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intimate clots may be absent in cases where large vessels are cut and the blood spurts free from the wound; as in the cases of infants killed by cutting the neck through at one stroke. The hemorrhage is also slight in punctured and in lacerated wounds, and in those inflicted by firearms. Similarly, wounds which have followed previous marked loss of blood, as after parturition, or possibly second to wounds of the heart or aorta, or in cases of shock, as after traumatism to the central nervous system, may be associated with comparatively slight hemorrhage. Clots that are formed in layers (laminated clots), showing that after the first portion of the clot was formed there was further bleeding, are also characteristic of hemorrhage during life.

243b. Healing. After the immediate results of the injury are passed, the wound tends to heal either by what is called primary intention, as is seen in the cases of aseptic wounds, in which the edges of the wound are kept in contact, and in which there is no appreciable quantity of pus formed. In these, healing takes place in the course of a week or ten days to such an extent that there is little chance of the wounds breaking open under ordinary circumstances. If the edges of the wounds are not kept in contact, or have become infected, the edges of the wound gape and the wound heals by granulation or secondary intention. In these cases, which include the majority of nonsurgical wounds, the edges of the wound remain. bloody for eight to ten hours, and then there is a swelling of the edges, due to the inflammation. For thirty-six to forty-eight hours there is a serous secretion that, on the third day, becomes purulent. On the fourth or fifth day suppuration is fully established, and this purulent discharge continues for from five to eight days, then a fibrous layer appears at the edge of the wound: first soft, due to the young epithelium, then becoming firmer, and hardening into the cicatrix or scar. Healing is complete in twelve to fifteen days, providing that the vitality of the body is good, and there has been no marked loss of substance. The process is prolonged in cases where there has been a distinct loss of tissue, where the vitality of the individual is below normal, and where there remains any foreign material in the wound, or where the edges of the wound are kept in motion, and not allowed to remain as much in contact as they should. 243c. Scar. The scar which follows the healing of a wound is distinctly red at first, but after an indefinite time, measured by months or years, becomes white, hard, smooth, shining, less sensitive

VOL. III. MED. JUR.-14.

than at first, and gradually decreases in size (except in the peculiar abnormal condition of scar hypertrophy, known as keloid). The scar does not disappear with time, though it does become less prominent. Taylor quotes58 the case of a man whose identity hung upon the presence of a wen on the hand. As neither wen nor scar could be found the identity of the man was not allowed.

244. Ante-mortem subcutaneous wounds; ecchymoses.-In the subcutaneous wounds and, also, to some extent, in the open wounds, there is a distinct discoloration of the skin, due to the effusion of the blood under the skin, and the changes which take place in that extravasation. Such an effusion of blood, with the associated discoloration of the skin, is called an ecchymosis or suggillation. If the extravasation be deeply seated, the external discoloration will not occur immediately, but may be delayed even for several days, and may not even correspond to the spot at which the injury was received, but will be found over that part to which the effused blood has gravitated. Indeed, the cutaneous discoloration may not appear till after death. Thus, in a person who died thirty-five hours after having received a kick from a horse, rupturing the bladder, there was no ecchymosis at the seat of the blow until after death. Likewise the amount of blood extravasated, except it lie immediately beneath the skin, is not proportionate to the amount of the external injury, since in many of those cases of violent death in which a heavily loaded vehicle has passed over the body, or a great weight has fallen upon it, there has been, externally, no discoloration whatever, or such a slight change in color that the vast amount of internal disorganization and hemor rhage could hardly be suspected.

Among numerous instances of this description are those cited from the experience of Casper and Dr. Ellis.50

The color of ecchymotic spots60 varies according to the time that has elapsed since they were produced. At first they are purple, and pass through various shades to black. Then through violet, green, and yellow, fading to the color of the skin, when they disappear. In general the discoloration appears within twelve hours after the injury, and sometimes immediately afterwards. The violet color is seen on the third day and the green from the fifth to the sixth day. The spot completely disappears in healthy persons on the

57Vaccination scars and scars in children in general increase in size as the size of the child grows. See Brit. Med. Jour., 1873, II., 774; and Paget's Lectures on Pathology, I., 49.

"Taylor, Med. Juris., p. 319.
See § 207, supra.

eo See & 207 et seq., supra.

tenth to the twelfth day. The changes are more rapid in the young than in the old, and depend, also, upon the force and extent of the blow.

244a. Ecchymoses from natural causes.- In addition to these discolorations due to injury, mention must also be made, by way of caution, of the ecchymoses from natural causes. It can hardly be necessary to caution the physician against the possibility of mistaking the ecchymoses observed in certain diseases for the effects of violence. The morbid states of the system in which they are seen have so many other striking peculiarities during life and after death, that it would hardly be paidonable for a professional inquirer to overlook or misinterpret them. Thus, in scurvy, purpura hemorrhagica, and petechial typhus, the shape, size, and distribution of the spots in various parts of the body, the absence of swelling or other indications of violence, and the pathological changes in the mucous membrane of the mouth and the intestines, together with the fluidity of the blood, will afford more than sufficient reasons for rejecting all suspicion of violence.

245. Physiological actions before death.-As bearing also upon the time of the infliction of the wounds that cause death must be mentioned two other sets of evidence: One, the actions of the person after receiving the wound; the other, showing what physiological actions have shortly preceded death.

Of the physiological actions that are significant in this connection, the filling of the stomach and the process of digestion are probably the most important. If simple fluids alone have been taken in, they will not be found in the stomach, as they are passed on at once into the intestines. If food has been taken in it will be found to be in some stage of digestion. If only a small quantity has been taken it may also have been passed on into the intestines but the larger masses of food do not begin to be passed on till one or two hours after digestion; and the stomach, as a rule, is not emptied till four or five hours after the meal. Any exact estimation of the time since the food was taken is impossible. We can merely state that digestion has been going on for a long time, or that it has just begun. In all probability digestion that has begun before death continues after death, even though there be no additional secretion of gastric juice.

The condition of the bladder may also be significant. If the person is in sound health and the bladder contains no urine it is evident that the bladder has just been emptied. The filling of the bladder is at the rate of about two ounces in an hour; but considera

ble variations from this rate are frequent, depending on the activity of the person, the action of the skin, and many other factors. Moreover, it does not follow that, if the bladder is not empty, the person has not just urinated, for the bladder may be but partially emptied, either by choice or because, in certain conditions, it cannot be completely emptied in the usual way.

The condition of the bowels is not so significant, for frequently the emptying of the rectum at defecation is incomplete, and, again, the filling is a much slower process than that of filling the bladder.

The condition of the uterus, whether or not recently emptied of the products of conception, or whether menstruation has just passed, has been considered in the sections treating of the diagnosis of previ ous pregnancy.61

246. Acts after receiving a mortal wound. The question as to whether a certain act can have been done after receiving a given wound is always one that must be decided upon the merits of each particular case. In speaking of multiple wounds as the cause of death,62 there have already been quoted a number of instances where, after receiving wounds that are usually considered mortal, other wounds have been inflicted by the person himself. That injuries of the brain, even with destruction of brain substance, are not neces sarily promptly fatal, or even fatal at all, is shown by the many cases of recovery from brain injury. Perhaps the most famous of these cases is that of Phineas P. Gage, known as the Tamping Iron case,63 where the man not only was not killed although the iron was driven through the skull, but he did not even lose consciousness. Likewise wounds of the heart are not necessarily fatal on the spot or even at all. Many such instances of delayed death after non-perforating wounds of the heart are now on record, and several instances of recovery, even after perforating wounds of the heart.

Vibert describes the case of a man who, after being shot in the chest, threw a lamp at his adversary. The lamp started a fire; and, to extinguish the fire, the wounded man fetched a pail of water from the court yard (the man's rooms were on the ground floor). When

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the fire was extinguished, the man lay down on the bed and died. Vibert performed the autopsy, and found that the left ventricle of the heart had been perforated by the revolver bullet. The bullet was found in the pericardium. The ball had probably remained for a while embedded in the heart muscle, preventing hemorrhage. Otherwise it is hard to understand how the man could have lived so long after the injury, and have done so much.

247. Post-mortem wounds in general.- Wounds that have been inflicted after death naturally show no signs of what is called the vital reaction, i.e., the processes of healing or of suppuration. There is no lymph exudate, pus exudate, or tumefaction of the edges of the wound. The blood which comes out of the blood vessels does so according to the laws of gravity or decomposition, not those of physiology, and therefore there is no spurting of blood from the vessels, and no active bleeding. The quantity of blood that escapes will be distinctly less than that from the wound in the living person. The blood does not so intimately infiltrate the tissues in the edges of the wound and stain them, and the clots of the blood are not so closely adherent to the wound; in fact the blood may not clot at all. The edges of the wound do not gape as widely (unless the wound is inflicted immediately after death), and the deeper tissues do not protrude.

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The distinction between wounds inflicted just before or immediately after death is often extremely difficult, if not impossible, especially when death results rapidly by hemorrhage from a large artery or vein. In these cases if a wound is made upon the dead body near to that which occasioned death, and the second wound be made soon after death, it will be impossible to distinguish the one from the other by any characteristic sign. Thus, in a case reported by Casper, in which a woman was instantly killed by a table knife that was thrust through the arch of the aorta, entering the chest between the first and second ribs, the wound presented sharp and smooth edges, without a trace of either fluid or dried blood; in fact it was exactly like a wound made upon the dead body. A case is very easily supposable, in which a wound in the region of the heart might be designedly inflicted after death; as for instance, to divert attention from the real cause of death, which may have been due to poisoning. Although no distinction may be possible from an inspection of the external wound, the absence of internal hemorrhage will, in such an instance, betray the period at which the wound was made.

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