496 WILLETS. 



pellagra before the skin lesions appear, and certainly it would be well if 

 diagnosis could be rendered thus early in all cases. However, as stated 

 before, the division of pellagra sine pellagra affords an opportunity for 

 incorrect conclusions to be drawn. Recently, I have read the reports of 

 two or three cases of pellagra which, in my opinion, were not pellagra 

 at all. Provisional diagnosis could be rendered in such instances and 

 time would indicate the positive diagnosis. 



The prognosis is guarded, even though the patient may recover from 

 one attack. The most hopeful cases are those of the chronic type with- 

 out mental involvement; the least so, those of the acute or fulminating 

 variety with pronounced mental impairment. Searcy says that the 

 majority of acute cases die within from ten days to six weeks after the 

 onset. The chronic ones recur in increasing severity year after year 

 and the patient finally dies of exhaustion, or of an ' intercurrent disease. 

 Some affections are said to have continued for twenty-five years. 



Fever, marked mental symptoms, and a typhoid state are looked upon 

 with gravity, as also is any complication. 



Lombrosso, in 1884, found that 13 per cent of a large number of cases died. 

 (Luvinder.) The death rate in Italy in 1905 was 4 per cent. (26) Of the cases 

 at the Peoria State Hospital, Illinois, 22 per cent died, 10 per cent were not 

 expected to recover, 17 per cent improved, and 51 per cent apparently had re- 

 covered, when reported. (Siler. ) (18) 



Italy especially has instituted prophylactic measures against pellagra, all her 

 efforts being directed against the use of spoiled maize as food. The Italian 

 law of 1902 regarding the prevention and cure of pellagra provides for a census 

 of the disease and a report of all new cases; artificial dessicating plants and 

 public storehouses for maize; exchanges where, under certain conditions, good 

 maize is given for spoiled; the exclusion from entrance into the country of 

 spoiled grain and the inspection of home-grown maize when brought to the mill; 

 the education of the public, including the school children, by means of lectures 

 and pamphlets as to the causation and prevention of pellagra; and farmers' 

 institutes to teach the peasantry better methods or agriculture. Apparently, 

 the measures have been very successful, as indicated by the fact that in 1906, 

 1907, and 1908 the new eases reported were, respectively, 6,783, 5,307, and 2,766. 

 ( Wollenberg. ) (26) However, it is pointed out that this decrease in the number of 

 new cases is coincident with an improvement in general conditions in Italy; that 

 emigration has reflexly widened the view of the peasant class so that they demand 

 and get better food and living conditions; that wages are higher and that the 

 consumption of meat is increasing. (Lavinder.) (9) 



The law of 1902 provides, as curative measures, for the establishment of rural 

 bakeries from which well-made, wheaten bread is distributed to those ill of 

 pellagra, and also hospitals (pellagrossari) for the treatment of the more 

 pronounced cases of the disease. There are now 22 such hospitals in Italy. 

 (Thayer.) (20) The patients are given a liberal diet and are treated symptomati- 

 cally, slight importance being placed on any one drug; and these efforts appear to 

 be successful, since in 1906 and 1907 the death rate from pellagra in Italy fell to 

 about one-fifth of the former death rate. (Wollenberg.) (26) 



Austria, in 1905, provided for its pellagrins by establishing community bakeries 

 where bread from fresh flour was distributed, each patient receiving daily a loaf 



