The following is a good example of a puffy tumour on the scalp, with inflammation and commencing suppuration, causing symptoms of compression, which were relieved by operation: No. 2901. Fracture of skull.-Private John Evans, æt. 25, wounded 16th April, 1855. 20th April admitted into Castle Hospital, Balaklava. Says he was blown up in a magazine in the trenches, and lay insensible for some time; received three small lacerated wounds on the left side of the head. Complained of headache and slight febrile symptoms for a few days. The wounds had healed up, and he walked about apparently well. May 14th and 15th.-He remained in bed complaining of violent pain in the head, was very drowsy and stupidlooking, and with difficulty could be got to speak to any one. 16th.-Lies in a semi-comatose state, with eyelids half closed, but is sensible when roused, and answers questions in monosyllables. Says the pain is greater and of a tight kind; right side of the face distorted and angle of the mouth drawn downwards; brows knit; pulse quick and hard; skin hot. On examining his head there appeared a small tumour, with distinct feel of fluctuation in the neighbourhood of one of the wounds; presented all the characteristics of Potts' puffy tumours. On making an incision, the pericranium was found separated by thin sanious discharge from a depressed fracture of the left parietal bone. By means of Hay's saw I was able to remove pieces of depressed bone and elevate others. The fracture was such as would be produced by a ball. The dura mater looked inflamed, and was coated by a lymph-like matter. The head symptoms gradually disappeared, but a fungus rose from the bottom of the wound. 21st.-Fungus was as large as a good-sized walnut, pulsating strongly, and had a red strawberry look; pledgets of lint soaked in Spt. Vini rect. were kept constantly applied, under the use of which it gradually went down. The wound healed, and he was discharged and sent home for duty on the 5th of July.-Donor, Dr. Jephson, K. D. G.

NECROSIS.

When the pericranium is detached from the bone, necrosis of the whole thickness may take place, and an abscess form

between the bone and dura mater, causing compression of the brain; most frequently, however, the external table only dies and exfoliates, so that separation of the pericranium and necrosis is not a certain indication of the formation of matter between the bone and dura mater. This latter membrane is more vascular than the pericranium, and when the dura mater is detached necrosis is much more likely to occur than when the pericranium alone is separated. When the injury is so severe as to detach both the pericranium and dura mater extravasation takes place, followed by necrosis of the whole thickness of the bone and the formation of matter and also in those cases where the dura mater is separated by itself. Symptoms of compression from the deposition of pus do not take place for days or weeks after the accident, whereas that from the effusion of blood is immediate or almost so. As matter continues to accumulate, the bone becomes necrosed, and, unless evacuated, it causes inflammation and ulteration of the membrane, and substance of the brain, and death. Mr. Pott states that the local signs following a smart blow on the head and attended with languor, pain, restlessness, watching, quick pulse, headache, and slight, irregular shivering, do almost invariably indicate an inflamed dura mater, and pus either forming or formed between it and the cranium.

Cases of compression of the brain from the formation of pus below the bone, requiring the application of the trephine, are of rare occurrence at the present day compared to former years, apparently from the more active antiphlogistic treatment pursued on the first symptoms of inflammation making their appearance; and also, when a patient has received a severe injury of the head, he is carefully watched.

When purulent matter has formed in the substance of the brain, at its base or on its surface operative measures are useless. The diploe, or the veins distributed in it, sometimes inflame and suppurate, and should a fissure exist and matter be discharged in any quantity, it should be evacuated. Inflammation of the veins of the diploe is a very serious disease, on account of the secondary abscesses which frequently form in distant internal organs, such as the liver and lungs, and also from its immediate effects upon the brain itself. It is now

generally supposed that these abscesses are connected with inflammation of the veins.

Mr. Prescott Hewitt states-"It has never fallen to my lot to see a single instance in which the application of the trephine, under such circumstances, had a successful issue. In every case in which I have seen the operation performed, the patient, notwithstanding the evacuation of the matter, has died of diffuse inflammation of the membranes." Still he recommends the use of the trephine, to give the patient the only chance of recovery. "Purulent infection was observed in fourteen out of the twentythree fatal cases of scalp wound; and although developed in other injuries, in none is it more frequently so than in those of the head, and that, too, in cases where the injury has apparently been of a trivial nature."

The well-known fact that this disease is found especially in injuries involving the osseous system will seem to explain the frequency of the development of this most formidable complication in accidents about the head, where the bones are not only abundantly supplied with cancellous tissue, but where are also found venous canals much larger and much more numerous than in any other part of the skeleton. That no cases of this kind should have fallen under Pott's notice is surprising, and the more so as Derault and others were, at about the same period, directing the attention of surgeons to this affection, as one of the most common consequences of injuries of the head. It has been thought by some foreign pathologists that the early application of the trephine made by Pott and other surgeons, in cases of exposed and contused bone, might, in some measure, seem to explain why these practitioners had not met with more cases of purulent infection in injuries of the head. M. Chassaignac, especially, thinks that the removal, by the trephine, of the contused bone before suppuration has taken place in its diploc, destroys the source from whence the secondary mischief is, for the most part, derived; but such an explanation can scarcely be admitted as a valid one; for in many cases of purulent infection after amputation we do not find extensive suppuration in the cancellous tissue of the bone; and also in cases in which suppurative inflammation did not exist in the bone previous to the removal of the limb.

Eleven cases of this description of injury were admitted from India, of whom six were sent to duty and five invalided for other diseases. In all of them, small portions of the external table of the skull came away necrosed. The scalp was not adherent to the bone in any of them.

The brain and meninges appear readily to support loss of bone by caries and necrosis, and to accommodate themselves to a denudation of osseous covering, which takes place gradually, whilst forcible removal by gunshot injury and operation is more generally resented.

The following cases are good examples of this tolerance of loss of bone caused by necrosis. No. 2895.-Three portions of necrosed parietal bone; the sequestræ embrace the entire thickness of the bone. The number of square inches of bone removed is about five and a half inches, and was taken from the superior and posterior angles of both parietal bones (see Plate I, fig. 1), from Thomas Walker, æt. 22, 95th Regiment; total service, five years; was dangerously wounded on the crown of the head at the battle of Inkermann, on the 5th of November, 1854, by a large fragment of a shell, which struck him on the vertex, producing a large lacerated wound, with extensive comminuted fracture of the upper and posterior third of each parietal bone. Immediately on being struck he fell down senseless, but got up again, and walked towards the Russian lines, in a semi-unconscious state, which he had nearly reached when he was perceived by two Bashi Bazouks, who intercepted him and brought him back. On admission into Fort Pitt Hospital the wound presented the following appearances. The two parietal bones were sepa

rated from each other to the distance of more than one inch at their upper border, and fully to the length of the posterior half of the sagittal suture. These borders projected above the scalp, forming a chasm, through which large quantities of purulent matter were pumped out at each pulsation of the brain. At the time of his admission the fragments admitted of only very partial movement, and were much too firmly attached to allow of their removal, but they gradually became sufficiently loosened from the attachment as to admit of this, which was successfully effected under the influence of chloroform. After the removal

of the bones the wound made rapid progress towards cicatrization, the discharge subsided, and the sinuses ceased to pour out purulent matter, while the patient's general health manifestly improved. He was invalided in April, 1855, and was then in pretty good health, and was in good and cheerful spirits; his memory was somewhat impaired, but in other respects he was in possession of all his mental faculties.

The next case is an injury of the left side of the head, two inches above the ear, from a portion of shell. About six months after, a puffy tumour formed, which was accidentally ruptured; necrosis followed; the patient became comatose from the pressure of pus on the brain, but he recovered to a certain extent. Subsequently it was considered necessary to apply the trephine, which gave great relief to the symptoms, with every prospect of perfect recovery. The necrosed portion of bone which was removed almost entirely consisted of the external table, except a small portion, about half an inch in extent, which consisted of both tables, and it is probable that some part of the purulent matter that was discharged when the trephine was applied came from the interior of the cranium, through the aperture thus formed, and also from the diploe. No. 2896.-A large sequestrum, about six inches in diameter, composed almost entirely of the external table of both parietal bones. There are only two small portions which include both tables. There is an opening in the bone, made by the trephine for the evacuation of matter. From Private George Brookland, æt. 29; 23rd Regiment. On the 20th September, 1854, at the battle of the Alma, received a gunshot wound of the neck; in this injury the bullet entered on one side, a little behind the thyroid cartilage, and made its exit on the other, about a corresponding level and position; he was likewise struck on the left side of the head, about two inches above the ear, by a portion of a shell weighing two pounds. On the day following the receipt of the injury he was sent to Scutari Hospital, where he recovered from the gunshot wound, but the injury of the head received no treatment. There was no external scalp wound caused by the injury, but he stated that he was never free from headache, which at times was excruciating. He returned to England in January, 1855, when the pain of the head became