GENERAL DISCUSSION OF PELLAGRA. 499 



is present. No burning sensation of the affected parts is experienced 

 by the patient, but he complains of some itching wherever dermatitis is 

 found. 



Unfortunatel)", the patient's mouth was not examined, but he stated 

 that his mouth was not at the time, and had not been, sore. Examina- 

 tion of the abdomen is negative, as is that of the lungs, but the heart 

 is found to be enlarged, the apex beat being displaced outward and 

 downward. No murmurs. The examination of the nervous system is 

 unsatisfactory because it is impossible, for the patient to understand 

 what is desired. However, fine tremors of the upper extremities are 

 present, the knee jerks appear to be diminished and the Babinski re- 

 flex is absent.- Mentally, the patient is at times irritable and moody, 

 but usually he is depressed and indifferent to what is going on around 

 him. His answers to questions are slow, as though he had difficulty in 

 finding words to express himself, and he apparently entertains vague fears 

 that some ill will befall him. Memory for recent events is good. He 

 has no hope of recovery. Pulse full, regular, 68 per minute. No capil- 

 lary pulse, exophthalmos absent; temperature normal. 



Facilities were not at hand for examining the blood or the urine, but 

 the latter was apparently normal as to color, . amount, and frequency. 

 The fasces were light yellowish, soft, decidedly acid in reaction and 

 negative for evidences of parasitism. 



The patient was in about the same condition each time he was seen, 

 and the above notes were taken from the results of examinations during 

 five visits. He was told to abstain from eating maize and rice but 

 that he might eat all he desired of other things, especially eggs, chickens 

 and milk. He was also given elixir of iron, quinine and strychnine. 

 The directions were not followed either as to diet or the tonic. 



Having had the opportunity of seeing a number of cases of pellagra 

 in the Georgia State Sanitarium during the past two years, I believe 

 the case here reported to be one of that disease. The involvement of 

 the hands and feet, the character of the bowel movements and the de- 

 pression, cardinal symptoms of pellagra, all form a very striking picture. 

 However, because of the impossibility of obtaining a perfectly accurate 

 history either from the patient or his family, because of the presence of 

 the second variety of dermatitis, which is new to me (but which is 

 not uncommon at San Antonio), and because o'f the fact that pellagra has 

 not yet been reported from the Philippine Islands, the diagnosis is 

 modified to a case of probable pellagra. 



It is well known that in certain parts of the Philippine Islands 

 maize forms the chief article of diet. This is true of the tobacco 

 districts of the Cagayan Valley, and among certain wild tribes (e. g., 

 Negritos) , in Bulacan and Pampanga Provinces. Since pellagra is found 

 in so many parts of the world where maize is cultivated and used as a 



