tions: (a) A rough, scaly, branny skin, chiefly involving the hands, forearms, elbows, arms, knees, rarely the body and face. In rare cases the entire body may be of a branny roughness. (b) An inflammatory condition ranging from the pink red of a light sunburn to a bright cedar wood tint of a severe eruption. To this inflammatory eruption, lasting from a few days to a few months, the name pellagrous dermatitis is given. The eruption disappears gradually by the exfoliation of the epidermis involved, and this is known as the "peeling" in pellagra. The eruption is most variable. It may be limited to a sunburn tint on the dorsa of the hands; it may be like a red glove that covers the hands and extends up the forearms; or in addition it may cover the sides of the nose-the butterfly figure, or in very rare cases it may surround the neck with a sternal prolongation like a four-inhand tie, known as Casal's cravat. In se vere acute pellagra, with fever, the typhoid type, large vesicles and bullae may form on the hands, or deep fissures. The elbows, knees, forehead, and instep are usually of the branny roughness. When the eruption is on, the patient is said to be in the midst of an attack. At this time, also, the digestive and nervous symptoms are usually at their worst. After the attack, the hands and face may resume their former smoothness, or they may appear thinner and rougher than normal. The palms of the hands and the plantar surfaces of the feet usually escape. The eruption is always bilateral, it is made worse by the sun, and is of convicting service in diagnosis.

2. Either preceding, accompanying, or just after the eruption, in the well developed cases, the digestive system causes the patient more disturbance than does the skin. The tongue loses its coat, becomes a coatless beety tongue, even far redder and more naked of its epithelium than the diabetic tongue. There is a true glossitis. The mucous membrane of the mouth takes on a fiery redness often involving the pharynx,

the "sore mouth" of the pellagrin. The diarrhoea usually begins at this time. Liquid stools more frequent between midnight and morning, have no relation to food; these average five to twenty a day and are extremely weakening. The rectal and vaginal mucosa may now become inflamed, and anorexia becomes prominent. Consider now this unhappy picture; weakness, diarrhoea, stomatitis, rectitis, vaginitis, dermatitis, and often, in the severe cases, mental changes.

3. In the mild cases or even after repeated mild attacks, the nervous system is very little affected. Ten per cent of pellagrins develop pellagrous insanity. Between this insane ten per cent, and those whose nervous system is unaffected, there is the larger number who nervously and mentally are below par. Dilated pupils, exaggerated reflexes, emotionalism, melancholia, despair, and suicidal tendencies are common; the patient may have a strange prescience that pellegra is his disease and death the end. Pathological changes occur in the cells of the cord and cortex. Inflammation of the meninges, dilatation of the superficial vessels of the cortex, edema and softening occur; often degeneration of the posterior columns, with pigmentation and conraction of the nerve cells.

Mentally the pellagrin has the morbid concentration of the neurasthenic. His blood pressure is low, his skin affected, his muscles weak, flesh lost, and he feels apart and afar from his former self. He rarely answers questions directly or accurately, he moves slowly, he would have you listen to him long as he relates the variations of his uffering. As the attack disappears, the appetite improves, the eruption passes, new smooth epithelium appears on the dorsa of the hands, the diarrhoea lessens, the mind improves, and the interest in life reasserts itself.

Now is the interval between attacks, the pellagra sine pellagra, the pellagra without the eruption. There are really two pellagras; the pellagra of the attack, recog

nizable by the stomatitis, dermatitis, and diarrhoea; the pellagra between attacks, so common among the women of the south. A mother on the farm, with the wear and tear of many children and no servants, perineal laceration, enteroptosis, no rest, coarse food and that of her own cooking, careless of teeth and toilet, gradually loses her appetite and flesh, has flurries of diarrhoea, wasted hands, no typical attack, just a nutritional slipping. These are the pellagrins without eruption. The disease, like a snake in the grass, is seen here and there by its symptoms, but the whole snake, or the typical attack, is not seen.

Pellagra is as variable as syphilis. One may have syphilis and its sole attack may be on the aorta with a syphilitic aortitis. It may attack the nervous system and we may have tabes or locomotor ataxia. Likewise, pellagra may come without eruption at all, or it may come chiefly with eruption. One may have it without disturbance of the digestive system at all and yet, on the other hand, one may have it so that one becomes exsanguinated and dies with it. It is one of the most variable of human dis

eases.

From Casal's time in Spain to the present day, pellagra has been connected in the minds of medical men and of the laity with poor food. The profession of Italy committed itself to Indian maize or corn as the cause. Indeed, between corn and some unknown infectious agent much serious work has been done and volumes of articles written. It is now generally agreed that the sum total of experiments, research, and argument, is against the infectious theory, and that it is a disease caused in some way by bad food, a faulty, unbalanced food, lacking in some of the articles necessary to furnish a-balanced food intake. It is, therefore, a nutritional disease, allied in etiology to beri-beri and scurvy. There are three ideas advanced in the effort to locate the nutritional fault: (a) that pellagra is caused by a lack of vitamines in the food,

Goldberger and his associates of the Public Health Service have thrown a flood of light on faulty food as a cause, and therapeutically one can feel reasonably confident that, taken in time, with a liberal supply of a well balanced dietary, the pellagrin has little to fear. The following is a summary of Goldberger's work:

(1) At the Mississippi Penitentiary Farm, on a diet of flour, corn meal, syrup, rice, sugar, pork fat, cabbage, turnip greens, turnips and coffee six convicts of a pellagra squad of eleven developed the disease.

(2) In two orphan homes in Mississippi, where pellagra had been common and recurrences the rule, as soon as the inmates were placed on a diet of meats, milk, peas, beans, fresh vegetables, and bread, with a lessening of the carbohydrate syrup content, the disease practically disappeared, and recurrences ceased.

(3) In a pellagra ward at the Georgia Asylum for the Insane, the advent of a similar balanced dietary gave similar results. The Illinois institutions report the same results.

With the use of a balanced, high protein, vitamine-containing diet in a pellagrin, the change for the better, with gain in weight and strength is marked. For example, a young married woman, always peculiar in regard to food, developed pellagra and lost forty pounds. It was discovered that from childhood she refused meats and eggs, was a knick-knack eater, choosing syrup, salads, and breads. On a milk-egg-meat diet, with rest, she gained fifty pounds, and is now active. There are those who develop the disease because they do not have the proper food, there are others who, having the proper food, do not eat it, and develop the disease.