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.