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C.O. 885

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In order to uphold the thrush causation of sprue, Dr. Bahr is obliged to have recourse to the deus ex machina of tropical pathology and assume a special viru- Otherwise lence of the fungus brought about by certain tropical conditions.” it would be impossible to explain the peculiar clinical features, geographical dis- tribution, and epidemiology of sprue. However, though I do not believe Monilia albicans to be the causative agent of sprue, I am quite prepared to consider it an important auxiliary infection, and to ascribe to it much of the frequency and severity of the buccal manifestations of the disease in the germ-laden atmosphere of the lower and warmer regions. As a secondary infection thrush is known to occur, with more or less frequency, in many other diseases. I need but mention pneumonia, diabetes, typhoid fever, pemphigus, and more especially the cachectic stages of cancer, tuberculosis, and syphilis.

In pellagra, as in sprue, the injured epithelium of the inflamed mucous mem- brane forms a favourable substratum for the growth of the Monilia, the spawn or mycelium of which may carpet the oral mucosa with patches of pearly-white membrane, but in the majority of cases neither the hyphal threads nor the conidia of the thrush fungus can be detected amongst the luxuriant flora of the inflamed buccal cavity, and any exudate present may be due to streptococci or other micro- organisms.

Like its dermatitis, so also the stomatitis of pellagra may-present all grada- tions, from a very mild type, frequently overlooked, to a severe, diffuse inflamma- As tion characterised by crimson rash, acute burning, and profuse salivation. a rule the mucous membrane inflammation occurs simultaneously with the skin eruption, and is of the same erythematous nature, giving rise to vesiculation and exfoliation. In pellagra, as in other diseases with marked skin manifestations, the mucosa become the seat of lesions identical with those of the external surface. In urticaria I have frequently seen the characteristic weals appear on the mucous The bulbous eruption of pemphigus may membranes of the mouth and throat. actually begin on the mucose of the mouth and pharynx. In dermatitis exfolia tiva, in purpura, in herpes zoster, in syphilis, we find on the mucosa lesions clearly comparable with those of the skin, even though they may exhibit slight modifica- In scarlet fever both skin and tions due to the difference of anatomical seat. mucous membranes show an identical erythematous rash very similar to that of pellagra, and as there are cases of "scarlatina sine eruptione" presenting the characteristic angina so there are cases of "pellagra sine pellagra" exhibiting an acute and typical stomatitis.

The gastro-intestinal symptoms of sprue and pellagra are exactly alike. In both diseases there may be anorexia, or, more frequently, a voracious appetite; there is always flatulence, pyrosis, and sometimes vomiting; the patient complains of gastric distress, especially after meals; thirst may be a troublesome symptom the abdomen is often greatly distended; and there may be uncomfortable bor- The evacuations are borygmi. Diarrhoea is usually present and often profuse. passed, as a rule, with neither griping pains nor tenesmus.

The truly important symptom in the whole syndrome of sprue appears to be It is characterized by copious, the diarrhoea, which is said to be "typical." pultaceous, foamy, light-coloured, ill-smelling_evacuations, passed as a rule in But "typical" evacuations are not the early morning or during the forenoon. always present. In the earlier stages, or during the quiescent periods, the stools At other times they become very numerous may be formed and dark coloured. and of a watery consistence. Then, again, there are cases without diarrhoea. ·

of incomplete sprue, to dis- Sir Patrick Manson calls them the "gastric cases

in which there is diarrhoea but no tinguish them from the "intestinal cases," mouth trouble.

When present it may

In pellagra diarrhoea is frequently entirely absent. vary considerably in appearance and nature. There may be, especially in the early stages, frequent muco-sanguinolent stools accompanied by colicky pain, there may be bilious stools or light-coloured, pasty, yeasty-looking, lienteric evacua- tions passed without effort, and, in the later stages, frequent watery stools, which cannot be checked. This serous flux is certainly the most typical form of diarrhoea in pellagra, and, as in sprue, it is the most important factor in bringing about the wasting and sinking of the patient.

Pellagra is really distinguished from sprue by its characteristic skin lesions and the nervous and mental symptoms, which may be very marked from the outset.

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In long standing cases of sprue, together with considerable wasting of the body and anæmia, the skin becomes dusky and dry, but the striking localized erythematous patches of the pellagrous eruption do not seem to pertain to sprue. However, some authors have recently asserted that they do occur. Dr. Stewart says:-

"In the differential diagnosis of pellagra and sprue there is only one symptom which calls for serious consideration, namely, the cutaneous lesions which are so frequently found in cases of pellagra, and from which the disease receives its name. From a study of the literature and from personal observations of these two diseases, it is apparent that cutaneous lesions are quite common, and more or less characteristic in cases of pellagra, while in cases of sprue characteristic cutaneous lesions have not been observed. Nevertheless, some of our best pellagrologues describe cases of pellagra sine pellagra, and from my own limited observations I can say that there are at least a few cases of sprue-cum-pellagra.' In two of my cases of sprue, one from Porto Rico, the other from Central America, there are skin lesions. In both, the dorsum of the hands was of a dark red colour, rough and parchment-like; in one there were recurring ecchy- motic areas such as Hyde described as occurring in cases of pellagra." Dr. Bahr states, in his "Researches on Sprue," that:-

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"In advanced stages of the disease, in which there was also marked anemia, curious pigmentations of the skin, consisting of brown patches of irregular outline, were present and were situated on the forehead, temples, cheeks, on the abdomen, and once on the legs."

The brown patches of irregular outline mentioned by Dr. Bahr were possibly nothing more than patches of chloasma cachecticorum, a pigmentary change of the skin common to all kinds of cachexy, whether due to sprue, malaria, syphilis, tuberculosis, or cancer. Such pigment patches are usually single, they do not affect the peculiar regional distribution and symmetry of the pellagrous dermatitis, and their surface is smooth. Many years ago, Sir Joseph Fayrer described similar skin symptoms in cases of hill diarrhoea.

The lesions described by Dr. Stewart are very different. They are clearly pellagra lesions, and, if they were really part and parcel of the sprue syndrome, we should have to admit the identity of the two diseases. But the cases in which they were observed came, one from Porto Rico, and the other from Central America, in both of which places sprue and pellagra are known to occur. It is, therefore, quite possible either that the diagnosis was wrong or that the two diseases were associated in each patient, blending and confusing their respective symptoms. Indeed, Dr. Stewart seems to base his diagnoses more on geographical considerations than on clinical data. He says:---

"I have under my care a case of pellagra of nine years' duration, which presents the typical pellagrous symptoms with the exception of the erythema. Instead of the erythema the skin of the dorsum of the hands is dry, atrophic. and presents a few small ecchymotic areas. This is evidently a case of 'pellagra sine pellagra,' but, had he come from China or the West Indies instead of Indiana, I would have diagnosed his case as being one of sprue, as I have done in the case of a missionary from China, whom I am also treating at the present time."

The distinction between chloasma patches and the residual pigmentation of the pellagrous dermatitis is not always easy, and certain authors-Lombroso, for one have described in pellagra "patches of chloasma and maculæ." Lombroso states that, at times, the whole surface of the body may become darkened. Finally, although I believe that the skin is always more or less affected at some time in the disease, there can be no doubt that the pellagrous erythema passes unrecognized in the great majority of cases, and, moreover, we should not forget that, owing to diagnostic difficulties, most authors give the name of pellagra only to such cases as present the unassailable tripod of symptoms, and, above all, a clear manifestation of the characteristic dermatitis.

With regard to nervous and mental symptoms, all we find mentioned in the literature of sprue is muscular weakness, loss of memory, depression, irritability,

and sleeplessness. Dr. Thin, in his book on Psilosis, says:—

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Many patients look anxious and depressed; some have a peculiar,

vacuous, absent expression; in some cases the mental condition is character- ized by dullness and indifference."