This section is from the book "Smith's Family Physician", by William Henry Smith. See also: Natural Physician's Healing Therapies: Proven Remedies that Medical Doctors Don't Know.
In this complaint there is always delirium, and there is generally, but not always trembling. There is sleeplessness, a busy, but not angry delirium; constant chattering; a trembling of the hands, and an eager and fidgety employment of them. To these are added other symptoms, which, though they are not so calculated to strike the looker on, are of not less importance, as they help to establish the nature of the case. The tremulous tongue is moist and creamy; the pulse, though frequent, is soft; the skin is perspiring, and most commonly the patient is drenched in sweat.
If you question the patient about his disease, he answers quite to the purpose; describes, in an agitated manner, his feelings; puts out his tongue, and does whatever you bid him: but, immediately afterwards he is wandering from the scene around him to some other that exists only in his imagination. Generally his thoughts appear to be distressful and anxious; he is giving orders that relate to his business, to persons who are absent; or he is devising plans to escape from some imaginary enemy. He is haunted by ocular spectres; fancies that rats, mice or other vermin are running over his head: sees spiders crawling on the ceiling, or a horse's head thrust through a wall of his room. He addresses remarks to strangers whom he erroneously believes to be present. He looks suspiciously behind the curtain, or under his pillow, and he is perpetually wanting to get out of bed; but he is readily induced to lie down again. It is seldom that he meditates harm, either to himself or to others: there is rather a mixture of cowardice and dread with the delirium. Dr. Watson says: "I shall never forget the markings of terror expressed on the features of one patient, whom I visited in the middle of the night at a hotel near my house, in consultation with the late Sir George Tuthill, and who declared that the Devil in person was menacing him from a corner of the room."
He continues: "An inquiry into the previous history of the patient is important. In a large majority of instances you will find that he has been an habitual drunkard; and very frequently that from some cause or other this habitual stimulus has been diminished or abandoned. Some accidental illness has befallen him, and he has been restricted to low diet, and, as a sailor would say, ' his grog has been stopped.' When, with symptoms such as I described just now, you hear a history of this kind, you may be satisfied that the disease is not inflammation of the brain, but delirium tremens. I believe that habitual intoxication of any sort may lead to this disorder; but distilled spirits more surely than wine, wine more than beer.
"But the disease is not confined to drunkards, although it is so commonly connected with that pitiable vice, as to have been called mania a potu. You meet with it occasionally in men who have overstrained their nervous system by other modes of strong excitement. Long-continued mental anxiety, that state of mind in which gamblers and great speculators (who indeed are gamblers) are accustomed to live, may cause it; anything by which the mind is overwrought. A well informed medical man, of temperate habits, told me that he was on the brink of delirium tremens in the year 1825. He had foolishly entangled himself in some of the speculations which prevailed here like an epidemic at that period, and his mind was on the tenter-hooks of suspense and apprehension for some time. He could not sleep, and he found himself ' everlastingly chattering.' It comes on in the course of certain diseases; as sometimes, for example, in apoplexy; and it is a very common result of bodily injuries and accidents, and of surgical operations. "Without knowing why it should be so, my own experience would lead me to the belief that delirium tremens is very uncommon among women. The number of beds for women in the physician's wards of the Middlesex Hospital is somewhat greater than for men. On the men's side of the house cases of delirium tremens are very frequent; whereas, I scarcely remember any on the women's. And we might expect that the more sensitive character of the female frame would render women especially liable to this peculiar consequence of the abuse of Alcohol. On the other hand, Dr. Boots thought he had seen quite as many instances of delirium tremens attacking women as men. The result of M. Bayer's observation is more in accordance with my own. Of 176 patients seen by him, 7 only were women. A still smaller ratio is recorded by Bang, ten in 456. The disorder appears to be more common in the summer than in the winter months."
Formidable as the disease unquestionably is, it is not so full of danger as the symptoms in the severe cases might seem to bespeak. As early as the year 1831, Dr. Ware, of Boston, in America, had watched the progress and behaviour of delirium tremens when left to itself-I mean when uninfluenced by drugs; and he states, as the result of experience in numerous cases, that it is what has been called a self-limiting disease; that it runs a tolerably fixed course, and tends to terminate in spontaneous sleep within a certain period, which he puts at from two and a half to three days. Dr. Peddie of Edinburgh bears similar testimony. He found the acute paroxysm to occur with remarkable uniformity, and to come to an end on the second or third day; sometimes earlier, rarely later than the fifth. The subsequent observations of Professor Dunglison, Professor Laycock, Dr. W. T. Gairdner and others, accords with these most interesting and most important statements. They tend to put delirium tremens into the category of those diseases which naturally end in recovery or death, within a definite period of time.
"It has now been ascertained that fatty degeneration of the heart is a very common accompaniment of delirium tremens. It is, no doubt, one result of those habits of life, of that course of chronic poisoning, to which the nervous disease also owes its origin. This state of the heart it is also most important that we should recognize, for it constitutes the great danger of the disease, which thus tends to death by exhaustion.
"The conclusion to be drawn from these facts is, not that the disorder should be left to run its course unchecked by medicine, but that the sleep that proves critical should be promoted, and, if possible, insured, and anticipated. The earlier it comes, the less there will be of effort and struggle on the part of the patient, and the less risk of fatal exhaustion. With this object of procuring sleep, must always be associated that of sustaining the patient by judicious feeding. Unluckily, the bad habit which is at the bottom of almost every one of these cases, takes away all appetite for food. When it is not so, when the patient can eat and digest wholesome food, the disease loses nearly all its danger. In general, it is necessary to ply him with nutriment that he can drink-hot beef tea. spiced with cayenne pepper, and the like. The less of nutritious food he can be persuaded to swallow, the more need is there of sleep.
"Of course it is desirable that the patient should be kept in bed, in a darkened and silent room. But in bed he sometimes cannot be persuaded to remain, and it may become necessary, and a most unfortunate necessity it is, to restrain his movements by force, to confine him to the bed by straps, or to muffle his limbs in a straight waistcoat. But physical coercion of no kind whatever should be resorted to, when by any means it can be avoided. The angry feeling and mental fret that it produces, and the exhausting struggles to escape or to resist the confinement, are always highly-injurious, and add sensibly to the patient's danger. A couple of strong and good-tempered attendants may exercise more gentle and more effectual restraint and persuasion upon the sick man than the ruder force of manacles: but, after all, the best restraint is the calm which an opiate may bring, when its use is not clearly forbidden.
"A still further danger there is, which the same opiate remedy might afford a prospect of averting, but which else must be averted by unceasing watchfulness. These patients, although generally harmless as respects both themselves and others, are sometimes full of gloomy thoughts and suicidal propensities, or they will rush with frantic terror into actual dangers, to escape the unreal perils with which their imaginations are haunted.
"Is a patient, in a paroxysm of delirium tremens, to be allowed a moderate quantity of, or to be absolutely debarred from, his accustomed stimulus?" This is a question that requires, and I think admits of, a definite answer. Whenever, as is sometimes the case, the intemperate use of spirits has continued up to the very outbreak of the paroxysm, it should be stopped at once, and the result carefully noticed. There is abundant evidence that the habit of drinking to excess may be abruptly arrested without detriment, nay, with manifest advantage to the drunkard's general health. But it would be rash and illogical to infer from this that there are no conditions of delirium tremens in which spirits are useful, or are even admissible. The opiate treatment, heedfully adopted, is sometimes, of itself, sufficient for its object; sometimes it is not, the patient remaining wakeful, agitated, and trembling, till it is supplemented by a single administration of the customary dram-"a hair (as the vulgar saying goes) of the dog that bit him-" a glass of gin or a pint of porter; after which, he presently sleeps, or becomes calm and steady. Facts of this kind, which are not mere coincidences, have been too often witnessed to admit of doubt about them. Now these are cases of which the distinguishing characters are not hard to recognize. They occur in persons who are of pale and haggard aspect, with a small and weak pulse, and no appetite for food. They present the phenomena of physical exhaustion combined with an aggravating nervous irritability. The feeble circulation and waning strength cry out for some temporary stimulus. We should not hesitate if we met with a similar condition without the delirium, and with it the proper practice is no less clearly indicated.
"If the patient's appetite be unimpaired, if he can take and appropriate good nourishing food-strong broths and the like-the stimulant may be rightly withheld. And in no case are ardent spirits to be persevered with as a part of the general treatment, but abandoned, or suspended, as soon as the immediate benefit has been secured." Bromide of Potash and Hydrate of Chloral have been of late strongly recommended in preference to Opium for producing sleep in these cases. The Bromide may be given in doses of twenty or thirty grains, and repeated in a few hours if necessary. The Hydrate of Chloral may be given in a dose of twenty grains, and repeated in three or four hours, if necessary.
Dr. Lyons says that Capsicum is a remedy of considerable value in delirium tremens. It produces a sense of warmth and comfort in the stomach, when first taken, allaying the agitation, debility, and cardiac and epigastric anxiety, which are such constant and distressing features of the disease. It should be given in from twenty to thirty grain doses, made up into pills.
Mr. H. Tyrrell mentions a case where twenty minims of the Tincture of Indian Hemp was given every four hours. After the third dose the patient fell into a deep sleep, which lasted about four hours. The use of Opium was inadmissible, as he had formerly been an Opium eater.