[Reprint from The Alienist and Neurologist, Jan., 1886.] States of Delirium in Inebriety.* By T. D. Crothers, M. D., Hartford, Conn., Superintendent Walnut Lodge. II THEN the different phases of delirium noted in ’ * inebriety are studied as particular stages of the disease, one is amazed at the new realm of pathological and psychological facts which appear. Why certain forms of delirium should be regarded as a special disease, called delirium tremens, and exempt the person from responsibility in law, is a mystery. Why this particular delirium has been so carefully studied, and all the early stages of the case been dismissed with the remark, that this or that form of alcohol had been used to excess, is equally strange. No special study of the delirium of typhoid or other fevers would indicate the nature and character of the real disease. No particular study of the deliriums of the insane would reveal the history and causation of insanity. Hence all study of delirium tremens, or other forms of delirium coming from the use of alcohol, are worthless and misleading, unless they are combined as chapters in the history of the case. In a late hospital report two hundred cases of delirium tremens are recorded, the age of the patient, his social state and the kind of spirits drank, comprise all the past history given. This report with its acute studies of the forms and progress of the delirium, the remedies used and the results, is of no value. In all these cases there were distinct premonitory stages, degrees of delirium and hallucinations, that could * Read at the semi-annual meeting of the American Association for the Cure of Inebriety, May 21, 1885, at Brooklyn, N. Y. 1 T. D. Crothers. 2 and should have been recognized. Groups of causes and conditions that retarded or accelerated the progress of the case. “Switch points,” where recognition and treat- ment would have stayed or cut short the march of the disease. Neurotic taints and heredities, nutrient per- versions, degenerations of both brain and organism, and an almost infinite variety of external and internal causes, entering into the history of the case, which pointed to a future stage of delirium tremens, dementia, idiocy, epilepsy and almost every form of paralysis and in- sanity. The absence of any of these facts are fatal to the value of the history of the case. My object is to call attention to some of these early stages of deli- rium that are unrecognized in practice at present. In a class of persons who use alcohol to excess at times, and are not regarded as inebriates, these masked deliriums are often prominent. Thus, in a case of a quiet, method- ical business man, who at times drank to excess, then abstained for indefinite intervals, during and after his drinking he would manifest intense and unusual activity in business. He would take an inventory of stock, balance his books, look over all his securities, and exhibit great suspicion of being cheated. In a few days he would settle down to his former habits of business. These deliriums always came on when using spirits, and while his judgment seemed unimpaired on other matters, his desire to increase his business, and protect himself from loss, absorbed every other consideration. In the second case, a lawyer who drank wine steadily, and only occassionally to excess, would at long intervals have what his friends termed, not inappropriately, “ a horse mania.” In this he would go from place to place trying to buy fast horses. He did not purchase, but tested many horses, and talked a great deal of their merits or demerits. When free from spirits he never manifested any taste for horses, rarely ever rode behind one, and was never seen on a race track. This delirium lasted a States of Delirium in Inebriety. 3 few days, and at no time did he seem unconscious of his acts and surroundings, and said, in explanation of his strange conduct, that he could not help it, and really wanted a horse at this time, but could not be suited. In a third case, a farmer who usually drank to excess on all holidays and special occasions would have a delirium to adopt small infants. He had no children and seemed to dislike them at any other time. He would in this state drive about the country and talk and act quite rational, visiting families who had small babes, and talk at great length about adopting them as his own. In the fourth case, a physician who at irregular intervals drank to excess, at the close of his drinking period became an enthusiastic musician, buying various horns and spending hours in practice. This lasted two or three days, and absorbed every motive and thought; then it was dropped and only taken up again when another drinking paroxysm came on. A fifth case, that of an inventor, a man of excel- lent judgment, and well read in science and mechanics. He drank steadily, and at long intervals he would have delirious dreams of perpetual motion, and shut himself up for days working on models to demonstrate the idea. In another case, a drinking man who at times was greatly intoxicated, and would recover with profound convictions of speedy death. This delirium would last two or three days, during which he would make great efforts to settle his business, bid good-bye to his friends, etc., etc. These cases were not considered inebriates or weak minded, but only odd at times. These so-called oddities were so many symptoms of grave disease. There is a large class of so-called moderate drinkers, and persons who are not known to use spirits to any excess, that at times show great changes of conduct and character, often attributed to weak will and vice, or some state of exhaustion from overwork. There are likewise cases of masked deliriums unknown and unrecognized. A man of reputation and most excellent character who drinks at home regularly, suddenly disappears for two or T. D. Crothers. 4 more days, then returns much prostrated and remains temperate for a long time. During this time of disap- pearance he is with lewd woman in some distant city, never leaving the room. He is never intoxicated, and at such times seldom drinks and seems quite clear in mind. This delirium is sudden in both its onset and termina- tion, and did not appear during two years of total abstinence. A few months after he began to use spirits it came on again. A second case is that of a quiet, retiring physician who uses spirits irregularly in modera- tion. Suddenly he would develop a religious delirium, pray and exhort in public, then relapses to his old retir- ing habits. These states were free from any other unusual act or conduct, and only explained as impulses which he could not or did not wish to control. A third case was that of a very careful, methodical business man, who rarely went away from home, and lived a life free from all excesses. For ten years he had used spirits at meals and for any disorder or illness. Suddenly he became very restless, would drop all his business and go away traveling for two or three days. He seemed to have no plan or purpose, only saying “ that he wished to go about a little.” These deliriums of travel increased and, by the advice of physicians, he went to Europe and came back much worse. Finally he became insane, and died in an asylum. A fourth case illustrates a large class that are not understood. A business man living methodically, and in the best surroundings, using spirits on the table and at night, in comparative great modera- tion, suddenly finds that he cannot sleep well, and is filled with strong suspicions that he is being cheated. In a short time this passes away, but returns with greater intensity. A council of physicians advise travel and rest; from this he returns worse than before. Finally a pronounced delirium comes on, and he is sent to an insane asylum. He is discharged improved, but his mental health is permanently impaired. Had his physicians recognized this incipient delirium and its real cause, States of Delirium in Inebriety. 5 alcohol, his recovery would have been permanent. A similar case was that of an office lawyer who lived an almost ideal life of regularity and quietness. From the advice of a friend he began to use spirits at meals and at bed-time. Two years later he had short periods of intense melancholy and fear of death. He thought his property was insecure and was filled with omens of coming disaster. A council of physicians advised travel and change, but his family physician, finding that he inherited an alcoholic taint, urged the giving up of all spirits. The latter council was taken and he re- covered. These strange, unrecognized deliriums appear in sudden changes of character and conduct, exhibiting strange instability of mind and purpose, and extreme credulity or skepticism. A man of excellent judgment will be duped by the most apparent frauds. He will exhibit confidence where he should not, and suspicion without any occasion. He will have impressive dreams and act upon them, become an investigator of spirit phenomena. Another class suddenly have political ambition for office, and, if wealthy, are the easy dupes of designing men. It may be safely said, that where a moderate (so-called) or excessive user of spirits, suddenly exhibits great changes of conduct, motive and character, he is laboring under a delirium. Such a case was that of a moderate drinking cattle dealer who willed all his property to the mission cause, and at his death two years after, it could not be shown that the man had any mental dis- turbance or conduct that denoted insanity. Yet this act was unusual and entirely inconsistent with his former views and conduct. A similar case was referred to me where a man who had been a planter and large owner of slaves, left all his property to found a college for colored students. He had been a moderate drinker, and at times after drinking had exhibited great eccentricities of conduct in many ways. He was a negro hater of the most pronounced type, and held tenaciously that the 6 T. D. Crothers. negro was incapable of education, and would be injured by it This doctrine he urged all his life. He died two weeks after the end of a quiet paroxysm of drinking. In my opinion this will was made in a state of marked delirium, although the lawyer and witnesses could not detect any abnormal mental state. In some cases of delirium tremens, where the early history has been ascertained, the exact form and char- acter of the delirium has been outlined long before. Thus the man who, after or during a drinking excess, has dreams of injury, and nightmares of some horrid object persecuting him, or who conceives that his best friends are plotting his ruin, will, by and by, suffer from a pronounced attack of delirium tremens. When these deliriums are only eccentricities of conduct, acts of unusual character and strange mental impulses, the same or worse stages of disease are sure to follow. As in sleep these obscure deliriums seem to unmask and reveal something of the degeneration going on in central brain regions. They may be traced in some cases to certain mental states and surroundings, whose impress had been fixed on the brain in the past. In the same way certain hereditary impulses are started into activity and grow up unexplainable, unless they are traced back to the ancestors. Often the strange hallucinations of sight and hearing, associated with delirium, have a physical causation that can be realized. Certain forms of alcoholic drinks seem to cause particular kinds of cell degenerations with special mental phenomena. These and other facts are supported by clinical studies and the histories of cases. The practical fact most prominent is that delirium tremens, or any other form of delirium, will be literally unknown unless its etiology is studied with as much care as its symptoma- tology. Another fact appears that when it is ascertained the patient uses spirits, either in excess or moderation, all forms of brain and nerve perversions may be expected. Also states of altered conduct and character, of short States of Delirium in Inebriety. 7 durations, are often masked deliriums and stages of dis- ease, the study and treatment of which gives promise of success that grows less as the case goes on. A great deal is to be done in this field before all the facts and phenomena of delirium following the use of alcohol will be understood. The recognition of inebriety as a disease, and its transfer from the realm of morals and religion to that of medical and scientific investigation, will open the door into a new field of the greatest practical interest.