DELIRIUM TREMENS.
Delirium tremens as an expression of acute or subacute alcoholic poisoning is in no essential degree a surgical condition. This form of toxic delirium may occur while the individual is still drinking inordinately, or not until several days have elapsed after active drinking has ceased. It is precipitated in many cases, where otherwise it would simply remain imminent, by surgical injuries and operations. In one in whom it is feared, the surgeon should become apprehensive in proportion as the muscular system becomes unsteady and tremulous, the mind disturbed, and the individual sleepless.
Patients in a well-marked condition of delirium tremens may become so uncontrollable and so lost to sensation of pain that it may be practically impossible to enforce the physiological rest which their surgical condition demands. The restraining sheet will answer for general purposes, but the strait-jacket and even the most carefully applied plaster splint or mechanical restraint will not always be sufficient to carry out the indication.
Ingenuity may be taxed beyond its limit to enforce the needed rest, for patients will tear off bandages and injure themselves in various ways.
Treatment.
—The local indications are in the direction of physiological rest. Constitutionally the indications are in two directions: First, to keep up nutrition and excretion; secondly, to properly medicate. Nutrition is difficult unless excretion is maintained. Hot-air baths, laxative enemas, preferably of cold water, when necessary, and administration of a fluid and easily assimilable diet are measures of the utmost importance. Should the case present features of an acute alcoholic gastritis, stomach feeding may be abandoned and the rectum utilized for this purpose. Medication should consist mostly of stimulants, with such sedatives, laxatives, diuretics, etc., as may be necessary. In surgical cases it is not wise to abruptly deprive these patients of the alcohol which they have so abused. Consequently in many instances a mild degree of alcoholic stimulation, at least for a time, should be continued. Two stimulants rank higher than all others as substitutes for alcohol, and in some degree antidotes to its effect. These are strychnine and digitalis. The former should be given preferably subcutaneously; the latter by the stomach if tolerated, otherwise by the rectum or beneath the skin. My own preference for the use of digitalis is in the direction of large and few doses. I have not hesitated in many instances to give 15 Cc. of ordinary tincture, repeated once or twice at intervals of a few hours, and then to discontinue it. The effect is to brace up the heart and to equalize the circulation, while at the same time it acts as an efficient diuretic. Adrenalin may be necessary, but should be used with discrimination.
Of the sedatives, bromides, chloral, and remedies of that class are those most often resorted to, and should be given in doses sufficient to meet the symptoms. They are all more or less depressant, and stimulation by strychnine, etc., is necessary even while they are being administered, in spite of the apparent physiological antagonism between them. Opium is the remedy of choice, and is best given in the form of morphine introduced beneath the skin.
The first indication is in the direction of ensuring rest and sleep, even at the expense of inconvenience or misfortune in other directions. I write this with a realizing sense of its significance, yet with positive conviction as to its truth.
Upon the assumption that this form of delirium is a toxemia of complicated type, only benefit can accrue, in aggravated cases, from a free venesection, followed by intravenous infusion of a pint or more of saline solution, at a temperature of 105° F.