492 WILLETS. 



gums and the buccal mucosa are the seat of a dirty, grayish deposit and perhaps 

 of ulceration, the mucosa of the stomach is frequently hypera?mic, especially at 

 the pyloric end, and slight areas of hyperemia are found in various locations in 

 the large and small intestine. Ulcerations also may occur and in various situa- 

 tions there usually is found a thinness of the walls of the intestine. When ex- 

 amined microscopically, this is found to be in the muscular tissue. In perform- 

 ing the autopsies, one is impressed with the slight pathologic changes in the 

 digestive tract as compared with the marked symptoms which often precede death. 



Tuczeh M calls attention to abnormal pig-mentation in the ganglionic cells, heart 

 musculature, hepatic cells and spleen. He believes that the hypercemia, anaemia, 

 oedema and, at times, inflammatory affections of the central nervous system and 

 its coverings, together with the obliteration of the central canal of the spinal 

 cord, are not peculiar to pellagra, but are present in many chronic affections of 

 the central nervous system and in senility. Other findings in the brain are 

 negative, except for fatty degeneration or calcification of the intima of small 

 blood vessels and pigmentation in the adventitial coats. However, in the cord, 

 Tuczeh u found fairly constant and important changes, namely, a degeneration in 

 the lateral columns in the dorsal region and in the posterior columns in the 

 cervical and dorsal regions, with very few changes in the lumbar region. Lom- 

 brosso i: confirmed these findings, as did Sandwith,(16) but they believed the 

 lesions of the posterior columns to have originated in the posterior nerve roots. 

 Harris(S) found a combined sclerosis and from the character of the lesions was 

 led to discredit the occurrence of so-called acute pellagra, believing that practically 

 all cases are chronic and die when suffering from an acute exacerbation. 



The skin changes usually consist of congestion, thickening and pigmentation, 

 and atrophic thinness. (Radcliffe-Crocker. ) 13 



The alterations in the blood, other than a secondary anaemia, are inconstant. 

 Relatively large mononuclear increase has been reported. In a few of Walker's (23) 

 cases the haemoglobin varied from 65 to 95 per cent, red cells from 2,500,000 to 

 5,292,000, whereas the white cells showed but slight and inconstant variations. 

 Nucleated red blood cells were found in three out of ten cases and were present 

 early in the disease and when the haemoglobin was either normal or above that 

 figure. 



To sum up, aside from the changes in the skin and those to be expected 

 in a general cachectic condition, practically the only constant pathologic 

 findings are those in the spinal cord. 



The attempt to discover prodromal symptoms has been unsatisfactory 

 for the reason that the great majority of eases in Europe have occurred 

 among the poorer agricultural classes, who are accustomed to pay but 

 little attention to the lesser ills of life, as well as to the fact that most 

 of the cases in the United States have been studied in insane institutions. 



One of my cases, a white female, recovered sufficiently to give a fairly 

 good history. The first symptoms which attracted her attention were 

 slight vertigo, insomnia, an increased appetite, irritability, occipital head- 

 ache, lassitude, a growing lack of interest in her home and family, slight 

 irregularity in her bowel movements (chiefly of a diarrhoeal nature), 



10 Quoted by Lavinder. 12 Quoted by Sandwith. 



11 Quoted by Sandwith. "Quoted by Lavinder. 



