We no longer have any doubt that beriberi and scurvy are diseases due to vitamine deficiency. We still have some doubts regarding rickets; but the doubt here is not so much whether rickets results from a deficiency of fat-soluble A, but rather to what extent is fat-soluble A necessary to prevent rickets? Even Dr. Hess, the opposition champion, does not deny that the presence of fat-soluble A in the diet is important; he simply questions whether this vitamine alone is sufficient to account for the disease; whether there are not other factors.

Pellagra is another one of those diseases that are due to nutritional deficiencies. As with rickets, we cannot as yet say very definitely that pellagra is due to the absence of one specific vitamine. The work of Dr. Goldberger, of the U. S. Public Health Service, points to a combination of causes, of which vitamine deficiency is one. The other causes may be due to deficiencies in the amino-acid content of the proteins, and deficiencies in the mineral salts.

Pellagra In The South

During the last twenty years the southern part of the United States has had no less than 500,000 cases of pellagra, and ten per cent of these have ended fatally. It is a disease which at one time was regarded as being confined exclusively to the poorer classes, but now we know that even the well-to-do may be sufferers; for the disease is due to an unbalanced diet, not merely to a poor diet. Of course it is also true to say that the greater percentage of pellagra patients come from the poorer classes, for even the rich who are foolish indulge in a great variety of dishes, so that the possibility of vital deficiencies in any one necessary constituent are lessened.

Symptoms

The symptoms in pellagra may be described in the words of our best-known pellagra specialist in this country, Dr. Goldberger:

"In a fairly well-developed though not advanced case the disease shows itself by a variety of symptoms, of which weakness, nervousness, indigestion, and an eruption form the most distinctive combination.

"The eruption is the most characteristic telltale of the disease and the main reliance in recognition. When the eruption first shows itself it may look very much like a sunburn, the deceptive resemblance to which may, in some cases, be heightened by the subsequent peeling with or without the formation of blisters. In many cases the inflamed-looking skin first turns to a dirty brown, frequently parchment-like, then quickly becomes rough and scaly, or cracks and peels. In many instances the redness is not noticed or does not occur, the first and perhaps the only thing observed being the dirty looking scaly patch of skin very much like and frequently thought to be no more than a simple weathering or chapping.

"Among the most distinctive peculiarities of the eruption is its preference for certain parts of the body surface. The backs of the hands in adults and the backs of the feet in children are its favorite sites. Other parts not infrequently attacked are the sides or front of the neck or both, the face, elbows, and knees. From these or other points, for it may attack any part of the body, it may spread to a varying degree. Another marked peculiarity of the eruption is its tendency to appear at about the same time, and to cover similar areas, both as to extent and peculiarities of outline, on both sides of the body. Thus it may be stated as the rule that if the back of one foot, one elbow, one knee, one side of the neck, one cheek, or the lid of one eye is affected, then the corresponding part on the other side of the body is affected, and affected to almost the same extent. This rule, however, is not without many exceptions."

Like the other diseases that we have discussed, pellagra has had its "infection theory" enthusiasts. There was some reason for such belief some ten years ago when it was noticed how rapidly it spread from place to place. But such a theory has now been thoroughly disproved. No pellagra germ has ever been isolated. All attempts to give persons pellagra by inoculating them with the blood or saliva of pellagra sufferers have failed. On the other hand, no difficulties whatsoever were encountered in curing patients by merely changing their diet, even though their surroundings were filthy in the extreme.

The Diet A Factor In Pellagra

Dr. Goldberger supplies us with several instructive examples. In an asylum which he investigated and which was surprisingly full of pellagra patients, the doctor noticed that the disease was confined to the inmates only; the doctors and nurses showed not a trace. Upon a careful investigation of the foods consumed, he found that the staff was abundantly supplied with meat and milk, whereas the inmates received but little of these precious foods. Dr. Goldberger thereupon added meat and milk to the diet of the inmates, and pellagra disappeared as if by magic.

Dr. Goldberger had similar experiences in three orphanages. In all of them pellagra made its appearance periodically, and many of the children suffered acutely from it. Here also the disease disappeared with the introduction of an improved menu.

And just as pellagra can be cured by changing the diet, so can it be deliberately induced by a onesided diet. Eleven convicts who had volunteered for the experiment were given a diet consisting chiefly of biscuits, corn bread, grits, rice, gravy and syrup, with only a few vegetables and no milk, meat, or fruit. Six of the convicts developed pellagra.

Pellagra Outbreak In Egypt In 1918

All of these experiences in our own country merely typify experiences elsewhere. An instructive example was the pellagra outbreak in Egypt in 1918. Thousands of Turkish and German prisoners were brought there and placed in concentration camps. Pellagra outbreaks were frequent and many, but the British doctors soon noticed that most of the pellagra sufferers were Turks; in fact, 90 per cent of the total were. Then the fact was brought out that for months past the Turks had received but two-thirds of their normal ration, which, even under the best of conditions, compared unfavorably with the rations allowed German or Allied soldiers. Their German general had reported that his Turkish soldiers were suffering from "long continued undernutrition." Increased food allowances, and more particularly, a more carefully balanced diet, soon improved the pellagra sufferers. And particularly instructive as throwing doubts on the infection theory was the observation how nearly immune to this disease were the German prisoners; and this, despite campaigning and living with the Turks.

Pellagra Studies By Officers Of The U8. Public Health Service

But if an improved, or still better, a well-balanced diet prevents pellagra, what factor or factors are of importance? We can answer this fairly accurately by examining the exhaustive report of the U. S. Public Health Service entitled, "A Study of the Diet of Non-Pellagrous and Pellagrous Households in Textile Mill Communities in South Carolina in 1916," the authors being Drs. Joseph Goldberger, G. A. Wheeler and Edgar Sydenstricker, Surgeon, Assistant Surgeon and Statistician, respectively, of the Service.

Seven villages in the northwestern part of South Carolina, each containing not more than 800 and not fewer than 500 inhabitants, were selected for study. Only white mill operators were considered; none of the families of mill officials, store managers and negro employees were included. A systematic search of pellagra cases was made from house to house. A careful survey of foods eaten by non-pellagrous and pellagrous households was made. This included a very elaborate social and economic program, for which Mr. Sydenstricker was particularly responsible. In all, the records of the food supply of 798 households, with an aggregate population of 4399 individuals, were obtained.

We shall now summarize the most characteristic portions of this report. One of its outstanding features was to show that protein consumed in non-pellagrous households included a greater proportion derived from animal foods, and a lesser proportion derived from cereals and, in general, vegetable foods, than in pellagrous families. We have but to return to the work of Professors Osborne and Mendel on amino-acids to draw the necessary inference. Proteins derived from vegetable sources are, on the whole, poorer in certain essential amino-acids than those derived from animal sources. The pellagrous households, therefore, have suffered from an insufficient supply of certain amino-acids. According to Professor Chittenden and Dr. Hindhede's standards, the protein requirements of the pellagrous part of the population were more than met; the disease could hardly have been due to a mere deficiency of protein.

In the non-pellagrous households the consumption of lean meat, milk, butter, cheese and eggs was greater than in the households with pellagra sufferers. Notice in this list the foods man has relished for ages past. All of them are rich in proteins, which in turn are rich in the essential amino-acids. In proportion to the non-pellagrous households, the sufferers consumed but small quantities of milk; and this makes it probable that the quantity and variety of mineral constituents in the diet were deficient.

But of extreme interest to us is the fact that a decreased consumption of milk, meat, cheese and eggs means a decreased supply of the all-important vitamines; at least, a decreased supply of fat-soluble A and water-soluble B.

"The indications afforded by this study would seem very clearly to suggest that the pellagra-producing dietary fault is the result of some one, or, more probably, of a combination of two or more factors: 1. A physically defective protein supply - that is - a defective amino-acid supply; 2. A low or inadequate supply of fat-soluble vitamine; 3. A low or inadequate supply of water-soluble vitamine; 4. A defective mineral supply. . . . The pellagra producing dietary fault may be corrected and the disease prevented by including in the diet an adequate supply of the animal protein foods."

This disease, viz., pellagra, illustrates excellently how, despite a sufficient number of calories, and despite a sufficient quantity of protein, the food may still be highly unsatisfactory.*

* At Yale University Professors Mendel and Underhill are now using the dog to study pellagra-like disease.