detached by a ricochet before striking the foot, which were scraped
off as it passed through the skin.
The wound was infected, and radiography was indicated for diagnosis.
[Illustration: Plate 155.]
SHRAPNEL--PLATE 155.
LOWER EXTREMITY.
Gunshot Wound of the Foot.
The sole of the foot lay next to the plate.
While the very clear, sharp outlines of the metal fragments would seem
to show them very near the plate and consequently at the platen side
of the tarsus, the foot is not of sufficient thickness to make a very
appreciable difference between shadows of such fragments on the dorsal
and on the plantar surfaces of the metatarsus. It is very probable
that the ball struck the convex, rather than the concave outline of
the transverse arch, as the missile has escaped with no fracture
of the bones, which would have been very difficult in mechanical
accomplishment if its course had been along the convex outline.
There is no fracture of the bones, although a shrapnel ball has passed
transversely through the foot, striking the heads of the second and
third metatarsals with only slight injury and leaving a few metal
particles at points of contact.
[Illustration: Plate 156.]
SHRAPNEL--PLATE 156.
LOWER EXTREMITY.
Gunshot Wound of the Left Foot by Multiple Missiles, Fracture of the
Metatarsus, and Lodgment of the Missile.
The sole of the foot lay next to the plate.
The normal outline of the shadow of the shrapnel ball shows it to lie
near the plate or at least beneath the plantar surface of the first
metatarsal. The fragments of metal lying near the fourth and fifth
metatarsals lie either in the same relation or on the plantar side
of the metatarsus. The metallic track leads to the wound of exit of
shrapnel ball, other than the one lodged.
Even though the missile has escaped, its identity can be creditably
established by the one remaining, which, it is morally certain, was
the escaped missile’s companion. These shrapnel particles again
demonstrate that the metal deposits seen in other wounds can be
identified as particles of lead scraped off from shrapnel balls in the
contact of the latter with bones.
[Illustration: Plate 157.]
OPERATIVE INTERFERENCE IN GUNSHOT WOUNDS.
In the 1,500 radiograph plates from which this collection was
selected, only four were found showing operative interference for the
repair of fractures.
While no data are available from which to determine accurately the
ratio of these operations to the entire number of fracture cases
under treatment, and as, most certainly, there were some formal
amputations, excisions, immediate immobilization of fractures, and
other operative procedures which were not submitted to radiography, it
may nevertheless be justly inferred from this radiographic evidence
that very few such operations were performed.
OPERATIONS--PLATE 157.
Gunshot Fracture of the Humerus.
This plate shows an attempt to wire a fracture of the humerus, which,
very probably, would have recovered as favorably without interference.
[Illustration: Plate 158.]
OPERATIONS--PLATE 158.
Gunshot Fracture of the Ulna.
This plate shows an attempt to wire the ulna in a clean wound.
[Illustration: Plate 159.]
OPERATIONS--PLATE 159.
Gunshot Fracture of the Radius and Ulna.
This plate shows an attempt to wire the radius and ulna where the
indications were rather doubtful.
[Illustration: Plate 160.]
OPERATIONS--PLATE 160.
Gunshot Fracture of the Tibia and Fibula.
This plate shows an attempt at immediate immobilization of the
fragments of the tibia which has failed to meet the mechanical
indications for maintaining correct position.
[Illustration: Plate 161.]
OPERATIONS--PLATE 161.
Amputation at the Knee Joint.
This plate shows a satisfactory result of a secondary amputation at
the knee, after the method of Gritti, following a severe naval shell
wound of the leg.
[Illustration: Plate 162.]
OPERATIONS--PLATE 162.
Excision of the Head of the Humerus.
This plate shows a case of Prof. De Page, of the Belgium Red Cross
Mission at Tash Kishla Hospital, in which the head of the humerus was
excised for extensive comminution of the head of the humerus with
infection.
[Illustration: Plate 163.
SOME MISSILES REMOVED FROM WOUNDED IN BALKAN WARS.
Figures reduced to two-thirds of natural size.]
PLATE 163.
Of the 46 missiles shown in the illustration, page 336, 1 to 14 are
rifle bullets; 15 to 22 are assorted fragments; 23 to 43 and including
44 are shrapnel balls; 45 is an automatic pistol ball, and 43 and 46
are the base and the fuse, respectively, of a shrapnel “nose” or
head of the 75-millimeter field gun.
Four rifle bullets, three shrapnel balls, and Nos. 20 and 27 were
removed from Turkish soldiers admitted to my service at Tash Kishla
Hospital in Constantinople. The remaining missiles, excepting No. 46,
were removed from Bulgarian soldiers on my service at the Etap and the
Queen’s Hospital at Kustendil, Bulgaria. The missile shown as No. 46
was removed by Dr. Tatarcheff, the Bulgarian surgeon in command of a
fixed hospital at Kodemos, Bulgaria, from the upper anterior thigh of
a patient whose history I have and whom I saw and photographed.
Of the fragments, Nos. 15 and 17 are pieces of the nickel jacket of
rifle bullets; No. 16 is the lead “core” of a rifle bullet; No. 22
is a fragment of the nickel jacket of a rifle bullet which holds a
small portion of the lead core; No. 18 is a brass tube which is carried
in the base of a shell to hold the detonating plunger and fulminate
cap; No. 19 is a piece of a foot plate or step of a gun carriage or
caisson; No. 20 is a shell fragment, and No. 21 is a flattened piece
of a shrapnel ball.
Of the bullets, No. 1 is Bulgarian, removed from a Bulgarian soldier
in an operation for an abdominal wound accidently inflicted during
the firing incident to the celebration attending the announcement of
peace; Nos. 6, 10, 11, and 14 are of the same caliber as the Bulgarian
and were fired from Montenegrin or Servian rifles; Nos. 2 and 3,
slightly smaller in caliber than all the others, are Greek, and Nos.
4, 5, 7, 8, 9, 12, and 13 are Servian, slightly larger than the Greek
and as much smaller than the Bulgarian. No. 1 is abraided at the base
by the jaws of a forceps by which it was removed from the wing of the
ilium in which it was firmly embedded; Nos. 4, 7, 8, 12, 13, 14 are
deformed by ricochet. No. 5 has its nose slightly abraided by the
same cause. No. 8 shows the lead core protruding from the base of the
jacket. Nos. 1, 2, 3, 6, 9, 10, and 11 are normal, as they struck the
body by direct impact. Nos. 2 and 3, which are Greek, have the nickel
jacket worn off on the apex so that the lead core is exposed, which
produces a slight degree of “dum-dum,” but as they struck the body
at very long range and without hitting a bone, they produced no
“dum-dum” effect.
Eight of the shrapnel balls were removed from the forearm of one
Bulgarian soldier. (Vide plate 109.)
No. 43 was removed from between the thoracic wall and the scapula, to
which position it passed by destroying the outer half of the clavicle,
penetrating 6 inches from the surface.
_The caliber of the missiles._
Millimeters.
Greek 6.50
Servian 7.00
Bulgarian 8.00
Montenegrin 7.05 and 8.00
For comparison it may be observed that the United States Army rifle
bullet is 7 millimeters, equal 30 caliber or 0.30 inch.
The caliber of shrapnel balls varies somewhat, as do the weight and
density, but all of them were approximately ½ inch or 125 millimeters
in diameter.
The caliber of all field guns (of modern type) in the Balkan wars were
75 millimeters, the “soixante-quinze” of the French, or about 3 inches.