PELLAGRA 905 



round ulcers persisting for some time, often seen at autopsy late in an 

 attack. Later these heal and the only .persistent sign in the intestine at 

 autopsy may then be the rather diffuse atrophy of the wall. The lesions 

 of the digestive tract are least well understood. Some authors (Roussel) 

 regard them as entirely trophic and dependent upon antecedent changes 

 in the nerves. Others regard them as an expression of direct toxic action 

 on the intestinal wall by the essential poison of pellagra during its ab- 

 sorption. Doubtless the normal intestinal microorganisms also play a 

 part, particularly after ulceration has occurred. 



Pathological Chemistry. Myers and Fine(a) found the gastric juice 

 of pellagrins often deficient in hydrochloric acid and not infrequently in 

 pepsin also. As a rule, the feces contain a marked excess of indol and 

 skatol. The urine, during the attack, commonly shows a trace of albumin 

 and a few tube casts and an excess of indican. The amount of indican 

 is manifestly related to the intestinal derangement. In some instances it 

 is present in enormous quantity. Metabolism studies on pellagrins have 

 shown that these patients possess normal ability to utilize the food prin- 

 ciples. In fact, in uncomplicated pellagra, the utilization is surprisingly 

 high, when one considers the other evidence of gastro-intestinal de- 

 rangement. 



There is a fairly voluminous literature dealing with chemical analysis 

 of maiza and of other food substances, in some instances coupled with the 

 production of disease in animals or in man by the administration of such 

 foods. The extensive and authoritative work of McCollum and the 

 highly dramatic report of Enright, coupled with the absence of pellagra 

 among the poorly nourished peoples during the recent war, have robbed 

 much of this work of its former interest. 



It is clear, however, that milk and milk products favor recovery 

 from pellagra and possess some pellagra-preventing power. Whether this 

 value resides in the fat, in the protein or in the lactose and derived lactic 

 acid, or in less definite accessory food factors would appear worthy of 

 investigation, but, inasmuch as the results of any treatment are liable to 

 considerable variation, a considerable series of cases critically tested would 

 be required to shed light upon this question. The beginner is liable to 

 ascribe too much importance to the favorable outcome of the attack of 

 pellagra, when treated by a dietary method, because he is, as a rule, 

 ignorant of the natural tendency for such attacks to terminate in recovery. 



Bacteriology. The work of Tizzoni and his associates, who have 

 isolated from the blood an organism, which they regard as the cause of 

 pellagra, may probably be dismissed as unreliable. The intestinal flora is 

 profoundly altered in pellagra. There is often a large increase in the 

 variety of organisms present in the feces as compared with the norari&l 

 as well as a disturbance in the numerical relationships of the normal (types. 

 Further investigations in this field are much to be desired. ^o ns-ib 



