After the completion of the operation, the scalp-flap is approximated and sewn into position, first by numerous buried fine silk sutures bringing together the aponeurotic layer of the scalp, and finally by a few silk or salmon-gut sutures passed through the skin itself. Gauze dressings are applied, the tourniquet loosened, and a roll-gauze bandage quickly applied circumferentially around the head, low down over the forehead and occipital region. This roll bandage in reality takes the place of the tourniquet, but is, of course, applied with moderate pressure only.
If the wool and bandage now applied over all should include the ears, these two organs should be well covered with vaseline. Few things are more uncomfortable to the patient than the contact of wool and bandage to the ears.
The tourniquet should be utilized whenever possible. In operations, however, that are conducted near the base of the skull--subtemporal decompression, cerebellar exploration, &c.--the surgeon, in his effort at hæmostasis, must rely on the application of digital pressure on either side of the incision, the more careful exposure of the vessels, and the application of forceps as soon as they are seen or divided, or by the utilization of Vorschütz’s hæmostatic safety-pins.
Other methods of controlling scalp-bleeding are as follows:--
1. Kredel’s hæmostatic sutures, passed with a large curved needle which slides along the bone and emerges about 5 to 7 cm. from the point of introduction. The silk ligatures are then tied over metal plates, so curved as to lie flush with the surface of the skull in the particular region involved. Four of these plates would be used in the formation of an osteoplastic flap, one on the distal side of each of the three scalp incisions, and one along the base of the flap.
2. The enclosure of the proposed incision by a running suture which, passing down to the bone, emerges about 1 inch further on, then so to speak repeating itself in part until the whole region is surrounded. The ligatures are then tightened up. This method takes some time in its application, and presents no advantages over the scalp-tourniquet.
3. The blocking of the main arterial supply--temporal, occipital, and supra-orbital vessels--by modified safety-pins, mass ligatures, &c. Arterial compression by means of the modified safety-pin as suggested by Vorschütz will be found most useful in those operations in which the scalp-tourniquet cannot be utilized--subtemporal decompression, &c.