tances, as in direct fracture of the roof of the
orbit from above, the exit should not be touched.

The flap having been raised, if the wound be a small perforation, a
1/2-inch trephine crown may be taken from one side; but it is rare for
the opening to be so small that the tip of a pair of Hoffman's forceps
cannot be inserted. The trephine is more often useful in cases of
non-penetrating gutter fractures where space is needed for exploration,
and the elevation or removal of fragments of the inner-table. Loose
fragments may need to be removed from beneath the scalp, but the
important ones are those within the cranium. These may either be of some
size, or fine comminuted splinters of either table, often at as great a
distance as 2 inches or more from the surface. The cavity must be
thoroughly explored and all splinters removed. I have seen more than
fifty extracted in one case of open gutter fracture. The brain pulp and
clot should then be gently removed or washed away, and the wound closed
without drainage. Fragments of bone, as a rule, are better not replaced,
but complete suture of the skin flap is always advisable in view of the
great importance of primary union, and the fact that a drainage opening
exists at the original wound of entry, and that the wound is readily
re-opened to its whole extent, should such a step be advisable.

The detection of fragments is easiest and most satisfactorily done with
the finger, and in all but simple punctures the opening should be large
enough to allow thoroughly effective digital exploration; the remarks
already made as to the factors determining the size of fragments are of
interest in this connection. The determination of the amount of brain
pulp which should be removed is somewhat more difficult; one can only
say that all that washes readily away should be removed, and its place
is usually taken up by blood.

Few fractures of the base are suitable for treatment; the only ones I
saw were those of direct fracture of the roof of the orbit or nose,
produced by bullets passing across the orbits; here the advisability of
interference with the injured eye led to opening of the orbit, and
sometimes exposed the fracture. Some patients recovered, even when the
damage had been sufficient to cause escape of pulped brain into the
orbit.

The after treatment simply consisted in keeping the patients as quiet as
circumstances would permit, and the administration of a fluid diet. In
some ca