Roberts[249] in 1920 made a study of twenty-five cases of pellagra encountered in private practice. In every instance the disease developed in families provided with an abundance of food of all kinds. An analysis of the actual consumption, however, showed that "not one of the patients ate a well rounded, balanced diet of meat, milk, eggs or wholesome vegetables." Either they were suffering from a lack of nourishment in every case or they were eating practically the same diet that Goldberger used experimentally in producing pellagra.
As defined by Barker[250] pellagra "is a disease characterized by peculiar cutaneous, digestive, nervous and mental disturbances, usually running a chronic course, with periodic exacerbation, but sometimes developing acutely and proceeding quickly to a fatal termination." He speaks of the disease as developing during the winter months usually with neurasthenic manifestations—fatigability, insomnia, slight vertigo, and feelings of apprehension, followed by digestive disturbances later in the spring. The parts of the skin surface exposed to the sun develop an erythema followed by a dermatitis. Nervous and mental symptoms may appear later. In some cases the disease tends to recur every spring. The skin lesions have been described as a characteristic "mask" shown on the face, the pellagrous collar, a bandlike eruption on the neck, Casal's "necklace" extending downwards over the sternum, the pellagrous "butterfly," "gauntlets," etc. The more common digestive disorders are stomatitis and glossitis, gastric disturbances and diarrhea. Neurological symptoms observed include hyperesthesia, paresthesia, anesthesia, tremors, paralyses, muscular pains, increased reflexes and occasional convulsions.
The literature of pellagra and its associated mental disturbances has been elaborately reviewed by Babcock.[251] The following references appear in a comprehensive study of this subject made by him in 1910. Griesinger[252] described the pellagrous psychoses as characterized by a vague, incoherent delirium, accompanied by loquacity and loss of memory without any violent excitement or special disorder of the intelligence. The depression gradually develops into a torpor of all the mental powers together with muscular weakness, a condition resembling general paresis. Mongeri[253] states that the psychoses usually begin with a period of depression accompanied by hypochondriacal ideas. This is followed by confusion and hallucinations of hearing. Delusions of persecution appear, with a marked tendency to suicide by drowning. Crimes of various kinds may be caused by the paranoid condition which usually terminates in deterioration. In speaking of chronic and acute forms Bianchi[254] says: "The former is characterized by general depression, melancholia, confusion, slow dementia, paresthesias and ataxic gait. Contractures and subsulti are absent, although in most instances the reflexes are exaggerated. In the acute form we have rapid elevation of temperature, 39° to 41° C.; intense neuro-muscular excitement, subsulti, contractures, muscular rigidity, exaggerated reflexes and confusion with phases of exaltation. There are numerous intermediate forms in which we observe a great variety of psychical phenomena, and also alternations of excitement and depression. Phases of remission and of apparent recovery are observed, especially at certain seasons." Régis[255] is quoted as follows: "It is recognized that the most common form of psychosis in pellagra is mental confusion with melancholy or dreamy delirium. This occurs more or less markedly in most of the cases. It is manifested by inertia, a passivity, an indifference, a considerable torpor; by insomnia, hallucinations often terrifying, both of sight and hearing; by delirious conceptions with fixed ideas of hopelessness, of damnation, of fear, anxiety, persecution, poisoning; of possession by devils and witches, of refusal of food, and so marked a tendency to suicide, and to suicide by drowning, that Strombio gave it the name hydromania. This melancholy depression, which can reach, in certain cases, even to stupor, is always based upon a foundation of obtusion, of intellectual hebetude, and of considerable general debility, which becomes permanent and terminates by degrees in dementia, in proportion as the pellagrous cachexia makes new progress. It is accompanied sometimes by a polyneuritis. The mental confusion of pellagrins can, in place of changing directly into dementia, turn to a chronic mental confusion. One may observe in pellagra, as in every grave intoxication, a morbid state resembling general paresis (pellagrous pseudo-general paresis). This occurs especially in the cases where instead of habitual melancholy ideas, the patients present ideas of satisfaction and of wealth." Procopiu[256] found his patients "sad, apathetic, silent; in the more advanced stage they are melancholy, and fall sometimes into an absolute mutism, or respond with difficulty, and have the air of not understanding what is said to them. Sometimes this melancholy is accompanied with stupor, and leads the poor pellagrins into dementia." He also speaks of the occurrence of sudden outbursts of manic excitement. Tanzi[257] refers to the existence of both pellagrous mania and melancholia but speaks of a characteristic amentia "which manifests itself acutely in loss of time and place, loss of memory, confusion, hallucinations, and paresthesias, from which there arise morbid impulses and delusions. Pellagrous amentia, often assumes a depressive form, which simulates melancholia, and in some cases either from time to time, or throughout the whole course of the psychosis, it is accompanied by exaltation, which gives it some resemblance to mania."
Gregor[258] in 1907 made a careful analysis of seventy-two cases. He classified these in seven groups: 1. Neurasthenia; 2. Acute stuporous dementia; 3. Amentia (acute confusional insanity); 4. Acute delirium; 5. Katatonia; 6. Anxiety psychoses; and 7. Manic-depressive insanity. The neurasthenic cases (9.72 per cent) exhibited headache, pain in the gastric region, vertigo, paresthesia and lassitude, with a sense of unrest and anxiety as well as ill-defined apprehensions. There was a sense of mental incapacity and feeling of illness, together with a mild depression and hypochondriacal tendencies. The cases diagnosed as acute dementia (13.88 per cent) were of the same general type but with more advanced symptoms. These showed a decided stupor, tending to remission, deep mental depression, a sense of insufficiency and "peculiar subjective troubles." The tendency to suicide was prominent and caused this group to be called melancholia by some. Many cases showed the gradual development of an affectless stupor. Catatonic symptoms and stereotypies occasionally occurred. Memory disturbances were well marked in this form. The psychoses disappeared invariably with the symptoms of the pellagra. The Amentia group (44.44 per cent) included long-continued cases with remission and intermissions. Terrifying hallucinations and violent motor excitement appeared frequently, followed by a stupor which was sometimes interrupted by delirium. Hallucinations were usually present and some had dream states. These cases often terminate unfavorably. Acute delirium constituted 2.7 per cent of the seventy-two cases, and katatonia occurred in 13.8 per cent. These cases passed rapidly into dementia. Anxiety psychoses (4.16 per cent) were diagnosed in a few instances, but were complicated by occasional stupors. Two and seven-tenths per cent of the cases were classified as manic-depressive insanity. Mobley, according to Babcock, found the following types represented at the Georgia State Sanitarium:—1. Acute intoxication psychosis, with psychomotor suspension; 2. Infective exhaustive psychosis, with psychomotor retardation or excitation; 3. Symptomatic melancholia with psychomotor retardation; and 4. Manic-depressive psychoses.
Singer[259] in 1915 suggested the following classification of the psychoses associated with pellagra:—
1. Disorders directly due to the pellagra toxin:
(a) Symptomatic depression; (b) Delirious pictures.
2. Disorders based on peculiarities in personal make-up, the attack of "insanity" being precipitated by pellagra;
(a) Manic-depressive disorders; (b) Hysteria; (c) Psychasthenia; (d) Dementia praecox; (e) Paranoic developments; and
3. Disorders due to definite brain changes with pellagra merely as a complication: