The case is different with older patients, especially those who have taken alcohol for long periods, and in whom symptoms of pneumonia or of cardiac failure manifest themselves. Here alcohol cannot be withheld unless at great risk; but such cases are comparatively rare, and even in them the alcohol should not be started at the very beginning of the attack. When there is dyspncea, pallor of the face, or lividity, or any approach to symp toms of syncope, with failure of pulse, alcohol must be given freely, in conjunction with large diluted closes (I dr.) of Spirit. Ammon. Aromat., and Strychnine hypodermically.
Bypnotics.—The use of these drugs in delirium tremens is the next serious question. There cannot he a doubt but that some cases would be better without them all through the attack, and it is equally certain that they should not be given in any case at the beginning. It appears probable that a patient who would not fall into natural sleep till about the fourth night if left alone, will not be sent to sleep by narcotics much sooner. It is also highly probable, where sleep has followed the use of a narcotic in the early stage, that the case has chanced to be one of those mild forms of the affection which would have terminated in sleep if left to itself. Should hypnotics then be administered at all in delirium tremens ? The answer to this question must be in the affirmative.
A very short curtailment of the period of excitement in bad cases may save life, and one cannot help reflecting, after witnessing the death of a patient, say upon the fourth day of a restless and exhausting delirium, that had sleep been induced by any means, even by chloroform, a short time before the fatal termination was due, a different result might have been obtained. This seems so highly probable that one must he under taking a very serious responsibility who would withhold all narcotics or hypnotics from a patient sinking from the exhaustion caused by a restless delirium and want of sleep. It must also be remembered that drugs like the Bromides and Hyoscine, even if they fail to induce sleep, may nevertheless quiet nervous excitement, and husband the strength of the patient.
It must be remembered that many deaths have been attributed to the free use of narcotics, and that Wilks stated he had seen many cases sent to their last sleep by opium. With this state ment all observers would agree had Wilks spoken of chloral instead of opium; but the physician HMV find himself placed in a grave difficulty when dose after (lose of narcotic fails to induce sleep in a patient apparently sinking from the exhaustion which sleep mould soon banish.
Owing to the slate of the digestion and ithsoriltive powers these closes may lie in the stomach or intestines unabsorbed for a time, and then may all rapidly enter the circulation at once; hence solid opium should never be administered in this condition, and hypodermics of morphia are certainly preferable even to liquid preparations given by the mouth. I t seems highly probable that an hypnotic, even when given before natural sleep is about to occur, renders this more prolonged and refresh and tenclsto hasten recovery, butwhen the judgment of the physician leads him to believe that a moderate hypnotic will be beneficial in a given case, he should not, however, think of giving it sooner than 24 or 3o hours after the onset of the symptoms.
Early restlessness and activity may he to sonic extent benefited by full doses of bromides, though they fail to induce sleep, and there can be little objection in carrying this routine out by administering the following mixture: Bromidi Tr. ...Yuc, Capsi•i 5ij.
Lig. .1mmon. Acct. 5iij.
iqwe Cam phora- T,viij. Fiat mislura. r Caution is needed in the use of Chloral, though many physicians still press it freely in this disease. The writer has long since abandoned it, having seen fatal cardiac failure caused by it. Chloralamide and other Chloral compounds are not so treacherous, hut they must also be given caution.
Narcotics, as 45 mins. Liq. Morphia! or 3o mins. 'I'r. Opii, may be given about the ordinary sleeping hour of the patient upon the second night of his attack, and if sleep does not follow it should not he repeated till the early hours of the morning, and not again till bed-time the following night. Should the state of affairs be the same upon this night as upon the second, the dose may lie repeated early upon the fourth morning. I f sleep does not supervene by the fourth night (say 72 hours after the onset of the disease), the situation \VIII become serious, and the dose may be again repeated, to be followed by 2o-3o mins. every four hours till sleep comes on. Should excitement follow each repetition of the opiate, its administration should be suspended, and it has been long observed that rapid improvement often follows one or two closes of Tartarised Antimony gr.), or the ITot Pack may be tried. This latter agent often helps the patient to fall asleep in mild cases without resorting to hypnotic drugs; the hot or warm bath is, however, contraindicated in the disease. Cold allusion may be employed when all hypnotics fail, but it should only be resorted to in robust subjects, and is especially valuable where there is any rise of temperature.