FORENSIC MEDICINE ANSWERS

1. Forensic medicine as a discipline, its tasks and connections with other medical and
paramedical disciplines.
FORENSIC MEDICINE – a branch of medicine that applies principles and knowledge of medical sciences to
solve problems in the field of law (or)
a branch of medicine that deals with the application of medical knowledge to legal problems and legal
proceedings.
TASKS:
 To assist law enforcement in correct incrimination of the offenses against human being
 To solve medical and biological phenomena within judicial activity
 To improve and support the quality of medical care (e.g. medical deficiencies, malpractice)
 To develop and to propose prevention measures of the morbidity and mortality due to vulnerable
external factor

CONNECTIONS:

MEDICAL SUBJECTS:

 anatomy
 pathology
 traumatology
 neurology
 obstetrics
 gynecology
 radiology
 toxicology

NONMEDICAL SUBJECTS:

 forensic sciences
 criminology
 chemistry
 physics
 biology
 law (criminal procedure code, criminal code, criminal civil code specific laws)

2. The history of forensic medicine. The Department of Forensic Medicine of “Nicolae

Testemitanu” SUMPh and its scientific work.
Chronologically there are 3 historical periods:
  Ancient period (lasted several thousand years until the 16th century) - the forensic medicine was
not separated from pathology and surgery, with no specialized experts
 Intermediate period (17th – 19th century) - characterized by scientific development, separation of
the specialty, appearance of forensic medical experts; started in Italy spreaded all over the Europe
 Modern period (20th century – present) scientific discoveries and approach (discovery of the blood
groups
(1901), DNA profile (1985).

3. Procedural basis of forensic expertise. Cases when forensic expertise is mandatory.

 The Criminal Code (CC)

 The Criminal Procedure Code (CPC)
 The Civil Procedure Code (CPC)
 The Law regarding forensic investigations
 Other national regulation and rules
 International legislative acts

The forensic investigations is compulsory To establish:

 cause of death
 injury severity
 mental condition of participants in proceedings(suspect, accused, victim, witness)
 age of participants in proceedings

4.Subjects of medico-legal examination. Expert’s duties, rights and responsibilities.

 PERSONS (alive)
 DEAD BODIES (corpses)
 BIOLOGICAL SAMPLES (e.g. blood, sperm, hair, tissues)
 MEDICAL AND LAW FILES (records)

Expert – officially certified person and appointed by bodies conducting proceedings to perform forensic
investigations and provide conclusions regarding certain facts, circumstances, material objects,
phenomena and processes, the human body and psyche

 Expert must be authorized in a specific specialty/science

 Expert applies special knowledge
 Expert provides scientific opinion (conclusion) on a relevant fact
 Expert provides scientific proofs
 Rights of experts:
Conducting an investigation the expert has the right to:
 participate in procedural acts at the request of the investigative body
 examine the materials of the criminal matter so far as this is necessary for the purposes of the
investigation
 request additional materials needed for investigation
 refuse to conduct the expert assessment if the assessment materials submitted to him or her
are not sufficient or if the questions are outside his or her specific expertise

Duties of experts:
Conducting an investigation the expert is required to:
 conduct an investigation if he or she has been appointed as an expert
 appear when asked by the body conducting the proceedings
 ensure that investigation is conducted thoroughly, completely and objectively and the expert
opinion
rendered is scientifically valid
 maintain the confidentiality of the facts which become known to him or her upon the conduct
of the investigation

Responsabilities of experts
The expert is responsible for:
 false conclusion
 disclosure of confidential information.

5. Forms of forensic expertise.

Primary (first investigation)

 Supplementary (additional investigation)

 Repeated (investigations are performed again)
 Individual (investigations performed by 1 expert)
 Commission (investigations performed by several experts)
 Complex (investigations performed in several fields of science)

6. Forensic medical documentation.

After autopsy:

 the medical death certificate- The medical death certificate is a standard form (blank) which
includes personal data of the dead person, time, cause and manner of death
  the autopsy report(forensic report)- Forensic report consists of 3 parts:
 introductory- The introduction of an expert's report shall set out:
 the date and place of the report preparation
 the name of the person who ordered the investigation
 the title and number of the criminal matter
 information concerning the expert
 the name of the object of the expert assessment or of the person regarding whom the
investigation was conducted
 questions asked to the expert in the order
 the names of the persons present at the investigation
 notification that expert has been warned about criminal punishment
 descriptive (main)- The main part of an expert's report shall set out:
 a description of the examination
 all the data found during examination (e.g. description of external and internal examination
during autopsy)
 final part- The final part of an expert's report shall set out the expert's opinion based on the
conducted examinations.
The final part contains conclusion – answers to questions

The expert's opinion (conclusion) must be:

 objective
 complete
 scientifically argumented
 within the area of expert's competence
 accessible

After clinical examination:

 the experts’ report(forensic report)

7.Death as a biological process. Terminal states.

Death is an irreversible process and it is the cessation of the main vital functions.

Biological point of view

• natural

• unnatural

Terminal states:
  Preagony -filiform pulse, pale or stained skin,breathing is superficial and frequent. May take
several hours
 Terminal break -stopping breathing (lasts 2 -4minutes)
 Agony- rare and superficial breathing, gradually, till irregular breathing act and CNS inhibition
 Clinical death- respiratory and cardiac arrest(4- 7 minutes)
 Biological death- irreversible death- itself

8. Medical and juridical classification of death.

Biological point of view

• natural

• unnatural

Juridical point of view (2 categories)

•violent

•nonviolent

Manner of death

•Natural

•Accident

•Suicide

•Homicide

•Undetermined (could not be determined)

9. Sudden death: general notions and its causes.

sudden death (suspicious death, without a doctor's supervision, etc.)

The medico-legal term “sudden death” (sometimes called "sudden unexpected natural death"), refers
to those deaths which are not preceded by significant symptoms. The term as used obviously excludes
violent or traumatic deaths.

The WHO’s definition is death occurring within 24 hours of the onset of symptoms.

Causes of Sudden Natural Death:

(1) Cardiovascular (6) Iatrogenic

(2) Respiratory (7) Miscellaneous

(3) Central Nervous System (8) Special causes in children

(4) Abdominal (9) Indeterminate

(5) Endocrine

Sudden Infant Death Syndrome (SIDS) – Cot or Crib Death

This condition may be defined as the death of an infant (under 1 year of age) which remains
unexplained after a thorough case examination including:

• A complete autopsy (including histological examination and toxicological investigations)

10. Principles of death diagnosing. Certain and probable signs of death.

There are two groups of signs of ascertaining the death: negative signs of life (orientational) and
positive signs of death (certain).

 Negative signs of life are following:

- lack of consciousness

- passive position of the body

- pale skin

- absence of respiratory movements

- absence of heart contractions and pulse

- lack of response to painful, thermic and odorous stimuli

- absence of reflexes

Negative signs of life have a suggestive value in the diagnosis of death, because these signs may be
found in other unconscious states.

 Positive signs of death are cadaverous changes – due to nonspecific physical and biochemical
processes of the living organism
 Early
 Belated
Beside the above described signs, you can use some diagnostic methods such as Magnus and
Beloglazov.

 The Magnus test consists in checking the cessation of peripheral circulation. An unpowerful
ligature is applied at the basis of a finger and look for changing the color. If the finger color
becomes bluish, it means the peripheral circulation is present and the person is alive.
 The Beloglazov test is performed by bilateral compression of the eyeballs. If the person is alive,
the pupils will shrink as result of mechanical excitation and contraction of smooth muscles of
iris. In the case of dead persons the pupils, due to the loss of innervation, change their shape
from round into oval, like cat eyes. This is also called the „cat’s eye test”.

11. Early cadaverous changes and their forensic importance.

 Algor mortis (cooling)- reduction in body temperature after death.

Depends on :
 External factors
•ambient temperature
•humidity
•movement of air
•clothing and their character
•medium of the corpse finding (immersion in water, at air)
 Internal or individual factors
•thickness of fat tissue (body mass)
•age
•cause of death

 Dehydration- Fine and wet structures of the skin and body (lips, sclera, genitals)
Signs of dehydration:
•brown parchment spots on the skin (scrotum, lips)
•triangular yellow or brown spots over the sclera of open eyes ( L’Arche spots)

Depends on:
•Environment: temperature and ventilation
•Individual features: nutrition, degree of dehydration,clothes.

 Livor mortis (postmortem hypostasis,lividity)

 Hypostasis
 Stasis
 Imbibition
  Rigor mortis- postmortem stiffness of muscles
The rigidity occurs faster
•high temperature
•convulsions

Rigor mortis may be weak or even absent

•poisoning (hemolytic substances, mushrooms,narcotics)
•malnutrition
•sepsis

 Autolysis (self digestion destruction of biological objects by their own enzymes

Depends on

•saturation of tissues by enzymes

•environment temperature

•tissue acidosis is faster in pancreas, adrenal glands, spleen,stomach, liver.

IMPORTANCE OF EARLY CADAVEROUS CHANGES:

 fact of death

 time of death
 probable cause of death by its color and intensity
 tempo of death installation
 initial position of the body
 if the initial position of the body was changed
 relief of corpse lodge.
12. Late cadaverous changes and their forensic importance.

 Destructive

–putrefaction- (decomposition) disintegration of proteins and tissues by aerobic and anaerobic

microorganisms

The conditions of putrefaction are

•temperature

•aeration

•humidity

Types of putrefaction

1.dry, when is less liquid and low humidity(massive bleeding,

2.moist: the presence of excessive water (e.g.edema)

3.gaseous: infectious (bacterial) disease,anaerobic putrefaction (e.g. sepsis,drowning (water and

microbes pass

through skin in soft tissue))

Signs of putrefaction:

 green grey discoloration of the skin

 venous net (marble skin)
 vesicles of putrefaction
 cadaveric emphysema
 fetid smell

–destruction of the corpse by animals (insects, fish,birds, mammals)

 Conservative preserving

–Mummification- is complete dehydration of thetissues due to dry air, high temperature and good
ventilation

–Lignification- (tanning) occurs in acid medium rich in tannic and humic acids (e.g. swamps)

–Saponification- (adipocere) develops in humid conditions with minimum access or lack of oxygen.

–Congelation

–Petrification
Forensic importance:

Estimation of the time of death by means of belated cadaverous changes.

13. Doctor’s mission and method of cadaver examination at the scene of death.
The first and main responsibility of the doctor at the scene of death is to establish the real death. If the
person is alive the medical care must provide and should be transported to a medical institution.

While examining the cadaver and the objects around it the doctor must keep to a scheme and
sequence of describing:

 location, position and attitude of the corpse;

 objects on the body and around it;
 clothes and footwear on the cadaver;
 general data about corpse;
 cadaverous changes;
 supravital reactions;
 anatomical peculiarities and corporal lesions;
 lodge of the cadaver;
 negative circumstances.

The examination on the death scene has the following main objectives:

 to look for evidences: discover, research, collect, pack, preserve and send them to next
examination;
 to identify the aggressor and the traumatic agent by the meticulous research of each element;
 to assess the circumstances of the crime (event), the aggressor’s and victim's movements;
 The doctor’s (medico-legal or another) tasks at the scene of death are the following:
 positive diagnosis of death;
 assessment of the postmortem interval (time of death);
 assistance (consultation) to the police officer in correct cadaver examination;
 consultation in discovering, collection, packing, and sending the biological samples (blood, hair,
sperm, etc.) to laboratory for further examination;
 relating the preliminary thought about the nature, mechanism, oldness of injuries, about
traumatic objects, and other medico-biological tasks;
 consulting the police officer on fulfilling the ordinance or request of the forensic examination of
the cadaver, evidences, biological samples and on correct formulation the questions for
forensic investigation.
14. Forensic and clinical (morphopathologic) autopsies. Reasons for forensic
examination of corpses.

 A forensic autopsy is a series of tests and examinations performed on the body to determine
the presence of an injury and/or to identify any disease that may have caused or contributed to
the death.

There are peculiarities of examination depending on the kind of investigation, but in all cases there is a
sequence of general actions:

1. identity checks

2. analysis of case circumstances

3. advising the medical records

4. annotation the anamnesis

5. medical examination

6. utilization of supplementary and special investigative methods

7. making the medico-legal conclusions and report of medico-legal examination or expertise

 The examination of injuries is done in cranio-caudal order, from right to left, antero-posterior,
and includes: localization, kind of injury, shape, dimensions, morphological appearance
(margins, ends, walls, surface), and adjacent tissue.
Thus, lesions are described as follows:

1. the lesion localization (anatomical region is fixed and its surface);

2. the kind of injury (ecchymosis, excoriation, wound, fracture, etc..);

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3. the lesion shape (compared to the geometric figures; if the form cannot be compared, the irregular
shape should be indicated);

4. the lesion orientation towards the midline of the body (organ, bone);

5. the lesion size (length, width, depth, height) in centimeters;

6. the color of the lesion and the adjacent regions;

7. the character of the lesion surface (relief, color);

8. the character of edges, walls, ends, bottom of lesion;

9. the presence of heterogeneous deposits or impurities (in/on the lesion or around it);

10. the state of adjacent tissues;

11. the signs of tissue regeneration (changing the color of the bruise, the state of the crust of abrasions
or wound).

REASONS OF MEDICO LEGAL EXAMINATION OF THE CADAVER:

• violent death (homicide, suicide, accident);

•sudden death (suspicious death, without a doctor's supervision, etc.);

• corpses of unknown persons, including the corpse of a newborn babies;

• death occurred in hospital within 24 hour after hospitalization (without a clinical diagnosis);

• death in hospital due to a disease and followed more than 24 hours of hospitalization, if there are
complaints of relatives

• malpractice (medical errors, mistakes, iatrogenic diseases, etc.)

15. Medico-legal criteria for time of death assessment.

Time of death

 the supravital reactions-

 Beloglazov test is positive in 10 15 minutes.
  Mechanical excitability of the muscles
 –Tendon reaction ( Zsako’s phenomenon) 1.5-2.5 h
 –Idiomuscular contraction till 10 h
 Electrical excitability of the skeletal muscle
 Pharmacological excitability of the iris muscle

 early cadaverous changes

•L’Arche spots occur over 5 6 hours
•At 16 18 0 C of environment, the cooling is near 1 0 C per hour
•Livor mortis
–hypostasis 1.5 2h 8 12h
–stasis 8 12h 24 36h
–imbibition over 24 36 hours
•Rigor mortis
–instals in 3 4 hours
–in all muscles over 8 14 hours
–destroyed after 10 12 hours does not restore
–24h it reaches its peak
–complete and independent resolution is found by 3 4 days

 belated cadaverous changes

 Putrefaction.
 Mummification
 Saponification
 Lignification
 Congelation
 Petrification

 biochemical markers- Biochemical markers gradually change their concentration and potential
after death, which is useful while estimating the time of death. The biochemical methods
require laboratory investigation of blood markers (electrolytes such as sodium, potassium,
calcium, magnesium, phosphorus, chloride; glucose; lactic acid; urea; etc.), vitreous markers
(electrolytes such as sodium, calcium, magnesium, chloride; urea; pH), cerebrospinal fluid
markers (electrolytes such as potassium, magnesium, sodium, calcium, phosphorus, chloride),
pericardial fluid markers (electrolytes, cholesterol, glucose, lactic acid, enzymes, etc.), muscle
markers (creatinine, enzymes), lung markers (surfactant, phospholipids), etc.

16. Medico-legal diagnosis and its principles. The forensic conclusions and their
requirements.
  Medico-legal diagnosis (forensic, pathological) is a summary of changes (lesions) found during
autopsy and recorded in the descriptive part of the „Autopsy Report”. All macroscopic findings
must be arranged by importance, using nosological and etiopathogenic principles. Initially it is
indicated the main lesion or pathology (the basic morphological manifestations), and its
complications, which served as the direct cause of death.

Then are noted the coexisting and preexisting injuries or/and diseases.

Therefore, the structure of a medico-legal diagnosis is:

Principal (main) disease (trauma) - causes the death itself or by its direct complication.

If there is more than just one, they may be: concurrent and associated, and must be ordered
anatomically (from head to legs) or according to current regulations.

Concurrent diseases or traumas are when each of them can cause the death itself.

Associated are diseases or traumas which can’t be the cause of the death itself but only in case of their
combination.

Complications are effects or pathological processes which are related etiologically and pathogenically
to the principal disease.

Preexisting (background) disease or trauma - influences pathogenically the principal disease or trauma,
but not etiologically.

Coexisting disease or trauma - exists simultaneously with the principal one and has no impact to it.

The forensic pathologist uses medical terms in diagnosis and it is not necessary to simplify them,
because the medico-legal diagnosis is not predestined to the police or other official organs.

 The conclusions start with listing of all available data (necropsy, preliminary tests, laboratory
investigations, etc.) as follows:

Based on the autopsy data, the medical files (if any), the circumstances of the case, the results of
laboratory investigations and in accordance with the exposed questions the conclusion is:

1. The cause of death – trauma, disease or direct complication served as cause of death. In a short form
indicate the basic signs of the principal disease (trauma) and its complications.

There are two ways to explanate the cause of death: from the principal disease to the complications or
from the complications to the principal disease, as follows:

„The cause of death served the stab wound of the chest with aortic injury, complicated by a
subsequent abundant bleeding and generalized anemia”, or
„The cause of death served the abundant bleeding and generalized anemia as complications of the stab
wound of the chest with aortic injury”.

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2. The time of death (based on objective data of rigor, livor and algor mortis, environment conditions,
data from the death scene, etc.). The expert indicates only the established interval of time and doesn’t
record exact date and time:

„Death occurred 10-12 hours ago, which is confirmed by…”

3. The localization of injuries (if any), their mechanisms of formation, the time they were produced,
causal relationship with death, and degree of injury severity.

4. The degree of drunkenness before death, based on toxicological investigation of blood.

5. Other questions of medico-legal competence.

17. Mechanisms of injures due to blunt objects and their peculiarities.

 The mechanism of formation that allows us to understand the sequence of the interaction
between the object and the human body, the phenomena generated by this interaction, the
morphological aspects, etc.is another important element in the formation of blunt object
injuries.

The main mechanisms of action of blunt objects are:

- Impact(Impact is a short (0,01-0,1 seconds) centripetal interaction between the human body and the
object.)

- Compression(is an action on the body or its parts between two objects which are moving towards
each other. There may be one moving object and one fixed.)

- Extension (tension)( is an opposite action than compression where the objects move one from
another.)

- Friction(is a tangential action between object and human body.)

 According to the mechanism of action of blunt objects, bruises, lacerations, and fractures are
frequently produced by impact; crushes of internal organs and soft tissues - by compression;
abrasions - by friction, etc., but some injuries can be produced by more than one mechanism
(e.g. laceration can be produced by impact, compression, extension or friction). Sometimes
there are more mechanisms causing a single lesion.
18. Classification of mechanical injuries. Medical causes of death due to mechanical
trauma.
By the shape of the interaction surface:

- flat and curved (oval, round, square, rectangular)

- spherical

- cylindrical

- angular

- edged

By their hardness:

- soft

- hard

By the size of the interaction surface:

- small (less than 16cm2)

- large (more than 16cm2)

or

- limited (the interaction surface is smaller than the injured part of the body)

- unlimited (the interaction surface is larger than the injured part of the body)

 The mechanical trauma usually leads to death by its complications, such as: traumatic or
hemorrhagic shock, bleeding, aspiration of blood or tissues, compression of vital organs,
embolism, reflex cardiac arrest, traumatic aneurysms, traumatic toxicosis, renal failure,
respiratory complications, and orders as infectious.

19. Morphologic peculiarities and medico-legal importance of ecchymosis and

abrasion.
 Bruise is discoloration of skin surface caused by leakage of blood into skin or underlying tissues
from damaged small calibre blood vessels

•As a rule is localized on the place of impact

•Can be displaced if underlying fat tissue is lax)

•Shape and dimensions depend on the traumatic surface of the object

• It changes its color due to hemoglobin process, but in good vascularized area it does not change the
color.

Bruising discoloration begins from the periphery to the center, due to uneven thickness, which is lower
periphery

•Fresh red, light red

•Some hours blue red

•3 -4 day appear green color

•7- 9 day appear yellow color

•6- 8 may be tricolor ( center purple, middle-green, the periphery yellow brown.

 An abrasion is a superficial injury of the skin involving epidermis without penetration of the full
thickness of teguments.

Healing has 4 stages:

Fresh abrasion -initial surface is wet, then dry till 12-24 hours

Crust formation:24 hour-3 -4 days

Crust removing:4-5 days 7 -12 days

Abrasion dent or remains(hyperemia, hyperpigmentation, hypopigmentation).

20. Morphologic peculiarities of lacerations (blunt, crushed wounds).

A laceration is a blunt force injury of the skin or mucosa that involves full their thickness.

Morphological appearance:

 Diversity of the shape

 Irregular & crushed edges
 Abrasions and bruises on the margins
 Rounded obtuse ends
 Tissue bridges
 Insignificant bleeding
 Hair follicles are crushed
21. Injuries due to unarmed person, morphologic peculiarities.
An unarmed man can cause injuries with various parts of the body such as fist, hand, foot, teeth, etc.
The most common lesions produced by an unarmed person are bruises and abrasions, but there may
also be fractures, internal organ damages and others.

The lesions can be quite serious and even lethal, especially when shock zones are struck (e.g. solar
plexus, carotid sinus) or when the person is acquainted with combat readiness, martial arts.

The fingers and nails produce specific lesions: round or oval bruises and semilunar abrasions. Their
localization allows us to identify the nature and manner of trauma. For example, in case of
strangulation by hands they are located on the neck, or in case of rape they can be found on the inner
thighs.

Human teeth cause injuries named bites and they range from trivial ones as bruises, abrasions to major
bite wounds with soft-tissue defects. The bite consists of two series of lesions arranged in the form of
arches with the concave side directed towards each other. The arch with the pronounced curve
corresponds to the inferior dental arcade and the one with the insignificant curvature – the upper
dental arcade. According to morphological features of the bites it is possible to identify the assailant.

22. The scheme and sequence of injuries description.

The scheme of describing an injury is:

- anatomical localization (the position of the wound in relation to anatomical landmarks)

- the height of the wound above heel level (if the need arises)

- the nature of the wound (abrasion, bruise, laceration, cut wound)

- shape (in comparison with geometrical figures or others)

- orientation (direction) of the injury related to anatomical planes and axes

- dimensions (length, width, depth)

- color of the injury and surrounded tissue

- morphological appearance (margins, ends, walls, surface and others, according to the injury)

- adjacent tissue

- hemorrhages, signs of healing

- dirties on the surface (oil, paint, soil)

Beside the macroscopic morphological description of the injury it is necessary to take photos, to make
schemes and to do supplemental investigation like:

- stereomicroscopic examination of the lesion (to find small particles and characteristics of the wound)

- radiographic examination (to appraise the fracture character-ristics, to find particles of the object)

- ultrasonographic examination (to discover internal bleeding, injuries of the internal organs)

- histological examination (to determine the ages and nature of trauma, to discover the vital signs of
the injury)

- traceological investigation (to identify the vulnerant object)

- experimental research (to remodel morphological appearances of the lesion)

The photography should be supplemented by drawing up the schemes. The schemes help understand
the mechanism of trauma, the side of impact, the position of the body during a traumatic event, and
other important circumstances. It is recommended to sketch the abrasions in red color, bruises –in
blue, wounds and laceration –in green, and fractures and lesions of internal organs in brown.

23. Principles of vulnerant objects identification.

The identification of the vulnerant object is an important target on examination of the injury. It is
possible by using these three principles of identification:

1. Morphological appearance (abrasion, bruise, laceration can be produced by a blunt object, cut
wound – cut object and so on),

2. Deposits from the wound on the object (blood, hair, tissue, etc.),

3. Deposits from the object on the wound (rust, paint, oil, etc.)

This way, it is very important to find, collect and examine all deposits from the wound and surrounding
tissue.

24. Traumas due to falling from a standing position, their morphologic peculiarities.
Falling is downward movement of the body from a standing position or from higher to a lower level.

Falling down (simple fall, from orthostatic position) is a changing the position of the body from vertical
into horizontal, followed by its hitting a support (soft soil, sand or hard asphalt, stone, sidewalk).
Kind and severity of injuries depend on:

•Place of landing (hard or soft)

•Declivity of the ground

•Presence and character of clothes

•Presence of acceleration

PECULIARITIES OF MORPHOLOGICAL APPEARANCE IN SIMPLE FALLING:

•Diverse lesions (from bruise, abrasions till fractures and damages of internal organs)

•Unipolar

•On prominent parts of the body

•Prevailing external over internal injuries

25. Traumas due to falling from height, their morphologic peculiarities.

Falling from height-from higher level

Falling from height a complex process of body interaction with objects on starting, finishing points and
during falling.

The starting (detachment) point represents the place of starting of falling.

The landing plan(surface) represents the place of finishing of falling,”laying on the ground”

The line joining the lines of detachment and landing is called the trajectory of falling.
26. Classification of road trauma. Vehicle traumatisms (autotrauma), their mechanisms.

27. Trauma due to pedestrian collision by car.

Phases of trauma: Phases of trauma:

1. vehicle collision with pedestrians 1. vehicle collision with pedestrians
2. fall the body on the car 2.
3. fall the body on the road 3. fall the body on the road
4. sliding on the surface of the roadway 4. sliding on the surface of the roadway

specific injuries Imprint injury (marker) radiator, headlight, screws, rear-view mirror, handholds, ladders,
lamps turn, etc. as bruising,excoriation, wounds

characteristic lesions

1. "Bumper fractures" (Xray can be done)

2. abrasion due to sliding on the road
28. Classification of sharp objects. Morphologic features of stab, cut and puncture wounds.

I. The simple mechanism of action

1. Puncture (awl, nail)

2. Cut (knife, razor, blade)

3. Chop (ax, hoe, spade, sword)

II. The combined mechanism of action

1. Stab (knife)

2. Sawed (saw)

3. Scissored (scissors)Etc.
Morphologic features of stab, cut and puncture wounds:

Stab Cut Puncture

Entry wound: • spindle-shaped (fusiform)
• triangular, linear, fusiform • regular edges
shape • linear direction
• one sharp end, another ∏,∩ • no tissue bridges
or M • sharp ends
• both ends sharp (if two- • non-leveled depth (deeper in
edged) the beginning)
• regular margins • the end point has a superficial
• the length is less than depth incision (mouse tail)
• hairs may be cut
• longer than deeper
• Shape depends on the
transversal section of the
object
• Abraded margins
• Ruptures on margins
• Size on skin is smaller than
depth
• Dangerous by the internal
bleeding

29. Chop wounds, their mechanism and morphologic features.

They have heavy , and long handle.

Morphological appearance:

• triangular, rectangular, linear, fusiform shape

• regular margins

• bone damage

• dehiscent (opened)

30. Firearms, their classification. Peculiarities of injuries due to hunting guns.

Fire-arm is a device that launches the projectile using kinetic energy from the burning powder

Classifications: There are five general categories of small arms:

1. handguns (pistols, revolvers)

2. rifles (АК-47)

3. shotguns (hunting gun)

4. submachine guns (PPSh41)

5. machine guns (IWINEGEV NG7) also can be homemade, improvised, and modified weapons.

31. Gunshot traumatic factors. Forensic assessment of the discharge ranges.

Legal medicine studies the conditions and circumstances of shooting based on the morphological
characters of wounds and residues detected on the body and clothing of the victim. The morphological
appearances, distances of discharge are established using the particularities of the action of the
traumatic factors and the residues, which are grouped into four:

1. the main traumatic factor – the projectile (ordinary or special bullet, pellets, wad and other hard
components of the hunting gun, atypical projectile);

2. additional or supplemental factors – gases and air from the barrel, flame, soot, gun oil, particles of
powder and metal;

3. secondary factors (projectiles) – fragments of obstacles, pieces of clothing and footwear, bone
fragments;

4. the firearm itself or its parts – muzzle, action, stock, pieces of detonated firearm

Forensic assessment of the discharge ranges.?????

32. Morphologic features of firearm wounds caused from close distance.

The close distance of discharge is conventionally divided into three main zones:

1) the zone of maximum action of explosive gases (small distance 1-5 cm);

2) the zone of deposition of soot, powder and metal particles (25-35 cm);

3) the zone of achievement the target by particles of metals and powder (35-200cm).

In the field of forensic medicine, the close distance of discharge is assessed based only on morphological
appearances of entry wound produced by the main traumatic factor of the shot (round or oval shape
wound, with scalloped or regular edges, „minus tissue”, abrasion and wiping collars) and supplemental
ones (deposits of soot, metal particles, powder, gun oil from the barrel)

33. Entrance and exit firearm wounds. Discharge direction estimation.

34. The blind and tangential wounds. The criminalistic importance of the bullet.

blind wounds: have only entry wound and track, but the exit wound is absent. It is formed in cases when
the bullet velocity is less (low kinetic energy).

- tangential wounds: are caused when the bullet touches glancingly the surface of the body, forming an
open channel – gutter. The wound obtains a long-oval shape, like a gutter, with irregular edges and
superficial ruptures of the dermis or epidermis. The beginning end of the wound is deeper, rounded, with
semilunar tissue defect, the opposite end (the exit) is sharp and superficial.

criminalistic importance of the bullet:

Specialists in this field are tasked with linking bullets to weapons and weapons to individuals. Obliterated
serial numbers can be raised and recorded in an attempt to find the registered owner of the weapon.
Nitric acid (HNO3) is the most common reagent used for this. Examiners can also look for fingerprints on
the weapon and cartridges. Fingerprints are key pieces of evidence. If crime scene investigators find
prints at a scene, they will be dusted, photographed, collected, and analyzed both by hand (using
comparison microscopes) as well as compared to databases for potential

35. Bone firearm injuries.

Flat bone firearm fracture: an orificial fracture is mainly formed, the cross section of the track has the
shape of a truncated cone with the base pointing in the direction of the bullet movement.

The classical features of the fractures (in case of perpendicular impact) are:

- on the lamina of the entrance – a round and regular orifice is formed and its dimensions are equal to
the diameter of the bullet

- on the lamina of the exit – an irregular orifice is produced and its dimensions are larger than the
diameter of the bullet due to the detachment of the spongy layer.

Long bone firearm fracture: an orificial fracture is formed if the epiphyseal regions are affected by the
bullet.

The diaphyseal fractures are comminuted and the following appearancesare determined:
at the entrance – a round orificial fracture, with regular edges, from which radial fissures are formed in
oblique-longitudinal directions, forming large trapezoidal or triangular bone fragments, looking like
butterfly wings, and this fracture is called „butterfly fracture”; at exit – a large bone defect is formed,
with irregular edges, from which multiple longitudinal fractures start

36. Firearms injuries of internal organs. Hydrodynamic effect.

Lungs.

The entry wound is round, visceral pleura is turned inward.

The exit wound is irregular, edges are turned outward. In the lumen of the injury track, flame-shaped
flaps of lung tissue located in the direction of the bullet movement can be found.

Heart.

The entry wound is round or oval, with regular and rounded edges. The exit wound is larger than the

entrance, with irregular shape and the edges broken and turned outward, in the direction of the bullet
movement.

Stomach, bladder.

If the cavitary organ is empty, the entry wound is round, with multiple ruptures of serous and mucous
layers.

If the organs are filled with liquid, there will be ruptures of the walls associated with mucous layer
detachments due to the hydrodynamic effect of the bullet

Liver, spleen.

The entry wound of a parenchymal organ is stellarshaped, with relatively small dimensions. The exit
wound is stellate or irregular and it is larger than the entry wound. The wound track is rectilinear, with
tissue destruction.

Brain.

The ballistic track is large, with tissue destruction and it has the shape of a truncated cone with the base
oriented toward the exit.

hydrodynamic effect – when the projectile encounters a cavitary organ filled with fluid (stomach, heart,
bladder). The rupture occurs due to hydrodynamic waves generated by the transmissive kinetic energy
from the bullet to liquid

37. Injuries due to contact shots, mechanisms and morphological features.

When the muzzle is directly in contact with the skin or clothing, the contact range of discharge is
determined, and all the traumatic factors of the shot (the muzzle, the projectile, and the additional
factors of the shot) take action it this case.
The contact can be hermetic – the muzzle is strongly attached to the target and non-hermetic – the
muzzle just reaches the target.

The muzzle may be oriented perpendicularly or at an angle to the surface of the body.

The entry wound may be stellar, cruciform, oval, round, with tissue defect (minus tissue), irregular
ecchymotic and crushed edges, the skin around the wound is detached from adjacent tissue.

Deposits of supplemental factors are inside the track and around the entry wound, and their shape
depends on the conditions of shooting:

- hermetic contact – the deposits are mainly inside the track, but can be around the entry wound as a
tight gray or black collar, reproducing the shape of the muzzle;

- non-hermetic contact – intense deposits around the wound, 3-5 centimeters in diameter;

- angle contact - deposits are uneven, fan-shaped, being more pronounced at the opposite side of the
muzzle contact.

The shot residues, found inside the track, are usually deposited on the walls, having a higher intensity at
its initial portion. In some cases, the soot may pass the whole track and deposits are found on the inner
surface of clothes, in the region of the exit wound. Carbon monoxide produced by burned powder
interacts with hemoglobin and myoglobin, coloring the blood and tissues in red-pink color.

In case of hermetic contact shot, a pattern injury can be produced around the entry wound called
„muzzle imprint” or „stanzmarke”. It consists mainly of an abrasion, sometimes associated with bruise
and superficial tears due to forced contact with the muzzle. Some conditions are necessary for forming
the stanzmarke, namely hermetic contact and the presence of a flat bone (e.g. skull) underlying the skin,
resulting in the formation of a pressure under the skin and at last it pushes violently the skin towards the
muzzle. The shape and dimensions of this injury reflect the constructive characteristics of the muzzle and
are an important sign for the identification of the weapon

38. General asphyxial signs.

External Internal
• Petechiae on the skin and mucosa of the face, • Fluidity of blood
conjunctiva • Congestion of internal organs, mainly
• Cyanosis (purple discoloration of nailbeds pulmonary and cerebral congestion
and face, including lips and earlobes) and edema
• Livor mortis are purple, faster, and wider • Spleen anemia - Sabinski
• Signs of involuntary urination, defecation and • Dilation of right ventricle
ejaculate • Petechiae on serosal surfaces (epicardium,
visceral pleura) – Tardieu

39. Hanging, autopsy findings.

manner

Suicide – as a rule
Homicide – rare

Accidental – very rare

Internal

Soft tissues hemorrhages

• Sternocleidomastoidian hemorrhages (Walker)

• Pericarotidian hemorrhages (Martin)

Transversal ruptures of the carotid arteries

intima (Amusat)

Hyoid and larynx fractures

Lymph node hemorrhages

Trauma of the cervical spinal column

40. Strangulation by ligature, autopsy findings.

41. Strangulation by hand(s), autopsy findings.

Morphological appearance:
External:

• Linear or semilunar abrasions

• Oval and round bruises

• Signs of self-defense

Internal:

• Massive soft tissues hemorrhages

• Hyoid and larynx fractures

42. Asphyxia due to thoraco-abdominal compression. Thanatogenesis and specific signs.

Tanatogenesis /thanatos = death/ Deals with processes leading to death, and with symptoms and signs
characteristic for dieing process.

Specific signs?????

43. Blockage of the upper airways. Their age’s peculiarities.

Type 1: foreign body situated between the oral cavity and oropharynx, while the epiglottis sits in normal
position,

Type 2: foreign body situated in the oropharynx just above the epiglottis pushing it posteriorly and
obstructing the airway, and

Type 3: foreign body obstructing the laryngeal inlet while pushing the epiglottis anteriorly.

At the time of autopsy, foreign bodies were detected by pathologists, occasionally in a different position,
presumably being dislodged in the act of organ removal especially for the "Type 1" pattern.

Choking refers to blockage of the internal airways, usually between the pharynx and the bifurcation of
the trachea. Causes of choking include metallic, plastic, or other foreign bodies, food material, as well as
acute obstructive lesions—edema of the glottis or larynx. Long-standing benign tumors or other
conditions could also compromise the upper respiratory tract, causing choking.

Age?????????
44. Suffocation (smothering), autopsy findings.

A mechanical asphyxia due to obstruction of the respiratory orifices (nose and mouth) by hand or soft
objects (pillow, plastic bag, mammary gland)

Mechanism of death: asphyxia

Morphological appearance:

– Bruises and abrasion round the nose and mouth

– Hemorrhages below lips mucosa and lacerations on it

– Signs of self-defense

– Particles from objects in mouth cavity and airways

45. Drowning, autopsy findings.

A mechanical asphyxia due to obstruction of airways by liquids.

Forms of drowning:

Aspiration

Spastic

Reflector

Mixt

Signs of drowning

• Foam (mushroom) at the mouth and nose (Krushewski)

• The increase in the circumference of the chest

• Smoothing over the supra- and subclavian fossae

• Foam inside the airways

• Pulmonary edema

• The fluid in the stomach and upper small

• intestine with silt, sand, algae (Fegerlund)

• Hemodilution in left half of the heart, blood is cherry-red color (Casper)

• Rasskazov-Lukomsky-Paltauf spots

• The submersion fluid in the sinus of sphenoid bone (Sveshnicov)

• Air embolism of the left heart (Isaev)

• Lymphohemia (Isaev)

46. Signs of body retention in water.

• Gooseflesh

• Pale skin

• Nipples and scrotum shriveled

• Hair loss

• Maceration of the skin (wrinkled, pale, "the hand of the laundress," "glove of death"

• Rapid cooling the corpse

• Destruction the corpse by aquatic animals

• Putrefaction is faster (after recovered from water)

• Adipocere

47. Injuries due to local high temperature.

Exposure of living tissue to high temperatures will cause damage to the cells.

The extent of the damage caused is a function of the length of time of exposure as well as of the
temperature to which the tissues are exposed.

Damage to the skin can occur at temperatures as low as 44°C if exposed for several hours; at
temperatures over 50°C or so, damage occurs more rapidly, and at 60°C tissue damage occurs in 3
seconds.

The heat source may be dry or wet; where the heat is dry, the resultant injury is called a 'burn', whereas
with moist heat from hot water, steam and other hot liquids it is known as 'scalding'.

1. Burning

Dry burns are classified by both severity and extent.

There are several systems of classification of the severity of burns, the most useful of which is:

1. first degree - erythema and blistering (vesiculation);

2. second degree - burning of the whole thickness of the epidermis and exposure of the dermis;

3. third degree - destruction down to subdermal tissues, sometimes with carbonization and exposure of
muscle and bone.

The 'Rule of Nines' is used to calculate the approximate extent on the body surface.
 just for reference

Where the burnt area exceeds 50 per cent, the prognosis is poor, even in first-degree burns.

2. Scalds

The general features of scalds are similar to those of burns, with erythema and blistering, but charring of
the skin is only found when the liquid is extremely hot, such as with molten metal.

The pattern of scalding will depend upon the way in which the body has been exposed to the fluid:

immersion into hot liquid results in an upper 'fluid level‘;

whereas splashed or scattered droplets of liquid result in scattered punctate areas of scalding;

runs or dribbles of hot fluid will leave characteristic areas of scalding - these runs or dribbles will
generally flow under the influence of gravity and this can provide a marker to the orientation of the
victim at the time the fluid was moving.

48. Death due to hypothermia. Morphologic changes.

Typical morphological findings in hypothermia are frost erythema, hemorrhagic gastric erosions, lipid
accumulation in epithelial cells of renal proximal tubules and other organs. Although being unspecific as
exclusive findings, they are of high diagnostic value regarding the circumstances of the case. The main
pathogenetic mechanisms of morphological alterations due to hypothermia are disturbances of
microcirculation, changes of rheology, cold stress, and hypoxidosis. Typical morphological findings can be
found in two thirds of all cases.
Pancreatic changes in hypothermia – Focal or diffuse pancreatitis – Hemorrhagic pancreatitis – Patches
of fat necrosis over organ surfaces – Increased serum amylase – Hemorrhages and focal or diffuse
interstitial leucocytic infiltrationAt autopsy, – Hemorrhages into the pancreas parenchyma as well as
under the mucosa of the pancreatic duct may be seen.

Hemorrhage into core muscles

• Dirnhofer and Sigrist (1979) Hemorrhages into muscles belonging to the core of the body can be used
as a diagnostic criterion of death due to hypothermia. Histology – Vacuolated degeneration of
subendothelial layers of the vascular walls with a lifting of epithelial cells – Misbalance of reduced
perfusion and normal oxygen requirement causes hypoxic damage of epithelial cells with resultant raised
permeability

Lipid accumulation

• Fatty changes in heart, liver, and kidneys have been described in fatalities due to hypothermia

• Lipid accumulation in epithelial cells of proximal renal tubules seem to be of high diagnostic
significance Base of the epithelial cells strong positive correlation between the grade of fatty change with
the occurrence of macroscopic signs of hypothermia

49. Electrical trauma. Factors and morphologic signs of electrocution.

External:

 Externally, the deceased’s clothing, shoes, gloves, head gear etc should be properly examined for
burns. Most of the time the examination of the scene of occurrence is of utmost importance in
concluding the case as electrocution.

 If the victim dies of cardiac arrhythmia, the deceased will appear pale and if dies due to respiratory
paralysis, then will appear cyanosed.

 The eyes are congested with dilated pupils. Rigor mortis appears early in electrocution and post
mortem lividity is well developed.
 In about 60% of the cases, external findings of electrocution may be there in the form of electric burn,
or contusion and laceration at the point of entrance and exit which may extend till the depth of muscle
and bones. Multiple grayish-white circular spots, which are firm to touch and free from zone of
inflammation may be found at the site of the entrance and exit.

 The deceased may have fracture of the limbs due to severe convulsion. Extensive ecchymosis with
occasional singeing of hair may be seen. But sometimes, the external findings may be very minimal and a
very thorough and careful examination is needed to diagnose a case of electrocution.

 Arcing of the current may produce characteristic pit like defects on the surface of the hair.

 Sometimes the electric entry point may be hidden inside the natural orifices like oral cavity or the
urethra, in cases where live wire is put inside the mouth or path of the current is through the flowing
water which the deceased was drinking or if the path of current is the urine flow, due to urination on a
high voltage live wire.

 Sometimes, the entrance and exit marks cannot be differentiated grossly. The site of the entrance may
be diagnosed histochemically by seeing deposition of metal particles on the skin. This metallization of the
skin is due to volatilization of the metal and the same being driven into the skin. It is also very difficult to
differentiate between ante mortem and post mortem electric burns.

(B) Internal:

 Usually asphyxial signs are present internally. The lungs are congested and edematous and the brain,
meninges and other solid organs are congested as well.

 Along the line of passage of the current, petechial hemorrhages may be found. e.g., under the
endocardium, pericardium, pleura , brain and spinal cord.

 The intima or the complete vessel wall may undergo necrosis. Vascular thrombosis may be seen in the
vicinity of the electric burns.

 Zenker’s degeneration is seen in the skeletal muscle along the path of the current. Small balls of molten
metal, derived from the metal of the contacting electrode may be seen carried deep into the tissues and
are called current pearls.

 Heat generated by calcium phosphate is seen typically as round density foci in radiological examination
and is termed as bone pearls or wax drippings. The bone may undergo micro-fractures at multiple planes
and necrosis.

 Focal petechial hemorrhages may be seen in brain and spinal cord and in some cases irregular tears
and fissures in the brain tissue and rupture of the walls of the arteries are seen.

 Occasionally, no lesions may be found both on external and internal examination and in such cases,
death is usually due to vagal inhibition.

50. Poisons and their classification.

51. Social and juridical classification of intoxications. Sources and
circumstances of intoxications.

1.Intentional or voluntary:

•homicides by poisoning

•suicide

•toxicomania (addiction) intentional form of periodic or chronic

intoxication by repeated consumption of toxic substances

2. Accidental or involuntary:

accidental itself ingesting toxic as a result of carelessness,

imprudence, ignorance;

drug consumption -errors of doctor, pharmacist, thepatient himself,

unlawful medicine. May be errors ofprescribing or drug delivery,
administration, etc..
professional can be industrial, agricultural due to ignoring the work
protective measures. They are usually chronic.

food intoxication consumption of poisonous food or drink by their

chemical or bacteriological component.

This may be due to confusion of plants, mushrooms,consumption

counterfeit, old, altered food or drink.

52. Conditions of poisoning. Toxic habituation.

The condition and severity of poisoning depends on:

•the substance introduced into the body

•the body

•the way of administration

•toxic behavior in the body, etc..

Dependent on substance:

Origin-The extraction of substances from not recommended food

sources, may make them toxic origin

Oldness- The age of some substances may induce or decrease the toxic
effect.

Dose-The pharmaceutical dose is the amount of substance that can

produce a determined result Distinguish therapeutic, toxic, lethal
doses

Concentration- sulphuric acid

Concentrate- aggressive corrosive

Diluted- sulfuric lemonade 0.002%;

antidote in poisoning with lead and barium.

Physical state of toxic- liquid solid gaseous

Most dangerous are liquids and gases which readily dissolves in the
body fluids and tissues! However, the solubility can be changed

ex:

calomel (Hg2 Cl 2 ) + chloride NaCl ) → to sublimate(HgCl 2)

lead salts administered with coffee →tannate of lead(PbTiO 3)

dependent on body:

age- young people and children are more susceptible to toxicants as

adults elders are susceptible to vascular, vomitive and purgative
substances

•sex- women are less resistant to the toxic thanmen, especially

pregnant women, lactating period, menstruation.

•weight

•individual predispositions

Health status of the body

determine:

•absorption rate

•elimination rate

•transformation of toxic in the body

•toxins tolerance, etc..

Diseases generally decrease body resistance to toxic.

•hypo or hypersensitivity to toxic

Hypersensitivity or intolerance:

Manifest reaction of the body to the toxic

congenital

acquired

Excessive susceptibility- idiosyncrasy

("Idios " own and sincrasus " constitution

Idiosyncratic was called the uncharacteristic response of a subject to

a chemical substance that normally does not occur by the
administration or its use.

Hyposensitivity:

Diminished reaction of the body to the toxic

congenital

acquired

Gained tolerance can occur to the alcohol,tobacco, opium, drugs etc..

It is considered that it is due to decrease the absorption and fixation

of receptor cells, increasing the detoxification process, etc..

•habituation to toxic

Habituation to the toxic is obtained by continuous administration of

low dose and gradually increased, reaching to withstand, without
clinical manifestations, toxic and even fatal doses.

53. Death scene examination in case of intoxication.

54. Ways of poisons introduction and elimination.

direct

Direct contact with blood

Hypodermic

Intramuscular

Intravenous...

They are: more dangerous faster

Indirect

Indirect contact with blood

Gastrointestinal

Respiratory

Transcutaneous...

They are: less dangerous, slower, widespread

55. Intoxications with acids. Morphological changes.

Acids

Are substances which molecules, in aqueous solution, dissociates into H

+ ions and saline radicals.

The degree of dissociation determines the strength of the acid and

toxicity.

Ways of entry:

Per os (most cases), Inhalation,

Transcutaneous, Trans mucosal

The mechanism of action

Hydrogen ion (H +)

•captures the tissue water

•coagulates protein  acidic albumin

•denatures proteins

HNO3 (>30%)

•Xantoproteic reaction: denatured proteins which contain

cyclic amino acids (phenylalanine, tyrosine, tryptophan)

form nitrocompounds (yellow)

HCI, H2 SO 4

•heat emanation ----> thermal action

СН3 СООН

•high resorptive properties hemolysis

The acute

period

•chemical burns

(coagulative necrosis)around the mouth andon the mucosa of the

digestive tract

•local inflammatory reactions.

The belated period

 stomatitis
 oesophagitis
 gastritis
 mediastinitis
  peritonitis
 pneumonia
 dystrophic changes in the myocardium, liver, kidney

Coagulative

necrosis (coagulation relatively hard and dry (dehydrated)

•relatively superficial with rough crust on the surface surrounded by

local inflammation dark brown or brown black

(H + → Hb → hematoporphyrin ,methemoglobin , acid hematin)

acid Morphological appearance

Sulphuric deep necrosis, brown-black
H2SO4

Nitric yellow burns

HNO3(> 30%)

Hydrochloric mucosa of the digestive tract get a dirty-gray color

HCl
acetic
СН3СООН •specific odor
•tumefaction of the mucosa of the upper segments of the digestive tract with
dark-red pigment imbibition

Oxalic marked mucosal hyperemia with multiple small hemorrhages

PhosphoricHOO
C-COOH, H3PO4

56. Intoxications with alkalies. Morphological changes.

Alkalis are substances containing hydroxyl group

(OH) and an anion of the metal. As acids, the alkali strong depends on
the degree of dissociation.

Ways of entry:

Per os (most Inhalation Transcutaneous Transmucosal,

Mechanism of action.

OH group tumefies, merges and dilutes the proteins → alkali

albuminates , soluble in water.

Due to high solubility alkalis penetrate deep into the tissues, forming a
moist necrosis (the colliquative necrosis).

Strong alkali degenerates not only soft tissue, the strong (hair, nails)
is affected! Heated alkali shows a greater destructive action.

Chnges:::

The acute period

Deep Colliquative necrosis:

•no demarcation zone

•marked tumefaction & edema, mucosal folds disappear

• white grey, sometimes greenish color.

The belated period

•forming multiple ulcers sometimes perforated

•mediastinitis

•peritonitis

•pneumonia

•dystrophic changes in the internal organs

57. Intoxications with Mercury compounds. Morphological changes.

MERCURY AND ITS DERIVATIVES

Metallic mercury (amalgams)

• Inorganic compounds:

- corrosive sublimate (HgCl2)

- calomel (Hg2Cl2)

- mercuric cyanide (Hg(CN)2)

- oxycyanide (Hg(CN)2∙HgO)

• organomercury compounds (pesticides, seed processing) containing

monoethylmercury chloride (C2H5HgCl)

Properties

• cumulative (affinity to the kidney, liver, gall bladder)

• it is slowly eliminated by kidneys and all secretory glands, including

salivary

Mechanism of action

• combine with the SH groups of proteins,

including enzymes and

→ inhibit the biological activity of the tissues

→ dissociate oxidative phosphorylation

→ disrupt intracellular metabolism

→ CNS disorders.

• precipitate the mucosal proteins (affinity

digestive tract)

Morphological changes

Acute period

• mucous membranes of the mouth, lips, throat, swell and is covered by

grey deposits (entry)

• kidneys increase in size and are congestive

Morphological changes

Late period (elimination)

•Mercury stomatitis (metallic (grey) deposits,gingival and buccal

swelling, ulcers, bleeding)

•Ulcerative colitis (large intestine mucosa is swollen, hyperemia with

deep necrosis, background gray deposits)

•Mercury nephritis (kidneys increase in size,

become pale, yellowish white, with thickening of

the cortical layer and multiple bleeding

suffusions

58. Intoxications with Arsenic compounds. Morphological changes.

ARSENIC AND ITS COMPOUNDS

Metallic arsenic

• Arsenic trioxide As2O3 (use: industry, rat

poison, in medicine)

• Paris green (use: pesticide, rodenticide

and

insecticide)

Way of penetration

• inhalation

• ingestion

Mechanism of action

•combine with SH groups of cellular enzymes

• inactivation of thiol enzymes lead to severe metabolic disorders

• destructive action on internal organs

•capilarotoxic !!! (Paresis and paralysis of the capillaries of all organs)

Clinical forms

Paralytic

•high doses !!

• In the first hours: general weakness, fear, deafness, seizures,

coordination disorders, paralysis

• Later: loss of consciousness, collapse, coma and death by stopping

Breathing

Gastrointestinal

• metallic taste in the mouth

• pains, burning sensations in the esophagus , stomach

• vomiting, abdominal pain

•choleric diarrhea), accompanied by pain, tenesmus , thirst,

• hepatomegaly, hemoglobinuria, oliguria or anuria

Morphological signs

Soon death

• catarrhal inflammation of the

mucosa of the digestive

tract

•small hemorrhages in the mucosa and serosa

•GAS, cerebral and pulmonary edema

• signs of dehydration

(GI form): paleness, dehydration

(intestines contained liquid (rice water)

Late death

•dystrophic manifestations in the internal organs

• gastritis and hemorrhagic colitis

•hemolysis

59. Hemolytic toxics. Postmortem signs of hemolysis.

Acetic acid (CH3 COOH)

Carbon tetrachloride (CCl4

Aniline (C6 H 5 NH 2 ) and its derivatives

Copper sulphate (CuSO 4

ArsenicHydrate (arsine )(AsH 3)

Venom of insects, snakes

Some toxic plant (fungi, plants), etc.

Mechanism of action:

By various mechanisms they destroy stroma of erythrocytes and

release hemoglobin in plasma.These substances have not only
haemolytic action.

Hemolysis signs:

recent:

 The blood is hemolyzed , dense, dark

 Early imbibition of the intima of the arteries, the aorta Spleno
hepatomegaly
 Acute pigmentary nefro necrosis

Tardive (after a period of survival):

 The yellow color of teguments, mucous a andsclera (jaundice)

 Splenohepatomegaly with dystrophic component (yellow color)
 Pigmentary nephrozo nephritis
 Hemosiderosis of the liver and spleen

60. Carbon monoxide intoxication, mechanism of action,

morphological changes and death scene investigation.

Properties:

• is produced from incomplete combustion ofcarbon containing

substances

-arsons

-fireplaces

-exhaust gases
• colorless, odorless, and tasteless gas

• soluble in water

• CO and air mixture is explosive → CO2

• penetrates by inhalation, but in the corpse byDiffusion

Mechanism of action:

CO +Hb = HbCO , fixation of Fe2

•Hb has 200 300 times higher affinity for CO

than O2

•HbCO dissociates 3500 times heavier H b O

CO has action on other biochemical systems,containing Fe:

• Myoglobin,

• cytochromes, cytochrome oxidase

• catalases, peroxidases, etc.

Doses and effects

1.5 to 3.1% the physiological norm

to 8.8%inhabitants of large cities

up to 18-22% smoking

20%headache, dyspnea

30%pronounced headache, nausea, disturbance of vision

50%confusion, collapse, syncope

60%convulsions, breathing disorders

70%coma, cardiovascular failure,possible death

80% and more lethal dose

Morphology

• The skin and mucos a are pink color likealive

• cadaverous lividity are bright red

•Blood is fluid, bright red

• Muscles are red or bright red

• General asphyxia signs

•detection of COHB (more than 70 80%, on

IHD, alcohol, old) from 40

61. Cyanides intoxication. Mechanism of death, autopsy findings.

Hydrocyanic (prussic) acid (HCN)

Sodium Cyanide (NaCN

Potassium Cyanide (KCN)

Glycosides with cyanide component (egamygdalin C 20 H 27 NO 11 ,

which is contained inbitter almonds (2.5 3.5%), persimmons (2
3%),apricots and plums (1 1.8%), cherries 0.8%).

Amigdaline by acids (including gastric) or by

emulsine (from almonds) is hydrolysed to

Dglucose , benzaldehyde and hydrogen cyanide.

Mechanism of action:

The cyanide group CN inhibits tissue enzymes,

especially mitochondrial, containing Fe, responsible

for the respiratory chain → tissue hypoxia

Morphology:

Oxygen is not used by the tissues and all blood is

enriched with O2 →

cherryred blood color (arterial and venous)

red pink skin

red pink livor mortis

smell of bitter almonds

Asphyxial stigmata (GAS)

62. Alcohol intoxications. Clinic evolution, autopsy findings.

Ethyl alcohol (C2 H 5 OH)

surrogates:

Insignificant risk(alcohol based tinctures, alcohol based water

solutions, colognes, lotions, etc.)

Medium risk-technical liquids based on alcohol

High risk(imminent danger) (methanol, ethylene glycol, dichloroethane)

Mechanisms of action:

CNS depression

Narcotic action (dichloroethane

Neurovascular (methylic alcohol)

Due to their toxic metabolites Other action dependent impurities

Alcohol dosage:
<0.3 ‰no influence of alcohol (physiological)

0.3-0.5 ‰ insignificant influence of alcohol

0.5-1.5 ‰ easy inebriety (drunk)

1.5-2.5 ‰ medium inebriety (drunk)

2.5-3 ‰ severe inebriety (drunkenness)

> 3 ‰severe alcohol intoxication

5-6 ‰ fatal intoxication

> 15 ‰sample contamination

Lethal dosage:

Methyl alcohol

It may vary, but the lethal minimum is 30ml

ethyleneglycol

100-200ml

dichloroethane

20-60ml

Morphological Signs:

There are no specific or characteristic morphological signs , but can

be:

•Edema of the face

•Specific alcohol odor from the mouth

•Congestion and cerebral edema

•Hemorrhages in stomach mucosa

•Hemorrhages in the pancreas

•General asphyxial signs (rapid death), etc.

63. Intoxication with drugs. Clinic evolution, autopsy findings.

Pg 193 payne simpsons book

64. Intoxication with poisonous mushrooms. Morphological and

toxicological diagnosis.

Amanita pantherina, Amanita muscaria

Toxicity: Muscarin , Muscaridine , Ibotenic Acid,

Muscimol , Bufotenin

Amanita phalloides Amanita verna Amanita virosa

Toxicity:Amanitin s : Amanitotoxin, Amanitin

Phaloidine s : phalloidin, phaloine

•Muscarine- neurotoxic (acetylcholinesterase inhibition)

•muscaridine -neurotoxic ( colinomimetic

•ibotenic acid- neurotoxic (psychoactive, hallucinogenic)

neurotoxic ( colinomimetic

•muscimol - like ibotenic acid ( it is a premuscimol)

•bufotenin Hallucinogen

•amanitin- haemolytic, hepato nephrotoxic (necrosis)

•phalloidin- blocks actin depolymerisation, inhibits ATP activity of actin

Gyromitra Helvetia ) esculenta Toxicity:

Giromitrin dissociates into monomethylhydrazine

(Helvelic, fumaric

(hemolytic) acids

Morchella esculenta- edible

65. Signs of sexual intercourse at males and females.

Signs of sexual intercourse

Signs of vaginal penetration at females are:

Early

• acute lacerations of the hymen (if virgin)

• bleeding

• sensibility

• the presence of the semen in the vagina (incontestable)

• the presence of the partner’s hairs in the vagina

Belated

• STDs

• pregnancy

Signs of vaginal penetration at partners (males) are:

Early

• partner’s hairs, blood and vaginal content (cells) on the neck of the
penis

• abrasions on glans penis (if brutal coitus)

• acute laceration of the frenulum (if brutal coitus)

Belated

• STDs

• scars (if there were lacerations)

Signs of acute (singular) anal penetration:

• sperm and hairs in anus

• acute anal fissure and laceration

• STDs

Signs of chronic anal penetration:

• anal dilatation (opening of the external and internal anal sphincters

with minimal traction on the buttocks)

• cuneiform deformation of the anus

• flattened anal folds

• chronic inflammation of anal mucosa with venous congestion

66. Medico-legal examination of pregnancy, postbirth and

postabortion states.

Diagnosis of pregnancy, recent birth, abortion, STDs is done together

with respective medical specialists

67. Rape, forensic questions.

Rape is a sexual intercourse committed through physical or
psychological coercion or taking advantage of a person's inability to
defend itself or to express their will.

Violent actions of sexual nature (art.172) such as homosexual or other

perverse forms of satisfying the sexual desire, committed through
physical or mental coercion or by taking advantage of a person's
inability to defend itself or to express their will.

Sexual harassment (art.173) is a physical, verbal or nonverbal behavior,

which violates human dignity or creates an unpleasant, hostile,
degrading, humiliating or offensive environment in order to induce a
person to sexual intercourse or other sexual actions.

The methodological principles of forensic obstetric-gynecologic

examination

The medico-legal examination of sexual states and crimes is done

based on an order or request from law authorities in cases of
disputable sexual states: determination of the sex, sexual maturity,
virginity, reproductive capacity, diagnose of pregnancy, recent birth,
abortion, contamination with STDs and in cases of sexual crimes: rape,
homosexual actions, sexual intercourse with a minor, child abuse, etc.

The effectiveness of the results of this examination is in relation to

time duration from the event till examination. Thus, the victim of
sexual crimes, as a way of exception, may be examined at its own
request, but it is mandatory to notify the law enforcement bodies, as
well.

The forensic obstetric-gynecologic examination is performed by the

medico-legal expert or together with a specialist in obstetrics and
gynecology. The victim is examined in specially arranged rooms of
forensic institution or polyclinics.
To avoid possible infection (sexually transmitted disease) forensic
experts recommend a dermatovenerological examination. These results
should be communicated in writing to the forensic doctor and the
expert uses the data in conclusions.

The garments that were on the victim at the time of the crime, on
which there may be traces of semen and blood, are subject of
compulsory forensic examination. The representatives of criminal
investigation (police, prosecutors) take them and send to laboratory
examination.

At the examination, in cases when the clothes had not been previously
taken, we have to inform the victim not to wash the clothes and the law
enforcement bodies to take them.

The obstetric-gynecologic case history must include special

(gynecological) anamnesis: from what age the menstruation started, its
character, duration, menstrual cycle length, the date of last menstrual
period; sex life, including the last sexual intercourse; the number of
pregnancies, abortions, childbirths, the postpartum illness; discharge;
surgeries, diseases (e.g. meningitis, encephalitis, syphilis, tuberculosis,
etc.).

132

12 Sexual assault

or video recordings (e.g. DVD) may be used. Most

jurisdictions will have guidelines for the safe custody

and viewing of such sensitive images.

■ Medical findings after sexual contact

Interpretation of findings, unlike the assessment and documentation of

findings, should only be undertaken by a doctor experienced in such
assessments and fully aware of current research concerning physical
findings after sexual assault. It is incorrectly assumed by many that
sexual assaults will result in injury to the victim whether adult or child.
This is incorrect and in the majority of cases medical abnormalities (in
both adults and children) will be absent. Conversely, consensual sexual
activity can result in injury to the body and genitalia.

The presence or absence of injuries in association with allegations of

sexual assault do not by themselves indicate whether the particular
activity was consensual or non-consensual, and it is essential that these
facts are understood when reporting and interpreting findings.

Many factors may affect the severity of injury in the female. Similar
injuries may be seen in both consensual and non-consensual sexual
contact.

Some of the factors that may influence the possibility of genital injury
are age of the complainant, type of sexual activity, relative positions of
the participants and degree of intoxication of either or both of the
participants. Consensual insertion or attempts at insertion of a finger
or fingers, penis or any other object into the vagina may result in
bruises, abrasions and lacerations of the labia majora, labia minora,
hymen and posterior fourchette. Consensual digital vaginal penetration
may result in accidental fingernail damage or injury to parts of the
female genital tract that may not be noticed at the time.

Non-genital injury of even a minor nature can often be very significant

evidentially and corroborate accounts of assault. Marks of blunt
contact (e.g.punches, kicks), restraint (e.g. ties around wrists or

Table 12.1 Type of sample taken and what may identifi ed by

analysis

Sample type What may be identifi ed by analysis

Blood Presence and amount of alcohol and drugs; identify DNA

Urine Presence and amount of alcohol and drugs

Hair (head), cut and combed Identify biological fl uids (wet and dry);
foreign material (e.g. vegetation, glass, paint, fi bres);

comparison with other hairs found on body; past history of drug use

Hair (pubic), cut and combed Identify biological fl uids (wet and dry);
foreign material (e.g. vegetation, glass, fi bres);

comparison with other hairs found on body; past history of drug use
(prescribed; licit and illicit)

Buccal scrape DNA profi ling

Skin swabs (at sites of contact) Identify biological fl uids (e.g. semen,
saliva – wet and dry); cellular material; lubricant

(e.g. KY, Vaseline)

Mouth swabs Identify semen

Mouth rinse Identify semen

Vulval swab Identify biological fl uids (e.g. semen, saliva); foreign

material (e.g. hairs, vegetation, fi bres)

Low vaginal swab Identify body fl uids (e.g. semen, saliva); foreign
material (e.g. hairs, vegetation, fi bres); identify

biological fl uids (e.g. semen, saliva); foreign material (e.g. hairs,

vegetation, fi bres)

High vaginal swab Body fl uids (e.g. semen, saliva); foreign material (e.g.
hairs, vegetation, glass, fi bres); identify
biological fl uids (e.g. semen, saliva); foreign material (e.g. hairs,
vegetation, fi bres)

Endocervical swab Identify biological fl uids (e.g. semen)

Penile swabs (shaft, glans, coronal sulcus) Identify biological fl uids

(e.g. semen)

Perianal swabs Identify biological fl uids (e.g. semen)

Anal swabs Identify biological fl uids (e.g. semen)

Rectal swabs Identify biological fl uids (e.g. semen)

Fingernail swabs, cuttings or scraping Identify foreign material (e.g.

skin cells), matching of broken nails

68. Reasons for forensic examination of alive persons.

Reasons of the person’s examination

All crimes against health, security, dignity and human life usually
require a forensic examination or expertise.

The reasons for forensic assistance of people can be:

 establishment of the presence the injury, its character, and

mechanism of causing, the degree of injury severity

 torture, inhuman or degrading treatment

 determination of general and professional incapacity to work,

generated by trauma

 health status assessment: simulation, dissimulation, aggravation,

artificial disease or lesion, self-mutilation
 examination of disputable sexual states: determination of the sex,
sexual maturity, virginity, reproductive capacity, diagnose of
pregnancy, recent birth, abortion, contamination with STDs, etc.

 expertise of sexual crimes: signs of sexual intercourse in the case of

rape, constrained homosexual actions, sexual intercourse with a minor,
child abuse, etc.

 alcohol or drugs consumption

 age determination

 person identification

 parentage expertise

69. Degree of injury severity, its assessment criteria.

Beginnings of the degree of injury severity assessment

In the Republic of Moldova the assessment of injury severity is done in

accordance with the Penal Code, Penal Procedure Code, Civil Code,

Regulation of assessment of the degree of injury severity, and other

normative acts.

There are the following degrees of injury severity:

- serious injury;

- medium injury;

- slight injury;

- insignificant injury.

The severity of injury is assessed based on four qualification criteria:

 1. the danger to life

2. the consequences not dangerous to life

3. the volume of permanent incapacity to work

4. the term of health disorder

criterion degree of injury severity

serious medium slight insignificant

danger to life + – – –

not dangerous + – – –
for life
consequences

volume of > 33% 33%-10% < 10% –

permanent
incapacity to
work

term of health – > 21 days 6 – 21 days < 6 days

disorder

(+ applicable, – inapplicable)

To determine the severity of injury it is sufficient only a criterion. If

there are several criteria, the most serious one is used, except for the
criterion of incapacity to work, when it is determined by summing the
percentages.

The volume of permanent incapacity to work is assessed in conformity

with the existing regulations, and it is a must to use this criterion only
after the treatment has finished. The term of health disorder is the
time necessary to restore the health, which is estimated in days.

70. Dangerous to life injuries.

Dangerous to life are the following injuries:

a. Open fractures of the skull, including without brain or meninges

damage.

b. Closed fractures of the skull, except facial section and isolated

cracks of external lamina of the skull roof.

c. Serious and medium cerebral contusion with objective signs of bulbar

damage.

All forms of clinical diagnosis "concussion, cerebral contusion" are

appreciated based on special instruction, approved by the Ministry of
Health.

d. Intracranial hemorrhages: extra- or subdural hematoma,

subarachnoid or intracerebral hemorrhages - when they are associated
with dangerous to life phenomena, certified by neurological and
neurosurgical data.

e. Penetrating injuries of the spine, including without spinal cord injury.

f. Fracture-luxations of cervical vertebrae, their body or both arches

fractures, unilateral arch fracture of the 1st and the 2nd cervical
vertebrae and fracture of odontoid apophysis of the 2nd cervical
vertebra, including without spinal cord disorder.

g. Dislocation and subluxation of cervical vertebrae, associated with

dangerous to life phenomena, certified by neurological data.

h. Closed injuries of the cervical spinal cord, associated with spinal

shock and other dangerous to life phenomena.
i. Fractures and fracture-luxation of one or several thoracic and
lumbar vertebrae, closed spinal cord injuries associated with spinal
shock or disturbance of pelvic organs functions, confirmed clinically.

j. Penetrating wounds of the pharynx, larynx, trachea, esophagus.

k. Closed fractures of the laryngeal or trachea cartilages with damage

of mucosa, when they cause a severe shock or other dangerous to life
phenomena.

l. Closed fracture of hyoid bone, thyroid and parathyroid glands lesions,

accompanied by breath disturbance, brain hypoxia or other dangerous
to life phenomena.

m. Chest injuries which have penetrated the pleural cavity,

pericardium, with or without damage to internal organs.

Localized subcutaneous emphysema without pneumothorax cannot be

considered a sure sign of penetrating chest lesion.

n. Penetrating abdominal wounds, with or without damage to internal

organs; open wounds of retroperitoneal space organs (kidneys, adrenals,
pancreas, etc.); penetrating injuries of the bladder, vagina, high and
medium part of rectum.

o. Closed injuries of the largest vessels, diaphragm, organs of the

chest, abdomen, pelvis, retroperitoneal space, including subcapsular
ruptures, confirmed by dangerous to life phenomena.

p. Open fractures of long tubular bones (humerus, femur and tibia),

open lesions of knee and hip joints, closed fractures of the femoral
bone diaphysis.

Closed fractures of the femur head, neck, trochanter, condyles and

epicondyle (without involving the medullary cavity). The closed marginal
fractures are assessed based on the term of health disorder or the
volume of permanent incapacity to work.

q. Open fractures of the radius, ulna and fibula, closed fractures of

large joints (shoulder, elbow, wrist, and ankle) are estimated based on
the term of health disorder or the volume of permanent incapacity to
work.

r. Pelvic fractures associated with severe shock or rupture of the

membranous part of urethra.

s. Injuries that are accompanied by a serious shock (gr.III-IV), an

abundant internal or external bleeding resulting in a collapse, a fat or
gas embolism confirmed clinically, a traumatic toxicosis with the
phenomena of acute renal failure, and other dangerous to life
conditions.

t. Injuries of large blood vessels: aorta, carotid arteries, subclavian,

axillary, brachial, cubital, iliac, femoral, popliteal, and their
accompanying veins.

The severity of other peripheral blood vessels injuries is assessed

based on the presence of dangerous to life phenomena.

u. Thermal burns of the 3rd and 4th degree with damage of more than
15% of the body surface; third degree burns with over 20% of the
body, second-degree burns which cover more than 30% of the body,
and burns on a smaller area, but associated with severe shock, airway
burns, edema, and stricture.

v. Barotrauma, electrocution, hypothermia, hyperthermical states

(heatstroke, hyperthermical shock) and chemical burns (due to
concentrated acids, alkalis, and other various substances), which have
generated dangerous to life phenomena, beside local changes.
w. Compression of neck organs and other types of mechanical asphyxia,
associated with a complex dangerous to life phenomena (disturbance of
the cerebral blood circulation, loss of consciousness, amnesia, and
others), confirmed by objective data.

x. Dangerous to life phenomena due to traumatic action on shockogenic

regions – sinocarotidian zone, celiac plexus, male genitals etc.

71. Serious non-dangerous injuries.

Serious injury qualified based on consequences not dangerous to life:

1. Anatomical loss of an organ or of its function:

a. The loss of sight is a complete blindness of either eyes or a stable

vision decrease when a person cannot count your fingers at a distance
of two meters and less (visual acuity 0.04 diopters and less).

The loss of sight of one eye results in permanent incapacity to work

more than one third, and it is also part of serious injuries.

The degree of severity of a blind eye injury requiring its enucleation is

estimated based on the duration of health disorder.

b. The loss of hearing is a complete deafness or irreversible state

when the victim cannot perceive the usual speech at a distance of 3-5
cm from the auricle.

The hearing loss in one ear results in permanent incapacity to work less
than 1/3 (one third) and it belongs to the medium injuries.

c. The loss of speech is a loss of ability to express thoughts through

clearly received and articulated sounds. This state may be determined
by the loss of tongue, anatomo-functional disorders of the vocal cord
or it may have a nerve origin (the respective centers of the central
nervous system).
d. The loss of an arm or a leg is a state when they are detached from
the trunk or when they lose of their functions (ex.: paralysis).

The anatomical loss of an arm is an amputation of this member from

the wrist or upper it and anatomical loss of leg – from ankle and upper
it. Other cases are considered as a loss of a part of the member and
are assessed based on the volume of permanent incapacity to work.

e. The loss of reproduction capacity is the loss of cohabitation,

fertilization, conception and birth ability on females and the loss of
cohabitation and fertilization on males.

2. Termination of pregnancy.

Abortion is a criterion of serious injury, if it is not a consequence of

individual peculiarities of the body (infantile uterus, plasmosis, pelvic
abnormalities, etc.) and if it has a causal relationship with the trauma.

The medico-legal expertise of such cases is done in commission with an

obstetrician-gynecologist.

3. Irreparable disfigurement of the face.

The irreparable disfigurement of the face includes adjacent regions

(pinna, the front and anterolateral regions of the neck).

The forensic doctor does not qualify injuries of the face and adjacent
regions as disfigurement, because this is a non-medical concept and it
is not within the competence of medicine. The expert simply assesses
the degree of injury severity in accordance with this Regulation, noting
only whether it is or is not repairable.

The injury is repairable if the morphological changes (scar, distortion,

mimic disturbance) can be considerable reduced by conservative
treatment (non-surgical). If, however, to remove the lesion or its
consequences a cosmetic surgery is needed, the injury is considered
irreparable.

4. Postaggression mental infirmity

The mental infirmity (postaggression mental illness) is determined by a

commission of psychiatrists together with the medico-legal expert, in
accordance with respective Regulation, taking into account the causal
relationship between trauma and mental illness.

5. Considerable permanent loss of general working capacity

If the corporal injury or posttraumatic health condition has generated

a stable and considerable incapacity to work, but not less than 33%, it
is qualified as serious injury.

The complete loss of professional work ability is established in

accordance with Regulation in force, and only when it is necessary,
being ordered by prosecution body or through a court decision.

The incapacity to work of invalids, caused by injury, is considered the

same way as for practically healthy persons, regardless of invalidity
and its group.

The children’s working incapacity is assessed similarly as for the

adults, according to this Regulation.

72. Medium, slight and insignificant injuries.

Medium injury

a. Qualification criteria of medium injury are:

 lack of danger to life

 lack of any consequences provided in this Regulation for serious

injury
 long-term health disorder

 significant permanent incapacity to work

b. The forensic doctor evaluates the term of health disorder based on

objective medical data, including those embodied during expertise.

c. The long-term health disorder is a consequence directly caused by

the injury (diseases, functions disorders, etc.), which has a duration of
more than three (3) weeks (more than 21 days).

d. The significant permanent incapacity to work is a general working

inability of more than 10%, but till 33% (one third) inclusively.

Slight injury

a. Qualification criteria of slight injury are:

 Short-term health disorder

 Insignificant permanent incapacity to work

b. The short-term health disorder is caused directly by the injury and

lasts more than 6 days but not more than 21 days (three weeks).

c. The insignificant permanent incapacity to work is a general working

inability of less than 10% inclusively.

Insignificant injury

Insignificant injury includes injuries that do not generate a health

disorder for more than six (6) days or a permanent incapacity to work.

73. Medico-legal examination of new born corpses. Specific

questions which must be solved.

The main reason of medico-legal examination of new-borns is

investigating such cadavers, when the mother is not known. Sometimes
new born cadavers are examined because his mother affirms that he
died quickly after birth or is stillborn. The issue of medico-legal
expertise of newborn body has the following objectives:

1. Making medico-legal investigation and expertise in cases of

neonaticide through examination of a newborn cadaver;

2. Establishing causes of sudden intrauterine, intranatal and neo natal

death;

3. Obstetrical incidents and accidents research;

4. Examination of violent death as a consequence of perinatal incidents

and accidents.

Key issues solved within expertise of newborn cadavers

During medico-legal examination of a newborn cadaver, several specific

issues are solved, which differ from those resolved during adult
cadavers expertise. These specific questions result from both the
ncessity to ascertain causes and circumstances of newborn death and
the legal assessment of persons responsible for their death. For these
reasons, the medico-legal expertise of the newborn cadaver should
identify the following:

1. Positive diagnosis of newborn

2. Assessment of fetal maturity

3. Calculation of fetal (gestational) age

4. Assessment of extrauterine life

5. Assessment of fetal viability

6. Assessment of extrauterine lifetime

7. Rating of child care after birth

8. Death cause identification

74. Positive diagnosis of new born and assessment of extra uterine
life.

Positive diagnosis of new born is confirmed by the presence of:

• the umbilical cord, which is fresh, without a ring of reddening;

• the placenta, which is not separated, weighs about 500 grams;

• the caput succedaneum (oedema and bleeding in the soft tissues

of the scalp), or analogous bleeding and oedema on breech

(buttocks) in case of breech presentation;

dark-green coloured meconium, situated in the large intestine and

Perianal region;

• the vernix caseosa (waxy white substance), coating the skin of

newborn, predominant in natural folds;

• maternal blood on fetal body, without any injuries.

Assessment of extrauterine life. A child can be born both alive and

dead. Death of a viable fetus could occur before, during or after birth.
A stillbirth is considered when fetus death occurs in the uterus.

Extrauterine breathing after birth causes very obvious macro-

scopic lung changes, which can be observed at a fresh cadaver after a

short period of survival. Unrespired lung is small, not expanded, it
occupies 1/3 of the thoracic cavity and is situated into costovertebral
sinuses. It has a smooth, dark-red or reddish-brown colored surface.
The texture of an unrespired lung is rubbery, uniform, liver-like, with
no crepitate areas. On slicing it has the same rubbery and uniform
aspect, on squeezing a small quantity of reddish liquid without bubbles
drips. A respired lung is expanded, fills almost entirely the pleural
cavity, the medial edges overlapping the mediastinum and a part of the
pericardium. It is white-rose colored, with mottled, doughy irregular
surface.

The lung is spongy, elastic, crepitates on palpation. On slicing

spontaneously a reddish sparkling liquid with air bubbles drips.

Magnified macroscopic examination of a respired lung discovers air

bubbles situated under the visceral pleura, having silver sectors aspect
(Haberda’s test).

In medico-legal practice the test, known as „docimasy” or „hydrostasy”

is used to differentiate stillborn lungs from those of infants who
breathed.

75. Flotation tests: scope, method and results.

Hydrostatic pulmonary docimasy (Galen’s test). The esophagus and

trachea are separated and a ligature is applied. After extraction of
the oral-cervical-thoracic complex, it is placed in a vessel filled with
water. Then the separated lungs are placed one by one in the water.

After this, small fragments of the parenchyma from different areas of

the lungs are immersed into the water. The test is considered positive
when the lung fragments or lungs float on the surface. An unrespired
lung could give a false positive result (floating) in case of frozen
cadavers, massive vernix caseosa aspiration (floating because of fat
content), after artificial respiration and, of course, in cases of
putrefaction due to gas accumulation. Putrefaction gas bubbles on the
surface of the lungs are of different sizes and irregular distribution.
Lung fragments squeezed into water evacuate putrefaction gases, but
do not eliminate residual air, so this test can serve for differential
diagnosis between positive and false-positive tests. In resuscitation
maneuvers artificial respiration produces unequal distension and/or
partial aeration, so flotation test is uncertain, a part of small
fragments float, other sink.

The respired lungs may give negative result (false negative test) in
cases of pneumonia, aspiration of amniotic fluid, partial atelectasis in
immature and premature newborns, by inefficient respiration and in
secondary atelectasis due to air resorption.

Hydrostatic gastrointestinal docimasy (Breslau’s test) highlights air

penetration into the digestive tract after birth due to respiration and
swallowing. Several ligatures are applied on the entrance to the
stomach and pylorus, loops of the small and large intestines and rectum
before

Fig. 5. Pleural cavities filled by

expanded lungs.

Fig. Macroscopic aspect of a

respired lung with Tardieu spots 6.

.the extraction of oral-cervical-thoracic-abdominal complex. The

sample is considered positive if the piece floats. In cases of stillborn
hydrostatic test may be false-positive due to gaseous putrefaction and
artificial respiration.

76. Violent causes of newborns death. Neonaticide: notion, classification.

violent – active infanticide (commissive) and passive(omissive).

Results of scientific research show that in 70% of cases infanticide is active, the
most frequent cause of death is mechanical asphyxia(suffocation, strangulation by
hands, blockage of airway by foreign bodies, drowning) and blunt trauma. Passive
infanticide is produced by abandonment and lack of care. Newborn cadavers are
often left in city dumps, thrown or buried in green areas, found in the street, in
toilets,basements, manholes and constructions.

77. Laboratory tests in medico-legal examination of cadavers.

consultation in discovering, collection, packing, and sending the biological samples (blood, hair, sperm,
etc.) to laboratory for further examination

Biochemical markers gradually change their concentration and potential after death, which is useful
while estimating the time of death. The biochemical methods require laboratory investigation of blood
markers (electrolytes such as sodium, potassium, calcium, magnesium, phosphorus, chloride; glucose;
lactic acid; urea; etc.), vitreous markers (electrolytes such as sodium, calcium, magnesium, chloride;
urea; pH), cerebrospinal fluid markers (electrolytes such as potassium, magnesium, sodium, calcium,
phosphorus, chloride), pericardial fluid markers (electrolytes, cholesterol, glucose, lactic acid, enzymes,
etc.), muscle markers (creatinine, enzymes), lung markers (surfactant, phospholipids), etc.

The list of organs (part, pieces of them) sent to laboratory investigations(toxicological,histopathological,

biological,bacteriological, radiological etc.)

78. Blood stains examination. Specific questions.

79. Types of blood stains and their mechanisms.

http://www.forensicsciencesimplified.org/blood/principles.html

80. Positive diagnosis of sperm stains.

Semen is detected by forensic scientists using the acid phosphatase (AP) test, as acid
phosphatase occurs in high levels in human semen. When testing clothing or other larger items
this involves a press test of filter paper onto a dampened item suspected to bear semen
staining. The filter paper is then removed and sprayed with the AP reagent. If a purple colour
develops, the presence of semen is indicated. This is confirmed by locating the stained area on
the garment and extracting some of the stain before making up a microscope slide containing
some of the extract. If spermatozoa are seen, the presence of semen is confirmed. If swabs are
to be tested they can also be pressed onto a piece of filter paper before AP is applied or,
alternatively, the swab can be extracted,the cellular fraction spun down and a fraction of the
liquid supernatant tested instead to conserve cellular material. In a similar manner, a
microscope slide is made to search for spermatozoa.It is important to note how much semen is
found on different swabs from different areas of the body as this can have a bearing as to how
recently semen was deposited. If a male has been vasectomized successfully, no sperm cells
should be present within an ejaculate.In these cases, a second chemical test can be used to
confirm the presence of semen. This is for prostate specific antigen (PSA) and uses an antibody
based technique to demonstrate the presence of PSA. The Florence Iodine test can also be
used, where a small amount of the reagant is introduced to a slide carrying some of the
extracted stain. If characteristic brown crystals form then the presence of semen is confirmed.
81. Medical law: definition, subjects of medical law relationship and
principles.
The medical law is a branch of law which regulates prerogatives, responsibilities and juridical
relations (professional, patrimonial non-patrimonial etc.) between patients and medical
professionals, or health care institutions.

SUBJECTS OF MEDICAL LAW:

medical professionals (doctors, assistants,nurses etc.)

patients

health care institutions

Ministry of Health

companies of healthcare insurance

educational and medical research institutions

doctors League

MEDICAL LAW RELATIONSHIPS

Interpersonal, social or another relationship becomes law relationship if breach of legal norms.

82. Medical law and its principles.

principle of legality - medical act must take place only within the legal regulations and scientific
progress

• principle of guaranteeing the right to health care - human priority prevail over the sole
interest of society or science

• principle of self-determination (autonomy). A health intervention can not be made until the
subject (ex.:patient)has given his free and informed consent

principle of guaranteeing the right to a second medical opinion in same medical question

• principle of inviolability of the human body-protectionand guarantee for everyone the

human dignity and identity, without discrimination

83. The main concepts in medical law: patient, his legal representative,
medical act,informed consent.
patient (consumer of health services) the person who needs, requests or uses health services,
regardless of his health, or who participate voluntarily in biomedical research.
patient's legal representative :a person represent , under the law, with no power of attorney,
the interests of a patient without full functioning capacity or who has been declared incapable
or with limited functioning capacity.

medical intervention (medical act)any examination, treatment, clinical research and patient
assistance or other action applied to the patient with a prophylactic, diagnostic, curative,
rehabilitation or biomedical research purpose and performed by a physician or other healthcare
worker.

consent agreement of the patient or his legal representative to perform a medical intervention,
expressed voluntarily, based on multilateral and comprehensive information received from the
doctor.

84. Relationship between doctor and patient. The paternalistic and

antipaternalistic modes of medical care.
From ancient times, physicians have recognized that the health and well-being of patients
depend upon a collaborative effort between physician and patient.Patients share with
physicians the responsibility for their own health care.

Paternalism is a behavior of a doctor which limits patient’s liberty or autonomy for his/her
decision

in medical act.The word paternalism is from the Latin pater for father.

Anti-paternalism is the view that we should not limit patient’s liberty or autonomy.

85. Patients’ informed consent: kinds, content, method of getting and

documentation.
Consent and manner of modifying of the treaty or refusal of medical intervention

(1) A required condition prior to the medical intervention is the patient's consent, with
exceptions

provided by law.

(2)The patient’s consent to medical intervention may be verbal or written, and shall be
performed by its registration in his/her medical documentation, with mandatory signature by
the patient or his/her legal representative (close relative) and the doctor.

For high-risk medical intervention (invasive or surgical nature),the consent is mandatory, in

written form, by completing a special form of medical documentation, called informed
consent.The list of medical interventions that require a written consent and the model of this
form is developed by the Ministry of Health.
the informed consent must contain the information presented in an accessible form for the
patient, about the:

• purpose,

• effect,

• methods of medical interventions,

• their potential risks,

• possible social, psychological, financial consequences,

• and also options of alternative treatment and medical care.

86. Patients’ refusal: method of getting and documentation.

The patient or his/her legal representative (close relative) has the right to opt out the medical
intervention at any stage, except cases of limiting patient’s rights, with bearing the
responsibility for such a decision.

In case of refusal of the medical intervention,expressed by the patient or his/her legal

representative(close relative), there will be explained the possible consequences in an
accessible form. The patient’s refusal shall be documented, indicating the possible
consequences, and shall be signed by the patient or his/her legal representative (close relative)
and by the treating physician.

In case of intentional evasion of the patient to put signature in order to certifying that he/she
was informed about the potential risks and possible consequences of refusal of the proposed
medical intervention, the document must be signed by the director, head of department and
the treating physician.

In case of refusal of medical care by the patient's legal representative (close relative), when
such assistance is necessary to save patient's life, guardianship (tutorial) bodies have the right
to request health care organizations to address the court for protection of the sick person.

87. Patients’ rights and their legal limitation.

respecting the fundamental human rights and

human dignity within health care system;

• recognition of human life and health as a supreme value;

• orientation toward maintaining the life, physical and mental health of the patient while
providing

health care services;

• respecting the moral and cultural values of patient's, and also his/her religious and
philosophical beliefs;

• recognition of the patient, and in cases provided by law, recognition of his/her legal
representative(close relatives), as the main participant in the decision on medical intervention;

• regulating the rights, responsibilities and conditions of patients' rights with the purpose of
protecting his/her health, and to respect the rights of others;

• mutual trust between patient and medical worker.

Check presentation relationship page 7-12

88.Guaranteeing patient’s right to confidentiality and its disclosure

requirements
All data regarding the identity and condition of the patient, results of investigations,diagnosis,
prognosis, treatment and personal data are confidential and will be protected even after
his/her death.

The confidential information may be disclosed only if the patient explicitly agrees, or at the
request of his/her legal representative or close relatives, depending the conditions imposed by
the patient, in the appropriate measure of ability to understand, in situations when the patient
exercise capacity is weakened or missing, or if the law is urgently requesting it8. Patients’ right
to confidentiality and its disclosure requirements.

Disclosure of confidential information without patient’s or his/her legal representative’s

consent is allowed in the following situations:

•a) to engage other specialists in the treatment process, including examination and treatment
in case of emergency when the patient is unable to express his/her wish because of his/her
health condition, but only to the required extend in order to take appropriate decisions;

•b) to inform the authorities and institutions of state sanitary- epidemiological service in the
event of a real danger of spreading of infectious diseases, poisonings and mass contamination;

•c) at the appropriate request of the prosecuting authority, court, in connection with a criminal
investigation or trial, in accordance with law

c1) at the request of the ombudsman and members of the advisory board, created by the
Center for Human Rights, in order to ensure protection of persons against torture and other
cruel, inhuman or degrading treatment;

• d) to inform parents or legal guardians of persons under the age of 18 years old, in case
exposing them to medical treatment;
• e) in case of a possibility that the harm to someone’s health is the result of illegal or criminal
actions,in this case the information being presented to the law enforcement authorities.

89. Patients’ responsibilities.

to take care of his/her own health and live a healthy lifestyle, excluding deliberate action that
are harmful to him/herself and others;

• to observe the methods of precaution while making contact with other people, including
health care workers, if he/she is aware of the presence of a disease that presents a social
danger;

• to undertake, in the absence of medical contraindications, mandatory prophylactic measures,

including immunizations, whose failure threatens their health and creates social danger

to provide the medical workers with complete information about the current and previous
diseases, about his diseases that present a social threat, including situations of voluntary
donation of blood, biological fluids, organs and tissues;

• to follow the rules of conduct established for patients within medical institutions and also
doctor’s recommendations during outpatient and inpatient treatment;

• to exclude the use of pharmaceuticals and other medical substances without doctor's
prescription and acceptance,including drugs, other psychotropic substances and alcohol during
the period of treatment in the medical institution;

• to respect the rights and dignity of other patients and health care staff.

90. Rights of medical and pharmaceutical professionals. Modes of their

protection.
Conducting an investigation the expert has the right to:

o participate in procedural acts at the request of the investigative body

o examine the materials of the criminal matter so far as this is necessary for the purposes of the
investigation

o request additional materials needed for investigation

o refuse to conduct the expert assessment if the assessment materials submitted to him or her
are not

sufficient or if the questions are outside his or her specific expertise

The expert is responsible for:

o false conclusion
o disclosure of confidential information

91. Medical care in emergencies. Law provisions.

In case of an emergency medical intervention necessary to save patient's life, when he/she
can’t express the wish, and consent of his legal representative (close relatives) can’t be
achieved on time, medical staff, in a manner authorized established by law, has the right to take
the right decision in the interests of the patient.

92. Liability of medical staff. Professional crimes of medical workers.

Medical misconduct is defined as behavior that

deviates from duty by a healthcare professional.

• practicing as a healthcare professional fraudulently

• practicing with gross incompetence or medical negligence

• omissions in medical examination, inappropriate interventions, etc.

• practicing while impaired by alcohol, drugs, physical or mental disability

• being convicted of a crime

• exercising undue influence on the patient, including the promotion of the sale of services,
goods, appliances, or drugs.

93. Lack of medical care. Law provisions.

Types of negligence

1.civil- if simple lack of skill & care DAMAGE (mandatory loss, pain etc.)

e.g- wrong dose, wrong prescription

- burden of proof lies with patient

-tried in civil courts

Punishment-fine

Damage that can be compensated by money is civil negligence

2. CRIMINAL- Gross negligence, utter carelessness/ willful negligence DAMAGE (death)

e.g- surgery at wrong site

surgery to wrong patient

wrong kind of surgery

mismatched blood transfusion

-tried in criminal court

Punishment; imprisonment 2yrs

3. CONTRIBUTORY- doctor and patient both are negligent

Doctor gives wrong dose and patient missed follow up

Burden of proof lies with the doctor

Partial defense

4.CORPORATE- Management is also responsible for the negligent act of the employee

94. Negligent attitude of medical staff. Law provisions.

Medical malpractice is professional negligence by act or omission by a health care provider in
which the treatment provided falls below the accepted standard of practice in the medical
community and causes injury or death to the patient.Between 15,000 and 19,000 malpractice
suits are brought against doctors each year in the US.

95. Medical error and mistake: classification and their causes.

A medical error occurs when a health-care provider chooses an inappropriate method of care
or improperly executes an appropriate method of care.Medical errors are often described as
humanerrors in healthcare: To Err is Human

96. Iatrogenic diseases: concept, classification.

Iatrogenic are diseases and pathological processes due to the professional activity of the
medical staff. May be:

• Psychical

• Somatic

– organizational

– traumatic

– toxic

– septic
97. Euthanasia: medical and legal problems.

98. Medical abortion: conditions of its legality.

99. Surgical sterilization: conditions of its legality.

100. Reanimation and transplantation: legal, ethical and medical aspects.

In countries with established transplant programs, organ transplantation is highly regulated. Of

particular concern is organ donation, with legal, medical, and social issues surrounding the
procurement of organs, without compensation, for transplantation. Many of those issues are
overcome by organ registries, in which individuals choose to become organ donors. Through
such registries, donors can indicate which organs they are willing to donate upon death.
Whether a person is a registered organ donor can then be indicated on a personal identification
card (e.g., a driver’s license), authorizing organ procurement once the individual is deceased. In
the absence of legal consent via registration as an organ donor, organ procurement
representatives are required to consult with next of kin for authorization to obtain organs from
the deceased person.

Another area of ethical concern is the dilemma posed by the shortage of donor organs.
Advances in immunosuppressive therapy have put increasing pressure on the supply of donor
organs, and medical personnel sometimes find themselves having to determine who among the
potential recipients should receive a lifesaving graft. Furthermore, there is a danger of
commercial interests becoming involved with people willing to sell their organs for personal
gain, and there is definite risk of illegal organ trafficking, in which organs are procured from
unwilling donors and then sold to facilities that offer transplant services.