erythema endemicum, sive pellagrum (Alibert)-maladie symptomatique des lésions du tube digestif (Biett). It is uncertain when the disease was first recognized; mention is made, in the records of the Milan Hospital for the year 1578, of a disease designated "pellarella," but no characters or symptoms are enumerated. Numerous authors maintain that it is of comparatively recent origin, and date its first appearance about the beginning of the last century. Its causes are equally uncertain, being by some attributed to the action of the sun, by others to atmospheric influence, or to the use of unwholesome, saltless food-of unfermented and deteriorated bread; Marzari blames the Indian corn and "nolcus sorghum;" the impure and muddy water which is drunk has been accused of it. When, from the causes, we pass to the characters of the disease, equal discrepancy of description is found; it has been compared to hypochondriasis, impetigo, vitiligo, lepra, elephantiasis, scorbutus, ephelides, mountain scurvy and "mal de la Rosa," and mange. Alibert says it is a species of exanthema, arising, not from ordinary inflammation, but from a virus which is generated; Biett regards it as always symptomatic of disorders in the digestive organs; Dr. Strambio, of Milan, thinks that it originates in an irritation and slow inflammation of the neurilema of the spinal nerves and marrow, which, in course of time, occasions a chronic gastro-enteritis; and Drs. Liberali and Carraro describe two degrees of the disease-the first of which, produced by the use of unwholesome, indigestible food, is designated a slow gastroenteritis, and the second, brought on by bodily sufferings and mental distress, is a slow gastro-meningitis. This melancholy disease is not confined to one sort of locality; Strambio has seen it rage among the smiling hills of Seprio, Brianza, and on the confines of Olonna; and has remarked that, while it proved very destructive in the arid parts of the Duchy, it has been less malignant in those which are better watered. He found it to be prevalent among the poor peasants, who live in the dry plains and hills, drink clear wholesome water, and

never feed on fish, or any salted meat; and on the contrary, to be much less common among the inhabitants of the wet and rice districts, who live a great deal on salt provisions, and who drink a very impure water. Similar observations have been made by Cerri, on the frequency of the disease in the dry grounds between Lago Maggiori and the Lake of Como, where the people live entirely on bread made of Indian corn, wheat, and rye, while the inhabitants of the mountains and wet country escape it. But, on the other hand, Dr. Griva has seen it in many of the damp provinces of Piedmont, and in the very dissimilar regions of Friuli, Treviso, the Venetian States, Padua, Parma, Piacenza, Florence, &c.

Three stages of the disease have been described:-In the first, the skin of the feet, hands, and such parts as are exposed to the sun, becomes red, is very itchy, and in time the epidermis falls off in scales; in the second, the skin is wrinkled, hard, and full of chaps; the person is haunted with fear, is anxious, and cannot sleep; he falls into a state of hypochondriasis, imbecility, or of mania, is troubled with diarrhoea and extreme debility, and loss of all muscular powers; yet there is no fever. The third or last stage is marked by fever, colliquative purging, stupor, and death. Strambio states that pellagra is successively of an intermittent, remittent, and continued type; that the cutaneous affection has also a threefold character, being at first scaly, then vesicular, and lastly desiccative, or in which the skin peels off without any preceding heat or redness; that the delirium is sometimes of an acute form, and that, at other times, it is chronic, shewing itself under the signs of deafness, melancholy, extreme taciturnity, attempts at suicide, especially by drowning. The duration of the disease is generally for several years. The class of the population who are by far the most subject to it are the peasantry. It is not often observed to attack children under 12 years of age. Some authors deem it contagious and hereditary; others deny both of these positions. The pathology of pellagra is not very satisfac

torily made out. The following appearances have been noted: a collection of yellowish serum between the membranes, and in the cavities of the brain-congestion of the vessels of the pia mater, plexus choroides, and of the cerebral substance, suppuration and hardening of the brain itself-inflammation of the spinal chord and of its membranesaccumulation of serum in the pleural cavities-inflammation and abscesses of the lungs-ulcers of the trachea-dropsy of the pericardium and of the abdomen-chronic peritonitis-ulceration of the stomach and intestines--hypertrophy-tubercles and scirrhus of the liver, &c.

The prognosis is always very unfavourable; by many the disease is deemed in

Case 1. A woman, aged 34, was admitted into the Milan Hospital with symptoms of gastric irritation. On examination, the hands, feet, and bosom were found affected with an erysipelatous eruption; the redness was uniform in some parts, patchy in others, and having the appearance of what artists term being stippled; its hue varied from a light to a very dark shade of red. The rest of the surface was not affected. The patient had been ailing for three months; had lost her appetite, strength, and she had become very desponding: the abdomen was slightly tender on pressure-the tongue was redconsiderable thirst. Since her infancy, this woman had been engaged in rural labours. She was treated with aperients, cooling drinks, and light, wholesome diet, and speedily got well; the erythema died away, and the skin was detached in small scales.

hospital in June, 1830. He had suffered slightly from the disease two years before; but, after remaining for several weeks, it disappeared on the commencement of Summer. It returned in the first week of March of this year (1830) with more severity; he experienced headach and confusion of senses, and a feeling of dragging along the spine; great debility, especially of the limbs, and lowness of spirits. The skin of the arms, hands, and feet was dry, furrowed, slightly wrinkled, and of a brown colour; here and there it was desquamating in small white or brownish scales, and was observed to be red and shining beneath these. The abdomen was tender on pressure-tongue red, no appetite, frequent purging, and loss of sensibility of the legs. He was treated principally with tepid baths, and, in the course of three or four weeks, had greatly recovered his health.

Case 3. A young female peasant, aged 17 years. She was much wasted in flesh, and her face indicated great distress. Tongue red, especially at the edges, and white in the centre; sensation of burning heat in the throat-abdomen painful on pressure-diarrhœa-pain and confusion of the head-extreme weakness of the lower limbs-frequent darting pains along the spinal cord. The skin of the nose and cheeks was covered with small yellow scales, and a similar appearance was seen on the bosom. The skin of the arms, hands, and feet was brown, dry, rough, and hard, and presented a dappled appearance; here and there were a few vesicles, and in other places the surface was scaly. She was treated with tepid baths, aperients and refrigerants, and wholesome diet, and speedily recovered.

a report of her case. Irritation in the throat and stomach, purging, great emaciation, aspect of old age; tongue red, pulse full and frequent, epidermis of the arms, hands and feet dry, rough, brown, scaly on the fore-arms, and forming a sort of hardened cuirass on the fingers; when the scales were removed, the subjacent skin was white, and little altered. Leeches behind the ears, and a treatment similar to that pursued in the former cases was adopted with good effects; but there was every chance of the disease returning on the next year.

Case 5. EXHIBITING THE EFFECTS OF

PELLAGRA ON THE MIND,

A woman, aged 25, had suffered several times from pellagric symptoms, but they were much aggravated in 1830; and when she entered the hospital the following were the symptoms; skin rough and very dry, in some places scaly; on the fore-arms and hands it was brown and appeared like a long glove drawn over them; when minutely examined, it was found covered with very minute scales, like those of a fish. For several days there was delirium, or rather alienation of mind. The state of the tongue and of the abdomen indicated gastro-enteritic irritation; considerable diarrhoea. Leeches and cooling aperients were ordered. The cerebral irritation gradually declined; and she then complained of a dull pain in the spinal cord, and utter inability to support herself on her legs. Under the use of the baths and the above treatment, she gradually recovered her health in considerable degree.

In the third stage or degree of the disease, the mental faculties become quite unhinged, and the bodily affection is much aggravated; the frame wastes, the features become sharp, complexion earthy, and aspect mournful and afflicted; headach, redness of conjunctiva, roughness and scaliness of the skin, which becomes disfigured with grooves and chaps; the reason falters, the mind is haunted with gloom and fear, and too often the wretched sufferer becomes quite lunatic, either moping in silent grief, or raving with

madness. The most common species of mania is, however, a religious fatuity. Case 6. CONFIRMED PELLAGRA RESEMBLING CONSIDERABLY ELEPHANTIASIS, AND THE LEPRA OF THE ANCIENTS.

The face of the patient was much emaciated, of a clear yellow hue, features very sharp, had long suffered from gastric irritation and protracted diarrhoea. The skin of the upper extremities from the fingers upwards to four inches above the elbow was covered with scales of a deep brown colour, very thick, especially on the back of the hands and fingers, so as to resemble the horny elevations or tubercles which we notice on the backs of some fishes; it was crossed in all directions with deep furrowed lines, which thus divided the hardened patches into numerous small, rough, coarse, and elephantiasis-like tubercles. The issue of the case is not stated.

When pellagra affects young children they are generally found rickety at the same time, with large tumid bellies, and maras

mus.

The following cases will illustrate the pathology of pellegra.

the

Case 7. A man, aged 44, had suffered for 10 years. The skin of the forearms, hands and feet, presented the usual appearances, previously enumerated; mind had become affected; the vision imperfect, and sometimes double; he could with difficulty stand upright, and he felt as if there was a weight which dragged the head and spine backwards. He died suddenly.

Autopsy. Not much emaciation; the bones of the cranium were thickened; the archnoid adhered in some places to the pia mater, and between this latter membrane and the brain, there was a copious deposition of an opaline, gelatinous substance; the meninges were injected with blood; substance of brain not changed; a considerable quantity of blood found at the base of the brain; a copious intermuscular bloody effusion over the lower cervical, and upper dorsal vertebrae; the membranes,