Errors or omission result in the production of undesirable artifacts or in the destruction of valid evidence:

a. Opening of the skull before blood is permitted to drain from the superior vena cava. If the head opened before the blood drained from it, blood will almost invariably escape into the subdural and subarachnoidal space, and such an observation may then be interpreted as evidence of ante-mortem hemorrhage.

b. The use of a hammer and chisel for opening the skull. A hammer and chisel should never be used for the purpose in a medico-legal autopsy. Fracture produced by the chisel are frequently confused with ante-mortem.

Failure to open the thorax under water if one wishes to obtain evidence of pneumothorax.

d. Failure to tie the great vessels between sites of transection and the heart when air embolism is suspected.

e. Failure to open the right ventricle of the heart and the

pul-monary artery in situ if pulpul-monary is

suspected.

Failure to remove the uterus, vagina and vulva en masse if rape or abortion is suspected.

(From the American Journal of Medicine and Pathology, Vol. 2, No. 4 (Dec. 1981) p. 306).

Negative Autopsies — An autopsy is called a negative autopsy if after all including gross and microscopic studies and

fail to reveal a cause of death. It is an autopsy which after a meticulous examination with the aid of other examinations does not yield any definite cause of death.

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There are reports that approximately 2 to of the total autopsy cases in medico-legal centers yield a negative result although theo-retically there must be a cause of death.

Negligent Autopsy — An autopsy wherein no cause of death is found on account of imprudence, negligence, lack of skill or lack of fore-sight of the examiner. The act or omission which may be inadvertent or deliberate may

1. Failure to have an adequate or and circumstances surrounding the death. Special circumstances surrounding death may require special autopsy techniques which the pathologist may fail to do during the autopsy. Air embolism, drug reaction, vagal inhibition may be left unnoticed because of absence of history.

2. Failure to make a thorough external examination — Animal bites, injection marks, electrical necrosis may be overlooked in a hasty external examination.

3. Inadequate or improper internal examinations — Condition of the organs, presence of air in pneumothorax or bubbles of air in the circulatory system may remain unnoticed by the pathologist.

4. Improper histological examination — Tissue blocks may not be taken in the proper areas, poor preparation of the microscopic slides and improper lighting during the process of examination may lead to an erroneous interpretation.

5. Lack of or other laboratory aids — A qualitative and quantitative determination of toxic materials or its metabolites must be shown. Sometimes difficulty is encountered by the forensic chemist because of the lapse of time and rapid elimination of the drug.

6. Pathologist incompetence — The examiner must have had vast experience in autopsy investigation and must have the capacity to distinguish pathological changes in the body tissues.

(Handbook of Forensic Pathology by Abdullah Fatteh, pp.

255).

Religious Objections to Autopsies:

There is no place in the Bible, in the Talmudic or ic writings, is there evidence that post-mortem examination is pro-hibited. According to traditional interpretation, which is not neces-sarily accepted by all Jewish groups, autopsies and transplantation of organs are permitted only in those cases where the gave consent.

INVESTIGATION CF DEATH ₁₈₁ There is no statement the Catholic Church which can be construed as prohibiting autopsies. Autopsies have been encour-aged when it appeared that benefit would accrue from them. Simi-larly, there appears to be nothing in the writings of the Protestant clergy to point to the prohibition of autopsies.

Chapter VI

nation of the cause of death. It must further be shown that the death is the direct and proximate consequence of the criminal or negligent act of someone. If death developed independent of an unlawful act, then the person who committed the unlawful act cannot be held responsible for the death.

However, there are some post-mortem findings of a physician which may be useful in the proper adjudication of the case. The presence of defense wounds on the victim may qualify the crime to homicide. The presence of serration or series of cuts in the borders of a stab wound may infer multiple thrusts of the wounding instru-ment and show the manifest intent of the offender to kill.

The of death is the injury, disease or the combination of both injury and disease responsible for initiating the trend or physiological disturbance, brief or prolonged, which produce the fatal termination. It may be immediate or proximate.

when trauma or disease kill quickly that there is no opportunity for sequelae or complications to develop. An extensive brain laceration as a result of a vehicular accident is an example of immediate cause of death.

2/The Proximate (Secondary) Cause of Death — injury or disease was survived for a sufficiently prolonged interval which permitted the development of serious sequelae which actually caused the death. If a stab wound in the abdomen later caused generalized peritonitis, then peritonitis is the proximate cause of death.

The mechanism of death is the physiologic derangement or bio-chemical disturbance incompatible with life which is initiated by the cause of death. It may be hemorrhagic shock, metabolic disturbance, respiratory depression, toxemic condition, cardiac arrest, tamponade, etc.

arrest is a terminal mechanism of most causes of death and can never stand independently as a reasonable ex-planation for the fatality. The cause of such arrest must be stated,

Cause of Death — This applies to cases

182

CAUSES OF DEATH

like hemorrhage, skull fracture, sepsis, trauma on the chest, etc. to make it valid as specific cause of death.

The manner of death is the explanation as to how the cause of death came into being or how the cause of death arose. The manner of death may be natural or violent.

Death — It is natural when the fatality is caused solely by disease (lobar pneumonia, ruptured tubal pregnancy, cancerous

cerebral hemorrhage due to hypertension,

or Unnatural Death — Death due to injury of any sort (gunshot, stab, fracture, traumatic shock, etc.). A physician must not include in the consideration of the manner of death that such violent death is suicidal, accidental or homicidal.

Such conclusion cannot be determined in the post-mortem examination. It requires a thorough investigation of all possible clues in which medico-legal findings are only a part

masquerade — deaths may be accompanied by minimal or no external evidence of injury or natural death where signs of violence may be present. In a case of homicide, the medical findings may tend to favor suicide or accidental death, and visa versa. Cases of such nature infer that the medical examination and police investigation is far from being complete. There is a need for further investigation and evaluation to unravel the truth.

Degree of Certainty to the Cause of Death:

When the structural abnormalities established beyond doubt the identity of the cause of death Intracerebral spontaneous hemorrhage, stab wound with profuse hemorrhage, crushing head injury in vehicular accident,

2. When there is that degree of probability amounting to almost certainty the cause of death. Lobar pneumonia, electrical shock).

3. When the cause of death is established primarily by historical facts which are confirmed or supported by positive or negative ana-tomic or chemical findings (Ex.: Tetanus, hydrophobia, drug reaction).

4. When neither history, laboratory and anatomic findings, taken individually or in combination is sufficient to determine the cause of merely speculate as to the cause of death Crib death among infants, Iatrogenic diseases).

Use of the Term

As much as possible the use of the term as a quali-fication to a cause of death must be discouraged as it is

184 LEGAL MEDICINE

not definite. In the prosecution of a case if the resulting cause of death is merely a probable consequence of a criminal act, such situation will fall short of beyond reasonable

and may lead to the acquital of the accused.

If sometime after painstaking the examiner cannot ascribe a definite cause of death on the body lesions found, the use of the

"probably" in the cause of death may be tolerated.

Steps in the Intellectual Process in the Determination of the Cause of Death:

1. Recognition of the structural organic changes or chemical abnor-malities responsible cessation of vital functions.

2. Understanding and exposition of the mechanism by which the anatomic and deviations from normal actually caused the death, or how the deviation created or initiated the train of suf-ficiently potent functional disturbance which led ultimately either to cardiac standstill or to respiratory arrest.

(The Pathology of Homicide by Lester Adelson (1974) p.

Instantaneous Physiologic Death (Death from Death from Primary Syncope with Instantaneous

This is sudden death which occurs within seconds or a minute or two (no more) after a minor trauma or peripheral stimulation of relatively simple and ordinarily innocuous nature. The peripheral irritation or initiates the inhibitory reflex.

The fulminant circulatory failure is caused by slowing or stoppage of the heart, reflex dilatation with profound fall in blood pressure or a combination of both mechanisms.

A blow to the larynx or solar plexus, a kick in the scrotum, pressure on the carotid sinus, etc. can cause such death.

Death by inhibition can be made only by exclusion and is com-pletely dependent on the availability of accurate information. After serious natural disease has been eliminated by autopsy and toxi-cological analyses are then only the physiologic death may be entertained Investigation of Death by Werner Spitz and p. 93).

Among the diseases wherein there are no specific finding, pathog-nomic of a disease still determined

1. Sudden Infant Death Syndrome (Crib Death) — This is the unex-pected death of infants, usually under six months of age, while in apparently good health. The sudden death cannot be predicted and there is no way to prevent or foretell on the basis of present knowledge. Although autopsies in some of the cases revealed the

CAUSES OF DEATH

presence of congenital heart disease or abnormality, contagious disease, nutritional deficiency and other pathological conditions, no consensus has yet been arrived at as to the definite cause of death.

Sudden Unexplained Nocturnal Death (SUND) — This is known as disease in Japan and in the Philippines.

It is the sudden death of healthy men of young age seen in East Asian countries. Awareness of relatives and the prompt delivery of resuscitation are the only effective means of treatment.

The term Dead on Arrival (DOA) must not be construed literally.

It may mean that the patient was actually dead on arrival or was dying on arrival. Death occurs on a precise time while dying is a continuing process. If a patient is dead then the procedure of management is resuscitative or to let him return to life again, while if the patient is dying, the procedure is to apply emergency measures to prevent death from ensuing.

DOA may be placed in the item "cause of in the death certificate even if the patient has stayed alive in the hospital or clinic for sometime provided the attending physician had not been given ample opportunity to arrive at a working diagnosis as to the cause of death. The working diagnosis need not be precise and exacting. It is sufficient that there are some bases to such conclusions.

If the attending physician cannot determine the cause of death, it will be much more appropriate to place under "Cause of Death" in the Death Certificate rather than DOA. It is more responsive to the purpose why such item is included in the certificate.

CLASSIFICATION OF THE CAUSES OF DEATH:

a. Natural b. Violent

Accidental (2) Negligent

(3) death.

(4) Parricidal Homicidal

This is death caused by a natural disease condition in the body. The disease may develop spontaneously or it might have been a consequence of physical injury inflicted prior to its development. If a natural disease developed without the Natural

186 LEGAL MEDICINE

intervention of the acts of another person, no one can be held responsible for the death.

death" is the termination of life which comes quickly under circumstances when its arrival is not expected.

It may be due to natural or violent cause. Heart diseases and cerebral apoplexy are the most common causes of deaths due to natural causes, while poisoning, asphyxia and severe trauma are frequent causes of violent death.

The natural death may or may not be associated with vio-lence. Although the history and external findings may show that death is due to natural cause, a complete autopsy must be made to determine exactly the cause of death and exclude the possibility of violent cause.

If signs of violence are associated with the natural cause of death, the physician must be able to answer the following questions:

Did the Person Die of a Natural Cause and were the Physical Injuries Inflicted Immediately After Death

If violence was applied on a dead person, the person inflicting the physical injuries cannot be guilty of murder, homicide or parricide. The act is considered to be an impossible crime and is penalized as such. In order that it may be considered an impossible crime, the person inflicting the physical injuries must have no knowledge that the victim is already dead at the time of infliction.

Criminal liability shall be incurred by any person who per-forms an act which would be an offense against persons and property, were it not for the inherent impossibility of its complishment. (Art. 4, No. 2, Revised Penal Code). The court having in mind the social danger and the degree of cri-minality shown by the offender shall impose upon him the penalty of mayor or a fine ranging from 200 to 500 pesos. (Art. 59, Revised Penal Code).

"A" has a grudge and wanted to kill One night "A"

entered the bedroom of and without knowing that died of heart failure an hour ago, inflicted several stab wounds on " B " "A" cannot be held liable for murder because it is an impossible crime. was already dead when the stab wounds were inflicted. However, the law still imposes penalty for such act depending upon the degree of criminality and social danger of the offender (Art. 59, Revised Penal Code).

CAUSES OF DEATH

the Victim Suffering from a Natural Disease and the Violence Only Accelerate the Death

If the violence inflicted on a person suffering from a natural disease only accelerated the death of the victim, the offender inflicting such violence is responsible for the death of the victim. It is immaterial as to whether the offender has no intention of killing the victim. The fact that the victim

the offender must be held responsible to whatever be the consequence of his wrongful act.

liability shall be incurred by any person committing a felony although the wrongful act done be different from which he intended (Art. 4, No. 1, Revised Penal Code).

Example:

gave a blow in the abdomen of Unfortunately died of severe abdominal hemorrhage due to the trau-matic rupture of the liver which was severely diseased. "A"

is liable for the death of even if has no intention to kill "A" must be held liable for consequences of his felonious act. However, he may avail himself of the

gating circumstance that he had no intention to commit so grave a wrong as that committed (Art. 13, Revised Penal Code).

A blow with a fist or a kick, although it did not produce external injuries but inflammation of the spleen and peri-tonitis although the victim was previously affected with the disease, the accused must be responsible for the death because he accelerated the time of death by his voluntary and unlawful act v. 23 Phil. 22).

The deceased was suffering from tuberculosis. The ac-cused gave fist blows in the hypochondriac region which caused bruising of the liver, followed by internal hemorrhage and death. The accused is liable for homicide (People v.

54, Phil. 544).

Did the Victim Die of a Natural Cause Independent of the Violence Inflicted?

If a person died of a natural cause and the physical injuries inflicted is independent of the cause of death, the accused will not be responsible for the death but merely for the physical injuries he had

Example:

and are sweethearts. at the fit of anger slapped in the face. is suffering from severe heart

LEGAL MEDICINE

disease. After the slapping, " B " died of heart failure. "A"

cannot be held responsible for the death of "B". He can only be held for slight physical injury brought about by the slapping.

The defendant struck a boy with the back of his hand on the mouth. Although the mouth was bleeding, he was able to work. A few days later, he developed fever and died. The court believed that the fever which caused the death was not the direct consequence of the injury inflicted. It was not denied that malaria fever was prevalent in the locality, so it was quite probable that the death was due to a natural cause.

The defendant was acquitted (U.S. v. Palaton, 49 Phil.

To make the offender liable for the death of the victim, it must be proven that the death is the natural consequence of the physical injuries inflicted. If the physical injuries is not the

cause of death of the victim, then the offender can-not be held liable for such death. Proximate cause is that cause, which in natural and continuous sequence, unbroken by an efficient intervening cause, produces injury or death, and with-out which the result would not have occurred.

So in natural death with concomitant physical injuries, it is necessary for the physician to determine whether the physical injuries would accelerate the death, or the injuries itself devel-oped independently and produced the death or that the person died absolutely of a natural cause.

A physician must determine for the interest of justice with absolute care at autopsy and laboratory examination the real cause of death. Opinion evidence must be given with caution and must be made after a thorough deliberation of the facts and other findings.

The Following are Deaths Due to Natural Cause:

Affection of the central nervous system:

(a) Cerebral

The sudden loss of consciousness followed by paraly-sis or death due to hemorrhage from thromboparaly-sis or embolism in the cerebral vessels.

Cerebral

This is brought about by the breaking or rupture of the blood vessels inside the cranial cavity.

Cerebral

This is the blocking of the cerebral blood vessels by bolus or matters in the circulation.

CAUSES OF DEATH Cerebral

This is the occlusion of the lumen of the cerebral vessels by the gradual thickening of its wall thereby preventing the flow of blood peripheral to it.

(b) of the Brain:

A circumscribed accumulation of infective materials in certain areas of the brain. It may coma or death when it ruptures or when it produces acute edema of the brain.

A circumscribed accumulation of infective materials in certain areas of the brain. It may coma or death when it ruptures or when it produces acute edema of the brain.

In document Legal Medicine by Pedro Solis (Page 179-198)