The Case of the Corpulent Commander Who Sustained a Fatal Fall

Albert B. Lowenfels, MD; Jennifer Dore, MD

Disclosures

February 19, 2008

How Would This Patient Be Diagnosed Today?

This is a likely explanation for William's final illness. When William's horse suddenly reared up while he was fighting the French during the battle at Mantes, his lower abdomen would have been abruptly thrust against the pommel of the saddle, and his extreme obesity would have increased the force of the impact. Pommel injuries while riding horseback are known to cause diastasis of the pubic symphysis and could have led to a retroperitoneal hemorrhage or an injury to the bladder, with leakage of urine into the retroperitoneum.[1,2] This happens in about 15% to 20% of patients with pelvic fracture. Gradual accumulation of urine (urinoma) with subsequent infection and/or uremia could have led to his delayed death -- 6 weeks after the initial injury. Both the timing and the mechanism of injury fit with a bladder injury and a ruptured pelvis. This diagnosis is also compatible with the large amount of purulent material that burst forth spontaneously during his burial.

Appendicitis is one of the commonest causes of acute abdominal pain, but only rarely has it been reported following blunt trauma to the abdomen. When appendicitis does occur after such an event, it is almost always uncertain whether a true causal relationship exists. Appendicitis is relatively frequent and its occurrence may be unrelated to the injury.

Suggested criteria for diagnosing traumatic appendicitis include:

  • No history of abdominal pain prior to the injury;

  • History of a significant injury directly to the abdomen;

  • Time interval between injury and symptoms of 6 to 48 hours; and

  • Progressive, unremitting symptoms leading to appendectomy with positive pathologic findings.[3]

This is one of the most common injuries following blunt abdominal trauma, but was it the cause of William's death? Delayed rupture of the spleen occurs in about 5% to 10 % of cases. The 6-week interval between William's injury and his death is longer than is usually reported in patients with delayed rupture of the spleen. Although delayed rupture of the spleen cannot be ruled out, it seems less likely than some of the other possibilities.[1,4,5]

Traumatic injuries to the small or large bowel are more common after penetrating trauma than after blunt trauma. Because of the immediate onset of peritonitis after bowel rupture, survival for 6 weeks without any type of intervention would be highly unusual.[2,6] Today patients with rupture of the bowel following blunt injury are operated soon after the injury; a delay of even 8 hours increases morbidity and mortality.[7]

Pancreatic injury would follow the known time course. Because of its protected location in the upper retroperitoneal space, pancreatic injury accounts for only about 5% of blunt abdominal injuries.[8] The clinical presentation is often subtle, consisting of abdominal pain and elevation of pancreatic enzymes. If the pommel struck William in the epigastrium, he could have sustained a pancreatic injury and subsequently either necrotizing pancreatitis or a pseudocyst could have developed. Both complications could lead to infection and eventually to multiple organ failure. The foul-smelling liquid exuding from the patient's burst abdomen could have been infected pancreatic juice.

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