1708 



PELLAGRA 



which we have met with was that of a young boy who was sup- 

 posed never to have left a large town, and yet was suffering from 

 pellagra. Careful inquiry elicited the fact that he was in the habit 

 of going for a day or so every year to stay with some relatives 

 who lived in a pellagrous area, and the time of the year chosen for 

 this visit was one in which acute cases occurred. In a locality 

 pellagra usually occurs among the poor, especially among field 

 labourers; but it may also occur among the rich and among 

 persons who habitually work indoors; it is, however, usually not 

 difficult to trace a relationship between the commencement of the 

 disease and a visit or residence in some pellagrous area, and very 

 often, again, a relationship to water. 



With regard to seasons, there is a universal consensus of opinion 

 that most attacks appear in the spring or early summer (in Egypt 

 with the Khamseen) , after which there is a diminution in the cases, 

 and although attacks may begin in the summer, they are not 

 common. In the autumn, hov/ever, there is a definite, though 

 secondary increase in the number of cases, which decrease almost 

 to nil in the winter. These statements are well borne out by the 

 curve of pellagra admissions into the Kasr-el-Ainy Hospital, 

 Cairo, for the years 1906-1911 inclusive. This curve, for which we 

 are indebted to the kindness of Dr. Keatinge, was most carefully 

 prepared by Dr. Stiven, and demonstrates the incidence of pellagra 

 as seen in that hospital. 



Pellagra may occur in hilly or even mountainous regions, where 

 it is often very common — as, for example, the Tyjrol- — but can 

 equally occur on the flat alluvial deposit of rivers— as, for example, 

 the delta of the Nile. It w^ould appear that pellagra extends from 

 near the Equator to the Shetland Islands in the north, and to South 

 Africa in the south, and that it encircles the world in an easterly 

 or westerly direction. In our experience the one important factor 

 to be certain that pellagra is endemic in a region is to find it in 

 very young children born in the region from which they have never 

 stirred. 



To summarize, pellagra has a world-wide distribution. It 

 occurs in hills and plains. The cases are densest near moving 

 freshwater, and usually begin in spring or autumn. 



Etiology.— The causation of pellagra is at the present time 

 unknown, so that we are compelled to consider possibilities 

 instead of facts- — a point which we desire the reader to bear in mind 

 while perusing the remarks we are about to offer for his con- 

 sideration. 



The extraordinary theories which we have found still in existence among 

 medical men in the various pellagrous regions which we have visited are: — 



1 . That it is not a disease, but merely dirt, and can be cured by turpentine, 

 soap, and water. This theory of course applies only to the quiescent stage 

 of a very chronic case, and is easily excluded by a little knowledge of the 

 disease. 



2. That it is not a disease per se, but merely a series of stray symptoms, 

 and that no one has studied the cases from the commencement of the disease 



