498 WILLETS. 



began. The patient says his chief articles of diet have been maize, grown 

 at San Antonio, and rice, but largely maize. 



Somewhat more than two years ago the patient had attacks of diarrhoea 

 alternating with constipation. The diarrhoeal stools were of a mushy 

 consistency, light yellow in color, and varied in number from two to six a 

 day. About the time the diarrhoea developed, the skin of the. extensor 

 surfaces of the hands and feet became rather thick and pigmented, and 

 the forearms, legs, thighs and buttocks were ' affected with a different 

 kind of a dermatitis. Previously, his neck had become enlarged an- 

 teriorly. It was impossible to determine whether the hands and feet were 

 reddened at first or whether the lesions were at any time moist. 



While the patient says his hands and feet have been continuously pig- 

 mented since the eruption first appeared, his answers to certain questions 

 tend to show that there have been three exacerbations or recurrences in 

 his symptoms. He refuses to take a bath, except by having the water 

 poured on his head, because his symptoms were more pronounced on one 

 occasion after having taken a bath in the usual way; he also, for similar 

 reasons, refuses to have his hair cut and his nails trimmed. 



Throughout this period the patient has slept well and has had a 

 good appetite, but has felt that he was growing weaker. In January, 

 1910, there were some skin lesions on his face. He realizes that he 

 has become irritable and depressed. He has not walked for several 

 months. 



The patient is a fairly well nourished man of above medium height. 

 His arms, and especially his legs, are diminished in size; the muscles 

 are flabby. He complains of nothing but weakness. His countenance 

 indicates mental depression, and this, together with his long hair and 

 nails, a peculiar dermatitis involving the hands and feet symmetrically 

 and an enlarged neck, probably from goiter, gives him a rather striking 

 appearance. 



A dry, rather thick, blackish, somewhat granular dermatitis involves 

 the extensor surface of the hands quite symmetrically, and fades away 

 rather abruptly slightly above the wrist joint; this gives place to 

 a dermatitis which extends nearly to the elbow, involves the whole 

 circumference of the forearm and is characterized by large, thin, grayish- 

 colored flakes. At the wrist joint the first variety of determatitis spoken 

 of extends around the forearms like a bracelet. The feet are affected 

 in precisely the same manner as the hands and with precisely the same 

 sort of dermatitis; it fades away rather gradually above the ankle joint 

 to give rise to the large, flaky variety of dermatitis which involves not 

 only the legs, but also the thighs and buttocks. This is more pronounced 

 on the lower than on the upper extremities. Both varieties of dermatitis 

 are symmetrical in distribution. The palmar and plantar surfaces are 

 not involved. Slight pufnness of the extensor surfaces of the fingers 



