Shrapnel—Plate 103.

UPPER EXTREMITY.
Gunshot Fracture of the Right Radius.

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 fracture.

The arm lies in slight pronation with the longitudinal ridges of the dorsal surface of the ulna, shown distinctly next to the photographic plate. The upper end of the lower radial fragment, shown as overlying the ulna, is inclined forward in the anatomical position. The metal particles are on the outer and posterior border of the radius.

The treatment in such cases is conservative.

Results as to function are uncertain.

Shrapnel—Plate 104.

UPPER EXTREMITY.
Gunshot Fracture of the Ulna.

The course of the missile was tangential along side of the upper end of the ulna and internal condyle of the humerus, with a splitting effect on the ulna, which formed three fragments by breaking off the olecranon, and one lateral fragment from the shaft of the bone without displacement. The line of metallic particles shows the path of the ball in its slight contact with the bones, beginning on the side of the ulna and extending along the side of the internal condyle from where the ball escaped through the skin. The wound, not infected, was treated as simple fracture. A few fine lines on the plate above the fracture are due to scratches on the negative.

Results in such cases should be good.

Shrapnel—Plate 105.

UPPER EXTREMITY.
Gunshot Fracture of the Right Metacarpus.

The course of the missile was from the outer border of the hypothnear eminence diagonally downward through the palm, lodging against the second metacarpal bone with fracture of last four metacarpals.

The metal particles are not seen on the fourth and fifth metacarpals because the violence at these points was transmitted through soft parts, but the projectile spent its remaining energy directly against the second and third metacarpals.

The palm of the hand was next to the photographic plate, as indicated by the immediate contact of the thumb. The shadow of the bones is not dense, but in deep contrast with the shadows of the ball and metal fragments, 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 hand.

The treatment is conservative, with judicious interference when opportunity shall offer for removal of the missile.

Shrapnel—Plate 106.

UPPER EXTREMITY.
Gunshot Fracture of the Left Metacarpus,
with Lodgment of the Missile.

The palm of the hand lies next to the plate. The ball is very slightly enlarged and the small metal fragments are indistinct, indicating that they and the ball lie on the back of the hand.

The ball struck the third knuckle and lodged beneath the skin between the fourth and fifth metacarpals, fracturing both bones without displacement of fragments. In the recent wound the condition would be apparent, but after days of inflammatory reaction and infection, the swelling is too great to make any determination by palpation.

The treatment is removal of the missile. Good results regularly follow.

Shrapnel—Plate 107.

UPPER EXTREMITY.
Gunshot Fracture of the Left Metacarpus,
with Lodgment of the Missile.

The hand lies with its ulnar side next to the plate, as is indicated by the sharp outline of the swollen hypothenar eminence, nearer the plate than the thumb, with the enlarged, poorly defined, and rarefied shadow of its metacarpal and phalanges.

As the normal size of the balls and the clear outline of the metal fragments must place them almost in contact with the plate, the ball is located near the fifth metacarpal. As this is the same case as is shown in plate 106, the conclusions drawn from each plate are confirmed by the other.

The wound is infected, as indicated by the swelling of the palm.

The treatment is removal of the missile, with management of the infection.

Shrapnel—Plate 108.

UPPER EXTREMITY.
Gunshot Wound of the Left Hand,
with Lodgment of the Missile.

The shadow of the hand is shown with the palm next to the plate, as indicated by the small, well-defined outline of the first metacarpal lying within the outline of the larger and less-defined shadow of the second metacarpal. The third finger is flexed at the first phalangeal joint, and the end of the second phalanx is outlined in deeper shadow, with its long axis vertical to the plate.

The position raises the first finger from the plate and very slightly enlarges the size of the shadow of the bullet, although it retains its sharp outline. The shadow of the ball being very nearly the normal size, the ball lies on the palmar side of the third metacarpo-phalangeal joint. It entered the hand on the outer border of the base of the first finger, and left a fragment of metal on its slight contact with the bone. The ball was deformed by ricochet before striking the hand, with almost completely spent velocity. The wound is infected.

The treatment is the management of infection.

Shrapnel—Plate 109.

UPPER EXTREMITY.
Multiple Gunshot Wounds of the Right Hand and Forearm,
with Fracture of the Metacarpus and Phalanges and
Lodgment of the Missile.

The hand lay with the palmar surface next to the plate. 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 metacarpus. 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 palm. The undeformed ball, then, lies, most probably, in front of the second metacarpal. The deformed ball shows, in its enlarged shadow and not so distinct in outline as the normal ball, that it is on the dorsal surface of the third and fourth metacarpals.

The undeformed ball caused the fracture of the phalanx and metacarpal of the thumb; the deformed ball fractured the neck of the third metacarpal; 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 finger; and another ball, 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 course, also escaped from the ulnar border of the forearm at a point indicated in the plate.

Four balls were concerned with this wound; two of them have lodged with some damage and two others have escaped, after inflicting a slight injury. Multiple shrapnel wounds are common. 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 discharge.

Several shrapnel balls, lodged in a small area without causing much damage or exhibiting much power of penetration, indicate low velocity at close range of shrapnel balls on discharge from the shrapnel envelope.

In a personal case, eight shrapnel balls were removed from a forearm.

CHEST.

Shrapnel—Plate 110.

CHEST.
Gunshot Wound of the Chest,
with Lodgment of the Missile in the Lung.

The posterior chest wall is next to the plate, as the posterior rib shadows are much more distinct and much smaller than the shadows of the anterior ribs.

The shadow of the ball is blurred, which shows that it moved with respiration and is, therefore, probably in the lung. The shadow is only slightly enlarged and is fairly dense, which indicates it to be not far from the ribs and, therefore, in the posterior portion of the lung.

The treatment of such cases is conservative; infection is not common; hÆmothorax pleurisy, empyema, pneumonia, and pulmonary abscess are most frequent complications, named in the order of frequency. Pulmonary abscess is very rare. Pneumonia was seen in a personal case.

Shrapnel—Plate 111.

CHEST.
Gunshot Wound of Chest, with
Lodgment of the Missile Superficially.

While the missile is not a shrapnel ball, it presents similar conditions and does not need to be separately classified.

The vertebral border of the scapula is distinctly shown in light shadow, indicating its position near the plate.

The outline of the missile is so distinct and the shadow so dense that it must lie near the plate, and is located superficially in the infraspinatus fossa.

Shrapnel—Plate 112.

CHEST.
Gunshot Wound of the Chest, with Fractured Rib
and Lodgment of the Missile in the Axilla.

The back of the patient lay on the plate, as is indicated by the normal size of the ribs behind and the exaggerated outline in front.

The ball struck the sixth rib behind and caused a fracture at the angle. It then continued its course to the axilla. The normal size of the shadow of the ball indicates that it lies superficially behind the head of the humerus.

The wound of the rib was infected superficially, and the secretion of the wound carried away the most of the metal particles which the ball in striking deposited on impact.

Shrapnel—Plate 113.

CHEST.
Gunshot Wound of the Chest, with
Lodgment of the Missile in the Axilla.

There is no wound of the bone.

The ball lies in the axilla, behind, not close to, the plate, because the density of the shadow is not very great and the size is slightly enlarged. The distance from the plate is probably that of the mid-axillary line.

The wound is not infected. Pain and impaired movement of the arm suggested localization of the missile and indicate removal in the subsequent course of treatment.

Shrapnel—Plate 114.

CHEST.
Gunshot Wound of the Chest, with the
Lodgment of the Missile in the Axilla.

The posterior chest wall lay next to the plate.

The almost normal size of the shadow of the ball indicates that it lies near the plate, and the blurred outline shows that it has moved with the chest in respiration. The ball lies, therefore, in the posterior axilla near the middle of the outer border of the scapula, imbedded in the thoracic muscles.

The treatment is expectant. Such wounds are rarely infected. Pain or impairment of function only would indicate removal of the missile from a clean wound.

PELVIS.

Shrapnel—Plate 115.

PELVIS.
Gunshot Fracture of the Crest of the Right Ilium,
with Lodgment of the Missile.

As the wound was received while the soldier was lying prone, the course of the missile in the body was from above downward, striking the crest of the ilium, on which it was fragmented, and trailing its fragments as far down as the great trochanter. The injury to the ilium was a crushing fracture, with the displacement of small fragments from the antero-superior spine.

As the sacrum was next to the photographic plate, the missile, judging from its indistinct shadow, lies farther from the plate and in front of the bone. 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 ilium.

The trail of the smaller metal fragments lies between the antero-superior spine and the great trochanter, anterior to the plane of the femur.

The treatment in such cases is always conservative.

LOWER EXTREMITY.

Shrapnel—Plate 116.

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

With the posterior aspect of the thigh lying next to the plate, the very greatly enlarged shadow of the deformed shrapnel ball indicates that it lies a relatively great distance from the plate, so that its location can be determined to be near the internal border of the adductor muscles, anteriorly, and below the transverse plane of the lesser trochanter.

Shrapnel—Plate 117.

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

With the sacrum lying next to the plate, the normal size, clear outline, and dense shadow of the shrapnel ball indicates its position to be near the plate. The location can be roughly estimated as the superficial gluteal region, external to the ramus of the ischium and near the aerior plane of the upper border of the acetabular cavity.

Shrapnel—Plate 118.

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

The normal size, distinct outline, and considerable density of the shadow of the shrapnel ball show that it lies very near the plate, posterior to the bone and in the buttocks, quite superficially.

The treatment in such cases is always conservative. Pain or impairment of function indicate removal after convalescence.

Shrapnel—Plate 119.

LOWER EXTREMITY.
Gunshot Fracture of the Femur,
with Lodgment of the Missile.

The direct subtrochanteric impact disintegrated the missile and delivered all of its energy to the bone, with a resulting transverse fracture of the upper end of the shaft of the femur and longitudinal fragmentation of the shaft. The course of the shrapnel ball was from behind forward and from above downward, 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 fracture. The uppermost large lead fragment, as shown by the depth of its shadow, lies farther behind the bone and nearer to the photographic plate than do the other pieces of the ball, as indicated by their lighter shadows. All of the fragments seem to lie behind the bone.

The conservative treatment of this wound is justified by the attempt at repair, as indicated by the callus formation; but it is manifest, from the extremely faulty position, that the indication for immobilization and extension in strong abduction were not appreciated.

Proper management of conservative treatment in such cases gives good results.

Shrapnel—Plate 120.

LOWER EXTREMITY.
Gunshot Fracture of the Femur,
with Lodgment of Multiple Missiles.

The position of the femur is in outward rotation, as shown by the full shadow of the lesser trochanter and the vanishing of the greater trochanter behind the shoulder of the neck. The two larger missiles lie on the outer side of the bone and the others lie in front on the seat of fracture. 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 bone.

The treatment in such cases is expectant and indication rarely arises for search for and removal of the missiles.

Shrapnel—Plate 121.

LOWER EXTREMITY.
Gunshot Fracture of the Shaft of the Femur,
with Lodgment of the Missile.

The course of the shrapnel ball was from within outward, striking the femur with the energy of high (shrapnel) velocity, with fragmentation of the missile by impact on the bone. The largest fragment, by the distinct outline of its shadow, lies close to the plate and behind the bone; a smaller metal fragment has been carried to the outer border of the thigh, where it lies superficially; another fragment lies in the seat of fracture.

The position of fragments is faulty, as the indications for extension and abduction have not been wholly met, although this is a case from the well-conducted service of GulhanÉ Hospital.

The treatment in such cases is conservative and the results are good.

Shrapnel—Plate 122.

LOWER EXTREMITY.
Gunshot Fracture of the Shaft of the Femur,
with Lodgment of the Missile.

The shrapnel ball, in its almost directly antero-posterior course from behind forward, has delivered the energy of high (shrapnel) velocity to the bone, which had absorbed it all in stopping the missile, with a resulting approach to a butterfly fracture with displacement of fragments.

The upper end of the lower fragment lies nearer to the plate than to the lower end of the upper fragment, with the deformed shrapnel ball lying behind the latter, closer to the plate.

The treatment in such cases is conservative, with good results to follow except as they may be imperiled by infection.

Shrapnel—Plate 123.

LOWER EXTREMITY.
Gunshot Fracture of the Femur,
with Lodgment of the Missile.

While the missile in this case may have been other than a shrapnel ball, the fracture is one produced by the impact of a missile delivering great striking energy, with a predominant cross-section factor in its composition. The fragments are due to the application of an energy in which the mass was distributed over a relatively large area on bone, which resulted in the displacement of the large fragments.

The treatment in such cases is conservative.

Results are favorable; infection is generally controlled.

Shrapnel—Plate 124.

LOWER EXTREMITY.
Gunshot Fracture of the Femur,
with Lodgment of Multiple Missiles.

The direct impact of two shrapnel balls, delivering all of their energy to the femur, resulted in a fracture with large fragments.

The exposure was made through a plaster splint, and shows a faulty position with progressing repair.

The treatment in such cases is conservative, but with respect for the indications to maintain proper position of the fragments.

Shrapnel—Plate 125.

LOWER EXTREMITY.
Gunshot Fracture of the Femur,
with Lodgment of the Missile.

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 lodges.

The distinct outline and dense shadow of the deformed missile indicates its position to be behind the bone.

The callus formation indicates the favorable progress of repair, but with the fragments in faulty position.

The treatment in such cases is conservative, with proper respect to the principles of maintenance of normal relation of the fragments.

Shrapnel—Plate 126.

LOWER EXTREMITY.
Gunshot Fracture of the Femur,
with Lodgment of the Missile.

The course of the shrapnel ball was antero-posterior, with an impact on the shaft of the femur, 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 ball. The sharp outline and density of the shadows of the missile, in contrast with the dense shadows of the bone, indicate that the missile lies closer to the plate than does the bone, although the flattened ball does not permit a comparison between its shadow and the normal size of the ball.

The advanced stage of convalescence is shown by the formation of callous.

The treatment in such cases is conservative and the results are good if proper position can be maintained.

Shrapnel—Plate 127.

LOWER EXTREMITY.
Gunshot Fracture of the Shaft of the Femur.

The impact of the missile was delivered with the energy of high (shrapnel) velocity at close range, as is indicated by the signs of another shrapnel wound, just above the outer tuberosity (in the lower left corner of the plate), where a deposit of metallic particle is evidenced.

The fragmentation of the missile, through its contact with the bone, indicates the great striking force of a missile which ricocheted from the bone. The general distribution of metallic particles through a wound of this class indicates certainly that the missile was unjacketed, and the destructive forces show that its sectional area was relatively larger, i. e., a shrapnel ball.

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 jacket. In this state the energy of a rifle ball must be so greatly reduced, through the violence of ricochet, that it would not retain enough striking force to cause its disintegration on impact with the bone. Besides, some particles of the jacket could be identified, as they are always bent or twisted so that their character is recognized in the shadow.

Shrapnel—Plate 128.

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

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

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

Shrapnel—Plate 129.

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

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

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

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

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

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

The results in such cases are usually good.

Shrapnel—Plate 130.

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

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

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

Results, except for infection, are good.

Shrapnel—Plate 131.

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

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

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

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

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

Shrapnel—Plate 132.

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

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

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

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

Shrapnel—Plate 133.

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

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

Shrapnel—Plate 134.

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

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

The line of projection is transversely through the tuberosities.

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

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

Shrapnel—Plate 135.

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

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

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

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

Shrapnel—Plate 136.

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

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

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

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

Shrapnel—Plate 137.

LOWER EXTREMITY.
Gunshot Fracture of the Tibia and Fibula.

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

Shrapnel—Plate 138.

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

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

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

Plate 139.

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