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were often treated with needless severity, and that blood was squandered most profligately by those who fastened their faith to the lancet only. But we have outlived those sanguinary days. Thanks to the help of those grand adjuvantia, calomel, opium, and antimony, it is long very long since we have seen a case requiring the repeated venesections common at the time of our noviciate. Peculiarities of constitution and other circumstances may compel us to pretermit the measure; but let the Paris and Vienna cases be what they may, I confidently appeal to the observant practitioners of this country, whether experience has not convinced them that if they are obliged to forego an early bleeding, the future management of the case becomes one of far greater difficulty than when it has been practised. I do not hesitate to say that the patients of a young practitioner may be endangered by the infusion of scepticism into his mind, as to the value of the orthodox treatment. For my own part I have an antipathy to the shedding of blood; it is the greatest possible relief to find that a case is one that does not require this remedy. Consider then what may be the effect of remarks, that insinuate a distrust of the necessity of active depletory measures on inexperienced practitioners with the same tendency, which from observation, I believe to be a very common one. In the early period of an illness, it is perhaps only from a nice balancing of indications that the inflammatory character of the disease is decided; but the patient shrinks from the lancet, the friends are averse to it, and now the doubts in the practitioner's mind, as to whether after all a bleeding is so very important, will turn the scale, and the bleeding is deferred. Twelve or fourteen, or, in country practice, twenty-four hours slip by before the next visit. And now the necessity is obvious enough, unless indeed the opportunity has been lost altogether. Imagine the case to be one not of pleurisy, but of peritonitis, and then judge what disastrous results ensue from the loss of time. I am sure I have my practical brethren with me when I express extreme jealousy of remarks, however enlightened may be their author, which tend to unnerve rather than to brace the young combatant in these life-and-death

encounters.

I cordially acknowledge the great benefits conferred by Dr. Combe on the laity in those admirable works of his, on Physiology applied to Health,' on 'Digestion,' and on the 'Management of Infancy.' I doubt not that thousands gratefully associate with the name of Combe the formation of habits that have enabled them to be their own conservators of health, and to go through their daily duties with ease and cheerfulness. But when Dr. Combe comes forward to lecture the profession on the importance of studying Nature, I beg leave to tell him that though Lord Bacon has been dead more than two centuries, he yet speaks, and in tones more intelligible and commanding than ever; that his sublime testamentary prediction has been long fulfilled; that not only did the "next ages" reverently take up his name and words, but that every suc ceeding age has resounded them yet louder and louder; that they are lisped by children, and syllabled by strange tongues on

"Sands, and shores, and desert wildernesses,"

and that no class of practical philosophers have more obediently remembered the words of the great master, than the followers of medicine from the days of Sydenham and Baglivi downwards. Dr. Combe has this time mistaken his mission; this is not his rôle; and we must bid him "sui plausu gaudere theatri."

I remain, my dear Sir, yours very sincerely,

J. A. SYMONDS.

IV. THE NATURAL HISTORY AND TREATMENT OF DELIRIUM TREMENS.

BY JOHN WARE, M.D.

[Delirium tremens is one of those acute diseases, the natural progressin other words, the Natural History of which is generally complicated and obscured, or at least rendered doubtful, by the effects of the treatment most commonly had recourse to in this country, viz. that by opium. It has been, therefore, thought a matter of practical importance to give an account of this very interesting and often dangerous malady, as it shows itself uninfluenced by treatment. The admirable Memoir from which the following extracts are taken, was published in Boston in the year 1831; and the reader will find the principal data on which its conclusions are founded, in our Number for January, 1839, p. 268. We are by no means prepared to assert that opium is, in no case, beneficial in delirium tremens; or that it will not sometimes procure sleep when this would not ensue spontaneously; but we are certain, from personal experience, that the opiate treatment has often failed, that it has been occasionally very injurious, and that the sleep which ushered in restoration has frequently, at least, been the mere concomitant or sequent of the medicine, and not its effect. At any rate, it is an essential element in the philosophical knowledge of the pathology and treatment of every disease, to be aware of its natural course, progress, and result.]

Although delirium tremens occurs in various states of the constitution, and in various diseases, and is to be looked upon as a possible event in almost all cases of indisposition among drunkards, yet there is a remarkable similarity in the phenomena presented by the affection, and in the course of symptoms through which it passes, whatever may have been the original state of constitution or disease from which it has proceeded. Its approach is often indicated by the existence of certain symptoms from the very commencement of indisposition. It is particularly likely to take place in those who have suffered from irritability of the stomach and frequent vomiting. Indeed, it often makes its appearance after having been preceded by no other symptom of disease, and comes on as soon as the vomiting ceases. There is commonly also in the beginning of those cases in which delirium finally ensues, a tremor of the hands and limbs, and more frequently of the tongue; a tremulousness of voice producing some indistinctness of articulation; a general anxiety; a hurried manner of moving and speaking; imperfect and disturbed sleep; and startings and twitchings of the limbs. These signs are by no means infallible. They are sometimes observed where delirium does not follow. But where they exist from the very first, are not diminished by the treatment adopted, and do not leave the patient with the other symptoms of his complaint, an attack of delirium tremens may be reasonably expected.

But, on the other hand, it frequently happens that the attack is not indicated by any such symptoms in the early history of the case. The patient appears to be getting on perfectly well, and the original disease to be subsiding in a satisfactory manner, when suddenly it becomes manifest that an attack of delirium tremens is threatened. In either case, however, whether there have been any premonitory symptoms or not, the disease follows very much the same course. The patient first complains that he has not slept well, that he has been disturbed all night by unpleasant dreams, that he has been hard at work, but that matters have not gone right, and his concerns have troubled and perplexed him. During the next day, perhaps, he is tolerably comfortable, has some appetite, moves about his house or place of business; yet he is uneasy and restless, and exhibits those appearances which have been already

Remarks on the History and Treatment of Delirium Tremens. From the Transactions of the Massachusetts Medical Society. 8vo, pp. 61.

described as indicating the approach of the disease. This continues for one or two days; each night being worse than the preceding, whilst in the day there is an increase of the anxiety, restlessness, and trembling of the limbs, tongue, and voice.

The night is then passed with only one or two short naps, from which the patient awakes with some strong impression upon his mind, of the fallacy of which it is difficult or impossible to convince him. His sleep has been filled with dreams of dangers and perplexities and annoyances, innumerable and indescribable. From this state he passes into that of complete watchfulness and delirium. The dreams of his sleeping become the fancies of his waking hours; and in his delirium he conceives himself to be engaged in the same occupations, beset by the same difficulties, and surrounded by the same dangers, that he has described as giving a character to his dreams. In fact it is difficult in many cases to point out the precise time at which the mind passes from the dominion of the conceptions which have been engendered in sleep, to that of those which are the offspring purely of the disease.

At whatever period this state of entire watchfulness and delirium begins, we are to date from it the commencement of what may be denominated a paroxysm of delirium tremens. Yet it will sometimes happen, that, on the morning succeeding the night, from the last continued sleep of which we are to date the commencement of the paroxysm, the patient does not exhibit any unequivocal marks of the delirium by which he is affected. The attendants inform us that he has had but little sleep, and has been very crazy, but we find him sufficiently rational to give an account of his feelings, and fully aware of whatever is going on about him. Still his aspect and manner are such as to convey to the mind of one accustomed to the disease, the true state of the case, even although there may be no actual exhibition of delirium during the period of the visit.

Most frequently, however, at this time there are occasional wanderings of mind, though not a continued state of delirium. Thus, while sitting by the patient, we perceive his eye become intently fixed upon some remote spot in the room, or outside a window, as if it had been suddenly caught by some remarkable object;-or he will speak in a loud and quick voice, as if making answer to some one who has addressed him from without, or from behind; or he will start up hastily from his seat or from the bed, and run to another part of the room, or to look beneath the bed, as if in pursuit of something. These impressions are, during the early part of the day, evanescent; but in the latter part the delirium returns, and becomes constant. It increases in violence till about the middle of the night, and then diminishes towards the morning.

On the morning of the second day the delirium is still complete, and is not altered in its character; but the patient is milder and more tractable than during the night. He is as fully possessed of the strange imaginations which have entered into his mind; but he is more easily influenced by his friends, and is more amenable to authority. The second night is generally worse than the first, and there is less abateinent of the disease in the ensuing or third morning, and in the early part of the day; still there is some alleviation of symptoms, like that of the day before. The third day is passed much in the same way as the second; but if the disease is to have a favorable termination, the delirium of the third night is less violent than that of the preceding, and the paroxysm terminates in sleep, sometimes in the course of the evening or first part of the night, but most commonly not until the latter part of the night or in the morning. When the disease is about to terminate unfavorably, the delirium continues undiminished until the fatal event takes place.

This description has been taken from cases which were left to take their own course, uninfluenced by medicine. In all essential points it will apply to a majority of cases. Still there are many variations in the time of day at which the paroxysm begins and terminates, in its length, and in other

particulars, which cannot be included under any general account. Thus its duration is sometimes less and sometimes greater than that assigned to it. Especially it is apt to be prolonged in those who have had repeated attacks, and in one such case I have known it to extend to nearly six entire days.

During the first part of his sleep the patient is generally uneasy and restless, his breathing is irregular, and is sometimes almost like that of a person dying. During the first few hours, he often wakes once or twice, perhaps gets up and renews the exercises of his delirious state, or else takes merely a little drink, but in either case, goes soon to sleep again.

Soon after getting into a sound sleep, the breathing becomes deep, slow, and sonorous; a profuse sweat breaks out, and for a long time the whole body is bathed with it. After six or eight hours the patient awakes tolerably rational, and sensible of what is going on about him, but generally with some impression left on his mind of the imaginary scenes through which he has passed. He continues for the next twenty-four or even forty-eight hours, to sleep during the greater part of the time. At the end of that period, his restoration appears complete, so far as the peculiar symptoms of delirium tremens are concerned; for he may still be the subject of other affections which have preceded the paroxysm, and which remain after it has subsided.

Almost invariably the occurrence of sleep at the close of the paroxysm is indicative of a favorable termination. In some rare cases, however, the patient actually dies after falling asleep, particularly where sleep has been procured by opium; indeed the only cases which I have seen or known, in which the disease has terminated in this way, have been treated by large doses of opium. In such a case no peculiar symptoms indicate a different result from that which we usually promise ourselves when the patient falls asleep, till after sleep has taken place. But then, instead of gradually passing from a disturbed into a more tranquil and natural slumber, he becomes first more unquiet and restless, moans, breathes with difficulty, and falls at length into a state of complete coma, from which he never awakes.

The disease terminates fatally in several other ways. Sometimes the patient is carried off by the sudden accession of convulsions, and this event is particularly to be looked for in those cases which have begun with them. They also occur very unexpectedly in cases which promise favorably, and which have afforded no ground for anticipating them. Sometimes the patient, after continuing the violent exertions of his delirium to the very last moment, without any of the peculiar signs of approaching dissolution, falls back and expires immediately. Sometimes, during the continuance of the delirium, death comes on from the effects of some disease with which it happens to be complicated, and dissolution occurs in the same way that it would from that disease alone.

There has been much uniformity of opinion among physicians concerning the object to the accomplishment of which the treatment is to be directed during the paroxysm. This object is the procuring of sleep. The absence of sleep is one of the most remarkable symptoms of the disease. When it terminates favorably, it terminates in sleep. It is not without foundation, therefore, that the treatment has had for its primary indication to bring about this termination. The patient, it has been emphatically said, “must sleep or die." There is no doubt that this is true. But may it not have been too hastily concluded from this undeniable position, that sleep must be procured by the assistance of art, or the patient will die? It is possible that the common impression which has been produced on our minds concerning this is erroneous in two points of view: 1, We have concluded that sleep is the cause of the salutary change which takes place in the disease; and 2, that sleep, in whatever way induced, will have the same effect, and that it is therefore to be induced by artificial means.

should go to Oxford, and tell the men who are construing Juvenal and Eschylus, that he hopes they have learned their accidence? Study Nature! Talk prose! Have we not been doing it all our lives? What were those curious inquiries into the roots and juices of plants in our early days-those porings over muscles and nerves, vessels and viscera, in vaulted cellars, those hospital walkings and dispensary trudgings,-those clinical labours, when, from the initial rigor to the terminal rhonchus, every phase of the case was carefully observed and faithfully depicted in those long, ledger-like note-books, and then the work of Nature further studied in the mortuary, with all aids and appliances from scalpel, scales, and measure;-and, since then, the nightwatchings many by the bedside, and the reflections of sleepless hours on the day's observations, and the endless interrogations of Nature, if haply one might attain to such knowledge of her doings, that here one might aid them, and there control or repress them? Or, to put individual experience aside, what have been the labours of the Baillies, the Laennecs, the Andrals, the Louis, the Brights, the Carswells, the Hasses, and Rokitanskis, and Vogels, and a host of recent histologists?-painful searchers all into the dark mysteries of Nature Physiology is good, but it is not the one thing needful. There is pathology also- there is a dark as well as a bright side of Nature. It has pleased Infinite Power and Goodness to mix up evil with good in this world, and to place man in it with instinctive and other instructions, to do all he can towards extirpating or abating the one, and fostering and increasing the other, and to hope for a better state of being in which the sad enigma will be unriddled, and partial ill be resolved into universal good. Study Nature! yesbut let it be no narrow, one-sided study! Measure the vis vitiatrix as well as the vis medicatrix! It is better to be on our legs facing evil, defying it, and wrestling with it, than to sit simpering in the easy chair of optimism and crying "Peace, peace-when there is no peace."

Misled by his fancy that my letter was a critique upon his own, Dr. Combe repeatedly alleges, that I regard a method of treatment in accordance with Nature as equivalent to doing nothing at all. But you no doubt perceived that I was really inquiring whether diseases might be left to take their own way, a question naturally suggested by your original article, in which you had made a vigorous and able reclamation for the somewhat neglected vis medicatria. After exposing the absurdity and nullity of the homoeopathic system, you asked, how are the apparent cures under this system to be accounted for? And you concluded very reasonably, that, if the cases had got well, they had got well of themselves-not from the interposition of what Dr. Combe chooses to call "his natural treatment," but from no treatment at all. In my remarks I said, that if the statements of homeopathic success could be depended upon, they were most momentous; and the question which Dr. Combe thinks so superfluous, was inevitable. But I soon satisfied myself from an analysis of Dr. Fleischmann's table, that there was no need for any concern about this document and the possible inferences from it, and my conclusion was subsequently confirmed by Dr. Balfour's excellent Report. I then discussed the question on other grounds, and endeavoured to show, not only that Nature is often inadequate to the cure of diseases, but also that she is often doing mischief. Among the instances I adduced was that of sympathetic disorders in dentition, upon which Dr. Combe thus comments: "In teething, Nature's efforts are directed to effecting a passage outwards for the advancing tooth. If, from any circumstance, she proves unable for the effort, sound principle would assuredly direct us to aid her in it, and remove the obstacles which obstruct her progress; and I am at a loss to know what more rational or direct aid we could lend her in her own way, than making the opening through the gum, which she has failed to accomplish for herself." (p 259.)

It is remarkable that men of "strong sense," but "blinded by a precon

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