[518 ] ENDEMIC PELLAGRA IN NORTHERN PORTUGAL BY A. MOURA MONTEIRO, HERCULANO COUTINHO, G. J. JANZ AND J. A. DE LOUREIRO Faculty of Medicine and Gentro de Saude de Lisboa, Lisbon, Portugal In Portugal endemic pellagra has been known for Breakfast, at sunrise: bread, sometimes milk or many years. Since 1896 about twenty-five papers salt cod. Dinner, at noon: soup, bread, sometimes have dealt with the subject, the most valuable being potatoes or rice. Afternoon meal, at 6 p.m.: bread, those of Pereira da Silva (1905) and Manuel Fer- onion or fruit. Supper, at sunset: soup, bread. reira (1927). No country-wide statistics of the Black tongue in dogs could not be investigated prevalence are available, but all authors agree that because the pellagrins are too poor to possess dogs. pellagra is widespread in all the maize-growing districts of Portugal. The purpose of the present work was to study the disease, using some of the MATERIAL AND METHODS recent methods for the appraisal of nutritional Population. From 15 June to 15 July 1942, we status. observed about 100 pellagrins from a few villages The county of Celorico de Basto (Minho), where with a population totalling about 3000. Of them, pellagra is frequent, was selected for the study, twenty-two women and eight men, all with skin which was made in the summer of 1942. It included symptoms, were selected for the clinical and thera- a clinical record of a group of patients, with special peutic study, but only eighteen; with their families, emphasis on possible symptoms of dietary deficiency, were included in the dietary survey. Owing to lack a series of laboratory tests, a dietary survey and a of time and shortage of nicotinamide we could not therapeutic test with nicotinamide. The examina- extend these examinations to possible cases of tions were carried out as thoroughly as the primitive deficiency without erythema. The ages of the thirty conditions of our field work permitted. persons included in the clinical and therapeutic The patients all belonged to the rural class and study varied from 11 to 67 years. Four were below the majority worked in the fields. In their food 20, four between 20 and 30, six between 30 and 40, habits, their primitive housing conditions and their six between 40 and 50, six between 50 and 60 and clothing and sanitation, these patients and their the remaining four 60 or over. Most of them worked families formed a very homogeneous social group. on the land, but there were a few in other trades. The predominantly vegetarian diet of this section There was, for example, one maidservant, one of the country is characterized by its simplicity and blacksmith, one embroideress and one beggar. In monotony. The bulk of the food is furnished by a five instances the disease had lasted over 10 years short list of articles, mainly white maize, dried and in one case 48 years. The remainder had had beans, olive oil and cabbage greens. Maize is by far signs or symptoms for less than 10 years, but only the most important food. Each week the quantity one for a single year. required is sent to the local water-mill, the grindi? Of the members of the eighteen families included stones of which are of granite. A sort of whole grai*1 the dietary survey twenty were adult males flour is obtained, which is made into a brear1 ^seven pellagrous), twenty-one adult females (seven- broa, different from the Italian 'polenta' ' jm teen pellagrous), seven children between 15 and 19 the bread rolls of the southern U.S.A. aize (five pellagrcjus), twelve children aged 10-14 (two proteins have few of the glutinous qualities so pellagrous), seventeen children aged 5-9 (two pella- desirable in bread making, a more palatable loaf is grous), and nine were younger children, all ap- obtained by adding about 10 % of rye to the maize parently normal. flour. Cabbage greens are the most popular vege- table among the poor in Portugal. The leaves, which Clinical investigation are similar to those of kale, are consumed as soup. As a rule each patient was seen three times at Soup is also the vehicle for the beans, the olive oil 5-day intervals. In the first interview a detailed and much of the bread. questionnaire about history and objective symp- The meals, usually four, conform with slight toms was answered. The diet was also inquired into variation to the following composition and schedule: and samples of blood and urine were collected. A Downloaded from https://www.cambridge.org/core. IP address: 170.106.33.22, on 25 Sep 2021 at 06:42:51, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0022172400019331 A. MOTJRA MONTEIBO AND OTHERS 519 supply of nicotinamide sufficient for 5 days was Foundation. In a few instances we judged it neces- then distributed. 0-10 g. of nicotinamide was given sary to analyse the local products. five times a day by mouth to nearly all patients. Three suffering from diarrhoea received 0-10 g. sub- RESULTS cutaneously daily. Co-operation was almost perfect. In the second interview the early effects of treat- Clinical examinations ment were investigated and the rest of the nicotin- History. With one exception the disease had lasted amide distributed. In the third all previously col- for 2 or more years. Each year the symptoms had lected data, particularly those about the diet, were tended to become more conspicuous and more checked, and each patient was once again thoroughly numerous. The first attacks as a rule had been mild examined. and short and confined to the hot season. Later the attacks had lasted longer and relapses had occurred. Biochemical study In the most chronic cases the patients were never Blood collected by vein puncture was divided in entirely free of symptoms, even in the winter two portions. One was allowed to clot, the other months. mixed with Heller & Paul's (1934) potassium- The disease had not prevented the women be- ammonium oxalate mixture. The erythrocyte pic- coming pregnant, but the age of minarche varied ture was worked out according to Wintrobe (1933). from 13 to 20 with a mean of 15-8 years, which is The other estimations were performed by the higher than the average of 14 years for normal girls colorimetric methods described by the following in Oporto (Paulo, 1936). Many women referred to authors: serum proteins (Robinson, 1940); calcium periods of amenorrhoea lasting from 2 to 10 months. (Loureiro & Janz, 1944); phosphorus (Fiske & General symptoms. Asthenia was the outstanding Subarow, 1925); carotene and vitamin A (Clausen subjective complaint, and the chief concern of the & McCoord, 1938). Urine was collected and pre- patients, on account of the relative incapacity pro- served with sulphuric acid for the estimation of duced by it. The sense of weakness had been very nicotinic acid (Melnick & Field, 1940) and porphy- variable, but in four cases it had made the sufferers rins (Beek, Ellinger & Spires, quoted by Spies, into total invalids. The onset of symptoms had been 1938). Evelyn's photoelectric colorimeter was used accompanied by loss of weight in about half the in all estimations. cases. Cutaneous symptoms and signs. All the patients Dietary survey had lesions of the skin; the hands were invariably The particular conditions under which we worked, affected and generally the feet and legs. The faces amidst an illiterate population, and without the and necks had usually escaped, only eight out of help of a nurse or dietician, led us to deviate from the thirty being affected. Most patients complained the standard types of dietary inquiry. The consump- of aching in the affected regions, less often of itching tion of non-perishable staple foods was obtained by or of a feeling of heat, burning or swelling worsened studying the family records over a period of months by exposure to sun or heat. The lesions consisted or years; the consumption of fresh foods, such as typically of erythema, excessive pigmentation and milk and cabbage, was assessed by direct measure- desquamation. Fissuring of the skin was rare and ment during the week. Working on such data the limited to the dorsum of the feet; vesiculation and daily family consumption was calculated, disre- oedema were exceptional. Only one case, which garding table or kitchen residues which are practi- had lasted for 48 years, presented the characteristic cally non-existent. Since almost the whole of the signs of true skin atrophy. At the time of observa- family income went into food, the people had a tion, most of the lesions were in the regressive stage. keen sense of the quantities eaten, at least of those MflDesquamation was usually scaly, less often larger of the staple foods with a cash value. Thid prev_>; "• pieces of skin were flaking off. All the lesions were any gross errors in our estimates. 'l~""T'!ed to the exposed parts and followed the usual t"'- r"r%tion of sun-tan. In contrast with the clas- The individual consumptions were computed T using Bigwood's (1939) coefficient for calories, sil "Ascriptions, however, we often found a transi- calcium and phosphorus and a per -capita distribu- tional zone between normal and affected skin. tion for iron and vitamins. These seemed the best Tongue lesions. Five cases were noted to have a methods, since the children were accorded ho moderate subacute glossitis, with redness and swel- dietary priorities. ling of the papillae, but the typical finding was an The following tables of the composition -'foods atrophic glossitis, present in twenty-one patients, were utilized: Chatfield & Adams (1942), Sherman usually limited to the tip and edges of the tongue (1939), Atwater & Bryant (1906), McVicar & Berry- and often associated with fissuring.