omed to meet in civil practice in
connection with fractures of the vault were decidedly rare, and, as has
already been mentioned, ocular evidence of extensive fissures extending
from perforating wounds of the vertex was wanting, except in the extreme
cases classed under heading I. For these reasons I am inclined to regard
them as uncommon.

Direct fractures of the base, on the other hand, were of common
occurrence, especially in the anterior fossa of the skull. These might
be produced either from within, the most characteristic form of gunshot
injury, or from without. The fractures from within were often simple
punctures of the roof of the orbit or nose.

Punctured fractures of the roof of the orbit caused little trouble as
far as the cranium was concerned, but the orbital structures often
suffered severely. I saw one or two very severe comminutions of the roof
of the orbit caused by bullets which had crossed the interior of the
skull; in one case the whole roof was in small fragments, while the
damage in others was not greater than chipping off some portion of the
lesser wing of the sphenoid. The roof of the orbit again was sometimes
very severely damaged by bullets which first traversed that cavity
itself; thus in one case which recovered, the bullet passed
transversely, smashing both globes, and fracturing the roof of both
orbits and the cribriform plate so severely as to lacerate both
dura-mater and brain, portions of the latter being found in the orbit on
removal of the damaged eyes.

Fractures of the middle and posterior fossae were met with far less
frequently, partly I think because vertical wounds passing from the
vertex to the base in these regions were with few exceptions rapidly
fatal, and partly from the fact that the occipital region, being
ordinarily sheltered from the line of fire, was rarely exposed to the
danger of direct fracture from without. As an odd coincidence I may
mention that in my whole experience during the war I only once saw
bleeding from the ear as a sign of fracture of the base, apart from
direct injuries to the tympanum or external auditory meatus.

_Symptoms of fracture of the skull, with concurrent injury to the
brain._--These consisted in various combinations of the groups of signs
indicative of the conditions of concussion, compression, cerebral
irritation, or destruction. Although the symptoms possessed no inherent
peculiarities, yet certain characteristics exhibited served to