REVIEW VI. 1. Clinical Illustrations of the Pathology and Treatment of Delirium Tremens. By THOMAS LAYCOCK, M.D., &c. (Edinburgh Medical Journal,' No. 40, Oct. 1858, p. 289.) 2. The Pathology of Delirium Tremens, and its Treatment without Stimulants or Opiates. By ALEXANDER PEDDIE, M.D., F.R.C.P., &c.-Edinburgh, 1854. pp. 51. 3. Statistics of Delirium Tremens. By Drs. MACPHERSON and ATKINSON. (The Indian Annals of Medical Science,' Nos. 5 and 6, pp. 1, 658. Oct., 1855; April, 1856.-Calcutta.) 4. Observations on the Use of the Shower Bath in Delirium Tremens and other similar cases of Cerebral Excitement. By ROBERT LAw, M.D., &c. (The Dublin Quarterly Journal of Medical Science,' No. 49, p. 33. Feb. 1858.-Dublin.) 5. Remarks on the Treatment and Pathology of Delirium Tremens. By CHARLES MOREHEAD, M.D., &c. (Transactions of the Medical and Physical Society of Bombay,' Nos. 6 and 9, 1843, 1849. pp. 139, 123. 'Clinical Researches on Disease in India.' Vol. ii. p. 530.-London, 1856.) 6. Observations on the Treatment of Delirium Tremens without Opium. By T. CAHILL, M.D. (The Dublin Journal of Medical Science,' vol. xv. p. 396, 1839.) 7. Cases of Delirium Tremens, with Commentary. By JOHN HUGHES BENNETT, M.D., &c. Clinical Lectures on the Principles and Practice of Medicine. pp. 409. Second Edition.-Edinburgh, 1858. 8. Meningitis Phantasmatophora; Brain Fever of Drunkards. (Elements of the Practice of Physic.' By DAVID CRAIGIE, M.D., &c. Vol. ii. p. 50.-Edinburgh, 1840.) 9. Remarks on the History and Treatment of Delirium Tremens. By JOHN WARE, M.D.-Boston, 1831. 10. Vergiftung durch Alkohol und Alkoholische Getränke (Alkoholismus. Morbi ex nimio usu et abusu Alkoholicorum). Von Dr. C. Ph. FALCK, zu Marburg. (Handbuch der Speciellen Pathologie und Therapie. Zweiter Band. Erste Abtheilung s. 293. Intoxicationen, Zoonosen, &c. Redigirt von Rud. Virchow.-Berlin, 1855.) Poisoning by Alcohol and Alcoholic Drinks. By Dr. C. Ph. FALCK. (Handbook of Special Pathology and of Therapeutics. Edited by Rud. Virchow. Vol. ii. p. 293.-Berlin, 1855.) A WELL known writer, not less remarkable for his paradoxes than for his taste and eloquence, observes,* that "He never met with a question yet of any importance which did not need for the right solution of it at least one positive and one negative answer, like an equa* Cambridge School of Art: Mr. Ruskin's Inaugural Address, delivered at Cambridge, Oct. 29th, 1858. tion of the second degree. Mostly matters of any consequence are three-sided or four-sided, or polygonal, and the trotting round a polygon is severe work for people any way stiff in their opinions. For myself, I am never satisfied that I have handled a subject properly until I have contradicted myself three times." Without any desire to keep Mr. Ruskin company in the last mentioned laudable endeavour, we purpose testing ourselves by one of his trials-i.e., by reconnoitring some of the sides of the polygon within which the subject of delirium tremens lies entrenched. Some portions of the fortification we have long considered dreadfully weak, and we have at length made up our mind to play upon them a little of our artillery. We take the privilege of selecting, of course, our own points of attack, declining to invest the whole circuit of circumvallation. We therefore state, in limine, that with the psychical, maniacal, forensic, and social relations of delirium tremens we shall have nothing to do, but will confine ourselves to some portions of its more material pathology, and the question of its treatment. We are satisfied that upon these matters our views have been-as the milliners say-cut on the bias; and the tendency of the prevailing doctrines concerning the heterodoxy of depletion and the orthodoxy of brandy and water in the treatment of disease generally, is to uphold the fashionable falsities we would here expose. In doing so, it may be possible that we speak unpleasantly dogmatic; but it should be remembered that to blend the history of the present with the politeness of drawing-rooms, is not easypraise may be thrown back as impertinence-blame will be as an insult, revenged. Since the time when the opinions of Abercrombie, Bright, Guldberg, Frank, Speranza, Andreæ, Craigie, and others, who regarded delirium tremens as symptomatic of some modification or variety of meningitis, went out of favour, the more generally received view of its nature has been such as is expressed by Dr. Watson, when he replies to his pupils: "You ask me what is the essential nature of the disease, and I can only state in reply, that it consists in nervous irritation. nervous exhaustion goes along with and augments the nervous irritability." ."* This view of its being the result of irritation and exhaustion of nervous power from excessive stimulation, has been associated with the belief that an identically similar state, as the delirium tremens à potu, may be seen to follow the abuse of opium, tobacco, and from extreme mental and emotional excitement. The opinion has also prevailed that it is the sudden withdrawal of the accustomed stimulus that generally constitutes the immediate exciting cause of the outbreak of the affection. Thus has resulted what seemed a legitimate corollary-viz., that the proper treatment for the malady consisted, on the one hand, in the continued administration of alcoholic stimulants, and on the other, "the great remedy is sleep; that . . . . opium must be given in full doses, and it must be fearlessly repeated if its desired effect do not follow."+ Now, speaking generally, we regard these several doctrines as essentially erroneous, and that both theoretic teaching and practical ex • Lectures on the Principles and Practice of Physic, vol. i. pp. 400, 401. Third edition. † Watson, op. cit. perience compel us to view the pathology and therapeia of delirium tremens in a very different light than the before-mentioned teaching implies. It might be fairly asked of us to explain how it happens, then, that for nearly half a century such doctrines have been so very widely taught and accepted, both in this country and elsewhere? We would reply, in the first place, the exact nature of the affection has not been generally recognised; secondly, the course and progress, or the "natural history," of it has not been attended to; thirdly, that from the student of medicine drawing his hospital experience far more abundantly and continuously from the surgical than from the medical wards, he has entered upon "practice" with a one-sided knowledge of the malady-viz., as occurring after shock to the nervous system of the intemperate man who has suffered injury, accident, or operation. Such student will necessarily be inclined to continue jurare in verbo magistri, and with which he will find the prevailing dogma of "general stimulation" admirably to square. With respect to the latter statement, it may be observed that since it is in the surgical wards that (as we with all deference think) the excessive use of alcoholic excitants is chiefly seen, the student is led to consider gin and bottled stout to be almost panaceas, to which may not unfrequently be added, with unsparing hand, that "queen of all the medicines," as Hofmann calls it-opium. The differences between certain diseases of the same names, occurring idiopathically and in patients after accident or operation, followed by suppuration, sloughing, &c., are just as little recognised by the student in the cases of erysipelas, pneumonia, &c., as they are in delirium tremens uncomplicated with and complicated by "shock." The result is that the therapeia of the one side is brought to bear likewise upon the other. No doubt but that the highly stimulating and supporting method of the surgeon is often admirably fitted to his peculiar cases, but equally plain is it to our minds that it requires sometimes not a little "toning down" in its application to the idiopathic forms of disease under the physician's care. If in times gone by the lancet was the cure for everything, in modern days we are not less exaggeratingly trustful in wine, brandy, and beer. We can "blow hot and cold" now just as readily as was done then. It has been stated,* under circumstances of some pretension, that we have taken "narrow views of disease, and that we are diverted from the course which a sounder pathology would dictate by small indications which ought to merge into general principles-that we complicate our ordinances with a multiplicity of detail." When we narrowly inquire in what "broad views of disease" (p. 41) consist, we find, quoad treatment-e.g., that ladies who have no appetite for breakfast, should take "a glass of rum and milk as a substitute" (p. 47); that maidens who rise too early from their beds, can have "healthy sleep prolonged, to a term regulated by the requisitions of the system," by "steel, bark, and mulled On the Prevalent Treatment of Disease. Two Lectures delivered in the Theatre of the Royal College of Surgeons, in July, 1853, by Frederick C. Skey, F.R.S., Professor of Anatomy and Surgery to the College, pp. 68. London, 1853. † Op. cit., p. 40. port wine at bed-time" (p. 52); whilst a solicitor or seamstress, who sleeps too much, can at once be relieved by taking "a glass of rum and milk at seven A.M., and adding two glasses of port wine to the usual quantity at dinner" (p. 49), or by drinking a tumbler of gin and water as an economical agent "at the mid-day meal" (p. 50). We discover, also, that whilst some of us weaker brethren " complicate our ordinances with a multiplicity of detail," these "broader views" of Young Medicine offer a happy refuge to their neophytes in the following very simple system of therapeutics. Alluding to the case of a young lady under his care, Mr. Skey observes: "While the weather was yet hot I ordered her to take a cold shower bath every day. I gave her steel in the form of Schwalbach water, twice a-day, to the amount of two-thirds of a quart bottle. Twice a-day two drachms of compound tincture of bark. Thrice in the day a full dessert-spoonful of cod liver-oil. Every morning a liniment of cantharides and turpentine to the upper part of the chest, alternately in front and on the back. She occupied a room without a curtain, and often slept with the window slightly open. She ate meat three times in each day, and she drank three full glasses of sherry during the remaining meals. I ordered her to be encased in flannel down to the wrists and ankles as the weather became colder; and on the accession of the slightest sensation of chill to take hot wine or brandy and water." (p. 65.) And this is the simple (!) system of therapeutics we are offered, by which "That odium chirurgicum, or rather odium medicum, the lancet and the scarificator, with all their concomitants of purgatives, laxatives, and diaphoretics, which tend to rob the body of its richest juices constituting the essence of its life itself, may be largely restricted in their operation." (!) (p. 67.) The simplicity of the method! Alas for the force of habit and association. How simple to every one appears the system of truth on which his whole mental education has been constructed! "There is not a man on the face of this earth for whom a narrow education has marked out the whole cycle of his ideas, who does not think his system of truth the most divinely simple of all, and consequently look upon every other as encumbered with darkness, sinuosity, and confusion."* Further, we cannot shut our eyes to the fact, that there is abundant evidence in the practice of some well-known physicians of the day, of their stretching the principles of the stimulant school of therapeutics beyond what must be considered their legitimate extent. We hear of acute pericarditis complicating rheumatism in its early stage, as a matter of course or of necessity being treated with ammonia, and a pint of brandy during the day; of typhoid fever from the onset, and under all circumstances, requiring a tablespoonful of brandy every hour; of its being suicide to take aught but gin and porter in pneumonia; and of "mulled port" being brought to bear upon the paroxysms of acute gout! But surely we shall not be thought desirous of reverting to the olden times, when bleeding and purgation were considered proper omnibus semper et ubique, if we insist upon the truth, as Morell, J. D. applied generally, of the following remarks of Dr. Wilks-though made by him only in reference to fever: "Patients die with stimulants, and without them, as well as recover on both plans. The fact is manifest, that these remedies can in some cases be dispensed with; and that in others, although freely given, do not save the patient's life.. ... I believe that a large number of patients have been saved by their timely administration; but at the same time, I do strongly oppose the opinion that wine or brandy can be looked upon in the light of specific remedies, or as antidotes to the disease. . . . . Over and over again have I been surprised at the favourable termination of many bad cases. Where little or no stimulant was made use of, patients to whom I should have ordered a large quantity of wine, had I had the opportunity, nevertheless recovered on the very small pittance they were able themselves to procure."* We would likewise offer for consideration to the extreme disciples of the "new method," who we fear must often run the dreadful chance of allowing the thread of life to be cut short in a state of drunkenness, the beautiful reply of a patient alluded to by Dr. Theophilus Thompson; "a venerable lady, more than ninety years of age, whom I once attended, and who, in answer to my arguments for the desirableness of endeavouring to maintain the circulation with brandy, made answer, 'Let me go home sober."" From the preceding observations it can readily be seen how it has happened that the prevalent doctrines connected with delirium tremens have continued to experience such great favour. No doubt some practitioners have rebelled against them, as reference to the works given at the head of this article will fully show; but though the names have neither been few nor insignificant which have been attached to teachings of a very opposite nature to those ordinarily received, we can scarcely regard these teachings as yet occupying any firmer position than as amongst the "Truths of science waiting to be caught, That float about the threshold of an age." The first point in connexion with delirium tremens, and in reference to which a change of opinion is warranted by theory and necessitated by experience, is as to the nature of the disease. Without denying that the nervous system in the intemperate man is suffering irritation and exhaustion, and that his delirium cum tremore may be associated with one or other, or both, of these states, as its immediate antecedents, yet we maintain that we gain no knowledge thus of the mode in which these states are brought about; and we do not include those generalizations on their causation, which the progress of modern science permits us to advance in rendering an account of the poisonous action of alcohol. So far as we are aware, Levèille was the first to make a right step in this way. He maintained that the disease consists in exaltation of the vital powers of the brain, excited by • Guy's Hospital Reports, p. 35. 1855. + Clinical Lectures on Pulmonary Consumption, p. 204. London, 1854. |