PELLAGRA (Ital. peile agra, smarting skin) is the name given, from one of its early symptoms, to a peculiar disease, of comparatively modern origin, occurring among the peasantry in Lombardy and other provinces of northern Italy, and in the Asturias (mal de la rosa), Gascony, Boumania, and Corfu. It is a progressive disease of nutrition tending towards profound paralytic and mental dis-orders, and is associated to a very significant extent, if not even invariably, with a staple diet of damaged maize along with other peculiarly wretched and hopeless con-ditions of living. Although Lombardy is the garden of Italy, its peasantry are over-worked, under-paid, and under-fed ; instead of a diet suited to their severe labour, their sustenance, consists largely of the more worthless kinds of Indian corn of their own growing, the produce of poorly-cultivated ground, sown late, harvested before maturity, and stored carelessly in its wet state; even if they grow a certain proportion of good maize-corn the millers, to whom they are often in debt, are more likely to grind the worst samples for the peasants' own use. The flour is either made into a kind of porridge—the "polenta" of Italy, the "cruchade" of Gascony, or the "mamaliga" of Boumania— or it is made into loaves, without yeast, baked hastily on the surface only or on one side, and raw and wet within, large enough to last a week, and apt to turn sour and mouldy before the week is out.

That pellagra is not a morbus miserise pure and simple, wanting some more specific cause, will be at once apparent when we consider that the misery of living is as old as the human race, whereas pellagra is a disease of the last hundred years or so, and that in Ireland, Russia, Upper Silesia, Galicia, or other headquarters of the morbi miserise, pellagra is unknown. The special factor is undoubtedly maize as an article of diet or as the staple diet; but it is, on the other hand, perfectly clear that there is nothing in a maize diet itself to induce pellagra. Compared with the enormous extent of the maize-zone both in the western and eastern hemispheres, the pellagra-area is a mere spot on the map ; excluding Corfu, it lies between the parallels of 46° and 42° N.; and the exception of Corfu is a signi-ficant one. It is only since 1856 that pellagra has become endemic in that island. Maize has always thriven well there; but wine-growing has displaced it to a great extent, and the maize, which is still largely in request with the peasantry, is now mostly imported ; it is in fact chiefly Roumanian maize of an inferior kind, and all the more deteriorated owing to its long water-transit by way of the Danube and Black Sea. Again, in the Danubian provinces themselves the peasantry of Transylvania, who are by no means well off, are free from pellagra, notwithstanding their addiction to polenta, having long ago learned the art of husbandry from the Saxon part of the population; they allow the maize to ripen to the utmost, and then let it dry on the ground and afterwards in barns, whereas the Wallack peasantry of Roumania, who are subject to pellagra, gather the corn before it is ripe, and shoot it into pits where it becomes musty. In other countries where the conditions of climate and soil are somewhat trying for maize, as in Burgundy, Franche Comte, and the Bresse in France, and in Mexico, the greatest care is taken to dry the Indian corn before it is stored; and it may be said that wherever these precautions are taken pellagra does not follow. It has happened on several occasions, after a particularly bad maize-harvest, that pellagra has risen almost to an epidemic. Again, its prevalence within its actual endemic area varies much from province to province or from commune to com-mune, being always last where the maize-diet is supple-mented by wheaten flour, rice, beans, chestnuts, potatoes, or fish.

Characters of the Disease.—The indications of pellagra usually begin in the spring of the year, declining towards autumn, and recurring with increasing intensity and per-manence in the spring seasons following. A peasant who is acquiring the malady feels unfit for work, suffers from headaches, giddiness, singing in the ears, a burning of the skin, especially in the hands and feet, and diarrhoea. At the same time a red rash appears on the skin, of the nature of erysipelas, the red or livid spots being tense and painful, especially where they are directly exposed to the sun. About July or August of the first season these symptoms disappear, the spots on the skin remaining rough and dry. The spring attack of the year following will probably be more severe and more likely to leave traces behind it; with each successive year the patient becomes more like a mummy, his skin shrivelled and sallow, or even black at certain spots, as in Addison's disease, his angles protruding, his muscles wasted, his movements slow and languid, and his sensibility diminished. Meanwhile there are more special symptoms relating to the nervous system, including drooping of the eyelid, dilatation of the pupil, and other disorders of vision, together with symptoms relating to the digestive system, such as a red and dry tongue, a burning feeling in the mouth, pain on swallowing, and diarrhoea. Peasants with this progressive malady upon them come to the towns spring after spring seeking relief at the various hospitals, and under a good regimen and a permanently improved diet the malady is often checked. But after a certain stage the disease is confirmed in a pro-found disorganization of the nervous system; spasms of the limbs begin to occur, and contractures of the joints from partial paralysis of the extensor muscles and pre-ponderant action of the flexors; melancholy, imbecility, and a strong suicidal tendency are common accompani-ments. A large number of pellagrous peasants end their days in lunatic asylums in a state of drivelling wretched-ness or raving madness ; many more drag out a miserable existence in the communes where their working years had been spent, sometimes receiving the communal relief to which the law entitles them; while the cases that are reckoned curable are in Italy received into the various endowed hospitals, of which there are a large number. Cases that are rapidly fatal end in delirium or a state of typhoid stupor; the more protracted cases are cut off at last by rapid wasting, colliquative and ill-smelling sweats, profuse diarrhoea, and dropsy. After death a variety of textural changes are found, which may be referred in general to trophic disorders, or disorders of tissue-nutrition; in a considerable number the kidneys are in the contracted state corresponding to the clinical condition of Bright's disease without albuminuria; another condition often remarked is thinning of the muscular coats of the intes-tine ; deposits of pigment in the internal organs are also characteristic, just as the discoloration of the skin is during life.

Treatment.—There is hardly any doubt as to the remedy for pellagra, just as there is hardly any doubt as to its cause. The question is mainly one of the social condition of the peasantry, of their food and wages ; it is partly, also, a question of growing Indian corn on a soil or in a climate where it will not mature unless with high farming. There is nothing in the resources of medicine proper to cure this disease ; as the cause is, so must the remedy be.





Affinities of Pellagra. —The disease has the general characters of a tropho-neurosis. The early involvement of certain areas of the skin, especially in exposed places such as the hands and feet, suggests leprosy ; as in that disease, there is first hyperesthesia and then loss of sensibility, sometimes a thickening of the surface and discolora-tions; and, although in pellagra the onset each successive spring and the subsidence towards autumn are distinctive, yet in leprosy also the cutaneous disorder is apt to come and go at hrst, reappearing at the same spots and gradually becoming fixed. The grand difference in leprosy, at least in the nodular variety of it, is that a new growth of a granulomatous kind arises at these spots in the skin and around the nerves. The occasional deep discoloration of the pellagrous skin in certain spots has suggested a resemblance to Addison's disease of the suprarenals, and has even made the diagnosis difficult. But after the cutaneous disorders the course of pellagra is something sui generis ; the melancholy, imbecility, or mania, as well as the mummified state of the body, are peculiar to it. With ergotism the points of resemblance are more perhaps in the causation than in the nosological characters ; both diseases are specifically due to damaged grain, ergotism being caused by the presence of an actual bulky parasitic mould on rye, whereas pellagra is more probably caused by fermentation and decomposition within the proper sub-stance of the maize-corn. As regards heredity, it is much less marked in pellagra than in leprosy, but there are good grounds for believing that the disease is in fact inherited sometimes by the offspring ; infants at the breast may show the symptoms of it, but that fact is not in itself conclusive for heredity, for the reason that infants at the breast are partly fed on the household polenta. As regards contagiousness, there is no more proof of it in pellagra than there is in leprosy.

Geographical Distribution and History.—Pellagra is peculiarly a disease of the peasantry, being hardly ever seen in residents of the towns. In Italy the number of peasants affected by it was estimated in 1879 at 100,000, the distribution being as follows :—Lombardy, 40,838 ; Venetia, 29,386 ; Piedmont, 1692 ; Liguria, 148 ; iEmilia, 18,728 ; Tuscany, 4382 ; the Marches and Umbria, 2155 ; Borne, 76. In Lombardy the worst centres are in the provinces of Brescia, Pavia, Piacenza, and Ferrara. In Italy the disease has increased very considerably within the last thirty years; thus, in the pro-vince of Vicenza the number of persons known to be pellagrous in 1853-55 was 1380, in 1860 it was 2974, and in 1879 it had risen to 3400. There are no accurate returns from the Asturias and other affected provinces of Spain, but the malady there is said to have declined very materially of late. In Gascony, where it did not begin until about fifty years ago, it is somewhat common, more in the Landes than in the Gironde ; in one district of the latter Petit estimates that there are 200 cases in a population of 6000. In Roumania the total number is given at 4500, Moldavia having a larger share than Wallachia. In Corfu it exists in 27 out of the 117 communes, the proportion of cases for the wdiole island being 3-2 per 1000 inhabitants.

Maize was grown in Europe for many years before pellagra showed itself (see MAIZE) ; but the outbreak of the disease corresponds on the whole closely in time (particularly in Gascony and Roumania) with the introduction of an inferior kind of maize as the staple food of the peasantry. The first accounts of pellagra come from Spain. Casal in 1762 described the disease in the Asturias under the name of mat cle la rosa ; it is said to have been noticed first in 1735 around Oviedo, being then confined within very narrow limits. The Asturias are still its headquarters in Spain, but it is prevalent also in Burgos, Navarra, Zaragoza, Lower Aragon, Guadalajara, and Cuenca, and it is met with in other provinces as well. In Italy it was first reported from the vicinity of Lago Maggiore, and a few years later (in 1750) it broke out simultaneously in the districts of Milan, Brescia, Bergamo, and Lodi, extending afterwards to Como, Cremona, Mantua, and Pavia, and to the whole of Lombardy before the end of the century. It became endemic also in Venetia on the one side and in Piedmont on the other, almost contemporaneously with this. Within the present century it has extended its area southwards into JEmilia and into Tuscany, wdiile it has become more prevalent in its earlier seats at the same time. There is very little of it in central Italy, while southern Italy with Sicily, is absolutely exempt, notwithstanding the common use of Indian corn in the form of bread and macaroni. The first authentic in-formation of its existence in Gascony came from near Arcachon in 1818, after which it spread along the coast of the Gironde and the Landes. It has extended subsequently along the left bank of the Garonne and towards the Pyrenees ; but around Dax it is said to have decreased considerably of late. In Roumania, where the medical profession is unanimous in tracing it to the use of damaged maize, it dates from about 1833-46. It is only since 1856 that it has become endemic in Corfu, under the circumstances already mentioned.

Literature.—La Pellagra in Italia, Rome, 1880 (official report, with appendices relating to France, Spain, and Roumania, and a copious bibliography extending to fifteen pages). An article on " The Pellagra in Italy," in the Edin. Rev. for April 1881, is based on this report. The authority for Corfu is Typaldos. The best inquiries on the toxic properties of damaged maize are those of Lombroso. See also Hirsch, Historisch-geographische Pathologie, vol. ii., 2d ed., Stuttgart, 1883 (Engl. trans.). (C. C.)


Footnotes

476-1 Of the peasantry of the Asturias, Townsend, a traveller of the last century, says:
"They eat little flesh, they drink little wine; their usual diet is Indian corn, with beans, peas, chestnuts, apples, pears, melons, and cucumbers; and even their bread, made of Indian corn, has neither barm nor leaven, but is unfermented, and in the state of dough ; their drink is water " (ii. 14).

The following is the most recent account (by Dr Petit) of the condition of the peasantry in the pellagrous district of the Gironde :

" The cultivation of this district consists of millet, rye, a small quantity of maize, and a few rare vineyards. The soil does not suffice for the nourishment of the miserable population who cultivate it. They are slovenly, and sleep in their clothes ; their labour is in general of the severest kind, and they are very ill fed. Their food is mostly a porridge of millet; maize is rarely part of their diet [elsewhere he says, " in all these provinces the flour of maize enters largely into the food of the people"], which includes a little rye-bread, sour most of the time, a few sardines, and rancid lard. Meat is almost excluded from their food ; sometimes on fete-days one may see a quarter of mutton or veal at the repast. Their usual drink is water, and mostly bad water ; wine is not drunk except in well-to-do families. Their dwellings are deplorable ; they are low-roofed and damp, built of wattle, and constantly enveloped in reek. It often happens that man and beast live together. Pellagra rages as an endemic among these populations."






The above article was written by: Charles Creighton, M.D.