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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![in tlio ih'st hiEitnnco, Uiut it is not coimi I'roin pressure, anil llmt it is not t-onm from inlhimmatiou of the brain. 1 need not dwell here npon the 8ym])toms of in- tlannnation of the brain, as I have already sulUciently discussed that sidjject in a former lecture; but I shall make a few remarks as to the diagnosis of the coma which is brought on by elfusion of blood within the cranium. This diagnosis is by no means always easy : ndtli the greatest precautions, you will now and then find yourselves mis- taken,— so closely do the symptoms of one kind of coma often resemble those of another. The points to which you must look are— 1st. The histoiy of the case. 2d. The mode of accession of the coma. 3d. The state of the pupils. 4th. The existence of a paralytic state. In most cases of apoplectic coma there have generally been some threatenings beforehand ; such as pain or uneasiness in the head, giddiness, muscse vohtantes, thanitus aurimn, or other subjective phe- nomena of the senses. You will be parti- cidar to inquire about these points. The coma of apoplectic effusions always comes on more or less suddenly. The sudden supervention of coma m a man previously healthy affords a strong presiunption in favour of the apoplectic natm’e of the coma; and this is especially the case when there have been no convulsions, no mental excitement or emotion, previous to the attack, and when epilepsy does not appear in his history. A dilated state of the pupils generally accompanies the apoplectic coma ; but as this is very common, even to a greater extent, in epileptic coma, it gives us no efficient aid in the diagnosis. Wlicn, however, one pupil is dilated, and the other natimal or contracted, we may have sti’ong suspicions of injiu'y of the bram. This is especially the case if the coma be accompanied or preceded by para- lysis of one side of the body. Wlien the apoplectic effusion takes place hi the vichuty of the tim'd pair of nerves, tearhig up the brain more or less, a highly contracted state of the pupils is apt to take place. The sudden occurrence of a hemiplegic paralysis simultaneously with the state of coma affords a strong indication that the cause is an apoplectic effusion. Even with this symiitom, however, you will occa- sionally be deceived. In the Lumleian Lectures I referred to a case of this kind, m which there were sudden hemiplegia and profound coma, and after death 1 was unable to find a clot in the brain. In invcstigathig cases of coma you must be most careful to imiuirc into the state of the renal and hejiatic secretions. When cither the liver or the kidneys fail, the pa- tient becomes comatose. The fiver may fail cither from actual non-elimination,— the elements of the bile remaining ui the blood,—the liver having lost its power of attracting them out of it,—or there may be some mechanical hnpediment to the How of the bde, eit her in disease of the ducts them- selves with in the fiver, or hi some stop- page of the hepatic or common ducts out- side the fiver. The hepatic derangement shows itself plainly enough in the jaundiced state of the patient. When the kidney is at fault I need not tell you that you will find the evidence of it in a careful chemical microscopical mvestigation of the urine. The former liistoiy of the patient affords the most valuable and important guidance in the diagnosis of the various forms of coma- tose affections. You must inquh'e into the state of the patient previous to the occur- rence of the coma, and must consider whether he has been the subject of epilepsy, , gout, rheumatism, hysteria, or renal disease, as the coma may arise from any of these conditions. You should also mquh'o into the previous habits of your patient, as to intemperance, takhig opium, &c., as coma may arise from the presence of opium or of alcohol hi the system. You must, then, before you fix upon yom' fine of treatment, be satisfied that the coma is not apoplectic,—that is, fi-om pressin'e ; and also that it is not due to the presence of opium or of alcohol in the system. ^ Excluding these, the coma may be trau- matic, fi’om shock, producing sunple con- cussion of the bram, or it may be epileptic, or renal epileptic, or hysterical, or rheu- matic, or gouty. I shall not dwell upon the diagnosis of these forms of coma from each other, but proceed to refer briefly to the treatment of each. First, then, as to the traumatic coma. Tliis is that state wliich surgeons describe under the name of concussion of the brahi. We have unquestionable evidence that it is not a state of inflammation, or of active disease of any kind, but simpl}' one of sus- pension of the powers of the brain due to the shock occasioned by the nijiuy. We do not know exactly what the precise condition of brain is in this traumatic coma. It is, how- ever, a state analogous to that of sleep, in which the natural actions of the brain are depressed rather than exalted : to use an expression borrowed from the Stock Ex- change, they are below par. In the milder cases, as when a patient is simply stunned, recovery takes jilace quickly and perfectly without any medical nitcrfcrcncc. A\ by](https://iiif.wellcomecollection.org/image/b21955566_0072.jp2/full/800%2C/0/default.jpg)
