Legal Medicine reviewer

MEDICO-LEGAL ASPECTS OF 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 heirs at the time of death. 3. The death of a partner is one of the causes of dissolution of partnership agreement. 4. The death of either the principal or agent is a mode of extinguishment of agency. 5. The criminal liability is extinguish by death. 6. The civil case for claims which does not survive is dismissed upon death of the defendant. Death – is the termination of life. Kinds of death: 1. Somatic or clinical death – persistence of vital functions 2. Molecular or cellular death – 3 to six hours after cessation of life 3. Apparent death or State of suspended animation – transient loss of consciousness in hysteria, uremia, electric shock

respiration is taking place. 3. Cooling of the body ( ALGOR MORTIS) - After death the metabolic process inside the body ceases. - The progressive fall of the body temp. is one of the most prominent signs. - First two hours after death the cooling is rapid. - Fall of temp. of 15 to 20 degrees Fahrenheit is considered as a certain sign of death. POST-MORTEM CALORICITY – is the rise of temp. of the body after death due to rapid and early putrefactive changes. Usually in the first 2 hours. = seen in cholera, liver abscess, tetanus, RF,Strynine poisoning, Peritonitis A.

Conditions connected with the body:

Factors delaying the rate of cooling of the body: 1. Acute pyrexial disease 2. Sudden death in good health 3. Obesity of person 4. Death from asphyxia 5. Death of the middle age Factors accelerating cooling: 1. Leaness of the body 2. Extreme age 3. Long-standing illness 4. Chronic pyrexial disease with wasting B. Conditions that are connected with the surroundings

Signs of death: 1. Cessation of heart action and circulation., Usually the auricle contract after somatic death fro a longer period than the ventricle, last to stop so called

Factors delaying cooling: 1. Clothings 2. Want of access of air to the body 3. Small room 4. Warm surroundings

ULTIMEN MARIENS. Methods of detecting the cessation of heart action and circulation: a) Examination of the heart- pulse, aucultation, flouro, ECG b) Examination of peripheral circulation = Magnus test – application of ligature around the base of the finger bloodless area at site of application dead man – no change = Opening of small artery- spurting = Icards test – injection of flourescein SQ - greenish yellow discoloration in the whole skin - dead man only in the area of injection = Pressure on fingernails = Diaphanous test – fingers are spread wide through a strong light- Red = Application of heat on the skin - blister = Palpation of Radial pulse = Dropping of melted wax 2. Cessation of respiration – more than 3 ½ minutes Methods of detecting cessation of respiration: a) Observance of movement of chest and abdomen b) With the aid of stet. c) Examination with a mirror d) Examination with a feather or cotton fibers e) Examination with a glass of water f) Winslow’s test – no movement in the image formed by reflecting artificial light on the water in a saucer and placed in the chest if

Factors accelerating cooling: 1. Unclothed body 2. Conditions allowing the access of air 3. Large room permitting the dissipation of heat 4. Cooling more rapid in water than in air Methods of estimating how long a person has been dead from the cooling of the body: 1. If body temp. is normal at the time of death: = the average rate of fall of the temp. during the first 2 ½ hours is ½ of the difference of the body temperature and that of the air. = the body attains the temp. of the surrounding air from 12 to 15 hours after death in tropical countries. 2. Chemical Method ( Schourup’s formula for the determination of the time of death of any cadaver whose CSF is examined for the concentrations of L.A., NPN, A.A. = L.A> 15 mg to 200 mg/100cc rapid in 1st 5 hours. = NPN inc. from 15 to 40 mg/100 cc in 1st 15 hours = A.A. inc. from 1 mg to 12 mg% 1st 15 hours. 4. INSENSIBILITY OF THE BODY AND LOSS OF POWER TO MOVE = may be seen in the living with- apoplexy, epilepsy , trance, catalepsy, hysteria 5. CHANGES IN THE SKIN – opacity, flattening, loss of elasticity 6. CHANGES IN AND ABOUT THE EYE a) Loss of corneal reflex – seen I n live pts: G.A., uremia, poisoning b) Clouding of cornea c) Flaccidity of the eyeball d) Pupil in the position of rest. e) TACHE NOIR DE LA SCLEROTIQUE – spot found in the after death.

narcotic

sclera

7. ACTION OF HEAT ON THE SKIN = Heat applied while alive – produced blister with serum and redness around the area.

= Following combinations of signs show death has occurred: a) Loss of animal heat to a point not compatible with life b) Absence of response of muscle stimulus c) Onset of rigor mortis. CHANGES IN THE BODY FOLLOWING DEATH 1. CHANGES IN THE MUSCLE – complete relaxation of the whole muscular system. Three Stages After Death: a) Stage of primary flaccidity ( POST-MORTEM IRRITABILITY) = muscle relax, may contract, dilated pupil, sphincters are relaxed = presence of molecular life = warm place: 1 hour and 51 minutes = chemical reaction of muscle is alkaline b) Stage of post-mortem rigidity ( CADAVERIC RIGIDITY , DEATH STRUGGLE OF MUSCLES OR RIGOR MORTIS) = whole body is rigid due to contraction of the muscles = starts at muscle of neck, lower jaw = Reaction is acidic due to inc. of lactic acid = develops 3 to 6 hours after death in temperate, earlier in warm = last from 2 to 3 days in temperate, warm: 24-48H cold weather 18-36H summer c) Stage of Secondary flaccidity or Commencement of putrefaction ( DECAY OF MUSCLES) = muscle are flaccid, not respond to stimuli, reaction is alkaline = due to dissolution of muscle proteins FACTORS INFLUENCING THE TIME OF ONSET OF RIGOR MORTIS (1) Internal Factors a) State of the muscles = healthy – appears late = Onset is hastened in: a.1 hunted animal a.2 prolonged convulsion/lingering illness a.3 death from- TY, Cholera, Phthisis, typhus b) Age = early onset – aged and newborn = delayed – good health, good muscular development c) Integrity of nerves = section of the nerve will delay onset, paralyzed muscle

(2) External factors a) Temperature = Hastened by high temperature = > 75 degrees will produce heat stiffening b) Moisture = rapidly but with short duration in moist air Conditions simulating RIGOR MORTIS: 1. Heat stiffening - > 75 degrees coagulates muscle

proteins resulting to rigidity. = “ Pugilistic attitude” flexed upper and lower limb = hands clenched, flexor stronger than extensors, burned to death 2. Cold stiffening = due to solidification of fats when exposed to cold temp. 3. Cadaveric spasm or Instantaneous Rigor = instantaneous rigidity due to extreme nervous tension, exhaustion, injury to the nervous system. = weapon in hand, weeds RIGOR MORTIS CADAVERIC SPASM 1. Time of appearance 3-6H after death Immediately after death 2. Muscles involved All muscles Certain group 3. Occurrence Natural phenomena May or may not appear 4. Medico-legal signif. Approximates time of death Determine nature of death 1. Contracted muscle 2. Elasticity 3. Litmus reaction 4. Contraction

RIGOR MORTIS Losses transparency Loss elasticity Acidic Absolute flaccidity

MUSCLE CONTRACTION More or less transparent Very elastic Neutral or sl. alkaline Possess inherent contraction

2. CHANGES IN THE BLOOD a) Coagulation of blood = blood may remains fluid inside the blood vessels 6-8H after death.

1. Consistency 2. Surface of blood vessels after 3. Clots

ANTE-MORTEM CLOT POST-MORTEM CLOT Firm Soft Raw after clots are removed Smooth, health Homogenous Can be stripped can’t be stripped off in layers

b) Post-mortem Lividity or Cadaveric Lividity , or Post-mortem Suggilation or Post-mortem Hypostasis or Livor Mortis = Stoppage of heart action and loss of tone of b.v. accumulates in dependent areas except in bony areas. = capillaries coalesce > purplish in color called Post-mortem lividity. = Hasten by death due to cholera, uremia, Typhus fever = appears 3 – 6 H after death and fully developed 12 H after death. Physical characteristics of Post-mortem Cadaveric Lividity 1. Occurs in the most dependent areas. 2. Involves the superficial layer of the skin 3. Does not appear elevated from the rest of the skin. 4. Color is uniform. 5. No injury of the skin Kinds of Post-mortem Cadaveric Lividity 1. Hypostatic lividity 2. Diffusion lividity Importance of Cadaveric lividity: 1. One of the signs of death. 2. Determines the position of the body has been changed after it’s appearance in the body. 3. Color of lividity may indicate the cause of death. a) asphyxia – lividity is dark b) CO poisoning – pink c) Hemorrhage – less marked d) Hydrocyanic acid – bright red e) Phosphorus – dark brown f) Potassium chlorate – coffee brown 4. Determines how long the person has been dead 5. Gives us an idea as to the time of death. Points to be considered which may infer the position of the body at the time of death: 1. Posture of the body when found. 2. Post-mortem hypostasis or lividity 3. Cadaveric spasm CONTUSSION (BRUISE)

POST-MORTEM HYPOSTASIS

1. Small bruises – Below epidermis in true skin cutis larger ones - below this

In the epidermis or

2. Cuticle

Unabraded

Abraded by the same violence that produce the bruise.

3. Bruise

Appears at the seat or surrounding may or may not be dependent

4.

Elevated, inflammatory condition CONTUSSION (BRUISE)

Always dependent Not elevated, blood in b.v.

POST-MORTEM HYPOSTASIS

5. Incision shows blood outside the b.v. = most certain test of difference

Blood inside the vessels

6.

Uniform color

Color variegated

Internal hypostasis in Visceral organs: 1. Lungs 2. Loops of intestine 3. Brain POST-MORTEM LIVIDITY OF ORGANS 1. Post-mortem staining in organs Irregular, most dependent parts 2. Mucous membrane Dull,lusterless 3. Inflammatory exudate Not seen

2. Evolution of gasses in the tissues CO2, ammonia, H2, Suphurated hydrogen, methane.= offensive odor Effects of pressure of gasses of putrefaction: a) displacement of the blood – bleeding in open wounds b) bloating of the body c) fluid coming out from nostrils, mouth d) extrusion of the fetus in a gravid uterus e) floating of the body 3. Liquefaction of the soft tissues Putrefy rapidly : Eyeball, lining of trachea, larynx , brain, stomach, intestine, liver, spleen Putrefy late : Highly muscular organs and tissues, Esophagus, diaphragm, heart, lungs, kidneys, U.B., uterus, P.G.

SIMPLE CONGESTION Uniform, all organs Not in congestion Not seen

Other changes in the blood 1. Hydrogen ion concentration – acid pH CO2, L.A., After 24H alkaline ammonia. 2. Breakdown of liver glycogen leads to accumulation of dextrose in the IVC and the right side of the heart. 3. Rise in NPN and Free A.A. 4. Chemical: = chloride in the plasma/RBC decrease due to extravascular diffusion, in 72 H only ½ of its content. = Mg – increases due to diffusion from without. = K – increases due to diffusion from the vascular endothelium. 3. AUTOLYTIC OR AUTODIGESTIVE CHANGES AFTER DEATH - After death, proteolytic, glycolytic and lipolytic ferments of the glandular tissues continue to act which lead to the autodigestion of organs.

Factors modifying the RATE of putrefaction: 1. INTERNAL FACTORS a) age : healthy adults, NB not yet fed, later than infants b) condition of body : full grown/obese – rapid , Stillborn- late c) cause of death : infection - rapid 2. EXTERNAL FACTORS a) Free air a.1 air : free air hastens decomposition a.2 moderate moisture - accelerates a.3 loaded with septic bacteria – early aerobes, later anaerobic - Clostridium welchii= decomposition b) Earth b.1 dry absorbent soil - retards b.2 moist fertile soil - accelerates c) Running water- more rapid than still water d) Clothings – early it hastens but delays in the later stage. - tight clothings - delay

Tissue changes in putrefaction:

Factors influencing the changes in the body after burial: 1. state of the body before death – thin slower, mummify 2. time elapsed between death and burial and environment of the body 3. effect of coffin – later 4. clothings and other coverings on the body when buried – pressure, insects 5. depth at which the body was buried - greater the later 6. condition and type of soil 7. inclusion of something in the grave which will hasten decompositionfood 8. access of air to the body after burial 9. mass grave – rapid 10. trauma to the body – violent death - slow

1. Changes in the color of the tissue Hemolysis of blood within blood vessels > Hgb diffuses through the walls

CHRONOLOGICAL SEQUENCE OF PUTREFACTIVE CHANGES OCCURING IN TEMPERATE REGIONS

4. PUTREFACTION OF THEBODY - Is the breaking down of complex proteins into simpler components associated with the evolution of foul smelling gasses and accompanied by the change of color of the body.

Reddish-brown in color In the tissues > Hgb undergo chemical change Greenishyellow 1st seen at R Iliac fossa MARBOLIZATION – prominence of the superficial veins with reddish discoloration which develops on both flanks of the abdomen, neck, and shoulder = look like “marbled” reticule of branching veins.

1-3 DAYS AFTER DEATH 3-5 DAYS 8-10 DAYS 14-20 DAYS 2-5 MONTHS

- greenish discoloration over iliac fossa, soft eyeballs - frothy blood from mouth, nostrils - abdominal distention, nails firm - blisters all over the body, maggots - skull exposed, orbits empty

IN TROPICAL REGION 12 HOURS 24 HOURS 48 H 72 H ONE WEEK TWO WEEKS

Rigor mortis all over, hypostasis, greenish-discoloration caecum Rigor mortis absent all over, abdominal distention Ova of flies, trunk bloated, face discolored Whole body grossly swollen, hairs and nails loose Soft viscera putrefied Soft tissues largely gone

ONE MONTH

Body skeletonized

PRESUMPTION OF DEATH Disputable presumption - not heard in 7 years

BEEN SUBMERGED IN WATER FIRST 4 OR 5 DAYS mortis FROM 5 – 7 DAYS face faded 1 – 2 WEEKS hands and 4 WEEKS 6 – 8 WEEKS hands/ feet with nails

Cold water little change, in rigor Skin on hands, feet is bleached, white Face swollen and red, skin of feet wrinkled Skin wrinkled, nail intact Abdomen distended, skin of come off

Factors influencing the floating of the body in water: 1. age – fully developed, well nourished - rapid 2. sex – females floats sooner 3. conditions of the body – obese float quicker 4. season of the year – moist hot air – putrefaction – floats due to gas 5. water- shallow and stagnant water of creeks, higher specific gravity - sea water floats sooner than fresh water, higher specific gravity 6. external influence – heavy-wearing apparel slower Only teeth, bones and hair remain for an indefinite time. Flat bones disintegrates faster than round bones. SPECIAL MODIFICATION OF PUTREFACTION 1. Mummification = is the dehydration of the whole body which results in the shivering and preservation of the body. = usually occurs when buries in a hot, dry with free access of hot air 2. Saponification or Adipocere fromation = a condition where the fatty tissues of the body are transformed to soft brownish-white substance known as ADIPOCERE at SQ level. 3. Maceration = softening of the tissues when in fluid medium in the absence of putrefactive mircro-org, seen in death in utero – reddish or greenish color, skin peeling off and arms flaccid and frail. HOW LONG A PERSON HAS BEEN DEAD? DURATION OF DEATH 1. Presence of rigor mortis : 2-3 hours after death 12 H fully developed 18-36 H disappears concomitant with putrefaction 2. Presence of Post-mortem lividity 3-6 H after death appears as small petechia-like red spots 3. Onset of decomposition 24-48 H after death manifested watery. foul smelling froth, mouth, nostrils 4. Stage of decomposition 5. Entomology of the cadaver – 24 H before eggs are hatched, maggots 6. Stage of digestion

- 3-4 H gastric empty 6-8 distal ileum, cecum

7. Presence of live flies in the clothing in the drowning victim – less than 24H

Presumption of death Absence of 7 years except succession 10 years Vessel for 4 years Armed forces 4 years In danger of death 4 years PRESUMPTION OF SURVIVORSHIP 1. under 15 y.o. – older survives 2. above 60 y.o.- younger 3. under 15, above 60 - former 4. over 15 and under 60 y.o. – male, older 5. under 15, or over 60 y.o. and the other in between - latter MEDICO-LEGAL INVESTIGATION OF DEATH Inquest Officer – is an official of the state charged with the duty of inquiring into certain matters. - in medico-legal examination: manner and cause of death The following officials of the government are authorized to make death investigations: 1. Provincial and City Prosecutors 2. Judges of the RTC, MTC 3. Director of NBI 4. SolGen Stages of MEDICO-LEGAL INVESTIGATION: 1.Crime Scene Investigation – investigation of place of commission of the crime 2.Autopsy - investigation of the body of the victim 1. Crime Scene Investigation - place where the essential ingredients of the crime took place. - Person composed the Search Team: a) Physician MLI trained b) Photographer c) Assistant, evidence collector, note taker 2. Autopsy - comprehensive study of a dead body, in addition to the external examination . Post-mortem examination- external exam without incision being made. Purpose of autopsy: 1. Determine cause of death 2. Correlate clinical diagnosis and symptoms 3. Determine effectiveness of treatment 4. Study the natural course of the disease 5. Educate students and physicians MEDICO-LEGAL OR OFFICIAL AUTOPSY: 1. Determine cause, manner, time of death 2. Recovering, identifying, preserving evidentiary material 3. Provide interpretation and correlation of facts related to death 4. Provide factual, objective medical report 5. Separating death due to disease from external causes. Dead body belongs to the state for cases that requires medico-legal autopsy.

8. State of clothings - pajama , night 9. Changes in CSF 10. Blood clots inside the b.v. in 6 –8 H after death. 11. Soft tissues of the body may disappear 1 to 2 years after burial.

Post-mortem conditions simulating disease, poisoning or injury: 1. post mortem hypostasis – contusion, inflammation , poisoning 2. blisters of the cuticle – scald and burns 3. swelling, detachment or splitting - injury

PATHOLOGICAL AUTOPSY 1. Requirement 2. Confirmation 3. Emphasis 4. Conclusion 5. Minor

MEDICO-LEGAL AUTOPSY

Consent of next of kin Clinical findings of research

Law that gives the consent Correlate tissue changes to criminal act Notation at all abnormal findings Effect of wrongful act Summation of all abnormal findings Specific to the purpose Need not be mentioned Included if useful

The following manner of death should be autopsied:

1. 2. 3. 4. 5. 6. 7.

Death by violence Accidental deaths Suicides Sudden death of persons who are in good health Death unattended by physician D.O.A. with no clinical diagnosis Death occurring in an unnatural manner

Mistakes in autopsy: 1. Error or omission in the collection of evidence for identification 2. Errors or omission in the collection of evidence required fro establishing the time of death 3. Errors or omission in the collection of evidence required fro the medico-legal examination. 4. Errors or omission result in the production of undesirable artifacts or in the destruction of valid evidence. Negative autopsies - if after all efforts including gross and microscopic studies and toxicological analysis fail to reveal a cause of death. Negligent autopsy No cause of death is found due to imprudence, negligence, lack of skill, lack of foresight. MEDICO-LEGAL CLASSIFICATION OF THE CAUSES OF DEATH a. Natural death – cause by natural disease condition in the body. b. Violent death 1. Accidental death 2. Negligent death 3. Infanticidal death 4. Parricidal death 5. Murder 6. Homicidal death If signs of violence are associated with the natural cause of death: The following are deaths due to natural causes: 1. Affection of the CNS a. Cerebral apoplexy – sudden loss of consciousness followed by paralysis or death due to Hemorrhage from thrombosis or embolism in the cerebral vessels. b. Abscess of the brain c. Meningitis of the fulminant type 2. Affection of the circulatory system a. Occlusion of the coronary vessels : =most common cause of Sudden death due to natural causes. b. Fatty or myocardial degeneration of the heart. c. Rupture of the aneurysm of the aorta d. Valvular heart disease e. Rupture of the heart 3. Affections of the Respiratory system a. Acute edema of the larynx b. Tumor of the larynx c. Diptheria d. Edema of the lungs e. Pulmonary embolism f. Lobar pneumonia

g.

Pulmonary hemorrhage

4. Affections of the GIT a. Ruptured PUD b. Acute intestinal obstruction 5. Affections of the GUT a. Acute strangulated hernia b. Ruptured tubal pregnancy c. Ovarian cyst with twisted pedicle 6. Affection of the glands a. Status thymico-lymphaticus b. Acute hemorrhagic pancreatitis 7. Sudden death in young children a. Bronchitis b. Congestions of the lungs c. Acute broncho-pneumonia d. Acute gastroenteritis e. Convulsion f. Spasm of the larynx B. Violent death - are due to injuries inflicted in the body by some forms of force. The physical injury must be the proximate cause of death. = That the victim at the time the physical injuries were inflicted normal health. = That the death may be expected from the physical injuries = That the death ensued within a reasonable time.

outside was in inflicted.

CLASSIFICATION OF TRAUMA OR INJURIES 1. 2. 3. 4. 5. 6. 7.

Physical injury – trauma sustained through the use of physical force. Thermal injury – injury by heat or cold Electrical injury – electrical energy. Atmospheric injury – due to change of atmospheric pressure. Chemical injury – chemicals Radiation injury – radiation Infection – microbic invasion

PENAL CLASSIFICATION OF VIOLENT DEATHS 1. Accidental deaths – due to misadventure or accident. Art. 12 no. 4 RPC Any person who while performing a lawful act with due care, causes an injury by mere accident without fault or intention of causing it. Ex. Patient died of ATS injection after proper skin test. 2. Negligent death – felonies may be committed when the wrongful act is due to reckless imprudence, negligence, lack of skill or foresight. Ex. Surgeon left a pack – Homicide through reckless imprudence 3. Suicidal death , destruction of one’s self - not punished, unfortunate being. - Art 253 RPC Giving assistance to suicide. Punishable because he has no right to destroy or assist in the destruction of life of another. 4. Parricidal deaths Art. 246 father, mother, child, (leg/illeg) ascendant, descendant, spouse (leg.) 5. Infanticidal deaths – Art. 255 killing of a child less than 3 days 6. Murder Art. 248 treachery, consideration, means of inundation, occasion of calamities, evident pre-meditation, cruelty 7. Homicidal deaths Art 249 DEATHS UNDER SPECIAL CIRCUMSTANCES 1. Death caused in a tumultuous affray Art 251. 2. Deaths or physical injuries inflicted under exceptional circumstances. Art 247

2. PATHOLOGICAL CLASSIFICATION OF THE CAUSES OF DEATH a. Death due to syncope – fatal and sudden cessation of the action of the heart. b.

Death from asphyxia – a condition in which the supply of oxygen to the blood or to the tissues or to both has been reduced below normal working level. Stage of increasing dyspnea 1 min Stage of Expiratory convulsion Stage of exhaustion 3 min

c. Death from coma

= The effect of the application of physical injury on person is the production of wound. = A disruption of the anatomic integrity of the tissues of the body. = However, not all physical violence will result in the production of wound. Physics of wound production: a.

MV2 Kinetic energy = __________ 2

`Velocity component is the important factor: M16 rifle with a velocity of 3200 ft/ sec causes damage more than a heavier .38 caliber. b.

SPECIAL DEATHS 1.

Judicial deaths – Art. III Sec.1 Par. 19 Phil. Const. “cruel and unusual punishment shall not be inflicted. ; electrocution, hanging, musketry, gas chamber. 2. Euthanasia or mercy killing 3. Suicide Automatism - due to drug may be considered as accidental rather than suicidal. Evidences that will infer death is suicidal: 1. 2. 3. 4. 5. 6. 7.

History of depression, mental disease. Previous attempt Injuries are located in areas accessible to hand. Effects of the act of self-destruction may be found in the victim;, empty bottle Presence of suicidal note. Secluded, not in public view. Evidences which rule out H,M, P

Time = The shorter the period of time needed for the transfer of energy, the greater the likelihood of producing damage. = If a person is hit on the body and the body moves towards the direction of the force applied, the injury is less as when the body is stationary. = The longer the time of contact between the object or instrument causing the injury, the greater will be the dissipation of energy. c.

Area of transfer = The larger the area of contact between the force applied on the body, the lesser the damage to the body. = By applying an equal force, the damage caused by stabbing is greater compared to a blunt instrument. d. Other factors = The less elastic and plastic the tissue > the greater that a laceration will result. =

Elasticity : Ability of the tissue to return to its normal sizes and shape after being deformed by a pressure. = A force transmitted through a tissue containing fluid will force the fluid away from the area of contact in all directions equally, frequently causing the tissue to lacerate. VITAL REACTION

4.

Death from starvation :

= It is the sum total of all reactions of tissue or organ to trauma, either observed micro or macroscopically.

Cause may be due to suicidal, homicidal or accidental. The human body without food losses 1/24th of its weight daily. And 40% loss>death

a. RUBOR – redness or congestion of the area due to an increase of blood supply as a part of the reparative mechanism. b. CALOR – Sensation of heat or increase in temperature.

Factors that influence the length of survival: age, condition of the body, sex, environment. MEDICO-LEGAL ASPECTS OF PHYSICAL INJURIES Physical injury : is the effect of some of stimulus on the body. Stab wound the effect is immediate but a blunt object is delayed production on the contusion.

c. DOLOR - pain due to involvement of the sensory nerve. d. LOSS OF FUNCTION- due to trauma, the tissue may not function. The presence of vital reaction differentiates an ante-mortem from a post-mortem injury. EXCEPT: vital reactions not seen even if injury inflicted during life: 1. During agonal state of a living person were cells don’t the trauma. 2. Sudden death as in sudden coronary occlusion.

react to

Causes of Physical Injuries CLASSIFICATION OF WOUNDS: 1. 2. 3. 4. 5. 6. 7.

Physical violence Heat or cold Electrical energy Chemical energy Radiation by radioactive substances Change of atmospheric pressure Infection

1. PHYSICAL INJURIES BROUGHT ABOUT BY PHYSICAL VIOLENCE

1. AS TO SEVERITY a. Mortal wound – caused immediately after infliction that is capable of death. Parts of body that are mortal – heart, vessels, CNS, lungs, other organs. b. Non-mortal wound - Not capable of producing death after infliction.

2. AS TO KIND OF INSTRUMENT USED lacerated

e.Extensive injury – Physical injury involving a greater area of the body beyond the site of the application of force. Example : Fall or MVA

a. Blunt instrument – contusion, hematoma, wound. b. Sharp instrument = Sharp-edge instrument> incised

wound = Sharp pointed

>

punctured wound = Sharp edge and sharp-pointed

6. AS TO REGIONS OR ORGANS OF THE BODY INVOLVED Injuries in various parts of the body 7. SPECIAL TYPES OF WOUNDS a) DEFENSE WOUNDS – Instinctive reaction of selfpreservation. > hands/fractures

> stab b)PATTERNED WOUND – Wound in the nature and shape of the instrument. > Wheels,abrasions from rope.

c. Wounds brought about by tearing force – lacerated wound d. By change in atmospheric pressure – barotraumas. e. Wounds brought about by heat or cold – frostbite, scald, burns. f. Wounds brought about by chemical explosion – GSW, shrapnel wound g. Wounds brought about by infection. 3. AS TO THE MANNER OF INFLICTION a) HIT – means of bolo, blunt instrument, axe. b) TRUST or STAB – bayonet dagger c) GUN POWDER EXPLOSION – Projectile or shrapnel wound. d) SLIDING or RUBBING or ABRASION 4. AS REGARDS TO THE DEPTH OF THE WOUND a) Superficial – wound involves only the layers of the skin. b) Deep – inner structures beyond the layers of the skin. PENETRATING WOUND - Wounding agent did not come out or Piercing a solid organ. PERFORATING WOUND – Wounding agent produces communication between the inner and outer portion of the hollow organs. OR piercing or traversing completely a particular part of the body causing communication between the points of entry and exit of the instrument or substance producing it.

c)SELF-INFLICTED WOUNDS - Wound produced on oneself but no intention to end his life. TYPES OF WOUNDS ( MEDICAL CLASSIFICATION) 1. CLOSED WOUND – no breach of continuity of the skin or mucous membrane. a. Superficial – When the wound is just underneath the layers of the skin or mucous membrane. a.1 –PETECHIAE – is a circumscribed extravasation of blood in the subcutaneous tissue or underneath the mucous membrane. Example : mosquito bite, blood disease, hanging a.2 – CONTUSSION – is the effusion of blood into the tissues underneath the skin on account of the rupture of the blood vessels as a result of the application of blunt force or violence. = size of contusion greater than the size of the object. = Location of the contusion is not always the site of application of the force. Example: Black eye> Forehead Medico-legal point of view: A contusion as indicated by its external pattern may correspond to the > shape of the object or weapon used. Extent > the possible degree of violence applied. Distribution> indicates the character and manner of in manual strangulation around the neck.

injury as

Age of Contusion: appreciated from its color change 5. AS REGARDS TO THE RELATION OF THE SITE OF APPLICATION OF FORCE AND THE LOCATION OF INJURY

The size tends to become smaller from the periphery to the center and passes through a series of color changes as a result of the > Disintegration of the RBC and liberation of hemoglobin.

a. Coup Injury – Physical injury which is located at the site of the application of force. b. Contre-coup injury – opposite the site of the application of force.

The contusion is red, purple soon after its complete development. 4 to 5 days > green 7 to 10 days > yellow and gradually disappears on the 14th or 15th day.

c. Coup contre-coup injury – site and also opposite of application of force.

The ultimate disappearance of color varies from 1 to 4 weeks depending upon the severity and constitution of the body.

d. Locus minoris resistencia – Physical injury not located at the site nor opposite the site of the application of force but in some areas offering the least resistance to the force applied. Example: Blow in fore head > contusion on the region of the eyeball.

The color changes starts at the periphery. CONTUSION VS. POST-MORTEM HYPOSTASIS Contusion Below the epidermis in the true skin in small bruises or extravasations, below this in larger ones and often much deeper still. The epidermis has no blood vessels to be ruptured.

Post mortem Hypostasis In the epidermis or in the cutis as a simple stain or a showing through the epidermis of the underlying engorged capillaries. Contusion Cuticle was probably abraded by the same violence that produced the bruise. In small punctures such as fleas bites, this is not observed. Post-mortem hypostasis Cuticle unabraded, because the hypostasis is a mere sinking of the blood, there is no trauma. Contusion A bruise appears at the seat of and surrounding the injury. This may or may not be a dependent part. Post-mortem hypostasis Always in a part which for the time of information is dependent. Contusion Often elevated because elevated blood and subsequent inflammation swell the tissues.

the more effusion of blood. 4. Disease – Contusion may develop with or without application of force. Example: Aplastic anemia, whooping cough 5. Age – Children and old age tend to bruise easily. 6. Sex – women, obese easily develops unlike boxers. 7. Application of heat and cold The distinction between ante-mortem and post-mortem contusions in an undecomposed body is that in ; 1.

Ante-mortem bruising: there is swelling, damage to epithelium, extravasation, coagulation and infiltration of the tissues with blood 2. Post-mortem bruising there are no such findings. -

a.3 HEMATOMA is the extravasation or effusion of blood in a newly formed cavity underneath the skin. When the blunt instrument hit a hard part of the body like a bony part which is superficially located. Force causes the subcutaneous tissue to rupture on account of the presence of a hard structure underneath..

DISTINCTION BETWEEN CONTUSION AND HEMATOMA 1.

Post-mortem hypostasis Not elevated, because either the blood is still in the vessels or at most has simply soaked into and stained the tissues. Contusion Incision shows blood outside the vessels. This is the most certain test of difference and can be observed even in very small bruises. Post-mortem hypostasis Incision shows the blood is still in its vessels and if any oozing occurs drops can be seen issuing from the cut mouths of the vessels. Contusion Color variegated. This is only true of bruises that are the same days old due to the changes in the hemoglobin produced during life.

In contusion- the effused blood are accumulated in the interstices of the tissues underneath the skin In hematoma blood accumulates in a newly formed cavity underneath the skin. 1.

in contusion, theskin shows no elevation and is ever elevated, the elevation is slight and is on account of inflammatory changes In hematoma – the skin is always eelevated.

2.

In contusion, puncture or aspiration with syringe of the lesion, no blood can be obtained. In hematoma – shows presence of blood and subsequent depression of the elevated lesion.

Abscess, gangrene, hypertrophy, fibroid thickening and malignancy are potential complications of hematoma. MUSCULO-SKELETAL INJURIES 1.

Post-mortem hypostasis Color is uniform. The well known change in color produced in blood Extravasated Into living tissues does not occur in dead tissues with the same regularity. Contusion If the body happens to be constricted at or supported on a bruised place, the actual surface of contact may be a little lighter than the rest of the bruise but will not be white. Post-mortem hypostasis In a place which would otherwise be the seat of hypostasis pressure of any kind even simple support is sufficient to obliterate the lumen of the venules and capillaries and so to prevent their filling with blood. White lines or patches of pressure bordered by the dark color of hypostasis are produced and marks of floggings, strangulation, etc. are thus sometimes simulated. FACTORS INFLUENCING THE DEGREE AND EXTENT OF CONTUSSION 1. 2.

General condition of the patient. Part of the body affected. Fatty tissues, bloody parts > contused easily Fibrous areas, muscle > less 3. Amount of force applied –The greater the force,

even

2. 3.

Sprain - partial or complete disruption in the continuity os a muscular or ligamentous support of a joint, due to a blow, kick or torsion force. Dislocation – displacement of the articular surface of bones entering into the formation of a joint. Fracture – solution of continuity of bone resulting from violence or some existing pathology.

a. Close or Simple Fx – no break in continuity of the overlying skin. b. Open or Compound Fx – Fx is complicated by an open wound caused by the broken bone which protruded tissues of the broken skin. c. Comminuted Fx – Fractured bone is fragmented into several pieces. d. Greenstick Fx – Fx wherein only one side of the bone is broken while the other is merely e. Linear Fx – when the Fx forms a crack usually in flat bones. f. Spiral Fx – break in the bones forms a spiral manner as seen in long bones. g. Pathologic Fx – Fx caused by weakness of the bone due to disease. 4.

with other

bent.

Strain – the over-stretching instead of an actual tearing or the rupture of a muscle or ligament which may not be associated with the joint.

5. Sublaxation – Incomplete or partial dislocation. INTERNAL HEMORRHAGE rupture of blood vessels which may cause hemorrhage due to the following:

a. b. c.

Traumatic intracranial hemorrhage. Rupture of parenchymatous organs. Laceration of other part of the body.

nature of the rubbing object and the 5.

direction of movement.

Abrasion heals in a short time and leaves no scar unless if not infected or if the whole thickness of the skin is involved.

CEREBRAL CONCUSSION ( COMMOTIO CEREBRI ) - THE JARRING OR STUNNING OF THE BRAIN CHARACTERIZED BY MORE OR LESS COMPLETE SUSPENSION OF ITS FUNCTIONS AS A RESULT OF INJURY TO THE HEAD WHICH LEADS TO SOME COMMOTION OF THE CEREBRAL SUBSTANCE.

Forms of abrasion 1. Linear abrasion – appears as a single line, straight or curve. = pinching with fingernails = curve a. = sliding the point of a needle = straight linear ab.

- is more severe when the moving or mobile head struck a fixed hard object as compared when the head is fixed and struck by a hard moving object.

2. Multi-linear – develops when the skin is rubbed on a hard rough object producing several linear marks parallel to one another. Example: MVA

Signs and Symptoms 1. unconsciousness which is more or less complete. 2. muscles are relax and flaccid. 3. eyelids are closed and the conjunctivae are insensitive. 4. surface of the body is pale, cold and clammy. 5. respiration is slow and sighing. 6. pulse is rapid, weak, faltering and scarcely perceptible to the fingers. 7. temperature is subnormal. 8. sphincters are relaxed with unconscious evacuation of the bowel and bladder. 9. reflexes are present but sluggish and in severe cases may be absent. Loss of memory for events just before the injury is a constant effect of cerebral concussion and is of medico-legal importance. 2.

OPEN WOUNDS

a. Abrasion ( Scratch, graze, impression mark, friction mark ) - it is an injury characterized by the removal of the superficial epithelial layer of the skin caused by a rub r friction against a hard rough object. - Contussion with abrasion = forcible contact before friction occurs. - the shape varies and the raw surface exudes blood and lymph which later dries and forms a protective covering as SCAB or CRUST. Characteristics of abrasion: 1. It develops at the precise point of the force causing it. 2. Grossly or with the aid of a hand lens the injury consists of parallel linear injuries which are in line with the direction of rub or friction causing it. 3. It may exhibit the pattern of the wounding material. 4. Usually ignored by attending physician. Medico-legal viewpoint = abrasions caused by fingernails may indicate struggle or assault and are usually located in the face, neck, forearms and hands. = abrasions resulting from friction on rough surfaces are located in bony parts and are usually associated with contusion or laceration. = nature of the abrasion may infer degree of pressure,

3. Confluent – linear marks in the skin are almost indistinguishable on account of the severity of friction and roughness of the object. 4. Multiple – several abrasions of varying sizes and shapes may be found in different parts of the body. Types of abrasion 1. Scratch – caused by sharp pointed object which slides across skin, like pin, thorn or fingernail. - Injury usually parallel to the direction of slide. = Fingernail scratch > broad at point of commencement tailing at the end.

the with

2. Graze – usually caused by forcible contact with rough, hard objects resulting to irregular removal of the skin surface. = course indicated by a clean commencement and tags on the end. 3. Impact or imprint abrasion ( patterned abrasion, stamping abrasion, abrasion a la signature) - those whose pattern and location provides objective evidence to show cause, nature of the wounding instrument and the manner of assault or death. = marks of grid of radiator, thread marks of wheel, teeth marks. 4. Pressure or friction abrasion – caused by pressure accompanied by movement usually observed in hanging or strangulation. = spiral strands of the rope as seen in the skin in hanging. Differential diagnosis: 1. Dermal erosion - gradual breakdown or very shallow ulceration of the skin which involves only the heals without scarring.

epidermis and

2. Marks of insects and fishes bites – skin injury is irregular with no vital reaction and usually found on angles of the mouth, margins of nose, eyelids and forehead. 3. Excoriation of the skin by excreta – found in infants and the skin lesions heals when the cause is removed. No apparent history of rubbing trauma on the affected area. 4. Pressure sore – usually found at the back at the region of bony prominence. History of longstanding illness, bed ridden.

ANTEMORTEM ABRASION COLOR LOCATION

reddish-bronze due to slight exudation of blood any area

VITAL with intravital reaction REACTION may show remains of damaged Epithelium

POSTMORTEM ABRASION yellowish and transparent over bony prominence Rough handling of the cadaver shows not vital reaction and is characterized by a separation of the epidermis from

Complete loss of the former. b. Incised wound ( cut, slash, slice) – produced by a sharp-edged ( cutting) – = = =

or sharp-linear edge of the instrument like a knife, razor, bolo, glass etc.

Impact cut > when there is forcible contact of the cutting instrument with the body surface. Slice cut > when cutting injury is due to the pressure accompanied with movement of the instrument Chopped or Hacked wound > when the wounding instrument is a heavy cutting instrument like saber > injury is severe

wound.

victim struggled when attacked

POSIT’N OF May be sitting or facing a THE BODY mirror or standing

Usually victim lying on bed or in other place.

WOUNDING Firmly grasp (cadaveric spasm) WEAPON or found lying beside the victim. BLOOD Bld found in front part of body DISTRIBUTION Hand smeared with blood. MOTIVE

Weapon is absent

Bld found at the back of neck. Hands are clean.

History of mental depression, Financial, social problems, alcoholism

PREVIOUS Hx May be present Of SELF-DESTRUCT’N

1. 2. 3. 4. 5. 6. 7. 8.

Characteristics of incised wound: Edges are clean cut. The wound is straight Usually the wound is shallow near the extremities and deep at the middle portion. Profuse hemorrhage because of the clean cut on the vessels. Gaping is usually present due to the retraction of the edges. Clothes will also show a clean cut if cut by the instrument. Faster healing if without complications. Incised wound made by broken glasses maybe irregular, needs to be removed.

Changes that occur in an incised wound: After 12 hours – edges are swollen, adherent with blood and with leukocyte infiltration. 2. After 24 hours – proliferation of the vascular endothelium and connective tissue cells. 3. After 36 to 48 hours –capillary network complete, fibroblasts running at right angles to the vessels. 4. After 3 to 5 days – vessels show thickening and obliteration. 1.

Why a person suffers from incised wound: 1. 2. 3. 4.

As a therapeutic procedure. As a consequence of self-defense Masochist may self-inflict incised wounds for self-gratification. Addicts and mental patients.

Suicidal wounds – usually located in peculiar parts of the body, accessible to the hand. the most common site is the wrist, radial artery and the neck. Homicidal wounds – usually deep, multiple and involves both accessible and non-accessible parts. clothing are usually involved Defense and other forms of wounds are present. Accidental wounds – multiple incised wounds observed on the passenger and driver of MVA due to broken windshields. kitchen knives in the preparation of food.

SUICIDAL WOUNDS

HOMICIDAL

WOUNDS DIRECTION Oblique from below left ear, below downwards across front neck just above Adams apple SEVERITY cause

Usually horizontal the adams apple

Usually not so deep and

Usually deep and may

may only involve trachea,

involvement of the

carotid and esophagus

and bones.

Usually present before the

Practically absent but

commencement of deeper

rarely be present when

cartilage SUPERF’L may CUT the

Absence of such history

Always absent

3. STAB WOUNDS – is produced by the penetration of a sharp and a sharp edged instrument like a knife, scissors. if the sharp edge is the one that comes in contact with the skin then it is an incised wound. If the sharp pointed portion first come in contact, it is a stab wound. = surface length may reflect the width of the wounding instrument. = smaller when the wound is not so deep. = wider if upon withdrawal is not in the same direction as seen in slashing movement. The presence of an abrasion from the extremity of the skin defect is in line with direction of the slashing movement. The extremities of stab wound may show the nature of the instrument used. a doubled bladed weapon shows both extremities to be sharp. A single bladed weapon – one of its extremities as rounded and contused, not seen if instrument is quite thin. The direction of the surface defect may be useful in the determination of the possible relative position of the offender and the victim when the wound was inflicted. As to whether the wound is slit-like or gaping depends on the direction of the wound to the Langers line. The depth of the wound may be influence by: 1. size and sharpness of the instrument. 2. area of the body involved 3. the degree of force applied Hemorrhage is always the most serious consequence of stab wound due to the severance of blood vessels or involvement of bloody organs.

How to describe stab wound: 1. length of the skin defect – edges must be coaptated first Tailing – the direction of withdrawal of the wounding weapon. 2. condition of the extremities = sharp extremity > sharpness of the instrument used. = If Both extremity are sharp > double bladed weapon is used. 3. condition of the edges. = edges are regular and clean cut> due to one stabbing act. = serrated or zigzag in appearance > several stabbing wounds ( series of thrust and withdrawal.) 4. linear direction of the wound – it may be running vertically, horizontally, or upward medially or laterally. 5. location of the stab wound – to include exact measurement from anatomical landmarks. 6. direction of the penetration – must be tridimentional 7. depth of the penetration 8. tissue and organs involved

Stab wounds may be: A.Suicidal 1. Located over vital parts of the body. 2. Usually solitary 3. Located over covered parts of the body, the clothing is not involved 4. Stab wound is accessible to the hand of the victim 5. Hand of victim is smeared with blood 6. Wounding weapon is firmly grasp by the hand of the victim. 7. If stabbing is accompanied with slashing movement > the wound tailing abrasion is seen towards the hand inflict the injury. 8. Suicide not may be present 9. Presence of a motive for self destruction. 10. No disturbance in the death scene with wounding instrument found near the victim. B. Homicidal – stabbing with homicidal intent is the most common Characteristics:1. Injuries other than stab wound may be present . 2. Stab wound may be located in any part of the body. 3. Usually more than one stab wound 4. A motive for stabbing, if none then the offender either insane/drugs 5. Disturbance in the crime scene

Characteristics: 1. The opening of the skin is very small, wound is much deeper than it is wide. 2. External hemorrhage is limited than internally may be severe. 3. Sealing of external opening is favorable for the growth and multiplication of anaerobic organism like bacillus tetani. Homicidal multiple and usually located in different parts of the body. wound are deep there are defense wounds on the victim. signs of struggle in the crime scene.

1.

located in areas of the body where the vital organs are located. usually singular, if multiple located in one area. parts of body involved is accessible by the hand of the victim. clothing usually not involved. wounding is made while the victim is in sitting or standing position , bleeding is towards the lower part of the body or clothing. no disturbance in the crime scene. wounding instrument found near the body.

Suicidal 2. 3. 4. 5. 6. 7.

Puncturing wound with puncturing instrument loaded with poison: 1. poison dart – cyanide or nicotine 2. fish spines 3. dog bites with hydrophobia virus 4. injection of air and poison as a way of euthanasia. 5.LACERATED WOUNDS ( TEAR, RUPTURE, STRETCH “PUTOK”) -

Medical evidence showing the intent of the offender to kill the victim: 1. there are more than one stab wounds 2. stab wounds located in different parts of the body 3. stab wounds are deep 4. serrated stab wounds means thrust and withdrawal of the wounding weapon to increase internal damages. 5. irregular or stellate shape skin defects> due to changing direction of the weapon with the portion of the instrument at the level of the skin as the lever.

1. 2. 3. 4.

is a tear of the skin and the underlying tissues due to forcible contact with a blunt instrument. May be produced by a hit with a piece of wood, iron bar, fist, stone, butt. If the force is applied to a tissue is greater than its cohesive force and elasticity> the tissue tears and a laceration is produced.

Characteristic: 1. 2. 3. 4. 5. 6. 7. 8.

4. PUNCTURED WOUND of a sharp instrument.

- is the result of a thrust pointed

= External injury is quite small but the depth is to a certain degree.; ice-pick, nail - Nature of the external injury depends on the sharpness of the end of the wounding instrument: = contusion of the edges> if end is not sharp = opening may be> round, elliptical, diamond shaped or cruciate. - External hemorrhage is limited although internal injuries may be severe.> blood vessels and bloody organs is fatal if no intervention applied. - Site of external wound can be easily sealed by dried bld, serum, or clotted bld. - Punctured wounds are usually accidental

shape and size of the injury does not correspond to the wounding instrument tear on the skin is rugged with extremities irregular, ill-defined. injury developed where the blunt force is applied. borders of the wound are contused and swollen. developed in areas where the bone is superficially located.like scalp. examination with the aid of hand lens shows bridging tissue joining the edges and hairs bulbs are intact. bleeding is not extensive due to blood vessels are not severed evenly. healing process is delayed and has a tendency to develop a scar.

Classification of lacerated wounds: 1.

Splitting caused by crushing of the skin between two hard objects. Ex: laceration of scalp hit by a bunt instrument, cut eyebrow of a boxer.

2. Overstretching of the skin When pressure is applied on one side of the bone> the skin over the area will be stretched up to a breaking point to cause laceration and exposure of the fractured bone. In avulsion: the edges of the remaining tissue is that of laceration. 3. Grinding compression the weight and the grinding movement may cause separation of the skin with the underlying tissues. 4. Tearing - this may be produced by a semi-sharped edged instrument causes irregular edges on the wound like hatchet and choppers.

which

Lacerated wounds are rarely suicidal.

= includes rifles, muskets, shotguns, revolvers, pistols, other deadly weapons which a bullet, ball, shell or other missile may be discharged by means of gunpowder or other explosives. = includes air rifle except of small calibers and limited range.

INCISED WOUNDS

LACERATED

WOUNDS Edges are clean cut, regular, well defined irregular, ill-defined

edges are roughly cut,

No contusion or swelling around the around the Incised wounds

swelling and contusion

Extremities of the wound are sharp, may be and irregular Round, or contused

lacerated wounds extremities are ill-defined

Examination by means of a hand lens Shows that hair bulbs are cut

hair bulbs are preserved

Healing is faster

healing is delayed

Caused by sharp edged instrument instrument

caused by a blunt

POSSIBLE INSTRUMENTS WHEN USED BY THE ASSAILANT IN INFLICTING THE INJURIES 1. 2. 3. 4. 5. 6.

contusion – blunt incised wound – sharp-edged instrument lacerated wounds- blunt punctured wounds – sharp pointed abrasion – body surface is rubbed on a hard surface GSW – the diameter of the wound of entrance may approximate the caliber of the wounding instrument.

Could the injury have been inflicted by a special weapon? A physician cant determine that a specific weapon was used in inflicting a wound. It is possible that it is caused by a certain instrument presented. He must be cautious in giving categoric statements Which of the injuries sustained by the victim caused death? If with conspiracy – no need coz the act of one is the act of all. If none- offenders are only responsible for their individual acts. If multiple injuries: which of the wound injured a vital organ. Or if same organ which caused the degree of damage. GUNSHOT WOUNDS Death or physical injuries brought about by powdered propelled substances: 1. Firearm shot = the injury is caused by the missile propelled by the explosion of the gunpowder located in the cartridge shell and the rear of the missile. 2. cause

detonation of high explosives - grenades = explosion inside the metallic container will fragmentation of the container.

I. FIREARM WOUND = Firearm : is an instrument used for the propulsion of a projectile by the expansive force of gasses coming from the burning of gunpowder. (technical definition)

= the barrel of any firearm shall be considered as a complete firearm for all purposes thereof.