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indicated by the old French popular name of “pian dartres," given in Martinique, Guadeloupe, Dominica, and St. Lucia to cases of yaws presenting, together with the characteristic lesions, a cracked, scaly condition of the hands and feet. Dr. C. W. Daniels has pointed out that of late years yaws has almost entirely disap peared from British Guiana. In Martinique it has also considerably diminished. In Barbados it is now entirely absent, although it appears to have been very preva- lent in the middle of the eighteenth century, when the Rev. Griffith Hughes wrote his Natural History of Barbados," and said: "The body-yaws and the running- The disappear- yaws, so common here, are disorders unknown in northern climates. ance of yaws from some of the West Indian Colonies is not the outcome of any endeavour of man to stamp out the disease, but the result of natural ecological changes analogous to those which have brought about the subsidence of leprosy over the greater part of Europe, and that of ague in the British fen districts, in the French Landes, in the valley of the Rhône, and in other places. The recently introduced method of intramuscular injections of salvarsan and neo-salvaraan in the treatment of yaws is acting like magic-one single injection often sufficing to effect a complete cure-but healing the victims and combating the disease are two very different things, although, no doubt, a progressive reduction in the number of germ-carriers might in the long run bring about the cessation of the disease. To strike at the root of the evil, we need in the first place a definite knowledge of the epidemiology of the disease, the study of which appears to have been hitherto almost entirely neglected. From observations and inquiries made in the Antilles, it appears to me that yaws affecta a peculiar topographical distribution, the investi- gation of which might yield very useful information. Another point which struck me very forcibly, and which might well explain the endemicity of the disease, is the very probable association of Castellani's Treponema with some insect dis- seminator. That insects may play an active part in the propagation of yaws is "Bancroft," in his a very old popular belief amongst the West Indian natives.
Essay on the Natural History of Guiana," published in 1769, says: "It is usually believed that this disorder is communicated by the flies which have been feasting on the diseased object to those persons who have sores or scratches which are uncovered; and from many observations I think this is not improbable, as none ever receive this disorder whose skins are whole." Numerous other authors have at various times mentioned this belief, but Dr. Lucius Nicholls, of St. Lucia, has gone farther. He has observed that the majority of cases are caused by the inoculation of surface injuries by a small fly known as Oscinis pallipes. My own observations in Jamaica, Trinidad, and Antigua tend to support Dr. Nicholls's conjecture as to I do not think I have ever met the agency of these flies in the transmission of yaws.
a case of the disease without seeing minute Oecinid flies (Hippelates sp., according to Mr. Jennings's provisional diagnosis) hovering round the patient. Of course these flies are not seen only on yaws cases, but are attracted to all kinds of wounds, sores, and ulcers of both man and animals. I have seen them again and again creeping in and out of the furrows and interstices between the sodden, foul- smelling, warty excrescences of mossy" feet in cases of elephantiasis, following the wretched patients wherever they trudged, just like parasitic Hippoboscid flies follow their respective host-species.
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Although I had the opportunity of examining a very large number of lapars in the leper asylums of Antigua, Barbados, Trinidad, and British Guiana, I never saw any indication of pellagra amongst them. Dr. L. T. Archer, physician to the Barbados Leper Asylum, told me that he had seen one case, but one only, in twenty years. I also failed to find any traces of pellagra in the very numerous cases of elephantiasis met with in Antigua, Barbados, and British Guiana.
A common associate of pellagra in the West Indies, and one which I have fre quently seen myself thus associated, is the so-called “dhobie itch," or "washerman's itch," a kind of ringworm of the intertrigenous regions of the body, caused by Epidermophyton cruris (Castellani). The prozigenous patches produced by this fungus are characterized by their bright red, slightly raised, abrupt' margina of splash-like irregularity, and are usually seen in the genito-orural region, the axille, the bend of the elbow, and the fold beneath the pandant breast. I was surprised to find that, notwithstanding its great prevalence and typical features, this common ringworm was wrongly diagnosed by many of the West Indian physicians. Some took it for pellagra, a mistake which, in the reverse order, has been made very frequently in Europe. Others called it Tinsa imbricata, a name given by Sir Patrick
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Manson to a ringworm of the Eastern Archipelago, characterized by the formation of rosettes composed of closely set concentric whorls of imbricated petal-like scales which, falling off, leave the skin marked like watered silk, with sinuous parallel lines and concentric rings. Numerous rosettes arising side by side and coalescing may arabesque large skin areas or the whole body with a veritable tatu. The striking pattern of the Papuan ringworm, so like that of an imprint of the friction ridges on our finger pads, is unmistakable. Who knows that it did not suggest the typical scroll design of New Guinea, which forms the major element in the tatu ornaments of the Polynesians and in the moko of the New Zealand Maoris ! These peculiar scrolls and spirals may well have been representative of the fungus pattern, a characteristic, though pathological, mark of Polynesian immigrants throughout the Bouth Sea Islands. They were marvellously incised in the skin by means of a pointed instrument repeatedly dipped in a black dye, itself made from the charred mycelium of a fungus (Cordyceps roberts) which grows within the body of the "awbeto or "bulrush caterpillar."
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The imbricated ringworm is said to have been recently introduced into Brazil, and it is quite possible that it may have reached some of the West Indian islands, but I have not seen it, although I especially looked for skin diseases, and saw hundreds of cases of the axillary ringworm in negroes, creoles, and whites.
Another disease occasionally seen in association with, and sometimes mistaken for, pellagra is vitiligo. I have had the opportunity of seeing two very striking cases of this disease, both in Hindu women of middle age—one through the courtesy of Dr. Q. B. de Freitas, at the Public Lunatic Asylum of Berbice, Dritish Guiana; the other through the courtesy of Dr. R. D. O'Neale, at Guave, Grenada. Both were cases of many years' standing, and the depigmentation had extended through- out the entire skin and mucous membranes. Indeed, with the exception of a few brownish spots on face, wrists, and feet, both women presented a perfectly smooth skin of milky whiteness, suffused by a delicate pidk flush. The Berblee case had some tufte of blanched hair over the front part of the head. Both these cases were looked upon as cases of pinta in the stage of achromia, but neither in them nor in the many others-some with only a few bleached spots on the backs of the hands or face which came under my observation in the various islands could I find any evidence of the Mexican dermatomycosis.
Cases of albinism in the negro are not at all uncommon in the West Indies. At Guave, Grenada, Dr. O'Neale took me to see a young woman whose negroid features were clothed in a somewhat freckled white skin, her eyebrows, her eye- lashes, and her woolly, frizzy hair were of the colour of flax, her weak, semi-closed tremulous eyes were light blue with a pink pupil, like those of a white rabbit, but she was strong, fat, pleasant, and intelligent. A most interesting case was Charlie Williams, a young albino boy of pure negro descent, with very white, crisp hair, whom I had the good fortune of meeting, quite casually, just outside the St. Cruz Almshouse in Jamaica. He was suffering from pellagra, and the eruption, although fading, was still perfectly recognizable on hands, forearms, legs, and neck, but, of course, instead of being soot-black, as it always is in the negro, it had the red colour it usually affects in fair whites.
Here I may mention a case of pellagra dermatitis seen in a polydactylone negro boy, the rash afightly affecting all the fingers, including the supernumerary, thumbs. I owe to Dr. F. A. de Verteuil's courtesy the opportunity of seeing this boy, who was an inmate of the Diego Martin Reformatory
Perhaps the disease most frequently confounded with pellagra is ichthyosis. I found it to be just as common in the West Indies as in Italy, where I had seen it once associated with pellagra in a boy, twelve years old, belonging to a family all the male members of which were affected by it. The father was a true Oannes in scaliness, if not in wisdom. Almost the entire skin of his trunk and limbs presented a most striking fish-scale aspect. In the West Indies I have seen every type of ichthyosis, from the mildest form of xeroderma to the most pronounced Ichthyosis Rystrie. In Antigua, Dr. MacDonald had a perfect menagerie of "fish "alligator men," and "porcupine men." In one of his cases of Ichthyosis simpler the extensor surfaces of the legs presented large black quadrilateral scalee divided by deep farrows, which strikingly resembled giraffe blotches. I even had the opportunity of seeing the "harlequin fetus," or fetal ichthyosis, which had been taker for congenital pellagra.
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By the side of a true ichthyosis I have frequently seen, especially in old or ill- nourished people, a dry, rough, scaly condition of the skin on legs and arms, probably