SCHOOL OF CRIMINAL JUSTICE AND PUBLIC SAFETY

General Luna Road, Baguio City Philippines 2600

REVIEW NOTES in
LEGAL MEDICINE

UB Criminology Board Review 2020

JAIME RODRIGO L. LEAL, MD

Ford Foundation International Fellow
in Forensic Science
University of Western Australia

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 TABLE OF CONTENTS

A. Introduction 3

B. Cause, Manner & Mechanism of Death 7

C. Time of Death & Postmortem Changes 12

D. Forensic Autopsy 17

E. Death Due to Fire 26

F. Deaths by Asphyxia 29

G. Drowning and Immersion in Water 34

H. Medico-Legal Aspect of Physical Injuries 38

I. The Pathology of Torture 53

J. Medico-Legal Aspect of Gunshot Wounds 61

K. Alcoholism and Drug Dependence 66

L. Poisoning and Forensic Toxicology

M. Pregnancy and Abortion

N. Medico-Legal Aspect of Sexual Violence

O. Child Abuse and Neglect

REVIEW NOTES in LEGAL MEDICINE

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 JAIME RODRIGO L LEAL, MD

A. INTRODUCTION

FORENSIC MEDICINE

Brief History
 In Worldwide Scale:
• IMHOTEP (2980 B.C.) - Chief Physician and Architect of the First Pyramid, that time,
was the first recorded report of murder trial written on clay tablet;
• HIPPOCRATES (460-355 B.C.) - Discussed the lethality of wounds;
• ARISTOTLE (384-322 B.C.) - Fixed animation of fetus at 40th day after conception;
• ANTISTIUS (100-44 B.C.) - The First Police Surgeon or Forensic Pathologist, he
performed the Autopsy on the body of Julius Caesar (23 Stab wounds);
• AMBROISE PARE (1575) - Considered Legal Medicine as a separate discipline in
his book;
• PAULUS ZACCHIAS (1584-1659) - A Papal Physician, regarded as the “Father of
Forensic Medicine”, published ”Questiones Medico- legales”;
• SEVERIN PINEAU (1598) - Worked on Virginity and Defloration;
• ORFILA (1787-1853) - Introduced chemical methods in Toxicology, "Founder of
Modern Toxicology”
 In the Philippines
• DR. RAFAEL GENARD Y MAS (1858) - A Spanish Physician, Published the first
medical texbook that includes medico-legal practice entitled “Manual de Medicina
Domestica”;
• IN 1871- teaching of Legal Medicine as an academic subject, UST;
• On March 31, 1876 - “Medico Titulares” was created by virtue of Royal Decree No. 188;
• In 1894, Rules regulating the services of “Medico Titular Y Forenses” was
published;
• In 1895 - Medico-legal Laboratory was established in the City of Manila;
• In 1908 - [Link] School incorporated the teaching of Legal Medicine, one hour a
week to 5th year med. Student;
• In 1919 - University of the Philippines created the Department of Legal Medicine and
Ethics, with Dr. Sixto de los Angeles as Chief;
• On Dec. 10, 1937, Commonwealth Act No. 181, creation of the Division of
Investigation under DOJ, Dr. Gregorion T. Lantin, Medico-legal Section Chief;
• On July 4, 1945, after the liberation of City of Manila, the US Army created the
Criminal Investigation Laboratory with Dr. Mariano Lara as Chief Medical Examiner;
• On June 19, 1947, R.A No. 157 - Creation of the NBI, Dr. Enrique V. De Los Santos as
Chief of MLD;
• Creation of the Medico-legal Division in the Criminal Laboratory Branch of the G-2 of
the PC;
• On June 15, 1954, R.A No. 1982 - creation of rural health units;
• June 18, 1949, R.A. No. 1934 - creation of the office of Medical Examiners and
Criminal Investigation laboratory under the Police Dept. of the City of Manila;
• On December 23, 1975, P.D. 856, Code of Sanitation, was promulgated

Forensic
 The word "forensic" comes from the Latin adjective “forensis” meaning public debate or forum.
Anything belonging to the court of law. The word forensic is used now to describe the debates
that occur in courts of law and is even more broadly defined as any matter that is "pertaining to
the law." (Evans, Wells, 1999)

Forensic Medicine/Legal Medicine:

 A branch of medicine that deals with the application of medical science for the purposes of law
and in the administration of justice (Solis);
 Deals with the interaction of medical science with the law (Simpson);
 The application of medical knowledge to the administration of law and to the furthering of justice
and, in addition, the legal relations of the medical man (Gradwohl);
 Refers to the practice of medicine to elucidate legal matters. It deals with the interaction of
medical science with the law.
 Medical aspects of law and medical jurisprudence; the medicine of the forum; or the law of
courts.

Anatomical Pathology

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  A medical specialty concerned with the diagnosis of disease based on the examination
of organs and tissues.
 A medical specialty that deals with the diagnosis of disease based on the macroscopic,
microscopic, biochemical, immunologic and molecular examination of organs and tissues.

Clinical Pathology
 A medical specialty that deals with laboratory examinations of samples removed from the body
(i.e. urinalysis, serology, etc.).

Forensic Pathology
 Branch of medicine which investigates death.

Clinical Forensic Medicine

 Branch of medicine which involves an interaction between the law, the judiciary and police
involving living persons.

Death Investigation
 Deals with the postmortem investigation of sudden, unexpected, suspicious or violent deaths.

Forensic Taphonomy
 Forensic taphonomy has been defined simply as the study of what happens to a human body after
death (Dirkmaat & Cabo, 2016).
 The other primary assessment is that of postmortem interval (PMI), and how long the body has
been at the location.
 Since most of what happens to the body (and evidence) at an outdoor setting is the result of
alteration or modification by natural agents such as plants, animals, soils, environment, gravity,
and many others, the recognition and documentation of the specific role played by each of these
natural agents is critical to understanding and explaining why evidence ends up where it ends up,
or why it looks as it looks at present. This allows forensic taphonomy experts to focus on unusual
patterns of dispersal or removal of evidence and remains that can provide indications of human
intervention (e.g., moving/removing remains to hide evidence).
 Providing hypotheses of the role that humans play in altering a scene or evidence after the death
event therefore represents one of two major assessments provided by a forensic taphonomic
investigation.
 Even though the scene, body, and evidence have been disturbed to some degree at all outdoor
scenes, it must be emphasized that much information remains and we will be able to present a
evidence-based scenario of what transpired at the scene based on proper documentation and
collection of that information. The forensic taphonomic approach to the processing and
understanding of the outdoor scene thus represents an important paradigm shift from the old-
school thinking that the outdoor scene is almost totally devoid of usable forensic information
(especially with respect to reconstructing past events) to the active scientific pursuit of
uncovering the fine details of past events hidden in the seemingly complex outdoor scene
(Dirkmaat & Cabo, 2016).

Forensic Thanatology
 Forensic Thanatology investigates the mechanisms and forensic aspects related to death, like
body changes that accompany death and the post-mortem period. Forensic Thanatology is known
as the scientific study of death.

Role of Medico-Legal Officer / Forensic Pathologist / Medical Examiner / Coroner

 Conducts Autopsies
 Conducts examination of victims of physical injuries
 Examination of victims of sexual abuse like rape
 Examination of arrested persons/suspects for detention or for release
 Conducts Exhumations
 Examines skeletal remains
 Serological Examinations
 Histopathological Examinations
 DNA Analysis
 Attend Court duties when summoned
 Conducts lectures/trainings/seminars in the field of Forensic Medicine
 Performs Crime Scene Investigation as a member of the SOCO Team during death investigation
(If a member of the PNP)
 Conducts Disaster Victim Identification (DVI)

Deaths Reportable to the Medico-Legal Officer / Forensic Pathologist / Medical Examiner

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  Violent deaths
 Accidents
 Deaths under suspicious or unusual circumstances
 Sudden and unexpected deaths
 Unattended deaths - Deaths without medical attendance or anyone dying with no physician to
complete the death certificate
 Deaths in custody → Deaths under police/military/NBI/PDEA custody or those in jail
 Deaths from disaster (disaster victim identification)
 Poisoning
 Diseases constituting a threat to public health
 Deaths related to employment
 Deaths associated with therapeutic or diagnostic procedures → Iatrogenic deaths
 Unlawful termination of pregnancy (complications of illegal abortion)
 Bodies to be cremated
 Unclaimed cadavers
 SIDS (sudden infant death syndrome) and alleged child abuse cases
 Alleged suicides

NOTE: Things Are Not Always What They Seem To Be

“What appears as suicide could be murder. What seems like murder could be culpable homicide.
What looks like culpable homicide could be an accident. What is apparently an accident could
turn out to be a case of suicide. So many possibilities, so many hidden stories. Things are not
always what they seem to be.” - (Leal, Philippine Daily Inquirer, August 2007)

Different Aspects of Forensic Medicine

 Death Investigation
 Crime Scene Investigation
 Examination of Skeletal Remains (Forensic Anthropology)
 Exhumation/Excavation of Skeletonized Remains (Forensic Archaeology)
 Forensic Taphonomy
 Forensic Thanatology
 Human Identification (including Disaster Victim Identification)
 Physical Injuries
 Pathology of Torture
 Gender-Based Violence
 Sexual Crimes
 Physical Examinations of suspects for detention /release
 Pregnancy and Delivery
 Abortion, Birth and Infanticide
 Paternity and Filiations
 Impotency and Sterility
 Insanity and Mental Deficiency
 Drug Dependency and Alcoholism
 Poisoning and Forensic Toxicology
 Forensic DNA Analysis
 Forensic Entomology
 Humanitarian Forensics

Medical Evidence
 Evidence - is the means sanctioned by the Rules of Court, of ascertaining in the judicial
proceeding the truth respecting a matter of fact.
 Medical Evidence – means employed to prove a fact is medical in nature;

Types of Medical Evidence:

A. Autoptic or Real – evidence made known or address to the senses of the court;

B. Testimonial – a physician may be commanded to appear in court to give his testimony; He

may be presented as an Ordinary or an Expert Witness;
C. Experimental – the witness may be allowed by the court to confirm his allegations or as a
corroborated proof to an opinion he previously stated;
D. Documentary
- Document - is an instrument on which is recorded by means of letters, figures, or marks intended
to be used for the purpose of recording that matter which may be evidentially used.
- Autopsy Report, Death Certificate, DNA Analysis Report, etc

E. Physical Evidence - these are articles and materials which are found in connection with the

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 investigation and which aid in establishing the identity of the perpetrator or the circumstances
under which the crime was committed, or in general assist in the prosecution of a criminal;

Types:
• Corpus Delicti Evidence - objects or substances which may be a part of the body of the
crime;
• Associative Evidence - evidence which link a suspect to a crime; clues like weapons, tools,
garments, fingerprints etc.;
• Tracing Evidence - evidence which may assist the investigator in locating the suspect.
Aircraft or ship manifest, physicians clinical record of medical treatment, bloodstains.

Methods of Preserving Medical Evidence:

 Photographs, audio/video, microfilm, photostat, xerox, voice tracings, CCTVs;
 Sketching - Rough Sketch or Finished Sketch;
 Description - putting into words the person or thing to be preserved;
 Manikin method - miniature model of a scene or of human body;
 Preservation in the mind of the witness - recital of his recollection.

Special Methods
 Whole human body - Embalming
 Soft tissues - 10% Formalin
 Blood– refrigeration, sealed bottle container, addition of chemical preservatives
 Stains – drying, placing in sealed container
 Poison – sealed container

B. CAUSE, MANNER AND MECHANISM OF DEATH

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

DEATH
 It is the termination of life. The cessation of all the vital functions of the body, without the
possibility of resuscitation. It is irreversible loss of the properties of living matter.

 Death maybe:
A. Brain Death - death occurs when there is irreversible coma, absence of electrical brain
activity and complete cessation of the vital functions without possibility of resuscitation.
B. Cardio-Respiratory Death - death occurs when there is continuous and persistent cessation
of heart action and respiration.

Kinds of Death
1. Somatic Death or Clinical Death - state of the body in which there is complete, persistent and
continuous cessation of the vital functions of the brain, heart and lungs which maintain life and
health; ultimen mariens.
2. Molecular or Cellular Death - refers to death of individual cells (3-6 hours later);
3. “Apparent Death” or “State of Suspended Animation” - Not really death but merely a transient
loss of consciousness or temporary cessation of the vital functions of the body on account of
disease, external stimulus or other forms of influence; May arise especially in hysteria, uremia,
catalepsy and electric shock, drowning, still-birth.

CAUSE OF DEATH (COD)

 Is the disease, injury or combination of disease and injury responsible for the fatality
 Any injury or disease that produces a physiological derangement in the body that results in the
individual dying
 The COD is the physician’s best opinion, with or without an autopsy. The physician list this on the
death certificate.
 The ff are causes of death: GSW of the head, SW of the chest, lung carcinoma, coronary
atherosclerosis

Underlying or Proximate Cause of Death

 Is that which, in a natural and continuous sequence unbroken by any efficient intervening cause,
produces the end result and without which the end result would not have occurred
 The underlying COD should be an etiologically-specific disease or injury that triggered the chain
of events leading to death and without which death would not have occurred
 Temporally, the most remote condition

Antecedent Cause of Death (Intervening or Intermediate)

 A disease or condition that occurred as a result of the underlying cause of death but was not the
final complication or immediate cause of death.

Immediate Cause of Death

 Is the final complication resulting from the underlying cause of death, occurring closest to the time
of death and directly causing death.
 A complication of the underlying cause interposed between proximate causation and fatal result
 There may be one or more immediate causes, and they may occur over a brief or prolonged
interval, but none absolves the underlying cause of its ultimate responsibility.
 Not etiologically-specific

NOTE: Please don’t write “cardiac arrest” or “cardiopulmonary arrest” as the cause of death. We already
knew that… These are not causes of death and, to a degree, are not even mechanisms of death. Yet,
clinicians continue to list these diagnoses on the death certificate and some government organizations
accept them as causes of death.

NOTE: An immediate or antecedent cause of death may not be identifiable in all cases. Therefore, an
underlying cause of death can stand alone.

MECHANISM OF DEATH

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  Are the alterations of physiology and biochemistry whereby the causes exert their lethal effect
 Physiological derangement produced by the COD that results in death
 Hemorrhage, sepsis, cardiac arrhythmias, congestive heart failure, asphyxia
 Never etiologically-specific
 Once again, this is the physician’s best opinion
 For purposes of death certification, the “immediate cause of death” and the “mechanism of death”
are interchangeable, but neither should be used as a substitute for an etiologically-specific
underlying cause of death in other than unique circumstances.
Note: Hemopericardium with cardiac tamponade (mechanism) due to ruptured infarct of myocardium
(immediate cause) due to arteriosclerotic heart disease (underlying cause)

MANNER OF DEATH
 The manner of death is for the lawyers and homicide investigators.
 It refers to the circumstances that led to death.
 It is an explanation of how the cause of death came about, either natural or violent
 Accidents, suicide, homicide and therapeutic complication are not causes of death; they are
manners of death
 “Manner of death” reflects an opinion based on available information: Activity just before death,
recent symptoms, previous medical records, scene investigation and other pertinent information
help the physician determine the manner of death
 Natural deaths – those caused exclusively (100%) by disease
 Violent deaths – Accidents, homicide or suicide

 The current 5-item classification system used in the Philippines are:

 Natural
 Accident
 Suicide
 Homicide
 Undetermined

 Internationally, there are two more concepts added in the classification of the “manner of death”.
These are:
 Therapeutic Classification
 Unclassified

 Natural

 Natural deaths are defined as those caused exclusively (100%) by disease or birth defect
 Therefore, if an injury (physical or chemical) contributes to death, no matter how minor
the contribution, the fatality cannot be classified natural
 NOTE: “Unnatural death” means homicide, suicide , accident

 Homicide

 At the very least, someone else did something wrong that set in motion a process that
resulted in the person’s death

 Suicide

 At the very least, the person did something that resulted in his or her death, and this was
more or less what the person intended

 Accident

 These deaths resulted from some kind of unplanned, unintended injury

 Therapeutic Complication

 The manner of death in fatalities that arise from predictable complications of diagnostic
and therapeutic procedures
 Inasmuch as deaths from predictable complications of diagnostic and therapeutic
procedures are not caused exclusively by disease, we are uncomfortable with classifying
them as “natural”.

 The term is nonjudgmental and non-accusatory

 This is not intended to be a synonym for medical malpractice
Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1
  Benefit → Consistency of classification and the avoidance of arbitrariness in selecting
natural or accident for difficult cases
 Initiated in Cuyahoga County (metropolitan Cleveland), Ohio in the 1960’s
 NOTE: In the Philippines, deaths due to medical error is classified as ACCIDENT
 But in my opinion, it seems unduly inflammatory to classify as “accident” those instances
in which predictable consequences or complications of appropriate therapy contribute to
death
 An additional benefit of using THERAPEUTIC COMPLICATION as a manner of death is
consistency of classification and the avoidance of arbitrariness in selecting natural or
accident for difficult cases.

 Undetermined

 When the circumstances and findings leave reasonable doubt about the classification
 When there is insufficient information about the circumstances surrounding the death to
make a ruling, or in some instances when the COD is unknown
 Classifying the manner of death as “undetermined” is made by an honest doctor who
knows he can’t really tell
 This isn’t a bad category for normal-looking, 10-year-old skeletons found in the desert,
most cases of “sudden infant death syndrome” with no proper death-scene work-up,
substance abusers or organic-brain-syndrome people found at the bottom of the stairs (“did
they fall or were they thrown?”), etc.
 NOTE: The COD might be unknown but the circumstances surrounding the death of the
decedent might point to homicide, suicide, accident or natural as the manner of death
 Example: Skeletonized remains of a young adult male without evidence of trauma

 Unclassified

 Those deaths where the all available facts related to the death investigation fail to allow for
a reasonable classification using the traditional designated manners.
 There is generally ample information available from the death investigation and there is
unlikely to be additional information that could be made available to influence manner
determination.
 In this instance, one is able to reasonably argue for multiple possible manners.
 This differs from “undetermined” in that one is not able to obtain sufficient information
from all aspects of the death investigation (due to multiple possible limitations) to
formulate a reasonable opinion with respect to manner.

NOTE: If I wrongfully bite you, and you go to the hospital and is rightfully treated with penicillin, and you
die of anaphylaxis (allergic reaction) as a result of the penicillin injection, your death is probably
homicide.

NOTE: If a person shoots himself, and spends six months in the hospital recovering, and dies of a
pulmonary embolus from being at bed rest for so long, it’s still a suicide.

NOTE: If a person dies of Pseudomonas sepsis (generalized infection) while undergoing a bone marrow
transplant for leukemia, manner of death is therapeutic complication.

NOTE: Physician-assisted suicide will be part (though hopefully still an infrequent part, thanks to more
humane terminal care in general) of mainstream medicine when you’re in practice. These deaths (along
with discreet acts of euthanasia) will be registered as natural deaths.

NOTE: If you find me dead in front of the TV, with a half-eaten cheeseburger dripping on my trouser leg,
stinking of tobacco, and I have a 3-vessel coronary disease and have been complaining of angina (chest
pain), and you don’t know something amiss or see anything curious on examining my body, go ahead and
sign me out as “natural, cause of death is atherosclerotic coronary artery disease”. Yeah, a few tricky
homicides probably get missed.

MODE OF DEATH is an unpopular word for what was apparent without a physician’s full work-up
(“shock”, “coma”, “pulmonary edema”, “sudden cardiac death”, perhaps even “pneumonia”.

SPECIAL DEATHS

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

A. Judicial Death - execution of death sentences.

Methods of Judicial Death:

1. Death by Electrocution – alternating current of 1,500 volts.
2. Death by Hanging
3. Death by Musketry – Firing squad
4. Death by Gas Chamber – Carbon monoxide, cyanide.
Other methods of capital punishment:
 Beheading
 Crucifixion
 Beating
 Cutting Asunder
 Precipitation from height
 Destruction by wild beast
 Flaying
 Impaling
 Stoning
 Strangling
 Smothering
 Drowning

B. Euthanasia
 Or “Mercy Killing” is the deliberate and painless acceleration of death of a person usually
suffering from an incurable and distressing disease.
 Types of Euthanasia:
• Active Euthanasia – intentional or deliberate application of the means to shorten the life
of a person.
• Passive Euthanasia – there is absence of application of the means to accelerate death,
but the natural course of the disease is allowed to have its way to extinguish the life of a
person.
Types of Passive Euthanasia
1. Orthothanasia – an incurably ill person is allowed to die a natural death
without the application of any operation or treatment procedure;
2. Dysthanasia – there is an attempt to extend the life span of a person by the use
of extraordinary treatment without which the patient would have died earlier.

C. Suicide
 Or self-destruction is usually the unfortunate consequence of mental illness and social
disorganization.
 Common Methods of Committing Suicide:
• Drugs and Poison
• Hanging
• Firearm
• Jumping from height
• Drowning
• Cutting and stabbing
• Suffocation by plastic bag
• Electrocution

Psychological Classification of Suicide

1. First degree – deliberate, planned, pre- meditated, self-murder;

2. Second degree – impulsive, unplanned, under great provocation;
3. Third degree – accidental suicide; voluntary self-injury
4. Suicide under circumstances which suggest lack of capacity for intention; psychotic, due to
effects of drugs or alcohol
5. Self-destruction due to self–negligence; reckless driving, chronic alcoholism
6. Justifiable suicide – self-destructive action of a person with a terminal illness

D. Starvation

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  Or Inanition, is the deprivation of a regular and constant supply of food and water which is
necessary to normal health of a person.
 Types of Starvation:
• Acute Starvation - when the necessary food has been suddenly and completely withheld
from a person
• Chronic Starvation - there is gradual or deficient supply of food.

NOTE: The human body without food loses 1/24th of its weight daily and a loss of 40% of the weight
results to death. Without food and water survival is up to 10 days, with water – 50-60 days

UNEXPECTED AND SUDDEN DEATH FROM NATURAL CAUSES

 Where a natural death is very rapid, virtually instantaneous → cause is cardio-vascular
 If a person collapses and is clinically dead when someone nearby runs to assist him, cause is
cardiac arrest. This type of collapse is the one which may respond best to cardiopulmonary
resuscitation.
 Extra-cardiac causes are rarely so rapidly fatal, although death in minutes is common.

Causes of Sudden and Unexpected Death: Cardiovascular System

 Coronary Artery Disease

- Coronary Insufficiency
- Complications of Atheroma
- Coronary Thrombus
- Myocardial Infarction
- Lesions in the cardiac conducting system
- Ruptured Myocardial Infarct
- Myocardial Fibrosis
- Papillary Muscle Rupture
- Hypertensive Heart Disease
 Aortic Stenosis
 Senile Myocardial Infarction
 Primary Myocardial Disease
 Diseases of the Arteries
Atheromatous Aneurysm
Dissecting Aneurysm of the Aorta
Syphylitic Aneurysms

 Intracranial Vascular Lesions

- Ruptured Berry Aneurysms
- Cerebral Hemmorhage
- Cerebral Thrombosis

 Respiratory System
- Pulmonary Embolism
- Massive Hemoptysis from cavitating Pulmonary Tuberculosis or from malignant tumor
- Chest Infections (viral influenza)

 Gastro-intestinal Sysytem
- Bleeding Gastric/duodenal peptic ulcer
- Mesenteric Thrombosis and Embolism
- Perforation of Peptic ulcer
- Intestinal Gangrene
- Torsion due to Peritoneal Adhesions Other aspects of Forensic Medicine
- Pregnancy - is the state of a woman who has within her body a growing product of
conception.
 Duration- 270-280 days

C. TIME OF DEATH (TOD) AND POSTMORTEM CHANGES

TOD determination – important in both criminal and civil cases

In criminal cases:

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 1. It can set the time of murder
2. Eliminate or suggest suspects
3. Confirm or disprove an alibi
Civil cases:
1. May determine who inherits property
2. Whether an insurance policy was in force
TOD determination
 Time of death is also known as “postmortem interval”
 No single marker to tell TOD
 A number of factors are or have been used in determining the time of death: rigor mortis, livor
mortis, body temperature, degree of decomposition, chemical changes in vitreous fluid, stomach
contents, insect activity and scene markers (includes uncollected mails or newspapers, whether the
lights are on or off, a TV schedule opened to a time and date, how the individual is dressed, when
the neighbors last saw the individual or observed a change in his habits, etc.)
 At best, just an ESTIMATE!
 There are no clear-cut methods for establishing the time of death, unless of course there was
someone present at the scene at the time of death
 Difficult, imprecise or inaccurate
 Often not possible
 The longer the PMI (i.e. the time between death and the attempt to determine TOD). the less
precise the estimate of the interval

POSTMORTEM CHANGES
1. Rigor Mortis

 Changes in the muscle after death

Primary Flaccidity Rigor Mortis Secondary Flaccidity

 Postmortem rigidity
 Stiffening of death
 A chemical reaction that causes rigidity in the muscle groups or stiffening of the body after death
due to the disappearance or depletion of adenosine triphosphate (ATP) from the muscle
 Rigor mortis occurs because metabolic activity continues in the muscles after death. ATP is needed
to maintain the relaxation of the muscles. So long as the store of glycogen in the muscle is
sufficient to permit the regeneration of ATP by the formation of lactic acid, the muscle remains
lax.
 When its store of glycogen is exhausted, the concentration of ATP falls, and the muscle becomes
rigid because of the formation of abnormal links between actin and myosin. The rigor mortis
persists until these links are destroyed by advancing autolysis.
 In addition to the conventional teaching that this is due to depletion of ATP with subsequent
binding of actin to myosin, I suspect this is die at least in part to the influx of calcium through
injured membranes.
 Usually appears 2-4 hrs after death
 Fully develops in 6-12 hrs
 Muscles return to a near-flaccid state in approximately 24-36 hours
 Secondary flaccidity coincides with the onset of decomposition → Rigor mortis disappears with
decomposition
 Rigor mortis involves all the muscles at the same time and at the same rate.
 It is said to appear first in the smaller muscles and then gradually spread to large muscle groups
 Small muscles first (fingers, face, jaw); later in the larger muscles
 Classical presentation of rigor mortis in its order of appearance: jaw → upper extremities → lower
extremities
 Cold and/or freezing will delay the onset of rigor mortis as well as prolong its presence
 The onset of rigor mortis is accelerated – due to exertion, epileptic seizure, fever or high body
temperature, some poisons (eg. strychnine)
 Very temperature-dependent in its degree and duration
 May indicate whether a body has been moved after death → If a body is moved to another location
while in full rigor, it will remain in its original position until rigor passes
Conditions Simulating Rigor Mortis

1. Heat Stiffening - exposure to temperature above 75‟ (placed in boiling water or burned to
death), coagulate the muscle proteins causing the muscles to be rigid. Body assumes a

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 “pugilistic attitude” (lower and upper extremities flexed, and hands clenched.
2. Cold Stiffening - stiffening is due to the solidification of fats when exposed to freezing
temperature.
3. Cadaveric Spasm or Instantaneous Rigor - the instantaneous rigidity of the muscles which
occurs at the moment of death due to extreme nervous tension, exhaustion, and injury to
the nervous system or to the chest.

 “Cadaveric spasm” is instantaneous rigor mortis → seen when death occurs with considerable
muscular exertion (gripping something, like a branch in someone falling down a mountain) and/or
major motor seizure and /or emotion (battlefield, torture).
 Instantaneous rigor may also be found following ingestion of cyanide but usually it is generalized
and symmetrical. Strychnine may produce the same but rigidity appears after ingestion.

RIGOR MORTIS CADAVERIC SPASM

TIME OF APPEARANCE 2 to 4 hrs after death Immediately after death

MUSCLE INVOLVED All muscles; symmetrical Only certain group of muscles;

asymmetrical

OCCURRENCE Natural phenomenon May or may not appear

MEDICO-LEGAL Approximate time of death Useful to determine the nature of

SIGNIFICANCE crime, e.g. weapon, hair, pieces of
clothing, weeds on the palms of
hands

2. Livor Mortis

 Color of death
 Also known as postmortem lividity (PML) / cadaveric lividity / postmortem hypostasis /
postmortem sugillation
 Setting of blood in the dependent regions of the body following death
 Reddish purple to purple coloration in the dependent areas of the body due to accumulation of
blood in the small vessels secondary to gravity → Uniform in distribution
 Gravitational pooling of blood
 Kinds:
a. Hypostatic lividity
 Blood still fluid in form inside blood vessels for 6-8 hours
 Changes as position of the body change (PML is UNFIXED)
b. Diffusion lividity
 Coagulated inside blood vessels or diffused into tissues
 Change in position will not change its location (PML is FIXED)

 Intravascular; not bruising (extravascular)

 Cherry red to pinkish color in deaths due to CO → due to carboxyhemoglobin
 Also cherry red in bodies exposed to cold temperatures (hypothermia) and in deaths due to
cyanide
 Evident within 30 minutes to 2 hrs. after death → Intensifies over time
 Becomes “fixed” in approximately 8-12 hrs → If a body is moved before that times, the livor
mortis will shift
 Blanching of livor mortis → significant for estimate of TOD
 The investigator can press on the skin in the dependent regions and, if the skin blanches the death
has probably occurred less than 12 hours ago → This phenomenon is known as hypostatic lividity
 This becomes fixed or patterned after a while (due to diffusion lividity), and can tell you if the
body has been moved.
 “Tardieu spots”
 Petechiae in dependent areas due to rupture of small vessels
 Takes 18-24 hrs. and indicates that decomposition is fast approaching
 This phenomenon is more common in asphyxial or slow deaths
 Not very important in determining the TOD → Yes, Virginia! PML is not a reliable indicator of
the time of death.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  More important in determining if the body has been moved → That is, PML is a better indicator of
whether the body has been moved since death.
 Does not occur in areas where external pressure has closed off blood vessels in the skin and
capillaries
 Livor mortis is occasionally misinterpreted as bruising by people unfamiliar with this
phenomenon. Application of pressure to an area of bruising will not cause blanching. An incision
into an area of contusion or bruising shows diffuse hemorrhage into the soft tissue. In contrast, an
incision into an area of livor mortis reveals the blood to be confined to vessels without blood in
the soft tissue.
 Livor mortis also occurs internally, with settling of blood in the dependent aspects of an organ.
This is most obvious in the lungs.
 Forensic significance:
a. It is one of the signs of death.
b. It may determine whether the position of the body has been changed after its appearance in
the body.
c. The color of lividity may indicate the cause of death.
NOTE: Livor mortis usually has a cherry red to pinkish color in deaths due to carbon
monoxide (CO), exposure to cold temperatures and in deaths due to cyanide poisoning.
This is due to carboxyhemoglobin.
NOTE: In asphyxia, the lividity is dark.
Hydrocyanic acid → bright red
Phosphorus → dark brown
d. It may determine how long a person has been dead.
e. It gives us an idea as to the time of death.
3. Body Temperature
 Algor Mortis: The cooling of the body after death
 Body cools following death at approximately 1.5F or 1C per hour → under normal conditions
and assuming the body’s temperature at death is 98.6F or 37C
 Body T changes after death to ambient T
 TOD calculation
 Lag phase of 3-4 hrs.
 Falls at 1 per hour
 If the body is fairly warm during the time of investigation, a core temperature can be obtained
by inserting a thermometer in the liver or rectum. This temperature is applied to the Moritz’s
formula and the approximate TOD or PMI is determined
 Moritz’s formula: 98.6 minus rectal T divided by 1.5 equals the number of hrs. since death or
37C minus rectal T
 Two assumptions that may not be true:
1. That body T at death was normal
2. That body cooling follows a uniform, consistent, repetitive pattern such that one can project
what the prior body temperature was and will be
 There are many variables, of course, including: the illness of the decedent, the amount of clothes
being worn, obesity, the room or outside temperature depending on the location of death
 Wide variability, i.e. body T varies from the site where it was taken (oral or rectal, brain or liver),
from individual to individual, by time of day, by the activity of the individual, and by the health of
the individual
 In temperate climate, there is minimal or no temperature loss during the first hour
4. Decomposition
 Involves two processes: autolysis and putrefaction
 Autolysis
 Aseptic tissue breakdown due to action of enzymes (prominent in pancreas)
 Auto-digestive changes after death

 Putrefaction
 Tissue breakdown due to bacteria
 Breakdown of complex proteins into simpler components, associated with the evolution of
foul-smelling gases due to bacteria

 Lag phase of 3-4 hrs.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  1st sign is greenish color of lower quadrant of abdomen
 Greenish-black color of face and neck
 Swelling of the body
 Protruded eyes and tongue
 Purging of body fluids

 Other changes, such as insect activity

 Maybe accelerated (obesity, heavy clothing, sepsis, hot environment, insect, animal) or slowed
(tight clothing, cold environment, refrigeration, embalming)
 Skeletonization may take a week or two, months or years→ dependent on environmental
temperature and the presence or absence of scavengers

a) Wet decomposition
 Putrefaction + autolysis
 Producing gas (fermentation)
 Emergence of decompositional fluid (purge fluid) from nose and mouth
 Color change (Hb breakdown)
 Features:
 Greenish skin discoloration→ lower quadrants of abdomen
 Greenish-black discoloration→ face and neck
 Green / black coloration along vessels (“marbling”)
 Bloating (60-72 hrs.)
 Hair loss
 Skin slippage, with fluid vesicles
 Purging of fluid from orifices

b) Mummification (dry decomposition)

 Dehydration of the whole body which results in the shrinking and preservation of the body.
 It may be natural or artificial kind of mummification
 Dry and warm environment→ in bodies exposed in strong sunlight
 Features:
 Brown/Black coloration
 Dry, wrinkled
 Leathery appearance

c) Maceration
 Softening of the tissues when in fluid medium in the absence of microorganism, ex. Death of
fetus in utero
 Intra-uterine decomposition (no bacteria)
 An aseptic autolytic process
d) Adipocere Formation or Saponification
 Condition wherein fatty tissues are transformed into soft brownish-white substance known as
adipocere (waxy material, rancid or moldy in odor, floats in water, dissolves in ether or
alcohol).
 Conversion to body fat to waxy, soap-like solid (composed of oleic, palmitic and stearic
acids) → Rare
 A variation of putrefaction
 Seen in bodies immersed in water or in damp, warm environments→ i.e. Requires high
humidity and/or water
 Body well preserved
 Facial features well preserved (identification)
 Needs a moist, cool environment which is oxygen depleted
 Body tissue is pale, waxy with a musty smell
 Adipocere is resistant to bacteriologic and chemical degredation

5. K+ level in vitreous
 As the time since death increases, so does K+ concentration in the vitreous
 Sturner & Gantner proposed a formula to estimate TOD based on vitreous K+ level → Invalid!
 Vitreous K+ level determined by the degree and rapidity of decomposition rather than the time
interval from death→ anything that hastens decomposition ↑K+ level of vitreous

6. Stomach contents

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  “PMI can be approximated by the state of digestion of the stomach contents. It normally takes at
least a couple of hours for foods to pass from the stomach to the small intestines; a meal still
largely in the stomach implies death shortly after eating, while an empty or nearly-empty stomach
suggests a longer time period between eating and death” – J. Batten
 Radioisotopic studies to determine time of gastric emptying, however, have revealed great
variations
 from meal to meal,
 from person to person, and
 day to day in the same person
 In one study where the subjects were given a self-selected meal that includes meats, seafood,
vegetables, soups, salads, pastries, desserts and fluids, and allowed to eat as much as they wanted
and to stop when they felt full, the gastric emptying time varied from 60 to 338 minutes with an
average of 277 +/- 44 minutes – JG Moore, et al
 “Gastric emptying of their solids or liquids is subject to relatively wide differences in the same and
different individuals even if the same meal is ingested” – Brophy et al
 Half emptying time for liquids = 178 ± 22 min
 Half emptying time for solids = 277 ± 44 min
 Larger meals → Longer emptying time
 Gastric emptying is closely correlated with the total number of calories in the meal than with meal
weight
 Meals of the same weight and different components were emptied at different rates
7. Environment factors

 Non-scientific markers
 Though “unscientific”, it is often more accurate than determinations made by “scientific”
means
 Pile of newspaper in front of the house
 Uncollected mails
 Dated receipt or slips of paper in the deceased’s pockets
 ATM/Credit card transaction
 Scientific markers
 Insect activity
 Decomposition

Common Postmortem Artefacts

 “Tache noire”
 Postmortem drying of sclera
 Brown to black band of discolored sclera where eyes are partly open & exposed to air
 Postmortem “pancreatitis”
 Stomach postmortem autolysis

TOD Calculation

 Rigor mortis
 Livor mortis
 “Body cooling”
 Postmortem changes
 K+ level in vitreous
 Stomach contents
 Insect activity
 Circumstantial evidence

ENDNOTES:
 The investigator can use these tools in combination and arrive at an approximate time window of
death. The existing methods for determining time of death are inexact; without a witness, time of
death can only be estimated.
 The longer the postmortem interval, that is, the time between death and the attempt to determine
the time of death, the less precise is the estimate of the interval.
 A newborn with near-zero internal body flora, and some other folks, may not putrefy.
 Things happen very differently in bodies deposited in the water. There are frequent surprises.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

D. FORENSIC AUTOPSY

Learning Objectives:
During this session each student will:
1. Know the different types of medico-legal death investigation systems.
2. Know the objectives of medico-legal death investigation.
3. Understand the significance of the medico-legal autopsy in death investigations.
4. Understand the different aspects involved in the autopsy of a dead body.
The purposes and administrative aspects of death investigation are dealt with in the lecture notes on Death
Investigation. Here, the practical aspects will be considered.

MEDICO-LEGAL DEATH INVESTIGATION

Three Main Types of Medico-Legal Death Investigation Systems

A. Coroner System
B. Medical Examiner System
C. Police-led System

Characteristics Coroner Medical Examiner Police-Led

Usually legal Forensic Pathologist or Police Officer
Head of System background Pathologist
(sometimes medical) Always a medical
professional
Staffing/Resources Often external experts Internal experts Internal or external
experts
Cooperate with police Cooperate with police All MLDI functions
on MLDI on MLDI within the police
Powers of Has right to enter crime Has right to enter crime Broad powers of
Investigation scene scene investigation
Inquest powers No inquest power
Can subpoena documents Authorized by law (for Can request for medical
(medical records) medical records) records (but can’t compel
Can summon witnesses No inquest powers hospital admin)
Location within Often judiciary Within health sector Law enforcement
Government
Jurisdiction Often include public Often include public Less likely to include
interest deaths interest deaths public interest deaths
Perceived as Perceived as
Independence independent (esp. deaths independent (esp. deaths
in custody) in custody)

NOTE: There is no “best” system.

GOAL: Answer 5 questions
 Fully
 Accurately
 Independently
 Impartially

Purpose of Medico-Legal Death Investigation

The objectives of medico-legal death investigation are to answer the following questions:
1. Who died? → Identity of the decedent, if known
2. Where did the death occur? → Place of death
3. When did the death occur? → Time of death
4. What was the cause of death? → What physical disease, physical condition, or physical injury
[or combination of] caused death?
5. What was the manner of death? → Natural, Homicide, Suicide, Accident, Therapeutic
Complication, Undetermined or Unclassified

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

Remember:
 Medico-legal death investigation does not establish criminal or civil liability.
 MLDI is distinct and independent from criminal investigation
 Objectives of Criminal Investigation:
 Determine if a crime has been committed;
 Obtain evidence to identify the person responsible for the crime; and
 Provide the best possible evidence to the prosecutor or the court.

 Autopsy is only one aspect of medico-legal death investigation.

 Body, History and Crime Scene are equally important → Diagnostic triangle of MLDI).
 Each of the three aspects of the medico-legal death investigation process are equally important
(like a three legged stool, which will fall over if one leg is removed or even shortened!)
1. Crime Scene:
 Attendance by police officers, CID, family doctor, police surgeon, forensic pathologist,
forensic scientists.
 The aim is to collect the maximum of information with the minimum of disturbance.
 Potential for professional conflicts.
 Photography, videos, trace evidence.
2. History:

 Social - from relatives, friends, police

 Medical - from physician, hospital notes; often indicates the likely cause of death
 Psychiatric - from psychiatrist, hospital notes; may indicate possibility of suicide.
3. Medico-Legal Autopsy:
The medico-legal autopsy differs from the hospital autopsy in two major respects:
 Purpose: What happened? To Who, When, Where, Why, and How.
 Technique: The external examination assumes much greater importance, special dissection
techniques and examinations, evidential materials, report formulation or commentary.

Three Steps in Medico-Legal Death Investigation

1. Circumstances
- Statement of Witnesses
- History
- The scene of incident
- Medical records
2. Examination of the Body
- Body Search
- Autopsy
3. Laboratory Tests
- Histopath
- Ballistics
- Toxicology
- DNA profiling
- Gunshot residue analysis

INVESTIGATING DEATHS IN CUSTODY

 “Deaths in custody” refers to those deaths in which the circumstances of the death place the
decedent in either direct or indirect contact with law enforcement such as incarceration,
apprehension, and pursuit.
 Other terms in the literature for deaths in custody include, but are not limited to, police
shootings, arrest-related deaths, apprehension deaths, legal intervention deaths, and in-custody
deaths. (NAME, 2017)

Legal Custody: Any person who is:

 Under the physical control and restraint of law enforcement, correctional officer, special police
officer, or authorized employee or agent of a secure facility, youth residential facility, including
 Under arrest

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  In the process of being arrested
 Detained, or
 In the process of being detained.
 Incarcerated or committed to any jail, any contract facility, correctional facility, including work
release, or mental hospital, or
 Juvenilely committed to a secure facility, including youth residential facility.

Phases of Deaths in Custody

Deaths in custody can be separated in four distinct phases:
 Pre-Custody: Deaths that occur during apprehension or pursuit.
 In-Custody: Deaths that occur during restraint, transport or booking/intake/holding.
 Incarceration: Deaths that occur while in prison or jail.
 Judicial Execution: Deaths purposely conducted by the criminal justice system.
NOTE: There may be overlap of these phases, therefore the medical examiner must carefully
review all records prior to making this distinction.

FORENSIC AUTOPSY
 Forensic autopsy is an important tool in the investigation of deaths. It is a comprehensive study of
a dead body performed by a trained physician employing recognized dissection procedures and
techniques. It may include removal of tissues and body fluids for further laboratory examination.
(Solis)
 The term “autopsy” means “to see for oneself” and is synonymous with the terms
“postmortem”, “postmortem examination”, and “necropsy”.
 In modern practice, an autopsy is usually taken to indicate a detailed examination which
includes the external examination of the corpse, and the evisceration and subsequent careful
dissection of the contents of the cranial, thoracic, abdominal, and pelvic cavities.

 Postmortem examination refers to an external examination of a dead body without incision being
made.

Kinds of Autopsy:

1. Hospital or Clinical Autopsy

 Consent from relatives: Spouse, descendants of the nearest degree, ascendants of nearest
degree, brothers and sisters (decreasing order)
 Purpose:
 Determine cause of death
 Provide clinical correlation of diagnosis and clinical symptoms
 Determine the effectiveness of therapy
 Study natural course of the disease process
 Educating students and physicians

2. Medico-Legal Autopsy
 Dead body belongs to the state for protection of public interest
 All that needs to be turned over to the next of kin would be burial of the deceased

The objectives of the medico-legal autopsy are manifold, serving to:

1. Determine the cause, manner and mechanism of death
2. Determine the time of death
3. To establish identity of the decedent
4. Documents injuries and all other autopsy findings
5. Determine the extent of injuries sustained by the victim that cause the death
6. Determine if there was foul play involved in suspicious deaths or alleged suicides
7. In violent deaths, it is mandatory for an autopsy to be performed to rule out foul play
8. Find out whether there is any contributing factor to the causation of death.
9. Recover, identify and preserve evidentiary material.
10. Provide interpretation and correlation of facts and reconstruct the circumstances surrounding the
death.
11. Separate natural death from unnatural death for protection of the innocent in suspicious deaths.
12. Provide a factual, objective medical report for prosecution and defense.
13. To provide expert testimony if the case goes to trial

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 14. For purposes of insurance claims.
Handling of Human Remains

 Document first - photos, sketches

 Minimal handling of the body
 Protect the hands - use paper bag (especially for Rape with Homicide cases)
 Wrap the body in white clean sheet/ cadaver bag
 Encircle the injection sites
 In the hospital, don’t remove tubes
 Document the location, number of injuries
 Medical records/ procedures done must accompany the body
 In the morgue, must log the case, include who brought the body, what time, who received it
 Don’t wash the body! Examining the clothing is an important part of autopsy.
 Photo before and after cleaning the body. Re-examine after cleaning.
 X-ray: GSW, domestic violence and child abuse cases
 Take photo with ruler and case number of each injury.
 Internal examination - autopsy proper
 Lab test: Toxicology, Histology, Microbiology, Serology, Ballistics
 Collect DNA samples
 Lastly, fingerprint and palm print

AUTOPSY AUTHORITY: Legal Perspective

Presidential Decree 856, Code of Sanitation

 In the Philippines, the only law governing the conduct of an autopsy upon the body of the deceased
lies with PD 856 – The Code on Sanitation
 Section 91. Burial Requirements: “If the person who issues a death certificate has a reason to
believe or suspect that the cause of death was due to violence or crime, he shall notify immediately
the local authorities concerned. In this case the deceased shall not be buried until a permission is
obtained from the provincial or city fiscal…”
 Section 95. Autopsy and Dissection of Remains: The autopsy and dissection of remains are subject
to the following requirements:
a. Persons who are Authorized to Perform Autopsies

1. Health Officers:
a) PHO/CHO
b) MHO
2. Medical Officers of Law Enforcement Agencies:
a) PNP Crime Lab MELO
b) NBI MELO
c) CHR
3. Members of the Medical Staff of Accredited hospitals
a) Hospital pathologists
b. Autopsies shall be performed in the following cases:
1. Whenever required by special laws;
2. Upon order of competent court, a mayor and a provincial or city fiscal;
3. Upon written request of police authorities;
4. Whenever the Solicitor General, Provincial or city fiscal as authorized by existing laws,
shall deem it necessary to disinter and take possession of the remains for examination
to determine the cause of death;
5. Whenever the nearest kin shall request in writing the authorities concerned in order to
ascertain the cause of death.

THE COMPLETE MEDICO-LEGAL AUTOPSY INVOLVES THE FOLLOWING STEPS:

A. EXAMINATION OF THE CRIME SCENE (CSI)

At the PNP Crime Lab, the medico-legal officer (MLO) responds to the crime scene at the request of the
homicide investigator to ascertain the essential facts concerning the circumstances of death and make a
preliminary examination of the dead body  body is identified  external evidence of trauma documented
and evaluated  exam of parameters to determine time of death.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

If the MLO who will conduct the autopsy was not present during the crime scene investigation, the
homicide detective who conducted the preliminary investigation and was present during the scene of crime
operation (SOCO) should attend the autopsy and provide the MLO with the following:
1. Description of the circumstances of death.
2. Description of the scene. (Complete notes taken at the scene include a description of the
deceased, color of any blood, injuries and wounds observed, etc.)
3. Condition of the body when first discovered (rigor mortis, lividity, temperature, putrefaction,
decomposition, maggots or other insect activity, etc.).
4. Statements taken at scene. (Digital photos can be taken in addition to the usual police photos
since they are ready for viewing immediately and can be available at autopsy.)
5. Police photographs taken at scene. (Polaroid photos can be taken in addition to the usual police
photos since they are ready for viewing immediately and can be available at autopsy.)
6. Diagram and sketches of the crime scene.
7. Any weapons or articles found at the scene which relate to the death (knives, guns, other
weapons, notes, papers, drugs, etc.).
8. Any questions formulated during the initial phase of the investigation. These may be evaluated
in the light of the medical evidence found by the pathologist.

B. IDENTIFICATION OF THE BODY

The body must be identified to the Medico-Legal Officer / Forensic Pathologist as the decedent for whom
autopsy authority has been given. Identification in 2 doctor autopsies is performed in front of the 2 doctors
performing the autopsy.

Methods of Human Identification

 Identification refers to the determination of the individuality of a person.

 In the prosecution of the criminal offense, the identity of the offender and that of the victim must
be established, otherwise it will be a ground for the dismissal of the charge or acquittal of the
accused.
Law of Multiplicity of Evidence in Identification
 The greater the number of points of similarities and dissimilarities of two persons compared, the
greater is the probability for the conclusion to be correct

Importance of Identification

1. In the prosecution of a criminal offense, the identity of the offender and that of the victim must
be established;
2. In facilitating settlement of the estate, retirement, insurance, and other social benefits;
3. It resolves the anxiety of the next of kin, other relatives, and fiends;
4. It may be needed in some transactions like cashing of checks, entering a premise, delivery of
parcels, sale of property, release of dead bodies to relatives, parties to contract, etc.

Methods of Identification

 By comparison - Postmortem findings are compared with the antemortem records.

 By elimination - If two or more persons have to be identified and all but one whose identity is not
yet identified, then one whose identity has not been established maybe known by the process of
elimination.

Rules in Personal Identification

1. The greater the number of points of similarities and dissimilarities of two persons compared, the
greater is the probability for the conclusion to be correct. This is known as the Law of Multiplicity of
Evidence in Identification.
2. The value of the different points of identification varies in the formulation of conclusion. In a fresh
cadaver, if the fingerprints on file are the same as those of the remains recovered from the crime
scene, they will positively establish the identity of the person while bodily marks, like moles, scars,
complexion, tattoo marks, clothing, etc. are merely corroborative. Visual recognition by relatives or
friends may be of lesser value as compared with fingerprints or dental comparison.
3. The longer the interval between the death and the examination of the remains for purposes of
identification, the greater is the need for experts in establishing identity.
4. Inasmuch as the remains to be identified is highly perishable, it is necessary for the team to act in the
shortest possible time especially in cases of mass disaster.
5. There is no rigid rule to be observed in the procedure of identification of persons.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

Methods of Identification of Persons:

• Non- Scientific Methods - Those which the laymen used to prove the identity. No special
training or skill is required of the identifier, no procedure or instrument is demanded; used
as an initial or provisional mode of identification.

• Scientific Methods - Those which are based on scientific knowledge. Identification made by
trained men, seasoned by experience and observation, primarily based on comparison and
exclusion.

Non-Scientific (Initial or Provisional) Identification

 Visual identification by the next of kin, relatives, friends, etc.
 Circumstantial evidence - ID cards, keys, documents, dentures, wallet, eyeglasses
 Occupational marks
 Race
 Stature or height or body build
 Weight
 Genitalia (bolitas, tattoo marks)
 Clothing and jewelries
 Distinctive marks like scars, post-operative scars, tattoo marks, body piercing, birth marks, moles,
tribal marks
 Deformities or congenital malformations
 Comparison of x-rays
Physical Description
 Sex
 Race
 Height and Build
 Growth of hair, color, length
 Body ornamentation, clothing, deformities

Problems with Visual Identification

 Facial features often distorted
 Identifying person stressed, not concentrating
 Presence of injuries, blood, effects of burning
 Face visualized without usual adornments (jewelry, makeup)
 Surrounding facilities not conducive to stress-free viewing
 Pressure to identify

Scientific Methods of Identification

 DNA Analysis - each person has a unique DNA profile (except identical twins)
 Fingerprints - no prints are alike, unchanged for life
 Dental Identification (Forensic Odontology)
 Identification of the Skeletal Remains (Forensic Anthropology)
DNA Samples for Identification
 Blood
 Teeth
 Bone marrow
 Hair roots
 Soft tissue
 Buccal swab
 Other body fluids
 Personal effects (clothing, jewelries, underwear, shave, toothbrush, etc.)
 From parents or offspring

Permanent Record is Made of the Method of Formal Identification:

 Personal (name, title, address),
 Body tag (record all details),
 Accompanying documentation.

PERSONAL EFFECTS AND CLOTHING

By contrast with the hospital autopsy, the examination of personal effects and clothing is an integral part of
the medico-legal autopsy providing information on life style, events leading to death, and often the actual
cause of death.

List of jewellery, valuables, and personal effects.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

Listed description of the clothing: Type of garment, colour, fabric type, location, if disarranged,
wet/moist/dry, stains (blood, vomit, faeces, urine, semen, dirt, oil, soot, etc.), damage (holes, cuts, tears).

Clothing findings are correlated with historical and scene information, e.g. appropriateness of clothing,
source of stains, trace materials. Clothing findings must also be correlated with other autopsy data, e.g.
injuries, source of blood stains.

C. EXTERNAL EXAMINATION OF THE BODY

This is a detailed head to toe examination of the naked body, documenting stains and soiling, general and
specific individualising characteristics, post-mortem changes (temperature, lividity, rigor mortis,
putrefaction).
The location, extent and type of staining or soiling of the body are described e.g. dual flow pattern of
blood from a wound, high velocity impact blood spatter from gunshot wound, coffee grounds vomitus and
melaena (upper gastrointestinal haemorrhage), antiseptic from medical intervention.
General body characteristics are recorded, namely: racial group, height, weight, head hair (colour, dyed,
length, style, balding), eyes (colour, pupil size, conjunctival congestion or petechial haemorrhages,
jaundice, prosthesis), nose and ear canals (blood, pus), earlobes (piercing, earlobe creases), face (hirsute
woman, clean shaven, beard, moustache), mouth (vomit, blood, tablet debris, teeth, dentures), breasts
(normally developed, atrophic, hirsute), genitalia (pubic hair pattern, circumcised, palpable testes), feet
(general hygiene, bunions, ingrowing nails).
More specific identifying characteristics are described fully: tattoos (location, design, colour, names),
scars (surgical and non-surgical, needle tracks, striae), skin lesions (naevi, senile keratoses, other skin
diseases), prosthesis, pacemaker.
Post-mortem changes are documented, namely:- body temperature to touch (alternatively state if the body
has been refrigerated), rigor mortis (extent and degree), hypostatic lividity (distribution, dual pattern,
colour, contact pallor), putrefactive changes.

INJURIES (EVIDENCE OF INJURY)

All injuries are described systematically either by grouping them according to anatomical location, e.g.
right arm, anterior chest, left leg (as in multiple injuries in vehicular collisions), or in numerical order (e.g.
where the number of injuries is few or where each and every injury is particularly important as in multiple
stab wounds). If numbered, it is stated that the order of numbering does not imply sequence of infliction or
degree of severity.
Injuries are described as to their type, e.g. bruise, abrasion, laceration, incised wound, puncture or stab
wound, gunshot wound, burn, fracture.
Injuries should be described with regard to their location, size, shape and color.
The location of the wound is given by general description (e.g. on the left side of the face, or over the rib
cage, immediately below the left breast) and by precise location in relation to fixed anatomical landmarks
(analogous to latitude and longitude). Suitable vertical landmarks are the heel, superior margin of the pubic
symphysis, superior anterior iliac crest, supra-sternal notch, orbital ridge, and crown. Suitable horizontal
landmarks are any midline structures, e.g. umbilicus, midline of the sternum and glabella.
The size of an injury is measured in two dimensions. The shape can be related to a geometric shape or
common object, often supplemented with drawings, sketches or by tracing patterned injuries onto acetate
sheets.
Internal injuries are described in continuity with the related externally apparent injuries, e.g. the bruising
and abrasion to the chest, then the fractured ribs, then the lacerated lung and haemothorax. This
organisation of the final report frequently does not correspond with the order of dissection and dictation of
findings.
In the final report remote injuries are segregated from recent injuries under separate subheadings.

SIGNS OF MEDICAL INTERVENTION

Medical intervention is described under a separate heading. This includes all medical equipment attached
to, or accompanying, the body, e.g. urinary catheter, endotracheal tube, oral airway, rods for external
fixation of fractures, arterial and intravenous lines, intravenous solutions or blood (with details of
contents).
External surgical incisions are described in continuity with the internal evidence of surgery.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

D. INTERNAL EXAMINATION OF THE BODY

The internal examination is systematic description of natural disease and does not include recent injuries,
all of which have been previously described under the appropriate heading. Negative observations are
included, e.g. no pulmonary thrombo-emboli, no significant coronary artery atherosclerosis, no skull
fracture, etc.

E. HISTOLOGY, TOXICOLOGY AND OTHER EXAMINATIONS

Any special dissections, e.g. neck dissection, or further examination of organs e.g. brain after formalin
fixation, together with microscopic, biochemical, and toxicological studies should be described at this
point.

Cause Mechanism Manner

Atherosclerotic coronary Electrical arrhythmia Natural
artery disease or heart failure
Stab wounds Internal or external blood loss Homicide, Suicide or Accident
Hanging Asphyxia Suicide
Strangulation Asphyxia Homicide

Cause of death: The disease process or injury responsible for initiating the train of events, brief or prolonged, which
produces the fatal end result.

Mechanism of death: The physiological or biochemical derangement produced by the above cause, which is
incompatible with life; i.e. how the disease or injury leads to death

Manner of death: The fashion in which the cause of death came into being; i.e. whether natural, accident, suicide,
homicide, unclassified (alcohol/drug deaths) or undetermined

OPINION (CONCLUSION OR COMMENTARY)

This section is interpretative and subjective, representing the opinion of the author. It includes the cause of
death as appearing on the death certificate. The commentary is in simple English and brings together all the
relevant information obtained from examination of the body, the scene of death and the history of the
decedent. Information obtained second-hand (hearsay) may be included e.g. from police reports, medical
records, fire investigation reports. The relevant issues are addresses i.e. what happened, to who, when,
where, why and how. It may be as brief or as detailed as the need dictates It is directed to the law officer
investigating the death and any other legally interested parties who may obtain access to the report
subsequently.
The commentary is analogous summary of a hospital autopsy which brings together the pathological
autopsy findings with the clinical findings and subsequent progress.

SIGNATURE

All medico-legal reports require the original signature of the author. Relevant degrees and other
qualifications are given. Occupational titles, e.g. Lecturer in Pathology, may be included.

NOTE: If you, the licensed physician, are caring for someone and he or she dies of his or her disease, you
fill out the death certificate and you didn’t even notify the medico-legal officer.

Deaths Reportable to the Medico-Legal Officer:

1. Criminal violence
2. Suicide
3. Accident
4. Trauma
5. Disaster
6. Sudden and unexpected deaths
7. Deaths under unusual or suspicious circumstances
8. Complications of illegal/criminal abortion
9. In police custody, jail or prison
10. Unattended deaths - Deaths without medical attendance or anyone dying with no physician to
complete the death certificate
11. Poisoning
12. Unclaimed bodies
13. Diseases constituting a threat to public health
14. Disease, injury or toxic agent resulting from employment

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 15. Death associated with diagnostic or therapeutic procedures (i.e., really unfortunate, unexpected
iatrogenic disease)
16. When a body is to be cremated, dissected, or buried at sea
17. When a dead body is brought into a new medico-legal jurisdiction without proper medical
certification

*In a typical community, around 15% of deaths will fall under the medico-legal officer's jurisdiction, and
of these, maybe 35-45% will get autopsied.

Investigative Information Provided by the Autopsy:

In addition to supplying the homicide investigator with an official cause of death, the medico-legal officer
conducting the autopsy can assist the investigation by answering such questions as:
1. What type of weapon was involved in the death? (A hammer or screwdriver might leave
impression-type wounds, for example.)
2. Are the wounds consistent with investigative evidence?
3. Which wound was the fatal wound? Where there are numerous gunshot or stab wounds this
determination frequently cannot be made.)
4. Approximately how long could the deceased have lived after the assault? (Survival time.)
5. How far could the deceased have walked or run?
6. Was the body dragged or dumped?
7. From what direction was the force applied?
8. What was the position of the deceased at the time of injury (sitting, standing, lying down,
etc.)?
9. Are the injuries ante-mortem or postmortem?
10. Is there any evidence of sexual assault (rape or sodomy)?
11. Was the deceased under the influence of drugs?
12. Was the deceased under the influence of alcohol?
13. Are there any foreign objects in the cadaver (bullets, broken blades, fibers, etc.)?
14. Is there any evidence of a struggle (defense wounds, etc.)?
15. What is the estimated time of death?

NOTE : Most initial injuries do not cause immediate death. There is often a "survival interval" during
which the person may engage in considerable activity before collapsing and dying. Hemorrhage into the
chest and heart cavities following a penetrating wound usually indicates that the individual survived for
only a short time, while bleeding into the stomach or lower abdominal tract indicates a longer survival
time.

NOTE : The presence of a wound on a body does not necessarily mean that someone else inflicted the
wound. Suicide must always be considered. It is a common error to believe that certain wounds would have
been too painful to be self-inflicted.

NOTE : There is no such thing as a wound which is too painful if the person is determined to take his or
her own life.

NOTE : An autopsy must be complete if it is to be accurate. The basic principle of death investigation is
"DO IT RIGHT THE FIRST TIME, YOU ONLY GET ONE CHANCE."

NOTE : The purpose of the forensic autopsy is more than just to establish the cause of death. It involves
the determination of all other factors which may or may not be involved.

NOTE : The medico-legal officer takes charge of the body, any clothing on the body, and any article on or
near the body that may assist the medical examiner in determining cause and manner of death.

References:

 Baden M. Autopsy. Unnatural Death: Confessions of a Medical Examiner. Ballantine Books, 1990:33-
47.
 Sadler DW. The Medico-Legal Autopsy. Department of Forensic Medicine, University of Dundee,
1998. From the Internet, 7 pages.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

E. DEATHS DUE TO FIRE

Medico-Legal Aspects

1. Identification

 Visual (If insignificant burns, ID easy)

 Charred : Fingerprints impossible
: Dental – most useful
: Sinus x-rays
: DNA typing
: Tentative- tattoos, scars, etc
 Dental
 Records, X-rays, Casts
 Fingerprints
 DNA typing
 Others
 Jewelry, clothing wallet, scars, tattoos

2. Victim alive at the time of fire?

 Scene
 Soot (in nostrils, mouth)
 Evidence of activity

 Postmortem
 Soot in airways
 Burning of throat
 Congestion of lungs
 Any other reasons for death?

 Toxicology
 Blood should be tested for CO (even if body is severely burned)
 Presence of CO means the person was alive at the time of fire
 Fatal CO blood saturation > 50%
 8-10% COHb can occur in heavy smokers
 Older people with COPD, coronary artery dse or severe anemia may die with 15-20%
 Small children and animals (dogs, cats, birds) build up fatal CO level faster than adults
because of their greater metabolic rates

3. Cause of Death (Was death due to fire?)

 Smoke inhalation (CO, hydrogen cyanide)

 Suffocation (oxygen depletion)
 Thermal injury (burns)

Death may be:

a. Immediate : Direct thermal injury (burns)
: Smoke inhalation
b. Delayed : Shock
(1-3 days) : Fluid loss
: Acute respiratory failure (hot gas injury)
c. Later : Sepsis
: Chronic respiratory failure
: Multiple organ failure (pneumonia, renal failure, liver failure, heart failure)

4. Manner of Death

 Accident
 Majority of cases
 Smoking
Faulty electrical wiring
Heaters (defective or misuse)
Children playing with matches

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 Cooking

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  Suicide
 Suicide by burning is rare
 Most have severe psychiatric problem
 Self-immolation → To show political dissent
 Examine clothes for accelerant

 Homicide
 Arson
a. Accelerants clothing/body
b. Fire debris

 Two circumstances
a. Homicide before the fire – Fire started deliberately in an attempt to destroy the body or
conceal cause of death
b. Homicide by fire

5. Other contributing factors

 Natural disease
 Intoxication
 Antemortem injuries : X-ray
: External examination
: Internal examination

6. Burns: Types

 Flame
 Contact with hot object
 Radiant heat
 Scalding
 Chemical
 Microwave

7. Prognosis

 Body surface area

“Rules of nines”

 Used to determine the extent of burns

 Different parts of the body are allocated percentages of its total surface area as nine or
multiples of nine
 Head = 9%
RUE = 9%
LUE = 9%
RLE = 18%
LLE = 18%
Front of torso = 18%
Back of torso = 18%
Neck/Genital area = 1%
TOTAL = 100%

 Age of Victim

 Age influences survival because it reflects general body health and overall resistance to
trauma
 25y.o.→ Good chance of recovery in up to 60% BSA burns
40y.o.→ Recovery in up to 40% burns
60y.o.→ 20% burns
80y.o.→5% burns

 Depth of burns
1st degree (superficial)
 Intact dermis
 Red skin
 Peels like sunburn

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 2nd degree (partial thickness)
 Red, moist, blistered
 Still some epidermis for skin to regenerate
 Very painful
 Heals without scarring (unless gets infected)
3rd degree (full thickness)
 Destruction of skin and appendages
 White leathery appearance
 Brown/Black
 Chars and scars
 No epidermis (needs skin graft)
 Heals with scarring
4th degree
 Incinerating injuries
 Deeper than skin

8. Postmortem Injuries and Artefacts

 Charring of body surface

 Pugilistic attitude (heat contracture of muscles)
 Remnants of clothing
 Heat splits of skin (heat ruptures)
 Heat fractures
 Extradural hemorrhage (heat hematoma)

Postmortem: False Impression of Injuries

 Heat fractures of bones and teeth
 Heat splits of skin
 Extradural hemorrhage

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

F. DEATHS BY ASPHYXIA
 Mechanical interference with breathing or blood supply to the brain (not only breathing
interference/obstruction then, but also compression of carotid arteries)
 Used loosely, lack of oxygen as mechanism of death
 Characterized by inadequate oxygenation of tissue
 Other terms
 Hypoxia: Reduced oxygen in the blood
 Cyanosis: Blue skin color with reduced oxygen in the blood

Types of Asphyxia
1. Environmental suffocation
2. Smothering
3. Choking
4. Neck compression
 Manual strangulation
 Ligature strangulation
 Hanging
5. Traumatic or crush asphyxia
 Chest compression
 Abdominal compression
6. Postural or positional asphyxia

Mechanism of Death

 Complex
 Carotid artery obstruction→ cerebral hypoxia
 Tracheal obstruction→ airway impaired
 Cervical spine fracture
 Vagal nerve stimulation
 Vagus nerve to heart and throat passes carotid artery down the neck→ stimulation can stop
the heart→ asystole
 Larynx mucosa (“café coronary”)
 Carotid sinus (blood pressure monitor in wall of carotid artery)

Pathological Findings

 “Classic signs of asphyxia”

 “Obsolete diagnosis quintet”
 Scathingly referred to by Lester Adelson
 Most of the signs are so non-specific that little reliance can be placed on them in the
absence of other confirmatory evidence
1. Petechiae (pin-point hemorrhages: Tardieu spots)
2. Congestion of organs*
3. Cyanosis*
4. Fluid blood*
5. Injuries of the method of asphyxia
*Nonspecific

Petechiae

 Pin-point hemorrhages (blood spots)

 Capillary rupture
 Back pressure
 Hypoxia makes wall fragile
 Sites seen
 External (eyelids, top of cheek, inside lips)
 Internal (larynx mucosa, epicardium, visceral pleura, thymus gland)
 Not specific to asphyxia
 CPR
 Lividity (face down)

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  Internally only → SIDS
 But petechiae + marks to neck = powerful combination
 Suffocation----------------------Negative
Smothering----------------------+
Choking--------------------------+
Neck compression--------------++
Crush-----------------------------+++
Postural---------------------------+++

Environmental Suffocation

 Low or no atmospheric oxygen

 Ships’ holds, vacuum, space, well, wardrobe, child in refrigerator
 Toxicological analysis: No value
 Circumstances of death
 Injuries: None
 No specific autopsy findings
 Petechiae are not present

Smothering

 External mechanical obstruction to breathing

 Occlusion of mouth and nose to prevent breathing
 By hands or by a cloth, pillow or plastic bag
 Accident
 Plastic bag→ child
 Infant co-sleeping
 “Overlaying” : Infant in parent’s bed
: Compression plus smoldering
: No diagnostic findings-? SIDS

 Suicide
 Plastic bag→ Adult (“Final Exit” suicide)

 Homicide
 Infant/child victim, nursing hime
 Adult victim (drugged, weak)
 Duct tape over mouth/nose→ Robberies, burglaries, kidnapping
 More deliberate homicide→ With pillow or bed covering

 Injuries
 Marks around nose/mouth (bruises, abrasions)
 Bruises inside lips
 Frenulum injury (bruise, laceration)
 Gum margin injury
 Difficult diagnosis: History and scene
 Typically no findings at autopsy: Petechiae – minimal if present

Choking

 Internal obstruction of the mouth or upper airway

 By foreign object like food (mostly meat) or gags
 Homicide: Gag rammed in mouth

 Accident
 Child→ Lolly, small toy, small ball, hotdog
 Elderly→ Dementia (aspirate food or foreign matter)
 Adult→ “Café coronary”, intoxicated

 Injuries: None
 Autopsy findings: Only findings are obstruction of the airways; No other typical findings
 Situation of massive aspiration
 Said to be rarely a cause of death (alone)
 Needs severe CNS depression (e.g. Stroke victim, absence of “gag reflex”)

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

Neck compression

 Three types: Hanging, ligature strangulation, manual strangulation

 Mechanism of death
 Not airway occlusion
 Cerebral hypoxia secondary to obstruction of carotid and vertebral arteries
 If there is acute occlusion of both carotid arteries, then an individual cannot survive on
vertebral artery blood supply alone
 About 11 lbs. (4.99 kg.) of force is necessary to compress carotid arteries
 Very rapid (10-15 sec) loss of consciousness if both carotid arteries occluded totally
 Jugular veins (draining head) lie adjacent to carotid arteries → Carotid artery plus jugular
vein occlude together
 Restraint holds by police (choker hold, sleeper hold) are also forms of neck compression

1. Manual Strangulation

 Throttling
 Compression of neck by hands
 Homicide – virtually all cases, high percentage female
 Suicide – not possible
 Accident – claim is usually of very brief “grab” by the neck claiming resultant vasovagal
reflex, implicit in the claim is an absence of applying continuous pressure to the neck
 Theory of vasovagal reflex:
Carotid sinus stimulation → bradycardia → vasodilation → hypotension → cardiac arrest
 Healthy skepticism required – usually severe underlying disease such as coronary artery
disease in cases where this has been alleged and autopsy performed

 Injuries
 Skin of neck
i. Finger pad bruises
ii. Fingernail abrasions
 Internally
i. Strap muscle bruises
ii. Fractures of thyroid cartilage (Adam’s apple)
iii. Fractures of hyoid bone

2. Ligature Strangulation

 Garroting
 Compression of neck by ligature
 Homicide – Most cases, women more than men, in women may be accompanied by sexual
assault
 Suicide- Very uncommon but possible
 Accident- Rare, usually clothing entangled in machinery

 Injuries
 Ligature mark (transverse)
 Internally: Lesser internal neck injury
 Fracture of hyoid bone or thyroid cartilage (10-15% of cases)

 Death due to occlusion of carotid arteries with resultant cerebral hypoxia

 Vertebral arteries not involved

3. Hanging

 Suspension of body resulting in compressive force to neck

 Ligature neck compression with body suspension
 Complete suspension
 Incomplete suspension
 Standing
 Sitting
 Kneeling
 Lying

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  Injuries
 Ligature mark (oblique)
 Fractures of thyroid cartilage*
 Fractures of hyoid bone*
 Intimal tears of carotid arteries
 Very unusual – cricoid cartilage injury, body of thyroid cartilage injury, cervical spine
fracture
*Fracture of hyoid bone or thyroid cartilage uncommon (only 10-15% of cases)

 Circumstances
 Suicide – mainly
 Accident – occasional
i. Infant – cot
ii. Child(boy) – playing “hangings”
iii. Adult – autoerotic asphyxia; slip in unusual circumstances
 Homicide – Extremely rare

 Noose→ Any “ligature” at hand (rope, electrical cord, tie, sheets, belt, dog chain, etc.)

Autoerotic Hanging

 Usually, young adult male (rarely female)

 Aim→ To induce transient cerebral hypoxia by short term “hanging” of themselves
 Accidental hanging, not suicide
 Failure of safety mechanisms
 Scene is diagnostic
 Typical features at scene
 Secluded location
 Undressed
 Cross-dressed (female underclothes)
 Masochism/bondage (ligature rope – escape mechanism)
 Pornographic literature
 Semi-erect penis
 Padding of ligature noose around neck

Traumatic or Crush Asphyxia

 Pressure fixation of chest wall and abdomen

 Trench collapse, pinned under vehicle, crowd collapse
 Florid asphyxial signs
 “Overlaying” – Compression + smothering in infants (see above)
 “Pressing”
 “Burking” –Chest compression + smothering

1. Chest compression

 Injuries
 Skin of chest: Patterned bruise/abrasion
 Internally: Muscle bruising, fractured ribs

2. Abdominal compression

 Injuries
 Skin of abdomen: Faints marks, if at all
 Possibly internal organ injury

Postural or positional asphyxia

 Variation of traumatic asphyxia

 Trapped in position such that the victim cannot breathe or the respiration is inadequate, e.g.,
suspended upside down for a long time

 Restraint (police arrest, security officers, mental cases)

 “Restraint asphyxiation”: Face down, hog-tie position
 Restraint holds: Neck compression with broad force (choker hold, sleeper hold)

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  Injuries: None
 Deaths associated with these holds are usually due to underlying cardiac disease and /or
drugs combined with stress on the heart due to the effects of catecholamines

Asphyxia: Problems

 Suffocation
 Gentle smothering
 Fleeting neck compression/ contact
 Ligature Strangulation (homicide or suicide)
 Time to unconsciousness and death
LOC = 10 -15 secs (?)
Death = 2 -3 mins (?)

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

G. DROWNING AND IMMERSION IN WATER

Drowning Deaths
 In Australia, about 450 deaths annually
 25/100,000 people
 MVC’s – 20/100,000
 Fatal falls – 6/100,000
 Same as homicide rate
Immersion
 A body retrieved from water is one of the major problems for a Forensic pathologist
Medico-Legal Questions
 Identity
 Immersion time
 Postmortem time
 Cause of death
 Injury assessment
Circumstances of Immersion

LOCATION
 Home
 Nappy bucket
 Goldfish pond
 Swimming pool

 Open water
 Lake, River, Ocean

ACCIDENT
 Bathtub : Slip over
 Home water : Infant/young child
 Open water :Leisure boat
: Commercial boat
: Swimming – intoxicated, tide change, incapacitated
: Diving

SUICIDE
 Bathtub
 Boat – jump overboard
 Ocean – swim out to sea
 About 3% of suicides in Australia are by drowning

HOMICIDE
 Concrete shoes
 Intoxicated and push in
 Non-swimmers are particularly vulnerable
 “Brides in the bath” case
 George Joseph Smith
 > 3 new wives
 1990’s – 1910’s
 1-2% of homicides in Australia are by drowning

BATHTUB DEATHS in WA: Recent Difficulties

 Young male child : Electrocuted on live taps

 Adult female : Homicide – contract killing

: To be a witness in criminal trial
: Clue was single “defense” cut on finger

 Adult male : Homicide – random killings

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 : Clue was multiplicity of bruises – struggle

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

Immersed Body: Identification

 Decomposition
 Open water especially – body floats to surface only with decomposition gas, unless
flotation jacket

 Injuries
 Immersed body usually head down – face injured on seabed
 Marine animal activity
 Boat injuries

Immersed Body: Cause of Death

 Natural disease, before falling into water
 Natural Disease< whilst in water
 Death at water’s edge, then washed away
 Injury, then thrown in (corpse disposal)
 Injury, whilst in water
 Immersion other than drowning
 Drowning

Immersion

FRESH WATER (Hypotonic)

 Large volume H2O → alveoli
 ↑ Blood volume +Hemolysis
 Dematures pulmonary surfactant (PS)

SALT WATER (Hypertonic)

 Plasma shifts into P. alveoli
 Hemoconcentration
 ↑ Blood electrolytes
 Dilute ± washes away PS

Drowning Sequence
 Initial voluntary breath-holding
 Rise in CO2, fall in O2 causes involuntary gasping
 Laryngeal spasm may follow inflow of water
 Loss of Consciousness
 2 apnea
 Resumption of involuntary gasping
 Convulsions
 Cardio-respiratory arrest

Immersion: Mechanism of Death

DROWNING
 Wet or Typical
 Fluid interference with breathing
 Fluid overload: electrolyte disturbance (?)

 Dry or Atypical
 Laryngospasm or vagal inhibition

HYPOTHERMIA

NEAR-DROWNING WITH DELAYED DEATH

 Lungs: Adult respiratory distress syndrome
 Brain: Hypoxic encephalopathy

Postmortem Findings

CLOTHING
 Diving equipment
 Flotation Device

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  Assault charges
 Disarray
 Tears
 Stains

EXTERNAL EXAMINATION
 Cutis anserina (gooseflesh): Erector pili muscles
 Washerwoman’s change : Wrinkling with prolonged emotion
 Marine vegetation : Cadaveric spasm
: Passive Entrapment
 Foam Cone (champignon de mousse)
 Injuries

INTERNAL EXAMINATION
 Frothy mucus in trachea
 Lungs dry or wet
 Swallowed water in stomach
 Middle car hemorrhage (barotrauma)
 Natural Disease
 Toxicology sample

Injuries

 Postmortem Injuries
 Head-down position underwater
*Sandy bottom – diffuse abrasion to face
*Rocks and coral – bruising and cuts
 Marine animals: Fish, Crabs, sea lice
 Boat / propellers
 Antemortem Injuries
 Cervical Spine – diving
 Wheals, stings – incapacitation
 Assault Injuries ?

Suspicious Injuries

DEFENSE INJURIES
 Bruised fingernails
 Bruised knuckles
 Bruised forearms

RESTRAINT / STRUGGLE INJURIES

 Bound wrists – bruised
 Biceps/triceps bruising

ASSAULT INJURIES
 Bruised face
 Bruised lips
 Scratch abrasions to neck – Internal neck injury

Investigation

 Microscopy
 Toxicology
 Gettler’s Test (Chloride) – not useful
 Diatoms
 Unicellular algae with silica shells
 > 1000 species – often localized to a particular area
 Absorbed into body with inhalation of fluid
 Tested on bone marrow

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

Remember

 Diagnosis of drowning is basically one of exclusion

 Therefore, Need complete autopsy to rule out any other cause of death

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

H. MEDICO-LEGAL ASPECT OF PHYSICAL INJURIES

Physical Injury - is the effect of some forms of stimulus on the body; it may be immediate or delayed

 Forensic usefulness of injuries

 Using patterns (in the injuries) or trace evidence to identify assailants and weapons
 Some specific points
 Ageing of injuries
 Self- inflicted injuries
 Mechanism of death with injuries

CAUSES OF PHYSICAL INJURIES

a. Physical violence or trauma
b. Heat or cold
c. Electrical energy
d. Chemical energy
e. Radiation by radioactive substances
f. Change of atmospheric pressure (barotrauma)
g. Infection

WOUND
 It is the solution of the natural continuity of any tissues of the living body;
 Disruption of the anatomic integrity of a tissue of the body.
 The effect of the application of physical violence on a person is the production of wound.
 The effect of physical violence may not always result to the production of wound, but the
wound is always the effect of physical violence.

VITAL REACTIONS OF A LIVING TISSUE OR ORGAN TO TRAUMA:

a. RUBOR - Redness or congestion of the area due to an increase of blood supply as part of the
reparative mechanism
b. CALOR - Sensation of heat or increase in temperature
c. DOLOR - Pain on account of the involvement of sensory nerve endings
d. LOSS OF FUNCTIONS - on account of the trauma, the tissue may not be able to function normally.

*NOTE: The presence of the vital reactions differentiates an ante-mortem from post-mortem
injury.

CLASSIFICATION OF PHYSICAL INJURIES

A. Medico-Legal Classification
1. Contusion (bruises or ecchymoses)
2. Abrasion (grazes or scratches)
3. Laceration
4. Incised wound
5. Stab wound
6. Punctured wound
7. Hack (or chop) wound
8. Gunshot wound
B. As to Severity
1. Mortal wound - wound capable of causing death immediately upon infliction
2. Non-mortal wound - wound not capable of causing death immediately after infliction or shortly
thereafter.
C. As to the Kind of Instrument Used
1. Blunt Force Injuries - Wounds brought about by a blunt instrument
a. Bruise – contusion, hematoma, ecchymosis, petechiae
b. Abrasion – graze, scratch, patterned or imprint abrasion, sliding abrasion
c. Lacerated wound or laceration – cut, tear
2. Sharp Force Injuries - Wounds brought about by a sharp or bladed instrument
a. Incised wound – cut, “laceration”
b. Stab wound

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 c. Punctured wound
d. Hacked or chop wound

3. Gunshot Wounds

D. As to the Manner of Infliction

 Hit - by means of bolo, blunt instrument, axe;

 Thrust or stab - dagger, bayonet;
 Gunpowder explosion - projectile or shrapnel wound;
 Sliding or rubbing - abrasion

E. As to the Depth of the Wound

 Superficial
- When the wound is just underneath the layers of the skin
- Examples: contusion, petechiae, hematoma
 Deep
- Involve inner structures beyond the layers of the skin
- Musculo-skeletal injuries
- Internal Hemorrhage - rupture of the blood vessels
- Cerebral Concussion - jarring or stunning of the brain
- Closed fractures
 Penetrating - stab wound, punctured wound, gunshot wound
 Perforating - produces communication between the inner and outer portion of hollow
organs; through and through injury

F. As regards to the relation of the site of application of force and the location of injury

a. Coup Injury
 Physical injury which is located at the site of the application of force;
 Signifies that the injuries are located beneath the impact site (usually caused by direct
blow)

b. Contre-coup Injury
 Physical injury found opposite the site of application of force;
 Injuries are on the opposite side from where the blow was initiated (can be caused by fall
from height)

c. Coup-contre-coup Injury
 Physical injury located at the site and also opposite the site of application of force;
 Injuries are located both on the impact site as well as the opposite side

d. Locus Minoris Resistencia

 Physical injury located not at the site nor opposite the site of the application of force but in
some areas offering the least resistance to the force applied;

e. Extensive Injury
 Physical injury involving a greater area of the body beyond the site of application of force.

f. Ectopic bruise
 Bruise at a site not corresponding with the impact site

G. Musculo-Skeletal Injuries
a. Sprain
 Partial or complete disruption in the continuity of a muscular or ligamentous support of a
joint
 Caused by blows, kick, or torsion force
b. Dislocation
 Displacement of the articular surface of bones entering into the formation of a joint

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 c. Fracture
 Solution of continuity of bone resulting from violence or some existing pathology
 It maybe:
• Close or Simple Fracture - No break in continuity of the overlying skin.
• Open or Compound Fracture - The broken ends of the bone protrude through the
skin; one or both bones are open to the outside.
• Comminuted Fracture - Fractured bone is fragmented into several pieces; the
bone is splintered, crushed, or broken into pieces, with smaller fragments lying
between main fragments.
• Greenstick Fracture - A partial fracture wherein only one side of the bone is broken
while the other side is merely bent.
• Linear Fracture - Fractures forms a crack commonly observed in flat bones
• Spiral Fractures - Break in the bones forms a spiral manner as observed in long
bones.
• Impacted Fracture - One end of the fractured bone is forcefully driven into the
interior of the other.
• Pathologic Fracture - Fracture caused by weakness of the bone due to disease
rather than violence.
• Pott’s Fracture - A type of ankle fracture that is characterized by a break in one or
more bony prominences on the sides of the ankle known as the malleoli, either
posterior, lateral (fibula) or medial malleolus (tibia).
• Colles’ Fracture - Fracture of the distal end of the lateral forearm bone (radius) in
which the distal fragment is displaced posteriorly; Colle’s is a fracture of the distal
radius +/- ulna; will result to “dinner fork deformity”.
• Corner Fracture - Refers to injury of the metaphysis, or the growing plate at either
end of long bones, such as the femur and tibia; the metaphysis is a piece of cartilage
in children, not yet a fully ossified bone; other names for a corner fracture are a
bucket-handle fracture or metaphyseal fracture; corner fracture is caused by jerking
the limb; highly specific for child abuse; mechanism → twisting or pulling of
extremity or acceleration/deceleration forces during shaking.
d. Strain
 Overstretching, instead of an actual tearing or rupture of the muscle or ligament which
may not be associated with the joint
e. Subluxation
 Bruise at a site not corresponding with the impact site

H. Special Type of Wounds

1. Defense Wound - wound which is the result of a person‟s instinctive reaction of self-
protection.
2. Patterned Wound - wound in the nature and shape of an object or instrument and which infers
the object causing it.
3. Self-Inflicted Wound - wound produced on oneself.

DEFENSE WOUNDS

• Typically seen when an individual has tried to defend himself against an attack.
• Result of instinctive reactions to assault or of the person‟s instinctive reaction of self-
protection.
• Most individuals will attempt to protect their eyes, head and neck by raising arms, flexing
elbows and covering head and neck.
• Extensor surface of forearms (ulnar side) may receive blows, the lateral/posterior aspects of
the upper arm, and the dorsum of hands.
• The outer and posterior aspects of lower limbs and back may be injured as an individual curl
into a ball, with flexion of the spine, knees & hips protecting anterior part of body.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

I. Legal Classification of Physical Injuries
a. Slight Physical Injuries
 Physical injuries which incapacitate the victim for labor or will require medical attendance
from one to nine days;
 Physical Injuries which did not prevent the offended party from engaging in his habitual
work or which did not require medical attendance; small contusions and abrasions.
 Ill-treatment of another by deed without causing any injury; slight slap on the face, holding
the arm tightly which did not even develop redness of the skin.
b. Less Serious Physical Injuries
 Physical injuries which will incapacitate the victim for labor or will require medical
attendance from ten to twenty- nine days;
 There is a manifest intent to insult or offend the injured person;
 There are circumstances adding ignominy to the offense;
 The victim is the offender‟s parents, ascendants, guardian, curators, or teachers;
 The victim is a person of rank or a person in authority, provided that the crime is not direct
assault.
c. Serious Physical Injuries
 Any person who shall wound, or assault another, shall be guilty of serious physical
injuries.
 Physical injuries which will incapacitate the victim for labor or will require medical
attendance for more than thirty days;
 The crime of serious physical injury may be due to:
1. Wounding
2. Beating
3. Assaulting
4. Administering injurious substance, without intent to kill

d. Mutilation
 The crime of serious physical injury may be due to:
 It is the act of looping or cutting off any part or parts of the living body.
 Depriving a person either totally or partially, of some essential organs for reproduction.
 Kinds of Mutilation (Art. 262, RPC)
1. Intentionally depriving a person, totally or partially of some of the essential organs
for reproduction;
2. Intentionally depriving a person of any part or parts of the human body other than
the organs of reproduction.
 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

Criminal Assault: Forensic Tasks

 Preserve evidence
 Identify assailant
 Blood - Hairs
 Semen - Fibers
 Identify weapon
 Pattern
 Trace Evidence
 Correlate injuries with alleged circumstances

Documentation of Injuries
 Written description
 Diagrams
 Photography
 Linear scale
 Pay attention to focus

Mechanism of death
 Hemorrhage (blood loss)

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  Aspiration of blood (choking of blood, pneumonia)

 Embolism (foreign substance in blood vessels)

 Fat embolism (bone fracture)
 Air embolism (neck vein puncture)
 Others – infection, pneumothorax (collapse of lungs), alcohol or drug effect

Identifying the Weapon

 Pattern to the injuries
 of the weapon

 Trace evidences
 Paint, wood, glass

Clothing
 Blood flow
 Assailant
 Trace evidence
 Weapon
 Pattern
 Trace Evidence

BLUNT FORCE TRAUMA

Definition: Injury produced by blunt object striking the body or impact of the body against a blunt surface
Tearing, shearing, and crushing. The amount of damage delivered by a blow from a blunt object varies
directly with:
 The force used in delivering the blow
 The surface area that takes the blow (i.e., blows to the head do more mechanical damage than
blows to the back; blows from a rounded pipe or a knob on a club do more damage than the side of
the board)
Severity due to several factors

 Nature of the weapon

 Amount of body surface
 Amount of force
 Time
 Region of the body inflicted
Identifying the Weapon
 Bruise : Pattern
 Abrasion : Pattern
: Trace evidence
 Laceration : Trace evidence
Internal Hemorrhage
 Rupture of the blood vessel which may cause hemorrhage, it may be due:
• Traumatic intracranial hemorrhage
• Rupture of parenchymatous organs
• Lacerations of other parts of the body

Cerebral concussion
 Or “Commotio Cerebri”
 It 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.
 More severe when moving or mobile head struck by a fixed hard object as compared when the
head is fixed and struck by a hard- moving object.
 Loss of memory for events just before the injury (retrograde amnesia) is a constant effect.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

A. BRUISES

 Bleeding into tissue – the surface is intact

 Bruises or contusions are areas of hemorrhage in soft tissue, due to ruptured blood vessels, due to
blunt force trauma. Same as "bruise". Usually, we reserve "contusion"/"bruise" for cases in which
the overlying skin is not broken. If it's palpable, it's a "hematoma".
 Contusion is uncommon in suicides.
 The blood in most skin bruises is mostly in the subcutaneous tissue. Bruises become more
prominent with time, because the blood cells and their liberated hemoglobin spread into the
overlying dermis.
 Contusion in deep tissue
 Possibly life-threatening
 Sometimes no external injury
 Like abrasions, contusions may or may not be patterned. A patterned contusion, unlike most
others, has most of its red cells in the dermis from the beginning, because the dermis was forced
between protuberances on the impacting surface.
 Some purists say that a bruise is a contusion visible through the skin.
 It's easier to bruise loose tissue (your orbit) than tightly-woven tissue (your palm).
 Don't mistake the "mongolian spot" or other pigmentation for a contusion. Remember that bruises
show up better on light-skinned people, and that scalp bruises are often hard to see. If in doubt,
incise the lesion.
 Colors of a bruise: Blue/purple  violet  green  yellow  vanishes. Sadly, the rate of color
change is tremendously variable, and you can't use it to estimate the time of a wound. One study
found the only reliable rule is that yellow always means  18 hours.
 Pretty reliable: If the color has clearly not begun to change, it is less than 48 hours. If the color has
obviously changed, it is more than 48 hours.
 Even heavy trauma may not produce a bruise. Conversely, bruises can be much larger than the
object that produced them, due to stretching and avulsion of nearby vessels.
 Factors making a bruise more severe:
 Lax tissue (around eyelids; older people; those genetic connective-tissue syndromes)
 Delicate tissues (children, older people)
 Scanty muscle mass / obesity
 Bleeding tendency (amyloidosis, alcoholism, hemophilia, aspirin-takers, patients receiving
anticoagulants)

 NOTE: Yes, you can produce a bruise on a newly-dead body, though with no blood pressure, it
won't be as impressive as one produced by the same force in life. And postmortem extravasation of
blood can simulate bruising.
 Future medico-legal officers: How to skin a body in search of contusions - something you'll need
to do if the person has died in police or prison custody.
 Advanced decomposition and livor mortis can produce lesions indistinguishable from contusions.

MAIN TYPES
 Contusions
 “Pasa”
 Effusion of blood into the tissues underneath the skin on account of rupture of the blood
vessels as a result of the application of blunt force or violence
 Area of bleeding into the skin or soft tissue due to blunt force
 Accumulation of blood underneath the skin.
 Difficult to see in dark people
 Children and women bruise easily
 Post-mortem contusion: rare

 Hematoma
 Extravasation or effusion of blood in a newly formed cavity underneath the skin
 Blood cyst, blood tumor, “bukol”)

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 Focal collection of blood within the area of contusion; or accumulation of blood into a
newly formed cavity
 Hematoma  similar mechanism to contusion but with elevated skin
 Ecchymosis
 Kiss mark

 Petechiae
 Circumscribed extravasation of blood in the subcutaneous tissue

MEDICO-LEGAL INTEREST
 Pattern (of the weapon)
 Age of injury
 Degree of force for that injury
 “Ectopic bruise”
 “Delayed bruise”

CLASSIC EXAMPLES
 Finger pad bruises to the neck - Manual strangulation, battered babies
 Different ages - Repeated assaults
 Inner aspect of thighs - Forceful intercourse or sexual assault
 Shoulder, wrist, arms - Forceful restraint, struggle, defensive, offensive
 Wrists and ankles - Dragging
 Chest - Resuscitation (CPR)

PROBLEMS WITH BRUISES

 Delayed appearance
 Ageing (relative)
 Site of trauma (location of bruise not necessarily the site of impact)  Ectopic Bruise
 Shape of object (not reflected in the appearance of the bruise)
 Degree of force (size of bruise an unreliable indicator of the degree of force causing it)
 Postmortem bruises
 Postmortem lividity

The Dilemma Of Aging Bruises*

James R Lauridson, MD

Clinicians and pathologists are frequently asked to establish the age of a bruise on a living or deceased
person. Law enforcement officers and the public feel that this is a skill that is easy to acquire. Often a
case will hinge on the opinion of a clinician or a pathologist concerning the age of a bruise. It is
difficult to overestimate the importance of opinions offered in these matters.

Two recent studies have been performed comparing colors and known age of bruising (references 2,3).
The first of these by Langlois and Gresham who conducted a prospective study of 369 photos of bruises
of known cause and timing from < 6 hr up to 21 days of 89 Caucasian subjects aged 10–100 yrs.
 Only conclusion from current study: Bruise with yellow color is >18 hr old
 Yellow color appeared faster in subjects <65 years old
 Absence of a yellow color does not mean that the bruise is less than 18 hrs old
 No statement re blue/purple/black/red color
 Bruises of identical age and cause on the same person may not appear as the same color and do not
change at the same rate.
 Color changes should be considered only as general guidelines in interpreting how old a bruise is.
 The best thing to do is to just state that the bruise appears either recent or old.

The second by Stephenson and Bialas studied 23 children having traumatic injuries. The following
conclusions were made by these authors:
 Red is not a good indicator for acute bruising and may appear at any time during the evolution of a
bruise.
 Blue and black cannot be used to estimate of aging.
 Yellow, which has been classically considered a late color, may occur as early as one day.
 Green may occur as early as two days.

These conclusions are similar to impressions drawn by medico-legal officers who have seen many
bruising injuries.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 Estimating injury age by the color of bruising is not scientific and the use of standard color chart tables
can cause miscarriage of justice in either falsely accusing an innocent person or allowing a guilty
person to be free.

AGEING OF BRUISES
 Bruise with a yellow color→ more than 18 hrs. Old
 Old tables re bruise dating by color widely cited, not scientifically proven (Schwartz and Ricci, 1996)
 Timing of bruise appearance
 Deep slower than superficial
 Periorbital/genital bruises appear quickly
 Bruises caused at the same time on a child may have different colors
 History is always important

 Microscopy
 Problem with biological variability
 30 min – 4H→ WBC’s in capillaries
 4H – 12H → PMN’s migrate into tissue
 12H – 3 days→ PMN’s increase, other types appear
 3days – 2 weeks→ this cellular reaction slowly subside with repair with fibrous scar tissue

INCREASED BLEEDING
 Alcoholism – liver disease↓ clotting factors
 Older age – fragile skin and blood vessels
 Hemophilia (and other clotting defects) – reduced clotting
 Medication – warfarin, aspirin
 Leukemia – reduced platelets

DEATH DUE TO EXTENSIVE BRUISING

 Am J for Med Path (Vol 13 1992 179-182)

 5 cases of death in NT asstd. with blunt injuries to skin and soft tissue (no internal body
organ injury)
 At least 20% of body surface area bruised
 Often high alcohol levels
 Mechanism of death : Hemorrhage
: Pneumonia (if survival)
: Fat embolism (esp. if bone fractures also)

ECTOPIC BRUISES
 Bruise at a site not corresponding with impact site
 Black eyes – impact anywhere on head
 Behind knee – impact on upper leg (survival needed)

B. ABRASIONS

 Superficial scraping due to friction impact with a rough surface.

 Removal or destruction of superficial (epithelial) layer of the skin due to contact with a rough
surface or due to friction with a hard-rough surface.
 Open skin, superficial loss of epidermis, dermal layer is visible
 Known as “gasgas”
 Trivial injuries medically but may be the most important injuries forensically
 Pattern: often indicate causative object/surface
 Often indicate direction of impact
 Always occurs at the site of impact
 Retrieval of foreign material: of significant medico-legal value
Abrasions result from friction removing the epidermis, with little or no damage to the dermis. They
heal with no scar.
Ante-mortem abrasions are reddish brown from inflammation and perhaps minor bleeding.
Postmortem abrasions are yellowish, translucent with a fibrin coating resembling parchment.
An abrasion may be the only external sign of blunt force injury, which may have done serious
internal damage.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 Pressure abrasions, from vertical force, are common over the zygoma and the side of the nose and
orbits when someone falls.
Patterned abrasions may tell the nature of the object causing the injury (i.e., tire tracks, pipes, rings
on a fist), or merely the clothing.
Nail scratches need no description; claw marks are deeper, U-shaped lesions that have penetrated
the upper dermis.

MAIN TYPES
 Scratches
 Caused by a sharp-pointed object which slides across the skin like a pin, thorn or fingernail
 Scraping type of injury
 “Kalmot”
 Ex. Dragging abrasion, scratches from fingernails, pins, plant thorns

 Graze or brush burn

 Caused by forcible contact with rough hard objects resulting to irregular removal of the skin
surface
 Commonly seen in large area of the body
 “Hit and run” victim, assault

 Gliding or Friction abrasion

 Pressure or friction abrasion
 Abrasion caused by pressure accompanied by movement, usually observed in hanging or
strangulation
 Skin crushed by force
 Ligature mark in hanging deaths

 Imprint or Patterned Abrasion

 Impact or imprint or patterned or stamping abrasion
 “Abrasion a la Signature”
 Those abrasion whose pattern and location provides objective evidence to show cause,
nature of the wounding material or instrument and the manner assault or death
 Pattern of object imprinted on the skin
 Safety belts, tire tread, car steering wheels

MEDICO-LEGAL INTEREST
 Direction (skin tags)
 Age of the injury
 Pattern and trace evidence

EXAMPLES
 Fingernails scratches to neck (strangling)
 Face, back, hands, knees (“collapse” injuries)
 Back of elbows (struggle, fit)
 Knuckles (fighting)

IDENTIFYING THE WEAPON

 Trivial injuries medically
 Maybe the most important injuries forensically

NON-FATAL SELF-INFLICTED INJURIES

 Reason are multiple
 Psychiatric illness
 Fabricate assaults
 Compensation
 Malingering
 Characteristic features
 Accessible site
 Superficial (especially in sensitive areas)
 Multiple
 Regular in appearance: equal depth throughout

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  If multiple, the parallel
 Avoid sensitive and vital areas
 Clothing removed to expose site
 Overall, look delicate and uniform

C. LACERATION

 Tear of tissue when stretched or crushed beyond its limits of elasticity

 A break in the skin or tissue (putok, punit)
 General rule on blows to the head
 Long object causes linear laceration
 Flat object causes irregular or Y-shaped laceration
 Laceration or tear, rupture, stretch – tear of the skin or underlying tissues due to forcible contact
with blunt instrument open skin.
 Splits and tears of skin and/or soft tissue, due to stretching-shearing or crushing, on the body
surface or deep inside.
 Don't mistakenly call an incised wound, produced with something sharp, a "laceration".
 You can spot lacerations with their irregular, crushed, abraded, undermined, bruised edges, and the
presence of elastic and connective-tissue bridges in their depths. It's usually (not always) easy to
tell from these incised wounds; lesions produced by very dull knives or the edges of boards may
produce difficulties.
 No, the shape of a wound doesn't tell the exact shape of the instrument which produced it. The
classic example is the Y-shaped lesion produced by a metal rod.
 An "avulsion" is a laceration in which a portion of soft tissue has been ripped, or sometimes only a
pocket of blood is created deep in the tissues.

MEDICO-LEGAL INTEREST
 Distinction from incised wound
 Trace evidence (pattern)
 Age of injury

EXAMPLES
 Top of head (scalp) – fall or blow
 Face – fall or blow
 Inside lips (frenulum) – typical punch to mouth

CLASSIFICATION OF LACERATED WOUND

 Splitting - caused by crushing of the skin between two hard objects, seen in scalp, eyebrows, chin
 Overstretching of the skin - pressure applied on one side of the bone, skin over the area will be
stretched up to a breaking point and exposure of the fractured bone
 Grinding compression - the weight and the grinding movement may cause separation of the skin
with the underlying tissues;
 Tearing - maybe produced by semi-sharp-edged instruments which causes irregular edges on the
wound, like hatchet and choppers

AVULSION
 It is the forceful tearing or separations of skin or tissues.

SHARP FORCE TRAUMA

Instead of producing lacerations, pointed and sharp things produce:

Incised wound: The track is less deep than the width of the skin wound.
Stab wound: The track is deeper than the width of the skin wound.
Punctured wound: Caused by sharp, pointed instruments.
Chop or hack wound: Incised wound plus an underlying bone fracture or groove, made by heavy
instruments.

Identifying the Weapon

 Incised wound : Usually forensically useless
 Penetrating wound : Wound characteristics may produce knife blade

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

A. INCISED WOUNDS

 Injury through the tissue, caused by contact with a sharp edge

 Injury from something sharp (like a stab wound), broader than it is deep (in contrast to a stab
wound).
 Wound produced by sharp-edged instrument like blade, razor, scalpel blade, broken glasses and
metal sheets.
 A cut, slice or slash
 It maybe Impact Cut → forcible contact with the cutting instrument
 Or Slice Cut → Injury is due to pressure accompanied with movement of the instrument
 Usually not fatal
 Defensive wound
 Length > depth → Wound that is longer than deep
 Dicing injuries: Incised wound from glass (as a windshield) or gravel
 Iatrogenic wound: Incisions made by doctors in the hospital ER or operating room

- Future pathologists: Don’t be fooled. Leave the tubing in prior to autopsy.

 Suicidal or Homicidal?
 Site - e.g. neck, wrist, face
 Tentative wounds - suicide
 Defense wounds - homicide

 A person may commit suicide by severing an artery, broken glass may cut the neck, or a neck
wound inflicted by a perpetrator may be fatal. (In neck wounds, death is likely to result from air
embolism.) A drunkard or druggie may die after punching out a pane of glass. Other incised
wounds are very rarely fatal.
 "Hesitation marks" are very superficial cuts made by the would-be suicide, prior to
making the fatal deep cut. They are generally present if it's a suicide. However,
perpetrators may also hesitate.
 Would-be suicides seldom shoot, cut or stab themselves through clothing.
 Perpetrators and would-be suicides will use their dominant hand and locate their cuts
accordingly.
 You'll see "defense wounds" on the palms (grabbed the knife), the backs and ulnar
aspects of the arms, and sometimes the legs.
 Homicidal incisions of the neck are usually long and deep if inflicted from the rear,
short if inflicted from the front.

 Most incised wounds have very shallow ends. A "wrinkle wound" is several discontinuous incised
wounds, caused when a knife wrinkles the skin, cutting only the crests.
 The dimensions of an incised wound tell you nothing about the weapon with which it was made.
Again, Langer's lines determine whether the wound will gap. (NOTE: "Gap" is a real verb, cognate
to "gape".)

MEDICO-LEGAL INTEREST
 No pattern (usually)
 No trace evidence
 “Defense” injuries
 “Hesitation” injuries

B. PENETRATING WOUNDS

STAB WOUND

 Are either penetrating or non-penetrating wounds deep into the tissue

 Depth > length → Deeper than long
 Produced by sharp-pointed and sharp-edged instrument like kitchen knife, fan knife or dagger
 Skin markings may tell the type of weapon used
 Homicidal, suicidal or accidental
 Defensive stab wounds
 Determine if single, double or triple bladed instruments
 It is common for stab wounds to be altered by surgeons
 MELO must determine if patient was brought to hospital
 Don‟t remove the knife from the body unless fingerprint was taken
 Examine the clothes
 Post-mortem stab wound → yellow to tan in color

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  Most fatal stab wounds are knife homicides. You can distinguish wounds by sharp instruments
from lacerations by:
a. Clean, sharp margins
b. Absence of bruising at the edges
c. Absence of bridging deep in the tissues
 The sharper the knife, the easier it is to penetrate the skin. Once the skin is penetrated, it's very
easy to go deeper until the bone is hit.
Note that a dull knife will give abraded, bruised margins, and a very dull knife will give jagged,
contused margins.
If tremendous force is used, you may see the pattern of the knife guard. If both ends of a stab
wound are blunt, the ricasso (i.e., the area near the guard where both edges are dull) or the guard
itself actually went in.
Knowledgeable perpetrators twist the knife, once inserted, to allow lungs to collapse and vessels to
be opened. This is likely to turn the skin wound into a "V", "L", or "Y".

 In the real world, it's impossible to determine the size or shape of a knife from the wounds
produced.
If the blade is not completely inserted, the track will be shorter than the blade. If great force is
used, the track will be longer than the blade. (Remember that the chest wall can be deformed
easily.)
If the blade is not completely inserted, the skin wound may be narrower than the blade. If the knife
is not moved straight in and out, the skin wound may be wider than the blade.
The elasticity of the skin may also make the width the width of the wound a few millimeters wider
or narrower than the blade (how?).
The shape of any knife wound will be determined mostly by Langer's lines. If the wound is
perpendicular to the lines, it will gape. If it is parallel, it will remain slit-like.
If the knife has a sharp and a dull edge, one end of the entry wound may be more pointed than the
other. In reality, both ends are usually sharp, since the knife usually enters obliquely and cuts as it
goes, and in any case, both sides of the actual knife tip are often sharp.
If there are multiple stab wounds, it's easier to make an educated guess about how thick and how
long the weapon was.
Future pathologists: Don't probe knife wounds much. You'll make them deeper and learn nothing
useful.

 You can produce a fatal stab wound with anything sharper than a table fork.
Scissors (open or closed), barbecue forks, Philips screwdrivers, broken bottles, and arrows (target
or hunting) all produce fairly distinctive wound patterns.
Some clever perpetrators deliver a single icepick blow into the auditory meatus, hoping the
pathologists will miss the entry wound and also decide, "Must be sudden coronary death, we don't
need to do the head."

 Much less common are fatal stab wounds that are self-inflicted or accidental (falls onto pitchforks,
fences, or knives in dishwater racks).

 Stab wounds kill by involving an important organ.

When the heart is involved, immediate death usually results from hemopericardium (bleeding in
the pericardial sac) and tamponade (compression of the heart by an accumulation of fluid in the
pericardial sac).
When the great vessels are involved, death usually results from hemothorax (bleeding in the chest
cavity) or hemoperitoneum (bleeding in the peritoneal or abdominal cavity).
When the lungs are involved, death usually results from hemothorax, less often from
pneumothorax.
When the gut is perforated, death usually results from peritonitis.
Neck wounds (stab or incised) kill by producing air embolism, asphyxiation, or exsanguination.
Death may also be due to compression of neck structures by a large hematoma.
In stab wounds of the brain, the patient often does not lose consciousness, at least immediately.
Fatal hemorrhage from a stab wound of the extremity is rare unless the femoral artery is severed.

MEDICO-LEGAL INTEREST

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  Bleeding (internal and external)
 Air embolism
 Wound characteristics
 Broken tip of weapon

WOUND CHARACTERISTICS
 Length……….(width of blade)
 Ends…………(sharp vs blunt)
 Depth………..(length of blade)
 “Hilt abrasion”

PUNCTURED WOUND

 Wound caused by a thrust of a sharp pointed instruments

 Like ice pick, nails, needles, pointed stick, thorn, fang of animal hook, spear
 What is more important is the depth of the wound rather than the size
 No prominent bleeding from the wound itself, bleeding /hemorrhage confined inside the body.

HACKED or CHOP WOUND

 Chop (or "hack") wounds are categorized separately because they combine features of incised
wounds and lacerations, or may appear intermediate.
 Caused by heavy cutting instrument or weapon
 Machete, meat-cleaver, axe, bolos, samurai and propeller wounds belong in this category.
 Typically, a chop wound will produce an obvious defect in the underlying bone. Depending on
how sharp the instrument is, the overlying wound may appear to be an incision or a laceration.
 Incised wound with bone cut/groove
 Soft tissue hemorrhage means patient still alive when injury was inflicted
 Injuries could cause decapitations or mutilations

FACTORS RESPONSIBLE FOR THE SEVERITY OF THE WOUNDS

• Hemorrhage
• Size of the Injury
• Organs involved
• Shock
• Foreign body or substance introduced into the body
• Absence of Medical or Surgical Intervention

FATAL EFFECT OF WOUNDS:

1. Wound may be DIRECTLY FATAL (mortal wound) by reason of:
a. Hemorrhage
b. Mechanical Injuries on the vital organs
c. Shock - is the disturbance of the balance of fluid in the body capable of producing delayed
or immediate death.

2. Wound may be INDIRECTLY fatal (non-mortal wound) by reason of:

a. Secondary hemorrhage following sepsis
b. Specific Infection - Septicemia, bacteremia, toxemia. tetanus, gas gangrene
c. Scarring Effect - Stricture, keloid formation
d. Secondary Shock - Septicemia, tetanus, peritonitis, TB meningitis

COMPLICATIONS OF PHYSICAL INJURY

1. Shock - the disturbance in the fluid balance of the body resulting to peripheral deficiency which is
manifested by decreased blood volume, reduced volume flow, hemoconcentration, and renal
deficiency.
- Anoxemia- reduction of the effective volume of oxygen carrying capacity of the blood
- Injury to the receptive nervous system
- Endothelial damage, thus increasing capillary permeability

2. Hemorrhage - is the extravasation or loss of blood from the circulation brought about by wounds in
the cardio-vascular system.

3. Infection - the appearance, growth and development of microorganisms at the site of injury.

4. Embolism - condition in which foreign matters are introduced in the bloodstream causing sudden

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 block of the blood flow in the finer arterioles and capillaries.
- Fat embolism
- Air embolism

HEALING OF WOUNDS
1. Power of human tissue to regenerate;
• Regeneration - is the replacement of destroyed tissue by newly formed similar tissue.
• The following regenerates rapidly:
a. Connective tissues
b. Blood forming tissues
c. Surface epithelium of the skin
• Those with no power or limited capacity to regenerate:
a. Highly specialized glandular epithelium
b. Smooth muscles
c. Neurons of the central nervous system
2. Kinds of healing wounds:
a. Healing by Primary (First) Intention – type of healing which takes place when there is
minimal tissue loss, more approximation of the edges and without significant bacterial
contamination
b. Healing by Secondary Intention – takes place when the injury causes a more extensive
loss of cells and tissues, healing process may produce large scar, greater loss of skin
appendages and slower reparative process;
c. Aberrated Healing Process – in some instances healing process deviates from the normal
way on a normal individual.

MEDICO-LEGAL INVESTIGATION OF WOUNDS

Rules to be observed by the Physician in the examination of wounds:
1. All injuries must be described, no matter how small.
2. Description of the wounds must be comprehensive; a sketch or photograph must be taken.
3. Examination must not be influenced by any other information obtained from others in making
a report or a conclusion.

Medico-Legal Investigation of Physical Injuries

1. General investigation of the surroundings;
2. Examinations of the wounded body:
a. Examinations that are applicable to the living and dead victim.
b. Examinations that are applicable only to the living.
c. Examinations that are applicable to the dead victim.
3. Examinations of the wound:
a. Character of the wound
b. Location of the wound
c. Depth of the wound
d. Condition of the surrounding wound
e. Extent of the wound
f. Direction of the wound
g. Number of wounds
h. Conditions of the locality

DISTINCTION BETWEEN ANTEMORTEM AND POSTMORTEM WOUNDS

Antemortem Wounds
1. Hemorrhage copious and generally arterial
2. Marks of spouting of blood from arteries
3. Clotted blood
4. Deep staining of the edges and cellular tissues
5. Edges gape, owing to the reaction of skin and muscles
6. Inflammation and reparative processes.
Postmortem Wounds

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 1. Hemorrhage slight or none at all, always venous
2. No spouting of blood
3. Blood is not clotted
4. Edges and cellular tissues are not deeply stained.
5. Edges do not gape, but are closely approximated to each other
6. No inflammation or reparative processes.

PROCEDURE IN THE EXAMINATION OF WOUNDS

A. Measure the injury by its length, width and distance from the anterior/posterior midlines (distance
from landmarks like Left/Right heel and apex/vertex of the head)

B. Depth of the wound on cases involving stab wound or punctured wound

C. Measurement of big areas of multiple injuries (abrasions, contusions, hematomas, lacerations,

shrapnel wounds).

References:

 Di Maio & Di Maio. Wounds due to Blunt Trauma. Forensic Pathology. New York, 1993: 87-107.
 Di Maio & Di Maio. Wounds due to Pointed and Sharp, Edged Weapons. Forensic Pathology. New
York, 1993: 171-206.
 Friedlander E. Ed's Pathology Notes on Violence, Accidents & Poisoning. April 1999, From the
Internet.
 Pounder D. Wounds. Department of Forensic Medicine, University of Dundee, 1993. From the
Internet, 17 pages.
 Rebosa A & Villasenor V. Forensic Medicine. UST Medical Board Reviewer in Legal Medicine.
Manila, 2019.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

I. THE PATHOLOGY OF TORTURE

TORTURE
 A “weapon” used
- To extract information or confession
- To destroy an enemy, political or otherwise
- Serves as a warning

 Side effects / Sequelae:

- Physical trauma
- Psychological trauma (PTSD)

 The deliberate, systemic or wanton infliction of physical or mental suffering by one or more
persons alone or on the orders of any authority, to force another person to yield information, or
make a confession, or for any other reason. (Declaration of Tokyo, 1975)

 Any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on
a person for such purposes as obtaining from him or a third person information or a confession,
punishing him for an act he or a third person has committed or is suspected of having committed,
or intimidating or coercing him or a third person, or for any reason based on discrimination of any
kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or
acquiescence of a public official or other person acting in an official capacity. It does not include
pain or suffering arising only from, inherent in or incidental to lawful sanctions. (Article 1 of the
UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or
Punishment / RA 9745 - Anti-Torture Law)

 The infliction of intense pain (as from burning, crushing, or wounding) to punish, coerce, or afford
sadistic pleasure. (Webster’s Dictionary)

 Torture includes such practices as searing with hot irons, burning at the stake, electric shock
treatment to the genitals, cutting out parts of the body, e.g. tongue, entrails or genitals, severe
beatings, suspending by the legs with arms tied behind back, applying thumbscrews, inserting a
needle under the fingernails, drilling through an unanesthetized tooth, making a person crouch for
hours in the Z‟ position, waterboarding (submersion in water or dousing to produce the sensation
of drowning), and denying food, water or sleep for days or weeks on end. (Stanford‟s
Encyclopedia of Philosophy)

 Freedom from Torture and Other Cruel, Inhuman and Degrading Treatment or Punishment, An
Absolute Right → Torture and other cruel, inhuman and degrading treatment or punishment as
criminal acts shall apply to all circumstances. A state of war or a threat of war, internal political
instability, or any other public emergency, or a document or any determination comprising an
"order of battle" shall not and can never be invoked as a justification for torture and other cruel,
inhuman and degrading treatment or punishment. (RA 9745 - Anti-Torture Law, Section 6)

 Prohibited Detention → Secret detention places, solitary confinement, incommunicado or other

similar forms of detention, where torture may be carried out with impunity are hereby prohibited.
(RA 9745 - Anti-Torture Law, Section 7)

 Any confession, admission or statement obtained as a result of torture shall be inadmissible in

evidence in any proceedings, except if the same is used as evidence against a person or persons
accused of committing torture. (RA 9745 - Anti-Torture Law, Section 8)

 Assistance in Filing a Complaint → The CHR and the PAO shall render legal assistance in the
investigation and monitoring and/or filing of the complaint for a person who suffers torture and
other cruel, inhuman and degrading treatment or punishment, or for any interested party thereto.
(RA 9745 - Anti-Torture Law, Section 11)

 Compensation to Victims of Torture → Any person who has suffered torture shall have the right to
claim for compensation as provided for under Republic Act No. 7309: Provided, That in no case
shall compensation be any lower than Ten thousand pesos (P10,000.00). Victims of torture shall
also have the right to claim for compensation from such other financial relief programs that may be

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 made available to him/her under existing law and rules and regulations. (RA 9745 - Anti-Torture
Law, Section 18)

Three Elements of Torture (RA 9745)

1. Any act, whether physical or mental, which results in severe pain or suffering.
2. Is intentionally inflicted or at the instigation of or with the consent or acquiescence of a public
official.
3. For such purposes as obtaining from him/her or a third person information or confession,
punishing him/her for an act he/she committed or intimidating or coercing him/her or a third
person, or for any reason based on discrimination of any kind.

Types of Torture
1. Physical Torture - A form of treatment or punishment inflicted by a person in authority or agent
of a person in authority upon another in his/her custody that causes severe pain, exhaustion,
disability or dysfunction of one or more parts of the body, such as:
a. Systematic beating, headbanging, punching, kicking, striking with truncheon or rifle butt or
other similar objects, and jumping on the stomach;
b. Food deprivation or forcible feeding with spoiled food, animal or human excreta and other
stuff or substances not normally eaten;
c. Electric shock;
d. Cigarette burning; burning by electrically heated rods, hot oil, acid; by the rubbing of pepper
or other chemical substances on mucous membranes, or acids or spices directly on the
wound(s);
e. The submersion of the head in water or water polluted with excrement, urine, vomit and/or
blood until the brink of suffocation;
f. Being tied or forced to assume fixed and stressful bodily position;
g. Rape and sexual abuse, including the insertion of foreign objects into the sex organ or
rectum, or electrical torture of the genitals;
h. Mutilation or amputation of the essential parts of the body such as the genitalia, ear, tongue,
etc.;
i. Dental torture or the forced extraction of the teeth;
j. Pulling out of fingernails;
k. Harmful exposure to the elements such as sunlight and extreme cold;
l. The use of plastic bag and other materials placed over the head to the point of asphyxiation;
m. The use of psychoactive drugs to change the perception, memory. alertness or will of a
person, such as:
(i) The administration or drugs to induce confession and/or reduce mental competency; or
(ii) The use of drugs to induce extreme pain or certain symptoms of a disease; and
n. Other analogous acts of physical torture
2. Mental or Psychological Torture - Refers to acts committed by a person in authority or agent of
a person in authority which are calculated to affect or confuse the mind and/or undermine a
person's dignity and morale, such as:
a. Blindfolding;
b. Threatening a person(s) or his/fher relative(s) with bodily harm, execution or other wrongful
acts;
c. Confinement in solitary cells or secret detention places;
d. Prolonged interrogation;
e. Preparing a prisoner for a "show trial", public display or public humiliation of a detainee or
prisoner;
f. Causing unscheduled transfer of a person deprived of liberty from one place to another,
creating the belief that he/she shall be summarily executed;
g. Maltreating a member/s of a person's family;
h. Causing the torture sessions to be witnessed by the person's family, relatives or any third
party;
i. Denial of sleep/rest;
j. Shame infliction such as stripping the person naked, parading him/her in public places,
shaving the victim's head or putting marks on his/her body against his/her will;
k. Deliberately prohibiting the victim to communicate with any member of his/her family; and
l. Other analogous acts of mental/psychological torture.

Medico-Legal Examination of Alleged Torture Victims

Clinical History

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  Information about the victim
 Information about the perpetrator
 Information about the events
 Consent for video documentation and subsequent examination/autopsy
 Radiologic studies
Medical Examination
 Note all pertinent positive and negative findings
 Documentation with photographs
 For each lesion and for the overall pattern of lesions, the physician should indicate the degree of
consistency between it and the attribution given by the patient.
 The following terms are generally used:
- NOT CONSISTENT: The lesion could not have been caused by the trauma described
- CONSISTENT WITH: The lesion could have been caused by the trauma described, but it
is non-specific and there are many other possible causes
- HIGHLY CONSISTENT: The lesion could have been caused by the trauma described,
and there are few other possible causes
- TYPICAL OF: This is an appearance that is usually found with this type of trauma, but
there are other possible causes
- DIAGNOSTIC OF: This appearance could not have been caused in any way other than
that described
Medico-Legal Report
 Unbiased, impartial
 Effective written reports and oral testimony not only require knowledge of torture and its after-
effects, but they also require accurate and effective communication skills.
 Written reports and oral testimony of clinicians should not include any opinion that cannot be
defended under oath or during cross-examination.
Contents of the Medico-Legal Report
 Case Information
 Background Information
- General Information: (age, occupation, education, family composition, etc.)
- Past Medical History
- Review of Prior Medical Evaluations of Torture and Ill-treatment:
- Psychosocial History Pre-Arrest

 Allegations of Torture and Ill-Treatment

- Summary of Detention(s) and Abuse
- Circumstances of Arrest and Detention
- Initial and Subsequent Places of Detention: (chronology, transportation, and detention
conditions)
- Narrative Account of Ill-treatment of Torture: (in each place of detention)
- Review of Torture Methods

 Physical Symptoms and Disabilities

- Describe the development of acute and chronic symptoms and disabilities and the
subsequent healing processes.
- Acute Symptoms and Disabilities
- Chronic Symptoms and Disabilities

 Physical Examination
 Photographs
 Diagnostic Test Results
 Consultations
 Conclusions and Recommendations
- Statement of opinion on the consistency between all sources of evidence cited above
(physical and psychological findings, historical information, photographic findings,
diagnostic test results, knowledge of regional practices of torture, consultation reports,
etc.) and allegations of torture and ill-treatment.
- Reiterate the symptoms and/or disabilities that the individual continues to suffer as a

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 result of the alleged abuse.
- Provide any recommendations for further evaluation and/or care for the individual.
Interpretation of Findings

 Physical Evidence:
- Correlate the degree of consistency between the history of acute and chronic physical
symptoms and disabilities with allegations of abuse.
- Correlate the degree of consistency between physical examination findings and
allegations of abuse. (Note: the absence of physical findings does not exclude the
possibility that that torture or ill-treatment was inflicted.)
- Correlate the degree of consistency between examination findings of the individual with
knowledge of torture methods and their common after-effects used in a particular region.

Diagnostic Features of Torture

1. Beating and Kicking

 Most common
 Usually a prolonged and dynamic occurrence
 Look for patterned injuries
 Skin with redness, swelling, intradermal bruising, subcutaneous bruising, surface abrasions
 Where the skin is lacerated, healing will be by scarring, leaving linear or other marks
 Double railway line (blows from a rod or thong)
 Cutting and piercing

2. Falanga
 Most common
 Also called falaka or bastonado
 The beating of the soles of the feet with blunt implements such as sticks, clubs, thin rod or rifle
butts
 Origins in the Middle East, but has been documented in India, Algeria, Uganda, Chile, Peru, Iran,
Bangladesh, and Azerbaijan.
 Usually goes on for hours and days and causes severe long-term damage
 Effects:
- Swelling and bruising in various fascial compartments of the foot
- Foot pads may be crushed
- Fractures
 Long term effects
- Chronic pain in the plantar fascia (arch) → profound limp
- Closed compartment syndrome
 Muscle necrosis
 Vascular obstruction
 Gangrene of the distal foot or toes
- Crushed heel and anterior footpads
- Fixed dorsiflexion of the great toe due to the destruction of the plantar aponeurosis
 Medical Documentation
- CT, MRI, bone scintigraphy (bone scan) may help in the documentation of the lesions.
- Scintigraphy → contrast binds to osteoblasts which demonstrate activity in any injury,
neoplastic or metabolic diseases of bone.
- Positive bone scan:
 Average: 5.5 years
 Longest: 12
- MRI:
 Thickening of the plantar aponeurosis (arch)
 No differences in the plantar musculature or plantar (heel) fat pad
- Ultrasound:
 Hypertrophy of the plantar aponeurosis
 Cheaper and more accessible imaging option as compared to both bone scan and
MRI

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

3. Telefono
 Damage to ears via “telefono technique” → hands are clapped violently against the side of the
head
 The infliction of simultaneous blunt force impacts against both ears, creating a pressure wave
that may cause rupture of the tympanic membranes and subsequent scar formation therein.
 Tympanic membrane ruptures less than 2 mm in diameter may heal within 10 days.
 Dislocation of the ossicles
 Fluid may be observed in the middle or external ear (otorrhea)

4. Suspension: Various Forms

a. Palestinian Hanging
- Victim hung by the hands which are tied together behind his back
- Injury to shoulder joint
b. Parrots Perch or Pau de Arara
- Suspension from a horizontal pole placed under the knees with the wrists bound to the
ankles
- Results in bruises and scars on the wrist and the back of the knees
- Permanent neurological damage may also become associated.
- Rupture of the cruciate ligaments of the knees or sensory or vascular damage below the
knees
c. Butchery Suspension
- Victim is hung either by the hands (“la bandera”) or the feet (“murcielago”)

5. Submarino
 Suffocation and partial drowning
a. Wet submarino
- A form of water torture where the victim is forced under water to the point of suffocation
or beyond
- When death occurs, the usual signs of drowning will be seen
- Aspiration into the airways of feces or other material when prisoners are forcibly
submerged into contaminated water
- Immersion in foul sewage
- Long-lasting cold showers have also been described
b. Dry submarino
- Partial asphyxia by holding a plastic bag over the head
- A plastic bag is tied over the head
- When the victim tries to bite his way out of it, he is beaten
- Dry submarino does not in itself produce any detectable lesions

6. Sexual Torture
 Suffocation and partial drowning
 Ranges from verbal abuse and humiliation to violent rape and sodomy
 Women may be forced to undress or parade naked in front of soldiers
 Males are subject to sodomy and in some regions this is said to be the rule rather than the
exception. Subsequently such victims may encounter sexual problems.

7. Electrical Torture
 Applied to skin, tongue, breast, nipples, penis or vulva
 Picana – current is applied with a pointed object
 Acute lesions at points of contact → reddish-brown without an acute inflammatory reaction
 May produce pigmented scars.
 Microscopically:
- Streaming of the epidermal nuclei
- Metals from the electrode such as copper or iron in the tissue sections by staining
techniques
- Lesions are segmental in contrast to the diffuse effects of heat.
- Calcification

8. Saw Horse
 El caballete
 A hard object on which the victim is forced to sit astride for hours or days.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

9. Prolonged standing
 Combined with constant loud noise and/or bright light → sleep deprivation, excessive sensory
stimulation, exhaustion
 Edema and petechiae of the legs

10. Positional torture

11. Dental torture

 “Going to the dentist”
 Extraction of teeth without anesthesia
 Often leaves late sequelae that can be documented by forensic odontologists.

12. Animal Bites

 May be difficult to differentiate from non-specific scratches and the scars are usually non-
specific.
 Dogs, rats, spiders and insects are often used for this purpose.

13. Burns
 May be applied with instruments such as metal rods and may leave characteristic patterned scars.
 Also, burns from hot irons, electric heating rings, cigarettes, ignited kerosene-soaked rags or
molten rubber, “battery fluid” in the form of sulfuric acid

14. Sleep Deprivation

 Physical and psychological aspects
 Leaves no trace
 UN Committee against Torture → “sleep deprivation for prolonged periods” constitutes torture

15. Food and Water Deprivation

 Frequent methods
 Acute stage of dehydration, it is possible to measure electrolyte disturbances, but only within a
few hours of release of captivity
 Malnutrition may only be evident in the first few days after release and it is important that it is
documented

16. Belana
 Or “The Roller”
 First described in 1994 in Kashmir
 A pole is placed on the victim → pressed down → rolled up over the legs and the body
 Ghotna in Punjab four feet long and four inches in diameter used for grinding corn or spices
 Crushes soft tissue including extensive damage to muscles → myoglobin release → renal failure
 Deep bruising is best illustrated by MRI or CT scan

17. Flogging
 Leaves a linear, often double contoured (“tramline”) pattern and may heal with hyperpigmented
scars.

18. Drugs
 Often administered to weaken the resistance or, as in the former Soviet Union, to alter the
prisoner’s personality.
 Usually detectable in the period shortly after release: both urine and blood samples may be of
value if they can be obtained early and analyzed

19. Shaking of the Head

 Shaken adult syndrome
 Subdural hematoma and retinal hemorrhages

20. Nail Torture

 Pointed objects are inserted under the finger or toenails or nails may be torn off.
 When they subsequently grow out, they may be deformed.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  The differential diagnosis is fungal nail infection that will be evident as crumbling, thickened
nails, and the mycological infection can be confirmed microbiologically.

21. Long standing application of ropes or chains

 There may be chronic wounds that may heal with scar formation and possibly atrophic skin
changes. Scars will often be linear and circumferential around the limb extremity

Some Common Psychological Torture Methods

 Threats
 Mock executions
 Isolation
 Witnessing torture sessions
 Sleep deprivation
 Constant exposure to bright light
 Not allowed to wash or to go to toilet
 Sexual humiliation
 Not allowed to wear clothes
 Constant interrogation
 Loud noise
 Total sensory deprivation
 Not allowed to be alone in the toilet
 Excrement abuse

Penalties for Violation of the Anti-Torture Law (RA 9745)

a) The penalty of reclusion perpetua shall be imposed upon the perpetrators of the following acts:
(1) Torture resulting in the death of any person;
(2) Torture resulting in mutilation;
(3) Torture with rape;
(4) Torture with other forms of sexual abuse and, in consequence of torture, the victim shall have
become insane, imbecile, impotent, blind or maimed for life; and
(5) Torture committed against children.
b) The penalty of reclusion temporal shall be imposed on those who commit any act of
mental/psychological torture resulting in insanity, complete or partial amnesia, fear of becoming
insane or suicidal tendencies of the victim due to guilt, worthlessness or shame.
c) The penalty of prision correccional shall be imposed on those who commit any act of torture resulting
in psychological, mental and emotional harm other than those described in paragraph (b) of this
section.
d) The penalty of prision mayor in its medium and maximum periods shall be imposed if, in
consequence of torture, the victim shall have lost the power of speech or the power to hear or to smell;
or shall have lost an eye, a hand, a foot, an arm or a leg; or shall have lost the use of any such
member; Or shall have become permanently incapacitated for labor.
e) The penalty of prision mayor in its minimum and medium periods shall be imposed if, in consequence
of torture, the victim shall have become deformed or shall have lost any part of his/her body other
than those aforecited, or shall have lost the use thereof, or shall have been ill or incapacitated for labor
for a period of more than ninety (90) days.
f) The penalty of prision correccional in its maximum period to prision mayor in its minimum period
shall be imposed if, in consequence of torture, the victim shall have been ill or incapacitated for labor
for mare than thirty (30) days but not more than ninety (90) days.
g) The penalty of prision correccional in its minimum and medium period shall be imposed if, in
consequence of torture, the victim shall have been ill or incapacitated for labor for thirty (30) days or
less.
h) The penalty of arresto mayor shall be imposed for acts constituting cruel, inhuman or degrading
treatment or punishment as defined in Section 5 of this Act.
i) The penalty of prision correccional shall be imposed upon those who establish, operate and maintain
secret detention places and/or effect or cause to effect solitary confinement, incommunicado or other
similar forms of prohibited detention as provided in Section 7 of this Act where torture may be carried
out with impunity.

j) The penalty of arresto mayor shall be imposed upon the responsible officers or personnel of the AFP,
the PNP and other law enforcement agencies for failure to perform his/her duty to maintain, submit or

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 make available to the public an updated list of detention centers and facilities with the corresponding
data on the prisoners or detainees incarcerated or detained therein, pursuant to Section 7 of this Act.

Duration of Penalties
1. Reclusion Perpetua → 20 years and 1 day to 40 years
2. Reclusion Temporal → 12 years and 1 day to 20 years
3. Prision Mayor → 6 years and 1 day to 12 years
4. Prision correccional → 6 months and 1 day to 6 years
5. Arresto Mayor → 1 month and 1 day to 6 months
6. Arresto Menor → 1 day to 30 days

“History repeats itself endlessly for those who are unwilling to learn from the past.”

- Leon Brown

#NeverAgainToMartialLaw

J. MEDICO-LEGAL ASPECT OF GUNSHOT WOUNDS

Gunshot Wound:

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  GSW - Wound caused by a bullet that was fired from a firearm
 The following accompanies the exiting bullet:
- Jet of flame 2 inches in length, 1400°F
- Cloud of gas
- Gun powder, burning and unburnt grains
- Soot or carbon from burnt gun powder
- Vaporized metal from bullet, cartridge case, and primer

Penetrating GSW: Occur when a bullet enters an object and does not exit.
Perforating GSW: The bullet passes completely through the object.

FORENSIC QUESTIONS WITH GUNSHOT INJURIES

 Which weapon?
- If more than one firearm at the scene
- If only one firearm, can you presuppose that weapon was fired?
- Collect fingerprints and DNA of firer on the weapon
- Victim’s blood and tissue on weapon
- Cartridge (still on firearm or ejected if an automatic weapon) → firing pin mark, ejector
pin mark, bridge face mark
- Bullet → Retrieved from body during autopsy, crime scene, etc; rifling score marks →
class characteristics (land and groove marks) and individual characteristics (fine
machining, scratch-like marks)
 Range of fire?
- The most useful aspect to be determined from the postmortem examination
- Why is it important? → Suicide vs Homicide / Accident
- Determined by evidence of:
 Muzzle imprint
 Scorching (due to flame)
 Gray discoloration of smoke (ie. burnt powder)
 Presence of unburnt powder
 Tattooing or stippling
 Wadding impact and spread of pellets if a shotgun
 Who pulled the trigger?
- If more than one suspect
- Fingerprints and trace DNA of firer on firearm (trigger, etc)
- Gunshot residues (GSR) on hands of firer (primer, powder, smoke) → Problem: regular
gun handling, false positives
 Others
- Direction of fire?
- Physical activity possible after the injury?

CATEGORIES: RANGE OF FIRE

1. Contact GSW
- The muzzle of the weapon is held against the surface of the body at the time of discharge
- May be hard, loose, angled or incomplete
- All residue is within the wound track
- Burnt wound edges
- Characteristics: Muzzle imprint or stellate-shaped or star-shaped laceration in the entrance
- Since the barrel contacts the skin, the gases released by the fired round go into the subcutaneous
tissue and cause the star-shaped laceration
a. Hard-contact GSW
- The muzzle of the weapon is jammed "hard" against the skin, indenting it, so that the skin
envelops the muzzle.

- The immediate edges of the entrance are seared by the hot gases of combustion and
blackened by the soot, which is embedded in the seared skin and cannot be completely
removed either by washing or vigorous scrubbing of the wound.
b. Loose-contact GSW

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 - The muzzle is held lightly against the skin.
- Soot is deposited in a zone around the entrance. This soot can be easily wiped away.
c. Angled-contact GSW
- The barrel is held at an acute angle to the skin so that the complete circumference of the
muzzle is not in contact with it.
- Gas and soot escaping from the gap, where contact is not complete, radiate outward from
the muzzle, producing an eccentrically arranged pattern of soot.
d. Incomplete contact GSW
- Variation of angle-contact wounds.
- Muzzle in contact with contoured skin surface (the body surface is not completely flat)
resulting in muzzle-skin gap.
- Variably located seared blackened zone adjacent to the wound.

2. Near Contact GSW

- Muzzle a very short distance from skin (gray zone between contact and intermediate-range
wounds).
- Wide blackened zone of soot baked into seared skin around wound (may not be distinguishable
from loose contact).
- In near contact angled wounds, the blackened seared zone on same side as muzzle, i.e., pointing
toward the weapon. That is the opposite of what is found in angled contact wounds.
- Scorching / burning / singeing / burning of hairs from muzzle flame
- Muzzle to target distance → 1 to 3 inches

3. Close Range GSW

- Soot / smudging / smoke staining on skin around entrance (can be wiped off)
- Muzzle to target distance → 3 to 6 inches

4. Intermediate Range GSW

- Powder stippling or tattooing → Cannot be wiped away; they are not burns
- Muzzle to target distance within about arms length, i.e., 2 to 3 feet.
- Sine qua non is individual, red-brown to orange-red propellant grain or powder tattooing.
- May be blocked by hair or clothing.
- Powder tattooing is an antemortem phenomenon and indicates that the individual was alive at the
time when shot.
- Postmortem tattooing have a moist gray or yellow appearance rather than the reddish-brown to
orange-red coloration of an antemortem wound.
- Reddish-brown to orange-red coloration of the powder tattooing → An antemortem phenomenon

5. Distant Range GSW

- Absence of gunshot residue
- Muzzle to target distance greater than about 2 feet or 24 inches
- One that exceeds the range at which powder tattooing occurs (beyond 2 to 3 feet)
- Round or oval with sharp margin
- Irregular abrasion ring due to; deformed bullet, wrong angle of bullet, irregularity of skin
- Jacketed bullet usually will not cause abrasion ring

ENTRANCE VERSUS EXIT WOUNDS

Entrance Wounds:
- Smaller than exit wounds
- Presence of an abrasion ring or contusion collar → which occurs when the bullet abrades the edges
of the hole as it indents and pierces the skin; not due to the bullet's rotational movement as it goes
through the skin; also not due to the bullet burning the skin; entrance wounds of the palms and the
soles as well as reentry wounds of the axilla usually do not have abrasion rings
- Round or oval in appearance
- Well-defined shape → usually neat appearance
- Inverted margins

Exit Wounds:
- Larger than entrance wounds
- Absence of contusion collar
- Irregular, not well-defined → Can be stellate, slit-like, crescent, circular or completely irregular

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 - Shored exit wounds - exit wounds with abraded margins
- Everted margins

Distinction Between Gunshot Wound of Entry from Exit

Characteristics GSW of Entry GSW of Exit

1. Size Usually smaller than the bullet or Usually bigger or larger than
missile the bullet or missile

2. Shape Round or Oval No definite shape

3. Edges Inverted Everted

4. Contusion Collar/Abrasion Always present Maybe absent

Ring

5. Singeing or burning of hairs Maybe present in contact/ near Always absent

fire within a distance of 3- 6
inches

6. Smudging, soot or smoke Maybe present in contact/near Always absent

fire within a distance of 6-
12 inches

7. Tattooing or stripling Maybe present in contact/near Always absent

fire within a distance of up 24
inches

8. Presence Always present after firing Maybe absent

9. Underlying tissues Not protruding Maybe seen protruding from

the wound

10. Paraffin Test Maybe positive Always negative

MISCELLANEOUS ENTRANCE WOUNDS

1. Grazed GSW - shallow; no actual perforation or tearing of the skin
2. Tangential GSW - extends down through the SQ tissue; skin is lacerated or torn by the bullet
3. Superficial perforating GSW - shallow through and through wounds in which the entrance and exit are
close
4. Re-entry wounds - bullet has passed one part of the body and then reentered another part
5. Shoring of an entrance wounds

STIPPLING: POWDER TATTOOING VERSUS PSEUDO-POWDER TATTOOING

1. Stippling
2. Powder tattooing - differentiate from postmortem insect bites
3. Pseudo-powder tattooing

BULLET WOUNDS OF THE SKULL

1. Bevelling
2. Gutter wounds - tangential wounds of the skull
3. Keyhole wound of the bone - bullet strikes the skull at a shallow angle

EXAMINATION OF THE CLOTHING

 If the bullet has gone through the clothing, the clothing should always be examined for the
presence of soot or gunpowder.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  The clothing may actually filter the gunshot residue, and if the clothing is not examined, one will
be presented with a GSW that has the appearance of a distant wound even though it is close
range.

CALIBER DETERMINATION BY SIZE OF ENTRANCE WOUNDS

 One cannot determine the caliber of the bullet that caused a particular entrance wound in the skin
by the measuring the size or diameter of the wound.
 In regard to bone, full metal jacketed bullets tend to produce entrance wounds in the bone with
the same diameter as the bullet.
- Caliber .25 FMJ bullet → 6 to 7 mm hole
- Caliber .22 lead bullet → 5 to 6 mm holes

Bullet Wipe - Gray coloration to the abrasion ring due to soot

Backspatter - Ejection of blood and tissue from an entrance GSW; common with shotguns or .357
Magnum

INVESTIGATION OF SUICIDE DUE TO FIREARMS

 GSW is within arm’s reach
 Weapon should be present at the scene
 Usually located in the temple, mouth, anterior neck, chest
 Not in the eye or back
 Suicide handgun wounds occur primarily to the head (80%), the chest (15%) and abdomen
(<5%) being less common.
 Within the head the common sites, in decreasing order of frequency, are temple, mouth,
undersurface of the chin and forehead. An unusual location raises a presumption of homicide.
 Suicidal shotgun wounds show the same site preference as handguns. Rifle wounds show a
distribution of head 50%, chest 35%, abdomen 15%.
 Women rarely use gun
 Multiple gunshot wounds suggest homicide.
 Most suicidal GSWs are contact and involve the head
1. For handguns, the temple is the favorite site, followed by the mouth, under the chin or
between the eyes.
2. Approximately 5% of right-handed individuals will shoot themselves in the left temple.
3. With long arms, the favorite sites in the head – temple and the mouth
 A contact wound creates a presumption of suicide rather than accident.
 A US study by Kohlmeier et al. revealed that 98% of suicidal GSW are contact wounds
 92.5% of homicidal GSW are intermediate or distant range, only 3% are contact wounds
 The majority of suicides (including gunshot suicides) do not leave suicide notes; it is only in 25%
of cases where a suicide note is found.
 In approximately 20-25% of the cases in which suicide is committed with a handgun, the
handgun will be found clutched in the hand. For long arms, this is approximately 20%.
 With rifle and shotgun wounds to the trunk (of the body) the trajectory may corroborate suicide.
With the weapon butt on the ground and the body hunched over it, the trajectory is downwards
(not upwards). Reaching for the trigger with the right hand rotates the body so that the trajectory
is right to left (vice versa if reaching with the left hand).
 Suicide by multiple gunshot is uncommon but not rare. → A victim may “test fire” the weapon
before inflicting the fatal shot.
 Occasionally, high velocity impact blood spatter will be deposited on the back of the hand
steadying the muzzle and the back of the firing hand.
 The hand holding the muzzle may show soot deposition on the radial margin of the forefinger
and the adjacent surface of the thumb and the radial half of the palm due to muzzle blast. With
revolvers the cylinder blast may cause soot deposition on the ulnar half of the palm.
 Contact wounds to cotton or cotton mixture cloth from medium and large calibre weapons
typically produces cruciform tearings; with synthetic materials there are burn holes with
scalloped melted margins.
 Tearing is less prominent with smaller amounts of gas from .22 rimfire ammunition. A gray to
black rim of “bullet wipe” may be present around the entrance hole.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

PROCEDURE IN THE EXAMINATION OF GUNSHOT WOUND
 Point of entry, shape/pattern, size, location (distance from landmarks like midlines, heel and
apex), characteristics, penetrance, direction
 Internal path or damages or trajectory
 Point of exit, shape/pattern, size, location
 Presence of re-entry GSWs

EXPLOSION INJURIES (SHRAPNEL WOUNDS)

When an explosion occurs, the generation of huge volumes of gas, expanded by chemical interaction and
great heat, causes a compression wave to sweep outwards;

 At the origin, this is many times the speed of sound, but rapidly slows down;
 The pure blast effects cause either physical fragmentation, disruption and laceration of the
victim, from high pressure and hot gas striking the body.

Effects of Explosive Devices

 Burns, both from the near effects of the explosion and secondary burns from conflagrations
started by the bomb;
 Missile injuries from parts of the bomb casing and from adjacent objects and fragments projected
by the explosion;
 Peppering by small fragments, debris, and dust propelled by explosion;
 Injuries due to the collapse of buildings, roofs, ceilings, etc.;
 Injuries and death due from vehicular damage or destruction, such as decompression, fire, and
ground impact of bombed aircraft and crash damage to cars, trucks, buses, etc.

K. ALCOHOLISM AND DRUG DEPENDENCE

ALCOHOL ABUSE
• Alcoholism or alcohol dependence is definedby t he American Medical Association (AMA) as:
 “a primary, chronic-disease with genetic, psychosocial, and environmental factors
influencing its development and manifes tations"

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 Description:
Alcoholism is characterized by:
A prolonged period of frequent, heavy alcohol use. The inability to control drinking once it has begun.
Physical dependence manifested by withdrawal symptoms when the individual stops using alcohol.
Tolerance or the need to use more and more alcohol to achieve the same effects.
A variety of social and/or legal problems arising from alcohol use.

Effects of Alcohol (mg/100ml alcohol in blood)

30-50- Impairment of driving and similar skills;
50-100- Reduced inhibitions, talkativeness, laughter, slight sensory disturbance;
100-150- Incoordination, unsteadiness, slurred speech;
150-200- Obvious drunkenness, nausea and ataxia; 200-300- Vomiting, stupor, possibly coma;
300-350- Danger of aspirating vomit, stupor or coma;
Over 350- Progressive danger of death from respiratory paralysis.

Symptomatic Changes Following Ingestion of Alcoholic Beverages:

 Stage of Excitement- feeling of wellness and slight excitation, actions, speech and emotions are
less strained.
 Stage of Confusion or Incoordination- muscular coordination is lost, blunting of all perceptive
mechanism. Nausea, vomiting, confusion, cardiac and respiratory symptoms appear.
 Stage of Narcosis or Coma- person passes into a deep sleep, pupils are dilated, breathing is
slow, and reflexes abolished. Death from paralysis of the cardiac or respiratory center.

L. POISONING AND FORENSIC TOXICOLOGY

Medico-legal Aspects of Poisoning

 Poisoning consist of damage to tissues by any chemical agent:

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  Accidental Poisoning- children eating tablets in mistake of sweets; faulty gas appliance,
contaminated sacks of grain or soft drink bottles.
 Suicidal Poisoning- most common method of self-destruction.
 Homicidal poisoning- traditional weapons of poisoner include heavy metals such as arsenic,
antimony, strychnine and cyanide

POISON:
A substance that is capable of causing the illness or death of a living organism when introduced or
absorbed. Synonyms: toxin, toxicant, venom, bane; Any substance that can cause severe organ damage
or death if ingested, breathed in, or absorbed through the skin.

Recognition of Poisoning
1. Sudden vomiting and diarrhea
2. Unexplained coma, especially in children
3. Coma in adult known to have a depressive illness
4. Rapid onset of a peripheral neuropathy such as wrist drop
5. Rapid onset of peripheral neuropathy or gastro-intestinal illness in persons known to be
occupationally exposed to chemicals

Samples Required for Toxicological Analysis

 Blood
 Urine
 Vomit and stomach contents
 Feces
 Liver and other organs (bile, lungs (glue sniffers))
 Hair and nail clippings Medicinal Poisons
 Analgesics
 Anti-depressant and sedative drugs
 Barbiturates (hypnotics)
 Chloral (trichloracetyldehayde)
 Phenacetin (phenacetin-aspirin-codeine preparation)
 Lithium (Psychiatric drug)
 Insulin

Medicinal poisoning, also called Drug Poisoning, harmful effects on health of certain therapeutic drugs,
resulting either from overdose or from the sensitivity of specific body tissues to regular doses (side
effects).

Corrosive and Metallic Poisons

 Corrosive Poisons
1. Acids such as strong mineral acids (sulfuric, nitric and hydrochloric acids) together with- organic
acids like acetic, formic and oxalic acids
2. Alkalis like sodium hydroxide (caustic sodas or lye), potassium hydroxide and calcium hydroxide
(lime)
3. Miscellaneous substances such as Lysol, salts of heavy metals such as chlorides of mercury,
zinc, etc. household bleaches and strong detergents.

Poisoning by strong acids, alkalies, strong antiseptic including bichloride of mercury, carbolic acid
phenol, Lysol, cresol compounds, tincture of iodine, and arsenic compounds. These agents cause tissue
damage similar to thatcaused by burns. If the substances have been swallowed any part of the
alimentary canal may be affected. Tissues
involved are easily perforated. Death may result from shock or from asphyxiation caused by
swelling of the throat.

METALLIC POISONS
 Heavy metal poisoning is the toxic accumulation of heavy metals in the soft tissues of the
body
1. Antimony
2. Mercury
3. Lead
4. Thallium
5. Iron

Agro-Chemical Poisons
 Pesticides
 Insecticides
 Herbicides (weed killers)

Gaseous Poisons
 Carbon monoxide

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  Carbon dioxide
 Ammonia
 Cyanogen gas and cyanides

Miscellaneous Poisons
1. Strychnine (use to kill pests, from earthworms to dogs)
2. Halogenated hydrocarbons (fire extinguishers, refrigeration and air conditioning)
3. Gasoline and kerosene
4. The glycols (industrial solvents and anti- freeze agents for motor vehicles

Strychnine Poisoning
• is a form of acute poisoning caused by the toxic agent Strychnine. It can be fatal to humans
and other animals and can occur by inhalation, swallowing or absorption through eyes or
mouth.
• It produces some of the most dramatic and painful symptoms of any known toxic reaction,
making it quite noticeable and
• a common choice for assassinations and poison attacks.
• For this reason, strychnine poisoning is often portrayed in literature and film.

M. PREGNANCY AND ABORTION

Legal Importance of Pregnancy

1. To substantiate a claim for divorce;
2. Claim of breach of promise or charge of seduction;
3. Alleged criminal abortion;
4. Civil disputes about the estate of dead husband;

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 5. Excused attendance as a witness in court; pregnancy of a convicted woman may postpone
or cancel the execution;
6. Charges of Infanticide or concealment of birth;
 For a variety of reasons, pregnancy maybe pretended and may require medical
evidence to disprove the condition.

Legal Termination of Pregnancy:

1. The termination must be performed by a registered medical practitioner;
2. Carried out in a health service hospital
3. Two doctors must examine the woman (not necessarily together);
4. Termination must be notified to Medical Officers of the appropriate govt. department;
5. There four circumstances from which the two certifying doctors must certify as the reason for
the termination of pregnancy:
a) it would endanger the life of the woman;
b) it would endanger her physical and mental health;
c) it would involve danger to the physical or mental health of any existing children;
d) that there is substantial risk that if the child were born, it would suffer physical or mental
abnormalities as to be seriously handicapped.

ABORTION
An Abortion- is the willful killing of the fetus in the uterus, or violent expulsion of the fetus from the
maternal womb and which results to the death of the fetus. Maybe Natural, Therapeutic or Criminal.

Causes of abortion
1. Death of the fetus- Congenital abnormality, poisoning
2. Abnormality of the uterus
3. Emotional condition- Fright, grief, anger
4. Abortificient drugs- Ergot, purgatives, Quinine, Lead and Mercury
5. Trauma- Direct or indirect
6. Hormonal deficiency
7. Acute specific fever and high temperature

Clinical Types of abortion

1. Missed Abortion- An ovum destroyed by hemorrhage into the choriospace, usually before the
fourth month of pregnancy. The hemorrhage takes place from maternal sinuses into the
decidua.
2. Threatened Abortion- Hemorrhage without dilatation of the internal os. Hemorrhage in early
stage of pregnancy maybe due to other causes other than threatened Abortion, it may be due to
ectopic pregnancy, cervical polyp, extensive erosion of the cervix.
3. Inevitable Abortion- Hemorrhage with dilatation, of the internal os and presence of rhythmical
pain.
4. Incomplete Abortion- Not all the product of conception has been expelled from the uterus,
fragments or portions of which is retained.
5. Complete Abortion- The whole product of conception is expelled.

Provisions of the revised penal code on abortion

1. Intentional Abortion- Any person who shall intentionally cause abortion, thru violence, use of
drugs or beverages, with or without the consent of the pregnant woman.
2. Unintentional Abortion- Any person who shall cause an abortion by violence, but
unintentionally.
3. Abortion practiced by the woman herself or by her parents, for the purpose of concealing
dishonor.
4. Abortion practiced by a physician or midwife and dispensing of abortive.

Kinds of abortion
1. Spontaneous or Natural Abortion- Abortion which occurs without any form of inducement or
intervention.
2. Induced Abortion- Abortion which will not take place had it not been for some form of
inducement or intervention. It maybe:
 Therapeutic Abortion- Abortion purposely done to preserve the life of the mother; Abortion
which the law allows under some specific justifications.
 Criminal Abortion- Abortion done without ant therapeutic indication but with criminal
intent and punishable by law.

Methods of Performing Abortion:

1. Drugs and toxins;
2. Instrumentation;
3. General Violence;
4. Local Interference;
5. Syringe Aspiration

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 Fatal Effects of Illegal Abortion:
1. Hemorrhage, from local genital trauma;
2. Sepsis, due to unsterile instruments or methods and lack of antibiotic cover;
3. Shock, maybe associated with hemorrhage or perforation of the vagina, uterus or adjacent
organs;
4. Air embolism, use of Higginson syringes (used to inject fluid into the uterus to separate the
chorionic membranes from the decidua);

Complications such as; leg vein or pelvic vein thrombosis, pulmonary embolism, disseminated intravascular
coagulopathy, renal failure, pyemia and septicemia.

N. MEDICO-LEGAL ASPECT OF SEXUAL VIOLENCE

Defloration
 Laceration or rupture of the hymen as a result of sexual intercourse.
Carnal Knowledge

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  Sexual bodily connection with a woman
 Slightest penetration of the sexual organ of a female by the sexual organ of a male.
 Not necessary that the vagina be entered or that the hymen be ruptured
 It is enough that the labia of the female organ was penetrated

MEDICO-LEGAL EXAMINATION
Acute Evidentiary Examination (less than 72 hours)

1. Medical/forensic exam is appropriate on an urgent basis

2. Advise patient:
 Do not bathe before exam
 Bring in clothes worn at time of assault and bring change of clothing
 Come to hospital with support person (family, friend, advocate), if possible

Non-Acute Examination (more than 72 hours)

1. Medical/forensic exam generally not indicated on emergency basis

2. Individual case circumstances may warrant urgent exam up to 96 hours after assault, e.g.,
multiple assailants, or patient was unconscious for a period of time
3. Refer to primary care provider or clinic for medical care
4. Refer to rape crisis center, advocacy organization or mental health counselor for
psychological support
5. Advise or assist patient in making police report.

In General, Physical Examination:

Findings of physical injuries noted such as:
 Abrasion
 Contusion
 Ecchymosis
 Lacerated wound
 Petecchiae
 Hematoma
 Punctured wound
 Scratch marks
 Burns:
 Cigarette burn
 Scalding injuries
 Other causes

Hymenal Laceration

 Classification – Simple, Complex, Compound

 Age
 Recent/acute, old
 Fresh, healing, healed
 Depth/Extent/Size
 Shallow, deep
 Location
 Anterior, posterior
 O' clock position
 A notch is a laceration until proven otherwise
 A notch is like a small indentation of the hymenal rim and is usually symmetrical, left
and right, found anteriorly or at the edges of the quadrants
 A small laceration is accompanied by a disclosure of abuse
 Attenuation of the hymenal tissue may be a sign of a healed laceration.
 A serrated hymenal rim may be normal.
 A fimbriated hymenal rim is usually associated with old history of vaginal penetration
(nonsexual)

Laboratory Examinations

 Swab for presence of semen for cases within 24 hours

 Acid Phosphatase or Prostate Specific Antigen
 Pregnancy test / ultrasound

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

  Drugs, alcohol
 Microscopic examination of vaginal swabs/TMG
 Trichomonas (exam is wet mount)
 Monilia (exam is KOH prep)
 Gram stain
 Culture for gonorrhea and chlamydia when resources are available
 Serology for STD (VDRL, Hep B, HIV)

ADAMS CLASSIFICATION
Medical findings can be categorized and interpreted using accepted classification systems such as the
Adams Classification System for Assessing Physical, Laboratory, and Historical Information in Suspected
Child Sexual Abuse (Adams, 2001).
Class 1 - Normal genital findings
Class 2 - Non-Specific genital findings
Class 3 - Medical evaluation suggestive of abuse or sexual contact.
Class 4 - Medical evaluation show clear evidence of blunt force or penetrating trauma.

“Virginity/ Virgin State” - no longer used due to vagueness

Kinds of Virginity
1. Moral Virginity - state of not knowing the nature of sexual life and not having experienced sexual
relation. Applies to children below the age of puberty.
2. Physical Virginity - condition whereby a woman is conscious of the nature of sexual life but has not
experienced sexual intercourse; a). True P.V.- condition wherein the hymen is intact with the edges
distinct and regular, opening is small barely admits the tip of the smallest finger of the examiner; b.)
False P.V.- condition wherein the hymen is unruptured but the orifice is wide and elastic to admit two
or more fingers of the examiner with lesser degree of resistance, hymen is laxed and distensible.
3. Demi-Virginity - condition of a woman who permits any form of sexual liberties as long as they
abstain from rupturing the hymen by sexual act,” inter-femora or inter- labial intercourse”
4. Virgo Intacta - the term refers to a truly virgin woman, that there are no structural changes in her
organ to infer previous sexual intercourse and that he is a virtuous woman.

SEXUAL CRIMES XXXX

RAPE
• REVISED PENAL CODE
• Carnal knowledge of a woman
• Force, threat, intimidation
• Unconscious or deprivation of reason
• Under 12 years of age

• RA 8353 – ANTI-RAPE LAW OF 1997

• An act of sexual assault by:
• Inserting penis into another person‟s mouth or anal orifice;
• Inserting any instrument or object into the genital or anal orifice of another
person.

Other Crimes against Chastity

• Seduction
• Acts of Lasciviousness
• Abduction
• Adultery and Concubinage

Seduction
Act of a man enticing women to have unlawful intercourse
Persuasion
Solicitation
Promises
Bribes
Or other means of employment of force
Kinds of seduction
Qualified
Simple

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 Ordinary Qualified Seduction
1. Offended party must be a virgin
2. Must be over 12 but under 18
3. There must be sexual intercourse between the offender and the offended party
4. Sexual act was done through abuse of authority or confidence

Incestuous Qualified Seduction

1. Sexual act between the offender and the offended party
2. Blood relation between the parties affected

Simple Seduction
1. Seduction of a woman over 12 but under 18 years of age
2. Offended party must be single or a widow of good reputation
3. Sexual intercourse must be done by the offender with her
4. Sexual act was done by means of deceit

Acts of Lasciviousness
• Acts which tend to excite lust; conduct which is wanton, lewd, voluptuous or lewd emotion
• Acts considered lascivious
• Embracing, kissing, holding a woman‟s breast
• Placing a man‟s private organ over a girl‟s genital organ

Abduction
• The carrying away of a woman by an abductor with lewd design
• Types
• Forcible Abduction-Abduction of a woman against her will with lewd design.
• Consented abduction-Abduction of a virgin over 12 but under 18 years of age, carried
out with her consent, and with lewd design.
Adultery
Elements of the crime
Woman is married
She had sexual intercourse with a man not her husband
The man with whom she had sexual intercourse knows her to be married even if the marriage
has subsequently been declared void

Concubinage
• Keeping a mistress in a conjugal dwelling
• Having sexual intercourse under scandalous circumstances with a woman not his wife
• Cohabiting her in any other place

Prostitution
• habitually indulge in sexual intercourse or lascivious conduct
• Habitual sexual intercourse or lascivious act is done for money or profit

OTHERS:
A. Corruption of Minors- any person who shall promote or facilitate the prostitutions or corruption
of persons underage (below the age of 18) to satisfy the lust of another. Age of legal consent is 18
years old, insofar as sexual offenses are concerned.
B. White Slave Trade- any person who are engage in the business or shall profit by prostitution
or shall enlist the services of women for the purpose of prostitution.
C. Abuse against Chastity- any person who by soliciting or making immoral or indecent advances
to a woman interested in matters pending before the offending officer for
decision, or under the offender‟s custody, or to the wife, daughter, or relatives with the same
degree by affinity of any person in custody of the offending warden or officer.
• SOLICIT- to propose earnestly and persistently something immoral or indecent.

Unnatural Sexual Offenses:

A. Grave Scandal Requisites of the crime:

1. The offender performs act or acts;
2. Such act or acts is/are highly scandalous and offending against decency and good customs;
3. It is also necessary that the act or acts be committed in public place or within the view or
knowledge of the public.

B. Immoral Doctrines, Obscene Publications and Exhibitions

Requisites of the Crime:

a. Those who shall publicly expound or proclaim doctrines openly contrary to public morals;

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 b. The authors of obscene literature, published with their knowledge in any form and editors
publishing such literature;
c. Those who in theaters, fairs, cinematography or any other place open to public view, shall
exhibit indecent or immoral plays, scenes, acts or shows;
d. Those who shall sell, give away or exhibit prints, engravings, sculptures or literatures which are
offensive to morals.

C. Vagrants and Prostitutes

• Prostitutes- women who for money or profit, habitually indulge in sexual intercourse or
lascivious conduct.

D. Unjust Vexation or any other coercion

 any human conduct, although not productive of some physical or material harm would,
however, unjustly annoy or vex an innocent person

Sexual Abnormalities

As to the choice of Sexual Partner:

1. Heterosexual-sexual desire towards the opposite sex;
2. Homosexual-sexual desire towards the same sex;
 Overt- persons who are conscious of their homosexual cravings and who make no
attempts to disguise their intention.
 Latent- persons who may or may not be aware of the tendency in that direction but are
inclined to repress the urge to give way to their homosexual yearning.
 Tribadism (Lesbianism)- a woman has the desire to have sexual intercourse with
another woman
3. Infantosexual- sexual desire towards immature person
 Pedophilia-person who have a compulsive desire to have sexual intercourse with a
child of either sex
Pedophile:
 Homosexual Pedophile- may attempt either oral or anal intercourse with his
victim;
 Heterosexual Pedophile- may attempt either oral, vaginal, anal, intracrural intercourse,
as well as cunnilingus, but attempts at vaginal penetration are most common.

4. Bestosexual- sexual desire towards animals; Bestiality (Zoophilia)- sexual gratification is

attained by having sexual intercourse with animals.
5. Autosexual (Self-gratification or Masturbation- a form of “self-abuse or solitary vice” carried
without the cooperation of another person.
6. Gerontophilia- sexual desire with elder person.
7. Necrophilia- sexual perversion characterized by erotic desire or actual sexual intercourse with
a corpse.
8. Incest- sexual relations between persons who by reason of blood relationship cannot legally
marry.

As to instinctual Strength of sexual urge:

1. Over Sex:
A. Satyriasis- excessive sexual desire of men to intercourse;
B. Nymphomania- strong sexual feeling of women, Hot or Fighter;
2. Under-sex (Sexual Frigidity)
a. Sexual Anesthesia- absence of sexual desire or arousal during sexual act in women
b. Dyspareunia- painful sexual act in women
c. Vaginismus- painful spasm of the vagina during sexual act
d. Old Age- weakening of sexual feeling in the elderly

As to the mode of sexual expression or way of sexual gratification:

1. Oralism- use of the mouth as a way of sexual gratification.

A. Fellation (Irrumation)- the female agent receives the penis of a man into her mouth and by
friction with the lips and tongue coupled with the act of sucking initiates orgasm.
B. Cunnilingus- sexual gratification is attained by licking or sucking the external female genitalia.
C. Anilism (Anilingus)- a person derives excitement by licking the anus of another person of
either sex.

2. Sado-masochism (Algolagnia)- pain or cruel act as a factor for gratification.

Flagellation- act of whipping or being whipped;

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 A. Sadism (Active Algolagnia)- infliction of pain on another is necessary or sometimes the sole
factor in sexual enjoyment.
 Cannibalism- biting without flesh eating but with presumed unconscious wish to consume;
 Love Bites- these are superficial punctuate contusions seen most frequently at the side
of the neck, breast or other parts of the body;
 Necrosadism or Lust Murder- infliction of such injuries cause death of the victim.
B. Masochism (Passive Algolagnia)- pain and humiliation from the opposite sex is the primary
factor for sexual gratification.

3. Fetishism- the real or fantasied presence of an object or bodily part is necessary for sexual
gratification.

Kinds of Fetishes:
a) Anatomic- particular portions of the anatomy, such as the breast or buttocks are the target of
interest for sexual stimulation.
b) Clothing- deviate may have interest centered on shoes, handkerchief, undergarments, either on
asexual partner or stolen from neighborhood wash line.
c) Necrophilic- deviate has the desire to be near a dead body and may or may not violate the
dead person for sexual gratification.

d) Odor (Ospresiophilia)- stimulus is pleasant or foul odor for sexual stimulation or gratification.
 Urolagnia- sexual excitement is associated with the sight of women urinating.
 Coprolagnia- sexual gratification is attained by seeing women defecate.
 Mysophilia- sexual response to filth or excretion.
 Pygmalionism- sexual deviation whereby a person has sexual desire for statutes.

e) Mannikinism- sexual desire with mannikins.

f) Narcissism- extreme admiration and love of one‟s self. Sexual gratification is attained by
looking at the mirror and appreciating his or her own self.
g) Negative fetish- marked dislikes for things, like eyeglasses, beard, haircut, as the sole
stimulus for gratification.
h) Saboteur fetish- deviate does damage while he gets satisfaction, like cutting clothes or hair.
i) Incendiarism- derives sexual pleasure from setting fire.
j) Vampirism- attains sexual stimulation at the sight of blood.

As to the part of the body

1. Sodomy- sexual act through the anus of another human being.
2. Uranism- sexual gratification attained by fingering, fondling with the breast, licking parts of
the body, etc.
3. Frottage- sexual gratification characterized by the compulsive desire of a person to rub his sex
organ against some parts of the body of another.
4. Partialism- a person has special affinity to certain parts of the female body. Usually sexual
intercourse is merely secondary to satisfy the sexual desire.

As to visual stimulus:
1. Voyeurism- sexual perversion characterized by a compulsion to peep to see persons undress.
Sometimes called “Peeping Tom”.
2. Mixoscopia (Scotophilia)- sexual pleasure is attained by watching couple undress or during
their sex intimacies

As to number:
1. Troilism (Menagea Trois‟) sexual perversion in which three persons are participating in the
sexual orgies. Combination may consist of two men and a woman, or two women and a man.
Sexual gratification is attained in the “eternal triangle”.
2. Pluralism- sexual deviation in which a group of persons participate in the sexual orgies. Two or
more couples may perform sexual act in a room, may exchange partners for “variety sake”
during the sexual festivals.

Other sexual deviates:

1. Coprolalia- sexual deviation characterized by the need to use obscene language to obtain sexual
gratification. Uttering profane words making some writings and sketches on the walls of toilets.
2. Don Juanism- sexual deviation characterized by promiscuity and making seduction of many
women as part of his career. Cannot find anyone to be a permanent companion.
3. Indecent Exposure (Exhibitionism)- the willful exposures in public places of one‟s genital
organ in the presence of another person‟s, usually the opposite sex. It is the act of men whose
sexual satisfaction is attained by exhibition with or without performance of masturbatory act.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 Women may expose themselves naked in public, as in “bubble and fan” and the “striptease”
acts in night clubs.

Sexual reversal:
1. Transvestism (“sexo-esthetic inversion”,
Psychical hermaphroditism or
“Metamorphosis Sexualis Paranoica”)-a form of deviation wherein a male derives pleasure from
wearing the female apparel, or in females who dressed themselves in male attire. Transvestism is
a symptomatic expression of some deep underlying sexual maladjustment amenable to
psychotherapy.
2. Transexualism- a dominant desire in some persons to identify themselves with the opposite sex as
completely as possible and to discard forever their anatomical sex. They may go to the extreme
of taking sex hormones, to develop secondary sexual characteristics of the opposite sex or may go
to the extent of subjecting themselves to surgery to change their anatomical sex.
3. intersexuality- a genetic defect where an individual shows characteristic of both sexes.

Classification of Intersexuality:
A. Gonadal Agenesis- sex organs (testes or ovaries) have never developed.
B. Gonadal Dysgenesis- the external sexual structures are present but at puberty the testes or the
ovaries fail to develop.
- Klinefelter‟s Syndrome- (XXY chromosomes), male type of dysgenesis, although the
anatomical structure is entirely male, the nuclear sexing is female (Chromatin Positive).
Testes are small with fibrosis.
- Turner‟s Syndrome- structurally and phenotypically female but the ovaries are small, there is
sterility with the absence of the second X- chromosomes.
C. True Hermaphroditism- state of bisexuality, having both ovaries and testes. The nuclear sex is
usually female.
D. Pseudohermaphrodite- sex organ is anatomically of one sex, but the sex characters are that
of the opposite sex
- Male Pseudohermaphrodite - gonads are testicles but the character is effeminate.
- Female pseudohermaphrodite - gonads are ovaries but with masculine character.

O. CHILD ABUSE AND NEGLECT

Death and Injury in Infancy

 Still-Birth- a child of more than 28 weeks gestational age, which after being- completely
expelled from the mother, did not breath or show any signs of life. When a child has not
breathed or has not shown any sign of life after being completely born.
 Live-Birth- The child after birth exhibited clear signs of vitality and viability is not necessary

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 NEONATICIDE-is generally defined as "the homicide of an infant aged one week or less.” The
psychiatrist Phillip Resnick further limits neonaticide to the killing of an infant on the day of Birth.
 Infanticide in general usage is defined as THE KILLING OF A CHILD LESS THAN 3 DAYS OLD,
other authors defined it as “the homicide of a person older than one week but less than one
year of age."
 Filicide is defined as "the homicide of a child (less than eighteen years of age) by his or her
parent or stepparent.

Causes of Still-birth:
1. Prematurity/Immaturity
2. Congenital diseases or malformations
3. General debilitating diseases- Infection, Kidney disease, Liver disease
4. Local disease of the Generative Organ- Placenta previa, Syphilis,
5. Fetal hypoxia
6. Placental insufficiency
7. Accidents in the Delivery- Abnormal presentation, Strangulation of the cord, Injudicious
forceps apllication
8. Violence, either deliberate or accidental at birth

Child Abuse Syndrome

 It is the physical, mental, and sexual abuse of children by parents or guardian.
 True Child Abuse also called child or baby battering or non-accidental injury- it differs from
common murder, in that it is usually the culmination of repeated injury, rather than a single
episode of deliberate killing like shooting, stabbing, strangulation etc.

Features of Child Abuse Syndrome

1. Infants can be of any age, most fatalities under 2 years;
2. Any social class can be involved, lower middle classes seems most at risk;
3. Lesions are in the skin and skeleton

Sudden infant death Syndrome (SIDS)

• SIDS is the sudden, unexpected death of a seemingly normal, healthy infant under one year of
age that remains unexplained after a thorough postmortem investigation, including an autopsy
and a review of the case history.
• Sudden Infant Death Syndrome (SIDS)- define as sudden death of an infant which is unexpected
by history and in whom a thorough autopsy fails to reveal an adequate cause of death. Also
known as
“Crib Death or Cot Death”

Features of SIDS
1. Most deaths take place between 1 and 7 months, with a peak at 2-3 months;
2. Slight predominance in males, seen in many types of death;
3. Incidence is markedly greater in one of a twin pair, whether identical or not;
4. There is marked seasonal variation in temperate zones, SIDS more common in colder and
wetter months;
5. There are social class differences, a higher incidence occurring in disadvantage families, such
as those with poor housing, lower occupational status, one-parent families, etc.

Other Features of SIDS

• Age – 2-4 months of age
• Physical Abnormalities
• Prematurity and Low Birth weight
• infants born to teenage mothers, poor mothers, and mothers who are smokers
• formula feeding rather than breastfeeding
• Infection
• prior death of a sibling from SIDS (although this is thought to be due to shared environmental
risk factors rather than genetic predisposition)
• Studies have reported that anywhere from 28 percent to 52 percent of infants who die of
SIDS are found lying face down
• SIDS also occurs about 1.5 times more frequently in boys than girls. The rate of SIDS in
African American infants is twice.

- In most cases, three techniques are used in an attempt to determine the cause of an infant's
death. These are:

• Death scene investigation. A thorough examination of the scene of death, including recording
baby's position, collecting items from the surrounding area, and
interviewing family members and/or caregivers, can sometimes point to an external
cause of death.
• Autopsy. The autopsy, usually performed by a medical examiner or coroner, focuses on finding
any identifiable cause of death. While parents may reject the idea of an autopsy because they

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1

 feel it violates their infant's remains, it is often the only tool that can definitively rule out other
potential causes of death.
6. Review of family history. Healthcare providers or police interview parents and/or caregivers
in order to determine the child's medical and family history, in an attempt to rule out possible
illness, child abuse, or other cause of death.

Notes in Forensic Medicine / JAIME RODRIGO L. LEAL, MD 1