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 ^n 
 
 OASES OF 
 
 GUNSHOT WOUNDS OF THE CHEST 
 
 sr 
 
 JAMES BELL, M.D., 
 
 Surgeon-M{i;ior in charge of Field Hospital with General Sir Fred. Middletun's 
 Division, North- West Field Force ; Surgeon to the Montreal General Hospital. 
 
 -H3 
 
 Reprinted from the Canada Medwal and Surgical Journal. 
 
i ! ' / <i ' i,^,Av'i' ' 
 
 {'■■'■"■' :,r:-<-:n 
 
RE-PRINTED FROM THE " CANADA MEDICAL ic SURGICAL JOURNAL," 
 
 AUGUST, 188C. 
 
 CASES OF GUNSHOT WOUNDS OF THE CHEST. 
 
 By JAMES BELL, M.D., 
 
 Surueon-Major in charge of Field Hospital with General Sir Fred- Middleton's 
 Division, North-West Field Force ; Surgeon to the Montreal General Hospital. 
 
 (Read h^ore the Medieo-Ghlritri/ical Society of Montreal.) 
 
 Case I. — Penetrating Wound of Lung ; Gangrene; Recovery. 
 Corporal J. E, L., 90th Battalion, aged 24, was wounded at 
 the Fish Creek fight on the 24th of April, 1885. He was shot 
 in the chest while lying facing the ravine in which the enemy 
 were concealed, at a distance of about one hundred yards from 
 him. The bullet passed through the second left costal cartilage, 
 beneath the sternum, downwards and outwards towards the right 
 side, making its exit through the 7th rib in the mid-axillary line. 
 Before being removed from the field he also received a flesh 
 wound over the right trochanter major, which, although not in 
 itself serious, added greatly to his sufferings on the journey to 
 Saskatoon and subsequently. He, with the other wounded from 
 Fish Creek, arrived in Saskatoon on the 2nd of May, having 
 been driven forty-five miles in a lumber waggon over the " trail." 
 The period of seven or eight days intervening between the time 
 of his injury and his arrival at Saskatoon was one of very great 
 hardship to a man in his condition. The weather was cold, 
 especially at night, and windy, and a considerable part of the 
 time wet ; their only shelter was the ordinary " bell " tent, and 
 there were neither the materials nor the facilities for making 
 warm and soothing applications to the chest, nor was there any 
 
suitable invalid diet. On arrival at Saskatoon, his condition was 
 very bad indeed. The greater part of the right lung was con- 
 solidated, and his breathing painful and rapid. There was also 
 high fever and troublesome diarrhoea. Empyema followed, and 
 on the 8th of May Deputy-Surgeon-General Roddick enlarged 
 the wound in the right axillary region, evacuating a quantity of 
 pus which was very foetid. The pleural cavity was then washed 
 out daily with antiseptic solutions (carbolic, alcoholic and boracic 
 at different periods); and from time to time portions of gangrenous 
 lung tissue presented at the wound and were removed. In spite 
 of these precautions, however, he continued to suffer from high 
 fever, perspirations, foetid discharge, and great weakness. On 
 the 23rd of May, with the advice and assistance of Dr. Roddick, 
 I a^ttempted to make a dependent opening. The patient was 
 etherized and an incision made in the eighth intercostal space, 
 posteriorly. On reaching the pleura, however, the lung was 
 found to be firmly adherent to the chest wall at this point. The 
 wound was therefore closed and the original axillary wound 
 enlarged, and the cavity explored with the finger and long 
 probes. A considerable amount of sloughy tissue was found 
 lying unattached in the cavity, and was removed. The cavity 
 was then emptied as well as possible, and washed out with weak 
 carbolic lotion. On introducing the finger into the cavity, it 
 was found to bo as large as a large-sized orange, and surrounded 
 on all sides by pulmonary tissue. It was an intra-pulmonary 
 cavity, and not, as we had supposed, a localized pleural sac. 
 4s he recovered from the ether, he was seized with a severe 
 and prolonged fit of coughing, in which he expectorated pus and 
 fluid from the pleural cavity which had a distinct carbolic odor,, 
 and caused unmistakeable tingling in his mouth. From this 
 time forward the pus was expectorated constantly and freely, 
 and in a day or two was free from smell. The wounds healed 
 up rapidly. All his symptoms subsided, and from this time his 
 recovery was uninterrupted. In a few days he was able to be 
 taken out into the air and sunlight, and in a couple of weeks 
 was convalescent. He was one of the last remiuning patients 
 at Saskatoon, and embarked on the hospital barge*on the 4th of 
 
 , ' i' 
 

 
 July, and was digoharged when he reached Winnipeg on the 
 15th of the same month. He has since enjoyed the best of 
 health, and at the present time writes that he is quite well and 
 strong. I have no doubt but that the thorough exploration of 
 the cavity and the removal of sloughy tissue on the 23rd of May 
 opened communication with a bronchial tube of considerable size, 
 and that henceforth the cavity was kept freely evacuated by 
 expectoration. This, I think, was the starting point on the road 
 to his recovery, which progressed with marvellous rapidity from 
 that time. ± 
 
 Case II. — Penetrating Wound of Chest. 
 
 Private H. H. M., 10th R.G., aged 19, was wounded at 
 Batoche on the 12th of May, 1885. When brought into the 
 zareba he was suffering from dyspnoea and painful inspiration. 
 He had also coughed up a little blood soon after receiving the 
 wound. On examination, a bullet wound was found about an 
 inch to the right of the vertebral column, opposite the fifth dorsal 
 vertebra. The track of the bullet could be traced as far as the 
 vertebral column, passing deeply through the muscles of the 
 back, and the bullet itself (a round one) was felt beneath the 
 skin at the angle of the left scapula. It was immediately re- 
 moved, and the wounds cleansed and dressed with iodoform. 
 There were no marked chest symptoms until after his removal 
 to Saskatoon, where he arrived on the 15th. The woun(^ -?«as 
 then suppurating freely, and he suffered from considerable ps'iu 
 and uneasiness in the side and high fever. A few days later 
 the left chest was found to be gradually filling with fluid ; a 
 hypodermic needle was introduced, and half a drachm of odor- 
 less[sero-pus withdrawn. The chest filled rapidly, and the patient 
 suffered from chills and fever. The pleural cavity soon became 
 filled to the apex, and displaced the heart slightly. The flow of 
 pus from the wounds now became greatly increased, and pus 
 was forced out from both wounds, but especially from the pos- 
 terior one (the wound of entrance of the bullet), on coughing. 
 I then administered ether, and made a free opening through the 
 7th intercostaf space and in the existing wound, and evacuated 
 
6 
 
 a large quantity of pus having a slightly foetid odor. Through 
 this opening also came, at this time, pieces of red cloth from his 
 tunic and pieces of his shirt and undershirt. On examination 
 while the patient was under ether, a long probe passed directly 
 into the pleural cavity from the original wound. The bullet was 
 found to have passed between the spines of the 5th and Gth 
 dorsal vertebrae, close to the bodies of the bones, and to have 
 roughened the edges of both spines. The opening of the cavity 
 and the insertion of a large drainage-tube gave great relief, and 
 all the active- symptoms subsided promptly, although the dis- 
 charge continued for a long time. His recovery was slow. 
 The pleural cavity was washed out with antiseptic solutions from 
 time to time, and nourishing food and stimulants were adminis- 
 tered, and the patient was soon able to leave his bed and go ouu 
 into the fresh air and sunlight in daytime. He was brought 
 down to Winnipeg on the hospital barge, still very weak, and 
 placed in the General Hospital there on the I5th of July, under 
 care of Dr. Kerr. He remained there for some time, and 
 reached his home in Toronto, I believe, about the end of Sep- 
 tember. He is now perfectly well. There was great retraction 
 of the chest wall during convalescence. 
 
 In this connection I wish to mention briefly two other cases 
 which did not come under my observation at the time their in- 
 juries were received, but which I saw later on : 
 
 Pvte. L., 65th Batt., was wounded on the 28th of May at 
 Frenchman's Butte. He was struck on the posterior wall of the 
 right chest, the bullet making its exit in front at a point nearly 
 opposite. He suffered from severe respiratory symptoms and 
 spat up some blood, and a penetrating wound of the chest was 
 diagnosed. He recovered rapidly, however, and when I saw 
 him on the 12th of July, his wounds being then perfectly healed, 
 there were no chest symptoms, no alteration in the conformation 
 of the chest, and no physical signs to indicate that the pleural 
 cavity or its contents had ever been disturbed in any way. 
 
 A similar case was that of Sergt. F., N.W.M.P., who was 
 wounded about a week later, in Steele's engagement at Loon 
 Lake. He also had very severe symptoms of pulmonary injury, 
 
 "^^J 
 
.1 m. 
 
 dyspnoea, bloody expectoration, hurried breathing, etc., but re- 
 covered rapidly and perfectly without any serious pleural or 
 pulmonary hiflammation. 1 saw him on the 18th of July, on 
 his return to Calgary to report for duty. He was then appa- 
 rently in perfect health. 
 
 In gunshot wounds of the chest, the important point in prog- 
 nosis is, of course, whether the bullet has penetrated the chest 
 walls or not. In the surgical history of the American Rebellion, 
 the mortality in a group of over 8000 cases of penetrating 
 wounds is given at H2.5 per cent, while in a similar group of 
 non-penetrating wounds the mortality is 2 per cent. The four 
 cases which I have reported show the difficulty of making an 
 exact diagnosis, unless the patient can be kept under the obser- 
 vation of the same surgeon throughout his illness ; and as our 
 knowledge of such wounds must be mainly derived from military 
 surgery, this is, of course, nearly always impossible. 
 
 Case II of this series was not thought to be a penetrating 
 wound when treated on the field. Cases III and IV were so 
 diagnosed, and yet, I think, the subsequent histories show that 
 Case II was undoubtedly a penetrating wound, and that the 
 others were not. One could hardly help making such a diag- 
 nosis, however, with the symptoms shown by these men at the 
 time of receiving the wound — cough, distressed and hurried 
 breathing, and bloody expectoration. The fact that the symp- 
 toms did not persist beyond a few days, and that there was no 
 evidence of pleural or pulmonary inflammation, or of the results 
 of such inflammation, makes it quite clear, I think, that these 
 were only wounds of the soft parts of the chest wall, external 
 to the pleura, and the blood expectorated at the time of the 
 wound may be explained by the contusion produced by the bullet. 
 I consider Case I an extraordinary recovery, under all the cir- 
 cumstances, and considering the nature of the injury and its 
 termination in gangrene, which destroyed a large portion of the 
 lung. Empyema followed as a matter of course, but, fortunately, 
 the axillary wound was favorably situated for the evacuation of 
 the pus and the removal of the necrosed pulmonary tissue.