CHAPTER 1 LEGAL MEDICINE

Legal Medicine
Is that branch of medicine that applies, medical and surgical concepts, scientific knowledge and skills
to medico legal issues, in order to assist the trier of facts in the proper dispensation of justice. Medical
Jurisprudence-is the study of the Medical Law and its applicable Jurisprudence that governs, regulates
and defines the practice of medicine.

In the Philippines, Legal Medicine is the appropriate name for Forensic Medicine.

Modern Legal medicine has a broad range of applications, it is used in civil cases such as paternity
and filiation, annulment of marriage, DNA testing, etc.

In all cases the medical examiner must conduct an investigation of the crime scene and also an
autopsy.
TECHNIQUES OF LEGAL MEDICINE:-Legal Medicine uses sophisticated laboratory techniques to detect
the presence of substances in the victim, in the suspected criminal, or at the crime scene.-Forensic
examination of substances found at a crime scene can often establish the presence of the suspect at
the crime scene.
LEGAL MEDICINE AND THE LEGAL SYSTEM-Courts routinely call upon physicians to give expert
testimony in a trial, especially concerning the findings of an autopsy and the results of laboratory
tests.-As an expert witness he is allowed to express an opinion about the validity of the evidence in a
case and may quote the statements of other experts in support of an opinion.-Ordinary testimony is
restricted to statements concerning what the witness actually saw or heard.-The evidence to be
presented by the legal medicine expert must signify a relation between the facts called the Factum
Probandum or proposition to be established and the factum Probans which is the material
evidencing the proposition.-The Physician must present RELEVANT, MATERIAL ANDCOMPETENT
EVIDENCE.HISTORY OF LEGAL MEDICINE:
Paulus Zacchias ( 1584 1659 ) is the Father of Forensic Medicine. He was the first to describe the
importance and application of medicine to the proper administration of justice.In the Phil. , the father of Legal Medicine can be rightfully bestowed to Dr. Pedro P. Solis. His book on
Legal Medicine copyrighted in 1987,contains the most extensive treatise and teachings in Philippine
Legal Medicine.
APPLICATION OF LEGAL MEDICINE TO LAW:
Legal Medicine is Applied to Law

1. Civil law- the determination and termination of civil personality- the limitation or restriction of a
natural persons capacity to act- marriage and legal separation- paternity and filiation- testamentary
capacity of a person making a will- the right to hereditary succession
2. Criminal Law-Felonies and circumstances which affect criminal liability-Civil liability ex delictuCrimes relative to opium and prohibited drugs-Crimes against persons-Crimes against chastity-Crimes
against civil status of persons-Quasi offenses
3. Remedial Law-Physical and Mental Examination of a person-Hospitalization of insane persons-Rules
of Evidence
4. Special Laws- Dangerous Drug Act- Youth and Child Welfare Code- Sanitation Code- Insurance lawLabor Code- Employees Compensation Law
5. CORPUS DELICTI- Is the body or substance of the crime and is defined as the fact that a crime
actually has been committed. In all criminal prosecutions, the burden is on the prosecution to prove
the corpus delicti.
QUANTUM OF PROOF
1. In Civil Cases the quantum of proof necessary to prove a civil complaint is a PREPONDERANCE
OF EVIDENCE. The party filing or bringing a civil complaint has the burden of proof and must
establish the truth and righteousness of his allegations by a preponderance of the evidence
admitted by a competent court.

2. In Criminal Cases the quantum is proof beyond reasonable doubt.-In a criminal case the
accused is entitled to an acquittal, unless his guilt is shown beyond reasonable doubt
-Presumption of INNOCENCE is conclusion drawn by the constitution and the law in favor of the
accused , while REASONABLEDOUBT, is a condition of mind produced by proof resulting from
evidence in the case.
3. To establish matters of defense- The doctrine of reasonable doubt applies only to incriminative
facts.
4. To establish self defense- One who sets up SELFDEFENSE must rely on the strength of his own
evidence and not on the weakness of that of the prosecution.
5. To establish Alibi- It must be proved by positive, cear and satisfactory evidence. Oral Evidence
of alibi is so easily manufactured and usually unreliable that it can rarely be given credence.
6. In Administrative Complaints- In cases filed before administrative or quasi-judicial bodies, a fact
maybe deemed established if it supported by substantial evidence which means that amount of
relevant evidence which a reasonable mind might accept as adequate to justify a conclusion.
CHAPTER 2 MEDICAL AND HOSPITAL JURISPRUDENCE
Medical Jurisprudence:
-Is the study of the Medical Law and its applicable Jurisprudence, that governs, regulates, and
defines the practice of medicine.

-It includes the rights, duties, obligations and liabilities of both physician and patient to each other
in a physician patient professional contract.
The Following Acts Constitute the Practice of Medicine:
1. To physically examine and diagnose a patient.
2. To physically examine and treat a patient
3. To physically examine and perform surgery in a patient
4. To physically examine and prescribe any remedy to a patient.

Any person who practice any of the above acts enumerated, without any valid certificate of
registration as a physician, is practicing illegal medicine.
The Nature of the Physician Patient Professional Relationship is
1. Consensual:
- based on mutual consent of both patient and physician.- Contracts that are consensual in nature,
are perfected upon mere meetings of the minds
2. Fiduciary:
- founded in trust, faith, and confidence reposed by one person in the integrity and fidelity of
another.
DUTIES AND OBLIGATIONS OF THEPHYSICIAN TOWARDS HIS PATIENTS:
1. He must possess that knowledge and skill possessed by an average physician.
2. He must use such knowledge and skill with ordinary care and due diligence.
3. He is obliged to exercise his best judgment in good faith.
4. He has the duty to keep the secrets and confidentialities of his patients.

The Terms and Conditions not included in the Physician Patient Professional Relationship Contract (
refer to book )

The only promise or guaranty that the law requires is that, the physician will treat the patient in
accordance with the standards of medical care.
PATIENTS RIGHTS RESPECTED BY PHYSICIANS:
1. The right to appropriate medical care and humane treatment.
2. The right to his religious belief.

3. The right to refuse treatment.

4. The right to Informed Consent.
5. The right to choose his physician.
6. The right to medical records.
7. The right to privacy and confidentiality.
8. The right to a second or third opinion.
9. The right to leave.
10. The right to information.
11. The right to self-determination.
12. The right to refuse participation in medical research
13. The right to express grievance
14. The right to be informed of his rights and obligations.

Obligations of the Patients to their Physicians ( Refer to Book )

SOCIATAL RIGHTS OF THE PATIENTSFROM THE GOVERNEMNT ( Refer toBook )

RIGHTS INHERENT IN THE PRACTICE OFMEDICINE:
1. The right to choose his patients
2. The right to limit the practice of his profession
3. The right to determine appropriate treatment procedures in the discretion and judgment of the
physician.
4. The right to avail of hospital privileges after being qualified.
5. The right to receive just and fair compensation from his patients.
Liabilities of a Physician Which May Arise from His Negligent or Wrongful Acts orOmissions:
1. Administrative Liability- A complaint under oath can be filed before the Professional Regulation
Commission Board of Medicine, for reprimand, of the license to practice medicine.
2. Criminal Liability- When an act or omission constitutes a crime, the physician can be imprisoned
or fined or both, as any other profession.
3. Civil Liability- The aggrieved party can be awarded monetary damages for any wrongful or
negligent act or omission, when the professional is found guilty. CASES ( Refer to Book )

Ex. Negligent or Wrongful Act Medical malpractice is a particular form of negligence which consists
in the failure of a physician or surgeon to apply to his practice of medicine that degree of care and
skill which is ordinarily employed by the profession generally, under similar conditions, and in like
surrounding circumstances
There are Four Elements involved in medical negligent cases:
1. Duty
2. Breach
3. Injury
4. Proximate Causation It has been recognized that expert testimony is usually necessary to
support the conclusion as to causation.

Ex. Whether A Hospital may be Held Liable for the Negligence of Physicians Consultants allowed
to Practice in its Premises.
CHAPTER 3 DEATH
Legal Presumption of Death:
-If absent without explanation from his or her usual or last place of residence for a long continuous
period.
-Circumstantial proof of death Ex. a passenger on an airplane that crashed is considered to have
died even if no remains can be recovered.

Rules of Evidence in Rule 131, section 5 paragraph X, paragraph JJ, and paragraph KK.

In common law the presumption of death does not arise until the expiration of seven years of
continuous absence.
DEATH IS THE COMPLETE CESSATION OF ALL THE VITAL FUNCTIONS OF THE BODY
WITHOUTPOSSIBILITY OF RESUSCITATION.
THE ASCERTAINMENT OF DEATH IS A MEDICAL AND NOT A LEGAL PROBLEM.
Death maybe
A. Brain Death occurs when there is a deeply irreversible coma, and absence of electrical brain
activity.
B. Cardio Respiratory Death occurs when there is continuous and persistent cessation of heart
action and respiration.
4 Kinds of Death:

1. Clinical or Somatic Death

2. Brain Death
3. Biological Death
4. Cellular Death Clinical or Somatic Death
This particular kind of death occurs when in the judgment of the physician with the use of his
clinical eye the bodys vital signs of life cease to exist continuously and permanently.
The clinical death is verifiable only by a physician after he observes that the patient no longer has
a heart beat no pulse rate, no spontaneous breathing and movement, with the pupils of the eye
widely dilated and not reactive to light and accommodation.-When a clinically dead person is
brought to the morgue the generalized contraction of the muscles or Rigor Mortis of the body
within 3 to 6 hours, may simulate are turn to life, because of the motion or movement of the body.
BRAIN DEATH
This kind of death follows clinical death almost immediately unless resuscitative procedures are
started promptly, because the human brain under normal conditions cannot survive loss of oxygen
for more than 6 to 10 minutes.
-Brain Death may occur in the
Stage 1 Cerebral Cortex- the highest center of the brain that is most sensitive to changes in the
supply of oxygen and blood to the brain. When the cerebral cortex dies, the patient is in cortical
death.
Stage 2 - Cerebellum It deals with the function of equilibrium. It follows the death of the cerebral
cortex.
Stage 3 Brainstem and Vital enters These centers controlling respiration, heart rate and blood
pressure, ultimately die. When it does, the patient is, Brain Stem Dead.
-If the brain stem is damaged, then the vital centers in the medulla maybe destroyed, causing the
respiratory center to fail.
-The occurrence of brain stem death is equivalent to Legal Death, so that Doctors can now issue a
Death Certificate, even though the heart is still beating, and make arrangements to harvest donor
organs and tissues at this stage.
-Further, in the presence of brainstem death, artificial respirators only achieve the maintenance of
an oxygenated circulation through a corpse or cadaver.
CRITERIA FOR DIAGNOSING BRAINSTEM DEATH. ( refer to textbook )Persistent Vegetative State
( PVS )

This condition exists, when irreversible destruction of the Cortex of the brain occurs without
damage to the vital centers, and there are permanent eyes
open state of unconsciousness, but cardiorespiratory functions continue, sometimes without
respiratory assistance, but most often with respiratory support.
-They do not however match the clinical criteria of Brain Death, in as much as they have elicitable
reflexes, spontaneous respirations and reactions to external stimuli.
HARVARD CRITERIA OF WHOLE BRAIN DEATH:
1. Unreceptivity and Unresponsitivity
2. No spontaneous movements or breathing
3. No reflexes
4. Flat EEG of Confirmatory value
WHOLE BRAIN DEAD
-When the brain ceased all functions, even though the heart continues to beat. As a rule doctors
can legally declare whole brain death twelve hours after they have corrected all treatable medical
problems, but the brain still doesnt respond even to induced pain , they eyes do not react to light
and the person doesnt breath without a respirator.
BIOLOGICAL DEATH
-All the components of the brain are dead
-There is also permanent extinction of bodily life.
-It is cardiorespiratory and brain death altogether with permanent cessation of all the anatomic
and physiological functions of the body organs.
CELLULAR DEATH:
-The death of the different parts of the body occurs at different times and stages.
-This is the reason why such organs as the corneas and the kidneys can be removed immediately
afterbiological death and transplanted successfully.
SIGNS OF DEATH:
1. Cessation of heart action andcirculation
2. Cessation of respiration
3. Cooling of the body ( Algor Mortis )
- The temperature of 15 20degrees Fahrenheit is considered as acertain sign of death.
4. Loss of motor power

5. Loss of sensory power

6. Changes in the skin
7. Changes in and about the eye
- There is loss of corneal reflex
CHANGES IN THE BODY FOLLOWINGDEATH
1. Changes in the Muscle
a. Stage of primary flaccidity
b. Cadaveric rigidity or rigor mortis
- muscular contraction which develops 3 6hours after death and may last for 24 36hours.
- may also be utilized to approximate the length of time the body has been dead from 3 to
36hoursc. Stage of secondary flaccidity or commencement of putrefaction Cadaveric Spasm
- is the immediate or instantaneous spasm or rigidity of the skeletal muscles occurring at the
moment of death due to exhaustion, etc. Medico legal Importance of Cadaveric Spasm( Refer to
Book )
2. Changes in the Blood
a. Coagulation of the blood
b. Post-mortem lividity or Livor Mortis
3. Autolytic or Auto Digestive Changes After Death
4. Putrefaction of the Body
PUTREFACTIVE CHANGES OCCURING AFTERDEATH ( Refer to Book )Kinds of Putrefaction:
1. Mummification
2. Saponification This is also called Adipocere Formation.
3. Maceration
Factors to Consider in Approximating the Duration of Death in a Cadaver
1. Entomology The presence of maggots in the cadaver indicates duration of death for more than 24
hours
2. Presence of live Fleas in clothing in death by drowning, a flea can survive for about 24hours
submerged in water. After 24 hours submersion in water the fleas die.
3. Blood vessel clots blood clotting occurs in6 -8 hours after death.
4. Post Mortem lividity develops in 3 to 6hours after death.

5. Rigor Mortis- begins to develop in 3 to 6hours after death and may last for 24 to 36hours after
death.
6. Onset of decomposition Decomposition takes place within 24 48 hours after death.
7. Food in the stomach
8. Skeletal soft tissues soft tissues may disappear from 1.5 years to 2 years after burial.
Position of the Body at the time of Death
1. Post Mortem lividity
2. Cadaveric spasm Death due to violence or inflicted physical injuries, usually manifest the position
of the body at the time of death.
Ex. In suicide by gunshot wound, the gun maybe tightly grasped in the hand of the deceased. In
drowning, the victim maybe holding objects that come in contact with his hands to cling to life.
MEDICOLEGAL IMPORTANCE OF RIGOR MORTIS AND CADAVERIC SPASM:
Rigor mortis is utilized to approximate the time of death. Generalized muscular contractions occur
from 3 to 6 hours until 36 hours.
Cadaveric spasm occurs immediately after death and is useful to ascertain the circumstances of
death.
Medico Legal Investigation of Death
Deaths which are not obviously due to natural causes, but are criminal, suspicious, accidental,
suicidal, murderous, homicidal, sudden or unexpected, or unexplained, need medico legal
investigation.
The Death Certificate
-The death certificate is a legal document necessary for burial of the dead, as it certifies the
occurrence of death. It is a document from the Office of the Civil Registrar General, listing the
particulars of an individuals death.
-It contains the Immediate Cause or Primary cause of death, the antecedent causes and underlying
cause of death
Immediate Cause or Primary Cause of Death
Ex. Suffocation due to drowning Asphyxia Cardio Respiratory Arrest
Antecedent Cause of Death are events or conditions that substantially contribute to the immediate
cause of death Ex. Acute peritonitis, Acute Hypovolemic shock, Acute Septic Shock,
Underlying Cause of Death is the basic cause or bottom line cause of death. It is the diagnosis of the
patients or victims illness or sickness that resulted to his death Ex. Acute Appendicitis,
Hepatocarcinoma, Pelvic Fracture, Stab or Gunshot Wound to the chest.

Non Natural Causes of Death Ex. Murder, Homicide, Suicide, Accident

Death Warrant is a warrant from the proper executive authority appointing the time and place for the
execution of the sentence of death upon a convict judicially condemned to suffer death.
Manner of Death
-Is the explanation as to how the cause of death arose, and maybe either Natural Death or Violent
Death
Lazarus Syndrome
-Is also called Lazarus Phenomenon is the spontaneous return of circulation after failed attempts at
resuscitation.
Implications of Lazarus Syndrome
-raise ethical and legal issues for doctors, who must determine when medical death has occurred,
when resuscitation efforts should end, and post mortem procedures such as autopsies and organ
harvesting may take place.
Lazarus Sign-Lazarus sign or Lazarus reflex is a reflex movement in brain dead patients, which causes
them to briefly raise their arms and drop them crossed on their chests.
-The phenomenon has been observed to occur several minutes after the removal of medical
ventilators used to pump air in and out of brain dead patients to keep their bodies alive.
NEAR DEATH EXPERIENCE
-Refers to a broad range of personal experiences associated with impending death, encompassing
multiple possible sensations including detachment from the body; feelings of levitation etc.
EUTHANASIA-Meaning good death ( well or good )-Refers to the practice of ending life in a painless
manner.
-Deliberate intervention undertaken with the express intention of ending life, to relieve intractable
suffering
Classification of Euthanasia:
1. Voluntary euthanasia is euthanasia conducted with consent
2. Involuntary euthanasia is euthanasia conducted without consent.
-is conducted where an individual makes a decision for another person incapable of doing so.
- also known as physician assisted death, physician assisted suicide or mercy killing.
3. Passive euthanasia entails withholding of common treatments
4. Active euthanasia entails the use of lethal substances or forces to end life and is the most
controversial means.
CHAPTER 4 REGIONAL TRAUMA

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Trauma is the leading cause of death in the first four decades of life and the 3 rd leading cause of
death in all age groups today.-Penetrating trauma particularly handguns isbecoming common in nearly
all areas of thecountry. Trimodal Distribution of Death from Trauma:1. Seconds to minutes of injury
due to theinjury to the brain, high spinal cord, heart,aorta and other large vessels. These patientscan
rarely be salvaged.2. Minutes to Few hours from injury ( TheGolden Hour )- It is in this period that
Advanced Trauma LifeSupport9 ( ATLS ) techniques are important.3. Several days to weeks of Injury
these aredue to sepsis or organ failure.SPECIFIC INJURIES1. Heada. Types of Head Injuries:a.1
Hematomaa.2 Contusionsa.3 Skull fracturesa.4 Hemorrhage2. Spine and Spinal Cord Injuries The most
common causes of severespinal trauma are motor vehicular accidents,falls, diving accidents, and
gunshot wounds.3. Chesta. Life Threatening InjuriesPnumothoraxHemothoraxFlail chest as in multiple
ribfractures Cardiac tamponadedue to penetrating injuriesb. Potentially Lethal Injuriesb.1. Pulmonary
Contussion withor without flail chestb.2. Thoracic Aortic Tear orRupture the most commoncause of
sudden death after avehicular accident or fall ( majordecelaration injury )c. Serious Chest Injuries4.
Abdomen Types of Injuries:a. Penetrating- Gunshot wounds of theabdomen carry 95% probabilityof
significant visceral injury- A bullet when it hits theabdomen will penetrate theabdominal wall, enter
theabdominal cavity and mostlikely injure more than oneorgan.- The incidence of abdominalinjury is
strikingly higher ingunshot wounds than in stabwounds.- The major cause of death ishemorrhage and
this occurswithin the first 24 hours- In stab wounds of theabdomen , only 2/3 penetratethe peritoneal
cavity; of theseonly cause significant visceralinjury that requires surgicalrepair.b. Blunt- The spleen
and liver are themost commonly injured organsdue to blunt trauma.- Their frequent incidence
alsoexplains why the mortality ratefollowing blunt trauma is higherthan that of penetrating injury.5.
Fractures and Dislocations The word fracture comes from the Latinword fractura which means a
break in thecontinuity of the bone. It is also a combinationof a break in the bone and soft tissue
injuryA. Open Fractures - 90% of openfractures are caused by vehicular accident.B. Hip fractures are
very common inelderly people and are usually caused by minorfalls. It is the most common cause of
traumaticdeath after the age of 75.6. Urologic- Hematuria following trauma- Blunt kidney injury is
usuallydue to motor vehicularaccidents which account for 70 90 % of kidney trauma.- Penile injury:
The erect penis is usually 6 8inches long and 1 -2 inches indiameter.

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