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					                          Chapter IX
                   MEDICO-LEGAL ASPECTS OF
                      PHYSICAL INJURIES

Physical injury in the effect of some forms of stimulus on the
body. The effect may only be apparent when the stimulus
applied is insufficient to cause injury and the body
resistance is great.     It may be real when the effect is
visible.
     The effect of the application of stimulus may be
immediate or may be delayed. A thrust to the body of a sharp
pointed and sharp edged instrument will lead to the immediate
production of a stab wound, while a hit by a blunt object may
cause the delayed product ion of a contusion.

    Causes of Physicial Injuries:
         A. Physical Violence
         B. Heat or Cold
         C. Electrical Energy
         D. Chemical Energy
         E. Radiation by Radio-Active Substances
         F. Change of Atmospheric Pressure (Barotrauma)

  A. PHYSICAL INJURIES BROUGHT ABOUT
BY PHYSICAL VIOLENCE

     The effect of the application of physical violence on a
person is the production of wound.
     A wound is the solution of the natural continuity of any
tissue of the living body.      It is the disruption of the
anatomic integrity of a tissue of       the body.  In several
occasions, the word physical injury is used interchangeably
with wound. However, the effect of the physical violence may
not always result to the production of wound, but the wound is
always the effect of physical violence.

Physics of Wound Production:
     Wound = Kinetic energy X time X area X “other factors”

                        MV2      M = Mass V= Velocity
    Kinetic Energy = --------------
                  2

Kinetic Energy:
     Inasmuch as kinetic energy is base on the mass and
velocity factors and that the velocity is squared, the
velocity component is the important factor. This explains why
an M-16 bullet which has a speed or 3,200 ft/sec. will do more
damage that a 0.38 caliber bullet which is heavier but has a
much slower velocity.
Time:
     The shorter the period of time needed for the transfer of
energy, the greater the likelihood of producing damage. If a
person is hit on the body and the body moves towards the
direction of the force applied, the injury is less as when the
body is stationary.   The longer the time of contact between
the object or instrument causing the injury, the greater will
be the dissipation of energy.
Area of Transfer:
     The larger the area of contact between the force applied
on the body, the lesser is the damage to the body.          By
applying an equal force, the damage caused by stabling is
greater compared to a blunt instrument.
“Other Factors”
     The less elastic and plastic the tissue, the greater the
likelihood that a laceration will result.       Elasticity and
plasticity refer to the ability of a tissue to return to its
“normal” size and shape after being deformed by a pressure.
     The movement of the parts of the body as a result of the
force being applied to them and the local stretching of tissue
during acceleration and deceleration cause most of the
internal injuries seen in traumatized individuals.
     A force transmitted through a tissue containing fluid
will force the fluid away from the area of contact in all
directions equally, frequently causing the tissue to lacerate
(Legal Medicine Annual 1980, Cyril Wecht ed., p. 36).

Vital Reaction:
     It is the sum total of all reactions of tissue or organ
to trauma.   The reaction may be observed macroscopically and
microscopically. The following are the common reactions of a
living tissue to trauma:
      a. “Rubor” – redness or congestion of the area due to an
         increase of blood supply as a part of the reparative
         mechanism.
      b. “Calor”   –  Sensation   of  heat   or   increase  in
         temperature.
      c. “Dolor” – Pain on account of the involvement of the
         sensory nerve.
      d. Loss of function – On account of the trauma, the
         tissue may not be able to function normally.
     The presence of the vital reaction differentiates an
ante-mortem from a post-mortem injury.
     In the following instances vital reactions or changes may
not be observed even if injury was inflicted during life:
     a. If physical injuries are inflicted during the period
        may no longer have the potential capacity to react to
        the trauma; and
     b. If death is so sudden as not to give the tissues of the
        body, the chance to react properly. This is commonly
        observed in deaths due to sudden coronary occlusion.

CLASSIFICATION OF WOUNDS:
1. As to Severity:
     a. Mortal Wound – Wound which is caused immediately after
     infliction or shortly thereafter that is capable of
     causing death.
     Part of the Body where the Wounds Inflicted are
Considered Mortal:
        (1) Heart and big blood vessels.
        (2) Brain and upper portion of the spinal Cord.
        (3)     Lungs.
        (4) Stomach, liver, spleen and intestine.
     b.    Non-mortal wound – Wound which is not capable of
     producing death immediately after infliction or shortly
     thereafter.
2. As to the Kind of Instrument Used:
     a.   Wound brought about by blunt instrument (contusion,
hematoma, lacerated wound).
     b. Wound brought about by sharp instrument:
        (1) Sharp-edged instrument (incised wound).
        (2) Sharp-pointed instrument (punctured wound.)
        (3)    Sharp-edge and sharp pointed instrument (stab
        wound).
     c.     Wound brought about by tearing force (lacerated
wound).
     d. Wound brought about by change of atmospheric pressure
(barotraumas).
     e. Wound brought about by heat or cold (frostbite, burns
or scald).
     f. Wound brought about by chemical explosion (gunshot or
shrapnel wound).
     g. Wound brought about by infection.
3. As to the Manner of Infliction:
     a. Hit – by means of bolo, blunt instrument, axe.
     b. Thrust or stab – bayonet dagger.
     c. Gunpowder explosion – projectile or shrapnel wound.
     d. Sliding or rubbing or abrasion.
4. As regards to the Depth of the Wound:
     a. Superficial – When the wound involves only the layers
of the skin.
     b.   Deep – When the wound involves the inner structure
beyond the layers of the skin.
        (1)   Penetrating -   one in which the wounding agent
        enters the body but did not come out or the mere
        piercing of a solid organ or tissue of the body.
          “Penetrating Wound – Wound where the dimension of
        depth and direction is an important factor in this
        description.   It involves the skin or mucous surface
        and the deeper underlying tissues or organs caused
        directly by the wounding instrument.    Punctured, stab
        and gunshot wounds usually belong to this type of
        wound.”
        (2)   Perforation – When the wounding agent produces
        communication between the inner and outer portion of
        the hollow organs.     It may also mean piercing or
        traversing completely a particular part of he body
        causing communication between the points of entry and
        exit of the instrument or substance producing it.
5. As regards to the Relation of the Site of the Application
of Force and the Location of Injury:
     a. Coup Injury – Physical injury which is located at the
site of the application of force.

    b.   Contre-Coup Injury – Physical injury located at the
    site and also opposite the site of application of force.

    c. Coup Contre-Coup Injury – Physical injury located at
       the site and also opposite the site of application of
       force.

    d. “Locus Minoris Resistencia” – Physical injury located
       not at the site nor opposite the site of the
       application of the force but in some areas offering the
       least resistance to the force applied. A blow on the
       forehead may cause contusion at the region of the
       eyeball because of the fracture on the papyraceous bone
       forming the roof of the orbit.
     e. Extensive Injury – Physical injury involving a greater
        area of the body beyond the site of the application of
        force.   It has not only the wide area of injury but
        also the varied types of injury. A fall from a height
        or a run-over victim of a vehicular accident may suffer
        from multiple fratures, laceration of organs, and all
        types of skin injuries.

       When the moving head hits a firm, fixed and hard
     object, brain contusion mauy develop at the opposite of
     the site of impact.
            A coup-contra-coup location of brain injury may be
     found when a fixed head is hit with a moving object and
     then falls on another hard object.

6.  As to the Regions or Organs of the Body Involved:
     The wounds of the different organs and regions of the
body will be discussed separately under “Injuries in Various
Parts of the Body.

7.   Special Types of Wounds:
      a.    Defense Wound – Wound which is the result of a
      person’s    instinctive  reaction   of    self-protection.
      Injuries suffered by a person to avoid or repel potential
      injury contemplated by the aggressor.
           A person who is conscious that he is going to be hit
      by a blunt instrument on the head may raise his flexed
      forearms over his head, causing injuries on the forearms.
           If someone is going to stab another with a sharp
      instrument the tendency of the potential victim is to
      take hold of the instrument thus causing the production
      of an incised or a stab wound on the palm of the hand.
      b. Patterned Wound – Wound in the nature and shape of an
      object or instrument and which infers the object or
      instrument causing it.
           Impact of the face on the radiator grill of a car
      may cause imprint of the radiator grill on the face.
           A person run over by a wheel of a car, tire marks
      are shown on the boy.
           Due to hanging, the nature of the abrasion mark on
      the neck may infer material used.
           Contusion produced by belt, branch of tree, metallic
      rod, etc. may have the shape of the wounding instrument.
c.    Self-inflicted Wound – Self-inflicted wound is a
wound produced on oneself.         As distinguished from
suicide, the person has no intention to end his life.
Motive of Producing Self-Inflicted Wounds:
     (1) To create or deliberately magnify an existing
        injury   or   disease  for  penion   or   workman’s
        compensation;
     (2) To escape certain obligations or punishment.
        During war time soldiers may cut their fingers to
        avoid frontline assignments and prisoners may
        inflict physical injuries on their body to avoid
        hard labor and just be confined in a hospital to
        receive food and rest.
     (3) To crate a new identity or destroy the existing
        one.   Finger prints may be destroyed by acid, by
        cutting or burning. A person may even request for
        the services of a plastic surgeon to crate a new
        identity or destroy existing ones.
     (4) To gain attention or sympathy.
     (5) Psychotic behavior.
Some Ways of Self-Mutilation:
     (1) Head banging or bumping – This is commonly
         observed in overactive children and causes
         hematoma.
     (2) Exposure of parts of the body to heat radiation
         from open fires, radiators, or protective grills
         over radiator (thermophilia).
     (3) Penetrating nail or spike to the chest wall, or
         inser4tion into the urinary bladder in a female.
     (4) Castration by amputation of the penis.
     (5) Trauma inflicted on the female genitalia to
         induce abortion or promotes hemorrhage and
         creates an anemia.
     (6) Subcutaneous injection of fecal matters to
         promote abscess formation.
     (7) Prinking of acne eruption to lead to a severe
         facial disfigurement.
     (8) Subcutaneous injection of air to create a
         condition of emphysema.
     (9) Nail-biting (onychophagia) which may lead to
         maceration of the skin and an infection.
     (10) Grinding of the teeth (bruxism) is frequently
         seen in the mentally retarded and can lead to
         abnormal tooth wear, a bilateral hypertrophy of
         the masseter and a pain on chewing.
         (11) Pressure on the subcutaneous tissue by a
             tightly applied cord or belt around the body:
              (a) Tribal customs of metal band around the
                 neck or a leg by some African tribes may
                 cause a permanent disfigurement.
              (b) Use of shoes made of metal by Chinese
                 women.
         (12) Pulling of the body hair (Trichotillomania).
         (Forensic Medicine A study in Trauma & Environmental
         Hazards by Tedeschi, Echert & Tedeschi, Vol. 1, p.
         496).

LEGAL CLASSIFICATION OF PHYSICAL INJURIES:
Mutilation:
Art. 262, Revised Penal Code:
     The penalty of reclusion temporal to reclusion perpetua
shall be imposed upon any person who shall intentionally
mutilate another by depriving him, either totally or
partially, of some essential organ for reproduction.
     Any other intentional mutilation shall be punished by
prison mayor in its medium and maximum periods.

Kinds of Mutilation Punishable Under the Code:
1. Intentionally depriving a person, totally or partially of
   some of the essential organs for reproduction, and
2. Intentionally depriving a person of any part or parts of
   the human body other than the organs for reproduction.
     Mutilation is the act of looping or cutting off any part
   or parts of the living body.     In order to be punishable
   under the Code, it must be intentional, otherwise it will
   be considered as a physical injury.
     The loss of an eye due to stabbing is not mutilation. It
   is evident that the putting out of an eye does not fall
   under the definition (U.S v. Bogel, & Phil. 285).
     “Mayhem” is the unlawful and violent deprival of another
   of the use of a part of the body so as to render him less
   able in fighting, either to defend himself or to annoy his
   adversary.   Mutilation of other parts of the body other
   than the organ of reproduction may be classified as mayhem.
   However, if it is not deliberate then it may fall on
   paragraph 2, Art. 263 Revised Penal Code (Serious Physical
   Injuries).
  Is vasectomy and tubal ligation within the purview of
  mutilation as defined and penalized by Art. 262 of the
  Revised Penal Code?
    On September 1973 upon the request of the Executive
  Director of the Population Commission, the Secretary of
  Justice rendered an opinion that vasectomy and tubal
  ligation are not mutilation and a legitimate method of
  contraception   despite the  fact   that  it   is   done
  intentionally and deprives a person of his power of
  reproduction because:

  “1. In the case of U.S. v. Bogel et. Al. 5 Phil. 285 (1907
    the supreme Court, in holding that the putting out of an
    eye is not mutilation under Article 415 of the Spanish
    Penal Code which penalized intentional mutilation, stated
    “Viada in his commentary on Article 415 which penalized
    intentional mutilations, points out that by mutilation
    (mutilacion) is understood, according to the “Diccionario
    de la Lengua Española”, the looping or clipping off
    (ceranmiento) of one part of the body. As this provision
    of the Spanish Penal Code was the source of the above
    quoted provision of the Revised Penal Code, its is the
    same expounded by Viada that the prohibition in the
    latter provision should be understood.
       You Stated that tubal ligation and vasectomy “do not
    involve looping or clipping off of the organs of
    reproduction of both sexes”. I understood that these two
    methods of surgical sterilization are affected by the
    closing of a pair of tubes in either man or the woman so
    that the sperm and ovum cannot meet; it does not involve
    the removal or reproductive glands or organs as in the
    case of castration, with which it is sometimes confused.
    (Encyclopedia Americana, Sterilization, Human Vol. 25 p.
    269; Betterment Association of American, I.C.)       Such
    being the case, I do not think that these method of
    contraception could be regarded as mutilation within the
    contemplation of Article 262, Supra.”

Serious Physical Injuries:
Art. 263, Revised Penal Code:

     Any person who shall wound, beat, or assault another,
shall be guilty of the crime of serious physical injuries and
shall suffer:
1. The penalty of prision mayor, if in consequence of the
   physical injuries inflicted, the injured person shall
   become insane, imbecile, impotent, or blind;
2. The penalty of prisi1on correccional in its minimum and
   medium periods, if in consequence of the physical injuries
   inflicted, the person injured shall have lost the use of
   speech or the power to hear or to smell, or shall have lost
   an eye, a had, a foot, an arm, or a leg or shall have lost
   the use of any such member, or shall have become
   incapacitate for the work in which he was thereto-for
   habitually engaged;
3. The penalty of prision correccional in its minimum and
   medium periods, if in consequence of the physical injuries
   inflicted, the person injured shall have become deformed,
   or shall have lost any other part of his body, or shall
   have lost the use thereof, or shall have been ill or
   incapacitated for the performance of the work in which he
   was habitually engaged for a period of more than ninety
   days;
4. The penalty of arresto mayor in its maximum period to
   Prision correccional in its minimum period, if the physical
   injuries inflicted shall have caused the illness or
   incapacity for labor of the injured person for more than
   thirty days.
     If the offense shall have been committed against any of
   the persons enumerated in article 246, or with attendance
   of any of the circumstances mentioned in article 248, the
   case covered by subdivision number 1 of this article shall
   be punished by reclusion temporal in its medium and maximum
   periods; the case covered by subdivision number 2, by
   prision correccional in its maximum period to prision mayor
   in its minimum period; the case covered by subdivision
   number 3 by prision correccional in its medium and maximum
   periods; and the case covered by subdivision number 4 by
   prision correccional in its minimum and medium periods.

    The provisions of the preceding paragraph shall not be
  applicable to a parent who shall inflict physical injuries
  upon his child by excessive chastisement.
    The crime of serious physical injuries may be due to:
    (1) Wounding;
    (2) Beating;
    (3) Assaulting (Art. 263); or
    (4) Administering    injurious   substances   (Art.   264)
       without the intent to kill.
   It may be committed through a simple negligence of
imprudence.
   The main purpose of dividing the provision into four
paragraphs is to graduate the penalties depending upon the
nature and character of the wound inflicted and their
consequences on the person of the victim.
   In paragraph one, the injured person became insane,
imbecile, impotent, or blind.
   Insanity has not been defined or qualified by the
article.
   Imbecility infers that the injured person must be of the
pre-adolescent age    and that on account of the physical
injuries   inflicted   there   is   an   arrest  of   mental
development.
   Impotency is the inability to grant to the partner sexual
gratification.
   Blindness must be total or involvement of both eyes. If
only one eye became blind, then the physical injury will
fall in paragraph 2 of Article 263.
   In paragraph two, the following nature and character of
the wound or consequences of the injuries inflicted must be
present:
a. Loss of the use of speech or the power to hear or to
   smell, or loss of an eye, a hand, a foot, an arm, or a
   leg;
b. Loss of the use of any such member; or
c. Becomes incapacitated for the work in which he was
   therefore habitually engaged.
   There must be a total loss of hearing capacity. If the
loss of power to hear is only in one ear, it is a serious
physical injury under paragraph 3, article 263 (People v.
Hernanez, 94 Phil. 49).
   Insofar as loss of a hand is concerned, the prosecution
must prove by clear and conclusive evidence that the
offened party actually cannot make use of his hand and that
the offended party actually cannot make use of his hand and
that such impairment is permanent (People v. Reli. C.A. 53
).G. 5695).
   In paragraph three, the following physical injuries or
their consequences are included:
a. Deformity;
b. Loss of any other member of his body;
c. Loss the use thereof; or
d. Becomes ill or incapacitated for the performance of the
   work in which he was habitually engaged for more that 90
    days,   as  a   consequence  of  the   physical  injuries
    inflicted.
    Deformity is a condition of physical ugliness.    It must
  be permanent and conspicuous. The loss of the front teeth,
  the development of a pigmented scar on the face or loss of
  the pinna of the ear are considered deformities. However,
  the development of a scar in covered parts of the body may
  not be considered deformity because it is not conspicuous
  and visible.
    “The loss of any other part of his body” means loss of
  the parts of the body not mentioned in paragraph 2, Art.
  263.
    Incapacity means the inability of the injured person to
  perform, or engage on a work or vacation before the
  sustained injury.
    In paragraph four, the injured person becomes ill or
  incapacitated for labor for more that thirty days and
  impliedly less than 90 days.
    It is noteworthy to mention that in paragraphs 3 and 4 of
  article 263 there is no mention of periods of medical
  attendance but merely incapacity.

Administering Injurious Substance of Beverages:
Art. 264, Revised Penal Code:
     The penalties established by the next preceding article
shall be applicable in the respective cases to any person who,
without intent to kill, shall inflict upon another any serious
physical injury, by knowingly administering to him any
injurious substances or beverages or by taking advantages of
his weakness of mind or credulity.
     Elements of the crime:
     a. The offender inflicted upon another person any serious
        physical injury.
     b. The infliction of physical injury was done knowing that
        the substance or beverage administered is injurious or
        took advantage of the victim’s weakness or credulity;
        and
     c. There was no intent to kill on the part of the
        offender.
        If the offender does not know that the substance
     administered is injurious, he cannot be held liable under
     the above provision.
        The throwing of acid on the face of someone does not
     fall within the provision because what the provision
     contemplates is administering or taking in the injurious
    substance or beverages (U.S. Chiong Songco, 18 Phil.
    459).
      The provision does not contemplate of slight or less
    serious physical injuries which is the consequence of
    injurious substances or beverages, but results only in
    serious physical injuries.
      If the administration of injurious substances or
    beverages   is  intentional,   the  crime   committed is
    frustrated murder. Treachery is inherent when injurious
    substances or beverages are introduced into the body.

Less Serious Physical Injuries:
Art. 265, Revised Penal Code:
     Any person who shall inflict upon another physical
injuries not described in the preceding articles, but which
shall incapacitate the offended party for labor ten days or
more, or shall require medical attendance for the same period,
shall be guilty of less serious physical injuries and shall
suffer the penalty of arresto mayor.
     Whenever less serious physical injuries shall have been
afflicted with the manifest intent to insult or offend the
injured person, or under circumstances adding ignominy to the
offense, in addition to the penalty of arresto mayor, a fine
not exceeding 500 pesos shall be imposed.
     Any less serious physical injury inflicted upon the
offender’s parents, ascendants, guardians, curators, teachers,
or persons of rank or persons in authority, shall be punished
by prision correccional in its minimum and medium periods,
provided that, in the case of persons in authority, the deed
does not constitute the crime of assault upon such person.
     The basis to determine whether the physical injury is
less serious or not is by either the period of medical
attendance or period of incapacity; both of which is ten days
or more but not more than thirty days.
     The fact that the injury only requires medical attendance
for two days but incapacitated the victim from attending to
his ordinary work for a period of 29 days makes the crime less
serious physical injuries (U.S. v. Trinidad, 4 Phil. 152).
     There must be proof as to the period of medical
attendance.    In the absence of such proof of medical
attendance or incapacity, although the wound actually healed
in more than 30 days, the crime committed is only slight
physical injuries (People v. Penesa, 81 Phil. 398).
     The crime of less serious physical injuries may be
qualifed and a fine or a higher penalty is imposed when:
    a. There is a manifest intent to insult or offend the
       injured person;
    b. There are circumstances adding ignominy to the offense;
    c. The victim is the offender’s parents, ascendants,
       guardian, curators or teachers; or
    d. The victim is a person of rank or person in authority,
       provided that the crime is not direct assault.

Obligation Imposed on Physicians Who have Treated Persons
Suffering From Serious and Less Serious Physical Injuries:

PRESIDENTIAL DECREE NO. 169

     WHEREAS, Pursuant to Proclamation No. 1021, dated
September 21, 1972 and No. 1104, dated January 17, 1973
martial law has been declared throughout the Philippines to,
among other goals restore and maintain peace and order;

     WHEREAS, for the attainment of the aforesaid goal, an to
enable the law-enforcement agencies to keep track of all
violent crimes, conduct timely investigation thereon and
effect the immediate arrest of the perpetrators thereof, it is
necessary   that  all   persons  treating   physical  injuries
resulting from any form of violence be required to report such
fact to said agencies;

     WHEREAS, while some of the victims of violent crimes, or
those who may have sustained physical injuries in the act of
committing or as a result of the commission of a crime submit
themselves for medical treatment in hospitals, medical
clinics, sanitariums, or other medical establishments or to
medical practitioners; they do not report their injuries to
the law-enforcement agencies for one reason or another;
     NOW, THEREFORE, I, FERDINAND E. MARCOS, pursuant to
Proclamation No. 1081, dated September 21, 1972 and No. 1104,
dated January 117, 1973 and in my capacity as Commander-in-
Chief of all the Armed Forces of the Philippines, do hereby
order and decree that:
     1. The attending physician of any hospital, medical
        clinic, sanitarium or other medical establishments, or
        any medical practitioner, who has treated any person
        for serious or less serious physical injuries as those
        injuries are defined in Articles 262, 263 264, and 265
        of the Revised Penal Code shall report the fact of
        such treatment personally or by the fastest means of
       communication to the nearest Philippine Constabulary
       unit without delay:    Provided, that no fee shall be
       charged for the transmission of such report thru
       government communication facilities; and
    2. The report called for in this Decree shall indicate
       when practicable the name, age, address and nearest of
       kin of the patient; the nature and probable cause of
       the injury; the approximate time and date when, and
       the place where the injury was sustained; time, date
       and nature of treatment; and the physical diagnosis
       and/ or disposition of the patients.

     I do further order and decree that any violation of this
Decree and/or the rules and regulations which shall be
promulgated by competent authorities in accordance herewith,
with malicious intent or gross negligence, shall suffer the
penalty of imprisonment for not less that one year nor more
than (3) years and/or a fine of not less direct. In addition,
the government license or permit of the attending physician to
practice his profession shall be cancelled by the Civil
Service Commission after the sentence imposed by the military
tribunal become final executory.
     The Secretary of Health and the Secretary of National
Defense shall promulgate the necessary rules and regulations
to carry out the purpose of this Decree.
     Done in the City of Manila, this 4th day of April, in the
Year of Our Lord, nineteen hundred and seventy-three.



                                 (SGD) FERDINAND E. MARCOS
                                          President
                                  Republic of the Philippines

Slight Physical Injuries and Maltreatment:
Art. 266, Revised Penal Code:
The crime of slight physical injuries shall be punished:
1. By arresto menor when the offender has inflicted physical
   injuries which shall incapacitate the offended party for
   labor from one to nine days, or shall require medical
   attendance during the same period;
2. By arresto menor or a fine not exceeding 200 pesos and
   censure when the offender has caused physical injuries
   which do not prevent the offended party from engaging in
   his habitual work nor require medical attendance;
3. By arresto menor in its minimum period or a fine not
   exceeding 50 pesos when the offender shall ill-treat
   another by deed without causing any injury.

Kinds of Slight Physical Injuries Punishable by the Code:
1. Physical injuries which incapacitate the victim for labor
   from one to nine days, or require medical attendance for
   the same period.
     This kind of slight physical injuries will require
   medical certification as to the duration of medical
   attendance, or period of incapacity. In case of divergency
   in the duration of medical attendance and incapacity, the
   physician must always consider the best interest of the
   victim in the determination of the period.
2. Physical injuries which did not prevent the offended party
   from engaging in his habitual work or which id not require
   medical attendance.
     If the victim merely suffered from small contusion or
   superficial abrasion    which   does  not require medical
   attendance or incapacity, this fall in the paragraph of
   slight physical injury.
3. Ill-treatment of another by deed without causing any
   injury.
     A slight slap on the face or holding tightly the arm of
   the victim which did not even develop redness of the skin
   may be a form of ill-treatment.
     If there is no evidence to show actual injury, or
   incapacity for labor, or period of medical attendance, the
   accused can only be guilty of slight physical injuries
   (People v. Penesa, 81 Phil. 398; People v. Amarao et al.,
   C.A. 36 O.G. 3462).
     A tender slap on the face, holding the arm tightly,
   application of pressure in some parts of the body, or mild
   blow which show of pressure in some parts of the boy, or
   mild blow which show no sign of physical violence may still
   be considered slight physical injuries or maltreatment (3rd
   paragraph).

Physical Injuries Inflicted in a Tumultuous Affray:
Art. 252, Revised Penal Code:
     When in a tumultuous affray as referred to in the
preceding   article,  only   serious  physical   injuries are
inflicted upon the participants thereof and the person
responsible therefore cannot be identified, all those who
appear to have used violence upon the person of the offended
party shall suffer the penalty next lower in degree that that
provided for the physical injuries so inflicted.
     When the physical injuries inflicted are of a less
serious nature than the person responsible therefore cannot be
identified, all those who appear to have used any violence
upon the person of the offended party shall be punished by
arresto from five to fifteen days.
     Elements of the Crime:
       a. There is a tumultuous affray;
       b. Participant(s)   suffered   from   serious  physical
          injuries;
       c. The person(s) who inflicted such serious physical
          injuries cannot be identified; and
       d. All those who appear to have used violence upon the
          person of the offended party shall be penalized by
          arresto from five to fifteen days.

TYPE OF WOUNDS (Medical Classification):
  1. Closed Wound – there is no breach of continuity of the
     skin or mucous membrane.
       a. Sperficial – When the wound is just underneath the
          layers of the skin or mucous membrane.
              (1)   Petechiae.
              (2)   Contusion.
              (3)   Hematoma.
       b. Deep.
              (1)   Musculo-Skeletal Injuries
                  (a)    Sprain.
                  (b)    Dislocation.
                  (c)    Fracture.
                  (d)    Strain.
                  (e)    Subluxation.
              (2)   Internal Hemorrhage.
              (3)   Cerebral Concussion.
  2. Open Wound – There is a breach of continuity of the skin
     or mucous membrane.
       a. Abrasion.
       b. Incised Wound.
       c. Stab Wound.
       d. Punctured.
       e. Lacerated.
CLOSED WOUNDS:
Petechiae:
     This is a circumscribed extravasations of blood in the
subcutaneous tissue or underneath the mucous membrane.     The
cause of passage of blood from the capillaries may be use to
the    increase   intra-capillary    pressure   or   increased
permeability of the vessel.    The hemorrhage may be small or
pinhead sized but several petechiae may coalesce to from a
bigger hemorrhagic area.    Mosquito or other insect bits may
cause the formation of circumscribed hemorrhages.
     Petechieae is not always a product of trauma. Petechial
hemorrhage may be a post-mortem finding in asphyxial death,
coronary occlusion and blood diseases.     It may also develop
post-mortem in death by hanging.      There is gravitation of
blood into the most dependent part of the body which h
eventually leads to the rupture of over-distended capillaries
specially seen at the region of the leg.

Contusion:
     Contusion is the effusion of blood into the tissues
underneath the skin on account of the rupture of the blood
vessels as a result of the application of blunt force or
violence.
     When a blunt force is applied, it momentarily compresses
the blood vessels at the pint of contact, thereby temporarily
forcing the blood out of the area and setting up a fluid wave
under pressure. When the pressure exceeds the cohesive force
of the cells forming the capillary, arteriole, or venule wall,
the vessel ruptures.
     Inasmuch as it used to take more time for the blood to
get out of the blood vessels, contusion does not immediately
develop after the application of force. It may develop after
a lapse of minutes or even hours after the application of
force. The variation depends on the part of the body injured,
tenderness of the tissues affected, condition of the blood
vessels involved, and natural disease.    Women are much more
easily bruised than men while boxers are less prone to suffer
contusion inspite of heavy punishment.
     The size of the contusion is usually greater than the
size of the object causing it. The location of the contusion
may not always indicate the site of the application of force.
For instance, a blow on the forehead may cause black-eye or
contusion around the tissues of the eye-bal, or a kick on the
leg may cause appearance of contusion at the region of the
ankle on account of the gravitation of the effusion between
muscles and fascia.
     On the medico-legal viewpoint, a contusion as indicated
by its external pattern may correspond to the shape of the
object or weapon used to produce it; its extent may suggest
the possible degree of violence applied; and its distribution
may indicate the character and manner of injury as in manual
strangulation   around  the   neck.     In   may  infer  grave
complications and consequences on account of serious injuries
of the underlying tissues.
     Age of Contusion:
     The age of contusion can be appreciated from its color
  changes.     The size tends to become smaller from the
  periphery to the center and passes through a series of
  color changes as a result of the disintegration of the red
  blood corpuscles and liberation of hemoglobin.
     The contusion is red sometimes purple soon after its
  complete development.
     In 4 to 5 days, the color changes to green.
     In 7 to 10 days, it becomes yellow and gradually
  disappears on the 14th or 15th day.
     The ultimate disappearance of color varies from one to
  four weeks depending upon the severity and constitution of
  the body.
     The color changes start from the periphery inwards.
     Distinction Between Contusion and Post-mortem Hypostasis
  (Supra p. 133).

    Factors Influencing the Degree and Extent of Contusion:
    (a) General condition of the victim – Some healthy
      persons are easily bruised.
    (b) Part of the body affected – Bloody parts of the body
      produce larger contusion, specially where subcutaneous
      tissue is loose. In areas of the body with excessive
      fat, contusion easily develops, while parts of the body
      with abundant fibrous tissue and good muscle tone,
      bruising is less.
    (c) Amount of force applied – Other factors being equal,
      the greater the force applied the more effusion of
      blood will develop.
    (d) Disease – Contusion may develop w3ith or without the
      application of force. Examples: Purpura, Hemophilia,
      Aplastic   anemia,   Whooping  cough,   even   vicarious
      menstruation.
    (e) Age – Children and old age persons tend to bruise
      more easily. Children have loose and tender skin. Old
      people have less flesh an the blood vessels are more
      fragile.
    (f) Sex – Women, especially if obese, easily develop
      contusion.     Athletes, like boxers do not develop
      contusion easily.
    (g) Application of heat and cold – If immediately after
      injury cold compress is applied the production of
      contusion will be minimized.     After it has already
      developed, application of warm compress will hasten its
      disappearance.
      The distinction between ante-mortem and post-mortem
    contusions in an undecomposed body is that in ate-mortem
    bruising, there is swelling, damage to epithelium,
    extravasations, coagulation and infiltration of the
    tissues with blood, while in post-mortem bruising there
    are no such findings.

Hematoma (Blood Cyst, Blood Tumor, “Bukol”):

     Hematoma is the extravasation or effusion of blood in a
newly formed cavity underneath the skin. It usually develops
when the blunt instrument is applied in part the body where
bony tissue is superficially located, like the head, chest and
anterior aspect of the legs. The force applied causes the
subcutaneous tissue to rupture on account of the presence of a
hard structure underneath. The destruction of the subcutaneous
tissue will lead to the accumulation of blood causing it to
elevate.
  Distinctino Between Contusion and Hematoma:
  (a)     In contusion the effused blood are accumulated in
     the interstices of the tissue underneath the skin, while
     in hematoma blood accumulates in a newly formed cavity
     underneath the skin.
  (b)     In contusion, the skin shows no elevation and if
     ever elevated, the elevation is slight and is on account
     of inflammatory changes, while in hematoma the skin is
     always elevated.
  (c)     In contusion, puncture or aspiration with syringe of
     the lesion no blood can be obtained, while in hematoma,
     aspiration will show presence of blood and subsequent
     depression of the elevated lesion.
     Abscess, gangrene, hypertrophy, fibroid thickening and
  even malignancy are potential complications of hematoma.
Musculo-Skeletal Injuries:
(1) Sprain – Partial or complete disruption in the continuity
    of a muscular or ligamentous support of a joint.       It is
    usually caused by a blow, kick or torsion force.
(2) Dislocation – Displacement of the particular surface of
    bones entering into the formation of a joint.
(3) Fracture - Solution of continuity of bone resulting from
    violence or some existing pathology.
     (a) Close or Simple Fracture – Fracture wherein there is
         no break in continuity of the overlying skin or where
         the external air has no point of access to the site
         of injury.
     (b) Open   or  Compound   Fracture   –    The  fracture  is
         complicated by an open wound caused by the broken
         bone which protruded with other tissues of the broken
         skin.
     (c) Comminuted   Fracture   -   the    fractured   bone  is
         fragmented into several pieces.
     (d) Greenstick Fracture – A fracture wherein only one
         side of the bone is broken while the other side is
         merely bent.
     (e) Linear Fracture – When the fracture forms a crack
         commonly observed in flat bones.
     (f) Spiral Fracture – The break in the bone forms a
         spiral manner as observed in long bones.
     (g) Pathologic Fracture – Fracture caused by weakness of
         the bone due to disease rather than violence.
(4) Strain – The over-stretching, instead of an actual tearing
    or the rupture of a muscle or ligament which may not be
    associated with the joint.
(5) Subluxation – Incomplete or partial dislocation.

Internal Hemorrhage:
     Rupture of blood vessel which may cause hemorrhage may be
due to the following:
     (a) Traumatic intracranial hemorrhage.
     (b) Rupture of parenchymatous organs.
     (c) Laceration of other parts of the body.

Cerebral Concussion (Commotio Cerebri):
     Cerebral concussion is the jarring or stunning of the
brain characterized by more or less complete suspension of its
functions, as a result of injury to the head, which leads to
some commotion of the cerebral substance.
     Cerebral concussion is much more severe when the moving
or mobile head struck a fixed hard object as compared when the
head is fixed and struck by a hard moving object.

    Sign  and Symptoms:
    (a)   Unconsciousness which is more or less complete.
    (b)   Muscles are relaxed and flaccid.
    (c)   Eyelids   are  closed   and   the  conjunctivae are
          insensitive.
     (d) Surface of the body is pale, cold and clammy.
     (e) Respiration is slow, shallow and sighing.
     (f) Pulse is rapid, weak, faltering and scarcely
          perceptible to the fingers.
     (g) Temperature is subnormal.
     (h) Sphincters are relaxed perhaps with unconscious
          evacuation of the bowel and bladder.
     (i) Reflexes are present but sluggish and in severe
          cases may be absent.
     Loss of memory for events just before the injury
(retrograde amnesia) is a constant effect of cerebral
concussion and is of medico legal importance.

OPEN WOUNDS:
1. Abrasion (Scratch, Graze, Impression Mark, Friction Mark):
     It is an injury characterized by the removal of the
   superficial epithelial layer of the skin caused by a rub or
   friction against a hard rough surface. Whenever, there is
   forcible contact before friction occurs, there may be
   contusion associated with abrasion.    The shape varies and
   the raw surface exudes blood and lymph which later dries
   and forms a protective covering known as scab or crust.

    Characteristics of Abrasion:
  a. It develops at the precise point of impact of the force
     causing it.
  b. Grossly or with the aid of a had lens the injury
     consists of parallel linear injuries which are in line
     with the direction of the rub or friction causing it.
  c. It may exhibit the pattern of the wounding material.
  d. It is usually ignored by the attending physician for it
     does not require medical treatment but it has far-
     reaching importance in the medico-legal viewpoint.
       (1) Abrasions caused by fingernails may indicate
            struggle or assault and a re usually located in
            the face, neck, forearm and hands.
    (2)   Abrasions   resulting  from   friction   on rough
          surfaces, either intentional or accidental are
          located on bony parts of the body and usually
          associated with contusion or laceration.
     (3) Nature of the abrasion may infer degree of
          pressure, nature of the rubbing object and the
          direction of movement.
e. Unless there is a supervening infection, abrasion heals
   in a short time and leaves no scar.         If the whole
   thickness of the skin is involved, healing may be
   delayed and occasionally with scar formation.

Forms of Abrasion:
a. Linear:
     An abrasion which appears as a single line. It may be
  a straight or curved line. Pinching with the fingernails
  will produce a linear curved abrasion, while sliding the
  point of a needle on the skin will produce a straight
  linear abrasion.
b. Multi-Linear:
     An abrasion which develops when the skin is rubbed on a
  hard rough object thereby producing several linear marks
  parallel to one another.    This is frequently seen among
  victims of vehicular accidents.
c. Confluent:
     An abrasion where the linear marks on the skin are
  almost indistinguishable on account of the severity of
  friction and roughness of the object.
d. Multiple:
   Several abrasions of varying sizes and shapes may be
   found in different parts of the body.

Types of Abrasions:

a. Scratch:
  This is caused by a sharp-pointed object which slides
across the skin, like a pin, thorn or fingernail.       The
injury is always parallel to the direction of slide.    The
commencement and termination are well defined and the depth
depends on the pressure applied.     The fingernail scratch
may be broad at the point of commencement and may terminate
with a tailing.
b. Graze:
  These are usually caused by forcible contact with rough,
hard objects resulting to irregular removal of the skin
surface.   The nature of the injury is dependent upon the
degree of roughness of the object and the amount of
pressure in the course of the sliding. The course will be
indicated by a clean commencement and tags on the end.

c. Impact or Imprint Abrasion (Patterned Abrasion, Stamping
   Abrasion. “Abrasion A La Signature”).
  Those whose pattern and location provides objective
evidence to show cause, nature of the wounding material or
instrument and the manner of assault or death.
  (1) Marks of the grid of the radiator may be imprinted on
      the skin.
  (2) Tire thread marks may be seen on the skin in
      vehicular accidents.
  (3) Muzzle imprint in contact fire gunshot wound of
      entrance.
  (4) Teeth impression mark in skin bites.

d. Press or Friction Abrasion:
  Abrasion caused by pressure accompanied by movement
usually observed in hanging or strangulation.  The spiral
strands of the rope may be reflected on the skin of the
neck.   The lesion may dry up and assume a papyraceous or
parchment like consistency.

Differential Diagnosis:
a. Dermal Erosion – A gradual breakdown or very shallow
    ulceration of the skin which involves only the epidermis
    and heals withour scarring. It may appear in spots and
    with no previous history of friction or sliding.
b. Marks of Insects and Fishes Bites – The skin injury is
    irregular with no vital reaction and usually found on
    angles of the mouth, margins of nose, eyelids and
    forehead.
c. Excoriation of the Skin by Excreta – This condition is
    only found among infants and the skin lesion heals when
    the cause is removed. There is no apparent history of
    rubbing trauma on the affected area.
d. Pressure Sore – Usually found at the back at the region
    of bony prominence.   History of long standing illness,
    bed ridden condition although pressure sore may start as
    a previous area of abrasion.
  Distinction Between Ante-mortem from Post-Mortem Abrasions:


      Point           Ante-mortem          Post-mortem
   Distinction          Abrasion             Abrasion

     Color       Reddish-bronze in     Yellowish and
                 appearance due to     translucent in
                 slight exudation.     appearance.

    Location     Any Area.             Generally occurs
                                       over bony
                                       prominence, such as
                                       elbow, and
                                       attributed to rough
                                       handling of the
                                       cadaver.


     Vital       With intravital       Shows no vital
    reaction     reaction and may      reaction and is
                 show remains of       characterized by a
                 damaged epithelium.   separation of the
                                       epidermis from
                                       complete loss of the
                                       former.


2. Incised Wound (Cut, Slash, slice):
     This is produced by a sharp-edge (cutting) or sharp-
   linear edge of the instrument, like a knife, razor, bolo,
   edge of oyster shell, metal sheet, glass, etc.    It may be
   an impact cut when there is forcible contact of the cutting
   instrument with the body surface, or slice cut when cutting
   injury is due to the pressure accompanied with movement of
   the instrument.
     When   the  wounding   instrument  is   a  heavy  cutting
   instrument, like axe, big bolo, saber, the wound produce is
   called Chopped or Hacked wound.       The injury is quite
   severe, edges may or may not be contused depending on the
   nature of the edge of the instrument used.
    Characteristics of Incised Wound:

  a. Edges are clean-cut and both extremitites are sharp,
     except in areas where the skin is loose or folded at the
     time of infliction.
  b. The wound is straight and may be shelving if inflicted
     with the wounding instrument applied with an acute angle
     of the surface of the body involved.
  c. Usually the wound is shallow near the extremities and
     deeper at the middle portion. However, this finding may
     be modified by the shape of the wounding instrument and
     part of the body involved.
  d. Because the blood vessels involved are clean-cut,
     profuse hemorrhage is invariably a feature.
  e. Gaping is usually present due to the retraction of the
     edges but in its presence and degree of retraction
     depends on the direction of the incised wound with the
     line of cleavage (Langer’s line).
  f. If the incised wound is located in parts of the body
     covered with clothes, the clothing itself will show
     clean-cut of its texture.
  g. In the absence of complication and/or when there is
     deeper involvement present, healing is relatively fast
     and the scar may not or may develop conspicuously.
  h. Incised wound caused by broken edge of glass may be
     irregular and may appear like a punctured or stab wound.
     Fragments of the glass may be removed from the incised
     wound. Examination with the aid of a magnifying lens is
     necessary to determine the presence and removal of
     particles of flakes of glasses in the wound.

            Changes that occur in an Incised Wound:
After 12 hours – Edges are swollen; adherent with blood and
      with leucocyte infiltration.

After 24 hours – Proliferation of the vascular endothelium and
      connective-tissue cells.

After 36-48 hours – Capillary network complete; fibrolasts
      running at right angles to the vessels.

After 3-5 days – Vessels show thickening and obliteration.
      (From: Grawohl’s Legal Medicine by F.E. Camps ed., 3rd
      ed., p. 272).
  Deep incised wound may cause clean-cut fracture of the
bone, severance of blood vessels and nerves or amputation.
Paralysis may develop on account of the severed nerve and
profuse hemorrhage may result to death.        Embolism or
supervening infection may later develop.
  Why a Person Suffers from Incised Wound:
a. As a therapeutic procedure – Pyogenic abscess and cystic
   conditions may be treated by incision.
b. As a consequence of self-defense – The sharp-edged
   instrument may be held by the victim in his attempt to
   avoid the offender to inflict more serious injuries on
   him.
c. Masochist may self-inflict incised wound as a means of
   sexual gratification.
d. Addicts and mental patients may suffer from incised
   wound irrationally.

  Incised Wounds may be Suicidal, Homicidal or Accidental:
a. Suicidal – located in peculiar parts of the body, like
   the neck, flexor surfaces of the extremities (elbow,
   groin, knee), wrist, and accessible to the hand in
   infliction the injury. The most common instrument used
   is the barber’s razor blade with an improvised handle.
   There is usually superficial tentative cut (hesitation
   cuts) and the direction varies with the location and the
   hand (left or right) used in infliction the injuri8es.
   The most common site of suicidal incised wounds are on
   the wrist with involvement of the radial artery and the
   neck.
b. Homicidal – The incised wounds are deep, multiple and
   involve both accessible and non-accessible parts of the
   body to the hands of the victim.       Defense and other
   forms of wounds may be present.     Clothings are always
   involved.
c. Accidental – Multiple incised wound is commonly observed
   on the passengers and driver of vehicular accidents on
   account of the broken windshield and glass parts of
   windows.    Stepping on oyster shell, broken glasses,
   sharp edges of metal sheets are common causes of inside
   wound on the sole of the foot. Those associated in the
   use of kitchen knives in the preparation of food,
   carpenters and handicraft workers who use sharp edged
   instruments are frequent victims of accidental incised
   wounds.
  Distinction Between Suicidal and Homicidal Cut-throat

                           Suicidal                Homicidal
Direction           Oblique,   from   below Usually       horizontal
                    left ear, downwards, below        the     Adam’s
                    across front neck just apple.
                    above Adam’s apple.

Severity            Usually not so deep       Usually deep and may
                    and may only involve      cause involvement of
                    trachea   carotid   and   the    cartilage  and
                    sometimes           the   bones.
                    esophagus is involved.

Superficial         Usually present before Practically absent but
cut                 the   commencement  of may rarely be present
                    deeper wound.          when     the    victim
                                           struggled         when
                                           attacked.

Position of         May be sitting facing Usually       victim   lying
the body            a mirror or standing. on bed        or in    other
wounding                                  place.

Wounding            Firmly        grasped Weapon is absent.
weapon              (Cadaveric spasm) or
                    found   lying  beside
                    victim.

Blood               Blood found in front Blood found at the
distribution        part   of   the  body. back   of  the neck.
                    Hand generally smeared Hands clean.
                    with blood.

Motive              History    of     mental Absence      of      such
                    depression,    domestic, history.
                    financial         social
                    problems,     alcoholism
                    etc.      May      prove
                    suicide.

Previous            May be present.           Always absent.
history        of
self-
destruction
3. Stab Wound:
     Stab wound is produced by the penetration of a sharp-
   pointed and sharp0 edged instrument, like a knife, saber,
   dagger, scissors.     It may involve the skin or mucous
   surface.    If the sharp edge portion of the wounding
   instrument is the first to come in contact with the skin,
   the wound produced is an incised wound, but if the sharp-
   pointed portion first come in contact, then the wound is a
   stab wound. As a general rule, like an incised wound, the
   edges are clean-cut regular and distinct.
     The surface length of a stab wound may reflect the width
   of the wounding instrument.     It may be smaller when the
   wound is not so deep inasmuch as it is only caused by the
   penetration of the tapering portion of the pointed
   instrument. It may be made wider if the withdrawal is not
   on the same direction as when it was introduced or the
   stabbing is accompanied by a slashing movement.       In the
   latter case the presence of an abrasion from the extremity
   of the skin defect is in line with direction of the
   slashing movement.
     The extremities of stab wound may show the nature of the
   instrument used.    A double-bladed weapon may cause the
   production of both extremities sharp.       A single bladed
   instrument may produce as one of its extremities rounded
   and contused. This distinction may not be clearly observed
   if the instrument is quite thin.
     The direction of the surface defect may be useful in the
   determination of the possible relative position of the
   offender and the victim when the wound was inflicted.
     As the whether the wound is a slit-like or paging depends
   on the looseness of the skin and the direction of the wound
   to the line of cleavage (Langer’s line).
     The depth may be influenced by the size and sharpness of
   the instrument, area of the body involved, and the degree
   of force applied.     Involvement of the bones may cause
   clean-cut fracture on it.      A portion of the wounding
   instrument, usually the tapering part, may remain in the
   body.    X-ray examinations may be needed to reveal its
   location.
     Hemorrhage is always the most serious consequence of a
   stab wound. This is due to the severance of blood vessels
   or involvement of bloody organs.
  In the Description of a Stab Wound, the following must be
included:

a. Length of the skin defect – The edges must be coaptated
   before the length is measured. If the abrasion tailing
   is present in one of the extremities, it must not be
   included in the measurement. The length of the tailing
   must be mentioned separately.     The tailing infers the
   direction of withdrawal of the wounding weapon.
b. Condition of the extremities – A sharp extremity may
   infer the sharpness of the edge of the instrument used.
   If both extremities are sharp, it may be inferred that a
   double-bladed weapon was used.
c. Condition of the edges – if the injury is due to one
   stabbing act, the edges are regular and clean-cut.
   However if the wound is caused by several stabbing acts
   (series of thrusts and withdrawal), the edges may be
   serrated or zigzag in appearance.
d. Linear direction of the surface wound – It may be
   running vertically, horizontally, or upward medially or
   laterally.
e. Location of the stab wound – Aside from mentioning the
   region of body where it is located, its exact
   measurement to some anatomical landmarks must be stated.
f. Direction of penetration – This must be tri-dimensional
   (backwards or forwards, upwards or downwards, and
   medially or laterally).
g. Depth of the penetration.
h. Tissue and organs involved.

Stab Wound(s) may be Suicidal, Homicidal or Accidental:
a. Suicidal – Evidences showing that the stab wound is
    suicidal:
     (1) It is located over the vital parts of the body.
     (2) It is usually solitary.      If multiple, they are
          located on one part of the body.
     (3) If located on covered parts of the body, the
          clothings are not involved.
     (4) The stab wound is accessible to the hand of the
          victim.
     (5) The hand of the victim is smeared with blood.
     (6) The wounding weapon is firmly grasped by the hand
          of the victim (cadaveric spasm).
    (7)  If stabbing is accompanied with slashing movement,
         the wound tailing abrasion is seen towards the
         hand inflicting the injury.
    (8) A suicide not may be present.
    (9) There is the presence of a motive for self-
         destruction.
    (10) No disturbance in the death scene, wounding
         instrument is found near the victim.
b. Homicidal – Stabbing with homicidal intent is the most
   common.
  Characteristics:
    (1) Injuries other than stab wound may be present.
    (2) Stab wound may be located in any part of the body.
    (3) Usually there are more than one stab wound.
    (4) There is a motive for the stabbing.      If without
         motive, the offender must be insane or under the
         influence of drugs.
    (5) There is disturbance in the crime scene.
  Medical evidences showing intent of the offender to kill
  the victim:
  a. There are more than one stab wounds.
  b. The stab wounds are located in different parts of the
     body or on parts of the body where vital organs are
     located.
  c. Stab wounds are deep.
  d. Stab wound with serrated or zigzag borders infers
     alternative thrust and withdrawal of the wounding
     weapon to increase internal damages.
  e. Irregular or stellate shape skin defects may be due to
     changing direction of the weapon with the portion of
     the instrument at the level of the skin as the lever.
     In this way a greater area of the level of the skin as
     the lever. In this way a greater area of involvement
     internally will be realized.

     Different measurement of the stab wounds may possibly
  be produced by one weapon if it is tapering towards the
  sharp point.    Withdrawal of the instrument not on the
  same direction as when it was introduced may increase the
  length of the skin defect.
     A sharpened three-cornered file (tres-cantos) when
  used as a stabbing weapon will produce three-cornered
  (extremities) skin defect.
     The most common immediate cause of death is hemorrhage
  particularly when located in the chest or abdomen.
       Accidental stab wounds are quite rare and are usually
    caused by falling against a projection sharp object like
    broken pieces of glass or flattened and pointed iron
    bars.

4. Punctured Wound:
     Punctured wound is the result of a thrust of a sharp
   pointed instrument. The external injury is quite small but
   the depth is to a certain degree. It is commonly produced
   by an icepick, needle, nail, spear, pointed stick, thorn,
   fang of animal and hook,
     The nature of the external injury depends on the
   sharpness and shape of the end of the wounding instrument.
   Contusion of the edges may be present if the end is not so
   sharp. The opening may be round, elliptical, diamond-shape
   or cruciate.     An accurate cross-section nature of the
   wounding object may well be appreciated when there is
   involvement of flat hard parts of the body especially the
   skull.
     External hemorrhage is quite limited although internal
   injuries may be severe. However, direction involvement of
   blood vessels and bloody organs may cause fatal consequence
   unless appropriate medical intervention is applied.
     The Site of the external wound can be easily sealed by
   the   dried   blood,  serum   or   clotted   blood  so  that
   introduction of pathogenic microorganism which does not
   require   the   presence   of   air   in   its   growth  and
   multiplication may find the place favorable, and may
   produce fatal consequences.

    Punctured wound is usually accidental        but   in   rare
  instances it may be homicidal or suicidal.

  Characteristics:
  a. The opening on the skin is very small and may become un-
     noticeable because of clotted blood and elasticity of
     the skin. The wound is much deeper than it is wide.
  b. External hemorrhage is limited although internally it
     may be severe.
  c. Sealing of the external opening will be favorable for
     the growth and multiplication of anaerobic microorganism
     like bacillus tetani.

    Medical evidences that then to show it is Homicidal:
  a. It is multiple and usually located in different parts of
     the body.   It may however be found in certain areas of
     the body.
  b. The wounds are eep.
  c. There are efense wounds on the victim.
  d. There is disturbance in the crime scene (sign of
     struggle).

    Proof to show it is Suicidal:
  a. Located in areas of the body where the vital organs are
     located.
  b. Usually singular but may be multiple but located in one
     area of the body.
  c. Parts of the body involved is accessible to the hand of
     the victim.
  d. Clothings usually is not involved.
  e. Wounding is made by the weapon while the victim is in
     sitting or standing position. There is bleeding towards
     the lower part of boy or clothing.
  f. No disturbance of the crime scene.
  g. Presence of suicide not.
  h. Wounding instrument found near the body of the victim.

    Punctured wound with puncturing instrument “loaded” with
  poison:
  a. Poison dart – cyanide or nicotine.
  b. Fish spines.
  c. Dog bits with hydrophobia virus.
  d. Injection of air and poison as a way of euthanasia.

5. Lacerated Wound (Tear, Rupture, Stretch “Putok”):
     Lacerated wound is a tear of the skin and the underlying
   tissues due to forcible contact with a blunt instrument.
   It may be produce by a hit with a piece of wood, iron bar,
   fist blow, stone, butt of firearm, or other objects without
   sharp objects.
     If the force applied to a tissue is greater than its
   cohesive force and elasticity, the tissue tears and a
   laceration is produced.
     Since the skin is composed of several types of tissues,
   namely epidermis, connective tissue, fat, blood vessels,
   nerves, glandular cells, etc. each having its own breaking
   point, the laceration will be irregular and having strands
   of tissues bridging.    The rupture of continuity may only
extend deeper the stronger layer like    that   of he galea
aponeuritica in case of scalp injury.

  Characteristics:
a. The shape and size of the injury do not correspond to
   the wounding instrument.
b. The tear on the skin is rugged with extremities
   irregular and ill-defined.
c. The injury developed is at the site where the blunt
   force is applied.
d. The borders of the wound are contused and swollen.
e. It is usually developed on the areas of the body where
   the bone is superficially located, like the scalp, malar
   region of the face, front part of the leg, dorsum of the
   foot, etc.
f. Examination with the aid of the hand lens shows bridging
   tissue joining the edges and hair bulbs intact.
g. Bleeding is not extensive because the blood vessels are
   not severed evenly.
h. Healing process is delayed and has more tendency to
   develop scar.

  Classification of Lacerated Wound:
a. Splitting caused by crushing of the skin between two
   hard objects.   This is best seen in laceration of the
   scalp caused by a hit of a blunt instrument, cut eyebrow
   of boxer and laceration of the chin of motorcyclist.
b. Overstretching of the skin. When pressure is applied on
   one side of the bone, the skin over the area will be
   stretched up to a breaking point to cause laceration and
   exposure of the fractured bone. In avulsion, the edges
   of the remaining tissue is that of laceration.
c. Grinding compression – The weight and the grinding
   movement may cause separation of the skin with the
   underlying tissues.
d. Tearing – This may be produced by a semi-sharp-edged
   instrument which causes irregular edges on the wound,
   like hatchet and choppers.

  Lacerated   wounds   may  involve   deeper  tissues like
laceration of the muscles and fracture of bones depending
upon the degree of force applied in causing it.
  It may be homicidal or accidental but rarely it is
suicidal. An insane person may hit his head on a concrete
  wall but when loss of consciousness develops he will not be
  able to continue further his act of self-destruction.

     DISTINCTIONS    Between   an   Incise   Wound   and   a   Lacerated
Wound:

         Incised Wound                   Lacerated Wound
Edges are clean-cut,     regular Edges    are    roughly    cut,
and well-defined.                irregular and ill-defined.

There   is  no  swelling  or There    is    swelling    and
contusion around the incised contusion around the lacerated
wound.                       wound.

Extremities of the wound are Extremities of the wound are
sharp or may be round or ill-defined and irregular.
contused.

Examination by means of a Examination with a magnifying
magnifying lens shows that the lens shows that he hair bulbs
hair bulbs are cut.            are preserved.

Healing is faster.                  Healing is delayed

Scar is linear or spindle- Scar is irregular.
shaped
It is caused by a sharp-edged It   is  caused by               a   blunt
instrument.                   instrument.


GAPING OF WOUND:
  The seapartion of the edges especially in deep wound may be
due to the following:
  1. mechanical stretching or dilatation – The presence of a
     mechanical device on the edges to prevent coaptation will
     cause separation.       The presence of a canula in
     tracheostomy, drain (rubber or gauze in an incised
     abscess, or a retractor during a surgical operation are
     examples of this type of gaping.
  2. Loss of tissue – Separation of the edges of a wound may
     be on account of loss of tissue bridging them. The loss
     of tissue may be due to:
     a. Destruction by pressure, infection, cell lysis, burning
        or chemical reaction.
  b. Avulsion or physical or mechanical stretching resulting
     to separation of a portion of the tissue.
  c. Trimming of the edges.    Debridment of the skin which
     come in contact with the bullet at the gunshot wound of
     entrance and the removal of necrotic material in an
     infected wound may cause separation of the edges.

3. Retraction of the edges – Underneath the skin are dense
   networks of fibrous and elastic connective tissue fibers
   running on the same direction and forming a pattern more
   or less present in all persons.     This pattern of fiber
   arrangement is called cleavage direction or lines of
   cleavage of the skin and their linear representation on
   the skin is called Langer’s Line.         These lines of
   cleavage are different in different parts of the body.

  If an incised wound or stab wound was inflicted wherein
the long axis of the wound is parallel or on the same
direction as the cleavage line of the part of he body
involved, the wound will appear narrow or slit-like because
the edges of the wound will not be subjected to the lateral
pull of the severed connective tissue fibers.
  If the long axis of the wound is perpendicular to or with
an angle with the lines of cleavage, the tendency of the
borders of the wound is to separate on account of the
retraction of the severed fibers.

Practical Ways of Determining How Much of the Skin Surface
is Involved in an Injury or Disease:

  The skin serves as a mechanical protection to the body.
It is punctuated with sensory nerve endings for pain,
temperature and touch. It also acts as a termo-regulator,
storage of water, excretor of sweat and also an organ for
absorption.
  The determination of how much skin involvement is
important in the mode of treatment and prognosis.       Such
determination may be significant in cases of burns,
contusion and dermal manifestation of certain diseases.
  In cases of burns in children and old age persons,
involvement of more than 70% of the body surface are almost
invariably fatal.
  In the estimation as to how much (by percentage) of the
body surface is involved, the rule of nine is used.
    Body surface expressed as percentage using the rule of
  nine:
    Whole of head and neck ………………………………………………… 9%  9%
    Whole of one upper extremity ………………………………… 9%  18%
    Whole of front chest and abdomen ……………………. 18% 18%
    Whole of posterior chest and abdomen ………… 18% 18%
    Whole of one lower extremity (front) …………… 9%  18%
    Whole of one lower extremity (back) ……………… 9%  18%
    Pudental area ………………………………………………………………………… 1%  1%
                            Total ………………………………………… 100%

Factors Responsible for the Severity of Wound:
1. Hemorrhage:
  a. Hemorrhage may influence the severity of wound by:
     (1) Trauma – Destruction of the blood vessel wall or
          increase permeability of its wall due to external
          force.
            Blood constitutes about 1/20 of the body weight of
          an adult. By volume, an average size adult has 5 to
          6 quarts of blood (one quart is 946 cc). A loss of
          one tenth of its volume may not cause any
          significant clinical change.    A loss of one quart
          may cause fainting even if the subject is lying
          down. But a loss of 1/3 to 2/5 of the circulationg
          blood may result to irreversible hypovolemic shock
          and may be fatal.
            The volume of blood lost may be related to the
          rate or space of time a certain volume of blood has
          been shed. The blood loss may be massive but if it
          occurred for a long period of time, the hemopoietic
          organs may be able to replace it thereby preventing
          the development of any untoward effects.
            Males can stand more lost of blood than females.
          Hypertension may cause excessive and rapid bleeding
          from an arterial wound.      Persons suffering from
          hemophilia and other clotting disorders and those
          being treated by anti-coagulants can cause prolonged
          bleeding.
     (2) Hemorrhage may result in an increase in pressure in
          or on the vital organs to affect the normal
          function:
            Intracranial hemorrhage may cause compression of
          the vital centers of the brain.       Hemopericardium
          (pericardial tamponade) may cause embarrassment of
          the contraction of the heart.    Hemorrhage into the
        chest cavity may cause diminution of the respiratory
        output with subsequent anoxia.
  (3)   Hemorrhage may cause mechanical barriers to the
        function of organs:
          Hemorrhage into the tracheo-bronchial lumina can
        cause asphyxia.    Interstitial hemorrhage into the
        muscles may cause disturbance in the contractility.

b. Causes of Hemorrhage:
  (1) Trauma – Destruction of the blood vessel wall or
       increase permeability of its wall due to external
       force.
  (2) Natural Causes:
       (a) Common causes of hemorrhage due to natural
       causes:
            i. Intra-cerebral hemorrhage (apoplexy):
                     The most common blood vessel involved is
                 the lenticulostraite branch of the middl
                 cerebral artery with subsequent bleeding
                 into   the   basal   ganglia   and   adjacent
                 structure.
            ii. Spontaneous subarachnoid hemorrhage:
                     Usually due to rupture or perforation of
                 a secular berry aneurysm, commonly located
                 at the bifurcation of one of the constituent
                 vessels of the circle of Willis or one of
                 its major branches.      This is usually a
                 congenital focal defect of the muscular
                 layer with subsequent over stretching and
                 degeneration of the internal elastic layer
                 of the blood vessel wall.
            iii. Rupture of the arteriosclerotic aneurysm
                 of the aorta:
                     The weakening and thinning of the aortic
                 wall may lead to fusiform or saccular
                 aneurysm usually located at the abdominal
                 portion.
              iv. Rupture of esophageal varices in cases of
                 cirrhosis of the liver and bleeding of
                 peptic ulcer of the stomach and duodenum.
              V.   Pulmonary   hemorrhage   may   be   due  to
                 tuberculosis,      lung      abscess,      or
                 bronchiectasis.     The hemorrhage may be
                 pofused to cause severe anemia or may be
                 small to cause asphyxia.
               vi. Ruptured ectopic pregnancy.
               vii.   Spontaneous    rupture   of   cavernous
                 hemangioma or hepatoma.
               viii. Rupture of the enlarge spleen (malaria,
                 infectious mononucleosis, typhoid fever).
               (Medico-legal   Investigation   of  Death   by
                 Fisher, p. 102)

2. Size of Injury:
     Burns affecting one-third of the body surface of the
  third degree type is usually fatal. Bigger wounds are more
  exposed to infection and other physical conditions of the
  surroundings

3. Organs Involved:
     Trauma on the vital organs of the body are always
  serious. Crushing wounds of the heart, brain or lungs are
  almost fatal.

4. Shock:
     Shock may occur with or without violence. A slight blow
  on the genitalia, slight burns in children or old persons,
  or slight violence on the head or neck may cause severe
  shock. However, violent traumas to healthy, strong persons
  may not produce shock.

5. Foreign Body or Substance Introduced into the Body:
     Incision with an unsterilized scalpel may not be serious
  as the bite of a venomous snake.     A foreign substance or
  body may be toxic by itself or may act as a physical
  irritant.

  The Foreign Body or Substance may be:
  a. Bacterial:
    Tetanus
    Pathogenic microorganism
  b. Viral:
    Hydrophobia
    Hepatitis
  c. Foreign body:
    Bullet
    Glass fragments
    Shrapnel
    Gauze or rubber drain
  d. Chemical:
  Cyanide
  Nicotine
e. Toxin:
  (1) Snake Venom – Snake bite       is characterized as two
       punctured wounds at the       center of the reddened
       affected area.   The venom    is injected through its
       fangs which is connected to   the poison gland.

        Snake Venom Toxicity will Depend on:
        (a) Potency of venom injected.
        (b) The amount of venom injected by the fang depends
            on the season of the year and the length of time
            the snake has eaten. If a snake has just killed
            his prey, the toxic content of its bite is
            smaller.
        (c) Size of the patient.
        (d) The immediate treatment instituted.

      Snake Venoms are of Two Principal Classes:
      (a)   Neurotoxic   –   It  primarily    paralyzes   the
    respiratory   and   cardiac   center   of    the   brain.
    Absorption of the venom may cause nausea, vomiting,
    ascending paralysis, coma, convulsion, and cardiac and
    respiratory arrest.
      (b) Hematoxic – Which affects particularly the
    blood. The manifestations are pain and swelling of the
    affected area, intravascular hemolysis, abdominal pain,
    nausea, vomiting, petechial hemorrhage on the gum,
    pulmonary and cardiac edema.

      Emergency Treatment may be:
      (a) Incision of the wound to promote more external
    hemorrhage to drain the venom.
      (b) Tourniquette above the site of the wound.
      (c) Placing ice on the bite site.
      (d)     Sucking the wound to drain venom with the
    mouth.
      (e) Administration of anti-snake venom serum.

  (2)   Scorpion Venom – The venom of the scorpion has
        neurotoxic, hemolytic and hemorrhagic effect.     A
        scorpion sting produces only one punctured wound on
        the center of a reddened area.    The main symptoms
        are pain, edema and reddening.
    (3)   Coelenterate Sting (Jellyfish) – The tentacles
          penetrate into the skin and cause explosion of the
          nematocyst and liberation of the venom.        The
          symptoms are extreme pain of the affected area,
          urticarial rash, abdominal pain, dilated pupils,
          paleness and labored breathing.

6. Absence of Medical or Surgical Intervention:
     A wound may not be fatal but on account of the neglect or
   ignorance in its management, it may become serious and
   fatal.

FATAL EFFECT OF WOUNDS:
1. Wound may be Directly Fatal by Reason of:
  a. Hemorrhage:
     An incised wound at the lateral aspect of the neck
  invoving the carotid artery without surgical intervention
  is fatal due to hemorrhage. While wounds in some areas of
  the body where big blood vessels are not present and the
  retraction of tissues are strong, death will not be a
  direct consequence due to hemorrhage in the absence of
  complication that may set in.
  b. Mechanical Injuries on the Vital Organs:
     A blow on the head may not necessarily produce external
  lesions but    may   produce  severe   meningeal  hemorrhage
  producing compression of the brain.    A punctured wound of
  the heart, even though how small, may produce death on
  account of the tamponade of the heart.
  c. Shock:
     This is the disturbance of the balance of fluid in the
  body capable of producing delayed or immediate death.

2. Wound may be Indirectly Fatal by Reason of:
  a. Secondary Hemorrhage Following Sepsis:
     A wound because of its nature and location is not capable
  of producing severe hemorrhage, but on account of infection
  that sets in, deeper tissues are involved including big
  blood vessels thereby producing severe hemorrhage.

  b. Specific Infection:
    Pathogenic microorganisms may develop and multiply in the
  wound causing septicemia, bacteremia, or toxemia. Tetanus,
  gas gangrene infection are common in open wounds.

  c. Scarring Effect:
    Chronic gonorrheal infection may cause stricture of the
  urethra.   Stricture of the esophagus may follow ingestion
  of irritant poison. Keloid formation in burns may not only
  cause deformity but disturbance of the normal respiration
  of locomotion.

  d. Secondary Shock:
  Nature of Death Due to Secondary Causes:
    A person may have recovered from    the immediate effects
  of the trauma or violence, but may later die of its
  secondary effects or changes.
    These changes may be classified as follows:
  1. Changes whose natural sequence are direct and obvious.

    Example: Septicemia,   tetanus    or   complications   arising
  from the wounds.

  2. Changes producing separate pathological lesions which in
  turn proves to be fatal.

    Example: Operation performed on a patient to ligate
  bleeding vessel inside the abdominal cavity with reasonable
  skill and with due diligence but as a result of which
  peritonitis developed and caused death of the patient.

  3. Changes where a definite        pathological   condition   was
  present before the injury.

    Example: a person suffering from tumor or cyst and was
  stabbed by someone.   The stab is not capable of producing
  death ordinarily.   The person may die of the pathological
  condition and the accused is liable for his death.

  4. Changes where a definite pathological condition of
  totally different nature arises after the wounding and the
  consequential sequence is doubtful

    Example: Tuberculosis meningitis that develops following
  a blow on the head.


COMPLICATIONS OF TRAUMA OR INJURY:
1. Shock:
     Shock is the disturbance of fluid balance resulting to
  peripheral deficiency which is manifested by the decreased
  volume of blood, reduced volume of flow, hemoconcentration
  and renal deficiency.    It is clinically characterized by
  severe depression of the nervous system.        Three major
  factors operate in the production of shock and all are
  likely to be associated together as the condition develops.

  a. Injury to the receptive nervous system.
  b. Anoxemia – Reduction of effective volume         of   oxygen
     carrying capacity of the blood.
  c.   Endothelial   damage,    thus   increasing      capillary
     permeability.

Kinds of Shock:
a. Primary shock:
     This is caused by immediate nerve impulse set up at the
  injured area which are conveyed to the central nervous
  system.   The impulse may also whelm the vital centers in
  the medulla thereby shock develops within a short time due
  to vasomotor collapse. If the reaction is not intense, the
  patient may live longer or may recover completely form the
  effect of the shock.

b. Delayed or Secondary Shock:
     Patient shows signs of general collapse which develop
  sometimes after the      infliction of     injury.     It   is
  characterized   by   a   low   blood    pressure,    subnormal
  temperature,   cold   clammy    perspiration,    muscular   in
  coordination, rapid and shallow respiration. The shock may
  be severe to produce death or the patient may recover
  completely form its effects.

2. Hemorrhage:
     Hemorahge is the extravasation or loss of blood from the
cirucoulation brought about by wounds in the cardio-vascular
system. The degree and nature of hemorrhage depends upon the
size, kind and location of the blood vessel cut.

       Kinds of Hemorrhage:
       a. Primary Hemorrhage:
             its is the bleeding which occurs immediately after
           the traumatic injury of the blood vessel.
       b. Secondary Hemorrhage:
             This occurs not immediately after the infliction of
           the injury but sometime thereafter on or near the
           injured area.
3. Infection:
     Infection is the appearance, growth and development of
microorganisms at the site of injury:

    How Injury or Trauma Acquires Infections:
         a. From the instrument or substance which produces
         the injury.

         b. From the organs involved in the trauma applied.
         A bullet wound may involve the intestine and causes
         its contents to spill out in the peritoneal cavity
         causing peritonitis.

         c. As an indirect effect of the injury which creates
         a local area of diminished resistance causing the
         invasion and multiplication of microorganisms.

         d.   Injury  may   depress   the  general   vitality,
         especially among the aged and the young children and
         makes the patient succumb to terminal disease.
         e. Deliberate introduction of microorganisms at the
         site of injury.

4. Embolism:
     This is a condition in which foreign matters are
  introduced in the blood stream causing sudden block to the
  blood flow in the finer arterioles and capillaries.

    The most Common Emboli in the Blood Stream are:
  a. Fat Embolus:
    (1) Causes of Fat Embolus:
         (a) By injection of oily substance into the
  circulation.
         (b) By injury of the adipose tissue which forces fat
  into the circulation.

  b. Air Embolism:
    (1) Causes of Air Embolism:
         (a) Gaping incised wound of the jugular vein.
         (b) Injection of soapsuds or air into pregnant
  uterus for the purpose of tubal insuflation or criminal
  abortion.
         (c) Injection of air into the urinary bladder for
  radiological study.
         (d) Insulfation of the other non-potent tubes or
  hollow organs.
         (e) Injection of air under pressure into the nasal
  sinus after a therapeutic lavage.

HEALING OF WOUNDS:
1. Power of the Human Tissue to Regenerate:
     Regeneration is the replacement of destroyed tissue by
  newly formed similar tissue.    The more highly specialized
  the tissue, the less is the capacity for regeneration.
  Capacity for regeneration decreases as age increases. The
  state of nutrition of the individual affect the capacity or
  regeneration.

    The Following Regenerates Rapidly:
    a. Connective tissues.
    b. Blood forming tissues.
    c. Surface epithelium of the skin.

    Those Having No Power or Limited Capacity to Regenerate:
    a. Highly specialized glandular epithelium.
    b. Smooth muscles.
    c. Neurons of the central nervous system.
          Small clean-cut wound is covered with lymph in 36
  hours.
          The edges adhere in two days and the wound heals on
  the 7th day leaving a linear scar.
          Larger incised wound shows swelling of the edges 8
  to 12 hours.     Blood-stained serum is present in 2 days
  which afterwards become seropurulent on the 3rd day, lasting
  in state from 4 to 5 days. Small red granulation forms in
  12 to 15 days and the epithelium grows from the edges.
  Scar develops later.
    In cases wherein a definite infection is present, the
  time of healing is very indefinite, however, at the advent
  of antibiotic and sulfa drugs, healing is somewhat
  accelerated.

    The time of Healing of Wounds is        Dependent   on   the
  following:
    a. Vascularity
    b. Age of the Person
    c. Degree of Rest or Immobilization
    d. Nature of the Injury
2. Kinds of Healing of Wound
  a. Healing by Primary (First) Intention:
     This type of healing takes place when there is minimal
  tissue loss, more approximation of the edges and without
  significant bacterial contamination.
     Histologically, within 24 hours following injury, there
  is an acute neutrophilic response, the epidermal layer
  thickened on account of the mitotic activities of the basal
  cells.   Scab will be formed on the surface on account of
  the dehydration of the surface clot.
     After three days, the neutrophils will be replaced by the
  macrophages and fibroblasts will appear in the epithelial
  layer.    Collagen fibers will bridge the raw area and
  epithelial proliferation will then cover the raw area.
  Newly formed capillaries sprout on all sides to from the
  vascular network and collagen fibrils become abundant and
  differentiated surface cells begin to proliferate to cover
  the exposed area.
     Complete return of the area to its normal state may
  appear after a lapse of one month with or without the
  formation of a scar.

  b. Healing by Secondary Intention:
    This takes place when the injury causes a more extensive
  loss of cells and tissues.       Inevitably, there is more
  necrotic debris and exudates that has to be removed.
  Inflammatory reaction is more intense as compared with
  healing by primary intention.     Granulation tissue growth
  bears all the responsibility for its closure.       Healing
  process may result to the production of a large scar and
  greater loss of skin appendages such as hair, sweat and
  sebaceous glands, and slower reparative process.

  c. Aberrated Healing Process:
    In some instances healing process deviates from the
  normal way on normal individual. Healing may result to:
    (1) Formation of Exuberant Granulation or “Proud Flesh” –
  Excessive amount of granulation tissue may protrude and
  prevent closing of the wound.     This can be remedied by
  excision or cautery.

    (2) Keloid Formation – There is abnormal amount of
  collagen formed in the connective tissue thus prodcing a
  large bulging tumorous scar, commonly known as keloid. It
  has been claimed to be hereditary.
  (3) Stricture – This is due to the contraction of the
fibrous tissue of the scar formed.

  (4) Fistula or Sinus Formation – A fistula is a
communication between an inner cavity and the outside.
Sinus is a tract of infection traversing the inner part o
the body.    Unless causal factor, usually infection or
foreign body is removed, the condition may remain for a
long time.

				
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