PELLAGRA

[ Read before the Texas Homoeopathic Medical Association, Oct. 14 and 15, 1931. ].

HUNTER B. STILES, M.D.

 

Pellagra has probably been known and endured for centuries in Italy and other Mediterranean lands, in Africa and the hot parts of other countries, especially among the very poor and ill nourished population. It has been called the Morbus Pauperum the Disease of the Poor. Disease of the Poorly Fed is more correct for the richest may also suffer if improperly fed.

When some of us began practice we knew pellagra only as a word, referring to a far distant disease, like beri-beri, away in distant lands, of no interest to us. Those were the days of free grass and free range, the days of thousands of cattle on the hills and plains, the days of meat retailing at three, five, eight cents a pound. This adequate supply of meat continued until the nineties. Then cattle became scarce in proportion to the population and meat across the counter began to rise in price until it went beyond the reach of the poor.

Other changes came about also, for example the development of the cotton mills and a great increase of tenant farmers in the south. Mill hands and tenant farmers ceased raising swine and poultry and keeping milk cows. Meat, eggs and milk disappeared from their diet. They could not afford to buy the high priced beef. Due to these factors they lived almost wholly on carbohydrates and hydro-carbons. Later we will consider the dire results of such a steady diet. The map of pellagra distribution in America follows pretty closely the state lines of the southern states rather than the isothermic lines.

Pellagra, in the light of recent investigations, is defined as a systemic deficiency disease. On this basis, it is to be classed with beri-beri, scurvy and rickets, but is unlike all of them, for it is caused by a different deficiency, which became pronounced in this country about 1900 and has continued to the present time.

Warm blooded animals are divided dietetically, into three distinct classes:.

1. Vegetarian or graminivorous.

2. Carnivorous.

3. Omnivorous. The omnivorous must have both vegetable and animal (nitrogenous) food in order to thrive. Humans are omnivorous. Those human races living almost wholly on vegetable food are inferior, in several points, from those living on vegetable and animal food. This paragraph is but a premise for discussion to follow.

The etiology of pellagra has been, during the past thirty years, a topic of much discussion based on several theories. Among the earlier theories was that of a certain Italian fly, which was said to produce the disease by its bite. Briefly, that theory has been abandoned. Then came the corn-smut theory, probably because most of the corn grown in Italy was very poor in quality, on account of poor land, and was consequently smutty. The homoeopathic provings of corn-smut, otherwise Ustilago maidis, show a toxic effect on the female system, but practically no symptoms resembling pellagra. Rye-smut, Ergot, does show many symptoms of pellagra, but in my practice it has been a disappointment in the treatment of this disease.

The U.S. Pellagra Commission mentions Ergot in their report, but says that while its outward manifestations resemble pellagra, the micro- scopic, inward results are very different. We would be interested to receive information as to pellagra in the rye-eating lands. Suffice it to say that in the southern part of our own country millions have been brought up on corn-bread, and we never hear of this disease as long as the protein ration is adequate. This paper throws to corn theory into the discard.

A more plausible theory, and one which suggests itself to every modern physicians mind, is the microbe theory. Even the modern laity assume that cause, and are afraid to come in contact with pellagrins. That theory, also, is vanishing. Dr. Edward Francis, U.S. Health Service, took samples, including cerebral and spinal fluids, from all parts of seventeen pellagrins in the Georgia Insane Asylum. Some of these samples were from living cases, some from post-mortems. He tried to develop cultures therefrom. All in vain. Not one culture developed anything suggesting a pellagrous microbe.

They either remained sterile, or developed extraneous microbes from contamination. Dr. Francis then prepared extracts from all parts-brain, spine, skin and internal organs-of dead and living pellagrins and injected them into some 94 rhesus monkeys. These monkeys are very susceptible to pellagra. He also introduced the extracts in other ways, by mouth, by nose, by rectum, in food and drink. Results negative. Only one monkey showed any sign of pellagra and this was probably contracted accidentally. The monkey recovered spontaneously. Dr. Francis report ends thus: “The work here reported furnishes no support for the view that pellagra is an infectious disease”.

The fact that in pellagra hospitals the physicians and nurses, always well-fed, never contract the disease, also contradicts the infection theory.

The theory of bad sanitation as a cause was easily disposed of by comparing sanitary and unsanitary villages. They showed no practical difference as to incidence of the disease.

The facts, above, reported, were deduced from long and meticulous experimentation, which fills many pages in the report, and proves what are not the causes of pellagra.

We will now consider another series of very carefully arranged experiments, in the dietetic line, made scientifically and cautiously, in the quest of the true cause of pellagra. These experiments were made in 1915, by Dr. Joseph Goldberger and Dr. G.A. Wheeler, of the U.S. Public Health Service, with the co- operation of Governor Brewer of Mississippi, and his penitentiary authorities. On one of the penal farms, the Rankin, a few miles from the capital city of Jackson, the doctors were permitted to select from volunteer convicts, a squad of perfectly healthy men, on whom to make the test.

Those subjected to the test were promised pardon and liberty on the following October 31. This date allowed too short a time for complete testing. But the promise was kept, and the members of the squad were all released on October 31, 1951. The Commission agreed in advance that no patient should be diagnosed as having pellagra unless the skin eruption appeared on him.

Twelve healthy men were selected, free from all constitutional disease, of good heredity, and unassociated with any pellagrous person. “One ran away, and then there were eleven.” All the other convicts on the farm, about 35, and all the free persons, officers, guards and their families, total of about 47, were controls, or standards of comparison. The sanitary environments of these controls, the working convicts were quite unsanitary, dirty, hot, infested with mosquitoes and bedbugs.

Their work hours were long, and the work hard. The test-volunteers were placed in a thoroughly disinfected, and well screened hospital at quite a distance from other buildings. Its sanitary arrangements were very good. Their bedding was clean, and their rooms well kept.

They were closely guarded, to obviate any claim that they were in any manner exposed to contagion, and to prevent the introduction of any forbidden diet. Each one, on transfer to the test house, was examined and found to have good appetite, normal sleep, good elimination and no skin eruption. In February, they were confined in the test house, and continued for two months on the usual regulation diet, to allow time for any incipient trouble to manifest itself. None appearing, all were placed on the monotonous, experimental diet on April 19, 1915. These men ranged in age from 24 to 55 years. They were worked moderately on the farm when in condition to work, and allowed ten minutes rest out of each hour. Not so the others. When they were sick, they stayed in the house.

From April 19, 1915 their diet was uniformly about as follows: White bread flour biscuits, corn bread, corn grits, polished rice, cane sugar, cane syrup, sweet potatoes, pork fat (not fat pork), cabbage, collards, turnips, turnip greens, coffee.

Up to July 28, the biscuits were made with buttermilk. Thereafter buttermilk was omitted, as a nitrogenous food. During the week ending June 27 each man received four ounces of beefsteak per day, thereafter none. The pork fat was simply lard, a hydro-carbon. Thus we see that the diet was practically wholly of a farinaceous nature, wholly carbo-hydrate and hydrocarbon, with no proteins of animal source whatever. And remember that humans are by nature omnivorous-they need nitrogenous food. There was no limit on such food as they had. They could and did eat to satisfaction. The food was of the best quality, and there was no corn-smut in any part.

Also observe that the cornmeal, the wheat flour and the rice were all highly finished, the envelopes of all being removed, and with them all the Silicea. Dr. Schussler would make a great point of that. On this diet, each man received from 2,500 to 3,500 calories. The working convicts, in the main building, received 3,500 to 4,500. The regular diet of the working convicts included all of the foregoing test menu, plus many kinds of vegetables, beef, mutton, pork and fish, one or another, sometimes two every day. Bear in mind also that they were worked harder than the test volunteers, and that they worked right through the hot summer in the sun, 10 or 12 hours daily. But they had the diet proper for the omnivorous class of animals.

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.

It behooves the southern physicians to study the disease and its therapy for the benefit of our profession, and through the profession, for the poor patients.

The Commission, which I have so often quoted, declares that no treatment is known or necessary except the proper diet, which will save those patients not too seriously damaged by the disorganizing process of the disease. With this dictum, the writer cannot agree. Having had some experience with the disease, even among those who could not, or just did not, adopt the right diet to any great degree, he has nevertheless cured all his cases except one, his first one, which had been relinquished as hopeless by her good old allopathic doctor, and was already in a much degenerated condition, and too poor and helpless to have the proper attention.

In the other cases by far the most efficient remedy was Arsenicum album, rather low in potency. Secale, resembling the disease in Herings pathogenesis, was a disappointment, for reasons perhaps such as stated by the Commission-that the resemblance was only apparent, and no inwardly or essentially real. Natrum mur. also seems very homoeopathic. Sulphur and phosphorus both resemble pellagra in many points, and should be carefully studied. In connection with these two remedies allow me again to quote the Commission, under their paragraph on treatment. As a form of dietetic treatment, they include vitamin extracts of beef-liver, which they seemed to find quite efficient as a cure. Be it said in passing, that having found essential identity of pellagra and its cause and cure in humans, monkeys, rats and pigs, they attach as much importance to considerations of the lower animals as to humans (which I am not disputing).

In giving the chemical constituents of this beef-liver extract or vitamins, as they term it, they included both phosphorus and sulphur, in quantities equal to from one-half to 1x potency, to 1 1/3 and 2x. Query: Was it the vitamin in the liver-extract which relieved the patients, or was it the Sulphur or was it the phosphorus? I have long suspected that the much talked of vitamin, which all the authorities call an unknown and unidentified substance, is nothing more or less than microscopic or ultramicroscopic quantities of certain tissue remedies and antipsorics well known to every properly educated homoeopathic physician. The scientists say they are not the mineral salts, etc., but what do such scientists know about 12x, the 30x, the 60x and the CM potencies?.

To conclude, as said before, one of the most remarkable results of the Commissions work was the discovery that Aluminum lactate actually produced a case of pellagra in a rabbit. An allopath would not be particularly interested in that discovery because he does not know or does not believe the law of cure. But to the homoeopath it is of most gripping importance. Perhaps here is a possible cure for the disease. Let us call that possibility to the attention of our profession and endeavor to procure human provings of this substance. Let us have our manufacturing pharmacists prepare different potencies and let us try them in our future cases of pellagra and similar conditions.

Of course the first thing in the treatment of pellagra is to place the patient on a proper diet including the protein elements of animal origin, such as fresh meats, milk, eggs, cheese. To this should be added fresh vegetables.

WACO. TEXAS.

We can understand why quantity becomes an indispensable factor to the materialist who confines his practice to appreciable doses of crude drugs.

We can understand the line of reasoning which predicates coarseness and fineness of particles pulverized within certain reasonable limitations by the trituration, for instance, of silex, salt and sugar; we can comprehend how the particle of these and similar solid substances may be ground finer and finer quite indefinitely, because their particles are held together by what is called cohesive attraction, and a uniform diffusion or blending of molecules cannot take place between solid bodies. But it is quite different with solutions. The crystals of common salt or sugar may be dissolved in water and become amorphous liquids that are so uniformly diffused as to completely destroy the existence of coarser or finer particles.

The process of attenuation by the Hahnemannian method may be continued until all trace of quantity has vanished beyond the recognition of every possible physical test, yet we find dynamic quality or potentiality surviving. A.R. MORGAN, M.D., 1892.

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