fusion, indicates the youth of this soldier, whose age could not have
been more than 16 years.]
[Illustration: Plate 96.]
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.
[Illustration: Plate 97.]
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.
[Illustration: Plate 98.]
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.
[Illustration: Plate 99.]
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).
[Illustration: Plate 100.]
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.
[Illustration: Plate 101.]
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.
[Illustration: Plate 102.]
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.
[Illustration: Plate 103.]
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.
[Illustration: Plate 104.]
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.
[Illustration: Plate 105.]
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.
[Illustration: Plate 106.]
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.
[Illustration: Plate 107.]
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.
[Illustration: Plate 108.]
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.
[Illustration: Plate 109.]
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.
[Illustration: Plate 110.]
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.
[Illustration: Plate 111.]
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.
[Illustration: Plate 112.]
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.
The wound of the rib was infected superficially, and the secretion of
the wound carried away the most of the metal particles which the ball
in striking deposited on impact.
[Illustration: Plate 113.]
SHRAPNEL--PLATE 113.
CHEST.
Gunshot Wound of the Chest, with Lodgment of the Missile in the Axilla.
There is no wound of the bone.
The ball lies in the axilla, behind, not close to, the plate, because
the density of the shadow is not very great and the size is slightly
enlarged. The distance from the plate is probably that of the
mid-axillary line.
The wound is not infected. Pain and impaired movement of the arm
suggested localization of the missile and indicate removal in the
subsequent course of treatment.
[Illustration: Plate 114.]
SHRAPNEL--PLATE 114.
CHEST.
Gunshot Wound of the Chest, with the Lodgment of the Missile in the
Axilla.
The posterior chest wall lay next to the plate.
The almost normal size of the shadow of the ball indicates that it
lies near the plate, and the blurred outline shows that it has moved
with the chest in respiration. The ball lies, therefore, in the
posterior axilla near the middle of the outer border of the scapula,
imbedded in the thoracic muscles.
The treatment is expectant. Such wounds are rarely infected. Pain or
impairment of function only would indicate removal of the missile from
a clean wound.
[Illustration: Plate 115.]
SHRAPNEL--PLATE 115.
PELVIS.
Gunshot Fracture of the Crest of the Right Ilium, with Lodgment of the
Missile.
As the wound was received while the soldier was lying prone, the
course of the missile in the body was from above downward, striking
the crest of the ilium, on which it was fragmented, and trailing its
fragments as far down as the great trochanter. The injury to the ilium
was a crushing fracture, with the displacement of small fragments from
the antero-superior spine.
As the sacrum was next to the photographic plate, the missile, judging
from its indistinct shadow, lies farther from the plate and in front
of the bone. The relative distinctness of the large fragment seen on
the wing of the ilium indicates its probable position to be on the
outside of the ilium.
The trail of the smaller metal fragments lies between the
antero-superior spine and the great trochanter, anterior to the plane
of the femur.
The treatment in such cases is always conservative.
[Illustration: Plate 116.]
SHRAPNEL--PLATE 116.
LOWER EXTREMITY.
Gunshot Wound of the Thigh, with Lodgment of the Missile.
With the posterior aspect of the thigh lying next to the plate, the
very greatly enlarged shadow of the deformed shrapnel ball indicates
that it lies a relatively great distance from the plate, so that its
location can be determined to be near the internal border of the
adductor muscles, anteriorly, and below the transverse plane of the
lesser trochanter.
[Illustration: Plate 117.]
SHRAPNEL--PLATE 117.
LOWER EXTREMITY.
Gunshot Wound of the Thigh, with Lodgment of the Missile.
With the sacrum lying next to the plate, the normal size, clear
outline, and dense shadow of the shrapnel ball indicates its position
to be near the plate. The location can be roughly estimated as the
superficial gluteal region, external to the ramus of the ischium and
near the aerior plane of the upper border of the acetabular cavity.
[Illustration: Plate 118.]
SHRAPNEL--PLATE 118.
LOWER EXTREMITY.
Gunshot Wound of the Thigh, with Lodgment of the Missile.
The normal size, distinct outline, and considerable density of the
shadow of the shrapnel ball show that it lies very near the plate,
posterior to the bone and in the buttocks, quite superficially.
The treatment in such cases is always conservative. Pain or impairment
of function indicate removal after convalescence.
[Illustration: Plate 119.]
SHRAPNEL--PLATE 119.
LOWER EXTREMITY.
Gunshot Fracture of the Femur, with Lodgment of the Missile.
The direct subtrochanteric impact disintegrated the missile and
delivered all of its energy to the bone, with a resulting transverse
fracture of the upper end of the shaft of the femur and longitudinal
fragmentation of the shaft. The course of the shrapnel ball was from
behind forward and from above downward, as is shown by the track of
the metal fragments and the lodgment of a larger lead fragment on the
shaft below the seat of fracture. The uppermost large lead fragment,
as shown by the depth of its shadow, lies farther behind the bone and
nearer to the photographic plate than do the other pieces of the ball,
as indicated by their lighter shadows. All of the fragments seem to
lie behind the bone.
The conservative treatment of this wound is justified by the
attempt at repair, as indicated by the callus formation; but it is
manifest, from the extremely faulty position, that the indication for
immobilization and extension in strong abduction were not appreciated.
Proper management of conservative treatment in such cases gives good
results.
[Illustration: Plate 120.]
SHRAPNEL--PLATE 120.
LOWER EXTREMITY.
Gunshot Fracture of the Femur, with Lodgment of Multiple Missiles.
The position of the femur is in outward rotation, as shown by the
full shadow of the lesser trochanter and the vanishing of the greater
trochanter behind the shoulder of the neck. The two larger missiles
lie on the outer side of the bone and the others lie in front on the
seat of fracture. The greatly deformed shrapnel balls and the slight
chipping fracture of the femur indicate that the greater portion of
the striking energy of the missiles was so dissipated in ricochet that
but little force was left for attack on the bone.
The treatment in such cases is expectant and indication rarely arises
for search for and removal of the missiles.
[Illustration: Plate 121.]
SHRAPNEL--PLATE 121.
LOWER EXTREMITY.
Gunshot Fracture of the Shaft of the Femur, with Lodgment of the
Missile.
The course of the shrapnel ball was from within outward, striking the
femur with the energy of high (shrapnel) velocity, with fragmentation
of the missile by impact on the bone. The largest fragment, by the
distinct outline of its shadow, lies close to the plate and behind the
bone; a smaller metal fragment has been carried to the outer border of
the thigh, where it lies superficially; another fragment lies in the
seat of fracture.
The position of fragments is faulty, as the indications for extension
and abduction have not been wholly met, although this is a case from
the well-conducted service of Gulhané Hospital.
The treatment in such cases is conservative and the results are good.
[Illustration: Plate 122.]
SHRAPNEL--PLATE 122.
LOWER EXTREMITY.
Gunshot Fracture of the Shaft of the Femur, with Lodgment of the
Missile.
The shrapnel ball, in its almost directly antero-posterior course from
behind forward, has delivered the energy of high (shrapnel) velocity
to the bone, which had absorbed it all in stopping the missile, with
a resulting approach to a butterfly fracture with displacement of
fragments.
The upper end of the lower fragment lies nearer to the plate than to
the lower end of the upper fragment, with the deformed shrapnel ball
lying behind the latter, closer to the plate.
The treatment in such cases is conservative, with good results to
follow except as they may be imperiled by infection.
[Illustration: Plate 123.]
SHRAPNEL--PLATE 123.
LOWER EXTREMITY.
Gunshot Fracture of the Femur, with Lodgment of the Missile.
While the missile in this case may have been other than a shrapnel
ball, the fracture is one produced by the impact of a missile
delivering great striking energy, with a predominant cross-section
factor in its composition. The fragments are due to the application
of an energy in which the mass was distributed over a relatively
large area on bone, which resulted in the displacement of the large
fragments.
The treatment in such cases is conservative.
Results are favorable; infection is generally controlled.
[Illustration: Plate 124.]
SHRAPNEL--PLATE 124.
LOWER EXTREMITY.
Gunshot Fracture of the Femur, with Lodgment of Multiple Missiles.
The direct impact of two shrapnel balls, delivering all of their
energy to the femur, resulted in a fracture with large fragments.