Chapter II: Part 2

While the missile, as revealed by its shadow, is not a shrapnel ball, the distribution of lead particles is more suggestive of a shrapnel than of a rifle projectile, and the ballistic conditions are more characteristic of the former than of the latter.

There was no abdominal reaction; the invasion of the abdomen was revealed by the radiograph.

The treatment in such cases is noninterference unless subsequent developments furnish definite indications.

RIFLE--PLATE 47.

LOWER EXTREMITY.

Gunshot Wound of the Gluteal Region, with Lodgment of the Bullet Near the Ischium.

Wound of entrance, over gluteal prominence on a transverse line through the great trochanter.

Wound of exit, none.

There was no bone injury in this case. The bullet, to have lodged in the soft parts after relatively slight penetration, must have struck the body at extreme range when its energy was almost spent in flight, for its normal outline indicates that it was not retarded by ricochet. The long axis is almost perpendicular to the plate. As the posterior pelvis was next to the plate, the fairly dense shadow shows the projectile was not far from the plate and behind the ischium.

The treatment is conservative; infection in such cases is extremely rare; and only pain or impaired function after many months of convalescence justifies operation for removal of the missile.

RIFLE--PLATE 48.

LOWER EXTREMITY.

Gunshot Wound of the Thigh, with Lodgment of the Bullet.

Wound of entrance, outer aspect of the thigh at the junction of the upper and middle thirds.

The slight penetration without bone injury and with slight deformity of the nose of the bullet indicates that the wound was caused by a ricochet shot at extreme range, after its energy was almost spent.

With the posterior aspect of the thigh next to the plate, the dense shadow and the nearly normal size of its outline indicate that the bullet was in the same relative position and that it lay posterior to the neck of the femur.

As such wounds are rarely infected, the treatment is conservative, and a search for the missile is only justified by serious infection, pain, or impaired function.

RIFLE--PLATE 49.

LOWER EXTREMITY.

Gunshot Wound of the Right Thigh, with Lodgment of the Bullet Behind the Femur.

There is no injury of the bone in this case, as the bullet lodged in the muscles posterior to the lower third of the femur without striking the bone. The lighter circular area of the larger end of the shadow of the projectile shows that its base is farther from the plate than its nose, which was probably flattened and bent by the ricochet which reduced its velocity so as to give it but slight power of penetration.

It is not easy to determine from inspection of the plate which side of the leg lay next to the plate.

With a history of the wound of the right thigh and with the outside of the leg next to the plate, the projectile must have lain near the plate on the outside behind the lower end of the femur, midway between the skin and bone.

The markings seen on the bone are not concerned with the wound, as the same effect in the plate is seen in the areas beside the bone.

The treatment is conservative; infection is rare.

RIFLE--PLATE 50.

LOWER EXTREMITY.

Gunshot Wound of the Right Thigh, with Lodgment of the Bullet Behind the Femur.

There is no injury to the bone. The large diameter, shortened length, and slight density of the shadow show the bullet to be some distance from and inclining toward the plate and lodged in the muscles behind the femur, nearer the side away from the photographic plate. It is difficult to identify the right or left thigh from the radiograph, but with the history of the wound in the right thigh and the outside of the leg next to the plate the ball would lie nearer the inside than the outside of the thigh, nearer the surface behind the femur. As the shadow shows irregular outline and the location of the bullet low velocity, the wound was caused by a ricochet shot at very long range.

The treatment is expectant and the course naturally favorable.

RIFLE--PLATE 51.

LOWER EXTREMITY.

Gunshot Wound of the Thigh, with Lodgment of the Missile.

As there is no injury to the bone, the bullet is not deformed. Its penetrating power was not great enough to carry it through the tissue so it must have struck the leg at extreme range when its energy was almost spent.

The actual length of the bullet is 1.25 inches; the length of the shadow is about 1.50 inches.

The increased length and the relatively slight density of the shadow indicate the bullet to be some distance from the plate. The case history places the wound in the right thigh, and the posterior surface of the leg lay next to the photographic plate. As the density of the shadow is not greater than the thickest portion of the bone, the bullet probably lies in front of the border of the outer tuberosity of the femur.

Although the surgeon’s diagnosis had to be made from the only available plate, there is something of a speculative element in these deductions, because if the reaction in the knee joint prevented the patient from extending the leg the increased length of the bullet shadow could be accounted for by this position, which would permit the bullet to lie behind the bone and yet far enough from the plate to account for the shadow enlargement. The nose of the bullet is at the epiphyseal line, which is shown in the femur.

RIFLE--PLATE 52.

LOWER EXTREMITY.

Gunshot Fracture of the Upper Shaft of the Femur.

The course of the bullet was anteroposterior and pierced the axis of the shaft of the femur with three radiating lines of fracture, resulting from the perforating action of the bullet striking the bone at long range and with greatly reduced energy.

This plate shows the lateral separation of large fragments, which is typical of gunshot wounds of long range.

Such wounds are usually not infected.

Emergency treatment is antiseptic dressing and coaptation with extension and temporary splint, so that it may support the bone for transportation and may be easily removable at place of continued treatment.

In these cases with lateral separation of fragments, it is imperative to supplement extension with pressure in a line perpendicular to the long axis of the femur.

RIFLE--PLATE 53.

UPPER EXTREMITY.

Gunshot Fracture of the Shaft of the Femur with Lodgment of the Bullet.

The course of the bullet was antero-posterior and diagonally inward from the antero-external border of upper third of the thigh. A thin longitudinal fragment was split off without transverse fracture.

The missile struck the thigh after its energy had been greatly reduced by ricocheting as a result of striking a resisting object which flattened its nose and “set up” its body, as shown by the wavy outlines of the shadows.

The dense and normal-size shadow shows the bullet to be near the plate and probably in the muscles superficially behind and below the lesser trochanter.

As the prominent outline of the lesser trochanter shows that the leg was in external rotation when the negative was made, it is evident that, with the rotation back to the anatomical position, the projection of the shadow of the bullet would fall close to or in line with the shaft of the femur; the position of the bullet is behind the femur.

The treatment is conservative, with no trouble to be expected from infection.

RIFLE--PLATE 54.

LOWER EXTREMITY.

Gunshot Fracture of the Lower End of the Shaft of the Femur.

The course of the bullet was anteroposterior through the axis of the femur. Several large fragments which were not displaced were separated by the force of impact. The separation of the fragments and the overriding of the ends of the proximal and distal large fragments were due to bearing bodily weight or to muscular contraction.

The projectile causing the wound was moving with the velocity of mid range. The wound of exit was not lacerated.

The emergency treatment is antiseptic dressing and temporary splint immobilization. Permanent dressing, with extension and lateral compression, is the rule.

Infection in such cases is frequent owing to lack of facilities for proper dressing on the field.

Results in saving life and limb are generally good.

RIFLE--PLATE 55.

LOWER EXTREMITY.

Gunshot Fracture of the Lower Third of the Shaft of the Femur.

The course of the bullet was diagonally anteroposterior, with a velocity near mid range, without causing much displacement of fragments.

The wound of entrance and exit would be almost the same in appearance.

Treatment and results would be similar to case shown on plate 54. Many of these wounds are infected, due, no doubt, to the difficulties of arranging a clean first-aid dressing and effecting satisfactory immobilization during the first stage of transportation.

Infection from clothing carried into the wound is rare, as the fairly high velocity of the bullet causes a spreading of the fibers without division or punched-out section before the bullet.

As a rule the infected cases of this class recovered without loss of limb. Amputation was very rare.

RIFLE--PLATE 56.

LOWER EXTREMITY.

Gunshot Fracture Below the Middle of the Femur, with Lodgment of the Bullet Near the Fracture.

The course of the projectile was transverse. The long splitting fracture, with few large fragments and the lodged undeformed missile, indicate that the injury to the bone was caused by the missile striking the bone with large cross section or at an inclined angle so that all of the remaining energy of the projectile at long range was absorbed by the bone.

Had the point of the ball struck the bone with the same energy, it would have produced smaller fragments and might then have passed beyond the bone. The normal size of the diameter, slightly shortened length, greater density of the point of the shadow, shows the bullet to lie behind the bone with its nose pointing slightly backward. The actual length of the bullet is 1.25 inches: the length of the shadow is 1 inch.

Treatment and results would be about the same as in plates 49 and 50.

RIFLE--PLATE 57.

LOWER EXTREMITY.

Gunshot Fracture About the Middle of the Femur, with Lodgment of the Fragments of a Deformed Bullet.

The course of the missile was transverse. All of the remaining energy of the retarded velocity of the short range of a ricochet shot was stopped by the bone with the result of a long splitting fracture, and the lodgment of one large and a few small fragments of the missile.

The small notched metal fragment lying to the right of the upper bone fragment is a small bent piece of the jacket, detached from the greatly deformed lead core, which can be faintly seen lying behind the lower end of the left side of the upper bone fragment.

The treatment is extension with lateral compression, although this case, showing by callus formation advancing convalescence, reveals very bad position.

Results as to life and limb are favorable in such cases, but some deformity is to be expected.

It should be noted that this is a case from Gulhané Hospital, the best military hospital in Constantinople, where the surgical service, under Prof. Wieting Pasha, was skillfully conducted.

RIFLE--PLATE 58.

LOWER EXTREMITY.

Gunshot Fracture of the Lower End of the Femur.

The course of the bullet was anteroposterior.

The long, oblique, splitting fracture without separate fragments indicates the long range of the missile in low velocity.

The wound was infected as is indicated by the drainage tubes in place. The well-advanced callus formation indicates established convalescence.

Results are favorable for recovery with only fair position and some shortening.

It may be observed that this is also a case from Gulhané Hospital.

RIFLE--PLATE 59.

LOWER EXTREMITY.

Gunshot Wound of the Left Knee-Joint, with Lodgment of the Missile in the Joint.

The course of the bullet was transverse, entering the capsule posterior to the patella without injury to the bone.

As its shadow projection is almost circular, the bullet must be standing almost on its end pointing toward the plate with its long axis almost parallel to the line of projection.

As the fibular side of the leg lay next to the plate and as the only slightly enlarged shadow of the bullet indicates it to be near the plate, its position is in the joint near the fibular side.

As the bullet is undeformed and its penetrating power very slight, its velocity was that of extreme range.

The emergency treatment, is, of course, a simple antiseptic dressing with the leg held in the most comfortable position by muscular action.

The subsequent treatment is removal of the bullet when proper surgical conditions obtain.

RIFLE--PLATE 60.

LOWER EXTREMITY.

Gunshot Fracture of the Tibia and Fibula, with Lodgment of the Missile.

The course of the bullet was diagonal from within outward and backward about the middle of the leg, with the impact tangential on the tibia and direct on the fibula. The bullet lies just behind the tibia.

It is apparent that the bullet has been greatly deformed and that its jacket has been badly torn from the core. The force of impact on the object from which it ricocheted must have been contributed by the velocity of short range, which reduced the striking energy so greatly that the bullet was lodged by the resistance of the tibia and fibula.

The wound was not infected, and callus formation shows that repair has begun.

The treatment in such cases, without infection, is noninterference. The lodgment of the missile need not prejudicate the prognosis, and certainly the additional damage in the search for the bullet is not warranted, except under special indications.

RIFLE--PLATE 61.

LOWER EXTREMITY.

Gunshot Fracture of the Lower Ends of the Tibia and Fibula.

The course of the bullet was transverse, with the velocity of mid-range.

The fragmentation of the fibula, lying close to the skin, would produce considerable laceration in the wound of exit.

The treatment is conservative. Infection would depend almost entirely upon the integrity of the first dressings and immobilization.

Results should be favorable, with care in subsequent treatment.

.

RIFLE--PLATE 62.

LOWER EXTREMITY.

Gunshot Fracture of the Upper Third of the Tibia, with Large Longitudinal Fragment.

The course of the bullet was anteroposterior and slightly diagonal from without inward through the shaft of the tibia.

The injury was due to the energy of impact of a bullet, in the high velocity of short range, striking the axis of the diaphysis, in which the greater part of its energy was expended in pushing away a wall of the canal.

Convalescence is well established without infection, as shown by callus formation.

The treatment in such cases is invariably conservative, with the removal of such fragments as may be detached by suppuration and sequestration.

RIFLE--PLATE 63.

LOWER EXTREMITY.

Gunshot Wound of the Middle of the Tibia, with Few Large Fragments.

The course of the bullet was transverse from without inward.

The direct impact of the bullet, in high velocity of short range, has produced the typical “X” fracture due to the radiating lines of force.

The wound was infected, as is shown by the drainage tubes in the wound.

The emergency treatment in such cases is simple antiseptic dressing and temporary splint immobilization.

The subsequent treatment is the management of the infection.

The results in such cases are favorable.

RIFLE--PLATE 64.

LOWER EXTREMITY.

Gunshot Fracture of the Tibia.

The course of the bullet was diagonal, from without inward and from before backward through the middle of the tibia. Small particles of metal have lodged at the site of the fracture--a condition which never occurs in a rifle wound with the jacket of the bullet intact, while it is the invariable accompaniment of a shrapnel wound of a bone.

It is inferred that the jacket of the bullet in this case was damaged by ricochet, or that some metal particles from the object against which the bullet ricocheted were carried into the wound, as some other small pieces of metal are seen in areas distant from the seat of fracture.

As the fragments are small and not displaced, the velocity of the missile, at least that of mid-range, was almost sufficient to perforate the bone without fracture.

RIFLE--PLATE 65.

LOWER EXTREMITY.

Gunshot Fracture of the Tibia.

The course of the bullet was transverse, from within outward, striking the bone near the outer border with the velocity of mid or long range, producing long fissures without separation of fragments.

The safety pin, of course, lies in the dressings and on the side away from the plate, as shown by its somewhat indefinite outline and increased length.

The wounds of entrance and exit are practically the same.

The treatment in such cases is that of a simple fracture, except for the management of an occasional infection, and the results are favorable.

RIFLE--PLATE 66.

LOWER EXTREMITY.

Gunshot Fracture of the Middle of the Tibia, with Lodgment of the Missile.

The course of the bullet was transverse, from without inward, striking on the side of the shaft of the tibia.

The bullet was so badly damaged by ricochet that only a portion of it was the cause of this wound.

The range was short, if not close, as the missile after striking a resisting object with force enough to break itself retained enough energy in a fragment of less than half its mass to cause a long fissure fracture, with the separation of smaller fragments.

The treatment is noninterference, except for infection, which, contrary to what might be expected from presumable contamination from the object from which it ricocheted, does not occur more frequently in ricochet than direct wounds with lodgment of the projectile.

RIFLE--PLATE 67.

LOWER EXTREMITY.

Gunshot Fracture of the Lower Third of the Tibia.

The course of the bullet, with reduced energy of long range, was anteroposterior, striking the inner border of the bone and punching out a circular area of small fragments with a single transverse line of fracture.

The wound of exit was slightly larger than the wound of entrance.

The treatment is conservative. Infection is not probable if emergency dressing is clean.

RIFLE--PLATE 68.

LOWER EXTREMITY.

Gunshot Fracture of the Lower Third of the Tibia.

The course of the bullet was diagonally anteroposterior, from without inward, striking the internal border of the anterior surface of the bone, and partially splitting off fragments from the side with a perforating effect.

The range of the shot was long.

The dense and irregular shadows to the right of the fracture are caused by the material used in dressing and indicate a slight infection. The small shadows on the tibial side are not a part of the wound, but are due to opaque material caught in the dressing.

RIFLE--PLATE 69.

LOWER EXTREMITY.

Gunshot Fracture of the Lower End of the Tibia.

The course of the bullet was transverse, from without inward, through the lower end of the bone, with a piercing effect and a fissuring of the upper fragment.

The velocity was that of short range.

The wound of exit would be slightly larger than that of entrance, as some small fragments can be seen extending along the tract of the missile from the line of transverse fracture toward the internal border of the leg. There was no laceration of the wound of exit. The wound was clean.

The treatment is conservative.

Results should be favorable. Infection would depend most probably upon the asepsis of the first dressing.

RIFLE--PLATE 70.

LOWER EXTREMITY.

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

The course of the bullet was from within outward, striking the posterior surface of the tibia about 2 inches above the ankle, and causing a slight crack in the bone at the point where its course was deflected.

The velocity was that of extreme range, as the wholly normal outline of the projectile and the slight penetration indicates that its energy was almost entirely lost in flight and not by ricochet.

The sharp outlines of the lower border of the fibula and the external border of the articular surface of the lower end of the tibia indicate the position of the fibula as next to the photographic plate.

The bullet lies at a very slight angle with the plate, as is shown by the curved outline of its base, which condition alone would give a projection shadow somewhat shorter than the bullet. But as the shadow is actually somewhat longer than the bullet (about one-eighth inch, or one-tenth its length), the position of the bullet is some distance from the plate and most probably lies behind the tibia, at the inside of the fibula.

RIFLE--PLATE 71.

LOWER EXTREMITY.

Gunshot Fracture of the Fibula.

The course of the bullet was anteroposterior through the lower third of the leg, striking the fibula squarely, passing through the bone with a perforating effect, accompanied by slight fragmentation and with a reduced velocity of long range.

The wounds of entrance and exit would be almost the same in appearance. Asepsis in such cases is the almost invariable rule, and the treatment after the simple dressing is that of a simple fracture.

RIFLE--PLATE 72.

LOWER EXTREMITY.

Gunshot Fracture of the Ankle.

The course of the bullet was anteroposterior, striking the fibula from behind with a velocity of long range, and causing some slight fragmentation without displacement of the fragments.

The joint architecture is slightly disturbed. The joint mortice is a bit widened by the external deflection of the external malleolus, which permits a slight outward rotation of the astragalus.

As the dangers of infection are usually escaped, the treatment is that for Pott’s fracture.

RIFLE--PLATE 73.

LOWER EXTREMITY.

Gunshot Wound of the Heel, with Lodgment of the Missile.

The course of the bullet was from behind forward through the insertion of the tendo Achillis and its lodgment along the outer border of the os calcis.

There was no injury to the bone. The path of the bullet is shown by the slight mottling above the posterior extremity of the os calcis.

The nose of the bullet is slightly deformed by ricochet at long range.

The very slight penetration and the slight deformity of the nose of the bullet indicates a velocity of extreme range of both impact of the ricochet and of the wound.

The sharp outline of fibula and the base of fifth metatarsal shows the fibula to be next to the plate. The only slight enlargement and square base of the shadow of the bullet show it to be parallel to the plate, or at right angles to the line of projection, and thus indicate its position to be on the fibula side of the os calcis, below the tip of the external malleolus.

RIFLE--PLATE 74.

LOWER EXTREMITY.

Gunshot Wound of the Heel.

This is the same case as shown in plate 69, but with the shadow projected from above downward instead of from side to side, as in the preceding plate. The interpretation of the shadows in the preceding plate is thus confirmed.

As the heel lay on the plate, the projectile at a sharp angle with the plane of the plate, several inches farther from the plate than in the preceding radiograph, and with the line of projection at about right angles to the long axis of the projectile, the shadow projection is considerably enlarged.

SHRAPNEL--PLATE 75.

HEAD.

Gunshot Fracture of the Vertex, with Intracranial Lodgment of the Missile.

Wound of entrance, left anterior parietal region.

Wound of exit, none.

The missile left a few small fragments spattered on the bone at point of entrance, with a slight deformation of the ball due to this cause, as shown in the plate.

The distinct outline and normal size of the ball shows it to be very near the plate and on the left side of the head, while the enlarged and blurred image of the safety pin shows its position to be on the side of the head farther away from the plate.

Emergency treatment is antiseptic dressing only. Subsequent treatment is directed to fragments and depression, without search for ball. Septic condition might indicate some later interference.

Results in such cases are favorable if wound is not infected.

SHRAPNEL--PLATE 76.

HEAD.

Gunshot Fracture of the Vertex.

Wound of entrance, upper right and mid-parietal region.

Wound of exit, none.

The missile probably was deformed before striking the skull, upon which it was fragmented by impact, with several fragments following the internal contour of the vertex and others remaining spattered about the wound of entrance.

It is probable that a larger mass of the shrapnel ball, causing the greater damage to the bone, ricocheted out of the wound.

The distinct outline of the central safety pin and the less definite image of the shrapnel fragments show the wound to have been farther from the plate than the safety pin on the left side.

The treatment is expectant, without search for the missile.

Results in such cases are favorable, except for danger of infection.

SHRAPNEL--PLATE 77.

HEAD.

Gunshot Fracture of Zygoma, with Lodgment of the Missile in the Zygomatic Fossa.

Wound of entrance, external border of right supra-orbital ridge.

Wound of exit, none.

A few metallic fragments are seen where the missile lodged near the point of impact with the bone.

The treatment is expectant. Removal of the ball from its superficial location is indicated if the wound is infected.

Result in such cases is favorable.

SHRAPNEL--PLATE 78.

HEAD.

Gunshot Fracture of the Mastoid Process.

Wound of entrance, upper posterior cheek, in front of the ear.

Wound of exit, posterior to mastoid process, lacerated.

The course of the missile was tangential, with the damage limited to the outer table of the mastoid. The metal particles scraped off of the ball by its contact with the bone mark the site of the wound.

Treatment is expectant.

Results are favorable.

SHRAPNEL--PLATE 79.

HEAD.

Gunshot Fracture of the Left Maxilla, with Lodgment of the Missile in the Neck Behind the Angle of the Jaw.

Wound of entrance, below infraorbital ridge, with course through the mouth.

Wound of exit, none.

Missile left a few small metallic fragments spattered on the bone at the point of entrance. There is slight mark of deformity of the missile caused by its contact with the bone, shown in its shadow in the plate.

The distinct outline and normal size of the ball shows it to have been on the side next to and near the plate.

Treatment indicated is expectant.

Results in such cases are favorable, as seat of probable infection is readily accessible.

In this particular case, recovery followed with the ball left _in situ_, without causing the patient trouble enough to induce him to permit interference.

SHRAPNEL--PLATE 80.

HEAD.

Gunshot Fracture of the Anterior Table of the Frontal Sinus, with Lodgment of the Missile in the Posterior Nares.

Wound of entrance, over the left internal super supra-orbital ridge, with course downward, slightly backward, and slightly to the left posterior nares.

Wound of exit, none.

The distinct outline and practically normal size of ball shows that the patient’s face was superimposed on the photographic plate, as the anterior location of the missile was suspected. The slight deformity of the ball is due to the impact with the bone. This personal case was received from the service of Prof. De Page, of the Belgian Red Cross Mission, at Josh Keshla Hospital, Constantinople, after an operation for infections of the frontal sinus, in which the anterior table was entirely removed, with free drainage into the posterior nares, before the radiograph was made or the exact location of the ball suspected. The missile is seen in the nares--very near the face--probably in the middle meatus, in the inferior turbinates, against the septum, deviated by its lodgment.

Convalescence was finally established and the frontal-sinus wound practically closed when, without any subjective symptoms, an obstruction was objectively determined in the left posterior nares, suggesting the radiograph.

The patient was so entirely free from any symptoms of the lodged missile that he wisely refused any meddlesome interference. He was discharged with sinus wound closed very remarkably without indication for plastic operation and with no symptoms.

SHRAPNEL--PLATE 81.

HEAD.

Gunshot Fracture of Anterior Table of the Parietal Bone and the Vomer, with the Lodgment of the Missile in the Posterior Nares.

This plate is a side view of the case in plate No. 80, showing the antero-posterior location of the ball.

The indefinite outline and enlarged size of the ball shows the ball to have been farther away from the plate than in plate 80.

SHRAPNEL--PLATE 82.

UPPER EXTREMITY.

Gunshot Wound of the Shoulder, with Lodgment of the Missile.

The course of the missile was transverse from the posterior surface of the greater tuberosity of the humerus to the internal border of the scapula, distributing small metallic fragments along its path.

There is no injury to the bone. The remnant of the ball has passed behind the scapula and lies near its superior angle.

The treatment in such cases is, of course, conservative, with no serious consequences expected from infection.

SHRAPNEL--PLATE 83.

UPPER EXTREMITY.

Gunshot Wound of the Shoulder, with Lodgment of the Missile.

The course of the ball was transverse through the posterior border of the deltoid muscle without contact with the bone, which would have been revealed by small particles of lead scraped off from the ball.

The actual size, normal outline, and great density of the shadow of the ball show that it lay next to the plate and that it is, therefore, lodged posterior and mesial to the glenoid portion of the scapula.

The treatment is noninterference unless removal be indicated by pain, impairment of function, or infection.

The results should always be good.

SHRAPNEL--PLATE 84.

UPPER EXTREMITY.

Gunshot Wound of the Shoulder, with Lodgment of the Missile.

The course of the bullet was from before backward and upward through the deltoid to the anterior surface of the head of the humerus.

The missile is not the conventional shrapnel ball, which is spherical and about one-half inch in diameter, for the shadow shows a larger axis in one direction with parallel sides, too symmetrical to be attributed to deformation. The ballistic conditions are those of shrapnel.

The missile struck the bone an inch or two below the point of lodgment. Its path is shown by particles of metal.

Pain or interference with function would be cause for interference in subsequent treatment, which otherwise would be expectant.

SHRAPNEL--PLATE 85.

UPPER EXTREMITY.

Gunshot Wound of the Shoulder, with Lodgment of the Missile.

The missile lies behind the head of the humerus, under conditions similar to the cases shown in plates 83 and 84.

The position of the hall is indicated by the outline and depth of shadow of the normal size of a shrapnel ball. The ball must therefore be very near the plate and behind the head of the humerus.

There is no injury to the bone. The slight deformity of the ball was caused by ricochet before it caused the wound, as no particles of lead are seen on the bone to account for the impact of the missile.

SHRAPNEL--PLATE 86.

UPPER EXTREMITY.

Gunshot Fracture of the Clavicle.

The ball ranged from before backward and upward, comminuting the outer half of the clavicle.

The fragments have been removed. The particles of metal which mark the path of the ball lie in front of the acromion process of the scapula, because lack of density and indistinct outline of the shadows show them to be farther from the photographic plate than the spine of the scapula which rested on the plate, escaping the imminent danger of wounding the subclavian vessels.

The treatment is conservative and results are favorable.

SHRAPNEL--PLATE 87.

UPPER EXTREMITY.

Gunshot Fracture of the Humerus.

The missile struck the bone and caused a long, splitting fracture, with some fragmentation of the proximal fragment.

The wound could have been caused by either a ricocheted rifle bullet or by a deformed shrapnel ball, either projectile being the low velocity of long range. These conditions are more common to shrapnel wounds, but the appearance of the larger metal fragment leads to the suspicion that it is a piece of the jacket of a rifle bullet.

The wound was not infected, and convalescence is well advanced, as is indicated by the callous formation.

SHRAPNEL--PLATE 88.

UPPER EXTREMITY.

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

The missile struck the shaft of the humerus from an anterior and external direction and caused a long diagonal splitting fracture with fragmentation, in which the bone absorbed all of the energy of the missile at the seat of fracture. The missile lies in the anterior surface of the humerus, in two fragments; the smaller, much less distinct, is seen about an inch above the larger.

The wound is not infected, and convalescence is well established, as is indicated by the callous formation, with overlapping of the fragments.

The treatment in such cases is conservative and the results are favorable.

SHRAPNEL--PLATE 89.

UPPER EXTREMITY.

Gunshot Fracture of the Humerus.

The course of the missile was from behind forward and outward, striking the bone on the posterior surface, causing a fracture with fragmentation, and lacerating the wound of exit with fragments of bones and with its own deformation.

The wound of exit is indicated in the plate.

The wound is infected.

Fragments of the missile lie on the posterior surface of the bone, as indicated by their dense shadow and distinct outline. The treatment in such cases is conservative and the results are favorable.

SHRAPNEL--PLATE 90.

UPPER EXTREMITY.

Gunshot Fracture of the Left Humerus.

The course of the missile was transverse from without inward, with a transverse fracture and fragmentation.

This wound might have been caused by either a shrapnel ball or a deformed rifle bullet, but the distribution of the metallic fragments rather indicate the course of a shrapnel ball.

The metallic fragments lie farther from the plate than the safety pin of the dressing, which, therefore, lies behind the bone and the fragments of the missile lie in front.

The treatment in such cases is conservative and the results are favorable. The subsequent course may indicate interference for mal-union.

SHRAPNEL--PLATE 91.

UPPER EXTREMITY.

Gunshot Fracture of the Left Humerus.

The course of the missile has been from without inward. The fragments of metal marking the path of the missile lie farther from the plate on the outer than on the inner side. This would indicate the former to be in front of the bone and the latter to be behind. The wound could have been caused by either a deformed rifle bullet or by a shrapnel ball, but the distribution of metallic fragments along the track of the missile rather indicates the agent to have been a shrapnel ball.

The case is similar in course and results to that shown in the preceding plate 90.

SHRAPNEL--PLATE 92.

UPPER EXTREMITY.

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

The missiles, shrapnel balls deformed by ricochet, were multiple, with a course from without inward and diagonally downward. The streaks of metal particles along the seat of fracture indicates the path of a shrapnel ball or fragment from the point of impact to the lower fragment of the fracture, where several deformed shrapnel fragments are lodged. Multiple wounds by shrapnel are common.

The wounds of entrance were small. There was no wound of exit. The wound was not infected. This is another evidence that does not defend the inference that ricocheted missiles are prone to introduce elements of infection into a wound.

The plaster dressing does not seem to meet the indications for support of the fracture.

The treatment is conservative in such cases.

Results are favorable.

SHRAPNEL--PLATE 93.

UPPER EXTREMITY.

Gunshot Fracture of the Right Humerus.

The course of the missile was transverse, from without inward and downward, striking the shaft of the bone squarely and producing a characteristic “butterfly” fracture, with a separation of the fragments.

The exposure was made with the ulnar side of the arm next to the plate, indicated by the clear outline of the internal condyle and the olecranon.

The nearly normal size of the shadow of the shrapnel ball shows it to be near the plate, and therefore to lie on the inside of the humerus. The irregular outline of the ball and the metallic fragments spattered about indicate that the ball was deformed by the detachment of fragments on direct impact with the bone. The wound is not infected.

The treatment is conservative in such cases and the results are good.

SHRAPNEL--PLATE 94.

UPPER EXTREMITY.

Gunshot Fracture of the Right Humerus.

The course of the missile was from behind forward, causing a transverse fracture of the humerus with some fragmentation.

The wound is in a state of established convalescence, with considerable separation of the ends of the large fragments and without infection, shown by the formation of callus and by an attempt at union in faulty position.

The trail of the metallic fragments of the missile from behind forward and their location near the anterior surface of the arm indicate the course of the missile, either a rifle bullet or a shrapnel ball--most probably the latter, as the lead core of the rifle ball, protected by the jacket, does not break up into as many small particles as does the shrapnel ball. The missile was deformed by ricochet before striking the bone.

The early treatment in such cases is conservative, although the subsequent course may indicate interference for malposition. The results are favorable.

SHRAPNEL--PLATE 95.

UPPER EXTREMITY.

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

The course of the missile was from before backward. The missile consisted of two large fragments of a richocheted shrapnel ball, almost spent in energy before striking the arm, as its penetration was just enough to pass through the soft parts and strike the humerus, causing a fissure without separation of fragments. The wound was clean.

The treatment in such cases is naturally conservative.

[The epiphysis of the olecranon being so distinct and showing no fusion, indicates the youth of this soldier, whose age could not have been more than 16 years.]

RIFLE--PLATE 96.

UPPER EXTREMITY.

(a) Gunshot Fracture of the Left Humerus--(b) Gunshot Fracture of the Left Elbow.

The missile was a rifle bullet with the reduced velocity of long range, passing transversely along the articulations of the elbow, fragmenting the radius and ulna and fissuring the humerus through both condyles.

The emergency treatment is antiseptic dressing and immobilization, with prompt transportation to the base.

Subsequent treatment is conservative, with proper immobilization.

Results as to limb are favorable, with probable loss of function of the elbow.

SHRAPNEL--PLATE 97.

UPPER EXTREMITY.

Gunshot Wound of the Right Elbow.

The course of the missile was superficial, downward and outward from above the internal condyle of the right humerus to the wound of exit over the internal border of the ulna. Metal fragments of the missile have lodged against the tip of the olecranum, with no fracture and with no damage to the joint. The low velocity of the missile, producing so slight a bone injury and the track of lead particles along the line of contact with the bones determines it to have been a shrapnel ball.

The wound was not infected.

The treatment in such cases is naturally conservative and the results are very favorable.

SHRAPNEL--PLATE 98.

UPPER EXTREMITY.

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

The course of the ball was from before backward, striking the lower end of the humerus squarely above and internal to the external condyle and splitting off the condyles with a line of fracture extending through the capitellum, without much separation of the fragment.

As the impact was direct, the energy producing such effect was that of low velocity.

The great radiographic penetration shown in this plate gives the shadows of the ball great distinctness and definite outline, especially in the line of fracture, although its opposite border is not in such sharp contrast. This appearance, together with the very slight enlargement, leads to the suspicion that the ball lies posteriorly, but a larger metal fragment, below the ball, is less clear and suggests a position anterior to the bone. With the posterior surface of the arm next to the plate and with but little difference in the distance from the plate to either the anterior or posterior surface of the bone, it is not easy to determine the location of the ball in the anteroposterior direction, but it would seem to be on the anterior surface of the bone.

The wound is not infected. The treatment is conservative and results favorable.

The subsequent course would probably indicate the removal of a foreign body from a site so near the joint.

SHRAPNEL--PLATE 99.

UPPER EXTREMITY.

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

Same wound as in plate 98.

The sharp holder of the greater sigmoid cavity and the head of the radius fully obscured by the coracoid process indicate, that in this exposure, the ulnar side of the arm was next to the plate.

With this condition and the enlarged shadow of the ball, the latter must lie a little distance away from the plate, and, actually, on the radial side of the humerus.

The position of the ball in the anteroposterior line is manifest, and its position confirms the deductions made therefrom in the preceding plate (98).

SHRAPNEL--PLATE 100.

UPPER EXTREMITY.

Gunshot Fracture of the Elbow.

The primary condition of this wound is not manifest from the appearance of the plate, which reveals only a destruction of the joint by fracture and an advanced stage of infection, involving the fragments and lower end of the shaft of the humerus, as indicated by the rarefaction of these parts.

Several fragments of the missile are in evidence; it is probable that others have escaped with drainage.

Drainage tubes are seen in the lower arm and upper forearm. The primary conservative treatment has been continued through two or three months.

The case is from Gulhané Military Hospital, where the scientific character of surgical service already referred to must lead to the inference that all the surgical indications have been met in the management of the case.

SHRAPNEL--PLATE 101.

UPPER EXTREMITY.

Gunshot Fracture of the Left Radius and Ulna, with Lodgment of the Missile.

The course of the missile was from within outward, striking the ulna a glancing blow just above the styloid process, fracturing the anterior surface, and then striking the internal border of the radius and causing a slight notching fracture with a longitudinal fissure.

The forearm lies in supination, with its posterior surface next to the plate. As the outline of the missile, as well as of the bone, is blurred, there is not enough differentiation in the shadows to indicate the anterior or posterior location of the missile with reference to the radius.

The shrapnel ball struck the bone with low velocity, as all of its remaining energy, absorbed by the two small bones, caused little damage and practically no displacement of fragments. The wound was not infected.

The treatment in such cases is, of course, conservative.

Results are uniformly good.

SHRAPNEL--PLATE 102.

UPPER EXTREMITY.

Gunshot Fracture of the Right Radius.

A fragmented shrapnel ball, coursing from without inward, struck the upper third of the shaft of the radius and caused a green-stick fracture. A fragment of the ball, larger than those seen in the plate, inflicted the greater damage and escaped through the wound of exit, to be seen below the large fragment on the left of the plate.

The olecranon process of the right ulna rests on the photographic plate, with the forearm in semipronation, so that the shadow of the radius falls nearly in line with that of the ulna. With the forearm restored to the anatomical position, the spattered metallic fragments, now seen lying over and to the left of the radius, would then be shown lying on the outer border of and posterior to the radius, except for the upper right metallic fragment, now lying over the ulna, which would be seen lying over the anterior surface of the radius. The six pellets seen in the lower forearm have not contributed to the injury of the bone. Their density and indefinite outline indicate a position in the forearm opposite to the side next to the plate. With the forearm in supination they would appear in their real position, in front of the ulna and on the outside of the radius.

SHRAPNEL--PLATE 103.

UPPER EXTREMITY.

Gunshot Fracture of the Right Radius.

The missile in its course from behind forward and from above downward left a trail of its metal particles along the line of its first contact until the bone yielded to the pressure in a transverse fracture.

The arm lies in slight pronation with the longitudinal ridges of the dorsal surface of the ulna, shown distinctly next to the photographic plate. The upper end of the lower radial fragment, shown as overlying the ulna, is inclined forward in the anatomical position. The metal particles are on the outer and posterior border of the radius.

The treatment in such cases is conservative.

Results as to function are uncertain.

SHRAPNEL--PLATE 104.

UPPER EXTREMITY.

Gunshot Fracture of the Ulna.

The course of the missile was tangential along side of the upper end of the ulna and internal condyle of the humerus, with a splitting effect on the ulna, which formed three fragments by breaking off the olecranon, and one lateral fragment from the shaft of the bone without displacement. The line of metallic particles shows the path of the ball in its slight contact with the bones, beginning on the side of the ulna and extending along the side of the internal condyle from where the ball escaped through the skin. The wound, not infected, was treated as simple fracture. A few fine lines on the plate above the fracture are due to scratches on the negative.

Results in such cases should be good.

SHRAPNEL--PLATE 105.

UPPER EXTREMITY.

Gunshot Fracture of the Right Metacarpus.

The course of the missile was from the outer border of the hypothnear eminence diagonally downward through the palm, lodging against the second metacarpal bone with fracture of last four metacarpals.

The metal particles are not seen on the fourth and fifth metacarpals because the violence at these points was transmitted through soft parts, but the projectile spent its remaining energy directly against the second and third metacarpals.

The palm of the hand was next to the photographic plate, as indicated by the immediate contact of the thumb. The shadow of the bones is not dense, but in deep contrast with the shadows of the ball and metal fragments, which are so clearly outlined with the ball of normal size that the ball is thus shown to lie on the palmar side of the hand.

The treatment is conservative, with judicious interference when opportunity shall offer for removal of the missile.

SHRAPNEL--PLATE 106.

UPPER EXTREMITY.

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

The palm of the hand lies next to the plate. The ball is very slightly enlarged and the small metal fragments are indistinct, indicating that they and the ball lie on the back of the hand.

The ball struck the third knuckle and lodged beneath the skin between the fourth and fifth metacarpals, fracturing both bones without displacement of fragments. In the recent wound the condition would be apparent, but after days of inflammatory reaction and infection, the swelling is too great to make any determination by palpation.

The treatment is removal of the missile. Good results regularly follow.

SHRAPNEL--PLATE 107.

UPPER EXTREMITY.

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

The hand lies with its ulnar side next to the plate, as is indicated by the sharp outline of the swollen hypothenar eminence, nearer the plate than the thumb, with the enlarged, poorly defined, and rarefied shadow of its metacarpal and phalanges.

As the normal size of the balls and the clear outline of the metal fragments must place them almost in contact with the plate, the ball is located near the fifth metacarpal. As this is the same case as is shown in plate 106, the conclusions drawn from each plate are confirmed by the other.

The wound is infected, as indicated by the swelling of the palm.

The treatment is removal of the missile, with management of the infection.

SHRAPNEL--PLATE 108.

UPPER EXTREMITY.

Gunshot Wound of the Left Hand, with Lodgment of the Missile.

The shadow of the hand is shown with the palm next to the plate, as indicated by the small, well-defined outline of the first metacarpal lying within the outline of the larger and less-defined shadow of the second metacarpal. The third finger is flexed at the first phalangeal joint, and the end of the second phalanx is outlined in deeper shadow, with its long axis vertical to the plate.

The position raises the first finger from the plate and very slightly enlarges the size of the shadow of the bullet, although it retains its sharp outline. The shadow of the ball being very nearly the normal size, the ball lies on the palmar side of the third metacarpo-phalangeal joint. It entered the hand on the outer border of the base of the first finger, and left a fragment of metal on its slight contact with the bone. The ball was deformed by ricochet before striking the hand, with almost completely spent velocity. The wound is infected.

The treatment is the management of infection.

SHRAPNEL--PLATE 109.

UPPER EXTREMITY.

Multiple Gunshot Wounds of the Right Hand and Forearm, with Fracture of the Metacarpus and Phalanges and Lodgment of the Missile.

The hand lay with the palmar surface next to the plate. The distinct outline of the small metal fragments and the natural size of the shadow of the undeformed shrapnel ball show that they lay on the anterior side of the metacarpus. The arrangements of the metal particles and bone fragments and the indication of the point of entrance of one wound on the outer border of the metacarpal of the thumb indicate the course of the balls to have been from the radial to the ulna side of the palm. The undeformed ball, then, lies, most probably, in front of the second metacarpal. The deformed ball shows, in its enlarged shadow and not so distinct in outline as the normal ball, that it is on the dorsal surface of the third and fourth metacarpals.

The undeformed ball caused the fracture of the phalanx and metacarpal of the thumb; the deformed ball fractured the neck of the third metacarpal; a ball which escaped from the wound and touched the base of the first phalanx of the middle finger and fractured the first phalanx of the little finger; and another ball, which glanced along the anterior surface of the lower end of the shaft of the radius and left a deposit of metal to mark its course, also escaped from the ulnar border of the forearm at a point indicated in the plate.

Four balls were concerned with this wound; two of them have lodged with some damage and two others have escaped, after inflicting a slight injury. Multiple shrapnel wounds are common. It may be said that the greater the number of balls lodged in a given area the less the distance of the plane from the apex of the cone of dispersion of a shrapnel discharge.

Several shrapnel balls, lodged in a small area without causing much damage or exhibiting much power of penetration, indicate low velocity at close range of shrapnel balls on discharge from the shrapnel envelope.

In a personal case, eight shrapnel balls were removed from a forearm.

SHRAPNEL--PLATE 110.

CHEST.

Gunshot Wound of the Chest, with Lodgment of the Missile in the Lung.

The posterior chest wall is next to the plate, as the posterior rib shadows are much more distinct and much smaller than the shadows of the anterior ribs.

The shadow of the ball is blurred, which shows that it moved with respiration and is, therefore, probably in the lung. The shadow is only slightly enlarged and is fairly dense, which indicates it to be not far from the ribs and, therefore, in the posterior portion of the lung.

The treatment of such cases is conservative; infection is not common; hæmothorax pleurisy, empyema, pneumonia, and pulmonary abscess are most frequent complications, named in the order of frequency. Pulmonary abscess is very rare. Pneumonia was seen in a personal case.

SHRAPNEL--PLATE 111.

CHEST.

Gunshot Wound of Chest, with Lodgment of the Missile Superficially.

While the missile is not a shrapnel ball, it presents similar conditions and does not need to be separately classified.

The vertebral border of the scapula is distinctly shown in light shadow, indicating its position near the plate.

The outline of the missile is so distinct and the shadow so dense that it must lie near the plate, and is located superficially in the infraspinatus fossa.

SHRAPNEL--PLATE 112.

CHEST.

Gunshot Wound of the Chest, with Fractured Rib and Lodgment of the Missile in the Axilla.

The back of the patient lay on the plate, as is indicated by the normal size of the ribs behind and the exaggerated outline in front.

The ball struck the sixth rib behind and caused a fracture at the angle. It then continued its course to the axilla. The normal size of the shadow of the ball indicates that it lies superficially behind the head of the humerus.