Part 2

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

RIFLE--PLATE 29.

UPPER EXTREMITY.

Gunshot Fracture of the Lower End of the Radius.