HEAD.
Plate 1.
Rifle—Plate 1.
HEAD.
Gunshot Fracture of the Skull, with Lodgment of the Missile.
The bullet in this case was so badly deformed by ricochet that part of both core and jacket were lost. While the appearance of the shadow seems to indicate a direct impact of the nose of the bullet, the line of contact with the skull must have been tangential, with some laceration of the scalp; otherwise a cursory examination of the scalp wound would have revealed the slightly protruding end of the bullet. The dark shadow above the projectile is due to material used in dressing. The great thickening of the scalp in the region of the wound shows a marked cellulitis. Small particles of the lead core of the bullet can be seen about the wound.
In such cases there is often a marked infection of the scalp without extension of infection to the cranial cavity, except from neglect. This is a case, though apparently simple, in which the radiograph was necessary for correct diagnosis without exploration.
The treatment in such cases is conservative, with removal of the projectile and care of the superficial infection or subsequent complications.
Plate 2.
Rifle—Plate 2.
HEAD.
Gunshot Wound of the Head, with Lodgment of the Missile.
Wound of entrance, near outer canthus, with course through eyeball to ethmoid body.
Wound of exit, none.
The Bulgarian Mannlicher bullet, shown half actual size on the plate, must be inclined on its long axis, about 30° from the perpendicular, to the plane of the plate.
The slight penetration of the missile and its normal character show that, having struck no intervening object, it indicted the wound at extreme range.
The treatment should meet the indication for removal of missiles in all superficial or easily accessible locations and when they cause reaction.
Results to be expected are favorable except for loss of the eye.
Plate 3.
Rifle—Plate 3.
HEAD.
Gunshot Fracture of the Ramus of the Lower Jaw.
Wound of entrance, in the cheek behind the angle of the mouth.
Wound of exit, below the tip of the mastoid.
The course of the bullet was almost tangential to the ramus of the jaw, anteroposteriorly. The slight fragmentation, which is hardly more than a splitting of the bone, with little or no displacement, indicates that the wound was made by a rifle bullet at moderate velocity and at mid or long range.
Treatment is expectant.
Plate 4.
Rifle—Plate 4.
HEAD.
Gunshot Fracture of the Ramus of the Lower Jaw.
Wound of entrance, over the anterior border of the right ramus.
Wound of exit, beneath the lobe of the ear.
The wound was made by a rifle bullet with the velocity of long range, because wounds of a shrapnel ball never show such slight injury without lodgment or without marks of lead.
The damage of the bone was very slight, as only a superficial fragment was chipped off. There were no signs of primary infection. Reaction and periostitis suggested the radiograph after infection had rarefied the fragment, shown but very faintly on the left side of the plate.
The postero-anterior skull radiograph was made with the face superimposed upon the photographic plate.
Treatment, incision and drainage.
Plate 5.
Rifle—Plate 5.
HEAD.
Gunshot Fracture of the Body of Lower Jaw, with Great Fragmentation and Displacement.
Wound of entrance, to the left side of the median line of the lower jaw below the alveolar process, with course ranging downward and backward.
Wound of exit, with extensive laceration, beneath lower border of the bone.
The wound was caused by a rifle bullet at high velocity at or less than mid range. The fragments are many and rather small, so that much bone was lost through the wound of exit. This effect was produced by the splitting due to the relative friability of the bone and to the imparting of the momentum of the missile to the detached fragments, which, together with the missile, effected the considerable laceration of the wound of exit.
Treatment, difficult; guided by septic conditions and surgical means available.
Results in such cases are favorable to life but topically unsatisfactory.