In a certain proportion of cases, more particularly during the later stages of such as prove fatal, small vesicles appear upon certain portions of the body and limbs; a thin, whitish fluid exudes under the cuticle, which soon breaks and a dark brown scab is formed, which becomes from one-fourth to one-half of an inch in diameter and one-sixteenth or two-sixteenths of an inch in thickness. These are quite irregularly scattered about the anterior surface of the body and limbs, but I have never observed ⚫ either sudamina or petechiæ.

Generally there occurs a crisis within two weeks. The delirium ceases and a dawning of consciousness returns. The stomach becomes more tolerant of food, the pulse less frequent, and the temperature normal. The interval which has passed is a mental blank, and with surprise patients inquire where they are. The cessation of the delirium is rarely followed by dementia or delusions, and when it is so, according to Dr. Ranney, it is only in cases which have had previous attacks of insanity. The recovery is usually quite rapid.

While the above enumeration of symptoms is fairly accurate in typical cases of acute delirium, yet it should be stated that cases are sometimes seen in which these symptoms appear only in a modified form. They have the essential characteristics but do not pass over into their fully developed character, and may not do so if patients are properly treated from the first, and are otherwise favorably conditioned.

Example 1.-Miss A. R., age thirty-two; admitted September 23, 1887; parents not living; has been a teacher during the past thirteen years. She was a fine scholarstanding the first in her class at graduation-and has risen to a high position as teacher. During the previous sum

mer vacation she had been in the country, but much engaged in planning the organization of a department of physics, of which she was to have charge the next year. Her sisters report that she did not appear quite as well as usual when she left the country for the city to resume the duties of the school, but little or nothing was thought of this. She entered at once upon duty at the opening of the school, and five days afterward felt "so nervous" that she consulted her physician and did not hear her classes; that same night she became delirious, and remained without sleep during seventy-two hours, when she was brought to the Retreat, with the report that notwithstanding the administration of three grains of morphine, with doses of chloral and bromide, during the previous night she had not slept and it required four persons to control her.

At the time of admission the pulse was 100 per minute, quite weak, but there was no rise in the temperature. The tongue was covered with a whitish coat and dry. She was constantly talking, repeating meaningless, rambling sentences or words, and addressing persons whom she seemed to see passing. The movements of hands and feet were constant, and she rolled from side to side, and would have gone to the floor if permitted. She was given hypodermically one-hundredth of a grain of hyoscine, but no chloral or morphine. The next night she slept one and one-half hours, and about the same on the third and fourth nights. There was. no sleep on the fifth night, but from this time forward there were two or more hours of sleep every night. After one or two days the tongue became brown, the lips dry and cracked, and the teeth covered with dark sordes, the bowels were constipated, the throat filled with thick, tenacious mucus, and she was unable to swallow. On the fifth night

the pulse rose to 140, and the temperature to 1001⁄2°. She was no longer able to articulate words, but still exhibited great motor activity. On the sixth and seventh and eighth days there was less of morbid restlessness, and by removing the mucus from the throat she was able to swallow a little tea. From the first there had been intolerance of all kinds of food, and even a small quantity of any liquid was soon vomited. From the tenth day after admission the stomach became tolerant of tea and milk and there were two or three movements of the bowels on some days. The enemata, which had been administered from the first, were sometimes expelled. Signs of returning consciousness began to appear, and she seemed to comprehend in some measure what was said to her. The pulse dropped to 82, and became stronger, and convalescence became established. At no time did there appear any petechial spots or sudamina, nor did the temperature rise above 100 degrees, nor did there appear any of the pemphigus-like eruptions on the limbs, such as appeared in Case 2.

I cannot but regard the effect of the hyoscine in this case as most favorable. Insomnia is one of the most marked features of this form of disease, and in this case other drugs had been faithfully tried without success. This appeared to control the marked motor activity in some measure, and by this means permitted some sleep during every twentyfour hours after the first night, with one exception. The strength was conserved by the use of frequent and large nutrient enemata, composed of beef tea, milk, and eggs. The marked value of this was shown by the fact that as late as the fourteenth day after admission, and while she was using milk and tea without disturbance of the stomach, an omission of the enemata for sixteen hours was attended

with increase in frequency of the pulse and greater weakness of it.

On the other hand, in fatal cases, which are far more numerous, the stupor becomes more profound, the paralysis of the vaso-motor nerves more complete, the blood settles under the nails of the fingers and toes, the capillary vessels of the dorsal surfaces become congested, rendering them of a dark blue color, the action of the heart more feeble, respiration more frequent, until the scene finally ends in a condition of profound insensibility and

coma.

Example 2.-J. A. T., a female; age, twenty; single; admitted in May, 1887; had worked during some months in an envelope factory. Her mother and father both living and invalids; both said to be affected with "nervous" disorders, and the mother to have been confined to her bed for a long time. Distant relations on both sides of the family have been insane. Patient had had the care of an invalid mother for two years prior to entering the factory, and had become somewhat invalided, and was at one time hysterical and under the care of a physician. Some eight days prior to admission, and while at work in the factory, she became suddenly excited, and said that some one had given her a "love powder," and continued to talk wildly and rush about the room where she was, until she was removed to her room in a carriage. After her arrival at the house she complained of pain in her stomach and had a slight convulsion; her excitement increased, and she screamed and shouted, at times shed tears, and was continually walking about the room into which she was locked, and tried to throw herself from the window. This general state of excitement continued without abatement during some days, and she obtained but very little sleep from the medicines

which were administered for the purpose of securing it, when she was removed to the Retreat.

On admission she was talkative and restless, but not greatly excited; would not stand on her feet, but persisted in remaining on the floor; had no appetite; tongue was covered with a creamy, white coat, and bowels costive. She did not apparently sleep, and her mind was much confused, so that she could not respond to questions, even if she made an effort to do so, which was seldom the case. After a day or two she would remain on the bed when placed there, and sometimes turn on her face, remaining in that position until the attendant placed her on her side or back. A whitish mucous secretion formed in the throat and ran out of her mouth, which she did not seem to notice; the pulse became weaker, though not rapid; the extremities were often cold, and she became more stupid, and took food in fluid form only when it was placed in her mouth. At the time of admission there was observed on the anterior portion of the chest, abdomen, and legs an eruption of pemphigus-like vesicles. As the case progressed these increased in number, and were located very irregularly upon the whole anterior surface of the body and legs. The feet and hands also became of a dark purple color, and the blood settled under the nails, while on the anterior surface of the knee, below the patella, the integument became swollen, inflamed, and very sensitive, though there was a degree of anasthesia in other portions of the body. Food was given in fluid form by the stomach and rectum in an abundant quantity, but she continued to become weaker and more stupid, and, finally, became comatose, in which state she remained several hours, and died on the thirteenth day after admission.

Morbid Anatomy.-It is thought to be more difficult to