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Sir Patrick Manson, in his “ Manual of Tropical Diseases," says:-

"

The patient may complain of feeling physically weak of loss of memory His friends wil and of inability to take exercise or to apply his mind. probably volunteer the information that he is irritable and unreasonable." In the majority of cases the nervous manifestations of pellagra are identical with those of sprue. The patient complains of lassitude, he is incapable of mental and physical work, he suffers from insomnia, and is easily provoked to anger. There is weakness of memory, depression, and anxiety. These, as a rule, are the nervous symptoms of the early stages and of the milder forms of the dianase, but many cases may reach a fatal termination without showing any greater nervous derangement. Indeed, several authors have asserted that pallagra may occur without the manifestation of any symptoms referable to the nervous system. On the other hand, in a proportion of cases there may be hallucinations and distur- bances of orientation. The patient may become profoundly melancholic, he may manifest suicidal tendencies and refuse to take food. Sometimes the picture is one of severe prostration with muttering delirium, muscular twitchings,” and car- phology. The patient does not often become maniacal, but sudden outbursts of exaltation or delirium may occur in cases of apparent stupor. Amongst the most characteristic symptoms are vertigo, headache, spinal tenderness, tremor, rigidities and spasms in the muscles of the lower extremities, uncertain and painful gait, tendency to fall forwards or backwarda, axaggeration of tendon reflexes, depression, confusion, and terminal dementia.

It is estimated that from 5 to 10 per cent of pallagrins drift, into lunatic asylums, but no reliance can be placed on any of the computations hitherto made. Unfortunately, neither in sprue nor in pellegra have we as yet, any micro- For a short time I believed that the scopic finding of diagnostic importance. examination of the blood might prove helpful, because in pellagra there is an early relative increase of the lymphocytes, which, according to Dr. G. C. Low, is not seen in sprue, however advanced the case may be. But Drs. G. Lovell Gulland and Alexander Goodall state that in sprue they found the lymphocytes to be relatively

in excess.

It is interesting to notice that, until quite recently, both Ching, and India, which are looked upon as the most important sprue centres, had not reported pollagre. Yet the disease is there right enough. Dr. Ray, in 1902, stated that he had seen several pellagra cases in one of the districts of North Behar, India. Dr.

in 1913, reported it from the Straits Settlements, and, in 1914, Dr. Maxwell recognized it in Northern China.

In justice to Dr. Manning, it must be stated that what he really claims is that the pellagra seen nowadays in Barbados is no other than the disease described by In his report of 1907, Hillary in 1766, under the name of Aphthoides chronica. "On certain cases of Psilosis pigmentosa," after quoting Hillary's description, he says:-

"The above description, written over a century ago, forms a pretty correct sketch of the disease which we have in Barbados, but it is not a finished portrait. It is possible that the disease which existed a century ago, and which has been so aptly described by Dr. Hillary, is the same disease which is attracting the attention of the medical faculty of the Colony to-day; for it has been pointed out by Dr. Thin, in his admirable work on psilosis or sprue, that the disease, as known in China, is not identical with the hill diarrhoea of India, and the cases of tropical diarrhoea in the Bengal and Bombay Presidencies are distinct from the psilosis linguæ et intestini, whilst the cases from Ceylon appear to be identical with the 'sprew' of the Dutch. The physicians of Ceylon separate cases of 'sore mouth of Ceylon' as being differentiated from the diarrhoea of the Indian plains and the diarrhoea of the hills. It is of very great importance to decide whether the 'sprew,' as described by Dutch physicians, the diarrhoea so prevalent in Cochin China, and described by French writers as the white diarrhoea and hill diarrhoea of Sir Joseph Fayrer, the Indian writers, is not one and the same disease. Bertrand, and Fontan believe them to be different forms of the same disease.

"If it be possible for this disease to assume different types in different individuals, or if it can be modified by race and climate, then it is possible that the disease, as we see it now in Barbados, is one of the forms of 'sprew*

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or pilosis.

There can be no doubt that the description which Hillary drew of the disease is perfectly correct and trustworthy so far as it goes, but it does not go far enough. In all probability the disease is altered, and its existing modifications may be the result of changes in food, peculiarities of life, or some other unknown conditions which have brought about the changes which are so apparent. One of the first symptoms which we cannot fail to notice is the appearance of certain pigmented patches which appear in the great majority of cases over the knuckles, wrists, elbows, ankles, and legs, and it is the presence of these pigmented patches that has raised the question whether these are not cases of pellagra. It was the appearance of these pigmented patches, together with the ordinary well marked symptoms of psilosis, that led the late Dr. Cuthbert Bowen to write a very admirable paper on this subject and suggest that the disease be called 'Psilosis pig- It matters not what we call it there cannot be the slightest doubt that we do have a large majority of these cases with well marked pigmentation running through all the phases of psilosis, and presenting all the post-mortem appearances of that disease."

mentosa.'

Having seen that confusion is quite possible between sprue and pellagra, that in the Island of Barbados for many years pellagra was actually taken for sprue, and that the disease described by Hillary under the name of Aphthoides chronica may have been pellagra and not sprue, the doubt might well arise as to there being any sprue at all in Barbados. Indeed, in 1908, Dr. Carnegie Brown, in his work

Sprue and its Treatment," says:—

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"I am aware that cases have from time to time been reported from various places in the western tropics, but it is questionable, in my opinion, whether genuine sprue ever originates in any part of the world except the tropical and subtropical regions of Eastern Asia."

Recent information on the geographical distribution of sprue does not uphold this doubt. I was unable myself to see a single case of aprue in Barbados, but the local physicians, and more especially Drs. John Hutson, J. F. E. Bridger, T. Sinclaire Browne, and Hallam Massiah assured me that genuine sprue is not uncommon in the island. Besides, we know that it has been reported from Jamaica and from other West Indian islands. In 1843, Schorrenberg_described cases of "Indian sprew," from the islands of Haiti and Porto Rico. In 1902, Moreno della Torre reported its presence in Cuba, and, in 1913, Dr. Bailey K. Ashford described several typical cases from the island of Porto Rico, where the disease has long been known by the names of “phthisis intestinal,” “escorbuto tropical,” and “añemia."

Probably confusion between sprue and pellagra in Barbados arose from the frequent concurrence of the two diseases. In an unpublished report of 1912, to the Acting Governor of Barbados, Dr. Bridger says:-

"In the majority of our cases, in the middle stages of the disease, we find during life a sprue-like diarrhoea as a fairly constant symptom, and post mortem the condition of the gut is similar to that observed in that disease. It is for these reasons that the disease has been thought to be sprue.

"These symptoms are explainable if the view is taken, which I believe to be the correct one, that we are not dealing with a single pathological entity.

These cases are, in my opinion, the outcome of two separate conditions, one superimposed on the other. I consider that this 'pigmentary' disease is true pellagra, in which the alimentary tract, during the progress of the disease, becomes the seat of a secondary catarrh of microbic or parasitic origin."

Identity of West Indian and European Pellagra.

One of the main objects of my visit to the West Indies was to ascertain whether the disease newly reported from these Colonies was really pellagra. In Jamaica the existence of the disease had been recognized for a number of years, but, accord- ing to Dr. D. J. Williams, "as the disease was unknown in the West Indies, the correctness of the diagnosis was questioned, and the erythematous condition of the exposed parts of the body attributed to sunburn." In Barbados, as we have already seen, the disease was long confounded with sprue. In an interim report on Pellagra at the Lunatic Asylum," by Drs. John Hutson, C. J. Manning, and E. Howard Bannister, to the Acting Colonial Secretary, 22nd July, 1907, we read the following statement:-

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