Legal Medicine by Pedro Solis

CID BENEDICT D. PABALAN's COPY

Chapter I GENERAL CONSIDERATION ^EGALM^DIClNllis a branch of medicine which deals with the application of medical knowledge to the purposes of law and in the administration of justice. It is the application of basic and clinical, medical and paramedical sciences to elucidate legal matters. Originally the terms legal medicine, forensic medicine and medical jurisprudence are synonymous and in common practice are used interchangeably. This concept prevailed among countries under the Anglo-American influence. The concept and practice of legal medicine in the Philippines is of Spanish origin. In modern times, especially in continental European countries, legal medicine has a similar meaning as the term forensic medicine, although, strictly speaking, legal medicine is primarily the application of medicine to legal eases while forensic medicine concerns with the application of medical science to elucidate legal problems. On the other hand, .medical jurisprudence (j'uris-law, prudentia-knowledge) denotes knowledge"of lawT in relation to the practice of medicine. It concerns with the study of the rights, duties and obligations of a medical practitioner with particular reference to those arising from doctor-patient relationship. According to the Rules of Court (Sec. 5, Rule 138) Medical Jurisprudence is one of the subjects in the law course before admission to the bar examination. This is based on the original concept but actually it must be the study of legal medicine as it was the intention and practice in the past. v Scope of Legal Medicine: The scope of legal medicine is quite broad and encompassing. It is the application of medical and paramedical sciences as demanded by law and administration of justice. The knowledge of the nature and extent of wounds has been acquired in surgery, abortion in gynecology, sudden death and effects of trauma in pathology, etc. aside from having knowledge of the basic medical sciences, like anatomy, physiology, biochemistry, physics and other allied sciences. ^Nature of the Study of Legal Medicine: A knowlege of legal medicine means the ability to acquire facts, the power to arrange those facts in their logical order, and to draw a 1

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conclusion from the facts which may be useful in the administration of justice. Aside from being a perceptor of fact, he must possess the power to impart to others verbally or in writing all those he has observed. A physician who specializes or is involved primarily with medicolegal duties is known as medical jurist, (meoical examiner, medicolegal officer, medico-legal expert). Inasmuch as administration of justice is primarily a function of the state, physicians whose duties are mainly medico-legal in nature are mostly in the service of the government. / Health officers, medical officers of Jaw enforcement agencies and members of the medical staff of accredited hospital are authorized by law to perform autopsies (Sec. 95, P.D. 856, Code of Sanitation). However, "it is the duty of every physician, when called upon by the judicial authorities, to assist in the administration of justice on matters which are medico-legal in character" (Sec. 2, Art. Ill, Code of Medical Ethics of the Medical Profession of the Philippines). To be involved in medico-legal duties, a physician must possess sufficient knowledge of pathology, surgery, gynecology, toxicology and such other branches of medicine germane to the issues involved. /Distinction Between an Ordinary Physician and a Medical Jurist: 1. An ordinary physician sees an injury or disease on the point of view of treatment, while a medico-jurist sees injury or disease on the point of view of cause. 2. The purpose of an ordinary physician examining a patient is to arrive at a definite diagnosis so that appropriate treatment can be instituted, while the purpose of the medical jurist in examining a patient is to include those bodily lesions in his report and testify before the court or before an investigative body; thus giving justice to whom it is due. 3. Minor or trivial injuries are usually ignored by an ordinary clinician inasmuch as they do not require usual treatment. Superficial abrasions, small contusion and other minor injuries will heal without medication. However, a medical jurist must record all bodily injuries even if they are small or minor because these injuries may be proofs to qualify the crime or to justify the act. Examples: a. The presence of physical injuries of a victim of sexual abuse may be presumptive proof that force was applied in the commission thereof, hence the crime committed must be rape.

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b. The presence of physical injuries on the offender of the crime of physical injuries may be a proof that the victim acted in self-defense. Other Definitions: yjl. Law is a rule of conduct, just, obligatory, laid by legitimate power for common observance and benefit. It is a science of moral laws founded on the rational nature of man which regulates free activity for the realization of his individual and social ends under the aspect of mutual demandable independence. (1 S.R.) The word "law" includes regulations and circulars which are issued to implement a law and have, therefore, the effect of law. ^Characteristics of Law: a. It is a rule of conduct; b. It is dictated by legitimate power; and c. Compulsory and obligatory to all (Civil Code by Padilla). Forms of Law: ' a. Written or Statutory Law (Lex Scripta): This is composed of laws which are produced by the country's legislations and which are defined, codified and incorporated by the law-making body. / Example: Laws of the Philippines, ^ b . Unwritten or Common Law (Lex non Scripta): This is composed of the unwritten laws based on immemorial customs and usages. It is sometimes referred to as case law, common law, jurisprudence or customary law. Example: Laws of England 2. Forensic: It denotes anything belonging to the court of law or used in court or legal proceedings or something fitted for legal or public argumentations (Black's Law Dictionary, 4th ed.) 3. Medicine: Medicine is a science and art dealing with prevention, cure and alleviation of disease. It is that part of science and art of restoring and preserving health. The term medicine is also applied to a science and art of diagnosing, treating, curing and preventing disease, relieving pain, and improving the health of a person, z 4. Legal: Legal is that which pertains to law, arising out of, by virtue of or included in law. It also refers to anything conformable to the letters or rules of law as it is administered by the court. J

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5. Jurisprudence: It is a practical science which investigates the nature, origin, development and functions of law. It is a science of giving a wise interpretation of the law and making just application of them to all cases as they arise. Judicial decisions applying or interpreting the laws shall form a part of the Philippine jurisprudence. The decisions contemplated are those rendered by the Supreme Court which is the final arbiter on legal issues. However, the decisions of the Court of Appeals may serve as precedent for inferior courts on points of facts. Principle of Stare Decisis: A principle that, when the court has once laid down a principle of law or intepretation as applied to a certain state of facts, it will adhere to and apply to all future cases where the facts are substantially the same. The principle is one of policy, grounded on the theory that security and certainty require that accepted and established legal principles, under which right may accrue, be recognized and followed, though later found to be not legally sound, but whether previous holding of court shall be adhered to, modified or overruled is within the court's discretion under the circumstance of the case before it (Black's Law Dictionary, 4th ed.). Branches of Law Where Legal Medicine may be Applied: 1. Civil Law — Civil law is a mass of precepts that determines and regulates the relation of assistance, authority, and obedience between members of a family and those which exist among members of a society for the protection of private interest (Sanchez Roman). Our civil laws are scientifically and systematically compiled in the Civil Code of the Philippines (Republic Act No. 386). In civil law, knowledge of legal medicine may be useful on the following: a. The determination and termination of civil personality (Art. 40 and 41), b. The limitation or restriction of a natural person's capacity to act (Art. 23 and 39); c. The marriage and legal separation (Book I, Title III & IV); d. The paternity and filiation ^Book I, Title VIII); and e. The testimentary capacity of a person making a will (Book III, Title IV).

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2. Criminal Law — Criminal law is that branch or division of law which defines crimes, treats of their nature and provides for their punishment. It is a body of specific rules regarding human conduct which have been promulgated by political authority, which apply uniformly to all members of the classes to which the rules refer, and which are enforced by punishment administered by the state (SutherlandCressey, Criminology, 7th ed„ p. 4). Penal laws and those of public security and safety shall be obligatory upon all who live or sojourn in the Philippine territory, subject to the principles of public international law and to treaty stipulations (Art. 14 Civil Code). The Philippine criminal law is codified in the Revised Penal Code and may also be found in the penal provisions of the special laws. Legal medicine is applicable in the following provisions of the penal code: a. Circumstances affecting criminal liability (Title I); b. Crimes against person (Title VIII), and c. Crimes against chastity (Title XI). 3. Remedial Law — Remedial law is that branch or division of law which deals with the rules concerning pleadings, practices and procedures in all courts of the Philippines. It is the law which gives a party a remedy for a wrong. It is intended to afford a private remedy to a person injured by the wrongful act. It is a designed law, which redresses an existing grievance or introduces regulation conducive to public good (Black's Law Dictionary, 4th ed.). Our remedial law is embodied in the Rules of Court of the Philippines and also in the remedial provision of Special Laws. Legal Medicine may be applied in the following provisions of the Rules of Court: a. Physical and mental examination of a person (Rule 28); b. Proceedings for hospitalization of an insane person (Rule 101); and c. Rules on evidences (Part IV). 4. Special Laws: a. Dangerous Drug Act (R.A. 6425, as amended) b. Youth and Child Welfare Code (P.D. 603) c. Insurance Law (Act No. 2427 as amended) d. Code of Sanitation (P.D. 856)

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e. Labor Code (P.D. 442) f. Employee's Compensation Law Some Bask Principles Governing Application and Effects of Laws: 1. Ignorance of the law excuses no one from compliance therewith or "ignorantia legis nominem excusat" (Art 3, Civil Code): The main reason for the provision is to prevent ignorance of the law as a means of defense for violation of the law. The provision refers to all kinds of domestic laws on grounds of expediency, policy and necessity. "Ignorance of the law" may refer to the literal wordings of the law and also to the meaning or interpretation given to the law. But the rule is not inflexible. It may only be applied when it is clearly manifested and inexcusably ignorant of the law. Mere ignorance of the facts of the law would furnish immunity from the punishment for violation of the penal code and immunity from the liability for actual loss for violation of personal or property right. 2. Laws shall have no retroactive effect, unless the contrary is provided (Art. 4, Civil Code): A law can only be applied to cases after its promulgation arid must not be given retroactive application. A law, however, may be given retroactive effects in the following instances: a. When the law provides the contrary (Art. 4, Civil Code). b. Penal laws shall be given retroactive effect if favorable to the accused who is not habitually delinquent (Art. 22, Revised Penal Code). c. When the statute is remedial in nature because there is no vested right in the rules of procedure. d. When the law creates a new substantive right. 3. Rights may be waived, unless the waiver is contrary to law, public order, public policy, morals or good customs, or prejudicial to a third person with a right recognized by law (Art. 6, Civil Code): A right is the power, privilege, faculty which entitles a man to have, or to do, or to receive from another within the limits prescribed by law. Waiving is the intentional or voluntary relinquishment, abandonment or throwing away, renunciation, surrendering of a known right. The rights granted to a person by law may be waived but in the following cases, the law does not allow such waiver: a. When such waiver will be contrary to the existing law.

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b. When it is against public order, public policy, morals and good customs. c. When in so waiving it is prejudicial to a third person with a right recognized by law. 4. Customs which are contrary to law, public order or public policy shall not be countenanced (Art. 11, Civil Code). A custom must be proved as a fact according to the rules of evidence (Sec. 12, Civil Code): Custom is a usage or practice of the people, which by common adoption and acquiescence and by long and unvarying habit, has become compulsory and has acquired the force of a law with respect to the place and subject-matter to which it relates (Black's Law Dictionary, 4th ed.). Customs constitute sources of supplementary law in default of specific legislation. However, if the custom is contrary to the existing law or to ' public order and policy, the law must prevail. 5. Laws are repealed only by subsequent ones, and their violation or non-observance shall not be excused by disuse, custom or practice to the contrary. When the court declares a law to be inconsistent with the constitution, the former shall be void and the latter shall govern. Administrative or executive acts, orders and regulations shall be valid only when they are not contrary to the laws or the constitution (Art. 7, Civil Code): The constitution is the fundamental law of the land. All acts, administrative or executive orders contrary to the provision of the constitution shall be deemed void. Any existing law which is inconsistent with a subsequent law is deemed repealed by the latter law. Administrative or executive acts, orders and regulations are considered valid when they are not in contravention with the existing laws. BRIEF HISTORY OF LEGAL MEDICINE 1. IN WORLDWIDE SCALE: The earliest recorded medico-legal expert was Imhotep (2980 B.C.). He was the chief physician and architect of King Zoser of the third dynasty in Egypt and the builder of the first pyramid. That time was the first recorded report of a murder trial written on clay tablet.

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LEGAL MEDICINE The Code of Hammurabi, the oldest code of law (2200 B.C.) included legislation on adultery, rape, divorce, incest, abortion and violence. Hippocrates (460-355 B.C.) in Greece discussed the lethality of wounds. Aristotle (384-322 B.C.) fixed animation of fetus at the 40th day after conception. About 300 B.C. the Chinese materia medica gave information on poison including aconite, arsenic and opium. Hashish was said to have been used as a narcotic in surgery about 200 B.C. That bodies of all women dying during confinement should immediately be opened in order to save the child's life was promulgated during the reign of Numa Pompilius in Rome (600 B.C.). The first "police surgeon" or forensic pathologist was Antistius. Julius Caesar (100-44 B.C.) was murdered and his body was exposed in the forum and Antistius performed the autopsy. He found out that Julius Caesar suffered from twenty-three wounds and only one penetrated the chest cavity through the space between the first and second ribs. Justinian (483-565 A.D.), in his Digest, made mention that a physician is not an ordinary witness and that a physician gives judgment rather than testimony. This led to the recognition of expert witness in court. The first textbook in legal medicine was included in the Constitute Criminalis Carolina which was promulgated in 1532 during the reign of Emperor Charles V in Germany. Pope Innocent III (1209) issued an edict providing for the appointment of doctors to the courts for the determination of the nature of wounds. Pope Gregory IX, in 1234, caused the preparation of Nova Compilatio Decretalium which concerned medical evidence, marriage, nullity, impotence, delivery, caesarian section, legitimacy, sexual offenses, crime against persons and witchcraft. In the 14th century, Pope John XXII expressed the need of experts in the ecclesiastical courts, in the diagnosis of leprosy and many medico-legal documents. In China, the Hsi Yuan Lu (Instructions to Coroner) was published. It is a five volume book dealing with inquest, criminal abortion, infanticide, signs of death, assault, suicide, hanging, strangling, drowning, burning, poisoning and antidotes, and examination of the dead.

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In 1575, Ambroise Pare considered legal medicine as a separate discipline and he'discussed in his book, abortion, infanticide, death by lightning, hanging, drowning, feign diseases, distinction between ante-mortem and post-mortem wound and poisoning by carbon monoxide and by corrosives. Paulus Zacchias (1584-1659), a papal physician, is regarded as the "father of forensic medicine." He published Questiones Medico-legales which dealt with the legal aspects of wounds and the first two chapter dealt with the detection of secret homicide. In 1598, Severin Pineau published in Paris a work on virginity and defloration. He confirmed the existence of the hymen and that it may not rupture during sexual intercourse. Orfila (1787-1853) introduced chemical methods in toxicology. In his Traite' des Poison, he mentioned mineral, vegetable and animal poison in relation with physiology, pathology and legal medicine. He was considered later as the founder of modern toxicology. The period thereafter is characterized by an appreciable increase in available publication on the subject dealing with modem innovative findings and procedures related to medical progress and changes in the laws. 2. IN THE PHILIPPINES: In 1858, the first medical textbook printed including pertinent instructions related to medico-legal practice by Spanish physician, Dr. Rafael Genard y Mas, Chief Army Physician, entitled "Manual de Medicina Domestica." In 1871, teaching of legal medicine, included as an academic subject in the foundation of the School of Medicine of the Real y Pontifica Universidad de Santo Tomas. On March 31, 1876 by virtue of the Royal Decree No. 188, of the King of Spain, the position of "Medico Titulares" was created and made in charge of public sanitation and at the same time medico-legal aid in the administration of justice. In 1894, rules regulating the services of those "Medico Titular y Forences" was published. In 1895, medico-legal laboratory was established in the City of Manila and extended at the same time its services to the provinces. In 1898, American Civil Government preserved the Spanish forensic medicine system. In 1901, Philippine Commission created the provincial, insular and municipal Board of Health (Act Nos. 157, 307 and 308) in the Philippines and assigned to the respective inspectors and pres-

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LEGAL MEDICINE idents of the same, medico-legal duties of the "Medico Titulares" of the Spanish regime. The Philippine Legislature maintained the pre-existing medico-legal system in full force in the Administrative Code. In 1908, the Philippine Medical School incorporated the teaching of Legal Medicine, one hour a week to the fifth year medical students. In 1919, the University of the Philippines created the Department of Legal Medicine and Ethics with the head having the salary of 4,000.00 pesos per annum, half-time basis, with Dr. Sixto de los Angeles as the chief. On January 10, 1922, the head of the Department of Legal Medicine and Ethics became the Chief of the Medico-Legal Department of the Philippine General Hospital without pay. On March 10, 1922,-the Philippine Legislature enacted Act. No. 1043 which became incorporated in the Administrative Code as Section 2465 and provided that the Department of Legal Medicine, University of -the Philippines, became a branch of the Department of Justice. On December 10, 1937, Commonwealth Act. No. 181 was passed creating the Division of Investigation under the Department of Justice. The Medico-Legal Section was made as an integral part of the Division with Dr. Gregorio T. Lantin as the chief. On March 3, 1939, the Department of Legal Medicine of the College of Medicine, University of the Philippines was abolished and its functions were transferred to the Medico-Legal Section of the Division of Investigation under the Department of Justice. On July 4, 1942, President Jose P. Laurel consolidated by executive order all the different law-enforcing agencies and created the Bureau of Investigation on July 8,1944. In 1945 immediately after liberation of the City of Manila, the Provost Marshal of the United States Army created the Criminal Investigation Laboratory with the Office of the Medical Examiner as an integral part and with Dr. Mariano Lara as Chief Medical Examiner. On June 28, 1945, the Division of Investigation, under the Department of Justice was reactivated. On June 19, 1947, Republic Act. No. 157 creating the Bureau of Investigation was passed. The Bureau of Investigation was created by virtue of an executive order of the President of the Philippines. Under the bureau, a Medico-Legal Division was created with Dr. Enrique V. de los Santos as the Chief.

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There exists a Medico-Legal Division in the Criminal Laboratory Branch of the G-2 of the Philippine Constabulary. All provincial, municipal and city health officers, physicians of hospitals, health centers, asylums, penitentiaries and colonies are ex-officio medicolegal officers. In remote places where the services of a registered physician was not available, a "Cirujano Ministrante" may perform medico-legal work. However, after the approval of Republic Act 1982 on June 15, 1954 which provided for the creation of rural health unit to each municipality composed of municipal health officer, a public nurse, a midwife and a sanitary inspector virtually abolished the appointment of Cirujano Ministrante thereby making qualified physicians to perform medico-legal functions. June 18, 1949, Republic Act 409 which was later amended by Republic Act 1934 provides (Sec. 38) for the creation of the office of the Medical Examiners and Criminal Investigation Laboratory under thej^jice Department of the City of Manila. On December 23, 1975, Presidential Decree 856 was promulgated and Sec. 95 provides: A. Persons authorized to perform autopsies: 1. Health officers 2. Medical officers of law enforcement agencies 3. Members of the medical staff of accredited hospitals B. Autopsies shall be performed in the following cases: 1. Whenever required by special laws; 2. Upon order of a 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 deem it necessary to disinter and take possession of the remains for examination to determine the cause of death; and 5. Whenever the nearest kin shall request in writing the authorities concerned to ascertain the cause of death. V MEDICAL EVIDENCE Evidence is the means, sanctioned by the Rules of Court, of ascertaining in a judicial proceeding the truth respecting a matter of fact (Sec. 1, Rule 128, Rules of Court). It is the species of proof, or probative matter, legally presented at the trial of an issue by the act of the parties and through the medium

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of witnesses, records, documents, concrete objects, etc., for the purpose of inducing belief in the minds of the court as to their contenti o n (Black's Law Dictionary, 4th ed.). If the means employed to prove a fact is medical in nature then it becomes a medical evidence. Same rules in all cases — The rules of evidence shall be the same in all courts and on all trials and hearings, whether civil or criminal (Sec. 2, Rule 128, Rules of Court). Admissibility of evidence — Evidence is admissible when it is relevant to the issue and is not excluded by these rules (Sec. 3, Rule 128, Rules of Court). It is considered relevant when it has the tendency to prove any matter of fact. It is something which by the process of logic, an inference may be made as to the existence or non-existence of a fact at issue. Relevancy of evidence (collateral matters) — Evidence must have such a relation to the fact in issue as to induce belief in its existence or non-existence; therefore, collateral matters shall not be allowed, except when they tend in any reasonable degree to establish the probability or improbability of the fact at issue (Sec. 4, Rule 130, Rules of Court). Collateral matters are those different from those or do not correspond with the matters in issue. Types of Medical Evidence: . /I. Autoptic or Real Evidence: This is an evidence made known or addressed to the senses of the court. It is not limited to that which is known through the sense of vision but is extended to what the sense of hearing, taste, smell and touch is perceived. Sec. 1, Rule 130, Rules of Court — View of an object — Whenever an object has such a relation to the fact in issue as to afford reasonable ground of belief respecting the latter, such object may be exhibited to or viewed by the court, or its existence, situation, condition, or character proved by witnesses, as the court in its discretion may determine. The court may require the physician to present the skeleton of the victim of a criminal act exhumed and examined for the judge to see the presence and degree of the ante-mortem fracture. Limitations to the Presentation of Autoptic Evidence: a. Indecency and Impropriety — Presentation of an evidence may be necessary to serve the best interest of justice but the notion of decency and delicacy may cause inhibition of its presentation.

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The court may not allow exposure of the genitalia of an alleged victim of sexual offense to show the presence and degree of the genital and extra-genital injuries suffered by the victim. There are other ways for the court to know the facts other than actual exhibition. b. Repulsive Objects and those Offensive to Sensibilities — Foul smelling objects, persons suffering from highly infectious and communicable disease, or objects which when touch may mean potential danger to the life and health of the judge may not be presented. However, if such evidence is necessary in the adjudication of the case, the question of indecency and impropriety or the fact that such evidence is repulsive or offensive to sensibilities, it may be presented. This will depend on the sound discretion of the court. -2. Testimonial Evidence: A physician may be commanded to appear before a court to give his testimony. While in the witness stand, he is obliged to answer questions propounded by counsel and presiding officer of the court. His testimony must be given orally and under oath or affirmation. A physician may be presented in court as an ordinary witness and/or as an expert witness: a. Ordinary Witness: A physician who testifies in court on matters he perceived from his patient in the course of physician-patient relationship is considered as an ordinary witness. Sec. 18, Rule 130, Rules of Court — Witnesses. Their qualification — Except as provided in the next succeeding section, all persons who, having organs of sense, can perceive, and perceiving, can make known their perception to others, may be witnesses. Neither parties nor other persons interested in the outcome of a case shall be excluded; nor those who have been convicted of crime; nor any person on account of his opinion on matters of religious belief. One of the^exceptions to the ordinary witness rule is the privilege j>fcommunication (confidential) between physician and patient. Although the physician perceived something through his organ of sense and has the power to transmit to others what he perceived, he is not allowed to disclose those informations to others as regards to matters he perceived from his patient during the physician-patient relationship.

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LEGAL MEDICINE Sec. 21(c), Rule 130, Rules of Court — Privileged communication — A person authorized to practice medicine, surgery or obstetrics cannot in a civil case, without the consent of the patient, be examined as to any information which he may have acquired in attending such patient in a professional capacity, which information was necessary to enable him to act in that capacity, and which would blacken the character of the patient. A medical witness can only testify on matters derived by his own perception. Hearsay informations are as a rule not admissible in court. Hearsay evidences are those not proceeding from the personal knowledge of the witness but from mere repetition of what he has heard others say. It is a, "second hand" evidence which rest mainly on the veffdty and competence of its source. Sec. 30, Rule 130, Rules of Court — Testimony generally confined to personal knowledge — A witness can testify only to those facts which he knows of his own knowledge; that is, which are derived from his own perception, except as otherwise provided in these ruje: One of the exceptions to the non-admissibility of hearsay evidence is dying declaration. The declaration of a dying person under the consciousness of his impending death as regards circumstance regarding his impending death is admissible in spite of the fact that it is a hearsay, it is made so because of necessity and it is trustworthy. Exceptions to the hearsay rule. Sec. 31, Rule 130, Dying declaration — The declaration of a dying person, made under a consciousness of an impending death, may be received in a criminal case wherein his death is the subject of inquiry, as evidence of the cause and surrounding circumstances of such death. Physicians are frequent recipients of dying declaration in the medical clinics and emergency rooms of hospitals. To be admissible it must be shown that the declarant was conscious of his impending death, that the declaration must be with regards to his impending death; that the declarant was in full possession of his mental faculties when he made the declaration; and that such evidence is presented in court in a case of homicide, murder or parricide wherein the declarant was the victim, b. Expert Witness: A physician on account of his training and experience can give his opinion on a set of medical facts. He can deduce or

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infer something, determine the cause of death, or render opinion pertinent to the issue and medical in nature. Sec. 42, Rule 130, Rulesof^Court — Opinion Rule — General Rule — The opinion of^witness is not admissible, except as indicated in the following section. Sec. 43, Rule 130, Rules of Court — Expert Evidence — The opinion of a witness regarding a question of science, art or trade, when he is skilled therein, may be received in evidence. The probative value of the expert medical testimony depends upon the degree of learning and experience on the line of what the medical expert is testifying, the basis and logic of his conclusion, and other evidences tending to show the veracity or falsity of his testimony. 3. Experimental Evidence: A medical witness may be allowed by the court to confirm his allegation or as a corroborated proof to an opinion he previously stated. The issue as to how long a person can survive, after the administration of lethal dose of poison can be shown by the administration of the said poison to experimental animals within the view of the court. 4. Documentary Evidence: A 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. The term applies to writings, to words printed, lithographed or photographed; to seals, plates or stones on which inscriptions are cut or engraved; to photographs and pictures; to maps or plans (Black's Law Dictionary, 4th ed.). Medical Documentary Evidence may be: a. Medical Certification or Report on: (1) Medical examination. (2) Physical examination. (3) Necropsy (autopsy). (4) Laboratory. (5) Exhumation. (6) Birth. (7) Death. b. Medical Expert Opinion. c. Deposition — A deposition is a written record of evidence given orally and transcribed in writing in the form of questions

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by the interrogator and the answer of the deponent and signed by the latter. 5. Physical Evidence: These are articles and materials which are found in connection with the 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. The identification, collection, preservation and mode of presentation of physical evidence is known in modern parlance as criminalistics. Criminalistics is the application of sciences such as physics, chemistry, medicine and other biological sciences in crime detection and investigation. On the investigator's viewpoint, the following are the different types of physical evidences: a. Corpus Delicti Evidence — Objects or substances which may be a part of the body of the crime. The body of the victim of murder, prohibited drugs recovered from a person, dagger with blood stains or fingerprints of the suspect, stolen motor vehicle identified by plate number and by body or engine serial numbers are examples of corpus delicti evidence. b. Associative Evidence — These are physical evidences which link a suspect to the crime. The offender may leave clues at the scene such as weapon, tools, garments, fingerprints or foot impression. Broken headlights glass found at the crime scene in "hit and run" homicide may be associated with the car found in the repair shop. Wearing apparel of the offender and other articles of value may be recovered where the crime of rape was committed. c. Tracing Evidence —These are physical evidences which may assist the investigator in locating the suspect. Aircraft or ship manifest, physician's clinical record showing medical treatment of suspect for injuries sustained in an encounter; blood stains recovered from the area traversed by the wounded suspect infer direction of the movement are examples of tracing evidence. Preservation of Evidences: The physical evidences recovered during medico-legal investigation must be preserved to maintain their value when presented as exhibits in court. Most medical evidences are easily destroyed or physically or chemically altered unless appropriate preservation procedure are applied. This problem is further compounded by the long space of time the evidence was recovered and its presentation in court. From its recovery and from becoming a part of the inves-

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tigation report, a preliminary investigation will be made by the prosecuting fiscal to prove that there is a prima facie evidence to warrant filing of the case in court. While in court, the case further suffers delays because of postponement of the hearings, preferential trials of other cases, raising of prejudicial issues to higher courts, etc. Preservation of evidence is indeed vital in medico-legal investigation. -Methods of Preserving Evidences: 1. Photographs, audio and/or video tape, micro-film, photostat, xerox, voice tracing, etc. Photography is considered to be the most practical, useful and reliable means of preservation. a. Photo-camera are available in many places. b. The object preserved is reduced in size in the picture proportionately with other objects adjacent or near it. c. An unlimited number of copies can be reproduced, each of which is identical to one another. In colored photographs variation may occur in the choice of the kind of film and printing paper used. Identification of voice from the recording instrument may sometimes be difficult. Audio-recording may be dependent on the speed, volume, pitch and timbre which may be changed by the instrument used in the recording and replaying. 2. Sketching — If no scientific apparatus to preserve evidence is available then a rough drawing of the scene or object to be preserve is done. It must be simple, identifying significant items and with exact measurement. -Kinds of Sketch: a. Rough Sketch — This is made at the crime scene or during examination of living or dead body. On the latter, an anatomic figure of the front, back and side part of the body must be made and the bodily lesions indicated. b. Finished Sketch — A sketch prepared from the rough sketch for court presentation. J Essential Elements to be Included in a Sketch: a. Measurement must be accurate. b. Compass direction must always be indicated to facilitate proper orientation in the case of crime scene. A c. Essential item which has a bearing in the investigation mus. oe included. d. Scale and proportion must be stated by mere estimation.

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e. There must be a title and legend to tell what it is and the meaning of certain marks indicated therein. 3. Description — This is putting into words the person or thing to be preserved. Describing a thing requires keen observation and a good power of attention, perception, intelligence and experience. It must cause a vivid impression on the mind of the reader, a true picture of the thing described. The following are the minimum standard requirements which must be satisfied in the description of the person or thing to make it complete: a. Skin Lesion — kind, measurement, other descriptive information of the lesion itself, location, orientation. b. Penetrating Wound (Punctured, Stab or Gunshot) — kind, shape, other information from the wound itself, location, orientation, direction, other structures involved, complications and foreign elements that may be present. c. Hymenal laceration — location, degree, duration, complication. d. Person — those requirement in portrait parle (see p. 53 supra). 4. Manikin Method — In a miniature model of a scene or of a human body indicating marks of the various aspects of the things to be preserved. An anatomical model or statuette may be used and injuries are indicated with their appropriate legends. Although it may not indicate the full detail of the lesion, it is quite impressive to the viewer as to the nature and severity of the trauma. 5. Preservation in the Mind of the Witness — A person who perceived something relevant for proper adjudication of a case may be a witness in court if he has the power to transmit to others what he perceived. He would just have to make a recital of his collection. Principal drawbacks of preserving evidence in the mind of the witness: a. The capacity of a person to remember time, place and event may be destroyed or modified by the length of time, age of the witness, confusion with other evidences, trauma or disease, thereby making the recollection not reliable. b. The preservation is co-terminus with the life of the witness. If the witness dies, then the evidence is lost. c. Human mind can easily be subjected to too many extraneous factors that may cause distortion of the truth. Other persons ./£may influence a witness to serve the interest of another or state untruthful facts to justify an end. 6. Special Methods — Special way of treating certain type of evidence may be necessary. Preservation may be essential from the time it

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is recovered to make the condition unchanged up to the period it reaches the criminal laboratory for appropriate examination. Preservation may be needed for the remaining portion of the evidence submitted for future verification and/or court presentation. Some of the Special Ways of Preservation are: a. Whole human body — embalming. b. Soft tissues (skin, muscles, visceral organs) — 10% formalin solution. c. Blood — refrigeration, sealed bottle container, addition of chemical preservatives. d. Stains (blood, semen) — drying, placing in sealed container. e. Poison — sealed container. Kinds of Evidence Necessary for Conviction: 1. Direct Evidence: That which proves the fact in dispute without the aid of any inference or presumption. The evidence presented corresponds to to the precise or actual point at issue. 2. Circumstantial Evidence: The proof of fact or facts from which, taken either singly or collectively, the existence of a particular fact in dispute may be inferred as a necessary or probable consequence. When is circumstantial evidence sufficient to produce conviction? a. When there is more than one circumstance; b. When the facts from which the inferences are derived are proven; and c. When the combination of all the circumstances is such as to produce a conviction beyond reasonable doubt (Sec. 4, Rule 123, Rules of Court). Weight and Sufficiency of Evidence: Rule 133, Rules of Court: Section 1. Preponderance of evidence, how determined. — In civil cases, the party having the burden of proof must establish his case by a preponderance of evidence. In determining where the preponderance or superior weight of evidence on the issues involved lies, the court may consider all the facts and circumstances of the case, the witnesses' manner of testifying, their intelligence, their means and opportunity of knowing the facts to which they tire testifying, the nature of the facts to which they testify, the proba

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bility or improbability of their testimony, their interest or want of interest, and also their personal credibility so far as the same may legitimately appear upon the trial. The court may also consider the number of witnesses, though the preponderance is not necessarily with the greatest number. From the foregoing provision of the Rules of Court, the following factors must be considered which party's evidence preponderate. a. All the facts and circumstances of the case. b. The witnesses' manner of testifying, their intelligence, their means and opportunities of knowing the facts to which they are ' testifying. c. The nature of the facts to which the witnesses testify. d. The probability and improbability of the witnesses' testimony. e. The interest or want of interest of the witnesses. f. Credibility of the witness so far as the same may legitimately appear upon the trial. g. The number of witnesses presented, although preponderance is not necessarily with the greatest number. Section 2 — Proof beyond reasonable doubt — In a criminal case, the defendant is entitled to an acquittal, unless his guilt is shown beyond reasonable doubt. Proof beyond reasonable doubt does not mean such a degree of proof as, excluding possibility of error, produces absolute certainty. Moral certainty only is required, or that degree of proof which produces conviction in an unprejudiced mind. It is presumed that a person is innocent of a crime until the contrary is proven beyond reasonable doubt. The doubt, the benefit of which an accused is entitled in a criminal case, is a reasonable doubt, and not a whimsical or fanciful doubt, based on imagined and wholly improbable possibilities and unsupported by evidence.

Chapter II ^'fjECEPTION DETECTION The knowledge of the truth is an essential requirement for the administration of criminal justice. The success or failure in making decisions may rest solely on the ability to evaluate the truth or falsity of the statement given by the suspect or witness. The task for its determination initially lies on the hand of the investigator. Modern scientific methods have been devised utilizing knowledge of physiology, psychology, pharmacology, toxicology, etc. in determining whether a subject is telling the truth or not. Although the scientific methods of deception detection have not yet attained legal recognition to have their results admissible as an evidence in court, they have been considered very useful as aids in criminal investigation. 1

Methods of deception detection which are currently being used or applied by law enforcement agencies may be classified as follows: 1. Devices which record the psycho-physiological response: a. Use of a polygraph or a lie detector machine b. Use of the word association test c. Use of the psychological stress evaluator Use of drugs that try to "inhibit the inhibitor": a. Administration of "truth serum'' b^Narcoanalysis or narcosynthesis c. Intoxication 3. Hypnotism 4. By observation 5. Scientific interrogation jo. Confession i I. RECORDING OF THE PSYCHO-PHYSIOLOGICAL RESPONSE The nervous control of the human body includes the central nervous system (the brain and the spinal cord) and the autonomic or regulating nervous system (sympathetic and parasympathetic). The central nervous system primarily controls the motor and sensory functions that occur at or above the threshold. It may be voluntary. The autonomic nervous system acts as a self-regulating autonomic response of the body. 21

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The autonomic nervous system is composed of two complimentary branches: the sympathetic and the parasympathetic nervous system, acting opposite each other. The fibers of both enervate are all organs where self-regulation is essential. When a person is under the influence of physical (exertion) or emotional (anger, excitement, fear, lie detection, etc.) stimuli, the sympathetic will dominate and over-ride the parasympathetic, thus, there will be changes in the heart rate, pulse rate, blood pressure, respiratory tracing, psychogalvanic reflexes, time of response to question, voice tracing, etc. The parasympathetic nervous system works to restore things to normal when the conditions of stress have been removed. It is the dominant branch when the condition is normal and the subject is calm, contented and relaxed. «/ The recording of some of the psycho-physiological reaction of a subject when he is subjected to a series of questions, and the scientific interpretation by trained experts are the basis of the tests. A. Use of a Lie Detector or Polygraph: It is not appropriate to call a lie detector a polygraph. A lie detector records physiological changss that occur in association with lying in a polygraph. It is the fear of detection of the subject which allows the determination. The fear of the subject when not telling the truth activates the sympathetic nervous system to a series of automatic and involuntary physiological changes which are recorded by the instrument. The instrument (lie detector) is like an electrocardiogram or electroencephalogram with recording stylets making tracings on moving paper at the rate of 6 inches per minute. The test must be made in a room especially built for the purpose. It must be quiet, private, sound-proof and free from any disturbances and distractions. Extrenuous noises, like blowing of horns, ringing of bells or telephone and loud conversations of persons must be avoided. The subject is seated on a chair beside a table where the instrument is located. The pneumograph tubes are placed around the chest and abdomen, the blood pressure cuff around the upper right arm, and the electrodes are attached to the two fingers of the other hand. The back of the chair is equipped with an inflatable rubber bladder for the purpose of recording the muscular contraction and pressure. All the gadgets attached are connected to the recording instrument. The subject must be placed in. a position so that he looks straight ahead. The subject is instructed to remain as quiet as possible, to answer all questions by "yes ' or "no", and to refrain from other

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verbal responses during the test. If any explanations are to be made, the subject is instructed to wait until the termination of the test. Phases of the Examination: 1. Pre-test interview 2. Actual interrogation and recording through the instrument 3. Post-test interrogation 1. Pre-test interview: Before the actual testing is done, the examiner must first make an informal interview of the subject which may last from 20 to 30 minutes, a. Purpose of the interview: (1) To determine whether the subject has any medical or psychiatric condition or has used drugs that will prevent the testing; (2) To explain to the subject the purpose of the examination; (3) To develop the test questions, particularly those of the types to be asked; (4) To relieve the truthful subject of any apprehension as well as to satisfy the deceptive subject as to the efficiency of the technique; (5) To know any anti-social activity or criminal record of the subject. 2. Actual interrogation and recording: With all the gadgets attached to the body of the subject, the instrument will start running by applying pressure on a button. The subject then will be asked to answer the following standard test questions: a. Irrelevant questions — These are questions which have no bearing to the case under investigation. The question may refer to the subject's age, educational attainment, marital status, citizenship, occupation, etc. The examiner asks these types of questions to ascertain the subject's normal pattern of response by eliminating the feeling of apprehension. b. Relevant questions — These are questions pertaining to the issue under investigation. They must be unambiguous, unequivocal and understandable to the subject. They must all be related to one issue or one criminal act. It is equally important to limit the number of relevant questions to avoid discomfort to the subject. Relevant questions must be very specific to obtain an accurate result.

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LEGAL MEDICINE Examples of relevant questions are "Did you shoot to death Mr. "X''? "Did you take the ring, wrist watch, and wallet of Mr. "X" after his death? " c. Control questions — These are questions which are unrelated to the matter under investigation but are of similar nature although less serious as compared to those relevant questions under investigation. If someone is being investigated for murder by shooting, the control questions may be "Have you ever used or fired a gun? ", "Do you have a gun? ", "Have you killed someone with a gun? ", etc.

In practice, the relevant — irrelevant question technique is used. The responses to the two types of questions are compared, if there is no significant difference between the relevant and irrelevant questions, the subject is reported to be truthful. However, if the subject responds more to the relevant questions, he is considered as not telling the truth. The use of control questions is considered by many polygraphists to be the most reliable and effective questioning technique. These are usually asked if there is doubt in the interpretation of the subject's response to relevant and irrelevant questions. 3. Post-test interrogation: The purposes of further questioning after the test are: a. To clarify the findings; b. To learn if there are any other reasons for the subject's responding to a relevant question, other than the knowledge of the crime; c. To obtain additional information and an admission for law enforcement purposes, if the results suggest deception. 4. Supplementary tests: Aside from the standard tests described above, the following special tests may be performed and incorporated as a part of the standard procedure or may be used as supplementary tests depending upon the result of the standard test in order to draw a better conclusion. a. Peak-of-tension test — The subject may be given this test if he is not yet informed of the details of the offense for which he is being interrogated by the investigator, or by other persons or from other sources like the print media. The examiner will prepare several questions, about seven, and one of them has a specific bearing on the matter under investigation. The specific question must refer to some

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details of the incident which could not have been known to the subject. A truthful subject, not aware of any question referrable to the subject of investigation, will respond by not building up tension. However, when the question which refers to a detail of the incident is asked, a guilty subject will develop a ''peak of tension'' which will be recorded in the tracing. b. Guilt complex test — This test is applied when the response to relevant and control questions are similar in degree and consistency and in a way that the examiner cannot determine whether the subject is telling the truth or not. The subject is asked questions aside from the irrelevant, relevant and controlled questions; a new series of relevant questions dealing with a real incident and that which the subject could not have committed. If the subject does not respond to the added relevant questions, it indicates that the subject was being deceptive as to the primary issue under investigation. However, no conclusion can be drawn if the response to the added guilt complex question is similar to the real issue questions. c. Silent answer test — This test is conducted in the same manner as when relevant, irrelevant and control questions are asked, but the subject is instructed to answer the questions silently, to himself, without making any verbal response. This test is effective when the subject's verbal response causes distortion in the tracing such as sniff or clearing of the throat. (Modern Legal Medicine, Psychiatry and Forensic Sciences by William Curran, Louis McGarry & Charles Petty, F. A. Davis Company, Philadelphia, 1980 p. 1187-1205). Reasons for the Inadmissibility To the Court of the Result of Polygraph Examination: 1. The polygraph techniques are still in the experimental stage and have not received the degree of standardization of acceptance among scientists. In a series of decisions of the state supreme courts in the United States (Fyre v. U.S., State v. Bonner (Wis.), People v. Becker (Mich.), People v. Forte, State v. Cole (Mich., (Beech v. State (Neb.), People v. Wechnick (Calif.), etc.), non-admissibility of the lie detector test was uniformly ruled. The common reason given was that, according to physiological and psychological authorities, the test has not gained a degree of development beyond the experimental stage. Until it is es-

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tablished that reasonable certainty follows from such a test, it would be an error to admit the results as evidence. The test is useful in the investigation of a crime but it has no place In the courtroom. 2. The trier of fact is apt to give almost conclusive weight to the polygraph expert's opinion. 3. There is no way to assure that a qualified examiner administered the test. The polygraph is capable of a high degree of accuracy only when conducted under controlled conditions by an examiner who is highly qualified due to his ability, experience, education and integrity. "The important areas that may affect the accuracy of the reported test result. . . .would be (1) his polygraphy training (2) the extent of his experience with respect to the years and number of tests he has conducted, (3) the operation of the polygraphy instrument itself (4) the accuracy of the polygraph technique. In addition, special consideration should be given to the number of tests and the number of questions asked during the test. . . (Modern Legal Medicine, Psychiatry and Forensic Sciences, by Curran, et. al, p. 1203). 4. Since the polygraph involves a certain unconscious quality of the examinee, he may unwittingly waive his or her right against self-incrimination. It becomes necessary to determine the scope of the defendant's waiver if he voluntarily submits to the test. (Am. J. of Trial Advocacy, Vol. 4, p.593). 5. The test itself cannot be relied upon because it has many errors. The factors that are responsible for the 26% errors of the lie detector are as follows: 1. Nervousness or extreme emotional tension experienced by a subject who is telling the truth regarding the offense in question but who is nevertheless affected by: a. Apprehension induced by the mere fact that suspicion or accusation has been directed against him; b. Apprehension over the possibility of an inaccurate liedetector test result; c. Over-anxiety to cooperate in order to assure an accurate test result; d. Apprehension concerning possible physical hurt from the instrument; e. Anger resentment over having to take a lie-detector test; f. Over-anxiety regarding serious personal problems unrelated to the offense under investigation;

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g. Previous extensive interrogation, especially when accompanied by physical abuse; and h. A guilt-complex or fear of detection regarding some other offense which he had committed. 2. Physiological abnormalities such as: a. Excessively high or excessively low blood pressure; b. Diseases of the heart; and c. Respiratory disorder. 3. Mental abnormalities such as: a. Feeblemindedness, as in idiots, imbeciles and morons; b. Psychosis or insanities, as in manic-depressives, paranoids, schizophrenics, paretics, etc. c. Psychoneurosis and psychopathia, as among the so-called "peculiar" or "emotionally stable" persons — Those who are neither psychotic or normal, and those from the borderline between these two groups. 4. Unresponsiveness in a living or guilty subject, because of: a. No fear of detection; b. Apparent inability to consciously control response by means of certain mental sets of attitudes; c. A condition of "sub-shock" or "adrenal exhaustion" at the time of the test; d. Rationalization of the crime in advance of the test to such an extent that lying about the offense arouses little or no emotional disturbance. e. Extensive interrogation prior to the test. 5. Attempt to "beat the machine" by controlled breathing or by muscular flexing. 6. Unobserved application of muscular pressure which produces ambiguities and misleading indications in the blood pressure tracing (Lie Detection and'Criminal Interrogation by Fred Imbau and John Reid, The Williams & Wilkins Co., p. 65). However, the results of the lie detector test may be admissible if there is a stipulation of the parties and counsels that they will accept said results. The reason is that if the defendant agrees to the admission of the polygraph result, then he should not be able to object if the subsequent result turns out to be unfavorable to him (State v. Valdez, 91 Ariz. 274, 371 p. 2d 894 (1962). The judge may have the discretion as to whether it is to be admitted or not. For example, it may not be admitted if done by an incompetent polygrapher. Can a person be compelled to be subjected to the lie-detector test?

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LEGAL MEDICINE Inasmuch as the test requires the subject to answer the questions either by "yes" or "no", it infers the use of intelligence and attention or other mental faculties which is self-incriminatory. Therefore, a person cannot be compelled to be subjected to the test.

B. Use of the Word Association Test: A list of stimulus and non-stimulus words are read to the subject who is instructed to answer as quickly as possible. The answers to the questions may be a "yes" or a "no". Unlike the lie detector, the time interval between the words uttered by the examiner and the answer of the subject is recorded. When the subject is asked questions with reference to his name, address, civil status, nationality, etc. which has no relation to the subject-matter of the investigation, the tendency is to answer quickly. But when questions bear some words which have to do with the criminal act the subject allegedly committed, like knife, gun or hammer which was used in the killing, the tendency is to delay the answer. The test is not concerned, with the answer, be it a "yes" or "no". The important factor) is the time of response in relation to stimulus or non-stimulus words. Like the use of the lie detector, the subject cannot be compelled to be subjected to the test without his consent. C. Use of the Psychological Stress Evaluator (PSE): When a person speaks, there are audible voice frequencies, and superimposed on these are the inaudible frequency modulations which are products of minute oscillation of the muscles of the voice mechanism. Such oscillations of the muscles or micro tremor occur at the rate of 8 to 14 cycles per second and controlled by the central nervous system. When a person is under stress as when he is lying, the microtremor in the voice utterance is moderately or completely suppressed. The degree of suppression varies inversely to the degree of psychologic stress in the speaker. The psychological stress evaluator (PSE) detects, measures, and graphically displays the voice modulations that we cannot hear. / When a person is relaxed and responding honestly to the questions, those inaudible frequencies are registered clearly on the instrument. But when a person is under stress, as when he is lying, these frequencies tend to disappear.

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1. Procedure: a. The examiner meets the requesting party to determine the specific purpose of the examination and to begin formulation of relevant questions. b. A pre-test interview is conducted with the subject to help him or her feel at ease with the examiner, to provide an opportunity to specify matters, to eliminate outside issues, and to review questions that will be asked. c. An oral test of about 12 to 15 "yes* or "no" questions is given which is recorded on a tape recorder. The questions are a mixture of relevant and irrelevant questions. d. Immediately following the test or at a later time, the tape is processed through the Psychological Stress Evaluator for analysis of the answers. e. If stress is indicated, the subject is given opportunity to provide additional clarification. A retest is given to verify correction and clarification (Legal Medicine 1980, Cyril Wecht, ed. p. 58). 2. Advantages of Psychological Stress Evaluator over the Lie Detector Machine: a. It does not require the attachment of sensors to the person being tested. b. The testing situation need not be carefully controlled to eliminate outside distraction; and c. Normal body movement is not restricted. / II. USE OF DRUGS THAT "INHIBIT THE INHIBITOR" A. Administration of Truth Serum: The term "truth serum" is a misnomer. The procedure does not make someone tell the truth and the thing administered is not a serum but is actually a drug. In the test, hyoscine hydrobromide is given hypodermically in repeated doses until a state of delirium is induced. When the proper point is reached, the questioning begins and the subject feels a compulsion to answer the questions truthfully. He forgets his alibi which he may have built up to cover his guilt. He may give details of his acts or may even implicate others. j The drug acts as depressant on the nervous system. Clinical evidence indicates that various segments of the brain particularly the cortex and diencephalon are selectively depressed in the reversed order of their evolutionary development. The use of drugs for the purpose is not without the element of danger and should not be attempted except by a physician who

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has had experience in using the drug. Scopolamine may sometime cause psychotic reactions. Statements taken from the subject while under the influence of truth serum are evolutionarily obtained hence they are not admissible as evidence. Because of the potential risks involved in the application of the procedure, it is seldom used by law-enforcement agencies. B. Narcoanalysis or Narcosynthesis: This method of deception detection is practically the same as that of administration of truth serum. The only difference is the drug used. Psychiatric sodium amytal or sodium p'enthotal is administered to the subject. When the effects appear, questioning starts. It is claimed that the drug causes depression of the inhibitory mechanism of the brain and the subject talks freely. The administration of the drug and subsequent interrogation must be done by a psychiatrist with a long experience on the line. Like the administration of truth serum, the result of the test is not admissible in court. I C. Intoxication with alcohol: The apparent stimulation effect of alcohol is really the result of the control mechanism of the brain, so alcohol, like truth serum, and narcoanalytic drugs "inhibit the inhibitor". The ability of alcohol to reveal the real person behind the mask which all of us are said to wear ("mask of sanity") is reflected in the age-old maxim, "In vino Veritas" ("In wine there is truth"). (Pathology of Homicide by Lester Adelson, Charles Thomas, 1974, p. 895). The person whose statement is to be taken is allowed to take alcoholic beverages to almost intoxication. At this point the power to control diminishes and the investigator starts pounding questions and recording answers. The questioning must start during the excitatory state when the subject has the sensation of his well-being and when his action, speech and emotions are less strained due to the lowering of the inhibition normally exercised by the higher brain centers. When the subject is already in the depressive state due to the effect of alcohol, he will no longer be able to answer any question. Confessions made by the subject while under the influence of alcohol may be admissible if he is physically capable to recollect the facts that he has uttered after the effects of alcohol have disappeared. 3ut in most instances, the subject cannot recall everything that he had mentioned or he may refuse to admit the truth of the statement given.

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III. HYPNOSIS Hypnosis is the alteration of consciousness ^nd concentration in which the subject manifests a heightened of suggestibility while awareness is maintained. Not all persons are susceptible to hypnotic induction. Subjects who are compulsive-depressive type, strong-willed like lawyers, accountants, physicians and other professionals are usually nonhypnotizable. Reasons Why Deception Detection Obtained Through Hypnosis Is Not Admissible in Court: 1. It lacks the general scientific acceptance of the reliability of hypnosis per se in ascertaining the truth from falsity; 2. The fear that the trier of fact will give uncritical and absolute reliability to a scientific device without consideration of its flaw in ascertaining veracity. 3. The possibility that the hypnotized subject will deliberately fabricate; 4. The prospect that the state of heightened suggestibility in which the hypnotized subject is suspended will produce distortion of the fact rather than the truth; and 5. The state of the mind, skill and professionalism of the examiner are too subjective to permit admissibility of the expert testimony (Am. J. of Trial Advocacy, 1981, p. 603). Confession while under hypnotic spell is not admissible as evidence because such "psychiatric treatment" is involuntary and mentally coersive (Leyra v. Demro, 347 U.S. 556, 74 S. Ct. 716, 98, 948 (1954). Although hypnosis may not yield admissible evidence it may be of some use during investigation as a discovery procedure. IV.^SERVATION A good criminal investigator must be a keen observer and a good psychologist. A subject under stress on account of the stimulation of the sympathetic nervous system may exhibit changes which may be used as a potential clue of deception. And since just one or a combination of the following signs and symptoms is not conclusive or a reliable proof of guilt of the subject, their presence infers further investigation to ascertain the truth of the impression. Physiological and Psychological Signs and Symptoms of Guilt: 1. Sweating — Sweating accompanied with a flushed face indicate anger, embarrassment or extreme nervousness. Sweating with a

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pallid face may indicate shock or fear. Sweating hands indicate tension. 2. Color cnange — If the face is flushed, it may indicate anger, embarrassment or shame. A pale face is a more common sign of guilt. 3. Dryness of the mouth — Nervous tension causes reflex inhibition of salivary secretion and consequently dryness of the mouth. This causes continuous swallowing and licking of the lips. 4. Excessive activity of the Adam's apple — On account of the dryness of the throat aside from the mouth, the subject will swallow saliva from the mouth and this causes the frequent upward and downward movement of the Adam's apple. This is observed in many guilty subjects. 5. Fidgeting — Subject is constantly moving about in the chair, pulling his ears, rubbing his face, picking and tweaking the nose, crossing or uncrossing the legs, rubbing the hair, eyes, eyebrows, biting or snapping of fingernails, etc. These are indicative of nervous tension. 6. "Peculiar feeling inside" — There is a sensation of lightness of the head and the subject is confused. This is the result of his troubled conscience. 7. Swearing to the truthfulness of his assertion — Usually a guilty subject frequently utters such expression. "I swear to God I am telling the truth" or "I hope my mother drops dead if I am lying", "I swear to God". . . etc. Such expressions are made to make forceful and convincing his assertion of innocence. 8. "Spotless past record" — "Religious man" — The subject may assert that it is not possible for him to do "anything like that" inasmuch as he is a religious man and that he has a spotless record. 9. Inability to look at the investigator "straight in the eye" — The subject does not like to look at the investigator for fear that his guilt may be seen in his eyes. He will rather look at the floor or ceiling. 10. "A or that I remember" expression — The subject will resort to the use of "not that I remember" expression when answering to be evasive or to avoid committing something prejudicial to him. r

V. SCIENTIFIC INTERROGATION Interrogation is the questioning of a person suspected of having committed an offense or of persons who are reluctant to make a full disclosure of information in his possession which is pertinent to the investigation. It may be done on a suspect or a witness.

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1. A suspect is a person whose guilt is considered on reasonable ground to be a practical possibility. 2. A witness is a person, other than the suspect, who is requested to give information concerning the incident. He may be a victim a complainant, an accuser, a source of information, an observer of the occurrence, a scientific specialist who has examined physical evidence or a custodian of official document. Attitude and Conduct of an Investigator: In the course of an interrogation of a suspect or witness, the interrogator must observe the following: 1. The interrogator should avoid creating an impression that he is an investigator seeking a confession or conviction. It is better for him to appear in the role of one who is merely seeking the truth. 2. Such realistic words or expressions as "kill", "steal", "confess" your crime, etc. should not be used by the interrogator. It is more desirable, from the psychological standpoint, to employ a milder terminology like "shoot", "take", "tell the truth", etc. 3. The interrogator should sit fairly close to the subject and between the two, there should not be a table or other pieces of furniture. 4. The interrogator should avoid pacing about the room. To give an undiverted attention to the person being interrogated, make it as such that will be more difficult for him to evade detection of deception or conceal his guilt5. The interrogator should avoid or at least minimize smoking, and he should also refrain from fumbling with a pencil, pen or other room accessories, for all these tend to create an impression of lack of interest or confidence. 6. The interrogator should adapt his language to that used and understood by the subject himself. In dealing with an uneducated and ignorant subject, the interrogator should use simple words and sentences. 7. Since the interrogator should always occupy a fearless position with regards to his subject and to the condition and circumstances attending the interview, the subject should not be handcuffed or shackled during his presence in the interrogation room. The interrogator should face the subject as "man to man" and not as policeman to prisoner. For Purposes of Investigation the Following are the Different Types of Criminal Offenders: 1. Based on behavioral attitude: a. Active aggressive offenders — They are persons who commit crime in an impulsive manner usually on account of their

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aggressive behavior. Such attitude is clearly shown in crimes of passion, revenge or resentments, b. Passive inadequate offenders — Persons who commit crimes because of inducement, promise or reward. They are gullible and easily persuaded to perform acts in violation of the penal laws. 2. Based on the state of mind: a. Rational offenders — Those who commit crime with motive or intention and with full possession of their mental faculties. Example: Killing with evident premeditation. b. Irrational offenders — They commit crime without knowing the nature and quality of his act. Example: Mad killer. 3. Based on proficiency: a. Ordinary offenders — These are the lowest form of criminal career. They are only engaged in crimes which require limited skill. They lack the capacity to avoid arrest and conviction. a. Professional offenders — They are highly skilled and able to perform criminal acts with the least chance of being detected. They commit crimes which require special skill rather than violence. Example: Pick-pocketing, shop-lifting. 4. Psychological classification: a. Emotional offenders— These are persons who commit crimes in the heat of passion, anger, or revenge, and also who commit offenses of accidental nature. Emotional offenders usually have feeling of remorse, mental anguish or compunction as a result of their acts. They have the sense of moral guilt. Their conscience "bother" them and they have difficulty resting or sleeping because of their feeling of guilt. The most effective interrogation approach to use for them is based upon sympathetic consideration regarding their offense and present difficulty. b. Non-emotional offenders — These are persons who commit crimes for financial gain and are usually recidivist or repeaters. Sympathetic approach is not effective. The interrogator should make a factual analysis of the suspect's predicament and appeal to his common sense and reasoning rather than to his emotion. Requirement for the Admissibility of Evidence Obtained Through Interrogation: Sec. 20 Art. IV, Bill of Rights, Philippine Constitution: No person shall be compelled to be a witness against himself. Any person under investigation for the commission of an offense

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shall have the right to remain silent and to counsel, and be informed of such right. No force, violence, threat, intimidation, or any other means which vitiates the free will shall be used against him. Any confession obtained in violation of this section shall be inadmissible in evidence. In compliance with the above provision of the constitution and the decision of the U.S. Supreme Court, in Miranda v. Arizona, 384 U.S. 436 (1966) safeguards were established for the interrogation of suspected (accused) person. If a person is to be interrogated, he must first be warned and advised that: a. He has the right to remain silent; b. Anything he says can be used against him in court of law; c. He has the right to consult with an attorney and to have the attorney present during the questioning; and d. If he cannot afford an attorney, one will be appointed for him prior to any questioning if he so desires. After such warning and in order to secure a waiver, the following questions should be asked. An affirmative answer to each question constitutes a waiver to the rights: a. Do you understand each of these rights I have explained to you? b. Having these rights in mind, do you wish to talk to us now? Some Techniques of Interrogation: The choices of methods of questioning depend on the personal and psychological evaluation of the subject by the interrogator, the nature of the crime under investigation, previous criminal record, and the social and educational background of the subject. 1. Emotional appeal — The interrogator must create a mood that is conducive to confession. He may be sympathetic and friendly to the subject. The subject may be willing to disclose more information if he is treated in a kind spirit. 2. Mutt and Jeff technique — In this technique there must be at least two investigators with opposite character; one (Mutt) who is arrogant and relentless who knows the subject to be guilty and will not waste time in the interrogation, and the other (Jeff) who is friendly, sympathetic and kind. When Mutt is not present Jeff will advice the subject to make a quick decision and plea for cooperation. 3. Bluff on split-pair technique — This is applicable where there are two or more persons who allegedly participated in the commission of a crime. All of them are interrogated separately and the results of their individual statements are not known to one another. While one of them is under interrogation, the interrogator may

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claim that the subject was implicated by the author and that there is no use for him to deny participation. 4. Stern approach — The questions must oe answered clearly, and the interrogator utilizes harsh language. Immediate response from the subject is demanded. 5. The subject is given the opportunity to make a lengthy, timeconsuming narration. There may be a moment when the subject becomes confused and desists from making further statement for fear of contradicting his previous statement. Basis of the Investigator's Inference that the Subject is Not Telling the Truth: 1. The subject's statement have many improbabilities and gaps on its substantial parts. 2. The subject's statements are inconsistent with the material facts. 3. The subject's statements are incoherent, conflicting with one another. VI. CONFESSION Confession is an expressed acknowledgment by the accused in a criminal case of the truth of his guilt as to the crime charged, or of some essentials thereof. Confession is different from admission, although admission includes, as one of its species, confession. Confession is a statement of guilt while admission is usually a statement of fact by the accused which does not directly involve an acknowledgement of guilt of the accused. The defendant stated in the preliminary investigation that he had inflicted upon the deceased the wounds -in question. It was held that such statement was not a confession of guilt but only an admission, inasmuch as the defendant might have inflicted the wound in self-defense (U.S. v. Team, 23 Phil. 64). An admission by one accused of rape that he had carnal intercourse with the complaining witness at the time and place mentioned in the information is not a confession of guilt of the crime charged unless he further admits that he cohabited with the woman without her consent, or by the use of force or threat (U.S. v. Flores, 26 Phil. 262). Kinds of Confession: 1. Extra-judicial Confession: This is a confession made outside of the court prior to the trial of the case.

LEGAL MEDICINE

37

Sec. 3, Rule 133, Rules of Court — Extra-judicial confession, not sufficient ground for conviction: An extra-judicial confession made by an accused, shall not be sufficient ground for conviction, unless corroborated by evidence of corpus delicti. Qbrpus delicti means the body of the crime or fact of specific loss or injury sustained. It may not necessarily be the body of the crime but may consist of facts and circumstances tending to corroborate the confession. The reason for the above rule is to guard against conviction based upon false confession of guilt. It is possible that a person might have confessed his guilt regarding an offense which someone has committed and when asked of his victim on the nature of the injuries inflicted by him, it does not coincide with the identity or nature of the injuries received by the victim. a. Extra-judicial confession may be: / ( l ) Voluntary extra-judicial confession: The confession is voluntary when the accused speaks on his free will and accord, without inducement of any kind, and with a full and complete knowledge of the nature and consequence of the confession, and when the speaking is so free from influences affecting the will of the accused, at the time the confession was made that it renders it admissible in evidence against him. (2) Involuntary extra-judicial confession: lA ^ C A W * * A M ' Confessions obtained through force, threat, intimidation, duress or anything influencing the voluntary act of the confessor. Confessions obtained from the defendant by means of force and violence is null and void, and cannot be used against him at the trial. (U.S. v. Lozada, 4 Phil. 266; U.S. v. Felipe, 5 Phil. 333). If a confession was made when a threat or promise was made by, in the presence of a person in authority, who has, or is supposed by the accused to have power or opportunity to fulfill the threat or promise, then the confession of the accused will be presumed to be the exclusive effect of inducement and therefore inadmissible (Early v. Com., 86 Va. 921). A confession made under the influence of spiritual advice or exhortation is not admissible. L

V

?

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LEGAL MEDICINE

A confession made under the influence of parental sentiment is not admissible (People v. Martinez, 42 Phil. 853). In confession through a "third degree", the duty of the physician is to determine the presence and extent of physical injuries on the subject. A physician must be cautious concluding that if physical injuries are present, they were inflicted in the course of a "third degree". It could be possible that the subject has self-inflicted those wounds in the guise that the confession was not voluntary. Maltreatment of Prisoners for the Purpose of Exhorting Confession or To Obtain Some Information is a Crime. Art. 235, Revised Penal Code — Maltreatment of prisoners: The penalty of arresto mayor in its medium period to prision correccional in its minimum period, in addition to his liability for the physical injuries or damaged caused, shall be imposed upon any public officer or employee who shall overdo himself in the correction or handling of a prisoner or detention of a prisoner under his charge, by the imposition of punishments not authorized by the regulations, or by inflicting such punishments in a cruel and humiliating manner. If the purpose of the maltreatment is to extort a confession, or to obtain some information from the prisoner, the offender shall be punished by prision correccional in its minimum period, temporary special disqualification, and a fine not exceeding 500 pesos, in addition to his liability for the physical injuries or damage caused. Elements of the crime: 1. The offender is a public officer or employee; 2. The offender has under his charge a (convicted) prisoner or a detention prisoner; 3. The offender maltreats the prisoner in any of the following way: a. By overdoing in the correction or handling of prisoner, either by (1) imposition of punishment not authorized by the regulation, or (2) by inflicting such punishment in a cruel and humiliating manner; or b. By maltreating such prisoner to extort a confession or to obtain some information from the prisoner. THE TOKYO DECLARATION The Tokyo Declaration which was endorsed by the World Medical Association in 1975 contains guidelines to be observed by physicians concerning torture and other cruel, inhuman, and degrading treatment or punishment in relation to detention and imprisonment.

DECEPTION DETECTION

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Preamble It is the privilege of the medical doctor to practice medicine in the service of humanity, to preserve and restore bodily and mental health without distinction as to persons, to comfort and ease the suffering of his or her patients. The utmost respect for human life is to be maintained even under threat, and no use made of any medical knowledge contrary to the laws of humanity. For the purpose of this Declaration torture is defined as the deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason. Declaration 1. The doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel inhuman or degrading procedures, whatever the offense of which the victim of such procedures is suspected, accused or guilty, and whatever the victim's beliefs for motives, and all the situations, including armed conflict and civil strife. 2. The doctor shall not provide any premises, instruments, substances or knowledge to facilitate the practice of torture or other forms of cruel, inhuman or degrading treatment or to diminish the ability of the victim to resist such treatment. 3. The doctor shall not be present during any procedure during which torture or other forms of cruel, inhuman or degrading treatment is used or threatened. 4. A doctor must have complete clinical independence in deciding upon the care for a person for whom he or she is medically responsible. The doctor's fundamental role is to alleviate the distress of his or her fellow men, and no motive — whether personal, collective or political — shall prevail against his higher purpose. 5. Where a prisoner refuses nourishment and is considered by the doctor as capable of forming an unimpaired and rational judgment concerning the consequences of such voluntary refusal of nourishment, he or she shall not be fed artificially. The decision as to the capacity of the prisoner to form such a judgement should be confirmed by at least one other independent doctor. The consequences of the refusal of nourishment shall be explained by the doctor to the prisoner. 6. The World Medical Association will support, and should encourage the international community, the national medical associations and fellow doctors, to support the doctor and his or her family in

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the face of threats or reprisals resulting from a refusal to condone the use of torture and other forms of cruel, inhuman or degrading treatment. (The New Police Surgeon by S.H. Burgress, pp. 134-136; JAMA Vol. 255, No. 20 May 23,1986, p. 2800) 2. Judicial Confession: This is the confession of an accused in court. It is conclusive upon the court and may be considered to be a mitigating circumstance to criminal liability. A plea of guilty when formally entered on arraignment is sufficient to sustain a conviction of any offense, even a capital one, without further proof. Sec. 2, Rule 129, Rule of Court — Judicial admissions: Admissions made by the parties in the pleadings, or in the course of the trial or other proceedings do not require proof and can not be contradicted unless previously shown to have been made through palpable mistake.

Chapter III MEI31G0-LEGAL ASPECTS OF IDENTIFICATION - identification is the determination of or thing.

t h e i n d i v i d u a l i t y nt

ajTimn

importance of Identification of Person: 1. 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 acquital of the accused. 2. The identification of a person missing or presumed dead will facilitate settlement of the estate, retirement, insurance and other social benefits. It vests on the heirs the right over the properties of the identified person. If identity cannot be established, then the law on presumption of death (Art. 390, Civil Code) must be applied which requires the lapse of seven years before a person can be presumed dead. In special instances, the seven years period may be reduced to four years (Art. 391, Civil Code). 3. Identification resolves the anxiety of the next-of-kin, other relatives and friends as to the whereabouts of a missing person or victim of calamity or criminal act. 4. Identification may be needed in some transactions, like cashing of check, entering a premise, delivery of parcels or registered mail in post office, sale of property, release of dead bodies to relatives, parties to a contract, etc. 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 TJIW 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 recovered from the crime scene, they will positively establish the identity of the person while bodily marks, like moles, scars, complexion, shape of nose, etc. are merely corroborative. Visual recognition by relative or friends may be of lesser value as compared with fingerprints or dental comparison. 41

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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. The process of taking fingerprints and its examination under a magnifying lens requires the services of an expert. When putrefaction has set in, the external bodily marks useful in identification might be destroyed so that it is necessary to resort to an anatomical or a structural examination of the body which requires knowledge of medicine' and dentistry. 4. Inasmuch as the object to be identified is highly perishable, it is necessary for the team to act in the shortest possible time specially in cases of mass disaster. 5. There is no rigid rule to be observed in the procedure of identification of persons. Methods of Identification: l.By comparison — Identification criteria recovered during investigation are compared with records available in the file, or postmortem finding are compared with ante-mortem records. Examples: a. Latent fingerprints recovered from the crime scene are compared with the fingerprints on file of an investigating agency. b. Dental findings on the skeletal remains are compared with the dental record of the person in possession of the dentist. 2. By exclusion — If two or more persons have to be identified and all but one is not yet identified, then the one whose identity has not been established may be known by the process of elimination. / IDENTIFICATION OF PERSONS The bases of human identification may be classified as: X- Those which laymen used to prove identity — No special training or skill is required of the identifier and nc instrument or procedure is demanded. 2 JPhose which are based on scientific knowledge — Identification is made by trained men, well-seasoned by experience and observation, and primarily based on comparison or exclusion. <

V L ORDINARY METHODS OF IDENTIFICATION Points of Identification Applicable to the Living Person Only: 1. Characteristics which may easily be changed: (j^ Growth of hair, beard or mustache — This may easily be shaved or grown within a short time. Arrangement may be changed.

MEDICO-LEGAL ASPECTS OF IDENTIFICATION artificial hair may be worn or ornamentation may be placed to changed its natural condition. ^b^Clothing — A person may have special preference for certain form, texture, or style. Certain groups of people are required to have specific cut, color or design, as in uniforms, worn by students, employees of commercial or industrial establishment, or groups of professionals. /c.^'requent place of visit — A person may have a special desire or ^ " n a b i t to be in a place if ever he has the opportunity to do so. "Sari-sari" stores, barber shops, coffee shops, beer gardens and recreation halls are common venues of visit of certain class of people. A wanted criminal may suddenly prevent himself from going to the place he used to visit for fear that he may be apprehended. ^^Grade of profession — A medical student of the upper clinical year may be recognized by the stethoscope; a graduate or student nurse by her cap, a mechanic by his tools, a clergyman by his robe, etc. A change of grade, trade, vocation or profession may be resorted to as a means of concealing identity. (eJBody ornamentations — Earrings, necklaces, rings, pins, etc. ^-^usually worn by persons may be points to identify a person from the rest. 2.\£haracteristics that may not easily be changed: a. Mental memory — A recollection of time, place and events may be a clue in identification. Remembering names, faces and subjects of common interest may be initiated during interview to see how knowledgeable a person is. b. Speech — A person may stammer, stutter or lisp. However, if the manner of talking is due to some physical defects, like harelip and cleft palate, that have been corrected by surgery, there may be a change in his manner of speech. The manner of talking and the quality of the voice are dependent on the vocal cavities (throat, mouth, nose and •inuses) and his manner of manipulating the lips, teeth, tongue, soft palate, and jaw muscles. The chances of two or more persons having the same size of vocal cavities and the same manner of articulation are remote and unlikely. Whispering, muffling and nose-holding do not change the speech characteristic. The speech may be recorded and preserved in a good tape recorder. A known standard may also be recorded for purposes of comparison. Identification can be achieved through the sound spectrographs analysis.

LEGAL MEDICINE c. Gait — A person, on account of disease or some inborn traits, may show a characteristic manner of walking. (1) Ataxic gait — A gait in which the foot is raised high, thrown forward and brought down suddenly is seen in persons suffering from tabes dorsalis. (2) Cerebellar gait — A gait associated with staggering movement is seen in cerebellar diseases. (3) Cow's gait — A swaying movement due to knock-knee. (4) Paretic gait — Gait in which the steps are short, the feet are dragged and the legs are held more or less widely apart. (5) Spastic gait — A gait in which the legs are held together and move in a stiff manner and the toes dragged. (6) Festinating gait — Involuntary movement in short accelerating steps. (7) Frog gait — A hopping gait resulting from infantile paralysis. (8) Waddling gait — Exaggerated alternation of lateral trunk movement similar to the movement of the duck. In the normal process of walking the rear portion of the heel is placed on the ground. This is subsequently followed by the other parts of the heel and the sole of the foot is pressed on the ground. The toes are the last to be pressed followed by the lifting of the foot making another step forward. The pressure at the rear portion of the heel and in the region of the toes is the most forceful, hence the impression is the most. During the process of running the foot marks are less distinct because of the slipping of the foot and the sand or soil thrown into the marks by the pressure of the tip of the toes. Gait Patterns: A scientific investigation of the gait pattern may be useful for purposes of identification and investigation of the crime scene. Gait pattern is the series of foot marks by a person walking or running. Examination of the gait includes the direction line, gait line, foot angle, principal angle and the length and breadth of the steps.

MEDICO-LEGAL ASPECTS OF IDENTIFICATION

45

at.. Gait pattern. A: direction line; B: gait line; C: foot line; D: foot angles; E: principal angle; F: length of step; G: breadth of step.

(A) Direction line — Expresses the path of the individual. (B) Gait line — The straight line connecting the center of the succeeding steps. It is more or less in zigzag fashion especially when the legs are far apart while walking. Stout, elderly people and those who want stability while walking have a more zigzag gait line. (C) Foot line — The longitudinal line drawn on each foot mark. There may be a difference in the foot line of the left and right foot. (D)Foot angle — The angle formed by the foot line and the direction line. In normal walking the foot angle is very characteristic of a person and cannot be altered immediately. However, it may be altered when a person is running, carrying a heavy weight or moving on a rugged terrain. (E) Principal angle — The angle between the two succeeding foot angles. (F) Length of step — When the distance between the center points in two successive heel prints of the two feet exceeds 40 inches, there is a strong presumption that the person is running. (G) Breadth of step — The distance between the outer contours of two succeeding foot marks or steps. The more apart the legs are while walking, the greater is the breadth of the step. (Crime Detection by Ame Svensson & Otto Wendel, p. 58) dr.'Mannerism — Stereotype movement or habit peculiar to an individual. It may be: (1) Way of sitting. (2) Movement of the hand. (3) Movement of the body. (4) Movement of the facial muscles. (5) Expression of the mouth while articulating. (6) Manner of leaning.

46

LEGAL MEDICINE e. Hands and feet — Size, shape and abnormalities of the hands and feet may be the bases of identification. Some persons have supernumerary fingers or toes far apart with bony prominence. Some fingers or toes are with split nails. Foot or hand marks found in the investigation of the crime scene may be: (1) Foot or hand impression — This develops when the foot or hand is pressed on mouldable materials like mud, clay, cement mixture, or other semi-solid mass. The impression can be preserved by making a cast of it with plaster of Paris. (2) Footprint or handprint — This is a footmark or handmark on a hard base contaminated or smeared with foreign matters like dust, flour, blood, etc.

t. Complexion — Complexion can be determined when the whole body is exposed preferably to ordinary sunlight. Dark complexion may be found fair with the use of bleaching chemicals, while fair complexion may temporarily be made dark with the use of an ointment with a dark pigment. Exposed parts of the body usually appear darker than those covered with clothing. g. Changes in the eyes — A person identified because he is nearsighted, far-sighted, color blind, astigmatic, presbyopic, or crosseyed. The eye may have arcus senilis, artificial pupils, irregular marks of the spectacles or cataract. Color of the iris, shape of the eyes, deformity of the eyeball and the presence of disease are useful bases of identification. h. Facies — There are different kinds of facial expressions brought about by disease or racial influence. (1) Hippocratic facies— The nose is pinched, the temple hollow, eyes sunken, ears cold, lips relaxed and skin livid. The appearance of the face is indicative of approaching death. (2) Mongolian facies — Almond eyes, pale complexion, prominence of cheek bones. (3) Facies Leonine — A peculiar, deeply furrowed, lion-like appearance of the face. This may be observed in leprosy, elephantiasis and ,leontiasis ossia. (4) Myxedemic facies — Pale face, edematous swelling which does not pit on pressure, associated with dullness of intellect, slow monotonous speech, muscular weakness and tremor.

MEDICO-LEGAL ASPECTS OF IDENTIFICATION

Base up

47

Base down Triangular face

The face may be round, oval, triangular or slightly square. Distinct identifying marks may be present on the face, such as, peculiarly attractive scars, moles, hair, nose and condition of the skin which an identifier may specially notice, i. Left— or right-handedness — The preferential use of one hand with skill to the other in voluntary motor acts. Ambidextrous people can use their right and left hands with equal skill. The best way to determine whether a person is left— or right-handed or ambidextrous is to observe him during his unguarded moments. j. Degree of nutrition — The determination must be in relation to the height and age. A person may be thin, normal or stout. This point of identification easily changes by refraining from / intake of fatty foods. Some persons are inherently skinny / inspite of heavy intake of nutritive food. ^Points of Identification Applicable to Both Living and Dead before -Ouaul of Lrecomposition: l^Oeeupatirnttl Marfrff — Certain occupations may result in some characteristic marks or identifying guides:

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a. A shoemaker develops depressed sternum. b. Painters have stains on the hands and fingernails. c. Engineers and mechanics may have grease on their hands. d. A dressmaker develops multiple punctured marks on finger tips. e. Baker and miller may have flour dust on their clothings and on their bodies. f. Mason have callosities on the palms of the hands. g. Scars caused by burns produced by scales or sparks or red hot iron may be seen at the back of the hands of blacksmiths. h. Involuntary tattooing of particles of coal may be seen on the hands of miners. i. Chemical stains may be present on the hands of dyers, photographic developers and printers. 2. Race — In the living, race may be presumed in: *^a. Color of the skin: Caucasian — Fair Malayan — Brown Mongolian — Fair Negro — Black b. Feature of the face: Caucasian — Prominent sharp nose Malayan — Flat nose with round face Mongolian — Almond eyes and prominent cheek bone Negro — Thick lips and prominent eyes c. Shape of the skull: Caucasian — Elongated skull Malayan — Hound head Mongolian — Round head Ked Indians and Eskimos — Flat head d. Wearing apparel — Casual and customary wearing apparel may indicate race as well as religion, nationality, region and custom. 3.

Rtntiijp A person ceases to increase in height after the age of "25. There is apparent shrinkage in height after a long standing debilitating disease. There is actual shrinkage in old age on account of the compression of the inter-vertebral and also the curvature of the spinal column. The growth of a person rarely exceeds five centimeters after the age of 18. The rate of growth is variable but it is most active from 5 to 7 and from 13 to 16 years of-age. When the rate of growth is increased, the horizontal growth is relatively retarded.

MEDICO-LEGAL ASPECTS OF IDENTIFICATION Methods of Approximating the Height of a Person: If the body is complete the height can be determined by actual measurement. Sometimes some part of the body is missing and the actual measurement may not be possible. The following are the methods to be used to approximate the height: a. Measure the distance between the tips of the middle fingers of both hands with the arms extended laterally and it will approximately be equal to the height. b. Two times the length of one arm plus 12 inches from the clavicle and 1.5 inches from the sternum is the approximate height. c. Two times the length from the vertex of the skull to the pubic symphysis is the height. d. The distance between the supra-sternal notch and the pubic symphysis is about one-third of the height. e. The distance from the base of the skull to the coccyx is about 44% of the height. f. The length of the forearm measured from the tip of olecranon process to the tip of the middle finger is 5/19 of the height. g. Eight times the length of the head is approximately equal to the height of the person. 4. Tattoo marks — Introduction of coloring pigments in the layers of the skin by multiple puncture. Tattoo marks may be in the form of initials, names, images or views.

_1,

Tattoo marks

so

l e g a l medicine Importance of Tattoo Mark: a. It may help in the identification of the person. The image inscribed may reflect the name, date of birth, language spoken, religion, name of spouse, etc. b. It may indicate memorable events in his life. c. It may indicate the social stratum to which the person belongs. Generally, tattooing is practiced by the members of the lower economic class. d. Lately, the presence of tattoo implies previous commitment in prison or membership in a criminal gang. Factors Responsible for the Permanency of Tattoo: a. Whether the punctures are superficial or deep to reach the true skin; b. Nature and solubility of the pigment used. Ordinary pen ink disappears in a short time while carbon introduced to the true skin layer is usually permanent. Soluble pigments easily disappear and may be seen in the lymph glands.

Methods of Removing Tattoos: a. By surgical excision - Shallow tattoo may disappear by simple rubbing or superficial incision and may leave no scar. Deepseated tattoo may be excised and usually leaves a scar. b. By electrolysis — The needle is inserted into the tattoo mark in a sufficient number of times using a current of 5 to 8 milliamperes. This forms a superficial eschar, which drops off in a week or so taking the pigment with it and leaving a superficial scar. c. By application of caustic substance — The caustic substance is applied to the tattoo mark and the pigment is removed with the eschar after inflammatory reaction. h.Wejghtr— This is not a good point of identification for it is """"easily changed from time to time. 6. Deformities — Congenital or acquired — deformities may cause ^-Peculiar way -of walking, body movement, facial expression, mannerisms, etc. Deformity like clubfoot, harelip, cleft palate, cystic conditions, bony prominence, etc., may be corrected surgically. Acquired deformities in the form of amputation, improper union of bones, depressed fracture, deforming scars may be the bases for identification. T_Birth marks — Birth marks may be a spot naevi, port wine, or a Mongolianblue spot. They may be removed by carbon dioxide snow, electrocautery, or by excision. The marks must be des-

MEDICO-LEGAL ASPECTS OF IDENTIFICATION cribed as to shape, location, dimension, color and degree of pigmentation. rnj»riv>fl leaving permanent results — Amputation, improper union of fractured bones. Q M o f g « — O r d i n a r i l y they are permanent but can be removed by '""""electrolysis, by radium or by carbon dioxide snow. 10^Jfcgc--==--A-^maining mark after healing of the wound. The fibrous tissue takes the place of the original tissue which has been injured or destroyed. A scar is devoid of specialized tissues so it does not contain pigment, sweat or sebaceous glands. Its number, exact location, size and shape, and whether it is elevated or depressed should be noted. Faint scars may be made visible by making the surrounding skin red upon applying friction with hand or by heat. Scar which develops after a secondary infection is usually marked. Scar increases in size in proportion with the growth of the person. Age of the Scar — A recently formed scar is slightly elevated, reddish or bluish in color, and tender to touch. In a few weeks to two months, the scar has inflammatory redness and it is soft and sensitive. Two to six months later, it becomes brownish or coppery red in color, free from contraction and corrugation, and soft. When the scar is white, glistening, contracted and tough, it is not less than six months. The period of scar formation may be delayed by sepsis, poor vascularity of the part involved, age, depth of the wound, mobility, presence of foreign body and health condition of the victim. Scar may or may not develop if the wound is small, superficial and healed by first intention. Characteristics of the scar may show the cause of the previous lesion: a. Surgical operation — Regular form and situation with stitch marks. b. Bums and scald — Scars are large, irregular in shape, and may be keloid. Scar of scald may show stippled surface. c. Gunshot — Disc-like, depressed at center and may be adherent to the underlying tissue. d. Tuberculosis sinus — Irregular in shape furrowed, with edges hardened and uneven.

LEGAL MEDICINE

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e. Flogging — Fine white lines diagonally across back, depressed small spot at interval. f. Gumma — Depressed scar following loss of tissue. g. Lupus — Bluish-white scar. h. Venesection — At bend of elbow, on dorsum of foot, or on temporal region. i. Wet cupping — Short parallel scars on lower part of the back and loin. 11. Tribal marks — Marks on the skin by tattooing or branding. In CliiratrdtngTheated metal is pressed on the skin and during the healing process a scar develops as a mark. The tribal marks are placed in the exposed parts of the body and used to identify person or membership of a tribe or social group. 12. Sexual orggjL=.Male organ may show previous circumcision. In lale"the uterus and breasts may show signs of previous pregnancy. Previous gynecological operation may be seen in the abdomen. 13. Blood examination — Blood type, disease, parasitic infection or -to~xic substances piesent may be utilized to distinguish one person from another. / ^ I H R O P O M E T R V (Bertitton Systemy Alphonse Bertillon, a French criminologist, devised a scheme utilizing anthropometrical measurement of the human body as the basis of identification. Basjs'of the Bertillon System of Identification: l.X'he' human skeleton is unchangeable after the twentieth year. The igh bone continues to grow somewhat after the period, but this 'is compensated by the curving of the spine which takes place at aboia the same age. / 2. It/is impossible to find two Jjuman beings having bones exactly like. 3/The necessary measurement can easily be taken with the aid of a simple instrument. Information Included in the System: 1. Descriptive data — Color of the hair, eyes and complexion, shape „ Whorl

4 Composite

d. Twin loop — There are at least two loops opening at the different sides. e. Accidentals — There are no rules that can be made in this pattern. They are rare and often with more than two deltas. /Poroscopy (Locard's method of identification): Examination of the ridges of the hands and fingers reveal to be studded with minute pores which are the openings of ducts or sweat glands. These pores are permanent as the ridges are and differ in number and shape in a given area in each person. Poroscopy, as a means of identification, is applied when only a part of the fingerprint is available for proper means of identification. Can fingerprints be effaced? John Dillinger, a notorious gangster and a police character attempted to erase his fingerprints by burning them with acid, but as time went by, the ridges were again restored to its "natural" feature. The acid he applied temporarily destroyed the epidermis of the bulbs of his fingers. As long as the dermis of the bulbs of the finger is not completely destroyed, the fingerprints will always remain unchanged and indestructible.

MEDICO-LEGAL ASPECTS OF IDENTIFICATION

61

Can fingerprints be forged? There is a considerable controversy regarding the possibility of forging fingerprints or making a simulated impression or a perfect replica of impression of fingers. Various experiments were conducted by authorities and although they could almost make an accurate reproduction, still there is no case on record known or have been written that forgery of fingerprints has been a complete success. The introduction of modern scientific equipment, new techniques and up-to-date knowledge in crime detection will always foil the attempt. /

The role of the teeth iri human identification is important for the following reasons: 1. The possibility of two persons to have the same dentition is quite remote. An adult has 32 teeth and each tooth has five surfaces. Some of the teeth may be missing, carious, with filling materials, and with abnormality in shape and other peculiarities. This will lead to several combinations with almost infinite in number of dental characteristics. 2. The enamel of the teeth is the hardest substance of the human body. It may outlast all other tissues during putrefaction or physical destruction. 3. After death, the greater the degree of tissue destruction, the greater is the importance of dental characteristics as a means of identification. 4. The more recent the ante-mortem records of the person to be identified, the more reliable is the comparative or exclusionary mode of identification that can be done. In order to make an accurate dental record available for purposes of comparison with that of the person to be identified, Presidential Decree No. 1575 was promulgated, requiring practitioners of dentistry to keep records of their patients. It provides the following: "Whereas, the identification of persons is a necessary factor in solving crimes and in settling disputes such as claims for damages, insurance, and inheritance; _ Whereas, in these cases where the identification of persons cannot be established through the regular means, identification through dentition has been proven to be necessary and effective; Whereas, however, records of dentition of persons are often not available due to the lack of systematic recording of dental practitioners of the dental history of their patients.

62

LEGAL MEDICINE NOW, THEREFORE, I, FERDINAND E. MARCOS, President of the Philippines, by virtue of the powers vested in me by the Constitution, do hereby order and decree the following:

Section 1. It shall be obligatory upon all practitioners of dentistry to keep and maintain an accurate and complete record of the dentition of all their patients which shall include a history and description of the patient's dentition and the treatment made thereon. Section 2. Upon the lapse of ten years from the last entry, dental practitioners shall turn over the dental records of their patients to the National Bureau of Investigation for record purposes: Provided, that the said practitioner may retain copies thereof for their own files. Section 3. Any violation of the provisions of this Decree shall be punishable by a fine of not less than one hundred pesos but not more than one thousand pesos. Section 4. This Decree shall take effect immediately. Done in the City of Manila, this 11th day of June, in the year of Our Lord, nineteen hundred and seventy-eight." However, the absence of dental records will not absolutely negate dental identification. Members of the family, close associates and friends may be witnesses to prove identity of dentition. Causes of Unreliability of the Dental Records: An ante-mortem dental record may be available but may be insufficient, and in some instances unreliable for purposes of comparison with the post-mortem findings because: 1. The dentist, in the course of diagnosis and treatment of the patient, may only concern himself with the affected teeth and may not care to have a detailed examination of the other teeth. 2. There may be no uniformity in nomenclature of the location and condition in the charting of the teeth. 3. Although there may be a law obliging dentists to have a record of their patient, the law does not mention the agency which will enforce it. 4. The dentist may have a record but may no longer be reliable on account of the lapse of time. There may be changes in the teeth which are not seen by the dentist. For purpose of uniformity, the following are the description of location for dental identification: 1. Teeth position: a. Anterior — From cuspid to cuspid inclusive (it includes cuspid, lateral and central incissor).

MEDICO-LEGAL ASPECTS OF IDENTIFICATION b. Posterior — All bicuspid and molar teeth. 2. Surface: Occlosal — O — Surface which is in contact with the opposing teeth when jaws are in occlusion (closed). Mesial

— M — Surface in direct contact with the adjacent tooth towards the midline.

Distal

— D — Surface in direct contact with the adjacent teeth away from the midline.

Buccal — B — Surface facing the lip or cheek. Lingual — L — Inward directed surface of the teeth. 3. Restoration: Amalgam (silver filling), gold inlay, gold foil, silicate, acrylic, temporary cement, crown. 4. Prosthesis: a. Fixed prosthesis — bridge b. Removable prosthesis: (1) Complete denture (2) Partial denture 5. Root canal treatment (endodentia). Dental Features Which May Be Included in the Description for Identification: 1. Malposition, overlapping, crowding and spacing teeth. 2. Number and location of deciduous or permanent teeth. 3. Missing (unerupted or extracted) or supernumerary teeth. 4. Peculiar shape, size, direction of growth of individual teeth. 5. Missing piece or fragment due to decay or trauma. 6. Restoration, prosthesis (surface, and material).

morphology, configuration

7. Root canal therapy on x-ray examination. 8. Bone pattern on x-ray examination. 9. Complete denture (type, shade and material). 10. Relationship of bite. 11. Oral pathology (tore, gingival hyperplasia, etc.).

LEGAL MEDICINE

64

Dental Chart

c

X RF AM S CG

— — — —

Caries Indicated for Extraction Retained Root Fragment Amalgam Filling Silicate Filling Gold Crown

AB P

- Bridge Abutment Pontic Gold Clasp Gl - Gold Inlay M - Missing due to Extraction U N - Unerupted

-

Other Aspects of Identification Which May Be Reflected in Dentition: 1. Personal, occupational and cultural traits: a. Cigarette smokers may have smoke marks mainly on the lingual surface of the anterior upper teeth. b. Seamstress, carpenter, cobblers may hold pins or nails between incissors and may cause formulation of groove. c. Wind instrument musicians may have altered position of their teeth due to mouth formation necessary for playing the instrument. d. Pipe smokers may develop an oval-shape notch at the occlusal surface or irregular gaps located at the angle of the mouth. e. Sandblasters and stone mason may cause abrasions on the labial or occlusal surface of their teeth. f. Poor oral hygiene, with many decayed teeth and no restorations infers individual of low economic status. Extracted teeth are also not replaced by bridgework. g. Excessive fruit juice drinker or carbonated drinks may cause dissolution of the enamel structure of the front teeth. h. Mutilation of teeth by filing or inlaying with precious metals or stone, not done professionally, may indicate tribal customs and cultural peculiarities.

MEDICO-LEGAL ASPECTS OF IDENTIFICATION 2. Age 9 yrs 11 yrs

12 permanent teeth (8 incisors and 4 molars). 20 permanent teeth (8 incisors, 8 premolar and 4 molar). 13 yrs 28 permanent teeth and no deciduous teeth. 8 to 10 yrs Calcification begin at the 3rd molar. 25 yrs Root-ends of 3rd molar completely calcified. Beyond 25 yrs. . . . Ends of the root of the 3rd molar have been completely calcified. After 30 yrs Carries frequently develop at the cementum. There may be gingival recession, decay attack of the root surface. 3. Sex Examination for the presence of Barr bodies from palatal scrappings. j y/C. HANDWRITING A person may be identified through his handwriting, handprinting and handnumbering. Sec. 23, Rule 132, Rules of Court — Handwriting, how proved: The handwriting of a person may be proved by any witness who believes it to be the handwriting of such person, and has seen the person write, or has seen writing purporting to be his upon which the witness has acted or been charged, and has thus acquired knowledge of the handwriting of such person. Evidence respecting the handwriting may also be given by a comparison, made by the witness or the court, with writings admitted or treated as genuine by the party against whom the evidence is offered, or proved to be genuine to the satisfaction of the judge. The genuiness of any disputed writing may be proven by any of the following ways: JL. Acknowledgement of the alleged writer that he wrote it; Statement of witness who saw the writing made and is able to identify it as such; By the opinion of persons who are familiar with the handwriting of the alleged writer, or 4r^By the opinion of an expert who compares the questioned writing with that of other writings which are admitted or treated to be genuine by the party against whom the evidence is offered. Sec. 44, Rule 130, Rules of Court — Opinion of ordinary witnesses: The opinion of a witness regarding the identity of handwriting of a person, when he has knowledge of the person or handwriting; the opinion of a subscribing witness to a writing; the validity of which is

6 6

LEGAL MEDICINE

in dispute, respecting the mental sanity of the signer; and the opinion of an intimate acquaintance respecting the mental sanity of a person, the reason for the opinion being given, may be received as evidence. In order for an ordinary witness to be qualified to express his opinion, it must be shown that he has some familiarity with the handwriting of the person in a way recognized by law. Some Practical Uses of Handwriting Examination: (^Financial crimes (bogus checks, cr'xlit card fraud, embezzlement). /fjDeath investigation (suicide notes, hotel registration cards, letter af explanation), obberies (pawnshop notes, cashing of stolen checks), idnapping with ransom (demand note, threatening letter). 'Anonymous threatening letters. Falsification of documents (deeds of conveyance, receipts). A

\Bibliotics is the science of handwriting analysis. It is the study of documents and writing materials to determine its jgerqjineness or authorship. One who had acquired special knowledge of the science of handwriting for purposes of identification is known as JZibliotisl or more commonly known as handwriting expert or qualified question document examiner.

se of Handwriting Examination: LUWhether the document was written by the suspect. [2) Whether the document was written by the person whose signature it bears. 3JWhether the writing contains additions or deletions. ^ W h e t h e r the document such as bills, receipts, suicide notes or checks are genuine or a forgery. Points to be Considered in Questioned Document Examination: Size, slant, spacing, proportion of the letters, speed and rhythm in writing, shading and change of position in pen hold, pressure, penlift, initial and terminal strokes, alignment, etc. Inasmuch as handwriting examination is basically comparative, the standard for such comparison must be suitable and sufficient. The greater the variation in a way of writing, the greater is the amount of standard writing needed to form a reliable impression. Handwriting examination done by comparison with known standards: To determine whether a certain instrument or document has been written by a certain person, it is necessary to compare the writings on such instrument or document with some standard writings of the same person for the purpose of comparison and determine the similarities. The standard (exemplar) writings with which the questioned writing has to be compared are of two types: 1. Collected (procured) standards — These consist of handwriting by the person who is suspected to have written the questioned document. It may be found in the private or public records of

LEGAL MEDICINE

the person or from other possible sources. Provided it is clear and sufficient, it is the most appropriate standard. 2. Requested standard — These are standards made by the alleged writer of the document in question upon request of the examiner or the persons interested in the examination. Inasmuch as one of the characteristics of good exemplar is that it must be contemporaneous with the date the questioned document was made, the use of the requested standards is applicable only to recently

MEDICO-LEGAL ASPECTS OF IDENTIFICATION written questioned documents, like extortion letter, "poison" notes, letter of threat or ransom, etc. Considering that it is a request from a suspected maker of the questioned document, there is a strong possibility for it to be written in a disguised way. Steps to be Undertaken to Minimize Conscious Efforts to Disguise the Requested Standard: 1. The writer should be allowed to write sitting comfortably at a desk or table and without distraction. 2. The suspect should not, under any condition, be shown the questioned document or be provided with instructions on how to spell certain words or what punctuation to use. 3. The suspect should be furnished with a pen and a paper similar to those used in the questioned document. 4. The dictated text may be the same as the contents of the questioned document, or at least should contain many of the same words, phrases, and letter combinations found in the document. In handwriting cases, the suspect must not be given any instruction on whether to use upper-case (capital) or lower-case lettering. 5. Dictation of the test should take place at least three times. If the writer is making a deliberate effort to disguise his writing, noticeable variations should appear between the three repetitions. Discovering this, the investigator must insist upon continued repetitive dictation of the text. 6. Signature exemplars can best be obtained when the suspect is required to combine other writings with a signature. For example, instead of compiling a set of signatures alone, the writer must be asked to completely fill out twenty to thirty separate checks or receipts, each of which includes a signature. 7. Before requested exemplars are taken from the suspect, a document examiner should be consulted and shown the questioned specimens (Criminalistics by Richard Saferstein, p. 336). Handwriting Characteristics of Illiterates: 1. They seldom follow any rule or baseline although at the beginning a position above the baseline is taken which continues in an ascending or descending course. Baseline is the ruled or imaginary line upon which the writing rests. 2. The tendency of the writing is to be raised involuntarily in the last letters of the word made by the extension of the fingers while the hand is being held in a fixed position. 3. The loop letters are often slanted too much because the upstrokes are made too long or nearly straight.

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LEGAL MEDICINE

4. Very unlikely to produce facsimile signatures in size, arrangement and proportion of parts. 5. The writing is not rhythmic, but made up of disconnected unskilled movement impulses which are not likely to be related in an exactly identical way. 6. Tremor or involuntary trembling is seen due to inability to control the pen in motion because of not being familiar with and self-conscious to the process of writing. 7. Formation and angle of letters are irregular and definitely show lack of knowledge of size and proportion. 8. Same speed is utilized from beginning to end and seldom is the pen raised to get a new adjustment. 9. Illiterate pencil-writing is usually produced with much pressure and may show the habit of wetting the pencil lead frequently. 10. In anonymous writing, illiteracy is indicated by faulty arrangement of words, lines, paragraphs and pages. 11. Combination of script forms and Roman capitals, or pen or pencil printing, containing freak forms, abbreviations or punctuation marks are individual creations. Handwriting Characteristics of Old Aged Persons: X^Due to lack of muscular control, the handwriting will not usually show fine lines continuously but the strokes are mostly rough and made with considerable pressure. 2^With the presence of tremor, the changes of direction are numerous and omission of parts of letters of strokes are common. Z. The concluding parts are often made with a nervous haste and carelessness and they may be much distorted. A\ Even with much tremor, the handwriting will usually show free connecting and terminal strokes made by the momentum of the hand. J£ Often shows very uneven alignment and may disregard entirely a line near which they are written. -o. Usually shows an unusual and erratic departure from its intended movement, particularly in the downward strokes. "7. There is a loss of individual departure from its intended movement, particularly in the downward strokes. ,-8TThere is a loss of individual rhythm as indicated by malformation and irregularity of speed in the writing of small letters. Disguised Writing: Disguised writing is the deliberate attempt on the part of the writer to alter his writing habit by endeavoring to invent a new writing style or by imitating the writing of another person.

MEDICO-LEGAL ASPECTS OF IDENTIFICATION

73

Physical Methods of Disguising Handwriting: a. By changing the direction of the slant. The forger may employ a backhand slant, instead of the usual forehand slant. b. By increasing or decreasing the speed in writing. c. By deliberate carelessness that will produce inferior style of writing. d. By making the letters unusually large or small. e. The forger may use the left hand instead of the right hand. f. Hand printing may be substituted for script. Characteristics of Disguised Writing: a. Inconsistent slant b. Inconsistent letter formation c. Change of capital letters d. Lack of free-flowing movement e. Lack of rhythm f. Unnatural starts and stops g. Irregular spacing h. Writing with unaccustomed hand (Criminalistics by Richard Saferstein, p. 692). Signature forgery: Signature forgery examination is the most common activity of a questioned document examiner. A signature may be found on a document which appears that a person has participated in its execution and the person denied that he had signed it. Such signature may be found in checks, deeds of conveyance, anonymous letters, receipts, etc. Classification of Signature Forgery: a. Traced forgery — The outlining of a genuine signature from one document onto another where the forger wishes it to appear. Traced forgery is basically drawing and consequently lacks free natural movement inherent in a person's normal writing. Ways of Achieving Traced Forgery * (1) The paper wherein the signature is to be copied is placed on top of the document containing the signature. By means of a strong light underneath, the forged signature is traced from the genuine, either directly or lightly by a pencil outline and then over-writing the pencil outline. (2) By placing the paper to receive the signature tracing underneath the document bearing the genuine signature and by indented outline on the underneath page, or by interweaving the documents with carbon paper to produce a carbon outline on the forged paper.

74

LEGAL MEDICINE

b. Simulated forgery — An attempt to copy in a freehand manner the characteristics of a genuine signature either from memory of the signature or from a model. It is accomplished without outline. The quality of the simulated signature varies with the writer's skill as a penman, the difficulty of the signature being imitated, the writer's ability to recognize and incorporate the details, his ability to concentrate on the important feature of the signature and his ability to discard all of his own natural habit of writing. c. Spurious forgery — One prepared primarily in the forger's own handwriting wherein little or no attempt has been made to copy the characteristics of the genuine writing. (Modern Legal Medicine, Psychiatry and Forensic Medicine by W. Curran et ai, p. 1235). The principle of identification of handwriting is also applicable to handprinting and handnumbering. Typewriter Identification: The identification of the typing machine used in a questioned document, like that in ballistics examination, may be on the basis of: 1. Class characteristics — those characteristics which serve to distinguish it from any other machine, such as: a. Manufacturer's characteristics b. Size and design of the type c. Line and letter spacing 2. Individual characteristics: a. Defects in the type face — Unusual manner of letter formation due to factory defect, misuse of the machine or wear and tear. b. Defects in the alignment — Malpositioning, spacing and alignment may be modified by loosening of the hinges and positioning of the letters on account of wear and tear and changes in the spring pressure. c. Other machine defects: (1) Skipping space (2) Irregular margin stops (3) Improper letter spacing (4) Improper ribbon actions A typewriter has 44 keys with 88 characters, each operating independently of one another and each being capable of damage or having inherent defects. Consequently, a variety of combinations of these defects may be the basis of typewriter identification. The questioned document may be compared with those made by the suspected typewriters.

Examination of Bones — Complete lay-out of the bones to determine duplicity i

and missing ones.

V D. IDENTIFICATION OF THE SKELETON Occasionally, before a physician is called to examine a dead body, the soft tissues have already disappeared and only the skeletal system remains. Ail the external identifications have already disappeared. In this particular case we resort to the study of bones. hi the examination of bones, the following points can be determined approximately: 1. Whether the remains are of human origin or not. 2. Whether the remains belong to a single person or not. 3. Height. 4. Sex. 5. Race. 6. Age. 7. Length of interment or length of time from date of death. 8. Presence or absence of ante-mortem or post-mortem bone injuries. 9. Congenital deformities and acquired injuries on the hard tissues causing permanent deformities. How to Determine Whether the Remains Are of Human Origin or Not: The shape, size and general nature of the remains, especially that of the head, must be studied. The oval or round shape of the skull and the less prominent lower jaw and nasal bone are suggestive of

76

LEGAL MEDICINE

human remains. A complete lay-out of the whole bones found and placing each of them on their corresponding places in the human body will be helpful. The presence of dental fixtures, rings on the fingers, earrings in the case of women, hair and other wearing apparels, together with the remains are strong presumption of human remains. How to Determine Whether the Remains Comes from a Single Individual or Not: A complete lay-out of the bones on a table in their exact locations in the human body is necessary. Any plurality or excess of the bones after a complete lay-out denotes that the remains belong to more than one person. However, congenital deformities as supernumery fingers and toes must not be forgotten. The unequality in sizes, especially of the limbs may be ante-mortem. Height: Several formulae using different constants have been forwarded in the approximation of the height of a person by measuring the long bones of the body. A. Actual measurement of the skeleton — To the actual length of the skeleton add 1 to 1-1/2 in. for the soft tissue. •, B. Pearson's Formulae for the reconstruction of the living stature of long bones, whose animal matters have disappeared and which are in a dry state. Males Females S = 81.306 plus 1.880 F S = 72.844 plus 1 . 9 4 5 F = 70.641 plus 2.894 H = 71.475 DIUS 2 . 7 5 4 H = 78.664 plus 2.376 T = 74.774 plus 2 . 3 5 2 T = 89.925 plus 3.271 R = 81.224 plus 3 . 3 4 3 R S = Stature F = Femur H = Humerus T = Tibia R = Radius Remarks: 1. The femur is measured from the head to the apex of the inner condyle. If the femur has been measured in the oblique position and not straight, add 0.23 for male and 0 . 3 3 for female to the length before using the above formulae. 2. The tibia is measured from the upper articular surface to the tip of the malleolus. If the tiDia has been measured with, and not without, the spine, subtract 0.96 for male, and 0 . 8 7 cm. for female, from the length before using the above formulae.

MEDICO-LEGAL ASPECTS OF IDENTIFICATION

77

3. The humerus and radius are measured in their greatest length. (Taylor's Principles and Practices of Medical Jurisprudence, S. Smith, 10th ed., Vol 1, p. 155). 4. Inasmuch as the formulae for male and female skeletons are different, it is necessary to determine the sex of the skeleton before the formulae may be applied. C. Stature from bone: Dupertuis and Hadden's General Formulae For Reconstruction of Stature From Lengths of Dry Long Bones Without Cartilage (Constant Terms in Metric and Adapted to English System) Constant term to be added after calculations in previous column armula

Stature-bone length coefficient(s)

Centimeters

Inches

69.089 81.688 73.570 80.405 69.294 71.429 66.544 66.400 64.505

27.200 32.161 28.965 31.655 27.281 28.112 26.198 26.142 25.396

56.006

22.050

61.412 72.572 64.977 73.502 65.213 55.729 59.259 60.344 57.600

24.178 28.572 25.581 28.938 25.674 21.941 23.330 23.757 22.677

57.495

22.636

Male (a) (b) (c) (d) (e) (f) (g) (h) (i) (k)

2.238 (femur) 2.392 (tibia) 2.970 (humerus) 3.650 (radius) 1.255 (femur + tibia) 1.728 (humerus + radius) 1.422 (femur) + 1.062 (tibia) 1.789 (humerus) + 1.841 (radius) 1.928 (femur) + 0.568 (humerus) 1.442 (femur) + 0.931 (tibia) + 0.083 (humerus) + 0.480 (radius) Female

(a) (b) (c) (d) (e) (f) (g) (h) (i) (k)

2.317 (femur) 2.533 (tibia) 3.144 (humerus) 3.876 (radius) 1.233 (femur + tibia) 1.984 (humerus + radius) 1.657 (femur) + 0.879 (tibia) 2.164 (humerus) + 1.525 (radius) 2.009 (femur) + 0.566 (humerus) 1.644 (femur) + 0.764 (tibia) + 0.126 (humerus) + 0.296 (radius)

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LEGAL MEDICINE

(From: Forensic Medicine by Keith Simpson, 7th ed., p. 25.) D.Topinard and Rollet, two French anatomists devised a formula fo' the determination of the height for males and females. Male Female Length of Femur x 3.66 or 3.71 equals height Length of Humerus x 5.06 or 5.22 equals height Length of Tibia x 4.53 or 4.61 equals height Length of Radius x 6.86 or 7.16 equals height (These formulae do not hold good in mixture of races.) E. Humphrey's Table: Humphrey made a table of the different height of bones for different ages and their corresponding statures. F. Lacassagne made the following coefficient for the determination of height: Bone Male Female Femur 3.66 3.71 Tibia 4.53 4.61 Fibula 4.58 4.66 Humerus 5.06 5.22 Radius 6.86 7.16 Ulna 6.41 6.66 E.Manouvrier made a formulae based on length of tibia, fibula, radius and ulna for the determination of height. MANOUVRIER'S STATURE TABLE FOR FEMALES ftbula Tibia Femur Cadaver Humerus Radius Ulna Length Mm. Mm. Mm. Cm. Mm. Mm. Mm. 283 284 363 / 140.0 263 193 203 288 289 368^ 142.0 195 266 206 293 294 , 373 144.0 270 197 209 298 299 378 145.5 199 273 212 303 304 383 147.0 201 276 215 307 309 388 148.8 279 203 217 311 314 393 149.7 282 205 219 316 319 398 151.3 285 207 222 320 324 403 152.8 289 209 225 325 329 408 154.3 292 211 228 330 334 415 155.6 214 297 231 336 340 422 156.8 302 235 218 341 346 429 158.2 307 222 239

MEDICO-LEGAL ASPECTS OF IDENTIFICATION 346 351 356 361 366 371 376

352 358 364 370 376 382 388

436 443 450 457 464 471 478

159.5 161.2 163.0 165.0 167.0 169.2 171.5

313 318 324 329 334 339 344

226 230 234 238 242 246 250

243 247 251 254 258 261 264 Coefficients for smaller bone lengths than given above. x4.88 x4.85 x3.87 x5.41 x7.44 x7.00 Coefficients for greater bone lengths than given above. x4.52 x4.42 x3.58 x4.98 x7.00 x6.49 MANOUVRIER'S STATURE TABLE FOR MALES Fibula Tibia Femur Cadaver Humerus Radius Ulna Length Mm. Mm. Mm. Cm. Mm. Mm. Mm. 153.0 295 318 319 392 213 227 323 324 398 155.2 298 216 231 328 330 404 157.0 302 219 235 333 335 410 159.0 306 222 239 338 340 416 160.5 309 225 243 344 346 422 162.5 313 229 246 349 351 428 '232 249 163.4 316 353 357 434 164.4 320 236 253 358 362 440 165.4 324 239 257 363 368 446 166.6 328 243 260 368 373 453 167.7 332 246 263 373 460 336 249 266 378 168.6 378 383 467 169.7 340 252 270 383 389 475 344 255 273 171.6 388 394 482 173.0 348 258 276 393 400 490 175.4 352 261 280 398 405 497 176.7 356 264 283 403 410 504 178.5 360 267 287 408 415 512 181.2 364 270 290 413 420 519 183.0 368 273 293 Coefficient for smaller bone lengths than given above. x4.82 x4.80 X3.92 ... x5.25 x7.11 x6.66 Coefficients for greater bone lengths than given above. x4.37 x4.32 x3.53 . .. x4.93 x6.70 x6.26 (From: Medical Jurisprudence by Gordon, Turner and Price, 3rd ed., pp. 354-355.)

80

LEGAL MEDICINE

F. Estimations of Total Foetal Length from One or More Bones (C.H. length) Diaphysis of femur x 6.71 = Total height Diaphysis of tibia x 7.63 = Total height Diaphysis of humerus x 7.6 = Total height Diaphysis of radius x 9.2 = Total height Diaphysis of clavicle x 11.3 = Total height Diaphysis of lower jaw x 10.0 = Total height (The lower jaw is measured from the symphysis menti to the tip of the condyle, the whole breadth of the mandibular symphyseal surface placed flat along the blade of the calipers; Smith, 1943). These ratios have been checked against the material recently obtained and have been found useful; they are not accurate during the early stage of embryonic life (Practical Forensic Medicine by Camp and Purchase, 1957, p. 29). Determination of the Sex of the Skeleton: In determining the sex of the skeleton, the following bones must be studied: A. Pelvis D. Femur B. Skull E. Humerus C. Sternum A. Pelvis: Differences Between a Male and a Female Pelvis: Male Female 1. Heavier construction wall 1. Lighter construction wall less more pronounced. pronounced. 2. Height greater and flays off 2. Height lesser and flays off its its wall more pronounced. wall less pronounced. 3. Pubic arch narrow and less 3. Pubic arch wider and round. rounder. 4. Diameter of the true pelvis 4. Diameter of the true pelvis less. greater. 5. Curve of the iliac crest 5. Curve of the iliac crest is of reaches a higher level. the lower level. 6. Narrow greater sciatic notch. 6. Wide greater sciatic notch. 7. Body of the pubis narrow. 7. Body of the pubis wider. 8. Iliopectineal line sharp. 8. Iliopectineal line rounded. 9. Obturator foramen egg9. Obturator foramen trishaped. angular. 10. Sacrum short and narrow. 10. Sacrum long and wide.

MEDICO-LEGAL ASPECTS OF IDENTIFICATION B. Sternum: Length of body Length of manubrium x 100 = 46.2 (male and 54.3 (female) C. Femur: Pearson and Bell made a study of the sex difference in the femur: Male Female Right Left Right Left 1. Bicondylar width 80.147 79.404 70.123 69.886 2. Vertical diameter of head 47.059 46.769 41.123 40.765 3. External condyle oblique length 61.846 61.048 55.804 55.176 4. Vertical diameter of neck 33.849 34.337 29.337 29.520 D. Humerus: Dwight gives the following measurement for male and female bones (humerus): Male Female 1. Vertical diameter of head 48.7 42.6 2. Transverse diameter of head 44.6 38.9 E. Cranium: Male Female 1. Less curve of shaft. 1. More curve of shaft. 2. Mastoid process larger. 2. Predominance of cranial roof over cranial base Mastoid process smaller. 3. Cranium placed horizontally 3. Cranium placed horizontally rests on mastoid process. rests on the occipital and maxilliary bones. 4. Styloid process shorter. 4. Styloid process longer and slender. 5. Forehead higher and more 5. Forehead less high and more oblique. vertical. 6. Superciliary ridges less sharp 6. Superciliary ridges sharper, or more rounded. 7. Zygomatic arches and frontal 7. Zygomatic arches and frontal sinuses more prominent. sinuses less prominent. 8. Lower jaw larger and wider. 8. Lower jaw narrower and lighter and chin not projecting.

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82

9. Face larger in proportion to the cranium.

9. Face smaller in proportion to cranium. t n e

Determination of the Race of the Skeleton: It is becoming more difficult to determine the race because of the amalgamation of races. For practical consideration there is hardly no race that is absolutely pure. The following points may be used in determining the race in the remains of a person: A. Extrinsic Factors: 1. Color of the skin 2. Facial features 3. Nature of the hair 4. Mode of dressing B. Indices: 1. Skull: Maximum width of the skull „ a. Cephalic Index = axunum length of the skuLl Below 70 — Hyperdolico-cephalic 70 — 74.9 — Dolico-cephalic — Semato — Caucasian 75 — 79.0 — Mesaticephalic — Mongolian 80 — 84.9 — Brachycephalic — Malayan u o u-4. i A Height of the orbit b. Orbital Index = w,.T..—ttt x 100 Width of the orbit Above 89 — Megasemes — Mongolian 84 — 89 — Mesosemes — Semato-Caucasian Below 84 — Microsemes — Malayan , , Breadth of the base , c. Nasal Index = • —r—r *~ x 100 Length of the nose Above 53 — Platyrrhine — Malayan 48 — 53 — Mesorrhine — Mongolian Below 48 — Leptorrhine — Semato — Caucasian TT ;„u „ . Height of the skull , _ Height Index = z—~———.—.—_ 100 Length of the skull X

M

T

T

0

n n

f T

A

x

2. Pelvis: Pelvic Index =

Anteroposterior diamete^ Transverse diameter Below 85 — Platypellic — Semato — Caucasian 86 — 95 — Dolicopellic — Malayan Above 95 — Mesopellic — Negroes x

1 Q Q

n n

1 0 0

MEDICO-LEGAL ASPECTS OF IDENTIFICATION

83

, . .. , Pubis length x 100 b. Ischium-pubis Index = —=—— :——— Ischium length Caucasians (200 cases): 95= Female Negroes (100 cases): < 84= Male; 84-88=Sex? ; > 88= Female. (GradwohVs Legal Medicine by Camps, Lucas & Robinson, 3rded.,p. 112). 3. Extremities: , , Length of the lower leg .. _ a. Crural Index = 7 — * . .. x 100 Length of the upper leg 95 — 98 — Semato-Caucasian 98 —102 — Mongolian and Malayan ,, _ Length of humerus + length of radius x 100 b. IntermembralIndex = — — — — 7 7 — — — — . . . . . Length of femur + Length of tibia (Modi p. 22) Indian — 67.27 European - 70.4 Negroes —70.3 ,t j Length of humerus „„ c. Humero-femoral Index = -=— .. x 100 Length of femur T

L

T

rt

r

1

Other Differential Racial Characteristics of Skeletons: Caucasian Elongated Raised Proportionately small

Mongolian Square inclined Small

4. Upper Extremity

Small

Small

5. Lower Extremity

Normal

Small

1. Skull 2. Forehead 3. Face

Negro Narrow and elongated Small and compressed Malar bones and jaw projecting; teeth set obliquely Long in proportion to body; forearm large in proportion to arm; hand small Leg6 large in proportion to thighs; feet wide and flat, heelbones projecting backwards.

AGE: Aside from the size of the bones and dental examination, the age of the person to whom the skeleton belongs may be determined by:

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84

1. Appearance of the ossification centers: External cuneiform, capitate, hamates heads of 1 year humerus, femur, tibia. Lower epiphysis of tibia, lower epiphysis of fibula, 2 years capitulum of humerus, first four metacarpal heads. Internal cuneiform, tarsal, navicular, triquetrum 3 years phalanges, patella. Midcuneiform, lunate, upper end of fibula, greater 4 years trochanter of femur. Scaphoid, trapezium, carpal, navicular, greater 5 years tubercle of the humerus, lower end of the fibula. Upper end of the radius, lower end of ulna, trape6-7 years zoid, scaphoid. Internal epicondyle of the humerus, rami of 8-9 years ischium and pubis, olecranon. Epiphysis of os calcis, pisiform, trochlea of hu10-11 years merus, lesser trochanter of femur. External epicondyle of the humerus, patella com12-14 years plete. Acromion, iliac crest. 14-16 years Tuber ischia. 17-19 years Inner clavicle. 20-21 years (A Simplified Textbook of Medical Jurisprudence Toxicology by C.K. Parikh, p. 39).

CO

2. Union of Bones and Epiphyses: Anterior fontanelles should be closed. 1-1/2 years The condylar portion of the occipital bone fuses years with the squama; the metopic suture also closes. 4 years The greater tubercle fuses with the head of the humerus. 5 years The condylar portion of the occipital bone fuses with the basi-occiput. 9 years The ilium, pubes and ischium should meet in the acetabulum, rami of ischium and pubis fuse. 13 years Ilium and pubes should be united but still separable on maceration. 15 years The epiphysis of os calcis (calcaneum) joins the bone; the coracoid should be united to the scapula. 16 years The olecranon should be united to the ulna. The head of the radius and the lower end of the 16-17 years humerus should be joined to their respective shaft. 17-18 years The internal condyle should be united to the humerus.

MEDICO-LEGAL ASPECTS OF IDENTIFICATION

85

18-20 yean

The head of the femur should have joined diaphysis; the epiphysis of long bones of the hand and foot should have united to the diaphyses; the basiocciput should be fused with the basisphenoid. 20 years The epiphyses of the fibula should be united to the diaphysis. Distal radius unites. 22 years The inner (secondary) epiphysis of the clavicle fuses. 25 years The crest of the ilium and the articular facts of the ribs should be united, if all the epiphysis have united, the person is above 25 years of age. (A Simplified Textbook of Medical Jurisprudence & Toxicology by C.K. Parikh, p. 40). 3. Dental Identification (supra p. 61)., 4. Obliteration of cranial sutures (see illustration). 4U-50

20-3Q

MOLAR root calcification more important than eruption

Approximate time of closure of cranial sutures. The inner aspect closes several years before the outer as a rule. Molar tooth root calcification is also noted.

Determination of the Duration of Interment: The period from the time of death up to the time of examination may be determined by the nature and presence of the soft tissues and the degree of erosion of the bones. Ordinarily, all the soft tissues in a grave disappear within a year. However, it is influenced by several factors.

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Fragmentation and erosion of bones after a long burial

The Bases of the Estimate for Duration of Interment are: 1. Presence or absence of soft tissues still adherent to the bones. 2. Firmness and weight, brittleness, dryness of the bones. 3. The degree of erosion of the surface of the bones. 4. The changes in the clothings, coffin, and painting. Determination of the Presence or Absence of Ante-Mortem or Postmortem Injuries: Individual bones must be examined in detail for possible fractures. Importance must be laid on whether these injuries in the bones occurred during life or in the process of exhumation. Note the presence of vital reaction, principally the signs of repairs. Superimposed Photography: This is a special method of determining the person to whom the skull belongs. The negatives of the picture of the skull and the suspected individuals are superimposed and printed. This will show whether the contour of the skull fits the contour of the face of the suspected person. E DETERMINATION OF SEX / Legal Importance of Sex Determination: 1. As an aid in identification: Habit, social life, manner of dressing, physical features and

MEDICO-LEGAL ASPECTS OF IDENTIFICATION

87

inclination are generally dependent on the sex. These points are useful in identification. 2. To determine whether an individual can exercise certain obligations vested by law to one sex only: V

above, ^AA^H 3. Marriage or the union of a man and a woman: Any male of the age of sixteen years or more, and any female at the age of fourteen years or more, not under any of the impediments mentioned in articles 80 to 84, may contract marriage (Art. 54, Civil Code). 4. Rights granted by law are different io different sexes: Majority commences upon the attainment of the age of twentyone years (Art. 402, Civil Code). Notwithstanding the provisions of the preceding article, a daughter above twenty-one but below twenty-three years of age cannot leave the parental home without the consent of the father or mother in whose company she lives, except to become a wife, or when she exercises a profession or calling, or when the father or mother has contracted a subsequent marriage (Art. 403, Civil Code). 5. There are certain crimes wherein a specific sex can only be the offender or victim: a. In rape (Art. 335, Revised Penal Code), seduction (Art. 337 & 338, Revised Penal Code), abduction (Art. 342 & 343, Revised Penal Code) or abuse against chastity (Art. 245, Revised Penal Code) a woman is the victim. b. In case of prostitution, the offender must be a woman: For purposes of this article, women who, for money or profit, habitually indulge in sexual intercourse or lascivious conduct, are deemed to be prostitutes (Art. 202, No. 5, Revised Penal Code). c. In adultery the offender is a married woman and in concubinage the offender is a husband.

(sts to Determine the Sex: pocial test: Differences in the social role of the sexes used to be clearly marked but now they are less than they used to be. Dress, hairstyle, general bodily shape provide an immediate and accurate answer to the vast majority of cases.

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Genital test: The presence of penis indicates a male, its absence and the presence of a vaginal opening, indicates a female. We may look for the testes in the scrotum and if they are absent we must not conclude that the individual is not a male. They may be in the abdomen or inguinal canal undescended. 3. Gonadal test: Presence of testes in male and ovary in female. This will involve exploration of the abdomen and in some cases a histological examination of the gonad to see whether its microscopic structure is characteristically ovarian or testicular. 4. Chromosomal test: f^-^t* *~W-cT Shortly after the war, Barr noticed that there was a difference between cells derived from men and women suitably stained and examined under the microscope. The nucleus of the cells is a densely staining area in the cell itself and Barr noticed that there was a small part of nucleus which stained deeply than the rest in woman's cells but not in cells from men. He observed this in white cells from the blood and cells obtained by scraping the mucous membrane of the mouth. This is called Barr bodies. (Medico-Legal Journal, Part 3, Vol. 40, p. 79). Problems in Sex Determination: Sex determination may be possible and can scientifically be distinguished on account of the biological structure differences; however, in the following instances there will be no way to determine the sex: 1. Gonadal agenesis — Sex organs (testes or ovaries) have never developed. 2. True hermaphrodism — A state of bisexuality. The gonads of both sexes are present which may be separated or combined as ovotestis. continuous and persistent cessation of heart action and respiration. Cardio-respiratory death is a condition in which the physician and the members of the family pronounced a person to be dead based on the common sense or intuition.

MEDICO-LEGAL ASPECTS OF DEATH

113

3. Some countries or states provide both brain and cardio-respiratory bases in an alternative or eclectic way in the determination of the moment of death. In 1970, the state of Kansas became the first to enact a statute which specifies more clearly the accepted alternatives for defining death. Section 1, Chapter 378 of the Kansas Statute provides the following: "A person will be considered medically and legally dead if, in the opinion of a physician, based on ordinary standards of medical practice, there is the absence of spontaneous respiratory and cardiac function and, because of the disease or condition which caused, directly or indirectly, these functions to cease, or because of the passage of time since these functions ceased, attempts at resuscitation are considered hopeless; and, in this event, death will have occurred at the time these functions ceased. Second, a person will be considered medically or legally dead if, in the opinion of a physician, based on ordinary standards of medical practice, there is the absence of spontaneous brain function; and if based on ordinary standards of medical practice, during reasonable attempts to either maintain or restore spontaneous circulatory or respiratory function in the absence of aforesaid brain function, it appears that further attempts at resuscitation or supportive maintenance will not succeed, death will have occurred at the time when these conditions first coincide. Death is to be pronounced before artificial means of supporting respiratory and circulatory function are terminated and before any vital organ is removed for purposes of transplantation." Brain Death: Inasmuch as there are no universally accepted criteria yet to establish a condition of brain death, the following proposal or recommendations are made by different committees or bodies: 1. According to the Harvard Report of 1968, the following are the characteristics of "irreversible coma": a. Unreceptivity and unresponsibility — There is a total unawareness to externally applied stimuli and inner need and complete unresponsiveness — our definition of irreversible coma. Even the most intense painful stimuli evoke no vocal or other response, not even a groan, withdrawal of his limb, or quickening of respiration. b. No movements or breathing — Observations covering a period of at least 1 hour by physicians is adequate to satisfy the criteria of no spontaneous muscular movements or spontaneous respiration or response to stimuli such as pain, touch, sound, or

114

LEGAL MEDICINE

light. After the patient is on a mechanical respirator, the total absence of spontaneous breathing may be established by turning off the respirator for three minutes and observing whether there is any effort on the part of the subject to breath spontaneously. (The respirator may be turned off for this time provided that at the start of the trial period the patient's carbon dioxide tension is within the normal range, and provided also that the patient had been breathing room air for at least 10 minutes prior to the trial). c. No reflexes — Irreversible coma with abolition of central nervous system activity is evidenced in part by the absence of elicitable reflexes. The pupil will be fixed and dilated and will not respond to a direct source of bright light. . . Ocular movement (to head turning and to irrigation of the ears with ice water) and blinking are absent. There is no evidence of postural activity (decerebrate or other). Swallowing, yawning, vocalization are in abeyance. Corneal and pharyngeal reflexes are absent. As a rule the stretch or tendon reflexes cannot be elicited, i.e. tapping the tendons of the biceps, triceps and pronator muscles, quadriceps and gastrocnemius muscles with the reflex hammer elicits no contraction of the respective muscles. Plantar or noxious stimulation gives no response. d. Flat electro-encephalogram — Of great confirmatory value is the flat or iso-electric E.E.G. We must assume that the electrodes have been properly applied, that the apparatus is functioning normally, and that the personnel in charge are competent. All of these tests shall be repeated at least 24 hours later with no change. It is emphasized that the patient be declared dead before any effort is made to take him off the respirator, if he is then on a respirator. 2. In 1969, the Ad Hoc Committee of Human Transplantation convened under the auspices of the Institute of Forensic Sciences, Duquesne University School of Law adopted the proposed criteria for the determination of death otherwise known as Philadelphia Protocol, and the following were considered: a. Lack of responsiveness to internal and external environment. b. Absence of spontaneous breathing movements for 3 minutes, in the absence of hypocarbia and while breathing room air. c No muscular movements with generalized flaccidity and no evidence of postural activity or shivering, d. Reflexes and response: (1) Pupils fixed and dilated, non-reactive to strong stimuli.

MEDICO-LEGAL ASPECTS OF DEATH

115

(2) Corneal reflexes absent. (3) Supra-orbital or other pressure response absent (both pain response and decerebrate posturing). (4) Absence of snouting or sucking response. (5) No reflex response to upper airway stimulation. (6) No reflex response to lower airway stimulation. (7) No ocular response to ice water stimulation of the inner ear. (8) No deep tendon reflexes. (9) No superficial reflexes. (10) No plantar responses. e. Falling arterial pressure without support by drugs or other means. f. Iso-electric electro-encephalogram (in absences of hypothermia, anesthetic agents and drugs intoxication) recorded spontaneously and during auditory and tactile stimulation. It is further laid down that these criteria shall have been present for at least 2 hours and that death should be certified by two physicians other than the physician of a potential organ recipient (Gradwohrs Legal Medicine, Francis Camps, Ann Robinson & Bernard Lucas, ed. 3rd ed. p. 51-52). Other Set of Criteria to Establish Brain Death: 1. Mohandas and Chou (1971) made a summary of the criteria of brain death which was accepted by the University of Minnesota Science Center. 2. The Ottawa General Hospital (1970) set up guidelines for the criteria of cerebral death. 3. In France (1968) the Council of Ministers published a decree which adopted the official definition of death on recommendation of the French Academy of Medicine. Although the consideration of brain death is the most ideal criteria, the difficulty and practicability of its application is a problem. Electro-encephalogram which is the most reliable instrument to determine brain activities is not available in many places. Even if available, the number of competent persons to apply the instrument and the interpretation of the results is quite limited. The use of the criteria of brain death may only be applied to those persons who are potential organ donors.

LEGAL MEDICINE f A. KINDS OF DEATH ^ j j ^ )MATIC DEATH OR CLINICAL DEATH: This is the 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^ It occurs the moment a physician or the other members of the family declare a person has expired, and some of the early signs of death are present. It is hardly possible to determine the exact time of death. Immediately after death the face and lips become pale, the muscles become flaccid, the sphincters are relax, the lower jaw tends to drop, the eyelids remain open, pupils dilate and the skin losses its elasticity. The body fluid tends to gravitate to the mostf dependent portions of the body and the body heat gradually assiimes the temperature of the surroundings. (OLECULAR OR CELLULAR DEATH: After cessation of the vital functions of the body there is still ^animal life among individual cells. This is evidence by the presence of/excitability of muscles and^ciliary movements and other functions of individual cells. About three to six hours later, there is death of individual cells. This is known as molecular or cellular death. Its exact occurrence cannot be definitely ascertained because its time of appearance is influenced by several factors. Previous state of health, infection, climatic condition, cellular nutrition, etc. influence its occurrence. ^APPARENT DEATH" OR "STATE OF SUSPENDED ANIMATION": This condition is not really death but merely aCtransient loss of consciousness or temporary cessation of the vital functions of the body on account of disease, external stimulus or other forms of influence.^ It may arise especially in hysteria, uremia, catalepsy and electric shock. It may be induced voluntarily as has been cited by foreign authors (Col. Townshend who could be able to pass into a state of pulselessness for half an hour). Involuntary suspension is shown in still-birth. A newly born child may remain at the state of suspended animation and may die unless prompt action is taken. A person who has been rescued from drowning may appear dead but life is maintained after continuous resuscitation. It is important to determine the condition of suspended animation to prevent premature burial. There are records of cases wherein a person was pronounced dead, placed in a coffin and

MEDICO-LEGAL ASPECTS OF DEATH

117

later angrily rise from it and walk unaided. The relative has sent death notice and placed wreaths near his coffin (Daily Mail England, 1948). ji B. SIGNS OF DEATHS

^XC^®

CESSATION OF HEART ACTION AND CIRCULATION: tl R C I ^ A " There must be anfentire and continuous cessation of the heart action and flow of blood in the whole vascular system^ A temporary suspension of the heart action is still compatible with life. The length of time the heart may cease to function and life is still maintained depends upon the length of time it is readily reestablished and upon the oxygenation of blood at the time of the suspension. \As a general rule, if there is no heart action for a period of five minutes death is regarded as certain^ Respiration ceases frequently before the stoppage of heart contraction and circulation. Usually the auricle of the heart contracts after somatic death for a longer period than the ventricle. And the auricle is the last to stop, hence called ultimen martens. In judicial hanging, the heart continues to beat for twenty minutes or half an hour after the individual has been executed although its beating is irregular and feeble. In decapitation of criminals, heart beating is present for an hour after decapitation has taken place. Methods of Detecting the Cessation of Heart Action and Circulation: a. Examination of the Heart: (1) Palpation of the Pulse: Pulsation of the peripheral blood vessels may be made at the region of the wrist or at the neck. The pulsation of the vessels is synchronous with the heart beat. Occasionally the pulsation is very imperceptible and irregular that the examiner experience much difficulty. (2) Auscultation for the Heart Sound at the Precordial Area: The rhythmic contraction and relaxation of the heart is audible through the stethoscope. Heart sound can be audible during life even without the aid of a stethoscope by placing the ear at the precordial area. Errors in the Method of Determining Heart Action: (a) The heart itself may, like other muscles, be in a state of apparent and not real death. (b) The heart sound may not always be appreciable to the ear even with the aid of the stethoscope.

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LEGAL MEDICINE

Difficulties in Auscultation may be Encountered in: (a) Stout person. (b) Fatty degeneration of the heart. (c) Pericardial effusion. (3) Flouroscopic Examination: Fluoroscopic examination of the chest will reveal the shadow of the heart in its rhythmic contraction and relaxation. The shadow may be enlarged and the excursion made less visible due to pericardial effusion. (4) By the Use of Electrocardiograph: The heart beat is accompanied by the passage of electrical charge through the impulse conducting system of the heart which may be recorded in an electrocardiograph machine. The electrocardiograph will record the heart beat even if it is too weak to be heard by auscultation. This is the best method of determining heart action but quite impractical, b. Examination of the Peripheral Circulation: (1) Magnus'Test: A ligature is applied around the base of a finger with moderate tightness. In a living person there appears a bloodless zone at the site of the application of the ligature and a livid area distal to the ligature. If such ligature is applied to the finger of a dead man, there is no such change in color. The color of the area where the ligature is applied will be the same as that one distal to it. There may be no appreciable change of color if a living person is markedly anemic. ( 2 ) Opening of Small Artery: In the living, the blood escapes in jerk and at a distance. In a dead man, the blood vessel is white and there is no jerking escape of blood but may only ooze towards the nearby skin. When bigger arteries are cut, blood may flow without pressure continuously. (3) Icard's Test: This consists of the injection of a solution of fluorescein subcutaneously. If circulation is still present, the dye will spread all over the body and the whole skin will have a greenish-yellow discoloration due to flourescein. In a dead man, the solution will just remain at the site of the injection. This test should be applied only with the use of the daylight as the color is difficult to be appreciated with the use of artificial light.

MEDICO-LEGAL ASPECTS OF DEATH

119

(4) Pressure on the Fingernails: If pressure is applied on the fingernails intermittently, there will be a zone of paleness at the site of the application of pressure which become livid on release. There will be no such change of color if the test is applied to a dead man. (5) Diaphanous Test: The fingers are spread wide and the finger webs are viewed through a strong light. In the living, the finger webs appear red but yellow in the dead. The finger webs may appear yellow in a strong light even if living in cases of anemia or carbon monoxide poisoning. (6) Application of Heat on the Skin: If heated material is applied on the skin of a dead man, it will not produce true blister. There is no sign of congestion, or other vital reactions. But if applied to a living person, blister formation, congestion, and other vital reactions of the injured area will be observed. (7) Palpation of the Radial Pulse: Palpation of the radial artery with the fingers, one will feel the rhythmic pulsation of the vessel due to the flow of blood. No such pulsation will be observed in a dead man. (8) Dropping of Melted Wax: Melted sealing wax is dropped on the breast of a person. If the person is dead, there will be no inflammatory edema at the neighborhood of the dropped melted wax.

y

CESSATION OF RESPIRATION: Like heart action, cessation of respiration in order to be considered as a sign of death must be continuous and persistent. A person can hold his breath for a period not longer than 3-1/2 minutes. In case of electrical shock, respiration may cease for sometime but may be restored by continuous artificial respiration. In the following conditions there may be suspension of respiration without death ensuing. a. In a purely voluntary act, as in divers, swimmers, etc. but it cannot be longer than two minutes. b. In some peculiar condition of respiration, like Cheyne-Stokes respiration, but the apneic interval cannot be longer than fifteen to twenty seconds; c. In cases of apparent drowning; d. Newly-born infants may not breathe for a time after birth and may commence only after stimulation or spontaneously later.

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Methods of Detecting Cessation of Respiration: a. Expose the chest and abdomen and observe the movement during inspiration and expiration. b. Examine the person with the aid of a stethoscope which is placed at the base of the anterior aspect of the neck and hear sound of the current of air passing through the trachea during each phase of respiration. c. Examination with a Mirror: The surface of a cold-looking glass is held in front of the mouth and nostrils. If there is dimming of the mirror after a time, there is still respiration. The dimming of the cold mirror is due to the condensation of the warm moist air exhaled from the lungs if respiration is still going on. However, it must not be forgotten that the dimming of the mirror may be due to the expulsion of the air from the lungs due to the contraction of the diaphragm in rigor mortis. Ordinarily there is no dimming of the mirror when the subject is dead. d. Examination with a Feather or Cotton Fibers: Place a fine feather or a strip of cotton in front of the lips and nostrils. If there is movement of the feather or cotton not due to external air, respiration is present. The feather or cotton fibers will be blown away during expiration and towards the nose and mouth during inspiration. This is not a reliable test as the slightest movement of outside air or nervousness of the observer will move the feather or cotton fibers. e. Examination with a Glass of Water: Place a glass half full of water at the region of the chest. If the surface of the water is smooth and stable, there is no respiration taking place, but if it waves or water movement is observed, then respiration is taking place. This is not a good test because of the difficulty of preventing movement of the place where the body lies. f. Winslow's Test: There is no movement of the image formed by reflecting artificial or sun light on the water or mercury contained in a saucer and placed on the chest or abdomen if respiration is not taking place. The reflection is utilized to magnify the / movement of the surface of mercury or water. . COOLING OF THE BODY (ALGOR MORTIS): 'After death the metabolic process inside the body ceases, yj No more heat is produced but the body loses slowly its temperature by evaporationJor by conduction to the surrounding atmosphere.

MEDICO-LEGAL ASPECTS OF DEATH

i r|

The progressive fall of the body temperature is one of the most prominent signs of death. /' The rate of cooling of the body is not uniform. It is rapid during the first two hours after death and as the temperature of the body gradually approaches the temperature of the surroundings, the rate becomes slower. It is difficult to tell exactly the length of time the body will assume the temperature of the surroun Several factors influence the rate of fall of the body temperature. The fall of temperature may occur before death in the following conditions: ( a. Cancer b. Phthisis c. Collapse The fall of temperature of 15 to 20 degrees fahrenheit is considered as a certain sign of death. Post-mortem Caloricity is the rise of temperature of the body after death due to rapid and early putrefactive changes or some internal changes. It is usually observed in the first two hours after death. Post-mortem caloricity may occur in the following conditions: a. Cholera. b. Yellow fever. c. Liver abscess. d. Peritonitis. e. Cerebro-spinal fever. f. Rheumatic fever. g. Tetanus. h. Smallpox. i. Strychnine poisoning. Factors Influencing the Rate of Cooling of the Body: a. Conditions that are connected with the body: (1) Factors Delaying Cooling: (a) Acute pyrexia! diseases. (b) Sudden death in good health. (c) Obesity of person. (d) Death from asphyxia. (e) Death of the middle age. (2) Factors Accelerating Cooling: (a) Leanness of the body. (b) Extreme age. (c) Long-standing or lingering illness. (d) Chronic pyrexial disease associated with wasting.

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b. Conditions that are connected with the surroundings: (1) Factors Delaying Cooling: (a) Clothings. (b) Want of access of air to the body. (c) Small room. (d) Warm surroundings. (2) Factors Accelerating Cooling: (a) Unclothed body. (b) Conditions allowing the access of air. (c) Large room permitting the dissipation of heat. (d) Cooling more rapid in water than in air. Methods of Estimating How Long a Person Has Been Dead From the Cooling of the Body: a. When the body temperature is normal at the time of death, the average rate of fall of the temperature during the first two hours is one-half of the difference of the body temperature and that of the air. During the next two hours, the temperature fall is one-half of the previous rate, and during the succeeding two hours, it is one-half of the last mentioned rate. As a general rule the body attains the temperature of the surrounding air from 12 to 15 hours after death in tropical countries (Medical Jurisprudence and Toxicology by Modi, 12th ed.,p. 121). b. To make an approximate estimate of the duration of death from the body temperature, the following formula has been suggested: (Normal Temperature) 98.4°F — (Rectal Temperature) Approximate number of hours after death This formula is only applicable to cases where the rectal temperature has not yet assumed the temperature of the surroundings, otherwise, the result will be constant. c. Chemical Method: Schourup's formula for the determination of the time of death of any cadaver whose cerebro-spinal fluid is examined for the concentrations of lactic acid (L.A.), non-protein nitrogen (N.P.N.) and amino acid (A.A.) and whose axillary temperature has been taken at the time the cerebro-spinal fluid has been removed.

MEDICO- LEGAL ASPECTS OF DEATH

123

36— T + antilog, L.A. + N.P.N. — 15 + A.A. — 1 180 16.7 7.35 4 T — temperature 1 = axillary temperature The lactic acid content of the cerebro-spinal fluid rises from 15 mg. to over 200 mg. per 100 cc. The rise is rapid during the first 5 hours following death. The non-protein nitrogen (N.P.N.) increases from 15 to 40 mg. per 100 cc. during the first 15 hours. This test is modified by ante-mortem anemia and rapid cooling of the body. Amino-acids (A.A.) increases from 1 mg. to 12 mg. percent during the first 15 hours, but the result is modified by rapid cooling of the body. Limitations of the Schourup's Formula: a. The method is only applicable to adults, as the rate of biochemical change in a child is far more rapid than in adult. It is the value to person over the age of 15 years. b. The cerebrospinal fluid must be free of blood, the presence of which raises the lactic concentration. c. Injuries must not have allowed the escape of cerebrospinal fluid. d. Death must have occurred' within a period 15 hours prior to the withdrawal of the sample of cerebrospinal fluid, as after that time the changes in the concentration per time unit become irregular (Modern Trend in Forensic Medicine by Keith . Simpson, 1953, pp. 83-84). INSENSIBILITY OF THE BODY AND LOSS OF POWER TO MOVE: After death the whole body is insensible. No kind of stimulus is capable of letting the, body have voluntary movement. This condition must be observed in conjunction with cessation of heart beat and circulation and cessation of respiration. The insensibility and loss of power to move may be present although living, in the following conditions: a. Apoplexy. b. Epilepsy. c. Trance. d. Catalepsy. e. Cerebral concussion. f. Hysteria.

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S ^ HMANGES AN IN THE SKIN:

The following are the changes undergone by the skin after death: a. The skin may be observed to be-pale and vgaxy-looking due to the absence of circulation. Areas of the skin specially the most dependent portions will develop livid discoloration on account of the gravitation of blood. bsLoss of Elasticity of the Skin: Normally when the body surface is compressed, it readily returns to normal shape. After death, application of pressure to the skin surface will make the surface flattened. Application of pressure with the finger tip will produce fitting impression like one observed in edema. Post-mortem Contact Flattening — On account of the loss of elasticity of the skin and of the post-mortem flaccidity of muscles, the body becomes flattened over areas which are in contact with the surface it rests. This is observed at the region of the shoulder blades, buttocks and calves if death occurs while lying on his back. Certain degree of pressure may be applied on the face immediately after death and may be mistaken for traumatic deformity. c. ppacity of the Skin: Exposure of the hand of a living person to translucent light will allow the red color of circulation to be seen underneath the skin. The skin of a dead person is opaque due to the absence of circulation. d. Effect of the Application of Heat: Application of melted sealing wax on the breast of a dead person will not produce blister or inflammatory reaction on the skin. In the living, an inflammatory edema will develop about the wax. 6. CHANGES IN AND ABOUT THE EYE: a. Loss of Corneal Reflex: The cornea is not capable of making any reaction to whatever intensity of light stimulus. However, absence of corneal reflex may also be found in a living person the following conditions: (1) General anesthesia. (2) Apoplexy. (3) Uremia. (4) Epilepsy. (5) Narcotic Poisoning. (6) Local Anesthesia.

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b. Clouding of the Cornea: The normal clear and transparent nature of the cornea is lost. The cornea becomes slightly cloudy or opaque after death. If the cornea is kept moist by the application of saline solution after death, it will remain transparent. Opacity of the cornea may be found in certain diseases, like cholera, and therefore is not a reliable sign of death. c. Flaccidity of the Eyeball: After death, the orbital muscles lose their tone making the intra-orbital tension rapidly fall. The eyeball sinks into the orbital fossa. Intra-orbital tension is low. d. The Pupil is in the Position of Rest: The muscle of the iris loses its tone. The pupil can not react to light. The size of the pupil varies at the time of death, however, if contracted, it may infer poisoning by narcotic drugs. A relaxed iris may be found in life in the following conditions: (1) Action of drugs like atropine. (2) Uremia. (3) Tabes dorsalis. (4) Apoplexy. e. Ophthalmoscopic Findings: (1) The optic disc is pale and has the appearance of optic atrophy. (2) The remaining portion of the fundus may have a yellow tinge which later changes to a brownish-gray or slate color. (3) The retina becomes pale like the optic disc. (4) The retinal vessels become segmented, no evidence of blood flow. The retinal veins and arteries are indistinguishable : f. Tache noir de la sclerotique": After death a spot may be found in the sclera. The spot which may be oval or round or may be triangular with the base towards the cornea and may appear in the sclera a few hours after death. At the beginning it is yellowish but later it becomes brown or black. This is believed to be due to the thinning of the sclera thereby making the pigmented choroid visible. lt

7 .'ACTION OF HEAT ON THE SKIN: This test is useful to determine whether death occurred before or after the application of heat. The heat is applied to a portion of the leg or arm. If death is real, only a dry blister is produced. The epidermis is raised but

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on pricking the blister, no fluid is present. There is no redness of the surrounding skin. In the living, the blister contains abundant serum and area of vital reaction (congestion) on the skin around is present. The Following Combinations of Signs Show Death has Occurred: a. Loss of animal heat to a point not compatible with life. b. Absence of response of muscle to stimulus. c. Onset of rigor mortis. ^O^C. CHANGES IN THE BODY FOLLOWING DEATH ^l^CHANGES IN THE MUSCLE: p f £ • After death, there is complete relaxation of the whole muscular system. The entire muscular system is contractile for three to six hours after death, and later rigidity sets in. Secondary relaxation of the muscles will appear just when decomposition has set in. The Entire Muscular Tissue Passes Three Stages After Death: Stage of primary flaccidity (post-mortem muscular irritability): The ^nuscles are relaxed and capable of contracting when stimulated^ The pupils are dilated, the sphincters are relaxed, ^-"Shd there is incontinence of urination and defecation. b. Stage of post-mortem rigidity (Cadaveric rigidity, or Death struggle of muscles or Rigor Mortis): The^whole body becomes rigid due to the contraction of the muscles."!This develops three to six hours after death and may last frorfftwenty-f our to thirty-six hours. Jc. Stage of secondary flaccidity or commencement of putrefaction (Decay of the muscles): The muscles become flaccid, noJonger capable of responding to mechanical or electrical stimulus and the reaction becomes alkaline. ~ /a. Stage of Primary Flaccidity or Period of Muscular Irritability: Immediately after death, there is complete relaxation and softening of all the muscles of the body. The extremities may be flexed, the lower jaw falls, the eyeball loses its tension, and there may be incontinence of urination and defecation. To determine whether the muscles are still irritable, apply electric current and note whether there is still irritability of the muscles. Normally during the stage of primary flaccidity, the muscles are still contractile and react to external stimuli, mechanical or electrical owing to the presence of molecular life after somatic death.

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This stage usually lasts about three to six hours after death. In warm places, the average duration is only one hour and fiftyone minutes (Mackenzie cited by Modi, p. 122). Chemically, the reaction of the muscle is alkaline and the normal constituents of the individual muscle proteins are the same as in life. b. Stage of Post-mortem Rigidity, or Cadaveric Rigidity, or Death Stiffening, or "Death Struggle of Muscles" or rigor mortis: Three to six hours after death the muscles gradually stiffen. It usually starts at the muscles of the neck and lower jaw and spreads downwards to the chest, arms, and lower limbs. Usually the whole body becomes stiff after twelve hours. All the muscles are involved — both voluntary and involuntary. In the heart, rigor mortis may be mistaken for cardiac hypertrophy. Chemically, there is an increase of lactic acid and phosphoric content of the muscle. The reaction becomes acidic. There is no definite explanation as to how such contraction of muscles occurs although it has been proven that there is coagulation of the plasma protein. In the medico-legal view point, post-mortem rigidity may be utilized to approximate the length of time the body has been dead. In temperate countries it usually appears three to six hours after death, but in warmer countries it may develop earlier. In temperate countries, rigor mortis may last for two or three days but in tropical countries the usual duration is twenty-four to forty-eight hours during cold weather and eighteen to thirty-six hours during summer. When rigor mortis sets in early, it passes off quickly and vice versa. Factors Influencing the Time of Onset of Rigor Mortis: (1) Internal Factors: (a) State of the Muscles: Rigor mortis appears late and the duration is longer in cases where the muscles have been healthy and at rest before death, It has been observed that in the following deaths, the onset of rigor mortis is hastened: i. Animal having been hunted to death. ii. Prolonged convulsion and lingering illness. iii. Death from typhoid fever, typhus, cholera and phthisis.

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LEGAL MEDICINE (b) Age: Rigor mortis has early onset in the aged and new-born. The onset is delayed in good health and good muscular development. (c) Integrity of the Nerves: Section of the nerve will delay onset of rigor mortis as shown in paralyzed muscles. (2) External Factors: (a) Temperature: The development of rigor mortis is accelerated by high temperature but a temperature above 75°C will produce heat stiffening. (b) Moisture: Rigor mortis commences rapidly but the duration is short in moist air. /

^ Conditions Simulating Rigor Mortis: (1) Heat Stiffening: If the dead body is exposed to temperatures above 75°C it will coagulate the muscle proteins and cause the muscles to be rigid. The stiffening is more or less permanent and may not be easily affected by putrefaction. The body assumes the "pugilistic attitude" with the lower and upper extremities flexed and the hands clenched because the flexor muscles are stronger than the extensors. Heat stiffening is commonly observed when the body of a person is placed in boiling fluid or when the body is burned to death. J@) Cold Stiffening: The stiffening of the body may be manifested when the body is frozen, but exposure to warm condition will make such stiffening disappear. The cold stiffening is due to the solidification of fat when the body is exposed to freezing temperature. Forcible stretching of the flexed extremities will produce a sound due to the frozen synovial fluid. J$) Cadaveric Spasm or Instantaneous Rigor: This is 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 injury to the chest. It is principally due to the fact that the last voluntary contraction of muscle during life does not

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stop after death but is continuous with the act of cadaveric rigidity. In case of cadaveric spasm, a weapon may be held in the hand before death and can only be removed with difficulty. For practical purposes it cannot be possible for the murderer or assailant to imitate the condition. In cadaveric spasm, only group of muscles are involved and they are usually not symmetrical. The findings of weapon, hair, pieces of clothing, weeds on the palms of the hands and firmly grasped is a very important medico-legal point in the determination whether it is a case of suicide, murder or homicide. The presence of weeds held by the hands of a person found in water shows that the victim was alive before disposal.. 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 /^sometime after ingestion. /Distinctions Between Rigor Mortis and Cadaveric Spasm: ( i f Time of Appearance: ^ i v t . K M ^ affiles-opY Rigor mortis appears three to six hours after death, while cadaveric spasm appears immediately after death. {^Muscles Involved: Rigor mortis involves all the muscles of the body whether voluntary or involuntary, while cadaveric spasm involves only a certain muscle or group of muscles and are asymmetrical. (3^0ccurrence: Rigor mortis is a natural phenomena which occurs after death, while cadaveric spasm may or may not appear on a person at the time of death. (^Medico-Legal Significance: Rigor mortis may be utilized by a medical jurist to approximate the time of death, while cadaveric spasm may be useful to determine the nature of the crime. 1

Distinctions Between Muscular Contraction and Rigor Mortis: Rigor Mortis Muscular Contraction (1) Muscle in rigor mortis (1) Contracted muscle is losses this translucency, more or less transparent, and becomes opague. or rather translucent. (2) It has lost this elasti(2) It is very elastic, i.e.,

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LEGAL MEDICINE capable of restoration to its original form as soon as the distorting force has ceased to act. (3) In reaction to litmus, it is either neutral or slightly alkaline, and any reduction in this alkalinity is very speedily removed. (4) If the contraction be overcome by mechanical force, the muscles though they may remain for a time uncontracted, possess still their inherent power of contraction; they may then keep the limb fixed in a new position or allow a return to the old position.

city and readily maintains a distorted position. (3) It is distinctly and constantly acid (until dec o m p o s i t i o n is advanced) owing to the development of sarcolatic and other acid metabolites. (4) If rigor mortis be overcome by mechanical force, absolute flaccidity corresponding in degree with the amount of mechanical movement, at once ensues, and there is no power to resume the old position nor any new one, except so far as gravity may cause a new position. This flaccidity is permanent till decomposition destroys the muscles.

(From: Taylor's Principles and Practice of Medical Jurisprudence, 11th ed.. Vol I, p. 179). c. Stage of Secondary Flaccidity or Secondary Relaxation: After the disappearance of rigor mortis, the muscle becomes soft and flaccid. It does not respond to mechanical or electrical stimulus. This is due to the dissolution of the muscle proteins which have previously been coagulated during the period of rigor mortis. This body while at the stage of rigor mortis, if stretched or flexed to become soft, will no longer be rigid. This condition f the muscles is not secondary flaccidity. CHANGES IN THE BLOOD: a. Coagulation of the Blood: The stasis of the blood due to the cessation of circulation

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enhances the coagulation of blood inside the blood vessels. Blood clotting is accelerated in cases of death by infectious fevers and delayed in cases of asphyxia, poisoning by opium, hydrocyanic acid or carbon monoxide poisoning. The clotting of blood is a very slow process that there is a tendency for the blood to separate forming a red clot at the lower level and above it is a white clot known as chicken-fat clot. Blood- may remain fluid inside the blood vessels after death for (Ho 8 hours. ^distinctions Between Ante-mortem from Post-mortem Clot: Ante-mortem Clot Post-mortem Clot (1) Firm in consistency.^- l ^ u^ ) consistency. (2) Surface of the blood"^ ' (2) Surface of the blood vessel raw after the ^ " ^ - v e s s e l s smooth and clots are removed. p£v t l f *Thealthy after the clots are removed. (3) Clots homogenous in (3) Clots can be stripped construction so it canoff in layers. not be stripped into layers. (4) Clot with uniform color. (4) Clot with distinct layer. bfPost-mortem Lividity or Cadaveric Lividity, or Post-mortem Suggillation or Post-mortem Hypostasis or Livor Mortis: The stoppage of the heart action and the loss of tone of blood vessels cause the blood to be under the influence of gravity. Blood begins to accumulate in the most dependent portions of the body. The capillaries may be distended with blood. The distended capillaries coalesce with one another until the whole area becomes dull-red or purplish in color known as post-mortem lividity.* If the body is lying on his back, the lividity will develop on the back. Areas of bone prominence may not show lividity on account of the pressure. If the position of the body is moved during the early stage of its formation, it may disappear and develop again in the most dependent area in the new position assumed. But if the position of the body has been changed after clotting or the blood has set in or when blood has already diffused into the tissues of the body, a change of position of the body will not alter the location of the post-mortem lividity. Ordinarily, the color of post-mortem lividity is dull-red or pink or purplish in color, but in death due to carbon monoxide 1

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LEGAL MEDICINE poisoning, it is bright pink. Exposure of the dead body to cold or hot may cause post-mortem lividity to be bright-red in color. The lividity usually appears three to six hours after death and the condition increases until the blood coagulates. The time of its formation is accelerated in cases of death due to cholera, uremia and typhus fever. Twelve hours after death, the post-mortem lividity is already fully developed. It also involved internal organs. Physical Characteristics of Post-mortem Lividity: (1) It occurs in the most extensive areas of the most dependent portions of the body. (2) It only involves the superficial layer of the skin. (3) It does not appear elevated from the rest of the skin. (4) The Color is uniform but the color may become greenish at the start of decomposition. (5) There is no injury of the skin. Kinds of Post-mortem (Cadaveric) Lividity: Hypostatic Lividity: The blood merely gravitates into the most dependent portions of the body but still inside the blood vessels and still fluid in form. Any change of position of the body leads to the formation of the lividity in another place. This occurs during the early stage of its formation. This appears during the later stage of its formation when the blood has coagulated inside the blood vessels or has diffused into the tissues of the body. Any change of position will not change the location of the lividity. Importance of Cadaveric Lividity: (1) It is one of the signs of death. (2) It may determine whether the position of the body has been changed after its appearance in the body. (3) The color of the lividity may indicate the cause of death. Example: a. In asphyxia, the lividity is dark. b. In carbon monoxide poisoning, the lividity is bright pink. Hemorrhage, anemia — less marked. Hydrocyanic acid — bright red. Phosphorus — dark brown. Potassium chlorate, Potassium bichromate — chocolate or coffee brown.

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c. If the body is found for considerable time in snow or ice the lividity is bright red. (4) It may determine how long the person has been dead. (5) It gives us an idea as to the time of death. Points to be considered which may infer the position of the body at the time of death: a. Posture of the body when found: The body may become rigid in the position in which he died. Post-mortem lividity may develop in the assumed position. This condition may occur and is of value if the state and position of the body was not moved before rigidity and lividity took place. b. Post-mortem Hypostasis (Lividity): Hypostatic lividity will be found in areas of the body which comes in contact with the surface where the body lies. If there is already coagulation of blood or if blood has already diffused into the tissues of the body, a change of position will not alter the location of the post-mortem lividity. c. Cadaveric Spasm: In violent death, the attitude of parts of the body may infer position on account of the spasm of the muscles. Example: (1) In drowning, the victim may be holding the sea weeds. (2) In suicide, the wounding weapon may be grasped tightly by the hands. Distinctions Between Contusion (Bruise) and Post-mortem Hypostasis: Contusion (Bruise) Post-mortem Hypostasis a. Below the epidermis in the a. In the epidermis or in the true skin in small bruises or cutis, as a simple stain or extravasations, below this in a showing through the epilarger ones, and often much dermis of underlying endeeper still. The reason is gorged capillaries, obvious, viz., that the epidermis has no blood-vessels to be ruptured. b. Cuticle was probably abraded b. Cuticle unabraded, because by the same violence that pro- the hypostasis is a mere duced the bruise. In small sinking of the blood; there punctures, such as flea bites, is no trauma. ^ this is not observed.

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c. A bruise appears at the seat of and surrounding the injury. This may or may not be a dependent part. d. Often elevated, because the extravasated blood and subsequent inflammation swell the tissues. e. Incision shows blood outside the vessels. This is the most certain test of difference, and can be observed even in very small bruises. f. Colour variegated. This is only true of bruises that are some days old; it is due to the changes in the haemoglobin produced during life.

g. If the body happens to be constricted at, or supported on, a bruised place, the actual surface of contact may be a little lighter than the rest of the bruise, but will not be white.

Always in a part which for the time of formation is dependent, i.e., at a place where gravity ordains it. Not elevated, because either the blood is still in the vessels or, at most, has simply soaked into and stained the tissues. Incision shows the blood is still in its vessels; and if any oozing occurs drops can be seen issuing from the cut mouths of the vessels. Colour uniform. The wellknown change in colour (green, yellow, etc.) produced in blood extravasted into living tissues does not occur in dead tissues with the same regularity. In a place which would otherwise be the seat of a hypostasis pressure of any kind, even simple support (the wrinkling of a shirt or necktie, garters, etc.) is sufficient to obliterate the lumen of venules and capillaries, and so to prevent their filling with blood. White lines or patches of pressure bordered by,the dark color of a hypostasis are produced and marks of floggings, strangulation, etc., are thus sometimes simulated.

(From: — Taylor's Principles and Practice of Medical Jurisprudence, 11th ed. 1949, Vol I, p. 175-176. Internal Hypostasis in Visceral Organs: Post-mortem lividity also occurs in the internal organs. The principal organs affected are the lungs, loops of the intestine and brain. It may in some instances be mistaken for disease.

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Post-mortem hypostasis in the organs may have the pathological appearance in the visceral organs. In the heart, it may simulate coronary occlusion while in the lungs it may appear like pneumonic changes. The intestine may be reddened to appear like strangulation. Differences between Post-mortem Lividity of Organs and Simple Congestion: a. Post-mortem staining in organs is irregular and occurs in the most dependent parts, while congestion is generally uniform and found all over the organs. b. The mucous membrane in post-mortem staining (lividity) is dull and lusterless, but not so in congestion. c. In post-mortem staining (lividity) inflammatory exudate is not seen, and areas of redness alternating with pale areas will be found if a hollow viscus is stretched out and held in front of a light. This is not seen in cases of simple congestion. Distinctions between Post-mortem Lividity from Hemorrhage of Scurvy, Phosphorus Poisoning, or Purpura: a. History Before Death: History will reveal the presence of scurvy, phosphorus poisoning or purpura. b. Time of Appearance: In cases of scurvy, purpura or phosphorus poisoning, the skin lesion is present even before death, while in cases of postmortem lividity it only appears after death. c. Location: In post-mortem lividity, it is only present in the most dependent portions of the body, while in purpura, scurvy or phosphorus poisoning, the lesions may be found and distributed all over the skin or organs. Other Changes in the Blood: a. Hydrogen ion Concentration — After death the Ph of the blood and tissues drops because of the terminal accumulation of C O 2 , glycogenolysis and glycolysis with accumulation of phosphoric acid and lactic acid, and splitting off of amino-acid and fatty acids. After about 24 hours, the reaction become alkaline due to the production of ammonia from enzymatic protein breakdown and the rise of serum concentration of nonprotein nitrogenous components. b. The breakdown of liver glycogen leads to the accumulation of dextrose in the inferior vena cava and right side of the heart.

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c. There is a rise of non-protein nitrogen and free amino-acid. d. Chemical — The chloride in the plasma and red blood cells falls due to the extravascular diffusion so that after 72 hours it is only 1/2 of its content. Magnesium content increases as a result of diffusion from without. Potassium increases owing to diffusion from the vascular endothelium. 3. AUTO LYTIC OR AUTODIGESTTVE CHANGES AFTER DEATH: After death, proteolytic, glycolytic and lipolytic ferments of glandular tissues continue to act which lead to the autodigestion of organs. This action is facilitated by weak acid and higher temperature. It is delayed by the alkaline reaction of the tissues of the body and low temperature. Their early appearance is observed in the parenchymatous and glandular tissues. Autolytic action is seen in the maceration of the dead fetus inside the uterus. The stomach may be perforated, glandular tissues become soft after death due to autodigestion and the action of autolytic enzymes. Microscopic examination of the tissues under the influence of autolytic enzymes shows disintegration, swelling or shrinkage, vacuolization and formation of small granules within the cytoplasm of the cells. There is also a change in the staining capacity and become desquamated from the underlying layers (Legal Medicine by Gradwohl, p. 135). 4. PUTREFACTION OF THE BODY: Putrefaction is the breaking down of the complex proteins into simpler components associated with the evolution of foul smelling gasses and accompanied by the change of color of the body. Tissue Changes in Putrefaction: The following are the principal changes undergone by the soft tissues of the body in the process of putrefaction: a. Changes in the Color of the Tissue: A few hours after death, there is hemolysis of the blood within the blood vessels and as a result of which hemoglobin is liberated. The hemoglobin diffuses through the walls of the blood vessels and stains the surrounding tissues thereby imparting a red or reddish-brown color. While in the tissues, the hemoglobin undergoes chemical changes and various derivatives of hemoglobin are formed. On account of these chemical changes the tissue color is gradually

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changed to greenish-yellow, greenish-blue, or greenish-black color. The earliest change is greenish color of the skin seen at the region of the right iliac fossa and it gradually spreads over the whole abdominal wall. Blood later extravasates into the cavities of the body. Marbolization — It is the prominence of the superficial veins with reddish discoloration during the process of decomposition which develops on both flanks of the abdomen, root of the neck and shoulder and which makes the area look like a "marbled" reticule of branching veins. This is observed easily among dead persons with fair complexion. b. Evolution of Gases in the Tissues: One of the products of putrefaction is the evolution of gases. Carbon dioxide, ammonia, hydrogen, sulphurated hydrogen, phosphoretted hydrogen, and methane gases are formed. The offensive odor is due to these gases and also due to a small quantity of mercaptans. The formation of gases causes the distention of the abdomen and bloating of the whole body. Gases formed in the subcutaneous tissues and in the face, and neck cause swelling of the whole body. Small gas bubbles are found in solid visceral organs and give rise to the "foamy" appearance of the organs. Effects of the Pressure of Gases of Putrefaction: (1) Displacement of the Blood: There may be post-mortem bleeding in open wounds on account of the increased pressure inside the body brought about by the accumulation of gases. The post-mortem lividity may be shifted to other parts of the body. The heart may empty itself of blood. (2) Bloating of the Body: On account of the accumulation of gas, the body is blown-up and swollen. The eyes may be protruding from its sockets, the tongue may come out of the mouth, and the face is black with thick lips having the appearance of a negro (tete de negri). ( 3 ) Fluid Coming Out of Both Nostrils and Mouth: Fluid coming out of both nostrils and mouth is usually in the form of froth. It is due to the putrefaction of the upper gastro-intestinal and respiratory tracts. ( 4 ) Extrusion of the Fetus in a Gravid Uterus: On account of the increased intra-abdominal pressure, the contents of the gravid uterus may be expelled, but this

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event is quite doubtful when the product of conception is nearing full term because of the difficulty of expulsion. There is more likelihood for the uterus to rupture inside the abdominal cavity. (5) Floating of the Body: The specific gravity of a decomposed body is much less as compared with a recently dead. This is brought about by the increase of gaseous content and increase in volume due to bloating without any increase in weight, c. Liquefaction of the Soft Tissues: As decomposition progresses, the soft tissues of the body undergo softening and liquefaction. The eyeballs, brain, stomach, intestine, liver and spleen putrefy rapidly, while highly muscular organs and tissues relatively putrefy late.

Decomposition in water with bloating of the whole body, blackening of the face and attitude of the extremities at the time of recovery.

Factors Modifying the Rate of Putrefaction: a. Internal Factors: (1) Age: Healthy adults decompose later than infants. It may be late in a newborn infant who have not yet been fed. Markedly emaciated person has the tendency to mummify.

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(2) Condition of the Body: Those of the full-grown and highly obese persons decompose more rapidly than skinny ones. Bodies of still-born are usually sterile so decomposition is retarded. ( 3 ) Cause of Death: Bodies of persons whose cause of death is due to infection decompose rapidly. This is also true when the diseased condition is accompanied with anasarca. Bodies whose sudden death is not due to microorganism decompose late. b. External Factors: (1) Free Air: (a) Air — The accessibility of the body to free air will hasten decomposition. (b) Moderate Moisture — Moderate amount of moisture will accelerate decomposition, but excessive amount will prevent the access of air to the body thereby delaying decomposition. Moisture is necessary for the growth and multiplication of bacteria, however, if the evaporation of fluid is marked, there will be mummification of the tissues and putrefaction will be retarded. (c) Condition of the Air — If the air is loaded with septic bacteria, decomposition will be hastened. (d) Temperature of the Air — The optimum temperature for specific decomposition is 70°F to 100°F. Decomposition does not occur at temperatures below 32°F or about 212°F. (e) Light — The organism responsible for the putrefaction prefers more the absence of light. (2) Earth: Dry absorbent soil retards decomposition while moist fertile soil accelerates decomposition. ( 3 ) Water: Decomposition in running water is more rapid than in still water. Bacteria-laden pools will accelerate decomposition. ( 4 ) Clothings: Clothings initially hasten putrefaction by maintaining body temperature but in the later stage, clothings delay decomposition by protecting the body from the ravages of flies and other insects. Tight clothings delay putrefaction

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due to the diminution of blood in the area on account of pressure. Physical Changes of the Body during Putrefaction in Chronological Order: a. External Changes: (1) Greenish discoloration over the iliac fossa appearing after one to three days. (2) Extension of the greenish discoloration over the whole abdomen and other parts of the body. (3) Marked discoloration and swelling of the face with bloody froth coming out of the nostrils and mouth. (4) Swelling and discoloration of the scrotum, or of the vulva. (5) Distention of the abdomen with gases. (6) Development of bullae in the face of varying sizes. (7) Bursting of the bullae and denudation of large irregular surfaces due to the shedding of the epidermis. (8) Escape of blood-stained fluid from the mouth and nostrils. (9) Brownish discoloration of the surface veins giving an arborescent pattern on the skin. (10) Liquefaction of the eyeballs. (11) Increased discoloration of the body generally and progressive increase of abdominal distention. (12) Presence of maggots. (13) Shedding of the nails and lossening of the hairs. (14) Conversion of the tissue into semi-fluid mass. (15) Facial feature unrecognizable. (16) Bursting of the abdomen and thoracic cavities. (17) Progressive dissolution of the body. b. Internal Changes: (1) Those which Putrefy Early: (a) Brain. (b) Lining of the trachea and larynx. (c) Stomach and intestines. (d) Spleen. (e) Liver. (f) Uterus (if pregnant or in puerperal stage). (2) Those which Putrefy Late: (a) Esophagus. (b) Diaphragm. (c) Heart. (d) Lungs. (e) Kidneys. (f) Urinary bladder.

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(g) Uterus (if not gravid). (h) Prostate gland. Organs rich in muscular tissues resist putrefaction longer than the parenchymatous organs with the exception of the stomach and intestines which by reason of their contents at the time of death decompose quickly. Factors Influencing the Changes in the Body after Burial: a. State of the Body Before Death: An emaciated person at the time of death will decompose slower as compared with well-nourished individual when placed under the same conditions and circumstances. Skinny person has more tendency to mummify, especially at the regions of the extremities. b. Time Elapsed between Death and Burial and Environment of the Body: If the temperature of the surroundings at the time of death is conducive for the growth and multiplication of bacteria, then the longer the time such body is exposed to such condition the faster is the decomposition. However, if the body has been frozen to death for quite a time, there will be retardation of body decomposition. The presence of filthy, pultaceous and organic materials in the surroundings coupled with the presence of light and optimum temperature will enhance the decomposition. c. Effect of Coffin: The use of a coffin will delay decomposition if it is airtight and hard. If soft and weak, water can easily percolate at the floor and top, thus it will not serve the purpose. The body in a coffin usually decompose later as compared with the body which is coffinless. d. Clothings and Any Other Coverings on the Body when Buried: Clothings and other body coverings delay decomposition. Most often the covered portions of the body are well preserved for sometime. The most probable reasons why clothings retard decomposition are: (1) It affords some protection from insects and aids adipocere formation keeping the body under it continuously moist by absorbing water from the soil. (2) The pressure of the clothings on the body. e. Depth at which the Body was Buried: As a general rule, the greater the depth the body has been buried, the better is the preservation. There is aeration in

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shallow grave and this is a conducive invitation for injects and other animals. The changes of temperature of the body on account of the changing weather conditions is more marked in shallow graves. f. Condition and Type of Soil: Dry, arid and sandy soil promotes mummification of the body. The presence of straw or other organic matters that will introduce more bacteria will accelerate decomposition. g. Inclusion of Something in the Grave which will Hasten Decomposition: Some organic materials, like food are sometimes included with the dead body inside the coffin because of their superstition that it will be utilized by the departed soul in its life hereafter. Its presence inside the coffin will accelerate putrefaction. h. Access of Air to the Body After Burial: Air may hasten evaporation of the body fluid and promotes mummification. Bacteria-laden air will promote decomposition. Humid air will enhance adipocere formation. However, accessibility of air means also accessibility of insects and other scavengers which will promote destruction of the soft tissues of the body. i. Mass Grave: This is seldom seen, except in mass massacre, war and in plane crash. There is relatively rapid decomposition of the bodies, j. Trauma on the Body: Persons dying from infection decompose rapidly while those dying of violent death decompose relatively slow. On account of the presence of several factors which modify decomposition of the body after death, it is quite difficult to make an estimate as to the duration of death of a decomposed body without considering those different elements influencing it. Chronological Sequence of Putrefactive Changes Occurring in Temperate Regions: Putrefactive Changes Time a. Greenish discoloration over the iliac fossae. The eyeballs are soft and yielding. 1 to 3 days after death. b. Greenish discoloration spreading over the whole abdomen, external genitals and other parts of the

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body. Frothy blood from the mouth and nostrils. 3 to 5 days after death. Abdomen distended with gas. Cornea fallen in and concave. Purplish red streaks of veins prominent on the extremities. Sphincters relaxed. Nails firm. 8 to 10 days after death. Body greenish-brown. Blisters forming all over the body. Skin peels off. Features unrecognizable. Scrotum distended. Body swollen up owing to distention. Maggots found on the body. Nails and hair loose and easily detached. 14 to 20 days after death. Soft parts changes into a thick, semi-fluid black mass. Skull exposed. Orbits empty. 2 to 5 months after death. (Casper, Forensic Medicine, cited by Modi, Medical Jurisprudence and Toxicology, 12 ed., 157, p. 134). Chronological Sequence of Putrefactive Changes Occurring in Tropical Region: Time Since Death Condition of the Body 12 hours Rigor mortis present all over. Hypostasis well-developed and fixed. Greenish discoloration showing over the caecum. Rigor mortis absent all over. Green dis24 hours coloration over whole abdomen and spreading to chest. Abdomen distended with gases. Ova of flies seen. 48 hours Trunk bloated. Face discolored and swollen. Blisters present. Moving maggots seen. Whole body grossly swollen and dis72 hours figured. Hair and nails loose. Tissues soft and-discolored. One week Soft viscera putrefied. Only more resistant viscera distinguishTwo weeks able. Soft tissues largely gone. Body skeletonized. One month

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(From: — Lambert's Medico-Legal Post-mortem in India, 2nd ed., p. 25). Body decomposition in warm countries, according to Lambert, will reduce the whole body to a skeleton in a month's time when exposed to air. In water, putrefaction proceeds twice as slowly as it is in air. When the body is buried, the rate depends on the mode of burial. In deep burial with coffin, putrefaction proceeds from four to six times as slowly as compared with that one in air, but with shallow coffinless burial, it is very slightly retarded.

Decomposition - Soft tissues of the chest and head have disappeared while those of the abdomen and extremities are mummified.

Chronological Sequence of Putrefactive Changes When the Body Has Been Submerged in Water: Putrefactive Changes Time a. Very little change if water is cold. Rigor mortis may persist. First four or five days. b. The skin on the hands and feet became sodden and bleached. The face appears softened and lias a faded white color. From five to seven days. c. Face swollen and red. Greenish discoloration on the eyelids, lips, neck and sternum. Skin of the hands and feet wrinkled. Upper

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surface of brain greenish in color. One to two weeks. d. Skin wrinkled. Scrotum and penis distended with gas. Nails and hair still intact. Lungs emphysematous and covered the heart. Four weeks. e. Abdomen distended, skin of hands and feet come off with nails like a glove. Six to eight weeks. (Observation of Devergie, cited by Modi, Medical Jurisprudence and Toxicology, 12th ed. 1957, p. 138). Factors Influencing the Floating of the Body in Water: a. Age: Bodies of fully-developed and well-nourished newly-born infants float relatively rapid. b. Sex: Women float sooner than men. This is due to the lightness of female bones and greater porportion of fat, hence lesser specific gravity. c. Conditions of the Body: Stout persons float quicker than skinny, lean and thin bodies. Bodies with loose clothings will soon come to the surface. d. Season of the Year: The moist hot air of summer is very favorable for putrefaction. Putrefaction makes the body bloat on account of gas formation, hence it will accelerate floating of the body. e. Water: Dead body floats in a shallow and stagnant water of creeks or pond sooner than in deep water of running stream. The stagnant water has higher specific gravity than clear water, so it is easy for the dead body to overcome it by gas formation. Body floats sooner in sea than in fresh water on account of the high specific gravity of sea water. f. External Influence: The presence of heavy-wearing apparel or the addition of weight in the pockets or attached to the body by means of rope or string will delay the floating of the body. Order of Putrefaction When the Body is in Water: a. Face and neck or sternum. b. Shoulders.

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146 c. Arms. d. Abdomen. e. Legs.

Decomposition — The whole body almost skeletonized

Influence of Bacteria in Decomposition: Decomposition is due to action of bacteria in various tissues of the body. During the early period of decomposition, aerobic activities are prominent. Later, the facultative aerobes and anaerobes are present. In the advanced stage, the activities of the anearobes are the most prominent with the production of gasses. The softening of the tissues is the result of bacterial action, proteolytic and autolytic ferments. The microorganism that plays an important and dominant role in decomposition is Clostridium welchii. This bacteria starts to grow in parenchymatous organs. It is responsible for the disintegration of cytoplasm, destruction of nuclei and generation of gases in the cells. Other bacteria which participate in tissue destruction during the period of decomposition are: a. Bacillus coli. b. Bacillus proteus vulgaris. c. Bacillus mesentericus. d. Bacillus aerogenes capsulatus.

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Other Destructive Agents During Decomposition: a. Flies: (1) Maggots (Larvae): The presence of maggots is dependent upon the accessibility of the body to adult flies. The flies lay eggs which after a time is hatched to form maggots. The maggots have a strong desire to live in damaged skin surface. Maggots may also be observed in bodies buried in shallow graves and even in floating decomposed bodies in water pools. (2) Adult Flies: The common house flies are carnivorous.* They devour the juicy areas of exposed portions of the body. Destruction by adult flies is observed better when the body is found on surface ground. b. Reptiles: Lizards and snakes are attracted to dead bodies and eat the soft tissues. Small bones may be fractured in the process and may be mistaken for injuries during the life time of the deceased. c. Rodents: Rats and mice will nibble the skin and other tissues and may show unexplainable injuries. The bones may also be attacked and showed certain degree of erosions. d. Other Mammals: The dogs may participate in the destruction of the soft tissues especially in cases where the victim is lying on the ground. In most instances, the different parts of the body is scattered and separated from one another. A part may be missing or seen in some far distant places. In India, jackals also participate in the destruction of decomposed tissues. e. Fishes and Crabs: If the body is in water, fish of almost all species and crustacean will be feeding on the soft tissues. Man-eating fishes like sharks may devour the whole body of a person. f. Molds: As a general rule, molds do not destroy the dead bodies but their growth cause disfigurement and minor superficial lesions on the skin. After a period of time, all of the soft tissues of the body will disappear. Only the teeth, bones and hair will remain. These tissues will remain undestroyed for an indefinite time. The bones may show signs of disintegration by the diminution of

LEGAL MEDICINE weight and erosion of the epiphysis. Flat bones disintegrate faster than round bones. The degree of ossification is also a factor in the bone destruction.

Death in the sea with post-mortem erosion of the face due to the activities of the fishes and other aquatic animals.

SPECIAL MODIFICATION OF PUTREFACTION: a. Mummification: Mummification is the dehydration of the whole body which results in the shivering and preservation of the body. It usually occurs when a dead body is buried in a hot, and arid place with dry atmosphere and with free access of hot air. In most cases, the natural physical appearance is not modified, hair may be kept intact although there may be change in color of the skin. The internal organs may be shrunken, hard and with a darkbrown or black color. If the whole fluid contents of the body has evaporated, preservation is for an indefinite time but the whole body may become brittle, weight markedly reduced and may later be destroyed by pulverization. Mummification is observed in warm countries where evaporation of body fluid takes place earlier and faster than decomposition. Death in deserts, like in Egypt, the body has more tendency to mummify. However, a mummified body may after a time be attacked by moths and verm ins causing destruction.

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Kinds of Mummification: (1) Natural Mummification; When a person is buried in hot, arid, sandy soil, there will be insufficient moisture for the growth and multiplication of putrefactive bacteria. The body will become dehydrated and mummified which is caused by the forces of nature. (2) Artificial Mummification: The principles involved in artificial mummuification are: (a) Acceleration of the evaporation of the tissue fluid of the body before the actual onset of decomposition. (b) Addition of some body preservatives to inhibit decomposition and to allow evaporation of fluid. This is made by treatment of the body with arsenic, formalin, resinous or tarry materials. b. Saponification or Adipocere Formation: This is a condition wherein the fatty tissues of the body are transformed to soft brownish-white substance known as adipocere. The layer of subcutaneous tissue is the frequent site of its formation. It occurs naturally in the visceral organs and even in non-fatty tissues of the body like the muscles. Adipocere is a waxy material, rancid or moldy in odor, floats in water, and dissolves in ether and alcohol. With diluted solution of copper sulfate, it gives a light greenish-blue color. It is inflammable and burns with a faint yellow flame. When distilled it produces a dense oily vapor. Some Theories on the Formation of Adipocere: (1) The fats of the body split into glycerol and fatty acids. The fatty acids combine with calcium, magnesium, potassium, sodium, and ammonium salts to form an insoluble soap. These ester of fatty acid somehow delay body decomposition and make the body surface greasy to touch. (2) There is gradual hydrogenation of pre-existing fat in the body like olein to higher fatty acids. Hydrogenation causes remarkable swelling and stiffening of the fats. The new hydrogenated fat is quite stable but on exposure to air becomes yellow, hard and brittle. Factors Influencing Adipocere Formation in Earth Burial: (1) State of Health Before Death: Adipocere formation depends primarily on the presence of fat in the body of the deceased. It is difficult for adi-

LEGAL MEDICINE pocere to develop in the state of extreme emaciation. Areas of the body where fat is abundant develop adipocere recognizable through the naked eye rapidly as compared with the other areas. The amount of water in the surroundings is not very essential to the phenomena. Water of the body may be drawn from the muscles and internal organs. (2) Time Interval between Death and Burial: Generally, the longer the space of time interval between death and burial, the greater is the degree of adipocere formation. This is further accelerated when the body is subjected to autopsy. Exposure of the internal organs to external elements promotes enzymatic and bacterial actions in the process of hydrolysis and glycerol formation. (3) Effect of the Coffin: The coffin has air space and if crudely made, it may allow water to come in contact with the body surface thereby enhancing hyrolysis of fat. If water has been freely admitted, colliquative putrefaction will develop for a longer time thus making adipocere formation scanty. (4) Presence of Clothings and Other Coverings of the Body: Adipocere formation is found to be more advanced under clothings or other body coverings, especially if the clothings are tight. (5) Type of Soil: Dry soil is conducive to mummification. Sufficiently moist soil accelerates adipocere formation. (6) Access of Air to the Body After Burial: The disturbance of a body in the grave shortly after burial or before the formation of adipocere prolongs its formation. (7) Mass Grave: There is more tendency for adipocere formation when several bodies are located in a grave because of the abundance of moisture. Maceration: This is the softening of the tissues when in a fluid medium in the absence of putrefactive microorganism which is frequently observed in the death of the fetus en utero. When the fetus dies en utero, provided that the death of the fetus is not due to attempted abortion or rupture of the membrane, the child is enclosed by the membrane in sterile con-

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dition. Putrefaction does not take place and the fetus becomes soft. The softening of the body may be due to the action of the autolytic and proteolytic enzymes and ferments. / The appearance of the fetus is typical. The hody is discolored either reddish or greenish with the skin peeling off and the arms flaccid and frail. As maceration advances, there is brownish-red discoloration of the skin. There may be blister formation and the odor is somewhat rancid. For a definite and appreciable degree of maceration to take place, it requires about twenty-four hours. DURATION OF DEATH In the determination as to how long a person has been dead from the condition of the cadaver and other external evidences, the following points must be taken into consideration: 1. Presence of Rigor Mortis: In warm countries like the Philippines, rigor mortis sets in from 2 to 3 hours after the death. It is fully developed in the body after 12 hours. It may last from 18 hours to 36 hours and its disappearance is concomitant with the onset of putrefaction. 2. Presence of Post-mortem Lividity: Post-mortem lividity usually develops 3 to 6 hours after death. It first appears as a small petechia-like red spots which later coalesce with each other to involve bigger areas in the most dependent portions of the body depending upon the position assumed at the time of death. 3. Onset of Decomposition: In the Philippines like other tropical countries, decomposition is early and the average time is 24 to 48 hours after death. It is manifested by the presence of watery, foul-smelling froth coming out of the nostrils and mouth, softness of the body and presence of crepitation when pressure is applied on the skin. 4. Stage of Decomposition: The approximate time of death may be inferred from the degree of decomposition, although it must be made with extreme caution. There are several factors which modify putrefaction of the body. For the stage of decomposition and the approximate time after death, see tabulations (supra p. 143). 5. Entomology of the Cadaver: In order to approximate the time of death by the use of the flies present in the cadaver, it is necessary to know the life cycle

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of the flies. The common flies undergo larval, pupal and adult stages. The usual time for the egg to be hatched into larva is 24 hours so that by the. mere fact that there are maggots in the cadaver, one can conclude that death has occurred more than 24 hours. 6. Stage of Digestion of Food in the Stomach: It takes normally 3 to 4 hours for the stomach to evacuate its contents after a meal. The approximate time of death may be deduced from the amount of food in the stomach in relation to his last meal. This determination is dependent upon the amount of food taken and the degree of tonicity of the stomach. The extent of the gastric emptying and the progression of the meal in the gastro-intestinal tract can be useful in estimating the time of death. However, the position and condition of the decedent's last meal is influenced by the following factors: a. Size of the Last Meal — The stomach usually starts to empty within ten minutes after the first mouthful has entered. A light meal leaves the stomach within 1-1/2 to 2 hours after being eaten. A medium-sized meal will require 3 to 4 hours. A heavy meal is entirely expelled into duodenum in 4 to 6 hours. b. Kind of Meal — Liquid move more rapidly than semi-solid and the latter more rapidly than solids. c. Personal Variation — Psychogenic pylorospasm can prevent departure of the meal from a stomach for several hours, contrariwise, a hypermotile stomach may enhance entry of food into the duodenum. d. Other Factors: (1) Kinds of Food Eaten — Vegetables may require more time for gastric digestion. The less fragmentation of the food will require more time to stay in the stomach. The absence or insufficiency of pepsin and other digestive ferments will delay the food in the stomach. Absence or insufficiency of the gastric hydrochloric acid content and lesser amount of liquid consumed with solid food will likewise delay gastric evacuation. The head of the meal ordinarily reaches the distal ileum and cecum between 6 and 8 hours after eating. The conclusion may be of value in the estimation of death if one is familiar with the decedent's eating habit and meal time, quantity of the last meal and the interval between the last two meals.

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7. Presence of Live Fleas in the Clothings in Drowning Cases: A flea can survive for approximately 24 hours submerged in water. It can no longer be revived if submerged more than that period. In temperate countries, people use to wear woolen clothes. If the body is found in water, the fleas may be found in the woolen clothings. The fleas recovered must be placed in a watch glass and observed if it is still living. If the fleas still could move, then the body has been in water for a period less than 24 hours. Revival of the life of the fleas is not possible if they are in water for more than 24 hours. 8. Amount of Urine in the Bladder: The amount of urine in the urinary bladder may indicate the time of death when taken into consideration, he was last seen voiding his urine. There are several factors which may modify urination so it must be utilized with caution. 9. State of the Clothings: A circumstantial proof of the time of death is the apparel of the deceased. If the victim is wearing street clothes, there is more likehood that death took place at daytime, but if in night gown or pajama, it is more probable that death occurred at night time. 10. Chemical Changes in the Cerebrospinal Fluid (15 Hours Following Death): a. Lactic acid increases from 15 mg. to 200 mg. per 100 cc. b. Non-protein nitrogen increases from 15 to 40 mg. ( c. Amino-acid concentration rises from 1 to 12% following death. 11. Post-mortem Clotting and Decoagulation of Blood: Blood clots inside the blood vessels in 6 to 8 hours after death. Decoagulation of blood occurs at the early stage of decomposition. The presence of any of these conditions may infer the approximate duration of death. 12. Presence or Absence of Soft Tissues in Skeletal Remains: Under ordinary condition, the soft tissues of the body may disappear 1 to 2 years time after burial. The disappearance of the soft tissues varies and are influenced by several factors. When the body is found on the surface of the ground, aside from the natural forces of nature responsible for the destruction of the soft tissues, external elements and animals may accelerate its destruction. 13. Condition of the Bones: If all of the soft tissues have already disappeared from the skeletal remains, the degree of erosion of the epiphyseal ends of

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long bones, pulverization of flat bones and the diminution of weight due to the loss of animal matter may be the basis of the approximation. Post-mortem Conditions Simulating Disease, Poisoning or Injury: a. Post-mortem hypostasis simulating contusion or inflammation or poisoning. b. Blister of the cuticle simulating scalds or burns. c. Swelling, detachment or splitting of the skin simulating injury. E. PRESUMPTION OF DEATH Rule 131, Sec. 5(x), Rules of Court: Disputable Presumption: That a person not heard from for seven years, is dead. Presumption of Death: Art. 390, Civil Code and Sec. 5(x), Rule 131, Rules of Court: After an absence of seven years, it being unknown whether or not the absentee still lives, he shall be presumed dead for all purposes, except for those of succession. The absentee shall not be presumed dead for the purpose of opening his succession till after an absence of ten years. If he disappeared after the age of seventy-five years, an absence of five years shall be sufficient in order that his succession may be opened.^ Art. 391, Civil Code and Sec. 5(x), Rule 131, Rules of Court: The following shall be presumed dead for all purposes, including the division of the estate among the heirs: (1) A person on board a vessel lost during a sea voyage, or an aeroplane which is missing, who has not been heard of for four years since the loss of the vessel or aeroplane. (2) A person in the armed forces who has taken part in war, and has been missing for four years: (3) A person who has been in danger of death under other circumstances and his existence has not been known for four years. Art. 392, Civil Code: If the absentee appears, or without appearing his existence is proved, he shall recover his property in the condition in which it may be found, and the price of any property that may have been alienated or the property acquired therewith; but he cannot claim either fruits or rents

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F. PRESUMPTION OF SURVIVORSHIP Sec. 5(jj), Rule 131, Rules of Court: When two persons perish in the same calamity, such as wreck, battle, or conflagration, and it is not shown who died first, there are no particular circumstances from which it can be inferred, the survivorship is presumed from the probabilities resulting from the strength and age of the sexes, according to the following: 1. If both were under the age of fifteen years, the older is presumed to have survived; 2. If both were above the age of sixty, the younger is presumed to have survived; 3. If one is under fifteen and the other above sixty, the former is presumed to have survived; 4. If both be over fifteen and under sixty, and the sexes be different, the male is presumed to have survived; if the sexes be the same, then the older; 5. If one be under fifteen or over sixty, and the other between those ages, the latter is presumed to have survived. Art. 43, Civil Code: If there is a doubt, as between two or more persons who are called to succeed each other, as to which of them died first, whoever alleges the death of one prior to the other, shall prove the same; in the absence of proof, it is presumed that they died at the same time and there shall be no transmission of rights from one to the other.

Chapter V MEDICO-LEGAL INVESTIGATION OF DEATH An inquest officer is an official of the state charged with the duty of inquiring into certain matters. In a medico-legal investigation, an inquest officer is the one charged with the duty of investigating the manner and cause of death of a person. He is authorized to summon witnesses and direct any person to perform or assist in the investigation when necessary. The following officials of the government are authorized to make death investigations: 1. The Provincial and City Fiscals: Sec. 983, Revised Aministrative Code: The district health officer, upon the request of any provincial fiscal of a province within his district, or of any judge of a Court of the First Instance (now Regional Trial Court), or of any justice of the peace (now, Municipal Trial Court), shall conduct in person, when practicable, investigations in cases of death where there is suspicion that death was caused by the unlawful act or omission of any person, and shall make such other investigations as may be required in the proper administration of justice. Sec. 38, Rep. Act 409 as amended by Rep. Act. 1934 (Revised Charter of the City of Manila): The City Fiscal shall also cause to be investigated the cause of sudden deaths which have not been satisfactorily explained and when there is suspicion that the cause arose from the unlawful acts or omissions of other person, or from foul play, and, in general, victims of violence, sex crimes, accidents, self-inflicted injuries, intoxications, drug addiction, states of malingering and mental disorders, which occur within the jurisdiction of the City of Manila, and the examination of evidences and telltale marks of crimes. For that purpose, he may cause autopsies to be made and shall be entitled to demand and receive for purposes of the office of the medical examiner, or the criminal investigation laboratory of the Manila Police Department, or subject to the rules and conditions previously established by the Secretary of Justice, the aid of the medico-legal section of the National Bureau of Investigation. If in case the fiscal

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of the city deems it necessary to have further expert assistance for the satisfactory performance of his duties in relation with medicolegal matters or knowledge, including the giving of medical testimony in the courts of justice, he shall request the same, in the same manner and subject to the same rules and conditions as above specified, from the office of the medical examiner, or from the criminal investigation laboratory of the Manila Police Department, or from the medico-legal officer of the said bureau, who shall thereupon furnish the assistance required in accordance with his powers and facilities. He shall at all times render such professional services as the Mayor or board may require and shall have such powers and perform such other duties as may be prescribed by law or ordinance. 2. Judges of the Courts of the First Instance (now Regional Trial Courts) Sec. 983, Revised Administrative Code (Supra). 3. Justice of the Peace (now Municipal Trial Courts) Sec. 983, Administrative Code (Supra). 4. The Director of the National Bureau of Investigation — Rep. Act. 157 (An act creating the National Bureau of Investigation). Sec. 1. — There is hereby created a Bureau of Investigation under the Department of Justice which shall have the following functions: (a) To undertake investigations of crimes and other offenses against the laws of the Philippines, upon its own initiative and as public interest may require; (b) To render assistance, whenever properly requested in the investigation or detection of crimes and other offenses; (c) To act as a national clearing house Of criminal and other information for the benefit of all prosecuting and law-enforcement entities of the Philippines, identification records of all persons without criminal convictions, records of identifying marks, characteristics, and ownership or possession of all firearms as well as the test bullets fired therefrom; (d) To give technical aid to all prosecuting and law-enforcement officers and entities of the Government as well as courts that may request its services; (e) To extend its services, whenever properly requested in the investigation of cases of administrative or civil nature in which the government is interested; (f) To undertake the instruction and training of a representative number of city and municipal peace officers at the request of their respective superiors along effective methods of crime

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investigation and detection in order to insure greater efficiency in the discharge of their duties; (g) To establish and maintain an up-to-date scientific crime laboratory and to conduct researches in the furtherance of scientific knowledge in criminal investigation; (h) To perform such other related functions as the Secretary (now Minister) of Justice may assign from time to time. Sec. 5. — The members of the investigation staff of the Bureau of Investigation shall be peace officers, and as such have the following powers: (a) To make arrests, searches, and seizures in accordance with existing laws and rules; (b) To issue subpoena or subpoena duces tecum for the appearance at government expense of any person for investigation; (c) To take and require sworn truthful statements of any person or person so summoned in relation to cases under investigation, subject to constitutional restrictions; (d) To administer oaths upon cases under investigation; (e) To possess suitable and adequate firearms for their personal protection in connection with their duties and for the proper protection of witnesses and persons in custody; Provided, that no previous special permit for such possession shall be required; (f) To have access to all public records and, upon authority of the President of the Philippines in the exercise of his visitorial powers, to record of private parties and concerns. 5. The Chief of Police of the City of Manila: Sec. 34, Rep. Act 409 (Revised Charter of the City of Manila) as amended by Sec. 1, Rep. Act. 1934 — Chief of Police: There shall be a chief of police. . . (who) shall cause medicolegal examination by the medical examiner of the Manila Police Department of victims of violence or foul play, sex crimes, accidents, sudden death when the cause thereof is not known, selfinflicted injuries, intoxication, drug addiction, states of malingering and mental disorders, which are being investigated by the Manila Police Department or, in exceptional cases, by other agencies requesting assistance of the Manila Police Department; and shall cause examination by the medical examiner of the Manila Police Department or by a criminal investigation laboratory established within said department, or evidences and telltale marks of crime. He shall have such powers and perform such further duties as may be prescribed by law or ordinances.

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6. Solicitor General: Sec. 95 (b) P.D. 856 (Code of Sanitation of the Philippines) Autopsies shall be performed in the following cases: 3 4. Whenever the Solicitor General, provincial or city fiscal as authorized by existing laws, shall deem it necessary to disinter and take possession of remains for examination to determine the cause of death. Stages of Medico-Legal Investigation: 1. Crime Scene Investigation (Investigation of the place of commission of the crime). 2. Autopsy (Investigation of the body of the victim). 1. CRIME SCENE INVESTIGATION: The crime scene is the place where the essential ingredients of the criminal act took place. It includes the setting of the crime and also the adjoining places of entry and exit of both offender and victim. Not all crimes have a well-defined scene, like estafa, malversation, continuing crimes, etc. However, where medical evidence may be present, like murder, homicide, physical injuries, sex crime, crime scene is almost invariably present.

Violent death in a vehicular accident scene.

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Crime scene investigation includes appreciation of its condition and drawing an inference from it. It also includes the collection of the physical evidences that may lead to the identity of the perpetrator, the manner the criminal act was executed, and such other things that may be useful in the prosecution of the case. Importance of Crime Scene Investigation: A great amount of physical evidence may be lost or unrecovered if the investigation merely starts at the autopsy table or in the medical examining room. Blood, semen and other stains, latent finger and foot prints, and articles of value that may lead to the identification of the offender and victim may be beyond the comprehension of the investigator if the crime scene is not investigated. In violent death.cases, the manner and cause of death may be inferred from the condition of the crime scene. The condition of the crime scene may indicate struggle, handgun firmly grasped in the palm of the hand of the deceased may indicate suicide, the presence of a great quantity of shed blood may infer hemorrhage as the cause of death of the victim. The investigator has the earliest possible opportunity to interview persons who have knowledge of the circumstances of actual events in the commission of the criminal act. The proximity of the narration to the actual occurrence makes it reliable than those given after a lapse of time. ^ Persons to Compose the Search Team: a. A physician who has had previous knowledge and training in medico-legal investigation must direct the search and assume responsibility for an effective search. b. A photographer who will take pictures of the scene and the pieces of evidence recovered. He may also act as sketcher and measurer. c. An assistant who will act as the note taker, evidence collector and helper. He must have previous knowledge and training in evidence collection. Equipment Needed in Crime Scene Investigation: a. Those needed in the search of physical evidence — Flashlight and magnifying lens. b. Those needed in the collection of evidence — forceps, knife, screw driver, scalpel, cutting instruments like plier, pair of scissors and fingerprint kit.

MEDICO-LEGAL INVESTIGATION OF DEATH

D. WHEEL METHOD

E. ZONE METHOD

METHODS OF SEARCH AT THE CRIME SCENE.

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c. Those needed in the preservation and transportation of evidence collected — Bottles, envelopes, test tubes, pins, thumb tacks, labelling tag and pencil. d. Those necessary for the documentation of the scene — Photographic camera, sketching kit, measuring tape, compass, chalk or any writing instrument. Methods of Conducting a Search: Before the actual performance of the search, it is advisable to stand aside and make an estimate of the situation. A picture of the whole area must be taken and the area must be cordoned or bystanders must not be allowed to get in. Depending upon the size, terrain and condition of the crime scene, the following methods of search may be applied: a. Strip Method — The area is blocked out in the form of a rectangle. The searcher proceeds slowly at the same pace along the path parallel to one side of the rectangle. b. Double Strip or Grid Method — The searchers will traverse first parallel to the base and then parallel to the side. c. Spiral Method — The searchers follow each other in the path in the spiral manner beginning from the center towards the outside or vice versa. d. Wheel Method — The searchers gather at the center and proceed outwards along radii or spokes. e. Zone Method — Whole area is divided into subdivisions or quadrants and search is made in the individual quadrants. Disposal of the Collected Evidence: All evidences collected must be protected, identified and preserved. Reasonable degree of care must be exercised to preserve shape, to minimize alterations due to contamination, chemical changes, addition of extreneous substances. In the process of transferring of the evidences, the number of persons who handle them must be kept at a minimum and each transfer should be receipted. Examination of the Dead Body in the Crime Scene: After a complete search, the investigating physician must make a thorough inspection of the dead body. Special consideration must be made on the following: a. Evidences which will tend to prove identity. b. Position of the victim. c. Condition of the apparel worn. d. Approximate time of death.-

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e. Presence of wounding instrument and its approximate distance from the body. f. Potential cause of death. In a death by gunshot, the clothing must be left Undisturbed at the crime scene. A lot of information may be gathered from it: a. The bullet might have produced an exit on the skin but failed to cause mark or tear on the clothings which through improper handling may not be recovered. b. Examination "in situ" may be useful in the determination of the site of entrance and exit of the bullet and also the trajectory of the shot. 2. AUTOPSIES: An autopsy is a comprehensive study of a dead body, performed by a trained physician employing recognized dissection procedure and techniques. It includes removal of tissues for further examination. Autopsies vs. Post-mortem Examination: Post-mortem examination — refers to an external examination of a dead body without incision being made, although blood and other body fluids may be collected for examination. Autopsy — indicates that, in addition to an external examination, the body is opened and an internal examination is conducted. (Modern Legal Medicine Psychiatry and Forensic Science by Curran, McGarry and Petty, p. 51 footnote). Kinds of Autopsies: a. Hospital or Non-official Autopsy b. Medico-legal or Official Autopsy a. Hospital or Non-official Autopsy: This is an autopsy done on a human body with the consent of the deceased person's relatives for the purposes of: (1) determining the cause of death; (2) providing correlation of clinical diagnosis and clinical symptoms; (3) determining the effectiveness of therapy; (4) studying the natural course of disease process; and (5) educating students and physicians (Forensic Pathology, A Handbook for Pathologists, Fisher and Petty, July 1977, p. 1). Inasmuch as previous consent of the next of kin is necessary before a non-official autopsy can be performed, the Civil

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Code states who is the rightful person to give such consent. The order is provided in Articles 294 and 305. The consent shall be obtained from: (1) The spouse; (2) the descendants of the nearest degree; (3) the ascendants, also of the nearest degree; (4) the brothers and sisters (Art. 294, Civil Code). In case of descendants of the same degree, or of brothers and sisters, the oldest shall be preferred. In case of ascendants, the paternal shall have a better right (Art. 305, Civil Code). b. Medico-Legal or Official Autopsy: This is an examination performed on a dead body for the purposes of: (1) determining the cause, manner (mode), and time of death; (2) recovering, identifying, and preserving evidentiary material; (3) providing interpretation and correlation of facts and circumstances related to death; (4) providing a factual, objective medical report for law enforcement, prosecution, and defense agencies; and (5) separating death due to disease from death due to external cause for protection of the innocent (Forensic Pathology, A Handbook for Pathologists, Fisher and Petty, July 1977, p. 1). In cases which require a medico-legal autopsy, the dead body belongs to the state for the protection of public interest until such time as a complete and thorough investigation into the circumstances surrounding the death and the cause thereof has been completed. The physician entasked to perform such autopsy is considered to be the authoritative agent and representative of the state who has the "property right" of the dead body. All that need to be turned over to the next of kin responsible for burial of the deceased is that remaining portion or portions of the body not needed for any medicolegal purposes (Forensic Medicine by Tedeschi, Eckert & Tedeschi, Vol. II, p. 972). Sec. 983, Revised Administrative Code — Investigation into cause of death (supra p. 156). Sec. 1089, Revised Administrative Code — Proceedings in cases of suspected violence or crime: If the person who issues a death certificate has any reason to suspect or if he shall observe any indication of violence or crime, he shall at once notify the justice of the peace (now Municipal Trial Judge), if he be available, or if neither the justice of the peace nor the auxiliary justice be available, he shall notify the municipal mayor, who shall take proper steps

MEDICO-LEGAL INVESTIGATION OF DEATH to ascertain the circumstances and cause of death; and the corpse of such deceased person shall not be buried or interred until permission is obtained from the provincial fiscal, if he be available, and if he be not available, from the mayor of the municipality in which the death occurred. When shall an Autopsy be Performed on a Dead Body: Sec. 95 (b), P.D. 856, Code of Sanitation: a. Whenever required by special laws; b. Upon order of a competent court, a mayor and a provincial or city fiscal; c. Upon written request of police authorities; d. 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; and e. Whenever the nearest kin shall request in writing the authorities concerned in order to ascertain the cause of death. Persons who are Authorized to Perform Autopsies and Dissections: The following are authorized to perform autopsies and dissections: a. Health Officers; b. Medical officers of law enforcement agencies; and c. Members of the medical staff of accredited hospitals. (Sec. 95 (a) P.D. 856). a. Health officers: The health officers referred to by the Sanitation Code are the district health officer (now provincial health officer) and local health officer (now the rural health officer). (1) District Health Officer (see Sec. 983, Revised Administrative Code (supra, p. 156). (2) Local Health Officer: Sec. 984, Revised Administrative Code —Person to make investigation — When it is not practicable for the district health officer to conduct such investigation in person, he may require any local health officer or member of a municipal board of health who is a registered physician to perform such duty; and where the services of a registered physician in the Government service cannot be thus obtained, he may require a "cirujano ministrante" who is a member of the board or a sanitary inspector to act in the matter. b. Medical Officers of Law Enforcement Agencies:

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LEGAL MEDICINE (1) Medical examiner of the City of Manila (See Sec. 34 and 38 of Rep. Act 409 as amended by Rep. Act. 1934). (2) Medical staff of the National Bureau of Investigation which is composed of those assigned in the central office in Manila under the Medico-Legal Section and those assigned in the regional offices of the Bureau in accordance with the administrative plantilla implementing Rep. Act. 157. (3) Medico-Legal officers of the Philippine Constabulary assigned in the Philippine Constabulary Crime Laboratory (PCCL) and those assigned in different regional commands. Insofar as medico-legal investigation of criminal cases occurring within the jurisdiction of the City of Manila is concerned, there are two officers qualified to make the investigation: (a) The medical examiners of the Manila Police Department; and (b) The Medico-Legal Officers of the National Bureau of Investigation. The Medical examiner or medico-legal officer "may investigate cases of sudden deaths, which have not been satisfactorily explained and when there is suspicion that the case arose from unlawful acts or omissions of other persons, or from foul play, and in general victims of violence, sex crimes, accidents, self-inflicted injuries, intoxication, drug addiction,. . ." (Sec. 38, Act. 409 as amended by Rep. Act. 1934). c. Members of the medical staff of accredited hospitals.

Distinction between Pathological (Non-official) and Medicolegal (Official) Autopsies: Pathological Autopsy Medico-legal Autopsy a. Requirement Must have the consent It is the law that gives of the next of kin. the consent. Consent of relatives are not needed. b. Purpose Confirmation of clini- Correlation of tissue cal findings of re- changes to the criminal search. act. c. Emphasis Notation of all ab- Emphasis laid on effect normal findings. of wrongful act on the body. Other findings

MEDICO-LEGAL INVESTIGATION OF DEATH

e. Conclusion

f. Minor or non-pathological

167

may only be noted in mitigation of the criminal responsibility. Summation of all ab- Must be specific for the normal findings irre- purpose of determining spective of its corre- whether it is in relation lation with clinical to the criminal act. findings. Need not be men- If the investigator tioned in the report. thinks it will be useful in the administration of justice, it must be included.

Other Salient Features Peculiar to Medico-Legal Autopsies: a. Clinical history of the deceased in most instances absent, sketchy or doubtful. b. The identity of the deceased is the responsibility of the forensic pathologist. c. The time of death and the timing of the tissue injuries must be answered by the forensic pathologist. d. The forensic pathologist must alert himself of the possible inconsistencies between the apparent cause of death and his actual findings in the crime scene. e. A careful examination of the external surface for possible trauma including the clothings to determine the pattern of injuries in relation to the injurious agent. f. The autopsy report is written in a style that will make it easier for laymen to read and more clearly organized insofar as the mechanism of death is concerned. g. fhe professional and environmental climate of a forensic pathologist is with the courts, attorneys and police who make scrutiny of the findings and conclusion. The following Manner of Death should be Autopsied: a. Death by violence. b. Accidental death. c. Suicides. d. Sudden death of persons who are apparently in good health. e. Death unattended by physician. f. Death in hospitals or clinics (D.O.A.) wherein a physician was not able to arrive at a clinical diagnosis as the cause of death. g. Death occurring in an unnatural manner.

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LEGAL MEDICINE PROCEDURE OF AUTOPSY

Guidelines in the Performance of Autopsies: 1. Be it an official (medico-legal) or non-official autopsy, the pathologist must be properly guided by the purposes for which autopsy is to be performed. In so doing the purpose of such dissection will be served. 2. The autopsy must be /comprehensive and must not leave some parts of the body unexamined. Even if the findings are already sufficient to account for the death, these should not be a sufficient reason for the premature termination of the autopsy. The existence of a certain disease or injury does not exclude the possibility of another much more fatal disease or injury. The findings of coronary disease does not exclude the probability of injury or poisoning. 3. Bodies which are severely mutilated, decomposing or damaged by fire are still suitable for autopsy. No matter how putrid or fragmentary the remains are, careful examination may be productive of information that bears the identity and other physical trauma received. Frequently a pathologist's reluctance to perform an autopsy on decomposed body is due to the odor or vermin rather than to his belief that the examination would not be productive. 4. All autopsies must be performed in a manner which show respect of the dead body. Unnecessary dissection must be avoided. A wife consented to the performance of an autopsy but specifically stated that it must be performed in a "decent" manner. The autopsy was done in broad daylight in the cemetery in full view of all the neighborhood residents. Thetourt held that the condition was violated and she was awarded damage even though she has consented to the examination (Hill V. Travelers Ins. Co. 294 S.W. 1097, Tenn. 1927). 5. Proper identity of the deceased autopsied must be established in non-official autopsy. An autopsy on a wrong body may be a ground for damages. Two patients occupying adjoining beds died within a fiveminute interval. There was authorization to perform an autopsy on one of them but the nurse interchanged the tags. The deceased wherein there was no authorization given was autopsied. The next of kin brought an action against the hospital administrator, the pathologist and the coroner for unauthor-

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169

ized autopsy. The liability was made on the nurse who unfortunately was not made as one of the defendants (Schwalb v. Connely, 179p. 2d 667, Colo.). The award for damages for wrongful autopsy is not on account of the mutilation of the deceased body but for the injury to the feelings and mental suffering of the living because of the illegal act. After the death of the husband and without the consent of the wife, an autopsy was performed on the body of the deceased. The widow filed a suit for unlawful autopsy and failure to replace the brain, heart and organs. The court held that there is no justification for the autopsy and dismemberment and have injured the feelings of the widow. The sum of $1,000 was awarded as reasonable damages (Gould v. State of New York, 181 Misc. 884, 46 N. Y.S. 2d 313). 6. A dead body must riot be embalmed before the autopsy. The embalming fluid may render the tissue and blood unfit for toxicological analyses. The embalming may alter the gross appearance of the tissues or may result to a wide variety of artifacts that tend to destroy or obscure evidence. An embalmer who applied embalming fluid on a dead body which in its very nature is a victim of violence is liable for his wrongful act. 7. The body must be autopsied in the same condition when found at the crime scene. A delay in its performance may fail or modify the possible findings thereby not serving the best interest of justice. Precautions to be Observed in Making Medico-Legal Post-mortem Examination: 1. The physician must have all the necessary permit or authorization to perform such an examination. Such permit must be issued by the inquest officer. The absence of such authorization may hold the physician civilly and criminally liable. 2. The physician must have a detaUed'liistory of the previous symptoms and condition of deceased to be used as his guide in the post-mortem examination. 3. The true^fuentity of the deceased must be ascertained. If no one claims the body, a complete date to reveal his identity must be taken. 4. Examination must be made in a Well-lighted place and it is advisable that no unauthorized person should be present.

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5. All external findings must be properly described and if possible a sketch must be made or photograph must be taken to preserve the evidence. 6. All steps and findings in the examination must be recorded. Rules in the Examination: 1. Look before you cut. 2. Never cut unless you know exactly what you are cutting. 3. Weigh and measure everything that can be weighed or measured. Stages in the Post-mortem Examination of the Dead Body: 1. Preliminary Examination: a. Examination of the Surroundings (Crime Scene): Attention must be focused on the furniture; bullet holes on the ceiling, floor and walls; amount, color, shape and degree of spread of the blood stains, position of the wounding weapon; foot and fingerprints and hairs and clothes. b. Examination of the Clothings: Look for marks to establish identity, kind and quality of the garment, stains, grease, cut and "tear or other marks of resistance and violence. c. Identity of the Body: Determine the height, weight, color of the hair and eyes, complexion, condition and number of teeth, bodily deformity, scars and tattoo marks, clothings, dog tag and fingerprints. 2. External Examination: a. Examination of the Body Surfaces: Inspect the natural orifice of the body. All wounds must be described in detail, blood stains and foreign bodies. b. Determination of the Position and Approximate Time of Death: In this stage, the presence and degree of hypostasis, rigor mortis and putrefaction and color of the blood stain must be noted. Examination of the hands for the presence of cadaveric spasm and wounding weapon may be necessary for the proper solution of the crime. 3. Internal Examination: Examine all body orifices for blood and foreign bodies. Blood coming out of the nostrils may imply fracture on the base of the anterior cranial fossa. Hemorrhage of the ears may imply fracture of the middle cranial fossa.

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171

Advantages of Starting Autopsy on the Head: 1. If the autopsy starts on the chest or abdomen, excision of the organs will cause the blood content of the brain and the meninges to necessarily lose its original pattern; 2. There is the unavoidable contamination of the body associated with the autopsy, which prevents liable culturing of microorganisms from the cranial contents; 3. Manipulation of other blood vessels, specially at the neck may result in air bubbles' being artificially drawn into the cerebral vessels, impairing fair evaluation of air embolism that might have occurred during life (Forensic Medicine, Vol. 1, by Tedeschi, Eckert and Tedeschi, p. 35). A primary incision must be made from the suprasternal notch to the pubic symphysis passing to the left of the umbilicus. Cut the rectus abdominis muscle at several points to expose the abdominal cavity and flap the skin at the region of the chest from the primary incision to the lateral aspect of the chest exposing the ribs. Disarticulate the sterno-clavicular joint and cut the ribs medial to the costo-chondral junction. Remove the breast and begin examining the following: Abdominal and Chest Wall: Fat — Amount, color, moisture, fibrosis. Musculature — Development, color, thickness, atrophic changes. Peritoneal Cavity: — Amount, character, color, consisFluid tency, purulent or bloody material. — Amount of fat, extent, adhesions, Omentum blood distribution. — Level of the anterior border, adLiver hesions, blood distribution, color, fatty or atrophic changes. Chest Cavity: Fluid Adhesions Pleura Mediastinum Thymus

— Amount, color, character, consistency, purulent or bloody material. — Kind, extent, concommitant disease, distribution. — Luster, hemorrhage, disease. — Enlargement of the lymph nodes, tumor. — Weight, lobulation, fatty degeneration.

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See a tabulation regarding the weight of the thymus gland with respect to age. Open the pericardial sac and examine its contents, principally the heart. The normal pericardial fluid is from 5 cc. to 6 cc. and yellowish in color. Remove the heart by cutting the root of the blood vessels connected with it. Examine the heart on the following points: Weight Normal in men — 300 grams; women 250 grams. External — Size, shape, consistency, contraction or relaxation of the ventricle. —

— Adhesions, amount of fat, luster, petechial hemorrhages, milky patches. Cavities — Amount of blood, blood clots, emboli, dilatation. Tricuspid — 12 cm.; Measure of the Orifices — Normal: pulmonary — 8.0 cm.; mitral — 10.0 cm.; aortic — 7.0 om. Thickness of the Ventricle — Normal: left — 1.4 cm.; right — 0.4 cm. Endocardium — Ulceration, vegetation and sclerosis of the valves, mural endocardium, thrombi, cordae tendinae, trabec u l e , papillary muscles. Mottling (Tigroid heart). Myocardium — Color, consistency, resistance to section infraction, sclerosis, fibrosis edema. Coronary Vessels — Special attention must be made to the anterior branch of the left coronary artery, sclerosis, atheroma, embolism. Epicardium

Removed both lungs by cutting the region of the hilus. After examining the fluid or adhesions within the chest wall, the following points must be considered in the examination: Weight — Normal: right — 400 grams; left — 350 grams. External Examination — State of collapse, size, consistency, color, crepitation, consolidation, luster, exudate, anthracosis, petechiae, blood distribution.

MEDICO-LEGAL INVESTIGATION OF DEATH 1. Size: Larger Smaller 2. Shape: Congenital changes Acquired changes

3. Weight: Increased Diminished 4. Color: Grayish-red Slaty-black Bluish-red Light-brownish

173

— Emphysema, pneumonia, edema. — Compression, atelectasis. — Abnormal furrows, increased number of lobes. — Pleuritis deformans, retractions due to fibrosis in the lung itself, furrows corresponding to the first rib, partial enlargement due to localized emphysema, change due to adhesions. — Edema, inflammation, congestion, induration. — Emphysema. — Variation due to age, occupation, content of air and blood. — Anthracosis. — Atelectasis. — Hemosiderin brown induration.

5. Air content and consistency: Note the softness, crepitancy, and compressibility. Marked softness — Formation of cavity or postmortem decomposition. Firm consistency — Consolidation. Compressibility — Emphysema. Cut Surface — Color, condition of consolidation, amount of air and fluid exuding on pressure, bronchi, blood vessels. Bronchial Lymph Nodes — Enlargement, anthracosis, tuberculosis. Examine the mediastinum for enlargement of the lymph glands, hemorrhage, inflammatory conditions and other pathology. Abdominal Cavity: Go to the abdominal cavity and remove the spleen by pulling it and cutting the vessels at the region of the hilus. Examine the spleen on the following points: Weight — Very variable, approximately 150 grams.

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External Examination

— Size, color, consistency, thickness of the capsule, smoothness or wrinkling of the capsule. Cut Surface — Resistance to cutting, bulging of cut surface, color, prominence of the Malphigian corpuscles, and trabeculae, consistency of the pulp by scraping with sharp edge of knife. Separate the intestine by cutting the mesentery near its attachment with the intestine from the jejenum downward. Open the duodenum and verify the potency of the common bile duct. Separate the stomach, duodenum, and pancreas by cutting at the cardiac end of the stomach. Stomach Small Intestine

Large Intestine

Rectum

— Distention, shape, contents, condition of the mucosa, post-mortem changes. — Length, external appearance, contents, mucosa, lymphoid follicles and Peyer's patches, obstruction, Merkel's diverticulum, parasites. — Length, external appearance, contents, mesocolic glands, epiploic appendages, thickness of the walls, condition of the mucosa, inflammation, ulcerations, condition of the appendix, parasites. — New growth, hemorrhoid, dysenteric ulcers, fistulae.

The liver is removed by separating it from the diaphragm, but avoid cutting the suprarenal glands at the upper pole of the kidneys. The following points must be taken into consideration in the examination of the liver: Weight

External Examination

Cut Surface

Male — 1,400 grams; Female: 1,200 grams (Filipino). Size, color, consistency, sharpness of the edges, rib markings, scars, thickness of the capsule, lobulation, granulation. Resistance to cutting, amount of blood vessels, condition of the bile duct.

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Gall Bladder

— Adhesions, distention, color and consistency ^>f the bile, condition and staining of the mucosa, thickness and adhesions of the walls, concretion, obstruction of the cystic, hepatic and the common bile duct. The kidneys must be removed after the removal of the adrenals and examine them on the following points: — 120 to 150 grams. The left is Weight heavier than the right. — Perirenal tissue, size, shape and External Examination consistency, color, thickness and adherence of the capsule, external surface of the cortex, granulation, cyst, fetal lobulation, condition of the veins. — Condition of the cut edges (everted Cut Surface or not). Proportionate thickness of the cortex and the medulla (normal — 1.3), cortical striation, pyramidal striation. — Pelvic fat, stones, inflammatory Pelvis changes. — Obstruction, dilatation, inflamUreter matory changes. — Distention and contents, condition Bladder of the mucosa and trigonum, opening of the ureter. Genital Organs: Male

Remove the prostate and the seminal vesicle with the urinary bladder. The testicle and the epididymis is removed by pushing through the inguinal glands and opening the internal inguinal ring. Note the condition of the testicle, epididymis, seminal vesicle and prostate. Remove the uterus and its adnexa together with Female the upper portion of the vagina. — Corpus luteum, hydatid cyst, tumor. Ovary — Distention, hydrosalpinx, pyosalFallopian Tube pinx, hematosalpinx adhesions. — Resting, menstruating, gravid, inUterus voluting, atrophic, tumor.

LEGAL MEDICINE

176 Cardio-Vascular System: Aorta Veins

Sclerosis, atheroma, syphilis, aneurysm. Thrombosis, phlebitis.

Neck Organs: Remove the larynx, pharynx and tongue including the tonsils. The condition of the lymph glands, obstruction and edema of the glottis, foreign body and materials in the larynx and trachea, condition of the thyroid gland, and condition of the tongue and tonsils should be noted. Head: The scalp is incised from the mastoid process of one side passing the vertex to the mastoid process on the opposite side. The flaps are turned down to the back and to the front. Note the presence of hemorrhage, bruise, hematoma and fracture of the skull. Open the skull by sawing at the forehead above the eyebrow to the region of the upper portion of the ear and another vertically a little behind the vertex and meeting the horizontal cut at the region of the upper portion of the ear. Remove the flap of bone and note the condition of the meninges. Remove the brain after cutting it from its attachment and the tentorium cerebelli. Examine the brain for pathological condition, hemorrhage, laceration, softening, and the base and side of the cranial box for hemorrhage and fracture. Make several incisions on the brain and study the injury or disease. Examination of the Extremities: There is no technical incision for the extremities. Just open what is deemed necessary and appropriate for the occasion. Weight and Measure of the Organs Removed: The specimen which are collected for further study must be placed in clean jars and brought to the laboratory are: LjOrgans for toxicological examination. 2. Slices of organs for histopathologic^ study. (For a more detailed examination of post-mortem examination, consult any textbook on pathology.) AVERAGE MEASUREMENT OF INDIVIDUAL ORGANS HEART: Weight of heart

Male 300 gms.

Both

Female 250 gms.

MEDICO-LEGAL INVESTIGATION OF DEATH Relative weight of heart to body 1 to 169 Length of heart 8.5 — 9 Circumference of Mitral orifice 10.9 cms. Tricuspid orifice 12.7 cms. Aortic orifice 8.0 cms. Pulmonary orifice 9.2 cms. Pulmonary artery Circumference base of ventricle Thickness of the wall of Left ventricle Right ventricle

177 1 to 162 8-8.5 10.4 cms. 12.0 cms. 7.7 cms. 8.9 cms.

8.0 cms. 28.8 cms. 1.1 —1.4 cms. 0.5 — 0.7 cms.

SPLEEN: Weight of spleen Measurement

150 —250 gms. 12.0 x 4.5 x 3.0 cms.

PANCREAS: Weight of pancreas Measurement

90 — 120 gms. 23.0 x 4.5 x 2.8 cms.

LIVER: Weight Measurement Length from right to left Width of right lobe Vertical diameter of right lobe Vertical diameter of left lobe KIDNEYS: Male Weight Measurement Thickness of: Cortex Medulla Relation to body weight Relation to weight of heart OVARY: Weight BRAIN: Weight

1500 to 1800 gms. 25 — 32 cms. 18 — 20 cms. 20 — 22 cms. 15 —16 cms. Both 150 gms. 11 x 5 x 4.5 cms.

Female

4.6 cms. 1 — 3 cms. 1:200 1:1.1 7.0 gms.

1,358 gms.

1,234 gms.

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ADRENALS: Weight Measurement WEIGHT OF THYMUS: Newborn I - 55 years j 6 - l10 O years j I I - 115 5 3years 20 years 16 - 20 j 253years 21 - 25 353years 26 - 35 453years 36 - 45 553years 46 - 55 653years 56 - 65 6 6 - 775 5 3years

4.8 — 7.3 gms. 40 x 20 x 2 mms. Both 13.26 gms. 22.08 gms. 26.18 gms. 37.52 gms. 25.52 gms. 24.73 gms. 19.8 gms. 16.27 gms. 12.85 gms. 6.08 gms. 6.00 gms.

Mistakes in Autopsies: 1. Error or omission in the collection of evidence for identification: a. Failure to make frontal, oblique and profile photographs of the face; b. Failure to have fingerprints made; c. Failure to have a complete dental examination performed. 2. Errors or omission in the collection of evidence required for establishing the time of death: a. Failure to report the rectal temperature of the body; b. Failure to observe changes that may occur in the intensity and distribution of rigor mortis — before, during and after autopsy. c. Failure to observe the ingredients of the last meal and its location in the alimentary tract. 3. Errors or omission in the collection of evidence required for other medico-legal examination: a. Failure to collect specimens of blood and brain for determination of the contents of alcohol and barbiturates; b. Failure to determine the blood group of the dead person if death by violence was associated with external bleeding; c. Failure to collect nail scrapings and samples of hair if there is reasonable chance that death resulted from assault. d. Failure to search for seminal fluid if there is a reasonable chance that the fatal injuries occurred incident to a sexual crime; e. Failure to examine clothings, skin and the superficial portion of the bullet tract for residue of powder, and the failure to

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179

collect samples of any residue for the purpose of chemical identification; f. Failure to use an X-ray for locating a bullet or fragments of bullet if there is any doubt with regard to their presence and location; g. Failure to protect bullet from defacement, such as is likely to occur if they are handled with metal instruments. h. Failure to collect separate specimens of blood from the right and left sides of the heart in instances in which the body was recovered from water. i. Failure to strip the dura mater from the calvaria and base of the skull. Many fractures of the skull have been missed because the pathologist did not expose the surface of the fractured bone. 4. Errors or omission result in the production of undesirable artifacts or in the destruction of valid evidence: a. Opening of the skull before blood is permitted to drain from the superior vena cava. If the head is opened before the blood drained from it, blood will almost invariably escape into the subdural and subarachnoidal space, and such an observation may then be interpreted as evidence of ante-mortem hemorrhage. b. The use of a hammer and chisel for opening the skull. A hammer and chisel should never be used for the purpose in a medico-legal autopsy. Fracture produced by the chisel are frequently confused with ante-mortem. c. Failure to open the thorax under water if one wishes to obtain evidence of pneumothorax. d. Failure to tie the great vessels between sites of transection and the heart when air embolism is suspected. e. Failure to open the right ventricle of the heart and the pulmonary artery in situ if pulmonary thrombo-embolism is suspected. f. Failure to remove the uterus, vagina and vulva en masse if rape or abortion is suspected. (From the American Journal of Forensic Medicine and Pathology, Vol. 2, No. 4 (Dec. 1981) p. 306). Negative Autopsies — An autopsy is called a negative autopsy if after all efforts, including gross and microscopic studies and toxicological analyses, fail to reveal a cause of death. It is an autopsy which after a meticulous examination with the aid of other examinations does not yield any definite cause of death.

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There are reports that approximately 2 to 10% of the total autopsy cases in medico-legal centers yield a negative result although theoretically there must be a cause of death. Negligent Autopsy — An autopsy wherein no cause of death is found on account of imprudence, negligence, lack of skill or lack of foresight of the examiner. The act or omission which may be inadvertent or deliberate may be: 1. Failure to have an adequate history or facts and circumstances surrounding the death. Special circumstances surrounding death may require special autopsy techniques which the pathologist may fail to do during the autopsy. Air embolism, drug reaction, vagal inhibition may be left unnoticed because of absence of history. 2. Failure to make a thorough external examination — Animal bites, injection marks, electrical necrosis may be overlooked in a hasty external examination. 3. Inadequate or improper internal examinations — Condition of the organs, presence of air in pneumothorax or bubbles of air in the circulatory system may remain unnoticed by the pathologist. 4. Improper histological examination — Tissue blocks may not be taken in the proper areas, poor preparation of the microscopic slides and improper lighting during the process of examination may lead to an erroneous interpretation. 5. Lack of toxicological or other laboratory aids — A qualitative and quantitative determination of toxic materials or its metabolites must be shown. Sometimes difficulty is encountered by the forensic chemist because of the lapse of time and rapid elimination of the drug. 6. Pathologist incompetence — The examiner must have had vast experience in autopsy investigation and must have the capacity to distinguish pathological changes in the body tissues. (Handbook of Forensic Pathology by Abdullah Fatteh, pp. 254255). Religious Objections to Autopsies: There is no place in the Bible, in the Talmudic or Post-Talmud ic writings, is there evidence that post-mortem examination is prohibited. According to traditional interpretation, which is not necessarily accepted by all Jewish groups, autopsies and transplantation of organs are permitted only in those cases where the decendants gave consent.

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181

There is no definite statement by the Catholic Church which can be construed as prohibiting autopsies. Autopsies have been encouraged when it appeared that benefit would accrue from them. Similarly, there appears to be nothing in the writings of the Protestant clergy to point to the prohibition of autopsies.

Chapter VI

nation of the cause of death. It must further be shown that the death is the direct and proximate consequence of the criminal or negligent act of someone. If death developed independent of an unlawful act, then the person who committed the unlawful act cannot be held responsible for the death. However, there are some post-mortem findings of a physician which may be useful in the proper adjudication of the case. The presence of defense wounds on the victim may qualify the crime to homicide. The presence of serration or series of cuts in the borders of a stab wound may infer multiple thrusts of the wounding instrument and show the manifest intent of the offender to kill. The cause of death is the injury, disease or the combination of both injury and disease responsible for initiating the trend or physiological disturbance, brief or prolonged, which produce the fatal termination. It may be immediate or proximate. Cause of Death — This applies to cases when trauma or disease kill quickly that there is no opportunity for sequelae or complications to develop. An extensive brain laceration as a result of a vehicular accident is an example of immediate cause of death. 2/The Proximate (Secondary) Cause of Death — The injury or disease was survived for a sufficiently prolonged interval which permitted the development of serious sequelae which actually caused the death. If a stab wound in the abdomen later caused generalized peritonitis, then peritonitis is the proximate cause of death. The mechanism of death is the physiologic derangement or biochemical disturbance incompatible with life which is initiated by the cause of death. It may be hemorrhagic shock, metabolic disturbance, respiratory depression, toxemic condition, cardiac arrest, tamponade, etc. Cardiorespiratory arrest is a terminal mechanism of most causes of death and can never stand independently as a reasonable explanation for the fatality. The cause of such arrest must be stated,

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like hemorrhage, skull fracture, sepsis, trauma on the chest, etc. to make it valid as specific cause of death. The manner of death is the explanation as to how the cause of death came into being or how the cause of death arose. The manner of death may be natural or violent. V.Natural Death — It is natural when the fatality is caused solely by disease (lobar pneumonia, ruptured tubal pregnancy, cancerous growth, cerebral hemorrhage due to hypertension, etc.). 2/violent or Unnatural Death — Death due to injury of any sort (gunshot, stab, fracture, traumatic shock, etc.). A physician must not include in the consideration of the manner of death that such violent death is suicidal, accidental or homicidal. Such conclusion cannot be determined in the post-mortem examination. It requires a thorough investigation of all possible clues in which medico-legal findings are only a part of. Medico-legal masquerade — Violent deaths may be accompanied by minimal or no external evidence of injury or natural death where signs of violence may be present. In a case of homicide, the medical findings may tend to favor suicide or accidental death, and visa versa. Cases of such nature infer that the medical examination and police investigation is far from being complete. There is a need for further investigation and evaluation to unravel the truth. Degree of Certainty to the Cause of Death: 1. When the structural abnormalities established beyond doubt the identity of the cause of death (Ex.: Intracerebral spontaneous hemorrhage, stab wound with profuse hemorrhage, crushing head injury in vehicular accident, etc.). 2. When there is that degree of probability amounting to almost certainty the cause of death. (Ex.: Lobar pneumonia, electrical shock). 3. When the cause of death is established primarily by historical facts which are confirmed or supported by positive or negative anatomic or chemical findings (Ex.: Tetanus, hydrophobia, drug reaction). 4. When neither history, laboratory and anatomic findings, taken individually or in combination is sufficient to determine the cause of deathr.but merely speculate as to the cause of death (Ex.: Crib death among infants, Iatrogenic diseases). Use of the Term "Probably": As much as possible the use of the term "probably" as a qualification to a cause of death must be discouraged inasmuch as it is

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not definite. In the prosecution of a criminal case if the resulting cause of death is merely a probable consequence of a criminal act, such situation will fall short of "proof beyond reasonable doubt" and may lead to the acquital of the accused. If sometime after painstaking effortB the examiner cannot ascribe a definite cause of death on the body lesions found, the use of the "probably" in the cause of death may be tolerated. Steps in the Intellectual Process in the Determination of the Cause of Death: 1. Recognition of the structural organic changes or chemical abnormalities responsible for cessation of vital functions. 2. Understanding and exposition of the mechanism by which the anatomic and other deviations from normal actually caused the death, or how the deviation created or initiated the train of sufficiently potent functional disturbance which led ultimately either to cardiac standstill or to respiratory arrest. (The Pathology of Homicide by Lester Adelson (1974) p. 15). Instantaneous Physiologic Death (Death from Inhibition, Death from Primary Shock, Syncope with Instantaneous Exitus): This is sudden death which occurs within seconds or a minute or two (no more) after a minor trauma or peripheral stimulation of relatively simple and ordinarily innocuous nature. The peripheral irritation or stimulation initiates the cardio-vascular inhibitory reflex. The fulminant circulatory failure is caused by (vagocardiac) slowing or stoppage of the heart, reflex dilatation with profound fall in blood pressure or a combination of both mechanisms. A blow to the larynx or solar plexus, a kick in the scrotum, pressure on the carotid sinus, etc. can cause such death. Death by inhibition can be made only by exclusion and is completely dependent on the availability of accurate information. After serious natural disease has been eliminated by autopsy and toxicological analyses are noncontributory, then only the physiologic death may be entertained (Medico-legal Investigation of Death by Werner Spitz and Russel Fisherm, p. 93). Among the diseases wherein there are no specific finding, pathognomic of a disease still determined are: 1. Sudden Infant Death Syndrome (Crib Death) — This is the unexpected death of infants, usually under six months of age, while in apparently good health. The sudden death cannot be predicted and there is no way to prevent or foretell on the basis of present knowledge. Although autopsies in some of the cases revealed the

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presence of congenital heart disease or abnormality, contagious disease, nutritional deficiency and other pathological conditions, no consensus has yet been arrived at as to the definite cause of death. /2. Sudden Unexplained Nocturnal Death (SUND) — This is known as "pok-kuri" disease in Japan and "bangungut" in the Philippines. It is the sudden death of healthy men of young age seen in East Asian countries. Awareness of relatives and the prompt delivery of resuscitation are the only effective means of treatment. The term Dead on Arrival (DOA) must not be construed literally. It may mean that the patient was actually dead on arrival or was dying on arrival. Death occurs on a precise time while dying is a continuing process. If a patient is dead then the procedure of management is resuscitative or to let him return to life again, while if the patient is dying, the procedure is to apply emergency measures to prevent death from ensuing. DOA may be placed in the item "cause of death" in the death certificate even if the patient has stayed alive in the hospital or clinic for sometime provided the attending physician had not been given ample opportunity to arrive at a working diagnosis as to the cause of death. The working diagnosis need not be precise and exacting. It is sufficient that there are some bases to such conclusions. If the attending physician cannot determine the cause of death, it will be much more appropriate to place under "Cause of Death" in the Death Certificate "undetermined" rather than DOA. It is more responsive to the purpose why such item is included in the certificate. MEDICO-LEGAL CLASSIFICATION OF THE CAUSES OF DEATH: a. Natural Death. b. Violent Death: (1) Accidental death. (2) Negligent death. (3) Infanticidal death. (4) Parricidal death. (5) Murder. (6) Homicidal death. Natural Death: This is death caused by a natural disease condition in the body. The disease may develop spontaneously or it might have been a consequence of physical injury inflicted prior to its development. If a natural disease developed without the

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LEGAL MEDICINE intervention of the felonious acts of another person, no one can be held responsible for the death. "Sudden death" is the termination of life which comes quickly under circumstances when its arrival is not expected. It may be due to natural or violent cause. Heart diseases and cerebral apoplexy are the most common causes of deaths due to natural causes, while poisoning, asphyxia and severe trauma are frequent causes of violent death. The natural death may or may not be associated with violence. Although the history and external findings may show that death is due to natural cause, a complete autopsy must be made to determine exactly the cause of death and exclude the possibility of violent cause. If signs of violence are associated with the natural cause of death, the physician must be able to answer the following questions: Did the Person Die of a Natural Cause and were the Physical Injuries Inflicted Immediately After Death ? If violence was applied on a dead person, the person inflicting the physical injuries cannot be guilty of murder, homicide or parricide. The act is considered to be an impossible crime and is penalized as such. In order that it may be considered an impossible crime, the person inflicting the physical injuries must have no knowledge that the victim is already dead at the time of infliction. Criminal liability shall be incurred by any person who performs an act which would be an offense against persons and property, were it not for the inherent impossibility of its accomplishment. . . (Art. 4, No. 2, Revised Penal Code). The court having in mind the social danger and the degree of criminality shown by the offender shall impose upon him the penalty of arresto mayor or a fine ranging from 200 to 500 pesos. (Art. 59, Revised Penal Code). "A" has a grudge and wanted to kill "B". One night "A" entered the bedroom of "B", and without knowing that "B" died of heart failure an hour ago, inflicted several stab wounds on " B " "A" cannot be held liable for murder because it is an impossible crime. " B " was already dead when the stab wounds were inflicted. However, the law still imposes penalty for such act depending upon the degree of criminality and social danger of the offender (Art. 59, Revised Penal Code).

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Was the Victim Suffering from a Natural Disease and the Violence Only Accelerate the Death ? If the violence inflicted on a person suffering from a natural disease only accelerated the death of the victim, the offender inflicting such violence is responsible for the death of the victim. It is immaterial as to whether the offender has no intention of killing the victim. The fact that the victim died, the offender must be held responsible to whatever be the consequence of his wrongful act. Criminal liability shall be incurred by any person committing a felony although the wrongful act done be different from which he intended (Art. 4, No. 1, Revised Penal Code). Example: "A" gave a blow in the abdomen of "R". Unfortunately " B " died of severe abdominal hemorrhage due to the traumatic rupture of the liver which was severely diseased. "A" is liable for the death of "B", even if "A" has no intention to kill "B". "A" must be held liable for consequences of his felonious act. However, he may avail himself of the mitigating circumstance that he had no intention to commit so grave a wrong as that committed (Art. 13, Revised Penal Code). A blow with a fist or a kick, although it did not produce external injuries but inflammation of the spleen and peritonitis and although the victim was previously affected with the disease, the accused must be responsible for the death because he accelerated the time of death by his voluntary and unlawful act (U.S. v. Rodriguez, 23 Phil. 22). The deceased was suffering from tuberculosis. The accused gave fist blows in the hypochondriac region which caused bruising of the liver, followed by internal hemorrhage and death. The accused is liable for homicide (People v. Ilustre, 54, Phil. 544). Did the Victim Die of a Natural Cause Independent of the Violence Inflicted? If a person died of a natural cause and the physical injuries inflicted is independent of the cause of death, the accused will not be responsible for the death but merely for the physical injuries he had inflicted. Example: "A" and "B" are sweethearts. "A" at the fit of anger slapped " B " in the face. "B" is suffering from severe heart

LEGAL MEDICINE disease. After the slapping, " B " died of heart failure. "A" cannot be held responsible for the death of "B". He can only be held for slight physical injury brought about by the slapping. The defendant struck a boy with the back of his hand on the mouth. Although the mouth was bleeding, he was able to work. A few days later, he developed fever and died. The court believed that the fever which caused the death was not the direct consequence of the injury inflicted. It was not denied that malaria fever was prevalent in the locality, so it was quite probable that the death was due to a natural cause. The defendant was acquitted (U.S. v. Palaton, 49 Phil. 117). To make the offender liable for the death of the victim, it must be proven that the death is the natural consequence of the physical injuries inflicted. If the physical injuries is not the proximate- cause of death of the victim, then the offender cannot be held liable for such death. Proximate cause is that cause, which in natural and continuous sequence, unbroken by an efficient intervening cause, produces injury or death, and without which the result would not have occurred. So in natural death with concomitant physical injuries, it is necessary for the physician to determine whether the physical injuries would accelerate the death, or the injuries itself developed independently and produced the death or that the person died absolutely of a natural cause. A physician must determine for the interest of justice with absolute care at autopsy and laboratory examination the real cause of death. Opinion evidence must be given with caution and must be made after a thorough deliberation of the facts and other findings. The Following are Deaths Due to Natural Cause: (1) Affection of the central nervous system: (a) Cerebral Apoplexy: The sudden loss of consciousness followed by paralysis or death due to hemorrhage from thrombosis or embolism in the cerebral vessels. i. Cerebral Hemorrhage: This is brought about by the breaking or rupture of the blood vessels inside the cranial cavity. ii. Cerebral Embolism: This is the blocking of the cerebral blood vessels by bolus or matters in the circulation.

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iii. Cerebral Thrombosis: This is the occlusion of the lumen of the cerebral vessels by the gradual thickening of its wall thereby preventing the flow of blood peripheral to it. (b) Abscess of the Brain: A circumscribed accumulation of infective materials in certain areas of the brain. It may produce coma or death when it ruptures or when it produces acute edema of the brain. (c) Meningitis of the Fulminant Type: There is inflammation of the covering membranes of the brain due to infection or some other causes. (2) Affection of the Circulatory System: (a) Occlusion of the Coronary Vessels: The occlusion may be due to embolism, thrombosis or stenosis of the coronary openings. This is the most common cause of sudden death due to natural cause. (b) Fatty or Myocardial Degeneration of the Heart: The heart muscles may gradually degenerate and replaced by fatty or fibrous tissues such that extra strain put on the heart may produce sudden heart failure. (c) Rupture of the Aneurysm of the Aorta. (d) Valvular Heart Diseases: The valves of the heart may be diseased either to become insufficient or stenotic and may produce sudden death. (e) Rupture of the Heart: This is found in severe cardiac dilatation with fibrosis of the myocardium. (3) Affections of the Respiratory System: (a) Acute edema of the larynx: This may develop from acute infection or from swallowing irritant substance. (b) Tumor of the larynx. (c) Diphtheria. (d) Edema of the lungs. (e) Pulmonary embolism. (f) Lobar pneumonia. (g) Pulmonary hemorrhage: Severe coughing or slight exertion may rupture a normal or diseased pulmonary vessel causing severe hemorrhage.

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LEGAL MEDICINE (4) Affection of the Gastro-Intestinal Tract: (a) Ruptured peptic ulcer. (b) Acute intestinal obstruction. (5) Affections of the Genito-Urinary Tract: (a) Acute strangulated hernia. (b) Ruptured tubal pregnancy. (c) Ovarian cyst with twisted pedicle. (6) Affection of the Glands: (a) Status thymico-lymphaticus: This is a condition associated with the enlargement of the thymus and hyperplasia of the lymphoid tissues in general. (b) Acute Hemorrhagic Pancreatitis: An acute inflammation of the pancreas accompanied with hemorrhages and in some cases suppuration and gangrene. (7) Sudden Death in Young Children: (a) Bronchitis. (b) Congestion of the lungs. (c) Acute broncho-pneumonia. (d) Acute gastro-enteritis. (e) Convulsion. , (f) Spasm of the larynx. Violent Death: Violent deaths are those due to injuries inflicted in the body by some forms of outside force. The physical injury must be the proximate cause of death. The death of the victim is presumed to be natural consequence of the physical injuries inflicted, when the following facts are established: (1) That the victim at the time the physical injuries were inflicted was in normal health. (2) That the death may be expected from physical injuries inflicted. (3) That death ensued within a reasonable time (People v. Datu Baginda, C.A. 44 O.G. 2287). Classification of Trauma or Injuries: (1) Physical injury — Trauma sustained thru the use of physical force. (2) Thermal injury — Injury caused by heat or cold. (3) Electrical injury — Injury due to electrical energy.

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(4) Atmospheric injury — Those due to the change of atmospheric pressure. (5) Chemical injury — Those caused by chemicals. (6) Radiation injury — Those brought about by radiation. (7) Infection — Those caused by microbic invasion. In violent death, the death of the victim is not due to the natural and direct consequence of the injuries inflicted. If there is an intervening cause other than the physical injuries, then the offender cannot be held liable for the death of the patient. Refusal of the victim to submit to a surgical operation do not relieve the accused from the natural and ordinary result of the felonious act and does not relieve him of his criminal liability (U.S. v. Marasigan, 27 Phil. 504). The presence of infection on the wounds inflicted if not deliberately induced by the victim makes the offender also responsible for it (People v. Red, C.A. 43 O.G. 5072). The accused inflicted physical injuries to the victim. While the victim was undergoing medical treatment, he removed the drainage from his wound and as a result of which he died of peritonitis. The defense made by the offender is that the deceased could not have died had he not removed the drainage. HELD: Death was the natural consequence of the mortal wound. The victim in removing the drainage from his wound did not appear as acting voluntarily and with knowledge that he was performing an act prejudicial to his health (People v. Quiamon, 62 Phil. 162). Penal Classification of Violent Deaths: (^Accidental Death: Death due to misadventure or accident. An accident is something that happens outside the sway of our will, and although it comes about through some act of will, lies beyond bounds of human forseeable consequences. In a pure accidental death, the person who causes the death is exempted from criminal liability. Art. 12, No. 4, Revised Penal Code: Exempting Circumstances: The following are exempt from criminal liability: 4. Any person who, while performing a lawful act with due care, causes an injury by mere accident without fault or intention of causing it.

LEGAL MEDICINE Elements of the Provision: (a) A person is performing a lawful act. (b) He performed it with due care. (c) He caused injury to another by mere accident. (d) He is without fault and with no intention of causing it. Example: A patient died a few minutes after the administration of penicillin by injection. The physician took the history from the patient as to the presence of allergic diseases, made the necessary tests and took other necessary precautions to prevent any untoward reaction. The physician cannot be held liable for the death of the patient because it is purely accidental. A driver who, while driving his automobile on the proper side of the road at a moderate speed and with due diligence, suddenly and unexpectedly sees a man in front of his vehicle coming from the sidewalk and crossing the street without any warning that he would do so, but because it is not physically possible to avoid hitting him, the said driver runs over the man. He is not criminally liable, it being a mere accident (U.S. v. Tayongtong, 21 Phil. 476, cited by L. Reyes). The accused was a driver of a loaded truck. While driving at a curve the front tire exploded and as a consequence of which the truck fell in a ditch and pinned one of the passengers. The tire, engine, brake and wheel were in good condition before the incident. HELD: There being no proof of excessive speed, the accident under consideration caused by the blow-out of the tire cannot give rise to liability of the driver (People v. Hatton (C.A.) 49 O.G. 1866). The accused while hunting saw wild chickens and fired a shot. He heard a human being cry and found that the victim was hit. There was no evidence of the intention of the accused to kill the deceased. HELD: If life is taken by misfortune while the actor is in the performance of a lawful act executed with due care and without intention of doing harm, there is no criminal liability (U.S. v. Tanedo, 15 Phtf 196). (2yNegligent Death: Death due to reckless imprudence, negligence, lack of skill or lack of foresight.'

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The Revised Penal Code provides that felonies may be committed when the wrongful act results from imprudence, negligence, lack or foresight or lack of skill. If death occurred due to the recklessness of someone, he may be charged for homicide through reckless imprudence. Example: A surgeon while performing a laparotomy to arrest bleeding, left foreign bodies (forcep or gauze) inside the abdominal cavity and as a result of which the patient died. The surgeon is liable for homicide through reckless imprudence. A physician is equally liable for the same offense if the untoward effects of the administration of drug administered is due to the want of the necessary precautionary measures in the administration of the drug. If a person does an act and death of the victim is a plain foreseeable consequence, then it is not accidental but homicidal through simple negligence or reckless imprudence. The defendant fired a shot on the ground to pacify a quarrel. The bullet ricochetted and hit a bystander who died thereafter. The defendant is guilty of homicide though reckless imprudence. It is apparent that he did not exercise precautionary measures, considering that the place is populated and there is likelihood to hit the bystander (People v. Nocum, 77 PhU. 1018). (^Suicidal Death (Destruction of One's Self): The law does not punish the person committing suicide because society has always considered a person who attempts to kill himself as an unfortunate being, a wretched person deserving more of pity than of penalty. But, a person who gives assistance to the commission of suicide of another is punishable because he has no right to destroy or assist in the destruction of the life of another. Art. 253, Revised Penal Code: Giving assistance to suicide: Any person who shall assist another to commit suicide shall suffer the penalty of prision mayor; if such person lends his assistance to another to the extent of doing the killing himself, he shall suffer the penalty of reclusion temporal. However, if the suicide is not consummated

LEGAL MEDICINE the penalty of arresto mayor in its medium and maximum periods shall be imposed. Acts Punishable in Giving Assistance to Suicide: (a) The offender assisted in the commission of suicide of another which was consummated. (b) The offender gave assistance in the commission of suicide to the extent of d6ing the killing himself which is consummated. (c) The offender assisted another in the commission of suicide which is not consummated. (4fParricidal Death (Killing of One's Relative): Art. 246, Revised Penal Code: Parricide: Any person who shall kill his father, mother, or child, whether legitimate or illegitimate, or any of his ascendants or descendants, or his spouse, shall be guilty of parricide and be punished by the penalty of reclusion perpetua to death. Requisites of the Crime: (a) A person was killed by the offender. (b) The person killed was the father, mother, or child, whether legitimate or illegitimate in relation with the offender, or other legitimate ascendants, or descendants or spouse of the offender. The father, mother or child killed must either be legitimate or illegitimate to make it parricide, so that the killing of one's illegitimate father is parricide. But, insofar as with the other ascendants or descendants or spouse, it must be legitimate to make it parricide. Thus, the killing of a common-law wife or one's illegitimate grandfather is not parricide. A moro who has three wives and killed the last married to him cannot be guilty of parricide (People v. Subano, 73 Phil. 692). A stranger who cooperated and took part in the commission of the crime of parricide is not guilty of parricide but only of homicide or murder as the case may be J (People v. Patricio, 46 Phil. 875). (Sr) Infanticidal Death (Killing of a child less than three days old): Art. 265, Revised Penal Code:

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Infanticide: The penalty provided for parricide in article 246 and for murder in article 248 shall be imposed upon any person who shall kill any child less than three days of age. If the crime penalized in this article be committed by the mother of the child for the purpose of concealing for dishonor, she shall suffer the penalty of prision correccional in its medium and maximum periods, and if said crime be committed for the same purpose by the maternal grandparents or either of them, the penalty shall be prision mayor. Requisites of the Crime: (a) A person was killed. (b) The person killed was a child less than three days old. The penalty to be imposed depends upon the killer of the child. If the killer is the father, mother or any of the legitimate ascendants, the penalty corresponding to parricide shall be imposed. If the killing is made by any other persons, the penalty for murder shall be imposed. There is no medical explanation why three days is made to distinguish infanticide from murder and parricide. Concealment of the dishonor is not an element of the crime but only mitigates penalty. So that if the mother or the maternal grandparents killed the child to conceal the dishonor the penalty for parricide is not imposed but only that jone provided in the second paragraph of Art. 255. (6TMurder: Art. 248, Revised Penal Code: Murder: Any person who, not falling within the provisions of article 246 shall kill another, shall be guilty of murder and shall be punished by reclusion temporal in its maximum period of death, if committed with any of the following circumstances: 1. With treachery, taking advantage of superior strength, with the aid of armed men, or employing means to weaken the defense or of means or persons to insure or afford impunity. 2. In consideration of a price, reward or promise. 3. By means of inundation, fire, poison, explosion, shipwreck, stranding of a vessel, derailment or assault

LEGAL MEDICINE upon a street car or locomotive, fall of an airship, by means of motor vehicles, or with the use of any other means involving great waste and ruin; 4. On occasion of any of calamities enumerated in the preceding paragraph, or of an earthquake, eruption of a volcano, destructive cyclone, epidemic, or any other public calamity; 5. With evident premeditation; 6. With cruelty, by deliberately inhumanly augmenting the suffering of the victim, or outraging or scoffing at his person or corpse. Requisites for the Crime of Murder: (a) The offender killed the victim; (b) The killing is attended by any of the qualifying circumstances mentioned; (c) There was the intent of the offender to kill the victim; (d) The killing is not parricide or infanticide. Whenever the killing is attended by more than one of the qualifying circumstances mentioned, only one of them will make the killing, murder and the rest will be considered as generic aggravating circumstances. The presence of several wounds inflicted by the offender prove murder because there is cruelty if the victim is alive, or scoffing or outraging at the corpse if inflicted after death. The presence of gunshot wound of entrance at the back as a general rule qualifies act to murder because there was treachery, i There is treachery when the offender commits any of the crimes against person, employing means, or method, or form in its execution thereof which tend directly or specially to insure its execution, without risk to himself arising from the defense which the offended party may make (Art. 14, Par. 16, Revised Penal Code). Death: Art. 249, Revised Penal Code: Homicide: Any person who, not falling within the provisions of article 246 shall kill another without the attendance of any of the circumstances enumerated in the next preceding article, shall be deemed guilty of homicide and be punished by reclusion temporal.

(7-Hlomicidal

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Requisites of the Crime of Homicide: (a) The victim of a criminal assault was killed; (b) The offender killed the victim without any justification; (c) There is the intention on the part of the offender to kill the victim and such presumption can be inferred from the death of the victim; (d) That the killing does not fall under the definition of the crime of murder, parricide or infanticide. If a pharmccist wrongly compound a prescription correctly prescribed by the physician and lethal dose of poisonous drugs were included and as a result of which the patient almost died, the crime committed is physicial injuries through reckless imprudence. It cannot be frustrated homicide through reckless imprudence because of the absence of intent to kill by the pharmacist (People v. Castillo, 76 Phil. 72). Frustrated homicide is distinguished from physical injuries in that in the commission of the latter there is no intent to kill. Death under Special Circumstances: (1) Death Caused in a Tumultuous Affray: Art. 251, Revised Penal Code: When while several persons, not composing groups organized for the common purpose of assaulting and attacking each other reciprocally, quarrel and assault each other in a confused and tumultuous manner, and in the course of affray someone is killed, and it cannot be ascertained who actually killed the deceased, but the person or persons who inflicted serious physical injuries can be identified, such person or persons shall be punished by prision mayor. If it cannot be determined who inflicted the serious physical injuries on the deceased, the penalty of prision correccional in its medium and maximum periods shall be imposed upon all those who shall have used violence upon the person of the victim. Requisites of the Crime: (a) The person was killed in a confused or tumultuous affray; (b) That the actual killer is not known; and (c) That the person or persons who inflicted the serious physical injuries or violence are known.

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(2) Death or Physical Injuries Inflicted under Exceptional Circumstances: Art. 247, Revised Penal Code: Any legally married person who, having surprised his spouse in the act of committing sexual intercourse with another person, shall kill any of them or both of them in the act or immediately thereafter, or shall inflict upon them any serious physical injury, shall suffer the penalty of de8tierro.

If he shall inflict upon them physical injuries of any other kind, he shall be exempt from punishment. These rules shall be applicable, under the same circumstances, to parents with respect to their daughters under eighteen years of age, and their seducers, while the daughters are living with their parents. Any person who shall promote or facilitate the prostitution of his wife or daughter, or shall otherwise have consented to the infidelity of the other spouse shall not be entitled to the benefits of this article. Requisites of the Crime: (a) Surprise of the spouse: i. There must be valid marriage. ii. That the guilty spouse was caught by surprise in the act of committing sexual intercourse with another person. iii. That the killing or the injury was inflicted to either or both at the very act or immediately thereafter. (b) Surprise of a daughter: i. The daughter is below 18 years of age. ii. The daughter is living with the parents. iii. The parents caught her by surprise committing sexual intercourse with the seducer. iv. The killing was done at the very act of sexual intercourse or immediately thereafter. 2. PATHOLOGICAL CLASSIFICATION OF THE CAUSES OF DEATH: An analysis of all deaths from natural causes will ultimately lead to the failure of the heart, lungs, and the brain, so that death due to pathological lesions may be classified into: a. Death from Syncope b. Death from Asphyxia c. Death from Coma.

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All of the above mentioned conditions invariably produce the so-called sudden death. Sudden death is the termination of life which comes quickly when it is not expected. a. Death from Syncope: This is death due to sudden and fatal cessation of the action of the heart with circulation included. , Causes of Death from Syncope: (1) Coronary disease, as embolism or thrombosis. (2) Rupture of the heart through softened infarct. ( 3 ) Myocardial degeneration. (4) Valvular diseases. (5) Rupture of the aortic and other aneurysm. (6) Systemic embolism occurring in bacterial endocarditis. ( 7 ) Congenital heart diseases of the newborn. (8) Reflex inhibition of the heart or of the cardiac center, as in shock, emotion or blow over the area of some of the sensory nerve. ( 9 ) Arterial hypertension with sclerosis. (10) Deficiency cf blood as in profused hemorrhage, especially if sudden. (11) Exhaustive diseases. (12) Extensive injury to the body from mechanical cause. Symptoms of Syncope: (1) Person falls and remains motionless. (2) Face is pale. ( 3 ) Pulse at the wrist disappears or is filiform. ( 4 ) Respiration ceases. In non-fatal cases, consciousness returns in a few second, but in fatal ones, the following other symptoms appear: (5) Person breaks out into cold sweat. (6) Dimness of vision. ( 7 ) Pulse rapid and filiform. ( 8 ) There may be vomiting and involuntary movement of the limbs. ( 9 ) The person may be passing into the state of delirium. (10) Death may be preceded by convulsion. b. Death from Asphyxia: Asphyxia is a condition in which the supply of oxygen to the blood or to the tissues or to both has been reduced below normal working level.

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LEGAL MEDICINE Gauges of Death from Asphyxia: (1) Diseases of the respiratory system, as pneumonia, acute bronchitis, bronchitis in infancy, rupture of the blood vessels in pulmonary tuberculosis with cavitation. (2) Impaction of foreign bodies in the larynx. (3) Compression of the larynx. (4) Pressure on the respiratory tract due to tumor, or intracranial hemorrhage. (5) Strangulation, suffocation, hanging, drowning, inhalation or irritant gases. (6) Refraction of the atmosphere. (7) Causes operating in the nervous system: (a) Paralysis of the respiratory muscles or respiratory center from injury or disease or action of poison. (b) Fixation of the respiratory muscles from over stimulation of the spinal cord as in strychnine poisoning. (8) Causes operating from the lung or pulmonary circulation: (a) Pleurisy with effusion. (b) Emphysema. (c) Pulmonary embolism. (d) Pulmonary thrombosis. Symptoms of Asphyxia: (1) Stage of Increasing Dyspnea : This stage usually lasts from 1/2 to 1 minute: (a) Increased rate and depth of respiration, leading to difficulty of breathing (dyspnea). (b) Exaggerated movement of inspiratory muscles soon replaced by exaggerated expiration. (c) Rise of blood pressure, consequently the heart beat becomes quicker and more forcible. (d) Person becomes bluish and consciousness is lost. (e) Pupils are contracted. (2) Stage of Expiratory Convulsion: (a) This stage lasts for about a minute: i. Marked expiratory effort. ii. Convulsive movement of the limbs accompanied by expiratory effort. iii. Blood pressure gradually lowers owing to the failure of the heart due to lack of oxygen.

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(3) Stage of Exhaustion: This stage lasts for about three minutes. The person lies still except for occasional deep inspiration. Blood pressure falls and pupils are dilated. Post-mortem Findings in Death from Asphyxia: (1) External Findings: (a) Lividity of the hps, fingers and toenails. (b) Livid markings on the skin. (c) Marked post-mortem lividity. (2) Internal Findings: (a) Lungs: i. Lungs engorged with dark blood. ii. On section, there is dark color frothy exudation. iii. Punctiform hemorrhages of the pleura (Tardieu Spots). iv. Reddish discoloration of the trachea and bronchial mucous membrane. (b) Heart: i. Subpericardial petechial hemorrhages. ii. Right ventricle of the heart dilated and engorged. iii. Left side of the heart and arterial system empty. (c) Abdominal viscera congested. (d) Brain congested and may show punctiform hemorrhages. (e) Blood dark in color. (f) Rigor mortis has slow onset. c. Death from Coma: Coma is the state of unconsciousness with insensibility of the pupil and conjunctivae, and inability to swallow, resulting from the arrest of the functions of the brain. Causes of Coma: (1) Gross lesions of the brain: (a) Depressed fracture. (b) Apoplexy. (c) Embolus. (d) Abscess. (e) Tumor. (2) Poisons: (a) Uremia. (b) Cholemia. (c) Acetonemia. (d) Ingested morphine.

LEGAL MEDICINE (e) Ingested alcohol. Symptoms of Coma: (1) Person unconscious. (2) Breathing is stertorous. (3) Pulse is full but intermittent. (4) Cold, clammy perspiration. (5) Imperfect perception of sensory impression. (6) Delirium. (7) Relaxation of all sphincter muscles. (8) Accumulation of mucous in the respiratory passages. Post-mortem Findings: The findings in coma are the same as in asphyxia, and addition, there is congestion of the brain and the spinal cord.

Chapter VII ^S^ECIAL DEATHS 1. JUDICIAL DEATH: Modern methods in the execution of death sentences have abandoned inhuman, cruel and barbarous means. Executions by garroting, decapitation by means of the guillotine and by drowning which were common during the medieval days are no longer practiced. The statutes of all countries state the legal procedure for the execution of death penalties. The constitution, like that of the Philippines, imposes certain limitations to the law-making body as to the method to be established. Art. Ill, Sec. 1, Par. 19, of the Philippine Constitution provides that "cruel and unusual punishment shall not be inflicted." The wait for the provision of the new constitution punishment prohibited must not only be cruel but also unusual or vice versa. Banishment may be unusual but not cruel and therefore valid. Death penalty is not cruel and unusual whether it be by hanging, shooting, or electrocution (Legarda v. Valdez, 1 Phil 146). Punishments are cruel when they involved torture or a lingering death, but the punishment of death is not cruel because it is not barbarous and inhuman. The purpose of the guaranty by the constitution is to eliminate many inhuman and uncivilized punishments formerly known, the infliction of which tend to barbarize present civilization (McElvaine v. Brush, 142 U.S. 155). Death Penalty: 1. Arguments in Favor of the Death Penalty: ( 1 ) It is the only method of eliminating the hopeless enemy of society — Escape from prison, commutation of sentence and pardon are ways that criminals, helped by their friends, escaped life imprisonment. ( 2 ) It deters potential criminals as no other form of punishment does. (3) Its brutalizing effect is an unproven assumption. — It is contended that if capital punishment is properly carried out, instead of brutalizing society, it satisfies the sense of justice and provides social satisfaction and a sense of protection. 203

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LEGAL MEDICINE (4) It is the only means whereby society is relieved of the support for those who continually war upon it. Society will be relieved of- expenses of maintaining the irreformable criminals who prey upon it. (5) It is a positive selective agency to wipe out the stock of irreformable criminals — Killing the hopeless criminals will eliminate some of the degenerated stock of society.

2. Arguments Against Death Penalty: (1) It is an irreversible penalty. — Mistaken judgments as to guilt can no longer be remedied. (2) It is not reformative. — Capital punishment indicates impossibility of reformation of offenders. No one is incorrigible sociologically. (3) Capital punishment is not a deterrent in effect. — There is no country where death penalty is imposed and criminality, diminished. (4) Capital punishment diminished the certainty of punishment. — It is a common experience that the court will not convict a person when the penalty to be imposed is death. If capital punishment is done away entirely, the court is more likely to convict and thus society is protected in greater measure. (5) Capital punishment violates humanitarian sentiments. — Men can take a life in self-defense or in the heat of passion, and have a relieving sense of justification, but to take in cold blood the life of a prisoner causes all the humanitarian sentiments developed in thousands of years to revolt. ( 6 ) Capital punishment is retributive — Revengeful acts of society is already an out of fashion philosophy. The test is to have a corrective approach. ( 7 ) It is a cold-blooded and deliberate kind of murder. — The executioner has no passion to justify the performance of his act. It is, however, a question whether a man who pulls the trap may not feel he is doing a public service that is even greater than a policeman who shoots a fleeing murderer or robber. Methods of Judicial Death: 1. Death by Electrocution: A person is made to sit on a chair made of electrical conducting materials with straps of electrodes on both wrists, ankles, and head. An alternating current voltage of more than 1,500 volts is put on until the convict dies.

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If the convict does not die after a few minutes that the current was put on, it is necessary to apply another current until he is pronounced dead by the physician. The law states that the penalty is death by electrocution so that the convict must be put to death. It is the duty of the administrator of the penitentiary to mitigate as much as possible the sufferings of the convict in the execution of death sentence. Art. 81, Revised Penal Code — When and how the death penalty is to be executed. — The death sentence shall be executed with preference to any other and shall consist in putting the person under sentence to death by electrocution. The death sentence shall be executed under the authority of the Director of Prisons, endeavoring so far as possible to mitigate the sufferings of the person under sentence during electrocution as well as during the proceedings prior to the execution. If the person under sentence so desire, he shall be anesthesized at the moment of the electrocution. Art. 82, Revised Penal Code — Notification and execution of the sentence and assistance to the culprit. — The court shall designate a working day for the execution, but not the hour thereof, and such designation shall not be communicated to the offender before sunrise of said day, and the execution shall not take place until after the expiration of at least eight hours following the notification, but before sunset. During the interval between notification and the execution, the culprit shall, in so far as possible, be furnished with assistance as he may request in order to be attended in his last moments by priests or ministers of the religion he professes and to consult lawyers, as well as in order to make a will and confer with members of his family or persons in charge of the management of his business, of the administration of his property, or of the care of his descendants. Art. 83, Revised Penal Code — Suspension of the execution of the death sentence. — The death sentence shall not be inflicted upon a woman within the three years next following the date of the sentence or while she is pregnant not upon any person over seventy years of age. In this last case, the death sentence shall be commuted to reclusion perpetua with the accessory penalties provided in article 40. Art. 84, Revised Penal Code — Place of execution and persons who may witness the same. The execution shall take place in the penitentiary of Bilibid in a space closed to public view and shall be witnessed only by the priests assisting the offender

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LEGAL MEDICINE and by his lawyers and by his relatives, not exceeding six, if he so request, by the physician and the necessary personnel of the penal establishment, and by such persons as the Director of Prisons may authorize. Death by electrocution is the only method recognized by our civil law. There is a growing sentiment to remove capital punishment although it is a means to discourage future wrongdoers. Death may be due to shock; respiratory failure due to bulbar paralysis or asphyxia;and due to prolong and violent convulsion.

2. Death by Hanging: The convict is made to stand in an elevated collapsible flatform with a black hood on the head, a noose made of rope around the neck and the other end of which is fixed in an elevated structure above the head. Without the knowledge of the convict, the flatform suddenly collapses which causes the sudden suspension of the body and tightening of the noose around the neck. Death may be due to asphyxia or injury of the cervical portion of the spinal cord. In the Philippines, this method of death execution is only allowed on death penalties imposed by military tribunals or court marshals. It is considered to be the most gruesome means of death and is imposed primarily to those who have been found guilty of very grave offenses. In the Philippines, death penalty that are imposed by the civil court must only be by electrocution. Hanging is not recognized as a means of executing death sentence, although the decision of the military tribunals may impose death by hanging. The following are the causes of death in judicial hanging: a. b. c. d. e. f.

Dislocation or fracture of the upper cervical vertebrae. Partial or complete severance of the spinal cord. Rupture of the cervical muscles. Asphyxia due to the pressure on the vagus nerve. Syncope due to the pressure on the vagus nerve. Cerebral anemia which results to an inhibition of the vital centers of the brain.

3. Death by Musketry: The convict is made to face a firing squad and is put to death by a volley of fire. The convict may be facing or with his back towards the firing squad.

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This method of execution of death penalty is applied to military personnel and decided by the court marshals. Death by musketry is considered less heinous than death by hanging. 4. Death by Gas Chamber: The convict is enclosed in a compartment and an abnoxious or asphyxiating gas is introduced. The most common gas used is carbon monoxide. The convict will not be removed from the gas chamber unless he is pronounced dead by the penitentiary physician. This method is not recognized by the Philippine civil or military law. In some states of the United States, it is a legal means of judicial death execution. Other Methods of Capital Punishment: 1. Beheading — The most common way of beheading is with the use of the guillotine. The device is something like a file-driver with a heavy axe to severe the head. The descent of the blade strikes the neck from behind and the head falls into a basket. 2. Crucifixion — Nailing the person on a cross and death develops by traumatic asphyxia. 3. Beating — A hard object is forcibly applied to the head to crush the skull. 4. Cutting asunder — Mutilating the body usually with sharp heavy instrument until death ensues. 5. Precipitation from a height. 6. Destruction by wild beast. 7. Flaying — skinning alive. 8. Impaling. 9. Stoning. 10. Strangling. 11. Smothering. 12T Drowning.

Euthanasia or "mercy killing" is the deliberate and painless acceleration of death of a person usually suffering from an incurable and distressing disease. It is universally condemned but some advocate its legalization based on humanitarian sentiments. In the Philippines there is no law dealing specifically with the matter but the general sentiment is that it is contrary to the principle that "no person has the right to end his own life, much

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less can he delegate such right to another." Medical ethics states that the duty of a physician is to save life, not to end it. Philosophically — It is the proper function of society to safeguard man's right to die when he chooses to, provided it will not prejudice the rights of others. Churches — All churches are against euthanasia because an individual does not have the full dominion over his life to the extent of determining whether or not he will continue to live. Only God who created mankind has the sole right to extinguish it. Medicine — There is no sense in performing euthanasia inasmuch as there is no physical pain so severe that modern medication available today cannot substantially provide relief. The physician may be mistaken in the diagnosis of impending death. Recovery, of the kind bordering closely on a miracle, may occur. There is belief in the saying, "While there is life, there is hope." Sociologically — The practice of euthanasia is an endorsement or toleration of society to suicide and a general approval of crime committed for a benevolent motive. Types of Euthanasia: 1. Active Euthanasia — Intentional or deliberate application of the means to shorten the life of a person. It may be done with or without the consent or knowledge of the person. Active euthanasia on demand is the putting to death of a person in compliance with the wishes of the person (patient) to shorten his sufferings. 2. Passive Euthanasia — There is absence of the 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. Consequently the concept of orthothanasia and dysthanasia was adopted. a. Orthothanasia — When an incurably ill person is allowed to die a natural death without the application of any operation or treatment procedure. b. Dysthanasia — When there is an attempt to extend the life span of a person by the use of extraordinary treatments without which the patient would have died earlier. Note: Dysthanasia does not comply with the definition of euthanasia. (Report on the 4th World Congress on Medical Law, Manila, March 16-17, 1976, p. 57).

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Ways of the Performing Euthanasia: 1. Administration of a lethal dose of poison. 2. Overdosage of sedatives, hypnotics or other pain relieving drugs. 3. Injection of air into the blood stream. 4. Application of strong electric currents. 5. Failure to institute the necessary management procedure which is essential to preserve the life of the patient. a. Failure to perform tracheostomy when there is marked distress in breathing due to laryngeal obstruction. b. Failure to give transfusion in severe hemorrhage. c. Depriving the child of nutrition. d. Removal of patient from a respirator when voluntary breathing is not possible. Who May Perforin Euthanasia: 1. The patient himself: A n y person who deliberately puts an end to his life commits suicide. Suicide is not a crime in our jurisdiction because a person committing suicide is a moral wreck and he must be given an eye of pity or sympathy rather than an eye of penalty by law. This is also based on a philosophy that a person has a complete dominion over his own body. 2. The physician, with or without the knowledge and consent of the patient: Even if a physician has humanitarian or merciful motive in putting to death a patient, his act his punishable in spite of the patient's consent. Art. 253, Revised Penal Code — Giving assistance to suicide — A n y person who shall assist another to commit suicide shall suffer the penalty of prision mayor; if such person lends his assistance to another to the extent of doing the killing himself, he shall suffer the penalty of reclusion temporal. However, if the suicide is not consummated, the penalty of arresto mayor in its medium and maximum periods shall be imposed. The above provision contemplates the following situations: a. If a physician assists a person in the commission of suicide (by giving him a lethal dose of poison, for example) without actually administering it, the law imposes upon him the penalty of prision mayor (6 yrs. and 1 day to 12 yrs. imprisonment). b. If the physician lends his assistance to another to the extent of doing the killing himself, he shall be punished by reclusion temporal (12 yrs. and 1 day to 20 yrs.);

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LEGAL MEDICINE c. If the suicide with the assistance of the physician is not consummated, the penalty of arresto mayor (1 month and 1 day to 6 months) in its medium and maximum period shall be imposed; and

3.

If poison was administered by the physician to the patient without the knowledge and consent of the patient, then it is murder. Treachery is inherent to the act of poisoning and treachery qualifies the killing to murder. In other jurisdictions, the modern attitude is to allow physicians to perform euthanasia in some special cases. In the case of Dr. Adams who was charged for murder by administering a pain-killing drug to a patient suffering from a painful and- incurable disease, which he was then acquitted, the court held that "If the first purpose of medicine (the restoration of health) could no longer be achieved, there was much for the doctor to do, and he was entitled to do all that was proper and necessary to relieve pain and suffering even if the means he took might incidentally shorten life by hours or perhaps even prolong it. The doctor who decides whether or not to administer the drug would not do his job if he were thinking in terms of hours or even in months. The defense in the present case was that the treatment given by Dr. Adams was designed to promote comfort, and if it was the right ana proper treatment the fact that it shortened life did not convict him of murder" (R. v. Adams, Crim., L.R. 365, 1957). In a recently decided case (In the matter of Karen Quinlan, N.J. Sup. Ct. Mar. 3 1 , 1 9 7 6 ) , Karen Quinlan had been in coma for almost a year and has been kept alive by a respirator. The father petitioned the court to authorize discontinuation of the respirator because there is no "reasonable possibility" that she would recover and to allow her to die "with grace and dignity". The court allowed such removal provided it is with the consent of the attending physician and a panel of hospital staff. The court based it on the right of privacy of the patient or the right of the patient to make life— sustaining medical decision and that since the patient was incompetent to make such decision, it belonged to her father acting as a guardian. The court does not question the "state's undoubted power to punish the taking of human life, but that power does not encompass individuals terminating treatment pursuant to their right of privacy".

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3. SUICIDE: Suicide or self-destruction is usually the unfortunate consequence of mental illness and social disorganization. Societal reaction to suicide varies in different jurisdiction. Some consider suicide a crime (Maryland, N e w Jersey, North Carolina, Oklahoma, South Dakota); others impose no penalty for suicide but suicide attempts are considered felonies or misdemeanors and could result to jail sentences. In criminal statistics there is under-reporting of suicide cases because of the following reasons: 1. Even if the facts are clear to support suicide, the strong opposition of the family, the physician, attorney and friends may cause a certification that it is accidental, because they are not only bereaved but also stigmatized. The legal and moral implications of suicidal death prevent certification of such manner of death. If insured may deprive the beneficiary from receiving the full value of the policy, the usual religious rites may not be accorded the deceased, and other benefits provided by law which the heirs are entitled may not be received. 2. There is a lack of generally accepted standards for determining death by suicide. To make death suicidal, it must be the direct, conscious, intentional act of self-destruction. Subconscious or sub intended acts which directly or indirectly cause or hasten death is not considered to be suicide. No single finding in the investigation of death is an absolute criterion of suicide. Suicide rarely occurs during the pre-addescent age. The incidence increase with the age but more in the elderly. There is more incidence in male than in female. Most victims have experienced depression of long duration prior to dying. Suicide occurs in almost every conceivable location but a vast majority of cases occur at home. It may occur in other places like hotel, automobile, jails, hospitals and mental institutions. The bodies of victims may be found in rivers, lakes, open fields. The scene of death is orderly. Psychological Classification of Suicide: 1. First degree — deliberate, planned, premeditated, self-murder. 2. Second degree — impulsive, unplanned, under great provocation or mitigating circumstances. 3. Third degree — sometimes called "accidental" suicide. This occurs when a person puts his or her life into jeopardy by

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LEGAL MEDICINE voluntary self-injury, but where we infer that the intention to die was relatively low because the method of self-injury was relatively harmless, or because provisions for rescue were made. The person was "unlucky" actually to die.

4. Suicide under circumstances which suggest a lack of capacity for intention, as when the person was psychotic or highly intoxicated from the effects of drugs, including alcohol. 5. Self-destruction due to self-negligence — for example, such self-destructive behaviors as chronic alcoholism, reckless driving, ignoring medical instructions, cigarette smoking, and similar dangerous activities. In general, such deaths are not at present classified as "suicide." 6. Justifiable suicide — for example, the self-destructive action of a person with a terminal illness. This last category is of considerable current interest to philosophers, theologians and social psychologists. (From: Psychological Aspects of Suicide by Robert Litman, Modern Legal Medicine Psychiatry and Forensic Science, Curran, McGarry & Petty, ed. 19, 980, F. A. Davis Co., p. 843). Common Methods of Commiting Suicide: 1. Drugs and poisons — Barbiturates, non-barbiturate sedatives, acids and other irritants, carbon monoxide, pesticides and herbicides, other organic and inorganic poisons. 2. Hanging. 3. Firearm. 4. Jumping from a height. 5. Drowning. 6. Cutting and stabbing. 7. Suffocation by plastic bag. 8. Electrocution. Suicide and Drug: "Automatism" due to drug may be considered as accidental rather than suicidal. A patient develops a state of toxic delirium after ingesting one or several doses of tlffe drugs, alcohol or a combination thereof and while in the delirious or automatism stage, takes much more of the drug unintentionally. Evidences That Will Infer Death is Suicidal: 1. History of depression, unresolved personal problem, or mental disease; 2. Previous attempt of self-destruction; 3. If committed by infliction of physical injuries, the wounds are

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located in areas accessible to the hand, vital parts of the body and usually solitary. 4. The effects of the act of self-destruction may be found in the body of the victim: a. Hand may be blood-stained if suicide was done by inflicting wound; b. Wounding hand may be positive to paraffin test in gunshot. The wound of entrance may show manifestation of a contact or near shot. c. Empty bottle or container of poison may be present at the suicide scene; d. Absence of signs of struggle; or e. Cadaveric spasm present in the wounding hand holding the weapon. 5. Presence of suicide note; 6. Suicide scene in a place not susceptible to public view, and 7. Evidences that will rule out homicide, murder, parricide, and other manner of violent death. DEATH FROM STARVATION Starvation or inanition is the deprivation of a regular and constant supply of food and water which is necessary to normal health of a person.

Death b y itarvation

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Types of Starvation: 1. Acute starvation — is when the necessary food has been suddenly and completely withheld from a person. 2. Chronic starvation — is when there is a gradual or deficient supply of food. Causes of Starvation: 1. Suicidal: a. People deprived of liberty or prisoners may go in a "hunger strike" to create sympathy. b. Mistaken belief that people can live without food for a prolonged period. c. Excessive desire to lose weight. d. Lunatics during depressive state. e. As an expression of political dissent. 2. Homicidal: a. Deliberate deprival of food for helpless illegitimate children, feeble-minded and old persons. b. Punishment or act of revenge by deliberate incarceration in an enclosed place without food m water. 3. Accidental: a. Scarcity of food or water during famines or draught. b. Shipwreck, entombment of miners caused by landslides, marooned sailors, or fall in a pit. Length of Survival: The human body without food loses l/24th of its weight daily, and a loss of 40% of the weight results to death. The length of survival depends upon the presence or absence of water. Without food and water, a person cannot survive more than 10 days, but with water a person may survive without food for 50 to 60 days. Factors that Influence the Length of Survival: a. Age — Children suffer earlier from the effects of starvation than old aged people. A child demand more food for growth and development. Assimilation and utilization of food elements is slowed and weakened in old age. b. Condition of the body — During starvation, fat stored up in the body is the one utilized to maintain life. It is but natural that a healthy person with more fat deposit can resist more deprival of food.

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1S

c. Sex — Women can withstand starvation longer because they have relatively more adipose tissues than men. d. Environment — Exposure to higher temperature will accelerate death. Suitable clothings will delay death. Active physical exertion will hasten death. Severe cold will also hasten death. The Length of Survival Depends Upon the Following: a. Presence or absence of water. b. Partial or complete withdrawal of food. c. Surroundings. d. Females survive better than males, but children and older persons die quickly. e. Condition of the body. Symptoms: 1. Acute feeling of hunger for the first 30 to 48 hours and this is succeeded by localization of the pain at the epigastrium which can be relieved by pressure. 2. A feeling of extreme thirst. 3. The face is pale and cadaverous. 4. Four or five days later, there is a general emaciation and absorption of the subcutaneous fat. 5. The eyes are sunkened, glistening dilated pupils and with anxious expression. 6. The lips and tongue are dry and with cracks, while the breath is foul and offensive. 7. The voice becomes weak, faint and inaudible. 8. The skin is dry, rough, wrinkled and emitting a peculiar disagreeable odor. 9. The pulse is weak and the temperature is subnormal. 10. The abdomen is sunkened and the extremities are thin, flaccid with marked loss of muscular power. 11. The intellect may remain for sometime, later becomes delirious and convulsion or coma appears before death. 12. Symptoms of secondary infection may later appear on account of the weakened resistance of the body. Cause of Death: 1. Inanition 2. Circulatory failure due to brown atrophy of the heart 3. Intercurrent infection

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Post-mortem Findings: 1. External Findings: a. Body greatly emaciated and emitting a peculiar offensive odor. b. The eyes are dry, red and open with the eyeballs sunkened. c. The skin is dry, shrivelled and sometimes with secondary skin infection. d. Bed sores may be present. 2. Internal Findings: a. The muscles are pale, soft, wasted with the subcutaneous fat almost completely disappeared. b. There is a general reduction in the size and weight of all organs, except the brain. c. The brain is pale and soft, while meningeal vessels are congested and frequently, there is a serous effusion in the ventricle. d. The heart is small, with flabby and pale muscles and generally empty chambers (brown atrophy). e. The lungs are edematous with hypostatic congestion. f. The stomach is small, contracted and empty with the mucous membrane less stained with bile. g. The intestine is thin, empty, with its thin and translucent wall and with the disappearance of the mucosal folds. h. There may be superficial or extensive ulceration of the colon as in ulcerative colitis. i. The liver, spleen, kidneys and pancreas are small and shrunken. Microscopically, the liver shows necrosis of the central zone. The liver damage was due to protein deficiency. j. The gall bladder is distended with bile while the urinary bladder is empty. k. There is demineralization of bones and in pregnant women, it may produce osteomalacia. 1. Findings are refenable to concomitant disease which may develop on account of the diminished resistance. Effects of Chronic Starvation: Incomplete withdrawal of food to the body may cause a different effect. The person will manifest symptoms referrable to the food deficiency. 1. Deprivation of protein in the diet reduces the amount of protein in the serum and edema, anemia, leucopenia and weakened cardiac function develop.

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2. Absence of various vitamins in the food for a long period of time may cause nutritional disturbance: a. Deficiency in Vitamin A will cause hyperkeratosis of the skin atrophy of the mucous membrane, drying up of the salivary and lacrimal glands and night blindness. b. Deficiency of Vitamin B will cause neuritis, sore tongue, hypertrophy of the heart, and other manifestations of beri-berL c. Deficiency of Vitamin C will cause hemorrhage in various parts of the body, kidneys, periosteum. Massive hemorrhage in the gums is observed in adults. d. Deficiency of Vitamin D and calcium may be followed by respiratory catarrh, anemia, osteomalacia and skeletal deformities. 3. Deficiency of sugar, fat and minerals produce various disturbance in the body. Medico-Legal Questions in Death Due to Starvation: 1. Determination whether death was caused by starvation: It is necessary to examine carefully the internal organs and to search for the existence of any disease which may possibly be the cause of death. Some diseases may also lead to pathological emaciation, like malignant disease, tuberculosis, diabetes mellitus, anemia and chronic diarrhea. Absence of any disease which may cause severe emaciation and the presence of a cause for the deprivation of food are the basis for the diagnosis of death by starvation. 2. Determination of the cause of the starvation: Starvation may be suicidal, homicidal or accidental. The condition of the surroundings, history and previous life of the victim and his mental condition before he starved must be taken into consideration in the determination of the cause.

Chapter VIII DISPOSAL OF THE DEAD BODY Sec. 1103, Revised Administrative Code: Persons Charged with Duty of Burial: The immediate duty of burying the body of a deceased person, regardless of the ultimate liability for the expense thereof, shall devolve upon the persons hereinbelow specified: (a) If the deceased was a married man or woman, the duty of burial shall devolve upon the surviving spouse if he or she possesses sufficient means to pay the necessary expenses. ( b ) If the deceased was an unmarried man or woman, or a child, and left any kin, the duty of burial shall devolve upon the nearest kin of the deceased, if they be adults and within the Philippines and in possession of sufficient means to defray the necessary expenses. (c) If the deceased left no spouse or kindred possessed of sufficient means to defray the necessary expenses, as provided in the two foregoing subsection, the duty of burial shall devolve upon the municipal authorities. Any person upon whom the duty of burying a dead body is imposed by law shall perform such duty within forty-eight hours after death, having ability to do so. Sec. 1104, Revised Administrative Code: Right of Custody to body: A n y person charged by law with the duty of burying the body of a deceased person is entitled to the custody of such body for the purpose of burying it, except when an inquest is required by law for the purpose of determining the cause of death; and, in case of death due to or accompanied by a dangerous communicable disease, such body shall until buried remain in the custody of the local board of health or local health officer, or if there be no such, then in the custody of the municipal council. C O N C E P T O F POSSESSION: The right of custody over a dead body means possession. Possession means the holding of a thing or enjoyment of a right. The possession of a thing means two things: either in the concept of 218

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ownership or the holder of a thing keeping it while the ownership belongs to another. Literally speaking, the right of custody does not -mean ownership of a dead body. The possessor cannot exercise the full rights of ownership. Kenny (Canada), in his Outlines of Criminal Law (15 ed. p. 219) cited a case of a group of individuals known as "resurrection men" who used to disinter dead bodies from cemeteries and sell them to the anatomy departments of medical colleges. Since the law provides that the crime of theft or robbery cannot be committed on things which have no owner, these people were not successfully prosecuted for theft. In the case of Philips v. Montreal General Hospital (33 S.C. 483; 14 R . L . 159) decided in Quebec, Canada, it has been held that there is a right of property in human remains, at least in a limited sense. The right of possession of a corpse is equivalent to ownership and any unlawful interference with that right is an actionable wrong. The surviving spouse has the preferential right and duty to make arrangements, for the funeral of the deceased spouse and to decide how the remains should be disposed of. This is also the rule in the United States, where the superior and preferred right of the surviving spouse to the burial and any other legal disposition of the remains of the husband is undisputed (Ameida Vda. de Carillo v. Carillo, 67 Phil. 92). Executor's Right of Custody Superior to the Right of Spouse Dead Body: If ever the deceased left a will stating among other things the manner his body will be disposed, such provision of the will if validly executed and allowed, will prevail over the provisions of the Administrative Code. An executor is the person mentioned in a will who will carry on the provision of the will. He is duty-bound to execute whatever is stated in the will after the death of the decedent. But, in the absence of a testamentary disposition, the right of the surviving spouse is paramount. In the case of Hunter v. Hunter, decided in Ontario, Canada (65 O . L . R . 586), the deceased had been a staunch and devout Protestant and an Orangeman. His wife is an equally devout Catholic. At the time of his last illness he expressed a wish to be buried in the place where his wife would be buried, which was taken to mean, in a Roman Catholic cemetery. He was then received into the Roman Catholic Church and died about three weeks later. One of the deceased's son-the plaintiff in the case-has been named

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executor of the will, and claimed the body for burial, which he intended should be in a Protestant cemetery. This was resisted by the widow who contended that her husband should be buried in a cemetery of the church he had joined recently. The court maintained the son's claim holding that, as executor, he had a right to have the body for the purpose of burial. The wife was prevented from interfering with that right (Cited by Meridith). METHODS OF DISPOSAL OF THE D E A D B O D Y : 1. Embalming: Embalming is the artificial way of preserving the body after death by injecting 6 to 8 quarts of antiseptic solutions of formalin, perchloride of mercury or arsenic, which is carried into the common carotid and the femoral arteries. Usually, alcohol is added to minimize the strong odor of the chemical and glycerine to lessen the evaporation of water from the tissues of the body. If the preservation of the body is for a longer time, the abdominal and thoractic viscera are removed, washed and soaked in strong antiseptic solution before they are returned. The skin is painted with vaseline or covered with plaster of Paris to prevent too much evaporation. 2. Burial or Inhumation: a. The body must be buried within forty-eight hours after death: Sec. 1092, Revised Administrative Code: Time within which body shall be buried: Except when required for the purposes of legal investigation or when specifically authorized by the local health authorities, no unembalmed body shall remain unhurried longer than fortyeight hours after death; and after the lapse of such period the permit for burial, interment, or cremation of any such body shall be void and a new permit must be obtained. When it has been certified or is known that any person died of, or with a dangerous communicable disease, the body of such person shall be buried within twelve hours after death, unless otherwise directed by the local board of health or other health authority. The dead body must be buried within forty-eight hours after death except: ( 1 ) When it is still a subject matter of legal investigation; ( 2 ) When it is specifically authorized by the local health authorities that the body may be buried more than 48 hours after death;

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( 3 ) Impliedly when the body is embalmed. If the person died of communicable disease, the body must be buried within 12 hours unless the local health officer permits otherwise. If the body is not buried within 48 hours after death, the permit previously issued is deemed cancelled and there is a need of a new permit. Considering the climatic conditions in the Philippines, the time limit provided for by law regarding burial time should be reduced to 24 hours instead of 48 hours. Decomposition of the body in tropical countries, like the Philippines, is relatively rapid. b. Death Certificate Necessary before Burial: Sec. 1087, Revised Administrative Code: Requirement of Certificate of Death — By whom to be issued: Except in cases of emergency, no dead body shall be buried without a certificate of death. If there has been a physician in attendance upon the deceased, it shall be the duty of the said physician to furnish required certificate. If there has been no physician in attendance, it shall be the duty of the local health officer or of any physician to furnish such certificate. Should no physician or medical officer be available, it shall be the duty of the mayor, the secretary, or of a councilor of the municipality to furnish the required certificate. Sec, 91, P.D. 856 Code of Sanitation — Burial Requirement: The burial of remains is subject to the following requirements: ( a ) No remains shall be buried without a death certificate. This certificate shall be issued by the attending physician. If there has been no physician in attendance, it shall be issued by the mayor, the secretary of the municipal board, or a councilor of the municipality where the death occurred. The death certificate shall be forwarded to the local civil registrar within 48 hours after death. The death certificate shall be forwarded by the person issuing it to the municipal secretary within forty-eight hours after death. The law requires the necessity of a death certificate before burial, except in emergency cases. The following may sign the death certificate: ( 1 ) The attending physician, if there is any; ( 2 ) The local health (municipal health officer) if there is no physician in attendance;

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LEGAL MEDICINE (3) The municipal mayor, if there is no local health officer and no physician in attendance; (4) The municipal secretary, in the absence of the mayor; ( 5 ) Any councilor. The order in the enumeration is exclusive and successive. The presence of the preceding person will exclude the succeeding person in the enumeration. Inasmuch as almost all municipalities of the Philippines have municipal health officers; the municipal mayor, secretary and any of the councilors are practically inhibited to sign the death certificate. It appears unusual and contrary to the intent and purpose of the death certificate when persons not qualified to know the cause of death, are authorized by law to sign it. This provision of the Administrative Code was promulgated during the time when physicians were quite scarce.

c. Permission from the Provincial Fiscal or from the Municipal Mayor is Necessary if Death is Due to Violence or Crime: Sec. 1089, RevisedAdministrative Code: Proceedings in case of suspected violence or crime: If the person who issues a death certificate has any reason to suspect or if he shall observe any indication of violence or crime, he shall at once notify the justice of the peace, if he be available, or if neither the justice of the peace nor the auxiliary justice be available, he shall notify the municipal mayor, who shall take proper steps to ascertain the circumstances and cause of death; and the corpse of such deceased person shall not be buried or interred until permission is obtained from the provincial fiscal, if he be available, and if he be not available, fjom the mayor of the municipality in which the death occurred. Sec. 91 ( f ) , P . D . 856 Code of Sanitation: If the person who issues a death certificate has reasons 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. If these officials are not available, permission shall be obtained from any government official authorized by the law.

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In cases of death wherein violence or crime is suspected, it is necessary to notify the following in order to determine the circumstances and nature of death: ( 1 ) Justice of the peace. ( 2 ) Auxiliary justice of the peace, if the former is not available. But the permission for burial may only be granted by: (1) Provincial fiscal. ( 2 ) Municipal mayor if the fiscal is not available. Sec. 1090, Revised Administrative Code: Burial and transfer permits: Municipal secretaries, in the capacity of secretaries of municipal boards of health in places where such boards have been organized, or, in places where there are no municipal boards of health, in the capacity of clerks to municipal councils, shall, upon the presentation of death certificates, issue permits for the burial or transfer of the dead and shall record on said certificates the place of interment and when practicable the number of the grave from which the body or remains have been transferred, and the disposition that is to be made of such body or remains. No permit shall be granted by any municipal secretary, or by any other person, to inter or disinter, bury or remove for burial, any human body or remains until a certificate of death, as hereinbefore required, shall have been filed; when it is impossible to secure a death certificate in the form and manner hereinbefore provided, municipal secretaries may issue the same upon such data as may be obtainable. In case of the transfer of bodies or remains from one municipality to another municipality, a copy of the death certificate shall accompany the transfer permit. Sec. 1094, Revised Administrative Code: Disposition of body and belonging of person dying of dangerous communicable disease: The body of a person dead of any dangerous communicable disease shall not be carried from place to place, except for the purpose of burial or cremation. It shall be the duty of the local health authorities to cause such body to be thoroughly disinfected before being prepared for burial and the house, furniture, wearing apparel, and everything capable of conveying or spreading infection shall also be disinfected or destroyed £ y fire. The local health authority, if there be any, subject to the approval of the Director of Health, shall,consistently with the provisions hereof, prescribe the conditions under which the

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LEGAL MEDICINE bodies of persons dying of a dangerous communicable disease shall be buried or cremated. Sec. 91 ( h ) , P.D. 856 Code of Sanitation: When the cause of death is a dangerous communicable disease, the remains shall be buried within 12 hours after death. They shall not be taken to any place of public assembly. Only the adult members of the family pf the deceased may be permitted to attend the funeral. Sec. 1091, Revised Administrative Code: Burial permit (Death Certificate) must be presented before burial: No sexton, superintendent, or other person having charge of a burial ground or cemetery shall assist in, assent to or allow any interment, disinterment or cremation to be made until a permit from the municipal secretary, authorizing the same, has been presented. Placing of body in overground tomb: Sec. 1099, Revised Administrative Code: Exhibition of permit to sexton: The placing of the body of any deceased person in an unsealed overground tomb is prohibited, unless the coffin, or casket containing the remains shall be permanently sealed. The provision shall not apply to tombs and vaults which are strictly receiving vaults for bodies or remains awaiting final disposition, nor to embalmed bodies awaiting final disposition. The depth of the grave must be at least 1-1/2 meters: Sec. 1100, Revised Administrative Code: Depth of grave: A grave shall be dug, when practicable, to a depth of one and one-half meters and after the implacement of the body shall be well and firmly filled. Sec. 91 ( c ) , P.D. 856 Code of Sanitation: Graves where remains are buried shall be at least one and onehalf (1-1/2) meters deep and filled well and firmly. The Law Penalizes Desecration of Burial Premises: Sec. 2695, Revised Administrative Code: Desecration of burial premises: Any person who wantonly or maliciously defaces, breaks, or destroys any tomb, ornament, or gravestone erected to any deceased person, or any momento or memorial, or any plant, tree or shrub pertaining to places of burial of a dead body, or

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who shall wantonly or maliciously remove any fence, post, or wall or any burial ground or cemetery, shall be punished by a fine of not more than two hundred pesos or by imprisonment for not more than six months, or both. Although it did not totally repeal the provision of the Administrative Code, The Code of Sanitation provides: Burial Grounds Requirements: P.D. 856)

(Sec. 90, Code of Sanitation,

The following requirements shall be applied and enforced: a. It shall be unlawful for any person to bury remains in places other than those legally authorized in conformity with the provisions of the Chapter. b. A burial ground shall at least be 25 meters distant from any dwelling house and no house shall be constructed within the same distance from any burial ground. c. No burial ground shall be located within 50 meters from any source of water supply. Other Burial Requirements: The burial of remains is subject to the following requirements: ( 1 ) Shipment of remains abroad shall be governed by the rules and regulations of the Bureau of Quarantine. ( 2 ) The burial or remains in city or municipal grounds shall not be prohibited on account of race, nationality, religious or political persuasion. ( 3 ) Except when required by legal investigation or when permitted by the local health authority, no unembalmed remains shall remain unburied longer than 48 hours after death. FUNERALS: Art. 305, Civil Code: The duty and the right to make arrangements for the funeral of a relative shall be in accordance with the order established for support, under article 294. In case of descendants are of the same degree, or of brothers and sisters, the eldest shall be preferred. In case of ascendants, the paternal shall have a better right. The order mentioned in the article 294 is as follows: a. The spouse; b. The descendants of the nearest degree; c. The ascendant, also of the nearest degree; d. The brothers and sisters.

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Att. 306, Civil Code: Every funeral shall be in keeping with the social position of the deceased. Art. 307, Civil Code: The funeral shall be in accordance with the expressed wishes of of the deceased. In the absence of such expression, his religious belief or affiliation shall determine the funeral rites. In case of doubt, the form of funeral shall be decided upon by the person obliged to make arrangement for the same, after consulting the other members of the family. Art. 309, Civil Code: Any person who shows disrespect to the dead, or wrongfully interferes with a funeral shall be liable to the family of the deceased for damages, material or moral. This provision is further implemented by the Revised Penal Code by considering it a criminal act. The funeral rite is a religious ceremony or manifestations of any religion. Art. 132, Revised Penal Code: Interruption of religious worship: The penalty of prision correccional in its minimum period shall be imposed upon any public officer or employee who shall prevent or disturb the ceremonies or manifestations of any religion. If the crime shall have been committed with violence, or threat, the penalty shall be prision correccional in its medium and maximum periods. Art. 133, Revised Penal Code: Offending the religious feeling: The penalty of arresto mayor in its maximum period to prision correccional in its minimum period shall be imposed upon anyone who, in a place devoted to religious worship or during the celebration of any religious ceremony shall perform acts notoriously offensive to the feeling of the faithful. Art. 2219, Civil Code provides that moral damages may be recovered for acts mentioned in Art. 309, Civil Coda) Limitations to the Funeral Rites: a. Will of Deceased: The deceased during his lifetime may have made a will or expressly stated to his next of kin that his body after his death must be disposed in the manner he desires. b. Burial of the person sentenced to death must not be held with pomp:

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Art. 85, Revised Penal Code: Provision relative burial:

to

the corpse of person executed and its

Unless claimed by his family, the corpse of the culprit shall, upon the completion of the legal proceedings subsequent to the execution, be turned over to the institute of learning or scientific research first applying for it, for the purpose of study and investigation, provided that such institute shall take charge of the decent burial of the remains. Otherwise, the Director of Prisons shall order the burial of the body of the culprit at government expense, granting permission to be present thereat to the members of the family of the culprit and the friends of the latter. In no case, shall the burial of the body of the person sentenced to death be held with pomp. c. Restriction as to funeral ceremonies in cases of deaths due to communicable disease: Sec. 1105, Revised Administrative Code: Restrictions as to funeral ceremonies in certain cases: In case of death due to dangerous communicable disease or due to any epidemic recognized by the Director of Health, the body of the deceased shall not be taken to any place of public assembly, nor shall any person be permitted to attend the funeral of such deceased person, except the adult members of the immediate family of the deceased, his nearest friends, not exceeding four, and other persons whose attendance is absolutely necessary. After the deceased shall have been buried for a period of one hour, a public funeral may be held at the grave or in a place of public assembly or elsewhere. In case of death due to other causes the right to hold public funerals in an orderly manner and to take the remains of the deceased into churches or other places for this purpose shall not be interferred with. Sec. 91 ( h ) , P.D. 856 Code of Sanitation: When the cause of death is a dangerous communicable disease, the remains shall be buried within 12 hours after death. They shall not ba taken to any place of public assembly. Only adult members of the family of the deceased may be permitted to attend the funeral. 3. Disposing of the Dead Body in the Sea: Some dead bodies are not buried, embalmed or cremated but thrown over board in an open sea provided that the deceased is

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not suffering from dangerous communicable disease. Such manner of disposal may be the will of the deceased or a part of religious practice. Sec. 1093, Revised Administrative Code: Permit for conveyance of body to sea for burial: Where death is not due to a dangerous communicable disease a special permit may, upon written request, be issued, by the officer authorized to issue burial permits, for the conveyance of a dead body to sea for burial. In such cases, the body must be transported in the manner prescribed by the municipal board of health, if such there be, and the marine laws governing burial at sea must be complied with. 4. Cremation: Cremation is the pulverization of the body into ashes by the application of heat. The body must first be identified before cremation, and no cremation must be made unless there is a permit to do so. Cremation must be made in a crematory made for the purpose. The time required to transform the human body to ashes is dependent upon the degree or intensity of heat applied, duration of the application of heat, physical condition of the body and the presence of clothings and other protective materials in the body. In a gas incinerator, it usually requires about four hours to transform the whole body into ashes. Instances When Permission for Cremation Must N o t Be Granted: a. If the deceased left a written direction that he or she must not be cremated. b. If the exact identity of the deceased has not yet been definitely ascertained. c. When the exact cause of death cannot be definitely ascertained and further inquiry or examination may be needed (Forensic Medicine by Kerr, 4th ed., p. 22). 5. Use of tiie Body for Scientific Purposes: Sec. 97, P.D. 856, Code of Sanitation: Use of remains for medical studies and scientific research: Unclaimed remains may be used by medical schools and scientific institutions for studies and research subject to the rules and regulations prescribed by the Department. Sec. 1107, Revised Administrative Code: Use of dead body for scientific purposes:

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The body of any deceased person which is to be buried at public expense and which is unclaimed by relatives or friends for a period of twenty-four hours after death shall be subject to the disposition of the Bureau of Health, and, by order of the Director of Health, may be devoted to the purposes of medical science and to the advancement and promotion of medical knowledge and information, subject to such regulations as said Director of Health, with the approval of the Department Head, may prescribe. The regulations of the Director of Health shall provide for the decent burial of the remains of such bodies and for defraying the necessary expenses incident thereto. Except as herein provided, it shall be unlawful for any person to make use of any dead body for any scientific investigation other than that of performing an autopsy. Corpse of prisoners after judicial execution may be turned over to institution of learning or scientific research: Art. 85, Revised Penal Code: Provisions relative to the corpse of the person executed and its burial: Unless claimed by the family, the corpse of the culprit shall upon completion of the legal proceedings subsequent to the execution, be turned over to the institute of learning or scientific research first applying for it, for the purpose of study and investigation, provided that such institution shall take charge of the decent burial of the remains. Otherwise, the Director of Prisons shall order the burial of the body of the culprit at government expense, granting permission to be present thereat to the members of the family of the culprit and the friends of the latter. In no case shall the burial of the body of a person sentenced to death be held with pomp. Sec. 98, P.D. 856, Code of Sanitation: Special precautions for safe handling of cadavers containing radioactive isotopes: a. Cadavers containing only traces (very small dose) of radioactive isotope do not require any special handling precautions. b. Cadavers containing large amounts of radioactive isotopes should be labelled properly identifying the type and amount of radioactive isotopes present and the date of its administration. c. Before autopsy is performed, the Radiation Health Officer or his duly authorized representative should be notified for proper advice. The pathologist and/or embalmer should be warned accordingly of the radioactivity of the cadaver so that radiation precautions can be properly enforced.

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d. Normal burial procedures, rules and regulations may be carried out on the above-mentioned cadaver provided that their amount of radioactivity has decayed to a safe level which will be determined by the Radiation Health Officer or his authorized representative. e. Cremation — If cremation is performed without autopsy, there is no handling problem; otherwise, autopsy precautions should be strictly enforced. Precautions should be taken to prevent any possible concentration of radioactivity at the base cf the stack of the crematorium. DONATION OF PART(S) OF HUMAN BODY PERMISSIONS T O USE H U M A N O R G A N S O R P O R T I O N S O F THE H U M A N B O D Y F O R M E D I C A L , S U R G I C A L , O R SCIENTIFIC PURPOSES, U N D E R C E R T A I N C O N D I T I O N S Republic Act N o . 349 as amended by Republic Act 1056 A N A C T T O L E G A L I Z E P E R M I S S I O N S T O USE H U M A N ORG A N S O R A N Y P O R T I O N O R P O R T I O N S O F THE H U M A N B O D Y F O R M E D I C A L , S U R G I C A L , O R SCIENTIFIC PURPOSES, U N D E R C E R T A I N C O N D I T I O N S Sec. 1. Any person may validly grant to a licensed physician, surgeon, known scientist, or any medical or scientific institution, including eye banks and other similar institutions, authority to detach at any time after the grantor's death any organ, part or parts of his body and to utilize the same for medical, surgical or scientific purposes. Similar authority may also be granted for the utilization for medical, surgical, or scientific purposes, of any organ, part or parts of the body which, for a legitimate reason, would be detached from the body of the grantor. Sec. 2. The authorization referred to in section one of this Act must: be in writing; specify the person or institution granted the authorization; the organ, part or parts to be detached, the specific use or uses to which the organ, part or parts are to be employed; and, signed by the grantor and two disinterested witnesses. If the grantor is a minor or an incompetent person, the authorization may be executed by his guardian with the approval of the court; in default thereof, by the legitimate father or mother, in the order named. Married women may grant the authorization re-

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ferred to in section one of this Act, without the consent of the husband. After the death of the person, authority to use human organs or any portion or portions of the human body for medical, surgical or scientific purposes may also be granted by his nearest relative or guardian at the time of his death or in the absence thereof, by the person or head of the hospital, or institution having custody of the deceased. Provided, however, that the said person or head of the hospital or institution has exerted reasonable efforts to locate the aforesaid guardian cr relative. A copy of every such authorization must be furnished the Secretary of Health. Sec. 2-A. The provisions of sections one and two of this Act notwithstanding, it shall be illegal for any person or any institution to detach any organ or portion of the body of a person dying of a dangerous communicable disease even if said organ or portions of the human body shall be used for medical or scientific purposes. A n y person who shall violate the provisions of this section shall be punished with an imprisonment of not less than six months nor more than one year. If the violation is committed by an institution, corporation or association, the director, manager, president, and/or other officials and employees who, knowingly or through neglect, perform the act or acts resulting in said violation shall be held criminally responsible therefore. Sec. 3. An authorization granted in accordance with the provisions of this Act shall bind the executors, administrators and successors of the deceased and all members of his family. Sec. 4. Any law or regulation inconsistent with the Act are hereby repealed. Sec. 5. This Act shall take effect upon its approval. A P P R O V E D , May 17, 1949, Amendment Approved June 12, 1954. Sec. 96, Code of Sanitation ( P . D . 856). Donation of Human Organs for Medical, Surgical and Scientific Purposes According to the Sanitation Code ( P . D . 856): Any person may donate an organ or any part of his body to a person, a physician, a scientist, a hospital or a scientific institution upon his death for transplant, medical, or research purposes Bubject to the following requirements: a. The donation shall be authorized in writing by the donor specifying the recipient, the organ or part of his body to be donated and the specific purpose for which it will be utilized.

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b. A married person may make such donation without the consent of his spouse. c. After the death of a person the next of kin may authorize the donation of an organ or any part of the body of the deceased for similar purposes in accordance with the prescribed procedure. d. If the deceased has no next of kin and his remains are in the custody of an accredited hospital, the Director of the hospital may donate an organ or any part of the body of the deceased in accordance with the requirements prescribed in this Section. e. A simple written authorization signed by the donor in the presence of two witnesses shall be deemed sufficient for the donation of organs or parts of the human body required in this Section, notwithstanding the provisions of the Civil Code of the Philippines on matters of donation. A copy of written authorization shall be forwarded to the Secretary. f. A n y authorization granted in accordance with the requirements of this Section is binding to the executors, administrators, and members of the family of the deceased. Persons w h o can grant permission to detach, after death, human organs or part or parts of the human body for medical, surgical and other scientific purpose: a. Before

Death:

( 1 ) By the deceased during his lifetime. ( 2 ) If the deceased is a minor or incompetent, permission may be executed by the guardian with the approval of the court or by the legitimate father or mother. A married woman may give consent without the consent of the husband. b. After Death: (1) The nearest relative. (2) In the absence of the nearest relative, permission may be given by the head of the hospital or institution having custody of the deceased. Persons permitted to detach human organs, or parts of the human body for medical, surgical and other scientific use: a. Licensed physicians and surgeons. b. Known scientists. c. Medical or scientific institutions including eye-banks. Requirements for a Valid Authorization: a. It must be in writing. b. It must specify the person or institution granted the authorization.

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c. It must specify the organ or part of the body to be detached. d. It must be signed by the grantor and two disinterested persons. e. A copy of the authorization must be furnished to the Secretary of Health. Limitation to the Authorization: It will be illegal to removed organs or portions of the human body if the deceased died of a dangerous communicable disease. Penal Provision: Imprisonment of not less than six months nor more than one year. If committed by an institution, the director, manager, president or other officials or employees who knowingly or through neglect performed an act or acts resulting in said violation shall be criminally responsible. EXHUMATION: The deceased buried may be raised or disinterred upon the lawful order of the proper authorities. The order may come from the provincial or city fiscals, from the court, and from any entity vested with authority to investigate. If the body is exhumed for the purpose of performing postmortem examination, no deodorant must be applied to the body for it might interfere in the detection of, chemicals. After the body has been disinterred, it must be identified by relatives, friends, or by marks on the body. The physician must describe the coffin, clothings, degree of decomposition before stating the actual disease or violence in his report. Sec. 1082, Revised Administrative Code: Cemetery permits — It shall be unlawful to establish, maintain, enlarge, reopen, or remove any burial ground or cemetery, or to disinter a human body or human remains, until a permit therefor, approved by the Director of Health, shall have been obtained. Questions: Is the National Bureau of Investigation required to obtain a permit from the Director of Health for exhumation of a dead body in the course of a legal investigation conducted by it? The query was made on the presumption that the one to perform the exhumation is a physician who is in a capacity to protect public health. Answer: In the opinion rendered by the Secretary of Justice the answer is yes. Sec. 1082 and 1095 of the Revised Administrative Code requiring a permit in disinterring a human or human remains from the Director of Health also extends to cases where exhu-

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mation has to be done for an autopsy by any person authorized to do so in the course of a legal investigation. The language of those two sections are clear and absolute in terms and admits of no exception. Nor any exception to the said requirement be found in any of the provisions dealing with legal investigations. This is so because the purpose of the requirement of said permit is the protection of health which may not be sacrificed where a legal investigation is being conducted (Opinion of the Secretary of Justice, No. 26, series of 1954). Sec. 1095, Revised Administrative Code: Permit to disinter after three years — Treatment of remains: Permission to disinter the bodies or remains of persons who have died of other dangerous communicable disease, may be granted after such bodies had been buried for a period of three years; and, in special cases, the Director of Health may grant permission to disinter after a shorter period when in his opinion the public health will not be endangered thereby. The body or remains of any such deceased person, upon exhumation, shall be immediately disinfected and inclosed in a coffin, case, or box, securely fastened, and this coffin, case, or box shall be placed in sn outside box which shall also be securely fastened. Sec. 1096, Revised Administrative Code: Special permit to disinter embalmed body receiving vault for transfer:

or to remove from

Special permits may be issued at any time for the disinterment or exhumation of remains of persons, dying of other than dangerous communicable disease, that have been properly embalmed by an undertaker or embalmer, or for the transfer or removal of bodies that have been placed in a receiving vault awaiting transportation from the Philippines. Boxes containing the bodies or remains shall be plainly marked so as to show the name of the deceased, place of death, cause of death and the point to which such bodies or remains are to be shipped. Sec. 1097, Administrative Code: Exhumation in case of death from dangerous communicable disease: Bodies or remains of persons who have died of any dangerous communicable disease may be exhumed only after the lapse of five years from burial, though in special cases the Director of Health may grant a permit to disinter after a shorter period when in his opinion the public health will not be endangered thereby.

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In every such case, the body or remains, after being disinfected must be placed in a suitable and hermetically sealed container! Sec. 92, Code of Sanitation — Disinterment Requirements: Disinterment of remains is subject to the following requirements; a. Permission to disinter remains of persons who died of nondangerous communicable diseases may be granted after a burial period of three ( 3 ) years. b. Permission to disinter remains of persons who died of dangerous communicable diseases may be granted after a burial period of five ( 5 ) years. c. Disinterment of remains covered in paragraphs "a" and " b " of this Section may be permitted within a shorter time than that prescribed in special cases, subject to the approval of the Regional Director concerned or his duly authorized representative. d. In all cases of disinterment, the remains shall be disinfected and placed in a durable and sealed container prior to their final disposal. Art. 308, Civil Code: No human remains shall be retained, interred, disposed of or exhumed without the consent of the persons mentioned in articles 294 and 305. The persons mentioned in articles 294 are: ( 1 ) Spouse; ( 2 ) Descendants of the nearest degree; ( 3 ) Ascendants of the nearest degree; and ( 4 ) Brothers and sisters. How Long Can Exhumation Be Done After Interment: a. If the person died of dangerous communicable disease, the dead body may be exhumed only after a lapse of five years from the date of burial. However, permit to disinter may be given after a shorter period when in the opinion of the Director of Health it will not endanger public health. Sec. 1097, Administrative Code — Exhumation in case of death from dangerous communicable disease — Bodies or remains of persons who have died of any dangerous communicable disease may be exhumed only after the lapse of five years from burial, though in special cases the Director of Health may grant a permit to disinter after a shorter period when in his opinion the public health will not be endangered thereby.

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LEGAL MEDICINE Sec. 92 (b & c), ( P . D . 856) Code of Sanitation — Disinterment requirements: a b. Permission to disinter remains of persons who died of dangerous communicable diseases may be granted after burial period of five ( 5 ) years. c. Disinterment of remains covered in paragraphs "a" and " b " of this Section may be permitted within a shorter time than that prescribed in special cases, subject to the approval of the Regional Director concerned or his duly authorized representative.

b. If a person died of a cause other than dangerous communicable disease, permission for exhumation may be granted after such body had been buried for a period of three ( 3 ) years. However, in special cases the Director of Health may grant permission after a shorter period when in his opinion the public health will not be endangered thereby. Sec. 1095, Revised Administrative Code — Permit to disinter after three years — Treatment of Remains — Permission to disinter the bodies or remains of persons who have died of other than dangerous communicable disease, may be granted after such bodies had been buried for a period of three years; and, in special cases, the Director of Health may grant permission to disinter after a shorter period when in his opinion the public health will not be endangered thereby. Sec. 92 ( a ) , ( P . D . 856) Code of Sanitation — Disinterment requirement — Permission to disinter remains of person who died of non-dangerous communicable diseases may be granted after a burial period of three ( 3 ) years. c. Sec. 1098, Revised Administrative Code — Shipment of remains by sea — No body or remains shall be shipped to the United States except under such conditions and regulations as may be prescribed by the United States Public Health Service. The outside box containing the body or remains of a deceased person intended for shipment by sea shall be plainly marked so as to show the name, age, nationality of the deceased person, the cause of death, and the destination of the remains. d. If the dead body is a subject matter of criminal investigation it may be exhumed anytime. Sec. 95 ( b ) , ( P . D . 856) Code of Sanitation — Autopsy shall be performed in the following cases — ( 4 ) Whenever the Solicitor General, Provincial or city fiscal as authorized by existing laws,

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shall deem it necessary to disinter and take possession of the remains for examination to determine the cause of death. Requirements to be Satisfied in Exhumation: a. Duration of interment as required (supra). b. Exhumation permit: Sec. 1082, Revised Administrative Code — Cemetery permits — It shall be unlawful to establish, maintain, enlarge, reopen, or remove any burial ground or cemetery, or to disinter a human body or human remains, until a permit therefor, approved by the Director of Health, shall have been obtained. c. Compliance of the sanitary requirements: Sec. 1095,2nd. par., Revised Administrative Code —Permit to disinter after three years — The body or remains of any such deceased person, upon exhumation, shall be immediately disinfected and inclosed in a coffin, case, or box, as securely fastened, and this coffin, case, or box shall be placed in an outside box which shall also be securely fastened. Sec. 92 ( d ) , ( P . D . 856) Code of Sanitation — In all cases of disinterment, the remains shall be disinfected and placed in a durable and sealed container prior to their final disposal. Procedures Followed in Medico-Legal Exhumations: a. There must be a formal request from any of the law enforcement agency or any entity or person authorized by law to make investigation addressed to any establishment or person authorized to perform medico-legal investigation. The request must mention the name of the deceased, place of interment, date of interment, suspicion as to the cause of death, etc. The reason for the request may be: ( 1 ) To determine the cause of death; ( 2 ) To determine the identity of the deceased; ( 3 ) To recover organs or tissues for further examination: ( a ) For toxicological analysis, ( b ) For histopathological examination, (c) Smears from vaginal canal and blood for alcohol determination; or ( 4 ) To recover foreign bodies: ( a ) Metallic fragment or whole slug for ballistic examination. ( b ) Operative sponge, medical instrument to prove negligence of surgeon. b. If the physician found out that there is justification to the exhumation and a strong probability for the purpose to be realized, he may then set the date and time of the exhumation.

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LEGAL MEDICINE c. A written request for exhumation of the body of the deceased must be sent to the Ministry of Health or the Regional Director concerned, mentioning among other things: (1) Name of the deceased. (2) Place of exhumation. ( 3 ) Date and time of exhumation. ( 4 ) Duration of interment. ( 5 ) Purpose of exhumation. The Ministry of Health aside from issuing the necessary permit together with the conditions to be complied with, will inform the local health officer concerned to assist the physician to perform the exhumation to see to it that public health will not be prejudiced.

d. During actual exhumation, the grave must be properly identified by the person who was present when the body was interred. e. During the process of disinterment care and diligence must be observed to avoid destruction, deformity, contamination or such other effects that will prevent the realization of its objectives. f. After opening the coffin, the body must be viewed by any or more persons who can identify the deceased. The names of the person who identified the grave, who viewed and identified the deceased must be included in the report. The exhuming physician must describe the coffin, wearing apparel and condition of the body. g. Actual autopsy and adoption of the procedure is needed to accomplish the purpose of the exhumation. h. Disinfection of the body and all the areas involved must be carried out with the assistance of the local health officer and return of the body to the burial place. What must be Included in the Exhumation Report: a. The name of the deceased and the personal circumstances (age, sex, civil status, address, occupation, etc.). b. The purpose(s) of exhumation; c. The name, address and designation of the requesting party; d. The date, time and place of exhumation; e. The description of the burial place; f. The name and address of person(s) who identified the burial place; g. The condition of the body and coffin (if there is) after disinterment.

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h. The name and address of the person(s) who identified the body of the deceased; i. The post-mortem examination and accomplishment of the pnrpose(s) of the exhumation; j. The conclusion(s) based on the findings and result of the examination; k. Remarks (if any); and 1. The signature and designation of the physician. Some Problems in Exhumation: a. Identity of the deceased: The exhumed buried deceased might not be subject-matter of exhumation especially when the burial ground is a cemetery. Mass burial of "salvaging" victims or disaster victims may cause serious problem to the physician. There must be a meticulous and time consuming attempt of the exhuming physician to establish identity in order that his report may be of some value in the investigative or judicial proceedings. b. Refusal of the next-of-kin to give consent or to cooperate in the exhumation-autopsy: This situation is frequently observed when the next-of-kin has a strong possibility to be involved in the investigation. The proper remedy to this situation is to petition the court to issue an order to exhume the body stating the specific reasons why exhumation-autopsy will serve the best interest of justice.

Chapter IX MEDICO-LEGAL ASPECTS OF PHYSICAL INJURIES Physical injury is the effect of some forms of stimulus on the body. The effect may only be apparent when* the stimulus applied is insufficient to cause injury and the body resistance is great. It may be real when the effect is visible. The effect of the application of stimulus may be immediate or may be delayed. A thrust to the body of a sharp pointed and sharp edged instrument will lead to the immediate production of a stab wound, while a hit by a blunt object may cause the delayed production of a contusion. ^ C a u s e s of Physicial Injuries: A^Thysical Violence J Br Heat or Cold J Or Electrical Energy A ECChemical Energy \ E. Radiation by Radio-Active Substances V F Change of Atmospheric Pressure (Barotrauma) G. Infection A. PHYSICAL INJURIES BROUGHT ABOUT BY PHYSICAL VIOLENCE The effect of the^apphcation of physical violence on a person is the production ofTwojund: ) f\ A wound is the solution of the natural continuity of any tissue of the living body. It is the disruption of the anatomic integrity of a tissue of the body. In several occasions, the word physical injury is used interchangeably with wound. However, the effect of the physical violence may not always result to the production of wound, but the wound is always the effect of physical violence. Physics of Wound Production: Wound = Kinetic energy X time X area X "other factors" MV Kinetic Energy = 240

2

M=Mass

V=Velocity

MEDICO-LEGAL ASPECTS OF PHYSICAL INJURIES Kinetic energy: Inasmuch as kinetic energy is based on the mass and velocity factors and that the velocity is squared, the velocity component is the important factor. This explains why an M-16 bullet which has a speed or 3,200 ft/sec. will do more damage than a 0.38 caliber bullet which is heavier but has a much slower velocity. Time: The shorter the period of time needed for the transfer of energy, the greater the likelihood of producing damage. If a person is hit on the body and the body moves towards the direction of the force applied, the injury is less as when the body is stationary. The longer the time of contact between the object or instrument causing the injury, the greater will be the dissipation of energy. Area of Transfer: The larger the area of contact between the force applied on the body, the lesser is the damage to the body. By applying an equal force, the damage caused by stabbing is greater compared to a blunt instrument. "Other Factors": The less elastic and plastic the tissue, the greater the likelihood that a laceration will result. Elasticity and plasticity refer to the ability of a tissue to return to its "normal" size and shape after being deformed by a pressure. The movement of the parts of the body as a result of the force being applied to them and the local stretching of tissue during acceleration and deceleration cause most of the internal injuries seen in traumatized individuals. A force transmitted through a tissue containing fluid will force the fluid away from the area of contact in all directions equally, frequently causing the tissue to lacerate (Legal Medicine Annual 1980, Cyril Wecht ea\, p. 36). Vital Reaction: It is the sum total of all reactions of tissue or organ to trauma. The reaction may be observed macroscopically and microscopically. The following are the common reactions of a living tissue to trauma: a. "Rubor" — Redness or congestion of the area due to an increase of blood supply as a part of the reparative mechanism. b. "Calor" — Sensation of heat or increase in temperature. c. "Dolor" — Pain on account of the involvement of the sensory nerve.

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d. Loss of function — On account of the trauma, the tissue may not be able to function normally. The presence of the vital reaction differentiates an ante-mortem from a post-mortem injury. In the following instances vital reactions or changes may not be observed even if injury was inflicted during life: a. If physical injuries are inflicted during the agonal state of a living person. The body cells or tissue during the period may no longer have the potential capacity to react to the trauma; and b. If death is so sudden as not to give the tissues of the body, the chance to react properly. This is commonly observed in deaths due to sudden coronary occlusion. t / c L A S S I F I C A T I O N OF WOUNDS: cV^fs to Severity: &S&ortal Wound — Wound which is caused immediately after infliction or shortly thereafter that is capable of causing death. Parts of the Body where the Wounds Inflicted are Considered Mortal: (a) Heart and big blood vessels. (2) Brain and upper portion of the spinal cord. (3) Lungs. (4) Stomach, liver, spleen and intestine. J^f Non-mortal wound — Wound which is not capable of producing death immediately after infliction or shortly thereafter. 3^. As to the Kind of Instrument Used: a. Wound brought about by blunt instrument (contusion, hematoma, lacerated wound). ~~ b. Wound brought about by sharp instrument: ( 1 ) Sharp-edged instrument~(incised wound). ( 2 ) Sharp-pointed instrument (punctured wound). ( 3 ) Sharp-edged and sharp pointed instrument (stab wound). c. Wound brought about by tearing force (lacerated wound). d. Wound brought about by change of atmospheric pressure (barotrauma). e. Wound brought about by heat or cold (frostbite, burns or scald). f. Wound brought about by chemical explosion (gunshot or shrapnel wound). g. Wound brought about by infection, ifc As to the Manner of Infliction: a. Hit — by means of bolo, blunt instrument, axe.

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b. Thrust or stab — bayonet dagger. c. Gunpowder explosion — projectile or shrapnel wound. d. SlidingTor rubbing or abrasion. ^4^s regards to the Depth of the Wound: a. /Superficial — When the wound involves only the layers of the skin. iyDeep — When the wound involves the inner structure beyond the layers of the skin. {Impenetrating — one in which the wounding agent enters the body but did not come out or the mere piercing of a solid organ or tissue of the body. "Penetrating Wound — Wound where the dimension of depth and direction is an important factor in its description. It involves the skin or mucous surface and the deeper underlying tissues or organs caused directly by the wounding instrument. Punctured, stab and gunshot wounds / usually belong to this type of wound." (£) Perforating — When the wounding agent produces communication between the inner and outer portion of the hollow organs. It may also mean piercing or traversing completely a particular part of the body causing communication between the points of entry and exit of the instrument or substance producing it. f^i^ >. As regards to the Relation of the Site of the Application of Force and the Location of Injury: a. Coup Injury — Physical injury which is located at the site of the application of force, -y. k***' s b. Contre-Coup Injury — Physical injury found opposite the site of the application force. c. Coup Contre-Coup Injury — Physical injury located at u\e site and also opposite the site of application of force. d. "Locus Minoris Resistencia" — Physical injury located not at the site nor opposite the site of the application of force but in some areas offering the least resistance to the force applied. A blow on the forehead may cause contusion at the region of the eyeball because of the fracture on the papyraceous bone forming the roof of the orbit. e. Extensive Injury — Physical injury involving a greater area of the body beyond the site of the application of force. It has not only the wide area of injury but also the varied types of injury. A fall from a height or a run-over victim of a vehicular

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accident may suffer from multiple fractures, laceration of organs, and all types of skin injuries. When a stationary head is hit by a moving object, there is the tendency for the development of contusion of the brain at the site of impact. When the moving head hits a firm, fixed and hard object, brain contusion may develop at the opposite of the site of impact. A coup-contra-coup location of brain injury may be found when a fixed head is hit with a moving object and then falls on another hard object. ( ^ 4 s to the Regions or Organs of the Body Involved: The wounds of the different organs and regions of the body will be discussed separately under "Injuries in Various Parts of the Body.' 7. Special Types of Wounds: a. Defense Wound — Wound which is the result of a person's instinctive reaction of self-protection. Injuries suffered by a person to avoid or repel potential injury contemplated by the aggressor. A person w h o is conscious that he is going to be hit by a Qblnni instrument on the head may raise his flexed forearms over his head, causing injuries on the forearms.

Incised ( d e f e n s e ) w o u n d

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If someone is going to stab another with Psharp instrument the tendency of the potential victim is to ta^e~Hbld of the instrument thus causing the production of an incised or a stab wound on the palm of the hand. vn-UAj„L \yPatterned Wound — Wound in the nature and shape of an object or instrument and which infers the object or instrument causing it. Impact of the face on the radiator grill of a car may cause imprint of the radiator grill on the face. A person run over by a wheel of a car, tire marks are shown on the body. Due to hanging, the nature of the abrasion mark on the neck may infer material used. Contusion produced by belt, branch of tree, metallic rod, etc. may have the shape of the wounding instrument. jtf Self-inflicted Wound—Self-inflicted wound is a wound produced on oneself. As distinguished from suicide, the person has no intention to end his life. Motive of Producing Self-inflicted Wounds: (1) To create or deliberately magnify an existing injury or disease for pension or workman's compensation; ( 2 ) To escape certain'obligations or punishment. During war time soldiers may cut their fingers to avoid frontline assignments and prisoners may inflict physical injuries on their body to avoid hard labor and just be confined in a hospital to receive food and rest. ( 3 ) To create a new identity or destroy the existing one. Fingerprints may be destroyed by acid, by cutting or burning. A person may even Request for the services of a plastic surgeon to create a new identity or destroy existing ones. (4) To gain attention or sympathy. ( 5 ) Psychotic behavior. Some Ways of Self-Mutilation: (1) Head banging or bumping — This is commonly observed in overactive children and causes hematoma. (2) Exposure of parts of the body to heat radiation from open fires, radiators, or protective grills over radiator (thermophilia). (3) Penetrating nail or spike to the chest wall, or insertion into the urinary bladder in a female. (4) Castration by amputation of the penis.

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LEGAL MEDICINE (5) Trauma inflicted on the female genitalia to induce abortion or promotes hemorrhage and creates an anemia. ( 6 ) Subcutaneous injection of fecal matters to promote abscess formation. ( 7 ) Pricking of acne eruption to lead to a severe facial disfigurement. ( 8 ) Subcutaneous injection of air to create a condition of emphysema. ( 9 ) Nail-biting (onychophagia) which may lead to maceration of the skin and an infection. (10) Grinding of the teeth (bruxism) is frequently seen in the mentally retarded and can lead to abnormal tooth wear, a bilateral hypertrophy of the masseter and a pain on chewing. (11) Pressure on the subcutaneous tissue by a tightly applied cord or belt around the body: (a) Tribal customs of metal band around the heck or a leg by some African tribes may cause a permanent disfigurement. ( b ) Use of shoes made of metal by Chinese women. (12) Pulling of the body hair (Trichotillomania). (Forensic Medicine A Study in Trauma & Environmental Hazards by Tedeschi, Eckert & Tedeschi, Vol. 1, p. 496).

LEGAL CLASSIFICATION OF PHYSICAL INJURIES: utilation: Art. 262, Revised Penal Code: The penalty of reclusion temporal to reclusion perpetua shall be imposed upon any person who shall intentionally mutilate another by depriving him, either totally or partially, of some essential organ for reproduction. A n y other intentional mutilation shall be punished by prision mayor in its medium and maximum periods. Kinds of Mutilation Punishable Under the Code: 1. Intentionally depriving a person, totally or partially of some of the essential organs for reproduction, and 2. Intentionally depriving a person of any part or parts of the human body other than the organs for reproduction. Mutilation is the act of looping or cutting off any part or parts of the living body. In order to be punishable under the Code, it must be intentional, otherwise it will be considered as a physical injury.

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The loss of an eye due to stabbing is not mutilation. It is evident that the putting out of an eye does not fall under the definition (U.S. v. Bogel, 7Phil 285). "Mayhem " is the unlawful and violent deprival of another of the use of a part of the body so as to render him less able in fighting, either to defend himself or to annoy his adversary. Mutilation of other parts of the body other than the organ of reproduction may be classified as mayhem. However, if it is not deliberate then it may fall on paragraph 2, Art. 263, Revised Penal Code (Serious Physical Injuries). Is vasectomy and tubal ligation within the purview of mutilation as defined and penalized by Art. 262 of the Revised Penal Code? On September 1973 upon the request of the Executive Director of the Population Commission, the Secretary of Justice rendered an opinion that vasectomy and tubal ligation are not mutilation and a legitimate method of contraception despite the fact that it is done intentionally and deprives a person of his power of reproduction because: "1. In the case of U.S. v. Bogel et. aL 5 Phil. 285 (1907) the Supreme Court, in holding that the putting out of an eye is not mutilation under Article 415 of the Spanish Penal Code which penalized intentional mutilation, stated "Viada in his commentary on Article 415 which penalized intentional mutilations, points out that by mutilation (mutilacion) is understood, according to the "Diccionario de la Lengua Espahola", the looping or clipping off (ceranamiento) of one part of the body. As this provision of the Spanish Penal Code was the source of the above quoted provision of the Revised Penal Code, it is the same expounded by Viada that the prohibition in the latter provision should be understood. Y o u stated that tubal ligation and vasectomy "do not involve looping or clipping off of the organs of reproduction of both sexes". I understood that these two methods of surgical sterilization are affected by the closing of a pair of tubes in either man or the woman so that the sperm and ovum cannot meet; it does not involve the removal of reproductive glands or organs as in the case of castration, with which it is sometimes confused. {Encyclopedia Americana, Sterilization, Human Vol. 25, p. 269; an article written by the Executive Director of the Human Betterment Association of American, I.C.) Such being the case, I do not think that these method of contraception could be regarded as mutilation within the contemplation of Article 262, Supra."

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/ Serious Physical Injuries: Art. 263, Revised Penal Code: Any person who shall wound, beat, or assault another, shall be guilty of the crime of serious physical injuries and shall suffer: 1. The penalty of prision mayor, if in consequence of the physical injuries inflicted, the injured person shall become insane, imbecile, impotent, or blind; 2. The penalty of prision correccional in its medium and maximum periods, if in consequence of the physical injuries inflicted, the person injured shall have lost the use of speech or the power to hear or to smell, or shall have lost an eye, a hand, a foot, an arm, or a leg or shall have lost the use of any such member, or shall have become incapacitated for the work in which he was theretofor habitually engaged; 3. The penalty of prision correccional in its minimum and medium periods, if in consequence of the physical injuries inflicted, the person injured shall have become deformed, or shall have lost any other part of his body, or shall have lost the use thereof, or shall have been ill or incapacitated for the performance of the work in which he was habitually engaged for a period of more than ninety days; 4. The penalty of arresto mayor in its maximum period to prision correccional in its minimum period, if the physical injuries inflicted shall have caused the illness or incapacity for labor of the injured person for more than thirty days. If the offense shall have been committed against any of the persons enumerated in article 246, or with attendance of any of the circumstances mentioned in article 248, the case covered by subdivision number 1 of this article shall be punished by reclusion temporal in its medium and maximum periods; the case covered by subdivision number 2 by prision correccional in its maximum period to prision mayor in its minimum period; the case covered by subdivision number 3 by prision correccional in its medium and maximum periods; and the case covered by subdivision number 4 by prision correccional in its minimum and medium periods. The provisions of the preceding paragraph shall not be applicable to a parent who shall inflict physical injuries upon his child by excessive chastisement. The crime of serious physical injuries may be due to: (1) Wounding; ( 2 ) Beating;

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( 3 ) Assaulting ( A r t . 263); or ( 4 ) Administering injurious substances (Art. 264) without the intent to kill. It may be committed through a simple negligence or imprudence. The main purpose of dividing the provision into four paragraphs is to graduate the penalties depending upon the nature and character of the wound inflicted and their consequences on the person of the victim. In paragraph one, the injured person became insane, imbecile, impotent, or blind. Insanity has not been defined or qualified by the article. Imbecility infers that the injured person must be of the preadolescent age and that on account of the physical injuries inflicted there is an arrest of mental development. Impotency is the inability to grant to the partner sexual gratification. Blindness must be total or involvement of both eyes. If only one eye became blind, then the physical injury will fall in paragraph 2 of Article 263. In paragraph two, the following nature and character of the wound or consequences of the injuries inflicted must be present: a. Loss of the use of speech or the power to hear or to smell, or loss of an eye, a hand, a foot, an arm, or a leg; b. Loss of the use of any such member; or c. Becomes incapacitated for the work in which he was therefore habitually engaged. There must be a total loss of hearing capacity. If the loss of power to hear is only in one ear, it is a serious physical injury under paragraph 3, article 263 (People v. Hernandez, 94 Phil. 49). Insofar as loss of a hand is concerned, the prosecution must prove by clear and conclusive evidence that the offended party actually cannot make use of his hand and that such impairment is permanent (People v. Reli. C.A. 53 O.G. 5695). In paragraph three, the following physical injuries or their consequences are included: a. Deformity; b. Loss of any other member of his body; c. Loss the use thereof; or d. Becomes ill or incapacitated for the performance of the work in which he was habitually engaged for more than 90 days, as a consequence of the physical injuries inflicted.

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Deformity is a condition of physical ugliness. It must be permanent and conspicuous. The loss of the front teeth, the development of a pigmented scar on the face, or loss of the pinna of the ear are considered deformities. However, the development of a scar in covered plots of the body may not be considered deformity because it is not conspicuous and visible. "The loss of any other part of his body" means loss of the parts of the body not mentioned in paragraph 2, Art. -263. Incapacity means the inability of the injured person to perform, or engage on a work or vocation before he sustained injury. In paragraph four, the injured person becomes ill or incapacitated for labor for more than thirty days and impliedly less than 90 days. It is noteworthy to mention that in paragraphs 3 and 4 of article 263 there is no mention of periods of medical attendance but merely incapacity. Administering Injurious Substances or Beverages: Art. 264, Revised Penal Code: The penalties established by the next preceding article shall be applicable in the respective cases to any person who, without intent to kill, shall inflict upon another any serious physical injury, by knowingly administering to him any injurious substances or beverages or by taking advantages of his weakness of mind or credulity. Elements of the crime: a. The offender inflicted upon another person any serious physical injury. b. The infliction of physical injury was done knowing that the substance or beverage administered is injurious or took advantage of the victim's weakness or credulity; and c. There was no intent to kill on the part of the offender. If the offender does not know that the substance administered is injurious, he cannot be held liable under the above provision. The throwing of acid on the face of someone does not fall within the provision because what the provision contemplates is administering or taking in the injurious substance or beverages (U.S. Chiong Songco, 18 Phil. 459). The provision does not contemplate of slight or less serious physical injuries which is the consequence of injurious substances or beverages, but results only in serious physical injuries. If the administration of injurious substances or beverages is intentional, the crime committed is frustrated murder. Treachery is.

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

LEGAL MEDICINE Obligation Imposed on Physicians W h o have Treated Persons Suffering From Serious and Less Serious Physical Injuries: P R E S I D E N T I A L D E C R E E N O . 169 W H E R E A S , Pursuant to Proclamation N o . 1081, dated September 21, 1972 and N o . 1104, dated January 17, 1973, martial law has been declared throughout the Philippines to, among other goals, restore and maintain peace and order; W H E R E A S , for the attainment of the aforesaid goal, and to enable the law-enforcement agencies to keep track of all violent crimes, conduct timely investigation thereon and effect the immediate arrest of the perpetrators thereof, it is necessary that all persons treating physical injuries resulting from any form of violence be required to report such fact to said agencies; W H E R E A S , while some of the victims of violent crimes, or those who may have sustained physical injuries in the act of committing or as a result of the commission of a crime submit themselves for medical treatment in hospitals, medical clinics, sanitariums, or other medical establishments or to medical practitioners, they do not report their injuries to the law-enforcement agencies for one reason or another; N O W , T H E R E F O R E , I, F E R D I N A N D E. M A R C O S , pursuant to Proclamation N o . 1081, dated September 21, 1972 and N o . 1104, dated January 17, 1973 and in my capacity as Commander-in-Chief of all the Armed Forces of the Philippines, do hereby order and decree that: 1. The attending physician of any hospital, medical clinic, sanitarium or other medical establishments, or any medical practitioner, who has treated any person for serious or less serious physical injuries as those injuries are defined in Articles 262, 263, 264 and 265 of the Revised Penal Code shall report the fact of such treatment personally or by the fastest means of communication to the nearest Philippine Constabulary unit without delay: provided, that no fee shall be charged for the transmission of such report thru government communication facilities; and 2. The report called for in this Decree shall indicate when practicable the name, age, address and nearest of kin of the patient; the nature and probable cause of the injury; the approximate time and date when, and the place where the injury was sustained; time, date and nature of treatment; and the physical diagnosis and/or disposition of the patient.

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I do further order and decree that any violation of this Decree and/or the rules and regulations which shall be promulgated by competent authorities in accordance herewith, with malicious intent or gross negligence, shall suffer the penalty of imprisonment for not less than one year nor more than ( 3 ) years and/or a fine of not less than 1,000 nor more than 3,000 pesos, as a military tribunal may direct. In addition, the government license or permit of the attending physician to practice his profession shall be cancelled by the Civil Service Commission after the sentence imposed by the military tribunal become final and executory. The Secretary of Health and the Secretary of National Defense shall promulgate the necessary rules and regulations to carry out the purpose of this Decree. Done in the City of Manila, this 4th day of April, in the Year of Our Lord, nineteen hundred and seventy-three. (SGD) F E R D I N A N D E. MARCOS President Republic of the Philippines Slight Physical Injuries and Maltreatment: Art. 266, Revised Penal Code: The crime of slight physical injuries shall be punished: 1. By arresto menor when the offender has inflicted physical injuries which shall incapacitate the offended party for labor from one to nine days, or shall require medical attendance during the same period; 2. By arresto menor or a fine not exceeding 200 pesos and censure when the offender has caused physical injuries which do not prevent the offended party from engaging in his habitual work nor require medical attendance; 3. By arresto menor in its minimum period or a fine not exceeding 50 pesos when the offender shall illtreat another by deed without causing any injury. Kinds of Slight Physical Injuries Punishable by the Code: 1. Physical injuries which incapacitate the victim for labor from one to nine days, or require medical attendance for the same period. This kind of slight physical injuries will require medical certification as to the duration of medical attendance, or period of incapacity. In case of divergency in the duration of medical attendance and incapacity, the physician must always consider the best interest of the victim in the determination of the period.

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2. Physical injuries which did not prevent the offended party from engaging in his habitual work or which did not require medical attendance. If the victim merely suffered from small contusion or superficial abrasion which does not require medical attendance or incapacity, this falls in the paragraph of slight physical injury. 3. Ill-treatment of another by deed without causing any injury. A slight slap on the face or holding tightly the arm of the victim which did not even develop redness of the skin may be a form of ill-treatment. If there is no evidence to show actual injury, or incapacity for labor, or period of medical attendance, the accused can only be guilty of slight physical injuries (People v. Penesa, 81 Phil. 398; People v. Amarao et al., C.A. 36 O.G. 3462). A tender slap on the face, holding the arm tightly, application of pressure in some parts of the body, or mild blow which show no sign of physical violence may still be considered slight physical injuries or maltreatment (3rd paragraph). Physical Injuries Inflicted in a Tumultuous Affray: Art. 252, Revised Penal Code: When in a tumultuous affray as referred to in the preceding article, only serious physical injuries are inflicted upon the participants thereof and the person responsible therefor cannot be identified, all those who appear to have used violence upon the person of the offended party shall suffer the penalty next lower in degree than that provided for the physical injuries so inflicted. When the physical injuries inflicted are of a less serious nature than the person responsible therefor cannot be identified, all those who appear to have used any violence upon the person of the offended party shall be punished by arresto from five to fifteen days. Elements of the Crime: a. There is a tumultuous affray; b. Participant(s) suffered from serious physical injuries; c. The person(s) who inflicted such serious physical injuries cannot be identified; and d. All those who appear to have used violence upon the person of the offended party shall be penalized by arresto from five to fifteen days. / T Y P E OF WOUNDS (Medical Classification): \/Closed Wound — There is nojareach of continuity of the skin or mucous membrane.

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a. Superficial — When the wound is just underneath the layers of the skin or mucous membrane. (1) Petechiae. r***-*"** ( 2 ) Contusion. \ - * * - « \ . ( 3 ) Hematoma. £ i M b. Deep. (1) Musculoskeletal Injuries. ( a ) Sprain. ( b ) Dislocation. (c) Fracture. ( d ) Strain. ( f ) Subluxation. (2) Internal Hemorrhage. ( 3 ) Cerebral Concussion. 2^. Open Wound — There is a breach of continuity of the skin or mucous membrane. ~~ " a. b. c. d. e.

1

Abrasion, q*!*Incised Wound, h-'iva Stab Wound. Punctured. Lacerated.

CLOSED WOUNDS: Petecbjaej_^___ This is a circumscribed extravasation of blood in the subcutaneous tissue or underneath the mucous membrane. The cause of passage of blood from the capillaries may be due to the increase intra-capillary pressure or increased permeability of the vessel. The hemorrhage may be small or pinhead sized but several petechiae may coalesce to form a bigger hemorrhagic area. Mosquito or other insect bites may cause the formation of circumscribed hemorrhages. Petechiae is not always a product of trauma. Petechial hemorrhage may be a post-mortem finding in asphyxial death, coronary occlusion and blood diseases. It may also develop post-mortem in death by hanging. There is gravitation of blood into the most dependent part of the body which eventually leads to the rupture of over-distended capillaries specially seen at the region of the leg. Contusion: Contusion is the effusion of blood into the tissues underneath the skin on account of the rupture of the blood vessels as a result of the application of blunt force or violence.

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When a blunt force is applied, it momentarily compresses the blood vessels at the point of contact, thereby temporarily forcing the blood out of the area and setting up a fluid wave under pressure. When the pressure exceeds the cohesive force of the cells forming the capillary, arteriole, or venule wall, the vessel ruptures. Inasmuch as it used to take more time for the blood to get out of the blood vessels, contusion does not immediately develop after the application of force. It may develop after a lapse of minutes or even hours after the application of force. The variation depends on the part of the body injured, tenderness of the tissues affected, condition of the blood vessels involved, and natural disease. Women are much more easily bruised than men while boxers are less prone to suffer contusion inspite of heavy punishment.

C o n t u s i o n of the right eyelids

The size of the contusion is usually greater than the size of the object causing it. The location of the contusion may not always indicate the site of the application of force. For instance, a blow on the forehead may cause black-eye or contusion around the tissues of the eye-ball, or a kick on the leg may cause appearance of contusion at the region of the ankle on account of the gravitation of the effusion, between muscles and fascia. On the medico-legal viewpoint, a contusion as indicated by its external pattern may correspond to the shape of the object or weapon used to produce it; its extent may suggest the possible degree

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257

of violence applied; and its distribution may indicate the character and manner of injury as in manual strangulation around the neck. It may infer grave complications and consequences on account of serious injuries of the underlying tissues. Age of Contusion: The age of contusion can be appreciated from its color changes. The size tends to become smaller from the periphery to the center and passes through a series of color changes as a result of the disintegration of the red blood corpuscles and liberation of hemoglobin. The contusion is red sometimes purple soon after its complete development. In 4 to 5 days, the color changes to green. In 7 to 10 days, it becomes yellow and gradually disappears on the 14th or 15th day. The ultimate disappearance of color varies from one to four weeks depending upon the severity and constitution of the body. The color changes start from the periphery inwards. Distinction Between (Supra p. 133).

Contusion

and

Post-mortem

Hypostasis

Factors Influencing the Degree and Extent of Contusion: (a) General condition of the victim — Some healthy persons are easily bruised. ( b ) Part of the body affected — Bloody parts of the body produce larger contusion, specially where subcutaneous tissue is loose. In areas of the body with excessive fat, contusion easily develops, while parts of the body with abundant fibrous tissue and good muscle tone, bruising is less. (c) Amount of force applied — Other factors being equal, the greater the force applied the more effusion of blood will develop. (d) Disease — Contusion may develop with or without the application of force. Examples: Purpura, Hemophilia, Aplastic anemia, Whooping cough, even vicarious menstruation. (e) Age — Children and old age persons tend to bruise more easily. Children have loose and tender skin. Old people have less flesh and the blood vessels are more fragile. (f) Sex — Women, specially if obese, easily develop contusion. Athletes, like boxers do not develop contusion easily. (g) Application of heat and cold — If immediately after injury cold compress is applied the production of contusion will be

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minimized. After it has already developed, application of warm compress will hasten its disappearance. The distinction between ante-mortem and post-mortem contusions in an undecomposed body is that in ante-mortem bruising, there is swelling, damage to epithelium, extravasation, coagulation and infiltration of the tissues with blood, while in post-mortem bruising there are no such findings. / H e m a t o m a (Blood Cyst, Blood Tumor, "Bukolg): /Hematoma is the extravasation or effusion of blood in a newly formed cavity underneath the skin. It usually develops when the blunt instrument is applied in part of the body where bony tissue is superficially located, like the head, chest and anterior aspect of the legs. The force applied causes the subcutaneous tissue to rupture on account of the presence of a hard structure underneath. The destruction of the subcutaneous tissue will lead to the accumulation of blood causing it to elevate. Distinction Between

Contusion and Hematoma:

(a) In contusion the effused blood are accumulated in the interstices of the tissue underneath the skin, while in hematoma blood accumulates in a newly formed cavity underneath the skin. ( b ) In contusion, the skin shows no elevation and if ever elevated, the elevation is slight and is on account of inflammatory changes, while in hematoma the skin is always elevated. (c) In contusion, puncture or aspiration with syringe of the lesion no blood can be obtained, while in hematoma, aspiration will show presence of blood and subsequent depression of the elevated lesion. Abscess, gangrene, hypertrophy, fibroid thickening and even malignancy are potential complications of hematoma. /Musculo-Skeletal Injuries: (1) Sprain — Partial or complete disruption in the continuity of a muscular or ligamentous support of a joint. It is usually caused by a blow, kick or torsion force. (2) Dislocation — Displacement of the articular surface of bones entering into the formation of a joint. ( 3 ) Fracture — Solution of continuity of bone resulting from violence or some existing pathology. (a) Close or Simple Fracture — Fracture wherein there is no break in continuity of the overlying skin or where the external air has no point of access to the site of injury.

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( b ) Open or Compound Fracture — The fracture is complicated by an open wound caused by the broken bone which protruded with other tissues of the broken skin. (c) Comminuted Fracture — the fractured bone is fragmented into several pieces. ( d ) Greenstick Fracture — A fracture wherein only one side of the bone is broken while the other side is merely bent. ( e ) Linear Fracture — When the fracture forms a crack commonly observed in flat bones. ( f ) Spina/ Fracture — The break in the bone forms a spiral manner as observed in long bones. (g) Pathologic Fracture — Fracture caused by weakness of the bone due to disease rather than violence. • ( 4 ) Strain — The over-stretching, instead of an actual tearing or the rupture of a muscle or ligament which may not be associated with the joint. / ( 5 ) Subluxation — Incomplete dislocation.

/Internal Hemorrhage: Rupture of blood vessel which may cause hemorrhage may be due to the following: (a> Traumatic intracranial hemorrhage. (b)- Rupture of parenchymatous organs. (c)-Laceration of other parts of the body. Cerebral Concussion (Commotio Cerebri): Cerebral concussion is the jarring or stunning of the brain characterized by more or less complete suspension of its functions, as a result of injury to the head, which leads to some commotion of the cerebral substance. Cerebral concussion is much more severe when the moving or mobile head struck a fixed hard object as compared when the head is fixed and struck by a hard moving object. s^Signs and Symptoms: (a) Unconsciousness which is more or less complete. ( b ) Muscles are relaxed and flaccid. (c) Eyelids are closed and the conjunctivae are insensitive. (d) Surface of the body is pale, cold and clammy. (e) Respiration is slow, shallow and sighing. ( f ) Pulse is rapid, weak, faltering and scarcely perceptible to the fingers. (g) Temperature is subnormal.

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(h) Sphincters are relaxed perhaps with unconscious evacuation of the bowel and bladder. ( i ) Reflexes are present but sluggish and in severe cases may be absent. Loss of memory for events just before the injury (retrograde amnesia) is a constant effect of cerebral concussion and is of medicolegal importance. / O P E N WOUNDS:

^ A b r a s i o n (Scratch, Graze, Impression Mark, Friction Mark): [ i t is an injury characterized by the removal of the superficial epithelial layer of the skin caused by a rub or friction against a hard rough surface.! Whenever, there is forcible contact before friction occurs, there may be contusion associated with abrasion. The shape varies and the raw surface exudes blood and lymph which later dries and forms a protective covering known as scab or crust.

Abrasions

Characteristics of Abrasion: a. ft develops at the precise point of impact of the force causing it. b. Grossly or with the aid of a hand lens the injury consists of parallel linear injuries which are in line with the direction of the rub or friction causing it. c. It may exhibit the pattern of the wounding material.

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261

d. It is usually ignored by the attending physician for it does not require medical treatment but it has far-reaching importance in the medico-legal viewpoint. ( 1 ) Abrasions caused by fingernails may indicate struggle or assault and are usually located in the face, neck, forearms, and hands. ( 2 ) Abrasions resulting from friction on rough surfaces, either intentional or accidental are located on bony parts of the body and usually associated with contusion or laceration. ( 3 ) Nature of the abrasion may infer degree of pressure, nature of the rubbing object and the direction of movement. e. Unless there is a supervening infection, abrasion heals in a short time and leaves no scar. If the whole thickness of the skin is involved, healing may be delayed and occasionally with scar formation. Torms of A brasion: a. Linear:

\MOA

An > abrasion which appears as a single line. It may be a straight or curved line. Pinching with the fingernails will produce a linear curved abrasion, while sliding the point of a needle on the skin will produce a straight linear abrasion. b. Multi-Linear: An abrasion which develops when the skin is rubbed on a hard rough object thereby producing several linear marks parallel to one another. This is frequently seen among victims of vehicular accidents. c.

Confluent: An abrasion where the linear marks on the skin are almost indistinguishable on account of the severity of friction and roughness o the object.

d. Multiple: Several abrasions of varying sizes and shapes may be found in different parts of the body. Types of Abrasions: a. Scratch: This is caused by ajsharp-pointed object which slides across the skin, like a pin, thorn or fingernail. The injury is always parallel to the direction of slide. The commencement and termination are well defined and the depth depends on the pressure applied. The fingernail scratch may be broad at the point of commencement and may terminate with a tailing.

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b. Graze: These are usually caused by forcible contact with rough, hard objects resulting to irregular removal of the skin surface. The nature of the injury is dependent upon the degree of roughness of the object and the amount of pressure in the course of the sliding. The course will be indicated by a clean commencement and tags on the end. c. Impact or Imprint Abrasion (Patterned Abrasion, "Abrasion A La Signature"):

Abrasion,

Stamping

Those whose pattern and location provides objective evidence to show cause, nature of the wounding material or instrument and the manner of assault or death. (1) Marks of the grid of the radiator may be imprinted on the skin. (2) Tire thread marks may be seen on the skin in vehicular accidents. (3) Muzzle imprint in contact fire gunshot wound of entrance. (4) Teeth impression mark in skin bites. d. Pressure or Friction Abrasion: Abrasion caused by pressure accompanied by movement usually observed in hanging or strangulation. The spiral strands of the rope may be reflected on the skin of the neck. The lesion may dry up and assume a papyraceous or parchmentlike consistency. .

~

,

,, ^

—.

.

A b r a s i o n in the f o r m of tire marks in a victim of vehicular accident

.

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263

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

Ante-mortem Abrasion

Post-mortem Abrasion

Color

Reddish-bronze. in appearance due to slight exudation of blood.

Yellowish and translucent in appearance.

Location

Any area.

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

Vital reaction

With intravital reaction and may show remains of damaged epithelium.

Shows no vital reaction and is characterized by a separation of the epidermis from complete loss of the former.

2. Incised Wound (Cut, Slash, Slice): This is produced by a sharp-edged (cutting) or ^sharp-linear edge of the instrument, like a knife, razor, bolo, edge of oyster shell,' metal sheet, glass, etc. It may be an impact cut when there is forcible contact of the cutting instrument with the body surface, or slice cut when cutting injury is due to the pressure accompanied with movement of the instrument. When the wounding instrument is a heavy cutting instrument, like axe, big bolo, saber, the wound produced is called Chopped or

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LEGAL MEDICINE

Hacked wound. The injury is quite severe, edges may or may not be contused depending on the nature of the edge of the instrument used. Characteristics of Incised Wound: a. Edges are cleanboth extremities are sharp, except in areas where the skin is loose or folded at the time of infliction. b. The wound is straight and may be shelving if inflicted with the wounding instrument applied with an acute angle to the surface of the body involved. c. Usually the wound is shallow near the extremities and deeper at the middle portion. However, this finding may be modified by the shape of the wounding instrument and part of the body involved. d. Because the blood vessels involved are clean-cut, profuse hemorrhage is invariably a feature. e. Gaping is usually present due to the retraction of the edges but Its presence and degree of retraction depends on the direction of the incised wound with the line of cleavage (Langer's line). f. If the incised wound is located in parts of the body covered with clothes, the clothing itself will show clean-cut of its texture. g. In the absence of complication and/or when there is deeper involvement present, healing is relatively fast and the scar may not or may develop conspicuously. h. Incised wound caused by broken edge of glass may be irregular and may appear like a punctured or stab wound. Fragments of the glass may be removed from the incised wound. Examination with the aid of a magnifying lens is necessary to determine the presence and removal of particles of flakes of glasses in the wound. Changes that occur in an Incised Wound: After 12 hours — Edges are swollen; adherent with blood and with leucocyte infiltration. After 24 hours — Proliferation of the vascular endothelium and connective-tissue cells. After 36-48 hours — Capillary network complete; fibrolasts running at right angles to the vessels. After 3-5 days — Vessels show thickening and obliteration. (From: Gradwohl's Legal Medicine by F.E. Camps ed., 3rd ed., p. 272).

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265

M u l t i p l e Incised w o u n d s ( H o m i c i d a l ) .

Deep incised wound may cause clean-cut fracture of the bone, severance of blood vessels and nerves or amputation. Paralysis may develop on account of the severed nerve and profuse hemorrhage may result to death. Embolism or supervening infection may later develop. ^ Why a Person Suffers from Incised Wound: a. As a therapeutic procedure — Pyogenic abscess and cystic conditions may be treated by incision. b. As a consequence of_self-defense — The sharp-edged instrument may be held by the victim in his attempt to avoid the offender to inflict more serious injuries on him. c. Masochist may self-inflict incised wound as a means of sexual gratification. d^Addicts and mental patients may suffer from incised wound irrationally. Incised Wounds may be Suicidal, Homicidal or Accidental: Suicidal — Located in peculiar parts of the body, like the jjeck, flexor surfaces of the extremities (elbow, groin, knee), wrist, and accessible to the hand in inflicting the injury. The most common instrument used is the Jaarber's razor blade with an improvised handle. There is usually superficial tentative cut (hesitation cuts) and the direction varies with the location and the hand (left or right) used in inflicting the injuries. The most

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266

common site of suicidal incised wounds are on the wrist with involvement of the radial artery and the neck. ^Homicidal — The incised wounds are deep, multiple and involve both accessible and non-accessible parts of the body to the hands of. the viGtim. "defense and other forms of wounds may be present. Clothings are always involved. ytil Accidental — Multiple incised wound isjoommonly observed on the passengers and _driver of vehicular accidents on account of the broken windshield and glass parts of windows. Stepping on oyster shell, broken glassesTsharp edges of metal sheets are common causes of incised wound on the sole of the foot. Those associated in the use of kitchen knives in the preparation of food, carpenters and handicraft workers who use sharp edged instruments are frequent victims of accidental incised wounds. Distinction Between Suicidal and Homicidal Cut-throat Suicidal Direction Oblique, from* Below left ear, downwards, .across front ^ e c k just .above Adam's apple. Severity Usually _noi_so deep and may only involve trachea carotid and sometimes the esophagus is involved. Superficial Usually present before Cut the commencement of deeper wound.

Homicidal Usually horizontal below tho "Adam's'apple.

Usually deep and may cause involvement of the cartilage and bones. Practically jibsent but may rarely be present when the victim struggled when attacked. Usually victim _lying on bed or in other place.

Position of the body

May be__sjtting facing a mirror or standing,

Wounding weapon

Firmly grasped (Cadaveric spasm) or found lying beside victim. Blood found in front part of the body. Hand generally smeared with blood.

Weapon is jjbsent.

History of mental depression, domestic, financial social problems, alcoholism etc. may prove suicide.

Absence of such history.

Blood distribution Motive

Blood found at the back of the neck. JIands clean.

MEDICO-LEGAL ASPECTS OF PHYSICAL INJURIES Previous history of selfdestruction

May be present.

267

Always absent,

Stab Wound: Stab wound is produced by the penetration of a sharp-pointed and sharp edged instrument, like a^knjfe, saber, dagger, scissors. It may involve the skin or mucous surface. IftRe sharp edgTportion of the wounding instrument is the first to come in contact with the skin, the wound produced is an incised wound, but if the sharp-pointed portion first come in contact, then the wound is a stab wound. As a general rule, like an incised wound, the edges are cleanzcut, regular and distinct. The surface length of a stab wound may reflect the width of the wounding instrument. It may be smaller when the wound is not so deep inasmuch as it is only caused by the penetration of the tapering portion of the pointed instrument. It may be made wider if the withdrawal is not on the same direction as when it was introduced or the stabbing is accompanied by a slashing movement. In the latter case the presence of an abrasion from the extremity of the skin defect is in line with direction of the slashing movement.

Incised and stab w o u n d s of the face and neck.

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LEGAL MEDICINE

The extremities of stab wound may show the nature of the instrument used. A double-bladed weapon may cause the production of both extremities sharp. A single bladed instrument may produce as one of its extremities rounded and contused. This distinction may not be clearly observed if the instrument is quite thin. The direction of the surface defect may be useful in the determination of the possible relative position of the offender and the victim when the wound was inflicted. As to whether the wound is a slit-like or gaping depends on the looseness of the skin and the direction of the wound to the line of cleavage (Langer's line). The depth may be influenced by the size and sharpness of the instrument, area of the body involved, and the degree of force applied. Involvement of the bones may cause clean-cut fracture on it. A portion of the wounding instrument, usually the tapering part, may remain in the body. X-ray examinations may be needed to reveal its location. Hemorrhage is always the most serious consequence of a stab wound. This is due to the severance of blood vessels or involvement of bloody organs.

M u l t i p l e stab w o u n d s

In the Description of a Stab Wound, the included:

following must be

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269

a. Length of the skin defect — The edges must be coaptated before the length is measured. If the abrasion tailing is present in one of the extremities, it must not be included in the measurement. The length of the tailing must be mentioned separately. The tailing infers the direction of withdrawal of the wounding weapon. b. Condition of the extremities — A sharp extremity may infer the sharpness of the edge of the instrument used. If both extremities are sharp, it may be inferred that a double-bladed weapon was used. c. Condition of the edges — If the injury is due to one stabbing act, the edges are regular and clean-cut. However if the wound is caused by several stabbing acts (series of thrusts and withdrawal), the edges may be serrated or zigzag in appearance. d. Linear direction of the surface wound — It may be running vertically, horizontally, or upward medially or laterally. e. Location of the stab wound — Aside from mentioning the region of body where it is located, its exact measurement to some anatomical landmarks must be stated. f. Direction of penetration — This must be tri-dimensional (backwards or forwards, upwards or downwards, and medially or laterally). g. Depth of the penetration. h. Tissue and organs involved. ^Stab Wound(s) may be Suicidal, Homicidal or Accidental: a. Suicidal — Evidences showing that the stab wound is suicidal: ( l ) - r t is located over the .vital parts of the body. (2) It is usually solitary. If multiple, they are located on one part of the body. (3) If located on covered parts of the body, the clothings are not involved. (AyThe stab wound is accessible to the hand of the victim. (5)-The hand of the victim is smeared with blood. (6)/The wounding weapon is firmly grasped by the hand of the victim (cadaveric spasm). ( 7 ) If stabbing is accompanied with slashing movement, the wound tailing abrasion is seen towards the hand inflicting the injury, (a HA suicide note may be present. (9)/There is the presence of a motive for self-destruction.

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(10)-No disturbance in the death scene, wounding instrument is found near the victim. b. Homicidal — Stabbing with homicidal intent is the most common. Characteristics: (1) Injuries other than stab wound may be present. (2) Stab wound may be located injmy part of the body. ( 3 ) Usually there are ©ore than one stab wound. (4) There is a motive for the stabbing. If without motive, the offender must be insane or under the influence of drugs. ( 5 ) There is disturbance in the crime scene.

S t a b w o u n d w i t h intestinal herniation.

^Medical evidences showing intent of the offender to kill the victim: a. There are more than one stab wounds. b. The stab wounds are located in different parts of the body or on parts of the body where vital organs are located. c. Stab wounds are_deep. d. Stab wound with serrated or zigzag borders infers alternative thrust and withdrawal of the wounding weapon to increase internal damages. e. Irregular or stellate shape skin defects may be due to changing direction of the weapon with the portion of the instrument at the level of the skin as the lever. In this way a greater area of involvement internally will be realized.

MEDICO-LEGAL ASPECTS OF PHYSICAL INJURIES

271

Different measurement of the stab wounds may possibly be produced by one weapon if it is tapering towards the sharp point. Withdrawal of the instrument not on the same direction as when it was introduced may increase the length of the skin defect. A sharpened three-cornered file (tres-cantos) when used as a stabbing weapon will produce three-cornered (extremities) skin defect. The most common immediate cause of death is hemorrhage particularly when located in the chest or abdomen. Accidental stab wounds are quite rare and are usually caused by falling against a projecting sharp object like broken pieces of glass or flattened and_pointed iron bars. x^Tpunctured Wound: ^ > '#^J£ . • Punctured wound is the result of a thrust 6f'a jharp pointed instrument. The external injury is quite small but the depth is to a certain degree. It is commonly produced by an icepick, needle, nail, spear,jJointed stick, thom, fang of animal ancfhook. The nature of the external injury depends on the sharpness and shape of the end of the wounding instrument. Contusion of the edges may be present if the end is not so sharp. The opening may be round, elliptical, diamond-shape or cruciate. An accurate cross-section nature of the wounding object may well be appreciated when there is involvement of flat hard parts of the body especially the skull. External hemorrhage is quite limited although internal injuries may be severe. However, direct involvement of blood vessels and bloody organs may cause fatal consequence unless appropriate medical intervention is applied. The site of the external wound can be easily sealed by the dried blood, serum or clotted blood so that introduction of pathogenic microorganism which does not require the presence of air in its growth and multiplication may find the place favorable, and may produce fatal consequences. / P u n c t u r e d wound is usually accidental but in rare instances it may be homicidal or suicidal. Characteristics: a. The opening on the skin is very small and may become unnoticeable because of clotted blood and elasticity of the skin. The wound is much deeper than it is wide. b. External hemorrhage is limited although internally it may be severe.

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c. Sealing of the external opening will be favorable for the growth and multiplication of anaerobic microorganism like bacillus tetani. Medical evidences that tend to show it is Homicidal: pppp a. It is multiple and usually located in different parts of the body. It may however be found in certain areas of the body. M

b. The wounds are deep. c. There are defense wounds on the victim. d. There is disturbance in the crime scene (sign of struggle). Proof to show it is Suicidal: a. Located in areas of the body where the vital organs are located. b. Usually singular but may be multiple but located in one area of the body. c. Parts of the body involved is accessible to the hand of the victim. d. Clothings usually is not involved. e. Wounding is made by the weapon while the victim is in sitting or standing position. There is bleeding towards the lower part of body or clothing. f. No disturbance of the crime scene. g. Presence of suicide note. h. Wounding instrument found near the body of the victim. Punctured wound with puncturing instrument "loaded" with poison: a. Poison dart — cyanide or nicotine. b. Fish spines. c. Dog bites with hydrophobia virus. d.Jnjection of air and poison as a way of euthanasia. Lacerated Wound (Tear, Rupture, Stretch "Pulok."): $ Lacerated wound is a tear of the skin and the underlying tissues due to forcible contact with a blunt instrument. It may be produced by a hit with a piece of .wood, iron bar, fist blow, stone, butt of firearm, or other objects without sharp objects. If the force applied to a tissue is greater than its cohesive force and elasticity, the tissue tears and a laceration is produced. Since the skin is composed of several types of tissues, namely epidermis, connective tissue, fat, blood vessels, nerves, glandular cells, etc. each having its own breaking point, the laceration will be irregular and having strands of tissues bridging. The rupture of

MEDICO-LEGAL ASPECTS OF PHYSICAL INJURIES

27 3

continuity may only extend deeper to the stronger layer like that of the galea aponeuritica in case of scalp injury. Characteristics: a. The shape and size of the injury do not correspond to the wounding instrument. b. The tear on the skin is rugged with extremities irregular and ill-defined. c. The injury developed is at the site where the blunt force is applied. d. The borders of the wound are contused and swollen. e. It is usually developed on the areas of the body where the bone is superficially located, like the scalp, malar region of the face, front part of the leg, dorsum of the foot, etc. f. Examination with the aid of the hand lens shows bridging tissue joining the edges and hair bulbs intact. g. Bleeding is not extensive because the blood vessels are not severed evenly. h. Healing process is delayed and has more tendency to develop scar. Classification of Lacerated Wounds a. Splitting caused by crushing of the skin between two hard objects. This is best seen in laceration of the scalp caused by a hit of a blunt instrument, cut eyebrow of boxer and laceration of the chin of motorcyclist. b. Overstretching of the skin. When pressure is applied on one side of the bone, the skin over the area will be stretched up to a breaking point to cause laceration and exposure of the fractured bone. In avulsion, the edges of the remaining tissue is that of laceration. c. Grinding compression — The weight and the grinding movement may cause separation of the skin with the underlying tissues. d. Tearing — This may be produced by a semi-sharp-edged instrument which causes irregular edges on the wound, like hatchet and choppers. Lacerated wounds may involve deeper tissues like laceration of the muscles and fracture of bones depending upon the degree of force applied in causing it. It may be homicidal or accidental but rarely it is suicidal. An insane person may hit his head on a concrete wall but when loss of consciousness develops he will not be able to continue further his act of self-destruction.

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pistinctions Between an Incised Wound and a Lacerated Wound: Incised Wound

Lacerated Wound

CJ*Edges are clean-cut, regular AUtfges are roughly cut, irregular and well-defined. and ill-defined. M& There is no swelling or con- S There is swelling and contusion tusion around the incised around the lacerated wound. wound. cj* Extremities of the wound are ^.Extremities of the wound are sharp or may be round or ill-defined and irregular, contused. Examination by means of a magnifying lens shows that the hair bulbs are cut. f

Healing is faster.

Examination with a magnifying lens shows that the hair bulbs are preserved, n Healing is delayed.

Vt Scar is linear or spindle-shaped. X Scar is irregular. St, It is caused by a sharp-edged 0 It is caused by a blunt instruinstrument. ment. GAPING OF W O U N D : The separation of the edges especially in deep wound may be due to the following:

Avulsion of the skin at the forehead with e x p o s u r e of the fractured skull and part of the brain.

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1. Mechanical stretching or dilatation — The presence of a mechanical device on the edges to prevent coaptation will cause separation. The presence of a canula in tracheostomy, drain (rubber or gauze) in an incised abscess, or a retractor during a surgical operation are examples of this type of gaping. 2. Loss of tissue — Separation of the edges of a wound may be on account of loss of tissue bridging them. The loss of tissue may be due to: a. Destruction by pressure, infection, cell lysis, burning or chemical reaction. b. Avulsion or physical or mechanical stretching resulting to separation of a portion of the tissue. c. Trimming of the edges. Debridment of the skin which came in contact with the bullet at the gunshot wound of entrance and the removal of necrotic material in an infected wound may cause separation of the edges. 3. Retraction of the edges — Underneath the skin are dense networks of fibrous and elastic connective tissue fibers running on the same direction and forming a pattern more or less present in all persons. This pattern of fiber arrangement is called cleavage direction or lines or cleavage of the skin and their linear representation on the skin is called Langer's line. These lines of cleavage are different in different parts of the body. If an incised wound or stab wound was inflicted wherein the long axis of the wound is parallel or on the same direction as the cleavage line of the part of the body involved, the wound will appear narrow or slit-like because the edges of the wound will not be subjected to the lateral pull of the severed connective tissue fibers. If the long axis of the wound is perpendicular to or with an angle with the lines of cleavage, the tendency of the borders of the wound is to separate on account of the retraction of the severed fibers. Practical Ways of Determining How Much of the Skin Surface is Involved in an Injury or Disease: The skin serves as a mechanical protection to the body. It is punctuated with sensory nerve endings for pain, temperature and touch. It also acts as a thermo-regulator, storage of water, excretor of sweat and also an organ for absorption. The determination of how much skin involvement is important in the mode of treatment and prognosis. Such determination may

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Line of cleavage Langer's line

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B o d y surface

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be significant in cases of burns, contusion and dermal manifestation of certain diseases. In cases of burns in children and old age persons, involvement of more than 70% of the body surface are almost invariably fatal. In the estimation as to how much (by percentage) of the body surface is involved, the rule of nine is used. Body surface expressed as percentage using the rule of nine: Whole of head and neck Whole of one upper extremity Whole of front chest and abdomen Whole of posterior chest and abdomen Whole of one lower extremity (front) Whole of one lower extremity (back) Pudental area

9% 9% 18% 18% 9% 9% 1%

Total Factors Responsible for the Severity of Wounds:

9% 18% 18% 18% 18% 18% 1% 100%

1. Hemorrhage: a. Hemorrhage may influence the severity of wound by: ( 1 ) Loss of blood incompatible with life: Blood constitutes about 1/20 of the body weight of an adult. By volume, an average size adult has 5 to 6 quarts of blood (one quart is 946 c c ) . A loss of one tenth of its volume may not cause any significant clinical change. A loss of one quart may cause fainting even if the subject is lying down. But a loss of 1/3 to 2/5 of the circulating blood may result to irreversible hypovolemic shock and may be fatal. The volume of blood lost may be related to the rate or space of time a certain volume of blood has been shed. The blood loss may be massive but if it occurred for a long period of time, the hemopoietic organs may be able to replace it thereby preventing the development of any untoward effects. Males can stand more lost of blood than females. Hypertension may cause excessive and rapid bleeding from an arterial wound. Persons suffering from hemophilia and other clotting disorders and those being treated by anticoagulants can cause prolonged bleeding. ( 2 ) Hemorrhage may result in ah increase in pressure in or on the vital organs to affect the normal function: Intracranial hemorrhage may cause compression of the vital centers of the brain. Hemopericardium (pericardial

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tamponade) may cause embarrassment of the contraction of the heart. Hemorrhage into the chest cavity may cause diminution of the respiratory output with subsequent anoxia. (3) Hemorrhage may cause mechanical barriers to the function of organs: Hemorrhage into the tracheo-bronchial lumina can cause asphyxia. Interstitial hemorrhage into the muscles may cause disturbance in the contractility. b. Causes of Hemorrhage: ( 1 ) Trauma — Destruction of the blood vessel wall or increase permeability of its wall due to external force. ( 2 ) Natural Causes: (a) Common causes of hemorrhage due to natural causes: i. Intra-cerebral hemorrhage (apoplexy): The most common blood vessel involved is the lenticulostraite branch of the middle cerebral artery with subsequent bleeding into the basal ganglia and adjacent structure. ii. Spontaneous subarachnoid hemorrhage: Usually due to rupture or perforation of a saccular berry aneurysm, commonly located at the bifurcation of one of the constituent vessels of the circle of Willis or one of its major branches. This is usually a congenital focal defect of the muscular layer with subsequent over stretching and degeneration of the internal elastic layer of the blood vessel wall. iii. Rupture of the arteriosclerotic aneurysm of the aorta: The weakening and thinning of the aortic wall may lead to fusiform or saccular aneurysm usually located at the abdominal portion. iv. Rupture of esophageal varices in cases of cirrhosis of the liver and bleeding of peptic ulcer of the stomach and duodenum. v. Pulmonary hemorrhage may be due to tuberculosis, lung abscess, or bronchiectasis. The hemorrhage may be profused to cause severe anemia or may be small to cause asphyxia. vi. Ruptured ectopic pregnancy.

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vii. Spontaneous rupture of cavernous hemangioma or hepatoma. viii. Rupture of the enlarged spleen (malaria, infectious mononucleosis, typhoid fever). (Medico-legal Investigation of Death by Fischer, p. 102). 2. Size of Injury: Burns affecting one-third of the body surface of the third degree type is usually fatal. Bigger wounds are more exposed to infection and other physical conditions of the surroundings. 3. Organs Involved: Trauma on the vital organs of the body are always serious. Crushing wounds of the heart, brain or lungs are almost fatal. 4. Shock: Shock may occur with or without violence. A slight blow on the genitalia, slight bums in children or old persons, or slight violence on the head or neck may cause severe shock. However, violent traumas to healthy, strong persons may not produce shock. 5. Foreign Body or Substance Introduced into the Body: Incision with an unsterilized scalpel may not be serious as the bite of a venomous snake. A foreign substance or body may be toxic by itself or may act as a physical irritant. The Foreign Body or Substance may be: a. Bacterial: Tetanus b~1f Pathogenic microorganism b. Viral: HydrophobiaW-H|f Hepatitis c. Foreign body: Bullet F- *>ZS (, Glass fragments Shrapnel Gauze or rubber drain d. Chemical: Cyanide Nicotine

o- ^

e. Toxin-: j-fr ( 1 ) Snake Venom — Snake bite is characterized as two punctured wounds at the center of the reddened affected area. The venom is injected through its fangs which is connected to the poison gland.

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Snake Venom Toxicity will Depend on: (a) Potency of venom injected. ( b ) The amount of venom injected by the fang depends on the season of the year and the length of time the snake has eaten. If a snake has just killed his prey, the toxic content of its bite is smaller. ( c ) Size of the patient. ( d ) The immediate treatment instituted. Snake Venoms are of Two Principal Classes: ( a ) Neurotoxic — It primarily paralyzes the respiratory and cardiac center of the brain. Absorption of the venom may cause nausea, vomiting, ascending paralysis, coma, convulsion, and cardiac and respiratory arrest. ( b ) Hematoxic — Which affects particularly the blood. The manifestations are pain and swelling of the affected area, intravascular hemolysis, abdominal pain, nausea, vomiting, petechial: hemorrhage on the gum, pulmonary and cardiac edema. Emergency Treatment may be: (a) Incision of the wound to promote more external hemorrhage to drain the venom. ( b ) Tourniquette above the site of the wound. (c) Placing ice on the bite site. ( d ) Sucking the wound to drain venom with the mouth. (e) Administration of anti-snake venom serum. ( 2 ) Scorpion Venom — The venom of the scorpion has neurotoxic, hemolytic and hemorrhagic effect. A scorpion sting produces only one punctured wound on the center of a reddened area. The main symptoms are pain, edema and reddening. ( 3 ) Coelenterate Sting (Jellyfish) — The tentacles penetrate into the skin and cause explosion of the nematocyst and liberation of the venom. The symptoms are extreme pain of the affected area, urticarial rash, abdominal pain, dilated pupils, paleness and labored breathing. Absence of Medical or Surgical Intervention: A wound may not be fatal but on account of the neglect or ignorance in its management, it may become serious and fatal.

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FATAL EFFECT OF WOUNDS: p M r V 1. Wound may be Directly Fatal by Reason of: a. Hemorrhage: 7p~£*SS An incised wound at the lateral aspect of the neck involving the carotid artery without surgical intervention is fatal due to hemorrhage. While wounds in some areas of the body where big blood vessels are not present and the retraction of tissues are strong, death will not be a direct consequence due to hemorrhage in the absence of complication that may set in. b. Mechanical Injuries on the Vital Organs: A blow on the head may not necessarily produce external lesions but may produce severe meningeal hemorrhage producing compression of the brain. A punctured wound of the heart, even though how small, may produce death on account of the tamponade of the heart. c. Shock: This is the disturbance of the balance of fluid in the body capable of producing delayed or immediate death. 2. Wound may be Indirectly Fatal by Reason of: a. Secondary Hemorrhage Following Sepsis: A wound because of its nature and location is not capable of producing severe hemorrhage, but on account of infection that sets in, deeper tissues are involved including big blood vessels thereby producing severe hemorrhage. b. Specific Infection: Pathogenic microorganisms may develop and multiply in the wound causing septicemia, bacteremia, or toxemia. Tetanus, gas gangrene infection are common in open wounds. c. Scarring Effect: Chronic gonorrheal infection may cause stricture of the urethra. Stricture of the esophagus may follow ingestion of irritant poison. Keloid formation in burns may not only cause deformity but disturbance of the normal respiration of locomotion. d. Secondary Shock: Nature of Death Due to Secondary Causes: A person may have recovered from the immediate effects of the trauma or violence, but may later die of its secondary effects or changes. These changes may be classified as follows: 1. Changes whose natural sequence are direct and obvious.

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Example: Septicemia, tetanus or complications arising from the wounds. 2. Changes producing separate pathological lesions which in turn proves to be fatal. Example: Operation performed on a patient to ligate bleeding vessel inside the abdominal cavity with reasonable skill and with due diligence but as a result of which peritonitis developed and caused death of the patient. 3. Changes where a definite pathological condition was present before the injury. Example: A person suffering from tumor or cyst and was stabbed by someone. The stab is not capable of producing death ordinarily. The person may die of the pathological condition and the accused is liable for his death. 4. Changes where a definite pathological condition of totally different nature arises after the wounding and the consequential sequence is doubtful. Example: Tuberculosis meningitis that develops following a blow on the head. COMPLICATIONS OF TRAUMA OR INJURY: 1. Shock: Shock is the disturbance of fluid balance resulting to peripheral deficiency which is manifested by the decreased volume of blood, reduced volume of flow, hemoconcentration and renal deficiency. It is clinically characterized by severe depression of the nervous system. Three major factors operate in the production of shock and all are likely to be associated together as the condition develops. a. Injury to the receptive nervous system. b. Anoxemia — Reduction of effective volume of oxygen carrying capacity of the blood. c. Endothelial damage, thus increasing capillary permeability. Kinds of Shock: a. Primary Shock: This is caused by immediate nerve impulse set up at the injured area which are conveyed to the central nervous system. The impulse may also whelm the vital centers in the medulla thereby shock develops within a short time due to vasomotor collapse. If the reaction is not intense, the patient may live longer or may recover completely from the effect of the shock.

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b. Delayed or Secondary Shock: Patient shows signs of general collapse which develop sometime after the infliction of injury. It is characterized by a low blood pressure, subnormal temperature, cold clammy perspiration, muscular incoordination, rapid and shallow respiration. The shock may be severe to produce death or the patient may recover completely from its effects. 2. Hemorrhage: Hemorrhage is the extravasation or loss of blood from the circulation brought about by wounds in the cardio-vascular system. The degree and nature of hemorrhage depends upon the size, kind and location of the blood vessel cut. Kinds of Hemorrhage: a. Primary

Hemorrhage:

It is the bleeding which occurs immediately after the traumatic injury of the blood vessel. b. Secondary Hemorrhage: This occurs not immediately after the infliction of the injury but sometime thereafter on or near the injured area. 3. Infection: Infection is the appearance, growth and development of microorganisms at the site of injury: How Injury or Trauma Acquires Infections: a. From the instrument or substance which produces the injury. b. From the organs involved in the trauma applied. A bullet wound may involve the intestine and causes its contents to spill out in the peritoneal cavity causing peritonitis. c. As an indirect effect of the injury which creates a local area of diminished resistance causing the invasion and multiplication of microorganisms. d. Injury may depress the general vitality, especially among the aged and the young children and makes the patient succumb to terminal disease. e. Deliberate introduction of microorganisms at the site of injury.

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

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The Most Common Emboli in the Blood Stream are: a. Fat Embolus: ( 1 ) Causes of Fat Embolus: (a) By injection of oily substance into the circulation. ( b ) By injury of the adipose tissue which forces fat into the circulation. b. Air Embolism: (1) Causes of Air Embolism: (a) Gaping incised wound of the jugular vein. ( b ) Injection of soapsuds or air into pregnant uterus for the purpose of tubal insuflation or criminal abortion. (c) Injection of air into the urinary bladder for radiological study. ( d ) Insuflation of the other non-potent tubes or hollow organs. ( e ) Injection of air under pressure into the nasal sinus after a therapeutic lavage. HEALING OF WOUNDS: 1. Power of the Human Tissue to Regenerate: Regeneration is the replacement of destroyed tissue by newly formed similar tissue. The more highly specialized the tissue, the less is the capacity for regeneration. Capacity for regeneration decreases as age increases. The state of nutrition of the individual aifects the capacity of regeneration. The Following Regenerates Rapidly: a. Connective tissues. b. Blood forming tissues. c. Surface epithelium of the skin. Those Having No Power or Limited Capacity to Regenerate: a. Highly specialized glandular epithelium. b. Smooth muscles. c. Neurons of the central nervous system. Small clean-cut wound is covered with lymph in 36 hours. The edges adhere in two days and the wound heals on the 7th day leaving a linear scar. Larger incised wound shows swelling of the edges 8 to 12 hours. Blood-stained serum is present in 2 days which afterwards become seropurulent on the 3rd day, lasting in state from 4 to 5 days. Small red granulation forms in 12 to 15 days and the epithelium grows from the edges. Scar develops later.

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In cases wherein a definite infection is present, the time of healing is very indefinite, however, at the advent of antibiotic and sulfa drugs, healing is somewhat accelerated. The Time of Healing of Wounds is Dependent on the following: a. b. c. d.

Vascularity Age of the Person Degree of Rest or Immobilization Nature of the Injury

2. Kinds of Healing of Wounds: a. Healing by Primary (First) Intention: This type of healing takes place when there is minimal tissue loss, more approximation of the edges and without significant bacterial contamination. Histologically, within 24 hours following injury, there is an acute neutrophilic response, the epidermal layer thickened on account of the mitotic activities of the basal cells. Scab will be formed on the surface on account of the dehydration of the surface clot. After three days, the neutrophils will be replaced by the macrophages and fibroblasts will appear in the epithelial layer. Collagen fibers will bridge the raw area and epithelial proliferation will then cover the raw area. Newly formed capillaries sprout on all sides to form the vascular network and collagen fibrils become abundant and differentiated surface cells begin to proliferate to cover the exposed area. Complete return of the area to its normal state may appear after a lapse of one month with or without the formation of a scar. b. Healing by Secondary Intention: This takes place when the injury causes a more extensive loss of cells and tissues. Inevitably, there is more necrotic debris and exudate that has to be removed. Inflammatory reaction is more intense as compared with healing by primary intention. Granulation tissue growth bears all the responsibility for its closure. Healing process may result to the production of a large scar and greater loss of skin appendages such as hair, sweat and sebaceous glands, and slower reparative process. c. Aberrated Healing Process: In some instances healing process deviates from the normal way on a normal individual. Healing may result to: ( 1 ) Formation of Exuberant Granulation or "Proud Flesh" — Excessive amount of granulation tissue may protrude and

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287

This can be remedied by

Keloid f o r m a t i o n after a severe acid b u m s .

( 2 ) Keloid Formation — There is abnormal amount of collagen formed in the connective tissue thus producing a large bulging tumorous scar, commonly known as keloid. It has been claimed to be hereditary. (3) Stricture — This is due to the contraction of the fibrous tissue of the scar formed. (4) Fistula or Sinus Formation — A fistula is a communication between an inner cavity and the outside. Sinus is a tract of infection traversing the inner part of the body. Unless the causal factor, usually infection or foreign body is removed, the condition may remain for a long time.

Chapter X MEDICO-LEGAL INVESTIGATION OF WOUNDS: The following rules must always be observed by the physician in the examination of wounds: 1. All injuries must be described, however small for it may be important later. 2. The description of the wounds must be comprehensive, and if possible a sketch or photograph must be taken. 3. The examination must not be influenced by any other information obtained from others in making a report or a conclusion. Outline of the Medico-legal Investigation of Physical Injuries: 1. General Investigation of the Surroundings: a. Examination of the place where the crime was committed. b. Examination of the clothings, stains, cuts, hair and other foreign bodies that can be found in the scene of the crime. c. Investigation of those persons who may be the witnesses to the incident or those who could give light to the case. d. Examination of the wounding instrument. e. Photography, sketching, or accurate description of the scene of the crime for purposes of preservation. 2. Examinations of the

Wounded Body:

a. Examinations that are applicable to the living and dead victim: (1) Age of the wound from the degree of healing. ( 2 ) Determination of the weapon used in the commission of the offense. ( 3 ) Reasons for the multiplicity of wounds in cases where there are more than one wound. ( 4 ) Determination whether the injury is accidental, suicidal or homicidal. b. Examinations that are applicable only to the living: ( 1 ) Determination whether the injury is dangerous to life. ( 2 ) Determination whether the injury will produce permanent deformity. ( 3 ) Determination whether the wound(s) produced shock. 288

MEDICO-LEGAL INVESTIGATION OF WOUNDS (4) Determination whether the injury will produce complication as a consequence, c. Examinations that are applicable to the dead victim: ( 1 ) Determination whether the wound is ante-mortem or postmortem. (2) Determination whether the wound is mortal or not. ( 3 ) Determination whether death is accelerated by a disease or some abnormal developments which are present at the time of the infliction of the wound. (4) Determination whether the wound was caused by accident, suicide or homicide. 3. Examinations of the Wound: The following must be included in the examinations of the wound. The report made in connection with such examination must also include in detail the following items: a. Character of the Wound: The description must first state the type of wound, e.g. abrasion, contusion, hematoma, incised, lacerated, stab wound etc. It must include the size, shape, nature of the edges, extremities and other characteristic marks. The presence of contusion collar in case of gunshot wound of entrance, scab formation in abrasion and other open wounds, infection, surgical intervention, etc., must also be stated. b. Location of the Wound: The region of the body where the wound is situated must be stated. It is advisable to measure the distance of the wound from some fixed point of the body prominence to facilitate reconstruction. This is important in determining the trajectory or course of the wounding weapon inside the body. c. Depth of the Wound: The determination of the exact depth of the wound must not be attempted in a living subject if in so doing it will prejudice the health or life. Depth is measurable if the outer wound and the inner end is fixed. No attempt must be made in measuring the stabbed wound of the abdomen because of the movability of the abdominal wall. c. Condition of the Surroundings: The area surrounding the wound must be examined. In gunshot wound near or contact fire will produce burning or tattooing of the surrounding skin. In suicidal incised wound,

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there may be superficial tentative cuts (hesitation cuts). Lacerated wound may show contusion of the neighboring skin. e. Extent of the Wound: Extensive injury may show marked degree of force applied in the production of the wound. In homicidal cut-throat cases, it is generally deeper than in cases of suicide. Homicidal wounds are extensive and numerous. f. Direction of the Wound: The direction of the wound is material in the determination of the relative position of the victim and the offender when such wound has been inflicted. The direction of the incised wound of the anterior aspect of the neck may differentiate whether it is homicidal or suicidal. g. Number of Wounds: Several wounds found in different parts of the body are generally indicative of murder or homicide. h. Conditions of the Locality: (1) Degree of hemorrhage. (2) Evidence of struggle. (3) Information as to the position of the body (4) Presence of letter or suicide note. (5) Condition of the weapon. Determination Whether the Wounds were Inflicted During Life or After Death: In the determination whether the wounds were inflicted during life or after death, the following factors must be taken into consideration: 1. Hemorrhage: As a general rule, hemorrhage is more profuse when the wound was inflicted during the lifetime of the victim. In wounds inflicted after death, the amount of bleeding is comparatively less if at all bleeding occurred. This is due to the loss of tone of the blood vessels, the absence of heart action and the post-mortem clotting of blood inside the blood vessels. Violence inflicted on a living body may not show the formation of a bruise until after death. 2. Signs of Inflammation: There may be swelling of the area surrounding the wound, effusion of lymph or pus and adhesion of the edges. Other vital reactions are present whenever the wound was inflicted during life, although it may be less pronounced when the resistance of

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the victim is markedly weakened. The vital reaction may also indicate the time of infliction of the wound. Post-mortem wounds do not show any manifesting signs of vital reaction. 3. Signs of Repair: Fibrin formation, growth or epithelium, scab or scar formation conclusively show that the wound was inflicted during life. But the absence of signs of repair does not show that injury was inflicted after death. The tissue may not have been given ample time to repair itself before death took place. 4. Retraction of the Edges of the Wound: Owing to the vital reactions of the skin and contractility of the muscular fibers, the edges of the wound inflicted during life retract and cause of gaping. On the other hand, in the case of the wound inflicted after death, the edges do not gape and are closely approximated to each other because the skin and the muscles have lost their contractility. sanctions between Ante-mortem and Post-mortem Wounds: Ante-mortem Wound U- ok* 1. Hemorrhage more or less copious and generally arterial. (AC

2. Marks of spouting of blood from arteries. 3. Clotted blood

Post-mortem

Wound

. Hemorrhage slight or none at all and always venous. . No spouting of blood.

auc . Blood is not clotted; if at all, it is a soft clot.

4. Deep staining of the edges and cellular tissues, which is not removed by washing.

. The edges and cellular tissues are not deeply stained. The staining can be removed by washing.

EfcrThe edges gape owing to the reaction of the skin and muscle fibers.

. The edges do not gape, but are closely approximated to each other, unless the wound is caused within one or two hours after death.

3* . Nd^mflammation or reparative 6. Inflammation and reparative 6 processes. processes. Toxicology by N.J. Modi, 12th (From: Medical Jurisprudence and ed. p. 237). y

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Determinations whether the wounds are homicidal, suicidal or accidental: 1. As to the Nature of the Wound Inflicted: a. Abrasions: Extensive abiasions on the body are always suggestive of accidental death, especially in death due to traffic accident. In suicidal death, abrasions are rarely observed. In case of murder, abrasions are not common except when the body is dragged on the ground. In homicide, abrasions may commonly be observed especially when the victim offered some degree of resistance to the attacker. b. Contusion: Contusion is rarely observed in suicidal death, except when the suicidal act was done by jumping from a height. A person contemplating to commit suicide will not choose a blunt instrument. Contusion in accidental death may also be found in any portion of the body. It is often due to a fall and due to a forcible contact with some hard objects. c. Incised Wounds:. Incised wounds are commonly observed in suicide and homicide. The depth, location and other surrounding circumstances will differentiate one from the other. Accidental cuts are frequent everyday occurrences, but rarely as a cause of death. Points to be Considered in the Determination as to whether the Wound is Homicidal, Suicidal or Accidental: 1. External signs and circumstances related to the position and attitude of the body when found. 2. Location of the weapon or the manner in which it was held. 3. The motive underlying the commission of the crime and the like. 4. The personal character of the deceased. 5. The possibility for the offender to have purposely changed the truth of the condition. 6. Other information: a. Signs of Struggle: Absence of signs of struggle is more in suicide, accident or murder. Contusion or abrasion may indicate trauma due to fist, finger or feet of the assailant.

MEDICO-LEGAL INVESTIGATION OF WOUNDS Presence of hair or portion of the skin (epidermis) on the nails of the assailant or deceased may be a clue in the determination whether death is suicidal, homicidal or accidental. b. Number and Direction of Wounds: Multiple wounds in concealed portions of the body are generally indicative of homicide. Single wound located in a position that the deceased could have been conveniently inflicted is usually suicidal. c. Direction of the Wound: This is important in the case of cut-throat. It is generally transverse in case of homicide while it is oblique in case of suicide. d. Nature and Extent of the Wound: Homicidal wounds may be brought about by any wounding instrument. Suicidal wounds are frequent due to sharp instruments. Accidental physical injuries may be of any kind. e. Stare of the Clothings: There is usually no change in the condition of the clothings in suicide case. In homicidal death, on account of the struggle which took place before death, the clothings of the victim are in a disorderly fashion. Length of Time of Survival of the Victim After Infliction of the Wound: In the approximation of the length of survival of the victim after receipt of the physical injury, the following factors must be taken into consideration: 1. Degree of Healing: The injured portion of the body undergoes certain chemical and physical changes as a normal course of repair. The capillaries are dilated and edema develops at once. This is followed by the migration of the white cells from the capillaries to the damaged area. Fibroblasts begin to proliferate later with the formation of the granulation tissues. Signs of repair of the wound appear in less than a day after the infliction of injury. By the degree of granulation tissue formation and other reparative changes, the age of the wound may be estimated. 2. Changes in the Body in Relation to the Time of Death: The length of time in the survival of the victim may be approximated from the systematic changes in the body. The degree of

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wasting, anemia, condition of the face, and bed sore formation may be a basis as to how long a person survived. 3. Age of the Blood Stain: The age of the blood stain may be determined from the physical color changes of the skin, although it is not reliable. Although there are some basis for such method, it must not be relied upon because the physical changes of the blood is modified by several external factors. 4. Testimony of the Witness When the Wound was Inflicted: The actual witness may testify in court as to the exact time the wound was inflicted by the offender. In this case, medical evidence as to the duration of survival is merely corroborative. Possible Instruments Used by the Assailant in Inflicting the Injuries: The determination of the wounding instrument may be made from the nature of the wound found in the body of the victim: 1. Contusion — produced by blunt instrument. 2. Incised wound — produced by sharp-edged instrument inflicted by hitting. 3. Lacerated wound — produced by blunt instrument. 4. Punctured wound — produced by sharp-pointed instrument. 5. Abrasion — body surface is rubbed on a rough hard surface. 6. Gunshot wound — the diameter of the wound of entrance may approximate the caliber of the wounding firearm. Could the injury have been inflicted by a special weapon? A physician cannot determine definitely that a certain specific weapon was used in inflicting a wound. He can only state that it is possible that a certain injury is possibly caused by a certain instrument presented. He must be cautious in making a categoric statement. Which of the injuries sustained by the victim caused death? If there are several offenders who conspired with one another in the commission of the offense, it is not necessary to determine who among them gave the fatal blow. In the crime of conspiracy, the act of one is the act of all. But if there is no conspiracy in the commission of the offense it is necessary to determine who among the offenders gave the fatal injury to the victim, because they are only responsible for their individual acts. In a case wherein the victim is a recipient of multiple injuries, the determination as to which of the injuries caused death is dependent on the testimony of the physician. This can be ascertained by

MEDICO-LEGAL INVESTIGATION OF WOUNDS examining individually the wounds and note which of them are involved in the injury to some vital organs or large vessels, or led to secondary results causing death. When two or more wounds involved the vital organs, it is difficult to ascertain which ^mong them caused the death. It is important to determine the degree of the damage of each of the wound caused on the vital organ. Which of the wounds was inflicted first? When there are several wounds present on the body of the victim, it is important to determine which of them was inflicted first because it may be necessary for the qualification of the offense committed. If the first wound was inflicted in a treacherous way that the victim after receipt is incapable of defense, then murder is committed, but if the fatal wound was inflicted last, it is possible that the crime committed is only homicide. In the determination as to which of the wounds present was inflicted first, the following factors must be taken into consideration: 1. Relative position of the assailant and the victim when the first injury was inflicted on the latter. 2. Trajectory or course of the wound inside the body of the victim. 3. Organs involved and degree of injury sustained by the victim. 4. Testimony of the witness. 5. Presence of defense wounds on the victim. If the victim tried to make a defensive act during the initial attack, then the defense wounds must have been inflicted first. Effect of Medical and Surgical Intervention on the Death: If the death of the victim followed a surgical or medical intervention, the offender will still be held responsible for the death of the victim if it can be proven that death was inevitable and that even without the operation, death is a normal and a direct consequence of the injuries sustained. It must be shown that the physician treating the victim must be competent and that in spite his exercise of care and diligence, still death was the final outcome. A person committing a felony shall be responsible for whatever will be the outcome of his felonious act. The wound inflicted by him must be the direct and proximate cause of the death of the victim. On the other hand, if the victim merely received minor wounds but death resulted on account of the gross incompetence or negligence of the physician, then the offender cannot be held responsible for the death. The offender can only be made responsible for the physical injuries inflicted on the victim and the physician must be made to answer for the death.

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Effect of Negligence of the Injured Person on the Death: If death occurred from complications arising from a simple injury owing to the negligence of the injured person in its proper care and treatment, the offender is still held responsible for the death. A person is not bound to submit himself to medical treatment for the injuries received during the assault. The fact that the victim would have lived had he received appropriate medical attention, is immaterial. Hence, the refusal of the deceased to be operated does not relieve the offender of the criminal liability for his death (People v. Sto. Domingo, C.A. — G.R. No. 3783, May 1939). But, if it could be proven that the negligence of the victim is deliberate and that this intention is really the cause of death on himself, then the offender cannot be held responsible for the death but only for the physical injuries he had inflicted. Power of Volitional Acts of the Victim after Receiving a Fatal

Injury: Sometimes it is necessary to determine whether a victim of a fatal wound is still capable of speaking, walking or performing any other volitional acts. A dying declaration may be presented by the prosecutor mentioning the accused as the assailant; the offender may allege that the physical injuries inflicted by him while the victim was inside his house and that he walked for some distance where he fell, or that the victim after the fatal injury made an attempt to inflict injuries to the accused which justified the latter to give another fatal blow. The determination of the victim's capacity to perform volitional acts rests upon the medical witness. As a general rule, severe injury of the brain and the cranial box usually produces unconsciousness, but after a while.the victim may be capable of performing volitional acts. The power to perform volitional acts is dependent upon the areas of the brain involved. Wounds of the big blood vessels, like the carotid, jugular or even the aorta, do not prevent a person from exercising voluntary acts or even from running a certain distance. Penetrating wound of the heart is often considered to be instantaneously fatal but experience shows that the victim may still be capable of locomotion. Rupture of the organs is not always followed by death. The victim has for sometime still retains the rapacity to move and speak. Extreme caution must be exercised by the physician in expressing his opinion as to the limitation of powers possessed by the injured person to perform acts of volition, locomotion, or speech subsequent to receipt of extensive or fatal injury or wound.

MEDICO-LEGAL INVESTIGATION OF WOUNDS Relative Position of the Victim and Assailant When Injury Was Inflicted: In the determination of the relative position of the victim and the assailant when the wound was inflicted, the following points must be considered by the physician: 1. Location of the wound in the body of the victim. 2. Direction of the wound. 3. Nature of the instrument used in inflicting the injury. 4. Testimony of witnesses. Extrinsic Evidences in Wounds: 1. Evidences from the Wounding Weapon: a. Position of the Weapon: The location and position- of the weapon at the scene of the crime may afford strong evidence in the court. As a rule, in cases of accidental or suicidal death, the wounding weapon is found near the body of the victim, but it is not uncommon to find the victim at some distance from the weapon when the victim is capable of walking. If the wounding instrument is firmly grasped by the victim, it is a strong presumption that it is a suicidal case. b. Blood on Weapon: The weapon responsible for the production of wound may be stained with blood. In some instances, the wounding weapon does not show blood stains because of the rapidity of the blow and compression of the blood vessels. Even if the weapon is stained with blood, it may be wiped out by the clothings in the process of withdrawal. The weapon must be subjected to a complete examination to determine whether it is the one used in the commission of the offense. c. Hair and Other Substance on Weapon: Hair or fibers of cotton, silk, linen and other fabrics may be found adhering on the weapon. It must be preserved and submitted for comparison with the clothings or hair found at the site of the injury on the victim's body. 2. Evidences in the Clothings of the Victim: Injuries inflicted on the covered portions of the body may also show injury on the covered apparel. In gurrhot wound, the hole in the clothings may be a factor in the determination of the site of the wound of entrance. Occasionally, two or more tears or holes

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are produced on the dress by a single wound. This can be explained by the presence of folds on the clothings. In gunshot wound, determination of the presence of gunpowder at the hole of entrance may show distance. The presence of cleancut tear in the clothings shows that a sharp-edged instrument was used. The presence of severe tearing of the clothing shows struggle. The degree of soaking of the clothings with blood may depict the degree of hemorrhage. 3. Evidences Derived from the Examination of the Assailant: The clothings of the assailant may be stained with blood from the victim. Tear may be present on account of the struggle which existed at the time of the commission of the offense. The fingernails may show foreign substances coming from the body of the victim. The offender may also show to a certain degree marks of violence. Paraffin test of the assailant's hands may be useful to determine whether he fired the gun in case of shooting. Determination of the degree of intoxication, mental condition, physical power, etc. of the offender may be necessary in the solution of the crime. 4. Evidences Derived from the Scene of the Crime: The condition of the surrounding objects, the amount of hemorrhage, the presence of identifying articles belonging to the victim or assailant, the wounding instrument, all these must be observed or collected by the investigator.

Chapter XI PHYSICAL INJURIES IN THE DIFFERENT PARTS OF THE BODY: 1. HEAD AND NECK INJURIES: Injuries of the head must not be underestimated. They must be treated with extreme care. The absence of an external wound on the head does not itself permit a conclusion that there is no internal damage. Contusion and hematoma of the scalp may only be appreciated during the post-mortem examination. The presence of hair further augments the difficulty of appreciating head injuries. The presence of bleeding from the ear, nostrils and mouth may be associated with basal fracture. Fracture of the vault and other portions of the cranial box may cause unconsciousness and this may be mistaken for simple intoxication. It is preferable to have the patient under careful, intelligent and continuous observation for at least twelve to twenty-four hours to avoid risk to the life of the patient. X-ray examinations may be useful in order to determine the presence of fracture. However, it is not uncommon that no fracture is observed, and yet the intracranial injury is quite severe. Factors Influencing the Degree and Extent of Head Injuries: a. Nature of the Wounding Agent: Weapons with a small striking face usually produce a localized depressed fracture with laceration of the scalp. The degree of injury depends upon the degree of violence applied, the thickness of the scalp struck and the weight of the weapon. Violent contact with the wheel of a motor vehicle causes fissure or comminuted fracture of the cranial box. There is always an associated injury of the brain substance and laceration of the meninges. Penetrating injuries of the skull like those caused by a dagger, a nail or a bullet, may leave a clean-cut opening with the shape and size of the wounding weapon. A glancing hit of a bullet may cause a gutter-like depressed fracture of the vault of the skull. 299

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b. Intensity of the Force: As a general rule, the intensity of force is proportional to the degree of damage it will produce. However, in cases where the striking face is small, the amount of force which produces the same injury is smaller. This is, however, qualified by the part of the skull involved. For example, less force is required to produce injury when applied at the temple than when it is applied elsewhere in the exposed surface of the skull. Heavy agents may require less force to produce extensive damage to the skull although the point of impact is wide. c. Point of Impact: There are areas in the cranium wherein if force is applied to them, the injuries are extensive. Fractures of the vaults, either on the side or at the back, usually causes a stellate comminution at the point of impact with linear extensions to some other areas. Basal fractures are often caused by transmitted force from some points of impact. d. Mobility of the Skull at the Time of the Application of Force: If the head is mobile, unsupported and free, the principal effects on the brain is due to the shearing movement imparted to the brain. It may produce contusion, laceration or hemorrhage without any fracture on the skull. If the head is fixed and supported, as when the head is caught by the wheel of a vehicle, jarring movement of the brain is absent but the fracture is extensive. Usually the fracture forms a line from the point of contact with the wheel up to the point of support of the head. There may be complete separation of the naso-facial mass from the rest of the skull. Head Injuries are Classified as to the Site of the Application of Force: a. Direct or Coup Injuries: These are injuries which occur at the site of the application of force and will develop as a natural consequence of the force applied. Direct Injuries may Result to: ( 1 ) In compression of the head by the wheel of a vehicle. ( 2 ) When the head strikes an object in motion, as bullets. ( 3 ) When the head is in motion and strikes an object, as in vehicular accidents. b. Indirect Injuries: These are injuries in the head which are not found at the site of the application of force. The injury may be at the opposite, or

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in some areas offering the least resistance, or in areas which have no relation with the site of the impact. ( 1 ) Contre Coup Injuries: These are injuries which develop opposite the site of the application of force. A blow on the occiput may produce laceration or contusion of the frontal lobe of the brain. This is observed when the head is free and mobile. ( 2 ) Remote

Injuries:

Remote applied in the head. fracture of

injuries are produced in cases where the force is some areas of the body which have no relation to A fall on the feet or buttocks may cause basal the skull.

( 3 ) "Locus Minoris Resistencia": The injury sustained in the head may not be at or opposite the application of force but may be found in some areas of the skull offering the least resistance. A blow on the head may cause a linear fracture of the roof of the orbit on account of the papyraceous nature of the bone. c.

Coup-contre-coup Injuries (Direct and Indirect Injuries): The injuries may be at the site of impact and at the same time found in some other pafts of the head which may be opposite the site of application of force, or elsewhere. A hammer blow in the frontal portion of the head may cause depressed fracture of the frontal bone and at the same time fracture of the roof of the orbit and laceration of the posterior lobe of the cerebrum.

Wounds of the Scalp: A wound of the scalp although small and negligible is always potentially serious because: a. It is difficult to prevent the spread of infection. b. There is proximity of the scalp to the brain. c. There is a free vascular connection between the structures inside and outside the cranium. d. It is frequently difficult to determine the extent of damage of the skull. Abrasion of the scalp is commonly unnoticed because of the protective covering of the hair. Contusion may not be visible because of the thick resistant scalp and may only be noticed on autopsy. Hematoma easily develops in the scalp because the cranium is located superficially and the subaponeurotic tissue is loose.

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The most common lesion of the scalp is a lacerated wound. There may or may not be involvement of the skull. Difficulty is sometimes experienced in differentiating a lacerated from an incised wound of the scalp. With the aid of a hand lens, the laceration shows irregular borders and hair bulbs are preserved. Laceration of the scalp may be due to the impact of a blunt force or to the sharp edges of the fractured skull. Incised wounds of the scalp in general involve the cranium. The force necessary may not be so strong as to produce a cleancut fracture of the cranium. Fractures of the Skull: Fractures of the skull may or may not be associated with injury on the scalp, but usually there is an accompanying injury inside the cranial box. Meningeal vessels are so situated in the furrows of the cranium that fracture of the cranium will always lead to laceration of the blood vessels. a. Fissure Fractures: Fissure or linear fracture involves the inner and outer table. It is usually caused by the impact of a blunt object and may appear as a radiating crack from the site of the application of force and may involve the base of the cranial fossae. b. Localized Depressed

Fracture:

Localized depressed fracture is sometimes called "Fracture a La Signature". It invariably shows the nature of the instrument that causes the fracture. The round face of the hammer may show a round depressed fracture in the cranium. c. Penetrating Injuries of the Skull: Sharp-edged instrument produces clean-cut fracture of the skull. The size and shape of the fracture may correspond to the shape of the wounding instrument. A gunshot produces an oval or round hole with bevelling of the inner table at the wound of entrance. The blade of the wounding weapon may be left inside without causing trouble but complications like infection may later develop and may cause a fatal consequence. d. Comminuted Fractures: Comminution of the skull may develop as a result of a fissure or a depressed fracture. The presence of comminuted fracture is an indication of the severity of force applied or the use of a heavy weapon. Majority of comminuted fractures are caused by motor vehicle accidents. In a near shot with a firearm, there is usually

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a radiating fissure fracture from the point of impact which forms a "spider w e b " comminution of the cranium. e. Pond or Indented Fracture: In the skull of infants wherein there is undue elasticity, the production of a pond or indented fracture is common. It may be a result of a simple compression of the skull, as in a pingpong ball. Fissure fracture is likely to develop around the periphery of the dent. f. Gutter Fractures: A tangential or glancing approach of a bullet may cause the production of a furrow in the cranium. It may involve both the outer and inner tables. The furrow may cause injury on the blood vessels causing intracranial hemorrhage or laceration of the brain. g. Bursting Fractures: It is an extensive fracture running parallel to the two points of contact, if mechanical force is applied on one side of the head, while it is pressed on the other side against a hard substance, such as a wall, while the individual is standing, or against the hard ground or floor, when he is in a lying posture. In such cases the fracture may extend transversely to the base of the skull. The passage of the wheel of a heavy vehicle over the head often causes a complete division of the skull into two parts. The direction of the burst correspond to that in which the wheel passed over the head. (From: A Handbook of Medical Jurisprudence & Toxicology with State Medicine & Post-Mortem Techniques by C.C. Mallik, p. 206). Intracranial Hemorrhages: Intracranial hemorrhages may occur even in the absence of a fracture. Hemorrhage may be present without trauma. The blood vessels of the brain may be diseased and may rupture spontaneously, a. Extradural or Epidural Hemorrhage (almost exclusively due to trauma): Extradural hemorrhage is caused by a fracture of the skull. The fracture will cause laceration of the blood vessels which are grooved at the inner table of the skull. The branches of the meningeal vessels are usually involved, the most frequent of which are the branches of the middle meningeal vessels. The laceration is commonly unilateral except when the fracture extends to the opposite side.

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Severe extra-dural h e m o r r h a g e w i t h compression of the brain

Hemorrhage at the region of the vault produces a discusshaped clot with compression of the brain substance and this may cause neurologic disturbance. If the patient lives for sometime, there will be an organization of the clot and a fibrous thickening of the dura. A person suffering from extradural hemorrhage may complain of headache, vomiting and drowsiness. The pupils may be dilated on the side of the hemorrhage. Examination of the cerebro-spinal fluid shows absence of blood, unless it is complicated with hemorrhage in other regions in the cranial cavity. b. Subdural Hemorrhage: Unlike extradural hemorrhage, subdural bleeding is essentially venous or capillary. It is the most common cause of cerebral compression. It may be a consequence of fracture of the skull, laceration of the brain, spontaneous rupture of the blood vessels on the surface of the brain or laceration of the dura and meningeal vessels. It usually comes from the small blood vessels which cross the subdural space to the subarachnoidal area. Majority of subdural hemorrhages are traumatic in origin although a few may be due to a natural disease of the blood vessels of the brain. There are difficulties in ascertaining the cause and source of such hemorrhage.

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Extensive s u b d u r a l h e m o r r h a g e

Ageing Subdural Hematoma

Munro-Merritt Method:

In the determination as to how long subdural hematoma existed, the study of the structure of its membrane is made as a basis (Munro-Merritt Method). 1st 24 hours

— Deposit of fibrin at the margin of the clot with red blood cells and leucocytes well preserved.

24 — 36 hours — Fibroblast found at the junction of the dura mater and the blood clot. 4 days

— Definite histological evidence of 2 to 3 layers of cell thickness neomembrane. The red blood cells have begun to lose their sharp contour.

4 to 5 days

— Increasingly prominent membrane with extension of the fibroblasts into the underlying clot. — The membrane has become 12 — 14 cells in thickness. Pigment-laden phagocytes are found. — Clot broken up into islands by the invasion of strands of fibroblasts.

8th day

11th day

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- Membrane has formed on the undersurface of the clot and strands of fibroblasts. Red blood cells have broken up. The outer layer of the neomembrane is 1/3 to 1/2 the thickness of the overlaying dura.

26th day

— Neomembrane is about the thickness of the overlying dura. Blood has liquified. Red blood cells not clearly apparent.

1 to 3 months — Progressive decrease in the number of nuclei of the fibroblasts and progressive hyalinization of the membrane. Large blood spaces ("sinusoidal vessels") filled with red blood cells have become increasingly prominent in the new-formed connective tissue. 6 to 12 months — Neomembrane has become thick and fibrous, blood has disappeared leaving only a few scattered pigment-laden phagocytes. The new-formed membrane is distinguishable 1 to 2 years — from the overlying dura only by the parallel arrangements of the connective tissue fibers which have become more or less completely hyalinized. (GradwohVs Legal Medicine by F.E. Camps ed., 3rd ed., p. 316). c. Subarachnoidal Hemorrhage: Subarachnoidal hemorrhage may be due to trauma or to spontaneous rupture of blood vessels. Its causes may be summarized as follows: ( 1 ) It may be produced by severe head injury especially in contre coup kind. (2) It may be due to ruptured cerebral aneurysm and is commonly seen at the base of the brain. (3) It may be an extension of the spontaneous hemorrhage of the brain which extends to the subarachnoid space. (4) In asphyxia there may be subarachnoidal hemorrhage in the form of petechial hemorrhage. d. Cerebral

Hemorrhage:

Cerebral hemorrhage may be traumatic or spontaneous in origin. If a person develops rupture of a blood vessel and suddenly collapses and falls on the ground producing a certain degree of head injury, it is quite difficult to ascertain the exact origin of the hemorrhage. A careful dissection of the brain

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tissue involved is necessary to determine the presence of pathology of the blood vessel. Traumatic cerebral hemorrhage is usually due to laceration or contusion of the brain in contre-coup injuries. Severe crushing of the skull in vehicular accident cases may cause the sharp fractured edges of the bone to lacerate the brain and produces severe cerebral hemorrhage. It may involve the gray matter only but in severe cases the hemorrhage extends up to the white matter. Distinction between Cerebral Apoplexy and Post-traumatic Intracerebral Hemorrhage: a. In traumatic intracerebral hemorrhage the interval between the injury and onset of "stroke" (symptoms) is usually a week or less. b. In traumatic intracerebral hemorrhage, the injury to the head must be sustained when the head is in motion and the hemorrhage is the result of the coup-contre-coup mechanism. c. The location of traumatic intracerebral hemorrhage is in the central white matter of the frontal or temporo-occipital region. Cerebral apoplexy is usually at the basal ganglia, a very uncommon site of traumatic intracerebral hemorrhage. d. History of hypertension prior to the "stroke" and evidence of degenerative disease are present in cerebral apoplexy. There is a history of head trauma in traumatic intracerebral hemorrhage. (Gradwohl's Legal Medicine, 2nd ed. by F.E. Camps, p. 312). Brain: a. Laceration of the Brain: Lacerations of the brain may be: (1) Direct or Coup Laceration: This is produced by the fracture of the skull. The edges of the fractured bone lacerate the arachnoid and the underlying brain tissue. It may occur any where in the brain but it usually follows the line of fracture. The most frequent sites are the parietal and the frontal lobes. ( 2 ) Contre-coup Laceration: Contre-coup laceration occurs usually directly across the point of impact and fracture. Contre-coup injuries occur only when the head is free to move at the time of the impact. If the head is held immovable the mechanism of contre-coup will not operate. A frontal impact may pro-

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LEGAL MEDICINE duce laceration of the cerebellum while an impact in the occipital region may cause contre-coup laceration of the fronta-. and temporal lobes of the brain. Brain laceration may lead to granulation tissue formation and ultimately to fibrosis in the absence of infection.

Histo-pathological changes following contusion and laceration of the cerebral cortex: Within 3 hours — Minimal alteration of the cellular elements at the margin of the wound. Microglia may show slight swelling of the cytoplasm of the dendrites. There is fracturing of the myelin sheath. Cortical nerve cells may show pyknotic changes. 6 to 12 hours — Pyknotic cells become more apparent and blood pigment is found between cortical neurons. Glial cells look swollen especially oligodendroglia in the white matter and perineuronal satellite cells in the gray matter, as cerebral edema begins to develop. 12 — 24 hours — Cortical nerve fibers show fairly numerous end-bulbs and early degeneration of the interrupted fibers. Microglia continue to show early swelling of their processes. Pyknotic change and pigmentary infiltration of the nerve cells are still present at the margin of the contusion. Loss of Nissl substance may be detected in larger nerve cells. 1—2 weeks — Increase in the number of granular corpuscles in activity of phagocytic action. Astrocytes are plump and the nuclei are very prominent. Cerebral edema is well shown by the spongy appearance of the white matter. Nerve cells in the border zone may show fatty degeneration or cytoplasmic vacuolation. 1 month

— Scarring process becomes fairly static. The gliotic astrocytic scar shrinks and appears gray or brownish in color. Blood vessels are thickened, hyalinized coats owing to increased density of astrocytic end-process attached to them.

(GradwohVs Legal Medicine by F.E. Camps ed., 2nd ed., pp. 317319).

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b. Edemas of the Brain: Edema of the brain which is usually the effect of trauma may be localized or generalized. ( 1 ) Localized Edema: Localized edema is observed in deep brain lacerations. The edematous area is soft, swollen, gelatinous and yellowishred in appearance. It is observed in abscess and neoplasm. ( 2 ) Generalized Edema: This is usually associated with severe trauma of the head. The brain has a swollen appearance, with flattening and broadening of the convolutions and diminution of the sizes of the ventricle. Microscopically, there is an intracellular, pericellular and perivascular accumulation of fluid. Edema of the brain of the generalized type may also be observed in a prolonged convulsive seizure, a sudden death due to tetanus antitoxin, an encephalitis, and in an excesssive hydration. c. Concussion of the Brain: Concussion of the brain is a transitory period of unconsciousness resulting from a blow on the head, unrelated to any injury to the brain which is apparent to the unaided eye. The cause of cerebral concussion is still undetermined. Some authorities consider it to be a rotational injury as it will occur only when the head is free to move but not when it is fixed. The symptoms of concussion vary upon the degree of injury. In a severe injury the patient may fall down and becomes unconscious. There is flaccidity of the muscles and sphincters are relaxed. The face is pale, pupils are dilated and insensible, skin is cold and clammy, the pulse is rapid, the respiration is slow, irregular and sighing and the temperature is subnormal. In cases of recovery, there is usually a retrograde amnesia of the accident and even events before and after it. The patient may also develop automatism and may perform criminal acts which may be mistaken to be volitional or voluntary. d. Compression of the Brain: On account of the severe intracranial hemorrhage, depressed fracture of the skull, or edema of the brain, compression of some vital areas of the brain may lead to paralysis or loss of consciousness. Natural diseases, like newgrowth, abscess and hydrocephalus may also cause compression of the brain.

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LEGAL MEDICINE In traumatic compression, the symptoms do not appear immediately after the injury. The symptoms depend upon the area of the brain involved but signs of increased intracranial pressure are always present. Vomiting, headache, irregular breathing, incontinence of urination and defecation, and paralysis are usually present. Recovery develops when the cause is completely removed but usually the patient has loss of memory, epilepsy, paralysis, or insanity as a sequelae.

Medico-Legal Questions in Intracranial Injuries: a. Is the origin of the intracranial hemorrhage due to trauma or disease? Extradural or epidural hemorrhage is always caused by trauma. The blood vessels causing the hemorrhage which are grooved at the inner table of the skull are usually lacerated by the fractured skull. Subdural hemorrhage is, as a rule, traumatic in origin but it may also be caused by some diseased condition of the blood vessels or by a local inflammatory process. Subarachnoidal hemorrhages are usually spontaneous and are usually caused by ruptured aneurysm or sclerotic vessels at the circle of the Willis. Hemorrhage in the brain substance is usually spontaneous and usually involves the deep tissues of the brain, pons and cerebellum. Age, blood pressure, chronic alcoholism, kidney disease must be taken into account to determine whether it is traumatic or spontaneous in origin. b. In cases of cerebral concussion, can the victim remember the incidents before, during or after the accidents? In mild form of cerebral concussion or after a psychological treatment, 'the victim may be able to recall the incident. A person may suffer from severe concussion and still retain a good memory of the past. In severe form of concussion, the victim may totally lose the recollection'of past events. c. Can the victim of head injuries still retain voluntary movement and speech? In severe head injuries with comminuted fracture of the skull there is immediate loss of consciousness such that voluntary movement and speech are no longer possible. Depressed fracture of the skull may cause also immediate loss of consciousness that may develop sometime after the impact.

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The capacity of the victim to retain voluntary movements and speech depends upon the loss of consciousness and the area of the brain involved. d. Post-traumatic Automatism: A person while under the state of post-traumatic automatism may commit a crime while in an unconscious state. He is considered to be exempted from criminal liability because he did not act with intelligence. There can be criminal intent if a person acted with voluntariness or with intelligence. A person under the state of post-traumatic automatism acted involuntarily. e. In gunshot wounds of the head, how can the point of entrance be determined? In some instances the gunshot wound on the head may not clearly show characteristic findings of a wound of entrance. The examiner must resort to the examination of the fracture of the skull. At fhe point of entrance, the injury at the outer table is oval or round while there is bevelling fracture at the inner table. The opposite is true at the point of exit. f. Post-traumatic Irritability: The victim of a head injury may suffer post-traumatic irritability and may lead to do acts of impulsive violence. If irritability develops after a head injury, it is doubtful if it will be a valid defense following the doctrine of acting under an irresistible impulse. But, if genuine traumatic psychosis develops later, the responsibility is evaluated in accordance with the general principle of appraisal of responsibility of insanity (Medical Trial Technic, Mar. 59, p. 32). Face: Generally, wounds on the face heal relatively faster as compared with wounds of the other parts of the body on account of its great vascularity. Most often, injuries on the face are serious because they produce ugly scars or other forms of deformity. Because of their proximity to and the presence of free communication with the brain, facial injuries are always a threat to life. As a whole, wounds on the face may be due to a blow, vehicular accident, kick, sharp instrument, gunshot, or a blunt weapon. Fractures of the facial bones, especially of the nasal bone and mandible, are quite frequent, a. Eye: Contusion of the soft tissue about the eyes is sub-conjunctival. Hemorrhage is frequently observed in a fist blow. Fracture

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of the base of the anterior cranial fossa may also produce contusion of the eyelids, and this may be distinguished from contusion due to a blow by the absence of swelling and skin injuries in the former. The eye may be lacerated by a blunt weapon or by a piece of stone. Acute inflammatory changes usually occur with injury of the cornea, iris and lens and may require total enucleation of the eyeball. Penetrating wounds due to sharp instruments or bullets may cause meningitis or total blindness. b. Nose: Fracture of the nasal bone is a common sequelae of fist blows, and may cause severe epistaxis and facial deformity. The nose may be bitten in a quarrel, cut with a sharp-edge instrument, and contused, abraded or lacerated by a blow. In suicide, the muzzle of the death gun might be placed in the nostril and may cause no visible wound of entrance. Injuries of the nose are usually dangerous to life on account of the extension of infection to the brain. c. Ear: A blow on the ear may produce a rupture of the tympanic membrane leading to permanent or temporary deafness. Hemorrhage coming from the ear may suggest fracture of the base of the middle cranial fossa. In a quarrel, the pinna of the ear may be cut off or markedly lacerated or contused by a strong blow. The trauma in the ear may cause septic infection and may extend to the brain and causes death. d. Mouth: Contusion, laceration and swelling of the lips are usually observed in a fist blow, kick or bite. It may or may not be associated with fracture of the teeth or injury of the gum. Fracture of the lower jaw is usually due to direct violence and the most common site is at the region of the insertion of the canine and at the region of the condyle. Fracture of the jaw is always associated with laceration of the gums which may extend to the floor of the buccal cavity. Occasionally a gunshot wound in suicidal case is found inside the mouth and investigators are usually at a loss in the examination and location of the wound of entrance. Infections following injury of the mouth may extend to the upper respiratory system and cause edema or gangrene of the glottis.

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Neck: Abrasions of the neck may be present in cases of manual strangulation. Ligature marks are present in death by hanging or strangulation by ligature. Incised wounds may be homicidal or suicidal. Suicidal cut-throat wounds are usually diagonal while homicidal wounds are usually horizontal. Incised and stab wounds of the neck may involve the trachea and the big blood vessels and nerves and in most cases, end fatally. Asphyxia, pneumonia, hemorrhage and shock are the common causes of death from neck injuries. Wounds of the esophagus are not common. They are usually accompanied by wounds of the trachea and large blood vessels of the neck. Severance of the recurrent laryngeal nerve causes aphonia. Contusion or rupture of the muscles, severance of the nerves are sometimes observed in severe trauma applied to the neck. Forcible blow in the anterior portion of the neck may cause unconsciousness or even death due to reflexed inhibitory action on the vagus nerve. Vertebral Column and Spinal Cord: a. Fracture of the Vertebrae: Fracture of the vertebrae is dangerous to life because of the involvement of the spinal cord. Injury of the cord due to fracture of the upper four cervical vertebrae causes paralysis of the phrenic nerve, while those due to fractures of the fifth cervical vertebra to the first dorsal vertebrae may cause paralysis of all the extremities. Injury of the cord at other levels may not cause immediate death but complications like hypostatic pneumonia, bed sores and other secondary infections may set in and cause death. The causes of the fracture of the spine may be: ( 1 ) Direct Violence: The fracture of the spine may be due to a blow by a heavy instrument coming from the back, fall from a height, collision with motor vehicles and hit of a projecting instrument. (2) Indirect Violence: Indirect violence may be due to a fall on the feet or buttocks, forcible bending of the body as in wrestling, a blow on the chin or forehead, forcible bending of the head towards the sternum, and slight twist of the body if the person is suffering from Pott's disease.

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LEGAL MEDICINE Recovery from spinal fracture may cause deformity or paralysis of certain areas of the body. Injury of the spine is usually associated with considerable, pain.

b. Concussion of the Spine: Concussion or jarring of the spinal cord may occur even without any visible signs of external injuries. A physician usually has much difficulty making diagnosis of concussion of the spine. The usual complaints are headache, restlessness, pain and tenderness over the spine, loss of sexual power, irritability of the bladder, inability to walk, weakness of the limbs, and derangement of the special senses. Concussion of the spine may be sustained in a motor vehicle collision and in a railway accident. 2. INJURIES IN THE CHEST: Injuries in the chest are important because vital organs are inside the chest cavity, namely: the heart, lungs and the principal blood vessels. Injuries to the Chest Wall: The chest wall is easily contused by the application of moderate force on account of the superficial location of the ribs. Lacerated wounds are rarely observed as a direct effect of violence, but are observed when the fractured ends of the ribs pierce the skin in severe crush injuries due to motor vehicle accidents. Stab wounds on the chest are quite common on account of its accessibility when both the assailant and the victim are in a standing position. The intercostal vessels may be involved, causing considerable hemorrhage. Stab wounds of the chest, as a general rule, involve the lungs, heart and the big blood vessels in the chest cavity. Bullet wounds of the chest may be superficial or may involve the pleural viscera. Hemorrhage, collapse of the lungs due to the removal of the negative intrathoractic pressure and pneumonia may develop if the victim does not die immediately. Fracture of the ribs causes severe pain during each phase of respiration and if complete, it may be associated with laceration of the parietal pleura or of the skin. The lungs and the heart may also be lacerated when there is an inward displacement of the fractured ends. Fracture of the Ribs may be Caused by: a. Direct Violence:

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The fracture of the ribs is at the site of the application of force as in cases of blow, stab, or bullet wounds, b. Indirect Violence: The fracture of the ribs is not at the point of the application of force, as in crush injuries in vehicular accidents, a pressure on the chest by heavy objects, a fall of earth or pressure with the knee. Fracture of the ribs is usually along the mid-axillary line or may run obliquely in the chest depending upon the manner the force was applied. Fracture of the ribs lacerates the parietal pleura and the sharp ends of the ribs cause injury to the lungs, heart and big blood vessels. The laceration of the skin may cause collapse of the lungs and the victim dies of asphyxia. The usual site of fracture of the sternum is the junction of the manubrium and the gladiolus. The fracture is usually transverse and most often associated with fracture of the ribs. It results from a sudden impact of heavy, blunt object or compression of the chest due to a fall or a vehicular accident. Fracture of the sternum may be associated with laceration of the pericardium and injury to the heart. Injuries to the Lungs: Hemorrhage in the pleural cavity coming either from the intercostal vessels or from the lung tissue itself may cause compression and collapse of the lungs and the patient may die of respiratory embarrassment or anemia. Contusion of the lungs may be caused by a blunt instrument with or without fracture of the ribs, or by compression of the chest. The lungs may be injured by a sharp-pointed instrument or by a bullet. Injury of the lungs may cause bloody froth coming out of the mouth. Severe traction exerted at the region of the hilus may tear the lungs at the point of attachment. Death is usually due to a severe shock or a rapid hemorrhage. Application of a severe crushing or grinding force in the chest wall causes extensive fracture of the ribs and may results to contusion and crushing injury to the lungs. The laceration may not be so severe but later the victim succumbs to lobar pneumonia. Complications of Lung Injuries: a. Hemorrhage — Injury to the lung may cause severe hemorrhage and about 1,500 cc. of blood may be recovered free in the pleural cavity.

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b. Compression of the lungs — The hemorrhage or the compression of the chest wall may cause limitation of the excursion of the lungs during respiration and ultimately the victim dies of asphyxia. c. Severe Pneumothorax — Laceration of the bronchi leads to the escape of air into the pleural cavity and embarrasses the respiration. d. Cerebral air embolism — Laceration of the lungs may also cause laceration of the pulmonary veinB and causes cerebral air embolism. e. Hemoptysis — The blood from the injured lungs may find its way to the bronchial tubes to the trachea and be spilled out through the mouth. If hemorrhage is severe, the blood may clot inside the bronchial tubes and causes acute asphyxia. f. Subcutaneous emphysema — Laceration of the parietal pleura and the lung tissue may cause the escape of air which finds its way into the subcutaneous tissue causing crepitation of the skin. Injuries to the Heart: The heart may fail and causes death due to an existing natural disease independent of trauma. Coronary insufficiency, myocardial fibrosis, valvular lesion or tamponade due to the rupture of the ventricle are common lesions. Wounds of the heart are produced by sharp instruments, bullets or the sharp ends of the fractured ribs. Contusion of the heart is easily produced on slight trauma on account of its vascularity. Wounds of the ventricle if small and oblique are less dangerous than those of the auricle because of the thickness of its wall. The right ventricle is the most common site of the wounds due to external violence, because it is the most exposed part of the heart. Foreign bodies like bullets, shrapnels, fragments of a shell may be embedded in the myocardium without any cardiac embarrassment. The person may live for a long time and may die of some other causes. Tearing of the heart from its attachments may be due to violent compression of the chest with the pressure forcing the organ downward and away from the neck The severe traction may cause the laceration of the aorta. v

Rupture of the heart is usually produced by a blunt instrument or by a crushing injury due to vehicular accidents. The heart is commonly ruptured at the right side towards the base. Death is due to severe hemorrhage, cardiac tamponade or shock.

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Crushing injuries of the heart are due to compression of the chest with the fractured fragments injuring the heart as in vehicular accidents, violent dynamite blast, or crushing of the chest between hard object. Wounds of the aorta and pulmonary vessels are rapidly fatal. Rupture of the aorta may be traumatic or spontaneous. Spontaneous rupture may be due to aneurysm. The cause of death is either the profuse hemorrhage or cardiac tamponade. Injuries of the Diaphragm: Wounds of the diaphragm due to a sharp instrument and bullets are caused by injuries either of the chest or abdomen. Their fatal effect is not on the injury to the diaphragm but on the accompanying injuries to the other organs. A n y penetrating wound in the diaphragm may cause a potent rent for diaphragmatic herniation. Rupture of the diaphragm is due to a sudden increase of intraabdominal pressure crushing injuries caused by vehicular accidents or traumatic compression of the chest. Death in diaphragmatic injuries may be due to shock, hemorrhage, intestinal obstruction caused by herniation, or the accompanying injuries. 3. ABDOMINAL INJURIES: Abdominal Wall: The skin may remain unmarked inspite of extensive internal injuries with bleeding and disruption of the internal organs. The areas most vulnerable are the point of attachment of internal organs, especially at the source of its blood supply and at the point where blood vessels change direction. The area in the middle superior half of the abdomen, forming a triangle bounded by the ribs on the two sides and a line drawn horizontally through the umbilicus forming its base, is vulnerable to trauma applied from any direction. In this triangle are found several blood vessels changing direction, particularly the celiac trunk, its branches (the hepatic, splenic and gastric arteries) as well as the accompanying veins. The loop of the duodenum, the ligament of Treitz and the pancreas are in the retroperitoneal space, and the stomach and transverse colon are in the triangle, located in the peritoneal cavity. Compression or blow on the area may cause detachment, laceration, stretch-stress, contusion of the organs (Legal Medicine 1980, Cyril H. Wecht ed., p. 41).

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Stomach: Spontaneous rupture of the stomach may be observed in cases of gastric ulcer or new growth. A blunt force applied at the upper portion of the abdomen may cause bruising or even rupture. The pyloric end and the greater curvature are the most frequent sites of a rupture. Penetrating stab wounds of the stomach are dangerous to life on account of a hemorrhage, infection and injury to the adjacent organs like the liver. Tearing of the stomach is common when the person is run over by a motor vehicle at the region of the abdomen. Intestine: Ulcer at the duodenum may rupture spontaneously. The same is true in cases of tuberculous, amoebic, cancerous or typhoid ulcerations. Peritonitis and hemorrhage are the common causes of death. Traumatic rupture may be due to a blow, kick, fall or vehicular accident. When force is applied to the front portion of the abdominal wall, the intestine may be pressed between the vertebral column and the force applied, producing either partial or complete severance or laceration. Its septic contents will scatter in the abdominal cavity and cause generalized peritonitis. Injuries caused by sharp instruments or by gunshots usually cause multiple lesions in the intestine and may also involve other visceral organs. The intestine may be involved in vehicular accidents and on account of the grinding force of the wheel, severe hemorrhage, laceration and herniation in the abdominal wall are usually observed. The mesentery may be contused, lacerated or crushed but in most cases its involvement is secondary to lesion in the intestine. Liver: The liver is one of the most vulnerable organs in the abdominal cavity because of its size, weight, location, friability, and fixed position. Injuries are frequently met in cases of blow, kick, crush, fall or sometimes in sudden contraction of the abdominal wall. The right lobe is more frequently involved than the left owing to its size and exposed location. Rupture is usually transversely or anteroposteriorly. On account of its extreme vascularity, the victim usually dies of severe hemorrhage, shock and very rarely of supervening infection. Sometimes recovery occurs after slight laceration but occasionally, abscess develops.

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Stab and gunshot wounds of the abdomen may involve the liver. Severe hemorrhage or shock usually causes the death. It may be lacerated by the fractured ends of the lower ribs in crush injuries. The gall bladder may be ruptured as a result of a kick, blow or crush injury. It may be inju*ed-by penetrating weapons. Death is due to hemorrhage and the effusion of bile into the peritoneal cavity. Spleen: The spleen usually suffers traumatic rupture resulting from the impact of a fall or blow and from the crushing and grinding effects of wheels of motor vehicles. Although the organ is protected at its upper portion by the ribs and also by the air-containing visceral organs, yet on account of its superficiality and fragility, it is usually affected by trauma. Congestion and diseased condition of the spleen, as in malaria, typhoid, kala-zar, make it more easily susceptible to slight trauma. Laceration of the spleen is more common at the region of the hilus and the lesion may be longitudinal or transverse. Lesion on the convex surface is also common especially when the force is applied to the left flank. On account of the vascular nature of the organ and its proximity to the plexuses of nerves, the victim usually dies of severe shock or hemorrhage. Penetrating stab wounds of the spleen are common but most often other visceral organs are also involved. Death is due to hemorrhage. Kidney: Traumatic injury of the kidney may be due to a blow at the lumbar region somewhere at the region of the 12th rib. It may be ruptured at the slightest violence when it is diseased as in cases of hydronephrosis, pyelonephritis, tuberculosis, abscess or tumor. The kidney may also be ruptured when the individual is run over by a vehicle or severely crushed from a fall Injury of the kidney is accompanied by peri-renal hematoma which consists of blood and urine. Death is due to a severe hemorrhage, loss of kidney functions and shock. Abdominal hemorrhage is present only if there is injury to the peritoneum concomitant to the lesions in the kidney. The adrenals may be contused, crushed or lacerated by severe violence. The right is more prone to injury of its vulnerable location. "Crush syndrome" — These are secondary kidney changes in crush injuries. Edema and anuria follow a crush. If death super-

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venes, the kidneys are found to be swollen, pale with marked degeneration of the cells lining the tubules (Taylor's Principles & Practice of Medical Jurisprudence by Simpson, 12th ed.. Vol II, p. 332). Pancreas: The pancreas may be injured by a violent blow at the epigastric region. Death may be due to hemorrhage, shock, or insulin insufficiency. If death does not occur immediately, fat necrosis is observed in the abdominal cavity on account of the leakage of the lipolytic enzyme. Spontaneous hemorrhage of the pancreas is frequently observed in the tropics. Its exact cause is still a matter of medical research. 4. PELVIC INJURIES: Fracture of the pelvic bones, especially of the pubis, is common in vehicular accidents and crush injuries. Separation of the symphysis may be observed without any external sign of injury. The patient may show difficulty of locomotion, and to a certain degree, damage to the urinary bladder. Urinary Bladder: The bladder may be involved in a blow, crush, or kick at the hypogastrium especially when distended with urine. Among parturient women, the bladder may rupture in the course of delivery. It may also be involved in fractures of the pubic bones. Spontaneous rupture is rare when it is over-distended due to urethal stricture, enlargement of the prostate, or tumor. Symptoms of rupture of the bladder are pain, tenderness at the lower portion of the abdomen, bloody urine, difficulty in urination and rigidity of the abdominal muscles. Death may be due to shock or super-imposed infection. Uterus: A non-gravid uterus is rarely involved in pelvic injuries, but a gravid uterus is likely to be ruptured in a blow, kick, or crush injuries. Spontaneous rupture of the uterus is commonly observed among pregnant women due to the injudicious use of drugs or abnormal presentation. Partial separation of the placenta may be spontaneous or due to trauma. Death is due to shock, hemorrhage, peritonitis or septicemia. Vagina: Laceration of the vagina may be due to a sexual act or a faulty instrumentation to induce a criminal abortion. The vaginal wall

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may be lacerated during parturition. 5. EXTREMITIES: Physical injuries on both upper and lower extremities are usually due to direct violence, crushing or some indirect force. a. Direct violence will result in a contusion and when the force applied is severe it may cause interstitial muscular hemorrhage and fractures of the underlying bone. Direct violence may be due to a fall, a vehicular accident, or a direct application of force. b. Indirect violence, such as twisting or pathological fracture of the bone underneath, causes laceration of the muscles around with marked hemorrhage. A patient may suffer deformity, shortening of the extremity and shock. c. Crushing injuries of the limb can result in severe soft tissue trauma and are most commonly caused by vehicular accidents or fall of heavy materials. These are usually accompanied by marked swelling, comminution of the bone and extravasation of the blood. Contusions and abrasions are frequent lesions of the extremities. Lacerated wounds are commonly observed in portion where the bones are superficially located as in the anterior aspect of the leg. Incised and punctured wounds of the hand are quite common on account of its utility and movability. Crushing injury of the extremities may cause laceration of the blood vessels and nerves. Injury of the intima of the blood vessels causes thrombus formation and in severe cases aneurysm may develop. Extravasation of the blood into the muscles causes swelling and pain. Fracture of the bones may be due to a direct violence, an indirect violence or a muscular action. Injury of the extremities may cause shock, hemorrhage and infection. The shock is principally due to the injury on the nerve, hemorrhage and fracture of the bones. Infection may be severe and may require amputation of the extremities.

Chapter XII DEATH OR PHYSICAL INJURIES CAUSED BY EXPLOSION Explosion is the sudden release of potential energy producing a localized increase in pressure. Investigation of death or physical injuries that is produced by explosion must be concerned in determining the following: 1. What exploded? 2. What caused it to explode? 3. H o w it produced the injury? 4. H o w was it initiated? Classification of Explosion as to the Source of Energy: 1. Mechanical (Hydraulic) Explosion — This occurs when the pressure inside a container exceeds its structural strength. Explosions of air pressure tanks for cleaning or paint spray, water pressure tanks to establish water pressure, and the air pumped kerosene burner are examples of mechanical explosions. These explode when the pressures applied are in excess of the strength of the containers. As the container disintegrates, there is a rapid localized increase in pressure resulting in the characteristic explosive sound. 2. Electrical Explosion — When electricity arcs through the air, a phenomenon that occurs when two objects of different electrical potential are brought close to one another, a large amount of heat develops. This heat rapidly expands the air in and around the arc which produces the popping sound of an arc. Lightning though it occurs in a much complex form with extremely high temperature, may be an example of an electrical explosion. 3. Nuclear Explosion — The release of a significant amount of energy by fusion or fission and consequently with a significant increase of destructiveness. Atomic Explosion — Atomic nuclei can be regarded as stored condensed energy. The uncontrolled release of this energy constitutes atomic explosion. 4. Chemical Explosion — Chemical explosion occurs when a chemical reaction'produces heat and gas at a rate faster than the surroundings can dissipate. At the start of the reaction the initial heat or gas 322

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pressure increases the rate of reaction, which progresses at a faster rate until the explosion results. Types of Chemical Explosion: a. Diffused Reactant Explosion — This is caused by the mixture of gas and air. If the gas and air are mixed in correct proportion, product of heat and subsequent pressure is produced. Explosion of diffused reactants must be initiated by flame, spark or sometimes heat. Mixture of gases with other materials may cause production of flame. The most common example of dispersed gas explosion is in the internal combustion engine. b. Condensed Reactant Explosion — This chemical explosion occurs when large quantity of heat and gas is produced as a result of rapid chemical reaction in a solid or liquid material. It has a point of origin so that the most severe damage is closest to the source and the effects diminish as the distance from the center increases. There is no need of atmospheric oxygen and if oxygen is required in the reaction it is incorporated into the explosive. Condensed reactant explosives may be classified as: ( 1 ) Low Order Explosive (Deflagrating Explosive) — Those which rely on burning and confinement to produce explosions. When the reaction is confined, the built-up of heat and pressure causes the reaction rate to increase rapidly to an explosion. Gunpowder is the best known low order explosive. When sufficiently heated the nitrate content is decomposed to nitrate and oxygen. The oxygen reacts with sulfur and carbon producing sulfur oxide, sulfur dioxide, carbon monoxide and carbon dioxide in various combinations. ( 2 ) High Order Explosive — This is the kind that detonates. Detonation is a chemical process which results in the extremely rapid decomposition of nitrogenous compounds. Releasing heat and gas is its reaction by-product. It is the shock wave spreading out of the explosion that causes the destructive effect of high explosive. Dynamite is an example of a high order explosive. (a) Stable High Order Explosive — This compound will not detonate unless they are subjected to detonation. This includes dynamite (nitroglycerin made stable by clay absorption). ( b ) Unstable High Order Explosive — Easily detonates from heat, flame, spark or percussion. This includes trinitrobenzene (Picric acid), fulminate of mercury, lead, antimony or bismuth and nitroglycerine (Clinics in

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LEGAL MEDICINE Laboratory Medicine by V. Di Maio, Vol. 3, No. 2, June 1983, pp. 309-314). Death or physical injuries due to detonation of high explosives may be due to the following causes: The destructive effects varies with the kind and amount of explosive used and the location of the victim at the time of the explosion. The explosion is accompanied by blast, flame and fragment primarily. The nature and extent of the injuries suffered by the victim may be: (a) If the victim is in contact with the explosive, as when he is manipulating, carrying or sitting on it at the time of the explosion, there is complete disruption or fragmentation of the body. Pieces of the body may be found several meters away from the site of explosion. Some parts of the body may be found hanging on the electric power line, bones completely shattered, skin and other soft tissues may be found scattered at a certain distance from the site of the explosion.

Burns a n d other injuries b r o u g h t a b o u t b y d y n a m i t e e x p l o s i o n .

The explosion causes sudden increase of atmospheric pressure which is immediately followed by a sudden fall. This compression-decompression effect causes displacement, distortion and bursting effects on body parts, especially in the brain and abdominal visceral organs. Aside from these injuries, there is rapid development of scattered foci or small

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hemorrhages mostly in organs which easily change in shape and which are rich in blood supply. ( b ) If the victim is not so close to the site of explosion, the body though badly injured may remain in one piece. Some parts may be dismembered but may be recovered within a few meters. Certain areas of the body may show severe injury, but the triad of punctate bruises, abrasions and lacerations may be found distributed all over the body. (All of these injuries have still the effect of the blast wave with a diminishing intensity.) (c) The peppering kind of injuries may be observed as the distance from the site of explosion increases. The density and severity becomes less until it disappears. However, one or more metallic fragments travelling with moderate velocity may strike the vital parts of the body and may cause death. ( d ) Other effects of the blast wave: i.

The impact of the high pressured wave can knock down the person.

ii.

In the respiratory organ, the bronchus may be lacerated or the mucosa of the trachea may develop petechial hemorrhages. This effect is not due to the entry of the high pressured wave along the trachea and bronchi but by its passing directly on the body wall.

iii. The ear is the organ most vulnerable to the blast. Most person at the vicinity of the explosion may suffer from slight reddening of the tympanic membrane which signifies that the cochlea has been damaged (e) Burns from the flame or heated gas — The instantaneous or momentary flame of high intensity during explosion may cause singeing of the eyebrow, scalp hair and eyelashes. Clothings may also be burned. Body surface in contact with the flame or exposed to the heated air may develop burns, the degree of which depends upon the intensity and duration of exposure. (f) Asphyxia due to lack of oxygen — Explosion causes consumption of oxygen in the surrounding atmosphere, thereby limiting the amount available for human consumption. (g) Poisoning by inhalation of carbon monoxide, nitrous or nitric gases, hydrogen sulfide, sulfur dioxide, or hydrocyanic gas — The by-products of combustion may be protoplasmic poison or may cause death by interfering with the

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LEGAL MEDICINE normal transportation and utilization of air by the tissues of the body. (h) Direct injury by the flying missiles — The injury due to flying missiles is influenced by the proximity of the individual to the site of explosion, velocity of the missiles, manner or approach of the missiles on the body surface involved and the subsequent complications arising from such injuries. The shrapnel wound may go much deeper or the foreign body may lodged inside the body. The edges of the missiles may be irregular or smooth so that the lesion on the skin may appear like an incised wound. If lacerated, the surrounding tissues may be contused. The following explosives may cause shrapnel wound: Grenade — Rifle or hand. Bomb — Demolition or incendiary. Mine.s — Underground or submarine. Exploding missiles — Anti-aircraft ( i ) Injuries from the falling debris — If the explosion took place in a building the victim may be injured and buried under the rubbles. The victim may suffer from multiple injuries of whatever description or die of traumatic or crash asphyxia.

Identification of the Site of Explosion and Collection of Evidences: The site of explosion may be identified by the presence of a crater. The original location of other objects located near the blast may be useful clues in the determination of the site of explosion. Soil and other debris may be collected for laboratory examination. The entire area must be systematically searched for traces of the detonation mechanism. All blown out materials must be tested for explosive residues. If the investigator arrived at the site immediately after the explosion, he may be able to smell the odor of the gas. One of the simplest way of collecting gas samples for analysis is to take a bottle full of water in the area where odor is the strongest and pour the water out of the container. The surrounding air will immediately replace the water removed from the bottle. Then the bottle must be tightly sealed and sent to the laboratory for examination. Scrapings from the debris and other materials at or near the site of the explosion may be subjected to extensive stereoscopic and microscopic examination. Particles of unconsumed explosive may be recovered.

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Fragments of the explosive materials and debris recovered may be rinsed with hot water so that water-soluble inorganic substances (nitrates and chlorates) may be extracted. The materials may be rinsed with acetone inasmuch as most explosives are highly soluble to acetone. The extract is concentrated and analyzed. Color Spot Tests for Common Chemical Explosives: Substances Chlorate Nitrate Nitrocellulose Nitroglycerin PETN RDX TNT Tetryl

Griess

Diphenylamine

No color Pink to red Pink Pink to red Pink to red Pink to red No color Pink to red

Blue Blue Blue-black Blue Blue Blue No color Blue

Alcoholic KC No color No color No color No color No color No color Red Red-violet

Griess Reagent: Solution 1 — Dissolve 1 mg. sulfanilic acid in 100 ml. of 30% acetic acid. Solution 2 — Dissolve 1 g. alpha-naphthylamine in 230 ml. of boiling distilled water, cool. Decant the colorless supernatant liquid and mix with 110 ml. of glacial acetic acid. A d d solutions 1 and 2 and a few milligrams of zinc dust to the suspect extract. Diphenylamine Reagent: Solution 1 — Dissolve 1 g. diphenylamine in 100 ml. concentrated sulfuric acid. Alcoholic KOH Reagent: Solution 1 — Dissolve 10 g. of potassium hydroxide in 100 ml. of absolute alcohol. (Criminalistics by Richard Saferstein, p. 242). Other Tests on Extract: 1. Infra-red spectrophotometry. 2. X-ray diffraction. 3. Gas chromatographic analysis. ATOMIC B O M B E X P L O S I O N : Atomic nuclei can be regarded as storage of highly condensed energy and that the uncontrolled release of this energy constitute an atomic explosion. The explosion is caused by the fission of about 100 pounds of uranium and liberates energy equal to that of a

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million tons of T N T . It produces millions of pounds per square inch of gas pressure, with heat comparable to the sun and light of more than 30 times as bright as the sun at noontime. After explosion, it produces a luminous ball of fire containing radioactive fission products, which increases upward in size and creates shock waves moving sidewards in all directions. The fireball may have the diameter of 7,200 feet in ten seconds and in one minute time it may reach a height of 4-1/2 miles. Place of Atomic Explosion: 1. Aerial Explosion — The bomb is made to explode on the air. 2. Ground Explosion — Explosion is made when the bomb reaches the ground. 3. Submarine Explosion — Explosion takes place underneath the surface of a body of water. Rays Emitted by Radioactive Substances During Explosion: 1. Alpha Rays — Composed of positively charged helium, having a high linear energy transfer and with a poor penetrating power that can be stopped by a sheet of paper. 2. Beta Rays — Composed of positively or negatively charged electrons with a higher penetrating power than the alpha rays but the ionizing power is much less. The electrons are travelling at a very high velocity and in some cases approaching the speed of light. 3. Gamma Rays — Composed of short rays with high energy and greater penetrating power and like neutrons it extends a significant distance and causes much damage to the human body. 4. Neutron Rays — Uncharged and composed of highly penetrating particles and basic element in nuclei of atoms. Characteristics of Nuclear B o m b Explosion that Distinguishes it from Conventional High Explosive B o m b Explosion: 1. It is many thousand times as powerful as a highly conventional bomb explosion and the effects of the blast are very prominent. 2. A large proportion of its energy is emitted as thermal radiation, causing skin burns and it is capable of starting a fire at a considerable distance. 3. The explosion emits a highly penetrating and harmful radiation, and the substance which remains after the explosion continues to emit radiation over a long period of time. (Forensic Medicine by Tedeschi, Eckert & Tedeschi, Vol. 1, p. 633). Effects of Atomic Explosion to the Human Body: The effects of atomic explosion of the human body are inversely proportional to the distance. One megaton of atomic bomb exploded

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in air can cause fire of up to a 10 miles radius. The pressure front of the blast can be felt one mile away in 2 seconds time. The blast wave is of sufficiently long duration which is accompanied by transient blast winds causing damages to the people and the surrounding structures. Other effects of atomic explosion are the same as that of ordinary chemical bomb explosion but of a much more severe intensity. Aside from the immediate traumatic effects, the radiation emitted by the radio-active substances can also have an effect which may be local or general. 1. General Effects: Massive dose causes generalized followed by coma and death.

erythema,

disorientation

Lesser dose may-cause nausea, vomiting followed by prostration and rapidly developing and persistent leukemia. Later symptoms may develop in the form of rise of temperature, ulceration of lymphoid, easy fatigability, oro-pharyngeal ulceration and severe leukopenia. 2. Local

Effects:

a. Individual Cells — It causes retardation of cell division, structural changes in the chromosomes and cytoplasm, vacuolization, and with evidence of maturation. There is loss of the supporting mesenchymal cells. b. Skin — Epilation of the hair with the follicles remaining intact, sweat glands lose their function, erector pili muscles not much affected. The skin become edematous and later disquamated and ulcerated. Radiation dermatitis is persistent, usually painful with patchy keratitis and foci of ulceration. Hyperpigmentation or depigmentation may later develop. c. Blood Vessels — There is endothelial necrosis and localized thrombosis. The blood vessels thicken because of the hyalinization of the collagen. Some blood vessels are occluded with the loss of the muscular layer. d. Eye — Cataract develops. e. Genital Organ — In female it causes sterility, abortion or stillbirth. In men, it also causes sterility without loss of sexual potency. • Factors Responsible for the EffectB of Radiation: 1. Age — Children and old persons are more susceptible to radiation. 2. Dosage — Bigger dose of radiation will cause more damaging effects on the body tissues.

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3. Kind of Radiation — The biological damage is not always proportional to the energy absorbed, but it depends on the kind of energy emitted. Gamma and neutron radiations are most destructive. 4. Fractional Doses — A single dose may be lethal when administered fractionally over a long interval of time. 5. Sensitivity — Muscles and connective tissue are radioresistant while actively dividing tissues like blood forming organs, intestinal epithelium are quite radiosensitive. Other Sources of Radiation: 1. Natural Source: a. Cosmic Origin — Radiation from the sun or from outer space. b. Terrestial Origin — Chiefly from radiothorium series of granite rocks. 2. Man-made Source: a. Diagnostic X-ray Equipment: The filament inside a vacuum tube is heated by a strong electric current so that it will emit electrons. The electron is driven on an anode target (Rhenium and molybdenum) which causes the development of electromagnetic energy, the wave length and the ability to penetrate depends on the kilovoltage applied. The higher the voltage, the shorter is the wave length and the more penetrating are the X-rays. As the X-ray passes the tissues of the body, the degree of absorption depends on the density. The bones absorb more X-ray than the air containing tissues. Naturally the film behind receives a differential amount of X-ray. The denser substance like the bone, will be represented by a lighter image while the less denser organs will have a darker image. In a fluoroscope, the X-ray after passing the body goes to a screen and the differential absorption of X-ray by the body is reflected in the fluoroscopic screen (Legal Medicine by Tadeschi p. €86). b. Clinical nuclear pharmaceutical agents. c. Therapeutic radiation apparatus. d. Radiation sources used in industry, like nuclear power plant The problem of the use of nuclear power in generating plants is the disposal of the radioactive waste which may be in the form of: ( 1 ) Gases chiefly emitted from the vapor.

Chapter XIII / G U N S H O T WOUNDS D E A T H O R P H Y S I C A L INJURIES B R O U G H T A B O U T B Y POWDERED PROPELLED SUBSTANCES Death or physical injuries brought about by the powder propelled substances may be due to the following: 1. Firearm Shot — The injury is caused by the missile propelled by the explosion of the gunpowder located in the cartridge shell and at the rear of the missile. The direction of the movement of the missile is influenced by the desire of the person firing the firearm. The missile may be single as in the case of a pistol or revolver or may be of multiple shots or pellets as in the case of a shotgun. The cartridge shell is physically preserved after the fire. 2. Detonation of high explosives, as in grenades, bombs and mine explosion. Explosion of the gunpowder inside the metallic container will cause fragmentation of the container. Each fragment or shrapnel is moving with certain velocity without any predetermined direction. I. FIREARM W O U N D Definition of Firearm: 1. Technical

Definition:

A firearm is an instrument used for thejpropulsion of a projectile_7 by the^expansive force of gases^coming from the burning of gunpowder. 2. Legal Definition: Section 877, Revised Administrative Code — "Firearm" defined: "Firearm" or "arm", as herein used, includes.jrifles,^muskets, shotguns, revolvers,^pistols, and jill other deadly weapons from "which a bullet, > a l l , shot, shell, or pfher missile may be discharged by means of gunpowder or other explosives. The term also includes air rifles except such as being of small caliber and limited range are used as toys. The barrel of any firearm shall be considered as a complete firearm for all purposes thereof. w

Penal Provisions of Laws Relative to Firearm: Section 2692, Revised Administrative Code: 332

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Unlawful manufacture, dealing in acquisition, disposition, or possession of firearms, or ammunitions therefor, or instrument used or intended to be used in the manufacture of firearms or ammunition: yjtr n r a + m .

n

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4R1

4. Multiple fresh healing fractures; "twist" fractures. 5. Trauma to the mouth, nose, ears and eyes. 6. In case of sexual abuse, injuries to the genitalia, peri-rectal and peri-vaginal may be present. 7. In case of child neglect, signs of mainourishment, poor hygiene, infection, poor growth and development may be observed. Facts to be Considered to Suspect that a Child is a Victim of Abuse: 1. The child is emotional, fearful and with a vague history of injury. 2. The parents present a vague and defensive detail of the child's "illness" or "injury". 3. Too many previous unexplained signs of injuries or history of previous illness. 4. Parents have extended delay in seeking medical cure. 5. Poor growth and development of the child. Social Reaction To Child Abuse and Neglect: 1. Report of Maltreated or Abused Child: Art. 166, Child and Youth Welfare Code ( P . D . 603): All hospitals, clinics and other institutions as well as private physicians providing treatment -shall, within forty-eight hours from knowledge of the case, report in writing to the city or provincial fiscal or to the Local Council for the Protection of Children or to the nearest unit of the Department of Social Welfare (Ministry of Social Service and Development), any case of a maltreated or abused child, or exploitation of an employed child contrary to the provisions of labor laws. It shall be the duty of the Council for the Protection of Children or the unit of the Department of Social Welfare to whom such a report is made to forward the same to the provincial or city fiscal. Violation of this provision shall subject the hospital, clinic, institution, or physician who fails to make such report to a fine of not more than two thousand pesos. According to Administrative Order No. I — A, series of 1981 of the Ministry of Health, dated July 6, 1981: The report shall be submitted directly to the nearest Ministry of Social Services and Development Office copy furnished the police authority concerned and the Provincial/City Fiscal. The report shall include the following information: a. Name of child. b. Date of birth, age and sex. c. Date and time of admission.

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d. Name of person who brought the child to the health institution. e. Address and relationship to the child. f. Name and address of the father /mother /guardian of the child if other than the person who brought the child. g. Tentative date of discharge. h. Medical findings/case summary relative to the maltreatment/ abuse/exploitation of the child. i. Evidence of parent's/employer's negative attitude towards the incident. The health authority concerned shall ensure that the report is acknowledged in writing by the Ministry of Social Services and Development Office within 24 hours." Art. 167, Child and Youth Welfare Code — Freedom from Liability of the Reporting Person or Institution: Persons, organizations, physicians, nurses, hospitals, clinics and other entities which shall in good faith report cases of child abuse, neglect, maltreatment or abandonment or exposure to moral danger shall be free from any civil or criminal liability arising therefrom. The provision of the Child and Youth Welfare Code ( P . D . 603), Art. 166 requiring mandatory reporting of child abuse by physician and medical institution has its advantages and disadvantages. a. Advantages: (1) It compels the hesitant physician or medical institution to report such child abuse or neglect so that proper remedial measures can be applied to protect the child. ( 2 ) The fact that the child under treatment due to the act of the parent(s) was known by the physician in the process of history taking, makes such information privileged or confidential and the physician normally has no right to disclose such information. But Art. 167 of the Code provides for freedom from liability of the reporting person, thereby placing the traditional right of the child above the parent's right to the privileged communication. b. Disadvantages: (1) It increases the health hazard of the child as the abusing parents will be reluctant to seek medical aid for the abused child. ( 2 ) The law's concentration on one child as seen by a physician fails to concern itself with the possibility of danger to the other siblings within the family. (3) If the reported parents are exonerated, released and reunited with the family, the pent-up anger felt against the

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authority may be released against the vulnerable child. 2. The court may deprive parents of their authority over the child or adopt other measures for the welfare of the child: Art. 332, Civil Code: The court may deprive the parents of their authority or suspend the exercise of the same if they should treat their children with excessive harshness or should give them corrupting orders, counsels or examples, or should make them beg or abandon them. In these cases, the court . . . or adopt such measures as they may deem advisable in the interest of the child. The court has a wide range of powers designed to give the highest practicable degree of flexibility in making dispositional decision. The judge may simply warn parents or counsel them. He may order medical and psychiatric treatment for the child and/or for the parents. He may order the child to be in a protective supervision in a welfare home. Although the parents have the right of custody of their children, the children have also the right to live. The judge must exercise sound discretion in balancing their respective interests. 3. Establishment of public and private welfare institutions for the care of abused, neglected, abandoned, infirmed, or other conditions which require aid, support or treatment. 4. Abuse, neglect or abandonment of children is made a criminal act or omission: a. If the child dies, then the offender is guilty of parricide: Art. 246, Revised Penal Code — Parricide: A n y person who shall kill his father, mother or child, whether legitimate or illegitimate, or any of his ascendants, or his spouse, shall be guilty of parricide and be punished by the penalty of reclusion perpetua to death. b. If the child did not die but was a victim with physical injuries, the offender can be charged with frustrated parricide, or physical injuries: c. If the child is abandoned or neglected, the offender can be charged for abandonment of minors: (1) Art. 276, Revised Penal Code —Abandoninga minor: The penalty of arresto mayor and a fine not exceeding 500 pesos shall be imposed upon anyone who shall abandon a child under seven years of age, the custody of which is incumbent upon him.

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LEGAL MEDICINE When the death of the minor shall result from such abandonment, the culprit shall be punished by prision correccional in its medium and maximum periods; but if the life of the minor shall have been in danger only, the penalty shall be prision correccional in its minimum and medium periods. The provisions contained in the preceding paragraphs shall not prevent the imposition of the penalty provided for the act committed, when the same shall constitute a more serious offense. ( 2 ) Art. 277, Revised Penal Code — Abandonment of minor by person entrusted with his custody; indifference of parents: The penalty of arresto mayor and a fine not exceeding 500 pesos shall be imposed upon anyone who, having charged with the rearing or education of a minor, shall deliver the said minor to a public institution or other persons, without the consent of the one who entrusted such child to his care or in the absence of the latter, without the consent of the proper authorities. The same penalty shall be imposed upon the parents who shall neglect their children by not giving them the education which their station in life requires and their financial condition permits.

Other Battered Victims: 1. Battered wife — The wife may be periodically subjected to maltreatment by the husband on the account of jealousy, infidelity, or incompatability of character. Attempt of the husband on the life of the wife is one ground for a legal separation. 2. Battered grannies (battered grandfather or battered grandmother) — Elderly persons may be extremely demanding, seeking more attention from the caring descendant or with child-like behavior which may be irritating and which may cause infliction of physical injuries. The same situation may happen where an over-demanding boarder may suffer maltreatment from the overworked caretaker of the home for the aged.

Chapter XXI MEDICO-LEGAL ASPECTS OF SEX CRIMES VIRGINITY A N D DEFLORATION A. VIRGINITY Virginity is a condition of a female who has not experienced sexual intercourse and whose genital organs have not been altered by carnal connection. A woman is a "virtuous female" if her body is pure and if she has never had any sexual intercourse with another, though her mind and heart is impure (Thomas v. State, 19 Ga. App. 104, 91 S.E. 247, 250). The presumption of a woman's virginity arises whenever it is shown that she is single and continuous until overthrown by proof to be contrary (U.S. V. Alvarez, 1 Phil. 242). A woman is presumed to be a virgin when unmarried and of good reputation. A defendant has the previous sexual intercourses with the victim before he was charged'with consented abduction for acts committed thereafter. The woman was considered "virgin" within the meaning of the law (U.S. v. Casten, 34 Phil. 808). However, in another case, it was established that the defendant's character, before the alleged seduction, was opened to question. The woman considered no longer a virgin (U.S. v. Suan, 27 Phil. 12). of Virginity: 1. Moral Virginity — The state of not knowing the nature of sexual life and not having experienced sexual relation. Moral virginity applies to children below the age of puberty and whose sex organs and secondary sex characters are not yet developed. 2. Physical Virginity — A condition whereby a woman is conscious of the nature of the sexual life but has not experienced sexual intercourse. The term applies to women who have reached sexual maturity but have not experienced sexual intercourse. There are no conclusive medical findings to show that a woman is physically virgin. Reliance is given to the absence of laceration of the hymen, but a woman might have had previous sexual 485

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intercourse and yet the hymen was unruptured while others might not have the experienced of sexual relations but have laceration of the hymen. If the findings show absence of laceration of the hymen, distinction should be drawn between true and false physical virginity. a. True Physical Virginity — A condition wherein the hymen is intact with the edges distinct and regular and the opening small to barely admit the tip of the smallest finger of the examiner e. n if the thighs are separated. b. False Physical Virginity — A condition wherein the hymen is unruptured but the orifice is wide and elastic to admit two or more fingers of the examiner with a lesser degree of resistance. The hymen may be laxed and distensible and may have previous sexual relation. In this particular instance the physician may not be able to make a convincing conclusion that the subject is virgin. 3. Demi-Virginity — This term refers to a condition of a woman who permits any form of sexual liberties as long as they abstain from rupturing the hymen by sexual act. The woman may be embraced, kissed, may allow her breasts to be fondled, her private organ to be held and other lascivious acts. The woman allows sexual intercourse but only "inter-femora" or even "inter-labia" but not to the extent of rupturing the hymen. 4. "Virgo Intacta" — Literally the term refers to a truly virgin woman; that there are no structural changes in her organ to infer previous sexual intercourse and that she is a virtuous woman. Inasmuch as there are no conclusive evidences to prove the existence of such condition, liberal authorities extend the connotation of the term to include women who have had previous sexual act or even habitually but had not given birth. Parts of the female body to be considered in the determination of the condition of virginity: 1. Breasts — The breasts (mammary glands) are functionally related to the reproductive system since they secrete milk for nourishment of the young child. At their inner structures are 15 to 20 lobes of glandular tissues supported by conr>active tissue namework with variable amount of adipose tissue. On the ventral surface of each breast is a cylindrical projection called nipple and at its rounded tip are perforations which are the openings of the ducts draining the milk glands. The nipple is surrounded by a pigmented area called areola which becomes dark brown during pregnancy.

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The size, consistency and shape of the female adult breast varies with age, degree of physical development, stage in the menstrual cycle, pregnancy, nutrition and hormonal factors. A fully developed breast may be classified according to shape as follows: a. Hemispherical Breast — The breast is like a hemisphere. The contour lines are not straight but form part of a circle or half of a sphere. b. Conical Breast — The breast has the shape similar to a cone. The outline consists of two converging lines which meet at the region of the nipple. c. Infantile or Flat Breast — The breast is only slightly elevated from the chest without distinct boundary and showing no definite shape. d. Pendulous Breast — The skin of the breast is loose making it capable of swinging in any direction. This is commonly observed among parturient breast-feeding mothers. A pendulous breast may be: ( 1 ) Hemispherical pendulous breast — It has the shape of a hemisphere but with loose skin. ( 2 ) Conical pendulous breast — It has the shape of a cone and is capable of swinging sidewise. The condition of the breast is not a reliable evidence to determine virginity. The size, shape and consistency of the breast may be hormonal or hereditary. The advent of artificial feeding makes it possible for parturient women to preserve the condition of the breast. 2. Vaginal Canal: As a general rule, the vaginal canal of a virgin is tight and the rugosities are sharp and prominent. Insertion of a finger or instrument may show certain degree of resistance. The wall of the vagina is composed of smooth muscle and fibroelastic connective tissue so that its tightness and degree of resistance on insertion of a finger or an instrument depends on the integrity of its wall, as well as on the potency of its lubricating secretion. The sharpness of the wall's rugosities may be diminished by insertion of foreign bodies, passage of clotted blood, self-manipulation, etc. and not by sexual intercourse. The canal may be inherently lax and rugosities not prominent since "birth. 3. Labia Majora and Labia Minora. The labia majora is firm, elastic and plump and its medial borders are usually in close contact with each other so as to cover the labia

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minora and the clitoris. The labia minora is soft, pinkish in close contact with one another, and its vestibule is narrow. Entry of the male organ may cause the labia to gape due to stretching of their borders. The condition of both labia is not a reliable basis in determining virginity. A woman may be a virgin but with a gaping labia, while others might have had previous delivery but the labia are still coaptated. The condition of the labia is much more related to the general physical condition of the woman rather than the absence or the presence of previous sexual intercourse. A stout woman usually can preserve the plump, coaptated and firm labia while skinny women usually have gaping labia. 4.

Fourchette: The fourchette present a V-shape appearance as the two labia minora unite posteriorly. After severe distention, the sharpness of the acute angle may become rounded with retraction of the edges. The rounding of the fourchette and the retraction of the edges can be a consequence of so many causes. Stretching apart of the thighs, instrumentation, horse or bicycle riding may produce the condition other than sexual intercourse.

5. Hymen: Physicians give much attention in the examination of the hymen in the determination of virginity. Classification

of Hymen:

a. As to shape and size of the opening: (1) Annular or circular — The opening is oval or circular located at the center of the hymen. There may be indentation of the borders. (2) Infantile — The opening is small, usually linear, fleshy and resistant. (3) Semilunar or crescentric — The concavity may be facing either side or upwards or downwards. The tapering ends of the crescent may be the frequent sites of laceration. ( 4 ) Linear — The opening is slit-like and usually running vertically. (5) Cribiform — The hymen presents several openings instead of a single one. In several instances the openings are quite small and will require the use of a hand lens to make them visible. ( 6 ) Stellate — hymenal opening is like a star.

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(7) Septate — There are two openings which may be of equal or different sizes separated by a bridge of hymenal tissue. After a sexual act there may be complete rupture of the bridging tissue or marked distention of one to make the other opening almost invisible. (8) Fimbriated — The border of the opening shows small irregular protrusion towards the opening. In some instances the fimbriation may be big enough that the examiner may mistake it to be a superficial laceration. ( 9 ) Imperforate — There is no opening on the hymen. When a woman starts to menstruate, surgery may be necessary to open the hymen to allow free passage of menstrual blood. b. As to structure and consistency: (1) Firm and with strong connective tissue and plenty of blood vessels — This type has more tendency to lacerate during the first sexual act and the laceration may produce relatively more hemorrhage.

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Thin hymen

( 3 ) Membranous hymen — Hymen is parchment-like, may be transparent and may lacerate without pain or appreciable bleeding. c. As to number of opening: (1) (2) (3) (4)

Single orifice — Having one opening. Septate — Having two openings. Multiple — Having several openings. Imperforate — Without orifice.

Virginity is N o t Synonymous with Chastity: A woman may resort to many forms of homosexual as well as heterosexual practices without losing her virginity, yet she may be unchaste. A woman may have a ruptured hymen and other signs of loss of physical virginity, yet she is chaste. She may resort to masturbation with rupture of the hymen and dilatation of the vaginal canal causing it to appear that she has had several sexual intercourses, yet she may still be a virgin. B. DEFLORATION 'efloration is the laceration or rupture of the hymen as a result of sexual intercourse. All other lacerations of the hymen which are not caused by sexual act are not considered as defloration.

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Parts of the female genitalia that must be examined to determine defloration: 1. Condition of the Vulva: Normally the labia majora and minora are in close contact with one another covering almost completely the external genitalia. After defloration, the labia may gape exposing the introitus vulvae. The finding may not be relied upon because some females may have inherently gaping labia, especially, asthenic women although there is no history of previous sexual act, while others may preserve the coaptated labia even if there has been previous sexual act. 2.

Fourchette: The normal V-shape of the fourchette is lost on account of the previous stretching during insertion of the male organ. Withdrawal of the stretching force will cause retraction of its walls with rounding of the base. Retraction of the fourchette is not a good sign of defloration inasmuch as it can be due to other causes. Ballet dancing, separation of the thighs, tree climbing, cycling, horse riding, insertion of foreign body, etc. may cause retraction of the fourchette without previous sexual act. The fourchette, together with the perineum and lower portion of the posterior vaginal wall, may be lacerated by sexual act or some other causes.

3. Vaginal canal: After repeated sexual acts, there is diminution of the sharpness or obliteration of the vaginal rugosities. There will be laxity of its wall so that insertion of a medium size tube during the medical examination can be done with slight resistance. The changes in the vaginal rugosities or the laxity of its wall cannot be relied upon as a proof of defloration because instrumentation during medical examination, masturbation or insertion of foreign bodies or other similar or related acts will cause the development of such condition. The vaginal wall, together with the vulva, may suffer injury during defloration or some other causes. Predisposing causes of vulvo-vaginal injuries during sexual act: a. Virginity — Sex organ does not have previous experience to stretching or coital act. b. Prepuberty — The genital organ is not yet fully developed to subject it to full physiological function.

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c. Genital disproportion — The male organ is unusually big or female organ infantile in size in spite of adult age. d. Unprepared or unaroused female — The vaginal secretion is absent, causing more friction. e. Position during the sexual act — Dorsal decubitus position with the thighs hyperflexed predisposes to deep penetration by the male organ and is contributory to vaginal vault lacerations. Vaginal position may not be in harmony with the movement of the penis. f. Brutality of the male partner during the sexual act. g. Recent vaginal surgery — The canal may become narrow and fibrous scar may replace the muscular vaginal wall at the site of surgery. h. Excessive active involvement of the female partner. i. Multiple sexual act among sex deviates (Nymphomaniac or satyriatic) or multiple consort — Continuous stretching and friction may weaken its wall. j . Renewed sexual activity after prolonged abstinence. k. Post-menopause. 1. Uterine retroversion. 4. Hymen: The hymen is lacerated during the initial sexual act. However, it is not always the case. Some hymen are thick, elastic and fleshy such that they can resist certain degree of distention without causing laceration. Some women may inherently have lacerated hymen probably on account of previous trauma during the early age. The fact that the hymen is intact does not prove absence of previous sexual intercourse and the presence of laceration does not prove defloration. Other Causes of Hymenal Laceration: a. Passage of clotted blood during menstruation. b. Ulceration due to disease, like diphtheria. c. Jumping or running. d. Falling on hard and sharp object. e. Medical instrumentation. f. Local medication. g. Self-scratching due to irritation. h. Masturbation. i. Insertion of foreign bodies, j. Previous operation. In the medical examination of the hymen, the following facts must be included:

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a. General condition of the hymen: This includes the width, thickness, elasticity, vascularity, and laxity. It may include pathological condition, like inflammatory changes, signs of previous trauma, developmental abnormality and foreign elements. b. Original shape of the orifice (opening): In case laceration is present, try to reconstruct the hymen by means of a probe and determine the original shape of the opening. It may be linear, circular, stellate, cresentric, septate, cribiform, imperforate and fimbriated. c. If lacerated, the following must be noted: ( 1 ) Degree of laceration: This refers to the extent of damage to the hymen which may be: (a) Incomplete laceration — Rupture or laceration of the hymen is considered incomplete when it does not involve the whole width or height of the hymen. Incomplete laceration may be: i. Superficial — The laceration does not go beyond one-half of the whole width of the hymen. ii. Deep — The laceration involves more than one-half of the width of the hymen but not reaching the base. ( b ) Complete laceration — The hymenal laceration involves the whole width but not beyond the base of the hymen. (c) Compound or complicated laceration — The laceration involves the hymen and also the surrounding tissues. It may involve the perineum, vaginal canal, urethra or rectum. Notches — Indentation of the hymen simulating lacerations. They may be symmetrical and may extend to the vaginal wall. The mucous membrane over the notch is intact. Notches may be mistaken for laceration. (2) Location of laceration: For the purpose of locating the site of the laceration, the hymenal orifice is related to the face of a watch while the subject is in lithotomy position. With the examiner facing the female genitalia, the location of the laceration will be described corresponding to the time in the face of a watch. By this procedure, a laceration at the region of the fourchette may be described as a laceration at 6:00 o'clock position in the face of a watch while on the horizontal

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LEGAL MEDICINE sides may be termed 9:00 (left side) and 3:00 (right side) positions. (3) Duration of the laceration: The determination as to how long the laceration took place can be approximated by the changes observed in the lacerated tissue. (a) Fresh bleeding laceration — The laceration is of recent origin. ( b ) Fresh healing with fibrin formation and with edema of the surrounding tissue — Usually after 24 hours. (c) Healed laceration with congested edges and with sharp coaptible borders — Depending upon the degree of laceration and the presence or the absence of complications, the said laceration could have occurred 4 to 10 days. Sometimes, the said finding is termed "recently healed" laceration. ( d ) Healed laceration with sharp coaptible borders without congestion — Some times have passed by after the laceration has healed. Ordinarily it can be inferred that hymenal laceration took place approximately more than ten days or 2 to 3 weeks. ( e ) Healed laceration with rounded non-coaptible borders and retraction of the edges — Laceration took place long before the date of the examination which is probably more than a month's time. ( 4 ) Complications of laceration: A vast majority of laceration of the hymen healed uneventfully, although in rare instances complications set in. The following are the possible complications: ( a ) Secondary infection — There may be activation of the bacterial flora in the vaginal canal or a superimposed infection may set in, especially among women with poor hygienic habit. Gonorrheal infection is not uncommon when the offender is suffering from the disease at the time of the sexual act. ( b ) Hemorrhage — This is a rare complication but this may be present in severe compound laceration of the hymen. Surgical intervention may' be necessary to control the bleeding. Blood analysis to determine the presence of blood disease may be indicated when there is disproportion between the injury and the amount of hemorrhage. Blood transfusion may be required when the

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condition of the patient demands replacement of the blood loss. (c) Fistulae formation — Recto-vaginal or vesico-vaginal fistula may develop in the case of compound laceration. This may require the services of a competent gynecologist to subject the patient to surgery. ( d ) Stricture — Hymenal laceration alone will not produce stricture but in case of involvement of the vaginal wall it may consequently result in narrowing of the canal on account of the scar formation. ( e ) Sterility — Trauma and infection may further involve the upper part of the female generative organ and may cause loss of procreation power. PHYSIOLOGIC CONSIDERATION: A. During Sexual Excitement: 1. Local Changes: The parasympathetic innervation of the sex organ is from the 2nd, 3rd and 4th spinal sacral segments, and the sympathetic innervation is from the 11th thoracic down to the 1st lumbar. In the male, the stimulus may be central or somesthetic or local tactile in origin. In the male, stimulation will cause erection of the penis due to active dilatation of the arteries through the nervus origentis. The erection is also brought about by the contraction of the ischiocavernous muscle producing compression of the dorsal vein of the penis, thus causing accumulation of blood under pressure. More sexual stimulus will be attained through friction during the sexual act coupled with the physical activities of the partner. In the female, sexual stimulation will cause tomescence of the clitoris, vestibule and labia minora. There is spontaneous vulvar lubrication. The lubricant is a transudate coming from the vaginal wall and its production ceases when the stimulus is removed. The lubricant dries quickly. There is labial engorgement and vaginal lengthening and widening. During the excitement, the vaginal canal increases in length from 7 to 8 cm. to 9.5 to 10.5 cm. At the level of the cervix there is a transverse expansion of the vaginal canal from 2 cm. to 4 cm. to 6.25 to 6.75 cm.

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2. Systemic Effects: a. An increase in the pulse rate; b. Marked increased in blood pressure making its peak during orgasm; c. An increase of peripheral flow of blood experienced as an increase of body warmth; d. Tomescence (engorgement of blood), which is the consequence of this peripheral flow concentrating on erectile tissue; e. Increased respiration; f. A decrease in bleeding during arousal, which is reversed subsequently; g. A decrease in sensory perception; (1) There is blunting of the sense of touch. ( 2 ) Pain may be largely lost; sensation which could be sharply painful may only be experienced as no more than a mild touch stimulation. ( 3 ) Alertness of hearing and vision is clearly decreased. B. During Orgasm: In the male, orgasm is the sensation resulting from the contraction of the smooth muscles of the genitalia and the striated muscles of the pelvic floor coinciding with ejaculation. Seminal emission is carried on by the peristaltic action of the vas deferens, seminal vesicle and prostate. Ejaculation results from the contraction of the pelvic floor muscle and the bulbospongiosus and ischiocavernosus muscles. In the female, during orgasm, there is contraction of the smooth muscles of the uterus and rhythmic contraction of the vaginal sphincter, the ischiocavernosus and the pelvic floor musculature. The physiological changes are similar in both male and female. The difference is only in the speed of response. In the male, sexual arousal is psychological followed by physical, while in the female it is primarily physical. DEATH RELATED TO SEXUAL ACT 1. Death of the Male Partner: a. Death from natural cause: During sexual intercourse, the male as an active subject develops increase blood pressure, tachycardia and hyperventilation due to emotional response and muscular exertion. If he is suffering from cardio-vascular disease or insufficiency

VIRGINITY AND DEFLORATION

497

of cardiac reserve, the increase demand on the cardiovascular system may not be met and he may die. This is also true in masturbation. If a person died outside his conjugal home, the dead is generally referred to as "D.I.S." or "death in the saddle". Sometimes it is jokingly claimed that "he died with his boots on" or "he died planting the Philippine flag". If death took place in a prostitution house, the children's comment is "Daddy died in the arms of a scarlet woman". b. Death may be due to the defensive act of the woman-victim: In cases of rape, the victim may be able to take hold of a sharp instrument and inflict injuries to the offender which may cause his death. 2. Death of the Female Partner: Women almost never suffer death from natural causes during the normal sexual act. The reason may be that they are less susceptible to cardio-vascular disease and that they play a passive role in sexual intercourse. Women can control their tendencies to over-excitement and they exert less physical effort in a sexual act than men do. Death of the female partner is usually accidental and not on account of a natural disease: a. The sexual intercourse might be done in a relatively confined space like the back seat of a car. Accidental strangulation or suffocation of the female partner may be due to the undue pressure applied on the chest, neck or face. The struggle of the female partner may remain unnoticed on account of the height of sexual excitement, and this may cause her death. b. In case of oral sex (fellatio) wherein the male penis is placed in the mouth of the female partner, the size and length of the penis may cause partial or total block of the air passage, causing asphyxia. Ejaculation of seminal fluid may oclude the lumen of the respiratory tract as in drowning. c. In case of cunnillingus (a perverted sexual act wherein the male licks the female genital organ), the male partner may blow air in the vulva and may cause air embolism especially when the woman is pregnant. The air may enter the blood circulation and causes immediate death. d. Saddists who may not be sexually satisfied by sexual intercourse but by inflicting physical injuries to the partner may cause death of the female partner.

498

LEGAL MEDICINE

e. Death of the female partner may be deliberately done by the male to conceal the crime of rape he has committed. The male partner may inflict physical injuries, or may cause asphyxiation by strangulation or by other means. f. The female partner may die of shock as a result of extreme physical and mental trauma in case of rape. g. Hemorrhage. h. Infection. 3. Death of Both Partners: a. Almost simultaneous death of both partners during sexual intercourse may be due to the performance of the sexual act in an enclosed place with carbon monoxide or other asphyxiant gas. Examination of their respective blood will reveal the presence of the gas incompatible with life. b. Homicide— suicide pact. ^SEX CRIMES Criminological Characteristics: 1. It is one of the ancient and universal crimes. It existed since the dawn of history. Although considered a crime by almost all countries of the world, society's reaction to its repression depends on the moral value and its gravity as a social problem. 2. There is a close physical contact between the offender and the victim. Murder and homicide may be committed with the offender at a distance from the victim. Estafa and many other crimes may be committed even without the physical presence of the victim. 3. As a general rule, it is a crime committed by one sex against the opposite sex. 4. Sex is an inborn instinct. A n y person without sex desire is considered abnormal. Satisfaction of the sexual instinct must be, in a way, acceptable by the moral standard. What is punishable is the anti-social means of attaining sexual gratification. In other crimes, no man is normally born with such criminal instinct. Murderers, defrauders, and other violators of the criminal law are not inborn characters of individuals. 5. Except probably the crime of rape and forcible abduction, most of the sex crimes do not belong to the so called conventional crimes. Considering other sex acts as crime depends on the moral value existing in a society. Seduction and consented abduction are considered as crimes in the Philippines but not in other countries.

SEX CRIMES

499

6. Many sex crimes are committed but not reported; if reported not investigated; if investigated, not prosecuted. This is on account of the fact that undue publicity may be prejudicial to the reputation of the victim. 7. It is a crime committed in strict privacy. If committed in public the offender must be a mental deviate. Reliance must therefore be made by the investigating officer or court on the testimony of the victim corroborated by the medical findings. 8. Although it is more frequent among the lower socio-economic class those who belong to the middle and upper classes are not immune in the commission of the crime. 9. Unlike other crimes, pardon, forgiveness or marriage between the offender and the victim will extinguish the criminal liability of the offender. 10. There is a seasonal variation in the frequency of commission. It is not the season that causes the variation but the social forces that may be present in a specific season. The month of May, for example, has more cases of sex offenses because Mayflower festivals, fiestas, picnics, excursions, etc. are frequent during this month. 11. The severity of punishment does not deter its commission. frequency has not been appreciably reduced by Martial law.

Its

12. Its occasional consequence (pregnancy) becomes a legal problem, e.g. support, abortion, legitimacy, unwanted child, inability to find a means of livelihood, etc. 13. If the offender is of past middle age, usually the victims are children. The primary reason is that old men will be ignored by elderly women so they focus their attention on children who can easily be enticed by candies or other things of value. 14. The psychic trauma suffered by the victims of sex crimes varies with the moral standard of the victim. Women of the "Maria Clara" type with morality of the Puritan Standard, may inflict fatal or serious injuries on the offender. Some may develop a feeling of worthlessness and as a consequence, may lead to selfdestruction, while others may be mentally deranged. Others may have a strong belief in the machinery of justice and file the complaint, but a great number of those who seek justice later become amenable to an amicable settlement. i

Other victims suffer from fear of unfavorable consequence, like pregnancy, social degradation and maltreatment by parents and other relatives.

500

LEGAL MEDICINE

When and H o w Rape is Committed — Penalties: Art. 335, Revised Penal Code: Rape is committed by having carnal knowledge of a woman under any of the following circumstances: 1. By using force or intimidation; 2. When the woman is deprived of reason or otherwise unconscious; and 3. When the woman is under twelve years of age, even though neither of the circumstances mentioned in the two next preceding paragraphs shall be present : The crime of rape shall be punished by reclusion perpetua. Whenever the crime of rape is committed with the use of a deadly weapon or by two or more persons, the penalty shall be reclusion perpetua to death. When by reason or on the occasion of rape, the victim becomes insane, the penalty shall be death. When the rape is attempted or frustrated and homicide is committed by reason or on the occasion thereof, the penalty shall be likewise death. When by reason or on the occasion of the rape, a homicide is committed, the penalty shall be death ( A s amended by Rep. Act 2632 and Rep. Act. 4111). Elements of the crime: a. The offender had carnal knowledge of the woman. The victim of the crime must always be a woman while the offender must inferentially be a man because sexual act must be done by a man and a woman. b. The carnal relation must be made under any of the following circumstances: (1) Use of force or intimidation; ( 2 ) The woman is deprived of her reason or otherwise made unconscious; or (3) The woman-victim is less than 12 years of age. Meaning of Carnal Knowledge: Carnal knowledge is the act of a man connection with a woman. There is carnal slightest penetration in the sexual organ of organ of the male. It is not necessary that

in having sexual bodily knowledge if there is the the female by the sexual the vagina be entered or

SEX CRIMES that the hymen be ruptured Black, 4th ed., p. 268).

501

(Black's Law Dictionary by Henry C.

For the consummation of the crime of rape, it is not necessary that there is rupture of the hymen. It is enough that the labia of the female organ was penetrated (People v. Oscar, 48 Phil. 527). Slightest penetration is enough, proof of emission is not necessary. The absence of spermatozoa in the vagina does not negate the commission of the crime of rape (People v. Canastre, 82 Phil. 480). Character of the Offended Party: The fact that the offended party may have been unchaste before alleged sexual act was consummated with force and intimidation constitute no defense. The person is guilty of rape if force and violence were used regardless of the good or bad morals of the offended party (People v. Blance, 45 Phil. 13). Evidences of Force or Intimidation: The mere initial reluctance of the offended party or verbal refusal alone will not prove force. It must be a manifested and tenacious resistance that is required by law (People v. Lago, C.A. 45 O.G. 1356). When force is an element in the crime of rape, it need not be irresistible. As long as it brings about the desired result, all consideration whether it is more or less irresistible are beside the point. When the offeflftied girl stated that she defended herself against the accused as long as she could, but he overpowered her and held her till her strength yielded, then accomplished his desire, there is evidence of sufficient force (People v. Mono, 56 Phil. 86). The offended woman shouted, struggled and kicked the accused but the offender pressed a hunting knife on her throat, overcame her resistance and succeeded in having sexual intercourse with her. Rape was committed (People v. Lago, C.A. 45 O.G. 1356). If the offender is the father of the girl who is of a tender age, it is not necessary that there are signs that she put up a determined resistance (People v. Alinea, C.A. 45 G. 140). The employment of force is established not only by the testimony of the injured girl but also by the signs of finger grips on the front part of her neck, on the arms and the fact that the garments worn at the time were torn and heavily stained with blood (People v. Lucero, 61 Phil. 361). A strong evidence of force is the presence of physical injuries found on the person of the victim in the course of medical examination. Contusions may be found on the face, arms and thighs.

502

LEGAL MEDICINE

When a woman has been forcibly made to lie down, she will utilize her elbow as the fulcrum so that abrasions will be observed on both elbows. In the attempt of the victim to stand, she will flex her neck forward. The offender will then push her head backwards, causing hematoma at the region of the occiput. To prevent penetration of the male organ she will try to flex her thighs and knees. The offender will give a strong blow to the inner aspects of both thighs so that the victim will be compelled to straightened them. The victim may suffer all types of physical injuries depending upon the resistance offered by her and the degree of force applied by the offender. Rape Committed by Employment of Intimidation: The application of threat will cause fear in the victim of the untoward consequence. If she will not accede to the will of the offender, the crime may constitute intimidation. Inasmuch as intimidation is purely subjective it cannot be proven by medical evidence. Rape Committed by Depriving the Victim of Her Reason or Otherwise Made Unconscious: 1. Deprival of Reason: a. Rape committed on insane or mentally deficient woman: The fact that the victim is a woman, 14 years of age, feebleminded and can only speak mono-syllables is sufficient to constitute the act committed to be rape (People v. Doing, C.A. 49 O.G. 2331). Sexual intercourse with an insane woman is considered rape (People v. Layson, C.A. 37 O.G. 318). But, sexual intercourse with a deaf-mute woman is not rape, in the absence of proof that she is an imbecile (People v. Nava, C.A. 40 O.G. 4237). The proof of the mental condition of the victim is the medical findings of the physician who must certify whether the woman-victim of rape is suffering from insanity or mental deficiency which is sufficient to deprive her of her reason. b. Rape committed while the woman is under the influence of alcohol or other depressant drugs: Inasmuch as the woman is not in possession of her rational mental faculties, in the absence of a decided case, this may also be rape. c. Sexual act on a woman under the influence of sex stimulating drugs:

SEX CRIMES

503

In the case of U.S. v. Lung (28 p. 235, 37 A.M. St. Rep. 505), cited by Reyes, where the consent of the woman was induced by the administration of drugs which incited her passion and the drug dose did not deprive her of her reason, the accused was not guilty of rape. But if this case should happen in the Philippines and would be decided by our local court, I think it would be a rape case because the stimulating drug actually deprived her of her reason. 2. The woman-victim is unconscious: a. Sexual act committed while the woman is on her natural sleep: The woman while asleep felt the weight of a man in carnal relation with her. Believing that he was her husband, she called him by his name but received no answer. She again called him and found out that the voice was different from that of her husband. She then pushed him and then ran after him. The offended party was a deep sleeper in the first hour of the night and it was not impossible for the accused to insert his organ into her genitalia before she awoke. The crime of rape was committed (People v. Gorcino, 53 Phil. 234). b. Sexual act on a woman suffering from sleeping sickness is also rape because the woman is unconscious. c. Sexual act on a woman who is unconscious because she was knocked-out:. If the offender inflicted physical injuries on a woman sufficient to make her unconscious before the sexual act was done, it is rape. On seeing a lavishing figure of a woman taking a bath, the accused hit her and after she became unconscious, he had sexual intercourse with her. The accused was found guilty of rape (People v. Sanico, C.A. 46 O.G. 98). d. Sexual act after administration of narcotics or other "knockout" drugs: The sexual act made on a woman while she is under the influence of narcotics or other depressant drugs is rape because the woman is unconscious. 3. When the woman is under 12 years of age: If the carnal relation is made on a female below 12 years of age, it is always rape regardless of whether or not force or intimidation is applied or the child is.not deprived of her reasons or otherwise unconscious. Rape of a woman below 12 years old is also called statutory rape. The sexual act is still rape even if the child consented or even if the child is a prostitute.

504

LEGAL MEDICINE

The reason for penalizing carnal relation is that one must not take advantage of the meager intelligence and incomplete physical development of a child below the age of 12. When the offended party is a girl less than 12 years old, rape is committed although she consented to the sexual act (People v. Villamora C.A. 37 O.G. 497). It is also rape even if the girl less than 12 years of age is a prostitute (People v. Perez, C.A. O.G. 6337).

Perineal laceration on a sexually a b u s e d child

Multiple rapes committed by each accused was independent of the others, because the essence of the crime of rape consists of carrying out carnal act of the offender with a woman against her will and each carnal access consummated is a complete attack on the honor, person and liberty of the offended woman (People v. Bernardo, 38 O.G. 3479). The victim and the accused must immediately be examined by the physician to have a strong medical evidence of rape, but the lack of medical examination of the victim is not an indispensible element in the prosecution of the crime of rape. Whether or not it will prosper will depend upon the evidences offered. As long as the evidences convince the court, a conviction of the crime of rape is proper (People v. Suarez, C.A. 40 O.G. 28). When the defendant has sexual intercourse twice in succession with the complainant, no evidence having been presented that

SEX CRIMES

SOS

there was any resistance on her part or that the defendant had used force, violence and intimidation, the defendant was acquitted (U.S. v. DeDios, 8 Phil. 279). The defendant attempted to commit the crime of rape in an open field on a woman whom he has courted for 2 years and in the presence of other persons. The offended party allowed the defendant to visit her after the attack. The defendant was acquitted (U.S. v. Estacio, 18 Phil. 432). A complaint in the prosecution of rape is not valid unless it is a complaint of the offended party. The complaint signed and sworn to by the chief of police is not valid in the prosecution for rape (People v. Manaba, 58 Phil. 665). An information not signed by the offended party is insufficient to confer jurisdiction on the court to hear and determine a charge of attempted rape (People v. Trinidad, 59 Phil. 163). The filing of the complaint by the father of the offended party who is a girl only fourteen years of age which alleges the commission of the offense is a sufficient compliance of the Revised Penal Code to confer jurisdiction for trial of the offense charged (People v. Imas, 65 Phil. 419). i

Instances When Rape is Punishable by Death: 1. When by reason or on the occasion of the rape, the victim becomes insane; 2. When the rape is attempted or frustrated and a homicide is committed by reason or on the occasion thereof; and 3. When by reason or on the occasion of the rape, a homicide is committed. Death of a woman from peritonitis as a result of having been infected with a venereal disease by a man having sexual intercourse with her against her will, will constitute the complex crime with homicide (People v. Acosta, 60 Phil. 158). Medical Evidences in Rape: 1. Evidences from the victim: Before actual examination is made on the subject, it is necessary to have a written consent from the subject herself or from her guardian if the victim is not of age. If the woman is confined in a correctional institution the consent may be given by the head of the institution. A short history of the alleged rape must be taken and it is advisable to reduce it in writing. The history must include all the circumstances leading to the abuse, the age of the victim at the time of the alleged commission of the offense and also the men-

506

LEGAL MEDICINE

strual history. It may be used as a guide to the examining physician as to the different points that must be emphasized in the course of the examination. Aside from the history, the following points must also be recorded by the physician. a. Date, time and place of alleged commission of rape: This is necessary in order to determine how long a time has elapsed after alleged commission of the offense before the victim filed the necessary complaint or subjected herself to the medical examination. If several days have gone by before the filing of the complaint, let her explain the cause of the delay. The place where the alleged offense was committed is necessary to determine which court can acquire jurisdiction over the case. b. Date, time and place of the examination: The date of the examination is material to the determination of the possible findings of the physician on the victim. A long interval of time between tha date of commission and the examination will remove the possibility of finding the effects of a recent sexual intercourse. c. Condition of the clothings: If force is applied in the commission of the offense, there will be tearing, staining with blood and semen, and soiling of the clothings. The clothings must be preserved after they have been thoroughly dried for further laboratory examination. d. The physician must observe the gait, the facial expression and the bodily and mental attitude of the subject. If the victim suffered from genital injuries she may walk with legs apart and slowly, with the face manifesting signs that she is suffering from pain. e. Physical and mental development of the victim: The height, strength and degree of muscular development of the woman must be noted to determine whether she has the capacity to resist any unlawful aggression. If the victim is a child, examination of the physical condition is usually not necessary because it is apparent to the age. In most cases, children are "bribed" or lured by attractive articles such as candies by the offender. The examiner must observe the mental state of the victim. She may be in the state of mental shock, under the influence of depressant drugs, alcohol or sex stimulants. The offender might have taken advantage of her insanity or mental deficiency.

SEX CRIMES

507

The victim may appear exhausted, despondent on account of the public humiliation she will suffer, or may be hostile to the investigator. Care and more psychologic approach is necessary in order to get her full cooperation and consent. f. Examination of the body for signs of violence: If actual force was applied in the commission of the crime, there must be signs of physical violence on the body of the victim. Her whole body must be subjected to inspection. Physical injuries must be described and the exact location must be determined. Areas of tenderness or swelling must not be overlooked and if necessary X-ray pictures must be taken to determine bone lesions. Determination of the probable age of the physical injuries found is material. Does it correspond to the alleged date of commission? . g. Examination of the genitalia, including the breast: The breasts must be examined for the presence of finger marks or application of pressure. They might have been roughly handled or the nipples bitten. The vulva may show swelling, tenderness, contusion, abrasion, laceration or may be smeared with blood, semen and other foreign bodies. The hymen may show fresh laceration, swelling or bruising. There may be healed lacerations or signs of physical virginity. In the pubic hair, the following medical evidence may be gathered: ( 1 ) Pubic hair of the offender. (2) Semen and spermatozoa. ( 3 ) Blood stains. ( 4 ) Body louse. Abrasion which is normally found in the posterior commissure is usually brought about by friction or a violent attempt of insertion. The vaginal canal may show obliteration of the rugosities or even purulent discharge. 2. Examination of the alleged offender: a. Physical development, mental condition and strength: The relative physical development and strength of the victim and the offender must be compared to determine whether the offender can overpower the resistance offered by the victim. b. Evidence of physical injuries: The whole body must be examined. The victim, in the course of the struggle, may inflict bodily harm to the offender.

508

LEGAL MEDICINE

Fingernail marks on the neck, arms and chest may be found. The frenum of the penis may be abraded or lacerated on account of the violent insertion on a relatively small vulvar or vaginal opening. c. Condition of the sex organ: Aside from the examination of the frenum, washing from the surface of the penis may reveal blood, seminal stain, vaginal epithelium and doderleins bacillus. The urethral meatus may be moist on account of the recent discharge. d. Evidence from the pubic hair: The pubic hair may be matted together due to blood stains or from seminal fluid discharge. Examine carefully for the presence of body louse. e. Potency of the offender: The offender may put up a defense that he is impotent and that it could have been hardly possible that he had committed the crime. It may be necessary to subject the offender to a strong sex stimulus sufficiently under normal condition to produce erection. f. Evidence of genital infection — If the offender is suffering from venereal disease which is transmitted to the victim during the criminal act, the crime committed is rape with physical injuries because infection in law is a physical injury. 3. Evidences from the companion of the victim: a. A history of the incident must be taken from the companion of the victim. Try to see whether they are consistent with the narration of facts by the victim. b. If the companion helped the victim when force was applied by the offender, the companion must be subjected to a physical and medical examination for physical injuries. c. Examination of the clothings may be necessary for signs of struggle. d. Investigation must be made to determine whether the companion might have participated as an accomplice to the crime. e. The mental condition, physical power, age and emotional state must be taken into consideration to determine the capacity to resist unlawful aggression from the offender. f. Examination must be made as to the presence of alcohol or other depressants which may diminish the companion's capacity to defend the victim from the offender.

SEX CRIMES

509

Investigation of the Crime Scene: 1. Disturbances in the place of commission may infer or affirm the statement of the victim that she did offer resistance. 2. Strands of hair, blood, seminal and other stains may be recovered to prove consummation and struggle. 3. Pieces of personal belongings of the offender and /or victim may be recovered to prove identity and physical struggle. 4. Investigation of witnesses who may possibly be material to the prosecution of the case may be conducted. EXAMINATION FOR SEMINAL FLUID AND SPERMATOZOA The semen is the viscid, albuminous fluid with faint grayishyellow color, having the characteristic fishy odor, and containing spermatozoa, epithelial cells, lecithin bodies and other substances. Spermatozoon is a living organism, normally present in the seminal fluid consisting of a head, neck and tail. It is from 50 to 55 microns in length. The head is ovoid and flattened when viewed in front and pearshape when viewed on the profile. The head is about 5 microns in length while the neck is very short. The tail is the longest part of the spermatozoon and consists of a long slender filament with tapering end. The ciliary movement of the tail is responsible for the forward movement of the spermatozoon. There are 2.5 to 5.0 cubic centimeters of semen per ejaculation. The semen contains 60 million spermatozoa per cubic centimeter, 80% of which are motile after 45 minutes. After 3 hours not more than 20% become abnormal in forms. The following specimens may be examined for seminal fluid and spermatozoa: 1. Wearing apparel of the victim and of the alleged accused. 2. Vaginal smear from the victim. 3. Stains on the body of the victim and of the accused. 4. Stains found at the site of the commission of the offense. PROCEDURE: 1. Gross Examinations: a. Inspection by means of the naked eye or with the use of the hand lens: The stain is grayish-white to faint yellow in color. In fabrics, the area occupied is slightly depressed. It usually has a maplike contour with silvery appearance of the surface. It is hardened with shiny borders.

LEGAL MEDICINE

510

b. Inspection by means of Ultraviolet light: This method is resorted to in order to make visible, small seminal stains or patches. Determine the side of the clothings where the stains are located. Under ultraviolet radiation, the seminal discharge shows bluish fluorescence. 2. Micro-Chemical Examinations: Moisten a portion of the stained fabric with very diluted hydrochloric acid solution (one drop in 50 cc. of water) and let the soaking stay for 1/2 to 5 hours depending upon the age of the stain. Allow the liquid portion to dry on the slide. Perform any of the following: a. Florence Test: Place a cover slip over the dried stain on the slide glass. Allow a drop of Florence solution to run under the slip. Place the preparation under the microscope and if semen is present, a group of crystals appears similar in color and in shape as the hemin, but larger in size. The crystals are dark brown, in clusters, rosettes, crossing over the microscopic field. Composition of the Florence Solution: Potassium iodide Iodine Distilled water

1.65 gms. 2.54 gms. 30.00 cc.

Value of the Test: This test is produced by the action of iodine on choline, a natural base found in many cells. It is not a specific test for spermatic fluid. The test is not a proof of seminal fluid but only of the presence of some vegetable or animal substance. A positive result is merely a presumptive evidence of seminal fluid; a negative result means, in all probability, it is not that of the seminal fluid. b. Berberio's Test: To the spermatic stain on the slide glass, a saturated solution (alcoholic or aqueous) of picric acid is added. The preparation is placed under the microscope and needleshape crystals with yellow color is produced. Some allege that this test is specific for spermatic fluid. The reaction probably depends-on the presence of spermatic secretion. c. Puramen Reaction: This is based on the presence of spermine in the prostatic fluid. A small part of the stain is extracted with a few drops

SEX CRIMES

511

of saline and put into a micro tube and to the extract is added a few drops of Puramen's reagent (5% solution of 2.4 dinitro l-naphthol-7-sulfonic acid, flavianic acid). The tube is then placed in a refrigerator for a few hours. In a positive reaction, a yellow precipitate of spermine flavianate can be seen at the bottom of the tube. When examined microscopically, the precipitate is found to consist of small cross-like crystals of a characteristic shape. Puramen reaction is found to be very reliable and rather characteristic of seminal fluid (Modern Criminal Investigation by Soderman, p. 250). d. Acid Phosphatase test: The semen produces a very high acid phosphatase activity as compared with other body fluids (saliva, perspiration, urine, etc.) and common vegetable and fruit juice stains. The method of estimating the activity of a stain on clothings or other materials is to extract with distilled water and perform the acid phosphatase determination on the filtered extract. The following solutions are necessary in the performance of the test: (1) Citrate buffer solution — pH 4.9 to 5.2: Citric acid monohydrate 18.9 g. dissolve in 500 ml. distilled water. Sodium hydroxide 1 N 180 ml. Hydrochloric acid 0.1 100 ml. The pH adjusted sodium hydroxide and hydrochloric acid to 4.9 to 5.2. A liter is prepared and stored in a refrigerator. The solution is stable for six months. (2) A suitable substrate: A saturated solution of sodium alpha-naphthanil phosphate. (3) A diazonium salt (Naphthanil Diazo Blue B) Reaction: If acid phosphatase is present, the substrate is hydrolized to produce alpha-naphthol, which is coupled with a diazonium salt to produce a highly colored dye. In the absence of the enzyme, the reaction does not appear. Procedure: There are three glass slides placed side by side on top of a white paper. Slide one (1) is the negative control with filter paper. Slide two ( 2 ) is the positive control with filtered paper impregnated with seminal stain. Slide three (3) is with the suspected material.

LEGAL MEDICINE

512

To each is added a drop of buffer solution followed by a drop of the substrate solution and finally a drop of the diazonium salt in solution. Result — The negative control 1 will remain yellow; Slide two with known seminal stain will turn deep purple immediately; Slide three will also become deep purple if semen is present but will have no change in color if semen is absent. The test is conclusive of the presence of semen. 3. Microscopic

Examinations:

a. A dried spermatic fluid stain on the slide is stained with hematoxylin or methylene blue and counter-stained with eosin. Examined under the microscope, under high power and under oil immersion, spermatozoa and bacterial infection can be seen. The presence of a complete spermatozoon will undoubtedly infer the presence of seminal fluid, although semen may be present without spermatozoa, such as in cases of aspermia (semen without spermatozoa) or oligospermia (semen with few spermatozoa). b. Dr. Hankin's Method: The fabric with seminal stain is boiled with tannin solution before dissolving in a solution of potassium cyanide so as to render the spermatozoa capable of removal. The fabric is then placed on a slide, teased with carbol-fuchsin. This is examined with a medium power lens. c. GangulCs Method: The same procedure as that of Dr. Hankin but the staining is with erythrocin and malachite green. This is claimed to be the best way to stain spermatozoa in India. 4. Biological

Examinations:

a. Precipitin Test (Biological test of Farnum): This is a test to determine whether the semen is of human origin or not. A rabbit is immunized with human semen for four to six weeks. After a time the blood is drawn and the blood serum is taken and its potency made at different dilutions. This is used for the test of unknown semen in the same way as blood precipitin is done. The presence of a white ring at the point of contact between unknown semen extract and the anti-human semen serum shows that the unknown is of human origin.

SEX CRIMES

513

b. Seminal Grouping: Specific agglutinable substances A and B are present in the semen, like that of the blood. Seminal grouping is similar to that of the blood. The test is of value for elimination. A positive result does not definitely imply that the person is the owner of the semen in question. A negative result will totally exclude the alleged accuse as the possible owner of the semen. The mere presence of speunatozoa on the stain shows the presence of spermatic fluid, but the absence of spermatozoa does not prove that the stain is not seminal. The semen may be present without spermatozoa. The presence of one complete, unbroken spermatozoon is sufficient to make the conclusion that the stain or fluid is seminal. It is quite necessary also to examine for infectious disease in connection with the laboratory examination for semen and spermatozoa. How long after sexual intercourse can spermatozoa be found in the vaginal canal? Authorities differ in their opinions in this respect: 1. ". . . but, there is every reason to believe that the life of the effective sperm in the maternal passage is very short, probably less than thirty hours" (Taylor's Principles and Practice of Medical Jurisprudence by K. Simpson, 12th ed.. Vol 2, p. 32). 2. "There has been a great number of observations this latter point, and the evidence points to a comparatively short life of the sperm in the female tract and the period appears shorter with the number of observations. It is a present belief that the life of the sperm in the vagina is a matter of hours and its total life in the female tract is a matter of two or three days at most" (Forensic Medicine by S. Smith, 10th ed., p. 311). 3. ". . . that spermatozoa may survive less than two hours in the vagina, but tfiey live as long as forty-three hours both in the cervix and uterus where the secretion are more favorable" (Medical Jurisprudence & Toxicology by J. Glaister, 12th ed., p. 325). 4. "Spermatozoa may remain motile in the vagina up to 17 days" (A Synopsis of Forensic Medicine & Toxicology by C. Thomas, 2nd ed., p. 97). 5. "Fertilization of the ovum does not necessarily occur immediately after coitus, as it is known that spermatozoa can remain alive in

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the upper recesses of the vagina for more than two weeks" (Coy\ p. 246). 6. "Some observers have reported finding spermatozoa in the vagina after seven hours while others have reported finding them as long as 48 hours after intercourse" (Homicide Investigation by L. Snyder, 1st ed., p. 327). Can a woman be raped while she is on her natural sleep? Occasionally, it may happen, but highly improbable. To a normal virgin it is hard to conceive that such act could ever be committed without her knowledge, inasmuch as she has never experienced it. But, such act may be possible to a woman who has had several sexual intercourses and to those who have given birth. Can a woman commit the crime of rape on a man? In the definition of the crime of rape, it is "committed by having carnal knowledge of a woman." The law specifically states that it can only be committed on a woirian and not on a man (inclusio unius et exclusion alterios). She committed acts of lasciviousness. Can rape cause death? Although it may not be usual, the introduction of a matured male sex organ into the vagina of a young girl may produce local injury sufficient to produce death. The death may be due to hemorrhage brought about by the laceration of the vaginal canal, shock, subsequent infection such as gangrene or peritonitis. Laceration of the vagina with accompanying hemorrhage can also occur even in adult women if the man's sex organ is exceptionally big, especially when the sexual act was done roughly. Can the husband commits the crime of rape on his wife? The husband cannot be guilty of rape committed on his wife. Marriage is a license of the husband to have sexual intercourse with his wife. The purpose of marriage is procreation and there can be no procreation if there is no sexual intercourse. However, if there is a decree of legal separation by the court, the husband may be guilty of rape on his wife. Legal separation does not dissolve the matrimonial tie between the husband and wife, but merely separation in bed. The husband may be guilty also of rape on his wife if he is a principal by cooperation or by inducement for the act committed by another man.

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OTHER CRIMES A G A I N S T CHASTITY A. SEDUCTION Seduction is the act of a man enticing women to have unlawful intercourse with him by means of persuasion, solicitation, promises, bribes, or other means without employment of force (Van de Velde v. Colle, 8 N.J. Misc. 782, 152 A. 615, 646). Not all countries recognize seduction as a criminal act but only a ground for civil liability. There are two kinds of seduction punishable under the Revised Penal Code: 1. Qualified seduction 2. Simple seduction

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Art. 337, Revised Penal Code — Qualified seduction — The seduction of a virgin over twelve years and under eighteen years of age, committed by any person in public authority, priests, house-servant, domestic, guardian, teacher, or any person who, in any capacity, shall be entrusted with the education or custody of the woman seduced, shall be punished by prision correccional in its minimum and medium periods. The penalty next higher in degree shall be imposed upon any person who shall seduce his sister or descendant, whether or not she be a virgin or over eighteen years of age. Under the provisons of this Chapter, seduction is committed when the offender has carnal knowledge of any of the persons and under the circumstances described herein.

/Types of Qualified Seduction: 1. Ordinary Qualified Seduction: Seduction of a virgin over twelve years and under eighteen years of age, committed by any person in public authority, priest, house-servant, domestic, guardian, teacher or any person who in any capacity, shall be entrusted with the education or custody of the woman seduced. 2. Incestuous Qualified Seduction: This includes seduction wherein there is blood relationship between the seducer and the seduced. Father seducing daughter or other descendants, or brother seducing sister. In this type of seduction, the woman seduced need not be a virgin or may be more than eighteen years of age. T h e penalty

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LEGAL MEDICINE imposed is one degree higher than that of ordinary qualified seduction. The reason for the reduction of the requirements and the imposition of a higher penalty is that the father or ascendant and the brother are obliged to lead the descendant or sister to the path of rectitude and morality, but instead virtually persuaded her to become immoral or be a party to the condemnable act. Elements of ordinary qualified seduction: a. The offended party must be a virgin; b. The offended party must be over twelve but under eighteen years of age; c. There must be sexual intercourse between the offender and the offended party; and d. The sexual act was done through abuse of authority or confidence. ( 1 ) Those who acted with abuse of authority: (a) Person in public authority ( b ) Guardian ( c ) Teacher ( d ) Person who in any capacity is entrusted with the education or custody of the woman seduced. ( 2 ) Those who seduced through abuse of confidence: ( a ) Priest ( b ) House-servant ( c ) Domestics Elements of incestuous qualified seduction: a. Sexual act between the offender and offended party; and b. Blood relation between the offender and offended party. (1) Brother who seduces his sister, or (2) Ascendant who seduces his descendant. A public school teacher who is in charge of education had sexual intercourse with a student, is guilty of qualified seduction (People v. Cariaso, 50 Phil. 884). The accused need not be the teacher of the woman seduced. Suffice it is if the accused is a teacher in the same school who has moral influence over the student (Santos u. People, 40 O.G. supp. 6, 23). The offended party went to the catholic church to confess. The accused priest embraced and kissed her and in spite of her resistance she was brought to the store-

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room of the convent where he was able to have sexual intercourse with her. The acts of the priest were proven in the trial court to constitute the crime of qualified seduction (U.S. v. Santiago, 41 Phil. 1 793). Sexual intercourse with the cousin of the wife who is living in the house and a virgin, under 18 but over 12 is guilty of qualified seduction because he took advantage of his authority and there is abuse of confidence (People v. Lauchengco, C.A. 45 O.G. 3845). B.

•E S E D U C T I O N : Art, 338, Revised Penal Code — Simple seduction — The seduction of a woman who is single or a widow of good reputation, over twelve but under eighteen years of age, committed by means of deceit, shall be punished by arresto mayor. Elements of the Crime: 1. The offended party is over twelve but less than eighteen years of age; 2. The offended party must be single or a widow of good reputation; 3. There must be sexual intercourse done by the offender with her; and 4. The sexual act was committed by means of deceit. The statute making simple seduction a crime is not to punish illicit intercourse, but to punish the seducer who by means of his promise of marriage, destroyed the chastity of an unmarried female of previous chaste character, and who thus draws her aside from the path of virtue and rectitude, and then fails or refuses to fulfill his promise, a character so despicable in the eye of every decent honorable man (People v. Iman, 62 Phil. 92). Deceit is a fraudulent and cheating misrepresentation, artifice, or device, used by one or more persons to deceive and trick another, who is ignorant of the true facts, to the prejudice and damage of the party imposed upon (French v. Vining, 102 Mass. 132, 3 Am Rep. 440). Deceit may be: a. Suggestion, as a fact, of that which is not true, by one who does not believe it to be true; b. The assertion, as a fact, of that which is not true, by one who has no reasonable ground for believing it to be true; c. The suppression of a fact, by one who is bound to disclose it, or who gives information of other facts which are likely to mislead for want of communication of that fact; or

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d. A promise made without any intention of fulfillment. , The most common form of deceit is the promise of marriage, but if the seducer is known to the victim to be married, even if the previous promise of marriage cause her to accede to the sexual act, the crime of simple seduction is not committed. Virginity is not an element of simple seduction. It is sufficient that the victim is a single or a widow of good reputation. Medical Evidences in the Crime of Seduction: Medico-legal investigation of a victim of seduction is practically the same as in the case of rape insofar as proof of sexual intercourse is concerned. However, medical proofs on account of the application of force, and conditions that will cause the victim to be deprived of her reason or otherwise unconscious are no longer relevant. Sometimes, the issue of the age of the victim becomes a problem and its determination through medical proofs may be necessary. The woman may claim to be less than 18 years old although she is more than that at the time of the alleged commission of the offense. If the alleged criminal act developed into pregnancy and birth of the child, the question of paternity may be necessary. CTS OF LASCIVIOUSNESS Acts of lasciviousness are acts which tend to excite lust; conduct which is wanton, lewd, voluptuous or lewd emotion (Black's Law Dictionary). Acts Considered Lascivious: 1. Embracing, kissing and holding the woman's breast (People v. Collado, 60 Phil. 610). 2. Placing of the man's private organ over a girl's genital organ (People v. Domondon, C.A. 364 O.G. 1977). There are two articles in the Revised Penal Code penalizing acts of lasciviousness, namely: 3. Art. 336, Revised Penal Code — Acts of lasciviousness. 4. Art. 339, Revised Penal Code — Acts of lasciviousness with the consent of the offended party. A. ACTS OF LASCIVIOUSNESS: Art. 336, Revised Penal Code — Acts of lasciviousness — Any person who shall commit any act of lasciviousness upon other persons of either sex, under any of the circumstances mentioned

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in the preceding article (rape), shall be punished by prision correccional. Elements of the Crime: 1. The offender commits any act of lasciviousness; 2. The lascivious act is done under any of the following circumstances a. By using force or intimidation. b. By depriving her of her reasons or otherwise unconscious. c. When the woman is under 12 years of age. 3. The offended party must be a person of either sex. The victim owed the defendant one peso. The defendant sent policemen to her house and arrested her. The victim was brought to the house of the accused and after beating her with a stick, the defendant compelled her to take off her clothes and dance before the defendant and many other persons. Such acts constitute the crime of acts of lasciviousness (U.S. v. Bailoses, 2 Phil. 49). Acts of lasciviousness had been committed by the defendant who held the offended party by the waist, touched her breast, hugged her with the intention of kissing her, and touched her private part against her will (People v. Famularcano, C.A. 43 O.G. 1721). The accused went to the house of the woman and found her to be alone. The accused gained admission to the house under the pretext of asking for a drink of water, and while inside the house, he embraced her against her will. The defendant threatened to kill her if she refused to submit to his desire. The acts constitute the crime of acts of lasciviousness (People v. Collado, 60 Phil. 610). B . A C T S O F L A S C I V I O U S N E S S W I T H T H E C O N S E N T O F THE OFFENDED PARTY: Art. 339, Revised Penal Code — Acts of lasciviousness with the consent of the offended party — The penalty of arresto mayor shall be imposed to punish any other acts of lasciviousness committed by the same persons and under the same circumstances as those provided in article 337 (qualified seduction) and 338 (simple seduction). Elements of the Crime: 1. The offender commits acts of lasciviousness; 2. The offended woman must be over 12 but under 18 years of

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age, except when the Victim is the sister or descendant of the offender; 3. The offender commits the act by abuse of authority, confidence, relationship or deceit; 4. The victim must be a woman, virgin, single, or widow of good reputation, except when she is the sister or descendant of the offender where virginity is not required. A man who embraced and kissed his girlfriend (lover) is not guilty of the crime of acts of lasciviousness with the consent of the offended party because consent was not obtained through abuse of confidence, authority, relationship, or by means of deceit. Medical Evidences in the Crime of Acts of Lasciviousness: Like in the crimes of rape and seduction, medico-legal investigation is involved in proving the lascivious act itself and the other elements to constitute the crime. Physical injuries may be suffered by the victim on the part of the body where the lascivious act was committed by insertion of his finger into the private part of the victim or through the application of bodily force with the consequent production of physical injuries.

Abduction is the carrying away of a woman by an abductor with lewd design. Lewd design is the intent of the abductor to have sexual intercourse with the woman abducted. This can be inferred from the acts of the offender. There are two types of abduction punishable under the Revised Penal code: 1. Forcible abduction ( A r t . 342) 2. Consented abduction ( A r t . 343) A. Forcible Abduction: Art. 342, Revised Penal Code — Forcible abduction — The abduction of any woman against her will and with lewd designs shall be punished by reclusion temporal. The same penalty shall be imposed in every case, if the female abducted is under twelve years of age. Elements of the Crime: 1. The victim abducted is a woman; 2. The abduction is against her will; and

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3. The abduction is with lewd design. The civil status, reputation and age of the woman abducted are not the ingredients of the crime, however, in case the woman is under 12 years of age, the crime committed is still forcible abduction even if the woman consented. If there are several abductors, it is sufficient that one of them had lewd design. Inference of lewd design may be deduced when the offender kissed and embraced the offended party, took the victim farther to an uninhabited place to perform lascivious acts on her. In forcible abduction, the act of the offender is violative of the personal liberty of the woman abducted, her honor and reputation, and of public order (U.S. v. de Vivar, 29 Phil. 458). B. Consented Abduction: Art. 343, Revised Penal, Code — Consented abduction — The abduction of a virgin over twelve and under eighteen years of age, carried out with her consent and with lewd designs, shall be punished by the penalty of prision correccional in its minimum and medium periods. ^Elements of the Crime: 1. The offended party must be a virgin; 2. The offended party must be over 12 but under 18 years old; 3. The carrying away of the offended party is with her consent; and 4. The taking away must be with lewd design. Rationale of the Provision: The purpose of the law is not to punish the wrong done to the girl, because she consents thereto, but to prescribe punishment for the disgrace to her family and the alarm caused therein by the disappearance of the one who is, by her age and sex, susceptible to cajolery and deceit (U.S. v. Reyes, 20 Phil 510). ^ a . ADULTERY AND CONCUBINAGE A. Adultery: Art. 333, Revised Penal Code — Who are guilty of adultery — Adultery is committed by any married woman who shall have sexual intercourse with a man not her husband and by the man who has carnal knowledge of her, knowing her to be married, even if the marriage be subsequently declared void.

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Adultery 6hall be punished by prision correccional in its medium and maximum periods. If the person guilty of adultery committed this offense while being abandoned without justification by the offended spouse, the penalty next lower in degree than that provided in the next preceding paragraph shall be imposed. Elements of the Crime: 1. The woman is married; 2. She has had sexual intercourse with a man not her husband; and 3. The man with whom she had sexual intercourse knows her to be married even if the marriage has subsequently been declared void. Reason for the Provision: Adultery is made a crime to avoid introduction of foreign blood in the family. Adultery may cause introduction of spurious heirs into the family wherein the right of the real heirs may be impaired (U.S. v. Mata, 18 Phil. 490). Blood examination of the children born by such adulterous act may be material in the presecution of the crime. If the married woman and the paramour were caught "in flagrante delicto", medical examination of the woman may be necessary to determine the presence of semen and spermatozoa in the vaginal canal. Biological seminal grouping may be done to prove the identity of the semen found. B. Concubinage: Art. 334, Revised Penal Code — Concubinage — A n y husband who shall keep a mistress in the conjugal dwelling, or, shall have sexual intercourse, under scandalous circumstances, with a woman who is not his wife, or shall cohabit with her in any other place, shall be punished by prision correccional in its minimum and medium periods. The concubine shall suffer the penalty of destierro. Ways of Committing the Crime: 1. Keeping a mistress in the conjugal dwelling; or 2. Having sexual intercourse, under scandalous circumstances, with a woman who is not his wife; or 3. Cohabiting with her in any other place. A married man committing concubinage violates the marital vow.

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PROSTITUTION Prostitutes are women who, for money or profit, habitually indulge in sexual intercourse or lascivious conduct (Art. 202, N o . 5, Revised Penal Code). Requirements to be satisfied before a woman may be considered a prostitute: 1. She habitually indulges in sexual intercourse or lascivious acts. A single isolated sexual intercourse or lascivious act for money profit will not make a woman a prostitute. There must be habituality or repeated acts. This makes prosecution for the crime difficult. Medical evidence on this matter is purely presumptive. A woman may still be considered a prostitute although she does not indulge in the habitual sexual intercourse because habitual indulgence in lascivious acts also makes her a prostitute. 2. When the habitual sexual intercourse or lascivious act is done for money or profit. Habitual sexual intercourses with several men but not for money or profit will not make a woman a prostitute. The penalty imposed on a woman who has been proven to be a prostitute is arresto menor or a fine not exceeding 200 pesos, and in case of recidivism, by arresto mayor in its medium period to prision correccional in its minimum period, or a fine ranging from 200 to 2,000 pesos, or both, in the discretion of the court (Art. 202, last par., Revised Penal Code). Reasons why some women become prostitutes: 1. Physiological and psychological traits — Prostitutes are seldom nymphomaniac, although nymphomaniacs may become prostitutes. Some of them are found to be emotionally unstable, psychopathic, neurotic, suggestible, or addicted to the use of tobacco, alcohol and narcotic drugs. They may be lonely and may lack association with the intimate family circle. 2. Economic factors — They are financially hard up and indulge in the business for fear of starvation. Their earnings are meager and cannot maintain a decent life or cope with the domestic needs. 3. Home and neighborhood — A great number of them comes from broken homes, over-crowded homes with members of both sexes sleeping in the same room, or having a male border or roomer. In some instances the mother is a prostitute, and

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the father is a pimp and their daughters are allowed to roam in the streets and being initiated in sexual intercourse. 4. Influence of contraceptives — The availability of contraceptives and prophylactic treatment for infection make it possible to indulge in sexual relationship without fear of pregnancy and infection. (Criminology by Taft and England, p. 266). Medico-legal Aspects of Prostitution: 1. Prostitution is one of the venues in spreading venereal and other diseases. 2. Evidences may be gathered to prove sexual or lascivious acts. Types of Prostitutes: 1. Call Girl — Receives telephone calls from the selected group of customers and makes arrangements to meet them at a designated place. 2. Hustler: a. Bar or tavern "pick-up" — Frequent places where liquor is sold, sometimes with the knowledge of the management, b. Street walker — She finds her customers in various places and makes the contact herself, but she may walk with taxicab drivers. 3. Door Knocker — A newcomer in the field of prostitution. She frequents small hotels and furnished rooms or roams in the hall room of these places. 4. Factory Girl — She works in regular house of prostitution. She accepts all comers and has nothing to do with the selection and solicitation of customers. She is under the direct supervision of a "madam" or "mama-san" (Criminology by R.G. Caldwell, 2nd ed., p. 125). Personnel Associated with Prostitution: 1. "Madam" or "Mama-san" — She is the general manager of the prostitution den. She handles cash, meets customers and transacts all business for the house. 2. Procurer — The person is charged with the duty of getting girls to work as prostitutes. 3. Transporter — The man or woman who takes prostitutes from town to another. 4. Pimp or "Bugao" — one who gets customers. He may be a taxicab driver, bartender, or a girl's own husband. He earn's by percentage basis.

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Types of Prostitution Houses: 1. Disorder House - Employs only 4 to 8 girls in the business This type is gradually disappearing as it is an easy target of organized program against prostitution. 2. Furnished Room House — This is operated by experienced madams. The house has 2 to 3 girls and also rooms for rent to legitimate roomers in order to maintain the appearance of respectability. 3. Call House — It is merely a place where a telephone is maintained by a madam. The customer calls, and the madam sends the girl out to meet him. Other Reasons for Indulging in Prostitution: 1. 2. 3. 4.

Poor social background with personality handicaps. Previous sexual experience in or out of wedlock. Contact with a person in or in the fringe of prostitution. Desire for money or forced by loneliness, desertion or broken promises.

Effects of Prostitution: 1. 2. 3. 4. 5. 6. 7.

Arrest and imprisonment. Venereal infection. Social ostracism. Poor personal hygiene. Excessive use of alcohol. Irregular habit of eating and sleeping. Demoralization and physical deterioration.

Medical Evidence in Prostitution: Genital examination required is the same as in any other sexual offense. Can rape be committed on a prostitute? Yes, virginity or chastity of character is not a necessary element of the crime of rape. However, medical proof of sexual intercourse is not a legal proof of the commission of rape. The fact that the offended person has been a person of unchaste character constitutes no defense to the charge of rape, provided that it is proven that the illicit relations complained of were committed with violence or force. The defendant in a criminal action for rape is guilty of the crime if force or violence was used, regardless of the good or bad character of the offended party (People v. Blance, 45 Phil. 113).

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V u l v a o f prostitute w i t h l e u c o d e r m a

Methods of Control: 1. Legalized but regulated: a. Segregation of prostitute in a restrictive area. b. License given to the house of prostitution. c. Periodic examination ol the prostitutes. Defects of the Method: a. Segregation does not segregate. b. Many prostitutes fail to register, either through negligence or desire to avoid the stigma which registration creates. c. The medical inspection does not protect. d. Regulations create a false sense of security (overconfidence). e. Regulations promote prostitution, foster immorality, corrupt officials and increase crime. 2. Strict prohibition: a. Strict enforcement of legislation against prostitution and all activities connected with it. b. Education of the public regarding sex, prostitution and venereal disease. c. Adoption of medical measures and establishment of medical facilities for the diagnosis and treatment of venereal disease. d. Rehabilitation of prostitutes.

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e. Adoption of codes of self-regulation and organization of community cooperation. Other persons involved in the business of prostitution are punished by the following provisions of the Revised Penal Code: A. Corruption of Minors: Art. 340, Revised Penal Code: A n y person who shall promote or facilitate the prostitution or corruption of persons under age to satisfy the lust of another, shall be punished by prision correccional in its minimum and medium periods, and if the culprit be a public officer or employee, including those in government owned or controlled corporations, he shall also suffer the penalty of temporary absolute disqualification (as amended by B.P. 92). Habitually or with abuse of authority or confidence was removed from the original provision as an element in promoting or facilitating the prostitution or corruption of persons under age to satisfy the lust of another. A single act without abuse of authority or confidence is now a crime. A mere proposal to promote or facilitate the prostitution or corruption of a person under age is already a consummation of the crime. The term under age presumably means below the age of 18, inasmuch as 18, insofar as sexual offenses are concerned, is the age of legal consent. B. White Slave Trade: Art. 341, Revised Penal Code: The penalty of prision correccional in its medium and maximum periods 6hall be imposed upon any person who, in any manner, or under any pretext, shall engage in the business or shall profit by prostitution or shall enlist the services of women for the purpose of prostitution. Ways of Committing the Crime: a. Engaging in the business of prostitution. b. Profiting by prostitution. c. Enlisting the services of women for the purpose of prostitution. Any one of the above mentioned act is sufficient to constitute offense which need not be habitual. Abuse Against Chastity Art. 245, Revised Penal Code: The penalties of prision correccional in its medium and maxi-

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mum periods and temporary special disqualification shall be imposed: 1. Upon any public officer who shall solicit or make immoral or indecent advances to a woman interested in matters pending before such officer for decision, or with respect to which he is requested to submit a report to, or consult with, a superior officer; 2. Any warden or other public officer directly charged with the care and custody of prisoner or persons under arrest who shall solicit or make immoral or indecent advances to a woman under his custody. If a person solicited by the wife, daughter, sister or relative within the same degree by affinity of any person in the custody of such warden or officer, the penalties shall be prision correccional in its minimum and medium periods and temporary special disqualification. Ways of Committing Abuse Against Chastity: 1. By soliciting or making immoral or indecent advances to a woman interested in matters pending before the offending officer for decision or with respect to which he is required to submit a report to, or consult with a superior officer. 2. By soliciting or making immoral or indecent advances to a woman under the offender's custody. 3. By soliciting or making immoral or indecent advances to the wife, daughter or relatives with the same degree by affinity of any person in custody of the offending warden or officer. Solicit means to propose earnestly and persistently something immoral or indecent. Mere proposal is sufficient. It is not necessary that the woman solicited yields to the solicitation of the offender. But proof of solicitation may no longer be necessary when there is sexual intercourse. A warden of a woman prisoner entered the cell and had illicit relation with her. On appeal the appellant argued there was no proof of solicitation. Absence of sufficient solicitation is not necessary when the act solicited was consumated (U.S. v. Morales, 29 Phil. 572). U N N A T U R A L SEXUAL OFFENSES AND SEXUAL ABNORMALITIES Unnatural sexual offenses are not only a deviation to the normal course of nature but also uncommonly observed manifestations of sexual perversion. Most of those persons suffering from the con-

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ditions do not exhibit criminal intent but manifesting mental aberrations which may be a subject-matter for the psychiatrist to treat. Environment, degree of education, degree of morality, habits, etc. are some of the factors responsible for such sexual maladjustments. There is no specific provision of our Revised Penal Code on any of the unnatural sexual offenses, although certain provisions of the code may be made applicable. Municipal ordinances of cities and towns may penalize unnatural sexual offenses in consonance with the power to promulgate rules and regulations necessary for the promotion of public safety, moral and welfare. Provisions of the Penal Code which may be Applicable to Unnatural Sexual Offenses: 1. Grave Scandal: Art. 200, Revised Penal Code: The penalties of arresto mayor and public censure shall be imposed upon any person who shall offend against decency or good customs by any highly scandalous conduct not expressly falling within any other article of the code. Requisites of the Crime: a. The offender performs act or acts; b. Such act or acts is/are highly scandalous and offending against decency and good customs; c. It is also necessary that the act or acts be committed in a public place or within the view or knowledge of the public (U.S. v. Samaniego, 16 Phil. 663). 2. Immoral doctrines, obscene publications and exhibitions: Art. 201, Revised Penal Code: That penalty of prision correccional in its minimum period or a fine ranging from 200 to 2,000 pesos, or both, shall be imposed upon: a. Those who shall publicly expound or proclaim doctrines openly contrary to public morals; b. The authors of obscene literature, published with their knowledge in any form, and the editors publishing such literature; c. Those who in theaters, fairs, cinematographs or any other place open to public view, shall exhibit indecent or immoral plays, scenes, acts or shows; and d. Those who shall sell, give away or exhibit prints, engravings, sculptures or literature which are offensive to morals.

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3. Vagrants and Prostitutes: Art. 202, Revised Penal Code: The following are vagrants: 1 2. Prostitutes. For the purposes of this article, women who, for money or profit, habitually indulge in sexual intercourse or lascivious conduct, are deemed to be prostitutes. Any person found guilty of any of the offenses covered by this article shall be punished by arresto mayor or a fine not exceeding 200 pesos, and in case of recidivism, by arresto mayor in its medium period to prision correccional in its minimum period or a fine ranging from 200 to 2,000 pesos, or both, in the discretion of the court. 4. Unjust vexation or any other coercion: Art. 287, 2nd paragraph, Revised Penal Code: Any other coercions or unjust vexations shall be punished by arresto menor or a fine ranging from 5 to 200 pesos, or both. Unjust vexation includes any human conduct, although not productive of some physical or material harm would, however, unjustly annoy of vex an innocent person (Guevarra). SEXUAL ABNORMALITIES: As to the Choice of Sexual Partner: 1. Heterosexual — Sexual desire towards the opposite sex. This is a normal sexual behavior, socially and medically acceptable. 2. Homosexual — (Michaelangelo, Shakespeare, Oscar Wilde, Waltz Whiteman), — Sexual desire towards the same sex. a. Kinds of Homosexuals: (1) Overt — Persons who are conscious of their homosexual cravings, and who make no attempts to disguise their intention. They make advances towards members of their own sex. ( 2 ) 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 special name for female homosexuals wherein a woman has the desire to have sexual intercourse with another woman. The "masculine

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woman may be the active subject during the sexual act. Most lesbians have antipathy towards men. 3. Infanto8exual — Sexual desire towards an immature person. a. Pedophilia — A form of sexual perversion wherein a person has the compulsive desire to have sexual intercourse with a child of either sex. Children of various ages participate in sexual activities, like fellatio, cunnilingus, fondling with sex organs, or anal sexual intercourse. Usually committed by a homosexual, between a man and a boy the latter being a passive partner. A Pedophile may be: a. Homosexual pedophile — may attempt either oral or anal intercourse with his victim. b. Heterosexual pedophile — may attempt either oral, vaginal, anal, intracrural intercourse as well as cunnilingus, but attempts at vaginal penetration are most common. Offenders entice their victim through promise of money, candy, etc. Reasons Why Physicians Fail to Detect Child Sexual Abuse: a. b. c. d.

The lack of "hard" physical evidence of abuse; A belief that sexual abuse does not exist; A fear of antagonizing parents; and Ignorance of how to obtain a detailed sexual history from the child.

Theories Why Adults become Interested in Children: a. Emotional congruence — Children are sexually attractive to adult for a number of reasons: (1) Children are nondominant; (2) Adults have low self-esteem, immaturity, socialization to male dominance or narcissism; and (3) Unconscious impulse, compulsively to repeat child-adult sex contact to master, and his or her own early experience of child-adult sexual abuse. b. Conditioning Modeling — Behavioral modeling begins with early childhood experience, positive or negative, and is conditioned by hormonal abnormalities, child pornography and the misattribution of arousal as being only from children. c. Blockage — Alternative sexual gratification may become blocked due to poor social skills with adults of the opposite sex, anxiety about sex, unresolved oedipal conflicts, unavailability of or

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conflict with a committed partner, as well as repressive socialsexual norms. d. Disinhibition — Sexual controls may become disinhibited due to senility, dementia, mental retardation, psychosis, drug or alcohol, impulse disorders, situational stress, failure of incest avoidance, a general cultural acceptance. (JAMA, Vol. 254, No. 16, Oct. 25, 1985). 4. Bestosexual — Sexual desire towards animals. a. Bestiality (Zoophilia) — Sexual gratification is attained by having sexual intercourse with animals. 5. Autosexual (Self gratification or masturbation) — It is a form of "self-abuse" or "solitary vice" carried without the cooperation of another person. Relation of Masturbation to Health and Sex Crime: a. It serves as a sedative for a variety of neurotic disposition. Many persons who suppress the urge to masturbate and give up the habit often develop an anxiety neurosis. b. It serves as an adequate form of sexual gratification. c. It prevents the development of homosexuality. d. It prevents the development of suicidal tendency on account of the absence of sexual gratification. e. It protects certain persons from committing sex crimes. Types of Masturbation: a. Conscious Type — The person deliberately resorts to some mechanical means of producing sexual excitement with or without orgasm: Ways of Masturbation: (1) In male: (a) By manual manipulation to the point of emission. ( b ) Ejaculation produced by rubbing his sex organ against some part of the female body without the use of the hand (frottage). ( 2 ) In female: (a) Manual manipulation of the clitoris. ( b ) Introduction of the penis-substitute. Medical evidences cannot go beyond to prove the emission of semen, and unless caught "in flagrante delicto," it is not likely that a person could be brought to trial. It may be a criminal act if done in public places or within the knowledge and view of the public. Psychiatric evaluation of the offender may be necessary.

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b. Unconscious type — The release of sexual tension may come about via the mechanism of nocturnal stimulation with or without emission, which may also be considered as "masturbation equivalent". The explanation is that the conscious urge to masturbate is repressed during the waking state and expressed during the sleep when we are less apt to censor our thoughts and desires. 7. Gerontophilia — Sexual desire with elder person. 8. Necrophilia — A sexual perversion characterized by erotic desire or actual sexual intercourse with a corpse. 9. 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. They are commonly called "hot" or "fighter". Both satyriasis and nymphomania are general expression of compulsive neurosis. 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. o. Vaginisimus — Painful spasm of the vagina during sexual act. d. Old age — Weakening of sexual feeling in the elderly. There may be the desire but there is difficulty of accomplishment. It may be accompanied by aberrant behavior, like exhibitionism, incest, or homosexuality. As to Mode of Sexual Expression or Way of Sexual Satisfaction: 1. Oralism — The use of the mouth as a way of sexual gratification. a. Fellatio (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 form of sexual perversion wherein 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.

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Flagellation — A sexual deviation associated specifically with the act of whipping or being whipped. a. Sadism (Active Algolagnia) — A form of sexual perversion in which the infliction of pain on another is necessary or sometimes the sole factor in sexual enjoyment. (1) Cannibalism — Sexual gratification attained by biting without flesh eating but with presumed unconcious wish to consume. (2) Love bites — These are superficial punctate contusions seen most frequently at the side of the neck, overlying or anterior to the sternomostoid muscle, breast and other parts of the body. The bitten tissue must be loose and the mark is caused by forcible sucking applied to tissue seized by the mouth. Usually during the act the teeth are guarded by the lips. Because of the sucking, contusion develops. The infliction of such injury although amorous may be a part of the sadistic attitude of the offender. It is called necrosadism or lust murder if the victim dies. The deviate has a strong homicidal urge, quite often suffering from organic brain disease or may be schizophrenic, epileptic or psychopath. b. Masochism (Passive algolagnia) — The pain and humiliation from the opposite sex is the primary factor for sexual gratification. 3. Fetishism — A form of sexual perversion wherein the real or fantasied presence of an object or bodily part is necessary for sexual stimulation and/or gratification. Kinds of Fetishes: a. Anatomic — Where particular portions of the anatomy, such as the breasts, or buttocks are the target of interest for sexual stimulation. b. Clothing — The deviate may have interest centered on shoes, handkerchief, undergarments, either on a sexual partner or stolen from a neighborhood washline. c. Necrophilic — The 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) — Fetish whose stimulus is pleasant odor or foul odor for sexual stimulation or gratification. (1) Urolagnia — A sexual deviation in which sexual excitement is associated with the sight of women urinating. In some instances, there is a desire to drink the urine.

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( 2 ) Coprolognia — A form of sexual deviation wherein sexual gratification is attained by seeing women defecate. (3) Mysophilia — Sexual response to filth or excretion. e. Pygmalionism — A sexual deviation whereby a person has sexual desire for statues. f. Mannikinism — Sexual desire with mannikins. g. Narcissism — A person has extreme admiration and love of one's self. Sexual gratification is attained by looking at the mirror and appreciating his or her own self. h. Negative fetish — The marked dislike for things, like eyeglasses, beard, hair cut, as the sole stimulus for gratification. i. Saboteur fetish — A deviate does damage while he gets satisfaction, like cutting clothes or hair. j. Incendiarism — Deviate derives sexual pleasure from setting fire. (Did Nero belong to this category? ). k. Vampirism — Deviate attains sexual stimulation or gratification 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 — A form of sexual gratification characterized by the compulsive desire of a person to rub his sex organ against some parts of the body of another. They generally achieve their erotic gratification by rubbing or pressing their organs against the buttocks of women in crowded subways, buses, theaters, or streetcars. The frotteur often pretends that the rubbing is accidental. 4. Partialism — A form of sexual deviation wherein a person has special affinity to certain parts of the female body. Sexual libido may develop in the breast, buttock, foot, legs, etc. of women. Usually, sexual intercourse is merely secondary to satisfy the sexual desire. A person may prefer rubbing his penis against the woman's breast or may prefer his partner to lie prone and kiss the buttocks or perform cunnilingus. Frottage differs from partialism in the sense that in the former there must be rubbing at certain parts of the body to arouse sexual stimulation, while in the latter the act may not only be rubbing but actual intercourse.

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As to Visual Stimulus: 1. Voyeurism — A form of sexual perversion characterized by a compulsion to peep to see persons undress or perform other personal activities. The offender is sometimes called "Peeping Tom". Usually after peeping, he masturbate in excess. 2. Mixoscopia (Scoptophilia) — A perversion wherein sexual pleasure is attained by watching couple undress or during their sex intimacies. As to Number: Normal sexual relation is only between a man and a woman, but deviation in sexual behavior may attain gratification when more than two persons are participating. 1. Troilism (Menage a trois') — A form of sexual perversion in which three persons are participating in the sexual orgies. The combination may consist of two men and a woman or two women and a man. The usual activity may be fellatio, kissing the buttock, sucking the breast, a "suixante-neuf" (sixty-nine) arrangement, or coitus combined with other sexual practices. Sexual gratification is attained in the "eternal triangle". A husband may request his wife to invite another woman and spend their night in a room. In their nude condition, the husband may perform cunnilingus to the woman and at the same time performing coitus with his wife. The invited woman may remain doing nothing other than kissing the buttock of the husband. 2. Pluralism — A form of sexual deviation in which a group of person participate in the sexual orgies. T w o or more couples may perform sexual act in a room and they may even agree to exchange partners for "variety sake" during the "sexual festival". Other Sexual Deviates: 1. Coprolalia — A form of sexual deviation characterized by the need to use obscene language to obtain sexual gratification. Sometimes they go beyond uttering profane words by making some writings and sketches on the walls of toilets. 2. Don Juanism — The term applied by psychiatrists to describe a form of sexual deviation characterized by promiscuity and making seduction of many women as a part of his. career. The pervert cannot find anyone to be a permanent companion. 3. Indecent exposure (Exhibitionism) — This is the willful exposure in public places of one's genital organ in the presence of other persons, usually of the opposite sex. Usually, the exhibitionist is naked. It is the act of men whose sexual satisfaction is attained

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principally by exhibition with or without performance of masturbatory act. Women may expose themselves naked in public as in "bubble and fan" dances and the "strip tease" acts in night clubs. In civilized society, exhibitionism committed in public places is harmful to the sense of decency and good morals, hence it is punishable. One evening two detectives and a reporter with a camera entered one of the burlesque shows and they found the theater dark with a dim light in the stage where a woman was seen swaying her hip to and fro and sometimes raising her feet one after another. She had on an "abbreviated" nylon panty and patches on her breasts to interrupt her stark nakedness. There were about 100 people inside the theater and while the girl (accused) was dancing the people shouted in Tagalog "Sigue, muna, sigue, nakakalibog". The dancer was later apprehended and charged for immoral exhibition. H E L D : She was found guilty, because the act deprived or corrupted those minds which were susceptible to immoral influence. The object of the law is to protect the public. The reaction of the public during the show showed the act to be immoral (People v. Aparici, G.R. 13375). Sexual Reversal: 1. Transvestism ("Sexo-esthetic inversion", "Psychical hemaphroditism" or "Metamorphosis sexualis paranoica") — A form of deviation wherein a male individual derives pleasure from wearing the female apparel. This condition is found sometimes in females who desire to dress themselves in male attire. The transvestite has a psychic identification with the opposite sex. A female transvestite may imagine that she possesses a penis. It is quite difficult to detect a female transvestite, since it is quite common for women to wear slacks or dress in masculine tailored ways. Transvestites are, as a rule harmless insofar as they have no desire to assault anyone. Like exhibitionists they are merely interested in attracting attention. Transvestitism is a symptomatic expression of some deep underlying sexual maladjustment amenable to psychotherapy. 2. Transexualism — There is a dominant desire in some persons to identify themselves with the opposite sex as completely as possible and to discard forever their anatomical sex. So strong is the compulsion to have the opposite sex that they hate their genitalia as a persistent evidence that they are not what they want to be, and

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sometimes attempt to castrate themselves or mutilate their external genitalia. They may go to the extreme of taking for a long period of time sex hormones to develop secondary sex characteristics of the opposite sex. They may go to the extent of subjecting themselves to surgery to change their anatomical sex. 3. Intersexuality — A genetic defect wherein an individual show intermingling, in varying degrees, of the characteristics of both sexes including physical form, reproductive organs, and sexual behavior. Classification of Intersexuality: a. Gonadal agenesis — The sex organs (testes or ovaries) have never developed. This condition can be determined very early in fetal life. b. Gonadal dysgenesis — The external sexual structures are present but at puberty the testes or the ovaries fail to develop. ( 1 ) Klenefetter's syndrome — A male type of dysgenesis in which although the anatomical structure is entirely male, the nuclear sexing is female (Chromatin positive), characterized by the presence of small testes with fibrosis and hyalinization of the seminiferous tubules. It is associated with X X Y chromosomes. ( 2 ) 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 — A state of bisexuality, having both ovaries and testicles. The nuclear sex is usually female. The character may be neutral or whichever is dominant. d. Pseudohermaphrodite — Sex organ is anatomically of one sex but the sex characters is that of the opposite sex. ( 1 ) Male pseudohermaphrodite — Gonads are testicles but the character is effeminate. ( 2 ) Female pseudohermaphrodite with masculine character.

— Gonads are ovaries but

Chapter XXII PREGNANCY Pregnancy is the state of a woman who has within her body the growing product of conception or a fecundated germ. It commences from the time the egg cell is fertilized and terminates at the time such product of conception is expelled or delivered. The average duration of pregnancy is 270 to 280 days from the first day of the last menstruation. There is no perfect way of determining its duration, although several methods are employed, none of the methods are perfectly reliable. Legal Importance of the Study of Pregnancy: 1. Pregnancy is a ground for the suspension of the execution of the death sentence in a woman: Art. 83, Revised Penal Code: Suspension of the execution of the death sentence: The death sentence shall not be inflicted upon a woman within the three years next following the date of the sentence or while she is pregnant, nor upon any person over seventy years of age. In this last case, the death sentence shall be commuted to the penalty of reclusion perpetua with the accessory penalties in article 40. 2. A conceived child is capable of receiving donation: Art. 742, Civil Code: Donations made to conceived and unborn children may be accepted by those persons who would legally represent them if they were already born. 3. A conceived child may exercise civil rights: Art. 40, Civil Code: Birth determines personality; but the conceived child shall be considered born for all purposes that are favorable to it, provided it be born later with the conditions specified in the following article. Art. 41, Civil Code: For civil purposes, the foetus is considered born if it is alive at the time it is completely delivered from the mother's womb. However, if the foetus had an intrauterine life of less than seven 539

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months, it is not deemed born if it dies within twenty-four hours after its complete delivery from the maternal womb. 4. Concealment of the woman that she is pregnant at the time of marriage is a ground for the annulment of marriage: Art. 85, Civil Code: A marriage may be annulled for any of the following causes, existing at the time of the marriage: ( 4 ) That the consent of either party was obtained by fraud, unless such party afterwards, with full knowledge of the facts constituting the fraud, freely cohabited with the other as her husband or his wife, as the case may be. Art. 86, Civil Code: Any of the following circumstances shall constitute fraud referred to in number 4 of the preceding article: (3) Concealment by the wife of the fact that at the time of the marriage, she was pregnant by a man other than her husband. No other misrepresentation or deceit as to character, rank, fortune or chastity shall constitute such fraud as will give grounds for action for the annulment of marriage. Art. 87, Civil Code: The action for annulment of marriage must be commenced by the parties and within the periods as follows: ( 4 ) For causes mentioned in number 4, by the injured party within four years after the discovery of the fraud. Instances W h y Some Women Claim Pregnancy Even if None Exists: 1. Pregnancy is a ground for the suspension of the death sentence in a woman: If a woman claims that she is pregnant at the time of execution, she may file for a motion or petition in court for the suspension of the execution of the death sentence, and if found to be pregnant, the execution will be deferred until she has delivered. 2. A lawful plea in mitigation when charged with theft: A woman may be accused of the crime of theft. She may raise the plea in mitigation of kleptomania brought about by her temporary insanity due to conceptfon. 3. A ground for widow's larger claim: A widow may claim larger damages as a result of the recent death of her husband on account of the negligence of another.

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4. Claim for the posthumous child: A widow may ask or petition the court for the share of the posthumous child in the estate of the deceased husband. 5. F o r black-mailing purpose: A woman may claim that she is pregnant for the purpose of black-mailing a man or for the purpose of inducing a man to marry her. Instances W h y Some Women Deny the Existence of Pregnancy: 1. When there is no ground for them to become pregnant: Women who are unmarried, or divorced, or who are living separately from their husbands for a time may be accused by someone that they are pregnant. To defend their moral and social reputation, they deny the existence of pregnancy. 2. Defense when accused of infanticide or abortion: The absence of previous pregnancy may be used as a defense when a woman is accused of infanticide or abortion. Infanticide cannot be committed unless there has been previous pregnancy. 3. Marriage inducement: A woman may deny the existence of pregnancy by another man, to induce the man to marry her. MEDICAL EVIDENCES OF PREGNANCY: Signs and symptoms of pregnancy may be divided into presumptive or probable and positive or certain: A. Presumptive or Probable Signs and Symptoms: 1. Cessation of Menstruation: A married woman who missed her menstruation is presumed to be pregnant, however, cessation of menstruation may be due to some other causes other than pregnancy. Emotional disturbance, anemia, systemic infection, disturbance in the function of the ovary, may bring about amenorrhea. It is also worthy of mention that a woman is capable of menstruating even though she is pregnant. This is possible during the first three months of pregnancy, but no longer possible during the later period on account of the fusion of the decidua vera to the decidua capsularis. A nursing mother may not menstruate during the period she is nursing the child. 2. Morning Sickness: This is the pernicious vomiting of a pregnant woman more manifest in the morning. Although this is a frequent phenomena in the early stage of pregnancy, other conditions may

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LEGAL MEDICINE also give rise to the same symptoms. The hypertonicity of the stomach, peptic ulcer, gastric hyperacidity may simulate morning sickness of pregnancy. 3. Changes in the Breast: There is increase in size and sensation of tightness of both breasts. The pinkish-brown color of the areolae are changed into dark-brown or black. The tubercles of Montgomery are developed and the tissues are erectile. Colostrum is found on the third month. Secretion of milk may occur in a non-pregnant woman, as in tumor of the ovary. 4. Progressive Enlargement of the Abdomen: At the end of the third month, the fundus of the uterus is at the level of the brim of the pubic bone. At later periods, there is gradual increase in size of the uterus capable of perception by palpation on the abdominal wall. The enlargement of the abdomen may be due to tumor of the uterus or ovarian cyst, or other abdominal pathology. The relation between the age of the fetus and the level of the fundus of the uterus is as follows: 3 calendar months (complete) — 3 fingers above the pubic bone. 4 calendar months " — Between the symphysis and umbilicus. — 3 fingers below the umbilicus. 5 calendar months — At the level of the umbilicus. 6 calendar months — 3 fingers above the umbilicus. 7 calendar months — 6 fingers above the umbilicus. 8 calendar months 9 calendar months — More than 8 fingers above the umbilicus. Note: In some women the 9th month has the same level as the 8th month because sometimes the head of the fetus approximates the pelvic cavity so that fundus does not go so high.

5. Changes in color of the vagina and softening of the cervix: There are different signs to show change in color of the vaginal wall and softening of the cervix. a. Jacquemin-Chadwick's Sign: There is a pale violet discoloration of the anterior wall of the vagina below the urethral meatus. The color changes to bluish as pregnancy advances and in some cases it becomes later very dark or black in color.

b. Hegar's Sign: Bi-manual examination of the gravid uterus shows extreme softening of the cervix. c. MacDonald's Sign: On account of the softening of the isthmus, the fundus of the uterus is anteflex, so by bi-manual examination, there is an easy approximation of the fundus and the cervix.

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LEGAL MEDICINE d. GoodelVs Sign: When the cervix of the uterus feels as hard as the tip of the nose, pregnancy does not exist, but when it is as soft as the lips, the uterus is gravid. 6. Funic Souffle or Umbilical Souffle: Funic souffle, sometimes called umbilical souffle, is the whistling sound synchronous with the fetal heart beat and is only of subordinate value owing to the possibility of other sounds being mistaken for it. 7. Ballottement: This is the feeling perceptible to the fingers on giving sudden impulse to the child through the neck of the uterus. The child floating in liquor amnii is driven by the impulse against the other side of the uterus, and it is this blow against the womb that is perceptible to the hand placed on the abdomen. 8. Braxton-Hick's Sign: This is the rhythmical contraction and relaxation of the uterus, perceptible to the hand when resting on the abdomen. The interval of contraction is usually five to twenty minutes and lasting from two to five minutes. Fibroid uterus may also give this sign.

9. Bladder Irritability : Irritability of the bladder is a common occurrence among pregnant women. This is noticeable at the second month of pregnancy, manifested as frequent urination. However, it has of no diagnostic value because even a non-pregnant woman may manifest the same symptom. 10. Capricious Appetite: Women during the early stage of pregnancy or even thereafter may have specially capricious appetite. The desire for a particular class or kind of food is shown by a conceiving woman. Not all women do manifest this sign and its presence will not conclusively show the presence of pregnancy. 11. Abnormality in Pigmentation: The pregnant woman usually manifest pigmentations in some parts of the body especially in the abdomen and perineum. It may not be very prominent among colored people. Pigmentation may be present in some diseases, like Addison's disease.

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12. Easy Fatigability: A pregnant woman easily gets tired on slight effort. This may be due to the weight of the gravid uterus and insufficiency of nutrient and oxygen supply to the tissues of the body due to the deviation of a portion to the growing fetus. Easy fatigability is present also in cardiac and pulmonary diseases, debilitating affection and old age. B. Positive Signs and Symptoms of Pregnancy: The finding of any of the following signs or symptoms of pregnancy will show conclusively its existence: 1. Hearing of the Fetal Heart Sounds (Mayor's Sign): The heart beat of the fetus is compared to the ticking of a watch under the pillow. The rate is 120 to 140 beats per minute. The location is at the anterior abdominal wall and is dependent upon the presentation and position of the fetus. Fat and amniotic fluid may interfere with the intensity of the sound, 2. Outlining of the Fetal Parts: By palpation, we can determine the head, neck, arm, back and buttocks. If these parts could be outlined, the pregnancy is sure, however, it may be confused with irregular ovarian cyst. 3. Movement of the Fetus (Quickening): The movement of the fetus may be felt by the woman and may be visible to other observers. This is an indisputable evidence of life, and is observed at the fifth month of pregnancy. 4. X-ray Examination: Fetal skull and vertebra are visible with x-ray examination. This is positive at the fifth month of pregnancy. X-ray is also valuable to determine the presence of plural pregnancy, malformation and death of the fetus. However, this must not be used injudiciously for diagnostic purpose only on account of its bad effect on the fetus. Laboratory Test for Pregnancy: A.Pregnancy Slide Test: 1. Principle — An agglutination-inhibition reaction is used to demonstrate the hormone human chorionic gonadotropin ( H C G ) which is excreted into the urine during pregnancy. H C G which is chemically bound to latex particles is agglutinated by HCG antibodies in the presence of free HCG, this reaction is inhibited because the antibodies are neutralized.

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2. Reagents: a. Pregnancy Slide Test antiserum (human H C G antiserum from rabbit) b. Pregnancy Slide Test antigen ( H C G latex suspension, chemically bound) 3. Procedure: Place 1 drop of urine, then 1 drop of Pregnancy Slide Test antiserum 1 in one of the circles on the test slide and mix thoroughly with a disposable stirring rod. A d d 1 drop of Pregnancy Slide Test antigen 2 (shake well). Mix well with the stirring rod, distributing the mixture over the whole area of the circle. Carefully agitate the slide with a circular motion to ensure that the fluid revolves slowly within the circle. Read the result after two minutes. 4. Interpretation of result — If there is no agglutination (homogeneous) the urine tested came from a pregnant woman. If there is agglutination (granular), the urine came from a non-pregnant woman. 5. Sensitivity — H C G concentration of 1.5-2.4 IU/ml urine and over are detectable with "Pregnancy Slide Test". A positive reaction is often possible within 5 days of the missed menstrual period. Usually the pregnancy will be diagnosed 12 days after the missed menstrual period. 6. Remarks — Fresh urine preferably morning urine is suitable for use. It is advisable to have controlled urine from known positive or negative subjects. If the result is doubtful, it is advisable to repeat the test a few days later. B. Gravindex HCG Slide Test — The principle involved and procedure is practically the same as the Pregnancy Slide Test. Gravindex is merely a trade name. Characteristics of the fetus in various periods throughout pregnancy (Calendar Months): End of first month

—Length — 1.0 cm.; Diameter — 2.0 cm.; Eyes, ears and mesodermic segments are distinguishable; Limb buds are present.

End of second month—Length — 3.0 cm.; Diameter — 6.5 cm.; Weight — 15.5 gm. End of third month —Length — 8.0 cm.; Weight — 85.0 gm.;

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Chorion laeve has lost most of its villi, neck is develop, oral and nasal cavities are separated by the development of the paint* Sexual organs have appeared, fingers and toes are present, and nails can just be detected. Ossification has begun in most of the bones. End of fourth month — Length — 13 cm.; Weight — 204 gm.; Sex can be distinguished; Skull partly ossified, with wide sutures and fontanelles. End of fifth month

—Length — 22.5 cm.; Weight — 450 gm.; Hair and lanugo have appeared; Skin begins to be covered with vernix caseosa.

End of sixth month

— Length — 30 cm.; Weight — 900-1,100 gm.; Skin is still wrinkled, but subcutaneous fat is beginning to form; Eyebrows appear;

End of seventh month— Length — 37.5 cm.; Weight — 1 Vt kg.; Eyelids open; Testicle is beginning to descend unto the scrotum; nails do not reach the tip of fingers; Lanugo disappearing from the face; Child is viable (28 weeks). End of eight month — Length — 42 cm.; Weight — 2 to 2 A kg.; Skin is only slightly wrinkled, and flesh colored; Lanugo beginning to be shed; Left testicle is generally in scrotum. l

At term

l

— Length — 50 cm.; Weight — 3 to Z A kg.; Nails beyond or at the level of the finger tips; Hair of the scalp is 5 cm. long; Lanugo is only seen on the shoulder. (Obstetrics and Gynecology by Aleck Bourne, 10th ed., p. 21-22).

Signs of Pregnancy in the Dead: In addition to the objective signs already mentioned, the following additional findings are present if the pregnant woman dies: 1. Presence of Ovum or Fetus: Examination of the uterine content will reveal the product of conception together with the placenta, amniotic fluid, and membrane. 2. Findings on the Uterus Itself: There is thickening, increase in size and capacity of the uterus. The mark of placental attachment may be seen.

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3. Corpus Luteum: Corpus luteum may be well-developed and attains a certain size, however, it may gradually retrogress, but it is usually welldeveloped at the time of delivery. The changes in the corpus luteum may also be found in fibroid tumor or other pathological condition and even in cases of congestion. Duration of Pregnancy: The average duration of pregnancy is 270 to 280 days from the onset of the last menstruation. There is no means of determining it with certainty. The evidence derived from pregnancy following a single coitus is trustworthy, but inasmuch as some authorities consider more than two weeks as the life span of the spermatozoa in the vaginal canal, it is hard to ascertain the exact date of fertilization. There is no synchrony between coitus and fertilization. Abnormally Prolonged Gestation: Cases in which pregnancy extends to 300 days can now be regarded as well established. Many examples of longer duration have been recorded, but most of them are doubtful. Eden quotes sex cases which have been accepted as authentic in which the calculated period of gestation lay between 311 and 336 days, the weights of the infant ranging from 12-3/4 to 13-1/4 pounds. In all cases where the gestation much over 300 days is alleged, confirmatory evidence should be expected in the exceptional weight and size of the child (A Handbook of Medical Jurisprudence and Toxicology by W. Brend, 8th Rev. ed., p. 113). Minimum Period of Gestation Compatible with Viability of the Child: Most authors hold that a child born at one hundred and eighty days of gestation may live. A child may be born alive before this period, but it is not viable or capable of living. A fetus of three or four months development may exhibit signs of life, movements of the limbs, etc., but cannot continue to live, owing to the want of development of the breathing muscles and breathing center. Most 6 months old infants die immediately or within a few days of birth; occasionally one has been reared (Cox's Medico-Legal Court Companion by Bhattacharyya, 4th Revised ed., p. 248). Methods of Estimating the Date of Expected Delivery: 1. From the date of the first day of the last menstruation, add seven days and count three months backwards. 2. Count forward nine calendar months from the date of the first day of the last menstruation and add one week.

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3. Count forty weeks or ten lunar months from the date of the first day of the last menstruation. 4. Determination of the level of the fundus of the uterus, (supra,

p. 542) 5. MacDonald Method: Measure the distance from the symphysis pubis up to the fundus of the uterus in centimeters divided by 3.5 gives the age in month of gestation. 6. Date of the quickening. It is customary to count ahead 24 weeks in multigravidas and 22 weeks in primagravidas from the date of the quickening. This has been found not to be reliable. Proofs of Previous Pregnancy: 1. Laxity of the abdominal wall. 2. Presence of striae of pregnancy on the abdominal wall. 3. Perineum is lax with a scar if there was previous laceration. Fourchette is markedly retracted. 4. Vestige only of the hymen is present (caruncula myrtiformis). 5. Breast is lax with enlarged nipples. 6. Vaginal examination shows previous laceration of the cervix. Super fecundation: This is the fertilization made by separate intercourses of two ova which have escaped at the same act of ovulation. Superfoetation: This is the fertilization of two ova which have escaped at different acts of ovulation. This is possible before the time the decidua vera has united with the decidua reflexa; that is, before the end of the third month of pregnancy. Pseudocyesis or Spurious Pregnancy: It is an imaginary pregnancy usually observed among women nearing menopause or in younger women who are very desirous of having children. The patient will present all the subjective symptoms of pregnancy, associated with an increase in the size of the abdomen due frequently to abnormal and rapid deposition of fat or to tympanism. The menses may not totally disappear but may present abnormalities which the patient may attribute to her supposed condition. The patient may imagine fetal movement which in reality is muscular contraction. There is great difficulty in persuading the woman to believe that she is not pregnant.

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Diagnosis of Fetal Death: The fetus inside the uterus must be presumed to be alive unless there are evidences to the contrary. The following are proofs that the fetus is dead: 1. Repeated examinations of the uterus show that the size remains stationary even after a lapse of a number of weeks and months. 2. Endocrine test for pregnancy is negative on more than one occasion. Moreover, death of the fetus may not mean death of the placental tissue which manufacture gonadotrophin. As long as the placental tissue continues to manufacture the trophic hormone, it will be positive in the urine. During the later months of pregnancy, the following are the additional proofs of death of the fetus: 3. Cessation of the fetal movement after they have been felt. 4. Absence of fetal heart sounds after a repeated and prolonged examination. 5. Positive signs of fetal death as shown by the palpation of softened macerated fetal head, with bones freely movable on each other and the scalp hanging over a loose sac. 6. The breasts cease to enlarge and become soft and flabby. May a Woman W h o Is Pregnant Be Unconscious of Her Condition? It is hardly credible but may happen in rare instances. A woman after being married for several years and has dismissed in her mind the possibility of being pregnant may grow stouter or may entertain the possibility that the enlargement of the abdomen is due to some internal pathology or disease. Is It Possible for a Child to be Born Without Human Form? Following the principles of heredity, no child can be born without human form. Hereditary qualities are transmitted from parents to offsprings. Monstrosities and other forms of abnormalities of a child does not divorce from the child the human form. Close inspections of the monsters and congenitally deformed children will show human form. Our present civil code eliminated "human form" as a requisite for the personality of a new-born child. Can Impregnation Occur When the Woman Is Unconscious? This has been proven in many cases. A woman may be under the influence of narcotics, anesthesia, alcohol or other knock-out drugs during the sexual intercourse which resulted in her pregnancy.

PREGNANCY

551

When Does Menstruation Commence? In the Philippines, menstruation used to commence at the age of twelve to fourteen. In colder countries, it may be established at the age of fourteen to sixteen. When Does Menstruation Cease? The average age when menstruation ceases is forty-five. However, there are records in literature wherein women menstruate at the age of seventy-three. The cessation of menstruation is also called climacterium or menopause. What Is The Earliest Age When Pregnancy Is Possible? As long as the woman is menstruating, she has also the potential capability of being pregnant. Some women have preconscious sexual development. Anna Mumenthaler menstruated regularly at the age of two, and gave birth to a full term child at the age of nine.

Chapter XXIII DELIVERY Delivery is the process by which a woman gives birth to her offspring. Puerperhun is the interval between the termination of labor (delivery) to the complete return of the reproductive organ to its normal nonpregnant state. Puerperium usually lasts from 6 to 8 weeks. The study of delivery is important because proof of delivery is necessary in judicial action on the following: 1. Legitimacy 2. Abortion 3. Infanticide 4. Concealment of birth 5. In slander or libel Methods of Delivery: 1. Natural

Route:

Expulsion of the products of conception through the normal passage; that is, through the vaginal canal. a. Spontaneous: When the products of conception passed out of the vagina without the aid of physician, midwife, instrumentation or surgical intervention. b. Surgical Intervention: When delivery is effected with the aid of surgery, e.g., Symphysiotomy. c. Instrumentation: The second stage of labor is modified by the use of instruments. Example: Forceps application. 2. Surgical Route: The expulsion of the products of conception is not through normal openings of the female generative tract but through some artificial openings brought about by surgery, a. Abdominal Caesarian Section: The child is delivered by opening the abdominal wall and the anterior wall of the uterus. 552

DELIVERY

553

b. Vaginal Caesarian Section: The child is delivered thru the surgical opening made through the vagina. c. Post-mortem Caesarian Section: When the pregnant woman meet sudden death either naturally or through violence and there is no chance of life, any person may open the abdomen to get the viable fetus en utero. A. SIGNS OF RECENT D E L I V E R Y : 1. Languid look, with pulse and temperature slightly increased: This usually disappears normally in two or three days after delivery. However, these symptoms may be present in other conditions or sickness, hence cannot be conclusive. 2. Peculiar odor: The characteristic odor of the lochial discharge is present up to the tenth day of confinement. The odor is fishy but sometimes the said odor is present on women who are menstruating normally. 3. Changes in the breast: There is a sensation of tightness of the breasts and milk may be expressed. The presence of colostrum corpuscles in the milk suggests that parturition has just taken place. 4. Flaccidity of the abdominal wall: The laxity of the abdominal wall is due to the distention when the uterus is gravid to accommodate the growing product of conception en utero. However, a previous ascites or cystic condition of the ovary or other internal pathology causing enlargement of the abdomen will also give rise to laxity of the abdominal wall. 5. Linea Albicantes present in the abdominal wall: At first it is reddish in color and is called linea rubra. It is brought about by the breaking of the capillaries when the abdomen is distended. Later, a scar-like tissue develops from the area and is called "Linea albicantes." This is also called striae of pregnancy. 6. Presence of Linea Nigra: During the course and development of the gravid uterus, there develops on the abdominal wall from the region of the symphysis pubis to the umbilicus or even above it a dark pigmentation of the skin. This pigmentation which is usually in the form of a straight line in the median line persists up to delivery. The origin of linea nigra is most probably hormonal.

554

LEGAL MEDICINE 7. Uterus is enlarged and palpable: Immediately after delivery, the uterus does not return to its original size. It takes time for its sub-involution. Due to the flaccidity of the abdominal wall, the enlarged uterus is easily palpable. 8. Laxity of the perineum with possible tear: The perineum is elastic and may yield to distention provided it is given ample time to stretch and provided the fetus is not so big in size. The passage of the fetus at the outer end of the birth canal is responsible for the relaxation of the connective tissue and muscles of the perineum. If there is abrupt distention, a perineal laceration may be produced. Laceration of the perineum is frequent when the second stage of labor is accentuated by push from the fundus of the uterus.

Vulva after Drevious childbirth and laceration of the perineum.

9. Vaginal canal is lax and with possible lacerations: The normal rugosities of the wall of the vaginal canal is lost due to severe distention. Occasionally, in severe perineal laceration, there is also involvement of the wall of the vaginal canal. 10. Cervix of the uterus is flabby, patulous and may be torn: The normal hard, doughly consistency of the cervix is lost, but instead it is soft "and flabby. In most cases there is laceration of the orifice.

DELIVERY

555

11. Presence of lochial discharge: Lochia is the discharge from the vagina after delivery. First it is bloody but later it is almost colorless. When bloody, it is called "lochia rubra" and when colorless, it is called "lochia serosa." When there is infection of the uterus after delivery, the odor of the lochial discharge is foul and usually black. 12. Evidence of placenta, umbilical cord and new-born child. 13. Positive Pregnancy Slide Test

(supra p. 545).

B . SIGNS O F R E M O T E D E L I V E R Y I N T H E L I V I N G : 1. Changes in the breast: The breast becomes pendulous and linea albicantes are found on the skin on account of the retraction of its size. There is dark color of the areolae and the consistency is soft. The nipples are prominent due to the sucking of the child. 2. Vulva and perineum: Scar of the previous laceration may be present. marked retraction of the fourchette and perineum.

There is

3. Hymen: Remains of the hymen may only be present in the form of carunculae myrtiformis. Very rarely is the hymen preserved after delivery. 4. Signs of previous laceration of the cervix: The opening of the cervical canal may no longer be seen as a round hole but slit-like on account of the previous laceration during delivery. 5. Presence of striae of pregnancy or linea atrophica on the abdominal wall. POST-MORTEM F I N D I N G S I N A W O M A N W H O D I E D R E C E N T L Y AFTER D E L I V E R Y : 1- Findings in the uterus: a. Laceration or contusion of the cervix. b. Uterus is enlarged and flabby. c. The inner surface of the uterus is bloody and rugged-looking. d. Dark color sloughy and gangrenous sinuses are evident at the endometrial lining at the site of the former placenta. e. There is relative hypertrophy and increase in thickness of the uterine wall.

556

LEGAL MEDICINE

2. Findings in the ovary: There is presence of corpus luteum. 3. Findings in the other organs: a. Hydremia of the blood. b. Slight anemia. depending upon the amount of hemorrhage in the delivery and immediately thereafter. c. Congestion and hypertrophy of the milk glands of the breast. 4. Pathology accountable for the cause of death: a. Signs of eclampsia. b. Findings of endometritis, peritonitis, toxemia, etc. c. Signs of cardiac, renal or pulmonary affection. d. Findings of rupture of the uterus. e. Signs of severe loss of blood during delivery.

Chapter XXIV ABORTION The Revised Penal Code does not define abortion, but merely mentions circumstances which makes abortion criminal and punishable. Authorities differ as to the length of intra-uterine existence which may be considered abortion. Some define abortion as the expulsion of the contents of a gravid uterus anytime before full term while others consider it as the forcible expulsion of the product of conception anytime before the age of viability. Viability is the point at which the fetus is "potentially able to live outside the mother's w o m b " , albeit with respiratory aid. And, later, as when it is capable of meaningful life outside the mother's womb (The Rights of Doctors, Nurses and Allied Health Professionals by Annas and Glantz, p. 202). In the legal viewpoint, 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. According to Viada, as long as the fetus dies as a result of violence used or of the drug administered, the crime of abortion exists, even if the fetus is full term. (

Whichever be the definition of abortion, the following are the principal elements of the crime: 1. That the expulsion of the product of conception is induced. 2. That the fetus dies either as an effect of the violence used, drug administered or the fetus was expelled before the term of its viability. Clinical Types of Abortion: V *"uj V*

**wi

Ic 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. /This is usually followed by the death with maceration or absorptidfTof the product of the conception. J'^A ^Threatened Abortion — Hemorrhage without dilatation of the internal os. Hemorrhage in early stage of pregnancy may be due to causes other than a threatened abortion, e.g., ectopic pregnancy, cervical polyp, extensive erosion of the cervix, etc. ^inevitable Abortion — Hemorrhage with dilatation of the internal os and presence of rhythmical pain. It may end by spontaneous 557

LEGAL MEDICINE

558

expulsion of the product of conception or may require medical intervention. Hemorrhage and infection are the potential complications. A. Incomplete Abortion — Not all the product, of conception has been expelled from the uterus; fragments or portions of which is retained. This will prevent contraction of the uterus and consequently uncontrolled bleeding will develop. Removal of the retained fragment must be done to avoid too much loss of blood and potential infection. j ^ * W * nj^^^ r

^Complete Abortion — The whole product of conception is expelled. Causes of Abortion: 1. Death of the fetus — Congenital abnormality, poisoning by minerals like lead, disease of the decidua, chorion, placenta, amnion, etc. 2. Abnormality of the uterus. 3. Emotional condition — Fright, grief and anger. 4. Abortificient drugs — Ergot, purgatives, 5. Trauma — Direct or indirect. 6. Hormonal deficiency. 7. Acute specific fever and high temperature. Provisions of the Revised Penal Code on Abortion: 1.

Intentional Abortion: Art. 256, Revised Penal Code: Any person who shall intentionally cause an abortion shall suffer: 1. The penalty of reclusion temporal, if he shall use any violence upon the person of the pregnant woman. 2. The penalty of prision mayor if, without using violence, he shall act without the consent of the woman. 3. The penalty of prision correccional in its medium and maximum periods, if the woman shall have consented. Elements of Intentional Abortion: a. That the woman is pregnant. b. That violence was applied, or drug was administered, or a person acts upon such pregnant woman. c. That the effect of such violence, drug or acts of the offender, the fetus dies or is expelled. d. That the offender has the intention to abort the pregnant woman.

ABORTION

559

Ways of Committing Intentional Abortion: a. By application of violence on the pregnant woman. b. By acting, but without use of violence, without the consent of the pregnant woman. This applies to the administration of drugs or beverages without her consent. c. By acting, with the consent of the pregnant woman. This applies to the administration or use of drugs or beverages with the full knowledge and consent of the pregnant woman herself. The purpose of the division of the crime into three paragraphs is to graduate the penalties depending upon the use of violence and knowledge of the pregnant woman. It is not based upon medical science. The accused gave herb extract in order to induce abortion on a woman. The woman aborted at about two hours after the administration. The accused burned the product of conception because of the belief that it is a fish-demon. It was held that the act constitutes prima facie proof of the intent of the accused in aborting the woman (U.S. v. Boston, 12 Phil. 134). If the intentional abortion resulted to the death of the pregnant woman, then the crime of abortion with homicide was committed. 2. Unintentional Abortion: Art. 2B7, Revised Penal Code: The penalty of prision correccional in its minimum and medium periods shall be imposed upon any person who shall cause an abortion by violence, but unintentionally. Elements of

Unintentional Abortion:

a. The woman must be pregnant; b. Violence was applied on such pregnant woman without the intention of aborting her; c. The woman aborted as a result of the violence. 3. Abortion practiced by the woman herself or by her parents: Art. 258, Revised Penal Code: The penalty of prision correccional in its medium and maximum periods shall be imposed upon a woman who shall practice an abortion upon herself or shall consent that any other person should do so. Any woman who shall commit this offense to conceal her dishonor, shall suffer the penalty of prision correccional in its minimum and medium periods. If this crime be committed by the parents of the pregnant woman or either of them, and they act with the consent of said

560

LEGAL MEDICINE

woman for the purpose of concealing her dishonor, the offenders shall suffer the penalty of prision correccional in its medium and maximum periods. Elements of the Crime: a. The woman is pregnant. b. Abortion is intended to be committed. c. Abortion is induced by: (1) The pregnant woman herself. (2) Other persons with the consent of the pregnant woman herself. (3) The parents of the woman, or either of them for the purpose of concealing her dishonor and with the consent of the woman herself. If a woman does an act of inducing abortion on herself, there is mitigation of criminal liability if the purpose is to conceal her dishonor. Concealment of dishonor is not mitigating if the abortion was committed by the parents of the pregnant woman or either of them. If a woman took poison for the purpose of committing suicide and because of the timely intervention of a physician she did not die but instead she aborted, she cannot be guilty of abortion because of the absence of intention to commit abortion. 4. Abortion practiced by a physician or midwife and dispensing of abortives: Art. 259, Revised Penal Code: The penalties provided in article 256 shall be imposed in its maximum period, respectively, upon any physician or midwife who, taking advantage of their scientific knowledge or skill, shall cause an abortion or assist in causing the same. Any pharmacist who, without the proper prescription from a physician, shall dispense any abortive shall suffer arresto mayor and a fine not exceeding 1,000 pesos. Requisites of the Crime: a. The woman is pregnant. b. The physician induced or assisted in causing the abortion with the use of scientific knowledge. c. The acts done by the physician or midwife was intended to cause an abortion. There must be the intention of the physician to produce abortion and the absence of intention will not make the physician criminally liable for such consequence.

ABORTION

S61

Problems Confronting the Provision of the Revised Penal Code Regarding Abortion: 1. If a woman or a third person induces abortion when pregnancy is beyond the period of viability. The child born as a result of such criminal act lives. Can there be a crime of abortion committed? 2. If a woman is not actually pregnant but she or a third person believes that she is pregnant. Abortion was induced on her by the third person and as a result of which she died. Is there a crime of homicide with intentional abortion? Kinds o f Abortion: — • ^Spontaneous

or Natural Abortion:

Abortion which occurs without any form of inducement or intervention. ^Induced

Abortion:

Abortion which will not take place had it not been for some form of inducement or intervention. Induced abortion may be: X- Therapeutic Abortion: Abortion purposely done to preserve the life of the mother. Preservation of the health of the mother may also be a ground to induce therapeutic abortion. The phrase "to preserve the life of the woman" does not only mean to preserve the life of the woman from death. b\ Criminal Abortion: Abortion done without any therapeutic indication but with criminal intent is punishable by law. Post-mortem Abortion: This is the expulsion of the product of conception after death of the pregnant woman brought about by the post-mortem contraction of the uterine muscles. It is possible during the early stage of preg• nancy when the fetus is small. During the later stage, the contraction of the uterus may cause its rupture and expel its contents of pregnancy into the abdominal cavity. Reasons Why Some Women Procure Abortion: 1. To preserve the life and health of the pregnant woman. 2. To terminate prematurely illegitimate pregnancy in order to coni ceal the dishonor of the woman. ;

3. Financial difficulty.

in the family.

Additional m e m b e r means an added expense

562

LEGAL MEDICINE

4. To preserve body form. Some women do not wish to make their pregnancies advance to full terms on fear that their bodies might be deformed. H o w Abortion is Induced or Procured: 1. By General Violence: This includes intentional violence, as exerting strong physical efforts in golf, horse riding, cycling, strong pressure applied on the abdomen, and other forms of strenuous and exhaustive exercises. Modi (Medical Jurisprudence and Toxicology, 12th ed., p. 336) mentioned the following methods employed to induce abortion: a. Severe pressure on the abdomen by kneading, blows, kicks, jumping and tight lacing. b. Violent exercise, such as riding on horseback, cycling, jumping from a height, jolting caused by driving on rough roads, long walks, running up and down the stairs, and carrying or lifting heavy weights. c. Cupping, usually by placing a lighted wick on the hypogastric region and turning a big glass bottle mouth downwards over it. It probably causes separation of the placenta or possibly injury to the uterine paries. d. Application of leeches to the pudenda, perineum and the inner surface of the thighs. 2. By Means of Local Violence: Local violence may be applied in any portion of the generative organ. This is usually resorted to when general violence and the use of drug fails to give the desired result. Local violence may be applied by the pregnant woman herself, by the physician, midwife, or by the parents. The most common methods applied are: a. Use of douche of warm and cold water. b. Injection of fluid into the uterine cavity. c. Use of luminaria tent or tangle tent to promote dilatation of the cervix. d. Use of soft rubber inserted into the cervix. e. Dilatation of the cervix by instrumentation. 3. By the Use of Drugs: This is the most common method resorted to by women to produce abortion. There is no drug or combination of drugs

ABORTION

563

which when taken by mouth or parenterally will definitely cause the healthy uterus to empty itself without endangering the life of the woman. Factors Responsible for Abortion After Ingestion or Administration of Poisonous Substances: a. General severe intoxication of the mother resulting in impairment of her circulation, metabolism and vital functions, or producing anemia and hemorrhage. b. Interruption or impairment of the placental blood circulation as a result of hemorrhage, vaso-spasm, thrombosis, lowering of the blood pressure, necrosis, and inflammation of endometrium and placenta. c. General convulsion of the body. d. Severe gastro-enteritis with vomiting and diarrhea. e. Irritation of automatic and peripheral nerves leading to uterine contraction. f. Direct transmission of the poison from the maternal through the placenta into the fetal circulation, thus damaging the fetus (Legal Medicine by R.H. Gradwohl, 1954, p. 812). Drugs Commonly

Used for Abortion:

a. Drugs acting directly on the uterus: (1) Emmenagogues: Emmenagogues are substances which increases the menstrual flow. The manner it promotes menstrual flow may be its direct effect on the uterus or indirectly by increasing bodily tone. (a) Direct Emmanagogues — These are substances which act directly on the uterus or on the nervous system in close relation to it. Examples: Ergot Potassium permanganate Apiol Aloes Pennyroyal Tamsy Cantharides Borax ( b ) Indirect Emmenagogues — These are substances which induce or increase menstrual flow by promoting and building the health of the person as a whole. Indirect Emmenagogues may be Classified as: i. Tonic — as iron, arsenic, strychnine. ii. Hematinics — as iron, copper, liver extracts. iii. Purgative — as magnesium sulfate, castor oil.

564

LEGAL MEDICINE (2) Ecbolics: Ecbolics are substances which when taken cause death or expulsion of the product of conception by stimulation of the uterine muscles. The Most Common Ecbolics are: (a) Ergot ( b ) Quinine (c) Pituitary Extract (d) Lead and Mercury

b. Drugs acting reflexly through the genito-urinory tract: These are drugs which produce irritation of the genitourinary tract and reflexly incite uterine contraction. Large dosage of the drug may cause severe inflammatory changes in the kidney and may cause uremia due to suppression of its function. Diuretics may also cause reflex contraction of the uterus but in a very mild way. The following drugs may act on the genito-urinary tract and may reflexly make the uterus to contract: (1) Oil of Pennyroyal ( 2 ) Oil of Tamsy ( 3 ) Oil of Turpentine c. Drugs acting reflexly through the gastro-intestinal tract: These are drugs whose principal site of action is the gastrointestinal tract but may cause uterine contraction due to its reflex action. The following drugs may fall under this category: ( 1 ) Castor oil ( 2 ) Magnesium sulfate ( 3 ) Croton oil

(4) Gamboge ( 5 ) Aloes ( 6 ) Elatrium

d. Drugs having poisonous effects in the whole body: These are drugs whose manner of action is not localized in certain tissues or organs but in the whole body. To this group are the animal, vegetable and mineral irritant poisons. 4. By Surgical Intervention: This is a method of abortion by the application or the use of instrument by gynecologist or by surgeon. Surgical intervention may be: a. Dilatation and curettage. b. Surgical abdominal route (hysterolaparotomy). 5. Modern methods of inducing or procuring abortion: a. Amniocentesis — Intrauterine injection of hypertonic saline or glucose solution (20% saline or 50% glucose). The needle is

ABORTION

565

inserted in the abdominal wall or vaginal route. This method is applied when pregnancy is beyond 2 months. Expulsion of the uterine content usually occur 24 to 48 hours after injection, b. Vacuum suction (commonly known as menstrual regulation) may be applied through the cervix. The suction apparatus will create a negative pressure of 0.4 — 0.6 kg. per cm. sufficient to detach and brake up the products of conception. The procedure is quite simple and usually applied to 12 — 14 weeks of pregnancy. Complications of Abortion: 1. Immediate Untoward Effects: a. Shock: The shock may be due adjacent organ, like the vessels. The injury may ments or the application

to the laceration of the uterus or the bladder, rectum, intestine or blood be due to the introduction of instruof hot fluid or corrosive substances.

No definite autopsy findings may be seen, except the presence of the gravid uterus, remnants of the fetus and placenta, and the laceration or perforation. Secondary shock may develop later and may be due to hemorrhage, infection or corrosions. b. Hemorrhage and Anemia: Occasionally, big pelvic vessels are injured or failure of the uterine wall to contract is observed in abortion. The rupture of the blood vessels may be due to the injury of the uterine and vaginal wall of injudicious instrumentation. Adherent placental tissue, infection, presence of foreign bodies and atony of the uterus may cause hemorrhage for failure of the uterine muscles to contract. c. Embolism: (1) Air Embolism: The air may enter the lacerated vessels of the vagina and uterine wall and carried by the blood to the inferior vena cava, heart and block the pulmonary circulation. In cases wherein the foramen ovale is potent, the air may escape pulmonary circulation and block the cerebral circulation. (2) Fat Embolism: The injection of oily fluid or laceration of the adipose tissue may cause the formation of fat emboli in the blood stream which may lodge in the heart, lungs and brain. Fat emboli may be observed in the renal glomeruli, coronary

LEGAL MEDICINE

566

vessels and also in the vessels of the choroid plexus of the brain. (3) Thromboembolism: Injury of the uterine wall may cause the formation of thrombus which may be detached and carried by the circulation to different parts of the body. (4) Bacterial

Embolism:

Infection of the uterus after an abortion may cause lump of bacteria to enter the circulation in the form of an embolus. d. Infection: Pathogenic organism may be introduced into the uterus and produce systemic symptoms. If death occurs, signs of toxemia may be observed at autopsy. Causes of Death in Infection: (1) Rapid development of bacteremia. ( 2 ) Thrombophlebitis of uterine, pelvic and femoral veins with multiple infarctions and abscesses (pyemia). ( 3 ) Bacterial

endocarditis

with

multiple

septic infarctions.

( 4 ) Purulent metritis, parametritis, localized or generalized peritonitis, ileus. (5) Purulent salphingitis, tubal or ovarian abscesses followed by peritonitis. ( 6 ) Diffusely spreading retroperitoneal cellulitis, toxemia and cachexia. e. Poisoning: Abortifacent irritants which may be locally applied may be absorbed into the circulation and produce systemic effects. Lysol, corrosive sublimate, iodine solution are frequently used for vaginal douche and may cause systemic poisoning. f. Vagal inhibition: Sudden dilatation of the cervix due to the introduction of some objects may cause sudden collapse due to reflex inhibition of the vagus nerve. g. Perforation of the bladder or any of the neighboring organs: In the insertion of the uterine sound to determine the position of the uterus or in the process of curretting, the bladder or the other surrounding organs may be perforated ' and which may eventually result to death due to hemorrhage or shock.

ABORTION

567

2. Delayed Untoward Effects: a. Infection: Infection may develop immediately or later on account of septic care. The infection may originate from the vaginal canal or from the blood stream coming from a focus of infection in the body. b. Fistula

Formation:

Communication between the vagina or the uterus with the rectum or bladder may be an after effect of perforation due to instrumentation. c. Sterility: Plugging of the fallopian tubes, infection of the ovaries may cause sterility, d."Pelvic Adhesion: Infection and trauma may cause the uterus or vagina to become adherent to the surrounding organs or tissues. MEDICAL EVIDENCES OF ABORTION: 1. Medical Evidences of Abortion in the Living: a. Presence of external signs of violence in the form of contusions, abrasions, hematoma, open wounds of whatever form on the body surface if induced by general violence. If violence is applied locally in the generative tract, injuries of whatever form or description may be seen therein. b. Examination of the generative tract:

,

( 1 ) Appearance of the external genitalia and vagina may show laceration, contusion, abrasions and other marks of instrumentation. ( 2 ) Examine the external os for softness, tear, and discharge. ( 3 ) Note the size of the uterus, its consistency and location. c. Examination of the instrument used for the presence of blood, placental tissue or fetal parts. d. History — Note the state of health beforehand after abortion. Inquire as to the motive of the abortion and history of having ingested or injected with abortives. e. Signs of previous pregnancy: ( 1 ) Condition of the breasts. ( 2 ) Laxity of the abdominal wall. (3) Paleness of integument. (4) General body weakness. (5) Presence of characteristic lochial discharge and odor.

568

LEGAL MEDICINE

( 6 ) Palpability of the uterus and laceration of the cervix and perineum. f. Examination of the expelled product of conception: (1) Blood examination for maternity and paternity. (2) Marks of instrumentation. (3) Signs of physical violence. ( 4 ) Proof of viability or non-viability of the fetus. ( 5 ) Presence of abortives and other toxic materials in the fetal blood. (6) Presence or absence of malformation. ( 7 ) Completeness of the placenta. (8) Other identifying marks.

A criminally a b o r t e d fetus a b o u t 5 to 6 m o n t h s of i n t r a u t e r i n e life.

g. Laboratory test for pregnancy. h. Testimony of the physician who completed the abortion or of other persons who witnessed the criminal act. 2. Medical Evidences of Abortion in the Dead: Aside from the evidences of abortion in the living which may be found in the dead, the following may be observed at autopsy: a. Evidence of instrumentation: This will include the presence of punctured wounds in the placenta, presence of remnants of the placenta inside the uterine cavity, presence of perforation of the uterus.

ABORTION

569

b. Examination of stomach and its contents: Abortifacent. drugs and other irritants may be found inside the stomach upon chemical examination. It is advisable to submit the whole of the stomach with its contents to a chemical laboratory examination for such determination. c. Examination of the kidneys and other organs for irritants: Like the stomach and its contents, other organs like the kidneys, liver, spleen must be subjected to a qualitative and quantitative chemical examination for the presence of irritant poisons. d. Examination of the uterine contents: Remnant of the product of conception for the following: ( 1 ) Infection. ( 2 ) Stage of pregnancy. ( 3 ) Other complication of abortion. e. Biological test: ( 1 ) Paternity test. ( 2 ) Test for pregnancy. f. Examination of some untoward effects of abortion: (1) Infection, toxemia or bacteremia. ( 2 ) Embolism. (3) Fistulae formation. (4) Pelvic adhesions. THERAPEUTIC ABORTION: Therapeutic abortion is an abortion which the law allows under some specific justifications. Legal Justification to Therapeutic Abortion: Art. 11, N o . 4, Revised Penal Code: Any person who, in order to avoid an evil or injury, does an act which causes damage to another, provided that the following requisites are present: First. That the evil sought to be avoided actually exists; Second. That the injury feared be greater than that done to avoid it; Third. That there be no other practical and less harmful means of preventing it. In the performance of an abortion, Iwo lives are involved, namely, ! the life of the mother and the life of the fetus. One life must be • sacrificed to save the life of another in case of therapeutic abortion.

570

LEGAL MEDICINE

If both lives can be saved in accordance with the present state of medical science, then there is no justification to such abortion, hence the physician must be criminally liable. A physician in performing a therapeutic abortion is doing an act to save the life or to preserve the health of the mother. In so doing, damage is done to the conceived child. The child is deprived of its future existence. The evil sought to be avoided is the danger on the life of the mother if such pregnancy will be allowed to continue. Such evil may be infection, organic condition or abnormality existing on the person of the woman and which under ordinary course of event will cause death. There is no practical and less harmful way of saving the life of the mother other than sacrificing the life of the conceived child. If there are other methods which may save both life, then the abortion cannot be considered justifiable. In the evaluation as to whose life must be spared, it is a common concept that the life of the mother must be preferred than that of the unborn child. A conceived child is not definitely sure of its independent existence while the mother has already manifested real life. Grounds for Therapeutic Abortion: The following conditions have been considered by some authorities to be a justifiable ground for therapeutic abortion: 1. Cardio-vascular conditions as congestive heart failure, auricular fibrillations, repeated hemoptysis, paroxysmal tachycardia. 2. Renal conditions as chronic nephritis, previous eclampsia, pyelitis, tuberculosis. 3. Pulmonary conditions as advanced tuberculosis. 4. Blood condition as severe anemia. 5. Gynecological conditions as refractory chorea gravidarum. 6. Organic nervous conditions as psychosis. 7. Miscellaneous conditions as diabetes, exophthalmic goiter. 8. Hereditary conditions as insanity. Modern diagnostic procedure can determine whether the conceived fetus en utero is suffering from defect or abnormality which may be severed to make independent existence not possible or ample assistance from other person during his lifetime is necessary. New drugs ( L S D , thalidomide, etc.) and non-conventional methods of reproduction ( in vitro fertilization, artificial ovulation ) may lead to the development of an abnormal fetus. If it can be proven

ABORTION

571

that the fetus is abnormal, will it not be a justifiable situation to induce an abortion? If the physician failed to induce abortion and the child born is abnormal, will it not be a ground for civil action against the physician for wrongful life? I . U . D . (intrauterine device) as a method of contraception which allows the fertilization of the egg cell by the sperm cell but prevent the implantation of the zygote into the uterus because of the mechanical device. Abortion is the premature expulsion of the product of conception. If it were so, then I . U . D . is an abortive. Why is it allowed as a contraceptive method and not prohibited like another way of committing an abortion? Is the eminent danger of committing suicide on account of her existing pregnancy be a ground to induce therapeutic abortion to save the life of the woman? Occasionally, on account of her disgrace in society, fear of violent reactions from her parents for the sinful and immoral acts she has committed, or for some other reasons that may be prejudicial to her future life, a woman may attempt in several occasions to commit suicide. In this instance, may a physician institute necessary measures to deliberately terminate the existing pregnancy to save her life? There are divergent decisions on this point. In the case of Hatchard v. State (48 N.W. 380 Wis.) a woman who threatened to commit suicide unless she could be relieved of the child with which she was pregnant does not present such a necessity for the performance of the operation to save the life of the woman. The intention of the law applies only to cases where death of the mother might reasonably be anticipated from natural causes unless the product of conception is destroyed. However, in a case cited by Camp and Purchase (Practical Forensic Medicine, p. 32, 1957), a married woman with unstable character finding herself pregnant, threatened to commit suicide. The physician whom she repeatedly made her threat during her unexpected visits referred her to a psychiatrist who recommended abortion. The operation was carried on by a reputed gynecologist but unfortunately, the patient died of gangrene of the uterus. The coroner did not recommend prosecution because the operation was done to save the life of the mother. Safeguards to be Observed by Physician in Performing Therapeutic Abortion: 1. The lawful abortion must be performed by a licensed physician or surgeon.

572

LEGAL MEDICINE

2. Abortion in order to be justifiable must be performed to save the life or to preserve the health of the mother. But modern advancement of medical science has reduced the number of diseases which will endanger the life and health if pregnancy is allowed to progress to full term. A physician must exercise due diligence in considering a disease or a combination of diseases or conditions as grounds for the therapeutic abortion. 3. Abortion must be performed openly in a hospital to avoid suspicion that it was done for some cause other than to save the life of the mother. Abortion performed in a private clinic wherein there are no sufficient facilities to cope with emergency which may arise in the course of the operation may be a ground for malpractice. 4. It is advisable to have the opinion of other competent physicians as to the justifiability of such therapeutic abortion. The opinion of one might be influenced by prejudice and misjudgment. 5. Enlightened and expressed consent must be obtained from the woman herself if she has no impediment to give consent. It is advisable to have also the consent of the husband, inasmuch as abortion will affect marital relationship. Reasons W h y It Is Difficult to Prosecute Physicians Committing the Crime of Abortion: 1. The crime is performed clandestinely by an intelligent being who is fully aware of his criminal act. 2. The physician has several medical reasons to justify his act. There is no hard and fast rule in medicine. He may claim that there is medical justification to such abortion because the woman is suffering from a disease which might imperil her life if pregnancy will be allowed to progress to full term. 3. In most cases, the products of conception removed which may be utilized as corpus delicti in the crime is lost. 4. The pregnant woman herself is in connivance with the physician and it is quite difficult to let her testify truthfully as to the actual happening. She, herself, is in pari delicto to the crime of criminal abortion. 5. Medical society seems to have a lukewarm attitude in helping the state prosecute the abortionist. Pros and Cons — Restrictive Abortion Law: A. Reason Justifying Restrictive Abortion Law: 1. From the moment of conception life begins to start and destruction of the growing product of conception will be con-

ABORTION

573

trary to the law of mankind. This is in line with the philosophy that God created man and only God can destroy it. B. Reasons for Liberal Abortion Law: 1. Where abortion is illegal, the rich can resort to high-cost and illegal but safe abortion at home or to a pleasure trip abroad combined with an abortion. The poor can only stay at home and face the consequence of high-risk and illegal abortion. This causes discrimination against the poor and favor the rich. It raises the serious issue of justice and equal protection under the law. 2. It is no secret, in countries forbidding abortion under any circumstances, abortion operations continue to exist with very few or non-prosecution. In the Philippines, the draconian and * restrictive abortion law has been accompanied in the recent years by non-prosecution, either of the woman or of the abortionists (In-depth Study on Law and Fertility Behavior: Preliminary Observation by Lee and Bulatao, 1972, p. 40). 3. Statistics has shown that children born as a consequence of denied abortion to terminate unwanted pregnancy are mentally and physically impaired. A n y unsuccessful illegal attempt to cause on her abortion, may cause trauma to the developing product of conception. An overburdened multipara or a single girl without support may cause psychiatric disturbance and the children may be a social welfare problem. The children are abandoned by parents in overcrowded orphanage. 4. A strict anti-abortion law is violative of the right of privacy of a person. The right of privacy means the right of the individual to the possession and control of his own person free from all restraints or interference of others. A woman should have the right to decide whether or not to bear children and that this right includes the right to have an abortion. 5. Modern advances in medical diagnostic procedures can determine whether a developing fetus inside the uterus is suffering from physical abnormalities. Allowing such product of conception to reach full term will cause sufferings on the part of the parents and an overburdened social welfare institution of the government. It is also a factor for the deterioration of the genetic stock if the defective factor is familiar thus making an abnormal stock proliferate further. 6. Recent trend in Central Europe and in America is towards liberalization of their restrictive abortion laws. At present more than 70% of the total world population are living in

574

LEGAL MEDICINE countries where abortion law is liberal. This trend is inconsonance to solve a future problem of an over-populated world.

Religious Consideration of Abortion: As a general rule, all induced abortion are considered sinful, illicit and against the tenets of the Catholic Church even if sanctioned by law. The principal basis is that every human being, even the child in the mother's womb, has the right of existence directly from God and that no human being has the right to destroy it. A conceived child has the right of existence as that of the mother. However, the Catholic Church classified abortion into two main categories for the purpose of determining whether it may be allowable or not: 1. Direct A bortion — Deliberate expulsion of the product of conception. This is never permitted by the Catholic Church even if the purpose is to save the life of the mother. 2. Indirect Abortion — When the expulsion of the product of conception is not the primary objective of an operation to save the life of the mother, but merely incidental or unavoidable to an operation. This type of abortion is qualifiedly permitted to some extent by the Catholic Church. Thus, the abortion which occurred incidental to an operation to suppress hemorrhage or removal of new growth is permissible. Among the Jews, destruction of the fetus for the purpose of saving the life of the mother is not only permissible but obligatory. To the Protestants, abortion is generally considered sinful.

Chapter X X V BIRTH Legal Importance of the Study of Birth: 1. Birth determines personality: Art. 40, Civil Code: Birth determines personality; but the conceived child shall be considered born for all purposes that are favorable to it, provided it be born later with the conditions specified in the following article. Art. 41, Civil Code: For civil purposes, the foetus is considered born if it is alive at the time it is completely delivered from the mother's womb. However, if the foetus had an intra-uterine life of less than seven months, it is not deemed born if it dies within twenty-four hours after its complete delivery from the maternal w o m b . 2. Appearance of a child is a ground for the revocation of donation: Art. 760, Civil Code: Every donation inter vivos, made by a person having no children or descendants, legitimate or legitimated by subsequent marriage, or illegitimate, may be revoked or reduced as provided in the next article, by the happening of any of these events. (1) If the donor, after the donation has legitimate or legitimated or illegitimate children, even though they be posthumous. 3. Proof of live-birth must first be shown before death of the child by the prosecution in the case of infanticide: Art. 255, Revised Penal Code — Infanticide: The penalty provided for parricide (reclusion perpetua to death) in article 246 and for murder (reclusion temporal in its maximum period to death) in article 248 shall be imposed upon any person who shall kill any child less than three days of age. In medicine, birth is the entire delivery of a child with or without its separation from the body of the mother. It is not necessary that the cord should have been cut or the placenta expelled. It is the cessation of the symbolic relation between the mother and the fetus. Birth may be: 575

576

LEGAL MEDICINE

A. STILL-BIRTH: When the child has not breathed or has not shown any sign of life after being completely born. Causes of Still-birth: 1. Immaturity. 2. Congenital diseases or malformation. 3. General debilitating diseases: a. Acute specific infection. b. Toxemia. c. Kidney disease. d. Acute liver disease. e. Septicemia. 4. Local disease of the generative organ: a. Syphilis. b. Ablatio placenta, intra-placental hemorrhage, or extensive infarction. c. Kind of the cord. d. Placenta previa. 5. Accidents in the delivery: a. Disproportion of the birth canal and the fetus. b. Injudicious forcep application. c. Prolapse of the cord or strangulation of the cord. d. Hemorrhage. e. Abnormal presentation. f. Influence of narcotics, anesthesia or intoxicating liquor. g. Puerperal insanity. h. Prolonged labor. i. Hasty parturition. j . Spasm of the larynx, k. Hemorrhage of the cord. 6. Violence, either deliberate or accidental at birth. B. L I V E - B I R T H . In live-birth the child after birth exhibited clear signs of vitality and viability is not necessary. In law, the presumption is every newborn child found dead was born dead. The burden of proof lies on those who declare otherwise. To have a child acquire personality distinct as that of the mother, there must be proof of life after complete separation from the mother's womb.

BIRTH

577

Proofs of Live-Birth: 1. Presence of Heart Action and Circulation: The presence of heart sound when the new-born is examined by means of a stethoscope is a sign of life. Sometimes the pulse is imperceptible by palpation especially when the child suffered much during labor. 2. Movement of the Child and Crying: The first instinct of the child after birth is restlessness and crying. Children born after severe and prolonged second stage of labor, may be too weak to move or cry. After a while, they begin to move and later cry upon application of bodily stimulus. 3. Presence of Respiration: Proofs that respiration has taken place: a. There is arching of the chest. b. Fall of the level of the diaphragm: Before birth, the diaphragm reaches the level of the 4th or 5th rib, but if respiration has taken place, it reaches to the level of the 6th or 7th ribs. This test is not conclusive but merely corroborative. c. Expansion of the lungs: Appearance of the lungs if respiration has taken place: (1) The lungs fill the thoracic cavity and overlapping the heart and thymus gland. (2) The lungs are voluminous, with rounded edges and pinkmottled color. (3) The surface is covered with mosaic of expanded air vesicles, giving a marble appearance. (4) On pressure, they crepitate, and on section they exude froth. Appearance of the lungs before respiration has taken place: (1) The lungs are found at the back of the thoracic cavity behind the heart and thymus gland. (2) The lungs are smooth, small, of a uniform dark blue-red color, with sharp edges and present the appearance of a piece of liver. (3) When squeezed between the finger and thumb they do not crepitate. (4) On section they appear solid and exude blood but not froth.

LEGAL MEDICINE

578

Hydrostatic Test (Fodere's Test; Static Test): Hydrostatic test is one of the tests to determine whether respiration took place on a newborn child before death. This test is based upon the principle that the specific gravity of the lungs becomes less as a result of the introduction of air in the air passages and air sacs. Procedure of the Test: Remove the entire lungs from the thoracic cavity and immerse them in water en bloc. If it floats, it shows that air has been driven in and the child has breathed; but if it sinks, the air sacs are not expanded and therefore breathing has not yet taken place. The lung is cut in small pieces and again placed in water. If it floats, air has entered into the air sacs. Value of the Test: The hydrostatic test is not conclusive that respiration took place when it is positive (when the lungs float) or when it is negative (when the lungs did not float), because there are several fallacies attached to the test. However, it is corroborative to other existing evidences. Fallacies of the Hydrostatic Test: a. Unexpanded lung may float if the child is subjected to artificial respiration or if gases due to putrefaction are present, even if the child is born dead. b. The child may have respired or breathed before it is completely born if the head is at the external os, or if the head protrudes on the outlet in head presentation, but dead at birth. c. The child may have breathed, but the lungs may not float on account of disease (atelectasis), or from' imperfect respiration, or on absolute persistency of foetal condition. d. The child may utter audible cry while inside the uterus or in the vagina. In cases of vagitus uterinus, the child is usually born dead but the lungs are perfectly expanded. To differentiate a naturally expanded lung from an artificially expanded lung, it is necessary to know the level of the diaphragm. If due to natural breathing, the level of the diaphragm reached the level of the 6th or 7th rib, while if artificially expanded, it may reach only the 5th rib. To differentiate whether the floating of the lungs is due to putrefaction, note the color, consistency and condition of the bubbles. In putrefaction, the lung is green, soft with bubbles at edges, while a naturally expanded lung is bright vermillion in color,

BIRTH

579

mottled appearance, bright-red alternating with bluish patches with air cells on surface in groups of four. When

is Hydrostatic Test Not Necessary:

Hydrostatic test is no longer necessary in the following instances because of the presence of stronger proofs of live-birth or still-birth. a. When the fetus is born less than 180 days of intrauterine life. b. When the fetus is a monster which is not capable of living a separate existence. c. When the umbilical cord is separated and the umbilicus is cicatrized. d. When the stomach on dissection contains coagulated or halfcoagulated milk as a result of digestion. e. When the fetus shows signs of intrauterine maceration. Differences Between Unexpanded and Expanded Lung Unexpanded

Lung

Expanded

a. Volume is small. b. Edges are more or less sharply projected beyond the thymus and heart. c. Color is dark brown or uniform purplish gray with no mottling.

d. Feels solid. e. On section, a blood exudes.

Lung

a. Volume is greater and fills the chest cavity. b. Edges are rounded and cover the thymus and heart. c. Color is bright vermillion and lungs show mottled appearance with bright red part alternating with bluish patches. d. Feels spongy and crepitant.

little

e. On section, blood stained frothy serum exudes on squeezing.

f. Absolute weight is 450-650 gms. g. Hydrostatic test — Negative.

f. Absolute weight is 9001,000 gms. g. Hydrostatic test —Positive. h. Microscopic examination shows expanded air sacs and with blood vessels engorged.

very

h. Microscopic examination shows collapsed air sacs.

4. Examination of the Stomach and Intestine: a. On opening the stomach of a still-born child, it contains only mucous, but after respiration, the stomach will contain mucous, air bubbles and saliva.

580

LEGAL MEDICINE The normal content before birth is albuminous substances and mucous. The presence of sugar, starch or milk indicates live-birth. b. Stomach-Bowel Test or Floatation Test or Breslau's Second Life Test: Ligate the cardiac end of the stomach and the lower end of the intestine and remove. Place the whole mass of organs in water. If the organs float, breathing has taken place. Dip the organs under water and open the stomach and intestine. Note the liberation of air bubbles going up the surface of the water, if breathing has taken place.

5. Changes in the Middle Ear (Wredin's Test): The middle ear of a child before birth is filled with gelatinuous, embryonic connective tissue. This disappears after the birth of the child. 6. Condition of the Skin: The skin of a newly born infant is bright red in color. This gradually changed to a lighter one. In 2 to 4 days, it darkens to brick-red, but may be yellow due to physiological jaundice. The normal appearance of the skin appears after a week. 7. Marks of Violence: Violence applied to a child while living will show some degree of vital reactions. Such reaction will not be seen in cases of still-birth. 8. Changes in the Umbilical Cord: The portion of the cord attached to the skin of the child begins to shrink and dry within 12 to 24 hours. There is inflammatory redness of the base from 36 to 48 hours. By the second or third day it shrivels up, mummifies, and falls on the fifth or sixth day. The healed cicatrix is seen within 10 to 12 days. Pulsation seen or felt in the cord indicates live-birth. In 12 to 24 hours it dries and slowly becomes shrivelled in 3 to 5 days%ind the cord separates with cicatrization of the wound. The surrounding skin shows capillary congestion. The ring of inflammation around the site is an evidence of life of at least 36 hours duration. The wound heals in 2 or 3 days and the scar develops within 10-12 days. Prolonged soaking of mummified umbilical cord can cause it to swell but not to return to its natural condition. If the child and the cord are submerged in a body of water after birth the cord will undergo liquifaction on account of decomposition.

BIRTH

581

9. Condition of the Heart and Blood Vessels: Ductus arteriosus closes within 3 days. Ductus venosus also closes within 3 days after birth. The foramen ovale may close on the second or third month. Proof of Live-Birth can be deduced in the following: 1. Well-developed signs of breathing. 2. Presence of air or food in the stomach. 3. Changes having taken place in the region of the umbilicus. If Born Alive, H o w Long Did the Child Survive? It is not possible to determine the exact length of time the child has lived after birth, but an approximate idea may be formed after consideration of the following points: 1. Changes in the Skin: At birth the body of the new-born child is bright-red in color and covered with vernix caseosa which may be present up to two days. The normal color of the skin is resumed after a week's time. The exfoliation of the skin in the abdomen occurs on the first three days after birth. 2. Presence of Caput Succedaneum: The caput succedaneum when present shows that the child was born with head presentation. There are color changes in the course of its absorption. The caput used to last up to the seventh day. 3. Changes in the Umbilical Cord: The mummification of the cord does not occur if the child is submerged in water after birth. An already mummified cord may again become soft after continuous soaking in water. 4. Changes in the Circulation: The umbilical artery begins to contract at about ten hours after birth. The umbilical vein and the ductus venosus obliterate on the 4th or 5th day and the ductus arteriosus on the 3rd day. The foramen ovale closes on the second or third month. Signs of Maturity of the Child at Birth: 1. Length of the fetus — 50 centimeters. 2. Weight - 3.0 kilos. 3. Lanugo hair almost disappeared. 4. Limbs and body plump. 5. Face lost its wrinkles. 6. Skin covered with vernix caseosa. 7. Head covered with hair about 2 inches long.

582

LEGAL MEDICINE

8. Nails project from the fingers but the toe-nails reach only to the end. 9. One or both testes are in the scrotum, or labia have close the vulva. 10. Lower end of femur may show center of ossification about 0.6 cm. in diameter. (Gradwohl's Legal Medicine by Camps, 3rd ed., p. 416).

Chapter XXVI / I N F A N T I C I D E (Neonaticide) InpaHticide is the killing of a child less than three days old. Art. 255, Revised Penal Code, Infanticide: The penalty provided for parricide in article 246 and for murder in article 248 shall be imposed upon any person who shall kill any child less than three days of age. Jf the crime penalized in this article be committed by the mother of the child for the purpose of concealing her dishonor, she shall suffer the penalty of prision correccional in its medium and maximum periods, and if said crime be committed for the same purpose by the maternal grandparents or either of them, the penalty shall be prision mayor. ' If the~killing was done by direct ascendants, or either of the same as that of__parricide. any other person, the penalty is

the parents, grandparents or other them, the penalty to be imposed is However, if the killing was done by the same as that of murder.

Lenient penalty is to be imposed when the killing was done by the mother or by the maternal grandparents, or either of them for the purpose of concealing her dishonor. Problems: lylnfancy is the period in the life of a child from birth up to one year.. Thereafter, it is called _childhood. This distinction is made on account of physiologic changes undergone by the child during infancy and childhood. Why is the crime of infanticide applied only to the killing of less than a three-day-old infant rather than within the first year of the life of the child? 2. During the process of delivery when the head and neck of the child are already out of the birth canal and the child has breathed spontaneously through the lungs, the child was deliberately put to death before expulsion of the other parts of the body. What crime was committed by the offender? The child was not yet capable of independent existence inasmuch as placental circulation was still maintained. Ideally it is foeticide, but it is not a crime in the Philippines. Can it be considered infanticide? 3. A child was born less than 7 months of uterogestation. Under ordinary condition, considering prematurity and underdevelop583

584

LEGAL MEDICINE

ment, there is more chance for the child to die, but with modern neonatal management the child had all the chances to live. A few hours after birth the child was deliberately killed. Is the killing a case of infanticide? According to Art. 41, Civil Code . . If the foetus had an intra-uterine life of less than seven months, it is not deemed born if it dies within twentyfour hours after its complete delivery from the maternal womb", and birth determines personality. Can the crime of infanticide be committed on someone who is not yet a person as contemplated by law? Motives for Committing Infanticide: 1. To conceal dishonor especially when there is no reason for her to give birth to a child. She may be single, widowed, estranged from the husband or living separately where access is not possible. 2. Financial reason — An added member to the family may cause increased financial burden. Care of the child may prevent the mother to pursue her means of livelihood. 3. Desired number of children has already been attained. Infanticide is made as a substitute for ineffective family planning. 4. Congenital abnormality of the child. 5. Parent is suffering from mental abnormality. 6. Belief that the child will bring bad luck to the family.

Criminological Characteristics: 1. It is most often committed by the mother. 2. The criminal act is almost always committed in the home. 3. The crime scene shows no manifest disturbance, no witnesses and no noise or outcry. 4LThe trauma applied is so minimal that when applied to an adult it will not even produce lethal effect. 5. A newly born child found dead was born dead. The burden of proof that a living child has been killed is placed on the prosecution. Type of Evidences in Infanticide: In cases of alleged infanticide the prosecution must show the following proofs: 1. That the child was born alive. 2. That the child was deliberately killed. 3. That the child killed was less than three days old.

INFANTICIDE

585

H o w the Crime of Infanticide is Committed: The crime of infanticide may be committed in two ways^JKimely: 1. By omission or neglect: a. Failure to ligate the umbilical cord: If the umbilical cord is not ligatecUafter it is cut, the child may bleed to death. Fatal hemorrhage may also occur, if the cord is not tightly ligated. ifTFailure to protect the child from heat and cold: The exposure of the child to heat and cold may cause the death of the child without leaving any mark of violence. This is usually done by depriving the child of necessary clothings. Failure to take the necessary help of a midwife or a skilled physician. dr. Failure to supply the child with proper food: The child may be deliberately starved to death. The stomach and intestine must be examined'for the presence of food, e. Failure to remove the child from the mother's discharge which resulted to suffocation. 2. By Commission: a. Inflicting physical injuries: A person with the use of kitchen utensils or any other hard or sharp objects may traumatize a child. b. Suffocation: The face of the child may be pressed into some soft tissues like a bed-sheet or a pillow. c. Strangulation: This is commonly made by placing a tight cord or rope around the neck. Manual strangulation is also common. d. Drowning: The child may be disposed of in a sewerage disposal in a creek, or in a deeper body of water with weight attached to the body to prevent floating. e. Poisoning: Denatured alcohol, tincture of iodine, or any other drugs which form a part of the household-remedies may be administered to the child. A thorough examination of the gastro-intestinal tract for irritation and an examination of the organs and its contents by a toxicologic are necessary to determine the kind of poison and the quantity taken.

586

LEGAL MEDICINE

f. Burning: This form of killing an infant is not common. This may be resorted to with the simultaneous burning of the dwelling place to conceal offense. g. Deliberate exposure to heat or cold: The child may be exposed to direct sunshine or may be placed in a basin of cold water until death. Post-mortem Findings in Cases of Infanticide: 1. Complete examination of the skin surfaces may show presence of marks of physical violence in the form of fingernail marks especially at the neck. There may be other forms as abrasion, contusion, hematoma, or lacerated wounds; ligature or pressure marks on the neck. 2. Examination of the mouth and upper portion of the alimentary tract may show signs of irritation if death is due to poisoning. 3. Laceration or other forms of injury of the upper portion of air passage with deformity of the trachea and larynx. 4. The lungs may show petechial hemorrhages, emphysema, or signs of drowning. 5. There may be fracture of the bones, laceration of the internal organs, cerebral hemorrhages, etc. 6. In cases of poisoning, the organs must be preserved and sent to a competent toxicologist for proper analysis.

Chapter XXVII PATERNITY AND FILIATION Paternity is the civil status of the father with respect to the child begotten by him. Filiation is the civil status of the child in relation to its mother or father (2 Sanchez Roman 952), Legal Importance of Detemining Paternity and Filiation: 1. For Succession: In legal succession, the right of the legitimate children is different from that of the illegitimate children. The law give more rights in the property of the deceased parent to legitimate children. 2. For Enforcement of the Naturalization and Immigration Laws: Naturalized citizens give "ipso facto" Philippine citizenship to their minor children at the time of their naturalization under certain qualifications. Thus, the* minors, in order to avail themselves of the effects of naturalization, must prove that they are legitimate children of the naturalized citizen at the time of naturalization. A minor child of a naturalized or permanent resident alien may be given the right to land into our shores upon proofs that such minor is a legitimate child of a naturalized Filipino or that of a permanent resident alien. Kinds of Children: A. Legitimate Children: 1. Legitimate children (proper). 2. Legitimated children. 3. Adopted children. B. Illegitimate Children: 1. Natural Children: a. Natural children (proper). b. Natural children by presumption. c. Natural children by legal fiction. 2. Spurious Children: a. Adulterous children. b. Incestuous children. c. Manceres children. d. Sacrilegious children.

588

LEGAL MEDICINE A. LEGITIMATE CHILDREN

A legitimate child is one who is born in lawful wedlock, or within a competent time afterwards. 1. Legitimate Children (Proper): Legitimate children (proper) are those who were born in lawful wedlock or within 300 days after the dissolution of marriage. Presumption of legitimacy: Art. 255, Civil Code: Children born after one hundred and eighty days following the celebration of the marriage, and before three hundred days following its dissolution or the separation of the spouses shall be presumed to be legitimate. Against this presumption no evidence shall be admitted other than that of the physical impossibility of the husband's having access to his wife within the first one hundred and twenty days of the three hundred which preceded the birth of the child. The physical impossibility may be caused by: (1) The impotence of the husband; ( 2 ) The fact that the husband and wife were living separately in such a way that access was not possible; and (3) By the serious illness of the husband. Requisites of the presumption: a. There is a valid marriage. b. The birth of the child took place after 180 days following the celebration of marriage or within 300 days following its dissolution or separation of the spouse. c. There is no physical impossibility of the husband having access to the wife during the first 120 days of the 300 days preceding the birth of the child. The presumption of legitimacy under Art. 255, Civil Code is conclusive: The presumption of legitimacy above-mentioned (Art. 255, Civil Code) is conclusive because: a. Sec. 4(a) of Rule 131 of the Rules of Court is a repetition of Art. 255 of the Civil Code. Sec. 4, Rules of Court — Quasi-conclusive presumptions of legitimacy: ( a ) Children born after one hundred eighty days following the celebration of marriage, and before three hundred days

PATERNITY AND FILIATION

589

following its dissolution or the separation of the spouses shall be presumed legitimate. Against this presumption no evidence shall be admitted other than that of physical impossibility of the husband's having access to his wife within the first one hundred and twenty days of the three hundred which preceded the birth of the child. b. The presumption in Art. 255, Civil Code is not qualified, while the presumptions in Art. 257, 258 and 259 of the same code qualified the presumption to be "prima facie" which infer that the presumption under Art. 255 is conclusive. Children born after 180 days following the celebration of marriage: a.JExample: A and B were married in Jan.l, 1980. A child was born after 180 days following their marriage. If there is no impossibility of access between A and B, the child is conclusively presumed to be legitimate. h/Reason for the presumption: The law considers that in order that a child beviable, it must have at least 180 days of development from fertilization to birth. Ar child born before 180 days after the celebration of marriage is not viable, it must have been brought about by a sexual act which occurred before the celebration of marriage. A child born before 180 days following the celebration of marriage is premature and underdeveloped to withstand external environment. - Child born within 300 days following its dissolution or separation of spouse: a. Example: A and B are legally married. On Jan. 1,1980, B, the husband died. 230 days after A became a widow, a child was born. The child is conclusively presumed to be legitimate insofar as the deceased husband provided there was no physical impossibility of access between A and B during the latter's lifetime. b. Reason for the presumption: The law based on medical science considers 300 days as the length of uterine development of a child. Normally, it is 280 days as the period of utero-gestation. But, it is not uncommon for pregnancy to be prolonged up to 300 days or even more, although there may be signs of post-maturity. To include those

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children who may be born more than the average duration of utero-gestation, the law extended the limit to 300 days. M was married with X on September 28, 1944. The husband, M, died on October 11, 1944. A child was born on April 24, 1945 or 208 days after the celebration of marriage and within 300 days following its dissolution. There being no showing that M is impotent, the court held that the child born is conclusively legitimate (Menciano v. Neri San Jose, G.R. No. L-1967, May 1951). Only evidence sufficient to rebutt the above presumption: That there is "physical impossibility of the husband's having access to his wife within the first one hundred and twenty days of the three hundred days which preceded the birth of the child." Example: (1) A and B were married and 7 months after marriage a child was born. Considering that each month has thirty days, the child is considered legitimate if, anytime three months before up to one month after the marriage, there was possibility of access between A and B. (2) A and B were legally married. Six months after A became a widow, a child was born. The child is presumed to be legitimate if B, the husband had access with his wife during the four months period before his death. If during the whole period of four months before he died he was living in a far distant place whereby access was not possible, then the child is not his own. .Causes of physical impossibility: (1) By the impotence of the husband. (2) By the fact that the husband and wife were living separately, in such a way that access was not possible. (3) By the serious illness of the husband (Art. 255, Civil Code). The impossibility of access must not be construed in its literal sense. It means inability to perform sexual intercourse. Impotency of the husband must be present during the first 120 days of the 300 days preceding the birth of the child. It must be an absolute impotency and not a relative one. It must be complete not partial. The serious illness suffered by the husband must occur during the period of conception of the child. Serious illness means such condition which will prevent the husband to perform sexual act with his wife. The fact that the husband is suffering from tuberculosis does not prevent him from performing the

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carnal act. The reputation of the tuberculosis towards eroticism (sexual propensity) is probably more dependent upon confinement than the consequences of the disease (Andal V Macaraig, G.R No. L-2474). Art. 258, Civil Code: A child born within one hundred eighty days following the celebration of marriage is prima facie presumed to be legitimate. Such a child is conclusively presumed to be legitimate in any of these cases: (1) If the husband, before the marriage, knew of the pregnancy of the wife; (2) If he consented, being present, to the putting of his surname on the record of birth of the child; and (3) If he expressly or tacitly recognized the child as his own. Prima facie means the presumption is true and correct unless it can be shown by other proofs to the contrary. A husband who knew of the existence of pregnancy of his wife before marriage and still married her, impliedly shows that he is the author of such pregnancy. If he is not responsible for such pregnancy, then he waived his right to contest its legitimacy. The consent of the husband to place his surname on the record of birth of the child is also a recognition that the child is his own. A man with a normal sense will not allow his surname be attached to one with a blood foreign to his. Expressed recognition may be made by the father of the child by telling other people that the child is his legitimate child. Tacit or implied recognition may be made by inference from the acts of the husband wherein recognition may be deduced. Allowing the child to live in the conjugal dwelling, giving the necessary support, furnishing the child of his daily needs imply that the child is his own. Recognition shall be made in the record of birth, a will, a statement before a court or record, or in any authentic writing (Art. 278, Civil Code). Art. 256, Civil Code: The child shall be presumed legitimate, although the mother may have declared against its legitimacy or may have been sentenced as an adulteress. Reasons for the provision: a. The status of a child must not be left at the mercy or the passion of the parents. A wife may while in the fit of her

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anger declare that the child is not that of the husband although it is not true. b. The husband may connive with the wife and let her declare the child as illegitimate and thus decrease his right over the properties of the husband. c. Between legitimacy and illegitimacy, the law is in favor of legitimacy. A child must not be punished by the wrongful acts of his parents. Presumption of illegitimacy based on ethnic reasons: Art. 257, Civil Code: Should the wife commit adultery at or about the time of the conception of the child, but there was no physical impossibility of access between her and her husband as set forth in article 255, the child is prima facie presumed to be illegitimate if it appears highly improbable, for ethnic reasons, that the child is that of the husband. For the purposes of this article, the wife's adultery need not be proved in a criminal case. Example: A and B, both white-Americans were legally married. During the period of conception for the child C, the wife had an illicit relation with X, a negro. The child born has dark skin, wiry and curly hair and with thick lips. There is no ancestor in A and B who is negro. The child C is prima facie presumed illegitimate. Marriage of women within 300 days following death of husband, annulment of marriage or other forms of marital dissolution: Art. 84, Civil Code: No marriage license shall be issued to a widow till after three hundred days following the death of her husband, unless in the meantime she has given birth to a child. The Revised Penal Code penalizes a widow re-marrying before the expiration of 301 days following her widowed: Art. 351, Revised Penal Code — Premature marriages: A widow who shall marry within three hundred and one days from the date of the death of her husband, or before having delivered if she shall have been pregnant at the time of his death, shall be punished by arresto mayor and fine not exceeding 500 pesos. The same penalties shall be imposed upon any woman whose marriage shall have been annulled or dissolved, if she shall marry before her delivery or before the expiration of the period of three hundred and one days after the legal separation.

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The purpose of the above provisions of law is to prevent disputed paternity of the child born after the subsequent marriage celebrated within the three hundred days following the dissolution of the first marriage. However, where deceased husband was proven to be impotent or sterile, the widow who contracted a premature marriage was not held criminally liable (People v. Masinsin, C.A. G.R. 9157, June 1953). Presumption of legitimacy if the widow marries within three hundred days following the death of the husband: Art. 259, Civil Code: If the marriage is dissolved by the death of the husband, and the mother contracted another marriage within three hundred days following such death, these rules shall govern: (1) A child born before one hundred eighty days after the solemnization of the subsequent marriage is disputably presumed to have been conceived during the former marriage, provided it be born within three hundred days after the death of the former husband; ( 2 ) A child born after one hundred eighty days following the celebration of the subsequent marriage is prima facie presumed to have been conceived during such marriage, even though it be born within the three hundred days after the death of the former husband. Example of N o . ( 1 ) : A widow married 100 days after the death of her first husband. A child is born 175 days after the celebration of the second marriage. The child is disputably presumed to be legitimate insofar as the first husband because the child is born within 180 days following the celebration of the second marriage and within 300 days after the death of the first husband. Example of N o . ( 2 ) : A widow married 80 days after the death of the first husband. A child is born 200 days after the celebration of the second marriage. The child born is prima facie presumed to be legitimate child of the second husband because the child was born after 180 days following the celebration of the second marriage. Flaw of the presumption: A widow married 50 days after the death of the first husband. A child was born 200 days following the celebration of the second marriage. Following the provision of the presumption, the child

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is legitimate insofar as the second husband. But the child is born only 250 days after the death of the first husband. It is possible that the widow was pregnant for one month at the time of death of the first husband, yet the presumption made the child prima facie legitimate as that of the second husband. Duty of a woman after annulment of marriage when she becomes a widow and pregnant: Art. 260, Civil Code: If after a judgment annulling a marriage, the former wife should believe herself to be pregnant by the former husband, she shall, within thirty days from the time she became aware of her pregnancy, notify the former husband or his heirs of that fact. He or his heirs may ask the court to take measures to prevent a simulation of birth. The same obligation shall devolve upon a widow who believes herself to have been left pregnant by the deceased husband, or upon the wife who believes herself to be pregnant by her husband from whom she has been legally separated. —. The Revised Penal Code impose penalty for simulation of birth and usurpation of the civil status: Art. 347, Revised Penal Code — Simulation of births, substitution of one child for another and concealment or abandonment of a legitimate child: The simulation of births and the substitution of one child for another shall be punished by prision mayor and a fine of not exceeding 1,000 pesos. The same penalties shall be imposed upon any person who shall conceal or abandon any legitimate child with intent to cause such child to lose its civil status. Any physician or surgeon or public officer who, in violation of the duties of his profession or office, shall cooperate in the execution of any of the crimes mentioned in the two next preceding paragraphs, shall suffer the penalties therein prescribed and also the penalty of temporary special disqualification. Usurpation of Civil Status: Art. 348, Revised Penal Code: The penalty of prision mayor shall be imposed upon any person who shall usurp the civil status of another, should he do so for the purpose of defrauding the offended party or his heirs; otherwise, the penalty of prision correccional in its medium and maximum periods shall be imposed.

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Child born after 300 days following dissolution of marriage or separation of the spouse: Art. 261, Civil Code: There is no presumption of legitimacy or illegitimacy of a child born after three hundred days following the dissolution of the marriage or the separation of the spouses. Whoever alleges the legitimacy or the illegitimacy of such child must prove his allegation. 2. Legitimated Children: Legitimation is defined as a remedy or process by which a child born out of lawful wedlock and are therefore considered illegitimate are by fiction of law considered legitimate by subsequent valid marriage of the parents. Art. 270, Civil Code: Legitimation shall take place by the subsequent marriage between the parents. Art. 272, Civil Code: Children who are legitimated by subsequent marriage shall enjoy the same rights as legitimate children. Children can be legitimated: a. Natural children (proper): Natural children are those born outside lawful wedlock of parents who, at the time of the conception of the former, were not disqualified by any impediment to marry each other (Art. 269, Civil Code). Example: A and B are both single and are of age. There are no other impediments for them to marry one another. Although unmarried, they had sexual intercourse and as a result of which a child is born. The child is considered to be natural. If the child is acknowledged by the parents to be thenown, then the child becomes an acknowledged natural child, and if the parents after acknowledgement subsequently married one another, the child becomes a legitimated child. Requisites for legitimation of natural child (proper): a / T h e child must be natural. b/The child must be acknowledged by both parents before marriage. c^There must be subsequent marriage of the parents.

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3. Adopted Children: Adoption is defined as the act or proceeding by which relations of paternity and filiation are recognized as legally existing between persons not so related by nature. The purpose of adoption is to establish a relationship of paternity and filiation and to afford persons who have no child of their own consolation of having one by legal fiction. The child wherein paternity and filiation is established is an adopted child and with all the legal rights as a legitimate child in relation to the adopting parents. Persons who may be adopted: a. The natural child, by the natural father or mother; b. Other illegitimate children, by the father or mother; c. A step-child, by the step-father or step-mother Civil Code); and

(Art. 338,

d. A n y person, even if of age, provided the adopter is sixteen years older (Art. 337, Civil Code). Persons who cannot be adopted: a. A married person, without the written consent of the other spouse; o. An alien with whose government the Republic of the Philippines has broken diplomatic relations; and c. A person who has already been adopted (Art. 339, Civil Code). Persons who may adopt: a. Every person of age, who is in full possession of his civil rights. (Art. 334, Civil Code) Persons who cannot adopt: a. Those who have legitimate, legitimated, acknowledged natural children or natural children by legal fiction; b. The guardian, with respect to the ward, before the final approval of his accounts; c. A married person, without the consent of the other spouse; d. Non-resident aliens, e. Resident aliens with whose government the Republic of the Philippines has broken diplomatic relations, and f. Any person who has been convicted of a crime involving moral turpitude, when the penalty imposed was six months' imprisonment or more (Art. 335, Civil Code).

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B. ILLEGITIMATE CHILDREN Illegitimate children are those who were born out _of lawful wedlock or after a competent time after its dissolution. 1. Natural Children: a. Natural

Children (Proper):

Natural children are those born outside wedlock of parents who, at the time of the conception of the former, were not disqualified by any impediment to marry each other (Art. 269, Civil Code). b. Natural Children by Legal Fiction: Natural children by legal fiction are those children born of void marriages or those born of voidable marriages after the decree of annulment. Example: A was married with B, his o w n step-daughter. The marriage is void. A child was born thereafter. The child is natural by legal fiction. c. Natural Children by Presumption: Natural children by presumption are those natural children acknowledged by the father or the mother separately if the acknowledging parent was legally competent to contract marriage at the time of conception (Borres and Barza v. Mun. of Panay, 42 Phil. 643). Example: A, a married woman who is living separately from his husband, had an illicit relation with B. The child born has been recognized by B to be his own. The child is considered to be natural by presumption. 2. Spurious Children: Illegitimate children who are not natural are considered spurious. Spurious children may be: a. Adulterous Children: These are children conceived in an act of adultery or concubinage. b. Sacrilegious Children: These are children born of parents who have been ordained in sacris. In civil law, there is no such kind of illegitimate children because a priest or a nun can marry. There is no impediment in law for them to marry. It is only the regula-

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tion of the church that prohibits it. In the Philippines, there is separation between the church and the state. c. Incestuous Children: These are children born by parents who are legally incapable of contracting valid marriage because of their blood relationship as marriage between brothers and sisters, father and daughter, etc.. d. Manceres: These are children conceived by prostitutes. It is very difficult to determine the father because of the nature of the business. Civil Liability of Persons Guilty of Crimes Against Chastity: Art. 345, Revised Penal Code: Persons guilty of rape, seduction or abduction shall also be sentenced: 1. To indemnify the offended woman. 2. To acknowledge the offspring, unless the law should prevent him from so doing. 3. In every case to support the offspring. The adulterer and the concubine in the case provided for in articles 333 and 334 may also be sentenced, in the same proceeding or in a separate civil proceeding, to indemnify for damages caused to the offended spouse. In cases of multiple rape, when three persons, one after another raped a woman, the offenders may not be required to recognize the offspring as it is impossible to determine the paternity of the child (People v. Pedro de Leon, et. al, G.R. No. L-2094). If the woman abused is married, the child born subsequently cannot be recognized by the offender (People v. Sanico, C.A. 46 O.G. 98) and if the woman who was raped was married and pregnant, the child born thereafter cannot be recognized and support cannot be demanded from the offender. The reason behind is that to allow the offender to give support and recognize the offspring will allow the offender to periodically visit the home of the offended party in order to comply with his duty and it will enhance disturbance in the family who are living in peace and tranquility (U.S. v. Yambao, 4 Phil. 204).

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EVIDENCE OF PATERNITY A N D FILIATION A. Medical Evidences: Is Parental Likeness: Heredity transmits traits and characteristics from parents to the offsprings. There must be some gross manifestation of the children which may be in common with the father. The following points may be considered by the examining physician to determine physically whether paternity and filiation exists between persons in question: a. b. c. di

General feature Manner of gesture Personal peculiarities Personal deformities

p. Gait, speech, and movement fr Color and texture of the hair gc Color of the eyes K. General built and size

2. Blood Grouping Test: The fact that the blood type of the child is a possible product of the parents, does not conclusively show that the child is born by such parents. But, if the blood type of the child is not the possible blood type when the blood of the parents are cross-matched, it shows definitely that the child is not that of the husband. A positive result is not conclusive, but a negative result is conclusive. 3. Evidences from the Mother: a. Proofs of Previous Delivery: The supposed mother may be subjected to an examination to determine the presence of signs of previous childbirth and which are compatible with the age of the child. b. Proofs of Physical Potency and Fertility: Although it is difficult to determine the physical potency in women inasmuch as a woman is a passive subject to a sexual act, the woman may be manifesting some acquired or congenital defect wherein impotency may be inferred. Atresia of the vaginal canal, imperforate hymen, etc. may be present. Fertility may be inferred from the presence of other pregnancies and the absence of organic abnormalities of the generative system. c. proof of Capacity to have Access with the Husband: A general physical examination of the woman is necessary to determine whether she is physically capable of having sexual intercourse with her husband.

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4. Evidences from the Father: a. Proof of Physical Potency and Fertility: Medical examination must be done whether the husband is capable of erection. A quantitative and qualitative examination of spermatozoa in the seminal fluid is necessary to determine fertility. The presence of disease, congenital or acquired abnormalities, etc. may be factors that may bring about impotency or sterility. b. Proof of Access: The physician must determine the health and vigor of the father, the presence of disease, which may bring about his incapacity to perform sexual intercourse. B. Non-medical Evidences: 1. Record of birth in the Civil Registrar, or by an authentic document or a final judgment (Art. 265, Civil Code). 2. Continuous possession of the status of a legitimate child (Art. 266, Civil Code). 3. Any other evidences allowed by the Rules of Court and special laws (Art. 267, Civil Code).

Chapter XXVffl PATERNITY A N D FILIATION ON NON-CONVENTIONAL METHODS OF PROCREATION The standard method of reproduction is the introduction of the male sperm into the generative organ of a female through sexual intercourse followed by fertilization, growth and development of the conceptus and its subsequent delivery. No technical manipulation or medication is employed as it is a physiologic process. However, modern advancement of medicine modified the conventional method as a solution to some specific problems of reproduction. Artificial Insemination and In Vitro Fertilization as a modality of management has gone beyond the experimental stage of procreation and now recognized and used to solve problems. Other methods are still in their experimental stage and whatever problems (medical, legal or moral) that may develop will depend and will be solved in the future. A. ARTIFICIAL INSEMINATION Artificial insemination is a medical procedure by which the semen is introduced into the vagina by means other than copulation for the purpose of procreation. Some physicians consider the term "therapeutic insemination" as a more suitable term for the procedure (Sagall). Artificial Insemination Classified According to the Source of Semen: 1. A . I . H . (Artificial Insemination Homologous, Artificial Insemination Husband) — When the sperm comes from the husband. 2. A . I . D . (Artificial Insemination Donor, Artificial Insemination Heterologous) — When the sperm comes from a donor other than the husband. 3. A . I . H . D . (Artificial Insemination Husband Donor, Polled Donor Semen) — When the donor semen comes from the husband and a third party donor. Medical Indications for Artificial Insemination : 1.

For A.I.H.: a. When the deposition of the husband's semen within the vagina is by coitus, this is prevented because of anatomic or psychologic 601

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LEGAL MEDICINE difficulties on the part of either husband or wife;

b. When the infertility is due to poor motility, paucity or otherwise defective sperm cells or too small a volume of the ejaculant. 2. ForA.I.D. or A.I.H.D.: a. Absolute male sterility (Azoospermia); b. Oligospermia — Less than 10 to 15 million sperm per cc. of semen with infertility of long duration; c. Hereditary disease in the husband making propagation inadvisable for eugenic reason; or d. An Rh blood incompatibility is expected to cause an abnormal baby in situations where other techniques to overcome such incompatibility are not applicable. Selection of Donor of Semen: In A . I . D . the selection of the appropriate donor of semen resides in the physician. If the child born becomes defective which can be traced from a physician's negligence or carelessness in choosing the donor, the physician may be held liable. The following are the obligations imposed on a physician in the selection of donors: 1. Proper screening must be made of the donor including chromosomes for genetic defects. 2. The donor must have the racial characteristic and physical proportion as those of the husband and wife and the blood type must be compatible with A . B . O . and Rh genotype of the wife. 3. The physician must ensure that the identity of the donor is not known to the parents and vice versa. 4. Complete physical examination with standard test for syphilis and gonorrhea is obtained not more than one week before the seminal fluid is collected. Precautions to be Observed by the Physician in Performing Artificial Insemination: 1. The physician should make certain by reasonable testing that the procedure is medically indicated for the couple who has requested conception by this method. The husband is infertile and such condition is permanent. 2. The physician should establish by proper evaluation that the couple requesting artificial insemination is emotionally stable and psychologically suited for this type of parenthood, which carries with it the responsibilities of the very presence of the child. This

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will constantly attest to both partners and the husband's incapacity for biologic fatherhood. 3. The physician must use all reasonable precautions in selecting the donor; with thorough medical, psychologic and social screening to exclude donor with potential transmissible undesirable traits, features and details. 4. The physician must, under no circumstances except by court order, reveal the fact of artificial insemination or 'the identity of the donor or of the couple to each other or to other persons. 5. The physician must use freshly donated sperm or frozen semen that has been prepared and stored according to currently accepted methods with the source properly identified. 6. The insemination procedure must be performed by the physician in accordance with the currently accepted techniques. 7. Full and valid consents and releases should be obtained in writing from all parties involved, and each consent must be an "informed consent," particularly on the part of the prospective parents, who should be fully appraised of the psychologic and legal complication and the possibility of the birth of a defective child (Legal Medicine Annual 1973 by C. Wecht, p. 483). Status of the Child Born by Artificial Insemination: Artificial insemination as a remedy for reproductive infertility has been developed and recognized recently. The issue as to the status of the children born as a consequence of artificial insemination has never been brought squarely in our court. The following may be the possible status of the child born as a consequence of artificial insemination : 1. In A . I . H . , there is no doubt that the child is a legitimate child of the husband because the semen came from him. No foreign blood is introduced into the family. 2. In A . I . D . , with the consent of the husband, the child born must also be considered legitimate although the fertilization semen is not from the husband. His consent to the artificial insemination may be considered as a waiver to the illegitimate status of the child. Even if the child is considered illegitimate, the child can be adopted by him making the child's status legitimate. 3. In A . I . D . , without the consent or if it is against the will of the husband, the child must be considered illegitimate, specifically a child born because of adultery. This is an intrusion into the conjugal home of a foreign element against the will of the husband. If the child is considered born because of adultery, did the wife commit adultery? Adultery is committed by "having sexual

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intercourse with a man not her husband", but there is no sexual intercourse in artificial insemination and therefore no such crime is committed by the wife. There are different ways a wife can commit adultery, like if she lies side by side with a man, kissing him, embracing and doing lascivious acts. But, the only lascivious act punishable by law is when sexual intercourse was done. Consent on A . L D . : In A . I . D . the consent and release for any future claim must be obtained by the physician from all parties in writing. The consent of the wife is necessary to avoid being held liable for an assault. The consent of the husband is necessary to avoid the wife being charged with adultery, or to ward the question of legitimacy of the child, issues of divorce, separation or inheritance. The consent and release of the donor should be obtained for the unrestricted use of the semen supplied and he should also certify in writing that he will make no effort to ascertain the identity of the couple involved. If the donor is married, the consent of the wife must also be obtained to the giving of semen because her marital interest may be affected by the donation. Foreign Court's Decisions: Child born by artificial insemination without the consent of the husband constitutes adultery: A woman attempted to obtain alimony from her divorced husband. The latter contended that his former wife committed adultery because the child born is not his biological child. The former wife claimed the child to he a product of artificial insemination. The court held that the artificial insemination without the husband's consent constitutes moral turpitude and adultery with the latter being defined as "the voluntary submission to another person of the reproductive powers or faculties of guilty person" (Osford v. Osford, 68Dom Law Reports, 251 Ont. Sup. Ct. 1921). The British House of Lords concurred with a ruling that the conception of a child by a man other than the husband constituted adultery and that, therefore, the resulting offspring was illegitimate (Russel v. Russel, A.C. 687 (1924) at 148). Child born by artificial insemination is legitimate: In a decree to a separation previously granted by the court, the husband was granted to have a weekend custody of the child born during the marriage. The wife petitioned for an amendment of the

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decree arguing that because the child has resulted from A . I . D . , the husband is not the father of the child and therefore he is not entitled to visitation right. The court, however, predicted on the assumption that the procedure had been performed with the consent of the husband, rules that "the child has been potentially adopted or semiadopted by the defendant and with the particular reference to visitation, he is entitled to the same right as those to which a natural parent under the circumstances would be entitled (Strand v. Strand 78N.Y.S. 2d 390(1918). In an action for a divorce, the Wife alleged that her husband had no visitation right since the child had been conceived from a donor sperm. The court upheld an axiomatic legal principle: "When a child is born within marriage by whatever legal method, there is legal presumption that both marriage partners are its parents (Ohlson v. OhlsonNo. 54, S. 138, 875 (Super. Ct. Cook Country, Sept. 1955). Child born by artificial insemination is illegitimate: The trial judge granted the divorce but denied the husband of visitation rights and the custody of an A . I . D . child declaring that "Heterologous artificial insemination", with or without the consent of the husband, is contrary to public policy and good morals, and constitutes adultery on the part of the mother. A child so conceived is not a child born in wedlock and therefore illegitimate. As such, the mother and the father have no rights or interests of the said child (Dornbus v. Dornbus, No. 51, S. 13 875 (Super Ct. Cook Country, No. 1954, appeal dismissed 12 III. App. 2d 473 (1956). A child conceived by A . I . D . is illegitimate, but the husband at the time of birth was obliged to give support. The trial judge ruled that because the husband had consented to the artificial insemination procedure there arose "an implied contract to support the child although the court considered the child illegitimate (Gursky v. Gursky, 242 NnYlS. 2d 406, 39 Misc. 2d 1083 Sup. Ct. 1936). Child born by artificial insemination is entitled for support: The husband consented in writing for artificial insemination of the wife. A male child was conceived and born. The spouse later had a divorce and the wife was given custody of the child. The wife later became ill and disabled so she applied for a state support of the child. The District Attorney brought a criminal action against the husband to force him to provide for the child's support. The court ruled that "reasonable man who, because of his inability to procreate, actively participates and consents to his wife's artificial insemination, knows that such behavior carries with it legal responsibilities of fatherhood and criminal responsibility of nonsupport (People v. Sorenson, 66 Cal. Rptr. 7, 437 P. 2d 499 (1968).

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LEGAL MEDICINE B. IN VITRO FERTILIZATION

In Vitro Fertilization (test tube baby) is the fertilization of the egg cell by the sperm cell extracted from the respective donors placed in an artificial medium and after reaching a certain stage of cellular division and development: 1. Implanted into a woman's uterus, or 2. Gestation (development of the embryo to a child) in an artificial womb. Whenever the embryo is allowed to develop in an artificial womb, it is know as ectogenesis (extra corporeal gestation). The first recorded child born by In Vitro Fertilization was Louise Brown who was born in England on July 24, 1978 (London Daily Mail). This was followed by the birth of the second in vitro fertilization child in Calcutta, India on October 6, 1978. Subsequent report followed from Scotland and Australia. In the United States, the first reported case was on February 1980 in Norfolk, Virginia. At present the total number is more than 2,000 children are already born through In Vitro Fertilization. Procedure of In Vitro Fertilization: The In Vitro Fertilization process begins with injections into the oocyte (ovum) donor of a hormone known as gonadotropin, which induces super-ovulation. Approximately 30 hours later, the oocytes are removed from the ovary by laparoscopy, a surgical procedure accomplished by inserting two thin glass tubes into the ovary through a small incision in the abdomen. The removed oocytes are placed in a Petri dish or a test tube containing growth medium simulating the environment of the woman's body. The medium is composed of a woman's blood, fluids from her reproductive tract, and nutrients. The oocytes are then fertilized by a sperm which has been held in vitro. The resulting conceptus is kept in a moist environment at room temperature where it divides and grows for a few days until it reaches the blastocyst stage, the stage at which the embryo normally enters the uterus. The conceptus is then picked up with a small hollow tube, inserted through the vagina and cervix into the uterus where it is implanted at a proper time in the menstrual cycle. After successful transplantation, the woman carried the blastocyst to term (Legal Medicine by Cyril Wecht, 1982, p. 240). Possible Situations in In Vitro Fertilization: 1. The ovum removed from the wife is fertilized by sperm from the husband and the resulting zygote is implanted into the wife's uterus.

NON-CONVENTIONAL METHODS OF PROCREATION This process is done because ( a ) the wife cannot conceive on account of the occlusion of the fallopian tube, or ( b ) although the couple can possibly have a child through normal intercourse but they want early screening of the conceptus for genetic defects, control the timing of the pregnancy or select a blastocyst with certain characteristics. The closure of the fallopian tube may be due to complication of a pelvic inflammatory disease, bilateral salpingectomy on account of repeated caesarian section or ectopic pregnancy, tuboplasty failure or unsuccessful tubal anastomosis, or congenital aplasia or hypoplasia of the fallopian tube. 2. The ovum removed from the wife is fertilized by the sperm coming from a third party (sperm donor) and is implanted into the wife's uterus. This situation may arise when (a) the husband is sterile, ( b ) the husband does not wish to transmit to the child a genetic defect, or (c) the wife cannot conceive through Artificial Insemination Donor ( A I D ) . 3. The ovum coming from a third party (ovum donor) is fertilized by the husband's sperm and the blastocyst is implanted into the wife's uterus. This situation is necessary when (a) the wife is sterile or ( b ) the wife does not like to transmit genetic defect to the child. 4. The ovum taken from a third party (ovum donor) is fertilized by the sperm coming from a third party (sperm donor) and the blastocyst is implanted into the wife's uterus. This procedure may be adopted when (a) both husband and wife are sterile, or ( b ) both of them refuse to transmit to the child their genetic defects. 5. The ovum removed from a single woman is fertilized by the sperm taken from a male donor; the blastocyst is implanted into the single woman's uterus. The procedure may be done when the single woman wishes to have a child but she cannot conceive naturally or by artificial insemination. 6. The ovum removed from the wife is fertilized by the husband's sperm and the blastocyst is implanted to a "host" or surrogate. There is genetic link of the child to the parents by the gestational link with a third party. 7. The ovum coming from the wife is fertilized artificially by the sperm coming from a third party (sperm donor) and the blastocyst is implanted into the surrogate's uterus.

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8. The ovum coming from a third party (ovum donor) is fertilized by the sperm coming from the husband and the blastocyst is placed into the uterus of the surrogate's uterus. 9. The ovum coming from a third party (ovum donor) is fertilized by the sperm coming from a third party (sperm donor) and the blastocyst is implanted into the uterus of a surrogate. Basis of Legality of In Vitro Fertilization: The constitution provides that "No person shall be deprived of life, liberty, or property without due process of law, nor shall any person be denied the equal protection of the laws." (14th amendment of U.S. and Article IV, Sec. 1, Philippines). From the term "liberty" emanates the right of privacy. In Meyer v. Nebraska (262 U.S. 390), the right of privacy denotes not only freedom from bodily restraints but also the right of the individual to contract, to engage in any of the common occupations of life, to acquire useful knowledge, to marry, to establish a home and bring up children, to worship G o d according to the dictate of his own conscience, and generally to enjoy those privileges long recognized by law as essential to the orderly pursuit of happiness as a free man. In Griswold v. Connecticut (381 U.S. 479, 1965), the right of privacy means the right to be left alone. It is the right of an individual to the possession and control of his own person, free from all restraints or interference of others, unless by clear and unquestionable authority of law. It is the right of parents or guardians to establish their family life as they see fit. Other implications of the right of privacy which may be the basis of legality of in vitro fertilization: a. Right of procreation — Procreation is fundamental to the very existence and survival of a race. A ban on the use of in vitro fertilization would prevent an individual from using means to fulfill his or her procreative mission. Inability to procreate is a malady and it is the duty of medicine to alleviate or cure the condition so as to make him enjoy life and realize his desire. b. Right of marital privacy — Prohibition of in vitro fertilization as a way to have children will mean government intrusion into the marital bedroom in search of evidence for violating the law. The freedom of personal choice in matters of marriage and family life is one of the basic liberties protected by the due process of law clause.

NON-CONVENTIONAL METHODS OF PROCREATION c. Right to decide whether to bear or beget — This is the right of a person to determine whether to carry or not to carry a product of conception, to be or not to be a mother or to raise or not to raise a family. d. Right of self-determination — "Every human being of adult age and of sound mind has the right to determine what shall be done on his own body (Schloendorff v. Society of New York Hospital 195 N.E. 92 N. Y. 1914). A modern definition of this concept is expressed in the case of Natanson v. Kline (350 P. 2d 1093 Kan. 1960) which stated that "a man is the master of his own body and he may expressly prohibit the performance of life-saving surgery..." Problems in In Vitro Fertilization: 1. The probability that the child to be born will be defective: Although there is no actual substantial proof that a child born through in vitro fertilization will in greater probability be defective, physicians are seemingly apprehensive to perform this non-standard procedure of procreation on fear that a civil suit for damage may be filed against them. A couple embarked in "in vitro fertilization" with their obstetrician initiating a culture combining sperm and oocytes, but later, destroyed the culture when he was convinced that the risk of the procedure was too great. The plaintiff sued to recover for their emotional pain and sufferings and a $50,000 verdict was awarded the couple (Del Zio v. Presbyterian Hospital, 74 Civ. 3588, U.S. Dis. Ct., SouthernDis. NY. 1978). Some of the probable causes of the birth of a defective child may be: a. Administration of hormone to the prospective source of ovum: A gonadotropic hormone is administered to induce more production of oocytes to give the physician the privilege of selecting which among is the best for fertilization. This may cause production of chromosomal abnormality (trisomy). Inasmuch as the oocyte is mixed with a pool of sperm, a single ovum maybe fertilized by multiple sperm and lead to the production of an abnormal embryo (triploidy). b. Mechanical manipulation of the oocyte and embryo: The mechanical removal from the ovum donor, the actual fertilization process in an artificial medium and the physical act

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of insertion into the uterus may cause injury or deformity on the cells or zygote. c. Mistake in the "screening process' or selection of the best ovum for fertilization. d. Defective donors (sperm and ovum). A physician need not fear too much of the possible liability on account of a defective child because: a. The plaintiff will find difficulty in proving negligence. The plaintiff will have a hard time establishing connection between physician's negligence and infant's defect because birth defects are well known to occur in normal or natural pregnancies. b. Prospective parents are normally briefed of the potential risks of the procedure before their consent is obtained. c. In vitro fertilization is still in the experimental stage and has yet to evolve a clearly defined standard of care by which to determine whether the action of the physician is negligent. d. The plaintiff is required to meet the difficult task of proving negligence. Social Problem in In Vitro Fertilization: The probability for a child born by in vitro fertilization to be defective is not remote for reasons stated (supra). Is our society willing to have this world to be inhabited by android, monsters, cyclopes, defectives and other forms of abnormalities? The progress of science must be geared towards improvement in the quality of men and not towards retrogression or deterioration. 2. Problem of surrogate mother: A surrogate mother is a woman who is not the source of the ovum and in whose uterus the in vitro fertilized egg is implanted to develop up to full term and delivered child. The term also applies when fertilized egg is removed from the uterus of a woman and implanted to the surrogate mother. The surrogate become the gestational mother of the child. Reasons why the services of a surrogate mother may be necessary: a. Necessity: (1) The genetic mother is unable to carry the child to term because of disease or injury. ( 2 ) The genetic mother may believe either that she is too old to safely carry a child to term, or that the child may be born with abnormalities. (3) The genetic mother may possess deleterious genetic traits which may be passed on to the child.

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611

( 4 ) Couple is unable to adopt a child. Adoption is expensive and time consuming process. There is shortage of available children ready for adoption. The couple may express preference as to the age, race or religion they wish to adopt. These diminish the likelihood of having a child by adoption, b. Convenience: A woman may not want to interrupt her career during the gestational period and therefore seek a more convenient method of having one without changing her actual way of life. Motivation of a woman to become a surrogate mother: a. Altruistic motive — A woman may be willing to be a surrogate mother for the sake of humanity. b. Material consideration — If the surrogate mother merely receives all expenses incurred in carrying the fetus to term and then delivered then the motive is altruistic. On the other hand, if the payment agreed upon is beyond the reasonable cost of pregnancy then it is tantamount to "rental" for the use of the uterus. Problems that may arise in the agreement in the use of surrogate mother for gestational purpose: a. If the surrogate mother decided to abort the child contrary to the wish of the genetic parents; b. The surrogate mother may decide to keep the child after birth rather than surrender him to the genetic parents; c. The parents may decide to abort the child because of the fear that abnormality may be present but the surrogate mother refuses to do so; d. If the child was born with abnormality and the parents refused to take the child from the surrogate mother; e. Can the couple enforce the contract in the event that the surrogate mother committed other breaches? ; and f. Is there a need to go through the procedure of adoption in order to legitimatize the child at birth? Potential solution to the problems of surrogate mother: a. By contract — There must be a contract specifically mentioning the rights and duties of each party. But the mere fact that the rights and duties are specified do not guarantee that the specifications will judicially be recognized. Any term that the court finds to be contrary to public policy will be striken out. It cannot be assured that all specified term will be judicially enforced. b. By legislation — The court is bound to enforce the legislation

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This method provides a

3. Problem of the status of the child born by in vitro fertilization (supra p. 607): a. Situation 1 — There is no doubt that the child is legitimate because the wife is genetically and gestationally the mother and the sperm came from the husband. In case of situation 5, the child born must be considered illegitimate in view of the absence of marriage between the single woman source of the ovum and the sperm donor. b. Situation 2 and 3 — Although one of the elements (ovum or sperm) in the fertilization process did not come from one of the spouses, the child may still be legitimate if there is consent of the sterile party to the in vitro fertilization. If the child is not considered legitimate, then the process of adoption may be done. The status that the child may be a problem may change if the in vitro fertilization was done with the knowledge and consent or against the will of the sterile spouse. c. Situation 4, 6, 7, 8 and 9 — The genetic parents are different f r o n the gestational mother. Adoption may be a legal remedy provide' there is no impediment to the application of the procedure, otherwise a special legislation may be necessary. C. OTHER NON-CONVENTIONAL METHODS OF PROCREATION 1. Artificial Inovulation — The removal of an unfertilized egg from a woman and placing it on the reproductive tract of another woman. 2. Embryo Transplantation — The removal of a fertilized egg from a woman's uterus to transfer to that of another woman's uterus. 3. Parthenogenesis ("Virgin Birth") — A type of sexual reproduction whereby the unfertilized egg with 23 chromosome compliment doubled its content to become a diploid cell that starts dividing as if it is a fertilized egg without the intervention of a male sperm cell, the resulting offspring is thus a female. It has been speculated that virgin birth occurs naturally in human being at the rate of one per three billion pregnancies. 4. Cloning — A type of a sexual reproduction whereby the nucleus of a female egg is removed (enucleation) which contains the genetic material and replaced with the nucleus of a body (somatic) cell of the same or another woman (renucleation). The renucleated egg is then placed in a uterus for gestation and normal development. The resulting offspring is genetically identical to the parent.

Chapter XXIX MEDICO-LEGAL ASPECT OF MARITAL UNION A N D DISSOLUTION A. AS TO REQUISITES OF A V A L I D M A R R I A G E : Art. 52, Civil Code: Marriage is not a mere contract but an inviolable social institution. Its nature, consequences and incidents are governed by law and not subject to stipulation, except that the marriage settlements may to a certain extent fix the property relations during the marriage. Art. 53, Civil Code: No marriages shall be solemnized unless all these requisites are complied with: (1) (2) (3) (4)

Legal capacity of the contracting parties; Their consent, freely given; Authority of the person performing the marriage; and A marriage license, except in a marriage of exceptional character (Sec. l a , Art. 3613).

Art. 54, Civil Code: A n y male of the age of sixteen years or upwards, and any female of the age of fourteen years or upwards, not under any of the impediments mentioned in articles 80 to 84, may contract marriage. (Arts. 80 to 84 refer to void and voidable marriages). Art. 61, Par. 2, Civil Code: In case either or both of the contracting parties, being neither widowed nor divorce, are less than twenty years of age as regards the male and less than eighteen years as regards the female, they shall, in addition to the requirements of the preceding articles, exhibit to the local civil registrar, the consent to their marriage, of their father, mother or guardian, or persons having legal charge of them, in the order mentioned. Such consent shall be in writing, under oath taken with the appearance of the interested parties before the proper local civil registrar or in the form of an affidavit made in the presence of two witnesses and attested before any official authorized by law to administer oaths. 613

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Art. 62, Civil Code: Males above twenty but under twenty-five years of age, or females above eighteen but under twenty-three years of age, shall be obliged to ask their parents or guardian for advice upon the intended marriage. If they do not obtain such advice, or if it be unfavorable, the marriage shall not take place till after three months following the completion of the publication of the application for marriage license. A sworn statement by the contracting parties to the effect that such advice has been sought, together with the written advice given, if any, shall accompany the application for marriage license. Should the parents or guardian refuse to give any advice, this fact shall be stated in the sworn declaration. A physician may be required to determine the ages of the contracting parties whenever the question of the validity of marriage is at issue. Such determination of the age may be made by the analysis of the peculiarities connected with the age, e.g., growth of the pubic hair, presence of the third molar, development of the breast, height, character, and educational attainment of the person. Art. 81, Civil Code: Marriages between the following are incestuous and void from their performance, whether the relationship between the parties be legitimate or illegitimate. (1) Between ascendants and descendants of any degree; ( 2 ) Between brothers and sisters, whether of the full or half blood; ( 3 ) Between collateral relatives by blood within the fourth civil degree. Art. 82, Civil Code: The following marriages shall also be void from the beginning: (1) Between stepfathers and stepdaughters, and stepmothers and stepsons,( 2 ) Between the adopting father or mother and the adopted, between the latter and the surviving spouse of the former, and between the former and the surviving spouse of the latter; ( 3 ) Between the legitimate children of the adopter and the adopted. B. AS TO M A R I T A L RELATION: Art. 109, Civil Code: The husband and wife are obliged to live together, observe mutual

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respect and fidelity, and render mutual help and support. Art. 110, Civil Code: The husband shall fix the residence of the family. But the court may exempt the wife from living with the husband if he should live abroad unless in the service of the Republic. Art. I l l , Civil Code: The husband is responsible for the support of the wife and the rest of the family. These expenses shall be met first from the conjugal property, then from the husband's capital, and lastly from the wife's paraphernal property. In case there is a separation of property, by stipulation in the marriage settlements, the husband and wife shall contribute proportionately to the family expenses. Art. 112, Civil Code: The husband is the administrator of the conjugal property, unless there is a stipulation in the marriage settlements conferring the administration upon the wife. She may also administer the conjugal partnership in other cases specified in this Code. Causes of Sexual Dissatisfaction After Marital Union: 1. Fear of consequence of repeated abortion. 2. Fear of unwanted pregnancy. 3. Faulty contraceptive methods. There is inadequate opportunity for orgasm. 4. Dyspareunia (Vaginisimus, or improper sex technique). 5. Fear of coitus. 6. Emotional frustration due to fertility. 7. Ignorance of the reproductive process and genital anatomy. 8. Aversion to coitus (frigidity). 9. No sex desire (low basal metabolic rate found). 10. Anatomic cause of unsatisfaction in coitus: a. b. c. d. e. 11. 12. 13. 14.

Tight resistant septate hymen. Size and location of the clitoris. Extreme obesity of either husband or wife. Infantile genital development. Pelvic abnormality, e.g., parametritis, torn perineum.

Disparity in age. Venereal disease. Masturbation preferred to coitus. Infidelity.

Reasons Why Patients Requested Contraceptive Advice: 1. Recent childbirth. 2. Desire to space offspring.

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3. Desired number of children already born. 4. Medical condition of the wife does not warrant pregnancy, e.g., hyperthyroidism, nephritis, tuberculosis, diabetes, heart disease, deaf-mutism, blindness or convalescence after acute illness such as typhoid fever or pneumonia, or after acute surgical procedure as appendectomy or rectal fistula. 5. Mental illness or emotional disturbance of husband and wife. 6. Economic conditions: a. b. c. d.

Unemployment of the husband. Wife sole or co-wage earner. Support or dependents. Desire to complete education or professional training.

7. Dissatisfaction of either or both partners with method of contraception employed. 8. Failure of other methods used. Causes of Non-consummation of the Sexual Act: 1. 2. 3. 4. 5. 6. 7.

Septate hymen. Tight thick hymen. Fear of pain or inability to stand pain. Ignorance of genital anatomy. Ignorance of sex technique. Fear of pregnancy. Sense of shame regarding genitals and coitus.

Contraceptive Methods: 1. Contraceptive Methods in General Condom Coitus interruptus Douche Suppository Safe period Nothing Gold-stem wishbone pessary Vaginal diaphragm (rubber) French pessary (cervical type) Lanteen pessary

Contraceptive jelly alone Coitus interruptus and douche Condom and pessary Condom and douche Condom and jelly External coitus Lactation Suppository and douche Abstinence

2. Male Method of Contraception: Condoms with jelly, suppository or douche. Coitus interruptus with douche.

MARITAL UNION AND DISSOLUTION 3. Female Methods of Contraception: Douche alone Douche and condom Douche with coitus interruptus Douche with pessary Douche with diaphragm Vaginal diaphragm Cervical type pessary Stem pessary (intracervical) Jelly alone 4. Other Methods:

617

Jelly with diaphragm Jelly with cervical type pessary Jelly with condom Suppository with douche Safe period Lactation

External coitus Abstinence Nothing used Some Common Complaints After Marital Union: 1. Male sex inadequacy. 2. Prolonged debilitating disease of one of the partners. 3. Anxiety over economic security. 4. Manual clitoral stimulation preferred to coitus. 5. Too frequent pregnancy. 6. Lack of privacy (poor housing). 7. Husband's preference to perversion. 8. Cultural aesthetic inequalities between parties. 9. Faulty attitude of husband and wife toward normal sex and marriage intimacies. (From: JAMA, Vol 115, No. 4, July 27, 1949, pp. 270-285, by Mario Pichel Warner, M.D.). C. A S T O A N N U L M E N T O F M A R R I A G E : Art. 85, Civil Code: A marriage may be annulled for any of the following causes, existing at the time of the marriage: (1) That the party in whose behalf it is sought to have the marriage annulled was between the ages of sixteen and twenty years, if male, or between the ages of fourteen and eighteen years, if female, and the marriage was solemnized without the consent of the parent, guardian or person having authority over the party, unless after attaining the ages of twenty or eighteen years, as the case may be, such party freely cohabited with the other and both lived together as husband and wife;

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(2) (3) That either party was of unsound mind, unless such party, after coming to reason, freely cohabited with the other as husband or wife; (4) That the consent of either party was obtained by fraud, unless, such party afterwards, with full knowledge of the facts constituting the fraud, freely cohabited with the other as her husband or his wife, as the case may be; (5) (6) That either party was, at the time of marriage, physically incapable of entering into the married state, and such incapacity continues, and appears to be incurable. Art. 86, Civil Code: Any of the following circumstances shall constitute fraud referred to in number 4 of the preceding article: (1) (2) ( 3 ) Concealment by the wife of the fact that at the time of the marriage, she was pregnant by a man other than her husband. There are several grounds for the annulment of marriage which are of medico-legal interest. A physician may be requested to determine the ages of the contracting parties, if the ground for the annulment of marriage is age. He may be required to examine the mentality of the party and to determine whether she or he could have been of unsound mind at the time of the celebration of marriage. The phrase "physically incapable of entering into married state" includes impotency of a party. The court or any of the parties in interest to the contract of marriage must determine whether or not she is pregnant at the time of the celebration of marriage. D. AS TO LEGAL SEPARATION: Our law recognizes only relative divorce but not absolute divorce. Art. 97, Civil Code: A petition for legal separation may be filed: ( 1 ) For adultery on the part of the wife and for concubinage on the part of the husband as defined in the Penal Code; or (2) An attempt by one spouse against the life of the other. Art. 333, Revised Penal Code — Who are guilty of adultery? Adultery is committed by any married woman who shall have sexual intercourse with a man not her husband and by the man

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who has carnal knowledge of her, knowing her to be married, even if the marriage be subsequently declared void. Adultery shall be punished medium and maximum periods.

by prision

correccional in its

If the person guilty of adultery committed this offense while being abandoned without justification by the offended spouse, the penalty next lower in degree than that provided in the next preceding paragraph shall be imposed. Art. 334, Revised Penal Code — Concubinage: A n y husband who shall keep a mistress in the conjugal dwelling, or, shall have sexual intercourse, under scandalous circumstances, with a woman who is not his wife, or shall cohabit with her in any other place, shall be punished by prision correccional in its minimum and medium periods. The concubine shall suffer the penalty of destierro.

Chapter XXX IMPOTENCY AND STERILITY I. IMPOTENCY Impotency is the physical incapacity of either sex to allow or grant to the other legitimate sexual gratification. A person may be impotent but not sterile, or sterile but not impotent although both conditions may exist at the same time. Legal Importance of Impotency: A. Impotency, if proven, legitimacy: Art. 255, Civil Code:

will

overthrow

the presumption

of

Children born after one hundred and eighty days following the celebration of marriage, and before three hundred days following its dissolution or the separation of the spouses shall be presumed to be legitimate. Against this presumption no evidence shall be admitted other than that of physical impossibility of the husband's having access to his wife within the first one hundred and twenty days of the three hundred days which preceded the birth of the child. This physical impossibility may be caused: (1) By the impotence of the husband; ( 2 ) By the fact that the husband and wife were living separately, in such a way that access was not possible; and ( 3 ) By the serious illness of the husband. B. Impotency may be a ground for the annulment of marriage: Art. 85, Civil Code: Marriage may be annulled for any of the following causes existing at the time of marriage: (5) ( 6 ) That either party was, at the time of marriage, physically incapable of entering into the married state, and such incapacity continues, and appears to be incurable. The physical incapacity referred to in the above provision includes impotency. 620

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In order that such impotency may be a ground for the annulment of marriage, the following requisites must be present: 1. One of the parties to the marriage is not aware of the existing impotency of the other party. If the other party to the marriage know of the impotency of the future spouse before the marriage, then it is considered a waiver on his part. 2. The impotency must be present at the time of the celebration of marriage. 3. The impotency suffered by the party must be incurable. If the impotency can be remedied by medical or surgical intervention, then it cannot be a ground for the annulment of marriage. 4. Such impotency must be absolute. C. Impotency may be a defense in rape: An accused in the crime of rape may claim of his inability to commit the offense on account of his impotency. Medical evidence must be shown in support of his allegation. D . Impotency may be sexual behavior:

a

cause

to

the development of abnormal

An impotent may resort to uranism, cunnilingus, homosexuality or other lascivious acts to satisfy the sexual partner. E. Impotency may be a cause for the development of suicide tendency: A person who is not in a capacity to give gratification to the sexual partner may consider himself to be "biologically dead". This results in humiliation, or a feeling of uselessness. He may then resort to self-destruction. Causes of Impotency: A. General or Functional, Not Connected Directly with the Sexual Organs: Any of the following factors lead to, cause, or produce permanent or temporary impotency. 1. Age: Inasmuch as the female is the passive agent in the sexual intercourse, there is no limit for her age, except when she is below the age of sixteen. As long as there is erection in the male, he is considered to be potent. 2. Illness: Diseases attended by general debility may temporarily remove the sexual power on the part of the male. Diseases of the brain and of the spinal cord may yield to permanent loss of potency. Mumps occasionally leads to the atrophy of the sex organs.

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3. Emotion: Some females manifest vaginismus due to actual pain on contact or to the fear of pain on sexual intercourse. This condition is usually common among virgins. This is produced by the violent contraction of the constrictor muscles of the vaginal orifice and may also be brought about by the contraction of the adductor muscles of the thighs. Anesthesia may cure the condition and pregnancy may produce a permanent cure. In the male, emotion may lead or produce temporary impotency. 4. Hormonal dysfunction may also lead to temporary or permanent impotency. B. Local or Organic, in Direct Connection with the Sexual Organs: 1. Congenital

Defects:

a. In Males: (1) (2) (3) (4)

Nondevelopment of the penis. Maldevelopment of the penis. Penis adherent to the scrotum. Duplex organ.

b. In Females: (1) Absence of vagina. ( 2 ) Vagina ill-developed, e.g., may be too small. ( 3 ) Vagina occluded by intrauterine disease. 2. Disease or Accident: a. In the Males: (1) Penis: ( a ) Acute diseases of the penis, as gonorrhea. ( b ) Chronic diseases as epithelioma. ( c ) Complete amputation of the penis. ( 2 ) Testis: (a) Removal of the testis. ( b ) Sexual abuse. b. In the Females: ( 1 ) Vaginal ulceration. ( 2 ) Diseases of the vulvae. ( 3 ) Obstruction of the vaginal canal due to tumor, cyst or fibroid. II. STERILITY Sterility is the loss of power of procreation and is absolutely independent of whether or not impotence is present. A man or a woman may be sterile and yet not impotent, and impotent yet not sterile.

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Causes of Sterility: A. General or Functional, Organs:

Unconnected Directly with the Sexual

Before puberty there is no spermatozoa in the seminal fluid, hence sterile, but as age increases, fertility also increases. B. Local Causes of Sterility: 1. Congenital

Conditions:

a. In the Male: ( 1 ) Absence or nondevelopment of testicle. ( 2 ) Absence or nondevelopment of penis. (3) Maldevelopment of the testicle. ( 4 ) Misplacement of the testicle. ( 5 ) Malformation of the penis, as in epispadias or hypospadias. b. In the Female: (1) Absence or maldevelopment of the ovary. (2) Absence or maldevelopment of the uterus. (3) Absence of the vagina. 2. Acquired

Conditions:

a. In the Male: (1) (2) (3) (4)

Complete amputation of the penis. Excision of the testicle. Diseases of the testicle. Atrophy of the testicle.

b. In the Female: (1) (2) (3) (4) (5)

Excision of the ovaries. Diseases of the ovary. Occlusion of the vagina from diseases. Diseases of the vagina. Occlusion of the Fallopian Tubes.

Methods of Sterilization: A. On the part of the male: 1. The source of sperm production can be eliminated by removing both testicle (Orchiectomy). 2. The tubular passage (vas deferens) through which the sperm are transported from the testicle to the urethra where they combined with the seminal fluid elaborated by the prostrate gland to form the ejaculant, can be divided and the cut ends tied (vasectomy); thus newly produced sperm cannot join the ejaculant and the ability of the male to fertilize the female is lost.

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B. On the part of the female: 1. The source of eggs (ovary) can be removed (oophorectomy). 2. The tubular appendages of the uterus (Fallopian tube) through which the eggs enter the uterine cavity where fertilization takes place, can be divided and the cut ends tied (Tubal ligation or salpingectomy), preventing newly produced eggs from reaching the uterus for fertilization. 3. The uterus ( w o m b ) itself can be removed (hysterectomy), thereby eliminating the site of fertilization and pregnancy.

Chapter XXXI MEDICO-LEGAL ASPECT OF DISTURBANCE OF MENTALITY I. INSANITY Insanity may be defined in its sociological, medical and legal concept. In the sociological viewpoint, insanity is the persistent inability through mental causes to adapt oneself to the ordinary environment. It is the loss of power of the individual to regulate his actions and conduct according to the rules of society in which he moves. Insanity in medicine is the prolonged departure of the individual from his natural mental state arising from bodily disease. Insanity in law covers nothing more than the relation of a person and the particular act which is the subject of judicial investigation. The term insanity is commonly used to be synonymous with lunacy, madness, unsoundness of mind, mental derangement, mental disorder or mental aberration or alienation. Legal Importance of the Determination: 1. In the Civil Code: a. Insanity is a restriction on the capacity of a natural person to act: Art. 38, Civil Code — Minority, insanity or imbecility, the state of being a deaf-mute, prodigality and civil interdiction are mere restrictions on capacity to act, and do not exempt the incapacitated person from certain obligations, as when the latter arise from his acts or from property relations, such as easements. b. Insanity modifies or limits the capacity of a natural person to act: Art. 39, Civil Code — The following circumstances, among others, modify or limit capacity to act: age, insanity, imbecility, state of being a deaf-mute. . . . The consequences of these circumstances are governed in this Code, other codes, the Rules of Court and in special laws. Capacity to act is not limited on account of religious belief or political opinion. 625

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c. Insanity at the time of marriage of any or both parties is a ground for the annulment of marriage: Art. 85, Civil Code — A marriage may be annulled for any of the following causes; existing at the time of marriage: (2) ( 3 ) That either party was of unsound mind, unless such party, after coming to reason, freely cohabited with the other as husband or wife. d. A testator must be of sound mind at the time of execution of a will: Art. 7y8, Civil Code — In order to make a will it is essential that the testator be of sound mind at the time of its execution. Art. 799, Civil Code — To be of sound mind, it is not necessary that the testator be in full possession of all his reasoning faculties, or that his mind be wholly unbroken, unimpaired, or unshattered by disease, injury or other cause. It shall be sufficient if the testator was able at the time of making the will to know the nature of the estate to be disposed of, the proper objects of his bounty, and the character of the testamentary act. Art. 800, Civil Code — The law presumes that every person is of sound mind, in the absence of proof to the contrary. Succession is a legal mode by virtue of which the property, right and obligations which in life belong to a person is acquired by his heirs. A will is a specie of conveyance whereby a person is permitted, with the formalities prescribed by law, to dispose of his property after his death with more or less freedom but limited to a certain degree by law (Riera v. Palmaroli, 40 Phil. 105). A codicil is an addition or supplement to a will either to add to or to take from the provisions of the principal disposition of the will. It must be executed with the same formalities as the will itself and when admitted to probate, forms a part of the will. It is derived from the Latin "codex''. e. A witness to* a will must be of sound mind: Art. 820, Civil Code — A n y person of sound mind and of the age of eighteen years or more, and not blind, deaf or dumb, and able to read and write, may be a witness to the execution of a will f. Insanity of the testator is a ground for disallowance of a will: Art. 839, Civil Code — The will shall be disallowed in any of the following cases:

DISTURBANCE OF MENTALITY

627

(1) ( 2 ) If the testator was insane, or otherwise mentally incapable of making a will, at the time of its execution. g. An insane cannot give consent to a contract: Art. 1327, Civil Code — The following cannot give consent to a contract: ( 1 ) Unemancipated minors: ( 2 ) Insane or demented persons, and deaf-mutes who do not know how to write. h. The guardian or the insane himself, if there is no parent or guardian shall be held liable for damages due to his insanity: Art. 2180, Par. 3, Civil Code — Guardians are liable for damages caused by the minors or incapacitated persons who are under their authority and live in their company. Art. 2182, Civil Code — If the minor or insane person causing the damage has no parents or guardian, the minor or insane person shall be answerable with his own property in an action against him where a guardian ad litem shall be appointed. A guardian ad litem is a guardian appointed by the court to prosecute or defend a suit on behalf of a party incapacitated because of minority or insanity. 2. In the Revised Penal Code: a. Insanity exempts a person from criminal liability: Art. 12, Revised Penal Code — Circumstance which exempt from criminal liability — The following are exempt from criminal liability: ( 1 ) An imbecile or an insane person, unless the latter has acted during lucid interval. b. A person who becomes insane after final sentence: Art. 79, Revised Penal Code — Suspension of the execution and service of the penalties in case of insanity — When a convict shall become insane or an imbecile after final sentence has been pronounced, the execution of said sentence shall be suspended only with regard to the personal penalty, the provisions of the second paragraph of circumstances number 1 of article 12 being observed in the corresponding cases. If at any time the convict shall recover his reason, his sentence shall be executed, unless the penalty shall have prescribed in accordance with the provision of this Code. The respective provisions of this section shall also be observed if the insanity or imbecility occurs while the convict is serving his sentence.

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3. In the Rules of Court: a. A guardian on the person of the insane must be appointed: Rule 92, Sec. 2, Rules of Court — Meaning of word "incompetent" — Under this rule, the word 'incompetent" includes. . . .those who are of unsound mind, even though they have lucid intervals. Rule 93, Sec. 1, Rules of Court — Who may petition for appointment of guardian for resident — Any relative, friend, or other person on behalf of a resident minor or incompetent who has no parent or lawful guardian. . . .An officer of the Federal Administration of the United States in the Philippines may also file a petition in favor of a ward thereof, and the Director of Health, in favor of an insane person who should be hospitalized, or in favor of an isolated leper, b. An insane cannot be a witness in court: Rule 130, Sec. 19 ( a ) , Rules of Court — Physical disqualification — The following persons cannot be a witness: (a) Those who are of unsound mind at the time of their production for examination, to such a degree as to be incapable of perceiving and making known their perception to others. Factors Having Positive Correlation with the Development of Mental Disorder: 1. Heredity — This is the most frequent and history reveals mental illness manifested by ascendants. 2. Incestuous marriage, blood incompatability of parents, maternal infection during the early stage of pregnancy. 3. Impaired vitality — Mental worry, grief, physical strain, unhygienic surroundings, infection, birth trauma may predispose a person to mental disorder. 4. Poor moral training and breeding — Improper breeding and moral training according to the social status, particularly on free will and self-control, undesirable association, etc. 5. Psychic factors — Emotional disturbance, such as love, hatred, passion, disappointment. 6. Physical factors: a. Non-toxic — Exhaustion resulting from severe physical and mental strain, illness, cerebral hemorrhage, trauma on the skull affecting the brain. b. Toxic — This may be produced by excessive formation or deficient elimination of waste product of metabolism; by microbic infection, or excessive use of certain drugs.

DISTURBANCE OF MENTALITY

629

Some Manifestation of Mental Disorders: The condition of insanity cannot be considered clinically by the manifestation of one sign or symptom, but it is essential to appreciate the condition of the mind as a whole. Although certain behavior may be observed in certain types of insanity, they may also be observed in the clinically non-insane. 1. Disorder of Cognition (Knowing): a. Disorder in Perception: ( 1 ) Illusion — a false interpretation of an external stimulus. It may be manifested with the sense of sight, hearing, taste, touch and smell. Example:

A dragonfly may be considered a vampire bat. A whistle sound may be considered a bomb explosion. A normal person may also suffer from illusion but further investigation by oneself may prove that his judgement is wrong.

( 2 ) Hallucination — An erroneous perception without external object of stimulus. Some Types of Hallucination: (a) (b) (c) (d) (e)

Visual Auditory Olfactory Gustatory Tactde

— Seeing things although not present. — Hearing voice in absolute silence. — False perception of smell. — False perception of taste. — False perception of touch, as feeling that a worm is creeping on the skin. (f) Kinesthetic — False perception of movement. ( g ) Hypnagogic — False sensory perception occurring midway between falling asleep and being awake. ( h ) Lilliputian — Perception of object as reduced in its size.

b. Disorder of Memory: ( 1 ) Dementia — A form of insanity resulting from degeneration or disorder of the brain characterized by general mental weakness, forgetfulness, loss of coherence, and total inability to reason but not accompanied by delusion or uncontrollable impulse (Hibbard v. Baker, 104 N.W. 339, 141 Mich. 124). Some Types of Dementia: (a) Acute Dementia — a form of temporary dementia, occurring in young people and induced by conditions

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LEGAL MEDICINE likely to produce that state, like malnutrition, overwork, dissipation or too rapid growth. ( b ) Dementia Paralytica(General Paralysis of the Insane) — Degeneration of physical, intellectual and moral power leading to paralysis ("cirrhosis of the brain"). ( c ) Dementia Praecox (Schizophrenia) — Dementia of the adolescence and characterized by loss of memory. ( d ) Senile Dementia — Occurring in advanced age and characterized by loss of memory, with childish and silly behavior and physical degeneration. (e) Toxic Dementia — Characterized by weakness of mind or feeble cerebral activity resulting from continuous administration or use of toxic chemicals. ( 2 ) Amnesia (Loss of Memory): (a) Anterograde Amnesia — Loss of memory of recent event. ( b ) Retrograde Amnesia — Loss of memory of past events and observed in trauma of the head.

c. Disorder of Content of Thought: ( 1 ) Delusion — A false or erroneous belief in something which is not a fact. A person suffering from delusion is not always insane. If he can correct his wrong belief by later experiences, by logic or information from other sources, then such delusion is not a proof of insanity. Some Types of Delusion: ( a ) Delusion of Grandeur ("Delirium of Grandeur', Megalomania or "folie de grandeur") — Erroneous belief that he is in possession of great power, wealth, wisdom, physical strength, etc. It is not always a sign of insanity. A person may think he is a king and dresses and acts as such. ( b ) Delusion of Persecution — A false belief that one is being persecuted. A person may feel that he is being poisoned and prepares for his coming end. (c) Delusion of Reference — One thinks that he is always the subject-matter of conversation, news, speech or action although it is not a fact. ( d ) Delusion of Self-accusation — A false belief to have committed a crime or hurt the feeling of others. (e) Delusion of Infidelity — A false belief derived from pathological jealousy that one's lover is unfaithful although she is chaste, and tries to assault her.

DISTURBANCE OF MENTALITY

631

( f ) Nihilistic Delusion — A false belief that there is no world, that one does not exist, and that his body is dead. This condition may occur in involutional melancholia. ( g ) Delusion of Poverty — A false belief that one is financially ruined and that he has no money, is starving, sick or even dead. ( h ) Delusion of Control — A false feeling that one is being controlled by other persons. (i) Hypochondriacal Delusion — A false feeling that one is suffering from an incurable disease, some parts of his body are not functioning, or that he is not physically capacitated to do a thing on account of the disease. (j)

Delusion of Depression — patient experiences feelings of uneasiness, worthlessness and futility.

( k ) Delusion of Negation — feeling that some parts of the body are missing. ( 2 ) Obsession — Thought and impulse which continually occur in the person's mind despite all his attempts to keep them out. It is an idea constantly obtruding on the consciousness inspite of efforts to drive them away from his mind. A person may lock the door of his bedroom and go to bed. While in bed he may get up to see if he has locked the door. He may go to bed again and again think and see whether the door is locked. He may repeat the act the whole night. Obsession is a condition of the mind bordering on sanity and insanity. It is sometimes associated with some sort of fear and usually occurs in persons suffering from nervous exhaustion. d. Disorder on the Trend of Thought: ( 1 ) Mania — A state of excitement accompanied by exaltation or a feeling of well-being which is out of harmony with the surrounding circumstances of the patient. The mind is hyperactive, with "flight of ideas" which may amount to incoherency. Delusion may be present, but it is usually fleeting in character. The increased mental activity also finds expression in increased muscular activity; the patient is restless and always occupied. His finer instincts are blunted; he becomes untidy with his clothing even to the extent of indecency. He is impatient, irritable, antagonistic and violent if interfered with. He is sleepless but his phy-

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LEGAL MEDICINE sical health is not greatly affected. (Forensic Medicine, Sydney Smith and Frederick Fiddes, 10th ed., p. 387). (2) Melancholia — Intense feeling of depression and misery which is unwarranted by his physical condition and external environment. He is absorbed by his miserable thought. Aural hallucination is common. Every patient suffering from melancholia is a potential suicide case.

The alternative condition of mania and melancholia is known as manic-depressive psychosis, hence called "folie circulaire." In between attacks of mania and depression is a period of cessation of symptoms of psychosis known as lucid interval. A n y person who committed a criminal act during lucid interval is criminally liable. 2. Disorder of Emotion (Feeling): a. Exaltation — Feeling of unwarranted well-being and happiness. b. Depression — Feeling of miserable thought, that a calamitous incident occurred in his life, something has gone wrong with his body functions and prefers to be quiet and in seclusion. c. Apathy — Serious disregard of the surrounding environment. d. Phobia — Excessive, irrational and uncontrollable fear of a perfectly natural situation or object. Some Types of Phobia: ( 1 ) Fear of Specific Objects: Birds — Ornithophobia Blood — Hematophobia Books — Bibliophobia Flowers — Anthophobia Men — Andro phobia

Robbers — Harpaophobia Sacred things — Hierophobia Sharp objects — Belonophobia Sun — Heliophobia Trees — Dendrophobia

( 2 ) Fear of Specific Situation: Childbirth — Tocophobia Crossing a bridge — Gephyrophobia Daylight — Phengophobia Drinking — Dipsophobia Height — Acrophobia

Going to bed — Clinopbobia Marriage — Gamophobia Open space — Agarophobia Pregnancy — Maieusiophobia Sexual intercourse — Coitophobia

( 3 ) Fear of Place: Churches — Ecclasiophobia Crowds — Ochlophobia Empty room — Kenophobia Sea — Thalassophobia Enclosed room — Home surroundings — Claustrophobia Ecophobia School — Scholionophobia _ River — Potamophobia

DISTURBANCE OF MENTALITY Railways — Siderodro mophobia

633

13 at table — Trikaidekaphobia

(4) Fear of Illness or Death: Death — Thanatophobia Disease — Pathophobia Germs — Spermophobia Heart disease — Cardiophobia Illness — Nosemaphobia

Inf ection — Mysophobia Infirnity — Apeirophobia Microbes — Bacilliphobia Snakes — Ophidiophobia Veneral Disease — Cypridophobia The fear of specific objects, situations, or places may develop as a result of an incident, while the fear of illness may start when a friend contracted an illness. Fear of death may develop when one nursed a dying patient and became morbidly convinced that he will in the future be in the same condition. 3. Disorder of Volition or Conation (Doing): a. Impulsion or Impulse (Compulsion) — Sudden and irresistible force compelling a person to the conscious performance of some action without motive or forethought. The person has no power to control it, however bad the consequence may be. Some Types of Impulsion (Compulsion Neurosis): (1) Pyromania — An irresistible impulse to set things afire. (2) Kleptomania — An irresistible impulse to steal articles of not much value. ( 3 ) Mutilomania — An irresistible impulse to maim animals. ( 4 ) Dipsomania — An irresistible impulse to indulge in intoxi cation either in alcohol or drugs. Repeated intoxication for a number of years with alcohol or drugs which is voluntary is not dipsomania. One having power to refrain from the use of intoxicating liquor or drugs and who becomes intoxicated voluntarily is not a dipsomaniac (Black's Law Dictionary by H. C. Black, 3rd ed., p. 933). (5) Homicidal Impulse — An irresistible inclination or impulse to commit homicide prompted usually by insane delusion either as a necessity of self-defense or avenging for justice, or as to the patient being the appointed instrument of a superman justice (Com. v. Sayre, 5 Wkly Notes Cas (Pa) 452). (6) Sex Impulse — This includes all irresistible acts of sexual perversion. ( 7 ) Suicidal Impulse — A strong desire to terminate one's life. This impulse may be present in acute depression.

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Distinction between Feigned and True Insanity: 1. Feigned insanity develops suddenly while true insanity develops insidiously, usually with the observance of some predisposing to an exciting cause if careful history of the case is taken. 2. There is no peculiar facial expression in feigned insanity which is commonly observed in true insanity. 3. Symptoms of insanity may only be observed in feigned insanity when he is conscious that he is under observation and becomes normal when he is alone and unobserved. There is such remission of symptoms in true insanity. 4. In feigned insanity the symptoms may be complete, numerous and may clinically refer to a specific clinical disease. In true insanity, although in some instances the symptoms may not refer to a specific clinical disease, there is more tendency to point to a specific clinical entity. 5. Violent exertion of feigned insanity usually leads to an early exhaustion while in true insanity the patient can withstand violent exertion without any sign of exhaustion and fatigue. 6. A feigned insane usually observes rules of personal hygiene and does not look dirty and filthy. A true insane is filthy, dresses dirtily and does not observe hygiene. (From: Medical Jurisprudence A Textbook of Toxicology by Modi, 12th ed., p. 382). Steps in the Diagnostic Procedure of Mental Affection: 1. Anamnesis: a. Family History: ( 1 ) Inquire on the medical condition of the parents and other ascendants, uncles, brothers, and sisters. ( 2 ) Inquire whether anyone of them suffered from nervous diseases, cerebral affection, suicide, syphilis, etc. b. Personal History: (1) Detailed characteristic from childhood to his present state. ( 2 ) Determine excess use of intoxicating drugs. (3) Sexual life, occupation, mental strain, head injury and early nervous affection. c. Information from relatives, friends and neighbors: Change of conduct and behavior, habit, previous conduct or maniacal episode.

DISTURBANCE OF MENTALITY

635

2. Physical Examination. 3. Instrumentations: X-ray, electroencephalogram, apparatus.

scanning

and

other modern

4. Mental Examination: Psychologic Testing Psychiatric Evaluation INSANITY A N D CRIMINAL RESPONSIBILITY: Fundamental Principles in Criminal Responsibility: 1. A sane man is assumed to be sequence of his criminal act.

wholly responsible for the con-

2. A person who commits a criminal act is presumed to be sane. The burden of proof lies on the accused to prove that he is not sane and cannot be held responsible for his criminal act. 3. The crime is always considered to be an affair of the mind as well as the body and to make an act or omission of a crime, there must be a criminal act (actus reus) and a criminal mind (mens rea). This is inconsonance with the legal maxim that "actus facit reum nisi mens sit rea" (There cannot be a guilty act unless there is a guilty mind). Mental Illness may be an Exempting or Mitigating Circumstance to Criminal Liability: 1. As an Exempting Circumstance: Art. 12, Revised Penal Code — Circumstances which exempt from criminal liability — The following are exempt from criminal liability: 1. An imbecile or an insane person, unless the latter has acted during a lucid interval. When the imbecile or an insane person has commited an act which the law defines as a felony (delito), the court shall order his confinement in one of the hospitals or asylums established for persons thus afflicted, which he shall not be permitted to leave without first obtaining the permission of the same court. Case Where Defense of Insanity were Upheld by Court: An accused who committed homicide and has been known to be suffering from dementia praecox with delusions that he was being molested sexually, or that his property was being taken, was considered insane and exempted from criminal liability (People v. Bonoan, 64 Phil. 87).

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The wife of the accused and her cousin testified that the accused was continuously out of his mind for many years. The assistant district health officer who examined the accused testified that he was suffering from violent mania and that condition could be present at the time he killed the deceased. There was no motive for the accused to kill the deceased. The court considered the accused insane (People v. Bascos, 44 Phil. 204). The accused was suffering from malignant malaria when she attacked, wounded and killed her husband. It has been shown that malaria affected the nervous system and caused complications like acute melancholia and insanity at times. The accused was considered not criminally liable (People v. Lucena, 69 Phil. 350). 2. As a Mitigating Circumstance: Art. 13, Revised Penal Code — Mitigating circumstances — The following are mitigating circumstances: 8. That the offender is deaf and dumb, blind or otherwise suffering from physical defect which thus restricts his means of action, defense, or communication with his fellow beings. 9. Such illness of the offender as would diminish the exercise of the will-power of the offender without however depriving him of consciousness of his acts. 10. A n d , finally, any other circumstance of a similar nature and analogous to those above mentioned. The fact that the accused is suffering from a mild behavioral disorder as a consequence of an illness she had in early life is regarded as mitigating circumstance under Art. 13, Par. 8 or in Par. 9 of the Revised Penal Code (People v. Amit. 82 Phil. 820). One who was suffering from acute neurosis which made him ill-tempered and easily angered was entitled to the mitigating circumstance because illness diminished his exercise of will power (People u. Carpenter C.A. G.R. 4168 Apr. 22, 1940). Phase In The Criminal Act Where The Evidence Of Insanity Of The Accused Must Be Established: The evidence of insanity must be referred to at the time preceding the act under prosecution or to the very moment of its execution. In order to ascertain a person's mental condition at the time of the act, it is permissible to receive evidence of the condition of his mind during a reasonable period both before or after that time. To prove insanity, circumstantial evidence, if clear and convincing, will suffice (People v. Bonoan, 64 Phil. 93).

DISTURBANCE OF MENTALITY

637

Rules Utilized By Courts to Determine Whether The Mental Condition Of An Accused Exempts Him From His Criminal Liability: Art. 12 ( 1 ) of the Revised Penal Code provides that "an imbecile or an insane person, unless the latter has acted during lucid interval" is exempt from criminal liability. In the medical viewpoint a person is insane when he is suffering from mental derangement or confusion or a condition which prevents a person from orienting himself. It is a prolonged departure of the individual from his natural mental state arising from bodily disease. The legal definition of insanity by which the court is guided is more of an intellectual and moral concept rather than medical. It is a defect of the mind which renders a person incapable of entertaining a criminal intent. The law further presumes every person to be sane and to possess a sufficient degree of reason to be responsible for his act unless the contrary can be proven. The following rules have been adopted by courts to determine whether an accused is suffering from insanity to exempt him from criminal liability : 1. Earlier Test for Insanity: a. "Wild Beast Rule": A person is exempted from criminal liability if he is totally deprived of his understanding and memory and knows no more than an infant, a brute, or a wild beast of what he is doing. The rule has been applied in England (Arnold case, 1724) and in the United States (State v. Pike, 49 N . H . 399), but was not universally accepted because: a. Its application is limited to violent crimes against a person; and b. It is quite hard to measure the aggressive behavior of a wild beast. b. Delusion Rule: A person is not responsible for his act if he is suffering from delusion although he knows that his act is wrong. This rule was applied to the James Hadfield case wherein the accused attempted to kill King George III of England while entering the Drury Lane Theater. Hadfield was found to be suffering from a delusion although he knew at the time that he was actually firing a gun at the King. A person with delusion may be insane but his suffering from delusion may not necessarily affect his judgement in a particular act. If a person who is suffering from delusion commits an illegal act which has no relation to the particular delusion from

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which he is suffering he must be considered responsible for such an act as if he were sane. 2. Later Tests for Insanity: a. McNaghten's Rule (1843): A defense on the ground of insanity can be established if it can be proven that at the time of committing the act: (1) The accused was laboring under such defect of reason or from a disease of the mind as not to know the nature and quality of the act he was doing, or ( 2 ) If he did know, he did not know that what he was doing was wrong. Under the rule, before an accused can be exempted from criminal liability, it must be proven first. (a) That the accused was suffering from the disease of the mind. It is the psychiatrist who must determine the presence of the disease of the mind, although what constitutes the disease is not entirely clear. An accused was held to be suffering from the disease of the mind when he attacked a person during a temporary loss of consciousness caused by congestion of the brain due to arteriosclerosis (Bratty v. Atty. Gen. of Northern Ireland, 1963). A person who is suffering from malignant malaria when she killed her husband was held not criminally liable because of insanity due to disease of the mind (People v. Lacena, 69 Phil. 330). ( b ) It must be proven that the accused did not know the nature and quality of the act he was doing. A person who, on account of mental disease, did not know the nature and quality of his act does not have criminal intent (mens rea). (c) If the accused knew the nature and quality of the act, then it must be proven that he did not know that what he was doing was wrong. "Wrong", insofar as McNaghten's Rule is concerned, means contrary to law. The knowledge that the act was in violation of criminal law has been held to be sufficient to justify holding the accused reponsible. The accused's delusion that the killing in question has been directed by God was not sufficient to excuse

DISTURBANCE OF MENTALITY

639

him in view of the showing that he knew it was against the law (McElroy v. State, 146 Tenn. 422). One who commits bigamy under the delusion that the act has been directed by a vision from God was held to be responsible when he admitted he knew at the time that the act was punishable by law of the State (People v. Schmidt, 216 N. Y. 324). Criticisms

to

the

McNaghtensRule:

(1) The rule is too rigid and strict that it unjustly subjects the insane to punishment. ( 2 ) It is based solely on cognitive factor and ignores emotion and will. ( 3 ) The test is unintelligible to psychiatrists because it requires a moral judgment by the physician; a judgment outside of his professional training, experience and competence. In the United State 36 states adopt the rule. b. Irresistible Impulse Rule: A person is considered insane when mental disease has rendered him incapable of restraining himself, although he understands what he is doing and knows it is wrong. Criticisms to the Irresistible Impulse Rule: (1) On account of its laxity it opens the door for the escape of many persons who are sane and should be prosecuted as criminals. (2) There is difficulty in differentiating irresistible impulse from impulse which can be actually resisted. ( 3 ) It fails to differentiate between real insanity and mere impulsive condition. c. Durham Rule: The accused is not criminally responsible if his act was the product of mental disease or mental defect. The determination of criminal responsibility is based on the answer to two questions: (1) Is the defendant suffering from a mental disease or defect? (2) If so, was his crime a product of the mental disease or defect? Criticisms to the Durham Rule: (1) There seems to be uncertainties in the definition of "mental disease or defect". Does it include personality disorders, character defect, sociopathic disorder which are clinically true mental diseases?

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LEGAL MEDICINE (2) There is ambiguity of the term "product". When is an act the "product" of the diseased mind or deranged mental condition within the scope of the rule? (3) The application of the rule will create a fear that all criminals would be regarded by psychiatrist as mentally ill, and hence, no one will be subjected to criminal prosecution or conviction.

d. Currens Rule: In order to make the accused not responsible for his act it must be proven that at the time of committing the prohibited act the defendant, as a result of mental disease or defect, lacked substantial capacity to conform his conduct to the requirements of the law which he has allegedly violated. Criticisms to the Currens Rule: Like the Durham Rule, a large number of the prison population will be considered not guiltv by reason of insanity. e. American Law Institute Rule: In 1955, The American L a w Institute with the support of the American Bar Association, formulated the following rule of criminal responsibility: (1) A person is not responsible for his criminal conduct if at the time of such conduct as a result of mental disease or defect he lacks essential capacity to appreciate the criminality of his conduct or to conform his conduct to the requirements of the law; ( 2 ) TVie term "mental disease or defect" does not include an abnormality manifested only by repeated criminal or otherwise anti-social conduct. Criticisms to the American Law Institute Rule: ( 1 ) Some authorities, even psychiatrists, objected to the inclusion of item ( b ) of the rule. It has been pointed out that such exclusionary division discriminates between the poor and the well-to-do offenders. The poor defendants cannot avail themselves of a more rigid and more searching inquiry into their mental state but merely superficial, one done by government physicians. ( 2 ) It does not give the court a simple, helpful guide in their effort to decide whether the accused was insane at the time of his act. ( 3 ) The phrase "or to conform his conduct to the requirement of the law" permits the defendant to find refuge in what is equivalent to the "irresistible impulse" test.

DISTURBANCE OF MENTALITY

641

There is a need of insanity defense in a civilized society to show that insane people who do not have criminal intent while performing a criminal act are not penalized. Recent court decisions are moving to a broader definition of mental illness. Some rules now even define mental disease and mental defect to include addiction, alcoholism and conceivably even the slightest abberation of the mind. The expansive meaning of insanity cannot always be tolerated by law. Law and psychiatry have been in collision in the recent past. No matter how mentally ill a person is, he may still probably be responsible to some degree. Psychiatrists should offer medical diagnosis and interpretation of signs of mental illness but not give legal judgment. The assassination attempt by Hinkley to President Ronald Reagan of the United States wherein the court considered Hinkley to be insane has caused the development of a strong public opinion of re-examination or restructuring of our law on defense of insanity. There is now a strong public opinion not to consider insanity as an exempting circumstance to criminal liability. The following proposition are suggested for future action: ( 1 ) An accused may be pronounced to be mentally ill. He can be treated in a mental hospital until recovery. After recovery he may then be transferred to prison to serve cut the remaining term. ( 2 ) The accused may be pronounced guilty with diminished responsibility. His mental condition may be considered only as a mitigating circumstance to his criminal liability. Or he may be convicted if found insane for a lesser offense because of emotional disturbance. II. MENTAL DEFICIENCY Mental deficiency (mental subnormality, mental retardation) is the below-normal intellectual functioning which originates from the arrest or incomplete development of the mind during the development period below the age of 18 which may be induced by various factors associated with the impairment of learning, social adjustment or maturation. Classical Classification: 1 Idiot - Usually congenital and due to defective development of the mental faculties. An idiot is wanting in memory, will power and emotion. He cannot express himself by language, is quiet,

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timid and easily irritated. He cannot guard himself against common physical dangers. The deficiency is usually associated with physical abnormalities like microcephaly and mongolism. Mentality never exceeds that of a normal child over 2 years old. The I.Q. is between 0 — 20. 2. Imbecile — Although the mental defect is not as severe as that of idiots, he cannot manage his own affairs. He may be able to speak but with poor command of the language. He can easily be aroused to passion and may show purposeful behavior. He may be trained to do simple work under supervision. The mental age may be compared to a normal child from 2 to 7 years old and the I.Q. is 20 - 40. 3. Feeble-minded — Person whose mental defect, although not amounting to imbecility, is pronounced such that he requires care, supervision, and control for his protection and for the protection of others. He is incapable of receiving proper benefit from instructions in ordinary school. He lacks initiative and ability for any work or responsibility. He has a mentality similar to that of a normal child between 7 to 12 years old and an I. Q. of 40-70. Moron — A feeble-minded person of considerably higher intelligence as that of an imbecile but his intellectual faculties and judgment are not as well developed as in a normal individual. He can carry routine duties in civilized society as long as the demands made upon his mental capacity is not too discretionary. He is amenable to the customs of the community and may not present so much of a social problem. 4. Moral Defective — In addition to the mental defect, there are strong vicious and criminal propensities, so that the person requires care, supervision and control for the protection of others. He is devoid of moral sense and often shows intellectual deficiency, though he may be mentally alert. He is careless; pleasure loving; and a devil-may-care sort of young man or woman who adheres to the principles of "live today for tomorrow we die", "live fast and die young" and "it is only happiness that counts". (A Sypnosis of Forensic Medicine & Toxicology by C. Thomas, 2nd ed., p. 125). Because of the stigma that may likely be attached to the child if the classical classification (idiot, imbecile, feeble-minded) is used, new classifications have been adopted by some countries. Mental retardation is classified as follows: 1. Profound — I.Q. is under 20, and capable at most to limited self-help. There is most likely a need for hospitalization or some type of environment in which care is available throughout his life-time.

DISTURBANCE OF MENTALITY

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2. Severe — I.Q. is between 20 and 35 and capable of habit training as a child. As an adult he is likely in need of a controlled environment. 3. Moderate — I . Q . is 36 to 51 and can develop academic skill equal to about the second grade level. As an adult he will most probably need a sheltered environment. 4. Mild — I.Q. is 52 — 67 and constitutes the greatest group of mentally retarded. He can develop academic skill to about the sixth grade level. As an adult he can develop social and vocational skills. Whether he is to be institutionalized or not depends more on his social skill and on the range of alternatives available to him than on his intellectual functioning. Although it is not a part of the original standard classification, a fifth degree known as borderline retardation with an I.Q. of 68 — 83 may be added. In England, under the Mental Health Act 1959, Part I, N o . 4, mental deficiency is simply classified as: 1. Severe Abnormality — A state of arrested or incomplete development of mind which includes abnormality of intelligence and is of such a nature or degree that the patient is incapable of living an independent life or of guarding himself against serious exploitation, or will be incapable when of an age to do. 2. Subnormality — A state of arrested or incomplete development of mind (not amounting to severe abnormality) which includes subnormality of intelligence and is of a nature or degree v/hich requires or is susceptible to medical treatment or other special care or training of the patient. Methods of Estimating Mental Capacity: 1. Intelligence Tests: At the age of 18 the human mind is presumed to have attained its full development. Knowledge acquired after such age comes from experience, memory and study. Intelligence testing may be used to (a) diagnose the degree of mental retardation, ( b ) study the ways in which the individual's intellectual ability is threatened by personality problems, and (c) as a means to understand personality dimensions. There are many different tests used by psychometrists and it is sufficient to mention some of them. a. Performance Tests (Don't Require the Use of Language): (1) Good Enough Draw-a-person Test — A subject is asked to draw a person and a number of corresponding points are

644

LEGAL MEDICINE given to different parts of the body and clothings. The total number of points is then converted into a quantitative measure of intelligence. The test can provide evidence for personality functioning and conflicts as well as intelligence estimate. (2) Raven Progressive Matrices Test: — A series of designs in which a part is removed from each member of the series, and the individual is presented with six alternative parts from which to choose the part which is missing in the original design. This test is useful in measuring the person's ability to reason by analogy, for comparison and to indicate the logical method of thinking.

b. Verbal Test — This depends essentially on words and numbers. c. Mixed (Verbal and Non-verbal) Test: (1) Binet Test — The individual is given credits in months for task completed successfully, and the individual's total score is the sum of the months of credit received for items passed. The total credit in months (mental age) in conjunction with the individual's chronological age is converted into an intelligence quotient ( I . Q . ) . The test is valuable for children under 10 years old. Example: If a person at the age of 20 was able to answer all the questions up to the age of 12, 2 in 8, 1 in 9 and 1 in 10 and each of the answers is equivalent to 2 months, then the person has an intelligence or mental age of 12 years and 8 months. ( 2 ) Wechsler Tests — (Wechsler Intelligence Scale for Children — Revised, WISC-R, and Wechsler Adult Intelligence Scale, W A I S ) : This consists of 12 subtests (six verbal and six non-verbal). The verbal test may consist of information, general comprehension, similarities and vocabulary. The performance test includes a variety of scales, like pictures, arrangements, block design, etc. The row for each subtest is converted to an equivalent weight score permitting comparison with other subtests. When the different weighed scores are added together, the clinician can obtain three different intelligence quotients: verbal, performance and full scale. 2.

Intelligence Quotient (I.Q.): Several test types are prepared corresponding to every age in months and these are answered by the person examined. The age of the person examined is determined in terms of months. The number of months corresponding to the test type answered

DISTURBANCE OF MENTALITY

645

divided by the age of the person in months is the intelligence quotient (I.Q.)Example: A child at the age of to answer the test for 7 years and 6 is equivalent to 100 months, while valent to 90 months. 90 divided by /. Q. Above 140 1 2 0 - 140 1 1 0 - 120 90 - 110 80 - 90 7 0 - 80 Below 70

8 years and 4 months was able months. 8 years and 4 months 7 years and 6 months is equi100 equals 90 as I.Q.

Classification "Near" genius or genius Very superior intelligence Superior intelligence Normal or average intelligence Dullness, rarely classified as feeble-minded Borderline deficiency, sometimes classified as dullness, often as feeble-minded Definitely feeble-minded

Principal Drawbacks to Different Intelligence Tests: 1. The tests seem to give undue weight to memory. 2. The tests do not take into consideration the vision or hearing of the subject. 3. The tests overlooked the fact that some persons are inattentive or nervous. 4. Cooperation of the person tested is absolutely necessary. Mental Deficiency and Criminal Responsibility: Imbecility, according to Article 12, par. 1 of the Revised Penal Code, is an exempting circumstance to criminal liability. Inferentially the condition of idiocy is also an exempting circumstance inasmuch as it is of a much more deficient degree as compared to imbecility. Feeble-mindedness is a mitigating circumstance provided in Article 13 par. 8, 9 or even 10 of the Revised Penal Code. Art. 13, Revised Penal Code — Mitigating Circumstances — The following are mitigating circumstances: 8. That the offender is deaf and dumb, blind or otherwise suffering from some physical defect which thus restricts his means of action, defense, or communication with his fellow beings. 9. Such illness of the offender as would diminish the exercise of will-power of the offender without however depriving him of consciousness of his acts. 10. And, finally, any other circumstance of a similar nature and analogous to those above mentioned.

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The fact that the accused is feeble-minded warrants the findings in his favor of the mitigating circumstance provided for in either par. 8 or 9 of Art. 13 of the Revised Penal Code, namely, that the accused is "suffering from some physical defect which thus restricts his means of action, defense or communication with his fellow beings" or "such illness as would diminish the exercise of his willpower" (People v. Formigones, 48 O.G. 1772). H o w the Court Becomes Aware of the Mental Condition of a Person: 1. Any party in a proceeding may present evidences to show the mental condition of a person. He who alleges something must prove the same by presentation of evidence in support of his allegation. In a criminal proceeding wherein the defense of insanity is invoked, the party must present proofs that the accused is insane and does not know the nature and quality of his act. In the probate of a will, the petitioner must present evidence to show that the testator is of a sound and disposing mind at the time of execution of a will. 2. Upon motion of one of the parties, the court may issue an order to submit a person to a physical and mental examination. Rule 28, Rules of Court: Physical and mental examination of person: Sec. 1. When examination may be ordered — In an action in which the mental or physical condition of a party is in controversy, the court in which the action is pending may in its discretion order him to submit to a physical and mental examination by a physician. Sec. 2. Order for Examination — The order for examination may be made only on motion for good cause shown and upon notice to the party to be examined and to all other parties, and shall specify the time, place, manner, conditions and scope of the examination and the person or persons by whom it is to be made. Sec. 3. Report of findings — If requested by the person examined, the party causing the examination to be made shall deliver to him a copy of a detailed written report of the examining physician setting out his findings and conclusions. After such request and delivery the party causing the examination to be made shall be entitled upon request to receive from the party examined a like report of any examination, previously or thereafter made, of the same mental and physical condition. If the party examined refuses to deliver such report the court on motion and notice may

DISTURBANCE OF MENTALITY

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make an order requiring delivery on such terms as are just, and if a physician fails or refuses to make such a report the court may exclude his testimony if offered at the trial. Ways of Hospitalizing an Insane Person: 1. Judicial

Method:

a. Upon petition by the Director of Health. b. The court upon knowledge that the imbecile or insane committed a felony. 2. Extra-judicial method: a. Voluntary. b. Involuntary. 1. Judicial Methods: a. Rule 101, Rules of Court: Proceedings for hospitalization of insane persons: Section 1. Venue. Petition for commitment — A petition for the commitment of a person to a hospital or other place for the insane may be filed with the Court of First Instance (Regional Trial Court) of the province where the person alleged to be insane is found. The petition shall be filed by the Director of Health in all cases where, in his opinion, such commitment is for the public welfare, or for the welfare of said person who, in his judgement, is insane, and such person or the one having charge of him is opposed to his being taken to a hospital or other place for the insane. Section 2. Order for hearing — If the petition filed is sufficient in form and substance, the court, by an order reciting the purpose of the petition, shall fix a date for the hearing thereof, and copy of such order shall be served on the person alleged to be insane, and to the one having charge of him, or on such of his relatives residing in the province or city as the judge may deem proper. The court shall furthermore order the sheriff to produce the alleged insane person, if possible, on the date of the hearing. Section 3. Hearing and judgment — Upon satisfactory proof, in open court on the date fixed in the order, that the commitment applied for is for public welfare or for the welfare of the insane person, and that his relatives are unable for any reason to take proper custody and care of him, the court shall order his commitment to such hospital or other place for the insane as may be recommended by the Director of Health. The court shall make proper provisions for the custody of property or

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money belonging to the insane until a guardian be properly appointed. Section 4. Discharge of insane — When, in the opinion of the Director of Health, the person ordered to be committed to a hospital or other place for the insane is temporarily or permanently cured, or may be released without danger he may file the proper petition with the Court of First Instance (Regional Trial Court) which ordered the commitment. Section 5. Assistance of fiscal in the proceeding — It shall be the duty of the provincial fiscal or in the City of Manila the fiscal of the city, to prepare the petition for the Director of Health, and represent him in court in all proceedings arising under the provisions of this rule. 2. The court may order confinement of insane or imbecile upon knowledge that he has committed^ felony: Art. 12, Par. 2, Revised Penal Code: When the imbecile or an insane person has committed an act which the law defines as a felony (delito), the court shall order his confinement, in one of the hospitals or asylums established for persons thus afflicted, which he shall not be permitted to leave without first obtaining permission of the same court. 2. Extrajudicial Methods: a. Voluntary: The insane person himself or with the assistance of the relatives or guardian during the lucid intervals or during such time that he is still normal may request his confinement in a hospital or asylum. This is common among persons who are afflicted with the disease and are aware of the advantage of hospitalization. b. Involuntary: The immediate relatives, the peace officer or other persons who are concerned with the welfare of the society may force the insane to be confined in a hospital. Such coersive confinement may be in accordance with the valid exercise of police power of the state or by virtue of ordinance. Police power is the power inherent in a government to enact laws within constitutional limitations, to promote order, safety, health, morals, and the general welfare of society. Sec. 2238, Revised Administrative Code — General power of council to enact ordinances and make regulations: —"The municipal council shall enact such ordinance and make such

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649

regulations, not repugnant to law, as may be necessary to carry into effect and discharge the powers and duties conferred upon it by law and such as shall seem necessary and proper to provide for the health and safety, promote the prosperity, improve the morals, peace, good order, comfort and convenience of the municipality and the inhabitants thereof, and for the protection of property therein". III. MALINGERING Malingering is the feigning or simulation of a disease or injury characterized by ostentation, exaggeration and inconsistency. Causes of Malingering: 1. To Avoid Military or Naval Training: A person may feign disease or injury because he is required by law to undergo military or naval training. Under the National Defense Act (Commonwealth Act N o . 1) all male citizens of the Philippines who have reached 20 years of age must undergo military training under penalty of law for failure to do so. All male college students enrolled must have at least two years of military training as a requisite for graduation. For some reason or cause, a person may malinger disease or injury so that he will not be subjected to such a requirement. 2. To Avoid Court Summons: A person may have received a summon from a court requiring him to appear on a specified date, time and place but refuses to appear because he is a defendant in the case wherein he wants to delay the proceeding, or he is afraid to be subjected to the ordeal of direct and cross examination. He may simulate that he is suffering from a disease or injury which incapacitate him to attend the trial. 3. As a Defense to a Criminal Prosecution: Impotency may be utilized by the defendant in the prosecution of the crime of rape. An accused while on trial may allege that it is not possible for him to commit the crime of rape because he is impotent. 4. To Increase Civil Liability: A plaintiff in a civil action for the recovery of damages and for the injury sustained may exaggerate the physical disability so that he may receive bigger award from the court. 5. To Promulgate Sympathy: A beggar may exaggerate incapacity or simulate disease or injury so that the public may be more sympathetic towards him and give him more alms.

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Types of Malingering: 1. "Feigned or Fictitious" Malingering: Malingering is built up out of pure imagination and does not have the slight basis of fact. The disease or injury which a person allegedly is suffering from does not exist at all. Example:

A person may simulate that he is totally blind while in fact both eyes are normal.

2. "Factitious" Malingering: This is a form of malingering whereby something really exists as a fact but is converted to a more serious disability or injury, or to an exaggeration of the real complaint. Here the person is really suffering from an injury or disease but he may exaggerate or amplify the seriousness of the complaint or nature of the injury or disease. Example: A person might have received a small superficial scratch but complained of severe and unbearable pain and incapacity to move. Points which Make a Physician Suspect that a Person is Malingering: 1. Presence of a Cause for the Subject to Malinger: A person may feign disease or injury because he wants to avoid something, like military training, court trial or other obligations which he does not like, or he wants to get something, like sympathy or greater civil damages. 2. Inconsistency Between the Injuries or Disease Suffered from and the Symptoms or Disability Manifested: In factitious malingering the subject may show certain manifestations which, in the ordinary course of life, are inconsistent or not proportionate to the actual physical disability present. 3. Symptoms Not Supported with Organic Lesion: A woman may allege that she has been abused by force and that she bied profusely, but on physical examination a few hours after the alleged assault, no sign of physical injury was noticed on her private organ. 4. Abrupt

Onset

of Symptoms:

If a person feigns insanity or some other diseases, he may manifest abrupt symptoms which are incompatible with the normal course of disease. 5. Refusal to be Subjected to Painful or Annoying Treatment: A person may feign that he is suffering from sprain or fracture of his upper or lower extremities. The physician may suggest the

DISTURBANCE OF MENTALITY

651

placing of the injured portion under plaster cast and the patient may refuse because it may put him to some inconvenience. A person may complain of some disturbance in the gastrointestinal tract but when prescribed magnesium sulfate, he refused to take it. Whenever a physician is requested to examine a patient to determine whether he is malingering or not, he must utilize all of his senses, have a keen observation and apply methods of detection appropriate for the occasion. Ways to Determine Malingering: There is no specific test for a specific form of malingering. The test applicable depends upon the demand of the occasion considering the attitude of the subject and the nature of the malingering. The tests may be: 1. General Procedure — The method is applicable to all forms of malingering: a. Observation of the subject during his unguarded moments: A person cannot always be conscious that somebody is observing him. He may for some moments unconsciously show his normal condition and not exhibit the disability feigned. b. Complete history and physical examination: The history that may be narrated by the subject may not be compatible with the result of the physical examination and the manifesting symptoms are common among malingerers. c. Application of general anesthesia. d. Application of sudden unexpected minimal amount of electrical stimulus. 2. Specific Procedure: a. Feigning Blindness: (1) Place a convex 12D lens before the "good" eye and a weak concave lens (say 0.25D) before the "blind" eye and ask the patient to read Snellen's test types from a distance of 6 meters. If he succeeds in reading it is a definite proof that he is malingering, since it is impossible to read the type through such convex lens. (2) Place a lighted candle patient, and a prism before the good eye. means that good vision (3) Take a firearm and towards the revolver,

at a distance of 6 meters from the with base upwards or downwards, If the patient can see two flames it is present on both eyes. with the patient focusing his eyes fire three or four shots in the air.

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Then all of a sudden aim the firearm towards him. If the patient is blind there will be no instinctive act of dodging. b. Feigning Deafness: (1) This is a method to determine whether only one of the ears is allegedly deaf. Place a loud tickling watch in the supposed sound ear and ask if he is able to hear the tickling. If he answers in the affirmative, gradually withdraw the watch and ask him when he can no longer hear the tick. Place the watch on the "deaf" ear and ask him if he hears the tick. He will certainly give a negative answer. N o w let him close both eyes and you place something metallic (which will make him believe it to be a watch) against the back of the deaf ear, at the same time hold the watch behind (but not touching) the sound ear and ask him if he is able to hear the tick. If he says no, then he is malingering. ( 2 ) Close the sound ear with cotton. Make a loud noise on the "deaf" ear. Notice the expression of the face. c. Feigning Insanity: There is no specific test or procedure to determine feigning insanity. A keen observation of the behavior coupled with the history and physical findings probably are the most reliable. IV. OTHER CONDITIONS MANIFESTING OR SIMULATING DISTURBANCE OF MENTALITY 1. Somnambulism: This is an abnormal mental condition whereby a person is performing an act while in the state of natural sleep. A somnambulist might be concentrated in a particular train of idea or obsessed by certain thoughts which baffled his mind that he tried to execute it while in the state of sleep. He may commit the crime of murder, infanticide, or parricide while under the influence of the fit. A somnambulist has no recollection of the events occurring during the fit and in several courts of different countries somnambulists are exempted from criminal liability. In a case cited by Modi, Marggie Alexander was charged of having killed her child with a razor while in the state of sleep. The jury gave a verdict of guilt but insane because the somnambulist did not know what she was doing nor was capable of appreciating the nature and quality of the act. In the Philippines, in the case of People v. Gimena (55 Phil604) the defendant attacked his wife with a bolo. The defense

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was that he was in the state of somnambulism when he attacked his wife. The court held that the offense charged was committed by the accused while in the state of somnambulism. Somnambulism is recognized by the court as an exempting circumstance as a manifestation of insanity. Here the defendant was placed under observation for sometime but it was not shown that he was suffering from somnambulism. 2. Semisomnolence or Somnolencia: A person is in a semisomnolence state when he is half asleep or in a condition between sleep and waking. A person may be suddenly aroused and may unconsciously commit a criminal act, like murder, infanticide or parricide, or some other crimes, while his mind is at the state of confusion. Criminal acts committed in this state do not show manifestations to justify insanity. There is no jurisprudence in the Philippines deciding squarely whether it will exempt a person from criminal liability. 3. Hypnotism or Mesmerism: A person is made unconscious by the suggestive influence of the hypnotist. He may commit a criminal act while under the influence of hypnotism which he may not be capable of doing while under a normal state. A person cannot be hypnotized against his will, and if a person volunteers to be hypnotized he must anticipate all the consequences of his acts while under the hypnotic spell. Hypnotism as a defense to a criminal act is not accepted with favor in the court. A person cannot take advantage of his own misconduct. However, under the Civil Code (Art. 1328) contracts agreed to during hypnotic spells are voidable. The Civil Code seems to acknowledge the absence of the normal state of mind of a person under the influence of hypnotism. 4. Delirium: Delirium is a state of confusion of the mind. It is characterized by incoherent speech, hallucination, illusions, delusions, restlessness, and apparently purposeless motions. A person may, when under the state of delirium, commit a crime. It may be advanced that a person committing a felonious act while in a delirious state may be exempted from criminal liability although there is no jurisprudence in the issue yet.

Chapter XXXII DRUG DEPENDENCE 1. Biosocial Factors Responsible for the Emergence of Drug Problems: a. It is less than three hours flight westward from the Philippines to the Golden Triangle, the primary source of opium supply for legitimate and illegitimate use. From this source narcotics have been transported all over the world and in some instances the Philippine ports are used for transshipment. There are several instances where opium has been discovered and confiscated in the airports allegedly en route to a foreign port. b. The Philippines is endowed by nature with a humid, warm tropical weather most conducive to luxuriant propagation and growth of marijuana plant. This accounts for vast tracks of land in the mountain region of the north yielding vigorous plants and bountiful harvest. c. A demographic study of our population revealed that a greater part of our population is getting younger and younger. A great number of our citizenry belongs to the age group most susceptible to marijuana. d. The Philippines is a mirror image of America. There are reports that in some states of the Union one out of four children is drug dependent. This prevailing situation in the United States is seemingly brought to our shores. e. Men are by nature pleasure loving or hedonistic. The feeling of euphoria, well-being, day-dreaming, hallucination, vigor, illusion, develops whenever a person is under the influence of drug. Whenever a man intends to do something, he always measures the amount of pleasure and pain that accompanies it. f. The profit motive of the pushers, planters, and retailers is another factor. In any human activity, profit and risk go hand in hand. More risk — more profit principles dominate human action in periods of economic difficulties. g. The gradual disappearance of the olden nuclear nature of the the Philippine family and the emergence of a permissive society . have contributed to the rise in drug problems. ( 1 ) The western system of less control of parents over children has gradually become a fashion of time. 654

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( 2 ) The world's clamor to respect human rights has reverberated in all corners of the world. ( 3 ) The constitutional provision that "no person shall be deprived of his right, liberty or property without due process of law" has been extended in its application to include almost everything. h. As we enter another decade, we begin to feel the impact of the discoveries, explorations, and researches done in the past. Scientists have discovered new drugs for the purpose of alleviating human diseases or symptoms of diseases. Pain, a scourge of mankind, is now a thing of the past. Exploration of the deeper structure of man, organ transplantation, and control of human behavior are now of common occurrence. Botanists, pharmacologists, and pharmacognosists have delved deeper into structures, contents, manner and site of action of the potent, contents of the members of the plant kingdom. New drugs have been synthesized, and have produced beneficial, as well as deleterious effects on mankind. D A N G E R O U S D R U G ACT The provisions of the Revised Penal Code on crimes relative to opium and other prohibited drugs (Art. 190 — 194) have been repealed by Republic Act N o . 6425 as amended, otherwise known as Dangerous Drug Act of 1972. During the past decades opium and other allied drugs have been considered to be the only drugs found to be harmful to mankind and society so that they are the ones subjected to social control. But, in the recent past, new drugs have been discovered to be naturally existing while others have been synthesized which are equally or even more harmful than opiates. It is therefore imperative to enact new laws to include and intensify control on all drugs deleterious to human beings and to society as a whole. In response to the social demand, the Dangerous Drug Act of 1972 was passed by the defunct Congress of the Philippines. A dangerous drug is a drug whose use is attended by risk and therefore unsafe, perilous and hazardous to people and/or to a society. A drug is any substance, vegetable, mineral or animal in origin, used in the composition or preparation of medicine or any substance used as medicine. The Dangerous Drug Act has classified drugs which are subject to control into prohibited drugs and regulated drugs. It did not define what is a prohibited or what is a regulated drug. It merely enume-

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rates the drugs which are included in the category of prohibited and those considered regulated drugs for the purpose of graduating penalties. Violation of different acts relative to prohibited drugs has higher penalties as compared with the same acts committed in violation of the regulated drugs. The classification is not based on their pharmacologic effects but on societal reaction in the control on specific acts of specific drugs. If society has a strong adverse attitude against any drug, then it will be included in the enumeration of prohibited drugs. The following drugs or group of drugs are considered dangerous and are governed, by the Dangerous Drug Act. 1. Prohibited Drugs: a. Opium and its active components and derivatives, such as heroin and morphine; b. Coca leaf and its derivatives, principally cocaine; c. Alpha and beta cocaine, hallucinogenic drugs, such as mescaline, lysergic acid diethylamide ( L S D ) and other substances producing similar effects; d. Indian hemp and its derivatives; e. All preparations made from any of the foregoing; and f. Other drugs, whether natural or synthetic, with the physiological effects of a narcotic drug (Sec. 2.2, N o . 1, R . A . 6425). 2. Regulated Drugs: a. Self-inducing sedatives, such as secobarbital, phenobarbital, pentobarbital, barbital, amobarbital and any other drug which contains salt or a derivative of a salt of barbituric acid; b. A n y salt, isomer or salt of an isomer, of amphetamine, such as benzedrine, or any drug which produces a physiological action similar to amphetamine; and c. Hypnotic drugs, such as methaqualone or any other compound producing similar physiological effects (Sec. 2. No. (2), R. A. 6425). Any drug or group of drugs included in the classification may cause a user to be drug dependent. Drug dependence means a state of psychic or physical dependence, or both, on a dangerous drug, arising in a person following administration or use of that drug on a periodic or continuous basis (Sec. 2(g), R . A . 6425). Drug dependence may either be a condition of drug addiction or drug habituation. 1. Drug addiction is a state of periodic or chronic intoxication produced by the repeated consumption of a drug, whether synthetic or natural, and found to be detrimental to the individual and to the society ( W H O ) .

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657

Characteristics of Drug Addiction: a. An overpowering desire or need (compulsive) to continue taking the drug or to obtain it by any means; b. A tendency to increase the dose; c. A psychological and physical dependence on the effects of the drug; and d. A detrimental effect to the society and to the individual. 2. Drug habituation is the desire to have continuous use of the drug but with the capacity to refrain physically from using it. Characteristics of Drug Habituation: a. The desire to use the drug is not compulsive but merely psychical; b. There is little or no tendency to increase the dose; c. The dependence is not physical but merely psychical; and d. The detrimental effect, if any, is primarily on the individual. PROHIBITED ACTS A N D RESPECTIVE THE D A N G E R O U S D R U G S A C T :

PENALTIES UNDER

1. Prohibited Drugs Prohibited Act

Penalty

3

Importation of prohibited drugs.

14 yrs. & 1 day to life imprisonment and a fine of 14,000 to 30,000 pesos.

4

Sale, administration, delivery, distribution and transportation of prohibited drugs.

12 yrs. & 1 day to 20 years imprisonment and a fine of 12,000 to 20,000 pesos. If the victim died, life imprisonment to death & a fine of 20,000 to 30,000 pesos.

5

Maintenance of a den, dive or resort for prohibited drugs.

12 yrs. & 1 day to 20 yrs. imprisonment and a fine of 12,000 to 20,000 pesos.

6

Employees and visitors of a prohibited drug's den.

2 yrs. & 1 day to 6 yrs. imprisonment and a fine of 2,000 to 6,000 pesos.

Section

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—

Manufacture of prohibited drugs.

Possession or use of prohibited drug.

Cultivation of plants which are sources of prohibited drugs.

Life imprisonment to death and a fine of 20,000 to 30,000 pesos. 6 yrs. & 1 day to 12 yrs. imprisonment and a fine of 6,000 to 12,000 pesos. 14 yrs. & 1 day to life imprisonment, revocation of license, and a fine of 14,000 to 30,000 pesos.

10

Failure to record prescriptions, sales, purchases, acquisitions and/or deliveries of prohibited drugs.

1 yr. & 1 day to 6 yrs. imprisonment, revocation of license, and a fine 1,000 to 6,000 pesos.

11

Unlawful prescription prohibited drugs.

of

8 yrs. & 1 day to 12 yrs. imprisonment, revocation of license, and a fine of 8,000 to 12,000 pesos.

12

Unnecessary prescription of prohibited drugs.

4 yrs. & 1 day to 12 yrs. imprisonment, revocation of license, and a fine of 4,000 to 12,000 pesos.

13

Possession of opium, pipe and other paraphernalia for prohibited drugs.

6 mos. & 1 day to 4 yrs. imprisonment and a fine of 600 to 4 000 pesos. :

2. Regulated Drugs 14

Importation drugs.

15

Sale, administration, dispensing, delivery, transportation of regulated drugs.

of

regulated

6 yrs. & 1 day to 12 yrs imprisonment and a fine of 6,000 to 12,000 pesos. 6 yrs. & 1 day to 12 yrs. imprisonment, revocation of iicense, and a fine of 6,000 to 12,000 pesos.

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16

Possession or use of regulated drugs.

17

Failure to record prescription, sales, purchases, acquisitions, and/or deliveries of regulated drugs.

6 mos. & 1 day to 4 yrs. imprisonment and a fine of 600 to 4,000 pesos. 6 mos & 1 day to 4 yrs. imprisonment and a fine of 600 to 4,000 pesos.

18

Unlawful prescription regulated drugs.

of

4 yrs. & 1 day to 6 yrs. imprisonment, revocation of license, and a fine of 4,000 to 8,000 pesos.

19

Unnecessary prescription of regulated drugs.

6 mos. & 1 day to 4 yrs. imprisonment, revocation of license, and a fine of 600 to 4,000 pesos.

Pharmacologic Classification of Dangerous Drugs: 1. 2. 3. 4. 5.

Hypnotics. Sedatives and Tranquilizers. Hallucinogens and Psychomimetics. Stimulants. Deliriants and Intoxicants. HYPNOTIC DRUGS

OPIATES AND THEIR DERIVATIVES: Opium is obtained from the milky exudate of the incised unripe seed capsules of the poppy plant, Papaver Somaiferum. The milky juice is dried in the air and forms a brownish gummy mass which contains 25% opium by weight. 1. Classification of Opium Alkaloids: Those that are naturally existing in the poppy plant: a. Morphine — Name derived from Morpheus, the God of Dream. b. Codeine c. Thebaine d. Papaverine e. Nescapine Those derived by chemical manipulation of the naturally occurring alkaloid: a. Heroin (diamorphine, diacetylmorphine).

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b. Dihydromorphinone (Hydromorphine, Dilaudid). c. Methyl dihydromorphinone (Metaphon). d. Apomorphine. Synthetic: a. Methadone Dolophine. b. Pethidine (Meperidine, Demerol). Heroin and dehydromorphinone are approximately five times as potent as morphine. Heroin is poorly absorbed after oral dosage and is usually given parenterally. Synthetic compounds are effective by mouth and methadone has more prolonged effect than pethidine. Chronic administration of the majority of opium and its derivatives causes tolerance and an increasing dose is necessary to produce effect. Dependence is physical and psychical and one is likely to develop into a chronic user and withdrawal of the drug may precipitate the symptoms of the withdrawal syndrome. 2. Derivatives of Opium Commonly Used: a. Morphine (sulfate, hydrochloride, acetate or tartrate) — Average dose 1/6 to 1/4 gr. given by mouth or by subcutaneous injection. b. Heroin — Therapeutic dose is 1/2 to 1/6 gr. and may be given in the same way as morphine. It may be sniffed with or without cocaine. c. Dionine — Therapeutic dose 1/10 to 1/2 gr. d. Dihydromorphinone (Dilaudid) — Therapeutic dose 1/20 gr. Taken like morphine or as suppositories. e. Metaphon — Effective dose is by mouth 1/20 gr. f. Pantopon — A propriety medicine containing all the alkaloids of opium and may be taken by mouth or by injection. g. Codeine — Therapeutic dose is 1/2 gr. and may be taken by mouth. h. Synthetic preparations. ( 1 ) Demerol — Therapeutic dose is 50 — 100 mg. and resembles morphine and atropine in action. ( 2 ) Methadone — Given by mouth or hypodermically. The therapeutic dose is 5 mg. 3. Signs and Symptoms of Opium Administration: Stage of Excitement: a. There is an increase in mental activity, restlessness or even hallucination. b. There is flushing of the face and increased action of the heart. This state is of short duration and in big dosages it may be absent.

DRUG DEPENDENCE

661

Stage of Stupor: a. The person suddenly becomes quiet. b. There may be headache, giddiness, lethargic condition and uncontrollable desire to sleep. c. When asleep, he can be aroused by external stimuli. d. Pupils are contracted, face and lips are cyanosed. e. There is itching sensation all over the skin. f. Pulse and respiration are still normal. Stage of Narcosis: a. The patient passed into a deep coma. b. He cannot be aroused by external stimuli. c. Muscles are relaxed and reflexes are lost. d. Skin secretion is completely suspended although the skin feels cold and clammy. e. The face is pale, the lips are livid and there may be a drop of the lower jaw. f. The pupils are contracted to almost a pinpoint and they're insensible to light. g. Conjunctivae are injected. h. The pulse is slow, small and compressible. i. Respiration is slow, labored and stertorous. If dosage is lethal and no prompt and proper treatment is given, the following symptoms of the toxicity may be observed: j. Lividity of the face increases and pulse becomes slower, irregular and imperceptible, k. Respiration becomes slower, feeble and later Cheyne-Stokes and the patient may die of asphyxia. 1. The heart may beat for a while but later stop, m. Convulsion may occur with the pupils dilated immediately after death. 4. Consequences of Continuous Use of the Drug: a. Development of tolerance to the drug. The drug is taken in large quantity without producing any effect or without fatal consequence. b. Physical and moral deterioration. c. Untruthfulness, dishonesty and mental deterioration. d. When under the influence of the drug, he is calm and composed, but becomes restless and irritable when deprived of the drug. e. May develop constipation and intercurrent infection, like tuberculosis. f. Those who try to inject themselves develop scars and abscesses in the skin.

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g. Some manifest suicidal tendencies or maniacal symptoms. 5. Early Presumptive Signs that a Person is Taking any Addictive or Habit Forming Drugs: At Home: a. Unaccountable change in habit and mode. b. Loss of appetite and weight. c. Sudden development of clandestine friendship especially with elder boys. d. Personality change for which the parents can find no rational explanation. e. Unexpected discovery of the tablet, capsule or peculiar smelling cigarette in the home. f. Unexpected neglect of personal appearance and hygiene. At School: a. Sudden loss of interest and performance in studies and sports. b. General evasiveness, truancy and problems over discipline. c. Unconscious depression and cheerfulness at work or play over a period should lead to suspicion. At Work: a. Late time-keeping. b. Frequent change of occupation. c. Problem with employer. d. Failure to settle down. 6. Evidences of Opium Addiction: a. Presence of symptoms as mentioned. b. History of partaking of drugs. c. Addict is skinny or asthenic — He prefers to buy drug than food. d. "Main liner" — Multiple pigmented punctured marks along the course of the superficial veins. e. "Skin popper" — Scars of previous subcutaneous abscesses also along the course of the superficial veins. f. Fresh needle puncture marks with underlying hemorrhage can be demonstrated in recent intravenous injection. g. Constriction of the pupil of the eyes. h. Weakness and paleness due to malnutrition. i. Blood examination reveals presence of the drug, j . Presence of the drug in the urine. k. Presence of paraphernalia for the administration of the drug. ( 1 ) "Cooker" — a bottle toy or spoon. (2) Syringe — usually an eye dropper. ( 3 ) Tourniquet — usually belt, shoelace or stocking.

DRUG DEPENDENCE

663

(4) "Spike" - a needle. 1. Withdrawal syndrome develops when deprived of the drug. 7. Withdrawal Syndrome: If an addict is suddenly deprived of opiate, the following symptoms may be observed: Objective Signs: a. 8 to 16 hours after withdrawal — nervousness, restlessness and anxiety. b. 14 hours later — frequent yawning, sweating, running of nose and lacrimination. c. 24 hours later — symptoms increase, pupils are dilated, gooseflesh develops and shivering attack. d. 36 hours — severe twisting of muscles, painful cramps of legs and abdomen, vomiting and diarrhea. e. 3 — 4 days — blood sugar rises; patient becomes sleepy on the 3rd day. Subjective Symptoms: a. Pain. b. Hallucination. c. General body weakness. d. Suicidal impulse. e. Depression. f. Criminal propensities. g. Colic. 8. Elimination of Opium: a. Through the stomach and intestine irrespective of whether the drug is administered by mouth or by injection. b. A great portion of the drug is oxidized in the liver. c. A small portion is eliminated through the urine. 9. Post-mortem Findings in Opium Poisoning: Nothing characteristic but signs of asphyxia are most prominent: a. Face and fingernails are livid. b. Froth comes out of both nostrils and mouth. c. Dark fluid blood is found in the heart and big blood vessels. d. Trachea is congested and filled with froth. e. Lungs are engorged, edematous and exudes frothy fluid. f. Stomach may contain brownish lump of opium mixed with brownish viscid fluid, if opium was ingested. g. Odor of opium may be present in the stomach content. h. There is brain congestion.

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i. Pupils are pinpoint-size. j. Multiple scars and abscesses along the course of the superficial veins in the arms and forearms are observed, k. Chemical examination of the blood shows the presence of the drug. SEDATIVES BARBITURATES: Barbituric acid or malonyl carbamide was the product of the synthesis of malonic acid and urea allegedly on St. Barbara day. Small dose has sedative effects while bigger dose may induce sound sleep. 1. Common Preparations and their Slang Equivalents: Short-acting preparation: a. Secobarbital (Seconal) — "red devil". b. Pentobarbital (Nembutal) — "yellow jackets", "nemmies". Intermediate acting preparation: a. Amobarbital (Amytal) — "blue heavens", "blue dragon". Long-acting preparations: a. Phenobarbital (Luminal) — "purple heart", "barbs". Combination: a. Secobarbital — amobarbital (Tuinal) — "tooies", "christmas trees", "rainbow". Barbiturates in general — "goofballs", "footpills". 2. Use of Barbiturates: Medicinal: a. Prescribed in the treatment of high blood pressure, insomnia and epilepsy. b. Used in the diagnosis and treatment of mental illness. c. Given to relax patient before and during surgery. Non-medicinal: a. To escape personal problems — usually insecurity, failure or frustration. b. A substitute for heroin when the supply of their preferred drugs runs short to intensify the effect of heroin. c. To quiet oneself down (Amphetamine abusers). d. Some patients have increased their prescribed dosage to the state of dependence.

DRUG DEPENDENCE

665

3. Signs and Symptoms: In ordinary dose: a. b. c. d. e.

Sedation without analgesia. Decrease in mental acuity. General sluggishness and slowed speech and comprehension. Emotional liability. Poor memory and faulty judgment.

f. Exaggeration of basic personal traits. In toxic dose: a. Ataxia and diplopia. b. Positive Romberg sign. c. Respiratory depression. d. Perceptual time distortion. e. Suicidal tendencies. f. Dysarthria (slurred speech). g. Toxic psychosis. h. Coma or death. Continuous administration will cause a marked degree of physical dependence and tolerance to all the barbiturates, and when suddenly withdrawn, Withdrawal Symptoms may be experienced, which include: a. b. c. d. e. f. g. h. i. j.

Anxiety. Involuntary twitching of the muscles. Tremor of the hands and fingers. Progressive weakness. Dizziness. Distortion of visual perception. Nausea and vomiting. Insomnia and loss of weight. Precipitated drop of blood pressure on standing, Convulsion of the grand mal type.

METHAQUALONE: Methaqualone is a sedative drug in a smaller dose and a hypnotic in a bigger dose. The effect is similar to barbiturates and action is within 30 minutes after administration; the effect is for 6 to 10 hours. It has no analgesic effect but can potentiate the analgesic effect of other drugs like codeine. The hypnotic dose is 150 — 500 mg. and the fatal dose is probably 5 grams. The symptoms of poisoning are nausea, gastric irritation, vomiting muscle twitching, hypertonia, cardiac arrhythmia, tachycardia and respiratory depression.

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666

Most fatal poisoning results from the ingestion of drug in combination with other drugs. It is possible that the combination made on the drug is more toxic than methaqualone alone due to potentiation. Excretion of the drug is relatively slow so it is inevitable that the drug will accumulate during multiple dosing. Post-mortem findings are not specific and similar to barbiturate poisoning. Mandrax, a proprietary medicine commonly used by adolescent drug dependents and contains 250 mg. of methaqualone with 25 mg. of diphenhydramine, an anti-histaminic drug. The combination has a powerful hypnotic effect and it is alleged to produce its effect by selective action of the thalamico-cortical part of the ascending reticular-activating system by reducing the inflow of sensory impulse to an otherwise unaffected cortex. This results into a state of indistinguishable form of normal sleep. The drug can also produce anti-histaminic effect. Psychological rather than physical dependence tends to occur after several dosage. Dependents sometimes complain about an effect called "Stonewalling '. This means that several mandrax tablets taken may cause insensitivity and drowsiness to such an extent that the individual may walk into a wall or barrier or crash a motor vehicle into a wall, an embankment or other obstacle. 1

The effect of mandrax is potentiated by alcohol. The drug is contra-indicated in epilepsy, eclampsia and marked hepatic dysfunction. Mandrax has been implicated as a cause of peripheral neuropathy.

H A L L U C I N O G E N S OR PSYCHOMIMETIC D R U G S 1. Classification: a. Natural Source Amanita muscaria — Mushroom Banisteria caapi — vine Cannabis sativa — Hemp Catnip — plant Datura — plant Epena — tree bark Iboga — plant root Kaba — Piper M. plant Nutmeg — tree seeds

Active principle Unknown Harmine Cannabinols Unknown Scopolamine Unknown Ibogaine Unknown Myristicine

DRUG DEPENDENCE Ololiuqui — Morning glory Peganum harmala — plant Peyote — cactus Piptadenia peregrina Psilocybe — Mushroom Virola — Nutmeg family

667 Lysergic acid Harmine Mescaline Bufotenin Psilocybin Elemicin

b. Synthetic Name DET DITRAN DMT DPT LBJ LSD MDA MMDA PCP PCPA STP-DOM TMA

Chemical Name Diethytrytamine pipidylbenzilate Pipidylbenzilate Dimethyl tryptamine N ( 1 ) N dipropyltryptamine N ( C H 3 ) 3 piperidylbenzilate H C L D Lysergic Acid Diamide 3, 4 Methylenedioxyamphetamine 5 methoxymethlenedioxyamphetamine Phencyclidine p-chlorophenylalanine 2, 5 dimethoxy 4 methylamphetamine 3, 4, 5, trimethoxyamphetamine

MARIJUANA. Marijuana is a Mexican term meaning "pleasurable feeling". Marijuana is a mixed preparation of the flowering tops, leaves, seeds and stem of the hemp plant, Cannabis sativa. The plant may grow from 3 to 10 feet high, but may grow as tall as 16 feet. The highest quality of marijuana is derived from choice hemp grown in hot, and humid places and from the mixture containing mostly of resin covered tops and upper leaves. The flowering tops of both male and female plants produce a sticky resin which contains Tetrahydrocannabinol or T H C , the major pharmacological active ingredient. The potency of the mixture depends on the resin content and this is determined mainly by the plant strain and also by the factors involved in cultivation, harvesting and preparation of the crop. There are many species of cannabis and other plants reported to contain T H C . On a study, it's been reported that 117 of 350 plants of cannabis contains 0% of T H C . Another study showed that the THC content ranges from 0.04% to 6.1%. Questions: 1. Does our local marijuana plant contain THC? 2. If so, how much does it averagely contain? 3. What will be the effect on the toxic contents if grown in high mountain or in the lowland?

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4. Which portion of the plant has relatively more THC content? 5. Which type of plant is more toxic, the mature? or the immature plant? Other Names for Marijuana: Pot, grass, Indian hemp, "damu", weed, bhang, ganja, chards, dagga, kif hash, hashish, tea, reefers, cigarette, stick, joint, smoke, straw, live, ped, Acapulco gold, bush, butter flower, muggles, griffe, Indian hay, loco weed, MJ, Mary Jane, love weed, Mary Warner, Mehasky, Sativa, reach. Classification of Marijuana: According to the U.S. Army Chemical Laboratory in Japan, Marijuana may be classified as: 1. "Vietnam Green" — Coming from southeast Asia and found to be twice as potent as those varieties grown in the United States. 2. "Acapulco G o l d " — Grown in southern Mexico and may contain as much as 2 to 4% T H C . 3. "Panama R e d " — Grown in the canal zone and is reputedly the strongest of all. Special Preparations of Marijuana: 1. Hashish or Charas— A preparation obtained by separating the pure resin from the tops, leaves and stem of the plant. It is dark green or brown and is smoked with tobacco in pipe. It is the most potent of all cannabis preparations. 2. Bhang — The dried leaves and fruit shoots are used as an infusion in the form of beverage. It is the least potent of all preparations. 3. Ganja — This consists of dried flowering tops of female plant with rusty green color and characteristic odor. It is mixed with tobacco and smoked in pipe. 4. Majun — Infusion of dried leaves and tops mixed with flour, milk, butter and sugar. Sometimes dhatura seeds are added to increase potency. 5. Reefers — Dried leaves and stem are sliced and made into cigarettes and smoked. In addition to being an extractable active principle from cannabis resin, tetrahydrocannabinol can be synthesized. It can be ingested or smoked, but smoking provides rapid induction of the drug effects. Ingestion delays the onset of action from 45 to 60 minutes. Synthetic tetrahydrocannabinol is more effective when smoked than when ingested. The reason probably is that the synthetic THC undergo heat-isomeration to a more potent compound with the combustion or smoking.

DRUG DEPENDENCE

669

Natural tetrahydrocannabinnol ingestion makes the power effect long lasting and there is more hang-over than when smoked. There is a strong possibility that certain toxic constituents of natural cannabis resin which entered the body when eaten are destroyed by heat combustion. Factors Influencing the Effects of Marijuana: 1. Dosage of the drug and modes of administration: 2. Potency of the preparation. 3. Period of use (short or long term). 4. Expectations and mood of the user. 5. Environmental or social setting. 6. Personality and psychology of the user. Effects of Marijuana: 1. Subjective Effects (after a number of inhalation): a. A feeling of lightness of the extremities, followed by "rushes" of warmth and well-being that eventually lead to a sense of relaxation and mild euphoria. b. A distortion of sense of time, distance, vision and hearing. ( 1 ) A minute seems like an hour. ( 2 ) Eyes tend to focus on one object to the exclusion of others. ( 3 ) Certain sounds become striking in character and music takes on a new dimension. c. Whetted appetite. Food and drink taste especially good. d. A tendency to be confused about the past, present and future. e. Impaired short-term memory. There is a deterioration in the capacity to carry out task requiring multiple mental steps to reach specific goals. f. Tendency to be easily distracted. g. The suggestibility and release of inhibition. h. Increased sense of sociability and hilarity. These effects are at peak, shortly after smoking and fade away after a few hours, leaving a desire to sleep. 2. Objective Effects: a. Moderate increase in resting pulse rate. b. Reddening of the eyes due to dilatation of the conjunctival blood vessels. c. Difficulty of speech and of remembering the logical trend of what was being said. d. Neurological and EEG examinations show slight increase in cortical functions.

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e. Tremor and muscular incoordination. f. In high dosage it may cause: (1) Frank hallucination, delusion and paranoid feeling. ( 2 ) Confused and disorganized thinking. (3) Toxic psychosis. 3. Other Undesirable Effects: a. Bronchitis and asthma may occur in susceptible individuals and may be treated symptomatically. b. Nausea and vomiting occasionally develop when a novice smokes too much but disappear as the effect of the drug wears off. c. Panic reaction occurs when the individual becomes frightened about the effects of the drug and starts to doubt that the changes are irreversible. It is more common among novice users and more frequently observe in areas where people believe that smoking marijuana causes deviant behavior, but rare where it is accepted as a recreational intoxicant. d. Amotivational Syndrome — This is characterized by a progressive change from conforming, achievement-oriented behavior to a state of relaxed drifting. As a result, the person affected seems unwilling to follow routines, endures frustrations or carry out long-ranged plans. In extreme cases, greater introversion is exhibited with the subject becoming totally involved with the present, while disregarding the future goal. He tends toward child-like magical thinking and reports greater creativity but less objective productivity. The condition is reversible and if smoking is discontinued the user returns to his pre-drug level of functioning. e. Acute toxic psychosis — A temporary malfunction or less in reality, this is self-limited and usually no drug is necessary. The patient must only be protected from injury for the duration of his disorientation. Marijuana is not addictive. Physical dependence and dose tolerance do not develop with its use and withdrawal symptoms are not seen when usage is discontinued. Psychic dependence may occur among marijuana users. Marijuana is a non-lethal drug to human subject. A high degree of safety has also been demonstrated in animal experiments. A dose of 150 mg. per kilo body weight in mice and huge dose have been given to dogs without causing death. There has been no reported case of fatal marijuana overdosage in man. (Historical Aspect of

DRUG DEPENDENCE Cannabis Sativa in Western Medicine by T.H. Mikuriya. Physician, 1656).

671 The New

The fact that many heroin addicts have smoked marijuana does not establish a casual relationship between marijuana smokers and opium addiction. The "stepping stone theory" is considered invalid and that the progression to stronger drugs that occurs is a result of personality and environmental factors and not dependent on the pharmacological properties of marijuana (Acute and Chronic Toxicity of Marijuana by D.E. Smith, U. of California Press, 1969). Marijuana does not cause aggressive criminal behavior. The pacifying effect of marijuana makes the individual non-aggressive rather than cause violent crime (Marijuana Problem by W.R. McGlothis, AmJ of Psychiatry, 125, 370, 1958). There is no evidence that marijuana leads to sexual debauchery. Marijuana is not an aphrodisiac. There were reports of greater sexual enjoyment while high and the possible explanation is the increase sensory awareness and the distortion of time which would seem to prolong the duration of orgasm (Cannabis by W.H. McGlothin, The Marijuana Paper, Indianapolis, 411, 1966). However, recent findings revealed that cannabis may act on hormone regulators and produces impotence and temporary sterility. Heavy marijuana smokers have lowered sperm counts and impotence. Hormones such as leuteihizing hormone, anti-diuretic hormone, growth hormone, and prolactin are also affected by marijuana (Marijuana by Gabriel G. Nahas, JAMA Vol. 233, No. 1, Jul. 1975). Marijuana also affects the body's cellular processes which include reduction of the number of T-lymphocytes with the resultant interference in the immune process. There is also increase in the number of cells with broken chromosomes (JAMA, Vol. 232,No. 9 June 2, 1975, p. 923). Metabolism: Marijuana has three major components: T H C , cannabidiol and cannabinol. All of them have pharmacologic activity. Variance in the amount of the active constituents has some bearing in the difference in pharmacologic activities. The metabolism of cannabinoid takes place in the liver and possibly on other site, like the lung. The cannabinoids are rapidly hydrolyzed into some form of 11-hydroxy compounds. A small amount is found in the blood and there is a major metabolites in the feces. There is a rapid elimination of T H C from the blood during the first 40 minutes, then a much slower elimination in the next 24 hours.

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L Y S E R G I C A C I D D I E T H Y L A M I D E ( L S D - 2 5 ; D ) — Lysergic acid diethylamide tartrate.) The drug was first synthesized by Dr. Albert Hoffman and Dr. Arthur Stell while working in a Swiss pharmaceutical firm. LSD is synthesized from the alkaloids or ergot (Claviceps purpurea), a fungus that parasitizes rye and other grains in Europe and America and diethylamide portion of ergotamine ergonevine, the active oxytocic and vasoconstrictor drugs. The synthesis was found to have strange and potent central effects. It may be medicinally used in the treatment of alcoholism and opium addiction and is the drug of choice to induce tranquility and reduces the need for analgesic in cases of terminal cancer. L S D is colorless, tasteless, odorless, usually in liquid form and taken orally. 1. Symptoms: a. Physiological — Dilatation of the pupils, over-activity of reflexes, increase of muscle tension, lack of coordination, visual disturbance, laughter. b. Somatic — Dizziness, weakness, tremor, nausea, drowsiness, parasthesia (sensation of pricking, tingling or creeping of the skin) and blurred vision. c. Perceptual — Alteration of shapes and color; music appreciation with abnormal intensity; focusing difficulty; sharpening of the hearing sense, recurrent voice accompanied by brilliant hallucinatory color sensation (synesthesia or seeing sound, hearing color, etc.). d. Psychic — M o o d alteration, tension, distortion of time sense, difficulty in thought expression, depersonalization, dreamlike feeling and visual hallucination. Delusion of omnipotence is common such that a user thinks he can fly from a high building. A number of deaths occur in this manner. 2. Dose and Tolerance: It is more than 100 times more potent than psilocybin and 4,000 times more potent than mescaline in producing psychological effect.' L S D is a very potent drug. A dose of 15 microgram can produce psychological effects. The normal dose is from 100 to 250 microgram. L S D has the capacity to develop rapid tolerance. In a few days of repeated use, a formerly effective dose will no longer cause a response but physical and psychological dependence does not develop.

DRUG DEPENDENCE 3. Untoward

673

Effects:

a. Acute panic reaction ("Bad trip", "freak-out") as a frequent complication may lead to suicide attempts. b. L S D removes the usual intrinsic restraints causing uncontrollable violence or aggression. c. It causes chromosomal breaks and/or chromosomal rearrangements which may persist as long as 15 months. This may cause malformation of the children to be born. Thalidomide is another allied drug which produces a broadly defined syndrome of limb, cranial nerve, heart, eye, ear and reproductive system defects of varying degree of severity. The fetus is susceptible to thalidomide only for 14 days; that is between the 36th to the 50th day following the last menstrual period. Absence of ears and paralysis of the cranial nerves is usually caused by thalidomide intake on the 35th to 36th day after the last menstruation. The arms are affected 3 to 5 days later. The legs are usually affected before the 43rd day. The 40th to 50th day marked the end of the sensitive period. Thalidomide given on these last days does no more than producing hypoplastic thumbs with three joints or anorectal stenosis. d. Damage on the white blood cells may cause leukemia. 4. Treatment: Phenothiazines and barbiturates, singly or in combination, have sometimes been found effective in treating an acute intoxicated state. The regular L S D user knows this well and may keep a supply of chlorpromazine on hand. OTHER H A L L U C I N O G E N S A N D PSYCHOMIMETIC DRUGS: DMT, DET and DPT are tryptamine derivatives which produce a syndrome similar to that of LSD but differ in the following ways: 1. The onset is more rapid, increasing the likelihood of a panic reaction; 2. The duration of action is only 1 to 2 hours; and 3. The autonomic effects consisting of pupil dilatation and elevation of blood pressure are more marked than in LSD. STP and DOAf induce an LSD-like reaction lasting for 72 hours or longer. Because of their long effect they are less popular than LSD. AfDA or "love pill" induce a relatively mild LSD-like reaction lasting 6 to 10 hours. The amphetamine-like effect it produces tends to persist longer than the psychomimetic effect. This causes

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euphoria instead of psychic depression as the "coming down" effect. MORNING GLORY (Ololiuqui, "HeavenlyBlue", "Pearly — The seeds contain compounds similar to L S D . Symptoms drowsiness, perceptual distortion, confusion, liability of hallucination, giddiness and euphoria may alternate with anxiety. The common side effect in oral ingestion includes vomiting and diarrhea. CACTUS-PEYOTE (Active principle-Mescaline) berance atop the plant are cut off and dried in peyote or mescal buttons which contain the active They are made into cakes, tablets or powder and in Northern Mexico in ceremonies.

Gates" include effect, intense nausea,

— The protuthe sun to form drug, mescaline. used by Indians

Mescaline produces effects similar to L S D but less potent. Although it may produce vivid hallucination, psychotic reactions are far less common as compared with L S D . MUSHROOM-PSILOCYBIN - This is available in powder and liquid form and extracted from mushroom (psilocybe) which grows in Mexico. The effect is similar to mescaline. DATURA — An anti-cholinergic agent and a constituent of "Asthmador", an over the counter preparation for asthma. High dose induces disorientation, confusion, hallucination and eventually coma. Other signs of mydriasis, tachycardia, decreased salivary action, urinary retention and warm, flushed skin are also observed. NUTMEG (Myristica) — It is the powdered seed kernel of the East, Indian Tree, Myristica fragrans, which contains a hallucinogenic substance thought to be myristicin. When ingested it produces euphoria, hallucination and acute psychotic reaction. The side effects are similar to that of atropine, but nutmeg produces early pupillary constriction. STIMULANTS AMPHETAMINES: Amphetamine was first synthesized in 1927 as a substitute for epinephrine which was isolated from the adrenal gland and from ephedrine obtained from the Chinese herb ephedra vulgaris. The Most Common Preparations of Amphetamine in the Market are: 1. Dextreamphetamine (Dexedrine) also called "co-pilot", "dexies", or "orange". 2. Amphetamine (Benzedrine) also called "bennies", "splash", "peaches".

DRUG DEPENDENCE

675

3. Methamphetamine (Methedrine: Desexyn) also called "meth" "speed", "crystal", "crank", "white cross tablets". 4. Dextroamphetamine plus amphetamine (Dipetamine; Biphetamine) also called "footballs". Amphetamine acts on the cerebral cortex causing alertness, excessive self-confidence and feeling of well-being. Drowsiness and sleep are prevented. Mood elevation and fantasy thinking are common effects and sexual excitation has been described. Medicinally, amphetamines are used ( 1 ) to curb the appetite in overweight persons, ( 2 ) to relieve mild depression such as accompanying grief, senility, menopause and convalescence, and ( 3 ) to keep patient awake in narcolepsy, a disorder characterized by brief attacks of deep sleep. Reasons Why Some Persons Abuse the Use of Amphetamine: 1. For thrill.' 2. As a substitute when other narcotic supplies are temporarily cut off. 3. To give a feeling of increased strength and endurance. 4. To reduce fatigue during athletic performance. 5. To ward a sleep among students cramming for the examination. 6. To effect a prolonged high when used in combination with other drugs, like alcohol, heroin or barbiturates. 7. As a body reducer by reducing appetite. Types of Amphetamine Abusers: 1. Adaptive abusers —Those who take amphetamine to bolster their functioning within conventional, interpersonal and social activities. 2. Excapist abuser — Those who abuse amphetamine to avoid such interpersonal and social activities. This type of abuser has a cycle having two phases of approximately equal duration. a. "Up" or active phase — The subject is given the drug, usually methamphetamine, at two to four hours interval for four to five days. During the time he remains awake. b. "Down" or reactive phase — After being awake and continuously active four or five days, the abuser then collapses from exhaustion, remaining in a semi-comatose state and sleeping intermittently for the next four or five days. Danger of Amphetamine Misuse: 1. Overactivity leading to social consequence (car accident) or aggressive behavior; stealing and murder may have been associated with excessive amphetamine taking. 2. Production of a psychotic illness of the schizophrenic type.

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LEGAL MEDICINE

3. Shock and collapse following amphetamine usage and excessive physical exertion. 4. May lead to habituation. 5. Risk of suicide during the withdrawal phase. Withdrawal Symptoms: Initially there is a sensation of chilliness, uneasiness and yawning. This symptom will be followed by rhinorrhea, lacrimation and mydriasis. Respiration will become labored and short with a feeling of anorexia. Later the person will fall asleep and if awakened the symptoms will become pronounced with tachycardia, fever and hypertension. Pain and cramp of the legs and abdomen will be observed. Perspiration, vomiting, diarrhea and tremor will be observed. Psychological dependence develops among chronic abusers only and may lead to social, economic and emotional deterioration. Possible complications that may develop in the course of continuous and excessive use of amphetamine: 1. Development of a syndrome resembling heat stroke with coagulopathy and renal failure. 2. Necrotizing angilitis, 3. Fatal collapse associated with marked fatigue and nervous tension. 4. Widespread hemorrhage, especially in the endocardium and myocardium and rapid development of myocardial fiber necrosis. 5. Psychosis and other permanent brain damages. 6. Frequent accidents in highway driving. Excretion: 50% of amphetamine is destroyed in the liver by dissemination and the rest in the kidneys at a slower rate. The drug use to appear in the urine 3 hours after administration. The presence of amphetamine is detected in body fluid by (1) gas chromatography with hydrogen flame detector or by ( 2 ) thin layer chromatography.

COCAINE: Cocaine is an alkaloid from the leaves of the coca shrub cultivated extensively in Bolivia and Peru. It is also grown in Java, Taiwan and Sri Lanka. The leaves are harvested from the plant not less than 10 months old. The matured leaves are plucked, dried and packed in bales. Cocaine may be taken by injection, by chewing or by sniffing of crystals through the nostrils. The coca leaf is chewed by many

DRUG DEPENDENCE

677

Indians of the Andes for its stimulating effects and also for depressing appetite. Repeated sniffing of cocaine crystals into the nasal passage may cause gradual erosion and perforation of the nasal membrane. Cocaine stimulates the sympathetic system causing increased pulse rate, dilatation of the pupils and perspiration. It is a euphoriant and speedily relieves fatigue. Cocaine is said to cause sexual excitement and the drug therefore is popular among the undersexed or sexual perverts. Tolerance to the drug is slow and dependence tends to be psychological rather than physical. If cocaine is taken for a period of time, especially in excessive dosage, it may cause pallor, poor appetite, salivation, loss of weight, and damage to the nasal membrane and cartilage in sniffers. Cutaneous scars of old injection sites may be evident and habitual cocaine eaters develop black teeth and tongue. Magnan's Symptom or the feeling as if grains of sand are lying under the skin or small insects (cocaine bugs) are creeping on the skin is the most characteristic symptom. It has been reported that cocaine leads to erotic tension in women. Death may be due to epilepsy or respiratory failure. The drug when withdrawn from the user may cause withdrawal symptoms in the form of insomnia, reactive depression, and paranoid attitudes which may lead to paranoid psychosis. Users of cocaine recently combine it with heroin called "mixing the gravy" to counteract lethargy and social isolation effect of heroin. Medically the use of cocaine has markedly declined and its major use is only as anesthesia of the nose and throat. On account of the disadvantages observed in the use, the synthetic procaine becomes the wildly used substitute under the trade name of novocain. Prostitutes inject a solution of cocaine into the vagina. This gives the individual a sense of local constriction and exhilarating systemic feeling. In men cocaine is applied locally to the glans penis to increase the duration of the sexual act. It may cause sexual perversion especially in homosexuality or in libidinous outrages. In fatal dose, death is due to cardiac or respiratory failure. Cocaine "body packer" Syndrorpe refers to the ingestion of multiple small packages of cocaine for the purpose of transporting the contraband. The drug is placed in a durable, non-digestible container, taken by mouth to be recovered at the place of destination in the fecal discharge. Aside from human beings, the pack-

678

LEGAL MEDICINE

ages are fed to camels or ducks. In the case of ducks they are slaughtered to retrieve the drug. Rupture of the container while in the alimentary tract with consequent cocaine poisoning has been reported in literature. DRUG DEATH: Drug related death may be classified into three categories: 1. Primary drug fatalities — those which death is due to the toxic or adverse effect of the chemical agent, with or without the contributory influence of pre-existing, unrelated natural disease. 2. Secondary drug fatalities — those arising from medical complications of drug abuse, such as viral hepatitis and bacterial endocarditis. 3. Drug-associated fatalities — those caused by homicidal, accidental and suicidal violence stemming directly or indirectly from activities related to the obtaining and use of illicit drugs. The qualitative and quantitative determination of the dangerous drug in the human body or the pathologic changes in organs cannot be utilized as the basis of the cause of death. There are other factors to be considered which may be responsible for the death: 1. The decedent may be usually susceptible to the deleterious effect of the drug; 2. The combination of the drugs taken can interact in an additive fashion; 3. Some pre-existing natural disease may have contributed to the death; 4. The rapid absorption of large quantity of the drug can kill prior to complete absorption of all the substance from the gastro-intestinal tract; 5. Normal metabolic degradation of the chemical can reduce its blood concentration during the prolonged survival interval in which respiratory complications and hypoxic encephalopathy maintain coma and act as the immediate cause of death. (Modern Legal Medicine, Curran, et. at., p. 1129).

Psychiatry

and

Forensic

Science

by

Identification of Some Dangerous Drugs: 1. Gross and Microscopic: Inasmuch as marijuana is smoked as leaf fragments, its identification may be used on the botanical features, grossly and microscopically by trained experts. A complete leaf may be identified by the characteristic irregular shape. Microscopically, identification depends largely on observation of short hair on the

DRUG DEPENDENCE

679

upper side of the leaf known as cystolith and the presence of longer nonglandular hair on the opposite side. 2. Micro-crystalline Test: A drop of chemical reagent is added to a small quantity of the drug on a microscopic slide. After a short time, a chemical reaction ensues producing a crystalline precipitate. It is the size and shape of the crystal under the microscopic examination that is characteristic of the drug. 3. Color Test: a. Opium and its derivative together with amphetamine: ( 1 ) Marquis test — (2% formaldehyde in sulfuric acid) — Turns purple in the presence of heroin and morphine as well as most opium derivatives. The test will also produce an orange-brown color when mixed with amphetamine and methamphetamine. b. Barbiturates: ( 1 ) Dillie Koppanyi test — (1% cobalt acetate in methanol is first added to the suspected material followed by 5% isoprophylamine in methanol). A violet-blue color is produced. This is a valuable screening test for barbiturates. ( 2 ) Zwikkers test — A d d approximately 0.5 ml. of 0.5% aqueous solution of copper sulfate to a small amount of sample. Mix gently and add an equal volume of a 5% solution of pyridine in chloroform. Shake first the layers, separate and observe the color of the chloroform layer. If the sample barbiturate, the sample contains barbiturate, the

contains the free acid or sodium salt of a chloroform layer will be purple. If the the free acid or sodium salt of a thiochloroform layer will be bright green.

Addition of one drop of glacial acetic acid to the chloroform, water system will: (a) Destroy the purple color of the chloroform layer and change it to a very weak blue if the sample contains the free acid or sodium salt of a barbiturate: ( b ) Reduce the color of the chloroform layer to a faint green if the sample contains the free acid or sodium salt of a thiobarbiturate. On further addition of the acid the color will change to a light yellow green. c. Marijuana: Duquenois-Levine test — Solution A is a mixture of 2% vanillin and 1% acetaldehyde in ethyl alcohol; solution B is concentrated hydrochloric acid; and solutions A , B and C are added respectively to the suspected material. A positive result is shown by purple color in the chloroform layer.

680

LEGAL MEDICINE

d. LSD: Van Urk test (1% p-dimethylaminobenzaldehyde and 10% concentrated hydrochloric acid in ethyl alcohol). This reagent turns blue-purple in the presence of L S D . However, owing to the extremely small quantities of L S D in illicit preparations, this test is difficult to conduct under field conditions. e. Cocaine: Cobalt Thiocynate test — (2% cobalt thiocyanate in water). This reagent produces a blue flaky precipitate in the presence of cocaine. The test is not reliable as many other drugs and diluents respond in the same manner. 4. Chromatography: a. Thin layer chromatography. b. Gas chromatography. In both methods the drug is separated from the diluent while providing for its identification. 5. Spectrometry: Selective absorption of light by drugs in the UV (Ultra-violet) and IR (Infra-red) regions of the electromagnetic spectrum. UV spectrum is not conclusive for the positive identification of drug because other drugs may very well produce an indistinguishable spectrum, but may be useful to establish the probable identity of the drug. IR spectrophotometry can specifically identify substances, but the substance to be identified must be in pure form. A combination of preliminary screening by UV followed by verification through infra-red spectrophotometry is the most ideal approach to drug identification. DELIRIANTS Drugs which cause delirium, intoxication and other mental and psychic disturbances when the toxic vapors and fumes are inhaled are not covered by the Dangerous Drug Act of 1972 as amended, hence Presidential Decree N o . 1619 was promulgated on July 23, 1979. Drugs included in P.D. 1619: Volatile substances including any liquid, solid or mixed substance having the property of releasing toxic vapors or fumes containing one or more of the following chemical compounds: Methanol Stryene Ethanol Napthalone Isopropanol N-pentane

DRUG DEPENDENCE Ethyl acetate N-propyl acetate N-butyl acetate Acetone Methyl ethyl ketone Methyl butyl ketone Benzene Tolouene Xylene

681

N-hexane N-heptane Methylene Chloride Trichloroethylene Tetrachloroethylene Nitrous oxide Dichlorodiflouremethane Isoamyl nitrate Chloroform

or other chemical substance which when sniffed, smelled, inhaled, or introduced into the physiological system of the body produces or induces a condition of intoxication, inebriation, excitement, stupefaction, dulling of the brain or nervous system, depression, giddiness, paralysis, or irrational behavior or in any manner changing, disturbing or distorting the auditory, visual and mental processes (Sec. 1). Acts which are Punishable: 1. The use or possession of volatile substances for the purpose of inhalation to induce or produce intoxication or any of the conditions described in Sec. 1 (Sec. 2). 2. The sale, administration, delivery, or giving away to another on any term whatsoever, or distribution, dispatch, transaction or transportation or acting as a broker in any such transaction, any substance or mixture or substances containing one or more of the chemical compounds mentioned in Sec. 1 (Sec. 4). 3. Maintenance of a den, dive or resort where any substance or mixture of substances containing one or more chemical compounds mentioned in Sec. 1 (Sec. 5). 4. The sale or offer to sell volatile substances to minors without requiring the written consent of their parents or guardians as a condition for such sale or offer to sell, provided that when the minor is 18 years or over and is duly licensed to drive a motor vehicle, such written consent shall not be necessary when the volatile substance sold or offered for sale is gasoline or any other motive fuel for vehicles. 5. The sale of, or offer to sell, to minors of liquors or beverages containing an alcoholic content of thirty percentum or above (60% proof or above) (Sec. 6). For public information the Dangerous Drug Board is obliged to publish the list of dangerous drugs and any subsequent changes in the list. "The Board shall give notice to the general public of the reclassification, addition to or removal from the list of any drug by publish-

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LEGAL MEDICINE

ing such notice in any newspaper of general circulation once a week for two consecutive weeks (Sec. 40, Dangerous Drugs Act of 1972 as amended — Reclassification, addition or removal of any drug from the list of Dangerous Drugs.) Effects of such Reclassification, Addition or Removal: 1. In the case of prohibited drug reclassified as regulated, the penalties for violation of this Act involving the latter shall, in case of conviction, be imposed in all pending criminal prosecutions. 2. In the case of regulated drug reclassified as prohibited, the penalties for violation of this Act involving regulated drugs shall, in case of conviction, be imposed in all pending criminal prosecutions. Present State of the Drug Problem in the Philippines: 1. Marijuana is now planted in almost every province of the country. a. The profit aspect is comparatively great. b. Local and foreign demand are probably more. c. The Philippine climate is most conducive to favorable growth. 2. There is an increasing number of our youth who are prospective users. 3. Pushers motivated by profit although unquantifiable are seemingly increasing in number. 4. Property offense can be directly correlated with drug dependence. "High" with the drug means high in crime. The effects of the drugs responsible are: a. Toxic psychotic effect. b. Release of inhibition. c. Confusion of thought and disorganization of ideas. d. Suggestibility. 5. There is an increase in vehicular accidents with the driver under the influence of drug due to: a. Distortion of time, distance, vision and hearing. b. Aggressiveness. c. Lack of inhibition. d. Deterioration of the capacity to carry out task requiring multiple steps to reach a specific goal. e. Mental confusion and psychosis. f. Desire to sleep during the later part. 6. Suicide is more common among drug users. This may be attributed to: a. Frank hallucination, delusion or paranoid feeling. b. Confused or disorganized thinking. c. Panic syndrome — feeling of worthlessness. d. Suggestibility and release of inhibition.

DRUG DEPENDENCE 7. 8. 9. 10.

683

Mental affection, like psychosis among drug users is on the rise. Truancy and drop-out in schools among users are rampant. The socio-economic condition of the family is affected. The socio-economic progress of our country has been markedly prejudiced.

Ways of Controlling or Combating the Drug Problem: 1. By preventing users to further use the drug. a. Counseling. b. Treatment and rehabilitation. c. Destruction of the source of the drug. d. Instilling into the mind the philosophy that "It is better late than never". 2. By preventing non-users from starting a life of drug dependence. a. Medical means:( 1 ) Research on the causes, epidemiology, symptomatology, prevention and cure. Drug dependence is a social malady and like any human disease can only be minimized, if not eradicated, by means of a scientific approach. ( 2 ) Formation and implementation of medical hypothesis: ( 1 ) Attentuation ( 2 ) Fortification b. Concerted social action: ( 1 ) Instilling the maxim that "drug dependence does not pay." ( 2 ) Preventive education: ( a ) Group counselling ( b ) Individual case study 3. In case of addition of a new drug to the list of dangerous drugs, no criminal liability involving the same under this Act shall arise until the lapse of fifteen (15) days from the last publication of such notice; and 4. In case of removal of a drug from the list of dangerous drugs, all pending criminal prosecution involving such a drug under the Act shall forthwith be dismissed (Sec. 40(4) D D A of 1972). PRESCRIPTION OF D A N G E R O U S D R U G S Prescription Forms: For the purpose of this Act, all prescriptions issued by physicians, dentists, veterinarians or practitioners shall be made out on forms exclusively issued by and obtained from the Board. Such forms shall be made of a special kind of paper and shall be distributed in such quantities and contain such information and other data as the Board may, by rules and regulations, require. Such forms shall not be issued

684

LEGAL MEDICINE

by the Board or any of its employees except to licensed physicians, dentists, veterinarians and practitioners in such quantities as the Board may authorize (Sec. 25 ( b ) , par. 2, D D A of 1972 as amended). However in emergency cases, the required prescription form may not be used: In such emergency cases, however, as the Board may specify in the public interests, prescriptions need not be accomplished on such forms (Sec. 25 ( b ) , 2nd par., Dangerous Drug Act of 1972 as amended). The following specific conditions fall within the category of emergency wherein the required form may not be used: 1. Where the prescription has to be used on a patient whose need for dangerous drugs is immediate and urgent and has been brought by the effects, or during the course of natural or other calamities, such as typhoons, earthquakes, conflagrations, etc., of such a magnitude as to preclude prompt access to the official prescription forms of dangerous drugs. 2. Where the need for prescribing the dangerous drugs has arisen as a result of a serious accident necessitating the administration of the drugs at the scene or in the vicinity of the accident and the required prescription forms are not readily available. 3. Where the need for the dangerous drug is urgent and its ready availability may, in the opinion of the prescribing physician, spell the difference between life and death of the patient, and for unavoidable and justifiable reasons the prescribed prescription form is not within access (Board Regulation N o . 4, Series of 1973). Obligations Imposed on Physician when Prescription Was Not Made on the Required Form: 1. The prescribing physician shall certify at the back of the ordinary prescription form utilized, as to the nature, time and place of the emergency conditions and the name and address of the patient, and shall see to it that his (physician's) full name and address is indicated in printed form beneath his signature. (Sec. 2, Board Regulation N o . 4, 8. 1978). 2. The prescribing physician shall, within three ( 3 ) days after issuing such prescription, inform the Board of the same in writing (Sec. 25 ( b ) D D A of 1979 as amended and Board Regulation N o . 4, series of 1973).

DRUG DEPENDENCE 685

Loss^of

Prescription Forms

for

Dangerous Drugs (DDR Form

No.

Sec 1. It shall be the duty of every physician, dentist, veterinarian or other practitwner to whom prescription form ( D D B FomTES for the dangerous drugs have been issued, to report any to* thereof to the Dangerous Drugs Board within twenty-four (24) hours from the discovery of such loss, indicating the circumstances surrounding the loss. Upon, receipt of said report, the Board shall cause the publication of the loss in a newspaper of general circulation. Sec. 2. Every loss of prescription forms for dangerous drugs shall be referred for investigation to any police or investigative agency as the Board shall determine. Whenever necessary the police or investigative agency may take possession of the prescription forms remaining in the possession of the physician, veterinarian, dentist or other practitioner. Should the findings of the police or investigative agency show negligence on the part of the physician, veterinarian, dentist or practitioner, the loss shall be reimbursed to the Board by the. negligent physician, veterinarian, dentist or practitioner, and he may be barred from further purchasing prescription forms (Board Regulation N o . 10, s. 1973). How to Make the Prescription: A physician, dentist, veterinarian or practitioner authorized to prescribed any dangerous drug shall issue the prescription therefor in one original and two duplicate copies. The original after the prescription has been filled, shall be retained by the pharmacist for a period of one year from the date of sale or delivery of such drug. One copy shall be retained by the buyer or by the person to whom the drug is delivered until such drug is consumed, while the second copy shall be retained by the person issuing the prescription (Sec. 25 ( b ) , Dangerous Drug Act of 1972 as amended). Duty of the Drugstore Owner in Filling Prescription: Whenever a prescription for dangerous drugs is filled by a drugstore, it shall be the duty of the drugstore owner to use the words " U S E D IN F U L L " to be stamped in bold prints diagonally across the original copy of said prescription in case the full quantity of the drug therein stated is sold, and the words "USED FOR O N L Y " in case the quantity of the drug therein stated is not fully m c n v / blank space must sold (Board Regulation N o . 11, s. 197d) U n e d a n * y indicate the number of tablets, capsules, etc. actually sold). l

4

7

T

h

e

Every pharmacist dealing in dangerous drugs shall keep a ? original record of sales, purchases, acquisitions and deliveries of dangerous drugs indicating therein:

686

LEGAL MEDICINE

1. Name and address of the pharmacist; 2. The name, address and license of the manufacturer, importer or wholesaler from whom dangerous drugs have been purchased; 3. Quantity and name of the dangerous drugs so purchased or acquired; 4. The date of acquisition or purchase; 5. The name, address and class A residence certificate of the buyer; 6. The serial number of the prescription and the name of the doctor, dentist, veterinarian, or practitioner issuing the same; 7. The quantity and name of the dangerous drugs so sold or delivered; 8. The date of sale or delivery. A certified true copy of such record covering a period of three calendar months, duly signed by the pharmacist or the owner of the drug store or pharmacy, shall be forwarded to the city or municipal health officer within fifteen days following the last day of every quarter of each year (Sec. 25 ( a ) , 2nd par., Dangerous Drug Act of 1972 as amended).

Chapter XXXIII ALCOHOLISM Ethyl alcohol ( C H O H , Ethanol, grain alcohol) i> a colorless transparent, volatile liquid with aromatic odor and with boiling point at 7 8 ° C . Like any other types of alcohol, it is formed out of the fermentation of various carbohydrates in grains, fruits or flowers, and from other materials subjected to and isolated by distillation. 2

5

Ethyl alcohol is commonly used as solvents, antiseptic and beverage. When ingested, it does not require digestion before absorption. Although the word "alcohol" refers to a large group of chemical compounds in possession of hydroxyl radical ( O H ) , whenever alcohol is used as part of a beverage, it refers to ethyl alcohol. Alcoholic beverages are primarily a mixture of water and ethyl alcohol with small amount of other substances which impart the characteristic odors and tastes. These substances are called "congeners" since they are simultaneously produced during the fermentation process. The congeners consist of organic acids and esters or even other types of alcohol. It is the congener content that imparts the so called "odor of alcohol" among drinkers. A drunkard is a person who habitually takes or uses any intoxicating alcoholic liquor and while under the influence of such, or in consequence of the effect thereof, is either dangerous to himself and to others, or is a cause of harm or serious annoyance to his family or his affair, or ordinary proper conduct. A habitual drunkard is one who excessively uses intoxicating drink. Habit should be actual and confirmed, but it is not necessary that it be continuous or of daily occurrence. It lessens individual resistance to evil thought and undermines will power, making its victim a potential evil doer. (People v. Amenamon, 37 O.G. No. 114, p. 2324). Classification of Commercially Available Alcoholic Beverages: 1. Wine — A product of natural alcoholic fermentation with wide variety of sugary materials including fruit juices and contains not less than 7% but not more than 17% of alcohol by volume. In fermented beverages the alcohol content is expressed in volume percent. 687

688

LEGAL MEDICINE

a. Red Wine — The wine contains the extracted pigments from the skin, stem and seed of the fermented fruit juice. The color ranges from pale straw to pale pink. b. White Wine — The product of fermentation of fruit juices only after removal of the skin and stem. They are not really colorless but impart a pale straw or green to gold or amber color. c. Dry Wine — Wine wherein practically all the sugar contents are fermented into alcohol. d. Sweet Wine — Wine which contains not less than 1 gram of sugar per 100 milliliter. e. Still Wine — Wine in which fermentation has been completed before bottling so that it contains only such properties of carbon dioxide produced in the fermentation which can be dissolved in the liquid in equilibrium with air under conditions of manipulation. f. Sparkling Wine — Wine that is bottled before fermentation has ceased so that it contains C O 2 gas in solution at greater than atmospheric pressure. The wine may also be impregnated with C O 2 b y allowing it t o undergo fermentation i n closed tanks and bottling under pressure or by simply carbonating the bottled wine under pressure. g. Fortified Wine — Wine whose alcoholic contents are derived partly from fermentation and partly from the addition of distilled spirit. This includes cherries, port and vermouth. h. Chinese Medicinal Wine — Wine which is a mixture of refined alcohol and Chinese herbs and contains not less than 2 0 % alcohol. i. "Ztosi" — Composed of fermented juice of sugar with the characteristic brown color, bitter taste and aroma imparted by dried leaves, bark, twigs and flowers of a tree called "samak" (Macaranga Tanarius). j. "Lambanog" — Native wine produced by distillation of fermented coconut sap ("tuba") and bottled at not less than 80% proof. 2. Distilled Liquor — Distilled liquors are alcoholic beverages produced from distillate of wines, distilled from grains or starch solution or distillate from aromatic substances. In distilled beverages the alcohol contents are expressed in proofs. "Proof" is approximately twice the percentage of alcohol by volume. The sole purpose of the distillation process is to increase the concentration of alcohol in the finished product. This is neces-

ALCOHOLISM

689

sary because fermentation ceases when the alcohol concentration is approximately 12% to 14% by volume. a. Whiskey — An alcoholic distillate from mass of cereal grains or cereal grain products saccharified by the action of yeast distilled at less than 74.7°C and aged at least three years and may contain a flavoring of caramel. b. Gin — The distilled product obtained from the original distillation of mash or by redistillation of distilled spirits with or over juniper berries and may contain other aromatic botanical substances or sugar. c. Rum — A distilled alcoholic beverage prepared by fermentation, distillation and aging of sugar cane products, e.g. sugar cane juice, molasses. It is a yellow-brown liquor of fine bouquet and sweet, smooth alcoholic taste. It may contain caramel and may be flavored with fruit or other flavoring from other botanical substances. d. Alcoholic Cordials and Liquors — These are distillates obtained by mixing or redistillating neutral spirits, usually brandy, with or over fruits, flowers, leaves, seeds or other botanical substances or their juices or with extracts derived from infusion, percolation or maceration of such botanical substances and to which sugar or dextrose or both have been added in an amount not less than 2.5% of the finished product and contain not less than 23% of absolute alcohol by volume. These may also contain natural or artificial coloring material. e. Vodka — Distilled liquor from grain spirit, filtered through activated carbon (charcoal) so as to render the product without distinctive character, aroma or taste. 3. Malt Liquors — Alcoholic beverages brewed from malt or from a mixture of malt and malt substitute, like rye, and may contain other cereal grains and starchy saccharine matters. A characteristic bitter flavor is imparted by the addition of hops. The amount of alcohol need not be stated in the label. a. Ale — a malt liquor brewed in such a manner as to possess the aroma, taste and character commonly attributed to ale and shall contain not less than 3.2% absolute alcohol. In its fermentation, top yeasts are utilized instead of bottom yeasts the latter being utilized in beer. b. Beer — The product of alcoholic fermentation of a mash in potable water of malted barley, hop and/or hop preparation with or without the addition of starchy and saccharine material and

690

LEGAL MEDICINE shall contain not less than 2% and not more than 10% by volume of alcohol.

c. Stout — A malt liquor brewed in such a manner as to possess the aroma, taste and character commonly attributed to stout and, to a marked degree, the flavor of hops. d. Porter — Malt liquor brewed in the manner used in brewing of stout but having in comparison with stout a less marked flavor of hops. An alcoholic beverage shall possess the characteristic attributed to the type of drink that is stated in the definition and standard of identification. The preparation must be free from any ingredient injurious to health, free from sediment of any kind, and shall be manufactured in premises built and maintained under hygienic condition. Causes of Drinking Alcoholic Beverages: 1. Curiosity — Children prefer to experience the pleasant and unpleasant effects rather than being told. 2. It is being served as a symbol of friendship and sociability. Social gathering with alcoholic beverages served becomes lively. Drinking is a part of our culture. 3. As an escape from unpleasant realities, it suppresses inner tension, deadens the pain of failure, frustration and anxieties. 4. Alcohol is a part of religious ceremonies. 5. As a stimulant to combat shyness, inferiorities and to suppress strong inhibition. 6. It is a source of heat and energy. One gram of alcohol may yield 7 calories, by the process of oxidation. One ounce of 100 proof whiskey may yield 100 calories. Provisions of L a w Regarding Alcoholism: 1. Intoxication is an alternative circumstance to criminal liability: Art. 15, Revised Penal Code — Their concept: Alternative circumstances are those which must be taken into consideration as aggravating or mitigating according to the nature and effects of the crime and the other conditions attending its commission. They are the relationship, intoxication, and the degree of instruction and education of the offender. The intoxication of the offender shall be taken into consideration as a mitigating circumstance when the offender has committed a felony in a state of intoxication, if the same is not

ALCOHOLISM

691

habitual or subsequent to the plan to commit said felony; but when the intoxication is habitual or intentional it shall be considered as an aggravating circumstance. 1. Mitigating: a. If intoxication is not habitual; or b. If intoxication is not subsequent to the plan to commit the felony. 2. Aggravating: a. If intoxication is habitual; or b. If intoxication is subsequent to the plan to commit the felony. 2. Public scandal committed by a person while drunk is punishable: To be drunk is not punishable, but if alarm and scandal happens in a public place while at the state of intoxication, it is punishable. Art. 155, Revised Penal Code — Alarms and scandals — The penalty of arresto menor or fine not exceeding 200 pesos may be imposed upon: 4. A n y person who while intoxicated or otherwise, shall cause any disturbance or scandal in public places. 3. Contracts agreed to in a state of drunkenness are voidableArt. 1328, Civil Code: Contracts entered into during a lucid interval are valid. Contracts agreed to in a state of drunkenness or during a hypnotic spell are voidable. 4. The law penalizing manufacture of liquor without license is valid: If a person administers beverages to another which is injurious to the latter without intent to kill, he is punished for his wrongful act. Art. 264, Revised Penal Code: Administering injurious substances or beverages: The penalties established in the next preceding article (arresto mayor in its maximum period to prision correccional in its minimum period) shall be applicable in the respective cases to any person who, without intent to kill, shall inflict upon another any serious physical injury, by knowingly administering to him any injurious substances or beverages or by taking advantage of his weakness of mind and credulity. 5. The state may prevent some people from drinking highly spirited wine: The state may promulgate laws which may prevent people of lower degree of civilization from drinking scientifically manu-

692

LEGAL MEDICINE

factored, highly spirited liquor. The reason is to promote peace and order. The accused was prosecuted and convicted for violation of Act 1639, which prohibits any native of the Philippine Islands, who is a member of the non-Christian tribes to buy, receive, have in possession, or drink any intoxicating liquor other than the native wine or liquor which the tribe has been accustomed to take. The accused attacks the legality of the law on the ground that it denies him of the equal protection of tr^e law. H E L D : Act 1639 is valid. The use of "non-Christian tribes" is not based upon accident or birth or parentage but upon the degree of civilization. The members of the non-Christian tribes have a low degree of civilization. The purpose of the prohibition is to insure peace and order in and among the people. It has been experienced in the past that people of a lower degree of civilization taking scientifically distilled wine with a high percentage of alcohol resulted to lawlessness and crimes thereby hampering the effort of the government to raise the standard of life and civilization (People v. Cayat, 68 Phil. 12). Absorption and Distribution of Alcohol: Inasmuch as alcohol when ingested does not require digestion, it is immediately absorbed in the walls of the stomach and duodenum. The maximum period of absorption occurs thirty to sixty minutes after the initial intake. The rate of absorption of alcohol in the stomach and intestine depends upon the following : 1. Concentration and total quantity of alcohol taken. The higher the percentage of alcohol taken, the greater is the volume of alcohol per unit of time. The greater the volume of alcohol consumed will likewise enhance the absorption. 2. Nature of the food in the stomach and intestine. Fatty food makes absorption slower as compared with sugar and other carbohydrates and proteins. 3. Volume of gastric content — The presence of sufficient amount of food and water in the stomach may delay the rate of absorption. 4. Diseased condition of the stomach and intestine. Achlorhydria, gastric atony and chronic gastritis cause slower absorption, however subtotal gastrectomy or a gastroenterostomy may cause abnormally early intoxication because of its early evacuation of food to the duodenum where absorption is more rapid. 5. Length of time the gastric content is held in the stomach prior to the opening of the pylorus and permeability of the stomach or

ALCOHOLISM

693

intestinal wall. Warm drinks dilate gastric capillaries to cause more absorption. 6. The optimum concentration of alcohol in beverages between 10 to 20% is the most rapidly absorbed. After absorption, alcohol is distributed throughout the body in proportion to the water contents. Parts of the body with more water content (blood, urine, brain, liver, kidney) have the highest concentration while those with low water contents (fat, bone) have the lowest concentration. Pharmacologic Effects of Alcohol: Ethyl alcohol depresses the central nervous system in descending order from the cerebral cortex to the medulla oblongata. It causes depression or temporary functional paralysis of the ganglionic cells. The more specialized the cells are, as in the cerebral cortex, the more sensitive they are to alcohol. A moderate dose will cause disturbance in the intellect and fine muscular movement, but bigger doses will involve depression of the ganglion cells of the lower brain centers in the basal ganglia and brain stem causing the person to be stuporous and even comatose. Effects on the Special Senses: 1. Vision — With increasing amount of alcohol intake the acuity is progressively diminished to the point where vision to obscure to a degree comparable to wearing dark sunglasses at night. There is diminution of the peripheral vision similar to that of a person viewing an object by means of a binocular (tunnel vision), the amount of blood alcohol is somewhere between 100 to 200 mg., ocular coordinator is impaired and diplopia develops. 2. Hearing — The increasing amount of alcohol intake diminishes the ability of the individual to perceive and appreciate varying intensities of sound. This is the very reason why in a drinking party at the start of the drinking the conversation is in a low tone, but as the alcohol level in the blood increases the group tends to talk louder. This also accounts for the tendency of drivers not to perceive the sound of horns and train whistles when intoxicated and to become more prone to vehicular accidents. 3. Touch — The sense of touch is diminished with the increased amount of alcohol intake. The blunting of touch sensation is responsible for frequent cigarette burns on the hand of chronic alcoholics. 4. Taste — There is a decrease in the sense of taste. When a person is drunk, all food taste good.

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5. Smell — The perception of smell is depressed by alcohol. Malodorous substances may be undetected by those under the influence of alcohol. "Proprioception" or the so-called "sixth sense" is also impaired. Blunting of judgment is one of the first mental functions affected by alcohol. This leads to automobile accidents, poor business decisions, gambling losses, fights and injuries. The faculty of attention deteriorates rapidly and this is the principal reason why individuals even with low level of alcohol end up as traffic victims. Motor skills are also impaired progressively with increasing amount of blood alcohol. Reaction time is prolonged. Ability to hear is blunted and recall memory is often markedly disturbed. Moral standard is blunted and lowered, and there is a tendency to distort reality. It increases the desire for sex but markedly impairs the performance; a prolonged intercourse without ejaculation is often the result (Legal Medicine Annual 1969, pp. 241-268). Other Effects: 1. 2. 3. 4.

Dilatation of the blood vessels of the cutaneous surface. Increase in the pulse rate. Weaker cardiac systole which tend to cause cardiac dilatation. Locally, it has direct irritation effect on the mucous membrane of the stomach and intestine. 5. Slight depression of the liver functions as indicated by the decrease in hepatic oxygen consumption and decrease in glycogen storage. 6. Fall of the blood pressure. Clinical Signs and Symptoms in Relation to Blood Alcohol Level: Blood Alcohol Clinical Signs and Symptoms 10 mg % Pleasant clearing of the head. 20 mg %, Physical feeling of well-being. 50 mg % The individual feels on top of the world and has the wisdom of Solomon and the talkativeness of Senator Claghorn. Increased self-confidence; decreased inhibitions; diminution of attention, judgment, and control. 100 mg % The individual is intoxicated and "under the influence". Experts in the field believe that no

ALCOHOLISM

695

innocent person would be convicted of being "under the influence" if he had a blood alcohol level of 100. Some mental confusion, incompetency; drowsiness; emotional instability; decreased inhibitions; loss of critical judgment; impairment of memory and comprehension. 150 mg % At this level all individuals are intoxicated, and deterioration in performance of acts of skill or judgment are present. 150-300 mg % Somewhere between these figures all individuals lose some degree of muscular coordination, including the ability to walk properly and coordinate other body movements. Disorientation; mental confusion; dizziness; sensory disturbances; deceased sense of pain; slurred speech; exaggerated emotional (state of grief, anger and fear). 300 mg % At this level most individuals become stuporous, incoordinated, and may even lose sphincter control. Apathy; general inertia; decreased response to stimuli; impaired consciousness; sleep or stupor. 400 mg % This is the anesthetic level. Alcohol is not a good anesthetic because there is a narrow margin between the anesthetic and the death level. Death from alcohol per se may occur at any level above 400 mg%. Complete unconsciousness; coma; depressed or abolished reflexes; embarrassment of circulation and respiration; incontinence of urine and feces. (From Legal Medicine Annual 1969, p. 254). Symptomatic Changes Following Ingestion of Alcoholic Beverages: Although human reaction varies from person to person, the clinical signs and symptoms following ingestion of alcohol may be divided into three stages, namely: 1. Stage of Excitement — This develops a few minutes after the initial dose of alcoholic drink has been absorbed and has reached the central nervous system. It is characterized by a feeling of wellbeing and slight excitation. The actions, speech and emotion are less strained. Self-confidence develops, as well as blunting of selfcriticism, self-consciousness and self-control.

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It is the manifestation during this state that makes the people entertain the erroneous belief that alcohol is a stimulant rather than a depressant. Alcohol does not stimulate the brain centers but rather "inhibits the inhibition" causing it to act freely without constraints. 2. Stage of Incoordination or Confusion — As the effects of alcohol become more pronounced, the nervous control of the body gradually diminishes. There is blunting of all perceptive mechanism. Muscular coordination is lost. The irritating effects of alcohol, like nausea and vomiting, confusion, cardiac and respiratory symptoms appear. 3. Stage of Narcosis or Coma — The person passes into a deep sleep and may only respond to strong stimuli. Pupils are dilated, breathing is slow and stertorous, pupils are dilated and reflexes, abolished. Death may ensue from paralysis of the cardiac or respiratory center. Degree of Intoxication: 1. Slight Inebriation — There is flushing of the face, with exaggerated mood, but a person is able to control his behavior. He shows no signs of mental impairment, incoordination of movement and difficulty of speech. 2. Moderate Inebriation — Person is talkative, argumentative and over-confident. There is slight impairment of mental faculties, difficulty of articulation, and loss of coordination to finer movements. The face is flushed with eyeballs congested. He is reckless and shows motor incoordination. He may be certified as being "under the influence of alcohol". 3. Drunk — The mind is confused, behavior is irregular and movement is uncontrolled. The speech is thick and incoordinated. Behavior is uncontrollable. 4. Very Drunk, "Dead drunk" — The mind is confused and disoriented. There is difficulty in speech and marked motor incoordination and often walking is impossible. 5. Coma — The subject is stuporous or comatose. Sometimes it is difficult to differentiate this condition with others having coma. Diagnostic Points of Drunkenness: 1. 2. 3. 4. 5.

Alcoholic smell of the breath or of the vomitus. Dry furred tongue or with excessive salivation. Irregular behavior. Congestion of the conjunctivae. Hesitancy or thickness of speech with impaired articulation.

ALCOHOLISM

697

6. Tremor or error of coordination and orientation. 7. Examination of the blood and the urine shows the presence of alcohol. 8. History of having taken alcoholic beverages. Physical Tests to Determine Drunkenness: 1. Romberg's test — Let the subject stand straight with heels together and with closed eyes for at least one minute. If he is not drunk, he will not sway to the front or to the sides, but if he is drunk the body will not be stable in the absence of any existing disease. 2. Let the subject stand straight with one foot ahead of the other so that the toes of one foot touch the heel of the other. This will remove the brace to prevent side sway. If drunk, there is more likelihood that the subject will sway sidewise and fall. The test is repeated after the subject is free from the effect of alcohol and make a comparison of stability. 3. Let the subject sit comfortably in a desk and get samples of his handwriting. Compare these writings, with those taken when he is free from the effects of alcohol. 4. Let the subject bend down and pick up a small object from the floor. If he stumbles, then his nervous system is not stable and that he may be drunk. 5. Let the subject walk straight forward to a comer of a room and rapidly turn around without stopping. Tell him to walk back. Y o u will notice that the subject may have uncertainty of steps, side steps, or he staggers while making the turn and in walking. Conditions Simulating Alcoholic .Intoxication: 1. Severe head injuries. 2. Metabolic disorders — e.g. hypoglycemia, diabetes precoma, uremia, hyperthyroidism. 3. Neurological conditions associated with dysarthria, ataxia, tremor, drowsiness — e.g., disseminated sclerosis, intracranial tumors, Parkinson's disease, epilepsy, acute aural vertigo. 4. The effect of a drug is unlikely to be confused with the effect of alcohol unless the drug has been taken for the first time and has produced an unexpected reaction, or unless it has been in an unusually large dose. (Some drugs whose effects simulate alcoholic intoxication are: insulin; the barbiturates; most of the antihistamine group of drugs; morphine; the new analgesics which tend to cause giddiness; certain drugs used in the treatment of asthma — e.g. remedies containing atropine; drugs used in the treatment of involuntary movement — e.g. hyoscine.)

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5. Certain pre-existing psychological disorder — e.g. hypomania, general paresis. 6. Prodromata of cerebral vascular emergencies, which may show themselves as confusional states, amnesia, or aphasia. The history may enable the doctor to settle any doubt. 7. High fever. 8. Exposure to carbon monoxide in sufficient concentration to give significant anoxemia. (Taylor's Principles and Practice of Medicine Jurisprudence by K. Simpson, 12th ed.. Vol. 2, p. 392). On account of a number of conditions simulating the condition of intoxication, a physician must exercise due care and diligence in the history taking, physical examination and in the observation of the signs and symptoms coupled with appropriate and available laboratory examination before the diagnosis of drunkenness is entertained. A patient became nauseated while driving his car and got out to vomit. A passing policeman arrested him for drunkenness. He went into a spasm in the cell and the defendant physician was called and saw the patient twice for five minutes each time. He adviced the policeman that the man was drunk. The patient died a few hours. An autopsy revealed that there was no alcohol in his blood and that he had coronary occlusion. The court found that a cause of action in the widow's complain properly pointed out that cursory examination fell below the reasonable standard of due care (Johnson v. Borland, 26 NW 2d 755, Mich. 1947). Relation of the Blood Alcohol Level to the Degree of Intoxication: 1. Persons with intoxicated.

blood alcohol below 0.05% are not considered

2. The majority of persons (80-90%) with blood alcohol levels between 0.1% and 0.15% will have their faculties so impaired as to render them unfit to drive motor cars with reasonable safety. 3. The majority of young people who are not habitual drinkers will be intoxicated to the extent of staggering when the blood level is about 0.15%. 4. The majority of all persons (80-90%) including habitual drinkers will be intoxicated to the extent of staggering when the blood alcohol level is approximately 0.2%. 5. The majority of persons will be in a coma when the blood alcohol level is approximately 0.5%

ALCOHOLISM

699

The American Medical Association and the National Safety Council of the United States recommended the following presumptive limits of intoxication: 1. Persons who have 0.05% alcohol or less in their blood are presumed to be uninfluenced by an alcohol. 2. Persons who have 0.05% to 0.10% alcohol in the blood are considered to possibly be under the influence of alcohol. 3. Blood alcohol level of 0.10% to 0.15% or more gives rise to the presumption that the person is drunk. The percentages of alcohol in the blood and in the urine are, on the average, parallel so that the determination of alcohol level in the urine will indicate the amount of alcohol in the blood. Amount of alcoholic beverage consumption to reach the level of 0.15% or higher: As a general rule, it is not the quantity of alcohol consumed that determines the degree of intoxication, although there is an existing relationship, but rather the amount that actually gets into the blood stream. It may require many times more alcohol to raise the blood level in an individual to a given point than is required for another individual. Likewise, it may take more alcohol to raise the blood alcohol in the same individual to a given point on different occasions. It has been found that the blood alcohol level of 0.15% or higher is considered definitely intoxicating, and to have such concentration in the blood will depend on the alcoholic beverage taken. The following are among the alcoholic beverages necessary to bring its level to 0.15% in the blood:

consumed

1. Whiskey (distilled spirit) — It requires the consumption of 8 oz.of whiskey to bring a blood level of 0.15%. The body eliminates about 1 oz. of whiskey per hour. Thus, if a person were to drink over a period of three hours, he would have consumed 11 oz. of whiskey to reach and maintain a blood level of 0.15%. 2. Wine (fermented spirit) — Wine with 20% alcohol requires 16 oz. to cause intoxication. The body eliminates 2 oz. per hour for every hour spent in the consumption of the wine in order to reach the level of 0.15%. 3. Beer (malt liquor) — With beer containing 3.7% by weight of alcohol, the amount required is 80 oz. plus 10 oz. for every hour spent in the consumption. The above consideration is dependent on the proof of the case of distilled spirit or the percent by volume in wine and beer, of a certain specific beverage manufacturer, actually contained in the bottle.

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Conversely, the amount of alcohol consumed may be determined from the blood alcohol concentration by applying the Widmarks formula, as follows: „. . . * , u i Fluid ounces of alcohol =

Ounces of Blood alcohol body weight x 0.68 x concentration 0.8

For a quick and easy consolidation of the formula the following may be used: 13.6 x weight in pounds x concentration of blood alcohol = minimum fluid ounces of pure alcohol (200 proof) to achieve the blood concentration. Double this and one has the fluid ounces equivalent to 100-proof whiskey. (Modern Legal Medicine, Psychiatry and Forensic Science by Curran, McGarry and Petty, p. 316). Factors Responsible for the Tolerance and Susceptibility to Alcohol: 1. Tolerance to Alcohol: T w o or more persons of the same age, sex, weight and environmental up-bringing may react differently to alcohol. One may be tolerant while others may be sensitive. Tolerance of a person to alcohol may be a result of two different factors namely: a. Consumption Tolerance — A person who has developed tolerance may have lesser percentage of blood alcohol as compared with another person who is not used to it when given the same quantity at the same time. The reason is that those habituated eliminate faster as compared with non-habitual drinkers. b. Constitutional Tolerance — If a person habitually drinks alcoholic beverages there develops a certain degree of adaptation by the body, thereby increasing the body threshold to it. Later, greater quantity and percentage will be tolerated and will lead to the diminution of its effects. 2. Susceptibility to Alcohol: The following factors render a subject unduly susceptible to the effects of alcohol: a. Exposure to extreme cold; or fatigue. b. Pre-existing post-concussional state. c. Chronic cerebral vascular state — e.g. hypertension, advanced cerebral arteriosclerosis. d. Cerebral depression caused by drugs, like barbiturates. e. Neurological disorders, like disseminated sclerosis, intracranial tumor. f. Psychological disorders.

ALCOHOLISM

701

H o w Alcohol Influences the Production of Trauma: Alcohol enhances the production of trauma in the following ways: 1. Alcohol increases the irritability and decreases the sense of responsibility of a person which, in effect, may cause him to become involved in quarrels or accidents. 2. If a person is under the influence of alcohol, the anesthetic effect of alcohol may obscure pain and other symptoms of injury so that serious trauma may be overlooked. 3. Alcohol, being a depressant, renders the individual susceptible to the effects of traumatic shock or hemorrhage. (Legal Medicine, Pathology and Toxicology Helpern and Umberger, 2nd ed., p. 183).

by

Gonzales,

Vance,

H o w Alcohol Diminishes the Driving Skill: The basic of the maxim that "Don't drive when drunk and don't drink when driving" is that alcohol deteriorates the driving skill in the following ways: 1. It increases the reaction time. The driver becomes sluggish in his reaction in an impending danger. 2. It creates a false feeling of confidence. 3. It impairs concentration, dulls judgment and degrades muscular coordination. 4. It decreases visual and auditory acuity. (Pathology of Homicide by Adelson, p. 910). Fate of Alcohol in the Body: After absorption of alcohol in the alimentary tract, it reaches the liver by way of the portal circulation. It is then eliminated from the body through two mechanisms, namely: 1. Oxidation — Approximately 90% of the blood alcohol is metabolized by the enzyme Alcohol Dihydrogenase ( A D H ) and the coenzyme Nicotinamide-adenine Dinucleotide ( N A D ) into aldehyde and acetate and finally converted into carbon dioxide and water. A major portion of the process occurs in the liver although it may occur in other parts of the body inasmuch as A D H is also present in the kidney and retina from birth. This is the basis of enzymatic method of alcohol determination on body fluid. 2. Excretion — The remaining portion of the blood alcohol (approximately less than 10%) remains as such excreted through the urine, lungs, saliva and perspiration. During the early period of the drinking, blood alcohol concentration is more than that of urine alcohol concentration. When the blood alcohol level is stabilized, the blood level is

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almost the same as that of the urine alcohol level. However, at the period after termination of the drinking, the urine alcohol level is higher than the blood alcohol level. The elimination of alcohol through the alveolar sacs follows the physical phenomena of diffusion. The amount of alcohol in the breath is proportional to the concentration of alcohol in the blood. The rate of elimination of alcohol varies in different individuals. As a general rule, a person of average weight (150 lbs.) eliminates approximately 10 cc. of alcohol per hour. Causes of Death in Alcoholics: 1. Acute Alcoholic Intoxication: a. Paralysis of the medullary center — Alcohol depresses the nervous system by affecting the cerebral cortex, basal ganglia, cerebellum, and finally the brain stem and medulla. b. Cardiac myopathy — The heart muscles may suffer direct damage from the high concentration of blood alcohol. c. Ingestion of alcohol and synergistic drugs, like barbiturates and tranquilizers may cause fatality. Potentiation of alcohol by psychotrophic drugs has been reported to have caused death. A blood level of 0.45% or greater is generally accepted as a fatal level, although death has occurred at a level below 0.35%. 2. Hidden Trauma: Alcoholics are prone to be victims of traffic accidents or other traumatic injuries. Acute intoxication produces considerable analgesia and may deceptively conceal physical injuries. They may suffer from subdural hematoma, brain concussion or abdominal injuries which may be considered symptoms of drunkenness. 3. Unexpected Aspiration of Food ("Cafe Coronary"): Aspiration of food into the respiratory passage may cause severe asphyxia. The sudden death in this case is characterized by the rapid onset of shortness of breath, choking on mealtime or vomiting and the presence of food particles on the respiratory system on post-mortem examination. 4. Poisoning by Congener or Contaminants in Alcoholic Beverages: Alcoholic beverages may accidentally contain toxic substances which may cause injury or death of the drinker. There is a wide variety of impurities that may be found but the following contaminants in bootleg liquors are quite common: a. Methyl Alcohol (CH OH, Methanol, Wood Alcohol) - The mechanism of methanol poisoning is its conversion to formaldehyde and formic acid which consequently causes acidosis. 3

ALCOHOLISM

703

In the eye, it may cause blindness. The symptoms start as photophobia, followed by blurred vision to permanent blindness. This is due to the action of the poison on the ganglionic cells of the retina with subsequent atrophy of the optic nerve. If blindness is not total, there is considerable contraction of the field of vision and an impairment of the color sense. b. Isopropyl Alcohol (Rubbing Alcohol) — The compound is converted in the body to acetone and excreted as such. Acetone is excreted through the lungs and produces hemorrhagic tracheobronchitis, bronchopneumonia and hemorrhagic pulmonary edema. It also causes lower nephron nephrosis, hemoglobinuria, fatty changes in the liver, respiratory paralysis and death. c. Ethylene glycol and/or Diethylene glycol — Either or both are present in industrial antifreeze mixture but may become contaminant to the alcoholic beverages. Ethylene glycol is marked central nervous system depressant and is oxidized in the body to toxic oxalic acid. The oxalic acid crystals plug the excretory tubules of the kidneys causing marked functional impairment and nephrosis. In the brain it may cause chemical meningitis and meningoencephalitis. Diethylene glycol is also a central nervous depressant and causes centrolobular hydropic degeneration and necrosis of the liver as well as bilateral cortical necrosis. 5. Diseases Associated with/or as a Complication of Alcoholism: The most frequent effect of continuous consumption of alcohol is that the development of fatty liver may ultimately become a condition of cirrhosis. A cirrhotic liver may cause rupture of the esophageal varices. Alcoholism may also cause hemorrhagic pancreatitis, bronchopneumonia and development of other infectious diseases. An alcoholic who is suddenly withdrawn from alcohol may suffer a state of excitement with hallucination known as delirium tremens. It is characterized by an attack of acute insanity with sleeplessness, marked tremors, excitement, fear and sometimes with strong suicidal tendencies. An alcoholic may develop Korsakow's psychosis. It is a syndrome characterized by hallucination, disorientation and multiple neuritis, and the loss of memory for recent events. Cortical atrophy is the main alteration grossly observed in fatal cases. Alcoholic Polyneuritis may also develop as a complication of alcoholism. There is a combined degeneration of the nerve fibers and myelin sheaths.

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Post-mortem Findings in Death Due to Alcoholism: Gross post-mortem findings are not characteristic. Most often the pathological findings were associated with or have developed a complication of alcoholism that had been observed. However, the following are some of the most common findings: 1. Presence of "alcoholic odor" of the stomach contents. The odor emitted is not due to alcohol but most often to that of the congener. 2. Congestion of the mucosa of the stomach. 3. Congestion of brain and its meninges. 4. Heart may be dilated and flabby and lungs congested and frothy, otherwise normal. 5. Blood, alveolar air and urine examinations reveal the presence of alcohol. Pathological Drunkenness: A condition wherein a small amount of alcohol intake may be sufficient to make a person drunk on account of an existing pathological condition of the body. Brain concussion, sun-stroke, epilepsy and other conditions may predispose a person to the effects of alcohol. Punch Drunkenness: This is not a condition of drunkenness. It may be observed among professional boxers who may have developed a peculiar physical and mental condition on account of repeated trauma on the head. The individual begins to have lack of concentration. He may change the subject-matter of a conversation abruptly and may ask the same question for several times. He has a bad memory of recent events. He is not too sociable, garrulous and boastful but rather timid and shy. His articulation may be glazed and slurring. Romberg's sign may be positive and locomotion may be ataxic and unsteady. Involuntary movement of a boxic nature may be present. He simulates continuously a person who is drunk. Laboratory Examination in Alcoholism: For the qualitative and quantitative determination of alcohol, blood, urine and respired air may be used from a living subject. Blood preferably extracted from the heart, and urine taken directly from the urinary bladder may be used to determine the presence of alcohol in the dead. The legal issue confronting physicians in the taking of specimens of blood, urine and breath has been resolved in the decision of the

ALCOHOLISM

705

U.S. Supreme Court in the case of Schmerber v. California (34 U.S. 757, 16 L. Ed. 908) where it was held that: 1. There was no violation of the defendant's constitutional privilege against self-incrimination because the privilege applies only to testimonial compulsion and does not apply to the taking of physical evidence from an accused. 2. The taking of a blood specimen by a physician in a simple medically acceptable manner of a hospital environment was not brutal and offensive. It did not constitute a violation of the due process clause of the constitution. 3. The taking of a blood specimen under such circumstances, despite the fact that the accused had objected and protested because his lawyer had advised him not to submit to any chemical test, did not deprive him of his constitutional right to counsel. The fact that his counsel had erroneously advised him that he could assert his privilege against self-incrimination with respect to a chemical test did not give him any greater rights to which he was entitled. 4. While the taking of breath or bodily fluid specimens from an accused for the purpose of analysis to determine blood alcohol concentration does come within the scope of the constitutional protection against unreasonable searches, the accused had been lawfully arrested before the blood specimen has been withdrawn. Under these circumstances the withdrawal was reasonable as an incident to a lawful arrest. Withdrawal of Blood from a Dead Body Cannot be a Ground for Civil Damage: A man was killed in an automobile accident. Because there was a reasonable cause to believe that he had been driving while intoxicated, the policeman in charge of the investigation asked the embalmer to draw a blood sample prior to the embalming of the body. The embalmer complied with the request. There was a very high alcohol level in the blood. The test result was admitted in evidence in suits brought by others injured in the accident against the driver's estate and they were awarded very substantial damages. The widow sued the embalmer for mental anquish for his disturbance of her husband's body. The court dismissed her complaint, holding that removal of blood did not disfigure the corpse, thus, she had no cause to a legal action (Hazelwood v. Stokes 483 SW 2d 576, Ky 1972).

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1. Analysis of Blood: Analysis of the blood is probably the most widely accepted way to determine the concentration of alcohol in the body. It is a direct method of estimation although the subject may refuse blood extraction for such analysis. Alcohol should not be used to sterilize the skin before withdrawal for it might possibly give a false high reading. The blood sample must be drawn by a physician, nurse or other competent technician under sterile condition. On account of the great number to be tested, especially those traffic violators, it makes the blood analysis quite impractical. 2. Analysis of the Breath: The concentration of alcohol in the blood can be determined indirectly by making a quantitative determination of alcohol in the respired air. The basis of the analysis is that there is a constant ratio between the concentration of alcohol in the blood stream and in the alveolar air.

Percentage of blood alcohol =

Gms. of Alcohol in breath x 2 Gms. of Carbon dioxide x 100

3. Analysis of the Urine: Urine as a specimen for alcohol determination has not gained widespread use because of variability in the different periods of alcohol intake. 4. Analysis of Body Tissue: This method is applicable in death cases. Examination of the brain for its alcohol content is a reliable diagnostic procedure. Other bloody organs like the liver, spleen, kidney may also be examined for alcohol contents. 5. Analysis of Saliva, Perspiration and Spinal Fluid: Although it may be done, examination of these fluids is seldom done. Objectives of Alcohol Examination: 1. For Screening — This is done to determine whether alcohol is present in the sample. The sample may be blood, urine, saliva, vitreous humor, stomach content or respired air (alveolar air). The instrument and the procedures must be simple for an ordinary layman or a police officer to perform the job. The apparatus must be portable so that the result will be available in the shortest possible time. The apparatus may be placed in a mobile laboratory for the purpose of screening drivers of motor vehicles.

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ALCOHOLISM

Insofar as breath alcohol determination is concerned, the following are the available instruments. Device & Manufacturer

Method of Detection

Alcolyzer (Intoximeters, Inc.)

Chromate salt in acid

Bect-ton-D ickenson (Becton-Dickenson)

Chromate salt in acid

Chromic Acid Kitigawa Drunk-OTester ( K o m o Chemical Industrial Company) Chromate salt in acid Sober-Meters SM-1, SM-6 SM-9 and SM-9A (Luckey Laboratories) Alco-Halt Catalytic combustion (Mine Safety Appliance Co.) Bat III (Century Systems, Inc.)

Catalytic combustion

Indicator Response Color Change Orange-yellow to green Color change Orange-yellow to green Color change Orange-yellow to blue-gray Color change Orange-yellow to green Lights-pass or fail

Pointer-warn fail

or

A . L . E . R . T . , Model Taguchi Mos ConducJ3A (Alcohol Counter tor Measures, Inc.)

Lights-Pass, warn or fail

Alco-Sensor (Intoximeters, Inc.)

Fuel cell

Lights-Pass, warn or fail

Alco-Sensor II (Tntoximeters, Inc.)

Fuel cell

Digital readout

(Forensic Science Handbook by Richard Saferstein, p. 626). 2. For Evidentiary Purpose — If in the screening process the sample had a positive result, the next procedure to be applied is the determination of the quantity of alcohol. The report is to be submitted in connection with such examination to be used as an evidence as to the presence and actual amount of alcohol in the submitted specimen. The procedure requires the use of precision instrument and should be performed in a regular chemical laboratory.

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LEGAL MEDICINE

Withdrawal of Blood for Alcohol Determination N o t Giving Evidence Against the Defendant: Withdrawal of blood from a person suspiciously drunk to determine the alcohol concentration in the blood is not self-incriminatory. The act is purely mechanical and it does not utilize the mental faculties of the subject. The defendant having been convicted of causing a death by driving an automobile while under the influence of intoxicating liquor, appealed to the Supreme Court of Colorado. The defendant contented on appeal that he was required to give evidence against himself by the admission of the result of a test of blood to determine the alcoholic content. H E L D : The original intent of the constitutional provision was to prevent the defendant being forced to give testimonial evidence against himself and did not contemplate the exclusion of evidence of physical facts relating to the defendant. The defendant is not deprived of any of his constitutional right by the admission of the testimony here in question. He is not compelled to testify against himself (Block v. People, 240 p. (2d) Colo. 1951). Chemical Test for Intoxication Admissible in Evidence: A n y chemical test for alcohol to determine whether a person is under the influence of alcohol is admissible as evidence in court. The tendency of our modern court is to accept scientific methods in crime detection provided that it has gone beyond the experimental stage and has already been perfected. The defendant was charged with the offense of driving his automobile when drunk and was found guilty by a jury in the trial court. He appealed to the criminal court of appeals of Oklahoma. The defendant contented that the drunkometer and urine analysis tests for the determination whether the defendant was under the influence of intoxicating liquor have not gained such scientific standing for infallibility as to justify admission of the expert testimony on it. H E L D : The court is of the opinion that we should favor the adoption of scientific methods for crime detection, where the demonstrated accuracy and reliability has become established and recognized. Justice is truth in action, and any instrumentality that aid justice in the ascertainment of truth should be embraced without delay. We believed that chemical tests of such body fluids as blood, urine, breath, spinal fluid gained that scientific recognition for infallibility as to be admissible in evidence.

ALCOHOLISM

709

Methods Used in Alcohol Detection: At present there are many kinds of apparatus perfected and laboratory procedures adopted in alcohol detection, but these different methods are actually based on any of the following principles: 1. Chemical Method — The sample is distilled and later allowed to react with a known quantity of oxides, usually chromate, and it determines the amount of chromate which has not reacted to alcohol. By computation the amount of alcohol in the sample can be determined. This is the principle involved in the use of breath alcohol determination with the use of Alco-tester (500), Breath analyzer (900A, 1000) and Alcometer ( A E - D 1 ) . 2. Enzymatic Method — A known quantity of purified alcohol dehydrogenase and its coenzyme nicotamide adenine nucleotide ( N A D ) is allowed to react to the sample. Alcohol is oxidized to aldehyde the coenzyme nicotinamide adenine dinucleotide ( N A D ) , and this can be measured colorimetrically or spectophotometrically. The dipstick method or quick quantification of ethanol in the body fluid is based on this principle: "A quarter-inch cellulose pad at one end of the strip is impregnated with a buffered solution containing yeast alcohol dehydrogenase ( A D H ) , nicotinamide — adenine dinucleotide, pyrazole iodonitrotetrazolium chloride ( I N T ) and deaphorase. When the strip is dipped into saliva, urine or serum that contains ethanol, it turns various shades of pink instantly because of a reaction between, on the one hand, the N A D H that is produced and, on the other, diaphorase and I N T . on the other. The amount of ethanol present can be quantitated by comparison with a color chart. By this method, ethanol concentrations in body fluids can be measured in only 60 seconds, a considerable savings in the time over methods that require the delivery of a sample to a laboratory plus testing time. In an emergency situation in which the patient cannot be tested by breath analysis, this is an obvious advantage (JAMA, Vol. 250, No. 13, Oct. 7, 1983). 3. Gas Chromatographic Method — The specimen may be first purified or injected directly to the apparatus. 4. Infrared Absorption Method — Alcohol is present as a vapor in breath. It absorbs specific wave lengths of infrared. An intoxilyzer measures alcohol by detecting the decrease in the intensity of infrared energy as it passes through the cell.

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Effect of Delayed Examination or Putrefaction of Sample: To have an accurate determination as to the quantity of alcohol in a specimen, immediate examination must be done. Fermentation of the alcohol present may take place and transforms it to acetaldehyde and ultimately to carbon dioxide and water. The sugar and other forms of carbohydrates and protein in the sample may also go through the action of enzymes, bacteria and fungi acting singly or in a combination that may be transformed into alcohol. The alcohol to be oxidized to form carbon dioxide and water is comparatively very much less than the amount of carbohydrates and protein material to be transformed into alcohol. Consequently, the longer the time interval between extraction and examination, the more it increases the alcohol contents of the sample. This condition is also true when extraction of body fluid is done a long time after death. "It, nevertheless, is worthwhile to do an alcohol analysis in such putrid sample despite the fact that it will not give a true picture of the state of intoxication of the deceased at the time of death. Alcohol concentration in excess of 0.20% would indicate alcohol consumption prior to death, while levels below 0.20% may be ascribed to possible putrefactive alcohol production" (MedicoLegal Investigation of Death by Spitz and Fisher, p. 482). Societal Reaction to the Problem of Alcoholism: 1. Promulgation of laws and regulations: a. Manufacturing of liquor only to a certain percentage of alcohol in beverages. b. Restricting the time and place of drinking and the availability of liquor to a particular age, sex and other socio-economic group. c. Subjecting drivers at random to an alcohol screening test, and if found positive, it is to be followed by a quantitative determination of blood alcohol. If blood alcohol exceeds the maximum tolerable limit prescribed, the driver can be arrested. 2. Various indoctrination methods may be employed to encourage moderation or abstinence, like education in schools and churches. 3. An institutional-organization approach, introduces substitute form of tension relief into the social structure. Subsequent removal of the cause of tension and diverting attention to something else can also be looked into. 4. A variety of therapeutic approaches are taken under the concept that an alcoholic is a patient:

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a. Therapy combines medicine with psychiatry, psychology, social case work and alcoholic anonymous. b. Pastoral counseling are given in churches. c. Half-way houses are built to bridge the gap between the penal institution and the community.

Chapter XXXIV MEDICO-LEGAL ASPECT OF POISONING Definition of Poison: A poison is anything other than physical agencies which is capable of destroying life, either by chemical action on the tissues of the living body, or by physiological action by absorption into the living system. Legally, a poison is a substance which, if applied or administered internally, has been applied or administered with the intention to kill or to do harm. The intent in the administration is the essential element in law. The quantity does not affect culpability, nor is the law concerned with the quantity in which the substance acts. (From: A Synopsis of Forensic Medicine & Toxicology by E. W. Caryl Thomas, 2nd ed., p. 142). In cases of suspected poisoning, it is not advisable to confine the toxicological analysis to the stomach and its contents because: 1. The gastrointestinal tract is only one of the means of entry of poison into the body. It is possible for poisonous substances to gain entry by inhalation, by absorption through the skin, by intravenous, intramuscular and subcutaneous injection, or by introduction into the vagina or rectum. Analysis of the gastric content would not eliminate poisoning as a factor when poison gains entrance into the body via other route. 2. Even if the poison was taken orally, after a significant period of time (4 to 6 hours) has elapsed from ingestion to death, the poison might have passed out of the stomach and could no longer be present in identifiable amount. 3. If analysis of the gastric contents disclosed presence of possible toxic substance, it is possible that the said poison could have been introduced post-mortem to conceal the real cause of death. 4. Except in cases of poisoning by strong corrosive agent, there must be a demonstration of absorption of the poisonous agent. This can be shown by the presence of the toxic materials in other organs or parts of the body. 712

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Site of Action of Poison: 1. Local Action: The poison may act on the skin or on the mucous membrane or on any part of the body where it is applied. Example: Sulfuric acid. 2. Remote

Action:

The poison may act remotely in any of the following ways: a. By the production of shock. Example: Poisoning by strong acid. b. By absorption into the blood and being carried to the organs they affect. Example: Morphine is absorbed by the blood and carried to the brain and depresses it. c. By transmission through the nerves of local parts affected going to the nerve centers and then reflected to the organs on which they act.

Site of Remote Actions of the Different Poisons are: a. On the Brain: Narcotics, alcohols, cerebral stimulants like caffeine. b. On the Cord: Strychnine. c. On the Peripheral Nerves: Conium, curare. d. On the Alimentary Tract*. Corrosives. e. On the Kidneys: Cantharides. f. On the Salivary Glands: Mercury. g. On the Liver: Phosphorus. h. On the Mucous Membrane: Arsenic i. On the Heart: Digitalis, j. On the Blood Vessels: Ergot, nitrites, k. On the Blood Cells: Snake venom.

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3. Both Local and Remote: The poison may act at the site of application and in some distant place. Example: Carbolic acid is an irritant to the alimentary tract and also toxic when absorbed. Condition of the cadaver when the organs or other tissues are removed which makes the examination difficult or the result meaningless: 1. Embalming: — A dead body must be autopsied and organs and other tissues saved for toxicological analysis before embalming because: a. Fixation of tissues by formaldehyde makes them more resistant to the action of organic solvents used for the extraction of nonvolatile organic substances, such as most drugs, leading to low recovery of these substances. b. It is extremely difficult, if not impossible, to detect and identify most volatile poisons. Cyanide, for example, reacts chemically with formaldehyde so that it is no longer identifiable in an embalmed body. c. Many embalming fluids contain methyl alcohol or ethyl alcohol or both so that analysis of these substances is rendered meaningless. 2.

Putrefaction: a. Most volatile compounds are lost as a result of putrefaction. b. Putrefaction of normal tissue components may produce substances which yield chemical reactions similar to those obtained from toxic compounds. c. Some substances, like alcohol and cyanide, may be produced in the process of putrefaction of normal components. d. Many substances which might be present in the tissue may undergo chemical changes and may no longer respond to the identifying test made for them.

Minimum Amount mination: 1. Brain 2. Liver 3. Kidney 4. Stomach content 5. Spleen 6. Urine 7. Blood 8. Bile

of Autopsy Specimens for Toxicological Exa— — — — — — — —

One hemisphere 500 gms. One whole kidney 50 gms. Whole spleen All avilable up to 100 cc. 100 cc. AH available

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Recommended Organs to be Saved for Suspicious Poisoning Poison to be Tested 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Arsenic (Acute poisoning) Arsenic (Chronic poisoning) Alcohol Cyanide or H C N Carbon monoxide Alkali Morphine and other alkaloids Barbiturates Phosphorus Lead Phenol Pesticide (insecticide) Antibiotic Kerosene, gasoline

Organs to be Submitted Liver, kidney, stomach contents Liver, urine, hair Blood, liver, kidney, urine, brain Stomach and liver Blood placed in a sealed container Stomach and contents, esophagus Stomach and contents, liver, urine Brain, liver, kidney, urine Stomach, liver, kidney Kidney, liver, bone Liver, kidney, stomach Stomach and contents, liver, blood Liver, blood Brain, liver, lungs, blood

Circumstances Affecting Action of Poison: 1.

Method of Administration: Poisons may enter the body in the following ways: a. Orally: Except irritants and corrosives, poisons must be digested or absorbed in the gastric or intestinal mucosa before producing effect. b. Hypodermically: Poison reaches the blood stream without passing the digestive organs. This method is only available for such substances that are soluble in the lymph and tissue juices. c. Intramuscularly: Absorption is faster than in the hypodermic method. d. Endodermically: The poison may be rubbed into and absorbed through the skin. e. By Rectum, Vagina or Bladder: Absorption through the rectum is about twice as much as absorption through the mouth. f. By the Lungs: Poison through this route may be made of a substance which can be transformed to gaseous state.

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2. Idiosyncrasy: Some persons possess sensitivity to certain foods or drugs. The most common drugs are potassium iodide, arsenical preparations, aspirin and the sulfas. As to foods, the most common are fish, shrimps, eggs and oysters. 3. Age: There are substances which are considered poison for babies but wholesome for adults, while the opposite is true for other substances. There are substances which children can take more than the proportionate dose in adults, like mercury and belladonna. In case of some other drugs, children may be so sensitive that they cannot take the proportionate dose for their age, like opium preparations. 4. Habit: The body may acquire tolerance to some drugs. Habit diminishes the effect of certain poisons. Tobacco, alcohol, opium, barbiturates, arsenic are good examples of this. 5. Dose: The effect of drugs and poisons in the body is usually proportional to the dose taken. Example: Alcohol, when taken in small dose, stimulates body reflexes and tone, while large amount depressed the whole body. Fatal Dose: This is the smallest dose known to cause death: smallest amount which will certainly cause death.

not the

Guide in Detennining the Single Dose of Drugs Suitable for Children: Clark's Rule: Divide the weight of the child in pounds by the average weight of the adult (150 lbs.) and take the fraction of the adult dose. Example: The weight of the child is 50 lbs. then 50/150 equals 1/3. So the child can take 1/3 of the adult dose. Young's Rule: Divide the age of the child by the age of the child plus 12, and the resulting fraction is the portion of the adult dose which may be used. Example: If the child is 6 years old, then 6/6+12 equals 6/18 or 1/3 of the adult dose.

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Cowling's Rule: Divide the age of the child on his next birthday by twenty-four and the fraction of the adult dose is to be used. Example: If the child is 8 years old, then 8/24 equals 1/3 of the adult dose. Gabius stated a series of fractions of the adult dose which may be used for different ages: For a child one year or less 2 years 3 years 4 years 7 years 14 years 20 years Above 20 years

1/12 1/8 1/6 1/4 1/3 1/2 2/3 For adult dose

6. Stare of the Stomach and Kidneys: Since the stomach is the first organ where the ingested food stays for a time, so it must be the first organ to be affected by the action of poison. If the organ is diseased or abnormal, it has less resistance to the effect of poison. A healthy person is usually more resistant to the action of the ingested poison in insoluble form. SIGNS A N D SYMPTOMS THAT M A Y LEAD ONE TO SUSPECT POISONING: 1. The complaints and symptoms appear suddenly like an acute abdomen, apoplexy, heart failure or cholera. 2. The symptoms appear when the individual is at the state of health. 3. The symptoms usually appear after a meal or after taking some food or medicine. The onset of the symptoms is influenced by the modifying factors mentioned, but it appears within an hour in most cases. 4. When several persons partake the food or drug at the same time, the approximate occurrence of the symptoms is at the same time. 5. The course of the symptoms may either be getting severe or having steady improvement. 6. The detection of the poison can be done on any of the following: a. food taken c. vomitus b. container