A second peculiarity is the restlessness of the delirium. The patient is invariably uneasy, apprehensive, always on the alert, declaring that some calamity threatens him or that some evil is about to befall him. In consequence of these apprehensions even momentary repose is wanting. If he lies down for a moment, it is only to rise again and peer under the bed or into the corners, turning his head from side to side in search of some realization of the fears that torment him. This sense of apprehension impels the patient to hurry ever onward from place to place in search of the repose which he nowhere finds. It is increased to positive terror by the ever-varying and constantly-renewed hallucinations which torment him, and from which he seeks to escape, no matter how great the obstacles to be overcome.
A third peculiarity of alcoholic delirium is insomnia. This condition is of the must marked and stubborn character, even continuing for several days in succession.
5. Delirium Tremens.—This is the characteristic form of alcoholic delirium, and, as is indicated by the name, is invariably accompanied by tremor. It must be looked upon as an episode or epiphenomenon of chronic alcoholism. It is rare that even prolonged temporary excesses in persons ordinarily sober are followed by delirium tremens. Such excesses in the subjects of chronic alcoholism are, however, perhaps the most common cause of this condition. Orgies, especially when associated with venereal excesses, very frequently terminate in delirium tremens. Occasionally also, but much less frequently than was formerly supposed, the abrupt discontinuance of alcohol is followed by the outbreak. Other exciting causes are violent emotions, as anger or fright; hardships, such as prolonged hunger, over-exertion, or watching; acute maladies, as pneumonia, dysentery, erysipelas, the exanthemata, or rheumatism; finally, serious traumatisms, with or without great loss of blood. Delirium tremens usually occurs in those addicted to the abuse of spirits, less frequently in beer-drinkers, and comparatively rarely in those whose excesses have been restricted to wine. The attack does not, as a rule, begin abruptly; its prodromes usually consist in an exaggeration of the previously existing symptoms of chronic alcoholism. The patient complains of malaise, restlessness; he becomes depressed, morose, anxious without cause, apprehensive of some calamity, or he is more impatient and choleric than before. The ability to apply himself to his ordinary occupations is lost. He complains of vertigo, ringing in the ears; sleep is disturbed, or there is already insomnia. At the same time the stomach is deranged, appetite is lost, the tongue is covered with a thick yellowish-white fur, and there is constipation or diarrhœa. The period of prodromes may last from a few days to a week.
The outbreak is characterized by delirium, without, at least in the greater number of cases, absolute loss of consciousness. That is to say, it is possible by addressing the patient with energy or by strongly arousing his attention to interrupt the delirium and for a moment recall the patient to himself. In the graver cases, however, loss of consciousness appears to be complete. The subjective impression of the delirium, as recollected at the termination of the attack, is that of a sense of overwhelming confusion and inability to recollect or co-ordinate the ideas that were crowding upon the brain. The hallucinations, as has already been indicated, relate almost exclusively to the organ of sight, more rarely to the hearing; also, and exceptionally, to the other organs of sense. They are almost always either terrifying or repugnant. The objects of the hallucinations of the sight have already been described. They consist of animals, serpents, and monsters, which crowd into the apartment, coming usually toward the patient, disappearing in the walls, in the floor, under the bed, or among the bed-clothing. These visions are usually aggressive, threatening the patient, throwing themselves upon him, striking him, or tearing at his vitals. They are sometimes replaced by phantoms, spectres of the most horrible character, skeletons, death's-heads, or by flames which surround the patient and threaten to consume him. Sometimes the hallucinations relate to the daily occupation of the patient, and he pursues his tasks with a feverish and distressing anxiety. These hallucinations are almost invariably of the most fleeting, incoherent, and variable kind.
Auditory hallucinations occur usually in individuals of marked neurotic tendencies. They are apt to be more coherent than the hallucinations of vision, and are often of the nature of those which occur in the delirium of persecution. Sometimes they consist of cries, of chiding, of menacing voices, of the repetitions of obscene words and suggestions; sometimes they are cries of horror or the roars of animals, sometimes explosions or the discharge of firearms; or, again, they are terrifying threats. Hallucinations of taste and smell are much more rare, and occur in the subacute forms of delirium tremens. The patient complains of annoying odors or disagreeable tastes, either constantly present or upon the taking of food or drink. Disturbances of general sensibility show themselves in hallucinations in regard to sensations of pricking, burning, or tearing of the surface of the body, or of animals or vermin crawling over the patient. Hallucinations relating to the sexual instinct are far from rare. The hallucinations of every form are apt to be more frequent and more troublesome during the night than during the day.
Restlessness, fear, and anxiety are characteristic phenomena of delirium tremens. The patient is not only terrified by the imaginary objects which surround him, but often in their temporary absence he experiences an equal degree of fear for which he can assign no cause. It is to this condition of apprehension that is due the desire to escape from his present surroundings which is so characteristic of the delirium in question. Under its influence the patient occasionally commits acts of violence of the most serious kind. Sometimes the delirium is more quiet: the patient converses with individuals whom he supposes to surround him; he busies himself with his familiar occupations, giving orders, directing work, dictating letters, and arranging his affairs. At other times the delirium takes the form of apprehension of poisoning, and food and medicine are alike stubbornly refused.
The countenance, as a rule, is animated, the eyes brilliant and injected, the look fixed or peering, but always eager, or the expression may be haggard and agitated. The physiognomy, although largely influenced by the character of the delirium, may be said to be in most cases characteristic.
Sensation is usually impaired; especially is this true of sensibility to pain.
Tremor, although occasionally slight, may be said to be never wholly absent. Sometimes it affects the muscles of all parts of the body; more commonly it is limited to the hands, arms, tongue, and lips; less frequently it manifests itself in the lower extremities. Slight tremor may be increased by causing the patient to hold his hands extended with the fingers separated. The movements of the hands consist of rapid rhythmical oscillations of nearly equal extent and duration. The tongue is protruded with a rapid jerking movement, and withdrawn with equal suddenness. It shows fibrillar trembling. The trembling is increased by voluntary movement, and is ordinarily associated with some loss of motor power. The gait is often hesitating and awkward; movements of the upper extremities are executed with difficulty, and speech is irregular and interrupted. The motor disturbances are occasionally associated with choreiform movements or actual epileptic convulsions.
Insomnia is a constant condition. It usually persists throughout the attack, and occasionally proves troublesome for several weeks after convalescence is in other respects complete.