First Description of Delirium Tremens was Made by Diego de Torres Villarroel in 1737

Mr Publisher,

Delirium tremens is one of the most severe consequences of alcohol withdrawal. It is an acute toxic- confusional state, with vital risk. It appears in less than 5% of alcohol withdrawals, and up to 30% of patients who experience seizures during alcohol abstinence [1]. It can be considered an independent form of alcohol withdrawal, because of its severity and its symptoms. It presents with vegetative dysfunction (hyperhidrosis, tachycardia, hyperthermia of up to 40-41 °C, and arterial hypertension). Alterations in the acid-base balance, electrolyte or glycemic imbalances, cardiovascular problems or intercurrent infections can complicate it. Even with treatment, it has mortality rates of 5% [2], andfour times more if left untreated [3]. Death causes canbe hyperthermia, cardiac arrhythmias, and complications of seizures or somatic comorbid illnesses [4]. It usually begins three days after the onset of withdrawal symptoms, and lasts from one to eight days (usually two or three).

The initial psychic symptomatology usually consists of insomnia, fear, and restlessness, although sometimes it shows up with hallucinations and seizures. The classical triad of symptoms is composed of a confusion state, sensoperceptive disorders (hallucinations and vivid illusions), and intense tremors. Level of consciousness is diminished or may fluctuate, with obnubilation and confusion, and can progress to coma. Attention is unfocused. There is disorientation, in space and time, and sense of reality is lost. Hallucinations can occur in any sensory modality, but microzoopsias are characteristics of such delirium: patients can see little arthropods running on sheets, their clothes, or their skin. On other occasions, they can see lights or flashes. The tremor, which called Delirium tremens, is wide, generalized around the body (it affects even the tongue), and intense [4].

Its first descriptions are said to have been made [5,6], in Great Britain, in 1813, by Sutton and Pearson. Pearson [7] treated 93 patients who suffered from “Brain fever”. He wrote that the cause was frequent and excessive alcohol intoxications, and said “It is distinguished from putrid fever, in never being contagious, or having purple spots; or ever having a cadaverous smell, or ever being received from human effluvia; and in the delirium being much more impetuous”. That same year, Sutton [8] published the book “Tracts on Delirium Tremens, on Peritonitis and on Some Other Inflammatory Affections”, where coined the term “Delirium tremens”. Both authors described the same symptoms: hands tremor, restlessness, thought irregularity, loss of memory, nightmares, loss of appetite, vomits, excessive sweating, pulse acceleration, hallucinations (concerning micropsias), and occupational worries.

Nevertheless, more than 70 years earlier, Diego de Torres Villarroel [9], (between 1736 and 1737) had published “Los deshauciados del mundo y de la Gloria” (The Disposed of the World and of Glory). That was a case report compilation, written in a poetic language. The first case of the second part (“first bed the frantic”), is about a 30-years-old man, with agitation, autonomous nervous system hyperactivity (tachycardia, hypertension, profuse sweating), tremors, hallucinations (microzoopsias), fluctuations of level of conscience, and disturbances of attention. He associated it with excessive alcohol intake, although outlined a physiopathology very influenced by iatromechanism [10].

Torres Villarroel was multifaceted, with a hazardous life, and even today, very controversial [11]. He was chairman of Astrology and Mathematics at the University of Salamanca (Spain), but he was also a priest and philosopher and received medical instruction. In his time, he was notorious as a fortune-teller, because he “predicted” the death of King Luis I of Spain [12,13]. He wrote very diverse works: satirical prose, poetry, theatre, religious works, and other more scientific, like “Los deshauciados del mundo y de la Gloria” The disposed of the World and of Glory, 1736-1737), “Anatomía de lo visible e invisible en ambas esferas” (Anatomy of the visible and invisible in both spheres, 1738), or “Tratados físicos y médicos de los temblores y otros movimientos de la tierra, llamados vulgarmente terremotos” (Physical and medical treatises on tremors and other movements of the eartrh, commonly called earthquakes, 1751) [13].

The description made by Torres Villarroel fits with the modern clinical criteria of Delirium tremens [14,15]. He attributed it to alcohol intake, but not to withdrawal. Also, medical literature considered too much drinking a casual factor until the forties of the XX century [16].

Fermentation, care of wines, and distillation techniques improved in the XVII century, which augmented the alcoholic degree, and could have made Delirium tremens proliferation [17,18].

Torres Villarroel made the first description of Delirium tremens. It is suitable to revise his works because they could show a more complex and modern vision of Spanish medicine in the XVIII century.

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The author declare no conflict of interest.