The Saunders-Sutton Syndrome: An Analysis of Delirium Tremens

Abstract

Detailed and critical study of 205 cases of delirium tremens (184 men and 21 women-99 seen before and 106 after 1957) sheds clear light on the clinical course of a syndrome that has been inadequately appreciated by most observers for more than a century. To avoid confusion with other alcohol withdrawal states, 4 criteria are set up for delirium tremens: hallucinations or mental confusion, hyperkinesis, wakefulness, and tremor[long dash]all subsequent to prolonged and excessive ingestion of alcohol. Three grades of the syndrome are distinguished: Grade I, in which the acute stage terminates within 24 hr.; Grade II, in which it terminates within 72 hr.; Grade III, in which it lasts longer than 72 hr. More than 75% of the patients fell in the first 2 groups and were over their delirium tremens within 3 days; the remainder required as long as 9 days. The prognosis in Grades I and II can be viewed with optimism. The alcoholic beverage preferred (distilled spirits in the group studied) and the number of years drinking (17. 9 yr. on the average) seemed to have no effect on the duration or severity of the syndrome which were, however, directly predictable from the extent of the preceding drinking bout. The overwhelming majority of patients in this study (80%) were single, divorced, or widowed; alcoholism had isolated the marked individual, severing most of his stabilizing interpersonal ties; prognosis was good as a patient, poor as a human being; the patient was likely to recover from his delirium tremens but not from his alcoholism. Death (in 13 of the 205) generally occurred within the first 3 days. If the patient is carried past the critical 3-day period, the prognosis is generally good, regardless of complications. Older alcoholics had a higher mortality than the younger patients. Convulsions, occurring in 35 of the 205, did not worsen the prognosis. Temperatures above 101 F were more likely to be associated with complications than with a prolonged course or death. Neither blood pressures nor heart rates were of prognostic significance. In 41% of the patients the liver was recorded as enlarged, but this did not indicate a fatal outcome. It is essential to differentiate between delirium tremens and hepatic coma which has a more ominous prognosis. The hyperglycemia sometimes seen in this syndrome is explained by the effect of alcohol on adrenal function. Initially, with heavy drinking, there is a tendency toward increase of adrenal function associated with hyperglycemia. With continued excessive drinking and poor nutrition, the opposite effect is predictable[long dash]adrenal exhaustion and hypoglycemia. The most effective therapy for delirium tremens is prevention of its onset. No drug will shorten it markedly, but personal medical attention and vigilant nursing care are of the utmost importance. Rehydration and nutrition therapy with electrolytes and vitamins are indicated in all cases. Sedation, effective in controlling convulsions and reducing hallucinations, may lead to fatalities if it is mishandled, particularly in combinations or in patients with severe liver disease.