The dura mater was thickened, luit entire, and adherent at tinplace of wound. The other brain-coverings were highly inflamed, and sero-purulent effusion existed bei th'-ni. A small abscess was found in the substai n. e Itrain. immediately below the place of injury, and d this, but separated frin it by a thin partition of, was a larger abscess in the anterior of the brain, whieh communicated with the lateral ricle of the left side. The small abscess had a distinet sae. luit the larger one had not. Dr. Taylor, who repor ase, adds, "these collections of pus mi.uht n of some standing, yet the patient had not a \ty hours before death." It is very possible that dissipation after dismissal occasioned the sad and fatal result.
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His 1> i dly grew worse. The wound, now dry and unhealthy, gave out but a slight gleety discharge. He made many attempts to vomit, which was encouraged by an emetic. His pupils became widely dilated, but remained sensible to the action of light. A fortnight after the setting in of these symptoms, he was found to be hemiplegic on the left side. I saw him at this period for the first time.
His respiration was sighing, and numbered twenty-two in the minute. His pulse was ninety, and contracted. His mouth and tongue were drawn to the right side. He was sensible when roused, but lay in a half state of sopor when not addressed. The next day the trephine was applied to the seat of injury, and the depressed bone removed or elevated. The dura mater was covered by a pulpy mass of lymph. No pus was found. Some spiculae of the inner table which lay on the dura mater were withdrawn. His symptoms in no way improved. His tongue was next day drawn to the left side, but his mouth was unaffected. He had several severe convulsions over both sides of his body, and he died two days after being trephined.
The skull was found fractured across the sagittal suture into both parietal bones. The dura mater was little detached round the seat of injury; but it was there dark and pulpy, having a semiorganized clot on its surface. The brain was softened at the place of injury, and had a clot as large as a walnut lying on it; while at two points on the opposite Of THE '2< ' spin iv, at the edge of the longitudinal fissure, soft spots t'.nind, about as larire as a sixpence. Pus existed abundantlv below tin- membranes, and bathed tli- ri-ht hemisphere, as well as extended to the base of the brain, between the hemispheres and under the. belliun.
The neglect as to diet and the maintenance of the secretions, wen probably the causes of death in the above case. It is certainly not always easy to maintain as careful a supervision on these points as is necessary. when n< i functional disturbaiiee whatever is present, and the injury seemingly slight; but this is only one of many examples which iniirht be addueed to show the ssity of the long and careful watching which sueh require. e above was one of the only two instances in which the trephine was employed in the general hospital, and both ended fatally. In the other case, it was used by one of my colleagues for signs of compression setting in early, with h..ne much and extensively depressed.