administered, and cold applied to the head by means of a bladder half filled with powdered ice, or cloths wet with iced water, or iced water and vinegar, the hair being first removed. At the same time the feet and legs should be immersed in hot water, followed by sinapisms to the feet and ankles. In conjunction with direct depletion by the lancet, active purgation will unquestionably be found an efficient remedy, by producing a revulsion from the diseased organs. There are but few cases in which the presence of gastro-enteric inflammation will forbid the employment of purgatives. Tartar emetic, in divided doses, combined with the saline diaphoretics, will no doubt prove beneficial in the early period of the stage of excitement. In the epidemic which occurred at Vicksburg, Miss., Dr. Hicks gave it in combination with camphor, and, as he states, with the best effects.* After blood-letting has been carried as far as it is thought prudent, under the circumstances of the case, especially if the patient falls into a state of coma, with feeble pulse and deficient reaction, blisters along the whole course of the spine will often be found of advantage. According to Dr. Ames, blisters to the upper portion of the spine very generally had the effect of removing or greatly relieving the cephalalgia, even when bleeding had failed to do so. In the malignant forms of the disease, the relief afforded by them was very great. Blisters to the scalp have been advised; we doubt, however, the propriety of their application to this part. In those cases where the attack commences with symptoms of collapse, or where such symptoms ensue after a transient and imperfect reaction, the most powerful excitants, mustard, ammonia, or turpentine, aided by heat and friction, should, without delay, be applied externally along the spine and to the extremities, and perseveringly employed, at short intervals, until the torpid sensibility is aroused. It is probable that, in these cases, the actual cautery, as employed by M. Rollet, will be found of advantage. He passes the iron, at a white heat, six, eight, or more times, at as many different points, along each side of the spinal processes. M. Rollet states that, in the worst cases, the first application of the actual cautery does not elicit from the patient any indication of sensibility, it is only at the third, fourth, or even fifth application that a slight muscular movement proves that pain is experienced. Some patients utter cries during the last applications, but immediately relapse again into a comatose condition. Should we succeed in establishing reaction, the patient must be carefully watched, and if it transcend the proper grade, resort should be immediately had to general and local blood-letting, to an extent proportioned to the violence of the symptoms, and the age and strength of the patient, at the same time, cold applications should be *R. Antimon. Tart. gr. ij. Pulv. Camphoræ, 3 ij. Mucil. g. Acaciæ, vj. M. Dose, a tablespoonful every two hours. made to the head, and the other means of keeping down excessive reaction employed. By several of the American writers on the disease, the early and free exhibition of mercury, both by the skin and mouth, with the view of producing promptly its specific action, is favourably spoken of. Dr. Ames, of Alabama, considers it a more efficient remedy than blood-letting, as well in the promptness as in the permanence of its beneficial effects. The French physicians condemn mercurial frictions-more, however, we suspect, from theoretical views, than from any actual experience of their bad effects. It is proper to remark that, in many cases, mercury, even when its specific effects have been induced early in the attack, has failed to exert any perceptible influence in retarding the fatal march of the disease. The same remark, however, may be made in reference to every other remedy that has been resorted to in this disease. Subsequent to venesection and the employment of the other antiphlogistic remedies, the administration of opium has been recommended by several of the French physicians. Forget commenced its use between the fifth and seventh days of the disease, in the form of a syrup containing half a grain of opium as a dose for an adult. This he found to relieve the pain of the head, and to calm the delirium and muscular spasms. M. Chaufard states that the early employment of the most energetic antiphlogistic means failed in his hands to cure the disease, but he found it to be promptly arrested by opium given in large doses,-in many cases it was advantageously combined with quinia. Before this plan was adopted, we are told, only one case was cured out of thirty, but afterwards the disease was even less fatal than in its sporadic form. M. Tourdes admits, with M. Chaufard, the inefficacy of the usual antiphlogistic remedies, but cannot agree with all the latter has said in praise of the curative effects of opium. Dr. Ames, of Alabama, does not consider the latter as generally safe in the more violent inflammatory cases, nor of any use in the congestive malignant cases. In the other forms of the disease, he speaks of it as a safe and very valuable remedy. At St. Augustine, Texas, we are informed by Dr. Roberts, that opium and mor phia were tried in a few cases, but without any good result, they appeared rather to increase the stupor, without relieving the pain and restlessness. To produce a sedative effect, some of the French practitioners employed, subsequent to antiphlogistics and revulsives, the water of the cherry laurel and that of valerian combined with mucilage. M. Maihle recommends in preference, the distilled water of bitter almonds, as furnishing more definite proportions of hydrocyanic acid. Quinia is recommended as a most efficacious remedy in cerebrospinal meningitis by certain of the French army physicians; by the majority, however, it is denounced as positively injurious. It was frequently employed by Dr. Ames in the graver forms of the disease, and sometimes with partial success. When the disease was attended by fever of a regular remittent form, he found it occasionally to arrest the paroxysms. In other forms of the disease, he found it, if not absolutely injurious, to afford not much encouragement for its repetition. Dr. Ames speaks highly of the effects of potass in this disease. It was given to children in doses of from three to five grains, every two hours. No case proved fatal in his practice, nor, so far as he could learn, in which the potass was freely and continuously employed. In many cases, unattended with febrile symptoms, properly so called, under the use of the remedy, the cephalalgia was speedily and permanently relieved, and in others, its administration was followed by a prompt reduction of arterial excitement, delirium, and the intense pain of the head. Etherial inspiration, it is said, was practised, with the best effects, by M. Basseron, physician-in-chief to the Military Hospital of Mustapha, in Algeria. During the period of excitement, cooling drinks should be allowed, and a strictly antiphlogistic diet enjoined. Absolute rest and quiet, with the seclusion of light, as far as it is consistent with due ventilation, are all important. In the comatose cases, and during the stage of collapse, care should be taken to prevent an accumulation of urine in the bladder. Convalescence from epidemic cerebro-spinal meningitis is usually protracted, and relapses are liable to occur from slight errors in diet and regimen, hence the greatest watchfulness is to be observed until the general health and strength of the patient are fully re-established. Dr. Hicks found the annexed prescription* to act as a most admirable tonic, after the violence of the disease had been subdued, for relieving the inertia of the nervous system that remained in every instance in which recovery took place. R. Iod. Ferri, j. Syr. Sarsapar. 3 iv. M. Given in doses of a teaspoonful every four hours, in a little water. DELIRIUM TREMENS AND MANIA. 443 XXV. DELIRIUM TREMENS AND MANIA. DELIRIUM tremens, or the mania a potu of the older authors, is a disease which we recognise, and can define only by its symptoms, since it belongs to that class of nervine affections, in which defect or derangement of the nervous power arises independently of any structural change cognisable to our senses. The whole of the symptoms in this affection, are essentially those of exhaustion, with that state of the nervine functions so commonly associated with it, and which is recognised, amongst medical men, as that of excessive irritability. This disease attacks exclusively those who have been subject to a long series of excessive nervine stimulation, accompanied by circumstances tending to derange the circulatory and digestive organs. All these conditions are combined in repeated and continued alcoholic intoxication, and therefore it has been regarded as especially a drunkard's disease, and hence the synonyme mania a potu: this, however, though true of by far the greater number of instances, is not so universally. The disease generally commences, or is preceded, by more or less of febrile excitement, during which there is often a sense of horror of some impending calamity, or the patient entertains a suspicion of some plot laid against him; there is a continued movement of the eyes, as if in apprehension of some approaching danger; hurriedness and excitability of manner; a degree of tremulousness in the limbs, and the same is observed of the tongue when the patient is asked to protrude it. This excitement and tremulousness continue until to the dread of approaching danger are added hallucinations, and the patient believes that he sees persons or other objects approaching to do him mischief. In this state of excitement he will, unless carefully watched, elude the restraint of his friends, and walk or run hurriedly for long distances, as if endeavouring to escape pursuit. These hallucinations are accompanied by delirium, the patient generally asserting that he is in some other place, commonly, to all appearance, under the idea that he has been kidnapped or removed by stealth or force; and whilst suspicious of all about him, he is more especially so of his nearest relatives, and those in whom he is most used to trust; his talking is incoherent, generally, however, in accordance with his hallucinations, or about some disappointment or loss in business, or some subject which has caused him peculiar anxiety of mind. This last form of delirium is more particularly observable in those in whom the disease has been induced by some circumstances other than intoxication. Sometimes, however, there is a degree of hilarity about the patient, and he will sing and be jocose at intervals. It is one of the peculiarities of this form of delirium, that a word will often bring him to a state of reason, though only for a very short time, after which he immediately recurs to his former delusions. With all this excitement, the pulse, though rapid, is very compressible, and the tongue is creamy and moist, the skin perspires freely, the urine is abundant, the bowels, though torpid, not obstinately constipated, and the pupils rather dilated, though obedient to the stimulus of light. If the disease be not checked by the appropriate treatment, the patient passes into a state of coma, or what is equally frequent, subsides rapidly from excitement to exhaustion, and sinks from gradual syncope. Another danger to be apprehended is the patient's destroying himself, either accidentally in his anxiety to escape from his imaginary danger, or by direct injury inflicted upon himself. The most common cause of delirium tremens is, as has been stated, intemperance, the disease generally commencing after a continuance of excessive drinking, wound up, perhaps, by an extraordinary debauch. Sometimes, too, the approach of the disease seems to cause an increased desire for stimulating drinks, this giving rise to some very great excess, the depression consequent upon which is the beginning of the attack. Sometimes it happens that, owing to a threatened attack of apoplexy, or some inflammatory affection, real or presumed, the patient is bled, or blood is lost by some accident incurred in a drunken fit; or it may be that the state of the liver, induced by alcohol, gives rise to an attack of hæmatemesis, and the loss of blood appears to be the immediate cause of the invasion of delirium tremens. It may be, too, that the sudden withdrawal of his accustomed stimulants brings it on when such stimulants have been forbidden, owing to the patient being under treatment for disease or accident. Sometimes a drunkard in a fit of remorse determines to abstain entirely, and this too may induce the disease. Intemperance in the use of alcoholic drinks is not, however, the alone cause of delirium tremens, indeed it may be questioned whether it is ever, in the strictest sense of the word, a cause at all, since its effect is merely to induce a state of susceptibility to those influences which are the real cause, and to which intemperate habits render him peculiarly exposed; and many cases have occurred which seem to show that this susceptibility may be induced by long-continued excitement of the nervous system in other ways. The excessive attention to business, where that business is of an exciting kind, has, when the excitement has ceased or been abruptly brought to a close by some heavy reverse, been known to be followed by the symptoms of delirium tremens. Another instance is afforded by the case of a young me dical practitioner, of strictly temperate habits, who, whilst successfully but anxiously engaged in a rapidly-increasing practice, became the subject of severe erysipelas, upon the subsidence of which he had an attack of delirium, with all the most characteristic signs of delirium tremens. The diagnosis of delirium tremens, in its perfect form, is not dif ficult: from phrenitis it may be distinguished by the softer pulse, the moist tongue, perspiring skin, scanty urine, and by what is perhaps a still more important sign, the dilated pupil: from acute mania it is to be distinguished mainly by the character of the delirium, which is |