful effect, but a very much more restricted field, being limited largely to children. TREATMENT 303 He uses arsenic in the form of Fowler's solution in dosage of 5, 10, 16, 20, and 30 drops, or in the form of pure arsenous acid (arsenic trioxide) dis- solved in slightly alcoholized water, in doses of one- fortieth to one-twentieth milligram, increasing, according to tolerance, up to 0.001, 0.002, or 0.003 gram and very rarely even to 0.01 gram. The ad- ministration of the drug is suspended for a few days from time to time. He cautions against certain dangers in its use, however, and mentions as dan- gerous symptoms the appearance around the neck of an herpetic eruption, profuse salivation, ano- rexia, vomiting, diarrhea, palpitation of the heart, syncope, burning in the pharynx and stomach, head- ache, great muscular weakness, and bronchitis. The possibility of arsenical neuritis should be kept in mind. He thinks certain types are especially helped by the administration of arsenic, and that certain others receive no benefit, as follows : Benefited. — Cases with marked marasmus; cases with incipient paresis; cases with sitophobia (gas- tralgic type) ; cases with vague mania but not sys- tematized delirium; cases in the aged, if not at the verge of decrepitude. Not benefited. — Cases in the young and in infants ;- cases well nourished and robust; cases with system- atized delirium; cases with mental alienation of twenty to thirty years' duration; cases having lobar pneumonia, tuberculosis, albuminuria, or severe vertigo. In cases of grave vertigo he sometimes uses the tincture of cocculus orientalis in doses of 3 to 6 drops daily, progressing slowly to 30 drops a day. 304 PEIXA6RA Among symptomatic remedies he seems to approve the use of calomel, castor oil, bismuth subnitrate, opium, tannin and other astringents, at times chlorate of potash and astringent enemas in the treatment of the diarrhea. In certain advanced cases ergot, strychnine and f aradism have sometimes been employed as useful adjuvants, and in alienated cases such hypnotics as chloral, paraldehyde and sometimes opium. In defending his use of arsenic and salt he con- tends that on empirical grounds alone he can be jus- tified, since experience has amply proven these rem- edies to be of immense benefit. But he further- more states that their use can be justified on rational grounds as well, and he quotes extensive experimental work to show the beneficial effects of arsenic on the heart, skin and nervous system, its antifermentative power, its effect on metabolism, etc. ; for chloride of sodium he brings forward similar evidence to show its action on the skin, its power of aiding in the assimilation of phosphates, increasing muscular force, aiding digestion, stimulating the development of cartilaginous and other tissues, its beneficial effect on the nervous system, etc. The general measures adopted in the treatment of the disease should be dietetic, hydrotherapeutic and medicinal. The diet is a matter of much importance and should be selected with some care. It should be easily assimilable, highly nutritious and should include meats. An abundant diet is recommended in spite of the frequent intestinal disturbances and TREATMENT 305 diarrhea. These disturbances are perhaps trophic largely, and not inflammatory, in their nature; and food is not so much contra-indicated as in some other intestinal states. Of course if the diarrhea is too free and the stools contain undigested material the diet must be regulated accordingly. It must not be forgotten, however, that the patient's condition usually requires all possible nourishments and effort must not be spared in the individual case, where possible, to meet the dietetic indications. Of course in the treatment of a number of pellagrins, as in institutions, the question of expense or feasibility often intervenes. The general diet given adults, for example, in the locanda sanitaria at Bagnolo Mella, in Italy, is as follows: First meal: meat broth, and coffee and milk, each on alternate days, with 150 grams of bread. Second meal : one liter of soup made of macaroni, 100 grams, vegetables, 100 grams, meat stock and condin^ents; boiled meat, 200 grams, with vegetables, 50 grams ; bread 300 grams ; wine 200 grams. Third meal : J4 liter of soup, made of rice, 50 grams, vegetables, 50 grams, meat stock and condiments; meat stew, 100 grams, with vege- tables, 50 grams ; bread 150 grams ; wine 200 grams. This diet is modified in many ways to suit individ- ual cases and appetites, and for children under twelve years is reduced in quantity. In commenting on this diet Ceresoli, the medical director, states that digestibility, which is to a large extent dependent upon cooking, is a matter of great importance; and for this reason he commends roasted meats, which for local reasons he has not 306 PELLAGRA used in his diet. Where there is repugnance to meat he substitutes cheese or eggs, and cheese he recommends highly. The wine, which is of good quality, stimulates a torpid digestion. Care is always taken by him that dietetic rules are subor- dinated to age, sex, temporary physiological acci- dents, idiosyncrasies, the condition of the gastro- enteric tract and to the greater or less tolerance of a reconstructive food supply. He also points out the especial need for nitrogenous substances in a diet for pellagrins. He seems to think it no easy matter nicely to adjust a diet to the needs of these sufferers, and that a diet, begun cautiously, can be gradually and judiciously enlarged properly to meet their needs. Hydrotherapy is considered a valuable adjuvant in the treatment of pellagra and is extensively em- ployed. Cold baths and warm baths, both simple and medicated, as well as douching, are employed. Such treatment must be used with discretion, of course, and consideration given to the stage of the malady, predominating symptoms, therapeutic indi- cations, age, sex, and general physical character- istics. In weak and prostrated individuals treat- ment is begun with warm baths of short duration, and the temperature is reduced and the time pro- longed as the patient improves. At the extremes of life the warm bath is preferable. The application of baths should be so regulated, of course, as to produce the best results, with in- creased oxidation of the tissues, more rapid elimina- tion, greater metabolic activity, increased appetite. TREATMENT 307 improved digestion and assimilation, and a strong tonic effect on the whole organism. Improvement is evident from increase in weight, in the firmness and force of the musculature, disappearance of prostration and subjective nervous symptoms, with increased physical and moral vigor. Vertigo, stuporous states, distressing paresthesias and even diarrhea are often benefited. Massage may sometimes be added with advantage. The medicated baths of sulphur or arsenic are used chiefly in certain conditions of the skin, some- times in cases with predominating intestinal disturb- ance accompanied by wasting. The salt bath or rub is of especial importance in children. This may be given as follows : The child is placed in a tub of warm water, the temperature of which may be practically judged by the hand, which should be able to bear it with comfort. A conve- nient receptacle of salt is placed near. The salt should be of a fine quality and should not contain coarse particles. A good kitchen or cooking salt answers all requirements. The attendant, having stood the child up in the tub, wets his hands and dips up a handful of the salt. With this he thor- oughly and firmly, but not roughly, rubs the child's body all over for some fifteen or twenty minutes. The child is then made to lie down in the water, the salt is washed off, and after a few minutes a cold douche is given. The child is then put to bed and at rest for a time. This may be done three or more times weekly. 308 PEULAGEA For further details concerning hydrotherapy the reader must consult special works on the subject. Among general measures rest is a matter of much importance, especially in acute conditions, and when there is fever. Change of climate and surroundings, if possible, particularly to colder latitudes, may be advised. Saline infusions may at times be of service. During the warm season avoidance of the sun's direct rays may prevent a bad erythema. Cleanli- ness, good nursing and fresh air are, of course, to be desired. With regard to the medical treatment, symptom- atic remedies must be used as needed. For insomnia chloral hydrate, paraldehyde, or some of the more recent hypnotics, like trional, sulfonal or veronal, may be tried. The dermatitis, if dry, may not require much attention, but moist dermatitis, espe- cially if extensive, cause much inconvenience. Such surfaces often become infected and may prove of no small concern. Oily applications or tincture of iodine may be used on dry surfaces. The moist con- ditions should be treated on general surgical prin- ciples. We have found a picric acid dressing (1 per cent, aqueous solution) of benefit, but it stains linen badly. A stubborn diarrhea will give much trouble at times and may prove rebellious to all treatment; the bismuth salts, the salicylate especially, various astringents, sometimes enemas of cold water, and at times opium along with the general and dietetic management, must be depended on for its control. Pain may at times require morphine, but we have not been forced to resort to its use to any great TREATMENT 309 extent, and it is, of course, to be avoided if possible. Complications, such as malaria, syphilis, intes- tinal parasites, should receive prompt attention with appropriate remedies. If much anemia be present many good observers think a bland preparation of iron is needed; some good preparation of arsenate of iron would seem of value, and such a preparation can now be obtained even for hypodermatic use. Mercury, except in cases complicated with syphilis, seems valueless. Following Wright's work with the succinamide of mercury in tuberculosis, we have given this salt a trial in several cases, but achieved no results except in syphilitic cases. The remedy proved quite irritating locally. The more or less recent introduction of certain new arsenical compounds seemed, in the light of Lombroso's work, to offer a better therapy for pel- lagra. Of these preparations three have come into more or less general use. These go by the names of atoxyl, soamin and arsacetin. Atoxyl and soamin are both trade names and are stated to be forms of sodium arsanilate, containing respectively about 26 per cent, and 22 per cent, of arsenic. They are sold in the form of the salt itself or in the form of hypodermic tablets. Arsacetin, introduced by Ehr- lich as an improvement over the other two, is described as an acetyl derivative of atoxyl. This is sold in the form of the salt itself. The arsenic of these salts is said to be liberated very slowly in the system, thus producing the ordin- ary therapeutic effects of arsenic with the advantage of a more continuous and less toxic action and less 310 PELJiAGEA irritation. Toxic effects from excessive dosage have been frequently noted, although their toxicity is far less than that of arsenic trioxide. Blindness, due to degeneration of the optic nerve, has occa- sionally resulted. All of these salts are soluble in water, arsacetin more so than the others, and they are largely used by the hypodermic or intramuscular method, their administration by mouth not being recommended for the reason that toxic symptoms may result from decomposition by the acids of the stomach. There has been much discussion as to the dosage of these remedies, but based on the extensive use of atoxyl and soamin in syphilis and trypanosomiasis, it would seem efiScient and safe to give as much as 0.5 to 0.65 gram on each of two succeeding days, and to repeat this dosage, with ten-day intervals, for many months. Others have given as much as 0.5 gram on alternate days until 7 grams have been given, then a rest for three months. The dosage of arsacetin is stated to be lower, but many workers have used the same dosage as with the other salts, without toxic results. Arsacetin has the advantage of being more soluble, is said to be less toxic, its solutions can be boiled and they keep well. It is perhaps needless to add that in administering these remedies antiseptic precautions should be observed, and local irritation thus avoided. Babes, in Roumania, seems first to have used atoxyl in pellagra and reported very favorably on his results. Warnock, in Egypt, then tried it ex- tensively, and concluded ultimately that "the value rinte XIX. South Carolina case. "Wet" form. Lesions identical with those of I'latc XVIII. Both cases under observation at same time and both rapidly fatal. TKEATMENT 311 of atoxyl in the treatment of advanced stages of pel- lagra such as are met with in this asylum has not been demonstrated," and he could not confirm the Roumanian experience. Reports on the use of these remedies in the United States have been almost universally unfavorable. We have used both soamin and atoxyl rather exten- sively, but have had only a limited experience with arsacetin. We have used them almost exclusively by the intramuscular method, and have observed no toxic effects except in one case. Our usual dosage has been 0.5 to 0.65 gram on alternate days for two to three doses, then a rest of ten days, and repeat for several weeks. Our work has largely been done with asylum cases, and the results have been disap- pointing. With a few non-asylum cases, however, we have noted improvement; and we are not in- clined, as yet, to discard these remedies as useless. Inveterate diarrheas have seemed at times to yield to atoxyl or soamin. Recently Babes, and others, have reported bril- liant results from the use of atoxyl and arsenic tri- oxide combined. The method is as follows : Atoxyl 0.5 gram hypodermatically ; externally on the sound skin, a rub with 5. grams of an ointment of arsenic trioxide (1 to 50) ; and internally a pill of arsenic trioxide (.001 to .002 gram) thrice daily; this treat- ment is given on two successive days, and, if neces- sary, is repeated once after an interval of one week. We have given this method a limited trial, but with- out observed benefit. 312 PELLAGRA We have used Fowler's solution of arsenic in many cases with apparently good effect. Donovan's solution has likewise been employed by some. It is needless to add that scores of other remedies have been employed and recommended in the treatment of pellagra, but they have not borne the test of time. Finally, we have the serum treatment and blood transfusion. There is a good deal of evidence tend- ing to show that specific antibodies are developed in the blood of pellagrins, and the serum of recovered cases has been reported as successfully used in the treatment of typhoid pellagra. Some workers have even expressed the confident hope of producing from the horse an efficient antiserum, but this has not yet been realized. It has also been suggested that pos- sibly so-called "blind staggers" in horses may be pellagra, and that the serum of animals recovered from this disease may be efficient in treatment. We have attempted to treat two cases with blood serum taken from recovered pellagrins. One case died from a pneumonia shortly after treatment was begun, the other seemed to improve for a while, but finally, after much emaciation, died of an intercur- rent tubercle of the lungs. It is. difficult to secure proper cured cases, otherwise such treatment is not difficult to carry out, and would seem well worth further effort. Cole has treated a number of cases by blood trans- fusion, after Crile's method, and reports very good results. For donors he has used both recovered pel- lagrins aiid others who have not had the disease. This procedure, while not difficult, requires expe- TREATMENT 313 rience. It is more difficult of application among the insane by reason of lack of cooperation on the part of the patient. Under certain conditions it may be regarded as a valuable surgical resource. The benefits of a change of climate were long ago recognized by the Italians and French and recently have been recommended in this country by Bass and others. » In conclusion, it may be said that treatment of advanced stages of the disease, especially in asylums, is very unsatisfactory. Early cases, without mental involvement, however, can be often successfully reached. Furthermore, in a disease like pellagra where so many persons are involved, especially among the poorer classes, the great desideratum is, of course, some specific treatment, inexpensive and easy to use. Elaborate and expensive measures do not fulfil the indications; and while such resources are of great value under certain rather exceptional conditions, they are, for general use, largely inap- propriate. CHAPTER X Corn and Pellagra in France. Eottssel and lombeoso. It would seem evident from what has been said that the prime necessity in the prophylaxis of pella- gra would be a radical change in dietary, but the practical question at once arises as to the means to be adopted in carrying out this reform ; and the fur- ther difficulty as to whether corn, even if sound,- should be interdicted. This immediately suggests an inquiry as to the food value or danger of com of good quality. Food Valtje or Corn. Not a few have asserted that pellagra may be due to a scarcity of nitrogenous material in corn, a scarcity all the more pernicious for that class of people like the peasants (in whom all admit a greater frequency of pellagra) who must constantly do severe manual labor. An attempt has been made to justify such an hypothesis from the less intensity of the disease among those who eat meat, like the city dwellers or the rich; and from the preference which is even yet given by the physiologists to nitrogenous food over a vegetable diet ; such considerations stimulating the belief that a lack of meat is dangerous to human health. Lombroso has shown how almost all the laboring classes and peasants of Europe live upon a vegetable diet ; and likewise the laboring populations of other nations as, for example, the Chinese and Japanese. FOOD VALUE OF CORN 315 As Beketoff* has said: "The physiologists have exaggerated certain statements on dietetics. They have not taken into consideration that there are immense masses of people who live contrary to their dicta and still perform labor. "Man has not the teeth of the carnivora; the length of his intestines is six times the length of his body; just as the ape, essentially fructivorous, has not a carnivorous structure. Moreover, a meat diet- ary is not as widespread as is supposed; it is rather the exception than the rule. Whereas the English- man eats on the average 100 grams of meat per day, the Frenchman eats but 35 grams, and only the Frenchman of cities at that. If meat diet were much extended, the lack of meat would become an insurmountable obstacle. The number of domestic animals is diminishing, and if all those in existence today were slaughtered, it would furnish for each inhabitant of Europe 400 grams of meat for one year, and no more. "All humanity may be divided into those who subsist on rice, on corn, on wheat, and on rye; the meat eaters representing a small minority." If the opinion were correct that lack of meat as food is the cause of pellagra, then all humanity would be pellagrous, including the peasants of Sicily and Sardinia, who, for whole months, eat only lettuce and figs ; and the Japanese, who eat almost nothing but rice, and rice contains even much less of hydro- carbons and albumenoids than does corn. It must not be concluded from this that these persons remain ♦Eevue sclentlflque, 1881. 316 PELLAGRA free from disease (beriberi) because they work less than the Italian peasant, or because they eat more. The Norwegian lumberman himself accomplishes his severe toil, as Virchow remarks, on a quantity of dry bread and cheese so small that one would scarcely believe it. Kingsford observes, with reason, that the animals that do the most severe labor, and are continually harnessed, such as horses, cattle, elephants, live on plants; and that the Grecian athletes ate only figs, nuts, cheese and bread. The Egyptian porters live on melons, onions, lentils and dates; and the Japanese day laborers live on rice, fruits, roots and herbs. In France, according to Eochard (Bertillon), the vigorous vine growers of Nievre eat meat only once a year, and the peasants of Morvan twice. Some have urged as a cause of pellagra the exclu- sive use of one food, but they have overlooked such instances as that of upper Italy, where certain peo- ple live among fruit trees and dairies. One result of a personal investigation among the population of the country in pellagrous regions has been the demonstration of the falsity of this assertion,^ and this appears still more clearly from the splendid researches of Bodio." In Villempenta, a region much affected by pella- gra, the ordinary food consists of wheat cakes ^Lombroso, Sulle Condlzioni economicoigienlcbe del contadini dell' alta e media Italia, Mllano, 1877. ^Sul Contratti agrarii e Sulle Condlzioni Materlall di vita del contadini d' Italia, 1879. FOOD VALXJE 0¥ CORN 317 cooked with oil or lard, rice, fish and pork, besides corn in the form of pancakes and polenta. At San Martino all' Argine, a place where pel- lagra is frequent, the nourishment is polenta, cheese, sardines, besides annually nine sacks of corn and three of wheat for every able-bodied laborer. At Mel, in Belluno, fifty per cent, of whose population is pellagrous, the food is polenta, cheese, milk, often beans and chestnuts, and on feast days, macaroni and rice. In the province of Lucca, the villages most affected eat beef and pork. Ceru gives these sta- tistics : Beef Pork Total Meat Population. Butchered. Butchered. Butchered Porcari 4,621 5,600 kg. 26,333 kg. 31,933 kg. Capaimerl.. ) 4,222 8,000 kg. 20,533 kg. 28,533 kg. } Possignano. j" 4,222 8,000 kg. 20,533 kg. 28,533 kg. Bodio says that the food of the inhabitants of the country districts around Cremona consists of polenta with a little pork, fish and rice. In Coresina rice and vegetable soup, polenta with cheese and vege- tables, kneaded bread, etc. In Melegnano, Pavesi found, after careful exam- ination, that the population consumed each week per head: Rice or Com In Soup 1,332 grams Corn Bread 1,350 grams Beans 232 grams Fat 332 grams Vegetables 133 grams Other Starchy Material 992 grams Proteid Substances 160 grams 318 PEULAGEA Jacini, in his classic work on landed estates, says that in lower Lombardy, at the height of the sum- mer, they give daily, to a domestic, 2 lbs. of corn; in winter 1 1-2 lbs., and in addition two to three measures of milk, two rice soups, and on Sunday sausages. The younger domestics have the same diet except the milk. Calderini also says that out of the pellagrous suf- ferers visited by him, who took meat diet, 18 per cent, of the women, and 41 per cent, of the men ate meat on Sunday, 87 per cent, daily took milk, 17 per cent, took wine, and 33 per cent, wheat bread. According to the facts noted in the report of Friuli, by the Engineer Camis: "In a population, which numbers 3 per cent, of pellagrins, each peas- ant consumes annually, besides 372 kilograms of corn, from ten to ninety kilograms of each of the following: beans, rice, potatoes, and other vege- tables, pork and bacon, olive oil, fish, chickens and wine. They do not eat beef except on festal days, for a marriage or an illness, or when an animal of the herd dies." In the province of Ferrara an adult hired peasant consumes on an average daily : During severe Usually (eight labor (four months of the months of the year.) year.) Polenta 1,000 grams . . . 160 grams. Milk Almost none Almost none. Eggs One-flfth A half. Onions One Two. Wheat Bread 50 grams. . . 400 grams. Macaroni 50 grams. . . 200 grams. Meat (principally pork) 10 grams. . . 60 grams. Cheese 5 grams ... 20 grams. Beans 150 grams. . . 40 grams. Fish 20 grams. . .Almost none. FOOD VALUE OF CORN 319 Apart from its readiness to undergo change, com, from a physiological standpoint, is an excellent food. But experience has proven that even so good a food as corn cannot, without harm, be continued exclu- sively for a long time. Agricultural experiments have shown, however, that animals fed on corn alone may fatten. For example, Guffart succeeded in fattening some hun- dreds of cattle on selected corn alone, although he found it much better to mix therewith forage or oat straw: 12 cows weighing 2,207 kilograms, attained, after being fed on corn alone for 156 days, 159 kilos per day, the weight of 2,951 kilograms. Eight cows, which in 453 days, had consumed 12,063 kilos of corn, along with 2,935 kilos of oat straw, increased from 3,549 kilos to 3,9^6.^ Dankoff has proven in his recent work that many ruminants perish if they are given the same food, as oats or turnips, for more than three months. That is due to the fact that the same food continued monotonously, surfeits and destroys the appetite; it is sufficient to change the diet and all danger is gone.'' Experience teaches us that the poorest laborer varies his diet on occasion of the smallest festival. One would therefore err if he pointed out as an etiological factor a diet insufficiently varied. It would be regrettable if the government, in fighting pellagra, should resort to the distribution of meat rather than establishing drying ovens and granaries for corn. ^Manuel de la culture du mais, 1879. "Arch. Anatomie et Physiologie, 1881, p 4,'i3. 21— P. 320 PELLAGRA If it is claimed that corn does not contain enough of the essential nutritious substances, or, at least, that it contains them in smaller quantities than other cereals, an answer may be found in the following tables of Giihring, of Bell and of Koenig and Dietrich : COMPAEISON OP CEREALS BY GOHRING. hS ^U . 'C s S.'S si ■3-S 1 so S5 • S! 09 ■ 1^ O.'O jag o 3 B» a< b fim—tt: bm fe-"! O Wheat flour 13.6 8fi.4 12.0 1.1 72.3 0.173 0.249 0.5 Rice meal 10.03 K9.97 11.7 2.(1 48.6 2.228 3.939 15 Corn meal 10.0 80.0 15.2 3.8 70.5 0.220 0.306 [For comparison, the following table taken from Bell's analyses,^ may be added : Constituents of the Gbains of the Common Cekeals. •Starch Nitrogenous matter (i. e., albumen, ce- renlln, etc.) Cellulose Sugar (saccharine body allied to cane sugar) Fat Mineral matter Moisture Total .' 63.71 15.53 3.03 2.57 1.48 1.60 12.08 63.51 49.78 14.67 13.53 2.36 5.14 2.66 11.86 64.66 14.27 1.86 1.94 3.58 1.35 12.34 61.87 14.87 3.23 4.30 1.43 1.85 12.45 100.00 100.00 100.00 100.00 100.00 77.66 9.34 Traces 0.38 0.19 0.28 12.15 100.00 *The starch includes from 1 to 1.5 per cent, of dextrim, and together with cellulose and sugar, comprises the carbohydrates of the cereals.] 'Quoted from Kenwood — Public Health Laboratory work, Lon- don, 1908. PKOPHTLAXIS 321 PERCENTAGE COMPARISON OF CEREALS ACCORDING TO KOENIG AND DIETRICH. Non-Nitrogenous Fatty ExtractlTes. Substances. Protelfls. Rice 72.47 1.76 8.38 Corn 65.43 5.56 9.90 Rye 65.16 1.96 13.31 Wheat 68.85 1.55 12.66 Irish potatoes 21. 0.15 2.17 The opinion that corn is dangerous because diffi- cult of digestion is without foundation. According to the above table of Koenig and Dietrich, and according to the demonstration of Uffelmann in his Hand-book on Hygiene, the nitrogenous substances contained in corn are very much more digestible than those of wheat bread, rye bread and Irish pota- toes. It may be added that according to Letheby, the quantity of nitrogenous matter contained in oats, barley and rye has a value of 1.90 francs, while in wheat bread it has 2.21 francs, in rice 3.80 francs, in potatoes 2.77 francs, in milk 7.39 francs, in pork 8.87 francs, and in com 1.08 francs. Prophylaxis. From all the proofs given that feeding upon spoiled corn alone is the cause of pellagra, there would seem a very definite and certain means of prophylaxis. To tell a peasant, as many do, that, if he wishes to protect himself against pellagra, he has only to have a good dietary, and then drink more wine, is correct ; but this advice is useless, harmful and even cruel irony. When one treats pellagrins at home, it is 322 PELLAGRA more difficult to nourish them with bread, meat and corn, than merely to give them counsel. They will continue to eat corn because they have no better, and cannot get any better; and the chances are that there is, in the corn they have, a variable but decided proportion of spoiled grain. If the unhappy peas- ants of Lombardy were able to have a better diet, they would have it without the advice of the phy- sicians, says Lombroso, and they would not have pellagra. Good diet, however, will never eradicate pellagra. The first therapeutic effort in the treat- ment of pellagra ought, nevertheless, to aim at the suppression of the cause of the trouble, that is, the dietary of spoiled corn, a thing easy to secure in hospitals. Clinical experience and pathological anatomy demonstrate that pellagra does not come from lack of proteid in corn, but from the use of corn which has become spoiled. As we have already said, corn, in proportion to its price, yields a quan- tity of nitrogen larger than that of any other aliment with the exception of beans. [Pellagra is a morbid entity, entirely distinct from mere inani- tion.] One should not, then, forbid corn to the peasant, but counsel him to harvest and preserve it in such a manner that it cannot spoil. With regard to general prophylactic measures, various suggestions may be made. Ameliorate or change the various modes of corn culture according to the region; for example, the culture of quaran- tina may be suppressed where corn ripens badly or is harvested too soon and, therefore, does not PROPHYLAXIS 323 become thoroughly dried; the corn called "dwarf corn," or "chicken corn," which matures more read- ily, may be substituted for it. In sandy ground the cultivation of white corn, which does not grow well there, ought to be abandoned from economical motives as well as for hygienic reasons. Intensive culture can be carried on only by means of irrigation, but then in certain districts watering costs from 25 to 50 francs per hectare. If, according to experienced farmers, in the place of quarantina, potatoes were planted, there would be a more profitable crop. Irish potatoes yield 100 hectolitres per hectare; the quarantina only 36; then, the bad weather does not spoil the potato crop as it does that of corn; finally, if you reckon 500 francs for seed, and eliminate the fodder, the pota- toes would still yield a greater profit by 100 francs. Other writers recommend millet in the place of potatoes. It is very nourishing, but does not yield so well as potatoes and it exhausts the soil. In regions where it rains regularly at the time of the harvest, there would be needed a place paved with good stones or with cement, with spacious room for storing the cereals after drying them in the sim. One could follow the example of the peasants of Mexico, where, after the harvest, they expose the grain to the sun during the day and put it under shelter again at sunset. It would be worth while to set up co-operative machines for shelling, and in this way the corn of the small farmers would be as quickly shelled as that of the large proprietors, without being more 324 PELLAGRA exposed to inclement weather. This would mean economy in wages. On the small farms it would be sufficient to have movable frames for exposing the ears of corn to the sun, as is done in the Tyrol, Tuscany and Liguria. The system of preservation ought to be completely changed. In most of the great public or private granaries of upper Italy, they should make general use of the means which, in the approval of all Europe, preserves the corn from dampness, fermen- tation, mice and worms, and which considerably diminishes the losses during preservation. To the apparatus of Devaux is due the freedom from pellagra enjoyed by the Irish, who, in later years have to some extent substituted the use of corn for potatoes in their dietary. This apparatus consists of a series of light iron frames or boxes, 15 meters high and 1.67 meters wide, each perforated by small holes like a skimmer, and the whole tra- versed from below upward by a tube or cylinder likewise perforated. The grain, through which the air must pass, is never placed in layers deeper than 65 to 70 centimeters, so that the air may easily per- colate. The air is heated and pumped through the apparatus by means of steam. While with ordinary methods of preservation there is expended from 1.50 even to 3 francs per hectoliter without obviating a loss of 8 per cent, to 16 per cent, through spoiling of the grain, or through the evaporation which follows heating, yet with this apparatus preservation costs only 7 or 8 centimes per hectoliter, and there is no greater loss in the weight and value of the grain. PBOPHTiAxia 325 The Pavy granary renews the air, drys and cleans the corn at a cost of 1.50 francs per hectoliter. For large landed estates the granary ventilator of Valery is suitable. Similar apparatus ought to be installed on board those ships which transport cereals, and on which com is piled up unprotected and exposed to rain. A great increase of pellagra in Italy^ in 1853, was due to corn imported from Odessa, which was exposed to continuous rains during transportation. In regions with a dry soil the corn containing less than 16 per cent, of water can be preserved in tight receivers communicating with the air (silos of Eomagna). The millers and bakers could use very simple arrangements like the screens used in Mexico. New industrial applications for the use of com other than its use for human food should be encouraged. For example, the manufacturing of spirits or alcohol, and above all, the feeding of stock. Premiums ought to be accorded to inventions which improve the baking of corn bread and its preservation in the ordinary bakeries. Laws ought to forbid the grinding and selling of mouldy corn. Oversight ought to be organized in the country at the time of harvest, and in the cities over the great warehouses at the time of summer heat. Severe fines ought to be prescribed against the proprietors who oblige their laborers and small farmers to eat spoiled com. These prohibitions were already in force in Venetia as early as 1776 (See Appendix III) , and are stiU so in Austria. But , 326 PELLAGRA in consequence of acquittals, a fine for selling spoiled food does not attain its end, and indifferent public opinion neutralizes the good effect of the laws. There should be established cheap cooperative bakeries among the peasants whereby they may protect themselves from dishonest bakers and millers. But perhaps a better method might be the adoption of some new process of preparing and cook- ing corn similar, for example, to that used in Mexico {tortilla) and in other countries. Treatment should be begun early in all cases, and as soon as the first gastric and nervous symptoms develop, the patients, if adults, should be given arsenous acid, and, if children, sodium chloride. In early cases symptoms yield readily to treatment and cures become difficult when the case is neglected for too long a time. Would it not be in the economic interests of the commune to aid in establishing such things as small provisional hospitals for early treat- ment of these cases, and the consequent prevention of hereditary diffusion of the disease? These indi- viduals, in this case, with the expenditure of a few lire, or even at times a few centesimi, might be saved to discharge their duty to society instead of perhaps remaining helpless burdens which may ulti- mately cost the commune hundreds of lire? It is worthy of note also that the Austrian government has adopted measures of this kind to aid pellagrins in their own homes. In some conditions, as after severe inundations, for example, when the inhabitants might be forced to live on spoiled corn, nothing would remain but to PKOPHYIAXIS 327 counsel depopulation of the region by means of emigration, if necessary, to other more favored places, even to America. The sons of pellagrous parents might be sent into the army or advised to emigrate to other countries which are free from pellagra. Finally information with regard to prophylaxis and treatment should be disseminated anjong the agricultural classes. Much can be done in this manner. (See Appendix IV.) Roussel, in his work, formally accepted spoiled corn as the cause of pellagra, and was the first to spread in France the ideas of Balardini. Later a physician of the department of the Hautes Pyre- nees, Costallat (1857), became the ardent and con- vinced defender of the "verderamist doctrine." "Pellagra is a slow poisoning by verderame or verdet," said he in reporting the presence of the parasite on the corn in the markets of Bagneres-de- Bigorre. These demonstrations and the different campaigns, which popularized them, have succeeded in France. The experimental demonstrations have been repeated by Balardini, EUia and others, either with the grain of spoiled corn or with polenta made from such grain; young chickens fed on it refuse to eat, lose weight, become droopy, tremulous, and very thirsty ; at the end of twenty-eight days they are in the last stage of exhaustion and moribund, In EUia's experi- mental chickens the feathers, moreover, became roughened and the skin became the site of a fur- furaceous desquamation. 328 PELLAGEA Lussana and Frua injected into the veins of dogs and of birds, the powder of corn, affected by verderame, mixed with water; at one time the aqueous extract of this substance; at another, finally, the very fine powder of verderame itself. Most of the subsequent symptoms observed, such as dys- pepsia, coagulation of the blood, pulmonary ecchymoses, vomiting, congestion of the liver, and intestinal inflammation could be attributed to the severity of the experiments, but not so, the apathy, clonic convulsions and paralysis, more or less com- plete, especially of the hind legs, which are observed in the dogs that, for a time, survive the initial intra- venous injections. These phenomena show charac- teristics too marked to be misinterpreted. Leplat, Jaillard and Lombroso have shown that the injection of Penicillium glaucum is harmless, provided the injection is so managed as not to pro- duce capillary embolism. Since then, Grawitz has claimed success in the pro- duction of infectious properties in Penicillium glaucum and in Aspergillus glaucus by appropriate cultural methods. Graffky and, later, Schultz, in the laboratory of E. Koch, convinced themselves that the foregoing investigator had been deceived. Aspergillus fumigatus, A. Flavescens and A. Niger are dangerous moulds, but they concern only pul- monary mycosis, and not general infections. There is also recognized a toxic Mucor stolonifer or Rhizo- pus nigricans, which forms the black mould of wheat bread. This, also, it would seem, is not to be incrim- inated. PROPHYLAXIS 329 Tizzoni, Panichi and Fasoli have isolated and cultivated a specific micro-organism common to typhoid pellagra, to pellagrous insanity and to ordinary chronic pellagra, in different and remote localities. They found it in all the principal viscera and in the, central nervous system ; they cul- tivated it and injected it into animals, obtaining morbid experimental symptoms analogous to those of severe pellagra and also nervous and typhoidal symptoms. The meninges, the cerebro-spinal fluid and the blood in severe cases of pellagra have been subjected to culture with success by these authors, who describe a specific diplococcus found in the viscera, especially the intestines, which enters the circulation and through its toxines later involves the nervous system. [Tizzoni's work has already been discussed in the chapter on etiology, §■. v.] The researches of Lombroso opened a phase entirely new in the struggle against pellagra, from the all important standpoint of the etiology of this scourge. As has been said, the discoveries made by Lombroso advance along the same lines as the very interesting observations of A. Gautier, Selmi (of Bologna), Brouardel and Boutmy, relative to the formation and the properties of cadaveric alkaloids — the ptomaines. The question here seems to con- cern alkaloidal bodies, which, if not ptomaines, are, at least, closely allied to them. [The nature and origin of these toxines is naturally of paramount importance to the Zeist idea.] 330 PEIJLAGEA Selmi has formally applied to spoiled corn the procedure used in the investigation of the ptomaines. It is a great honor to Lombroso to have taken up and sustained, by experinlent, the pregnant idea of his illustrious compatriot, Balardiai, which others blushed to hear called "the Italian doctrine."* The assent of Husemann and Cortez, and of Felix (of Bucharest) and of the authorities assembled at Genoa in 1880, Manassei, Schilling, de Pietra-Santa and others, have in large measure compensated the Professor of Turin for the rather hasty judgment, in 1875, of the Commission of Lombardy Institute. Besides corn, other cereals, such as wheat, rye, oats and millet, denounced by Faye, are susceptible of being invaded by fungi before or after the harvest, , as Bouchut has remarked. From such cereals intes- tinal disturbances may arise which are more or less pellagroid in their nature. If com, which is an exotic plant of comparatively recent introduction into Europe, and which has not yet acquired the power of adapting itself to environment as has wheat, is to be grown in various localities, and remain free from deleterious change, then it will be necessary to find upon our continent conditions of soil and climate which approach that of its native land. Unless this is done the grain will never arrive at perfect maturity, or only arrive at it in a state of uncertain vigor, not actually diseased, perhaps, but easily subject to general or specific morbid influ- ences. It seems, indeed, that everywhere, Mexico included, the grain of corn has a delicate germ, •Scientific Congress of Paris, 1867. VARIETIES OF CORN 331 badly protected by its envelop, incessantly menaced by dangers and atmospheric influences. Even in Cen- tral America there is need of having it properly stored, and still it is not eaten until it has been care- fully prepared. It is probable that it was the object of especial care at the time of its transplantation to Europe as a rare and valued plant, but since then the farmers have strangely relaxed and corn is cultivated on all sorts of soil. No attention is paid to the better varieties most apt properly to mature, but concern is given only to those which give the greatest yield ; and advantage is taken of the rapid growth of some varieties to sow them even when summer is closing, as if corn were not a plant of warm countries. The principal varieties of corn cultivated in Italy are: (a) Summer Corn {zea mays vulgaris aestiva) ; (b) Autumn Corn (s. m. autumnalis) ; (c) Quarantina Com (s. m. praecox) ; (40-day com) ; (d) Beak Com (s. m. rostrata) ; (e) Cinquantina {z. m. sub-praecox) ; (50-day com) ; (f) Dwarf Corn {z. m. minima) ; (g) White Autumn Com {z. m. autumnalis leu- cosperma) ; (h) Red Com {z. m. rubra). White corn succeeds in clayey soil, but only the yellow variety can be cultivated in sandy soils. One of the great advantages of corn for rural populations is the fact that certain varieties can 332 PELLAGRA be sown as an after crop in a field which has already yielded, in the same year, a harvest of rye or legumes ; but in this case it cannot be planted until the end of June or July. It is necessary, however, that it mature early enough to be harvested before the bad weather. If it is not cut by the middle of September, there is great risk of its being stored damp. The grain of the variety called sessanta, or "60-day corn," which requires two months for maturing, cannot be harvested before the end of September, and is almost always stored unripe and permeated by dampness. Furthermore, after cutting, it does not dry readily upon the ground, because the days are short and rainy. The conditions are par- ticularly bad when the peasants, induced by the large yield, have sown in the mountainous regions either this variety, or even the cinquantina (50- day corn.) The varieties sea mays aestiva, and s. m. autumnalis, which require four to five months for maturing, frequently produce crops which have been soaked by the rains while ripening in the field. These are, however, the preferred kinds, in Umbria, for human food, the early varieties being cut green for forage. The poor system of crop rotation, followed in upper Italy, has been censured (Koussel, Lom- broso), probably with reason; because corn, like every other vegetable growth, loses in quality if it is planted on the same ground several times at short intervals. The summer and autumn corn occupies the land nearly all the season. IMPORTED CORN 333 The unripe and damp grain could, with a little effort, be improved and preserved, if it were placed in thin piles in dry granaries, and well aired. This was formerly done when the cultivation of corn was important; but today too much is harvested to give the crop the necessary care; it is piled up and becomes heated. White corn, very much cultivated in Moldavia and Wallachia (Eoumania) is particu- larly subject to alteration. In Italy there is used not only home-raised com, but imported as well. There are merchants in Um- bria who sell great quantities of com brought in from Albania, and also from the Danube provinces, and Venetia. Some is landed at Ancona, which comes from the orient in coasting vessels, especially from Albania and also from the Danube provinces. Though it is damaged and several years old, trade, nevertheless, keeps it going, and it is here that the millers come to the aid of the merchants by mixing bad meal with good. Lombroso, by concealing his identity as expert and philanthropist, easily found dozens of samples of rotten corn in the stores of the merchants of all the regions of Italy. These grain dealers know how to disguise the defects of their wares. Thus spoiled com is common in Italy. But who eats it, and especially who eats it almost exclusively ? Not the farmers in easy circumstances; these eat other cereals with the com, and, furthermore, the corn is of good quality ; the macaroni of which they make soup is made largely of wheat flour. They introduce into their diet rice, potatoes, cheese, oil. 334 PELLAGRA fat, sometimes meat, or fish when they dwell near a lake or the sea. Many drink wine. It has been remarked that the cantons, where formerly wine abounded, have become pellagrous since the oidium has restricted vine-growing. Those who eat scarcely anything but corn, receiv- ing it in a spoiled condition during most of the year, are the poor laborers of the fields, whose existence is at the mercy of the landed proprietor or of the large farmer {wffitatore) employing them. In Italy the landed estates are rarely divided, the land belongs to great lords, who usually live in the cities, as in England and in Ireland. The land owner rents out large tracts to a middle man, who, in turn, sublets portions to families of laborers (coloni). Each family pays him regularly in kind, in proportion to the amount of land they have in charge; he employs them, furthermore, at various kinds of work at poor wages. This is the system called affitanza, the most widely spread in upper Italy, and which is oftenest met with in the cantons afflicted with pellagra. It is through this system, says Senator Jacini, that one realizes the strange association of enormous production with the poverty of the producing class. Except in especially favor- able seasons, when the renter has paid his land rent, selling his rye and wheat to pay such rent or to meet divers expenses of the family, there remains to him only corn enough to last till the next harvest. This makes living very hard, as may readily be under- stood. Often, towards the end of winter, the renter having no com whatever left, must borrow from the AGKICULTDEAL METHODS 335 farmer, who gives him the poorest quality, and for this he must return sound grain after the next har- vest. The system of mezzadria, or farming on shares, is but little better than the preceding. The proprie- tor himself divides his land into small portions ; the share farmer, who takes one of them, owns at least the cattle and farming implements; he is something more than the slave of the affitatore. Nevertheless, many of the mezzadri are pellagrous; they scarcely use more than 1,000 to 1,800 grams of corn per day in the form of hard, badly cooked cakes, with vari- ous legumes. As for the simple farm hands, it is com- mon for corn to be their only daily food, and what spoils in the master's cribs falls to their lot. But it is necessary to live ! These wretched people know in advance what awaits them: 0, mangiare questa minestra! 0, scHtare questa -finestra! Cioe andar- sene via. [O ! to eat this soup ! O ! to jump out of this window ! Either is suicidal !] A man named Giardini, according to Lombroso, brought dying to the hospital, stammered out : "My trouble is rotten polenta!" When cured, he stated that he and a dozen hands on the Bisone farm, had been fed for six months on corn beaten down in the fields by hail; and as the cattle would not eat it, men were compelled to do so. It is in this way that upon the most fertile land of the world, the plains of Lombardy and the valley of the Po, an entire class of the people is forced to live on produce fit only for the refuse heap. Many peasants mix spoiled with good corn, think- ing they will be safe because of the good therein. Some eat who do not wish to confess it, fearing to be 336 PELLAGRA accused of carelessness in gathering the harvest, or of having stolen it from the stalks of the master before it ripened (Lombroso). When the corn has become toxic, Lombroso says, neither parching nor the action of alcohol nor super- ficial boiling succeeds in freeing it from its injurious properties. To do this would require boiling at 120 degrees C. with quick lime, then drying in an oven, a fact which explains why polenta and corn cakes made of spoiled grain remain injurious. These two preparations, polenta and cakes, are, by far, the commonest forms in which corn is eaten. Although corn bread (yellow bread, fane giallo), has in it almost always a little rye meal, about one- tenth, it is not easily digested on account of its compactness, and so all writers condemn it even more than polenta or corn meal gruel. Corn enters into the minesira (which is a soup) either in the form of meal or in the form of macaroni (pasta). Formerly in the departments of southwestern France, the field hands ate a greater variety of corn products, alone or mixed with other things, than they do today. The regular preparations were: the meture, mesture or mesturet, made in Beam with corn meal and water, mixed to a dough, and baked in an earthern pan in the oven ; the cruchade of the Landes, more often made of millet meal prepared as the preceding, but baked in a plate, which renders the cake thinner, better baked and more easy to digest; the migues or micoles, balls of corn meal dough, to be added to pork soup; the broye (in COEN PRODUCTS 337 Beam), touradiso (in Bigorre) or corn dough; the Jiariat, corn dough for soup made with cabbage and grease (Lourdes) ; the miliasse and the tougnos (Lauraguais), thin corn cakes, with salt and some- times with honey. At the time of the journey of Eoussel and the researches of Costallat, aggravating agricultural blimders were seen in the French provinces of the southwest, as in upper Italy; the crop rotation which every two years permits the replanting of corn upon the same field; the cultivation of white corn, and of slow growing varieties; the same relations between the proprietors and laborers, the share sys- tem of farming and the estivandiers (boss-hands) ; the most numerous class compelled to eat the cheapest food, and, consequently, of the worst qual- ity. Indeed, the peasants ate corn so much that they had to bring in additional supplies of it from Armagnac; and this corn proved to be so much damaged that only the very poor ate it, while people in easy circumstances fed it to animals (Roussilhe). In the Landes, particularly, they usually cultivated the variety which is planted in June or July in fields which have earlier in the season already yielded a crop of rye. The mainaUga, which the Wallachian peasants regularly eat, is a corn gruel like polenta (Schrei- ber). The Eoumanians also harvest their corn before maturity and pile it in silos where it easily ferments. Experience shows that the people who eat com perfectly matured, well preserved and protected 338 PELLAGRA from dampness, do so with impunity. It is, there- fore, necessary to recommend the varieties which rapidly mature, especially quaraittina corn. Direc- tions should be given for early sowing, and not after the previous harvest of some other crop. Advice should also be given with regard to diversity in crop rotation so as not to permit the planting of corn on the same land without an interval of three or four years. The topping of the ear to hasten maturation complicates the work and probably would be neglected or be impossible in cultivation on a large scale. Corn harvested before the rainy season ought to be dried in the field or the ears hung up with open shuck in a high granary, dry and airy, as is done in Franche-Comte and in Burgundy. The grain ought not to be left in large, but in small piles. In Bresse, in Franche-Comte, and in Burgundy, says Perrusset, of Macon, after having gathered the ears the shuck is drawn back and two piles are made. The ears intended for meal, which is to be made into cakes, are exposed to the air, suspended by the shuck which is left on the stem, under the shade of the farm buildings or in the interior of the apartments. When the com is thus well dried, it is shelled for grinding. The corn intended for gourdes, red gruel and polenta, is subjected to a kind of drying process. Then there is also corn called foumaye (dried in the oven), to use the expression of the country, and it is made into meal. Meal of com thus dried has a very agreeable odor. It is especially in this form that corn is used for food in the previously mentioned countries (Koussel). CORN PRODUCTS 839 Thus it is before the formation of verdet that corn should be dried and heated naturally or artificially. When the moulds are developed, it is too late, since the poison, which is now no longer a fungus, resists the boiling temperature. This would indeed kill the fungi, and, perhaps, their spores; but it does not destroy the properties of the alkaloidal bodies, once they are formed. The distinction is important and it is a precious gleam of light which we owe to Lom- broso. In southern America, as in Mexico, according to Parmentier, care is taken to sun the newly gathered ears and put them under cover for the night, and never to put them in piles. When they are ready for shelling this operation is carried out and the grain dried again in the sun. Corn meal does not demand less care, being even more easily affected than the grain. Within the limits of the possible, it is necessary to abandon by degrees the practice of using corn meal in the form of bread, cakes, cruchade; even when mixed with rye it is only with diflSculty that a trustworthy product is obtained in these forms. The peasants, unskillful or negligent as they are, obtain from it only a food, which is hard, glutinous, indi- gestible, and difficult of preservation. The Mex- icans avoid eating corn in this state; it is almost always gruel (atole) that they make. It is true that they have a cake called tortilla, which plays a large part in their daily diet; but this is prepared in a manner which deserves to be noted. They commence by adding to water in a vessel sufficient slaked lime 340 PELLAGRA to make a thick gruel, then corn in full grain is boiled in this for eighteen hours. At the end of this time the corn is taken out, washed carefully in clean water, and afterwards crushed by kneading to make a dough which is then formed into cakes. These are baked on a hot iron griddle and turned often during the baking. Enough gas is formed in the center of the dough to cause it to swell and make the bread light. There is evidently a great moral awakening to be wrought among the populations of southeastern Europe by general education and instruction in dietetics. The prophylactic measures advised for all these provinces, by the Commission of Inquiry of 1879, is: "Amelioration of the condition of the peasants, the introduction of meat and wine in their dietary." The advice is good, but how shall we put it into practice in the present state of land ownership in these districts, and under the existing agricultural, economic system which the victims thereof are unable to reform? The intervention of the state with protective measures, by the organiza- tion of sanitary surveillance, would perhaps be proper. On this delicate ground the question of hygiene joins hands with the sociological question. Everywhere there should be supervision of the trade in food stuffs and the sale of spoiled corn ought to be prohibited. Wherever the monotony of living on corn alone is broken by the use of some other food, which counter-balances its effects, pellagra has diminished or disappeared. PELLAGRA IN FBANCB 341 Meat, milk, wine, fish, cheese and even potatoes and legumes, these have proven to be potent for prophylaxis always when the peasant has been able to substitute them more or less completely for corn in his daily diet. The importance of favoring variety in the cultivation of crops, and of using some economical inducement to this end would then seem to be indicated. On the other hand we possess henceforth in Europe the means of equalizing our lack of meat by purchasing, cheaply and in a good state of preservation, the surplus of the New World and of Australia. In France where the division of the landed estates permits the peasant to acquire individual ownership, pellagra has disappeared, for example, from the Landes. How did this happen? They made of a marshy waste a rich and fertile country by the exploitation of the seacoast pines, and by the cultiva- tion of the better cereals, even of the vine, all accom- plished by the marvelous works of drainage, which are the glory of the government of that region. Fever rapidly disappeared, and this is always a bless- ing and is moreover an indirect guarantee against pellagra. Corn is still cultivated, and is even still eaten; but it is, in part, given to the stock; and, if it is used for human food, there is added wheat or other cereals, legumes, and also meat and wine. The peasant of Landes now eats meat several times a week, and drinks wine, if not of the first quality, at least an alcoholic drink made with malt, raisins and corn sugar. A good part of the com is transformed into sugar in several factories. Today the Landes 342 PELLAGRA has railroads, which guarantee the transportation and exchange of food stuffs of all sorts. Intelli- gence, the will of individuals, the aid of the local government, such are, if not the entire prophylaxis against pellagra, at least the instruments of this great work. "With a little good will on the part of the landed proprietors," says Senator Mantegazza, "and also of the better class of peasants, it would be possible in a half century to abolish pellagra." "Pel- lagra ought to disappear and this new disease enter into the category of extinct maladies" (J. Arnould). EOUSSEL AND LOMBROSO. In 1907, a monument to Theophile Eoussel was unveiled in the Avenue de 1' Observatoire, and elo- quent orators delivered addresses. The career of Eoussel, the statesman, was recalled, also that of the philanthropist, for to him are due the laws of the 4th of February, 1873, against drunk- enness ; those of the 23d of December, 1874, for the protection of children and the law in regard to delinquent children. He exercised much influence over the passage of the law of 1893, upon free med- ical aid, as also upon the reports of the senate rela- tive to reforming the law of 1838. But one fact which nobody recalled — ^his first feat of arms on a field of public charity and hygiene — was his battle against pellagra. At that date, in 1845, it was a living question in France; today not only the disease, but almost the very name of it, has laeen forgotten, since, thanks to him, its ravages have practically ceased. HOUSSEL AND LOMBEOSO 343 Eoussel recognized that pellagra is "a chronic intoxication, characterized, essentially, by a scaly erythema limited to those parts most exposed to the action of the heat and light, a chronic disturbance of the digestive tract, of which the most usual index is an obstinate diarrhea, and finally by a lesion, more or less severe, of the nervous system, termin- ating sometimes in mental alienation and paralysis." Eoussel contributed his part in showing that the cause of this intoxication lies in a food poison contained in spoiled corn, and that it affects those people who use such products for their food. In Europe corn is a relatively recent addition to the human dietary, having been imported there about 1700 [?]. Pellagra made its appearance soon afterwards, and wherever the cultivation of corn as a cereal has extended, pellagra has followed in its wake; and has in turn disappeared coinci- dently with the abandonment of corn as human food, or with the institution of the necessary precau- tions against moisture and decomposition of the grain, of the meal or of their cooked products. At the time when Eoussel commenced to sound the cry of alarm in France, pellagra in Italy had been the subject of special studies by Strambio and by the coterie of Italian clinicians who followed him. It is known that polenta, made from corn meal, is still the principal food in certain parts of Italy and Spain; and various national dishes are prepared from corn. Accordingly, pellagra makes fearful ravages in these countries. Two per cent, of the population of certain agricultural districts of Spain 344 PELLAGRA are said to be affected, and in Italy there are still (1908) nearly 80,000 pellagrins notwithstanding the crusade which Lombroso, following the example of Roussell in France, has led against it. At last there has sprung from these efforts special legislation, which regulates the hygienic condition of the granaries and corn transports, the supervision of the special markets, the control of foodstuffs of this kind, and seeks the suppression of fraudulent methods. But numerous congresses and a unity of effort on the part of experts and public officials has been necessary to repress this evil. In France, the Academy of Medicine, stimulated by the first work of Roussel, supported his demand for a commission to study the matter in Spain and in Italy. From this resulted a series of debates and finally investigations in the district of Landes, the people of which at that time were suffering from pellagra. To these circumstances we owe the im- portant studies of Roussel on this disease. At his visit, in 1844, to the afflicted districts men- tioned in the report of Leon Marchand, he found conditions somewhat improved, and the disease appeared to him to be less serious than had been reported. In a general way the disease seemed to show some connection with deplorably inferior food, and, more especially, with the use of corn which had been harvested under conditions favorable to mould- ing. In Landes, Roussel obtained useful information from physicians in active practice, whose names should not be forgotten: such are Dejean, Courbin, PELLAGRA IN FEANCE ' 345 Gazaillan, the two Bergerons, Lemaire (of Mimi- zan), Gazaban (of Aurice), Lestelle (of Cauna), Comin (of Sos), Dabos and de Calviere (of Gaba- ret). It was at Mimizan that Roussel first. heard popular names of pellagra, some of which have been the occasion of much dispute; for example, Mai d'Arrouse, de Saint-Amans, de Bascons, de Sainte- Rose. The last two are taken from certain places of pilgrimage commonly visited by the sick; the name mal de Saint-Amans is only a corruption of Saintes- Mains, the anointed hands of a certain colossal crucifix, from which the pilgrims took salve where- with to rub themselves. However, in 1847, pellagra was reported by the doctors Eoussilhe (of Castelnaudary), and Gales (of Villefranche) in a second locality in France, not far from the first, in the country districts of Laura- guais. Roussel used the occasion of his journey to verify the facts. Here, without possible error, was pellagra again, and, to all appearance, pellagra from the poisons of corn. Finally, the departments of Hautes and Basses Pyrenees were reported as a third disease center; and as Dr. Dozons, of this region, had, in 1845, protested against the conclusion of Roussel, reached on the very ground where corn is cultivated, the learned pellagrologist made a visit to his critic in the Pyrenees. It was seen, without difficulty, that the quarrymen of Lourdes, who use a great deal of corn, but of very good quality, were not suffering from pellagra, but certain peasants of the neighborhood were victims of it. On the other hand, the disease appeared at Cauterets, in the Can- 346 PELLAGRA tons of Nay, of Claraq and of Arudy, and extended even into the Canton of Pau (Gros, Pomes, Suber- bielle, Fourcade, Darthez, Gazaban, Juppe, Petrique, Talamon), always in connection with an extensive use of corn, and by reason of the poverty of the inhabitants, most often corn of the worst quality. Later (1855-1857), in this same region at the foot of the Pyrenees, Costallat (of Bagneres), together with Verdoux (of Labassere) , Duplin (of Laborde), Pedebidou, Lacoste (of Ibos), confirmed the diag- nosis of pellagra, and showed, by exact facts, its connection with the eating of spoiled corn. The work of Costallat was the occasion of a report by Duplais (1858) to the council of hygiene of the Hautes-Pyrenees. The disease, regarded therefore as an obscure malady, known only to transalpine travelers, was all at once proclaimed as widely spread in France. Up to then the people did not know how to recognize it, or, perhaps, it was hidden under false diagnoses. But the time had come when, despite the lack of any real scientific knowledge of the matter, the disease was found everywhere, just as now is found widely prevalent the typhoid fever of Louis, the endocarditis of Bouilland, the disease of Bright, the paralysis of Duchenne, etc. Lan- douzy, director and professor of the clinical school of Eheims, found cases of it, especially in the poor houses, a prey to vice and uncleanliness, and to physical and moral miseries. The eminent director of the clinic himself described the special symptoms of the different types and showed to his students not only pellagra without direct connection with corn KOUSSEL AND LOMBEOSO 347 (hereditary pellagra), but pellagra without poverty, pellagra without nervous troubles, typhoid pellagra, etc. (Eoussel). Under the influence of the same movement, Ch. Bouchard also discovered pellagra in the Hotel Dieu of Lyons, and in the infirmary of the poorhouse of Ehone. Harmon, a pupil of Lan- douzy, brought to the attention of the faculty of Paris nine cases in sustaining his thesis (1861). Bourgade (Clermont-Ferrand) published two cases. The physicians of Paris, themselves, found some cases of "sporadic pellagra." The Academy of Sciences, in 1865, crowned that work of Theophile Roussel, from which a large part of this chapter is taken. Landouzy and Bouchard have also studied the complex symptoms of this poisoning, more and more difficult to find in France, now that the cry of alarm sounded by Roussel in the middle of the nineteenth century has borne its fruits, and the use of the com as human food has been largely abandoned in France. The author found in Egypt a situation as lament- able as that among the agricultural populations of Italy, and of southwest France at the commence- ment of the nineteenth century. Koumania and southeastern Europe are still poisoned in this way, and will be for a long time. The recent uprising of the Roumanian peasants is directly associated with their wretchedness in which pellagrous poisoning plays no small part. Regis, at Bordeaux, and Mairet at Montpellier, have recently (1908) made an investigation which concludes the series of studies on pellagra in France, 348 PELLAGRA for it shows that pellagra has lived its day, and that there remains only the vestiges of hereditary taint manifested by mental troubles, erythemas, etc., occurring in a generation who have never eaten corn, but whose parents were poisoned by it. The asylums of Auch, of Montpellier and of Pau contain still some survivors of the terrible pellagrous insanity, which Roussel has, so to speak, dried up at its sources, by announcing its cause ; and, with the assistance of the medical corps of these regions, by influencing the people to give up this food product. The industrial improvement among the people has completed the work of liberating France from the use of a cereal now abandoned to animals. Let us hope that the vine growers' crisis and its miseries will not replimge the south of France into these distresses. The writer believes that it is not without interest that he has recalled this page in the life history of a good man, who has, among other merits, the glory of having so completely delivered his country from this scourge that even before his death the people had almost lost the memory of it. Less happy than France, in this respect, Italy still suffers from the terrible scourge of pellagra, though having blazed out the way leading to an unwearied scientific crusade. At the head of the present movement we must recognize Professor Cesare Lombroso, from whom we have borrowed the essential points for the writing of this book, which is but a feeble reflection of the enormous labor of a long life. For Lombroso consecrated a large part of his life to the fight against this cause of degenera- E0TJS8EL AND LOMBEOSO 349 tion so prevalent in his beautiful native country. More tried than France by international disturb- ances of war, followed by internal crises, Italy, in the course of the miseries of the century, has especially suffered from pellagrous poisoning. Like all the social poisons, this has been a disease of poverty closely dovetailed with the social evils from which she is freeing herself by degrees. As did Roussel for France, so in Italy, Lombroso has shown how to direct successfully the work of social redemp- tion. If it is less complete, it is because the disease was deeper seated than with us; and if France was the first to free herself, this was due to the cry of alarm in Italy, whose echo Roussel caught and resounded in his own country. To Italy and her scientific leaders public acknowledgment is due. To Lombroso, particularly, the illustrious philanthrop- ist and master, who has kindly permitted me to epi- tomize his great work, the writer owes this acknowl- edgment. -1 e 9 6 -i^— i ^ 3 3 d i H i S E § SP^ UJ z: UJ LU I UJ s: 03 j3/|vo: 3li < \ UJ ! ' > UJ ''S* UJ ^s ^ UJ ,^' -r^ UJ 1 ^ UJ ) J UJ 4 <; UJ s: ,A LI ^? Ul J < UJ S. 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UJ i 1 d UJ £ i 1 • oj UI £ ^ » s UJ £ •c \ c 1 ^ o 1 10 o c c CVJ O ^ O g^ g a5 ^ UJ 1 1 UJ 1 1 1 UJ 1 1 1 UJ 1 1 UJ z: 1 1 UJ 1 1 UJ 1 UJ 1 1 UJ 1 UJ 1 UJ Q: iia • — ^ 1 UJ « ^ 1 1 UJ 3. .VI ^i not IV± 31 ^ 1 UJ ( ^ UJ ( ^ 1 34 • X UJ \ 'n: IHJ Aa 3>^ aa ( < 1 UJ UJ 4 s o O o O IT C o o CM c o c c 0" § s^ ^ A. ENGLISH BIBLIOGRAPHY. AMERICAN AND BRITISH. 1791 Townsend, J. : A Journey through Spain In the years 1786 and 1787. Lond. 1791. 3 vols. 2. 9-11. (Brief observations on Mai de la Rosa.) 1799 P : An Account of the Pellagra ; a Disease Bndemial in the Duchy of Milan. Lond. M. Rev. & Mag., 1799, I, 179-184. Stramblo, G. : An Account of the Appearances, on Dissection In ten Cases of the Pellagra. Abstr. from Dr. Stramblo's Treatise on the Pellagra, 1787, — Communication to : Lond. Med. Rev. & Mag., 1799, I, 488-494. 1817 Holland, H. : Pellagra In Lombardy. Med. Chlr. Tr., Lond., 1817, VIII, 317. 1820 Holland, H. : On the Pellagra, a Disease Prevailing in Lombardy. Med.-Chir. 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BIBLIOGRAPHY 353 1882 Sherwell, S. : Report on a Case of Pellagra. J. Cutan. and Ven. Dls., N. Y., 1882-3, I, 142-145. 1884 Wilson, E. : Pellagra. Qualn's Diet, of Med., Tth Ed., 1884, p. 1103. 1885 Crelghton, C. : Article on Pellagra. In : Encyclopedia Britannlca, 1885, XVIII, 476-477. 1887 Pons Sanz, A. : Pellagra In Badajoz. Lancet, 1887, Oct. 22, 825. Van Harlingen, A. : Pellagra. Ref. Hndbk. of Med. Scl., 1st Ed., 1887, Vol. V, p. 535. 1892. ill Tuczek, F. : Pellagra. In Tuke's Diet. Psycholog. med. Vol. II, 8to., Phil. 1892. 1893 Tuczek, F. : Pellagra. From Ms : Monographic sur la pellagre, 1893. In : Church and Petersen : Nervous and Mental Diseases. Phila. and Lond., 5th Ed., 1905, p. 462. 1895 Kaposi, M. : Pellagra. In Ma : Pathology and Treatment of Diseases of the Skin. Transl. by J. C. Johnston. 8ro. New York, 1895, p. 224-226. Also in later eds. 1897 Allbutt, T. C. : Grain Poisoning — Pellagra. In Ma : Syst. of Med., Lond., 1897, II, 800-804. Warnock, John : Pellagra. In : Repts. Egypt. Gov't. Hospital for Insane, Cairo, 1897. (Valuable information each year subse- quently.) 1898 Sandwith, F. M. : Pellagra in Egypt. Brit. J. Dermat., Lond., 1898, X, 395-406, 1 PI. Also Reprint. Also in : J. Trop. M., Lond., 1898-9, I, 63-70, 1 PI. Also (Abstr.) Brit. M. J., Lond., 1898, II, 881. 1899 Anon : Grave Increase of Pellagra. Lancet, Lond., 1899, II, 1134. 354 PELLAGRA 1901 Sandwlth, F. M. : Tbree Fatal Cases of Pellagra, with Examina- tion of the Spinal Cords. J. Path, and Bacterid., Edlnb. and Lond., 1900-01, VII, 460-464. : Pellagra. In : Encyclop. Med., 1901. Also reprint. 1902 Harris, H. F. ; Anehylostomlasis in an Individual Presenting all the Typical Symptoms of Pellagra. Am. Med., Phila., 1902, IV> 99-100. .4180 : Tr. M. Ass. Georgia, Atlanta, 1902, 220-222. Ray, U. : The Pellagrous Affections of the Skin in North Behar. Indian M. Gaz., Calcutta, 1902, XXXVII, 289. Scheube, B. ; Pellagra in his Dis. of Warm Countries. Lond. & N. T., 1902. Sherwell, S. : A Note Relative to a Case of Pellagra (Abstract). Tr. Am. Dermat. Ass., 1902, Chicago, 1903, 96. Tuczek, F. : Pellagra. In : D. H. Tuke's Diet, of Psycholog. Med., Lond., 1902. Warnock, J. : Some Cases of Pellagrous Insanity. J. Ment. Sc, Lond., 1902, XLVIII (Jan.), 1-9, 2 PI. 1903 Corlett, W. T. : Pellagra. In : Reference Handb. of Med. Sc. (Buck), N. Ed., N. Y., 1903, VI, 520-522. EadclifCe-Crocker, H. : Pellagra. In his : Dis. of the Skin. Phila., 1903, 3rd Ed., 149-155. Sandwith, F. M. : How to Prevent the Spread of Pellagra In Egypt. Lancet, Lond., 1903, I, 723. 1904 Stelwagon, H. W. : Pellagra. In Ms : Treatise on Dis. of the Skin. 8 vo. N. T. & Lond., 1904, 3rd Ed., pp. 160-163. 1905 Sambon, L. W. : Remarks on the Geographical Distribution and Etiology of Pellagra. Brit. M. J., Lond., 1905, II, 1272-1275. Sandwlth, P. M. . Pellagra. In his : Med. Dis. of Egypt. Lond., 1905, p. 281. 1906 Allbutt, T. C, and Rolleston, N. D. : Pellagra. In their : System of Med., Lond., 1906, II, 892-97. BlancU, L. : Pellagrous Insanity. In his : Text-Book of Psy- chiatry. Tr. from the Ital. by J. H. Macdonald. 8 vo., London, 1906, 760-763. Also In Bull. 111. State Bd. of Health, Aug., 1909, 821-324. BIBLIOGEAPHT 355 Brown, A. C. : Pellagra Occurring In England. Practitioner, Lond., 1906, LXXVI, 679-685. Pellagra near Milan. Lancet, Lond., 1906, I, 1431. 1907 Babcock, J. W., and others : What are Pellagra and Pellagrous Insanity? Does Such a Disease Bzlst In South Carolina, and What are its Causes? An Inquiry and Preliminary Report. Eep. Bd. Health South Carolina, 1907, Columbia, 1908, 60-78. Reprint. Also : J. South Car. Med. Ass., Greenville, 1908, IV, 64-76. Also : Am. J. Insan., Bait., 1907-8, LXIV, 703-725, 2 Pi. Also : Reprints. Harris, H. P. : Pellagra. Rep. Georgia St. Bd. Health, 1907, IV, Atlanta, 1908. Merrill, T. C. : A Sporadic Case Diagnosed as Pellagra. J. Am. Med. Ass., Chicago, 1907, XLIX, 940. Manson, Sir P. : Pellagra. In Ma : Tropical Diseases, 4th 'Ed., Lond. & N. Y., 1907, 328-340. Also in: Bull. 111. State Bd. of Health, Aug., 1909, 325-333. Roberts, W. E. : A Tennessee Case of Pellagra. Am. J. Clin. M., Chicago, 1907, XVI, 1348. Searcy, G. H. . An Epidemic of Acute Pellagra. Tr. M. Ass. Alabama, Montgomery, 1907, 387-393. Also : J. Am. M. Ass., Chi- cago, 1907, XLIX, 37. Wood, E. J. : A Mixed Infection with Tertian and Quartan Malaria Occurring In a Patient with Symmetrical Gangrene. J. Am. M. Ass., Chicago, 1907, XLIX, 1891-1895. Also: Reprint. 1908 Bellamy, R. H. : Pellagra ; its occurrence in this country ; Report of a case. J. Am. M. Ass., Chicago, 1908, LI, 397-399. Card, W. R. i Report of Two Cases of Pellagra. Trans. Miss. State Med. Assoc, 1908. Conference on Pellagra, held under the Auspices of the State Board of Health of South Carolina, at the State Hospital for the Insane, Oct. 29, 1908. 8 to., Columbia, S. C, 1909, 59 pp. Ann. Rep. So. Car. State Bd. of Health, 1908, XXIX, 123-180. Also reprint. Papers : •Moore, N. M. : Etiology of Pellagra. •Wood, E. J. : , Pellagra — Some Problems in the Study of its Etiology. •Watson, J. J. : Etiology of Pellagra. The Italian Maize Theory, or the Theory of Lombroso. •Thompson, J. L. : The Roumanian Theory as to the Cause of Pellagra •Taylor, J. H. : The Protozoan Theory of Pellagra. Also : Reprint. •McCampbell, J. : A Theory as to the Cause of the Recent Appearance In This Country of Pellagra. •Taylor, I. M. : Personal Experience with Some Cases of Nervous and Mental Diseases Showing the Pellagra Syndrome. 356 FEIXiAGBA ■McConnell, H. E. : Clinical Observations on Pellagra. .Frontls, D. B. : Report of Three Cases of Pellagra In One Family. •Neuffer, G. A. : Four Cases of Pellagra. Lancaster, R. A. ; A Case of Pellagra. Powers, M. R. : Tbe Supposed Relationship of Damaged Grain to Epizootic Cerebro-Spinal Meningitis of Horses (Blind Staggers). ♦Griffin, H. H. : The Pathology of Pellagra. •Whaley, B. M. : Report on the Examination of tbe Eyes In Eighteen Cases of Pellagra. •Babcock, J. W. : The Diagnosis and Treatment of Pellagra. •Printed also In Jour, of South Carolina Medical Association, Nov., 1908. Cutting, W. Bayard, Jr. : Pellagra In Italy. Unpublished Con- sular Report to Asst. Sec. of State from Milan, Italy, Nov. 2, 1908. Ferrero, G. : Lombroso, Prophet and Criminologist. Century Magazine, LXXVI, 6, 925, N. T., 1908. Harris, H. F. : Pellagra. Trans. Med. Assoc, of Ga., 1908. King, J. M. : Pellagra, with Report of Cases. South. M. J., Nashville, 1908, I, 289-293. Lavinder, C. H. : Pellagra, a Prficls. Pub. Health Rep. D. S. Pub. Health and Mar. Hosp. Service, Wash., 1908. Also : Reprint, 22 pp. 1 PI. Leach, S. : A Case of Pellagra. Tr. M. Ass. Alabama, Mont- gomery, 1908, 446-452. Lee, L. and Cross, E. S. : Pellagra — a report of two cases. Trans. Med. Assoc, of Ga., 1908. McCampbell, J. : Some Observations on Pellagra In This Coun- try, with Special Reference to Pellagrous Insanity. Charlotte (N. C.) M. J., 1908, LVIII, 83-86. Moore, N. M. : Pellagra : Report of Case with Remarks on Etiology. J. Am. M. Ass., Chicago, 1908, LI, 1076. Pellagra in South Carolina. (Editorial) J. Am. M. Ass., Chi- cago, 1908, L, 450. Sandwith, P. M. : Pellagra. In : Green's Encyclop. and Diet, of Med. and Surg., Edinb. and Lond., 1908, VII, 374-378. Stoddart, W. H. B. : Pellagra and Pseudo-Pellagra. In IHs : Mind and Its Disorders. 8 vo., London, 1908, 430-431. Symposium on Pellagra at Meeting of North Car. Med. Soc, June 16-18, 1908. Trans. N. C. Med. Soc, 1908. Papers : Wood, E. J. : Symptoms and Diagnosis of Pellagra. McCampbell, J. : Observations on Pellagra. Lavinder, C. H. : Etiology and Pathology of Pellagra. Discussion of above papers. Wood, B. J. : The Appearance of Pellagra in the United States. Tr. Coll. Phys., Phila., 1908, 3 S., XXX, 196-224. 2 PI. Also: 3. Am. M. Ass., Chicago, 1909, LIII, 274-282. BIBLIOGRAPHY 357 1008-9 Randolph, J. H. Notes on Pellagra and Pellagrins, with Report of Cases. Arch. Int. Med., Chicago, 1908-9, II, 553-568. 1 PI. AUo: Mobile M. and S. J., 1909, XIV, 65-87. Also: J. Bouth, M. Ass., Shreveport, 1909, VI, 305-330. AI«o: Reprint. Rudolph, C. M. : Pellagra. Alabama M. J., Birmingham, 1908-9, XXI, 283-291. Searcy, G. H. : Pellagra in the Southern States. N. Orl. M. and S. J., 1908-9, LXI, 413-423. 4 PI. 1909 Allen, W. : Amebae In the Stools of Pellagrins. N. York M. J., etc., 1909, XC, 1212. Alsberg, C. L. : The Relation of the Production and Utilization of Maize to Pellagra. Symposium at Meeting of the Am. Soc. of Trop. Med., 1909. : Agricultural Aspects of the Pellagra Problem in the United States. N. York M. J., etc., 1909, XC, 50-54. Also: Reprints. Aulde, J. : Pellagra ; an Inquiry. N. Y. M. J., etc., 1909, XC, 1142-1144. B , W. A. ; Pellagra. South. M. J., Nashville, 1909, II, 857. Bailey, E. B. : Report of Fifteen Cases of Pellagra. J. Am. M. Ass., Chicago, 1909, LIII, 2159. Bass, C. C. : Complement Fixation with Lecithin as Antigen in Pellagra. Prelim. Note. J. Am. M. Ass., Chicago, 1909, LIII, 1187. Also: N. Y. M. J., etc., 1909, XC, 1,000. Bondurant, B. D. ; Pellagra, with Report of Eight Cases. Tr. Am. Neurological Ass., May, 1909. Also : Woman's M. J., Clncin., 1909, XIX, 183-187. Also : Med. Rec, N. Y., 1909, LXXVI, 300-304. Brown, R. D., and Low, R. C. ; Pellagra. Edinb. M. J., 1909, III, 197-202. Bryan, : Pellagra as Observed at the South Atlantic and Cape Fear Quarantine Stations. Pub. Health Report U. S. Pub. Health and Mar. Hosp. Serv., Wash., 1909, XXIV, 1489. Carter, M. H. : Pellagra, the Medical Mystery of Today. Mc- Clure's Mag., N. Y, 1909, XXXIV, 94-104. Clarke, A. B. : Diseases of the Eye in Pellagra. Med. Rec, N. Y., 1909, LXXVI, 1032. Cole, H. P. ; The Transfusion of Blood as a Therapeutic Agent, with Report of Transfusion in a Case of Pellagra. South. M. J., Nashville, 1909, II, 631-638. Also : Reprint. : Transfusion of Blood in a Case of Pellagra. J. Am. M. Ass., Chicago, 1909, LII, 633. Conference (National) on Pellagra, held under the Auspices of South Carolina- State Board of Health at State Hospital for the Insane, Columbia, S. C, Nov. 3 and 4, 1909. In: Ann. Rep. St. 358 PELLAGRA Bd. Health of South Car., 1909, XXX, 124-419. Also Reprint. Papers : Sandwlth, F. M. : Introductory Remarks, 136-141. Kerr, J. W. : Pellagra as a National Health Problem, 142-146. Watson, R. J. : Economic Factors of the Pellagra Problem In South Carolina, 147-154. Also : Reprint. Lavinder, C. H. : Notes on the Hematology of Pellagra, 155-162. Discussion on papers of Drs. Kerr and Lavinder, 162-167. Zeller, G. A. : Pellagra. Its Recognition in Illinois and the Measures Talsen to Control It, 168-174. Siler, J. F., and Nichols, H. J. : Aspects of the Pellagra Problem in Illinois. Part I. A Statistical Study of 100 Cases at the Peoria State Hospital (J. 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L. : Personal Observations on Pellagra, 347-349. Randolph, J. H., and Green, R. N. : Further Observations on Pellagra with Points on Prognosis, 350-356. Parker, E. : Clinical Observations of Pour Cases of Pellagra, 857-364. Buchanan, J. M. : Pellagra at East Mississippi Insane Hospital, 366-370. BIBLIOGRAPHY 359 Miller, J. E. ; Report of a Case of "Pellagra Universalis," 371- S74. Lunney, J. : Report of a Sporadic Case of Pellagra, 375-376. Maddox, T. : Report of Eight Cases of Pellagra, 377-382. Griffin, H. H. . Is Pellagra Communicable, or Hereditary ? 383- 388. Discussion on the paper of Dr. Griffin, 388. Young, M. B. : Pellagra in Children, 389-392. Torrence, C. : A Case of Labor in a Pellagrin, with Subsequent History of Mother and Child, 393-396. Clarke, A. B. : Diseases of the Eye in Pellagra, 397-400. Whaley, E. M. : Eye Symptoms of Pellagra, 401-405. Drewry, W. F. : Comments on Twenty-one Cases of Pellagra, 406-409. DeJarnette, J. S. : Pellagra, the Corn Curse, 410-415. 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Alsbei-g, C. L. : The Relation of the Production and Utilization of Maize to Pellagra. Lavinder, C. H. : Etiology of Pellagra. — Discussion. Tanzi, E. : Pellagra. In his : Text-Book of Mental Diseases. Transl. from the Italian by W. Ford Robertson and T. C. Mackenzie. 8 TO., London, 1909, 286-308. Taylor, J. H. : The Question of the Etiology of Pellagra. N. T. Med. J. XC, 1909, 1208-1212. AUo: reprint. Thayer, W. S. : Note on Pellagra in Maryland (2 cases). Johns Hopkins Hosp. Bull., Bait, 1909, XX, 193-200. 2 PI. AUo : South. Pract., NashTlUe, 1909, XXXI, 357-378. Townseud, A. M. : Pellagra ; Its History and Symptomatology. J. Nat. M. Ass., Tuskegee, Ala., 1909, I, 88-91. Treatment of Pellagra. (Edit.) Lancet, Lond., 1909, II, 1364-5. Treatment of Pellagra by Polymineralized Radio-ActlTe Solution. (Edit.) Boston M. and S. J., 1909, CLXI, 520. Turner, J. S. ; Pellagra : Texas M. News, Austin, 1909, XIX, 141-152. Walker, N. P. : Clinical Features of So-Called Acute Pellagra. J. Am. M. Ass., Chicago, 1909, LIII, 15. Also: South. Pract, Nashville, 1909, XXXI, 378-382. Warfleld, L. M. : Notes on Pellagra. Interstate M. J., St. Louis, 1909, XVI, 819-824. Watson, J. J.: Pellagra. N. York M. J., etc., 1909, LXXXIX, 936. Also : Reprint Welton, C. B. : Eye Symptoms of Pellagra ; Preliminary Report of Examination of Eyes of Fifty-flve Patients. J. Am. M. Ass., Chicago, 1909, LIII, 1636. Whaley, E. M. : The Ocular Symptoms in Pellagra. Ophth. Eec, Chicago, 1909, XVIII, 510-513. Williamson, O. L. : Pellagra in Arkansas. J. Am. M. Ass., Chicago, 1909, LIII, 717. Wolff, B. : The Skin Lesions of Pellagra. Am. J. Dermat and Genlto-Urin. Dls., St Louis, 1909, XIII, 343-346. Wollenberg, R. A. C. : Pellagra in Italy. Pub. Health Rep. U. S. Pub. Health and Mar. Hosp. Serv., Wash., 1909, XXIV, No. 30, July 23. : Statistics and the Law with Reference to the Disease (Pellagra) in Italy. Texas Med. News, Austin, 1909, XIX, 221. Wood, E. J. : Present Status of the Pellagra Problem. Char- lotte (N. C.) M. J., 1909, LX, 69-73. : Pellagra. Abatr. from: 3. Am. M. Ass., Chicago, July 24, 1909. South. M. J., Nashville, 1909, II, 979-980. BIBLIOGRAPHY 363 : "Pellagra sine Pellagra," with a DlflEerentlal Diagnosis from Sprue. Trans. Trl-State Med. Assoc, 11th Vol., 446. Wood, B. J., and Bellamy, R. H. : Pellagra. Bull. North Car. Bd. Health, Raleigh, 1909, XXIV, 83-91. Wood, G. W. : Pellagra : Perhaps. Am. J. Clin. M., Chicago, 1909, XVI, 1348. Zeller, G. A. : Pellagra ; Its Recognition In Illinois and the Steps Taken to Control the Disease. Bull. 111. State Bd. of Health, Aug., 1909, pp. 307; 314. Illus. 1909-1910 Bass, C. C. : Pellagra ; a Report of Eleven Cases from Missis- sippi; Presentation of a Case. N. Orl. M. and S. J., 1909-10, LXII, 177-182. : A Case of Pellagra Caused by Amylophagy Result- ing from Uncinariasis. NashTille J. M. & S., CIV, 308-310. Cross, E. S., and Lee, L. : Pellagra ; a Report of Two Cases. Atlanta Jour.-Rec. Med., 1909-10, XII, 191-202. Dasplt, H. . Some Blood Findings in Twenty Cases of Pellagra In the Insane Asylum of the State of Louisiana. N. Orl. M. & S. J., 1909-10, LXII, 716, 1 ch. DeJarnette, J. S. : Pellagra ; the Corn Curse. Virginia M. Semi- Month., Richmond, 1909-10, XIV, 366-369. Dorsey, R. T. : Etiology of Pellagra. Atlanta Jour.-Rec. Med., 1909-10, XII, 401-406. Drewry, W. P. : Pellagra ; a Clinical Study and Report of Four- teen Cases. Virginia M. Semi-Monthly, Richmond, 1909-10, XIV, 265 ; 300 ; 326. Also : Texas M. News, Austin, 1909, XIX, 156-162. Alao : Reprint. Eiker, B. L. : Pellagra ; Notes Taken from the National Confer- ence on Pellagra, held at Columbia, S. C. Iowa Med. J., etc., Des Moines, 1909-10, XVI, 287. Hummel, E. M. : Two Cases of Pellagra. N. Orl. M. and S. J., 1909-10, LXII, 434-438. 2 PI. Discussion, 469-471. Jarrell, W. W. : Report of a Case of Pellagra in Metcalf, Ga. Atlanta Jour.-Rec. Med., 1909-10, XII, 464. Kerr, J. W. : Pellagra as a National Health Problem. Louisville Month. J. M. and S., 1909-10, XVI, 225-228. Lavlnder, C. H. : Notes on the Hematology of Pellagra. Read before the Conf. on Pellagra, Columbia, S. C, Nov., 1909. Virg. Med. Semi-Month., Richmond, 1909-10, XIV, 465. Newman, E. D. : A Case of Pellagra in New Jersey. J. Med. Soc. N. J., Orange, 1909-10, VI, 606-608. Parker, R. : Pellagra and Clinical Observations of Two Cases. Virginia M. Semi-Month., Richmond, 1909-10, XIV, 341-345. Phenix, N. J. : Pellagra in Colorado, Texas. Texas State J. M., Fort Worth, 1909-10, V, 276. Eohrer, C. W. G. : Pellagra ; Its Etiology, Pathology, Diagnosis 364 PELLAGRA and Treatment. Virginia M. Semi-Month., Richmond, 1909-10, XIV, 417-421. Saunders, C. H. : Pellagra : Report of a Case. Virginia M. Semi- Month., Richmond, 1909-10, XIV, 299. Schultze, P. P. : Pellagra : Report of a Case. Iowa M. J., etc., Des Moines, 1909-10, XVI, 289. Slack, H. R. : Pellagra, with Report of Cases. Atlanta Jour.-Rec. Med., 1909-10, XII, 343-350. , and McCall, W. R. : Pellagra : Report of Cases with Treatment. Old Dominion J. M. and S., Richmond, 1909-10, IX, 317-323. Thomas, J. N. : Report of [Three] Cases of Pellagra at State Asylum, Plncville, La. N. Orl. M. and S. J., 1909-10, LXII, 35-40. 2 PI. Also : Reprint. Thrash, E. C. : Symptomatology of Pellagra. Atlanta Journal- Rec. Med., 1909-10, XII, 425-428. Townsend, A. M. : Pellagra. J. Nat. Med. Ass., Tuskegee, Ala., 1910, II, 65-70. Transactions of National Conference on Pellagra, held under auspices of So. Car. State Brd. Health at St. Hosp. f. the Insane, Columbia, S. C, Not. 3rd and 4th, 1909, 8to., 297 pp. Columbia, S. C, 1910. See Conference (National) for papers read. (In this list). Unique (A) Experience with Pellagra. Am. J. Insan., Bait., 1909-10, LXVI, 711-714. Vanderhoof, D. : Pellagra in Virginia ; Report of a Case. Old Dominion J. M. and S., Richmond, 1909-10, IX, 324-328. Van Wart, R. M. : Report of a Case of Pellagra. N. Orl. M. and S. J., 1909-10, LXII, 244-249. Discussion, 280-282. 1910 Allison, B. and Allison, W. : Pellagra ; with Report of Cases. Med. Fortnightly, St. Louis, 1910, XXXVIII, 285-290. Alsberg, C. L. and Black : The Determination of Deterioration of Maize with Special Reference to Pellagra. Bull. Dept. of Agri- culture, Wash., 1910. Anderson, P. V. : Personal Experiences with a Few Cases of Pel- lagra. Med. Rec, N. M., 1910, LXXVII, 531-535. Anderson, W. : Pellagra, or Maidismus. Elect. M. Gleaner. N. S. VI, 4, 277, 1910. Babcock, J. W. : The Pellagra Problem, Past and Present. N. York M. J., etc., 1910, XCI, 44-46. : The Prevalence and Psychology of Pellagra. Trans. Am. Med.-Psych. Assoc, 1910. Also in Jour. S. C. Med. Assoc, Sept. and Oct., 1910. Also: Reprints. Bacon, J. H. : A Case of Pellagra In Illinois. J. Am. Med. Assoc, Chicago, 1910, LIV, 1783. BIBLIOGRAPHY 365 Bass, C. C. : The Early Symptoms of Pellagra. Interstate M. J., St. Louis, 1910, XVII, 175-178. : Climatic Treatment of Pellagra. A Preliminary Report. Jour. Am. Med. Assoc. LV, 11, 940. Bone, R. L. : Pellagra, with Exhibition of Case. Kentucky M. J., 1910, VIII, 1673. Blue, B. : Pellagra in California. Calif. State J. of Med., San Fran., 1910, VIII, 101. Bowen, J. T., and Towle, H. P. . Progress in Dermatology ; Pel- lagra. Boston M. and S. J., 1910, CLXII, 605-612. Cantlie, J.: Pellagra Investigating Committee (British). Pros- pectus, March 1, 1910. Castellanl, A., and Chalmers, A. J. : Pellagra. In their : Manual of Tropical Medicine. Lond. and N. Y., 1910, 906-911. Cole, H. P., and Wlnthrop, G. J. : Pellagra ; Transfusion in Eleven Cases. J. Am. M. Ass., Chicago, 1910, LIV, 1354-1356. Cooper, G. R. ; Pellagra. Eclectic M. J., Cincin., 1910, LXXI, 12. Corlett, W. T. ; A Case of Pellagra. Trans. Am. Dermatolog. Assoc, 1910. Dearborn, P. M. : Pellagra and Its Recent Manifestations. Hahne- mann Month., Phila., 1910, XLV, 250-257. Delcourt, A. J., Sr. : Pellagra. J. Am. M. Ass., Chicago, 1910, LIV, 1121. Drewry, W. F. ; Some Observations on Pellagra. 8° Richmond, 1910. Rept. from Old Dominion J. M. and S. Richmond, 1910, X. Ejker, B. L. : Pellagra. Bull. Iowa State Institutions, 1910, XII, 2, 104. Eason, 3. S. : Report of a Case ; Possibly Pellagra. J. Am. M. Ass., Chicago, 1910, LIV, 792. Fitzgerald, Clara P. : A Case of Pellagra in Massachusetts. J. Cutan. Dis. incl. Syphilis, N. T., 1910, XXVIII, 42-46, 2 PI. Fox, Howard : Personal Observations on the Skin Lesions of Pellagra. Med. Record, N. Y., Feb. 5th, 1910. Also : Reprint. : A Case of Pellagra. N. Y. Med. J., Feb. 26, 1910. Aleo : Reprint. Gaumer, G. F., and Gaumer, G. J. : Pellagra in Yucatan. Am. M. J., St. Louis, 1910, XXXVIH, 89-101. Also in: BlUngwood's Therapeutist," & in Eclect. Med. Gleaner, N. S. VI, 4, 263, 1910. Gotthell, W. S. : Pellagra. Progressive Med., Sept., 1910, 117. Green, A. F. : Pellagra ; Gnat Causes Pellagra. Eclect. M. J. Cincin. 1910, VIII, 387-391. Hyde, J. N. : Pellagra and Some of Its Problems. Am. J. M. Sc, Phila., 1910. N. S. CXXXIX, 1-26. 3 PI. AUo : Reprint. Jelks, J. L. Amebiasis : Complicated in One Instance by Pellagra. J. Tenn. M. Ass., Nashville, 1910, III, 94-106. King, J. M. : The Treatment of Pellagra. Internat. Clin., Phila., 1910, 20 S., I, 58-61. 2 PI. : Report, with Illustrations, of Pellagra at Nash- ville, Tenn. Gulf States J. M. & S., etc.. Mobile, 1910, XVI, 277-292. 4 PI. 366 PELLAGRA King, H. D. : The Etiologic Controversy Regarding Pellagra. J. Am. M. Ass., Chicago, 1910, LIV, 859-866. Lavlnder, C. H. : On the Prophylaxis of Pellagra. Lancet-Clinic, Ciucin., 1910, CIII, 234. — : Pellagra. 111. Med. J., Springfield, 1910, XTII, 48. : The Theory of the Parasitic Origin of Pellagra. Pub. Health Rep. U. S. Pub. Health and Mar. Hosp. Serv., Wash- ington, 1910, XXV, 735-737. Lockwood, W. F., Beck, H. G., and Rohrer, C. W. G. : Clinical Hist, and Path, of Pellagra. Med. and Chir. Fac. of Md., Apl. 26-28, 1910. Jour. A. M. A. LIV, 21, 1720. Lockwood, W. F. : Clinical Notes on Four Cases of Pellagra. Old Dominion J. M. and S., 1910, X, 414-417. Long, J. D. : Pellagra. Jour. Am. Med. Assoc, LV, 9, 734, 1910. Discussion. Also : Reprint. MacNeal, W. J. : Pellagra. Illinois M. J., Springfield, 1910, XVII, 59-67. Marie, A. : Pellagra. Trans, by LaTinder, C. H., and Babcock, J. W., Columbia, S. C. The State Co., 1910. Merriwether, F. T. : Pellagra. Charlotte (N. C.) M. J., 1910, LXI, 231-233. Miles, G. W. : Some Remarks on the Treatment of Pellagra. Med. Rcc. N. T., 1910, LXXVIII, 448. Nichols, H. J. : Hook-worm Disease and Pellagra. Military Sur- geon, Wash., 1910, XXVI, 646-657. Norris, H. : Treatment of a Case of Pellagra by Appendicostomy. Prelim. Rept. Charlotte, N. C, M. J., 1910, LXII, 1-3. Pcgram, R. W. S. : Pellagra. Charlotte, N. C, M. J., 1910, LXII, 100. Pellagra (The) Field Commission. (Editorial) Brit. M. J. Lond., 1910, I, 1255. Perry, M. L. ; Two Cases of Pellagra In Kansas. Trans. Am. Med. Psych. Assoc, 1910. Pittman, H. M. : Pellagra in Perryvllle, Kentucky, M. J. Bowling Green, 1910, VIII, 1739. Reed, H. S. : The Fungus, Diplodia, as a Possible Factor in the Aetiology of Pellagra. N. T. M. J., etc., 1910, XCI, 164-169. Robertson, J. W. : Pellagra, an Abstract. Hosp. Bull. Univ. Maryland, Bait., 1910, VI, 29. Rohrer, C. W. G. : The Pathology of Pellagra. Maryland M. J. Bait., 1910, LIII, 298-300. Rudolph, C. M. : Clinical Types of Pellagra. Alabama M. J., Bir- mingham, 1910-11, XXIIL 142-145. Russel, C. K. : Pellagra. Article in : Osier's Modern Med., Phlla. and New York, 1910, VII, 139-141. Sage, D. N. : Pellagra. Atlanta Jour.-Rec. Med., 1910-11, LVI, 20-28. Sambon, L. W. : Progress Report on the Investigation of Pellagra. Jour. Trop. Med. and Hygiene, 1910, XIII, 18, 27. AUo : No. 19. BIBLIOGRAPHY 367 Scott, W. B. : A Case o( Pellagra. North West Med. II, 9 N. S., 282. Slier, J. F., and Nichols, H. J. : The Pellagra Problem, Past nnd Present. Med. Times, Lond., 1910, XXXVIH, 120 ; 139 ; 160 ; 188. and — — ■ — : Observations on Pellagra at the Peoria State Hospital, Peoria, III. Med. Eec, N. T., 1910, LXXVII, 87-98. Silver, D. R. : Corn and Pellagra ; a Contribution to Our Knowl- edge of Their Relation as Probable Cause and Etfect. J. Am. M. Ass., Chicago, 1910, LIV, 452. Alao : Reprint. South Carolina Commercial Feed Stuffs Act, Act of the General Assembly, Session of 1910, Columbia, S. C. : Rules and Regulations Governing the Sale of Commercial Feed Stuffs in the State of S. C, as provided for In Sections 11 & 12 of "An Act to Regulate the Sale of Commercial Feed Stuffs," etc. Columbia, S. C, 1910. ■: Rules and Regulations Governing the Inspec- tion and Sale of Agricultural Seeds sold in the State of South Carolina, as provided for in "An Act Regulating the Sale of and Providing for an Inspection of Agricultural Seeds sold in the State of S. C. and to provide Penalties for Violations," approved Feb. 26, 1910. Columbia, S. C. Symposium on Pellagra. Trans. Florida Med. Assoc, 191S. Papers : Randolph, J. H. : The Nervous and Mental Symptoms of Pellagra, and What Can be Done for Them? Winthrop, G. J., and Cole, H. P. : The Value of Transfusion In Pellagra. Turck, E. C. ; Pellagra Complicating a Laparotomy. Stem, Samuel: Pellagra In Philadelphia. Tappan, J. W. : Photographs of a Case of Pellagra. Bull. El Paso Co. M. Soc, El Paso, Tcias, 1910, II, No. 3. Trasfc, J. W. : Pellagra. Detroit M. J., 1910, X, 227-230. Tucker, B. G. : Pellagra ; Its Treatment. Read at Ann. Conf. of State & County Health Officers, Nashville, Apr. 6, 1910. South. Pract., Nashville, 1910, XXXII, 222-226. Warren, F. B. : Pellagrins — Newest Disease Victims. Illust. Tech. World Mag., Jan., 1910, XII, 5, 509. Warthin, A. S. : Report of a Case of Pellagra, with Post Mortem Findings. Physician and Surg., Detroit and Ann Arbor, 1910, XXXII, 17-21. Watson, J. J. : The Symptomatology, Pathology and Treatment of Pellagra. N. York M. J., etc., 1910, XCI, 46-48. : Symptomatology of Pellagra. Intemat. Clin., Phila., 1910, 20 S., I, 42-57, 2 PI. Aleo : Reprint. : Symptoms of Pellagra. Lancet Clinic, Mch. 5, 1910. Waugh, W. F. : A Case of Pellagra in Illinois. Med. Rec. N. Y., 1910, LXXVIII, 191. 24— P. 368 FELIiAGRA : Pellagra In Illinois. Chicago M. Times, 1010, XLIU, 273-278. Webster, G. W. : Pellagra with Special Reference to Etiology and Diagnosis. Illinois M. J., Springfield, 1910, XTIII, 139-151. Wolfe, J. J. : Pellagra ; the Causative Agent and the Method of Infection. South Atlantic Quarterly, 1910, IX, 43. Zeller, 6. A. : Pellagra : Some Clinical and other Features of the Disease, Interstate Med. Jour., XVII, 10, 745. Illust. 1910-11 Bloss, J. E. : Pellagra. Report of a Case. West. Va. Med. Jour., 1910-11, V, 13-16. Lavinder, C. H. : Report of a trip to Italy Investigating pellagra, with reference to its origin, spread and control. Ann. Rept. of the Surgeon General of the U. S. P. H. and M.-H. Service for the fiscal year 1910. Wash. 1911. Wlnthrop, G. J. and Cole, H. P. : The Value of Transfusion in Pellagra. N. Ore. M. and S. J., 1910-11, LXIII, 90-97. B. FOREIGN BIBLIOGRAPHY. CHRONOLOGICAL AND ALPHABETICAL.* 1740 Feljoo: Lettre i. Casill sur le "mal de la Rosa" dans la Galice, 1740. See Roussel : De la pellagre, p. 277. 1755 Thlery : Description d'une maladle appel£e "le mal de la Rosa." Recuell p€rlodigue d'observations de mSdeclne, de ctalrur- gle et de pharmacle, ]uln, 1755, Paris, 2d Ed., 1783. 1762 Cas&I, Caspar : Historla natural y medlca de el prlncipado de Asturias. Obra pfistuma que escriblft (1735) el Doct. D. Caspar Cas&l, medico de Su Magestad j su Protom€dlco de Castllla, Acad- £mlco de la Real Academla Medlca Matrltense &c., sacada a luz por el Doct. Juan Joseph Garcia SevlUano. En Madrid, ABo de 1762. P. 327, i III. "De alEectlone quae vulgo In hac reglone "mal de la Rosa' nuncupatur." 1771 FrapolU, Fr. : Animadverslones In morbum vulgO pelagram. Milan, 1771. 1776 Fanzago, F. L. : D'una specie partlcolare dl Scorbnto. Venezla, In : Nuova RaccoUa dl opnscoU scelU suUe sclenze e suUe arti, t. III, p. 217, Milan, 1780. Odoardl, J. : D'una spezle partlcolare dl scorbuto. Belluno, 1776. 1776. In : Sulla pellagra memorla di F. L. Fanzago, I, II, Padua, 1815. 1780 Gherardlnl, M. ; Descrlzlone della pellagra. Milan, 1780. •The foreign bibliography of pellagra la very extensive, especi- ally the Italian. It has, therefore, been decided to include nere only the leading articles upon the subject in other languages. The reader is referred to the Index Catalogue of the Library of the Sur- geon General's Office, United States Army, Vol. X, first series, and vol. XII, second series, and to the more recent volumes of the Index Medicua. For older literature see also Hirsch II, p. 171, The literature up to 1887 has been carefully compiled by Salveraglio, q. T. In this list. 370 PELLAGRA. 1781 Albera, G. M. : Trattato teor. prat, della malattla dell' insolato Al primavera volgarmente detto pellagra. Varese, 1781. 1786 Strambio, Gaet. : De pellagra observatlones In reglo pellagro- sorum nosocomlo factae ; ann. 1-5. Milan, 1786-1789. : Due dlEsertazionl suUa pellagra, t. II. Milan, 1794. 1788 Jansen, F. X. : De pellagra morbo in Medlol. ducatu endemlco. Lugdunl (Leyde), 1788. Also in: Delect, opusc, by P. Franck, t, I. Tlcini, 1790. 1789 Fanzago, Francesco-Lutgl : Mem. sopra la pellagra. Padua, 1789. : Parallel! tralla pellagra ed alcune malattle. Padua, 1792. : Memoria suUa pellagra. Padua, 1815. Soler, L. : Osservazloni med. prat., che formano la storla esatta dl una particolare malattla, chlmata pellagra. Venice, 1791. 1791 Bona, Paul D. : Discorso comparatlvo Bopra la pellagra, I'ele- fantiasl del Greci e lepra degli Arabi e lo scorbuto. Venice, 1791. 1792 Thiery : Observation sur une maladle end£migue des Asturies en Espagne, gu'on appelle "mal de la Rosa." M£d. iclalrie, Paris, 1792, IV, 78-81. 1795 Allionl, C. : Baggionamento suUa pellagra. Turin, 1795. 1805 Le Vacber de la Feutrie : Recherches sur la maladie end^mlgue dans le Milanals. Paris, 1805. 1807 Cerri, 6. : Trattato della Pellagra. Milan, 1807. 1810 Marzari, J. B. : Sagglo med. politico suUa pellagra o scorbuto BIBLIOGEAPHT 371 ttaliano. Venice, 1810. : Delia pellagra e della manlera