FORENSIC MEDICINE &
TOXICOLOGY
LEGAL PROCEDURES, MEDICAL LAW & ETHICS
? Forensic (Legal) Medicine: Application of medical knowledge to aid in the administration of justice
? Medical Jurisprudence: legal responsibilities of a physician, with reference to those arising from physician
patient relationship (e.g. medical negligence cases)
? Medical ethics: moral principles which should guide the members of medical profession
HISTORY OF FORENSIC MEDICINE
? Oldest known medicolegal code: The Code of Hammurabi, King of Babylon
? First medicolegal autopsy was done in Bologna(ltaly) in 1302, by Bartolomeo De Varignana
? First book of forensic medicine published by Fortunato Fedele
Zacchias
? Paulus Zacchias - Father of Legal Medicine and Father of Forensic Psychiatry
? Orfila - Founder of Modern toxicology
LEGAL PROCEDURES
? Criminal Procedure Code (CrPC)
Provides mechanism for punishment of offences
Deals with police duties in arresting offenders, in production of documents, investigating offences
Actual procedure in trials, appeals, references revisions and transfer of criminal cases.
evidence
? Criminal law - offences against public interest
? Civil law - disputes between two individuals or parties
Plaintiff - party bringing the action
? Cognizable offence(S 2 (c) CrPC) - where a police officer can arrest a person without warrant from the
magistrate. E.g. Rape, Murder, Dowry death, ragging, death due to negligence
INQUEST
? Inquiry or investigation into the cause of death
medical negligence, deaths due to animal attacks, suspicious deaths etc
Police inquest
? Section 174, CrPC
? Usually by Sub Inspector or Inspector - Investigation officer
? Prepares the inquest report - Panchanama
Magistrate inquest
? Conducted by a District Magistrate - Collector, Tahsildar, Deputy Commissioner, Revenue divisional officer
? Section 20 - 23 CrPC
? Done in case of
1%. Death in police custody and while under police interrogation
Death due to police firing
Death in prisons, reformatories, Borstal school
Dowry deaths
Exhumation
Any person dies or disappears, or rape is alleged to have been committed on any woman, while such
person or woman is in the custody of police
Examiner's system - doctor visits the scene of crime and conducts the inquest, it is superior to Coroner's and
Police inquest
Coroner's inquest and Medical examiner's system - not followed in India
COURTS OF LAW
Imprisonment
Fine
Supreme court
Any sentence
High court
Any sentence authorized by law
Any amount of fine
Sessions court
by law (but
Any amount of fine
death
Assistant sessions court
Any amount of fine
Chief Judicial magistrate
7 years imprisonment
Any amount of fine
First class Judicial magistrate
3 years imprisonment
5000 rupees
Metropolitan Magistrate
1 year imprisonment
1000 rupees
? Supreme Court and High Court usually hear referrals not trials.
? Courts below the rank on Sessions court cannot hear murder trials as they cannot award death sentence
? Juveniles: Boys < 16 years; Girls < 18 years
? Juvenile Magistrates are generally women
? Juvenile Justice board
Metropolitan Magistrate or First class Judicial Magistrate
? Newspapers, magazines and visual media are prohibited to disclose particulars that can lead to the
identification of the juvenile in conflict with law
MEDICAL EVIDENCE
? Documentary
Medicolegal reports - wound certificate, postmortem certificate etc.,
Dying declaration
? Oral
? Direct: evidence of a person who has been seen, heard or perceived the fact
? Hearsay : witness states what he has heard others saying
Oral evidence is more important than documentary evidence, because
? Oath administered
? Cross examination is done
? Common witness: (Witness of fact or Occurrence witness) gives evidence about the facts observed or
perceived by him (first-hand knowledge rule)
? Expert witness: a person who has training, skill or knowledge, experience in a subject and capable of drawing
opinions and conclusions from the facts observed by him. E.g: doctor, firearms expert, fingerprints expert
Hostile witness: witness who conceals a part of truth or completely gives false evidence (S. 191 IPC)
Perjury - Giving false evidence under oath (S 191, 192 IPC). Punishment 7 years imprisonment (S 193 IPC)
RECORD OF EVIDENCE IN A COURT OF LAW
Oath - child below 12 years is not required to take an oath
? Witness examined by public prosecutor and accused by defense lawyer
? To elicit all the relevant facts
? No leading questions
? Leading questions may be asked if the witness is hostile
? Witness examined by defense lawyer and accused by public prosecutor
? To elicit facts favorable to the defence side
? To test the accuracy of the statements made by the witness
? To modify or explain what has been said
? Leading Questions allowed
? No time limit
3. Re-Examination (Re Direct Examination)
? Similar to direct examination
4. Questions by the Judge
? Can ask questions at any time of proceedings
Dying declaration
? Section 32 lEA
of two witnesses
? Before recording it should be certified by the doctor that his mental functions are normal (compos mentis)
? Oath is not administered
? Leading questions are not allowed
give oral evidence
? Police officer should not be present at the time of declaration
Dying deposition
? Not followed in India
? Opposite lawyer present at the scene
? Cross examination allowed
? Recorded by Magistrate
Superior to dying declaration
Presumption of death
? Section 107 lEA: a person is presumed to be alive, if there is nothing to suggest the probability of death
within 30 years
? Section 108 lEA: if it is proved that the same person has not been heard for 7 years by them who
MEDICAL LAW & ETHICS
? Functions of Indian Medical council
? Maintenance of Medical register
? Maintenance of standards of Medical education
? Appeal against disciplinary action
? Warning notice - list of practices which are considered as professional misconduct
Foreign medical degrees
? First schedule - recognized medical qualifications granted by universities in India
? Third schedule
Part I - those granted by medical institutions not included in the first schedule
Part II - those granted outside India not included in second schedule
Functions of State Medical councils
? Disciplinary control - issues warning to the person who has done professional misconduct
PENAL ERASURE/PROFESSIONAL DEATH SENTENCE
? Removal of the name of the doctor from the medical register
? Main cause-Serious Professional Misconduct/Infamous conduct (conduct of the doctor that is regarded
? Done by the State medical council
? Other instances of removal of name
After death
Name entered by fraud, impersonation
from a trader in drugs or manufacturer or labs
Adultery- voluntary Sexual intercourse with a person other than his or her spouse
Covering- Assisting someone who has no medical qualification to attend, treat or perform an operation
Six A's - Professional misconduct
? Advertising
? Abortion(unlawful)
? Addiction
? Alcohol
PROFESSIONAL NEGLIGENCE (MALPRAXIS)
? Absence of reasonable care and skill or willful negligence of a medical practitioner in the treatment of a
patient which causes bodily injury or death of the patient
? Doing something that one is not supposed to do or failing to do something that one is supposed to do
? Duty: Existence of a duty of a care by the doctor
? Dereliction: Failure on the part of the doctor to maintain applicable standard of care and skill
? Direct causation: Failure to exercise proper care must lead to damage
? Foreseeability of the damage: The damage should be of a type that would have been foreseen by a
Res Ipsa Loquitor
? The thing or fact speaks for itself
? Usually the professional negligence of a physician must be proved in the court by the expert evidence of
another physician
Examples:
? Failure to give ATS in cases of injury causing tetanus
? Burns from application of hot water bottles or from X-ray therapy
? Prescribing an overdose of medicine producing ill effect
? Blood transfusion misadventure
? Failure to remove swabs during operation which leads to complications or death
? Loss of use of hand due to prolonged splinting
Novus Actus Interveniens
? The person is responsible not only for his actions but also for the logical consequences of all those actions
Medical Maloccurence or Act of God
? Inspite of good medical attention and care, in some cases, an individual fails to respond properly or may
suffer from adverse reactions of drug
? Breaking of needle during intra muscular injections due to sudden muscular spasm
? Damage to RLN during thyroidectomy
Civil Negligence
? Patient/relatives may charge against the doctor for compensation or
? Examples
Failure to get informed consent
Failure to give proper instructions
Failure to warn the patient about side effects
? Gross absence of skill or care of the doctor during treatment that resulted in serious injury or death of the
patient
? When the doctor performs an illegal act
? Undue delay in treatment of an assault victim that resulted in death
? Examples
Amputation of wrong finger or wrong limb
Leaving instruments or swabs inside abdomen
Performing criminal abortion
? The patient or his attendant is also negligent by not co-operating with the doctor
? His negligence along with doctor's negligence has resulted in the damage
? Without the negligence of the patient the damage would not have occured
? Examples
Not giving adequate medical history
Leaving the hospital against doctor's advise
Failure to seek further medical assistance if symptoms persist
Defenses against negligence
? Duty discharged according to existing standards of medical practice
? Contributory negligence
? The damage is due to the intervention of a third person without the doctor's knowledge
? The damage is an expected outcome of the disease
A misadventure is an accident or disaster, in which an individual is injured or died due to some
unintentional act by a doctor/hospital
Hypersensitivity reaction or anaphylaxis with drugs like penicillin, aspirin etc
Damage by radiation or radioisotopes
Medical Maloccurence
? Res-judicata - a matter [already] judged: once a lawsuit is decided, the litigant parties are barred' from
raising the same issue again in the courts
Contributory negligence is not a defense against a criminal negligence
Civil negligence
Criminal negligence
No specific and clear violation of law need be proved
Simple absence of care and skill
Gross negligence, inattention or lack of competency and
disregard to the life and safety of the patient
Conduct of the physician is compared to generally
accepted simple standard of professional conduct
Consent for the act is a good defence
Consent is not a defence
Trial by civil court
Strong evidence is sufficient
Guilt should be proved beyond reasonable doubt
Punishment: Liable to pay damages
Imprisonment
? Liability for the act of another or Principle of Respondent Superior
? An employer is held legally responsible for the negligent acts of his/her employees appointed by him
Medical records
? MR of indoor patients - should be maintained for a period of 3 years from the date of commencement of the
? Routine case records - should be preserved upto 6 years after completion of treatment and upto 3 years
after death of the patient
? Where there is a chance of litigation arising for medical purpose of negligence, record should be preserved
for atleast 25 years specially in case of minors
making index and summary of the case
? Records of public interest are transferred to public record library after 50 years for release to public and
those involve confidentiality of the individuals are released only after 100 years
CONSENT
? To examine, treat or operating a patient without consent amounts assault as per law, even if it is done in
good faith
Types of consent
? Implied consent (e.g: when the person holds out his arm for injection)
Written consent
Verbal consent
Rules of consent
? Oral consent should be obtained in the presence of a disinterested third person. E.g. nurse
procedure
? Blanket consent: consent obtained at the time of admission to the hospital for all procedures after
admission. Not valid
? A woman of 18 years and above can give valid consent for sexual intercourse (Section 375 IPC, 2013
? A child under 12 years and an insane person cannot give valid consent. Consent is obtained from the parent
or the guardian
Loco Parentis: in an emergency situation, when the parent or guardian is not available, the person in-
charge of the child can give consent
school can give consent
Informed consent - understanding by the patient of
? The nature of his condition
? The nature of the proposed treatment or procedure
? The details of the alternative courses of treatment that are available
? Risks and benefits involved in both the proposed and alternative treatment
? Relative chances of success or failure of both procedures
? All disclosures must be in the language the patient can understand
? District consumer dispute redressal forum - upto 20 lakhs
? State consumer dispute redressai forum - > 20 lakhs upto 1 crore
? National consumer redressal commission - > 1 crore
The Transplantation of Human Organs Act - 1994
which if wholly removed cannot be replicated
? Bone marrow transplant is outside the purview of this act
? Organs that can be donated after death: kidney, heart, liver, lungs, pancreas, eyes, ear drums and ear
bones
? Live donor: "donor" means any person, not less than eighteen years of age, who voluntarily authorises, the
removal of any of his human organs for therapeutic purposes
Important years
? Indian Medical Council Act - 1956
? The Protection of Human Rights Act - 1993
? Declaration of Helsinki by World Medical association - 1964 (Code of ethics on Human experimentation)
EUTHANASIA
? Mercy killing or Assisted suicide
which cannot be repaired or cured
? Legally permitted in: USA, Uruguay, Poland, Australia, Switzerland, Nether lands
? Not legalized in India
Types
? Active (Positive)euthanasia
Act of commission
Death induced by direct/indirect action
E.g. giving large dose of a drug that hastens death
Act of omission
No specific medicine or life supporting measures given
Death induced by discontinuation of life sustaining measures
E.g. stopping heart lung machines in a severely defective new born, disconnecting ventilator in a brain
? Voluntary euthanasia
Euthanasia induced at the will of an individual by his request
A patient suffering from an incurable disease requesting the doctor to terminate his life
? In/Non voluntary euthanasia
E.g. a person with irreversible coma or a severely defective infant
Paternalism - abuse of medical knowledge so as to distort the doctor-patient relationship in such a way the
patient is deprived of his ability to take rational choice
Important sections related to Injury, Death, Murder, and Suicide
Offence
44
Injury
46
299
Culpable homicide amounting to murder
300
Murder definition
Murder punishment
304
Culpable homicide not amounting to murder
304-A
304-B
Dowry death
306
Abetment of suicide
Attempt to commit suicide
319
Hurt
320
351
Assault
326 A & B
Causing grievous hurt by throwing acid
290 1PC
Frotteurism
294 IPC
Exhibitionism
Necrophilia, Necrophagia
312
314 IPC
Causing miscarriage
Abandoning a girl child
318 IPC
Concealment of birth of a girl child
354 IPC
354 - A
Sexual harassment
354 - C
Voyeurism
Stalking
370 (PC
Trafficking
375 IPC
376 IPC
Punishment for rape
377 IPC
Unnatural offences
Adultery
416 CrPC
High court has the power to postpone the execution of death
sentence of a pregnant woman until 6 months after delivery or
Punishment for rape -Section 376 IPC
S 376 (1) IPC
Imprisonment > 7 years + fine
S 376 (2) IPC - rape committed
? By Police officer
fine
? By Public servant taking advantage of his official
position on a women working under him
? By Custodial rape
? By Relative, guardian or teacher
? During Communal violence
? On pregnant women
? On women suffering from mental or physical
disability
? Causes grievous injury, disfigures or endangers life
of a
? Repeatedy on the same woman
S 376-A IPC: Rape resulting in death or persistent
Rigorous imprisonment > 20 years
vegetative state
S 376-B IPC: Sexual intercourse by husband upon his wife
Imprisonment 2 - 7 years + fine
during separation
S 376-C IPC: Sexual intercourse by a person on authority
S 376-D IPC: Gang rape
Rigorous imprisonment > 20 years
S 376-E IPC: Repeat offenders
Imprisonment for life or death
82 IPC
A child under 7 years of age is incapable of committing an offence
84 IPC
Criminal responsibility of mentally ill
An act done by a person, due to intoxication is not an offence, if he is intoxicated
without his knowledge or against his will
86 IPC
An intoxicated (voluntary drunkenness) person is criminally responsible, if he had
87 IPC
A person above 18 years of age can give valid consent to suffer any harm, which
may result from an act not intended or not known to cause death or grievous hurt
89 IPC
90 IPC
Consent given by a person under fear of injury, intoxication, misunderstanding of a
fact is not valid
92 IPC
an offence
Sections related to poisoning
39 CrPC
Private practitioner should inform the police or magistrate, if he
suspects homicidal poisoning
309 IPC
Private practitioner need not inform the police if he is sure that the poisoning is
suicidal
Not preserving samples with the intention of protecting the accused
Other sections related to medical practice
IPC section
Definition
Nothing is said to be done in good faith which is done without due care and
attention
74
Nonattendance in obedience to summons from court
Omission to produce document to public servant
176
Omission to give notice or information to public servant
177
179
Refusing to answer public servant authorized to question
191
Giving false evidence (Perjury)
Issuing or signing false certificate
201
Causing disappearance of evidence of offence or giving false information to screen
offenders
Destruction of document to prevent its production as evidence
269
Negligent act likely to spread infection of disease dangerous to life
270
160
Police officer has the power to summon any witness (doctor) to police station for
recording a statement
87 - 93
Other important sections
? Section 53, CrPC: A registered medical practitioner can examine a person who is arrested on a charge of an
offence using reasonable force, if requested by a police officer not below the rank of Sub-Inspector
? Section 53-A CrPC: When a person is arrested on a charge of committing an offence of rape or an attempt to
commission of offence, it shall be lawful for a registered medical practitioner employed in a hospital run by
the government or a local authority and in the absence of such a practitioner within the radius of 16 km from
the place where the offence has been committed, by any other RMP acting at the request of a police officer
not below the rank of a sub-inspector to examine the arrested person with use of reasonable force as
? S 363, 364, 366 IPC - kidnapping
Dowry Death
S 304-B IPC
Death of a woman caused by any burn or bodily injury or occurs otherwise than under
Punishment: 10 years imprisonment which may extend to life + fine
S 498-A IPC
Whoever (husband or relative) subjects woman to cruelty shall be punished with 3 years
imprisonment
injury to her or harassment with a view to coerce her for dowry
S 113-A &
Presumption as to abetment of suicide by a married woman and
S 113-B lEA
S 174 (3) CrPC
Procedure in dowry death
MEDICOLEGAL AUTOPSY
Types of Autopsy
? Medicolegal autopsy - consent of relatives not needed
? Virtual autopsy Nirtopsy - a combination of CT & MRI
? Psychological autopsy - A procedure for investigating a person's death by reconstructing what the person
thought, felt, and did before death, based on information gathered from personal documents, police reports,
contact with the person before the death - to assess the mental status of the person at the time of death
The PM examination should be conducted in daylight as far as possible because color changes such as
jaundice, changes in bruise and changes in lividity cannot be appreciated accurately in artificial light
Method of removal of organs
? Individual organs are removed one by one
? Cranial cavity exposed first, followed by thoracic, cervical and abdominal cavities
ROKITANSKY'S TECHNIQUE
? In-situ dissection, combined with en block removal
LETULLE'S TECHNIQUE
? En masse removal of cervical, thoracic, abdominal and pelvic organs and dissected as organ block
? Advantage - all attachments are intact
GHON'S TECHNIQUE
AIR EMBOLISM
? Head should be opened first and the surface vessels of brain examined for gas bubbles
? Left ventricle is filled with froth if air is present in sufficient quantity to cause death
? Pericardial sac opened and filled with water. Right heart is punctured with a scalpel and twisted -air bubbles
? Pyrogallol test: Air is brought in contact with alkaline Pyrogallol solution, which turns brown -indicates
antemortem air embolism
Obscure autopsy
? Where a definite cause of death is not found
Negative autopsy
? When the cause of death could not be found, even after gross and microscopic examination, toxicological
analysis, histo-pathological examination and microbiological investigations
EXHUMATION
? Magistrate conducts the inquest
? Preferably done in daytime
? No time limit in India
? Autopsy (first or second) done
? Artifact is any change caused or feature introduced in a body after death, that is likely to lead to
misinterpretation of medico-legally significant (antemortem) findings
Artifacts introduced after death and before autopsy
? Resuscitation artifacts: injuries due to defibrillator application, Cardiac massage, Central line, Positive
pressure ventilation, Laryngoscope
? Artifacts due to handling of the body: Undertaker's fracture, Postmortem abrasions
? Artifacts due to burns: Heat ruptures, Heat hematoma
IDENTIFICATION
CORPUS DELICTI
? Latin meaning - body or essence of crime
? Refers to the principle that a crime must have been proven to have occurred before a person can be
convicted of committing that crime
? The corpse of a murdered victim with injuries indicate that a crime has been committed
RACE
Pure Aryans (Indians)
Chinese, Europeans
Mongols
Aborigines, negroes
70-75
75-80
>80
Type of skull
Mesaticephalic
Brachycephalic
Orbits
Square
Round
Nasal opening
Broad
Narrow and elongated
Palate
Rectangular
Triangular
Round or horse shoe shaped
? Cephalic index = Maximum breadth of skull/ Maximum AP diameter of skull X 100
? Brachial index = Length of radius/Length of Humerus X 100
? Crural index = Length of tibia/Length of femur X 100
? Inter-membranal and Intra-membranal index
Barr body
? Barr body is the inactive X chromosome in a female somatic cells (Buccal smear)
? It is rendered inactive in a process called lionization
? Number of barr bodies = Number of X chromosomes - 1
Davidson body: small nuclear attachment in the neutrophils of females
Greater sciatic notch is the ideal feature in pelvis to determine sex of a female child
Chilotic line - anthropometric line in pelvis, the index of which is used in determination of sex
Sex indices
? Washburn ischiopubic index = Pubic length / Ischia( length X 100
? Corporbasal sacral index = Breadth of 1st sacral vertebra / Breadth of base of sacrum X 100
? Sternal index = Manubrial length / Body length X 100
? Recognizable sex differences do not appear until after puberty in bones except pelvis
? Single best bone to determine sex (both in adult and child) - pelvis
Feature
Male skull
Muscle ridges, Glabella,
More prominent
Less prominent or absent
Supraorbital ridges,
Fore head
Steeper, less rounded
Vertical, round
Fronto-nasal junction
Smoothly curved
External acoustic meatus
Bony ridge along upper border
Absent
Small
Large
eminences
Mastoid process
Small, smooth, pointed
Condylar facet
Long and slender
Short and broad
Large, U shape
Small, parabolic
Occipetal condyles
Large
Feature
Male pelvis
Female pelvis
General
Flat bowel
Ilium
Less vertical
More vertical
Not frequent, narrow, shallow
More frequent, broad and deep
Acetabulum
Large, directed laterally
Obturator foramen
Large, oval with base upwards
Small, triangular with apex forwards
Greater sciatic notch
Large, wide, shallow
Ilieo-pectineal line
Well marked and rough
Round and smooth
Inverted
Everted
Subpubic angle
V shaped, angle 70-75
Pelvic brim
Heart shaped
Circular or elliptical, more spacious
Pelvic cavity
Broad and round
Sacrum
Long, narrow, even curvature,
Short, wide, upper half almost straight,
lower half curve forward
Krogman's degree of accuracy of sex determination with bones
? Entire skeleton
= 100%
= 95%
? Skull alone
= 90%
? Skull and Pelvis
? Long bones alone
= 80%
AGE
DENTITION
? Age 7 to 12 years is the age of mixed dentition
? Superadded permanent teeth are those which don't have deciduous predecessors (permanent molars)
? Successional permanent teeth are those which erupt in the place of deciduous teeth.
? In some persons due to inadequate jaw space, the third molars never erupt into the oral cavity, particularly
Temporary teeth
Age (months)
Lower central incisor
6-8
7-9
Upper lateral incisor
7-9
Lower lateral incisor
First molar
12-14
Canine
17-18
20-30
Permanent teeth
Age(years)
First molar
Central incisor
6-8
Lateral incisor
7-9
9-11
Second premolar
10-12
Canine
Second molar
12-14
Third molar
17-25
GUSTAFSON'S METHOD
Age estimation in adults > 21 years can be done based on the physiologic changes of teeth - Gustafson's method.
Criteria
? Attrition - wear and tear changes of the incisal or occlusal surface of the teeth
? Paradentosis - regression of gums resulting in loosening of teeth and they fall off
? Cementum apposition - deposition of Cementum in the root forming incremental lines
? Root resorption - involves both Cementum and dentin
? Root transparency - canals of denting gets filled up by minerals after 30 years of age and the dentin becomes
transparent. This is the most reliable criteria.
X-Rays
? Number of ossification centres at 11th week of IU life - 806
? Number of ossification centres at birth - 450
? Number of bones in adult skeleton - 206
Pelvis
Appearance
Fusion
Ischiopubic rami
Tri radiate cartilage
13 years
15 years
Iliac crest
18 - 20 years
Ischial tuberosity
16 years
20 - 21 years
1 year
17
18 years
Greater trochanter
Lesser trochanter
12 - 14 years
Shoulder
Head of the humerus
18 - 19 years
Greater tuberosity
3 years
Lesser tuberosity
Coracoid process
Body: 5-6 years
16 - 17 years
Tip: 10-11 years
14 - 15 years
17 - 18 years
Elbow
Lower end of humerus
1 year
14-16 years
Lateral epicondyle
11 years
9-11 years
Medial epicondyle
6-7 years
16-17 years
Radial head
5 years
16-17 years
Olecranon process
Wrist: Appearance of carpal bones
Scaphoid
Lunate
Triquetrel
Trapezium
Trapezoid
Capitate
Hammat
4 yrs
3 yrs
11-12 yrs
6 yrs
2 months
2 years
Ossification centres
F
Epiphysis of base of 1st metacarpal
2-3 years
15 - 17 years
2 years
18-19 years
Ulnar styloid process
5 years
Age group
X-ray region
6 - 12 years
13
- 16 years
Elbow, Pelvis
16
Ankle joint
17
- 18 years
Hip joint
- 19 years
Knee, Shoulder, Wrist
20
- 21
Ossification centres present before birth
? 2 months - Upper segments of sacrum, Mandible
? 5 months - Middle segments of sacrum
? 6 months - Calcaneum
? 8 months - Lower segments of sacrum
? 9 months - Lower end of femur
? 10 months - Upper end of tibia
Age of the fetus - Rule of Hasse
? If the crown-heel length is > 25 cm, then the length divided by 5 gives age in months
Fusion of Skull sutures & Closure of fontanelles
Lateral and occipital fontanelles
< 2 months
6 - 8 months
Anterior fontanelle
1.5 - 2 years
Metopic suture
Basi-Occiput fusion with basi-sphenoid
18 - 21 years
Sagittal suture
30 - 40 years
40 - 50 years
? Anterior 3rd
50 - 60 years
? Middle 3rd
40 - 50 years
? Lower half
50 - 60 years
? Upper half
45 years
Sternum
? Four pieces of the body of the sternum fuse with one another between 14 - 25 years
? Xiphoid fuses with the body - 40 years
Closure of sutures begins 5-10 years earlier on the inner side than the outer side
Most successful age estimation can be done from sagittal suture
When the endocranium fuse and ectocranial suture does not fuse - lapsed union
Sacral bones fuse and become a single bone between 21 - 25 years
The best single criteria to determine age from 3rd to 5th decade is the pubic symphysis
AGE
MEDICOLEGAL IMPORTANCE
7 months IU
> 5 years
Criminal responsibility as per Railways act
< 7 years
No criminal responsibility as per Section. 82 IPC
Criminal responsibility if sufficient maturity of understanding the nature and
consequences of act as per Section. 83 IPC
< 12 years
Consent to be obtained from parent/guardian for examination, surgery etc
Cannot be employed in factory jobs
14 - 15 years
Non-hazardous factory jobs can be given in day time
> 15 years
< 15 years
Sexual intercourse with a girt, even his wife, with or without consent amounts to
rape
< 16 years
< 16 years
Taking away a boy without consent of the parent/guardian - kidnapping
< 18 years
Juvenile (boy or girl)
Sexual intercourse with a girl, with or without consent amounts to rape
> 18 years
Valid consent for any harm not known to cause death or grievous hurt
Valid consent given by a girl for sexual intercourse
Can make valid will
> 21 years
Attainment of majority for those under the guardianship of court
No age limit to give evidence in a court. A child of any age can give evidence if the court is convinced that
DACTYLOGRAPHY
? Fingerprint system was first used in India
? Sir Francis Galton systematized this method in 1892
? It is the study of epidermal ridges and their configurations (dermatoglyphics)
? They are broadly classified into 4 types
Loops - most common type
Whorls
Arches
? Final identification is made based on the comparison of characteristics like - ridge endings, bifurcations, lake
formation, broken ridges, short ridges etc.,
? Permanent impairment of finger prints - leprosy, electric injury, radiation
? Atrophy of the ridges seen in coeliac disease, dermatitis
? The papillary ridges of the epidermis of hand are studded with microscopic pores through which sweat
exudes during life
? The number of pores, their size, shape, width, position over a region is individualistic
? This study of pores is called Poroscopy (Locard's method)
Formulas for stature estimation
? Pearson's formula
? Dupertuid & Hadded formula
? Trotter & Gleser formula
Rule of thumb
Bone
% of height
Humerus
Tibia
22
Femur
27
35
Hair
? Trichology - study of hair
? Hair grows at a rate of 0.4mm/day and nails at 0.1mm/day
pigment, medullary index <0.3
? Animal hair - coarse and thick, cuticle scales are large with wavy projections, thin cortex, thick medulla,
pigment mostly near medulla, medullary index >0.5
? In human hair, Barr bodies are found in hair follicles (24-34% in females; 4-8% in males)
resist the treatment
? ABO blood groups can be determined in a single hair if hair bulb is present, from any part of the body
? Singeing of hair is seen in burns and close range firearm injury.
? Singeing is helpful in differentiating burns from scalds
Podogram - foot prints
Rugoscopy - palatal rugae
Calligraphy - study of handwriting
Fragmented hair - Negroes, new born, fetus
Preauricular sulcus is used to determine sex
Osteometric board: Used to measure length of a bone
Anthropometry - Bertillon system
Pink teeth - in decomposed or skeletonized body, pink teeth may be noted near the gum line
Dentaire Internationale system
THANATOLOGY & POSTMORTEM CHANGES
Thanatology - deals with death in all its aspects
dispositional context
BRAIN DEATH
UK criteria for diagnosis of brain death
Preconditions
? Patient on ventilator (spontaneous respiration had ceased)
? Diagnosis of the disorder leading to brain death has been firmly established
Exclusions
? Hypothermia (rectal temperature >35? C)
? Neuromuscular blocking agents, excluded as a cause for RS failure
? No profound abnormality of serum electrolytes, acid base balance, glucose concentrations and any
metabolic and endocrine cause of coma has been excluded
Tests for confirming brain death
? Corneal reflexes absent
? Vestibulo-ocular reflexes absent
? No motor responses to adequate stimulation
? No gag reflex
MINNESOTA CRITERIA (criteria for brainstem death formulated by Mohan Dass and Chou)
? Known but irreparable intracranial lesion
? No spontaneous movement
? Apnea when tested for a period of 4 minutes
phenomenon, ciliospinal reflex, gag reflex, vestibular response to caloric stimulation, tonic neck reflex
? EEG not mandatory
? Spinal reflex not important
? All the above findings remain unchanged for atleast 12 hours
? Unreceptivity and unresponsivity
? No spontaneous muscular movements
? Apnea
? Absence of elicitable reflexes
SUSPENDED ANIMATION or APPARENT DEATH
? Signs of life are not present as the functions are interrupted for some time or reduced to minimum
? Voluntarily produced by yoga practitioners (death trance)
? Involuntary suspended animation is seen in
? Insanity
? Drowning
? After anesthesia
? Electrocution
? Sunstroke
? Hypothermia
? Cholera
? Concussion of brain
POSTMORTEM CHANGES
Immediate changes (Somatic death)
Early changes (Cellular death)
Late changes (Decomposition)
?
Changes in the skin
? Putrefaction
? Cessation of respiration
Changes in the eye
? Mummification
? Cessation of circulation
?
? Adipocere
? Primary flaccidity of muscles
?
Livor mortis
Rigor mortis
HANGES IN THE EYE AFTER DEATH
? Pupillary dilatation
? Cornea: dull, hazy. opaque and wrinkled
mucus forms two yellow triangles on either side of cornea in 3 - 4 hours
? Flaccidity of the eye ball: due to fall in intraocular pressure. Within 2 hours, 10P falls to zero
? Retina: If the retina is viewed through and ophthalmoscope, there will be fragmentation or segmentation
(rail-road or tram-track appearance) of blood columns in retinal vessels (Kevorkian sign)
LGOR MORTIS or POSTMORTEM COOLING
? It is the cooling of the body after death
? After death, heat is lost by
Radiation (transfer of heat to the surrounding air by infrared rays)
Conduction (transfer of heat by direct contact with another object)
? Body loses heat by 2 - 3?C in 1st hour
? Then 1 - 1.5?C for each subsequent hour until the body reaches the environmental temperature
? Initial maintenance of body temperature which may last for some hours - the so-called "temperature
? Followed by a relatively linear rate of cooling
? Subsequently slows rapidly as the body approaches the environmental temperature.
? The preferred site for measuring temperature is either the rectum or the abdominal cavity
? A chemical thermometer with graduations from 0 to 50? C is used
Normal body temperature - Rectal temperature
Rate of temperature fall per hour
Rate of cooling is affected by
Difference in temperature between the body and the environment:
Surface area of the body:
? Larger surface area: speeds up cooling rate.
? Children: increase surface area gives rapid heat loss.
Body weight: Larger body weight (due to excess fat): slower cooling and vice versa
Clothing: Thick clothes slows down cooling rate
Environmental temperature: Higher humidity and rapid air velocity: rapid cooling rate
Water: Rapid cooling rate; More rapid in flowing water than still water
Postmortem caloricity
? Seen in the following cases
? Violent muscular contractions before death
o
Tetanus
Strychnine poisoning
o
Seizures
? Asphyxial deaths - strangulation
? Death due to temperature regulation disorders
? Sun stroke
? Pontine haemorrhage
POSTMORTEM HYPOSTASIS
? Blood gradually settles down in the toneless capillaries in the dependent parts of the body
? Seen externally as patches of purple or reddish purple discoloration of the skin
Sites of hypostasis: Depends on the position of the body before death:
? Supine: Lividity is seen on the back
discoloration will be pale (contact pallor)
? Vertical: e.g. hanging. PM staining seen on legs, feet, forearm and hands (glove and stocking hypostasis)
? Drowning: face, upper limbs and abdomen
? Face-down death: as in epilepsy, drunken victims - whitening around nose Et tips.
Heart: mistaken for MI
Lungs: mistaken for pneumonia
Intestine: mistaken for hemorrhagic infarction
Timing
? Gradually increase in size and coalesce with each - uniform area of staining in 5 to 6 hours
? If the body is left undisturbed for 6 to 8 hours, lividity becomes fixed and does not alter in position even if
the position of the body is altered
? May not develop at all if the position of the body is continuously changed as seen in fast flowing waters of
PM staining does not develop in
? Drowning in running water
? Areas of contact flattening
? Severe anemia
? Body refrigerated immediately after death
Poison/Condition
Postmortem staining
Phosphorus, Copper
Carbon monoxide
Cherry-red
Nitrites, aniline, chlorates
Chocolate or copper brown
Pink/Bright red
Refrigerated bodies, hypothermia
Bright pink
Opium
Hydrogen sulphide
Bluish green
Clostridium perfringens septicemia
Bronze or greenish brown
? Rigor mortis is the stiffening and shortening of muscles after death
? Affects all muscles of the body, both skeletal and smooth
? When the ATP level falls to 85% then the muscle becomes rigid
? When the ATP level fails to 15% then the rigidity is maximum
? Does not start in all the muscles simultaneously (Nysten's rule)
? It becomes most evident in the smaller muscles early (less reserve glycogen)
? Myocardium is the first involuntary muscle to become rigid
? Eyelids face
neck
upper limbs
thorax
abdomen
fingers and toes
(Proximo-distal progression)
? Passes off in the same order as it appeared
India
Temperate countries
Time of onset
1 - 2 hours
Duration
Summer
18 - 36 hours
2 - 3 days
24 - 48 hours
Rule of 12 or Rule of Dozen or March of Rigor
? First 12 hours after death: Rigor mortis affects the whole body
? Next 12 hours: retained
Conditions affecting Rigor mortis
? Age
Extremes of age rapid onset
Does not occur in fetus < 7 months
Cold and wet
onset slow, duration longer
Hot and dry
onset fast, duration shorter
Asphyxia, pneumonia, nervous disease with muscle paralysis & dehydration slow onset
Septicemia & poisoning
rapid onset, may even be absent
Excessive physical work before death rapid onset
HEAT STIFFENING
? Occurs due to exposure of body to intense heat (burning, high voltage electrocution)
? Due to heat, coagulation of muscle proteins occur
? When the body is recovered and kept in normal temperature - Rigor mortis does not occur
COLD STIFFENING
? Occurs due to exposure of the body to extreme cold (< minus 5?C)
? Solidification of subcutaneous fat and muscles occurs
? Freezing of synovial fluid in joints and other body fluids
GAS STIFFENING
? During putrefaction, due to the gases liberated, the entire body is bloated and stiffened
? When the gases escape, again the body becomes flaccid
CADAVERIC SPASM
? Rarely seen
? Seen immediately after death (no primary flaccidity)
? Small groups of muscle which were already in a contracted state at the time of death, remains contracted
after death, till molecular death occurs
? Usually associated with violent deaths coupled with emotional disturbance at the time of death
? Mechanism not clearly understood
Examples
? Drowning: grass and weeds caught in the hands during struggle, will be seen clutched in the hand after death
? Suicidal cut throat/gun shot: the weapon will be firmly grasped in the hand
CADAVERIC SPASM
Freezing and exposure to temperature above
Cannot be produced by any other method
65?C will produce rigor
Instantaneous
All muscles of the body both voluntary and
Restricted to a single group of voluntary muscles
involuntary are involved
Very great force required to overcome it
Molecular death occurs
Does not occur
Muscles do not respond to electrical stimuli
Body temperature - cold
Warm
Indicates time of death
Indicates manner of death
No primary flaccidity
DECOMPOSITION
Involves two processes
? Autolysis
AUTOLYSIS
? Self-digestion of tissues due to lysosomes and their digestive enzymes (Hydrolases)
? Earliest autolytic changes occur in parenchymatous and glandular tissues and in the brain.
? Earliest external sign is a whitish, cloudy appearance in cornea
? The chief destructive agent of Putrefaction is Clostridium welchii
? Lecithinase is the most important enzyme causing hemolysis, liquefaction of clots, gas formation and
disintegration of tissue.
Color changes
? First internal sign - discoloration in the under surface of liver
? Color Change is due to conversion of Hb to sulfamethemoglobin
? Color change appears 12-18 hours in summer and 1-2 days in winter
? Marbling of skin - greenish pattern in the skin resembling braches of a tree, starts at 24 hours; becomes
? Marbling is due to staining of superficial veins with sulpha-methemoglobin
Foul smelling gases
? Blisters 18-24 hours; first seen on the lower surface of trunk and thighs
? Skin slippage; anus and uterus prolapse 2- 3 days
? Separation of skull sutures children 3-5 days
? Postmortem luminescence is usually due to contamination by bacteria (Photobacterium fischeri) or fungi
(Armillaria mellea)
Liquefaction of tissues: 5-10 days
As a general rule, the organs undergo putrefaction in the following order:
Larynx & trachea
Stomach, intestines & Spleen
Liver (foamy liver) lungs
Brain
Prostate, uterus Skin, muscle, tendon
Bones
? Virgin uterus is the last organ to putrefy, gravid uterus and uterus soon after delivery putrefies rapidly
? Optimum temperature for putrefaction 21 ?C. putrefaction arrested below 0?C and above 48?C
Delayed putrefaction
? Peritonitis
? Anaemia, Debility, Wasting
? Sepsis
? Asphyxia
? Carbolic acid poisoning
? Intestinal obstruction
? Strychnine poisoning
? Heavy metal poisoning (Arsenic)
? Clostridia) infections
? Zinc chloride poisoning
MUMMIFICATION
? Dehydration/drying, desiccation and shriveling of the cadaver occurs due to evaporation of water
? Skin becomes dark and tightly adherent to skeleton
? Mummification requires 3 - 6 months
? A mummified body is odourless
? Absence of moisture in the air
? Dry or warm air currents
? Chronic arsenic and antimony poisoning favors antimony poisoning
Medicolegal importance
? Face is distorted due to shrinkage of soft tissues
ADIPOCERE or SAPONIFICATION or GRAVE WAX
? Modification of putrefaction
? Due to hydrolysis and hydrogenation of body fats
Prerequisites
? Abundant body fat
? Moisture
? Warm temperature
? Bacteria producing fat splitting enzymes like Cl.welchii
Features
? Seen over face, breasts, buttocks or limbs
? Smells like ammonia
Medicolegal importance
? Facial features are preserved and helps in identification
? Wounds are also preserved well and helps in determining cause of death
Casper's dictum
? Body decomposes in air twice rapidly as in water and eight times as rapidly as in soil
Embalming
? Treatment of the dead body with antiseptics and preservative to prevent putrefaction
? Causes chemical stiffening similar to rigor mortis
? Normal rigor mortis does not develop
? Rigidity is permanent
? Blood grouping cannot be made out
wintergreen, water
? Cavity embalming fluid - formalin, methanol, liquefied phenol, sodium lauryl sulphate, mercuric chloride,
eucalyptus oil
MECHANICAL INJURIES
Injury (Section 44 IPC) - Any harm illegally caused to any person in body, mind, reputation or property
Blunt force injuries
Sharp force injuries
? Abrasions
? Incised wounds
? Rifled weapon wounds
? Contusions
? Smooth bored weapon (Shot gun) wounds
? Lacerations
? Chop wounds
? Fractures
? Wound caused by superficial damage to the skin, no deeper than the epidermis
? It can be caused by friction against or fall on a rough surface, compression or by fingernails, thorns or teeth
bite
Scratch abrasion
? Sharp or pointed object not sharp enough to cause incised wound, but pointed enough to scratch
? E.g. thorn, fingernails, tip of knife
? Clean area at the start of the wound and tags at the end
? Helps in determining the direction of force
? Synonyms: grinding or sliding abrasions, brush burns
? Most common type - Commonly seen in road traffic accidents
? Occurs when the skin is rubbed (friction) against some rough surface
? Uneven, longitudinal parallel lines of abrasion are seen
Pressure abrasion
? Synonym: crushing abrasion
? Sustained pressure of a rough object at 90? - crushing of the superficial layers of the skin
? No force on impact, but sustained pressure after the object comes in contact with body surface
Impact abrasions
? Synonym: Contact abrasion or Imprint abrasion
? There is a moment of forceful impact, after that no contact of the object with body
? E.g: radiator grill mark, tyre tread marks seen in RTA
abrasion is reproduced on the body surface)
Healing of a typical abrasion (Starts from the periphery)
? Fresh
: bright red
: bright red scab
? 2 - 3 days
: reddish brown scab
? 4 - 7 days
? After 7 days
: scab dries, shrinks and falls off
Antemortem abrasions
Postmortem abrasions
Seen anywhere on the body
?
Seen over bony prominences
?
?
Yellowish, pale and translucent
?
Scab slightly raised above skin surface
Scab lies below the skin level
?
Vital reaction positive
?
Medicolegal importance of abrasions
? Direction of force can be determined in scratches and grazes
? Pattern on the weapon is seen on the skin surface in pressure and impact abrasions
? Age of injury can be estimated by assessing the healing
Throttling - crescentic fingernail abrasions on neck
Smothering - finger nail abrasions around mouth and nose
Sexual assaults - abrasions over breasts, genitals, inside of thighs, around anus.
? In cases of rape and assault, the fingernails scrapings of the victim may contain the skin fragments of the
CONTUSION (BRUISE)
? Effusion of blood into tissues due to rupture of blood vessels caused by blunt trauma
? Patterned bruise
Hammer - round
? Delayed or Come-out bruise: a deeply situated bruise may manifest externally only after several hours or
days or after death
? Migratory or Ectopic or Percolated contusions: injury at one site, contusion at a remote site due to
gravitation of blood
Fracture of floor of middle cranial fossa - bruising over mastoid (battle's sign)
Fracture of jaw - bruising in the neck
Fracture of pelvis - bruising over thigh
Hypostasis
Distension of blood vessels with blood in dermis
Due to ruptured vessels
Occurs on dependent parts
Occurs at the site of injury
Involved area swollen
Clearly defined margins
Margins merge with surrounding area
Bluish purple in color
On incision blood is seen inside blood vessels which
Extravasation of blood into the surrounding
can be easily washed away
area which cannot be easily washed away
Artificial bruise
True bruise
Caused by Juice of marking nut, calotropis
Dark brown color
Color changes
Well defined margins
Merge with surrounding areas
Absent
Redness seen in the surrounding skin
Redness in the site of injury
Itching present
Time
Color change
Pigment
Red
Hemoglobin
Few hrs to 3 days
Blue
4th day
Bluish black to brown,
Hemosiderin
5-6 days
Hematoidin
7-12 days
Yellow
Bilirubin
Normal
---
LACERATIONS
? Laceration is an irregular open wound caused by a blunt force injury
? There will be rupture or tear of skin and/or deeper tissues
? Margins - irregular, uneven, ragged with torn edges
? Shelving - one margin over rides the other which indicates the direction of force
? Pieces of tissues attached in between the edges - tissue bridges
? Hair bulbs are crushed
? Depth - varies with force and may contain foreign matter like dust, sand, paint of the vehicle involved etc.
Split laceration
? Occurs when the bone is superficial and subcutaneous tissues are scanty
? Edges appear to be clean cut (incised looking lacerations)
? Commonly seen over - scalp, lower jaw, iliac crest, shin etc
Stretch laceration
? Occurs in vehicular run over accidents, when the skin is stretched
? Fractured segment of a bone pierces the skin and projects out
Avulsion
? When a shearing or grinding force is applied, the skin is separated from the underlying tissues
(flaying)
INCISED WOUNDS
? Clean cut through the tissues (skin, subcutaneous tissues, blood vessels) by a sharp weapon
? Shape - usually spindle shaped due to gaping by skin elasticity
? Margins - usually everted except sites like neck, scrotum and axilla because of underneath muscles adherent
to skin
? Length - no relationship with the length of cutting edge of the weapon
? Breadth - Much wider than the cutting edge, because of the retraction of divided tissues with everted
? Depth - towards the termination depth becomes progressively shallow - tailing of wound
? Cut injuries over face, nose, ears, genitals are usually homicidal
Incised wounds
Lacerated wounds
Caused by blunt weapon
Margins: Regular, clean cut, everted
Margins irregular
Shape: spindle shaped
Length is greater than width Et depth
Wounds may be of any length, breadth and depth
No abrasions on edges
Abrasions seen on edges
Contusion of surrounding and underlying tissues
Underlying tissues cleanly cut
Deeper tissues unevenly divided - tissue bridging across the
margins
Hair bulbs - crushed
Foreign particles - absent
Foreign particles - present
Tailing indicates direction of force
Circumstances: usually homicidal or
Usually homicidal or accidental, almost never suicidal
suicidal, rarely accidental
Tentative cuts - suicidal
Beveled cuts - homicidal
Stretch laceration & Avulsion: accidental
Chop wounds
? Wounds produced by fairly heavy weapons like Axe, Hatchet, Big sword
? Margins - ragged abraded and contused
STAB WOUNDS
? Produced when a pointed weapon or object or instrument is forcibly thrust into the body
? Length
Slightly smaller because of elasticity of skin or
Larger because of the lateral movement of the victim or assailant
? Breadth - may not approximate with each other because of gaping
? Depth - greatest among the 3 dimensions
Wound should not be probed to find the length in a living person as it may dislodge a blood clot and
result in fatal hemorrhage
? Margins - regular and clean cut
? Shape - depends on the type of weapon and site of injury
the skin at each end of the corner - fishtailing
Double edged weapon - spindle shaped or elliptical
? Direction
Indicated by the track of wound
Hesitation/Tentative cuts
? Multiple, Parallel, Superficial cuts
? Accessible and vital sites - neck, wrist, ankle, chest, abdomen
? Usually in suicidal cuts
Suicidal cut throat
Homicidal cut throat
? In a right handed individual ? above
? Usually on both sides
? Multiple, superficial, parallel wounds.
? Single or multiple.
? Only one wound is deep.
? If multiple, many wounds are deep
? Wounds cross each other at deep level
wound
? Hesitation or tentative cuts present
? Absent
? Absent
? Wounds may be seen on other accessible Parts
? Severe injuries may be seen on head, face
of the body - wrist, chest, groin, ankles etc
? Defence wounds - absent
? Defence wounds present
? Weapon firmly grasped in hands due to
? Weapon is usually absent at the scene of
crime
? Clothes are usually not damaged
? Cuts in the cloth corresponding to injury over
the body seen
? Disturbance of the scene, disarray of furniture,
Stains on the mirror if the person was standing
foot prints, tears and loss of buttons in the
in front of it, suicidal note etc
DEFENCE WOUNDS
? Injury received by the victim of an attack while trying to defend himself against the assailant
? Often found on the hands and forearms, where the victim has raised them to protect the head and face
? Present on the feet and legs where a victim attempts defense while lying down and kicking out at the
? The presence of defense wounds is highly suggestive of homicide
? Defence wounds are absent: if the victim is unconscious, taken by surprise, attacked from the back, under
the influence of alcohol or drugs
FABRICATED WOUNDS
Produced by a person on his own body (self-inflicted), or
Occasionally, caused by another person with his consent (self-suffered)
? Motive - To bring false charges against enemies, Fictitious sexual assault by women to bring a rape charge
against enemy
? Usually caused by a sharp weapon
? Usually superficial wound - abrasions or incised wounds
? Wound over accessible parts
? Tears in the clothes don't correspond to those in the body.
'SKULL FRACTURES
Fractures of vault of skull
? Fissure # (linear #)
Broad surface like ground, Weapon with broad striking surface, Fall on feet, buttocks
? Comminuted #
Vehicle, railway accidents
Heavy weapon with broad striking surface
? Pond #(indented #)
Obstetric forceps cause injury to infant skull
Blow from blunt objects
? Gutter # - from oblique bullet wounds
? Ring or foramen # - fall from height on foot or buttocks
Undertaker's fracture
? Caused due to the head falling backwards forcibly after death, which tears open one of the inter vertebral
disc usually around C-6 and C-7
? It is a postmortem artifact due to rough handling of the body
Fractures of base of skull
? Ring fracture
Fissured fractures around foramen magnum
Seen in fall from height when the person lands on feet or buttocks
INTRACRANIAL HEMORRHAGES
EXTRADURAL or EPIDURAL HEMORRHAGE
? Between the skull and the dura mater
? MC source of bleeding - middle meningeal artery
? Other sources - diploic veins, transverse sigmoid sinuses, anterior and posterior meningeal arteries, anterior
ethmoidal arteries
? It is the least common type of all intracranial hemorrhage
? Usually accompanied by a fracture of skull, most commonly fissured fracture
? The classic lucid interval occurs in 20-50% of patients with EDH
? CT scan: lenticular or biconvex appearance of hemorrhage
? EDH with volume greater than 30 mL need emergency surgical evacuation
? Etiology
Traumatic
Coagulopathy (hemophilia, liver disease, thrombocytopenia)
Anticoagulation therapy (warfarin, heparin)
Spontaneous (cerebral tumors, AV malformation, and aneurysms)
? Source of bleeding: bridging veins (vein that connects cortical surface of brain to a dural sinus)
? Subdural hematoma is the most common type of traumatic intracranial mass lesion
? Acute subdural hematomas occur most commonly over the parietal region
Acute subdural hematoma (< 72 hours old) - hyperdense, crescent-shaped mass
Subacute SDH (2nd and 3rd weeks) - isodense, lens shaped
Chronic SDH (after 3 weeks) - hypodense
Duret hemorrhages
? Occur in midline
? Commonly occurs after asymmetrical herniation of brainstem
LUCID INTERVAL
? Lucid interval is seen in
Subdural hematoma
Insanity
Heat stroke
Postictal phase after a seizure in epileptic patients
? Injury to the skull and brain occurs at the site of impact
? Occurs when a moving object hits a static head
CONTRE-COUP INJURY
? Injury to the skull and brain occurs on the side opposite to the site of impact
PEDESTRIAN INJURIES
Primary impact injuries
? Due to the first impact between the vehicle and the pedestrian
? In adults - usually seen on the legs (# tibia - bumper #)
? Patterned abrasion or bruising produced by bumper, radiator grill, head lights etc.
? Helps in identifying the offending vehicle
Secondary impact injuries
? Caused by the subsequent impact of the body with the same vehicle after the primary impact
? Head injuries are common
? Seen on the same side as the primary impact injury
Secondary injuries or tertiary impact injuries
? Injuries caused when the victim falls on ground or any other object
? Base of skull fracture
? He may be run over and crushed against the ground resulting in flaying injuries
? Found on the parts opposite to the primary impact
Injuries to occupants of vehicle
shattering of the windscreen glass into multiple small cubical fragments with relatively blunt edges - seen in
front seat occupants
? Steering wheel impact injury - seen in driver
Transverse fracture of the sternum
Rupture of aorta
? Transverse intimal tears of aorta - ladder tears
Motorcyclist's injury
? Motor cyclists fracture or Hinge fracture: Due to heavy impact on one side of the head, fracture is produced
? Tail-gating or Under running injury
Usually occurs in darkness
When the motor cyclist drives into the back of a large vehicle
Due to sudden and unexpected stoppage of the large vehicle moving in front
The following injuries constitute grievous hurt
1. Emasculation
2. Permanent privation of sight of either eye
3. Permanent privation of sight of either ear
5. Destruction or permanent impairment of powers of any member(organ or limb carrying out a distinct
function) or joint
6. Permanent disfiguration of the head or face
7. Fracture or dislocation of a bone or tooth
ordinary pursuits for a period of 20 days
'PUNCH DRUNK SYNDROME
? Boxer's encephalopathy or dementia pugilistica or chronic traumatic encephalopathy
? A condition seen in boxers and alcoholics, who suffer repeated cerebral concussions due to repeated blows
? In the initial stage there will be deterioration of speed and incoordination
? Later they develop weakness in the lower limbs, hand tremors, and mental dullness.
? Final stage is characterized by slurred speech, dementia, ataxia, broad based gait and Parkinsonism like facial
appearance
Puppe's rule- determines the sequence of shots when several bullets have struck the cranium
Whiplash injury - acute hyperflexion followed by acute hyper extension of spinal cord
Stab injury to heart most common in - right ventricle
Driver's injury, Horn boss injury or Steering wheel impact injury - buckled sternum
Langer's line: gaping is more if the incision is made at right angles to Langer's line
Causes of death from wounds
Immediate or Primary causes
? Hemorrhage (MCC)
? Infection/Sepsis (MCC)
? Neurogenic Shock
? Thrombo-embolism
? Crush syndrome
? Air embolism
? Fat embolism
? Acute Respiratory Distress Syndrome (ARDS)
? Miscellaneous
Antemortem wounds
Post mortem wounds
Edges are swollen and everted
Gaping present
No gaping, edges are approximated
Abundant bleeding
Slight or no bleeding
Venous bleeding
Evidence of spurting of blood seen
No spurting
Blood extravasated in the subcutaneous tissue
Adjacent tissues are stained which cannot be removed by
Easily washed away
washing
Coagulated blood seen in wounds
Vital reaction positive
Negative
Increased enzyme activity
No enzyme activity
? Falanga (bastinado) - physical torture with canes or rods are used to beat on the soles
? Telefono - repeated slapping on the sides of head over ears
? Wet submarino(latina) - forced immersion of head in water contaminated with urine or feces
? Dry submarino - tying a plastic bag over the head until suffocation
? Cattle prod - electric shock especially over the genitals
? Chepuwa - the legs and thighs are tied very tightly with bamboo sticks to induce severe pain
? Ghotna - rolling a wooden log over the thighs up and down, while the log is weighed by one or two
policemen standing on it
going to hit him. He hears the sound of a vehicle very near to him, causing fear and shock
? Dunking - victim is immersed into water, taken out after some time and given chance to confess
Declaration of Tokyo by World Medical association in 1975 - guidelines for medical doctors concerning
torture
FIREARM INJURIES
Proximal (Internal) ballistics: study of firearms and projectiles
Intermediate (External) ballistics: study of motion of a projectile after being ejected from the firearm till the
time it hits the target
Rifling
? In rifled firearms, the interior of the barrel - parallel, spirally twisted grooves
? In smooth bored firearms - interior surface is smooth
? Rifling imparts a spin or rotation to the projectile and it acquires a gyroscopic steadiness, preventing it from
? Paradox guns: if the barrel is partly smooth bored and partly rifled
Tvoes of stun aowder
Black powder
Smokeless powder
? 75% potassium
? 20% smokeless
? Single base: nitrocellulose alone
powder
? Double base: Nitrocellulose +
? 15% charcoal
? 80% black powder
? 10% sulphur
? Most effective type ? capable of
? Single grain of black
imparting high velocity to the projectile
? Single grain of smokeless powder
200 - 250 cc of gas
? produces 800 - 900 cc of gas
Parts of a firearm
Chamber - in which cartridge or magazine is
lodged
and the firing pin
Cylinder - where explosion takes place Barrel -
Hollow steel tube
Rear end of barrel - breech
Choking
? In smooth bored firearms the barrel becomes narrower towards the muzzle end to minimize the dispersion
of pellets
? Cylinder bore: a barrel that is not choked
? Calibre of a rifled firearms is measured between two diametrically opposite lands
? Calibre of a shot gun is expressed in terms of the number of balls of lead which can be made out of 1 pound
of the metal, so that each fits exactly into the bore of the weapon
? Helixometer - instrument to examine the interior of the barrel
Firing range
Shot gun
30 - 40 m
Revolver, Pistol
Rifle
1000 m
Military rifle
3000 m
Effects
Flame
Singeing, burning, blistering
Smoke
Gun powder
Tattooing, stippling, peppering
Distance travelled by different components of explosion
Revolvers and Pistols
Rifles
Smoke
30 cm
30 cm
Flame
45 cm
8 cm
Gun powder
60 - 90 cm
60 cm
75 - 100 cm
Contact shot (point black shot)
Close shot (within the range of flame)
? Large wound, shows cavitation
? Circular wound
? Singeing of hair +
wound
? Burning, blackening and tattooing +
? Over abdomen - circular wound
? Muzzle imprint may be present
collar +
? Margins contused and everted
? Singeing of hair present
minimal/absent
? Tissues are cherry red in colour (carbon
monoxide)
Distant shot (beyond the range of gun powder)
? No burning, no blackening, no singeing
? Circular wound < diameter of the bullet
? Tattooing +
? Abrasion collar +
? Burning, blackening, tattooing absent
? Round entrance wound
? Abrasion collar present
? When the bullet (projectile of a rifled firearm) penetrates the skin while entering, due to spin, the edge of
the entrance wound may be abraded in the form of a collar
? Absolute proof of entrance wound of a rifled firearm (always seen)
? Main factors contributing to abrasion collar
Elasticity of the skin
? When the bullet comes in contact with the skin, its spinning action develops great friction against the
elasticity of the skin
? Thus it produces a collar of abrasion all around the wound of entry
? Helps to determine direction of firing
When the bullet enters the skin at right angles - round abrasion collar
When the bullet enters the skin obliquely - oval or oblique abrasion collar
WOUNDS PRODUCED BY SHOTGUN
Close shot
? Large, irregular hole resulting from the
? Circular defect with irregular borders
explosive blast effect
? Burning + Blackening + Tattooing +
? Pellets enter the body en masse
? The shot (pellets) enter the body en masse
? Rat hole entry wound (30 cm - 1 m)
? Satellite holes around entry wound (2 - 3 m)
Near shot
Distant shot
? Circular or oval wound
? Smudging upto 30 cm
? No burning, blackening or tattooing
? Wad causes mild abrasions upto 30 cm
? Wad may be present inside the wound (upto
5m)
? The pellets travel as a compact mass upto 45
? Pellets disperse significantly - the size of the
cm
? After that disperse and enter as individually
? Beyond 6 metres - no central hole
Rule of thumb: the diameter of spread in inches = range in yards x 1.5
Entrance wound
Size smaller than the diameter of bullet
Larger
Inverted edges
Everted edges
Absent
Burning, blackening and tattooing seen
Absent
Fat protrusion not seen except in contact shot
Tissues may be cherry red due to CO
No colour change
Fibres of clothing may be turned in
Turned out
Absent
Shored (supported) exit wound
? If the skin at the exit wound is supported (belt, waist band of trousers or if the body leans against the wall,
chair, door)
? Resembles wound of entrance
Bullet wounds in skull
? Wound is funnel shaped; funnel opening up in the direction in which the bullet is travelling
? Entrance wound
Inner table - beveling (sloping surface)
? Exit wound
Inner table - punched hole
Outer table - beveling (sloping surface)
? It is directly related to the kinetic energy at the moment of impact (E=mv2/2)
? Thus the wounding power depends mainly on the velocity of the bullet
Peculiar effects of firearms
? Ricochet bullet - before striking the target, bullet strikes an intervening object and then rebounds to the
? Yawing bullet - travel in irregular fashion, produce a key hole entry wound
? Dum Dum bullet - a jacketed bullet with nose cut off
? Tumbling bullet - rotates in end to end
? Souvenir bullet - left in the body for body for some time and covered with dense fibrous tissue
the next one
? Frangible bullet - fragments at the site of impact
? Mushroom bullet - expand upon impact and thus produces more serious wounds
? Kennedy phenomenon - Surgical alteration or suturing of gunshot wounds, evaluation of wounds become
? Crime bullet or exhibit bullet: bullet found in the body
? Test bullet: test fired bullet
? Tracer bullet
Projectiles that are built with a small pyrotechnic charge in their base
visible to the naked eye
This enables the shooter to follow the projectile trajectory to make aiming corrections
Autopsy in a case of death due to firearms
? Whole body X-ray to localize the bullet/pellets
? All skin wounds should be dissected out carefully with surrounding tissue and preserved in glass containers
containing rectified spirit
? The bullet should be removed with fingers or rubber tipped forceps and not with toothed metal forceps
? It should not be washed as it would remove any residues
in court
Tests for firearms
Neutron activation analysis
Atomic absorption spectroscopy (AAS)
Flameless AAS
Bullet rotates at 3000 revolutions per second as it leaves the barrel of a rifle
Incendiary bombs - primarily cause burns
Motolov cocktail - an incendiary bomb, bottle filled with gasoline and a rag to serve as a wick which is
lighted and thrown at the target
THERMAL INJURIES, LIGHTNING, ELECTROCUTION, TRACE EVIDENCE, FORENSIC
PSYCHIATRY
BURNS
Area of body
Infant
Child
Adult
20
19
9
Front of trunk
16
18
Back of trunk
20
18
Upper limbs
20
19
Lower limbs
20
30
36
0
0
1
Minimum temperature for producing a burn is 44?C for about 6 hours
? First 24 hours - neurogenic shock
? 24 - 48 hours - hypovolemic shock
? After 48 hours - septic shock
Findings indicative of ante mortem burns
? Carboxy hemoglobin in blood
? Albumin and chloride in blisters
? Healing and granulation
? Increased enzymes in blisters
Pugilistic (boxing or fencing) attitude occurs both in ante mortem and postmortem burns
Curling's ulcer - sharply punched out mucosal defects in duodenum in 10% burns deaths
Heat ruptures can be differentiated from incised/lacerated wounds by
? Presence of intact nerves, blood vessels and connective tissue in the floor
? Absence of bruising or other vital reactions in the margins
? Irregular margins
Antemortem burns
Postmortem burns
Absent
Blister contains serous fluid with proteins and chloride.
Air and thin clear fluid.
Base - red
Vital reaction present
Absent
Enzymatic activity present
Absent
Absent
Carbon particles in airway
Absent
SCALDS
? Liquid above 60?C or steam
Burns
Scalds
Site: At and above the site of contact
Splashing absent
Splashing present
Skin: Dry, wrinkled
Soddened and bleached
Blisters over scald area
Charring, singeing present
Absent
Clothes burnt
HEAT CRAMPS/ MINER'S CRAMPS/STOKER'S CRAMPS
? Persons working in high temperature and sweating is profuse
? Vigorous exercise also results in loss of electrolytes through profuse sweating in hot weather
? Rapid dehydration and loss of sodium and chloride from the body through sweat
? Treatment - i.v. saline causes rapid relief
HEAT PROSTRATION/HEAT SYNCOPE/ HEAT COLLAPSE/HEAT
? Most common hyperthermia syndrome
? Failure of CVS to compensate for hypovolemia
tower limbs
? Skin cold, pupils dilated, pulse thready
? Treatment - rest with head down position
HEAT HYPERPYREXIA/ HEAT STROKE
? Very high body temperature (upto 110?F or 43.3?C)
? No sweating, Delirium, coma, convulsions, multiple organ failures
? Predisposing factors - high temperature, increased humidity, minor infections, old age, alcoholism
? Necrosis of the muscles (rhabdomyolysis) and myocardium due to nitrosylation of the ryanodine receptor
? Treatment: rapidly cooling the body with ice water till the rectal temperature falls below 102?F
Disorder
Body temperature
Skin
Heat cramps
37?C
Moist and cool
Normal
<40?
Sweating
Normal
Heat stroke
Dry (anhydrosis)
Impaired consciousness
FROST BITE
? When the tissue temperature drops below 0 ?C (32?F)
? Vascular endothelium is damaged, stasis progresses rapidly to microvascular thrombosis.
? Finally, thrombosis, dermal ischemia, and superficial necrosis appear
? Usually occurs in extremities
? Blisters can also be seen
? Immersion foot results from repetitive exposure to wet cold above the freezing point.
? The subsequent development of bullae is often indistinguishable from frostbite.
? This vesiculation rapidly progresses to ulceration and liquefaction gangrene.
ELECTROCUTION
? Electrocution is rare at less than 100 volts and most deaths occur at more than 200 volts
? Alternating current (AC) is more dangerous than equal voltage of direct current (DC). This is because when
AC comes in contact with muscles, it produces tetanic muscle contractions and does not allow the person to
release the contact with the source of current
? The electric burn at the point of entry is called Joule burn or endogenous burn
? Spark burn or exogenous burn is produced by intermittent contact and arcing of current from the conductor
to the skin. There is an air gap between metal and skin
? Multiple burnt or punched out lesions are produced due to an arc dancing over the body surface which
? If the point of entry is one upper limb and the point of exit is the opposite foot, the current will pass across
the chest and most likely to produce myocardial fibrillation
? Current passing through the head may cause brain stem damage with central respiratory paralysis
? Skeletal muscle in the path of the current may show Zenker's degeneration
the tissues
? Heat generated by the current may melt the calcium phosphate, which is seen radiographically as round
density foci (bone pearls or wax drippings)
? There may be bone necrosis or Zig-zag microfractures
Current voltages
? Domestic current - 220 to 240 volts.
? Industrial current - upto 400 kilovolts
? Lightning - > 1000 million volts
? 1000 million volts; 20000 amperes
? Attracted by the highest points
? Chooses the easiest path
Postmortem appearances
Rupture of ear drums
Contusions, lacerations, fractures, rupture of organs
Clothes may be torn or stripped off and thrown apart
Shoes may be burst open
Linear burns over skin creases and folds
Medicolegal importance
? Most deaths occur in the open (persons sheltering under trees, open fields, carrying something which
attracts lightening)
? The crime scene may suggest sexual offence or criminal violence - clothes stripped off, abrasions, contusions
and lacerations in a body found in an open field
? Diagnosis should be based on the history of thunderstorm in the locality, evidence of effects of lightning in
the vicinity of the body and fusion or magnetization of metallic substances
? Superficial thin irregular tortuous markings on skin resembling branches of a tree
? Fern-like pattern of erythema over the shoulders or flanks
? Does not correspond to vascular channels
? Not associated with burning
TRACE EVIDENCE
? Locard's principle of exchange: When any two objects come into contact, there is always a transfer of
material from each object on the other
Tests for blood stains
Confirmatory tests
? Benzidine test (Alder's test)
? Haemin crystal test (Teichmann test)
? Phenolphthalein (Kastle Mayer test)
? O-toluidine test
? Immunological test - precipitin test
? Leucomalachite green test
? Spectroscopy - most reliable for detecting
both recent and old stains
Blood grouping from blood stains
? Latte's crust method
? Absorption inhibition
? Latex method
? Mixed agglutination
Agglutinogens in the stain are retained for longer time, even though red cells are destroyed. The absorption
DNA TYPING/DNA FINGERPRINTING
? DNA finger printing was developed by Dr. Alec Jeffreys in 1985
? Short tandem repeats(STR) are used as markers for human identification in forensic casework Mitochondrial
DNA analysis is the method of choice when dealing with environmentally challenged samples and also used
Samples collected for DNA analysis
? Muscle is the most ideal source for extracting DNA. 100mg muscle with NS or dimethyl sulphoxide (DMSO)
solution saturated with sodium chloride as a preservative
? 5ml of i.v blood with heparin or EDTA
? Semen, vaginal swabs, saliva sent in the dried condition
? Urine 10ml (frozen)
? Hair (10-20) picked using forceps without damaging the root (cut hair without root is not useful)
? Femur or humerus with bone marrow and molar teeth without preservative
Tests for seminal stains
? Creatine phosphokinase test
? Acid phosphatase test
? Barberio's test (crystals of spermin picrate)
FORENSIC PSYCHIATRY
? Mens rea - criminal mind
? Actus rea - actual physical act causing death
written by a testator in his own hand writing
? Testamentary capacity is the mental ability of a person to make a valid will
? Observation time for a person for diagnosis of insanity - usually 10 days, but with the permission of
Magistrate may be extended to 30 days
days
? Section 84 IPC: (based on McNaughten rule) Nothing is an offence which is done by a person, who at the
time of doing it, by reason of unsoundness of mind, is incapable of knowing the nature of the act or that he is
doing what is either wrong or contrary to the law
Can make valid will
Can give valid evidence in a court of law
Is legally responsible for his deeds
REAL INSANITY
Gradual onset
Sudden
No motive
Motive present(commission of crime)
factors present(h/o insanity in parents,
Absent
sudden monetory loss)
Facial expression ? peculiar (vacant look) or fixed look of
excitement
voluntary
Insomnia present
Cannot persist, sleeps soundly after a day
Patient can stand exertion of fatigue, hunger and sleep for
Cannot stand exertion for more than a few
several days without breaking down
days and breaks down
Resents for fear of detection
THE MENTAL HEALTH ACT, 1987
Terminologies changed
? Mentally ill person ( instead of lunatic)
? Mentally ill prisoner (instead of criminal lunatic)
Provisions of the act
? Mentally ill person - a person who is in need of treatment by reason of any mental disorder other than
? Establishment and maintenance of psychiatric hospitals can be done only with license which has to be
renewed every five years
? Govt. appoints 5 visitors (atleast 1 Medical officer) for each nursing home - inspection every month -
examine - examine every minor patient
? Impulse is a sudden and irresistible force compelling a person to the conscious performance of some action
without motive or forethought and preparation
Types of impulses
? Pyromania: Irresistible desire to set fire to things
? Dipsomania: An irresistible desire for alcoholic drinks at periodic intervals
? Oniomania: Irresistible desire for shopping
? Mutilomania: Irresistible desire to injure and mutilate animals.
STARVATION
? Feeling of hunger lasts for 30 - 48 hours
? Loss of 40% of body weight is usually fatal
? If both water and food are withdrawn, death occurs in 10 - 12 days
? Rigor mortis sets in and disappears quickly
? Gall bladder is distended with bile
? Baby-farmer: child starved by their parents or guardians
MECHANICAL ASPHYXIA
HANGING
? Typical hanging - knot at the occiput
? Atypical hanging - knot elsewhere
? Complete hanging - no part of the body touches the ground
Causes of death in hanging
? Venous congestion
? Asphyxia
? Asphyxia + venous congestion (mcc)
? Reflex vagal inhibition
? Fracture dislocation of cervical vertebrae
Tension required to occlude various structures in the neck
? Jugular veins - 2 Kg
? Trachea - 15 Kg
? Vertebral arteries - 20 Kg
Judicial hanging
? Atypical hanging (knot under the angle of jaw)
Postmortem findings in hanging
External
Internal
? Cyanosis
? Petechiae (Tardieu spots) noted
? Petechiae
? Over forehead, face, temples,
? Fluidity of the blood
? Tissues under the ligature mark are dry, pale and glistening
? Le Facies sympathique
? Transverse intimal tears of carotid arteries ? in cases
? Salivary dribbling
? Glove and stocking hypostasis
? Thyroid cartilage fracture
? Ligature mark
? Hyoid bone fracture
? Dribbling of saliva
? Le Facies Sympathique - if the ligature press the cervical sympathetic chain, the eye on the same side is open
and pupils dilated
? Intimal tears in the carotid artery
Hyoid bone # seen in 0 - 60 % (common above 40 yrs)
STRANGULATION
? Ligature strangulation: neck constricted with a ligature
? Manual strangulation or Throttling: Neck constricted with hand
? Mugging - strangulation caused by holding the neck of the victim in the bend of the elbow
? Bandsola - neck constricted between two bamboo sticks
'MANUAL STRANGULATION OR THROTTLING'
? Constriction of the neck by hands
PM findings
? Linear or crescentic abrasions (nail marks) on the neck
? Bruising - one prominent bruising on one side of neck (thumb) and three to four abraded contusions on the
other side (other fingers)
? Fracture of superior thyroid horn
? Fracture of hyoid bone
HANGING
LIGATURE STRANGULATION
Ligature mark
? Oblique
? Transverse
? Does not encircle the neck completely
? Below chin and above thyroid cartilage
? At or below thyroid cartilage
? Base -pale, hard and parchment like
? Base - soft and reddish
Bruising of neck muscles common
Neck stretched and elongated
Not so
Hyoid bone fracture may occur
Thyroid cartilage fracture less common
Thyroid cartilage fracture more common
Carotid intimal tears seen
Rare
Absent
Bleeding from nose, mouth and ears uncommon
Common
Subconjunctival hemorrhage absent
Hyoid bone fractures
? Inward compression # or adduction # (periosteum torn outside) - throttling
? Antero posterior compression # or abduction # (periosteum torn inside) - hanging
? Avulsion# or tug # or traction# - due to muscular over activity
? In any case of suspected injury to the neck and suspicious deaths (hanging, strangulation), neck should be
opened last
? After opening abdominal, thoracic and cranial cavity and removing all the viscera and draining all the blood,
neck should be opened - bloodless dissection of neck
? In ligature strangulation & throttling - extravasation of blood, injury to neck structures and muscles
DROWNING
? Wet drowning/Primary drowning: water is inhaled into the lungs
? Dry drowning: water does not enter the lungs; death results from immediate sustained laryngeal spasm
survives for 24 hours
? Immersion syndrome/Hydrocution/Submersion inhibition:
Death due to cardiac arrest due to vagal inhibition
Stimulation of the vagal nerve endings
o Water striking the epigastrium while diving
o Sudden inrush of cold water into the ears
? Predisposing factors
Young swimmers
Excitement and emotions
Overeating prior to swimming
Fresh water drowning
0.6%NaCI
>3%NaCI
Denatures the surfactant
Dilutes surfactant
Hemoconcentration
Hyponatremia, Hypocalcemia, Hyperkalemia
Hypernatremia
Cause of death - ventricular fibrillation, cardiac failure
due to volume overload and hypoxia of myocardium
edema
Lungs ? ballooned and light, emphysematous, shape
Lungs - ballooned and heavy,
soft, shape not retained,
heard, little froth, no fluid
collapse on removal, c/s ? no
crepitus, copious fluid and froth
External
? Dilated pupils, Light pink PM staining, RM develops early
? Fine , white , leathery, copious froth in mouth and nostrils (most characteristic finding)
? Weeds, gravel, twigs or leaves present in water may be firmly grasped in hands due to cadaveric spasm
? Cutis anserina or goose skin and retraction of scrotum and penis due to submersion in cold water(reaction
phenomenon)
Internal
? Lungs - voluminous, completely occupy thoracic cavity, bulge out from chest when sternum is removed,
? Emphysema aquosum - edematous lungs with froth and Paultauf's hemorrhage
? Edema aquosum - edematous lungs without froth and Paultauf's hemorrhage
? Hydrostatic lung: if a dead body is thrown into water, due to the hydrostatic pressure water passes into the
lungs
Gettler's test
? Chloride content of the right and left chambers of heart is normally equal on both sides
? In fresh water drowning, 50% reduction in chloride concentration on the left side of heart
? In salt water drowning, 30-40% increase in chloride concentration on the left side of heart
features
? Diatoms - unicellular algae, walls made of silica
? Serum strontium levels are raised in drowning
? Plasma specific gravity on the left side of heart < right side(left> right in non-drowning cases)
Findings suggestive of ante-mortem drowning
? Froth from mouth and nostrils
? Cadaveric spasm
? Emphysema aquosum
SEXUAL/AUTO-EROTIC ASPHYXIA/ASPHYXIOPHILIA
? Young males with abnormal sexual behavior
? Sexual pleasure by partial reduction of blood supply to the brain
? Compressing the blood vessels in the neck
? Circumstantial evidence - Padding under the ligature, undressed or dressed like a women, pornographic
literature, drugs like cocaine, alcohol
Caf? coronary (Food asphyxia)
? The term, 'Cafe Coronary' , was coined by Dr Roger Haugen
? Death appears to be due to heart attack. Hence the name caf? coronary (misnomer)
? At autopsy a large piece of food bolus is found obstructing the larynx
? Death is due to choking
? The suppression of gag-reflex due to alcohol or drugs makes the individual susceptible to Cafe Coronary
Spanish windlass technique - a type of suicidal strangulation
Burking - a combination of homicidal smothering and traumatic asphyxia
Choking - obstruction of internal air passages by food particles or foreign body, usually accidental
Smothering - asphyxia caused by closing mouth and nostrils
SEXUAL JURISPRUDENCE & INFANTICIDE
IMPOTENCE & STERILITY
Impotence - inability of a person to perform sexual intercourse
Frigidity - inability to initiate or maintain sexual arousal in female
Satyriasis - excessive sexual desire
Quoad hanc (Impotentia quoad persona) - a male impotent with a particular woman but not with other
women
occur due to the passage of sperm from external genitalia to the uterus
Artificial insemination
? Artificial Insemination Homologous (AN) - If the semen used is derived from the women's husband
? Artificial Insemination Donor (AID) or Heterologous artificial insemination - If the semen is obtained from a
? Artificial Insemination Homologous Donor (AIHD) - A mixture of husband's semen with the donor semen
(Pooled semen) is used
VIRGINITY
? Hymen
? Thin (but firm) fold of connective tissue
? 1 mm in thickness
? Usually has a central aperture
? Diameter of hymenal orifice in prepubertal children in mm = age in years
? Semi lunar/crescentic type - most common
? Annular type - may appear intact even after sexual intercourse has taken place
? Fimbriated type - may appear torn even in the intact state
? The ruptured segments of hymen gradually become thicker and smaller and appear as small fleshy pyramidal
? After vaginal delivery, the hymenal tags may disappear or attain irregular thick margins carunculae
myritiformis
Virginity
Defloration
Torn or intact; loose and elastic
Intact, Rigid and inelastic
Wide opening easily allowing two fingers to
Narrow opening hardly allowing tip of a finger to pass
Labia majora adjacent to each other; completely closing the
Labia majora are separated, flabby, vaginal orifice
vaginal orifice
seen at lower end
Clitoris enlarged
Fourchette - intacy
Fourchette - torn
Vagina is narrow, more prominent rugae
rugae are less obvious
PREGNANCY
Probable signs of pregnancy
? Amenorrhea
? Enlargement of abdomen
? Breast changes
? Morning sickness
? Goodell's sign (softening of cervix)
? Quickening
? Braxton-Hick's sign (intermittent uterine
? contractions)
? Jackquemier's or Chadwick's sign
? Batlotment
(discoloration of vagina)
? Urinary disturbances
? Immunological tests
? Sympathetic disturbances
? Biological tests
? Fetal parts and movements felt by placing the hands on the abdomen
? Fetal heart sounds
? Placental souffl?
? Funic or Umbilical souffl?
? Ultrasound
Spurious or Phantom pregnancy (Pseudocyesis)
? The woman believes that she is pregnant, though she is not.
? May present with enlargement of abdomen due to fat deposition or some pathological condition
? May even have false labour pains
? All the symptoms vanish once she is informed that she is not pregnant
? Seen in women who strongly desire for a child or who are afraid of being pregnant
? Occurs in young women and women nearing or just achieved menopause
coitus at short interval
Super fetation - fertilization of second ovum in a woman who is already pregnant (ova from different
menstrual cycle)
Atavism - child does not resemble parents, but grand parents
delivered the child.
Posthumous child - child who is born after the death of its father
Surrogate mother (Womb leasing)
o
incapable to carry child
o
Consent should be obtained prior to the procedure
DELIVERY
Lochia (discharge from the uterus which lasts for 2 -3 weeks after delivery)
? Lochia rubra: first 4-5 days after delivery, bright red color
? Lochia serosa: next 4 days, thin, pale and serous discharge
? Lochia alba: after 9th day, dirty white color
NULLIPARA
MULTIPARA
Size
Smaller (7 x 5 x 2 cm)
Weight
40 - 50 g
80 - 100 g
Length
Body is twice the length of cervix
Upper surface of
Less convex Et is in the same line
More convex & is at a higher level than the
of broad ligament
line of broad ligament
Uterine cavity
Convex inner walls, small triangular
cavity with less space
cavity
Scar for placental
Not seen
attachment
External Os
Small, roundish dimple like depressed Transverse slit like opening.
opening.
Circular, well defined.
Not well defined, margin wrinkled.
Uterus returns to normal size 6 weeks after delivery
Natural abortion
? Spontaneous
? Accidental
Artificial abortion
? Criminal
The World Medical Association, adopted a resolution on therapeutic abortion - Declaration of Oslo (1970)
The MTP ACT - 1971 (Amended 1975 & 2002)
? Therapeutic - when the continuation of pregnancy endangers the life of woman or cause serious injury to
her physical or mental health
? Eugenic - Risk of the child being born with serious physical or mental abnormalities
The women in the first 3 months of pregnancy suffers from German measles, small pox, chicken pox,
If the pregnant woman is treated with drugs like thalidomide, cortisone, aminopterine, antimitotic drug
or she consumes hallucinogens or antidepressants
If she is treated by X rays or other irradiation
Insanity of the parents
? Social - when the pregnancy is a result of failure of contraception in case if a married woman which is likely
to cause serious mental injury
? Environmental - when social or economic environment, actual or reasonably expected can injure mother's
health
? Chief Medical Officer of the district is empowered to certify that a doctor has the sufficient training
? A doctor is qualified if he/she has assisted 25 cases of MTP in a recognized hospital
? Consent of the husband not necessary
? No need for the woman to produce age proof, oral statement is enough
? Duration of pregnancy < 12 weeks - one doctor can perform
? 12-20 weeks - two doctors must agree that there is an indication for MTP
? In case of emergency, can be performed by a single doctor, even without training, even after 20 weeks, even
without consulting another doctor, even in a private hospital which is not recognized
Natural offences
Unnatural offences
Sexual perversions
Sex linked offences
Sodomy
Sadism
Voyeurism
Incest
Masochism
Stalking
Adultery
Tribadism
Sexual harassment
Buccal coitus
Fetichism
Trafficking
Indecent assault
NATURAL SEXUAL OFFENCES
RAPE
? Age of the accused - in India there is no age limit under which a boy is considered physically incapable of
committing rape
? Sexual intercourse or sexual acts by a man with his own wife, wife not being under sixteen years of age, is
not sexual assault
violent nor physically coerced
? Marital Rape - forceful sexual intercourse with wife who is living separately from him, without her consent.
It is punishable with imprisonment up to two years provided the age of the wife is not < 12 years
Examination of rape victim
? In a virgin, tearing of hymen usually occurs posteriorly in the 4 or 8 'O clock position or 5 or 7'O clock
position
Genital examination of rape accused
? Smegma under the prepuce
and smegma bacilli (Mycobacterium smegmatis)
Smegma usually gets wiped off during sexual intercourse
Absence of smegma is not a conclusive evidence of sexual intercourse as it can be cleaned during bath
Presence of smegma is an evidence that the person did not have sexual intercourse or complete
? Lugol's iodine test
Shaft of the penis is examined for the presence of vaginal epithelial cells
Vaginal epithelial cells have high glycogen content
Shaft of the penis is wiped off with a clean filter paper and the filter paper is exposed to vapours of
Brown colour indicates the test is positive (surest sign of recent sexual intercourse)
? Pap test
Wash the penis in sterile saline
Stain with pap stain to demonstrate vaginal cells, cervical cells, Barr body
? Nail scratches over face, chest
? Bite marks over arms and other parts
? Bruises
? Tearing of frenulum
? Sexual intercourse by a man with a woman who is closely related to him by blood (prohibited degrees of
relationship) e.g. daughter, sister, granddaughter, step sister.
? In India, incest as such, is not an offence
ADULTERY (S. 497 IPC)
married woman and someone other than her husband
UNNATURAL SEXUAL OFFENCES S 377 IPC
? Sodomy/Buggery - anal intercourse
? Gerontophilia - when the passive agent is an adult in sodomy
? Pedophile - adult who repeatedly engages in sexual activities with children
? Eunuchs - male prostitutes in India, act as passive agents in sodomy
? Buccal coitus or Sin of Gomorrah or Coitus per os- penis introduced into the mouth
? Tribadism/Lesbianism/Sapphism - female homosexuality
Lateral buttock traction test - to examine the victim of sodomy
SEXUAL PERVERSIONS
? Uranism - general term for sexual perversion which includes sexual gratification by fingering, fondling, licking
and sucking the genitalia of opposite sex
? Sadism - sexual gratification obtained from acts of cruelty or infliction of pain on the partner
? Lust murder - murder serves as a stimulus for sexual act
? Necrophilia (S 297 IPC)- sexual intercourse with dead bodies
? Necrophagia(S 297 IPC) - eating the flesh, drinking the blood of the victim to drive sexual pleasure
? Bondage/ Algolagnia - sadism+masochism
? Fetichism - sexual excitement by seeing undergarments of a women
? Transvestism/Eonism - desire to be identified as opposite sex
? Scatalogia - obscene telephone calls
? Annilingus (rimming) - kissing the anus
? Cunnilingus - oral stimulation of female genitalia
? Masturbation (Onanism, ipsation, autoeroticism) - deliberate self-stimulation for sexual arousal
? Exhibitionism (S 294 IPC) - exposure of genitalia in a public place to obtain sexual pleasure
? Urolagnia - sexual pleasure by seeing the act of urination
? Caprolagnia - sexual pleasure by the smell or sight of faeces or defaecation
? Undinism - by urinating over the partner
? Narcism - self love
? Bobbit syndrome - female amputates penis of her mate partner
? Trolism - sexual practice by involving 3 persons; 2 of one sex and one of the opposite sex
? Mixoscopia - sexual satisfaction by the sight of others engaged in sexual intercourse
? Oedipus complex - sexual desire of son towards his mother
? Pharoan complex - sexual desire of brother towards his sister
? Onanism/ipsation/masturbation - self stimulation which effects sexual arousal
SEX LINKED OFFENCES
? Voyeurism/Scotophilia - see people undress to be sexually satisfied
? Stalking - following a person, monitoring by internet, email, or any electronic communication, spying a
person despite clear indication of disinterest by that person, resulting in loss of mental peace of that person
? Trafficking - for the purpose of exploitation, whoever recruits, transports, harbours, transfers, receives a
person in illegal way
INFANTICIDE
Infanticide - unlawful destruction of a child less than one year
Foeticide - killing of fetus at any time before birth
Still birth - born after 28th week of pregnancy, which did not show any signs of life after birth. The child was
alive in utero, but dies during the process of birth
Spalding's sign - in fetal death, loss of alignment and overriding of skull bones (due to shrinkage of
cerebrum)
Rigor mortis at birth
Maceration
o Aseptic autolysis
o Occurs when the dead child remains in the uterus for 3-4 days surrounded with liquor but exclusion
o If air enters the liquor after death, putrefaction occurs instead of maceration
o First sign of maceration - reddening of skin with peeling and slippage (after 12 hours)
Mummification
Tests for live birth
66 Gms. Not reliable
? Plocquet's test - the ratio of weight of lungs to weight of the body before respiration - 1/70; after respiration
- 1/35. Not reliable
? Hydrostatic test or Raygat's test - the specific gravity of lungs before respiration: 1040-1050; after
? Breslau's second life test or stomach bowel test - air swallowed into the stomach which floats
? Wredin's test - middle ear changes after birth
? Vagitus uterinus - respiration(cry) of the fetus while in the womb after the rupture of membranes Vagitus
vaginalis - respiration while the head is in the vagina
Unexpanded lungs may
Hydrostatic test is not necessary when
may sink due to
float from
? Putrefaction
? Fetus is a monster
? Congenital syphilis
? Artificial
-
? Atelectasis
? inflation
? Fetus born before 180 days of gestation
? Stomach contains milk
? disease
? Umbilical cord has separated and a scar has
formed
Time
Blood clots at the cut end
2 hrs
Vessels closure and drying
Inflammatory ring
36-48hrs
Mummification
2-3days
5-6days
Healing of ulcer and scar formation
10-12days
BATTERED BABY SYNDROME or CAFFEY'S SYNDROME
? Youngest or the eldest child
? Repetitive physical injuries as a result of non-accidental violence
? There may also be deprivation of nutrition, care and affection
? The classical feature of this lesion are discrepancy between the nature of injuries and the explanation
? Fractures and injuries will be at different stages of healing
? Most characteristic lesion - laceration of mucosa inside the upper lip and often tear of frenulum
? Nobbing fractures - multiple rib # in the posterior angle
? X-ray shows string of beads appearance in the para vertebral gutter after callus formation
SUDDEN INFANT DEATH SYNDROME/CRIB DEATH/COT DEATH
? Age group 2 weeks to 2 years (Most vulnerable age 3-4 months)
? Incidence 0.2 to 0.4% of all live births
? Rainy and winter season
? Male: female=3:2
? Lower and middle class
? Most deaths in the early morning
Proposed causes
? Local hypersensitivity of the respiratory tract to bovine mild
? Viral infection of the respiratory tract
? Beds and pillow falling accidentally over the mouth and nose
? Accidental prone position of the baby
TOXICOLOGY
Viscera preserved routinely in cases of suspected poisoning
? Stomach and contents
? Small intestine (upper part 30 cm) and contents
? One half of each kidney
? Blood (30 ml)
? Urine (30 ml)
Collection of blood
? After removal of viscera - from iliac veins
? Blood should never be collected from pleural or abdominal cavities
Additional viscera to be preserved in special circumstances
Viscera preserved
Heart
Strychnine, Digitalis, Oleander
Brain
OPC, opiates, CO, cyanide, strychnine, barbiturates, anesthetics
Strychnine, gelsemium
CSF
Alcohol
Bile
Vitreous
Alcohol, Chloroform
Skin
Hypodermic injection marks
Arsenic, antimony, thallium, radium
Fat
Insecticides and pesticides
Poison
All poisons except corrosives, aconite
Saturated saline
All acids except carbolic acid
Rectified spirit
Sodium fluoride + potassium oxalate
Blood (oxalic acid, ethylene glycol, fluoride)
Sodium citrate
Carbon monoxide
Urine
Thymol or Toluene
Histopathological examination
10% formalin
50% glycerine
? Viscera for chemical analysis should not be preserved in formalin, as extraction becomes difficult
Poison
Odour
Garlic
selenium, parathion, malathion, aluminium phosphide
Ethanol, chloroform, nitrites
Sweet or fruity (acetone/apple like)
Acrid
Hydrogen sulphide, mercaptans, disulfiram
Rotten egg
Zinc phosphide
HCN
Bitter almonds
OPC
Kerosene
Burnt rope
Carbon monoxide
Coal gas
Nitrobenzene
Methyl salicylate
Wintergreen
Poison
Stomach mucosa appearance
Slate colored
Arsenic
Red velvety
Sulphuric acid
Nitric acid
Yellow
Oxalic acid
White, bleached, scalded appearance
Grey or brown, leathery
Copper
Blue or green
Poison/Drug/Condition
Hematuria, Hemoglobinuria, Berries, Beet root
Red
Drugs: Dilantin, Phenothiazines, Adriamycin
Rifampicin, Pyridium, Urate crystals
Aniline, Brufen
Pink
Deferoxamine therapy (Et elevated serum iron)
Vin rose urine
Green
Riboflavin
Yellow
Vitamin A, warfarin
Phenol or Carbolic acid
Green or Black
Nitric acid
Brown
Liquid gold
Picric acid
Ruby red
Porphyrins
Tests
Poisons
Marsh & Reinsch test
Arsenic
Salicylates
Ferric chloride test
Phenol, Phenothiazines, Pheynlbutazone, Salicylates
Lee Jones test
Qualitative Desferrioxamine colour
Iron
test (QDCT)
Meixner test, Melzer test
Isonitrile test
Carbon tetrachloride, Chloroform, Chloral hydrate
Tensilon test
Botulism
Corrosives (acids and alkalis)
Marqui's test
Opium
Gastric lavage
? Relative contraindications
Convulsant poisons
Comatose patients
Volatile poisons
Marked hypothermia
Hemorrhagic diseases
Gastric lavage in hydrocarbon poisoning
? Useful in - camphor, halogenated, aromatic, (heavy) metal-containing, and pesticide-containing
? Contraindicated in - gasoline, kerosene, furniture polish, mineral spirits
Activated charcoal
? Most preferred method
? Large surface area - adsorbs poisons and thus reduces their absorption
? Dose: 1-2g/kg body weight
Emesis
? Only recommended method - syrup of ipecacuanha (ipecac) - oral, acts both by activating peripheral sensory
receptors in the GIT and stimulating vomiting center in the medulla
complications
? Apomorphine (s.c, i.m), copper sulphate, tartar emetic and zinc sulphate as emetics are obsolete
ANTIDOTES
Physical or mechanical
Universal antidote
Activated charcoal
Weak non-carbonate alkalis for acids
2 parts of charcoal
Weak vegetable acids for alkalis
1 part magnesium oxide
starch, barely water or milk
Freshly prepared ferric oxide for arsenic
Diluents - water, milk
Common salt for silver nitrate
Boiled rice or vegetables
Copper sulphate for phosphorus
Drug overdose
Antidote
Poison
Paracetamol,
N-Acetyl cysteine,
Cyanide
Amyl nitrite , sodium nitrite,
methionine
Dicobalt edetate,
Beta adrenergics
Propranolol
dimethyl aminophenol
Alpha adrenergics
Phentolamine
Amanitins
Beta blockers
Isoprenaline, Glucagon
Organic peroxides
Ascorbic acid
Atropine
Botulism
Guanidine
Opium
OPC
Oximes, Atropine
Benzodiazepines
Flumazenil
Fomepizole
Ethanol
Theophylline
Beta blockers
Ethanol
Isoniazid
Pyridoxine
Nitrates
Heparin
Protamine sulfate
Ergotism
Sodium nitroprusside
Fab antibodies
Radioactive metals
Pentetic acid (DTPA)
Malignant hyperthermia
Carbon monoxide
Tocopherol
Central anticholinergics
Physostigmine
Sodium salicylate
Peripheral
Neostigmine
Thallium
anticholinergics
When the nature of the poison is not known, universal antidote or coma cocktail (not used now) may be
given
Universal antidote
? Activated charcoal (50%)
? Dextrose - 100ml of 50% solution
? Magnesium oxide (25%)
? Thiamine-100mg
? Naloxone-2mg
Hemodialysis is useful in the following poisons
Hemodialysis not useful in
Ethanol
Salicylates
Copper sulphate
Methanol
Acetaminophen
Kerosene
Ethylene glycol
Bromides
Boric acid
Chloral hydrate
Fluorides
Thiocyanates
Benzodiazepines
Barbiturates
Aspirin
Digitalis
Miosis
Carbolic acid
Formalin
Alcohol (constricted in coma)
Carbon monoxide
Caffeine
Aconite
Cyanide
Opium
Amphetamine
Calotropis
OPC, carbamates
Methyl dopa
Cocaine
Barbiturates
Nicotine
Datura (Atropine)
Benzodiazepines
Nux vomica
Drugs and Cosmetics act, 1940
Regulates the import, manufacture, distribution and sale of all kinds of drugs
Any patent or proprietary medicine should display on the label or container, either the true formula or a list
of ingredients
Drugs and Cosmetics Rules, 1945
Schedule C: Biological and special products
Schedule F: Vaccines and sera
Schedule G: Hormone preparations
Schedule H: Drugs (Poisons to be sold only on the prescription of a RMP)
Schedule J: List of diseases for the cure of which no drug should be advertised
AGRICULTURAL POISONS
ORGANOPHOSPHORUS POISONS
ORGANOCHLORINES
Aryl phosphates
DDT, BHC(lindane)
HETP, TEPP, OMPA
Parathion (Follidol, Killphos)
Dimefox, Isopestox
Methyl parathion
Dieldrin, Endosulfan
Malathion(Kill bug, Bugsoline)
Endrin (plant penicillin),
Sulfotepp, Demeton
Paraoxon
Mirex
Diazinon (Tik 20)
Toxaphene , Paraquat
? MOA: inhibits true cholinesterase and pseudo cholinesterase
? Muscarinic signs and symptoms - broncho constriction, increased bronchial secretions and pulmonary
? Nicotinic - fasciculation, dyspnoea and cyanosis due to respiratory paralysis
? Intermediate syndrome
Seen in 20% patients
After 1-4 days
(spares distal muscles) and the muscles of respiration, resulting in ventilatory failure Due to prolonged
cholinesterase inhibition and muscle necrosis
Due to inadequate treatment, sub-therapeutic administration of oximes and inadequate ventilation
It does not respond to oximes and atropine
? Delayed syndrome
1-5 weeks after exposure
Peripheral neuropathy due to demyelination
Distal muscle weakness, toe drop, sparing of neck and proximal muscles
? Diagnosis
Cholinesterase determination in blood
Normal values 77 - 142 in red cells and 41 - 140 in the plasma
Plasma cholinesterase is more sensitive and fall more rapidly before that of red cells
? Treatment
Atropine 2-4mg given i.v. every 10-15 mins
Atropine should be continued until the tracheobronchial tree is cleared of the secretions and most
secretions are dried, but not pupillary status
Cholinesterase reactivators like diacetyl monoxime(DAM), pralidoxime(2-PAM)
? Chromolachryorrhoea(red tears) due to accumulation of porphyrin in lacrimal glands
? Oximes are not effective in: Edrophonium, Dime fox, Methyl diazinon, Organo-carbamates (Carbaryl,
Propoxur)
CORROSIVE POISONS
STRONG ALKALIES
? Desiccation or denaturation of superficial
? Saponification of fats and dissolves
proteins
? Coagulation necrosis
? Liquefaction necrosis
? Eschar formation
? Favors penetration
? Extensive damage
? Gastric strictures and perforation
? Esophageal strictures
SULPHURIC ACID
? Burning pain from mouth to stomach, Hematemesis (coffee ground colour), Intense thirst
? Stomach - converted into a soft, spongy, black mass which ready disintegrates on touch
? Vitriolage: throwing concentrated sulphuric acid on the face of the person with an intention to damage,
disfiguration or death
? Fuming liquid with a peculiar, penetrating odour
? Xanthoproteic reaction - yellow discoloration of tissues due to production of picric acid
? More abdominal distension due to gas formation
OXALIC ACID
? Hypocalcemia - tetany, Chvostek's sign, Trosseau sign
? Oxaluria - envelope shaped calcium oxalate crystals in urine
? Mucous membrane of tongue, mouth, pharynx, esophagus & stomach - bleached and scalded appearance
CARBOLIC ACID/CARBOLISM
(carboluria)
? Scanty urine containing albumin and hemoglobin
? Chronic poisoning (Phenol marasmus) causes pigmentation of skin and sclera - oochronosis(also seen in
alkaptanuria)
? PM appearances: gastric mucosa is swollen, grayish white, hardened (leather bottle stomach)
Treatment of acid poisoning
? Give a demulcent, olive oil, milk, egg white or starch water
? Prednisolone may be given to prevent esophageal stricture and shock
? Tracheostomy - if there is edema of glottis
Should not be done in acid poisoning
? Gastric lavage
? Alkaline carbonates or bicarbonates which liberate CO2, as they cause distension and rupture
METALLIC POISONS
ARSENIC
? Copper acetoarsenite - paris green
? Permissible limits of arsenic in ground water - 0.05mg/L
? The gastroenteric type of poisoning resembles cholera
? Greatest quantity is seen in - liver
? Most affected part of the stomach ? pylorus
? Subendocardial petechial hemorrhages of the ventricle is typical of arsenic poisoning (also found in
phosphorus, barium, mercury and in cases of heat stroke and acute infectious disease e.g. influenza)
? Rigor mortis lasts longer than usual, Delays putrefaction
? Necrosis of intestinal mucosa with hemorrhagic gastroenteritis
? Hypotension, delayed cardiomyopathy
Chronic poisoning
? Aldrich Mee's line on finger nails
? Chronic consumption of water containing high arsenic concentrations lead to vasospasm and peripheral
vascular insufficiency - black foot disease
? Diabetes, peripheral neuropathy, gangrene
? Cancer of skin, lung, liver (angiosarcoma), bladder, kidney.
? Chelating agent - Dimercaprol
Arsenic poisoning
Cholera
Pain in the throat - before vomiting
Purging - after vomiting
Before vomiting
Dark colored bloody stools initially,
Rice water stools, never blood stained
Tenesmus and anal irritation present
Absent
Vomitus contains mucus, bile and blood
Watery without mucus, bile and blood
Not inflamed
Arsenic was used as murder weapons in royal families, and called as "the poison of kings and king of poisons"
MERCURY
? Mercuric ion binds with sulphydryl groups of cytochrome enzymes and interferes with their function
ACUTE POISONING
? Inhalation: manifestations similar to Kawasaki disease
? IV injection: Mercurialism (thrombophlebitis, granuloma formation and pulmonary embolism)
? Necrosis of renal tubules, albuminuria, uremia and acidosis
HYDRARGYRISM or CHRONIC MERCURY POISONING
? Classic triad of gingivitis, tremors (Danbury tremors) and neuro psychiatric changes
? Advanced condition of Danbury tremors is called Hatter's shakes or glass blower's shakes
? Most severe form is called concussio mercurialis
mercury in mirror manufacturing films.
? Pink disease or Acrodynia is an idiosyncratic reaction seen in children due to chronic mercury exposure
? Mercurialentis - brownish deposit of mercury on anterior lens capsule
? Kidney - membranous glomerulonephritis, PCT necrosis
? Diphtheritic colitis
? If mother consumes during pregnancy - cerebral palsy in child
? BAL is the chelating agent of choice
Dimethylmercury, a compound only found in research labs, is supertoxic--a few drops of exposure via skin
Intracellular glutathione - acting as thiol donor, is the main protective mechanism against mercury induced
CNS and kidney damage
LEAD
Chronic poisoning (saturnism, plumbism)
? Facial pallor is the earliest sign
? Punctuate basophilia or basophilic stippling
? Blue line on gums called lead line or Burtonian line (seen with poor oral hygiene, at the junction of gums and
teeth due to deposition of lead sulphide)
? Lead palsy - common in adults, wrist drop, foot drop may occur
? Encephalopathy - most common manifestation in children
? Diagnosis
Coproporphyrin in urine
Blood lead > 25 micro gram per 100ml (Gold standard)
Urine lead > 0.25 microgram per liter
X ray - radio opaque bands (lead lines) at the metaphyses of long bones in children. The width of the
lead lines are related to the duration of exposure. These lines reflect bone growth arrest
Blood level (pg/ml)
Effects
10
Decreased IQ level, Decreased hearing, Growth retardation
Impaired peripheral nerve function
20
Increased nerve conduction velocity
Increased erythrocyte protoporphyrin
40
Decreased Hb synthesis
100
Encephalopathy
Frank anemia
Colic
150
Death
Treatment
? A confirmed venous blood lead level (BLL) of 45 g/dL or more requires prompt chelation therapy
? BLLs between 44 and 70 pg/dL - DMSA
? BLLs of > 70 pg/dL with encephalopathy - CaNa2EDTA + BAL
? High blood calcium levels favors storage of lead, white calcium deficiency causes lead to be released into
blood stream
Half-life of lead in bone: 20-30 years
COPPER
? Copper sulphate (blue vitriol) and copper subacetate(verdegris) are poisonous
? Death is due to hepatic or renal failure or both
? Treatment : stomach wash with 1% potassium ferrocyanide which is an effective antidote
? Hemodialysis is useful in early stages
? Chelation with penicillamine or BAL or EDTA
? Post mortem appearances - greenish blue froth at mouth and nostrils
? Chronic inhalation of copper sulfate - Vineyard sprayer's lung disease
? Ptyrlism - chronic poisoning
? Chronic contact with swimming pool water containing algicidal copper chemical compounds may cause
green hair discolouration
? Copper sulphate is used in the treatment of phosphorus poisoning - stomach wash with 0.2% copper
Thallium
? Classic triad of alopecia, skin rash, painful neuritis with confusion
? Maculopapular skin eruption with butterfly distribution on face
? Mee's line on nails
? Caused by inhalation of fumes produced when metals are heated above their melting point
? Metals involved (decreasing order of frequency): Zinc, copper, magnesium, iron, chromium, cadmium
INORGANIC IRRITANTS
Red phosphorus
Garlic odour
Odourless
Luminous in dark
Ignites at 34 degrees, so kept under water
Non inflammable
Highly toxic
Non toxic
Used on the sides of match box
? Acute poisoning - vomitus and stools are luminous in dark - Smoky stool syndrome
? Chronic poisoning due to frequent inhalation of fumes over many years cause osteomyelitis and necrosis of
jaw with multiple sinuses discharging pus - phossy jaw or glossy jaw
ABRUS PRECATORIUS
? Seeds contain active principle abrin, a toxalbumen, which is similar to viperine snake venom
? Abrine, hemaglutinin, abralin are other toxins
? When an extract of seeds is injected under the skin of the animal, inflammation, edema, oozing of
? Sharp pointed needle like objects called suis are prepared from the paste of seeds, which are forced into the
skin of animal or human for homicide (2 suis used to resemble fangs of viper) -used in cattle by leather
workers to obtain hides cheaply or for revenge
Artificial bruise is produced by
? Semecarpus
? Plumbago rosea
SNAKES
Poisonous snakes
Head scales
Large
? Small - viper
? Large + pit between eye and nostril - pit viper
cobra or coral snake
? Large, no pit, third labial does not touch nose and
eye - krait
Belly scales - large and cover entire breadth
Head usually triangular
Usually round or oval
Fangs - hollow like hypodermic needles
Short and solid
Several small teeth
Tail - rounded or flattened
Always rounded
Habits - usually nocturnal
Snake venom
? Cholinesterase is rich in venom of cobra and krait
? Hemolysins, cytolysins are rich in viper venom
Ophitoxaemia is poisoning by snake venom
Cobra. Krait
Viper
Sea snakes
? Hemotoxic (Vasculotoxic)
? Myotoxic
? Ptosis - earliest neurologic symptom
? Marked local symptoms -
? Ophthalmoplegia ? extraocular
reddish and painful swelling,
signs
muscle weakness, strabismus,
? Polymyositis,
diplopia
? Hematuria, hemorrhages in
? Trismus
the
? Myoglobinuria
? Death due to respiratory failure
? GIT, conjunctiva, brain etc
? Death due to shock &
6mg of dried venom
hemorrhage
? Lethal dose - 15 mg
? Krait - no local symptoms, intense drowsiness and intoxication
SCORPION STING
? Mixture of neurotoxic and cardiotoxic venom
? More toxic than that of snakes, but only a small quantity is injected
from the adrenals
? Local burning pain, swelling and paresthesias
? Sweating, salivation, vomiting
? Mydriasis
? Arrhythmias
? Pulmonary edema
? Oliguria
Cantharides/Spanish Fly/Blister Beetle
? Ingestion - nephrotoxicity, priapism, convulsions
TOXALBUMEN
? A Toxalbumen is a super-toxic protein that resembles bacterial toxin in action, causes agglutination of red
cells with some hemolysis and is antigenic
Ricin in Ricinus communis
Crotin in Croton tiglium
Abrin in Abrus precatorius
? Animal toxalbumen: snake and scorpion venoms
ALCOHOL
? Absolute alcohol - 99.95% alcohol
? Rectified spirit - 90-95% ethanol + 5-10% methanol + traces of castor oil
? Methylated spirit - 99% alcohol + 5% wood naptha
? Safety limit of alcohol : Male - 210g /week; Female - 140g/ week
? Action : Low concentration - CNS stimulant; High concentration - CNS depressant
? Diaphoresis, diuresis(inhibits ADH), stimulates appetite
Beverage
Vodka
60 - 65
Rum, liquor
50 - 60
40 - 45
Port, sherry
20
Wine, champagne
Beer
4 - 8
Blood level of alcohol (mg %)
Behavior
Sober
20 - 70
Drinking
80 - 100
150 - 300
Intoxicated, drunk
>400
Coma
Symptoms
0 - 50
Mild euphoria
50 - 100
100 - 150
Confusion, impaired memory, slow reaction time
150 - 300
Staggering gait, increasing confusion, loss of muscle
300 - 400
Decreased response to stimuli, stupor
>400
Deep coma, death
? Widmark's formula : a = prc (blood); a = 3/4prq (urine)
? Henry's law: alveolar: blood alcohol = 2100: 1
Methods to find blood and urine alcohol levels
? Alcohol dehydrogenase method
? Gas chromatography(most specific)
? Breath analyzer
? Cavett test
Alcohol induced thiamine deficiency
Korasakoff's syndrome (chronic)
? Global confusion
? Amnesia
? Ophthalmoplegia
? Ataxia
events)
LCOHOL WITHDRAWL SYNDROMES
Alcoholic ketoacidosis
Delirium tremens
? Onset: 24-36 hours
? Onset: 24-72 hours
? Objects appear distorted,
? During withdrawl or after
? Sudden withdrawl, temporary
shadows seem to move
excess, trauma, acute infection
? Treatment: Chlorpromazine
? Drowsiness, confusion,
may precipitate
? THR,TRR, Kussmaul's
? Dramatic onset of Clouding of
breathing
consciousness, disorientation, loss
? Blood alcohol typically not
of recent memory
? Clonic-tonic movements
high
? High anion gap metabolic
? Agitation, restlessness, tremors,
acidosis
ataxia
? Insomnia, Autonomic
ketones
disturbances
? Treatment: diazepam
? McEwan's sign - in alcoholic coma, pupil is constricted if the patient is stimulated by pinching or slapping the
cheek, the pupils dilate and the slowly constrict. Differentiates alcoholic coma from coma due to other
causes
? Fatal dose: 150 - 250 ml of absolute alcohol taken in one hour; 60 - 200 ml of methyl alcohol
? Statutory limit for driving in India: 30 mg% (S 185 of Motor Vehicles Act)
Methanol
? Early symptoms - vertigo, head ache, stiff neck
? Later - ocular toxicity (fixed dilated pupils, diminished [snow-storm] vision, optic atrophy)
? Formic acid is responsible for retinal toxicity and high anion gap metabolic acidosis
? Antidotes: ethanol, fomepizole
? Fatal dose: 70 - 100 ml
BARBITURATES
? Pupils are initially constricted, later dilated
? Hypothermia
? Cutaneous blisters barbiturate blisters over dependent parts (buttocks, back of thighs, calves and forearms)
PSYCHEDELICS (HALLUCINOGENS)
? Feeling of depersonalization
? The feeling of being able to fly under its influence may can lead users to jump from windows
? Flash back phenomenon - experiences recurrence of the effects of previous LSD trip
? Hyperacusis, synesthetic experiences (stimulation of one sensory modality is perceived as sensation in a
perceptions
DELIRIANT POISONS
DATURAI
? Clinical features: blind as a bat, dry as a bone, red as a beet and mad as a wet hen
COCAINE
? Initially used as a local anesthetic
? Stage of excitement: dilated pupils, hypertension which may lead to cerebral bleeding, feeling of tingling and
numbness of the hand and feet, a numb feeling at the place where the drug has touched
? Usual route of intake is the application to the nasal mucous membrane (snorting)
? Cocainism: Chronic abuse cause blackening of tongue and teeth
? Ulceration and perforation of nasal septum
? Magnan symptom/cocaine bugs/formication is characteristic of chronic cocaine abuse where
CANNABIS (INDIAN HEMP)
? Cocaine + heroine = speed ball
? Active component tetra hydro cannabinols (THC)
? Chronic poisoning
Hashish insanity (run amok)
Amotivation syndrome
? Does not produce physiological dependence or addiction but psychological dependence and tolerance
develop
Bhang - mildest, decoction from dried leaves and fruit shoots; 15% of active principle
Majoon - sweet prepared from plant extract
Ganja (marihuana, reefer, joint) - leaves and flower tops of female plant; 15-25% of active principle
Charas or Hashish - resin exuding from leaves and stems; 25-40% of active principle
Sinsemilla - seedless marijuana
SPINAL POISONS
STRYCHNOS NUX VOMICA
? Active principles - Strychnine, Brucine, Loganine
neurons of the anterior horn cells resulting in release excitation
? GABA is not involved
Clinical features
? Convulsions at intervals
? Emprosthotonus (body is bent forwards)
? Pleurosthotonus (body is bent laterally)
? Trismus (lock jaw)
? Risus sardonicus (spasm of facial muscles producing a characteristic grimace)
? Dilated pupils
Tetanus
Strychnine poisoning
History of injury
History of poison consumption
Gradual onset
Sudden onset
Trismus occurs early
Groups of muscles affected at a time
All muscles affected simultaneously
Muscle rigidity is sustained between convulsions
Muscles relaxed in between convulsions
Positive for strychnine
HCN - (Prussic or Sheele's acid or cyanogens)
? Smell of bitter almonds
? Cyanide inhibits cytochrome oxidase, carbonic anhydrase and blocks final step of oxidative phosphorylation
? Reduces the oxygen carrying capacity of blood by preventing oxygen uptake by Hb
? Blood contains normal oxygen content
? Potassium ferrocyanide and ferricyanide are non-poisonous
? Sodium nitroprusside - an antihypertensive, overdosage results in cyanide toxicity
? Treatment:
Amyl nitrite, Sodium nitrite
Sodium thio sulphate
Hydroxyl cobalmine
4-dimethyl phenol
KEROSENE POISONING
? Lethal dose: 30 to 100 mL
? Kerosene is toxic both through inhalational and oral routes
? Death is mainly due to ventricular fibrillation and respiratory failure in inhalational poisoning
? The pupils are initially constricted and later dilated.
? Aspiration of as little as 0.2 mL of kerosene oil can produce chemical pneumonia & pulmonary oedema.
? The chest radiograph may reveal perihilar densities, basal pneumonia, and atelectasis.
? Activated charcoal is not useful
? Antibiotic and steroids are not indicated
WAR GASES
? War gases are chemicals used to produce damage and destruction during warfare
Examples
Lachrymators or Tear gases
Chloro-aceto-phenone (CAP)
? Not harmful to life
? Severe lacrimation due to intense irritation
Ethyl iodo-acetate
? Spasm of eyelids
? Temporary blindness
Chlorine
? Can be fatal
Phosgene
? Inhalation causes dyspnea, chest tightness, cough,
death due to pulmonary edema
Nasal irritants or Strenutators
Diphenyl chlorarsine (DA)
? Vapours cause intense pain and irritation in the
nose and sinuses
Diphenyl cyanarsine (DC)
? Head ache, nausea and vomiting
Nerve gases
? Inhibit the transmission of nerve impulses
GD(Sarin)
? Consciousness is lost within seconds
GB (Soman)
GF (Cyclosarin)
Paralysants
Carbon monoxide
? They act by different mechanisms interfering with
oxygen transport
Hydrogen cyanide
Vesicants or Blistering gases
Sulphur, Mustard, Oximes
redness, vesication and ulceration
SUBSTANCE ABUSE
Substance abuse in India
? 20-30% of adult males and around 5% of adult females use alcohol
? 24 % adult males and 3% of adult females are smokers
? 33 % males and 18% females use smokeless tobacco product
Drug
Slang name
Knock out drops
Alcohol + Chloral hydrate
Mickey Finn
Methylene-dioxy-methamphetamine (MDMA)
Methylene-dioxy-amphetamine
Love drug
Street heroin (brown sugar)
Smack, Junk, Dope
Black stuff, brick
Cocaine
Star dust, happy dust, heaven dust, coke, snow
Cannabis
Barbiturates
Candy, goof ball
Narcotics
Cotton brothers, Dr. White
God's machine, Miss Emma
Amphetamine
Speed, crystal, Superman drugs
Phencyclidine
Ketamine
Purple, jet, super k
Addicts jargon
Meaning
Euphoria following IV injection of narcotic
Bull horrors
Paranoid delusions induced by cocaine
Chicago leprosy
Chinaman on the
To suffer withdrawl symptoms
back/monkey on the back
Cold turkey
abuse
Croaker
Doctor
Dream stick, Gong, Joy stick
Eye opener
First shot of the day
Giving birth
Difficult expulsion of constipated stools by an opium addict
Barbiturate addict
Gow head, Hop head
Opium addict
Grass hopper, Viper
Joy popper, Pleasure shooter
Occasional injection addict
Kiester plant
A condom or finger stall filled with drugs kept concealed in rectum
Non addict
Torpedo
Alcoholic drink with chloral hydrate
Huffing
Bagging
Inhaling and exhaling into the bag
Chasing the dragon
Inhalation of vapours of heroin
Unpleasant LSD experience
Trip
Effects of LSD
Soft drugs
Hard drugs
opium, heroin, cocaine, methedrin
Food poisoning
? Death cap - Amantia phalloides
? Most common fish poisoning - ciguatera poisoning
? Ptomaines - alkaloids formed as a result of bacterial decomposition of protein
? Leucomaines - when ptomaines are formed in living cells
? Cadaveric alkaloids - when ptomaines are formed in dead tissue
? Poisonous calabar bean (physostigmine) is given in an attempt to detect guilt
? Person who vomits up the bean is innocent
? Person who becomes ill or dies is considered guilty
Fetal lobster syndrome (Boric acid poisoning)
? Presenting with syndactyly
? Aplasia and hypoplasia of phalanges, metacarpals and metatarsals
Hippus - aconite poisoning
Oxalic acid (acid of sugar) causes hypocalcemia. Used as a bleach to remove stains, removing writing and
Poppers - street term for various alkyl nitrites take for recreational purposes through direct inhalation
Itai-Itai disease (ouch-ouch) - a combination of osteoporosis and osteomalacia associated with renal disease,
in post-menopausal women in Japan, due to irrigation of rice fields with cadmium containing water
Conium Maculatum (hemlock) administered to Socrates for execution
chlorpromazine + alcohol
Quinine - cardiac poison and an abortifacient that causes partial deafness
Cinchonism - caused by repeated doses of quinine either therapeutic or overdose
Gila monster - a species of venomous lizard
TOXICOLOGY
LEGAL PROCEDURES, MEDICAL LAW & ETHICS
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? Forensic (Legal) Medicine: Application of medical knowledge to aid in the administration of justice
? Medical Jurisprudence: legal responsibilities of a physician, with reference to those arising from physician
patient relationship (e.g. medical negligence cases)
? Medical ethics: moral principles which should guide the members of medical profession
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? Medical etiquette: conventional laws of courtesy observed between the members of medical professionHISTORY OF FORENSIC MEDICINE
? Oldest known medicolegal code: The Code of Hammurabi, King of Babylon
? First medicolegal autopsy was done in Bologna(ltaly) in 1302, by Bartolomeo De Varignana
? First book of forensic medicine published by Fortunato Fedele
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? The greatest of all works was the "Questions Medicolegales" (medicolegal questions) written by PaulusZacchias
? Paulus Zacchias - Father of Legal Medicine and Father of Forensic Psychiatry
? Orfila - Founder of Modern toxicology
LEGAL PROCEDURES
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? Indian Penal Code(IPC) - defines offences and prescribes punishments? Criminal Procedure Code (CrPC)
Provides mechanism for punishment of offences
Deals with police duties in arresting offenders, in production of documents, investigating offences
Actual procedure in trials, appeals, references revisions and transfer of criminal cases.
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? Indian Evidence Act(IEA) - categories of evidence, procedure of collection, preservation and use of differentevidence
? Criminal law - offences against public interest
? Civil law - disputes between two individuals or parties
Plaintiff - party bringing the action
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Defendant - the accused in civil and criminal cases? Cognizable offence(S 2 (c) CrPC) - where a police officer can arrest a person without warrant from the
magistrate. E.g. Rape, Murder, Dowry death, ragging, death due to negligence
INQUEST
? Inquiry or investigation into the cause of death
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? Conducted in cases of unnatural deaths - suicide, homicide, accidents, occupational deaths, deaths due tomedical negligence, deaths due to animal attacks, suspicious deaths etc
Police inquest
? Section 174, CrPC
? Usually by Sub Inspector or Inspector - Investigation officer
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? Conducts the investigation, in the presence of two or more respectable persons (Panchas)? Prepares the inquest report - Panchanama
Magistrate inquest
? Conducted by a District Magistrate - Collector, Tahsildar, Deputy Commissioner, Revenue divisional officer
? Section 20 - 23 CrPC
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? In any case of death, Magistrate can conduct an inquest, instead of or in addition to police inquest? Done in case of
1%. Death in police custody and while under police interrogation
Death due to police firing
Death in prisons, reformatories, Borstal school
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Death in psychiatric hospitalsDowry deaths
Exhumation
Any person dies or disappears, or rape is alleged to have been committed on any woman, while such
person or woman is in the custody of police
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Coroner's court is a court of inquiry and not a court of trial, which has some judicial powers + MedicalExaminer's system - doctor visits the scene of crime and conducts the inquest, it is superior to Coroner's and
Police inquest
Coroner's inquest and Medical examiner's system - not followed in India
COURTS OF LAW
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CourtImprisonment
Fine
Supreme court
Any sentence
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Any amount of fineHigh court
Any sentence authorized by law
Any amount of fine
Sessions court
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Any sentence authorizedby law (but
Any amount of fine
death
Assistant sessions court
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10 years imprisonmentAny amount of fine
Chief Judicial magistrate
7 years imprisonment
Any amount of fine
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Chief Metropolitan MagistrateFirst class Judicial magistrate
3 years imprisonment
5000 rupees
Metropolitan Magistrate
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Second class judicial magistrate1 year imprisonment
1000 rupees
? Supreme Court and High Court usually hear referrals not trials.
? Courts below the rank on Sessions court cannot hear murder trials as they cannot award death sentence
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Juvenile Magistrates? Juveniles: Boys < 16 years; Girls < 18 years
? Juvenile Magistrates are generally women
? Juvenile Justice board
Metropolitan Magistrate or First class Judicial Magistrate
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Two social workers (atleast 1 woman)? Newspapers, magazines and visual media are prohibited to disclose particulars that can lead to the
identification of the juvenile in conflict with law
MEDICAL EVIDENCE
? Documentary
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Medical certificates - age certificate, death certificate etc.,Medicolegal reports - wound certificate, postmortem certificate etc.,
Dying declaration
? Oral
? Direct: evidence of a person who has been seen, heard or perceived the fact
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? Indirect or Circumstantial? Hearsay : witness states what he has heard others saying
Oral evidence is more important than documentary evidence, because
? Oath administered
? Cross examination is done
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WITNESSES? Common witness: (Witness of fact or Occurrence witness) gives evidence about the facts observed or
perceived by him (first-hand knowledge rule)
? Expert witness: a person who has training, skill or knowledge, experience in a subject and capable of drawing
opinions and conclusions from the facts observed by him. E.g: doctor, firearms expert, fingerprints expert
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etc.Hostile witness: witness who conceals a part of truth or completely gives false evidence (S. 191 IPC)
Perjury - Giving false evidence under oath (S 191, 192 IPC). Punishment 7 years imprisonment (S 193 IPC)
RECORD OF EVIDENCE IN A COURT OF LAW
Oath - child below 12 years is not required to take an oath
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1. Examination in Chief(Direct Examination)? Witness examined by public prosecutor and accused by defense lawyer
? To elicit all the relevant facts
? No leading questions
? Leading questions may be asked if the witness is hostile
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2. Cross Examination? Witness examined by defense lawyer and accused by public prosecutor
? To elicit facts favorable to the defence side
? To test the accuracy of the statements made by the witness
? To modify or explain what has been said
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? The credibility and competence of the witness will be tested? Leading Questions allowed
? No time limit
3. Re-Examination (Re Direct Examination)
? Similar to direct examination
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? No leading Questions4. Questions by the Judge
? Can ask questions at any time of proceedings
Dying declaration
? Section 32 lEA
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? Magistrate should be called to record, if there is no time the doctor or any citizen can record in the presenceof two witnesses
? Before recording it should be certified by the doctor that his mental functions are normal (compos mentis)
? Oath is not administered
? Leading questions are not allowed
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? If the declarant survives, declaration is not admitted, but has corroborative value and the person is called togive oral evidence
? Police officer should not be present at the time of declaration
Dying deposition
? Not followed in India
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? Oath administered? Opposite lawyer present at the scene
? Cross examination allowed
? Recorded by Magistrate
Superior to dying declaration
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Not followed in IndiaPresumption of death
? Section 107 lEA: a person is presumed to be alive, if there is nothing to suggest the probability of death
within 30 years
? Section 108 lEA: if it is proved that the same person has not been heard for 7 years by them who
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are expected to hear about him if he would be alive, then such a person will be presumed deadMEDICAL LAW & ETHICS
? Functions of Indian Medical council
? Maintenance of Medical register
? Maintenance of standards of Medical education
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? Recognition of foreign medical qualifications? Appeal against disciplinary action
? Warning notice - list of practices which are considered as professional misconduct
Foreign medical degrees
? First schedule - recognized medical qualifications granted by universities in India
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? Second schedule - those granted outside India? Third schedule
Part I - those granted by medical institutions not included in the first schedule
Part II - those granted outside India not included in second schedule
Functions of State Medical councils
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? Medical Register? Disciplinary control - issues warning to the person who has done professional misconduct
PENAL ERASURE/PROFESSIONAL DEATH SENTENCE
? Removal of the name of the doctor from the medical register
? Main cause-Serious Professional Misconduct/Infamous conduct (conduct of the doctor that is regarded
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disgraceful & dishonorable)? Done by the State medical council
? Other instances of removal of name
After death
Name entered by fraud, impersonation
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Dichotomy (fee splitting) receiving or giving commission or other benefits obtained by a medical practitionerfrom a trader in drugs or manufacturer or labs
Adultery- voluntary Sexual intercourse with a person other than his or her spouse
Covering- Assisting someone who has no medical qualification to attend, treat or perform an operation
Six A's - Professional misconduct
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? Adultery? Advertising
? Abortion(unlawful)
? Addiction
? Alcohol
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? Association(with unqualified persons)PROFESSIONAL NEGLIGENCE (MALPRAXIS)
? Absence of reasonable care and skill or willful negligence of a medical practitioner in the treatment of a
patient which causes bodily injury or death of the patient
? Doing something that one is not supposed to do or failing to do something that one is supposed to do
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? Liability for negligence arises if the following conditions are satisfied (Elements of negligence)? Duty: Existence of a duty of a care by the doctor
? Dereliction: Failure on the part of the doctor to maintain applicable standard of care and skill
? Direct causation: Failure to exercise proper care must lead to damage
? Foreseeability of the damage: The damage should be of a type that would have been foreseen by a
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reasonable physicianRes Ipsa Loquitor
? The thing or fact speaks for itself
? Usually the professional negligence of a physician must be proved in the court by the expert evidence of
another physician
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? When this rule applies, the patient need not prove the negligence of the doctorExamples:
? Failure to give ATS in cases of injury causing tetanus
? Burns from application of hot water bottles or from X-ray therapy
? Prescribing an overdose of medicine producing ill effect
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? Breaking needles and leaving it at the site? Blood transfusion misadventure
? Failure to remove swabs during operation which leads to complications or death
? Loss of use of hand due to prolonged splinting
Novus Actus Interveniens
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? An unrelated action intervening? The person is responsible not only for his actions but also for the logical consequences of all those actions
Medical Maloccurence or Act of God
? Inspite of good medical attention and care, in some cases, an individual fails to respond properly or may
suffer from adverse reactions of drug
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? Inevitable accident - not avoidable by any precautions? Breaking of needle during intra muscular injections due to sudden muscular spasm
? Damage to RLN during thyroidectomy
Civil Negligence
? Patient/relatives may charge against the doctor for compensation or
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? The doctor may charge against the patient for getting fees? Examples
Failure to get informed consent
Failure to give proper instructions
Failure to warn the patient about side effects
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Criminal Negligence? Gross absence of skill or care of the doctor during treatment that resulted in serious injury or death of the
patient
? When the doctor performs an illegal act
? Undue delay in treatment of an assault victim that resulted in death
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? When the negligence of accused went beyond the matter of compensation? Examples
Amputation of wrong finger or wrong limb
Leaving instruments or swabs inside abdomen
Performing criminal abortion
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Contributory negligence? The patient or his attendant is also negligent by not co-operating with the doctor
? His negligence along with doctor's negligence has resulted in the damage
? Without the negligence of the patient the damage would not have occured
? Examples
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Not following the instructionsNot giving adequate medical history
Leaving the hospital against doctor's advise
Failure to seek further medical assistance if symptoms persist
Defenses against negligence
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? No duty owed to the patient? Duty discharged according to existing standards of medical practice
? Contributory negligence
? The damage is due to the intervention of a third person without the doctor's knowledge
? The damage is an expected outcome of the disease
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? Therapeutic misadventureA misadventure is an accident or disaster, in which an individual is injured or died due to some
unintentional act by a doctor/hospital
Hypersensitivity reaction or anaphylaxis with drugs like penicillin, aspirin etc
Damage by radiation or radioisotopes
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Death during blood transfusionMedical Maloccurence
? Res-judicata - a matter [already] judged: once a lawsuit is decided, the litigant parties are barred' from
raising the same issue again in the courts
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? Time limitation (Res indicata) - within 2 years for criminal cases; 3 years for civil casesContributory negligence is not a defense against a criminal negligence
Civil negligence
Criminal negligence
No specific and clear violation of law need be proved
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Must have specifically violated a particular criminal lawSimple absence of care and skill
Gross negligence, inattention or lack of competency and
disregard to the life and safety of the patient
Conduct of the physician is compared to generally
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Not compared to a single testaccepted simple standard of professional conduct
Consent for the act is a good defence
Consent is not a defence
Trial by civil court
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Trial by criminal courtStrong evidence is sufficient
Guilt should be proved beyond reasonable doubt
Punishment: Liable to pay damages
Imprisonment
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Vicarious Liability? Liability for the act of another or Principle of Respondent Superior
? An employer is held legally responsible for the negligent acts of his/her employees appointed by him
Medical records
? MR of indoor patients - should be maintained for a period of 3 years from the date of commencement of the
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examination? Routine case records - should be preserved upto 6 years after completion of treatment and upto 3 years
after death of the patient
? Where there is a chance of litigation arising for medical purpose of negligence, record should be preserved
for atleast 25 years specially in case of minors
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? Medicolegally important record should be preserved upto 10 years, after which they can be destroyed aftermaking index and summary of the case
? Records of public interest are transferred to public record library after 50 years for release to public and
those involve confidentiality of the individuals are released only after 100 years
CONSENT
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? Consent is defined as voluntary agreement, compliance or permission? To examine, treat or operating a patient without consent amounts assault as per law, even if it is done in
good faith
Types of consent
? Implied consent (e.g: when the person holds out his arm for injection)
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? Expressed consentWritten consent
Verbal consent
Rules of consent
? Oral consent should be obtained in the presence of a disinterested third person. E.g. nurse
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? Written consent - Necessary for anesthesia, diagnostic and surgical procedure. Should refer to one specificprocedure
? Blanket consent: consent obtained at the time of admission to the hospital for all procedures after
admission. Not valid
? A woman of 18 years and above can give valid consent for sexual intercourse (Section 375 IPC, 2013
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amendment)? A child under 12 years and an insane person cannot give valid consent. Consent is obtained from the parent
or the guardian
Loco Parentis: in an emergency situation, when the parent or guardian is not available, the person in-
charge of the child can give consent
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E.g: When a child of a residential school needs emergency Appendicectomy, the head master of theschool can give consent
Informed consent - understanding by the patient of
? The nature of his condition
? The nature of the proposed treatment or procedure
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? Expectations of the recommended treatment and the likelihood of success? The details of the alternative courses of treatment that are available
? Risks and benefits involved in both the proposed and alternative treatment
? Relative chances of success or failure of both procedures
? All disclosures must be in the language the patient can understand
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Consumer Protection Act, (CPA/COPRA) - 1986? District consumer dispute redressal forum - upto 20 lakhs
? State consumer dispute redressai forum - > 20 lakhs upto 1 crore
? National consumer redressal commission - > 1 crore
The Transplantation of Human Organs Act - 1994
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? Defines human organ as - any part of the human body consisting of a structured arrangement of tissues,which if wholly removed cannot be replicated
? Bone marrow transplant is outside the purview of this act
? Organs that can be donated after death: kidney, heart, liver, lungs, pancreas, eyes, ear drums and ear
bones
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? In case of unclaimed bodies in hospital or prison, organs can be removed after 48 hours? Live donor: "donor" means any person, not less than eighteen years of age, who voluntarily authorises, the
removal of any of his human organs for therapeutic purposes
Important years
? Indian Medical Council Act - 1956
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? The Workmen's compensation Act - 1923? The Protection of Human Rights Act - 1993
? Declaration of Helsinki by World Medical association - 1964 (Code of ethics on Human experimentation)
EUTHANASIA
? Mercy killing or Assisted suicide
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? Painless killing of a person who is suffering from incurable disease, senility, permanent damage to the brainwhich cannot be repaired or cured
? Legally permitted in: USA, Uruguay, Poland, Australia, Switzerland, Nether lands
? Not legalized in India
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Types
? Active (Positive)euthanasia
Act of commission
Death induced by direct/indirect action
E.g. giving large dose of a drug that hastens death
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? Passive (Negative)euthanasiaAct of omission
No specific medicine or life supporting measures given
Death induced by discontinuation of life sustaining measures
E.g. stopping heart lung machines in a severely defective new born, disconnecting ventilator in a brain
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dead patient? Voluntary euthanasia
Euthanasia induced at the will of an individual by his request
A patient suffering from an incurable disease requesting the doctor to terminate his life
? In/Non voluntary euthanasia
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Induced in patients who are unable to express their wishesE.g. a person with irreversible coma or a severely defective infant
Paternalism - abuse of medical knowledge so as to distort the doctor-patient relationship in such a way the
patient is deprived of his ability to take rational choice
Important sections related to Injury, Death, Murder, and Suicide
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Section (IPC)Offence
44
Injury
46
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Death299
Culpable homicide amounting to murder
300
Murder definition
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302Murder punishment
304
Culpable homicide not amounting to murder
304-A
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Causing death by rash and negligent act304-B
Dowry death
306
Abetment of suicide
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309Attempt to commit suicide
319
Hurt
320
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Grievous hurt351
Assault
326 A & B
Causing grievous hurt by throwing acid
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Sections related to Sexual offences, Abortion, Pregnancy, and Infanticide290 1PC
Frotteurism
294 IPC
Exhibitionism
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297 IPCNecrophilia, Necrophagia
312
314 IPC
Causing miscarriage
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317 IPCAbandoning a girl child
318 IPC
Concealment of birth of a girl child
354 IPC
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Indecent assault354 - A
Sexual harassment
354 - C
Voyeurism
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354 - DStalking
370 (PC
Trafficking
375 IPC
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Rape definition376 IPC
Punishment for rape
377 IPC
Unnatural offences
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497 (PCAdultery
416 CrPC
High court has the power to postpone the execution of death
sentence of a pregnant woman until 6 months after delivery or
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to commute itPunishment for rape -Section 376 IPC
S 376 (1) IPC
Imprisonment > 7 years + fine
S 376 (2) IPC - rape committed
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Rigorous imprisonment > 10 years +? By Police officer
fine
? By Public servant taking advantage of his official
position on a women working under him
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? By Member of armed forces? By Custodial rape
? By Relative, guardian or teacher
? During Communal violence
? On pregnant women
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? Women < 16 years? On women suffering from mental or physical
disability
? Causes grievous injury, disfigures or endangers life
of a
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? woman? Repeatedy on the same woman
S 376-A IPC: Rape resulting in death or persistent
Rigorous imprisonment > 20 years
vegetative state
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or deathS 376-B IPC: Sexual intercourse by husband upon his wife
Imprisonment 2 - 7 years + fine
during separation
S 376-C IPC: Sexual intercourse by a person on authority
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Imprisonment 5 - 10 years + fineS 376-D IPC: Gang rape
Rigorous imprisonment > 20 years
S 376-E IPC: Repeat offenders
Imprisonment for life or death
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Sections related to criminal responsibility & Consent82 IPC
A child under 7 years of age is incapable of committing an offence
84 IPC
Criminal responsibility of mentally ill
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85 IPCAn act done by a person, due to intoxication is not an offence, if he is intoxicated
without his knowledge or against his will
86 IPC
An intoxicated (voluntary drunkenness) person is criminally responsible, if he had
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intention or knowledge of committing a crime87 IPC
A person above 18 years of age can give valid consent to suffer any harm, which
may result from an act not intended or not known to cause death or grievous hurt
89 IPC
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A child under 12 years and an insane person cannot give valid consent90 IPC
Consent given by a person under fear of injury, intoxication, misunderstanding of a
fact is not valid
92 IPC
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Any harm caused in good faith, even without the person's consent is notan offence
Sections related to poisoning
39 CrPC
Private practitioner should inform the police or magistrate, if he
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176 IPCsuspects homicidal poisoning
309 IPC
Private practitioner need not inform the police if he is sure that the poisoning is
suicidal
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201 IPCNot preserving samples with the intention of protecting the accused
Other sections related to medical practice
IPC section
Definition
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52Nothing is said to be done in good faith which is done without due care and
attention
74
Nonattendance in obedience to summons from court
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175Omission to produce document to public servant
176
Omission to give notice or information to public servant
177
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Furnishing false information179
Refusing to answer public servant authorized to question
191
Giving false evidence (Perjury)
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197Issuing or signing false certificate
201
Causing disappearance of evidence of offence or giving false information to screen
offenders
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204Destruction of document to prevent its production as evidence
269
Negligent act likely to spread infection of disease dangerous to life
270
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Malignant act likely to spread infection of disease dangerous to life160
Police officer has the power to summon any witness (doctor) to police station for
recording a statement
87 - 93
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Legal protection to medical doctorsOther important sections
? Section 53, CrPC: A registered medical practitioner can examine a person who is arrested on a charge of an
offence using reasonable force, if requested by a police officer not below the rank of Sub-Inspector
? Section 53-A CrPC: When a person is arrested on a charge of committing an offence of rape or an attempt to
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commit rape, and there are reasonable grounds to believe, that an examination will afford evidence as to thecommission of offence, it shall be lawful for a registered medical practitioner employed in a hospital run by
the government or a local authority and in the absence of such a practitioner within the radius of 16 km from
the place where the offence has been committed, by any other RMP acting at the request of a police officer
not below the rank of a sub-inspector to examine the arrested person with use of reasonable force as
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required? S 363, 364, 366 IPC - kidnapping
Dowry Death
S 304-B IPC
Death of a woman caused by any burn or bodily injury or occurs otherwise than under
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normal circumstances within seven years of marriagePunishment: 10 years imprisonment which may extend to life + fine
S 498-A IPC
Whoever (husband or relative) subjects woman to cruelty shall be punished with 3 years
imprisonment
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Cruelty - willful conduct that drives the woman to commit suicide or grave mental or physicalinjury to her or harassment with a view to coerce her for dowry
S 113-A &
Presumption as to abetment of suicide by a married woman and
S 113-B lEA
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Presumption as to dowry deathS 174 (3) CrPC
Procedure in dowry death
MEDICOLEGAL AUTOPSY
Types of Autopsy
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? Clinical/Pathological autopsy - consent of relatives needed? Medicolegal autopsy - consent of relatives not needed
? Virtual autopsy Nirtopsy - a combination of CT & MRI
? Psychological autopsy - A procedure for investigating a person's death by reconstructing what the person
thought, felt, and did before death, based on information gathered from personal documents, police reports,
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medical and coroner's records, and face-to-face interviews with families, friends, and others who hadcontact with the person before the death - to assess the mental status of the person at the time of death
The PM examination should be conducted in daylight as far as possible because color changes such as
jaundice, changes in bruise and changes in lividity cannot be appreciated accurately in artificial light
Method of removal of organs
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VIRCHOW'S TECHNIQUE? Individual organs are removed one by one
? Cranial cavity exposed first, followed by thoracic, cervical and abdominal cavities
ROKITANSKY'S TECHNIQUE
? In-situ dissection, combined with en block removal
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? In bodies with highly transmissible diseases like HIV, hepatitis BLETULLE'S TECHNIQUE
? En masse removal of cervical, thoracic, abdominal and pelvic organs and dissected as organ block
? Advantage - all attachments are intact
GHON'S TECHNIQUE
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? Cervical, thoracic, abdominal and pelvic organs are removed as organ blocksAIR EMBOLISM
? Head should be opened first and the surface vessels of brain examined for gas bubbles
? Left ventricle is filled with froth if air is present in sufficient quantity to cause death
? Pericardial sac opened and filled with water. Right heart is punctured with a scalpel and twisted -air bubbles
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escape in cases of air embolism? Pyrogallol test: Air is brought in contact with alkaline Pyrogallol solution, which turns brown -indicates
antemortem air embolism
Obscure autopsy
? Where a definite cause of death is not found
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? There may be minimal, indefinite or obscure findingsNegative autopsy
? When the cause of death could not be found, even after gross and microscopic examination, toxicological
analysis, histo-pathological examination and microbiological investigations
EXHUMATION
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? Lawful digging out of a buried body from the grave for medico-legal examination? Magistrate conducts the inquest
? Preferably done in daytime
? No time limit in India
? Autopsy (first or second) done
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ARTIFACTS? Artifact is any change caused or feature introduced in a body after death, that is likely to lead to
misinterpretation of medico-legally significant (antemortem) findings
Artifacts introduced after death and before autopsy
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? Agonal artifacts: Regurgitation, Esophago-gastromalacia? Resuscitation artifacts: injuries due to defibrillator application, Cardiac massage, Central line, Positive
pressure ventilation, Laryngoscope
? Artifacts due to handling of the body: Undertaker's fracture, Postmortem abrasions
? Artifacts due to burns: Heat ruptures, Heat hematoma
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Artifacts introduced during autopsy: Skull fractures, Visceral damage, Hyoid bone fractureIDENTIFICATION
CORPUS DELICTI
? Latin meaning - body or essence of crime
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? The substantial and fundamental evidence that a crime has been committed? Refers to the principle that a crime must have been proven to have occurred before a person can be
convicted of committing that crime
? The corpse of a murdered victim with injuries indicate that a crime has been committed
RACE
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FeaturesPure Aryans (Indians)
Chinese, Europeans
Mongols
Aborigines, negroes
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Cephalic index70-75
75-80
>80
Type of skull
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DolicocephalicMesaticephalic
Brachycephalic
Orbits
Square
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TriangularRound
Nasal opening
Broad
Narrow and elongated
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RoundPalate
Rectangular
Triangular
Round or horse shoe shaped
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Races indices? Cephalic index = Maximum breadth of skull/ Maximum AP diameter of skull X 100
? Brachial index = Length of radius/Length of Humerus X 100
? Crural index = Length of tibia/Length of femur X 100
? Inter-membranal and Intra-membranal index
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SEXBarr body
? Barr body is the inactive X chromosome in a female somatic cells (Buccal smear)
? It is rendered inactive in a process called lionization
? Number of barr bodies = Number of X chromosomes - 1
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? Absent in maleDavidson body: small nuclear attachment in the neutrophils of females
Greater sciatic notch is the ideal feature in pelvis to determine sex of a female child
Chilotic line - anthropometric line in pelvis, the index of which is used in determination of sex
Sex indices
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? Sciatic notch index = Width of notch / Depth of notch X 100? Washburn ischiopubic index = Pubic length / Ischia( length X 100
? Corporbasal sacral index = Breadth of 1st sacral vertebra / Breadth of base of sacrum X 100
? Sternal index = Manubrial length / Body length X 100
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Sex determination from skeleton? Recognizable sex differences do not appear until after puberty in bones except pelvis
? Single best bone to determine sex (both in adult and child) - pelvis
Feature
Male skull
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Female skullMuscle ridges, Glabella,
More prominent
Less prominent or absent
Supraorbital ridges,
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Zygomatic archFore head
Steeper, less rounded
Vertical, round
Fronto-nasal junction
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Distinct angulationSmoothly curved
External acoustic meatus
Bony ridge along upper border
Absent
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Frontal and parietalSmall
Large
eminences
Mastoid process
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Large, round, bluntSmall, smooth, pointed
Condylar facet
Long and slender
Short and broad
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PalateLarge, U shape
Small, parabolic
Occipetal condyles
Large
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SmallFeature
Male pelvis
Female pelvis
General
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Deep funnelFlat bowel
Ilium
Less vertical
More vertical
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Preauricular sulcusNot frequent, narrow, shallow
More frequent, broad and deep
Acetabulum
Large, directed laterally
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Small, directed antero-laterallyObturator foramen
Large, oval with base upwards
Small, triangular with apex forwards
Greater sciatic notch
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Smaller, narrower, deeperLarge, wide, shallow
Ilieo-pectineal line
Well marked and rough
Round and smooth
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Ischial tuberosityInverted
Everted
Subpubic angle
V shaped, angle 70-75
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U shaped, (obtuse) angle 90-100Pelvic brim
Heart shaped
Circular or elliptical, more spacious
Pelvic cavity
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Conical and funnel shapedBroad and round
Sacrum
Long, narrow, even curvature,
Short, wide, upper half almost straight,
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promontory well markedlower half curve forward
Krogman's degree of accuracy of sex determination with bones
? Entire skeleton
= 100%
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? Pelvis alone= 95%
? Skull alone
= 90%
? Skull and Pelvis
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= 98%? Long bones alone
= 80%
AGE
DENTITION
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? At the age of 3 years all the temporary teeth are erupted? Age 7 to 12 years is the age of mixed dentition
? Superadded permanent teeth are those which don't have deciduous predecessors (permanent molars)
? Successional permanent teeth are those which erupt in the place of deciduous teeth.
? In some persons due to inadequate jaw space, the third molars never erupt into the oral cavity, particularly
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the mandibular third molars (impacted teeth) which can be visualized by orthopantogramTemporary teeth
Age (months)
Lower central incisor
6-8
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Upper central incisor7-9
Upper lateral incisor
7-9
Lower lateral incisor
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10-12First molar
12-14
Canine
17-18
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Second molar20-30
Permanent teeth
Age(years)
First molar
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6-7Central incisor
6-8
Lateral incisor
7-9
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First premolar9-11
Second premolar
10-12
Canine
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11-12Second molar
12-14
Third molar
17-25
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GUSTAFSON'S METHOD
Age estimation in adults > 21 years can be done based on the physiologic changes of teeth - Gustafson's method.
Criteria
? Attrition - wear and tear changes of the incisal or occlusal surface of the teeth
? Paradentosis - regression of gums resulting in loosening of teeth and they fall off
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? Secondary dentin - deposition of denting in the pulp cavity? Cementum apposition - deposition of Cementum in the root forming incremental lines
? Root resorption - involves both Cementum and dentin
? Root transparency - canals of denting gets filled up by minerals after 30 years of age and the dentin becomes
transparent. This is the most reliable criteria.
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Boyde's method - most accurate method of age estimation, based on incremental lines on teethX-Rays
? Number of ossification centres at 11th week of IU life - 806
? Number of ossification centres at birth - 450
? Number of bones in adult skeleton - 206
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? Appearance & fusion of ossification centre in females can be in advance of the male upto 1 yearPelvis
Appearance
Fusion
Ischiopubic rami
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6 yearsTri radiate cartilage
13 years
15 years
Iliac crest
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14 years18 - 20 years
Ischial tuberosity
16 years
20 - 21 years
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Head of femur1 year
17
18 years
Greater trochanter
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4 yearsLesser trochanter
12 - 14 years
Shoulder
Head of the humerus
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6 months to 1 year18 - 19 years
Greater tuberosity
3 years
Lesser tuberosity
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5 yearsCoracoid process
Body: 5-6 years
16 - 17 years
Tip: 10-11 years
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Acromion process14 - 15 years
17 - 18 years
Elbow
Lower end of humerus
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Capitulum1 year
14-16 years
Lateral epicondyle
11 years
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Trochlea9-11 years
Medial epicondyle
6-7 years
16-17 years
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Upper end of radius and ulnaRadial head
5 years
16-17 years
Olecranon process
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9 yearsWrist: Appearance of carpal bones
Scaphoid
Lunate
Triquetrel
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PisiformTrapezium
Trapezoid
Capitate
Hammat
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4-5 yrs4 yrs
3 yrs
11-12 yrs
6 yrs
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5 yrs2 months
2 years
Ossification centres
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AF
Epiphysis of base of 1st metacarpal
2-3 years
15 - 17 years
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Radial styloid process2 years
18-19 years
Ulnar styloid process
5 years
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17-18 yearsAge group
X-ray region
6 - 12 years
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Elbow, Wrist13
- 16 years
Elbow, Pelvis
16
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- 17 yearsAnkle joint
17
- 18 years
Hip joint
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18- 19 years
Knee, Shoulder, Wrist
20
- 21
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PelvisOssification centres present before birth
? 2 months - Upper segments of sacrum, Mandible
? 5 months - Middle segments of sacrum
? 6 months - Calcaneum
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? 7 months - Talus? 8 months - Lower segments of sacrum
? 9 months - Lower end of femur
? 10 months - Upper end of tibia
Age of the fetus - Rule of Hasse
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? If the Crown-Heel length is 25 cm, then the square root of length gives age in months? If the crown-heel length is > 25 cm, then the length divided by 5 gives age in months
Fusion of Skull sutures & Closure of fontanelles
Lateral and occipital fontanelles
< 2 months
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Posterior fontanelles6 - 8 months
Anterior fontanelle
1.5 - 2 years
Metopic suture
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3 yearsBasi-Occiput fusion with basi-sphenoid
18 - 21 years
Sagittal suture
30 - 40 years
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? Posterior 3rd40 - 50 years
? Anterior 3rd
50 - 60 years
? Middle 3rd
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Coronal suture40 - 50 years
? Lower half
50 - 60 years
? Upper half
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Lambdoid suture45 years
Sternum
? Four pieces of the body of the sternum fuse with one another between 14 - 25 years
? Xiphoid fuses with the body - 40 years
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? Manubrium fuses with the body - 60 yearsClosure of sutures begins 5-10 years earlier on the inner side than the outer side
Most successful age estimation can be done from sagittal suture
When the endocranium fuse and ectocranial suture does not fuse - lapsed union
Sacral bones fuse and become a single bone between 21 - 25 years
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Gap may persist between S1 and S2 after 25 years- lapsed unionThe best single criteria to determine age from 3rd to 5th decade is the pubic symphysis
AGE
MEDICOLEGAL IMPORTANCE
7 months IU
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Viability attainted by the fetus - killing after this age - infanticide> 5 years
Criminal responsibility as per Railways act
< 7 years
No criminal responsibility as per Section. 82 IPC
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7 - 12 yearsCriminal responsibility if sufficient maturity of understanding the nature and
consequences of act as per Section. 83 IPC
< 12 years
Consent to be obtained from parent/guardian for examination, surgery etc
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< 14 yearsCannot be employed in factory jobs
14 - 15 years
Non-hazardous factory jobs can be given in day time
> 15 years
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Can be employed in any factory job< 15 years
Sexual intercourse with a girt, even his wife, with or without consent amounts to
rape
< 16 years
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Convicted boys are sent for reformatory school for punishment< 16 years
Taking away a boy without consent of the parent/guardian - kidnapping
< 18 years
Juvenile (boy or girl)
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Taking away a girl without consent of parent/guardian - kidnappingSexual intercourse with a girl, with or without consent amounts to rape
> 18 years
Valid consent for any harm not known to cause death or grievous hurt
Valid consent given by a girl for sexual intercourse
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Attainment of majorityCan make valid will
> 21 years
Attainment of majority for those under the guardianship of court
No age limit to give evidence in a court. A child of any age can give evidence if the court is convinced that
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the child is truthfulDACTYLOGRAPHY
? Fingerprint system was first used in India
? Sir Francis Galton systematized this method in 1892
? It is the study of epidermal ridges and their configurations (dermatoglyphics)
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? Cannot be used to fix paternity as the patterns are not inherited and different even in identical twins? They are broadly classified into 4 types
Loops - most common type
Whorls
Arches
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Composite? Final identification is made based on the comparison of characteristics like - ridge endings, bifurcations, lake
formation, broken ridges, short ridges etc.,
? Permanent impairment of finger prints - leprosy, electric injury, radiation
? Atrophy of the ridges seen in coeliac disease, dermatitis
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Poroscopy? The papillary ridges of the epidermis of hand are studded with microscopic pores through which sweat
exudes during life
? The number of pores, their size, shape, width, position over a region is individualistic
? This study of pores is called Poroscopy (Locard's method)
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? Useful when only fragments of fingerprints are availableFormulas for stature estimation
? Pearson's formula
? Dupertuid & Hadded formula
? Trotter & Gleser formula
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? Steele - stature estimation from fragmented bonesRule of thumb
Bone
% of height
Humerus
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20Tibia
22
Femur
27
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Spine35
Hair
? Trichology - study of hair
? Hair grows at a rate of 0.4mm/day and nails at 0.1mm/day
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? Human hair - fine and thin, cuticle scales are thin and short, thick cortex, thin medulla, evenly distributedpigment, medullary index <0.3
? Animal hair - coarse and thick, cuticle scales are large with wavy projections, thin cortex, thick medulla,
pigment mostly near medulla, medullary index >0.5
? In human hair, Barr bodies are found in hair follicles (24-34% in females; 4-8% in males)
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? Roots of hair from children will dissolve rapidly in a solution of caustic potash, but in older people roots willresist the treatment
? ABO blood groups can be determined in a single hair if hair bulb is present, from any part of the body
? Singeing of hair is seen in burns and close range firearm injury.
? Singeing is helpful in differentiating burns from scalds
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Cheiloscopy - lip printsPodogram - foot prints
Rugoscopy - palatal rugae
Calligraphy - study of handwriting
Fragmented hair - Negroes, new born, fetus
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Non fragmented hair - Mongols, CaucasiansPreauricular sulcus is used to determine sex
Osteometric board: Used to measure length of a bone
Anthropometry - Bertillon system
Pink teeth - in decomposed or skeletonized body, pink teeth may be noted near the gum line
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Commonly used systems for dental charting (numbering) - Palmer's notation, Haderup system, FederationDentaire Internationale system
THANATOLOGY & POSTMORTEM CHANGES
Thanatology - deals with death in all its aspects
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Forensic taphonomy - study and interpretation of postmortem processes of human remains in thedispositional context
BRAIN DEATH
UK criteria for diagnosis of brain death
Preconditions
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? Patient deeply comatose? Patient on ventilator (spontaneous respiration had ceased)
? Diagnosis of the disorder leading to brain death has been firmly established
Exclusions
? Hypothermia (rectal temperature >35? C)
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? Coma not due to depressant drugs (narcotics, hypnotics, tranquilizers)? Neuromuscular blocking agents, excluded as a cause for RS failure
? No profound abnormality of serum electrolytes, acid base balance, glucose concentrations and any
metabolic and endocrine cause of coma has been excluded
Tests for confirming brain death
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? Pupils fixed and unreactive to light? Corneal reflexes absent
? Vestibulo-ocular reflexes absent
? No motor responses to adequate stimulation
? No gag reflex
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? No respiratory movement after ventilator is discontinuedMINNESOTA CRITERIA (criteria for brainstem death formulated by Mohan Dass and Chou)
? Known but irreparable intracranial lesion
? No spontaneous movement
? Apnea when tested for a period of 4 minutes
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? Absence of brainstem reflexes (Dilated and fixed pupils and absence of corneal reflex, Doll's eyephenomenon, ciliospinal reflex, gag reflex, vestibular response to caloric stimulation, tonic neck reflex
? EEG not mandatory
? Spinal reflex not important
? All the above findings remain unchanged for atleast 12 hours
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HARVARD CRITERIA? Unreceptivity and unresponsivity
? No spontaneous muscular movements
? Apnea
? Absence of elicitable reflexes
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? Isoelectric EEGSUSPENDED ANIMATION or APPARENT DEATH
? Signs of life are not present as the functions are interrupted for some time or reduced to minimum
? Voluntarily produced by yoga practitioners (death trance)
? Involuntary suspended animation is seen in
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? New born infants? Insanity
? Drowning
? After anesthesia
? Electrocution
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? Narcotic poisoning? Sunstroke
? Hypothermia
? Cholera
? Concussion of brain
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? ShockPOSTMORTEM CHANGES
Immediate changes (Somatic death)
Early changes (Cellular death)
Late changes (Decomposition)
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? Cessation of brain function?
Changes in the skin
? Putrefaction
? Cessation of respiration
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?Changes in the eye
? Mummification
? Cessation of circulation
?
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Algor mortis? Adipocere
? Primary flaccidity of muscles
?
Livor mortis
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?Rigor mortis
HANGES IN THE EYE AFTER DEATH
? Pupillary dilatation
? Cornea: dull, hazy. opaque and wrinkled
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? Tache noir: if the eyelids are open after death, desiccation of conjunctiva and deposition of cell debris andmucus forms two yellow triangles on either side of cornea in 3 - 4 hours
? Flaccidity of the eye ball: due to fall in intraocular pressure. Within 2 hours, 10P falls to zero
? Retina: If the retina is viewed through and ophthalmoscope, there will be fragmentation or segmentation
(rail-road or tram-track appearance) of blood columns in retinal vessels (Kevorkian sign)
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? Increase in potassium concentration in vitreousLGOR MORTIS or POSTMORTEM COOLING
? It is the cooling of the body after death
? After death, heat is lost by
Radiation (transfer of heat to the surrounding air by infrared rays)
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Convection (transfer of heat through moving air currents)Conduction (transfer of heat by direct contact with another object)
? Body loses heat by 2 - 3?C in 1st hour
? Then 1 - 1.5?C for each subsequent hour until the body reaches the environmental temperature
? Initial maintenance of body temperature which may last for some hours - the so-called "temperature
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plateau"? Followed by a relatively linear rate of cooling
? Subsequently slows rapidly as the body approaches the environmental temperature.
? The preferred site for measuring temperature is either the rectum or the abdominal cavity
? A chemical thermometer with graduations from 0 to 50? C is used
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Time since death =Normal body temperature - Rectal temperature
Rate of temperature fall per hour
Rate of cooling is affected by
Difference in temperature between the body and the environment:
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? Larger the difference, faster the cooling rateSurface area of the body:
? Larger surface area: speeds up cooling rate.
? Children: increase surface area gives rapid heat loss.
Body weight: Larger body weight (due to excess fat): slower cooling and vice versa
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Edema: Slower cooling rate.Clothing: Thick clothes slows down cooling rate
Environmental temperature: Higher humidity and rapid air velocity: rapid cooling rate
Water: Rapid cooling rate; More rapid in flowing water than still water
Postmortem caloricity
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? In few cases, there is a slight rise in body temperature after death - postmortem caloricity? Seen in the following cases
? Violent muscular contractions before death
o
Tetanus
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oStrychnine poisoning
o
Seizures
? Asphyxial deaths - strangulation
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? Septicemic deaths - cholera and other infections? Death due to temperature regulation disorders
? Sun stroke
? Pontine haemorrhage
POSTMORTEM HYPOSTASIS
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? Synonyms: Livor Mortis, Post Mortem Staining, Post Mortem Lividity, Darkening Of Death? Blood gradually settles down in the toneless capillaries in the dependent parts of the body
? Seen externally as patches of purple or reddish purple discoloration of the skin
Sites of hypostasis: Depends on the position of the body before death:
? Supine: Lividity is seen on the back
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The areas which are in direct contact with the surface such as the shoulder blades, buttock & calvesdiscoloration will be pale (contact pallor)
? Vertical: e.g. hanging. PM staining seen on legs, feet, forearm and hands (glove and stocking hypostasis)
? Drowning: face, upper limbs and abdomen
? Face-down death: as in epilepsy, drunken victims - whitening around nose Et tips.
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? Hypostasis of Viscera:Heart: mistaken for MI
Lungs: mistaken for pneumonia
Intestine: mistaken for hemorrhagic infarction
Timing
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? Begins as mottled patches between 1 to 3 hours after death? Gradually increase in size and coalesce with each - uniform area of staining in 5 to 6 hours
? If the body is left undisturbed for 6 to 8 hours, lividity becomes fixed and does not alter in position even if
the position of the body is altered
? May not develop at all if the position of the body is continuously changed as seen in fast flowing waters of
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riversPM staining does not develop in
? Drowning in running water
? Areas of contact flattening
? Severe anemia
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? Heavy blood loss? Body refrigerated immediately after death
Poison/Condition
Postmortem staining
Phosphorus, Copper
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Yellow or dark brownCarbon monoxide
Cherry-red
Nitrites, aniline, chlorates
Chocolate or copper brown
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Hydrogen cyanidePink/Bright red
Refrigerated bodies, hypothermia
Bright pink
Opium
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BlackHydrogen sulphide
Bluish green
Clostridium perfringens septicemia
Bronze or greenish brown
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(RIGOR MORTIS or CADAVERIC RIGIDITY? Rigor mortis is the stiffening and shortening of muscles after death
? Affects all muscles of the body, both skeletal and smooth
? When the ATP level falls to 85% then the muscle becomes rigid
? When the ATP level fails to 15% then the rigidity is maximum
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Order of appearance? Does not start in all the muscles simultaneously (Nysten's rule)
? It becomes most evident in the smaller muscles early (less reserve glycogen)
? Myocardium is the first involuntary muscle to become rigid
? Eyelids face
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jawneck
upper limbs
thorax
abdomen
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lower limbsfingers and toes
(Proximo-distal progression)
? Passes off in the same order as it appeared
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India
Temperate countries
Time of onset
1 - 2 hours
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3 - 6 hoursDuration
Summer
18 - 36 hours
2 - 3 days
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Winter24 - 48 hours
Rule of 12 or Rule of Dozen or March of Rigor
? First 12 hours after death: Rigor mortis affects the whole body
? Next 12 hours: retained
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? Next 12 hours: passes offConditions affecting Rigor mortis
? Age
Extremes of age rapid onset
Does not occur in fetus < 7 months
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? Environmental temperature:Cold and wet
onset slow, duration longer
Hot and dry
onset fast, duration shorter
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? Cause of death:Asphyxia, pneumonia, nervous disease with muscle paralysis & dehydration slow onset
Septicemia & poisoning
rapid onset, may even be absent
Excessive physical work before death rapid onset
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Conditions simulating Rigor mortisHEAT STIFFENING
? Occurs due to exposure of body to intense heat (burning, high voltage electrocution)
? Due to heat, coagulation of muscle proteins occur
? When the body is recovered and kept in normal temperature - Rigor mortis does not occur
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? E.g. Burns - pugilistic attitudeCOLD STIFFENING
? Occurs due to exposure of the body to extreme cold (< minus 5?C)
? Solidification of subcutaneous fat and muscles occurs
? Freezing of synovial fluid in joints and other body fluids
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? If the body is kept in a warm temperature, Rigor mortis develops very rapidly and passes off quicklyGAS STIFFENING
? During putrefaction, due to the gases liberated, the entire body is bloated and stiffened
? When the gases escape, again the body becomes flaccid
CADAVERIC SPASM
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? Synonyms: Instantaneous rigor, Cataleptic rigidity, Death clutch? Rarely seen
? Seen immediately after death (no primary flaccidity)
? Small groups of muscle which were already in a contracted state at the time of death, remains contracted
after death, till molecular death occurs
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? Usually associated with violent deaths coupled with emotional disturbance at the time of death
? Mechanism not clearly understood
Examples
? Drowning: grass and weeds caught in the hands during struggle, will be seen clutched in the hand after death
? Suicidal cut throat/gun shot: the weapon will be firmly grasped in the hand
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RIGOR MORTISCADAVERIC SPASM
Freezing and exposure to temperature above
Cannot be produced by any other method
65?C will produce rigor
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Onset 1 - 2 hrs after deathInstantaneous
All muscles of the body both voluntary and
Restricted to a single group of voluntary muscles
involuntary are involved
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Moderate force can overcome rigorVery great force required to overcome it
Molecular death occurs
Does not occur
Muscles do not respond to electrical stimuli
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RespondBody temperature - cold
Warm
Indicates time of death
Indicates manner of death
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Occurs after primary flaccidityNo primary flaccidity
DECOMPOSITION
Involves two processes
? Autolysis
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? PutrefactionAUTOLYSIS
? Self-digestion of tissues due to lysosomes and their digestive enzymes (Hydrolases)
? Earliest autolytic changes occur in parenchymatous and glandular tissues and in the brain.
? Earliest external sign is a whitish, cloudy appearance in cornea
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PUTREFACTION? The chief destructive agent of Putrefaction is Clostridium welchii
? Lecithinase is the most important enzyme causing hemolysis, liquefaction of clots, gas formation and
disintegration of tissue.
Color changes
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? First external sign - greenish discoloration of skin over the region of caecum? First internal sign - discoloration in the under surface of liver
? Color Change is due to conversion of Hb to sulfamethemoglobin
? Color change appears 12-18 hours in summer and 1-2 days in winter
? Marbling of skin - greenish pattern in the skin resembling braches of a tree, starts at 24 hours; becomes
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prominent in 36-48 hours? Marbling is due to staining of superficial veins with sulpha-methemoglobin
Foul smelling gases
? Blisters 18-24 hours; first seen on the lower surface of trunk and thighs
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? Maggots 1- 2 days? Skin slippage; anus and uterus prolapse 2- 3 days
? Separation of skull sutures children 3-5 days
? Postmortem luminescence is usually due to contamination by bacteria (Photobacterium fischeri) or fungi
(Armillaria mellea)
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Liquefaction of tissues: 5-10 days
As a general rule, the organs undergo putrefaction in the following order:
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Larynx & trachea
Stomach, intestines & Spleen
Liver (foamy liver) lungs
Brain
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Heart Kidneys, bladderProstate, uterus Skin, muscle, tendon
Bones
? Virgin uterus is the last organ to putrefy, gravid uterus and uterus soon after delivery putrefies rapidly
? Optimum temperature for putrefaction 21 ?C. putrefaction arrested below 0?C and above 48?C
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Rapid putrefactionDelayed putrefaction
? Peritonitis
? Anaemia, Debility, Wasting
? Sepsis
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? Severe hemorrhage? Asphyxia
? Carbolic acid poisoning
? Intestinal obstruction
? Strychnine poisoning
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? Abortion? Heavy metal poisoning (Arsenic)
? Clostridia) infections
? Zinc chloride poisoning
MUMMIFICATION
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? A modification of putrefaction occurs in dry climate? Dehydration/drying, desiccation and shriveling of the cadaver occurs due to evaporation of water
? Skin becomes dark and tightly adherent to skeleton
? Mummification requires 3 - 6 months
? A mummified body is odourless
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Prerequisites? Absence of moisture in the air
? Dry or warm air currents
? Chronic arsenic and antimony poisoning favors antimony poisoning
Medicolegal importance
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? Features of the body like wounds, tattoo marks are preserved? Face is distorted due to shrinkage of soft tissues
ADIPOCERE or SAPONIFICATION or GRAVE WAX
? Modification of putrefaction
? Due to hydrolysis and hydrogenation of body fats
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? Commonly seen in bodies immersed in water or in damp, warm environmentPrerequisites
? Abundant body fat
? Moisture
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? Still air? Warm temperature
? Bacteria producing fat splitting enzymes like Cl.welchii
Features
? Seen over face, breasts, buttocks or limbs
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? It takes atleast 3 weeks for adipocere formation? Smells like ammonia
Medicolegal importance
? Facial features are preserved and helps in identification
? Wounds are also preserved well and helps in determining cause of death
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Casper's dictum
? Body decomposes in air twice rapidly as in water and eight times as rapidly as in soil
Embalming
? Treatment of the dead body with antiseptics and preservative to prevent putrefaction
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? The three goals of embalming are sanitization, presentation and preservation (or restoration)? Causes chemical stiffening similar to rigor mortis
? Normal rigor mortis does not develop
? Rigidity is permanent
? Blood grouping cannot be made out
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? Typical embalming fluid - formalin, sodium borate, sodium citrate, glycerine, sodium chloride, eosin, solublewintergreen, water
? Cavity embalming fluid - formalin, methanol, liquefied phenol, sodium lauryl sulphate, mercuric chloride,
eucalyptus oil
MECHANICAL INJURIES
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Injury (Section 44 IPC) - Any harm illegally caused to any person in body, mind, reputation or property
Blunt force injuries
Sharp force injuries
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Firearm injuries? Abrasions
? Incised wounds
? Rifled weapon wounds
? Contusions
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? Stab wounds? Smooth bored weapon (Shot gun) wounds
? Lacerations
? Chop wounds
? Fractures
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ABRASIONS? Wound caused by superficial damage to the skin, no deeper than the epidermis
? It can be caused by friction against or fall on a rough surface, compression or by fingernails, thorns or teeth
bite
Scratch abrasion
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? Synonym: linear abrasion? Sharp or pointed object not sharp enough to cause incised wound, but pointed enough to scratch
? E.g. thorn, fingernails, tip of knife
? Clean area at the start of the wound and tags at the end
? Helps in determining the direction of force
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Graze abrasion? Synonyms: grinding or sliding abrasions, brush burns
? Most common type - Commonly seen in road traffic accidents
? Occurs when the skin is rubbed (friction) against some rough surface
? Uneven, longitudinal parallel lines of abrasion are seen
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? Epithelium heaped up at the end of these lines which indicates the direction of forcePressure abrasion
? Synonym: crushing abrasion
? Sustained pressure of a rough object at 90? - crushing of the superficial layers of the skin
? No force on impact, but sustained pressure after the object comes in contact with body surface
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? E.g. Ligature mark in hanging and strangulationImpact abrasions
? Synonym: Contact abrasion or Imprint abrasion
? There is a moment of forceful impact, after that no contact of the object with body
? E.g: radiator grill mark, tyre tread marks seen in RTA
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? Impact abrasions and Pressure abrasions - Patterned abrasions (as the pattern of the object causing theabrasion is reproduced on the body surface)
Healing of a typical abrasion (Starts from the periphery)
? Fresh
: bright red
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? 12 - 24 hours: bright red scab
? 2 - 3 days
: reddish brown scab
? 4 - 7 days
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: dark brown scab? After 7 days
: scab dries, shrinks and falls off
Antemortem abrasions
Postmortem abrasions
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?Seen anywhere on the body
?
Seen over bony prominences
?
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Bright red?
Yellowish, pale and translucent
?
Scab slightly raised above skin surface
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?Scab lies below the skin level
?
Vital reaction positive
?
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Vital reaction negativeMedicolegal importance of abrasions
? Direction of force can be determined in scratches and grazes
? Pattern on the weapon is seen on the skin surface in pressure and impact abrasions
? Age of injury can be estimated by assessing the healing
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? Manner of injuryThrottling - crescentic fingernail abrasions on neck
Smothering - finger nail abrasions around mouth and nose
Sexual assaults - abrasions over breasts, genitals, inside of thighs, around anus.
? In cases of rape and assault, the fingernails scrapings of the victim may contain the skin fragments of the
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assailant, from which DNA typing can be doneCONTUSION (BRUISE)
? Effusion of blood into tissues due to rupture of blood vessels caused by blunt trauma
? Patterned bruise
Hammer - round
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Rod, stick or whip - tram line bruise? Delayed or Come-out bruise: a deeply situated bruise may manifest externally only after several hours or
days or after death
? Migratory or Ectopic or Percolated contusions: injury at one site, contusion at a remote site due to
gravitation of blood
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Fracture of floor of anterior cranial fossa - bruising around eye (black eye or spectacle hematoma)Fracture of floor of middle cranial fossa - bruising over mastoid (battle's sign)
Fracture of jaw - bruising in the neck
Fracture of pelvis - bruising over thigh
Hypostasis
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BruiseDistension of blood vessels with blood in dermis
Due to ruptured vessels
Occurs on dependent parts
Occurs at the site of injury
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No elevation of involved areaInvolved area swollen
Clearly defined margins
Margins merge with surrounding area
Bluish purple in color
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Color depends on the timeOn incision blood is seen inside blood vessels which
Extravasation of blood into the surrounding
can be easily washed away
area which cannot be easily washed away
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Artificial bruise
True bruise
Caused by Juice of marking nut, calotropis
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TraumaDark brown color
Color changes
Well defined margins
Merge with surrounding areas
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Vesicles presentAbsent
Redness seen in the surrounding skin
Redness in the site of injury
Itching present
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AbsentTime
Color change
Pigment
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At firstRed
Hemoglobin
Few hrs to 3 days
Blue
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Reduced Hb4th day
Bluish black to brown,
Hemosiderin
5-6 days
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GreenHematoidin
7-12 days
Yellow
Bilirubin
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2 weeksNormal
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LACERATIONS
? Laceration is an irregular open wound caused by a blunt force injury
? There will be rupture or tear of skin and/or deeper tissues
? Margins - irregular, uneven, ragged with torn edges
? Shelving - one margin over rides the other which indicates the direction of force
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? Bruising of the margins and underlying tissues seen? Pieces of tissues attached in between the edges - tissue bridges
? Hair bulbs are crushed
? Depth - varies with force and may contain foreign matter like dust, sand, paint of the vehicle involved etc.
Split laceration
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? Skin gets crushed between two hard surfaces (weapon and bone) and splits? Occurs when the bone is superficial and subcutaneous tissues are scanty
? Edges appear to be clean cut (incised looking lacerations)
? Commonly seen over - scalp, lower jaw, iliac crest, shin etc
Stretch laceration
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? When the skin gets stretched beyond its limits of elasticity, stretch laceration occurs? Occurs in vehicular run over accidents, when the skin is stretched
? Fractured segment of a bone pierces the skin and projects out
Avulsion
? When a shearing or grinding force is applied, the skin is separated from the underlying tissues
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? Occurs in vehicular run over accidents, where skin flap is completely removed from the underlying tissues(flaying)
INCISED WOUNDS
? Clean cut through the tissues (skin, subcutaneous tissues, blood vessels) by a sharp weapon
? Shape - usually spindle shaped due to gaping by skin elasticity
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? Margins - Regular, clean cut and well defined? Margins - usually everted except sites like neck, scrotum and axilla because of underneath muscles adherent
to skin
? Length - no relationship with the length of cutting edge of the weapon
? Breadth - Much wider than the cutting edge, because of the retraction of divided tissues with everted
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margins - gaping? Depth - towards the termination depth becomes progressively shallow - tailing of wound
? Cut injuries over face, nose, ears, genitals are usually homicidal
Incised wounds
Lacerated wounds
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Caused by sharp weaponCaused by blunt weapon
Margins: Regular, clean cut, everted
Margins irregular
Shape: spindle shaped
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IrregularLength is greater than width Et depth
Wounds may be of any length, breadth and depth
No abrasions on edges
Abrasions seen on edges
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No contusion of adjacent tissuesContusion of surrounding and underlying tissues
Underlying tissues cleanly cut
Deeper tissues unevenly divided - tissue bridging across the
margins
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Hair bulbs - cleanly cutHair bulbs - crushed
Foreign particles - absent
Foreign particles - present
Tailing indicates direction of force
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Shallow tails seen, but not related to direction of forceCircumstances: usually homicidal or
Usually homicidal or accidental, almost never suicidal
suicidal, rarely accidental
Tentative cuts - suicidal
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Split laceration & tears: mostly homicidalBeveled cuts - homicidal
Stretch laceration & Avulsion: accidental
Chop wounds
? Wounds produced by fairly heavy weapons like Axe, Hatchet, Big sword
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? Abrasions and bruising seen at the margins and underlying tissues? Margins - ragged abraded and contused
STAB WOUNDS
? Produced when a pointed weapon or object or instrument is forcibly thrust into the body
? Length
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May be same as the breadth of the blade of weapon orSlightly smaller because of elasticity of skin or
Larger because of the lateral movement of the victim or assailant
? Breadth - may not approximate with each other because of gaping
? Depth - greatest among the 3 dimensions
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No relationship with the length of the weaponWound should not be probed to find the length in a living person as it may dislodge a blood clot and
result in fatal hemorrhage
? Margins - regular and clean cut
? Shape - depends on the type of weapon and site of injury
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Single edged weapon - wedge shaped or triangular. Blunt end of the wound may have small splits inthe skin at each end of the corner - fishtailing
Double edged weapon - spindle shaped or elliptical
? Direction
Indicated by the track of wound
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Helps to determine the relative position of the victim and assailant at the material timeHesitation/Tentative cuts
? Multiple, Parallel, Superficial cuts
? Accessible and vital sites - neck, wrist, ankle, chest, abdomen
? Usually in suicidal cuts
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? Inflicted by the victim before the final fatal deep cutSuicidal cut throat
Homicidal cut throat
? In a right handed individual ? above
? Usually on both sides
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downwards, from left to right side? Multiple, superficial, parallel wounds.
? Single or multiple.
? Only one wound is deep.
? If multiple, many wounds are deep
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? Superficial wounds merge with the single main? Wounds cross each other at deep level
wound
? Hesitation or tentative cuts present
? Absent
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? Tailing present? Absent
? Wounds may be seen on other accessible Parts
? Severe injuries may be seen on head, face
of the body - wrist, chest, groin, ankles etc
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and neck? Defence wounds - absent
? Defence wounds present
? Weapon firmly grasped in hands due to
? Weapon is usually absent at the scene of
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cadaveric spasmcrime
? Clothes are usually not damaged
? Cuts in the cloth corresponding to injury over
the body seen
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? Circumstantial evidence: room locked inside,? Disturbance of the scene, disarray of furniture,
Stains on the mirror if the person was standing
foot prints, tears and loss of buttons in the
in front of it, suicidal note etc
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cloth etcDEFENCE WOUNDS
? Injury received by the victim of an attack while trying to defend himself against the assailant
? Often found on the hands and forearms, where the victim has raised them to protect the head and face
? Present on the feet and legs where a victim attempts defense while lying down and kicking out at the
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assailant? The presence of defense wounds is highly suggestive of homicide
? Defence wounds are absent: if the victim is unconscious, taken by surprise, attacked from the back, under
the influence of alcohol or drugs
FABRICATED WOUNDS
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? Fabricated, fictitious, forged or invented wounds are those which may beProduced by a person on his own body (self-inflicted), or
Occasionally, caused by another person with his consent (self-suffered)
? Motive - To bring false charges against enemies, Fictitious sexual assault by women to bring a rape charge
against enemy
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Characteristics? Usually caused by a sharp weapon
? Usually superficial wound - abrasions or incised wounds
? Wound over accessible parts
? Tears in the clothes don't correspond to those in the body.
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? Age of wound doesn't coincide with the history given by the person.'SKULL FRACTURES
Fractures of vault of skull
? Fissure # (linear #)
Broad surface like ground, Weapon with broad striking surface, Fall on feet, buttocks
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? Depressed #(fracture a la signature) - Heavy weapon with a small striking surface? Comminuted #
Vehicle, railway accidents
Heavy weapon with broad striking surface
? Pond #(indented #)
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Only in infantsObstetric forceps cause injury to infant skull
Blow from blunt objects
? Gutter # - from oblique bullet wounds
? Ring or foramen # - fall from height on foot or buttocks
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? Diastatic or sutural # - blunt injuryUndertaker's fracture
? Caused due to the head falling backwards forcibly after death, which tears open one of the inter vertebral
disc usually around C-6 and C-7
? It is a postmortem artifact due to rough handling of the body
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Fractures of base of skull
? Ring fracture
Fissured fractures around foramen magnum
Seen in fall from height when the person lands on feet or buttocks
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? Hinge fracture or Motor cyclist's fractureINTRACRANIAL HEMORRHAGES
EXTRADURAL or EPIDURAL HEMORRHAGE
? Between the skull and the dura mater
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? Etiology: almost always traumatic? MC source of bleeding - middle meningeal artery
? Other sources - diploic veins, transverse sigmoid sinuses, anterior and posterior meningeal arteries, anterior
ethmoidal arteries
? It is the least common type of all intracranial hemorrhage
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? The region most commonly involved is the temporal region (70-80%)? Usually accompanied by a fracture of skull, most commonly fissured fracture
? The classic lucid interval occurs in 20-50% of patients with EDH
? CT scan: lenticular or biconvex appearance of hemorrhage
? EDH with volume greater than 30 mL need emergency surgical evacuation
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SUBDURAL HEMORRHAGE / HEMATOMAI? Etiology
Traumatic
Coagulopathy (hemophilia, liver disease, thrombocytopenia)
Anticoagulation therapy (warfarin, heparin)
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latrogenic (lumbar puncture)Spontaneous (cerebral tumors, AV malformation, and aneurysms)
? Source of bleeding: bridging veins (vein that connects cortical surface of brain to a dural sinus)
? Subdural hematoma is the most common type of traumatic intracranial mass lesion
? Acute subdural hematomas occur most commonly over the parietal region
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? CT scanAcute subdural hematoma (< 72 hours old) - hyperdense, crescent-shaped mass
Subacute SDH (2nd and 3rd weeks) - isodense, lens shaped
Chronic SDH (after 3 weeks) - hypodense
Duret hemorrhages
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? Secondary herniation hemorrhages of midbrain and pons? Occur in midline
? Commonly occurs after asymmetrical herniation of brainstem
LUCID INTERVAL
? Lucid interval is seen in
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Extradural hematomaSubdural hematoma
Insanity
Heat stroke
Postictal phase after a seizure in epileptic patients
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COUP INJURY? Injury to the skull and brain occurs at the site of impact
? Occurs when a moving object hits a static head
CONTRE-COUP INJURY
? Injury to the skull and brain occurs on the side opposite to the site of impact
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? Occurs when moving head hits a stationary blunt surfacePEDESTRIAN INJURIES
Primary impact injuries
? Due to the first impact between the vehicle and the pedestrian
? In adults - usually seen on the legs (# tibia - bumper #)
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? In children - usually seen in head or thighs (# femur - bumper #)? Patterned abrasion or bruising produced by bumper, radiator grill, head lights etc.
? Helps in identifying the offending vehicle
Secondary impact injuries
? Caused by the subsequent impact of the body with the same vehicle after the primary impact
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? Victim is thrown upwards after the primary impact and he falls against the hood, wind shield or roof? Head injuries are common
? Seen on the same side as the primary impact injury
Secondary injuries or tertiary impact injuries
? Injuries caused when the victim falls on ground or any other object
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? Graze abrasions and tire marks? Base of skull fracture
? He may be run over and crushed against the ground resulting in flaying injuries
? Found on the parts opposite to the primary impact
Injuries to occupants of vehicle
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? Sparrow foot marks or Dicing injuries - Multiple punctate lacerations or superficial cuts of the face due toshattering of the windscreen glass into multiple small cubical fragments with relatively blunt edges - seen in
front seat occupants
? Steering wheel impact injury - seen in driver
Transverse fracture of the sternum
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Contusion and rupture of heartRupture of aorta
? Transverse intimal tears of aorta - ladder tears
Motorcyclist's injury
? Motor cyclists fracture or Hinge fracture: Due to heavy impact on one side of the head, fracture is produced
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across the floor of the middle cranial fossa? Tail-gating or Under running injury
Usually occurs in darkness
When the motor cyclist drives into the back of a large vehicle
Due to sudden and unexpected stoppage of the large vehicle moving in front
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GRIEVOUS HURT (Section 320 IPC)The following injuries constitute grievous hurt
1. Emasculation
2. Permanent privation of sight of either eye
3. Permanent privation of sight of either ear
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4. Privation of any member or joint5. Destruction or permanent impairment of powers of any member(organ or limb carrying out a distinct
function) or joint
6. Permanent disfiguration of the head or face
7. Fracture or dislocation of a bone or tooth
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8. Any hurt which endangers life or which causes the sufferer to be in severe bodily pain or unable to follow hisordinary pursuits for a period of 20 days
'PUNCH DRUNK SYNDROME
? Boxer's encephalopathy or dementia pugilistica or chronic traumatic encephalopathy
? A condition seen in boxers and alcoholics, who suffer repeated cerebral concussions due to repeated blows
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to the head? In the initial stage there will be deterioration of speed and incoordination
? Later they develop weakness in the lower limbs, hand tremors, and mental dullness.
? Final stage is characterized by slurred speech, dementia, ataxia, broad based gait and Parkinsonism like facial
appearance
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Retraction balls are seen in diffuse axonal injuryPuppe's rule- determines the sequence of shots when several bullets have struck the cranium
Whiplash injury - acute hyperflexion followed by acute hyper extension of spinal cord
Stab injury to heart most common in - right ventricle
Driver's injury, Horn boss injury or Steering wheel impact injury - buckled sternum
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Six penny bruise - bruises found in neck in throttling caused by finger tipsLanger's line: gaping is more if the incision is made at right angles to Langer's line
Causes of death from wounds
Immediate or Primary causes
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Remote or Secondary causes? Hemorrhage (MCC)
? Infection/Sepsis (MCC)
? Neurogenic Shock
? Thrombo-embolism
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? Injury to a vital organ? Crush syndrome
? Air embolism
? Fat embolism
? Acute Respiratory Distress Syndrome (ARDS)
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? Disseminated intravascular coagulation (DIC)? Miscellaneous
Antemortem wounds
Post mortem wounds
Edges are swollen and everted
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No swelling of the edgesGaping present
No gaping, edges are approximated
Abundant bleeding
Slight or no bleeding
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Arterial bleedingVenous bleeding
Evidence of spurting of blood seen
No spurting
Blood extravasated in the subcutaneous tissue
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No extravasation of bloodAdjacent tissues are stained which cannot be removed by
Easily washed away
washing
Coagulated blood seen in wounds
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Not seenVital reaction positive
Negative
Increased enzyme activity
No enzyme activity
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TORTURE? Falanga (bastinado) - physical torture with canes or rods are used to beat on the soles
? Telefono - repeated slapping on the sides of head over ears
? Wet submarino(latina) - forced immersion of head in water contaminated with urine or feces
? Dry submarino - tying a plastic bag over the head until suffocation
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? Parrot's perch - head down from a horizontal pole placed under the knees with wrists bound to ankle? Cattle prod - electric shock especially over the genitals
? Chepuwa - the legs and thighs are tied very tightly with bamboo sticks to induce severe pain
? Ghotna - rolling a wooden log over the thighs up and down, while the log is weighed by one or two
policemen standing on it
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? Sham execution - victim is blind folded and asked to stand before a wall and then threatened that a vehicle isgoing to hit him. He hears the sound of a vehicle very near to him, causing fear and shock
? Dunking - victim is immersed into water, taken out after some time and given chance to confess
Declaration of Tokyo by World Medical association in 1975 - guidelines for medical doctors concerning
torture
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FIREARM INJURIES
Proximal (Internal) ballistics: study of firearms and projectiles
Intermediate (External) ballistics: study of motion of a projectile after being ejected from the firearm till the
time it hits the target
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Terminal (Wound) ballistics: study of injuries produced by firearmsRifling
? In rifled firearms, the interior of the barrel - parallel, spirally twisted grooves
? In smooth bored firearms - interior surface is smooth
? Rifling imparts a spin or rotation to the projectile and it acquires a gyroscopic steadiness, preventing it from
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wobbling? Paradox guns: if the barrel is partly smooth bored and partly rifled
Tvoes of stun aowder
Black powder
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Semi-smokeless powderSmokeless powder
? 75% potassium
? 20% smokeless
? Single base: nitrocellulose alone
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nitratepowder
? Double base: Nitrocellulose +
? 15% charcoal
? 80% black powder
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Nitroglycerine? 10% sulphur
? Most effective type ? capable of
? Single grain of black
imparting high velocity to the projectile
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powder produces:? Single grain of smokeless powder
200 - 250 cc of gas
? produces 800 - 900 cc of gas
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Parts of a firearm
Chamber - in which cartridge or magazine is
lodged
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Bolt - The part incorporating the trigger, springand the firing pin
Cylinder - where explosion takes place Barrel -
Hollow steel tube
Rear end of barrel - breech
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Distal end of barrel - muzzleChoking
? In smooth bored firearms the barrel becomes narrower towards the muzzle end to minimize the dispersion
of pellets
? Cylinder bore: a barrel that is not choked
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Caliber? Calibre of a rifled firearms is measured between two diametrically opposite lands
? Calibre of a shot gun is expressed in terms of the number of balls of lead which can be made out of 1 pound
of the metal, so that each fits exactly into the bore of the weapon
? Helixometer - instrument to examine the interior of the barrel
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Fire armFiring range
Shot gun
30 - 40 m
Revolver, Pistol
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100 - 300 mRifle
1000 m
Military rifle
3000 m
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Component of explosionEffects
Flame
Singeing, burning, blistering
Smoke
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Blackening, smudging, foulingGun powder
Tattooing, stippling, peppering
Distance travelled by different components of explosion
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Shot gunsRevolvers and Pistols
Rifles
Smoke
30 cm
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30 cm30 cm
Flame
45 cm
8 cm
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15 cmGun powder
60 - 90 cm
60 cm
75 - 100 cm
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WOUNDS FROM REVOLVERS, PISTOLS, RIFLESContact shot (point black shot)
Close shot (within the range of flame)
? Large wound, shows cavitation
? Circular wound
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? Over skull - Stellate, cruciate or cruciform? Singeing of hair +
wound
? Burning, blackening and tattooing +
? Over abdomen - circular wound
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? Abrasion collar/ grease collar/ dirt? Muzzle imprint may be present
collar +
? Margins contused and everted
? Singeing of hair present
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? Burning, Blackening, Tattooing -minimal/absent
? Tissues are cherry red in colour (carbon
monoxide)
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Near shot (within the range of gun powder)Distant shot (beyond the range of gun powder)
? No burning, no blackening, no singeing
? Circular wound < diameter of the bullet
? Tattooing +
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? Margins inverted? Abrasion collar +
? Burning, blackening, tattooing absent
? Round entrance wound
? Abrasion collar present
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ABRASION COLLAR? When the bullet (projectile of a rifled firearm) penetrates the skin while entering, due to spin, the edge of
the entrance wound may be abraded in the form of a collar
? Absolute proof of entrance wound of a rifled firearm (always seen)
? Main factors contributing to abrasion collar
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Gyroscopic movement of the bulletElasticity of the skin
? When the bullet comes in contact with the skin, its spinning action develops great friction against the
elasticity of the skin
? Thus it produces a collar of abrasion all around the wound of entry
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? It is seen in entry wound of rifled firearms at all ranges? Helps to determine direction of firing
When the bullet enters the skin at right angles - round abrasion collar
When the bullet enters the skin obliquely - oval or oblique abrasion collar
WOUNDS PRODUCED BY SHOTGUN
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Contact shotClose shot
? Large, irregular hole resulting from the
? Circular defect with irregular borders
explosive blast effect
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? Burning + Blackening+ Tattooing +? Burning + Blackening + Tattooing +
? Pellets enter the body en masse
? The shot (pellets) enter the body en masse
? Rat hole entry wound (30 cm - 1 m)
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? Cherry red discoloration of tissues? Satellite holes around entry wound (2 - 3 m)
Near shot
Distant shot
? Circular or oval wound
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? Beyond 2 metres? Smudging upto 30 cm
? No burning, blackening or tattooing
? Wad causes mild abrasions upto 30 cm
? Wad may be present inside the wound (upto
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? Tattooing +5m)
? The pellets travel as a compact mass upto 45
? Pellets disperse significantly - the size of the
cm
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central role decreases? After that disperse and enter as individually
? Beyond 6 metres - no central hole
Rule of thumb: the diameter of spread in inches = range in yards x 1.5
Entrance wound
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Exit woundSize smaller than the diameter of bullet
Larger
Inverted edges
Everted edges
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Bruising, abrasion collar and grease collarAbsent
Burning, blackening and tattooing seen
Absent
Fat protrusion not seen except in contact shot
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PresentTissues may be cherry red due to CO
No colour change
Fibres of clothing may be turned in
Turned out
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Lead ring seen on radiological examinationAbsent
Shored (supported) exit wound
? If the skin at the exit wound is supported (belt, waist band of trousers or if the body leans against the wall,
chair, door)
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? Near-Circular exit wound surrounded by abrasion? Resembles wound of entrance
Bullet wounds in skull
? Wound is funnel shaped; funnel opening up in the direction in which the bullet is travelling
? Entrance wound
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Outer table - punched holeInner table - beveling (sloping surface)
? Exit wound
Inner table - punched hole
Outer table - beveling (sloping surface)
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Wounding power of bullet? It is directly related to the kinetic energy at the moment of impact (E=mv2/2)
? Thus the wounding power depends mainly on the velocity of the bullet
Peculiar effects of firearms
? Ricochet bullet - before striking the target, bullet strikes an intervening object and then rebounds to the
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target? Yawing bullet - travel in irregular fashion, produce a key hole entry wound
? Dum Dum bullet - a jacketed bullet with nose cut off
? Tumbling bullet - rotates in end to end
? Souvenir bullet - left in the body for body for some time and covered with dense fibrous tissue
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? Tandem bullet or piggy back bullet-2 bullets ejected one after other, first one failed to leave and ejected bythe next one
? Frangible bullet - fragments at the site of impact
? Mushroom bullet - expand upon impact and thus produces more serious wounds
? Kennedy phenomenon - Surgical alteration or suturing of gunshot wounds, evaluation of wounds become
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difficult? Crime bullet or exhibit bullet: bullet found in the body
? Test bullet: test fired bullet
? Tracer bullet
Projectiles that are built with a small pyrotechnic charge in their base
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Ignited by the burning powder, the pyrotechnic composition burns very brightly, making the projectilevisible to the naked eye
This enables the shooter to follow the projectile trajectory to make aiming corrections
Autopsy in a case of death due to firearms
? Whole body X-ray to localize the bullet/pellets
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? All wounds should be photographed? All skin wounds should be dissected out carefully with surrounding tissue and preserved in glass containers
containing rectified spirit
? The bullet should be removed with fingers or rubber tipped forceps and not with toothed metal forceps
? It should not be washed as it would remove any residues
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? The doctor should mark his initials at the base with a sharp pointed instrument to facilitate its identificationin court
Tests for firearms
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Harrison and Gilroy testNeutron activation analysis
Atomic absorption spectroscopy (AAS)
Flameless AAS
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Dermal nitrate (paraffin test)Bullet rotates at 3000 revolutions per second as it leaves the barrel of a rifle
Incendiary bombs - primarily cause burns
Motolov cocktail - an incendiary bomb, bottle filled with gasoline and a rag to serve as a wick which is
lighted and thrown at the target
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THERMAL INJURIES, LIGHTNING, ELECTROCUTION, TRACE EVIDENCE, FORENSIC
PSYCHIATRY
BURNS
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Estimation of % of body surface area burnsArea of body
Infant
Child
Adult
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Head and neck20
19
9
Front of trunk
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2016
18
Back of trunk
20
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1618
Upper limbs
20
19
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18Lower limbs
20
30
36
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Genitals0
0
1
Minimum temperature for producing a burn is 44?C for about 6 hours
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Cause of death in burns? First 24 hours - neurogenic shock
? 24 - 48 hours - hypovolemic shock
? After 48 hours - septic shock
Findings indicative of ante mortem burns
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? Soot in the upper respiratory tract? Carboxy hemoglobin in blood
? Albumin and chloride in blisters
? Healing and granulation
? Increased enzymes in blisters
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? Presence of carbon particles in terminal bronchioles - absolute proof of life during burnsPugilistic (boxing or fencing) attitude occurs both in ante mortem and postmortem burns
Curling's ulcer - sharply punched out mucosal defects in duodenum in 10% burns deaths
Heat ruptures can be differentiated from incised/lacerated wounds by
? Presence of intact nerves, blood vessels and connective tissue in the floor
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? Absence of clotted blood as heat coagulates blood in the vessels? Absence of bruising or other vital reactions in the margins
? Irregular margins
Antemortem burns
Postmortem burns
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Line of rednessAbsent
Blister contains serous fluid with proteins and chloride.
Air and thin clear fluid.
Base - red
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Base - pale, dry, hardVital reaction present
Absent
Enzymatic activity present
Absent
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Carboxyhemoglobin > 10%Absent
Carbon particles in airway
Absent
SCALDS
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? Application of moist heat? Liquid above 60?C or steam
Burns
Scalds
Site: At and above the site of contact
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At and below the site of contactSplashing absent
Splashing present
Skin: Dry, wrinkled
Soddened and bleached
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Blisters at the circumference of burnt areaBlisters over scald area
Charring, singeing present
Absent
Clothes burnt
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Clothes wet, not burntHEAT CRAMPS/ MINER'S CRAMPS/STOKER'S CRAMPS
? Persons working in high temperature and sweating is profuse
? Vigorous exercise also results in loss of electrolytes through profuse sweating in hot weather
? Rapid dehydration and loss of sodium and chloride from the body through sweat
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? Severe and painful cramps of muscles of arms, legs, abdomen? Treatment - i.v. saline causes rapid relief
HEAT PROSTRATION/HEAT SYNCOPE/ HEAT COLLAPSE/HEAT
? Most common hyperthermia syndrome
? Failure of CVS to compensate for hypovolemia
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? Person standing in the sun becomes pale, his BP falls and collapses suddenly due to pooling of blood in thetower limbs
? Skin cold, pupils dilated, pulse thready
? Treatment - rest with head down position
HEAT HYPERPYREXIA/ HEAT STROKE
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? Failure of heat regulating center in hypothalamus? Very high body temperature (upto 110?F or 43.3?C)
? No sweating, Delirium, coma, convulsions, multiple organ failures
? Predisposing factors - high temperature, increased humidity, minor infections, old age, alcoholism
? Necrosis of the muscles (rhabdomyolysis) and myocardium due to nitrosylation of the ryanodine receptor
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type 1 (RYR) in skeletal muscle? Treatment: rapidly cooling the body with ice water till the rectal temperature falls below 102?F
Disorder
Body temperature
Skin
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Mental statusHeat cramps
37?C
Moist and cool
Normal
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Heat exhaustion<40?
Sweating
Normal
Heat stroke
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>40?Dry (anhydrosis)
Impaired consciousness
FROST BITE
? When the tissue temperature drops below 0 ?C (32?F)
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? Ice crystal formation distorts and destroys the cellular architecture? Vascular endothelium is damaged, stasis progresses rapidly to microvascular thrombosis.
? Finally, thrombosis, dermal ischemia, and superficial necrosis appear
? Usually occurs in extremities
? Blisters can also be seen
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TRENCH FOOT/IMMERSION FOOT? Immersion foot results from repetitive exposure to wet cold above the freezing point.
? The subsequent development of bullae is often indistinguishable from frostbite.
? This vesiculation rapidly progresses to ulceration and liquefaction gangrene.
ELECTROCUTION
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? Voltage is the fundamental force or pressure that causes electricity to flow through a conductor? Electrocution is rare at less than 100 volts and most deaths occur at more than 200 volts
? Alternating current (AC) is more dangerous than equal voltage of direct current (DC). This is because when
AC comes in contact with muscles, it produces tetanic muscle contractions and does not allow the person to
release the contact with the source of current
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? Currents of 10mA cause pain and muscle contractions and 100mA is fatal? The electric burn at the point of entry is called Joule burn or endogenous burn
? Spark burn or exogenous burn is produced by intermittent contact and arcing of current from the conductor
to the skin. There is an air gap between metal and skin
? Multiple burnt or punched out lesions are produced due to an arc dancing over the body surface which
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produce crocodile flash burns? If the point of entry is one upper limb and the point of exit is the opposite foot, the current will pass across
the chest and most likely to produce myocardial fibrillation
? Current passing through the head may cause brain stem damage with central respiratory paralysis
? Skeletal muscle in the path of the current may show Zenker's degeneration
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? Small balls of molten metal (current pearls), derived from the contacting electrode, may be carried deep intothe tissues
? Heat generated by the current may melt the calcium phosphate, which is seen radiographically as round
density foci (bone pearls or wax drippings)
? There may be bone necrosis or Zig-zag microfractures
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Zenker's degeneration - a type of coagulative necrosis, also seen in acute infections like typhoidCurrent voltages
? Domestic current - 220 to 240 volts.
? Industrial current - upto 400 kilovolts
? Lightning - > 1000 million volts
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LIGHTNING? 1000 million volts; 20000 amperes
? Attracted by the highest points
? Chooses the easiest path
Postmortem appearances
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? Blast effects due to air expansion around the flashRupture of ear drums
Contusions, lacerations, fractures, rupture of organs
Clothes may be torn or stripped off and thrown apart
Shoes may be burst open
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? Burn effectsLinear burns over skin creases and folds
Medicolegal importance
? Most deaths occur in the open (persons sheltering under trees, open fields, carrying something which
attracts lightening)
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? Persons seated in motor vehicles are not affected because of insulation provided by the tyres? The crime scene may suggest sexual offence or criminal violence - clothes stripped off, abrasions, contusions
and lacerations in a body found in an open field
? Diagnosis should be based on the history of thunderstorm in the locality, evidence of effects of lightning in
the vicinity of the body and fusion or magnetization of metallic substances
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ARBORESCENT BURNS/FILIGREE BURNS/LICHTENBERG'S FLOWERS? Superficial thin irregular tortuous markings on skin resembling branches of a tree
? Fern-like pattern of erythema over the shoulders or flanks
? Does not correspond to vascular channels
? Not associated with burning
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? Staining of tissues by Hb or rupture of capillaries along the pathway of currentTRACE EVIDENCE
? Locard's principle of exchange: When any two objects come into contact, there is always a transfer of
material from each object on the other
Tests for blood stains
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Presumptive testsConfirmatory tests
? Benzidine test (Alder's test)
? Haemin crystal test (Teichmann test)
? Phenolphthalein (Kastle Mayer test)
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? Haemochromogen test (Takayama test)? O-toluidine test
? Immunological test - precipitin test
? Leucomalachite green test
? Spectroscopy - most reliable for detecting
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? Luminol testboth recent and old stains
Blood grouping from blood stains
? Latte's crust method
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? Absorption-elution technique? Absorption inhibition
? Latex method
? Mixed agglutination
Agglutinogens in the stain are retained for longer time, even though red cells are destroyed. The absorption
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inhibition and absorption elution method are employed for grouping of such old stains.DNA TYPING/DNA FINGERPRINTING
? DNA finger printing was developed by Dr. Alec Jeffreys in 1985
? Short tandem repeats(STR) are used as markers for human identification in forensic casework Mitochondrial
DNA analysis is the method of choice when dealing with environmentally challenged samples and also used
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in cases of disputed maternitySamples collected for DNA analysis
? Muscle is the most ideal source for extracting DNA. 100mg muscle with NS or dimethyl sulphoxide (DMSO)
solution saturated with sodium chloride as a preservative
? 5ml of i.v blood with heparin or EDTA
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? Blood clot or dried blood stains from the scene of crime can be sent? Semen, vaginal swabs, saliva sent in the dried condition
? Urine 10ml (frozen)
? Hair (10-20) picked using forceps without damaging the root (cut hair without root is not useful)
? Femur or humerus with bone marrow and molar teeth without preservative
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? Finger nail scrapingsTests for seminal stains
? Creatine phosphokinase test
? Acid phosphatase test
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? Florence test? Barberio's test (crystals of spermin picrate)
FORENSIC PSYCHIATRY
? Mens rea - criminal mind
? Actus rea - actual physical act causing death
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? A person is Criminally responsible only when both actus rea and mens rea are present Holograph will is onewritten by a testator in his own hand writing
? Testamentary capacity is the mental ability of a person to make a valid will
? Observation time for a person for diagnosis of insanity - usually 10 days, but with the permission of
Magistrate may be extended to 30 days
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? Reception order - issued by the magistrate for admission and detention of a psychiatric patient, valid for 30days
? Section 84 IPC: (based on McNaughten rule) Nothing is an offence which is done by a person, who at the
time of doing it, by reason of unsoundness of mind, is incapable of knowing the nature of the act or that he is
doing what is either wrong or contrary to the law
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? During lucid interval a personCan make valid will
Can give valid evidence in a court of law
Is legally responsible for his deeds
REAL INSANITY
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FEIGNED INSANITYGradual onset
Sudden
No motive
Motive present(commission of crime)
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Predisposingfactors present(h/o insanity in parents,
Absent
sudden monetory loss)
Facial expression ? peculiar (vacant look) or fixed look of
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No peculiarity, frequently change, exaggerated andexcitement
voluntary
Insomnia present
Cannot persist, sleeps soundly after a day
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or twoPatient can stand exertion of fatigue, hunger and sleep for
Cannot stand exertion for more than a few
several days without breaking down
days and breaks down
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Frequent examination - does not mindResents for fear of detection
THE MENTAL HEALTH ACT, 1987
Terminologies changed
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? Psychiatric hospital (instead of mental hospital or asylum)? Mentally ill person ( instead of lunatic)
? Mentally ill prisoner (instead of criminal lunatic)
Provisions of the act
? Mentally ill person - a person who is in need of treatment by reason of any mental disorder other than
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mental retardation? Establishment and maintenance of psychiatric hospitals can be done only with license which has to be
renewed every five years
? Govt. appoints 5 visitors (atleast 1 Medical officer) for each nursing home - inspection every month -
examine - examine every minor patient
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IMPULSE? Impulse is a sudden and irresistible force compelling a person to the conscious performance of some action
without motive or forethought and preparation
Types of impulses
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? Kleptomania: An irresistible desire to steal articles of little value and of no use to the person? Pyromania: Irresistible desire to set fire to things
? Dipsomania: An irresistible desire for alcoholic drinks at periodic intervals
? Oniomania: Irresistible desire for shopping
? Mutilomania: Irresistible desire to injure and mutilate animals.
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? Suicidal and homicidal impulses: e.g: run amok in cannabis poisoningSTARVATION
? Feeling of hunger lasts for 30 - 48 hours
? Loss of 40% of body weight is usually fatal
? If both water and food are withdrawn, death occurs in 10 - 12 days
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? If food alone is withdrawn, death occurs in 6 - 8 weeks? Rigor mortis sets in and disappears quickly
? Gall bladder is distended with bile
? Baby-farmer: child starved by their parents or guardians
MECHANICAL ASPHYXIA
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HANGING
? Typical hanging - knot at the occiput
? Atypical hanging - knot elsewhere
? Complete hanging - no part of the body touches the ground
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? Partial hanging - body touching the groundCauses of death in hanging
? Venous congestion
? Asphyxia
? Asphyxia + venous congestion (mcc)
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? Cerebral anoxia? Reflex vagal inhibition
? Fracture dislocation of cervical vertebrae
Tension required to occlude various structures in the neck
? Jugular veins - 2 Kg
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? Carotid arteries - 5 Kg? Trachea - 15 Kg
? Vertebral arteries - 20 Kg
Judicial hanging
? Atypical hanging (knot under the angle of jaw)
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? Tear of spinal cord due to Fracture dislocation at C2-C3 or C3-C4Postmortem findings in hanging
External
Internal
? Cyanosis
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? Congestion of viscera? Petechiae (Tardieu spots) noted
? Petechiae
? Over forehead, face, temples,
? Fluidity of the blood
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eyes? Tissues under the ligature mark are dry, pale and glistening
? Le Facies sympathique
? Transverse intimal tears of carotid arteries ? in cases
? Salivary dribbling
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associated with long drop (e.g. judicial hanging)? Glove and stocking hypostasis
? Thyroid cartilage fracture
? Ligature mark
? Hyoid bone fracture
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Postmortem findings that indicates antemortem hanging? Dribbling of saliva
? Le Facies Sympathique - if the ligature press the cervical sympathetic chain, the eye on the same side is open
and pupils dilated
? Intimal tears in the carotid artery
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Ligature mark is seen in both AM and PM hangingHyoid bone # seen in 0 - 60 % (common above 40 yrs)
STRANGULATION
? Ligature strangulation: neck constricted with a ligature
? Manual strangulation or Throttling: Neck constricted with hand
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? Garroting - victim attacked from behind, throat may be grasped or ligature thrown and neck constricted? Mugging - strangulation caused by holding the neck of the victim in the bend of the elbow
? Bandsola - neck constricted between two bamboo sticks
'MANUAL STRANGULATION OR THROTTLING'
? Constriction of the neck by hands
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? Always homicidalPM findings
? Linear or crescentic abrasions (nail marks) on the neck
? Bruising - one prominent bruising on one side of neck (thumb) and three to four abraded contusions on the
other side (other fingers)
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? Hemorrhage and bruising into the deeper structures of the neck? Fracture of superior thyroid horn
? Fracture of hyoid bone
HANGING
LIGATURE STRANGULATION
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Ligature markLigature mark
? Oblique
? Transverse
? Does not encircle the neck completely
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? Encircles the neck completely? Below chin and above thyroid cartilage
? At or below thyroid cartilage
? Base -pale, hard and parchment like
? Base - soft and reddish
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Bruising of neck muscles not commonBruising of neck muscles common
Neck stretched and elongated
Not so
Hyoid bone fracture may occur
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Uncommon (more common in manual strangulation)Thyroid cartilage fracture less common
Thyroid cartilage fracture more common
Carotid intimal tears seen
Rare
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Salivary dribbling presentAbsent
Bleeding from nose, mouth and ears uncommon
Common
Subconjunctival hemorrhage absent
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Subconjunctival hemorrhage presentHyoid bone fractures
? Inward compression # or adduction # (periosteum torn outside) - throttling
? Antero posterior compression # or abduction # (periosteum torn inside) - hanging
? Avulsion# or tug # or traction# - due to muscular over activity
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Neck dissection? In any case of suspected injury to the neck and suspicious deaths (hanging, strangulation), neck should be
opened last
? After opening abdominal, thoracic and cranial cavity and removing all the viscera and draining all the blood,
neck should be opened - bloodless dissection of neck
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? In hanging - no extravasation of blood in tissue planes? In ligature strangulation & throttling - extravasation of blood, injury to neck structures and muscles
DROWNING
? Wet drowning/Primary drowning: water is inhaled into the lungs
? Dry drowning: water does not enter the lungs; death results from immediate sustained laryngeal spasm
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? Secondary drowning/Post immersion syndrome/Near drowning: submersion victim who is resuscitated andsurvives for 24 hours
? Immersion syndrome/Hydrocution/Submersion inhibition:
Death due to cardiac arrest due to vagal inhibition
Stimulation of the vagal nerve endings
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o Sudden entry of water into nasopharynx or larynxo Water striking the epigastrium while diving
o Sudden inrush of cold water into the ears
? Predisposing factors
Young swimmers
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Under the influence of alcoholExcitement and emotions
Overeating prior to swimming
Fresh water drowning
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Sea water drowning0.6%NaCI
>3%NaCI
Denatures the surfactant
Dilutes surfactant
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Hemodilution, hemoglobinuriaHemoconcentration
Hyponatremia, Hypocalcemia, Hyperkalemia
Hypernatremia
Cause of death - ventricular fibrillation, cardiac failure
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Cause of death - pulmonarydue to volume overload and hypoxia of myocardium
edema
Lungs ? ballooned and light, emphysematous, shape
Lungs - ballooned and heavy,
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retained, do not collapse after removal, c/s ? crepitussoft, shape not retained,
heard, little froth, no fluid
collapse on removal, c/s ? no
crepitus, copious fluid and froth
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Post Mortem findings in a case of DrowningExternal
? Dilated pupils, Light pink PM staining, RM develops early
? Fine , white , leathery, copious froth in mouth and nostrils (most characteristic finding)
? Weeds, gravel, twigs or leaves present in water may be firmly grasped in hands due to cadaveric spasm
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which strongly suggests antemortem drowning? Cutis anserina or goose skin and retraction of scrotum and penis due to submersion in cold water(reaction
phenomenon)
Internal
? Lungs - voluminous, completely occupy thoracic cavity, bulge out from chest when sternum is removed,
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impressions of ribs seen on the anterior surface? Emphysema aquosum - edematous lungs with froth and Paultauf's hemorrhage
? Edema aquosum - edematous lungs without froth and Paultauf's hemorrhage
? Hydrostatic lung: if a dead body is thrown into water, due to the hydrostatic pressure water passes into the
lungs
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? Paltauf's hemorrhages - subpleural petechial hemorrhagesGettler's test
? Chloride content of the right and left chambers of heart is normally equal on both sides
? In fresh water drowning, 50% reduction in chloride concentration on the left side of heart
? In salt water drowning, 30-40% increase in chloride concentration on the left side of heart
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? A 25% difference in chloride content considered significant. But this test has doubtful value Other labfeatures
? Diatoms - unicellular algae, walls made of silica
? Serum strontium levels are raised in drowning
? Plasma specific gravity on the left side of heart < right side(left> right in non-drowning cases)
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? Magnesium content of the left side of heart is 1.25mg/1000ml > right sideFindings suggestive of ante-mortem drowning
? Froth from mouth and nostrils
? Cadaveric spasm
? Emphysema aquosum
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? Paltauf's hemorrhagesSEXUAL/AUTO-EROTIC ASPHYXIA/ASPHYXIOPHILIA
? Young males with abnormal sexual behavior
? Sexual pleasure by partial reduction of blood supply to the brain
? Compressing the blood vessels in the neck
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? Accidental death due to tightening of ligature? Circumstantial evidence - Padding under the ligature, undressed or dressed like a women, pornographic
literature, drugs like cocaine, alcohol
Caf? coronary (Food asphyxia)
? The term, 'Cafe Coronary' , was coined by Dr Roger Haugen
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? A healthy but grossly intoxicated person suddenly collapses and dies during or after a meal? Death appears to be due to heart attack. Hence the name caf? coronary (misnomer)
? At autopsy a large piece of food bolus is found obstructing the larynx
? Death is due to choking
? The suppression of gag-reflex due to alcohol or drugs makes the individual susceptible to Cafe Coronary
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Lynching: homicidal hangingSpanish windlass technique - a type of suicidal strangulation
Burking - a combination of homicidal smothering and traumatic asphyxia
Choking - obstruction of internal air passages by food particles or foreign body, usually accidental
Smothering - asphyxia caused by closing mouth and nostrils
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Gagging - asphyxia caused by forcing a cloth in the mouthSEXUAL JURISPRUDENCE & INFANTICIDE
IMPOTENCE & STERILITY
Impotence - inability of a person to perform sexual intercourse
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Sterility - inability of a male to beget children and inability of a female to conceive childrenFrigidity - inability to initiate or maintain sexual arousal in female
Satyriasis - excessive sexual desire
Quoad hanc (Impotentia quoad persona) - a male impotent with a particular woman but not with other
women
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Fecundation ab extra - when sperm is deposited in the vulva (no penetration of penis), insemination canoccur due to the passage of sperm from external genitalia to the uterus
Artificial insemination
? Artificial Insemination Homologous (AN) - If the semen used is derived from the women's husband
? Artificial Insemination Donor (AID) or Heterologous artificial insemination - If the semen is obtained from a
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person other than the husband? Artificial Insemination Homologous Donor (AIHD) - A mixture of husband's semen with the donor semen
(Pooled semen) is used
VIRGINITY
? Hymen
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? Membranous diaphragm at the vaginal introitus? Thin (but firm) fold of connective tissue
? 1 mm in thickness
? Usually has a central aperture
? Diameter of hymenal orifice in prepubertal children in mm = age in years
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? Usually gets ruptured (posteriorly) during first sexual intercourse? Semi lunar/crescentic type - most common
? Annular type - may appear intact even after sexual intercourse has taken place
? Fimbriated type - may appear torn even in the intact state
? The ruptured segments of hymen gradually become thicker and smaller and appear as small fleshy pyramidal
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projections - carunculae hymenales (hymenal tags)? After vaginal delivery, the hymenal tags may disappear or attain irregular thick margins carunculae
myritiformis
Virginity
Defloration
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HymenTorn or intact; loose and elastic
Intact, Rigid and inelastic
Wide opening easily allowing two fingers to
Narrow opening hardly allowing tip of a finger to pass
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passLabia majora adjacent to each other; completely closing the
Labia majora are separated, flabby, vaginal orifice
vaginal orifice
seen at lower end
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Clitoris smallClitoris enlarged
Fourchette - intacy
Fourchette - torn
Vagina is narrow, more prominent rugae
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After repeated intercourse, becomes patulous andrugae are less obvious
PREGNANCY
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Presumptive signs of pregnancyProbable signs of pregnancy
? Amenorrhea
? Enlargement of abdomen
? Breast changes
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? Hegar's sign? Morning sickness
? Goodell's sign (softening of cervix)
? Quickening
? Braxton-Hick's sign (intermittent uterine
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? Pigmentation of skin? contractions)
? Jackquemier's or Chadwick's sign
? Batlotment
(discoloration of vagina)
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? Uterine souffl?? Urinary disturbances
? Immunological tests
? Sympathetic disturbances
? Biological tests
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Positive signs of pregnancy? Fetal parts and movements felt by placing the hands on the abdomen
? Fetal heart sounds
? Placental souffl?
? Funic or Umbilical souffl?
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? X-ray diagnosis (not done now)? Ultrasound
Spurious or Phantom pregnancy (Pseudocyesis)
? The woman believes that she is pregnant, though she is not.
? May present with enlargement of abdomen due to fat deposition or some pathological condition
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? May have false feeling of movement of fetus inside? May even have false labour pains
? All the symptoms vanish once she is informed that she is not pregnant
? Seen in women who strongly desire for a child or who are afraid of being pregnant
? Occurs in young women and women nearing or just achieved menopause
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Super fecundation - fertilization of two ova formed from the same menstrual cycle by two separate acts ofcoitus at short interval
Super fetation - fertilization of second ovum in a woman who is already pregnant (ova from different
menstrual cycle)
Atavism - child does not resemble parents, but grand parents
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Suppositious child - a child presented by a woman to have been delivered by her, though she has notdelivered the child.
Posthumous child - child who is born after the death of its father
Surrogate mother (Womb leasing)
o
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Accepts pregnancy and bears child either by artificial insemination or IVF for another woman who isincapable to carry child
o
Consent should be obtained prior to the procedure
DELIVERY
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Lochia (discharge from the uterus which lasts for 2 -3 weeks after delivery)
? Lochia rubra: first 4-5 days after delivery, bright red color
? Lochia serosa: next 4 days, thin, pale and serous discharge
? Lochia alba: after 9th day, dirty white color
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FEATURESNULLIPARA
MULTIPARA
Size
Smaller (7 x 5 x 2 cm)
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Larger (10 x 6 x 2.5 cm)Weight
40 - 50 g
80 - 100 g
Length
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Body is of same length as cervixBody is twice the length of cervix
Upper surface of
Less convex Et is in the same line
More convex & is at a higher level than the
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Fundusof broad ligament
line of broad ligament
Uterine cavity
Convex inner walls, small triangular
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Concave inner walls, wider and larger, roundedcavity with less space
cavity
Scar for placental
Not seen
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Present. Very faint.attachment
External Os
Small, roundish dimple like depressed Transverse slit like opening.
opening.
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Internal OsCircular, well defined.
Not well defined, margin wrinkled.
Uterus returns to normal size 6 weeks after delivery
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ABORTIONNatural abortion
? Spontaneous
? Accidental
Artificial abortion
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? Justifiable or Therapeutic or Legal? Criminal
The World Medical Association, adopted a resolution on therapeutic abortion - Declaration of Oslo (1970)
The MTP ACT - 1971 (Amended 1975 & 2002)
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Indications? Therapeutic - when the continuation of pregnancy endangers the life of woman or cause serious injury to
her physical or mental health
? Eugenic - Risk of the child being born with serious physical or mental abnormalities
The women in the first 3 months of pregnancy suffers from German measles, small pox, chicken pox,
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toxoplasmosis, viral hepatitis, any severe viral infectionIf the pregnant woman is treated with drugs like thalidomide, cortisone, aminopterine, antimitotic drug
or she consumes hallucinogens or antidepressants
If she is treated by X rays or other irradiation
Insanity of the parents
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? Humanitarian - if the pregnancy is caused by rape? Social - when the pregnancy is a result of failure of contraception in case if a married woman which is likely
to cause serious mental injury
? Environmental - when social or economic environment, actual or reasonably expected can injure mother's
health
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Rules? Chief Medical Officer of the district is empowered to certify that a doctor has the sufficient training
? A doctor is qualified if he/she has assisted 25 cases of MTP in a recognized hospital
? Consent of the husband not necessary
? No need for the woman to produce age proof, oral statement is enough
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? It is enough for the woman to state whether she was raped , it is not necessary that a complaint is lodged? Duration of pregnancy < 12 weeks - one doctor can perform
? 12-20 weeks - two doctors must agree that there is an indication for MTP
? In case of emergency, can be performed by a single doctor, even without training, even after 20 weeks, even
without consulting another doctor, even in a private hospital which is not recognized
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SEXUAL OFFENCESNatural offences
Unnatural offences
Sexual perversions
Sex linked offences
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RapeSodomy
Sadism
Voyeurism
Incest
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BestialityMasochism
Stalking
Adultery
Tribadism
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NecrophiliaSexual harassment
Buccal coitus
Fetichism
Trafficking
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Transvestism etcIndecent assault
NATURAL SEXUAL OFFENCES
RAPE
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? Consent - a woman of 18 years and above can give valid consent for sexual intercourse? Age of the accused - in India there is no age limit under which a boy is considered physically incapable of
committing rape
? Sexual intercourse or sexual acts by a man with his own wife, wife not being under sixteen years of age, is
not sexual assault
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? Statutory Rape - sexual intercourse with a girl below 18 years of age even with her consent. It is neitherviolent nor physically coerced
? Marital Rape - forceful sexual intercourse with wife who is living separately from him, without her consent.
It is punishable with imprisonment up to two years provided the age of the wife is not < 12 years
Examination of rape victim
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? Completely undressed and examined using ultra-violet light to detect seminal stains? In a virgin, tearing of hymen usually occurs posteriorly in the 4 or 8 'O clock position or 5 or 7'O clock
position
Genital examination of rape accused
? Smegma under the prepuce
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Smegma is a thick cheesy secretion with a disagreeable odour, containing desquamated epithelial cellsand smegma bacilli (Mycobacterium smegmatis)
Smegma usually gets wiped off during sexual intercourse
Absence of smegma is not a conclusive evidence of sexual intercourse as it can be cleaned during bath
Presence of smegma is an evidence that the person did not have sexual intercourse or complete
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penetration? Lugol's iodine test
Shaft of the penis is examined for the presence of vaginal epithelial cells
Vaginal epithelial cells have high glycogen content
Shaft of the penis is wiped off with a clean filter paper and the filter paper is exposed to vapours of
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Lugol's iodineBrown colour indicates the test is positive (surest sign of recent sexual intercourse)
? Pap test
Wash the penis in sterile saline
Stain with pap stain to demonstrate vaginal cells, cervical cells, Barr body
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Injuries in a rape accused suggestive of forcible sexual intercourse? Nail scratches over face, chest
? Bite marks over arms and other parts
? Bruises
? Tearing of frenulum
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INCEST? Sexual intercourse by a man with a woman who is closely related to him by blood (prohibited degrees of
relationship) e.g. daughter, sister, granddaughter, step sister.
? In India, incest as such, is not an offence
ADULTERY (S. 497 IPC)
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? Voluntary sexual intercourse between a married man and some-one other than his wife or between amarried woman and someone other than her husband
UNNATURAL SEXUAL OFFENCES S 377 IPC
? Sodomy/Buggery - anal intercourse
? Gerontophilia - when the passive agent is an adult in sodomy
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? Paederasty - when the passive agent is a child (catamite) in sodomy? Pedophile - adult who repeatedly engages in sexual activities with children
? Eunuchs - male prostitutes in India, act as passive agents in sodomy
? Buccal coitus or Sin of Gomorrah or Coitus per os- penis introduced into the mouth
? Tribadism/Lesbianism/Sapphism - female homosexuality
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? Bestiality - sexual intercourse by a human being with a lower animalLateral buttock traction test - to examine the victim of sodomy
SEXUAL PERVERSIONS
? Uranism - general term for sexual perversion which includes sexual gratification by fingering, fondling, licking
and sucking the genitalia of opposite sex
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? Paraphilias - unorthodox sex play by using objects or parts of the body? Sadism - sexual gratification obtained from acts of cruelty or infliction of pain on the partner
? Lust murder - murder serves as a stimulus for sexual act
? Necrophilia (S 297 IPC)- sexual intercourse with dead bodies
? Necrophagia(S 297 IPC) - eating the flesh, drinking the blood of the victim to drive sexual pleasure
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? Masochism - opposite to sadism, asking the partner to inflict pain on himself for sexual pleasure? Bondage/ Algolagnia - sadism+masochism
? Fetichism - sexual excitement by seeing undergarments of a women
? Transvestism/Eonism - desire to be identified as opposite sex
? Scatalogia - obscene telephone calls
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? Fellatio (irrumination) - oral stimulation of mate genitalia? Annilingus (rimming) - kissing the anus
? Cunnilingus - oral stimulation of female genitalia
? Masturbation (Onanism, ipsation, autoeroticism) - deliberate self-stimulation for sexual arousal
? Exhibitionism (S 294 IPC) - exposure of genitalia in a public place to obtain sexual pleasure
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? Frotteurism (S 290 IPC) - sexual satisfaction by rubbing his genitals against a female in crowd? Urolagnia - sexual pleasure by seeing the act of urination
? Caprolagnia - sexual pleasure by the smell or sight of faeces or defaecation
? Undinism - by urinating over the partner
? Narcism - self love
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? Pygmalionism - falling in love with an object made by him? Bobbit syndrome - female amputates penis of her mate partner
? Trolism - sexual practice by involving 3 persons; 2 of one sex and one of the opposite sex
? Mixoscopia - sexual satisfaction by the sight of others engaged in sexual intercourse
? Oedipus complex - sexual desire of son towards his mother
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? Electra complex - sexual desire of daughter towards her father? Pharoan complex - sexual desire of brother towards his sister
? Onanism/ipsation/masturbation - self stimulation which effects sexual arousal
SEX LINKED OFFENCES
? Voyeurism/Scotophilia - see people undress to be sexually satisfied
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? Indecent assault - any offence committed on a female with the intention to outrage her modesty? Stalking - following a person, monitoring by internet, email, or any electronic communication, spying a
person despite clear indication of disinterest by that person, resulting in loss of mental peace of that person
? Trafficking - for the purpose of exploitation, whoever recruits, transports, harbours, transfers, receives a
person in illegal way
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INFANTICIDE
Infanticide - unlawful destruction of a child less than one year
Foeticide - killing of fetus at any time before birth
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Filicide - killing of child by parentsStill birth - born after 28th week of pregnancy, which did not show any signs of life after birth. The child was
alive in utero, but dies during the process of birth
Spalding's sign - in fetal death, loss of alignment and overriding of skull bones (due to shrinkage of
cerebrum)
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Dead birth - died in utero and shows one of the signs following deliveryRigor mortis at birth
Maceration
o Aseptic autolysis
o Occurs when the dead child remains in the uterus for 3-4 days surrounded with liquor but exclusion
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of airo If air enters the liquor after death, putrefaction occurs instead of maceration
o First sign of maceration - reddening of skin with peeling and slippage (after 12 hours)
Mummification
Tests for live birth
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? Static or Fodere's test - average weight of both lungs before respiration is 30-40gms; after respiration is 60-66 Gms. Not reliable
? Plocquet's test - the ratio of weight of lungs to weight of the body before respiration - 1/70; after respiration
- 1/35. Not reliable
? Hydrostatic test or Raygat's test - the specific gravity of lungs before respiration: 1040-1050; after
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respiration: 940. Not of much value? Breslau's second life test or stomach bowel test - air swallowed into the stomach which floats
? Wredin's test - middle ear changes after birth
? Vagitus uterinus - respiration(cry) of the fetus while in the womb after the rupture of membranes Vagitus
vaginalis - respiration while the head is in the vagina
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The expanded (respired) lungsUnexpanded lungs may
Hydrostatic test is not necessary when
may sink due to
float from
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? Pneumonia? Putrefaction
? Fetus is a monster
? Congenital syphilis
? Artificial
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? Fetus is macerated or mummified-
? Atelectasis
? inflation
? Fetus born before 180 days of gestation
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? Hyaline membrane? Stomach contains milk
? disease
? Umbilical cord has separated and a scar has
formed
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Changes in the umbilical cordTime
Blood clots at the cut end
2 hrs
Vessels closure and drying
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12-24hrsInflammatory ring
36-48hrs
Mummification
2-3days
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Falls off5-6days
Healing of ulcer and scar formation
10-12days
BATTERED BABY SYNDROME or CAFFEY'S SYNDROME
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? Slightly more in male children? Youngest or the eldest child
? Repetitive physical injuries as a result of non-accidental violence
? There may also be deprivation of nutrition, care and affection
? The classical feature of this lesion are discrepancy between the nature of injuries and the explanation
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offered by the guardian, and delay between the injury and medical attention which cannot be explained? Fractures and injuries will be at different stages of healing
? Most characteristic lesion - laceration of mucosa inside the upper lip and often tear of frenulum
? Nobbing fractures - multiple rib # in the posterior angle
? X-ray shows string of beads appearance in the para vertebral gutter after callus formation
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? Infantile whiplash syndrome - shaking a child causes subdural hematoma and intra ocular bleedingSUDDEN INFANT DEATH SYNDROME/CRIB DEATH/COT DEATH
? Age group 2 weeks to 2 years (Most vulnerable age 3-4 months)
? Incidence 0.2 to 0.4% of all live births
? Rainy and winter season
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? Premature birth? Male: female=3:2
? Lower and middle class
? Most deaths in the early morning
Proposed causes
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? Prolonged sleep apnea (most important)? Local hypersensitivity of the respiratory tract to bovine mild
? Viral infection of the respiratory tract
? Beds and pillow falling accidentally over the mouth and nose
? Accidental prone position of the baby
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TOXICOLOGY
Viscera preserved routinely in cases of suspected poisoning
? Stomach and contents
? Small intestine (upper part 30 cm) and contents
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? Liver (200 - 300 g)? One half of each kidney
? Blood (30 ml)
? Urine (30 ml)
Collection of blood
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? Before autopsy 20m1 of blood can be drawn from femoral vein (or jugular or subclavian vein)? After removal of viscera - from iliac veins
? Blood should never be collected from pleural or abdominal cavities
Additional viscera to be preserved in special circumstances
Viscera preserved
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PoisonHeart
Strychnine, Digitalis, Oleander
Brain
OPC, opiates, CO, cyanide, strychnine, barbiturates, anesthetics
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Spinal cordStrychnine, gelsemium
CSF
Alcohol
Bile
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Narcotics, cocaine, methadone, glutathione, barbituratesVitreous
Alcohol, Chloroform
Skin
Hypodermic injection marks
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Bone, nailsArsenic, antimony, thallium, radium
Fat
Insecticides and pesticides
Poison
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PreservativeAll poisons except corrosives, aconite
Saturated saline
All acids except carbolic acid
Rectified spirit
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Blood (Alcohol, cocaine, cyanide, CO)Sodium fluoride + potassium oxalate
Blood (oxalic acid, ethylene glycol, fluoride)
Sodium citrate
Carbon monoxide
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Liquid paraffinUrine
Thymol or Toluene
Histopathological examination
10% formalin
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Suspected rabies50% glycerine
? Viscera for chemical analysis should not be preserved in formalin, as extraction becomes difficult
Poison
Odour
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White Phosphorus (diwali poison), arsenic, thallium,Garlic
selenium, parathion, malathion, aluminium phosphide
Ethanol, chloroform, nitrites
Sweet or fruity (acetone/apple like)
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Paraldehyde, chloral hydrateAcrid
Hydrogen sulphide, mercaptans, disulfiram
Rotten egg
Zinc phosphide
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Rotten fishHCN
Bitter almonds
OPC
Kerosene
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CannabisBurnt rope
Carbon monoxide
Coal gas
Nitrobenzene
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Shoe polishMethyl salicylate
Wintergreen
Poison
Stomach mucosa appearance
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MercurySlate colored
Arsenic
Red velvety
Sulphuric acid
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Black, spongy, perforated, charring and eschar formationNitric acid
Yellow
Oxalic acid
White, bleached, scalded appearance
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Carbolic acidGrey or brown, leathery
Copper
Blue or green
Poison/Drug/Condition
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Color of urineHematuria, Hemoglobinuria, Berries, Beet root
Red
Drugs: Dilantin, Phenothiazines, Adriamycin
Rifampicin, Pyridium, Urate crystals
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OrangeAniline, Brufen
Pink
Deferoxamine therapy (Et elevated serum iron)
Vin rose urine
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Pseudomonas aeruginosa infection, Oxalate poisoningGreen
Riboflavin
Yellow
Vitamin A, warfarin
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Yellowish orangePhenol or Carbolic acid
Green or Black
Nitric acid
Brown
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BarbituratesLiquid gold
Picric acid
Ruby red
Porphyrins
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PurpleTests
Poisons
Marsh & Reinsch test
Arsenic
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Trinder's testSalicylates
Ferric chloride test
Phenol, Phenothiazines, Pheynlbutazone, Salicylates
Lee Jones test
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Cyanide (blue color), Salicylates (Purple color)Qualitative Desferrioxamine colour
Iron
test (QDCT)
Meixner test, Melzer test
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Amatoxin (Mushroom)Isonitrile test
Carbon tetrachloride, Chloroform, Chloral hydrate
Tensilon test
Botulism
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Litmus testCorrosives (acids and alkalis)
Marqui's test
Opium
Gastric lavage
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? Only absolute contraindication is corrosive poisons except carbolic acid? Relative contraindications
Convulsant poisons
Comatose patients
Volatile poisons
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Upper GIT diseases like esophageal varicesMarked hypothermia
Hemorrhagic diseases
Gastric lavage in hydrocarbon poisoning
? Useful in - camphor, halogenated, aromatic, (heavy) metal-containing, and pesticide-containing
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hydrocarbons? Contraindicated in - gasoline, kerosene, furniture polish, mineral spirits
Activated charcoal
? Most preferred method
? Large surface area - adsorbs poisons and thus reduces their absorption
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? Most effective within 1 hour of ingestion? Dose: 1-2g/kg body weight
Emesis
? Only recommended method - syrup of ipecacuanha (ipecac) - oral, acts both by activating peripheral sensory
receptors in the GIT and stimulating vomiting center in the medulla
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? Household emetics like mustard powder and common salt are not very effective and may lead tocomplications
? Apomorphine (s.c, i.m), copper sulphate, tartar emetic and zinc sulphate as emetics are obsolete
ANTIDOTES
Physical or mechanical
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ChemicalUniversal antidote
Activated charcoal
Weak non-carbonate alkalis for acids
2 parts of charcoal
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Demulcents ? egg albumin,Weak vegetable acids for alkalis
1 part magnesium oxide
starch, barely water or milk
Freshly prepared ferric oxide for arsenic
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1 part tannic acidDiluents - water, milk
Common salt for silver nitrate
Boiled rice or vegetables
Copper sulphate for phosphorus
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Pharmacological antidotesDrug overdose
Antidote
Poison
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AntidoteParacetamol,
N-Acetyl cysteine,
Cyanide
Amyl nitrite , sodium nitrite,
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Acetaminophenmethionine
Dicobalt edetate,
Beta adrenergics
Propranolol
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hydroxycobalamine, 4,dimethyl aminophenol
Alpha adrenergics
Phentolamine
Amanitins
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Benzyl penicillinBeta blockers
Isoprenaline, Glucagon
Organic peroxides
Ascorbic acid
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Cholinergic agentsAtropine
Botulism
Guanidine
Opium
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NaloxoneOPC
Oximes, Atropine
Benzodiazepines
Flumazenil
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Ethylene glycol,Fomepizole
Ethanol
Theophylline
Beta blockers
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MethanolEthanol
Isoniazid
Pyridoxine
Nitrates
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Methylene blueHeparin
Protamine sulfate
Ergotism
Sodium nitroprusside
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DigitalisFab antibodies
Radioactive metals
Pentetic acid (DTPA)
Malignant hyperthermia
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DantroleneCarbon monoxide
Tocopherol
Central anticholinergics
Physostigmine
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BerylliumSodium salicylate
Peripheral
Neostigmine
Thallium
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Prussian blueanticholinergics
When the nature of the poison is not known, universal antidote or coma cocktail (not used now) may be
given
Universal antidote
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Coma cocktail? Activated charcoal (50%)
? Dextrose - 100ml of 50% solution
? Magnesium oxide (25%)
? Thiamine-100mg
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? Tannic acid (25%)? Naloxone-2mg
Hemodialysis is useful in the following poisons
Hemodialysis not useful in
Ethanol
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ArsenicSalicylates
Copper sulphate
Methanol
Acetaminophen
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Sodium chlorateKerosene
Ethylene glycol
Bromides
Boric acid
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OPCChloral hydrate
Fluorides
Thiocyanates
Benzodiazepines
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LithiumBarbiturates
Aspirin
Digitalis
Miosis
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MydriasisCarbolic acid
Formalin
Alcohol (constricted in coma)
Carbon monoxide
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Chloral hydrateCaffeine
Aconite
Cyanide
Opium
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ClonidineAmphetamine
Calotropis
OPC, carbamates
Methyl dopa
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BelladonnaCocaine
Barbiturates
Nicotine
Datura (Atropine)
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Viper biteBenzodiazepines
Nux vomica
Drugs and Cosmetics act, 1940
Regulates the import, manufacture, distribution and sale of all kinds of drugs
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Controls the purity, quality and strength of drugsAny patent or proprietary medicine should display on the label or container, either the true formula or a list
of ingredients
Drugs and Cosmetics Rules, 1945
Schedule C: Biological and special products
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Schedule E: List of poisonsSchedule F: Vaccines and sera
Schedule G: Hormone preparations
Schedule H: Drugs (Poisons to be sold only on the prescription of a RMP)
Schedule J: List of diseases for the cure of which no drug should be advertised
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Schedule L: Antibiotics, antihistaminics, recent chemotherapeutic agentsAGRICULTURAL POISONS
ORGANOPHOSPHORUS POISONS
ORGANOCHLORINES
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Alkyl phosphatesAryl phosphates
DDT, BHC(lindane)
HETP, TEPP, OMPA
Parathion (Follidol, Killphos)
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Aldrin, ChlordaneDimefox, Isopestox
Methyl parathion
Dieldrin, Endosulfan
Malathion(Kill bug, Bugsoline)
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ChlorthionEndrin (plant penicillin),
Sulfotepp, Demeton
Paraoxon
Mirex
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TrichlorfonDiazinon (Tik 20)
Toxaphene , Paraquat
? MOA: inhibits true cholinesterase and pseudo cholinesterase
? Muscarinic signs and symptoms - broncho constriction, increased bronchial secretions and pulmonary
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edema, bradycardia, miosis, water loss due to sweating, salivation, lacrimation, micturition, diarrhea? Nicotinic - fasciculation, dyspnoea and cyanosis due to respiratory paralysis
? Intermediate syndrome
Seen in 20% patients
After 1-4 days
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Weakness spreads rapidly from the ocular muscles to those of the head and neck, proximal limbs(spares distal muscles) and the muscles of respiration, resulting in ventilatory failure Due to prolonged
cholinesterase inhibition and muscle necrosis
Due to inadequate treatment, sub-therapeutic administration of oximes and inadequate ventilation
It does not respond to oximes and atropine
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Supportive treatment and mechanical ventilation if required? Delayed syndrome
1-5 weeks after exposure
Peripheral neuropathy due to demyelination
Distal muscle weakness, toe drop, sparing of neck and proximal muscles
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It does not respond to oximes and atropine? Diagnosis
Cholinesterase determination in blood
Normal values 77 - 142 in red cells and 41 - 140 in the plasma
Plasma cholinesterase is more sensitive and fall more rapidly before that of red cells
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? Treatment
Atropine 2-4mg given i.v. every 10-15 mins
Atropine should be continued until the tracheobronchial tree is cleared of the secretions and most
secretions are dried, but not pupillary status
Cholinesterase reactivators like diacetyl monoxime(DAM), pralidoxime(2-PAM)
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? Cause of death - respiratory paralysis? Chromolachryorrhoea(red tears) due to accumulation of porphyrin in lacrimal glands
? Oximes are not effective in: Edrophonium, Dime fox, Methyl diazinon, Organo-carbamates (Carbaryl,
Propoxur)
CORROSIVE POISONS
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STRONG ACIDSSTRONG ALKALIES
? Desiccation or denaturation of superficial
? Saponification of fats and dissolves
proteins
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proteins? Coagulation necrosis
? Liquefaction necrosis
? Eschar formation
? Favors penetration
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? Eschar limits penetration? Extensive damage
? Gastric strictures and perforation
? Esophageal strictures
SULPHURIC ACID
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? Chalky white teeth, Swollen, sodden and blackish tongue, Swollen lips? Burning pain from mouth to stomach, Hematemesis (coffee ground colour), Intense thirst
? Stomach - converted into a soft, spongy, black mass which ready disintegrates on touch
? Vitriolage: throwing concentrated sulphuric acid on the face of the person with an intention to damage,
disfiguration or death
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NITRIC ACID? Fuming liquid with a peculiar, penetrating odour
? Xanthoproteic reaction - yellow discoloration of tissues due to production of picric acid
? More abdominal distension due to gas formation
OXALIC ACID
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? In the form of oxalate, it is present in spinach, rhubarb, cabbage? Hypocalcemia - tetany, Chvostek's sign, Trosseau sign
? Oxaluria - envelope shaped calcium oxalate crystals in urine
? Mucous membrane of tongue, mouth, pharynx, esophagus & stomach - bleached and scalded appearance
CARBOLIC ACID/CARBOLISM
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? Oxidized to pyrocatechol and hydroxyquinone whose excretion urine which turns green on exposure to air(carboluria)
? Scanty urine containing albumin and hemoglobin
? Chronic poisoning (Phenol marasmus) causes pigmentation of skin and sclera - oochronosis(also seen in
alkaptanuria)
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? Gastric lavage is indicated as it hardens the tissues and hence risk of perforation is less? PM appearances: gastric mucosa is swollen, grayish white, hardened (leather bottle stomach)
Treatment of acid poisoning
? Give a demulcent, olive oil, milk, egg white or starch water
? Prednisolone may be given to prevent esophageal stricture and shock
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? Eye burns are irrigated with water or sodium bicarbonate solution? Tracheostomy - if there is edema of glottis
Should not be done in acid poisoning
? Gastric lavage
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? Emetics? Alkaline carbonates or bicarbonates which liberate CO2, as they cause distension and rupture
METALLIC POISONS
ARSENIC
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? Copper arsenite - sheele's green? Copper acetoarsenite - paris green
? Permissible limits of arsenic in ground water - 0.05mg/L
? The gastroenteric type of poisoning resembles cholera
? Greatest quantity is seen in - liver
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? Red velvety appearance of mucosa of stomach? Most affected part of the stomach ? pylorus
? Subendocardial petechial hemorrhages of the ventricle is typical of arsenic poisoning (also found in
phosphorus, barium, mercury and in cases of heat stroke and acute infectious disease e.g. influenza)
? Rigor mortis lasts longer than usual, Delays putrefaction
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Acute poisoning? Necrosis of intestinal mucosa with hemorrhagic gastroenteritis
? Hypotension, delayed cardiomyopathy
Chronic poisoning
? Aldrich Mee's line on finger nails
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? Rain drop pigmentation on skin(meastes like rash)? Chronic consumption of water containing high arsenic concentrations lead to vasospasm and peripheral
vascular insufficiency - black foot disease
? Diabetes, peripheral neuropathy, gangrene
? Cancer of skin, lung, liver (angiosarcoma), bladder, kidney.
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? Arsenophagists - some people take arsenic daily as tonic or aphrodisiac and acquire tolerance? Chelating agent - Dimercaprol
Arsenic poisoning
Cholera
Pain in the throat - before vomiting
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After vomitingPurging - after vomiting
Before vomiting
Dark colored bloody stools initially,
Rice water stools, never blood stained
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later rice water stoolsTenesmus and anal irritation present
Absent
Vomitus contains mucus, bile and blood
Watery without mucus, bile and blood
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Conjunctiva inflamedNot inflamed
Arsenic was used as murder weapons in royal families, and called as "the poison of kings and king of poisons"
MERCURY
? Mercuric ion binds with sulphydryl groups of cytochrome enzymes and interferes with their function
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resulting in inhibition of oxidative phosphorylation & cellular respirationACUTE POISONING
? Inhalation: manifestations similar to Kawasaki disease
? IV injection: Mercurialism (thrombophlebitis, granuloma formation and pulmonary embolism)
? Necrosis of renal tubules, albuminuria, uremia and acidosis
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? Membranous colitis develop after many daysHYDRARGYRISM or CHRONIC MERCURY POISONING
? Classic triad of gingivitis, tremors (Danbury tremors) and neuro psychiatric changes
? Advanced condition of Danbury tremors is called Hatter's shakes or glass blower's shakes
? Most severe form is called concussio mercurialis
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? Mercurial Erethism - refers to psychological effects of mercury toxicity and is seen in persons working withmercury in mirror manufacturing films.
? Pink disease or Acrodynia is an idiosyncratic reaction seen in children due to chronic mercury exposure
? Mercurialentis - brownish deposit of mercury on anterior lens capsule
? Kidney - membranous glomerulonephritis, PCT necrosis
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? Minimata disease - due to eating of fish poisoned by organic mercury (methyl mercury)? Diphtheritic colitis
? If mother consumes during pregnancy - cerebral palsy in child
? BAL is the chelating agent of choice
Dimethylmercury, a compound only found in research labs, is supertoxic--a few drops of exposure via skin
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absorption or inhaled vapor can cause severe cerebellar degeneration and deathIntracellular glutathione - acting as thiol donor, is the main protective mechanism against mercury induced
CNS and kidney damage
LEAD
Chronic poisoning (saturnism, plumbism)
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? Occupational hazard in those involved in the manufacture of batteries, pigments, car radiators, tin cans? Facial pallor is the earliest sign
? Punctuate basophilia or basophilic stippling
? Blue line on gums called lead line or Burtonian line (seen with poor oral hygiene, at the junction of gums and
teeth due to deposition of lead sulphide)
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? Colic and constipation? Lead palsy - common in adults, wrist drop, foot drop may occur
? Encephalopathy - most common manifestation in children
? Diagnosis
Coproporphyrin in urine
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Aminolaevulinic acid in urine > 5 micro gramsBlood lead > 25 micro gram per 100ml (Gold standard)
Urine lead > 0.25 microgram per liter
X ray - radio opaque bands (lead lines) at the metaphyses of long bones in children. The width of the
lead lines are related to the duration of exposure. These lines reflect bone growth arrest
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Lead poisoning in childrenBlood level (pg/ml)
Effects
10
Decreased IQ level, Decreased hearing, Growth retardation
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Fetal effects by transplacental transferImpaired peripheral nerve function
20
Increased nerve conduction velocity
Increased erythrocyte protoporphyrin
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Decreased vitamin D metabolism40
Decreased Hb synthesis
100
Encephalopathy
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NeuropathyFrank anemia
Colic
150
Death
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Treatment
? A confirmed venous blood lead level (BLL) of 45 g/dL or more requires prompt chelation therapy
? BLLs between 44 and 70 pg/dL - DMSA
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? BLLs of > 70 pg/dL without encephalopathy - CaNa2EDTA + DMSA or BAL? BLLs of > 70 pg/dL with encephalopathy - CaNa2EDTA + BAL
? High blood calcium levels favors storage of lead, white calcium deficiency causes lead to be released into
blood stream
Half-life of lead in bone: 20-30 years
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50% of ingested lead is absorbed in children (< 15% absorbed in adults)COPPER
? Copper sulphate (blue vitriol) and copper subacetate(verdegris) are poisonous
? Death is due to hepatic or renal failure or both
? Treatment : stomach wash with 1% potassium ferrocyanide which is an effective antidote
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? Emetics are contraindicated? Hemodialysis is useful in early stages
? Chelation with penicillamine or BAL or EDTA
? Post mortem appearances - greenish blue froth at mouth and nostrils
? Chronic inhalation of copper sulfate - Vineyard sprayer's lung disease
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? Copper deposits in tissues - chalcosis? Ptyrlism - chronic poisoning
? Chronic contact with swimming pool water containing algicidal copper chemical compounds may cause
green hair discolouration
? Copper sulphate is used in the treatment of phosphorus poisoning - stomach wash with 0.2% copper
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sulphate forms copper phosphide, which is relatively harmlessThallium
? Classic triad of alopecia, skin rash, painful neuritis with confusion
? Maculopapular skin eruption with butterfly distribution on face
? Mee's line on nails
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Metal fume fever (brass chills, Monday fever, smelter shakes)? Caused by inhalation of fumes produced when metals are heated above their melting point
? Metals involved (decreasing order of frequency): Zinc, copper, magnesium, iron, chromium, cadmium
INORGANIC IRRITANTS
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White phosphorusRed phosphorus
Garlic odour
Odourless
Luminous in dark
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Non luminousIgnites at 34 degrees, so kept under water
Non inflammable
Highly toxic
Non toxic
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Used as rodenticide , in fire worksUsed on the sides of match box
? Acute poisoning - vomitus and stools are luminous in dark - Smoky stool syndrome
? Chronic poisoning due to frequent inhalation of fumes over many years cause osteomyelitis and necrosis of
jaw with multiple sinuses discharging pus - phossy jaw or glossy jaw
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ORGANIC IRRITANTSABRUS PRECATORIUS
? Seeds contain active principle abrin, a toxalbumen, which is similar to viperine snake venom
? Abrine, hemaglutinin, abralin are other toxins
? When an extract of seeds is injected under the skin of the animal, inflammation, edema, oozing of
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hemorrhagic fluid from the site of puncture which resembles viper snake bite? Sharp pointed needle like objects called suis are prepared from the paste of seeds, which are forced into the
skin of animal or human for homicide (2 suis used to resemble fangs of viper) -used in cattle by leather
workers to obtain hides cheaply or for revenge
Artificial bruise is produced by
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? Calotropis? Semecarpus
? Plumbago rosea
SNAKES
Poisonous snakes
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Non poisonous snakesHead scales
Large
? Small - viper
? Large + pit between eye and nostril - pit viper
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? Large + third labial touches eye and nasal shields -cobra or coral snake
? Large, no pit, third labial does not touch nose and
eye - krait
Belly scales - large and cover entire breadth
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Small and do not cover entire breadthHead usually triangular
Usually round or oval
Fangs - hollow like hypodermic needles
Short and solid
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Teeth two long fangsSeveral small teeth
Tail - rounded or flattened
Always rounded
Habits - usually nocturnal
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Not soSnake venom
? Cholinesterase is rich in venom of cobra and krait
? Hemolysins, cytolysins are rich in viper venom
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? Cardiotoxin - cobra venomOphitoxaemia is poisoning by snake venom
Cobra. Krait
Viper
Sea snakes
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? Neurotoxic? Hemotoxic (Vasculotoxic)
? Myotoxic
? Ptosis - earliest neurologic symptom
? Marked local symptoms -
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? Little or no local? Ophthalmoplegia ? extraocular
reddish and painful swelling,
signs
muscle weakness, strabismus,
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persistent bleeding, blisters? Polymyositis,
diplopia
? Hematuria, hemorrhages in
? Trismus
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? Complete paralysis after 2 hoursthe
? Myoglobinuria
? Death due to respiratory failure
? GIT, conjunctiva, brain etc
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? Lethal dose: cobra - 12mg; krait -? Death due to shock &
6mg of dried venom
hemorrhage
? Lethal dose - 15 mg
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? Cobra - burning pain and mild swelling at the site of bite, slight intoxication? Krait - no local symptoms, intense drowsiness and intoxication
SCORPION STING
? Mixture of neurotoxic and cardiotoxic venom
? More toxic than that of snakes, but only a small quantity is injected
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? Venom is a potent autonomic stimulator resulting in the release of massive amounts of catecholaminesfrom the adrenals
? Local burning pain, swelling and paresthesias
? Sweating, salivation, vomiting
? Mydriasis
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? Hypotension followed by hypertension, bradycardia followed by tachycardia? Arrhythmias
? Pulmonary edema
? Oliguria
Cantharides/Spanish Fly/Blister Beetle
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? Local application - vesicle formation? Ingestion - nephrotoxicity, priapism, convulsions
TOXALBUMEN
? A Toxalbumen is a super-toxic protein that resembles bacterial toxin in action, causes agglutination of red
cells with some hemolysis and is antigenic
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? Plant toxalbumen or phytotoxinRicin in Ricinus communis
Crotin in Croton tiglium
Abrin in Abrus precatorius
? Animal toxalbumen: snake and scorpion venoms
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CNS DEPRESSANTSALCOHOL
? Absolute alcohol - 99.95% alcohol
? Rectified spirit - 90-95% ethanol + 5-10% methanol + traces of castor oil
? Methylated spirit - 99% alcohol + 5% wood naptha
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? Surgical spirit - 90-95% ethanol + 5-10% methanol? Safety limit of alcohol : Male - 210g /week; Female - 140g/ week
? Action : Low concentration - CNS stimulant; High concentration - CNS depressant
? Diaphoresis, diuresis(inhibits ADH), stimulates appetite
Beverage
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% of alcoholVodka
60 - 65
Rum, liquor
50 - 60
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Whisky, gin, brandy40 - 45
Port, sherry
20
Wine, champagne
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10 - 15Beer
4 - 8
Blood level of alcohol (mg %)
Behavior
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< 10Sober
20 - 70
Drinking
80 - 100
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Under the influence150 - 300
Intoxicated, drunk
>400
Coma
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Conc. of alcohol in blood (mg %)Symptoms
0 - 50
Mild euphoria
50 - 100
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Increased confidence, impaired judgment, nystagmus100 - 150
Confusion, impaired memory, slow reaction time
150 - 300
Staggering gait, increasing confusion, loss of muscle
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coordination300 - 400
Decreased response to stimuli, stupor
>400
Deep coma, death
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? Urine alcohol: blood alcohol = 1.35 : 1? Widmark's formula : a = prc (blood); a = 3/4prq (urine)
? Henry's law: alveolar: blood alcohol = 2100: 1
Methods to find blood and urine alcohol levels
? Alcohol dehydrogenase method
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? Kozelka & Hine test? Gas chromatography(most specific)
? Breath analyzer
? Cavett test
Alcohol induced thiamine deficiency
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Wernicke's encephalopathy (acute)Korasakoff's syndrome (chronic)
? Global confusion
? Amnesia
? Ophthalmoplegia
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? Confabulation (filling the memory gaps by imaginary? Ataxia
events)
LCOHOL WITHDRAWL SYNDROMES
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Alcoholic hallucinosisAlcoholic ketoacidosis
Delirium tremens
? Onset: 24-36 hours
? Onset: 24-72 hours
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? Onset: 3-5 days? Objects appear distorted,
? During withdrawl or after
? Sudden withdrawl, temporary
shadows seem to move
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heavy drinkingexcess, trauma, acute infection
? Treatment: Chlorpromazine
? Drowsiness, confusion,
may precipitate
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Rum fits? THR,TRR, Kussmaul's
? Dramatic onset of Clouding of
breathing
consciousness, disorientation, loss
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? Onset: 7-48 hours? Blood alcohol typically not
of recent memory
? Clonic-tonic movements
high
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? Vivid visual hallucinations? High anion gap metabolic
? Agitation, restlessness, tremors,
acidosis
ataxia
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? Markedly elevated serum? Insomnia, Autonomic
ketones
disturbances
? Treatment: diazepam
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? Marchiafava syndrome - corpus callosum degeneration? McEwan's sign - in alcoholic coma, pupil is constricted if the patient is stimulated by pinching or slapping the
cheek, the pupils dilate and the slowly constrict. Differentiates alcoholic coma from coma due to other
causes
? Fatal dose: 150 - 250 ml of absolute alcohol taken in one hour; 60 - 200 ml of methyl alcohol
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? Cause of death: depressant action on brainstem respiratory center; aspiration of vomitus? Statutory limit for driving in India: 30 mg% (S 185 of Motor Vehicles Act)
Methanol
? Early symptoms - vertigo, head ache, stiff neck
? Later - ocular toxicity (fixed dilated pupils, diminished [snow-storm] vision, optic atrophy)
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? CNS depression is more intense and prolonged? Formic acid is responsible for retinal toxicity and high anion gap metabolic acidosis
? Antidotes: ethanol, fomepizole
? Fatal dose: 70 - 100 ml
BARBITURATES
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? Fatal period: 1-4 days? Pupils are initially constricted, later dilated
? Hypothermia
? Cutaneous blisters barbiturate blisters over dependent parts (buttocks, back of thighs, calves and forearms)
PSYCHEDELICS (HALLUCINOGENS)
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LSD (LYSERGIC ACID DIETHYLAMIDE)? Feeling of depersonalization
? The feeling of being able to fly under its influence may can lead users to jump from windows
? Flash back phenomenon - experiences recurrence of the effects of previous LSD trip
? Hyperacusis, synesthetic experiences (stimulation of one sensory modality is perceived as sensation in a
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different modality, e.g., sound produces a sensation of colour), changes in body image, time spaceperceptions
DELIRIANT POISONS
DATURAI
? Clinical features: blind as a bat, dry as a bone, red as a beet and mad as a wet hen
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? Patient tries to pull imaginary threads from tips of his fingers (carphologia) and threads imaginary needles.COCAINE
? Initially used as a local anesthetic
? Stage of excitement: dilated pupils, hypertension which may lead to cerebral bleeding, feeling of tingling and
numbness of the hand and feet, a numb feeling at the place where the drug has touched
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? Stage of depression: death due to respiratory or cardiac failure; sudden death may occur due to arrhythmias? Usual route of intake is the application to the nasal mucous membrane (snorting)
? Cocainism: Chronic abuse cause blackening of tongue and teeth
? Ulceration and perforation of nasal septum
? Magnan symptom/cocaine bugs/formication is characteristic of chronic cocaine abuse where
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there is a feeling of grains or small insects are creeping under the skin (tactile hallucination)CANNABIS (INDIAN HEMP)
? Cocaine + heroine = speed ball
? Active component tetra hydro cannabinols (THC)
? Chronic poisoning
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GynacomastiaHashish insanity (run amok)
Amotivation syndrome
? Does not produce physiological dependence or addiction but psychological dependence and tolerance
develop
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? Various forms of cannabisBhang - mildest, decoction from dried leaves and fruit shoots; 15% of active principle
Majoon - sweet prepared from plant extract
Ganja (marihuana, reefer, joint) - leaves and flower tops of female plant; 15-25% of active principle
Charas or Hashish - resin exuding from leaves and stems; 25-40% of active principle
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Marijuana - dried flowering tops crushed and smoked in a pipeSinsemilla - seedless marijuana
SPINAL POISONS
STRYCHNOS NUX VOMICA
? Active principles - Strychnine, Brucine, Loganine
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? MOA: Competitive antagonism of inhibitory neurotransmitter glycine at the post-synaptic junction of motorneurons of the anterior horn cells resulting in release excitation
? GABA is not involved
Clinical features
? Convulsions at intervals
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? Opisthotonus (spasmodic hyperextension of spine - body is bent backwards )? Emprosthotonus (body is bent forwards)
? Pleurosthotonus (body is bent laterally)
? Trismus (lock jaw)
? Risus sardonicus (spasm of facial muscles producing a characteristic grimace)
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? Consciousness is not lost till the end? Dilated pupils
Tetanus
Strychnine poisoning
History of injury
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History of poison consumption
Gradual onset
Sudden onset
Trismus occurs early
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Trismus occurs lateGroups of muscles affected at a time
All muscles affected simultaneously
Muscle rigidity is sustained between convulsions
Muscles relaxed in between convulsions
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Chemical analysis negativePositive for strychnine
HCN - (Prussic or Sheele's acid or cyanogens)
? Smell of bitter almonds
? Cyanide inhibits cytochrome oxidase, carbonic anhydrase and blocks final step of oxidative phosphorylation
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and prevents the formation of ATP? Reduces the oxygen carrying capacity of blood by preventing oxygen uptake by Hb
? Blood contains normal oxygen content
? Potassium ferrocyanide and ferricyanide are non-poisonous
? Sodium nitroprusside - an antihypertensive, overdosage results in cyanide toxicity
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? Fatal dose: HCN: 50-60mg; KCN: 200-300mg? Treatment:
Amyl nitrite, Sodium nitrite
Sodium thio sulphate
Hydroxyl cobalmine
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Dicobalt EDTA4-dimethyl phenol
KEROSENE POISONING
? Lethal dose: 30 to 100 mL
? Kerosene is toxic both through inhalational and oral routes
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? Severe poisoning - pulmonary oedema, haemoptysis, mental confusion, cyanosis, convulsion and coma.? Death is mainly due to ventricular fibrillation and respiratory failure in inhalational poisoning
? The pupils are initially constricted and later dilated.
? Aspiration of as little as 0.2 mL of kerosene oil can produce chemical pneumonia & pulmonary oedema.
? The chest radiograph may reveal perihilar densities, basal pneumonia, and atelectasis.
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? Induction of vomiting or gastric lavage is contraindicated due to increased risk of aspiration? Activated charcoal is not useful
? Antibiotic and steroids are not indicated
WAR GASES
? War gases are chemicals used to produce damage and destruction during warfare
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TypesExamples
Lachrymators or Tear gases
Chloro-aceto-phenone (CAP)
? Not harmful to life
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Bromo-benzyl cyanide (BBC)? Severe lacrimation due to intense irritation
Ethyl iodo-acetate
? Spasm of eyelids
? Temporary blindness
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Lung irritants or AsphyxiantsChlorine
? Can be fatal
Phosgene
? Inhalation causes dyspnea, chest tightness, cough,
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labored and noisy breathing, cyanosis, collapse anddeath due to pulmonary edema
Nasal irritants or Strenutators
Diphenyl chlorarsine (DA)
? Vapours cause intense pain and irritation in the
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Diphenylamine chlorarsine (DM)nose and sinuses
Diphenyl cyanarsine (DC)
? Head ache, nausea and vomiting
Nerve gases
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GA (Tabun)? Inhibit the transmission of nerve impulses
GD(Sarin)
? Consciousness is lost within seconds
GB (Soman)
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? Convulsions may followGF (Cyclosarin)
Paralysants
Carbon monoxide
? They act by different mechanisms interfering with
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Hydrogen sulphideoxygen transport
Hydrogen cyanide
Vesicants or Blistering gases
Sulphur, Mustard, Oximes
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? On contact with skin, it causes intense itching,redness, vesication and ulceration
SUBSTANCE ABUSE
Substance abuse in India
? 20-30% of adult males and around 5% of adult females use alcohol
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? 48% of adult males and 25% of adult females use tobacco in some form? 24 % adult males and 3% of adult females are smokers
? 33 % males and 18% females use smokeless tobacco product
Drug
Slang name
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Chloral hydrateKnock out drops
Alcohol + Chloral hydrate
Mickey Finn
Methylene-dioxy-methamphetamine (MDMA)
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Ecstasy, club drug or rave drugMethylene-dioxy-amphetamine
Love drug
Street heroin (brown sugar)
Smack, Junk, Dope
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OpiumBlack stuff, brick
Cocaine
Star dust, happy dust, heaven dust, coke, snow
Cannabis
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Grass, pot, reefer, rope, viper's weed, marijuanaBarbiturates
Candy, goof ball
Narcotics
Cotton brothers, Dr. White
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MorphineGod's machine, Miss Emma
Amphetamine
Speed, crystal, Superman drugs
Phencyclidine
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Angel dust, peace pillKetamine
Purple, jet, super k
Addicts jargon
Meaning
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All lit upEuphoria following IV injection of narcotic
Bull horrors
Paranoid delusions induced by cocaine
Chicago leprosy
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Multiple skin abscesses in injection drug abuserChinaman on the
To suffer withdrawl symptoms
back/monkey on the back
Cold turkey
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To suffer withdrawl symptoms following abrupt stoppage of narcoticabuse
Croaker
Doctor
Dream stick, Gong, Joy stick
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Opium pipeEye opener
First shot of the day
Giving birth
Difficult expulsion of constipated stools by an opium addict
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Goof erBarbiturate addict
Gow head, Hop head
Opium addict
Grass hopper, Viper
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Marijuana addictJoy popper, Pleasure shooter
Occasional injection addict
Kiester plant
A condom or finger stall filled with drugs kept concealed in rectum
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Square apple or squareNon addict
Torpedo
Alcoholic drink with chloral hydrate
Huffing
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Inhaling vapors of a volatile substance in a clothBagging
Inhaling and exhaling into the bag
Chasing the dragon
Inhalation of vapours of heroin
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Freak out or bad tripUnpleasant LSD experience
Trip
Effects of LSD
Soft drugs
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amphetamine, barbiturates, cannabis, LSDHard drugs
opium, heroin, cocaine, methedrin
Food poisoning
? Death cap - Amantia phalloides
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? World's most venomous animal - box jelly fish? Most common fish poisoning - ciguatera poisoning
? Ptomaines - alkaloids formed as a result of bacterial decomposition of protein
? Leucomaines - when ptomaines are formed in living cells
? Cadaveric alkaloids - when ptomaines are formed in dead tissue
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Ordeal of poison? Poisonous calabar bean (physostigmine) is given in an attempt to detect guilt
? Person who vomits up the bean is innocent
? Person who becomes ill or dies is considered guilty
Fetal lobster syndrome (Boric acid poisoning)
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? Split hand/split foot malformation (Median clefts of hand and feet)? Presenting with syndactyly
? Aplasia and hypoplasia of phalanges, metacarpals and metatarsals
Hippus - aconite poisoning
Oxalic acid (acid of sugar) causes hypocalcemia. Used as a bleach to remove stains, removing writing and
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signature illegallyPoppers - street term for various alkyl nitrites take for recreational purposes through direct inhalation
Itai-Itai disease (ouch-ouch) - a combination of osteoporosis and osteomalacia associated with renal disease,
in post-menopausal women in Japan, due to irrigation of rice fields with cadmium containing water
Conium Maculatum (hemlock) administered to Socrates for execution
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Brompton's cocktail (previously used for pain relief in terminal cancer) cocaine + morphine +chlorpromazine + alcohol
Quinine - cardiac poison and an abortifacient that causes partial deafness
Cinchonism - caused by repeated doses of quinine either therapeutic or overdose
Gila monster - a species of venomous lizard
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