WOUNDS OF THE THORAX AND THORACIC ORGANS.
Wounds of the thorax caused by incising, puncturing, or blunt instruments. These wounds are most often punctured wounds; contused wounds are common and incised wounds are not rare. They are perhaps most often homicidal in origin or at least inflicted by another, and the accidental origin of these wounds is probably the least common.
Incised or punctured non-penetrating wounds of the thoracic wall are rarely grave. Bleeding, as a rule, is not serious, though it may be quite free. Such wounds may be accompanied by emphysema, though not penetrating, owing to the movements of the chest and a valve-like action of the edges of the wound. Contused wounds of the thorax are more dangerous, especially if the violence was great, owing to the complicating fracture of the ribs, rupture of the thoracic viscera, etc.
Fracture of the ribs is a common result of contusions of the chest. It is more dangerous when due to a direct blow or injury, as then the splintering occurs internally and may wound the lungs, heart, or large vessels, while with fracture from indirect violence, from compression of the chest, the splintering of the ribs occurs externally. Fracture of the upper ribs requires more force than that required to fracture the lower ones, and consequently the former is the more dangerous. The diagnosis of fracture of the ribs is generally quite easy by means of crepitus felt or heard, false motion, local tenderness, etc. Fracture of the sternum may be serious if depressed on account of the wounding of the viscera behind it. Devergie[668] cites such a case where the depressed portion of the sternum produced a transverse non-penetrating wound of the heart about an inch in length, which had caused death in thirteen days. Simple fracture of the sternum without displacement of the fragments is rarely serious unless injury of the thoracic viscera is produced by the same violence. Wounds or injuries of the thorax are grave or not according as they penetrate or injure the thoracic viscera or do not do so. A wound may just penetrate the thoracic wall without wounding the thoracic viscera, and is then serious as a rule only when followed by inflammation. In fact, many of the penetrating wounds of the thorax wounding the viscera are only grave on account of consecutive inflammation. We have already seen that various characteristics of wounds of the thorax, especially of stab-wounds, enable us to determine the kind of weapon used, its size, sharpness, etc., and sometimes to identify the weapon itself. In much the same way we can often determine whether the wound was suicidally or homicidally inflicted. The cause of death in wounds of the thorax may be directly due to the wounding of one or more of the thoracic viscera, or it may be due to the inflammation occasioned by it. Wounds of the lower part of the thorax may involve at the same time the thoracic cavity proper and its contained viscera, the diaphragm and the abdomen and its viscera. This is the order in which the different parts would be met with in a wound from behind forward; the order might be the reverse of this in a wound from before backward. Penetrating wounds of the thorax may involve the lungs, heart, or great blood-vessels. Of these, the lungs are most often injured, which is easily accounted for by the greater size of the lungs. In wounds of the lungs the immediate danger is from hemorrhage. The hemorrhage appears externally through the wound and from the mouth, being coughed up. Where the lungs are injured by a blow, fall, or crush without external injury, blood appears in the mouth only. The blood coughed up from the lungs is bright red and frothy, and it may also be frothy at the external wound. Hemorrhage from the external wound may be slight, especially if the wound is oblique and acts as a valve. In wounds of the lungs most of the blood may collect in the pleura or in the lungs, and thus, by compression from without or by displacement by the blood within it, prevents air from entering the lungs and produces asphyxia, which may be fatal. More or less dyspnœa usually occurs at first. Emphysema is generally present in the cellular tissues, but this latter symptom may also occur at times with non-penetrating wounds of the chest. If death does not occur speedily from hemorrhage by compression of the lungs or heart, there are good hopes of saving the patient, but the prognosis should be reserved. For even when the first effects of the wound of the lung are survived, the patient may die from the effects of inflammation, recurring hemorrhage, or a too sudden relaxation of regimen. Thus, for instance, if too much food, talking, or exertion are indulged in the case may on this account terminate fatally, and such aggravating causes of death may mitigate the sentence.
Wounds of the heart are among the most fatal. Although it was once considered, and is usually thought now by laymen, that wounds of the heart must be necessarily and instantly fatal, the facts are otherwise. If the wound is small and oblique life may be prolonged, and cases are recorded[669] in which wounds of the heart were not directly fatal, and in some of which recovery would have probably resulted if not for other diseases. Cases in which the heart wall was wounded but not penetrated, and in which healing took place, are not very rare.[670] Thus Callender removed a needle from the substance of the heart. But there is perhaps only one case[671] on record in which a wound penetrating the cavities of the heart was recovered from. It is the rule rather than the exception that wounds of the heart, penetrating or not, are not immediately fatal. Thus in a series of twenty-nine cases of penetrating wounds mentioned by Devergie,[672] as collected by Ollivier and Sanson, only two ended fatally within forty-eight hours, the rest in periods ranging from four to twenty-eight days. This delay in the fatal result has been attributed to the arrangement of the muscle fibres crossing one another and tending to close the wound, or at least to make it smaller. As to the various parts of the heart wounded, the right side, especially the ventricle, is most often wounded. Thus out of fifty-four cases of wounds of the heart, Taylor[673] states that the right ventricle was wounded in twenty-nine cases, both ventricles in nine, the right auricle in three, and the left auricle in one case. This greater frequency of wounds of the right side of the heart is easily accounted for by its more exposed position anteriorly, just beneath the chest wall in a part of its extent. The rapidity of death depends largely upon the site and extent of the wound. Lutaud[674] states that out of twenty-four cases of wounds of the right ventricle only two were fatal within forty-eight hours, and out of twelve cases of wounds of the left ventricle three were not immediately fatal. Wounds of the auricles are generally fatal immediately, especially if the cavity is extensively laid open. It is the general opinion that wounds of the auricles are most rapidly fatal, next those of the right ventricle, and lastly those of the left ventricle. This difference is probably due to the comparative thickness of the walls of these parts. Thus the wall of the left ventricle is so thick as to tend to close a wound unless it be extensive. In wounds of the heart death rarely occurs from external hemorrhage, which may be quite slight or even altogether wanting where the wound is due to a crush or fracture of the ribs. Death is usually due to the compression of the heart by the blood in the pericardium. This usually causes syncope, or a slighter pressure may be fatal by causing cerebral or pulmonary anæmia or shock. Death may occur suddenly in this manner or not until after some time. Thus in penetrating stab-wounds little or no blood probably escapes at first, in most cases, but it may ooze or, later on, suddenly burst out into the pericardium. Therefore after a wound of the heart the patient does not, as a rule, die immediately, as formerly and often at the present time erroneously supposed. This fact is of little importance as a rule in surgery, for the patients generally die sooner or later, but it is of importance in medical jurisprudence, for upon it may hang the solution of questions of murder, suicide, or justifiable homicide. It also accounts for the fact that the injured person can exercise voluntary power after the injury. Thus Watson[675] met with a case where a man ran eighteen yards and died six hours after a stab-wound of the right ventricle. The coronary artery was divided and the pericardium was filled with blood. Also Boileau met with an accidental penetrating stab-wound through both ventricles in a soldier who ran two hundred yards, then fell and died in five minutes. A boy admitted to Guy’s Hospital in 1879 lived forty-two hours with a bayonet-wound transfixing the right auricle, the septum, the left ventricle, the mitral valve, and entering the left auricle.
Minute wounds of the chest are sometimes made by needles, etc., in the region of the heart with the intention of killing infants or children. Taylor[676] also mentions the case of a fatal wound of the heart from a needle, the result of accident. We have already cited the case of a needle lodged in the heart wall and removed by Callender by operation. That the puncture of the heart by a small instrument is not necessarily serious is proved by the experiments of Senn,[677] by which he found that “the heart can be punctured with a perfectly aseptic, medium-sized aspirator needle without any great immediate or remote danger.”
In cases of RUPTURE OF THE HEART the question may come up as to whether it was the result of disease or violence. We have already seen that rupture of the heart may occur from falls or crushes without marks of violence to the chest. In general, we may say that in rupture of the heart from violence the right side and base are most often involved, while in rupture from disease the left ventricle is generally ruptured, especially near the apex. The exciting causes of rupture of a diseased heart are often violent emotions or exertion, which may both be present in a quarrel with another and cause rupture without direct violence. The cause need be but slight if the heart is diseased, whether the cause is a natural one or outward violence. Rupture from disease may therefore excite suspicions of murder, but those cases can usually be satisfactorily solved by examination of the organ post mortem. A slight degree of violence may cause rupture of a diseased heart about ready for rupture from natural causes. When a diseased heart ruptures during a quarrel, the symptoms of rupture of the heart may be observed to come on suddenly before and without the infliction of any violence.
Wounds of Arteries and Veins, especially within the thorax.—Wounds of large trunks are generally speedily mortal. In the chest we may occasionally meet with wounds of the intercostal or internal mammary vessels or the vena azygos veins. These wounds are often serious and may be fatal. We have already seen that blood in the large cavities of the body, like the chest, is commonly not coagulated, or at least the greater part of it. We have already seen, too, that after wounds of the carotid artery the victim may preserve the power of locomotion for a short time, but not the power of struggling. This fact may be important to help distinguish between murder and suicide. In such wounds of the carotid the voice may be lost, as the trachea is often divided. Death from wounds of large vessels may be due to loss of blood, and if this danger is passed the case may still terminate fatally, as in a case where the brachial was tied for injury and death occurred in three days from gangrene. The wounds of comparatively small vessels may prove fatal from hemorrhage, etc.
In wounds of blood-vessels death may occur from the entrance of air into them. In some cases where this is supposed to have occurred it is quite probable that death was really due to hemorrhage. A considerable quantity of air may enter the circulation, especially the arterial circulation, without a fatal result. When death does occur it is owing (1) to “mechanical over-distention of the right ventricle of the heart and paralysis in the diastole,” or (2) to “asphyxia from obstruction to the pulmonary circulation consequent upon embolism of the pulmonary artery.”[678] Senn found that fatal air embolism could hardly occur spontaneously in a healthy jugular vein, as the walls collapse readily from atmospheric pressure.
Wounds and Ruptures of the Diaphragm.—These may be due to weapons, fracture of the ribs, falls or crushes, and disease. They also occur as the result of congenital malformation, though these cases seldom survive long. These injuries are generally homicidal or accidental in origin. As a rule, the viscera are wounded at the same time, or, if not wounded, at least herniated, and may thus become strangulated. It is therefore hard to estimate the danger in such cases, but the prognosis is at all times serious. The most serious cases of such injury to the diaphragm are due to violent contusions or falls when the stomach and intestines are full. The hemorrhage is usually slight, but hernia of one or more of the abdominal viscera usually occurs in such cases, and is said to be more readily produced during inspiration when the fibres are on the stretch. According to Devergie, rupture of the diaphragm with hernia is more common on the left side in the central tendon in front of the crura and at the junction of the left muscular leaflet. Also on either side of the ensiform cartilage and especially on the left side there occurs an area of the diaphragm which may be congenitally weak or even absent, and here too rupture and hernia are likely to occur. Phrenic or diaphragmatic hernia occurs especially after lacerated wounds, even after the wounds have apparently healed. If hernia occurs long after the injury was inflicted, it may be asked whether the wound was the cause of the hernia, and so of death. This can only be determined by examination. Almost any or all of the movable abdominal viscera may be found in a diaphragmatic hernia. It was once supposed that this accident would be immediately fatal, but this is far from the truth. Devergie relates the case where a person lived nine months with the stomach and colon in the chest and died from another cause. Thus a person may have a phrenic hernia and die from another cause, or having had a rupture or wound of the diaphragm he may suddenly acquire a diaphragmatic hernia by reason of a blow or sudden exertion, or the latter may strangulate an existing hernia. A person with a diaphragmatic hernia may have the power of moving or walking, but is more or less incapacitated owing to the compression of the lungs which exists and the consequent dyspnœa, etc.