Thomas Sutton.

Tracts on delirium tremens, on peritonitis, and on some other inflammatory affections, and on the gout online

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i



TRACTS



OS-



DELIRIUM TREMENS, &c.



TRACTS



ON



DELIRIUM TREMENS,



PERITONITIS,



SOME OTHER INTERNAL INFLAMMATORY AFFECTIONS,



%\tt (t^Ottt.



BY

V

THOMAS SUTTONj M.D.

Of the Royal College of Physicians ; late Physician to the Forces, and
Consulting Physician to the Kent Dispensary.



LONDON :

Printed by James Moyes, Greville Street,
FOR THOMAS UNDERWOOD, 32, FLEET STREET.



1813.



'^ ,f;f ?






CONTENTS.



PAGE

On Delirium Tremens 1

On Peritonitis - _- > 78

On the Gout .....,-.. 193



The way of theory and hypothesis is
much the cheapest and most expedi-
tious method of making a Physician. —
A heated imagination will always supply
us with knowledge, such as it is, much
faster than the ordinary course of nature.
The road of experience is tedious, and
requires great judgement, as well as
patience. — Vide Heberden's designed
Preface for the Medical Transactions,
1767.



DELIRIUM TREMENS,



JLHE term phrenitis has, for a great
number of years, been intended to
convey the idea of a disease materially
affecting the brain with continued deli-
rium, and connected with violent morbid
exertions. This disease has been divided
into two species : the one, arising from
a primary affection of the brain, ac-
companied with fever, has gained the
name of idiopathic phrenitis : the other,
as it was found to follow febrile affec-
tions, and was not immediately con-
nected with these diseases in their com-
mencement, has been called sympathetic
phrenitis; and the cure of it has been



2

recommended to be governed, in a great
degree, by the nature of the affection
which preceded it. But the disease
termed idiopathic phrenids, has been
generally considered to be of the inflam-
matory kind, and most frequently to
consist of active inflammation of the
brain, attended with fever, and therefore
to require the most powerful antiphlogis-
tic remedies, such as copious blood-let-
ting, active purgatives, vesicatories, &c.
The investigations of anatomists have
supplied us with numerous instances of
the state of the brain under this disease,
which have disposed the profession to
entertain not only the most serious ap-
prehensions for the event of such cases,
but have stamped a confirmation on the
practice which has been for many years
pursued. Nevertheless, upon however
strong a foundation this practice may ap-
pear to rest, it will be proper to point
out, that misconceptions have prevailed
respecting the nature and treatment of



a disease which has generally gone ujijder
the name of phrenitis; and, with the
name, has been conducted, in the cure,
on the same principles.

As the account I am about to give of
this disease will be of some length, I am
obliged to adopt some term which may
express my allusion to this last affection.
This will serve to avoid the necessity of
frequent circumlocution, and the con-
fusion which would otherwise result in
the progress of the narrative. The
name, therefore, which I have adopted,
though possibly not the most appro-
priate, will serve to convey a notion of
an essential symptom of the disease, and
will be sufficiently explicit for my pre-
sent purpose.

Dehrium tremens, and likewise the
treatment, which will be pointed out as
we proceed, are known to some profes-
sional men to a certain extent; but to
many they are wholly unknown : and the
disease has not yet taken a station in



4

medical writings * So far as my obser-
vations and inquiries have gone on this
point, its treatment is acknowledged by
pnly a few, who have not collected any
very ample information on the subject.

From the year 1798, to 1807, 1 resided
on the eastern coast of Kent; first in
quahty of physician to the forces, and
latterly in that of a private practitioner
in physic. During this abode, and early
in my residence there, I was led to see
the distinction between phrenitis and

* Doctor William Saunders, late physician to
St. Guy's, and for many years lecturer on medicine
at that hospital, whose opinion I had the advantage
of obtaining on this tract, considered the assertions
in this paragraph to be perfectly correct; but
stated to me, that he had mentioned the disease
alluded to in his lectures for many years, and
had been in the habit of noticing and disti^figuish-
ing it from phrenitis during forty 3'ears of his
practice. It is a considerable gratification to me
to be able to introduce the opinion of this respect-
able physician on some important points connected
with this subject.



delirium tremens, at least in regard ta
the treatment. Hitherto I had consi-
dered the diseases to be the same, and
to depend upon active inflammation of
the brain, or its membranes, and to
require copious depletion, vesicatoriesj
purging, &c., as usually recommended in
books of medicine for the cure of the
former disease. I however found, that
this latter disease was, in that quarter^
treated by different practitioners in two
very distinct ways. The one party, with
myself, considering the disorder to be
active inflammation of the brain, or its
investing membranes, conducted the
treatment according to this supposition:
the other, without pretending to any pre^-
cise notions of this affection, in so far
as the contents of the cranium might be
concerned, were in the habit of using
opium in large and repeated doses. I
very soon perceived that the latter prac-
tice carried with it all the success. A
respectable friend of mine, the late Mr.



6



Boys, the historian of Sandwich, and
long a practising surgeon and apothecarj
of that place, told me, that for many
years he treated delirium tremens as
phrenitis, and employed the remedies
usually recommended in the latter dis-
ease, with such want of success, that he
considered almost every patient to be
lost to whom he was called under that
affection, which was a common com-
plaint in that part of the kingdom. He
further added, that, on this account, he
felt great reluctance to giving his attend-
ance in such cases ; but, after he had
begun the use of opium in the treatment
of the disease, the prospect became so
comparatively bright, that he expe-
rienced the utmost satisfaction from the
' success of the practice.

I have never been able to discover how
a practice, so different from that Avhich
the general appearance of the symptoms
seems to warrant, came to be adopted;
neither through my inquiries in East



Ivent, nor in my intercourse with medical
practitioners in the metropohs, who have
employed opium in the cure of the dis-
ease. From one of the latter, a respect-
able physician, I received in substance the
following answer. — " I know, from expe-
rience, that opium is of great use in this
disease, and that when sleep is procured,
the patient most frequently gets better ;
but I have nothing to guide me to form
an opinion from, as to what may be the
state of the brain, nor in regard to the
modus operandi of the remedy, than
that the measure of its beneficial efficacy
is by procuring sleep.^' — -This, then, is
the sum of what I have collected from
others. I shall now proceed to commu-
nicate the information I have acquired,
from my own experience, in regard to
the history, treatment, and nature of the
affection : and for which purpose, I shall
commence by giving a history of the dis-
ease in as condensed a form as possible.
Frequently the attacks of this disease



8



do not come on suddenly ; but for some
days previously, the patient complains of
being unwell, with loathing of food, list-
lessness, debility, and want of comfort-
able rest. He has pain in the head, and
sometimes vomits, and appears to be dull
and dejected. The pulse, in the com-
mencement of the disease, in its ordinary
occurrence, is by no means quick; but
may frequently be observed with a sort
of unsteady, nervous fluttering : there is
not much heat on the skin; and the
tongue is generally furred, but moist. In
this stage of the disease, the patient feels
very little disposition to lie down for any
length of time ; but is ever uneasy, and
desirous of a change of position ; and
there is a general agitation of the frame,
with tremors of the hands. Associated
with these, the mind is perceived to
waver ; and, if the disease proceeds, this
becomes every day more manifest. In
others, a state such as described, conti-
nues for some time, and wears off.



As the disease advances, the faculties
do not, generally speaking, show them-
selves in disorder, by any extravagance
of thought; but by fatiguing conversations
on common affairs frequently repeated ;
and by broken discourses, caused evi-
dently by forgetfulness and confusion of
intellect. In the further progress of the
disease, the patient discovers great
anxiety of mind about his affairs, ap-
pears ever to be desirous to be where
business is, and makes great, repeated,
and violent efforts to liberate himself
from those about him, if under restraint,
in order to accomplish the objects that
press most forcibly on his mind. These
exertions are, however, not made in op-
position to others, though violent, with
either malignity or ill-nature ; nor does
the patient mark his restraints with the
appearance of much anger or displeasure.
He seems to be forgetful of what has
immediately passed, and only to be pro-



io



pelled to action by those strong impres*
sions in his mind respecting the objects
above alluded to. In other respects he
is tractable, and there is seldom any diffi-
culty in administering medicine to him*
In this situation he loses the sensations
of pain, and complains of no bodily un-
easiness; though, when in a considerable
degree of this delirium, he knows mo-
mentarily those about him of his family
and friends. The tremors of the hands,
which constantly accompany this com-
plaint, are now great, with unceasing
workings and elevation of the tendons of
the wrists; to which are very frequently
associated subsultus tendonum, and often
singultus. By the action of the tendons
of the wrist, as above described, the hands
are drawn inwards, sometimes to such
extent, joined to the constant tremors, as
to allow a very imperfect knowledge of
the state of the pulse. When the patient
is at all still, he is constantly picking the



li



bedclothes, and in various motions with
his hands*. The evacuations are uncon-

* The accurate history of a disease is always a
most important part of information ; but when it
is necessary to distinguish one disease from ano-
ther to which it bears great resemblance, and
which may require opposite treatment, then an
accurate view of the progress and symptoms of a
disease becomes most essential. There are two
disorders, phrenitis and mania, with which deli-
rium tremens may be occasionally confounded,
and from which it ought to be distinguished. This
will, I trust, be accomplished, by attention to the
history of the disease now given; and I feel grati-
fied by having the concurrence of Doctor Saunders
in regard to the accuracy of my description of the
disorder.

Doctor Saunders, however, thinks some observa-
tions, such as the following, might be given, on
the occasional employment of the hands, in addi-
tion to what I have stated. He has often consi-
dered the motion of the hands in this state of
disease, as if the patient might, with imperfect
vision, be searching for things, and occasionally
rapidly catching, or avoiding them : such, for in-
stance, as if ia search for rats or mice, being things
he wished partly to lay hold of, and partly to
avoid.



u



sciously rejected, in the height of the
paroxysm. The pulse at this time be-
comes very rapid; but may occasionally
appear to be more debilitated than it
really is, on account of the tremors and
subsultus tendonum in the manner above
stated : and for these reasons, accuracy, in
regard to the true condition of the pulse,
cannot always be attained ; and, though
it seemed scarcely possible to be felt a
short time before, on sleep being in-
duced, and the workings of the tendons
allayed, it will be found frequently to
possess sufficient firmness and force.
Accompanying the exertions at this time
made, there is generally a most profuse
sweat, which is sometimes clammy and
cold ; from which, occasionally, an offen-
sive odour escapes. The heat of the skin
varies much, but is seldom intense ; and
the tongue is not often inclined to be
dry, or the patient thirsty. The^general
appearance of the countenance is dull,
and the eye frequently suffused. The



13

state of the bowels vary ; but, during the
yiolence of the disease, frequent stools
are not common. In the height of the
paroxysm^ the patient is in an unremit-
ting state Cff watchfulness, which conti^-
nues until the disease is alleviated, or is
succeeded by insensibility, which may
partake of coma or apoplexy, ending
in death.

This disease will continue, with great
violence, from three da^^s to a week, and
with moderate symptoms for a longer
time, and is sometimes seen in the form
of a chronic affection.

The following cases will give some fur-
ther information respecting the history of
this disease, and serve as an introduction
to the treatment which has been found
to be the most beneficial, and afford
instances from which some general infer-
ences may be drawn respecting the na-
ture and causes of this disorder.



u



Case 1.

I attended a patient, with , Doctor
Michel of Woolwich, who' was at first
attacked with acute rheumatism, under
which he had laboured for ten days ; but,
in the three days previous to my visiting
him, he had become very delirious, and
without sleep. When I saw him, he had
a strait waistcoat on ; of course might
be considered to have been very ungo-
vernable. He had been bled in the course
of the day, and the blood was buffy ; the
bowels had been acted on freely, a sti-
mulating composition had been applied
to the head, and a blister between the
shoulders: notwithstanding which, all the
symptoms had become worse. The pulse
was very quick*: there were continual

* Doctor Saunders observed, that he knew no
disease in which the pulse became so rapid, and
recovery ensued, as in numerous cases of this affec-
tion ; which perfectly accords with my observation :



15



workings of the tendons, with consider-
able tremors and profuse sweats. After
making inquiry respecting the habits of
the patient, and collecting all the inform-
ation I judged to be necessary, I pro-
posed to administer forty drops of lauda-
num in a draught every two hours, until
sleep was procured. Three of these
draughts were given in succession, when
the patient fell asleep, and continued so
for some hours. I saw him again at the
interval of sixteen hours : he was then col-
lected ; and, after recommending forty
drops of tincture of opium to be given
morning and evening, for some few days,
I took my leave; and was happy to find,
on future inquiry, that the patient reco-
vered rapidly from that period.

but the recoveries alluded to have been effected by
the treatment which is about to be pointed out ;
the efficacy of which, and its preference to aU
others. Doctor Saunders has been confirmed in,
from a long experience, and attentive observation.
I never, saw a case of recovery, when the pulse was
very rapid, except by the en^ployment of opium.



16



Case 2.



I was desired to see a patient with
Messrs. Brown and Bungej, of Rother-
hithe, who was reported to have been at-
tacked, some time ago, with a fit; at pre-
sent she was wandering and sleepless,
had loss of appetite, vomitings consider-
able debility, with quick and weak pulse,
and tremors of the hands. I was given
to understand, that the patient had been
addicted to habits of indulgence in drink-
ing. Some medicines were prescribed to
relieve the pressing symptoms ; and on
calling the following day, the patient was
found to be somewhat relieved. A plan
was laid down to be pursued, and it was
agreed that I should call again in three
days. Among other medicines, a draught
with thirty drops of tincture of opium
was prescribed to be given every night at
bed*time. When I next visited the pa-
tient, she was considerably worse; her



17

nights had been passed very restlessly,
she had constant delirium, with quick
pulse, and considerable tremors and
workings of the tendons of the wrist.
Under this state of things, forty drops of
tincture of opium were directed to be
given every two hours, until sleep was
procured. Three draughts, with the
above quantity of opium, were succes-
sively administered ; the patient slept for
some hours, and was, when I saw her the
following morning, collected. The patient
continued the use of opium for some
short time, as occasion seemed to de-
mand, and acquired such a state of
health, as to be thought capable of un-
dertaking a long journey. On the second
day after leaving Rotherhithe, she was
attacked with a fit at Bagshot, and died
rapidly.

Case 3.

- I visited a patient, with Mr. Green of
Lewisham, in delirium tremens, under



18



the following circumstances. The patient
was a robust man, and about fifty years
of age. When I saw him, he was
agitated and wandering, with consider-
able tremors, quick pulse, and under a
profuse sweat: he had been very untract-
able for some hours, and had got from
the house, having none but female at-
tendants about him. His nose had bled
freely in the course of the day, previous
to my seeing him. The bowels had been
evacuated, and this was the third day
of his illness. Under these circumstances,
it was agreed to administer two grains of
extract of opium every two hours, until
sleep was induced. The patient took
four doses before this was effected,
and I found him tranquil and rational
the next morning. He afterwards con*
tinned the same dose of the extract night
and morning, and took opening and
mildly tonic medicines during the day,
by which plan he recovered completely
in a short time.



19



Case 4.

1 some time ago visited a patient on
the third day of the attack of dehrium
tremens, whose treatment on the two
first days had been conducted on the
antiphlogistic and depleting plan, to
some extent, with increase of disease.
On the third day, the surgeon who
attended the patient had been advised
to try the effects of opium; and, in conse-
quence, four doses of the extract, in two
grain pills, had been administered every
two hours. As this plan did not appear
to succeed, the case was considered
to be hopeless. When I saw the pa-
tient, it was two hours from the last
visit of the attending surgeon, and
three from the time of taking the last
pill, when he was in a profound sleep,
the respiration quiet, the pulse full and
regular, with neither tremor, subsul-
tus tendonum, or hiccough; the con-
trary of which had been the case a few



2,0



hours before. The patient was the next
day completely tranquil and rational,
and recovered, without interruption. .



Case 5.

I visited a publican of about fifty
years of age, who was reported to have
had slight aberrations of mind, some
days before I saw him. His pulse was
rather quicker than natural, his hands
in a state of tremor, and he com-
plained of some confusion in the head.
He was a man inclined to corpulency;
and as his disease was at present mild, I
directed some opening medicines, re-
questing the party might be kept quiet,
take food easy of digestion, and avoid
fermented liquors. I apprized the family
of the nature and probable progress of
the disease. The patient was not better
on the following day, when some blood
was directed to be drawn by cupping;



21



and as the purgative had acted with
freedom, I directed a draught, with
thirty drops of laudanum, to be given in
the evening. The patient passed the fol-
lowing night with great restlessness, and
the delirium had evidently increased.
'J 'his day was the third of my visiting him ;
and I directed a pill, containing a grain
of opium, to be taken every six hours.

Fourth day. — The patient was very
delirious, and it became necessary to
have two men constantly by his bed-
side to restrain him ; his pulse was hur-
ried, he had considerable tremors, and
profuse sweats. Two grains of opium
were now directed to be taken every
three hours. In the evening he had
taken three of the last pills, when I
directed them to be given every two
hours, and he took four doses through
the night, but no sleep took place.

Fifth day. — In the morning I ordered
five grains of extract of opium to be
given immediately, and three grains



32



every two hours, until rest was procured.
In the evening, Dr. Babington saw the
patient with me. In the course of the
preceding twenty-four hours, the patient
had taken a scruple of opium, which had
been procured at Apothecaries' Hall, but
no actual sleep had taken place: he
was, however, much more tranquil ; the
tremors were much diminished ; the pulse
more moderate ; and I judged that the
night would not be passed through with-
out some favorable change. Dr. Babing-
ton concurred with me in the plan of
treatment that had been adopted ; and
we agreed to pursue the administration
of opium to even a greater extent, if
required. As, however, some favorable
changes had arisen, it was determined
to give five grains of extract of opium
immediately, and to repeat it in three
grain pills every two hours, till our
views were attained. Three of these pills -
were administered as directed, and the
patient fell into a tranquil sleep, of two



23



hours' duration, and was much better
in every respect the next morning. The
patient was in an advanced state of
convalescence in the course of a week,
from the favorable change taking place.
From the time of the amendment, for
the three succeeding days, three grains of
extract of opium were directed, morning
and evening ; afterwards a two grain pill
of the extract was given every night,
for some days. In addition to the use
of opium, the bowels were kept open
by saline purgatives ; and a medicine
with camphor mixture and tincture of
castor, was directed to be taken with the
pills.

Case 6.

The patient was a robust young man
and much given to drinking of spirits.
Two days previous to my seeing him, he
had been bled largely and blistered and



24



the bowels had been freely opened.
Afterwards, opium had been given with
tolerable freedom ; notwithstanding which,
the delirium had continued unabated,
with- uninterrupted sleeplessness. On
my visit, it was agreed to give two grains
of opium every two hours, until rest was
procured. When I agaiji saw the
patient, he had in the course of twelve
hours taken eight grains of opium ; but
as the friends were possessed with the
idea of the impossibility of his recovery,
they had, for several hours, laid aside the
administration of medicine. During the
interval of my visits, blisters had been
applied to the calves of the legs. I now
found the patient, after having been
much exhausted by exertion, exceed-
ingly restless, in a profuse clammy sweat,
with tremors, a very constant subsultus
tendonum, a pulse scarcely to be per- <
ceived, the countenance fallen, and the
eyes muddy : the urine had been dis-
charged involuntarily, and the patient



25



was constantly occupied in picking the
bed-clothes. Under such a state of
things, the chances of recovery appeared
to be little. But as we were assured of
the nature and origin of the disease, and
had seen much beneficial effects from
opium, under some very unpromising
circumstances of delirium tremens, it was
determined still to advise its use, and
to encourage the friends to hope that
something favorable might yet ensue, by
following the directions that would be
given. It was then directed to give two
grains of opium every hour, until rest
was procured, which happened after the
fourth dose ; and the patient had a tran-
quil sleep of some hours. The next day
I found him rational, his pulse free and
not quick, the subsultus tendonum gone,
the tremors much diminished, and he
discovered some inclination for food.
The patient took six grains of opium, in
divided doses, for some days, and got, in
a short time, into good health.



26



Case 7.

This patient was verging towards sixty


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Online LibraryThomas SuttonTracts on delirium tremens, on peritonitis, and on some other inflammatory affections, and on the gout → online text (page 1 of 11)