GENERAL DISCUSSION OF PELLAGRA. 493 



difficulty in remembering names, and a vague fear that some calamity 

 would befall her. She did not recall having nausea, a burning sensation 

 in the stomach, or abdominal pain particularly referred to the epigastric 

 region, symptoms mentioned by various writers as prodromal of the 

 disease. 



When pellagra is well established, the symptoms fall into three 

 groups, skin lesions, digestive symptoms, and nervous and mental man- 

 ifestations. 



The skin lesions are symmetrical in distribution and involve chiefly, 

 almost exclusively, the uncovered portions of the body: the hands, feet, 

 face and neck. The elbows frequently are involved and lesions in un- 

 usual locations are reported : For instance, Walker had two cases in which 

 the nipples were attacked and one case in which the umbilicus was af- 

 fected. The extensor surfaces of the hands and feet are involved pri- 

 marily; the palmar and plantar usually are not affected. The first ap- 

 pearance of the lesions generally is erythematous, but initial erythema 

 may be lacking (Lavinder) (7) . The erythema not infrequently is ac- 

 companied by some local puffiness and a sensation of burning, the whole 

 picture being somewhat like sunburn. D'Oleggio believed the condition 

 to be caused by the sunlight and as the lesions in Italy, at least, tend to 

 recur in the springtime, he called it vernal insolation, the popular name 

 being malde sole. 



Vesicles and bulke which easily become infected may follow the ery- 

 thema and these, upon breaking down, disclose a raw, weeping, and at 

 times ulcerated surface. In other cases, the skin dries and desquamates, 

 leaving a slightly pigmented surface, or possibly a normally appearing 

 skin. However, initially the skin may be dry, rather thick and pig- 

 mented to a bronze or blackish color. As the attacks are repeated, a 

 chronic thickening and an increase in the pigmentation occur in the 

 -affected parts. The majority of writers believe that there is no relation, 

 between the severity of the skin lesions and the constitutional disturb- 

 ance, while others consider the moist variety of lesion to be a grave 

 symptom. 



In the digestive tract, stomatitis is present in a large percentage of 

 cases. The edges and under surface of the tongue, the floor of the 

 mouth and the inside of the cheeks usually are reddened and the tongue 

 may later appear to have lost its epithelium, constituting the so-called 

 "bald" tongue. A whitish pellicle frequently is present upon the lower 

 gum and this may involve all the mucous membrane of the buccal cavity. 

 Its first appearance not rarely is back of the last molar tooth. Ab- 

 dominal distress, a burning sensation in the stomach, nausea and vomit- 

 ing-may be present. Diarrhoea is the rule, but there may be constipation. 

 The diarrhoeal stools are characteristically of a light yellow or greenish- 

 yellow color, they have a very offensive odor and a decidedly acid reac- 



