The mysterious bullet in the heart

Shot in the lungIn 1852 The Monthly Journal of Medical Science published a report from Burma, where British forces had just begun to fight the Second Anglo-Burmese War.  They landed on April 12th and captured the city of Rangoon shortly afterwards, setting up a field hospital in a priest’s house requisitioned for the purpose. Six surgeons travelled with the army, and in December they sent home a digest of some of their more interesting cases. They included a soldier who had been shot in the bowels and who was administered port ‘in considerable quantities’ – he died six days later. But the most striking story was this one:

A private in the 80th, a stout well-made man, was struck on the 14th April, on the left shoulder by a musket ball about an inch to the outside of the coracoid process. The course was then downwards and inwards into the thorax.

The coracoid process is a hook-like protuberance on the shoulder-blade.

The breathing was at once interfered with, being short and catching, with cough and bloody sputa; and there was considerable emphysema of the cellular tissue near the wound.

‘Emphysema’ here does not refer to the lung condition; in its general sense it means an accumulation of gas within the tissues. That and the bloody sputum are clear signs of a lung injury.

He went on very well, though obviously getting thin and pale, and expressed himself as wonderfully easy. The chest in time contracted, while percussion became dull, and the respiratory sound could not be heard, while on the right side the sound became puerile.

Percussion – striking the chest – gives useful diagnostic information. Healthy lungs give a hollow sound because they are full of air; the ‘dull’ response in this case indicates that either they or the pleura (the membrane around the lungs) were filling with fluid. ‘Puerile’ is a term still used today to describe the breathing sounds of children. These are louder than in the adult, partly because children have a thinner chest wall. To detect similar sounds in an adult is potentially a bad sign.

On the 5th May he was removed to the depot at Amherst; there he gradually became thinner and weaker, till he was reduced to a skeleton, at the same time he continued to say he was “very well, considering.”

Very well, considering he had a bullet in his chest. How British.

The side was now resonant, but there was no respiratory sound. Emphysema reappearcd after being absent for several weeks. About the end of June he began to sink, and one evening he suddenly expired.

Nothing out of the ordinary so far. But now the doctors had a surprise. When they opened the body they could not at first work out the course of the musket ball. But then they found a passage between the second and third ribs. Inside the ribcage there was a large abscess within the pleura – probably caused by infection.

The lung was very much condensed and pressed towards the heart, an opening in its pleural covering showed the continuation of the course of the ball, and this was farther traced as far as the root of the lung, where the examiner failed to trace it further. In the lung was found a piece of red cloth, and another of white cotton, closely appressed.

This is a common finding in shootings: fragments of clothing travel with the projectile and lodge in the tissues. Since garments are often alive with microorganisms, cloth fragments are one possible cause of infection in gunshot wounds. But here’s where things get really interesting:

On opening the pericardium, the apex of the heart appeared thickened, and a hard body was distinctly felt at that point. When the cavities were laid open, the musket-ball was found in the left ventricle, lying at the apex, with a thin covering of white lymph partly covering it. No injury to the heart could be found, nor any evidence of diseased action. The right lung was healthy, as well as the other organs of the body. The heart, as found, was put in spirit, to be sent to Calcutta.

In summary: a bullet was found inside his heart, which was uninjured, with no sign of an entry wound. Impossible? Not at all. The journal’s editor adds a note which supplies a wholly plausible explanation:

This is one of the most strange cases on record. The only conceivable way by which the ball found its way into the ventricle is by one of the pulmonary veins first into the auricle, and then by the mitral valve into the ventricle. I am sorry I did not see the whole dissection, as the tracing of the ball at the root of the lung would have been most interesting. But I saw the heart as it lay before it was opened, and felt the bullet at the apex.—A. C.

This may be the first such case ever observed, but many more have since been recorded. During the Second World War surgeons often encountered (and for the first time removed) bullets in the heart which had migrated there in the bloodstream – usually from the lungs or the surrounding major blood vessels, but sometimes from more remote parts of the body.

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