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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![should not this be tlio case with tlic more prolonged cases, in which the stunning cirects of tlie injury last considerably longer? Indeed, I do not know why it should not; and I beUeve that in the gi-eat majority of cases tliis state of coma passes off spontaneously, just as it does in the shghter cases. ili'c we, then, in cases of concussion of tlie brain, to content om’selves with looking on, and to do nothing ? I beheve that the opinion is rapidly gaining ground tliat this expectant method,—this system of non- mterference,—is the best. TJiion this point, howener, I speak with diffidence, and must refer you to tlie great surgical authorities. I shall only add, that most of those witli whom I have conversed on this subject have expressed themselves most favoiu’able to tins plan. Among them I may espe- cially refer to my friend and neighbour Mr. Brausby Cooper, wliose large experi- ence at Guy’s Hospital entitles Iris opinion to great weight. In conversation upon this subject, he hkened tire state of coma after concussion to a state of sleep which has a distinctly reparative object and effect. Most of you will remember the case of a woman who was thrown from a window by lier liusband, not long ago admitted into one of the sru-gical wards. Tliis wonran had very decided traumatic coma. At fu’st it was thought that some depression of bone had taken ])lace; but it was soon foimd that the injury was limited to the external table of the skull. Tliis patient recovered comjiletely and most satisfacto- rily under a trcafuient which was mainly of the expectant kind. Then do I advise you absolutely to do nothing in these cases ? My advice is, to attend to the functions,—reheve the bowels by mild means, support the system with- out stimidatiug the patient, imless great debility calls for more active support; and, that you may not appear to the friends of tho patient to be absolutely inactive, shave the head, apply cold to it, or, if there be no contra-uidication, apply a small blis- ter now and then. Formerly all these patients used to be bled, almost as a matter of coimse, and with the view of anticipating the inflam- mation which it was expected woidd follow upon reaction after the shock. But this idea of inflammation foUoiidng reaction rests upon no good ground: it was sug- gested by the occasional occurrence of de- lirium after this form of coma, the delu’ium being supposed to indicate a state of in- flammation. Wo now, know, however, that delirium is by no means a certain indi- cation of inflammation within the cranium, and more especially delirium arising out of coma. Dehrium passing into coma would be a more likely indication of an inflamma- tory affection. You will ask, are there no circumstances which justify bleeding in cases of trau- matic delirium ? I cannot take upon my- self to answer this question in the nega- tive. I do, however, say that it appears to me a very unmeaning practice to bleed in anticipation 0/inflammation ; and that you shoidd wait for some decided symptom, some good evidence of inflammation or of congestion, before you subject yom- pa- tient to the risks wliich arise out of the loss of blood. Treatment of epileptic coma.—The epi- leptic coma is the most common form of coma we meet ndth; and here, like- Avise, the expectant mode of treatment, with moderate purging, answers better than any other. This condition presents many analogies to the traumatic coma. The brain experiences a shock from the epileptic discharge. The shock is generally followed by a longer or shorter sleep, from wliicli the patient awakes up relieved, and often Avith no other sjaiiptom than a feehng of exhaustion. We do not find that anytliing euts short the attack. Bleeding depresses the heart’s action, and is favourable to the development of tho epileptic state, and therefore it caimot tend to cut short the coma. Epileptic coma, like traumatic coma, may go on for a very considerable time, and yet the patient Avill perfectly recover. As an instance of this kind I aatII refer to the case of Eliza Wilhams, a girl of 13 or 14 years of age, who was admitted into Augusta Avard on the 26th of March last, m a state of profound insensibility, which con- tinued till the 30th, a period of four days, and for a week afterwards in a less profound degree. In tliis case the treatment was of tho expectant kuid. We kept this patient’s bowels open, and attended to her general nutrition, taking care to avoid any causes AA’liieh might operate injmiously on her. She recovered perfectly; had several epi- leptic fits afterwards, with coma of very short duration, and left the hospital much improved in her general condition. There are, however, cases of coma in wliich more active treatment than tliis is reqimed ; as, for instance, in cases of coma aiasuig from rheumatic fever, gout, or scar- let fever, or in coma arising from poisonuig by urea, in diseased states of the kidney. In such cases it is vei-y necessary to do something more than watch; your treat- ment must bo of the eliminating kind, such as blistering and pinging; at tho same time, it is necessary to uphold the](https://iiif.wellcomecollection.org/image/b21955566_0073.jp2/full/800%2C/0/default.jpg)
