CHAPTER XVII

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ACUTE INTOXICATIONS, INCLUDING DELIRIUM TREMENS.

DELIRIUM TREMENS.

Delirium tremens as an expression of acute or subacute alcoholic poisoning is in no essential degree a surgical condition. This form of toxic delirium may occur while the individual is still drinking inordinately, or not until several days have elapsed after active drinking has ceased. It is precipitated in many cases, where otherwise it would simply remain imminent, by surgical injuries and operations. In one in whom it is feared, the surgeon should become apprehensive in proportion as the muscular system becomes unsteady and tremulous, the mind disturbed, and the individual sleepless.

Patients in a well-marked condition of delirium tremens may become so uncontrollable and so lost to sensation of pain that it may be practically impossible to enforce the physiological rest which their surgical condition demands. The restraining sheet will answer for general purposes, but the strait-jacket and even the most carefully applied plaster splint or mechanical restraint will not always be sufficient to carry out the indication.

Ingenuity may be taxed beyond its limit to enforce the needed rest, for patients will tear off bandages and injure themselves in various ways.

=Treatment.=--The _local indications_ are in the direction of _physiological rest_. _Constitutionally_ the indications are in two directions: First, _to keep up nutrition_ and _excretion_; secondly, _to properly medicate_. Nutrition is difficult unless excretion is maintained. Hot-air baths, laxative enemas, preferably of cold water, when necessary, and administration of a fluid and easily assimilable diet are measures of the utmost importance. Should the case present features of an acute alcoholic gastritis, stomach feeding may be abandoned and the rectum utilized for this purpose. _Medication_ should consist mostly of stimulants, with such sedatives, laxatives, diuretics, etc., as may be necessary. In surgical cases it is not wise to abruptly deprive these patients of the alcohol which they have so abused. Consequently in many instances a mild degree of alcoholic stimulation, at least for a time, should be continued. Two stimulants rank higher than all others as substitutes for alcohol, and in some degree antidotes to its effect. These are _strychnine_ and _digitalis_. The former should be given preferably subcutaneously; the latter by the stomach if tolerated, otherwise by the rectum or beneath the skin. My own preference for the use of digitalis is in the direction of large and few doses. I have not hesitated in many instances to give 15 Cc. of ordinary tincture, repeated once or twice at intervals of a few hours, and then to discontinue it. The effect is to brace up the heart and to equalize the circulation, while at the same time it acts as an efficient diuretic. _Adrenalin_ may be necessary, but should be used with discrimination.

Of the sedatives, bromides, chloral, and remedies of that class are those most often resorted to, and should be given in doses sufficient to meet the symptoms. They are all more or less depressant, and stimulation by strychnine, etc., is necessary even while they are being administered, in spite of the apparent physiological antagonism between them. Opium is the remedy of choice, and is best given in the form of morphine introduced beneath the skin.

The first indication is in the direction of ensuring rest and sleep, even at the expense of inconvenience or misfortune in other directions. I write this with a realizing sense of its significance, yet with positive conviction as to its truth.

Upon the assumption that this form of delirium is a toxemia of complicated type, only benefit can accrue, in aggravated cases, from a free venesection, followed by intravenous infusion of a pint or more of saline solution, at a temperature of 105° F.

TRAUMATIC OR POSTOPERATIVE MANIA.

It is difficult to distinguish this form of mania from that known as _puerperal mania_, the two conditions being essentially similar. This, too, is to be regarded as a complicated toxemia, in which products of defective metabolism, of insufficient elimination, and of phagocytic activity mingle in a blood whose corpuscular elements are already much disturbed by injury or hemorrhage. Regarding these cases from a surgeon’s standpoint, and carefully avoiding any attempt at minute explanation of the phenomena, such cases are met with in the practice of operating surgeons, as in the experience of obstetricians, presenting themselves either as mild forms of harmless mental aberration, or assuming almost any of the types of insanity as made out and classified by experts in that subject. From the mildest mental alienation up to intense and even homicidal or suicidal mania, one may meet with all degrees of departure from the normal standard. Bowel washing, hot-air baths, hepatic stimulants, and carefully regulated nutrition will usually restore to the brain its natural food supply, and hence its normal function. I have repeatedly seen much good result from the exhibition of small doses (0.30 to 0.50) of potassium iodide.

TOXIC ANTISEPTICS.

As stated above, it is generally recognized that in people of peculiar idiosyncrasies the administration of certain drugs ordinarily considered harmless is followed by more or less toxic symptoms. Obviously if this were universally the case, or true in the majority of instances, the use of these drugs would speedily be abandoned. As it is, it is well to have in mind the consequences which are occasionally known to ensue, and perhaps to weigh in every case the chances as to whether it is worth while to use a given substance of known occasional toxic power as against another which is not known to possess it.

Of the less active antiseptic agents, _boric acid_ is considered absolutely innocuous, yet is known sometimes to cause intestinal disturbance, while in one instance serious toxic effects followed its use. _Naphthalin_ will sometimes produce vertigo or vasomotor symptoms, especially when administered internally. Many of the antiseptic materials used are more or less irritating to the skin, and such local expressions as _eczema_, etc., provoke little comment.

_Iodine_ is a drug whose activity should be borne in mind. Applied upon the surface, it tans the skin and does no good. Injected in solutions of varying strength into serous cavities (for example, hydroceles, etc.) it gives rise to symptoms which may be alarming. Fatal poisoning following its injection into an ovarian cyst has been reported, and alarming symptoms have been produced by injection of the ordinary solution into a hydrocele sac. Much of the virtue ascribed to _iodoform_ is credited to the liberation of free iodine by its decomposition. Whether or not this be true, iodoform is one of the most frequently toxic of the antiseptic agents in ordinary use. In mild cases it produces headache, restlessness, wakefulness, and often a distinct taste of iodoform in the mouth. In more pronounced degrees of poisoning there is fever, often with mental derangement which may amount to delirium or even to acute mania, and may cause well-founded suspicion of meningitis. Death after its use has repeatedly occurred from syncope or in coma.

_Carbolic acid_ produces unpleasant effects, both upon patient and operator, or with whoever it may come in contact. Aside from its local effect upon the skin, which is most unpleasant, but which usually passes away within a few hours, it seems to affect especially the kidneys, causing often temporary albuminuria with discolored urine, deranged secretion, and sometimes more acute forms of disturbance, similar to those met with after its internal use. Carbolic poisoning was observed most frequently during the era when Lister’s original directions were scrupulously followed, and at a time before it was learned that it is much better to remove dirt than to try to antagonize its action. Eminent surgeons were compelled to discontinue its use because of its unpleasant effect upon themselves as well as upon their patients.

Among the powerful antiseptic agents in common use are the soluble preparations of _mercury_, ordinarily _corrosive sublimate_, in solutions of varying strength, which are used for irrigation, douching, etc., and for preparation of dressings. An intense eczema may follow its local use, and symptoms of mercurial poisoning may appear in individuals of peculiar susceptibility to this drug. Salivation, intestinal irritation, and other phenomena of mercurial poisoning have been produced, with the result that the solutions and preparations of corrosive sublimate are much weaker than those which were used at first. The drug eczema produced by _corrosive sublimate_ interferes with one of the essentials of ideal wound healing--_i. e._, physiological rest. The area involved should be protected with a sterilized powder or by anointing it with sterilized ointment.

## PART III.

SURGICAL PRINCIPLES, METHODS AND MINOR PROCEDURES.

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