Complications

Among those involving the nervous system the most frequent are epileptiform seizures which may precede by thirty-six or forty-eight hours the onset of the delirium, or they may occur during the attack. The most formidable as well as the most common complication is pneumonia, which affects chiefly the apex of one lung and assumes from the beginning a grave aspect.

Prognosis

There are two possible terminations: recovery and death.

Recovery is the rule. It takes place within four or five days after a deep and prolonged sleep. The sleep may come on suddenly or it may be preceded by a period of calmness.

The duration of delirium tremens is sometimes abnormally brief (several hours), and at other times abnormally long (a few weeks or even months).

Convalescence is marked at the beginning by a certain amount of confusion which persists for some time and which may or may not be associated with delusions.

Death may occur from exhaustion, from an epileptiform attack, or from some complication (pneumonia).

Diagnosis

Attacks very similar to delirium tremens are seen outside of alcoholism, notably in senile dementia, general paralysis, and meningitis of the cerebral convexity. In the latter affection the diagnosis is based upon the existence of specially marked and numerous focal symptoms such as Jacksonian epilepsy, strabismus, etc., upon the condition of the optic disc, and upon the course of the disease.

The points of differentiation from general paralysis and from senile dementia will be studied in connection with these affections.

Pathological Anatomy

To the lesions of chronic alcoholism already considered are added exudative hyperemia and inflammatory diapedesis, which are the expression of an acute process analogous to that observed in infections.

The nerve-cells lose their normal shape and structure, their angles become blunted, and their chromatophylic granulations are broken up or disappear entirely. The nerve fibers degenerate.

These lesions are present throughout the cortex, including centers of projection. It is not rare to find also a certain degree of degeneration in the pyramidal bundles and in the posterior columns.

The visceral lesions are often dependent upon some complicating infection, such as influenza, infection by the pneumococcus, or typhoid fever.

The heart is the seat of a myocarditis which in many of the fatal cases constitutes the immediate cause of death.

The liver shows degeneration which is so frequent and at times so pronounced that Klippel1 has been led to attribute delirium tremens to autointoxication of hepatic origin.

The lesions in the kidneys are, according to Herz,2 those of acute parenchymatous nephritis. He states that these lesions are constant.

Pathogenesis

Delirium tremens is not to be considered as a simple alcoholic intoxication, a sort of belated drunkenness caused by an accumulation of the poison in the organism. Its clinical aspect in fact differs radically from acute intoxication. Moreover it is apt to break out even after several days' abstinence. Finally, the patient recovers even when alcohol is administered in large doses during the delirium.

1 Klippel. Du delire des aicooliques. Lesions anatomiques et pathogenic Mercredi medical, Oct., 1893. - De l'origine hepotique de certains delires des aicooliques, Ann. med., psych., Sept.-Oct., 1894.

2 Abstract in Centralblatt fur Nervenheilkunde und Psychiatrie, May, 1898.

Some authors, Wernicke among them, attribute delirium tremens to sudden withdrawal of alcohol. This view finds corroboration in the army experiences during the World War. In all National Army cantonments the arrival of almost every contingent of drafted recruits was followed within a few days by the development of a crop of cases of delirium tremens for which there seemed to be no cause other than the suddenly enforced abstinence.

An important fact upon which Joffroy frequently insisted in his lectures is that delirium tremens often breaks out at the occasion of a supervening infection, such as influenza, pneumonia, or suppuration. Thus it seems that the disease is caused by two agencies, alcoholism and some supervening condition, most frequently an infection.

By what mechanism does their combination produce this effect? - Possibly by determining an autointoxication by insufficiency either of the liver (Klippel) or of the kidneys (Herz).

It should be remembered, however, that in many cases the second factor, the accidental infection, is not found. Perhaps, reduced to some disorder possessing in itself no apparent gravity, such as an attack of gastric indigestion, it passes unnoticed.

If it is true that delirium tremens is, as suggested above, a result of sudden withdrawal of alcohol, a condition, in other words, analogous to the symptoms of abstinence seen in cases of drug addiction, then its development in cases of supervening acute diseases or injuries may be due mainly to the abstinence incidentally resulting from the patient's confinement to bed either at home or in a hospital.

Treatment

Rest in bed is very useful and is applicable in the great majority of cases. More than in any other psychosis, in this disease mechanical restraint is dangerous and must be prohibited.

The administration of alcohol is a time-honored practice and was found very efficacious in the army cases referred to above. It seems to do good in many ways and in many types of cases: (1) It seems capable of preventing delirium tremens. If the withdrawal of alcohol in a case of chronic alcoholism is accomplished not suddenly, but gradually, the danger of delirium may be lessened or obviated. (2) In the prodromal period or very soon after the onset of delirium tremens the administration of alcohol may abort the attack. (3) In the course of delirium tremens the judicious administration of alcohol seems to lessen agitation, improve the physical condition, shorten the attack, bring early sleep, and prevent exhaustion with its possible fatal termination. (4) In cases apparently threatened with heart failure alcohol seems to be the most efficacious stimulant.

The food should be substantial, yet such as would least tax the digestive system. A milk diet admirably fulfills this double indication. A glass every hour during the day may be given, so that the patient will get about 2\ or 3 quarts a day. Sometimes it is useful to add eggs, beef juice, or chopped meat. During convalescence full diet may be gradually resumed.

As regards medication, sedatives and hypnotics may be required early and heart stimulants late in the course. Bromides, paraldehyde, and chloral are commonly used and, for stimulation, strychnin, digitalein, caffein, and ether. Alcohol in these cases seems to be, however, the best sedative, hypnotic and stimulant and its administration may render all other medication unnecessary.