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last some months, but the patient always relapses. In the last stage he becomes thinner, and more demented; the congestive attacks are more frequent; he takes to his bed through sheer debility, and is noisy, wet, and dirty, dying, as a rule, from asthenia, with probably some hypostatic pneumonia in about two or three years, from the beginning of his illness. These cases can only be treated in an asylum, and it is important to certify them early, owing to their tendency to squander money, and thereby to ruin themselves and those dependent upon them. Even should long remissions take place, it is much better to keep the patient in the asylum, for the relapse is bound to come sooner or later. I know of a case where a general paralytic was thrice discharged from an asylum "recovered," each time to return "relapsed,” after having rendered his wife pregnant again-a truly wretched lookout for the unhappy offspring.

Puerperal Insanity.—This form of insanity is most frequent in women of insane heredity, especially where this heredity exists in the female line. It may take the form of mania, melancholia or dementia. If the insanity comes on within a fortnight of delivery, the maniacal form is the commonest. Sleeplessness, restlessness, and refusal of food are early symptoms. The pulse is frequent, the tongue white, and the bowels are constipated. The patient may be suicidal or homicidal, or both, and she generally takes a dislike to her husband and her child.

When puerperal insanity develops a month or more after delivery, it usually takes the melancholic form. Sleeplessness and refusal of food are again marked symptoms. Suicidal tendencies are most likely present, as also may be hallucinations of smell; and here, again, the hatred towards husband and child may be even more marked.

In both of the above cases the milk and lochia may remain normal, but a suppression of one or both is most likely, and the lochia are sometimes offensive. The prognosis is usually favorable, unless a typhoid condition should set in. Improvement is often preluded by a return of the milk and lochia, if these have been in abeyance. In rare cases, however, the pa

tient may sink into permanent weakmindedness.

Treatment may be carried out at home under the care of two nurses, and almost constant supervision and vigilance on the part of the physician, but even with these provisos, if the patient be violently homicidal or acutely suicidal, or require forcible feeding, she will do better under asylum treatment. The diet should be generous, with plenty of milk, eggs and beef tea, and, perhaps, some port wine. Sleep is best obtained by a warm bath and a dose of alcohol at night, narcotics not being usually successful in these cases, but should such be imperative, some preparation of opium is the least harmful. Attention must be paid to the condition of the bowels and the vagina.

It is important to remember that there may sometimes set in, a few days after labor, a transitory delirious condition, which often yields readily to a purge and a narcotic draught, but during which the patient may commit infanticide, and yet have no recollection of her crime.

Alcoholic Insanity.-For the purpose of this paper, I propose to divide alcoholic insanity into:

1. Acute alcoholic insanity or delirium tremens.

2. Insanity from drink (proper).

3. An incurable condition of chronic mania or dementia, which may be a sequel to repeated attacks of either (1) or (2).

(1) Delirium Tremens.--I am aware that many authorities do not include this among the insanities, but as it is the form or alcoholic neurosis most frequently met with in private practice, I think it should be included here. After a short period of restfulness, sleeplessness and general irritability, with tremors, the patient becomes delirious, talking incessantly. He makes futile attempts to dress himself or to pack his portmanteau, as if going on a journey, but he never gets any further in his preparations; indeed, motor restlessness is extreme. Hallucinations of sight are always present, and generally refer to such small animate objects as beetles, spiders, rats, etc. Hallucinations of hearing, taste and common sensation are less common, though I have often seen them. The skin is clammy and sweating, the tongue furred. Vomiting may take place. The temperature is normal, or perhaps slightly raised. Convulsions may occur, and a sharp rise of temperature may foretell meningitis.

The disease is of an asthenic type, and the patient may die of heart failure after only a few days' illness. Ordinary cases get quite well, as a rule, in a week or so. They can be treated quite successfully at home under constant and intelligent supervision. In the early stage before de. lirium has set in, an aperient and a few doses of a bromide mixture, with, perhaps, a chloral draught at night, will very likely do all that is required. Even in the second stage the same course of treatment is often successful. If chloral does not produce sleep, a round dose of morphia, hypodermically, say half a grain, will prove efficacious. Complete rest in bed, with plenty of fluid nourishment, are essentials.

It is a moot point whether in these cases stimulants should be cut off altogether, or whether they should be allowed in reduced quantities. My own experience has been that if the patient be seen in the premonitory stage, an attack of true de lirium tremens is most likely to be precipitated by cutting off all stimulant, as is so often done, while, on the other hand, a reduced quantity of the stimulant the patient has been used to, may ward it offa very important consideration in the case of a business man. If the second state has set in, the patient is better without a stimulant. He will have to put up with at least a week's illness, so the opportunity may be advantageously taken of ridding his system of alcohol as far as may be. Cases of delirium tremens should not be sent to an asylum if this step can be possibly avoided. It is hard that a man should be branded as a lunatic for such a fleeting disease, however much his own excesses may have caused it.

(2) True insanity from drink is a disease of grave import, and of much longer duration than the above. Before it declares itself, the chronic alcoholic has probably begun to manifest such symptoms as diminished will-power and general moral deterioration. He becomes sus. picious and dissatisfied, and a common early symptom in a man is a delusion that his wife is unchaste. In the case of a

woman, the husband may be similarly suspected. Presently, hallucinations set in, especially those of hearing and touch, and delusions about plots and poisoned food, and now the patient becomes dangerous. When thoroughly developed, this form of insanity may assume either a maniacal or a melancholic type, the former sometimes carrying with it exalted delusions. There may also be tremors and some inco-ordination of speech, so as to lead to a suspicion of general paralysis, but any doubt is soon cleared up by treatment and suppression of alcohol, when in true alcoholic insanity marked improvement will soon take place. Many of these cases get perfectly well, but complete recovery is not rapid, and may be a matter of two years or more. A persistently intemperate person may have several attacks, and subside eventually into incurable chronic mania or dementia. Epilepsy may occur in the course of true insanity from drink. Treatment can only be carried out in an asylum, as the patient's delusions, especially those as to his wife's unchastity, render him very dan. gerous. Moreover, it is only in an asylum that he can be thoroughly kept from alcohol.

Chronic mania or dementia from longcontinued alcoholic excess does not differ materially in its symptoms from ordinary dementia, and the only treatment in this complaint is detention in an asylum.

Dipsomania or Periodic Alcoholism requires a few words here, though in this disease the mental condition is the cause instead of being the effect of alcoholism. True dipsomania differs from alcoholism in being a periodic seizure. It is rare before the age of thirty. A neurotic heredity is nearly always present. The attacks are preceded by headache, sleeplessness and depression of spirits, and then the terrible craving comes on when the sufferer will swallow anything alcoholic if he can not obtain the ordinary beverages. Methylated spirit, medicinal tinctures, and even varnish have all been pressed into the service of the dipsomaniac. The attack may last for days or weeks, and is succeeded by great prostration and remorse, and I have known of suicide being committed under such circumstances. At the present moment I have such a case under my care, where the patient is actively suicidal. He will settle down in the course of a few days as he has done before.

These cases can scarcely be looked upon as certifiably insane, and even if admitted to an asylum they could not be detained there after the urgent symptoms had passed off. Confinement in an inebriates' home is almost the only treatment likely to prove of benefit, but if there be strong hereditary tendency to dipsomania, any treatment is almost hopeless.

In conclusion, I suggest that the cases of insanity occurring in private practice, and demanding early decision as to treatment, may be conveniently classified as follows:

(a) Cases which may be treated at home with a fair prospect of recovery.Mild hypomania, simple melancholia, puerperal insanity when not actively suicidal or homicidal, acute alcohol insanity (delirium tremens).

(b) Cases which may possibly be managed at home at any rate, for a time.Delusional insanity of the imbecile and inoffensive type. A very few cases of general paralysis during long remissions.

(C) Cases in which asylum treatment is absolutely imperative.-Acute mania, melancholia with delusions, agitated melancholia, stuporous melancholia, chronic melancholia, general paralysis when well marked, true insanity from drink, alcoholic dementia.

ternal causes, such as the rashes of scarlatina, of copaiba, and of gouty eczema, I observed that in each of these apparently widely diverse conditions there were the common features of an inflamed skin and of a blood-supply containing a specific and definite irritant, even if the precise nature of that irritant could not always be demonstrated.

"Excretory irritation" is the name I gave to the action of any blood-borne irritant capable of setting up inflammation in its passage through one or more excretory organs of the body.

As the result of my investigations, it seems to me to be a general law that any substance capable of setting up a symptomatic inflammation of the skin might affect other excretory organs in the same way. The results of this general conclusion are far-reaching and practical. If a drug be found to cause a rash, for instance, then it may be suspected of inflaming other excretory outlets, and of thus becoming a starting point of organic disease.

The chief eliminating organs of the body are, of course, the kidneys, skin, alimentary canal and the lungs. Their excretory function is interchangeable up to a point, as when in cold weather the activity of the skin is lessened, and that of the kidneys increased, as shown by the larger amount of urine passed during the winter, or in advanced stages of chronic nephritis, when urea is thrown off freely by skin, lungs and bowels.

This power of vicarious function, however, has its limits. If the action of the skin be arrested absolutely, as in the classical case of the Italian child coated with gold leaf to play the part of an angel in a public procession, the results are rapidly fatal.

In advanced Bright's disease, again, the available limit of relief by sweating and purging is quickly reached.

A little consideration will show that the action of many familiar drugs is due to the irritation, or, if the term be preferable, the stimulation of the various excretory organs of the body. Take the case of mercury, which acts as a diuretic, a purgative, and a stimulant of the liver, besides exercising a powerful action in some skin diseases. The experimental aspects in this drug have been ably sum

(Written for the MEDICAL BRIEF.] "Excretory Irritation,” or the Oorrelation of Symptomatic Skin Rashes With Other Organic Inflamma

tions.

BY DAVID WALSH, M. D., Senior Physician Western Skin Hospital, London,

W., Etc. London, England.

At the Birmingham meeting of the British Medical Association, in 1890, I read a short paper,* discussing certain forms of symptomatic rash, and their relation to inflammations of excretory organs other than the skin. Taking various forms of dermatitis associated with in

*Medical Press and Circular, October 22, 1890.

marized by Dr. C. D. F. Phillips.* He quotes Riederer and others, and concludes that mercury has a special determination to the liver and kidneys, and is eliminated mainly by the bile or the urine. He also cites Pavy, Overbeck and Kussmaul to show that during pronounced mercurialism albuminuria may occur with or without hematuria.

It would be outside the scope of the present article to follow up this particular point in detail, but mercury may be briefly compared vith arsenic and iodine. Concerning these three drugs in another article I wrote:

“We may draw the following general conclusions as to arsenic, mercury, or iodine, or of their compounds as used in practical medicine:

1. They are alterative, antiseptic and poisonous.

2. They are epithelial irritants.

3. They are eliminated from the body by one or all the various excreting organs.

4. They may cause multiple dermatitis.

5. In moderate doses they may cause diuresis or transient albuminuria, and in large doses, albuminuria, hematuria, and suppression of urine.

6. In large doses they have been shown experimentally to disorganize the kidneys in lower animals, and a similar result has been often met with in acute poisoning in man."

There is no need to labor the point as to the constant use of excretory irritants or stimulants by physicians. Ample evidence of the fact may be found in the names applied to various groups of remedies according to their action upon this or that eliminating organ. Thus we have had from time immemorial such terms as expectorants, diuretics, and purgatives. With regard to the last mentioned class, purgatives, most of them act ultimately by the stimulation of liver or intestinal excretion. In the case of calomel it seems likely that the drug is absorbed in the stomach and duodenum to be excreted by way of liver and intestine. If mercurial ointment be absorbed through the skin, or a dose of perchloride be injected sub

ism;

cutaneously, the drug is partially excreted by the liver, and presumably partly, also, by the bowel, and acts as an aperient. Similarly, castor oil absorbed through the skin is excreted in the intestinal tract, and acts as a purgative. In both these latter instances the action clearly results from the stimulation of glandular, and, perhaps, also of muscular structures, set up by the passage of a particular drug from the blood to the intestines. This general statement applies to the glandular stimulation of the liver as well as of the bowel.

The principle of general excretory irritation as manifested by certain drugs introduced into the circulation was then extended, in my original paper, to diseases attended by rash. In that case it soon became evident that a similar connection could be established between a common blood-borne irritant and inflammation of the various channels of exit of materials excreted from the body. Scarlet fever affords a good instance. It may safely be assumed to depend upon invasion by a specific pathogenic micro-organ

an early sign is a diffuse scarlet rash, followed by desquamation. The kidneys are often seriously affected, probably to a small extent in every case, and the nephritis not infrequently drifts into chronic kidney disease; diarrhea sometimes occurs;

bronchial inflammations are common, and sore throat one of the most characteristic signs. Gout, to take another general disease, is often accompanied by eczema and other skin troubles, The tendency of gouty patients to bronchitis, dyspepsia, diarrhea and kidney troubles, need not-from my point of view, all of excretory origin-be pointed out to medical men.

The various blood-borne substances capable of setting up irritation of the excretory organs of the body I called “internal irritants," as a matter of convenience. Some of the reviewers in 1897 made merry over that title, but in spite of that attitude it is now in daily use both by dermatologists and by general physicians.

Under the name of "Internal Irritants” I included all substances circulating in the blood capable of setting up a skin rash or dermatitis of any kind. They were classified under the headings of:

*Materia-Medica and Therapeutics, C. D. F. Phillips - Third Edition, London, 1904, p. 673.

Excretory Irritation. David Walsh, M. D., London, Bailliere & Cox, 1897, p. 59.

(a) Drugs.

(b) Accumulation of normal excretory products in blood (e. g., uremia, jaundice).

(c) Specific disease poisons:

1. Pathogenic micro-organisms and their products, e. g., enteric fever.

2. Products of micro-organisms used as drugs, e. g., antitoxin.

3. Poisons obscurely produced, e. g., that of gout.

The reader who has followed my line of reasoning so far will be able to apply it readily enough to the foregoing classification.

Actual proof, direct and indirect, of the presence of the various kinds of internal irritants in connection with inflammation of various excretory organs has been found in the following ways:

1. Some irritant drugs, as iodine, bromine, arsenic, have been detected in the excretions of the inflamed skin, as well as of other excretory organs.

2. In eczema of gouty persons, urates have been found on the skin surface, and urea in uremic conditions.

3. In the case of infectious fevers, the specific micro-organisms themselves must necessarily be thrown off from the body or the disease would not be spread. (Even in the case of diphtheria the specific bacillus has been found in the urine.)

4. In the excretions of organs other than the skin the presence of the internal irritants, whether chemical or bacterial, has been often demonstrated by chemists and bacteriologists.

If the general law-as I venture to call it-of excretory irritation be true, it will be of universal application. From it one may draw a number of deductions, the truth of which may be readily tested. Starting with the proposition that under the influence of an internal (or bloodborne) irritant the skin suffers as one of a group of excretory organs, and that all those organs may be similarly affected by an internal irritant, it follows that we must look with suspicion upon any rashproducing drug as a possible source of mischief in the kidney and other excretory organs. To take an instance, sulphonal often produces an erythematous or purpuric rash; it may also set up hema.

toporphyrinuria, a serious and often fatal condition.

Horatio C. Wood* states that the exan. them of sulphonal poisoning may be bullatous, but is usually a minutely papulous eruption which has been described by some as resembling that of measles, by others as like that of scarlet fever. It is often symmetrical, and shows a disposition to follow the nerve trunks. With regard to hematoporphyrinuria, it may be pointed out that hematoporphyrin (ironfree hematin) occurs normally in the urine in minute quantities, and may be considerably increased without affecting its color. When present in large quantities, the urine presents a dark port wine aspect, and does not give the guaiac reaction. The early recognition of hematoporphyrinuria is best made by the spectroscope. Its importance in cases of chronic sulphonal poisoning can not be overestimated, and, as Murrell has pointed out, such cases not uncommonly terminate fatally. The excretion of port-wine urine by a patient taking sulphonal is an indicator for immediately stopping the administration of the drug, and for giving alkalies freely. After death, Stern and Oswald found necrotic changes in the epithelium of the renal glomerali and of the secreting portions of the tubules, whilst Kast found, in dogs, hemorrhage into the glomeralar capsules. In some cases the renal trouble has been confined almost to a glomeralar or cortical nephritis.

The obvious practical lesson is that sulphonal is not the simple and harmless drug that many works on materia medica and therapeutics would have us believe.

Another rash - producing hypnotic, chloral hydrate, irritates the kidney. It is excreted by the kidneys, partly unchanged, but chiefly as glycuronic acid, producing slight diuresis and spurious glycosuria. Probably part escapes by the skin also, as a variety of eruptions may attend its prolonged use. Paraldehyde, trional, acetanilid, phenazone, phenacetin, may any of them produce a rash. The possibility of their setting up kidney mischief will add another argument against

* Therapeutics, Its Principles and Practice. Eleventh Edition, 1902.

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