902 WAKD J. MAcNEAL 



warrant a grave doubt as to the accuracy of diagnosis or the adequate 

 search for antecedent cases in such instances. Malnutrition and lack of 

 food are conspicuous among the poor of large cities where pellagra is 

 quite unknown, but in pellagrous districts a very large proportion of the 

 poorly nourished and especially the women and children are attacked by 

 pellagra. 



Regional Incidence. Pellagra is prevalent in certain parts of Turkey, 

 Egypt, Roumania, Austrian Tyrol, Northern Italy, West Indies, Yucatan 

 and the Southern United States. It has occurred in South Africa and 

 the Malay States. Within these large areas it occurs in small endemic 

 foci, the great mass of the population being relatively free from the dis- 

 ease. In fact, pellagra is contracted especially by those who actually 

 reside in the same house with pellagrins or next door to such houses. 



Race, Age and Sex. Pellagra is more prevalent in the white race than 

 in negroes in the United States. It is, however, a much more fatal 

 disease in the negro, doubtless because of the lower racial resistance, 

 greater poverty and poorer diet of this race. The great bulk of the 

 cases occur in women and children, but old men are also attacked rather 

 frequently. Men in the age period 15 to 45 years are rarely afflicted 

 with pellagra unless they suffer from some other depressing condition. 

 The death rate is almost nil in children, and most of them recover in a 

 few years. In women the death rate is moderately low, but the tendency 

 to continued recurrence very high. After the age of 50 years the death 

 rate is well above 20 per cent in the first year and recovery is rare. 



Social Status. In Europe pellagra has been recognized as especially 

 prevalent among the peasants. The industrial factory workers and the 

 commercial population of towns and cities have largely escaped it. In 

 general, pellagra has there been associated with extreme poverty. In 

 the United States, social status is less definitely established. Perhaps the 

 nearest approach to a caste is furnished by the colored population of the 

 Southern States, in which greater poverty appears to be correlated with a 

 lesser prevalence of pellagra. In the white population of these States, 

 pellagra is moderately prevalent among the farmers, but far more prev- 

 alent in the families of the industrial laborers in the small factory com- 

 munities, such as those of cotton mills, and in the more insanitary sections 

 of some of the cities of moderate size, such as Charleston, South Carolina, 

 and Nashville, Tennessee. Institutional outbreaks, especially in lunatic 

 asylums and in orphanages, have also received prominent notice in this 

 country. Occasional cases of pellagra are, however, observed in the well- 

 to-do and cultured members of society, as, for example, a physician, a 

 wealthy landed proprietor addicted to alcohol, the sister of a State legis- 

 lator, an actress, a lecture entertainer, a nurse, a sister of charity, a 

 sister of a prominent physician, a wife of a merchant, a son of a wealthy 



