A Story About Delirium Tremens

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Understatement: An Experimental Study of the Etiology of “Rum Fits” and Delirium Tremens is an just another interesting article.  No IRB would ever approve this study today, and its HIPAA violations would certainly have the authors’ medical licenses revoked.

This 1955 article stands as one of the landmark studies in Toxicology, providing the first solid evidence that – contrary to popular belief at the time – withdrawal of alcohol (not intoxication) led to “rum fits” and delirium tremens.  The study gave first proof to what we know today about tolerance, withdrawal, and DTs.  What makes it remarkable, however, is the way it’s written – like a novel.

The main characters in this story go by first names like JACK, JUNIOR, SLIM, and RED (picture Morgan Freeman’s character in Shawshank Redemption).  And instead of the usual demographics chart loaded with numbers and percentages, Isbell et al vividly described each character in words:

“TONY was 35 years of age and was the eldest of nine children in a middle-class family.  He left school while in the twelfth grade in order to go to work, and thereafter led a wandering, unstable life.  He was married and apparently quite attached to his wife.  His police record showed chiefly violations of the marijuana and narcotics laws.  TONY was pleasant, affable, and somewhat shy in the presence of authority…”

The study recruited 10 imprisoned “volunteers”, all former morphine addicts.  The objective was to maintain each subject continually in the maximum state of intoxication for up to 3 months, and then to discontinue the whisky abruptly.  They document the craziness that ensued…

Alcohol was given orally at intervals of 1 or 2 hours from 6am to 12 midnight, with supplementary drinks at 2am or 3am, and in an average daily dose of 266 to 489 mL of 95% ethyl alcohol for 7 to 87 days.  That’s almost 1L of 100-proof whisky daily.  Isbell’s team was able to show in the experiment that convulsions and delirium did not appear during periods where the blood alcohol levels were sufficiently high, but rather when the alcohol was withdrawn and the blood alcohol levels dropped.

Maurice, Red, and Bob dropped out after <16 days of drinking, and Tom after 34 days.  Their withdrawal symptoms were brief and mild, consisting of mostly tremulousness, nausea, perspiration, and insomnia.

The other six patients drank for 48 to 87 days.  During the cessation period, all developed tremors, marked weakness, nausea, vomiting, diarrhea, hyperreflexia, fever and hypertension.  Two had transient visual or auditory hallucinations or both.  Two had seizures and three had frank delirium.  

Al, who drank the longest, had this described of his first night of abstinence:

“ During the first night he saw a disembodied head which was shrunken and had the appearance of heads prepared by a tribe of South American Indians.  The eyes of the head followed the patient as he moved in bed.”

Tony had it the worse:

“He felt that members of a Sicilian gang were trying to kill him with guns that could shoot curves around corners (like that Angelina Jolie movie?).  He insisted that he had been cut with knives and he was constantly attempting to escape from his pursuers.  Many of his hallucinations were of a sexual nature; he stated that he was insulted and that he had been called a “fag.”

It was surprising to all the amount of alcohol that can be consumed in 24 hours without significantly high blood alcohol levels and without significant clinical evidence of intoxication, so long as the dosage was spread throughout the entire 24 hours.

Interestingly, the authors also found that small changes in the amount of alcohol consumed resulted in disproportionately large differences in the blood alcohol level.  For instance, a small decrease in consumption can cause blood alcohol levels to fall, and thus, precipitate withdrawal symptoms.  Additionally, a “metabolic tolerance” was observed.  When the dosage of alcohol which initially caused a high blood alcohol concentration was simply maintained, the concentration of alcohol in the blood fell slowly and nearly reached zero.  A small increase in the dosage of alcohol and a change in the schedule of drinking prevented this metabolic tolerance.

Lastly, they found that no evidence of residual impairment could be detected 3 months after discontinuance of drinking.  Thus, like any good novel, our main characters: Maurice, Red, Bob, Tom Charley, Jack, Al, Junior, Slim, and Tony all lived happily ever after.

The End.

 

V.Nguyen @himynameisvince

Isbell H. et al,  An experimental study of the etiology of “rum fits” and delirium tremens. Q J Stud Alcohol. 1955 Mar; 16(1):1-33

 

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