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.
Fig. 21.—Ruptures of the Liver from a Fall from a Considerable Height, causing Immediate Death.
Wounds and ruptures of the gall-bladder result in the effusion of bile. While rupture of the liver is not necessarily followed by peritonitis, rupture of the gall-bladder with the effusion of bile generally causes peritonitis, and is fatal in this way and not from hemorrhage. Rupture of the gall-bladder may be favored by the presence of gall-stones, but the result is still attributable to the injury.
Spleen.—Ruptures of the spleen may be due to a bruising violence in this region, and here too the skin may not show the marks of the contusion, though this fact is still employed by the defence to try to disprove the connection between the injury and the result. It is important to remember, from a medico-legal point of view, that an enlarged and softened spleen may be ruptured from a comparatively slight muscular exertion. This might occur in a sudden movement to avoid a blow, and the charge of manslaughter might be affected by the mode of the production of the injury and the previous abnormal condition. Only direct violence is liable to rupture the healthy normal spleen. Rupture and wounds of the spleen may be and generally are fatal from hemorrhage, owing to the vascularity of the organ; more rarely are they fatal from shock. Peritonitis is not a result to be expected.
The hemorrhage accumulates in the lower and left side of the abdomen or in the pelvis, and coagulation is imperfect if present at all.
Kidneys.—These are occasionally ruptured from violence, but more often from accident. Wounds of the kidney are rare, owing to the depth from the surface at which they lie. They are more accessible from behind. A wound from behind is generally extra-peritoneal unless it perforates the organ; not so a wound from in front. Accidents in which the lumbar region is forcedly flexed are most apt to be followed by injury to the kidney. The injury may cause no prominent symptoms, but usually lumbar pain and tenderness, frequent micturition and hematuria, and in severe cases the symptoms of hemorrhage and shock are present. The injury may be speedily fatal from hemorrhage or collapse, or more slowly fatal from peritonitis, when the peritoneum is involved, or from abscess and septic infection, or from uræmia if the other kidney is diseased. Slight injuries are generally recovered from. As is the case with the liver and spleen, so after injuries of the kidney the victim may walk about, etc., unless there is copious and immediate hemorrhage.
The bladder may be wounded directly through the hypogastrium, vagina, or rectum; it may be punctured by a broken fragment of the pelvis, especially the pubis, or it may frequently be ruptured from blows, crushes, or falls. The latter accident occurs especially where the bladder is distended. The bladder may also rupture spontaneously from over-distention, which may or may not be favored by disease of the bladder wall, in which case rupture occurs more easily. Medico-legally the question may arise whether the rupture was spontaneous or due to injury. In this connection it should be remembered that the injury may leave no external mark of violence, and a case is recorded in which the bladder was ruptured by a fall in wrestling; but the question can be determined only by an examination of the bladder. If the wall of the bladder is thinned by the pressure of a calculus or from other causes, or if it is weakened by tubercular, syphilitic, or carcinomatous deposits or ulcerations, it may be spontaneously ruptured from slight distention or a slight degree of violence may rupture it. If violence has been employed it is responsible for the rupture, though the diseased condition may act as a mitigating circumstance; not so a distended bladder, as the latter is not abnormal. In spontaneous rupture from over-distention without disease of the bladder wall, stricture, hypertrophied prostate, or some such condition must be present to account for the over-distention. Spontaneous rupture of the bladder can, therefore, only occur when either disease of the bladder wall or obstruction of the urethra is present. No condition excludes rupture from violence. If there is an injury followed by the symptoms of rupture of the bladder and death and the bladder and urethra are healthy, there can be little doubt that death was due to the injury. Wounds or rupture of the bladder may be extra-peritoneal or intra-peritoneal. Rupture from disease of the bladder wall occurs at the site of the diseased and weakened spot, which is most often at the base of the bladder. Rupture of the bladder from violence occurs most often on the postero-superior wall, running downward from the urachus, in which case the peritoneum would be involved. A punctured wound of the bladder wall may be so minute that the leakage is very slow and the customary symptoms may be obscured, or the opening may be valvular in character, perhaps allowing escape of urine only when the bladder is not distended. The symptoms consist of pain, inability to micturate, and the presence of blood in the little fluid which can be drawn by a catheter. Fluid injected is not all returned and the bladder cannot be distended. After a time varying from a few hours to a few days, depending upon the size of the opening and the condition of the urine, peritonitis or peri-vesical cellulitis is set up, the former being generally fatal, the latter not necessarily so. Prompt surgical treatment may save the patient’s life by avoiding peritonitis. Extra-peritoneal ruptures are far less dangerous than intra-peritoneal, as in the former case cellulitis and abscess in the cellular tissue around the bladder, which may subsequently be treated by operation and drainage, take the place of peritonitis in the latter case, for which prevention is the only safe treatment. In extra-peritoneal rupture death, if it occurs, is generally due to septicæmia; in the intra-peritoneal variety it is due to peritonitis. These cases of injury to the bladder may die suddenly and speedily from shock or from peritonitis in three to seven days, or not until fifteen days or so. In punctured and incised wounds the urine escapes more slowly, peritonitis develops less early, and death is longer delayed. Hemorrhage in injury to the bladder is not usually serious; the blood is found partly in the bladder, partly in the pelvis, where the fluid extravasated by peritonitis is also found. The victim of a wound or rupture of the bladder may often walk about for some time after the injury.
Stomach and Intestines.—Punctured wounds, or, more rarely, incised wounds of the abdomen may involve these organs, or they may be ruptured by blows, crushes, and falls, or from disease. Stab-wounds of these viscera may be multiple from a single stab, the instrument traversing one coil, perhaps, and then wounding others, though this is less often the case than with gunshot wounds. Ruptures too may be multiple, though less often so than wounds. The ileum is most liable to rupture, though several cases of rupture of the jejunum are on record. Like the bladder, the stomach and, to a less extent, the intestines are more liable to be ruptured when distended. Ruptures of the stomach or intestines are seldom attended with much hemorrhage, while wounds may occasionally cause a serious and fatal hemorrhage from the wounding of a large blood-vessel. The principal danger lies in the leakage of the contents of the stomach and intestines, which almost always sets up a septic peritonitis. This may sometimes become localized and go on to spontaneous cure, though as a rule it becomes general and is fatal. In such cases early operation may avoid the fatal peritonitis. A punctured wound may be so small as to be closed by the mucous membrane, avoiding the escape of the contents of the gut. Or a wound may not entirely penetrate the wall of the stomach or intestines, which only gives way some days, perhaps, after the injury, though the injury is entirely responsible for the delayed result. These injuries are sometimes fatal immediately or very speedily from shock, while in other cases of very extensive injury there may be almost no shock, and the victim is aware of no serious injury. It is an important point to remember medico-legally that spontaneous rupture of the stomach or intestines may occur owing to ulceration due to disease. This can be determined by a careful examination of the wall of the stomach or intestines at the site of the rupture. A slight injury may also cause rupture if the wall of the gut is weakened by disease, as the disease causes greater liability to rupture. Here too it is to be remembered that a severe injury causing rupture may leave no mark of violence on the abdominal wall. The power of walking or other muscular exertion after such injuries of the stomach or intestines is not infrequently preserved, as recorded in numerous cases.[683] The prognosis in such injuries of the stomach and intestines is always extremely grave.
Incised, Punctured, and Contused Wounds of the Genital Organs.
These are not common as medico-legal cases. Self-castration or mutilation is sometimes practised by lunatics, idiots, or even intoxicated persons. Thus a man who, while intoxicated, cut off his genital organs and died the next day from the effects of hemorrhage was seen by Demarquay.[684] Circumcision in infants is also sometimes fatal from phlegmonous inflammation.[685]
Incised, lacerated, or contused wounds of the female genitals may be fatal from hemorrhage from many small vessels. Deeply incised wounds of the female genitals proves wilful and deliberate malice; accident is out of the question and suicide is improbable in such cases. But we sometimes have to determine between accidental, self-inflicted, and homicidal wounds of these parts, as accidental wounds may occasionally resemble those made by design and so may furnish more or less difficulty, unless all the circumstances are known. Thus Taylor[686] relates the case of a child in whom a sharp-pointed stick entered and passed through the posterior wall of the vagina as she fell from a tree. The stick was removed by a woman, and the child died in a little over a day from peritonitis. Unless the circumstances were known, this case might have caused suspicion of homicide.
Lunatics, idiots, and drunkards sometimes inflict on themselves wounds unlike ordinary suicidal ones. In other cases the various points we have enumerated in a previous section to distinguish between suicide, homicide, and accident may be applied to solve the case.
Contused wounds, such as kicks, etc., of the female genitals may be fatal from hemorrhage due to the laceration of the parts.[687] Like the wounds of the eyebrows, contused wounds of the vulva may sometimes resemble incised wounds owing to the sharp bony surfaces beneath. Careful examination allows a discrimination to be made from incised wounds. If hemorrhage occurs a long time after the alleged violence, it is probably due to natural causes, especially in cases of metrorrhagia, etc. It may be alleged in defence that contused wounds of the female genitals were inflicted post mortem, but besides the other features which we have already seen help to distinguish between ante-mortem and post-mortem wounds, we may add that kicks and other contusions of the vulva, if fatal, are so from hemorrhage or effusion of blood, and no post-mortem hemorrhage is enough to cause death.