In the absence of pulmonary complications the respiration is not disturbed, save as a result of the restlessness and physical effort which sometimes quicken it. The same statement is true of the pulse. The action of the heart is usually enfeebled, and the first sound weak. The temperature is normal. The skin is frequently bathed in copious perspiration. There is complete loss of appetite, and in most cases inability to retain food. Thirst is constant, often tormenting. The tongue is sometimes moist, and coated with thick white or yellow fur; sometimes hard and dry, sometimes red. The urine is scanty, dark-colored, and sedimentary. It occasionally shows traces of albumen. Constipation is the rule.
The duration of delirium tremens is from three to seven, or even ten or twelve, days. The course of the attack is paroxysmal or remittent. The symptoms usually undergo some improvement during the day, only to become more urgent at night. The periods of remission are occasionally marked by transient slumber; the recovery by prolonged and deep sleep. But this is by no means the rule. Several varieties of delirium tremens have been described by writers upon the subject. These are—the grave form, characterized by violence of the motor disturbances, aggravated delirium, and gravity of the general condition; the febrile form, in which after the third or fourth day the temperature, without pulmonary or other discernible complications, suddenly rises to 104° F. or beyond that point, with great aggravation of the general symptoms; the adynamic form, marked by failing heart-power, feeble or imperceptible pulse, profuse sweats, collapse, stupor, which deepens into coma and ends in death; and finally, the subacute form. Here the patient is quiet, but restless. The delirium scarcely passes beyond the limits of occasional wandering, and relates chiefly to matters connected with the daily interests and occupations of the patient. Tremor is more or less marked, and sleeplessness is stubborn.
The termination of delirium tremens is in—1, recovery; 2, in death; 3, in the chronic form; and 4, in other forms of insanity.
1. Recovery.—Except in the grave forms recovery may be said to be the rule. Occasionally ushered in by a prolonged, almost critical, sleep, more frequently it takes place by gradual improvement. In the latter case the remissions are more and more prolonged, and attended by increasing repose alike of body and of mind, and by tendency to sleep. The hallucinations become feebler and less tormenting, at length recurring only in the evening or at night, and especially as the patient is about falling asleep. The anxiety and restlessness grow less urgent, consciousness becomes more secure, the trembling diminishes, and recovery is slowly established. The tremor is apt to persist some days into convalescence.
2. Death.—This mode of termination is not very common in the ordinary forms of delirium tremens. In the grave forms it is usual, sometimes occurring suddenly, sometimes gradually from intensification of the symptoms and failure of nervous power; or it may occur in consequence of pulmonary, cerebral, or renal complications; finally, the fatal termination is often due to the acute disease or the traumatism by which the delirium tremens has been excited, and of which it is, in fact, a complication.
3. Chronic Delirium Tremens.—This mode of termination, described by Lentz, is rare. The acute phenomena subside; the restlessness and the mental agitation diminish. Insomnia gives place to sleep, which is light and disturbed by dreams and nightmare; most of the hallucinations lose their activity and frequency, and finally disappear. The changing delirium settles into a fixed delirium of persecution; the tremor, while it becomes fainter, persists, and the condition is permanent.
4. Other Forms of Insanity.—This mode of termination has been studied especially by Magnan, who has classified the cases of delirium tremens into three different groups, according to their tendency to recover or to the development of mental alienation. The first group includes those cases which run a favorable course and terminate in complete convalescence; the second group, those cases in which the convalescence is prolonged and characterized by repeated relapses; the third group is composed of cases which likewise show a strong tendency to relapse, but in which the delirium continues after the other active symptoms have subsided. This form shows itself most frequently among the subjects of hereditary alcoholism. After repeated attacks the delirium becomes chronic. Morbid mental phenomena replace or accompany symptoms more directly referable to organic disturbances of the nervous system. Tremor gradually diminishes and disappears, the gastric symptoms subside, insomnia passes away, even hallucinations disappear, or at all events become infrequent; but the delirium which developed coincidently with these symptoms continues, and finally becomes chronic, losing to a great extent its original characteristics and constituting a form of insanity. Finally, dementia constitutes an occasional mode of termination in delirium tremens. It does not often develop immediately, although cases of this kind have been recorded. More commonly, the alcoholic subject, losing little by little his mental activity after each attack of delirium tremens, subsides by degrees into absolute and irremediable dementia. Paretic dementia may also develop after prolonged alcoholic excesses characterized by repeated attacks of delirium tremens.
The anatomical lesions after death from delirium tremens shed no light on the pathogenesis of the condition. Meningeal congestion, œdema of the pia mater and of the cortical substance of the brain, scattered minute extravasations of blood, and some augmentation of the cerebro-spinal fluid have been observed. In the greater number of cases no lesions whatever beyond those characteristic of chronic alcoholism have been discovered.
6. Alcoholic Insanity.—Among the psychical derangements, it remains to notice briefly the more prominent forms of insanity which develop in the course of chronic alcoholism, in consequence either of hereditary or of acquired morbid mental tendencies. These are—a, melancholia; b, mania; c, chronic delirium; d, dementia; e, paretic dementia.