THE 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. Pellagra constituted 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 Lombroso formulated 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 and lipoids, 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
factors concerned 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
involved were:
"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 or they 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 violent excitement 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 whole course 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 were complicated
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 with pellagra:—
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 found what 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 statistics in 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.