with bedsores, and neglected, he dies from exhaustion or from some intercurrent disease.
The duration of pellagra is exceedingly variable. It may last only two or three years; it usually extends to ten, fifteen, or more.
In a proportion of cases, more especially if the patient leaves the endemic area and comes under favourable hygienic influences early in the disease, recovery may take place.
Cases differ considerably. In some the nervous symptoms predominate, in others the gastro-intestinal, in others again the cutaneous. Forms of hyperæs thesia may occur in different regigns of the body. Ocular symptoms, such as ptosis, hemeralopia, diplopia, amblyopia, mydriasis, are not uncommon. The urine is generally alkaline, and may rapidly become ammoniacal. It may also contain tube casts and traces of albumin. The erythrocytes and hæmoglobin are diminished. Sambon and Terni in Italy, Grigorescu and Galasescu in Roumania, have noticed a relative increase of the mononuclear leucocytes, a point differentiating the eruption of pellagra from ordinary erythemas; but it cannot be said that, although usually disturbed, the differential leucocyte count is constant or characteristic.
A very acute form has been described under the name of " pellagra typhus." In this there are intense prostration, high temperature, muttering delirium, pronounced nervous tremor, generalized rigidity and convulsions.
It has been estimated that in Italy from 4 to 10 per cent, of the pellagrins become permanently insane. Similarly, in the United States of America the pellagrins are becoming a notable feature in the lunatic asylums.
Morbid anatomy.— The pathological characteristics essential to pellagra are usually obscured by complicating diseases.
A constant and striking feature is the great emaciation. The viscera show chronic degenerative changes, particularly fatty degeneration and a characteristic deep pigmentation. The intestinal walls
