Part 1
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
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 -----------------------+--------+---------+---------+-------
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.
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.