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"Two of us, Dr. Hutson and Dr. Bannister, are of opinion that this disease (which is characterized by morbid conditions of the skin and mucous membrane of the digestive tract, and by symptoms referable to the nervous system), although not identical in all respects with the pellagra of Southern Europe and Egypt, has many of the salient features of that disease, and is essentially a form of pellagra modified by local differences of climate, race, and social conditions, and we therefore regard the use of the term 'psilosis pigmentosa' as tending to confuse still further the nomenclature of the disease."
In other islands at the time of my visit either the disease had not been recog- nized yet or it was looked upon as some local variety or modification of pellagra, being often confounded with other diseases, and, indeed, cases of vitiligo, xeroderma, ichthyosis, Keratosis pilaris, Tinea cruris, and various kinds of syphilodermata were shown to me as possible cases of pellagra.
Having had the opportunity of examining a very considerable number of West Indian pellagrins in all stages of the disease, I can assert quite definitely that the reported disease is genuine pellagra, and that it differs in no way whatever from the pellagra I have seen in Europe and in the United States of America. Pellagra, like leprosy, syphilis, and tertian fever, which have an equally world-wide distribu- tion, is identically the same disease wherever found, whether in Europe, Asia, Africa, America, or Oceania. But though pellagra is everywhere the same, its microbic associations and complications may differ considerably from place to place, and thus alter, more or less, its features.
Associated Diseases.
Certain local variations of the pellagra syndrome dry or wet type of derma- titis, presence or absence of gastro-intestinal symptoms, different nature of stoma- titis and diarrhoea, variable predominance of certain nervous and mental symptoms ---repeatedly observed by physicians practising in places widely separated or climatically and orographically dissimilar, induced me to study with special care the disease which might be found associated with pellagra in various countries and districts, so as to learn to clearly distinguish and separate their manifestations from the true pellagra syndrome, and see how far they might explain its variations. Already, in my Progress Report, published in 1910, I mentioned several of the associated infections observed in different parts of Italy, and I pointed out the important rôle played by some of them in favouring the development of pellagra, in accelerating its course, in modifying and aggravating its symptoms, and in determining its mode of termination. Moreover, I showed that combination with other diseases had often been a cause of confusion in the diagnosis of pellagra. In certain parts of Italy, where pellagra was frequently associated with either scurvy, dysentery, or ankylostomiasis, on account of the local prevalence of the respective concurrent disease, I found that the superadded symptoms of the complicating infection had come to be regarded by the local practitioners as part of the pellagra symptom-complex; so much so, that, even when met singly, the scorbutic gingivitis, the dysenteric stool, and the hookworm anæmia were looked upon as indications of pellagra. Sometimes, however, these diseases were in turn complicated by some cutaneous affection, such as ordinary sunburn, eczema, ichthyosis, ringworm, or vitiligo, which was not infrequently mistaken for a pellagrous dermatitis. As we have now a more or less clear conception of the clinical features of scurvy, of anky- lostomiasis, and of some of the more common dysenteric diseases, these diagnostic mistakes are obvious enough, yet a careful consideration of the observed facts leads me to think that several manifestations usually looked upon as symptomatic of pellagra are really due to as yet unrecognized associated infections, the presence, absence, or interchangeableness of which may probably explain, in part at least, the striking local variations exhibited by this disease. Indeed, the more we study the natural history of diseases, the more we become aware of the complexity of their ecology, and I have no doubt that in several maladies the accepted syndrome will be found to be due not solely to the pathogenic activity of the main causative agent. but to groups or associations of micro-organisms, and maybe to combinations of associations. As an example, I might mention "malaria," which at one time was burdened with almost the entire pathology of tropical and temperate regions. Even now, though laboratory and experimental research has given us a clear picture of the symptoms pertaining to each individual type of plasmodiasis, physicians continue to confound with it all kinds of associated diseases.
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In the West Indies I found pellagra associated with many other diseases. Syphilis and tuberculosis, on account of their great, unrestricted prevalence, are. found in quite a number of cases. Gonorrhoea is also a very common complaint, and I have been told of a case combining pellagra and gonorrheal arthritis. Dysentery is said to be a frequent associate, but I was unable to ascertain the nature of the dysentery, whether bacillary, amoebic, or other. In Barbados, at the St. George's Almshouse, Dr. N. L. Boxhill showed me a little girl, three years of age, was suffering from dysenteric diarrhoea. Together with Dr. Johnston I examined her fæces, and we found them swarming with Balantidium minutum Schaudinn. Ankylostomiasis is another frequent associate of pellagra throughout the West Indies. At the Bridgetown Almshouse, Barbados, I had the opportunity of seeing a female creole patient whose feet presented a severe dermatitis caused by a curious combination of "ground itch" and pellagra rash. The patient was exceedingly pale and somewhat puffy about the face. She must have been reinfected again and again.
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As in Italy, so also in the Antilles, ankylostomiasis seemed to favour the development and enhance the gravity of pellagra. But whilst in Italy the disease was almost exclusively due to the Agchylostoma duodenale of Dubini, in the West Indies it was caused principally by the Necator americanus of Stiles. The common intestinal parasites Ascaris lumbricoides and Trichiuris trichiura occur frequently in the West Indies as in other parts of the world, and therefore are usually found in pellagrins. In Egypt Schistoma hæmatobium Bilharz and Schistosoma mansoni Sambon are found in almost every case of pellagra, and I expected to find the latter species in the pellagrins of some of the West Indian Islands, such as Antigua or Dominica, but I did not come across a single case; neither could I get any exact information about its geographical distribution. It is certainly not found in Barbados, where I should be surprised if it had escaped Dr. Johnston's keen observation, and it is certainly found in Guadeloupe and Martinique, where it has been determined again and again by the able surgeons of the French Navy, but with regard to the other islands we have no information, because until now clinical microscopical work has been most unwisely neglected. A case of intestinal schistosomiasis has been seen by Dr. H. A. Nicholls in Dominica, but the patient came from Mozambique; another case was seen by Dr. Branch in Antigua, but he may have contracted the disease in the Island of St. Kitts, from whence he came, or in some other island.
I have seen two cases of pellagra associated with the ulcerative granuloma of the pudenda: one in the hospital of St. John's, Antigua, the other in St. George's Almshouses, Barbados. The Barbados patient, a negress, twenty-one years of age, may have contracted both diseases in Trinidad, whence she had just returned, after a residence in that island of about thirteen years. She presented a marked pellagrous dermatitis on face, dorsum of hands, wrists, elbows, and genitals, accom- panied by severe stomatitis, profuse salivation, great muscular weakness, pain in the back, and giddiness. The ulcerative granuloma affected the vulva, the vagina, and the rectum, and had rendered the labia majora so greatly cedematous that they suggested an elephantiasis. In the genito-crural region the pellagrous lesions had a raw and sodden appearance, and in places intermingled with the weeping nodular masses of the ulcerating granuloma. This loathsome disease, first described by Macleod and Maitland in India, and by Ozzard, Neal, Conyers, and Daniels in British Guiana, seems to be not uncommon in some of the West Indian Islands, totally absent in others. Its causative agent, discovered independently, at about the same time, by Dr. Donovan in India, and by Dr. K. S. Wise in British Guiana, was shown to me by the latter in his laboratory at the Georgetown Hospital, Demerara. Dr. Wise procured a fresh scraping from a patient in the hospital and prepared a film by the jelly intravitam staining method. It was a wonderful sight. The field of the microscope was studded with roundish sporozoon organisms, vary- ing in size between two and eight microns in diameter. At first small, compact, deeply-stained, they gradually swelled, paled, broke up their cytoplasm into eight, twelve or twenty merozoites, and then suddenly burst, like explosive fruits, scatter- ing their boomerang-shaped spores in every direction.
Yaws. er "pian," as the French call it, is another disease, occasionally seen in association with pellagra in some of the West Indian Islands, and especially in Jamaica, Trinidad, St. Lucia, and Dominica, where it is still very common. With
the exception of a doubtful case in Trinidad, I have not myself seen this association, but it has been recorded at the Kingston Lunatic Asylum, Jamaica, and is probably