[Illustration: FIG. 5. THE SCALP-TOURNIQUET. _Back View._] There is one other exception to the satisfactory working of the scalp-tourniquet. In the presence of a superficial cerebral tumour, especially when of a malignant nature, the normal communication between the intra- and extra-cranial vascular systems may be so exaggerated that those scalp-vessels which receive diploic and emissary venous communications will give rise to some trouble. This difficulty should be overcome--not by rapidity in the formation and turning down of the flap--but by clipping each vessel as exposed or divided, by the application of pressure and by foraminal occlusion (see also p. 17). I found Cushing’s tourniquet rather inconvenient in its application, and, after various modifications, am accustomed to use the one depicted in the illustration. It consists of two flat metal bands connected posteriorly by a strong rubber connecting link, the two bands passing in front through a metal fixation piece possessing a screw which, when tightened up, allows of the maintenance of the desired pressure. The median tape, previously mentioned, helps to keep the tourniquet in position. The tourniquet is applied as follows: the whole head is enveloped in gauze--two or three layers thick, and cut to the size and shape of a large handkerchief. The tourniquet is slipped over the head, as low down as possible, and then tightened up. The median tape, having a loop behind through which the tourniquet passes, is laid in the middle line and tied round the screw on the fixation piece. The gauze should then be moistened with saline solution or some mild antiseptic, so that it clings tightly to the underlying scalp and becomes sufficiently translucent to allow of the recognition of any underlying landmarks that may have been previously mapped out with the scalpel, iodine, silver nitrate, or aniline pencil. The scalp-flap is then framed by incisions carried down to the bone, through gauze and scalp, in one sweep. The flap is turned down and covered with gauze. By the adoption of this method hæmorrhage from scalp-vessels is efficiently controlled and the risk of wound infection is reduced to a minimum. 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.