FORENSIC MEDICINE AND DEONTOLOGY

BY ALI RAZA HASHMI

1. Subject, objectives and content of forensic medicine. Main problems of the forensic medical dentistry.

SUBJECT, OBJECTIVES AND CONTENT OF FORENSIC MEDICINE

❖ Subject: -
➢ Forensic medicine is a branch of medicine that focuses on determining the cause of death by examining a corpse;
➢ A post mortem is performed by a medical examiner, usually for the purposes of the law (civil and criminal investigations);
➢ Coroners and medical examiners are also frequently asked to confirm the identity of a corpse.
❖ Objectives: -
➢ The medical examiner performs autopsies/postmortem examinations to determine the cause of death;
➢ The autopsy report contains an opinion about the following:
 The pathological process/injury/disease that leads to a person's death (the mechanism of death);
 The manner of death/the circumstances surrounding the cause of death, which include the following: -
• Homicide • Natural • Undetermined
• Accidental • Suicide
➢ Forensic pathologists collect and examine tissue specimens under the microscope (histology) to identify the presence or absence of natural
disease and other microscopic findings such as asbestos bodies in the lungs or gunpowder particles around a gunshot wound;
➢ They carry out toxicological analyses on body tissues and fluids to determine the chemical cause of accidental overdoses or deliberate poisonings;
➢ The medical examiners can also serve as expert witnesses in courts of law testifying in civil or criminal law cases.
❖ Content of forensic medicine: -
➢ Forensic medicine has several branches: -
(A) Forensic pathology: -
 Medical knowledge is used to determine the cause of death by performing autopsies/post-mortem examinations;
 Involves interpreting the mechanism of injuries & giving medicolegal opinions (e.g. the amount of force, position of the victim and
assailant);
(B) Clinical Forensic Medicine: -
 Medicolegal examination of sexual offences (e.g. rape cases) or injuries in physical assaults/battered babies;
 Assessment of degree of permanent disabilities following an accident (for compensation);
(C) Forensic Toxicology: -
 Deals with the sources, characters, properties of poisons, the symptoms they produce, their fatal effects & fatal doses.
(D) Medical Ethics: -
 Deals with the moral principles medical professionals should follow in relation with each other, their patients, and the State.
(E) Medical jurisprudence: -
 Deals with the legal responsibilities of the medical examiner (particularly in the relationship with the patient), such as: -
• Medical negligence; • Misconduct.
• Consent;
MAIN PROBLEMS OF THE FORENSIC MEDICAL DENTISTRY

❖ Forensic odontology (forensic dentistry) is a forensic specialty in which medico-legal problems involving teeth or bite marks are passed to a dentist who
has been trained and is qualified in forensic work;
❖ The forensic odontologist has two main areas of expertise: -
➢ Assisting in identification, usually of the dead: -
 The forensic odontologist is commonly requested to confirm the identity of a body by comparing antemortem dental chartings with the
information gained from a direct examination of the teeth;
 The odontologist may also be asked to make dental chartings of bodies whose identity remains unknown or unconfirmed, so that, should
dental information become available at a later date, the two sets of records may be then be compared;
 It is important to remember that neither a living individual person nor a body can be identified simply by taking a dental chart – that chart
has to be compared with, and found to match, a chart whose origins are known;
 The forensic odontologist is also of prime importance in mass disasters where trauma is likely to make visual identification impossible;
 The advantage of dental identification is that the teeth are the most resistant tissues in the body and can survive total decomposition;
 Where no previous records are available, examination of the mouth and the teeth can still give some general information on age, sex and
ethnic origin.
➢ The examination and comparison of bite marks: -
 Bites can occur on both the victim and the suspect since teeth can be used as a weapon by the aggressor and in self-defence by the victim;
 Bite marks can be altered through stretching, movement, or change in environment after the bite.
 Factors that may affect the accuracy of bite mark identification include: -
• Time-dependent changes of the bite mark on living • Poor photography;
bodies; • Poor impressions;
• Similarities in dentition among individuals; • Poor measurement of dentition characteristics.
 Most bite mark analysis studies use porcine skin (pigskin), because it is comparable to the skin of a human (and it is considered unethical to
bite a human for study);
 Limitations to the bite mark studies include differences in properties of pigskin compared to human skin (although similar histologically, pigskin
and human skin behave in dynamically different ways due to differences in elasticity);
 Bite mark analysis is also controversial because dental profiles are subject to change: -
• The loss of teeth or the alteration of arch configuration through a variety of procedures is common in human populations;
• The onset of oral diseases such as dental caries has been shown to alter the arch and tooth configuration and must be taken into account
when comparing a dental profile to the bite mark after a significant amount of time has passed since the mark was made.
2. General theory of mechanical injuries in maxillofacial area and their features. Methods of examination and objectives of expertise.

General theory of mechanical injuries in maxillofacial area and their features.

❖ Facial trauma, also called maxillofacial trauma, is any physical trauma to the face;
❖ Facial trauma can involve soft tissue injuries such as burns, lacerations and bruises, or fractures of the facial bones such as nasal fractures and
fractures of the jaw, as well as trauma such as eye injuries;
❖ Symptoms are specific to the type of injury; for example, fractures may involve pain, swelling, loss of function, or changes in the shape of facial
structures;
❖ Facial injuries have the potential to cause disfigurement and loss of function (e.g. blindness or difficulty moving the jaw);
❖ Although it is seldom life-threatening, facial trauma can also be deadly, because it can cause severe bleeding or interference with the airway; thus a
primary concern in treatment is ensuring that the airway is open and not threatened so that the patient can breathe;
❖ Depending on the type of facial injury, treatment may include bandaging and suturing of open wounds, administration of ice, antibiotics and pain killers,
moving bones back into place, and surgery;
❖ When fractures are suspected, radiography is used for diagnosis;
❖ Treatment may also be necessary for other injuries such as traumatic brain injury, which commonly accompany severe facial trauma.

Methods of examination and objectives of expertise.

❖ Signs & symptoms: -
➢ Fractures of facial bones, like other fractures, may be associated with pain, bruising, and swelling of the surrounding tissues (such symptoms can
occur in the absence of fractures as well);
➢ Fractures of the nose, base of the skull, or maxilla may be associated with profuse nosebleeds;
➢ Nasal fractures may be associated with deformity of the nose, as well as swelling and bruising;
➢ Deformity in the face, for example a sunken cheekbone or teeth which do not align properly, suggests the presence of fractures;
➢ Asymmetry can suggest facial fractures or damage to nerves;
➢ People with mandibular fractures often have pain and difficulty opening their mouths and may have numbness in the lip and chin;
➢ With Le Fort fractures, the midface may move relative to the rest of the face or skull.
❖ Diagnosis: -
➢ Radiography, imaging of tissues using X-rays, is used to rule out facial fractures;
➢ Angiography (X-rays taken of the inside of blood vessels) can be used to locate the source of bleeding;
➢ However, the complex bones and tissues of the face can make it difficult to interpret plain radiographs;
➢ CT scanning is better for detecting fractures and examining soft tissues, and is often needed to determine whether surgery is necessary, but it is
more expensive and difficult to obtain;
➢ CT scanning is usually considered to be more definitive and better at detecting facial injuries than X-ray;
➢ CT scanning is especially likely to be used in people with multiple injuries who need CT scans to assess for other injuries anyway.
❖ Classification: -
➢ Soft tissue injuries include abrasions, lacerations, avulsions, bruises, burns and cold injuries;
➢ Commonly injured facial bones include the nasal bone (the nose), the maxilla (the bone that forms the upper jaw), and the mandible (the lower jaw);
➢ The mandible may be fractured at its symphysis, body, angle, ramus, and condoyle;
➢ The zygoma (cheekbone) and the frontal bone (forehead) are other sites for fractures;
➢ Fractures may also occur in the bones of the palate and those that come together to form the orbit of the eye;
➢ There are 3 typical locations for facial fractures, known as Le Fort I, II, and III fractures: -
1. Le Fort I fracture (also called horizontal maxillary fractures): -
 Involves the maxilla, separating it from the palate;
2. Le Fort II fractures (also called pyramidal fractures of the maxilla): -
 Cross the nasal bones and the orbital rim;
3. Le Fort III fractures (also called craniofacial disjunction and transverse facial fractures): -
 Cross the front of the maxilla and involve the lacrimal bone, the lamina papyracea, and the orbital
floor, and often involve the ethmoid bone;
 The most serious Le Fort fractures, which account for 10–20% of facial fractures, are often associated
with other serious injuries;
❖ Prognosis & complications: -
➢ By itself, facial trauma rarely presents a threat to life, however it is often associated with dangerous
injuries, and life-threatening complications such as blockage of the airways: -
 The airway can be blocked due to bleeding, swelling of surrounding tissues, or damage to structures;
 Burns to the face can cause swelling of tissues and thereby lead to airway blockage;
 Broken bones such as combinations of nasal, maxillary, and mandibular fractures can interfere with the
airway;
 Blood from the face or mouth, if swallowed, can cause vomiting, which can itself present a threat to the
airway because it has the potential to be aspirated;
➢ Even when facial injuries are not life-threatening, they have the potential to cause disfigurement and
disability, with long-term physical results: -
 Facial injuries can cause problems with eye, nose, or jaw function and can threaten eyesight;
 Injuries involving the eye or eyelid, such as retrobulbar haemorrhage, can threaten eyesight too;
➢ Incising wounds of the face may involve the parotid duct;
➢ This is more likely if the wound crosses a line drawn between the tragus of the ear to the upper lip (the approximate location of the course of the
duct is the middle third of this line);
➢ Nerves and muscles may be trapped by broken bones: -
 In these cases, the bones need to be put back into their proper places quickly;
 For example, fractures of the orbital floor or medial orbital wall of the eye can entrap the medial rectus or inferior rectus muscles;
 In facial wounds, tear ducts and nerves of the face may be damaged;
➢ Fractures of the frontal bone can interfere with the drainage of the frontal sinus and can cause sinusitis;
3. Forensic medical expertise in cases of blunt force trauma – abrasions, contusions, and lacerations.
❖ Blunt force trauma is caused when an object, usually without a sharp or cutting edge, impacts the body or the body impacts the object;
❖ Three types of injury may result from such an impact: -
1. Abrasions; 2. Contusions; 3. Lacerations.
❖ The severity, extent, and appearance of blunt trauma injuries depend on: -
➢ The amount of force delivered to the body: -
 If a weapon deforms or breaks on impact, less energy is delivered to the body to produce injury, because some of the energy is used to
deform or break it;
 Thus, the resultant injury is less severe than one would have if the weapon did not deform or break.
➢ The time over which the force is delivered: -
 Similarly, if the body moves with the blow, this increases the period of time over which the energy is delivered and decreases the severity of
the injury.
➢ The region struck/extent of body surface over which the force is delivered: -
 For any given amount of force, the greater the area over which it is delivered, the less severe the wound;
 The size of the area affected by a blow depends on the nature of the weapon and the region of the body;
 If a blow is delivered to a rounded portion of the body, such as the top of the head, the wound will be much more severe than if the same force
is delivered to a flat portion of the body, such as the back, where there will be a greater area of contact and more dispersion of force.
➢ The nature of the weapon: -
 For a weapon with a flat surface, such as a board, there is diffusion of the energy and a less severe injury than that caused by a narrow object,
for example, a steel rod delivered with the same amount of energy;
 If an object projects from the surface of the weapon, then all of the force will be delivered to the end of the projection
and a much more severe wound will be produced.
Abrasions
❖ An abrasion is an injury to the skin in which there is removal of the superficial epithelial layer of the skin (the epidermis) by
friction against a rough surface, or destruction of the superficial layers by compression;
❖ Antemortem abrasions have a reddish-brown appearance and heal without scarring;
❖ Abrasions produced after death are yellow and translucent with a parchment-like appearance;
❖ They are important to the forensic pathologist in that they indicate where a blunt instrument or a blunt force has interacted with
the body;
❖ They may be the only external evidence of trauma to the body;
❖ There are three types of abrasions: -
1. Scrape or brush abrasions: -
➢ In scrape (brush) abrasions, the blunt object scrapes off the superficial layers of the skin, leaving a
denuded surface;
➢ At times, these abrasions may be fairly deep, extending down to the dermis;
➢ In such instances, there may be leakage of fluids from vessels with deposit of a serosanguineous fluid on
the surface of the abrasion which dry, forming the familiar reddish-brown scab;
➢ One of the most common types of scrape abrasions is the linear abrasion known as the scratch;
➢ Extensive scrape-like abrasions (graze or sliding abrasions) are seen in pedestrians who slide across the
➢ pavement after being hit by a motor vehicle;
➢ Particles of gravel, dirt, or glass may be embedded in such wounds;
➢ Similar scrape abrasions may be produced when a victim’s body is dragged over a rough surface;
2. Impact abrasions: -
➢ In impact abrasions, the blunt force is directed perpendicular to the skin, crushing it;
➢ Such abrasions tend to be focal and are commonly seen overlying bony prominences where a thin layer of
skin covers bone;
➢ Impact abrasions over the supraorbital ridge (eyebrow), zygomatic arch (cheekbone), and the side of the
nose are commonly seen in individuals who are unconscious when they collapse, and strike their heads
on the ground.
3. Patterned abrasions: -
➢ A patterned abrasion is a variation of an impact abrasion;
➢ Here, the imprint of either the offending object, such as a pipe, or intermediary material, such
as clothing, is imprinted or stamped on the skin by the crushing effect of the blunt object;
Contusions
➢ A contusion or bruise is an area of haemorrhage into soft tissue due to rupture of blood vessels
caused by blunt trauma;
➢ Contusions may be present not only in skin, but also in internal organs, such as the lung, heart,
brain, and muscle;
➢ A large focal collection of blood in an area of contusion is referred to as a hematoma;
➢ A contusion can be differentiated from an area of livor mortis in that, in a contusion, blood has escaped into soft tissue and cannot be wiped or
squeezed out, as in an area of livor mortis;
➢ The extent and severity of a contusion depends not only upon the amount of force applied, but also on the structure and vascularity of the tissue
that is contused;
 ➢ Thus, contusions are more readily incurred in areas with thin, lax skin and in fatty areas;
➢ Contusions might reflect the configuration of the object used to produce the contusion; that is, they
might be patterned;
➢ When an individual is struck with a flat object, such as a board, it is quite common to find parallel linear
contusions corresponding to the edges of the board, with normal-appearing tissue in between;
➢ A contusion at a site does not necessarily indicate the point of trauma, since soft tissue bleeding will
follow the path of least resistance;
➢ Bruises can also be difficult to detect in dark-skinned individuals;
➢ Contusions, like abrasions, indicate that blunt force has been applied to a particular area;
➢ Absence of a bruise, just as absence of an abrasion, does not indicate that there was no blunt force to that area;
➢ This is especially true of the anterior abdominal wall, where there may be massive internal injury in the absence of external evidence of trauma.
Another point to remember is that a contusion might be much larger than the object that produced it;
➢ As a rule, bruises are not fatal, however, multiple contusions with extensive soft tissue hemorrhage may produce shock and death from massive
blood loss (this is seen occasionally in battered children);
➢ The size and severity of a contusion is not always indicative of the amount of force applied, though, obviously, the greater the force, the greater the
contusion;
➢ Certain factors influence the size of a contusion: age, sex, the condition and health of the victim, and the site and type of tissues struck;
➢ Children and the elderly bruise more easily because of loose delicate skin in the former and loss of subcutaneous supportive tissue in the latter;
➢ Well-conditioned, muscular individuals are more resistant to bruising;
➢ Alcoholics with cirrhosis, individuals with bleeding diatheses, and individuals taking aspirin bleed more easily (a single therapeutic dose of aspirin
irreversibly inhibits platelet function for the 7-d life of the platelets with resultant inhibition of haemostasis and a prolonged bleeding time);
Lacerations
❖ A laceration is a tear in tissue caused by either a shearing or a crushing force;
❖ Just as with contusions, one can have lacerations of internal organs as well as the skin;
❖ Lacerations of the skin tend to be irregular with abraded contused margins;
❖ They are caused by blows from blunt objects, falls, or impact from vehicles;
❖ The appearance of the laceration may not accurately reflect the instrument that produced it;
❖ Thus, a steel rod might produce not only a linear laceration of the scalp, but also a Y-shaped one;
❖ As a general rule, however, long, thin objects, such as pipes and pool cues, tend to produce linear lacerations,
while objects with flat surfaces tend to produce irregular, ragged, or Y-shaped lacerations;
❖ Lacerations occur most commonly over bony prominences, such as in the head, where the skin is fixed and can
more easily be stretched and torn;
❖ Since different components of soft tissue have different strengths, there is usually incomplete separation of the stronger elements, such as blood
vessels and nerves, so that when one looks into the depth of the laceration, one sees “bridges” of tissue running from side to side;
❖ The presence of bridging proves decisively that one is not dealing with an incised wound;
❖ The depths of the laceration should be explored for the presence of foreign material that could have been deposited there by the weapon or surface that
caused the laceration;

4. Traumatic injuries of the bones on the maxillofacial area due to blunt objects; mechanism of occurrence of injuries.
❖ Fractures of the mandible, maxilla, zygoma and zygomatic arch are produced predominantly by assaults and motor vehicle accidents;
❖ All can be fractured by a single blow;
❖ Maxillary fractures can be placed in five categories: -
1. Dentoalveolar: -
➢ In dentoalveolar fractures, direct force applied anteriorly or laterally causes separation of a fragment of
the mandible;
➢ This fragment generally contains a number of teeth.
2. LeFort I: -
➢ The LeFort I fracture is a transverse fracture of the maxilla, above the apices of the teeth, through the
nasal septum and maxillary sinuses, the palatine bone and the sphenoid bone.
3. LeFort II: -
➢ The LeFort II (the “pyramidal”) fracture has the same path posteriorly;
➢ As it proceeds anteriorly, however, it curves upward near the zygomatic-maxillary suture, through the
inferior orbit rim onto the orbital floor, through the medial orbital wall and across the nasal bones and
septum.
4. LeFort III: -
➢ The LeFort III is a high transverse fracture of the maxilla that goes through the nasofrontal suture, through the medial orbital wall and fronto-
zygomatic suture, across the arch and through the sphenoid.
5. Sagittal: -
➢ Sagittal fractures run in a sagittal plane through maxilla
5. Traumatic injuries of the teeth.
❖ Dental trauma refers to trauma (injury) to the teeth and/or periodontium (gums, periodontal ligament, alveolar bone), and nearby soft tissues such as the
lips, tongue, etc;
❖ Types: -
1. Dental injuries: -
➢ Enamel infraction ➢ Enamel-dentine fracture involving pulp exposure
➢ Enamel fracture ➢ Root fracture of tooth
➢ Enamel-dentine fracture
2. Periodontal injuries: -
➢ Concussion (bruising)
➢ Subluxation of the tooth (tooth knocked loose)
➢ Luxation of the tooth (displaced): -
 Extrusive  Intrusive  Lateral
➢ Avulsion of the tooth (tooth knocked out)
3. Injuries to supporting bone: -
➢ This injury involves the alveolar bone and may extend beyond the alveolus;
➢ There are 5 different types of alveolar fractures: -
 Communicated fracture of the socket wall;
 Fracture of the socket wall;
 Dentoalveolar fracture (segmental): -
• Changes to occlusion;
• Multiple teeth moving together as a segment and are normally displaced;
• Bruising of attached gingivae;
• Gingivae across the fracture line often lacerated;
 Fracture of the maxilla (Le Fort fracture, zygomatic fracture, orbital blowout);
 Fracture of the mandible.

6. Traumatic injuries caused by teeth.

 7. Motor vehicle accidents.
❖ In motor vehicle deaths, autopsies are performed to: -
➢ Determine the cause of death;
➢ Confirm that death was caused by injuries suffered in the accident;
➢ Determine the extent of these injuries;
➢ Detect any disease or factor, e.g., drugs, that could have contributed to the accident or death;
➢ Detect any criminal activity associated with the death;
➢ Document all findings for subsequent use in either criminal or civil actions;
➢ Establish positive identification of the body, especially if it is burnt or severely mutilated.
❖ The injuries in motor vehicle crashes are the result of: -
➢ Impaction of the individual on some portion of the interior of the car;
➢ Violation of the integrity of the passenger compartment by intrusion of part of the car or of another object, e.g., another vehicle or a lamppost, into
the passenger compartment;
➢ Ejection from the motor vehicle;
➢ Fire.
❖ Causes of motor vehicle accidents: -
1. Impairment of the driver by alcohol, drugs, or a combination of both (most common);
2. Human error — speed, reckless driving, and falling asleep at the wheel.
3. Environmental hazards, such as bad weather, slick or icy roads, poorly marked roads, and poorly constructed roads (least common)
❖ The probability of a fatality depends to a degree on the size and type of vehicle involved in a crash;
❖ Small vehicles, by virtue of their size, are less able to absorb crash energy, thus, severe injury and fatalities are more common with such vehicles;
❖ Motor vehicle accidents can be divided into four categories, depending on how the accident occurred: -
1. Front impact crashes: -
➢ When two vehicles crash head-on, or a vehicle crashes into a fixed object, unless the driver and passengers are
restrained, they will continue their forward movement, even though the car has stopped;
➢ If unrestrained, the driver’s knees will impact the instrument panel; the chest the steering wheel; and the head the
windshield, sun visor region above the windshield, or the frame (generally in this order);
➢ The same pattern of injuries would be true for unrestrained passengers, except they would impact the dashboard
rather than the steering wheel;
➢ In unrestrained individuals, the usual sequence and pattern of injuries is knee–femur–hip–chest–head;
➢ If the driver is restrained by belts, but without an airbag, the knees still impact the instrument panel but the head flexes
forward, with the chin impacting either the sternum or, in severe collisions, the steering wheel;
➢ Unrestrained individuals in the back seat will hit the bac k of the front seat, the passengers in the front seat come up
against the windshield or the sun visor area;
➢ Objects protruding from the instrument panel, such as levers or knobs, can produce patterned abrasions on the victims;
➢ If the head of the driver or front seat passenger impacts the windshield, there will be abrasions and superficial cuts of
the forehead, nose, and face, with the injuries having a vertical orientation;
➢ Thin slivers of windshield glass might be embedded in the wounds or be found loose on the clothing;
➢ Windshields are designed to prevent serious cuts and people going through them (the latter, however, can still occur if
the windshield pops out of the frame;
➢ Blunt force impact on the windshield, while not causing serious incised wounds, can, with enough force, produce fairly
severe soft tissue injuries;
➢ These wounds, because of their location, often bleed very heavily, appearing very dramatic and life threatening;
➢ In addition to the external injuries, impaction of the head with the frame of the car above the windshield can cause
basilar skull fractures, closed head injury, and fractures of the neck;
➢ In neck injuries, the most common fatal injuries are upper cervical fractures or dislocation at the atlanto-occipital
junction;
➢ The chest of the driver can impact the steering wheel; the chest of the passenger, the dashboard;
➢ Evidence of injury from such an impact varies from imprinted abrasions/contusions of the wheel or instrument panel
to complete absence of any evidence of external injuries;
➢ The following internal injuries are fairly typical, depending on the amount of force and the age of the victim: -
 Transverse fracture of the sternum (usually at the third intercostal space);
 Bilateral rib fractures;
 Impaling injuries of the lung caused by fractured ribs;
 Contusions, internal lacerations, and rupture of the pulmonary parenchyma;
 Rupture of the heart;
 Transection of the aorta;
 Lacerations of the liver and spleen;
➢ Because of the elastic nature of the sternum or ribs in young individuals, there can be extensive thoracic injuries without fracture;
➢ In elderly individuals, death can occur with injuries that a younger person might survive;
➢ Thus, rib fractures, minor cardiac contusions, pulmonary contusions, and some minor intrathoracic or intraabdominal injury that younger
people will survive might cause death in an elderly individual with an unstable cardiac status;
➢ Occasionally, there will be a motor vehicle accident in which the driver impacts the steering wheel and in which no anatomical cause of death
presents after a complete autopsy and toxicological screen;
➢ There may be soft tissue trauma to the chest and a fractured sternum or ribs, but insufficient injuries to explain death;
➢ Such deaths are caused by fatal cardiac arrhythmia secondary to a cardiac contusion;
➢ Examination of the heart might fail to reveal any evidence of impact because of the suddenness of the death.
➢ If the knees impact the dashboard, there may be fractures of the patella or the distal femur;
➢ There also can be dislocation at the hip joint or a fracture of the femur at its neck: -
 In one, a woman in her early fifties was a passenger in the front seat of a car;
 She impacted her knees against the dashboard in a minor crash;
  She was seen in the emergency room of a trauma center where she complained of leg pains and had obvious bruising of the knees;
 The knees were X-rayed, but no fractures were seen;
 The woman said that she could not walk, so she was given crutches and sent home;
 A day and a half later, she was found dead in bed;
 At autopsy, a fracture of the neck of the right femur was found, with massive bleeding into the musculature and soft tissue of the thigh;
 Death was caused by exsanguination;
 The doctors in the emergency room, while dutifully X-raying the knees, had not examined the rest of the femur and had completely
missed the fracture that produced death.
➢ Seat belts: -
 Seat belts, while effective in decreasing the incidence of death and injury, can, themselves, produce
injuries, even death;
 Lap belts can produce tears of the mesentery and omentum and occasionally laceration of the bowel;
 Shoulder belt use may be reflected by a linear abrasion running downward and medially on the left side of
the neck of the driver or the right side of the neck of the front passenger;
➢ In addition to the aforementioned injuries, one also sees dicing injuries, which are superficial cuts of the skin
caused by the fragments of glass produced when the side and back windows of a car shatter;
➢ Glass used in these windows is tempered glass, which is designed to shatter into little glass cubes on violent impact;
➢ This is to prevent the individuals in the car from incurring serious cuts from slivers of glass;
➢ The marks produced by these little cubes of glass tend to be linear, right angled, and very superficial (they are not life threatening);
➢ In head-on crashes, the floorboards can be driven upward and inward, twisting the foot on the ankle and causing a fracture;
2. Side impact crashes: -
➢ These crashes usually occur at intersections when a car is struck broadside by another vehicle going through the intersection at right angles to
the first;
➢ In such cases, dicing injuries can be found on either one or both sides of a driver, depending on whether the side glass is propelled into the
driver; the driver into the glass, or both;
➢ Side impact crashes can also occur when a car skids sideways, striking a fixed object such as a tree or pole with its side;
➢ In car-to-car collisions, where the impact is to the driver’s side, force is applied from the shoulder level downward;
➢ The head can flex laterally through the side window, striking the impacting vehicle;
➢ If the impacting vehicle is a truck, the force is delivered from roof to floor level, and the intruding vehicle can make direct contact with the head;
➢ When a side impact occurs, fatalities usually occur in the car impacted rather than the car impacting, because the engine protects the
impacting driver and passengers;
➢ In side impact collisions with fixed objects, that is, when a car slides sideways into a fixed object, the driver or a passenger if not restrained
may partially pop out the window, impact the fixed object, and then pop back into the vehicle;
➢ If the impact is from the right (i.e., the passenger’s) side, the injuries will tend to be more severe on the right side of the body (and vice versa);
➢ Transection of the aorta may occur’
➢ Lacerations of the heart, liver, and spleen; fractures of the neck; and basal fractures can also occur.
3. Rollovers: -
➢ Rollover crashes are generally less lethal than head-on and side impact collisions, provided the individual is not ejected or the vehicle rolls into
an unyielding object such as a tree;
➢ Anything that prevents ejection of an occupant increases the probability of survival;
➢ Because of better design, present day car doors usually do not open in rollovers, instead, the unrestrained individual is ejected out the
window;
➢ If one is not wearing a seat belt, one may be thrown about the passenger compartment like a rag doll;
➢ The injury patterns in rollover accidents in which an individual is not restrained are much more variable because the individual is thrownabout,
impacting surfaces willy-nilly (there is no specific injury pattern);
➢ If the individual is ejected and the car rolls over his trunk but not his head, there may be no external evidence of trauma;
➢ Subsequent autopsy, however, can reveal massive ruptures of the lungs, heart, liver, spleen, and mesentery.
4. Rear impact crashes: -
➢ Rear impact crashes are the least common form of fatal accident;
➢ This is because the occupants of the front seat of the impacted car are protected by the trunk and rear passenger portion of the vehicle;
➢ These usually decelerate the impacting vehicle sufficiently to protect individuals in the front seat;
➢ People in the impacting automobile are protected by their car’s engine;
➢ Rear impact crashes account for many civil suits involving whiplash syndrome;
➢ Although relatively uncommon, one of the potential dangers with the rear impact crash is rupture of the gas tank, with ignition of the fuel;
➢ Rupture of the tank is, of course, proportional to the speed of impact;
➢ In rear impact collisions, there may be seatback failure such that the back of the front seat goes horizontal;
➢ At the same time, the occupant of the seat can go backward, impacting the rear seat or the roof, or even be ejected out the rear window;
➢ This can result in serious, if not fatal, head and/or neck injuries, and can occur even if the individual is wearing a seatbelt.
❖ Pedestrian death: -
➢ When a pedestrian is struck by a motor vehicle, the pattern and severity of the injuries, depend on four factors: -
1. The speed of the vehicle;
2. Its physical characteristics;
3. Whether it was braking;
4. Whether the victim was a child or an adult;
➢ Relationship between speed at impact and injuries: -
 The speed of the vehicle is probably the most important factor in the causation of severe injuries;
 Between 20 and 40 km/h, the nature of the injuries produced changes, becoming severe;
 This is not to say, however, that severe, even fatal, injuries cannot occur at lower speeds;
 4 types of injury correlate with impact velocity: -
1. Fracture of the spine; 3. Inguinal skin rupture;
2. Rupture of the thoracic aorta; 4. Dismemberment
8. Wounds caused by sharp objects – stab and incised-stab wounds.
❖ Stab wounds: -
➢ A stab wound is deeper than it is long and it is the depth of the injury that makes it so often fatal and hence of such forensic interest;
➢ Any weapon with a point or tip can cause a stab wound; the edge of the blade does not need to be sharp.
➢ For penetration to occur, the tip must be pressed against the skin with sufficient force to overcome the natural elasticity of the skin;
➢ The commonest weapon used is a knife of some sort, but swords, shards of glass, broken bottles etc. can be used and even screwdrivers,
metal rods, railings etc. can all cause stab wounds if sufficient force is applied;
➢ The appearances of a stab wound on the skin usually reflects the cross-sectional shape of the weapon used;
➢ If a blade of some sort is used, the following general comments apply: -
 A slit-like wound will distort after removal of the weapon by the action of the elastic fibres present in the skin (if the fibres run at right angles to
the wound, it will be pulled outwards and get shorter and wider; if they run parallel to the wound, it will be pulled lengthways and the edges will
tend to close and the wound elongate slightly);
 The size of the wound also depends on the shape of the blade and how deeply it was inserted.
 Movement of the knife in the wound, either by the assailant ‘rocking’ it or by the victim moving to escape, will cause the wound to be enlarged;
 If the knife is twisted or rotated, a triangular wound may be caused.
 Many knives have only one cutting edge, the other being blunt; this design may be reproduced in the wound where one ‘V’-shaped sharp point
can be seen and one blunt point;
 The depth of a wound can be greater than the length of the blade if a forceful stab is inflicted (this is because the abdomen and, to a lesser
extent, the chest can be compressed by the force of the hilt or hand against the skin);
 A blunt object such as a screwdriver or spike will tend to indent, split and bruise the skin on insertion.
 Different types of screwdriver will cause different patterns of injury;
 Sharp but irregular instruments such as scissors or chisels will leave particular patterns of injury, with a ‘Z’ shape from scissors and a
rectangular shape from a chisel;
➢ The factors that determine how much force is needed for penetration to occur are: -
 The sharpness of the tip of the weapon: -
• The sharper the tip, the easier it is to penetrate the skin;
 The speed of the contact: -
• The faster the contact, the greater the force applied and the easier it is to penetrate the skin.
 Whether clothing has been penetrated: -
• Clothing increases the resistance to penetration.
 Whether bone or cartilage has been injured: -
• Skin offers very little resistance to a stabbing action by a sharp knife, but penetration of these denser tissues will require greater force.
❖ Incised-stab wounds: -
➢ An incised-stab wound is a stab wound that is converted to an incised (slashing) wound;
➢ The wound starts out as a stab wound with the knife plunged into the body;
➢ The knife, instead of being immediately withdrawn, is pulled toward the assailant, slicing through the tissue, extending the length of the wound in
the skin such that the wound is now longer than deep;
➢ This is accomplished in one continuous flowing movement;
➢ In Figure 7.19, the deceased was stabbed on the right side of the neck with the tip of the knife penetrating into the third cervical vertebra;
➢ The knife was then pulled anteriorly, toward the assailant, slicing through skin, muscle and the jugular veins;
➢ Usually, one cannot tell the direction the knife was drawn through the tissue from examination of the wound alone;
➢ The only way a differentiation can be made is if there is a nick or forked configuration to one end of the wound (if present, this indicates that the
blade was drawn toward this end).
9. Wounds caused by sharp objects – incised and chop wounds.

❖ Incised wounds: -
➢ Incised wounds or cuts are produced by sharp-edged weapons or instruments.
➢ A knife is the classical example of a weapon used to inflict an incised wound, though, in
fact, any instrument with a sharp edge can do so e.g. a piece of glass, metal, or paper;
➢ The sharp edge of the instrument is pressed into and drawn along the surface of the skin,
producing a wound whose length is greater than its depth;
➢ In incised wounds, the length and depth of the wound will not provide information as to
the weapon (a 3-inch-long incised wound could have been
➢ produced by a 6-inch blade, a 2-inch blade, a razor, or even a piece of glass);
➢ Incised wounds should not be confused with lacerations: -
 Incised wounds have clean-cut straight edges free of abrasion or contusion;
 There is no bridging in the depth of the wound;
 Lacerations, which are tears in the skin caused by blunt force, generally have
ragged, abraded margins with bridging of the base.
➢ If the blade is held at an oblique angle to the skin, the wound will present a bevelled or undermined edge;
➢ If the angle is extreme, a skin flap will be produced;
➢ On occasion, a single slash with a sharp, edged weapon might produce
more than one incised wound, known as wrinkle wounds, which occur
when the skin is not flat, but “wrinkled,” that is, in folds: -
 Here, the cutting-edge skips from crest to crest of the skin, leaving a string
of cuts, all of which have resulted from a single slash;
 Usually, these lie in a straight line and it is fairly simple to deduce what has
occurred;
 If the skin is thrown into irregular folds, an irregular zigzag wound may be produced by a single swipe of the blade;
 In such a case, the blade rolls up the skin before cutting through it;
➢ The edges of an incised wound tend to separate or gap: -
 The extent to which the wound gaps and the shape it subsequently assumes depend on whether it is parallel, transverse, or oblique to the
direction of the elastic fibers in the skin (Langer’s lines);
 Thus, an incised wound parallel to the contractile fibers will gap less than one made at a right angle or obliquely across the fibers because the
fibers will pull the skin apart and evert the edges;
➢ Incised wounds are usually not fatal (most are seen in emergency rooms, where they are treated with a few sutures and the victims released);
➢ Incised wounds are most frequently inflicted on the exposed portions of the body (the head, neck, and arms);
➢ If the victim survives, the wounds usually heal by primary intention, leaving a thin, linear scar;
➢ Fatal incised wounds generally involve the arms and neck and are usually suicidal;
➢ Homicidal incised wounds almost always involve the neck.
➢ Suicidal incised wounds are generally inflicted on those parts of the body most accessible to the victim;
➢ The victim may expose the portion of the body to be incised, e.g. he may open his collar before cutting his throat, or pull up his shirt before cutting
his chest or abdomen;
➢ In self-inflicted incised wounds, one will often find hesitation marks: -
 These are superficial incised wounds adjacent to the fatal incised wound;
 They are very superficial and often do not go through the skin;
 One has the impression that the deceased attempted to cut the skin, but either because of pain or hesitancy, did not initially cut deep, but
rather made multiple, very superficial cuts, almost like paper cuts, until finally, he built up enough courage to actually cut through the skin;
 Very superficial incised wounds identical to hesitation marks occasionally can be seen in homicidal incised wounds of the neck.
 This could be caused by either struggling of the individual prior to the infliction of the fatal wound or perhaps the perpetrator’s initial hesitancy
to cut the victim’s throat.
➢ Suicide: -
 Fatal incised wounds of the arms are almost always suicidal;
 As a means of attempting suicide, cutting one’s wrists is a poor method;
 Most people have a vague knowledge of anatomy and do not know where to sever a major vessel;
 In addition, they usually do not cut deep enough;
 Some individuals cut their forearms vertically, rather than horizontally, due to an ignorance of anatomy;
 In self-inflicted incised wounds of the extremities, right-handed individuals usually cut the left wrist or forearm whilst left-handed individuals, the
right wrist or forearm;
 These incised wounds are typically found on the flexor surface and radial aspect of the forearm;
 Thus, the presence of linear scars on the flexor surface in these areas suggests that an individual has attempted suicide in the past.
➢ Defense wounds: -
 Defense wounds are wounds of the extremities incurred when an individual attempt to ward off a pointed or sharp-edged weapon;
 They are most commonly found on the palms of the hands, due to attempts to grasp or ward off the knife; the back (extensor surface) of the
forearms and upper arms and on the ulnar aspect of the forearms;
 Rarely, defense wounds will be found on the feet or legs (in such a case, the individual might have kicked out at the knife to try to ward it off,
or he might have curled up and tried to cover his vital areas with the legs);
➢ Incised wounds of the neck: -
 Incised wounds of the neck can be accidental, homicidal, or suicidal;
 Accidental wounds are extremely rare, usually seen only when an individual goes through a sheet of glass or is struck in the neck by a flying
fragment of glass or some other sharp-edged projectile;
  Homicidal incised wounds of the neck present two different pictures, depending
on whether they are produced from the back or the front: -
• Most commonly, a person’s throat is cut from behind;
• The head is pulled back, exposing the neck, and the knife is then drawn across it;
• Often, the victim is face down on the floor or ground at the time the wound is
inflicted.
• The perpetrator usually starts the incision high up on the side of the neck opposite
to the hand he is using;
• The knife is drawn across the neck, from left to right by a right-handed assailant
and from right to left by a lefthanded individual;
• Homicidal incised wounds of the neck inflicted from the front tend to be short and
angled;
• A right-handed individual typically inflicts incised wounds on the left side of the
victim’s neck, with the slashes running downward and medially at an oblique
angle;
• Wounds across the front of the neck tend to be horizontal and short, extending a
short distance to the right or left of the midline;
• The characteristics of the wounds produced by a frontal attack are obvious with an
understanding of the etiology;
• Instead of the neck’s being cut with one long, continuous motion, these wounds
are inflicted by “swipes” or slashes made while facing the individual.
❖ Chop wounds: -
➢ Chop wounds are produced by heavy instruments with a cutting edge, e.g. axes, machetes, and meat cleavers;
➢ The presence of an incised wound of the skin, with an underlying comminuted fracture or deep groove in the bone, indicates that one is dealing
with a chopping weapon;
➢ When the perpetrator pulls out a weapon that has embedded itself in the bone, he might give it a sharp twist, fracturing or breaking off the adjacent
bone;
➢ In tangential wounds of the skull, chopping instruments may cut off disks of bone;
➢ While most chop wounds appear incised, when there is a combination of cutting and
crushing, they can have both incised and lacerated characteristics;
➢ Chopping weapons cutting through bone can impart characteristic striations on
the bone unique to each type of weapon: -
 Hacking blows produce wounds in bone characterized by at least one smooth, flat
side with fracturing of the other side;
 Cleavers produce clean, narrow wounds without fractures at the entry site; machetes
wider, less-clean wounds with small fragments of bone at the entry site and fractures
in the bed of the cut;
 Axes make crushing, fragmenting wounds with fractures;
 Boat or airplane propellers can produce chop-like wounds of the body (on occasion,
a body will be pulled from the water with multiple chop wounds);
10. Firearms injuries – main and additional factors of the shot, mechanism of trauma, ranges of shot.

Main and additional factors of the shot

❖ Main factors: -
➢ The features of the firearm: -
 Types of firearms: -
• According to their use: -
o Fighting; o Sporting; o Atypical (hand-made
o Hunting; o Special; and modified).
• According to the length of the barrel: -
o Long barrelled; o Medium barrelled; o Short barrelled.
• Pattern of the barrel’s internal surface: -
o Smooth barreled (smooth-bore); o Lanes and grooves (rifled);
• By the number of charges: -
o Single chargeable; o Multi chargeable.
➢ The type of the injuring shell: -
 Size of the calibre: -
• Small calibre – 5 - 6mm; • Medium calibre – 7-9mm; • Big calibre – over 10mm.
 Some bullets are designed or modified to slow down or stop in the body, which increases the damages caused by them;
 The so called “dumdum” bullets split open (like a star or flower), which increases their damaging effects.
❖ The additional injuring factors: -
➢ The action of secondarily formed projectiles e.g. metal particles, rocks, fractured bones;
➢ Fire, gases, soot, gun powder particles which are not burnt or not fully burnt and metal;
➢ Distances of shooting (distant range shooting, close range shooting, contact shooting);

Mechanism of trauma
❖ The main damaging factor is the projectile/missile;
❖ The trauma occurs when the missile transfers its kinetic energy to the injured tissues;
❖ Entrance wounds: -
➢ Contact wounds from a rifled weapon are generally circular, unless over a bony area such as the head,
➢ There may be a muzzle mark if the gun is pressed hard against the skin and a pattern may be imprintet;
➢ There may be slight escape of smoke with some local burning of skin and hair if the gun is not pressed tightly;
➢ At close range, up to about 20 cm, there will be some smoke soiling and powder burns, and skin and hair may be burnt, although this is very
variable and depends upon both the gun and the ammunition used;
➢ The shape of the entry wound gives a guide to the angle that the gun made with that area of skin;
➢ A circular hole indicates that the discharge was at right angles to the skin, whereas an oval hole, perhaps with visible undercutting, indicates a more
acute angle;
➢ Examination of the entry wound will show that the skin is inverted;
➢ The defect is commonly slightly smaller than the diameter of the missile due to the elasticity of the skin;
➢ Very commonly, there is an ‘abrasion collar’ or ‘abrasion rim’ around the hole, which is caused by the friction, heating and dirt effect of the missile
when it indents the skin during penetration;
➢ Over 1 m or so, there can be no smoke soiling, burning or powder tattooing;
➢ At longer ranges (which may be up to several kilometres with a high-powered rifle), the entrance hole will have the same features of a round or oval
defect with an abrasion collar;
➢ At extreme ranges, or following a ricochet, the gyroscopic stability of the bullet may be lost and the missile begins to wobble and even tumble, and
this instability may well result in larger, more irregular wounds.
❖ Exit wounds: -
➢ The exit wound of a bullet is usually everted with split flaps, often resulting in a stellate appearance;
➢ There can be no burning, smoke or powder soiling;
➢ If the bullet has been distorted or fragmented or if it has fractured bone, the exit wound may be considerably larger and more irregular and those
fragments of bullet or bone may be represented by multiple exit wounds;
➢ Where skin is firmly supported, as by a belt, tight clothing or even leaning against a partition wall, the exit wound may be as small as the entrance
and may fail to show the typical eversion;
➢ The exit wounds may also show a rim of abrasion as seen in entrance wounds (although this is commonly broader than that of an entry wound);
➢ The internal effects of bullets depend upon their kinetic energy: -
 Low-velocity, low-energy missiles, such as shotgun pellets and some revolver bullets, cause simple mechanical disruption of the tissues by
pushing them aside;
 High-velocity bullets cause far more damage to the tissues as they transfer large amounts of energy, which results in the formation of a
temporary cavity in the tissues;
 This cavity is many tens or hundreds of times larger than the calibre of the bullet itself;
 This cavitation is especially pronounced in dense organs such as liver and brain, but occurs in all tissues if the energy transfer is large enough
and results in extensive tissue destruction away from the track itself.

Ranges of shot
❖ Gunpowder comes out of the muzzle in two forms.
1. Completely burned gunpowder, called “soot” or “fouling,” can be washed off the skin;
2. Particles of burning and unburned powder can become embedded in the skin or bounce off and abrade the skin (the marks on the skin are called
“tattooing” or “stippling.”
❖ The presence/absence of gunpowder on the clothing or skin indicates whether the gunshot was contact (loose or tight), close, intermediate,
or distant: -
 1. Tight contact: —
➢ All gunpowder residue is on the edges or in the depths of a wound;
➢ There may be searing or burning of wound margins, or reddening of surrounding skin due to carbon monoxide gas produced by burning
powder;
➢ There is often tearing of the skin around the entrance wound (especially in head wounds) because of pressure buildup and blow-back of the
skin toward the muzzle.
2. Loose contact: —
➢ Gunpowder may escape from the barrel and be deposited around the edges of a wound.
3. Close range: —
➢ Close range gunshot wounds occur at muzzle-to-target distances of approximately 6–12”;
➢ Both fouling and stippling are present.
4. Intermediate range: —
➢ These wounds occur at muzzle-to-target distances of approximately 12” to 3’;
➢ There is no fouling, only stippling or deposition of particles on clothing.
5. Distant wounds: —
➢ No fouling or stippling.

11. Firearms injuries from pellets and explosions – main and additional injuring factors, ranges of shot, mechanism of trauma.

Main and additional injuring factors

❖ Explosions:
➢ Main injuring factors: -
 Blast effects: -
• The blast consists of a wave of compression that passes through the air/water;
• The compression wave is followed by a zone of negative pressure;
• The shock wave acts as a blunt object with wide surface.
 Fire and hot gases;
 Projectiles from the bomb (most commonly metal particles).
➢ Additional injuring factors: -
 Burns - directly from the near effects of the explosion and secondarily from fires started by the bomb;
 Missile injuries from parts of the bomb casing or shrapnel or from adjacent objects;
 Peppering by small fragments of debris and dust propelled by the explosion;
 All types of injury due to collapse of structures caused by the explosion;
 Injuries and death from vehicular damage or destruction, such as decompression, fire and ground impact of bombed aircraft and crash
damage to cars, trucks, buses etc.
❖ Pellets: -
➢ Main injuring factors: -
 Air weapons rely upon the force of compressed air to propel the projectile, usually a lead or steel pellet;
 The energy of the projectile will depend mainly on the way in which the gas is compressed;
 The simple spring-driven weapons being provide less energy, while the more complex systems can propel projectiles with the same energy
(and hence at approximately the same speed) as many ordinary handguns.

Ranges of shot
❖ Explosions: -
➢ In military explosions, the release of energy may be so high that death and disruption from blast effects may occur over a wide area;
➢ In contrast, terrorist devices, rarely compare with military effectiveness and thus the pure blast effects are far more limited;
➢ The energy developed by an explosion decreases rapidly as the distance from the epicentre increases;
➢ When an explosion occurs, the chemical interaction results in the generation of huge volumes of gas, which are further expanded by the great heat
that is also generated;
➢ This sudden generation of gas causes a compression wave to sweep outwards from the origin, at many times the speed of sound.
Mechanism of trauma
❖ Explosions: -
➢ The pure blast effects can cause either physical fragmentation or disruption of the victim solely from the effects of the wave of high pressure and
hot gases striking the body;
➢ A minimum pressure of about 700 kilopascals (100 lb/sq inch) is needed for tissue damage in humans;
➢ There will also be pressure effects upon the viscera and these effects are far more damaging where there is an air/fluid interface, such as in the air
passages, the lungs and the gut;
➢ Ruptures and haemorrhage of these areas represent the classical blast lesion;
➢ As dangerous as the effect of the blast may be, many more casualties, fatal and otherwise, are caused by the additional injuring factors of
explosive devices, especially in the lower-powered terrorist bombs;
❖ Pellets: -
➢ The injuries caused by the projectiles from air weapons will depend upon their design, but entry wounds from standard pellets are often
indistinguishable from those caused by standard bullets in that they have a defect with an abrasion rim;
➢ The relatively low power of these weapons means that the pellet will seldom exit, but if it does do so, a typical exit wound with everted margins will
result.
12. Cause and manner of death in cases of mechanical trauma.
❖ Cause of death: -
➢ The cause of death is any injury or disease that produces a physiological derangement in the body that results in the death of the individual;
➢ Thus, although differing widely, the following are examples of causes of death: -
 A gunshot wound to the head  Adenocarcinoma of the lung;
 A stab wound to the chest;  Coronary atherosclerosis.
➢ How to determine the underlying cause of death: -
 There are 2 categories of underlying cause of death related to mechanical trauma: - Wound type Underlying COD
1. Penetration and sharp force injury: - Gunshout wound Gunshot injury
• The determination of underlying COD in this group is based on the wound Cut wound (on throat) Cut throat
type responsible for the death: - Chopping wound Chopping injury
2. Blunt force injury: - Stab wound Stabbing injury
• Information of wounds and circumstances of death is needed to determine
the underlying COD in this category: -
o Wound type; o Location of wounds along;
o The number of wounds; o Injurious object;
• Some wounds are specific to the cause, such as a sole mark which relate to death by stomping;
• The degree of wound distribution over the body is also a clue to the underlying COD;
• Many wounds scattered all over the body, mainly on prominent parts, suggests traffic injury more than beaten to death.
• Fracture of large and/or deep bones; such as pelvis, femur, thoracic and lumbar spine scarcely appear if one is beaten to death.
• A circumstance of death is very meaningful to underlying COD (sometimes findings from body examination are not helpful): -
o In some cases, eye-witnesses who saw the event and information from family or friends is needed: -
- For instance, a man had been sick from pancreatic cancer and had chronic serious abdominal pain for months and was
admitted to a hospital;
- Many witnesses saw him climb and jump out of the window on the 9th floor of the hospital building to the road;
- The circumstance is obviously revealing the underlying COD.
o The place where the body found is found is another clue for the determination of underlying COD: -
- For example, a body with serious blunt force injury on the head and face found next to a trail in a forest supposedly died
from being hit by someone rather by traffic injury.
➢ Immediate causes of death in mechanical trauma commonly include: -
1. Rough mechanical damage, incompatible with life: -
 Smashing and tearing of parts of the body (head, thorax, abdomen etc.);
 Rupture of vital organs (heart, lungs, brain, liver, etc.).
2. Blood loss: -
 Massive blood loss leads to haemorrhagic shock due to acute anaemia and hypovolemia;
 Rapid blood loss of 1/3 to ½ of the blood volume leads to death (rapid blood loss leads to rapid death even if less blood is lost, especially
if the injured vessel is near the heart - here the mechanism of death is associated with a sharp drop in respiratory rate).
3. Compression of vital organs by blood or air: -
 Compression of the brain: -
• Epidural hematoma; • Subarachnoid hematoma;
• Subdural hematoma; • Intracerebral hematoma;
 Compression of the heart (traumatic tamponade);
 Compression of the lungs: -
• Haemothorax; • Pneumothorax; • Hemopneumothorax.
❖ Mechanism of death: -
➢ The mechanism of death is the physiological derangement produced by the cause of death that results in death;
➢ Examples of mechanism of death would be: -
 Haemorrhage;  Septicaemia;  Cardiac arrhythmia;
➢ There are 2 components of mechanism of death: -
1. Terminal event: -
 The common final pathway of death;
 It is composed of 6 items which are: -
I. Asystole; IV. Cardiopulmonary arrest;
II. Cardiac arrest; V. Electromechanical dissociation;
III. Ventricular fibrillation; VI. Respiratory arrest.
2. The other component is non-specific physical derangements which are between the immediate COD and the terminal event.
➢ A particular mechanism of death can be produced by multiple causes of death and vice versa;
➢ Thus, if an individual dies due to massive haemorrhage, it can be produced by a gunshot wound, a stab wound, a malignant tumour of the lung
eroding into a blood vessel and so forth;
➢ The reverse of this is that a cause of death, for example, a gunshot wound of the abdomen, can result in many possible mechanisms of death, e.g.
haemorrhage or peritonitis.
❖ The manner of death: -
➢ The manner of death explains how the cause of death came about;
➢ Manners of death can generally be categorized as: -
 Natural;  Suicide,  Undetermined.
 Homicide;  Accident;
➢ Just as a mechanism of death can have many causes and a cause many mechanisms, a cause of death can have multiple manners;
➢ An individual can die of massive haemorrhage (the mechanism of death) due to a gunshot wound to the heart (the cause of death), with the manner
of death being homicide (somebody shot the individual), suicide (they shot themselves), accident (the weapon fell and discharged), or
undetermined (one is not sure what occurred).
13. Death caused by high and low temperatures.

❖ The examination of bodies recovered from fires: -

➢ Not all bodies recovered from fires have burnt to death, in fact, the majority of deaths in fires are the result of inhalation of smoke and noxious
gases (cyanide, carbon monoxide, oxides of nitrogen, phosgene etc.);
➢ Bodies recovered from the scene of a fire may have been burnt both before and after death and it can be difficult or impossible to differentiate
these burns, especially where considerable destruction has taken place;
➢ As a general guide, the ante-mortem burn usually has broad, erythematous margins with blisters both in the burned area and along the edge,
whereas post-mortem burns tend to lack this erythema or it is at least less pronounced;
➢ Heat applied to the recently dead body (up to at least 60 minutes after cardiac arrest) can still produce a red flare of erythema, so great care
must be taken in any attempt to determine the time at which a burn was caused;
➢ Fire is a good means of attempting to conceal the injuries and other marks that may indicate that the deceased was a victim of homicide;
➢ It will almost certainly cause some destruction of forensically useful evidence;
➢ As a result, all burnt bodies must be viewed with particular care and the possibility that the death might have occurred before the fire began
must be considered;
➢ The scene should be examined by specialist fire investigators, with the assistance of the pathologist if necessary;
➢ The position of the body when discovered is important because sometimes, when flames or smoke are advancing, the victim will retreat into a
corner, a cupboard or other hiding place, or they may simply move to a place furthest away from the fire or to a doorway or window, all of
which may indicate that the victim was probably still alive and capable of movement for some time after the start of the fire;
➢ The colour of the skin in areas that have been protected from burns and smoke staining should be noted - if they are ‘cherry-pink’, this
indicates that the blood is very likely to contain significant quantities of carboxyhaemoglobin;
➢ Other features that indicate that the victim was alive and breathing while the fire was burning are the presence of soot particles in the larynx,
trachea and bronchi;
➢ The findings of soot in the airways and carbon monoxide in the blood indicate that the person was breathing after the fire began;
❖ Causes of death in burns and scalds: -
➢ The actual cause of death from burns is complex and results from the interplay of many factors: -
 The directly destructive effects of heat on the respiratory tract leading to asphyxia;
 The combined toxic effects of carbon monoxide, cyanide and the multitude of other noxious gases (oxides of nitrogen, phosgene etc.) that are
inhaled;
 The release of toxic material from the extensive tissue destruction;
 The ‘shock’ due to pain all cause or contribute to death.
❖ Injuries on burned bodies: -
➢ A careful search must be made for any ante-mortem injuries that may have caused or contributed to death;
➢ It is always advisable to x-ray a burned body, especially if the fire damage is so extensive as to make examination of the skin surface impossible;
➢ However, not all injuries on burned bodies are sinister, for instance, where skin has been subjected to severe burning or charring, it will often split;
➢ These splits can also be caused by post-mortem movement during recovery of the body when charred and brittle skin is moved;
➢ Another misinterpreted injury is the ‘heat haematoma’ inside the skull: -
 This spurious ‘extradural haematoma’ lies between the bone and dura and is caused when severe heat has been applied to the scalp,
resulting in expansion of the blood in the skull diplöe and the intracranial venous sinuses, which rupture, resulting in the formation of a
collection of blood outside the meninges;
 The blood is brown and spongy, unlike a true haematoma, but the simple presence of this collection of blood may mislead the unwary doctor
performing an autopsy into thinking that this is the result of a trauma.
❖ Hyperthermia: -
➢ Very few signs at autopsy will indicate a person died from hyperthermia;
➢ The most important sign is body temperature;
➢ If a body is found at a scene soon after death, an increased temperature will be evident;
➢ If a decedent is not found for many hours, or is discovered the next day, a diagnosis may be impossible;
➢ There are a number of causes of hyperthermia. Older people may succumb to heat during summer months because of an underlying disease which
contributes to their inability to cope with heat, or their dwellings may not have an appropriate cooling system;
➢ Malignant hyperthermia is a syndrome which develops in people who react to certain drugs, such a phenathiozines(thorazine) or halothane;
➢ The use of cocaine and methamphetamine are also associated with hyperthermia;
➢ In some of these cases there is a genetic predisposition toward developing “malignant” hyperthermia.
❖ Hypothermia: -
➢ Any fall in body core temperature of more than a few degrees is hypothermia, but clinical effects are minimal providing the core body temperature
remains above about 35°C;
➢ People whose temperature falls to 28°C or less are almost certain to die, even with treatment;
➢ When a dead person is found and hypothermia is suspected, it can be difficult or impossible to prove because post-mortem cooling (including
storage in a mortuary refrigerator) can cause some similar changes to appear in the skin;
➢ However, if the body shows areas with indistinct, blurred margins that are pink or brown-pink, particularly over and around joints such as the knees,
elbows and hips, a diagnosis of hypothermia should be considered;
➢ The pink colour is due to unreduced oxyhaemoglobin as the cold tissues have little uptake of oxygen;
➢ Internally, quite commonly, the stomach lining is studded with numerous brown-black acute erosions, which are exactly the same as those seen in
many types of pre-death stress;
➢ Increased viscosity of the blood due to low temperatures may lead to sludging of blood in the small vessels of many organs and this may lead to
micro-infarcts;
➢ This mechanism is probably the cause of the haemorrhagic pancreatitis and associated fat necrosis that are also features of many cases of
hypothermia.
➢ Hypothermia may be linked with a strange condition, particularly in the elderly, in which people take off some or all of their clothing (reciprocal
undressing);
➢ They may then hide themselves in corners, in cupboards or under piles of furniture or household goods - this is called the ‘hide-and-die syndrome’;
➢ If hypothermia of the extremities has been present for a long time, there may be ‘frost-bite’, which is infarction of the fingers with oedema& redness.
14. Death caused by electricity.

❖ Injury and death from the passage of an electric current through the body are common in both industrial and domestic circumstances;
❖ The essential factor in causing harm is the current (i.e. an electron flow) which is measured in milliamperes (mA): -
➢ It is related to the voltage and resistance of the tissues;
➢ Voltage is a measure of the electromotive force and ohms are the resistance to the conduction of electricity;
➢ This is expressed in the formula: A = V/R.
❖ Almost all cases of electrocution originate from the public power supply, which is delivered throughout the world at either 110 or 240V (it is rare for death
to occur at less than 100V);
❖ The current needed to produce death varies according to: -
➢ The time during which it passes;
➢ The part of the body across which it flows (usually, the entry point is a hand that touches an electrical appliance or live conductor): -
 When a live metal conductor is gripped by the hand, pain and muscle twitching will occur if the current reaches about 10 mA;
 If the current in the arm exceeds about 30 mA, the muscles will go into spasm, which cannot be voluntarily released because the
 flexor muscles are stronger than the extensors;
 The result is that the hand to grip or to ‘hold on’;
 This ‘hold-on’ effect is very dangerous as it may allow the circuit to be maintained for long enough to cause cardiac arrhythmia, whereas the
normal response would have been to let go so as to stop the pain.
❖ In either case, the current will cross the thorax, the most dangerous area for a shock because of the risks of cardiac arrest or respiratory paralysis;
❖ The tissue resistance is important: -
➢ Thick dry skin, such as the palm of the hand or sole of the foot, may have a resistance of 1 million ohms, but when wet, this may fall to a few
hundred ohms and the current, given a fixed supply voltage, will be markedly increased (this is relevant in wet conditions such as bathrooms, or
when sweating);
❖ The mode of death in most cases of electrocution is ventricular fibrillation due to the direct effects of the current on the myocardium (the victims of such
an arrhythmia will be pale);
❖ Even more rare are the instances in which the current has entered the head and caused primary brainstem paralysis, which has resulted in failure of
respiration (this may occur when workers on overhead power supply lines or electric railway wires touch their heads against high-tension conductors,
usually 660V);
❖ Electrical lesions: -
➢ When high voltages or prolonged contact have occurred, extensive and severe burns can be seen, but a few seconds’ contact with a faulty
appliance may leave minimal signs;
➢ Where the skin is wet or where the body is immersed, as in a bath, there may be no signs at all, as the entrance and exit of the current may be
spread over such a wide area that no focal lesion exists;
➢ The focal electrical lesion is usually a blister, which occurs when the conductor is in firm contact with the skin;
➢ The skin is pale, often white, and an areola of pallor (due to local vasoconstriction) is a characteristic feature;
➢ Blisters may also appear and vary from a few millimetres to several centimetres;
➢ The skin often peels off the large blisters leaving a red base;
➢ The other type of electrical mark is a ‘spark burn’, where there is an air gap between metal and skin;
➢ In high-voltage burns, multiple sparks may crackle onto the victim and cause large areas of damage, sometimes called ‘crocodile skin’ due to its
appearance.
➢ Internally, there are no characteristic findings in fatal electrocution.
❖ Lightning: -
➢ Lightning may kill by either a direct or an indirect strike;
➢ The victim usually dies by heart stoppage;
➢ Metal on the clothing or body may heat up and cause secondary injuries;
➢ Occasionally, a red fern-like pattern may develop on the skin.
15. General theory of mechanical asphyxiation – types of asphyxiations, cause and manner of death, autopsy findings.

General theory of mechanical asphyxiation

❖ In the forensic context, asphyxia is usually obstructive in nature, where some physical barrier prevents access of air to the lungs
❖ This obstruction can occur at any point from the nose and mouth to the alveolar membranes.
❖ Other conditions in which the body cannot gain sufficient oxygen may occur without any obstruction to the air passages;
❖ Given the many possible causes for this lack of sufficient oxygen to the cells of the body, the clinical and pathological features of the many different
types of ‘asphyxia’ are very varied;
❖ The ‘classical’ features of asphyxia are found where the air passages are obstructed by pressure applied to the neck or to the chest and where there
has been a struggle to breathe;

Types of asphyxiation

Cause and manner of death

❖ A person with obstructed air entry will show various phases of distress and physical signs;
❖ The exact timing and the sequence of events will be very variable, but they may progress as listed below: -
1. Increased efforts to breathe, facial congestion and the onset of cyanosis;
2. Deep, laboured respirations or attempts at respiration with a heaving chest, deepening congestion and cyanosis, as well as the appearance of
petechiae if venous return is impaired;
3. Loss of consciousness and possible convulsions and the evacuation of bladder and vomiting;
4. Reduction in the depth and frequency of respiration, irreversible brain damage begins, the pupils dilate and death ensues.
❖ At any stage through this progression, death may occur suddenly from cardiac arrest.

Autopsy findings
The classical features of ‘asphyxia’ are: -
1. Congestion of the face: -
➢ Congestion is the red appearance of the skin of the face and head;
➢ It is due to the filling of the venous system when compression of the neck or some other
obstruction prevents venous return to the heart.
2. Oedema of the face: -
➢ Oedema is the swelling of the tissues due to transudation of fluid from the veins caused by
the increased venous pressure as a result of obstruction of venous return to the heart.
3. Cyanosis (blueness) of the skin of the face: -
➢ Cyanosis is the blue colour imparted to the skin by the presence of deoxygenated blood in
the congested venous system and, possibly, in the arterial system.
4. Petechial haemorrhages in the skin of the face and the eyes: -
➢ Petechial haemorrhages (petechiae) are tiny, pinpoint haemorrhages, most commonly seen
in the skin of the head and face and especially in the lax tissues of the eyelids (they are also
seen in the conjunctivae and sclera of the eye);
➢ They are due to leakage of blood from small venules as a result of the raised pressure in the
venous system;
➢ They are not diagnostic of asphyxia because they can appear instantaneously in the face and
eyes following a violent episode of sneezing or coughing.
16. Mechanical asphyxiation due to pressure of neck and torso.

❖ When pressure is applied to the neck, the effects listed below may occur: -
➢ Obstruction of the jugular veins, causing impaired venous return of blood from the head to the heart (this leads to cyanosis, congestion, petechiae
etc);
➢ Obstruction of the carotid arteries, which if severe, causes cerebral ischaemia;
➢ Stimulation of the baroceptor nerve endings in the carotid sinuses, which lie in the internal carotid artery just above the carotid bifurcation, leading
to effects on the heart through the vagus nerve;
➢ Elevation of the larynx and tongue, closing the airway at pharyngeal level (it is difficult to occlude the airway at laryngeal or tracheal level, due to
the rigidity of the strong cartilages, unless extreme pressure is applied).
❖ 3 forms of pressure on the neck are of prime forensic importance: -
1. Manual strangulation: -
➢ This is a relatively common mode of homicide used by a man against a woman or a child and it is
sometimes associated with a sexual attack;
➢ It is relatively unusual for a man to throttle another man, and women rarely strangle, except as a means of
infanticide;
➢ Manual strangulation may be performed by one or both hands, from the front or the back;
➢ The external signs are abrasions and bruises on the front and sides of the neck;
➢ Typical fingertip bruising may be seen, which consists of disc-shaped or oval-shaped bruises about 0.5–1
cm in size;
➢ There may also be linear abrasions or scratches from fingernails;
➢ When pressure has been more prolonged, the classic signs of venous obstruction will be seen, with
cyanosis, oedema and congestion of the face together with showers of petechiae in the eyes and face and
sometimes bleeding from nose and ears;
➢ If pressure has been sustained, congestion and cyanosis of the neck structures will also be seen and there
may be petechiae on the epiglottis and visceral pleura;
➢ Caution must be used in interpreting bleeding into the posterior neck tissues, as this is a very common
artefact in all types of autopsy;
➢ When strangulation or hanging is suspected from the circumstances or from the external appearances, it is
important that the dissection of the neck should not be carried out until the great veins in the thorax have been opened, which allows the blood
from the head and neck to drain and for the dissection to be performed in a relatively bloodless field;
➢ The larynx is commonly damaged during manual strangulation and the most vulnerable structures are the superior horns of the thyroid
cartilage, which may be fractured on one or both sides.
➢ The hyoid bone is much less often injured, but when it is injured, one or both of the greater horns may be broken;
➢ These fractures of the laryngeal cartilages rarely occur in children or young people as the cartilage is pliable, but the calcification and
ossification of increasing age render these cartilages more brittle and vulnerable to trauma;
2. Ligature strangulation: -
➢ Here, a constricting band is tightened around the neck, which usually results in marked congestion
and cyanosis and extensive petechiae in the face;
➢ All types of ligature can be used (rope, wire, string, electric and telephone cable, scarves,
stockings, pieces of cloth etc.);
➢ The mark on the neck will usually reflect the material used for the ligature: -
 If a wire or thin cord was used, the mark will usually be clear-cut and deep with sharply
defined edges:
 If a soft fabric is pulled taut, it will commonly fold into a series of firm ridges or bands that may
produce interlacing deeper areas of bruising on the neck of the victim, which can suggest the
use of a narrow ligature.
➢ The ligature mark is a vital piece of evidence, especially when the killer has taken away the actual
ligature;
➢ The mark on the neck may reproduce the pattern of the object, such as spiral or plaited weave, and
the width of the mark can sometimes give a clue as to the size of the ligature;
➢ If the ligature has been left on after death or if sliding friction has occurred, the mark on the neck
will be a brownish, dried leathery band;
➢ It is important to look for the site of a crossover of the ligature mark or for any knots that may be present (these may be at the front, back or
the sides and will give some idea of the relative position of the perpetrator);
➢ The ligature mark may lie horizontally or at an angle, but, crucially, it will not have a suspension point, which is commonly found in many
hangings;
➢ There may be scratches and bruises on the neck, which may have been caused when the victim tried to pull off the ligature, or when there had
also been attempts at manual strangulation preceding or following the application of a ligature.
➢ Ligature strangulation is best treated as homicide until it is shown conclusively not to be so;
➢ Accidents do happen in which ligatures pass around the neck and become tightened and it is certainly possible for a person to kill themselves
by ligature strangulation.
3. Hanging: -
➢ Hanging or ‘self-suspension’ is a form of ligature strangulation in which the pressure of the ligature on the neck is produced by the weight of
the body itself;
➢ Many hanging deaths occur in which the victim is slumped in a sitting, kneeling or halflying position, being suspended from a low point such as
a door handle, bed knob etc.
➢ Most hangings, especially the free-swinging positions, show none of the ‘classical signs’ of asphyxia, as death has occurred almost
instantaneously, presumably from sudden pressure on the neck producing vagal inhibition;
 ➢ The usual free-swinging suicidal hanging shows a mark on the neck that is somewhat
sloped and does not run around the full circumference of the neck;
➢ The junction of the noose and the vertical part of the rope of the noose is pulled upwards
and away from the skin and so no mark is left;
➢ The apex of the triangle formed in this way is called the suspension ‘peak’ or ‘point’ and
indicates the position of the junction of the noose and vertical part of rope;
➢ This suspension peak or point is a distinguishing feature from ligature strangulation.
➢ Excluding judicial execution, hanging is mostly commonly a suicidal act of males;
➢ Some cases are accidental and entanglement with cords and ropes can occur; amongst
children, many tragedies have happened due to leather or plastic restraint harnesses getting
around the necks of unattended infants.
❖ Mechanical asphyxia due to pressure on the torso: -
➢ It can be subdivided into 3 types:
1. Traumatic asphyxia: -
 Traumatic asphyxia occurs when a heavy weight presses down on an individual’s chest
or upper abdomen, making respiration impossible;
 One common form of traumatic asphyxia is individuals under a car, repairing it, when
the jack slips and the vehicle falls on top of them;
 At autopsy, there is congestion of the head, neck, and upper trunk with numerous
petechiae in these areas, the sclerae, the conjunctivae and the periorbital skin;
 Internally, there is often no evidence of trauma in spite of the heavy weight on the chest;
 Individuals who survive an episode of traumatic asphyxia usually make an uneventful
recovery, though occasionally there is some permanent visual impairment due to retinal
haemorrhage;
2. Positional asphyxia: -
 Positional asphyxia is virtually always an accident and is associated with alcohol or drug
intoxication;
 In this entity, individuals become trapped in restricted spaces, where, because of the
position of their bodies, they cannot move out of that area or position;
 This results in restriction of their ability to breathe, followed by death;
 There is usually marked congestion, cyanosis, and petechiae;
 Positional asphyxia might occur if individuals fall down a well and are wedged between
the walls;
 Every time they exhale, they slip farther and farther down the well, preventing inhalation.
(don’t laugh you evil sods).
3. Riot-crush or “human pile” deaths: -
 Riot-crush, as the name implies, occurs in riots, when the chest is compressed by
stampeding people piling on top of each other;
 Respiratory movements are, thus, prohibited by this human pile.
17. Mechanical asphyxiation due to obstruction of mouth, nose and airways.
❖ Smothering: -
➢ Smothering with a pillow or other object (including a hand) pressed over the nose and mouth will only very rarely cause any petechiae, any
significant cyanosis or congestion unless the victim struggles and fights for breath against the obstructed airways;
➢ Smothering may be virtually impossible to diagnose if it is applied to those who cannot or do not resist – the old, the infirm or the very young;
➢ If the victim does struggle, there may be bruises and abrasions to the face, on the lips or inside the mouth (where lips are pressed against teeth).
❖ Gagging: -
➢ The air passages may be obstructed when a cloth or soft object is pushed into the mouth, or placed across the mouth, often during a robbery when
the victim is tied up and the cloth is used to ensure their silence;
➢ Initially, breathing occurs via the nose, but with time, nasal mucus and oedema close the posterior nares and progressive asphyxia develops.
❖ Choking: -
➢ Manual strangulation is occasionally referred to as ‘choking’, but this is incorrect;
➢ The term choking should be applied to the internal obstruction of the upper airways by an object or substance impacted in the pharynx or larynx;
➢ Choking is, most commonly, accidental and the causes include dentures in adults and inhaled objects such as small toys, balls etc. in children;
➢ In medical practice there are risks associated with individuals who are sedated or anaesthetized, when objects such as extracted teeth or blood
from dental or ENT operations may occlude the airway without provoking the normal reflex of coughing;
➢ Obstruction commonly leads to respiratory distress with congestion and cyanosis of the head and face.
➢ Café coronary: -
 Perhaps the commonest cause of choking is the entry of food into the air passages;
 If food enters the larynx during swallowing, it usually causes gross ‘choking symptoms’ of coughing, distress and cyanosis, which can be fatal
unless the obstruction is cleared by coughing or some rapid treatment is offered.
 However, if the piece of food is large enough to occlude the larynx completely, it will prevent not only breathing but also, speech and coughing;
 The individual may die silently and quickly, the cause of death remaining hidden until the autopsy - this is the so-called café coronary;
 The airways are normally protected from the entry of food or vomit by powerful reflexes, and anything that can reduce/eliminate those reflexes
will put an individual at greater risk (e.g. acute alcohol intoxication, depressant drugs, anaesthetics or many kinds of neurological disease);
 The acid nature of vomit will have an inflammatory effect in addition to the simple mechanical obstruction of the material;
 However, the finding of stomach contents in the larynx, trachea and bronchi is common at autopsy and it is not safe to conclude, on autopsy
findings alone, that death was due to aspiration of stomach contents;
18. Concepts of “poisons” and “poisonings”. Conditions on which depend the effects of poisons;

Concepts of “poisons” and “poisonings”.

❖ Poisons: -
➢ Poisons are substances that cause disturbances to organisms, usually by chemical reaction or other activity on a molecular scale, when a sufficient
quantity is absorbed by an organism;
➢ The terms toxin, poison and venom should be distinguished: -
 A toxin is a poison produced by organisms in nature;
 Venoms are toxins that are injected by a bite or a sting.
❖ Poisonings: -
➢ Poisoning is a condition or a process in which an organism becomes chemically harmed severely (poisoned) by a toxic substance or venom of an
animal;
➢ There are 2 main types of poisonings: -
 Acute poisoning: -
• Acute poisoning is exposure to a poison on one occasion or during a short period of time;
• Symptoms develop in close relation to the degree of exposure;
• Absorption of a poison is necessary for systemic poisoning (that is, in the blood throughout the body);
• In contrast, substances that destroy tissue but do not absorb, such as lye, are classified as corrosives rather than poisons;
• Furthermore, many common household medications are not labelled with skull and crossbones, although they can cause severe illness or
even death;
• In the medical sense, toxicity and poisoning can be caused by less dangerous substances than those legally classified as a poison;
 Chronic poisoning: -
• Chronic poisoning is long-term repeated or continuous exposure to a poison where symptoms do not occur immediately or after each
exposure;
• The patient gradually becomes ill, or becomes ill after a long latent period;
• Chronic poisoning most commonly occurs following exposure to poisons that bioaccumulate, or are biomagnified, such as mercury,
gadolinium, and lead.

Conditions on which depend the effects of the poisons.

1. Factors related to the substance: -
A. Form and innate chemical activity: -
❖ Form: -
➢ The form of a substance may have a profound impact on its toxicity especially for metallic elements, also termed heavy metals;
➢ For example, the toxicity of mercury vapor differs greatly from methyl mercury;
➢ Another example is chromium (Cr3+ is relatively nontoxic whereas Cr6+ causes skin or nasal corrosion and lung cancer);
❖ The innate chemical activity of substances also varies greatly: -
➢ Some can quickly damage cells causing immediate cell death;
➢ Others slowly interfere only with a cell's function;
➢ For example:
 Hydrogen cyanide binds to the enzyme cytochrome oxidase resulting in cellular hypoxia and rapid death;
 Nicotine binds to cholinergic receptors in the central nervous system (CNS) altering nerve conduction and inducing gradual onset of
paralysis.
B. Dosage: -
❖ The dosage is the most important and critical factor in determining if a substance will be an acute or a chronic toxicant;
❖ Virtually all chemicals can be acute toxicants if sufficiently large doses are administered;
❖ Often the toxic mechanisms and target organs are different for acute and chronic toxicity.
C. Exposure route: -
❖ The way an individual comes in contact with a toxic substance, or exposure route, is important in determining toxicity;
❖ Some chemicals may be highly toxic by one route but not by others;
❖ 2 major reasons are differences in absorption and distribution within the body;
❖ For example:
➢ Ingested chemicals, when absorbed from the intestine, distribute first to the liver and may be immediately detoxified.
➢ Inhaled toxicants immediately enter the general blood circulation and can distribute throughout the body prior to being detoxified by the
liver.
❖ Different target organs often are affected by different routes of exposure.
D. Absorption: -
❖ The ability to be absorbed is essential to systemic toxicity;
❖ Some chemicals are readily absorbed and others are poorly absorbed;
❖ For example, nearly all alcohols are readily absorbed when ingested, whereas there is virtually no absorption for most polymers;
❖ The rates and extent of absorption may vary greatly depending on the form of a chemical and the route of exposure to it;
❖ For example:
➢ Ethanol is readily absorbed from the gastrointestinal tract but poorly absorbed through the skin.
➢ Organic mercury is readily absorbed from the gastrointestinal tract; inorganic lead sulfate is not.
2. Factors related to the organism: -
A. Species: -
❖ Toxic responses can vary substantially depending on the species;
❖ Most differences between species are attributable to differences in metabolism;
❖ Others may be due to anatomical or physiological differences;
❖ For example, rats cannot vomit and expel toxicants before they are absorbed or cause severe irritation, whereas humans and dogs are
capable of vomiting;
 ❖ Selective toxicity refers to species differences in toxicity between two species simultaneously exposed;
❖ This is the basis for the effectiveness of pesticides and drugs;
❖ For example: -
➢ An insecticide is lethal to insects but relatively nontoxic to animals;
➢ Antibiotics are selectively toxic to microorganisms while virtually nontoxic to humans.
B. Life stage: -
❖ An individual's age or life stage may be important in determining his or her response to toxicants;
❖ Some chemicals are more toxic to infants or the elderly than to young adults.
C. Gender: -
❖ Gender can play a big role in influencing toxicity;
❖ Physiologic differences between men and women, including differences in pharmacokinetics and pharmacodynamics, can affect drug activity;
❖ In comparison with men, pharmacokinetics in women generally can be impacted by their lower body weight, slower gastrointestinal motility,
reduced intestinal enzymatic activity, and slower kidney function (glomerular filtration rate);
❖ Delayed gastric emptying in women may result in a need for them to extend the interval between eating and taking medications that require
absorption on an empty stomach;
❖ Other physiologic differences between men and women also exist;
❖ Slower renal clearance in women, for example, may result in a need for dosage adjustment for drugs such as digoxin that are excreted via the
kidneys;
❖ In general, pharmacodynamic differences between women and men include greater sensitivity to and enhanced effectiveness, in women, of
some drugs, such as beta blockers, opioids, and some antipsychotics.
D. Metabolism: -
❖ Metabolism, also known as biotransformation, is the conversion of a chemical from one form to another by a biological organism;
❖ Metabolism is a major factor in determining toxicity;
❖ The products of metabolism are known as metabolites;
❖ There are two types of metabolism: -
1. Detoxification: -
➢ In detoxification, a xenobiotic is converted to a less toxic form;
➢ This is a natural defence mechanism of the organism;
➢ Generally, detoxification converts lipid-soluble compounds to polar compounds.
2. Bioactivation: -
➢ In bioactivation, a xenobiotic may be converted to more reactive or toxic forms;
➢ Cytochrome P-450 (CYP450) is an example of an enzyme pathway used to metabolize drugs;
➢ In the elderly, CYP450 metabolism of drugs such as phenytoin and carbamazepine may be decreased;
➢ Therefore, the effect of those drugs may be less pronounced;
➢ CYP450 metabolism also can be inhibited by many drugs;
➢ Risk of toxicity may be increased if a CYP450 enzyme-inhibiting drug is given with one that depends on that pathway for
metabolism.
E. Distribution within the body: -
❖ The distribution of toxicants and toxic metabolites throughout the body ultimately determines the sites where toxicity occurs;
❖ A major determinant of whether a toxicant will damage cells is its lipid solubility;
❖ If a toxicant is lipid-soluble, it readily penetrates cell membranes;
❖ Many toxicants are stored in the body;
❖ Fat tissue, liver, kidney, and bone are the most common storage sites;
❖ Blood serves as the main avenue for distribution;
❖ Lymph also distributes some materials.
F. Excretion: -
❖ The site and rate of excretion is another major factor affecting the toxicity of a xenobiotic;
❖ The kidney is the primary excretory organ, followed by the gastrointestinal tract, and the lungs (for gases);
❖ Xenobiotics may also be excreted in sweat, tears, and milk;
❖ A large volume of blood serum is filtered through the kidney;
❖ Lipid-soluble toxicants are reabsorbed and concentrated in kidney cells;
❖ Impaired kidney function causes slower elimination of toxicants and increases their toxic potential.
G. Health status: -
❖ The health of an individual or organism can play a major role in determining the levels and types of potential toxicity;
❖ For example, an individual may have pre-existing kidney or liver disease;
❖ Certain conditions, such as pregnancy, also are associated with physiological changes in kidney function that could influence toxicity.
H. Nutritional status: -
❖ Diet (nutritional status) can be a major factor in determining who does or does not develop toxicity. For example: -
➢ Consumption of fish that have absorbed mercury from contaminated water can result in mercury toxicity (an antagonist for mercury
toxicity is the nutrient selenium);
➢ Some vegetables can accumulate cadmium from contaminated soil (an antagonist for cadmium toxicity is the nutrient zinc);
➢ Grapefruit contains a substance that inhibits the P450 drug detoxification pathway, making some drugs more toxic.
19. Forensic medical classification of poisons and poisonings. Toxodynamics and toxicokinetics of poisons.

Forensic medical classification of poisons and poisoning.

❖ Classification of poisons: -
1. Based on their toxic effects in the body as: -
A. Poisons which cause death by anoxia: -
➢ Poisons which make haemoglobin incapable of transporting oxygen (e.g. Carbon monoxide, nitrites);
➢ Poisons which inhibit cellular respiratory enzymes (e.g. cyanides);
➢ Poisons which destroy haemopoietic organs (e.g. radioactive substances).
B. Poisons, which on contact cause irritation or corrosiveness of the organs (skin) or damage the organ through which they are
excreted (GI tract, respiratory tract, urinary tract): -
➢ Irritant gases;
➢ Alkaline corrosives;
➢ Corrosive inorganic acids/corrosive organic acids;
➢ Heavy metals.
C. Poisons, which damage protoplasm or parenchyma: -
➢ These poisons produce local irritation and after absorption cause damage to the cells and capillaries (e.g. Phosphorus and carbon
tetrachloride);
D. Poisons, which affect the nerve cells and fibres (e.g. Hypnotics, narcotics, anaesthetics, alcohol, some alkaloids and glycosides).
2. Based on their chemical and physical nature: -
A. Organic poisons;
B. Inorganic poisons: -
➢ Inorganic poisons fall into two classes: -
I. Corrosives: -
 Substances that rapidly destroy or decompose the body tissues at point of contact;
 Some examples are: -
• Hydrochloric, nitric, and sulfuric acids; • Sodium hydroxide;
• Phenol; • Iodine.
II. Metals and their salts: -
 Corrosive and irritate locally, but the chief action occurs after absorption when they damage internal organs, especially those of
excretion;
 Some examples are: -
• Arsenic; • Iron; • Mercury.
• Copper; • Lead;
C. Gaseous poisons: -
➢ These poisons are present in the gaseous state and if inhaled, destroy the capability of the blood as a carrier of oxygen and irritate or
destroy the tissues of the air passages and lungs;
➢ Inhaled or ingested cyanide, used as a method of execution in gas chambers, almost instantly starves the body of energy by inhibiting the
enzymes in mitochondria that make ATP;
➢ When in contact with the skin and mucous membranes, gaseous poisons produce lacrimation, blistering, inflammation, and congestion;
➢ Examples include: -
 Carbon monoxide;  Sulphur dioxide;  Chemical warfare
 Carbon dioxide;  Ammonia gas; agents
 Hydrogen sulphide;  Chlorine gas;
D. Nitrogenous/non-nitrogenous organic poisons: -
3. Based on their origin as plant poisons, toxins, venoms, man-made, etc.
❖ Classification of poisonings: -
1. Acute: -
➢ Acute poisoning is associated with exposure to a relatively large, often single, dose of a toxic agent, this being followed by rapid manifestation
of more severe clinical signs of intoxication;
➢ It is also defined as sudden violent syndrome caused by a single large dose of poison.
2. Sub-acute: -
➢ In sub-acute poisoning the exposure level is lower and the survival time longer, than in acute poisoning, but the period between exposure and
manifestation of signs of poisoning and possible death is again relatively short;
➢ Symptoms of toxicity develop gradually;
3. Chronic: -
➢ Chronic poisoning is usually caused by multiple exposures to the poison, while individual quantities are not sufficiently large to produce clinical
intoxication;
➢ It is also defined as persistent lingering condition brought about by small repeated doses;
➢ A relatively long delay is observed between the first exposure to the toxic agent and the eventual development of signs of poisoning;
➢ Agents that cause chronic poisoning exhibit a cumulative effect;
➢ They either accumulate within the body or produce additive tissue damage;
➢ Once this level becomes critical, symptoms of poisoning develop;
➢ In some cases, the development of symptoms of poisoning may be noticed many months after the exposure, even if there is no contact with
the poison during the intervening period;
➢ In the chronic toxicity studies, the exposure time is six months to two years for rodents and one year for non-rodents.

Toxodynamics and toxicokinetics.

❖ Toxicodynamics: -
➢ Toxicodynamics describes the dynamic interactions of a toxicant with a biological target and its biological effects;
 ➢ A biological target, also known as the site of action, can be binding proteins, ion channels, DNA, or a variety of other receptors;
➢ When a toxicant enters an organism, it can interact with these receptors and produce structural or functional alterations;
➢ The mechanism of action of the toxicant, as determined by a toxicant’s chemical properties, will determine what receptors are targeted and the
overall toxic effect at the cellular level and organ level.
❖ Toxicokinetics: -
➢ Toxicokinetics is the description of both what rate a chemical will enter the body and what occurs to excrete and metabolize the compound once it
is in the body;
➢ 4 potential processes exist for a poison interacting with a person: -
1. Absorption: -
 Absorption describes the entrance of the chemical into the body, and can occur through the air, water, food, or soil.
2. Distribution: -
 Once a chemical is inside a body, it can be distributed to other areas of the body through diffusion or other biological processes.
3. Metabolism: -
 At this point, the chemical may undergo metabolism and be bio transformed into other chemicals (metabolites);
 These metabolites can be less or more toxic than the parent compound.
4. Excretion: -
 After this potential biotransformation occurs, the metabolites may leave the body, be transformed into other compounds, or continue to be
stored in the body compartments.
20. Corrosive, destructive and blood poisons.

Corrosive poisons
❖ Corrosive substances are used as suicidal poisons and for homicide and assaults in the form of ‘acid bombs (they are also used as agents of torture);
❖ Corrosives irritate, necrose or destroy any surface with which they come into contact;
❖ These actions depend on the concentration of the substance and the length of time for which it acts;
❖ If used in a very concentrated form, the damage is almost instantaneous and is likely to be very severe;
❖ The action of any corrosive substance is a surface phenomenon, whether on the skin or the respiratory or gastrointestinal mucosa, but continued
contact will enable the corrosion to penetrate deeply, so perforation of internal structures such as the oesophagus or stomach may occur with prolonged
exposure;
❖ There is often spillage of the corrosive agent on the exterior of the body, and the patterns of skin injury can help to reconstruct the way in
which the substance was taken or applied: -
➢ For example, a person swallowing acid or alkali from a cup whilst standing or sitting usually has overflow marks around the corners of the mouth
and dribbles that run down the chin, neck and perhaps chest.
➢ If they were lying down or had immediately fallen back, the trickle marks are likely to be down the side of the face, cheeks and on to the side of the
neck. Coughing and spluttering may project the poison on to the hands, clothing or nearby objects – the fingers are often held to the mouth and
also become corroded;
➢ Deliberate splashing with acid will result in areas or spots of injury and there may be vertical dribbles from the points of contact if the victim was
standing;
❖ Internally, oesophageal and gastric damage is to be expected if the substance is swallowed, and there may also be overflow into the glottis and larynx,
with aspiration into the trachea and bronchi, which may cause extensive damage;
❖ Lung damage and bronchopneumonia are common sequelae if the victim survives the acute phase;
❖ Vomiting is an additional risk as acid or alkali already swallowed may be aspirated into the larynx during uncontrolled regurgitation;
❖ If victims survive, they may need surgical repair of acute perforations and, at a later stage, treatment for stenosis caused by scarring of the oesophagus,
pharynx and stomach;
❖ The common corrosives include: -
➢ Acids: –
 Strong mineral acids (sulphuric, nitric and hydrochloric);
 Organic acids like acetic, formic and oxalic;
➢ Alkalis: –
 E.g. sodium hydroxide, potassium hydroxide, calcium hydroxide and ammonium hydroxide;
➢ Miscellaneous substances: –
 Household bleaches and strong detergents containing sodium hypochlorite and sodium acid sulphate.
❖ The symptoms are obvious and immediate: -
➢ Pain at the sites of exposure usually the mouth and on the skin; ➢ Difficulty in breathing;
➢ Difficulty in swallowing/choking; ➢ If the amount ingested is significant, there will be signs of
➢ Chest and abdominal pain; shock, with collapse, a weak and rapid pulse, hypotension and
➢ Vomiting; possibly death, even if treatment is available straightaway.
❖ Autopsy findings: -
➢ At autopsy, the lips, face and other affected skin are likely to be discoloured and corroded, depending upon the amount/type/conc. of the corrosive;
➢ Corrosion may extend for a variable distance down into the pharynx, oesophagus and stomach and may even extend into the small intestine,
depending upon the volume swallowed;
➢ Acids tend to corrode and thicken the mucosa, whereas alkalis turn the lining into a slimy, soft pulp;
➢ Perforation of the oesophagus or stomach is most common with sulphuric, hydrochloric or hydrofluoric acids.

Blood poisons
❖ What is blood poisoning: -
➢ Blood poisoning is a serious infection and occurs when bacteria are in the bloodstream;
➢ Despite its name, the infection has nothing to do with poison;
➢ Although not a medical term, “blood poisoning” is used to describe bacteraemia, septicaemia, or sepsis;
➢ Sepsis is a serious, potentially fatal infection;
➢ Blood poisoning can progress to sepsis rapidly.
❖ What causes blood poisoning: -
➢ Blood poisoning occurs when bacteria causing infection in another part of your body enter your bloodstream;
➢ The presence of bacteria in the blood is referred to as bacteraemia or septicaemia;
➢ The terms “septicaemia” and “sepsis” are often used interchangeably, though technically they aren’t quite the same: -
 Septicaemia, the state of having bacteria in your blood, can lead to sepsis;
 Sepsis is a severe and often life-threatening state of infection if it’s left untreated;
 Any type of infection — whether bacterial, fungal, or viral — can cause sepsis;
 These infectious agents don’t necessarily need to be in a person’s bloodstream to bring about sepsis.
➢ Such infections most commonly occur in the lungs, abdomen, and urinary tract;
➢ Sepsis happens more often in people who are hospitalized, where the risk of infection is already higher;
➢ Because blood poisoning occurs when bacteria enter your bloodstream in conjunction with another infection, you won’t develop sepsis without
having an infection first.
21. Poisonings with ethyl and methyl alcohols.

Ethyl Alcohol
❖ Ethanol is a small, water-soluble molecule that becomes distributed evenly throughout the body
water;
❖ It passes easily across the blood–brain barrier and has a profound depressant effect upon the
cerebral function;
❖ It is a drug with huge morbidity and mortality, with direct toxic effects on the body tissues, as
well as significant indirect effects (it is a very common catalyst in the majority of assaults and
homicides);
❖ Effects of alcohol: -
➢ Alcohol depresses the nervous system and any apparent initial excitant effect is due to
suppression of inhibition by the cerebral cortex;
➢ The drug begins to act at the lowest concentrations upon the higher centres and it affects
the lower centres of the central nervous system only when the BAC becomes higher;
➢ The effects of high levels of alcohol on the lower centres may jeopardize the function of the
cardiorespiratory centres in the brainstem, with a consequent danger of death;
➢ The earliest signs of alcohol intoxication can be found on objective testing with BAC as low
as 30 mg/100 mL, when driving skills begin to deteriorate;
➢ Behaviour begins to change at a very variable level, but this is also influenced by emotional
and environmental factors (a person is likely to appear more uninhibited in a student party
than in a very formal function given the same level of alcohol);

Methy Alcohols
❖ Poisoning caused by methyl alcohol is relatively uncommon;
❖ Methanol is oxidized by the liver to formaldehyde, which in turn is oxidized to formic acid (formic acid is 6 times more toxic than methanol);
❖ Symptoms of acute methanol poisoning are: -
➢ Weakness; ➢ Headache; ➢ Cyanosis.
➢ Nausea; ➢ Epigastric pain;
➢ Vomiting; ➢ Dyspnea;
❖ The symptoms may occur within half an hour after ingestion or may not appear for 24 h;
❖ If a fatal amount of methyl alcohol has been ingested, the above-mentioned symptoms will be followed by: -
➢ Stupor; ➢ Hypothermia;
➢ Coma; ➢ Death (death is nearly always preceded by blindness);
➢ Convulsions;
❖ If the individual does survive, he may be permanently blind, due to a specific toxicity for the retinal cells;
❖ Death in methyl alcohol poisoning is caused by the acidosis from production of organic acids and the CNS depressant action of the alcohol;
❖ Acidosis is the primary toxic factor in methyl alcohol poisoning, with the central nervous system depression a relatively minor factor;
❖ Formic acid is the primary agent responsible for the severe metabolic acidosis and ocular toxicity of methanol;
❖ Ingestion of 70–100 mL of methyl alcohol is usually fatal, though death may occur with ingestion of as little as 30–60 mL;
❖ As little as 10 mL of methanol can cause permanent blindness;
❖ Methyl alcohol can usually be detected up to 48 h after ingestion because of the slow rate of oxidation;
❖ The minimum lethal blood level in methyl alcohol poisoning is approximately 80 mg%.
22. Poisonings with substances of abuse (drugs of abuse).
❖ Heroin: -
➢ At autopsy of an individual who has died of an overdose of heroin, the lungs are heavy and show congestion;
➢ Microscopic examination of the lungs commonly reveals foreign-body granulomas with talc crystals (the talc probably has been used as a cutting
agent) and cotton fibres;
➢ The cotton originates from the “strainer” (A piece of cotton may be added to the mixture to “strain out” the impurities);
➢ There is usually enlargement of the periportal lymph nodes;
➢ Microscopic examination of the liver will reveal a chronic triaditis with a mononuclear cell infiltrate;
➢ Following injection, heroin (diacetylmorphine) is almost immediately metabolized to monoacetlymorphine (half-life 9 min).
➢ Monoacetylmorphine is then hydrolysed to morphine (half-life 38 min);
➢ Because of this, if one performs a toxicologic analysis on an individual who died from an overdose of heroin, one does not detect heroin in the
blood, but rather morphine and monoacetyl morphine;
➢ If both monoacetylmorphine and morphine are detected in the blood, then the individual took heroin;
➢ Small amounts of codeine may be detected in the blood or urine;
➢ Morphine is not metabolized to codeine, rather the codeine detected represents impurities in the compound used;
➢ Therefore, in heroin overdoses, on toxicological analysis one may detect morphine, monoacetylmorphine, and extremely low levels of codeine;
➢ Death is not directly related to blood concentration, due to the high tolerance individuals can build up;
➢ Therefore, a level that makes one individual “high” will kill another.
❖ Cocaine: -
➢ Cocaine can be sniffed, shot intravenously, or smoked as “crack.”;
➢ When smoked as crack, it is immediately absorbed by the lungs and reaches the brain within seconds;
➢ It takes slightly longer for its action to affect the brain when injected intravenously;
➢ Cocaine is a relatively short-acting drug such that to maintain a high, one has to take it every 15 min to an hour;
➢ Since it is a potent vasoconstrictor, snorting the drug can occasionally cause ulceration and perforation of the nasal septum with long-term use;
➢ Sudden death caused by an overdose of cocaine is linked to all three routes of abuse;
➢ It is more common, however, following intravenous injection and smoking of crack than snorting;
➢ Cocaine-related deaths are generally not dose related;
➢ Cocaine causes sudden death by 2 mechanisms: -
1. Cardiac arrhythmia caused by the direct action of the cocaine on the myocardium: -
 Cocaine acts on the heart to increase heart rate and force of contraction by blocking the reuptake of norepinephrine at the neuroeffector
junctions;
 It also causes increased release of catecholamines, which also stimulate the heart;
 Cocaine works on the alpha receptors in the coronary arteries to cause contraction, reducing myocardial perfusion;
 Thus, as the myocardium needs increasing amounts of oxygen, due to the stimulation of the beta-1 receptors, the amount of blood
perfusing the myocardium is reduced by vasoconstriction of the coronary arteries.
2. Cardiopulmonary arrest induced by the CNS action of the drug (cocaine, being a potent stimulant of the CNS, in overdoses can
overstimulate the CNS with subsequent cardiopulmonary arrest).
➢ Cocaine is rapidly hydrolyzed to benzoylecgonine and other derivatives by blood cholinesterases;
➢ After being taken, cocaine appears almost immediately in the urine;
➢ Habitual, prolonged, heavy use of cocaine can make an individual aggressive, violent, and paranoid;
➢ A chemical paranoid psychosis may be induced by the prolonged and heavy use of cocaine;
➢ Such individuals may become extremely violent and assaultive;
➢ They are often immune to the effects of pepper spray;
➢ They may die suddenly and unexpectedly during or immediately after a struggle.
❖ Methamphetamine and amphetamine: -
➢ Methamphetamine is a potent CNS stimulant that is readily produced illicitly;
➢ In the brain, it acts by both increasing release of dopamine and blocking its re-absorption, causing hyperstimulation of receptor neurons;
➢ Methamphetamine is also a cardiovascular stimulant;
➢ It blocks re-uptake of norepinephrine and causes an increase in catecholamine release;
➢ The euphoric effect is similar to cocaine but may last as long as ten times that of cocaine;
➢ Methamphetamine is metabolized to amphetamine, its major active metabolite;
➢ Amphetamine itself is rarely encountered;
➢ In overdoses, methamphetamine causes: -
 Restlessness;  Hallucinations;  Convulsions;
 Confusion;  Coma;  Cardiac arrhythmias;
➢ With chronic abuse, just like cocaine, it can produce a chemical paranoid psychosis;
➢ It is usually taken orally or intravenously though it may be snorted or smoked;
➢ Methamphetamine may be transformed into amphetamine hydrochloride (“ice”) which is smoked like crack cocaine;
➢ Methamphetamine has a half-life of 11–12 hours, with 45% excreted in urine unchanged over a number of days;
➢ Long-term use may be associated with myocardial fibrosis;
➢ Chronic use of methamphetamine may cause psychoses that can persist for months;
➢ Just like cocaine, methamphetamine-related deaths are generally not dose related;
➢ Just like cocaine, individuals may die suddenly during or immediately after a manic episode.

Lysergic acid diethylamide (LSD)

❖ This hallucinogenic substance, which is not addictive, was commonly used in the 1960s;
❖ It was associated with a number of deaths because of accidents during the so-called ‘trip’, as distortion of perception persuaded the users that they
could fly from high windows or stop passing buses with their bare hands;
❖ The hallucinations and visual disturbances associated with this drug can be terrifying (‘bad trip’) and some users have developed frankly psychotic
states resembling schizophrenia;
❖ The tiny (microgram) doses needed meant that LSD could be circulated with relative impunity, carried in a single drop soaked into a lump of sugar or a
scrap of blotting paper;
❖ Other hallucinogenic drugs include mescaline, originally extracted from a Mexican cactus, and psilocybin, a drug obtained from the ‘magic mushrooms’;
❖ More dangerous is phencyclidine, nick-named ‘angel dust’ or PCP (an acronym of its chemical name, phenyl-cyclohexyl-piperidine);
❖ This can be injected, inhaled or smoked, often in conjunction with other drugs;
❖ It produces hyperexcitability, often aggressive, and has led to many deaths, some of them suicidal or homicidal.

Solvent abuse
❖ During the 1980s and 1990s, a new form of addictive or dependent behaviour emerged, which was originally called ‘glue sniffing’ because the most
widely used substance that contained the active compound – toluene – was an adhesive;
❖ Toluene is not the only substance abused and nowadays a wide variety of volatile substances is used, most of which are organic solvents, giving the
name to the syndrome;
❖ The usual way in which these substances are used is by placing some of the solvent-containing material in a plastic bag and holding the open end over
the nose and mouth;
❖ Alternatively, the pure solvent is soaked onto a handkerchief or rag and the vapour is inhaled;
❖ Both methods give the desired effect of intoxication and hallucination;
❖ Volatiles such as paint stripper, typewriting erasing fluid, brush cleaner, household aerosols, fabric cleaner, gasoline as well as glue solvents are
misused in this way, as are many common materials that contain substances such as ethylene chloride, carbon tetrachloride, benzene, halon,
trichloethane, toluene, xylene and trichlorethylene;
❖ Another variation is the use of gases, such as butane, propane and bromo-fluoro-carbons;
❖ These can be obtained from cylinders for cigarette-lighter refills and cooking stoves and from fire extinguishers;
❖ The gas, under high pressure, may be sprayed directly into the mouth for inhalation, sometimes causing sudden death, perhaps from vagal stimulation
by the freezing gas;
❖ Death in any form of solvent abuse may be sudden and unexpected and from a variety of causes;
❖ Many of the solvents seem to sensitize the myocardium to catecholamines (adrenaline and noradrenaline) so that, even after the sniffing has ceased,
any sudden fright that releases catecholamines can precipitate ventricular fibrillation and cardiac arrest;
❖ Vomit entering the air passages, sheer hypoxia (especially if the plastic bag is placed over the head) or a direct toxic effect of the substance on the
tissues, especially the brain and myocardium, are alternative mechanisms;
❖ Little is found on examination of these victims, although if glue has been used frequently, there may be sores and blistering on the lips, and microscopic
damage to the cells of the liver, cerebral and cerebellum may occur;
❖ If solvent abuse is suspected, blood samples taken for toxicology must fill the container so that the solvent is not lost from the ‘head space’ when the lid
is removed;
❖ Organ samples must be placed in nylon bags to prevent loss of the solvent during transportation to the laboratory.

Complications of injections
❖ The repeated injection of drugs damages the peripheral veins wherever they are used, most commonly in the arms, hands and legs but sometimes in
the groin or neck;
❖ Repeated use of the same vein or group of veins leads to phlebitis and thrombosis, especially if the injected substance is either irritant or non-sterile;
❖ On examination, it is possible to see that the veins eventually become dark in colour under the skin and may feel hard and cord-like due to thrombosis
and fibrosis (the overlying skin may even ulcerate);
❖ Skin abscesses, which may extend deep into the subcutaneous tissues and depressed areas of fat atrophy, may complicate sites of intravenous drug
abuse and there is often fat necrosis and, with deep injection sites, chronic myositis;
❖ When healed, the superficial multiple puncture sites along a vessel may result in linear, white or silvery scars lying along the axis of the limb;
❖ There are numerous other complications, including septicaemia and subacute bacterial endocarditis, which may occur where pyogenic organisms are
injected or enter the bloodstream from abscesses and other sites of infection;
❖ Shared syringes: -
➢ The use of shared syringes and needles between groups of addicts can transmit hepatitis B and C, HIV virus and even malaria;
❖ Other complications of drug dependence are pulmonary tuberculosis and pneumonias, which develop from a combination of increased exposure to the
infective organisms due to poor living conditions and reduced resistance and poor nutrition.

Solid drugs
❖ Tablets are crushed or capsules are opened and the solid contents are then dissolved in water, commonly with a little citric acid to acidify the water and
using some heat from a lighter or candle;
❖ The water may be clean but is very seldom sterile and, more commonly, it is from a highly contaminated source such as a toilet;
❖ The solution obtained is drawn up into a syringe and then injected;
❖ Any undissolved fragments of drug or tablet filler will become impacted in the capillary beds and commonly lead to micro-emboli in the lungs and liver;
❖ Birefringent material (commonly the starch filler from the tablets) and granulomas can often be seen on microscopic examination of the lungs and there
may also be a wide spectrum of pulmonary changes, from acute abscesses to chronic fibrosis, associated with these debris emboli.

Overdosage and hypersensitivity

❖ Deaths may occur very rapidly, especially with the intravenous use of heroin (indeed, death may be so rapid that the needle and syringe may still be in
the vein when the body is found;
❖ A few of the deaths of ‘first-time users’ may be due to some personal hypersensitivity to the drug;
❖ However, the relative lack of hypersensitivity when using heroin or other opiates clinically suggests that if hypersensitivity does occur, it is more likely
that it is to some contaminant in the material that was injected rather than to the drug itself;
❖ Habituated users are not immune to sudden death;
❖ This may be due to hypersensitivity on the basis of previous exposure, but it may also be due to taking an excessive amount of drug, either deliberately
or accidentally, because a different supply has less diluent cut into it and so the same amount of powder contains a greater amount of active drug;
❖ The post-mortem features are commonly those of acute left ventricular failure with gross pulmonary oedema, which may rarely be apparent on external
examination as a plume of froth exuding from the mouth and nose.
23. Forensic medical expertise of living individuals – occasions, legal requirements, methods of examination, documentation.

Occasions
❖ A substantial part of clinical forensic medicine includes assessing and interpreting injury caused by all means (including physical, chemical, mechanical,
thermal and other related causes);
❖ Forensic medical examination of individuals is performed for the following purposes: -
1. Assessment of health damage (injury);
2. Assessment of health status (e.g. simulation, dissimulation, aggravation, artificial diseases, self-induced injuries);
3. Verification of sexual assault (rape, violent fulfilment of sexual desire etc.);
4. Solving other medical questions: -
➢ The nature of the injury (weapons and/or mechanisms involved);
➢ When the injury occurred;
➢ The mode of occurrence (accidental, self-harm or due to assault/sexual assault);
➢ The legal implications of diagnosis and potential consequences e.g. non accidental injury, intentional self-injury, torture etc.).
❖ The forensic specialist must give expert and definitive opinions for consideration by the appropriate legal authorities.

Legal requirements
❖ Forensic medical examination will be performed according to the expert examination order of the processor;
❖ Forensic medical examination can be performed either by a single expert or by a commission of experts;
❖ Forensic medical examination of an individual will be performed in a specially designed room suitable for medical examination and taking analysis;
❖ When the person is hospitalised, the examination can be performed in the hospital, and if agreed with the processor, also in a detention institution or at
the individual’s home;
❖ Forensic medical examination of the individual includes: -
 Review of preliminary data: -
 Medical examination of the victim;
 Assessment of medical documentation;
 Performance of additional investigations, if necessary;
 Preparation of an expert opinion.

Methods of examination, documentation.

❖ The following should be documented in the expert examination report: -
➢ Individuals explanation of the circumstances (what happened, when it happened and where);
➢ Health complaints (when including the complaints in the expert examination report it is recommended to state that such complaints were recorded
according to the words of the individual);
➢ Has the individual turned to the doctor (if yes, then to which healthcare institution, how long was the treatment period, has the individual been on
sick leave due to the injury, and are there any recommendations from the doctor);
➢ Has the individual had injuries before (if yes, then when, and which injuries have required treatment in the hospital);
➢ Past illnesses and injuries, in case they might affect the course of the current injury.
❖ Objective examination: -
➢ The aim of an objective examination is to describe the individual’s objective findings that differ from the normal findings, and can refer directly to the
presence of the injury or consequences of an injury;
➢ Objective examination includes the documentation of general status and description of the injuries: -
 General status will include the documentation of the individual’s: -
• Constitution; • Palpation findings;
• Height and weight (if applicable); • Condition of the respiratory and cardiovascular
• Behaviour; systems (blood pressure, respiratory rate and heart
• Physical condition (attitude towards the injury); rate);
• Skin colour/pigmentation (cyanosis, yellowish, pale); • Condition of the nervous system and visual and
• Oedema (around the eyes, face, feet); hearing organs will be assessed and described (e.g.
• Reddening of the eyes and sclera; assessment of simpler neurological symptoms like
• Observation of the spine and extremities (does the standing with closed eyes, tremor in extended hands,
person use supportive aids, are the gait and posture muscle rigidity and symmetry of muscle strength in
normal, are there any differences in the length of the extremities).
extremities);
 Description of the injuries: -
• When describing the injuries, it is important to take into account when the individual turned to medical examination, i.e. how much time
has passed since the occurrence of the injuries;
• The shorter this time period is, the better the possibilities are for the expert to define the time and mechanism of the occurrence of the
injuries;
• Frequently the individual is not able to turn to forensic medical examination as he/she needs medical treatment;
• In such an event it is the task of the doctor to document the presence of injuries in medical documentation, and also describe the injuries;
• It is important to indicate in the expert examination report the following data: -
o Localisation of the injuries (e.g. left or right side of the body, distance from permanent anatomical landmarks, third of an extremity,
flexion or extension surface, localisation in relation to anatomical lines and intercostal spaces on chest).
o Type of injuries (haematoma, bone fracture, laceration, etc.);
o Shape of injuries (e.g. irregular, round, oval, rectangle like, quadrate like, in case the injury resembles some well-known object, the
name of the object may be used);
o Characterisation of the surface of injury (e.g. covered with crust, lower or higher than the surrounding skin level, or at the same
level with the surrounding skin);
o Colour of onjuries (main colour should be the last one mentioned, e.g. bluish purple and reddish brown);
 o Dimensions of the injuries (length, width or diameter);
o Description of wound edges, corners and condition of the surrounding soft tissue in case of wounds;
o Shape, colour and dimensions in case of healed wounds.
• Injuries detected in medical examination will be photographed and numbered, and will be added to the expert examination report as a
table of labelled photographs with the signature and stamp of a forensic medical expert;
• Injuries detected in medical examination can be also indicated on a chart;
• Healthcare documentation: -
o Medical documents are provided to the forensic medical expert by the processor, or will be sent with the individual when he/she
comes to forensic medical examination;
o In the event that medical examination takes place in a hospital, the documents will be provided by the treating doctor;
o For the purpose of forensic medical examination, only original documents, or certified copies issued by the healthcare institution are
allowed;
o When documenting the contents of these documents in the expert examination report, it is not allowed to change their content, but it
is allowed to correct typing errors;
o The following data from the healthcare documentation will be included in the forensic examination report: -
- Date when the documents arrived in the department of forensic medical examination;
- Type of document (original or copy);
- Name of healthcare institution;
- Date and time when the patient turned to healthcare institution;
- General condition of the patient (consciousness, heart rate, blood pressure, respiration rate and other objective findings
characterising the general condition of the patient at the time when he/she turned to the healthcare institution);
- Description of the injuries;
- Initial clinical diagnosis;
- Diagnostic investigations;
- Treatment;
- Final clinical diagnosis;
25. Forensic medical thanatology – dying and death, diagnosis, and forensic medical classification of death.
Forensic medical thanatology
❖ Forensic medical thanatology is the scientific study of death;
❖ It investigates the mechanisms and forensic aspects of death, such as bodily changes that accompany death and the post-mortem period, as well as
wider psychological and social aspects related to death.
Dying and death
❖ Dying and death: -
➢ Dying means the transition from life to death;
➢ The terminal states are the boundaries between life and death;
➢ It consists of 4 stages: -
1. Pre-agony: -
 The pre-agony is characterized by the diverse duration (hours or days) of deep violations of the vitally important organism functions;
 Dyspnoea, the decreasing of the arterial pressure and darkening of the consciousness are observed in this period;
 Gradually the pre-agony transitions into agony.
2. Agony: -
 Agony is a stage which precedes death;
 The function of vital organs is severe disturbed, and the conditions required for the survival of an organism cannot be met: -
• Unconsciousness; • No pulse on arteries.
• Blood pressure is undetectable;
 The agony lasts 2-4 minutes, sometimes more.
3. Clinical death (reversible injury): -
 Circulation stops completely, leading to the cessation of breathing and nervous system activity (however the metabolism still continues);
 The life can be restored on this stage.
4. Biological death (irreversible injury): -
 The biological death is characterized by the irreversible changes in the organism.
Diagnosis and forensic medical classification of death.
❖ Clinical death: -
➢ Clinical death is the medical term for cessation of blood circulation and breathing, the two necessary criteria to sustain human life;
➢ It occurs when the heart stops beating, a condition called cardiac arrest;
➢ It may be reversible;
➢ The organs can be used for transplantation;
➢ Signs and symptoms at the onset of clinical death: -
 Consciousness is lost within several seconds;  Irregular gasping may occur during this early time period,
 Measurable brain activity stops within 20 to 40 seconds; and is sometimes mistaken by rescuers as a sign that
 No pulse on arteries (carotid or femoral); CPR is not necessary;
 Dilatation of eye pupils;  During clinical death, all tissues and organs in the body
 Duration of clinical death is 30 minutes; steadily accumulate a type of injury called ischemic injury;
❖ Brain death: -
➢ Brain death is the complete loss of brain function (including involuntary activity necessary to sustain life);
➢ It differs from persistent vegetative state, in which the person is alive and some autonomic functions remain;
➢ It is also distinct from an ordinary coma, whether induced medically or caused by injury and/or illness, even if it is very deep, as long as some brain
and bodily activity and function remains;
➢ Patients classified as brain-dead can have their organs surgically removed for organ donation;
➢ Medical criteria: -
 A brain-dead individual has no clinical evidence of brain function upon physical examination;
 This includes no response to pain and no cranial nerve reflexes;
 Brain electrical activity can stop completely, or drop to such a low level as to be undetectable with most equipment;
 An EEG will therefore be flat (though this is sometimes also observed during deep anaesthesia or cardiac arrest);
 The diagnosis of brain death is often required to be highly rigorous, in order to be certain that the condition is irreversible;
 Legal criteria vary, but in general require neurological examinations by two independent physicians;
 The exams must show complete and irreversible absence of brain function and may include two isoelectric (flat-line) EEGs 24 hours apart;
 The patient should have a normal temperature and be free of drugs that can suppress brain activity if the diagnosis is to be made on EEG
criteria;
 Also, a radionuclide cerebral blood flow scan that shows complete absence of intracranial blood flow must be considered;
❖ Somatic death: -
➢ Somatic death means that the individual will never again communicate or deliberately interact with the environment;
➢ The individual is irreversibly unconscious and unaware of both the world and his own existence;
❖ Biological death: -
➢ Biological death means the cessation of respiration (the utilization of oxygen) and the normal metabolic activity in the body tissues and cells;
➢ Cessation of respiration is followed by autolysis and decay, which, if it affects the whole body, is indisputable evidence of true death;
➢ The differences in cellular metabolism determine the rate with which cells die and this can be very variable:
-
 Skin and bone remains metabolically active and thus ‘alive’ for many hours and these cells can be successfully
cultured days after somatic death;
 White blood cells are capable of movement for up to 12 hours after cardiac arrest;
 The cortical neuron, on the other hand, will die after only 3–7 minutes of complete oxygen deprivation;
 A body dies cell by cell and the complete process may take many hours.
➢ It usually takes place one to two hours after stoppage of vital functions of body and is irreversible;
➢ A person cannot be revived if biological death has taken place;
➢ Most organs become dead after biological death and cannot be used for organ transplantation.
➢ The obvious signs of biological death are as follows (in sequential order): -
26. Early post mortal changes. Forensic medical fross examination of the maxillofacial area of cadaver
1. Paleness of the body (pallor mortis): -
 This occurs more vividly in those with light/white skin;
 Cause: -
• Pallor mortis results from the collapse of capillary circulation throughout the body;
• Gravity then causes the blood to sink down into the lower parts of the body, creating livor mortis.
 Timing and applicability: -
• Pallor mortis occurs almost immediately, generally within 15–25 minutes, after death;
• Paleness develops so rapidly after death that it has little to no use in determining the time of death, aside from saying that it either happened
less than 30 minutes ago or more, which could help if the body were found very soon after death.
2. Algor Mortis: -
 Algor mortis, the second stage of death, is the change in body temperature post mortem, until the ambient temperature is matched;
 This is generally a steady decline, although if the ambient temperature is above the body temperature (such as in a hot desert), the change in
temperature will be positive, as the (relatively) cooler body acclimates to the warmer environment;
 Generally, temperature change is considered an inaccurate means of determining time of death, as the rate of change is affected by
several key factors, including: -
o Stability or fluctuation of the ambient temperature. o Diseases or drugs which increase body temperature and
o The level and thickness of clothing or similar materials. thereby raise the starting temperature of the corpse at the
o The thermal conductivity of the surface where a body lies. time of death
3. Rigor mortis (post-mortem rigidity): -
 Characterized by stiffening of the limbs of the corpse caused by chemical changes in the muscles post-mortem;
 In humans, rigor mortis can occur as soon as four hours after death;
 Physiology: -
• After death, respiration in an organism ceases, depleting the source of oxygen used in the making of adenosine triphosphate (ATP);
• ATP is required to cause separation of the actin-myosin cross-bridges during relaxation of muscle;
• When oxygen is no longer present, the body may continue to produce ATP via anaerobic glycolysis;
• When the body's glycogen is depleted, ATP concentration diminishes, and the body enters rigor mortis as it is unable to break those bridges;
• Normal relaxation would occur by replacing ADP with ATP, which would destabilize the myosin-actin bond and break the cross-bridge;
• However, as ATP is absent, there must be a breakdown of muscle tissue by enzymes (endogenous or bacterial) during decomposition;
• As part of the process of decomposition, the myosin heads are degraded by the enzymes, allowing the muscle contraction to release and the
body to relax;
• Decomposition of the myofilaments occurs 48 to 60 hours after the peak of rigor mortis, which occurs approximately 13 hours after death.
 Timing and applicability: -
• The degree of rigor mortis may be used in forensic pathology, to determine the approximate time of death;
• A dead body holds its position as rigor mortis sets in;
• If the body is moved after death, but before rigor mortis begins, forensic techniques such as livor mortis can be applied;
• If the position in which a body is found does not match the location where it is found (for example, if it is flat on its back with one arm sticking
straight up), that could mean someone moved it;
• Several factors also affect the progression of rigor mortis, and investigators take these into account when estimating the time of death;
• One such factor is the ambient temperature: -
o In warm environments, the onset and pace of rigor mortis is sped up due to a favourable environment for the metabolic processes that
cause decay, whilst low temperature slow them down;
o Therefore, for a person who dies outside in frozen conditions rigor mortis may last several days more than normal, so investigators may
have to abandon it as a tool for determining time of death.
4. Post-mortem lividity (livor mortis): -
 Livor mortis (lividity/post-mortem hypostasis) is a reddish-purple coloration in dependent areas of the body due to accumulation of blood in the
small vessels of the dependent areas secondary to gravity;
 Post-mortem lividity is occasionally misinterpreted as bruising by people unfamiliar with this phenomenon;
 Dependent areas resting against a firm surface will appear pale in contrast to the surrounding livor mortis due to compression of the vessels in this
area, which prevents the accumulation of blood;
 Thus, areas supporting the weight of the body, for example, the shoulder blades, buttock and calves in individuals lying on their backs, show no
livor mortis, but appear as pale or blanched areas;
 Tight clothing, for example, a brassiere, corset, or belt, which compresses soft tissues, collapsing the vessels, also produces pale areas;
 Timing and applicability: -
• Livor mortis is usually evident within 30 min to 2 h after death;
• In individuals dying a slow lingering death with terminal cardiac failure, livor mortis may actually appear antemortem;
• Livor mortis develops gradually, reaching its maximum coloration at 8–12 h, at about which time it is said to become “fixed”: -
o Livor mortis becomes “fixed” when shifting or drainage of blood no longer occurs, or when blood leaks out of the vessels into the
surrounding soft tissue due to haemolysis and breakdown of the vessels;
o Fixation can occur before 8–12 hours if decomposition is accelerated, or at 24–36 h if delayed by cool temperatures;
o Prior to becoming fixed, livor mortis will shift as the body is moved;
• Although livor mortis may be confused with bruising, bruising is rarely confused with livor mortis: -
o Application of pressure to an area of bruising will not cause blanching;
o An incision into an area of contusion or bruising shows diffuse haemorrhage into the soft tissue;
o In contrast, an incision into an area of livor mortis reveals the blood to be confined to vessels, without blood in the soft tissue;
• Livor mortis also occurs internally, with settling of the blood in the dependent aspects of an organ (this is most obvious in the lungs);
• As the blood accumulates in the dependent areas, the pressure of the settling blood can rupture small vessels, with development of petechiae
(minute haemorrhages or Tardieu spots) and purpura (patches of purplish discoloration);
• This usually takes 18–24 h and often indicates that decomposition is fast approaching;
27. Late post mortal changes. Forensic medical gross examination of the maxillofacial area of cadavers.
1. Putrefaction: -
❖ Putrefaction is the fifth stage of death, following pallor mortis, algor mortis, rigor mortis, and livor mortis;
❖ In broad terms, it can be viewed as the decomposition of proteins, and the eventual breakdown of the cohesiveness between tissues, and the
liquefaction of most organs;
❖ This is caused by the decomposition of organic matter by bacterial or fungal digestion, which causes the release of gases that infiltrate the body's
tissues, and leads to the deterioration of the tissues and organs;
❖ The approximate time it takes putrefaction to occur is dependent on various factors: -
➢ Internal factors: -
 Age at which death has occurred: -
• Stillborn foetuses and infants putrefy slowly due to their sterility;
• Otherwise, however, generally, younger people putrefy more quickly than older people.
 The overall structure and condition of the body: -
• A body with a greater fat percentage and less lean body mass will have a faster rate of putrefaction, as fat retains more heat and it carries
a larger amount of fluid in the tissues.
 The cause of death: -
• The cause of death has a direct relationship to putrefaction speed, with bodies that died from acute violence or accident generally
putrefying slower than those that died from infectious diseases;
• Certain poisons, such as potassium cyanide or strychnine, may also delay putrefaction, while chronic alcoholism will speed it;
• Antemortem or post-mortem injuries can speed putrefaction as injured areas can be more susceptible to invasion by bacteria.
➢ External factors: -
 Environmental temperature: -
• Decomposition is accelerated by high atmospheric or environmental temperature, with putrefaction speed optimized between 21 °C and
38 °C, further sped along by high levels of humidity;
• This optimal temperature assists in the chemical breakdown of the tissue and promotes microorganism growth;
• Decomposition nearly stops below 0 °C (32 °F) or above 48 °C (118 °F).
 Moisture & air exposure: -
• Putrefaction is ordinarily slowed by the body being submerged in water, due to diminished exposure to air;
• Air exposure and moisture can both contribute to the introduction and growth of microorganisms, speeding degradation;
• In a hot and dry environment, the body can undergo a process called mummification where the body is completely dehydrated and
bacterial decay is inhibited.
 Clothing: -
• Loose-fitting clothing can speed up the rate of putrefaction, as it helps to retain body heat;
• Tight-fitting clothing can delay the process by cutting off blood supply to tissues and eliminating nutrients for bacteria to feed on.
 Burial factors: -
• Speedy burial can slow putrefaction;
• Bodies within deep graves tend to decompose more slowly due to the diminished influences of changes in temperature;
• The composition of graves can also be a significant contributing factor, with dense, clay-like soil tending to speed putrefaction while dry
and sandy soil slows it.
 Light exposure: -
• Light can also contribute indirectly, as flies and insects prefer to lay eggs in areas of the body not exposed to light, such as the crevices
formed by the eyelids and nostrils.
❖ The first signs of putrefaction are signified by a greenish discoloration on the outside of the skin on the abdominal wall corresponding to where the
large intestine begins, as well as under the surface of the liver;
❖ Certain substances, such as carbolic acid, arsenic, strychnine, and zinc chloride, can be used to delay the process of putrefaction;
❖ Process: -
➢ The bacterial digestion of the cellular proteins weakens the tissues of the body;
➢ As the proteins are continuously broken down to smaller components, the bacteria excrete gases and organic compounds, such as the
functional-group amines putrescine (from ornithine) and cadaverine (from lysine), which carry the noxious odour of rotten flesh;
➢ Initially, the gases of putrefaction are constrained within the body cavities, but eventually diffuse through the adjacent tissues, and then into the
circulatory system;
➢ Once in the blood vessels, the putrid gases infiltrate and diffuse to other parts of the body and the limbs
➢ The visual result of gaseous tissue-infiltration is notable bloating of the torso and limbs;
➢ The increased, internal pressure of the continually rising volume of gas further stresses, weakens, and separates the tissues constraining the
gas;
➢ In the course of putrefaction, the skin tissues of the body eventually rupture and release the bacterial gas;
➢ As the anaerobic bacteria continue consuming, digesting, and excreting the tissue proteins, the body's decomposition progresses to the stage of
skeletonization;
➢ This continued consumption also results in the production of ethanol by the bacteria, which can make it difficult to determine the blood alcohol
content (BAC) in autopsies, particularly in bodies recovered from water.
❖ Timeline: -
1 – 2 days Pallor mortis, algor mortis, rigor mortis, and livor mortis are the first steps in the process of decomposition before the process of
putrefaction.
2 – 3 days Discoloration appears on the skin of the abdomen;
The abdomen begins to swell due to gas formation.
3 – 4 days The discoloration spreads and discoloured veins become visible.
5 – 6 days The abdomen swells noticeably and the skin blisters.
10 – 20 days Black putrefaction occurs, which is when noxious odors are released from the body and the parts of the body undergo a black discoloration.
2 weeks The abdomen is bloated and internal gas pressure nears maximum capacity.
3 weeks Tissues have softened;
Organs and cavities are bursting;
The nails fall off.
4 weeks Soft tissues such as the internal organs begin to liquefy and the face becomes unrecognizable;
Leads to skeletonization where the skin, muscles, tendons and ligaments degrade exposing the skeleton.
➢ Timeline for the decomposition of organs in the body: -
1. Larynx and trachea 7. Liver 13. Oesophagus
2. Infant brain 8. Adult brain 14. Pancreas
3. Stomach 9. Heart 15. Diaphragm
4. Intestines 10. Lungs 16. Blood vessels
5. Spleen 11. Kidneys 17. Uterus
6. Omentum and mesentery 12. Bladder
➢ The rate of putrefaction is greatest in air, followed by water, soil, and earth;
➢ The exact rate of putrefaction is dependent upon many factors such as weather, exposure and location;
➢ Thus, refrigeration at a morgue or funeral home can retard the process, allowing for burial in three days or so following death without embalming;
➢ The rate increases dramatically in tropical climates;
➢ The first external sign of putrefaction in a body lying in air is usually a greenish discoloration of the skin over the region of the caecum, which
appears in 12–24 hours;
➢ There is also visible marbling of vessels;
➢ The first internal sign is usually a greenish discoloration on the under surface of liver.
2. Decomposition: -
❖ The process of decomposition within human remains is the action of breaking down organic substances into simple organic matter over time;
❖ There are 5 general stages of decomposition, each with specific signs to help identify the stage : -
1. Fresh: -
➢ Within the first stage, fresh, the remains are usually intact or uncontaminated by bugs and visible bacteria;
➢ Often, the remains are cold and livor mortis has begun, in which the blood follows the laws of gravity and pools of whichever side of the body
is laying toward the ground.
2. Bloat: -
➢ Going to the next stage, bloat, in which the remains begin to fill with gases that are being emitted from the bacteria inside the body;
➢ This also causes the remains to purge from the nose or mouth;
➢ The body can also experience what is called "skin slippage" in which the first layer of skin begins to slough off the remains.
3. Active decay: -
➢ Once the remains have experienced the bloat stage, the body is now in active decay, in which different bugs and insects are often helping
break down the remains along with active bacteria thriving in the body;
➢ Here you will see skin start to blacken as well as the arrival of different insects;
➢ The most common insect that is found with human remains is the maggot;
➢ You can also determine PIM, the post-mortem interval, using entomology and looking at the length of a maggot;
➢ For example, if a maggot is 15 millimetres long it is one week old, which can determine the body has been dead for at least one week.
4. Advanced decay: -
➢ Within advanced decay all of the remains have become discoloured and often blackened;
➢ Putrefaction has also almost completed, in which the tissues and cells have broken down and liquidized as the body decayed.
5. Dry/remains: -
➢ Once the bloating has ceased and usually the remains soft tissue has collapsed in, onto itself;
➢ At the end of active decay, the remains have often dried out and are beginning to skeletonize.
❖ The decomposition of human remains can vary within these five stages due to the many different environments that humans can be placed within;
❖ Different aspects such as temperature, location and body size can create variance in how human remains decompose: -
➢ Decomposition within hot and humid environments: -
 Heat helps active bacteria grow fast and thrive within the warmer environment, causing the remains to break down faster and begin to bloat
quicker from the gases.
➢ Decomposition within cold environments: -
 Within colder and dryer environments, the stages of decomposition are slowed down;
 The lower temperatures cause a slowing of bacteria growth which causes the bloating stage to slow significantly;
 In extreme temperatures, bacteria activity can be almost non-existent as the bacteria cannot survive within the low temperature.
➢ Decomposition within water: -
 The addition of water drastically affects the stages of decomposition and the breakdown of human remains;
 The remains bloat much faster when sitting in water as water is being absorbed by the remains along with bacteria breaking down material;
3. Skeletonization: -
❖ Skeletonization refers to the final stage of decomposition, during which the last vestiges of the soft tissues of a corpse or carcass have decayed or
dried to the point that the skeleton is exposed;
❖ By the end of the skeletonization process, all soft tissue will have been eliminated, leaving only disarticulated bones;
❖ In a temperate climate, it usually requires three weeks to several years for a body to completely decompose into a skeleton, depending on factors
such as temperature, humidity, presence of insects, and submergence in a substrate such as water;
❖ In tropical climates, skeletonization can occur in weeks, while in tundra areas, skeletonization may take years or may never occur, if sub-zero
temperatures persist;
❖ The rate of skeletonization and the present condition of a corpse or carcass can be used to determine the time of death;
❖ After skeletonization, if scavenging animals do not destroy or remove the bones, acids in many fertile soils take about 20 years to completely
dissolve the skeleton of mid- to large-size mammals, such as humans, leaving no trace of the organism;
❖ In neutral-pH soil or sand, the skeleton can persist for hundreds of years before it finally disintegrates;
❖ Alternately, especially in very fine, dry, salty, anoxic, or mildly alkaline soils, bones may undergo fossilization, converting into minerals that may
persist indefinitely.
28. Individual identification by dental status, single teeth, teeth prosthetic construction (age, sex) – main methods of examination.
❖ Forensic odontology (forensic dentistry) is now a forensic specialty in its own right and, wherever possible, medico-legal problems involving teeth or bite
marks should be passed to a dentist who has been trained and is qualified in forensic work;
❖ The forensic odontologist has two main areas of expertise: -
1. Assisting in identification, usually of the dead; 2. The examination and comparison of bite marks.
❖ In the living, odontology can also be used in the estimation of age in young people, especially for purposes of immigration, adoption and similar civil
matters;
❖ The forensic odontologist is commonly requested to confirm the identity of a body by comparing antemortem dental chartings with the information gained
from a direct examination of the teeth;
❖ The odontologist may also be asked to make dental chartings of bodies whose identity remains unknown or unconfirmed despite a police investigation,
so that, should dental information become available at a later date, the two sets of records may be then be compared;
❖ It is important to remember that neither a living individual person nor a body can be identified simply by taking a dental chart – that chart has to be
compared with, and found to match, a chart whose origins are known.
❖ The forensic odontologist is of prime importance in mass disasters where trauma is likely to make identification impossible;
❖ The great advantage of dental identification is that the teeth are the hardest and most resistant tissues in the body and can survive total decomposition
and even severe fire;
❖ Where no previous records are available, examination of the mouth and the teeth can still give some general information on age, sex and
ethnic origin: -
➢ In a young person aged 20–25 years or less, the eruption of the deciduous and permanent teeth can be compared with standard charts;
➢ In the absence of teeth, a general idea of age can also be gained by the appearance of the jaws, especially the mandible, as the edentulous jaw is
thinner;
➢ In the hands of an expert, the teeth may also give a clue as to gender and race: -
 The gender is not very reliable and depends upon size and molar cusp numbers;
 The identification of ethnicity is limited to the upper incisors, which in some mongoloid races show a characteristic ‘shovel-shaped’ concavity,
and the palate in negroid people is said to have a deeper U-shape.

29. Personal identification by bitemarks.

❖ Bite marks can be recorded in violent crimes such as sexual offences, homicides, child abuse cases, and during sports events;
❖ The severity of bite marks depends upon: -
➢ Duration; ➢ Degree of movement between tooth and tissue.
➢ Degree of force applied;
❖ Classification: -
➢ Bite marks can be broadly classified as: -
1. Non-human (animal bite marks); 2. Human bite marks
➢ Based on the manner of causation, the bite marks can be: -
1. Non-criminal (such as love bites);
2. Criminal, which can further be classified into: -
I. Offensive (upon victim by assailant);
II. Defensive (upon assailant by victim).
➢ Bite marks can cause 7 types of trauma on the skin: -
1. Haemorrhage (a small bleeding spot); 5. Incision (neat punctured or torn skin);
2. Abrasion (undamaging mark on the skin); 6. Avulsion (removal of skin);
3. Contusion (ruptured blood vessels and bruising); 7. Artefact (bitten-of piece of body);
4. Laceration (near puncture of the skin);
❖ Many individuals have been positively identified and convicted on the basis of bite marks since bite marks can be as individual as
fingerprints: -
➢ The arrangement, size and alignment of human teeth are individualistic to each person;
➢ Teeth, acting as tools leave recognizable marks depending on tooth arrangement, malocclusion, habits, tooth fracture, missing/extra teeth, etc.;
➢ Bite mark identification is based on the individuality of a dentition, which is used to match a bite mark to a suspect;
➢ Bite marks are often considered as valuable alternative to fingerprinting and DNA identification in forensic examinations.
➢ Thus, in any case in which a bite mark is present on an individual, whether living or dead, the mark should first be swabbed for recovery of saliva
for DNA testing;
➢ The bite mark should then be documented photographically, with a scale present in the picture;
❖ If a forensic odontologist is on call, he should be summoned at the time of the examination to perform the aforementioned: -
➢ The examination and comparison of bite marks: -
 Bites can occur on both the victim and the suspect since teeth can be used as a weapon by the aggressor and in self-defence by the victim;
 Bite marks may be found virtually on any part of the human body;
 Bite marks can be altered through stretching, movement, or change in environment after the bite.
 Factors that may affect the accuracy of bite mark identification include: -
• Poor photography; • Poor measurement of dentition characteristics;
• Poor impressions; • Time-dependent changes of the bite mark in living
• Similarities in dentition among individuals; bodies;
 Most bite mark analysis studies use porcine skin (pigskin), because it is comparable to the skin of a human (and it is considered unethical to
bite a human for study);
 Limitations to the bite mark studies include differences in properties of pigskin compared to human skin (although similar histologically, pigskin
and human skin behave in dynamically different ways due to differences in elasticity);
 Bite mark analysis is also controversial because dental profiles are subject to change: -
• The loss of teeth or the alteration of arch configuration through a variety of procedures is common in human populations;
• The onset of oral diseases such as dental caries has been shown to alter the arch and tooth configuration and must be taken into account
when comparing a dental profile to the bite mark after a significant amount of time has passed since the mark was made.
30. Medical deontology – definition, deontological resources.
Definition
❖ Medical deontology is defined as a discipline for the study of norms of conduct for the health care professionals, including moral and legal norms as well
as those pertaining more strictly to professional performance;
❖ It is set of ethical standards and principles of behaviour of medical practitioners while executing their professional duties;
❖ There are several key values outlined in medical deontology: -
1. Autonomy: -
➢ The definition of autonomy is the ability of an individual to make a rational, uninfluenced decision;
➢ Therefore, it can be said that autonomy is a general indicator of a healthy mind and body;
➢ The progression of many terminal diseases is characterized by loss of autonomy, in various manners and extents (for example, dementia, a
chronic and progressive disease that attacks the brain can induce memory loss and cause a decrease in rational thinking, almost always
results in the loss of autonomy);
➢ Psychiatrists and clinical psychologists are often asked to evaluate a patient's capacity for making life-and-death decisions at the end of life;
➢ Persons with a psychiatric condition such as delirium or clinical depression may lack capacity to make end-of-life decisions;
➢ For these persons, a request to refuse treatment may be taken in the context of their condition;
➢ Unless there is a clear objection from the patient, persons lacking mental capacity are treated according to their best interests;
➢ This will involve an assessment involving people who know the person best, such as family members and friends, to what decisions the person
would have made had they not lost capacity;
2. Beneficence: -
➢ The term beneficence refers to actions that promote the well-being of others;
➢ In the medical context, this means taking actions that serve the best interests of patients and their families.
3. Non maleficence: -
➢ Nonmaleficence means non-harming or inflicting the least harm possible to reach a beneficial outcome;
➢ Harm and its effects are considerations and part of the ethical decision-making process in medicine.
4. Justice: -
➢ Justice concerns the distribution of scarce health resources and the decision of who gets what treatment (fairness and equality).
5. Dignity: -
➢ Dignity: the patient and practitioner have the right to dignity.
6. Truthfulness and honesty;
7. Informed consent: -
➢ Informed consent in ethics usually refers to the idea that a person must be
fully informed about and understand the potential benefits and risks of their
choice of treatment;
➢ An uninformed person is at risk of mistakenly making a choice not
reflective of his or her values or wishes.
8. Medical privacy and confidentiality: -
➢ Medical privacy allows a person to keep their medical records from being
revealed to others;
➢ Confidentiality is commonly applied to conversations between doctors and
patients, this is known as patient physician privilege;
➢ Legal protections prevent physicians from revealing their discussions with
patients, even under oath in court.
❖ Medical deontology has 3 subdivisions: -
1. Medical jurisprudence: -
➢ This is defined as the science which applies the principles and practice of
the different branches of medicine to the explanation of doubtful questions
in a court of justice.
2. Medical ethics: -
➢ This is defined as system of moral principles that applies values and
judgments to the practice of medicine.
3. Medical hodegetics: -
➢ Medical hodegetics means guidelines for the study of medicine;
➢ The guidelines which cover the ideal principles which must be learnt while
studying medicine as were once envisioned by the ancient “ father of the
medicine”, Hippocrates.
Deontological resources
❖ There have been many scriptures and declarations throughout history which
have been catalysts in the development of medical deontology: -
➢ The Hippocratic Oath remains the basis of ethical medical behaviour (though
some of the detail is now obsolete)
➢ Declarations of the World Medical Association in 1949: -
31. Medical care, medical aptitude. Legality of medical practice; rights and obligations of medical workers. Forced and compulsory treatment.

Medical care
❖ Health care or healthcare is the maintenance or improvement of health via the prevention, diagnosis, and treatment of disease, illness, injury, and other
physical and mental impairments in people;
❖ Access to health care may vary across countries, communities, and individuals, largely influenced by social and economic conditions as well as health
policies;
❖ Health care systems are organizations established to meet the health needs of targeted populations;
❖ According to the World Health Organization (WHO), a well-functioning health care system requires: -
➢ A financing mechanism;
➢ A well-trained and adequately paid workforce;
➢ Reliable information on which to base decisions and policies;
➢ Well maintained health facilities to deliver quality medicines and technologies.
❖ Delivery: -
➢ The delivery of modern health care depends on groups of trained professionals and paraprofessionals coming together as interdisciplinary teams;
➢ This includes professionals in medicine, psychology, physiotherapy, nursing, dentistry, midwifery and allied health, along with many others such as
public health practitioners, community health workers and assistive personnel, who systematically provide personal and population-based
preventive, curative and rehabilitative care services;
➢ It includes work done in providing primary care, secondary care, and tertiary care, as well as in public health: -
1. Primary care: -
 Primary care refers to the work of health professionals who act as a first point of consultation for all patients within the health care
system;
 Such a professional would usually be a primary care physician, such as a general practitioner or family physician;
 Depending on the nature of the health condition, patients may be referred for secondary or tertiary care;
 Primary care involves the widest scope of health care, including all ages of patients, patients of all socioeconomic and geographic origins,
patients seeking to maintain optimal health, and patients with all types of acute and chronic physical, mental and social health issues,
including multiple chronic diseases;
 Consequently, a primary care practitioner must possess a wide breadth of knowledge in many areas;
 Continuity is a key characteristic of primary care, as patients usually prefer to consult the same practitioner for routine check-ups and
preventive care, health education, and every time they require an initial consultation about a new health problem;
 Common chronic illnesses usually treated in primary care may include, for example: -
• Hypertension; • COPD; • Back pain;
• Diabetes; • Depression and • Arthritis;
• Asthma; anxiety; • Thyroid dysfunction;
 Primary care also includes many basic maternal and child health care services, such as family planning services and vaccinations.
2. Secondary care: -
 Secondary care includes acute care: necessary treatment for a short period of time for a brief but serious illness, injury, or other health
condition;
 This care is often found in a hospital emergency department;
 Secondary care also includes skilled attendance during childbirth, intensive care, and medical imaging services;
 The term "secondary care" is sometimes used synonymously with "hospital care";
 However, many secondary care providers, such as psychiatrists, clinical psychologists, occupational therapists, most dental specialties or
physiotherapists, do not necessarily work in hospitals.
3. Tertiary care: -
 Tertiary care is specialized consultative health care, usually for inpatients and on referral from a primary or secondary health professional,
in a facility that has personnel and facilities for advanced medical investigation and treatment;
 Examples of tertiary care services are: -
• Cancer management; • Treatment for severe burns;
• Neurosurgery; • Advanced neonatology services;
• Cardiac surgery; • Palliative care.
• Plastic surgery;
4. Quaternary care: -
 The term quaternary care is sometimes used as an extension of tertiary care in reference to advanced levels of medicine which are highly
specialized and not widely accessed;
 Experimental medicine and some types of uncommon diagnostic or surgical procedures are considered quaternary care;
5. Home and community care: -
 Many types of health care interventions are delivered outside of health facilities;
 They include many interventions of public health interest, such as food safety surveillance, distribution of condoms and needle-exchange
programs for the prevention of transmissible diseases;
 They also include the services of professionals in residential and community settings in support of self-care, home care, long-term care,
assisted living, and other types of social care services;
 Community rehabilitation services can assist with mobility and independence after loss of limbs or loss of function;
 Many countries, especially in the west, are dealing with aging populations, so one of the priorities of the health care system is to help
seniors live full, independent lives in the comfort of their own homes;
 There is an entire section of health care geared to providing seniors with help in day-to-day activities at home such as transportation to
and from doctor's appointments along with many other activities that are essential for their health and well-being.
Medical aptitude
❖ Aptitude, by definition, is a natural ability, tendency, talent, or capability to learn, understand, or acquire a particular skill;
❖ Therefore, medical aptitude is the aptitude that one possesses enabling them to perform efficiently and successfully in the healthcare profession.
❖ Medical professionals are required by law to perform certain aptitude tests before and during their career in order to assess their ability within their
profession;
❖ By doing so, the standard of healthcare that one provides remains high and reliable;
❖ Medical professionals must possess a particular set of skills (skills that make them a dream for people who ill #liamneeson#taken#lol), such
as: -
➢ Ability to work long hours, often under pressure; ➢ Communication skills, compassion and a good bedside
➢ Good practical skills; manner;
➢ Ability to solve problems; ➢ Drive to continue learning throughout career;
➢ Effective decision-making skills; ➢ Analytical ability;
➢ Leadership and management skills; ➢ Time management.

Legality of medical practice

❖ Medical law is the branch of law which concerns the prerogatives and responsibilities of medical professionals and the rights of the patient;
❖ It should not be confused with medical jurisprudence, which is a branch of medicine, rather than a branch of law.
❖ The main branches of medical law are the law of torts (most notably medical malpractice) and criminal law in relation to medical practice and treatment.
❖ Medical matters come into interaction with the law in 4 aspects: -
1. Legislation and administrative regulations affecting medical practice;
2. Court judgments on problematic or controversial ethical issues in medicine;
3. Medical matters or personnel may become subjects of lawsuits when issues of medical malpractice or alleged medical negligence arise;
4. Use of medical matters as evidence in courts for other criminal or civil proceedings such as cases of homicide, rape, wounding, workman's
compensation and insurance claims.

Rights and obligations of medical workers

❖ An International Code of Medical Ethics (derived from the Declaration of Geneva) was originally adopted by the World Medical Association
and currently reads: -
➢ A physician shall always maintain the highest standards of professional conduct;
➢ A physician shall not permit motives of profit to influence the free and independent exercise of professional judgement on behalf of patients;
➢ A physician shall, in all types of medical practice, be dedicated to providing competent medical service in full technical and moral independence,
with compassion and respect for human dignity;
➢ A physician shall deal honestly with patients and colleagues and strive to expose those physicians deficient in character or competence or who
engage in fraud or deception;
➢ A physician shall respect the rights of patients, of colleagues and of other health professionals and shall safeguard patient confidences;
➢ A physician shall act only in the patient’s interest when providing medical care which might have the effect of weakening the physical and mental
condition of the patient;
➢ A physician shall use great caution in divulging discoveries or new techniques or treatment through non-professional channels;
➢ A physician shall certify only that which he has personally verified.

Forced and compulsory treatment

❖ Involuntary treatment refers to medical treatment undertaken without the consent of the person being treated;
❖ In almost all circumstances, involuntary treatment refers to psychiatric treatment administered despite an individual's objections;
❖ These are typically individuals who have been diagnosed with a mental disorder and are deemed by a court or by two doctors to be a danger to
themselves or to others;
❖ Forced treatment: -
➢ Adults usually have the right to refuse healthcare, however, they can be forced to receive care in certain situations: -
 In emergencies where they may be unconscious (this can lead to legal issues surrounding consent later on, as the patient may object to
having received certain medical treatment that they did not want and would rather have continued to suffer, e.g. organ transplants,
administration of certain drugs etc.);
 For personal hygiene
 For infectious diseases (The government requires diseases that travel easily, like tuberculosis, to be treated right away, especially if one
wishes to travel);
 If the court has ordered the person to receive care (overlaps into compulsory treatment);
 In exceptional situations, health care institutions can also use force, isolation, medication or other types of restraints to prevent harm to a
patient or someone else (the use of these methods must be minimal and must be noted in the patient’s medical record);
❖ Compulsory treatment: -
➢ This is treatment that a patient is required to receive by law, or the order of a judge;
➢ In this situation, a person’s consent is irrelevant because they will receive the treatment, regardless of whether they object to it or not, as they will
be breaking the law if they do not abide;
➢ It is done to look out for the best interests of the patient and for the people around them;
➢ Examples include: -
 Treatment for psychosis;  Treatment of infectious diseases;
 Vaccination programmes;  Court ordered therapy.
32. Clinical death, brain death, biological death. Tissue and organ transplantation.

Clinical death
❖ Clinical death is the medical term for cessation of blood circulation and breathing, the two necessary criteria to sustain human life;
❖ It occurs when the heart stops beating, a condition called cardiac arrest;
❖ It is also known as somatic or systemic death;
❖ It may be reversible;
❖ The organs can be used for transplantation;
❖ At the onset of clinical death: -
➢ Consciousness is lost within several seconds;
➢ Measurable brain activity stops within 20 to 40 seconds;
➢ Irregular gasping may occur during this early time period, and is sometimes mistaken by rescuers as a sign that CPR is not necessary;
➢ During clinical death, all tissues and organs in the body steadily accumulate a type of injury called ischemic injury;
❖ Limits of reversal: -
➢ Most tissues and organs of the body can survive clinical death for considerable periods;
➢ Blood circulation can be stopped in the entire body below the heart for at least 30 minutes, with injury to the spinal cord being a limiting factor;
➢ Detached limbs may be successfully reattached after 6 hours of no blood circulation at warm temperatures;
➢ Bone, tendon, and skin can survive as long as 8 to 12 hours;
➢ The brain, however, appears to accumulate ischemic injury faster than any other organ;
➢ Without special treatment after circulation is restarted, full recovery of the brain after more than 3 minutes of clinical death at normal body
temperature is rare;
➢ Usually brain damage or later brain death results after longer intervals of clinical death even if the heart is restarted and blood circulation is
successfully restored;
➢ Brain injury is therefore the chief limiting factor for recovery from clinical death.
❖ Controlled clinical death: -
➢ Certain surgeries for cerebral aneurysms or aortic arch defects require that blood circulation be stopped while repairs are performed;
➢ This deliberate temporary induction of clinical death is called circulatory arrest;
➢ It is typically performed by lowering body temperature to between 18 °C and 20 °C (64 and 68 °F) and stopping the heart and lungs;
➢ This state is called deep hypothermic circulatory arrest;
➢ At such low temperatures most patients can tolerate the clinically dead state for up to 30 minutes without incurring significant brain injury;
➢ Longer durations are possible at lower temperatures.

Brain death
❖ Brain death is the complete loss of brain function (including involuntary activity necessary to sustain life);
❖ It differs from persistent vegetative state, in which the person is alive and some autonomic functions remain;
❖ It is also distinct from an ordinary coma, whether induced medically or caused by injury and/or illness, even if it is very deep, as long as some brain and
bodily activity and function remains;
❖ Patients classified as brain-dead can have their organs surgically removed for organ donation;
❖ Medical criteria: -
➢ A brain-dead individual has no clinical evidence of brain function upon physical examination;
➢ This includes no response to pain and no cranial nerve reflexes;
➢ Brain electrical activity can stop completely, or drop to such a low level as to be undetectable with most equipment;
➢ An EEG will therefore be flat (though this is sometimes also observed during deep anaesthesia or cardiac arrest);
➢ The diagnosis of brain death is often required to be highly rigorous, in order to be certain that the condition is irreversible;
➢ Legal criteria vary, but in general require neurological examinations by two independent physicians;
➢ The exams must show complete and irreversible absence of brain function and may include two isoelectric (flat-line) EEGs 24 hours apart;
➢ The patient should have a normal temperature and be free of drugs that can suppress brain activity if the diagnosis is to be made on EEG criteria;
➢ Also, a radionuclide cerebral blood flow scan that shows complete absence of intracranial blood flow must be considered;

Biological death
❖ Biological death means the cessation of respiration (the utilization of oxygen) and the normal metabolic activity in the body tissues and cells;
❖ Cessation of respiration is soon followed by autolysis and decay, which, if it affects the whole body, is indisputable evidence of true death;
❖ The differences in cellular metabolism determine the rate with which cells die and this can be very variable: -
➢ Skin and bone will remain metabolically active and thus ‘alive’ for many hours and these cells can be successfully cultured days after somatic
death;
➢ White blood cells are capable of movement for up to 12 hours after cardiac arrest;
➢ The cortical neuron, on the other hand, will die after only 3–7 minutes of complete oxygen deprivation;
➢ A body dies cell by cell and the complete process may take many hours.
❖ It usually takes place one to two hours after stoppage of vital functions of body and is irreversible;
❖ A person cannot be revived if biological death has taken place;
❖ Most organs become dead after biological death;
❖ These organs cannot be used for organ transplantation.

Tissue and organ transplantation

❖ The laws relating to tissue and organ donation and transplantation are dependent upon the religious and ethical views of the country in which they apply;
❖ The organs and tissues to be transplanted may come from one of several sources: -
➢ Homologous transplantation: -
 Tissue is moved between sites on the same body;
 For instance, skin is taken from the thigh to graft onto a burn site or bone chips from the pelvis may be taken to assist in the healing of the
fragmented fracture site of a long bone;
 Homologous blood transfusion can be used where there is a religious objection to the use of anonymously donated blood.
 ➢ Live donation: -
 In this process, tissue is taken from a living donor whose tissues have been matched to or are compatible with those of the recipient;
 The most common example is blood transfusion but marrow transplantation is now also very common;
 Other live donations usually involve the kidneys as these are paired organs and donors can, if the remaining kidney is healthy, maintain their
electrolyte and water balance with only one kidney;
 Most kidneys for transplant are derived from cadaveric donation, but live donation is also possible and this, associated with a high demand for
kidneys, especially in Western countries, has resulted in a few surgeons seeking donors (in particular poor people from developing countries)
who would be willing to sell one of their kidneys;
 This practice is illegal in many countries and, if not specifically illegal, it is certainly unethical;
 With increasing surgical skill, the transplantation of a part of a singleton organ with large physiological reserve (such as the liver) has been
attempted;
 These transplants are not as successful as the whole organ transplants and the risks to the donor are considerably higher.
➢ Cadaveric donation: -
 In many countries, cadaveric donation is the major source of all tissues for transplantation;
 The surgical techniques to harvest the organs are improving, as are the storage and transportation techniques, but the best results are still
obtained if the organs are obtained while circulation is present or immediately after cessation of the circulation;
 Kidneys are more resilient to anoxia than some other organs and can survive up to 30 minutes after cardiac stoppage;
 Cadaveric donation is now so well established that most developed countries have sophisticated laws to regulate it;
 However, these laws vary greatly: -
• Some countries allow the removal of organs no matter what the wishes of the relatives;
• Other countries allow for an ‘opting-out’ process in which organs can be taken for transplantation unless there is an objection from
relatives;
• The converse of that system is the one practised in the UK, which requires ‘opting in’;
• In this system, the transplant team must ensure that the donor either gave active permission during life or at least did not object and also
that no close relative objects after death;
• The Human Tissue Act allows the person ‘in lawful possession’ of a body to authorize the donation of tissues or organs only if he has no
reason to believe that (a) the deceased had indicated during life that he objected to donation and that (b) the surviving spouse or relative
of the deceased objects.
• If an autopsy will be required by law for any reason, the permission of the Coroner investigating the death must be obtained before
harvesting of tissue or organs is undertaken;
• In general, there is seldom any reason for the legal officer investigating the death to object to organ or tissue donation because it is self-
evident that injured, diseased or damaged organs are unlikely to be harvested and certainly will not be transplanted and so will be
available for examination;
• In what is almost always a tragic unexpected death, the donation of organs may be the one positive feature and can often be of great
assistance to the relatives.
➢ Xenografts: -
• Grafting of animal tissue into humans has always seemed tempting and clinical trials have been performed with limited success;
• There is considerable difficulty with cross-matching the tissues and considerable concern about the possibility of transfer of animal viruses to
an immunocompromised human host;
• Strains of donor animals, usually pigs, are being bred in clinically clean conditions to prevent viral contamination, but there is still no guarantee
of a close or ideal tissue match;
• Also, the complexity of their breeding and rearing means that these animals are expensive.

33. Euthanasia
❖ Euthanasia is the practice of intentionally ending a life to relieve pain and suffering;
❖ Classification: -
➢ Euthanasia may be classified into three types, according to whether a person gives informed consent: -
1) Voluntary: -
o Voluntary euthanasia is conducted with the consent of the patient;
o When the patient brings about his or her own death with the assistance of a physician, the term assisted suicide is often used instead.
2) Non-voluntary: -
o Non-voluntary euthanasia is conducted when the consent of the patient is unavailable.
3) Involuntary: -
o Involuntary euthanasia is conducted against the will of the patient.
➢ Voluntary, non-voluntary and involuntary types can be further divided into passive or active variants: -
o Passive euthanasia entails withholding treatment necessary for the continuance of life;
o Active euthanasia entails the use of lethal substances or forces (such as administering a lethal injection), and is the more controversial variant.
34. Crimes in medical practice – classification

❖ The term medical malpractice refers to all failures in the conduct of doctors but only where it impinges upon their professional skills & ability;
❖ Malpractice can be conveniently divided into two broad types: -
1. Medical negligence – where the standard of medical care given to a patient is considered to be inadequate: -
➢ It is impossible to give a complete list of negligent situations in medical practice;
➢ Types of medical negligence: -
 Obstetrics & gynaecology: -
• Brain damage in the newborn due to hypoxia from prolonged labour;
• Failed sterilization by tubal surgery resulting in unwanted pregnancy;
 Orthopaedics and accident surgery: -
• Missed fractures, especially of the scaphoid, skull, femoral neck and cervical spine;
• Tissue and nerve damage from over-tight plaster casts;
• Undiagnosed intracranial haemorrhage;
• Missed foreign bodies in eyes and wounds, especially glass;
• Inadequately treated hand injuries, especially tendons.
 General surgery: -
• Delayed diagnosis of acute abdominal lesions;
• Retention of instruments and swabs in operation sites;
• Operating on the wrong patient;
• Operating on the wrong limb, digit or even organ;
• Operating on the wrong side of the body;
• Failed vasectomy, without warning of lack of total certainty of subsequent sterility;
• Diathermy burns.
 General medical practice: -
• Failure to visit a patient on request, with consequent damage;
• Failure to diagnose myocardial infarcts or other medical conditions.
 Anaesthesiology: -
• Failure to refer a patient to hospital or for specialist opinion;
• Toxic results of drug administration;
• Peripheral nerve damage from splinting during infusion;
• Incompatible blood transfusion;
• Incorrect or excessive anaesthetic agents;
• Allowing awareness of pain during anaesthesia.
 General errors: -
• Inadequate clinical records and failure to communicate with other doctors involved in the treatment of a patient;
• Failure to admit to hospital when necessary;
• Failure to obtain informed consent to any procedure;
• Administration of incorrect type or quantity of drugs, especially by injection.
2. Professional misconduct – where the personal, professional behaviour falls below that which is expected of a doctor: -
➢ The professional behaviour of a doctor, either in connection with his treatment of patients or in other area of his behaviour, may lead to
allegations of misconduct that are separate from the civil actions for negligence discussed in the previous section;
➢ Where the personal or professional conduct of a doctor is seriously criticized, his worthiness to continue as a recognized member of the
medical profession may be at stake;
➢ This aspect is dealt with by various tribunals of the official authority responsible in that particular country for granting registration or a licence to
practise medicine;
➢ These tribunals can examine the fitness of any doctor to remain an accredited physician and this mechanism of referral and review is
designed primarily to protect the public from unsuitable or even dangerous doctors;
➢ There is a general level of ethical behaviour, morality and competence that should be subscribed to by doctors all over the world;
➢ These high standards are not born of snobbery or elitism but of practical necessity, for if patients are to derive the maximum benefit from
diagnosis and treatment, they must be confident that their physician is responsible, diligent, honest and discreet;
➢ Patients are less likely to reveal intimate details of their medical history or to cooperate in treatment without the necessary ingredient of faith
and confidence in the treating doctor;
➢ Thus, doctors must actually possess, and be seen to possess, all the better qualities that will befit them to manage life-and-death issues;

35. Premeditated crimes in dentistry practice.

❖ Something premeditated is planned in advanced and has a purpose behind it (in other words, it's no accident);
❖ Therefore, premeditated crimes in dental practice are those crimes committed by the dentist in which the dentist knew fully in advance that they were
committing a crime for their personal gain;
❖ Examples can include: -
➢ Fraud, e.g. forging a patient’s medical history to aid them in winning a legal battle;
➢ Recommending and carrying out unnecessary and harmful dental procedures;
➢ Not carrying out the legal protocols in relation to obtaining the informed consent of the patient;
➢ Lying to the patient about the circumstances of certain dental procedures (e.g. possible side effects, cost of treatment, prognosis of treatment);
➢ Improper management of the legalities and finances of the dental practice (e.g. tax avoidance, operating without a diploma/qualifications, hiring
unqualified staff, treating non-suitable patients etc.);
➢ Not disclosing any systemic diseases before beginning practice (e.g. working with HIV or hepatitis);
36. Negligent acts of medical workers and ignorance of the profession.
❖ Medical treatment is not provided with an absolute guarantee of complete success;
❖ All patients have the legal right to expect a satisfactory standard of medical care from their doctor even though it is accepted that this can never mean
that the doctor can guarantee a satisfactory outcome to the treatment;
❖ Before a patient can succeed in a civil action for negligence against a doctor, it must be established: -
1. That the doctor had a duty of care towards the patient: -
➢ Once it is established that there is a duty of care, the doctor must then provide both diagnosis and treatment at a reasonable ‘standard of care’
– that is, consistent with the doctor’s own experience and training;
➢ It is accepted that doctors cannot be expected to know the details of every single recent advance in all areas of medicine, but the patient can
expect a doctor to have kept up to date with major developments in his own and in closely related fields, now often referred to as Continuing
Professional Development (CPD).
2. That there was a failure in that duty of care: -
➢ For negligence to be established, there must be a ‘breach’ of this standard of care, either by omission (failing to do something) or by
commission (doing something wrong);
➢ It is accepted that the circumstances under which a doctor treats a patient may have a considerable bearing on the reasonable standard of
care that the patient may expect, for example treatment in an acute emergency when there is neither the time nor the facilities may legitimately
be less ideal than that given for the same condition in a non-urgent situation;
3. Resultant physical or mental damage: -
➢ Even if a patient can prove the presence of a duty of care and a breach of the standard of care, he cannot succeed in a legal action unless he
can also show that he has suffered physical or mental damage;
➢ If a doctor prescribes some obviously inappropriate or even harmful medicine but the patient refuses to take the medicine, the patient cannot
then recover compensation from the doctor because he has suffered no damage.

37. Mistakes in medical practice.

❖ Definition: -
➢ A medical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient;
➢ This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behaviour, infection, or other ailment;
➢ The word error in medicine is used as a label for nearly all of the clinical incidents that harm patients;
➢ Medical errors are often described as human errors in healthcare;
➢ There are many types of medical error, from minor to major.
❖ Causes: -
➢ Medical errors are associated with inexperienced physicians and nurses, new procedures, extremes of age, and complex or urgent care;
➢ Poor communication (whether in one's own language or, as may be the case for medical tourists, another language), improper documentation,
illegible handwriting, spelling errors, inadequate nurse-to-patient ratios, and similarly named medications are also known to contribute to the
problem;
❖ Examples: -
➢ Errors can include: -
o Misdiagnosis or delayed diagnosis;
o Administration of the wrong drug to the wrong patient or in the wrong way;
o Giving multiple drugs that interact negatively;
o Surgery on an incorrect site;
o Failure to remove all surgical instruments;
o Failure to take the correct blood type into account, or incorrect record-keeping.

38. Incidents in medical practice

There wasn’t much information available for this question. The main thing to know is the difference between ‘mistakes’ and ‘incidents.’ A mistake is usually
done through human error, i.e. something which was in human control such as administration of surgical equipment. An incident occurs when something
happens which was out of human control i.e. a rare unknown side effect to a specific drug. This is what the lecturer told me.