CHAPTER 1

INTRODUCTION

Learning Objectives
At the end of this chapter, the student will be able to:
• Define Forensic Science, Forensic Toxicology, and Forensic Anthropology
• Distinguish and differentiate these fields of science
• Enumerate the roles performed by a forensic physician
• Define Forensic Pathology and describe its role in criminal investigation

Forensic Science
Forensic science deals with the application of scientific facts to legal
problems and the judicial process. Forensic means the analysis of information
suitable for use in a court of law; it comes from the Latin word "forensis," which
means forum (Brenner, 2000). Issues used to be debated in public in the forum, but
now occur in civil and criminal courts where conflicting evidence is presented to
determine the truth.
Special areas of forensic sciences can be applied to the documentation of
evidence and to the solution of various criminal and civil problems, thereby providing
enormous value to law enforcement and justice.
Every aspect of forensic science involves (1) the careful and proper collection,
documentation and evaluation of evidence; (2) the chain of custody or the written
documentation of all the stages of transfer of evidence from the crime scene to the
laboratory and the court; (3) the admissibility of tests, evidence and testimony,
based on legal standards; and (4) the opinion of an expert witness regarding issues
that relate to specific forensic science fields such as forensic ballistics, questioned
document examination, fingerprint examination, polygraphy, and legal medicine
(Prahlow & Byard, 2012).

The Field of Forensic Medicine

Legal medicine, forensic medicine, and medical jurisprudence are terms used
interchangeably to refer to branches of medicine that apply the principles and
knowledge of the medical sciences in the field of law. The terms will also be used
interchangeably in this book.
The field of legal medicine is typically associated with death and autopsies, but
it also applies in other legal processes, such as determining whether a violent crime
is a homicide, suicide or accident, or whether they constitute negligence, sexual
assault, physical abuse or domestic violence. Practitioners are sometimes referred
to as forensic pathologists or forensic physicians.
 Forensic medicine is a branch of medicine that covers both the fields of
forensic pathology and clinical forensic medicine. Forensic pathology involves the
investigation of unnatural, unexpected, or violent death, whereas clinical forensic
medicine involves an interaction between the living person, medicine, and legal
processes. In broad terms, the forensic pathologist deals with the deceased while
the forensic physician deals with living individuals. However, the clinical and
pathological aspects of forensic medicine tend to overlap, and different countries
have medical doctors who are involved in both the clinical and the pathological
aspects of legal medicine.
Each practitioner should be aware of their respective responsibilities, not only
to their patient or the deceased, but to the society as whole; they should also be
able to utilize their medical expertise in the pursuit of fairness and justice within the
framework of legal requirements and ethical values.

Forensic Pathology
The word 'pathology' literally means "the study of disease." A pathologist is a
physician who determines a patient's diagnosis from an examination of a tissue
sample or cells under the microscope.
Forensic pathology is a subspecialty that deals with the investigation of
sudden, unexpected, and/or violent deaths. The main role of most forensic
pathologists is to undertake forensic death investigations and perform medico-legal
autopsies. These activities will be discussed in further detail in corresponding
chapters in this book.
Executing accurate and complete documentation of findings is crucial to the
work of the forensic pathologist. The forensic pathologist also undertakes the death
certification or the completion of an official death certificate, which includes some
personal information of the deceased, as well as the cause of death (the disease or
injury that was responsible for death) and the manner of death (the means or
circumstances by which the cause of death occurred). They are also often required
to provide official testimony in court regarding the deaths they have investigated
(Prahlow & Byard, 2012).
Most hospital autopsies involve natural deaths; hence, hospital pathologists
primarily attempt to explain the signs and symptoms of natural disease through
autopsies focused on internal organs; they are generally not as concerned about
information that can be crucial in civil and criminal actions. Forensic pathologists are
concerned with the reason behind the occurrence of death; thus, they must
investigate the context of surrounding events before and after the death of the
deceased, especially in homicidal, accidental, and suicidal cases. Needless to say,
forensic pathologists are more alert to unnatural deaths. Their investigation can
begin with the determination of the following (Wecht, 1997):
 1. Who is the victim? (identification based on sex, race, age, and distinguishing
characteristics)
2. When did the death and related injuries occur?
3. Where did the death and related injuries occur?
4. What injuries are present? (identification based on type, distribution, pattern,
path, and direction)
Pathologists deal with death and tragedy every day; they can serve important
functions by helping to convict the guilty or exonerate the innocent, by helping
families deal with the death of a loved one (once they know the exact cause and
manner of death), by preventing future deaths and injuries from dangers that have
proven to be deadly, and also by alerting and educating the public and the
government in an effort to prevent these hazards from being repeated (Adelman,
2007).

Clinical Forensic Medicine

Over the years, practitioners of clinical forensic medicine have been called
police surgeons, forensic medical officers or forensic medical examiners. Nowadays,
they are more widely known as forensic physicians.
The forensic physician is tasked to undertake a variety of functions. The
following illustrates the variety of functions a forensic physician may be asked to
undertake (Payne-James, History and Development of Clinical Forensic Medicine,
2005).
Typical Roles of a Forensic Physician
• Determination of fitness to be detained in custody
• Determination of fitness to be released
• Determination of fitness to be charged: competent enough to understand the
charge/s
• Determination of fitness to transfer from one jail facility to another or to the
court where the alleged case is being heard and tried
• Determination of fitness to be interviewed by the police or another detaining
body
• Advise that an independent person is required to ensure rights for the
vulnerable or mentally disordered
• Assessment of alcohol and drug intoxication and withdrawal
• Comprehensive examination to assess a person's ability to drive a motor
vehicle, in general medical terms and related to alcohol and drug misuse
• Undertake intimate body searches for drugs
• Documentation and interpretation of injuries
• Take forensic samples
• Assess and treat personnel who are injured while on duty (e.g., police
personnel), including needle-stick injuries
 • Pronounce life as extinct at a scene of death and undertake preliminary
advisory role
• Undertake mental state examinations
• Examine adult complainants of serious sexual assault and the alleged
perpetrators
• Examine alleged child victims of neglect or physical or sexual abuse
• Examine victims and assailants in alleged police assaults

Additional Roles of a Forensic Physician

• Provide expert opinion in courts and tribunals
• Certify death in custody investigation
• Serve as part of pressure group and independent investigators in ethical and
moral issues (victims of torture, war crimes, female genital mutilation)
• Administer medicine to refugees (medical and forensic issues)
• Administer medicine to asylum-seekers (medical and forensic issues)
• Implement principles of immediate management in biological or chemical
incidents
Clinical forensic medicine involves the examination of living patients who have
certain rights (e.g., right of confidentiality) and capabilities (e.g., capacity to give
consent). The medical doctor examining prisoners or victims of abuse must,
therefore, consider the boundaries among the conflicting rights of the person
examined, the processes of investigation, and the interests of justice. A forensic
physician has a dual responsibility to the patient and the general public that might
come in conflict, such as when a rape victim requests for confidentiality at the
expense of the perpetrator becoming free of criminal charges.
In clinical forensic medicine, most examinations have both therapeutic and
forensic aspects. The doctor has the primary responsibility of providing care and
actual treatment (or giving a referral for further treatment). However, the
examination will most likely involve the interpretation of evidential content, such as
major or minor injuries that could later be the subject of detailed cross-examination
in court. While the doctor has a duty of confidentiality to the person examined, the
forensic physician also has an obligation to provide necessary and appropriate
information to the police to facilitate the investigation of a crime.
Forensic Toxicology
Forensic toxicology is a forensic science discipline that deals with the
identification and quantification drugs, poisons, and other toxic substances in body
tissues and fluids. Victims who are suspected to have been accidentally or
purposely poisoned are examined by the toxicologist to detect toxic substances in
the blood, urine, spinal fluid, gastric contents, bile, and tissues (Brenner, 2000).
 A discussion of poisons and their relevance in medico-legal investigations is
discussed further in Chapter 7.

Forensic Anthropology
The scientific field of physical anthropology is concerned with the study of
humans in relation to their physical characteristics. The subspecialty of forensic
anthropology is concerned with the examination of bones and skeletal remains in
order to provide information about sex, race, age, and time of death. Forensic
anthropologists can differentiate between post-mortem changes to help in identifying
mysterious remains and to determine whether the death was caused by foul play
(Brenner, 2000).
Forensic anthropology is discussed in more detail in a latter chapter.

Review Questions
• What is Forensic Science?
• What is Forensic Toxicology? How is it different from Forensic
Anthropology and Forensic Pathology?
• What are the roles performed by a forensic physician?
• What is Forensic Pathology? What is its role in criminal investigation?

CHAPTER 2
HISTORY AND DEVELOPMENT OF FORENSIC MEDICINE
Learning Objectives
At the end of this chapter, the student will be able to:
• Describe the relevance of the Code of Hammurabi in the field of forensic
medicine
• Present some highlights in the history of forensic pathology
• Comprehend the basic concepts covered by major published works in forensic
pathology from its inception to the present date
The connection between medicine and legal processes has existed for centuries,
although the use of the terms forensic medicine and medical jurisprudence only
began in the early 19th century. As pointed out by Thomas Stuart Traill in 1840, the
field emerged in Germany where it was known as state medicine; later, it became
known as legal medicine in France and Italy and as medical jurisprudence or
forensic medicine in the United Kingdom (Payne-James, 2005; Payne-James et al.,
2005).
Early History of Legal Medicine
As early as 3000 BC, works on pharmacology (the study of drug action) and
pharmacognosy (the study of medicines derived from natural sources) were already
written in China. Chinese archeologists also discovered bamboo pieces dating from
about 220 BC (Qin Dynasty), which contained rules and regulations for examining
injuries.
The Code of Hammurabi is the oldest medico-legal code dating back to 2200
BC. The Code, named after the king of Babylon (now Iraq), featured the rights and
duties of medical practitioners. The Code also described varied forms of punishment
for improper treatment and malpractice during that time.
There were also writings indicating the practice of forensic medicine in the
Roman Republic (509 BC to 27 sc), such as poisoning punishments based on the
degree of injury caused by an assailant, and disposal of the dead. After the murder
of Julius Caesar in 44 Bc, the physician Antonius examined the body and declared
that there were 23 stab wounds, only one of which was fatal. Hence, the death was
attributed to the multiple stab wounds and loss of blood. That autopsy report
remains the earliest known post-mortem report in history.
There were other historical examples of the link between medicine and the law
throughout the world. In India, the laws of Manu, which date back to around 10 Bc,
contained provisions regarding public health, sexual matters, and the competence of
witnesses in courts. In Roman Egypt, forensic medical examination and
investigation were performed based on papyri dating from the 1st to the 4th century
AD. In Persia (now Iran), medical practices were restricted to certain castes and
classes of the community, injuries were categorized, medical fees were limited to an
official scale, cases of medical malpractice were meted with penalties, and abortion
was considered a serious crime. In classical Greece, physicians testified in court as
expert witnesses. The first Holy Roman Emperor, Charlemagne (742-814 AD)
required the need for expert medical testimony in matters regarding wounding,
abortion, rape, incest, infanticide, and suicide.
In 1507, Bishop George of Bamberg, Germany proclaimed the first penal code
that necessitated the use of medical evidence in certain cases. In 1553, Emperor
Charles V of Germany proclaimed the Constitutio Criminalis Carolina, the code of
law that originated legal medicine as a specialty. Cases of murder, wounding,
poisoning, hanging, drowning, infanticide, and abortion has since required expert
medical testimony.
In 1575, Ambrose Paré, a French military surgeon who is known as the father
of surgery and modern forensic pathology, published a book on medico-legal
reports. He is also a pioneer in surgical techniques and battlefield medicine, and
wrote about deaths from lightning, ante-mortem versus post-mortem injuries, and
poisoning by carbon monoxide and corrosives.
In 1595, Andreas Libavius of Germany wrote about cruentation, a medieval
method of finding proof against a suspected murderer, wherein the wounds of a
victim is believed to spontaneously bleed if he were to be touched by the murderer
post-mortem. King James VI of Scotland (1566-1625) subscribed to this practice in
his 1597 book Daemonologie, in which he also approved and supported the practice
of witch hunting.
In 1597, Italian physician Codronchius published Methods Testificandi, which
discussed wounds, poisoning, and sexual matters. In 1602, Fortunatus Fidelis of
Sicily, considered the earliest writer on medical jurisprudence, published De
Relationibus Medicorum, a systematic treatise on legal medicine in four volumes.
Between 1621 and 1635, Paulus Zacchias wrote Quaestiones Medico-
Legales, a seven-book series widely considered a major work in the field. Paulus
Zacchias was the principal physician to Popes Innocent X and Alexander VII as well
as the adviser for the Romana Rota (the highest papal court of appeals). He is
considered the father of legal medicine.
The historical references enumerated above show the long history of medical
practitioners using their expertise in the context of law.

Forensic Medicine in the Late 18th Century and Beyond

By the late 18th century, several more books and treatises on forensic
medicine were published in the English language, as enumerated below.
• In 1783, William Hunter published the essay, On the Uncertainty of the
Signs of Murder in the Case of Bastard Children, which is considered the
first true "forensic medicine" publication from England.
• In 1788, Samuel Farr published Elements of Medical Jurisprudence, which
was translated from the 1767 publication by Fazelius of Geneva entitled
Elemental Medicinae Forensis.
• In 1816, George Male, the father of English medical jurisprudence,
published the Epitome of Juridical or Forensic Medicine, which is considered
an original and satisfactory work. Due to its popularity, a second edition was
published in 1821.
• In 1789, Professor Andrew Duncan delivered the first course of lectures on
legal medicine to medical students in Britain. In 1792, the lectures were
published as the Heads of Lectures on Medical Jurisprudence.
• In 1813, in New York, Benjamin Rush, a physician and professor of
medicine as well as a signatory of the Declaration of Independence,
published his lectures, one of which included a study on medical
jurisprudence.
 • In 1821, John Gordon Smith published a book entitled The Principles of
Forensic Medicine Systematically Arranged and Applied to British Practice,
wherein he asserted that forensic medicine, medical jurisprudence, or
legal/judiciary/juridical medicine are synonymous terms.
• In 1840, Thomas Stuart Traill published the second edition of Outlines of a
Course of Lectures on Medical Jurisprudence while he was serving as a
Regius Professor of Jurisprudence and Medical Police at Edinburgh in
Scotland, United Kingdom. The first edition was published in 1834.
Other historical highlights include the development of the field in the academe.
In 1803, Andrew Duncan Jr. (son of Professor Andrew Duncan who delivered the
first course of lectures on legal medicine in Britain) became the first Chair of
Forensic Medicine in Edinburgh. In 1804, J.A. Stringham, a physician who also
trained in Edinburgh, was appointed as a lecturer in medical jurisprudence at the
College of Physicians and Surgeons of New York. Academic chairs of medical
jurisprudence were subsequently established in the United Kingdom, specifically in
1839 in Glasgow and in 1875 in Aberdeen.
In 1844, William Guy, Professor of Forensic Medicine at King's College in
London, published Principles of Forensic Medicine, a book that signified how the
field of medical jurisprudence was gradually becoming more distinct and specialized
from other related fields. In fact, much of the relevant ideas considered during that
time remain relevant to today's practitioners of forensic medicine, as shown in the
following chapter contents of Guy's book.
1. Medical evidence • Real and apparent death
2. Personal identity • Sudden death
• Identity • Survivorship
• Age 8. Death by drowning
• Sex • Death by hanging
3. Impotence • Death by strangulation
• Rape • Death by suffocation
• Pregnancy 9. Wounds
• Delivery 10. Death by fire
4. Feticide or criminal abortion • Spontaneous combustion
• Infanticide • Death by lightning
• Legitimacy • Death from cold
5. Life assurance • Death from starvation
• Feigned diseases 11. Toxicology
6. Unsoundness of mind • Specific poisons
7. Persons found dead
 CHAPTER 3
MEDICO-LEGAL INVESTIGATION

Learning Objectives
At the end of this chapter, the student will be able to:
• Enumerate the kinds of medico-legal cases
• Distinguish between cellular and somatic death
• Identify the three modes of death
• Describe the goals of a death investigation
• Enumerate the main functions of a forensic medical examiner in assessing a
death scene
• Identify the natural causes of death

Medico-legal Cases
The term "medico-legal cases" generally refers to something related to both
medicine and law. In the field of law enforcement, medico-legal cases refer, on the
one hand, to those that involve injuries or ailments, in which investigations are
essential to determine the cause and the responsible party. This also means that
medico-legal cases involve medical cases with legal implications for the attending
physician, specifically in terms of determining whether law enforcement authorities
must be notified for further investigation. On the other hand, it could also refer to
legal cases or police investigations that may require the expertise of a medical
practitioner.
The items below are examples of cases that usually have medico-legal
implications, some of which shall be discussed in further detail in other chapters.
• Assault and battery, including domestic violence and child abuse
• Accidents like road traffic accidents (RTA), industrial accidents, etc.
• Cases of trauma with suspicion of foul play
• Electrical injuries
• Poisoning and/or alcohol intoxication
• Undiagnosed coma
• Chemical injuries
• Burns and Scalds
• Sexual offenses
• Abortion
• Suicide/attempted suicide
• Cases of asphyxia as a result of hanging, strangulation, drowning, suffocation,
etc.
• Custodial deaths
 Medico-legal considerations, decisions, definitions, and policies provide the
framework for informed consent, professional liability, and many other aspects of
current practice in the health care field. They are significant in the process of making
many patient care decisions and determining definitions and policies for the
treatment of mentally incompetent people and minors, the performance of
sterilization or therapeutic abortion, and the care of terminally ill patients (Mosby's
Medical Dictionary, 2009).
Medico-legal investigations involve the discovery, preservation, documentation
and analysis of evidence, as well as the reconstruction of events leading to the
injury or death under investigation. The investigation process involves the following
steps: (1)investigation of the circumstances, including witnesses, investigators,
history, the scene and medical records; (2) searching the body; and (3) laboratory
examinations, such as those involving ballistics, DNA, toxicology. serology, x-ray,
and chemical analysis.
Careful documentation of every step in the investigation process is critical to
forensic problem solving. The forensic pathologist or forensic physician must ensure
that their interpretations and conclusions are based on sound medical principles.
Errors and mistakes could result in wrongful convictions that could result in serious
liabilities for the medico-legal practitioner. Throughout history, innocent people have
suffered arrest and incarceration due to negligence. This is why medico-legal
practitioners must be careful with their work.

Definition of Death
Simply put, death is the cessation of life. In the medical and legal sense, human
death has been traditionally defined as the complete and irreversible cessation of
heart and lung activity. However, controversies arise when religious and ethical
concerns come into play. For example, a person who has been dead for several
hours can still have functional sperms that can fertilize an egg. A dead person's cells
can also be cultured in a laboratory to be kept "alive" for decades. To clarify this
distinction, the medical profession considers separately the death of a single cell (or
cellular death) and the cessation of the integrated functioning of an individual
(somatic death). Somatic death, therefore, refers to the death of the person, while
cellular death refers to the death of the cells within the person (Adelman, 2007).
Cellular death is defined as "the cessation of respiration (the utilization of oxygen)
and the normal metabolic activity in the body tissues and cells," and is "soon
followed by autolysis and decay, which, if it affects the whole body, is indisputable
evidence of true death" (Shepherd, 2003, p. 27). The cells can still be cultured days
after if the skin and bones remain metabolically active. However, the complete
process may take hours because the body dies cell by cell.
Meanwhile, somatic death occurs when "the individual is irreversibly unconscious
and unaware of both the world and his own existence" (Shepherd, 2003, p. 28).
Unlike during deep sleep or under anesthesia or temporary coma, unconsciousness
in somatic death is "irreversible."
The following are the three modes of death (Sharma, 2011).
1. Coma- Death results primarily from the failures of the vital centers of the brain;
the person becomes unconscious and loses all reflexes, after which the heart
and lungs slowly cease to function.
2. Syncope- Death occurs primarily as a result of heart failure, possibly due to
blood loss, power loss of the heart muscle, or neurogenic shock.
3. Asphyxia- Death occurs primarily when the respiratory function of lungs stops
as a result of lack of oxygen, resulting in failure of the heart and brain.
If a person dies within 24 hours without suffering from a recognizable cause, such
death would be called a sudden death.
Death Investigation
One of the most important duties of the forensic pathologist is to investigate the
death of an individual by examining all the medical, scientific, and evidentiary
information. Death investigations usually involve sudden, unexpected or violent
deaths, even those that may be related to natural deaths. Depending on jurisdiction,
a death investigation may include an initial investigation and the examination of the
body, followed by further investigations.
The following are the goals and purpose of death investigation (Adelman, 2007):
1. To help and serve the living;
2. To seek the truth objectively, intellectually and without bias or emotional
coloration;
3. To document guilt and protect the innocent;
4. To determine the identity of the deceased;
5. To determine the medical cause of death; and
6. To determine the manner of death.
From a legal perspective, one of the most critical tasks of the forensic pathologist
is to establish the cause and manner of death. Based on the objectives enumerated
above, the forensic pathologist must also estimate the time of death, infer the type of
weapon used, determine additive effect of trauma or pre-existing conditions, as well
as establish the identity of deceased. By understanding the role of the pathologist
and the natural changes that occur in the body after death, the criminal investigator
can gather information that is deemed useful to everyone involved in the
investigation.
jurisdiction over a reported case, after which they will obtain Death investigators
initially determine which locality has identification information about the deceased,
such as the name, birth date, gender, address, and legal next-of-kin. The
investigator will also gather other significant information such as time of death,
where the person died, whether or not there are injuries, the position and condition
of the body, evidence of post-mortem changes, environmental information, when
and where the person was last known to be alive, medical history, employment
status, recent activities, relationship issues, and recent state of mind (Prahlow &
Byard, 2012).
Death Scene Investigation
The death scene must be well documented so that the pathologist and criminal
investigator can perform a thorough investigation. The following are the main
functions of the forensic medical examiner in the death scene (Crane, 2009):
• To observe the scene and take detailed contemporaneous notes;
• To confirm that death has taken place;
• To ensure that trace evidence is not removed or destroyed from the body or
its surroundings;
• To offer an opinion as to the possible nature of death; and
• To assist and supervise the removal of the body from the scene where
necessary.
A visit at the death scene (or where the fatal incident began) will also provide
information to the forensic medical examiner about the final events preceding death,
along with critical information about the circumstances of death. It is also through a
scene investigation that the medical examiner can determine the best approach with
which to conduct the autopsy, especially when investigating unusual or suspicious
deaths.
A death scene is usually secured by the police for the safety of all crime scene
officers. The area is cordoned by police barrier tapes in order to control access to
the crime scene. Police detectives, fire department personnel, and utility workers
may also be involved in the investigation process; thus, it is important to make sure
that the death scene is not contaminated or disturbed.
The following are among the details to be noted by the death scene investigators
(Prahlow & Byard, 2012):
• General conditions of the scene (indoors versus outdoors, temperature, wet
versus dry, etc.);
• The specific location of the incident;
• The body position;
• The presence or absence of rigor mortis, livor mortis and body cooling;
• The presence or absence of important trace evidence on or around the
body;
• The presence or absence of drugs or drug taking paraphernalia; and
• The presence of weapons, electrical devices, or other pertinent objects or
materials.
Witnesses, police detectives, and other authorities involved in the scene, such
as fire department personnel and emergency medical services, may also provide
vital information. Follow-up investigations may also be necessary when additional
information arise even after the autopsy and upon review of all available information.
While investigating the death scene, forensic pathologists and other law
enforcement officers must work cooperatively as a team in order to "solve the
medical mystery of why that particular person died at that particular time, under
those particular circumstances" (Lew & Matshes, Death Scene Investigation, 2005,
p. 9). It is important to note that while law enforcement has jurisdiction over the
entire scene, it is the forensic medical examiner who has jurisdiction over the
deceased body.
To effectively conduct the autopsy, the medical examiner will need to
determine the nature and extent of injuries of the body, especially in a homicide
case. This can be very helpful for police officers to focus their efforts in finding the
assailant. For example, if the medical examiner has ascertained that the injuries are
gunshot wounds but there are no casings on the scene, the police can immediately
search for a possible suspect with a revolver. Determining the extent of injuries can
also help in prescribing other necessary laboratory tests.
Death Certification
Death certification refers to the completion of the medical death certificate,
which includes personal information of the deceased (name, birthdate, etc.), as well
as the cause and manner of death (to be discussed further in the next section). If the
cause of death is natural, with no unusual or suspicious features, the doctor who last
attended the deceased (or the administrator of the hospital or clinic where the
person died) can immediately issue the death certificate and certify the cause of
death. The death certificate is then forwarded to the local health officer and then to
the Office of Civil Registrar for registration.
The World Health Organization (WHO) has issued instructions to assist
physicians and surgeons in the completion of medical certificates of cause of death
in keeping with a recommended international standard (World Health Organization,
1979). This format of indicating the primary pathological condition is used in most
countries. The format also allows for the inclusion of predisposing conditions and
multiple pathologies (most often used for the elderly) that have contributed to death.
Cause of Death

Cause of Gunshot
death Wound

peritonitis septicemia hemorrhage

Mechanisms of death
 The cause of death helps to answer the question of why death occurred. It
refers to the disease, injury, or a combination of these that produces a physiological
derangement in the body and can be considered responsible for the death. It is the
physician's best opinion (with or without an autopsy) on the specific medical
diagnosis denoting a disease or injury. Examples include strangulation, gunshot
wound, or myocardial infarction.
The underlying or proximate cause of death refers to the condition or the initial
incident or act that triggered the chain of events leading to death. In a natural and
continuous sequence that is unbroken by any efficient intervening cause, the
underlying cause of death produces the end result, without which the end result
would not have occurred. Meanwhile, the antecedent cause of death refers to the
intervening or intermediate disease or injury that occurred as a result of the
underlying cause of death.
The immediate cause of death refers to the final complication resulting from
the underlying cause of death, occurring closest to the time of death and directly
causing death. An immediate or antecedent cause of death may not be identifiable
in all cases. Therefore, an underlying cause of death can stand alone. For example,
consider a man who is burned extensively in a house fire and dies two weeks later
due to sepsis. In this case, the proximate cause of death is burns, and the
immediate cause of death is sepsis.
Another example is a pedestrian who is accidentally hit by a car, remains in
and out of coma for several months in the hospital, and eventually dies of
bronchopneumonia, which is a natural complication of his coma and confinement to
bed. The immediate medical cause of death is bronchopneumonia, but the
underlying cause of death would be the injuries resulting from being hit by a car.
Mechanism of Death

Mechanism Massive
of death Hemorrhage

Gunshot Stab Wound Blunt Force e

Wound

Causes of death

The mechanism of death refers to the physiological derangement set in motion

by the causes of death, which leads to the cessation of cellular electrical activity.
These are alterations of physiology and biochemistry whereby the causes exert their
lethal effects. The mechanism of death is more closely linked to the immediate
cause of death (if any) than to the underlying cause of death. For purposes of death
certification, immediate causes and mechanisms are interchangeable.
Manner of Death
The manner of death refers to the means or circumstances by which the cause
of death occurred. The manner of death could be natural, accident, suicide,
homicide, therapeutic complication, or undetermined. It is usually the lawyers and
police investigators who determine the manner of death, but physicians can also
make such conclusion based on the information about the decedent's (a legal term
referring to a person who died) activity just before death, recent symptoms, and
previous medical records.
Natural deaths are caused exclusively by some type of organ failure due to old
age or disease. An example is a man with an inherited weakness in the aorta who
suffers a heart attack, causing enough blood loss into the chest to compress the
heart and prevent it from beating.
A homicide refers to the intentional killing of one person by another person. At
the very least, someone else did something wrong that set in motion a process
resulting in the person's death. For example a robber who shoots a sales clerk
surely intends to cause harm, and a drunk driver who runs a red light and hits
someone is guilty of criminal negligence.
A suicide refers to the intentional taking of one's own life. At the very least, the
person did something that resulted in his or her own death, in accordance with what
he/she has intended to happen.
An accident is the result of an unexpected, unforeseen, and unintended fatal
event. These refer to deaths in which trauma causes or contributes to the cause of
death, and the harm inflicted is not intentional.
A therapeutic complication refers to fatalities that arise from complications of
diagnostic or therapeutic procedures. The term, however, is non-judgmental and
non-accusatory, and is not synonymous to malpractice.
The manner of death is considered undetermined when the circumstances
surrounding the death cannot be explained, when the findings leave considerable
doubt about the classification of the manner of death, or when there is insufficient
information about the circumstances surrounding the death.
Sudden Natural Death
As previously mentioned, the manner of death is considered natural if the
cause is some type of organ failure due to old age or disease. Natural disease is
considered as "an inherent pathologic process resulting from the body's natural,
usually long-term, response to a combination of genetic (internal) and environmental
(external) factors" (Prahlow & Byard, 2012, p. 243). This definition includes
contracting and dying from infectious diseases as well as certain external lifestyle
factors, such as poor diet, a sedentary lifestyle and chronic substance abuse, as
influences within the realm of natural disease. Hence, when an elderly with a long
history of heart disease is found dead at home, and the police finds no evidence of
foul play, the doctor of the deceased can issue a death certificate based upon the
medical history and indicate that the manner of death is natural.
Instances where there is a well-documented history of potentially lethal natural
disease allows for a straightforward cause of death determination. However, in
cases where death has occurred suddenly, unexpectedly, or without obvious
explanation as to why the individual died, a forensic medical examiner is called in to
investigate the case. For example, a movie personality may suddenly collapse in
front of numerous fans; a mother recovering in the hospital suddenly gasps and falls
back into her bed; a father doing simple carpentry work at home suddenly collapses
on the floor and dies on the spot. Many of these deaths occur by natural causes, but
the forensic medical examiner will certify it as natural only until other causes like
trauma, poisoning or assault have been ruled out.
Many forensic practitioners define "sudden death" as death that occurs within
24 hours without suffering from a recognizable cause. However, it would be practical
to divide sudden death into two categories to prevent confusion regarding time
intervals from collapse to resuscitation and pronouncement of death (Di Maio &
Dana, 2007, p. 40).
• True sudden death or instantaneous death - this refers to death that occurs
within seconds of the onset symptoms or infliction of trauma, or absolutely
no warning
• Non-instantaneous sudden death - this refers to death that occurs within
minutes of the onset symptoms or infliction of trauma
Instantaneous deaths almost invariably involve diseases of the cardiovascular
system, whereas broader definitions (those occurring within 24 hours) can involve
virtually any organ system or disease.
The natural causes of death as defined in Sharma (2011, pp. 40-41), are listed
below:
1. Diseases of the Cardiovascular System - these include myocardial infarction,
hypertension, acute myocarditis due to infections like enteric, diphtheria,
ischemic heart disease, sub-acute bacterial endocarditis, rupture of aneurysm,
angina, left ventricular failure, congenital abnormalities, occlusion of coronary
arteries due to thrombosis/embolism or atherosclerosis, right ventricular failure
due to lung diseases, cardiomyopathies, etc.
2. Diseases of the Respiratory System - these are diseases that produce
asphyxia, such as acute edema of glottis, membrane deposit in larynx or
tumor pressing on trachea, spasm of vocal cords, etc.; these also include
other respiratory reasons, such as air embolism, rupture of emphysematous
bullae or tubular cavity, hemothorax, pneumothorax, hydrothorax, lung
 carcinoma, asthma, pneumonia, acute bronchitis, and acute regurgitation of
stomach content into lungs in comatose conditions, etc.
3. Diseases of the Alimentary System these include hematemesis due to
esophageal varices, peptic ulcer, carcinoma of stomach or esophagus,
perforation of peptic ulcer, peritonitis, acute gastroenteritis, acute pancreatitis,
bursting of liver abscess, rupture of enlarged spleen, strangulated hernia,
obstructive cholecystitis, drinking of a large quantity of water in heated
condition, etc.
4. Diseases of the Central Nervous System (CNS) - these include hypertension
or atherosclerosis causing haemorrhage in various parts of the brain like
cerebrum, pons, or internal capsule (the leading cause of sudden death due to
diseases of the central nervous system); brain abscess, acute meningitis,
tuberculoma, encephalitis due to bacterial or viral infections,
encephalopathies, epilepsy, or brain tumors.
5. Diseases of the Genitourinary System - these are prominent diseases include
rupture of bladder due to enlarged prostate, stricture of the urethra or
malignancy, acute or chronic renal failure due to diseases, electrolyte
imbalance, renal diseases, tumors, uterine hemorrhages due to tumors like
fibroid or malignant tumors, etc.
6. Systemic Diseases these include bleeding disorders, diabetes mellitus,
Addison disease, cerebral malaria, convulsions, etc.
7. Sudden scare or fearfulness or emotional stress that precipitates neurogenic
shock ог induce myocardial infarction leading to death.
8. Some diagnostic or therapeutic procedures that may induce syncope, which
may lead to death; common procedures are lumbar puncture, vaginal
examination, catheterization of distended bladder, drainage of fluids from
pleural or pericardial cavities, etc.
9. Reflex inhibition of vagus that may occur due to sudden impaction of a foreign
body in the larynx.
It should be noted that medico-legal documents must be prepared in duplicate,
with utmost care in giving all necessary details that must be written with a ball-point
pen without errors and overwriting. Should there be corrections made on the
document, then the document should be authenticated with the full signature and
stamp of the doctor. Furthermore, no abbreviation should be used.
In addition, the next-of-kin must be informed of the death. In fact, during an
evaluation, the attending doctor is also legally bound to inform the police unit
concerned (by telephone) about the arrival of a medico-legal case. In this case, the
informal verbal communication should be followed by more formal communication
done in writing.
Review Questions
• What are some examples of medico-legal cases handled by forensic
medical examiners?
• What is the difference between cellular and somatic death?
• What are the three modes of death?
• What are the goals of a death investigation?
• Describe the main functions of a forensic medical examiner in assessing
a death scene.
• What are the most common natural causes of death?
 CHAPTER 4
INJURIES AND WOUNDS
Learning Objectives
At the end of this chapter, the student will be able to:
• Identify the more common types of physical injuries considered as medico-
legal cases
• Distinguish between blunt force and sharp force injuries
• Define the different types of blunt force and sharp force injuries
• Describe the different kinds of firearm injuries
• Identify the different kinds of burn injuries
• Distinguish between focal and diffuse brain injuries as main examples of head
injuries.

In the forensic medical context, physical injury refers to the damage inflicted on
"any part of the body due to the deliberate or accidental application of mechanical or
other traumatic agent" (Payne-James, Crane, & Hinchliffe, 2005, p. 127). A wound is
a disruption of the continuity of tissues and lining epithelium (layer of the skin)
produced by external mechanical force. The term injury is used synonymously with
wound, but the former can have a wider meaning, which encompasses not only
damage produced by physical force, but also damage produced by other means
such as heat, cold, chemicals, electricity, and radiation.
When an attending doctor conducts a clinical examination of a patient with
injuries and wounds and thinks that some kind of law enforcement investigation is
essential so as to ascertain responsibility regarding the case, the doctor should
immediately register it as a medico-legal case. It is also not up to the patient nor
other concerned parties to decide whether the case should be registered as medico-
legal. Further, the doctor should focus on recording observations correctly and not
on acting as a detective.
Cases that should be labeled as medico-legal may include any of the following
(Sharma, 2011):
1. Roadside accidents, factory accidents or any other unnatural mishaps
2. Suspected or evident homicides or suicides (including attempted ones)
3. Suspected or evident poisoning
4. Burn injuries due to any cause
5. Injury cases where foul play is suspected, i.e., if a doctor thinks that the patient
is an accused or a victim in a criminal case
6. Injury cases where there is a likelihood of death in the near future
 7. Suspected or evident sexual offenses
8. Suspected or evident criminal abortions
9. Unconsciousness, when the cause is not clear
10. Cases brought dead with improper history
11. Cases referred by courts
It is important for forensic physicians and forensic pathologists to appropriately
assess and document injuries to provide effective assistance in establishing the
cause, which may later become an issue in courts or other legal processes.
Documentation should be provided unambiguously and in detail so that it will be
comprehensible not only to other doctors but also to law enforcement officers, legal
advisers, and the courts. The documentation may include hand-drawn notes,
photographs, and annotated pro forma diagrams or body charts.
The following are potential relevant factors to be determined when the doctor
notes the history of the injured person (Payne-James, Crane, & Hinchliffe, 2005, p.
129):
• How was the injury sustained? Are weapons involved and are they still
available?
• What time was the injury sustained? The assault may have been reported
days or weeks after the incident, or there may be several injuries from
different incidents. Specific times should be documented.
• Has the injury been treated?
• Are there pre-existing illnesses? (e.g., skin disease)
• What are the patient's regular physical activities? (e.g., contact sports)
• Does the patient take regular medication? (e.g., anticoagulants, steroids)
• Is the victim right- or left-handed? How about the suspect? This may affect
the interpretation of injury causation.
• Is the patient under the influence of drugs and alcohol?
• What is the clothing worn by the patient?
The attending doctor should also assess potential relevant information
regarding the injury by looking at specific characteristics, such as the type, location,
pain, tenderness, stiffness, causation, handedness, size, shape, color, orientation,
age, time, and transient nature of injury. Injuries can be classified according to
cause, namely, blunt force injuries, sharp force injuries, gunshot injuries, burns, and
head injuries. These and other medico-legal terms discussed in this chapter are
critical in documenting injuries.
In the medical sense, the abdomen of the human body is subdivided into
smaller regions. The two most common schemes divide it either into four (4)
quadrants or nine (9) divisions. This is an essential in documenting the location of
the injuries and wounds.
The Four Abdominopelvic Quadrants
The Right Upper Quadrant (RUQ) contains the following: the right portion of
the liver, right kidney, a small portion of the stomach, portion of the ascending and
traverse colon, as well as parts of the small intestine; while the Left Upper Quadrant
(LUQ) is where the left portion of the liver, the larger portion of the stomach, the
pancreas, left kidney, spleen, portions of the transverse and descending colon, and
parts of the small intestine are located. For its part, the Right Lower Quadrant (RLQ)
is the location of the cecum, appendix, part of the small intestines, the right
reproductive organs, and the right ureter; while the Left Lower Quadrant (LLQ)
serves as the location of the most of the small intestine, some of the large intestine,
the left reproductive organs and the left ureter (O'Connell Smeltzer, et al. 2010).

Figure 1. The Four Quadrants of the Abdomen

The Nine Abdominopelvic Divisions
The nine abdominopelvic divisions are as follows: right hypochondriac, right
lumbar, right inguinal (or the right iliac), epigastric, umbilical, hypogastric (or the
pubic), left hypochondriac, left lumbar, and the left inguinal (or left iliac). The outer
and uppermost segments are the right and left hypochondriac regions, respectively.
The epigastric division lies in between these two. The right and left lumbar divisions
are the outer middle sections, while the umbilical region is between these two. The
lowest divisions are the right and left iliac region with the hypogastric between them
(Nath, 2006).

Figure 2. The Nine Divisions of the Abdomen

Blunt Force Injuries
Blunt force injuries are those
resulting from forceful contact with a
blunt object, such as fists, hammers,
baseball bats, furniture, floors, walls,
roads, trees, or the interior surfaces of
vehicles. They are among the most
common types of trauma encountered
by forensic pathologists.
The injury can be caused by
either a moving object that strikes the
body (such as the blow from a baseball
bat) or a moving body that strikes an unyielding object (such as a fall that involves
forces associated with sudden deceleration). It can also occur when the physical
force is applied more slowly by the pressure of crushing, squeezing, or pinching.
The three main types of blunt force injuries include (1) abrasions, which are
produced by the crushing or scraping of the skin; (2) contusions or bruises, which
occur when the elastic limit of subcutaneous blood vessels is exceeded so that they
tear and bleed; and (3) lacerations, which involves a greater force to tear the skin.
These blunt force injuries may occur singly or together in any combination, all at one
time or inflicted one after the other at different times.
Abrasions
Abrasions are also known as scrapes,
scratches, ог grazes. They refer to
superficial injuries involving only the outer
layers of the skin; they do not penetrate the
full thickness of the epidermis. When a blunt
object impacts the surface of the skin, it
results in the disruption and loss of
superficial layers, or the crushing or loss of
skin or mucous membrane. Abrasions may
bleed only slightly, heal quickly and
oftentimes, leave no scar.
Brush abrasions of are broad patches,
the frictional element which gave rise to the
term brush burns (e.g., carpet burns). Brush
burns are commonly in their most florid form
as road rash following a motor/vehicular
accident in which the victim slides along the
road surface. seen
 A scratch is a linear abrasion produced
by drawing a sharp point over the surface of
the skin or mucous membrane. Common
examples of such sharp points include plant
thorns, barbed wire, human fingernails, and
animal claws. The scratch marks may be
distinguished as coming from an adult or
child by looking at the spacing and
convergence of the scratches. Skin scrapings
may be recovered from beneath the fingernails used for scratching, and likewise be
linked to the person who was scratched through serology or DNA techniques.
Abrasions are sometimes considered superficial or trivial and are, therefore,
easily overlooked by regular attending physicians. However, to the forensic
pathologist or the forensic physician, abrasions may provide valuable information.
The patterning is clearer than that observed in bruises, because abrasions
frequently take a fairly detailed impression of the shape of the object causing them.
Often, careful examination can indicate the exact site where the object struck
the skin, the shape of the causative object, and the to when it struck the For
example, a forensic pathologist investigating a case of manual strangulation might
find visible signs of attack on the neck through small, crescent-shaped abrasions
caused by the fingernails of the victim or assailant.
Trace evidence from the object, such as dirt or glass, can also be found on the
contaminated graze, whereas skin fragments from the victim may be recovered from
the wounding weapon. These may have important medico-legal significance and
should be carefully preserved for subsequent forensic analysis.

Contusions
A contusion, also known as
bruise or ecchymosis (plural:
ecchymoses), refers to a
discoloration resulting from
hemorrhage beneath the skin,
tissue or mucosa, without any
associated breach in the sur face.
It is generally produced when
blunt force has caused a
disruption of blood vessels with
escape of red blood cells into the
surrounding tissues, such as a
blow or a fall, but can also result from crushing, squeezing or pinching. The blood
vessels most commonly ruptured are the capillaries and small veins, rather than
arteries.
Any tissue may bruise, but bruises confined to deeper tissues, as in the
skeletal muscle, are not visible on the skin surface. Bruises of the deep tissues,
even when fatal, may not be evidenced by any injury to the skin surface. For
example, a fatal head injury where there is a subdural hematoma may be
encountered without recognizable superficial bruising (also known as internal
hemorrhage). A fatal strangulation with extensive bruising of the muscles of the neck
may be accomplished without obvious bruising of the skin. Blows to the abdomen
produce bruising and ruptures of internal organs, but such blows may not produce
any abdominal wall bruising.
Contusions tend not to accurately
reflect the shape of the object that
produced them and they change shape
with time. In other cases, the surface
detail of the striking object or wounding
weapon may be imprinted as a patte rned
bruise on the skin and may be seen
during physical examination which can be
documented by photography.
The patterned injury or imprint bruises usually occurs following a heavy
impact, like from a shod foot or motor
vehicle or from the muzzle or foresight
of a gun in a contact gunshot wound.
With death occurring soon after
inflicting injury, the diffusion of blood is
limited and thus obscuring the
imprinted pattern.
There are cases where bruises
give a more general impression of the
wounding weapon or object, such as a
belt used to hit a child . Finger-pad can
also be seen on the neck in throttling, on the upper arms in restraint, on the thighs in
rape, and on the chest and face in cases of child abuse.
The size of a bruise is not a reliable indicator of the degree of force that
caused it. There are several other factors that could influence bruise size, such as
anatomical site, gender, age, or the presence of natural disease. Females
commonly bruise easily, and patients with blood dyscrasia or blood disorder bruise
easily. Blood thinning medications, such as warfarin, may also accentuate
hemorrhages.
 Elderly individuals bruise more easily because of the degenerative changes in
the blood vessels and the supportive tissues of the skin and subcutaneous fat. In the
very old and frail, a finding of senile purpura can be seen. This is characterized by
sharply-defined geographic areas of "spontaneous" bruising to the backs of the
hands and forearms. Meanwhile, there are individuals, such as children, who may
have been victims of significant violence and have significant internal injury, but
show little to no external evidence of injury.
Contusions may change color as they age before finally fading away. A fresh
bruise is typically dark red (the color of venous blood) and soon turns to a dusky
purple. Thereafter, the color changes progressively from the periphery of the bruise
towards the center. It can be brown, green, yellow, and a pale straw color before
finally disappearing. These color changes reflect the breakdown of hemoglobin into
colored products as part of the inflammatory process. The time frame of the color
change is extremely variable depending upon the size, depth and location of the
bruise and the general health of the individual.
Most contusions disappear within one to four weeks normally (complete
healing) barring any medical complications. In general, contusions having green or
yellow margins are three or more days old and those with dark red or dusky purple
color are fresh, having been inflicted within a day or so. The accurate estimation of
the age of a single bruise is notoriously difficult but fresh bruises are easily
distinguishable from bruises that are several days old.
Establishing that bruises are of different ages, and therefore inflicted at
different times, is important in the assessment of allegations of repeated assaults,
such as in child abuse and spousal abuse.
The color of bruises does not change after death, but they may become more
evident against the now pale skin, or may alternatively be obscured by the post-
mortem skin color changes of lividity and decomposition. It may be difficult to
distinguish a bruise sustained at the time of death from one that occurred ante
mortem (before death), and such bruises are best described as having occurred
approximately "at or about the time of death."
Contusions to the deep tissues can be present without any evident skin
surface injury, particularly if the force applied is by a smooth object over a wide
area. Such deep bruises may spread under the influence of gravity and body
movement, following the path of least resistance along natural or traumatic planes of
cleavage of the tissues, making them visible only after dissection and otherwise not
visible on the skin surface.
The shifting of deep bruises explains their delayed appearance at the skin
surface some days after infliction, often located at sites distant from the points of
impact. For example, the delayed appearance of bruising around the eyes follows a
blow to the forehead, bruising behind the knee follows a blow to the lateral thigh or a
fractured neck of femur, and bruising to the neck follows a fractured jaw.
 A second examination of the alleged victim of an assault after an interval of a
few days may show visible bruising where previously there had been only swelling
or tenderness of deep bruising. Such second examinations are recommended as
best practice.
Skin and mucosal bruises may be accompanied by abrasions and lacerations,
but they are not usually associated with cuts and stabs, where there is a free flow of
blood from the cut vessels rather than infiltration of blood into the tissues.
Bruising is essentially a vital phenomenon, in which the infiltration of blood into
the tissues occurs under the pressure of the circulating blood. This is why after
death, the lack of blood pressure means that a considerable force is required to
produce a bruise on the cadaver. Such post-mortem bruises are disproportionately
small relative to the force applied, which may be evident from associated fractures,
and the resultant bruises are usually only a few centimeters in diameter.
In assessing whether the contusion is ante-mortem or post-mortem, the
findings and circumstances as a whole should be considered as these can cause
confusion. However, finger-pad bruises to the insides of the upper arms may be
produced by simply lifting the cadaver, particularly in those elderly women who have
abundant loose upper-arm fat, which is often congested due to post-mortem lividity.
Any livid dependent area of a corpse bruises more readily post-mortem as a result
of the vascular congestion.
Post-mortem lividity, which
is the gravitational pooling of
blood within the blood vessels
after death, may be confused
with bruising. However, the
pattern and distribution of lividity
usually makes the distinction
straightforward.
Various terms exist to
describe the gross appearance
of a contusion. These include
petechiae, ecchymosis, and hematoma. Petechiae or petechial hemorrhages are
small punctate hemorrhages or very small contusions. They are minute reddish
purplish spots containing blood that a ppears in the skin and mucous membranes
as a result of localized hemorrhage. Sizes range from pinpoint to pinhead.
 Ecchymoses are the so-called "love bites"
(also called hickeys in American slang or
chikinini in Filipino). These are superficial
contusions produced by the negative pressure
of mouth suction. They are usually located at
the side of the neck, on breasts or inner thighs,
especially in victims of alleged sexual abuse or
sexual assault.
If the extravasated blood collects as a
discreet tumor-like pool, the lesion is referred to
as a hematoma, which is defined as a focal
space-occupying collection of blood that expands and/or distorts the tissue
configuration. In most cases, the sac of blood or hematoma eventually dissolves. In
some cases, however, it may continue to grow or show no change. If the sac of
blood does not disappear, then it may need to be surgically removed.
The following are the different types of hematoma identified:
1. Subdermal hematoma (under the skin)
2. Othematoma (between the skin and the layers of cartilage of the ear)
3. Perichondral hematoma (ear)
4. Perianal hematoma (anus)
5. Subungual hematoma (nail)
6. Head/brain
a. Cephalohematoma (between the periosteum and skull)
b. Epidural hematoma (between the skull and the dura mater)
c. Subdural hematoma (between the dura mater and arachnoid mater)
d. Subarachnoid hematoma (between the arachnoid mater and pia mater)
e. Subgaleal hematoma (between the galea aponeurosis and periosteum)

Lacerations
A laceration refers the splitting of tissues and the
forceful tearing of the skin when an object impacts the skin
with a force that exceeds its elastic capacity. Lacerations
result from blunt force or acceleration/deceleration injuries,
and are different from incised wounds resulting from sharp
objects.
Direct crushing, typically between an unyielding
object on the one side and underlying bone on the other,
will result in split-like lacerations of the skin. Such skin
splits occur most commonly where the skin lies close to the underlying bones, such
as on the scalp, eyebrows, cheeks, elbows, knuckles, knees, and shins.
Lacerations have the following characteristic features (Crane, 2009, pp. 104-105).
• They are ragged wounds with irregular division of the tissue planes
• They tend to gape because of the pull of elastic and muscular tissues
• Their margins are often bruised and abraded; these are important diagnostic
features that must be looked for with a hand-lens if necessary
• Blood vessels, nerves, and delicate tissue bridges may be exposed in the
depth of the wound soiled by, for instance, grit, dirt or particles of glass
• Occasionally, the margins are shelved or flaps of skin are produced by a
shearing blow, the direction of which can then be deduced
• Laceration of skin overlying bone may split the skin so cleanly as simulate to
an incision; this is particularly SO on the scalp, face or shin, but close
examination of the wound together with the history of how the injury came to
be sustained should clarify the situation.
Lacerations do not generally reflect the shape or size of the object that produced
them. They may be smaller than the impact area or may extend beyond the impact
area. However, like contusions and abrasions, lacerations may have forensic value
in death certification and in courtroom testimony, such as when the degree of
violence and suffering are discussed.
Sharp Force Injuries
Sharp force injuries refer to damage to tissues or organs by objects or weapons with
sharp edges or pointed ends. They are generally classified into three, namely;
incised, stab, and chop wounds.
Lacerations are to be distinguished from sharp force injuries. On the one hand,
lacerations are caused by crushing of tissues by the application of a blunt force,
while a sharp force wound is a cut. For example, when an orange fruit is crushed
with the blunt force of a hammer, the result is similar to a laceration with abraded,
torn, and irregular edges. On the other hand, when the orange is sliced with a sharp
knife, the result is like a clean incised wound (Prahlow & Byard, 2012).
Straight wounds can be referred to as linear, while rounded wounds can be
described as curvilinear; the ends are called the angles, while the sides are called
margins. Tool, marks found in the wound should be documented for later
comparison against the striations of a suspect's weapon.
Incised Wounds
Incisions or incised parallel wounds
refer to cuts or slices caused by a sharp-
edged object that has impacted the body in
an approximately or tangential direction.
Most often, the object that caused the injury
was moving in a slashing motion, with the
angles at either end having a sharp
appearance.
Incised injuries usually have clean
edges, minimum bruising, and no bridging of
nerves or vessels. Wounds tend to be straight and longer than their depth, with no
contusions and abrasions. Blood vessels
Incised injuries usually have clean edges, minimum bruising, and no bridging
of nerves or vessels. Wounds tend to be straight and longer than their depth, with no
contusions and abrasions. Blood vessels and nerves are cleanly divided and
bleeding is often profuse. When caused by a blade slash, the incision will appear
deeper at their origin and shallower at the end from which the blade is withdrawn.
In general, however, it would be impossible to determine the direction at which
an incised wound was inflicted (for example from right to left across the neck).
Penetration of at least the full thickness of the skin is usual, but shallow and partial
thickness skin cuts can also occur, such as the common "paper cut."
In clinical practice some medical practitioners might label both incised wounds
and lacerations as "lacerations." This may create confusion when clinical medical
records are used in legal proceedings, such as when implicating certain sharp-
edged weapons as the causative object. To ensure clear forensic value of medical
records, documentation should ensure the clear distinction between an incised
wound, which implies contact with a sharp-edged weapon and a laceration, which
implies contact with a blunt object or weapon.
The key features of incised wounds reflect the fact that they are produced by
keen-edged objects rather than blunt objects. Incised wounds typically have well
defined margins with no associated abrasion or bruising of the adjacent skin. There
is always complete severance of all tissues within the depth of the wound, so that
there are never any of the tissue bridges that characterize lacerations.
Most incised wounds are knife wounds. However, forensic physicians and
forensic pathologists cannot safely make this conclusion by examining the wound
alone. This is because knife wounds look similar to incised wounds caused by
razors, shards of glass, sharp edges of machinery, and other sharp tools. There are
also marked differences in the nature of knife blades. Cuts produced by a serrated
knife blade may give an indication of the nature of the blade if the cut is tangential to
the skin surface, such that the serrations leave shark-fin skin tags at the wound
edge, or parallel scratch abrasions on the adjacent skin.
Occasionally, incised wounds have irregular or ragged margins because either
the causative object had an irregular edge, such as broken glass, or the cut was
made across skin folds, such as on the neck or palm, so that the wound assumes a
different shape when the folds flatten out.
Cleanly severed blood vessels
within an incised wound bleed profusely,
and if large vessels are cut then the
hemorrhage may be sufficient to kill. Such
extensive hemorrhage commonly results
in blood soaking of clothing, together with
blood staining and spattering of
surroundings, thus openi ng up the
possibility of reconstructing the events
through blood spatter analysis. When
large veins are severed, particularly in the
neck, air may be drawn into the circulation, obstructing the flow of blood through the
heart and killing the victim by air embolism.
Stab Wounds
A stab wound is the result of a pointed or sharp
and pointed object forced inward. A stab wound is
also sometimes called puncture, perforating, or
penetrating wounds. The direction of force is usually
perpendicular to the skin surface. It is often caused by
a weapon being thrust at, or into a victim. However, a
stab wound may also be the result of a moving body
against a relatively stationary pointed object (Prahlow
& Byard, 2012).
The typical feature of stab wounds is a depth
greater than their width or length. They often have
little or no external blood but present danger to vital
organs. Stabbing can cause serious penetrating
injuries that, in turn, can lead to hemorrhage (or
occasionally air embolism) and result in rapid death.
The victim may also die later from infection, pulmonary embolism or other
complications.
Causative objects include knives, daggers, scissors, screwdrivers, and pokers.
On the one hand, a dagger with a sharp point and double-edged blade tends to
produce an elliptical wound with sharp edges and clean-cut ends. The single-edged
blade of the kitchen knife, on the other hand, may cause squaring or fish-tailing of
one extremity of the wound caused by the non-cutting back of the blade. When a
pair of scissors is used for stabbing, the wound looks more rounded with bruising
surrounding the margins.
Although the above instances show that the appearance of the wound in the
skin can point to a possible weapon, the wound could also have a jagged
appearance when the weapon is withdrawn at a different angle from the way it
entered the body. Further, the skin's elasticity enables it to close tightly around the
stabbing object and close again if the object is removed. Hence, the length of the
wound could shorten and the width could increase (Crane, 2009).
Both incised wounds and stab wounds typically retain no trace evidence from
the weapon, but they are associated with blood staining of the weapon, clothing and
crime scene. A commonly asked question in the courts is the amount of force
required to produce a specific stab wound. This is usually a difficult, if not
impossible, question to answer. The sharpness of the point of the weapon is the
most important factor in determining the degree of force required to produce a stab
wound.
Chop Wounds
Chop wounds are caused by
objects with relatively sharp edges (e.g.,
hatchet, axe, tom-ahawk, boat propeller,
or lawn mower blade) possessing a
reason-able weight resulting in a
combinatio n of sharp and blunt force
injuries at the point of impact. Chop
wounds tend to have an incised
appearance on the skin surface, with
associated bruises, abrasions, and
significant underlying blunt trauma (Prahlow & Byard, 2012).
Defensive Wounds
Defensive wounds refer to injuries sustained by victims attempting to defend
themselves from attack. The wounds are often found on the victim's fingers, hands,
forearms, and upper arms. Defensive injuries may include not only sharp force
injuries, but also blunt force injuries and gunshot wounds. They are highly
suggestive of homicide.
When attacked with blunt objects, the instinctive reaction of the victims is to
raise their arms and cover their head in an attempt to protect their eyes, head, and
neck. The arms, therefore, become exposed surfaces for impacts against blows.
When the victim curls into a ball in a fetal position, the outer and posterior aspects of
the lower limbs and back may be injured (Payne-James, Crane, & Hinchliffe, 2005).
 In sharp-blade attacks, the victim will often try to disarm the assailant and
seize the weapon, sustaining injuries in the process. Cuts to the palms and fingers
result from attempts to grab or deflect the weapon, whereas slash and stab wounds
to the backs of the hands and the forearms result from shielding movements. By
contrast with the pattern seen in defensive wounds, if the knife slips within the hand
of the assailant then the blade typically cuts either the base of the little finger or the
web of the thumb of the assailant.
Gunshot wounds sustained through the arms could be from raising arms in
front in a defensive posture. Defensive wounds may also be present in the legs of
victims attacked on the ground kicking away an assailant.
If an individual claiming to be a victim of assault lacks such defensive injuries,
it is possible that he or she has been incapacitated through alcohol, drugs, or other
injuries. Another possibility is that the wounds may have been self-inflicted.
Self-Inflicted Wounds
Self-infliction of shallow cuts as a form of self-harm, which falls short of
attempted suicide, are parallel, shallowly incised wounds that heal and leave
multiple, fine, horizontal, linear white scars. They are often located in reasonably
accessible areas, such as the forearms, upper thighs, abdomen, and the front of the
chest; they are most prominent on the non-dominant arm. They usually do not to
involve sensitive areas, such as the eyelids, nipples and genitalia.
When seen in clinical practice, the scars raise the possibility of a personality or
psychiatric disorder, with an attendant risk of suicide in custody. If seen at autopsy,
they raise the index of suspicion for suicide, alcohol and drug abuse, or high risk
behavior leading to accidental death.
Occasionally, individuals self-inflict incised wounds in order to falsely allege
that they have been assaulted. These injuries have a pattern that reflects
handedness, easy accessibility of the injured parts, infliction by pressing the sharp
edge against the skin and then running it across the skin surface rather than
slashing movements, and the avoidance of sensitive or critical areas such as
nipples, lips, and eyes.
There are also individuals known as "cutters" who engage in self-injury and
deliberately cut their skin, usually on the arms. In some instances, there may be
associated psychiatric disorder (such as a borderline personality disorder or
depressive illness). However, there are also instances among pre-teens, teenagers,
and young adults where there is no suicidal intent or definite psychiatric diagnosis
(Prahlow & Byard, 2012).
Due to the risk of suicide, it is important to carefully assess injuries that may
indicate deliberate self-harm. The items listed below are possible indicators that may
assist in the recognition or suspicion that injuries are self-inflicted. These are not
diagnostic but some may give an indication of self-infliction (Payne-James, Crane, &
Hinchliffe, 2005, р. 143).
• Must be on an area of body accessible to the person to injure themselves
• May be superficial or minor
• Regular with an equal depth at the beginning and end (for cuts)
• Regular and similar in style or shape (for scratches, burns, etc.)
• Multiple
• Parallel or grouped together
• In right-handed persons, the injuries are predominantly on the left side (and
the converse for left-handed individuals)
• There may be lesser injuries where initial attempts at self-harm are made
(tentative scars)
• There may be old scars of previous self-harm
• There may be a psychiatric history
Firearm Injuries
Firearm injuries refer to those caused by projectiles (missiles or bullets) fired
from guns. When a bullet or projectile has entered but not exited the body, it is
termed as penetrating, if the projectile has passed completely through the body, it is
termed as perforating. Wound characteristic are influenced by the caliber of the
weapon and the distance from the gun to the victim (Prahlow & Byard, 2012).
In cases of non-fatal injuries, the forensic physician or the hospital clinician
has to ensure that the initial appearance of the wound is accurately documented
because surgical treatment may distort the wound characteristics. Fragments,
bullets and pellets found and removed from the body must be handed over to the
appropriate authorities (Payne-James, Crane, & Hinchliffe, 2005).
In cases of fatal injuries, the autopsy examination should include the retrieval
of the bullet for examination of a ballistics expert who will determine the type of
firearm used and match the specific bullet to a specific gun. The forensic pathologist
can also assist in reconstructing the positions of the shooter and the deceased
relative to each other by determining the entrance and exit wounds as well as the
trajectory of the bullet within the body (Adelman, 2007).
Weapons and Ammunitions
Knowledge of the construction and mechanism of guns and the ammunition
from which they were fired is also important. The basic structure of a firearm
consists of the following parts (Prahlow & Byard, 2012):
• The grip - the appendage designed to be held in order to use the gun. It is
that portion of the mechanism that is held by the hand and orients the hand in
a forward, vertical orientation, similar to the position one would take with a
conventional pistol. Grip serves multiple functions such as magazine housing
or bipod
 • The barrel - the tube through which a bullet travels when a gun is fired
• The trigger - the lever that activates the firing mechanism of a gun
• The internal mechanisms that transfer the trigger pull into the firing of the
bullet (usually including a "firing pin")
• The firing chamber or the part that holds the cartridge containing the bullet or
projectiles to be fired
• A mechanism that allows for quickly supplying another round (bullet)to be
fired.
The three basic types of firearms are handguns, rifles, and shotguns. Handguns
are weapons with short barrels that can generally be held and controlled with one
hand. The usual handgun barrel is rifled. Handguns include (a) revolvers, which
contain a cylinder within which multiple bullets are placed; and (b) semiautomatic
pistols, which have a self-loading aspect that can fire continuously so long as the
trigger is depressed.
Rifles are long-barreled firearms that are available in different models with a
variety of ammunition. The two general categories are the (a) rim fire or low-velocity
rifle, which is used in hunting small game and is commonly of 22 caliber; and the (b)
center fire or high-velocity rifle, which is used in hunting and in war and has a higher
muzzle velocity, typically in the 2000 to 3500 feet/second range.
Hunting ammunition is generally designed to break apart on impact so that the
projectile is less likely to completely perforate the target and harm something behind
the target, whereas military ammunition is designed to completely perforate the
target. High-powered rifles produce devastating wounds when fired both at close
and distant ranges.
Shotguns are long guns with smooth (non-rifled) barrels; these are designed to
fire a shell containing a single large lead slug or lead pellets that, on exiting the
barrel, spread out in a cone-like distribution to cover a large surface area.
Ammunitions include tiny lead pellets called "birdshot," large pellets called
"buckshot," and a single large lead projectile called "slug."
There are generally two types of ammunition utilized in shotguns. They can fire
"shots," which are spherical metal (lead or steel) pellets that are available in a
variety of sizes, ranging from small "birdshot" (diameter of 0.05-0.22 in) to large
"buckshot" (diameter of 0.24-0.36 in). The shot pellets are contained within a shot-
shell cartridge, where the collection of pellets overlie various forms of "wadding,"
which separates the pellets from the underlying gunpowder. Different ammunition
manufacturers utilize different types of wadding.
A second type of ammunition used in shotguns is the shotgun "slug." A slug is a
single, large piece of metal (usually lead) that is fired from the weapon. Generally,
shotguns wounds are highly destructive when fired at close range, but loses its
destructive nature at increasingly distant ranges (Lew, Dolinak, & Matshes, 2005;
and Prahlow & Byard, 2012).
 The barrel of a gun is an important factor in firearms identification. It varies
depending on the manufacturer of the guns. The rifling consists of spiral grooves
that cut the length of the interior or bore of the barrel. When a rifled weapon is
discharged, the rifling causes the bullet to spin around its long axis like that of a
spinning-top. This lends gyroscopic stability to the bullet in flight, increasing the
accuracy of the weapon.
As a gun is fired, it expels not just the bullet but also a host of other things, such
as flame; the heated, compressed and expanded gas; and the residue. The residues
include the bullet (jacket, lead), the powder particles (grains, soot, graphite), the
primer (lead, barium, antimony), the barrel (lubricant, rust, dust, scraping), and the
cartridge case (copper, zinc).
A bullet is a projectile that is fired from a gun. It came from the French word
boulette ("a small ball"), reflecting the fact that original projectiles were small lead
spheres, or the so-called musket ball. The ammunition or cartridges for rifled
weapons consists of a cartridge case. On its base is a chemical primer with a
chemical propellant above and the bullet clamped on top.
Wound Ballistics
Basic knowledge of ballistics (the science of the motion of projectiles) is essential
for an examiner to have a proper understanding of wounds caused by firearms.
Wound ballistics refers to the study of the effects of penetrating projectiles on the
body.
The morphology, pathway, and exit of a gunshot wound from the body are
dependent on several factors, such as the weapon used and the bullet's shape,
size, and weight. The nature of the wound can also be affected by the angle of
impact, the depth of penetration, and the character of the target tissue (i.e., bone or
fat). Wounding potential could also depend on the placement, penetration, yaw, and
fragmentation of the projectile.
Bullets disrupt tissues by two principal mechanisms:
1. Direct laceration of the tissues occurs when the bullet penetrates just as
with any penetrating object. This is the main mechanism of tissue damage
in low-velocity gunshot wounds from such weapons as pistols. The
permanent cavity visible in the body accurately reflects the tissue damage
produced by the bullet.
2. A temporary cavity is formed in high-velocity rifle wounds. There is transfer
of kinetic energy from the bullets and it is so great that it creates a
temporary cavity of up to 30 times the diameter of the bullet at a pressure of
100-200 atmospheres over a time span of 5-10 milliseconds. The result is a
small permanent cavity surrounded by a wide zone of hemorrhage and an
even wider zone of tissue damage, which may not be obvious on
examination.
 The wounding potential of a bullet is due to the mass and its velocity (KE= M x
V). High velocity projectiles have the greatest wounding potential because the
kinetic energy increases in proportion to an increase in the velocity squared. The
wounding effect of the bullet is due to the transfer of its kinetic energy to the tissues.
If the bullet did not exit the body, all its kinetic energy is transferred to the tissues. If
the bullet exits the body, only some of the kinetic energy will be transferred to the
tissue.
The loss of bullet's kinetic energy and its wounding effect is influenced by the
wobbling and tumbling of the bullet as it passes through the body, the bullet's
deformation and break-up, and the long wound tracks and passage through denser
tissues.
Gunshot Wounds
A gunshot wound is a penetrating
wound that leaves a skin defect where the
projectile passes through the skin. As
general rule, a gunshot exit wound is
larger and more irregular than a gunsho t
entry wound due to the effect of bullet
tumbling and bullet deformation.
Gunshot wounds are typically
categorized by examining characteristics
of wound and looking for the presence of
gunshot residues. The presence of
gunshot residue is used to determine
approximate muzzle to garment/target
distance.
If the muzzle of the weapon is in contact with the skin at the time of discharge,
then it may leave a muzzle impression, which is an imprint bruise-abrasion
surrounding the skin defect of the gunshot wound. Muzzle imprint is produced by the
passage of discharge gases into the wound track with resultant billowing out of the
skin against the muzzle of the gun. When this happens, the stretched skin may
lacerate, thus leaving an irregular stellate gunshot wound entrance. Furthermore,
the skin may stretch beyond its limits and tear around the bullet wound.
Gunshot wounds through the bony areas (i.e. skull, ribs, sternum, and pelvic
bones) may leave coned defects with a smaller hole on the entry side of the bony
plate and a larger beveled defect on the other side.
If the bullet strikes an intermediate object, it will cause the bullet to yaw or tumble
and will create an irregular-shaped entrance hole. This is also known as a keyhole
entrance.
 The following are possible indicators that a gunshot wound is caused by a
suicidal act:
• Gunshot wound is within arm's reach;
• Wounding weapon is present;
• Wound is usually on the mouth, temple, anterior neck or chest, and not in
the eye, abdomen or back;
• .Women rarely use guns; and
• .Multiple gunshot wounds would suggest homicide.
X-rays of gunshot victims, both living and dead, provide valuable information.
This should always be performed in autopsies on gunshot fatalities, if the facilities
are available. X-rays may identify any projectiles present, along with their locations,
or may identify projectile fragments if the bullet has exited. From such information,
the path of the projectile through the body and the type of ammunition or weapon
used can be determined.
Gunshot Entry Wound
A typical entrance wound has a round or oval-shaped skin defect, surrounded by
a rim of abrasion called the abrasion collar or circumferential marginal abrasion. It is
a result of the forward motion of the bullet indenting the skin and grazing it at the
time of its entry. The abrasion ring appears reddish-brown but can darken to almost
black with post-mortem drying. It is typically absent from exit wounds. Bullet caliber
cannot be determined by looking at the wound because the skin stretches on
impact.
When a bullet enters the skull, it produces a sharp-edged "punched-out" hole in the
outer table, with a larger corresponding "beveled-out" hole in the inner table.

Gunshot entry wounds vary in their overall appearance based on the range of fire
or how far the muzzle of the weapon is from the target. Distance ranges are
categorized as contact, close contact, intermediate, or distant. Determining the
range of fire from the wound appearance is of forensic importance.
Entry wounds have several inherent characteristics depending on the range of
fire (Prahlow & Byard, 2012, p. 488).
• Contact wounds have associated charring of the skin, with soot deposited
within the depths of the wound. Some contact wounds also have muzzle
imprint abrasions
• In close-range entrance wounds, wherein the muzzle is close to, but not in
contact with the skin), soot and gunpowder will be evident around the
entrance skin defect. Gunpowder stipple marks or gunpowder tattooing are
embedded in the skin as gunpowder particles that actually strike and injure
the skin and cannot be washed away. With most handguns, soot combined
with gunpowder stippling around gunshot entrance wounds can occur when
the muzzle of the weapon in up to about 12 inches from the skin.
 When the body is exposed to a very high temperature, the muscles contract
and draw the arms and legs into a bent position due to the coagulation of proteins.
This burned position or fencing posture has been compared to the stance of a
pugilist or a boxer and is referred to as the "pugilistic attitude."
Classification of Burns
Burns can be classified in various ways. Clinically, they may be classified as
superficial or deep. Superficial burns refer to those affecting only the epidermis or
the outer layer of the skin; deep burns involve the dermis (the deep vascular inner
layer of the skin), tissues and bones (Sharma, 2011).
Burns in the skin can also be classified in degrees, depending on the depth of
injury or the severity of tissue destruction.

1. First Degree Burns

These injuries involve only the epidermis and are characterized by erythema,
edema, and pain. They are produced by prolonged exposure to low intensity heat or
very brief exposure to high intensity heat (e.g mild sunburn), and manifests as red
discoloration and superficial inflammation. When it heals, skin peeling typically
occurs. Wound healing is completed in approximately 5 to 10 days with no residual
scarring.
2. Second Degree Burns
Second degree burns are also called partial thickness burns. The most
superficial second degree burns totally affect the epidermis as well as the upper
third of the dermis. Such burns involve blister formation and are extremely painful. It
heals in approximately 7 to 14 days with minimal scarring.
A deep second degree burn extends beyond the upper third of the dermis but
not beyond the dermis itself. Ironically, these deeper burns are less painful due to
the destruction of nerve endings in the dermis. Wound healing is extremely slow,
sometimes requiring several weeks to months. This may lead to dense scarring, if
not treated by skin grafting.
3. Third Degree Burns
Third degree burns or full thickness burns destroy the full thickness of the
epidermis and dermis. Heat coagulation of dermal blood vessels leaves the tissue
avascular with a characteristic waxy white appearance. In a prolonged contact
between subcutaneous fat and flame, the burn has a leathery brown or black
charred appearance. There is lack of pain because all the nerve endings are
destroyed. These burns require skin grafting because skin regeneration is not
possible.
4. Fourth Degree Burns
These burns are also described as charring injury due to incineration of
tissues. There is complete destruction of the skin and subcutaneous tissues, as well
as complete or partial charring of the bone.

Types of Burns
There are several types of burns, depending on the agent causing the
application of heat.

Dry Burns
Dry heat sources result in dry burns. Examples of such sources are avens, stove
tops, hot engines, mufflers, radiator grill, clothes irons, hair dryers, heating pads and
furnaces. In children, such burra may be either accidental or inflicted. Fire-related
injuries also involve dry burning (Prahlow & Byard, 2012). These are discussed
separately below.

Scalds
Scalds are produced by moist heat or steam, or any hot liquid such as water,
oil or even molten rubber or metal. They are typically less severe than burns
produced by dry heat. The scalded area appears erythematous (abnormal redness
of the skin resulting from dilation of blood vessels) with desquamation (loss of bits of
outer skin) and blistering of the usually sharply demarcated area of injury. Scalds do
not cause charring of the skin or skin or hair dye, but may result if first, second, or
third degree burns.
Scalding burns can be a result of immersion in scalding hot liquid, splashing or
spilling of hot liquid over the body, or superheated vapor causing severe injury to the
mucosa of the airway. The location and pattern of the scalded regions may help
differentiate between accidental and homicidal or intentional scalding (Di Maio &
Dana, 2007).
Chemical burns
Chemical burns are produced through contact with corrosive acids and alkalis.
Most of these injuries involve direct tissue damage, which causes drying and
blistering, destruction of proteins or fat, or interference with cellular metabolic
processes. It may take several hours before the burn manifests (Prahlow & Byard,
2012).
As with scalds, the pattern of chemical burns can give an indication as to how
they occurred. Throwing liquid corrosives over a victim is more often intended to
produce facial disfigurement rather than death. Suicide by ingestion of strong acid or
alkali has also become more common.
Fire Burns
Burns that occur from building or home fires are the most common types of
thermal injuries encountered in death investigations. Such burns can be caused by
the radiant heat injury alone, from tissues being in contact with burning clothes or
bedding, or from the victim actually being on fire. Death investigations in fires
involve identifying the victim and ascertaining whether the victim died during or
before the fire occurred.
To assess whether the decedent was breathing during the fire (and therefore not
dead before the fire), the following indications in autopsy can be observed (Prahlow
& Byard, 2012, p. 754):
• Bright pink-red discoloration of tissues that indicate elevated levels of carbon
monoxide.
• Soot within the airways, including the nose, mouth, larynx, trachea and main
stem bronchi indicating that smoke had been inhaled); and
• Elevated level of carbon monoxide in the blood shown on the toxicology
report.
Radiant Burns
Radiant burns are caused by a heat source close to the victim or
electromagnetic energy radiating out from an energy source. They may produce skin
blisters and erythema, and charring may result from prolonged exposure. Sources of
electromagnetic energy include ultraviolet and ionizing radiation. In contrast to dry
burns where direct contact with the heat source is required, radiant heat burns do
not require direct contact with a heat source.
Explosion and Blast Injuries
Explosion and blast injuries can be encountered in military environments or in
industrial or civilian situations. A blast is greater than the speed of sound, and its
primary effect is due to compression wave that can cause burns, lacerations, and
hemorrhage. Blast wave injuries may also involve flying debris striking the body,
injuries produced by the propelled body striking another object, or other
mechanisms of trauma, including crushing injuries and burns.
Electrical Injuries and Electrocution
Deaths through electrocution result from an overwhelming transmission of
electrical current to the body. Such cases are usually difficult to identify if there are
no electrical burns or other autopsy findings to suggest electrocution. A detailed
investigation with the help of an electrical engineer is sometimes necessary in order
to examine power tools or electrical devices to determine how and why an individual
became electrically energized. Oftentimes, the electrocution is linked to old and
poorly maintained electrical devices that have become defective in their circuitry
(Dolinak, Matshes, & Lew, Environmental Injury, 2005).
There are several factors that determine the severity of electrical injury (Di
Maio & Dana, 2007, p. 228).
• The nature of the current (AC, DC or pulsating DC)
• The voltage involved
• If alternating current, the frequency involved
• The amount of current
• The length of time the victim is in contact with the current
• The condition of the earth (dry or wet), if the earth is part of the circuit
• Resistance of the body
• The path of the current through the body
Alternating currents (AC) are more dangerous than direct currents (DC), because
the former produce contraction of muscles by which a person is not able to release
the grip on the wire through which the current is flowing. High voltage currents of up
to 7,000 volts are very dangerous; in fact, even low voltage currents (110 to 220
volts) of high amperes are dangerous. The human body's resistance to electricity is
decreased when wet or wearing wet clothes, or when carrying a metallic article
touching the ground. Greater duration of current also means more damage; in fact,
even low voltage current for a long duration can cause spasm of muscles and the
person may not be able to release himself and die (Sharma, 2011).
When a person first touches an electric source, he will feel some tingling, shocks,
and severe muscular contraction or spasm. Burns may be found at the point of
entrance or exit of electricity. Skin may also split due to burns. Headache and loss of
memory is also possible in later stages. Investigators who are removing the victim
immediately from the source of electrocution should adopt safety techniques, such
as wearing gloves. The victim should be immediately resuscitated and checked for
possible ventricular fibrillation.
Low voltage currents of up to 220 volts can cause death by ventricular fibrillation,
mid-voltage currents of up to 1000 volts can cause ventricular fibrillation and
respiratory failure, and high voltage current of above 1000 volts can cause direct
respiratory failure. Delayed death may also occur due to infection, paralysis, etc.
A person can also die from electrical shock and show no outward signs. In most
cases, however, electrical shocks leave marks on the body and internal burns may
be discovered during an autopsy.
Lightning Injuries
A lightning bolt is produced when the charged under-surface of a thunder-cloud
discharges its electricity to the ground. A lightning may directly strike the victim, or
strike a nearby object and then jump from the object to the victim through a side
flash. It can also be an object which conducts the lightning to a victim in contact with
the said object such as when a worker is in contact with the metal crane.
The injuries sustained may be electrical burns, or blast from the wave of heated
air created by the lightning strike. The physical examination findings may range from
a completely unmarked body to bizarre and extreme trauma on the body hit by the
lightning.
A dead body found in an open space should raise the possibility that it was hit by
a lightning strike. When there are injuries, the clothing may be torn or damaged and
the hair may be seared. A patterned skin burns as a result of the metal object being
hit by the lightning such as buckle of a belt, which may be left magnetized or even
melted. Typical findings include severe burns with skin blisters, charring of the
specific body part, ruptured tympanic membranes, fractures, and lacerations.
Causes of Death Due to Burns
When a significant area of the skin is destroyed by burning, it is possible for the
victim to die rapidly or to survive the initial injury only to die later due to metabolic
complications, electrolyte disturbances, shock, and infection (Prahlow & Byard,
2012).
Deaths from severe burns usually occur within 24 hours or within the first week.
The immediate causes of death include shock, suffocation, and injuries.
Hypovolemic shock can be the result of severe loss of fluids, while vasovagal shock
can arise out of fearfulness or severe pain.
Smoke entering the air passages can lead to asphyxia through suffocation. In the
process of sustaining burns during a house fire, the person may sustain further
injuries from falling walls or hitting objects. Most of the late causes of deaths
(occurring after 48 hours) are due to infection causing meningitis, peritonitis,
pneumonia and other complications. In cases where infection sets in, death may
occur even after weeks (Sharma, 2011).
Head Injuries
The effects of an injury may vary depending on the exact area of the body that
sustained such injury. For example, a blow in the head will be more catastrophic
than a similar blow to the chest. Injuries to the head are particularly important
because of the brain's vital role in sustaining the life of the individual.
When a person suffers from a head injury, it may result to loss of
consciousness. These are often associated with the acceleration or deceleration of
the head where the brain moves within the skull. Cerebral concussion (sometimes
called stunning) following a head injury is characterized by temporary loss of
consciousness due to a disturbance of brain function without any identifiable
pathological changes in the brain.
 After suffering from concussion, the person may have retrograde amnesia,
which is loss of memory extending backwards in time from the moment of impact.
The longer the period of unconsciousness and the deeper the coma, then the more
likely it is that irreversible brain damage has occurred.
Brain injuries may be: (a) focal, which occurs just deep to the area of head
impact; or (b) diffuse, which is a consequence of the acceleration/deceleration
forces applied linearly or rotationally. Focal brain injuries are comprised of
contusions in the area of impact, in association with fracture lines and in a
stereotypical distribution resulting from impact with bony irregularities of the skull
present in the anterior and middle cranial fossae.
Prolonged alterations in consciousness may be due to parenchymal, subdural,
or epidural hematoma. Most frequently involved areas of the brain are (a) the frontal
poles and the contiguous under-surfaces of the frontal lobes, (b) the temporal poles
and the contiguous lateral and inferior surfaces of the temporal lobes, and (c) the
occipital poles, particularly the cortex adjacent to the Sylvian fissures.
When an object strikes a stationary head, it produces damage located beneath
the impact site; this is called coup injury. When an object strikes a moving head
(e.g., in road accidents or falling from height), there may be a coup injury on the site
of impact but the cortical damage can be seen on the opposite side of the brain,
which is called contra coup injury (Sharma, 2011).

This separation of patterns of head injury enables the forensic pathologist to form an
opinion about the situation of the head at the time of the injury. The key lies in the
movement of the brain within the skull. In a coup injury wherein a static head is
struck, the skull is