Chapter I: Part 1

Transcriber's Note:
Underscores “_” before and after a word or phrase indicate
_italics_ in the original text.
Small capitals have been converted to SOLID capitals.
Old or antiquated spellings have been preserved.
On Pg 173, the reference to “plate No. 81” was corrected to
“plate No. 80”.
On Pg 181, the references to “plates 85 and 86” was corrected to
“plates 83 and 84”.

WAR DEPARTMENT :: OFFICE OF THE SURGEON GENERAL
BULLETIN No. 9
OCTOBER, 1915

GUNSHOT ROENTGENOGRAMS

A COLLECTION OF ROENTGENOGRAMS TAKEN IN
CONSTANTINOPLE DURING THE TURKO-BALKAN
WAR, 1912-1913, ILLUSTRATING
SOME GUNSHOT WOUNDS IN THE
TURKISH ARMY

BY
CLYDE S. FORD
Major, Medical Corps

PUBLISHED BY AUTHORITY OF THE ACT OF
CONGRESS APPROVED MARCH 3, 1915, AND
WITH THE APPROVAL OF THE SECRETARY OF
WAR, FOR THE INFORMATION OF
MEDICAL OFFICERS

WASHINGTON
GOVERNMENT PRINTING OFFICE
1916

TABLE OF ILLUSTRATIONS.

RIFLE WOUNDS.

HEAD.

Page.
PLATE 1. Gunshot fracture, skull, lodgment of missile 12
2. Gunshot fracture, head, lodgment of missile 14
3. Gunshot fracture, lower jaw, ramus 16
4. Gunshot fracture, lower jaw, ramus 18
5. Gunshot fracture, lower jaw, body 20

SPINAL REGION.

6. Gunshot wound, spinal region, lodgment of missile 22
7. Gunshot wound, spinal region, lodgment of missile 24

UPPER EXTREMITY.

8. Gunshot fracture, humerus 26
9. Gunshot fracture, humerus, lodgment of missile 28
10. Gunshot fracture, humerus, lodgment of missile 30
11. Gunshot fracture, humerus 32
12. Gunshot fracture, humerus 34
13. Gunshot fracture, humerus 36
14. Gunshot fracture, humerus, lodgment of missile 38
15. Gunshot fracture, humerus, external condyle 40
16. Gunshot fracture (_a_) humerus, (_b_) ulna 42
17. Gunshot fracture, elbow 44
18. Gunshot fracture, elbow 46
19. Gunshot fracture, elbow 48
20. Gunshot fracture, elbow 50
21. Gunshot fracture, radius and ulna 52
22. Gunshot fracture, radius and ulna 54
23. Gunshot fracture, radius and ulna 56
24. Gunshot fracture, radius and ulna 58
25. Gunshot fracture, radius 60
26. Gunshot fracture, radius 62
27. Gunshot fracture, radius 64
28. Gunshot fracture, radius 66
29. Gunshot fracture, radius, lower end 68
30. Gunshot fracture, radius, lower end 70
31. Gunshot fracture, radius, lower end 72
32. Gunshot fracture, ulna 74
33. Gunshot fracture, ulna 76
34. Gunshot fracture, ulna 78
35. Gunshot fracture, ulna 80
36. Gunshot fracture, ulna 82
37. Gunshot fracture, ulna 84
38. Gunshot fracture, ulna 86
39. Gunshot fracture, ulna 88
40. Gunshot fracture, ulna 90
41. Gunshot fracture, wrist 92
42. Gunshot fracture, wrist 94
43. Gunshot fracture, metacarpus 96
44. Gunshot fracture, phalanx 98

CHEST.

45. Gunshot wound, chest 100

PELVIS.

46. Gunshot wound, pelvis 102

LOWER EXTREMITY.

47. Gunshot wound, gluteal region 104
48. Gunshot wound, thigh 106
49. Gunshot wound, thigh 108
50. Gunshot wound, thigh 110
51. Gunshot wound, thigh 112
52. Gunshot fracture, femur 114
53. Gunshot fracture, femur 116
54. Gunshot fracture, femur 118
55. Gunshot fracture, femur 120
56. Gunshot fracture, femur 122
57. Gunshot fracture, femur 124
58. Gunshot fracture, femur 126
59. Gunshot wound, knee 128
60. Gunshot fracture, tibia and fibula 130
61. Gunshot fracture, tibia and fibula 132
62. Gunshot fracture, tibia 134
63. Gunshot fracture, tibia 136
64. Gunshot fracture, tibia 138
65. Gunshot fracture, tibia 140
66. Gunshot fracture, tibia 142
67. Gunshot fracture, tibia 144
68. Gunshot fracture, tibia 146
69. Gunshot fracture, tibia 148
70. Gunshot fracture, tibia 150
71. Gunshot fracture, fibula 152
72. Gunshot fracture, ankle 154
73. Gunshot wound, heel 156
74. Gunshot wound, heel 158

SHRAPNEL WOUNDS.

HEAD.

75. Gunshot fracture, vertex 160
76. Gunshot fracture, vertex 162
77. Gunshot fracture, zygoma 164
78. Gunshot fracture, mastoid process 166
79. Gunshot fracture, maxilla 168
80. Gunshot fracture, supra-orbital 170
81. Gunshot fracture, supra-orbital 172
82. Gunshot wound, shoulder 174
83. Gunshot wound, shoulder 176
84. Gunshot wound, shoulder 178
85. Gunshot wound, shoulder 180
86. Gunshot fracture, clavicle 182
87. Gunshot fracture, humerus 184
88. Gunshot fracture, humerus 186
89. Gunshot fracture, humerus 188
90. Gunshot fracture, humerus 190
91. Gunshot fracture, humerus 192
92. Gunshot fracture, humerus 194
93. Gunshot fracture, humerus 196
94. Gunshot fracture, humerus 198
95. Gunshot fracture, humerus 200
96. Gunshot fracture, humerus and elbow 202
97. Gunshot fracture, elbow 204
98. Gunshot fracture, elbow 206
99. Gunshot fracture, elbow 208
100. Gunshot fracture, elbow 210
101. Gunshot fracture, radius and ulna 212
102. Gunshot fracture, radius 214
103. Gunshot fracture, radius 216
104. Gunshot fracture, ulna 218
105. Gunshot fracture, metacarpus 220
106. Gunshot fracture, metacarpus 222
107. Gunshot fracture, metacarpus 224
108. Gunshot wound, hand 226
109. Gunshot wound, multiple, hand and forearm 228

CHEST.

110. Gunshot wound, chest 230
111. Gunshot wound, chest 232
112. Gunshot wound, chest 234
113. Gunshot wound, chest 236
114. Gunshot wound, chest 238

PELVIS.

115. Gunshot fracture, ilium 240

LOWER EXTREMITY.

116. Gunshot wound, thigh 242
117. Gunshot wound, thigh 244
118. Gunshot wound, thigh 246
119. Gunshot wound, femur 248
120. Gunshot wound, femur 250
121. Gunshot wound, femur 252
122. Gunshot wound, femur 254
123. Gunshot wound, femur 256
124. Gunshot wound, femur 258
125. Gunshot wound, femur 260
126. Gunshot wound, femur 262
127. Gunshot wound, femur 264
128. Gunshot wound, knee 266
129. Gunshot wound, knee 268
130. Gunshot wound, knee 270
131. Gunshot wound, knee 272
132. Gunshot wound, knee 274
133. Gunshot wound, knee 276
134. Gunshot wound, knee 278
135. Gunshot wound, leg 280
136. Gunshot wound, leg 282
137. Gunshot fracture, tibia and fibula 284
138. Gunshot fracture, tibia and fibula 286
139. Gunshot fracture, tibia and fibula 288
140. Gunshot fracture, tibia and fibula 290
141. Gunshot fracture, tibia 292
142. Gunshot fracture, fibula 294
143. Gunshot fracture, fibula 296
144. Gunshot fracture, fibula 298
145. Gunshot fracture, fibula 300
146. Gunshot fracture, fibula 302
147. Gunshot fracture, fibula 304
148. Gunshot fracture, “Pott’s” 306
149. Gunshot wound, multiple, leg 308
150. Gunshot fracture, astragalus 310
151. Gunshot fracture, calcaneus 312
152. Gunshot wound, heel 314
153. Gunshot wound, heel 316
154. Gunshot wound, foot 318
155. Gunshot wound, foot 320
156. Gunshot wound, foot, multiple 322

OPERATIVE INTERFERENCE, GUNSHOT WOUNDS.

157. Gunshot fracture, humerus 324
158. Gunshot fracture, ulna 326
159. Gunshot fracture, radius and ulna 328
160. Gunshot fracture, tibia and fibula 330
161. Amputation, knee 332
162. Excision, head of humerus 334

INTRODUCTION

These roentgenograms are not presented as exhibiting a state of perfection in the art or method by which they were produced, although they show the results of some of the best and most modern apparatus of Europe employed in the hands of very skillful operators. Some plates are included which are indistinct and generally so unsatisfactory from a technical viewpoint as to be of little interest, if all of them were not intended to show the general character of the diagnostic assistance that the roentgenologist rendered the military surgeon in the base hospitals of Constantinople during the Turko-Balkan War.

The collection of these plates resulted from a systematic visiting of the hospitals of Constantinople in the winter of 1912-13, during the course of the first Balkan War, and including all of the military hospitals of the military zone, with the incidental purpose of selecting from the roentgenographic plates, which had been prepared wherever apparatus was installed, such examples of the roentgenography of gunshot wounds as might show characteristic lesions without relation to detailed clinical record.

More than 1,500 plates were examined, and from them more than 200 were selected as exhibiting some lesion that seemed to be characteristic of some form of gunshot wound, even though the case history could not be obtained. From these selected plates photographic prints were made. As some of these photographs displayed somewhat similar conditions, only 162 of them are herewith produced.

As the photographic and reproduction processes have transferred the rights and lefts of the original negatives several times, the plates as they appear here are interpreted, for right and left, as though they were the original photographic plates, which are physically positive although they are chemically negative; i. e., the right and left sides of the page should be read as the right and left sides anatomically. If this distinction be not observed, some confusion may arise from the habit of roentgenologists in regarding a roentgenograph as a positive print of a negative plate.

I regret that I can not here acknowledge by name my appreciation and gratitude to the roentgenologists of all hospitals from which I secured permission to reproduce their plates. To Prof. Wieting Pasha, the commandant of Gulhané Hospital; to Dr. Ishmael Bey, the roentgenologist of the Hamedian Hospital; to Dr. Englander, the roentgenologist of the Austrian Hospital--to all of whom I am particularly indebted--I wish to acknowledge my thanks.

_Projectiles._--The projectiles which figure in the illustrations were those employed by the nations at war. They are derived (1) from the Turkish pointed bullet weighing approximately 15.0 grams--it is fired from the German Mauser and has all the ballistic values of the projectile from this weapon; (2) the Bulgarian bullet, blunt nosed or ogival headed and the same as the steel-jacketed bullet of the Austrian Mannlicher; (3) shrapnel balls and fragments of the shrapnel, and (4) fragments of steel shells from field artillery.

During the evolution of reduced caliber rifles experiments were made on cadavers at different ranges. In the published writings of these workers a great deal was said on the subject of highly destructive effects which are pretty generally described as _explosive effects_. The experimenters were careful to explain that these exaggerated and highly destructive effects were only seen when firing into cadavers at close ranges and when the bullet traveling at a maximum velocity happened to collide with resistant structures like the compact substance of bone in the diaphysis of the long bones, such as the femur, tibia, humerus, etc., and the head, as well as organs loaded with fluid or semifluid masses like the stomach, urinary bladder, and intestines. In other tissues offering but little resistance like lung tissues, soft parts generally, and epiphyseal ends of bone, the wounds inflicted were considered humane in character. Attention should be called to the infrequency of wounds showing explosive effects by the rifles of reduced caliber employed in the Turko-Balkan and Spanish-American wars. The same thing may be said of the Turko-Italian, Anglo-Boer, and Russo-Japanese wars, all of which were fought with the new armament.

The reason for the infrequency of the explosive effects in these wars is due to the fact that the battles were fought in the open at the ordinary battle ranges beyond the zone of explosive effects. This fact is all the more emphasized in the present world war, in which the rifle fire is employed principally in trench warfare at near-by ranges, and where all the wounds which involve the resistant structures of the body show the characteristic features usually described as those of explosive effects.

In describing the plates the terms used in connection with range are as follows:

(1) Close range, from 0 to 100 yards.
(2) Short range, from 100 to 500 yards.
(3) Mid range, from 500 to 1,000 yards.
(4) Long range, from 1,000 to 2,000 yards.

The wound effects of the modern military rifle bullet at various ranges are usually classified as follows:

(1) Explosive range, from 0 to 500 yards.
(2) Perforating range, from 500 to 1,500 yards.
(3) Penetrating range, from 1,500 to 2,500 yards.

The difficulty in adhering strictly to the last table as far as the characteristic features of wounds are concerned is this: In battle the chances of ricochetting of bullets is said to be in the proportion of one to three. Naturally, the moment a bullet ricochets it loses more or less of its remaining velocity. The destructive lesion to be expected from a given shot at a given range against a certain resistant structure can not be depended upon to occur as it will when the shot is made with scientific accuracy in the shooting gallery against cadavers.

_Trajectory_, or the curved line of flight of a projectile, has nothing to do with its wound-producing quality, except to increase the wound-producing frequency when it flattens and approaches the straight line of sight, because it will then pass through a greater portion of the space between the gun and the target, which may be occupied by men, without going over their heads. The greater the velocity, the flatter the trajectory becomes.

The American, German, and Turkish rifles, with about the same trajectory, can be fired through a tube 24 inches in diameter at a range of 500 yards, and the vertical rise of the curve of flight would not hit the top of the tube. But where the range is increased to 1,000 yards it would be necessary to enlarge the tube to a tunnel, 15 feet in diameter, in order to fire the bullet through it without striking the top in its greatly increased curve in flight.

_Velocity_ is the principal factor of the wound-producing power of the small-caliber bullet, although the latter quality is definitely related to the cross-sectional area and weight as well as to the hard metal jacket which preserves its form. The greater the velocity of any particular bullet the more serious is its wound.

_Energy_, as the resultant of the components of _weight_ and _velocity_, represents the _real_ damaging quality, striking force, or “punch” of a projectile, with a variation in wound effect as the energy is distributed over the surface of the body, through the cross-sectional area and the form of the point of the projectile, and the elements of construction which a affect the preservation of its shape. As the energy is expressed in the formula,

E = (WV^{2})/(2_g_),

it is evident that the increase or decrease of the velocity factor gives greater variation than the increase of weight.

_Range_ is important only as indicating the amount of _remaining energy_ which may be known to reside in the projectile at any stage of its flight. Without reference to the ballistic condition (velocity, weight, form, and construction, etc.) of a particular projectile, _range_ has no surgical significance. To the military surgeon, however, it is a term of the greatest interest when these ballistic conditions are known, as it gives him a very definite indication of the remaining energy or the damaging effect of a projectile at the different stages in its flight.

The remaining energy of the American “Springfield,” or German “S” bullet, for instance, will pass it through the bodies of two men at 2,000 yards and an energy of 8 kilogram-meters, which remains at about twice that distance, will cause a disabling wound.

Wound infections are more rare in campaign in the more sparsely settled and rough countries with soldiers of the more primitive class, simple domestic habits, and greater natural resistance.

Wound treatment should be primarily directed toward the control of infection with only secondary regard for the correction of deformities which should follow as a secondary measure after resolution is established.

All treatment should be based on principles applied in the following order:

(1) Life saving.
(2) Restoration of function.
(3) Economy of the patient.

Amputation should be very rare.

Conservation to a degree that seems to be beyond the experience and conception of the civil surgeon should always be practiced, as reiterated by Delorme, who says: “In order to avoid the excess of operative measures which has been seen in recent wars I am urged to enjoin all potential military surgeons to practice almost uniform conservation.”

_Weight and muzzle velocity of several projectiles._

-----------------------+------------------+-----------------
| Weight. | Velocity.
Projectile. +--------+---------+---------+-------
| Grams. | Grains. | Meters. | Feet.
-----------------------+--------+---------+---------+-------
American (Springfield) | 9.07 | 150 | 800 | 2,700
French | 12.8 | 197 | 701 | 2,301
German | 10.0 | 154 | 860 | 2,821
Austrian | 15.8 | 244 | 626 | 1,952
-----------------------+--------+---------+---------+-------

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.

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.

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.

Results are favorable.

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.

Results, good.

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.

RIFLE--PLATE 6.

SPINAL REGION.

Gunshot Wound of the Spinal Region--Lodgment of the Missile in the Lumbar Muscles.

The bullet is lodged deep in the muscles of the back and not in the abdomen, as determined by inspection of the plate.

(_a_) The shadow of the bullet is enlarged laterally, because, while on the side of the body next to the plate and to the spine, it is at some little distance from the plate, which accounts for the larger diameter of the shadow; and it is shortened longitudinally, because its long axis is inclined at an angle to the plate.

(_b_) The outline of the shadow is distinct, an evidence that it is extra-abdominal, as otherwise its outline would be blurred by the diaphragmatic movement of respiration imparted to the abdominal viscera during the Röntgen exposure.

RIFLE--PLATE 7.

SPINAL REGION.

Gunshot Wound of the Spinal Region, with Lodgment of the Missile.

The bullet was either dum-dummed or unjacketed because its soft nose mushroomed, striking the crest of the ilium, penetrated the lumbar muscles, and struck the side body of the third lumbar vertebra without producing fracture.

The exposure, as the spinous processes show, was made with the spine next to the plate, and the slight shadow, somewhat larger than the projectile--to judge the size from the undeformed diameter--shows it to be anterior to the vertebra. The shadow is deep enough to indicate the location fairly near to the plate, and, almost certainly, not in the abdominal cavity, where the distance from the plate would have made the shadow less dense and the movement of respiration probably would have given it a blurred outline. The shadow of the localizing cross gives a standard of density to be compared with the shadow of the projectile in making the estimation.

The treatment is conservative; only pain, paralysis, impaired function, or sepsis indicate interference.

RIFLE--PLATE 8.

UPPER EXTREMITY.

Compound Fracture of the Humerus in Advanced State of Repair with Callus Formation.

Wound of entrance, just above middle of anterior aspect of arm.

Wound of exit, about the same height, posteriorly.

The course of the missile was anteroposterior, with high velocity of short range through the bone with a splitting effect, leaving a few fragments, large and small, which were not much displaced and caused but little deformity.

Wound was not infected. The absorption of smaller and the overlapping of larger fragments caused some shortening.

Treatment, expectant.

Results, favorable.

RIFLE--PLATE 9.

UPPER EXTREMITY.

Gunshot Fracture of the Right Humerus, with Lodgment of the Missile.

Wound of entrance, antero-external aspect of upper third of arm.

Wound of exit, none.

The missile, deformed by ricochet, struck the bone with greatly reduced velocity and without sufficient energy to perforate the bone by which it was deflected slightly from its course and lodged in the arm.

This is something of the same effect that might have been caused by a shrapnel ball, under the same ballistic conditions with a normal shrapnel velocity giving about the same penetrating force.

The wound, without infection, is in the first week or two of repair, before any callus has formed.

Treatment is expectant.

Results favorable.

RIFLE--PLATE 10.

UPPER EXTREMITY.

Gunshot Fracture of the Left Humerus, with Lodgment of the Missile.

Wound of entrance, anterior surface of upper third of the arm.

Wound of exit, none.

The shadow of the missile shows by its distinct outline and normal diameter at the tip that the missile lies on the side near the plate; the shortened length of the projectile indicates that the long axis lay in an acute angle with a perpendicular to the plate.

The irregular outline of the base of the shadow and the fact of lodgment shows that the missile was deformed and that it was incidentally retarded in velocity by ricochet, so that its penetrating force was not sufficient to carry it through the arm.

The fragments of bone are large and the wound is of the same character as might have resulted from a shrapnel ball, for the normal ballistic conditions of the latter simulate the conditions that produced the wound.

The drainage tubes seen in the plate indicate infection.

The conventional treatment in such cases is drainage and other management of the infection without formal search for the projectile.

Results should be favorable.

RIFLE--PLATE 11.

UPPER EXTREMITY.

Gunshot Fracture of the Humerus.

Wound of entrance, anterior internal aspect of middle and upper third of arm.

Wound of exit, opposite.

The missile has struck the side of the bone and pursued a course through the shaft, so that a transverse fracture, as well as the separation of several medium-sized fragments, resulted from the splitting effect of the missile.

A larger missile, i. e., a shrapnel ball, with the same striking energy could have been stopped by the bone, but a wider distribution of the same energy carried by a larger cross section would have produced larger fragments.

In this case the location of the shrapnel ball would furnish unquestioned evidence; or, if a shrapnel ball had produced this particular bone destruction, its path among the fragments would have been marked by traces of lead. Two metal fragments indicate that the lead core of the bullet was exposed.

The wound, not infected, was treated expectantly.

Result in such cases is favorable.

RIFLE--PLATE 12.

UPPER EXTREMITY.

Gunshot Fracture of the Humerus.

The course of the missile was anteroposterior through the middle of the arm.

The ballistic conditions and lines of force applied to the bone were somewhat, if not entirely, similar to those producing the fracture shown in plate 11. The missile struck the wall of the shaft without passing through the medullary canal, but a secondary fragmentation of the two large fragments did not follow except for the breaking of the tip of the distal fragment.

The range was long.

There was little deformity and no infection.

Plaster dressing was applied and the slight outline of callus formation indicates the process of repair. The lack of contrast in the shadow of the bone is due to the opacity of the plaster dressing through which the Roentgen exposure was made.

Treatment in such cases is expectant.

Results should be uniformly good.

RIFLE--PLATE 13.

UPPER EXTREMITY.

Gunshot Fracture of the Right Humerus, with Lodgment of the Missile.

Wound of entrance, about middle of the anteriorinternal aspect of the arm.

Wound of exit, none.

The course of the missile was from without, downward and inward to a point of lodgment above the internal condyle. The distinct outline and normal size of the base of the bullet shows it to be near the plate, with the internal condyle next to the plate in the exposure.

The bullet mushroomed when it struck the bone with a “soft nose,” in which the lead was not protected by a tough metal jacket. It may have been dum-dummed; it is remotely possible that the nose of the jacket was split by ricochet, or it is more probable that it was of the unjacketed variety.

The effect is identical with that of a shrapnel ball, striking with its normal low velocity, which is about the same as that of the missile in this wound.

The invariable characteristic of a shrapnel wound of a bone, namely, the small particles of metal marking its course in contact with the bone, is seen in this plate.

The treatment in such cases is expectant, with due regard to the character of the infection, and without primary search for the missile.

The results are generally favorable.

RIFLE--PLATE 14.

UPPER EXTREMITY.

Gunshot Fracture of the Humerus, with Lodgment of the Missile.

The missile was a fragment of a ricocheted rifle ball, with a part of the lead core carried in a portion of the jacket. The course was from before, backward, striking the humerus in lower third, and leaving particles of lead along its trade.

The wound was only slightly infected. Several detached fragments of bone have been removed.

The treatment in such cases is conservative, with management of the infection and without formal search for the projectile.

The results in such cases are favorable with some shortening of the bone.

RIFLE--PLATE 15.

UPPER EXTREMITY.

Gunshot Fracture of the External Condyle of the Left Humerus, with Lodgment of the Missile.

Wound or entrance, internal and posterior aspect of the arm above the internal condyle.

Wound of exit, none.

The bullet was greatly deformed by ricochet, with the loss of the greater part or all of its jacket.

The line of contact of the unprotected lead with the bone is marked by the same small fragments of lead almost invariably seen in shrapnel wounds. The ballistic conditions in this case are quite similar to those of a shrapnel wound, as the projectile has struck the bone with low velocity. The very slight displacement of a single large fragment from which the missile is slightly withdrawn indicates that the striking energy was relatively low and that the elastic tissues, stretching around the missile at its striking point, contracted after its energy had been expended and then withdrew the missile from its farthest point of advance.

The treatment in such cases warrants only the interference suggested by infection and the interference of the missile with function.

The results expected are most favorable.

RIFLE--PLATE 16.

UPPER EXTREMITY.

Gunshot Fracture of the Humerus.

The transverse course of the bullet, striking the posterior wall of the shaft without entering the medullary canal, has fractured the bone transversely, with a tendency toward splitting off a large fragment from the distal fragment.

The bullet under these ballistic conditions of high velocity and not distant range might have bored its way through the cancellous tissue of the epiphysis of the same bone without any fractures.

Gunshot Fracture of the Ulna.

The transverse course of the bullet in striking the ulna at high velocity and not distant range has shown a tendency to bore a hole through the bone. A smaller bullet or a larger bone of the same structure might easily have provided conditions to permit this effect. The wounds of exit and entrance in each of these wounds presented almost identically the same appearance.

The treatment in such cases is that of a simple fracture, as there is almost always no infection in such wounds.

Results are favorable.

RIFLE--PLATE 17.

UPPER EXTREMITY.

Gunshot Fracture of the Elbow.

The bullet in transverse course and high velocity through both bones of the forearm struck the head of the radius, thus starting several splitting lines of fracture and separating large fragments. Smaller fragments which received some of the energy of the missile have been carried along with it in turn, striking the ulna and carrying away smaller fragments from it and causing the laceration which marks the wound of exit.

Such wounds, with laceration of soft parts and fragmentation of the bone, are prone to infection, against which treatment is directed. The indications to be met are much like those of the wound shown in plates 18 and 19. Excision or immediate methods of bone repair are contraindicated by infection.

Results will depend upon the nature and extent of infection.

RIFLE--PLATE 18.

UPPER EXTREMITY.

Gunshot Fracture of the Elbow, without Injury to the Great Vessels and Nerves.

Wound of entrance, posterior to the external condyle.

Wound of exit, large laceration in front and above the internal condyle.

The wound is an example of the misnamed “explosive” action of a rifle bullet. The force and direction of the missile, in high velocity, split the bone into many fragments, and, transmitting its energy to some of the fragments, carried them through the skin and caused the large laceration at the point of exit by the simultaneous escape of the bullet and fragments. The wound was so heavily infected, that a cellulitis advanced to the shoulder and to the wrist to such extent that the arm was marked by eminent surgical opinion for amputation. Free incision, drainage, antisepsis and incidental removal of detached fragments controlled the infection and brought about slow resolution. After six months of careful treatment the wound was healed with an ankylosed elbow with normal function of the forearm, except for limited rotation.

Treatment indicated in such cases is always conservative. Infections contraindicate any formal surgical interference. The dangers of infection in such cases are to be risked to avoid amputation.

Results may be considered favorable even with elbow ankylosis.

RIFLE--PLATE 19.

UPPER EXTREMITY.

Gunshot Fracture of the Elbow, without Injury to the Great Vessels and Nerves.

This is a plate made of the same subject shown in plate 18, when convalescence was several weeks farther advanced, as is indicated by the removal of fragments and extensive callus formation.

Both radiographs were made after the apprehension of systemic infection had passed; the second plate after an additional number of fragments had been removed.

RIFLE--PLATE 20.

UPPER EXTREMITY.

Gunshot Fracture of the Elbow.

Wound of entrance, posterior aspect of forearm internal to and below the olecranon.

Wound of exit, external border over head of radius.

The course of the bullet was diagonally anteroposterior from within outward, striking the posterior border of the upper end of the ulna and passing through the head of the radius, carrying the fragments of the latter before it and lacerating the wound of exit. The energy of impact also fissured the upper end of the shaft of the ulna and fractured the neck of the radius without detaching the large fragments.

This is the effect of a rifle bullet at short range, or possibly a ricochet shot at mid range.

The emergency treatment is antiseptic dressing with splint immobilization.

The subsequent treatment is conservative, whether the wound is clean or infected. The course of treatment of such an infected wound might extend from four to six months.

NOTE.--As the soldier always escapes the burden of explanation when
the wound of entrance is anterior rather than posterior, it should
be remembered that the forearm may occupy positions in relation to
the body which exposes the anatomically posterior aspect of the
forearm to missiles directed toward the anterior surface of the body;
and as the wounds of the forearm herein presented are described in
the anatomical position, there is no justifiable impeachment of the
soldier’s valor in an inference that he was shot from behind when
the wound of entrance involves the posterior aspect of the forearm.

RIFLE--PLATE 21.

UPPER EXTREMITY.

Gunshot Fracture of the Radius and Ulna.

The course of the bullet at short range was transverse through both of the bones, with a splitting effect and without much small fragmentation.

The wound of exit in this case was slightly lacerated, but not very much larger than the wound of entrance.

The treatment should be conservative. Emergency treatment should not include exploration, and nothing but the conventional iodine dressing and splints should be applied.

RIFLE--PLATE 22.

UPPER EXTREMITY.

Gunshot Fracture of the Radius and Ulna.

The course of the bullet at short range was transverse through the upper forearm, striking the radius in the center of the shaft and the ulna nearer the border. Several small fragments followed the course of the bullet, but did not emerge with it at the wound of exit to cause a laceration.

The capitellum was next to the photographic plate and the angular line of the radius can be seen crossing the straighter line of the ulna.

Further information is obtained from the examination of another view, plate 23, made of the same subject.

RIFLE--PLATE 23.

UPPER EXTREMITY.

Gunshot Fracture of the Radius and Ulna.

This plate was made from the wound shown in plate 22, with the arm in greater inward rotation. This position shows the wide separation of the large fragments of the radius.

Emergency treatment in such cases is antiseptic dressing only, without exploration, and with fixation by splints for transportation. The degree of infection determines the subsequent course of conservative treatment, with operative methods for correction of deformity reserved for further stage of convalescence and for best surgical facilities.

RIFLE--PLATE 24.

UPPER EXTREMITY.

Gunshot Fracture of the Radius and Ulna in the Upper Third of the Forearm.

The course of the projectile was from within, outward and diagonally forward, with a direct impact on the ulna, and a tangential impact on the radius, with several lines of splitting fracture in the latter without detaching fragments. Particles of metal, spattered around the point of first impact, were deposited by the lead core of a bullet, exposed by a torn jacket, which struck the second bone with its jacketed surface.

The treatment is always conservative--meeting indications in case of infection.

Results are good for saving the limb, but not for avoiding deformity.

RIFLE--PLATE 25.

UPPER EXTREMITY.

Gunshot Fracture of the Radius.

Wound of entrance, posterior surface of forearm over radius above the middle.

Wound of exit, below and in front of wound of entrance.

The course of the ball in mid range was from behind, forward, and slightly downward.

While the images of both bones of the forearm are superimposed, because they both lay in the plane of the projection of the shadow, it is probable that the radius lay nearer the photographic plate, because the head of the radius is shown in clearer outline. The fragments of the fracture can be seen as related to the outlines of the radius.

There is no displacement and only slight fragmentation, so that the bullet must have almost succeeded in making a punctured wound in the radius.

The treatment in such cases is regularly that for simple fracture, as such wounds are almost always aseptic.

The results are uniformly good.

RIFLE--PLATE 26.

UPPER EXTREMITY.

Gunshot Fracture of the Radius.

Wound of entrance, midway between radius and ulna and midway between elbow and wrist, anterior aspect of the forearm.

Wound of exit, over radius at point opposite.

The course of the bullet, in the medium velocity of mid range, in piercing the medullary canal has almost succeeded in drilling the bone without splitting off several longitudinal fragments. Small fragments followed the course of the missile, without being energized sufficiently to lacerate the point of exit by escaping with the projectile.

The wound of exit in such cases hardly differs enough from the wound of entrance to be distinguishable. This condition so often obtains that the great majority of perforating rifle wounds of the forearm do not show the blow-out or “explosive” effect which seems to be generally misunderstood as a classic accompaniment.

The bullet was traveling at high velocity of perhaps less than mid range.

The treatment is usually that of a simple fracture, and warrants no interference except in case of occasional infection.

Results are almost always good.

RIFLE--PLATE 27.

UPPER EXTREMITY.

Gunshot Fracture of the Radius.

The course of the bullet, at long range, has been diagonally anteroposterior through the shaft, causing only a diagonal fracture.

The plate was made after a two-weeks’ convalescence, as is shown by the beginning of callus formation.

The treatment is that of a simple fracture.

Results are good.

RIFLE--PLATE 28.

UPPER EXTREMITY.

Gunshot Fracture of the Radius.

The course of this bullet was anteroposterior and diagonally from above downward through the shaft, punching out one side of the shaft and effecting a diagonal fracture through the bone with only slight displacement. The wound was infected.

The radiograph was taken during the course of treatment, after the several small fragments found by the punched-out portion of the bone were removed. A small drainage tube is in the wound, but the size of the forearm shows that the reaction is very moderate.

The treatment is that of a simple fracture, except for the indications to be met in the control of infection.

Results are good.

RIFLE--PLATE 29.

UPPER EXTREMITY.

Gunshot Fracture of the Lower End of the Radius.

The course of the bullet in long range was diagonally anteroposterior through the ulnar side of the lower end of the bone, with the wound of entrance on the anterior and the wound of exit on the posterior aspect of the wrist. The wound of exit was slightly lacerated by several small fragments driven off from the ulnar side of the radius. These fragments were removed through an incision before the radiograph was made.

The emergency treatment of such cases is only antiseptic dressing and splint immobilization.

When wound is aseptic or after it has closed, a secondary operation for coaptation, with proper facilities available, might be indicated.

The results as to full restoration of joint function are not favorable.

RIFLE--PLATE 30.

UPPER EXTREMITY.

Gunshot Fracture of the Lower End of the Radius.

The course of the missile was diagonally transverse, striking the radius in its lower third.

The projectile in this case is unknown, as it might have been either a shrapnel ball or a deformed rifle bullet with a torn jacket, exposing the lead core and marking its course with small particles of lead.

The fissures in the lower fragment and the finer fragmentation at the seat of impact, indicate a great striking energy, that more often resides in the high velocity of a rifle bullet than the low velocity of a shrapnel ball. The wound is therefore classified with rifle wounds.

The treatment is conservative. The course in such cases, without infection, is very favorable, and not unfavorable even with infection.

Results should be good.

RIFLE--PLATE 31.

UPPER EXTREMITY.

Gunshot Fracture of the Lower End of the Radius.

Wound of entrance, anterior aspect of wrist, over internal border of radius.

Wound of exit, posterior aspect of wrist between radius and ulna, with laceration.

The range was described as “close”--within a hundred yards--with the bullet in high velocity. The energy of the projectile, imparted to small fragments of cancellous tissue, drove them through the wound of exit, and caused the laceration of the superficial tissues. The wound was infected (swelling of soft parts clearly shown): resolution followed extended treatment, with ankylosis of the wrist and radial displacement of the carpus.

Emergency treatment in all such cases is antiseptic dressing without exploration or manipulation of fragments, and with splint immobilization.

Results are unfavorable as to function, depending upon extent of destruction of tendons.

RIFLE--PLATE 32.

UPPER EXTREMITY.

Gunshot Fracture of the Ulna.

The course of the bullet was transverse through the arm at the junction of the middle and upper thirds from behind the radial border externally to the ulnar border internally, striking the wall of the medullary canal with a punching effect that partly split off short longitudinal fragments and caused transverse and longitudinal cracks, without separation or displacement of fragments.

The same ballistic conditions applied to cancellous tissue at the end of the bone would probably have bored through it without fracture.

This effect is generally seen in wounds of small-caliber bullets traveling at reduced velocity of long range.

The treatment is that of a simple fracture.

Results, in such cases without infection, could not be bad.

RIFLE--PLATE 33.

UPPER EXTREMITY.

Gunshot Fracture of the Left Ulna.

The course of the missile was from within outward, ranging downward to the wrist, by deflection, after striking the ulna in its upper half. The considerable striking energy retained in a small portion of the mass--consisting of only the nose and a little more of the jacket of the bullet, but sufficient to fragment a large section of the bone, and then to traverse more than half the length of the forearm--leaves no doubt that the shot was fired at very close range, and that the bullet was broken on a nearly resisting surface, leaving in the nose of the bullet a striking force equal to that of the entire projectile at long range.

The posterior surface of the forearm is next to the plate, as the distinct outline of the styloid process of the ulna and the posterior border of the articular surface of the radius shows. The radius and ulna are parallel in the most natural position of supination. The normal diameter and sharp outline of the nose of the bullet show it to be next to the plate and on the posterior surface between radius and ulna.

Fragments of the exposed lead core of the bullet have scraped off on the line of fracture in a manner peculiar to shrapnel wounds, but never seen in bullet wounds in which the jacket covers all of the lead core.

The treatment is regularly conservative and without interference, as in this particular wound, which was aseptic.

Secondary treatment may indicate correction of bone deformity.

RIFLE--PLATE 34.

UPPER EXTREMITY.

Gunshot Fracture of the Ulna.

The ballistic conditions of the projectile causing the wound shown in this plate are substantially those of the wound shown in plate 32.

The wound of entrance and exit would be practically the same in chipping off a few small fragments and causing a clean transverse fracture without any displacement.

The bullet at long range has struck the wall of the medullary canal, appearance.

Treatment that of a simple fracture.

Results must be good.

RIFLE--PLATE 35.

UPPER EXTREMITY.

Gunshot Fracture of the Ulna.

The course of the bullet at long range has been anteroposterior through the middle of the forearm, passing through the side of the shaft, chipping off a few small fragments and causing a long oblique fracture.

The conditions were much the same as those shown in plates 28 and 29, except that the striking energy of the projectile was somewhat greater with the velocity of mid range.

The treatment, without infection, is that of a simple fracture.

Results will be uniformly good.

RIFLE--PLATE 36.

UPPER EXTREMITY.

Gunshot Fracture of the Ulna.

The course of the bullet was anteroposterior through the ulna a little above the middle of the forearm, and fairly through the long axis.

This is a bone effect much similar to those shown in plates 28, 29, and 31, except that this condition is due to the impact of a missile, with a still higher velocity of shorter range, imparting its energy to small fragments of bone, which added their momentum to the destructive force of the projectile.

No large fragments were carried along with the missile to cause any more destruction of tissue in exit than in entrance, so that the skin wounds, under these conditions, are about the same in appearance.

The treatment is conservative and expectant with immobilization.

Results in such cases are uniformly good.

RIFLE--PLATE 37.

UPPER EXTREMITY.

Gunshot Fracture of the Ulna.

The course of the bullet was in an anteroposterior direction at a high velocity of short range, which, imparting its energy to the fragments, drove some of them through the tissues as “secondary missiles” and caused a laceration of the wound to exist.

The longitudinal fragmentation and splitting indicates a considerable energy of the projectile, which may have been deflected, as its long axis was turned somewhat from the trajectory at the time of impact.

The emergency treatment is antiseptic dressing and splint immobilization.

The subsequent treatment is conservative with the removal of detached fragments and with control of infection as the course indicates.

RIFLE--PLATE 38.

UPPER EXTREMITY.

Gunshot Fracture of the Left Ulna.

The course of the bullet was transverse through the middle of the forearm, striking the posterior border of the ulna.

Small fragments were broken from the posterior wall of the medullary canal, without destroying the longitudinal continuity of the anterior wall.

The velocity of the bullet was probably that of mid-range, as the striking energy of the impact was fairly great.

The posterior surface of the forearm lay next to the plate.

The emergency treatment is antiseptic dressing and splint immobilization.

The subsequent treatment is that of a simple fracture, as infection is not usual.

RIFLE--PLATE 39.

UPPER EXTREMITY.

Gunshot Fracture of the Left Ulna.

The course of the bullet, with the velocity of long range, was anteroposterior through the lower third of the forearm, striking the outer side of the bone. The initial velocity of the projectile was much reduced, as is shown by the tendency to puncture the bone without much fragmentation.

There was no displacement of fragments as a direct result of the impact, although muscular contraction has caused some slight subsequent overriding.

The wounds of entrance and exit were about the same, if not quite similar in appearance.

The emergency treatment is the conventional antiseptic dressing with splint immobilization.

The subsequent treatment is usually that of a simple fracture, as infection in such cases is rare.

RIFLE--PLATE 40.

UPPER EXTREMITY.

Gunshot Fracture of the Ulna.

The course of the bullet was obliquely anteroposterior through the lower third of the forearm, striking the radial edge of the bone with a velocity of long range.

The wounds shown in plates 35 and 39 represent conditions similar to those causing this wound, except that the ranges were progressively greater.

In this case the projectile exhibited a punching effect at the point of impact, and although the lines of force are shown in characteristically divergent fissures, the energy imparted to the fragments--less than in the preceding cases--has not been sufficient to separate or to displace the fragments.

The emergency and subsequent treatment is conventionally conservative, as in the preceding cases.

RIFLE--PLATE 41.

UPPER EXTREMITY.

Gunshot Fracture of the Wrist.

Wound of entrance, posterior aspect of forearm over the lower end of the radius, with the bullet ranging forward and slightly downward to the wound of exit and covering with great laceration the anterior aspect of the wrist joint.

The range was close, and the energy of the high velocity of the missile was imparted to fragments, which, becoming “secondary missiles,” emerged with the projectile to cause extensive laceration and destruction of tissue.

The case was received for amputation in the second week, when a grave degree of infection extended in a cellulitis to the elbow. The ulnar nerve and vessels were intact, but the flexor tendons were almost entirely destroyed.

The plate, made after several weeks, when infection was under control and after the end of the radius and fragments of the carpus had been informally removed, shows a rarefaction of the carpus and proximal ends of the metacarpus, due to infection and disuse.

Frequent incisions and extension of drainage, with removal of detached fragments, was continued for several months. The wound was closed in the sixth month, with ankylosis and deformity of the wrist, as shown in plate 42.

RIFLE--PLATE 42.

UPPER EXTREMITY.

Gunshot Fracture of the Wrist.

This plate, presenting a lateral view of the wound shown in plate 41, shows considerable deformity of the joint, after four months’ treatment, which was even more marked two months later, when the case was discharged with an ankylosis of the wrist joint, contracture of the flexor tendons of the fingers, and slight flexor function of the thumb, permitting apposition with the first finger.

The result, while leaving much to be desired, preserved a function of the hand vastly superior to that of a forearm stump.

The treatment in such cases is always courageously conservative, with amputation only as the extreme measure to save life, with risks of judgment in favor of conservatism.

Corrective measures may be employed after management if the treatment of the infection is successful and when the case passes out of the military category. It is not possible, during a long infection, to maintain better position in such cases.

RIFLE--PLATE 43.

UPPER EXTREMITY.

Gunshot Fracture of the Metacarpus.

Wound of entrance, inner aspect of the hand over proximal end of the fifth metacarpal.

Wound of exit, on the outer border of the hand over the distal end of the second metacarpal.

The velocity of the bullet was in mid or long range, as it displaced no fragments, and as it made a point of entrance and exit about the same in appearance.

The wound was infected, which is more frequently the case in the hand than in the forearm.

The treatment is conservative with free incision and drainage in the management of infection.

RIFLE--PLATE 44.

UPPER EXTREMITY.

Gunshot Fracture of the Third Phalanx.

The course of the bullet was anteroposterior through the base of the proximal phalanx of the middle finger, with a velocity of long range. It practically punctured the bones and split off a few fragments without displacement.

The wound of entrance would be much the same as the wound of exit, with the latter, but a little larger.

Treatment is conservative.

RIFLE--PLATE 45.

CHEST.

Penetrating Gunshot Wound of the Chest, with Lodgment of the Projectile Near Posterior Chest Wall.

Point of entrance, pectoral border and fourth rib.

Point of exit, none.

The distinct shadow of the angle of the ribs shows that the posterior chest wall was next to the photographic plate, and that the larger and less distinct outline of the anterior portions of the upper ribs was farther from the plate.

The nearly normal size of the shadow of the projectile shows it to be much nearer the posterior than the anterior chest wall. The blurred outline shows it to have moved with respiration. Such conditions locate its position within the thoracic cavity.

The emergency treatment is antiseptic dressing and rest.

The subsequent treatment depends upon pleural involvement or the extremely rare infection of the lung.

These cases are nearly all aseptic, and if the great vessels and nerves of the chest escape injury results are generally favorable.

RIFLE--PLATE 46.

PELVIS.

Gunshot Wound of the Pelvis, with Lodgment of the Missile in the Abdomen.

The course of the bullet was from behind forward, striking the crest of the ilium, on which it was deflected, and spattering off some lead fragments. The slight penetration indicates a velocity of extremely long range and a striking energy lessened by ricochet.

The irregular outline of the shadow of the projectile shows its deformity, and the blurred outline indicates intra-abdominal movement with respiration.