Legal Medicine Lecture Series 2nd Ed

Legal Medicine Lecture Series 2nd Ed Atty. Molly Cr. Abiog, M.D.

General Considerations: I. Definition: Legal Medicine is 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 clinical and paramedical sciences to elucidate legal matters. Legal Medicine, Forensic Medicine and Medical Jurisprudence are all synonymous with each other and in common practice, are used interchangeably.in ordinary parlance. Schools of Medicine, hospitals and government entities adopt either name, representing one of its departments or divisions in its organizational setup. However there are subtle differences as pointed out by Dr. Pedro Solis, the author of our official textbook: Strictly speaking, Legal Medicine is primarily the application of medicine to legal cases while Forensic Medicine concerns with the application of medical knowledge to elucidate legal problems. William J. Curran, a prominent Harvard professor of legal medicine, defines legal medicine as encompassing those specialty areas of medicine concerned with relations to substantive law and legal institutions. Forensic medicine, on the other hand, deals with investigation , preparation, preservation and presentation of evidence and medical opinion in courts and other legal, correctional and other law-enforcement settings. Then again, according to Dr. Henry C. Lee, an eminent U.S. forensic expert, forensic medicine has a broader definition than legal medicine. It encompasses a variety of fields in forensic science such as, pathology, anthropology, odontology, toxicology, entomology, et al. Its application is limited not only to legal issues but also covers historical, environmental and social political issues. This may be further elucidated by stating that Legal Medicine refers to substantive law defining the relationship between and among hospitals, doctors, patients, whereas Forensic Medicine deals with activities or acts punishable under our local laws. Medical Jurisprudence denotes the knowledge of law 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 a doctor-patient relationship. According to Sec. 5 Rule 138, one of the requirements to be admitted to the Bar examination is Medical Jurisprudence as a subject in the law course. Actually, Medical Jurisprudence is more properly referring to the course taken in the College of Medicine but fit purposes of the College of Law it should be the study of legal medicine. The expertise needed in Forensic Medicine encompasses practically every branch of Medicine. It is a subspecialty of a medical specialty. So that before a doctor can go into the field of Legal Psychiatry, he must first specialize in Psychiatry; before he can go into Forensic Gynecology, he must have first been trained in basic Gynecology, and the same is true for the other fields of medicine. Any branch science so long as it is involved with the collection, preservation and presentation of evidence to be presented in a legal forum is covered by the practice of Forensic Medicine. So that now we have experts in different areas of forensic science such as serology, chemistry, toxicology. etc. I.

Scope of Legal Medicine: The scope of Legal medicine is quite broad and encompassing. Legal Medicine page

1

E.g. The knowledge of the nature of the extent and nature of wounds as applied in surgery would involve not only knowledge of medical science but also physics, physiology, pharmacology, etc. Formula: Physics of Wound Production: Wound = Kinetic Energy x Time x Area x “other factors” Kinetic Energy= MV2 M=Mass V= Velocity 2 Kinetic Energy: Kinetic energy is based on mass and velocity factors and that velocity is squared, the velocity component is the important factor. This explains why an M-16 bullet which has a velocity of 3,200 ft/sec will do more damage than a .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 contact between the object and 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 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 had 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 a contact in all directions equally, frequently causing the tissue to lacerate (Legal Medicine Annual 1980, Cyril Wecht ed., p. 36).

IV.

Nature of the Study of Legal Medicine: Knowledge of legal medicine of legal medicine means: a. the ability to acquire facts; b. the power to arrange those facts in their logical order; c. and to draw a conclusion from the facts which may be useful in the administration of justice; d. He must posses the power to impart to others verbally or in writing all those he has observed.

V. WHAT THEY ARE AND WHAT THEY ARE NOT: A common misconception among the public is that medico legal practitioners of necessity must also be lawyers. This is not true because for as long as they are handling cases involving legal duties connected with any aspect of health care, they are doing medicolegal work and therefore, fall under this category. Legal Medicine page

2

Common also among the public is the belief that one has to be a pathologist to be involved in this line of work. Again, this is not true because victims can be both living or dead. When victims survive the trauma and are admitted to hospitals, they are referred to practitioners in Forensic Medicine. But when they eventually die or is dead at the onset, autopsy must be doen to document officially the cause of death and this is now in the realm of the Forensic Pathologist. A physician who specializes or is involved primarily with medico-legal duties is known as a Medical Jurist (also called Medical Examiner, Medico-legal Officer, Medico-legal Expert). [e.g. Dr V.V. Villasenor (PNP Crime Laboratory), Dr. Ronaldo Bandonill (NBI)] On the other hand, Atty. Molly Cr. Abiog, M.D. is only a doctor and a lawyer, but not a Medico-legal Officer. Medicolegal practitioners can either be in the service of the government or in private practice. In government , they are connected with law enforcement agencies such as thw police departments or with legitimate investigative bodies such as those with the PNP Crime Laboratory or with the Medicolegal division of the National Bureau of Investigation. They may also be physicians employed by the government either as Municipal or Provincial Health Officers as they are mandated by law to perform autopsies on medicolegal cases. As private practitioners, they are consultants in private hospitals to whom are referred medicolegal patients. They become part of the Hospital Team that monitors the patient’s condition while confined at the Hospital. When the patient’s case goes to court, the medicolegal practitioner is called to testify on the fact of the injury, the treatment the patient received in the Hospital, his expert opinion as to the cause of the patienty’ Vl. Who are authorized by law to perform autopsies? Sec. 95, P.D. 856, Code of Sanitation: 1. Health Officers 2. Medical Officers of Law enforcement agencies 3. Members of the Medical Staff of Accredited hospitals 4. Code of Medical Ethics of the Medical Profession of the Philippines. Sec. 2. Art. III states: “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”. VII. Distinction between an ordinary physician and a medical jurist: Ordinary Physician 1.

Sees an injury or illness on the point of view of treatment sees injury or illness from the

Medical Jurist Point of view of treatment from the point of view of CAUSE

2. Purpose is examining patient is to arrive at a definite Diagnosis-Rx Rx

Purpose is to examine patient is to include those bodily lesions in his report and testify before the court before an investigation body result: justice where justice is due-given.

3.

proofs

Minor or trivial ignored -they do not require Rx.

to qualify the crime or to justify an

act. Medical jurists must record all bodily injuries even if they because these injuries may be

Legal Medicine page

3

VIII. What are these so-called MEDICOLEGAL CASES? The following are cases considered medicolegal in nature: 1. Injuries or deaths involving persons who have no means of being identified; 2. Persons pronounced as “dead on arrival” (DOA). To be classified as being dead on arrival at the emergency room of a Hospital or a DOA is liberally construed to mean also dying within a short period of time from arrival which may be within one hour or as long as 24 hours depending on the circumstances of the case. 3.

They also involve deaths under the following circumstances: a. b. c. d. e.

4.

Death occurring within 24 hours of admission when the clinival cause of death is unknown or undeterminable; Unexpected sudden death especially when the deceased is in apparent good health; Death due to natural disease but associated with physical evidence suspicious of foul play; Death as a result of violence, accident, suicide or poisoning; Death due to improper of negligent act of another person;

They also involve victims of physical injuries caused by the following: a. b. c. d. e. f.

physical violence such as gunshot wound, stab wound, mauling, etc.; vehicular accident; asphyxia; electrocution, chemical or thermal insult; accident, attempted Homicide or suicide; poisoning.

5.

Cases of child abuse, domestic violence, rape, alcoholism and drug addiction;

6.

Cases involving the mental competency of the patient;

7.

Iatrogenic causes brought about by negligent acts or omissions of the hospital staff resulting in violation of rights of patients or leading to his physical and mental incapacitation, physical injury and death.

Under Philippine laws, medicolegal deaths must undergo mandatory autopsy. No consent is required for the autopsy although the next of kin is informed of this requirement and his signed consent obtained as a matter of courtesy. The death certificate cannot be completed without the autopsy. If the hospital has no authority to conduct autopsy, it refers the case to a government body which can do it—either to the PNP or the NBI or top a Municipal or Provincial Heath Officer. If the Hospital has the authority to conduct autopsy but the relatives refuse to cooperate, the death certificate is merely filled up by putting as the cause of death “undetermined”. In effect, it is also as if no death certificate has been issued because legally the body cannot be buried without a cause of death. IX. Major capabilities of a medico-legal officer: 1. conducts autopsy 2. conducts examination of victims of sexual crimes 3. conducts examination of victims of Physical injuries Legal Medicine page

4

4. 5. 6. 7. X.

Conducts examination lf skeletal remains Conducts blood and blood stain, seminal fluid/stain-examination of body fluids Exhumation of bodies Histopathological examinations.

Branches of Las where Legal Medicine maybe applied: A. Civil Law: 1. Paternity and filiations; 2. Determination of or change in Civil Personality/Status of persons; a. Adoption, Declaration of Nullity of Marriage, Legal Separation, etc. B. Criminal Law: 1. Circumstances affecting criminal liability 2. Crimes against persons 3. Crimes against chastity C.

XI.

Remedial Law 1. Rules on evidence 2. Proceedings for hospitalization 3. Physical/mental examination of a person

Autopsies shall be performed in the following cases: Whenever required by special laws. Upon order of a competent court, mayor and a provincial or city fiscal. Upon written request by police authorities. Whenever the Solicitor General, provincial or city fiscal deem it necessary to dissenter and take possession of the remains for examination to determine cause of death. 5. Whenever the nearest kin shall request in writing the authorities concern to ascertain the cause of death. 1. 2. 3. 4.

XII.

FORENSIC Science Disciplines: Hair Analysis Fiber Analysis Glass fragments and paint chips analyses Ballistics and Tool marks Fingerprints Footwear Tire Impressions

DNA Analysis Forensic Anthropology Forensic Archaeology Forensic Pathology Forensic Odontology Questioned Document analysis Forensic Psychiatry and Psychology Blood Splatter Analysis

ASSIGNMENT: 1. Bring to class medico-legal certificate next meeting Case Demonstration: An 18 year old female, single, came to a medical clinic complaining that she has been raped. History of the Present Complaint: One (1) month PTC, Mr. X by use of force and intimidation had carnal knowledge with her at Burnham Park @ 2:00 p.m. For fear of her parent’s wrath, she kept what happened to herself and came for medical examination only today. Examination results: 1. Recently healed hymeneal lacerations at 4 and 6 o’clock; 2. No signs of recent application of force at the perineal area; 3. Internal Examination, admits 2 examining fingers with ease; shallow vaginal rugosities; 4. Laboratory Examinations: Positive for spermatozoa, no gram negative cocci. Legal Medicine page

5

Conclusions: -non-virgin state; -healed lacerations at 4 and 6 o’clock -presence of Spermatozoa, Conclusion: recent sexual intercourse within the last 24 hrs.

LECTURE 2:

MEDICAL EVIDENCE:

I. Definition: Evidence- (Sec. 1, Rule 128)

Legal Medicine page

6

-

-

Is the means suctioned by the Rules of Court of ascertaining in a judicial proceeding the truth respecting a matter of fact. If the means to prove a fact is medical in nature, then it becomes medical evidence.

II. Types of Medical Evidence: 1. Autoptic or Real Evidence- made known or addressed to the senses of the court, not limited to vision. Sec. 1 Rule 130 , Rules of Court: Limitations to the presentation of autoptic or real evidence: 1. Indecency and Impropriety 2. Repulsive objects and those offensive to the sensibilities 2. Testimonial Evidence-Physician may be commanded to appear before the court to give his testimony. Physician may be presented in court as an ordinary witness 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- Exemption to the ordinary witness rule, privilege of communication between physician and patient- (Sec. 24 (c), Rule 130) Hearsay information is as a rule not admissible in court (Sec. 30, rule 130) Exemption to non-admissibility of hearsay evidenceDYING DECLARATION (Sec 37, Rule 130) b. Expert Witness: A physician on account of his training and experience can give his opinion on a set of medical facts. Sec. 49, Rule 130, Opinion Rule 3. Experimental Evidence: Example: A doctor may come to court and give lethal injection of poison to a rat to demonstrate its effect on human beings. 4. Documentary Evidence: Most common is medico-legal certificate. Bring-out your medico-legal certificate. Types: a. Medical Certificate- Medical Examination, Physical Examination, Necropsy (autopsy), Laboratory Examination, Exhumation, Birth Certificate and Death Certificate. b. Medical Expert Opinion- Conclusions c. Depositions 5. Physical Evidence: These are articles or materials that 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 the criminal. Types: a. Corpus Delicti Evidence: Objects or substances, which may be part of the body of the crime. b. Associative Evidence: Physical Evidence which link a suspect to a crime. e.g. broken headlights of a car wearing apparel of offender in the crime scene of rape. Legal Medicine page

7

c. Tracing evidence: Physical Evidence that may help the investigator to locate the suspect. e.g. drops of blood going towards the direction where the suspect fled. III. Preservation of evidence: This is necessary and vital in medico-legal investigation: Methods: 1. Photography 2. Sketching a. Rough sketch b. Finished sketch 3. Description: Putting into words the person or thing to be preserved. 4. Manikin Method: In a miniature model of 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 neither may nor indicated the full detail of the lesion, it is quite impressive to the viewer as to the nature and severity of the trauma. 5. Preservation is the mind of the witness: Disadvantages: a. Capacity 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 truth. Other persons may influence a witness to serve the interest of another or state untruth facts to justify an end. 6. Special Method: Special way of treating certain type of evidence may be necessary. Preservation may be essential from the time it is recovered to make the condition unchanged up to the period it reaches the criminal laboratory for appropriate examination.

QUALITIES of a good EXPERT WITNESS:              

Reputable professional background (education, formal training, work/experience, office, affiliations) Personal integrity and good judgment; Attitude of competence, credibility and concern; Objective, neutral, independent and sincere; “the truth, the whole truth and nothing but the truth”; credibility hinges on not just “what” was said but “how” it was said; convincing; able to communicate (clear, articulate, simple, concise; in lay man’s terms); a good teacher; is not an advocate even if he/she testifies for only one side of the case; opinions/conclusions are reached independently of interests of litigants; informs the counsel of the party engaging his services of all favorable and unfavorable information; must acquaint himself/herself of courtroom procedures, decorum, layout, availability of presentation aids; is entitled to funds covering travel and attendance in court, and an expert witness fee; Legal Medicine page

8

       

must not be compensated on a contingent fee basis; preferably makes an oral report orally rather than in writing; is served with a subpoena to indicate he is not a voluntary witness; is put on call during the trial; must disclose to the lawyer who engages him anything that he thinks might affect the effectiveness of his testimony; is willing to disagree with so-called authorities if convinced that they are wrong; recognizes that contrary opinions will not necessarily discredit him; is most effective if firmly convinced that the theory of liability espoused by counsel is viable and he/she corroborates this.

“A good lawyer wants you to find out the TRUTH, and he/she wants to know ahead of time so he/she is not caught by surprise later on. If an expert’s opinion opinion is contrary to what the lawyer expects to prove his case, all is not lost. He might want to settle rather than go to trial.”

Assignment for Lecture 2: Make a Trial Brief for the presentation of an expert witness who is a physician in this case. Grade credit for Preliminary Examination: 20% of Final Grade. Case: Andawi Jeoffrey.

LECTURE 3: DECEPTION DETECTION The knowledge of truth is an essential requirement for the administration justice. Methods of deception detection, which are currently being used or applied by law enforcement agencies: 1. Devices which record psycho-physiological responses a. Use of a polygraph or lie detector machine b. Use of the word association test Legal Medicine page

9

2.

3. 4. 5. 6.

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 Hypnotism By observation Scientific interrogation Confession

I. RECORDING OF THE PSYCHO-PHYSIOLOGICAL RESPONSE The Central Nervous System primarily controls the motor and sensory functions that occur at or above the threshold. It may be voluntary or . Types: 1. Automatic Nervous System- a self-regulating automatic response of the body 2 Complementary branches a. Sympathetic: Physical strain, emotional (fear, anger, excitement, lie detection) b. Parasympathetic: Works to restore things to normal (calm, contented, relaxed)

Picture from p. 239, Human Physiology, fourth ed., Stuart Ira Fox. A. Polygraph: it is appropriate to call it a lie detector. A lie detector records physiological changes that occur in association with lying in a polygraph. It is the fear of the subject that 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.

Picture of a Polygraph Machine: Reasons for the inadmissibility to the court of the result of polygraph examination: 1. Experimental Stage: lacks degree of standardization -Useful in investigation of a crime but has no place in courtroom 2. Tier of facts given almost conclusive heights to the polygraph experts’ opinion. - The judge is the one running the show in the courtroom and not the polygraph expert. 3. No assurance of a qualified examiner to a qualified examiner to administer the fact. -The polygraph is capable of a high degree of accuracy only when conducted under controlled condition by an examiner who is highly qualified due to his stability, experience, education and integrity. - Not quantifiable 4. Examinee- he may unwittingly waive his or her right against the selfincrimination. Why? ---- Unconscious quality of determining the truth. 5. Test has many errors=25% can a person be compelled to be subjected to a lie detector test. B. Use of the Word Association Test Lists of stimulus and non-stimulus words are read to the subject who is instructed to answer as quickly as possible. Legal Medicine page 10

Methods: 1. The answer to the question may be “yes” or “no”. 2. The answer of the subject is to be recorded. 3. When the subject is asked questions with reference to his name, address, civil status, nationality, etc. that has no relation with the subject-matter of the investigation, the tendency is to answer quickly. 4. When the question bear some words which have to do with the criminal act the subject allegedly committed, like knife, gun or hammer which is used in the killing, the tendency is to delay the answer. 5. The test is not concerned with the answer, be it a “yes” or a “no”. the important factor is the time of response in relation to stimulus or non-stimulus words. 6. The subject cannot be compelled to be subject 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 oscillation of the muscles or microtremor occurs at the rate of 8 to14 cycles per second and controlled by the nervous system. When a person is lying, the microtremor in the voice utterance is moderately or completely suppressed. The degree of suppression varies inversely to the degree of psychological stress in the speaker. PSE detects, measures and graphically displays the voice modulation that we cannot bear. II. USE OF DRUGS THAT “INHIBIT THE INHIBITOR” A. Use of “Truth Serum,”-misnomer The procedure does not make someone tell the truth and the thing administered is not a serum but is actually a drug. -Hyoscine hydrobromide-by injection -Repeated doses – state of delirium -Is needed – questioning begins -Patient – feels the compulsion to tell the truth, forgets his alibi. -Drug – depressant of CNS- (cortex, diencephalons) -Admissibility as evidence B. Narcoanalysis or Narcosynthesis: -Use of Sodium amytal/ Sodium penthotal -Drug causes the depression of the inhibitory mechanism of the brain and the subject talks freely. C. Alcohol Intoxication: “In Vino Veritas” -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 masim. Methods: 1. 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 2. The questioning must start during the executor state when the subject has the sensation of his ell-being and when his action, speech and emotion are less strained due to the lowering of the inhibition normally exercised by the higher brain centers. When the subject is already in depressive state, he will no longer be able to answer any question. 3. 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 uttered after the effects pf alcohol have disappeared. Legal Medicine page 11

4. Subject may not recall everything that he has mentioned or he may refuse to admit the truth of the statement given. III. HYPNOSIS: the alteration of consciousness and concentration in which the subject manifests a heightened of suggestibility while awareness is maintained. Not all person are susceptible to hypnotic induction, subjects who are compulsivedepressive type, strong-willed like lawyers, accountants, physicians and other professionals are usually non-hypnotizable. Reasons why Hypnotism is not Admissible in Court 1. It lacks the general scientific acceptance of reliability of hypnosis per se in ascertaining the truth from falsity. 2. The fear that the truer of fact will give uncritical and absolute reliability to a scientific device without consideration of its flaws 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 hypnotize subject as suspended will produce distortion of the fact rather than the truth 5. The state of the mind, skill and professionalism of the examiner are too subjective to permit admissibility of the expert testimony 6. Confession while under hypnotic spell is not admissible as evidence because such “psychiatric treatment” is involuntary and mentally coercive. 7. Although hypnosis may not yield admissibility evidence it may be pf some use during investigation. IV. OBSERVATION: 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 that may be used as a potential clue of deception. And since just one or a combination of the following signs and symptoms are not conclusive pr a reliable proof of guilt of the subject, their presence infers further investigation to ascertain the truth of the impression. A. Physiological and Psychological Sign and Symptoms of Guilt: 1. Sweating-Sweating accompanied by a flushed face indicate anger, embarrassment or extreme nervousness. Sweating with a pallid face may indicate shock or fear. Sweating hands indicate tension. 2. Color Change-Flushed face: anger, embarrassment and shame -Pale face: sign of guilt 3. Dryness of the Mouth- Swallowing and licking of the lips 4. Excessive Activity of the Adam’s Apple 5. Fidgeting-subject is constantly moving about in the chair, pulling his ears, rubbing his face, picking and tweaking the nose, crossing and uncrossing his legs, rubbing the hair, eyes, eyebrows, beating and snapping fingernails, etc. These are indicative of nervous tension. 6. “Peculiar feeling inside”- There is a tension 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 of a, lying”, ”I swear to God”…etc. Such expressions are made to make forceful and convincing his assertion of innocence. 8. Spotless past records-“Religious man”-The subject may assert that it is not nor 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-subject does not look into the investigators eyes for the fear that his guilt may be seen in his eyes. He will rather look at the floor or at the ceiling.

Legal Medicine page 12

10.

“Not 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.

V. SCIENTIFIC INTEROGATION: It may be done on a suspect or a witness; lawyer ought to know how. For purposes of investigation, the following are the different types of Criminal Offenders: 1. Based on behavioral attitude: a. Active aggressive offenders- impulsive manner -Aggressive behavior e.g. crimes of passion, revenge and resentments. b. Passive inadequate offenders 2. Based on the state of the mind: a. Rational offenders: Those who commit crime with motive or intention and with full possessing of their mental faculties. E.g.: Killing with evident premeditation b. Irrational offenders: Those who commit crime without knowing the nature and quality of his act. Example: Mad killer 3. Based on proficiency: a. Ordinary offenders- they are engaged in crimes which require limited skill. b. Professional offenders-they are highly skilled and able to perform criminal acts with the least chance of being detected. They require skill rather than violaence. Example: Pick-pocketing and shoplifting 4. Psychological classification: a. Emotional offenders-Persons who commit crimes in the heat of passion, anger or revenge, and also who commit offenses of accidental nature. They usually have a feeling of remorse, mental anguish or compunction as a result of their acts. They have a sense of moral guilt. The most effective interrogation: sympathetic approach b. Non-emotional offenders: persons who commit crimes for financial gain Usually recidivist or repeaters. Interrogation technique: Appeal to his common-sense and reasoning rather than to his emotion. Techniques of Interrogation: 1. EMOTIONAL Appeal— The interrogator must create a mood that is conducive to confession. He must be sympathetic and friendly to the subject. 2. Mutt and Jeff 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 and kind. When Mutt is not present, Jeff will; advise the subject to make a quick decision and plea for cooperation. 3. Bluff on split-pair technique ---This is applicable when there are several persons who participated in the commission of the crime. The suspects are interrogated separately, the results of the individual statements are not known to each other. And the interrogator may claim that the subject is being implicated by the other and that there is no use for him to deny participation.

Legal Medicine page 13

4. Stern approach –The questions must be answered clearly and the interrogator uses harsh language. Immediate response from the subject is demanded. 5. The subject is given the opportunity to make lengthy, time consuming narration. Basis of investigator’s Inference that the subject is not telling the truth: The subject’s statements have many improbabilities and gaps on its substantive parts. The subject’s statements are inconsistent with material facts. The subject’s statements are incoherent, conflicting with one another.

1. 2. 3.

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. Difference between confession and admission: CONFESSION is an admission of guilt while ADMISSION is usually a statement of fact by the accused which doers not directly involve an acknowledgment of guilt. Kinds of Confession: 1.

Extrajudicial confession- made by an accused, shall not be sufficient ground for conviction, unless corroborated by evidence of corpus decti. i. Voluntary ii. Involuntary

2.

Judicial confession- made in open court, admissible against the accused.

Maltreatment of Prisoners for the purpose of Exhorting confession or to obtain some information is crime punishable under Article 235, Revised Penal Code.

Torture: as defined under The Tokyo Declaration: -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.

Legal Medicine page 14

LECTURE IV: Identification and DNA Fingerprinting IDENTIFICATION-is the determination of the individuality of a person or a thing Importance: 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 of acquittal 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 the 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 presume 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 of registered ma8l in post office, sale of property, release of dead bodies to relatives, parties to contact, etc. Rules in Personal Identification: Legal Medicine page 15

1. Laws of Multiplicity of Evidence in Identification- the greater the number of points of similarities and dissimilarities of two persons compared, the greater is the probability for the conclusion to be correct. 2. The value of the different points of identification varies in the formulation of a conclusion. a. Fingerprints- positively establish the identity of the person while bodily marks, like moles, scars; complexion, shape of nose, etc. are merely corroborative. b. Visual recognition- by relatives, friends maybe of lesser value as compared with fingerprints and dental comparison. 3. The longer the interval between death and the examination of the remains for purposes of identification, the greater is the need for experts in establishing identity. 4. Inasmuch as the object to be identified is highly perishable, it is necessary for the team to act in the shortest possible time especially in case of mass disaster. 5. No rigid rule observed in the procedure of identification of persons. Methods of Identification: 1.

By comparison- Identification criteria recovered during investigation- compared of records available in the file or post-mortem finding are compared with antemortem 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 records 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: I. Ordinary Methods of Identification: those which laymen use to prove identity. 1. Characteristics which may easily be changed: a. Growth of hair, beard and mustache b. Clothing c. Frequent place of visit d. Grade of profession e. Body ornamentations 3. Characteristics which may NOT easily be changed: a. Mental memory b. Speech c. Gait d. Mannerism – stereotype movement or habit peculiar to an individual. e. Hands and feet f. Complexion g. Changes in the eyes h. Facies i. Left or right handedness j. Degree of Nutrition Points of Identification Applicable to both living and dead before decomposition sets in: 1. Occupational Marks: 2. Race a. color of skin Legal Medicine page 16

b. features of face c. features of skull d. wearing apparel 3. Stature: a person ceases to increase in height after the age of 25. Methods of Approximating the Height of a Person: 1. Measures distance between the tips pf the middle fingers of both hands extended laterally equals to height; 2. 2X length of one arm plus 12.5 inches from the clavicle and 1.5 inches from the sternum is the approximate height. 3. 2X the length from the vertex of the skull to the public symphysis is the height. 4. The distance between the supra-sternal notch and the publish symphesis is about one-third of the height. 5. The distance from the base of the base of the skull to the coccyx is about 44% of the height. 6. Length of forearm from tip of olecranon process to the tip middle finger is 5/9 of the height. 7. 8X 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. Importance: 1. Helps in identifying a person. 2. Indicates memorable events in his life. 3. Indicate the social stratum to which the person belongs. 4. Implies previous commitment in previous or membership in a criminal gang. 5. Weight- easily changes from time to time. 6. Deformities- congenital or acquired 7. Birth marks- spot naevi, port wine, or a mongolian blue spot. c. described as to shape. Location, dimension, color, or degree of pigmentation. 8. Injuries leaving permanent results- amputation, improper union of fractured bones. 9. Moles 10. Scar

i.

iv.

vi. vii.

11. Remaining mark after healing of wounds. Characteristics of the scar may show the cause of the previous lesion: Surgical operation: regular form and situation of stitch marks ii. Burns ands scald- scars are large, irregular in shape, and may kelooid. Scar of scald may show stipples surface iii. Gunshot wounds- depressed are center and may be adherent to the underlying tissue. Tuberculosis sinus- Irregular in shape furrowed, with edges. v. Flogging- Fine white lines diagonally across back, depressed small spots are interval. Gumma- depressed scar following loss of tissue. Venesectionviii. Wet cupping- Short parallel scars on lower part of the back and loin. 12. Tribal marks- marks on the skin by tattooing or branding 13. Sexual organ- circumcision 14. Blood examination- blood type, disease, parasitic infection or toxic substances present may be utilized to distinguish one person from another.

Legal Medicine page 17

ANTHROPOMETRY (Bertillion System) Anthropometrical measurement of the human body as the basis of identification. Basis: 1. The human skeleton is unchangeable after the twentieth year. 2. It is impossible to find two human beings having bones exactly alike. 3. The necessary can easily be taken with the aid of a simple instrument. PORTRAIT PARLE’- (Spoken Pictures)- Is a verbal, accurate and picturesque description of the person identified. In many instances the investigator does not have a picture of the wanted or missing person. The only way to have an idea of the prominent physical features is for the witnesses or someone who has knowledge of the identity to tell him. If a skilled investigative illustrator is available, a picture of the person to be identified may be drawn or sketched. As a check to the sketch or drawing made, it must be shown to the person(s) who gave the information to see wethwer it tallies wioth the person to be identified. ROGUE’S GALLERY or PHOTOGRAPHIC FILES- marked files wherein the picture(s) of a suspect is compared with the cartographic sketch EXTRNSIC FACTORS IN IDENTIFICATION: 1. 2. 3. 4. 5. 6.

Ornamentaions Personal belongings Wearing apparel Foreign bodies Identification by close relatives Identification records on file at the police department, immigration bureau, hospitals, etc. 7. Identification photograph LIGHT AS A FACTOR IN IDENTIFICATION: Particularly important when there is an eye witness to a crime: 1. Clearest Moonlight or starlight: Experiments have shown that the best-known person cannot be recognized by the clearest moonlight at a distance greater than 16 to 17 yards and by starlight any farther than 10-13 yards. a.

Broad daylight: A person can hardly recognize another person at a distance farther than 100 yards if the person has never been seen before, but persons who are almost strangers may be recognized at a distance of twenty-five yards.

b.

Flash of firearms: By experiment, letters 2 inches high can be read with the aid of the flash of caliber .22 firearms at a distance of two feet, BUT it is hardly possible for a witness to see the assailant in case of a hold-up pr a murder because: 1. Usually the assailant is hidden. 2. The assault is unexpected and attention of witness is at its minimum.

c.

Flash of lightning: Legal Medicine page 18

Produces sufficient light for the identification of an individual provided that the person’s eye is focused towards the individual he wishes to identify during the flash. d.

Artificial light: Identity is relative to the kind and intensity of the light. Experiments maybe made for every particular artificial light concerned.

II. Scientific Methods of Identification A. Fingerprinting B. Dental Identification C. Handwriting D. Identification of skeleton E. Determination of sex F. Determination of age G. Identification of blood and blood stains H. Identification of hair and fibers A.

FINGERPRINTING: considered most valuable method of identification; universally used because: 1. There are no two (2) identical fingerprints - Chances of (2) fingerprints being the same are calculated to be 1: 64,000, 000,000 (population of the world) which is - 10x the number of fingers existing in the world 2. Fingerprints are not changeable: Fingerprints are formed in the fourth month of pregnancy. During the latter stage of pregnancy as well as after birth, the pattern enlarges but no changes take place in the number and arrangement of the friction ridges. It can be said that fingerprints are an indelible signature which a person carries from the cradle to the grave.

Uses of Fingerprints: 1. Help establish identification in cases of dead bodies and unknown or missing persons. 2. Fingerprints recovered for scène of crimes are associative evidence, associative persons are weapons 3. Fingerprints on file are useful for comparative purposes and for the knowledge of previous criminal records. 4. Among illiterate, right thumb printing is recognized as a substitute for signature on legal documents (Philippines), left thumb (India) and right pointing finger (Spain).

Dactylography- the art and study of recording Fingerprint as a means of identification. Dactyloscopy- the art of identification by comparison of fingerprints. It is the study and utilization of fingerprints. Poroscopy- type study of identification of the pores found on the papillary or friction ridges of the skin for purposes of identification. It is also called as the Locards’ Method of Identification.

Methods of Producing Impressions (Fingerprints) Legal Medicine page 19

1. Plain method 2. Rolled method Kinds: 1. Real Impressions 2. Chance Impressions a. Visible print- visible without previous treatment. Visible immediately after impression. b. Plastic print- printed on paraffin, putty, resin, cellophane, plastic, tape, butter, soap, and etch. c. Latent print- prints that are not visible after impression but made visible by the addition of some substances.

How to develop latent prints: 1.Application of fine powder 2.Chemical development by funning and immersion

How to get fingerprint impressions are taken from Dead bodies a. fresh dead bodies b. Floaters- shortly recovered by bodies of water Floater- has been immersed in water for longer time. c. Same procedure as described may be applied to putrefied or burned bodies according or circumstances.

Poroscopy (Locard’s method of identification)- is applied when and only a part of the fingerprint is available for proper means of identification. d. Can fingerprints be effaced? Can fingerprints be forged?

B. DENTAL IDENTIFICATION: Dental identification is important in the following reasons 1. The possibility of two (2) persons to have the same dentition is quite remote. Why? -32 teeth (Adult) have five (5) surfaces. . Some of the teeth may be missing, carious, with filling materials, and with abnormality in shape and other peculiarities. 2. The enamel of the teeth is the hardest substance of the human body 3. After the death, the greater the degree of the tissue destruction, the greater is the importance of dental characteristics as 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. P.D. 1575 requires that practitioners of dentistry to keep records for 10 years of their patients to make accurate dental records available for purposes of comparison or exclusionary mode of identification. Upon the lapse of ten years, they shall turn over the dental records to the NBI. Forensic Odontologist- dentist specializing in dental identification  Sex- examination for the presence of Barr bodies (sex identification) from palatal scrapping. HANDWRITING:

Legal Medicine page 20

A person may be identified through: 1. handwriting 2. handprinting 3. hundnumbering The Sec.22, Rule 132 of Court: the genuineness of any disputed handwriting may be probed by: 1. Acknowledgement of the alleged writer that he wrote it. 2. Statement of the witness who saw the writing made and is able to identify it as such. 3. By the opinion of persons who are familiar with the handwriting of the alleged writer. 4. By the opinion of an expert who compares the questionable writing with that of other writings which are admitted or treated to be genuine by the party against whom the evidence is offered. See Sec. 50 (b), Rule 130- Opinion of Ordinary witness. Some practical uses of handwriting examination: 1. 2. 3. 4. 5. 6.

Financial crimes- bogus checks, credit cards fraud and embezzlement Death investigation- suicide notes, hotel registration cards, letter of explanation. Robberies- pawnshop receipts, cashing of stolen checks Kidnapping with ransom- demand notes, threatening letter. Anonymous threatening letters Falsification of documents- deeds of conveyance, receipts

Bibliotics- is the science of writing analysis, determinants genuiness and authorship Handwriting- is a complex interaction of nerves, memory and muscular movement. It is influenced by several factors and may be changed or modified during the life-span of a person. As a respondent, can you be compelled to give a sample of your signature/handwriting for the purpose of comparing the same to a questioned signature? Why?  No, because handwriting is not a mere physical movement of one’s arms, movement of hands, but involves one’s intelligence.  Therefore, it is a testimonial knowledge violative of the right against selfincrimination. Two (2) types if handwriting examination done by comparison with known standards: 1. Collected (procured) standard- These consist of handwriting by a person suspected to have written the questioned document. It may be found in public or private records of the person or from other sources. Provided it is clear and sufficient, it is a most appropriuate standard. - 15 handwriting specimens (used as standards) 2. Requested standard- These are standards made by the alleged writer of the document in question upon the request of the examiner or persons interested in the examination. Inasmuch as one of the characteristics of a good exemplar is that it must b contemporaneous with the date of the questioned document was made, the use of the requested standards is applicable only or recently written questioned documents, like extortion or “poison” notes or letter of threat or ransom, etc. * Please review the following: Handwriting Characteristics of Illiterates, Old Aged Persons and Disguised Writing, pp.71-73 of your book, Forensic Medicine by Solis, 1988 ed.

Legal Medicine page 21

Signature forgery – 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 1. 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: a. The paper wherein his signature is to be copied is placed o 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. b. 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. 2. Simulated forgery- an attempt to copy in a freehand manner the characteristics of a genuine signature either from memory of the signature of from a model. 3. Spurious forgery- forger’s own handwriting wherein little or no attempt has been made to copy the characteristics of the genuine writing. IDENTIFICATION OF SKELETON: In the identification of bones, the following points should be determined approximately: 1. Whether remains are of human origin or not 2. Whether 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 anti-mortem or post-mortem bone injuries. 9. Congenial deformities and acquired injuries in the hard tissues causing permanent deformities. -Superimposed photography How to determine Whether the remains are of human origin or not: 1. Size, shape and general features of the remains, especially that of the head must be studued; 2. Complete lay-out of the whole bones found and arranging them in their corresponding anatomical places; 3. Presence of dental fixtures, rings on the fingers, earrings in the case of women, hair and other wearing apparel, together with the remains---are strong presumption of human remains. How to determine whether the remains comes from a single individual or not: 1. A complete lay-out of the bones on a table in their exact locations in the human body is necessary. 2. Any plurality or excess of the bones after a complete lay-out denotes that the remains belong to more than one person. 3. However, congenital deformities must not be forgotten. 4. The unequality in sizes, specially in the limbs may be antemortem. Legal Medicine page 22

5.

The basis of the estimate for duration of interment: 1. Presence or absence of soft tissue 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 clothing, coffin and painting.

DETERMINATION OF SEX: Legal importance of determination of Sex Determination 1. As an aid in identification 2. To determine whether an individual can exercise certain obligations vested by law on one sex only. 3. Marriage or the union of a man and a woman 4. Rights granted by law are different to different sexes. 5. There are certain crimes wherein a specific sex can only be the offender or victim. How to determine sex: 1. Social tests 2. Genital tests 3. Gonadal tests 4. Chromosomal test Problems in Sex Determination 1. Gonadal agenesis- (testes or ovaries) have never developed 2. Tue hermaphrodism- A state if bisexuality DETERMINATION OF AGE: Legal importance of Determination of Age: 1. As an aid in identification 2. Determination of criminal liability 3. Determination of suffrage 4. Determination of exercise of civil rights 5. Determine the capacity to contract marriage. 6. As a right to certain crimes- rape, infanticide, seduction (qualified, simple), consented abduction. Determination of the age of a fetus: 1. Application of the Hess’s Rule or Haasse’s Rule: a. Fetus less than 25 cm. long (Crown to feet length)- get the square root of the length in cm. and the result is the age of the fetus in months. b. Fetus more than 25 cm. long or more- divide the length of the fetus by 5, and the result is the age of fetus in months. 2. Examination of the product conception. IDENTIFICATION OF BLOOD AND BLOOD STAINS: Legal importance of the study: 1. For disputed parentage (maternity and paternity) 2. Disputed maternity may arise a. Alleged switching of babies the nursery of the hospital; Legal Medicine page 23

b. Cases of stray children claimed by two (2) or more women; c. For ownership of dead fetus or newly born child found in the trash. 3. Circumstantial or corroborative evidence against or in favor of the perpetrator of a crime. E.g. “A” stabbed to death“B” found with blooded knife- examination shredded 4. Determination of cause of death 5. Determination of direction of escape of victim or assailant -Tapering end of blood spot is towards the direction of the moving source of blood. 6. Determination of approximate time of commission of crime. 7. Determination of place of commition of crime. 8. Determination of presence of certain diseases. Process of Blood Examination: 1. Determine whether the stain is due to blood; 2. If due to blood, determine whether it is of human origin or not. (Precipitin test) 3. If it is of human origin, to what group does it belong? (A, B, AB, O) 4. Does it belong to the person in question? 5. The manner, degree and condition of the article, which have been stained; 6. Age of stain

Prescriptin test: If a positive result is obtained, more or less conclusive way that the blood stains is of human origin although anthropoid ape may give the same result.

Blood Grouping: Value of Test- it may solve disputed parentage (paternity and maternity) - A positive result is not conclusive but a negative is conclusive that he is not the child of the alleged parents. Inheritance Patterns of ABO Blood Groups: Group of Parents Group of Children Exclusion Case OxO O A, B, AB OxA O, A B, AB OxB O, B A, AB AxA O, A B, AB AxB O, A, B, AB BxB O, B A, AB O x AB A, B O, AB A x AB A, B, AB O B x AB A, B, AB O AB x AB A, B, AB O Differential Characteristics of Blood from different Sources 1. Artificial Blood a. Bright scarlet in color b. Leaves blood vessel with pressures c. High oxygen content 2. Venous Blood Legal Medicine page 24

a. Dark red in color b. Does not spill far from the wound c. Low oxygen content 3. Menstrual Blood a. Does not clot b. Acidic in reaction owing to mixture with viginal mucous. c. On microscopic examination, there are viginal epithelial cells. d. Contains large number of Deoderlein’s bacillus. 4. Man’s or Woman’s Blood- there is no method of differentiating a man’s blood from a woman’s blood. 5. Child’s Blood a. At birth, it is thin and soft compared with that of an adult. b. Red blood cells are nucleated and exhibit greater fragility. c. Red blood cells count more than an adult. IDENTIFICATION OF HAIR AND HAIR FIBERS: Parts of the hair: 1. Cuticle- the outer layer of hair 2. Cortex or middle layer- longitudinal fibers bearing the pigment 3. Medulla or core- contains air bubbles and some figments. Distinction of human hair from animal hair, see p. 107, textbook. Estimation of Age based on the Hair: a. Hair of children is fine, short, and deficient of pigments and, as a rule, devoid of medulla. b. Adolescent age- hair may appear to the pubis. Hair on scalp becomes long, wity and thick. c. Older people- color usually white or gray with marked absorption of pigments and degenerative stages.

DNA (Deoxyribonucleiuc Acid ) Analysis Pronounced: ( dee-oxy-rye-bo-new-klee-ic acid ) Forensic science is not just DNA analysis. Not all forensic issues can be resolved by DNA analysis. I. DNA FINGERPRINTING A more recent method of identification is through a person’s DNA, referred often as DNA fingerprinting because of its irrefutable way of identifying a person, much like a fingerprint. Unless two people are identical twins or clones, the chance that any two individuals would have the same DNA fingerprint is one in several billion. So reliable is this method that if the DNA sequence from a suspect doesn’t match, with the specimen, the suspect is excluded from having left that specimen. In rape cases, there would be no need for the rape victim to testify as to whether the sexual act took place with a particular suspect since the vaginal fluid or the semen obtained from the woman’s vagina can contain the suspect’s DNA.

WHAT IS DNA AND HOW DOES IT WORK?

Legal Medicine page 25

Theoretically, wherever a person is, he is continually shedding off his DNA in some form of biological specimen such as saliva, blood, urine, sweat, and even semen and vaginal fluid. No matter how minute the amount, this can be collected and because of its uniqueness will identify the source from whence it came. It is such a powerful tool that, theoretically, it can prove that a particular group of people had been together in one room or one place. If a suspect’s DNA is collected from a particular area, it can at the very least put the suspect in the vicinity of the crime. It is so sensitive that if the specimen is not properly handled, even the DNA of the collector may contaminate the specimen. Briefly, the procedure involves taking a DNA pattern sequence from a human cell, cutting it with an enzyme that recognizes a distinctive site. Through electrophoresis, there is separation of these fragments by size. Then this is probed with a piece of radioactive DNA as a result of which bands will appear, corresponding to the length of these fragments, appearing like a bar code like the commercial products sold in supermarkets. But how can this help in identifying a dead body? Through its mitochondrial DNA which can only be passed on in the egg and so only from the mother, identification can readily be accomplished. By comparing the dead body’s DNA with any female or male relative on the maternal side, one can be sure with certainty that the body is that of someone related to them. DNA typing is a well-established tool for the identification of human remains. It is such a powerful tool that it is resorted to regularly and especially when the traditional methods of identification have not yielded positive results. Since DNA is relatively resistant to decomposition, especially in bones, this method can be useful in conditions of incineration, fragmentation or decomposition where ideal specimens can no longer be obtained. Of the many techniques of DNA analysis, the mitochondrial DNA (mt DNA) analysis is the most effective identification although technically the most challenging. In difficult cases, the possibility of extracting useful DNA is far better that nuclear DNA. This involves the study of a relatively small amount of DNA found in the cytoplasm of human cell. It consists of a single strand present in each mitochondrion, which is responsible for aerobic metabolism of the cell. In contrast to a single copy of nuclear DNA per cell, there are hundreds to thousands of copies of mitochondrial DNA per cell. Irrespective of other methods of identification, the trend in the States is for the medical examiner to retain a small specimen such as blood from an autopsied body. This is preserved as a card on file for easy reference, especially when the identification should later be questioned. Locally there are several agencies that can do this competently. What appears to be a major stumbling block to its widespread use is its a relatively expensive procedure. As with other modern technology, it is hoped that one day the procedure will be cheap enough to allow a DNA file for everybody.

A.

What is DNA? 4. 5. 6. 7. 8. 9.

DNA is the chemical substance which makes up our chromosomes and controls all inheritable traits (i.e. eye, hair, skin color); DNA is different for every individual except identical twins; DNA is found in all cells with a nucleus (white blood cells, soft tissue cells, bone cells, hair root cells, and spermatozoa) Half of the individual’s DNA/chromosomes come from the father, the other half from the mother; DNA is a double-starnded molecule; The DNA strands are made of four (4) different building blocks: A connects with T, G connects with C; Legal Medicine page 26

10. 11. 12. 13.

The four building blocks and their sequence in DNA makes up the letters of the genetic code; An individual’s DNA remains the same throughout his life; In specific regions on a DNA strand each person has a unique sequence of building blocks or genetic code; It is a persons unique genetic code that allows scientists to identify an individual to the exclusion of all others.

B. Characteristics of DNA:  Each person has a unique DNA profile;  Each person’s DNA is the same in every cell;  An individual’s DNA profile remains the same throughout life;  Most DNA is the same from person to person;  Some DNA varies from person to person C. How does DNA solve crimes? DNA profiling:  

determines the exact genotype of a DNA multiple; Distinguishes one human being from another by identifying a DNA “barcode” unique to every individual.

D. DNA identification applications:       

Sexual assault; Homicidal and violent crimes; Exculpate wrongly accused suspects; Identify serial crimes; Identify human remains; Sex offender tracking; Parentage testing.

E.

DNA parentage testing applications:  Child support enforcement;  Criminal paternity;  Identify human remains;  Kinship and sibling analysis;  Twin zygosity.

F.

Non-forensic uses of DNA methods:  Genetic and other disease diagnosis;  Rare, endangered and extinct animals research;  Identify war casualties;  Historical identification issues. G.

DNA Parentage evidence sources:

H.

Paternity: Fresh blood cord blood abortus, prenatal samples saliva (buccal swabs) Possible results of DNA Analysis:

Maternity: abandoned, switched, kidnapped infants

Legal Medicine page 27

1.

2.

3.

I.

Exclusion – the DNA profile from the evidence sample does not match the profile of the suspect’s reference sample; the suspect is excluded as a source of the evidence; Inclusion – the DNA profile of the reference sample matches that of the evidence sample; the suspect is included `as a potential source of the evidentiary DNA; Inconclusive – not possible to determine if the samples are the same; may arise from sample degredation; contamination, or failure to observe some part of the protocol.

Evidentiary issues in forensic DNA analysis and testing:    

Admissibility; Evidentiary weight; Reading and understanding DNA analysis Report; Presenting and making the report admissible.

J.

Random match probability:  Statistical expression of the significance of the profile match;  Probability that an innocent individual, unrelated to the suspect and chosen randomly from the population, will match the DNA profile taken from the crime sample.

K.

Likelihood Ratio:  

L.

Statistical expression of the significance of the profile match; The ratio of the probability that the DNA profile in the evidence sample come from the suspect, and the probability that the DNA came from a random, unrelated person.

Presenting DNA (or any scientific evidence ) and making it admissible:      

Use of expert witness testimony; Integrity of the sample(s); Chain of custody; Interpretation of results and probabilities; Relevance; Competence.

M.

Preservation of DNA evidence:  Air dry (no heat) all stains or swabs;  Store frozen in paper bags;  Tissue stored frozen are preferably without preservatives(forlain or embalming fluid);  Refrigerate liquid blood up to few weeks; freeze for long term storage. The FORENSIC EXPERT as consultant or witness:    

Complex scientific, medical or technical assistance; Evaluation of the case; Literature research; Advise counsel about the discovery of evidence;

CONSULTANT vs. WITNESS Legal Medicine page 28

 

Consultant provides advice in preparing a case and may become an advocate; Expert witness discusses facts and provides objective opinions based on facts and should not be an advocate.

“If the law made you a witness remain a man of science. You have no victim to avenge, no guilty or innocent person to ruin or save. You must bear within the limits of science.” (Paul H. Broussard, Chair of Forensic Medicine , Sorbonne, 1897)

DNA expert witness testimony:  Professional qualification and expertise;  Reliability of the DNA testing process;  Reliability of the laboratory itself;  Interpretation of the results of the DNA test. A forensic scientist with appropriate education, training and exp[erience is the person best qualified to interpret scientific evidence, form a conclusion about it , and provide an opinion about its significance in the context of the case.

LECTURE V

MEDICO-LEGAL ASPECT ON DEATH

Importance of Death Determination 1. The civil personality of a natural person is extinguished by death 2. The property of a person is transmitted to his heir at the time of death. 3. The death of a partner- causes dissolution of partnership. 4. Death of either agent of principal is code pf extinguishments of agent. 5. The criminal liability of a person is extinguished by death. 6. The civil case for claim, which does not survive, is dismissed upon death of the defendant. (Sec.20, Rule 3, new rules civil pro.)

Legal Medicine page 29

Death: is the termination of life. It is the complete cessation of all the vital functions without possibility of resuscitation. Distinguishing death vs. dying  The ascertainment of death is clinical and nor legal  Previously, complete and persistent cessation of cardio-respiratory function is the standard criteria in the determination of death. Scientific development and advancement lead to development of uncertainty of death 1. Increasing use of mechanical resuscitation devices, which can maintain reparation and cardiac function almost indefinitely. “Technological Imperative” 2. There is an increasing demand of organs for transplantation 3. Coma- Following administration of excessive doses of modern sedatives and hypnotics could be mistaken for death.

Based on the Criterion Used in its Determination, Death may be: 1. Brain death- death occurs when there is irreversible coma, absence of electrical brain activity and complete cessation of all vital functions without possibility of resuscitation. 2. Cardio-Respiratory Death- death occurs when there is continuous and persistent cessation of heart action and respiration.

Brain Death: In as much as there is no universally accepted criteria yet to establish a condition of brain death, this recommendation are made by different committees or bodies (Harvard Report of 1968 Characteristics of Irreversible coma: a. Unreceptively and irresponsibility b. No movement or breathing: observation covering a period of at least satisfy the criteria of no spontaneous muscular movements or spontaneous respiration or response to stimuli such as pain, touch, sound, and light. c. No reflexes: Irreversible coma- abolition function of CNS evidenced by elicitable reflexes. Example: deep tendon reflex: KNEE-JERK REFLEX BABINSKI REFLEX SIGNIFICANCE d. Flat electro-encephalogram: (isoelectric EEG) -All these tests should be repeated within 24 hours later without any change. *The patient must be declared dead before any effort is made to take him of the respirator, if he is then on a respirator.

Brain Death- is the most ideal criteria, however, Electro-encephalogram (EEG), which is the most reliable machine to determine brain activities, is not available in many places and number of component persons to apply the instrument is and the interpretation of the results is quite limited.

 The use of the criteria of brain death may be applied to potential organ donors. Kinds of Death 1. Somatic death or clinical death 2. Molecular or cellular death- 3-6 hours later. 3. Apparent death or state of suspended animation. Legal Medicine page 30

–

Signs of Death 1. Cessation of heart action and circulation-As a general rule: if there is no heart action for 5 minutes, death is regarded as certain. 2. Cessation of respiration- a person can hold his breath no longer than 3 ½ minutes. Following conditions where there is suspension of respiration without death: a. Purely voluntary act- swimmers, divers, cannot be longer than 2 minutes. b. Chyne-Strokes conditions- diabetic complication -The apneic interval cannot be longer than fifteen to twenty (15-20) seconds. c. Apparent drowning d. Newly born infants CRITERIA: Stages of COMA

3. Cooling of the body (ALGOR MORTIS) -Fall of temperature of 15 to 20 degrees Fahrenheit is considered sign of death. -Post-mortem CaloricityMethods of estimating how long a person has been 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 2 hours. = ½ of the difference between body temperature and that of the air. -Next 2 hours = ½ of the previous rate -Next 2 hours= ½ of the previous rate  General rule: the body attains the temperature of the surrounding air for 12 to 15 hours after death in tropical countries. b. Approximate estimate of duration of death from body temperature; (Normal temperature) 98.4 °F - (Rectal temperature) 15 =Approximate number of hours after death 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 concentration of lactic acid (L.A.), non-protein nitrogen (N.P.N.) and amino acid (A.A) and whose axillary temperature has been taken the time the cerebro-spinal fluid has been removed.

4. Insensibility of the body and loss of power to move: 5. Changes in the skin Importance: a. Skin- pale and waxy-looking due to the absence of circulation -Most dependent part specially some areas develop vivid discoloration on account of gravitation of blood. b. Loss of elasticity: When skin surface is compressed, it readily returns to normal shape. Example: Application of pressure-produce fitting impression. -Post-mortem Contact Flattening-because of loss of elasticity and flaccidity of muscles, the body becomes flattened over areas, which are in contact with the surface it rests. Example: shoulder blades, buttocks and calves -If death occurs while lying on back c. Opacity of the Skin: (Diaphanous Test) Legal Medicine page 31

-Skin of dead person when exposed 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 application of heat: (Melted Sealing Wax) -Will not produce blisters or inflammatory reaction.

6. Changes in and about the eyes: a. Loss of corneal reflexes b. Clouding of the cornea c. Flaccidity of the eyeball- the eyeball sinks into the orbital fossa. Intra-orbital is low. d. Pupil is in the position of rest -Dilated/ contracted reflexes -Action of drugs like atropine constricts -Uremia -Tabes dorsalis -Apoplexy 7. Action of heat in the skin: Useful to determine whether the application of heat occurred before of after death. -If after death-dry blisters is produced *Epidermis is raised, no fluid on pricking *No redness of surrounding of the skin -If before death (living person)= blister is wet with vital reaction (Inflammation and congestion)

The following combination of Signs show death has accured: 1. Loss of animal heats to appoint no compatible with life. 2. Absence of response to muscular stimulus 3. Ones of rigor mortis.

Changes in the body of the following death: 1. Changes in the muscles: Stages after death: a. Stage of primary flaccidity (post-mortem muscular irritability) -First 2 hours after death to 6 hours -Complete relaxation of the whole muscular system after somatic death. -Pupils are dilated, sphincter are relaxed, therefore, 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. -Due to coagulation of person’s proteins -Development after 3 to 6 hours up to 25-36 hours reaction to acid c. Stage of secondary flaccidity or commencement of putrification. (Decay of the muscles) The muscles become flaccid, no longer capable of responding to mechanical or electrical stimulus and reaction becomes alkaline. Factors influencing the Time of onset of Rigor Mortis: 1. Internal Factors: a. State of the Muscles: -If the muscles have been healthy and at rest before death- onset of R.M.-late , the duration longer. Legal Medicine page 32

- In the following cases onset of R.M. hastened: i. Animal having been hunted to death ii. Prolonged convulsion and lingering illness. iii. Death for fever, thyphus, cholera and phthisis. b. Age: Aged and unborn -Delayed in good health and good muscular development. 2. External Factor a. b.

Temperature: accurate by high temperature but temperature above 75 °C will produce heat stiffening. Moisture: High R.M. onset rapid and duration is short.

a

Conditions Simulating Rigor Mortis 1. Heat Stiffening: Temperature – 75 °C -Observed in body if person placed in a boiling fluid then the body is burned to death. -“Pugilistic Attitude” 2. Cold Stiffening – Body is frozen and solidification of fats 3. Cadavaric Spasm or instantaneous Rigor- instantaneous rigidity of the muscles, which occurs at the moment of death to extreme nervous tension, exhaustion and injury to the nervous system or injury to the chest. Reason: The last voluntary contraction of the muscle during the life does not stop after death but is continuous with the act of cadaveric rigidity. Important: In case of cadavic 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 initiate the condition.  -Groups of muscles involve and they are usually not symmetrically.  -The findings of weapon, hair, pieces of clothing, weeds on the palms of the hands and firmly grasped is very important. - Medico-legal point in determination whether it is a case of suicide, murder or homicide. Example: The presence of weeds in the hands as a person found in water shows that the victim was alive before disposal.

Distinction between Rigor Mortis and Cadaveric Spasm: 1. Time of appearance 2. Muscles Involved 3. Medico-legal significance.

Changes in the Blood: a. Coagulation of Blood - Blood may remain fluid inside the blood vessels after death for 6 to 8 hours.

Distinction between Ante-mortem from Post-mortem Clot: Ante –mortem Clot Post-mortem Clot 1. Firm in consistency

1. Soft in Consistency

2. Surface of the blood vessels

2. Surface of the blood Legal Medicine page 33

raw after the clots are removed

smooth after the clots are removed

3. Clots homogeneous in construction so it cannot be stripped into layers

3. Clots can be stripped off layers

4. Clot with uniform color. b. Post- Mortem Lividity or Cadaveric Lividity or Post-mortem

Sangulation 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 the bone prominence may not show lividity on account of the pressure. If the body is moved during early stage- initial lividity may disappear and develop again in the new position assumed. BUT if the position of the body is moved after clotting has set in or when blood has already differed into the tissues of the body, a change in position will not alter the location of post-mortem lividity. Example: (12 hrs. fully developed) Lividity begins to appear 3 to 6 hrs, after death and the condition increase until blood coagulation for 12 hrs. Kinds: 1. Hypnostatic 2. Diffusion lividity

Importance of Cadaveric Lividity: 1. Sign of death 2. Determine whether body position has been moved after its appearance in the body. 3. Color of the lividity may indicate the cause of death Example: asphyxia-dark CO poisoning-bright pink He-anemia-lieu marked 4. Determine how long the person has been dead. 5. Gives us an idea as to time of death.

Distinction between Contusion (Bruise) and Post-mortem Hypostasis Contusion (Bruises) 1. Below the epidermis in the true skin in small bruises or extravasations; larger ones deeper still

Post-mortem Hypostasis 1. In the epidermis

Legal Medicine page 34

2. Cuticle abraided by the same violence that produce bruise. 3. Bruises appear at the site of injury 4. Often elevated due to inflammation 5. Incision shows blood outside vessels ●Most important distinction 6. Color varies- with time 7. Color changes @ area of pressure

2. Cuticle-unabraided because there is no trauma. 3. Forms at the most dependent portion because of gravity. 4. Not elevated 5. Incision-blood still inside vessels 6. Color is uniform 7. White lines or patches of Pressure

Autolyctic or Autodigestive Changes after death: Putrefaction of the body- is the breakdown of complex proteins into simpler components associated with evolution of foul smelling gasses and accompanied by a change in color of the body.

●Special Modification of Putrefaction● 1. Mummification-dehydration of the whole body results in shivering and preservation of the body e. Occurs in hot, dry, arid place and with free access to hot air. 2. Saponification or Adipocere Formation Adipocere- is a waxy material, rancid or moldy in odor. -Condition wherein the fatty tissues of the body are transformed into a softbrownish-white substance known as adipocere. 3. Maceration- this is the softening of the tissues when in a fluid medium in the absence of putrefactive microorganism. Example: death of the fetus in utero. Determination of Duration of Death: From the conditions of cadaver and other external evidence: 1. Presence of Rigor Mortis- 2 to 3 hours after death. Complete after 12 hours and lasts for 18 to 36 hours. -disappears with onset of decomposition. 2. Presence of Post-mortem lividity. -Develops in 3 to 6 hrs, after death. -Found on most dependent portion of the body. . 3. Onset of Decomposition: -Decomposition early in Philippines, average time of onset is 24 to 48 hrs, after death -Manifested by watery, foul-smelling froth coming out of the nostrils and mouth, softness of the body and presence of crepitations, when pressure is applied on the skin. 4. Stage of Decomposition: -Degree of decomposition (refer tabulation in the Book p. 143) 5. Entomology of Cadaver: -The usual time for an egg to be hatch into larva is 24 hrs. -Presence of maggots implies that death has occurred more 24 hrs. 6. Stage of Food Digestion in the Stomach: - It takes 3-4 hrs, for stomach to evacuate food contents after a meal. 7. Presence of live fleas: -Flea can survive for 24 hours even if submerged in water. Legal Medicine page

35

-Fleas cannot be revived 8. State of Clothing 9. Cerebro-Spinal Fluid (CSF) -Lactic acid increase from 15 mg. To 200 mg. Per 100 cc. -Non-protein nitrogen increases from 15 to 40 mg. -Amino acid concentration rises from 1 to 12 % followint death 10. Post-mortem Clotting and Coagulation of Blood: -Blood clots inside the blood vessels in 6-8 hours after death. 11. Presence or Absence of soft Tissues in Skeletal Remains: - 1-2 years after burial and soft tissues disappear. Post-mortem Conditions simulating disease, Poisoning, or Injury: 1. Post-mortem hypostasis-(Post-mortem Lividity) -Simulating contusions or inflammation or poisoning. 2. Blister of the cuticle simulating scalds or burns. 3. Swelling, detachment or splitting of the skin simulating injury.

Please review Presumption of death- Rules of Court/Civil code- aticle 391, 392, Rule 131

LECTURE VI MEDICO-LEGAL INVESTIGATION OF DEATH The following officials of the government are authorized to make death investigation: 1. Provincial and City Fiscals 2. Judge of Regional Trial Court (RTC) 3. Judge of Municipal Trial Court (MTC) 4. Division of National Bureau of Investigation (NBI) 5. Chief Police of City of Manila 6. Solicitor General

Stages of Medico-Legal Investigation 1. Crime Scene Investigation 2. Autopsy-investigation Crime Scene- is the place where 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. Legal Medicine page

36

SOCO- Scene of the Crime Operation CSST- Crime Scene Search Team In violent death cases, the manner and cause of death may be inferred from the condition of the crime scene.

Kinds of Autopsies: a. Hospital or Non-official Autopsy b. Medico-legal or Official Autopsy

Hospital of Non-Official Autopsy: Purposes: 1. 2. 3. 4. 5.

determining the cause of death providing correlation of clinical diagnosis and clinical symptoms determining the effectiveness of theraphy studying the natural course of disease process educating students and physicians

Medico-Legal or Official Autopsy: Purposes: 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; 5. Separating death due to disease from death due to external cause for protection of the innocent

The following Manner of Death should be Autopsied: 1. 2. 3. 4. 5. 6.

Death by violence Accidental Death Suicides Sudden death of persons who are apparently in good health Death unattended by physician 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 7. Death occurring in an unnatural manner.

Medico-Legal classification of the causes of death: a. Natural Death b. Violent Death

a. Natural Death - caused by natural disease condition in the body -in natural deaths with concomitant physical injuries, it is necessary for the physician to determine whether the physical injuries would accelerate death, or the injuries itself developed independently and produced/death or that the person died absolutely of a natural cause.

b. Violent Death: -are those due to injuries inflicted in the body in some forms of outside force. The physical injury must be the proximate cause of death. Legal Medicine page

37

Death due to Physical injury inflicted if: 1. Victim – normal health before inflicting P. I. 2. Death expected from P. I. inflicted. 3. Death ensued with in a reasonable time

Classification of Trauma or Injuries: 1. 2. 3. 4. 5. 6. 7.

Physical injury - sustained thru physical force Thermal injury – caused by heat or cold Electrical injury – Injury due to electrical energy Atmospheric injury – due to change of atmospheric pressure. Chemical injury – caused by chemicals Radiation injury – those brought about by radiation Infection – caused by microbic invasion

Penal Classification of Violent Death: 1. Accidental Death – due to misadventure or accident. 2. Negligent Death – death due to reckless imprudence, negligence, lack of skill or lack of foresight. 3. Suicidal death 4. Parricidal Death (Art. 246) 5. Infanticidal Death 6. Murder (Art. 248) 7. Homicidal Death

Pathological Classification of the Causes of Death: 1. Death from Syncope – death due to sudden fatal cessation of the action of the heart with circulation included. 2. Death from Asphyxia – condition which the supply of Oxygen to the blood or to the tissues or to both has been reduced below normal working level. 3. 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. SPECIAL DEATHS 1. Judicial Death: RA 8177 (Assignment, read the legal provisions)

DISPOSAL OF THE DEAD BODY Duty to bury body – Sec. 1103 Admin. Code a. surviving spouse, if none b. nearest kin of deceased, if none c. municipal authorities

Right of custody own dead body = possession – concept of ownership - Holder of a thing keeping it while ownership belongs to another .

Executor’s Right of Custody Superior to the Right of Spouse Dead body. If the deceased left a will – prevail over rights of Spouse Absence of will – right of spouse is paramount

Methods of Disposal of the Dead Body: 1. Embalming 2. Burial of human remains: Legal Medicine page

38

2.1 must be buried with in 48 hrs after death if no embalming except: a. when it is the subject matter of legal investigation b. when authorized by local health authorities. c. Impliedly when the body is embalmed 2.2 Death Certificate Necessary before Burial issued by: d. attending physician e. local health officer f. municipal mayor g. municipal secretary h. any councilor. 2.2 Permission from the Provincial Fiscal or from the Municipal Mayor is Necessary if Death is Due to Violence Crime: Sec. 1090: Burial and Transfer Permit Sec. 1091: Burial permit (death certificate) must be presented before burial Sec. 1094: Disposition of body and belonging of person dying of dangerous communicable disease

Limitations to the Funeral Rites: a. Will of Deceased b. Burial of the person sentenced to death must not be held with pomp: c. Restrictions as to funeral ceremonies in cases of deaths due to communicable disease: 3. Disposing of the dead Body in the Sea: 4. Cremation 5. Use of the Body for Scientific Purposes: 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 labeled properly identifying the type and amount of radioactive isotopes present and the date of its administration. c. Before autopsy is performed, Radiation Health Officer or his duly authorized representative should be notified for proper advice. d. Normal burial procedure e. Cremation R.A. 349 as amended by R.A. 1056 DONATION OF PARTS OF HUMAN BODY Donation of Human Organs for Medical, Surgical and Scientific Purposes According to the Sanitation Code (P.D. 856). Gen. Rule

“ When TREATMENT is beneficial, GIVE When TREATMENT is useless, in general, DO NOT GIVE When TREATMENT is of doubtful benefit, GIVE because that defends life better”.

Sometimes social death comes ahead of biological death. When the person who is dying is abandoned he or she has died already, although physically there is life Guidelines for Physicians to aid this in cases where a decision to withhold or withdraw nutrition and hydration is to be made 1. Unconscious, imminently dying patient (progressive and rapid deterioration) -the dying process has begun and cannot be reversed. Legal Medicine page

39

-Nutrition and hydration – useless and all things considered, no longer a reasonable burden 2. Conscious, imminently dying patient -nutrition and hydration – are useless possibly burdensome, and need not be artificially provided but may be of desired by patient 3. Conscious, irreversibly ill, not imminently dying patient -persons is conscious, beyond cure or reversal of the discase, but able to function to some degree -nutirition and hydration sustain life, so they are not useless, and usually they are not unreasonably burdensome -nutrition and hydration should be provided unless or until there is clear evidence that provision of nutritious and hydration constitutes an unreasonable burden for the patient. 4. Unconscious, non-dying patient -nutrition and hydration should be supplied -feeding is not useless because it sustain life -there is no indication that the persons is suffering, nor is there any clear evidence that the provision of nutrition and hydration is an unreasonable danger or burden -In such a case, the withdrawal of nutrition/hydration brings about death by starvation/dehydration -Absent any other indication of a definite burden for the patient withdrawal of nutition/hydration is not morally justifiable

Pulling the plug: The Hippocratic Oath – provides that a doctor has to protect life to the extent that he can. -once licensed to practice, a doctor swears to heals, to alleviate suffering and to preserve life. -Advances in medical technology has wrought important and previously unheard of tools in his endeavor, enabling the physician to save the past had to accept death as inevitable and imminent -In many situations where the patient is unable to speak for himself it is the relatives who ask the doctor to withdraw all forms of life support from the patient because they could not hear his suffering or to artificially prolong his life because they could not bear to lose him

DNR – order - * Do Not Resuscitate LECTURE VII: MEDICO-LEGAL ASPECTS OF PHYSICAL INJURIES Physical injury - is the effect of some forms of stimulus on the body. Causes of Physical Injuries: a. Physical Violence b. Heat or Cold c. Electrical Energy d. Chemical energy e. Radiation by Radio-Active Substance f. Change of Atmospheric Pressure g. Infection Physics of Wound Production:

Wound = kinetic energy x time area x “other factors” 1. Kinetic Energy = MV2 Velocity component is more important Legal Medicine page

40

2 Ex. M-16 Machine gun – Speed of bullet 3,200ft/sec. .38 cal. – bullet heavier, slower V= 600 ft/sec 2. Time- the longer time of impact, the lesser injury 3. Area of transfer – the larger the area the lesser injury 4. Other factors – skin elasticity, prox. Of base/hard

Vital reaction – sum total of all reactions of tissue or organ to trauma: Rubor, calor, Dolor, Loss of function, tumor Presence of vital reaction differentiates injury inflicted during life or post-mortem except: 1. Physical Injuries inflicted immediately before death 2. Death –sudden

Classification of Wounds: 1. As to severity a. mortal wound b. non-mortal wound 2. As to kind of instrument used/agent a. blunt instrument – contusion, hematoma, lacerated wound b. sharp instrument 1.1 sharp edged – incised wound 1.2 sharp pointed – punctured wound 1.3 sharp-edged – pointed – stab c. tearing of force – lacerated wound d. change of atmospheric pressure – barotraumas e. heat of cold f. chemical explosion – gunshot or shrapnel 3. As to the manner of Infliction a. hit – bolo, blunt instrument, axe b. thrust or stub – bayonet, dagger c. gunpowder explosion – projectile or shrapnel wound d. sliding or rubbing – abrasion 4. As regards to depth of wound: a. superficial – includes only layers of the skin b. Deep – beyond layers of the skin; Penetrating – 2 meanings: 1.a. wounding agent enters the body but did not come out 1.b. the mere piercing of a solid organ or tissue of the body c. Perforating – 1.a. Wounding agent produces communication between inner and outer portion of the hollow organs. 1.b. piercing or traversing completely as particular part of the body causing communication between the points of entry and exit of the instrument or substance producing it. 5. As regards to the Relation of the Site of the Application of Force and the Location of Injury: a. Coup Injury – Physical Injury which is located at the site of the application of force. b. Contre-Coup Injury – Physical injury found opposite the site of the application force. c. Coup Contre-Coup Injury – Physical Injury located at the site and also opposite the site of application of force. d. “Locus Minoris Resistencia” – Physical injury located not al 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 Legal Medicine page

41

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. (e.g. fall from a height; run-over victim of vehicular accident may suffer from multiple fractures, laceration of organs, and all types of skin injuries. 6. As to the Regions or organs of the Body involved: 7. Special types of Wounds: a. Defense Wound – result of a person’s instinctive reaction of selfprotection/preservation. b. Patterned Wound – wound in the nature/shape of an object or instrument and which infers the object or instrument causing it. e.g. hanging rope, plastic cord, c. Self-inflicted wounds – wound produce on one-self as distinguished from suicide; person has no intention to end his life. Motive of producing Self-inflicted Wounds: 1. deliberately magnify an existing injury or disease for pension or workman’s compensation 2. escape certain obligation or punishment. 3. create a new identity or destroy the existing one. 4. gain attention or sympathy 5. psychotic behavior.

Mutilations: Maylem – is the unlawful and violent deprival of another of the use of a part of the body so as to render him able in fighting either to defend himself or to annoy his adversary. Therefore Mutilation of other parts of the body other than the organ of reproduction. May be classified as maylem.

Serious Physical Injuries – Art. 263, RPC the crimes may be due to: 1. wounding 2. beating 3. assaulting 4. administration of injurous substances – w/o the intent to kill  Note: par..3 and 4 of Art. 363, RPC no mentioned periods of medication attendance but merely incapacity.

Less Serious Physical Injuries - Art. 265, RPC More or less than 10 days but not more than 30 days incapacity or medical attendance. 1. there must be proof of pd. Of med. Attendance or pd. Of incapacity. 2. Basis to detention whether Physical Injuries is less serious or not medico-legal aspects of Physical Injuriescoverage of M.T.E. 3. The fact that injury requires only med. Rx for 2 days but incapacitated the victim for 28 days makes the crine kess serious Physical injuries. 4. In the absence of proof of med. Attendance or incapacity, fact that the wound healed more than 30 days makes only the crime of slight Physical injuries

Slight Physical Injuries – Art. 265 RPC Legal Medicine page

42

Kinds: 1. Physical Injuries which incapacitate victim for labor from 1-9 days or require med. Attendance for the same period. This kind will require med. Cert. As to the duration of medical attendance, or period of incapacity. Incase of divergency in the duration of medical attendance and incapacity, the physician must always consider the best interest of the victim in the determination of the period. 2. Physical Injuries which did not incapacitate or require medical attention. 3. Ill-treatment of another by deed. Review Physical Injuries inflicted in Tumultous Affray Art. 252

Types of Wounds A. Closed Wounds – no breach in continuity of skin Superficial – wound is within skin / mucous membrane a. Petechiae – circumstancial extravasation of blood subcutaneous tissue c. Contusion – 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. b. Hematoma – extravasation or effusion of blood in a newly formed cavity underneath the skin. Distinction between Contusion and Hematoma: i. In contusion the effused blood are accumulated in the interstices of the tissue underneath the skin. ii. In hematoma blood accumulates in a newly formed cavity underneath the skin. c. Contusion - skin shows no elevated – if only slight acct. of inflammatory, while in hematoma – skin always slunted Contusion – aspiration with syringe – no blood can be obtained Abscess, gangrene, hypertrophy, fibroid, thickening, and even malignancy are potential complications of hematoma. Ecchymosis – “kiss mark”, a type of hematoma Deep: Musculo-Skeletal Injuries: 1. sprain – partial or complete disruption in the continuity of a muscular or ligamentous support of a joint. Caused by blow, kick or torsion force. 2. Dislocation – displacement of the articular surface of bones entering into the formation of a joint. 3. Fracture – solutions of continuity of bone resulting from violence or existing pathology Types: a. closed or simple b. open or compound c. Comminuted Fracture d. Greenstick Fracture e. Linear Fracture f. Spiral fracture g. Pathological Fracture 4. strain – the over stretching of muscle a ligament which may not be properly associated with a joint. 5. subluxation – Incomplete or partial dislocation Internal Hemorrhage : caused by rupture of blood vessel due to Traumatic intracranial hemorrhage Legal Medicine page

43

Rupture of parenchymatous organs Laceration of other parts of the body Cerebral Contusion – the stunning or jarring 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. -loss of memory for events just before the injury

B. Open Wound – there is breach in the continuity of the skin or mucous membrane. 1. Abrasion (scratch, graze, Impression Mark, Friction Marck) -Injury characterized by the removal of the superficial epithelial layer of the skin caused by a rub or friction against hard, rough surface. -May be associated with contusion if there is forcible contact CHARACTERISTICS:  develops at the precise point of impact  injury consist of parallel linear of the rub or friction causing it.  may exhibit the pattern of the wounding material  usually ignored by attending physician for it does not require medical treatment but it has far-reaching importance in the medico legal viewpoint.  -abrasions caused by fingernails  -usually located in bony parts of the body associated with contusions and laceration  -nature of abrasions may infer degree of pressure, nature of rubbing object and the direction of movement.  abrasion heals in a short time and leaves no scar.

FORMS OF ABRASION: a. b. c. d.

Linear multi-linear confluent multiple

TYPES: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Scratch – sharp pointed object which slides over skin Graze – forcible contact Impact or Imprint Abrasion (Pattern abrasion, stamping abrasion or “abrasion a la signature”) marks of the grid of radiator tire thread marks muzzle imprint – contact fiercing teeth impression – skin bites pressure or Friction Abrasions – hanging or strangulation

Incised wound – (cut, slash, slice) - produced by a sharp edged or sharp linear edged of the instrument. (e.g. knife, razor, bolo, glass, metal sheet)  impact cut  slice cut CHARACTERISITICS: 1. edges – clean cut, both extremities are sharp 2. wound straight or shelving – acute to body 3. wound shallow near extremities; deeper at middle position 4. because clean cut; profuse huge is a features. 5. Gaping 6. If incised wound is covered are = even clothing show clean cert texture 7. Healing by 10 intention Legal Medicine page

44

8. Incised wounds may be suicidal, homicidal or accidental

Stab wound – produced by the penetration of a sharp-pointed and sharp-edged instrument, like a knife, saber, dagger, scissors 1. if sharp-edged portion is the first come in contact with 1 skin –incised wound produced. 2. If sharp-pinted – first –stab wound produced 3. Like incised wound edges are clean-cut, regular and distinct 4. Surface length – reflect/withdrawal – not same direction as introduction or stabbing accompanied by slashing movement. 5. Direction of the surface defect may be useful in determination of rel. position of the offender and the victim when the wound was inflicted. 6. Hemorrhage is always the most serious consequence of a stab wound.

In the description of the stab wound, the ff. must be included: 1. length of skin defect, abrasion tailing – measured separately- infers direction of withdrawal of the wounding weapon 2. condition of the extremities3. condition of the edges- one stabbing act – edges regular and clear cut 4. several stabbing act – edges serrated or zigzag 5. Linear direction of the surface wound – vertically, horizontally, or upward medially or laterally 6. Location of the stab wound – see pg. 268 7. Direction of penetration 8. Depth of penetration 9. Tissue and organs involved.

Stab wound may be suicidal, homicidal, accidental : 1. suicidal – evidence 2. homicidal – most common

Characteristics: a. b. c. d.

presence of other injuries location – any part of body more than one stab wound – gradually + motive for stabbing if w/o motive, the offender must be insane or under the influence of drugs e. + disturbance in the crime scene

Medical evidences showing intent of offender to kill the victim: 1. > 1 stab wounds 2. stab wound located in different parts of the body or parts where vital organs are found 3. deep 4. serrated or zigzag borders 5. irregular or stellate shape – due to changing direction of weapon – greater internal damage Most common – immediate cause of death is hemorrhage

Punctured wound: 1. produced by a thrust of a sharp – pointed instrument 2. external injury small – depth is usually deep 3. produced by ice pick, needle, nail, spear, pointed stick, thorn, fang of animal – hook

Legal Medicine page

45

4. nature of external injury – depends on sharpness and shape of the end of the wounding instrument 5. contusion of edges may be present of end not so sharp 6. external injuries – minimal – internal injuries severe. 7. site of the external wound can be easily sealed by the dried blood, 8. serum or clotted so that introduction of anaerobes e.g. tetanus – secondary infection

Punctured wound – usually accidental, rarely homicidal Lacerated wound (Tear, rupture, “Putuk”, stretch) - tear of the skin + underlying tissues due to forcible contact with a blunt instrument, e.g. piece of wood, iron bar, fist blow, stone, butt of firearm.

Characteristics: 1. shape and size of injury does not correspond to wounding instrument. 2. tear of skin – rugged with extremities irregular and ill-defined 3. injury at the site where blunt force is applied 4. borders of wound – contused and swollen 5. usually develop in areas where bone is superficially located. Scalp, dorsum of foot, front leg. 6. exam with hard lens – bridging tissues and instant hair bulbs 7. heeding not extensive because Blood usual are not severed evenly 8. healing process delayed – scars usually develop.

It may be homicidal or accidental but rarely suicidal Distinction between Incised wound vs. Lacerated wound (8) Incised Wound Edges are clean-cut, regular and welldefined There is no swelling or contusion around the incised wound Extremities of the wound are sharp or may be round or contused Examination by means of a magnifying lens shows that the hair bulbs are cut Healing is faster Scar is linear or spindle-shaped It is caused by a sharp-edged instrument

Lacerated Wound Edges are roughly cut, irregular and ill-defined There is swelling and contusion around the lacerated wound Extremities of the wound are illdefined and irregular Examination with a magnifying lens shows that the hair bulbs are preserved Healing is delayed Scar is irregular It is caused by a blunt instrument

Fatal effect of Wounds: 1. Wound may be directly by reason of: a. Hemorrhage b. Mechanical Injuries to vital organs c. Shock 2. Indirectly by: a. secondary hemorrhage due to sepsis b. specific infection c. secondary shock d. scarring effect Legal Medicine page

46

Kinds of Healing of wounds:

  

1. Healing by primary intention 2. Healing by secondary intention 3. Aberrated healing process: formation of exuberant granulation tissue or “ground flesh” belvish formation fistula or sinus formation

Examination of the wound: 1. 2. 3. 4. 5. 6. 7. 8.

character location depth of the wound condition of the surrounding extent of the wound direction of the wound number of wounds condition of the surroundings a. degree of hemorrhage b. evidence of struggle c. position of body d. presence of letter or suicide note e. condition of the wound

Avulsion forcible tearing of skin or tissues: Contusion age: 4-5 days – color becomes green 7-10 days – color becomes yellow 14-15 days – disappear gradually up to – 4 weeks

The distinction between ante-mortem and post-mortem contusions in an undecomposed body is that:  

Ante-mortem bruising – there is swelling, damage to epithelium extravasation, coagulation, and infiltration of tissues with blood Post-mortem contusion - none

Hematoma (blood cyst or “bukol”) production of a new cavity with blood. In the presence of several injuries, the medico-legal officer should answer the following questions: 1. Which of the injuries sustained by the victim caused death?  in conspiracy not necessary to determine who among several offenders inflicted the fatal wound.  In “free for all” – it is necessary to determine. (P.I./death is tumultuous affray)  In case where victim sustained multiple injuries – medicolegal problem? Examine wound individually.  Important to determine degree of damage of each wound.

2. Which of the wounds was inflicted first?  necessary to qualify offense Legal Medicine page

47

 

fatal wound inflicted 1st with treachery – Crime committed is murder fatal wound inflicted last – possible crime committed – Homicide

How determine which wound was inflicted first: 1. 2. 3. 4. 5.

Relative position of assailant and victim when the first injury was inflicted to latter. Trajectory or course of the wound inside the body Organs involved and degree of injury sustained Testimony of witness Presence of defense wounds of victim.  defense wound must be inflicted first before fatal wound

Effect of negligence of the injured person on the death: Extrinsic Evidence in wounds: 1. Evidences from the wounding weapon  position of wound  blood in weapon  hair and other substances on weapon 2. evidence in the clothing of victim 3. evidence derived from assailant  clothing  marks of violence  paraffin test  degree of intoxication, mental coordination, physical power 4. evidences derived from the scene of the crime

LECTURE VIII:

GUNSHOT WOUNDS

Death or Physical Injuries brought about by the powder propelled substances may be due to the ff: A. Firearm shot – injury caused by the missile propelled by the explosion of the gunpowder located in the cartridge shell and at the rear of the missile. i. In the Philippines, it is unlawful to carry a firearm without a license. ii. The barrel alone is considered a complete firearm. iii. There are basically two (2) types of firearms, namely: iv. a. Rifled weapon so called due to the spiral grooving on the inside of the barrel imparting a spinning or gyroscopic effect to the bullet as the missile is fired.

b. Shotgun Legal Medicine page

48

2 types of rifled weapon:  Rifle- has a long barrel of about two to three feet in 

length, has a high muzzle velocity of about 1,0004,000 ft/sec. assuring accuracy at a considerable range Pistol- has a short barrel of about one to twelve inches in length; it has a low muzzle velocity of about 6001,000 ft/sec and is accurate only at a very short range.

2 types of pistol: 1. Revolver the ammunition is put in chambers in a metal cylinder which revolves before each shot to bring the next live round opposite the barrel  After the bullet has been fired, the brass case which contained the explosive, remains in the cylinder and must be removed by hand 2. Automatic pistol The ammunition is found in a magazine which is attached to the butt or handle of a gun B. Detonation of high explosives – e.g. grenades, bombs and mine explosion i. Explosion of gunpowder inside the metallic container ii. Each fragment/shrapnel is moving with a certain velocity with out any predetermined direction iii. The detonation of high explosives can be very destructive not only to property but also to the people nearby, causing death instantaneously iv. When the victim is very near the source of explosion (arm’s length), the damage can be so devastating that there is complete disruption or fragmentation of the body due to displacement, distortion and bursting of body parts. v. When the victim is a few meters away, he may still be fatally injured but the body remains in one piece vi. Shrapnels and other flying objects resulting from the blast may strike a vital part of the person’s body and cause death vii. Asphyxia due to the inhalation of the b y-products of combustion such as carbon Monoxide, nitrous or nitric gas, hydrogen sulfide, sulfur dioxide or hydrocyanic gas may be lethal

Powder burns- blackening of the margin of a gunshot wound of entrance. Blackening is due to : 1. Smoke effect of smudging 2. Combined effects - gunpowder tatooing - to certain extent –> burning of wound margin

Abrasion collar – (contuso – abraded collar, marginal abrasion) The pressure of the bullet on the skin will cause the depressed portion --> rubbed by the rough surface of the bullet. Perpendicular approach – prod. Even width of collar acute angle approach – abrasion collar wider at the acute angle of approach

Destructive mechanism of Gunshot: 1. Laceration and permanent cavity in the bullet trajectory

Legal Medicine page

49

2. Creation of a temporary cavity-the greater the velocity, the larger the temporary cavity formed 3. Hydrostatic force- when bullet traverses organs with fluid, the liquid contents are displaced radially away from the bullet path producing extensive laceration in the fluid path 4. Shock wave- when the bullet velocity is greater than 1,087 feet/sec, the destruction caused by kinetic energy is a radial direction perpendicular to the path of the bullet 5. Fragmentation or disintegration of the bullet- when the bullet hits a hard object, (bone), it fragments to several pieces each with an energy like the mothe bullet causing laceration, fracture and shocking effect (“shocking power” or knockdown power”) 6. Fragmentation of hard brittle object in the trajectory- Bone fracture in the trajectory may cause additional damage on the surrounding tissues and even in the wound of exit 7. Muzzle blast in contact fire- when the gun muzzle in pressed in contact with the skin when fired, all of the products of combustion primarily the muzzle blast will penetrate the tissues causing severe mechanical destruction on account of pressure. The explosive effect will cause laceration of soft tissues and fracture of bones. 8. Other consequential effects on the body of the victim- hemorrhage, infection, paralysis, shock, loss of function may cause diability or death on the victim

Gunshot wound of Entrance (Entrance defect, inshoot): Gunshot wound of entrance depends upon the ff: 1. Caliber of the wounding weapon:     

General Rule – the higher the caliber of the wounding bullet, the greater will be the size of the wound of entrance Manner of approach of the bullet to the skin Distance of the muzzle of firearm to skin surface Deformity or splitting of the bullet Surface of the skin involved are factors which modifies the size and shape of the wound of entrance

2. Characteristics inherent to the wounds of entrance: 

oval or circular with inverted edges except in near shot or in grazing or slap wound

How produced: Bullet comes in contact of the skin  causes indentation of skin surface  extreme pressure  skin tissues give way  rough surface of bullet comes in contact with the skin  contusion or abrasion collar is produced. 1. in most cases, the size of wound of entrance is smaller than the caliber of the wounding bullet on account of the retractions of the connective tissues of skin.

3. Characteristics inherent to Wound of exit: Legal Medicine page

50

2. usually larger than wound entrance why?  The deformity of the bullet in its course inside the body,  the lack of support beyond the skin,  velocity of missile  Stellate, slit-like, cruciform or markedly lacerated.

4. Direction of fire: (trajectory): right angle approach – wound of entrance is circular in shape except:  

missile is deformed contact firing/near acute angle approach – wound of exit is oval Contusion a abrasion collar widest on the side of the acute angle approach

when bullet hits bony tissue – great possibility of deflection of the bullet course.

5. Shape and composition of the missile: -modify the shape of the wound of entrance - some bullets (hollow-point, dum-dum and soft point bullets) are purposely made to enhance deformity upon hitting hard objects 6. Range: 

close range fire – injury not only due to the missile but also due to



the pressure of the expanded gases, flame and other solid products of combustion distant fire – usually produces the characteristics effect of the bullet alone

7. Kind of weapon:  High powered weapon has more destructive effect as compared with low powered one 8. Shape of bullet  Conical shape free end bullets have more piercing power without marked tissue destruction  Bullets with hemispherical free ends are more destructive CONTACT FIRE- the nature and extent of injury is caused not only by the force of bullet but also by the gas of muzzle blast and part of body involved.

Factors for consideration: o Effectiveness of the sealing between the gun muzzle and the skin o Amount of gas liberated by the combustion of the propellant o Nature of the bullet: bigger cal. Bullet the more destructive Legal Medicine page

51

o soft or hollow point bullet has tendency to flatten and causes none damage o Part of body involved: a. when the bone is superficially located under skin b. when the bone is deeply located in loose soft parts of the body PRESSED and FIRM CONTACT FIRE: 1. On parts of body when bone is superficial: Commonly observed on the head where the skull is just beneath the skin. CHARACTERISTICS; 1. Wound of entrance is large, frequently star-shaped secondary to tear radiating from the entrance wound caused by the blast effect which ff. the sudden release of gases into a confined area between skin and underlying bone. 2. edges of wound are everted – creeping of gases between scalp and bone – skin moves toward muzzle 3. entrance wound is blackened by a. burns, b. tattooing and smudging c. singeing of the hair 4. Muzzle imprint – on the skin- iron-like effect on pressed skin

Causes of Muzzle Imprint: o Gun Muzzle is pressed on the body at the time of the fire and the heated muzzle during the blast produced an ironing effect on the skin o Gun Muzzle is pressed on body – pushed momentarily away and then hit the body again because of the continous inward pressure o gun fired on areas of body where bony tissue is superficial e.g. scalp – muzzle blast creep between scalp and connective tissue and the skull skin pushed to press on gun muzzle. 5. bullet may cause radiating fracture and the pressure of the gases may cause 6. fragmentation of the skull and severe laceration of the brain and its meninges 7. Blood and tissue become pink due to carbon monoxide 8. Fragments of lead and bullet jacket may be found Metal Fouling – when bullet travels the whole length of the tight fitting barrel, it is rotated by the lands and grooves  its surface is scraped by the lands  is ejected from the barrel and strikes the target. It may lodge on the clothing or may cause small abrasions or superficial lacerations on the skin around the main wound. 9. Singeing of hair

B. Parts of the body where bone is deeply located: a. Wound of entrance is usually large, circular and without radiating b. Edges are everted due to outward slapping of the skin c. Singeing of the hair, blackening of the wound due to fouling burn, and tattooing Legal Medicine page

52

d. Muzzle imprint due to outward slapping of the skin and heat e. Pinkish color of the deeper structures due to carbon monoxide

Loose Contact or Near Fire: 1. Entrance wound – large, circular or oval depending upon the angle of approach of the bullet 2. Abrasion collar or ring is distinct 3. Smudging, burning and tattooing are prominent with singeing of the hair 4. Muzzle imprint may be seen depending upon the degree of slapping of the skin of the gun muzzle 5. There is blackening of the bullet tract to a certain depth 6. Carboxyhemoglobin is present in the wound and surreounding areas.

Short Range Fire: 1 – 15 cm. distance: 1. 2. 3. 4. 5.

Edges of the entrance inverted If within the flame reach Smudging is present due to smoke Powder tattooing is present abrasion ring or collar is present

Medium range fire more than 15 cm. but less than 60 cm. 1. 2. 3. 4.

Gunshot wound with inverted edges and with abrasion collar is present burning effects smudging may be present if less than 30 cm. distance gunpowder tattooing is present but of lesser density and has a wider area of distribution 5. contact ring is present

Fired more than 60 cm. distance: 1. Gunshot wound is circular or oval depending on the angle of approach with abrasion collar. 2. wound of entrance has no burning, smudging or tattooing 3. contact ring is present

Microscopic Examination of Gunshot Wound of entrance: 1. In contact or near contact fire: a. Epithelial damage and power residue deposit are present 1. Massive heat may carbonize the epithelial cells 2. The hot bullet may produce coagulation necrosis 3. Basilar cells are swollen and vacuolated 4. The corium may show thermal changes manifested by nuclear shrinkage, pyknosis and vacuolization 2. In far distant fire: a. spotty deposit of powder or skin and SQ tissues b. cellular destruction along course of bullet

Instances when the size of the wound of entrance do not approximate the caliber of the firearm: Legal Medicine page

53

Rule: Distant fire – the diameter of the gunshot wound of entrance almost same as the caliber of the wounding firearm

A. Factors which make the wound of entrance bigger than caliber: a. contact or near fire b. deformity of the bullet which entered c. bullet might have entered the skin - sidewise d. acute angular approach of the bullet

B. Factors which make the wound of entrance smaller than the caliber a. fragmentation of the bullet before penetrating the skin b. contracting of the elastic tissues of the skin

Other evidences or findings used to determine entrance of gunshot: When course of bullet is through and through and there is difficulty in the determination as to which is the entrance because it does not show characteristic findings, or it has been modified by healing, infection or surgical intervention, the medical examiner must resort to the following:

1. Examination of the clothing, if involved in the course of the bullet: a. the fabric of the clothing may show punch in destruction at the site of the wound of entrance b. examination for particles of gunpowder on the clothing at the site near the wound in question.

2. Examination of internal injuries caused by bullet a. in a case where the missile hits a bone, the bone fragments are driven away from the wound of entrance b. Destruction of the bone at the surface facing the wound of entrance is oval and with sharp edges, while the surface facing the wound of exit is bigger, irregular and beveled. c. Direction of the cartilage and other soft tissues will be driven away from the gunshot wound of entrance.

3. Testimony of witnesses: The testimony of the witness as to the position of the victim and the assailant when the firearm was fired may determine which of the wounds is the entrance wound.

Determination of the Trajectory of the bullet: Inside the body of the victim: 1.

External examination a. Shape of wound of entrance: oval? Circular? Deformed bullet? b. Shape and distribution of contression or abrasion collar? c. Difference in level between entrance and exit wound how? Reference point (sole of foot) d. By probing the wound

2.

Internal examination a. actual dissection and tracing the course of the wound at autopsy. b. Fracture of bones and course in visceral organs c. Location of bone fragments and lead particles d. X-ray examination Legal Medicine page

54

3.

other evidences to show trajectory a. relative difference in the vertical location of the entrance from the exit in the clothing b. relative position and distance of the assailant from the victim in the reconstruction or reenactment of the crime c. testimony of witness

GUNSHOT EXIT (OUTSHOOT) WOUND;

Characteristics: 1. Does not show characteristic shape like wound of entrance 2. may be slit-like, stellate, irregular or even similar to wound of entrance due to absence of external support beyond skin – bullet – tear – or shatter skin 3. edges of wound are everted and occasionally portions of inner tissues protruding 4. aside from bone, skin is one of most resistant so that    

bullet might not penetrate skinlodged just underneath the skin. After exit from skin- no more energy- does not penetrate clothing Bones may be involved in trajectory- create additional injury to wound of exit Variation of shape attributable to bullet deformity and due to wabbling and stumbling movement during its course and fragmentation of missiles.

SHORED GUNSHOT OF EXIT: If place of gun shot wound of exit is pressed on the hard object as when the victim lying on his back on hard object or in small caliber shots (.22 cal) the GSW of exit – circular with abrasion at its border.

 tight fitting clothes, waist band, belt collar, brassiere may also support the skin to enhance formation of a circular wound of exit. This is known as a shored gunshot wound of exit. How produced? Outstretched skin is impaled, sandwiched and crushed between the outgoing bullet and the unyielding object is over the exit site, thus making the wound to be circular with abrasion collar at its margin. Proper coaptation of the wound margin is impossible because of the loss of skin just like those observed in the entrance wound. In contrast with the entrance wound, the supported exit wound shows a scalloped or punched-out abrasion collar and sharply contused skin in between the radiating skin lacerations marginating the abrasion. DISTINCTION BETWEEN GUNSHOT W ENTRANCE vs. EXIT: Size Edges Shape

Smaller than missile because of elasticity of the tissue Inverted Usually oval/round depending upon the angle of approach of the bullet Present due to invagination of the skin and spinning of the missile Present when firing is near

Contusion Collar Tattooing/ smudging Underlying Not protruding

Always bigger Everted Definite shape Absent Absent May be seen protruding from the Legal Medicine page

55

tissues Always present after fire Paraffin test may be positive Smudging Present always if near/contact fire Singing of Contact fire hair

wound Maybe absent if missile is lodged in the body Paraffin test always negative Present or absent 6 inches

THE ODD and EVEN RULE in Gunshot Wounds:  

If the number of gunshot wounds of entrance and exit found in the body of the victim is even, presumption is that no bullet is lodged in the body. If the number of the gunshot wounds of entrance and exit is odd, the presumption is that one or more bullets might have been lodged in the body

Instances when the number of GSW of entrance is less than the # of GSW of exit in the body of victim: 1. bullet-entered body – split into several fragments, each of which made a separate exit 2. one bullet –entered natural orifice of body –-> producing wound of exit 3. 2 or more bullets entering the body through a common entrance and later making individual exit wounds. 4. near shot w/ gunshot – entered common wound – disperse – separate wound exit.

Instances when the number of GSW of entrance is more than of GSW of exit : 1. 2. 3.

one or more bullets not through and through and the bullet is lodged in the body exit of bullets in natural orifices of body different shots prod. diff. GSW of entrance but prod. a common exit.

Instances when there is no GSW of exit but the bullet is not found in the body of the victim: 1. bullet – gastro-intestinal tract – expelled through mouth by coughing 2. near fire with blank cartridge produced a wound of entrance but no slug may be recovered 3. bullet may enter the wound of Entrance and upon hitting the bone the course is deflected to have the wound of entrance as the wound of exit.

How to determine the number of fires made by the offender: 1. Determination of the number of spend shells: search at the scene of the crime or at the place where the offender made the fire for spent bullets if the weapon used is automatic pistol or rifle In case of revolver fire the empty shells may still be found at the cylindrical magazine. In machine gun fire, the cartridge may still be found at the cartridge belt .

2. Determination of entrance wounds in the body of the victim Although most often erroneous, the investigator may be given an idea as to the number of minimum number of shots made. The number of wounds of entrance may not show the exact number of fires because: a. not all fires may hit the body of the victim. Legal Medicine page

56

b. The bullet may in the course of the flight hit a hard object, thereby splitting it and each fragment may produce separate wounds of entrance. c. The bullet may have perforated apart of the body and then made another wound of entrance. 3. Number of shots heard by witnesses: The witnesses might be able to count the number of shots especially if the shots were made at sufficient intervals of succession. However in cases of machine gun fire, there is difficulty in ascertaining the number heard and the testimony of witness as to the number of shots must be admitted with caution.

Determination whether the wound is ante-mortem or post-mortem: If the wound indicated that there has been profuse hemorrhage, or there are signs of vital reactions in the tissue, then the gunshot wound is ante-mortem. The presence and degree of vital reactions depend upon the period of survival of the victim. It may be manifested in the form of swelling, effusion of lymph or other evidences of repair. Microscopically, there is congestion and leucocytic infiltration. Wounds inflicted after death show no evidence of profuse hemorrhage., no reaction of the edges, no vital reaction.

Determinations whether GSW is suicidal, homicidal or accidental: 1. Evidences to prove that the GSW is suicidal: a. The fire is usually contact or near fire, as shown by the presence of burning, smudging and tattooing at the area around the GSW of entrance. b. The presence of usually but ONE GSW. c. Portions of the body involved are usually those accessible to the hand of the victim. d. The presence of a suicide note. Care must be taken in determining the authenticity of such note. e. History or cause of despondency. f. Wounding weapon usually held tightly in the palm of the hand of the victim or found nearby. A state of cadaveric spasm may be observed g. Exclusion of other evidences to show that the case is not suicide. 2. Evidences to show that the GSW is homicidal: a. The site or sites of wound entrance has no point of election. b. The fire was made when the victim is usually at some distance from the assailant. c. Signs of struggle (defense wounds) may be present in the victim. d. There may be some disturbance of the surroundings on account of previous struggle. e. Wounding firearm is usually not found at thew scene of the crime.

3.Evidences to show that the GSW is accidental: a. b. c. d.

Usually there is but one shot. There is no special area of the body involved. Consideration of the testimony of the assailant. Testimony of the witnesses.

Points to be considered and included in the report of physician: 1. complete description of the wound of entrance and exist 2. Location of wound Legal Medicine page

57

3. 4. 5. 6.

i. part of the body involved ii. distances of the wound of h direction – length of bullet tract organs or tissues involved in the location of the missile, if lodged in the body diagram, photograph, sketch, drawing showing location of wounds

Questions that a physician is expected to answer in court; 1. 2. 3. 4. 5. 6. 7. 8.

Could the wound or wounds be inflicted by the weapon presented to him? At what range was it fired? What is the direction of the fire? Self-inflicted? Signs of struggle May it be possible for the victim to fire or resist attack after the injury was sustained by him? Did the victim die spontaneously Where was the relative position of the assailant and the victim when the shot was fired?

Tests for presence of powder residues: 1. On the skin – dorsum of hand or site of the wound of entrance: Dermal Nitrate test (Paraffin test, diphenylamine test, lungs test, Gonzales’ tests) (+) – describe process Test not conclusive but corroborative only False negative results: caused by; 3. thick gloves 4. strong wind 5. firearm with cloud chamber 6. high humidity 7. test done after 72 hrs. False (+) 1. farmers dealing with fertilizers, cosmetics, cigarettes, urine and other nitrogenous compounds with nitrate/nitrites

Legal Medicine page

58

LECTURE IX: DEATH BY ASPHYXIA - is the general term applied to all forms of violent death which results primarily from the interference with the process of respiration or the condition in which the supply of oxygen to the respiration or the condition in which the supply of oxygen to the blood or to the tissues or both has been reduced below normal level. Types: 4. Anoxic Death – associated with the failure of the arterial blood to become normally saturated with oxygen. Due to: a. Breathing in an atmosphere without or with insufficient oxygen, as in high altitude b. Obstruction of the air passage due to pressure from outside, as in traumatic crush asphyxia c. Paralysis of the respiratory center due to poisoning, injury or anesthesia, etc. d. Mechanical interference with the passage of air into or down the respiratory tract due to:  closure of the external respiratory orifice, like in smothering and overlaying  obstruction of the air passage, as in drowning, choking with foreign body impact, etc.  respiratory abnormalities, like pneumonia, asthma, emphysema and pulmonary edema 5. Anemic Anoxic Death – due to a decreased capacity of the blood to carry oxygen. Due to: a. Severe hemorrhage b. Poisoning like carbon monoxide c. Low hemoglobin level in the blood 6. Stagnant Anoxic death – brought by the failure of circulation. Due to a. heart failure b. shock c. arterial and venous obstruction, incident to embolism, vacular spasm, varicose vains, or the use of tourniquet 7. Histotoxic Anoxic death – due to the failure of the cellular oxidative process, although the oxygen is delivered to the tissues, it cannot be utilized properly. CLASIFFICATION OF ASPHYXIA: 1. Hanging 2. Strangulations: a. strangulation by ligature b. manual strangulation or trottling c. Special forms of strangulations: - palmar - garroting - mugging or yoking - compression of the neck with stick 3. Suffocation a. smothering or closing of the mouth and nostrils by solid objects b. choking or closing of the air passage by obstruction of its lumen 4. Asphyxia by submersion or drowning 5. Asphyxia by pressure on the chest Legal Medicine page

59

6. Asphyxia by irrespirable gases. CAUSES OF DEATH IS HANGING; 1. Simple asphyxia by blocking the air passage 2. Congestion of venous blood vessels in the brain 3. Lack of arterial blood in brain due to pressure on the caretid arteries 4. Syncope due to pressure on the vagus and carotid sinus which leads to reflex irritation and paralysis of the medullary autonomic. 5. Injury on the spinal column and spinal cord. 6. It may be any be combination of the above-mentioned causes. Time Required in the process of Death: 1. Severity of constricting force: If constricting force is only sufficient to occlude the windpipe/trachea, death is delayed; If pressure is sufficient to occlude the carotid art., jugular viens and vagles nerve, then unconsciousness develops immediately and death is accelerated. 2. Point of application of the Ligature. Below larynx-death instantaneous Above larynx - > 3-5 min. – death Knot is on side of neck – delay death KNOT below the jaw – delay death Determination whether death is by hanging or strangulation: Hanging

Strangulation with Ligatures

1. Hyoid bone – injured 2. direction of ligature mark is inverted v- w/ apex as the site of knot 3. ligature usually at the level of hyoid bone 4. ligature groove deepest opposite/ site of the knot 5. vert. Is present

- spared - ligature mark horizontal - lig. Usually below larynx - lig. Groove is uniform in depth in its whole course - vert. Injuries not present

Asphyxia by Submersion or Drowning Mechanism of drowning: Person- (does not know how to swim)--- falls into a deep body of water – body sinks bec. Of momentum of fall – and sp. Grav. Of body > than H2O - body will be buoyed up – because of instinctive movement of individual and air under clothings - while under H2O – breath is held – but upon reading surface – there is an attempt to breath – air and H2O gets into mouth and nostrils - subj. will raise his hard – will cause him to sink - subj. alt. Appears and disappears on surface – everytime he attempts to breath H2o and air gets in - violent coughing occurs – which will expel air in the lungs – greater desire to breath – more H2o is drawn in lungs and stomach - H2O files bronchioles – push residual air – surface of lungs – ballooning soggy and edematous. - Death 2-5 minutes (average time) If dead body recovered in H2O – physician must answer the ff. questions: 2. Did death occur prior to entry in H2O? If so what was the cause of death? 3. Did drowning cause death? If so is it fresh/salty H2O pool? 4. Any ante-mortem injuries? If so did they play any part in the death 5. Any post-mortem injuries? Legal Medicine page

60

6.

was there any natural disease? Poisoning? Contribution to death?

Post-Mortem; Internal Findings: a. Respiratory System: 1. “Emphysema aquosum”- remedial air - balloons 2. “Edema Aquosum” - H2O is air sacs 3. “Champignon d’ocume” – whitish foam – nostrils mouth Gettler’s Test – quantitative determination of the chlorise content of the blood in the right and left ventricle of the heart. - difference if of at least 25 mcg. Proves that death occurred in fresh salt H2O and drowning is the cause of the death - salt H2O – Cl content of right side vert is less than lt. = fresh H2O – CL- lt of right side less than lt.

2. 3. 4. 5. 6.

b. c. d. e. f.

Findings Conclusive that the Person Died of Drowning: presence of materials or foreign bodies in hands of victim Emphysema auosum and edema of the lungs H2O in stomach similar to medium where body was fd. Submerged champignon d’ocume and foreign bodies presence of H2O in the middle ear.

Burking – invented by Burks and Hare – murdering people to be sold to medical schools Death by Crucifixion – interested on the how Jesus Christ dies? - when person is nailed on the cross the wt. is supported by the nailed feet. In order to breath – person has to raise his body and throne his weight on his feet. - When on the cross- intercostal muscles are stretched – chest cage is fixed. Alternative lowering and raising of the body--- lead to exhaustion – unconsciousness – death by classification is traumatic Asphyxia Assignment: Medico –legal Aspects of Sex Crimes: Heart Stomach Brain Blood Other organs

E. Compression Asphyxia (Traumatic Asphyxia or crush asphyxia) e.g. death by cruxifixion; death by burking - rarely attempted is suicide F. Asphyxia by Breathing Irrespirable Gases a. CO “silent killer” CO + Hg – carbohemoglobin – 250x more stable than Oxyhemoglobin Main action is O2 deprivation Accidental and suicidal death by CO common b. CO2 – prod. of human resp., decomp. Of org. matter and fermentation c. H2S – hydrogen sulfide d. Hydrogen Cyanide – bamboo shoots DEATH O PHYSICAL INJURIES DUE TO AUTOMOTIVE CRASH OR ACCIDENT DEATH OR PHYSICAL INJURIES DUE TO ATHLETIC SPORTS CHILD ABUSE OR NEGLECTED CHILD

Legal Medicine page

61

LECTURE X: MEDICO-LEGAL ASPECTS OF SEX CRIMES Virginity – is a condition of a female who has not experienced sexual intercourse and whose genital organs have not been altered by canal connection

1.

2.

3. 4.

Kinds of Virginity: Moral virgin – state of not knowing the nature of sexual life and not having experienced sexual relation. - applies to children < age of puberty sex organs and secondary char. not developed Physical Virgin – condition where a female is conscious of the nature of the sexual life byt has not experienced sexual intercourse. There is no conclusive medical finding that a woman is physically virgin. Reliance is made as absence of laceration of the hymen a) True physical virgin b) False physical virgin Demi-virginity – this term refers to a condition of a female who permits any form of sexual liberties as long as they abstain from rupturing the hymen by sexual act Virgo Intacta – literally term refers to a truly virgin female, no structural changes in her organ to infer previous sexual intercourse and that she is a virtous female.

Parts of the Female body to be Considered in the determination of the Condition of Virginity: 1. Breasts – Condition not reliable to determine virginity 2. Vaginal Canal – as a gen. Rule, the vaginal of a virgin is tight and the repositories are sharp and prominent. Insertion of the fingers or the instrument may show certain degree of resistance. The sharpness of the walls repositories may be diminished by insertion of foreign bodies, passage pf clotted blood, self-manipulation etc. and not by sexual intercourse 3. Labia Majora/Minora – condition not a reliable basis to determine virginity eg. Stout female – usually pressure a firm, coaptated and plumb labia skinny female – usually have gaping labia 4. Fourchette – present a v-shaped appearance as the 2 labia minora unite posteriorly may become rouding with stretching 5. Hymen – physicians – give importance to the exam. Of hymen in the determination of virginity Types of Hymen – read your own Virginity is not synonymous with chastityDefloration- is the laceration or rupture of the hymen as a result of sexual intercourse. - all other lesions of the hymen which are not due to sexual intercourse is not considered as defloration. In the medical examination of the hymen the following facts must he included: 1. Gen. Condition of the hymen: width, thickness, vascularity and laxity other pathal conditions such a. Inflammatory charger, signs of previous trauma, developmental abn. And foreign elements b. Original shape of Orifice c. If lacerated the ff. must be noted: Legal Medicine page

62

1. degree of laceration a. incomplete laceration 1. superficial – does not go beyond ½ width of hymen 2. deep laceration involve more than ½ width but does not reach bone b. complete – involves whole width of hymen but does not reach base c. compound or complicated – laceration involves hymen and surr. Tiss. Eg. Perineum,vaginal canal, urethra or rectum 2. location of laceration – relate to face of watch 3. duration of laceration – may be approximated by changes observed in the macerated tissues a. fresh bleeding – recent ___ than 24 hours b. fresh healing with fibrin formation and with edema of the surroung tissue – usually 24 hours c. healed laceration with congested edges and with sharp coaptible borders – depending on degree of laceration and the presence or absence of Cx - 4-10 days old - called also “recently healed” d. healed laceration with sharp coaptible borders without congestion - laceration took place > 10 days or 2-3 weeks e. healed laceration with rounded non-coaptible borders and retraction of the edges – depending on degree of laceration – laceration took place more than a month’s time 4. Complications of laceration a. secondary infection – bacterial: b. hemorrhage – present in severe cpd. laceration of hymen – surgery may be necessary c. fistulae formation – recto-vaginal or vesico-vaginal fistula; correction surgey d. stricture – laceration involving vaginal wall – scar formation/healing – narrowing of vaginal canal e. sterility – secondary infection – uterus – fallopian tube

Psychophysiological Sexual Pxns. Sexuality has to do with one’s identity roles, relationships, perceptions and expectations, as well as biological functions, sexual intercourse, though important is a very small part of human sexuality. Majority of sexuality has to do with one’s identity as a man or woman, with the way in which such of us sees and understands oneself and others.

Sexual Arousal and Response: 2 Physiologic characteristics of sexual excitement commons to all mammals 1. Engorgement and dilation of genital and pelvic blood vessles (also sometimes breasts) by Arterial blood supply – penile erection - vaginal lubricant therefore this 2 are the major indication female of sexual excitement 2. increased myotomia, that is > voluntary muscle tention e.g. muscular tension, restlessness, vol. And invol. Movements, thrusting, clasping and grimacing etc.

Legal Medicine page

63

Masters and Johnson have described sexual response cycles for men and women 4 stages: 1. excitement phase 2. plateau 3. orgasm 4. resolution

Death related to Sexual Act 1. Death of the male partner: a. Death from natural causes b. Death may be due to the defensive act of the female victim 2. Death of the female partner: a. accidental strangulation or suffocation of the female partner – secondaty to pressure on the chest neck or face. b. Oral Sex (fellatio) whole penis – total block of the air passage – asphyxia - ejaculation of seminal fluid may oclude respiratory tract. c. Case of cunnillingus – male licks the female general oral – blow air – vulva – air – especially pregnant – circulation - death d. Saddists e. Death of Female partner to conceal crime of rape f. Female partner may die of shock – extreme physical and mental trauma g. Hemorrhage h. Infection 3. Death of both partners a. sexual act in enclosed place with carbon monoxide or other asphyxiant gas b. homicide – suicide pact Criminal Characteristics: 1. It is one of the ancient and universal crime. 2. there is close physical contract between the offender and the victim. Murder and homicide may be committed at a distance. Estafa and other crimes may be committed even w/o physical presence 3. As a gen. Rule, it is a crime committed by one sex against the opposite sex 4. Sex is an inborn instinct. Any person with out sex drive is considered abnormal. - anti-social means of attaining sexual gratification is one punished 5. Seduction and consisted abduction are considered as crimes in the Philippines but not in other countries 6. Many sex crimes are committed but not reported if reported, not investigated, if investigate, not prosecuted. Why? - under publicly may be prejudicial to the reputation of the victim 7. It is a crime committed in strict privacy – - reliance therefore is made on the testimony of the victim corroborated by the medical findings. 8. Unlike other crimes, pardon, forgiveness or marriage between the offender and the victim will extinguish the criminal liability of the offender 9. Severity of punishment does not deter its commission 10. Consequence – pregnancy – becomes a legal problem 11. Offender is post middle age – victims are children 12. Psychic trauma suffered by the victims of sex crimes varies with the moral standard of the victim.

Legal Medicine page

64

Medical Evidence of Rape: 1. Evidence from the victim: -before actual examination – written consent from subject herself or from her guardian/parent if victim is not of age - short history of alleged rape- writing age of victim is not of age a. date, time, place of alleged commission of rape b. date, time, place of examination c. condition of clothing - tearing, staining of blood and semen; - soiling of clothing – presumed as evidence d. Physician must observe the gait, the facial expression, bodily and mental attitude of the subject. e. physical and mental developmental of the victim f. examination of the body for signs of violence - Determination of probable age of physical injuries found in material - Does it correspond to the alleged date of commission. g. examination of the genitalia, including the breasts 2. Examination of alleged offenders a. physical development, mental condition and strength b. evidence of physical injuries c. condition of the sex organ d. evidence from the pubic hair e. potency of the offender f. evidence of genital infection 3. Evidence from the companion of the victim Investigation of the scene of the crime – never go to trial w/o seeing the scene of the crime Examination for seminal fluid and spermatozoa Semen – viscid, albuminous fluid w/ faint grayish – yellow color, having a characteristic fishy odor.

Legal Medicine page

65