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.