1728 



PELLAGRA 



simply a pellagrin with an infection with one or more of the 

 organisms causing enteric fever. 



Terminal infections with various micro-organisms have been noted, 

 and complicate the post-mortem findings. Thus, Bon records the 

 occurrence of Streptococcus pyogenes in the blood as found by 

 examination immediately after death. 



Diagnosis.' — Everywhere since pellagra was first recognized there 

 has been great difficulty in its diagnosis, and it would appear 

 necessary to consider not merely the signs exhibited by the patient, 

 but the frame of mind in the observer in attempting to write upon 

 this subject. 



For the diagnosis of pellagra two conditions are necessary in the 

 observer. The first is that he must suspect its presence, and be 

 on the outlook for it in any and every country; and the second 

 is that he must not be unduly swayed by any setiological theory, 

 and must be prepared to make a diagnosis of pellagra in a person 

 of any age, any race, any social condition, living in any place, 

 whether tropical, temperate, or frigid; resident in a town or in 

 the country; and he must do this without consideration of the 

 dietary or the surroundings, with perhaps the sole exception of 

 being^more intently awake to the possible occurrence of the disease 

 in lunatic asylums. 



As there are at present no microscopical, bacteriological, para- 

 sit ological, hsematological, or chemical reactions which can be said 

 to be diagnostic of the disease, with, perhaps, the sole exception 

 of the pellagra-like symptoms prodaced by one of the American 

 Commissions, by injecting defibrinated blood into monkeys, and ys 

 these animal jinjections are not within the range of practical politics 

 for purposes 'of diagnosis, we must trust entirely to clinical mani- 

 festations. 



The cardinal signs of the disease may be summarized into — 

 (i) the cutaneous signs, (2) the gastro-intestinal signs, and (3) the 

 nervous signs. 



In order to make a definite diagnosis, there must be either the 

 presence or a definite history of the cutaneous signs of pellagra 

 associated with symptoms belonging to one of the other groups. 



I. Cutaneous Signs .—When a person shows more or less sym- 

 metrical erythema, dermatitis, pigmentation, or a condition more 

 or less resembling chronic dry eczema on either the backs of the 

 hands, the dorsa of the feet, the face, the back and sides of the 

 neck, or the front of the chest, especially if these eruptions are 

 limited by a more or less definite elevated margin to the areas 

 habitually exposed to light, suspicion should at once be aroused 

 that the disease is pellagra. If a history can be obtained that this 

 eruption appeared for the first time in spring or autumn, and more 

 especially if a history of recurring attacks can be obtained, the 

 suspicion becomes almost a certainty. If to these signs there are 

 added the fact that the skin symptoms become worse on exposure 

 to the sun, or that there are at the same time disturbances of the 



