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VARIOUS FORMS OF ALCOHOLIC DELIRIUM
DR. V. MAGNAN,
PHYSICIAN TO ST. ANNE ASYLUM, PARIS ; LAUREATE OF THE INSTITUTE, ETC.
W. S. GREENFIELD, M.D., M.R.C.P.
H. K. LEWIS, 136 GOWER STREET, W.C.
3:13 J )<S
PRINTED BY H. K. LEWIS,
136 GOWER STREET.
In bringing the following work before the notice of the profes-
sion in England, I have been influenced in part by the desire to
fill up an acknowledged gap in medical literature. There are
few medical subjects on which less has been written than on
delirium tremens and chronic alcohoHsm, and that in spite of
their constant presence, and their great social importance. It
is true that during the last two or three years considerable at-
tention has been devoted to the subject of the uses of alcohol
in health and disease, and to the evils resulting from excessive
drinking. But, as yet, this increased attention has not resulted
in any notable addition to our medical hterature.
The systematic English works on the subject are scanty and
meagre, and two years ago the same might with truth have
been said of the papers and reported cases to be found in
periodical literature. Possibly this fact may be due to the
limited view which has been taken of the subject, and the want
of more careful clinical observation specially directed to it.
The extreme frequency, one might almost say the constancy, of
the alcohoHc element m disease, combined with the frequency of
drunkenness and delirium tremens, have also perhaps led to some
of this neglect. The effects of continued drinking on the viscera
have been regarded as almost Umited to the production of
cirrhosis of the hver, chronic gastritis, and granular kidney ;
delirium tremens has been considered a disease of so well marked
and uniform character as to require no special study. Never-
theless, the views as to its treatment, and the statements as to
its clinical phenomena will be found to be widely at variance
in different hospitals, and amongst different schools of medicine.
Doubtless there have been many who have taken a wider view
of the subject, and have arrived at a more intimate knowledge
of the action of the poison in its less common forms, but with
few exceptions they have not placed their observations on record.
Thus alcohoHc paraplegia was recorded and described some years
ago by Dr. Wilks,* and other nervous disorders by Dr. Handfield
Jones, but these affections have hardly been noticed in text-
books of medicine. -f-
The systematic works which treat especially of the effects of
alcohol, are Dr. Anstie's book on Stimulants and Narcotics\
and Dr. Mareet's On Chronic Alcoholic Intoxication.^ The for-
mer, however, deals mainly with the physiological action of al-
cohol, and the latter must now be considered as somewhat
meagre. Some valuable clinical remarks will be found in
Dr. Handfield Jones's work on Functional Nervous Disorders;
and articles, for the most part brief, in the various text books
of Medicine and Surgery may also be referred to.
The widespread interest which has been manifested during
the past two or three years in the various questions connected
with the use and abuse of alcohol has shown that the subject is
one on which the public in general as well as the profession feels
strongly. Yet it is in great measure to the medical profession
that this increased interest is due. The declaration as to the
evil effects of the indiscriminate administration of alcohol as a
medicine, which was signed by a large number of leading practi-
tioners, although regarded by many as ill-advised, undoubtedly
did much to draw popular attention to the subject, and this has
been kept alive by articles in newspapers, magazines, and re-
views which have largely echoed the opinions of the profession.
It may be worth while to mention some of the various ques-
* Lancet 1872. Vol. I., p. 320.
t It is true that tliis form of disease (alcoholic paraplegia) appears to be of
far less frequent occurrence in England than in some other countries. I am
informed by a friend, a physician of great experience in Sydney, New South
Wales, that it is not at all uncommon in Australia, and is there a well re-
cognized form, of disease. Experiments on dogs and other animals have shewn
that paraplegia is one of the more immediate physiological effects of alcohol
upon them. Hence it is not surprising that its long continued use in man
should result in degeneration of the cord, which in some cases may be produc-
tive of paraplegia, in others of a condition closely allied to locomotor ataxy.
t London, Macmillan, 1864. Â§ 2nd edition. London, 1862.
tions to which the attention of the community, but still more of
the profession has been directed. These may be classified as
they relate to the use or abuse of alcohol. Under the former we
may range the inquiries into its physiological action on man
and animals by means of experiment and observation, together
with the question of its use as an article of diet ; the investiga-
tions as to its employment in disease, especially fever, and its
power of lowering the temperature, increasing the force of the
pulse, and preventing or controlling the waste of tissue.
As regards its abuse, apart from the evils resulting to the
individual in the form of visceral degeneration and disease,
which will especially occupy our attention, there are the ques-
tions of its excessive or needless employment as a food or as a
medicine : the evils of the multiplication of temptations to
drinking, and the means of reducing them and of checking'
drunkenness. And, lastly, the legislative enactments for the pun-
ishment of drunkennesss, and for the restraint or incarceration
of habitual drunkards. To these might perhaps be added the
more remote questions of the effects of drinking in the general
deterioration of the population, and the association of drunken-
ness, crime and insanity in the offspring of drunken parents.
The time has not yet arrived for the collection and summing
up of all the work which has been done in these various
branches of the subject, since the work is still in progress.
But we may venture to mention merely some of the more im-
portant work on each subject, though only briefly to indicate it.
The physiological action of alcohol on the healthy system ha&
been the study of various investigators, amongst whom in Eng-
land the names of Parkes, Anstie, Edward Smith and Brunton
must always rank amongst the first. The continued and exact
investigations of the lamented Dr. Parkes on the effects of alcohol
on digestion, excretion and the production offeree, and the action
of alcohol on the complex vital functions, have formed a ground-
work of knowledge of the highest value, and which must be of the
greatest use to all future observers. To Dr. Anstie we not only
owe much valuable original observation both physiological and
clinical, but to him is due the credit of having for some time
been almost alone in keeping the subject before the notice of the
profession. Since his untimely death, Dr. Brunton has done
good service in a similar direction, and to liim we are indebted
for a recent paper, read before the Medical Society of London, which
well expounded our present knowledge of the physiological action
of alcohol, whilst the discussion upon it shewed the general interest
in the subject. It is not our purpose here to apportion to each
the credit for research in one or other part of the subject, nor to
take up in detail the various points which have received atten-
tion from these and other observers. But we may mention also the
names of Drs. Einger and Bickards as having made experiments
on the action of alcohol in relation to the elevation and depres-
sion of temperature.
The value of the various forms of alcoholic beverages as arti-
cles of diet has been largely discussed of late, and this from a
more scientific standpoint than previously. The researches of
Dr. Parkcs, to which we have already referred, the observations
made during the Ashantee war, and the discussion on the issue
of the spirit ration, have much increased our knowledge and have
diffused that already acquired.
With respect to the value of alcohol as an article of diet, some
members of our profession, as for example. Sir Henry Thompson,
have been led by a long course of observation, to conclude that
even in moderate quantity, it is not only needless but injurious
in its ultimate effects upon the system. The statistics of insur-
ance companies seem to point in the same direction, so far as the
healthy portion of the population is concerned, though these, Hke
all other statistics, are liable to misconception. The profession
is greatly indebted to Dr. B. W. Eichardson for bringing together
and popularizing the results of his own investigations and those
of others on these and various other points connected with the
action of alcohol, in the recent Cantor Lectures.*
Besides the declaration of the medical profession before re-
* On Alcohol : â€” A course of six Cantor Lectures delivered before the Society
of Arts, by Benjamin W. Richardson, M.D., F.R-S. London, 1876.
ferred to, we are bound to mention with respect the recommen-
dation made by the College of Physicians for a Government
enquiry into the evils of intemperance and the means of prevent-
ing it. The legislation of late years, although it has not gone
so far as some have wished, and undoubtedly still leaves mu<Ã®h
to be desired, has been in the dkection of controlhng the
supply of drink and imposing penalties for intoxication.
These facts show that there is a steadily increasing current of
popular opinion, which will undoubtedly gain in force and
lead to further legislation ; and we may hope that this will
take the form of diminishing the temptations to di-mk and
the facilities for obtaining it at late hours. The immense im-
provement effected by the earher hour of closing of pttbHc houses
was so marked in hospital experience, that it is greatly to be
regretted that the hours should again have been lengthened.
On one other point pubHc opinion is not as yet ripe for legis-
lation, and even in our own profession there is considerable
difference of view upon it, viz. the control to be exercised by the
State over habitual drunkards. Nor can we expect that until
more unanimity of opinion prevails,, both as to^ its desirabihty
and as to the cases in which it is hkely to prove beneficial,,
there will be any sufficient influence on pubHc opinion to lead
to legislation,* It is to be hoped that the efforts of the com-
mittee of the British Medical Association on this question, wiU
be ultimately productive of a good result.!
Fiually, the terrible results of drunkenness on the children
of drunken parents, and the clos^e relation of vice, crime and
insanity in their offspring with the habits of the parents, on.
which Dr. Maudsley and others have given such startling facts,
will tend to impress the necessity of checldng the evil as far as
* Much needless obscurity has been thrown over this question, by the con-
fusion of such totally distinct forms of disease as dipsomania and chronic alcohol-
ism: even medical journals have been guilty of this error, which has added mucli
to the difficulty of a clear comprehension of the subject.
t Brit. Med. Journal Aug., 12, 1876, p. 214,
All these facts, pointing as they do to an increase in the in-
terest in the subject, lead us to hope that a systematic work deal-
ing with the subject in all its scientific bearings will at no distant
date be possible. At the present time the data are not suifi-
The scope of the present work does not of course include the
several topics of interest in relation to alcohol which have been
indicated above. It deals, in fact, with only one branch of the
subject, viz., the poisonous action of alcohol in an overdose, and
the conditions of disease resulting from it.
It may be well to mention the opportunities which have fallen
to the author for the observation and investigation of alcoholism.
Unquestionably one of the main reasons why so little attention
is given to the subject in Enghsh medical literature, is the
want of opportunity of continuous observation on any large
number of cases of alcoholism. At some time or other every
hospital physician or surgeon sees a considerable number of cases
of delirium tremens. An especially large number, however,
enter the surgical wards for some accidental or self-inflicted
injm-ies â€” or the malady breaks out under the influence of trau-
matic conditions. It is to the injury rather than to the delirium
that the attention of the surgeon is directed, and some symptoms
of the latter may be ascribed to the former. So too in the cases
coming under the care of the physician, those of simple alcohoHc
delirium are rapidly cured, often before his visit, and the more
severe and often fatal cases of delirium tremens are either
complicated by some other disease, or appear to be so. Hence
the well marked cases of severe uncomplicated delirium tremens
coming under the notice of any individual physician are compar-
What is of still greater importance is that in very few cases
do we have the opportunity of seeing the same patient in succes-
sive attacks, and of watching the progressive effect of continuous
alcohohc poisoning. We see indeed daily the effects of alcohol
on the constitution, and its various symptoms in those who in-
dulge in it to excess ; the post-mortem room reveals to us only
too often the resulting degeneration of the organs, in their seve-
ral stages ; and frequently we are convinced of the presence of
such degenerations during the Hfe of our patients, although we
can get no positive proof of their existence ; but very rarely can
we trace for ourselves the whole course of the downward progress,
or even mark its steps at definite epochs.
Hence it is that opportunities for systematic observation such
as have been enjoyed by the author of this work, are of excep-
tional value, and it is desirable for us to give some account of
them for the benefit of the English reader.
The Bureau d'Admission of the department of the Seine at the
St. Anne Asylum in Paris, of which Dr. Magnan is one of the
two physicians, is an institution to which no exact parallel exists
in England. To it are brought all the cases of insanity previous
to their admission to the various pubHc asylums, and all cases
of acute delirium and mania which fall under the care of the
pohce in Paris. It is here that they are examined and their
admission or rejection decided upon ; if admitted they are drafted
to the one or other of the asylums which is the most suited to the
class of the patient or the form of his malady.
The Bm*eau d'Admission is quite distinct from the St. Anne
Asylum itself, and under altogether different administration.
In order to provide accommodation for the temporary lodgment
of patients on then* way to other asylums, and also for the recep-
tion of the more acute cases, it is provided with about 50 beds,
and is fitted up in every way as a small asylum.
Here then are brought all the cases of dehrium tremens and
of simple alcohohc delirium which fall under the notice of the
police, and a large number from the lower and middle classes,
and here they are treated until their recovery. Cases too of
fever with delirium are not unfrequent, and it need scarcely be
said that acute delirious mania is also often seen.
Hence it comes to pass that a very large proportion of all the
cases of delirium tremens occurring in Paris and its vicinity
come under observation here, and this not only in one attack,
but again and again, and when at last by repeated attacks they
have become mentally deranged or greatly weakened, they again
come under notice for transference to asylums. The results of
such opportunities of observation could scarcely fail to be pro-
ductive of an increase in our knowledge, and their value is
necessarily augmented by the fact of their being utihzed by ex-
perienced alienists, and seen side by side with other forms of
It should be added that there is also an out-patient depart-
ment, to which not only cases of mental derangement but of all
forms of nervous disorder, especially epilepsy, are gratuitously
admitted, and to this department those who have before been
under treatment for the acuter symptoms of alcohohsm resort
for the treatment of the various nervous disorders induced by
On certain points the observations of the author wUl be found
at variance with the opinions currently received in England. That
delirium tremens when uncomplicated by inflammatory disease
is a dehrium without fever is an opinion commonly stated in
books, and upon this belief not only diagnosis but treatment are
not unfrequently based. Were it not so conclusively shown
by the cases here recorded that this view is incorrect, it would
have been easy to adduce cases which have fallen under my own
observation in which elevation of temperature has been a well-
marked symptom.* The importance of the recognition of this
fact, or rather of the converse, that elevation of temperature in
delirium tremens does not necessarily indicate visceral inflam-
mation, might also have been illustrated by cases in which alco-
holic stimulation has been resorted to on the ground of supposed
pneumonia, the non-existence of which was only discovered after
the fatal issue. The error has doubtless arisen from non-
observation or observation limited to cases of acute alcoholic
delirium, in which the elevation is slight or wanting.!
* The profuse perspiration, wliich causes great surface cooling, together with
the agitation of the patient, often render observations taken with the ther-
momefer in the axilla either impossible or valueless. The temperature ought
in these cases to be taken in the rectum.
t It must be remembered that the imni'idiate efifect of alcohol poisoning is to
It may perhaps be thought that the vakie of the work is mar-
red by the fact of the differences in the forms of alcohoHc beve-
rage in use in France from those most commonly taken in
England, and especially by the reference to the eEeGte oÃ® absinthe,
which is comparatively Httle used in this country. That this
objection is not generally considered a serious one is shown
by the fact that the work has already been translated mto
German, Spanish, Itahan and Kussian. But further consider-
ation will, I believe, show that it is no disadvantage. The
broad features of alcoholic poisoning whether acute or chronic
are similar whatever the form in which spirit is taken in
excess. The effects, especially in the acuter forms, are un-
doubtedly largely dominated and modified by national and in-
dividual temperament, but however varied the accent and inflec-
tion, the language, so to speak, is the same. So too, there is no
doubt that each form of spirit has to some extent a different
action, and that there is a real difference in the immediate effects
of beers, wines, and spirits, which is not wholly accounted for
by the different degree of dilution of the alcohol contained m
It would be a great gain to our knowledge both as regards the
employment of the various forms of spirituous liquors in medi-
cine and diet, and our scientific knowledge of the effects of alco-
hol itself, if we could precisely determme the effects, physiologi-
cal and toxic, of the various ingredients of the beverages most
commonly employed in this country, and ascertain how far they
tend to modify the action of alcohol in the system, or to produce
additional symptoms. The very minute quantity of these sub-
stances, except where other liquors or "bitters" are purposely
added to them, or where adulteration is practised, renders this a
difficult task. Certain of these substances are known, and to
some extent the variety in action of different spirits and wines
are matters of popular knowledge, but the precise physiological
effects of each in repeated small doses are as yet but httle known.
lower the temperature. For furtlier details, I may refer the reader to Wunder-
lich's Medical TJiernwmetrij. (New Syd. Soc. Trans.), pp. 117 and 137.
The chemical researches- of Drs. Dupre and Thudichum have,
however, paved the way for further physiological investigation
in this subject, and its completion is we trust not far distant.
For information on this subject we must refer the reader to Dr.
Eichardson's able lectures,* where also will be found some
valuable remarks on the effects of absmthe.
But so far from its being a disadvantage that the substance
which is so commonly taken in France in combination with alco-
hol is especially discussed in this essay, it is we think, a gain,
as it affords a clear and definite example of the specific effects of
one form of adulteration, and leads us to hope that a clearer
light may be likewise thrown on the action of other analogous
substances. It is very probable that the various forms of " bit-
ters" and the like which are so largely consumed in this country
have some action similar to that of absinthe, although less po-
tent and deadly, nor must it be supposed that the use of the
latter itself is either unknown or very rare in this country, f
I have thought it desirable to say thus much in explanation of
the scope and objects of the work, and I can but trust that the
many defects in the translation of which I am fully conscious,
will hot be such as to interfere with the real value of the work.
If in any way the work tends to the diffusion of knowledge of
the deadly effects of alcohol, and to an increased attention to the
results of excess in drinking and a greater activity in the efforts
now being made to arrest its i^rogress ; and if a perusal of the
cases herein recorded carries the inevitable conviction that
means other than moral should be employed to restram the
chronic drunkard, the work will not be in vain, even apart
from its more immediate scientific object.
* Richardson loc. cit. Led. V. pp- 76 et seq.
t Ricliardson loc. cit., p. 78.
Introduction . , â€¢ 1
Plan and division of the work ..â€¢...â€¢â€¢â€¢. 3
Immediate Action op Alcoholic Beverages ; Drunkenness. â€”
Prolonged Action; Alcoholic Delirium.
ARTICLE I.â€” Drunkenness in man; period of excitement; intellectual
disturbance; incoherence; paralysis; anaesthesia; coma ... 5
Convulsive drunkenness 6
ARTICLE II. â€” Drunkenness and alcoholic delirium in the dog â€¢ â€¢ 7
1. Drunkenness; excitement; stupor; paralysis; anaesthesia; comatose
condition â€¢ â€¢ . â€¢ 7
2. Alcoholic delirium ; changed behaviour ; irritability ; hallucinations ;
delirium ; trembling ; vomiting ; gastro-enteritis 8
Modes of termination ; death by cold ; by broncho-pneumonia ; by as-
phyxia ; by accident ; by cachexia 10
Pathological anatomy; acute lesions ; presence of alcohol in the organs 11
Chronic lesions, (fatty degeneration, sclerosis) 12
Experiment I. â€” Prolonged action of alcohol in the dog .... 18
ARTICLE III. â€” Action of absinthe on animals; muscular shocks; .
vertigo; epileptic attack ; hallucinations; delirium .... 22
Experiment II. â€” Epileptic attacks and hallucinations in the intervals
between the attacks, due to injection of essence of absinthe into the
stomach . 26
Experiment III â€” Epileptic attacks and hallucinations under the influ-
ence of essence of absinthe injected into the veins 26
Appearance of hallucinations in man (as in the animal), more rapid under
the influence of absinthe, than under that of alcohol .... 29
Case I. â€” Rapid appearance of delirium under the influence of absinthe
Alcoholic Delirium in Man.
Change of character ; irritability ; hallucinations and delirium . . 33
ARTICLE I. â€” General characters of alcoholic delirium . . . .33
1. Painful character of the hallucinations 33
2. Changeable character of the hallucinations 34