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.
WOUNDS AND CONTUSED INJURIES OF THE ABDOMINAL WALL AND VISCERA.
Such wounds and injuries of the abdominal wall may be incised, punctured, or due to blunt instruments, etc. They are usually homicidal or accidental, seldom suicidal except in delirious patients or lunatics. The cause of death in such cases may be due to hemorrhage, shock, etc., or to secondary inflammation, which is especially likely to occur in penetrating wounds. The kind of weapon used may often be judged from the nature of the wound. Incised and non-penetrating punctured wounds are usually simple and not grave, but may be otherwise from hemorrhage from the deep epigastric artery, or from inflammation in or between the muscles, or in the subperitoneal connective tissue. In the latter case peritonitis may occur, but is rare. A ventral hernia may, however, result later on, as also from a cicatrix, especially if it is transverse. In such cases the question arises whether the natural results of the wound were aggravated by unskilful or improper treatment or even wilful neglect on the part of the patient or practitioner.
Contusions of the abdomen are more serious often than those of the chest, for there is less power of resistance. We have already seen that death may occur from a contusion of the abdomen too slight to show a mark of ecchymosis or a serious injury internally. This has been attributed by some to an effect on the solar plexus or reflexly on the cardiac plexus causing a fatal inhibition. Lutaud and others have expressed the doubt whether the cases reported by Travers, Allison, Watson, Cooper, Vibert, and others were carefully examined, and have inferred that some visible organic change must have been present. Some such cases, however, have been examined with especial reference to this point, and no physical injuries and no other cause of death elsewhere has been found. There is no ground, therefore, for a jury to doubt that a contusion of the abdomen was the cause of death because there are no visible marks of injury.
Again, it is a well-known fact that the blows severe enough to cause rupture of the abdominal viscera may sometimes leave no trace of violence in or on the abdominal wall. On the other hand, it must be remembered that effusions of blood may be found post mortem in the sheaths of muscles without indicating violence, so that blood may be found effused in considerable quantity in and around the abdominal muscles without violence having been done. In such cases, therefore, we should note whether abrasions or ecchymoses of the skin are absent or not. If they are absent and there is no other evidence of a blow, the medical witness should hesitate to attribute such an effusion of blood between the muscles to an act of violence.
As in the case of the chest, so wounds of the abdomen are serious, as a rule, mainly as they involve the abdominal viscera. The viscera may be wounded by a penetrating wound or by rupture, and the fatal result is due sometimes to internal hemorrhage or to shock, but generally to secondary septic peritonitis, which may be fatal in a few hours or only after days or weeks. Occasionally wounds of the abdominal viscera undergo spontaneous cure without surgical interference and with or without medical treatment. But as a rule they are fatal unless they receive proper surgical treatment. A wound of the abdominal wall may be penetrating without wounding any of the viscera. Such wounds may be fatal if they are infected, otherwise they usually heal readily and without danger unless they are extensive and the abdominal contents are exposed to the air. The gravity of penetrating wounds varies somewhat with the particular viscus or viscera injured. It is well not to examine wounds of the abdomen by the finger or probe too freely unless a laparotomy is anticipated; for a simple wound or penetrating wound without wounding of the viscera may thus be infected. Enough examination is necessary to diagnose between a simple and a penetrating wound of the abdominal wall.
RUPTURE OR WOUNDS OF THE ABDOMINAL VISCERA.
The Liver is most often wounded of any of the abdominal viscera, with the possible exception of the intestines, because of its size, and it is most often ruptured partly because of its size, but mostly owing to its friable consistence. Such injuries most often involve the right lobe, as it is much the larger of the two principal lobes. The anterior surface and inferior border is the most frequent site both of wounds and ruptures of the organ. Ruptures rarely pass entirely through the organ, but are generally not more than an inch or two in depth. They are usually directed antero-posteriorly or obliquely, rarely transversely, and the lacerated granular edges are not much separated as a rule (see Fig. 21). Rupture of the liver may be due to a blow, crush, or fall, or even to sudden muscular action if the organ is large and fatty. Thus Taylor[679] relates the case of a woman who died after child-birth of uræmic convulsions, and in whom there was quite an extensive hemorrhage into the liver beneath its capsule, and apparently due to violent muscular contraction. As we have already seen, the liver may be ruptured without the abdomen showing the marks of external violence. Rupture or wound of the liver is one of the causes of the fatality of wounds and injuries of the abdomen. The fatal result may be and often is due to hemorrhage; in other cases it is due to shock or the occurrence of peritonitis. Wounds of the liver heal readily and hemorrhage is arrested at once, as a rule, by the approximation of the edges. There may be little blood in and about the wound, but it collects in the right iliac region or in the pelvis and is not wholly coagulated. Unless the wound or rupture involves the vena cava, portal vein, or a large branch of either of these, the hemorrhage is apt to be slow and the victim may survive hours or even days, except for active exertion or repeated violence. Two cases illustrating the slowness of the hemorrhage have occurred in Guy’s Hospital. In one[680] the man, showing no urgent symptoms at the time, was sent away, and died a few hours later in a police-station. In this case the liver was ruptured nearly through its thickness, and a basinful of blood had been effused, causing death. In the other case,[681] which occurred to Wilks, the patient survived the accident ten days, and Taylor[682] cites a case which was reported to have ended fatally eight years after the accident. As a rule the injury is fatal, without treatment, within forty-eight hours. Not being immediately fatal as a rule, the victim of a rupture or wound of the liver can walk about, and may be capable of more or less severe muscular exertion after the injury, though the fact of such exertion has sometimes been used by the defence to prove that the rupture was not due to the particular violence in question.