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lated with the weak solution of the nitrateof silver, and the compound calomel pillswere ordered to he repeated.

Srd day. Both ulcers on the orifice ofthe prepuce have acquired a red margin.The groin is well. The ulcers on thecommon skin of the penis are healingrapidly. The treatment of the precedingday was continued.

5th day. Sores at the orifice of penisgreatly diminished in size. Those on

the outside of penis healing rapidly; groinwell; mouth not sore. :Same treatmentcontinued.

i tli day. Sores at the orifice of the pre-puce much less; those on the common skinof the penis nearly healed ; mouth notsore. The pills and solution of the nitrateof silver repeated. ,

9th day. Ulcers on the common skin ofthe penis healed. Those at the orifice ofprepuce nearly the same as at last report.The pills repeated. I12th day. The sores at the orifice of the

:prepuce healed, and this covering is muchmore relaxed than at last report; mouthslightly sore. The pills repeated.

Remarks.—When primary syphilis isseated at the orifice of the prepuce, its ci-catrization is always slow when the ulceris left to unassisted nature. This iscaused partly by the stream of urine irri-tating the sore, and partly by the pres-sure which urining requires, tearing openthe ulcers in such a manner as preventstheir healing. Notwithstanding theseopposing circumstances, however, theamendment in this case was particularlyrapid. It is also to be observed, that thecontraction of the orifice of the prepuce,which is always found when ulcers takeplace in this situation, in place of beingmore permanent than if the ulcer had notbeen treated with caustic, relaxed withmuch more rapidity than would have been.expected by those who have not witnessedthe action of the nitrate of silver in thesecases. ,

In conclusion, to-day, let me observe,that there are many circumstances con-nected with the cases which we have con-sidered in this lecture to which it is de- Isirable that I should revert on anotheroccasion.

WHOOPING-COUGH.—Dr. Saudras says,that one of the surest therapeutic meansagainst whooping-cough, is change of airand place of habitation. It is the first

thing he recommends, and considers him-self authorized to do so from experience.When this is impracticable, he makes useof the belladonna, the root of which mayhe taken in powder without offence to thetaste.—Bul, Therap.

CLINICAL LECTURE

BY

MR. BRODIE,Delivered at St. George’s Hospital.

CONCUSSION OF THE BRAIN.—ERYSIPELAS.

- DEATH.

GENTLEMEN, - Thomas Turnham, ex-

coachman to the Duke of Wellington, aet. 45,was bronght to the hospital Dec. 7th, 1833,at half-past 1 p.m., having received a se-vere blow over the region of the left tem-poral bone and orbit, from falling whilstexercising some horses in Hyde-park.When admitted he was insensible and

breathed laboriously, and there was a

severe contusion over the left eyelid. Hespat up a small quantity of blood uponbeing placed in bed, and was immediatelybled by the house-surgeon, and purged! with calomel and Dover’s powder, and hada senna draught administered to him somehours afterwards. A cold lotion was

ordered to be kept constantly applied overthe contused eyelid and neighbouringparts.

3 Dec. !J. Insensible; very restless all lastnight, drowsy, tosses about a good deal inbed. The contusion of the left eyelid hasextended, and is swelled and puffy; great

! redness over it, but hardly amounting to; erysipelas, having more the appearance ofdiffused phlegmon. Pulse 110, regular,and compressible ; skin hot and feverish;bowels open. The prognosis of the casewas now unfavourable, from the patient’sgross habit of body. He was ordered to takethe Haustus Salinæ with Vinum Antimonii.The Decoctum Cydoniæ to be applied to the

parts instead of the cold lotion.Eight vespere. The appearance of the

contused parts has now assumed that of, erysipelas ; the redness has extended ;pulse quick; very restless, tossing con-stantly in bed.

Dec. 10. The puffy swelling and erysi-pelatous redness of the left eyelid haveextended over the cheek of the same side ;the right eyelid was also swelled and cede-matous, and closed up by a dark blush oferysipelatous inflammation, extendingdow-nwards and inwards towards the nose,and outwards over the malar bone; pulse98, and compressible. He has taken a doseof house-physic, and the Decoctum Cydoniœis applied as a lotion to the parts.

Vespere. Very restless, can hardly bekept in bed; pulse 120, full and bounding.

Dec. 11. He remained much in the same

state as yesterday. To-day I saw him and

punctured the erysipelatous surface of the

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left side of the face with a lancet; thepunctures bled freely, and appeared to givethe patient much relief. He was orderedHazrst. Salin. effervesc. c. Carbon. Ammon.,gr. iv in excess.

Vespere. Much the same; restlessnesssomewhat less.

Dec. 12. Appears better; is more scn-sible ; bowels open ; understands what issaid to him; pulse 110, and full. The

house-surgeon ordered him port-winc,which I countermanded, prescribing beef-tea instead. ’

Vesper-e. Very restless and irritable;pulse 120, and small. The house-surgeonordered him port-wine in addition to thebeef-tea.

Dec. 13. He died at half-past eight a.m.this day.Autopsy ei,glat hours after death.—On

separating the cranium from the mem-branes beneath, no paiticular abnormalappearances were presented. On remov-

ing them the superior surface of the cere-brum was tinged, by the fulness of thevessels in the cerebral convolutions. In

slicing off the upper surface of the brain, itappeared of a natural consistence; thelateral ventricles were filled with serum,each containing about ij. The cerebellum, ipons varolii, pons olivare, &c., were firmer iand paler than natural. A quantity offluid was effused at the base of the brain,and pus was found in the orbit of the left

eye. The lungs were somewhat engorged,and small in volume. The stomach, live:’,and other abdominal viscera, were healthy,hut loaded with fat. I.This man, Gentlemen, came into the

hospital seven davs since, having fallen onthe left side of his head. On admissionthe general symptoms of concussion werepresent; those of compression were notso well marked, the stertor in breathingbeing very slight. The blush of erysipelaswhich appeared on the left side of the face,three days after admission, was over thepart where he received the blow. The

symptoms of concussion never entirelyleft him, and he could with difficulty beroused from his state of stupor. No veryparticular morbid appearances are dis-

cernible, and, judging from the case alto-gether, I should say that the man diedfrom inflammation of the brain, as the con-sequence of concussion. You know wefrequently meet with cases of concussionwhich end fatally from inflammation ofthe brain, within 48 hours after the re-

ceipt of the injury,—before even there istime for effusion to come on. In order toexplain the nature of this case clearly toyou, I must speak of the injuries done tothe brain under two distinct heads,—theone where there is an external wound of

the scalp,—the other where no external: wound exists. In this case there was no. external wound unless you can call the

; slight graze on his temple a wound. Wherethere is no wound, the case is called one

of " contusion,"-and the effects following: a contusion are either concussion or com-

pression, and these latter are the causesof all the symptoms which follow a con.tusion. Compression implies the fact ofpressure existing on the brain from some

i cause,-a portion of depressed hone, or therupture of a hloodvessel within the sub-stance of the brain or on the dura mater.Inflammation of the hrain, or a tumourwithin the cranium, may cause pressurein the same manner. Where there is con-

cussion, tlfe animal and sensorial functionsare greatly disturbed by the shocle, thoughafter death no particular morbid appear-

ance may he discoverable; but the softnervous texture of the hrain is so minute

that its lesion may baffle our closest ob.I scrvation.

But to which of these two divisions didthis case belong, compression or coiieus.sion ? The disturbance of the vital func-tions would lead me to pronounce it to be acase of compression rather than of concus-sion. If a patient receive a blow, andrecover from it after a short time, thecase is a simple one of concussion, but ifthe syirptoms he of a grave nature, andlast for a considerable time,-if there beiiisensibility, with complete or partial pa-ralysis of the limbs,-if the pupils he

dilated, and the breathing laboured andstertorous, you may generally concludethat these symptoms result from pres-sure.

But there are intermediate cases be-tween concussion and compression. Aper-son mav receive a blow, which may befollowed hy stertorous breathing and di.lated pupils, from which he may soon re-cover, and these may be caused by a slightdegree of extravasation internally, withoutany very great loss of motion or sensation,and symptoms such as these may be re-ferred generally to compression. The

symptoms attending concussion wouldhave been slighter even than these, andit may be as well here to point out to youthe general diagnostic marks attendingthe two states of compression and con-

cussion. In concussion, then, there is a

slight degree of insensibility, from whichthe patient may be, in some measure,roused; the pupils are at first dilated, andthen contracted; there is no paralysis ofthe limbs, or stertorous breathing; or ifthis latter symptom be present, it exists

only for a very short time. In compres-sion there are insensibility and paralysis;stertorous breathing, and dilated pupil,

591

which is not influenced by the light. Ifthe pupil be either dilated or contracted,it will remain permanently so. Sometimesthe pupil of one eye will be contracted,and the other dilated. When there is anyextravasation on the brain, there is slightdelirium or convulsive action of the mtis-cles, sometimes lasting for one or two

hours, which will frequently occur, if theextravasation be only so slight as not evento produce pressure. The symptoms inTurnham’s case were dependent on con-cussionor slight compression—those whichgenerally attend upon concussion, but theylasted longer than is usual in such cases.The post-mortem examination showed theearly symptoms of the case to be depend-ent upon concussion. He was very pro- fperly bled on the spot where the accident

Itoccurred. It sometimes happens that,after concussion, the heart’s action will lfail, and syncope will come on ; and when I

the pulse rises, you should bleed the ha,- Itient. If in collapse, do not wait until

complete reaction is established before youbleed, but do it at once, for the brain can-not hear the pressure of the blood upon it,and the blow may have ruptured a ves-sel ; and if reaction is completely esta-lilished, the vessel may again pour out (hIood. In these cases, as Mr. POTT veryproperly observes, you first have concus- Ision and then compression. If you do notbleed when the pulse rises, compressionwill, of course, come on; and if you dobleed, you will enable the patient to bearthe injury better, and to recover from theeffects of it sooner. This patient was also ibled on the day after the accident, as hehad not recovered from the .effects of theconcussion. I believe the patient may re-cover his senses sooner if he be bled, buttime does much in all cases of this kind,and bleeding is proper also, in order thatthe patient may better meet the attack ofinflammation of the brain, which is so fre-quent a sequel of concussion. Thus Ihave given you three good reasons for

bleeding in all such cases. In recom-

mending bleeding, I do not advise you toremove large quantities, for you cannot

by so doing prevent inflammation of thebrain. It will come on do what you will,and will continue for a certain time, andrun a certain course, which you cannot Istop or check, and all that you can do isto conduct it to a favourable termination.If you take large quantities of blood fromthe patient, he will not be so well able tobear the inflammation, for you cannot bleedhim largely when the inflammation is oncefairly established. In cases of this kind,therefore, remove small quanttties at atime, watch the patient narrowly, and ifthe pulse rise, take away Hve, eight, or

! ten ounces, at a time, according to thesymptoms. Get the bowels well opened,and give the patient such purgative medi-cines as will induce watery evacuationsfrom the mucous membrane of the intes-tines, and thus determine blood to themfrom the brain.

The inflammation of the eyelid in thiscase difl’ered from the common erysipela-tous inflammation, inasmuch as it was notushered in by any shivering, and present-ed no defined margin of redness on theskin. The redness here was more likelyto arise from diffuse cellular inflanitna-tion, as the man was of a large gross ha.bit, and bad constitution,-altogether a

bad subject for such an accident. lIe hadalso a frequent small, feeble, pulse, which

prevented the exhibition of remedies pro-per for the affection of the head.

We are led to the conclusion that thesymptoms depended upon concussion.There was serum found in the base of thebrain, and also in the ventricles, conse-quent upon concussion, inflammation, andeffusion. Many of the symptoms of theexternal affection depended upon the effu-

sion of p-is into the orbit of the eye underthe scalp and occipito-frontalis muscle.Concussion of the brain is not necessarilyfatal. The greater number of cases re-cover, but not without inflammation of thebrain or its membranes supervening,which is not after all very severe. It ge-nerally comes on two or three days afterthe accident, with pain in the’head, hotskin, frequent pulse, the insensibilitychanging to delirium,—the blood, whendrawn, exhibiting the inflammatory crust.The symptoms may continue ft cm two or

three days to a week or a fortnight, duringwhich time the patient may require bleed-ing, purging, and starvation. But everynow and then, in spite of the most activetreatment, effusion will take place. If the

patient die soon, you will find only a

slight degree of effusion in the ventriclesand cells between the membranes of thearachnoid and pia mater. If he bear upfor a longer period, pus will be mixedwith the serum in the ventricles, andsmeared over the membrane of the arach-

noid. Under these circumstances the in-flammation frequently kills in a shorttime. Sometimes the inflammation willbe so intense as to exhaust the energies oflife even before there is time for effusionto come on. Of this I have seen a fewexamples.