GUNSHOT ROENTGENOGRAMS

TABLE OF ILLUSTRATIONS.

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 = WV²  ,
      2g

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.”

Rifle Wounds

HEAD.