Part 7
A slight fissure fracture of the fibula may be seen in the upper portion of the plate.
SHRAPNEL--PLATE 145.
LOWER EXTREMITY.
Gunshot Fracture of the Fibula, with Lodgment of the Missile.
The fibular side of the leg lay next to the plate.
The sharp outline, great density, and normal size of the shadow of the shrapnel ball shows the ball almost in contact with the plate.
The metallic particles marking the contact of the ball and the fibula, at the seat of a diagonal fracture, without displacement of fragments, are shown so distinctly that they must also be near the plate.
The course of the ball, therefore, was from without, ranging inward and upward with the slight energy of long (shrapnel) range. The ball lies on the fibular side superficially, just in front of the fibula.
SHRAPNEL--PLATE 146.
LOWER EXTREMITY.
Gunshot Fracture of the Right Fibula.
The plate exposed with the tibial side down shows the wound in the course of treatment, with a drainage tube in position after the detached fragments of several inches of the fibula have been removed on account of infection. Several fragments of the missile are shown on the lower fragment of the fibula.
Conservative treatment is evident and good results should follow.
SHRAPNEL--PLATE 147.
LOWER EXTREMITY.
Gunshot Wound of the Lower End of the Right Fibula.
As the heel lay next to the photographic plate, the right ankle is easily identified. The clear shadows of even the very small metallic particles show them also next to the plate and, therefore, on the posterior surface of the external malleolus, where a shrapnel ball at extremely low velocity struck and produced a slight fracture, or more of a fissure, without separation of fragment.
The joint mortise is intact, as the line of fracture does not extend to the articular surface.
The shrapnel ball in such cases would lie just beneath the skin or escape through an adjacent wound.
SHRAPNEL--PLATE 148.
LOWER EXTREMITY.
Gunshot (Pott’s) Fracture of the Left Ankle.
As the heel lies next to the plate, the left ankle is easily identified.
The course of the missile is shown by a metallic track from the internal to the external malleolus, and by a point of greater contact with the internal malleolus at the upper border of its articulation with the astragulus, resulting in an oblique fracture, separating the tip of the external malleolus.
At the point of first impact the posterior faciculus of the internal lateral ligament was severed. The missile therefore passed directly through the ankle joint, entering just behind the tip of the external malleolus, coursing over the posterior portion of the superior tibial articulation of the astragalus in front of the tendo Achillis to strike the upper articular surface of the external malleolus, with the resulting fracture. By this mechanism, the joint mortise has been widened by outward displacement of the external malleolus, while the rupture of the internal lateral ligament permitted the outward rotation of the astragulus, thus producing rather faithfully, by direct violence, a condition which might be called a “simulated Pott’s fracture” of the first degree.
By the metallic path of the missile it is known that its soft metal mass was not protected by a hard metal jacket; by the slight damage done to the bone, which lay directly in its path, its velocity and consequent energy are revealed as very slight; by the absence of larger metallic fragments it is shown that the missile was not deformed nor robbed of its energy through ricochet; and as only these conditions can be furnished by a lead ball, undeformed and traveling at low velocity, the missile was a shrapnel ball.
SHRAPNEL--PLATE 149.
LOWER EXTREMITY.
Multiple Gunshot Wound of the Leg.
This plate exhibits the characteristic marking of the metal particles of a shrapnel ball scraped off by contact with the bone, showing the course of the ball in relation to the bone.
The evidence that two shrapnel balls struck the tibia without causing a fracture indicates that the velocity of shrapnel balls is, sometimes at least, very low and that this low velocity may occur at a comparatively short range from the point where the shrapnel balls are discharged from the chamber or near the apex of the “cone of dispersion.” Such multiple wounds are caused before the balls have been so widely dispersed as when they arrive at the base of the “cone of dispersion.”
SHRAPNEL--PLATE 150.
LOWER EXTREMITY.
Gunshot Fracture of the Left Astragalus, with Lodgment of the Missile.
The external border of the foot lay next to the plate, as is shown by the articulation of the cuboid.
A fragment detached from the posterior inferior border of the astragalus and several small metal particles lying behind the fragment are in evidence.
The enlarged shadow of the ball indicates that it does not lie close to the plate, and it must then lie at least as far away as the internal surface of the calcaneus and at a depth from the sole that can be measured on the plate.
SHRAPNEL--PLATE 151.
LOWER EXTREMITY.
Gunshot Fracture of Left Calcaneus.
The fibular side lay next to the plate, as shown by the shadow of the fibula and the calcaneo-cuboid articulation.
As the metallic particles, showing the path of the missile, appear to be next to the plate, the course of the missile was from the external border of the tendo Achillis diagonally downward and forward, causing only a slight fissure of the calcaneus. A missile, to have done so little damage and to have left a metallic track showing its contact with the bone, must have been unjacketed and of low velocity, and therefore a shrapnel ball.
SHRAPNEL--PLATE 152.
LOWER EXTREMITY.
Gunshot Wound of the Heel, with Lodgment of the Missile.
The tibial side of the foot lay next to the photographic plate.
The normal size, great density, and sharp outline of the shadow of the shrapnel ball show that it lay also close to the plate and about an inch below the inside of the body of the calcaneus. No metallic particles mark the track of the ball in this case, because the course was parallel to the inner surface of the bursa without forceful, or perhaps any, contact with the bursa, and passing through soft tissue, only.
SHRAPNEL--PLATE 153.
LOWER EXTREMITY.
Gunshot Wound of the Heel, with Lodgment of the Missile.
That the inner border of the foot lay next to the plate is shown by the articulation between astragalus, scaphoid, internal cuneiform, and first metatarsal.
The metallic particles show the course of the ball from the posterior calcaneo-astragaloid ligament to below the anterior inferior border of the calcaneus.
As the shadow of the ball is enlarged and the shadow of the fragments blurred, their position is not near the plate and their location is therefore on the external plane of the calcaneus, with the ball lying near the sole.
SHRAPNEL--PLATE 154.
LOWER EXTREMITY.
Gunshot Wound of the Foot.
The plate shows, in the wound of entrance, the metal particles deposited by a shrapnel ball which passed out of the sole of the foot without damage to the bone.
The missile carried some small particles of lead, almost wholly 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.
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.
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.
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.
OPERATIONS--PLATE 158.
Gunshot Fracture of the Ulna.
This plate shows an attempt to wire the ulna in a clean wound.
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.
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.
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.
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.
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.