GENERAL DISCUSSION OF PELLAGRA. 495 



A vaginitis is quite common in the genito-urinary tract, occurring 

 about the same time as the skin lesions and the stomatitis. Coupled 

 with these various symptoms there is an increasing emaciation as the 

 pellagra recurs from year to year, until finally the patient dies of exhaus- 

 tion or some intercurrent disease. 



While nearly all of the old-world cases are of the chronic type just described, 

 there are records of acute ones (Lavinder) (V). Walker(23) reports 51 cases of 

 so-called acute pellagra in the United States; Searcy (17) 88 of epidemic acute 

 pellagra, and Zeller(27), of Illinois, 130. Harris (5) is inclined to believe that all 

 cases are chronic because of the nature of the pathologic lesions in the spinal 

 cord, even of those who died in an apparently acute attack. In this connection 

 it is interesting to note that Siler(lS) found that many of the Illinois series gave 

 a history of preceding attacks, whereas SO per cent of Searey'sd?) were previously 

 in good health. Certainly, there is a wide divergence clinically between the cases 

 clearly chronic, recurring yearly, and those apparently acute, which, without 

 giving a history of a preceding attack, terminate fatally in from about one week 

 to two months. 



The various symptoms of pellagra develop quickly and are severe in 

 these rapidly fatal cases. The development of stomatitis, skin lesions, 

 and digestive disorders in which vomiting is not uncommon and diarrhoea 

 is persistent, leading to rapid emaciation, pronounced nervous and mental 

 manifestations, vaginitis, slight fever and the occurrence of bedsores, is 

 so rapid that the picture is rather explosive in character when compared 

 with typically chronic cases which continue for years. 



The division of pellagra into varieties 'depends upon the symptoms 

 which are most pronounced. On this basis, the following division is 

 given (Procopin) : li (1) gastro-intestinal; (2) nervous, with mania; 

 (3) nervous, with paralysis; (4) pellagra sine pellagra; and (5) typhoid 

 pellagra. 



Some authors discredit the occurrence of pellagra sine pellagra, and 

 .doubtless it is true that this division affords a good opportunity for other 

 affections to be diagnosed as pellagra. There is no symptom more 

 characteristic of pellagra than the skin lesions. However, I have seen 

 at least one case in which the lesions were very slight and fleeting in 

 character. In 8 per cent of Searcy's (1?) series the. cutaneous system was 

 not involved. In the typhoid variety, a typhoid state has developed, but 

 the Bacillus typhosiis is absent. 



The diagnosis of a well-marked case which exhibits the typical skin 

 lesions, stomatitis, diarrhoea and depression is made easily after the phy- 

 sician has once seen pellagra. As in other affections, the atypical cases 

 offer difficulties. A history of maize eating is important. In my opinion, 

 the strongest evidence of pellagra is found in the skin lesions, and in the 

 absence of this symptom one should be cautious in rendering a diagnosis. 

 The London School of Tropical Medicine instructs its students to diagnose 



11 Quoted by Lavinder. 



