[Reprinted from The International Journal of Surgery, March 1897] 
GUNSHOT-WOUND OF THE OHEST.-BEPORT OF A 
OASE.--RECOVERY. 
By Samuel Kennedy, Ph.G., M.D., 
Shelbyville, Ind. 
President Mitchell District Medical Society; Secretary U. S. 
Board of Pension Examining Surgeons; Surgeon G. C. G. 
St. L. {Big 4) R.R.; Member of Shelby County Medical 
Society; Mitchell District Medical Society; Indiana 
State Medical Society; American Medical 
Association; American Academy of Rail- 
way Surgeons; Indiana Pharma- 
ceutical Association; American 
Pharmaceutical Association. 
I have the pleasure of reporting to you to-day what 
I believe to be one of the most remarkable cases of 
gun-shot wound of the chest (with recovery) on 
record. It is, so far as I am able to learn, without a 
parallel in the annals of surgery. It is that of James 
Hall, Jr., who Jives eight miles south of this city. 
He was born on January 25, 1881, and is, conse- 
quently, sixteen years of age. On Saturday afternoon 
Nov. 14, 1896, he left his home to hunt rabbits. He 
had an old-fashioned double-barreled shot-gun, a 
muzzle-loader of sixteen-gauge bore. The barrels are 
very long-the gun, in years past, being called a 
squirrel gun. After having been gone but a short 
time his dog started a rabbit and he fired but missed 
the game.. He then stopped to load the empty barrel. 
He carried his ammunition in bottles, and while he 
poured the charge of powder and shot into his hand, 
he placed the butt of the gun on the ground, the bar- 
rels reaching across the left breast in an oblique direc- 
tion. While standing in this position the other barrel 
was in some unaccountable manner discharged. It 
was loaded with black powder and No. 4 shot. He 
says that he does not know how many shot were in 
the gun, but thinks there must have been a handful 
and powder in proportion. The load struck him in 2 
the left breast, as is shown in the accompanying photo- 
graph, which was taken on Nov. 26th, or twelve days 
after the injury was received. He was now alone and 
the nearest house was eighty rods away, and to get to 
it he was compelled to walk across a field of wheat 
wet with recent rains. The shock did not knock him 
down, but he says he knew he was hurt and started 
for the house. On the way he noticed that his clothes 
were on fire and he put it out with the blood. On 
nearing the house he met two men who lifted him 
over the fence and assisted him to the house. Here 
Fig. 1. 
a part of his clothing was removed, and he was left 
sitting on a chair while the nearest physician was sent 
for. He arrived shortly, and after a hasty examina- 
tion a physician from this city was also summoned. 
Upon his arrival a consultation was held and the 
conclusion reached that it was unnecessary to do any- 
thing for him, as he could live but a short time at 
most. In fact, one of them sat at his side and pared 3 
two or three apples and fed them to him, saying that 
"as he had but a short time to live he might as well 
have what he wanted to eat." They left without offer- 
ing him any assistance or relief whatever, and the 
people who were, as is usual on such occasions, panic- 
stricken, stood around waiting for the boy's death. 
After waiting about two hours for the boy to die, and 
he not doing so, Dr. W. G. McFadden and myself 
were summoned by telephone. We arrived at the 
house at about 9 p.m., some six hours after the injury 
had been received. He was still sitting on the chair 
where he had been placed six hours previously. He 
was almost covered with blood, and the lung was 
protruding from the wound with each inspiration, 
thus producing a horrible hissing sound as the air 
entered the cavity of the chest, and at the same time 
there was a gush of blood from it. The wound was, 
in consequence of the close proximity of the gun, 
badly powder burned, and this, no doubt, prevented a 
much greater hemorrhage than there was. Upon 
examination we found the wound to be in the infra- 
clavicular and mammary regions of the left side. It 
measured 7%x4y£ in. Almost all of the pectoralis 
major muscle was gone and the sternal end of the 
third rib and the middle third of the second rib were 
cut away, making an opening into the chest about 
three inches square. It also removed a portion of 
the pleura costalis about the same size, besides the 
intercostal muscles. The load did not enter the 
chest, but was deflected forward by the ribs and came 
out just below the clavicle. We picked out seven of 
the shot from just beneath the clavicle, and these 
with two others were tlie only ones found. The pulse 
was 150 and at times hardly perceptible. The respira- 
tions numbered 38. His feet and hands were cold, as 
was also his nose, and he was almost dead from the 
shock incident to the injury. After a short consulta- 
tion it was decided that the best thing to do was to 4 
close up the wound, as it might prevent collapse of the 
lung. We immediately set about doing this and in a 
few minutes had it washed as thoroughly as was possi- 
ble under the circumstances. The entire length of 
the wound was then stitched up with silk, using the 
interrupted suture. Over this we placed a dressing of 
iodoform gauze and then strips of adhesive plaster in 
order to more thoroughly exclude the air and hold the 
gauze in position. He was then placed in bed and 
vigorous means resorted to in order to bring about 
reaction. Hypodermatic injections of strychnia, 
xV Sr-j glonoin, gr., and morphia, % gr., were 
given, as well as liberal doses of whiskey. Hot bricks 
were placed around his feet and body. In a few 
minutes his pulse was much stronger and it came 
down to 126. 
We left him at about 10:30 P.M., much more com- 
fortable than when we arrived. The next morning 
his pulse was 120 and respiration 30. He had rested 
well nearly all night and was feeling very well. The 
dressings were not disturbed. The next day (Monday) 
the dressings were removed, and we found that the 
stitches had loosened somewhat and were gradually 
separating. 
On Tuesday 17th the dressings were removed, and 
after doing so the lung completely collapsed and he 
experienced great difficulty in breathing. On closing 
up the aperture it seemed to be restored and he again 
breathed normally. On the next day they were re- 
moved, and the lung again collapsed to remain so ever 
since. There was now a total collapse of the lung, 
and we could get a good view of the interior of the 
chest and noticed for the first time that the heart was 
exposed to view, and every pulsation could be plainly 
seen. I have on a number of occasions sat at his 
bed-side and watched it for as much as ten minutes at 
a time. The wound was now dressed daily. The 
stitches were removed on the fourth day, as they were 5 
now doing no good, and the wound was washed with 
hydrogen peroxide and then the chest with a saturated 
solution of boracic acid, having the patient sit up in 
bed in order to get the fluid out. The wound was 
then packed with iodoform gauze and bandaged. 
This method of dressing the wound was continued 
for the next two weeks, or until it was deemed 
advisable to do an operation to close up the wound. 
After the second day there was a very large amount 
of fluid secreted, there being not less than a quart 
daily. It at first consisted of a serous fluid, then 
gradually became sero-purulent and then purulent in 
character. The amount remained at about a quart a 
day for three weeks and then became less, until it is 
now almost nil. 
On Sunday 22d he experienced great difficulty in 
breathing, his pulse had again reached 142, his 
respirations numbered 36, and he was worse than he 
had been for several days. I washed out the wound 
and chest as usual and dressed as before. On the 
next day I saw him early and found that he was 
greatly improved. Respiration 23 and nearly normal. 
His pulse had also come down to 112 and was full and 
strong. 
November 24th, his pulse was 110 and respiration 
23. Until this time he had experienced great diffi- 
culty in breathing and would often ask to be fanned. 
From this time on this trouble became less and is not 
now noticeable. November 28th, pulse 100, respira- 
tion 28. The temperature at no time has exceeded 
101*. 
On Thursday December 10, 1896, Dr. J. W. Marsee, 
of Indianapolis, came down to see the case with me. 
It was deemed advisable to again close up the wound. 
Chloroform was administered, the granulating sur- 
faces of the wound were scraped off and the skin and 
fascia cut loose in order that the edges of the wound 
might be drawn together. As the sternal end of the 6 
second rib was splintered it was cut off and made 
smooth. An opening for drainage was then made in 
the fifth intercostal space of the left side (in the most 
dependent portion of the chest cavity). A few days 
later I had an aluminium drainage tube made and 
placed in it, and this has been in place ever since and 
can be plainly seen in the photograph. This opening 
was sufficient to allow free drainage from the cavity. 
The edges of the wound were drawn together (as 
they had been on the night he was injured) and 
stitched up with catgut sutures of the interrupted 
Fig. 2. 7 
variety. A continuous suture of catgut was also put 
in besides three anchor sutures of silkworm gut. The 
anchor sutures were put in at the middle of the 
wound, and then one at about half way between this 
and the ends of the wound. These sutures were 
drawn up very tight so that the tension on the other 
stitches was almost entirely relieved. Over this was 
placed a dressing of iodoform gauze and a figure of 8 
bandage. He stood the chloroform well and came 
out from under it nicely. He was then removed 
from the operating table to the bed and we left him 
about noon. I saw him again about 8 p. m. He 
was somewhat restless and I gave him a hypodermatic 
injection of morphia, gr., with atropia. 
Friday, December 11th (the day after the operation), 
pulse 110, temperature 99|Q. Rested well all night 
The dressings were removed on the third day. The 
upper part of the wound began to separate, as before, 
but the lower part was healing by first intention. 
On account of suppuration in the wound it became 
necessary to remove the stitches on the sixth day after 
the operation. They were all removed, and for 
several days I washed out the chest with the boracic 
acid solution by throwing it (with a fountain syringe) 
into the opening for drainage and allowing it to come 
out at the wound above. About a quart of solution 
was used each time. The tube was removed, and 
while washing out the chest it was boiled for fifteen 
minutes before being replaced. 
As the last operation had closed up only a part of 
the wound I decided to operate again. On December 
21st I again drew the edges of the wound together 
and put in catgut sutures. These were placed in 
deep and closed it from the bottom. After this had 
been accomplished skin-grafting was begun. In this 
manner the wound was for the third time closed 
entirely. 
Each operation did its part in closing up at least a 
part of the wound. The next operation would close 8 
up a part, and so on. The last operation answered 
the purpose admirably and I succeeded in getting it 
closed permanently. Meantime I washedvOH^bhe 
chest as before daily, now letting the fluid escape 
from the opening below. 
The patient was kept in bed constantly until 
December 25th, when he was carried out to the table 
to eat his Christmas dinner. Since that time he has 
been gradually gaining strength and is now up every 
day. He is allowed to walk around the house and 
goes to the table for his meals, but has not been out of 
the house on account of the inclemency of the 
weather. His temperature is now normal. His 
pulse is from 84 to 95 and respiration 25. His 
appetite is also good. The drainage tube is still being 
used, but will be discarded soon. The adhesions are 
now quite firm, and as the skin-grafting has been 
finished very little remains to be done except to watch 
him. There is quite a depression at the wound 
where the chest is sunken, but he walks as straight as 
ever and is not at the present time perceptibly 
crippled from it. 
The accompanying photographs were taken on 
November 26th and January 20th, and show the con- 
ditions much better than words can describe them. 
This is a concise history of the case with the method 
of treatment. There are many subjects that might 
be discussed in connection with it, such as emphysema, 
pneumo-thorax, traumatic pleurisy, haemothorax, 
traumatic pneumonia, etc., but I do not care to take 
either the time or the space to do so at present. I 
shall keep close watch of the case and may at some 
future time give you a further account of it with an- 
other photograph taken, say six months from the 
present time. 
79 E. Franklin St.