Shrapnel—Plate 128.

LOWER EXTREMITY.
Gunshot Wound of the Left Knee,
with Lodgment of the Missile in the Joint.

The slight enlargement and moderate density of the shadow of the projectile indicates a position a short distance from the plate. A slight shadow dependent from the external condyle on the outside of the ball and a metallic marking just outside of the upper contour of the outer tuberosity indicate an injury to the joint and the path of the ball from above the outer tuberosity into the joint capsule.

The probabilities are that the ball lies between the head of the tibia and the patellar notch of the femur, but the absolute certainty of this deduction must be supported by an exposure in a lateral plane, which is shown in plate 129.

Shrapnel—Plate 129.

LOWER EXTREMITY.
Gunshot Wound of the Left Knee,
with Lodgment of the Missile in the Joint.

As the fibular shadow is about the normal size and clearly outlined, the fibular side of the leg lay next to the plate.

As the shadow of the ball is dense and not much enlarged, it must lie near the plate. A light shadow in front of the ball, which shows the anterior crucial ligament, and a metallic marking above the patella, suggests the path of the ball.

As this is a lateral projection of the same case that is shown in plate 128 in an antero-posterior projection, these conclusions are thus verified.

The missile lies in the joint capsule between the head of the tibia, in front of the spine, and the patellar notch of the femur.

As a foreign body in the knee joint which seriously interferes with its function, removal is indicated when surgical facilities are at hand.

The results in such cases are usually good.

Shrapnel—Plate 130.

LOWER EXTREMITY.
Gunshot Wound of the Left Knee,
with Lodgment of the Missile in the Joint.

The line of projection of the shadow is directed obliquely from behind, focussed on the internal aspect of the knee, with the fibula next to the plate. As the shadow of the shrapnel ball is much enlarged and not very dense, the ball must lie some distance from the plate and away from the fibular side of the joint. As the distances through the knee joint are about the same in all cases and as shrapnel balls are approximately the same size, it is evident that the ball lies farther away from the plate than it does in plate 129, where it is about the middle of a transverse line through the joint. It must lie, therefore, superficially between the head of the tibia and the internal condyle of the femur.

Removal is indicated under favorable surgical conditions. Infection of the joint may occasionally indicate drainage and removal as emergency treatment.

Results, except for infection, are good.

Shrapnel—Plate 131.

LOWER EXTREMITY.
Gunshot Wound of the Knee,
with Lodgment of the Missile.

That the knee is not fully extended is shown by the exaggerated outline of the tibial head.

The enlarged and only fair density of the shadow indicates that the shrapnel ball lies some distance away from the plate. As the bone is not injured, the missile must lie either in front of or behind the femur, and its enlarged shadow shows the position to be in front of the femur, just above the articular surface, and probably within the reflection of the capsular ligament.

A comparison with the size of the shadows of the balls shown in plates 128 and 130 will show this one to be greater than the former and less than the latter, and so it must bear about the same relation in the distance from the plate. This would account for the location in front instead of behind the femur.

The treatment is conservative, and removal is indicated when function is disturbed.

Shrapnel—Plate 132.

LOWER EXTREMITY.
Gunshot Wound of the Knee,
with Lodgment of the Missile.

The fibular side of the leg lay next to the photographic plate, as shown by the enlarged fainter outline of the internal tuberosity.

The shadow of the shrapnel ball is neither as normal in size as that of the external condyle nor as exaggerated as that of the internal condyle, and the position is probably neither as close to the plate as the former nor as far away as the latter.

The missiles lie about the middle of the anterior surface of the lower end of the femur, above the articular surface.

Shrapnel—Plate 133.

LOWER EXTREMITY.
Gunshot Wound of the Right Knee,
with Lodgment of the Missile.

The ball struck the outer condyle just above the articular surface with only enough energy to damage and slightly crack the bone. The injury to the bone and the metallic mark of the impact can be seen just above the outer border of the articular cartilage of the outer condyle.

Shrapnel—Plate 134.

LOWER EXTREMITY.
Gunshot Wound of the Left Knee,
with Lodgment of the Missile.

The outer tuberosity lay next to the photographic plate, with the knot in the localizing wire on the inside of the leg and farther away from the plate.

The line of projection is transversely through the tuberosities.

The shadow of the ball, as it is somewhat enlarged, not sharply defined, and of medium density, must lie about midway between the lines of the localizing wire or in the popliteal space just above and between the tuberosities, much nearer the popliteal surface than the bone. An accurate localization of the ball in a transverse line, however, would require an exposure of another plate in an antero-posterior line, but in this actual case the localization of the ball had to be made from this single plate, as only one exposure was made.

The ball struck the border of the popliteal space of the femur just above the tuberosity, without energy enough to cause a fracture, deform the ball, or even to leave, as a mark of contact, metal particles of the ball.

Shrapnel—Plate 135.

LOWER EXTREMITY.
Gunshot Wound of the Left Leg,
with Lodgment of the Missile.

The posterior surface of the leg lay next to the plate, as shown by the outline of the head of the fibula, but any estimate of distance from the plate, based on depth of the shadows, is of little value because there is no contrast between localizing-wire shadows in front of and behind the leg.

The slightly enlarged shadow of the ball indicates it to be farther from the plate than it would be if it lay behind the fibula. As the shadows of the metal fragments on the tibia are not sharp enough to indicate their position to be near the plate, the ball has lodged anteriorly between the tibia and fibula after ricocheting from the anterior surface of the tibia. The ball, being undeformed, struck the tibia with so little force that it barely penetrated the skin.

The reaction of infection in such wounds makes a diagnosis on physical examination difficult and indicates radiography.

Shrapnel—Plate 136.

LOWER EXTREMITY.
Gunshot Wound of the Leg,
with Lodgment of the Missile.

The leg lay with its posterior surface next to the photographic plate. The enlarged shadow of the ball and the blurred outlines of the metal fragments require them to be some distance from the plate and therefore on the anterior surface of the tibia.

The impact has been from within outward with so little energy that the ball only touched the internal border of the tibia and lodged beneath the skin.

Without the reaction of inflammation and infection, diagnosis could be made by palpation, but extensive swelling indicates radiography.

Shrapnel—Plate 137.

LOWER EXTREMITY.
Gunshot Fracture of the Tibia and Fibula.

The fibular side of the leg lay next to the plate, as the distinct and not exaggerated outlines of the fibula can be seen in the dense shadow of the tibia. The wound, as indicated by the callous tissue, is shown in a state of repair, after the larger detached fragments of the fracture had been removed. The wound was caused by a missile carrying considerable energy. The small particles of metal marking the course of the missile show it was a shrapnel ball.

Shrapnel—Plate 138.

LOWER EXTREMITY.
Gunshot Fracture of the Right Tibia and Fibula.

This plate shows a type of wound caused by a number of fragments of a shrapnel ball or other similar missile. The missile was deformed by a near-by ricochet, from which large and small fragments struck simultaneously and distributed themselves over a large area. The larger fragments carried enough energy to fracture the bone by transmitting all of their energy in lodgment and by possibly breaking up into smaller fragments.

In this case the energy of the missile was transmitted to the tibia, with fracture and great fragmentation of the bone. The fracture of the tibia was secondary, resulting from indirect violence, due to the loss of the support of the tibia.

Shrapnel—Plate 139.

LOWER EXTREMITY.
Gunshot Fracture of the Right Tibia and Fibula.

The course of the missile was from within outward and from before backward, striking both the fibula and the tibia, with fragmentation and displacement of both bones.

The fibula lay next to the plate, as indicated by its distinct normal shadow and the exaggerated outline of the internal malleolus.

The trail of metal fragments is typical of a shrapnel ball with the energy of high shrapnel velocity, but any lead missile without a protective jacket, under like conditions, might have produced the same effect.

The treatment is conservative until some positive indication arising in the course of an infection directs interference.

Shrapnel—Plate 140.

LOWER EXTREMITY.
Gunshot Fracture of the Left Tibia and Fibula,
with Lodgment of the Missile.

As the heel lay on the plate it is easy to identity the tibia and fibula of the left leg.

The course of the ball from the internal malleolus across to the lower end of the tibia and fibula is well marked by the trail of metal particles left by the contact of the ball with the bones. The indistinctness of the shadows of the lead particles and of the ball and the very slight enlargement of the ball indicates a contact with the anterior surface of the tibia and of the fibula with lodgment of the ball beneath the skin at the anterior border of the lower end of the fibula. The remaining energy of the missile was almost entirely spent on the tibia, causing a long oblique fracture, so that the contact with the fibula resulted in a crack only, without the separation of a fragment.

The treatment in such cases is conservative, with the subsequent removal of the ball from its superficial location.

Shrapnel—Plate 141.

LOWER EXTREMITY.
Gunshot Fracture of the Left Tibia,
with Lodgment of the Missile.

The course of the ball was from without and behind, ranging upward and inward, striking the tibia on the outer border, and causing a splitting fracture without displacement of fragments. The missile was most probably deformed by ricochet before it struck the bone, as there is too little bone injury to account for the spattering and wide distribution of the fragments by the direct impact of an undeformed ball. Two metallic fragments lying over the fibula were probably additional missiles detached from the ball as it ricocheted near the wound.

The treatment in such cases would be conservative, while meeting the indications of infection.

Shrapnel—Plate 142.

LOWER EXTREMITY.
Gunshot Fracture of the Left Fibula,
with Lodgment of the Missile.

This plate furnishes another example of the fragmentation of a shrapnel ball by ricochet on a near-by object before striking the body.

A slight fracture of the fibula is seen (at the top of the plate) with the lodgment of multiple missiles over a wide area, without other injury to the bones.

The fragments seen through the shadow of the tibia lie nearer the plate than the smaller fragments on the fibula. As the largest fragment, lying below, shows a much enlarged semicircular outline, its position is not close to the plate and it must lie superficially on the inner side of the leg.

Shrapnel—Plate 143.

LOWER EXTREMITY.
Gunshot Fracture of the Right Fibula.

This plate shows the right leg, because the calf always rests on the plate in the absence of a contraindication, which does not occur in this case, and because the slight angle of approach of the tibia and fibula identifies the relation of the lower end of these bones.

The nature of the fracture, without much fragmentation and with no displacements of fragments, indicates a slight striking energy of the missile, which was disintegrated by ricochet before striking the bone.

The fragments of a shrapnel ball, spattered on a near-by object, struck the leg in front over a wide area, as indicated by the fragments lying over the tibia and smaller ones lying on the inside of the bone. The larger metal fragment, on the fibula, is some distance from the plate, and probably lies in front of the bone, while the smaller ones, seen in sharper outline, lie behind.

Shrapnel—Plate 144.

LOWER EXTREMITY.
Gunshot Fracture of the Left Fibula.

This is another example of the condition, shown in plate 143, in which a shrapnel hall or similar missile is disintegrated by ricochet before a fleeting the wound.

By comparison of the shadows of the missiles with the shadows of the portion of the localizing wire lying nearer the plate (shown more deeply and distinctly), and with the portion lying in front of the leg, it can be concluded that the fragments lie superficially in front of the bones.

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.

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.

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.