Strychnine is usually given as a routine treatment in the less acute cases. With muscular atrophy massage is of prime importance. Electrical stimulation is also usually employed. With the palsies there is great danger of contractures so that even the bed clothing should not rest upon the paralyzed feet. Even splints may be necessitated. CHAPTER XIX PELLAGRA DEFINITION AND SYNONYMS =Definition.=—For a time it seemed as if the old idea that pellagra was connected with a dietary defect, chiefly as regarded some factor in a preponderating diet of maize, had been replaced by one assigning as cause some infectious process, probably protozoal, possibly bacterial. The important advances recently made in the study of beriberi have tended once more to swing the pendulum to the food deficiency etiology. The latest views assign to food deficiency the basic etiology, but regard some other factor, possibly an infectious one, as secondarily operative. The disease is essentially chronic with periodic exacerbations but may run a rather acute course with a rapidly fatal termination. The trend of symptoms consists of (1) mild neurasthenic manifestations in the winter to be followed in the spring by (2) disturbances of the alimentary tract, consisting of stomatitis, burning sensations going up the oesophagus, gastric eructations and recurring diarrhoeas. (3) In addition to the neurological and alimentary tract symptoms we have the third and diagnostically the most important group, those of the cutaneous system. The pellagrous eruption is characterized by strikingly symmetrical, sharply delimited patches of erythema, resembling sunburn. The sites of preference are backs of hands, extending up the forearms, bridge of nose or neck. The neurasthenia tends to pass into a toxic psychosis or even a confusional insanity. =Synonyms.=—Maidismus, Alpine Scurvy, Asturian Leprosy, Mal de la Rosa, Mal del Sole. HISTORY AND GEOGRAPHICAL DISTRIBUTION =History.=—Strambio considers some of the references of Hippocrates to refer to pellagra but Castellani and Chalmers state that after searching the writings of Hippocrates they have been unable to find any references to a disease showing a resemblance to pellagra. The first definite description of the disease is generally credited to Casal who, in 1735, described the disease as it existed in the Asturias. In his writings he notes that the peasants lived chiefly on corn and that they rarely had fresh meat. Casal’s paper was not published until 1762 but Thitery, who visited Spain and was shown cases of pellagra by Casal, described the disease in 1755 and gave full credit to Casal for the recognition of the disease. The name of the disease was given it by Frapolli, in 1771, the derivation being from pelle—skin, and agra—rough. The disease had then existed in Italy for a considerable time. Casal called the disease mal de la rosa.