mark their site, or large flakes of skin desquamate, leaving a raw surface; slight cicatrices remain as an evidence of former ulceration. "The whole clinical picture being analogous to a burn of the first degree." (Dr. Babcock). The wet form involves a greater area than the dry, such as the axillæ, groins, palms, etc. This form has been frequently diagnosed as dermatitis exfoliativa. The eruption is an index of the severity of the disease; an extensive, severe eruption usually bespeaks a severe infection.

Digestive Disorders.-The buccal mucosa becomes very red, the tongue and mucosa of lips showing particularly this characteristic symptom. If the throat is examined this redness will be observed as far as one can see into the pharynx. Flakes of exfoliated epithelium will be seen adhering to the gums, and the tongue being denuded of its epithelium is smooth and glistening. Now its color being a cardinal red and it being a cardinal symptom of the disease, I have denominated it the cardinal tongue. Sandwith calls it the "bald tongue." This stomatitis is accompanied by a very profuse flow of thick saliva, in some cases so profuse that the saliva dribbles out the corners of the patient's mouth. Ulcers often form on the tongue. Intelligent patients suspect they have been salivated by mercury. When the mouth is opened strings of saliva will extend from the upper to the lower teeth. My attention was directed by Dr. Babcock over a year ago to small black or bluish black spots on the tongue, and since then I have observed these papillæ in a number of cases, all negroes. The name of "stipple tongue" has been given this.condition by Dr. Lavinder. The tongue may be either pointed and tremulous, or large, flabby, swollen and indented.

The salivary glands may be swollen and tender. This with the salivation and condition of the swollen gums has been mistaken for mercurial. salivation, but just remember that in mercurial salivation there is always quite a disagreeable odor to the breath, and, while there is an odor to the salivation in pellagra, it is not the same disgusting fetid odor that is characteristic of mercurial ptyalization.

The acme of the stomatitis corresponds to the acme of the eruption on hands. Other mucous membranes are inflamed, proctoscopic examination reveals a bright red mucosa as far up the gut as can be seen.

Hemorrhoids are sometimes complained of. One of my patients thus complaining showed on examination only an intense redness of the mucosa, still she insisted that she suffered acutely from piles. This patient was then in a state of mild delirium, and probably there was some irritation. that caused her to refer to trouble in that locality. She was far advanced in the disease and this was the only symptom complained of. It is not unusual, however, for patients to complain of dis

Sometimes a patch of

comfort in this locality. eruption is found at the muco-cutaneous junction around the anus, and the patients complain of considerable discomfort from it. The mucosa of the vagina is also a seat on inflammation and vulvovaginitis is not at all infrequent.

Stomach-Burning sensation in the esophagus, and stomach is quite frequently present. Pyrosis is sometimes a prominent feature with or without belching. "Pyrosis is never absent" (Lombroso). Vomiting occasionally occurs, but is not a constant feature of the disease. feature of the disease. When the disease is advanced dysphagia is complained of by some patients, and this may be accompanied by strangling when fluids are taken.

Marked gastric symptoms are in evidence in some cases. I have known a case of pellagra diagnosed as gastric cancer. The only abnormality detected by abdominal section was an excessive redness of the peritoneal coat of stomach. After a few days the patient was rolled out into the sun, and soon there appeared on her forehead and hands an intense erythema. This aroused suspicion, and two competent consultants were called in. From the history of repeated attacks of eruption, and the picture presented by patient, the diagnosis of pellagra was made and the subsequent course of eruption (color, etc.), tongue, diarrhea and depression, put the diagnosis beyond doubt. Hematemesis is sometimes seen.

Diarrhea. This is a feature of the disease at some time in its course. It varies from a few soft stools a day to twenty or more; sometimes they contain blood and mucus; they are frequently involuntary when the patients are bedridden. This occurs when there is no mental hebetude. In a number of cases I have noticed that the stools are as frequent at night as in the day. The diarrhea is obstinate and not affected by the ordinary treatment or diet. I have seen it persist in spite of large doses of bismuth and opium and a rigid diet, and improve when drugs were discontinued and diet not restricted. It is not dependent upon errors in diet, but is a neuropathic manifestation, due to disease of the spinal cord and the sympathetic system.

The fact that the normal reflex in the intestines is greatly increased by the pathologic changes in these structures, may explain the diarrhea, since it produces hyperperistalsis in the same manner that irritants applied to the skin produce an exaggerated vasomotor dilatation with the erythema as a result. In rare cases there may be constipation. These cases are very mild, and show very slight mental depression or none at all. In the terminal stage, when temperature sets in, the diarrhea sometimes stops. Hemorrhages from the bowels may occur. Meteorism is present with the diarrhea, and sometimes persists after the bowels have lost their frequent action. The diarrhea follows the same course of the erythema and stomatitis, i.c., it has exacerbations and remissions and persists through the spring

and summer months, with a slight recrudescence in October, then disappears during winter to reappear the following spring.

Pupils.-Pupillary abnormalities are quite striking in some localities and in some seasons, varying in the same locality from year to year. In the year 1908, in South Carolina, pupillary dilatation was the rule, the mydriasis being extreme in some cases. It may be either bilateral or unilateral; if unilateral, the right pupil is most apt to be dilated. During this year, 1909, I have seen few cases with dilated pupils. Contraction of pupils is sometimes

Pellagrous eruption, showing pigmentation and symmetry. Commencing desquamation on right hand.

met with. The pupils react sluggishly to both light and accommodation, and "resist the action of homatropin considerably longer than the normal" (Dr. Whaley). Diplopia and photophobia are not unusual. These pupillary phenomena must be due to a disturbance in the cilio-spinal center. This center is situated in the spinal cord between the first cervical and second dorsal nerves, the portion of the cord that is nearly always affected in pellagra.

Pain in the Back.-This was a striking feature in some of the Italian cases that I saw, the pain being so severe that the sufferers walked stooped over, this attitude furnishing one of the seven varieties of the disease described in the Italian proverb. I have had only a few patients to complain of pain in back among the number studied in America. Pains in various portions of the body are often complained of. Tenderness at some point along the spinal column is almost constant. It is usually in the middorsal region and is easily elicited by pressure with the finger along the spine. The tenderness varies on the two sides, in some cases being more acute on the right. The tenderness is not over the spinous processes, but over the point where the nerves emerge from the canal.

Temperature and Pulse.-The mild cases are prac

tically afebrile, i.e., temperature less than 100°. The A.M. temperature is often subnormal-96° to 97.5°. Temperatures of 102° to 108° or over are not unusual in cases progressing to a fatal termination from so-called typhoid pellagra.

The pulse is accelerated-80 to 100 in ordinary cases-but increases with the toxemia or temperature, and counts of 160 are not unusual in fatal cases. Very rapid respiration is occasionally encountered without any appreciable cause for it.

There is nothing characteristic about the urine, except that alkaline urine is a bad prognostic sign (Lombroso).

The reflexes are usually exaggerated, though they may be normal, diminished or lost. Like other signs, they vary with locality and season. The patella reflex being especially more lively-the slightest touch eliciting a lively jerk, the knee-jerk varies on the two sides, in some cases being more lively on the right, the side that has the most exquisite spinal tenderness. In very severe cases, or rather those in which there are tetanic contractions, ankle-clonus may be found. In those cases that are paretic the reflexes are abolished.

There is usually analgesia or anesthesia at the site of the eruption.

Vertigo is complained of by nearly all of the sufferers, and should always be asked about if not mentioned by them. Its presence should always excite suspicion, and other pellagrous stigmata sought for.

PSYCHIC PHENOMENA.

Briefly, mental depression is as constant as the erythema and diarrhea, and varies from a mild case of the blues to severe melancholia. The patients seem to have "forgotten how to laugh." The poor sufferers imagine they have not a friend on earth, that even their own children or parents dislike them and have some irreconcilable grievance against them. They are easily provoked to anger, and in many ways indicate lack of mental force. Hallucinations and delusions are sure to occur at some time in the disease, and no two patients will have the same delusions. In Italy 10 per cent. become insane. As yet we cannot form any opinion as to what proportion of our patients will become insane, but if statistics are properly kept it will be a very easy matter to ascertain what proportion is demented.

While pellagrins are never loquacious, at times they are complaining of real or imaginary ills. As the disease advances they talk less, often not answering questions, and finally pass into a state of absolute mutism. This portion of the pellagrous syndrome is very important and pellagrous insanity properly calls for separate consideration.

Gait. The gait is either simple paralytic or paralytic spastic. The patients walk with their legs far apart, and as paresis sets in the stride is very much decreased, and the patient assumes a peculiar shuffling gait.

CASE I.-Mrs. T., white, widow, no children, aged sixty-two, family history good. Always in good health until present illness, which commenced Decemer 1, 1907, with diarrhea and lack of energy. The diarrhea gradually became more severe, and the motions were as frequent at night as they were during the day. About January 1, 1908, mouth was quite sore and salivation extreme. Mental depression and weakness gradually increased until she was forced to take her bed about May 1. The eruption appeared on hands about March 15, and was so severe that her physician thought she had gangrene. Temperature ran for three weeks from 100° to 101°. May 23, admitted to Columbia Hospital; weight 89 pounds; visceral examination negative; urine normal; pulse 68; temperature 96.5°. There existed on hands and forearms patches of pellagrous eruption, the dirty fringe being very noticeable. The palms of the hands were exfoliating, and had been the seat of an intense dermatitis, bullæ having formed on them which contained seropus. She endeavored to keep her hands concealed, as they were unsightly, and did not care for any one to touch them, fearing that she might contaminate them. There was also a patch of dermatitis on each elbow about the size of a half-dollar. Tongue and buccal mucosa very red; saliva profuse and tenacious. Patella reflexes exaggerated, right most lively; pupils contracted. Tenderness in mid-dorsal region, right side more tender than left; vertigo on standing. She remained in hospital until November, 1908. During that time she had frequent remissions and exacerbations of diarrhea, they being most severe from time of admission until about the first of August, when she gradually commenced to improve in her physical condtion. The greatest number of stools was in July (16th) when fourteen were recorded in twentyfour hours. The stools were principally involuntary from May 30 to August 3. Bed sore appeared June 12; nausea and vomiting June 4, and continued until July 15. All medicine, including bismuth and opium was discontinued July 13, and on the 15th there was no nausea or vomiting. Herpes zoster developed September 16. As her physical condition improved, her mental condition became worse; she imagined she was covered with microbes, and every day would have great numbers of fibers of lint and wool in a pus basin to show me "the things that were tormenting her to death." The latter part of November she became excited, and it was thought best to transfer her where she could be restrained. She was sent to a private institution at the North, and remained there until June of this year. There has been no recurrence of the diarrhea or eruption. She is the picture of perfect health to-day; weighs 130 pounds.

She admits being very fond of corn bread, that she ate it every day. She also states that for months before she was taken sick neither her corn bread nor hominy were properly cooked, the servant she had at that time being very careless.

CASE II. Mrs. S., aged twenty-one, white, married, three children living, four dead (no miscarriages), native of North Carolina, husband country merchant, distributing considerable quantities of shipped goods, including corn, by car loads. Health always good until four years ago, when she pre

sented the pellagrous syndrome-diarrhea, eruption on hands, stomatitis, salivation and vertigo. These lasted all spring and summer, disappearing during winter; they have returned each spring with increased severity. The first year the symptoms were noticed, quite a number of young chickens in the yard lost their feathers, were very red, did not grow, and finally became ataxic and died. She was in a state of valetudinarianism practically for four years, being frequently accused by her husband of being hysterical, as she often cried; was apprehensive that something dreadful would happen to her. In February, 1909, complained of burning in stomach; later diarrhea, eruption and salivation appeared, symptoms being more severe than any previous attack.

Condition June 13, 1909: Fairly well nourished woman; facial expression that of melancholy, absolutely mute; patella reflexes absent. Pupils dilated; cardinal tongue; strings of saliva extend from upper to lower teeth when mouth is opened. Takes

L. C., Case III. Showing eruption on face and neck. Note line of demarcation on neck.

June 17, refused food; quiet.
June 18, rested quietly. Bed sore.

June 19, fairly quiet day, temperature and pulse both elevated and limbs slightly rigid and tremulous, low muttering delirium; continuous rectal irrigation was commenced. The temperature gradually rose, and the neuro-muscular manifestations became more accentuated, until the condition reminded one of strychnine poisoning. Evidence of intense toxemia was present-low, muttering delirium, carphology, subsultus and dry tongue. All of these symptoms continued with increasing severity until the morning of the 24th, when death closed the

scene.

CASE III-Before taking up the anamnesis of this case it will be necessary to review the family history, although the patients were not seen by me. L. C., male, aged eleven, parents living, father being a miller. One sister died three years ago of pellagra, at fourteen years, and brother, of same disease, at eleven years, four years ago. Both died in August, the two fatal cases having developed the disease in their fifth and fourth years respectively. The disease manifested itself in the spring, and was supposed to be ivy poisoning. Remissions and exacerbations occurred during the spring and summer, and in winter the dermatitis and diarrhea were en

tirely absent. The disease increased in severity for six years in the case of the boy, till finally, after being unable to walk for two months, he was confined to bed for four months, and, following one month of excessive vomiting and diarrhea, died of exhaustion. On several occasions he vomited dark clotted blood. The girl had the disease mildly at first-sore mouth, diarrhea and eruptions on hands and feet. With her the disease lasted nine years. She had vertigo, burning in stomach, pain in back of neck and between shoulders, head drawn back, high fever; was treated for "spinal trouble" and hysteria. There was a tendency to stagger and fall backwards after any exertion. This was a striking feature of the case for the last two years of her life. There was no vomiting till shortly before death, nor was the diarrhea so severe as in her brother's case. In April, 1906, she complained of intense burning in stomach, "like she was burning up." The eruption, stomatitis and diarrhea then appeared, and she soon became very weak and was confined to bed till August, when she died, evidently of typhoid pellagra. For about two weeks before death she had convulsions with increasing frequency. Hemorrhages from bowels. There was opisthotonos, arms and legs rigid; mouth quite tremulous, "like she was chewing," subsultus marked, and for the last week of life temperature was "very high."

These histories are obtained from the father and mother. Furthermore, the father states that it was the habit of these children, as soon as they were old enough to accompany him to his work, when playing about. the mill-house, frequently to eat raw meal hot from the rock. The first year that either of the children was affected, he remembers that the local corn crop was practically a failure the previous year, and that he ground a great deal of shipped corn that he knew was damaged, spoiled or rotten.

So far as can be learned, neither the father nor the mother has at any time had the symptoms of a disease that suggests pellagra. It should also be recorded that the disease was not recognized as

pellagra during the lives of these two children. Furthermore, the father states that, so far as possible, he selected the best corn only for his family use. This may explain why the parents escaped, while the children ate raw meal of any sort and contracted pellagra.

L. C., aged eleven, brother of the above-described cases. He developed the disease at two years of age, the pellagrous syndrome-dermatitis, stomatitis and diarrhea-appearing every year in the spring. The diarrhea has never been severe-three or four actions a day in the early spring months. He has a tendency to stoop forward, and when tired falls down on his all-fours.

Physical Examination.- October 10, 1909. A fairly well nourished but small boy; mentality low for his age; pupils moderately dilated, but not as much as they were in June; patella reflexes aggravated. Not mentally depressed; sometimes plays as other children do, and again is unusually quiet. The accompanying photograph will show the extent of the eruption.

CASE IV.-Miss C. C. S., aged tyenty-five, white. Aunt on mother's side had "nervous spells." Family history otherwise negative. Previous health

good. Was taken sick in March, 1904. First symptom was indigestion, diarrhea and burning pain in stomach and "smothering feeling." Could not stand to look at water or hear it splash, as it would make her very nervous, blind and dizzy, and cause her to have shortness of breath. Was very thirsty, but was almost prohibited from drinking by the sensation produced by the sight of water, and only when thirst could be endured no longer would she force herself to swallow a few mouthfuls. Mouth was very red and sore, with quantities of thick saliva. Eruption came on hands and arms about two months after onset of diarrhea, and one month later came on face. These symptoms continued until September, when improvement set in and she thought she was well.

In spring of 1905 there was a repetition of all the symptoms, but more severe.

Well during winter. In spring 1906 light attack, except mental depression was more pronounced.

These exacerbations and remissions have occurred each year since. In 1907 the diarrhea was more severe than at any other period of the disease, the bowels acting as often as twenty times a day for days at a time.

March, 1908, all symptoms returned, eruption. being more extensive than at any previous attack. Mental depression marked, vertigo severe.

Had a

desire "to run and go away hundreds of miles." Would be unable to sleep at night, and would get. up and walk around house for hours, and not stop until forced to do so from exhaustion.

Seen by me July 16, 1908.

Examination.- Emaciated woman, apparently thirty-five years old. Heart and lungs normal; abdomen negative, except for slight meteorism. Radial arteries palpable. Pellagrous eruption on hands, arms, elbows and below elbows, neck, face and chest. The extensive distribution in this case was

due to her wearing a very thin shirt waist; although extensive, the eruption was symmetrical. Tongue a cardinal red and bald, abundance of thick

saliva. Pupils widely dilated; reflexes exaggerated; marked tenderness in mid-dorsal region. Answers questions intelligently and promptly. She was advised to give up all products of corn in diet. No medicine prescribed.

Was seen in May, 1909; was then the picture of health and had gained twenty-five pounds. Blaud's pills with atoxyl prescribed.

On May 20 a slight diarrhea set in and two weeks later the eruption appeared.

The following report was received from her, Septemer 29: Entirely free of eruption; disappeared two weeks ago; has been very slight this year. Has kept out of sun; every time she went out the eruption would come back. Bowels have not been loose; rather constipated. Mouth has been very sore, as though "burnt with lye." Troubled with sleeplessness. Complains of her stomach feeling weak, though for the last two weeks that has been relieved to a great extent. Some months ago had a very profuse "flow," lasting three weeks, "almost a hemorrhage."

INFLAMMATION OF THE SEMINAL VESICLES.*

TH

BY J. N. BAUGHMAN, M.D.,

EVANSVILLE, IND.

HE seminal vesicles, two in number, are situated between the base of the bladder and the rectum. They are about two and onehalf inches long, but, when uncoiled, are about five to six inches in length. The upper or back portion of each vesicle is formed of a blind pouch or culde-sac, and is placed about the termination of the ureters into the bladder.

The anterior extremities are pointed, and converge toward the base of the prostate gland, and, joining with the vas deferens of either side, form the ejaculatory duct, one on either side, and which are about three-quarters of an inch in length, and open into the under surface of the prostatic portion of the urethra.

The seminal vesicles are largest in the posterior part, and gradually converge to the ejaculatory duct rather in the appearance of the Big Stick we have seen pictured in the newspapers for the last few years, and are like it in more ways than shape, for within the confines of this little space originate more joy and sorrow, more bliss and cussedness, more happiness and sin, than in all the rest of the entire male anatomy.

Women are not troubled in the possession of seminal vesicles or a prostate gland.

The seminal vesicles vary in size in different individuals, and are capable of holding from one-half to three or four drachms of fluid. The seminal fluid is, at least partially, secreted within these bodies, and retained there until expelled by the The seminal fluid spasmodic action of ejaculation.

*Read before the Ohio Valley Medical Association, Evansville, Ind., November 11-12, 1909.