LEGAL MEDICINE

Forensic or Legal Medicine

- Deals with the application of medical knowledg
e to the purpose of law and in the administratio
n of justice.
- Application of basic clinical, medical and para
medical sciences to elucidate legal matters.
 Medical Jurisprudence
- Deals with the organization and regulation of
medical profession.
- legal responsibilities of the physician w/ particular
reference to those arising from physician – patient
relationship such as, medical negligence cases,
consent, rights and duties of doctors, infamous
conduct, medical ethics etc.
 Forensic
 Denotes anything belonging to the court of
law or use in court or legal proceeding or
something titled of legal or public
argumentation.
 Forensis = obtain
 Forum = public
 Medicine
 Dealing with prevention, cure and alleviation o
f disease.
 Restoring and preserving health

 Diagnosing, treating, curing and preventing

disease, relieving pain, and improving the health

of a person.
 Branches of Medicine
 Pediatrics
 Geriatrics
 Obstetrics
 Gynecology
 EENT
 Surgery
 General medicine
Branches of Medicine
 Legal Medicine
 Pathology
 Physiology
 Evidence
 Is the means sanctioned by law of ascertaining
in a judicial proceeding the truth respecting a
matter of fact.
 Medical Evidence
 The means sanctioned by the rules of court of
ascertaining in a judicial proceeding the truth
respecting a matter of fact wherein scientific
medical knowledge is necessary.
 Forms of Evidence

1. Real or Autoptic – a physical evidence that can be seen

and inspected
2. Testimonial – either oral/written taken from the witness
about the question in issue.
3. Documentary – written evidence presented to the court
by the expert witness about the subject matter in dispute
and not excluded by the rules of court.
4. Experimental – Extracted from experiments and performe
d in court to perform certain matter of fact
 ORDINARY EVIDENCE MEDICAL EVIDENCE

 Unlicensed gun in one’s  A gun used in shooting

possession. a person
 Testimony or an  Testimony of a

ordinary witness physician (expert witness)

 Land title  Medical certificate/

 Experiment in court to autopsy report

prove the liquid in a
bottle is poisoned.
FORENSIC ASP
ECT of DEATH
 Death
 Complete, permanent and irreversible cessati
on of the vital functions without possibility of
resuscitation.
 Kind of Death
1. Somatic or Clinical Death – state of the body in
which there is complete, persistent and consistent
cessation of the vital functions of the brain, heart
and lungs which maintains life and health.
2. Molecular or cellular death – 3-6 hrs. later, death
of individual’s cells.
3. Apparent Death or State of Suspended Animation
– merely a transient loss of consciousness or tempor
ary cessation of the vital functions of the body on
account of disease, external stimulus, it may arise
specially in hysteria, uremia, catalepsy and electrical
shock.
 Cause, Manner and Mecha
nism of Death
Cause of Death
 Refers to the disease, injury or combination of dise
ase or injury responsible for the fatality
 Any injury or disease that produces a physiological
derangement in the body that results in the individu
al dying
 GSW of the head, SW of the chest, lung cancer, my
ocardial infarction
 The physician’s best opinion, with or without an aut
opsy
 Cause, Manner and Mecha
nism of Death

Underlying or Proximate Cause of Death

- is that which, in a natural and continuous sequenc
e unbroken by any efficient intervening cause, pro
duces the end result and without which the end re
sult would not have occurred
- etiologically-specific disease or injury
- GSW of the head, SW of the chest
 Cause, Manner and Mecha
nism of Death

Antecedent Cause of Death

- “intervening” or “intermediate” cause of death
- disease or injury that occurred as a result of the u
nderlying cause of death
- BUT was not the final complication or immediate c
ause of death
 Cause, Manner and Mecha
nism of Death

Immediate Cause of Death

- refers to the final complication resulting from the u
nderlying cause of death
- occurring closest to the time of death and directly
causing death
- there may be one or more immediate causes
- not etiologically-specific
 Cause, Manner and Mecha
nism of Death
NOTE:
An immediate or antecedent cause of death may not b
e identifiable in all cases. Therefore, an underlying ca
use of death can stand alone.
 Cause, Manner and Mecha
nism of Death
Mechanism of Death
 Are the alterations of physiology and biochemistr
y whereby the causes exert their lethal effects
 Physiological derangement produced by the caus
e of death that results in death
 Never etiologically-specific
 Hemorrhage, sepsis, cardiac arrhythmias, exsang
uination, asphyxia
 Cause, Manner and Mecha
nism of Death

Mechanism of Death
- Not acceptable as an underlying cause of death
- For purposes of death certification, immediate cau
ses and mechanisms are interchangeable
- The physician’s best opinion
 Cause, Manner and Mecha
nism of Death
Mechanism of Death: physiological derangement

GUNSHOT Cause of death

WOUND

Mechanism Massive peritonitis septicemia hemorrhage

of death hemorrhage

Mechanisms of death

GSW SW Blunt Force

Causes of death
 Cause, Manner and Mecha
nism of Death
NOTE:
1. Massive bleeding (mechanism) secondary to multiple
stab wounds in the chest (underlying cause)
2. Asphyxia (mechanism) by hanging (underlying cause)
3. Bleeding in the brain (mechanism) due to blunt
traumatic head injury (underlying cause)
4. Bleeding in the chest cavity/hemothorax (mechanism)
secondary to multiple punctured wounds of the chest
(underlying cause)
Objective
 To be able tOK understand what manner of
death is
 To be able to recognize the importance of t
he manner of death to crime investigation
 To be ble to determine and explain the diffe
rent manner of deaths.
 Cause, Manner and Mecha
nism of Death
Manner of Death
 Is for the lawyers and homicide investigators
 Refers to the circumstances that led to death
 An explanation of how the cause of death came ab
out, either natural or violent
 Accidents, suicide, homicide and “undetermined”
 Activity just before death, recent symptoms, previ
ous medical records, crime scene invest and other
pertinent info help the MLO determine the manner
of death
 Cause, Manner and Mecha
nism of Death

Manner of Death
1. NATURAL
- deaths caused exclusively (100%) by disease or
birth defect
- if an injury (physical or chemical) contributes to
death, no matter how minor the contribution, the
fatality cannot be classified natural
NOTE: “Unnatural death” means homicide, suicide or
accident
 Cause, Manner and Mecha
nism of Death

Manner of Death
2. HOMICIDE
- at the very least, someone else did something
wrong that set in motion a process that resulted
in the person’s death
 Cause, Manner and Mecha
nism of Death

Manner of Death
3. SUICIDE
- at the very least, the person did something that
resulted in his or her death, and this is was
more or less what the person intended
 Cause, Manner and Mecha
nism of Death

Manner of Death
4. ACCIDENT
- these deaths resulted from some kind of
unplanned, unintended injury
 Cause, Manner and Mecha
nism of Death

Manner of Death
5. UNDETERMINED
- when the circumstances and findings leave
unreasonable doubt about the classification
- when there is insufficient info about the
circumstances surrounding the death
- in some instances, when the COD is unknown
- Example: Skeletonized remains of a young
adult male without evidence of trauma
 Cause, Manner and Mecha
nism of Death

Manner of Death
6. THERAPEUTIC COMPLICATION
- the manner of death in fatalities that arise from
complications of diagnostic or therapeutic
procedures
- the term is nonjudgmental and non-accusatory
- not a synonym for malpractice
- initiated in Cuyahoga County (Cleveland, Ohio)
in the 1960s
 Time of Death Determination

In criminal cases:
1. It can set the time of murder
2. Eliminate or suggest suspects
3. Confirm or disprove an alibi
Civil cases:
1. May determine who inherits property
2. Whether an insurance policy was in force
 Time of Death Determination

- No single marker to tell Time of Death

- At best, just an ESTIMATE!
- Difficult, imprecise or inaccurate
- Often not possible
- The longer the postmortem interval (PMI), the less
precise the estimate of the interval
Postmortem Process

Human Remains
‫׀‬
Early postmortem changes
‫׀‬
Later postmortem changes
‫׀‬
Autolysis (early stage decomposition)
‫׀‬
Putrefaction (later stage decomposition)
‫׀‬
Liquefaction & Disintegration
‫׀‬
Skeletal
 Time of Death

“Livor mortis, rigor mortis and algor mo

rtis … provide, at best, ‘postmortem wi
ndows’”.
- Stephen J. Cina, Charleston County Medical
Examiner’s Office, Charleston, SC 29425, USA
 Rigor Mortis
• 1* Flaccidity Rigor Mortis 2* Flaccidity
• Stiffening of death
• Due to disappearance of ATP from muscle
• Appears 2 to 4 hrs after death
• Fully develops in 6 to 12 hrs
• Classical presentation:
Jaw upper extremities lower extremities
• Rigor mortis disappears with decomposition
• Accelerated – exertion, epileptic seizure, fever, some
poisons (i.e. strychnine)
• Temperature–dependent in its degree and duration
• May indicate whether a body has been moved
• “Instantaneous rigor mortis” – Cadaveric spasm
 Rigor Mortis vs Cadaveric Spasm

• Time of appearance: 2 to 4 hrs - immediately

• Muscles involved: symmetrical; - asymmetrical;

all muscles only certain
grp of muscles

• Occurrence: natural - may or may

phenomena not appear

• Medico-legal
significance: tells TOD - determine
nature of crime
 Livor Mortis

• Postmortem lividity; PM hypostasis; PM sugillation

• The earliest postmortem change
• Reddish purple to purple coloration due to settling of
blood in dependent areas of the body
• Gravitational pooling of blood
• Intravascular; not bruising (extravascular)
• Evident within ½ to 2 hrs after death
• Becomes “fixed” at 8 to 12 hrs (i.e. if a body has been
moved before that time, the livor mortis will shift)
• Secondary flaccidity with decomposition
• Blanching of livor mortis – significant for estimate of
TOD
 Livor Mortis

• Cherry red to pinkish color – in deaths due to CO

poisoning
• Also cherry red in bodies exposed to cold
temperatures (hypothermia) and in deaths due cyanide
• Not a reliable indicator of the TOD
• Better indicator whether the body has been moved
• Does not occur in areas where external pressure has
closed off blood vessels in the skin and capillaries
 Algor Mortis

• Body cooling after death

• Core body T – insert thermometer in liver or rectum
• Most accurate indicator of TOD during the 1st 24 hrs
• Body temperature changes after death to ambient T
• TOD calculation: Falls at 1* C or 1.5* F per hour
• Moritz’s formula:
No. of hrs since death = (98.6 degree F – rectal T)
1.5
• Assumptions that may not be true:
1) That body T at death was normal, i.e. 98.6* F
2) That body cooling follows a uniform,
consistent, repetitive pattern
 Algor Mortis

• Wide variability, i.e. body T varies from the site where

it was taken (oral or rectal, brain or liver), from
individual to individual, by time of day, by the activity
of the individual, and by the health of the individual
• In temperate climate, there is minimal or no
temperature loss during the 1st hour
 K+ Level in Vitreous

• As time since death increases, so does K+

concentration in the vitreous
• Sturner & Gantner proposed a formula to estimate
TOD based on vitreous K+ level – invalid!
• Vitreous K+ level determined by the degree and
rapidity of decomposition rather than the time
interval from death
• Anything that hastens decomposition increases K+
level of vitreous
 Stomach Contents

• “PMI can be approximated by the state of digestion

of the stomach contents” – J. Batten
• However, radioisotopic studies to determine time of
gastric emptying have revealed great variations
- from meal to meal
- fr person to person
- day to day in the same person
• Gastric emptying is closely correlated with total # of
calories in the meal than with meal weight
• Meals of the same weight & different components
were emptied at different rates
 Stomach Contents

 Gastric emptying varie

s from person to pers
on, amount of meal an
d time of the day
 Half gastric emptying t
ime: 4 hrs
 Stress will delay diges
tion
 Environmental Factors
• Non-scientific markers
- Though “unscientific”, it is often more accurate
than determinations made by “scientific” means
- Pile of newspapers in front of the house
- Uncollected mails
- Dated receipts or slips of paper in the deceased’s
pockets
- ATM / Credit card transactions
• Scientific markers
- Insect activity
- Decomposition
- K+ level in vitreous
 TOD Calculation

• Rigor Mortis
• Livor Mortis
• “Body Cooling”
• Postmortem Changes
• K+ level in Vitreous
• Stomach Contents
• Insect Activity
• Circumstantial Evidence
 Decomposition

• Involves two processes: autolysis & putrefaction

• Autolysis – aseptic tissue breakdown due to
enzymes (prominent in pancreas)
• Putrefaction – tissue breakdown due to bacteria
• Other changes, such as insect activity
• Accelerated by: Obesity, heavy clothing, sepsis, hot
environment, insect, animal
• Slowed by: Tight clothing, cold environment,
refrigeration, embalming
• Skeletonization: may take a week or two, months or
years – dependent on environmental T and the
presence of scavengers
Introduction to
FORENSIC
AUTOPSY
Jaime Rodrigo L Leal, M.D.
Ford Foundation International F
ellow in Forensic Science – Univer
sity of Western Australia
 AUTOPSY IN THE PHILIPPINE
SETTING – FACTS & MYTHS
LEGAL PERSPECTIVE
In the Philippines, the o
nly law governing the c
onduct of an autopsy u
pon the body of the dec
eased lies with
PD 856 – The Code on S
anitation
Section 91 – Burial Requiremen
ts
 Paragraph F (Sec. 91)
“If the person who
issues a death
certificate has a
reason to believe or
suspect that the
cause of death was
due to violence or cri
me, he shall notify immediately the local aut
horities concerned. In this case the
deceased shall not be buried until a
permission is obtained from the provincial o
r city fiscal…”
Section 95. Autopsy and Dissection
of Remains

The autopsy and dissection

of remains are subject to
the following requirements:
(a) Persons authorized
to perform these are:
1. Health officers
2. Medical officers of law enforcement
agencies
3. Members of the medical staff of accredited
hospitals
(b) Autopsies shall be performed
in the following cases:

1. Whenever required by special laws

2. Upon orders of a competent court, a
mayor and a provincial or city fiscal
3. Upon written request of police
authorities
4. Whenever the Solicitor General,
provincial or city fiscal as authorized
by existing laws, shall deem it
necessary to disinter and take possess
ion of remains for examination to determ
ine the cause of death
5. Whenever the nearest kin shall
request in writing the authorities
concerned to ascertain the cause of
death.
 (c) Autopsies may be
performed on
patients who die in
accredited hospitals
subject to the
following requirements:

1. The Director of the hospital shall

notify the next of kin of the death
of the deceased and request
permission to perform an autopsy.
2. Autopsy can be performed when the
permission is granted or no objection is
raised to such autopsy within 48 hours
after death.
3. In cases where the deceased has no
next of kin, the permission shall be
secured from the local health authority.
4. Burial of remains after autopsy:
After an autopsy, the remains shall be i
nterred in accordance with the provisions i
n this Chapter.
The public is exposed to a wealth of forensic p
athology in the media, particularly in TV progr
ams such as CSI, Law and Order, Silent Witne
ss (UK) and The Closer.
However, these representations are rarely acc
urate.
 Kinds of aut
opsies

 Hospital or non-off
icial autopsy
 Medico-legal or off
icial autopsy
 Kinds of Autopsies

 HOSPITAL/ NON-OFFICIAL AUTOPSY

 Consent from relatives
 Spouse, descendants of the nearest

degree, ascendants of nearest degree,

brothers and sisters (decreasing order)
 Kinds of Autopsies
 HOSPITAL/ NON-OFFICIAL AUTOPSY
 Purpose:
 Determine cause of death

 Provide clinical correlation of diagnosis

and clinical symptoms

 Determine the effectiveness of therapy

 Study natural course of the disease

process
 Educating students and physicians
 Kinds of Autopsies

 MEDICO-LEGAL or OFFICIAL AUTOPSY

 Dead body belongs to the state for protection
of public interest
 All that needs to be turned over to the

next of kin would be burial of the

deceased
Kinds of Autopsies
 DEATH INVESTIGATION
The aims of death investigation are to answer
the following questions:
1. Who died? (identification of the deceased)
2. Where? (place of death)
3. When? (time of death)
4. Why? (cause of death)
5. How? (manner & mechanism of death)
* Autopsy is only one part of death investigation.
* Body, History and Crime Scene are equally important (
diagnostic triangle).
 FORENSIC AUTOPSY

 The forensic autopsy is an important tool in the

investigation of deaths. It is a comprehensive stud
y of a dead body, performed by a trained physicia
n employing recognized dissection procedure and
techniques. It involves removal of tissues for furth
er examination.
 Postmortem examination refers to an external e
xamination of a dead body without incision being
made.
“Death marks the end of the physical body, but
the body tells the story of its works and days
at autopsy; sometimes a whole biography is the
re in the cast and color of blood and bone, the
wounds and scars gathered in a lifetime. We ca
n’t see the last image on the retina, but we can
see what was eaten, breathed, injected. The w
ay people die is a reflection of the way they liv
e… ”

- Michael Baden, M.D.

 FORENSIC AUTOPSY

OBJECTIVES:
1. Must establish the cause and manner of death
.
a. Suicidal
b. Natural
c. Accident
d. Homicidal
e. Therapeutic Complication
2. Identification of the deceased, if unknown.
 FORENSIC AUTOPSY

3. Determine time of death or injury.

4. Recover, identify & preserve forensic evidence.
5. Documentation of injuries or lack of them.
6. Reconstruction and interpretation of how the in
juries occurred.
Ex. The scene and the clothing are
included
 FORENSIC AUTOPSY

7. Find out whether there is any contributing facto

r to the causation of death.
8. Provide interpretation and correlation of facts a
nd reconstruct the circumstances surrounding t
he death.
9. Provide a factual, objective medico-legal report
for prosecution and defense.
10. Separate natural from unnatural death for prote
ction of the innocent in suspicious deaths.
 Investigative Information Pr
ovided by the Autopsy
1. What type of weapon was involved in the death?
2. Are the wounds consistent with investigative evidence?
3. Which wound was the fatal wound?
4. Approximately how long could the deceased have lived af
ter the assault? (Survival time)
5. How far could the deceased have walked or run?
6. Was the body dragged or dumped?
7. From what direction was the force applied?
8. What was the position of the deceased at the time of inj
ury (sitting, standing, lying down, etc.)?
 Investigative Information Pr
ovided by the Autopsy
9. Are the injuries antemortem or postmortem?
10. Is there any evidence of sexual assault (rape or sodomy)?
11. Was the deceased under the influence of drugs?
12. Was the deceased under the influence of alcohol?
13. Are there any foreign objects in the cadaver (bullets, brok
en blades, fibers, etc.)?
14. Is there any evidence of a struggle (defense wounds)?
15. What is the estimated time of death?
 AUTOPSY REPORT

1. External Examination
- Age, sex, race, physique, ht/wt, nourishment
- Congenital malformations, scars, tattoos, old injuries
- Clothing: An integral part of the medico-legal autopsy
- General description of the state of the body: PM changes
2. Evidence of recent medical or surgical intervention
3. Evidence of Injury: external & internal injuries
- Type: GSW, SW, abrasions, lacerations, IW, PW, burn
- Location, Size, Shape, Color
 AUTOPSY REPORT

4. Internal Examination
- Head, chest & abdominal cavities
- Blood, vitreous, urine & bile should be retained
- For decomposed body: Retain muscle, liver & kidney
5. Laboratory Tests
- Toxicology, histology, microbiology, serology
6. Fingerprints/palm prints – taken prior to release of body
7. Opinion: Cause, manner and mechanism of death
 FORENSIC AUTOPSY

 Most initial injuries do not cause immediate death. There is

often a “survival interval” during which the person may eng
age in considerable activity before collapsing and dying.
 The presence of a wound on a body does not necessarily mea
n that someone else inflicted the wound. Suicide must alway
s be considered. It is a common error to believe that certain
wounds would have been too painful to be self-inflicted.
 There is no such thing as a wound too painful if the person i
s determined to take his or her own life.
 FORENSIC AUTOPSY

 An autopsy must be complete if it is to be accurate. The basi

c principle of death investigation is “DO IT RIGHT THE FI
RST TIME, YOU ONLY GET ONE CHANCE.”
 The purpose of the forensic autopsy is more than just to esta
blish the cause of death. It involves the determination of all
other factors which may or may not be involved.
 The medico-legal officer takes charge of the body, and any a
rticle on or near the body that may assist the MLO in deter
mining cause and manner of death.
 Deaths Reportable to the
Medico-Legal Officer
- Criminal violence
- Suicide
- Accident
- Trauma
- Disaster
- Sudden and unexpected deaths
- Deaths under unusual or suspicious circumstances
- Complications of illegal/criminal abortion
- In police custody, jail or prison
- Deaths without medical attendance
- Poisoning
 Deaths Reportable to the
Medico-Legal Officer
- Unclaimed bodies
- Diseases constituting a threat to public health
- Disease, injury or toxic agent resulting from empl
oyment
- Death associated with diagnostic or therapeutic pr
ocedures
- When a body is to be cremated, dissected or burie
d at sea
- When a body is brought into a new medico-legal j
urisdiction without proper medical certification
- Sudden infant death syndrome
Dr. Charles Petty has identified
popular misconceptions concern
ing the medico-legal autopsy:
1. That the time of death can be
precisely determined by the
examination of the body.
2. That the autopsy always
yields the cause of death.
3. That the autopsy can be
properly carried out even
without a “history”.
4. That embalming will not
obscure the effects of trauma
and disease.
5. That only true and suspected
homicide victims need
examination.
6. That the cause and manner of
death are the only results of
the autopsy.
7. That the autopsy must be
immediate.
8. That the poison is always
detected by the toxicologists.
9. That the autopsy is criminally
or prosecution oriented