From their diet, the volunteers derived the usual ratio of calories necessary for men doing moderate or light work, as they did. They also derived from 41 to 54 grams of protein element, about 90 percent of which was of vegetable origin. The working convicts derived about twice as much protein as the volunteers and 20 percent to 35 percent of this was from animal food, while nearly all that of the volunteers was from cereal foods. Evidently, vegetable protein is not equal in value to animal protein. Such were the difference between the diets of the volunteers and the working convicts.
For about four weeks all went well with these men; no complaints. Then began troubles to appear, approximately in this order:.
1. Insomnia.
2. Loss of appetite, with gastric discomforts.
3. Weakness.
4. Headache.
5. Nervousness, ill defined.
6. Diarrhoea.
7. A bilateral roughness and eruption on the scrotum.
8. Sore, red mouth and tongue.
9. Rash extending to fingers and hands.
10. Rash, appearing on the neck and exposed parts of the chest.
11. Rash usually on exposed parts, later appearing on feet and legs.
12. Exaggeration of the patellar reflex.
13. In a few cases in the test mental aberrations appeared but the test ended before this result and other impending results appeared clearly.
14. In practice we also meet cases complaining of a metallic taste in the mouth, especially a coppery taste.
Some of these symptoms are found in simple starvation, others are peculiar to pellagra alone.
The diarrhoea becomes very profuse, watery and offensive as in the proving of Sulphur, Psorinum, etc. This results from the excoriation of the mucous membrane of the small bowel.
The eruption on the scrotum came late, in October, the sixth month of the study. In some cases it appeared during the last few days of the month. Had the study continued three or four weeks longer all the patients would probably have shown it.
The eruption was the deciding diagnostic symptom. Six of the eleven patients showed it. By prior agreement these only were diagnosed as pellagrins, but the other five had already shown the subjective and some of the objective symptoms necessary, under the circumstances, for the diagnosis of pellagra. These were specific symptoms, different from the common symptoms of ordinary starvation. A diet adequate in carbo-hydrates furnishes fuel and force and can keep the machinery running for sometime but it cannot reconstruct or repair waste and soon the machinery breaks down. Thus it was with these eleven patients.
To the symptoms recorded above in these early and mild cases those of us who have seen extreme cases of pellagra can add other and more serious cases. We find the profound melancholy; the insanity; the paralysis of locomotor muscles; the ataxic, wooden leg gait, the foot coming down loudly on the heel; the excoriating ptyalism; the leucorrhoea; the enteric and cystic incontinence, and the general foulness of the system and whole person. Bear in mind, also, the seasonal appearance and aggravation of the disease, ninety per cent of the cases appearing from April to July, after which it declines.
In short, pellagra is a most malignant and, in the advanced stage, a most loathsome disease, now endemic in the south, and we owe it to ourselves and to these unfortunates to make a thorough study of its cause, its prevention and its therapy. Remember that its approach is insidious, its early symptoms general and common in character. Then do not forget to inquire as to diet.
Be it noted strongly, that during all these six months, not a case in the slightest resembling pellagra appeared among the free and convict controls, although the latter were in a very unsanitary environment and working very hard. They were, however, receiving daily a full ration of animal food in various forms, i.e., nitrogen.
These results of the test, and the observations of practitioners seem to prove beyond doubt that pellagra is a disease of deficiency, just as are beri-beri, rickets and scurvy. It is not infective. It is caused not by a presence but by an absence, not by what goes in, but by a presence but by an absence, not by what goes in, but by what does not go in, i.e., proteins.
Early in my study of this disease, I wrote to the office of the surgeon-general of the U.S. Army, inquiring as to the occurrence of pellagra in the army. No class of men in the world is better fed, better exercised, better protected in health than our army. I fully expected just such a reply as was received. Lt. Col. Albert G. Love replied as follows:.
So far as I am aware the disease was not diagnosed as such during the Civil War. No doubt such cases might have occurred in the prisons referred to without being recognized.
Since 1917, when the disease was first officially diagnosed in the U.S. army there have been 142 cases. By years they were as follows:.
Case
1917 25
1918 102
1919 10
White men 115
Colored men 15
1920 3
1921 1
1926 1
Porto Ricans 1
Not stated 11.
The states from which they came were as follows.
South Carolina 21
Texas 18
Georgia 14
North Carolina 14
Tennessee 13
Mississippi 12
Alabama 7
Florida 5
Louisiana 5
Arkansas 4
Oklahoma 4
Pennsylvania 3
Illinois 3
Kentucky 2
Virginia 2.
Other states and territories one each.
you will understand that in a number of these cases the disease may have existed in an unrecognized state, or in its incipiency, when the man was enrolled in the army, as of the 142 cases 127 had been in the army less than one year when diagnosed, and of this 127, 48 less than two months.
This letter shows that pellagra does not originate in the army, unless incipient when the man enlists. All these 142 cases, except those of 1920, 1921, and 1926, were brought in already with the diseases, in the military drag-net of the German war. And those of the excepted years probably had the disease when they enlisted. This letter is another testimonial to the value of nitrogenous food.
The Commission concluded, after this study, that diet lacking nitrogenous, i.e. protein elements is the real and only cause of pellagra, except one other, and that one other, mentioned in the most casual way, without further discussion, is of vast importance, as being a possible medical cure. It is Aluminum lactate, which on a rabbit, produced symptoms and internal pathology identical with pellagra. Being allopaths, the Commission paid no further attention to this discovery. More of this later.
PELLAGRA PATHOLOGY.
The results of this deficiency of the nitrogenous element in diet are sensible, visible and terrible. Many are outwardly visible in life, many more are visible microscopically and microscopically post-mortem. These are elaborately recorded in the report of the Commission. Consideration for available time and for your patience demands a very cursory recital of them here.
GENERAL SYMPTOMS, such as weakness, insomnia, nervousness (indefinitely described), and progressive emaciation appear first and persist to the end of the case. The other clinical symptoms have been sufficiently enumerated in the paragraphs on the conduct of the dieting experiments.
The post-mortem examinations show congestion, and inflammation in the brain, ulcerations and adhesions of the meninges, and the same changes in the spine. The cerebrum and cerebellum are injected throughout. Hence the headaches and insanities. The mouth, tongue and fauces become inflamed and ulcerated, and this condition extends to stomach and bowels. The mucous lining of the stomach becomes tumid, ulcerated, and finally suffers destructive disorganization, the mucous, submucous and muscular layers sloughing apart from each other. The villi of the small bowels, and the mucous membrane thereof are excoriated, producing the foul watery diarrhoea which marks some cases.
The lungs become disorganized and have haemorrhagic effusions into the air-cells. The heart becomes the seat of severe damage. The pericardium is thickened to an incredible degree, in one case to three centimeters. The heart-muscle suffers fatty degeneration. The spine shows destructive degeneration in cross-sections, thus explaining the symmetrical, bilateral symptoms of the disease, especially marked in the dermatitis. As before stated, the dermatitis began in all the test patients, bilaterally on the scrotum. This is peculiar, and we should remember it in suspicious cases and in early cases. Whether it appears also on the labia majora is not stated. Liver, kidneys and sometimes the pancreas suffer in a like manner to the foregoing.
The worst effects are in the spleen, the blood-making organ, which is wrecked. Such being the case, of course we find depraved blood, and depraved blood promotes and hastens the damage and destruction of the other organs, and produces rapid and profound anaemia. A rather late symptoms and pathological condition is that degeneracy of the spine and connected nerves which produces the exaggerated patellar reflex, and the ataxic gait, marked by a peculiar wooden leg walk, the foot coming down hard on the heel.
The eruption is probably the result of disability of the trophic nerves in the parts of the spine affected. The digestion suffers much in the early and later stages, on account of low hydrochloric supply. Animal diet promotes hydrochloric secretion, and in these cases there is little animal diet. The last days of the pellagrin are most horrible, to the patient, to the family and to the attendants. He becomes foul, paralyzed, and often insane.
TREATMENT.
Our works on therapeutics afford us nothing on pellagra. They were written by physicians in the northern states, or in Europe (not Italy), by men who never saw the disease.
