Voegtlin and Harries (19) have reported a number of cases of pellagra in infants which were nursed by pellagrous mothers, and cite older literature which shows that in the past a considerable number of cases of pellagra have been observed in infants. The cases observed by Voegtlin and Harries were observed in the light of all the accumulated knowledge of recent years concerning the relation of the disease to faulty diet, and are therefore of special importance in revealing the cause of this condition.

314. Report Of Cases Of Pellagrous Mothers Nursing Babies Who Did Not Develop The Disease

A mother suffering from severe pellagrous lesions was admitted to the hospital while nursing a seven-months-old infant. The child did not show any symptoms of the disease. The mother was placed upon the following diet (Diet A) during her stay of 35 days in the institution. This diet is of a type commonly used by pellagrins.

Diet A

Breakfast

Hominy, 75 grams; butter, 15 grams; corn syrup, 30 grams; wheat bread, 100 grams; coffee, with 20 grams of sugar and 20 c.c. of milk.

Dinner

Potatoes, 150 grams; cabbage, 50 grams; turnip tops, 50 grams; fat pork, 30 grams; wheat bread, 100 grams.

Supper

Corn meal mush, fried in pork fat, 50 grams; lean boiled ham, 25 grams; prunes, 30 grams; wheat bread, 100 grams; coffee, with 20 grams of sugar and 20 c.c. of milk.

Samples of milk were secured from this patient, and from four others who were restricted to the same diet. These were analysed by the most approved chemical methods for all constituents which can be determined by such methods. The lactose, fat, total nitrogen and total solids were found to fall within normal limits, but were below the average in amounts. The total ash and phosphorus content were normal, but the sodium and chlorin content were above the normal, whereas the calcium, magnesium and potassium were present in amounts below the normal. No tests were applied to show the vitamin content of any of these milks. Their total volume was found to be greatly diminished in many cases.

None of the infants of five mothers suffering from somewhat severe symptoms of pellagra, showed any signs of the disease. It is very difficult to in any way correlate the occurrence of pellagra in infants with the character of the milk of mothers who nurse them, for it would seem that if any relation existed between the character of the diet of a mother and the causation of her attack, the infants suckled by them should, especially when the symptoms are severe, more frequently develop pellagra. On the contrary, pellagra in infants which are nursed by mothers suffering from the disease is by no means common. Such mothers usually feed their infants on the same food which they themselves eat, when the breast milk is too scanty to suffice for the children. This replacement of a considerable amount of mother's milk by food which leads to pellagra in the adult should, theoretically, go far toward causing the disease in an infant, yet this result is seldom observed. No one has been able to demonstrate the presence of anything toxic in the milk or blood of pellagrins, so the theory that the disease may be an intoxication has no support.

There can be no reasonable doubt that the milk produced by pellagrous women, is in general deficient in all three of the vitamins which are known to produce specific syndromes, and the occasional occurrence of pellagra in infants where the mothers are suffering from this disease, could, on first thought, seem best accounted for on the assumption that it is caused by lack of a specific vitamin. This view receives support from the experimental work of Voegtlin reported above, in which pellagrins were reported to have been greatly improved by "vitamin preparations" made from liver or thymus. It would seem logical that the mother might, even when she were so severely starving for a hypothetical anti-pellagra vitamin, as to cause in her a severe form of the disease, still continue to transfer to her milk such small amounts of the substance in question as might be furnished in her food, or be available from her own tissues. This idea is not supported by analogy with the character of the milk produced by lactating females whose diets are lacking in one or another of the factors, A, B or C, since these are not in the milk unless supplied by the diet of the lactating mother.

The last suggested hypothesis, that when the mother has pellagra but her nursing infant does not, protection is afforded the latter through sacrifice on the part of the mother for the teleologi-cal purpose of preserving her offspring, receives a severe blow by the observation of Voegtlin and Harries. They observed an infant about one year of age, to develop severe symptoms which unmistakably indicated pellagra, although her mother, nursed her throughout this time, and showed no evidence of the disease. She was, however, obviously undernourished and suffered from chronic indigestion. No other member of the family consisting of parents and four children besides the patient, showed any signs of pellagra. This observation would seem to entirely negate the theory that the disease can be explained as being due to lack of a specific vitamin in the mother's milk, for she did not have the disease. This particular case would seem to support the view that pellagra is due to an infection with which this child came into contact.