DIAGNOSIS 



1729 



alimentary canal or of the nervous system, and especially if there 

 is the presence or the history of vertigo y then the diagnosis is certain. 



2. GastrO' Intestinal Signs. — Gasiro- intestinal symptoms are 

 usually present, but they may be extremely mil(J, and they may be 

 absent. Those most commonly met with during exacerbations are — 

 Salivation, stomatitis, dyspepsia due to hypochlorhydria, diarrhoea, 

 dysenteric symptoms, alternating with constipation, or simply 

 constipation appearing or recurring in the spring or autumn. 

 A diagnosis cannot be made by these symptoms alone, which must 

 be considered in conjunction with the cutaneous in order to arrive 

 at a conclusion. If no cutaneous symptoms are visible, it is justi- 

 fiable to place the patient in strong sunlight in order to see whether 

 the dermatitis will appear. 



3. Nervous Symptoms.— Oi all the nervous symptoms early ex- 

 hibited, the vertigo is the most common, and should be carefully 

 inquired for, as the patient often does not associate shght morning 

 vertigo with the disease, and will therefore omit to mention the feet. 



Other important symptoms are the melancholia, the myas- 

 thenia, the tremblings, and often curious delusions, and the irritable 

 condition of the temper, recurring in the spring or autumn; but 

 these must be associated with evidence of skin lesions before a 

 diagnosis can be made. 



It wiU thus be observed that, while the diagnosis may be a matter 

 of extreme simplicity in a typical case, it may also be one of great 

 difficulty in atypical cases. Perhaps [the greatest difficulty is 

 met with in lunatics and young ^children. 



1. Lunatics. — In these cases the patient has been admitted into 

 the asylum suffering from one of the well-known forms of mental 

 disease, but most probably from melancholia or dementia, more 

 rarely from attacks of mania. It may be noted that at times he 

 suffers from diarrhoea or dysentery, which is often assigned to what 

 used to be called ' lunatic asylum diarrhoea ' or ' dysentery.' It 

 may also be noted that at .'times he spits considerably, which s'mply 

 means that he has an excess of saliva; but, much more importantly, 

 it is noticed that he suffers from chronic eczema on the back of his 

 hands, from angioneurotic oedema so called, both of which are often 

 common in lunatics. Such cases require careful investigation, 

 not with a view of making a diagnosis of pellagra, but with a view 

 of excluding, if possible, the diagnosis that the case is really 

 pellagra. 



2. Young Children. — In young children the disease is very apt 

 to be overlooked, and the red eruption on the face and hands, etc., 

 followed by pigmentation, is generally attributed to sunburn or 

 to eczema, while the alimentary disturbance is assigned to infantile 

 gastro-intestinal derangements, and not connected with the skin 

 lesions. A careful inquiry will show whether these symptoms 

 have or have not a seasonal incidence, and in any case they should 

 arouse suspicion ^of pellagra, which should only be eliminated after 

 ^lareful inquiry. 



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