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
[Illustration]
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
-----------------------+--------+---------+---------+-------
[Illustration: Plate 1.]
RIFLE--PLATE 1.
HEAD.
Gunshot Fracture of the Skull, with Lodgment of the Missile.
The bullet in this case was so badly deformed by ricochet that part
of both core and jacket were lost. While the appearance of the shadow
seems to indicate a direct impact of the nose of the bullet, the
line of contact with the skull must have been tangential, with some
laceration of the scalp; otherwise a cursory examination of the scalp
wound would have revealed the slightly protruding end of the bullet.
The dark shadow above the projectile is due to material used in
dressing. The great thickening of the scalp in the region of the wound
shows a marked cellulitis. Small particles of the lead core of the
bullet can be seen about the wound.
In such cases there is often a marked infection of the scalp without
extension of infection to the cranial cavity, except from neglect.
This is a case, though apparently simple, in which the radiograph was
necessary for correct diagnosis without exploration.
The treatment in such cases is conservative, with removal of the
projectile and care of the superficial infection or subsequent
complications.
[Illustration: Plate 2.]
RIFLE--PLATE 2.
HEAD.
Gunshot Wound of the Head, with Lodgment of the Missile.
Wound of entrance, near outer canthus, with course through eyeball to
ethmoid body.
Wound of exit, none.
The Bulgarian Mannlicher bullet, shown half actual size on the plate,
must be inclined on its long axis, about 30° from the perpendicular,
to the plane of the plate.
The slight penetration of the missile and its normal character show
that, having struck no intervening object, it indicted the wound at
extreme range.
The treatment should meet the indication for removal of missiles in
all superficial or easily accessible locations and when they cause
reaction.
Results to be expected are favorable except for loss of the eye.
[Illustration: Plate 3.]
RIFLE--PLATE 3.
HEAD.
Gunshot Fracture of the Ramus of the Lower Jaw.
Wound of entrance, in the cheek behind the angle of the mouth.
Wound of exit, below the tip of the mastoid.
The course of the bullet was almost tangential to the ramus of the
jaw, anteroposteriorly. The slight fragmentation, which is hardly
more than a splitting of the bone, with little or no displacement,
indicates that the wound was made by a rifle bullet at moderate
velocity and at mid or long range.
Treatment is expectant.
Results are favorable.
[Illustration: Plate 4.]
RIFLE--PLATE 4.
HEAD.
Gunshot Fracture of the Ramus of the Lower Jaw.
Wound of entrance, over the anterior border of the right ramus.
Wound of exit, beneath the lobe of the ear.
The wound was made by a rifle bullet with the velocity of long range,
because wounds of a shrapnel ball never show such slight injury
without lodgment or without marks of lead.
The damage of the bone was very slight, as only a superficial fragment
was chipped off. There were no signs of primary infection. Reaction
and periostitis suggested the radiograph after infection had rarefied
the fragment, shown but very faintly on the left side of the plate.
The postero-anterior skull radiograph was made with the face
superimposed upon the photographic plate.
Treatment, incision and drainage.
Results, good.
[Illustration: Plate 5.]
RIFLE--PLATE 5.
HEAD.
Gunshot Fracture of the Body of Lower Jaw, with Great Fragmentation
and Displacement.
Wound of entrance, to the left side of the median line of the lower
jaw below the alveolar process, with course ranging downward and
backward.
Wound of exit, with extensive laceration, beneath lower border of the
bone.
The wound was caused by a rifle bullet at high velocity at or less
than mid range. The fragments are many and rather small, so that much
bone was lost through the wound of exit. This effect was produced by
the splitting due to the relative friability of the bone and to the
imparting of the momentum of the missile to the detached fragments,
which, together with the missile, effected the considerable laceration
of the wound of exit.
Treatment, difficult; guided by septic conditions and surgical means
available.
Results in such cases are favorable to life but topically
unsatisfactory.
[Illustration: Plate 6.]
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.
[Illustration: Plate 7.]
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.
[Illustration: Plate 8.]
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.
[Illustration: Plate 9.]
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.
[Illustration: Plate 10.]
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.
[Illustration: Plate 11.]
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.
[Illustration: Plate 12.]
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.
[Illustration: Plate 13.]
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.
[Illustration: Plate 14.]
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.
[Illustration: Plate 15.]
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.
[Illustration: Plate 16.]
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.
[Illustration: Plate 17.]
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.
[Illustration: Plate 18.]
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.
[Illustration: Plate 19.]
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.
[Illustration: Plate 20.]
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.
[Illustration: Plate 21.]
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.
[Illustration: Plate 22.]
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.
[Illustration: Plate 23.]
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.
[Illustration: Plate 24.]
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.
[Illustration: Plate 25.]
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.
[Illustration: Plate 26.]
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.
[Illustration: Plate 27.]
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.
[Illustration: Plate 28.]
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.
[Illustration: Plate 29.]
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.
[Illustration: Plate 30.]
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.
[Illustration: Plate 31.]
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.
[Illustration: Plate 32.]
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.
[Illustration: Plate 33.]
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.
[Illustration: Plate 34.]
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.
[Illustration: Plate 35.]
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.
[Illustration: Plate 36.]
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.