In the event of failure to find pus at the first attempt, the evacuator is withdrawn, introduced at the same site, but now passed in other directions--directly inwards, slightly upwards, and finally, slightly backwards, in each case for not more than 1¹⁄₂ inches.
By wide separation of the blades of the evacuator the pus is allowed to escape, to be immediately wiped away by the assistant. Irrigation of the cavity should never be attempted, not so much because of the difficulties attendant on that process, but because of the danger of infecting the neighbouring meningeal regions.
Previous to withdrawal of the evacuator, a small rubber or cigarette drainage-tube is introduced, projecting into the abscess cavity at the one end, and brought out through the scalp-flap at the other. It is advisable to stitch the tube in position.
The dural flaps are replaced in their proper position, but no attempt is made at sewing them together. The scalp-flap is sutured with the aid of a few salmon-gut stitches and the dressings applied. The tube may be shortened daily, and dispensed with after seven to ten days, according to the progress of the case.
_Trephining for cerebellar abscess._ The abscess usually occupies the antero-external aspect of the lateral lobe of the cerebellum. It can be drained with advantage below the level of the lateral sinus and behind the posterior border of the mastoid process.
The patient should be in the semi-prone position, the head as forwardly flexed as the administration of the anæsthetic allows.
The incision starts below the external occipital protuberance, and, following the line of the occipital crest, curves downwards along the posterior border of the mastoid process, terminating at the apex of that prominence. The cutaneo-muscular flap is turned down, every precaution being taken to diminish hæmorrhage, insomuch as severe bleeding may take place from occipital vessels, and from the mastoid and other emissary veins. Hæmorrhage from the former source is controlled with forceps, that from the emissary veins by the introduction of the end of a blunt probe into the orifice of the foramen. More permanent occlusion can be obtained by plugging the foramen with catgut, with a sterilized wooden match, or by means of special ivory, bone, and wooden pegs.