PUBLIC RECORD OFFICE
Reference :-
..................CO. 885
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ALLY WITHOUT PERMISSION OF THE BE REPRODUCED PHOTOGRAPHIC- COPYRIGHT PHOTOGRAPH—NOT TO
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membrane of the tongue and buccal cavity. The lips externally are bright red, and especially vivid in black people. In mulattoes the contrast with The the surrounding skin is less marked, while in the latter the pigmentation on the dorsum of the hands and feet is naturally more pronounced. tongue, when protruded, assumes a long, narrow, pointed shape. Its papillæ are elevated, and aphthous ulcers are often, though not invariably, found on its lateral margins. Saliva constantly dribbles from the mouth, the patient filling cup after cup, both by day and night. This salivation, Dr. Thin tells me, does not occur in East Indian psilosis. Partly owing to the rawness of the mouth, and partly to the constant accumulation of the saliva, speech is both painful and difficult, the secretion having to be swallowed or When the disease attacks the robust, expectorated with every sentence.
the general appearance of the patient may be healthy, but in the latter stages The redness of the lips and the condition is one of extreme emaciation.
In addition to tongue can be recognized from a considerable distance. these alimentary symptoms, the backs of the hands only in some cases, in others the dorsal aspects of the feet as well, are seen to have taken on a It often coal-black pigmentation. In light mulattoes it is more marked. assumes the form of a gauntlet. The pigmentation of the extremities, in the only two instances in which I have seen the disease in white persons, was of the hue which results from painting the skin with tincture of iodine. As will be seen on reference to the accompanying drawings, the pigmenta- tion is very symmetrical, its limits being almost identical on the two sides of the body. It often extends no higher than the flexures of the wrists, but in the majority of cases reaches the level shown in the illustration. The symmetry of these lesions is most striking and highly suggestive of syphilis; and indeed, in the first few cases that came under my notice, there was undoubtedly a syphilitic accompaniment. Latterly, however, I have been able in several cases entirely to eliminate syphilis as an etiological factor. As regards the etiology of this curious disease I have at present no sugges- tion to offer. The pathological process giving rise to the foregoing picture is by no means clear. The features of the disease are, however, unmistak- able and constant. The only variation is in their severity."
The above description is so full and clear that there can be no doubt whatever that, under the name of Psilosis pigmentosa, Dr. Brown was portraying genuine pellagra.
believe we can go still farther back, and, indeed, to the very middle of the eighteenth century, when the disease had not yet been described in Italy, since, in a book on "Observations on the changes of the air, etc., in the Island of Barbados," published in 1766, Dr. Hillary describes, under the name of Aphthoides chronica, à disease which appears to have been pellagra. Unfortunately, several authors, copying one from the other, have quoted Dr. Hillary's sketch as the first descrip- tion of sprue. I doubt the correctness of this interpretation, and, in any case, I wish to point out that his description applies just as well to pellagra. It is true that Hillary does not describe the characteristic features of the pellagra dermatitis, The but neither does he describe the typical features of the sprue diarrhoea. symptoms he mentions-pyrosis; stomatitis; red, beefy tongue; salivation; eructa- tions; sometimes vomiting; diarrhoea of longer or shorter duration, with, at times, a sense of heat and tenesmus; excoriations and soreness of the anal and genital mucosa; impetigo around the mouth; skin generally dry; pulse small, low, and weak; emaciation, atrophy, and marasmus-are common to both diseases, and, if anything, apply more to pellagra than to sprue, especially when we add to the general picture of the disease, quoted below, the remarks he makes farther on (page 286) about the "Coldness, Driness and Roughness of the Patient's skin and the Coldness and Driness of the skin, especially of the extreme Parts of the Body."
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Dr. Hillary's sketch is the following:
DJ
"And I shall begin with the Description of a Disease, which I think I may safely say is new, and has never yet been described by any Author, neither Ancient nor Modern, nor even by any of the Arabian Physicians, most of whom lived and practised in the Countries of Persia, Arabia, and Ægypt; but of late years is become endemical and frequent in Barbadoes, and the other West India Islands.
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From the best accounts that I can obtain, this Malady has been some chance time seen in this Island, near these thirty Years, though but very seldom; and after I came there in 1747, I did but see one Person who had it, in the first four Years of my residing there; and three more in the next three Years: But within the four last Years past, it is become so frequent, that I have seen some scores of Patients labouring under it, yet it seems not to be in the least infectious or contagious.
"The Patient who labours under the disease, usually first complains of an uneasy sensation, or slight burning Heat about the Cardia, or upper Mouth of the Stomach; which comes slowly on, and gradually increases, and rises up the Oesophagus into the Mouth, without any Fever, or the least feverish Heat, or much Pain attending it; most commonly without any observable Intemperance or Irregularity in living, or without any Surfeit, taking Cold, or any sort of Fever or other Disorder, which it can be attributed to, preceding it, or any manifest or immediate Cause to which it can be ascribed.
Soon after this burning Heat, little small Pustulæ, or Pimples, filled with a clear acrid Lymph, no bigger than a Pin's head, begin to rise; gener- ally first on the End and Sides of the Tongue, which gradually increase in Number, not in Magnitude, and slowly spread under the Tongue, and some- times to the Palate and Roof of the Mouth, and the Inside of the Lips; and soon after the thin Skin which covers those Pustulæ, slips off, and the Tongue looks red and a little inflamed, though not swelled, yet is almost raw like a Piece of raw Flesh, and is so tender and sore, that the Patient can eat no Food but what is soft and smooth, nor drink anything that is vinous, spirituous, or the least pungent, without acute Pain; so that some suffer much from the want of proper Food. In some a Ptyalisme comes on, and continues a long time, which is so far from being of any Service. or giving any Relief to the Patient, that on the contrary it drains and exhausts the Fluids of the Body, and greatly wastes and sinks them.
"In this State they continue several Days, or Weeks, and sometimes for Months, sometimes a little better, then worse again; and after a considerable time, sometimes longer, and sometimes shorter, the Pustulæ will disappear and the Mouth grow well, without any Medicines or Applications, or any manifest Cause, and continue so for several Days or Weeks; but soon after this, the Patient finds a burning heat in the Oesophagus and Stomach, attended with Ructuses and sometimes Vomitings, by which a clear acrid Lymph, or waterish Phlegm, which is very hot, and most commonly very acid, is brought up; though in some few it is not so acid; This generally continues but some little time before a Diarrhoea comes on, and continues a longer or shorter time in different Patients, and sometimes for a longer or shorter time in the same Person, and in some it continues for many Weeks; and in all it greatly wastes their Flesh and Strength, and sinks their Spirits very much. The Diarrhoea after continuing a longer or shorter Time, sometimes stops without taking any Medicines, or doing any thing to stay it, and the Patient thinks himself better for a short Time, and sometimes for a longer Time; but in general the acrid Humour soon returns to the Mouth again, with all the same Symptoms, but somewhat increased and aggravated; and after some stay there, it removes from thence to the Stomach and Bowels again; and thus a Metastasis of the Humour from the Mouth to the Bowels, and vice versa, is frequently, and sometimes suddenly made, without any manifest or perceptible Cause. Some chance time, though but seldom, after the Disease has continued a long time, it affects all the Prima Via from the Lips to the Anus at the same time, and excoriates the last; and I have observed in one or two Cases, where the Pustulæ appeared about the genital Parts, as we sometimes find the Aphthæ do, as Hippocrates (de Natur. Muliebr. C. 61, Epidem. Lib. 3, &c.) observes; and in one or two Cases I observed it to break out like an Impetigo, about the Mouth.
The patients are all along without any Fever or feverish Heat, and their Pulse is all this Time rather smaller, lower, slower, and more languid than it was when they were in full Health; and their Body and countenance rather paler and somewhat colder, especially in the extreme Parts, than