The food deficiency theory receives further support from the beneficial results of a rich and varied diet in the treatment of the disease. Even those authorities who disagree with this theory as to the origin of the disease concur in advocating an improved dietary as a means of combating its development. Siler 42 states that his advice is always to build up the nutrition particularly by the use of milk and eggs, and that in a large majority of cases, though not all, the results are good.

Goldberger 43 asserts that" For the cure of pellagra the only medicine we have is the diet." For both prevention and treatment, the diet should be well balanced, including a sufficient amount of milk or lean meat (fowl, fish, pork, beef, etc.) and an abundance of green vegetables (cabbage, collards, turnip greens, spinach, string beans, snap beans) and fruits (apples, peaches, prunes, apricots). At least 1.5 pints of sweet milk or buttermilk should be taken daily. If but little milk be taken, 0.5 pound of lean meat should be eaten at least three or four times a week. Eggs or cheese may partly replace, or better still, be eaten in addition to the meat. Dried soy bean is highly recommended as a substitute for meat. It may be eaten either boiled or baked. A portion of the flour or corn meal used in biscuit or corn bread may be replaced by soy bean meal.43a.

Ridlon 44 used the following diet in the treatment of pellagra:

Patients received one quart of fresh milk a day, two eggs, poached or soft boiled, a day; wheat bread three times a day, butter, one-half ounce, three times a day; coffee once a day if desired; fresh, lean meat three times a day, either beef, mutton, chicken, veal, or pork; oatmeal or wheat once a day; dried beans or peas either baked or boiled or made into a soup, once a day; one other vegetable, either fresh legumes, turnips, carrots, onions, potatoes, or cabbage, once a day; stewed fruit three times a week; and rice once a week. In addition the patients were allowed fruit juices or fresh fruit, as apples, oranges, or peaches, in season.

41 Chick and Hume, Bioch. J. 14, 135, 1020.

42 Siler, Proc. 2nd Pan. Am. Sci. Cong. Sect. 8, Pt. 2, p. 12. 43 Goldberger, Pub. Health Repts. 33, 481, 1018.

43a Symptoms resembling pellagra in the human being have been produced on a diet lacking in antaneuritic principles and consisting of protein 40 g., carbohydrates 402 g., fat 109 g., ash 30 g., per day. The calorific value therefore would be about 3070 calories. (Sullivan and Jones, Hyg. Lab. Bull, 120, 117, 1920. See also Sullivan, lb. p. 127).

44 Ridlon, Pub. Health Repts. 31, 1979, 1916.

This diet includes a large proportion of the animal and vegetable proteins and there is also a diminution in the proportion of sugars and starches.

No sirup, corn products, or fat white meat (salt fat pork), and no canned vegetables were allowed, not because these articles in themselves are unwholesome, but because experience has shown that, alone or in combinations, they have commonly formed a conspicuously large portion of the prepellagrous diet.

Two groups were compared, those receiving only the dietetic treatment outlined, and those receiving medication as well. Ridlon states that the thirteen patients receiving no medication were comparable as to severity and in all other respects to the eighteen patients who received various drugs in addition to the dietetic treatment. The lat-ter group made more rapid or marked improvement than the former. The average duration of stay under treatment of the fifteen patients receiving medication who improved was 86.8 days, and the average gain in weight 11.7 pounds. The shortest period under treatment was 26 days, and the longest 189 days. The average duration of stay under treatment in the thirteen patients receiving only dietetic treatment was 83.6 days, and the average gain in weight was 18.3 pounds. The shortest period under treatment was 29 days, and the longest 191 days. Patients showing predominating symptoms of the skin and alimentary tract as a rule show a ready response to treatment, and improvement is noted within a week to ten days.

On the other hand, those who have suffered from repeated attacks and have sustained a serious danger to the nervous system require a longer period for the repair of this damage.

Ridlon concludes that in pellagra the dietetic treatment is of paramount importance, the successful diet being one in which the animal and leguminous protein component has been relatively increased and the non-leguminous vegetable component relatively decreased.

Roberts 45 recommends feeding on at least 2,000 calories per day and as much more as can be given with safety, with special emphasis on lean meats, eggs, milk, butter, and vegetables containing proteins.

45 Roberts, J. Am. Med. Ass. 75, 21, 1920.

Experience in other countries runs parallel with that of American physicians. Bravetta46 asserts that good food represents the best remedy to assuage, to cure and perhaps to cause the complete disappearance of pellagra.47

If we allow that there is strong presumptive evidence for the view that pellagra is caused by deficiency in the diet we are at once confronted with the problem of determining the nature of the deficiency.

Funk 48 classed pellagra along with scurvy as due to lack of vitamins, and later observers have for the most part held this as at least a possible contributary factor.49 Voegtlin, Neill and Hunter50 have conducted an interesting study on the effect of adding vitamin preparations to the ordinary diet of pellagrins in amounts based on the body weight of the patients and calculated from the doses necessary to cure severe polyneuritis in fowls. The vitamin preparations used were of two different types, those from animal sources (liver and thymus gland) and those from vegetable sources (Funk's vitamin fraction from yeast and rice polishings). The liver and thymus extracts were tested and found to possess antineuritic properties, though they were less effective in this respect than the yeast or rice preparations. The liver extract, at least, and possibly the thymus extract as well, must have contained vitamin A as well as B.51 Although the results are not entirely conclusive they appear to indicate that the administration to cases of pellagra of these preparations made from yeast and rice polishings over a considerable period of time and in large amounts (based on the curative dose for fowls) in general failed to modify the course of the disease.

46 Bravetta, Riv. pellagrolog. ital. 15, 43, 1915. Tropical die. Bull. 7, 59, 1916.

47 See also Rondoni, 8perimentale, 69, 723, 1915. Trop. Dis. Bull. 7, 63, 1916.

48 Funk, Munch. Med. Wochenschr. 61, 698, 1914.

49 Goldberger, Wheeler, and Sydenstricker, Pub. Health Repte. 35, 648, 1920; Chittenden and Underhill, Am. J. Physiol. 44, 13, 1917; Voegtlin and Harrie, Hyg. Lab. Bull. 116, 84, 1920; Vedder, 3rd Rep. Thompson Pell. Com. 338-372; Voegtlin, Sullivan and Myers, Publ. Health Repts. 31, 935, 1916; Wood, 8ci. Am. Supp. 82, 43, 1916.

50 Voegtlin, Neill and Hunter, Hyg. Lab. Bull. 116, 1920.

51 Osborne and Mendel, J. Biol. Ghem. 34, 17, 1918.