DELIRIUM (a Latin medical term for madness, from delirare, to be mad, literally to wander from the lira, or furrow), a temporary form of brain disorder, generally occurring in connexion with some special form of bodily disease. It may vary in intensity from slight and occasional wandering of the mind and incoherence of expression, to fixed delusions and violent maniacal excitement, and again it may be associated with more or less of coma or insensibility. (See Insanity, and Neuropathology.) Delirium is apt to occur in most diseases of an acute nature, such as fevers or inflammatory affections, in injuries affecting the brain, in blood diseases, in conditions of exhaustion, and as the result of the action of certain specific poisons, such as opium, Indian hemp, belladonna, chloroform and alcohol.
Delirium tremens is one of a train of symptoms of what is termed in medical nomenclature acute alcoholism, or excessive indulgence in alcohol. It must, however, be observed that this disorder, although arising in this manner, rarely comes on as the result of a single debauch in a person unaccustomed to the abuse of stimulants, but generally occurs in cases where the nervous system has been already subjected for a length of time to the poisonous action of alcohol, so that the complaint might be more properly regarded as acute supervening on chronic alcoholism. It is equally to be borne in mind that many habitual drunkards never suffer from delirium tremens.
It was long supposed, and is indeed still believed by some, that delirium tremens only comes on when the supply of alcohol has been suddenly cut off; but this view is now generally rejected, and there is abundant evidence to show that the attack comes on while the patient is still continuing to drink. Even in those cases where several days have elapsed between the cessation from drinking and the seizure, it will be found that in the interval the premonitory symptoms of delirium tremens have shown themselves, one of which is aversion to drink as well as food - the attack being in most instances preceded by marked derangement of the digestive functions. Occasionally the attack is precipitated in persons predisposed to it by the occurrence of some acute disease, such as pneumonia, by accidents, such as burns, also by severe mental strain, and by the deprivation of food, even where the supply of alcohol is less than would have been likely to produce it otherwise. Where, on the other hand, the quantity of alcohol taken has been very large, the attack is sometimes ushered in by fits of an epileptiform character.
One of the earliest indications of the approaching attack of delirium tremens is sleeplessness, any rest the patient may obtain being troubled by unpleasant or terrifying dreams. During the day there is observed a certain restlessness and irritability of manner, with trembling of the hands and a thick or tremulous articulation. The skin is perspiring, the countenance oppressed-looking and flushed, the pulse rapid and feeble, and there is evidence of considerable bodily prostration. These symptoms increase each day and night for a few days, and then the characteristic delirium is superadded. The patient is in a state of mental confusion, talks incessantly and incoherently, has a distressed and agitated or perplexed appearance, and a vague notion that he is pursued by some one seeking to injure him. His delusions are usually of transient character, but he is constantly troubled with visual hallucinations in the form of disagreeable animals or insects which he imagines he sees all about him. He looks suspiciously around him, turns over his pillows, and ransacks his bedclothes for some fancied object he supposes to be concealed there. There is constant restlessness, a common form of delusion being that he is not in his own house, but imprisoned in some apartment from which he is anxious to escape to return home. In these circumstances he is ever wishing to get out of bed and out of doors, and, although in general he may be persuaded to return to bed, he is soon desiring to get up again. The trembling of the muscles from which the name of the disease is derived is a prominent but not invariable symptom. It is most marked in the muscles of the hands and arms and in the tongue. The character of the delirium is seldom wild or noisy, but is much more commonly a combination of busy restlessness and indefinite fear. When spoken to, the patient can answer correctly enough, but immediately thereafter relapses into his former condition of incoherence. Occasionally maniacal symptoms develop themselves, the patient becoming dangerously violent, and the case thus assuming a much graver aspect than one of simple delirium tremens.
In most cases the symptoms undergo abatement in from three to six days, the cessation of the attack being marked by the occurrence of sound sleep, from which the patient awakes in his right mind, although in a state of great physical prostration, and in great measure if not entirely oblivious of his condition during his illness.
Although generally the termination of an attack of delirium tremens is in recovery, it occasionally proves fatal by the supervention of coma and convulsions, or acute mania, or by exhaustion, more especially when any acute bodily disease is associated with the attack. In certain instances delirium tremens is but the beginning of serious and permanent impairment of intellect, as is not infrequently observed in confirmed drunkards who have suffered from frequent attacks of this disease. The theory once widely accepted, that delirium tremens was the result of the too sudden breaking off from indulgence in alcohol, led to its treatment by regular and often large doses of stimulants, a practice fraught with mischievous results, since however much the delirium appeared to be thus calmed for the time, the continuous supply of the poison which was the original source of the disease inflicted serious damage upon the brain, and led in many instances to the subsequent development of insanity. The former system of prescribing large doses of opium, with the view of procuring sleep at all hazards, was no less pernicious. In addition to these methods of treatment, mechanical restraint of the patient was the common practice.
The views of the disease which now prevail, recognizing the delirium as the effect at once of the poisonous action of alcohol upon the brain and of the want of food, encourage reliance to be, placed for its cure upon the entire withdrawal, in most instances, of stimulants, and the liberal administration of light nutriment, in addition to quietness and gentle but firm control, without mechanical restraint. In mild attacks this is frequently all that is required. In more severe cases, where there is great restlessness, sedatives have to be resorted to, and many substances have been recommended for the purpose. Opiates administered in small quantity, and preferably by hypodermic injection, are undoubtedly of value; and chloral, either alone or in conjunction with bromide of potassium, often answers even better. Such remedies, however, should be administered with great caution, and only under medical supervision.
Stimulants may be called for where the delirium assumes the low or adynamic form, and the patient tends to sink from exhaustion, or when the attack is complicated with some other disease. Such cases are, however, in the highest degree exceptional, and do not affect the general principle of treatment already referred to, which inculcates the entire withdrawal of stimulants in the treatment of ordinary attacks of delirium tremens.
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