and 31, except that this condition is due to the impact of a missile,
with a still higher velocity of shorter range, imparting its energy to
small fragments of bone, which added their momentum to the destructive
force of the projectile.
No large fragments were carried along with the missile to cause any
more destruction of tissue in exit than in entrance, so that the skin
wounds, under these conditions, are about the same in appearance.
The treatment is conservative and expectant with immobilization.
Results in such cases are uniformly good.
[Illustration: Plate 37.]
RIFLE--PLATE 37.
UPPER EXTREMITY.
Gunshot Fracture of the Ulna.
The course of the bullet was in an anteroposterior direction at a high
velocity of short range, which, imparting its energy to the fragments,
drove some of them through the tissues as “secondary missiles” and
caused a laceration of the wound to exist.
The longitudinal fragmentation and splitting indicates a considerable
energy of the projectile, which may have been deflected, as its long
axis was turned somewhat from the trajectory at the time of impact.
The emergency treatment is antiseptic dressing and splint
immobilization.
The subsequent treatment is conservative with the removal of detached
fragments and with control of infection as the course indicates.
[Illustration: Plate 38.]
RIFLE--PLATE 38.
UPPER EXTREMITY.
Gunshot Fracture of the Left Ulna.
The course of the bullet was transverse through the middle of the
forearm, striking the posterior border of the ulna.
Small fragments were broken from the posterior wall of the medullary
canal, without destroying the longitudinal continuity of the anterior
wall.
The velocity of the bullet was probably that of mid-range, as the
striking energy of the impact was fairly great.
The posterior surface of the forearm lay next to the plate.
The emergency treatment is antiseptic dressing and splint
immobilization.
The subsequent treatment is that of a simple fracture, as infection is
not usual.
[Illustration: Plate 39.]
RIFLE--PLATE 39.
UPPER EXTREMITY.
Gunshot Fracture of the Left Ulna.
The course of the bullet, with the velocity of long range, was
anteroposterior through the lower third of the forearm, striking the
outer side of the bone. The initial velocity of the projectile was
much reduced, as is shown by the tendency to puncture the bone without
much fragmentation.
There was no displacement of fragments as a direct result of the
impact, although muscular contraction has caused some slight
subsequent overriding.
The wounds of entrance and exit were about the same, if not quite
similar in appearance.
The emergency treatment is the conventional antiseptic dressing with
splint immobilization.
The subsequent treatment is usually that of a simple fracture, as
infection in such cases is rare.
[Illustration: Plate 40.]
RIFLE--PLATE 40.
UPPER EXTREMITY.
Gunshot Fracture of the Ulna.
The course of the bullet was obliquely anteroposterior through the
lower third of the forearm, striking the radial edge of the bone with
a velocity of long range.
The wounds shown in plates 35 and 39 represent conditions similar to
those causing this wound, except that the ranges were progressively
greater.
In this case the projectile exhibited a punching effect at the
point of impact, and although the lines of force are shown in
characteristically divergent fissures, the energy imparted to the
fragments--less than in the preceding cases--has not been sufficient
to separate or to displace the fragments.
The emergency and subsequent treatment is conventionally conservative,
as in the preceding cases.
[Illustration: Plate 41.]
RIFLE--PLATE 41.
UPPER EXTREMITY.
Gunshot Fracture of the Wrist.
Wound of entrance, posterior aspect of forearm over the lower end of
the radius, with the bullet ranging forward and slightly downward to
the wound of exit and covering with great laceration the anterior
aspect of the wrist joint.
The range was close, and the energy of the high velocity of the
missile was imparted to fragments, which, becoming “secondary
missiles,” emerged with the projectile to cause extensive laceration
and destruction of tissue.
The case was received for amputation in the second week, when a grave
degree of infection extended in a cellulitis to the elbow. The ulnar
nerve and vessels were intact, but the flexor tendons were almost
entirely destroyed.
The plate, made after several weeks, when infection was under control
and after the end of the radius and fragments of the carpus had been
informally removed, shows a rarefaction of the carpus and proximal
ends of the metacarpus, due to infection and disuse.
Frequent incisions and extension of drainage, with removal of detached
fragments, was continued for several months. The wound was closed in
the sixth month, with ankylosis and deformity of the wrist, as shown
in plate 42.
[Illustration: Plate 42.]
RIFLE--PLATE 42.
UPPER EXTREMITY.
Gunshot Fracture of the Wrist.
This plate, presenting a lateral view of the wound shown in plate
41, shows considerable deformity of the joint, after four months’
treatment, which was even more marked two months later, when the case
was discharged with an ankylosis of the wrist joint, contracture of
the flexor tendons of the fingers, and slight flexor function of the
thumb, permitting apposition with the first finger.
The result, while leaving much to be desired, preserved a function of
the hand vastly superior to that of a forearm stump.
The treatment in such cases is always courageously conservative, with
amputation only as the extreme measure to save life, with risks of
judgment in favor of conservatism.
Corrective measures may be employed after management if the treatment
of the infection is successful and when the case passes out of the
military category. It is not possible, during a long infection, to
maintain better position in such cases.
[Illustration: Plate 43.]
RIFLE--PLATE 43.
UPPER EXTREMITY.
Gunshot Fracture of the Metacarpus.
Wound of entrance, inner aspect of the hand over proximal end of the
fifth metacarpal.
Wound of exit, on the outer border of the hand over the distal end of
the second metacarpal.
The velocity of the bullet was in mid or long range, as it displaced
no fragments, and as it made a point of entrance and exit about the
same in appearance.
The wound was infected, which is more frequently the case in the hand
than in the forearm.
The treatment is conservative with free incision and drainage in the
management of infection.
[Illustration: Plate 44.]
RIFLE--PLATE 44.
UPPER EXTREMITY.
Gunshot Fracture of the Third Phalanx.
The course of the bullet was anteroposterior through the base of the
proximal phalanx of the middle finger, with a velocity of long range.
It practically punctured the bones and split off a few fragments
without displacement.
The wound of entrance would be much the same as the wound of exit,
with the latter, but a little larger.
Treatment is conservative.
[Illustration: Plate 45.]
RIFLE--PLATE 45.
CHEST.
Penetrating Gunshot Wound of the Chest, with Lodgment of the
Projectile Near Posterior Chest Wall.
Point of entrance, pectoral border and fourth rib.
Point of exit, none.
The distinct shadow of the angle of the ribs shows that the posterior
chest wall was next to the photographic plate, and that the larger and
less distinct outline of the anterior portions of the upper ribs was
farther from the plate.
The nearly normal size of the shadow of the projectile shows it to be
much nearer the posterior than the anterior chest wall. The blurred
outline shows it to have moved with respiration. Such conditions
locate its position within the thoracic cavity.
The emergency treatment is antiseptic dressing and rest.
The subsequent treatment depends upon pleural involvement or the
extremely rare infection of the lung.
These cases are nearly all aseptic, and if the great vessels and
nerves of the chest escape injury results are generally favorable.
[Illustration: Plate 46.]
RIFLE--PLATE 46.
PELVIS.
Gunshot Wound of the Pelvis, with Lodgment of the Missile in the
Abdomen.
The course of the bullet was from behind forward, striking the crest
of the ilium, on which it was deflected, and spattering off some lead
fragments. The slight penetration indicates a velocity of extremely
long range and a striking energy lessened by ricochet.
The irregular outline of the shadow of the projectile shows its
deformity, and the blurred outline indicates intra-abdominal movement
with respiration.
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.
[Illustration: Plate 47.]
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.
[Illustration: Plate 48.]
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.
[Illustration: Plate 49.]
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.
[Illustration: Plate 50.]
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.
[Illustration: Plate 51.]
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.
[Illustration: Plate 52.]
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.
[Illustration: Plate 53.]
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.
[Illustration: Plate 54.]
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.
[Illustration: Plate 55.]
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.
[Illustration: Plate 56.]
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.
[Illustration: Plate 57.]
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.
[Illustration: Plate 58.]
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.
[Illustration: Plate 59.]
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.
[Illustration: Plate 60.]
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.
[Illustration: Plate 61.]
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.
[Illustration: Plate 62].
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.
[Illustration: Plate 63.]
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.