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.