The tube is allowed to remain for thirty-six hours or more, according to the condition of the patient.
The operation may be carried out on one or on both sides of the skull; if on the one side only, on that side at which laceration of the brain is probably existent. In connexion with this it is necessary to state that laceration by contre-coup is more common than direct brain-injury. Thus, if the blow be inflicted on the right parieto-occipital region, the operation should be conducted in the left temporal region.
In the absence of all localizing features the decompression should be carried out on the _right_ side of the head, in order to avoid all possibility of including, in the hernial protrusion that may result, the motor speech area of Broca.
In cases of severe head-injury the surgeon must be prepared for many disappointments, but, from my own experience, it would appear that Cushing’s operation frequently brings about the most satisfactory results.
It should, however, be clearly understood that indiscriminate decompression operations only bring discredit on the method in general. They should only be carried out in suitable cases.
TREATMENT OF FRACTURES OF THE VAULT OF THE SKULL
=Indications for operation.= It is the general custom to divide fractures of the vault into two groups--those demanding operative treatment and those in which an expectant attitude is advised--and between these two groups a sharp line of demarcation is drawn. There is, however, no such line of demarcation. In the event of the general condition of the patient being compatible with operative interference, such treatment is urgently called for under the following conditions:--
_All_ cases of depressed fracture, whether diagnosed by palpation or by inference, whether simple or compound, whether complicated or not.
_All_ cases of fracture complicated by extra-dural or localized subdural extravasation of blood.
In all these instances, from the presence of depressed fragments of bone, from associated injury to the intracranial contents, or from other causes, no mere expectant policy should be pursued. The surgeon has to look into the future, to bear in mind the possibility of meningeal infection, and the more remote results of head-injuries in general (see Chapter VI). In other words, early and active surgical interference is imperatively demanded, for not only is it necessary to strain every endeavour to save the patient’s life, but the surgeon should also adopt those procedures which guard most effectually against the more remote possibilities of the case.