Vol. 60, 1909 - University of North Carolina at Chapel Hill

ORIGINAL COMMUNICATIONS. 71
^ive US difficulty. When we first see the ery- form of the disease. In tlie discussion of
thema of the exposed part definitely demar- a paper presented by the writer to the Colcated
by the clothing from the sound skin lege of Physicians of Philadelphia, last
and without any other symptom, we are November, Dr. H. A. Cotton. Ruperintenoften
at a loss to know whether we have an dent of the State Hospital for the Insane,
outbreak of pellagra or a simble sunburn, at Trenton, X. J ., mentioned a class of cases
It is never wise to make the diagnosis with- recently described by Adolph Meyer under
out the presence, or the history of the past the term "central neuritis," in which the
occurrence, of a simple stomatitis, or a mental symptoms were quite similar to
diarrhea, or both, but when we have the those of "pellagra-sine-pellagra." Assotriad
of symptotLs; symmetrical erythenia ciated with the stupor or anxious delirium
of the exposed parts, diarrhoea, and sto- he mentioned rigidity, peculiar muscular
matitis, we need not hesitate to make a de- spasms or jactitations, and ob.^tinate diar-
finile diagnosis. We frequently see cases rhoea. All these cases terminated fatally,
without stomatitis atid without a history of The etiology of central neuritis is obscure,
having had it, but it is very infrequent not but the process is probably due to an intoxto
find diarrhoea or some other very defin- ication, and as Dr. Cotton sakl, the histoite
digestive disturbances which are usually pathology has been definitely described and
numerous and varied. A burning sensation can easily be diagnosed by a compein
tlie epigastrium and a pain just below tent neuro-pathologist. While the two disthe
left scapula are common symptoms, eases cannot be counted altogether similar,
"Pel1agra-sine-i)ellagra" was mentioned still, they probably arose from the same
at the meeting last year, but at that time we pathological process. It was my good forfeit
that our experience was insufficient to tune to secure the brain and spinal cord
warrant any reliability in attempting to from one of my cases of "pellagrasinemake
this difficult diagnosis. Since that pellagra," which I submitted to Dr. Cotton,
time, we have extended our experience He writes me as follows:
along this line and we feel justified in con- "My suspicioTis regarding the similarity
eluding that not only does such a condition of this process with that of central neuritis
exist, but that it may be diagnosed. It is is well borne out in this case. The large
is a well known fact that tlie severity of motor cells and a great many cells in other
the attack of pellagra is in no way indi- regions show 'axonal reaction' to a very
cated by the extent or severity of the skin marked degree.
lesion. We have seen many cases with a "The condition has been somewhat delarge
amount of the skin surface affected, scribed by Maranesco and other Italians as
and yet the patient recover, while again, 'chromatolysis' but none of them have rein
other cases where the area of affected cognized that it is an "axonal reaction'. In
skin was small, the patients have succumb- other words, it is a parenchymatous degened.
In most of our cases of "pellagra sine- eration of the central nervous system. "
pellagra" we have found that a careful in- The case above referred to was unquesvestigation
of the previous medical history tionably one of pellagra, and the pathologic
was very suggestive of one or more pre- finding as reported by Dr. Cotton, is most
viousoutbreaksof definite pellagra. Again, important, because, as Dr. Cotton says, it
we found, on careful examination of the is altogether probable that this condition,
skin, in most of these cases, a faint line which has been described as central neuritis
representing the limit of what must have is probably prevalent in the insane institubeen
a skin lesion of mild degree. We are tions of New York and Massachusetts. It
rather disjjosed to conclude that "pellagra- is certainly worthy of further investigation
sine-pellagra" is a misnomer, and that in to determine the question of the possible
all these cases, at one time or another, identity of central neuritis with this atypical
there have been definite skin lesions form of pellagra. It is also probable that
of pellagra, though they may have many of the cases diagnosed dementia-parbeen
very insignificant. Our cases of alytica, in which have occurred peculiar
"pellagra-sine-pallagra were chararter- skin lesions, are really pellagra.
ized by stomatitis, diarrhoea, and well In the fourth Annual Report of the State
marked nervous and mental symptoms. In Hoard of Health of the Commonwealth of
all cases the patients were melancholy. In C.eorgia, 1908, Dr. H. I'. Harris reported
two cases the patients were markedly ema- the occurrence of sprue. I'rom Dr. Harris'
ciated and the reflexes were very much ex- description, it would be extremely difficult
aggerated. Blood cultures taken from to diagnose this condition from "pellagrathese
patients were negative, but this was sine-pellagra", owing to the fact that the
expected, as we have learned by experience characteristic symptoms of sprue are stomathat
the organism can only be isolated from titis, diarrhea, emaciation, and mental disthe
blood of those suffering the acute turbauces very similar to pellagra. In my