Definition. An endemic, chronic, constitutional disease, affecting the digestive, cerebrospinal and cutaneous systems, and usually terminating fatally.
In 1762 Gaspar Casal applied the name of “mal de la rosa” to a disease that had been known in Spain since 1735, and his description of the conditions now known as pellagra (so named by Frappoli in 17760 is still classical in many particulars. For many years this disease has been endemic in certain sections of southern Europe, especially in northern Italy and Romania, in Egypt and Mexico; and in addition isolated instances of its occurrence have been noted in many widely scattered sections of the globe. Although sporadic cases have been reported in our country since 1864, it is only since the report of Seavey in 1907, concerning cases in Alabama, and the investigations of Drs. Babcock and Waston of Columbia, s.C., which culminated in their trip to Italy in the summer of 1908 to establish the identity of the suspected American and of the Italian types of pellagra, that a widespread interest in the disease has arisen, not limited to dermatologists and alienists, but among general practitioners and health officials, especially of the affected section of the United States. This interest is due not doubt to the alarming increase in the number of case of an almost acute epidemic type which have been found in South and North Carolina and Georgia, as well as in numerous well-scattered sections of twenty-two States. It is estimated that there are at least 10,000 cases now present in the United States and they are here to stay and increase unless prompt and efficient steps are taken to discover the causal factors.
Symptoms. Pellagra can present a multiplicity of symptoms, some of which are fairly characteristic, varying with the individual, and the country in which he lives, but the whole picture of the disease course, extending over some months or years, can alone establish a sure diagnosis in the absence of many typical acute cases and the lack of confirmatory diagnostic factors, such as the microscope or serum diagnosis. Usually the gastrointestinal and cutaneous symptoms precede the cerebral and cerebrospinal complications. Despite the fact that sporadic cases are being reported constantly, the endemic character of the disease should never be forgotten. Essentially chronic in its course, it shows periods of remission and aggravation in recurrent attacks. There is often an indefinitely described prodromal period covering several winters preceding the spring during which the only apparent onset, includes a peculiar psychic depression, headache, dizziness, lassitude and general weakness, articular and rheumatic pains of trunk, legs, and especially of hands and feet. A coated tongue, gaseous eructations, tense abdomen and diarrhea and eye symptoms occur in a large percentage of case. The skin eruption, considered by itself, is rather, harmless and quite unimportant as compared with the graver gastrointestinal and nervous phenomena, but as a diagnostic feature it is all- important.
The skin involvement may be primary or secondary and presents characteristic symmetry in location, more or less typical color and a well-defined and circumscribed border, especially of the lesions on the neck and hands. Usually the areas exposed to the sun, as the face, neck, upper chest and back, dorsal surface of hands and feet, lower part of the forearms, or even the elbows if exposed, or, as in the case of native Egyptians, the entire body, and rarely unexposed parts show a dermatitis starting not unlike a ptomaine eruption, toxic erythema or sunburn. The term “pellagrous collar” or neck band corresponds to the area exposed to light and is limited by the upper border of the shirt. The lesions appear as diffuse, bright, livid red or dull brownish-red macules which may become greatly swollen and itch when exposed to the sun. Later they become chocolate-colored and gradually disappear or may continue, as in the evolution of a typical dermatitis, developing vesicles, bullae, pustules and crusts. Within from one or three weeks the subactue symptoms disappear and olive-brown pigmentation, desquamation, atrophy and superficial scarring ensue. After a number of these attacks, the affected skin loses its elasticity, is shining, tender, bronze-brown in colour and markedly atrophic. The epidermic is thin and looks like silk. Weakness and emaciation follow, with a dry, red, denuded tongue, marked stomatitis, painful swallowing, an aggravation of cerebral symptoms, delirium, uncontrollable diarrhoea, and death. In some cases that I have seen the dermal symptoms were the principal ones, but in all well-developed types they became minor in importance, but enough has been said to emphasize the gastrointestinal and cutaneous features and their serious import, so lastly, a word concerning the mental symptoms which give rise to the great and necessary interest taken in this disease by the authorities of public insane asylums here and abroad. Melancholia is the common type, showing in mild cases disinclination to thought or action; later, refusal of food and suicidal tendencies. Maniacal symptoms rarely develop but may do so during apparent stupor. The sensorimotor disturbances are of all degrees, even to paralysis.