The nervous symptoms of this stage are chiefly vertigo, headaches, which are usually occipital, and depression of spirits. Insomnia may be a marked feature. Lack of mental concentration is often noted.
Second Stage.—In the second stage we have a continuation and aggravation of the skin and alimentary tract symptoms with pronounced neurological manifestations. Tremors of the tongue and hands appear. There is great muscular weakness of the legs. Paraesthesias in great variety are common. Pain on pressure in the dorsal and lumbar regions of the back is common. The gait is more that of marked muscular weakness.
Attacks of giddiness with tendency to fall forward or backward are often reported. The deep reflexes may show variations from normal and there may be variations in the reflexes of the two sides, thus the patellar reflex on one side may be exaggerated and that on the other normal or diminished. Ankle clonus is rare. Neurological manifestations are slight in pellagrous children, the main symptoms being the cutaneous ones.
The mental state is confused and the patient shows depression and is often morose. The most common psychosis is that of simple retardation. The patient answers questions in monosyllables and in a low tone of voice after a more or less prolonged delay. Goldberger states that mental disturbances sufficient to require institutional care do not occur in more than 2 or 3% of cases.
In the second stage the urine shows rather marked indicanuria and the faeces contain an excess of skatol. Loss of weight is as marked a feature of pellagra as of tuberculosis. Well nourished pellagrins are the exceptions.
Third Stage.—With the setting in of a confusional insanity and a terminal cachexia we have the third and last stage of the disease. On account of so many of the victims of pellagra becoming inmates of insane asylums the disease is peculiarly dreaded.
Fig. 87.—Wet dermatitis. Localization usual. Hands oedematous. Cachectic state. South Carolina case. (From Lavinder and Babcock.)
Pellagra often runs a rather acute course in the U. S., the patient dying within two or three months. The usual course in Europe is one prolonged over years, with at times intermissions covering one or more years.
A form of pellagra known as typhoid pellagra often shows a high fever with symptoms more or less resembling a very toxic case of typhoid.