,transcriber's ,note3 ,underscores 80 before and after a word or phrase indicate italics in the original text4 ,small capitals have been converted to ,,solid capitals4 ,old or antiquated spellings have been preserved4 ,on ,pg #agc1 the reference to 8plate ,no4 #ha0 was corrected to 8plate ,no4 #hj04 ,on ,pg #aha1 the references to 8plates #he and #hf0 was corrected to 8plates #hc and #hd04 ,,war ,,department 33 ,,office ,,of ,,the ,,surgeon ,,general ,,bulletin ,no4 #i ,,october1 #aiae ,,gunshot ,,roentgenograms ,a ,,collection ,,of ,,roentgenograms ,,taken ,,in ,,constantinople ,,during ,,the ,,turko-,,balkan ,,war1 #aiab-aiac1 ,,illustrating ,,some ,,gunshot ,,wounds ,,in ,,the ,,turkish ,,army ,,by ,,clyde ,s4 ,,ford ,major1 ,medical ,corps ,,published ,,by ,,authority ,,of ,,the ,,act ,,of ,,congress ,,approved ,,march #c1 #aiae1 ,,and ,,with ,,the ,,approval ,,of ,,the ,,secretary ,,of ,,war1 ,,for ,,the ,,information ,,of ,,medical ,,officers ,illustration ,,washington ,,government ,,printing ,,office #aiaf ,,table ,,of ,,illustrations4 ,,rifle ,,wounds4 ,,head4 ,page4 ,,plate #a4 ,gunshot fracture1 skull1 lodgment of missile #ab #b4 ,gunshot fracture1 head1 lodgment of missile #ad #c4 ,gunshot fracture1 lower jaw1 ramus #af #d4 ,gunshot fracture1 lower jaw1 ramus #ah #e4 ,gunshot fracture1 lower jaw1 body #bj ,,spinal ,,region4 #f4 ,gunshot wound1 spinal region1 lodgment of missile #bb #g4 ,gunshot wound1 spinal region1 lodgment of missile #bd ,,upper ,,extremity4 #h4 ,gunshot fracture1 humerus #bf #i4 ,gunshot fracture1 humerus1 lodgment of missile #bh #aj4 ,gunshot fracture1 humerus1 lodgment of missile #cj #aa4 ,gunshot fracture1 humerus #cb #ab4 ,gunshot fracture1 humerus #cd #ac4 ,gunshot fracture1 humerus #cf #ad4 ,gunshot fracture1 humerus1 lodgment of missile #ch #ae4 ,gunshot fracture1 humerus1 external condyle #dj #af4 ,gunshot fracture 7a7 humerus1 7b7 ulna #db #ag4 ,gunshot fracture1 elbow #dd #ah4 ,gunshot fracture1 elbow #df #ai4 ,gunshot fracture1 elbow #dh #bj4 ,gunshot fracture1 elbow #ej #ba4 ,gunshot fracture1 radius and ulna #eb #bb4 ,gunshot fracture1 radius and ulna #ed #bc4 ,gunshot fracture1 radius and ulna #ef #bd4 ,gunshot fracture1 radius and ulna #eh #be4 ,gunshot fracture1 radius #fj #bf4 ,gunshot fracture1 radius #fb #bg4 ,gunshot fracture1 radius #fd #bh4 ,gunshot fracture1 radius #ff #bi4 ,gunshot fracture1 radius1 lower end #fh #cj4 ,gunshot fracture1 radius1 lower end #gj #ca4 ,gunshot fracture1 radius1 lower end #gb #cb4 ,gunshot fracture1 ulna #gd #cc4 ,gunshot fracture1 ulna #gf #cd4 ,gunshot fracture1 ulna #gh #ce4 ,gunshot fracture1 ulna #hj #cf4 ,gunshot fracture1 ulna #hb #cg4 ,gunshot fracture1 ulna #hd #ch4 ,gunshot fracture1 ulna #hf #ci4 ,gunshot fracture1 ulna #hh #dj4 ,gunshot fracture1 ulna #ij #da4 ,gunshot fracture1 wrist #ib #db4 ,gunshot fracture1 wrist #id #dc4 ,gunshot fracture1 metacarpus #if #dd4 ,gunshot fracture1 phalanx #ih ,,chest4 #de4 ,gunshot wound1 chest #ajj ,,pelvis4 #df4 ,gunshot wound1 pelvis #ajb ,,lower ,,extremity4 #dg4 ,gunshot wound1 gluteal region #ajd #dh4 ,gunshot wound1 thigh #ajf #di4 ,gunshot wound1 thigh #ajh #ej4 ,gunshot wound1 thigh #aaj #ea4 ,gunshot wound1 thigh #aab #eb4 ,gunshot fracture1 femur #aad #ec4 ,gunshot fracture1 femur #aaf #ed4 ,gunshot fracture1 femur #aah #ee4 ,gunshot fracture1 femur #abj #ef4 ,gunshot fracture1 femur #abb #eg4 ,gunshot fracture1 femur #abd #eh4 ,gunshot fracture1 femur #abf #ei4 ,gunshot wound1 knee #abh #fj4 ,gunshot fracture1 tibia and fibula #acj #fa4 ,gunshot fracture1 tibia and fibula #acb #fb4 ,gunshot fracture1 tibia #acd #fc4 ,gunshot fracture1 tibia #acf #fd4 ,gunshot fracture1 tibia #ach #fe4 ,gunshot fracture1 tibia #adj #ff4 ,gunshot fracture1 tibia #adb #fg4 ,gunshot fracture1 tibia #add #fh4 ,gunshot fracture1 tibia #adf #fi4 ,gunshot fracture1 tibia #adh #gj4 ,gunshot fracture1 tibia #aej #ga4 ,gunshot fracture1 fibula #aeb #gb4 ,gunshot fracture1 ankle #aed #gc4 ,gunshot wound1 heel #aef #gd4 ,gunshot wound1 heel #aeh ,,shrapnel ,,wounds4 ,,head4 #ge4 ,gunshot fracture1 vertex #afj #gf4 ,gunshot fracture1 vertex #afb #gg4 ,gunshot fracture1 zygoma #afd #gh4 ,gunshot fracture1 mastoid process #aff #gi4 ,gunshot fracture1 maxilla #afh #hj4 ,gunshot fracture1 supra-orbital #agj #ha4 ,gunshot fracture1 supra-orbital #agb #hb4 ,gunshot wound1 shoulder #agd #hc4 ,gunshot wound1 shoulder #agf #hd4 ,gunshot wound1 shoulder #agh #he4 ,gunshot wound1 shoulder #ahj #hf4 ,gunshot fracture1 clavicle #ahb #hg4 ,gunshot fracture1 humerus #ahd #hh4 ,gunshot fracture1 humerus #ahf #hi4 ,gunshot fracture1 humerus #ahh #ij4 ,gunshot fracture1 humerus #aij #ia4 ,gunshot fracture1 humerus #aib #ib4 ,gunshot fracture1 humerus #aid #ic4 ,gunshot fracture1 humerus #aif #id4 ,gunshot fracture1 humerus #aih #ie4 ,gunshot fracture1 humerus #bjj #if4 ,gunshot fracture1 humerus and elbow #bjb #ig4 ,gunshot fracture1 elbow #bjd #ih4 ,gunshot fracture1 elbow #bjf #ii4 ,gunshot fracture1 elbow #bjh #ajj4 ,gunshot fracture1 elbow #baj #aja4 ,gunshot fracture1 radius and ulna #bab #ajb4 ,gunshot fracture1 radius #bad #ajc4 ,gunshot fracture1 radius #baf #ajd4 ,gunshot fracture1 ulna #bah #aje4 ,gunshot fracture1 metacarpus #bbj #ajf4 ,gunshot fracture1 metacarpus #bbb #ajg4 ,gunshot fracture1 metacarpus #bbd #ajh4 ,gunshot wound1 hand #bbf #aji4 ,gunshot wound1 multiple1 hand and forearm #bbh ,,chest4 #aaj4 ,gunshot wound1 chest #bcj #aaa4 ,gunshot wound1 chest #bcb #aab4 ,gunshot wound1 chest #bcd #aac4 ,gunshot wound1 chest #bcf #aad4 ,gunshot wound1 chest #bch ,,pelvis4 #aae4 ,gunshot fracture1 ilium #bdj ,,lower ,,extremity4 #aaf4 ,gunshot wound1 thigh #bdb #aag4 ,gunshot wound1 thigh #bdd #aah4 ,gunshot wound1 thigh #bdf #aai4 ,gunshot wound1 femur #bdh #abj4 ,gunshot wound1 femur #bej #aba4 ,gunshot wound1 femur #beb #abb4 ,gunshot wound1 femur #bed #abc4 ,gunshot wound1 femur #bef #abd4 ,gunshot wound1 femur #beh #abe4 ,gunshot wound1 femur #bfj #abf4 ,gunshot wound1 femur #bfb #abg4 ,gunshot wound1 femur #bfd #abh4 ,gunshot wound1 knee #bff #abi4 ,gunshot wound1 knee #bfh #acj4 ,gunshot wound1 knee #bgj #aca4 ,gunshot wound1 knee #bgb #acb4 ,gunshot wound1 knee #bgd #acc4 ,gunshot wound1 knee #bgf #acd4 ,gunshot wound1 knee #bgh #ace4 ,gunshot wound1 leg #bhj #acf4 ,gunshot wound1 leg #bhb #acg4 ,gunshot fracture1 tibia and fibula #bhd #ach4 ,gunshot fracture1 tibia and fibula #bhf #aci4 ,gunshot fracture1 tibia and fibula #bhh #adj4 ,gunshot fracture1 tibia and fibula #bij #ada4 ,gunshot fracture1 tibia #bib #adb4 ,gunshot fracture1 fibula #bid #adc4 ,gunshot fracture1 fibula #bif #add4 ,gunshot fracture1 fibula #bih #ade4 ,gunshot fracture1 fibula #cjj #adf4 ,gunshot fracture1 fibula #cjb #adg4 ,gunshot fracture1 fibula #cjd #adh4 ,gunshot fracture1 8,pott's0 #cjf #adi4 ,gunshot wound1 multiple1 leg #cjh #aej4 ,gunshot fracture1 astragalus #caj #aea4 ,gunshot fracture1 calcaneus #cab #aeb4 ,gunshot wound1 heel #cad #aec4 ,gunshot wound1 heel #caf #aed4 ,gunshot wound1 foot #cah #aee4 ,gunshot wound1 foot #cbj #aef4 ,gunshot wound1 foot1 multiple #cbb ,,operative ,,interference1 ,,gunshot ,,wounds4 #aeg4 ,gunshot fracture1 humerus #cbd #aeh4 ,gunshot fracture1 ulna #cbf #aei4 ,gunshot fracture1 radius and ulna #cbh #afj4 ,gunshot fracture1 tibia and fibula #ccj #afa4 ,amputation1 knee #ccb #afb4 ,excision1 head of humerus #ccd ,,introduction ,these roentgenograms are not presented as exhibiting a state of perfection in the art or method by which they were produced1 although they show the results of some of the best and most modern apparatus of ,europe employed in the hands of very skillful operators4 ,some plates are included which are indistinct and generally so unsatisfactory from a technical viewpoint as to be of little interest1 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 ,war4 ,the collection of these plates resulted from a systematic visiting of the hospitals of ,constantinople in the winter of #aiab-ac1 during the course of the first ,balkan ,war1 and including all of the military hospitals of the military zone1 with the incidental purpose of selecting from the roentgenographic plates1 which had been prepared wherever apparatus was installed1 such examples of the roentgenography of gunshot wounds as might show characteristic lesions without relation to detailed clinical record4 ,more than #a1ejj plates were examined1 and from them more than #bjj were selected as exhibiting some lesion that seemed to be characteristic of some form of gunshot wound1 even though the case history could not be obtained4 ,from these selected plates photographic prints were made4 ,as some of these photographs displayed somewhat similar conditions1 only #afb of them are herewith produced4 ,as the photographic and reproduction processes have transferred the rights and lefts of the original negatives several times1 the plates as they appear here are interpreted1 for right and left1 as though they were the original photographic plates1 which are physically positive although they are chemically negative2 i4 e41 the right and left sides of the page should be read as the right and left sides anatomically4 ,if this distinction be not observed1 some confusion may arise from the habit of roentgenologists in regarding a roentgenograph as a positive print of a negative plate4 ,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 plates4 ,to ,prof4 ,wieting ,pasha1 the commandant of ,gulhan ,hospital2 to ,dr4 ,ishmael ,bey1 the roentgenologist of the ,hamedian ,hospital2 to ,dr4 ,englander1 the roentgenologist of the ,austrian ,hospital--to all of whom ,i am particularly indebted--,i wish to acknowledge my thanks4 ,projectiles4--,the projectiles which figure in the illustrations were those employed by the nations at war4 ,they are derived 7#a7 from the ,turkish pointed bullet weighing approximately #ae4j grams--it is fired from the ,german ,mauser and has all the ballistic values of the projectile from this weapon2 7#b7 the ,bulgarian bullet1 blunt nosed or ogival headed and the same as the steel-jacketed bullet of the ,austrian ,mannlicher2 7#c7 shrapnel balls and fragments of the shrapnel1 and 7#d7 fragments of steel shells from field artillery4 ,during the evolution of reduced caliber rifles experiments were made on cadavers at different ranges4 ,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 effects4 ,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 bones1 such as the femur1 tibia1 humerus1 etc41 and the head1 as well as organs loaded with fluid or semifluid masses like the stomach1 urinary bladder1 and intestines4 ,in other tissues offering but little resistance like lung tissues1 soft parts generally1 and epiphyseal ends of bone1 the wounds inflicted were considered humane in character4 ,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 wars4 ,the same thing may be said of the ,turko-,italian1 ,anglo-,boer1 and ,russo-,japanese wars1 all of which were fought with the new armament4 ,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 effects4 ,this fact is all the more emphasized in the present world war1 in which the rifle fire is employed principally in trench warfare at near-by ranges1 and where all the wounds which involve the resistant structures of the body show the characteristic features usually described as those of explosive effects4 ,in describing the plates the terms used in connection with range are as follows3 7#a7 ,close range1 from #j to #ajj yards4 7#b7 ,short range1 from #ajj to #ejj yards4 7#c7 ,mid range1 from #ejj to #a1jjj yards4 7#d7 ,long range1 from #a1jjj to #b1jjj yards4 ,the wound effects of the modern military rifle bullet at various ranges are usually classified as follows3 7#a7 ,explosive range1 from #j to #ejj yards4 7#b7 ,perforating range1 from #ejj to #a1ejj yards4 7#c7 ,penetrating range1 from #a1ejj to #b1ejj yards4 ,the difficulty in adhering strictly to the last table as far as the characteristic features of wounds are concerned is this3 ,in battle the chances of ricochetting of bullets is said to be in the proportion of one to three4 ,naturally1 the moment a bullet ricochets it loses more or less of its remaining velocity4 ,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 cadavers4 ,trajectory1 or the curved line of flight of a projectile1 has nothing to do with its wound-producing quality1 except to increase the wound-producing frequency when it flattens and approaches the straight line of sight1 because it will then pass through a greater portion of the space between the gun and the target1 which may be occupied by men1 without going over their heads4 ,the greater the velocity1 the flatter the trajectory becomes4 ,the ,american1 ,german1 and ,turkish rifles1 with about the same trajectory1 can be fired through a tube #bd inches in diameter at a range of #ejj yards1 and the vertical rise of the curve of flight would not hit the top of the tube4 ,but where the range is increased to #a1jjj yards it would be necessary to enlarge the tube to a tunnel1 #ae feet in diameter1 in order to fire the bullet through it without striking the top in its greatly increased curve in flight4 ,velocity is the principal factor of the wound-producing power of the small-caliber bullet1 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 form4 ,the greater the velocity of any particular bullet the more serious is its wound4 ,energy1 as the resultant of the components of weight and velocity1 represents the real damaging quality1 striking force1 or 8punch0 of a projectile1 with a variation in wound effect as the energy is distributed over the surface of the body1 through the cross-sectional area and the form of the point of the projectile1 and the elements of construction which a affect the preservation of its shape4 ,as the energy is expressed in the formula1 ,e 7,,wv#b7_/7b;g71 it is evident that the increase or decrease of the velocity factor gives greater variation than the increase of weight4 ,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 flight4 ,without reference to the ballistic condition 7velocity1 weight1 form1 and construction1 etc47 of a particular projectile1 range has no surgical significance4 ,to the military surgeon1 however1 it is a term of the greatest interest when these ballistic conditions are known1 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 flight4 ,the remaining energy of the ,american 8,springfield10 or ,german 8,s0 bullet1 for instance1 will pass it through the bodies of two men at #b1jjj yards and an energy of #h kilogram-meters1 which remains at about twice that distance1 will cause a disabling wound4 ,wound infections are more rare in campaign in the more sparsely settled and rough countries with soldiers of the more primitive class1 simple domestic habits1 and greater natural resistance4 ,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 established4 ,all treatment should be based on principles applied in the following order3 7#a7 ,life saving4 7#b7 ,restoration of function4 7#c7 ,economy of the patient4 ,amputation should be very rare4 ,conservation to a degree that seems to be beyond the experience and conception of the civil surgeon should always be practiced1 as reiterated by ,delorme1 who says3 8,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 conservation40 ,weight and muzzle velocity of several projectiles4 ---------------------------------------- ------------------ ,weight4 ,velocity4 ,projectile4 --------------------------------- ,grams4 ,grains4 ,meters4 ,feet4 ---------------------------------------- ---------------- ,american 7,springfield7 #i4jg #aej #hjj #b1gjj ,french #ab4h #aig #gja #b1cja ,german #aj4j #aed #hfj #b1hba ,austrian #ae4h #bdd #fbf #a1ieb ---------------------------------------- ---------------- ,illustration3 ,plate #a4 ,,rifle--,,plate #a4 ,,head4 ,gunshot ,fracture of the ,skull1 with ,lodgment of the ,missile4 ,the bullet in this case was so badly deformed by ricochet that part of both core and jacket were lost4 ,while the appearance of the shadow seems to indicate a direct impact of the nose of the bullet1 the line of contact with the skull must have been tangential1 with some laceration of the scalp2 otherwise a cursory examination of the scalp wound would have revealed the slightly protruding end of the bullet4 ,the dark shadow above the projectile is due to material used in dressing4 ,the great thickening of the scalp in the region of the wound shows a marked cellulitis4 ,small particles of the lead core of the bullet can be seen about the wound4 ,in such cases there is often a marked infection of the scalp without extension of infection to the cranial cavity1 except from neglect4 ,this is a case1 though apparently simple1 in which the radiograph was necessary for correct diagnosis without exploration4 ,the treatment in such cases is conservative1 with removal of the projectile and care of the superficial infection or subsequent complications4 ,illustration3 ,plate #b4 ,,rifle--,,plate #b4 ,,head4 ,gunshot ,wound of the ,head1 with ,lodgment of the ,missile4 ,wound of entrance1 near outer canthus1 with course through eyeball to ethmoid body4 ,wound of exit1 none4 ,the ,bulgarian ,mannlicher bullet1 shown half actual size on the plate1 must be inclined on its long axis1 about #cj from the perpendicular1 to the plane of the plate4 ,the slight penetration of the missile and its normal character show that1 having struck no intervening object1 it indicted the wound at extreme range4 ,the treatment should meet the indication for removal of missiles in all superficial or easily accessible locations and when they cause reaction4 ,results to be expected are favorable except for loss of the eye4 ,illustration3 ,plate #c4 ,,rifle--,,plate #c4 ,,head4 ,gunshot ,fracture of the ,ramus of the ,lower ,jaw4 ,wound of entrance1 in the cheek behind the angle of the mouth4 ,wound of exit1 below the tip of the mastoid4 ,the course of the bullet was almost tangential to the ramus of the jaw1 anteroposteriorly4 ,the slight fragmentation1 which is hardly more than a splitting of the bone1 with little or no displacement1 indicates that the wound was made by a rifle bullet at moderate velocity and at mid or long range4 ,treatment is expectant4 ,results are favorable4 ,illustration3 ,plate #d4 ,,rifle--,,plate #d4 ,,head4 ,gunshot ,fracture of the ,ramus of the ,lower ,jaw4 ,wound of entrance1 over the anterior border of the right ramus4 ,wound of exit1 beneath the lobe of the ear4 ,the wound was made by a rifle bullet with the velocity of long range1 because wounds of a shrapnel ball never show such slight injury without lodgment or without marks of lead4 ,the damage of the bone was very slight1 as only a superficial fragment was chipped off4 ,there were no signs of primary infection4 ,reaction and periostitis suggested the radiograph after infection had rarefied the fragment1 shown but very faintly on the left side of the plate4 ,the postero-anterior skull radiograph was made with the face superimposed upon the photographic plate4 ,treatment1 incision and drainage4 ,results1 good4 ,illustration3 ,plate #e4 ,,rifle--,,plate #e4 ,,head4 ,gunshot ,fracture of the ,body of ,lower ,jaw1 with ,great ,fragmentation and ,displacement4 ,wound of entrance1 to the left side of the median line of the lower jaw below the alveolar process1 with course ranging downward and backward4 ,wound of exit1 with extensive laceration1 beneath lower border of the bone4 ,the wound was caused by a rifle bullet at high velocity at or less than mid range4 ,the fragments are many and rather small1 so that much bone was lost through the wound of exit4 ,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 fragments1 which1 together with the missile1 effected the considerable laceration of the wound of exit4 ,treatment1 difficult2 guided by septic conditions and surgical means available4 ,results in such cases are favorable to life but topically unsatisfactory4 ,illustration3 ,plate #f4 ,,rifle--,,plate #f4 ,,spinal ,,region4 ,gunshot ,wound of the ,spinal ,region--,lodgment of the ,missile in the ,lumbar ,muscles4 ,the bullet is lodged deep in the muscles of the back and not in the abdomen1 as determined by inspection of the plate4 7a7 ,the shadow of the bullet is enlarged laterally1 because1 while on the side of the body next to the plate and to the spine1 it is at some little distance from the plate1 which accounts for the larger diameter of the shadow2 and it is shortened longitudinally1 because its long axis is inclined at an angle to the plate4 7b7 ,the outline of the shadow is distinct1 an evidence that it is extra-abdominal1 as otherwise its outline would be blurred by the diaphragmatic movement of respiration imparted to the abdominal viscera during the ,rntgen exposure4 ,illustration3 ,plate #g4 ,,rifle--,,plate #g4 ,,spinal ,,region4 ,gunshot ,wound of the ,spinal ,region1 with ,lodgment of the ,missile4 ,the bullet was either dum-dummed or unjacketed because its soft nose mushroomed1 striking the crest of the ilium1 penetrated the lumbar muscles1 and struck the side body of the third lumbar vertebra without producing fracture4 ,the exposure1 as the spinous processes show1 was made with the spine next to the plate1 and the slight shadow1 somewhat larger than the projectile--to judge the size from the undeformed diameter--shows it to be anterior to the vertebra4 ,the shadow is deep enough to indicate the location fairly near to the plate1 and1 almost certainly1 not in the abdominal cavity1 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 outline4 ,the shadow of the localizing cross gives a standard of density to be compared with the shadow of the projectile in making the estimation4 ,the treatment is conservative2 only pain1 paralysis1 impaired function1 or sepsis indicate interference4 ,illustration3 ,plate #h4 ,,rifle--,,plate #h4 ,,upper ,,extremity4 ,compound ,fracture of the ,humerus in ,advanced ,state of ,repair with ,callus ,formation4 ,wound of entrance1 just above middle of anterior aspect of arm4 ,wound of exit1 about the same height1 posteriorly4 ,the course of the missile was anteroposterior1 with high velocity of short range through the bone with a splitting effect1 leaving a few fragments1 large and small1 which were not much displaced and caused but little deformity4 ,wound was not infected4 ,the absorption of smaller and the overlapping of larger fragments caused some shortening4 ,treatment1 expectant4 ,results1 favorable4 ,illustration3 ,plate #i4 ,,rifle--,,plate #i4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,right ,humerus1 with ,lodgment of the ,missile4 ,wound of entrance1 antero-external aspect of upper third of arm4 ,wound of exit1 none4 ,the missile1 deformed by ricochet1 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 arm4 ,this is something of the same effect that might have been caused by a shrapnel ball1 under the same ballistic conditions with a normal shrapnel velocity giving about the same penetrating force4 ,the wound1 without infection1 is in the first week or two of repair1 before any callus has formed4 ,treatment is expectant4 ,results favorable4 ,illustration3 ,plate #aj4 ,,rifle--,,plate #aj4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,left ,humerus1 with ,lodgment of the ,missile4 ,wound of entrance1 anterior surface of upper third of the arm4 ,wound of exit1 none4 ,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 plate2 the shortened length of the projectile indicates that the long axis lay in an acute angle with a perpendicular to the plate4 ,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 ricochet1 so that its penetrating force was not sufficient to carry it through the arm4 ,the fragments of bone are large and the wound is of the same character as might have resulted from a shrapnel ball1 for the normal ballistic conditions of the latter simulate the conditions that produced the wound4 ,the drainage tubes seen in the plate indicate infection4 ,the conventional treatment in such cases is drainage and other management of the infection without formal search for the projectile4 ,results should be favorable4 ,illustration3 ,plate #aa4 ,,rifle--,,plate #aa4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,humerus4 ,wound of entrance1 anterior internal aspect of middle and upper third of arm4 ,wound of exit1 opposite4 ,the missile has struck the side of the bone and pursued a course through the shaft1 so that a transverse fracture1 as well as the separation of several medium-sized fragments1 resulted from the splitting effect of the missile4 ,a larger missile1 i4 e41 a shrapnel ball1 with the same striking energy could have been stopped by the bone1 but a wider distribution of the same energy carried by a larger cross section would have produced larger fragments4 ,in this case the location of the shrapnel ball would furnish unquestioned evidence2 or1 if a shrapnel ball had produced this particular bone destruction1 its path among the fragments would have been marked by traces of lead4 ,two metal fragments indicate that the lead core of the bullet was exposed4 ,the wound1 not infected1 was treated expectantly4 ,result in such cases is favorable4 ,illustration3 ,plate #ab4 ,,rifle--,,plate #ab4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,humerus4 ,the course of the missile was anteroposterior through the middle of the arm4 ,the ballistic conditions and lines of force applied to the bone were somewhat1 if not entirely1 similar to those producing the fracture shown in plate #aa4 ,the missile struck the wall of the shaft without passing through the medullary canal1 but a secondary fragmentation of the two large fragments did not follow except for the breaking of the tip of the distal fragment4 ,the range was long4 ,there was little deformity and no infection4 ,plaster dressing was applied and the slight outline of callus formation indicates the process of repair4 ,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 made4 ,treatment in such cases is expectant4 ,results should be uniformly good4 ,illustration3 ,plate #ac4 ,,rifle--,,plate #ac4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,right ,humerus1 with ,lodgment of the ,missile4 ,wound of entrance1 about middle of the anteriorinternal aspect of the arm4 ,wound of exit1 none4 ,the course of the missile was from without1 downward and inward to a point of lodgment above the internal condyle4 ,the distinct outline and normal size of the base of the bullet shows it to be near the plate1 with the internal condyle next to the plate in the exposure4 ,the bullet mushroomed when it struck the bone with a 8soft nose10 in which the lead was not protected by a tough metal jacket4 ,it may have been dum-dummed2 it is remotely possible that the nose of the jacket was split by ricochet1 or it is more probable that it was of the unjacketed variety4 ,the effect is identical with that of a shrapnel ball1 striking with its normal low velocity1 which is about the same as that of the missile in this wound4 ,the invariable characteristic of a shrapnel wound of a bone1 namely1 the small particles of metal marking its course in contact with the bone1 is seen in this plate4 ,the treatment in such cases is expectant1 with due regard to the character of the infection1 and without primary search for the missile4 ,the results are generally favorable4 ,illustration3 ,plate #ad4 ,,rifle--,,plate #ad4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,humerus1 with ,lodgment of the ,missile4 ,the missile was a fragment of a ricocheted rifle ball1 with a part of the lead core carried in a portion of the jacket4 ,the course was from before1 backward1 striking the humerus in lower third1 and leaving particles of lead along its trade4 ,the wound was only slightly infected4 ,several detached fragments of bone have been removed4 ,the treatment in such cases is conservative1 with management of the infection and without formal search for the projectile4 ,the results in such cases are favorable with some shortening of the bone4 ,illustration3 ,plate #ae4 ,,rifle--,,plate #ae4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,external ,condyle of the ,left ,humerus1 with ,lodgment of the ,missile4 ,wound or entrance1 internal and posterior aspect of the arm above the internal condyle4 ,wound of exit1 none4 ,the bullet was greatly deformed by ricochet1 with the loss of the greater part or all of its jacket4 ,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 wounds4 ,the ballistic conditions in this case are quite similar to those of a shrapnel wound1 as the projectile has struck the bone with low velocity4 ,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 tissues1 stretching around the missile at its striking point1 contracted after its energy had been expended and then withdrew the missile from its farthest point of advance4 ,the treatment in such cases warrants only the interference suggested by infection and the interference of the missile with function4 ,the results expected are most favorable4 ,illustration3 ,plate #af4 ,,rifle--,,plate #af4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,humerus4 ,the transverse course of the bullet1 striking the posterior wall of the shaft without entering the medullary canal1 has fractured the bone transversely1 with a tendency toward splitting off a large fragment from the distal fragment4 ,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 fractures4 ,gunshot ,fracture of the ,ulna4 ,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 bone4 ,a smaller bullet or a larger bone of the same structure might easily have provided conditions to permit this effect4 ,the wounds of exit and entrance in each of these wounds presented almost identically the same appearance4 ,the treatment in such cases is that of a simple fracture1 as there is almost always no infection in such wounds4 ,results are favorable4 ,illustration3 ,plate #ag4 ,,rifle--,,plate #ag4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,elbow4 ,the bullet in transverse course and high velocity through both bones of the forearm struck the head of the radius1 thus starting several splitting lines of fracture and separating large fragments4 ,smaller fragments which received some of the energy of the missile have been carried along with it in turn1 striking the ulna and carrying away smaller fragments from it and causing the laceration which marks the wound of exit4 ,such wounds1 with laceration of soft parts and fragmentation of the bone1 are prone to infection1 against which treatment is directed4 ,the indications to be met are much like those of the wound shown in plates #ah and #ai4 ,excision or immediate methods of bone repair are contraindicated by infection4 ,results will depend upon the nature and extent of infection4 ,illustration3 ,plate #ah4 ,,rifle--,,plate #ah4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,elbow1 without ,injury to the ,great ,vessels and ,nerves4 ,wound of entrance1 posterior to the external condyle4 ,wound of exit1 large laceration in front and above the internal condyle4 ,the wound is an example of the misnamed 8explosive0 action of a rifle bullet4 ,the force and direction of the missile1 in high velocity1 split the bone into many fragments1 and1 transmitting its energy to some of the fragments1 carried them through the skin and caused the large laceration at the point of exit by the simultaneous escape of the bullet and fragments4 ,the wound was so heavily infected1 that a cellulitis advanced to the shoulder and to the wrist to such extent that the arm was marked by eminent surgical opinion for amputation4 ,free incision1 drainage1 antisepsis and incidental removal of detached fragments controlled the infection and brought about slow resolution4 ,after six months of careful treatment the wound was healed with an ankylosed elbow with normal function of the forearm1 except for limited rotation4 ,treatment indicated in such cases is always conservative4 ,infections contraindicate any formal surgical interference4 ,the dangers of infection in such cases are to be risked to avoid amputation4 ,results may be considered favorable even with elbow ankylosis4 ,illustration3 ,plate #ai4 ,,rifle--,,plate #ai4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,elbow1 without ,injury to the ,great ,vessels and ,nerves4 ,this is a plate made of the same subject shown in plate #ah1 when convalescence was several weeks farther advanced1 as is indicated by the removal of fragments and extensive callus formation4 ,both radiographs were made after the apprehension of systemic infection had passed2 the second plate after an additional number of fragments had been removed4 ,illustration3 ,plate #bj4 ,,rifle--,,plate #bj4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,elbow4 ,wound of entrance1 posterior aspect of forearm internal to and below the olecranon4 ,wound of exit1 external border over head of radius4 ,the course of the bullet was diagonally anteroposterior from within outward1 striking the posterior border of the upper end of the ulna and passing through the head of the radius1 carrying the fragments of the latter before it and lacerating the wound of exit4 ,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 fragments4 ,this is the effect of a rifle bullet at short range1 or possibly a ricochet shot at mid range4 ,the emergency treatment is antiseptic dressing with splint immobilization4 ,the subsequent treatment is conservative1 whether the wound is clean or infected4 ,the course of treatment of such an infected wound might extend from four to six months4 ,,note4--,as the soldier always escapes the burden of explanation when the wound of entrance is anterior rather than posterior1 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 body2 and as the wounds of the forearm herein presented are described in the anatomical position1 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 forearm4 ,illustration3 ,plate #ba4 ,,rifle--,,plate #ba4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,radius and ,ulna4 ,the course of the bullet at short range was transverse through both of the bones1 with a splitting effect and without much small fragmentation4 ,the wound of exit in this case was slightly lacerated1 but not very much larger than the wound of entrance4 ,the treatment should be conservative4 ,emergency treatment should not include exploration1 and nothing but the conventional iodine dressing and splints should be applied4 ,illustration3 ,plate #bb4 ,,rifle--,,plate #bb4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,radius and ,ulna4 ,the course of the bullet at short range was transverse through the upper forearm1 striking the radius in the center of the shaft and the ulna nearer the border4 ,several small fragments followed the course of the bullet1 but did not emerge with it at the wound of exit to cause a laceration4 ,the capitellum was next to the photographic plate and the angular line of the radius can be seen crossing the straighter line of the ulna4 ,further information is obtained from the examination of another view1 plate #bc1 made of the same subject4 ,illustration3 ,plate #bc4 ,,rifle--,,plate #bc4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,radius and ,ulna4 ,this plate was made from the wound shown in plate #bb1 with the arm in greater inward rotation4 ,this position shows the wide separation of the large fragments of the radius4 ,emergency treatment in such cases is antiseptic dressing only1 without exploration1 and with fixation by splints for transportation4 ,the degree of infection determines the subsequent course of conservative treatment1 with operative methods for correction of deformity reserved for further stage of convalescence and for best surgical facilities4 ,illustration3 ,plate #bd4 ,,rifle--,,plate #bd4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,radius and ,ulna in the ,upper ,third of the ,forearm4 ,the course of the projectile was from within1 outward and diagonally forward1 with a direct impact on the ulna1 and a tangential impact on the radius1 with several lines of splitting fracture in the latter without detaching fragments4 ,particles of metal1 spattered around the point of first impact1 were deposited by the lead core of a bullet1 exposed by a torn jacket1 which struck the second bone with its jacketed surface4 ,the treatment is always conservative--meeting indications in case of infection4 ,results are good for saving the limb1 but not for avoiding deformity4 ,illustration3 ,plate #be4 ,,rifle--,,plate #be4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,radius4 ,wound of entrance1 posterior surface of forearm over radius above the middle4 ,wound of exit1 below and in front of wound of entrance4 ,the course of the ball in mid range was from behind1 forward1 and slightly downward4 ,while the images of both bones of the forearm are superimposed1 because they both lay in the plane of the projection of the shadow1 it is probable that the radius lay nearer the photographic plate1 because the head of the radius is shown in clearer outline4 ,the fragments of the fracture can be seen as related to the outlines of the radius4 ,there is no displacement and only slight fragmentation1 so that the bullet must have almost succeeded in making a punctured wound in the radius4 ,the treatment in such cases is regularly that for simple fracture1 as such wounds are almost always aseptic4 ,the results are uniformly good4 ,illustration3 ,plate #bf4 ,,rifle--,,plate #bf4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,radius4 ,wound of entrance1 midway between radius and ulna and midway between elbow and wrist1 anterior aspect of the forearm4 ,wound of exit1 over radius at point opposite4 ,the course of the bullet1 in the medium velocity of mid range1 in piercing the medullary canal has almost succeeded in drilling the bone without splitting off several longitudinal fragments4 ,small fragments followed the course of the missile1 without being energized sufficiently to lacerate the point of exit by escaping with the projectile4 ,the wound of exit in such cases hardly differs enough from the wound of entrance to be distinguishable4 ,this condition so often obtains that the great majority of perforating rifle wounds of the forearm do not show the blow-out or 8explosive0 effect which seems to be generally misunderstood as a classic accompaniment4 ,the bullet was traveling at high velocity of perhaps less than mid range4 ,the treatment is usually that of a simple fracture1 and warrants no interference except in case of occasional infection4 ,results are almost always good4 ,illustration3 ,plate #bg4 ,,rifle--,,plate #bg4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,radius4 ,the course of the bullet1 at long range1 has been diagonally anteroposterior through the shaft1 causing only a diagonal fracture4 ,the plate was made after a two-weeks' convalescence1 as is shown by the beginning of callus formation4 ,the treatment is that of a simple fracture4 ,results are good4 ,illustration3 ,plate #bh4 ,,rifle--,,plate #bh4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,radius4 ,the course of this bullet was anteroposterior and diagonally from above downward through the shaft1 punching out one side of the shaft and effecting a diagonal fracture through the bone with only slight displacement4 ,the wound was infected4 ,the radiograph was taken during the course of treatment1 after the several small fragments found by the punched-out portion of the bone were removed4 ,a small drainage tube is in the wound1 but the size of the forearm shows that the reaction is very moderate4 ,the treatment is that of a simple fracture1 except for the indications to be met in the control of infection4 ,results are good4 ,illustration3 ,plate #bi4 ,,rifle--,,plate #bi4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,lower ,end of the ,radius4 ,the course of the bullet in long range was diagonally anteroposterior through the ulnar side of the lower end of the bone1 with the wound of entrance on the anterior and the wound of exit on the posterior aspect of the wrist4 ,the wound of exit was slightly lacerated by several small fragments driven off from the ulnar side of the radius4 ,these fragments were removed through an incision before the radiograph was made4 ,the emergency treatment of such cases is only antiseptic dressing and splint immobilization4 ,when wound is aseptic or after it has closed1 a secondary operation for coaptation1 with proper facilities available1 might be indicated4 ,the results as to full restoration of joint function are not favorable4 ,illustration3 ,plate #cj4 ,,rifle--,,plate #cj4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,lower ,end of the ,radius4 ,the course of the missile was diagonally transverse1 striking the radius in its lower third4 ,the projectile in this case is unknown1 as it might have been either a shrapnel ball or a deformed rifle bullet with a torn jacket1 exposing the lead core and marking its course with small particles of lead4 ,the fissures in the lower fragment and the finer fragmentation at the seat of impact1 indicate a great striking energy1 that more often resides in the high velocity of a rifle bullet than the low velocity of a shrapnel ball4 ,the wound is therefore classified with rifle wounds4 ,the treatment is conservative4 ,the course in such cases1 without infection1 is very favorable1 and not unfavorable even with infection4 ,results should be good4 ,illustration3 ,plate #ca4 ,,rifle--,,plate #ca4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,lower ,end of the ,radius4 ,wound of entrance1 anterior aspect of wrist1 over internal border of radius4 ,wound of exit1 posterior aspect of wrist between radius and ulna1 with laceration4 ,the range was described as 8close0--within a hundred yards--with the bullet in high velocity4 ,the energy of the projectile1 imparted to small fragments of cancellous tissue1 drove them through the wound of exit1 and caused the laceration of the superficial tissues4 ,the wound was infected 7swelling of soft parts clearly shown73 resolution followed extended treatment1 with ankylosis of the wrist and radial displacement of the carpus4 ,emergency treatment in all such cases is antiseptic dressing without exploration or manipulation of fragments1 and with splint immobilization4 ,results are unfavorable as to function1 depending upon extent of destruction of tendons4 ,illustration3 ,plate #cb4 ,,rifle--,,plate #cb4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,ulna4 ,the course of the bullet was transverse through the arm at the junction of the middle and upper thirds from behind the radial border externally to the ulnar border internally1 striking the wall of the medullary canal with a punching effect that partly split off short longitudinal fragments and caused transverse and longitudinal cracks1 without separation or displacement of fragments4 ,the same ballistic conditions applied to cancellous tissue at the end of the bone would probably have bored through it without fracture4 ,this effect is generally seen in wounds of small-caliber bullets traveling at reduced velocity of long range4 ,the treatment is that of a simple fracture4 ,results1 in such cases without infection1 could not be bad4 ,illustration3 ,plate #cc4 ,,rifle--,,plate #cc4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,left ,ulna4 ,the course of the missile was from within outward1 ranging downward to the wrist1 by deflection1 after striking the ulna in its upper half4 ,the considerable striking energy retained in a small portion of the mass--consisting of only the nose and a little more of the jacket of the bullet1 but sufficient to fragment a large section of the bone1 and then to traverse more than half the length of the forearm--leaves no doubt that the shot was fired at very close range1 and that the bullet was broken on a nearly resisting surface1 leaving in the nose of the bullet a striking force equal to that of the entire projectile at long range4 ,the posterior surface of the forearm is next to the plate1 as the distinct outline of the styloid process of the ulna and the posterior border of the articular surface of the radius shows4 ,the radius and ulna are parallel in the most natural position of supination4 ,the normal diameter and sharp outline of the nose of the bullet show it to be next to the plate and on the posterior surface between radius and ulna4 ,fragments of the exposed lead core of the bullet have scraped off on the line of fracture in a manner peculiar to shrapnel wounds1 but never seen in bullet wounds in which the jacket covers all of the lead core4 ,the treatment is regularly conservative and without interference1 as in this particular wound1 which was aseptic4 ,secondary treatment may indicate correction of bone deformity4 ,illustration3 ,plate #cd4 ,,rifle--,,plate #cd4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,ulna4 ,the ballistic conditions of the projectile causing the wound shown in this plate are substantially those of the wound shown in plate #cb4 ,the wound of entrance and exit would be practically the same in chipping off a few small fragments and causing a clean transverse fracture without any displacement4 ,the bullet at long range has struck the wall of the medullary canal1 appearance4 ,treatment that of a simple fracture4 ,results must be good4 ,illustration3 ,plate #ce4 ,,rifle--,,plate #ce4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,ulna4 ,the course of the bullet at long range has been anteroposterior through the middle of the forearm1 passing through the side of the shaft1 chipping off a few small fragments and causing a long oblique fracture4 ,the conditions were much the same as those shown in plates #bh and #bi1 except that the striking energy of the projectile was somewhat greater with the velocity of mid range4 ,the treatment1 without infection1 is that of a simple fracture4 ,results will be uniformly good4 ,illustration3 ,plate #cf4 ,,rifle--,,plate #cf4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,ulna4 ,the course of the bullet was anteroposterior through the ulna a little above the middle of the forearm1 and fairly through the long axis4 ,this is a bone effect much similar to those shown in plates #bh1 #bi1 and #ca1 except that this condition is due to the impact of a missile1 with a still higher velocity of shorter range1 imparting its energy to small fragments of bone1 which added their momentum to the destructive force of the projectile4 ,no large fragments were carried along with the missile to cause any more destruction of tissue in exit than in entrance1 so that the skin wounds1 under these conditions1 are about the same in appearance4 ,the treatment is conservative and expectant with immobilization4 ,results in such cases are uniformly good4 ,illustration3 ,plate #cg4 ,,rifle--,,plate #cg4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,ulna4 ,the course of the bullet was in an anteroposterior direction at a high velocity of short range1 which1 imparting its energy to the fragments1 drove some of them through the tissues as 8secondary missiles0 and caused a laceration of the wound to exist4 ,the longitudinal fragmentation and splitting indicates a considerable energy of the projectile1 which may have been deflected1 as its long axis was turned somewhat from the trajectory at the time of impact4 ,the emergency treatment is antiseptic dressing and splint immobilization4 ,the subsequent treatment is conservative with the removal of detached fragments and with control of infection as the course indicates4 ,illustration3 ,plate #ch4 ,,rifle--,,plate #ch4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,left ,ulna4 ,the course of the bullet was transverse through the middle of the forearm1 striking the posterior border of the ulna4 ,small fragments were broken from the posterior wall of the medullary canal1 without destroying the longitudinal continuity of the anterior wall4 ,the velocity of the bullet was probably that of mid-range1 as the striking energy of the impact was fairly great4 ,the posterior surface of the forearm lay next to the plate4 ,the emergency treatment is antiseptic dressing and splint immobilization4 ,the subsequent treatment is that of a simple fracture1 as infection is not usual4 ,illustration3 ,plate #ci4 ,,rifle--,,plate #ci4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,left ,ulna4 ,the course of the bullet1 with the velocity of long range1 was anteroposterior through the lower third of the forearm1 striking the outer side of the bone4 ,the initial velocity of the projectile was much reduced1 as is shown by the tendency to puncture the bone without much fragmentation4 ,there was no displacement of fragments as a direct result of the impact1 although muscular contraction has caused some slight subsequent overriding4 ,the wounds of entrance and exit were about the same1 if not quite similar in appearance4 ,the emergency treatment is the conventional antiseptic dressing with splint immobilization4 ,the subsequent treatment is usually that of a simple fracture1 as infection in such cases is rare4 ,illustration3 ,plate #dj4 ,,rifle--,,plate #dj4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,ulna4 ,the course of the bullet was obliquely anteroposterior through the lower third of the forearm1 striking the radial edge of the bone with a velocity of long range4 ,the wounds shown in plates #ce and #ci represent conditions similar to those causing this wound1 except that the ranges were progressively greater4 ,in this case the projectile exhibited a punching effect at the point of impact1 and although the lines of force are shown in characteristically divergent fissures1 the energy imparted to the fragments--less than in the preceding cases--has not been sufficient to separate or to displace the fragments4 ,the emergency and subsequent treatment is conventionally conservative1 as in the preceding cases4 ,illustration3 ,plate #da4 ,,rifle--,,plate #da4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,wrist4 ,wound of entrance1 posterior aspect of forearm over the lower end of the radius1 with the bullet ranging forward and slightly downward to the wound of exit and covering with great laceration the anterior aspect of the wrist joint4 ,the range was close1 and the energy of the high velocity of the missile was imparted to fragments1 which1 becoming 8secondary missiles10 emerged with the projectile to cause extensive laceration and destruction of tissue4 ,the case was received for amputation in the second week1 when a grave degree of infection extended in a cellulitis to the elbow4 ,the ulnar nerve and vessels were intact1 but the flexor tendons were almost entirely destroyed4 ,the plate1 made after several weeks1 when infection was under control and after the end of the radius and fragments of the carpus had been informally removed1 shows a rarefaction of the carpus and proximal ends of the metacarpus1 due to infection and disuse4 ,frequent incisions and extension of drainage1 with removal of detached fragments1 was continued for several months4 ,the wound was closed in the sixth month1 with ankylosis and deformity of the wrist1 as shown in plate #db4 ,illustration3 ,plate #db4 ,,rifle--,,plate #db4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,wrist4 ,this plate1 presenting a lateral view of the wound shown in plate #da1 shows considerable deformity of the joint1 after four months' treatment1 which was even more marked two months later1 when the case was discharged with an ankylosis of the wrist joint1 contracture of the flexor tendons of the fingers1 and slight flexor function of the thumb1 permitting apposition with the first finger4 ,the result1 while leaving much to be desired1 preserved a function of the hand vastly superior to that of a forearm stump4 ,the treatment in such cases is always courageously conservative1 with amputation only as the extreme measure to save life1 with risks of judgment in favor of conservatism4 ,corrective measures may be employed after management if the treatment of the infection is successful and when the case passes out of the military category4 ,it is not possible1 during a long infection1 to maintain better position in such cases4 ,illustration3 ,plate #dc4 ,,rifle--,,plate #dc4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,metacarpus4 ,wound of entrance1 inner aspect of the hand over proximal end of the fifth metacarpal4 ,wound of exit1 on the outer border of the hand over the distal end of the second metacarpal4 ,the velocity of the bullet was in mid or long range1 as it displaced no fragments1 and as it made a point of entrance and exit about the same in appearance4 ,the wound was infected1 which is more frequently the case in the hand than in the forearm4 ,the treatment is conservative with free incision and drainage in the management of infection4 ,illustration3 ,plate #dd4 ,,rifle--,,plate #dd4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,third ,phalanx4 ,the course of the bullet was anteroposterior through the base of the proximal phalanx of the middle finger1 with a velocity of long range4 ,it practically punctured the bones and split off a few fragments without displacement4 ,the wound of entrance would be much the same as the wound of exit1 with the latter1 but a little larger4 ,treatment is conservative4 ,illustration3 ,plate #de4 ,,rifle--,,plate #de4 ,,chest4 ,penetrating ,gunshot ,wound of the ,chest1 with ,lodgment of the ,projectile ,near ,posterior ,chest ,wall4 ,point of entrance1 pectoral border and fourth rib4 ,point of exit1 none4 ,the distinct shadow of the angle of the ribs shows that the posterior chest wall was next to the photographic plate1 and that the larger and less distinct outline of the anterior portions of the upper ribs was farther from the plate4 ,the nearly normal size of the shadow of the projectile shows it to be much nearer the posterior than the anterior chest wall4 ,the blurred outline shows it to have moved with respiration4 ,such conditions locate its position within the thoracic cavity4 ,the emergency treatment is antiseptic dressing and rest4 ,the subsequent treatment depends upon pleural involvement or the extremely rare infection of the lung4 ,these cases are nearly all aseptic1 and if the great vessels and nerves of the chest escape injury results are generally favorable4 ,illustration3 ,plate #df4 ,,rifle--,,plate #df4 ,,pelvis4 ,gunshot ,wound of the ,pelvis1 with ,lodgment of the ,missile in the ,abdomen4 ,the course of the bullet was from behind forward1 striking the crest of the ilium1 on which it was deflected1 and spattering off some lead fragments4 ,the slight penetration indicates a velocity of extremely long range and a striking energy lessened by ricochet4 ,the irregular outline of the shadow of the projectile shows its deformity1 and the blurred outline indicates intra-abdominal movement with respiration4 ,while the missile1 as revealed by its shadow1 is not a shrapnel ball1 the distribution of lead particles is more suggestive of a shrapnel than of a rifle projectile1 and the ballistic conditions are more characteristic of the former than of the latter4 ,there was no abdominal reaction2 the invasion of the abdomen was revealed by the radiograph4 ,the treatment in such cases is noninterference unless subsequent developments furnish definite indications4 ,illustration3 ,plate #dg4 ,,rifle--,,plate #dg4 ,,lower ,,extremity4 ,gunshot ,wound of the ,gluteal ,region1 with ,lodgment of the ,bullet ,near the ,ischium4 ,wound of entrance1 over gluteal prominence on a transverse line through the great trochanter4 ,wound of exit1 none4 ,there was no bone injury in this case4 ,the bullet1 to have lodged in the soft parts after relatively slight penetration1 must have struck the body at extreme range when its energy was almost spent in flight1 for its normal outline indicates that it was not retarded by ricochet4 ,the long axis is almost perpendicular to the plate4 ,as the posterior pelvis was next to the plate1 the fairly dense shadow shows the projectile was not far from the plate and behind the ischium4 ,the treatment is conservative2 infection in such cases is extremely rare2 and only pain or impaired function after many months of convalescence justifies operation for removal of the missile4 ,illustration3 ,plate #dh4 ,,rifle--,,plate #dh4 ,,lower ,,extremity4 ,gunshot ,wound of the ,thigh1 with ,lodgment of the ,bullet4 ,wound of entrance1 outer aspect of the thigh at the junction of the upper and middle thirds4 ,the slight penetration without bone injury and with slight deformity of the nose of the bullet indicates that the wound was caused by a ricochet shot at extreme range1 after its energy was almost spent4 ,with the posterior aspect of the thigh next to the plate1 the dense shadow and the nearly normal size of its outline indicate that the bullet was in the same relative position and that it lay posterior to the neck of the femur4 ,as such wounds are rarely infected1 the treatment is conservative1 and a search for the missile is only justified by serious infection1 pain1 or impaired function4 ,illustration3 ,plate #di4 ,,rifle--,,plate #di4 ,,lower ,,extremity4 ,gunshot ,wound of the ,right ,thigh1 with ,lodgment of the ,bullet ,behind the ,femur4 ,there is no injury of the bone in this case1 as the bullet lodged in the muscles posterior to the lower third of the femur without striking the bone4 ,the lighter circular area of the larger end of the shadow of the projectile shows that its base is farther from the plate than its nose1 which was probably flattened and bent by the ricochet which reduced its velocity so as to give it but slight power of penetration4 ,it is not easy to determine from inspection of the plate which side of the leg lay next to the plate4 ,with a history of the wound of the right thigh and with the outside of the leg next to the plate1 the projectile must have lain near the plate on the outside behind the lower end of the femur1 midway between the skin and bone4 ,the markings seen on the bone are not concerned with the wound1 as the same effect in the plate is seen in the areas beside the bone4 ,the treatment is conservative2 infection is rare4 ,illustration3 ,plate #ej4 ,,rifle--,,plate #ej4 ,,lower ,,extremity4 ,gunshot ,wound of the ,right ,thigh1 with ,lodgment of the ,bullet ,behind the ,femur4 ,there is no injury to the bone4 ,the large diameter1 shortened length1 and slight density of the shadow show the bullet to be some distance from and inclining toward the plate and lodged in the muscles behind the femur1 nearer the side away from the photographic plate4 ,it is difficult to identify the right or left thigh from the radiograph1 but with the history of the wound in the right thigh and the outside of the leg next to the plate the ball would lie nearer the inside than the outside of the thigh1 nearer the surface behind the femur4 ,as the shadow shows irregular outline and the location of the bullet low velocity1 the wound was caused by a ricochet shot at very long range4 ,the treatment is expectant and the course naturally favorable4 ,illustration3 ,plate #ea4 ,,rifle--,,plate #ea4 ,,lower ,,extremity4 ,gunshot ,wound of the ,thigh1 with ,lodgment of the ,missile4 ,as there is no injury to the bone1 the bullet is not deformed4 ,its penetrating power was not great enough to carry it through the tissue so it must have struck the leg at extreme range when its energy was almost spent4 ,the actual length of the bullet is #a4be inches2 the length of the shadow is about #a4ej inches4 ,the increased length and the relatively slight density of the shadow indicate the bullet to be some distance from the plate4 ,the case history places the wound in the right thigh1 and the posterior surface of the leg lay next to the photographic plate4 ,as the density of the shadow is not greater than the thickest portion of the bone1 the bullet probably lies in front of the border of the outer tuberosity of the femur4 ,although the surgeon's diagnosis had to be made from the only available plate1 there is something of a speculative element in these deductions1 because if the reaction in the knee joint prevented the patient from extending the leg the increased length of the bullet shadow could be accounted for by this position1 which would permit the bullet to lie behind the bone and yet far enough from the plate to account for the shadow enlargement4 ,the nose of the bullet is at the epiphyseal line1 which is shown in the femur4 ,illustration3 ,plate #eb4 ,,rifle--,,plate #eb4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,upper ,shaft of the ,femur4 ,the course of the bullet was anteroposterior and pierced the axis of the shaft of the femur with three radiating lines of fracture1 resulting from the perforating action of the bullet striking the bone at long range and with greatly reduced energy4 ,this plate shows the lateral separation of large fragments1 which is typical of gunshot wounds of long range4 ,such wounds are usually not infected4 ,emergency treatment is antiseptic dressing and coaptation with extension and temporary splint1 so that it may support the bone for transportation and may be easily removable at place of continued treatment4 ,in these cases with lateral separation of fragments1 it is imperative to supplement extension with pressure in a line perpendicular to the long axis of the femur4 ,illustration3 ,plate #ec4 ,,rifle--,,plate #ec4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,shaft of the ,femur with ,lodgment of the ,bullet4 ,the course of the bullet was antero-posterior and diagonally inward from the antero-external border of upper third of the thigh4 ,a thin longitudinal fragment was split off without transverse fracture4 ,the missile struck the thigh after its energy had been greatly reduced by ricocheting as a result of striking a resisting object which flattened its nose and 8set up0 its body1 as shown by the wavy outlines of the shadows4 ,the dense and normal-size shadow shows the bullet to be near the plate and probably in the muscles superficially behind and below the lesser trochanter4 ,as the prominent outline of the lesser trochanter shows that the leg was in external rotation when the negative was made1 it is evident that1 with the rotation back to the anatomical position1 the projection of the shadow of the bullet would fall close to or in line with the shaft of the femur2 the position of the bullet is behind the femur4 ,the treatment is conservative1 with no trouble to be expected from infection4 ,illustration3 ,plate #ed4 ,,rifle--,,plate #ed4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,lower ,end of the ,shaft of the ,femur4 ,the course of the bullet was anteroposterior through the axis of the femur4 ,several large fragments which were not displaced were separated by the force of impact4 ,the separation of the fragments and the overriding of the ends of the proximal and distal large fragments were due to bearing bodily weight or to muscular contraction4 ,the projectile causing the wound was moving with the velocity of mid range4 ,the wound of exit was not lacerated4 ,the emergency treatment is antiseptic dressing and temporary splint immobilization4 ,permanent dressing1 with extension and lateral compression1 is the rule4 ,infection in such cases is frequent owing to lack of facilities for proper dressing on the field4 ,results in saving life and limb are generally good4 ,illustration3 ,plate #ee4 ,,rifle--,,plate #ee4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,lower ,third of the ,shaft of the ,femur4 ,the course of the bullet was diagonally anteroposterior1 with a velocity near mid range1 without causing much displacement of fragments4 ,the wound of entrance and exit would be almost the same in appearance4 ,treatment and results would be similar to case shown on plate #ed4 ,many of these wounds are infected1 due1 no doubt1 to the difficulties of arranging a clean first-aid dressing and effecting satisfactory immobilization during the first stage of transportation4 ,infection from clothing carried into the wound is rare1 as the fairly high velocity of the bullet causes a spreading of the fibers without division or punched-out section before the bullet4 ,as a rule the infected cases of this class recovered without loss of limb4 ,amputation was very rare4 ,illustration3 ,plate #ef4 ,,rifle--,,plate #ef4 ,,lower ,,extremity4 ,gunshot ,fracture ,below the ,middle of the ,femur1 with ,lodgment of the ,bullet ,near the ,fracture4 ,the course of the projectile was transverse4 ,the long splitting fracture1 with few large fragments and the lodged undeformed missile1 indicate that the injury to the bone was caused by the missile striking the bone with large cross section or at an inclined angle so that all of the remaining energy of the projectile at long range was absorbed by the bone4 ,had the point of the ball struck the bone with the same energy1 it would have produced smaller fragments and might then have passed beyond the bone4 ,the normal size of the diameter1 slightly shortened length1 greater density of the point of the shadow1 shows the bullet to lie behind the bone with its nose pointing slightly backward4 ,the actual length of the bullet is #a4be inches3 the length of the shadow is #a inch4 ,treatment and results would be about the same as in plates #di and #ej4 ,illustration3 ,plate #eg4 ,,rifle--,,plate #eg4 ,,lower ,,extremity4 ,gunshot ,fracture ,about the ,middle of the ,femur1 with ,lodgment of the ,fragments of a ,deformed ,bullet4 ,the course of the missile was transverse4 ,all of the remaining energy of the retarded velocity of the short range of a ricochet shot was stopped by the bone with the result of a long splitting fracture1 and the lodgment of one large and a few small fragments of the missile4 ,the small notched metal fragment lying to the right of the upper bone fragment is a small bent piece of the jacket1 detached from the greatly deformed lead core1 which can be faintly seen lying behind the lower end of the left side of the upper bone fragment4 ,the treatment is extension with lateral compression1 although this case1 showing by callus formation advancing convalescence1 reveals very bad position4 ,results as to life and limb are favorable in such cases1 but some deformity is to be expected4 ,it should be noted that this is a case from ,gulhan ,hospital1 the best military hospital in ,constantinople1 where the surgical service1 under ,prof4 ,wieting ,pasha1 was skillfully conducted4 ,illustration3 ,plate #eh4 ,,rifle--,,plate #eh4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,lower ,end of the ,femur4 ,the course of the bullet was anteroposterior4 ,the long1 oblique1 splitting fracture without separate fragments indicates the long range of the missile in low velocity4 ,the wound was infected as is indicated by the drainage tubes in place4 ,the well-advanced callus formation indicates established convalescence4 ,results are favorable for recovery with only fair position and some shortening4 ,it may be observed that this is also a case from ,gulhan ,hospital4 ,illustration3 ,plate #ei4 ,,rifle--,,plate #ei4 ,,lower ,,extremity4 ,gunshot ,wound of the ,left ,knee-,joint1 with ,lodgment of the ,missile in the ,joint4 ,the course of the bullet was transverse1 entering the capsule posterior to the patella without injury to the bone4 ,as its shadow projection is almost circular1 the bullet must be standing almost on its end pointing toward the plate with its long axis almost parallel to the line of projection4 ,as the fibular side of the leg lay next to the plate and as the only slightly enlarged shadow of the bullet indicates it to be near the plate1 its position is in the joint near the fibular side4 ,as the bullet is undeformed and its penetrating power very slight1 its velocity was that of extreme range4 ,the emergency treatment1 is1 of course1 a simple antiseptic dressing with the leg held in the most comfortable position by muscular action4 ,the subsequent treatment is removal of the bullet when proper surgical conditions obtain4 ,illustration3 ,plate #fj4 ,,rifle--,,plate #fj4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,tibia and ,fibula1 with ,lodgment of the ,missile4 ,the course of the bullet was diagonal from within outward and backward about the middle of the leg1 with the impact tangential on the tibia and direct on the fibula4 ,the bullet lies just behind the tibia4 ,it is apparent that the bullet has been greatly deformed and that its jacket has been badly torn from the core4 ,the force of impact on the object from which it ricocheted must have been contributed by the velocity of short range1 which reduced the striking energy so greatly that the bullet was lodged by the resistance of the tibia and fibula4 ,the wound was not infected1 and callus formation shows that repair has begun4 ,the treatment in such cases1 without infection1 is noninterference4 ,the lodgment of the missile need not prejudicate the prognosis1 and certainly the additional damage in the search for the bullet is not warranted1 except under special indications4 ,illustration3 ,plate #fa4 ,,rifle--,,plate #fa4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,lower ,ends of the ,tibia and ,fibula4 ,the course of the bullet was transverse1 with the velocity of mid-range4 ,the fragmentation of the fibula1 lying close to the skin1 would produce considerable laceration in the wound of exit4 ,the treatment is conservative4 ,infection would depend almost entirely upon the integrity of the first dressings and immobilization4 ,results should be favorable1 with care in subsequent treatment4 ,illustration3 ,plate #fb4 ,,rifle--,,plate #fb4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,upper ,third of the ,tibia1 with ,large ,longitudinal ,fragment4 ,the course of the bullet was anteroposterior and slightly diagonal from without inward through the shaft of the tibia4 ,the injury was due to the energy of impact of a bullet1 in the high velocity of short range1 striking the axis of the diaphysis1 in which the greater part of its energy was expended in pushing away a wall of the canal4 ,convalescence is well established without infection1 as shown by callus formation4 ,the treatment in such cases is invariably conservative1 with the removal of such fragments as may be detached by suppuration and sequestration4 ,illustration3 ,plate #fc4 ,,rifle--,,plate #fc4 ,,lower ,,extremity4 ,gunshot ,wound of the ,middle of the ,tibia1 with ,few ,large ,fragments4 ,the course of the bullet was transverse from without inward4 ,the direct impact of the bullet1 in high velocity of short range1 has produced the typical 8,x0 fracture due to the radiating lines of force4 ,the wound was infected1 as is shown by the drainage tubes in the wound4 ,the emergency treatment in such cases is simple antiseptic dressing and temporary splint immobilization4 ,the subsequent treatment is the management of the infection4 ,the results in such cases are favorable4 ,illustration3 ,plate #fd4 ,,rifle--,,plate #fd4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,tibia4 ,the course of the bullet was diagonal1 from without inward and from before backward through the middle of the tibia4 ,small particles of metal have lodged at the site of the fracture--a condition which never occurs in a rifle wound with the jacket of the bullet intact1 while it is the invariable accompaniment of a shrapnel wound of a bone4 ,it is inferred that the jacket of the bullet in this case was damaged by ricochet1 or that some metal particles from the object against which the bullet ricocheted were carried into the wound1 as some other small pieces of metal are seen in areas distant from the seat of fracture4 ,as the fragments are small and not displaced1 the velocity of the missile1 at least that of mid-range1 was almost sufficient to perforate the bone without fracture4 ,illustration3 ,plate #fe4 ,,rifle--,,plate #fe4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,tibia4 ,the course of the bullet was transverse1 from within outward1 striking the bone near the outer border with the velocity of mid or long range1 producing long fissures without separation of fragments4 ,the safety pin1 of course1 lies in the dressings and on the side away from the plate1 as shown by its somewhat indefinite outline and increased length4 ,the wounds of entrance and exit are practically the same4 ,the treatment in such cases is that of a simple fracture1 except for the management of an occasional infection1 and the results are favorable4 ,illustration3 ,plate #ff4 ,,rifle--,,plate #ff4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,middle of the ,tibia1 with ,lodgment of the ,missile4 ,the course of the bullet was transverse1 from without inward1 striking on the side of the shaft of the tibia4 ,the bullet was so badly damaged by ricochet that only a portion of it was the cause of this wound4 ,the range was short1 if not close1 as the missile after striking a resisting object with force enough to break itself retained enough energy in a fragment of less than half its mass to cause a long fissure fracture1 with the separation of smaller fragments4 ,the treatment is noninterference1 except for infection1 which1 contrary to what might be expected from presumable contamination from the object from which it ricocheted1 does not occur more frequently in ricochet than direct wounds with lodgment of the projectile4 ,illustration3 ,plate #fg4 ,,rifle--,,plate #fg4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,lower ,third of the ,tibia4 ,the course of the bullet1 with reduced energy of long range1 was anteroposterior1 striking the inner border of the bone and punching out a circular area of small fragments with a single transverse line of fracture4 ,the wound of exit was slightly larger than the wound of entrance4 ,the treatment is conservative4 ,infection is not probable if emergency dressing is clean4 ,illustration3 ,plate #fh4 ,,rifle--,,plate #fh4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,lower ,third of the ,tibia4 ,the course of the bullet was diagonally anteroposterior1 from without inward1 striking the internal border of the anterior surface of the bone1 and partially splitting off fragments from the side with a perforating effect4 ,the range of the shot was long4 ,the dense and irregular shadows to the right of the fracture are caused by the material used in dressing and indicate a slight infection4 ,the small shadows on the tibial side are not a part of the wound1 but are due to opaque material caught in the dressing4 ,illustration3 ,plate #fi4 ,,rifle--,,plate #fi4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,lower ,end of the ,tibia4 ,the course of the bullet was transverse1 from without inward1 through the lower end of the bone1 with a piercing effect and a fissuring of the upper fragment4 ,the velocity was that of short range4 ,the wound of exit would be slightly larger than that of entrance1 as some small fragments can be seen extending along the tract of the missile from the line of transverse fracture toward the internal border of the leg4 ,there was no laceration of the wound of exit4 ,the wound was clean4 ,the treatment is conservative4 ,results should be favorable4 ,infection would depend most probably upon the asepsis of the first dressing4 ,illustration3 ,plate #gj4 ,,rifle--,,plate #gj4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,tibia1 with ,lodgment of the ,missile4 ,the course of the bullet was from within outward1 striking the posterior surface of the tibia about #b inches above the ankle1 and causing a slight crack in the bone at the point where its course was deflected4 ,the velocity was that of extreme range1 as the wholly normal outline of the projectile and the slight penetration indicates that its energy was almost entirely lost in flight and not by ricochet4 ,the sharp outlines of the lower border of the fibula and the external border of the articular surface of the lower end of the tibia indicate the position of the fibula as next to the photographic plate4 ,the bullet lies at a very slight angle with the plate1 as is shown by the curved outline of its base1 which condition alone would give a projection shadow somewhat shorter than the bullet4 ,but as the shadow is actually somewhat longer than the bullet 7about one-eighth inch1 or one-tenth its length71 the position of the bullet is some distance from the plate and most probably lies behind the tibia1 at the inside of the fibula4 ,illustration3 ,plate #ga4 ,,rifle--,,plate #ga4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,fibula4 ,the course of the bullet was anteroposterior through the lower third of the leg1 striking the fibula squarely1 passing through the bone with a perforating effect1 accompanied by slight fragmentation and with a reduced velocity of long range4 ,the wounds of entrance and exit would be almost the same in appearance4 ,asepsis in such cases is the almost invariable rule1 and the treatment after the simple dressing is that of a simple fracture4 ,illustration3 ,plate #gb4 ,,rifle--,,plate #gb4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,ankle4 ,the course of the bullet was anteroposterior1 striking the fibula from behind with a velocity of long range1 and causing some slight fragmentation without displacement of the fragments4 ,the joint architecture is slightly disturbed4 ,the joint mortice is a bit widened by the external deflection of the external malleolus1 which permits a slight outward rotation of the astragalus4 ,as the dangers of infection are usually escaped1 the treatment is that for ,pott's fracture4 ,illustration3 ,plate #gc4 ,,rifle--,,plate #gc4 ,,lower ,,extremity4 ,gunshot ,wound of the ,heel1 with ,lodgment of the ,missile4 ,the course of the bullet was from behind forward through the insertion of the tendo ,achillis and its lodgment along the outer border of the os calcis4 ,there was no injury to the bone4 ,the path of the bullet is shown by the slight mottling above the posterior extremity of the os calcis4 ,the nose of the bullet is slightly deformed by ricochet at long range4 ,the very slight penetration and the slight deformity of the nose of the bullet indicates a velocity of extreme range of both impact of the ricochet and of the wound4 ,the sharp outline of fibula and the base of fifth metatarsal shows the fibula to be next to the plate4 ,the only slight enlargement and square base of the shadow of the bullet show it to be parallel to the plate1 or at right angles to the line of projection1 and thus indicate its position to be on the fibula side of the os calcis1 below the tip of the external malleolus4 ,illustration3 ,plate #gd4 ,,rifle--,,plate #gd4 ,,lower ,,extremity4 ,gunshot ,wound of the ,heel4 ,this is the same case as shown in plate #fi1 but with the shadow projected from above downward instead of from side to side1 as in the preceding plate4 ,the interpretation of the shadows in the preceding plate is thus confirmed4 ,as the heel lay on the plate1 the projectile at a sharp angle with the plane of the plate1 several inches farther from the plate than in the preceding radiograph1 and with the line of projection at about right angles to the long axis of the projectile1 the shadow projection is considerably enlarged4 ,illustration3 ,plate #ge4 ,,shrapnel--,,plate #ge4 ,,head4 ,gunshot ,fracture of the ,vertex1 with ,intracranial ,lodgment of the ,missile4 ,wound of entrance1 left anterior parietal region4 ,wound of exit1 none4 ,the missile left a few small fragments spattered on the bone at point of entrance1 with a slight deformation of the ball due to this cause1 as shown in the plate4 ,the distinct outline and normal size of the ball shows it to be very near the plate and on the left side of the head1 while the enlarged and blurred image of the safety pin shows its position to be on the side of the head farther away from the plate4 ,emergency treatment is antiseptic dressing only4 ,subsequent treatment is directed to fragments and depression1 without search for ball4 ,septic condition might indicate some later interference4 ,results in such cases are favorable if wound is not infected4 ,illustration3 ,plate #gf4 ,,shrapnel--,,plate #gf4 ,,head4 ,gunshot ,fracture of the ,vertex4 ,wound of entrance1 upper right and mid-parietal region4 ,wound of exit1 none4 ,the missile probably was deformed before striking the skull1 upon which it was fragmented by impact1 with several fragments following the internal contour of the vertex and others remaining spattered about the wound of entrance4 ,it is probable that a larger mass of the shrapnel ball1 causing the greater damage to the bone1 ricocheted out of the wound4 ,the distinct outline of the central safety pin and the less definite image of the shrapnel fragments show the wound to have been farther from the plate than the safety pin on the left side4 ,the treatment is expectant1 without search for the missile4 ,results in such cases are favorable1 except for danger of infection4 ,illustration3 ,plate #gg4 ,,shrapnel--,,plate #gg4 ,,head4 ,gunshot ,fracture of ,zygoma1 with ,lodgment of the ,missile in the ,zygomatic ,fossa4 ,wound of entrance1 external border of right supra-orbital ridge4 ,wound of exit1 none4 ,a few metallic fragments are seen where the missile lodged near the point of impact with the bone4 ,the treatment is expectant4 ,removal of the ball from its superficial location is indicated if the wound is infected4 ,result in such cases is favorable4 ,illustration3 ,plate #gh4 ,,shrapnel--,,plate #gh4 ,,head4 ,gunshot ,fracture of the ,mastoid ,process4 ,wound of entrance1 upper posterior cheek1 in front of the ear4 ,wound of exit1 posterior to mastoid process1 lacerated4 ,the course of the missile was tangential1 with the damage limited to the outer table of the mastoid4 ,the metal particles scraped off of the ball by its contact with the bone mark the site of the wound4 ,treatment is expectant4 ,results are favorable4 ,illustration3 ,plate #gi4 ,,shrapnel--,,plate #gi4 ,,head4 ,gunshot ,fracture of the ,left ,maxilla1 with ,lodgment of the ,missile in the ,neck ,behind the ,angle of the ,jaw4 ,wound of entrance1 below infraorbital ridge1 with course through the mouth4 ,wound of exit1 none4 ,missile left a few small metallic fragments spattered on the bone at the point of entrance4 ,there is slight mark of deformity of the missile caused by its contact with the bone1 shown in its shadow in the plate4 ,the distinct outline and normal size of the ball shows it to have been on the side next to and near the plate4 ,treatment indicated is expectant4 ,results in such cases are favorable1 as seat of probable infection is readily accessible4 ,in this particular case1 recovery followed with the ball left in situ1 without causing the patient trouble enough to induce him to permit interference4 ,illustration3 ,plate #hj4 ,,shrapnel--,,plate #hj4 ,,head4 ,gunshot ,fracture of the ,anterior ,table of the ,frontal ,sinus1 with ,lodgment of the ,missile in the ,posterior ,nares4 ,wound of entrance1 over the left internal super supra-orbital ridge1 with course downward1 slightly backward1 and slightly to the left posterior nares4 ,wound of exit1 none4 ,the distinct outline and practically normal size of ball shows that the patient's face was superimposed on the photographic plate1 as the anterior location of the missile was suspected4 ,the slight deformity of the ball is due to the impact with the bone4 ,this personal case was received from the service of ,prof4 ,de ,page1 of the ,belgian ,red ,cross ,mission1 at ,josh ,keshla ,hospital1 ,constantinople1 after an operation for infections of the frontal sinus1 in which the anterior table was entirely removed1 with free drainage into the posterior nares1 before the radiograph was made or the exact location of the ball suspected4 ,the missile is seen in the nares--very near the face--probably in the middle meatus1 in the inferior turbinates1 against the septum1 deviated by its lodgment4 ,convalescence was finally established and the frontal-sinus wound practically closed when1 without any subjective symptoms1 an obstruction was objectively determined in the left posterior nares1 suggesting the radiograph4 ,the patient was so entirely free from any symptoms of the lodged missile that he wisely refused any meddlesome interference4 ,he was discharged with sinus wound closed very remarkably without indication for plastic operation and with no symptoms4 ,illustration3 ,plate #ha4 ,,shrapnel--,,plate #ha4 ,,head4 ,gunshot ,fracture of ,anterior ,table of the ,parietal ,bone and the ,vomer1 with the ,lodgment of the ,missile in the ,posterior ,nares4 ,this plate is a side view of the case in plate ,no4 #hj1 showing the antero-posterior location of the ball4 ,the indefinite outline and enlarged size of the ball shows the ball to have been farther away from the plate than in plate #hj4 ,illustration3 ,plate #hb4 ,,shrapnel--,,plate #hb4 ,,upper ,,extremity4 ,gunshot ,wound of the ,shoulder1 with ,lodgment of the ,missile4 ,the course of the missile was transverse from the posterior surface of the greater tuberosity of the humerus to the internal border of the scapula1 distributing small metallic fragments along its path4 ,there is no injury to the bone4 ,the remnant of the ball has passed behind the scapula and lies near its superior angle4 ,the treatment in such cases is1 of course1 conservative1 with no serious consequences expected from infection4 ,illustration3 ,plate #hc4 ,,shrapnel--,,plate #hc4 ,,upper ,,extremity4 ,gunshot ,wound of the ,shoulder1 with ,lodgment of the ,missile4 ,the course of the ball was transverse through the posterior border of the deltoid muscle without contact with the bone1 which would have been revealed by small particles of lead scraped off from the ball4 ,the actual size1 normal outline1 and great density of the shadow of the ball show that it lay next to the plate and that it is1 therefore1 lodged posterior and mesial to the glenoid portion of the scapula4 ,the treatment is noninterference unless removal be indicated by pain1 impairment of function1 or infection4 ,the results should always be good4 ,illustration3 ,plate #hd4 ,,shrapnel--,,plate #hd4 ,,upper ,,extremity4 ,gunshot ,wound of the ,shoulder1 with ,lodgment of the ,missile4 ,the course of the bullet was from before backward and upward through the deltoid to the anterior surface of the head of the humerus4 ,the missile is not the conventional shrapnel ball1 which is spherical and about one-half inch in diameter1 for the shadow shows a larger axis in one direction with parallel sides1 too symmetrical to be attributed to deformation4 ,the ballistic conditions are those of shrapnel4 ,the missile struck the bone an inch or two below the point of lodgment4 ,its path is shown by particles of metal4 ,pain or interference with function would be cause for interference in subsequent treatment1 which otherwise would be expectant4 ,illustration3 ,plate #he4 ,,shrapnel--,,plate #he4 ,,upper ,,extremity4 ,gunshot ,wound of the ,shoulder1 with ,lodgment of the ,missile4 ,the missile lies behind the head of the humerus1 under conditions similar to the cases shown in plates #hc and #hd4 ,the position of the hall is indicated by the outline and depth of shadow of the normal size of a shrapnel ball4 ,the ball must therefore be very near the plate and behind the head of the humerus4 ,there is no injury to the bone4 ,the slight deformity of the ball was caused by ricochet before it caused the wound1 as no particles of lead are seen on the bone to account for the impact of the missile4 ,illustration3 ,plate #hf4 ,,shrapnel--,,plate #hf4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,clavicle4 ,the ball ranged from before backward and upward1 comminuting the outer half of the clavicle4 ,the fragments have been removed4 ,the particles of metal which mark the path of the ball lie in front of the acromion process of the scapula1 because lack of density and indistinct outline of the shadows show them to be farther from the photographic plate than the spine of the scapula which rested on the plate1 escaping the imminent danger of wounding the subclavian vessels4 ,the treatment is conservative and results are favorable4 ,illustration3 ,plate #hg4 ,,shrapnel--,,plate #hg4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,humerus4 ,the missile struck the bone and caused a long1 splitting fracture1 with some fragmentation of the proximal fragment4 ,the wound could have been caused by either a ricocheted rifle bullet or by a deformed shrapnel ball1 either projectile being the low velocity of long range4 ,these conditions are more common to shrapnel wounds1 but the appearance of the larger metal fragment leads to the suspicion that it is a piece of the jacket of a rifle bullet4 ,the wound was not infected1 and convalescence is well advanced1 as is indicated by the callous formation4 ,illustration3 ,plate #hh4 ,,shrapnel--,,plate #hh4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,humerus1 with ,lodgment of the ,missile4 ,the missile struck the shaft of the humerus from an anterior and external direction and caused a long diagonal splitting fracture with fragmentation1 in which the bone absorbed all of the energy of the missile at the seat of fracture4 ,the missile lies in the anterior surface of the humerus1 in two fragments2 the smaller1 much less distinct1 is seen about an inch above the larger4 ,the wound is not infected1 and convalescence is well established1 as is indicated by the callous formation1 with overlapping of the fragments4 ,the treatment in such cases is conservative and the results are favorable4 ,illustration3 ,plate #hi4 ,,shrapnel--,,plate #hi4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,humerus4 ,the course of the missile was from behind forward and outward1 striking the bone on the posterior surface1 causing a fracture with fragmentation1 and lacerating the wound of exit with fragments of bones and with its own deformation4 ,the wound of exit is indicated in the plate4 ,the wound is infected4 ,fragments of the missile lie on the posterior surface of the bone1 as indicated by their dense shadow and distinct outline4 ,the treatment in such cases is conservative and the results are favorable4 ,illustration3 ,plate #ij4 ,,shrapnel--,,plate #ij4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,left ,humerus4 ,the course of the missile was transverse from without inward1 with a transverse fracture and fragmentation4 ,this wound might have been caused by either a shrapnel ball or a deformed rifle bullet1 but the distribution of the metallic fragments rather indicate the course of a shrapnel ball4 ,the metallic fragments lie farther from the plate than the safety pin of the dressing1 which1 therefore1 lies behind the bone and the fragments of the missile lie in front4 ,the treatment in such cases is conservative and the results are favorable4 ,the subsequent course may indicate interference for mal-union4 ,illustration3 ,plate #ia4 ,,shrapnel--,,plate #ia4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,left ,humerus4 ,the course of the missile has been from without inward4 ,the fragments of metal marking the path of the missile lie farther from the plate on the outer than on the inner side4 ,this would indicate the former to be in front of the bone and the latter to be behind4 ,the wound could have been caused by either a deformed rifle bullet or by a shrapnel ball1 but the distribution of metallic fragments along the track of the missile rather indicates the agent to have been a shrapnel ball4 ,the case is similar in course and results to that shown in the preceding plate #ij4 ,illustration3 ,plate #ib4 ,,shrapnel--,,plate #ib4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,right ,humerus1 with ,lodgment of the ,missile4 ,the missiles1 shrapnel balls deformed by ricochet1 were multiple1 with a course from without inward and diagonally downward4 ,the streaks of metal particles along the seat of fracture indicates the path of a shrapnel ball or fragment from the point of impact to the lower fragment of the fracture1 where several deformed shrapnel fragments are lodged4 ,multiple wounds by shrapnel are common4 ,the wounds of entrance were small4 ,there was no wound of exit4 ,the wound was not infected4 ,this is another evidence that does not defend the inference that ricocheted missiles are prone to introduce elements of infection into a wound4 ,the plaster dressing does not seem to meet the indications for support of the fracture4 ,the treatment is conservative in such cases4 ,results are favorable4 ,illustration3 ,plate #ic4 ,,shrapnel--,,plate #ic4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,right ,humerus4 ,the course of the missile was transverse1 from without inward and downward1 striking the shaft of the bone squarely and producing a characteristic 8butterfly0 fracture1 with a separation of the fragments4 ,the exposure was made with the ulnar side of the arm next to the plate1 indicated by the clear outline of the internal condyle and the olecranon4 ,the nearly normal size of the shadow of the shrapnel ball shows it to be near the plate1 and therefore to lie on the inside of the humerus4 ,the irregular outline of the ball and the metallic fragments spattered about indicate that the ball was deformed by the detachment of fragments on direct impact with the bone4 ,the wound is not infected4 ,the treatment is conservative in such cases and the results are good4 ,illustration3 ,plate #id4 ,,shrapnel--,,plate #id4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,right ,humerus4 ,the course of the missile was from behind forward1 causing a transverse fracture of the humerus with some fragmentation4 ,the wound is in a state of established convalescence1 with considerable separation of the ends of the large fragments and without infection1 shown by the formation of callus and by an attempt at union in faulty position4 ,the trail of the metallic fragments of the missile from behind forward and their location near the anterior surface of the arm indicate the course of the missile1 either a rifle bullet or a shrapnel ball--most probably the latter1 as the lead core of the rifle ball1 protected by the jacket1 does not break up into as many small particles as does the shrapnel ball4 ,the missile was deformed by ricochet before striking the bone4 ,the early treatment in such cases is conservative1 although the subsequent course may indicate interference for malposition4 ,the results are favorable4 ,illustration3 ,plate #ie4 ,,shrapnel--,,plate #ie4 ,,upper ,,extremity4 ,gunshot ,wound of the ,humerus1 with ,lodgment of the ,missile4 ,the course of the missile was from before backward4 ,the missile consisted of two large fragments of a richocheted shrapnel ball1 almost spent in energy before striking the arm1 as its penetration was just enough to pass through the soft parts and strike the humerus1 causing a fissure without separation of fragments4 ,the wound was clean4 ,the treatment in such cases is naturally conservative4 ,the epiphysis of the olecranon being so distinct and showing no fusion1 indicates the youth of this soldier1 whose age could not have been more than #af years4 ,illustration3 ,plate #if4 ,,rifle--,,plate #if4 ,,upper ,,extremity4 7a7 ,gunshot ,fracture of the ,left ,humerus--7b7 ,gunshot ,fracture of the ,left ,elbow4 ,the missile was a rifle bullet with the reduced velocity of long range1 passing transversely along the articulations of the elbow1 fragmenting the radius and ulna and fissuring the humerus through both condyles4 ,the emergency treatment is antiseptic dressing and immobilization1 with prompt transportation to the base4 ,subsequent treatment is conservative1 with proper immobilization4 ,results as to limb are favorable1 with probable loss of function of the elbow4 ,illustration3 ,plate #ig4 ,,shrapnel--,,plate #ig4 ,,upper ,,extremity4 ,gunshot ,wound of the ,right ,elbow4 ,the course of the missile was superficial1 downward and outward from above the internal condyle of the right humerus to the wound of exit over the internal border of the ulna4 ,metal fragments of the missile have lodged against the tip of the olecranum1 with no fracture and with no damage to the joint4 ,the low velocity of the missile1 producing so slight a bone injury and the track of lead particles along the line of contact with the bones determines it to have been a shrapnel ball4 ,the wound was not infected4 ,the treatment in such cases is naturally conservative and the results are very favorable4 ,illustration3 ,plate #ih4 ,,shrapnel--,,plate #ih4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,right ,elbow1 with ,lodgment of the ,missile4 ,the course of the ball was from before backward1 striking the lower end of the humerus squarely above and internal to the external condyle and splitting off the condyles with a line of fracture extending through the capitellum1 without much separation of the fragment4 ,as the impact was direct1 the energy producing such effect was that of low velocity4 ,the great radiographic penetration shown in this plate gives the shadows of the ball great distinctness and definite outline1 especially in the line of fracture1 although its opposite border is not in such sharp contrast4 ,this appearance1 together with the very slight enlargement1 leads to the suspicion that the ball lies posteriorly1 but a larger metal fragment1 below the ball1 is less clear and suggests a position anterior to the bone4 ,with the posterior surface of the arm next to the plate and with but little difference in the distance from the plate to either the anterior or posterior surface of the bone1 it is not easy to determine the location of the ball in the anteroposterior direction1 but it would seem to be on the anterior surface of the bone4 ,the wound is not infected4 ,the treatment is conservative and results favorable4 ,the subsequent course would probably indicate the removal of a foreign body from a site so near the joint4 ,illustration3 ,plate #ii4 ,,shrapnel--,,plate #ii4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,right ,elbow1 with ,lodgment of the ,missile4 ,same wound as in plate #ih4 ,the sharp holder of the greater sigmoid cavity and the head of the radius fully obscured by the coracoid process indicate1 that in this exposure1 the ulnar side of the arm was next to the plate4 ,with this condition and the enlarged shadow of the ball1 the latter must lie a little distance away from the plate1 and1 actually1 on the radial side of the humerus4 ,the position of the ball in the anteroposterior line is manifest1 and its position confirms the deductions made therefrom in the preceding plate 7#ih74 ,illustration3 ,plate #ajj4 ,,shrapnel--,,plate #ajj4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,elbow4 ,the primary condition of this wound is not manifest from the appearance of the plate1 which reveals only a destruction of the joint by fracture and an advanced stage of infection1 involving the fragments and lower end of the shaft of the humerus1 as indicated by the rarefaction of these parts4 ,several fragments of the missile are in evidence2 it is probable that others have escaped with drainage4 ,drainage tubes are seen in the lower arm and upper forearm4 ,the primary conservative treatment has been continued through two or three months4 ,the case is from ,gulhan ,military ,hospital1 where the scientific character of surgical service already referred to must lead to the inference that all the surgical indications have been met in the management of the case4 ,illustration3 ,plate #aja4 ,,shrapnel--,,plate #aja4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,left ,radius and ,ulna1 with ,lodgment of the ,missile4 ,the course of the missile was from within outward1 striking the ulna a glancing blow just above the styloid process1 fracturing the anterior surface1 and then striking the internal border of the radius and causing a slight notching fracture with a longitudinal fissure4 ,the forearm lies in supination1 with its posterior surface next to the plate4 ,as the outline of the missile1 as well as of the bone1 is blurred1 there is not enough differentiation in the shadows to indicate the anterior or posterior location of the missile with reference to the radius4 ,the shrapnel ball struck the bone with low velocity1 as all of its remaining energy1 absorbed by the two small bones1 caused little damage and practically no displacement of fragments4 ,the wound was not infected4 ,the treatment in such cases is1 of course1 conservative4 ,results are uniformly good4 ,illustration3 ,plate #ajb4 ,,shrapnel--,,plate #ajb4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,right ,radius4 ,a fragmented shrapnel ball1 coursing from without inward1 struck the upper third of the shaft of the radius and caused a green-stick fracture4 ,a fragment of the ball1 larger than those seen in the plate1 inflicted the greater damage and escaped through the wound of exit1 to be seen below the large fragment on the left of the plate4 ,the olecranon process of the right ulna rests on the photographic plate1 with the forearm in semipronation1 so that the shadow of the radius falls nearly in line with that of the ulna4 ,with the forearm restored to the anatomical position1 the spattered metallic fragments1 now seen lying over and to the left of the radius1 would then be shown lying on the outer border of and posterior to the radius1 except for the upper right metallic fragment1 now lying over the ulna1 which would be seen lying over the anterior surface of the radius4 ,the six pellets seen in the lower forearm have not contributed to the injury of the bone4 ,their density and indefinite outline indicate a position in the forearm opposite to the side next to the plate4 ,with the forearm in supination they would appear in their real position1 in front of the ulna and on the outside of the radius4 ,illustration3 ,plate #ajc4 ,,shrapnel--,,plate #ajc4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,right ,radius4 ,the missile in its course from behind forward and from above downward left a trail of its metal particles along the line of its first contact until the bone yielded to the pressure in a transverse fracture4 ,the arm lies in slight pronation with the longitudinal ridges of the dorsal surface of the ulna1 shown distinctly next to the photographic plate4 ,the upper end of the lower radial fragment1 shown as overlying the ulna1 is inclined forward in the anatomical position4 ,the metal particles are on the outer and posterior border of the radius4 ,the treatment in such cases is conservative4 ,results as to function are uncertain4 ,illustration3 ,plate #ajd4 ,,shrapnel--,,plate #ajd4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,ulna4 ,the course of the missile was tangential along side of the upper end of the ulna and internal condyle of the humerus1 with a splitting effect on the ulna1 which formed three fragments by breaking off the olecranon1 and one lateral fragment from the shaft of the bone without displacement4 ,the line of metallic particles shows the path of the ball in its slight contact with the bones1 beginning on the side of the ulna and extending along the side of the internal condyle from where the ball escaped through the skin4 ,the wound1 not infected1 was treated as simple fracture4 ,a few fine lines on the plate above the fracture are due to scratches on the negative4 ,results in such cases should be good4 ,illustration3 ,plate #aje4 ,,shrapnel--,,plate #aje4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,right ,metacarpus4 ,the course of the missile was from the outer border of the hypothnear eminence diagonally downward through the palm1 lodging against the second metacarpal bone with fracture of last four metacarpals4 ,the metal particles are not seen on the fourth and fifth metacarpals because the violence at these points was transmitted through soft parts1 but the projectile spent its remaining energy directly against the second and third metacarpals4 ,the palm of the hand was next to the photographic plate1 as indicated by the immediate contact of the thumb4 ,the shadow of the bones is not dense1 but in deep contrast with the shadows of the ball and metal fragments1 which are so clearly outlined with the ball of normal size that the ball is thus shown to lie on the palmar side of the hand4 ,the treatment is conservative1 with judicious interference when opportunity shall offer for removal of the missile4 ,illustration3 ,plate #ajf4 ,,shrapnel--,,plate #ajf4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,left ,metacarpus1 with ,lodgment of the ,missile4 ,the palm of the hand lies next to the plate4 ,the ball is very slightly enlarged and the small metal fragments are indistinct1 indicating that they and the ball lie on the back of the hand4 ,the ball struck the third knuckle and lodged beneath the skin between the fourth and fifth metacarpals1 fracturing both bones without displacement of fragments4 ,in the recent wound the condition would be apparent1 but after days of inflammatory reaction and infection1 the swelling is too great to make any determination by palpation4 ,the treatment is removal of the missile4 ,good results regularly follow4 ,illustration3 ,plate #ajg4 ,,shrapnel--,,plate #ajg4 ,,upper ,,extremity4 ,gunshot ,fracture of the ,left ,metacarpus1 with ,lodgment of the ,missile4 ,the hand lies with its ulnar side next to the plate1 as is indicated by the sharp outline of the swollen hypothenar eminence1 nearer the plate than the thumb1 with the enlarged1 poorly defined1 and rarefied shadow of its metacarpal and phalanges4 ,as the normal size of the balls and the clear outline of the metal fragments must place them almost in contact with the plate1 the ball is located near the fifth metacarpal4 ,as this is the same case as is shown in plate #ajf1 the conclusions drawn from each plate are confirmed by the other4 ,the wound is infected1 as indicated by the swelling of the palm4 ,the treatment is removal of the missile1 with management of the infection4 ,illustration3 ,plate #ajh4 ,,shrapnel--,,plate #ajh4 ,,upper ,,extremity4 ,gunshot ,wound of the ,left ,hand1 with ,lodgment of the ,missile4 ,the shadow of the hand is shown with the palm next to the plate1 as indicated by the small1 well-defined outline of the first metacarpal lying within the outline of the larger and less-defined shadow of the second metacarpal4 ,the third finger is flexed at the first phalangeal joint1 and the end of the second phalanx is outlined in deeper shadow1 with its long axis vertical to the plate4 ,the position raises the first finger from the plate and very slightly enlarges the size of the shadow of the bullet1 although it retains its sharp outline4 ,the shadow of the ball being very nearly the normal size1 the ball lies on the palmar side of the third metacarpo-phalangeal joint4 ,it entered the hand on the outer border of the base of the first finger1 and left a fragment of metal on its slight contact with the bone4 ,the ball was deformed by ricochet before striking the hand1 with almost completely spent velocity4 ,the wound is infected4 ,the treatment is the management of infection4 ,illustration3 ,plate #aji4 ,,shrapnel--,,plate #aji4 ,,upper ,,extremity4 ,multiple ,gunshot ,wounds of the ,right ,hand and ,forearm1 with ,fracture of the ,metacarpus and ,phalanges and ,lodgment of the ,missile4 ,the hand lay with the palmar surface next to the plate4 ,the distinct outline of the small metal fragments and the natural size of the shadow of the undeformed shrapnel ball show that they lay on the anterior side of the metacarpus4 ,the arrangements of the metal particles and bone fragments and the indication of the point of entrance of one wound on the outer border of the metacarpal of the thumb indicate the course of the balls to have been from the radial to the ulna side of the palm4 ,the undeformed ball1 then1 lies1 most probably1 in front of the second metacarpal4 ,the deformed ball shows1 in its enlarged shadow and not so distinct in outline as the normal ball1 that it is on the dorsal surface of the third and fourth metacarpals4 ,the undeformed ball caused the fracture of the phalanx and metacarpal of the thumb2 the deformed ball fractured the neck of the third metacarpal2 a ball which escaped from the wound and touched the base of the first phalanx of the middle finger and fractured the first phalanx of the little finger2 and another ball1 which glanced along the anterior surface of the lower end of the shaft of the radius and left a deposit of metal to mark its course1 also escaped from the ulnar border of the forearm at a point indicated in the plate4 ,four balls were concerned with this wound2 two of them have lodged with some damage and two others have escaped1 after inflicting a slight injury4 ,multiple shrapnel wounds are common4 ,it may be said that the greater the number of balls lodged in a given area the less the distance of the plane from the apex of the cone of dispersion of a shrapnel discharge4 ,several shrapnel balls1 lodged in a small area without causing much damage or exhibiting much power of penetration1 indicate low velocity at close range of shrapnel balls on discharge from the shrapnel envelope4 ,in a personal case1 eight shrapnel balls were removed from a forearm4 ,illustration3 ,plate #aaj4 ,,shrapnel--,,plate #aaj4 ,,chest4 ,gunshot ,wound of the ,chest1 with ,lodgment of the ,missile in the ,lung4 ,the posterior chest wall is next to the plate1 as the posterior rib shadows are much more distinct and much smaller than the shadows of the anterior ribs4 ,the shadow of the ball is blurred1 which shows that it moved with respiration and is1 therefore1 probably in the lung4 ,the shadow is only slightly enlarged and is fairly dense1 which indicates it to be not far from the ribs and1 therefore1 in the posterior portion of the lung4 ,the treatment of such cases is conservative2 infection is not common2 hmothorax pleurisy1 empyema1 pneumonia1 and pulmonary abscess are most frequent complications1 named in the order of frequency4 ,pulmonary abscess is very rare4 ,pneumonia was seen in a personal case4 ,illustration3 ,plate #aaa4 ,,shrapnel--,,plate #aaa4 ,,chest4 ,gunshot ,wound of ,chest1 with ,lodgment of the ,missile ,superficially4 ,while the missile is not a shrapnel ball1 it presents similar conditions and does not need to be separately classified4 ,the vertebral border of the scapula is distinctly shown in light shadow1 indicating its position near the plate4 ,the outline of the missile is so distinct and the shadow so dense that it must lie near the plate1 and is located superficially in the infraspinatus fossa4 ,illustration3 ,plate #aab4 ,,shrapnel--,,plate #aab4 ,,chest4 ,gunshot ,wound of the ,chest1 with ,fractured ,rib and ,lodgment of the ,missile in the ,axilla4 ,the back of the patient lay on the plate1 as is indicated by the normal size of the ribs behind and the exaggerated outline in front4 ,the ball struck the sixth rib behind and caused a fracture at the angle4 ,it then continued its course to the axilla4 ,the normal size of the shadow of the ball indicates that it lies superficially behind the head of the humerus4 ,the wound of the rib was infected superficially1 and the secretion of the wound carried away the most of the metal particles which the ball in striking deposited on impact4 ,illustration3 ,plate #aac4 ,,shrapnel--,,plate #aac4 ,,chest4 ,gunshot ,wound of the ,chest1 with ,lodgment of the ,missile in the ,axilla4 ,there is no wound of the bone4 ,the ball lies in the axilla1 behind1 not close to1 the plate1 because the density of the shadow is not very great and the size is slightly enlarged4 ,the distance from the plate is probably that of the mid-axillary line4 ,the wound is not infected4 ,pain and impaired movement of the arm suggested localization of the missile and indicate removal in the subsequent course of treatment4 ,illustration3 ,plate #aad4 ,,shrapnel--,,plate #aad4 ,,chest4 ,gunshot ,wound of the ,chest1 with the ,lodgment of the ,missile in the ,axilla4 ,the posterior chest wall lay next to the plate4 ,the almost normal size of the shadow of the ball indicates that it lies near the plate1 and the blurred outline shows that it has moved with the chest in respiration4 ,the ball lies1 therefore1 in the posterior axilla near the middle of the outer border of the scapula1 imbedded in the thoracic muscles4 ,the treatment is expectant4 ,such wounds are rarely infected4 ,pain or impairment of function only would indicate removal of the missile from a clean wound4 ,illustration3 ,plate #aae4 ,,shrapnel--,,plate #aae4 ,,pelvis4 ,gunshot ,fracture of the ,crest of the ,right ,ilium1 with ,lodgment of the ,missile4 ,as the wound was received while the soldier was lying prone1 the course of the missile in the body was from above downward1 striking the crest of the ilium1 on which it was fragmented1 and trailing its fragments as far down as the great trochanter4 ,the injury to the ilium was a crushing fracture1 with the displacement of small fragments from the antero-superior spine4 ,as the sacrum was next to the photographic plate1 the missile1 judging from its indistinct shadow1 lies farther from the plate and in front of the bone4 ,the relative distinctness of the large fragment seen on the wing of the ilium indicates its probable position to be on the outside of the ilium4 ,the trail of the smaller metal fragments lies between the antero-superior spine and the great trochanter1 anterior to the plane of the femur4 ,the treatment in such cases is always conservative4 ,illustration3 ,plate #aaf4 ,,shrapnel--,,plate #aaf4 ,,lower ,,extremity4 ,gunshot ,wound of the ,thigh1 with ,lodgment of the ,missile4 ,with the posterior aspect of the thigh lying next to the plate1 the very greatly enlarged shadow of the deformed shrapnel ball indicates that it lies a relatively great distance from the plate1 so that its location can be determined to be near the internal border of the adductor muscles1 anteriorly1 and below the transverse plane of the lesser trochanter4 ,illustration3 ,plate #aag4 ,,shrapnel--,,plate #aag4 ,,lower ,,extremity4 ,gunshot ,wound of the ,thigh1 with ,lodgment of the ,missile4 ,with the sacrum lying next to the plate1 the normal size1 clear outline1 and dense shadow of the shrapnel ball indicates its position to be near the plate4 ,the location can be roughly estimated as the superficial gluteal region1 external to the ramus of the ischium and near the aerior plane of the upper border of the acetabular cavity4 ,illustration3 ,plate #aah4 ,,shrapnel--,,plate #aah4 ,,lower ,,extremity4 ,gunshot ,wound of the ,thigh1 with ,lodgment of the ,missile4 ,the normal size1 distinct outline1 and considerable density of the shadow of the shrapnel ball show that it lies very near the plate1 posterior to the bone and in the buttocks1 quite superficially4 ,the treatment in such cases is always conservative4 ,pain or impairment of function indicate removal after convalescence4 ,illustration3 ,plate #aai4 ,,shrapnel--,,plate #aai4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,femur1 with ,lodgment of the ,missile4 ,the direct subtrochanteric impact disintegrated the missile and delivered all of its energy to the bone1 with a resulting transverse fracture of the upper end of the shaft of the femur and longitudinal fragmentation of the shaft4 ,the course of the shrapnel ball was from behind forward and from above downward1 as is shown by the track of the metal fragments and the lodgment of a larger lead fragment on the shaft below the seat of fracture4 ,the uppermost large lead fragment1 as shown by the depth of its shadow1 lies farther behind the bone and nearer to the photographic plate than do the other pieces of the ball1 as indicated by their lighter shadows4 ,all of the fragments seem to lie behind the bone4 ,the conservative treatment of this wound is justified by the attempt at repair1 as indicated by the callus formation2 but it is manifest1 from the extremely faulty position1 that the indication for immobilization and extension in strong abduction were not appreciated4 ,proper management of conservative treatment in such cases gives good results4 ,illustration3 ,plate #abj4 ,,shrapnel--,,plate #abj4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,femur1 with ,lodgment of ,multiple ,missiles4 ,the position of the femur is in outward rotation1 as shown by the full shadow of the lesser trochanter and the vanishing of the greater trochanter behind the shoulder of the neck4 ,the two larger missiles lie on the outer side of the bone and the others lie in front on the seat of fracture4 ,the greatly deformed shrapnel balls and the slight chipping fracture of the femur indicate that the greater portion of the striking energy of the missiles was so dissipated in ricochet that but little force was left for attack on the bone4 ,the treatment in such cases is expectant and indication rarely arises for search for and removal of the missiles4 ,illustration3 ,plate #aba4 ,,shrapnel--,,plate #aba4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,shaft of the ,femur1 with ,lodgment of the ,missile4 ,the course of the shrapnel ball was from within outward1 striking the femur with the energy of high 7shrapnel7 velocity1 with fragmentation of the missile by impact on the bone4 ,the largest fragment1 by the distinct outline of its shadow1 lies close to the plate and behind the bone2 a smaller metal fragment has been carried to the outer border of the thigh1 where it lies superficially2 another fragment lies in the seat of fracture4 ,the position of fragments is faulty1 as the indications for extension and abduction have not been wholly met1 although this is a case from the well-conducted service of ,gulhan ,hospital4 ,the treatment in such cases is conservative and the results are good4 ,illustration3 ,plate #abb4 ,,shrapnel--,,plate #abb4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,shaft of the ,femur1 with ,lodgment of the ,missile4 ,the shrapnel ball1 in its almost directly antero-posterior course from behind forward1 has delivered the energy of high 7shrapnel7 velocity to the bone1 which had absorbed it all in stopping the missile1 with a resulting approach to a butterfly fracture with displacement of fragments4 ,the upper end of the lower fragment lies nearer to the plate than to the lower end of the upper fragment1 with the deformed shrapnel ball lying behind the latter1 closer to the plate4 ,the treatment in such cases is conservative1 with good results to follow except as they may be imperiled by infection4 ,illustration3 ,plate #abc4 ,,shrapnel--,,plate #abc4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,femur1 with ,lodgment of the ,missile4 ,while the missile in this case may have been other than a shrapnel ball1 the fracture is one produced by the impact of a missile delivering great striking energy1 with a predominant cross-section factor in its composition4 ,the fragments are due to the application of an energy in which the mass was distributed over a relatively large area on bone1 which resulted in the displacement of the large fragments4 ,the treatment in such cases is conservative4 ,results are favorable2 infection is generally controlled4 ,illustration3 ,plate #abd4 ,,shrapnel--,,plate #abd4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,femur1 with ,lodgment of ,multiple ,missiles4 ,the direct impact of two shrapnel balls1 delivering all of their energy to the femur1 resulted in a fracture with large fragments4 ,the exposure was made through a plaster splint1 and shows a faulty position with progressing repair4 ,the treatment in such cases is conservative1 but with respect for the indications to maintain proper position of the fragments4 ,illustration3 ,plate #abe4 ,,shrapnel--,,plate #abe4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,femur1 with ,lodgment of the ,missile4 ,the condition shown in the plate is the characteristic result of direct impact of a projectile of low velocity and great sectional area in which all of the energy is delivered to the bone against which it lodges4 ,the distinct outline and dense shadow of the deformed missile indicates its position to be behind the bone4 ,the callus formation indicates the favorable progress of repair1 but with the fragments in faulty position4 ,the treatment in such cases is conservative1 with proper respect to the principles of maintenance of normal relation of the fragments4 ,illustration3 ,plate #abf4 ,,shrapnel--,,plate #abf4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,femur1 with ,lodgment of the ,missile4 ,the course of the shrapnel ball was antero-posterior1 with an impact on the shaft of the femur1 which fragmented both the ball and bone through the imparting or the entire striking energy of the ball to the bone by the lodgment of the ball4 ,the sharp outline and density of the shadows of the missile1 in contrast with the dense shadows of the bone1 indicate that the missile lies closer to the plate than does the bone1 although the flattened ball does not permit a comparison between its shadow and the normal size of the ball4 ,the advanced stage of convalescence is shown by the formation of callous4 ,the treatment in such cases is conservative and the results are good if proper position can be maintained4 ,illustration3 ,plate #abg4 ,,shrapnel--,,plate #abg4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,shaft of the ,femur4 ,the impact of the missile was delivered with the energy of high 7shrapnel7 velocity at close range1 as is indicated by the signs of another shrapnel wound1 just above the outer tuberosity 7in the lower left corner of the plate71 where a deposit of metallic particle is evidenced4 ,the fragmentation of the missile1 through its contact with the bone1 indicates the great striking force of a missile which ricocheted from the bone4 ,the general distribution of metallic particles through a wound of this class indicates certainly that the missile was unjacketed1 and the destructive forces show that its sectional area was relatively larger1 i4 e41 a shrapnel ball4 ,the hard metal jacket of a rifle bullet would not give off its particles in contact with the bone unless it were so greatly deformed as to have almost entirely lost its jacket4 ,in this state the energy of a rifle ball must be so greatly reduced1 through the violence of ricochet1 that it would not retain enough striking force to cause its disintegration on impact with the bone4 ,besides1 some particles of the jacket could be identified1 as they are always bent or twisted so that their character is recognized in the shadow4 ,illustration3 ,plate #abh4 ,,shrapnel--,,plate #abh4 ,,lower ,,extremity4 ,gunshot ,wound of the ,left ,knee1 with ,lodgment of the ,missile in the ,joint4 ,the slight enlargement and moderate density of the shadow of the projectile indicates a position a short distance from the plate4 ,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 capsule4 ,the probabilities are that the ball lies between the head of the tibia and the patellar notch of the femur1 but the absolute certainty of this deduction must be supported by an exposure in a lateral plane1 which is shown in plate #abi4 ,illustration3 ,plate #abi4 ,,shrapnel--,,plate #abi4 ,,lower ,,extremity4 ,gunshot ,wound of the ,left ,knee1 with ,lodgment of the ,missile in the ,joint4 ,as the fibular shadow is about the normal size and clearly outlined1 the fibular side of the leg lay next to the plate4 ,as the shadow of the ball is dense and not much enlarged1 it must lie near the plate4 ,a light shadow in front of the ball1 which shows the anterior crucial ligament1 and a metallic marking above the patella1 suggests the path of the ball4 ,as this is a lateral projection of the same case that is shown in plate #abh in an antero-posterior projection1 these conclusions are thus verified4 ,the missile lies in the joint capsule between the head of the tibia1 in front of the spine1 and the patellar notch of the femur4 ,as a foreign body in the knee joint which seriously interferes with its function1 removal is indicated when surgical facilities are at hand4 ,the results in such cases are usually good4 ,illustration3 ,plate #acj4 ,,shrapnel--,,plate #acj4 ,,lower ,,extremity4 ,gunshot ,wound of the ,left ,knee1 with ,lodgment of the ,missile in the ,joint4 ,the line of projection of the shadow is directed obliquely from behind1 focussed on the internal aspect of the knee1 with the fibula next to the plate4 ,as the shadow of the shrapnel ball is much enlarged and not very dense1 the ball must lie some distance from the plate and away from the fibular side of the joint4 ,as the distances through the knee joint are about the same in all cases and as shrapnel balls are approximately the same size1 it is evident that the ball lies farther away from the plate than it does in plate #abi1 where it is about the middle of a transverse line through the joint4 ,it must lie1 therefore1 superficially between the head of the tibia and the internal condyle of the femur4 ,removal is indicated under favorable surgical conditions4 ,infection of the joint may occasionally indicate drainage and removal as emergency treatment4 ,results1 except for infection1 are good4 ,illustration3 ,plate #aca4 ,,shrapnel--,,plate #aca4 ,,lower ,,extremity4 ,gunshot ,wound of the ,knee1 with ,lodgment of the ,missile4 ,that the knee is not fully extended is shown by the exaggerated outline of the tibial head4 ,the enlarged and only fair density of the shadow indicates that the shrapnel ball lies some distance away from the plate4 ,as the bone is not injured1 the missile must lie either in front of or behind the femur1 and its enlarged shadow shows the position to be in front of the femur1 just above the articular surface1 and probably within the reflection of the capsular ligament4 ,a comparison with the size of the shadows of the balls shown in plates #abh and #acj will show this one to be greater than the former and less than the latter1 and so it must bear about the same relation in the distance from the plate4 ,this would account for the location in front instead of behind the femur4 ,the treatment is conservative1 and removal is indicated when function is disturbed4 ,illustration3 ,plate #acb4 ,,shrapnel--,,plate #acb4 ,,lower ,,extremity4 ,gunshot ,wound of the ,knee1 with ,lodgment of the ,missile4 ,the fibular side of the leg lay next to the photographic plate1 as shown by the enlarged fainter outline of the internal tuberosity4 ,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 condyle1 and the position is probably neither as close to the plate as the former nor as far away as the latter4 ,the missiles lie about the middle of the anterior surface of the lower end of the femur1 above the articular surface4 ,illustration3 ,plate #acc4 ,,shrapnel--,,plate #acc4 ,,lower ,,extremity4 ,gunshot ,wound of the ,right ,knee1 with ,lodgment of the ,missile4 ,the ball struck the outer condyle just above the articular surface with only enough energy to damage and slightly crack the bone4 ,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 condyle4 ,illustration3 ,plate #acd4 ,,shrapnel--,,plate #acd4 ,,lower ,,extremity4 ,gunshot ,wound of the ,left ,knee1 with ,lodgment of the ,missile4 ,the outer tuberosity lay next to the photographic plate1 with the knot in the localizing wire on the inside of the leg and farther away from the plate4 ,the line of projection is transversely through the tuberosities4 ,the shadow of the ball1 as it is somewhat enlarged1 not sharply defined1 and of medium density1 must lie about midway between the lines of the localizing wire or in the popliteal space just above and between the tuberosities1 much nearer the popliteal surface than the bone4 ,an accurate localization of the ball in a transverse line1 however1 would require an exposure of another plate in an antero-posterior line1 but in this actual case the localization of the ball had to be made from this single plate1 as only one exposure was made4 ,the ball struck the border of the popliteal space of the femur just above the tuberosity1 without energy enough to cause a fracture1 deform the ball1 or even to leave1 as a mark of contact1 metal particles of the ball4 ,illustration3 ,plate #ace4 ,,shrapnel--,,plate #ace4 ,,lower ,,extremity4 ,gunshot ,wound of the ,left ,leg1 with ,lodgment of the ,missile4 ,the posterior surface of the leg lay next to the plate1 as shown by the outline of the head of the fibula1 but any estimate of distance from the plate1 based on depth of the shadows1 is of little value because there is no contrast between localizing-wire shadows in front of and behind the leg4 ,the slightly enlarged shadow of the ball indicates it to be farther from the plate than it would be if it lay behind the fibula4 ,as the shadows of the metal fragments on the tibia are not sharp enough to indicate their position to be near the plate1 the ball has lodged anteriorly between the tibia and fibula after ricocheting from the anterior surface of the tibia4 ,the ball1 being undeformed1 struck the tibia with so little force that it barely penetrated the skin4 ,the reaction of infection in such wounds makes a diagnosis on physical examination difficult and indicates radiography4 ,illustration3 ,plate #acf4 ,,shrapnel--,,plate #acf4 ,,lower ,,extremity4 ,gunshot ,wound of the ,leg1 with ,lodgment of the ,missile4 ,the leg lay with its posterior surface next to the photographic plate4 ,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 tibia4 ,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 skin4 ,without the reaction of inflammation and infection1 diagnosis could be made by palpation1 but extensive swelling indicates radiography4 ,illustration3 ,plate #acg4 ,,shrapnel--,,plate #acg4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,tibia and ,fibula4 ,the fibular side of the leg lay next to the plate1 as the distinct and not exaggerated outlines of the fibula can be seen in the dense shadow of the tibia4 ,the wound1 as indicated by the callous tissue1 is shown in a state of repair1 after the larger detached fragments of the fracture had been removed4 ,the wound was caused by a missile carrying considerable energy4 ,the small particles of metal marking the course of the missile show it was a shrapnel ball4 ,illustration3 ,plate #ach4 ,,shrapnel--,,plate #ach4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,right ,tibia and ,fibula4 ,this plate shows a type of wound caused by a number of fragments of a shrapnel ball or other similar missile4 ,the missile was deformed by a near-by ricochet1 from which large and small fragments struck simultaneously and distributed themselves over a large area4 ,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 fragments4 ,in this case the energy of the missile was transmitted to the tibia1 with fracture and great fragmentation of the bone4 ,the fracture of the tibia was secondary1 resulting from indirect violence1 due to the loss of the support of the tibia4 ,illustration3 ,plate #aci4 ,,shrapnel--,,plate #aci4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,right ,tibia and ,fibula4 ,the course of the missile was from within outward and from before backward1 striking both the fibula and the tibia1 with fragmentation and displacement of both bones4 ,the fibula lay next to the plate1 as indicated by its distinct normal shadow and the exaggerated outline of the internal malleolus4 ,the trail of metal fragments is typical of a shrapnel ball with the energy of high shrapnel velocity1 but any lead missile without a protective jacket1 under like conditions1 might have produced the same effect4 ,the treatment is conservative until some positive indication arising in the course of an infection directs interference4 ,illustration3 ,plate #adj4 ,,shrapnel--,,plate #adj4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,left ,tibia and ,fibula1 with ,lodgment of the ,missile4 ,as the heel lay on the plate it is easy to identity the tibia and fibula of the left leg4 ,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 bones4 ,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 fibula4 ,the remaining energy of the missile was almost entirely spent on the tibia1 causing a long oblique fracture1 so that the contact with the fibula resulted in a crack only1 without the separation of a fragment4 ,the treatment in such cases is conservative1 with the subsequent removal of the ball from its superficial location4 ,illustration3 ,plate #ada4 ,,shrapnel--,,plate #ada4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,left ,tibia1 with ,lodgment of the ,missile4 ,the course of the ball was from without and behind1 ranging upward and inward1 striking the tibia on the outer border1 and causing a splitting fracture without displacement of fragments4 ,the missile was most probably deformed by ricochet before it struck the bone1 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 ball4 ,two metallic fragments lying over the fibula were probably additional missiles detached from the ball as it ricocheted near the wound4 ,the treatment in such cases would be conservative1 while meeting the indications of infection4 ,illustration3 ,plate #adb4 ,,shrapnel--,,plate #adb4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,left ,fibula1 with ,lodgment of the ,missile4 ,this plate furnishes another example of the fragmentation of a shrapnel ball by ricochet on a near-by object before striking the body4 ,a slight fracture of the fibula is seen 7at the top of the plate7 with the lodgment of multiple missiles over a wide area1 without other injury to the bones4 ,the fragments seen through the shadow of the tibia lie nearer the plate than the smaller fragments on the fibula4 ,as the largest fragment1 lying below1 shows a much enlarged semicircular outline1 its position is not close to the plate and it must lie superficially on the inner side of the leg4 ,illustration3 ,plate #adc4 ,,shrapnel--,,plate #adc4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,right ,fibula4 ,this plate shows the right leg1 because the calf always rests on the plate in the absence of a contraindication1 which does not occur in this case1 and because the slight angle of approach of the tibia and fibula identifies the relation of the lower end of these bones4 ,the nature of the fracture1 without much fragmentation and with no displacements of fragments1 indicates a slight striking energy of the missile1 which was disintegrated by ricochet before striking the bone4 ,the fragments of a shrapnel ball1 spattered on a near-by object1 struck the leg in front over a wide area1 as indicated by the fragments lying over the tibia and smaller ones lying on the inside of the bone4 ,the larger metal fragment1 on the fibula1 is some distance from the plate1 and probably lies in front of the bone1 while the smaller ones1 seen in sharper outline1 lie behind4 ,illustration3 ,plate #add4 ,,shrapnel--,,plate #add4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,left ,fibula4 ,this is another example of the condition1 shown in plate #adc1 in which a shrapnel hall or similar missile is disintegrated by ricochet before a fleeting the wound4 ,by comparison of the shadows of the missiles with the shadows of the portion of the localizing wire lying nearer the plate 7shown more deeply and distinctly71 and with the portion lying in front of the leg1 it can be concluded that the fragments lie superficially in front of the bones4 ,a slight fissure fracture of the fibula may be seen in the upper portion of the plate4 ,illustration3 ,plate #ade4 ,,shrapnel--,,plate #ade4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,fibula1 with ,lodgment of the ,missile4 ,the fibular side of the leg lay next to the plate4 ,the sharp outline1 great density1 and normal size of the shadow of the shrapnel ball shows the ball almost in contact with the plate4 ,the metallic particles marking the contact of the ball and the fibula1 at the seat of a diagonal fracture1 without displacement of fragments1 are shown so distinctly that they must also be near the plate4 ,the course of the ball1 therefore1 was from without1 ranging inward and upward with the slight energy of long 7shrapnel7 range4 ,the ball lies on the fibular side superficially1 just in front of the fibula4 ,illustration3 ,plate #adf4 ,,shrapnel--,,plate #adf4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,right ,fibula4 ,the plate exposed with the tibial side down shows the wound in the course of treatment1 with a drainage tube in position after the detached fragments of several inches of the fibula have been removed on account of infection4 ,several fragments of the missile are shown on the lower fragment of the fibula4 ,conservative treatment is evident and good results should follow4 ,illustration3 ,plate #adg4 ,,shrapnel--,,plate #adg4 ,,lower ,,extremity4 ,gunshot ,wound of the ,lower ,end of the ,right ,fibula4 ,as the heel lay next to the photographic plate1 the right ankle is easily identified4 ,the clear shadows of even the very small metallic particles show them also next to the plate and1 therefore1 on the posterior surface of the external malleolus1 where a shrapnel ball at extremely low velocity struck and produced a slight fracture1 or more of a fissure1 without separation of fragment4 ,the joint mortise is intact1 as the line of fracture does not extend to the articular surface4 ,the shrapnel ball in such cases would lie just beneath the skin or escape through an adjacent wound4 ,illustration3 ,plate #adh4 ,,shrapnel--,,plate #adh4 ,,lower ,,extremity4 ,gunshot 7,pott's7 ,fracture of the ,left ,ankle4 ,as the heel lies next to the plate1 the left ankle is easily identified4 ,the course of the missile is shown by a metallic track from the internal to the external malleolus1 and by a point of greater contact with the internal malleolus at the upper border of its articulation with the astragulus1 resulting in an oblique fracture1 separating the tip of the external malleolus4 ,at the point of first impact the posterior faciculus of the internal lateral ligament was severed4 ,the missile therefore passed directly through the ankle joint1 entering just behind the tip of the external malleolus1 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 malleolus1 with the resulting fracture4 ,by this mechanism1 the joint mortise has been widened by outward displacement of the external malleolus1 while the rupture of the internal lateral ligament permitted the outward rotation of the astragulus1 thus producing rather faithfully1 by direct violence1 a condition which might be called a 8simulated ,pott's fracture0 of the first degree4 ,by the metallic path of the missile it is known that its soft metal mass was not protected by a hard metal jacket2 by the slight damage done to the bone1 which lay directly in its path1 its velocity and consequent energy are revealed as very slight2 by the absence of larger metallic fragments it is shown that the missile was not deformed nor robbed of its energy through ricochet2 and as only these conditions can be furnished by a lead ball1 undeformed and traveling at low velocity1 the missile was a shrapnel ball4 ,illustration3 ,plate #adi4 ,,shrapnel--,,plate #adi4 ,,lower ,,extremity4 ,multiple ,gunshot ,wound of the ,leg4 ,this plate exhibits the characteristic marking of the metal particles of a shrapnel ball scraped off by contact with the bone1 showing the course of the ball in relation to the bone4 ,the evidence that two shrapnel balls struck the tibia without causing a fracture indicates that the velocity of shrapnel balls is1 sometimes at least1 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 8cone of dispersion40 ,such multiple wounds are caused before the balls have been so widely dispersed as when they arrive at the base of the 8cone of dispersion40 ,illustration3 ,plate #aej4 ,,shrapnel--,,plate #aej4 ,,lower ,,extremity4 ,gunshot ,fracture of the ,left ,astragalus1 with ,lodgment of the ,missile4 ,the external border of the foot lay next to the plate1 as is shown by the articulation of the cuboid4 ,a fragment detached from the posterior inferior border of the astragalus and several small metal particles lying behind the fragment are in evidence4 ,the enlarged shadow of the ball indicates that it does not lie close to the plate1 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 plate4 ,illustration3 ,plate #aea4 ,,shrapnel--,,plate #aea4 ,,lower ,,extremity4 ,gunshot ,fracture of ,left ,calcaneus4 ,the fibular side lay next to the plate1 as shown by the shadow of the fibula and the calcaneo-cuboid articulation4 ,as the metallic particles1 showing the path of the missile1 appear to be next to the plate1 the course of the missile was from the external border of the tendo ,achillis diagonally downward and forward1 causing only a slight fissure of the calcaneus4 ,a missile1 to have done so little damage and to have left a metallic track showing its contact with the bone1 must have been unjacketed and of low velocity1 and therefore a shrapnel ball4 ,illustration3 ,plate #aeb4 ,,shrapnel--,,plate #aeb4 ,,lower ,,extremity4 ,gunshot ,wound of the ,heel1 with ,lodgment of the ,missile4 ,the tibial side of the foot lay next to the photographic plate4 ,the normal size1 great density1 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 calcaneus4 ,no metallic particles mark the track of the ball in this case1 because the course was parallel to the inner surface of the bursa without forceful1 or perhaps any1 contact with the bursa1 and passing through soft tissue1 only4 ,illustration3 ,plate #aec4 ,,shrapnel--,,plate #aec4 ,,lower ,,extremity4 ,gunshot ,wound of the ,heel1 with ,lodgment of the ,missile4 ,that the inner border of the foot lay next to the plate is shown by the articulation between astragalus1 scaphoid1 internal cuneiform1 and first metatarsal4 ,the metallic particles show the course of the ball from the posterior calcaneo-astragaloid ligament to below the anterior inferior border of the calcaneus4 ,as the shadow of the ball is enlarged and the shadow of the fragments blurred1 their position is not near the plate and their location is therefore on the external plane of the calcaneus1 with the ball lying near the sole4 ,illustration3 ,plate #aed4 ,,shrapnel--,,plate #aed4 ,,lower ,,extremity4 ,gunshot ,wound of the ,foot4 ,the plate shows1 in the wound of entrance1 the metal particles deposited by a shrapnel ball which passed out of the sole of the foot without damage to the bone4 ,the missile carried some small particles of lead1 almost wholly detached by a ricochet before striking the foot1 which were scraped off as it passed through the skin4 ,the wound was infected1 and radiography was indicated for diagnosis4 ,illustration3 ,plate #aee4 ,,shrapnel--,,plate #aee4 ,,lower ,,extremity4 ,gunshot ,wound of the ,foot4 ,the sole of the foot lay next to the plate4 ,while the very clear1 sharp outlines of the metal fragments would seem to show them very near the plate and consequently at the platen side of the tarsus1 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 metatarsus4 ,it is very probable that the ball struck the convex1 rather than the concave outline of the transverse arch1 as the missile has escaped with no fracture of the bones1 which would have been very difficult in mechanical accomplishment if its course had been along the convex outline4 ,there is no fracture of the bones1 although a shrapnel ball has passed transversely through the foot1 striking the heads of the second and third metatarsals with only slight injury and leaving a few metal particles at points of contact4 ,illustration3 ,plate #aef4 ,,shrapnel--,,plate #aef4 ,,lower ,,extremity4 ,gunshot ,wound of the ,left ,foot by ,multiple ,missiles1 ,fracture of the ,metatarsus1 and ,lodgment of the ,missile4 ,the sole of the foot lay next to the plate4 ,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 metatarsal4 ,the fragments of metal lying near the fourth and fifth metatarsals lie either in the same relation or on the plantar side of the metatarsus4 ,the metallic track leads to the wound of exit of shrapnel ball1 other than the one lodged4 ,even though the missile has escaped1 its identity can be creditably established by the one remaining1 which1 it is morally certain1 was the escaped missile's companion4 ,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 bones4 ,illustration3 ,plate #aeg4 ,,operative ,,interference ,,in ,,gunshot ,,wounds4 ,in the #a1ejj radiograph plates from which this collection was selected1 only four were found showing operative interference for the repair of fractures4 ,while no data are available from which to determine accurately the ratio of these operations to the entire number of fracture cases under treatment1 and as1 most certainly1 there were some formal amputations1 excisions1 immediate immobilization of fractures1 and other operative procedures which were not submitted to radiography1 it may nevertheless be justly inferred from this radiographic evidence that very few such operations were performed4 ,,operations--,,plate #aeg4 ,gunshot ,fracture of the ,humerus4 ,this plate shows an attempt to wire a fracture of the humerus1 which1 very probably1 would have recovered as favorably without interference4 ,illustration3 ,plate #aeh4 ,,operations--,,plate #aeh4 ,gunshot ,fracture of the ,ulna4 ,this plate shows an attempt to wire the ulna in a clean wound4 ,illustration3 ,plate #aei4 ,,operations--,,plate #aei4 ,gunshot ,fracture of the ,radius and ,ulna4 ,this plate shows an attempt to wire the radius and ulna where the indications were rather doubtful4 ,illustration3 ,plate #afj4 ,,operations--,,plate #afj4 ,gunshot ,fracture of the ,tibia and ,fibula4 ,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 position4 ,illustration3 ,plate #afa4 ,,operations--,,plate #afa4 ,amputation at the ,knee ,joint4 ,this plate shows a satisfactory result of a secondary amputation at the knee1 after the method of ,gritti1 following a severe naval shell wound of the leg4 ,illustration3 ,plate #afb4 ,,operations--,,plate #afb4 ,excision of the ,head of the ,humerus4 ,this plate shows a case of ,prof4 ,de ,page1 of the ,belgium ,red ,cross ,mission at ,tash ,kishla ,hospital1 in which the head of the humerus was excised for extensive comminution of the head of the humerus with infection4 ,illustration3 ,plate #afc4 ,,some ,,missiles ,,removed ,,from ,,wounded ,,in ,,balkan ,,wars4 ,figures reduced to two-thirds of natural size4 ,,plate #afc4 ,of the #df missiles shown in the illustration1 page #ccf1 #a to #ad are rifle bullets2 #ae to #bb are assorted fragments2 #bc to #dc and including #dd are shrapnel balls2 #de is an automatic pistol ball1 and #dc and #df are the base and the fuse1 respectively1 of a shrapnel 8nose0 or head of the #ge-millimeter field gun4 ,four rifle bullets1 three shrapnel balls1 and ,nos4 #bj and #bg were removed from ,turkish soldiers admitted to my service at ,tash ,kishla ,hospital in ,constantinople4 ,the remaining missiles1 excepting ,no4 #df1 were removed from ,bulgarian soldiers on my service at the ,etap and the ,queen's ,hospital at ,kustendil1 ,bulgaria4 ,the missile shown as ,no4 #df was removed by ,dr4 ,tatarcheff1 the ,bulgarian surgeon in command of a fixed hospital at ,kodemos1 ,bulgaria1 from the upper anterior thigh of a patient whose history ,i have and whom ,i saw and photographed4 ,of the fragments1 ,nos4 #ae and #ag are pieces of the nickel jacket of rifle bullets2 ,no4 #af is the lead 8core0 of a rifle bullet2 ,no4 #bb is a fragment of the nickel jacket of a rifle bullet which holds a small portion of the lead core2 ,no4 #ah is a brass tube which is carried in the base of a shell to hold the detonating plunger and fulminate cap2 ,no4 #ai is a piece of a foot plate or step of a gun carriage or caisson2 ,no4 #bj is a shell fragment1 and ,no4 #ba is a flattened piece of a shrapnel ball4 ,of the bullets1 ,no4 #a is ,bulgarian1 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 peace2 ,nos4 #f1 #aj1 #aa1 and #ad are of the same caliber as the ,bulgarian and were fired from ,montenegrin or ,servian rifles2 ,nos4 #b and #c1 slightly smaller in caliber than all the others1 are ,greek1 and ,nos4 #d1 #e1 #g1 #h1 #i1 #ab1 and #ac are ,servian1 slightly larger than the ,greek and as much smaller than the ,bulgarian4 ,no4 #a 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 embedded2 ,nos4 #d1 #g1 #h1 #ab1 #ac1 #ad are deformed by ricochet4 ,no4 #e has its nose slightly abraided by the same cause4 ,no4 #h shows the lead core protruding from the base of the jacket4 ,nos4 #a1 #b1 #c1 #f1 #i1 #aj1 and #aa are normal1 as they struck the body by direct impact4 ,nos4 #b and #c1 which are ,greek1 have the nickel jacket worn off on the apex so that the lead core is exposed1 which produces a slight degree of 8dum-dum10 but as they struck the body at very long range and without hitting a bone1 they produced no 8dum-dum0 effect4 ,eight of the shrapnel balls were removed from the forearm of one ,bulgarian soldier4 7,vide plate #aji47 ,no4 #dc was removed from between the thoracic wall and the scapula1 to which position it passed by destroying the outer half of the clavicle1 penetrating #f inches from the surface4 ,the caliber of the missiles4 ,millimeters4 ,greek #f4ej ,servian #g4jj ,bulgarian #h4jj ,montenegrin #g4je and #h4jj ,for comparison it may be observed that the ,united ,states ,army rifle bullet is #g millimeters1 equal #cj caliber or #j4cj inch4 ,the caliber of shrapnel balls varies somewhat1 as do the weight and density1 but all of them were approximately inch or #abe millimeters in diameter4 ,the caliber of all field guns 7of modern type7 in the ,balkan wars were #ge millimeters1 the 8soixante-quinze0 of the ,french1 or about #c inches4