Pellagra, an American problem

Front matter

Class /_____/ Book 1

Copyright^ .

COPYRIGHT DEPOSIT.

Preface To The Second Edition

The success of the first edition of this book seemed to indicate that it filled a need of the profession. In this second edition many changes and additions have been made, bringing the consideration of Pellagra as a national problem up to our present state of knowledge.

The chapter on Etiology contains the result of the investigations of Dr. Joseph Goldberger, Special U. S. Agent for the study of this disease, and the Thompson-McFadden Pellagra Commission, whose careful and scientific labors have received deserved commendation. The efforts of other students have also been recognized.

The chapter on Treatment contains a number of late therapeutic suggestions, including the employment of emetin for the frequently ameba-infected mouth and intestines, the scarlet ointment for obstinate dermatitis, and others, which I have found helpful.

I am indebted to numerous friends for criticisms and constructive advice; and especially to the members of the Thompson-McFadden Commission, who have both officially and personally extended valuable aid, is offered grateful acknowledgment.

While the causation of Pellagra is not yet entirely proved, the conviction is expressed that we are much nearer the goal of etiologic certainty, pathologic assurance, and consequent therapeutic confidence.

George M. Niles.

920 Candler Building,

Atlanta, Ga.

January, igi6.

Preface

In presenting this work I feel that a literature on the subject of pellagra should be advanced by American observers.

We should not be deterred because of its recent visitation, nor should we be content to leave its investigation to our friends in Europe, though they have been wrestling with this problem for near two centuries; and we may find it difficult to rival them in erudition as well as the profundity with which they have considered some of the unsolved pathologic and etiologic questions. A condition confronts us, and we must needs be up and doing in order to meet it.

I have no apology to offer for expressing my candid opinions and firm convictions. Should subsequent experience and knowledge convince me that I have fostered error, I shall be the first to announce it and make the necessary amends. No advancement has ever been made except by following a new idea to an established fact, and in the light which is now guiding me I can see no incorrect premise nor any false conclusions; yet I do not expect the approbation of all whose opinions I court and whose words I respect.

To go forward and not backward in the management of this threatened scourge will require much clinical observation, much laboratory labor, special technic in the examination and treatment of the various phases of pellagra, a

8 PREFACE

practical knowledge of physiology and physiologic chemistry, the medical uses of special drugs, baths, waters, and electricity, and, with it all, time and patience.

It will be most interesting a few years hence to look back in a retrospective manner on the efforts of to-day, on the possibly erroneous viewpoints with which we have considered pellagra, and our somewhat halting footsteps in its therapeutics. We are glad in this connection, however, to lay to our souls the flattering unction that our efforts are at least sincere and justified by present results.

To many kind friends I convey my appreciation for helpful suggestions and other courtesies; but particularly do I wish to thank Dr. J. W. Babcock, of Columbia, and Dr. C. H. Lavinder, of the Public Health and Marine-Hospital Service, for both their encouragement and consideration.

To the medical profession I offer this book for what it is, not claiming that it speaks the "last word," but that it represents the labors of a student who is endeavoring with a spirit of courage and optimism to contribute a worthy portion to the sum total of our information concerning pellagra, this American problem.

George M. Niles.

920 Candler Building, Atlanta, Ga.

Chapter I

Pellagra, as an American problem, is now receiving marked attention in many sections of this country. Up to less than eight years ago it appeared upon the sociologic horizon as a cloud no larger than a man's hand, but it has continued to grow and expand, until at present it looms up before the sober observer with portentous solemnity.

Pellagra may be defined as an endemic malady, characterized by an erythema (generally symmetric) upon the exposed surfaces of the body, by gastro-intestinal disturbances, and by nervous and psychic phenomena.

This definition is necessarily incomplete, for to describe this protean disease in a few words would require the graphic imagination of a Carlyle, or the word-painting of a Macaulay.

The synonyms for pellagra are numerous, among which are Alpine Scurvy, Asturian Leprosy, Asturian Rose, Disease of the Landes, Maidismus, Psychoneurosis Maidica,

Mai de la Rosa, Mai del Sole, Mai de Misere, Mai del Padrone, and many others.

To Frapolli we owe the present name of the disease (pelle, skin, and agra, rough), and the same writer declared that the disease was an ancient one, and none other than the sickness pellarella, which was noted in 1578 by the authorities of the Hospital Major, of Milan.

As to the pronunciation, the varieties are almost legion. It would seem fair to permit a man the privilege of pronouncing his own name; or to the resident of a state or country the like privilege of pronouncing the name of his abode. For instance, we grant to the residents of Iowa the right to say Ioway, or to those living in Arkansas the rather bizarre-sounding Arkansaw. By this same token it seems proper to permit the Italians, who gave us the name, to also teach us the pronunciation. After consulting with not a few, but with many educated Italians, those in a position to speak with authority, the writer is convinced that the most widely accepted pronunciation gives the a in pellagra the same sound as in the word father, with the accent on the second syllable.

Some, of course, will take issue with this, as would be the case with any other word not possessing the sanction of ancient and world-wide custom in its pronunciation; but the sound of a in this word, as given above, is probably used more than any other.

To trace back the history of this disease, among the rather scattered archives of the middle ages, is both interesting and difficult. Dr. Howard D. King, of New Orleans, recently contributed a most valuable historic study of pellagra, and to him, as well as to Dr. A. Marie, we are indebted for much of this data.

To weave a history of pellagra without encountering the visage of maize seems almost impossible. Through the tangled skein, as it is interwoven with the destinies of several nations and peoples, we see the rise and decline of pellagra almost coincident with the consumption of Indian corn; and, try as we may, we cannot disassociate the two.

In 1600 Baruino, in a medical treatise, called attention to a peculiar malady prevailing among certain tribes of the American Indians. From his incomplete description, it apparently resembled the pellagra of to-day. Even then he ascribed it to the use of corn, which the Indians used constantly as a part of their diet.

Francisco Scipione, an Italian poet, archeologist, and litterateur, also described a similar disease but a few months after Baruino, his description being much more complete. About this time there was also noted a peculiar disease among horses, in which those animals seemed both paretic and tabetic, showing a malnutrition with loss of hair. This was supposed to have been produced by feeding them spoiled corn.

In Spain corn was introduced as an article of food in the period between 1680 and 1700. Strange to say, the first authentic accounts of pellagra appeared just about this time. According to Babes and Sion, as claimed by Dr. Babcock, it is probable that pellagra appeared in Europe long before its scientific description, but was classed as either gastro-intestinal, or nervous, or mental, or leprous, or scorbutic diseases. It is, therefore, somewhat difficult to determine whether or not pellagra appeared in Europe before the advent of Indian corn as a food.

The first really scientific account is ascribed to Gaspar Casal, who, in 1735, observed it in the vicinity of Oviedo. Several years later he wrote of it fully, describing it as seen in the Asturias, and giving it the name "Mai de Rosa." For a long time the disease was found only in this region, and in somewhat narrow limits. Even to this day Oviedo seems a focus.

In Italy it appeared about twenty-five years later than in Spain. Frapolli, to whom, as previously said, we are indebted for the word pellagra, believed he had found a picture of pellagra in the description of la pellarella in 1578. This was more probably a case of syphilis. About the time Frapolli named it, Adoardi, of Venetia, called it "scorbutus alpinus."

By 1776, also a notable year in American annals, the disease had spread to such an extent that the Venetian authorities, at the request of the Sanitary Commission of Venice, issued an edict prohibiting the sale or exchange in the public markets of corn having a bad odor or taste, or which was discolored. Even at that time, exacerbations and remissions of pellagra during different seasons of the year were noted, for D'Oleggio, in 1784, suggested the term "vernal insolation," meaning the "sunburn of spring." Also in that year a special hospital for those afflicted in this manner, and for special study of the disease, was established in Legano by royal warrant, and called the Joseph II Pellagra Asylum. The elder Strambio, a man admirably fitted by both education and ternperament for such a position, was appointed chief physician.

From this period, up to 1839, but little was done to check the ravages of pellagra, when Ballardino declared that it was produced by eating damaged maize, claiming that he had demonstrated it beyond a perad venture. His views, as happens to any one making radical statements, met with ridicule, and, while the discussion waxed warm, the flames of the disease spread with amazing rapidity. From 1839 to 1856, a space of seventeen years, there was an increase of from 14 to 28 per thousand, or from 20,282 to 38,777. This alarming increase brought the Lombard government to action, and it was high time. A commission from the Institute Lombardo was appointed to investigate, and to report ways and means to combat this state of affairs. Commissions, like petit juries, are often remarkable bodies, and this was no exception. They reported that while, in their opinion, Ballardino's theory as to spoiled or damaged maize being a causative factor was in the main correct, they did not believe that a diet free from maize would either exert a favorable influence or prevent the disease.

It would appear that there were then, as in this day, factional differences among the bodies of thought, where, unfortunately, prejudice was permitted to blind sober judgment, and personal animus to warp scientific conclusions.

'This commission, therefore, attributed the improvement in the afflicted peasantry, not to elimination of corn as a food, but more hygienic methods of living.

'Twas ever thus.

To give an idea of the amazing spread of pellagra during those years, it might be mentioned that, in the province of Vicenzo, the number of known pellagrins between 1853 and 1855 was 1380; in i860, 2974; and 1879, 3400. These figures covered only one province.

In 1879 it was estimated that the number of peasants suffering with pellagra had reached the appalling number of 97,855, being distributed as follows: Lombardy, 40,838; Venetia, 29,386; Emilia, 18,728; Tuscany, 4382; Marches and Umbria, 2155; Piedmont, 1692; Liguria, 148; Rome, 76.

In Lombardy, where the disease always seemed to flourish most, the worst infected centers were Buscia, Pavia, Piancenza, and Ferrara. Next to Lombardy, it was most severe in Venetia and Emilia. In these three provinces the number of pellagrins in 1880 formed about 30 per 1000 of the whole agricultural population. This was also reflected in the military reports from those provinces, for from 18 to 20 per cent, of the conscripts were reported unfit for duty on account of illness of this character. Furthermore, in Italy, there were, in 1874, 945 pellagrous lunatics. In 1877 there were 1348.

The years 187 1 to 1884 showed the "high- water mark" of this disease, 104,067 being officially reported. There was but little fluctuation in the figures until 1899, when there appeared a noticeable decline among the afflicted peasantry.

In a government report "Analli di Agricoltura, No. 18," which, to an extent, corresponds to the bulletins issued by our Public Health and Marine Hospital Service, is published the melancholy pellagra statistics for the St. Clement's Hospital of Venice for a period of six years preceding, and it shows, with frightful distinctness, the extent of the "el delirio della miseria," as the Italians call it:

Total number insane. Pellagrous insane.

1874 558 178

1876 666 175

1877 802 215

1878 859 294

1879 924 337

In 1884 conservative estimates placed the number of pellagrins in Italian hospitals and insane asylums at 10,000, and the civic burden was so onerous that a bill, aimed at the prevention, was introduced in the Chamber of Deputies at Rome through the efforts of the Zannardelli cabinet in 1902.

In 1903 there were thought to be about 60,000 cases in Italy proper, though some of the statistics were unreliable. The last census of 1905 shows but 55,000 pellagrins in that country, and well-posted observers consider that this number has remained almost stationary up to the present date.

There are several reasons mentioned by Dr. L. W. Sambon which militate against correct reports; the patient does not always admit having pellagra; there is no compulsion requiring the authorities to be notified; and, not the least important, is the fact that local pride and a desire to show a decrease in a given locality cause the knowledge of some cases to be suppressed. Sambon, therefore, thinks that at present a fair estimate of pellagrins in Italy would be 100,000, though he admits that the mortality is not near so great as formerly. This briefly but fairly covers the situation in Italy. 2

I 8 PELLAGRA

In France, too, pellagra has wielded an important place in history. First reported in the vicinity of Arcachon in Gascony in 1818, it steadily spread along the coast of the Gironde and the Landes. Marchand, in 1826, called attention to its prevalence in the southern provinces of France. Dr. Petit, an observing French physician, of that locality, noted it about 1828, stating that it was more common in the Landes than in the Gironde district, and that at one time there were about 200 cases in a population of 6000.

According to Dr. C. H. Lavinder, it was first observed in France by the elder Hameau in the vicinity of Teste in 18 1 8, whence came the French appellation "maladie de la Teste."

From these districts, the malady spread along the left bank of the river Garonne and toward the Pyrenees Mountains. Fortunately for the people in the vicinity of Dax, the disease never assumed serious proportions there.

From 1829 to 1880, pellagra was one of the live subjects in the sociologic thought and literature of France. But, as remarked by Regis, there suddenly came a silence, and for the last thirty years but few cases have been reported. This sudden change is hard to explain. Some think that it has simply disappeared, "like the figment of a vision, leaving not a rack behind"; others think that there has been established a gradual immunity, or that the people have become so habituated to it that they have lost both interest and fear, viewing it with that fatalistic indifference of the Oriental.

At any rate, pellagra is no longer noticeable in France to any extent. Happy country!

In Spain, according to Triller, in spite of intelligent

-Egyptian case of pellagra, taken after death. (Courtesy of Dr. F. N.

Sand with.)

.. Egyptian case of pellagra, showing symmetric " gauntlet " and " anklet "; also showing the pellagrous " breast-plate " observed in those whose breasts are habitually exposed to the sun. (Case of Dr. Sandwith.)

prophylaxis, this disease at present affects fully 20 per cent, of the inhabitants of certain provinces. It should not be forgotten that here, in the Asturias, pellagra was first described in 1735.

Casal spoke of the conditions there as follows: "Corn is the principal food of the laborer there; soups are made of it, to which they usually add milk; they likewise eat eggs, fish, and cheese; very rarely they buy fresh meat and occasionally salt meat."

"Here, as elsewhere, they begin by misconceiving the real origin of the affection," for different writers attempted to prove that it came from leprosy. Their hypotheses, of course, were not proved.

In Roumania the first recorded case was in 18 10, and it seems comparatively easy to trace the progress of the disease along with the importation of wet and damaged corn by the inferior vessels of the coastwise trade.

From the period between 1833 to 1846 pellagra attracted much attention, and was called by the people "Buba Tranjilar."

Between 1854 and 1859 the government began to take notice, finding 4500 recognized cases in Moldavia and Wallachia. In 1885 this number had grown to 16,260, and in 1886 to 19,797.

In 1898 the peasant population of Roumania was estimated at 5,300,000, and the statistics pointed to 21,000 pellagrins among this number.

In 1906 Triller thought there were at least 30,000 there, and in 1907 other observers estimated the number at 40,000.

Corfu, one of the Ionian islands, famed in song and story, has also suffered the burden of this affliction. It became epidemic there in 1856, and at this day exists in 30 out of the 117 communes. The percentage of pellagrins in the whole population is probably 3.2 per 1000 inhabitants. Typhaldos, of Corfu, has given the disease much study, and from him we have gotten some valuable information from many viewpoints.

Austria has not been exempt, for in the Tyrol, especially in Bukowina, having a population of 38,000, 2.9 per cent, are pellagrous. In this region of Austria there are seventeen institutions, where the peasantry can get proper food, and receive instructions as to cooking, hygiene, and other helpful knowledge.

This country has deeply considered the situation in its legislative assemblies, has enacted wise laws, restraining and educational, and seems to have the disease well in hand.

In Great Britain, only two cases were reported up to 19 13, one by Drs. Brown and Carruthers, of Rock Ferry, and the other by Drs. R. Dods Brown and Cranston Low, assistant physicians in the Royal Edinburg Asylum. Since that date, however, Dr. Sambon has discovered many previously undiagnosed cases in England, 53 being observed in one hospital.

In Africa, as in other warm countries, this malady has gained a strong foothold. It was first recognized in 1847, by Pruner, who had observed it previously in Italy.

Pruner's statements did not meet with a favorable reception, for Hirsh and others "laughed him to scorn." Nothing further was said or done, until 1892, when, at a medical congress held at Cairo, Dr. F. N. Sandwith, senior physician and lecturer on medicine, Kasr-el-Ainy Hospital, Cairo, read a splendid paper on pellagra and its prevention.

He stated that, through the courtesy of Dr. J. Warnock, superintendent of the lunatic asylum of that region, he saw 40 or 50 pellagrous lunatics. Since 1893, Dr. Sandwith has seen more than 1100 cases, and asserts that it is quite prevalent in Lower Egypt, though not so much in Upper Egypt. He thinks that the proportion of those who lose their minds is not so large in Egypt as in Italy, though unable to explain why.

Dr. C. H. Lavinder, who has studied in Egypt also, rather differs from some of Dr. Sandwith's conclusions, mainly as to its slight prevalence in Upper Egypt.

Leaving for a time the consideration of this disease among the congested populations of the "Old World," we come nearer home, and still do we find the hideous face of this specter confronting us at every stage of our investigations. Suffice it to say, that hardly a country in Southern Europe has escaped, for Algeria, Tunis, Bulgaria, Servia, Portugal, Dalmatia, Croatia, Bosnia, Turkey, and even as far north as Poland, where freedom shrieked when Kosciusco fell, do we find it.

It will be most interesting to note the effect on the future prevalence of pellagra that may result from the European war now raging. These enlightening facts must, of necessity, be left to the historian of a later day.

In Jamaica, in 1888, Dr. Henry Strachan, senior medical officer, reported 510 cases of "malarial multiple neuritis," observed in the Kingston, Jamaica, Public Hospital, and on 121 of these patients full notes were taken.

"The patients complained of numbness and burning heat in the palms and soles, often accompanied by cramps, worse at night and in wet weather. Impaired vision and hearing were noted, and a feeling of constriction around the lower part of the chest. An eczematous condition appeared on the tops of the eyelids, the angles of the mouth, and the mucocutaneous margins of the nostrils; the lips were usually red, and the palms hot to the touch and hyperemic. Later, motor pains of upper and lower extremities appeared. Pain was constant, especially of the feet. Emaciation developed with the progress of the disease. Pigmentation of the palms, lips, and soles was present; respiration was impaired, and death ensued from paralysis of the respiratory muscles. Death was rare, recovery being the rule.

"Soreness of the mucocutaneous borders, i. e., eyelids, lips, urethra, anus, vulva, etc., was almost the first symptom. Wasting and contraction of the muscles was very marked in extreme cases, the 'claw hand' and foot being pronounced features. ... In the last stage, when the patient is greatly wasted, there may be delusions with feeble attempts at violence. In this condition they may be committed to asylums.

"The eyelids are red and irritated; a slightly eczematous condition develops at the corners of the mouth and round the margin of the nostrils, with a fine branny desquamation. . . . The lips and buccal cavity are hyperemic, and there may be loss of surface epithelium on the tongue. Palms and soles are hypermic, due to dilated arterioles, and later they are deeply pigmented, the color varying from brown to intense black. The gait is typically ataxic. The disease attacks both sexes, youths and adults." (Marie.)

For quite a while this was called "Strachan's disease/'

but, in the light of present knowledge, we may safely class it pellagra.

Dr. Patrick Manson, in writing on " beriberi " (Tropical Diseases), takes issue, and in a foot-note writes as follows: "Dr. Strachnan has described a form of multiple neuritis which he calls malaria. The disease is endemic, and very common in Jamaica. It differs from beriberi, inasmuch as it is not attended with edema, is frequently attended with implication of the cranial nerves, and is rarely fatal. We have no account of any similar disease of other tropical countries. . . ."

Dr. G. L. Manning, the medical superintendent of the lunatic asylum at Barbadoes, has reported similar cases there, and thinks the trouble contagious, recommending the isolation of all patients.

Dr. D. J. Williams, of Kingston, Jamaica, writes, "The existence of pellagra was recognized here about twelve years ago, but as then it was unknown in the West Indies, and the correctness of the diagnosis was questioned, and the erythematous condition of the exposed limbs attributed to sunburn.

"Four or five years ago the disease was very prevalent. . . . With generous diet, rest in bed and tonics, the majority improved temporarily; others made no improvement, but suffered from chronic diarrhea, progressive weakness and emaciation, until death ended the scene." - Mexico, Brazil, Uruguay, and the Argentine Republic have had their share of pellagra, though from some of these countries the reports are hazy and indefinite.

A graphic account concerning conditions dietetic and pellagrous in Yucatan, Mexico, has been furnished by Dr.

G. F. Gaumer of Izamal. He writes, " In 1882, in Yucatan, locusts destroyed vegetation, especially Indian corn. Corn being the only cereal used in Yucatan for bread, famine seemed inevitable, until the merchants began to import it from New York. This importation continued till 1 89 1, when the country had recovered from the devastation of the locusts. The imported corn was brought in the holds of vessels as ballast. By reason of exposure to heat and humidity on the voyage, the corn underwent fermentation and became unfit for food. The constant eating of this spoiled corn led to the slow development of pellagra.

"The disease was confined to the lower and middle classes, who were obliged to purchase the cheapest corn in the market. The wealthy classes escaped, as they did not eat the imported corn. For the next ten years, 1891 to 1 901, Yucatan produced enough corn for home consumption, and cases of pellagra no longer developed. The old cases ran their course fatally. From 1901 to 1907 the corn crops were almost total failures, and corn was again imported in larger amounts than ever before. Mobile and New Orleans were the chief sources of supply, but some came from Vera Cruz — all by water. Again pellagra became epidemic, but was not confined to the middle and lower classes as before. It had been found more profitable to raise hemp than corn, so all classes used the imported cereal. Consequently, pellagra spread alike among the rich and poor. At the close of 1907, 10 per cent, of the inhabitants were the victims of pellagra, and in August, 1909, not less than 8 per cent, of the population had the disease."

Egyptian case of pellagra. Note the " breast-plate " on exposed surface

of breast.

fe

African case of pellagra, showing erythema on back of neck and shoulders.

Chapter II Pellagra In The United States

As early as 1863 two cases were recognized in New York and Massachusetts — one by Dr. John P. Gray, of Utica, New York, and one by Dr. Tyler, of Somerville, Mass. It might not be amiss to mention that, at this time, there were reports of a supposed epidemic of pellagra near Halifax, Nova Scotia, though details were lacking and the diagnosis was only inferential.

We now come to the discussion of certain conditions in some of the large detention camps or prisons during the late Civil War. More particularly, may we revert to Libby Prison, at Richmond, Va., and the Anderson ville prison, both used for Federal prisoners, though the former was mainly for officers, and the latter for private soldiers.

The war was dragging its weary length, both sides were embittered by the internecine strife, and both had severely taxed their resources to carry on the conflict.

Far be it from the writer to enter into any discussion of any issues involved, or the wisdom or unwisdom of measures employed in the management of these prisons.

It is well known that the mortality was frightful.

Right at that time the South was staggering in the struggle for governmental existence; all sustaining industries were paralyzed, and it was a problem to find sufficient sustenance for her own soldiery and people, with the added burden of providing for all these prisoners. Corn was the principal, sometimes the only available, food to be had, and the facilities for transporting and preserving it were far from ideal.

The writer has been able to interview several veterans of intelligence, who were at Andersonville during that dreadful period — two who were guards and one who was a prisoner — and the details, even softened by all the years of healing time, were harrowing in the extreme.

The hygienic facilities were primitive, nor was much effort made to enforce those supposed to be in vogue. A major part of the diet was of corn products, some of which had been through more than one wetting and drying, and which were mouldy or wormy. The water was bad, the surroundings were depressing, and these poor men suffered the pangs of illness, to which were added the sorrows of nostalgia — that dread of wanderers far from home.

Little wonder it was that they sickened and died, and fortunate the few who, " by reason of strength,'' were able to withstand the noisome odors, the scanty and unwholesome food, and the depressing influences on every side.

Dr. J. W. Kerr, of Corsicana, Texas, has written a report of some of the conditions, and, in the light of a clearer retrospective vision, he believes that pellagra was the evil agent responsible for many deaths.

The veterans mentioned above have told the writer how the men had a supposed eczema; how tney loathed their food, and how it served them after it was eaten; how their skins were rough and hard, and how their hands were sore and cracked; how their bowels were chronically loose — so much that there was a pathetic joke that a prize would be given any prisoner having a solid fecal movement. Upon this weight was superimposed the melancholy deepening into the different forms of dementia, where indifference to fate brought about increased carelessness as to common rights in their adversity, or hygienic precautions that would have ameliorated the common lot.

Whether or not this was really pellagra will probably not be positively known, but there is a widespread belief among students of history that such was the disease which brought to an untimely end many of the flower of the Federal army.

From 1864 up to 1883 we hear nothing more of this disease, when one case was reported by Dr. S. Sherwell, of Brooklyn, New York, in a Genoese sailor.