When the acute disease has been removed, should a discharge continue from the ear, it is necessary to be very prompt with such measures as may remove it, for if allowed to go on, it will become habitual, and its cure will be almost impossible. For this purpose, blisters behind the ears, either repeated or kept open by the ceratum sabinæ, and astringent washes made with the sulphate of zinc or the vegetable astringents are often useful: or, should these fail, a solution of nitrate of silver, two or three grains to the ounce, applied to the meatus with a camel's hair pencil, may be tried. But all these means are frequently insufficient, and the constitution must be brought into a more healthy state by tonic remedies, by sarsaparilla, and by change of air; a preference being given to a sea-side residence. Sometimes a little alterative medicine, as a few grains of Plummer's pill to the adult, or a quarter of a grain of calomel, with two or three grains of dried soda and a few grains of chalk, to children, will much assist in overcoming this troublesome and even dangerous malady.

DELIRIUM TREMENS.

This term is applied to what appears to be, or is very closely allied to, a modification of Arachnitis, occurring in persons whose nervous system has been brought by various circumstances into a very irritable state. The symptoms by which it is chiefly indicated are, a state of delirium marked by some leading peculiarities, together with sleeplessness, tremors, and profuse perspiration. The attack is often preceded by a few days of uncomfortable and irritable feeling, so that there are instances of those who have been several times affected with it giving intimation to their family of the approaching paroxysm: but very frequently it comes on after a few hours of febrile irritation; the patient beginning to talk incoherently, to express sus

picions of something going on around him, some plots laid, or some designs harboured, in which it seldom happens that those who actually surround him are the persons implicated, for he usually fills his chamber with imaginary beings who attempt boldly to seize him, or lie in wait for him hidden beneath his bed or in a closet. His manner and actions mark alternately the greatest alarm and the most furious determination to resist or escape. In his most tranquil and collected moments he is not to be trusted, for the transition from that state to the greatest violence is instantaneous: he is often recalled by a word to an apparent state of reason, but as quickly his false impressions return: there is sometimes evidence at the time of a state of double consciousness, a condition of the mind which is sometimes remembered by the patient when the paroxysm is over, so that he relates the curious history of day dreams which have passed before him while he was still conscious of the presence of his friends.

The pulse is during all this commotion comparatively little influenced, or is accelerated and weak; the tongue sometimes covered with a dyspeptic fur, but more generally healthy or morbidly red: the appetite is gone, and perfect wakefulness is an almost constant attendant. All these symptoms may continue for some days, sometimes marked by greater violence, sometimes admitting of a broken conversation with those around; and it generally happens that the transition from disease to health is as sudden as the first appearance of the paroxysm had been, this change usually taking place in consequence of sleep procured by medicine, out of which the patient awakes perfectly restored.

The diagnosis of Delirium tremens has already been referred to when speaking of the marks by which Arachnitis may be distinguished from the delirium of fever, from acute

mania, and from this disease. It is chiefly in the history of the attack, the comparative softness of the pulse, the moisture of the tongue, the perspirable state of the skin, and the peculiarity of the mental derangement, that we trace the distinctive signs of Delirium tremens.

Causes of Delirium tremens.—The exciting causes of this disease are almost always connected with habitual intemperance, though this is sometimes so mingled with sources of mental annoyance or anxiety, as to give a colourable pretext for ascribing it to them. It very often happens that the immediate exciting cause is a sudden cessation from habitual intemperance; and not unfrequently the intemperance has for a few previous days been carried, by a kind of paroxysm, to a most unusual extent; and then, either in consequence of the direct excitement, or on a sudden cessation from the excitement, the disease almost suddenly betrays itself. It is occasionally induced by other causes in persons whose habits have predisposed them; and hence, it is not uncommon to see this form of delirium the result of large depletion by bleeding, which had been apparently rendered necessary by inflammatory attacks, hæmoptysis, or other diseases.

The prognosis must be very guarded, as it is always doubtful. A large majority however of these cases recover, if there is no very decided tendency to other disease in the brain, or great organic derangement in other parts; but ultimately the habits, on which the disease depends, destroy life, whilst some are cut off in the paroxysm itself, exhausted and worn out by its violence, or sometimes dying very unexpectedly by a kind of sudden collapse.

Treatment.—It is a question which at once presents itself in a disease marked by such manifest symptoms of excitement, how far we should attempt by depletion to make an impression on the system; and to an inexperienced person the decision would most probably be in favour of rather

active bleeding: it is therefore of the more importance that the student should have this question placed most prominently before him when speaking of Delirium tremens, and that the greatest caution should be inculcated in this respect. This is one of the strongest examples of that influence which the nervous system may be considered to exert in diseases more directly affecting the brain and nerves, whereby a certain irritation appears to augment those symptoms, which in some other cases might be wholly ascribed to inflammatory action: and the result of large depletion generally proves that the symptoms increase as the power of the system is diminished; so that if led on by a wrong estimate of the phænomena, the practitioner may be betrayed into a repetition of measures which lead to a fatal issue. While it cannot be asserted that bleeding is never admissible in Delirium tremens, the general rule must certainly forbid its use; and the occasional exceptions are, when the disease arises in persons of a very full or robust constitution, and when the origin of the attack can be plainly shown to connect itself with direct excitement. When, therefore, it is considered necessary to bleed, it should be followed by the administration of an opiate, as a grain or two grains of opium with a grain or two of calomel. The remedy, however, to which we look with greater confidence, and which can seldom be dispensed with, as forming part of the early treatment, is free purging. The disease generally takes place under circumstances very favourable to morbid accumulations in the intestines, and vitiated secretions both in them and the liver; and we may always proceed on the impression that such is the case, exhibiting without fear a considerable dose of calomel and colocynth, followed by a warm senna mixture; and as soon as this has had time to commence its action, a powerful dose of opium should be administered. Two grains of solid opium, or forty minims of the tincture of opium, may be first given; and

this may be followed every hour by a grain of opium, to which a grain or two of calomel is advantageously added, till tranquillity or sound sleep is induced. At the same time, ammonia, in doses of five or six grains, or camphor to about the same extent, rubbed up in an emulsion, may be taken from time to time according to the state of the patient. It not unfrequently happens, that when the bowels have been freely opened, sleep is in a few hours induced, out of which the patient arises greatly relieved and refreshed, and sometimes even cured. It is, however, frequently a much more difficult task to bring about this most desirable remission of the symptoms; and many alternate administrations of purgatives, of opiates, and of stimulants, will in general be requisite. It may be found necessary to vary the stimulants; whilst in some instances a moderate quantity of the accustomed stimulus by which the disease may be considered as induced, will be found useful. Small quantities also of wine or spirit, or very often of porter, may be cautiously allowed; and if the least inclination is expressed for solid food, whether animal or farinaceous, this likewise may be given in small quantities with the best result. When there is much febrile action present, antimonial remedies are admissible; and two or three grains of the James' powder, or a quarter or eighth of a grain of the antim. potass. tart., may be occasionally combined with the opium.

It is desirable to use as little personal restraint as possible; but in many cases it becomes absolutely necessary to subject the patient to some form of confinement, both for his own safety and for that of the attendants; and to prevent the exhaustion which would arise from the constant struggles to which he would be exposed. Whenever such measures are unavoidable, they should be considered as a necessary evil, to be continued no longer and to no greater an extent than they are imperatively called for; but no vigilance can