PELLAGRA 355 



reflexes. C) Sooner or later in the third period, there is cachexia 

 and mental weakness, with hemiplegia or paraplegia, and finally 

 with serous diarrhea, petechiae, muscle atrophy and incontinence. 

 Normal temperature prevails, as a rule; only exceptionally is terminal 

 fever observed in the last days of the disease. In addition to these 

 four types, there are light abortive forms, which we shall describe 

 in the consideration of expermental pellagra in man. 



SYMPTOMATOLOGY AND PATHOLOGY OF PELLAGRA 



L G astro-intestinal tract 



The pellagrous tongue is of diagnostic importance: in the early 

 stage, coated; later, deep red, fissured in the middle and around 

 the edge, often painful. The gums, spongy, red, easily bleeding as 

 in scurvy; sometimes there is alveolar pyorrhea. Swelling and red- 

 dening of the mouth and pharynx muscosa with aphthae or small 

 vesiculae, pyrosis, gastralgia, nausea and vomiting occur. In an 

 investigation of the stomach of 20 cases, Johnson (1309) found a 

 lack of hydrochloric acid in 16. This finding was confirmed by 

 Givens (1310), who noted, however, cases in which hydrochloric 

 acid and pepsin were present, especially in children. Pellagrous 

 diarrhea is of importance; in a spring attack it may happen that 

 there will be from 10 to 20 evacuations daily, often slimy and bloody. 

 In the final stages, the evacuations occur still more frequently, serous 

 and colorless; indicanuria is often noted. All the symptoms along 

 the gastro-intestinal tract appear to be of central nervous origin. 

 Siler (1311) preferred not to regard as pellagra those cases without 

 gastro-intestinal disturbances, though it seems to us that such a 

 differentiation would be only artificial. 



In acute cases, in the stomach, swelling and reddening with erosions, 

 especially at the pylorus were found. In chronic cases, the mucous 

 membrane of the stomach was pale, covered with mucous, and the 

 muscles were atrophic. In the intestine, in acute cases, there was 

 enteritis with ulcerations in the small and large intestine, less 

 frequently in the duodenum; in chronic cases, according to Lynch 

 (1312), the mucosa was pale, covered with mucus, and atrophic; 

 the musculosa was thinned. The liver was tough, atrophic, and 

 occasionally showed fatty degeneration. 



