On the pathology and treatment of delirium and coma : the Lumleian lectures for 1850 / by R.B. Todd.
- Date:
- 1850
Licence: Public Domain Mark
Credit: On the pathology and treatment of delirium and coma : the Lumleian lectures for 1850 / by R.B. Todd. Source: Wellcome Collection.
Provider: This material has been provided by the Royal College of Physicians of Edinburgh. The original may be consulted at the Royal College of Physicians of Edinburgh.
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![pTirenitis arc examples of epileptic delii’ium. Now it is obviously of great importance to bo able to tliagnose a ease of epileptic deli- rium, and to draw a clear distinction be- tween it and tlie several forms of deliriiun which I have described. For tlic purpose of this diagnosis you must avail yourselves of both negative and positive evidence. Ey the former you will be able to exclude the various other forms of deUriunr which I have enumerated. The liistory, and the absence of certain obvious phenomena, wUl denote that it is neither ery- sipelatous nor typhoid, nor pneumonic nor rheumatic; and the absence of certain other symptoms, as pain in the head, sickness, sluggish pulse, and the non-existence of the tendency to coma, will point out that the symptoms are not due to inflammation of the brain or its membranes. Then you must satisfy yourselves that it is not deh- rium tremens; in which you will again de- rive much aid from the history of the ^ja- tient, and from ascertaining whether he has been intemperate in his habits or not; also from the absence or presence of the peculiar tremor in the voluntary actions, and from the chai’acter of the defrrium, which in de- lirium tremens is generally of the busy kind. You will further inquire whether the pa- tient’s dehriiim may not be of the hysterical kind, to which I referred m a former lectm-e; whether he had not subjected himself to ex- hausting influences, sexual or otherwise, and 80 given rise to the delirious state. Having thus determined that the deli- rium rmder wliich your patient labom’s is not to be referred to any one of these varie- ties, it is highly probable that it must be ©f the epileptic kind ; and you must now look for some positive signs to prove that it is so. The aspect of the patient will aSbrd some help : there is, in these cases, a pecu- liar haggard, wearied aspect of the comite- nance, with dilated pupils, wliich should always excite your suspicions as to the epi- leptic nature of the disease. The character of the delirium is also to be taken into ac- comit; it is almost always of the noisy and violent kind; the patient is uproarious, to use a common expression, wakeful and talkative. Then, if previously the patient have suSered from regular epileptic paroxysms; if the delirium have been ushered in with a fit; if epilepsy be distmctly a feature of his family history; if the convulsive fit have occurred in the course of the paroxysm of delirium,—any or all of these pouits will as- sist you greatly in detenninmg the epilep- tic character of the delirium. What, then, is the appropriate treatment for a case of cpUcptic dehrium ? Have wo any royal road to cut short the paroxysm, and bring the patient quickly to his senses f I fear that we can no more cut short tliis maniacal ]jaroxysm, than we can cut short the convulsive lit of epilepsy. Indeed, tlie paroxysm of dehrium may be looked upon as a prolonged epileptic fit. It is a fit in which the disturbance of cerebral nutrition is mainly limited to the convolu- tio7is of the bram. In the ordinary con- vulsive fit, the parts of tlio brain wliich im; affected are probably the tubcrcula qua- drigemina and tlie hemispheres : in tlie de- lu'ious fit, without coJivulnions, the latter parts alone arc aflected. In some of tlie milder cases of epile^atie disease we see this isolation of the mental affection and of the convulsive very conspicuously. Thus, we obseiwe ui some cases that the parox- ysm consists only in a momentary loss of consciousness, from which the patient instantaneously recovers ; while in others it consists of sudden convulsive starts affect- ing the upper or lower exti’cmities or both, and which, when the latter are affected, are sometimes so severe as to throw the patient down. Yet m many of these the patient retains liis consciousness perfectly undis- tm'bed. You have examples of both of these states nowin the hospital; one inSutherland ward, in the man whose skin was darkened by a course of nitrate of silver, which he took before his admission. This man has the smaller fits of loss of consciousness, mo- mentary faintings, of wliichhewiUsometimes have several in the com’se of the day. The other case is a lad of Jewish parents, who has the convulsive startings to a very great ex- tent, sometimes fifteen or twenty times a day, and frequently with great violence; but he assures us that never, in even the most severe of them, by which he is thrown down with violence, does he lose his consciousness. This lad, however, has also the regidar and fully developed fits, but not more frequently tliau once in tluee or four weeks. It is not, then, unreasonable to suppose that if you may have a short and very tem- porary affection ofthe intelleet and conscious- ness, you may also have a prolonged affection of them, constituting the epileptic delirium, which may be ushered in by a regular fit, or which may be detennined by a regidar fit. Now I apprehend that no one, now-a-days, will pretend that we have as yet discovered any mode of cutting short the ordinai'y epi- leptic convulsive paroxysm. Many means for this pm’pose liave been proposed; sucli as putting salt in the mouth, pressure on the carotids, bleeding, splashing with cold water, but none have been followed with any degree of success which justifies us in adopting them. I do not say that you may 7iot, if you fancy, try the more hai’mlcss of fhem, such as the salt, and the cold water ; but anythuig which interferes with the eh-](https://iiif.wellcomecollection.org/image/b21955566_0070.jp2/full/800%2C/0/default.jpg)
