CHAPTER IXTHE PSYCHOSES WITH PELLAGRA
The origin of pellagra is shrouded in mystery. Although first described by Casal, the name now attached to the disease was suggested by Frappoli in 1771. He referred to it as of ancient origin at that time and probably identical with the "pellarella" reported in Milan in 1578. Niles[242]is of the opinion that the peculiar malady existing among the American Indians and mentioned by Baruino in 1600 was almost certainly pellagra. It is interesting to note that he attributed it to the use of corn. The disease was observed in Spain by Gaspar Casal in 1735 and appeared in Italy about twenty-five years later. Of the 4,404 admissions to the St. Clement's Hospital at Venice between 1873 and 1880 over thirty per cent showed symptoms of pellagra. In 1912, according to Niles, the number of cases in Italy was estimated at approximately one hundred thousand. The disease was apparently first reported in France in 1818. It has been common in Egypt since 1892 at least and is said to have occurred there as early as 1847. Cases were reported in this country by John P. Gray at the Utica State Hospital and by Tyler at the McLean Hospital, in Somerville, Massachusetts, in 1863. It is now thought to have been very common in the Andersonville and Libby prisons during the civil war, although not diagnosed as such at the time.
Few cases were reported in this country prior to 1907, when it was found to be present at the Columbia, South Carolina, State Hospital by Babcock. Pellagraconstituted seven per cent of the admissions to that institution in 1908, fifteen per cent in 1909, twenty in 1910, over twenty-seven in 1911 and twenty-six per cent in 1915. Sixty-one per cent of the deaths in the hospital during the latter year were due to that disease. The health officer of the state reported four hundred cases in South Carolina in 1909 and six thousand in 1914. Babcock is now of the opinion that pellagra undoubtedly existed for twenty years or more at Columbia before its significance was known. In 1910 the disease was found to be present in thirty different states and represented about three thousand cases.[243]Of these the largest numbers were in Virginia, North Carolina, South Carolina, Georgia, Alabama, Mississippi, Louisiana, Texas, and Illinois. The importance of this question had already been recognized and a national conference was held on the subject at Columbia in 1909. During the same year the governor of Illinois appointed a commission to make a thorough study of pellagra in that state. The disease has been made the subject of elaborate investigation and study by the United States Public Health Service and several publications have been issued by that department.[244]
Notwithstanding the extended discussion and scientific research of the last few years, the question as to the definite etiology of pellagra has not as yet been positively settled. The maize or Indian corn theory was first advocated by Mazari in 1810. He believed the symptoms to be due to a deficiency in gluten. Sette in 1826 attributed the disease to a fungus (scimelpige) growing on corn and producing a poison from the oil in the grain. The smut of corn, "Ustilago Maydis," was suggested as a possible factor by Pari in 1860. In 1872 Lombrosoformulated his toxic theory: "In pellagra we are dealing with an intoxication produced by poisons developed in spoiled corn through the action of certain microorganisms, in themselves harmless to man." He also announced the discovery of "pellagrosein," a toxic substance extracted from spoiled corn. In 1902 Ceni advanced the theory that the disease was caused by the action of certain moulds such as the aspergillus fumigatus and flavescens. The Illinois Pellagra Commission in 1911 came to the conclusion after an elaborate investigation of the subject that the primary etiological factor involved was a living microorganism of unknown nature, that the probable source of infection was through the intestinal tract and that a deficient amount of animal protein in the diet probably acted as a predisposing cause. Funk in 1914 suggested a vitamin deficiency in the diet brought about by the consumption of overmilled corn. Voegtlin[245]in the same year expressed the opinion that the disease was essentially a chronic intoxication,—"While the agents at work in this intoxication are as yet unknown, I am inclined to believe that toxic substances exist in certain vegetable foods, not necessarily spoiled, which, if consumed by man over a long period of time, may produce an injurious effect on certain organs of the body.... It is probably more than a mere coincidence that the population of that part of the world in which pellagra is endemic lives on a mainly vegetable diet."
In 1916 a study was made by Koch and Voegtlin[246]of the chemical changes found in the nervous system in pellagra which was very significant in its results. They found an increase in water with a decrease in proteins andlipoids, the latter reaction being attributed to a degeneration in the white matter. There was also a relative increase in the cholesterol content, looked upon as a compensatory protective function tending to replace the loss in lipoids. The most marked chemical alterations were found in the cord. On feeding monkeys and rats with an exclusive vegetable diet, changes in the chemical reaction of the brain and cord of almost exactly the same type were brought about experimentally.
Goldberger[247]in 1916 made an interesting report of a series of investigations carried on by the United States Public Health Service at Jackson, Mississippi. A large number of cases of pellagra were treated by largely supplementing the dietary with fresh meats, milk and leguminous vegetables. The carbohydrate content was reduced at the same time but corn was not entirely discontinued. Of 209 cases studied, 172 remained under continuous observation with a recurrence of symptoms in only one case. In a similar experiment made at the Georgia State Sanitarium seventy-two patients, all of whom had shown attacks previously, were treated for a year without symptoms. A number of volunteers at the Mississippi State Penitentiary were given a test diet consisting of wheat flour, corn meal, grits, cornstarch, white polished rice, granulated sugar, cane syrup, sweet potatoes, pork fat, cabbage, collards, turnip greens and coffee. Of the eleven convicts receiving this diet, six developed a typical dermatitis with slight nervous and gastrointestinal symptoms. The results of these investigations were not offered by the United States Public Health Service as being conclusive and incontrovertible evidence as to the etiology of pellagra, which must still be looked upon as being somewhat in doubt. The dietetic factorsconcerned in the production of the disease have been under serious consideration for a century or more.
This information was supplemented by a study of pellagra in the general population of the cotton mill communities in South Carolina.[248]In comparing the dietaries of pellagrous households with those of the families escaping infection it was found that the former consumed less meat, milk, butter, cheese and eggs. The value of their diet in calories and proteins was lower. The proteins contributed, moreover, were more largely from cereals, peas, beans, etc. The carbohydrate content was also lower. They concluded that the particular points involvedwere:—
"1. A physiologically defective protein supply,
"2. A low or inadequate supply of fat-soluble vitamin,
"3. A low or inadequate supply of water-soluble vitamin, and
"4. A defective mineral supply."
They were also of the opinion that the disease could be prevented by "including in the diet an adequate supply of animal protein foods (particularly milk, including butter, and lean meat)."
Roberts[249]in 1920 made a study of twenty-five cases of pellagra encountered in private practice. In every instance the disease developed in families provided with an abundance of food of all kinds. An analysis of the actual consumption, however, showed that "not one of the patients ate a well rounded, balanced diet of meat, milk, eggs or wholesome vegetables." Either they were suffering from a lack of nourishment in every case orthey were eating practically the same diet that Goldberger used experimentally in producing pellagra.
As defined by Barker[250]pellagra "is a disease characterized by peculiar cutaneous, digestive, nervous and mental disturbances, usually running a chronic course, with periodic exacerbation, but sometimes developing acutely and proceeding quickly to a fatal termination." He speaks of the disease as developing during the winter months usually with neurasthenic manifestations—fatigability, insomnia, slight vertigo, and feelings of apprehension, followed by digestive disturbances later in the spring. The parts of the skin surface exposed to the sun develop an erythema followed by a dermatitis. Nervous and mental symptoms may appear later. In some cases the disease tends to recur every spring. The skin lesions have been described as a characteristic "mask" shown on the face, the pellagrous collar, a bandlike eruption on the neck, Casal's "necklace" extending downwards over the sternum, the pellagrous "butterfly," "gauntlets," etc. The more common digestive disorders are stomatitis and glossitis, gastric disturbances and diarrhea. Neurological symptoms observed include hyperesthesia, paresthesia, anesthesia, tremors, paralyses, muscular pains, increased reflexes and occasional convulsions.
The literature of pellagra and its associated mental disturbances has been elaborately reviewed by Babcock.[251]The following references appear in a comprehensive study of this subject made by him in 1910. Griesinger[252]described the pellagrous psychoses as characterized by a vague, incoherent delirium, accompanied by loquacity and loss of memory without any violentexcitement or special disorder of the intelligence. The depression gradually develops into a torpor of all the mental powers together with muscular weakness, a condition resembling general paresis. Mongeri[253]states that the psychoses usually begin with a period of depression accompanied by hypochondriacal ideas. This is followed by confusion and hallucinations of hearing. Delusions of persecution appear, with a marked tendency to suicide by drowning. Crimes of various kinds may be caused by the paranoid condition which usually terminates in deterioration. In speaking of chronic and acute forms Bianchi[254]says: "The former is characterized by general depression, melancholia, confusion, slow dementia, paresthesias and ataxic gait. Contractures and subsulti are absent, although in most instances the reflexes are exaggerated. In the acute form we have rapid elevation of temperature, 39° to 41° C.; intense neuro-muscular excitement, subsulti, contractures, muscular rigidity, exaggerated reflexes and confusion with phases of exaltation. There are numerous intermediate forms in which we observe a great variety of psychical phenomena, and also alternations of excitement and depression. Phases of remission and of apparent recovery are observed, especially at certain seasons." Régis[255]is quoted as follows: "It is recognized that the most common form of psychosis in pellagra is mental confusion with melancholy or dreamy delirium. This occurs more or less markedly in most of the cases. It is manifested by inertia, a passivity, an indifference, a considerable torpor; by insomnia, hallucinations often terrifying, both of sight and hearing; by delirious conceptions with fixed ideas of hopelessness, of damnation, of fear, anxiety,persecution, poisoning; of possession by devils and witches, of refusal of food, and so marked a tendency to suicide, and to suicide by drowning, that Strombio gave it the name hydromania. This melancholy depression, which can reach, in certain cases, even to stupor, is always based upon a foundation of obtusion, of intellectual hebetude, and of considerable general debility, which becomes permanent and terminates by degrees in dementia, in proportion as the pellagrous cachexia makes new progress. It is accompanied sometimes by a polyneuritis. The mental confusion of pellagrins can, in place of changing directly into dementia, turn to a chronic mental confusion. One may observe in pellagra, as in every grave intoxication, a morbid state resembling general paresis (pellagrous pseudo-general paresis). This occurs especially in the cases where instead of habitual melancholy ideas, the patients present ideas of satisfaction and of wealth." Procopiu[256]found his patients "sad, apathetic, silent; in the more advanced stage they are melancholy, and fall sometimes into an absolute mutism, or respond with difficulty, and have the air of not understanding what is said to them. Sometimes this melancholy is accompanied with stupor, and leads the poor pellagrins into dementia." He also speaks of the occurrence of sudden outbursts of manic excitement. Tanzi[257]refers to the existence of both pellagrous mania and melancholia but speaks of a characteristic amentia "which manifests itself acutely in loss of time and place, loss of memory, confusion, hallucinations, and paresthesias, from which there arise morbid impulses and delusions. Pellagrous amentia, often assumes a depressive form, which simulates melancholia, and in some cases either from time to time, or throughout the wholecourse of the psychosis, it is accompanied by exaltation, which gives it some resemblance to mania."
Gregor[258]in 1907 made a careful analysis of seventy-two cases. He classified these in seven groups: 1. Neurasthenia; 2. Acute stuporous dementia; 3. Amentia (acute confusional insanity); 4. Acute delirium; 5. Katatonia; 6. Anxiety psychoses; and 7. Manic-depressive insanity. The neurasthenic cases (9.72 per cent) exhibited headache, pain in the gastric region, vertigo, paresthesia and lassitude, with a sense of unrest and anxiety as well as ill-defined apprehensions. There was a sense of mental incapacity and feeling of illness, together with a mild depression and hypochondriacal tendencies. The cases diagnosed as acute dementia (13.88 per cent) were of the same general type but with more advanced symptoms. These showed a decided stupor, tending to remission, deep mental depression, a sense of insufficiency and "peculiar subjective troubles." The tendency to suicide was prominent and caused this group to be called melancholia by some. Many cases showed the gradual development of an affectless stupor. Catatonic symptoms and stereotypies occasionally occurred. Memory disturbances were well marked in this form. The psychoses disappeared invariably with the symptoms of the pellagra. The Amentia group (44.44 per cent) included long-continued cases with remission and intermissions. Terrifying hallucinations and violent motor excitement appeared frequently, followed by a stupor which was sometimes interrupted by delirium. Hallucinations were usually present and some had dream states. These cases often terminate unfavorably. Acute delirium constituted 2.7 per cent of the seventy-two cases, and katatonia occurred in 13.8 per cent. These cases passed rapidly into dementia. Anxiety psychoses (4.16 per cent) were diagnosed in a few instances, but werecomplicated by occasional stupors. Two and seven-tenths per cent of the cases were classified as manic-depressive insanity. Mobley, according to Babcock, found the following types represented at the Georgia State Sanitarium:—1. Acute intoxication psychosis, with psychomotor suspension; 2. Infective exhaustive psychosis, with psychomotor retardation or excitation; 3. Symptomatic melancholia with psychomotor retardation; and 4. Manic-depressive psychoses.
Singer[259]in 1915 suggested the following classification of the psychoses associated withpellagra:—
1. Disorders directly due to the pellagra toxin:
(a) Symptomatic depression; (b) Delirious pictures.
2. Disorders based on peculiarities in personal make-up, the attack of "insanity" being precipitated by pellagra;
(a) Manic-depressive disorders; (b) Hysteria; (c) Psychasthenia; (d) Dementia praecox; (e) Paranoic developments; and
3. Disorders due to definite brain changes with pellagra merely as a complication:
(a) Arteriosclerotic dementia; (b) Senile dementia; (c) Presenile psychoses; (d) General paralysis of the insane.
He found mental disturbances of some kind in about forty per cent of the cases examined. As a general rule they appeared after the patient had shown evidence of several attacks of the disease. The psychoses occurred in men between the ages of twenty-one and forty and in women between forty-one and sixty. About ninety-five per cent of the mental disorders were to be attributed directly to the effect of the toxin. The remaining five per cent represented individuals with a defective nervous organization or were purely incidental complications.Singer found peculiarities in make-up associated frequently with a predisposition to pellagra. He also expressed the opinion that chronic forms of "insanity" are very rarely caused by the diseases.
Sandy[260]made a study of 160 cases at the state hospital at Columbia, South Carolina, in 1916 based on a classification of psychoses quite similar to the one now in use. He found that thirty-five per cent of these belonged to the infective exhaustive group. As a matter of fact, this is the conclusion almost anyone would reach from reading the observations of the earlier writers. These cases were usually characterized by "more or less marked delirium, being accompanied by some confusion and disorientation, there frequently being also hallucinations accompanied by more or less agitation and restlessness." Physically he found, besides well marked symptoms of pellagra, evidences of severe exhaustion, loss of weight, emaciation, fever, sordes, anorexia, and typhoid facies. "In the milder forms of these 'delirious pictures,' as Singer calls them in his contribution to the report of the Thompson-McFadden Pellagra Commission, and as he pointed out, the periods of clouding (of consciousness) may be quite brief and episodic. In such cases in the intervals when the consciousness is practically clear, the general attitude is one of symptomatic depression." Sandy found characteristic manic-depressive forms in eleven per cent of the series reviewed. The depressed types were more common. Here he found retardation of speech and action with a dearth of ideas. In these cases he looks upon pellagra as being merely an exciting etiological factor. The prognosis was not so favorable, however, as it usually is in manic-depressive psychoses, death often being due to the development of central neuritis. In three per cent of the total he foundwhat could only be described as symptomatic depressions, the emotional condition not being so marked as one would expect in the manic-depressive group. In twelve per cent a diagnosis of dementia praecox was made. In these the pellagra was merely an incident and not an etiological factor.
In several patients Sandy found a symptom complex strongly suggestive of general paresis, thus confirming the findings of other observers. These showed speech and writing defects, absent or sluggish pupillary reaction, swaying in the Romberg position, altered deep reflexes, disorientation, memory disorders and other evidences of deterioration. The Wassermann reactions were negative in both the blood and spinal fluid tests and no lymphocytosis was shown on cell counts. These cases he thinks belong in the infective exhaustive group, and usually die of central neuritis, a condition already referred to and described originally by Turner and Meyer. Sandy also found pellagra associated with various senile psychoses. This group constituted ten per cent of those studied. Fourteen per cent of the series he left unclassified owing to lack of history, etc. Some of these showed simple deterioration, others suggested neurasthenia, and some, general paresis. Of the remaining cases three were epileptic imbeciles, three, constitutional inferiority with episodes of some kind, and three were not insane. Cases associated with chorea and hysteria were also observed. On analyzing these most important findings the assumption would seem to be warranted that pellagra is an incident in certain psychoses—(senility and dementia praecox), that it is a precipitating factor in certain cases (manic-depressive), and that the characteristic conditions due to the disease are toxic and assume the infective-exhaustive form, occasionally simulating general paresis.
The policy of the Association's committee on statisticsin the differentiation of these conditions is shown by the following quotation on this subject from the last edition of the manual:—
"The relation which various mental disturbances bear to the disease pellagra is not yet settled. Cases of pellagra occurring during the course of a well established mental disease such as dementia praecox, manic-depressive insanity, senile dementia, etc., should not be included in this group. The mental disturbances which are apparently most intimately connected with pellagra are certain delirious or confused states (toxic-organ-like reactions) arising during the course of a severe pellagra. These are the cases which for the present should be placed in the group of psychoses with pellagra."
A study of recent statistics would tend to show that pellagra is not at this time a factor of importance in our institutions. In Massachusetts in 1919 the admission rate for this disease was .33 per cent. In New York state hospitals during a period of eight years it was only .03 per cent. In twenty-one hospitals in fourteen other states it amounted to only 1.28 per cent. This includes a number of institutions in the south. There were 263 cases (.37 per cent) in 70,987 first admissions to forty-eight hospitals in sixteen different states. The admissions reported from the southern institutions indicate that pellagrous psychoses are comparatively infrequent as a rule. During the year 1918 pellagra constituted 10.7 per cent of the admissions to the Columbia State Hospital. During the biennial period of 1917 and 1918 the admission rate at the Arkansas State Hospital for Nervous Diseases was 8.31 per cent. None were admitted to the Spring Grove State Hospital at Catonsville, Maryland. In 1919 the admission rate at the Western State Hospital at Staunton, Virginia, was 1.14 per cent, at the Central State Hospital, Petersburg, Virginia, 1.39 per cent, and at the Georgia State Sanitarium at Milledgeville,2.49 per cent. One and sixty-one hundredths per cent of the admissions to the Louisiana State Hospital during 1920 were diagnosed as psychoses due to pellagra. Very few cases are reported in the northern institutions.