"The Treatment of Pellagra." Transactions of the Medical Association of the State of Alabama (April 1914): 247-265.

              THE TREATMENT OF PELLAGRA.  EARLE F. MOODY, M. D., Dothan, Ala.  [Transactions of the Medical Association of the State of Alabama (April 1914): 247-265.]

The prophylactic treatment of a disease, the cause of which is unknown is necessarily a hazardous undertaking and entails many speculative and questioned precautionary measures.
 While the scope of this paper should be limited to the treatment of pellagra it is important in dealing with its preventative treatment to discuss briefly some of the more accepted etiological theories.
 For more than two centuries the maize or the spoiled corn theory as advocated by Lombroso was considered the sole factor in the production of pellagra in Italy, and extracts made from this product containing a substance called "pellagrosein" brought about symptoms, when injected in animals, so typical of pellagra that it seemed no longer a moot question.
 Accepting Lombroso's theory, the Italian Government established free dessiccators [desiccators] for the drying of corn and installed a system of governmental inspection of corn that was about to be eaten, and in 1903, the year after the inauguration of this system, the mortality from pellagra was very materially reduced.
	While most students of this disease have discarded the maize theory it is well to insist on the use of the best grain products.
	Sambon believes that the disease is transmitted by the simulium group of biting flies, especially that specie that inhabits fast running streams.  If his contentions are true, the modus operandi of preventing an attack by these flies will be very difficult, for they do not enter the house and screening will do us no good.
	Mizelle, of Atlanta, has suggested that cotton seed oil products may cause pellagra, but I attach no importance to this idea since the disease antedates cotton seed oil by many centuries.
	My experience with the malady during its prevalence in my section has led me to believe that it occurs almost wholly among those people of weakened resistance, either by age, disease or drugs.
	Early recognition seems a most important part of its successful treatment.
	When the patient’s vitality has been lowered by prolonged intoxication, no remedy has given me very good results.
	As soon as the diagnosis is made, assure the patient that pellagra has been improved or cured.  Do your best to eliminate, as far as possible, the melancholia, which is always present.  Discourage discussions of the disease with neighbors and friends.
	In the earlier stages insist the patient should have cheerful company.  I have frequently seen depression abate with a proper diversion of thought. 
	Personal hygeine [hygiene] should be supervised.  Daily baths, good ventilation with plenty of light are important factors in improving the general condition.
	It is essential that diseases complicating pellagra be treated and removed as far as possible.  Uncinariasia, syphilis, malaria and tuberculosis must be looked for and the proper treatments instituted, for the pellagrin is so overwhelmingly intoxicated with pellagra that he cannot carry an extra diathesis or cachexia.
	A gain in weight is the best indication of improvement, so do everything possible to aid nutrition.  The assimilation of the proteins, carbohydrates and fats is deficient.  So it is well to arrange a diet that will carry each of these elements of nourishment in a way that can be most easily digested.  Food seems to affect the diarrhea very little, however, I try to get the patient to take sufficient quanitities.
	An alkaline antiseptic mouth wash will help the stomatitis, and an astringent bowel mixture containing opium will usually benefit the diarrhea.  In the typhoidal type sedatives and anodynes give very disappointing results for the relief of the nervousness.  The eruption comes and fades away with or without treatment, but ichthyol in zinc oxide ointment relieves the dry and cracked erythematous skin.  The burning and aching feet and legs, evidences of a neuritis, are among the last symptoms to disappear in convalescing patients.
	In fact symptomatic medication has very little effect and until there is a general improvement in the patient no remedy exerts a very favorable influence.
	It seems that the profession has accepted arsenic as the only treatment that offers a hope for the cure of this disease, and the arylarsonates have afforded the best results.  Some physicians favor atoxyl and give from five to seven grains every third day for a long period without any untoward effect.
	Cacodylate of soda, given in the same manner, has its advocates.
	Salvarsan and neosalvarsan, after repeated and increased doses, have been followed by a recurrence of symptoms in some of my cases.
	Soamin (22 per cent. arsenic) has been my preference.  Following somewhat the suggestions of Dr. Martin, of Hot Springs, I give three to five grains hypodermically, every second to third day until a hundred and twenty grains are given.  It is best to anticipate the spring and fall exacerbations of symptoms by beginning the first of February and giving this drug as stated above, and again during the latter part of the summer.  During the intervals of these treatments three or four grains of soamin give once a week and, the arsenite of iron by hypodermic will usually keep the patient in good conditions.
	I believe that this course of treatment should be pursued for several years after all evidences of pellagra are gone.
	This remedy, soamin, has given me very encouraging results, especially in the chronic types.  It will help the sore mouth, check the diarrhea and relieve the depression as no other drug has done for me.


DISCUSSION.
	Dr. F. A. Webb, of Calvert:  It was my privilege to see some of the first cases of pellagra that were diagnosed in our State.  Some years ago at our Mt. Vernon Hospital I was invited down by Dr. George Searcy and Dr. McCafferty to see some cases they were in doubt about.  I looked the cases over and frankly told them I did not know what the trouble was.  Drs. Searcy and McCafferty began a study of those cases and finally diagnosed them as pellagra.  These were the first cases of pellagra I had ever seen in my section.  Since then we have been studying the question very closely at the Insane Hospital at Mt. Vernon, and as yet we cannot find any cause.  We know that it is a toxemia, but just what that toxemia is we have not been able yet to decide.  We know at first that it manifests itself by some disturbance of the intestinal tract.  The next is the skin, the third the terminal or nervous manifestations.  We carried on an experiment at the hospital in regard to feeding patients with corn meal to see what effect it would have.  We found that corn meal did not cause pellagra at all, but by withdrawing all corn products from patients that had pellagra they seemed to improve.  The corn products seemed to irritate the intestinal tract.  In one case we invited Dr. Cole to try transfusion.  This was practically a terminal cause.  He did this on one patient and there was a decided improvement, but it only lasted six or eight months, and then relapsed.
	Sunlight also seems to have an influence on the skin manifestations.  We find that in patients working the fields, exposed to the sunlight – the skin manifestations are aggravated.  If possible, the hands should be shielded by gloves or otherwise for the skin trouble.
	In the way of treatment, we have not found any specific.  Every case has to be treated according to the stage we find it in.  Personally I have found in the arsenite of copper, 1/200th to 1/120th of a grain, has served me well.  Dr. Faulk, at Tuscaloosa, who has observed it very closely, tells me that scalded milk is the very best thing in these cases.  He says he believes he has done more good by leaving medicine entirely alone and putting the patients on scalded milk.

	Dr. A. M. Stovall, or Jasper:   This is a question that I feel interested in.  It is a thing that has been discussed here in a very interesting way, but there is another point that has not been touched upon in the discussion, and that is information to the public about cases of pellagra.  I have been peculiarly situated in the town where I live.  I have been threatened with a suit for discussing the subject.  A friend of mine, a lawyer, said if I did not quit talking about pellagra they were going to bring suit against me.  Only day before yesterday a man came to Jasper for treatment for pellagra.  He first inquired for a doctor, Dr. Williams.  I told him that if he had come to be treated by this pellagra cure I would not have anything to do with him.  He said he wanted a diagnosis, that his doctor at home had not had many cases.  I said I would examine him and call in some one else.  On examination I found no symptoms of pellagra, and called in Dr. Grote, who on examination found it to be an old case of hook worm disease.
	Now what we want to do is to let the people know what the history of the disease is.  The doctors want to know it themselves, and then the masses of the people should know it.  These advertising people create the impression that fervently they do not believe it.  Information concerning the history of the disease should be spread abroad.
	I treated a case eighteen years ago.  I called it eczema.  She had typhoid fever and became insane and I was preparing to send her to Tuscaloosa.  In the fall when the cold weather came the insanity cleared up and the skin symptoms cleared up, and she went fifteen years without a symptom.  Then she developed a mild case.  It was pronounced pellagra.  She then said that if that was pellagra she had had it fifteen years ago, only worse.  Now those are the cases that the advertising men get hold of and make such wonderful reports on.  I should like to have this commission issue a pamphlet to the people and show that everybody does not die.  It would be a great relief to the people and to the doctors who are treating these cases.  Do not tell your patients they are going to die.  We want to get the people to know the clinical history of the disease.  They think it is something entirely new and that the doctors do not know anything about it.  Then when these advertising men come along they know it all.  A man over in our county who can scarcely read knows more about pellagra than Dr. Siler and all his commission.
INFORMATION FOR THE PUBLIC ABOUT PELLAGRA.
	The word pellagra is formed from two Italian words and means rough skin.  It came into use in medical literature in 1771.  Pellagra is a disease of many symptoms and variations.  If a doctor is called to a patient and makes a diagnosis of typhoid fever, pneumonia, scarlet fever, whooping cough, or some other disease, and some friend inquires of the doctor what he finds to be the trouble and he replies that Mr. A has typhoid fever, the friends know about the course and symptoms that attend typhoid fever.  If he should say that he had pneumonia the friends would expect to find his patient with a cough, pain in his side, fever, etc.  But what does he expect to see if the doctor should say that he has pellagra?  The average man or woman has no idea about the disease, only that it is a new disease, and some think that every one who has the disease must die.
	In typhoid fever the doctor expects ten or fifteen patients out of every hundred to die.  In pneumonia he expects twenty-five or thirty out of every hundred cases to die.  In pellagra he expects forty cases in every hundred to die.
	While pellagra has only recently become known to the public in the United States, yet it has been well known in Italy for nearly two hundred years, and the Italian government has spent hundreds of thousands of dollars studying the disease.  In Italy children often have the disease, and boys who have had it often when grown up are strong men and are accepted in the army and go through life without showing any signs of the disease.
	Pellagra is a general disease, the whole system is affected by it.  It is not a disease of any one system or organ, the eutaneous or skin system, the digestive system, and the nervous system are all affected in some cases.  There are cases in which some one of these systems seems more affected than another.  The patient may be affected with hook worm and other parasites.
	Relation of Pellagra to Seasons. – It usually appears first in the spring and early summer.  It may reappear in the early autumn months of September and October.  It usually omits the autumn advent, disappearing during the winter – these cases are often referred to as being cured – and reappears the following spring.  This may occur for three or four years and the disease disappear entirely, or it may gradually get worse each year.  The attacks may be very mild or may be very severe.  Numbers of persons have been known to have a severe attack which would last until fall and then disappear for one, two, three, five, ten or fifteen years without a symptom.  These cases are great cases for the patent medicine man to prey upon and parade them to the public to show what his medicine will do.
	There are very few specifics in medicine.  What do we mean by a specific in medicine?  It is a remedy specifically indicated for a particular disease.  Quinine is considered a specific for malaria, for by the proper use and administration of this drug the death rate in malaria is very low.  Thymol is a specific for hookworm, diphtheritic antitoxin in diphtheria is a specific if given early.  A remedy to be considered a specific must be administered successfully to a large number of cases after a careful diagnosis has been made by those who are competent to make a correct diagnosis and see the treatment carried out.  With these matters properly attended to if the death rate is reduced to a reasonable degree the remedy may be considered a specific.  As an example, take diphtheria antitoxin.  Before its use there was a death rate of seventy in every hundred cases.  The report of the Health Department of Chicago shows that from October 5, 1895, to February 28, 1899, of 4,071 cases of diphtheria only 276, or 6.77 in each 100 cases died.  Now when some doctor or patent medicine man can show this kind of decrease in the death rate of pellagra his remedy will be entitled to the confidence of doctors and the public.  But what will he have to do to get this?  He will have to have hundreds of cases treated with his remedy and all be open to inspection just as diphtheritic antitoxin was.

	Dr. W. H. Moon, or Goodwater:  May I ask one question as to the treatment?  You know this question has been discussed before this Association for a number of years, and the first thing brought out as to the season was that in the winter time pellagra rarely developed, but in the spring or summer-time.  We have summer houses for raising flowers in the winter time; could we not have winter houses to keep a certain degree of temperature and a certain amount of darkness to protect these pellagra patients from the influence that seems to cause the skin symptoms?  That question occurred to me the first time I ever heard it discussed, and it is still in my mind, and I have never heard it spoken of.  Therefore, I ask the question.
	Dr. Joseph Franklin Siler, Corps, U. S. A.:  Mr. President and Gentlemen – It is a great pleasure for me to be present at this meeting, more particularly as this is my native state.  I have enjoyed very much the papers which have been read on pellagra this afternoon and will only say a few words.
	I enjoyed very much Dr. Pruett’s paper and he made some references to the work of our Commission about which I would like to say a word.  I get the impression from Dr. Pruett’s paper that he considers our Commission made up of laboratory workers.  Dr. Pruett has very wisely said that we should all draw our own conclusions about the etiology of pellagra.  To my mind, the most important thing for us to do is not so much to draw conclusions but to collect facts.  In almost every community in the South it is possible for us to collect interesting and perhaps highly important facts with reference to pellagra and some, if not many, of these facts will eventually lead us to the solution of this question.  To my mind, it is important that we do not attempt to draw too many conclusions from observations made in one community.  With reference to the impression that Dr. Pruett has gotten of our work, I would like to say that we have men who are assigned to different lines of work.  It is true that we have men who are doing laboratory work and that alone, but I would not like you to get the impression that the conclusions to be found in our records are drawn from laboratory work alone.  Two members of the Commission, Dr. Garrison and myself, together with other workers have nothing whatsoever to do with the actual laboratory work.  Our work is confined altogether to a study of the population in endemic areas of pellagra.  We go to the homes of the cases of pellagra and study the sanitary condition of these homes, the food consumed by the people, the general conditions under which they live and all other facts which seem to us to have any bearing on the etiology of the disease.  From these studies, we have drawn a certain number of conclusions.  I would also like it understood that our work has not been confined to one particular community.  We have studied conditions throughout the Southern States.  One member of our Commission has made observations of pellagra in Italy and one member had the pleasure of making a trip throughout the British West Indies last year with Dr. Sambon.  In taking up this work, we tried to do it without any bias whatsoever.  We felt that there were too many theories as to the cause of pellagra and determined to confine our efforts to the accumulation of a number of facts.  The facts which we have accumulated are intended to answer, as far as possible, the following questions:  Is pellagra due to corn products?  If so, is it due to good corn or to spoiled corn?  If not due to corn products, is there some other special element of the diet which may cause it?  Is it possible that the people who contract pellagra can have in their diet some constituent which lacks the so-called vitamins?  Can the disease be a general deficiency disease?  We have made up case history blanks to be filled for each case in which we attempt to answer some of these questions.  I have come to Alabama for the purpose of extending our epidemiological work and you gentlemen can be of great help to us.  We are attempting to collect facts just now, rather than propound theories.  We know that each of you have made important observations with reference to pellagra in your own community.  If you would only put these observations on record it would not be long before we knew something very definite about pellagra.  One of the crying needs of the South is vital statistics.  It is very difficult for us to get any information with reference to pellagra in the South because of the fact that physicians in practice in the South do not report their cases.  If they would only make complete reports on pellagra to the State Health authorities, our work would become much easier.  At [As?] it is, it is necessary for us to go out to each community ourselves.  Dr. Pruett seems to think we have dismissed the corn theory on insufficient grounds.  I will go over in a brief way some of the facts which we have secured in our studies during the past two years and you may draw your own conclusions as to the etiology of the disease.  In the first place, I may say that in 1909 and 1910 it was my good fortune to study pellagra in an Institution at Peoria, Illinois, where about 10 per cent. of a population of 2,000 individuals had pellagra.  Fortunately, we had records of the exact amount of each article of food purchased at the Institution and these records went back for a number of years.  It was not possible for these people to have eaten more than two tablespoonfuls of corn products a day and as a matter of fact the amount consumed was usually less than this.  If corn products had anything to do with the epidemic at Peoria the corn products could not have been spoiled.  The corn meal used at this Institution was purchased from a local mill and the miller took particular pride in the fact that he used only the very highest grade and best quality of corn to be bought on the market.  If pellagra was due to corn in this Institution, it necessarily had to be due to good corn.  In 1909, we decided to initiate a feeding experiment in this Institution.  Two cottages of a capacity of 60 patients each were selected for this study.  The selected patients (men) who had shown no evidence of pellagra were placed in these wards.  They were under the special care of one of the staff doctors and in one ward an excess of corn was introduced into the diet (about 12 oz. per day).  In the control ward no corn products whatsoever were allowed.  Patients in these two cottages were kept on these diets for exactly one year.  At the end of a year’s time, we found that in the corn free ward three cases of pellagra had occurred with two suspects while in the corn ward two cases had occurred with one suspect.  Another interesting thing about the epidemic of Peoria is the fact that in 1909 there were 177 cases of pellagra, in 1910 67 and in 1911 14, since which time no new cases have occurred in the Institution.  We know, furthermore, that in this Institution pellagra occurred with much greater frequency in certain wards than in others and we know furthermore that about as many males contracted the diseases as females.
	In our studies in Spartanburg County, S. C., we have found that the disease shows inequalities in distribution.  In some townships the incidence rate is very high while in others practically no cases occur.  By the end of 1913 we had collected records more or less complete of 847 cases of the disease in Spartanburg County.  It is a curious fact that so far as race is concerned the distribution of pellagra in Spartanburg County is quite unequal.  There are about three cases in white people to one in negroes.  These figures hold good for North Carolina and Georgia while for Alabama, Mississippi and other far Southern States the racial distribution of the disease is equal.  In our work in Montgomery, Ala., we have so far collected statistics of 196 cases.  100 of these cases have been in whites and 96 have occurred in negroes.  The distribution of the population is about equal and I think that we may say that the racial distribution of pellagra in the City of Montgomery is about equal.  In South Carolina, North Carolina and Georgia, industrial communities (cotton mills) are very common.  In the county in which our most intensive studies are being made, there are 30 cotton mills and the population of the mill village communities attached to these mills ranges from 250 to about 2,000 individuals.  It is in these cotton mills that pellagra is very prevalent.  We have found that in the mill communities in Spartanburg County, the prevalence of pellagra was 104 per 10,000 while in rural communities it was only about 19 per 10,000.  The diet of the people living in rural communities and of those living in cotton mill villages does not differ to any great extent.  It seems to us that the most reasonable explanation of the difference in the racial incidence of pellagra in the cotton mill states and in Alabama, Mississippi and Louisiana is to be accounted for by industrial conditions and congestion of population in these mill communities.  We have found, furthermore, that pellagra seems to attack individuals at certain age periods.  Thus, we find that the highest incidence rate of pellagra is in women from 20 to 45 or 50 years of age.  At this period of life but few men contract the disease, the rate being more than 9 women to every man.  After 50 years of age, the disease attacks men as frequently as it does women.  Under 10 years of age, we have found pellagra to be not at all unusual.  Children are quite subject to the disease and curiously enough as many boys as girls are affected.  Another very interesting point about the age incidence of the disease is the fact that children under 2 years of age very seldom contract pellagra.  The disease in children is very milk and is almost always followed by recovery.  We have been following the disease in children during the past two years and it is not at all uncommon to find that children show very definite symptoms of pellagra one year and are perfectly well the following year.  We have studied the occupation of over 700 cases of pellagra and can find no definite connection between occupation and pellagra.  It seems to us, however, that the high morbidity rate in women, children, and in old people or both sexes tends to point to the home as the place where the disease originates most frequently.  During 1913 we made some very intensive studies in certain mill villages in Spartanburg County, S. C.  We have made a particular study of the question of association and were very much struck by the fact that so many of our cases have shown association with a preexisting case of pellagra in the same house or next door.  As a matter of fact, of the incident cases occurring in 1912 and 1913, we secured a very definite history of very close association with a preexisting case in 80 per cent. of the total number of cases.  Two or three years ago it was the general impression that when pellagra occurred in a family, only one individual had the disease.  It is quite probable that a number of physicians at this meeting still hold that view.  Our work, however, has shown us that this is by no means true.  Physicians who treat cases of pellagra see the majority of their cases in their office and have no occasion to examine the other members of the family.  In our work, however, we make it a point to visit the homes and in the course of our investigations of conditions at and around the home, we make an examination of the other members of the family.  In this way, we find cases of pellagra which are never seen by the practicing physicians, more particularly, cases of pellagra in children.  We feel quite confident that if physicians seeing cases will make it a point to examine other members of the family from time to time during the pellagra season, they will confirm our findings.  The physicians in Spartanburg County until recently held the view that cases occurred singly in families.  Now they are finding secondary cases with very great frequency.  We feel that association is a very striking feature in pellagra and our date suggests that it is of much greater importance than has been thought to be the case. 
	During 1913, we made a very complete survey of 6 mill villages in Spartanburg County.  In a house-to-house canvass of these mill villages we collected the vital statistics of each person and the food habits and the sanitary surroundings of each family.  The data thus collected covers a population of over 5,000 individuals.  We have analyzed the food data with reference to the use of shipped corn, local corn, corn meal, fresh meat, canned good, eggs and milk.  With reference to corn meal, we have found that in these 6 villages over 3,000 individuals ate corn meal daily and of this number 98 or 3.2 per cent were pellagrins.  About 700 individuals were using corn meal only rarely or never and of this number 41 or 6 per cent. are pellagrins.  Thus, we found that the number of pellagrins in the group of the population using corn meal rarely or never was twice as great as that among the group of the population using corn meal every day.  The only food which seemed to have any bearing on the incidence rate of pellagra was milk.  Individuals using milk (buttermilk) every day were much less subject to pellagra than that group of the population using it rarely or never.  We found, however, several cases of pellagra in individuals drinking sweet milk or buttermilk every day.  In our study of the food of the inhabitants in these mill villages it was impossible for us to discover an essential pellagra-producing food or an essential pellagra-preventing food and the data which we have analyzed suggest to us that neither of them exists in the dietary of the population.  In these mill villages it was also possible for us to determine as to whether or not there was any distinct tendency for secondary cases of pellagra to develop in the vicinity of primary or preexisting cases.  For the purpose of this study we divided the population into three zones:  The first zone included all persons living in the same house with a preexisting case of pellagra; the second zone, all persons living next door to a preexisting case; the third zone, all persons in the village living at a greater distance than next door to a preexisting case.  This study showed that 6 per cent. of the individuals living in the same house with a preexisting case of pellagra contracted the disease; that 1.7 per cent. living next door contracted it and that .5 per cent. living in the third zone or further away than the next door came down with the disease.  This appeared to us to be very significant and indicated that there is very close relationship between primary and secondary cases.  The conclusions seem warranted that in these mill villages, pellagra in some way transmitted to non-pellagrous individuals from a preexisting case and that an important factor in this transmission is residence in close proximity to an antecedent case.
	Another interesting observation has been the apparent connection between active foci of pellagra and unsanitary methods of disposal of human wastes.  Thus, in the City of Spartanburg, we have found that the active foci of pellagra are confined to those sections of the city in which unscreened surface or pail privies are in use.  The disease appears to avoid those parts of the city in which a water carriage system of sewage disposal is in use.  In Spartanburg County pellagra prevails to a greater or less extent in all the mill villages and in all these mill villages the type of privy is an unscreened surface or pail one.  We were able to find two mill villages in the state in which water carriage system of disposal had been installed.  In one of these villages, Newry Mill, located in Oconee County, a water carriage system had been installed twenty years ago and the history of pellagra in this village indicates that they have had five or six cases.  All of these cases, however, with one possible exception, came into the village with pellagra and the disease has not spread.  The other village, the Republic Mill, in the northern part of the state, installed a water carriage system three years ago.  The history of this village also indicates that four or five cases have moved into the village and that no case has certainly contracted the disease there.  These observations seem to be of possible importance and this year we hope to extend them to other communities.  If these facts can be confirmed, it suggests to us that even though we may not have found the specific cause of the disease we can at least point out methods for its control.  This year we hope to extend our observation along these lines.  That is the purpose of my visit to Montgomery at this time.  A superficial survey of conditions here suggests that the active foci of pellagra in Montgomery are confined very largely to what is known as the “West End” and to “North” Montgomery and that in these sections unscreened surface privies are in use.
	These are only a few facts which we have ascertained.
	We feel that we can absolutely exclude corn meal as the essential cause of pellagra.  There is no question that pellagra most frequently attacks people who are below par, so does tuberculosis and so do other diseases.  It, however, does not confine itself to the lower classes of the population and to those who have complicating disease or are below par.
	With reference to diagnosis, I feel that we should be guarded in diagnosis unless the skin symptoms are present or unless we can get a very clear history of their previous occurrence.  I have no doubt that many of you can diagnose pellagra before the skin symptoms have appeared but it is my belief that we should be guarded in our diagnosis.  It is quite easily possible to mistake Sprue and cases of Amoebic or Bacillary Dysentery for Pellagra.  I have seen doctors make a diagnosis of pellagra on the so-called mental symptoms alone.  Recently, we have had two or three curious instances of this kind.  Doctors who are practicing where pellagra is endemic are not to be blamed for suspecting pellagra when mental symptoms are present but they should also think of other things.  For example, I have during the past year seen two cases diagnosed as pellagra on the mental symptoms alone and there was no question about the fact that the mental symptoms were due entirely to mental changes incident to the menopause. 
	So far as treatment is concerned, I do not feel that I can say anything to you gentlemen.  There is, however, one thing that I have come to realize during the past two years and that is that in pellagra we are dealing with a disease which resembles in many respects tuberculosis.  It is usually very chronic and as in tuberculosis is difficult to diagnose in its early stages.  As a matter of fact, I have seen a number of cases of pellagra diagnosed as tuberculosis.  It seems to me also that many doctors take too pessimistic a view of pellagra.  So many doctors tell these patients that nothing can be done for them.  I agree with Dr. Niles, of Atlanta, that psychotherapy is most important in these cases.  Tell them that you can do something for them, because you can.  If you can build up their bodies it will frequently enable them to throw off pellagra.  As you all know, the mental symptoms in pellagra are frequently one of the worst features of the disease and on the mental attitude taken by the patient depends very largely whether or not he will recover and it is my opinion that we should give these people all the hope possible because there is hope.  The annual death rate in pellagra is not more than 10 per cent.  It undoubtedly was much higher three or four years ago but it is my opinion that although pellagra is steadily increasing every year it is not so virulent as was the case three or four years ago.  It is my belief that we should treat these cases exactly as we treat cases of tuberculosis.  We find that people who have carried out this treatment conscientiously, who will take from 8 to 10 eggs a day, who will drink a large amount of milk and who will rest, frequently do not have recurrences.  They appear to recover.  It is particularly important that such cases should be followed up quite early in the spring, that they be given tonics and forced feeding during the latter part of the winter and early spring in order that they may be in better condition to throw off a possible recurrence.
	A member:  I would like for the Doctor to tell us what he considers the pathognomonic symptoms of pellagra as distinguished from other conditions.
	Dr. Siler:  So far as our records are concerned, we never call a case pellagra unless skin symptoms are present or unless there is a very definite history of their previous occurrence.  There is no question but that you can make a diagnosis of pellagra prior to the development of skin symptoms but I think that we should be guarded in telling patients that the disease is pellagra unless we can get a clear history of skin symptoms.  Of course, a provisional diagnosis of pellagra can be made before the appearance of such symptoms and a proper line of treatment instituted.  It is my belief, however, that no patient should be told that he has pellagra in the absence of skin symptoms.
	Dr. T. G. McWhorter:  Will you give me your opinion on one point – did I understand you to say that in the development of these new cases, they usually occur in those associated with pellagrins?
	Dr. Siler:  Yes.
	Dr. McWhorter:  And that is an analogy to those who associate with consumptives.
	Dr. Siler:  Exactly so.  We made a very thorough study of association last year and as I have pointed out to you, 80 per cent. of our patients showed very close association with preexisting cases of pellagra in the same house or next door.  Furthermore, our study of the domicile has shown that in the mill villages intensively studied by us, secondary cases of pellagra occur in a very restricted zone, usually in the same house with or next door to a preexisting case.  What this means, I am not prepared to say.  My views with reference to pellagra are very similar to those expressed by a number of men here this afternoon, that is, that pellagra usually attacks people who are below par – individuals who are poorly nourished, who have insufficient food or who have some predisposing disease.  It is not so common in people who live under good sanitary conditions, and who eat a sufficient amount of well cooked food.  I would go further, however, and say that it spreads in some way from a preexisting case.  The data which we have accumulated to my mind, indicates that pellagra is not indirectly due to the consumption of corn meal either good or bad, that it is not a general deficiency disease but that it is an infection of some kind transmitted from person to person in some way, at present undetermined.
	Dr. George W. Williamson, Hargrove, Ala.:  I would like for Dr. Siler to tell us what the study of the Commission has shown in regard to the transmission of the disease by insects.
	Dr. Siler:  We have been working constantly along these lines.  During the past two seasons we have had the good fortune to have associated with us in our work two or sometimes three entomologists from the Bureau of Entomology, U. S. Department of Agriculture.  During the first year’s work, they made a very comprehensive study of all insects that might possibly have anything to do with pellagra.  Their final decision was that the insect which was most likely to be concerned in transmission is one which must be present around the house in the day time.  For a number of reasons, they eliminated the bed-bug, mainly for reason of sex distribution.  Mosquities were eliminated because of the fact that there is no day biting mosquito in Spartanburg County.  The most common day biter is the Aedes calopus.   These mosquitoes were introduced into Spartanburg County in about June, 1913, and were fairly common during the latter part of the season of 1913.  In 1912, however, they were not present.  They evidently were introduced from the low country in May or June, 1913.  The winged insect most likely to be concerned in pellagra transmission, should it be proven to be a transmissible disease, was in their opinion Stomoxys calcitrans.  As this insect most nearly filled the requirements, their work was mostly confined to it during the second season.  Attempts were made to transmit the disease from patients to monkeys through the medium of the Stomoxys calcitrans.  Many of the facts brought out in our second year’s work, more particularly, those with reference to close association and proximity of domicile have led us to scrutinize with much more care those insects most closely domiciled with man.  These insects naturally would be the lice, fleas and bed-bugs.  It is our intention to study these insects with much greater case during the present season, more particularly lice.  We have attempted to transmit pellagra to numerous monkeys.  In this transmission work, we have used suspensions of materials from pellagrins including saliva, duodenal fluid, feces, tissues from the pharynx, stomach, intestines, brain, spinal cord, blood and lymph from cutaneous lesions.  Almost all of these animals died in the late summer of 1913.  Most of them died of dysentery but none had definite symptoms of pellagra.  With reference to Simulium, in our work in Spartanburg County we found Simulium to be very common in streams but they did not bite human beings with any great frequency.  For many reasons it was possible in our opinion to eliminate them from consideration as possible transmitting agents in pellagra.  Our studies of Simulium have been extended to other communities, other states, other countries.  We investigated pellagra in the Panhandle region of Texas where the rain-fall is very low and where running streams are very scarce.  We found cases of pellagra in these sections and insects of the genus Simulium were altogether unknown to the local population and the nearest breeding places for such insects were from 60 to 125 miles away.  Insects of the genus Simulium could have no connection with these cases.  We have observed cases of pellagra on an island on the coast of South Carolina many miles distant from possible breeding places for Simulium.  Through the courtesy of Dr. Sambon we had the pleasure of studying pellagra in the British West Indies in the fall of 1913.  In the island of Barbados we found that over 500 individuals had died of pellagra during the past 2 ½ years and insects of the genus Simulium were searched for with great care by entomologists of the British Government, by Mr. Jennings of the U. S. Bureau of Entomology and by Dr. Sambon himself.  Insects of the genus Simulium were not found on the island of Barbados and the geological formation of the island is such that it would not be possible for them to breed to any great extent.
	A Member:  Would catarrhal conditions of the intestine have anything to do with it?
	Dr. Siler:  They would act as predisposing factors and might exaggerate the intestinal symptoms. 
	A Member:  Would not the dust in the mills explain the prevalence in mill villages?
	Dr. Siler:  Pellagra is more prevalent in mill communities than in rural communities in South Carolina but when you consider the actual foci of the disease, we have found that pellagra is just as prevalent in some farming sections as it is in mill villages.  They have just as much pellagra in other parts of South Carolina as they have in Spartanburg.  Spartanburg has unjustly gotten the reputation that is has more pellagra than anywhere else by reason of the fact that our Commission has been working there are has succeeded in getting records of almost all the cases.  As a matter of fact, there is just as much pellagra in the adjoining counties to Spartanburg County and in the whole of Piedmont section as there is in Spartanburg County.  Furthermore, the records indicate that Georgia has as much pellagra as South Carolina.  To show how these things go, I may say that recently we made a hurried investigation of pellagra in Charlotte, N. C.  It was the general impression that they had had probably 40 or 50 cases around Charlotte.  As a matter of fact, we secured records of 200 cases which were or had been present.  I might say that we are making a similar study of pellagra in the City of Montgomery and so far we have collected records of 196 cases of pellagra, within the city itself.  This, of course, does not mean that our records show 196 cases here now but it includes cases which have been reported in the past.  I do not doubt that when we have completed these records and when all the doctors have turned in their cases, we find that between 300 and 400 cases have occurred in this city.  These facts mean that pellagra is a very serious problem in the South.  If the doctors throughout the State would only keep records of their cases and report them to the State Health Officials, we would soon have some definite idea as to just what the pellagra situation in Alabama is.
	Dr. Pruett (closing):  I did want to say a few words in closing the subject, but we have had a good deal of an argument and I won’t say anything further.