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when they were well: No Thirst, except what the Diarrhoea causes, when The Patient's Skin is it continues long, and that generally moderate. generally dry, all the Time of the Disease, and he perspires very little.

"The frequent Metastases which the acrid Humour makes from the Mouth to the Stomach and Bowels, and -from these to the Mouth again, greatly emaciate, weaken and consume the Patient. For when it is in the Mouth, both it and the Tongue are so excoriated, raw, tender and sore, that they can take no Nourishment, but such as is very soft, smooth and mild, and in a liquid Form, without giving them exquisite Pain: and when it is in the Stomach, it gives a painful burning Sensation, and a frequent gulping up, or vomiting a little clear, acrid, acid Liquor, and their Food also; so that the stomach can retain and digest nothing but what is very soft, smooth and light, and sometimes not even that. And when the Humour falls upon the Intestines, it produces a Diarrhoea with a Sense of Heat, and sometimes a Griping (tho' the last not often), and sometimes with hot Stools and a Tenesmus; so that most of the nutricious Juices run off that Way, which greatly wastes and sinks the Patient. These Circumstances continu- ing, and the Disease frequently changing from place to place, almost con- tinually deprives the Sick of their proper Nourishment, whence a true Atrophy is produced, which at the last either sinks the Patient, or brings on a Marasmus, which soon ends in Death.

'This is a true and I think an exact Description of this Disease, and its Symptoms, which too often seizes several of the Inhabitants of Barbadoes, and I believe of the other West India Islands also, and has been too often fatal to several of them.

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As it is a new Disease we must give it some Name; shall we call it an Aphthoides Chronica, or an Impetigo Primarum Viarum? or what? But I will not dispute with any about its Name, as that is only a Dispute about Words; and if any Person will give it a better Name, I will readily agree with him, and thank him also."

In order that we may give the correct interpretation to the above description, which, for the lack of certain details, applies just as well to sprue as to pellagra, we need to consider other elements, such as distribution and relative prevalence of both diseases at the present day and in periods intervening between now and Hillary's time. At the present day pellagra is certainly far more in evidence than sprue, and a quarter of a century ago the conditions were evidently the same. Dr. Cuthbert Bowen tells us that the disease observed by him in Barbados between 1888 and 1903 was different to the East Indian sprue. Local records go no farther, but Italian experience teaches that pellagra, though exhibiting at times consider- able fluctuations in prevalence, occupies for centuries the very same locations. In Jamaica, as pointed out by Dr. Stannus, one might perhaps trace back the disease malarial peripheral neu- to 1888, when Dr. Strachan, describing what he called ritis," seems to have jumbled together malaria, pellagra, and the peculiar "neuritis " which prevails in certain parts of the island.

Pellagra and Sprue are they Identical?

Though now in Barbados the majority of physicians differentiate between sprue and pellagra, yet Dr. C. J. Manning, Superintendent of the Lunatic Asylum, still holds to the opinion he put forward in 1907, that pellagra, such as he has seen This view cannot be put it in the island, is nothing more nor less than sprue.

aside without careful consideration, because both diseases appear to be present in the island, and because in practice it may at times be almost impossible to distinguish between them, and also because within recent years several authors have advocated their possible identity.

Dr. E. J. Wood, in his admirable treatise on Pellagra, published in 1912, says: "The symptoms of sprue, except for the absence of skin manifestations, are almost identical with pellagra. After a careful study of the two' diseases

is unable to distinguish so-called 'pellagra sine pellagra' sprue. It is highly probable that cases have been called sprue they were really pellagra with inconspicuous skin lesions."

one

In August, 1911, Dr. Burnett. of Edinburgh, wrote:-

from

when

So convinced am I that the two diseases are one and the same that

I feel that I am in duty bound to put my opinion on record in order that

it may be confirmed or refuted by those who have had more experience with these diseases."

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Dr. Charles E. Stewart, of Battle Creek, Michigan, U.S.A., at the Interna- tional Medical Congress held in London in 1913, read a paper on "The probabler identity of pellagra and sprue," in which, after stating that he had studied the two diseases side by side, he said "Sprue and pellagra are so much alike that. we are justified in concluding that there is a very strong possibility of their having a common ætiology."

My knowledge of sprue being based almost entirely upon the very unsatis factory literature of the disease, I do not feel justified in expressing any very definite opinion on the matter. The two diseases are, in many ways, remarkably alike, yet they appear to be distinct.

Both pellagra and sprue may terminate fatally within one or two years, but, in the great majority of cases, they both exhibit a protracted course of several, often many, years' duration, characterized by alternating periods of exacerbation and comparative quiescence. Both show a like seasonal incidence in adaptation to local meteorological conditions. Both, as a rule, fall more heavily upon the female sex, both appear to be only indirectly contagious, both lead almost inevit- ably to cachexia, and both are frequently cut short by intercurrent diseases.

Pellagra has all the symptoms of sprue, but, in addition, it presents other symptoms which, so far, do not appear to have been observed in sprue.

The symptom generally regarded as the "most important" and pathogno- monic in sprue is an aphthous inflammation which frequently affects the mucous membranes of the mouth, pharynx, and oesophagus, and occasionally those of the genitals. The very name of sprue is but a synonym of thrush, and "Ceylon sore mouth" is another local appellation which recalls this striking and trouble some feature of the disease, but the stomatitis is by no means always present, and, indeed, it may be far less common than supposed if, as seems likely, other local forms of white flux, such as the "hill diarrhoea" of India, are nothing more nor less than "

sprue" minus the complicating thrush, or, to be more correct, with seldom any mouth complication.

A similar inflammation of the mucous membranes of the mouth, pharynx, oesophagus, rectum, vulva, vagina, and prepuce is also found with equal frequency in pellagra, and, as in sprue, it occurs with greater prevalence in the pellagrins of the plains than in those of the hills.

Dr. Dominique Duplan, in his report on the Pellagra of the Hautes-Pyrénées, published in 1858, points out that the characteristic stomatitis and other mouth symptoms (thirst, ptyalism, red tongue, etc.) observed in almost every case by the physicians of the Landes, are far from constant in the endemic areas of the Hautes- Pyrénées, and Lussana in his work on pellagra, published in 1859, says:—

"Just as in the case of pyrosis, so also the tongue symptoms (denuda- tion, redness, dryness, etc.) I found to be far less common in the pellagrins of my Alpine climes than they are observed and described by other authors, especially in the pellagrins of the Lombardy plains. My observations find confirmation in the analogous ones made by Morelli on the pellagrins of the Tuscan hills and mountains, in whom he found the tongue to be usually normal."

Dr. P. H. Bahr, who has recently made an exhaustive investigation of sprue in the Island of Ceylon, states, in his paper read before the Society of Tropical Medicine and Hygiene, April, 1914, that he is inclined to believe, with Kohlbrugge, De Haan, and Le Dantec, that the disease is a hyphomycotic infection due to the ordinary thrush fungus Monilia albicans. He says his observations indicate that not only can yeasts be cultivated from the majority of sprue stools and salivas, but that in the acute as well as in the terminal stages of the disease this fungus is the most prevalent organism in the tongue lesions, salivas, and stools of victims of the disease."

To my mind, the evidence adduced does not appear to be convincing, and I should consider it just as reasonable to ascribe the disease to Spirocheta vincenti, or to the most constant of all mouth organisms, Streptococcus brevis. An instruc- tive example is that of scarlet fever. In this disease, the almost constant presence of Streptococcus pyogenes in the throat lesions, its activity in the production of complications, its agency in determining a fatal issue, and its occurrence at autopsy in the various organs and tissues, led certain authors to regard it as the causative agent of scarlatina, but this view had to be rejected because the very same organ- ism is found just as constantly in other diseases. Thus it is found in almost every fatal case of smallpox, its diffusion throughout the tissues probably taking place either during the agenal stage or post mortem.