1726 



PELLAGRA 



is the history given by the friends of the development of some 

 extraordinary habit of dietary, to the influence of which the disease 

 is often assigned. These extraordinary cravings appear to us to 

 be due to the dyspepsia (hypochlorhydria) so commonly met with 

 in pellagrins. 



We have rather insisted upon the occurrence of pellagra in young' 

 children because we are of the opinion that it is often overlooked. 



Skin Eruption. — The skin eruption is usually limited to the 

 regions exposed, being at first delineated in a most exact manner 

 by the clothing ; but in very rare cases it may be universal, and it 

 is said sometimes to appear limited, as though by clothing, in naked 

 gipsy children. It appears on the dorsum of the forearms, and on 

 the hands and feet, only reaching the flexor aspect after several 

 attacks. The most common sites are the hands and forearms, 

 elbows, feet, legs and knees, the upper part of the chc:3t, the 

 shoulders, neck, and face. More rarely it appears on the genital 

 organs and around the anus in both sexes. Sandwith points out 

 that in Egyptian peasants the unguinal phalanx of the hand is 

 seldom affected, due to the fact that wlhen the hoe is grasped it 

 is protected against the sun's rays. The nails and hair are not 

 affected, but rarely there is a dry, scaly condition of the palms 

 of the hands. 



The skin eruption may show the following conditions:^ — (i) Con- 

 gestion; (2) inflammation; (3) thickening and pigmentation; 

 (4) atrophic thinning. 



The affected part turns a bright, dark, or livid red colour, which 

 at first disappears on pressure, and is generally delineated by a very 

 clearly raised limiting line. Associated with this erythema there 

 is a burning sensation, but usually no pain. In course of time the 

 part becomes swollen and tense, and bullae may form. After 

 lasting a variable period of days or weeks, the eruption gradually 

 subsides, leaving the skin rough, pigmented, and thickened, and 

 thus earning the names of ' pell'agra ' and ' qushuf.' 



This erythema disappears in the winter, but reappears the next 

 spring with increased virulence, and in due course develops into a 

 dermatitis, which produces an exfoHation of the epidermis in grey 

 or brown flakes. Every attack leaves the affected area a little 

 more pigmented, a little more thickened, and a little less elastic. 



After lasting about four or five years the skin begins to atrophy, 

 and becomes wrinkled and inelastic. This atrophy is most marked 

 on the back, hands, and feet. Special terms have been given to 

 the eruption when in certain areas — e.g., the 'glove,' the 'boot,' 

 Casall's ' necklace,' or ' cravat,' and the ' mask.' 



Roberts has introduced the rather useful term ' dermotagra ' for 

 the dry, scaly, thickened skin seen over the olecranon process, 

 over the knees, and more rarely on the palms of the hands. Over 

 the elbow and knee the skin is rough, thickened, and wrinkled; 

 on the palms of the hands it is merely rough and thickened. 



Another interesting dermatological feature of pellagra is the 



