_The treatment of the fracture and of the dural rent._ A scalp-flap is framed, suited to the occasion and formed with due regard to existent scalp laceration. The fracture being fully exposed, depressed or comminuted fragments of bone are elevated or removed. Complete exposure of the sinus-wall, both in front and behind the site of laceration, is required, and for this purpose the craniectomy forceps may be called into requisition. In the event of copious bleeding during these procedures, strips of gauze should be inserted on either side of the sinus rent between the dura and the bone, thus compressing the sinus and stopping the bleeding. The sinus rent may be treated after one or other of the following methods:-- 1. It may be sewn up with mattress sutures of fine catgut, by which means it may be possible to stop the hæmorrhage without interfering with the sinus blood-stream. 2. The open mouth of the sinus may be puckered up by means of a purse-string suture. 3. The needle may be passed right round the sinus on either side of the rent, piercing the falx cerebri in the case of the superior longitudinal sinus and the tentorium cerebelli in wounds of the lateral sinus. The two ligatures are then tightened up and the bleeding controlled. 4. The gauze plugs (see above) may be allowed to remain for twenty-four hours or more, and then carefully withdrawn. _The treatment of the subdural hæmorrhage._ Though the complete evacuation of the clot is seldom practicable, much may be done to remedy the condition. The tenseness of the dura mater, the absence of pulsation, and the peculiar plum-colour imparted to that membrane by the presence of underlying blood-clot point to the nature of the trouble. The dura mater is incised and the presenting clot removed, as far as circumstances permit, with the aid of a spoon and irrigation (hot saline solution at a temperature between 110° and 115° Fahrenheit). Free drainage must be supplied, and it is necessary, therefore, that a counter incision should be made at the most dependent part of the clot. A suitable region may present itself if the bone be extensively comminuted. Under other circumstances, a narrow channel may be cut in the bone, prolonged in the downward direction, till the lower limits of the clot have been reached (see Fig. 56). [Illustration: FIG. 56A. THE OPERATIVE TREATMENT OF SUBDURAL HÆMORRHAGE. _First stage._ The skull has been trephined over the upper part of the clot and the bone cut away in the downward direction in order to reach the lower limits thereof. The dura mater has been incised, crucially in the upper part and vertically in the lower part.] [Illustration: FIG. 56B. THE OPERATIVE TREATMENT OF SUBDURAL HÆMORRHAGE. _Second stage._ The clot has been removed and the dura mater sewn up. A drainage tube has been inserted so as to drain the subdural region through the lower part of the scalp-flap.]