Module 2 – Forensic Medicine
THE MEDICO-LEGAL AND DEATH
DEATH is defined as the state of complete persistent cessation of respiration, circulation, and other vital function of the body. It is the return of the body to a stable equilibrium, chemically and physically.
WARNING: This module contains graphic images some readers may find gruesome and disturbing!
KINDS OF DEATH:
1. SOMATIC DEATH (or Clinically Death)
Occurs when a physician declares a person has expired due to complete, persistent, and continuous cessation of the vital function of the brain, heart, and lungs. But there is still animal life among individual cells as evidenced by the presence of excitability of muscles and ciliary movement of individual cells.
EARLY SIGNS OF DEATH:
● Face and lips become pale
● Muscles become flaccid
● Sphincters are relaxed
● The lower jaw tends to drop
● Eyelids open and pupils dilate
● Skin loses its elasticity
● Body fluids tend to gravitate to dependent portion
● Body heat gradually assumes the temperature of the surroundings.
MOLECULAR OR CELLULAR DEATH
Occurs three to six hours after death. There is death to individual cells. This is also death confined to cells or tissues of the human body.
APPARENT DEATH (or State of Suspended Animation)
This condition is not really death but a mere transient loss of consciousness or temporary cessation of the body. The following condition may produce Apparent Death:
(a) Hysteria
(b) Uremia
(c) Catalepsy
(d) Electric Shock
(e) Drowning
MEDICO-LEGAL IMPORTANCE – to prevent premature burial.
LEGAL IMPORTANCE OF DETERMINING DEATH
[1] The civil personality of a natural person is extinguished by death.
[2] Property of a person transmitted to his heirs at the time of his death
[3] A civil case for a claim, which does not survive is dismissed upon the death of the defendants.
SIGNS OF DEATH
1. Cessation of Heart Action and Circulation.
As a general rule, if there is no heart action for a period of five minutes, death is regarded as certain. The auricle is the last to stop, hence called “ULTIMAN MARIENS”. In judicial hanging, the heartbeats for 20-30 minutes after the individual has been executed. In decapitation, the beating is present for an hour after decapitation.
Methods of Detecting Cessation of Heart Action
(1) Palpation of pulse
(2) Auscultation of heart sound (picture below)
(3) Fluoroscopic examination
(4) Use of electrocardiograph
Methods of Examining Peripheral Circulation
(1) Magnus Test
(2) Opening of small artery
(3) Icard’s Test
(4) Diaphanous Test
(5) Application of heat on the skin
(6) Palpation of pulse
2. Cessation of Respiration.
A person can hold his breath no longer than 3 ½ minutes. In electric shock, respiration may cease for some time but maybe restored by continuous artificial respiration.
Conditions in which suspension of respiration is present without death ensuing:
● Purely voluntary act; example divers, swimmers, etc.
● Peculiar conditions like Chene-Strokes Respiration (apneic interval not longer than 15 – 20 seconds do)
● Apparent drowning
● Newly born infants
Methods of Detecting Cessation of Respiration
● Observation of the chest movement during inspiration and expiration.
● Auscultation or examination using a stethoscope
● Use of mirror – dimming or mirror if there is respiration due to moist air.
● Examination with the feathers or cotton fibers
● Examination with the glass of water
● Winslow test – the movement of the image formed by reflecting artificial or sunlight on the water
3. Cooling of the Body
[1] The progression fall of body temperature is due to the cessation of the metabolic process, one of the most prominent signs of death, which is rapid during the first 2 hours after death.
[2] Fall of the temperature of 15°F to 20°F is considered a certain sign of death.
[3] Conditions where fall of temperature occur before death are as follows:
● cancer
● phthisis
● collapse
[4] Conditions wherein there is the rise of temperature immediately after death usually observed in the first two hours (post-mortem caloricity).
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- Cholera
- Cerebro-spinal fever
- Liver abscess
- Rheumatic fever
- Small fox
- Strychnine poisoning
- Yellow fever
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4. Insensibility of the Body and Loss of Power to Move
Conditions in which the above is present in the living:
(1) Apoplexy
(2) Epilepsy
(3) Trance
(4) Catalepsy
(5) Cerebral Concussion
(6) Hysteria
5. Changes in the Skin Following Death
(1) Pale and waxy looking
(2) Loss of elasticity
(3) Opacity
(4) Effect of the action of heat
6. Change in and About the Eye
(1) Loss of corneal reflex
(2) Clouding of the cornea
(3) Flaccidity of the eyeball
(4) The pupil is in the position of rest
(5) Ophthalmoscopic findings
(6) Tache noir de la scleratique – yellowish to black round triangular spot found in the sclera.
7. Action of the Heat on the Skin
Only dry blister is found on dead. In living, blister contains fluid. (Below is an example of a blister for a living body, this means the defense mechanism of the body is still functioning)
CHANGES IN THE BODY FOLLOWING DEATH
CHANGES IN THE MUSCLES
there are three stages after death:
I. Stage of Primary Flaccidity:
Characteristics are as follows:
[1] Occurs 3 – 6 hours after death;
[2] Muscles relaxed, contracts when stimulated, pupils dilated sphincters relaxed so there is no incontinence or urination and defecation.
II. Stage of Post-mortem Rigidity
Cadavers rigidity or rigor mortis (or death struggle) of muscles characteristics:
[1] Occurs 6 – 24 hours and last to 36 hours after death;
[2] The whole body becomes rigid due to muscular contraction;
[3] Chemically, there is an increase in lactic acid and phosphoric contents of muscles. The reaction becomes acidic;
[4] Healthy muscles delay the onset;
[5] Aged, newborn, high temperature, moist air hastens the onset.
III. Stage of Secondary Flaccidity
There is the commencement of putrefaction. Muscles become flaccid and soft due to the dissolution of muscles protein which has been previously coagulated during the period of rigor mortis.
CONDITIONS SIMULATING RIGOR MORTIS
(1) HEAT STIFFENING – when the dead body is exposed to a temperature above 75°C, muscle proteins coagulate and cause the muscles to be rigid. The body assumes the “pugilistic attitude”. (most often this happen on that death due to fire)
(2) COLD STIFFENING – when a dead body is frozen, there is stiffening due to the solidification of fat. Exposure to warm conditions will make such stiffening disappear.
(3) CADAVERIC SPASM – sometimes known as INSTANTANEOUS RIGOR. Instantaneous rigidity of muscles after death due to extreme nervous tension, exhaustion, injury to the nervous system, or injury to the chest. Below is an example of a cadaveric spasm.
| DISTINCTIONS: | Cadaveric Spasm | Rigor Mortis |
| Time of appearance | 3-6 hours after death | immediately after death |
| Muscle involved | all muscles | a certain group of muscles or asymmetrical |
| Occurrence | natural phenomena | may or may not appear |
| Medico-legal importance | approximate time of death | may determine the nature of the crime |
CHANGES IN THE BLOOD
COAGULATION OF BLOOD
This occurs 6 – 8 hours after death due to the cessation of circulation. Clotting is accelerated by infections and fevers. Clotting is delayed in cases of asphyxia, poisoning by opium, hydrocyanic acid, or carbon monoxide poisoning.
DISTINCTIONS:
| Anti Mortem Clot | Post Mortem Clot |
| Firm in consistency | Immediately after death |
| The surface of the blood vessel is raw if a clot is removed | Smooth and healthy |
| Homogenous in construction | Can be stripped off in layers |
| Uniform in color | With distinct layer |
POST MORTEM LIVIDITY
Or post-mortem suggilation or post-mortem hypostasis or liver mortis. This is the accumulation of blood in the most dependent portion of the body giving a dull red or purplish color.
Kinds of Post-mortem Lividity:
(a) Hypostatic Lividity
(b) Diffusion Lividity
The above phenomenon can be explained and elaborated in my 12 minutes video on how to calculate the time of death where all three-stage may occur in a body after death.
Let’s watch the video:
SPECIAL MODIFICATION OF PUTREFACTION
MUMMIFICATION
Dehydration of the body resulting in shivering and preservation of the body when buried in a hot, arid, place with a dry atmosphere and with free access to hot air. An example is a death in desserts, like in Egypt.
Kind of Mummification:
(1) Natural Mummification
(2) Artificial Mummification
(3) By exposure to heat
(4) By treatment with formalin, arsenic, etc.
SAPONIFICATION
Fatty tissues of the body are transformed into soft brownish substances known as adipocere.
DURATION OF DEATH DETERMINATION:
[1] Presence of Rigor Mortis – 3 – 6 hours & may last from 18-36 hours
[2] Presence of Post-mortem Rigidity – 3 – 6 hours after death.
[3] The onset of Decomposition – 24 to 48 hours after death
[4] Stage of Decomposition
[5] Entomology of cadaver – the presence of maggots after more than 24 hours
[6] Stage of Digestion of Food in Stomach – it takes 3–4 hours for the stomach to evacuate its contents after each meal.
[7] Presence of live fleas in the clothing in drowning cases
[8] Amount of urine in the bladder
[9] State of clothing:
● If the victim is wearing street clothes, the likelihood is that death occurred at daytime;
● If the victim is wearing a nightgown or pajamas, death occurred at nighttime.
[10] Chemical Changes in CSF (15 hours after death)
● Lactic Acid – 15mgs to 200mgs%
● NPN – 15 mgs to 40 mgs%
● Amino Acid Concentration – 1 to 12%
[11] Post-mortem clotting and coagulation – 6 to 8 hours after death
[12] Presence or absence of soft tissues in the skeletal remains.
[13] Conditions of bones.
PRESUMPTION OF DEATH
Disputable Presumption:
That person not heard for seven (7) years is dead:
Presumption of Death:
[a] After an absence of 7 years, it being unknown whether or not the absentee still lives, he shall be presumed dead for all purposes, except for those of succession;
[b] The absentee shall not be presumed dead for the purpose of opening his succession till after the absence of ten (10) years.
[c] If he disappeared after the age of 75 years, an absence of 5 years shall be sufficient in order that his succession may be opened;
[d] The following shall be presumed dead for all purposes, including the division of state among the heirs:
● A person who boards a vessel lost during a sea voyage, or an airplane which is missing, who has not been heard of for four (4) years since the lost of the vessel or airplane;
● A person who has been in danger of death under other circumstances and his existence has not been known for four (4) years;
● A person in the armed forces who has taken parts in war, and has been missing for four (4) years.
PRESUMPTION OF SURVIVORSHIP
When the person perishes in the same calamity, such as wreck, battle, or conflagration, and is not shown who dies first, there are no particular circumstances from which it can be inferred, the survivorship is presumed from the probabilities resulting from the strength and ages of the sexes, according to the following:
[1] If both were under the age of fifteen (15) years, the older is presumed to have survived;
[2] If both were above the age of sixty (60), the younger is presumed to have survived;
[3] If one is under fifteen (15) and the other is above sixty (60) the former is presumed to have survived;
[4] If both be over fifteen (15) and under sixty (60), and the sexes are different, the male is presumed to have survived; if the sexes be the same, then the older;
[5] If one be under fifteen (15) or over sixty (60), and the other between those age, the latter is presumed to have survived.
MEDICO-LEGAL ASPECT OF DEATH
EUTHANASIA
It is a willful, deliberate, and painless acceleration of the death of a person. The most common method utilized is the administration of drugs like opiates and other sedatives to mitigate the suffering of a person affected with a dreadful disease.
Principle: No person has the right to end his own life, much less can he delegate such a right to another medical ethics regards the duty of the physician to save a life, not to end life.
CRIMINAL LIABILITY OF PHYSICIAN PERFORMING EUTHANASIA
[1] MURDER – if the patient has no knowledge that he will be put to death by the physician.
[2] GIVING ASSISTANCE TO SUICIDE – if the patient consented to be put to death by the physician (Art. 253, Revised Penal Code)
CAUSES OF DEATH
NOTE: The main purpose of a medico-legal post-mortem investigation is to determine the cause of death. In most instances, the medical findings tend to prove or disprove the probability or improbability that a crime has been committed.
MEDICO-LEGAL CLASSIFICATION OF THE CAUSE OF DEATH
1. NATURAL DEATH
This death is caused by a natural disease condition in the body. It may develop spontaneously or as a consequence of physical injury inflicted prior to its development. If a natural disease without the intervention of the felonious act of another person no one can be held responsible for the death
SUDDEN DEATH – termination of life, which comes quickly under, circumstances when its arrival is not expected. An example is heart disease.
2. VIOLENT DEATH
VIOLENT DEATH due to injuries inflicted in the body by some form of outside force. The physical injuries must be the proximate cause of death.
Violent deaths are:
● Accidental death
● Negligent death
● Infanticidal death
● Parricidal Death
● Murder
● Homicidal death
● Suicidal death
Poisoning, asphyxia, and severe trauma are the most frequent causes of violent death. If signs of death are associated with the natural cause of death, the physician must be able to answer this question. Did the person die of a natural cause and were the physical injuries inflicted after death?
Note: When does death is presumed to be a natural consequence of physical injuries inflicted?
● That the victim at the time of physical injuries was inflicted was in normal health;
● That the death may be expected from physical injuries inflicted;
● The death ensued within a reasonable time.
CLASSIFICATION OF TRAUMA OR INJURY
1. Physical injuries – the use of force
2. Thermal injury – caused by heat or cold
3. Electrical injury due to electric energy
4. Atmospheric injury – due to change of atmospheric pressure
5. Chemical injury – caused by chemicals
6. Radiation injury – caused by radiation
7. Infection – caused by a microbic invasion
PENAL CLASSIFICATION OF VIOLENT DEATH
1. ACCIDENTAL DEATH
Death due to misadventure or accident. An accident is something that happens outside the sway of our will, and although it comes about through some act of will, lies beyond the bounds of human forcible consequences. In a pure ACCIDENTAL DEATH, the person who causes the death is exempted from criminal liability.
2. NEGLIGENT DEATH
Death due to reckless imprudence, negligence, lack of skill, or lack of foresight.
3. SUICIDAL DEATH
Death through destruction of oneself. The law does not punish the person committing suicide, because society has always considered a person who attempts to kill himself as an unfortunate being, a wretched person deserving more pity than a penalty; But a person who gives assistance to the commission of suicide of another is punishable because he has no right to destroy or assist in the destruction of the life of another.
Acts Punishable in Giving Assistance to Suicide:
[1] The offender assisted in the commission of suicide to another, which was consummated.
[2] The offender gave assistance in the commission of suicide to the extent of doing the killing himself, which is consummated.
[3] The offender assisted another in the commission of suicide, which is not consummated.
4. PARRICIDAL DEATH
The killing of one’s relative. Any person who shall kill his father, mother, or child, whether legitimate or illegitimate or any of his descendants or ascendants, of his spouse, shall be guilty of parricide and shall be punished by a penalty ranging from reclusion Perpetua to death.
5. INFANTICIDAL DEATH
Killing of a child less than three (3) days old.
6. MURDER
Any person who, not falling within the provisions of Article 246, shall be guilty of murder and shall be punished by Reclusion Temporal in its maximum period to death.
Note: Whenever killing is attended by more than one of the qualifying circumstances mentioned, only one of them will make the killing, and the rest be considered generic aggravating circumstances.
Example of cruelty: The presence of several wounds inflicted by the offender may prove murder because there is cruelty if the victim is alive, or scoffing or outraging the corpse if inflicted after death.
Example of treachery: The presence of a gunshot wound if the entrance is at the back as a general rule qualifies the criminal act to murder because there was treachery.
7. HOMICIDAL DEATH
Any person not falling within the provision of Article 246 shall kill another without the attendance of any of the circumstances enumerated in the next preceding article (murder), shall be deemed guilty of homicide, and be punished by reclusion temporal.
8. DEATH UNDER SPECIAL CIRCUMSTANCES UNDER THE PENAL CODE
● Death Caused in Tumultuous Affray
● Death of Physical Injuries Under Exceptional Circumstances:
PATHOLOGICAL CLASSIFICATION OF THE CAUSES OF DEATH
An analysis of all death from natural causes will ultimately lead to the failure of the heart, lungs, and the brain so that due to pathological lesions may be classified into:
(1) Death from Syncope
(2) Death from Asphyxia
(3) Death from Coma
Death from Syncope:
This is death due to sudden and fatal cessation of the action of the heart with circulation included
Causes of Death from Syncope
(1) Coronary disease, as embolism or thrombosis.
(2) Rupture of the heart through softened infarct.
(3) Myocardial degeneration.
(4) Valvular diseases.
(5) Rupture of the aortic and other aneurysms.
(6) Systemic embolism occurring in bacterial endocarditis.
(7) Congenital heart diseases of the newborn.
(8) Reflex inhibition of the heart or of the cardiac center, as in shock, emotion, or blow over the area of some of the sensory nerve.
(9) Arterial hypertension with sclerosis.
(10) Deficiency of blood as in profuse hemorrhage, especially if sudden.
(11) Exhaustive diseases.
(12) Extensive injury to the body from a mechanical cause
Symptoms of Syncope:
(1) The person falls and remains motionless.
(2) The face is pale.
(3) Pulse at the wrist disappears or is filiform.
(4) Respiration ceases.
In non-fatal cases, consciousness returns in a few second, but in fatal ones, the following other symptoms appear:
● Person breaks out into cold sweat.
● Dimness of vision.
● Pulse rapid and filiform.
(5) There may be vomiting and involuntary movement of the limbs.
(6) The person may be passing into a state of delirium.
(7) Death may be preceded by convulsion.
Death from Asphyxia:
Asphyxia is a condition in which the supply of oxygen to the blood or to the tissues or to both has been reduced below normal working level.
Causes of Death from Asphyxia
[1] Diseases of the respiratory system, like pneumonia, acute bronchitis, bronchitis in infancy, rupture of the blood vessels in pulmonary tuberculosis with cavitation.
[2] Impaction of foreign bodies in the larynx.
[3] Compression of the larynx.
[4] Pressure on the respiratory tract due to tumor, or intracranial hemorrhage.
[5] Strangulation, suffocation, hanging, drowning, inhalation, or irritant gases.
[6] Refraction of the atmosphere.
[7] Causes operating in the nervous system:
● Paralysis of the respiratory muscles or respiratory center from injury or disease or action of the poison.
● Fixation of the respiratory muscles from overstimulation of the spinal cord as in strychnine poisoning.
[8] Causes operating from the lung or pulmonary circulation:
● Pleurisy with effusion.
● Pulmonary embolism.
● Pulmonary thrombosis.
Symptoms of Asphyxia
I. Stage of Increasing Dyspnea:
This stage usually lasts from 1/2 to 1 minute:
[1] Increased rate and depth of respiration, leading to difficulty of breathing (dyspnea).
[2] Exaggerated movement of inspiratory muscles soon replaced by exaggerated expiration.
[3] Rise of blood pressure, consequently the heartbeat becomes quicker and more forcible.
[4] A person becomes bluish and consciousness is lost.
[5] Pupils are contracted.
II. Stage of Expiratory Convulsion:
[1] This stage lasts for about a minute:
[2] Marked expiratory effort.
[3] Convulsive movement of the limbs accompanied by expiratory effort.
[4] Blood pressure gradually lowers owing to the failure of the heart due to lack of oxygen.
III. Stage of Exhaustion:
This stage lasts for about three minutes. The person lies still except for occasional deep inspiration. Blood pressure falls and pupils are dilated.
Post-mortem Findings in Death from Asphyxia:
(a) External Findings:
[1] Lividity of the lips, fingers, and toenails.
[2] Livid markings on the skin.
[3] Marked post-mortem lividity.
(b) Internal Findings:
– Lungs:
● Lungs engorged with dark blood.
● On the section, there is dark color frothy exudation.
● Punctiform hemorrhages of the pleura (Tardieu Spots).
● Reddish discoloration of the trachea and bronchial mucous membrane.
– Heart:
● Sub-pericardial petechial hemorrhages.
● The right ventricle of the heart dilated and engorged.
● The left side of the heart and arterial system empty.
– Abdominal viscera are congested.
– Brain congested and may show punctiform hemorrhages.
– Blood dark in color.
– Rigor mortis has a slow onset.
Death from Coma
Coma is the state of unconsciousness with insensibility of the pupil and conjunctivae, and inability to swallow, resulting from the arrest of the functions of the brain.
Causes of Coma:
(1) Gross lesions of the brain:
● Depressed fracture.
● Apoplexy.
● Embolus.
● Abscess.
● Tumor.
(2) Poisons:
● Uremia.
● Cholemia.
● Acetonemia.
● Ingested morphine.
● Ingested alcohol.
Symptoms of Coma:
[1] A person is unconscious.
[2] Breathing is stertorous.
[3] Pulse is full but intermittent.
[4] Cold, clammy perspiration.
[5] Imperfect perception of sensory impression.
[6] Delirium.
[7] Relaxation of all sphincter muscles.
[8] Accumulation of mucous in the respiratory passages.
Post-mortem Findings:
The findings in coma are the same as in asphyxia, and in addition, there is congestion of the brain and the spinal cord.
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