98791112-legal-medicine.doc

CHAPTER 1 LEGAL MEDICINE HISTORY OF LEGAL MEDICINE: - Paulus Zacchias ( 1584 – 1659 ) is the ‘ Father of Forensic Medicine”. He was the first to describe the importance and application of medicine to the proper administration of justice.

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

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In the Phil. , the father of Legal Medicine can be rightfully bestowed to Dr. Pedro P. Solis. His book on Legal Medicine copyrighted in 1987, contains the most extensive treatise and teachings in Philippine Legal Medicine. APPLICATION OF LEGAL MEDICINE TO LAW: Legal Medicine is Applied to Law 1. Civil law - the determination and termination of civil personality - the limitation or restriction of a natural person’s capacity to act - marriage and legal separation - paternity and filiation - testamentary capacity of a person making a will - the right to hereditary succession

In the Philippines, Legal Medicine is the appropriate name for Forensic Medicine. Modern Legal medicine has a broad range of applications, it is used in civil cases such as paternity and filiation, annulment of marriage, DNA testing , etc. In all cases the medical examiner must conduct an investigation of the crime scene and also an autopsy.

TECHNIQUES OF LEGAL MEDICINE: - Legal Medicine uses sophisticated laboratory techniques to detect the presence of substances in the victim, in the suspected criminal, or at the crime scene. - Forensic examination of substances found at a crime scene can often establish the presence of the suspect at the crime scene.

2. Criminal Law - Felonies and circumstances which affect criminal liability - Civil liability ex delictu - Crimes relative to opium and prohibited drugs - Crimes against persons - Crimes against chastity - Crimes against civil status of persons - Quasi – offenses

LEGAL MEDICINE AND THE LEGAL SYSTEM - Courts routinely call upon physicians to give expert testimony in a trial, especially concerning the findings of an autopsy and the results of laboratory tests. - As an expert witness he is allowed to express an opinion about the validity of the evidence in a case and may quote the statements of other experts in support of an opinion. - Ordinary testimony is restricted to statements concerning what the witness actually saw or heard. - The evidence to be presented by the legal medicine expert must signify a relation between the facts called the “ Factum Probandum” or proposition to be established and the “ factum Probans” which is the material evidencing the proposition. - The Physician must present RELEVANT, MATERIAL AND COMPETENT EVIDENCE.

3. Remedial Law - Physical and Mental Examination of a person - Hospitalization of insane persons - Rules of Evidence 4. Special Laws - Dangerous Drug Act - Youth and Child Welfare Code - Sanitation Code - Insurance law

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- Labor Code - Employees Compensation Law

that amount of relevant evidence which a reasonable mind might accept as adequate to justify a conclusion.

5. CORPUS DELICTI - Is the body or substance of the crime and is defined as the fact that a crime actually has been committed. In all criminal prosecutions, the burden is on the prosecution to prove the corpus delicti.

CHAPTER 2 MEDICAL AND HOSPITAL JURISPRUDENCE Medical Jurisprudence: - Is the study of the Medical Law and its applicable Jurisprudence, that governs, regulates, and defines the practice of medicine. - It includes the rights, duties, obligations and liabilities of both physician and patient to each other in a physician patient professional contract.

QUANTUM OF PROOF 1. In Civil Cases – the quantum of proof necessary to prove a civil complaint is a PREPONDERANCE OF EVIDENCE. The party filing or bringing a civil complaint has the burden of proof and must establish the truth and righteousness of his allegations by a preponderance of the evidence admitted by a competent court.

The Following Acts Constitute the Practice of Medicine: 1. To physically examine and diagnose a patient. 2. To physically examine and treat a patient 3. To physically examine and perform surgery in a patient 4. To physically examine and prescribe any remedy to a patient.

2. In Criminal Cases – the quantum is proof beyond reasonable doubt. - In a criminal case the accused is entitled to an acquittal, unless his guilt is shown beyond reasonable doubt - Presumption of INNOCENCE is a conclusion drawn by the constitution and the law in favor of the accused , while REASONABLE DOUBT, is a condition of mind produced by proof resulting from evidence in the case.

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Any person who practice any of the above acts enumerated, without any valid certificate of registration as a physician, is practicing illegal medicine.

3. To establish matters of defense - The doctrine of reasonable doubt applies only to incriminative facts.

The Nature of the Physician Patient Professional Relationship is 1. Consensual: - based on mutual consent of both patient and physician. - Contracts that are consensual in nature, are perfected upon mere meetings of the minds

4. To establish self defense - One who sets up SELF DEFENSE “ must rely on the strength of his own evidence and not on the weakness of that of the prosecution”.

2. Fiduciary: - founded in trust, faith, and confidence reposed by one person in the integrity and fidelity of another.

5. To establish Alibi - It must be proved by positive, dear and satisfactory evidence. “ Oral Evidence” of alibi is so easily manufactured and usually unreliable that it can rarely be given credence.

DUTIES AND OBLIGATIONS OF THE PHYSICIAN TOWARDS HIS PATIENTS: 1. He must possess that knowledge and skill possessed by an average physician. 2. He must use such knowledge and skill with ordinary care and due diligence. 3. He is obliged to exercise his best judgment in good faith. 4. He has the duty to keep the secrets and confidentialities of his patients.

6. In Administrative Complaints - In cases filed before administrative or quasi judicial bodies, a fact maybe deemed established if it supported by “ substantial evidence” which means

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

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The only promise or guaranty that the law requires is that, the physician will treat the patient in accordance with the standards of medical care.

- A complaint under oath can be filed before the Professional Regulation Commission Board of Medicine, for reprimand, of the license to practice medicine. 2. Criminal Liability - When an act or omission constitutes a crime, the physician can be imprisoned or fined or both, as any other profession. 3. Civil Liability - The aggrieved party can be awarded monetary damages for any wrongful or negligent act or omission, when the professional is found guilty.

PATIENTS RIGHTS RESPECTED BY PHYSICIANS: 1. The right to appropriate medical care and humane treatment. 2. The right to his religious belief. 3. The right to refuse treatment. 4. The right to Informed Consent. 5. The right to choose his physician. 6. The right to medical records. 7. The right to privacy and confidentiality. 8. The right to a second or third opinion. 9. The right to leave. 10. The right to information. 11. The right to self determination. 12. The right to refuse participation in medical research 13. The right to express grievance 14. The right to be informed of his rights and obligations. 

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

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

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SOCIATAL RIGHTS OF THE PATIENTS FROM THE GOVERNEMNT ( Refer to Book ) RIGHTS INHERENT IN THE PRACTICE OF MEDICINE: 1. The right to choose his patients 2. The right to limit the practice of his profession 3. The right to determine appropriate treatment procedures in the discretion and judgment of the physician. 4. The right to avail of hospital privileges after being qualified. 5. The right to receive just and fair compensation from his patients.

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

Liabilities of a Physician Which May Arise from His Negligent or Wrongful Acts or Omissions: 1. Administrative Liability

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

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Stage 1 – Cerebral Cortex- the highest center of the brain that is most sensitive to changes in the supply of oxygen and blood to the brain. When the cerebral cortex dies, the patient is in cortical death.

In common law the presumption of death does not arise until the expiration of seven years of continuous absence.

DEATH – IS THE COMPLETE CESSATION OF ALL THE VITAL FUNCTIONS OF THE BODY WITHOUT POSSIBILITY OF RESUSCITATION. THE ASCERTAINMENT OF DEATH IS A MEDICAL AND NOT A LEGAL PROBLEM.

Stage 2 - Cerebellum – It deals with the function of equilibrium. It follows the death of the cerebral cortex.

Death maybe A. Brain Death – occurs when there is a deeply irreversible coma, and absence of electrical brain activity.

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B. Cardio Respiratory Death – occurs when there is continuous and persistent cessation of heart action and respiration.

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4 Kinds of Death: 1. Clinical or Somatic Death 2. Brain Death 3. Biological Death 4. Cellular Death

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Stage 3 – Brainstem and Vital centers – These centers controlling respiration, heart rate and blood pressure, ultimately die. When it does, the patient is, Brain Stem Dead. If the brain stem is damaged, then the vital centers in the medulla maybe destroyed, causing the respiratory center to fail. The occurrence of brain stem death is equivalent to Legal Death, so that Doctors can now issue a Death Certificate, even though the heart is still beating, and make arrangements to harvest donor organs and tissues at this stage. Further, in the presence of brain stem death, artificial respirators only achieve the maintenance of an oxygenated circulation through a corpse or cadaver.

CRITERIA FOR DIAGNOSING BRAIN STEM DEATH. ( refer to textbook ) Persistent Vegetative State ( PVS ) - This condition exists, when irreversible destruction of the Cortex of the brain occurs without damage to the vital centers, and there are permanent eyes – open state of unconsciousness, but cardio respiratory functions continue, sometimes without respiratory assistance, but most often with respiratory support. - They do not however match the clinical criteria of Brain Death, in as much as they have elicitable reflexes, spontaneous respirations and reactions to external stimuli.

Clinical or Somatic Death - This particular kind of death occurs when in the judgment of the physician with the use of his clinical eye the body’s vital signs of life cease to exist continuously and permanently. - The clinical death is verifiable only by a physician after he observes that the patient no longer has a heart beat no pulse rate, no spontaneous breathing and movement, with the pupils of the eye widely dilated and not reactive to light and accommodation. - When a clinically dead person is brought to the morgue the generalized contraction of the muscles or Rigor Mortis of the body within 3 to 6 hours, may simulate a return to life, because of the motion or movement of the body.

HARVARD CRITERIA OF WHOLE BRAIN DEATH: 1. Unreceptivity and Unresponsitivity 2. No spontaneous movements or breathing 3. No reflexes 4. Flat EEG of Confirmatory value

BRAIN DEATH - This kind of death follows clinical death – almost immediately unless resuscitative procedures are started promptly, because the human brain under normal conditions cannot survive loss of oxygen for more than 6 to 10 minutes. - Brain Death may occur in the

WHOLE BRAIN DEAD

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c. Stage of secondary flaccidity or commencement of putrefaction

When the brain ceased all functions, even though the heart continues to beat. As a rule doctors can legally declare whole brain death twelve hours after they have corrected all treatable medical problems, but the brain still doesn’t respond even to induced pain , they eyes do not react to light and the person doesn’t breath without a respirator.

Cadaveric Spasm- is the immediate or instantaneous spasm or rigidity of the skeletal muscles occurring at the moment of death due to exhaustion, etc. Medico legal Importance of Cadaveric Spasm ( Refer to Book )

BIOLOGICAL DEATH - All the components of the brain are dead - There is also permanent extinction of bodily life. - It is cardiorespiratory and brain death altogether with permanent cessation of all the anatomic and physiological functions of the body organs.

2. Changes in the Blood a. Coagulation of the blood b. Postmortem lividity or Livor Mortis 3. Autolytic or Auto Digestive Changes After Death 4. Putrefaction of the Body

CELLULAR DEATH: - The death of the different parts of the body occurs at different times and stages. - This is the reason why such organs as the corneas and the kidneys can be removed immediately after biological death and transplanted successfully.

PUTREFACTIVE CHANGES OCCURING AFTER DEATH ( Refer to Book ) Kinds of Putrefaction: 1. Mummification 2. Saponification – This is also called Adipocere Formation. 3. Maceration

SIGNS OF DEATH: 1. Cessation of heart action and circulation 2. Cessation of respiration 3. Cooling of the body ( Algor Mortis ) - The temperature of 15 – 20 degrees Fahrenheit is considered as a certain sign of death. 4. Loss of motor power 5. Loss of sensory power 6. Changes in the skin 7. Changes in and about the eye - There is loss of corneal reflex

Factors to Consider in Approximating the Duration of Death in a Cadaver 1. Entomology – The presence of maggots in the cadaver indicates duration of death for more than 24 hours 2. Presence of live Fleas in clothing – in death by drowning, a flea can survive for about 24 hours submerged in water. After 24 hours submersion in water the fleas die. 3. Blood vessel clots – blood clotting occurs in 6 -8 hours after death. 4. Post Mortem lividity – develops in 3 to 6 hours after death. 5. Rigor Mortis- begins to develop in 3 to 6 hours after death and may last for 24 to 36 hours after death. 6. Onset of decomposition – Decomposition takes place within 24 – 48 hours after death. 7. Food in the stomach 8. Skeletal soft tissues – soft tissues may disappear from 1.5 years to 2 years after burial.

CHANGES IN THE BODY FOLLOWING DEATH 1. Changes in the Muscle a. Stage of primary flaccidity b. Cadaveric rigidity or rigor mortis - muscular contraction which develops 3 – 6 hours after death and may last for 24 – 36 hours. - may also be utilized to approximate the length of time the body has been dead from 3 to 36 hours

Position of the Body at the time of Death 1. Post Mortem lividity 2. Cadaveric spasm – Death due to violence or inflicted physical injuries, usually manifest the position of the body at the time of death. Ex. In suicide by gunshot wound, the gun maybe tightly grasped in the hand of the deceased

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In drowning, the victim maybe holding objects that come in contact with his hands to cling to life.

Ex. Murder, Homecide, Suicide, Accident Death Warrant – is a warrant from the proper executive authority appointing the time and place for the execution of the sentence of death upon a convict judicially condemned to suffer death.

MEDICOLEGAL IMPORTANCE OF RIGOR MORTIS AND CADAVERIC SPASM: Rigor mortis is utilized to approximate the time of death. Generalized muscular contractions occur from 3 to 6 hours until 36 hours.

Manner of Death - Is the explanation as to how the cause of death arose, and maybe either Natural Death or Violent Death

Cadaveric spasm occurs immediately after death and is useful to ascertain the circumstances of death.

Lazarus Syndrome - Is also called Lazarus Phenomenon is the spontaneous return of circulation after failed attempts at resuscitation.

Medico Legal Investigation of Death - Deaths which are not obviously due to natural causes, but are criminal, suspicious, accidental, suicidal, murderous, homicidal, sudden or unexpected, or unexplained, need medico legal investigation.

Implications of Lazarus Syndrome - raise ethical and legal issues for doctors, who must determine when medical death has occurred, when resuscitation efforts should end, and post mortem procedures such as autopsies and organ harvesting may take place.

The Death Certificate - The death certificate is a legal document necessary for burial of the dead, as it certifies the occurrence of death. It is a document from the Office of the Civil Registrar General, listing the particulars of an individual’s death. - It contains the Immediate Cause or Primary cause of death, the antecedent causes and underlying cause of death

Lazarus Sign - Lazarus sign or Lazarus reflex is a reflex movement in brain dead patients, which causes them to briefly raise their arms and drop them crossed on their chests. - The phenomenon has been observed to occur several minutes after the removal of medical ventilators used to pump air in and out of brain dead patients to keep their bodies alive.

Immediate Cause or Primary Cause of Death Ex. Suffocation due to drowning Asphyxia Cardio – Respiratory Arrest Antecedent Cause of Death are events or conditions that substantially contribute to the immediate cause of death Ex. Acute peritonitis, Acute Hypovolemic shock, Acute Septic Shock,

NEAR DEATH EXPERIENCE - Refers to a broad range of personal experiences associated with impending death, encompassing multiple possible sensations including detachment from the body; feelings of levitation etc.

Underlying Cause of Death is the basic cause or bottom line cause of death. It is the diagnosis of the patients or victim’s illness or sickness that resulted to his death Ex. Acute Appendicitis, Hepatocarcinoma, Pelvic Fracture, Stab or Gunshot Wound to the chest.

EUTHANASIA - Meaning good death ( well or good ) - Refers to the practice of ending life in a painless manner. - Deliberate intervention undertaken with the express intention of ending life, to relieve intractable suffering

Non Natural Causes of Death

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Classification of Euthanasia: 1. Voluntary euthanasia – is euthanasia conducted with consent

a. Life Threatening Injuries Pnumothorax Hemothorax Flail chest as in multiple rib fractures Cardiac tamponade due to penetrating injuries b. Potentially Lethal Injuries b.1. Pulmonary Contussion with or without flail chest b.2. Thoracic Aortic Tear or Rupture – the most common cause of sudden death after a vehicular accident or fall ( major decelaration injury ) c. Serious Chest Injuries 4. Abdomen Types of Injuries: a. Penetrating - Gunshot wounds of the abdomen carry 95% probability of significant visceral injury - A bullet when it hits the abdomen will penetrate the abdominal wall, enter the abdominal cavity and most likely injure more than one organ. - The incidence of abdominal injury is strikingly higher in gunshot wounds than in stab wounds. - The major cause of death is hemorrhage and this occurs within the first 24 hours - In stab wounds of the abdomen , only 2/3 penetrate the peritoneal cavity; of these only ½ cause significant visceral injury that requires surgical repair. b. Blunt - The spleen and liver are the most commonly injured organs due to blunt trauma. - Their frequent incidence also explains why the mortality rate following blunt trauma is higher than that of penetrating injury.

2. Involuntary euthanasia – is euthanasia conducted without consent. -is conducted where an individual makes a decision for another person incapable of doing so. - also known as physician assisted death, physician assisted suicide or mercy killing. 3. Passive euthanasia – entails withholding of common treatments 4. Active euthanasia – entails the use of lethal substances or forces to end life and is the most controversial means. CHAPTER 4 REGIONAL TRAUMA Trauma – is the leading cause of death in the first four decades of life and the 3 rd leading cause of death in all age groups today. -Penetrating trauma particularly handguns is becoming common in nearly all areas of the country. Trimodal Distribution of Death from Trauma: 1. Seconds to minutes of injury – due to the injury to the brain, high spinal cord, heart, aorta and other large vessels. These patients can rarely be salvaged. 2. Minutes to Few hours from injury ( The Golden Hour ) - It is in this period that Advanced Trauma Life Support9 ( ATLS ) techniques are important. 3. Several days to weeks of Injury – these are due to sepsis or organ failure. SPECIFIC INJURIES 1. Head a. Types of Head Injuries: a.1 Hematoma a.2 Contusions a.3 Skull fractures a.4 Hemorrhage 2. Spine and Spinal Cord Injuries The most common causes of severe spinal trauma are motor vehicular accidents, falls, diving accidents, and gunshot wounds. 3. Chest

5. Fractures and Dislocations The word fracture comes from the Latin word “fractura” which means a break in the continuity of the bone. It is also a combination of a break in the bone and soft tissue injury A. Open Fractures - 90% of open fractures are caused by vehicular accident. B. Hip fractures are very common in elderly people and are usually caused by minor falls. It is the most common cause of traumatic death after the age of 75. 6. Urologic

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- Hematuria following trauma - Blunt kidney injury is usually due to motor vehicular accidents which account for 70 – 90 % of kidney trauma. - Penile injury: The erect penis is usually 6 – 8 inches long and 1 -2 inches in diameter. - Avulsion of the prepuce – this may follow accidents where the foreskin called prepuce is detached or lacerated by a blunt force. - Fracture of the penis – this is the traumatic rupture of the corpora cavernosa penis resulting from a forceful trauma to the flaccid organ. - Amputated penis – the penis of an avid womanizer is sometimes intentionally cut or amputated by a jealous derange wife or lover.

Article 257. Unintentional Abortion – who shall caused an abortion by violence but not intentional. Article 258. Abortion Practiced by the Woman Herself or By Her Parents Article 259. Abortion Practiced by a Physician or Midwife and Dispensing of Abortives Article 260. Responsibility of Participants in a Duel Article 261. Challenging to a Duel CHAPTER 2 PHYSICAL INJURIES a. Article 262. Mutilation – Any person who shall intentionally mutilate another by depriving him, either totally or partially , of some essential organ of reproduction. b. Article 263. Serious Physical Injuries – Any person who shall wound, beat, or assault another, shall be guilty of the crime of serious physical injuries c. Article 264. Administering Injurious Substances or Beverages d. Article 265. Less Serious Physical Injuries – Any person who shall inflict upon another physical injuries which shall incapacitate the offended party for labor for 10 days or more, or shall require medical attendance for the same period e. Article 266. Slight Physical Injuries and Maltreatment. - When the offender has inflicted physical injuries which shall incapacitate the offended party for labor from one to nine days, or shall require medical attendance during the same period.

7. Arterial trauma 8. Burns CLASSIFICATION OF WOUNDS 1. AS TO LEGAL CLASSIFICATION Chapter 1 DESTRUCTION OF LIFE a. Article 246. Parricide b. Article 247. Death or Physical Injuries Inflicted Under Exceptional Circumstances c. Article 248. MURDER - Any person who, not falling within the provisions of Article 246 shall kill another, shall be guilty of murder and shall be punished by Reclusion Perpetua, to death if committed with any of the following attendant circumstances; 1. With treachery 2. In consideration of a price , reward or promise 3. By means of inundation etc. 4. On occasion of any of the calamities etc. 5. With evident premeditation 6. With cruelty etc

Chapter 3, RAPE – When and How rape is committed 1. By a man who shall have carnal knowledge of a woman under any of the circumstances a. Through force, threat, or intimidation b. When the offended party is deprived of reason or otherwise unconscious c. By means of fraudulent machinations or grave abuse of authority d. When the offended party is under twelve ( 12 ) years of age or is demented, even though none of the circumstances mentioned above is present. 2. By any person who, under any of the circumstances mentioned in paragraph 1 hereof, shall commit an act of sexual assault by inserting his penis into another person’s mouth or anal orifice or any instrument or object into the genital or anal orifice of another person.

Article 249 HOMICIDE Article 251. Death Caused in a Tumultous Affray Article 252. Physical Injuries Inflicted In a Tumultuous Affray Article 253. Giving Assistance to Suicide Article 254. Discharge of Firearms Article 255. Infanticide Article 256. Intentional Abortion

Classification of Wounds 2. AS TO THE DEPTH OF THE WOUND a. Superficial – When the wound involves only the layer of the skin b. Deep – When the wound involves the structures beyond the layers of the skin. b.1 Penetrating – the wound enters the body but does not come out. Punctured, stab and gunshot wounds usually belong to this type of wound.

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b.2 Perforating – there is a communication between the outside, inner and the outer side. There is both a point of entry and exit.

Cerebral Concussion – there is a brief loss of consciousness and sometimes memory after a head injury that doesn’t cause obvious physical damage.

Classification of Wounds 3. AS TO MORTALITY a. Deadly Wound- Death results immediately, after the infliction of the wound. Deadly wounds though mortal, maybe prevented with prompt medical treatment.

Cerebral Contusion – they are bruises to the brain, usually caused by a direct, strong blow to the head. They are more serious than concussions. B. OPEN WOUNDS - There is a break in the continuity of the skin Examples: 1. Abrasion 2. Bruise 3. Incised wound 4. Stab wound 5. Punctured wound 6. Perforating wound 7. Lacerated wound 8. Bites 9. Gunshot wounds

b. Non Deadly Wounds – Does not result to death immediately, after the wound is inflicted. A non deadly wound may cause death later, due to complications i.e. tetanus, septicemia Classification of Wounds: 4. AS TO THE WOUNDING INSTRUMENTS USED: a. Sharp Instruments – Ex. incised wound, punctured wound, stab wound dagger or kitchen knife b. Blunt Instruments – A block of wood or iron produces contusion, hematoma, abrasions, lacerated wound when used to strike, attack, wound, beat or assault another Classification of Wounds: 5. AS TO THE CONSEQUENTIAL INJURY AFTER THE APPLOCATION OF FORCE a. Coup Injury b. Coup Centre Coup Injury c. Contre Coup Injury d. Locus Minoris resistancia e. Extensive injury

B. OPEN WOUNDS – there is a break in the continuity of the skin B.1. Abrasion – Scratch, friction mark B.2. Bruise – cause by a blunt injury to the tissues which damage blood vessels beneath the surface, allowing blood to extravasate or leak into the surrounding tissues. B.3. Incised wound B.4. Stab wound B.5. Punctured wound B.6. Perforating wound B.7. Lacerated wound – result of an injury from a blunt instrument. In cerebral laceration, the brain tissue is torn often with an accompanying visible head wounds and skull fractures. B.8. Bites – they maybe abraded, bruised or rarely lacerated. They are usually seen in sexual assaults and in child abuse and also by animal bites B.9. Gunshot wounds

Classification of Wounds: 6. AS TO THE INTEGRITY OF THE SKIN A. CLOSED WOUNDS – Presents no break in the integrity or continuity of the skin. There maybe only outward manifestations of injury internally. Ex. of closed wounds: 1. petechiae – a circumscribe extravasation of blood in the subcutaneous tissue. 2. contusion – effusion of blood into the tissues underneath the skin as a result of a blunt force. Ex. black eye 3. Hematoma 4. Blunt injury 5. Musculoskeletal injuries Ex. Sprain, Dislocation, Fracture, Strain

TEST FOR THE PRESENCE OF POWDER RESIDUES: 1. Paraffin test or Dermal Nitrate test – present on the skin of the hand dorsum or site of the wound of entrance. This test is not conclusive because fertilizers, cosmetics, cigarettes, urine and other nitrogenous compounds with nitrates will give a positive reaction. A negative test is also not conclusive . The test usually gives a positive result even after a lapse of 3 days or even if the hands are subjected to ordinary washing

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1. Opium and its active components and derivatives such as heroin and morphine. 2. Coca leaf and its derivatives, principally cocaine. 3. Hallucinogenic drugs such as mescaline, lysergic acid diethylamide ( LSD ) and other substances producing similar effects. 4. Other drugs whether natural or synthetic with the physiological effects of a narcotic drug.

2. Use of Scanning Electron Microscope with a linked X – ray analyzer. This method appears to be more specific but seldom used because the instrument is expensive. SPECIAL TYPES OF WOUNDS 1. Assailant’s wounds – these wounds are sustained by the assailant from the victim, while the former is in the process of attacking, wounding, assaulting, beating or killing his victim. 2. Defense wounds – in the process of defending himself from the attacks, assault, wounding, beating or violence of the assailant, the victim sustains defensive wounds usually in the upper extremities. 3. Victim’s wounds – these are wounds sustained by the victim, from the assailant, the former not having the chance or opportunity to defend himself. The victim’s wounds maybe located in any part of the body. 4. Self – Inflicted wounds – these are wounds self inflicted by the person on himself. The wounds are usually found on the accessible parts of the body, usually with no intention to kill himself. Unless the victim is insane, self inflicted wounds are for a fraudulent or self serving purpose. 5. Homicidal wounds – these are the serious wounds sustained by the victim resulting to his death, from the criminal assailant. Usually the wounds are situated in the areas of the neck, chest, the abdomen and the skull. 6. Accidental wounds – these wounds are sustained by the victim, without any fault or intention whatsoever on the part of the accused to inflict the wounds on the victim. The wounds are usually located on any part of the victim’s body. 7. Suicidal wounds – these are wounds self inflicted by the victim on himself, and usually seen on the temple, the roof of the mouth, and other fatal body areas, accessible to the hand of the victim.

B. REGULATED DRUGS 1. Self inducing sedatives such as secobarbital, phenobarbital, pentobarbital, barbital and any drug which contains salt or derivative of a salt of barbituric acid. 2. Any salt of amphetamine such as Benzedrine or any drug which produces a physiological action similar to amphetamine. 3. Hypnotic drugs, such as methaqualone producing similar physiologic effects. IMPORTANT TERMS in the DANGEROUS DRUG ACT OF 2002 1. Drug Syndicate 2. Illegal Trafficking 3. Chemical Diversion 4. Planting Evidence 5. Drug Dependence Two Classes of Drug Dependence: a. Drug Addiction – is a state of periodic or chronic intoxication produced by the repeated consumption of a drug, whether synthetic or natural and found to be detrimental to the individual and to the society. Characteristics of Drug Addiction: A. An overpowering desire or need to continue taking the drug or to obtained it by any means.

CHAPTER 5 COMPREHENSIVE DANGEROUS DRUGS ACT OF 2002 REPUBLIC ACT 9165

- a tendency to increase the dose. -a psychological and physical dependence on the effects of the drug. - a detrimental effect to the society and to the individual

A DANGEROUS DRUG is a drug whose use is attended by risk and therefore is unsafe, perilous and hazardous to people and society. A DRUG is any substance , vegetable, mineral or animal in origin, used in the composition or preparation of medicines or any substance used as medicines.

B. Drug Habituation – is the desire to have a continuous use of the drug but with the capacity to refrain physically from using it.

The Dangerous Drug Act of 1972, include the following Dangerous Drugs as follows: A. PROHIBITED DRUGS

Characteristics of Drug Habituation: - The desire to use the drug is not compulsive but merely psychical.

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16. Unlawful Prescription of Dangerous drugs - There is little or no tendency to increase the dose THE CUSTODY AND DISPOSITION OF CONFISCATED, SEIZED AND OR SURRENDERED DANGEROUS DRUGS, PLANT SOURCES OF DANGEROUS DRUGS, CONTROLLES PRECURSORS AND ESSENTIAL CHEMICALS, INSTRUMENTS AND PARAPHERNALIA AND OR LABORATORY EQUIPMENT – The PDEA shall take charge and have custody of all dangerous drugs, plant sources of dangerous drugs, controlled precursors and essential chemicals, as well as Instruments paraphernalia and laboratory equipment so confiscated, seized and or surrendered, for proper disposition in the following manner ( Refer to Book ).

- The detrimental effect if any, is primarily on the individual. 6. Protector 7. Pusher 8. Controlled Delivery 9. Den, Dive or Resort 10. PDEA – The Philippine Drug Enforcement Agency, which is the implementing arm of the Dangerous Drugs Board.

IMPORTANT PROVISIONS OF R.A. 9165 OR THE COMPREHENSIVE DANGEROUS DRUGS ACT OF 2002

UNLAWFUL ACTS AND PENALTIES IN THE DANGEROUS DRUGS ACT OF 2002 ( R.A. 9165: 1. Importation of Dangerous Drugs and or Controlled Precusors and Essential Chemicals. 2. Sale, Trading, Administration, Dispensation, Delivery, Distribution and Transportation of Dangerous Drugs and or Controlled Precursors and essential Chemicals. 3. Maintenance of a Den, Dive or Resort 4. Employees and Visitors of a Den, Dive or Resort 5. Manufacture of Dangerous Drugs and or Controlled Precursors and Essential Chemicals 6. Illegal Chemical Diversion of Controlled Precursor and Essential Chemicals 7.Manufacture or Delivery of Equipment , Instrument, Apparatus and Other paraphernalia for Dangerous Drugs and or Controlled Precursors and Essential Chemicals 8. Possession of Dangerous Drugs 9. Possession of Equipment, Instrument , Apparatus and Other Paraphernalia for Dangerous drugs. 10. Possession of Dangerous D During Parties, Social Gatherings or Meetings 11. Possession of Equipment, Instrument, Apparatus and Other Paraphernalia for Dangerous Drugs During Parties, Social Gatherings or Meetings 12. Use of Dangerous drugs 13. Cultivation or Culture of Plants Classified as Dangerous Drugs or are Sources thereof 14. Failure to Maintain and Keep the Original Records of transactions on Dangerous drugs and or Controlled Precursors and Essential chemicals 15. Unnecessary Prescription of Dangerous Drugs

Section 22. Grant of Compensation, Reward and Award Section 23. Plea Bargaining Provision Section 36. Applicants for Driver’s License Section 38. Laboratory Examination or test on Apprehended / Arrested Offenders Section 39. Accreditation of Drug Testing Centers and Physicians Section 40. A physician, dentist, veterinarian or practitioner authorized to prescribe any dangerous drug shall issue the prescription therefore in one original and 2 duplicate copies. Section 54. Voluntary Submission of a Drug Dependent to Confinement, Treatment and Rehabilitation Section 55 Exemption from Criminal Liability Under the Voluntary Submission Program Section 56. Temporary Release from the Center; After Care and Follow up Treatment Under the Voluntary Submission Program Section 58. Filing of Charges Against a Drug Dependent who is not rehabilitated Under the Voluntary Submission Program. Section 61. Compulsory Confinement of a drug dependent who refuses to apply under the Voluntary Submission Program Section 62. Compulsory Submission of a Drug Dependent Charged with an Offense, to Treatment and Rehabilitation Section 70. Probation or Community Service for a First Time Minor Offender In Lieu of Imprisonment Section 73. Liability of a Parent, Spouse or Guardian Who refuses to Cooperate with the Board or any Concerned Agency Section 77. The Dangerous Drugs Board

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Section 82. Creation of the Philippine Drug Enforcement Agency ( PDEA ) Section 85. The PDEA Academy Section 90. Jurisdiction Section 91. Responsibility and Liability of Law Enforcement Agencies and Other Government Officials and Employees in Testifying as Prosecution Witnesses in Dangerous Drug Cases Section 92. Delay and Bungling in the Prosecution of Drug Cases

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PHARMACOLOGIC CLASIFICATION OF DANGEROUS DRUGS 1.Hypnotics 2. Sedatives and Tranquilizers 3. Hallucinogens and Psychomimetics 4. Stimulants 5. Depressants 6. Deliriants and Intoxicants

Subjective effects of Marijuana: - There is a feeling of lightness of the extremities followed by rushes of warmth and well being that eventually lead to a sense of relaxation, mild euphoria and a dreamy state where ideas are disconnected. Objective Effects of Marijuana: - Moderate increase in resting pulse rate, reddening of the eyes due to dilatation of the conjunctival blood vessels. Difficulty of speech and of remembering of the logical trend of what was being said.

Used to treat anxiety and to induce sleep can cause both psychologic and physical dependence.

C. HALLUCINOGENS OR PSYCHOMIMETIC DRUGS: Marijuana – ( Cannabis Sativa ) is a Mexican term for pleasurable feeling. Marijuana is not addictive. Physical dependence and dose tolerance do not develop with its use. Psychic dependence may occur.

A.Hypnotics: Opiates and Their Derivatives – Opium is obtained from the milky exudates of the unripe seed capsules of the poppy plant, Papaver Sornoiferum.

Lysergic Acid Dsethylamide ( LSD ) - These drugs are false hallucinogens. - It produces impaired judgement so that a user might think that he can fly, and may even jump out a window to prove it, resulting in severe injury or death.

Derivatives of opium commonly used are morphine, heroin, and codeine. Its synthetic preparation are Demerol and Methadone.

D.STIMULANTS: Amphetamines – methamphetamines ( Shabu, speed ); methylenedioxymethamphetamine ( MDMA, ecstasy or Adam ) - Acts on the cerebral cortex causing alertness, excessive self confidence and feeling of well being. Physical performance may to some degree temporarily improve.

Narcotics that have a legitimate medical used as powerful pain relievers are called Opioids, and include codeine, oxycodone, meperidine, morphine and hydromorphone. Heroin which is prohibited is a very strong pain reliever and narcotic

Untoward Effects: - They increase the blood pressure and heart rate. Fatal heart attacks have occurred even in healthy, young athletes. The blood pressure maybe so high that a blood vessel in the brain ruptures causing a stroke.

Signs and Symptoms of Opium Administration: 1. Stage of Excitement 2. Stage of Stupor 3. Stage of Narcosis

Coccaine – is an alkaloid from the leaves of the coca shrub cultivated in Bolivia and Peru. - It produces effects similar to amphetamines, but is a much more powerful stimulant.

B. SEDATIVES: Barbiturates: - are the products of malonic acid and urea, synthesized on St. Barbara day.

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b. Dyspareunia c. Vaginismus d. Old age C. As to the mode of sexual expression 1. Oralism a. Fellatio b. Cunnilingus c. Analism

Is used to excite the undersexed. Is a euphoriant and readily relieves fatigue

Untoward Effects: - Same as amphetamine E. DEPRESSANTS: - Angel dust - Depresses the brain and abusers usually become confused and disoriented shortly after taking the drug. - Can be combative and because they don’t feel the pain they may continue fighting even when hit hard.

2. Sado – masochism a. Sadism b. Masochism 3. Fetishism a. Anatomic b. Clothing

CHAPTER 6 SEXUAL DYSFUNCTIONS AND SEXUAL CRIMES .

SEXUALITY – IS A NORMAL BIOLOGICAL URGE AND AN IMPORTANT PART OF THE HUMAN EXPERIENCE.

c. Necrophilic d. Odor ( ospresiophilia )

4 Stages of a Sexual Response: 1. Desire 2. Arousal 3. Orgasm 4. Resolution

Kinds of Ospresiophilia 1. Urolagnia 2. Coprolagnia 3. Mysophilia a. Narcissism b. Saboteur Fetish c. Vampirism

SEXUAL DYSFUNCTIONS ( Classification ) A. As to choice of sexual partners 1. Homosexual 2. Infanto sexual 3. Besto sexual 4. Auto sexual 5. Gerontophilia 6. Necrophilia 7. Incest

D. As to the part of the body 1. Sodomy 2. Uranism 3. Frottage 4. Partialism E. As to visual stimulus 1. Voyeurism 2. Scoptophilia F. As to number 1. Troilism 2. Pluralism G. Other sexual deviates.

B. As to instinctual strength of the sexual urge: 1. Over sex 2. Under sex or sexual frigidity a. Sexual anesthesia

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1. Don Juanism 2. Indecent exposure 3. Coprolalia H. Disorders of sexual function: 1. Premature ejaculation 2. Retarded ejaculation 3. Low sexual desire disorder 4. Sexual aversion disorder 5. Sexual arousal disorder in women 6. Inhibited orgasm 7. Dyspareunia 8. Vaginismus I. Sexual reversal 1. Transvertism 2. Transexualism 3. Intersexuality

SEMEN AND SPERMATOZOA: ERECTILE DYSFUNCTION ( Impotence ) - The diagnosis of Erectile Dysfunction is important especially in complaints of rape. It must be proven convincingly that the accused is permanently impotent, so that the crime of rape cannot be proved beyond reasonable doubt. -

Impotence usually results from vascular impairment, neurologic disorders, drugs, abnormalities of the penis or psychological problems that interfere with sexual arousal. These includes injury, diabetes mellitus, stroke and drugs like all antihypertensive and psychotics, antidepressants and some sedatives. Alcohol can also cause impotence and also low levels of testosterone SEX CRIMES IN THE REVISED PENAL CODE: A. Rape B. Carnal Knowledge - is the act of a man in having sexual bodily connection with a woman. There is carnal knowledge if there is the slightest penetration in the sexual organ of the female by the sexual organ of the male.

SEXUAL CRIMES: Chaste – An unmarried woman who has had no carnal knowledge with men or that she never voluntarily had unlawful sexual intercourse. These also denotes purity of mind and innocence of heart. Virgin – A woman who has had no carnal knowledge of man. Her genital organs have not been altered by carnal connection.

C. Seduction - is the art of a man enticing women to have unlawful intercourse with him by means of persuasion, solicitation, promises, bribes or other means without employment of force

Kinds of virginity 1. Moral virginity – the state of not knowing the nature of sexual life and not having experience sexual relation. 2. Physical virginity – A condition whereby a woman is conscious of the nature of sexual life but has not experienced sexual intercourse. 3. Demi – virginity – This term refers to a condition of a woman who permits any form of sexual liberties as long as they abstain from rupturing the hymen by sexual act. The woman allows sexual intercourse, but only inter femora or even inter labia, but not to the extent of rupturing the hymen. 4. Virgo intacta – A truly virgin woman. There is no structural change in her organ, notwithstanding the fact of a previous sexual intercourse.

D. Acts of Lasciviosness E. Acts of Lasciviousness with Consent of the Offended Party F. Abduction 1. Forcible Abduction 2. Consensual Abduction G. Adultery H. Concubinage I. Bigamy J. Marriage Contracted Against the Provisions of Law K. Premature Marriage L. Performance of Illegal Marriage Ceremony

DEFLORATION – This is the laceration or rupture of the hymen, as a result of sexual intercourse. All other lacerations which are not due to coitus are not considered defloration.

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M. Prostitution N. Corruption of Minors O. White Slave Trade P. Abuse Against Chastity

2. Somatiform disorders – encompasses several psychiatric disorders in which people report physical symptoms but deny having psychiatric problems. 3. Generalized Anxiety Disorders 4. Panic Attacks and Panic Disorder

PROVISIONS OF THE REVISED PENAL CODE APPLICABLE TO UNNATURAL SEXUAL OFFENSES

5. Phobic Disorders a. Agoraphobia b. Specific phobias c. Social phobia 6. Obsessive Compulsive Disorder 7. Post Traumatic Stress Disorder 8. Depression and Mania 9. Bipolar Disorder 10. Suicidal Behavior 11. Eating Disorders a. Anorexia nervosa b. Bulimia nervosa c. Binge eating disorder 12. Personality Disorders a. Paranoid b. Schizoid c. Histrionic d. Narcissistic e. Antisocial f. Borderline g. Avoidant h. Dependent

1. Grave Scandal ( Art. 200 ) 2. Immoral Doctrines, Obscene Publications and Exhibitions ( Art. 201 ) 3. Vagrants and Prostitutes ( Art. 202 ) 4. Grave Threats ( Art. 282 ) 5. Light Threats ( Art. 283 ) 6. Other Light Threats ( Art. 285 ) 7. Grave Coercions 8. Unjust Vexation or Any Other Coercion ( Art. 287 ) CHAPTER 7 MENTAL HEALTH DISORDERS Mental Health Disorders – include disturbances in thinking, emotion, and behavior. There is a complex interaction between the physical, psychologic, social, cultural and hereditary influences. Factors that Contribute to the Development of Mental Disorders: 1. Heredity – the most frequent factor that contributes to insanity and a good history will reveal the ascendants afflicted with the same. 2. Incestous Marriage – The mental illness is accentuated when they are blood relatives. 3. Impaired Vitality – Stress, tension, worry, grief may predispose to insanity 4. Poor Moral Training and Breeding – Corrupt moral upbringing in the family due to immorality of the parents 5. Psychic Factors – Factors like love, hate, rage, anger, passion disappointments 6. Physical Factors a. Non toxic factors – exhaustion resulting from severe physical and mental strain and traumatic injuries to the head. b. Toxic factors – drug addiction, infections of the brain

i. Obsessive – Compulsive j. Passive Aggressive k. Dissociative 13. Schizophrenia – a serious mental disorder characterized by loss of contact with reality ( psychosis ) , hallucinations, delusions ( false beliefs ) , abnormal thinking, disrupted work and social functioning Types of Schizophrenia: a. Paranoid b. Hebephrenic

KINDS OF MENTAL HEALTH DISORDERS: 1. Psychosomatic disorders – physical disorders caused by psychologic factors.

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c. Catatonic

b. Kleptomania c. Dipsomania d. Homicidal impulse e. Sex impulse f. Suicidal impulse

14. Delusional Disorder 15. Psychological Incapacity – a waste basket diagnosis because it is so broad a term, that it covers all possible Mental Disorders. SOME MANIFESTATIONS OF MENTAL DISORDERS: 1. Disorders of Cognition ( Knowing ) a. Illusion b. Hallucination 2. Disorders of Memory a. Dementia 3. Disorders in the Content of Thought A. Delusion a. Delusion of grandeur b. Delusion of persecution c. Delusion of reference d. Delusion of Self – Accusation e. Delusion of infidelity f. Nihilistic delusion g. Delusion of poverty h. Delusion of control i. Delusion of depression B. Obsession 4. Disorders in the trend of thought Types: a. Mania b. Melancholia

DISTINCTIONS BETWEEN TRUE AND FALSE INSANITY: 1. True insanity develops insidiously usually with the existence of some predisposition to an exciting cause if careful history is taken, while false insanity develops suddenly with no existing predisposition. 2. In true insanity, there is a peculiar facial expression, which is absent in false insanity 3. In true insanity, there is a continuous and persistent manifestation of insanity, which is only present in false insanity when the pretender is under observation, and absent when not under observation. 4. In true insanity, there is a clinical entity of a specific mental disorder, which is absent in false insanity. 5. In true insanity, the patient can endure a violent or stressful activity without fatigue, which is not present in false insanity 6. In true insanity, the patient does not observe personal hygiene, in false insanity, the pretender observes hygiene Insanity or Mental Illness is an exempting or mitigating circumstance to Criminal Liability as provided in the following: 1. As an exempting Circumstance Article 12 of the Revised Penal Code provides, “ When the imbecile or an insane person has committed an act which the law defines as felony, the court shall order his confinement in one of the hospitals or asylums established for persons thus afflicted and he shall not be permitted to leave without first obtaining the permission of the same court.

5. Disorders of Emotions or Feelings – a disorder in the state of mind, fervor, or sensibility, not in accord with reality. 6. Disorders of volition or conation ( doing ) Kinds of Conation: A. Impulsion or Impulse ( Compulsion ) – a sudden and irresistible force compelling a person to the conscious performance of some action without motive or forethought.

2. As a mitigating Circumstance Article 13, of the Revised Penal Code provides, the following are mitigationg circumstances:

Types of Compulsion: a. Pyromania

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a. That the offender is deaf and dumb, blind or otherwise suffering from physical defect which thus restricts his means of action, defense or communication with his fellow beings

Insanity modifies or limits the capacity of a natural person to act as providedin Article 39, also of the Civil Code.

The American Law Institute formulated the following Rules on Criminal Responsibility and states that; 1. A person is not responsible for his criminal conduct if at the time of such conduct as a result of mental illness or defect, he lacks essential capacity to appreciate the criminality of his conduct or to conform his conduct to the requirement of the law.

Insanity at the time of marriage of any or both parties is a ground for the annulment of marriage.

2. The term “ mental disease or defect “ does not include an abnormality manifested only by repeated criminal or otherwise anti social conduct Fundamental Principles of Insanity and Criminal Responsibility: 1. A sane man is assumed to be wholly responsible for the consequence of his crime. 2. A person who commits a criminal act is presumed to be sane. 3. Crime is always considered as an affair of the mind as well as the body and to make an act or omission a crime, there must be a criminal act ( actus reus ) and an criminal mind ( mens rea ) . Actur facit reum, nisi mens sit rea. Mental Deficiency – or mental retardation, is sub average intellectual ability present from birth or early infancy. Intelligence is both determined by heredity and environment. In most cases of mental deficiency, the cause is unknown. Classification of mental deficiency: 1. Idiot – The idiot’s intelligence never exceeds that of a normal child over 2 years old. The IQ is between 0 – 20. This is usually congenital. 2. Imbecile – the imbecile’s intelligence is compared to a normal child from 2 – 7 years old and the IQ is 20 – 40. 3. Feeble Minded – his mentality is similar to that of a normal child between 7 – 12 years old and an IQ of 40 – 70. The Legal Importance of determining the person’s state of mind are the following In Criminal law, insanity exempts a person from criminal liability In Civil law, Insanity is a restriction of the capacity of a natural person to act as provided in Article 38 of the Civil Code.

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