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 punctured fracture. _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. _All_ elevated fractures. _All_ compound fractures. 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. With regard to _simple_ fractures, if it can be determined that the fracture, whether fissured, stellate, or comminuted, is simple and uncomplicated by any serious intracranial lesion, no active surgical treatment is required. The determination of such conditions is, however, quite another matter, always difficult and sometimes, from the presence of overlying hæmatomata, quite impossible. In the general estimation of these cases it should be borne in mind that simple uncomplicated vault fractures are decidedly rare. For instance, Dwight, in 145 cases of fractured skull that came to autopsy, only found six that evidenced a fissured fracture localized to the vault. It may, of course, be urged that these statistics are fallacious, insomuch as simple uncomplicated vault fractures would probably not come to the post-mortem table. Clinical evidence, however, coincides with Dwight’s statistics, and clinical evidence shows, furthermore, that a blow sufficing to fracture the vault of the skull almost invariably results in further injury.