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In this excellent monograph Hotz first gives a brief historical review of endemic nontropical sprue and then lists the cardinal symptoms. Usually the onset of diarrhea is sudden, and it persists for weeks or months, in spite of treatment. The abdomen becomes markedly distended; buccal aphthous ulcers often appear; the tongue burns; emaciation becomes extreme—a loss of weight of 10 Kg. may occur within several weeks or months. Diagnosis is possible from the foregoing clinical picture if the disease has progressed sufficiently. Steatorrhea occurs in all cases (fat is seen microscopically in the stools, more frequently as fatty acid crystals; stools have an acid reaction; the skin gradually assumes a gray-brown coloration) often with an icteric tinge not like that of pernicious anemia but more like that of Addison's disease. Hypocalcemia (concentrations below 9 mg. of calcium per hundred cubic centimeters) and hypophosphatemia occur and may lead to tetany. Megaloblasts
Die einheimische Sprue.. Am J Dis Child. 1940;60(4):1005. doi:10.1001/archpedi.1940.02000040224021