(a) Arteriosclerotic dementia; (b) Senile dementia; (c) Presenile psychoses; (d) General paralysis of the insane.
He found mental disturbances of some kind in about forty per cent of the cases examined. As a general rule they appeared after the patient had shown evidence of several attacks of the disease. The psychoses occurred in men between the ages of twenty-one and forty and in women between forty-one and sixty. About ninety-five per cent of the mental disorders were to be attributed directly to the effect of the toxin. The remaining five per cent represented individuals with a defective nervous organization or were purely incidental complications. Singer found peculiarities in make-up associated frequently with a predisposition to pellagra. He also expressed the opinion that chronic forms of "insanity" are very rarely caused by the diseases.
Sandy[260] made a study of 160 cases at the state hospital at Columbia, South Carolina, in 1916 based on a classification of psychoses quite similar to the one now in use. He found that thirty-five per cent of these belonged to the infective exhaustive group. As a matter of fact, this is the conclusion almost anyone would reach from reading the observations of the earlier writers. These cases were usually characterized by "more or less marked delirium, being accompanied by some confusion and disorientation, there frequently being also hallucinations accompanied by more or less agitation and restlessness." Physically he found, besides well marked symptoms of pellagra, evidences of severe exhaustion, loss of weight, emaciation, fever, sordes, anorexia, and typhoid facies. "In the milder forms of these 'delirious pictures,' as Singer calls them in his contribution to the report of the Thompson-McFadden Pellagra Commission, and as he pointed out, the periods of clouding (of consciousness) may be quite brief and episodic. In such cases in the intervals when the consciousness is practically clear, the general attitude is one of symptomatic depression." Sandy found characteristic manic-depressive forms in eleven per cent of the series reviewed. The depressed types were more common. Here he found retardation of speech and action with a dearth of ideas. In these cases he looks upon pellagra as being merely an exciting etiological factor. The prognosis was not so favorable, however, as it usually is in manic-depressive psychoses, death often being due to the development of central neuritis. In three per cent of the total he found what could only be described as symptomatic depressions, the emotional condition not being so marked as one would expect in the manic-depressive group. In twelve per cent a diagnosis of dementia praecox was made. In these the pellagra was merely an incident and not an etiological factor.
In several patients Sandy found a symptom complex strongly suggestive of general paresis, thus confirming the findings of other observers. These showed speech and writing defects, absent or sluggish pupillary reaction, swaying in the Romberg position, altered deep reflexes, disorientation, memory disorders and other evidences of deterioration. The Wassermann reactions were negative in both the blood and spinal fluid tests and no lymphocytosis was shown on cell counts. These cases he thinks belong in the infective exhaustive group, and usually die of central neuritis, a condition already referred to and described originally by Turner and Meyer. Sandy also found pellagra associated with various senile psychoses. This group constituted ten per cent of those studied. Fourteen per cent of the series he left unclassified owing to lack of history, etc. Some of these showed simple deterioration, others suggested neurasthenia, and some, general paresis. Of the remaining cases three were epileptic imbeciles, three, constitutional inferiority with episodes of some kind, and three were not insane. Cases associated with chorea and hysteria were also observed. On analyzing these most important findings the assumption would seem to be warranted that pellagra is an incident in certain psychoses—(senility and dementia praecox), that it is a precipitating factor in certain cases (manic-depressive), and that the characteristic conditions due to the disease are toxic and assume the infective-exhaustive form, occasionally simulating general paresis.
The policy of the Association's committee on statistics in the differentiation of these conditions is shown by the following quotation on this subject from the last edition of the manual:—
"The relation which various mental disturbances bear to the disease pellagra is not yet settled. Cases of pellagra occurring during the course of a well established mental disease such as dementia praecox, manic-depressive insanity, senile dementia, etc., should not be included in this group. The mental disturbances which are apparently most intimately connected with pellagra are certain delirious or confused states (toxic-organ-like reactions) arising during the course of a severe pellagra. These are the cases which for the present should be placed in the group of psychoses with pellagra."
A study of recent statistics would tend to show that pellagra is not at this time a factor of importance in our institutions. In Massachusetts in 1919 the admission rate for this disease was .33 per cent. In New York state hospitals during a period of eight years it was only .03 per cent. In twenty-one hospitals in fourteen other states it amounted to only 1.28 per cent. This includes a number of institutions in the south. There were 263 cases (.37 per cent) in 70,987 first admissions to forty-eight hospitals in sixteen different states. The admissions reported from the southern institutions indicate that pellagrous psychoses are comparatively infrequent as a rule. During the year 1918 pellagra constituted 10.7 per cent of the admissions to the Columbia State Hospital. During the biennial period of 1917 and 1918 the admission rate at the Arkansas State Hospital for Nervous Diseases was 8.31 per cent. None were admitted to the Spring Grove State Hospital at Catonsville, Maryland. In 1919 the admission rate at the Western State Hospital at Staunton, Virginia, was 1.14 per cent, at the Central State Hospital, Petersburg, Virginia, 1.39 per cent, and at the Georgia State Sanitarium at Milledgeville, 2.49 per cent. One and sixty-one hundredths per cent of the admissions to the Louisiana State Hospital during 1920 were diagnosed as psychoses due to pellagra. Very few cases are reported in the northern institutions.