(b) The vessel may be underrun on either side of the bleeding-point.
(c) The vessel may be seized with artery forceps and twisted.
(d) The hæmorrhage may be arrested by means of gauze plugs.
(e) The foramen spinosum may be occluded with bone or wooden pegs.
(f) The common or external carotid arteries may be ligatured.
Every effort should be made to control the hæmorrhage by means of ligature, silver clip, underrunning, or torsion. Gauze plugs may usually be relied on to stop the bleeding, but they possess the great disadvantage of exercising pressure on the cortex and preventing expansion of the brain.
Occlusion of the foramen spinosum and ligature of the carotid arteries complicate and prolong the operation. The foramen spinosum is occluded in the following manner: the dura mater is quickly stripped up with the fingers away from the base of the skull, the soft parts gently but firmly retracted and the foramen identified. Its occlusion may be effected by means of a sterilized wooden match or bone peg, by a small piece of bone derived from those osseous fragments which have been removed during the operation, or with the aid of a piece of catgut; in each case the occluding medium should be well driven into the foramen.
It is open to doubt whether ligature of the carotid arteries is ever necessary, though several cases have been recorded in which such a procedure was carried out. The external carotid should be tied in preference to the common vessel, further interference with the blood-supply of the brain increasing necessarily the risk of cerebral œdema, &c.
The hæmorrhage having been arrested by one or other of these methods, the cavity is thoroughly washed out with hot saline solution and drained, a small rubber drainage-tube being brought out through the scalp-flap. The tube should be removed after twenty-four to thirty-six hours, according to the circumstances of the case.