SOME CASES 
OF 
Delirium Tremens, 
TREATED WITH 
HALF-OUNCE DOSES 
OF 
Tincture of Digitalis. 
BY 
HENRY HUN, M.D., 
Lecturer on Nervous Diseases in the Albany Medical College. 
Reprinted from The Medical Annals. 
ALBANY, N. Y.: 
Burdick & Taylor, Printers, 481 Broadway. 
iSSg. SOME CASES 
OF 
Delirium Tremens 
TREATED WITH 
HALF-OUNCE DOSES 
OF 
Tincture of Digitalis. 
BY 
HENRY HUN, M.D., 
Lecturer on Nervous Diseases in the Albany Medical College. 
Reprinted from The Medical Annals. 
ALBANY, N. Y.: 
Burdick & Taylor, Printers, 481 Broadway. 
i88S. SOME CASES OF DELIRIUM TREMENS TREATED 
WITH HALF-OUNCE DOSES OF THE 
TINCTURE OF DIGITALIS. 
HENRY HUN, M.D., ALBANY, 
Lecturer on Nervous Diseases In the Albany Medical College. 
During the past twenty years the giving of digitalis in large 
doses has been recognized as one of the standard methods of 
treatment of delirium tremens, and, although within the last ten 
years this form of treatment has been replaced, rightly, I think, 
by a combination of hydrate of chloral and bromide of potas- 
sium, yet I would like to present to the society a report of six 
cases of delirium tremens treated by half-ounce doses of the 
tincture of digitalis. 
The discussion of these cases will be more fruitful if we con- 
sider, in this connection, the other common methods of treating 
this disease, and there-is one question as to the cause of disease 
on the answer to which will depend, in great part, our plan of 
treatment. 
It has long been a matter of dispute whether delirium tre- 
mens is due to the direct poisonous action of the alcohol or 
whether it is due to the sudden stopping of drinking, and hence 
to the sudden withdrawal from the system of its accustomed 
stimulant. There can be no doubt that in many cases delirium 
tremens is caused directly by drink. Many patients have entered 
the hospital during my term of service in a wild condition of 
delirium tremens who have continued to drink up to the very 
hour of entrance. On the other hand, a number of patients have 
entered the hospital in a drowsy, stupid condition brought on by 
drink, and it was not until a day or two later that delirium tre- 
mens proper came on. In these cases it might seem as though 
the delirium tremens did not appear until the drink was with- 
drawn and then appeared in consequence of this withdrawal. 4 
It is well known that drunkards can put off an impending 
attack of delirium tremens by continuing to drink, but whether 
they can thus postpone the attack indefinitely is a matter of 
doubt; judging from my limited experience, I should say not. 
After a time the stomach is apt to get into such a condition 
that it will no longer retain alcoholic drinks ; but, even in 
those cases where the stomach will tolerate the alcohol, still the 
attack of delirium tremens will sooner or later come on and 
cannot be indefinitely postponed by drink. The opinion that 
delirium tremens is caused directly by the drink and not by its 
withdrawal has ol late years gained more and more ground, and 
at the present time I think the great majority of those who have 
had much experience in the treatment of delirium tremens in- 
cline to this view and hence believe in stopping all alcoholic 
drinks immediately, instead of gradually diminishing the quan- 
tity of them, as has been advocated by those who believe that the 
withdrawal of the alcohol is the cause of the disease. 
The question is somewhat different in the case of injuries. 
When an habitual drunkard, who has enfeebled his nervous 
system as well as all the other organs of his body by the long 
continued abuse of alcohol, receives some severe injury, he soon 
afterwards becomes tremulous and delirious and passes into a 
condition of very dangerous exhaustion. Now, this form of 
delirium tremens may, perhaps, in part depend on the sudden 
withdrawal of the usual alcoholic stimulant, but it depends, it 
seems to me, in much greater part on the shock which the injury 
produces upon the enfeebled nervous system and on the extra 
work incident to the process of repair which is thrown upon 
the enfeebled and diseased internal organs, especially upon the 
kidneys. In this form of the disease it seems necessary to ad- 
minister alcohol in some form, although I am inclined to believe 
that digitalis would be a better stimulant to the heart and kid- 
neys in these cases. I have, however, no experience in this 
surgical form of the disease and in what follows I refer only to 
those cases which are the result of excessive drinking for a few 
days or weeks. 
In the form of delirium tremens which is the result of a short 
but excessive abuse of alcoholic drinks, and which is caused by 
the direct poisonous action of the alcohol, the first thing to be 
done in the way of treatment is to prevent any more alcohol 
from entering into the system, and to eliminate as soon as possi- 5 
ble the alcohol already in the system. By means of some pur- 
gative, such as calomel, we may get rid of any alcohol which is 
in the alimentary canal and liver, and by means of a diuretic we 
can increase the action of the kidneys and favor the sweating 
which nature of her own accord usually produces in such cases. 
For, as is well known, alcohol is eliminated by the skin, lungs 
and kidneys, especially by the kidneys. Besides seeking to 
eliminate the alcohol we must also try to keep up the strength 
of the patient, for not only is the body enfeebled by drink, but 
it is customary for a person when drinking heavily to go days 
and weeks without taking any food whatever. On this account 
we must try and keep the patient quiet, so that he may not 
waste any more strength, and we must try and get him to eat 
often, tempting him to take milk, and milk with an egg in it, 
and broths, and as soon as possible solid food. 
Such is the general treatment of delirium tremens-food, rest, 
a diuretic and moderate purgation, with entire abstinence from 
alcohol; and this general treatment is by far the most important 
of any. 
On such general treatment the vast majority of cases will re- 
cover; for it must not be forgotten that delirium tremens is a 
self-limited disease of very short duration. As long ago as 
1831, Dr. Ware, of Boston, showed that this disease might safely 
be left to itself to run its course and that it teminated in recov- 
ery in from sixty to-seventy-two hours. It is rarely possible, 
however, to employ this expectant form of treatment; the 
patients are frequently so noisy and so violent that they must 
be put into a strait-jacket, or what is still better, must be 
cofined in a padded room. Even when the appliances are at 
hand, there is always danger that the patient may wear himself 
out with his efforts and die from exhaustion. In private practice 
the friends of the patient will usually insist on some quieting 
medicine being given. 
On this.account it seems desirable to find some drug which 
will allay the excited action both of the brain and heart, and 
produce sleep, so that the patient may not exhaust himself 
completely before the disease has run its course and the greater 
part of the alcohol has been eliminated; and yet it is impor- 
tant always to bear in mind that the patient will, in all proba- 
bility, recover without treatment, and that there is no necessity 
for any very heroic measures. 6 
Since the practice of bleeding, which not infrequently caused 
a fatal termination in this disease, was abandoned, a number of 
remedies have beeen introduced with the hope of causing sleep 
and a speedy termination of the disease, and these remedies are 
all used at the present day. The first of these remedies to be 
tried was opium, which was given in such large and frequent 
doses that it in many cases substituted opium for alcohol poison- 
ing, and in this way caused the death of the patient. In most 
cases of delirium tremens it is very difficult to produce sleep 
with opium, and such large quantities have to be given that this 
kind of treatment is more dangerous than the expectant treat- 
ment. It is safer to give morphia hypodermically than opium 
by mouth, because it is impossible to say how rapidly absorption 
takes place from the stomach in cases of delirium tremens. The 
treatment by opium was almost universal until 1860. 
In I860, Mr. Jones, of Jersey, recommended the use of tincture 
of digitalis in large doses in delirium tremens, and cited seventy- 
seven cases of cure by this means and only one death. He was 
led to adopt this method of treatment because a patient with 
delirium tremens swallowed by mistake an ounce of the tincture 
of digitalis, with benefit to himself. Mr. Jones recommended 
that half an ounce of tincture of digitalis be given and repeated 
in four hours, and that six hours later two drachms of the tinc- 
ture be given. This method of treatment was soon very exten- 
sively tried, and the dose was even increased in some cases. 
Thus, Dr. D. M. Williams gave half an ounce of tincture of 
digitalis at two, four and seven o'clock-that is, an ounce and 
a half in five hours, and the patient made a rapid recovery. The 
method of treatment by tincture of digitalis proved itself to 
be superior to that by large doses of opium, and also to two 
other methods introduced at about the same time. One of these, 
which was recommended by Dr. Kinnear, consisted in giving 
large doses (a scruple) of cayenne pepper every two or three 
hours, and the other, introduced by Dr. Peddie, consisted in 
giving tartar emetic in small but frequent doses. 
About 1870 hydrate of chloral was tried in delirium tremens, 
the bromide of potassium having been used with much success 
a few years before. In hydrate of chloral we have, I believe, 
the best agent for producing a calm and refreshing sleep in cases 
of delirium tremens, and thus hastening recovery. At the same 
time, the following cases of digitalis treatment are not without 7 
interest, for I think that there are some cases of great depression, 
with a rapid, feeble pulse, in which the digitalis is, perhaps, of 
greater service than the chloral. 
Case I.-Male, aged 38, who is in the habit of indulging in 
periodical sprees. This time has been drinking hard and eating 
little or nothing during the past week. Has slept but little. 
Has no hallucinations, but feels nervous. On entrance patient 
was still stupid from drink. There was a slight tremor of hands 
and tongue, and he was very nervous and dreaded the approach- 
ing night. At 5 p. m. his pulse was 130 to 135, compressible, 
and at that time he was given half an ounce of tincture of digi 
talis. He passed a pretty quiet night. The next morning his 
pulse was 90 and stronger. He felt better, but had no appetite. 
The next night he was again given half an ounce of tincture of 
digitalis. He slept well, felt much better, began to eat well. 
Pulse was 75, but upon any exertion it ran up to 90-100. Two 
days later he was discharged well. 
This was not a very severe case. The pulse was, however, 
quite high, but fell rapidly under the effect of the digitalis, and 
when the circulation was quieted sleep came. There was no 
decided effect on the excretion of urine. 
Case II.-Male, aged 56, who is in the habit of indulging in 
periodical sprees. This time has been drinking hard and eating 
almost nothing during the past two weeks. Has slept very little. 
During the past two nights has seen bears, wolves and other 
animals in constant motion. Is very nervous. On entrance 
patient looked very much broken down and as if he were going 
to have a very severe attack. His speech was stammering and 
indistinct, and his hands and tongue were very tremulous. At 
1 p. m. his pulse was 85 and of fair strength, and at that time he 
was given half an ounce of tincture of digitalis. At 5 p. m. he was 
given fifteen grains of chloral and thirty grains of bromide of 
potassium, and this dose was repeated at 8 p. m. He slept at 
intervals during the night, although he continued to be troubled 
by hallucinations of sight. The next morning he felt better, 
although he was still very tremulous. During that day he took 
two drachms of tincture of digitalis at 2 p. m. and again at 6 p. m., 
and at 8 p. m. he was given ten grains of chloral and twenty grains 
of bromide of potassium. He slept well during the night. The 
next morning he was less tremulous and began to eat with appe- 
tite, and required no more medicine while he remained in the 8 
hospital, except a little compound tincture of gentian for his 
appetite. 
This case was a much more severe one than the first, and in 
addition to the digitalis a small amount of chloral and bromide 
was given, which doubtless aided in the production of sleep. 
The hallucinations in this case were bears, wolves, etc., and 
it is curious how rare it is to find any hallucination about 
snakes, although formerly the disease was often called " seeing 
snakes." 
Case III.-male, aged 28; had been drinking bard and eating 
little or nothing during the past two or three weeks. He com- 
plained of feeling very nervous and of not being able to sleep, 
but had no hallucinations. On entrance- there was almost no 
tremor of hands and tongue. He was given fifteen grains of 
chloral and thirty grains of bromide of potassium every four 
hours. He slept a little that night, and remained in the 
same condition during the next day. But the next day after 
-that is, after he had been in the hospital forty-eight hours- 
the symptoms of delirium tremens became much more decided, 
notwithstanding the chloral and bromide which he had taken. 
He became much more tremulous and nervous. The chloral and 
bromide was stopped, and in the evening he was given half an 
ounce of tincture of digitalis. He passed a restless night, and 
on the next day he was very tremulous and violent and had a 
great many hallucinations. He was given two drachms of tinc- 
ture of digitalis, but in the night he became so violent that he 
had to be put in a strait-jacket. On the next morning, that is, 
on the fifth day of his stay in the hospital, he was still in the 
strait-jacket, and was very violent, trying to escape from three 
men who were constantly trying to shoot him. He was given 
one-third of a grain of sulphate of morphia hypodermically and 
two hours later one-quarter of a grain, but he continued very 
violent, and destroyed the furniture in the room. Towards 
evening he became exhausted and passed a fairly quiet night, 
and on the next day was so quiet that the srait-jacket could, be 
removed. In the evening he became very tremulous and ner- 
vous and violent. His pulse was 110 and compressible. He 
was then given half an ounce of tincture of digitalis, after 
which he went to sleep and slept well most of the night. The 
next morning the pulse was *65, full and strong. There was 
scarcely any tremor, and the patient felt well and eat with appe- 9 
tite, and the next day was discharged from the hospital well. 
This was a very violent case of delirium tremens, which came 
on in spite of the chloral and bromide which the patient was 
taking, and which ran its course uncontrolled by the digitalis or 
morphia in the doses in which they were given. The half ounce 
of tincture of digitalis which was given when the disease was at 
its end and when the patient was tremulous and exhausted and 
had a rapid, compressible pulse seemed to have had a very good 
effect. 
Case IV.-Male, age 29. Has been drinking heavily during 
the past two months and very hard during the past two weeks. 
He has eaten next to nothing; has slept pretty well. On en- 
trance the patient was very tremulous and nervous and so rest- 
less that he could not sit still for a moment. He staggerd so 
that he could scarcely walk. He coughed almost constantly 
and raised a large amount of thick yellow phlegm. I suspected 
pneumonia, but was unable to make any satisfactory exam- 
ination, because of the restlessness of the patient. His pulse 
could not be accurately counted, but was apparently 130. 
Patient complained greatly ol oppression in breathing and of 
pain in the chest. At 11.30 a. m. patient was given half an 
ounce of tincture of digitalis, and at 8 p. m. he was given 
another half ounce. He passed a restless night, but in the 
morning was rather steadier, and he eat a little. At noon he was 
given half an ouce of tincture of digitalis, but his pulse contin- 
ued rapid. At 4 and 7 p. m. he was given a hypodermic injec- 
tion of one-quarter of a grain of sulphate of morphia. He had 
a very bad night. In the morning his pulse was 112, and he 
was very tremulous. He complained greatly of the oppression 
in his chest. He had hallucinations of hearing, and heard peo- 
ple trying to break into his room. At noon he was given half 
an ounce of tincture of digitalis, which he immediately vomited. 
He continued to grow wilder. In the evening he was given half 
an ounce of tincture of digitalis and one-quarter of a grain of 
morphia hypodermically. During the night he was violent, and 
kept pounding on the door of his room. At 3 a. m. he began to 
grow exhausted. His pulse then was strong and full, but inter- 
mitted every four or five beats. It could not be counted on 
account of the tremor. He sank rapidly and died at 5 a. m. 
This case was the only one that died. The digitalis was 
given pretty freely but. did not reduce the frequency of the 10 
pulse, although the pulse kept strong and full till within a very 
short time before death. I am inclined to think, from the appear- 
ance of the patient, that pneumonia was present in this case. 
The half grain of morphia Which was given hypodermically did 
not quiet him at all. 
The other two cases do not need extended notice. In one, a 
woman, chloral and bromide in moderate doses had been given 
without much effect, but one drachm and a half of fluid extract of 
digitalis, followed some hours afterwards by a drachm of the 
fluid extract, produced sleep, and the patient made a rapid re- 
covery. In the other case the patient was given half an ounce 
of tincture of digitalis on entrance, but it produced no other good 
effect than to reduce the pulse from 130 to 102. Afterwards 
sleep was produced by chloral and bromide, and the patient made 
a good recovery. 
From these cases it is seen that tincture of digitalis in half- 
ounce doses is well borne by the system. In most cases it causes 
a reduction in the frequency of the pulse, and by thus allaying 
the vascular excitement it often causes sleep. As a sleep- 
producing agent it is far inferior to chloral and bromide of 
potassium. In the case which terminated fatally I think pneu- 
monia was present, although I wras unable to hold an autopsy. 
The pulse did not indicate poisoning by digitalis. Tincture of 
digitalis, it seems to me, is only of value in very exceptional 
cases of delirium tremens where the pulse is very rapid and 
weak and there is great exhaustion. In such cases half-ounce 
doses of the tincture may be of use in strengthening the heart's 
action and producing a more regular circulation. In all other 
cases hydrate of chloral seems to me to be preferable. 
During the summer and fall while these six cases were being 
treated with tincture of digitalis, seven other cases of delirium 
tremens entered the hospital which were treated by chloral and 
bromide. All of these cases made a rapid recovery. To be of 
much service the chloral must be given in doses of at least 
twenty grains, and doses of thirty and forty grains are certainly 
much more effective. It is true that doses of thirty and even 
twenty grains of chloral have caused death, but such cases are 
very rare, and Lewin, in his recent book on the "Untoward 
Effects of Drugs," thinks that deaths from chloral are due to 
impurities in the drug, and do not occur when the chloral is 
pure.